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AN ELEMEK^aMY treatise

ON

MIDWIFERY;

OR,

PRINCIPLES OF TOKOLOGY AND EMBRYOLOGY.

i^' .L

ALF. A. L. M. VELPEAU, M. D.

ETC. ETC.

TRANSLATED FROM THE FRENCH, WITH NOTES,

BY CH. D. MEIGS, M. D.

MEMBER OP THE AMERICAN PHILOSOPHICAL SOCIETY; LECTURER ON MIDWIFERY
AND THE DISEASES OF WOMEN AND CHILDREN, &C. &C.

SECOND AMERICAN EDITION.

PHILADELPHIA:
GRIGG k ELLIOT, 9 NORTH FOURTH STREET.

1838.

/

Eastern Disti'lct of Pennsylvania, to wit:

Be it remembered, that on the ninth day of February, in the fifty-fifth year of
the independence of the United States of America, A.D. 1831, John Grigg, of the
said district, has deposited in this office the title of a book, the right wheBeof he
claims as proprietor, in the words following, to wit:

An Elementary Treatise on Midwifery: or Principles of Tokology and Embry-
ology. By Alf. A. L. M. Velpeau, M.D. &c. &c. Translated from the French
by Charles D. Meigs, M.D. Member of the American Philosophical Society;
Lecturer on Midwifery and the Diseases of Women and Children, &c. &c.

In conformity to the act of the congress of the United States, entitled, " an act
for the encouragement of learning, by securing the copies of maps, charts and
books to the authors and proprietors of such copies during the times therein men-
tioned;" and also to the act, entitled, "an act supplementary to an act, entitled,
' an act for the encouragement of learning, by securing tlie copies of maps, charts
and books to the authors and proprietors of such copies during the times therein
mentioned,' and extending the benefits thereof to the arts of designing, engraving
and etching historical and other prints."

D. CALDWELL,
Clerk of the Eastern District of Pennsylvania.

Philadelphia:

T. K. & P. G. Collins, Printers,

No. 1 Lodge Alley.

NOTICE.

The great demand for Velpeau's Midwifery, the whole of
the first edition of which has been for some time exhausted,
has induced its proprietor to publish a second edition. The
translator has taken the liberty, which he hopes will not be
displeasing to the celebrated author of the work, of addmg a
few notes at the foot of the page, which are marked with the
initial letter M. It was with the utmost deference for the
author of the volume, that, in some of these notes, he has
ventured to express his dissent from a few of the opinions of
one who, at the present time, stands scarcely second to any
physician in Europe.

CH. D. MEIGS.

Philadelphia, Jlpril20th, 1838.

Q>^B7s

/ '

TO

THOMAS C. JAMES, M.D.

PROFESSOR OF MIDWIFERY AND THE DISEASES OF WOMEN AND
CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA.

Respected Sir:

I take the liberty of addressing the following work to you,
not only for the purpose of showing my sense of your high
rank and authority in the science and art so ably treated of
by M. Velpeau, but also as a testimonial of my gratitude for
many acts of kindness received at your hands.

I was induced to undertake the preparation of it for the
American press, by a sincere desire to see so excellent a book
in the hands of the profession in this country, a book which,
as I think, cannot be read without exciting m the mind senti-
ments of great respect for the science of Tokology, as M.
Velpeau denominates it, and a corresponding desire to see it
advanced in all the relations of its real usefulness and dignity.
I am willing to admit that we have, already, a good book in
the American edition of Baudelocque's work, which, however,
is but an abridgement. We have no translations of the works
of Capuron, Maygrier, Gardien, Duges, Flamant, or those

admirable writings of Mesdames Lachapelle and Boivin. It

1*'

vi DEDICATION.

did not seem improper, therefore, to add to our stock one of
the most enlightened and recent of the French authorities.

M. Velpeau will readily be admitted, by those who read
this volume, to be a man of talents and industry of a high
order; an admission, confirmed not merely by reference to his
writings, but also by the sentiments of public journahsts in
his own country, where the competition among men of letters
is so great and stirring, that he who attains to distinction, will
be, ipso facto, considered as having deserved it. In the re-
public of letters in France palmam qui meruit ferat may be
regarded as a maxim in daily use and practice.

The admirable composition of Dr. Denman, of which Pro-
fessor Francis has lately furnished the pubUc with an improved
edition, and the systems of Burns, Ashwell, and Ryan, camiot
be regarded as completely filling the chasm which has opened
in the last half century between the old limits of the science
and its present advanced station. I ought not in this enumera-
tion to omit a reference to the work of Dr. Dewees, which,
rich as it is in business details, and valuable for the soundness
of its practical precepts, may, nevertheless, without the fear of
disparagement, be considered less full and complete in regard
to its anatomical and physiological features, and the ample
collation of good authorities, than the volume which I have
the honor to present to you. To say that Dr. Dewees's "Sys-
tem of Midwifery" is creditable to the science and to himself,
is not enough, where it is universally admitted to be honorable
^ to the country.

Denman, Burns, Dewees and Velpeau, will, I trust, be con-
sidered as a collection of authorities, at the least, small enough
for any student or any practitioner of the delicate, difficult and
responsible Art of Midwifery: if so, I shall be. absolved from
the charge of adding to the number of authors, one whose
works are useless or superfluous.

In relation to the manner in which I have executed my

DEDICATION. vii

humble task, nothing ought to be said by me, further than
that I have aimed to give a transcript of the author's perform-
ance, and not to substitute one of my own under his name and
authority.

There are some slight errors which I shall not point out,
because I presume every reader of such a work is as com-
petent as I am to correct them: I have no excuse to oiler to
those who may detect them, except that the proofs have been
read with much attention, and a desire to attain a great degree
of correctness.

You, I hope, sir, who know how much of my time is absorb-
ed in the business of my profession, will have the goodness to
overlook all such minor faults of the translation as might na-
turally occur, mider the circumstances in which I am placed,
and accept it, and with it the assurance of my profound re-
spect.

CH. D. MEIGS.

Jan. 28/A, 1831.

AUTHOR'S PREFACE.

Confounded with the other branches of medicine, and pur-
sued almost exchisively by mere medicasters during a long
series of ages, the Art of Midwifery has advanced with ex-
treme slowness. Among the Egyptians, the Hebrews, the
Greeks, and the Romans, it was reduced in some sort to what
concerns the cutting of the umbilical cord; and even at the
present time, in countries that are imperfectly civilised, those
who make a profession of it inspire so little confidence, that
the husband is still compelled to imitate the conduct of the
first man, that is to say, he becomes the accoucheur of his wife.
These primitive notions have doubtless long ceased to exist
amongst us; in our day the Art of Midwifery is especially seen
to acquire a rapid movement, and to progress equally with the
other departments of the art of curing. It would, however,
be wrong to conclude from hence, that every thing has been
already done, and that no further improvements can be made.
The Science of Obstetrics ought to follow the movements of
the age, and advance if it would not retreat. It seems to me
that it may be defined, the ensemble of knowledge relative
to the reproduction of the human species. By studying it
under this extensive and philosophic view, and by doing away

X PREFACE.

the absurd and vulgar prejudice, that it is impossible to be at
the same time a skilful accoucheur and an able physician, we
shall succeed in establishing it upon a basis worthy of the
subject!

In this book I have endeavored not to be unjust to any one.
I have spoken on all occasions without being influenced by
hatred or prejudice, and I may add, without enthusiasm, and
with absolute independence. The sciences compose a republic
in which every man is at liberty to make researches, to examine
and think for himself, as well as to say what he thinks. Truth
is the avowed object of all who cultivate them: it may be
reached by a hundred different routes, and I could never un-
derstand how any reasonable man could be offended because
his ideas fail to be received as laws for other men.

In adopting a course somewhat different from that pursued
by the modern classic writers, I was not misled as to its merits.
No person attaches less importance to classifications than I do,
or is more fully convinced that every one has an equal right
to choose for himself. The course I have chosen appeared to
me to be more natural than any other; I found that one was
necessary for my purposes, and I preferred this one; I shall,
therefore, make no further attempt to justify it. It belongs to
the public to decide whether it be good or bad.

I have given a name to the science of the accoucheur; in
the first place, because it is a substitute for a periphrasis; and
in the next, because it is quite extraordinary that that science
should have remained until the present day without any spe-
cial qualification in France. From the earliest years of my
studies, I employed the term {obstetricie) obstetrics, derived
from the Latin obstetrix, midwife. I think it more uniform
in acceptation than the word obstetrique, which is used in
Germany, and which M. Dug^s has desired to establish among
us. But the word tokology, derived from toxoi, child-birth,
and from ^oyoy, word, out of which may be constructed the

PREFACE. xi

terms tokological, tokologist, tokologue, tokograph, Sic, and
which present nothing hard or difficult in their pronunciation,
has seemed to me more conformable to the habits of our lan-
guage and the rules of grammar.

It is of the nature of a preface to set forth the motives of the
author of a doctrinal book, and the advantages which he sup-
poses himself to enjoy over his predecessors. I hope that I
may be permitted to dispense with this common form. Since
the time of Baudelocque very good treatises on Midwifery
have been composed; I am the first to proclaim it, and have
not the smallest intention to contest the rights which their
authors may have acquired to the enjoyment of the public es-
teem. But at the present day, every thing proceeds with such
rapidity, that each moment is, so to speak, marked by new
wants. Besides, as the last speaker, I might hope that I could
produce a work, if not better, at least equally useful with
others; it remains to be seen whether I have succeeded.

In composing it, I have attempted to make a profitable use,
not only of the works of my own countrymen, whether an-
cients or contemporaries, but also of all such foreign writers as
I could have access to. Numerous materials have also been
furnished by between one thousand and twelve hundred la-
bors, examined with care either at the Maternite at Tours,
and the hospital Saint Louis, while I was a student there, or
at the hospital de Perfectionnement, while I was in service
there as chef de Clinique, or at my amphitheatre and in my
private practice, since I began to teach tokology; lastly, I have
thought it best to embody in the work a detailed extract of a
treatise on Embryology, which I have been preparing for a
long time past.

I may be permitted to make an appeal to my brethren upon
this subject. If, in the space of six years, I have been enabled
to make dissections of nearly one hundred and forty products
of conception within the "third month of gestation, I am in-

xii PREFACE.

debted for those opportunities to the kindness of a great many
physicians and female practitioners of midwifery. I shall testify
my thankfulness to them in another work, but in the mean
time, I cannot express the amount of obligations they will con-
fer by continuing to send me such specimens.

CONTENTS.

CHAPTER I.

Of the Parts that are concerned in Generation, Pregnancy, and Labor, 17

Of the Pelvis, ....... 17

ARTICLE I.
SECTION 1.

Of the Bones of the Pelvis, . . . . . 18

§. L Of the sacrum, ..... 18

§. II. Of the cocc)rx, . . . . . 19

§. III. Of the coxal bones, .... 20

SECTION 2.

Of the Articulations or Symphysis of the Pelvis, . . 21

SECTION 3.

Of the Pelvis in General, ..... 23

§. I. External surface, ..... 23

§. II. Internal surface, ..... 23

§. III. Straits of the pelvis, .... 25

§. IV. Dimensions of the excavation, ... 27

§. V. Base of the pelvis, ..... 28

§. VI. Dimensions of the pelvis unconnected with its axes or

straits, ...... 29

§. VII. Differences of the pelvis in respect to ages, sexes, and

species, ...... 29

§. VIII. Of the recent pelvis, .... 32

§. IX. Uses of the pelvis, .~ .... 33

2

XIV

CONTENTS.

SECTION 4.
Of the Deformed Pelvis, ....
§. I. Deformity from excess of amplitude,
§. II. Defonnity from want of amplitude, .
§. III. Faulty direction of the axes,
§. IV. Causes of deformities of the pelvis,
§. V. Of the mensuration of the pelvis,

34
35
35

40
40
42

ARTICLE II.

Of the Sexual Organs,

SECTION 1.

Of the External Parts of Generation,
§. I. Of the mons veneris,
§. 11. Of the labia,
§. III. Of the lesser labia,
§. IV. Of the clitoris,
§. V. Of the vestibule,
§. VI. Of the urethra,
§. VII. Of the hymen,
§. VIII. Of the myrtiform or vaginal caruncles,
§. IX. Of the perineum, fossa navicularis, fourchette, froenum,

commissure, .....

§. X. Differences betvi^een the external organs of generation in

women and those of brutes,
§. XI. Anomaly of the external organs of generation.

SECTION 2.

Internal Genital Organs, .

§. I. Of the uterus, .

A. External surface, .
E. laternal surface,

C. Dimensions of the womb,

D. Structure, .
§. II. Fallopian tubes,
§. III. Ovaries,
§. IV. Ligaments of the uterus,
§. V. Of the Vagina,
§. VI. Of the sexual organs in general.

48

49
49
49
50
51
52
53
53
55

55

56
57

58
58
58
60
61
62
67
68
70
72
73

§. VII. Varieties in the internal organs of generation in animals, 74

CONTENTS.

§. VIII. Difference according to ages,
§. IX. Anomalies, .
§. X. Hermaphrodism,

XV

75
76
81

CHAPTER II.

Functions of the Sexual Organs, .

ARTICLE I.

Of Menstruation, or the Catamenial Discharge,

ARTICLE II.

Of Reproduction,

SECTION 1.

Of the Generation or Procreation of Germs,
§. I. Of the female germ, .
§. II. Of the male germ.

Of Fecundation, .
Of Conception, .

SECTION 2.

SECTION 3.

83

83

92

95
95
96

99

102

CHAPTER HI.

History of Gestation,

Of True Pregnancy,

ARTICLE I.

SECTION 1.
Of Uterine Pregnancy, . . . . .

§. I. Local phenomena, . . . .

§. II. Sympathetic phenomena and rational signs.

103

104

104
104
116

XVI

CONTENTS.

§. III. Sensible signs, ..... 121

§. IV. Of touching, ..... 121

§. V. Of ballottement, ..... 126

§. VI. Of auscultation, ..... 128

SECTION 2.

Of Extra-uterine Pregnancy, ..... 133

§. I. Of ovarian pregnancy, .... 133

§. II. Of abdominal pregnancy, .... 134

§. III. Of tubal pregnancy, .... 135

§. IV. Of interstitial pregnancy, . . ... 136

§. V. Causes of extra-uterine pregnancy, . . . 137

§. VI. Signs and terminations of preternatural pregnancy, 138

ARTICLE II.

Of False Pregnancy,

143

ARTICLE III.

Of Pregnancy as it regards the sex of the Foetus, . . 146

§. I. Is it possible to ascertain the sex of the foetus during

pregnancy? . . . . . .146

§. II. Is it possible to procreate either sex at pleasure? . 148

§. III. Of the influence of the seasons and of public pros-
perity upon the production of the sexes and the pro-
portion of conceptions, .... 151

CHAPTER IV.

Of the Human Ovum,

153

ARTICLE I.

Of the Appendages of the Foetus,

SECTION 1.

Of the Membranes, .....

§. I. Of the caduca or comiecting membrane,
§. II. Of the proper membranes of the ovum,
A. Of the chorion.

153

153
153
158
158

CONTENTS.

XTU

B. Of the amnios,
ni. Of the water of the amnios, .

SECTION 2.

Of the Vesicles of the Embryo, .

§.I.

Of the umbilical vesicles,

§.II.

Of the allantois.

SECTION 3

Of the Cord and Placenta,

§.I.

Of the umbilical cord,

S.II.

Of the placenta.

163
161

167
167
172

176
176
180

Of the Foetus,

ARTICLE II.

SECTION I.

Development of the Embryo and of the Foetus, .
§. I. Of the embryo in general,
§. II. Of the head and organs of the senses,
§. III. Of the members and lower parts of the trunk,
§. IV. Of the foetal head at term,
§. V. Of the attitude and position of the foetus during preg-
nancy, .....
§. VI. Of superfcetation, ....

SECTION 2.

Functions of the Foetus, .

§. I. Of the nourishment of the foetus,
§. II. Circulation of the foetus,
§. III. Of the respiration of the foetus,
§. IV. Of the viability of the foetus,

189

190
191

193
195
202

207
209

213
213
231

225
227

ARTICLE III.

Of Abnormal Expulsions of the Human Ovum,

SECTION 1.
Of Abortion, .....

SECTION 2.

Of the terra of Gestation and of Retarded Births,

2*

231

231

246

XVlll

CONTENTS.

SECTION 3.

Of Precocious or Early Births, .

249

CHAPTER V.

Of Labor,

250

ARTICLE L

Of Labor in General,

SECTION 1.
Of the Causes of Labor, ....

§. L Efficient causes, ....

§. IL Determining or occasional causes,

SECTION 2.
Of Labor, .....*

§. I. Precursory or preliminary symptoms of labor,
§. II. First stage, or period of dilatation, .
§. III. Second stage, or period of expulsion,
§. IV. Of labor-pains,
§. V. Of the dilatation of the OS uteri,
§. VI. Of the discharge of glairy mucus,
§. VII. Of the bag of waters,

253

254

254
260

264

265
267
268

272
277
280

282

ARTICLE II.

Of Eutocia or Simple Labor,

SECTION 1.

Of Natural Eutocia,

§. I. Presentation of the vertex,
First, or occipito-anterior position,

A. First variety.

Left occipito-acetabular poistion,

B. Second variety.
Right occipito-acetabular position.

285

289
290
292

293

297

1

CONTENTS. xix

C. Third variety.
Occipito-pubic position, . . . . . . 299

Second, or occipito-posterior position, .... 302

A. First variety.

Left fronto-acetabular position, ..... 303

B. Second variety.

Right fronto-acetabular position, ..... 305

C. Third variety.

Fronto-pubic position, ...... 307

§. II. Presentation of the face, .... 310

A. Right mento-iliac position, . . . . 313

B. Left mento-iliac position, .... 313

C. Mento-sacral position, . . . . 314

SECTION 2.
Of Unnatural Eutocia, . . . . . . 315

§. I. Presentation of the feet, . . . .321

First; Calcaneo-anterior position, . . . .321

A. First variety.

Loins in front and towards the left, . . . .321

B. Second variety.

Loins in front and towards the right, .... 323

C. Third variety.

Loins directly in front, ...... 324

Secondly ; Calcaneo-posterior position, ... - 325

Presentation of the knees, ..... 329

Presentation of the breech, . . . • . . 330

SECTION 3.

Of the Conduct of the Accoucheur during Labor, . . 332

332
336
339
340

§. I. Of the diagnosis, ....

§. II. To determine the position, . . .

§. III. Of the prognosis, ....

§. IV. Of the attentions necessary for the woman in labor,

ARTICLE in.
Of Dystocia, ....... 367

SECTION 1.
Accidental Dystocia, ... . . . . 369

XX CONTENTS.

§. I. Of hemorrhagic dystocia, .... 369

§. II. Of convulsive dystocia, .... 385

§. III. Dystocia caused by premature descent of the umbili-
cal cord, ...... 395

§. IV. Dystocia from excessive length or shortness of the

umbilical cord, ..... 398

§. V. Aneurismal dystocia, .... 400

§. VI. Dystocia from asthma, hydrothorax, gibbosity, dropsy, 400

§. VII. Hernial dystocia, ..... 401

§. VIII. Dystocia from syncope, .... 401

SECTION 2.

Essential Dystocia, ...... 403

§. I. Dystocia occasioned by the state of the female organs, 403

§. II. Dystocia depending on the foetus, . . . 413

SECTION 3.

Dystocia from Wrong Presentations of the Foetus, . . 418

§. I. Deviated positions of the head, . . . 418

§. II. Deviated breech positions, . . . . 419

§. III. Deviated positions of the trunk of the body, . . 419

CHAPTER VI.

Obstetric Operations, ...... 427

ARTICLE I.
Of Turning, ....... 427

SECTION 1.
Of Turning in General, ...... 428

SECTION 2.
Of Version by the Head, ..... 434

SECTION 3.
Of Turning by the Feet or Pelvis, .... 437

§. I. Of bringing down the feet when the head is at the

orifice, ...... 441

CONTENTS.

XXI

A. Left occipito-iliac position, . . . 441

B. Right occipito-iliac position, . , . 449
§. II. Of turning by the feet in presentations of the trunk, . 450

A. Positions of the shoulder and side, . . . 451
First; positions of the left shoulder, .... 451
Second ; positions of the right shoulder, .... 454

B. Presentation of the sternum, . . . 455

C. Presentation of the back, .... 455

SECTION 4.

Of the Manoeuvre in Presentations of the Pelvis, . . 456

A. Positions of the feet, .... 457

B. Positions of the breech, .... 459

SECTION 5.

Presentation of the Arm, . ..... 461

General Recapitulation on the Manoeuvre, . . . 465

ARTICLE IL

Of the Forceps, ....

SECTION !.•
The Forceps in itself considered,

SECTION 2.

Of the Use of the Forceps,

§. I. Occipito-anterior position, .

§. II. Occipito-posterior position, .

§. III. Left occipito-iliac position,

§. IV. Right occipito-iliac position,

§. V. Positions of the pelvis,

§. VI. The child is completely or partially double,

§. VII. The head separated from the body remains alone in

the pelvis, .....
§. VIII. Recapitulation on the employment of the forceps.

466

466

469
473

478
478
479
479

481

481
483

ARTICLE III.

Of the Lever,

484

xxu

CONTENTS.

SECTION 1.

Of the Lever in itself considered,

SECTION 2.

Use of the Lever,

§. I. Use of the lever as a crotchet,
§. II. Of the lever used as a lever, .

484

485
486
487

ARTICLE IV.

Of the Fillet, .

488

ARTICLE V.

Of the Locked Head,

489

ARTICLE VI.

Of the Measures rendered necessary by Narrowness of the Pelvis, 494

SECTION 1.
Of Regimen as a means of enabling Women with Contracted
Pelvis to be delivered without the assistance of any
surgical operation, . . , , . 497

SECTION 2.

Of Abortion brought on for the purpose of rendering symphyse-
otomy or the Cesarean Operation unnecessary, . 497

SECTION 3.
Of Symphyseotomy, ...... 504

SECTION 4.
Of the Cesarean Operation, &c., . .... 513

SECTION 5.
Vaginal Cesarean Operation, ..... 527

SECTION G.
Of Cephalotomy and Embryotomy, .... 529

SECTION 7.
Of Crotchets and their Use, ..... 532

CONTENTS. xxiii

SECTION 8.
Of the Extraction of the Head when it has been left alone in the

Genital Passages, ...... 535

CHAPTER VII.

Of the Natural Phenomena which follow the Delivery of the

Fcetus, ....... 538

ARTICLE I.

Of the Delivery of the After-birth, .... 538

SECTION 1.

Of Simple or Natural Delivery of the After-birth, . . 538

SECTION 2.
Of Complicated Delivery of the After-birth, . . . 545

ARTICLE II.
Management of the Child, ..... 561

SECTION 1.
Of the Foetus in a Healthy State, .... 561

SECTION 2.

§. I. Of tying and cutting the cord, . . . 561

§. II. Of cleansiug the child, .... 566

§ III. Of dressing the child, .... 568

SECTION 3.

Of the Fcetus in a State of Disease, .... 569

§. I. Of asphyxia, ..... 569

§. II. Of the apoplectic state, .... 574

§. III. Of some other states of the new bom child, . . 576

ARTICLE III

Management of the Lying-in Woman, .... 578

I

AN ELEMENTARY

TREATISE ON MIDWIFERY

CHAPTER I.

Of the Parts that are concerned in Generation^ Preg'
nancy, and Labor.

ARTICLE I.

Of the Pelvis.

1. The pelvis, a sort of bony girdle or cavity, which constitutes
the inferior termination of the trunk of the body, is found, in the
human species, between the spine, which it supports posteriorly,
and the thigh bones, on which it rests anteriorly. Its shape, which
is very irregular and difficult to describe, resembles in some mea-
sure that of a cone with its apex and base strongly inclined towards
each other, on their anterior face. Regarding it as an appendage
both of the vertebral column and of the inferior extremities, the ana-
tomists who lived antecedently to the time of Vesalius, gave no par-
ticular description of it. Diemerbroeck, Dionis, Saint Hilaire, Mau-
riceau, and De La Motte scarcely dwell for a moment upon it in
their works: and even at the present day, the learned who aim to
promote the honor of what is called philosophical anatomy, have,
for the major part, returned in this respect to the same way of think-
ing as the ancient naturalists. But although the development of
the skeleton might, in a system of general zoology, permit us to take
3

18 OF THE PELVIS.

such a view of it, it does not follow that we ought to do so in toko-
logy. The accoucheur must necessarily study the pelvis as a por-
tion distinct from, and, as far as connected with his art, independent
of the rest of the body. Hence it is, that all authors since the time
of Smellie and Levret have followed this course; which I shall ac-
cordingly adopt.

SECTION 1.
Of the Bones of the Pelvis.

2. There are four bones in the adult pelvis: the sacrum and coc-
cyx posteriorly, and on the median line; and the coxal bones in front,
and on the sides. As he who is destined to engage in the practice
of midwifery ought to be made acquainted with the entire pelvis, I
do not deem it necessary to dwell at length upon the graphic details
that are to be found in most of the classical works upon each con-
stituent portion of it. On this subject there exists, even in our most
modern works, quite a faulty mode of exposition, which it is proper
to reform: after the manner of Baudelocque, the pubis, the ilium
and ischium are minutely described as so many separate bones,
while, for the most part, the coxal bone is almost entirely lost sight
of; and yet it alone possesses any considerable interest in relation
to midwifery, inasmuch as the three pieces of which it is composed
are united into one before the individual is liable to become preg-
nant.

§. I. Of the Sacrum {os sacrum, s. clunium).

3. The sacrum, a single bone, situated between the last lumbar
vertebra and the coccyx, is locked in, as it were, between the two
ossa ilia.

4. Of a triangular or pyramidal shape, curved forwards on its an-
terior surface, it presents to the examiner, successively, an internal
or pelvic region, and external or posterior region, two edges, a base
and an apex.

5. Its anterior surface, somewhat concave, presents, 1. Along its
middle, four or five quadrangular facettes, and the same number of
transverse lines; 2. Outwardly, the five anterior sacral holes, ter-
minating in an equal number of converging grooves, for the passage
of the anterior branches of the sacral nerves; 3. More outwardly
still, and between these openings, certain rough, uneven surfaces,
for the attachment of the pyramidal muscles.

6. Its posterior surface, which is convex and very uneven, exhi-

OF THE PELVIS. 19

bits, along its middle, a series of protuberances which, by their union,
constitute the crista of the sacrum; above this crest is seen the open-
ing of the sacral canal; below are the two branches formed by its
bifurcation, the triangular space which terminates the spinal canal,
and the tubercles or points called the horns of the sacrum. On
either side of the false vertebral spines, are seen the sacral grooves,
the posterior sacral holes, and still nearer to the edges of the bone
are to be found certain rough surfaces that serve for the attachment
of the posterior sacro-iliac ligaments.

7. Its edges may be divided into two portions: one, superior,
very thick, exhibits, on its anterior half, a semilunar articular facette
which unites it to the coxal bone; on its posterior half, a hollow, and
certain rough protuberances for the attachment of the sacro-iliac
ligaments; the other, inferior, thin, almost sharp, serves for the in-
sertion of the sacro-sciatic ligaments.

8. Its base, very broad, looks upwards. On its middle may be
seen a plain elliptical surface, situated transversely, inclined more or
less backwards, and which is articulated with the last lumbar verte-
bra; outwards, and a little forwards, a triangular surface, the lesser
wing of the sacrum, which is slightly depressed towards its anterior
face, and concurs in forming the internal iliac fossa; lastly, we ob-
serve on the posterior surface, the opening of the sacral canal, and
the two articular apophyses of the first piece of the sacrum.

9. Its apex, thin, elliptical, slightly convex, is received into the
base of the coccyx.

10. The sacrum, a simple prolongation of the spine, is formed by
the union of five vertebrae. Near forty points of ossification may be
observed in it; at birth it is still formed of fifteen pieces, three for
each vertebra; but soon afterwards it only exhibits five, which, also,
always coalesce before the age of puberty.

§. II. Of the Coccyx {ossa coccygis).

11. The coccyx is a sort of rudimental sacrum, whose anterior
face almost plane, supports the end of the rectum, while its pos-
terior surface, slightly convex, is only separated from the skin by
the posterior sacro-coccygeal ligament. Its edges serve as points
of attachment for the small sciatic ligament, and ischio-coccygeus
muscle; its base, somewhat concave, surmounted laterally by two
prolongations resembling horns, is articulated with the apex and cor-
nua of the sacrum. Its apex, tubercular and rounded, gives inser-
tion to the external sphincter of the anus.

12. The three or four pieces of which it is composed, mere ves-
tiges of an equal number of vertebral bodies, remain for a long

20 OF THE PELVIS.

while movable upon each other; however, they at length coalesce;
but, in most women, the bone, as a whole, loses its power of moving
upon the sacrum only at a very advanced age.

§. III. Of the Coxal bone (os coxalium).

13. The bone of the ilium, the hip bone, the nameless bone, or
more properly, as was long ago indicated by Celsus, the coxal bone,
situated between the femur and the sacrum, alone forms the two an-
terior and lateral thirds of the pelvis.

14. Of an irregular quadrangular shape, looking as if strangulated
at its middle, and twisted in two opposite directions, the coxal bone
exhibits two surfaces and four edges.

15. On its internal or pelvic surface, which is divided into two
nearly equal portions, we distinguish, above, a large excavation
called the internal iliac fossa, which is filled by a muscle of the same
name; behind, an articular surface, of a semilunar shape, called the
articular facette; still farther behind, certain rugosities, similar to
those observed on the edge of the sacrum, with which they unite.

On its inferior half, and posteriorly is seen a plane, almost trian-
gular surface, which corresponds to the cotyloid cavity, and to the
body of the ischium; in its middle, the sub-pubal opening; in front,
the internal face of the pubis, and of the ischio-pubal ramus.

16. A semicircular edge, thick, smooth, and rounded posteriorly,
thin and sharper in front where it terminates in the crista of the
pubis, an edge which forms the greatest part of the superior strait,
and unites these two halves of the pelvic surface of the coxal bone.

17. Its external or femoral surface exhibits, on its upper half,
what is called the external iliac fossa, filled by the three glutei mus-
cles; below, the sub-pubal hole, the external face of the ischium and
ischio-pubic ramus; in the middle, the cotyloid cavity.

18. Its upper edge, or the iliac crista, thicker both posteriorly and
anteriorly than in the middle, twisted like an italic s, divided by the
anatomists into an external lip, an internal lip, and an interstice,
for more conveniently describing the attachment of muscles, termi-
nates in front, by the anterior-superior spine of the ilium, and behind,
by the postero-superior spine of the ilium.

19. Its lower edge presents three portions; superiorly, an oval
surface for the articulation of the pubes; inferiorly, the tuberosity of
the ischium; and in the middle, the edge of the ischio-pubic ramus,
turned somewhat outwards.

20. On its anterior edge, proceeding from above, downwards,
and from the ilium towards the pubis, we remark the superior iliac
spine; a small semilunar notch; the inferior iliac spine; the groove

OF THE PELVIS. 21

for the psoas and iliac muscles; the ileo-pectineal eminence, for the
insertion of the lesser psoas; a triangular surface, smooth, inclined
forwards, and concealed by the pectinalis muscle; the crest; then the
spine of the pubis; and, lastly, the angle of the pubis.

21. On its posterior edge, in proceeding from above doAvnwards,
is seen the posterior superior spine of the ilium; a small irregular
notch; the postero-inferior spine of the ilium, which articulates with
the sacrum; the great ischiatic notch; the ischiatic spine; the small
ischiatic notch, and the most posterior portion of the tuberosity of the
ischium.

22. At birth, the coxal bone is composed of three distinct pieces:
one superior, the ilium, which constitutes the hip and the two iliac
fossa; one inferior, the ischium, which supports the weight of the
body when seated; the third, anterior, the pubis, to which are ap-
pended, as it were, the organs of generation. It is in the cotyloid
cavity, at the ileo-pectineal eminence, and in the middle of the ischio-
pubal ramus, that these three bones at length are blended into one
about the period of puberty; but there are commonly added in child-
hood, a plate for the crest of the ilium, one for the tuberosity of the
ischium, another point of ossification for the antero-inferior spine,
and a fourth for the spine of the pubis; which sometimes do not
coalesce with the principal pieces until a very late period.

SECTION 2.
Of the Articulations, or Symphyses of the Pelvis.

23. There are three principal articulations of the pelvis: one for
the two pubes in front, and two for the bones of the ilium and the
sacrum behind.

24. At the anterior or median symphysis, the bones are kept in
contact by a fibro-cartilaginous substance called the interpubal liga-
ment, and whose thickness is far from being uniform at every point
of the kind of ring or oval circle which it represents. Its thickness,
which is very considerable on the upper part, a little less so in front,
and much less so behind, becomes suddenly much greater below,
where the fibrous body assumes the name of sub-pubal or triangular
ligament. In the centre, the articular surfaces are separated by a
very thin plate of cartilage, which in early life, and even in a good
many adult women, is moistened by a small quantity of synovial
fluid.

A portion of the periosteum lines the posterior surface, a fibrous
lamina of the same material is observed in front, and these two layers

3*

22 OF THE PELVIS.

have received the names of anterior and posterior ligaments of the
symphysis pubis.

25. The sacro-iliac or posterior symphyses are much more com-
plex than the preceding. There the sacrum is locked, like a double
wedge, between the coxal bones, so that it offers a very efficient re-
sistance to the weight of the body, which presses it from above down-
wards, and to the efforts of the pelvic viscera, which tend to force
it backwards; its articular surfaces, although uneven, are nevertheless
covered with a very thick diarthrodial cartilage, while those of the
iliac bones are wholly destitute of them.

26. The name of posterior sacro-iliac ligament is given to a col-
lection of fibrous bundles, that are yellow, elastic, mixed with small
lumps of fat which fill up the uneven and rugous excavation that is
seen behind the cartilaginous surfaces. These fibrous bundles of
the same nature with the yellow ligaments of the vertebrae, are com-
posed of fibres decussating in every direction, and are united almost
intimately with the sacrum and coxal bones. Being of considerable
strength, they give an extraordinary solidity to the articulation which
they concur in forming. There is not, rigorously speaking, any an-
terior sacro-iliac ligament: a simple lamella of the pelvic periosteum
serves in its stead.

27. Other small fibrous bands also serve, but less immediately,
to unite the bones of the pelvis behind. These are the sacro-sciatic,
and sacro-spinal ligaments; which, by passing from the posterior
spines of the ilium, and from the inferior half of the edge of the sa-
crum to the spine, and tuberosity of the ischium, convert the two
ischiatic notches into holes.

28. The connections of the pelvis with the vertebral column and
with the coccyx, are effected by two amphiarthroses.

2\h One, the sacro-coccygeal articulation, is composed, 1. Of an
elliptical fibro-cartilaginous lamina, which unites the point of the sa-
crum to the base of the coccyx; 2. Of the posterior sacro-coccygeal
ligament, a sort of prolongation or extension of the supra-spinal
ligament of the vertebrae, which closes the lower extremity of the
sacral canal; and 3. Of the anterior sacro-coccygeal ligament,
formed of two lateral bands united at their point on the front of the
second or third piece of the coccyx. Naturally very movable in
women, this articulation permits the coccyx to turn backwards, from
half an inch to an inch, while the child is passing through the lower
strait.

30. The other, the sacro-vcrtebral articulation, differs from the
vertebral amphiarthroses, only in the thickness of its fibro-cartilage;
in the obliquity of the articular faces of the last lumbar vertebra, and

1

OF THE PELVIS. 29

of the sacrum, an obliquity which produces the sacro-vertebral angle,
or the promontory ; and by the presence of the ilio-lumbar ligament,
which extends from the last transverse vertebral apophysis to the
posterior extremity, and not to the posterior spine of the iliac crest,
as is incorrectly asserted by several modern authors.

31. The obturator membrane, and the ligament of Fallopius,
which extends from the anterior superior spine of the ilium to the
spine of the pubis, constituting the crural arch, and separating, be-
fore it terminates, into two columns to form the inguinal ring, com-
pletes the ligamentous apparatus of the pelvis.

SECTION 3.
Of the Pelvis in general.
§. I External Surface.

32. The principal use of the external surface of the pelvis, which
is very uneven, is to give attachment to the muscles which surround
the coxo-femoral articulation; it may be divided into four regions.

33. The first, anterior, bounded on the sides by the cotyloid cavi-
ties, presents, in its middle, the front of the symphysis of the pubis,
and laterally, the external obturator fossa, filled w^ith the correspond-
ing muscle.

34. The seconA, posterior, bounded by the projection of the coxal
bones, is formed almost wholly by the posterior surfaces of the sa-
crum and coccyx. Consequently, we may observe in this region
the sacral crista and the lower orifice of the spinal canal; the sacral
portion of the vertebral grooves filled with the point of the sacro-spi-
nal muscle, and in the bottom of which are seen the ten posterior
sacral holes, from whence pass the nerves of the same name.

35. The two last, lateral, enclosed by the preceding, present the
external iliac fossae above; below and behind, the posterior surface
of the sacro-ischialic ligaments, and the plane of the notches or holes
of the same name; below and forwards, the cotyloid cavity which
receives the head of the femur.

§11. Internal ^Surface.

30. The ancient authors have compared the pelvis to a barber^s
basin. Although trivial, this comparison, nevertheless, gives a pretty
exact idea of it. We may, with the moderns, divide its inner face
into two parts: one, superior, which bears the name of gre&ter ba-
sin, upper basin, or abdominal basin, on account of its dimensions,
its situation, or the parts it encloses; the other, inferior, and which
is also known as the lesser basin, or the pelvic excavation.

24 OF THE PELVIS.

37. The abdominal basin constitutes part of the belly. Of an
elliptical form, largely notched in front, where it corresponds to the
hypogastrium, notched also behind, in order to receive the lower end
of the spine, this cavity is composed of the tMro internal iliac fossae,
which belong to the coxal bones, as well as to the lesser wings of
the sacrum, and which are occupied by the sigmoid flexure of the
colon on the left, the crecum on the right, and by some folds of the
small intestines on both sides.

38. The lesser basin may be considered as part of a canal larger
in the middle than at its two extremities, curved anteriorly, and des-
tined to contain the internal genito-urinary organs, the rectum, and
the hypogastric and sacral vessels and nerves. In order to obtain
a clearer idea of it, it is well to follow the advice of M. Chaussier,
that is to say, to remove the greater basin by a horizontal section
with a saw. Like the external surface, it may be divided into four
regions, and circumscribed in the same way, always excepting the
lateral regions, which leave the internal face of the ilium above
them.

39. The anterior region of the lesser basin, very greatly notched
below by the pubic arch, slightly convex from above downwards,
and concave transversely, comprises the posterior face or the bodies
of the pubes, of the ischio-pubal rami, and of the obturator mem-
branes. We may remark, 1. On the median line a perpendicular
crest, more or less salient, formed by the posterior part of the sym-
physis pubis; 2. Outwardly, the internal obturator fossa, surmounted
by a canal, (and not a simple hole,) oblique from behind forwards,
and from without inwards; through this, which is called the sub-pu-
bal or obturator canal, the obturator vessels and nerves proceed from
the interior of the pelvis to the inner side of the thigh.

40. The posterior region, very much excavated, is represented by
the anterior surface of the sacrum, of the coccyx, and of the root of
the sacro-ischiatic ligaments.

41. The lateral regions, formed in front by the internal face of
the cotyloid portion and the rest of the ischium, behind by the inner
face of the sacro-ischiatic ligaments, are largely opened by the two
sciatic holes. Of these two openings, one, superior and the largest,
is of an oval shape, and gives passage from within the pelvis, 1. To
the pyramidal muscle, which is inserted into the great trochanter;
2. To the great sciatic nerve, which proceeds to be distributed on
the back part of the thigh, the outer and back part of the leg, and
to the whole foot; 3. To the gluteal artery, and to the internal pubic
vessels and nerves: the other, inferior, much smaller, of a triangular
shape, is filled by the internal obturator muscle, which proceeds to

OF THE PELVIS. 25

join tlie tendon of the pyramidalis in the digital cavity of the great
trochanter, and by the pudic vessels and nerves which re-enter the
pelvis to be distributed in the perineum.

42. Suppose a vertical cut, which should divide the lesser basin
into four equal parts, there would be found four planes inclined to-
wards each other at their points. The two anterior inclined planes
comprise a portion of the lateral regions and the whole of the ante-
rior region of the excavation; the two posterior are formed by the
front of the sacrum and coccyx, by the sciatic ligaments and notches,
and the sacro-iliac articulations. It is always on two of these four
surfaces that the extremities of the diameters of the foetal head glide,
during parturition.

§. III. 8trait§ of the Pelvis.

43. A. Superior strait. The sort of horizontal circle which
separates the internal surface of the pelvis into two parts, is called
the superior or abdominal strait, greater strait, or margin of the
pelvis: formed behind by the sacro-vertebral angle and the anterior
edge of the lesser wings of the sacrum, outwardly by the rim which
limits the iliac fossa below, in front by the superior posterior edge
of the body of the pubis; it is thick or rounded in the first portion
described, while in the second it, on the contrary, grows thin, and
is transformed, so to speak, into a crest.

44. Its form in the dried pelvis approaches more or less to that of
an oval, of the heart on a card, or of an ellipse; but with the soft parts
it represents a triangle, with the base in front.

45. Its inrJination downwards and forwards, when the woman is
on foot, varies from thirty-five to fifty degrees. This inclination is
less in the silting posture, and Avhen the person lies down or bends
forwards; it increases in pregnant women, in those who make use of
their abdomen to support heavy burthens, as is the case at Paris with
the women who sell fruit, vegetables, fish, &;c.; also while on the
knees; and whenever, for the purpose of preserving the equilibrium,
we attempt to throw the upper end of the central line of the body
backwards.

46. Its axis is an imaginary line extending from the umbilical
region to the lower two-thirds of the front of the sacrum. Every
degree of inclination of which the plane of the strait is susceptible, is
equally applicable to its axis, since the latter must pass through the
former. The upper extremity of this may rise higher or fall lower,
according as its lower extremity recedes from or approaches towards
the point of the coccyx. In this respect there are infinite shades of
difference, which must not be lost sight of in practice, whether the

86 OF THE PELVIS.

labor be terminated spontaneously, whether the child must be turned,
sought for by the hand, or delivered with instruments.

47. Its principal diameters are four in number: the sacro-pubal,
or antero-posterior, which extends from the most salient point of the
sacro-vertebral angle to the posterior surface of the symphysis pubis;
the transverse or bis-iliac, which passes from the lower edge of one
iliac fossa to a point diametrically opposite; the two oblique or mean
diameters, which proceed from the sacro-iliac symphysis, and termi-
nate behind the ileo-pectineal eminence of the opposite side.

48. The length of the first or small diameter is, according to
Madame Boivin, and most of the French authors, four inches; and
four inches and four lines according to Meckel; that of the second
is five inches; that of the third from four inches and four lines to
four inches and a half: so that their union gives a circumference of
about thirteen inches and a half. But these dimensions are subject
to great variety, and ought not to be understood here except in a
very general manner.

49. B. Inferior strait. The inferior strait, lesser strait, perineal
strait, or apex of the pelvis, is formed by the point and edges of the
coccyx, the edges of the sacro-sciatic ligaments, of the tuberosities
of the ischium, and the ischio-pubal rami; it accordingly presents
three triangular projections, the coccyx behind, and the two ischia
on the sides; as well as three indentations, one anterior, very deep,
known as the arch of the pubis, and two others, posterior, still deeper
and very irregular when the sciatic ligaments are removed, but, on
the contrary, quite superficial when these fibrous bands are in their
natural situation. Its form is precisely like that of the heart on a
playing-card; only it may become oval by the retreat backwards or
the removal of the coccygeal triangle; it being in the mean while
understood that the widest, most open part of these figures is always
turned backwards.

50. Like the abdominal strait, the inferior strait has four diame-
ters: one, the coccy-pubal, or antero-posterior, is measured from the
point of the coccyx to the top of the arch of the pubis; another, the
transverse, or 6is-ischiatic, from the posterior and interior part of
one tuberosity of the ischium to that of the opposite side; the two
last, or the oblique diameters, reach from the point where the rami
of the pubes and the ischia meet, to the middle of the edge of the
sacro-sciatic ligaments.

51. These diameters are generally found to be four inches each;
however, M. Meckel gives to the first four inches and four lines,
and four inches six lines to the second. M. Delpech is surely incor-
rect in giving as the mean term four inches and a half to one, and

OF THE PELVIS. 27

five inches to the other. The mobility of the coccyx, and the elas-
ticity of the sciatic ligaments, render the antero-posterior diameter
capable of being prolonged four, six, eight, or even twelve lines,
while the oblique diameters are also evidently capable of being elon-
gated; the transverse, on the contrary, I have always found to be
a few lines less than four inches. Thus the circumference of the
perineal strait should be about twelve inches.

52. In general, the plane of the inferior strait is inclined slightly
upwards, so that the line that represents it crosses that of the supe-
rior strait in front of the symphysis of the os pubis; however, it is
sometimes found to be horizontal, and even below the level of the
coccyx.

53. The axis of the inferior strait is represented by a straight line
drawn from the interior of the pelvis, and cutting the middle of the
coccy-pubal diameter at right angles; the upper extremity of this
line most commonly rises as high as the sacro-vertebral angle, and
sometimes is found to be even parallel with the spinal column, and
may approach even nearer to the axis of the superior strait in very
many instances, as is proved by the late researches of professor
Naegele, and as I have ascertained for myself.

54. In order to obtain correct notions on this subject, it is neces-
sary to suppose the coccyx depressed, as it is by the head of the
foetus at the moment of delivery; the posterior extremity of the
coccy-pubal diameter will then be found lower than its anterior
extremity; and the axis of the strait descends obliquely from behind
forwards, under an angle of from fifteen to twenty decrees, passing
from the anterior face of the first or second piece of the sacrum,
through the middle of the space which separates the anterior parts
of the tuberosities of the ischia; it is requisite, further, not to forget
that in the living subject, and particularly during the passage of the
head, the obliquity of this line is so much increased, that it becomes
almost parallel with the plane of the superior strait.

§• IV. Dimensions of the Excavation.

55. The anterior wall of the pelvic cavity, opposite to the sym-
physis of the pubis, is only eighteen lines high; but more outwardly
it is near three inches: the depth of the middle portion of the lateral
regions is at least three inches and a half; the posterior wall is at
least five along the median line, following the curve of the sacrum;
and only four in a straight line, from the promontory to the point of
the coccyx. From these differences it is manifest that the inclina-
tion of the straits will always be about two inches and a half, and in
an inverse proportion, in each case; for the pubis cannot be depress-

28 OF THE PELVIS.

ed towards the horizon without an equal or apparent degree of ele-
vation of the coccyx. The sacro-pubal diameter is increased, by de-
scending to the centre of the excavation, from six to ten lines, on
account of the concavity of the sacrum; the transverse diameter, on
the contrary, diminishes gradually as it approaches the ischiatic,
where it is only four inches. The oblique diameters alter but very
little, and I am ignorant of the facts that might warrant Mr. Meckel
in assigning to them a length of five inches and four lines.

56. As the anterior face of the sacrum presents us with a cavity
that is irregular and of greater or less depth, it is easy to understand
that a series of right lines that should fall perpendicularly upon it
could not be parallel; that ihey would all converge towards each
other, and cross at angles more or less acute in front of the articu-
lation of the pubis, with the exception of one that would be exactly
horizontal. For the same reason, we may imagine that the plane
represented by each of these lines must have an axis as well as those
of the straits, and consequently, that we cannot refuse to admit an
axis of the excavation. The union of all these axes would give a
curve, concave anteriorly, and whose two extremes would be repre-
sented by the central lines of the superior and inferior straits. By
viewing the axis of the pelvis in this light, the accoucheur will always
have before him the direction of the plane of the anterior face of the
sacrum; of the coccyx, and even of the perineum; and as this is the
plane that directs the head of the foetus, such a mode of regarding
it seems to me more simple, and much more useful for practice,
than the method indicated by certain authors, and which is burthened
with geometrical formulas.*

§. V. Base of the Pelvis.

57. The great circumference or base of the pelvis looks upwards
and forwards. Its plane is parallel to that of the abdominal strait.
It is formed posteriorly by a notch, in the bottom of which is seen
the base of the sacrum, and which is naturally filled by the last ver-

• tebra, the ileo-lumbar ligaments, and the quadratus iumborum mus-
cles; outwardly, by the superior edge of the coxal bone, which affords

* Vide Deventer {Ohserv. Sur le Manuel des Accouchemens, 1734), who
appears to have been the first to indicate that the cavity of the pelvis is not paral-
lel to the axis of the body; Muller {^Collect, de Holler); Roederer (De axis pel-
vis, S(C. Gott. 1751); Smellie (Treatise on the Theory, Sfc. 1771); Levret (Art
des Accouchemens, 1766); Camper (Translation of Mauriceau, 1759); Stein (^rt
d^Accoucher, 1804); Lobstien (Bulletin de la Faculte de Medecine de Paris,
1815); Flamant (These de M. Guillemot, Paris, 1824, No. 164); Baker's Draw-
ing, and especially the learned Memoir of M. Neegele (Das Wiebliche Becken,
Sfc. Carlsruhe, 1825, and in Archives de Medecine, June, 1827).

OF THE PELVIS. 29

attachment to the three broad muscles of the abdomen; that is to
say, to the external oblique by its outer lip, to the transversalis by
its inner lip, and to the internal oblique by its interstice; in front by
the great hypogastric notch which looks from above downwards, and
from without inwards; by the antero-superior spine of the ilium, to
which are attached Poiipart's ligament, the sartorius muscle, and a
part of the iliac muscle and the fascia lata; a small semilunar depres-
sion for the passage of some nervous filaments going to the thigh;
the antero-inferior spine of the ilium, which gives insertion to one
of the roots of the rectus femoris muscle; a second depression for
the passage of the united psoas and iliacus muscles; the linea ileo-
pectinea, sometimes scarcely discernible, and sometimes very salient,
and which receives the attachment of the psoas parvus; a third de-
pression or triangular space filled up by the origin of the pectineus
mi\scle, and corresponding to the crural vessel and nerves; the pecti-
neal crista or postero-superior edge of the pubis, oblique from with-
out inwards, which forms part of the superior strait, and terminates
in the spine of the pubis, to which is attached the outer pillar of the
abdominal ring and the rectus abdominis muscle; lastly, by the upper
edge of the symphysis pubis.

§. VI. Of the Dinieussoiis of* the Peliis, wn-
coniiected T^ith its Axes or straits.

58. The space comprised between the two anterior inferior spines
of the ilia measures eight or nine inches; that between the antero-
superior, from nine to ten; and from ten to eleven between the mid-
dle portions of the cristse of the ilia. The length of the crest of the
ilium, following its course from the postero-superior spine to the
antero-superior tuberosity is eight inches, and six inches in a straight
line. The base of the sacrum is four inches across, and two inches
and a half from front to rear. From the middle of the iliac crista
to the tuberosity of the ischium is seven inches, and the margin of
the excavation cuts this line into two nearly equal portions; the sym-
physis pubis, which is eighteen lines high, is only half an inch thick.
The arch of the same name is from three and a half to four inches
wide at its base where it blends with the bis-ischiatic diameter, and only
ten or twelve lines at its apex; its height is two inches and a half,
and the bony semicircle of which it is composed is folded forwards
and outwards, as if it had been turned in this way by the passage of
some hard and rounded body, while still in a soft and plastic state.

§. VII. Differences of the Pelvis, in respect to
A^es, 8exes and Species.

4

30 OF THE PELVIS.

59. At birth the pelvis is extremely narrow and very much elon-
gated; the curves of the iliac crista are scarcely begun, and the
position of the ilium is almost vertical; the pelvic cavity is conoidal
and not excavated, the sacrum is so much elevated that a horizontal
line passes under the point of the coccyx at the same time that it
rests on the top of the pubis; its transverse are much shorter than
its antero-posterior diameters. The bones are still bordered with
thick layers of temporary cartilages, and the whole is so compres-
sible that the dimensions of the pelvic extremity of the fcetus may
easily accommodate themselves to those of the maternal pelvis dur-
ing labor. After two or three years, some new osseous points are
produced, but they do not always coalesce entirely with the rest of
the coxal bone until the age of fifteen or twenty years. The spine
of the pubis has even been seen to acquire a length of six or eight
lines, and remain movable like an independent piece, which has
caused it to be compared to the marsupial bones of the didelphic
animals.

60. It is therefore not until the fifteenth or eighteenth year thai
the evolution and union of the several osseous points of the pelvis
are entirely completed; so that previously to this age it is not the
height of prudence to expose a woman to become pregnant.

61. In men the pelvis always retains, in respect to its form, the
same characters it had in infancy. All its parts are narrower and
deeper than they are in women; the coccy-pubal diameter is only
three inches and a quarter, the bis-ischiatiy three inches, and the
bis-iliac four and a half. There are only seven or eight inches be-
tween the antero-superior spinous processes, and eight or nine from
the middle of one iliac crista to the opposite one. The arch of the
pubis is straight, not wide in front, and almost triangular; the sym-
physis of these bones is at least two inches long, and the thyroid
foramen approaches also to the form of a triangle; the sacrum is
much less curved, the excavation not so deep, and the superior strait
more inclined, rounder, more like an oval or a circle; the iliac fossae
are more hollow, the great trochanters are not so far apart, the bones
in general thicker, and especially more uneven on their outer sur-
faces; in the male pelvis, every thing bespeaks strength and solidity,
and is so arranged as to render progression easy.

63. In women, on the contrary, the articulations are not so com-
pact, they are thinner; the iliac cristas are wider, and turned out-
wards more than the base of the thorax, which gives a greater breadth
to the hips. The trochanters widely separated, by increasing the
transverse extent of the base of support of the body, also render
walking more difficult, and give to the sex a gait that is altogether

OF THE PELVIS. 31

peculiar; in a word, nature seems here to have sacrificed strength
and ease of motion to the advantage of pregnancy and parturition.

(>3. In the male pelvis the coccyx early unites with the point of
the sacrum, and the three symphyses frequently anchylose in old
age; in women the sacro-coccygeal articulation remains movable
even until the period of decrepitude; the sacro-iliac and pubic articu-
lations are rarely anchylosed, even at the most advanced age.

G4. In thin women, and in those ivho are very tall, the pelvis is
not so wide, and resembles more nearly that of the male, than in
persons of a short and well proportioned stature; which, in the opi-
nion of the common people, causes the former to bear children with
more difficulty than the latter.

G5. The pelvis of animals is notably different from that of the
human species. If Roussel and some other philosophers had paid
attention to this circumstance, they doubtless would not have main-
tained that labor requires no aid, because brutes are delivered of their
young without needing assistance, and almost without pain. In
fact, in most quadrupeds, the pelvis, scarcely curved, in reality pre-
sents only one single axis; the sacrum is almost parallel with the
spine; the straits are only slightly inclined, and the walls of the pel-
vic canal are nearly all of the same length; the coxal bones are so
narrow, straight and elongated, that there is, so to speak, no iliac
fossa; so that delivery is not exposed, in these species, to the same
hazards as in man.

66. It must not be thought, however, that nature changes thus
suddenly, and without gradation, the forms of organs in a series of
creatures; in the monkeys, the pelvis, by differing from that of the
inferior animals, is found already to approximate somewhat to the
character of the human pelvis; it is only by ascending the zoological
scale, that we find it gradually becoming more perfect; its various
shades may be traced in the ourang-outang, the Bosjesmans, who
from their organisation seem to constitute the connecting link be-
tween the monkey and man, in the Ethiopian or Negro, and the
Malay or Japanese races, before coming up to the Caucasian race,
in which it is removed as far as possible from the form observed in
the other mammiferse;* whence w,e have a right to presume that
parturition is so much the more painful, as the species is more per-

* On this subject the reader may consult an interesting work by Dr. Wro-
lick, who had in Holland an opportunity of comparing the pelvis of the Negro,
the Javanese, Bosjesmans, Mustee, and the Hottentot Venus, who was seen by
many persons at Paris, and who was a verita!)le Howzouanasse. Le Bulletin
des Sciences Medicales for February 1827 contains an extract from this memoir,
which is also to be found in the bookstores at Paris.

32 OF THE PELVIS.

feet, and vice versa: a compensation as admirable as it is singular,
and which occasions danger in some measure to multiply and accu-
mulate around an animal in proportion as his intelligence becomes
more perfect.

67. In the kangaroo and other marsupial animals, the pelvis is
prolonged in front by means of the spines of the pubes; which form
two separate bones, and support the pouch, in which the second
gestation of these animals is effected; its narrowness in the cabiai
and the mole would not admit of the escape of the young; but during
gestation the pieces are disjoined, and separate considerably from
each other. In the cetacese there are only some traces of a pelvis;
and in birds, reptiles and fishes, where it serves only in depositing
the egg, we find it gradually decomposed, until it disappears.

§. VIII. ®f tlie recent Pelvis.

68. The soft parts which naturally cover the interior of the pelvis,
produce certain changes in its form and dimensions, the knowledge
of which is indispensable to the accoucheur.

69. The inferior strait, for example, is shut up by a kind of par-
tition, which is called the floor of the pelvis; a partition which di-
minishes the height of the excavation, and seems to be the antagonist
of the diaphragm, or rather of the abdominal muscles, during the
efforts of inspiration, defaecation, and the emission of urine, and dur-
ing parturition.

70. This floor is composed of two fleshy layers: one, superior,
concave above, is formed by the levator ani and ischio-coccygeal
muscles; the other, inferior, concave below, is composed of the
sphincter ani, transversus perinei, ischio-cavernosus, and constrictor
vaginae muscles. There also are found the lower hemorrhoidal and
the internal pudic vessels and nerves, with fat and cellular tissue in
greater or less abundance.

71. Lastly, it is pierced, as it were, on the median line by the
urethra, the vagina, and the termination of the rectum. Its lower
face is lined by an aponeurosis which seems to rise from the great
sciatic ligament, and the inner lip of the pubic arch, and the strength
of which, although very variable, will be found greatest as it is ex-
amined nearest to its origin. A portion of the pelvic aponeurosis
covers its upper region, and I think with Camper and M. Desor-
meaux, that the disposition of the fibrous laminae may exert some in-
fluence on the promptitude or tardiness of labor, particularly in wo-
men who have never had children.

72. The superior strait is more elevated in the recent than in
the dried skeleton, by the entire thickness of the psoas muscles,

OF THE PELVIS. 33

which, with the iliac vessels, form a sort of column, extending from
the sides of the sacro-vertebral angle, to the linea ilio-pectinea, so
as in a considerable degree to contract the bis-iliac diameter, and
also to increase the inclination of the strait very much. Instead of
being elliptical, or representing an oval whose large extremity should
be turned backwards, this strait is now almost circular, or in the
shape of a triangle with the base forwards; the sacro-iliac notches
scarcely exist, and the sacro-vertebral angle is much less prominent
than is commonly supposed, from the idea formed of it upon inspec-
tion of the dried pelvis.

73. From the researches to which I have devoted myself, and
whose results have been already made known, I find that the en-
trance of the pelvis is widest between the ilio-pectineal eminences:
at this point its transversal diameter is four inches and some lines,
while the bis-iliac diameter, properly so called, is only three inches
and a half to four inches. Beneath the promontory and the psoas
muscles, the transverse diameter is really five inches, and the con-
cavity of the sacrum gives quite as great a length to the antero-pos-
terior diameter.

74. The bottom of the excavation is of a lozenge shape, with an-
gles corresponding on the one hand to the ischiatic spines, and on the
other to the middle line of the sacrum and posterior surface of the
pubic symphysis. These four angles indicate the place of union of
the four inclined planes, which thus represent four triangles, tending
to approach each other at their points.

75. The sacral vessels and plexus, as well as the pyramidalis mus-
cle, are found in the posterior triangles: the anterior planes enclose
the internal obturator muscles and part of the levator ani. The
pelvic fascia is exactly applied over all these parts; an abundant
layer of cellular tissue, in which are imbedded the internal iliac ves-
sels, the hypogastric flexus and arteries, a layer which, by the de-
position of fat, sometimes becomes so thick as to diminish the cavity,
and thus render labor more difficult, lines the whole, and is separated
from the viscera by the intermediate peritoneum.

§. IX. Tses of the Pelvis,

76. The diflferent bony pieces which compose the pelvis are sus-
ceptible of only a very slight movement upon each other; notwith-
standing assertions to the contrary, the kind of sliding that takes
place between the sacrum and coxal bones, as well as between the
ossa pubis, in consequence of a fall upon the feet, for example, can-
not in any manner be compared to articular motion of whatsoever
species.

4*

34 OF THE PELVIS.

77. The pelvis is the base of the trunk; it forms a complete ring,
the posterior half of which, says M. Desormeaux, supports the en-
tire weight of the body, while the anterior serves as its abutment, so
that the weight of the trunk and thoracic members, transmitted
through the vertebral column to the sacrum, expends itself first on
the ossa ilia, and next on the pubes, which press against each other
with more or less force.

78. To the lateral parts of this circle are attached the pelvic
members, which in certain postures, in their turn, support the whole
of this burthen, whether conjointly or separately. This use of the
pelvis though interesting to the physiologist, is still more so to the
accoucheur, for it accounts for the vicious and singular forms that
are sometimes assumed by the pelvic cavity, when ossification either
proceeds too slowly or retrogrades. Another use of the pelvis is to
enclose and protect the bladder, the rectum, the uterus, the tubes,
and ovaries. During pregnancy it supports the womb, and main-
tains it in a proper attitude. During labor it gives passage to the
infant, by impressing upon it the most favorable direction, and by
affording a point d'appui to the soft parts of generation.

SECTION 4.
Of the Deformed Pelvis.

79. It would perhaps be more rational not to speak of deformities
of the pelvis, until we should come to treat of difficult labor; but the
custom of examining them immediately after treating of the natural
conformation having prevailed for so long a time, I have not felt my-
self at liberty to deviate from it.

80. The pelvis is deformed whenever it is sufficiently altered,
either in its natural form or dimensions, to render parturition difficult,
dangerous, or impossible. In this view, a pelvis may be mal-formed,
although its conformation be regular, and it may have a mal-confor-
mation, although it be not deformed. Nevertheless, these two con-
ditions being almost always united, it has happened that the books
have commonly confounded them both together. Sacombe, it is true,
desired to see a distinction made between mal-configuration and
mal-conformation; but this distinction, being purely grammatical, has
not been adopted, and scarcely deserves to be combated.

81. The direction of the axes and planes of the pelvis, the di-
mensions of its diameters, and even its form, are doubtless far from
being, in all pelves, exactly similar to those I have mentioned above;
but a few lines more or less, an inclination more or less decided, a

OF THE PELVIS. 3&

slight mal-conformation, not sufficient to prevent a labor from termi-
nating without danger — it may be conceived that these deformities,
properly so called, must be pretty rare.

All deformities of the pelvis may be referred to its excess of am-
plitude, its narrowness, or the faulty direction of its axes.

§. I. Deformity rroni Excess of Amplitude.

82. It would seem at the first glance, that a very large pelvis
ought to be rather advantageous than unfavorable in pregnancy
and labor; but observation and reason prove that this is not always
the case.

During gestation, the womb being less completely supported,
may be upset, either backwards or forwards, as long as its dimen-
sions do not exceed those of the abdominal strait* and it may in-
cline in any direction after the fourth month.

A large pelvis favors the descent of the womb and the prompt
termination of labor, and, consequently, exposes the woman to all
those accidents which occasionally follow rapid delivery; that is to
say, to inertia, inversion of the uterus, and hemorrhage.

I agree, nevertheless, with Madame Lachapelle, that these incon-
veniencies have been exaggerated, that it is generally easy to prevent
them, and that the falling of the child, the premature detachment of
the placenta, and the rupture of the cord have perhaps never been
produced by this cause rather than by some other.

§. II. Deformity from Want of Amplitude.

83. It has been incorrectly maintained that the pelvis cannot be
contracted in one direction without becoming larger in another, and
that, consequently, the circumferences of its straits never vary.
Observation has superabundantly demonstrated that in a consider-
able number of women, the pelvis retains, after the age of puberty,
most of the characters it had in infancy, and that its form approaches
more or less to that of the male; and so far, its absolute capacity-
remains less than it ought to be in the normal state.

Besides, since it is fully admitted that there may be excessive
capacity, I see not why there should be any repugnance to assert
that it may also be too small in all its directions at once; however,
this general and regular narrowness is pretty rare, and I have not yet
learned that it has ever involved the necessity of a serious operation.

84. It may be said, therefore, that relative or partial smallness is
the only kind that involves real danger; it is most commonly met witk

* I have seea a retroversion in a young virgin.— M>

36 OF THE PELVIS.

at the supenor strait, less common at the perineal strait, and met with
still less" frequently in the excavation; it may affect the antero-pos-
terior, transverse or oblique diameters, either taken separately, or
several of them conjointly.

85. According to my researches I find that it most frequently
affects the oblique diameters of the superior strait, and more generally
one than both of them at once; shortening of the transverse dia-
meter is the rarest of all, and has perhaps never been met with
alone.

86. These different deformities give to the entrance of the pelvis
forms as various as they are easy to conceive of. Shortening of the
antero-posterior diameter may depend on too great a saliency of the
sacro-vertebral angle, and then the strait is cordiform, if, at the same
time, the symphysis of the pubis is driven backwards, the pelvis
exhibits the appearance of the figure go, lying in a horizontal posi-
tion. When both of the oblique diameters are affected, the bodies
of the pubis, by approaching the promontory, may, if there be no
derangement of the symphysis, give to the strait the shape of a tri-
angle, a trapezium, or a trefoil, according as the ends of the bis-iliac
diameter shall form angles more or less acute or rounded. These
pelves, which have been denominated trilobaled or trifoliated, also
present this peculiarity, that the three segments are sometimes
equal, while at other times the anterior portion, or the right, or left,
is much smaller than the other two. It may also happen, that the
two acetabula may tend to approach each other, in proportion as
they approximate towards the sacrum; the pubes in this case, bent
at a right angle to the ileo-pectineal eminences, project from one
inch and a half to two inches in front, become parallel to the antero-
posterior diameter, and have between them a space of only a few
lines. The figures of two pelves of this sort may be seen in a dis-
sertation by Weideman. Madame Boivin has given a design of one
that belongs to the same category; but the most extraordinary one
is that belonging to M. Jeuffrion, and a model of which in plaster
was deposited by M. Maygrier in the Museum of the Ecole de Me-
decine. In this pelvis the two pubes proceed directly backwards to
the points where they unite with the ilia, that is, to the extent of a
full inch and a half; near the acetabula, as well as immediately behind
the symphysis, the interval between them is only three lines; all
this portion, therefore, is completely foreign to the circle of the
strait, and the antero-posterior diameter measures in reality only two
inches and a half, instead of five, as would have been supposed had
it been measured externally during life.

87. When only one of the oblique diameters is deformed, it com-

OF THE PELVIS. 37

monly produces a disposition that it is highly important to notice.
If, for example, the contraction occurs on the right side, the left
may present an excess of amplitude. In this case, it is clear, that
if the head presents Avith the occiput turned to the right, the labor
might not come to a conclusion without assistance; whereas if it had
presented to the left, nature would have sufficed for her own relief.
This remark indicates with sufficient clearness, that in order to pro-
cure an easy delivery for a woman with such a conformation, it is
only necessary to turn, and bring down the child in the first or se-
cond position of the feel; so that the occiput may correspond to the
largest side of the strait. It also explains why a woman who has
been spontaneously delivered of her first child, may not perhaps get
through, in a second labor, without symphysiotomy or the Caesarian
section, and vice versa.

88. In 1825, 1 was requested to attend a woman who had been in
labor for two days; the head would not engage; I sought for the
feet, and terminated the labor. In 1826, the same woman was
brought to the hospital de la Faculte, having been four days in labor.
The waters were gone off, and the head was strongly engaged; the
womb, being very closely applied to the foetus, would not allow the
operation of turning; the application of the forceps was attempted by
MM. Desormeaux, Deneux and myself, but nothing could induce
the head to descend. This woman, who became pregnant again in
1827, gave me timely notice when her labor came on; I felt for the
feet, and every thing was promptly and happily terminated. The
different issue of these three labors depended upon this, that in one
case, the back part of the head presenting to the right, where the
pelvis was greatly contracted, could not pass through the strait,
while in the other, by turning the occiput to the left, where the
natural dimensions were preserved, the passage of the head was not
impossible.

89. Unless the sacrum itself be contracted, it is rarely that a les-
sening of the transverse diameter of the abdominal strait is capable
of interfering with the escape of the child. There are almost always
to be found more than four inches between the iliac fossae, and this
kind of deformity only occasions an increase of sacro-pubal diameter,
by giving to the strait the form of an oval, or a greatly elongated
heart.

90. Sometimes the narrowing affects only one side of the pelvis,
as is seen in a specimen in the museum of the Faculte: in that case
the deformity comprises both the greater and lesser basin.

91. All these deformities may be combined in various ways, or
exist singly, and in very different degrees. Charles Bell tells us
that in the pelvis of a woman who had been long affected with osteo-

38 OF THE PELVIS.

malacia, there remained a space of about three lines only in the an-
tero-posterior diameter, and only about half an inch betwixt the iliac
fossae.* Baudelocque cites a case in which there were only nine
lines from the sacrum to the pubis. A contraction almost as great
as the one just mentioned, is observable in a specimen that I saw
in the Museum de I'Ecole de Medecine; however, any body can
understand how many shades there may be between these extreme
contractions and the normal dimensions of the pelvis.

92. The inferior strait is perhaps more frequently enlarged than
contracted; when the base of the sacrum is depressed towards the
pubis, or the pubis driven backwards towards the sacrum, it almost
always is in the direction of a see-saw movement, which separates
the coccyx more or less from the top of the pubic arch. Although
it may be laid down as a general rule that the inferior strait enlarges
while the superior strait contracts, it is, nevertheless, possible that
they may both be narrowed at the same time, and that too in their
corresponding diameters.

93. The approximation of the tuberosities of the ischia towards
each other, too great a straightness, or a triangular form of the pubic
arch, coinciding almost always with a long symphysis pubis, give
birth to what is called barrure, the most coiiiiiion and dangerous of all
the deformities of the perineal strait; for as the foetal head must pass
through the pubic arch, rather than behind the ischia where the soft
parts arrest it, the barrure renders the delivery extremely difficult;
the retroversion of the coccyx does no good in this case, and if the
child is born at last, it is at the expense of an extensive laceration
of the perineum.

94. The coccyx, also, very often becomes almost horizontal, and
may, by rising upwards, more or less affect the coccy-pubal diame-
ter, especially where the base of the sacrum is thrown back. It
also pretty frequently happens that one of the ischia with its ramus
inclines towards the centre of the strait, while the opposite ischium
and the coccyx do not alter their position. In fine, the varieties of
form are here less numerous than in the superior strait; but the de-
grees of contraction should be understood in the same manner.

95. Faults of the excavation coincide almost always with the con-
tractions of one or the other strait, and sometimes with both of them
simultaneously. They depend either on too great, or on an insuffi-
cient curvature of the sacrum.

96. In the former case the bone is bent, as it were, upon its an-

* In a woman who had already had six children, M. Nsegele saw such a de-
formity of the pelvis as to leave only two lines on the left, and six lines on the
right between the fourth lumbar vertebra and the superior brim of the symphysis
pubis.

OF THE PELVIS. 39

terior face, and the sacro-pubal or coccy-pubal diameters are to a
greater or less degree diminished, while the antero-posterior diame-
ter is found to be larger than natural; in other instances, although
very greatly curved, it is not the less removed to a great distance
from the pubis, whether at its base or apex.

In the second case, the anterior face of the sacrum being actually
plane, or even slightly convex, as may be seen in a specimen belong-
ing to the collection of the Ecole, the pelvic cavity, instead of dilating
betwixt its straits, becomes smaller, or on the other hand, it enlarges
regularly, from the promontory to the pomt of the coccyx; according
as the base of the sacrum seems to have see-sawed forwards or
backwards.

97. When the sacrum is too concave, and when both the straits
are narrowed, if the head, by means of great efforts, comes down to
the excavation, it stops there, becomes locked, can neither advance
nor retreat, and renders the labor so dangerous that even the Cae-
sarian operation itself might be insufficient for its termination. If
it be too straight, and the lower strait is too much contracted, the
head will descend at first very promptly, but as it passes through a
conical canal, it will soon be arrested, and with difficulty clear the
apex.

98. Whenever narrowness of one of the straits coincides with ex-
cessive amplitude of the other, the progress of the labor is neces-
sarily perplexed. Is the abdominal strait faulty through insufficient
amplitude? the head will long remain arrested at it, but will pass
through at last; then, meeting almost no resistance, it will traverse
the apex of the pelvis with great celerity, at a moment perhaps when
the accoucheur, judging of the duration of the labor by the time
that has been already occupied, is informing the assistants that seve-
ral hours must elapse before it can be concluded. Has the inferior
strait, on the contrary, lost its dimensions? the foetus engages with
extreme quickness, and the practitioner, who does not suspect the
real condition of the pelvis, announces that the woman will speedily
be relieved, whilst perhaps the very best planned succors are becom-
ing indispensably necessary.

99. If the symphysis pubis forms a crest projecting backwards a
few lines, as I have seen it do in two instances, it does not prevent
the delivery from being accomplished; but during the passage of the
head it may contuse the bladder and the uterus, and favor the
laceration of these organs. Sometimes one of the acetabula projects
into the excavation, or it may be one of the sciatic spines, turned
very much inwards, that deforms the cavity, as was observed both
by Levret and Madame Lachapelle; exostoses of every sort and

40 OF THE PELVIS.

shape have been met with; scirrhus, fibrous tumors, &c. may also
be developed so as to interfere with parturition; but it must be
acknowledged that a majority of the faults of the excavation depend
upon too great or too small a curve of the sacrum.

§. III. Faulty dii'ection of the Axes.

100. Nearly all these faults of conformation change, to a greater
or less degree, the planes and axes of the pelvis. When the sacro-
vertebral angle projects too much towards the pubis, the hoUowness
of the lumbar region being necessarily augmented, it happens that
the angle between the spine and sacrum, instead of being one hun-
dred and thirty-five degrees, may yield only one hundred and thirty,
or even one hundred and twenty degrees; the axis of the superior
strait, therefore, inclines forwards, and approaches the horizontal
line; if the coccyx and the point of the sacrum, restrained by the
sacro-sciatic ligaments, are not drawn away by this see-saw, the
plane of the inferior strait is depressed to the level, or below the
level of the horizontal line, and may even become parallel to the
plane of the superior strait, which in some measure justifies the
opinion of Messrs Sosmmering, Carus, Naegele, &c., who think
that even in the natural strait the perineal strait inclines downwards
and not upwards. But this disposition, far from bringing the axis
of the apex of the pelvis towards the perpendicular, or, from inclin-
ing it backwards, as at the first glance might be supposed, carries it,
on the contrary, considerably in front, inasmuch as the anterior face
of the coccyx must determine its direction. When the pubis rises
and the promontory becomes obtuse, the axis of the superior strait
approaches towards the vertical line, and in some cases becomes
parallel to the axis of the trunk of the body; if, in this case, the pos-
terior wall of the excavation fails in being sufficiently concave, the
two pelvic axes may become parallel, although the plane of the in-
ferior strait be much inclined forward. This conformation, which
especially favors the laceration of the perineum, gives rise, during
labor, to difficulties that have not been sufficiently dwelt on in our
classical works, and to which M. Lobstein endeavored to direct the
attention of the profession in 1817.

§. IV. Causes of deformities of the Pelvis.

101. In order correctly to understand the causes of faulty con-
formations of the pelvis, it is right to study them as they act in in-
fancy, during puberty, or at the adult age. Until the sixth or seventh
year, they are very well explained by a reference to rachitis, which
is almost the only cause of them. The bones that are chiefly affected

OF THE PELVIS. 41

in this disease, being constantly pressed between two opposing forces
must give way in that direction in which the strongest force operates,
or towards the point where tliere is the least resistance.

102. Thus, admitting that the softening of the bones is every
where equally great, that the child is standing on its feet, and rests
with the same pressure on both legs, it is evident that the base of
the sacrum will be depressed towards the pubis, and the cotyloid
cavities will be pushed upwards towards the promontory. Hence,
there will be shortening of the sacro-pubic, as well as of the oblique
diameters: if the child stands on its feet, but leans more on one foot
than on the other, the oblique diameter of one side only will be
contracted; if he remains seated, the hollow of the sacrum will be-
come deeper, while the antero-posterior diameters of the two straits
will be lessened; if he be habitually laid upon his back, the curve
of the sacrum, instead of augmenting, will disappear, as v/ell as the
pelvi-vertebral angle, and the coccy-pubic diameter will generally
lose somewhat of its dimensions; a lateral posture will influence the
transverse diameters, &c.

103. Although the weight of the body then will account for most
of the vicious forms of the pelvis, it must, nevertheless, be admitted
that their production is in certain cases singularly favored by the
active power of the muscles that surround the coxo-femoral articu-
lation; so much the more, as the bones, most commonly softened
only at some particular points, retain every where else all the solidity
that is desirable.

104. After the first periods of childhood, the deformities of the
pelvis are almost always the result of a disease, as that malacosteon,
either general or partial, which is so common in England, of osteo-
malacia, of irregular action of the muscles, and of bad habits in
respect to attitude. It is thus that young girls, who, for the purpose
of increasing the prominence of their hips and the depth of the
lumbar hollow, keep the pelvis and head thrown strongly backwards
while they project the abdomen and breast as far forwards as possi-
ble, never think that for the purpose of obtaining some elegance of
form, they run the risk of being never able to become mothers, with-
out exposure to the greatest danger.

105. In a diseased hip joint the head of the femur has been seen
to push the bottom of the acetabulum into the pelvis, and even to
pierce through the acetabulum. Madame Lachapelle gives the case
of a woman who was affected with a spontaneous luxation of the
thigh bone, and in which the false acetabulum projected so far into
the pelvic excavation as to interfere with the labor; the amputation
of a thigh, but not of a leg, in an adult woman, and a fortiori in a
5

42 OF THE PELVIS.

young girl is also capable of vitiating the pelvis, and in the following
manner: — The artificial limb, being obliged to bear upon the ischium,
the acetabulum of the sound side has alone to support the weight of
the body. Now the laws of mechanics teach us that in this state of
things, the oblique diameter corresponding to the natural limb may
become contracted so much, as to render delivery dangerous, as has
been proved by the observations made by D'Herbiniaux and Madame
Lachapelle.

106. Fractures and luxations, unequally consolidated, caries,
syphilis, &c. have also sometimes given rise to obstacles to partu-
rition. To recapitulate, it may be said that rickets almost always
occasions deformed pelvis in young children, for at that age the
members, of which the coxal bones constitute a part, generally par-
ticipate in the diseased condition; while later in life, as for example,
at the approach of puberty, as osteo-malacia almost solely affects
the spinal column, the curves of the spine may be carried to the
greatest extent without the pelvis, in reality, suffering any change.
For further details on this subject the reader may consult, with ad-
vantage, the works of M. Portal, of Choulant, Shaw, Barafield, of
MM. La Chaise, Pravaz, &c., on spinal deformity and the diseases
of the spine and pelvis.

§. V. Of the mensiu'ation of the Pelvis.

107. When called upon to ascertain the state of a woman's pel-
vis, we ought to begin by interrogating the parents, or persons about
her, as to the manner in which her childhood had been passed;
whether her first steps were slow and difficult, and whether she
remained for a long time weakly; when we learn that the joints had
been large and as if swelled; that she had been ricketty or phthisical,
we may infer that rachitis had existed, and that her pelvis is pro-
bably deformed. We should next examine very attentively the
other parts of her body, and if there be any preternatural curve in
the spine, if the knees are large and turned inwards, if the lower
jaw projects too much forwards, if the teeth are bluish and ex-
hibit transverse strise, the same inference may be drawn; while we
may suppose the contrary if none of the above circumstances should
exist.

108. The theory oihomologues, a theory which, as is well known,
teaches that, in animals, not only is the right side an exact repeti-
tion of the left, but also that the lower half of the trunk repre-
sents the superior half; that the anterior half encloses the same
elements as the posterior, has very naturally given rise to an idea,
that the pelvis ought only to be a repetition of the head. In Ger-

OF THE PELVIS. 43

many, therefore, where this doctrine has numerous partisans, there
appeared some years since a work in which Dr. Weber endeavored
to demonstrate that the head and the pelvis are subject to the same
laws of evolution; that the good or bad conformation of one of these
parts always corresponds exactly with a similar state of the other;
that the narrowness and depth of the male pelvis, for example, are
in exact accordance with the form of the male head, whose vertical
and antero-posterior diameters, in general, exceed the transversal,
while the opposite condition is observable in the female, &c.

109. Consequendy, M. Weber desires that the inspection of the
head should give us an exact idea of the condition of the pelvis. His
method is very simple: the occipito-frontal, bi-parietal, and fronto-
mastoid diameters of the head, exactly represent the sacro-pubic,
bis-iliac and oblique diameters of the pelvis.

The superior strait is proportioned to the cranium, and the face
is proportioned to the inferior strait.

Although Mr. Weber cites cases in support of his system, I am
obliged, nevertheless, to say that I have seen the very best shaped
pelvis coincide with the most deformed crania, and vice versa;
however, it has appeared to me as it did to Madame Lachapelle,
that the more the upper part of the face projects, the larger is the
pelvis.

110. These preliminary researches being completed, we pass on
to the examination of the pelvis itself, with all possible decency and
circumspection. If the woman's gait is easy, free and unconstrained;
if the hips are on the same level, wider than the base of the thorax,
and well rounded, the great trochanters properly separated from
each other; if she is not hollow backed; if the sacrum has neither too
much nor too little convexity; if the symphysis of the pubis is nei-
ther sunk in nor protuberant, nor too long, there will be some good
reason for reporting a good conformation; by placing the fingers be-
tween the labia and the root of the thighs we can ascertain whether
or not the pubic arch is narrow, whether it forms a sufficiently large
arch of a circle, and whether the ischia are too near each other.

111. It is not necessary, for the purpose of correctly appreciating
all these circumstances, to uncover the woman, or to make her lie
down; if there be any fear of alarming her modesty, the examina-
tion may be made through her chemise. When all the characters
of a good conformation are met with, it is common to dispense with
any farther examination; but if some of those characters be want-
ing, we should endeavor to determine the kind of deformity that
does exist: a hollow back, with a very decided saliency of the pubis,
indicates an extreme degree of inclination, and a trilobated form of

44 OF THE PELVIS.

the superior strait. If the symphysis be at the same time depressed,
we may affirm that the sacro-pubic diameter is shortened, and that
the strait is bilobated, or of the figure of an oo . Hips uneven or
too much elevated, and depressed external iliac fossae disclose a
fault of the bis-iliac diameter. The approximation of the ischia,
the convexity of the sacrum, and the forward inclination of the coc-
cyx need only to be hinted at to render it easy even to the least
skilful person to recognise them in an instant.

1 12. As it is essential to the happiness of families that we should
arrive at mathematical results, and as the employment of the hand
yields them only in a vague and approximative manner, the ac-
coucheurs have invented an infinity of instruments for the purpose
of exactly measuring the pelvis, whether externally or internally;
these instruments are called pelvimeters or mecometers.

113. Only two of them can be applied externally; one, the {com,'
pas cVepaisseur) calliper of Baudelocque, which is almost exclu-
sively employed, on account of its simplicity; and the other, the
meconieter of Chaussier, which is scarcely used except at the Mater-
nite of Paris. The calliper serves to measure, 1. The sacro-pubic
diameter, by placing one of the buttons in front of the symphysis
pubis, and the other on the first spinous process of the sacrum; 2.
The oblique diameters, by placing one of the ends of the calliper
on the external surface of the great trochanter, and the other on the
projecting portion of the opposite sacro-iliac junction. In the first
situation, the cursor must measure seven inches; so that by deduct-
ing two inches and a half for the sacrum and half an inch for the
pubis, there may remain four inches for the antero-posterior diameter
of the superior strait. For the oblique diameters, it should measure
nine inches, for we must deduct two inches and three quarters for
the trochanter, the neck of the femur and the acetabulum, and one
inch and three-quarters for the posterior symphysis.

114. Baudelocque has asserted that the thickness of the bones
rarely varies more than one or two lines in the antero-posterior dia-
meter, and that the results obtained by the calliper may be relied on.
Madame Lachapelle, on the contrary, regards this mode of proceed-
ing as very deceptive, and thinks the thickness of the sacrum may
vary from four to five lines. Madame Boivin goes still farther, for
she says the thickness indicated by Baudelocque varies from four to
twelve lines. One thing certain is, that leanness or fatness does not
diminish or increase in a sensible degree the thickness of the soft
parts, on the points to be touched by the instrument, and that the
differences of thickness of the sacrum and pubis mentioned by Mes-
dames Lachapelle and Boivin, are at least extremely rare.

OF THE PELVIS. 45

115. As to the measurement of the oblique diameters, the length
of the neck of the femur has appeared to vary too much to permit
practitioners to repose much confidence in it ; but I think, on this
subject there has been a very general misapprehension ; for among
a pretty considerable number of well formed pelves I have never
found in this direction a difference exceeding a quarter of an inch,
more or less, than the one indicated.

As the cristse of the ilia may be considerably raised or much de-
pressed, without the straits having undergone any modification, we
should be exposed to too many and too serious mistakes, were we
to take half the distance between them as the measure of the bis-
iliac diameter. This last is surrounded by too many muscles, and
moreover is of too little importance for us to measure it in any
other way than with the hand.

116. The fingers suffice for ascertaining the state of the inferior
strait. According to the authors, the woman should be seated upon
the edge of a chair, but she may also be examined while standing
up. The ball of the fore finger is placed upon the point of the coc-
cyx, and the point of the thumb on the edge of the snb-pubic liga-
ment, after which the two fingers, being held at the same distance
apart, are referred to a graduated scale to ascertain the degree of
separation. While the extremity of the index is pressed against the
point of the coccyx, the radial edge of the finger, instead of the thumb,
may be pressed against the top of the pubic arch ; but there is more
danger in this method of painfully pressing against the external sexual
organs, if their sensibility happens to be excited. To measure the
ischiatic diameter, we must press the points of two fingers against the
lips of the ischia, at the spot where the great sacro-sciatic ligament is
inserted, taking care to push the fat aside by gentle pressure.

117. Although it is true that this exterior exploration does not
enable us to pronounce with confidence as to the nature and degree
of deformity of the pelvis, it is nevertheless the only one we can have
recourse to in virgins ; in other women it is permissible to attempt
the internal mensuration, which it has been proposed to perform in
a great many different ways.

118. Coutouly was the first to propose measuring the interior
of the pelvis by means of a pelvimeter, which bears his name. It
is impossible to convey a clearer idea of such an instrument, fre-
quently modified by its inventor, than by comparing it to the shoe-
maker's rule employed in measuring the length of the foot. It is
introduced, closed, into the vagina, after which it is opened, and one
of its branches rests against the pubis, while the other is applied to
the sacro-vertebral projection. Now, the movable or sliding branch

5*

46 OF THE PELVIS.

being graduated externally, it is easy to estimate the distance that
separates the two vertical pieces. In this manner we can measure
the sacro-pubic diameter with the most rigid exactness on the dried
pelvis, but in living women, Coutouly's instrument is rarely applicable,
except in the case of pregnancy ; it is not so, however, in a woman
in labor, if the summit of the head be engaged in the strait; besides,
when it can be made use of, its introduction must always be very
painful, and its results will be most generally fallacious. This pel-
vimeter therefore deserves the neglect into which it has sunk.
Many accoucheurs have endeavored to find a substitute, but as
those they have proposed have not fulfilled the ends intended by their
authors, any better than Coutouly's, they have been quite as little
employed as his. The thimble with which Asdrubali armed the
fore finger, in order to increase its length ; the sort of foot rule,
in the shape of a compass or pincers, with branches of unequal
lengths, which can be opened in the pelvis; those made with the arms
straight, hollow, or full and graduated, according to the plans of
Stein, Creve, and Aitken, aflTord us results not at all more precise
than the others.

119. The internal mensuration may be well effected by the fingers
or hand. When the woman is not in labor, or when the head is not
as yet engaged, the point of the fore finger may readily be carried
to the promontory : the root of the finger is then raised up against
the arch of the pubis, and the place where it touches is marked with
a finger nail of the other hand. Nothing can be easier after this
than to ascertain the distance from pubis to sacrum. Unlike other
pelvimeters, the finger is a feeling instrument, the point of which
will not slip away from the promontory of the sacrum without the
operator knowing it ; thus one of the most frequent causes of error
is at once obviated. It is true, that as the line represented by the
finger falls below, and not on a level with the top of the symphysis,
as it ought to do, we commonly find the length greater than it ought
in reality to be, but by subtracting four or five lines on account
of this obliquity, we shall have for tlie remainder pretty exactly the
measurement of the space between the sacro-vertebral angle, and
the top of the symphysis pubis. There are two circumstances, how-
ever, that may easily lead us into error. The first is where the
upper edge of the symphysis seems to have fallen backwards ; and
the second, where the contrary obtains. Here indeed the antero-
posterior diameter, of the superior strait, might appear very great,
although in fact it were very small, and reciprocally. But the appli-
cation of the calliper externally would readily correct the mistake
likely to arise from such a disposition of the bones.

. OF THE PELVIS. 4!r

120. During labor, we can, if needful, pass the whole hand into the
vagina; the thumb and forefinger are then separated, so as to place
one on the sacro-vertebral angle, and the other behind the pubis;
the hand is withdrawn in that position, and we can, with the assis-
tance of a foot-rule, determine, within one or two lines, the dimen-
sions of the sacro-pubic diameter, without having recourse to the
loop of thread proposed by Storck, the armed hand of Koep, or any
other of the thousand inventions for that purpose. Instead of using
the thumb and index finger, I have sometimes availed myself of the
index and medius fingers passed high up into the vagina; after hav-
ing separated them as far as possible, and placed the points of them
on each extremity of the diameter, which it is designed to measure,
two fingers of the other hand are to be placed between their roots
in order to keep them apart, and then they should be withdrawn
from the female organs.

121. With the finger we have the advantage of appreciating all
sorts of deformities of the pelvis, whatever be their seat, their nature
or degree, the straightness of the sacrum, as well as excess of its
curve; also, exostoses and tumors of whatsoever nature, the trans-
verse as well as the antero-posterior diameters. By pressing with
a certain degree of force against the point of the coccyx it is pos-
sible even to learn how much may be gained in the coccy-pubio
diameter, by the retreat of the coccyx backwards. Those who have
objected that the finger is not always long enough to reach the angle
of the sacrum, have forgotten that a pelvis, in which the forefinger
cannot reach to the promontory, is thereby proved to be so spa-
cious, that the accoucheur need not trouble himself to examine it
any farther. Moreover, it cannot be denied that, although it is never
very diflicult to discriminate between a deformed pelvis and one that
is not so, it is nevertheless impossible, in certain cases, to determine
the exact nature and degree of each particular deviation; it is there-
fore no more than right to give the praise they deserve to the efTorts
lately made by Madame Boivin to obtain more precise results: the
instrument which she has invented, and which she has named intro-
pelvimeter, although founded on the same principles as Coutouly's,
differs from it, nevertheless, very considerably. As its branches are
separately introduced, one into the rectum, and the other into the
vagina, and as the curve of the rectal branch is very deep, it may be
used in the virgin as well as in the pregnant woman, and at any
stage of labor; it may even be employed in ascertaining the oblique
and transverse diameters, and by altering its vaginal branch it could
easily be converted into a calliper. Nevertheless, I doubt we shall

48 OF THE PELVIS.

not be able to obtain from this apparatus such exact results as its in-
ventor seems to hope for.

123. However multiplied the means of measuring the pelvis, it
must have been seen from the foregoing, that even the most skilful
accoucheur will never be able to attain to the mathematical precision
that is desirable; but is this a reason for rejecting them entirely, and
asserting with Puzos that the operation itself is of no use ? This
author, otherwise so correct, has assuredly gone too far, in saying that
a young woman ought to be forbidden to marry, if she had ever been
affected with rickets, or if she have a spinal deviation, and humanity
and justice both appeal from his judgment. How many ill-shaped
women bring large robust children with the greatest ease into the
world ? Another serious inconvenience might attach to such a
general proscription : many women would pay no respect to the
prohibition, and not be slow in convincing themselves that they had
been frightened with dangers wholly chimerical. Hence, what al-
most always occurs when the effect does not follow the threat, those
who run some risks upon being married, and those who run no risks
at all would equally turn a deaf ear to advice. On the other hand,
it would be absurd to deny the importance of pelvimetry, in labor,
when a decision must be made between embryotomy, and the dan-
gerous operations that may be performed upon the mother. Finally,
by citing, for the purpose of proving the uselessness of pelvic men-
suration, the cases of women who were not afraid to become preg-
nant again after having once undergone the Caesarian operation,
Puzos seems to me to have misunderstood their true position: is it
really the attraction of pleasure that always induces them to yield
to the brutal husband that the law has given to them: is it fair to
compare a woman who fears above all things to lose the affections
of a man to whom she is united for life, to a young girl, who, free
from all entanglements, ought to think first, and above all, of her
own safety ?

ARTICLE 11.

Of the Sexual Organs^

123. In women, as in men, the organs of reproduction are partly
enclosed within the pelvis, and partly exposed on the exterior sur-
face of that cavity,

OF THE SEXUAL ORGANS. 49

SECTION I.
Of the External Parts of Generation.

124. Under the title of external genital organs are generally com-
prehended the mons Veneris, the vulva, and the perineum.

Mere appendages of the internal organs, these parts perform
only a secondary office in the great generative function; but during
the expulsion of the ovum, they undergo changes and are exposed
to dangers which render the exact knowledge of them very useful to
the physician-accoucheur.

§. I. Of the Mons Teneris.

125. The Mount of Venus {the sur-pubal eminence, pubes) is a
sort of relief formed by the soft parts that cover the front of the
pubis; it is principally composed of fat, fibrous filaments, and cel-
lular tissue. In fat women it is sometimes separated from the
belly by a transverse groove of considerable depth; the degree of
its projection also varies on the same account, but much more on
account of the projection of the bones which support it being differ-
ent in different subjects.

126. The skin that covers it is very thick, elastic, not very ex-
tensible, and covered with hair in the adult; it contains a great
number of sebaceous follicles, and the whole represents a sort of
cushion, the uses of which are, according to many authors, connect-
ed with the business of copulation. The composition of the mons
Veneris very fully explains the violent pain which accompanies phleg-
monous inflammation of the part, and enables us to comprehend
why abscesses formed within it should be promptly opened.

§. II. Of the liahia (labia pudendi externa).

127. A sort of cutaneous folds which seem to result out of the
bifurcation of the lower part of the mons Veneris, the two labia sepa-
rate farther and farther from each other, for about half their length,
and then approach to be united again about an inch in front of the
anus, exhibiting two commissures, one superior or pubic, the other
inferior or perineal. Their external surface, formed by the skin of
the thighs, is, like the pubes, covered with hair, at puberty. Their
internal surface is smooth, glabrous, and of a rose color; a con-
siderable number of sebaceous or mucous follicles are observed
upon it. The accoucheur ought to be aware that the matter furnish-
ed by these follicles may become acrid, and irritating to such a de-

50 OF THE SEXUAL ORGANS.

gree, as to give rise to a discharge that has often been mistaken for
blennorrhagia, particularly in uncleanly women.

In young girls, the thickness of the labia is greater above than
below. In women who have borne children the contrary com-
monly obtains. Moreover, before the age of puberty, they are very
close together, and pretty firm. After marriage they separate
from each other, become flaccid, bluish, and lose the regularity of
their form.

Composed, like the mons Veneris, of filamentous cellular tissue and
fat, they are also, like it, subject to phlegmonous inflammation, attend-
ed with violent pain, and which ought to be opened early, taking
care to plunge the instrument to a considerable depth if it is de-
sired to avoid relapses and sinuses.

128. As the tissue of which they are composed is much looser
than that of the mons, and they arc exposed to more friction, they
are subject not only to purulent collections, but also to bloody extra-
vasations, serous effusions, &c., which may acquire a considerable
size.

129. The great labia may also become the seats of hernia, and
other tumors, which should not be confounded with those above
mentioned. The slit which they circumscribe, and which is placed
in the direction of the coccy-pubic diameter, is called the vulva,
while the whole of the external genitals is specially designated by
the word pudendum. This slit contains several parts, situated in
a direction from above downwards : — these are the lesser labia and
the clitoris, the vestibule, the meatus urinarius, the vulvar orifice of
the vagina, the hymen, the fossa navicularis, and the fourchette.

§. III. Of the liCSSer I^abia. {labia pudendi interna).

130. Thus denominated because they are, in fact, much smaller
than the preceding, known also as the nymphse; the lesser labia have
been compared to a young cock's comb. They arise, superiorly,
by two branches, which are continuous with the prepuce of the
clitoris: they then descend, divergingly, on the inner face of the
greater labia, and terminate insensibly about the middle of these
latter, opposite to the orifice of the vagina. They are of a firm
consistence, and a reddish color; they are formed of a tegumentary
fold of a mucous character, very delicate, and very sensible, and also
of an erectile or spongy tissue, very closely resembling that of the
corpus cavernosum in men.

131. At birth the nymphae generally protrude beyond the level
of the greater labia; in young virgins, on the contrary, the labia al-
most entirely conceal the nymphae; and in adult women who have

OF THE SEXUAL ORGANS. 51

had children, the lesser labia again become very salient, while they
lose their firmness and their rosy hue.

132. In this respect numerous varieties are to be observed; some-
times, indeed, their appearance undergoes no alteration ; at other
times they acquire a considerable length, either as regards their
whole extent, or only near their posterior extremity. This hyper-
trophy, which is in some cases natural, but most commonly acci-
dental, is sometimes carried to such an extent as to interfere with
coition ; so that it was formerly not uncommon to amputate the
nymphae. In some countries they are, naturally, much longer than
in our European regions. In Persia and Turkey, for instance, if
we may beheve the reports of travellers, it is frequently found
necessary to excise them.

133. From the time of Kolbe all the naturalists have spoken of a
peculiar fold, known as the Hottentot apron, and on which Tackard,
Sparman, Banks, Peron, Le Vaillant, Lesueur, and several others
have emitted very different notions. Evidently depending on the
prolongation of the lesser labia, as was seen by Ten Rhyne, it is
not among the civilised Hottentots that it is met with, but among the
savage tribes of the environs of the cape, discovered by the Dutch,
who call them Bosgismans or Bochinmans, that is to say Bushmen.
On this subject no further doubt can be entertained, since an indi-
vidual of this species came to be exhibited at Paris, under the title
of the Hottentot Venus, In fact, the drawing of it furnished by
M. Flourens, and the descriptions pubHshed by MM. Cuvier and
Virey, show that, instead of being three or four lines, the nymphae
of this woman were several inches in length. It is true, there is a
wide difference between these dimensions and those attributed by
certain travellers to the Hottentot apron ; but it is easy to conceive
of an extent of six or eight in an organ which has been seen actually
to measure three inches, provided if, by means resorted to in that
country, they are subjected to continual tractions, always increasing
in force, from childhood up to adult age.

134. The uses of the nymphas are little known ; the ancients be-
lieved that they served to direct the course of the urine, whence
their name of nymphae. Smellie, and all the writers who have fol-
lowed him, pretend that they unfold, or disappear in labor so as
to favor the enlargement of the vulva; but this assertion is wholly
false ; it is said, lastly, that being endowed with an exquisite degree
of sensibility, their use is to augment the pleasure of the veneral act.

§. IV. Of* the Clitoris. ( coles feminarum).

135. The clitoris is a tubercle which authors have compared to the

53 OF THE SEXUAL ORGANS.

uvula, and which represents, on a small scale, the penis of the male.
In the clitoris are distinguishable a loose extremity, round, and of
an acorn shape, and a body which is attached by two roots to the
ischio-pubic rami ; but it has not a canal as is the case in the male
yard. A fold of skin covers it, serves as a prepuce, and then
proceeds to disappear in each of the lesser labia, of which it seems
to be the root.

138. During the first months of uterine life, the clitoris is as long
and large as the penis ; at birth its dimensions are still considerable.
But from that time it ceases to grow, if it does not even diminish,
so that at the age of puberty it is in general not more than four or
five lines in length. There are, however, some women in whom it
obtains a much greater development. It has been, on some occa-
sions, seen to reach the length of from one to five inches ; in such
cases it scarcely diflfers from its analogue in the other sex.

137. Such a disposition as the above, is further remarkable, inas-
much as it coincides with certain characteristics which have even
led to the belief, that individuals of such conformation belonged to
neither sex peculiarly ; that is to say, these women generally have
very small breasts, hard features, a beard, and a temper which leads
them to prefer labor and occupations foreign to the pursuits of the
sex. They are stout women, and are fond of procuring illicit en-
joyments with persons of their own sex. In a word, such are the
individuals who have generally given rise to the questions relative to
hermaphrodism.

138. Such is the intimate structure of the clitoris, that during
coition, the blood accumulates within, swells it, and occasions its
erection ; the delicate membrane that invests it, being of the same
nature as that of the nymphae, and very sensitive, it has in conse-
quence been concluded, that with nymphae it is the chief seat of vene-
real pleasure. The clitoris rarely exhibits any morbid affections; but
as its size, when excessive, may incommode during copulation, and
as its uses are not very essential, it has in several instances been sub-
jected to the operation of amputation.

§. V. Of the Vestibule.

139. Circumscribed by the clitoris, the inner face of the nym-
phae, and the meatus urinarius, the vestibule is a small triangular
space, depressed, corresponding to the upper part of the arch of the
pubis, through which Celsus and M. Lisfranc have recommended
that the bladder should be opened, for the purpose of extracting the
stone in females, and which performs no special function relative to
generation.

OF THE SEXUAL ORGANS. 53?

§. VI. Of the Irethra.

140. Beneath the vestibule is perceived the orifice of the urethra;
this opening is separated from the vagina only by a kind of tubercle,
which projects more or less in different persons, and which termi-
nates its anterior middle column. On account of this tubercle, no-
thing is so easy as to sound a vs^oman's bladder without uncovering
her, for after a very little practice, the finger suffices for distinguish-
ing it and guiding the sound. In women the urethra is large, coni-
cal, about twelve or fifteen lines long, scarcely curved; it has nei-
ther prostate gland nor bulb; its lower wall may be said to be con-
founded with the anterior wall of the vagina, and would be rubbed,
contused, and lacerated much more frequently than it is, were it
not that it is situated at the very top of the pubic arch, in a free
space, which is so narrow that neither the occiput nor forehead of
the child can reach it to lodge in it. Its natural direction, short-
ness, extensibility, and width, readily explain the ease with which
the catheter is introduced, the rare occurrence of urinary calculi in
women, and the fact that even fecundation has sometimes taken
place where the womb opened only into the bladder.

141. The orifice of the vagina, irregular, and of greater or less
size in women who have borne children, more rounded, but of
equally variable dimensions in married v^omen who have never yet
become mothers, is in virgins contracted by the hymen.

§. VII. Of the Hymen {valvula vaginalis).

142. Admitted by some and rejected by others during the seven-
teenth and eighteenth centuries, the hymen, and not the membrane
of the hymen, as it is denominated in several French works, is a fold
which always exists, provided it have not been destroyed, in young
girls. In shape resembling a half moon with its concave and sharp
edge turned forwards, its extremities are sometimes so much pro-
longed as to unite under the urethra, and thus form a circular valve,
whose breadth, however, diminishes as it approaches the meatus
urinarius : being on its convex edge continuous with the mucous
membrane of the vagina and vulva, the hymen may contract the en-
trance of the vulvo-uterine canal in very various degrees, and even
close it entirely. Its circle always contracts from behind forwards.
I have sometimes detected muscular fibres in it, which were arranged
in a decussating manner as in the womb; in such cases, it was thick,
strong, elastic, and very much developed; at other times I have seen
it thin, transparent as a pellicle, and very easily broken; in general
it is thicker at birth than at any other period of life. In new born

6

54 OF THE SEXUAL ORGANS.

infants it often presents the shape, the rosy tint, and softness of the
lesser labia.

143. Regarded as the seal of virginity by the vulgar, and for a
long time so considered by medico-jurists and magistrates, the hymen
has on more than one occasion been the cause of an iniquitous de-
cision by the tribunals, either in condemning an innocent woman, or,
on the contrary, in absolving one who was scandalously guilty. But
at present it is universally admitted that a thousand causes foreign
to the act of coition may destroy it, and that copulation itself does
not always occasion its rupture. If this membrane be thin, delicate
and broad, a sudden or extensive movement of the limbs, excoria-
tions, the appearance of the menses, &c., may cause it to disappear.
If it be thick, muscular, elastic, but narrow, the sexual union would
not be prevented, and the hymen might remain whole until labor
should take place, as is proved by the cases mentioned by Pare,
Naegele and others; but I believe it incapable in any case of furnish-
ing a real obstacle to the escape of the child.* If the hymen be broad
and resisting, while at the same time it either partially or completely
closes the canal of the vagina, it might form an insurmountable ob-
stacle to the flow of the menses outwards, and by retaining the
blood in the vagina or womb, give rise to symptoms that would be
more or less important, according to circumstances. Smellie, Den-
man, (fee, report the cases of women in whom this state of things
produced all the general symptoms of pregnancy, and who reco-
vered their ordinary health as soon as an incision into the hymen
had allowed of the escape of the blood with which the parts vrere
filled. I have been consulted on account of one young lady twenty-
two years of age, whose hymen had prevented the consummation of
marriage. I met with another specimen, in the corpse of a woman
about forty years of age, who had cohabited with her husband for a
long time, but without having any children. As a general rule,
however, the hymen is ruptured at the first sexual approach, which
in consequence of this laceration is accompanied with more or less
pain, and a slight discharge of blood. When once torn, its shreds

* I consider the hymen to be a fold or duplicature of the mucous lining of the
orijicium vagina. It is in all respects analogous to the valvulae conniventes of
the bowel. In many individuals it is ruptured by the sexual congress; in others
it escapes uninjured, and is not unfrequently met with in the examinations made
during the conduct of labors. Like the other tissues with which it is con-
nected, it is tractile and distensible to such a degree, that it is even possible for
a child to be born without destroying it, as I have ascertained in my attendance
on persons confined with a second parturition. I make this statement with
confidence, as I am sure it will be confirmed by persons much engaged in ob-
stetric practice, who will take the trouble to make the inquiry. — M.

OF THE SEXUAL ORGANS. 55

contract, and give rise to one or more tubercles, known by the name
of myrtiform caruncles.

§. VIII. Of the jHyrtiform or Vaginal Carun-
cles.

144. There are still a great many physiologists who think that the
myrtiform caruncles are special organs, and independent of the hy-
men; they found their opinion on the circumstance that they are
sometimes found even where the hymen is whole, and that their
number and situation do not appear to be accounted for on any other
hypothesis. The opposite opinion tends, it is true, to predominate;
but as its supporters have not refuted their antagonists so convin-
cingly as to dissipate all doubts on the subject, I have sought for the
cause of such a discrepancy of sentiment, and believe I have disco-
vered it. Of the four caruncles commonly observed at the entrance
of the vulvo-uteriue canal, and which correspond to the four extre-
mities of the vertical and transverse diameters of this opening, two,
namely, that which is near the meatus urinarius, and that which is
near the fourchette, belong to the middle columns of the vagina,
while the other two only are the remains of the hymen. The for-
mer, therefore, exist even in virgins, while the latter ought only to
be met with after coition. It is clear, moreover, that these latter, or
the lateral caruncles, may vary in number, size and situation, accord-
ingly as the hymen is broken into two, three, or four shreds, of
equal or unequal sizes, in this or that direction, and according as
the hymen itself was of greater or less thickness and breadth; these
latter caruncles are altered in form, and sometimes disappear entirely
in consequence of labor, while, on the other hand, the median car-
uncles enlarge, rather than diminish with the progress of age.

§. IX. Perineum, Fo§sa JVavicularis, Four-
chette, Froenum, Commissure.

145. Between the perineal commissure of the vulva, or greater
labia, and the convex edge of the hymen, or posterior semi-circum-
ference of the outer orifice of the vagina, is seen the fossa navicu-
laris; the fourchette or the frcenum forms its anterior edge, and
ought not to be confounded with its posterior edge, which is the
commissure itself. It most commonly happens that the fourchette
is torn in a first labor, and the fossa navicularis is thereby forever
destroyed.

146. The perineum, which separates the vulva from the anus, is
scarcely an inch, or an inch and a half in length; its inferior surface
is composed of skin; it happens, but rarely, that it is covered with

56 OF THE SEXUAL ORGANS.

hairs, which, if they be cut off, produce, while growing again, the
effect of a brush, and sometimes occasion intolerable pain, the
cause of which it is well to understand. Above, that is, between
the skin and the point where the rectum and vagina come into im-
mediate contact, there is a triangular space filled with fleshy fibres,
cellular tissue, fat, nerves and vessels, and which, constituting a part
of the perineum, allow it to elongate itself very considerably during
labor; to such a degree, indeed, as will be seen in the sequel, that
from being only an inch long, as in its natural state, it may be ex-
tended even to four or five inches in length, when most strongly
pressed upon by the head.

147. "Without repeating on this occasion what I have elsewhere
said, of the arrangement of the parts that compose the female peri-
neum, I think it may be, nevertheless, useful to recall to mind the
mean dimensions, which, after a great number of observations, I have
been enabled to establish in relation to the various objects which I
have now examined.

It is found:

1. That from the upper part of the pubis to the clitoris is two
inches and a half.

2. From the anterior commissure of the vulva to the anus, three
inches and a half.

3. From the clitoris to the posterior commissure of the vulva, one
inch and a half.

4. From the posterior commissure of the vulva to the point of the
coccyx, three inches.

5. From the coccyx to the anus, about eighteen lines.

6. From the anus to the vulva, fifteen lines, allowing only a few
lines besides for the orifice of the rectum.

It is also useful to know that the constrictor vaginze muscle,
which is analogous to the accelerator urinae of the male, is inclosed
within the body of the greater labia, and that it is so strong in some
individuals, as to contract with energy during coition, and consider-
ably lessen the size of the orifice of the vagina; that the only im-
portant artery in the neighborhood of these parts, the pudic artery,
is confined as it were entirely towards the circumference of the
perineal s,trait, and consequently, that it is not on account of he-
morrhage that lacerations of this region are likely to prove dan-
gerous.

§. X. Dill^rence betireeii the External Or-
gans of* Generation of* Women, and those of
Brutes.

OF THE SEXUAL ORGANS. 57

148. In reviewing the principal zoological classes, it is easy to
perceive that the external sexual parts, mere organs of coition, as
in the human species, are far from exhibiting the same characters,
and the same completeness in all cases.

In fishes, reptiles and birds, the cloaca supplies their place, except
in some species that have a clitoris; in the mammiferae, the horizon-
tal posture renders a mons Veneris useless, and accordingly, not a
trace of it is to be found.

According to M. Cuvier, neither do the nymphae exist in any
family; however I have reason to think I observed it in the giraffe
which is now in the Jardin du Roi.

149. The vulva and greater labia are met with in all classes, but
with very various forms. The interior is almost always wrinkled,
as in the cow, the tiger, &c. Placed lengthwise in the majority of
animals, it is in some cases transverse as in the hyena, or circular
as in the rabbit and in most of the rodentia; very shallow as in
women; it forms in the guinea pig a canal as long as, or even longer
than the vagina of the bear and some species of the monkey; all of
them have a clitoris, which in some is very small, and very large in
others, the monkey for example, where it is connected as to size with
an excessively lascivious disposition. The hymen, attributed by most
authors to woman alone, is certainly to be found in a great number
of animals. Is the plait or circle that separates the vagina from
the vulva in the she goat, the ewe, and the bitch any thing else?
M. Cuvier has noticed it in the hyena and the daman. It is im-
possible to mistake it in the semi-lunar membrane which contracts
the vagina of the virgin mare and she ass, or in that which was no-
ticed by Steller in the lamantin of the north: I think the giraffe has
it also. The greater labia, the clitoris, and the hymen are there-
fore the most constantly met with of all the external organs of
generation; and in all the species, these parts of coition are, there-
fore, rather destined to augment the pleasure of the venereal con-
gress than to play any fundamental part in the great act of repro-
duction.

§. XI. Anomaly of the external Organs of Ge-
neration.

150. I have already spoken of the preternatural development
of the clitoris and nymphae, as well as the extreme length of these
parts among certain nations; I have now to remark, that the greater
labia have been in some instances found wholly wanting, in conse-
quence of malformation of the individual; sometimes they adhere
to each other, either at one spot or throughout their whole extent,

6»

58 OF THE SEXUAL ORGANS.

as in the three examples cited by Madame Boivin, us was seen by
Cassan and M. Williaume, who saw one case each, and as is fre-
quently met with in Persia, Egypt, Turkey, and throughout almost
the whole of Africa, where the barbarous custom of infibulation is
still practised. Borelli says he saw, in the hospital of Castro, a little
girl who had two vulvas, one above the other. It might also be
said that where the vagina is completely double, there are two
lateral vulvas. The same anomalies are found to occur in the
nymphae, which Neubauer in one case found to be triple, and which
depend, too, more frequently on an acquired disease than on a pri-
mitive fault of the conformation.

SECTION 2.

Internal Genital Organs.

The internal parts of generation in women consist of the womb,
the vagina, the fallopian tubes, the ovaries, and the ligamentous at-
tachments.

§. I. Of the Uterus {matrix),

151. The uterus or womb is a hollow muscle, destined to lodge
and nourish the ovum during pregnancy, and expel it by the process
of labor. It is therefore essentially the organ of gestation, and not
of generation, as has been erroneously repeated by several authors.

152. Situation. Situated in the pelvic excavation, behind the
bladder, in front of the rectum, beneath the small intestines, and
continuous below with the vagina, the uterus, in its unimpre^nated
state, is generally placed in the direction of the axis of the superior
strait.

153. Configuration. Its shape is that of a pear or a small flat-
tened gourd, or further, of a truncated cone, compressed antero-pos-
teriorly, its base being turned upwards, its apex downwards.

154. Division. For the purpose of explaining the phenomena of
pregnancy, the womb is divided into fundus, body, and neck. The
fundus comprises all that portion that is found above a horizontal
line drawn from one fallopian tube to the other; the body extends
from this same line to the contracted portion which marks the com-
mencement of the neck; and the latter, more or less swelled, con-
stitutes the lower portion of the organ.

A. External Surface.
155. The external surfacB of the womb has been divided into, 1.

OF THE SEXUAL ORGANS. 59

An anterior region, which is slightly convex, its upper half being'
covered with peritoneum, and the remainder being in contact with
the basfond of the bladder; 2. A posterior region, much more convex
than the preceding, covered in its whole extent with peritoneum,
and separated from the rectum by a space or chink in which the
intestines may become strangulated; S. Three edges, one of which,
superior, convex, and smooth, corresponds to the fundus, and two
others, lateral, convex on their superior half, and concave be-
low, are lost, as it were, in the broad ligaments; 4. Three angles^
the two first, superior and lateral, unite the three edges, and seem to
give origin to the tubes, the ligaments of the ovaries, and the round
ligaments; the third, inferior, far more important than the others,
is seen in the upper part of the vagina, and deserves very special at-
tention.

It exhibits an orifice resembling a transverse slit, dividing it into
two lips, and has received the name of the /enc/t's mouth {os tineas).
Of these two lips, the anterior, which is thicker and broader than
the pos/enor, IS also, indeed, somewhat the longest. Nevertheless,
as the vagina ascends higher behind than in front, it seems when a
woman is carefully touched, that the posterior is longer than the
anterior lip. To this peculiarity, doubtless, ought to be attributed
the error into which many accouclieurs have fallen, who, not con-
tent with asserting that the anterior lip is the shortest, have also
represented it as being the thinnest in drawings which in other re-
spects were most carefully made. To convince any one of the pro-
portional length of the two lips of the neck, it is only necessary to
separate the womb from the vagina in the dead subject. It will
then be seen that the posterior lip is at the same time the thinnest,
the narrowest, and the shortest. However, this difierence is not
to be seen, except in women who have borne children. In virgins
the lips are very near to each other, and we can scarcely feel with
the finger the line-like slit that separates them; but it may be dis-
tinguished, as has been judiciously remarked by M. Dubois, by com-
paring the sensation produced by touching it, to that experienced
by touching the point of the nose with the end of a finger. Some-
times, however, instead of such a narrow slit, we meet with a cir-
cular orifice; a modern author has even taken occasion from this cir-
cumstance, to advance the opinion, that such is the natural arrange-
ment of the part: but this is evidendy an error. M. Desormeaux
tliinUs that this last mentioned form is particularly to be met with
in women who are not apt for fecundation; but this is an opinion
which requires to be supported by additional evidence. Besides,
we must take care not to confound this circular form with that which

00 OF THE SEXUAL ORGANS.

is pretty often observed at a certain stage of pregnancy, in women
who have borne children before; which it is not always an easy
matter, however, to avoid.

156. Before women become mothers, the lips of the os tincae
are smooth, regular and pretty firm, although supple; the whole neck
terminates in an extremity which is rather accwmina/cc? than bulging.
After one or two confinements, its slit is wider, more uneven; the
free extremities of the lips are farther apart; the anterior is elon-
gated, often ends in a point, and exhibits tubercles or bumps, which
are also found on the posterior lip, and separated from each other by
crevices of greater or less depth, and in greater or less number,
chiefly in the left. It is true, however, that this last mentioned dis-
position does not demonstrate with mathematical certainty that there
have been several pregnancies, for it may be occasioned by disease.
It should also be understood, that the contrary state persists in some
women, after a great many lyings in. Thus, in a woman, in her
seventh pregnancy, I have seen the vaginal angle of the womb more
regular than in another whom I examined by way of comparison, and
who was in her first pregnancy: but in this, as in every thing else,
we should remember the rule without forgetting the exceptions.

B. Internal Surface.

157. The womb presents an internal surface, which is also called
its cavity, and which the accoucheurs divide into superior portion or
cavity of the body, and inferior portion or cavity of the neck.

158. Cavity of the body. The first, of a triangular shape, with
sides separated from each other only by a layer of mucus which is
more or less thick, sometimes exhibits, on the median line, a sort of
raphe or crest, which runs through its whole length, and is joined
by other oblique or transverse lines. The sides of this cavity, as
well as its bottom, are almost straight, sometimes slightly convex in
young girls, while they generally remain pretty concave after a
lying-in. Its two superior angles are continuous with the origin of
the fallopian tubes, which are sometimes expanded like a funnel, and
ought, according to M. Geoffroi St Hilaire, to be regarded as the
rudiment of the aduterum, which is remarked in most of the mam-
miferse; its inferior angle is called the superior, uterine or internal
orifice of the neck, and is the point by which the two cavities of the
womb communicate with each other.

159. Cavity of the neck. The cavity of the neck of an oval
shape, is twelve or fifteen lines in length, and five or six lines in
width at its widest part, and one or two lines from front to rear.
On its two walls, and particularly on the posterior one, are found

OF THE SEXUAL ORGANS. 61

certain plaits or lines, which have been carefully studied of late by
Madame Boivin. This is a sort of gathering, which seems to be only
a continuation of that which is found in the womb itself, but much
more developed. The median crest, the largest of all, more salient
in the middle, than at either end, is formed, as it were, by the approxi-
mation of many small secondary folds crowded together. The trans-
verse lines are all oblique from above downwards, and from the
sides, inwards, towards the preceding line, on which they terminate,
like the barbs of a feather, on their stem. Slightly concave upwards
they leave pretty deep grooves between each other, in which a good
many mucous follicles are to be found, and occasionally, some small
round transparent vesicles, a sort of hydatids, formerly regarded as
germs, and for a long time known as the eggs of Naboth. More
deeply seated, that is, beneath this network, which constitutes what
is called the arbor vitae, there is another one, somewhat differently
disposed, but which cannot be examined until we come to speak of
the structure of the organ. At the place where the two walls of
the neck unite, and where the transverse lines too are confounded,
are also seen two longitudinal lines.

160. The superior opening of the neck having been above indi-
cated as the uterine orifice, it is useless to return again to the consi-
deration of it. The inferior orifice divides the lips of the os tincae
from each other; and as it opens into the vagina, it may very pro-
perly be called the vaginal orifice of the womb. From what has
been said, and which ought to be understood of the cervix of a young
woman, previously to being fecundated, it is evident that the inferior
angle of the uterus ought to be quite acute, that a little higher up
the size of the neck should be greater, and that this part ought to
be again contracted, and, as it were, strangulated at the place where
it unites with the body of the organ.

C. Dimensions of the Womh.

161. In women who have never had children, the womb, measured
from the most salient point of the fundus to the end of the anterior
lip of the neck, I have found to be of an average length of from
twenty-six to twenty eight lines; from one fallopian tube to the other,
from seventeen to twenty lines; from front to rear, in the thickest
part, nine to eleven lines; at the neck I have found that there were,
transversely, ten to twelve lines, five or six lines from front to rear,
eight or ten lines across at ihe place where it is strangulated, and
that there were four lines of thickness at the same point. The pa-
rieles of the womb are four lines in thickness at the body, and two
or three at the neck; the lips project two or three lines into the
vagina, and the slit that separates them is of about the same extent.

62 OF THE SEXUAL ORGANS.

162. After several pregnancies the uterus is from two and a half
to three inches in its entire length; twenty to twenty-four lines wide
at the fundus, fifteen to sixteen at the widest part of the cervix,
twelve to fourteen lines thick at the body, eight to ten at the neck,
and each of the walls are six lines in thickness: the vaginal orifice
is half as large again as in a virgin.

In the first named state, the womb weighs from eight to twelve
drachms, and in the second about two ounces. It will be seen that
these dimensions are very near those given by Rosderer; and they
are the results of a considerable number of measurements taken on
the dead subject.

D. Structure.

163. An external membrane, an internal membrane, a peculiar
tissue, numerous vessels, nerves and cellular tissue enter into the
composition of the womb.

164. a. The external membrane, of a serous character, belongs
to the peritoneum; posteriorly, it descends lower than the cervix, on
to the posterior surface of the vagina, while, in front, it is reflected
upon the bladder after having invested the anterior surface of the body
of the uterus, and before it reaches the cervix. Very closely adhe-
rent along the upper edge and median line of the uterus, it becomes
less so nearer the sides, and in the neighborhood of the broad liga-
ments may be easily detached. Observers have not agreed in rela-
tion to its thickness, doubtless because it has often been confounded
with the layer immediately beneath it, but which in reality ought
to be distinguished from it. On the whole, it is thin and very
dense.

165. Sub-peritoneal layer. This is a kind of doubling which gives
to the peritoneal layer a borrowed thickness, covers every part of the
uterus, extends itself into the broad ligaments, and is, indeed, only
a portion of the common sub-peritoneal fascia, which at this point
assumes most of the characters of the yellow fibrous tissue; that is
to say, it is elastic, strong, dense, and may be converted into real
muscular tissue, as has been remarked by Madame Boivin, and as I
have several times observed myself.

166. b. The existence of the internal membrane is not admitted
by all anatomists. Gordon, Chaussier, M. Ribes, (fee. reject it;
the most careful dissections, putrefaction, ebullition, chemical re-
agents, have all failed in demonstrating its existence to these observers,
except towards the close of pregnancy; but at that period it con-
stitutes, according to them, a pellicle of new formation, and not a
natural membrane. Beclard also taught that the internal membrane

OF THE SEXUAL ORGANS. 63 .

of the uterus is not a complete mucous membrane, and that it has no
epithelium. It ^is true, that except during pregnancy, we cannot
always demonstrate the existence of an uterine mucous membrane,
but in several women who died while pregnant, or shortly after deli-
very, I have succeeded in raising very distinct portions of it. But
even could we not succeed in separating it mechanically, analogy
would suffice to convince us of its presence: the mucous membranes
are exclusively provided with villi; they alone furnish mucus in the
healthy state, and muco-purulent matters in a state of disease ; it is
on their surface that we meet with polypi and sanguine exhalations.
Hence, the glairy discharge that occurs during labor, the leucor-
rhoeal discharges, the menstrual function, &c., all prove that the
inner surface of the womb performs the same functions, and is sub-
ject to the same diseases as the mucous membranes. I conclude,
therefore, that, if we can in reality refuse to admit the existence of a
membrane, we shall at least be forced to admit that the uterus pos-
sesses a mucous surface. During several weeks, no organ of the
foetus is, properly speaking, invested with a mucous membrane ; not
one of them can be divided into lamellze of different natures ; they
are all formed of a homogeneous tissue ; the intestines, like the other
hollow organs, are possessed not of internal and external membranes,
but of surfaces ; it is only at a later period, little by little, and in the
same situations where they are observed after birth, that the distinc-
tion of tissues, established by the zoologists, are effected. Thus, the
interior of all the cavities, of all the canals that communicate nearly
or remotely with the atmosphere, exhibit the aspects of villous sur-
faces ; but to this fundamental character are added others which
differ according to the organ, and reduce every portion into har-
mony with the uses of the parts it helps to constitute. Sometimes
it is a moveable lamina, thick and wrinkled, as in the alimentary
canal ; in other instances, it is a thin smooth layer, difficult to sepa-
rate from the subjacent tissues, as in the ureters, the vasa deferen-
tia, &-C. Although follicular and villous, this element may adhere
so intimately to the substance of the organs, that it is impossible to
separate it ; and this is the case with the womb. Nature, true to
her great principle, seems here to take pleasure in varying forms
without multiplying means ; on some points she is content with a
mere rudiment, while at other points she at once attains perfection ;
but on the other hand, that which, so to speak, she leaves incomplete
in the normal state, is rendered complete by disease, or by some
eventual condition ; in this way it happens that a pregnancy, a poly-
pus, or some other lesion, have, in more than one instance, rendered
the mucous membrane of the uterus altogether evident.

64 OF THE SEXUAL ORGANS.

167. c. Peculiar tissue, or parenchyma. Situated between the two
preceding layers, and alone constituting almost the entire essential
and fundamental part of the organ, the proper tissue of the womb
has been the subject of the researches, of a great many very able
anatomists. Bonacciolus, Swamraerdam, Meckel and Ruysch,
Noorthwyck, Sue, Hunter, Loder, Weisse, M. Lobstein, Belloni,
and very recently, Madame Boivin, have striven to demonstrate its
texture, before, during, and after pregnancy ; but in spite of so many
exertions, opinions are still far from being unanimous in regard to
its nature.

168. Nature of the peculiar tissue of the tvomb. The same thing
has taken place in regard to the womb, as always occurs in anatomy,
whenever the analogies and comparisons, which authors are obliged
to draw for the purpose of illustrating their ideas, are rigorously
construed according to the letter. When Vesalius asserted that the
womb is a muscle, Walter, taking the muscles of the skeleton, and
even the heart or the intestines as his type, found no difficulty in
proving that Vesalius had made a mistake. Although, on the one
hand, Malpighi, Ruysch, Noorthwyck, Wrisberg, Meckel, Lobstein,
and the major part of modern anatomists, have arranged themselves
on the side of Vesalius, we see, on the other, Boehmer, Blumenbach,
&;c., alleging reasons, that are apparently very plausible, to prove
that it is at least not founded on the state of the organ when unim-
pregnated. Both sides have often been right; but, by referring to
forced approximations, they have too often lost sight of the object
to render it possible to reconcile so many various observations.

Previously to asserting that the womb does or does not contain
muscular tissue, it would have been proper to determine what are
the characters of that tissue in general; to show that the red color
is not essential to it, since it is wanting in the muscles of fishes,
reptiles, and even in the muscular coat of the human intestines; and
that the same is true of the fibrous appearance, since it is met with
in the tendons, aponeuroses, &c., but that it alone enjoys the faculty
of contractility, and contains fibrine.

Li the second place, it should be considered indispensable to re-
cognise a truth that is too much overlooked in our days: which is,
that the fleshy fibre must necessarily pass through several less per-
fect gradations of development; that, in some organs, it remains in
the rudimental condition, and is developed only by accident. Thus,
the trachea, and the bronchia, even the arteries of large animals, the
elephant among others, evidently exhibit muscular fibres, while the
same organs in the human species rarely exhibit them with any dis-
tinctness. The gall bladder, the vesiculae seminales, Sic, are not

OF THE SEXUAL ORGANS. 65

furnished with them, according to most of the modern anatomists;
but let these organs be examined when their coats, strongly hyper-
trophied, have been long distended, and we shall be soon forced to
admit that they possess a muscular coat, as the ancients believed,
and as I have seen myself. The womb, previously to puberty, is
only a rudimental muscle; when not gravid, its organisation, it is
true, is but a sketch, but it is only towards the end of pregnancy
that we can possibly test its nature. Every circumstance tends to
establish that the cellulo-fibrous, elastic yellow tissue which com-
poses the basis of the inter-laminar and inter spinal ligaments of the
vertebrae, constitutes also the web of a very great variety of other
organs. It is no where more abundant than in the uterus. Hence
it appears that this element holds a middle place, and serves in some
sort as a passage between the cellular and muscular systems; the
chemists have detected fibrine in it, and I have seen it, on various
points, transformed into real contractile tissue. I am scarcely afraid
to assert that wherever it is met with, it may accidentally develop
muscular fibres, and that these fibres exist naturally in some zoologi-
cal species.

169. In order, therefore, to understand the essence of the uterine
tissue, it ought to be studied during its gravid state: then only is it
red, contractile, formed of tomentose fibres; then only does it con-
tain a great proportion of the fibrine; and presents, in a word, all
the characters of the most perfect muscular tissue.

170. Disposition of the fibres. Vesalius, Malpighi, and the
first anatomists who admitted their existence, contented themselves
with saying that the fibres of the womb are so interlaced, that it
is impossible to trace out their direction. Ruysch and some others
advanced, that being principally collected about the fundus of the
organ, they compose an orbicular muscle, a sort of disc, the use
of which is to detach the placenta at the period ofslabor. Hunter,
Sue, &c., admit that it forms a number of layers variously crossed;
A. Leroy teaches that they give rise to two layers of muscles,
one internal and one external; and M. Meckel, who, in common
with several German anatomists, partially adopts this sentiment,
thinks that each of the two principal layers ought to be divided
into several other secondary layers. Baudelocque, and most of the
French anatomists, abandoning all hopes of assigning to these fibres
a determinate direction, have contented themselves with teaching
that they are disposed in loops, parallel to the axis of the uterus,
or in horizontal circles; that the body and fundus of the womb are
chiefly composed of the former, while the latter are found more

7

4

66 OF THE SEXUAL ORGANS.

especially in the neck. Indeed it will be hereafter seen that great
stress has latterly been laid on this idea, which is relied on for the
exj Sanation of the process by which the cervix is effaced during
pregnancy, and dilated in labor, &c., and also the occasional causes
of parturition. Lasdy, Madame Boivin, to whom we are indebted
for some valuable researches on this subject, has observed a much
greater number of fleshy layers in the womb than any preceding
author. She admits, 1. A longitudinal fascicle; which occupies
the median line in front and rear; and extends from the fundus to
the neck; 2. On each surface of the organ, and on both sides of
the vertical column three layers of transverse fibres, which proceed
to lose themselves, outwards, in the tubes, the ligaments of the
ovaries, the round ligaments, and the posterior ligaments; 3. At the
superior angles of the uterus, and deeply seated, a circular layer,
the centre of which corresponds to the origin of the tubes, and which
interlaces and confounds itself with the opposite one; 4. And lastly,
Very near the mucous surface, a layer that is thinner than any of the
others.

I have myself dissected a very great number of wombs, at every
period of age, both unimpregnated and during the gravid state, and I
am convinced that each of these modes of regarding the subject has
some foundation. The imbrication noticed by Malpighi and his
predecessors is not to be disputed, and does not exclude the exis-
tence of the muscle spoken of by Ruysch. This last author, although
opposed by Heister, Haller, &c., was almost entirely right: it suf-
fices merely to examine the inner surface of the womb, at the close
of pregnancy, to recognise the stratum of muscular fibres he men-
tions; only, instead of one orbicular disc admitted by the celebrated
Dutch anatomist, there are two. The two layers spoken of by A.
Leroy, Rosenberger, M. Meckel, Sic, are completely apparent in
the last month of gestation; but it must not be expected that they
can be found independent of each other. Considered in a general
manner, all these peculiarities agree together very well, and further,
they agree with the sentiment of those who insist upon it that the
womb contains none but fibres arranged in loops or vertically, and
in circles or horizontally.

171. Conclusions. Upon the whole, the following are what I
have most invariably observed on this subject. 1. Beneath the peri-
toneum there is a first stratum that is thin, dense, elastic, cellulo-
fibrous, and sometimes, but not always, muscular, in which the
fibres have no determinate direction; 2. A thicker layer of transverse
fibres, which, united in different planes, and imbricated like the con-

OF THE SEXUAL ORGANS. 67

stridor muscles of the pharynx, all tend outwards, and converge
towards the four principal points mentioned by Madame Boivin;
3. More deeply seated, are found other transverse fibres; but the
longitudinal and oblique fibres predominate, especially at the neck,
where they constitute the basis of the ridges observed on the inner
surface of the organ; lastly, above is seen the pretended detrusor
placentse of Ruysch, which seems to be nothing more than an ex-
pansion of the circular fibres of the Fallopian tubes.

The basis of all these strata is the yellow cehulo-fibrous tissue,
surcharged with fibrine; the fleshy tissue developes itself in this pri-
mitive web as in the intestines; but inasmuch as the womb seems to
be composed by the union of two cylindrical canals, and as it is
necessary that it should be endowed with great strength, it is not as-
tonishing that its multiplied fibres should aflect the most complex
and varied directions.

173. d. Blood-vessels. Two orders of arteries are appropriated
to the gestative organs: one, known as the uterine arteries, furnish-
ed by the hypogastrics, penetrate into the substance of the womb at
the cervix; the others, the ovarian, given oflf by the aorta or the
emulgents, pass along in the broad ligaments, and after being pardy
distributed in the ovaries, proceed to the sides of the body of the
womb itself. In ramifying, those of the left side inosculate with
those of the right, those from above with those from below, and as
all of them are strongly compressed in the substance of the tissue in
which they creep, they are doubled and redoubled a great many
times. The veins, distributed in the same manner as the arteries,
go to the internal iliac vein from one part, and to the ovarian veins
from the other. During pregnancy, these various canals, partially
unfokled and largely dilated, run chiefly between the two fleshy strata
so much insisted upon by A. Leroy.

173. e. Its lymphatic vessels pass into the pelvic and iliac gang-
lions; its nerves came from the sacral plexus, and from the gangli-
onic system by the renal and hypogastric plexuses. The former
are distributed almost exclusively upon the cervix, and it is natural
to attribute to them the excessive sensibility enjoyed by this part;
while the latter, being here destined to furnish only the vegetative
sensibility, must be more regularly distributed to all parts of the
womb.

§. 11. Fallopian Tubes {ticbse Fallopianx).

174. The uterine tubes, or Fallopian tubes, (seminiferous ducts,)
are two small, hollow cylinders, four or five inches long, as large
as the barrel of a quill, and extending from the lateral angles of the

68 OF THE SEXUAL ORGANS.

womb, with which they are continuous, to near the ihac fossas,
where they terminate in a laciniated and loose extremity, called the
devil's-bit (morsus diaboli,) or fimbriated extremity of the tube,
This tortuous tube is inclosed in the upper edge of the broad liga-
ment; its cavity, which, at the womb, is large enough to admit of a
middle sized probe, at first contracts by degrees, so that near its
middle a bristle can scarcely be passed through it, it then enlarges,
and soon acquires a diameter of two or three lines. Among the
fringes which terminate its loose extremity is one that is harder and
longer than the rest, which fixes itself to the ovary, and seems to be
the real continuation of the tube.

175. Structure. The composition of the seminiferous tubes is in
all respects similar to that of the uterus itself. They are enveloped
externally by the peritoneum, which adheres closely to them, and a
mucous membrane, folded in the direction of their length, lines them
within. A pretty thin layer of fleshy fibre is found betwixt these
two laminag; its fibres are of two sorts, like as in the small intes-
tines: one sort, longitudinal, are only a prolongation of the trans-
verse stratum of the surface and fundus of the uterus; the others,
which are circular, cut the former at right angles, and seem to be
appendages of the orbicular muscle of Ruysch. As to the internal
coat, its existence has been denied; but to the proofs related above,
(166) 1 may add, that in a woman of middle age, I and M. Baude-
locque, Jun. saw the mucous membrane of the Fallopian tube as
movable, and as easily separable, as it is in the oesophagus; its valvu-
lar folds, mentioned by those authors who assert that the ovule may
easily pass to the womb, but cannot possibly retrograde towards the
ovary, and especially, that the semen masculinum cannot pass
through the tube, have been the products only of the imagination of
those who needed them for the defence of their preconceived theories.
The tubes receive all their vessels from the ovarian branches; their
nerves belong to the great sympathetic, and, like the uterus, their
basis is an elastic, fibrous, cellular tissue.

§. III. Ovaries {ovaria).

176. The ovaries, long known as the testes muliebres, and which
may be called the female seminal glands, are situated in the upper
part of the broad ligaments, behind, and a little below the tubes,
near the superior angles of the uterus, to which they are attached
by the ligament of the ovary, Oblong, slightly flattened from front
to rear, being of the size and almost of the shape of an almond or a
large bean, the ovaries have a superior, convex and loose edge, while
their inferior edge is straight, receives vessels, and proceeds to join

OF THE SEXUAL ORGANS. 69

the ovarian fringe of the tube. Their surface even, or scarcely
botryoidal in women who have never been fecundated, presents, on
the contrary, in those who have had children, inequalities, fissures
and reliefs in a greater or less degree. Differing as much both in
appearance and nature from the salivary glands to which Pean com-
pared them, as they do from the seminal glands of the male, the
ovaries possess a structure which is peculiar to themselves, as is the
case in all the special organs. A sort of parenchyma of a reddish
gray color, composed of lamellae and filaments variously interlaced,
constitute their principal tissue. Since the time of R. De Graaf, it is
admitted that there really do exist in this parenchyma certain
transparent vesicles, from twelve to twenty in number, and which
are denominated ovules or germs. In it also we occasionally meet
with accidental vesicles, true hydatids, which should not be con-
founded with the former, but which may possibly be only degene-
rated ovules. According to De Graaf, " vessels and preparative
nerves enter into these vesicles, on the tunics of which several of
their branches, after various divarications, distribute themselves, as
occurs in the yolk of the egg while it is still attached to its ovary."
A strong, thick, and very tough membrane serves as the shell or
envelop of this tissue; and according to my observations, this fibrous
membrane is only an appendage of the ligament of the ovary; that
is to say, the ligament of the ovary, which is one or two inches in
length, and one or two lines thick, is formed by a fascicle, from the
transverse layer of the posterior surface of the uterus, and when it
reaches the point of the seminal gland, its fibres separate in order to
envelop the parenchyma in question. It is evident that the proper
tunic of the ovary is altogether distinct from the peritoneal layer,
from which, however, it is impossible to separate it. In naming it
dartos, it is probable that the ancients did not suppose that, like the
dartos of the male, it approaches by its nature very nearly to the
contractile or muscular tissue.

177. Until the time of Fallopius, it was generally taught that the
germ was carried from the ovary to the uterus by difierent canals,
of which the tube did not constitute any part; the ligament of the
ovary was supposed to be the principal one; it formed the deferent
canal. Warthon and Mauriceau admitted one or two others, which
passed from the edge of the ovarium and opened into the vagina;
but it was long ago demonstrated that the ligamentous cord of the
ovary is solid, and contains no canal; however, the other passage,
also forgotten for a whole age, has just been recalled to the attention
of naturalists by M. Gartner of Copenhagen, who looks upon it as
an organ that is always to be met with in the large quadrupeds. I

7*

70 OF THE SEXUAL ORGANS.

have vainly sought for it in the human subject, and found nothing
even remotely resembling it. The ovary is the essential organ of
generation, the organ in which germs are formed.

§. IV. Iii§^aii[ient§ of the Uterus.

178. In investing the internal organs of generation, the peri-
toneum gives birth to several ligamentous folds, which it is proper
now to describe.

Of these, the chief are the broad ligaments, which constitute a
transverse partition, and divide the whole depth of the pelvis into
two cavities, one anterior and the other posterior; in the former the
bladder is situated, and in the latter, which is deepest, is found the
rectum; the two laminae of the peritoneum, of which the broad
ligaments are composed, separate when they reach the sides of the
womb, in order to spread out on its surfaces; downwards and out-
wardly, they also deploy so as to be continuous with the peritoneum
which lines the cavity of the pelvis; their superior border, which is
loose, extending from the angles of the uterus to the iliac fossa, is
divided, as it were, into two or three secondary folds, which are
called its lesser wings; one of these, the posterior, encloses the
ovary and its ligaments; another (the middle one according to M.
Dubois and the other authors who admit three of them; but the
anterior one, according to Baudelocque, M. Desormeaux, and all
the accoucheurs who contend that there are only two) contains the
Fallopian tube, and is the highest; the third, mentioned by some
and rejected by others, and which is in fact scarcely distinguishable
in the natural state, is found in front of, and lower down than either
of the preceding ones, and encloses the round ligament. The two
serous laminae of the broad ligament are not in immediate contact;
they are separated by a layer of cellular tissue, of various thickness
in different individuals, and this layer, which downwards and out-
wards becomes blended with the sub-peritoneal cellular tissue, or the
fascia propria of the pelvis and iliac fossae, is sometimes found to
contain muscular fibres; so that we find, in the broad ligaments,
nearly the same elements as in the womb itself.

179. The round ligaments or sur-pubic cords, fibious bundles,
which take their rise in front of and a Utile below the Fallopian tubes,
follow the oudine of the anterior semi-circumference of the superior
strait, and proceed, after passing through the inguinal rings, to ter-
minate in the groins and mons Veneris, are the only ones which have
been deemed, with the broad ligaments, worthy of attention. Formed
of reddish and wavy fibies, which rise from the anterior and middle
transverse layers of the womb, the round ligaments are evidendy of

OF THE SEXUAL ORGANS. 7l

a muscular nature. Dionis asserted that the use of the round liga-
ments was to depress the os tincae by contracting during the sexual
embrace, and thus to bring it closer to the male organ; but as their
origins are lower than their insertions, it is manifest that their con-
traction in that 'case would produce a rather contrary effect. But
further, the womb without them would be always retroverted by the
bladder, which is repeatedly distended with urine in the course of
every twenty-four hours: they also uphold it until towards the mid-
dle of pregnancy; but further than this nothing is certainly known in
regard to their uses, and there is no occasion for me to enter into an
argument against the opinion of the ancients, especially of Spigelius,
who supposed that the semen passed through them in its passage to
the clitoris. Being put on the stretch by the ascent of the womb,
it is possible that they may, when the woman is on foot, and parti-
cularly when on her knees, occasion pretty smart pains in the groins
and thighs.*

180. Douglass, A. Petit, Sue, &;c., have noticed four other liga-
ments, two anterior (utero-vesical of Madame Boivin), and two pos-
terior {idero-sacral, id.); the two former, very small in most women,
passing from the sides of the cervix uteri to the lateral parts of the
bas-fond of the bladder, are occasionally composed, in addition to
their peritoneal coat, of a few fleshy fibres, that seem to be detach-
ed from the antero-inferior transverse layer of the neck of the womb.
The latter, which are much stronger and more constantly observed,
originate a little lower down, from the posterior surface of the cer-
vix, run backwards, each forming a crescent, the concavity of which
looks towards the median line, and are attached to the sides of the
rectum, where they are lost in the cellular tissue and peritoneum
which invests the front of the sacrum; from numerous facts that
have come under my notice, I am of the opinion that they are of
the same nature as the round ligaments, and that their fleshy fibres
are furnished by the postero-inferior transverse layer of the uterus;
consequently, it may be conceived that they may lend to prevent the
retroversion of the womb, and be in this respect congeners of the
round ligaments; that their use is to prevent the os tiucae from being
carried forwards; and that the knowledge of them is far from being
uniniportant to the accoucheur.

* It is very common for women laboring under prolapsus uteri to complain of
pain and soreness in the regions traversed by tlie cords. I am accustomed to
the prescription of leeches for tliese regions, in many cases of uterine disease —
as I consider tlial blood taken from capillaries here, actually effects depletion of
the vessels of the uterine circulation. — M.

72 OF THE SEXUAL ORGANS.

§. V. Of the Tagina.

181. The vagina or vulvo-uterine canal, an oro-an for eduction
and copulation, is a cylindrical canal, four or five inches long, by
about an inch in diameter, which extends from the vulva, where it is
continuous with the labia and hymen, up to the neck of the uterus,
to whose circumference it is attached. Its direction is nearly paral-
lel to that of the posterior wall of the excavation, that is to say, it is
concave in front, and convex posteriorly, is situated in the axis of
the inferior strait, and forms an angle of about sixty-five degrees
with the great diameter of the womb. From this disposition, it
happens that its posterior wall is much longer than the anterior, and
its two extremities being inclined towards each other in front, re-
present pretty correcdy the planes of the two straits of the pelvis.

182. Connections. The posterior region of its external surface,
resting for the middle three-fifths of its whole extent on the fore part
the rectum, assists in forming the recto-vaginal septum; in approach-
ing the vulva its lower fifth leaves the rectum, at a distance equal to
the whole thickness of the perineum; its superior fifth, loose in the
pelvis, is invested by the peritoneum. Its anterior region is con-
nected by means of a dense and firm cellular tissue, first to the bas-
fond of the bladder, so as to form the vesico-vaginal septum, then to
the urethra, which gives rise to the urethro-vaginal septum. The
sides of the vagina are surrounded with vessels, nerves, and a very-
abundant cellular tela.

183. The interior of the vagina presents a number of wrinkles
or folds, analogous to those which are met with in the cavity of the
cervix; the middle column of its parietes, sometimes divided into
two, three, or four small parallel columns, increases in thickness as
we approach nearer to the vulva; the same is true of the transverse
folds; so that the vagina, which is smooth, or almost smooth above,
is most commonly rugose and plaited below, like the palate in the
ruminating animals. I have already stated (144), that below the
meatus urinarius and at the fourchette, these two middle columns
constitute the anterior and posterior myrtiform caruncles. Larger
in young persons who have never cohabited, and in brunettes with a
dry fibre, than in women who are in an opposite condition, all these
wrinkles are effaced during labor, but in general, reappear soon
afterwards.

184. The vaginal cavity terminates above in a circular groove,
or cul de sac, much deeper behind than in front. Supple, thin, and
situated between organs liable to alternate dilatation and contraction,
the sides of the vagina are habitually in almost complete contact;
but, as they are endowed with great sensibility, it happens that the

OF THE SEXUAL ORGANS. 73

capacity of the vulvo-uterine canal varies considerably. Sometimes
it is found to be wider at its middle than in any where else, and
that is because the womb is too much depressed; at other times it
is only the superior portion, especially in women who have had
children, that is found dilated as it were; which depends on the
neck of the uterus having remained after delivery lower than it was
before marriage. In fine, we shall hardly find it of equal dimen-
sions throughout, except in those who have scarcely ever, as yet,
yielded themselves up to venereal enjoyments.

185. Structure. Two layers enter into its composition; one, ex-
ternal, a real prolongation of the external laminae of the uterus, has,
for its basis, the yellow cellulo-fibrous tissue, and contains a small
number of interlaced, very pale muscular fibres, which must not be
confounded with the elliptical muscular rings of its vulvar orifice,
and which belong to the constrictor vaginae muscle. These latter,
indeed, act under obedience to the will; the former, on the contrary,
are not brought into play except by the gratifications of love. Ar-
teries, and more especially numerous veins, pass through this tissue,
and form, particularly below, a real spongy or erectile stratum, which
swells under the frictions of coition, and may then contract so much
as manifestly to diminish the width of the vagina.

186. The other, internal, is continuous with the mucous mem-
brane of the vulva, and is blended, on the lips of the cervix, with
that which lines the cavity of the womb; that half which is nearest
the pudendum presents all the characters of the most perfect mu-
cous laminae; in it are found an epithelium, follicles, villi, &c. Near
the neck it cannot be separated from the subjacent tissues, and, at
that point, nothing demonstrates the existence of follicles and villi.
It covers all the duplicatures of the vagina, but docs not compose
them, whatever may have been said to the contrary by a crowd of
authors. The raucous follicles are principally seated at the bottom
of these folds, where also the venereal chancre is found to be occa-
sionally concealed.

187. Two small glands, noticed from time immemorial by the
anatomists, under the name of vaginal glands, or prostates of Bar-
tholin, and which have been erroneously classed among the simple
ToUicles, are to be seen under the lateral myrtiform caruncles, be-
twixt the mucous membrane and the muscular coat: their uses are
little understood; M. Gartner, however, thinks they may serve as the
point of origin or termination of the canal discovered by him.

§. VI. Of the Sexual Organs in g-eiieral.

188. The sexual organs, taken as a whole, and regarded in a

74 OF THE SEXUAL ORGANS.

philosophical light, may be considered as a dependency of the tegu-
mentary laminae; that is to say, the mucous membrane constitutes
the most important and constantly present portion of them. In
the lower animals, as well as in those whose sexual system is in the
highest degree complex, the germs are always created at the bottom
of a mucous cavity, whether it consist of a simple excavation, or
constitutes a canal that is straight, tortuous, &c. However, the
generative cavily is sometimes composed of a doubled homogeneous
lamina, of equal thickness throughout its whole extent, as in worms,
and the species that have no uterus; sometimes, on the contrary, this
duplicature is at first very thin in one portion of its extent, becomes
in the next place very thick at another point, and gradually becomes
thin again in a third, as is the case in women.

189. Although, in the human species, the generative apparatus
forms, as it does in brutes, only a long canal reaching from the
ovary to the vulva, it exhibits to us, nevertheless, one of the most
perfect of the secretory apparatuses. The ovaries constitute its
glandular portion, the uterus is the reservoir, and the vagina the
excretory duct; so that they may, in respect to their peculiar func-
tions, be divided into formative, productive, and transmitting organs
(the ovaria and tubes), into gestative organ (the womb), and into
eduetive, conjunctive, or copulative organs {the vagina and vulva.)

§. vn. Tarieties in the Internal Org^ans of
Generation in Animals.

190. A long tube, extremely thin, double, wound upon itself
within the body of the animal, and terminating in a sort of vagina,
performs all the generative functions in the lumbricoid worms.
Fishes possess enormous ovaries, which contain as many as two
hundred thousand ovula, are continued without interruption into the
oviducts or tubes, and have a directly external opening. The ova-
ries of reptiles resemble bunches of grapes, but of various lengths;
in birds they present numerous cells, in which the eggs are lodged;
the oviduct, always open and trumpet-shaped at its superior extre-
mity, terminates, below, in the cloaca, which supplies the place of a
vagina. The mammiferaj alone possess an uterus, but with the ex-
ception of that of the monkey, it is very different from the human
Avomb; yet their Fallopian tubes and ovaries difl'er only by slight
.«hades from those of women. Almost all the rodentia, the rumi-
nantia, the solipedes, the amphibia, &lc., possess a womb divided into
three cavities; a middle one, which represents the neck, and two
lateral ones, called the horns, which must not be confounded with
the Fallopian tubes. These horns, or adnterum, are generally very

OF THE SEXUAL ORGANS. 75

long, and sometimes are two, three, or four times as long as the cer-
vix, which in the Guinea pig, the hare, &c., can scarcely be said to
exist at all. Hence it may be said, that there are in reality two
wombs, two tubes, and two ovaries for one single vagina.

191. Separated in some instances by a very decided contraction
from the vulva, and in others continuous, without any line of demar.
cation, with the vulva, sometimes twice or thrice as long as the vul-
var canal, as in the bitch, sometimes, on the other hand shorter, as
in the bear, the vagina of the mammiferae exhibits numerous varie-
ties, in respect to its dimensions, the arrangement of its folds, and
its connection with the womb.

But the most remarkable genital system is that of the didelphic
or marsupial animals: besides the tubes, their womb is composed
of two horns, each of which opens by an orifice furnished with a
valvular cushion into a tliird cavity, largely expanded, of the shape
of a cul de sac. This cul de sac rests upon the vagina, and sepa-
rates it from its horns, but does not open into its cavity. It sends
off a small canal which proceeds downwards and backwards, then
mounts upwards in a semicircular manner to the orifice of the vagina,
where it opens. Further, on the lower part of the belly, they have
a very complicated kind of sac, which contains small teats, and
where their young are deposited at a very early period; as if for a
second gestation.

192. Careful dissections of most of the large animals confirm
what I have now advanced, touching the nature of the peculiar tissue
of the sexual organs of the human female (1G8): the muscular fibres
are very evidently seen in the uterine horns of the cow, the mare,
&c., where they affect the same arrangement as the small intestines:
the same is true of the cervix, where their direction is chiefly trans-
versal, and of the broad ligaments, where they constitute several
distinct bundles.

§. VIII. Difference according to Ages.

193. In the early periods of uterine life, the ovary, very large,
and particularly very much elongated, forms a sort of yellowish sac,
which is uninterruptedly continuous with the Fallopian tube, as in
fishes. Very small in proportion, very slender, and almost lost in
the middle of the broad ligaments, it is thicker the nearer we come
to the vagina, above which it terminates by a neck that is soft, very
projecting, and of a considerable size; at the ninth month the vagina
is very long, and wide enough to admit of the introduction of the
finger; its mucous membrane, as well as that of the cervix, is very
evident; but the body of the ^Yorab is so firm, that it would be diffi-

76 OF THE SEXUAL ORGANS.

cult to separate its different tissues. From birth to puberty the
genital organs of the young girl undergo no special change; nothing
in them discloses the great part they are destined at some period to
play in the economy, and they merely follow in their evolution the
progress of that of the constitution. At the age of from twelve to
eighteen years, they awake from their long stupor. The womb
rapidly attains to double the size it had previously acquired, both in
breadth and thickness; the base of the wedge, which it resembles,
instead of remaining low down, rises higher up, and thenceforth the
woman commences a new aera. Although not so marked, yet the
changes that take place in the ovaries and Fallopian tubes are not the
less undeniable.

As long as a woman has had no children, the genital organs re-
main in this state; after one or more pregnancies, the ovaria become
covered with protuberances, wrinkles or cicatrices, and they still
increase a little in size. The tubes, almost strangers to the great
revolution operated in the general system, scarcely differ from their
condition previously to the first pregnancy, or from what they will
be at a ripe age, unless affected by diseases, of which they often be-
come the seat; the form and proportions of the uterus remain unal-
tered, only it continues of a rather increased size. The vagina be-
comes shorter and wider, while the strength of the round ligaments
is more or less augmented. In old age the ovaria are atrophied,
become elongated, and of a very irregular shape; the womb tends
again back to its original size; the cavity of its body becomes so con-
tracted, that the stricture which connects it with the neck is some-
times found to close it completely up, as has been very judiciously
indicated by M. Mayer.

§. IX. Anomalies.

194. The anomalous conditions of the sexual apparatus, which
are as numerous as they are diversified, all seem to depend upon a
want, an arrest, or an aberration of development, or on a disease
occurring anteriorly or posteriorly to the period of birth.

195. No authentic case exists of a complete and simultaneous
absence of all the internal female organs of generation; but Chaus-
sier, Madame Boivin, M. Duges and Cassan, have made mention of
a person who had only one ovary, one tube, and so to speak, only
one half the uterus. The absence of the ovana has been ascertained,
in more than one instance, although the other parts of generation
were in a natural state: only one was absent in the case mentioned
by M. Jadelot. M. Renauldin has seen them reduced to the smallest
possible size in a woman about forty years of age; the Graafian vest-

I

OF THE SEXUAL ORGANS. 77

cles may fail to become developed in them, and that necessarily oc-
casions sterility.

196. The tubes are rarely found wanting, nor do they often de-
viate from their ordinary direction; but they occasionally become
accidentally closed, sometimes near the ovary, and at others at a
point nearer to the uterus.

197. M. Renauldin gives a very remarkable case of absence of
the uterus: the cervix alone existed in a rudimental state. This
fact is confirmatory of those previously reported by Bousquet, The-
den, Engle, Lieutaud, M. Caillot, and of the one recently made
public by M. Breschei. Sometimes the womb is very much elon-
gated, as in the monkeys; it is oftener found divided into two equal
or unequal portions, either partially or completely, internally or only
externally, and sometimes on both surfaces at once. Sometimes
there is a sort of accidental sac superadded to the natural organ,
into which it opens, as in the case related by Dionis; or, on the
contrary, with which it has no communication, as in the example
given by Canestrini. Most generally, the division is at the median
line, either externally and at the fundus, as in one instance furnished
in the Leipsic Commentaries and another related by Eisenmann,
or on the posterior surface, as in Morgagni's case, or on the fundus
and both surfaces at the same time; and then the womb, really two-
horned, resembles more or less that of the quadrupeds. Sometimes
the division comprises only the superior part of the organ, which at
other times is separated quite down, into two portions; sometimes
the two horns unite at an acute angle, and touch at their corres-
ponding surfaces; in other cases they affect a transverse position,
and only unite at the upper end of the vagina, so as to form the cer-
vix. Internally, the septum is also far from being always of the
same magnitude. At times it is only a little spur that divides the
fundus of the uterine cavity into two sinuses, as in the example cited
by Eisenmann. In the specimen deposited at the Museum of the
Faculty, by M. Dupuytren, it is simply represented by a double me-
dian crest, attributable to an hypertrophy of the natural vertical
columns of the cavities of the body and cervix. This septum may
stop at the superior part of the cervix uteri, or descend as low as
into the vagina; it may be complete, and divide the womb into two
perfectly distinct cavities, or may be pierced in some portion of its
length, and allow one of the cavities to communicate freely with the
other. The neck itself may be single, as in the instances related by
Bauhin, Sylvius, Riolan, Celti, Purcell, Marquet, Ferlan, Tiedemann,
Madame Boivin; or double, as in the cases of Grosel, Mademoiselle
De la Marche, Cruger, Bartholin, Haller, Litre, De Tressan, Eisen-

8

78 OF THE SEXUAL ORGANS.

mann, Callisen, Boehmer, Tiedemann, MM. Lallemant, Dupuytren,
Dumeril, Dubois, West, Cassan, Recamier, Gamier and Ollivier
D' Angers, and in a case that I saw in a womb, the account of which
was recently published by M. A. Berard.

198. In all these cases, the uterine orifices opened into a simple
or double vagina, according to circumstances; but in a subject
dissected by Saviard and Duverney, one of them opened into the
rectum, while the other maintained its natural disposition. A simi-
lar case may be found in the works of Valisnieri; at any rate, whe-
ther the OS tincae be simple or compound, whether it be the termi-
nation of a two horned womb, or of one of a perfecdy natural form,
it is not extremely uncommon to see it terminate in the rectum, the
bladder, or urethra, or even in the hypogastrium, above the pubis.

199. Is it now necessary to remark that the question so long
debated, as to double uteri, resolves itself into a mere logomachy?
If by double uterus we are to understand the simultaneous existence
of two wombs, each possessed of two tubes and two ovaries, it is
clear that none such have been met with; if, on the contrary, to
constitute this condition it is only necessary to have a more or less
complete division of the natural uterus into two equal or unequal
parts, each one having its own tube, ovary, cavity and cervix, there
are too many examples, it is an anomaly too often observed, and too
easy to be explained according to the laws of the animal economy,
to permit us to entertain the shadow of a doubt about it at the pre-
sent day.

200. The gestative organ is subject to other irregularities. M.
Baudelocque discovered, and had a drawing made of a preternatural
canal, which extended from the right tube to the cavity of the neck,
passing in the substance of the parietes of the womb. Madame
Boivin also makes mention of a kind of irregular canal which seemed
to form a communication betwixt the ovary and the superior part of
the vagina; and perhaps there is no great difference between this
anomaly and the canal mentioned by M. Gartner. Several authors
have spoken of wombs obliterated either wholly, or in part; either
by a primitive faultiness of the development, or accidentally; the
cervix uteri may present a considerable length and size, as in the
remarkable cases cited by Bichat, MM. Lallemant, Segard, Gar-
dien, &c., and its position may be deranged by preternatural adhe-
sions, which fix one of its faces or edges too near the margin of the
pelvis, either in front, on one side, or backwards. The ovaries may
escape from the pelvis through the openings at the groins, descend
into the upper part of the labia pudendi, or pass over to the side
opposite to that they ought to occupy, and become entangled with

OF THE SEXUAL ORGANS. 79

the tubes in such a manner as to be extricated with difficuUy, as in
a case that fell under my own notice.

201. Vicious conformations of the vagina are not less frequent
than those of the womb. Its total absence is pretty common. MM.
Boyer, Caillot, Willaume, and an infinity of others, have seen it
terminate in a cid de sac above the vulva, and not open externally
at all; in some cases its vulvar opening exists, but is obliterated
above and does not extend to the uterus. All the students of the
school of Paris may have seen a woman of this conformation a few
months since in the wards of the Hotel Dieu. I have observed a
similar disposition in a woman of about thirty years of age, who had
been delivered of a child five years previously, and had not had her
menses since that period.* In M. Sue's case the rectum opened
into the vagina, and the vagina into the bladder; nevertheless, the
vulvo-uterine passage may open into the bladder of urine, without
the bowel being at all deviated from its natural course, as is proved
in the cases related by Maret, Palfin and Cassan; the vagina is more
frequently found to terminate in the rectum at various distances

* I have now a patient under care who is about 19 years of age. The exter-
nal organs are well formed. The pudendum being covered with hair as in a
healthy individual. Upon separating the labia it is found that there is no va-
gina. A shallow cul de sac is all that exists at the bottom of the vulva. A style
in the urethra and a finger in the rectum enable me to know that no vagina is
interposed between the rectum and the urethra. The uterus, or what is sup-
posed to be the uterus, is so large as to occupy the whole excavation, and to be felt
two inches above the brim of the pelvis by a hand externally applied. The pa-
tient has suffered for several years from monthly attacks of the most violent pain,
which is only to be mitigated by large anodyne doses. Hoping to find a portion
of vagina attached to the cervix. Dr. Randolph, by means of horizontal strokes of
a bistoury effected an opening which was large enough to receive the thumb, and
at least 3^ inches in depth — yet, no vagina was discovered, nor coiJd we learn
where the cervix uteri was placed. This artificial vagina was kept dilated with
a golden bougie, which at last was abandoned on account of the pain and irrita-
tion it caused. The distress of the patient increased pari passu with the monthly
growth of the pelvic tumor, which we supposed to be the womb filled with
menstrual blood, and hermetically enclosed. As a last resource, it was deter-
mined to tap the womb, and accordingly Dr. Randolph with great precautions
pushed the point of a curved trocar at least 2i, inches in a direction perpendicu-
lar to the surface of the tumor. No fluid followed the puncture. The patient
had a slight fever afterwards from which she recovered in a few days. Such is
the lamentable situation of this young and estimable girl. The agonies she en-
dures at each menstrual period are pitiable.

For a case of Atresia vaginae in which the womb was tapped, a remarkably
successfiil operation performed by Dr. Randolph, see the Phil. Prac. of Midwifery
by C. D. Meigs, p. 360.— M.

80 OF THE SEXUA.L ORGANS.

from the anus. The septum which divides it is pretty often com-
posed either of a simple froenum, connate or accidental, situated
transversely, or parallel to its axis, near the vulva, or cervix, or
tov(^ards the middle of the canal; or, of a valvular fold, more or less
strong; or, of a real diaphragm. I have observed all these differ-
ences both in the living and dead subject. This septum may give
to the vagina the appearance of two united cylindrical canals, each
having a hymen, as occurred twice to Callisen and once to Eisen-
mann, or a single external opening, as noticed by Bartholin and Hal-
ler; sometimes it exists only above and below, and allows the two
vaginae to communicate with each other, about their middle or near
the neck; most frequently, as remarked by Majocchi, Bcehmer,
Cassan, &c., it does not reach to the vulva, and further, is in general
only the continuation of a similar disposition of the womb.

202. If such observations were good for nothing but to satisfy an
idle curiosity, I should not have dwelt so long on them; but many
of them are closely concerned with the practice of tokology; others
explain several phenomena, of which it would be otherwise difficult
to give any account; sterility, several kinds of extra-uterine preg-
nancy, superfetation, retention of the menses, fecundation and de-
livery through the anus, and want of menstruation, are cases in
point. When the womb is double, if the woman becomes preg-
nant in one side only, and there are, meanwhile, two orifices, quite
separate from each other in the vagina, two different persons, al-
though equally learned, may establish a very different diagnosis,
even during labor. Two distinguished physicians, says Tiedemann,
met together to see a woman who supposed herself on the point of
lying in; having touched her, one declared that the neck was in a
natural state; the other found it dilated, and said that the head was
engaged. Another examination showed them that the neck was
double. M. West laid before the Academy of Medicine a nearly
similar case, collected at the 3Iaternite of Paris: at the commence-
ment of the labor one of the pupils not only thought that dilata-
tion had not begun, but that the neck was not quite effaced; the
other found it dilated nearly one inch; the woman having died in
labor, the post mortem examination showed the reason of this dif-
ference of opinion; the womb, which was double, terminated by a
double OS tincae in the vagina.

203. If by imagining laws we could compel nature to obey them,
I should be content to say with Tiedemann and Meckel, that a ma-
jority of the irregular conformations of the genitalia are only in-
stances of a persistence of their primitive, but natural state of organ-
isation; that the uterus bicornis, for example, depends upon this, that

OF THE SEXUAL ORGANS. 81

the two half cylinders which are said to constitute its first rudiments,
have disobeyed the laws of conjunction discovered by M. Serres;
but, unfortunately it happens in this as in most other cases, the mo-
tives, the causes escape our research, and these brilliant concep-
tions have but one fault, and that is, they do not agree with actual
observation. I am bold to affirm, from numerous researches, that
the womb and vagina in reality present, from their very first appear-
ance, the same form, and the same general characters, as those they
possess after their complete development.

§. X. HerinapBirodi^m.

204. A being in whom two sexes are united is called an herma-
phrodite; this name, according to fable, is derived from Hermaphro-
dite, the son of Mercury (Egft;;j) and Venus (A^goSifi^j,) who was
condemned by the gods to unite his body to that of Salmacis for
having despised the charms of that nymph. Often debated in the
courts of justice in times past, and by the physiologists of all ages,
the question of hermaphrodism or androgyny, almost wholly aban-
doned towards the close of the last century, seems on the point of
coming up again to divide the opinions of the learned. In the mo-
noecious plants, in zoophytes, and various molusca, such as the oys-
ter and snail, the two germs are found to exist in the same indivi-
dual; but the sexes are observed to be separate in the dioscious
vegetables, and in the animal kingdom, in worms, insects, and also
in fishes, reptiles, birds, and mammiferous animals. So that her-
maphrodism in the human species is, at least to all appearance,
contrary to those laws that preside over the grand distinctions of
living beings. Notwithstanding this, M. Tiedemann, setting out on
the principle that the embryo is at the beginning neither male nor
female, admits the possibility of hermaphrodism, and his opinion is
maintained in Germany by M. Meckel and several other physiolo-
gists. It is true that a strange assemblage of organs has been fre-
quently noticed, which, though in the same subject, appeared to
belong to different sexes; but all cases of this sort, when divested
of the marvellous with which ignorance or the love of the marvel-
lous has clothed them, may be easily classed with some kind of
monstrosity of one or the other of the sexes. No individual has
ever been seen to possess both the male and female genital organs.
On some occasions an enormous clitoris has induced the belief that
the individual was at once male and female, and, like some of the
gasteropoda, capable both of fecundating and being fecundated.
Sometimes it is a slightly developed penis, an hypospadiaeos, a slit in
the scrotum, that have been mistaken for a vulva and clitoris, as in

82 OF THE SEXUAL ORGANS.

the case recently presented to the Academy by M. Ruillier, and that
which all the physicians in Paris may have had an opportunity to
examine in a man who exhibited himself for a long time here to the
public. At other times it is either a prolapsion or a prolongation of
the cervix uteri which inexperienced observers have mistaken for a
penis, as happened with the judges of Toulouse in the famous affair
of Margaret Malaure.

In certain cases, however, one might be considerably embarrassed
in forming an opinion: a person who possessed all the external
characters of a pretty woman, presented herself to M. Marjolin, and
begged him to examine her and inform her to which sex she belong-
ed: in the labia of a pretty well formed vulva, the professor felt
two oblong tumors, which were of the size of the male testicles;
there was a vagina which terminated in a blind sac behind the
pubis, and the bladder opened under the root of a body, which
bore a much stronger resemblance to the penis than to the clitoris.
Professor Mayer dissected a child six months old, that had no vulva,
but a penis perforated Avith an urethra, and on the sides of which
were observed two small roundish tumors inclosed in a fold of skin,
and yet it had an uterus.

205. I think, without, however, being able to affirm it, that the
person examined by M. Marjolin was a female, with congenital her-
nia of the ovaries and preternatural development of the clitoris; M.
Mayer's case was certainly a girl, also affected with hernia of the
ovaries, and whose vagina opening into the bladder, was continuous
with the urethra.

206. It may therefore be admitted, agreeably to the sentiments of
M. Marc, that hermaphrodism is only apparent, and its species may
be divided into three genera: one in which there is monstrosity in the
male; the second, in which the feminine sex cannot be mistaken;
and the third, in which it is not so easy to characterise the individual.
The Memoirs of the Academy of Sciences, those of the Academy
of Dijon, the Philosophical Transactions, the Bulletins of the Fa-
culty of Medecine of Paris, a Memoir by M. Pierquin, almost all
the scientific collections, a work by the learned German professor
Burdach, contain numerous cases more or less analogous to those I
have above analysed.

83

CHAPTER II.

Functions of the Sexual Organs.

ARTICLE 1.
Of Menstruation, or the Catamenial Discharge.

207. Puberty, or the marriageable age, is announced in girls, a?
it is in boys, by numerous changes. The general organisation,
which, until that period, had progressed alike in both beings, seems
suddenly to take an opposite direction in each. The young girl be-
comes more timid and reserved; her form becomes more rounded,
her voice alters, but to take on a softer and more harmonious tone;
her bosom is developed; the cellular tissue extends from the front
of the breast and the hypogastrium, as from two centres, towards the
neck, while it at the same time proceeds to form a soft cushion for
the upper part of the limbs. Her eyes, which are at once brilliant
and languishing, express commingled desires, fears, and tenderness;
the sensations she experiences, and the sense of her own weakness,
are the causes why she no longer dares to approach the companions
of her childhood but with a downcast look. On the other hand, the
gentle modesty that animates her countenance, and the seductive
graces of her demeanor, soon disclose a power whose existence
she never suspected, and which renders it true to say that the mar-
riageable age in the softer sex is the spring tide of nature and the
season of the pleasures; but a new function, the catamenial, the abso-
lute compass of good or bad health in women, is established with
more or less difficulty in the midst of this great revolution, and by
the disorders or accidents which it involves, sometimes dashes with
bitterness those happy seasons to which it should naturally serve as
the prelude.

208. Definition. Menstruation consists in a sanguineous dis-
charge from the sexual parts. It is a natural function, to which
women have in all ages of the world been subject. The supposi-

84 OF MENSTRUATION.

tions of Emmet, of Roussel, of M. Aubert, &c., who think that the
menses are the result of civilisation, appear to me wholly unfounded.
Neither is it true that the women of the arctic pole, the aborigines of
Brazil, and of some other countries in America, are exempt from
them. Nothing, however, of the kind exists in animals, with the
exception of the ourang-outang, some of the monkeys, and the bat,
which, according to some naturalists, are subject to a periodical dis-
charge. If, in other species, such as the quadrupeds, the cetaceae,
birds, (fee, we sometimes find that a colored mucus escapes from
the cloaca or vulva, it will be, in general, only at the approach of the
season for copulation, and it would be unreasonable to compare this
phenomenon with the function of menstruation.

209. The menses, still known among the common people as the
regies,* luncs, mois,Jleurs orjlueurs, purgation, affaires, and epo-
qiies, appear at puberty, and cease with fecundity, during pregnancy,
and while the woman gives suck. As soon as they appear, fecunda-
tion is possible, and as long as they continue to return at the natural
period, we may conclude that the woman has not conceived. Ob-
servers have often made mention of women who were not regulated,
and had never been so, but who enjoyed, nevertheless, a good state
of health; it is to be observed, however, as remarked by Linnaeus,
that they were sterile. I am acquainted with a lady who is not re-
gulated, ruddy, and of a good size, in blooming health, married for
ten years, whose greatest desire is to become a mother, but who has
lost all hope of becoming so; her husband, moreover, is young, loves
her tenderly, and before he married her had begotten a child by an-
other woman. I have seen another at the hospital of Tours, who
had never seen any thing, as she expressed it, but who, notwith-
standing, was the mother of a strong and healthy son of fifteen or
eighteen years of age. It seems to me to be almost certain that the
absence of the menses generally depends upon some faulty confor-
mation of the womb or its appendages; so that it may be easily con-
ceived that it is generally a sign of sterility. Deventer and Baude-
locque have known women who were never regular except during
pregnancy, and I have collected several similar cases.

210. Eruption. In our temperate climes the menses commence
between the twelfth and sixteenth year; a little earlier, from eight
to twelve years, in southern climates; and a little later, from fifteen
to twenty years in the north. Some travellers even pretend that the

* I have left the French terms in this place untranslated, for they are unsus-
ceptible of translation. I have preferred to give in a note the English names in
common use. They are menses, flowers, monthly discharge, show, regular dis-
charge, monthlys, time, and most commonly they are alluded to with a nod. — M.

OF MENSTRUATION. 85

Turkish women, are capable of becoming mothers at the age of seven
or eight years. Dr. Prideaux, for example, relates that Cadijah,
aged five years, was regular when Mahomet espoused her. But
this story, like most others that come from countries of whose man-
ners and customs we know so little, is only a popular tale, for I
find in a faithful translation of the Koran, that Cadijah was upwards
of forty years old when she married the prophet. Others tell us,
that near the poles, and on the northern slopes of mountains, it is
not uncommon for the menses, not to appear until the twenty-third or
twenty-fourth year.

211. The discrepancies presented by opposite climates in mass,
is found to be true in the details in every country, and occasionally
in every province and city. A country life and occupations, sim-
plicity of manners, a frugal regimen, like the temperature of northern
regions, procrastinate the first menstrual epoch; a life of leisure, the
imitative arts, such as painting and music, the habit of frequenting
balls, the theatre, lascivious books and pictures, good living, the use
of stimulating drinks, and living in populous cities, tend on the other
hand, like the temperature of the equatorial latitudes, to accelerate its
appearance. It is less precocious also in a robust woman, of a
lymphatico-sanguine temperament, very fat, and whose sensibility is
not very acute, than in those who are thin, delicate, nervous, irri-
table and sanguine. Even at Paris, girls are occasionally observed
to become regular at ten, eleven and twelve years: I know two who
were so, one at nine and a half, and the other at ten and a half years;
and I am in the habit of visiting a family where the young lady, who
at fourteen, is as tall and robust as a majority of women at twenty,
has been entirely in a state of puberty since she was eight years and
a half old. Children are also spoken of who were regular at birth,
or between the first and fifth year of their age, but it is reasonable to
suppose that this discharge must have been owing to some disease,
or at least had nothing in common with the catamenial flow. On
this subject I cannot however withhold a case recently made public;
it is that of a young girl at Havannah, whose menses appeared first
when she was eighteen months old, and have since that continued to
return once a month; the child, moreover, has a bosom, a very de-
cided character of countenance, and all the marks of anticipated
puberty. Other persons also are seen at this capital, who did not
menstruate until their seventeenth, eighteenth, nineteenth, or twen-
tietii years. Osiander noticed at Gottlngen, that of one hundred
and thirty-seven women, nine became regular at twelve years of
age, eight at thirteen, twenty-one at fourteen, thirty-two at fifteen,
twenty-four at sixteen, eleven at seventeen, eighteen at eighteen, tea

86 OF MENSTRUATION.

at nineteen, eight at twenty, one at twenty-one, and one other at
twenty-four years of age.

Preceded, commonly, by a sense of general lassitude, of uneasiness
in the limbs, of weight in the loins, of heat, of tension in the epigas-
trium and perineum, by a slight pruritus of the sexual parts, by a
mucous discharge, that is clear or yellow, and more or less abundant,
it happens also that the first eruption of the menses is in many women
effected without its being announced by any precursory symptoms; it
is then rarely abundant, nor does it commonly last more than two or
three days. In general they do not become regular until after three
or four periods; in the succeeding appearances, the discharge lasts
variously from a few hours to a week, but the average term is four
or five days.

212. The quantity of blood that escapes amounts, according to
Hippocrates, to two colylse, or to eighteen ounces according to
Galen. Haller computes it at six, eight, or twelve ounces, and Bau-
delocque at only three or four ounces; in general it is more profuse
in persons and places where its appearance is most precocious, so
that European women who go to inhabit a warm climate, as for
example Batavia or Java, often perish in consequence of their pro-
fuse menstrual evacuations. M. Desormeaux has remarked, and I
have also had occasion to observe it, that country girls who come to
Paris to go to service, not unfrequently find that their menses are
stopped or considerably diminished. As the different periods are not
always alike in the same woman, as they are sometimes more abund-
ant or less so every second or third period, alternately, it is impossi-
ble to have any certain data on this subject. Again, as the blood
that flows from the organs can only be collected on cloths or in
vpater, it is manifest the observer must frequently make up an erro-
neous opinion, and that he ought to count upon obtaining merely ap-
proximative results.

213. Nature. The minds of the ancient physiologists were
strongly exercised in regard to the catamenial blood. It is similar,
says Hippocrates, to that of a slaughtered animal; or again, accord-
ing to Aristotle, to that which flows from a simple wound. There
are now but few opponents of this system among medical men. But
very different ideas prevailed at Rome in the time of Pliny, and are
still very commonly upheld among the public. If we might believe
the celebrated Roman naturalist, the menstrual fluid, endowed with
the most noxious qualities, would be considered as a dangerous poison,
whose exhalations alone are sufficient to turn all the sauces of a whole
kitchen, the cheeses of a whole dairy, to make a whole family sick, and
wilt all the flowers of a parterre; travellers inform us that even now,

OF MENSTRUATION. 87

in some parts of America, women are so much dreaded during their
pienstrual periods, that they are forbidden to go out of doors except
in cases of urgent necessity; and further, that they are obliged to
wear a mark that advertises people of their situation, so that they
may flee out of their way. While ridiculing, as they deserve, such
fables as these, the moderns have perhaps too much neglected that
portion which may be true. It is very rarely that a vulgar prejudice
does not contain some truth. If we reflect on the odor derived
from the different secretions of animals, or the aroma exhaled from
the skin of certain women, is it fair to reject without distinction all
that has been said in relation to the menstrual excretion? I am
certainly far from giving credit to the peculiarities related by Pliny,
Columella and the Arabians; but I do not see why the miasms that
escape from a female during the flow of her menses, should be in-
capable of turning a fluid so easily afl'ected as milk, nor why it could
not possibly have the same effect on certain sauces. Besides, it is
evident that blood retained for some time within the sexual organs,
particularly of women who are inattentive to cleanliness, may, by
being decomposed, acquire certain deleterious properties.

Its odor is too variable to permit us to compare it to the marigold,
rather than to any thing else. From its being found fluid, although
long retained in the womb, we are not authorised to conclude with
M. Lavagna, that it contains no fibrine; we too frequently see it es-
cape in clots from women who get up to walk about after having
been long in a sitting posture, to be able to say with Dionis, that
menstrual blood never coagulates. According to all appearances, it
contains less fibrine than that from other parts of the body, but is not
entirely without it. Being mixed with the mucous and serous mat-
ters naturally furnished by the internal surface of the genital organs,
the menstrual blood is thus rendered more viscous; and ought not to
exhibit the same characters as that which escapes from a wound.

214. Progress. The menstrual fluid is, in most women, at first
very liquid, serous, scanty, and not high colored; its consistence
and quantity increase on the second day; on the third it is in almost
every respect similar to the blood that escapes from the nose in
epistaxis; the fourth restores to it the characters of the second, and
on the fifth its appearances are analogous to those of the first; some-
times, on the contrary, the evacuation has a slower course, and is
not really abundant until the fourth or fifth, while in others the blood
flows from the commencement in as great a quantity as on the second
or third days. In some cases it appears one day, does not return
the next, and flows in abundance afterwards. It most commonly
comes away in the shape of simple small drops, which flow fast.

88 OF MENSTRUATION.

and some women are obliged to be very careful to prevent it from
falling in quantities to the ground.

215. The periodical return o( the menses ordinarily takes place
every month, as their name indicates, or rather every twenty-eight or
twenty-nine days which brings them into relation with the lunar
periods; in an infinity of people they are observed to recur at nearer
or remoter periods; sometimes only twenty-two, twenty, eighteen,
and even fifteen days elapse between each catamenial revolution; I
know a person who is never more than twelve days free from it;
and I have the care of another who is almost always affected with it,
but who in other respects is in good health, only she is thin, and of
an extreme sensibility. These frequent returns of the menses, with-
out any peculiar change in the health, are particularly to be ob-
served in warm countries, and in nervous women. The emaciation
which attends this state is at the critical period frequently succeeded
by plumpness more or less decided, as if the sanguine discharges to
which nature had become accustomed were now turned to the
benefit of the whole organism!

Others are regular every thirty-second, thirty-fifth, or fortieth day,
and even every two or three months, without being in the least in-
commoded, as is pretty frequently observed to be the case in Green-
land, Lapland, and other cold countries; and neither is it uncommon
to observe the same thing in our own country places; but none of
these anomalies contradict the principles established by physiolo-
gists in all ages.

216. Without daring to set up the simple results of my own ob-
servations, in opposition to those who assert that all women are
regular in the first fortnight of the month, half from the first to the
eighth, and the rest from the eighth to the fifteenth, I cannot refrain
from stating that I have seen as many who were menstruating at
the close as at the beginning of each month in the year; I therefore
do not believe it possible to establish any thing certain on this head.

217. Causes. Physiologists have been for a long time divided in
regard to the causes of menstruation, and at the present day even,
every thing seems to indicate that there will not be a unity of senti-
ment very soon on this point. Some authors have stated, with Aris-
totle and Galen, Simson, Astruc, and M. Lobstein, that the meuses
depend upon a general or local plethora, upon a superabundance of
blood: others, with Osiander, pretend that the menses are occa-
sioned by too large a proportion of carbon and azote being contained
in the blood of the uterus. Dr. Clifton refers them to the relative
weakness of the venous parieles, and to the perpendicular effort of
the blood. Paracelsus, Sylvius, and De Graaf think they are pro-

OF MENSTRUATION. 89

duced by a principle of fermentation: Stahl and M. Duges suppose
they arise under the influence of an irritamentuin or peculiar moli-
men; Emmet, who attributes them to an erection, and Lecat, who
qualifies them as an amorous phlogosis, suppose them to be the
effect of venereal desires. But who does not herein perceive that
vain show of words so prodigally made use of in ancient physiology,
or, that such suppositions as these only serve to protract, without
solving the problem?

218. The periodicity of the menses has not been explained any
better than their general cause. Aristotle, Vanhelmont, Mead, and
even our elegant Roussel, attributed it to the influence of the moon.
From the physicians, this opinion has passed among the people, and
the poets have converted it into a proverb by the following verse:

Luna vctus vetulas, juvenes nova luna repurgat.

But to show its fallacy, we need only recollect that the same
woman may be regular at difllsrent lunar phases, once in the space
of several, or even of one single year; however, this is a point on
which there is need for new researches, and for the complete clear-
ing up of which, numerous observations would be required.

219. Many attempts have been also made with the view to ascer-
tain the final causes of menstruation, but it must be confessed with
equally ill success. What in fact is proved by saying that this func-
tion disposes and maintains the uterus in a state apt for fecundation;
that its suppression during pregnancy permits the ovum to grow and
be developed without weakening the female? It is generally quite
well kuown that conception does not take place until the menses
have appeared, nor after they have ceased to return; but the why
and the how are not known: they are the sign and not the cause of
fecundity; the absence of the menses does not produce sterility; but
women, who do not menstruate are often found to be sterile, because,
in either case something is wrong in the state of the genital organs.

220. Seat. The seat of the menstrual discharge is another sub-
ject on which the naturalists continue still to dispute. The Greeks,
the Arabians, and a majority of writers of all ages place it in the ute-
rus; but Columbus, Severin Pineau, Bohn, as well as a crowd of
moderns, and among them M. Desorraeaux, have seen the menses
escaping immediately from the vagina, or the different parts which
constitute the vulva; the uterus, it is said, cannot furnish them when
they flow during pregnancy.

221. It appears to me to be easy to reconcile these opinions.
The blood of the menses undeniably comes from the uterine cavity
in the majority of instances; facts the most multiplied and authentic

9

90 OF MENSTRUATION.

prove it incontestably. Thus, in persons whose menses had been
long suppressed, in consequence of disease, or had never appeared,
in consequence of some faulty organisation of the vagina or vulva,
the womb has an hundred times been found full and distended with
blood ; in others who died while menstruating, the cavity of the
womb has been seen covered with ecchymoses, and sometimes filled
with clots of blood. If the os tincae be confined in the cupule of a
pessary with a cylindrical opening passing through it, the blood will
be found to escape therefrom: when there is a prolapsus, it may be
seen distilling from the cervix; and in the natural state, we find by
placing the finger between the lips of the os tincae, that the fluid
escapes from the part.

222. On the other hand it is equally certain that it has sometimes
been seen to exude from the interior of the vagina or vulva; I do
not perceive, indeed, how it can be otherwise in a woman who con-
tinues to menstruate during her whole gestation. But these cases
are exceptions, anomalies, and do not invalidate the general rule :
menstruation is then deviated from its general route, as is the case
when it takes place from the urethra, the rectum, the pulmonary
passages, the breasts, or some portion of the tegumentary surfaces.
These irregularities, moreover, are rare, and appear to have been
in more than one instance the effect of real disease.

223. Source. Attempts have been made, also, to ascertain the
immediate source of the menses, one party placing it in the veins,
alono- with Vesalius; in the arteries, with Ruysch; or the capillaries,
with Winslow and Meibomius; others think it is to be found in cer-
tain particular glandules, as Lister; or in peculiar little receptacles,
as Simson; or lastly, with Astruc, in a supposed set of venous sinu-
ses. There are as many gratuitous suppositions as there are opi-
nions, all of them referring to a question as idle as it is difficult of
solution. The menstrual blood escapes from the womb by exhala-
tion or by perspiration, as in all the lieraorrhagies of the mucous
membranes, but without our being able to learn whether it transudes
from the venous rather than from the arterial capillaries, and vice
versa. In this respect, whether the discharge be derived from the
body or cervix of the womb, from the vagina, or elsewhere, the me-
chanism of the function is always the same, and that is what it im-
ports us to know.

224. Cessation. The age at which the menses cease to appear
is not less variable than that of their first eruption. Most generally
it is from forty-five to fifty years; but some women are exempted
at the age of forty, or even at thirty-six, thirty, twenty-six, or twen-
ty-four, as in the instances cited by Haller and others, and of which

OF MENSTRUATION. 91

I also have known several. Some continue to menstruate without
any inconvenience until fifty-five, sixty, sixty-five, and even seventy
years of age. Cases are related of persons who have lost them at
the usual period, and become regular again at eighty, ninety, ninety-
five, or, according to the report of Blancardi, even at one hundred
and five years of age. But, as M. Desormeaux remarks, although
these kinds of return are not rare at sixty, seventy, or seventy-five
years, it is at least certain they ought rather to be considered as the
sign of some disease, than as a real resumption of the menstrual func-
tion. However, in the fact itself, there is nothing which the laws
of the animal economy render incomprehensible. In the same man-
ner as certain plants sometimes flourish a second time in autumn,
after having been withered at the close of spring, so, also, a woman
may, under certain circumstances, return, as it were, to her young
age again, when she is just touching the decline of life. It is a last
effort of nature to restore a more prosperous season, but which
serves, unhappily, only to hasten a dissolution which she in vain
desires to retard. Thus it appears that, in the natural order, the
menses ought to cease between the fortieth and fiftieth years in our
temperate climes; between thirty and forty in warm climates, and
from forty-five to fifty under the colder zones: in other words, their
whole duration is, every where, near about thirty years; where they
are precocious they disappear sooner, and where their appearance
is more tardy they are also prolonged to a later period of life. All
cases that are in opposition to this general rule, ought, in my opi-
nion, to be registered as among the exceptions, or regarded as pa-
thological.

225. The change of life (^age du rilour) is marked by the gradual
disappearance of the charms of puberty; the bosom and the cheeks
become flaccid, the skin is wrinkled, appears to be too large, and
loses its delicateness; the eyes sink in the orbits; the carnation of
the cheeks is supplanted by a yellowish tint; that empurpled blush
which once, amidst smiles, sat on her rosy lips, is chased away by a
bluish and leaden hue; every circumstance proclaims that the sea-
son of the pleasures is past, and that she can no longer rely on the
attractions peculiar to the sex. It is, therefore, very properly, that
this period is called the critical time, or critical age; but attempts
have been erroneously made to justify these epithets, by reference
to the numberless dangers with which, according to the general opi-
nion, women are at this period surrounded. In fact, the statistical
researches published by Moret and Finlayson, MM. Chateauneuf
and Lachaise, prove that not more women than men die between
the ages of forty and fifty years. Nevertheless, the menses rarely

92 OF MENSTRUATION.

cease suddenly, or without occasioning some disorder: on some occa-
sions their suppression is preceded by a gradual diminution of the
duration of each period, and of the quantity of blood lost; or on the
contrary, by an increase which sometimes converts them into a
pretty abundant hemorrhage; sometimes they cease, return again to
cease and return, before a final stop is put to them; they become
irregular in character; a mucous discharge is established; lassitude,
sense of suffocation, nervous complaints, even severe diseases occur
in some cases; but in others, also, nothing of all this is observed to
happen, and the health, which up to that period had been precarious,
becomes quite confirmed; strength is restored; the emaciated indi-
vidual grows fat, and finds nothing but benefits in the loss of her
catamenial discharges.

ARTICLE II.

Of Reproduction.

11^. Designed for the perpetuation of species, reproduction is a
function peculiar to living beings. Inert bodies are produced, but
never reproduce. "Without contradiction, reproduction constitutes
one of the most astonishing phenomena of animated nature: and
how many efforts have been made, from the beginning of time until
now, to ascertain its mechanism! Indeed, ought not man, whose
prerogative it is to think, first to endeavor to understand himself?
Can any thing in the universe interest him so much as his own ori-
gin? Yet these efforts so multiplied, these researches so ably con-
ducted, and these labors, of all sorts pursued so perseveringly by
the most celebrated men, have hitherto scarcely served to any other
end than to show him how deep is the mystery that veils the com-
mencement of his existence.

227. Pythagoras and his disciples said that the embryo is formed
out of the menstrual blood, and a kind of moisture that descends
from the brain during coition, and that it is developed according to
the laws of harmony.

228. Empedocles and Hippocrates, who are not less obscure than
the former on this subject, thought that both the male and female
enclosed the molecules of embryos of both sexes, and that these
molecules were united in the womb during the sexual union.

229. Aristotle, with certain modifications, reproduced the idea of
Pythagoras, and by an ingenious metaphor, made of the womb a real
sculptor's shop, where the woman furnished the marble, the man
brought the workman, and the embryo represented the statue.

OF REPRODUCTION. 93

230. Galen set forth an opinion diametrically opposite to that of
the celebrated naturalist of Stagyra; he insists that the embryo is
produced from the semen of the male, and that the material furnished
by the woman serves solely for its nourishment.

231. R. De Graaf thought he could demonstrate that all animals
come from an egg, and says that in the human species itself, the
germs exist in the ovary, in the form of ovules, or little transparent
vesicles. The ancient doctrine, entitled the system of mixed germs,
was soon generally abandoned, while the new hypothesis, known as
the system of ovules, spread with the rapidity of lightning. This is
the doctrine that prevails at the present day; but as may well be
supposed, it has not reached the nineteenth century without hav-
ing experienced numerous modifications. According to De Graaf,
Meckel, &c., the little ovule is only a kind of rudimental embryo,
which is only waiting for life in order then to commence its own de-
velopment; and this life can only be imparted to it by the prolific
semen of the male; according to Ruysch and Haller, the seminal
liquor is conveyed unaltered, by the Fallopian tube, to the ovary,
while others think that a very subtle vapor, an aura seminalis, only
is detached from it, and which produces the same effect; several wri-
ters have advanced the opinion, that the semen, at first absorbed in
the vagina or uterus, and carried from thence into the torrent of the
circulation, does not return to the ovary to fecundate a vesicle until
it has undergone several elaborations.

232. Soon after the discovery of the ovules. Ham, Harstoecker,
and Lewenhoeck affirmed that the germs exist, quite formed, in the
reproductive fluid of the male; that these germs, which they called
animalcules, are living; that a single drop of sperm contains many
thousands of them; that being projected in the act of coition into
the uterine cavity, they all perish with the exception of one, or more,
which are fortunate enough to reach the Fallopian tube; that one
of them reaches the ovary, enters and lodges in % vesicle prepared
for that purpose, and afterwards returns to the womb in the shape
of a litde ovum, &;c. Hence is established a new system, since
called the system of animalcules, a system which gives to man an
immense share in the act of fecundation, while the ovular hypothesis,
as understood by De Graaf, attributes almost the whole of it to the
woman.

233. Harvey, supported by the munificence of a great king; Hal-
ler, with his extraordinary talents; Spallanzani, with that good faith
and spirit of observation for which he was so remarkable; for the
purpose of clearing up this great question, multiplied their experi-
ments almost infinitely, and their labors have led, or seem to lead,

9*

94 OF REPRODUCTION.

to this common conclusion, to wit, that the union of germs takes
place in the ovary, and that the development of the product of
fecundation is a simple evolution, and not an epigenisis, as was for-
merly maintained.

234. Nevertheless, the doctrine of epigenisis has never been
wholly abandoned; Maupertuis still defended it in his Venus Phy-
sique, published in 1754, asserting that the seed of the two sexes is
formed of particles that are never commingled save in the womb,
just as certain chemical elements mutually attract and combine with
each other. Buffon was even very near reviving it, by presenting
it in a new light: this celebrated writer supposed that at the moment
when the venereal enjoyment was at its greatest height, there were
separated from every portion of the body, and of the two conjoined
bodies at the same moment, a determinate number of organic mole-
cules; that each of these molecules possessed a figure proportioned
to the part of the body from whence it was disengaged, but which
are similar in the two sexes; that having reached the uterus, all the
similar molecules are mutually attracted towards each other, so that,
for example, those that were furnished by the eye, the nose, the ear,
or the arm, the lung, or the heart, or finger of the woman, can only
combine with the molecules from the eye, nose, ear, arm, lung, heart
or finger of the man.

235. Not one of these opinions is wholy destitute of foundation;
not one but has been defended with talent, and combated by very
good arguments; none without its partisans and antagonists; but the
nature of this work not admitting of my entering into very long de-
tails so as to exhibit the just value of each of these doctrines, I shall
leave the subject with what has been above said.

236. Reproduction, in those beings that occupy a high grade on
the zoological scale, is an extremely complex act; in order to a
good understanding of it as a whole, it ought to be analysed, in some
measure, in the several gradations of the animal kingdom. In the first
place, it is proper to remark, that the words reproduction, generation,
fecundation, conception, have each a distinct grammatical accepta-
tion, and it is wrong to employ them as synonymes, especially when
speaking of mammiferous animals. The word reproduction, for ex-
ample, is applicable to the whole function, while generation ought
to be understood as meaning the simple creation of germs; the term
fecundation, in its turn, only expresses the act which unites the two

germs, or by which one of these germs vivifies the other; the word
conception, which signifies to retain, can only be reasonably employ-
ed to designate the action which causes the fecundated germ to be
retained within the sexual organs; lastly, the word reproduction is

OF REPRODUCTION. 95

the general term, while the three others belong only to separate
phenomena, which may either exist unconjoined or altogether, ac-
cording to the class in which they happen to be observed.

237. Thus polypi, which reproduce themselves by germs, have
generation, but no fecundation nor conception. The batracian rep-
tiles also produce germs; but these germs are of two species, those
of the male, and those of the female; they must be mixed in order
for reproduction to take place, but as the mixture is effected exte-
riorly, the batracians have no conception, although they have both
a generation and a fecundation. In birds there is retention of the
fecundated germ, and consequently, generation, fecundation, and
conception. In the mammiferae and man, the vivified and conceived
germ is developed within the animal; and there is, further, in these
cases, gestation, and even expulsion or parturition, at the end of
pregnancy. The function of reproduction then is composed, in the
human species, 1. Of generation, or the formation of the germ;
2. Oi fecundation, or the vivification of the germ; 3. 0( conception,
or the retention of the vivified germ; 4. Of gestation or pregnancy;
5. Of parturition or the expulsion of the ovum.

SECTION 1.

Of the Generation or Procreation of Germs.

238. In the infusory animals which break to pieces of themselves,
and the zoophytes which we reduce to fragments that give birth to
an equal number of entire beings, germs are nothing more than
analogues of the general mass of the individuals from which they
have been separated. Their generation is, in this respect, analo-
gous to that of those plants that are multiplied by slips or grafts.
A little further on in the scale, germs cannot be produced except by
peculiar organs which constitute the sexes, and in that case the
sexes are sometimes united in the same individual, sometimes they
exist in two different individuals. Snails, oysters, a pretty consi-
derable number of other molusca, and all the monocecious plants
are in the first case, that is to say, they are hermaphrodites; the
dioecious plants, and almost all animals are found in the second; so
that reproduction is here bi-sexual, and the male and female germs
are always furnished by different individuals.

§. I. Of the Female Crerm.

239. In ascending the scale from fishes up to women, the female
germ appears to be formed in the ovary (233); it is always found

96 OF REPRODUCTION.

to present itself under the appearance of a vesicle, known by the
name of ovule. In ireptiles and birds the ovule is very large, com-
paratively to that of women; in all the mammiferae its reproduction
is extremely simple: the ovary is a gland whose special function it
is to secrete ovules, as the liver secretes bile, &c. MM. Prevost
and Dumas assure us that they have proved that the ovules are really
formed by the ovary, and by nothing but the ovary; that they always
exist in this gland, in adult females, who are capable of fecundation;
that they are not developed until puberty, and are not found in old
age; that animals that copulate at all seasons of the year also have
them without interruption until they become sterile, while on the
other hand they are only met with at the season of copulation in
those animals that have only one rutting time in each year.

240. These vesicles, at first very small, grow at last to the size of
a hempseed. As in fowls, they do not all grow at the same time;
one or two generally exceeding the rest, and reaching the state of
maturity first. Their coats are then thick and opake, rise more or less
above the surface of the ovary, and seem as if they would burst its
investinor membrane. At this period of its evolution the germ is
composed of two small coats, one external, the largest adheres to
the tissue of the ovary; the other, internal, smaller, really constitutes
the ovule, while MM. Prevost and Dumas propose to restrict the
name of vesicle to the former.

241. After the discovery of the ovules, and particularly during the
last century, philosophers were desirous to know whether they are
transmitted from the mother to the daughter, together with the prin-
ciples of her organs; or whether, on the other hand, they are not
formed until the age of puberty. This question, which gave rise
to the celebrated theory of the encasmg" of germs one within another,
has been especially argued by Swammerdam, Haller and Bonnet.
The latter insisted with great zeal, that we ought to carry back the
orio-in of the human beings that now cover, have covered, or will
hereafter cover the globe in all succeeding ages, to the ovary of the
first woman; that is to say, that the ovaries of the first woman must
have enclosed, shut up one within another, the germs of all the ge-
nerations that have succeeded, or will hereafter succeed; in a word,
the whole human race. But these infinite divisions, in which the
imagination loses itself, have caused the idea of the pre-existence of
germs to be rejected, and at the present day they are regarded as the
results of a mere secretion.

§. II. Ol* tiie male Germ.

242. The germ furnished by male animals, is a whitish, viscid

OF REPRODUCTION. 97

liquor called seed, prolific matter or seminal fluid i when this
liquid escapes from the urethra, it is composed of a substance se-
creted by the testicles, of the fluid exhaled from the vesiculae semi-
nales, and of the prostatic liquor. But which of all these various
elements is the fecundating principle? It is not the aura seminalis;
for Spallanzani could never fecundate the eg^s of frogs without
bringing them into immediate contact with the seminal liquor of the
male. Does it result from the mixture that I have just mentioned?
No; for the fluids furnished by the vesiculae seminales, the prostate
and the urethra, can only be regarded as the vehicle of that derived
from the testicles. Does it depend upon the animalcules named after
Lewenhoeck? Several authors maintain the affirmative, and their
opinion has found numerous echoes in various parts of the learned
world.

243. According to Lewenhoeck, the animalcules are microscopic
corpuscles, endowed with the faculty of moving in a determinate di-
rection, and for a determinate end. Their large extremity, which
is also flattened, gives origin to their caudiform portion, which is
delicate and very much elongated. According to some of his parti-
sans, they may be divided into young, old, adult, weakly, strong,
male and female, Sic; and Plantade, of Montpellier, under the
assumed name of Dalempatius, refining still more on what had been
already advanced upon this subject, made out of a drop of prolific
liquor, a well governed nation; he imagined a king, princes, minis-
ters, magistrates, paupers, rich persons, merchants, soldiers, chil-
dren, old men, &c. Raillery produced, on this occasion, an eflect
that could not be brought about by the most peremptory reasoning.
The animalcular hypothesis appeared to be absurd, and thenceforth
nobody dared to advocate it.

244. It is true that it had already been asserted that these corpus-
cles exist, and that they sometimes exhibit the form that had been
assigned to them, but that they also appear on some occasions un-
der another form, and that they do not in any case belong more
peculiarly to the seminal liquor than to any other of the animal
fluids; in a word, that they do not play any special part in the act
of reproduction, or at the least, they are not the essential agents of
fecundation.

245. According to MM. Prevost and Dumas, the animalcules de-
scribed by Lewenhoeck do not exist except in the male organs of
generation, aijd diff'er from the mobile globules of the other fluids of
the organism by their form, which is always the same in the same
zoological species; by their mode of progression; by the situation in
which they are found, &c.; they always have an enlarged extremity

98 OF REPRODUCTION.

and an elongated portion; their head, which is sometimes oval or
almost circular, sometimes lozenge-shaped, at others resembles the
catkin of the bulrush; but as it is at the same time flattened, it can-
not be recognised, except when seen in front. Their point, some-
times straight, very long, and conical as in the dunghill cock, some-
times short and fine as in the dog, at others very long and flexuous,
pretty much resembles the tricocephalous worms, or the slenderest
worms that inhabit the human body. Upon the whole, the spermatic
animalcula has a general resemblance to the tadpole of the batracians;
its dimensions do not exceed one, two, or three hundredths of a mil-
limeter; it is not to be seen in the seminal liquor previous to the age
of puberty, nor in old men, nor in the interval of the seasons at which
certain animals copulate, nor in the mule, which, as is well known,
is incapable of reproduction; it is not met with in the matter furnish-
ed by the urethra, the prostate, or the seminal vesicles, and it is to
be found with the same characters in all those animals that are wholly
or partially deprived of these organs. It is produced by the testicle
which secretes it. Every prolific animal contains it in its prolific
gland, and frequently in its deferent duct. The movement of these
corpuscles seems to take place under the influence of a will; they
always move forwards; they can be killed by an electric discharge,
and thenceforth their motion ceases to be active. In escaping from
the formative gland, the viscous matter in which they are enveloped
is too thick to permit them to exercise any visible motion; but it is
only necessary to mix them with some other liquid, or permit them
to become diluted in the seminal vesicle or urethra, in order that their
mobility should come immediately into play.

246. Simple microscopic globules, on the contrary, have neither
head nor tail, are round or of irregular shapes, sometimes larger and
sometimes smaller, and move only under the influence of some ex-
ternal impression, and without any determinate end. They exist in
all the fluids of the economy, in the blood, in the serum, in the milk,
even in the spermatic liquor, before puberty, as well as at all other
periods of life, and in all animals.

247. MM. Prevost and Dumas by their numerous experiments on
artificial fecundation, became convinced that the animalcules alone
constituted the germ; they never effected a vivification when the
liquid they made use of did not contain them, or when these living
molecules had been killed or destroyed in any way, whereas fecunda-
tion took place whenever the liquor they employed contained even
a few animalcules.

248. Although the experiments of these physiologists bear marks
of the greatest good faith and accuracy, I cannot, nevertheless,

OF REPRODUCTION. 99

withhold all reference to the authorities which prevent us from adopt-
ing, excepting in the most circumspect manner, the conclusions that
might be drawn from them. In Italy, Spallanzani has maintained
that animalcules are completely foreign to the fccundative act; in
spite of the assertions of Gleichen, the opinion of Spallanzani pre-
vails in Germany; in France, MM. Bory de Saint Vincent and Du-
trochet are of nearly the same opinion; M. Virey regards them as
containing certain small balloons dist«|ded with a kind of pollen, and
which burst when they reach the organs of the other sex; and M.
Raspail has very recently come out against the doctrine of animal-
cules, which, according to him, are nothing more than certain organic
debris, or products of the decomposition of the sperm.

ii49. What among so many contradictory assertions, are we to be-
lieve? what opinion must we adopt? However it may be, we may
consider it as demonstrated that the female germ is an ovule, and that
that of the male is contained in his spermatic fluid, and that this liquid
contains such animalcules as were described by Lewenhoeck; but
that, in the present state of science, the relative importance of each.
of these principles is unknown.

SECTION 2.
Of Fecundation.

250. When the germs have acquired their full size, a new pheno-
menon, by combining some of their principles, imparts to them mo-
tion and life; this phenomenon \?, fecundation, which, as to its inti-
mate mechanism, is perhaps always effected in the same manner, but
which appears to be effected in different ways in different animated
beings. Although the snail has double sex, it cannot fecundate itself;
a copulation with another individual similar to itself is necessary, and
then each of them fecundates, and is at the same time fecundated.

251. Just as it happens in the monooscious plants, where, so to
speak, the pollen meets, by accident only, the ovary of the female
individual; so in many fishes and molusca, chance only seems to lead
the male to where the female had deposited her ova, so that he may
bedew it with his sperm.

252. In the batracian animals, such as the frog, although there is
no real copulation, copulation is, nevertheless, requisite, and fecunda-
tion is effected while the female ova are in the act of escaping from
her organs.

253. Lastly, in the ophidian animals, birds, the mammiferae, and
man, it is necessary that the germ of the male should fecundate the
other in the interior of the female organs.

100 OF REPRODUCTION.

254. Seat. But the point in the organs at which the two germs
meet is not yet completely ascertained. Is it in the ovary ? Is it
in the oviduct 1 Is it in the womb ? All the ancients agreed that
the vivification of the germs takes place in the womb, whether, like
Pythagoras, they call to their aid an extremely subtle nervous prin-
ciple, whether they invoke, like Harvey, a magnetic impregnation,
or whether they content themselves with the seminal liquor of the
male, to explain the fact: almost all the ovarists, on the contrary,
have thought it could only be effected in the ovary, and a great ma-
jority of the physiologists of the present day are of this way of
thinking.

255. Among the animalculists, one party believed that fecundation
takes place in the womb without any participation by the ovule, or
with Maupertuis, that the animalcules attracted the ovarian vesicles
to the womb in order to effect their agglomeration or germification.
Others, with Andry, supposed that a single animalcule reaches the
ovary, enters an ovule by lifting a small valve, and thai fecundation
is effected at that moment. P'inally, MM. Prevost and Dumas, re-
turning in this respect to the idea of Buffon, of Maupertuis, of Aris-
totle and Hippocrates, admit that the uterine cavity is the seat of
fecundation.

256. To maintain this last hypothesis, they rely on the circum-
stance that they were never, in their experiments, able to find any
animalcules in the Fallopian tubes, and, a fortiori, in the ovaries;
while they frequently met with them in the womb or its horns; on
the fact, that before the ovules can become impregnated, they must
be enveloped in a coat of mucus, which they receive while in the
tube on their way to the womb; that they could never succeed in the
artificial fecundation of ovules taken directly from the ovary, while
nothing was easier than to vivify such as had traversed the tube and
the oviduct, &c. But Ruysch saw the prolific matter in the Fallo-
pian tubes of a woman who was taken in adultery and killed on the
spot by her husband; Haller found semen in the seminiferous ducts
of the female animals on which he experimented. Besides, are we
authorised to deny the existence of a fact observed by others, because
we have ourselves sought for it in vain? Have we a right to infer,
because the eggs of frogs cannot be fecundated unless they have been
previously more or less thickly covered with a coating of mucus,
that the same thing holds true in women? Further, these ovules
which MM. Prevost and Dumas found unfit for fecundation, could
not have been forcibly detached from the ovary without having been
somewhat altered by the instrument; and that too, by the admission
of the experimenters themselves. Though the existence of ovarian
pregnancies is far from being demonstrated; though the fact of an

OF REPRODUCTION. 101

embryo half in the tube and half in the ovary, as reported by Bus-
siere, requires some new evidence; though a great many cases of
extra-uterine pregnancy, examined with care, are very far from being
conclusive, the experiments of Nuck, who placed a ligature on the
tube, betwixt the womb and ovary, direcUy after copulation, and
upon killing the animal some time afterwards, found that fecundation
had taken place, and that the ovum, stopped by the thread, had be-
gun to develop itself in the ovarian moiety of the seminiferous canal;
those of Haighton, who found that fecundation did not take place in
rabbits on that side where he had tied the tube, &c., appear to prove
incontestably, that the union of the germs does not take place in the
womb.

, 257. Mechanism. As to the mechanism of this union, it is still
covered with an extremely thick veil. After coition, one of the
vesicles enclosed in the ovary enlarges with great rapidity, soon
rises above the surface of the organ, gradually thins its coat, which
at length bursts; when this vesicle bursts, a much smaller vesicle,
which is the real germ, escapes from it (239); this germ engages at
once in the tube, which mean while was spasmodically applied, like
a cupping-glass, to the portion of the ovary from which, during a
fruitful coition, the vesicle escapes.

258. The capsule which contained the germ before it was rup-
tured, constitutes what has by Valisnieri, Santorini, Cruikshank,
Buffon and Home, been called the yellow body {corpus luteum); its
rupture occasions a small bleeding wound, which cicatrises by de-
grees, and leaves in its place a wrinkled or depressed scar, more or
less deep, and which Littre, Haller, and some others mistook for the
real yellow body.

259. That which takes place in regard to a single ovule, may
also occur to two, to three, or a greater number. Supposing that
the evolution of the ovule is put in play by the commotion that ac-
companies coition, by a sort of electric commotion, by an aura
seminalis, by means of an animalcule, or by any principle whatsoever
of the prolific matter; that this principle reaches the germ directly
from the woman, or that it reaches it only after having passed through
the general circulation, it always happens that after a fecundation
has been effected, there is detached from the ovary an ovule so mo-
dified, that it is soon recognised as a being similar to the one that
produced it. This is what is demonstrated by observation; but we
know nothing further about it. The systems of preformation or evo^
lution, of emboitement or panspermy, of epigenesis and catageitesis,
expansive force, resisting force oi ihe ancients; the nisus formativus
of Blumenbach, reproduced tmder a new point of view, and clothed

10

102 OF REPRODUCTION.

by M. Mayer, with the philosophical jargon of the German schools,
teach us nothing in relation to the intimate nature of this work, which
is as extraordinary as it is curious.

SECTION 3.

Of Conception.

260. When the union of the germs is effected in the interior, the
new product resulting therefrom is commonly retained, or arrested in
some part of the sexual system. But this phenomenon constitutes
what is properly called conception. It is evidently distinct from
fecundation; for wherever the latter is effected exteriorly to the
animal, as in fishes and many reptiles, conception cannot be truly
said to exist, while in the higher classes it always does exist. At a
first view, it might seem useless to make a distinct phenomenon of
it, and that it might without inconvenience be confounded with ges-
tation; but upon a closer inspection we are easily convinced of the
contrary. Indeed the ophidians and birds have no gestation, and
yet they have a conception. Conception, therefore, comprehends
what takes place between the instant of vivification, and the moment
when the fecundated germ begins to be developed; whether it at-
taches itself for this purpose to some point of the generative pas-
sages, or whether it has to be expelled in order to undergo the pro-
cess of incubation exteriorly.

103

CHAPTER III.

History of Gestation.

261. If the fecundated or conceived ovum passes out of the organs
of the mother before the germ begins its development, as in birds,
there is no gestation, and the animal is called oviparous. If the
embryo is formed while passing through the oviduct, but so that it
cannot separate itself from its shell until after it is laid, as in certain
reptiles, there is still, properly speaking, no gestation, and such ani-
mals are called ovo-viviparous. Whenever, on the contrary, the egg
undergoes its entire incubation in the interior of the generative sys-
tem, and the foetus is not expelled until the development of its organs
enables it to live and grow in the external world, pregnancy or ges-
tation is said to exist; this is observed to take place in the mammi-
ferae only; in this case there exists a gestative organ, a single uterus,
or one womb and two ad uterum, destined to lodge the product of
fecundation until it attains its maturity, and such animals are deno-
minated viviparous.

Pregnancy, in the human species, is one of the phenomena of re-
production which it most imports us carefully to study. The words
pregnancy and gestation are not synonymous witli the words preg-
nant woman or woman with child. The former express a function
and all that appertains thereto, from its origin until its termination.
The latter indicate merely the actual state of a woman who contains
within herself a fecundated or conceived ovum.

262. Division. If the fecundated ovum reaches, without being ob-
structed, the cavity of the womb, and maintains itself there, the preg-
nancy is said to be good, natural, or uterine; if it remains and is devel-
oped in the ovary, if it falls into the cavity of the peritoneum, stops in
the Fallopian tube, or becomes engaged in the substance of the womb
itself, it on the contrary receives the title of bad, preternatural, or
extra-uterine. The first species is then divided into three varieties.

1. Simple pregnancy where the womb contains only a single ovum.

2. Double, triple, quadruple, or compound pregnancy, when there

104 HISTORY OF GESTATION.

are two, three, or four foetuses. 3. Complicated pregnancy, where
a polypus, a great quantity of water, or any diseased state of the
product of the conception, or of the womb itself takes place.

The second comprises four varieties determined by the seat occu-
pied by the fecundated germ; so that authors admit, 1. An ovarian
pregnancy; 2. An abdominal or peritoneal pregnancy; 3. A tubal
pregnancy; and 4. A mixed or interstitial pregnancy.

After having observed that a great variety of diseases, sometimes
give rise to most of the symptoms of pregnancy, the French writers,
adopting a still more general first division, have established a true
and 2i false or apparent pregnancy, differing from each other in this,
that the former is characterised by the presence, and the latter by the
absence of the fcstus; they have next described false pregnancy as
ventose, serous, sanguine, polypous, cancerous, nervous, molar, hy-
daiic, &c., accordingly as the increased size of the belly depends on
the presence of gas, water, blood, polypous or other tumors in the
Avomb, the existence of a scirrhus, an hydatiform or fleshy mole, an
undefinable nervous state, &c.

ARTICLE I.

Of True Pregnancy.

SECTION 1.
Of Uterine Pregnancy.

263. As soon as pregnancy takes place, important and numerous
phenomena are manifested in the economy. Of these some are
local, physical, material: others are variable, transient, general: some
are common to all kinds of gestation, while others are peculiar to
some sorts only.

As uterine pregnancy comprises almost all of them, and further, as
it constitutes the only normal kind of gestation in the human species,
I shall speak, in the first place, only of those which belong to it, and
shall not treat of the special phenomena until I come to the article in
which I shall designate the means of distinguishing it from all the
rest.

264. The constitutional movement occasioned by copulation is
only momentary, both in women and in men, where fecundation is

OF TRUE PREGNANCY. 105

not to result from it. In the opposite case, the state of turgescence,
of erection or spasm of the uterus and tubes, continues, and is the
prelude to a new kind of life in the former of these organs. Its
volume, its form, its situation, attitude, structure, its properties, all
are about to be changed.

265. Volume. After a conception takes place, the womb re-
mains in a state of fluxion, which gradually augments its size in
every direction; according to some accoucheurs, this growth is very
regular and uniform until the end of ihe pregnancy; others assert
that it is irregular and by starts. M. Desormeaux thinks it is per-
formed very slowly in the first months, and on the contrary, with
great rapidity in the two or three last; in the first case, at the ex-
pense of the walls of the organ alone, and in the last, of the walls
and cavity both. Not only does the body undergo this augmenta-
tion; Madame Boivin maintains, that in the second month, the neck
is almost two inches in length. At the end of the third month, the
womb is nearly two inches and a half through in every direction,
and three inches and a half in the fourth month. At this last nam-
ed period, we observe in the dead subject, that the plaits near the
inner orifice are unfolded, and extended in long, very delicate
ridges.

266. At seven months, the superior third of the cervix has be-
come common with the inferior portion of the body, from which it
may however be distinguished by a rose-colored zone, very difftrent
from the deep red tint of the rest of the womb. Its inferior por-
tion, whiter, larger, and softer than the other, has still a dimension
of about fifteen lines; but we must not here confound the neck, pro-
perly so called, with the os tincae, which is only five or six lines long.
The neck, which is thicker below than above, is still about an inch
long at eight months, and is not wholly lost in the uterine ovoid,
until in the course of the ninth month, so that, from the commence-
ment of pregnancy until the eighth month, it grows thinner, deploys
and is gradually widened, without losino' meanwhile much of its real
length.

267. While admitting a part ot these assertions to be true, I
think it nevertheless more correct to say with M. Desormeaux, that
if we leave the os tincae out of the question, the ne^k loses about
one-third of its total length by the fifth month, one half in the sixth,
two-thirds or three-fourths in the seventh, three-fourths or four-
fifths in the eighth, and the remainder disappears in the course of the
ninth.

268. At full term the vertical diameter of the womb is twelve
inches in length, the antero-posterior nine inches, and the trans-

10*

106 OF TRUE PREGNANCY.

verse eight and a half. At the level of the tubes, its circumference
is about twenty-six inches, and only thirteen at the uterine portion
of the cervix, which, according to Madame Boivin, ought then to be
five inches higher than the external orifice. Levret says that the
superficies of the womb, which, when unimpregnated, is only equal
to sixteen inches, is three hundred and thirty-nine at the commence-
ment of labor; that its cavity, which is four-fifths of an inch in the
former case, rises to four hundred and eight in the latter; that its
mass, which is only four inches and a third before pregnancy begins,
is fifty-one at child-birth; but the cavity of the womb is evidently
carried too far by Levret, for in this way it might hold seventeen
pounds of water, while the whole ovum in general does not weigh
more than from seven to ten pounds.*

269. Form. Instead of remaining flattened on its two surfaces,
the womb becomes rounded, and soon grows of a pyriform shape.
The vaginal angle seems to contract; to grow smaller; its orifice
sometimes becomes circular, or ceases to represent a simple linear
or transverse slit, particularly in first pregnancies; on other occa-
sions it is pretty largely open, its lips become thicker and softer,
chiefly in those women who have borne several children. In some
instances of first pregnancy, it seems to close completely up, so that
it can scarcely be distinguished by the finger.

270. The womb next gradually assumes the form of an oval, with
its point downwards. Its posterior wall, which was, even before
impregnation (155), more protuberant than its anterior one, grows
so disproportionately that the tubes seem to descend considerably,
until their roots appear to answer to the point of union of the pos-
terior two-thirds, and anterior third of the uterine circumference.
Its fundus also enlarges very much. Of dimensions nearly equal in
every direction, abom the fifth or sixth month the organ of gestation
exhibits the figure of a spheroidal vase terminated by a very short
neck; it might be compared to a hog's bladder, with the urethral
extremity served round with thread for the space of an inch or two:
supposing that some one should now unwind the thread by degrees,
from above downwards, while another blows into the bladder from
the fundus, so as to distend it, we can acquire a pretty clear idea of
the gradual efi'acement of the apex of the womb.

271. At the close of pregnancy, the neck is nothing more than a
ring, formed merely by the lips of the os tinc<e, and the thickness
of which varies according as the woman is in her first pregnancy, or ,

* A patient under my care gave birth to twins, one of which weighed in the
scales, 8^ and the other 8 pounds; the placenta was at least 1 pound, the water
10 ounces=18 pounds. — M.

OF TRUE PREGNANCY. 107

as she has already had several children. In the former case, this
ring scarcely exists; a circle that grows thinner and thinner, and
sometimes quite sharp at its edge, is ordinarily substituted for it;
in the second, it pretty often retains a thickness of two, three, or
four lines, until labor comes on. Its orifice remains habitually
closed; its lips are smooth, even and thin, even to the last, in those
who have never borne children; in others it gapes a little at an early
period; I have in many cases been able to introduce the end of my
finger into it, in women who were five and a half or six months
gone, and who were used for the purposes of the practical lessons
of my lying-in-room. Wider and softer below, it is then found to
be harder and narrower above; its cavity resembles a pretty long
finger of a glove, so that we can touch the naked membranes, and
ascertain the position of the child several months before the end of
pregnancy.

272. Position. At the same time that the length and volume of
the womb are increasing, it undergoes other changes, both of its
posture and relations to other parts; the cervix is depressed, and
appro£>ches nearer to the vulva: this phenomenon, which is very de-
cided in some women, and scarcely appreciable in others, is most
frequently met with, and is observable for a longer time in women
who have t\ie pelvis large, and who are of a soft or naturally lax fibre;
and less commonly in those of an opposite constitution, although it
is not a rare thing to find it in young and robust women, even in a
first pregnancy; but the os tincse does not fail to rise up by degrees;
at three months, \\ is about at the same place it occupied before im-
pregnation; after this, continuing gradually to rise, it sometimes
gets as high as the s^cro-vertebral angle, while, on the contrary, it
begins in other instances to descend again, at about the sixth, the
seventh or eighth month> and approaches pretty near the inferior
strait.

273. The fundus, which at the third month is not higher than
the level of the superior strait, rises two finger breadths above it in
the course of the fourth, approaches to the navel in the fifth, gets on
a level with that central point, or even above it, at the end of the
sixth, still goes upwards in the seventh and eighth, but never reaches
either the diaphragm or liver, nor does it ever fill up the epigastric
region, as has been hyperbolically or thoughtlessly stated by some
of the standard authors. I have observed that it often remains in
the meso-gastric region until labor takes place. Besides, with some
exceptions, it can scarcely happen otherwise, for in the last months
of pregnancy, the centre of the pelvis is often from fifteen to
eighteen inches distant from the navel. However, the womb, being

108 OF TRUE PREGNANCY.

burthenod as it were with the weight of the ovum, seems to sink or
lo be somewhat crushed downwards; which compels it to enlarge
proportionably in the transverse and in the antero-posterior diame-
ters, which until then it had not done.

274. Direction. While the womb remains unconstrained in the
excavation, and its fundus is not arrested by the base of the sacrum,
its posterior half, forming a larger mass than its anterior half, tends
to make it turn over backwards, so that as the os tincae sinks down-
wards, it inclines forwards, sometimes more, sometimes less, and
gets farther from the sacrum, and nearer to the pubis; a deviation
that is favored by the alternate fulness and emptiness of the urinary
bladder. Imperfectly supported in front by the abdominal parietes
pressed upon through the medium of the viscera by the diaphragm,
and particularly as the woman in order to maintain her equilibrium
is obliged to carry her head and shoulders somewhat backwards, the
womb, as soon as it is sufficiently enlarged to touch the promontory,
can no longer rise except in the line of the axis of the superior strait.
Applied posteriorly against a solid, salient and rounded part, it with
difficulty preserves its station on the median line, as it proceeds up-
wards into the abdomen, almost always deviates to one side or the
other, to the right eight times out of ten, so that one of its sides, the
left, if the inclination is to the right, and the right if it is inclined to
the left, soon turns forwards; whence it happens, thai its anterior
region looks a little to the right in the former instance, and to the
left in the latter; in a word, the womb seems to hai'e turned on its
great axis.

275. The inclination of the womb to the righc rather than to the
left, has been explained in a hundred different ways. The presence
of the rectum, habitually filled, in pregnant women with hard ster-
coraceous matter, has appeared to some persons sufficient to account
for it; but the right lateral obliquity is to be met with also in per-
sons,'who are not of a costive habit, and even in individuals laboring
under diarrhoea. M. Desormeaux adds, that while rising into the
abdomen, the organ of gestation is thrust to the right by the mass of
small intestines, and the sigmoid flexure of the colon; which de-
pends, says he, on this, that the mesentery, fixed on the front of the
spine, descends obliquely from right to left. But there is an error
as to the fact here, for the mesentery is directed from left to right;
and I am astonished that M. Desormeaux, in general so correct,
should have overlooked it; besides, though the sigmoid flexure of
the colon is on the left, the caecum, which is still larger, is on the
right. Others have thought with Levret, that the insertion of the
placenta, by restricting the dilatation of one particular portion of

OF TRUE PREGNANCY. 109

the womb, might occasion lateral obliquities to take place. In the
first place, it is not true that the portion of the womb in contact with
the placenta enlarges less than the other parts of the organ; and
further, even if we could admit the fact, it would be necessary for
the placenta to be attached almost always to the right, which is con-
trary to what is found to be the case. Madame Boivin attributes
right lateral obliquity to the excessive strength of the right round
ligament of the womb; but in that case the right angle of the womb
ought not to be so distant as it is found to be from the right abdomi-
nal canal. I could more willingly admit, that being unable to rest
upon the front of the spine, the womb generally inclines to the right,
in consequence of the individual's habit of sleeping upon that side,
and of using the right arm rather than the left; but it would be fur-
ther necessary to prove that in women who have the opposite habits,
the right obliquity is never met with.

276. While the fundus and body of the womb incline forwards
and to the right, the cervix generally tends backwards and to the
left; however, it would be wrong to suppose it must be always so:
the orifice may remain in the centre of the excavation, although the
anterior or lateral obliquities may be very great, or it may even be
directed further backwards than is indicated by the position of the
fundus. I have frequently found its plane parallel to the anterior
surface of the sacrum in the last stages of pregnancy, although there
was not any anterior inclination; it may also be turned to the right,
though the fundus is inclined to that side, which is a much rarer case.

277. Thickness of the walls. Galen, Paul iEginette, and Mau-
riceau also have advanced that the uterus grows or distends only at
the expense of the thickness of its walls; Riolan, Deventer, De La
Motte, and Roederer, on the other hand have maintained that this
thickness increases during pregnancy, while the moderns admit that
it remains as it was previously to fecundation. Such discrepancy
of opinion upon a fact easy to be ascertained, looks, at a first view,
very strange; but let it, nevertheless, be explained with reference to
the situation in which the observers were placed. The ancients,
as they could not open dead bodies, were compelled to reason from
analogy; seeing that the coats of the bladder grow thin in propor-
tion as they become more and more expanded, and that the same
thing, in a large number of animals, holds good as to the uterus and
its horns, they did not suppose it could happen otherwise in the
human species. Besides, they might found their opinions upon the
fact, that in women dying with uterine hemorrhage during labor,
or in the last three months of gestation, in those affected with hy-
drometry, or in whom the ovum contains too large a quantity of

no OF TRUE PREGNANCY.

amniotic fluid, the muscular coat of the womb is indeed very thin,
and sometimes reduced to one lialf, a third, and even a quarter of
its natural thickness.

Others might have been induced to defend a diametrically oppo-
site sentiment, because during the first eight days after parturition,
a period in which more childbed women die than in any other, the
parietes of the womb, in contracting, really thicken so much as to be
an inch, or even fifteen lines through, at the fundus. But, since nu-
merous opportunities have been enjoyed of interrogating nature in
a better way, hypotheses founded on false analogies or on excep-
tionable or badly explained cases, have given way before the truth.

278. It is now known that the womb preserves nearly the same
thickness during the whole course of pregnancy as it had when un-
impregnated; (I say nearly, for sometimes it is a line or two thicker
or thinner:) that this thickness, always greatest at the insertion of
the placenta, generally diminishes from the fundus towards the cer-
vix, where it is frequently found to be not more than two or three
lines, or even less; that it increases a little in all parts of the organ
at the same time, until the third or fourth month, and then remains
rather below its primitive limits, except the cervix, which at that
period, especially, grows thinner, to exceed them again in the
last stages of pregnancy. It is, therefore, useless to argue against
the opinion of Jenty, who maintains that this thickness is much more
apparent than real, and that it is solely owing to the accumulation
of blood in the uterine vessels.

279. Structure. In its unimpregnated state, the organisation of
the womb seems to be only incipient; it is perfected, or developed, in
pregnancy (169); its fibres which were pale, dense, and inextrica-
bly tangled, soften, become redder, and soon represent layers and
bundles easy to detect and to follow. The cellular tissue which
was before so firm, dense, and elastic, relaxes, becomes supple,
and indeed resembles the common cellular tela, and in this way
permits the other elements, which it held in bondage as it were, to
follow the impulse that animates the whole womb. The arterial
branches folded upon each other a thousand times, like the vas de-
ferens, and bridled in this condition by dense, elastic laminae, cede
to the general relaxation, and gradually become lengthened; their
angles, at first so sharp, with their doublings, grow blunter, enlarge,
and at last exhibit only certain zigzags of greater or less depth,
tortuosities which do not impede the circulation, and their calibre,
before the end of gestation, comes to be double, triple, and even
quadruple its diameter previous to fecundation.

280. The veins undergo tlie same metamorphoses: already, in the

OF TRUE PREGNANCY. Ill

natural state, larger and less tortuous, they enlarge, and are developed
still more rapidly than the arteries; at term they are observed to
furrow the fleshy layer in every direction, and form a net-vi^ork which
in some measure separates it into two planes. They are large
enough to admit a goose quill, and in some instances, even the end
of the little finger; near the mucous membrane they dilate so as to
constitute cones with inverted bases; cones described by Astruc,
under the name of uterine sinuses, but which Haller restored to
their proper nature by denominating them venous sinuses; and to
which Hunter thinks no particular name should be given.

281. The lymphatic vessels are, according to Cruikshank, so
amplified that they may, by injecting them with mercury, be made as
large as crow-quills, and to form a kind of coating of silver to the sur-
face of the womb; the nerves themselves, according to Hunter, also
increase sensibly in size; which accounts for certain alterations of
function we shall have occasion to treat of in a subsequent page.

282. The mucous membrane, the existence of which it is so dif-
ficult to demonstrate in the unimpregnated state, becomes more
evident, redder, more villous; distinct shreds of it can be separated;
the folds which it forms for the purpose of enclosing the ridges of
the cervix, relax and disappear, but not until the last half of preg-
nancy; the serous coat also is far from being unaffected by all these
changes, and Bichat was evidently mistaken when he asserted that
the peritoneum, like the other diaphanous membranes, possesses
no extensibility. At the end of pregnancy, the meso-rectum re-
mains; the broad ligaments, and other folds, though tightened, are
not effaced, yet lose some of their proportional dimensions, and even
somewhat of their absolute dimensions. Besides, admitting that
they do become completely unfolded, their laminae would be insuffi-
cient to cover a circumference of twenty-six inches. It is evident,
then, that the serous coat increases in the same proportion as the
fleshy coat of the womb; that it is extensible, and remains in con-
tact with the same points of the subjacent layers, from the com-
mencement to the end of gestation. I have even remarked, as M.
Ristelhueber has, that, instead of becoming thinner, it rather increases
in thickness, and that its adherences scarcely relax at all while it is
undergoing this amplification.

283. Functions and properties. In proportion as the uterine
vessels deploy themselves, the blood is determined thither, and at
last the womb, like a sponge, is gorged with that fluid; however,
the menses are suppressed as soon as fecundation is effected, and
some physiologists have attributed to this circumstance most of the
modifications which are then experienced by the womb; but we

112 OF TRUE PREGNANCY.

cannot adopt such an opinion, for the same changes are observed
in women who continue to be subject to a periodical discharge
during pregnancy, and where the uterus is distended by a polypus,
while they are not met with in a case of simple amenorrhoea. Tra-
versed by larger nerves, and receiving a larger supply of vivifying
fluids, the uterus enjoys a livelier sensibility: in the unimpregnated
state it may be touched, struck, pressed upon, without, so to speak,
causing the woman to feel any pain; during the growth of the ovum,
on the contrary, the least jar, the least touch of the fostus are in-
stantly felt by the mother; both its sensibility and contractility are
of a grade almost as high as that of the organs of relation.

284. To explain the extraordinary development of the uterine
caviiy, the ancients taught that the ovum dilates it by growing, just
as we can dilate a glass tube by blowing into it, as we distend a
bladder by filling it with a fluid or air, or as we can spread out a
ball of soft wax. Puzos has not rendered this hypothesis more sus-
tainable, by calling to its support the laws observed by fluids in trans-
uding from without to the inner side of any inert vessel; for as, in
physics, the force of impulsion of fluids is measured by the height
and thickne?s of the column, it is clear that in this case, the distend-
ing effort would increase in an inverse ratio to the resistance; that,
from being very feeble at the beginning, when the density of the
organ is considerable, it would at the close be doubled ten times to
overcome a less difficulty. Would it be any better to say, with Van
Helmont, that the womb dilates spontaneously under the influence
of a bias meteorisant, or to admit, with Levret and the moderns, that
like the heart and the erectile tissues, it grows actively, and by the
mere force of its vital properties? But in reasoning thus, the fact
is explained without indicating the cause. It is at least certain that
the dilating force, altogether foreign to the product of conception,
exists in the gestative organ itself: a circumstance that beyond
question proves this to be the case, is, that in preternatural preg-
nancies, as remarked by Levret, Bertrandi, Meckel, Chaussier, &c.
the uterine cavity, though empty, dilates as it does in an ordinary
gestation.

285. To explain this dilatation, it is useless, with Malpighi, to refer
to a fermentative principle contained in the semen, or with Blumen-
bach, to a peculiar vital action; the turgescence occasioned by fe-
cundation, and kept up by the ovum, affords a very satisfactory rea-
son for it; the congestion, of which the womb is the seat, invites to
it an excess of nutrition; the new molecules incessantly deposited
there, necessarily elongate its fibres; the vascular channels are both
uncoiled and enlarged at the same time, and as this unfolding and

OF TRUE PREGNANCY. 113

elongation cannot take place without increasing the extent of the
curves or circles represented by each fibre and vessel in the organ, it
follows that the amplification of its cavity must be an inevitable con-
sequence of the augmented nutrition of its parietes.

286. Moreover, the ovum and the womb enlarge both together;
and though the end or the function of the thing contained is not to
enforce the distention of that which contains it, it at least serves to
support its parietes, and to keep up its due measure of irritation.
In this, as in all other cases, nature finds the means of multiplying
effects without augmenting the number of causes.

287. Appendages of the uterus. The changes effected in the
position, size, and weight of the womb will of necessity occasion
some alterations in the disposition of the circumjacent parts.

288. In consequence of the depression of the cervix during the
fiirst months, the vagina becomes shorter and wider; at a later pe-
riod being drawn upwards along with tjie uterus, it becomes elon-
gated, and at length forms a kind of cone with the apex at the vulva.
By means of the fluids it imbibes it becomes softened; its anterior
and posterior columns sometimes acquire a very considerable size,
especially near their lower ends.

289. The Fallopian tubes, retained by the broad ligaments
against the sides of the womb, enlarge, become redder, more vascu-
lar, and, as it were, spongy on the inner surface of their funnel
shaped portion.

290. The ovaries, which are depressed in the same way, also in-
crease in size; their vessels dilate, sometimes become varicose, so as
even to burst, and occasion a fatal hemorrhagy.

The fibres of the round ligaments are better expressed, enlarged and
redder, so that at the period of labor, they compose two real muscu-
lar cords, whose contraction is in certain cases so evident, that I have
in three diflferent women observed it myself, and also pointed it out
to several persons during the contraction of the womb for expelling
the after birth.

291. The bladder rises above the superior strait; the urethra is
concealed behind the symphysis of the pubis, becomes almost verti-
cal, its orifice retreats under the summit of the pubic arch, and the
introduction of the catheter in pregnant women, is thus rendered
more difficult; it may also happen that the urinary bladder, being
more forcibly compressed above than below its fundus, may project
against the upper part of the vagina, making a tumor there, of which
I have often met with cases in the latter half of gestation.

292. The rectum being, as it were, strangulated above, and no
longer receiving any impulsion from the diaphragm, becomes dis-

II

114 OF TRUE PREGNANCY.

tended with stercoraceous matters, and in that way interferes with
the form of the posterior wall of the vagina.

293. The small intestines, being raised upwards by the fundus of
the uterus, in front of which they are sometimes partially placed,
may be in that way so compressed as to occasion colic pains of a
more or less violent character; at other times their most movable por-
tions engaged in the recto-vaginal excavation, where they are liable
to be strangulated and give rise to very serious affections; but they
are most frequently thrust towards the lumbar regions, or else mount
directly up, pressmg against the arch of the colon, the stomach and
liver.

The diaphragm itself being pushed upwards into the thorax,
whose base it enlarges, while its vertical diameter is lessened, is in
some degree hindered from executing its contractile movement.

294. The skin on the lower part of the belly becomes thinner, is
covered with whitish blemishes and streaks, arranged in zigzag or
curved lines, with the convexity downwards; its meshes enlarge like
that of a piece of stuff that yields upon being stretched, without,
however, tearing. After the lying-in it appears to be covered all
over with reticulated scars, and becomes wrinkled or covered with
plaits; in short women, as observed by M. Desormeaux, and I will
add, in those where the abdomen attains to a very considerable size,
this state of the skin is propagated as far as the thighs and breech.

295. The aponeuroses become frayed; the inguinal ring enlarges
a little, but the linea alba undergoes the greatest changes because
it is more peculiarly charged with resisting the weight of the womb
and the viscera; instead of one inch, it sometimes is four inches
wide at its middle; towards the end of pregnancy we find in its
place nothing more than a tissue or net-work with meshes more or
less supple.

296. The navel opens a little, grows more salient and thinner,
which renders the occurrence of umbilical hernia very easy. In a
great many women there is such a separation of the aponeurotic
fibres upon the median line, that it seems as if it were pierced with
a lozenge-shaped, or elliptical opening, the ends of which approach
sometimes nearer, sometimes less near to the epigastrium or pubis.
Further, in this case there is left, after the labor is over, an oblong
tumor, a kind of eventration, which is sometimes increased by sub-
sequent pregnancies to such a degree, as to permit the womb to turn
very much over in front, above the superior strait.

297. The pressure exercised by the womb upon the vessels of
the pelvic excavation necessarily impedes the venous circulation of
the surrounding parts; the external organs of generation, too, and

OF TRUE PREGNANCY. 115

the lower limbs, are often seen to be infiltrated, covered with varices,
and affected with considerable pain; pains that may depend upon the
compression of nerves belonging to the lumbar and sacral plexuses.

298. The pelvis relaxes, and its articulations, so firm and solid,
change so much, as in some women to become quite movable.
Avicenna, Aetius, Fernel, and most of the ancients had doubtless ob-
served it, for they placed rigidity of the symphyses among the causes
of difficult labor: this opinion however was pretty generally aban-
doned about the time of Pare; for S. Pineau, vigorously opposed by
the surgeons of Paris for having maintained it, never could convince
them of it, until he exhibited the body of a newly delivered woman
who had been executed. Since then, Bertin and Bouvart, in a cele-
brated thesis; Smellie, Levret, Plessman, Piet, Desault, M. Boyer,
Baudelocque, Beclard, Chaussier, Madame Boivin, &c., have ad-
mitted the softening of the pelvic articulations: some as a constant
occurrence; others as an exception; some as a state proper to facili-
tate parturition, as a wise precaution of nature; others as a dan-
gerous disease. At present the existence of the fact cannot be
doubted, and all the questions relating to this long debated point are
of easy solution. Reason indicates, and observation proves that the
ligamentous bands of the pelvis become more soft and supple in
many pregnant women; and that, in common with all the surround-
ing parts, they contain a larger quantity of fluid; but it is impossible
for such an afflux of fluids to take place without the articular surfaces
being separated. This process, however, is so moderate in a ma-
jority of cases, that neither the woman nor the accoucheur perceive
it. Smellie has seen it carried to such an extent that the bones
could be made to ride over each other; Denman also mentions cases
of considerable separation; Madame Boivin says it is not uncommon
to find a distance of four, six, eight, ten, and even twelve lines be-
tween the pubes, and naturalists are aware that in some of the mam-
miferae, the bones of the pelvis, too narrow to permit the birth to
take place, separate so widely during gestation, as to be in a manner
lost in the soft parts.

299. In these cases of extreme softening, standing and walking,
which in some individuals are both fatiguing and painful at the close
of pregnancy, may produce inflammation and suppuration of the
symphyses, numerous examples of which are upon record; in these
cases too it is right, as Baudelocque teaches, to class their mobility
among the pathological alterations: on the other hand, we may con-
ceive that in a slightly contracted pelvis, such a softening may to a
certain extent have a beneficial effect upon the labor, as has been
asserted by several authors; but for promoting this softening, is it

116 OF TRUE PREGNANCY.

proper, in accordance with Pineau, to repose any confidence upon
the action of baths, cataplasms, and other means of the same nature?
Is it possible, without any bad effect, to increase it by mechanical
efforts, such as dilating efforts for example? Can we believe with
Denman, and others, that the pressure exerted by the child's head
has something to do with its production, when the labor is violent,
and yet progresses slowly?

According to Baudelocque, the ligaments alone share in this ope-
ration; MM. Piet, and Chaussier are wrong in teaching that the
cartilaginous plates are equally concerned in it.

The symphysis of the pubis, being in almost all respects similar to
the articulation of the bodies of two vertebrae, explains why the soft-
ening affects it more frequently, and always to a greater degree
than the posterior symphyses; and how it happens that in a majority
of women who have borne children, its surfaces are commonly rather
more distantly separated than they were before pregnancy took
place.

300. The consistency even of the bones of the pelvis is some-
times so altered, that they become flexible. Weidman relates a re-
markable instance of this kind: the inferior strait was so contracted,
that the caesarian operation appeared to be indispensably necessary;
but in attempting to pass up his hand, he perceived that the ischia
and the pubic arch yielded like cartilage, and the labor terminated
without an operation. M. Hofmeister has lately published a case
nearly similar, and not less curious. According to Burns and other
English accoucheurs, this state of things often exists as a symptom
of the dangerous disease they describe under the title of malacosteon.

§. II. Sympathetic Phenomena, and Mational

Si^ns.

301. The numerous material modifications that have just been
enumerated, act more or less upon the rest of the system, and give
rise to what are by agreement denominated the general, common,
rational, vague, uncertain, and doubtful signs of gestation.

302. It is a common notion, long ago inculcated by Hippocrates
and Galen, that a fruitful copulation is accompanied with much live-
lier enjoyment than an ordinary coitus, and that it is felt at the same
moment by both the parties. According to Aristotle the copulative
organ of the male is withdrawn less moist than commonly from the
female organs, and the seminal fluid does not escape from them.
Immediately after coition the two beings fall into a state of languor,
of weakness, of uncommon sadness; the woman feels a disposition
to faintness, to syncope, to have horripilation, colic, and a sort of

OF TRUE PREGNANCY. 117

vermicular motion which seems to proceed from the womb and pass
to the iliac fossae or flancs; borborygmi, first in the uterus, Avhich
seems to be full of gas, and then throughout the whole abdomen, and
sometimes a general shivering, beginning in the abdomen, complete
the series of symptoms which announce that fecundation has taken
place.

303. This first condition is succeeded by pregnancy, properly so
called. The eyes lose their vivacity, their brilliancy, have an ex-
pression of languor, and seem to sink in their orbits; the eyelids
grow dark and are surrounded with a blackish, livid, or leaden circle;
the nose grows sharper and longer; the mouth widens by the sepa-
ration of its corners; all the features of the face seem to retire
backwards, which renders the chin more prominent; the face be-
comes pale, is covered with spots of various sizes and numbers,
sometimes reddish, or of a more or less deep brown; sometimes,
but more rarely, of a dead or milk white color; in a word, it be-
comes masked.

The neck swells, becomes softer, and is the seat of a congestion,
which, according to Diogenes, was formerly indicated by Democritus,
and which Catullus has mentioned in the following lines:

Non, illam nutrix, oriente luce, revisens,
Hesterno colluin, poterit circumdare filo;

a congestion which Dumas says he has positively observed.* The
breasts enlarge, become more tender, firmer; sometimes a few drops
of whitish serosity can be extracted from them; the nipple rises and
is more prominent; the areola enlarges and grows visibly browner;
the delicacy of their tegumentary layer increases, and they also occa-
sionally exhibit some whitish stains, analogous to those on the face.

304. The pulse, at first embarrassed, acquires a greater degree
of frequency, and then of force and hardness; it becomes larger,
fuller, sometimes irregular, and somewhat bounding, quick and
feverish; towards the term of labor, it is found to be, says Bordeu,
convulsive-like, intermittent and corded; in fine, the artery seems
to be more tense, beats with more Irequency and velocity; the cir-
culation being more active, hemorrhages are commoner and more
dangerous; blood drawn from a vein, or escaping accidentally from
the organs, is found to be covered with a sizy coat, of variable
thickness, according as the fibrine or crassamentum happens to be

* There is more poetry than truth in the lines of Catullus. The feet become
less swelled, and the neck and face more swelled by a night spent in the hori-
zontal posture, and the lines are as applicable to niea as they are to women. — M.

II*

118 OF TRUE PREGNANCY.

above or below the natural proportions. The temperature of the
body rises, and enables pregnant women to bear cold belter than
others; the insensible transpiration is also more abundant, and at
the commencement yields an odor of prolific matter, but which
afterwards becomes acrid or of a peculiar nature. The urine flows
more abundantly, is cloudy, and contains a larger sediment; all the
secretions are more energetically effected; the saliva, in particular,
is often furnished in great quantity, so that some women are attacked
with a vetil ptyalis7n. The liver, being deranged in its secretions, is
said to occasion the stains or ephelides of the face and skin.

305. The sense of taste and the digestion are still more specially
perverted; anorexia, nausea, and even vomiting supervene, and are
frequently followed with a complete loss of appetite; the woman now
desires for food none but the most singular and sometimes disgusting
objects. At one while her greatest happiness is to eat clay, ashes,
lime, or to craunch charcoal; at another she places her delight in half
putrid meat, spiders, or other unclean animals: in general she is dis-
pleased with fat, and an animal regimen; fruits and vegetables suit
her better; some ardently desire sour drinks, and love none but food
prepared with vinegar, as salad, Sic.

306. This state of inappetency and disgust is succeeded, after the
few first months, by a very decided appetite, in some cases almost
voracious, by easy digestion, fondness for wine and other spirituous
drinks; but in the last third part of pregnancy, the digestive functions
again become disturbed, doubtless because the stomach, being at that
period too small, can only take in very small quantities of food and
drink.

307. The moral condition of the female is also subject to pretty
numerous changes : some women, naturally gay, good tempered,
and amiable, become sad, melancholy, cross, unsociable, and vice
versa. In a good many women, the passions, although previously
moderate, acquire an extraordinary violence, cannot be subdued,
and cause the commission of the most atrocious crimes; in others,
there are merely some singular desires, such as to eat a particular
kind of fruit or meat or game, or some particular dish, no matter
at what price; an irresistible tendency to steal objects of small value,
or for which they have no use, and corruption of their manners or
character. There are some whose wit is never more lively, more
penetrating, more agreeable; while others fall into a sort of stupidity
and apathy quite unnatural in them. In general the activity of the
intellectual faculties is augmented, whether in the whole, or only in
part; in one case the memory, or a taste for the arts or sciences, are
modified; in others the judgment becomes exquisite, or the imagina-

OF TRUE PREGNANCY. 119

tion is exalted to such a degree, that some women have, during their
pregnancy, attained to a surprising degree of perfection in those
works of genius, those arts or sciences, which they had previously
cultivated with indifference and without success; some lose their
senses and become crazy, always at the same periods of their preg-
nancy; others are seen in whom mania never disappears, and who
never become composed except during this function.

308. Many diseases supervene, are suspended, or disappear; some-
times odontalgia, without any caries of the teeth, is renewed every
time the woman becomes pregnant; sometimes neuralgia, whether
suborbital, facial, or of any other sort; chorea or St. Vitus's dance;
convulsions, or other motions, hysterical or epileptiform; in other
cases, pulmonary consumption of a very advanced stage seems to re-
trograde, or even gives place to a highly flourishing state of health;
a pretty considerable number of different diseases, such as chronic or
obscure inflammation of the lungs or digestive passages, and serious
and profound organic lesions are affected in the same manner. But
although it is true that after parturition some of the affections that
are happily modified by gestation do not return, it is but too certain
that a major part of them thenceforth progress towards a fatal ter-
mination with frightful rapidity.

309. Such is the series of sympathetic phenomena noticed in preg-
nant women by accoucheurs: it has been seen that they are nume-
rous; but, unhappily, every one of them may exist; they may even
be met with altogether, without the patient's being pregnant; while
on the other hand, pregnancy often takes place without giving rise to
them. Besides, how can we rely upon those that depend upon sen-
sations experienced during or immediately after coition? Women,
like all the rest of the human race, easily believe what they desire,
and are willing to conceal even from themselves what they dread.
They therefore will or will not experience such and such symptoms,
accordingly as they do or do not wish to be pregnant. How can we
subsequently recognise among the disturbances or disorders of the
mind that which appertains to pregnancy, and distinguish it from that
which is occasioned by perverseness, or that which depends upon
actual disease?

310. Be this as it may, there are a great many cases in which, by
proper attention, an able accoucheur can make excellent use of the
rational signs, in forming his opinion. For example, when the mask
on the face is rapidly manifested in a woman who has never had it
before, who lives in a large city, and is not exposed to the heat of
the sun, it becomes a very probable sign of pregnancy. The same
may be said of the violet circle round the eyes, and of the swelling

120 OF TRUE PREGNANCY.

and sensibility of the breasts, when they are independent of the men-
strual function ; of the nausea, ptyalism, and disordered digestion,
perversion of the desires and appetite, when they are not results of a
morbid suppression of the catamenial discharge. As to the odor
given out by the skin; as to the perspiration, the increased tempera-
ture, the condition of the pulse, the urine, the color of the nipple
and its areola, the size of the neck, the changes in the aspect of the
face, &c., their existence is too variable, too fugacious, or depends
upon too many different causes, or they are of too difficult determi-
nation, to permit us to repose the least confidence in them. They
are merely so many resources which the learned and upright physi-
cian abandons to the shameless quack, or to the credulous ignorant
vulgar who are duped by them. Upon the whole, the rational signs,
when united in a certain number, and properly weighed, most com-
monly suffice to make us believe in the existence of gestation, but
never to give us a mathematical certainty of it, to warrant us in
affirming to it before a court, even although in addition to these
there should be a suspension of the periodical flux.

311. Menses. However, in women who have no interest in de-
ceiving us, the last mentioned phenomenon deserves the greatest at-
tention; it is the most conclusive, and sometimes the only one to be
met with; but inasmuch as it is frequently the cause or the effect of
a great number of affections of more or less importance, and wholly
independent of pregnancy, it is not an easy matter to interpret it
correctly. If it happen suddenly, without being preceded by any
accident or disease that might account for it, and in a woman who

/is commonly very regular, it may constitute an almost certain sign
of pregnancy, while in the contrary condition, its value, always much
lessened, can be determined only by a circumspect and experienced
practitioner. I have no occasion to remark that it is of jio value
where pregnancy occurs before the first eruption of the menses.
Further, it is well known, that a woman whose menses have been
for some time suppressed, either from disease or merely from the
progress of age, may become pregnant; that some women are
never regular except when they are pregnant; and that the continu-
ance of the menses after fecundation is found occasionally to be al-
most epidemic, or at least, much more frequent in some years than
in others.

312. Size of the Belly. The enlargement of the abdomen in a
woman old enough to be fecundated, ordinarily suffices with the
public, to make them presume that she is pregnant. It is otherwise
with physicians. It is occasioned by so many diseases, that it ought
in this respect to be classed in the same category as the suppres-

OF TRUE PREGNANCY. 121

sion of the menses. Nevertheless, its ordinary rate of progress is
such as to yield a very important sign, and one which, alone, is, in
a good many cases, sufficient to render it certain that there is preg-
nancy.

313. The belly often tumifies or swells by insensible degrees from
the first week after conception has taken place; it afterwards dimi-
nishes or is even flattened about the beginning of the second month;
vjrhence the common proverb, a ventre plat, enfant il y a. It soon
afterwards grows again in a regular manner, and never stops until the
term of parturition. At first it projects along the median line and
lower part of the hypogastrium; while the navel seems to sink be-
neath its natural level. Until the fourth month, the iliac regions ap-
pear to grow hollow instead of projecting in proportion with the hy-
pogastrium. About the end of the third month, the navel approaches
towards the level of the skin, which it soon sarpasses, so as in some
women to form a protuberance of an inch or two, in the course of the
fifth, sixth or seventh month. Upon the whole, the special character
of a pregnant woman's abdomen is that it grows from below upwards,
and remains a long time flattened on its sides, although its middle
portion already projects considerably. I shall have further occasion
to advert to this point when I point out the means of distinguishing
true pregnancy from the affections with which we are liable to con-
found it.

§. III. iSeiisible iSig-ns.

314. The sensible signs of pregnancy are obtained by means of
the touch, or of auscultation, and from the material changes efliected
in the womb.

315. The touch. The introduction of one or two fingers into
the vagina, while the other hand is applied to the front of the abdo-
men, is called, in tokology, the touch. Recourse is had to it for the
purpose of ascertaining the disease of the vulva, of the vagina, the
womb, the bladder, the rectum, and all the organs contained within
the pelvic cavity; to learn the good or bad conformation of the pel-
vis, the nature, species, and degree of its contraction; but especially
for appreciating the modifications of the cervix uteri, either in re-
gard to its size, its consistence, position, length or temperature;
and the weight, form, extent, situation, and dimensions of the womb
itself during the course of pregnancy.

316. The touch has always been looked upon as the compass of
the accoucheur, but this has not hindered some persons, Puzos
among others (122), from vigorously objecting to its employment.
Roussel says that " accoucheurs ought to expunge from their books

123 OF TRUE PREGNANCY.

the impertinent directions that they give concerning the touch."
According to him the operation is too alarming to the modesty of a
respectable woman, too contrary to good morals, and gives signs
too vague lor it ever to be had recourse to. But Roussel speaks
here more like a rhetorician than a physician; his arguments, drawn
from its abuse, have no bearing on the rule. Though, in many cases,
the touch is insufficient, until two or three months have elapsed after
conception, to convince us either that pregnancy does or does not
exist, it is, nevertheless, the surest means of exploration in our power.
It not only serves to determine whether gestation exists, but it fur-
ther indicates the degree, the kind; it alone can teach us whether
labor is near at hand or begun, whether it is in an advanced stage,
whether the child presents aright, whether the assistance of art is
useless or necessary, whether every thing is right after labor, &c.
The touch then is the principal lever, or at least one of the most
powerful resources of tokologic science. But, in order to practise
it with success, to avoid the gross mistakes that it may cause us to
commit, to derive from it every possible advantage, it is necessary to
practise it for a long time inasmuch as practice alone can make us
skilful in such an operation.

317. Position of the ivoman. When the woman is affected with
ascites, hydrothorax, asthma, organic disease of the heart or great
vessels, when her breathing is difficult, she should stand up during
the operation of the touch, so as to avoid the fatigue and even dan-
ger that might be incurred by placing her in a horizontal posture.
If on the other hand she is weak, threatened with syncope, hemor-
rhage, or convulsions; if the womb is strongly inclined forwards, or
if from any other cause the neck is thrown very far backwards, it is
better for her to lie down. Finally, if any difficulty be experienced,
she should be examined in both positions, alternately.

318. The muscles must first be placed in a state of relaxation.
If the woman is lying down, she should be told to bend her legs
and thighs, as well as her head and breast, which are to be gently
raised with pillows or bolsters. In the contrary case, she is to be
placed against a wall, a piece of furniture or any solid body for her
support; she then separates and slightly bends her lower limbs
while she at the same time inclines her head and breast a litde for-
wards. To prevent the awkwardness of such a posture, she may be
permitted to rest her elbows or hands upon the arms of some other
person, or simply upon the edge of a table, or on a couple of chairs
placed expressly for that purpose on each side of her.

319. Before we begin the operation, the finger should be covered
with mucilage of flaxseed, ar marshmallow root, olive or almond oil;

OF TRUE PREGNANCY. 123

bnlter, hog's lard, cerate, while of eggs, or any kind of grease.
Mucilage is the best; but when it is not at hand, it little matters
what substance we have recourse to, provided it be unctuous, and
not irritating.

320. There are two reasons for making use of grease in this way:
it would not be so easy without this precaution to penetrate into the
vagina; the labia, and the hairs that cover them, might be pulled, and
thus be to some women very painful; if the accoucheur should hap-
pen to have any excoriation upon his finger, he would by this means
be less exposed to contract syphilis, the itch, or other contagious
disease with which the woman might be affected.

We should learn to touch as readily with the left hand as with the
right.

321. Supposing that two fingers can appreciate the physical cha-
racters of a body better than one. Stein recommends the introduc-
tion of the fore and middle finger together: some of that writer's
countrymen have followed his advice; but with the exception of a
few very rare cases, it is never conformed to in France. The sen-
sation felt, instead of being clearer with two fingers, is on the con-
trary more confused, and the index when employed singly very cer-
tainly penetrates much farther than if the medius is introduced along
with it.

322. In the first place, in order to introduce it, it should be held
straight and strongly abducted from the other finger; or these lat-
ter are flexed so that the thumb is placed in the palm of the hand.
In common, either of these two methods may be employed indiffer-
ently, but the former does not suit for women whose external or-
gans of generation are swelled, sensitive, inflamed or painful; the
latter is applicable to all cases, and, consequently, I think it prefer-
able, but that does not prevent me from using the other mode some-
times.

323. It is never indispensably necessary to uncover the woman;
if she be lying down, the accoucheur should place himself beside her
bed, and the hand being put under the bed clothes, is carried up to
the vulva, passing beneath the ham corresponding to the hand that is
employed; if she is standing up, one knee should be put to the
floor; according to some it should be the one that corresponds to
the hand that is made use of, according to others it should be the
opposite one. The former allege the advantage of having a place
to rest the elbow on, and of thus obtaining more firmness and surety
in the requisite motions. For my part, I think we can touch very
well in either way; however, I have for a long time past adopted
the latter mode, both in my, own practice, and in my instructions;

124 OF TRUE PREGNANCY.

I find that the arm is freer, that it may be more easily inclined for-
wards or backwards, raised or depressed; that it accommodates it-
self better to the necessarily varying stature of women, to the dif-
ferent degrees of pregnancy, and height of the womb. After all, it
is rather a matter of choice than of necessity.

324. The index finger arranged as before said, with its radial edge
turned towards the arch of the pubis, is first directed on to the peri-
neum, or posterior part of the vulva; the point of the finger is then
drawn along forwards so as to pass in between the labia, and pene-
trate into the vagina in the axis of the perineal strait, that is to say,
from below upwards, and from before backwards, as if it were in-
tended to reach the sacro-vertebral angle. Previously to searching
for the neck, it is proper to explore the state of the rectum, of the
bas-fond of the bladder, of the longitudinal columns of the vagina,
and the conformation of the straits and excavation of the pelvis:
after this first stage, the os tincae is to be examined; the thickness
and length of its lips whether relative or absolute should be ascer-
tained, as well as their bumps or tubercles, their depressions or slits,
their regularity or unevenness, and the form and direction of the
orifice; we should next endeavor to determine the length of the neck
as well as the size of the womb, which must be raised up so as to
learn its weight, while its dimensions also may be ascertained, if,
while the finger touches it in the vagina, we can also succeed in
feeling and pressing upon its fundus through the abdominal parietes
with the other hand.

325. With these precautions, it is often possible, after the end of
the third month, in a lean woman whose abdomen is pretty flaccid,
to take hold of the womb by its neck and fundus at the same time;
to make it incline backwards, or to either side; to judge of its mo-
bility, form and size; to measure very exactly its length and weight;
to become certain whether or not it is in a natural state, and whether
or not the substance it contains is fluid.

326. The depression of the cervix, its gentle inclination forwards
or backwards, its density, its length and volume, whether a little
more or less considerable, exhibit varieties too multiplied, and may
depend upon causes too diverse for us to place much reliance upon
them. Besides, to judge of them, we should have touched the same
woman once or oftener, before she was suspected of being pregnant,
and every one knows that this is a condition rarely met with. Al-
phonse Le Roy, in asserting with the decided tone that characterised
liim, that augmented heat of the cervix was suflScient ground for
him to afiirm that pregnancy had taken place, has only given an addi-
tional proof of his arrogance and temerity. If conception does in-

OF TRUE PREGNANCY. 125

crease the calorification of that part, indeed, do not all the irritative
affections produce the same result? Is not the heat of the cervix
various in different women, and even in the same woman at every
moment of the day, of the week, or month, or year? Must it not
present innumerable shades, according to the heat peculiar to each
practitioner's finger, and also according to the necessarily varying
temperature of the same practitioner's hand?

327. Hippocrates and the ancient physiologists taught that the va-
ginal orifice of the womb closes immediately after fecundation, so as
to prevent the escape of the semen; Mauriceau and other accoucheurs
have remarked, further, that the cervix becomes sharper than it was
in the course of the two months preceding fecundation; that it as-
sumes the form of a cone with its base turned upwards. These
changes, ii is true, take place in some women, but they so often fail
in those who have never borne children, and are so fugacious, so
difficult in common to recognise, so slightly marked after a first
pregnancy, that it is almost impossible to derive any a^lvantage from
them.

328. Stein affirms that in the first two months, the posterior lip,
naturally the shortest, becomes the longest, and at length reaches the
same level with the anterior one; that the slit in the os tincae is trans-
formed into an opening more or less regularly rounded and circular;
that the pubic face of the lower segment of the womb gives birth to
a soft and more or less projecting tumor; and that these changes
most commonly suffice to prove that the woman is with child. But
it is so common to meet with a circular form of the lower orifice of
the womb in women who are not pregnant and who have borne
several children, and even in young virgins to see the posterior lip
as long or even longer than the other, either absolutely or only in
appearance, that the assertions of Stein do not really deserve a se-
rious refutation.

329. I cannot, however, refrain from mentioning a peculiarity
which perhaps imposed itself upon him as that anterior projection
which is vaguely treated of in the French translation of his work.
It has happened to me several times, and I have pointed it out to a
number of my pupils, to find, in women who had been already
touched by a good many persons, that the anterior lip was sensibly
longer and softer than at the commencement of our practical sittings;
examining this lip with care, it was then easy to feel a real crepitation,
and to find that it was swelled, and fungus-like; but this was a state
wholly foreign to gestation, and which was produced solely by the
frequen'tly repeated touchings to which we had subjected the woman.
At other times, we feel aboye the vagina, immediately in front of the

12

126 OF TRUE PREGNANCY.

anterior lip, a softer, larger, more regular and less elastic tumor
which does not crepitate; but this projection, which I have met with
at every stage of pregnancy, evidently depends upon the bladder,
the bas-fond of which presses the corresponding wall of the vagina
more or less downwards; I should not dare to affirm, moreover,
that it does not pretty frequently exist independently of the state of
gestation.

,S30. Thus, until the second or third month, the sensible signs,
the touch itself, cannot, any more than the rational signs, give us a
mathematical certainty of the existence or non-existence of gestation.
They sometimes permit us to establish a diagnosis that is more or
less probable, but never certain; so that during this period, the touch
is in fact but a feeble resource, and women should not, without strong
motives, be subjected to it.

At a later period, although the practitioner cannot affirm posi-
tively that there is a foetus in the womb, he can at least be sure that
the organ is considerably increased in size. Thenceforth all that is
necessary is to distinguish real gestation from the diseases that are
sometimes confounded with it. Soon afterwards we are able to
perform the hallottement, and to perceive tlie spontaneous move-
ments of the child, which are the only phenomena that prove beyond
question the existence of pregnancy.

331. Ballottement. In effecting what is called baUottement, after
having first placed the index finger under the cervix, the summit of
the other hand is to be applied over the fundus of the womb, by
pressing it against the belly, which is to be carefully depressed so as
to push away the bowels and fat. In Jhis way the womb is held in
the most exact manner possible, by the two extremes of its longitu-
dinal diameter, and now the womb is to be suddenly pushed upwards
with the finger that is in the vagina, while the hand on the hypogas-
trium attends to and judges of the motion experienced by the ovum.
The fcEtus, which is moveable, free, and the only solid substance
within the amniotic fluid, strikes directly opposite to the point
that received the impulse. If the hand that is outside receives no
shock, the motion is to be sent back to the other one in the vagina.
Should the first attempt fail, it is repeated several times, communi-
cating the impulse with each hand alternately, and taking all proper
precautions not to give the woman any pain. The same thing hap-
pens here that is seen in physics when experiments are made on the
transmission of motion. Indeed, let a vessel full of water be struck
on any part of its circumference, and the little figures that have been
suspended in it by means of glass bubbles or small bits of cork will
immediately move to the opposite side. But it is easy to understand

OF TRUE PREGNANCY. 12T

that, in order to obtain this result, the foetus must have attained to a
certain size, that there must be a sufficient quantity of liquor amnii,
that the uterus and parietes of the abdomen must not be too thick,
and that the operation must be done with a dexterity and skill that
can only be acquired by practice on the natural subject.

332. Whenever a solid and moveable body has struck one or both
hands during the operation for ballottement, there can be no further
doubt as to the woman's being pregnant; but care should be taken not
to be imposed upon by the jar of a fluid, or any other kind of motion.
It is only from the fourth to the sixth month that the ballottement
presents a resource of any importance; for it is rarely that the jar
of the foetus can be perceived before the end of the third; and in
the next three months of gestation it is in general too easy to deter-
mine the state of the woman to make such a recourse needful.

333. Motions of the child. J9a//o^/emennm presses on the ovum
only a passive motion, which is the same whether the fostus is dead
or alive, and which would be the same were it possible for a poly-
pus or any other solid and large body to be free and moveable in a
uterus filled with any kind of fluid. Ballottement makes us know
that pregnancy exists; but active or spontaneous motions alone give
us the certainty that the foetus is living.

334. The child does not move in an active liiaiiner until after it8
muscular system has acquired a certain degree of development; and
still its motions must be so weak, that the woman can hardly per-
ceive them until in the course of the fourth month. At the begin-
ning she has a feeling oi formication; after which they acquire a force
that varies according to the vigor of the child, the stage of preg-
nancy and the good or bad health of the mother. Their strength
most commonly increases until the birth; sometimes they increase
for one or two months, become less marked in the sixth and seventh,
and resume their activity towards the end of pregnancy. M. De-
sormeaux has seen them cease entirely from the end of the fifth
month, and the child nevertheless be born strong and healthy at full
term; in other instances they are never perceived at all: some able
practitioners, such as Mauriceau, De la Motte, Baudelocque, &c.
mention women in whom attempts had in vain been made to excite
them, and who were nevertheless delivered of robust and w-ell grown
children. It may be supposed that plethora, some constraint, some
difficulty in the circulation of the fluids of the ovum, or even those of
the woman herself may render them duller, slower, more obscure and
vague; and that the free exercise of all the functions, cheerfulness
and contentment of the mother, and a proper degree of strength on
the part of the child, give them more energy and vivacity. Deli-

128 OF TRUE PREGNANCY.

cate, nervous and irritable women feel them sooner and plainer
than those whose sensibility is less exquisite, who are not in the
habit of carefully analysing their sensations, and who, in consequence
of their temperament or disposition being naturally more quiet, pos-
sess a calmer imagination and less impressible organs: the former
sometimes assert that they have felt the child move at the end of the
third month, (which seems almost impossible, since the muscles are
still mostly gelatinous,) while the latter do not commonly speak of it
until towards the end of the fourth.

If the motions of the child are very decided, quick, and frequent,
it is not necessary for them to move the abdominal parietes in an
evident manner, as is sometimes seen, to guard the woman against
confounding them in any way with motions of another kind; but when
they are weak and return but rarely, nothing is more common than
for other sensations wholly independent of them to be mistaken for
them; so that the prudent accoucheur should never pronounce upon
them without having made himself perfecdy sure.

335. For this purpose it often suffices to apply the hand, which
must be cold and naked, to the abdomen; it may be previously rub-
bed with brandy, Cologne water, &c., or dipped in cold water, with
vinegar and ammoniac in it. This application produces a sudden
transition in the temperature of the hypogastrium, which re-acts upon
the child and causes it to move in a convulsive manner. If this
simple means does not succeed, the palm of the hand is to be placed
on one side of the abdomen, which should then be properly struck
with the other, as in examining into the existence of ascites. The
fostus thus disturbed scarcely ever fails to move with some force: and
this is a sort of ballottement, which possesses the advantage over the
common method of not requiring the finger to be introduced into the
sexual organs, but which has also the disadvantage that it cannot be
usefully employed until after the fifth month.

Auscultation. After having properly performed the touch, having
attempted to effect the ballottement, and to feel the motions, whether
active or passive, of the fcetus in vain, we have no method of solving
the problem left except auscultation.

336. After Laennee had shown that it is possible to see with the
ear what is passing inside of the chest, it was natural to suppose
that auscultation would soon be applied to the investigation of the
diseases or functional changes of other parts of the body. MM.
Major and Fodere had already given some hints on the subject
when Mr. Kergaradec, in an interesting memoir, maintained, that
gestation may be ascertained with great certainty by means of the
stethoscope. According to that physician, two kinds of sounds may

OF TRUE PREGNANCY. 129

be heard in the womb of a pregnant woman: one, which aUhoiigh
quicker and shorter, is analogous to that of a feeble respiration, is
the bruit de soiijffie which he has denominated the placental sound;
the other, similar to the ticking of a watch wrapped up in cloths,
depends on the beating of the heart, and may be called the sound
of the heart. The former is isochronous with the pulsations of the
mother, which hinders it from being confounded with the respira-
tory sounds; but it is in almost every respect similar to that caused
by muscular contractions, that heard in the large arterial trunks
when spasmodically contracted or compressed by some external
tumor, and in the heart itself in certain pathological states*at pre-
sent not well understood; so that some well performed experiments
are still necessary in order to demonstrate that it appertains to preg-
nancy rather than to some other condition of the female. M. Ker-
garadec thought that it corresponded to the place where the placenta
is attached, and was produced by the passage of blood from the womb
to the vessels of the ovum, or in other words by the uterine or pla-
cental circulation; but although some facts seem to support this ex-
planation, there are many others opposed to it, and my own observa-
tions lead me to regard them as but very improbable conjectures. In
the majority of cases, it requires a very practised ear to perceive
them at all, and this is doubtless the reason which has induced many
physicians to reject them altogether.

337. I have myself in vain sought for it in a great many subjects;
on the other hand I have distinctly heard it in a great many others.
It was sufficiently strong in three women who were confined at the
Hospital de Perfectionnement, and in two others who were made
use of for the practical demonstrations of my course, for the least
skilful medical students and female students in midwifery to hear it
very plainly. I have never met with it except in the second half of
pregnancy. If Laennec and M. De Lens, who say that they have
heard it before the end of the third month, were not mistaken, that
alone appears to me to be reason enough why it is impossible to at-
tribute it to the placento-uterine circulation.

338. It should be sought for between the anterior edge of the
pelvis and the navel, and lower down in proportion as the pregnancy
is less advanced.

339. The double-beat, or sound of the heart cannot be confounded
with any other; for the pulsations can be counted to the number of a
hundred to a hundied and forty or a hundred and fifty per minuie,
while the mother's pulse beats only from sixty to seventy-five in the
same space of time : growing stronger as the foetus grows older,
this sound can scarcely be appreciable before the fourth month; of

12*

130 OF TRUE PREGNANCY.

a necessarily variable intensity, on account of a great many circum-
stances that are difficult to characterise, it is never heard better
than when the child's back corresponds to some part of Ihe anterior
surface of the uterus; I have scarcely ever failed to detect it when
able to seek for it with all suitable care; the anterior curve of the
foetus, and the relations of the heart to the spine, are the reasons
why the back is the only part that is evidently capable of transmit-
ting the double beat to the ear of the observer. From this remark
it may be conceived that they may change their place if the foetus
changes its position, and that before affirming that they do not exist
at all, we should have by turns explored the hypogastrium and the
loins, the flanks, and all the various parts of the circumference of
the pelvis.

340. In order to perform the auscultation, the woman must be
lying down, although in fact she might be allowed to stand up; if
the pregnancy be somewhat advanced the ear will suffice, and some-
times succeeds better than the stethoscope with persons not in the
habit of using that instrument. However, it can only be conveniently
applied on the anterior half of the abdomen. Moreover, the friction
of the gown or any other part of the woman's dress, whom it is un-
necessary to uncover during the operation, may frequently deceive us
as to the nature of the sounds we hear. The stethoscope in gene-
ral yields a clearer or more intense sound; besides, it can be applied
at all stages of pregnancy, and to all the points to which the foetus
seems able to turn its back; the end piece is to be taken off; then
after having felt for the womb, it is placed first on the left, then on
the right, and next on the middle of the hypogastrium; it is even
applied to the loins, the posterior face of the sacrum, the cristae of
the ilia, the front of the pubis, &,c.

341. Were it always possible, the child's back, the corresponding
parietes of the womb and abdomen, the stethoscope and the ear of
the accoucher should not be separated by any void space and by nO
other part, and they should constitute as it were a continuous body,
without any interruption whatever.

342. The sound of the heart is a certain sign both of pregnancy
and of the child's being alive; its strength, in general, indicates the
vigor and good health of the child; during labor, when accidents
occur, or when a serious operation appears to be indispensable, its
simultaneous existence at two opposite sides of the abdomen will
render it certain that the womb contains two children; if met with
in a woman whose uterus is but little developed, no doubt remains
of there being an extra uterine pregnancy; but its absence, like that
of the active or passive motions of the foetus, does, not afford a con-
clusive proof that there is no gestation, or that the child is not living.

OF TRUE PREGNANCY. 131

343. *As to the bruit de souffle, its- nature is still too little under-
stood to enable a circumspect practitioner, at present to pronounce
from its single testimony that such or such a woman is or is not
pregnant.

343. To determine the stage of pregnancy. After having by
means of the simple touch, of ballottcment, of muscular movements,
or of auscultation, ascertained that there is pregnancy, it is still fur-
ther useful, sometimes, to determine its stage; on this subject I shall
not repeat what has already been said concerning the changes ef-
fected every month in the state of the cervix, the body and fundus of
the womb; I shall content myself with remarking that, in order to
obtain a just idea of these changes, especially those of the neck, it is
often needful to touch in a diflerent manner from that in which it is
commonly done. In the first place we are not to understand by
the neck that portion merely of the womb that projects into the
vagina, but rather all the cylindrical portion of the summit of the
uterine ovoid, a kind of appendix which cannot be completely felt
except by pushing back the vaginal cul de sac with the finger, in the
centre of which is felt the os tincae; in the second place, in women
who have had children, we should make an allowance for the thick-
ness of its lips; lastly, when the uterus is oblique in front, and the
pelvis not very large, the orifice may be so high up, that in order to
reach it, the radial side of the finger must be turned backwards, or
the perineum somewhat depressed, while with the other hand ap-
plied upon the epigastrium, the fundus of the womb is thrust back-
wards towards the vertebral column. In other cases, particularly
where the superior strait is very ample, the neck looks directly to-
wards the anterior surface of the sacrum; to touch here, we are
obliged to carry the finger almost horizontally backwards, and then
to bend it forwards in the shape of a hook; in other women we meet
in the superior half of the excavation, a rounded tumor, in the pos-
terior part of which the neck appears to be obliquely hollowed out
like the ureters in the parietes of the bladder: with all these precau-
tions, a skilful accoucheur can say, what is, within from fifteen to
thirty days, the period of pregnancy; but it would be dangerous to
forget that there are numberless causes of error, and that we should
never, before a court, give a decisive opinion until we have previ-
ously acquired a mathematical certainty of the fact concerning which
we have to pronounce.

344. Compound pregnancy. It was natural to suppose that the
uterus would be larger when containing two or more children, than
when it encloses only a single one. Hence also almost all those
appearances that depend upon the pressure upon and displacement

133 OF TRUE PREGNANCY.

of the soft parts both of the pelvis and abdomen, have been enume-
rated among the symptoms of compound pregnancy. But all that
has been said on this subject throws but a vague light upon the ques-
tion; varices, infiltration, oedema, swellings, difficulty in moving the
lower limbs, engorgement of the labia pudendi, dyspepsia, difficulty
in making water, in walking, breathing, digesting; an elliptical or
flattened shape of the bag of waters; weakness of the uterine con-
tractions; lypothymia and syncope; the belly being larger, rounder,
rather depressed than salient along its median line; motions of the
foetus felt with more force and frequency, and on both sides of the
abdomen at once, &c., all fail, too frequently in twin pregnancies,
for us to place much confidence in them: besides, all these signs are
rarely met with together, and a majority of them may be met with
where there is only a single foetus in the womb; which, further, may
be easily imagined to be the case, inasmuch as the size of the gesta-
tive organ may be much larger in some cases of simple pregnancy
than in others where the gestation is evidently double or triple.

345. Baudelocque teaches that the touch is able to conduct us to
more satisfactory results. He says, for example, that where the
belly is very large, if there be only one foetus, the ballottement will
be very easy; while if there be two of them, there will, on the con-
trary, be some difficulty in effecting it, and that their motions or their
most projecting portions can be distinctly felt through the parietes
of the abdomen, in several places at the same time. It may be added
that we ought to be able by means of auscultation to hear the sound
of the heart at two places, at some distance from each other, and
that if the pulsations denominated placental are of any use in obste-
trics, they will also be heard at two distinct points.

346. The union of these signs would give us, without the least
doubt, a certainty of the woman's being pregnant with two or more
children; but the want of them is far from always constituting a
negative sign of compound pregnancy. M. Desormeaux cites a
case wherein the most manifest ballottement coincided with a very
great size of the abdomen, and in which that able accoucheur could
only detect a single foetus, while the ovum in fact contained two.
On the other hand, the ear cannot detect the cardiac pulsations of
two foetuses, when they are so situated that one is above or in front
of the other, so that it is most commonly impossible, previously to
delivery, to affirm whether the pregnancy is simple or double.

OF TRUE PREGNANCY. 133

SECTION 2.
Of Extra-lit erine Pregnancy.
§. I. Of OTarian Pregnancy.

347. Andry, and the animalculists, who, like him, supposed that
the living corpuscles of the seed passed along the Fallopian tubes in
order to join the ovule in the female seminal gland, did not attempt
to contest the existence of ovarian pregnancy, and among modern
practitioners there are few who think of calling it in question; Boer-
haave even thought lie could divide it into external and internal, but
this question appears to me to have been too lightly judged, and to
deserve a new examination.

348. In whatsoever manner, indeed, fecundation is really effected,
whether by means of an aura, an animalcule, or by any other prin-
ciple of the semen, it must happen that the germs of the two sexes
shall come in contact with each other; this contact cannot take place
without a rupture of the covering of the ovary, and of the capsule
of the ovule; so that by the simple admission that an ovule is vivi-
fied, it can no longer be said to be enclosed in the ovary, unless
we believe with Chaussier, that the male germ reaches that of the
female by means of absorption. A great many cases of ovarian preg-
nancy are to be found in the various scientific collections: an infinity
of physicians and accoucheurs of merit have stated that they have
met with them in practice; but it is easy, upon a moment's reflection,
to perceive that not one of the cases hitherto published, not even
those of Littre and Smith, prove undeniably that ovarian pregnancy
has ever been seen. It is so easy in the dead body to confound this
kind with abdominal pregnancy, those who have treated of them
have given so few details, pathological anatomy was at that period so
little cultivated, that no result can in fact be obtained from the obser-
vations of the authors; and while the moderns shall not have demon-
strated, with the scalpel, that the ovum is sometimes really situated
in the ovary and not in the adjacent parts, reason dictates to us that
we should not admit the existence of ovarian pregnancy.

349. I have learned at my own expense how easy it is to be im-
posed upon in this matter. In 1824 and 1825 I met with the
remains of extra-uterine conceptions in four different subjects; I re-
moved the sexual parts with great care, and thought I was in pos-
session of four facts in proof of the existence of ovarian gestation.
I presented them to the Societe Philomathiqiie, where several mem-
bers expressed doubts as to the possibility of the fact. MM. Blain-
ville and Serres were good enough to assist at the dissection, which

134 OF TRUE PREGNANCY.

I performed the next day. We satisfied ourselves that three of these
tumors were outside of the germiferous gland; we experienced
greater difficulty in regard to the fourth, which did not exceed an
inch in size; but at length, after having completely isolated the Fal-
lopian tube, we found that the debris of the conception was con-
tained in a special sac between the peritoneal coat and the proper
covering of the ovary which was wholly distinct from it. Certainly,
none of the facts that have been cited as proofs of the existence of
ovarian pregnancy have been more carefully examined; and certes,
if it had not been for the objections and the presence of an able de-
fender of the opposite opinion, we should have remained convinced
that the seat of the tumor was in the very parenchyma of the ovary.

§. 11. AbdoiniJia] Pregnancy {peritoneal, ventose, ex-
ternal, 4'C.)

350. Admitting that fecundation is effected in the ovary, it is very
natural that the vivified ovule should sometimes fall into the belly
instead of being engaged in the Fallopian tube; in reflecting upon
the anatomical arrangement of the parts, one is disposed to believe
that such accidents are not uncommon; if, says Bianchi, it does not
occur more frequently, it is doubtless because a very great majority
of the germs that escape in this way die before they become attached
to the serous membrane that receives them. However, some mo-
dern accoucheurs have asserted that it could not occur; that the pe-
ritoneum is not sufficiently vascular to supply to the germ the requi-
site means of development; that in the instances in which dissection
had shown the foetus and its secundines to be in the abdomen, there
had been previously a tubal or uterine pregnancy. It is true that the
tube and the ovary are commonly, and sometimes a part of the uterus
itself is, lost as it were in the mass of the tumor, and that it would
be imprudent in that case to affirm that the ovum was not originally
located in another place; but it is at the same time an incontro-
vertible fact that in many of the published cases, both the ovary and
the tube retained their natural condition, and were completely foreign
to the sac which contained the fcBtus. On the other hand the vete-
rinary physicians, more competent even than accoucheurs to solve
this problem, have completely embraced the affirmative, relying on
numerous and authentic facts that have been noted for thirty years
past; besides, the difference between the structure of the peritoneum
and that of the womb cannot in fact serve as a basis for any good
argument; the ovum, which may be compared to the bud of a plant
endowed with life that is still very obscure, is so constituted as to
unite with the first living parts whereon nature places it. The in-

OF TRUE PREGNANCY. 135

terior of the womb or of the tube doubtless suits it better; but are
we allowed on that account to say that it can never take root in any
other situation? Therefore nothing in the laws of the organism for-
bids us to admit the possibility of a peritoneal pregnancy, and I
should not have taken the trouble to combat the opposite opinion,
were it not that M. Dubois still maintains it, and throws around it
all the weight of his imposing authority.

351. The fecundated vesicle, soon covered with a velvety pile
similar to the spongioles of the roots of plants, must rapidly contract
adhesions with the surfaces on which it rests; there is an afflux of
fluids to that point, appearances similar to those of a local and very
circumscribed inflammation soon occur, and an accidental sac is
soon organised around the little ovum, which is, so to speak, thence-
forth protected against the action of the surrounding organs.

§. III. ©f Tubal Preg^nancy.

352. Tubal pregnancy, more common than any of the others,
and the only one that has not been contested by the partisans of
ovarian fecundation, could only be rejected by authors who believe
that vivification takes place in the womb; but the cases on record
are now so numerous that it is no longer permissible to entertain
the slightest doubt in relation to it. Without mentioning those that
are detailed in the works of Bartholin, of Riolan, of Bianchi and
others; in the dissertations of MM. Bry, de Bouillon, Bonis; of those
related in the Revue Medicate (1826) the Nuovo Giorn. del Lett. Ital.
(1825,) of another reported by M. Vallerand, Nouv. Bihl. Med.
(1826,) and of an infinitude of others that have been published in the
French and Foreign Scientific Collections, I will state that in 1816
I saw in the body of a woman who died at the hospital of Tours, a
very perfect ovum in the second month of its growth, which was
very completely enclosed in the outer half of the Fallopian tube,
of which the root, the fimbriated extremity, the canal, and all the
other parts were still easy to be recognised. Any one may see, in
the Museum of the Ecole de Medecine, a wax model which mathe-
matically demonstrates the same thing. We may conceive, further,
that in this species of pregnancy, the product of fecundation may
attach itself to any portion of the length of the tube, but that it will
most frequently stop in the trumpet part of it, and that after a cer-
tain lapse of time, it must be difiicult to decide, at a glance, whether
the pregnancy is tubal, rather than abdominal or ovarian. It may
besides be conceived, that the uterine duct, soon distended, and
thinned, might burst, and transform a tubal into a peritoneal preg-
nancy; so that the latter may, in fact, be either primitive or essen-

136 OF TRUE PREGNANCY.

tial, or else secondary, or accidental; but it is superfluous, with
Boehmer, to describe both an internal and an external tubal preg-
nancy.

§. IV. Of Interstitial Pregnancy.

353. The ancients made no mention of what M. Mayer has pro-
posed to denominate interstitial pregnancy. Noticed by Schmidt,
Albers, Hederich, Carus, MM. Cliet, Bellemain and Lartet, Dance
and Moulin, it had been studied with some care by MM. Mayer and
Meckel in Germany: but scarcely any thing had been said on the
subject when M. Breschet, to whom MM. Bellemain and Lartet
had abandoned the specimen which had served as the basis of their
observation, undertook to collect all the known facts in relation to
the topic.

The ovum in this case does not lodge betwixt the peritoneum or
the mucous coat and the proper tissue of the womb; but in the very
substance of the fleshy structure. In five out of seven cases, it has
been found on the left side, above, behind, before, or below the
tube, which did not in any case, as we are assured, communicate
with the cavity that contained the production. It is at least cer-
tain, that in the one I had an opportunity of examining along with
M. Breschet, there was no communication between the natural,
cavity of the genital organs and the preternatural sac which con-
tained the foetus. M. Meniere has published in the Archives Gene-
rales de Medecine some very judicious reflections on interstitial preg-
nancy; but the case he "had in connection with M. Dujardin does
not appear to me to belong to that class. Dionis, Canestrini, Ein-
senman and Ramsbotham , have each related a case wliich seems to
be more like it.

Attempts have hitherto been vainly made to explain the mechanism
of this kind of pregnancy; M. Breschet has supposed that when the
ovule is about to enter the uterus, it might upon meeting with some
obstacle, engage in the open orifice of some one of the venous
sinuses that open at the origin of the Fallopian tubes, and thus
gradually insinuate itself into the very substance of the parietes of
the womb. But as these orifices have no existence in fact, the ex-
planation falls to the ground of itself. On the other hand, a(hnitting
that the angles of the uterus, at birth, being very long, bear a partial
resemblance to the horns of the womb or tlie ad uterum of quad-
rupeds, M. Breschet presumes that the narrow passage which then
leads to the seminiferous tube, might, by becoming obliterated, com-
pel the germ to deviate from its ordinary route. But if it be true that
such a conformation is sometimes met with, I can at least affirm

OF TRUE PREGNANCY. 137

that it is rarely so, and is not according to the natural order of
things. This, therefore, is also but a gratuitous hypothesis. The
same must be true of the passage discovered by M. Baudelocque,
Jun. in the side of the womb, as well as of the preternatural cavities
mentioned by Morgagni, Valsalva, &c. It is true we may have
recourse to anatomical varieties, to diseases, anomalies, to deviations
of all sorts, and indulge in a thousand suppositions; but the wisest
course is to confess, frankly, that the mechanism of interstitial preg-
nancy is wholly unknown.

§. V. Causes of extra-uterine Pregnancy.

354. The density, the preternatural thickness of the covering of
the ovule, or envelopes of the ovary, too strong an adhesion of the
germ, its being situated too deep or too near the ligament of the
ovary, the obliteration, paralysis, spasm, bad direction, excessive or
insufficient length, engorgement, or antiperistaltic motion of the
Fallopian tube, inflammation and ulceration of its mucous membrane,
induration of its trumpet end, or of one or more of its fringes, the
contraction of its external orifice, all the changes and anomalies that
this canal may exhibit, whether in regard to its conformation or its
situation, a laceration of the womb, spoken of by Boehffier, Bianchi,
and Weinckneicht, may well have produced some in?<;ances of extra-
uterine pregnancy; but it is certain, that in this I'espect science is
possessed of scarcely any thing beyond probabilities. Astruc believed
that unnmrried women were more liable to be sdected with this sort of
accident than others. Kruger, who unite? in this opinion, supposes
that the ovule remains in the ovary, stoj)s in the tube, or slips into the
peritoneum, because fear, alarm, i^xlignation, by attacking women
suddenly in the midst of the mo?i lively enjoyment, or shortly after-
wards, must occasion a distu-'Oance in the whole organism, whose
eflfecls reach even to the sexual organs. A case by M. Lallemand,
and another by Baudelocque, seemed to lend some support to the
opinion of Astruc; n\ fact, the extra-uteriiie conception in the two
women who wer^ the subjects of it, seem to have been efTected,
■at the very instant of a violent fright, occasioned in one by the Ve-
membrance of some piece of forgetfulness, and in the other by a
sudden noise, which made her afraid of being caught in flagrante
delicto; but as nothing similar has been noticed in other cases, this
explanation can only be regarded as a tolerably plausible hypothesis.
355. Those who insist that fecundation is effected in the womb,
necessarily reject all these modes of viewing it, and can give no
account of extra-uterine pregnancy, but by. [supposing a retrograde
movement, by means of which the ovule reti)rr»s from the uterus into
13

138 OF TRUE PREGNANCY.

the tube, &c. The assertions of Planchon, who affirms that the tubes
are slightly dilated in the first weeks of conception, a remarkably
curious case reported by Patune, in which it is said that the umbili-
cal cord of a foetus enclosed in the fimbriated extremity was inserted
into a globose placenta, situated in the very cavity of the womb, are
very rare facts, and ought to be met with anew before they can give
much weight to such conjectures.

§. VI. Signs and Terminations of Preterna-
tural Pregnancy.

356. The continuance of the menses, severe pains in the hypo-
gastrium, nausea, and frequent vomiting, as well as several other
distressing symptoms, considered as signs of extra-uterine pregnancy,
sometimes indeed do accompany it ; but as they also are oftener
wanting, and not at all uncommon in natural pregnancy, their pre-
sence is, on that account alone, of very little weight. Though the
breasts undergo no change, secrete no milky fluid; though the belly
is uneven, its growth more rapid, and its development chiefly on one
side; '.hough the motions of the foetus are earlier felt, and through
surfaces apparently very thin; though the womb remains quite small,
in some casfc« of extra-uterine pregnancy, the contrary happens in a
still greater nuiaber of cases, and one or more of these irregularities
is frequently met with even in simple pregnancy.

However, though U is true that the womb sometimes increases in
size in such cases, it is equally true that the changes which it then
experiences are seldom sufSciently marked to make us believe in the
existence of a natural pregnaacy of four or five months' standing.
If, therefore, the abdominal tumor has risen early above the mar-
ginal strait, and is found in one of i\>e iliac fossae; if it appears to be
full of bumps, varicose, and if pulsaticns can be felt in it; if it be
easy to feel the protuberances and motions of the foetus, while the
parietes of the abdomen preserve nearly their natural thickness, and,
on the other hand, we can ascertain by the touch that the weight
and size of the womb are not at all, or but slightly increased; that
the cervix has not to any sensible degree diminished in length, al-
though it has altered in respect to its position, direction, density, and
even form, then it is evident that the pregnancy is preternatural.

357. Still it may be conceived, that although the ovum has fixed
itself to some part in the pelvis, or to some point on the periphery
of the womb; or has been arrested very near the root of one of the
tubes, or even in the substance of the parietes of the uterus, all these
signs may in fact not exist, and the preternatural pregnancy be con-
founded with an ordinary gestation. In these cases the uterus swells,

OF TRUE PREGNANCY. 139

softens, undergoes a major part of the changes that characterise real
pregnancy, its cavity becomes filled with a concrescible matter which
is amorphous, a kind of membrana caduca or anhisious layer, ob-
served by Berlrandi, Chaussier and others; the form of the belly and
the motions of the fostus exhibit nothing peculiar, and ballotteraent
itself is not always impossible.

358. In general, the sexual organs depart but very little from
their natural state, when the foetal cyst is not within the tube, and
contracts no adhesions with the womb. On this subject, the case
noticed by M. de Bouillon should be regarded only as an uncommon
exception. In these cases the cervix rarely becomes much short-
ened, nor does its orifice dilate in any considerable degree ; it is
found to be much lower or higher, more forward or backward, or to
one side, than the presumed period of the pregnancy would seem to
indicate.

359. After all, neither the rational nor sensible signs suffice, until
the end of the tliird month, to prove that pregnancy is extra-uterine.
After this period, it will in most cases be possible, by means of some
or all of them, to establisli an almost certain diagnosis; the evidence
derived from them will at least give rise to suspicions sufliciently
strong to fix the attention of the practitioner.

360. As to the distinctive signs of the different species of extra-
uterine pregnancy, I do not think it would be useful to treat of them
in this place ; the knowledge of them could not be beneficially ap-
plied; besides, all those that have been mentioned are too uncertain

to doeorvo the least COnfidBiico: eiiice, eveji on the dead body, we can

scarcely decide, even by means of the scalpel, whether the ovum is
situated in the tube, the ovary, or the peritoneum, it would be in some
measure ridiculous to desire to obtain any certainty in relation there-
to, on the living subject.

361. Extra-uterine pregnancy commonly terminates before the
fifth month; Baudelocque, MM. Arnault, Novara, Delisle and some
others have nevertheless seen it much more prolonged, and even to
the term of ordinary gestation. These authors, especially the for-
mer, mention a very remarkable circumstance; it is that in these
cases, at the close of a kind of labor, attended with intermittent
pains, that are sometimes pretty strong, a commencement of dilata-
tion of the neck, a discharge of mucus, of a bloody fluid, and what
seems still more surprising, very regular contractions of the womb
or of the foetal cyst are observed to take place. In foct we may
conceive of a part of these phenomena in tubal pregnancy; the tube
being composed of the same elements as the womb, it is quite na-
tural for it to enjoy the same properties; but, in abdominal preg-

140 OF TRUE PREGNANCY.

nancy, we can only account for the contraction of the cyst by sup-
posing that there has been a development of fleshy fibres in its
parietes, at ths cost of the elastic cellular layer which is enclosed
in the peritoneum of the pelvis.

362. Termination. Interstitial pregnancy alone admits of a pos-
sibility of extracting the fcetus by the natural passages; the caliber of
the tube, and its slight dilatability, do not allow us even to think of it
in the other species; in this view, therefore, extra-uterine pregnancy
is always dangerous, both for the mother and child: its natural ter-
minations are the death of the foetus, and rupture of the cyst.

363. Death of the fcetus. It is rare for the fostus to continue
alive beyond the second or third month; after its death, which hap-
pens for want of nutrition, or in consequence of inflammation of its
envelops, it sometimes happens that the liquor amnii as well as all
the other fluid portions of the ovum are absorbed, the child hardens,
petrifies, or is transformed into gras de cadavre, the cyst contracts,
thickens, and becomes fibrous, fibro-cartilaginous, or even osseous,
and the whole resolves itself into a solid tumor, which may remain
in the abdomen for an indefinite period, without compromilting the
life of the woman. In other cases the sac is transformed into a real
suppurating cavity, the fostus is decomposed, dissolved, or putrefies,
and then the cyst soon contracts adhesions with the surrounding parts,
so as speedily to open into the bladder, the caecum, the colon, the
small intestines, the rectum, or directly outwards through the pari-
etes of the belly or perineum, if not immediately into the peritoneum.
Sometimes the ovum becomoe merely filled With a fluid -which io
more or less thick and transparent, of a yellow, brown, gray, or red-
dish color, but not purulent; or it is converted into a cyst, in which
as much as one hundred and fifty pounds of fluid have been found,
and containing the debris of a fcetus: an instance of which is reported
by Vassal.

The first case is the most fortunate of all; with it should be classed
most of those pretended pregnancies that have been said to last two,
four, ten, fifteen, twenty, thirty, and even forty years: the second is
always accompanied or followed by serious symptoms; inflammation
is propagated to the circumjacent parts, gives rise to violent fever, and
sooner or later brings on a fatal termination; the patient most com-
monly becomes hectic, for she is exhausted by an abundant suppura-
tion; sometimes, also, all the parts of the foetus escape one after an-
other; the sac is gradually emptied, becomes clean, and contracts;
the suppuration ceases by degrees, and the wound at last closes, or
at least is reduced to the state of a fistulous ulcer, which is rather
more troublesome than dangerous.

OF TRUE PREGNANCY. 141

364. Every species of extra-uterine pregnancy may terminate by
the laceration of the ovum, and of the sac which serves in place of a
womb; examples of this kind, if we may credit M. Mesniere, have
been noticed both in instertitial and abdominal pregnancy; but tubal
pregnancy most frequently terminates in this way: although very
extensible, the parietes of the tube are, nevertheless, too thin to ad-
mit of the enlargement of the cyst beyond the third or fourth month.
In some instances the rupture occurs suddenly and seems to be
occasioned by some exertion, or fall, &c.; sometimes, on the other
hand, it is effected and prepared for by slow degrees, by the mecha-
nical thinning, the softening, or some other change of a portion of
the foetal sac. In all cases where no conservative adhesions have
been formed, the water of the amnios, the fostus, and the blood that
flows from the lacerated surfaces, pass into the cavity of the perito-
neum; iipothymia, syncope, convulsions incessantly repeated, and
intolerable pains, often carry off the sufferer in a few hours; in other
instances vital resistance does not so readily yield; a violent perito-
nitis comes on, and death succeeds on the second, third, or fourth
day. Finally, in some rare cases, nature, with proper assistance,
resists the first dangers of this redoubtable tempest, and a protracted
inflammation permits the effused matters to accumulate in a more
circumscribed space, and give birth to a real abscess, which may
still leave some chance of saving the patient.

365. Treatment. The impossibility of <;ertainly recognising the
nature of extra-uterine pregnancy in the 5rst months of its existence,
is the reason why attempts to remec'y it are scarcely ever made until
the occurrence of symptoms, apiiouncing the death of the foetus or
rupture of its coverings: besiJes, the powers of art are so limited in
these circumstances, that the only assistance which it is possible to
afford would be almost as dangerous, in itself considered, as the na-
tural terminations of the affection. Gastrotomy, the only remedy
that has been proposed, can boast of no successes as yet; in one case,
published by M. De Bouillon, the woman survived eighteen days;
nature, on the contrary, when left to her own resource, has several
times succeeded in triumphing over all obstacles. Nevertheless, the
fears of Levret and Sabattier, in regard to hemorrhage, suppuration,
and wounds of the peritoneum, are evidently exaggerated; it would
seem, a priori, that gastrotomy ought to be much less frequently
fatal than is commonly supposed.

366. On the other hand, although we have no right to invoke past
experience in its favor, we should not forget that, having been
hitherto performed in despair of all other assistance, we have no
reason to be surprised at its not having prevented death from taking

, 13*

142 OF TRUE PREGNANCY.

place. I think, therefore, with M. Desormeaux, that if recourse
Avere had to it early, before the formidable array of inflammatory
symptoms have developed themselves, before peritonitis becomes of
itself mortal, a considerable number of women might be saved. It
has been maintained that in all cases it should not be had recourse
to until the seventh month of pregnancy, unless it be certain that the
fcEtus is dead, and the cyst opened into the peritoneum; that other-
wise, we should, without advantage to the mother, sacrifice the life of
a child which we might possibly have conducted to its full term, and
rescued alive. This reasoning is good for nothing; the chances of
success in the operation are so much the more numerous in propor-
tion as the pregnancy is less advanced; in this case there is too lit-
tle probability of the future life of the foetus, for it to be balanced
against that of the mother. After seven months, when the child is
viable,* reason and humanity both dictate its performance without
hesitation. Even although the accoucheur should not arrive until
after the rupture of the cyst, he should still instantly open the parie-
tes of the abdomen; with the operation death is but too probable,
but without it, is nearly certain.

367. In cases where gastrotomy is not applicable, we must be
content to prescribe for symptoms, to moderate the violence of in-
flammation, to prevent as far as possible the formation of pus, to fa-
vor the production of adhesions, so as to circumscribe the eflusion,
to sustain, or also to diniinish the strength by means of regimen or
blood-letting, according as the appearances of reaction or exhaustion
may seem to require; we must asdst in the escape of those portions
of the ovum which present themsewes in the vagina, the bladder
the rectum; if abscesses form, they mu^t be opened; and we must
prevent the stagnation of pus or of any makers in a state of decom-
position; in one word, we should put under contribution, one after
another, accordingly as they may be indicated, baths, injections,
enemata, a severe diet, an analeptic regimen, general or local bleed-
ing, and rest or exercise. f

* I have left this word untranslated: it expresses that state of development in
which a child may live, when independent of its connection with the mother. I
trust the reader will pardon me for introducing it here, especially as it is getting
much into use among the profession in this city. — M.

t Inasmuch as the diagnosis of extra uterine pregnancy can in no case be ab-
solutely clear and undeniable, the question of gastrotomy is one of the most difficult
that can be presented to the surgeon. While the woman continues to enjoy even a
moderate degree of health, I think few surgeons could be found, bold enough to re-
commend or effect the incisions requisite for the extraction of the foetus; the more
particularly, since the patient may, as in many examples has been shown, con-

OF TRUE PREGNANCY. » 143

ARTICLE II.
Of False Pregnancy.

368. Numberless cases prove that various diseases may give rise
to a belief in the existence of pregnancy in women who are not
gravid, and vice versa. A woman of the Fauxbourg Saint Marceau
was with child, says M. Desormeaux; certain impudent quacks
plunged a trocar into her abdomen, and she died in a few hours af-
terwards. I was called, in consultation, to a lady, in order to de-
cide whether it was necessary to perform the csesarian operation;
the patient was affected with peritonitis of which she recovered, and
a scirrhous ovarium of which she died! It is useless to invoke the
rules of art against errors so gross; but there are cases so obscure
that the most skilful practitioner may easily mistake their true na-
ture. M. Lefebvre, in his thesis, has shown that even animals pretty
frequently exhibit similar anomalies.

369. Retention of the menses, ascites, or encysted dropsy tym-
panitis, polypi, scirrhus, cancers of the womb, tumors in the ovaria,
the tubes or the pelvis and other lesions besides, often produce a
major part of the rational signs, and even some of the sensible signs
of pregnancy. However, one must be very inattentive or inexpe-
rienced, not to avoid mistakes in almost all these cases.

370. Who can confound the symptoms of scirrhus of the cervix,
and ulcers of the uterus with the phenomena of gestation, after hav-
ing touched the woman? Is not the presence of a polypus most
commonly accompanied with hemorrhage. Does it ever admit of
ballottement, or make us believe we feel the spontaneous motions of
a fo3tus? Do the progress of the affections, the state of the cer-
vix, &c. in any case resemble those of natural pregnancy?

371. The accumulation of blood, serum, or gas in the womb
might indeed impose upon us in this matter. On this subject we

tinue to live for ten, twenty, and even fifty years, without great suffering or dis-
comfort, and as she enjoys the further prospect of getting rid of the difficulty by
suppuration, and the other modes pointed out by M. Velpeau. A csesarian opera-
tion would be far less dangerous than a gastrotomy for extra uterine pregnancy,
because the contraction of the womb after delivery, by the ceesarian section, obvi-
ates the great danger of internal hemorrhage; a circumstance which cannot be pre-
dicated of the incisions into an accidental sac containing the extra uterine foetus.
For a very excellent paper on uterine pregnancy, see Dr. James's article in North
Amer. Med. and Surg. Journal, Vol. IV. p. 275.— M.

144 OF FA.LSE PREGNANCY.

may refer to the memoir lately published by Madame Boivin. But
if the womb is filled with blood, or if the person has always had dif-
ficult menstruation, the touch shows that the hymen is imperforate,
that the vagina or some other part of the genital organs are not
properly formed; if it be a married woman, or one whose menses
had been previously regular, there will, in general, be found at the
same time more or less numerous indications of disease, which clear
up the diagnosis; besides, the motions of the fcetus are never met
with in those cases.

372. In the case of hydrometra we are in possession of the same
resources, and the local affection is accompanied with so serious a
change in the general health, that with a little reflection error be-
comes from that very circumstance almost impossible.

373. In uterine tympanitis the womb may acquire a considerable
size, but it always remains very light, there is no ballottement, and
percussion of the belly occasions such a resonance as at once dissi-
pates all uncertainty.*

374. Encysted dropsy, fibrous or scirrhous tumors, any unna-
tural growth in the ovary or parts connected with the womb, might,
at most, be confounded with extra-uterine pregnancy, inasmuch as
the neck in those cases undergoes only very slight changes; the
want also of the positive signs of the presence of a child, the general
state and progress of the affections Avill always suffice to prevent us
from asserting that there is one, and frequently to lead us to main-
tain that there is no gestation in the case.

375. As to ascites, peritoneal tympanitis, effusions of pus or blood
in the abdomen, encephaloid, fibrous, scrofulous, steatomatous, or
any other kind of tumors, and the various lesions of organs contain-

* I seize this occasion to say that I cannot admit the existence of uterine
tympanitis as a disease proper. — It is not possible to retain air within the cavity
of the womb without the aid of a tampon of some sort. There is no ground to be-
lieve in the existence of such a malady. — Nevertheless, in some women, air is
occasionally discharged with noise from the vagina, as I can witness, having
repeatedly heard it myself in several different individuals — but this only takes
place upon some sudden motion, as stooping, &lc. and it consists in the expulsion
of air not from the womb but from the vagina. The uterus is sometimes higher,
sometimes lower down in the same woman: when it rises upwards, as upon lying
down, air enters the vagina and is retained there, until, upon some sudden effort
ofthe woman, it is forced out again, in consequence of the womb being again
forced downwards by the movement of the body or change of attitude. I have
also witnessed the discharge of volumes of foetid air from the womb, upon the
forced removal of a putrid and crepitating placenta. But this is a case of acci-
dental distention — and not a real case of disease worthy of the title tympanitis
uteri.— M.

OF FALSE PREGNANCY. 145

ed in the belly, they are so many diseases or symptoms of diseases,
which only resemble pregnancy in the distention of the abdomen
they occasion, and a few other still more inconclusive signs. If the
peritoneum is distended with gas, percussion will show it at once to
be so: in ascites the fluid, falling to the lowest places, according
to the laws of gravity, will give to the belly a form too readily dis-
tinguishable from that of pregnancy for those two states to be con-
foun>led, and the difference is still greater in all the other affections
that I have just now mentioned.

376. The group of symptoms, known as nervous or hysterical
pregnancy, have most frequently been the cause of error on this
head. It is most frequently met with about the period of cessation
of the catamenia, or in unmarried women of an irritable or nervous
habit, in such as having lost their first children, are much tormented
with a desire of having more, those who have remained several years
in a state of widowhood, and think they have been fecundated by a
second husband. The menses are suppressed, nausea, qualms,
changes in the breasts, in the digestion, and sometimes all the ra-
tional signs of pregnancy supervene, and now and then the woman
goes so far as to say that she feels the motions of the child quite
strong: and what is more, there have been skilful accoucheurs who
have partaken of the error. According to M. Orfila, professor Du-
bois was not afraid to confess that he had himself been deceived.

377. A lady, thirty-eight years of age, who had had no children
for twelve years, and who would have given the world to become a
luoilicr Dy xlit! mail wiiU Whom stie was associaieo, sent Ajr me in
1823 to prevent an abortion with which she thought herself threat-
ened. According to her account, she was four months gone with
child; the size of her abdomen, and numerous sympathetic pheno-
mena seemed to confirm her assertions; she had felt the motion,
and the slight discharge of blood that alarmed her had been provoked
by violent exercise. After two or three days her fears were quieted;
but they recurred again two months later. New hopes again succeed-
ed. The period so ardently desired arrived at last; labor pains
came on; a skilful midwife repaired to the woman, who was over-
whelmed with joy: three days passed away in pretty severe suffer-
ing without appearing to advance the period of delivery; I was call-
ed upon: I examined her, and found the cervix as well as the body
of the womb in a natural slate. I pronounced her to be not preg-
nant; she became enraged; I was dismissed, and learned four days
afterwards that her belly had fallen, that nothing had passed out from
the sexual organs, and that the woman's health was restored.

378. Here, as in all analogous cases, the examination of the organ

146 SEX OF THE FCETUS.

of gestation would have sufficed after the fifth month to destroy the
iUusion; but the patient cherished her error so dearly, that she would
not permit herself to be examined; and more particularly as she en-
tertained not the shadow of a doubt as to her condition.

I do not here treat of molar pregnancy, nor hydatid pregnancy,
because moles and hydatids of the womb being nothing but products
of unnatural conception, give rise to the same phenomena as natural
pregnancy, and always end in abortion.

ARTICLE TIL
Of Pregnancy ^ as it regards the Sex of the Foetus.

§. L Is it possible to ascertain the sex of the
fcBttis during pregnancy.

379. When we reflect on the powerful and various reasons that
should lead man to seek in the future for what may subserve or dis-
turb his interests and his passions, the desire of knowing the sex of a
child still inclosed in the womb of its mother surely seems to be quite
legitimate. The woman who becomes pregnant rarely fails to attach
an idea of greater happiness to one sex than to the other. In the most
common conditions of social life the husband himself is often tor-
mented with the same inquietudes. If to this sentiment which is so

general bo added tliC fcaro wf a wliulc raillll_y tVivoatoncd -«illj oKtino-

tion for want of heirs male; the alarm of a whole people; the various
clashing designs of all nations united by the bonds of civilisation
when the reigning dynasty of a great empire has no hope save in
the being who is as yet unborn, we shall comprehend the efforts
that have in all past time been made to satisfy public curiosity on
this head.

380. The gods, diviners, and sorcerers, have in turn been con-
sulted: at Rome, Livia had patience enough, assisted by her women,
to complete the incubation of an egg with the warmth of her hands;
being persuaded that if a male was hatched from this egg, the child
with which she was pregnant would be a boy, and that the reign of
Augustus might thus be continued. The Egyptians and IniUans
depended on the state of the heavens, or on the nature of the con-
stellations, at the moment of fecundation; the Greeks and all the
people of the ancient world used to rely upon the phases of the moon,
&c. But unfortunately not one of these auspices but has deceived
the credulity of poor man.

SEX OF THE FCETUS. 147

381. Founding on the debatable principle that the male embrj^o
is sooner developed than the female, Aristotle pretends, as well
as Hippocrates and many other ancient authors, that the woman
quickens earlier with a boy and later with a girl. Setting out with

■the same idea, the relative strength of the foetus has been transferred
to tiie' mother; it has been said that she feels more vigor, activity,
gaiety, contentment; that her eyes are more lively, her face more
blooming, her pulse larger, more frequent, her digestion easier; that
all her functions, in a word, are executed more freely, when she is
to bear a male child, than when she is pregnant with a female; that
a brown or black ray along the median line of the belly, greater
strength, livelier color, nipples more prominent, a harder and tenser
breast, stronger pulsation of the carotids, veins larger on the right
than on the left side, announce the presence of a boy; that in getting
up or walking the woman advances the right knee or foot first; that
the womb is inclined to the right, that the urine is constantly loaded,
that it deposits a lateritious sediment, if there be a male child; and
that opposite phenomena are observed when it is of the female sex.

382. I do not think it needful to combat in a serious way the
reasons by which physiologists and physicians have supported these
assertions; I should not have deemed it worth while even to mention
them, if they h;id not given rise to a crowd of prejudices that are
spread among the vulgar, prejudices which the quacks make the
most of, and which the ablest accoucheur is sometimes compelled
to manage as well as he can, when unable wholly to destroy them.
I shall content myself with observing that the several phenomena I
have just now enumerated have been, and continue to be met with
every day, as much, and not more for one sex than for the other;
that what passes as indicating a boy, Osiander, relying upon calcula-
tions, asserts that he has most frequently observed in women who
brought forth only girls, and that none of the numerous signs, estab-
lished, o priori, upon false notions, have ever been confirmed by the
careful observation of facts. All that can be said in this regard is,
that certain women, when they are pregnant with a boy, feel certain
symptoms, so distinct from those they experience when carrying a
female, that they can scarcely be deceived; but then the signs attri-
buted to pregnancy with the male sex sometimes announce the pre-
sence of a female foetus, and vice versa; most frequently there is a
blending of tiie phenomena proper to the two opposite sexes, which
always return with the same character for the same sex; so that these
peculiarities, entirely individual, only applicable to a few subjects,
and moreover pretty rare, can be of no use except to those women
alone who are aff'ected with th.era.

148 SEX OF THE FCETUS.

383. The old women say that if the first conception takes place
during the waxing of the moon it will produce a boy, but if in the
wane the woman will on the contrary be delivered of a girl; others
equally skilful admit that the child will be of the same sex with the
last one the mother bore, provided the moon did not change within
three days after that confinement; finally, some accoucheurs, freely
trusting to chance, ascertain first what the family or the lady most
desire, and very good naturedly promise what is wanted. It is best
in my opinion to pursue just the contrary course: if a girl is wanted,
promise a boy and vice versa. The reason of this is, that if you
are deceived, the woman, happy to have the sex she longed for,
readily forgives your mistake, and is satisfied to laugh at your pre-
tended skill. If it turns out as you promised, on the other hand,
the parents are compelled in spite of their disappointment to pro-
claim your cleverness.

384. Here is, besides, another unfaihng method: as our ances-
tors performed so many miracles with the moon, we may also make
a small trial of the power of this wonderful planet. If obliged to de-
clare the sex of the foetus before its birth, we may content ourselves
with asserting that it will be like the last child, provided the moon
does not change within the first nine days of the lying in, and that
the contrary will happen in the other event: now if the event should
confirm the sentence, nothing more is wanting; but if on the con-
trary it should be of the sex that was not expected, all we have to
do is to go back and see that the reckoning had been badly made,
that if the moon has not changed her nature, she has at least changed
her phase, which amounts to the same thing; any body may see that
in this way error cannot occur, for the lunar phases recur every
seven days. There is perhaps a little tricking in this course of pro-
ceeding; but provided no more weight is given to it than it really
deserves, we may, in acting thus, satisfy every body and do no harm
to any one.

§. II. Is it possible to procreate either sex at
pleasure?

385. The desire of knowing before hand the sex of the foetus has
given rise to one of the most piquant questions in physiology. It
has been asked whether man can by means of known influences
determine the production of one sex rather than the other; and this
point in the science, which was discussed in the time of Hippo-
crates, still engages the attention of several naturalists.

386. Relying, we scarcely know on what, unless it be upon
the grand idea that the strongest side belongs to the strongest being,

SEX OF THE F(ETUS. 149

the father of medicine teaches that both in animals and in the human
species, the right testicle and the right ovary produce male germs,
while female germs come from the left; this opinion of the ancients,
without having ever been generally adopted, without having ever
been fortified by a single direct experiment, has nevertheless passed
down for ages, and claims even in our day some partisans, even
among learned physicians. However, admitting the fact, one great
difficulty would still remain to be got over in applying it. How
shall the seminal matter of the right gland, rather than that of the
left, get into the womb, and vice versa? In quadrupeds indeed it
would be possible to take away from one the right and from another
the left prolific gland; but what man would submit to such a muti-
lation for the sake of being able to procreate a boy rather than a girl?
Another expedient was evidently necessary; and Millot has gravely
advised the couple to lie, during a fruitful copulation, on the side
where the germ of the sex they desire to have is found. We might
to a certain extent excuse the ancients, who believed that the human
uterus was two-horned like that of brutes, for entertaining such an
opinion, for believing that the semen of the right ovary would per-
haps stop in the right horn, provided the two individuals took the
precaution of lying on the corresponding side during the coition;
but in the nineteenth century such conjectures are merely subjects
for ridicule, and scarcely deserve the trouble of refutation.

387. Moreover, it is actually demonstrated that the basis of this
hypothesis is entirely false. Legallois caused rabbits from which
he had removed one ovary to be covered, and found that it did not
prevent them from engendering young of different sexes; as to the
human species, without mentioning the cases of men who having
lost one of the genital glands have notwithstanding procreated both
boys and girls, I will relate two facts that are decisive on this subject.
A woman died some years ago at the Maternite at Paris; she was
the mother of ten or twelve children of both sexes, and neverthe-
less her sexual organs were so disposed, that there was only one
ovary and one tube attached to the corner of a womb which was
itself reduced to one of its halves. In the case by MM. Jouvet and
Garnier, communicated to the Academy by M. Ollivier (d' Angers),
it appears that the woman had been confined five times; that she
had had four boys and one girl, that the first four pregnancies seemed
to have been effected in the left uterine sinus, and the fifth and last
only in that on the right side. Lastly, all naturalists know that, in
animals, where the uterus is completely bi-lobated, the same horn
is often filled at the same time with both male and female foetuses.
388. While doing justice to these suppositions, physiologists
14

150 SEX OF THE FCETUS.

have, notwithstanding, retained a hope of one day ascertaining the
conditions which cause one sex to be born rather than the other.
M. Bory-de-Saint-Vincent has already emitted the bold opinion,
that certain organic particles are susceptible of passing with nearly
the same facility into the vegetable or animal state. Mr. Edwards
thinks he has observed that the molecules of several confervee, and
other beings of doubtful nature, may be at will transformed into in-
dividuals of either organic kingdom. Finally, there were commu-
nicated, in 1825, to the Snciete Philomatique, certain researches
which would tend to induce the belief that by modifying in a certain
way the influences under which the fecundation and entire repro-
duction of insects is eflected, it is possible to occasion the produc-
tion either of males or females at pleasure.

389. The ancient agriculturists were convinced, and country peo-
ple still think, that if the north wind prevails, that if the season be
dry and cool rather than warm and moist, when goats, sheep and
cows are admitted to the males, there will be fewer females pro-
duced, than under the influence of a contrary state of the atmos-
phere. They are persuaded, moreover, that in order to obtain a
larger proportion of males, there is no better plan than to cause the
females to be covered by the most vigorous animal of the kind.
They therefore take care to choose the most active, the strongest,
the youngest and most robust buck, or ram, or bull, or stallion they
can And.

390. Besides, these traditions have been lately subjected to the
test of experiment, and fully confirmed by the interesting researches
of M. Giron De Bussaringue. Numerous observations have been
made by this philanthrophic cultivator, on horses, cows, sheep, birds,
&c., for several successive years, and according to all appearance,
with the greatest care. Now, they go to show that the stronger the
male at the period of fecundation, the greater is the chance of ob-
taining males. For instance, in a flock of sheep, those that are first
covered produce fewer males than those that come immediately after
them, and these many more than the last moiety; for the ram does
not appear to enjoy his whole prolific energy until after a certain
number of copulations, and afterwards he becomes exhausted, gra-
dually losing his strength.

391. Other reasons still may be cited in support of those above
mentioned; pigeons, doves, partridges; and many other birds that
unite in couples, during each season of their loves, produce nearly
(he same number of males as of females. The gallinaceae, the com-
mon fowl, on the contrary, and geese, ducks, turkeys, (fee, where
the same male suflices for several females, furnish many more fe-

SEX OF THE FCETUS. 151

males than males of their respective species; while bitches, cats and
she wolves, which ordinarily permit the approaches of several dogs,
(fcc, engender more males than females. In fine, it is snpposed that
where polygamy is allowed in the human species, as in Persia and
Turkey, there are more girls than boys born, and that in Europe
where this custom is not tolerated, the contrary is generally found to
be the case, or at least that the proportions of the two sexes are about
equal.

Consequently, it becomes probable that the nature of the sex is
determined by that one of the couple whose prolific power, whether
absolute or relative, is greatest at the moment of conception. It is
true that numerous researches are yet necessary, to transform this
proposition into a mathematical truth; but if it should ever be con-
firmed by authentic and careful observation, it is evident that the
act of procreating the sexes at will, will no longer be a chimera, and
that we ought not give up the hope of being able to predict to preg-
nant women, that they shall be delivered of a boy rather than of a
girl. But it is doubtful whether by adopting the course and language
of M. Mayer, we shall ever attain to any thing satisfactory on this
interesting point of physiology.

§. III. Of the Influence of the Seasons and of
Fuhlic Prosperity on the Production of the
ISexes and on the Proportion of Conceptions.

39'.i. An important inquiry, and which flows naturally from the
preceding, would be to know, whether, in poor countries or in years
of scarcity and in provinces where the inhabitants are naturally
weakly, idle and wretched, the female sex exceeds the male in num-
ber: in order to resolve it, it would be necessary to consult the records
of the civil state of people in the most opposite conditions; this work,
which several moderns are on the point of undertaking, has by M.
Bailly been already performed for the city of Celles, from which it
appears that the proportion of girls is decidedly larger than that of
boys, in that barren and poor canton. However, M. Villerme, who
devotes himself with such praiseworthy ardor to this branch of sta- .
tistics, and who has made his observations on a much larger scale,
has not come to the same conclusions; he has found that, in Sologne
and other very poor departments, there are born as large a propor-
tion of males as in the most opulent and agreeably situated cities;
that the miserable peasants of Scotland, reduced to the necessity of
living on potatoes and beans, procreate as many male children as the
rich inhabitants of the environs of London.

After all, though it be right to state that prosperity or misery exert

n% SEX OF THE F(ETUS.

no marked influence on the proportion of the sexes, there is no rea-
son why we should be surprised at it; for men and women are
placed in the same circumstances. That merely proves that abso-
lute force is not in this case one of the essential conditions, but it
does not in any respect diminish the important bearing of the rela-
tive force of the couple.

393. There is no one who has failed to remark that births are
more numerous at certain times and in certain countries, and more
rare in others; but no attempt has been made to explain these appa-
rent anomalies, nor prove that they were in some degree fixed in
their recurrences. M. Villerme has taken upon himself this double
care; in a memoir read to the Academy of Sciences, he says that
out of a total of 7,651,437 births, reduced (ramenees) to 12,000,
1093 took place in January, 1136 in February, 1117 in March,
1057 in April, 1000 in November, 981 in December, 981 in Sep-
tember, 964 in October, 965 in May, 927 in August, 896 in June,
and 884 in July, and that, consequently, the relative frequency of
conceptions is far from being the same at all seasons of the year.

394. M. Villerme, always relying on calculations, in the same
way passes successively in review the influence of holidays and pub-
lic rejoicings, the first period of marriage, fasts and privations, tem-
perature, latitude, vegetable or animal regimen, prosperity, civilisa-
tion, liberty, the poverty and the calamities of the population, on the
number of fecundations, and demonstrates that many more children
are born under a fine climate, in countries where the arts, industry,
commerce and the sciences flourish, where the air is salubrious and
the earth fertile, than in the contrary conditions; that famine and
years of scarcity, especially occasion extraordinary changes in the
rate of population, &c.

In regard to the faculty of procreating at will children that shall
be beautiful, endowed with great genius, and without bad passions,
I can only refer the reader to the Callipedie of CI. Quillet, to the
Megalanthropo genie of M. Robert, or lastly to the Traite de la
Philopedie>

153

CHAPTER IV.

Of the Human Ovum.

395. The human ovum, like that of other mammiferae, is com-
posed of the foetus and its appendages.

ARTICLE I.

Of the tdppcndages of the Foetus.

396. The appendages of the foetus consist of the membranes, the
placenta and cord of the umbilical vesicle and allantois, and of the
liquor amnii.

SECTION 1.

Of the Membranes.

The covering of the ovum is formed of three concentric layers,
the caduca, the chorion and the amnios.

§• I. Of the Caduca or Connecting Membrane.

397. The caducous membrane, membrana decidua, cellvlosa, sin-
uosa, spongiosa, common or pre-existing memhrane, connecting or
conjunctive membrane, epichorion, &c., is so evident at all periods
of gestation, that it must have been noticed by every physiologist
who has paid much attention to the examination of the human se-
cundines. Thus Aret.neus speaks of it pretty clearly under the
name of porous layer; Fabricius under that of membranous substance
of the placenta; G. Fallopius under the title of feshy substance, fyc;
Spigelius under that of the thick and fleshy portion of the chorion;
Ruysch under that of the velvety chorion; Rouhault, Littre, Hobo-
ken, under that of chorion; Haller under that of external ot fun-

14*

154 APPENDAGES OF THE FCETUS.

gous chorion; lastly, Needham, Diemerbroeck; Noorthwyck, with
Hoboken, Rouhault and Littre, have described it by the name of
chorion, while to the true chorion they give the name of allantois;
but these obscure descriptions were only fit to hinder the researches
of observers, and can in no respect be compared with that given of
it by W. Hunter.

398. Formation. Impregnation determines in the uterus, a spe-
cific irritation, which is promptly followed by an exudation of co-
agulable matter, which concretes and soon transforms itself into a
kind of sac filled with a transparent and slightly rosy fluid. In
contact with the whole extent of the parietes of the uterine cavity,
this kind of bladder or membrane continues in some instances with-
in the origin of the Fallopian tubes, and always into the upper part
of the cervix, in the shape of soUd concrete cords; it never in a na-
tural state has any opening.

399. The ovule, after having passed through the tube, necessarily
depresses the caducous membrane, so that it may glide on betwixt
it and the uterus, to the internal surface of which it at last attaches
itself; from this moment the pre-existing membrane is composed
of two portions: one, very large, lining the whole interior of the
womb, except the part which is in contact with the germ, bears the
name of uterine or external caduca; the other, very small, depressed
by the lower half of the fecundated vesicle, which it envelopes, con-
stitutes the reflected caduca, internal caduca or epichorion. The ex-
tent of the former augments in the same ratio with that of the
womb, and the aggrandisement of the latter necessarily follows the
growth of the germ. Therefore the cavity which separates them,
and which is nothing more than the altered cavity of the primitive
sac, is the greater, the nearer we are to the first periods of ges-
tation.

400. The uterine caduca preserves a pretty considerable thick-
ness, especially in the vicinity of the placenta, until the close of
pregnancy; the epichorion, on the contrary, grows insensibly thin-
ner, so that at the period of labor it is sometimes of an extreme
tenuity.

One, by sinking down into the other, at length comes to be in
contact with it, a little sooner or later, about the fourth month,
for example; after this, the two layers remain in a state of more or
less perfect contiguity until the expulsion of the after birth, with-
out however being even confounded together, notwithstanding the
assertions of Hunter and all others who have treated of this subject
since his day. It is evident, then, that this membrane is managed

• CADUCA. 155

in regard to the ovule, as the pleura is in relation to the lung, or as
the serous membrane of the pericardium is in respect to the heart.

401. The external surface of the caduca is uneven and porous,
in contact with the interior of the womb, and invests the chorion as
far as to the circumference of the placenta, but is not prolonged
over the spongy surface of that body: to the former its adherence
is very slight and is effected only by means of mucous filaments
very easy to break, and which certainly are neither vessels nor nerves;
to the latter the union is much more intimate, and so much the
more so as the development of the ovum is more advanced. During
the first two months indeed it is pretty easy to extract the ovule from
that portion of the sac which constitutes its epichorion; while at a
later period, the numerous lilaments that habitually invest the germ
contract such solid adhesions with the reflected caduca, that it be-
comes more and more difficult to effect this separation without rup-
ture.

403. The internal surface being moistened by a fluid, although
tuberculated, is nevertheless smooth, and lined with an extremely
delicate pellicle. After the fluid has disappeared and the reflected
portion has come to be in contact with the uterine layer, this sur-
face soon assumes the characters of the former. The liquid which
fills the cavity of the caduca, and keeps its two surfaces apart, is
sometimes quite limpid, but most commonly reddish, viscid, similar
to melted glass, or rather to white of eggs, and appears to be com-
posed of a large proportion of water, and of albumen, and gelatin.

403. Circumference. At the place where the caduca turns back
so as to invest the ovum, it forms a circle, which at first exhibits the
form of a fold more or less regularly rounded, but which afterwards
is gradually transformed into a thin and sharp edge, and ends at last
by being more or less evidently continuous with the circumference
of the placenta.

This is a point in the history of the connecting membrane on
which I most insisted in 1824, and is, notwithstanding, one on which
the greatest doubt has remained in the minds of observers.

404. Hunter, Baillie, Wrisberg, Krummacher, Blumenbach, Stein,
MM. Lobstein, and Meckel, Beclard, &c., have indeed admitted the
two lamina? of the caducous membrane, but still persist in the belief
that the placenta does not fix itself to the womb until after having
passed through them.

405. Chaussier and M. Duges, on the contrary, suppose that the.
uterus is at first merely filled with lymph or coagulable albumen;
that the little egg, on arriving from the ovary, dips into the midst of
this substance, and becomes covered with it; that the villi of the

156 APPENDAGES OF THE FOETUS.

chorion must be confounded or blended with it in order to form the
placenta, and that, in consequence of the growth of the womb, the
caduca, at first single, is separated into two layers. But I now pos-
sess so many facts in favor of the doctrine laid down above, that I
cannot unite in any respect with the sentiment of these authors.

406. Ruysch, Haller, the two Hunters, M. Lobstein, and all those
who have treated at some length of the membrana caduca, say they
have met with vessels in it, even in great numbers, and, consequent-
ly, that it is organised. I, on the contrary, do not believe that it is
organised at any period of gestation. It is so easy to convince one's
self of its inorganic condition by examining it in a fresh after-birth,
that I can hardly understand how this remark has escaped the atten-
tive observers whom I have above mentioned, as well as all those
who have succeeded them.

By examining it previously to the end of the second month, it will
be found to be soft, supple, spongy; that it is very elastic, tears with
extreme facility, and contains not a vestige of organic elements ;
that it is only contiguous to the womb, and adheres to the chorion
merely by means of the villi that always cover the ovule.

At the close of pregnancy, it preserves the same softness, the
same elasticity: it is always of a reddish gray color, easily reduci-
ble into shreds; its adhesions to the uterus have not undergone any
change, only its epichorion layer has become considerably thinner,
in consequence of the mechanical distension it has been subjected
to; its composition is in all respects the same as at first; in one
word, from the instant of its formation, until its exclusion from the
sexual organs, it has never appeared to me that the caduca could be
regarded in any other light than as a simple inorganic layer; how-
ever, I can affirm that I have carefully examined it in more than four
hundred specimens discharged at full term or by abortion.

407. It is true that it is sometimes sprinkled with reddish, stellated
points, or bloody stri2e, Avhich might, under certain circumstances,
induce a belief of the existence of vessels in its substance; we may
also see, especially on its inner surface, an extremely delicate pel-
licle, which might frequently be mistaken for a cellular coat; lastly,
it also seems to be pretty frequently formed of fibres placed side by
side, or even interlaced in various directions; but these spots, and
striae of blood, no more indicate the presence of vessels here, than
when they are met with on those membraniform concretions that
are thrown off by children in croup, &c.

408. If this membrane were really organic, if it were the seat of
a real circulation, can we conceive that it would never contract any
adhesions, that it would not be intimately blended with the internal

CADUCA. 157

surfaces of the womb, and the external one of the chorion, which it
lines for nine months? Finally, to decide the question, it should
suffice us to remember that the characters of this singular membrane
are in every respect similar, at the moment of parturition, to what
they were at the commencement of pregnancy, a period wherein
nobody has pretended to have seen a trace of organisation.

409. If then the caducous membrane is not an organic membrane,
if it is merely an adventitious coat, as M. Blainville calls it, or the
result of a concretion taking place in the uterus, the name of an-
histous* membrane which I propose to bestow upon it, and which
is synonymous with inorganic membrane, appears to me to be the
only one that can be advantageously applied to it.

410. Uses. I shall not stop to combat the opinion of those who
think that the anhistous membrane serves to nourish the foetus dur-
ing the first weeks of its existence; to remark that the umbilical
cord is always inserted on that portion of the ovule which is not
covered with this concretion, ought to be sufficient to demonstrate
that it is unconnected with the nutrition of the first lineaments of the
foetus. Its use is to sustain the vesicle on some one point of the
uterine cavity. I know it may be objected that it fixes and main-
tains itself as firmly in animals as in women, and just as well in
extra-uterine as in natural pregnancy; but in brutes, the surface of
the ovule, and the form of the parts through which it has to pass,
are far from being in all respects similar to those that are noticed
in the human species. The uterine horns in brutes difller from the
human uterus in this respect, that they never dilate enough to per-
mit the germ that passes through or stops in them to be in contact
with all the points of the circle to which it corresponds, in one of
those organic tubes. Further, when the product of fecundation
accidentally develops itself in the peritoneum, or the tube, or even
in the substance of the uterus, it remains uniformly contiguous to the
walls of the cavity which it has appropriated; so that the caduca,
such as I understand it, is not at all necessary in these two circum-
stances, and its absence, therefore, does not at all prove that in re-
lation to ordinary gestation it has not the uses I have just assigned
to it.

Another use of the anhistous membrane seems to me to be to
circumscribe the placenta, and determine the place of its insertion;
but I defer the examination of this point to another article.

411. Analogy. Those who have embraced the opinion of Hun-
ter have asserted that the caduca does not exist except in wo-

* From itTTo; tela, and a, privative.

158 APPENDAGES OF THE FCETUS.

men, and they were so far right, that it has no where been found
possessed of the same characters it exhibits in the human species;
but if, laying aside the idea of a complete analogy, we are content
to seek for its elements, more or less modified in other vertebral
animals, we soon perceive that it is in almost all of them replaced
by a coat which is equally inorganic. Thus, in the ophidian rep-
tiles its analogue is a simple mucous imhiitus; in the batracians it
is represented by a similar but much thicker layer; in birds, not-
withstanding what M. Dutrochet has said, the calcareous shell is its
substitute, and as M. Cuvier has already maintained; lasUy, in
almost every species of the mammiferse there is to be found a lamella
on the external surface of the chorion, which is sometimes nearly
fluid, at others pretty consis:ent, and of a considerable thickness, of
a greenish or yellowish color, and which serves as a caduca.

§. II. Proper Membranes of the Oviini.

A. Of the Chorion.

412. To prevent, for the future, the chorion from being con-
founded with any other membrane, it will suffice to remember what
I have just said concerning the caducous membrane, and that it
constitutes the first organised or solid tunic of the ovum as we pass
from the womb to the foetus, and the second in proceeding from the
foetus to the womb.

413. Primitive condition. In a production of ten or twelve days
standing, the chorion presents the appearance of a velvet-like hyda-
tid, or a small transparent vesicle; its external surface, free from all
adhesions, is somewhat fungous or fretted throughout its whole ex-
tent; its interior is filled with a clear serous fluid.

414. In products of three or four weeks, the chorion is not smooth
on both its surfaces, as has been erroneously slated by a multitude
of commendable writers. I have never, whatever care I may have
taken, seen it smooth exteriorly, nor velvety internally. \ At a fort-
night, at three weeks, at one month as well as at two, 1 have always
found its external surface covered with the same down, its internal
surface even and polished, and its transparency neither more nor
less decided than at any other period of gestation.

415. Granulations, and villosities. It is generally thought that
the down that covers the chorion is of a vascular nature; but as early
as 1823 I ventured to oppose this hypothesis. What proves that the
filaments of the chorion are not vessels is this, that they are to be
seen before blood vessels of the cord are recognisable. Besides, until
the sixth week, every flock is at least as large as one of the umbilical

CHORION. 159

vessels; so that as there are only three of these, it is difficult for
them to give birth to the others, which amount to several hundred.
Further, these villosities, all independent of each other, are regu-
larly spread over the whole periphery of the ovule, while the cord
and placenta are only connected with one point of this vesicle; and
notwithstanding the efforts of an infinitude of very able anatomists,
nobody has proved that they are hollow rather than concrete, vas-
cular rather than solid cellular filaments; lasdy when examined with
a lens, they are found to form certain areolar spongioles, and not
permeable conduits.

416. The abnormal continuance, or preternatural growth of the
swellings abovementioned have led me to suppose that such hyda-
tids as are found in bunches in the womb are not vesicular worms,
as is commonly supposed, but rather the product of an abortive
ovum, whose small gangliform bodies have taken on an unnatural
growth. I am in possession of a considerable number of specimens
which sustain this view of them; some of them I have shown to
M. Desormeaux, and again, very recently, M. Delange, physician
at Falaise, has sent me one, the examination of which leaves no
doubt on this point. My opinion on this subject is further fortified
by the cases of Albinus, Wrisberg, Reuss, Sandifort, and even by
those recently made public by Madame Boivin.

417. Until the third, fourth or fifth week of pregnancy, the inner
surface of the chorion is in contact with a very delicate lamella,
constituting part of a peculiar body which I shall, provisionally, de-
nominate the relicuhtted sac. From this period until the sixth week
or second month, it is no longer separated from the amnios except
by a perfectly transparent, vilriform substance. In the natural state,
this substance never contracts any intimate adhesions to any organ
capable of altering its natural appearances.

418. According to Needham, J. Fabricius, Noorthwyck, Harvey,
Lacourvee, Hoboken, Liltre, Rouhalt, (fee. the thickness of the cho-
riott is considerable; but the error of these anatomists evidently
depends upon their having confounded the chorion and caducous
membrane under the same title.

I have studied the chorion, whether at term or other periods of
pregnancy, in a great number of specimens, and have always found
in my dissections, that it is every where transparent and thin, as
well upon the placenta as elsewhere. This, indeed, is a fact, which
any one may readily ascertain, by taking care to macerate a na-
tural afterbirth in water, so as more easily to separate the reflected
cadiica from it. Then the appearances of the chorion are found to

160 APPENDAGES OF THE FCETUS.

be exactly the same throughout: so that the thesis of Phil. Beclard,
and M. Meckel's Manual of anatomy contain several manifest errors
on this subject.

Hewson, and many who preceded him, have asserted that the
chorion is formed of several coats, which, being early applied to
each other, come at last to constitute only a single one; that the
placenta results from the unfolding and thickening of these laminae,
from which each of the umbilical vessels receives a sheath, &.c.
But I have already shown, in 1824, that the reason of this
supposition probably depends upon the presence of a concrete
lamellar layer, which indeed does invest the vascular roots of the
placenta, and separates it from the external surface of the chorion.
At present I may add, that if Ruysch, Haller, and so many others,
supposed the chorion to be constituted of a variable number of
layers, it was because they had never separated it from the mem-
branacaduca; but I do not understand how MM. Chevreul, May-
grier and Dutrochet could have ever reproduced this old notion.

At a fortnight, and at three weeks, as well as at two months, the
chorion in the human subject is simple, and although, at a later
period, other laminae become connected with it they belong to bo-
dies not as yet described, and which cannot, under any pretext, be
considered as its appendages.

419. Hippocrates has pretended that the membranes of the foetus
arise from the umbilicus. Harvey has said that the chorion, the
amnios and chord, are merely prolongations of the child's belly; and
Burton, defending the same opinion, expresses himself still more
positively on this subject. I myself related some cases, in 1824, in
support of such an hypothesis. At the same time an Italian anato-
mist, M. Mondini, contributed to strengthen it by means of some
particular researches and reasonings. M. Moux states that the
chorion, after investing the chord, is continuous with the derm of the
foetus. It should be remarked that M. Chevreul is of the same opi
nion. Finally, M, Blainville seems to have held a similar opinion.

But the chorion constitutes a part of the ovule at the moment of
fecundation; the abdominal parietes are not developed until after
the spine; the chorion presents the same characters and form before
the appearance of the skin that it exhibits afterwards; the chorion
and the skin are therefore two parts quite independent of each other.

430. The chorion can be referred neither to the derm, the mus-
cles, the aponeuroses, nor peritoneum; however, it is difficnlt to call
in question its cellular nature, or to deny its analogy with the
serous membranes, of which, besides, it presents all the characters.

CHORION. 161

■whether physical or physiological. Does it contain nerves and
lymphatic, sanguineous, exhalent and inhalent vessels?

These two last mentioned kinds of vessels having only been ad-
mitted in animal bodies upon the say so of the physiologists, espe-
cially Bichat, who never saw them, it is good philosophy to reject
their existence without discussion, until they shall have been demon-
strated by more conclusive proofs. The same may be said of the
lymphatics, which the imagination alone of Schroeger and some
others seems to me to have detected in the chorion. As to nerves, I
think I may say without offence to Chaussier, MM. Ribes, Home,
and Bauer, that they are no more to be found there, than the ex-
halents and lymphatics.

421. The question in relation to blood-vessels deserves much
more attention. Admitted by a great many savans of the highest
merit, and that too upon a certain num.ber of proofs; rejected by
other authors not less able, and upon considerations not less powerful,
it becomes, upon that account merely, very difficult to settle one's
opinion in relation to them.

In attempting to separate the reflected anhistous coat from the
exterior surface of the chorion, we soon perceive an indefinite num-
ber of filaments passing from each one of these laminae to the other,
and which are more numerous as we approach the circumference of
the placenta, or are nearer to the commencement of the pregnancy.
' But these filaments which Sandifort and others mistook for vessels,
are nothing but the remains of the villous tomentwa of the ovule,
and not canals carrying on any circulation whatever. The chorion
exists before the embryo; with the exception of the portion that is
to support the placenta, it is completely separated from the womb
by an inert stratum; the umbilical and placental vessels do not make
their appearance in the new being until the ovule attaches itself to
the internal surface of the uterus; it is only, therefore, in the area
circumscribed by the reflection of the anhistous membrane, that the
villi of the chorion can allow any vessels to be developed.

422. The chorion is met with in all the vertebral animals; but
with such modifications that most physiologists have been unable as
yet to agree concerning its nature: in the batracian reptiles, as in
women, it forms the covering of the ovule; in the saurians it ex-
hibits a much greater thickness and solidity, although it has the same
relations with the organs of the female. In the ophidians it com-
poses that membrane which is so dense and difficult to break, and
which constitutes the shell or outer covering. In birds the chorion
is much farther removed from the vitellus, and in. fact is not formed
until after several other lamince. This is .the membrane that lines
15

162 APPENDAGES OF THE FCETUS.

the inner surface of the calcareous shell, and which is known as the
membrane of the shell. Finall}'-, in the mammiferae, as well as in
the human species, it supports the placenta or the cotyledons, and
throughout the remainder of its extent is separared from the womb
or its horns, only by an inorganic layer of variable consistence and
thickness.

B. Of the Amnios.

In the opinion of all observers, the amnios, also designated by the
terms amiculum, auguelette, aurelia, charta virginea, &c., is the
inner membrane of the human ovum; smooth, transparent, separated
from the foetus by the fluid which bears the same name, it slightly
adheres to the chorion by means of the mucous filaments or lamellae
which cover its outer surface.

423. In an abortion of from ten to twelve days, for which I am
indebted to the kindness of Madame Lachapelle, and which was only
four lines in diameter, I found inside of the chorion a small trans-
parent sac, on the upper part of which the microscope detected an
opaque corpuscle of a whitish color. Did this little sac represent
the amnios? Was the white point the embryo?

In an ovule of twelve or fifteen days, presented to me by M. Ber-
mond of Bourdeaux, I found fixed on a part of the cavity of the cho-
rion a small transparent sac, about three lines long.

In another of about three iveeks, and for which also I am indebted
to the extreme complaisance of M. Bermond, the amnios represented
a vesicle three or four lines in diameter, and was stuck, as it were, on
the inner surface of the chorion.

In a fourth very perfect specimen of about twenty days, which
Madame Charonnet was good enough to give me in April 1825,
the ovule separate from the reflected coat of the anhistous mem-
brane, measured only eight or ten lines; the amnios, excessively
delicate and white, was separated from the embryo only by a space
of a line and a half, and after being reflected along the origin of
the cord, seemed to be continuous without any line of demarcation
with the integuments of the little foetus, which, further, was well
formed.

In an ovule of about an inch in diameter aged three weeks or a
month, given me by Madame Le Brun, the amnios formed a little
sac, separated from the foetus by a moderately thick stratum of fluid,
and which left the greater portion of the cord exposed in the cavity
of the chorion.

In an ovum received from M. Fournier, Surgeon of the Royal
Stables, on which, from the accounts of the woman, and the size

AMNIOS. 163

of the chorion, '^ust have been from two months and a half to three
mouths old, but which, from the size of the embryo, seemed not to
be more ihan four or Jive weeks, the amnios was a sac three or four
times smaller than the chorion, and was reflected along the cord
at the distance of a line and a half from its root, so as to give it a
sheath quile up to the belly. This amnios, besides, presented all
the characters of the normal state.

In an ovum of six or seven zveeks, presented to me by Madame
Lachapelle, the amnios, nearly as large as the chorion, had begun
to reflect itself in the form of a funnel upon the cord, at the distance
of six lines from the navel, which it reached after enveloping the
vessels, the pedicle of the vitelline sac, the intestinal bulb, &;c.

In another older ovum, which was brought to me by M. Morisse,
an accoucheur at Paris, the amnios was still separated by a consi-
derable space from the chorion, and was applied to the cord so as
to sheathe it, beginning at the place where the prolongation of the
umbilical cord was implanted, and extending as far as the belly,
where, according to all appearances, it was continuous with the
epidermis.

In a specimen of eight or nine weeks, which M. Boulon d' Abbe-
ville gave me, the external surface of the amnios touched, so to speak,
the chorion, and invested the whole of the cord, which, already very
long and spiral, still contained the intestinal mass in one of its en-
largements.

In one of at least three months, very perfect, which M. Morisse
procured for me twenty-four hours after it had been passed by the
woman, the epidermis was so entirely separated from the other pans
of the fcetus by a thick stratum of slightly muddy serum, that it might
have been removed with the greatest ease; the same was observed
along the cord from one end to the other; only the pellicle was here
close to the vessels at four different points which gave rise to four
contractions and four vesicles placed at equal distances; but the
adhesions of the amnios at the contracted spaces of the umbilical
cord, and those that the epidermis had preserved with some portions
of the limbs, did not prevent me from remarking the most perfect
continuity between all these lamellae.

424. From these notions it follows, that during the first fortnight
of gestation, the amnios has no immediate connection with the foetal
end of the umbilical cord, on which, at a somewhat later period, it
doubles, so as to furnish it with a sheath, and place itself in contact
with the inner surface of the chorion; that this disposition is main-
tained, saving in a few exceptions, until the abdominal parieies are
completely formed; that until then there is no continuity between

164 APPENDAGES OF THE FCETUS.

the amniotic membrane and the epidermis, but that this continuity is
afterwards difficult to deny.

425. It also follows, that the amnios is far from touching the in-
ternal surface of the chorion at all periods of pregnancy, as is gene-
rally supposed, but that these two membranes are, on the contrary,
separated from each other by a considerable space, during a period
which differs in different individuals.

This space, which is at first very large in proportion to the cavity
of tlie chorion, much larger than the amnios itself during the whole
of the first month, afterwards diminishes by degrees, in proportion
to the increase of the amnios, so that at two months it about equals
that which separates the embryo from its envelop; at length the
disproportional growth of this last named membrane causes it to dis-
appear almost entirely, so that towards the fourth or fifth month we
are obliged to suspect, in order to be able to recognise its exis-
tence.

426. It is useless to repeat what I have said as to the non-exist-
ence of vessels in the proper tissue of the chorion, for the purpose
of showing that they are far more certainly wanting in the amnios:
indeed, nothing leads us to admit of their existence in the latter; it
is never covered with villi like the former; it never has any intimate
connection with any vascular organ, and all that has been said upon
the subject by various authors, in fact, consists of mere assertions, or
rather of pure suppositions.

As the remarks in this article prove evidently that the amnios
forms only one single coat at the various periods of gestation, I shall
not stop to combat those who have thought it to be composed of
several layers in the commencement of its development.

§. III. Of the l¥ater of the Amnios.

427. Besides the fostus and the cord, the amnios contains a fluid
called the water of the amnios, or amniotic liquor.

428. At the beginning these waters form but a thin stratum; their
proportional quantity afterwards increases rapidly, until towards the
end of the second month, when the inner membrane of the ovum
comes in contact with the chorion: at three months the weight of
the amniotic fluid considerably exceeds that of the foetus; but at
term the weight of the foetus, in turn, considerably exceeds that of
the fluid in which it floats. At birth, in fact, there are commonly
not more than from ten to thirty ounces of fluid. However, it would
not be correct to say, with Madame Boivin and several others, that
the quantity of fluid diminishes in an absolute manner from the mid-
dle of pregnancy until the moment of parturition. It is, on tiie con-

LIQUOR AMNII. 165

trary, certain that it augments until the close, but in less proportion
than at the commencement of gestation.

But in this respect very great differences are observed; instead of
one pound, there may be two, four, and even ten pounds, or only a
few ounces; its abundance is generally in an inverse ratio to the
vigor, size, and strength of the foetus, and robust constitution of the
woman; so that a fcstus weighing five pounds, for example, will
float in two, three, or four pounds of the water, while only three or
four spoonfuls will be found about a child of eight or nine pounds
weight.

429. According to some authors, its nauseous insipid smell some-
what resembles that of semen; on the whole, it is nearly similar to
that exhaled from the belly of a slaughtered animal: unctuous, pos-
sessing rather more consistence than pure water, the liquor amnii is
clear, like simple serum, or of a slightly citron or greenish color,
ordinarily transparent, it is not unfrequently lactescent, thick, mixed
with albuminous flocks, of a gray, yellow or blackish color; its taste
is both sweetish and slightly saltish; in some cases it is so acrid and
astringent as to pucker the skin of the accoucheur's fingers, when he
keeps them beyond a few seconds in the vagina or womb.

430. It does not appear to contain more animal matter in the first
than in the last half of pregnancy, and in this respect the remarks of
Harvey, Lacourvee, Ruysch, and Osiander seem to me to be wholly
faulty; its chemical composition is very complicated, and besides, has
only been studied in animals, MM. Vauquelin and Buniva found
it to contain: water, 98.8; albumen, salts of soda and lime, 1.2.
M. Berzelius says that it contains fluoric acid; Scheele says he found
free oxygen in it; M. Geoffroi Saint-Hilaire admits that it contains
atmospheric air in a state of mixture: but MM. Lassaigne and Chev-
reul, at a later period, discovered that what one of them had mistook
for air, was nothing but a gas composed of carbonic acid and
azote.

431. The chemical nature of the water of the amnios differs, as
has been truly said by Van-den-Bosh from all the other fluids of. the
body. The acids, alcohol, ebullition coagulate it only with great
difiicully, or even not at all; some suspect it to contain a free acid;
others an alkali; but one of these opinions must be incorrect, for
acids, as is well known, do not remain in contact with alkalies with-
out soon forming salts. From all the foregoing, we may conclude
that tlie composition of the amniotic liquid requires new analyses.

432. Trusting to certain experiments of Monroe, who by inject-
ing warm water into the uterine vessels, found it to transude upon
the inner surface of the amnios; to Haller's assertion that the waters

15*

166 APPENDAGES OF THE FCETUS.

become impregnated with the odor, color, and even nature of me-
dicinal substances taken by the woman; to the existence of suppose!
vessels between tlie womb and envelop of the ovum, most physio-
logists have admitted that the liquor amnii is directly furnished by
the mother. Others, however, have maintained the contrary, and
believe with Scheele, Winslow, Van-den-Bosh, and M. Lobstein,
that it comes chiefly from the fcetus, particularly from the placental
vessels; Chaussier, Beclard and Meckel seem to hold a mixed opi-
nion, and endeavor to reconcile both the above hypotheses.

433. Those who refer the liquor amnii to the foetus, have placed
its source in the sweat, the insensible transpiration, or the urinary
secretion, or in the glands or particular bodies of the placenta, or in
the vessels which Needham, Fabricius, Ruysch and Haller say they
observed betwixt the lamellae of the amnios; some of the ancients
made of it a coUiquamentum, coming from the semen, &c. Such as
attribute it to the mother merely say that it is poured out by exha-
lation in the interior of the ovum.

434. I do not think it would be useful to refute these opinions
one by one; I shall content myself with remarking that there is no
vascular connection betwixt the womb and the membranes; that the
spongy coat is separated from that organ by an inorganic layer, the
membrana caduca, and that for more than a month the amnios does
not even touch the inner face of the chorion, to show that the fluid
in question is not derived immediately from the uterus; the propor-
tional quantity of the liquid being much greater in the first period
of pregnancy, ought also to suffice to show that it cannot be sup-
posed to come directly from the foetus.

Every thing proves that the water of the amnios is the product of
a transudation, or of a simple exhalation, like the serosity of the
pleura, the pericardium, the peritoneum or arachnoid, and like the
synovial fluid of the tendinous sheaths, or of the articulations; and
that tliis perspiration does not require for its production the existence
of special canals; that it is an instance of mere vital imbibition: the
viscid matters, the muddy appearance, the yellow or greenish flocks
frequently met with in it, do not in any respect belong to it; for they
are nothing more than portions of meconium, or of the induitiis se-
parated from the fcelus, or even of the vitriform substance, and also
of the vesicles which exist primarily between the membranes.

435. Its uses are, 1. To favor the active or passive motions of
the foetus, wliich, if it were without the liquor, would be every where
pressed by the uterus, and could not develop itself; 2. To permit
the isolation of the limbs and of their diflTerent parts; to prevent the
fingers from remaining in contact and adhering together; to oppose

LIQUOR AMNII. 167

the adhesion of the fore-arm, or of the legs and thighs to the breast
and abdomen, as happened in a case related by M. Morlanne, where
the fostus was born with such adliesions six weeks after the discharge
of the waters; 3. To protect the child against the shocks and jars
that might be experienced by the mother, and particularly by the
womb; to protect the tender being from all kinds of compression, and
to furnish it with a kind of lepid bath which might favor the circula-
tion of its fluids, and afford to it a facility for moving according to
the laws of gravitation, and to have the head always directed towards
the neck of the uterus; 4. To keep the membranes always apart,
maintain the dilatation of the womb, and keep up a gentle pressure
upon the cord and surface of the child; 5, In labor, to permit the for-
mation of the bag of waters, a real segment of a sphere, which by
gradually engaging in the cervix, singularly promotes its dilatation;
6. After the rupture of the membranes, to lubricate the genital or-
gans, to soften them, and thereby render the passage of the head
easier and less painful; 7. Lastly, to render operations much more
simple and free from danger when compelled to introduce the hand
into the womb.

SECTION 2.
Of the Vesicles of the Embryo.
§. I. Of the Umbilical Vesicle.

436. The umbilical vesicle is an organ that was unknown to the
ancients, of which much has been said by the moderns, either with
a view to place its existence beyond doubt, or on the contrary to
reject it as among anomalies or pathological changes, but which has
not been described so exactly as to enable physiologists to get a
clear idea of it.

Albinus was the first author who really observed it, and had a
drawing made of it; if several persons have supposed they could dis-
cover some notions concerning it in the works of a remoter period,
that is because the same anatomists, having seen it only a k\v times,
they were often mistaken in regard to its characteristics.

437. It is wrong, for example, for MM. Lobstein, Beclard and
Meckel, to carry the knowledge of it back to the times of Needham
and Diemerbroeck, or even of Ruysch; MM. Oken, Dutrochet,
Beclard, Meckel, Bojanus, &c., taking as a type the one described
by M. Lobstein, have asserted that the umbilical vesicle is at first
supported by the front of the embryo spine; that when at its greatest
dimensions, it may be from four to six lines in diameter; and that at

16S APPENDAGES OF THE FCETUS.

first its dimensions exceed those of the embryo. Now if it be true that
many assertions emitted on this subject are correct, it is not less so,
that what M. Lobstein has observed does not prove it to be so; for the
ovum of which he has given a drawing being certainly in an unna-
tural state, all the data resulting from the examination of such a spe-
cimen, can be of no weight in science.

Another figure of the umbilical vesicle, in the human species, is
annexed to M. Meckel's memoir; but it must be that the drawing
is a bad representation of the original, or that the original has un-
dergone some change, for the vitelline sac, the embryo itself, and its
envelops are not commonly disposed in that way at the end of the
fourth week.

Among all the drawings that have been mentioned by authors,
without excepting that of M. Dutrochet, I am acquainted with
only two that incontestably represent the umbilical vesicle in its na-
tural state in the first six or eight weeks of pregnancy; they are
those of A^lbinus and Soemmering, and yet much is wanting espe-
cially to the former, in a great many respects.

438. However, the numerous cases I have collected enable me
to affirm that the human ovum always contains, until the eighth week
of its growth, a vesicle similar or nearly similar to those noticed by
Albinus, Scemmering, MM. Meckel, Dutrochet, &c.; that if nu-
merous naturalists failed to meet with it, it was because they sought for
it in specimens from which it had disappeared, either by the natural
progress of pregnancy, or by the rupture of the membranes in the
abortion, or in consequence of some morbid state, or the decom-
position of the parts that enter into the texture of the ovum, or
lastly, because they were not sufficiendy practised in these sorts of
researches always to detect it, though it really existed.

In a total of about one hundred and thirty sp-^cimens, examined
before the end of the third month, I only met with the umbilical ve-
sicle in a stale that could be called natural, thirty times. I have had
drawings made of six of these vesicles, and I still possess some that
are pretty well preserved in alcohol.

439. The umbilical vesicle is a small pyriform sac of a rounded
or spheroidal shape, which about the fifteenth or twentieth day after
fecundation is as large as a common pea, that is to say from two
to four lines in diameter. It probably acquires its greatest dimen-
sions in the course of the third or fourth week; at least, I have al-
ways found it smaller beyond the first month. I confess I never
had an opportunity of examining but one before the first fortnight,
and that was also smaller. When reduced to the size of a corian-
der seed, which commonly takes place about the fifth, sixth or

UMBILICAL VESICLE, 169

seventh week, it generally ceases to diminish, but becomes flattened
and then insensibly disappears; sometimes it can no longer be found
at the third month, while in other cases it may be met with in abor-
tions of four, five or six months.

440. It is incontestably situated betwixt the chorion and amnios.
If I maintained a contrary opinion in 1824, it was because I then
confounded it with a vesicular body which to a certain extent re-
sembles it, but which in fact differs very widely from it, as I shall
have occasion to show in the sequel.

441. Until the fortieth or fiflieth day it is enclosed in the reticu-
lated body or vitriform layer; after that it unites with, and applies
itself either to the internal surface of the chorion or to the outer sur-
face of the amnios. It would seem then that one of these membranes
encloses it betwixt its layers; indeed it is most frequendy met with
thus, though I have found it peifectly free in ova of two and even
three months.

442. The characters of the pedicle by which it is attached to the
embryo vary according to the stage of the pregnancy; until the
end of the first month, and in the natural state, I have not found it
less than two, nor more than six lines long; at this period of its de-
velopment it is often a quarter of a line thick, and in becoming
confounded with the vesicle undergoes a sort of infundibuliform ex-
pansion. Towards the abdomen it does not enlarge, neither does
it contract in any sensible degree. Its continuity with the intestinal
tube can now no longer be called in question in the Jiuman subject.
Before the parieles of the abdomen are completely formed, it is
divided, as it were into two portions by the amnios, which it appears
to have traversed or perforated. One of these portions is found
betwixt the spine and the spot to be subsequently occupied by the
umbilicus; the other remains without, between the amnios and the
vesicle.

443. After the first month the canal elongates, becomes more
and more delicate; its umbilical portion is lost in the cord, and can
no more be traced as far as the belly; its length may extend to half
an inch, an inch or even one inch and a half. Whenever I liave
found the vesicle further than this from the root of the cord, it mani-
festly depended upon its pedicle havuig been broken by the trac-
tions naturally exercised upon it by the membranes when these
parts acquire an early and pretty strong adherence to each other.
Accordingly as this rupture is effected earlier or later, as the adhe-
sions are stronger or weaker, as the pregnancy is more or less
advanced, the vitelline sac is found to be more or less remote from
the umbilical cord, or if you please, more or less approximated to
the circumference of the placenta.

170 APPENDAGES OF THE FOETUS.

444. This stem is unquestionably hollow until the twentieth or
thirtieth day, for I was able in two specimens to squeeze the liquid
from the vesicle into the intestine without rupturing any thing;
whence it follows that the objections of MM. Emmert, Hcech-
stetter, Cuvier, &;c. are of no value, at least in so far as they are
applicable to man. It becomes obliterated at a period wliich has
not appeared to me to be always the same; in general, however, it
may be said to be no longer permeable at five weeks, and its oc-
clusion takes place from the navel towards the vesicle in proportion
as the cord becomes more complete.

445. The parietes of the vitelline sac are strong, resisting, pretty
thick, and difficult to lacerate; they have never appeared to me to
be more frail than the other membranes of the ovum, unless they
had been previously rendered thinner by some morbid change or by
some mechanical cause. Smooth and even when the vesicle is
full, they wrinkle or fold, on the contrary, when that little body is
emptied; they are generally of a yellowish color, but perhaps this
tint depends upon the fluids they contain; their transparency too is
imperfect, which may depend upon the same cause.

446. Those who have examined the umbilical vesicle in brutes,
and who have admitted its continuity with the intestines, pretend
that it is composed of three laminse. According to M. Dutrochet
the same is observable in the human species, but, so far as I know,
this is only a mere assertion advanced without proof. However, as
to the vesicle, I have never in any instance found it to consist of
several membranes; its pedicle in particular is homogeneous and
not lamellated. So that I think we may very well admit in this
apparatus the existence of a mucous surface and a serous surface,
but not of a serous membrane and a mucous membrane; still less
of a muscular coat: besides, it is not until a much later period of
life that these distinctions of the tissues are effected, even in those
organs where they are subsequently most decided (166).

447. However this may be, arterial and venous vessels are visibly
distributed upon it; I have observed them not only in the substance
of the parietes of the vitello-intestinal canal, but also in those of
the vesicle itself; in the latter twice, and more than twenty times in
the former. In the former case I saw them compose a very beautiful
net work with arborescent ramifications extremely easy to follow,
without any particular preparation, and even with the naked eye.
In the latter, they consisted of two trunks becoming larger and larger
as they approached towards the abdomen.

448. These vessels, denominated the omphalo-mesenterlc vessels,
would be better named vitello-mesenteric, or simply vitelline. Ac-
cording to my own observation, they do not empty themselves into

UMBILICAL VESICLE. 171

the superior mesenteric vein and artery; I have always remarked
that they join one of the branches of the second or third order of these
great vessels, particularly those that proceed to be distributed to
the caecum. I have often traced them in the abdomen, through
the umbilical ring, and as far as one, two, and even three inches
along the cord, in products of six weeks, and two or three months
old. But they disappear at these different periods, and at last are
lost in the spongy tissue of the umbilical cord, before arriving at the
vesicle. I have several times succeeded in injecting them, and then
they appeared of the size of a large hair; in general, however, they
are so fine, that they are easily broken if sought for without the
greatest care.

449. Inasmuch as I have seen them in an ovule at the same time
with the pedicle of the vitelline sac, from which they were perfectly
distinct, it appears to me they should henceforth be considered as
destined to carry to and take up from the parietes of the vesicle and
its canal, the materials that serve for the nutrition of this curious ap-
paratus; and not for the transfer of the vitelline substance into the
general circulation.

Many reasons drawn from analogy, have led to a comparison be-
tween the vitelline matter and the yelks or vitelline substance of
the eggs of birds. In the largest umbilical vessel I ever saw, and
perhaps the only one where there was no possibility of this sub-
stance having undergone any change whatever, it was of a very de-
cided pale yellow, consequently opake, of the consistency of a pret-
ty thick emulsion, and different in all respects from serum or any
other known fluid of the economy. In others I have found it more
fluid and clearer, and in others yellower and thicker; in several spe-
cimens it consisted of one or two small concrete clots, resembling in
a remarkable manner the yelk of egg cooked and floating in a
slightly colored fluid; to conclude, its color is analogous to that
exhibited by the parietes of the vesicle itself, after the sixth week
of its growth. We ought, consequently, to admit, that it is a
nutritious substance, a sort of oil in a great degree similar to that
which constitutes the vitelline fluid of the hen's egg.

450. The uses of this apparatus then are evidently connected
with the nutrition of the primary lineaments of the foetus; it fur-
nishes to the embryo its means of growth, until the cord and um-
bilical vessels are formed, or rather until the ovule becomes exactly
applied to the inner surface of the womb; numerous materials then
pass from the parts of the woman to those of the ovum, and the
umbilical vesicle soon beco.mes useless. Under this view, the appa-
ratus I am speaking of can be but temporary, and created to the

172 APPENDAGES OF THE FCETUS.

end of giving time to nature to establish, with her accustomed gen-
tleness and regularity, the permanent means of nutrition in the ova
of mammiferous animals. From the moment of fecundation until
the ovule is found in immediate contact with the inner surface of
the womb, the product of human conception is in almost all respects
similar to the egg of a bird: like it, free, and independent of every
part of the mother, it must contain whatever is necessary within
itself; it must contain a substance, by the expenditure of which the
growth of the embryo can be effected, just as the chick must enclose
within its shell a material subservient to its evolution. But in one
this arrangement is only transient, while in the other it remains until
the embryo is hatched: but this difference depends upon this, that
in the former, incubation is performed in the interior of a living or-
gan, an organ capable of distributing nutritive matter in abundance
to the young product within it; while in the second, it all passes in
the open air, outside of the parts of the adult animal.

§. II. Of the Allantoic.

451. The allantois has by turns been admitted and rejected in
the human ovum, from the earliest history of anatomy until our own
times, and even now most authors agree in rejecting its existence.
All indeed who have described it speak of it merely from analogy,
or have mistaken it for an organ with which it is important that it
should not be confounded.

M. Lobstein has described the umbilical vesicle itself for the
allantois; M. Dutrochet is still farther from the truth in taking for
this organ the inorganic pellicle that lines the interior of the mem-
biana caduca. Lacourvee, Hoboken, Diemerbroeck, Hales, Nouf-
ville, Littre, Rouhault, &c., affirm that they have observed it at all
periods of pregnancy; some have even given drawings of it; but all
their observations are referable to a primary error; it is the cKorion,
confounded anteriorly to their day with the anhistous membrane,
that they have described in place of the allantois.

452. In an ovum of about twenty days old, for which I am in-
debted to the kindness of Dr. Terreux, the space between the amnios
and chorion, which was quite considerable, as it should be in the
first month of pregnancy, was almost entirely filled by a fungous
substance of a brownish yellow color, which was less thick the
nearer it was observed to the umbilical cord, while it was several
lines thick at the point diametrically opposite. Notwithstanding
this great thickness, it was impossible for me to divide it into several
laminae; it appeared to be formed of an infinite number of filaments
and lamellae, disposed without regular order, but so as to form a

ALLANTOIS. 173

sort of reticulated magma. By pressing upon it with the dissect-
ing needle, I squeezed from it some particles of a whitish pulpy-
matter; upon detaching it from the chorion, I found it adhered to it
by some very delicate and fragile filaments; that its adherence to
the amnios and vitelline sac was less regularly established; lastly,
that it also enveloped the cord on which the amnios was not as yet
folded, and that it could be traced to the belly of the embryo, as far
as the pedicle of the umbilical vesicle.

453. It is rare, exceedingly rare, to have an opportunity of ex-
amining so perfect a product of conception; M. Henoque, however,
procured one for me that was still more so. This ovum, three or
four weeks old, and very recent, had undergone no change of shape,
nor laceration; immediately under the chorion there was a tissue of
a dull white color, extremely delicate, and almost as easy to tear as
the retina. Notwithstanding all the care taken, it was ruptured
merely by the pressure I made upon another point of the ovum in
dividing the chorion. It was full of an emulsive or cream-like sub-
stance of a slightly yellowish white, and which tended to escape in
homogeneous grumes. Its inner surface gave birth to fibres and
lamellae, and to numberless prolongations which decussated in every
direction, like what is observable in the spleen, the seminal gland,
the corpora cavernosa, and as is said to be the case also, in the
hyaloid membrane of the eye. These filaments, after traversing the
semi-fluid white matter, proceeded to a second lamella, which, with-
out any intermedium, was in contact with the periphery of the am-
nios, of the umbilical vesicle, and of its pedicle. Certain isolated
shreds, being washed and floated, exhibited an almost perfect trans-
parency, and much less thickness than the amnios.

454. To sum up, this new organ constituted a sac with a double
coat, moulded upon the cavity of the chorion, enclosing the umbili-
cal vesicle and the amnios, after the manner of the serous mem-
branes, forming interiorly a true net work with large unequal
meshes, in which the emulsive fluid was lodged. Its two coats, se-
parated at one place by a distance of more than three lines, became
more and more proximate towards the root of the umbilical cord;
near the belly they appeared to be confounded with each other, but
their extreme tenuity prevented from ascertaining what organ of the
abdomen they were continuous with.

Have I now any right to conclude that this body was really the
allantois? It is true I did not succeed in demonstrating its commu-
nication with the bladder, but this communication has been no bet-
ter demonstrated in reptiles, and even in many of the mammiferae;
moreover, the bladder itself was so small, or so little developed in
.16

174 APPENDAGES OF THE FCETUS.

this specimen, that I am not sure of having seen it; besides, as on
the one hand the summit of the urinary bladder naturally reaches
as far as the umbilicus, and as on the otlier side 1 traced the reticulated
sac from the root of the cord as far as the navel, it was impossible
to make a nearer approach, without reaching it, or without actually
demonstrating it, to render this communication more probable.

In embryos more advanced, I have many times traced the urachus
into the umbilical cord, where it unravels and is transformed into a
porous tissue, and terminates either in one of the swellings when
they still exist, or in the gelatinous tissue of the placental stem after
passing on for six or eight lines, or one inch, or fifteen lines. I have
seen more; in an ovum of five or six weeks old, the prolongation
from the bladder proceeded to, and was lost in the vitriform layer,
which at this period takes the place of the porous body of the ovule;
I must however confess, that having blown air into the bladder, I
could not make it penetrate into the urachus, which always retained
the characters of a solid filament.

455. From the fifth week after conception until the close of preg-
nancy, there is betwixt the chorion and amnios a transparent stra-
tum, either colorless or of a somewhat greenish red; this stratum,
instead of being merely serous, is lamellated after the manner of the
vitreous body; it diminishes in thickness in proportion to the deve-
lopment of the other membranes; the quantity of fluid contained in
its meshes is, on the contrary, in the inverse ratio of the progress of
gestation; by diminishing in thickness, it at length comes to form
only a homogeneous pulpy stratum, to transform itself into a simple
gelatinous or mucous coating, which, in many women, wholly dis-
appears before the period of delivery; several of its lamellae are
confounded together at the external surface of the amnios, princi-
pally in the environs of the root of the umbilical cord: the same
thing takes place, but more rarely as to the chorion, which explains
why the umbilical vesicle, observed after the sixth week of gestation,
is very often united, as if framed in, with the membranes of the cho-
rion and amnios; this matter occupies the place of the reticulated
body, and like the latter is continuous with the gelatinous portion of
the cord. But is it independent of the porous sac which precedes
it; or rather is it only a modification thereof? This last conjecture
seems to me, to be, if not certainly true, at least extremely probable.

456. In order to acquire more enlarged notions concerning the
bodies in question, naturalists may advantageously have recourse to
comparative anatomy; for I have found betwixt the allantois of ovi-
parous reptiles, and the reticulated body of the human ovum, the
most exact resemblance.

ALLANTOIS. 175

In raammiferae I have observed, even at the close of gestation,
that the urachus, after traversing the umbilical cord, expands into a
smooth tissue, that is porous, and as it were, drilled full of holes,
which at last unites intimately with the corresponding surfaces of
the membranes between which it is naturally placed. In this crib-
riform membrane we meet at other periods with certain pelotons of
concrete fatty matter, similar to the hippomanes of horses; and as
the bladder opens into it, it unquestionably constitutes part of the
allantois.

There are, therefore, between the sac known as the allantois in
the mammiferae, birds, and reptiles, and the reticulated body which
I discovered in the human ovum, the most striking agreement in re-
spect to resemblance and nature.

457. In maintaining that the allantois is designed to contain the
urine of the foetus, naturalists have in all ages relied chiefly upon its
communication with the bladder in brutes, upon the saline taste of
the fluid met with in it, and, according to Daubenton, on the uri-
nary smell observed in it. I do not think that, even in the vivipa-
rous animals, these data are sufficient to establish such an opinion;
the urinary odor is a character which is surely too fugacious for
us to attach any great importance to it, and on this point is it quite
sure that Daubenton was not mistaken? In tlie second place, what
does the salt taste prove? Do we not meet with it in the water of
the amnios? Was it not communicated by the last named fluid to
the former? What connection can there be between the urine and
the viscid, fatty, whitish matter contained in the allantois of the bi-
sulcae; between the urine and that white, feculent and reticular mass
contained in the allantois of the chick about the tenth day of incu-
bation; between the urine and the milky, flaky fluid I have observed
in the ovum of an adder? Certainly none: to contain the urine is
not the only, is not even the chief use of the allantois.

As to the human species, whether the reticulated body is analo-
gous to the allantois, or constitutes a different organ, whether it com-
municates with the bladder by means of some channel, or is inde-
pendent of it, it appears to me impossible to establish the least affi-
nity between tlie substance found in it and the urinary fluid.

Its functions, like those of the reticulated body, are in my opinion
connected with the early nutrition of the germ. Perhaps it serves
for the development of some particular organ, or some special appa-
ratus; on this subject, we may indulge in a thousand conjectures; but
fearing to stray in the field of supposition, I prefer to wait for
new facts. I shall content myself with showing that the inner sur-
face of the shreds I have turned back on it, were covered with an

176 APPENDAGES OF THE FCETUS.

adherent layer of a cream-like matter contained in its interior; that,
in the microscope, it presented a villous appearance, and that from
this double peculiarity it is probable that the substance in the reticu-
lated body is secreted by its own parietes. This, moreover, would
be an argument in favor of the opinion of Harvey, of Joerg, and of
Oken, in relation to the fluid of the allantois in animals. I will ob-
serve further, that this matter preserves its cream-like, flaky aspect,
its appearances of an emulsive fluid, its characters of a nutritive
substance, until the ovule is well fixed in the womb, and then disap-
pears very rapidly, giving place to the albuminous stratum, which
remains until the termination of pregnancy. I make no mention here
of a third vesicle described in the Jsis by M. Pockels, under the
title of the erythroid vesicle, because I have never noticed it, and be-
cause I believe the author is mistaken in relation to it.

SECTION 3.

Of the Cord and Placenta.

§. I. ©1* the Uinljilical Cord {funiculus timUlicalis).

458. The umbilical cord is a stem by which the abdomen of the
foetus is connected with the membranes of the ovum, from the com-
mencement until the end of pregnancy.

459. Its length, although variable, is notwithstanding generally the
same as, or a little greater or less than that of the foetus at birth, that
is to say, from fifteen to twenty inches. Denman, L'Heritier, and
MM. Morlanne and Maygrier, have spoken of cords measuring four,
five, and even six feet in length; others have been seen only a few
inches long, which even retained the placenta in contact with the
foetus; but these extremes of dimension are rare, and some of the
notices of them require to be repeated.

460. Some times thicker, at others more slender, it generally is
about the size of the little finger. In this respect its anomalies,
which are much more apparent than real, depend upon whether the
spongy tissue of which it is partly composed is engorged with fluids
which constitutes fat cords, or on the other hand almost entirely
desiccated, and then the cord is lean. However, they may also de-
pend upon varieties in the absolute thickness of their vessels or
sheaths.

461. Although smooth and polished like the serous membranes,
the human cord, nevertheless, exhibits many nodosities of diflerent
kinds, on which I must dwell for a moment: on some occasions they
are real knots, either simple or complex; more frequently, however*

UMBILICAL CORD. 177

they are doublings, vascular nooses, whether of the arteries or- of the
vein; the former are met with particularly where the cord is very
long, are owing to the movements of the foetus, are effected in the
same way as the twisting of the cord about the neck, limbs, or other
parts of the child, frequently met with in parturition, and it may be
said are but the definitive result of this last mentioned disposition.

The second, known in all ages, are, according to Harvey, more
frequently formed by the vein than by the arteries; but, according to
my own researches and those of Hoboken, more frequently by the
arteries than by the vein: being produced by the folding of one or
both these vessels, after the manner of the varicose knots in other
parts of the body, there may be only one or several of them on the
same cord. Rhodion and Avicenna among the ancients, and the old
women of all periods, pretend that by means of the number of these
knots, their remoteness from or nearness to each other, and their
color, it is possible to ascertain the number and sex of the children
the woman is to have in future, the interval between each of the
confinements, &c. These ridiculous pretensions, begotten by the
superstition of oar ancestors, doubtless do not deserve to be seriously
opposed; but they are so often met with among the public, that I
thought they ought not to be passed over in silence. Although they
have never been accused of interfering with the omphalo-placental
circulation, it may nevertheless be concluded that if very numerous
and close, and presenting very acute angles, these turnings might be
the means of obstructing to a greater or less degree the flow of the
blood in its proper vessels.

462. The point of the belly which gives insertion to the umbilical
cord, is at a greater distance from the breast, or nearer the pubis, in
proportion as the pregnancy is less advanced. At birth, it generally
corresponds, according to Chaussier and M. Bigeschi, to the middle
of the space between the vertex and soles of the feet. It ordinarily
terminates in the centre of the placenta; but it is also sometimes
found attached very near the circumference of that body: in the for-
mer case, the branches of which it is composed diverge by expand-
ing in the covering of the ovum; in the latter, it is not a rare occcur-
rence to find it creeping betwixt the membranes a longer or shorter
time before it is lost in the placental parenchyma. Of an equal size
throughout its whole extent in some subjects, it is in others much
more slender near its root than near the abdomen, and reciprocally.

463. Development. Trusting to false analogies, hypothetical
data, or careless observations, authors have asserted that it does not
begin to be distinct until after the first month of gestation. The
youngest embryos I have ever dissected had the umbilical cord. I

16*

178 APPENDAGES OF THE FOETUS.

am no.w in possession of several of from one fortnight to three weeks
old, which are only three or four lines long, and in which the cord
is equal to, or even exceeds the length of the foetus. Relying upon
very numerous facts, I think I can establish it as a general rule that
the length of the cord is about equal to, or somewhat exceeding that
of the foetus, at all periods of pregnancy.

It is slender and cylindrical until the end of the third week: a
little later from the fourth to the seventh, the eighth, or even the
ninth week, it acquires a considerable relative size, exhibits tuber-
cles, vesicles or swellings, which I have no where seen described,
which are to the number of two, three or four and separated by the
same number of contractions. In the course of the third it becomes
smaller, in consequence of the shrinking away of its swellings;
finally, from this period until the termination of pregnancy it ceases
to grow in proportion to the other parts of the foetus.

464. Its composition is far from being the same at all stages of its
evolution. At the commencement, it really consists only of a small
solid cylinder, to which the amnios does not furnish any coat. From
the fifth week it contains the duct of the umbilical vesicle, and a por-
tion of the urachus or allantois, and some of the intestines. But
about the second month, the alimentary canal has re-entered the
abdomen, the urachus, the vitelline duct and its vessels have become
obliterated, so that at three months, as at nine, the umbilical stem is
formed only of two arteries, the vein of the same name, of the gela-
tin of Warthon or spongy tissue of Rouhault, and of the amniotic
sheath.

465. DiemerbroBck, Wrisberg, Schroeger, and Michaelis have ad-
mitted the existence of lymphatic vessels in the cord; MM. Chaus-
sier, Darr, Reuss, &c. think they have discovered nerves in it going
to the solar plexus; but it is probable these authors permitted them-
selves to be imposed on by some remains of the urachus, the vitel-
line vessels or duct, &c. At least I have never been able, with all
the pains I could take to verify their assertions; a circumstance in
which my researches agree with those of MM. Lobstein and Meckel.

466. Although there is in man only one umbilical vein, as an
ordinary rule, cases are cited where there were two, as occurs in a
great many of the mammiferae. In other cases, instead of two arte-
ries, only one is found; I have seen an instance of this sort, and M.
Blandin has deposited a second in the Museum of the Faculty.

These vessels are not visible until the first fortnight, or the second
month after conception, and do not assume the spiral form until after
the disappearance of the swellings of the cord, that is, from the
seventh to the eighth week. The reason of this twisted appearance

UMBILICAL CORD. 179

seems to.me to be very plain: it depends on the rotatory movements
of the child in the womb, and ten times out of twelve it turns from
left to right, according to my own and Meckel's observations. In
some subjects, the cord is turned in one direction near the placenta,
and in the opposite one near the child's belly; most frequently it
looks like a real rope, and hence, doubtless, is derived its name,
cord. Sometimes all three of the vessels turn on one ideal axis; at
others the vein is twisted round the arteries, but in general the
arteries are twisted round the vein.

467. It is altogether incorrect to say with Hoboken, Reuss and
some other anatomists, that there are valves in the umbilical vein;
I have been convinced of the contrary a hundred limes by careful
dissection. Rouhault has remarked that the dimensions of this vein
are double those of both the arteries.

The common sheath that envelopes them continues transparent for
about two months, and during this period permits us very distinctly
to see them in its centre; after which it grows more and more
opaque as the pregnancy advances. I have already said that it does
not exist at the commencement; it is seen to form by degrees be-
tween the first and the end of the second month, progressing from
the embryo towards the root of the cord in the following manner:
the amnios, at first much smaller than the chorion, and as if pierced
with a circular hole, to allow the pedicle of the vitelline sac and
umbilical vessels to penetrate into the abdomen, is afterwards re-
flected along the umbilical cord as the ovum enlarges, but so as not
to afford a complete sheath to its vessels until the tunics of the foetus
come into contact with each other.

468. Notwithstanding that these vessels do not in general sepa-
rate or divide until they reach the placenta, it would be a mistake to
suppose they never do so. Their division may take place at the
distance of one, two or four inches from the inner surface of the
chorion, and even very near the abdomen of the child. In this case
their first divisions, diverging like the rays of a parasol, fall upon
points pretty near the circumference of the placenta. Examples of
this kind have been figured by various authors. I have seen one
belonging to M. Deneux, and have two of my own. Those obser-
vers, who, like Van-der-Wiel, Schurig, &c. have supposed that a
single foetus might have more than one umbilical cord, have pro-
bably been misled by this anomaly, for it is pretty nearly certain that
two cords never existed in the same subject.

469. In the scientific collections may be found facts tending to
prove that the belly is not the only point to which the cord may be
attached; that it has been seen inserted upon the breast, the neck.

180 APPENDAGES OF THE F(ETUS.

the limbs, &c. But none of these observations are of a nature to
enforce conviction; they should be received vi^ith great reserve, for
they rather give evidence of the credulity of their authors, than of
what they wish to prove. However, there is at Brussels, in the ana-
tomical museum of a gentleman of that city, a foetus, with the cord in-
serted upon the cranium, and which M. J. Cloquet has had an oppor-
tunity of examining. If I might speak of a thing I have never seen,
I should say the abnormal cord originally belonged to a second foetus,
and became accidentally attached to the cranium, that the natural
cord also existed, and that the cranial cord did not penetrate beyond
the integuments: I have seen one case that might give rise to ideas
similar to those I am now combating. A monstrous foetus, born
at the seventh month, and for which I am indebted to the goodness
of Madame Jagu, had the umbilical cord so disposed, that at first
view there seemed to be four of them; two of them departing from
the belly and the other two from the breast. But it was only a
natural cord, doubled several times, and the angles of the folds of
which had adhered to the membranes and also to the skin of the
foetus.

§. H. Of the Placenta {hepar uterinum).

470. The placenta, thus named by Fallopius from its resem-
blance in shape to a flattened cake, is that part of the ovum which
is found in immediate contact with the organs of the mother, and
is continuous at its circumference with the reflected c:.duca. It is
only found in the mammiferous animals, where it exhibits very va-
rious shapes. In the dog it is a complete zone surrounding the en-
tire chorion; the placenta of the ruminating animals is multiple, and
presents itself to the view of the observer under the appearance of
unequal and pedicillate masses. In the rodentia it is composed of a
circular plate formed of two layers, which are to a certain extent
dissimilar. In the horse it consists of a simple reddish and granular
layer, which covers the whole extent of the chorion. In the human
species where I have particularly to examine it, it is a softish and
spongy, flattened, circular, oval or reniform body; its width, ordi-
narily from six to eight inches, is sometimes smaller and at others
greater. Its thickness is also very variable, and, moreover, very
unequal in different parts of the same one; generally from one inch
to an inch and a half at the centre, it goes on lessening towards the
circumference, which is frequently only a few lines in thickness, but
which is occasionally, in some points, thicker than the centre itself.

As its diameters are from six to eigiit inciies, it is useless to say
that its circumference is from eighteen inches to two feet.

PLACENTA. 181

471. One of its surfaces, the fatal, inner, smooth, vascular,
membranous. Sic, surface, is lined by the chorion, which adheres to
it, and by the amnios, which can always be separated from it by
merely peeling it off. In spreading upon it, the principal divisions
of ihe vessels of the cord form a very beautiful diverging net work.

472. Its other, external or uterine surface, viewed in the womb
or upon an entire ovum, appears porous and fungus-like, but even;
neither cracks nor orifices of sinuses are seen; it only exhibits a
few salient points; the anhistous membrane does not cover it; a
simple pellicle lines it and covers its lobes.

When the placenta is out of the womb, this surface is, on the
contrary, extremely uneven, lobes of various sizes are seen upon
it, and they are separated by fissures of greater or less depth; and
this happens because, in detaching and expelling the placenta, the
uterus, by doubling up, lacerates the thin inorganic pellicle which
concealed the intervals between its numerous cotyledons.

I have had six opportunities of observing it in situ, and in none
of them could I discover either sinus or opening having the least
resemblance to what authors have described as such. It is proba-
ble that the observers have been deceived by some accidental open-
ings and excavations, such as are often met with, but which are
owing to the pellicle, before mentioned, being lacerated here and
there, and rendering it an easy matter to penetrate into the placental
fissures, as into so many excavations.

At the full term of pregnancy, the circumference of the placenta
is continuous, without any decided line of demarcation, with the
double layer of the caducous membrane; and this is doubtless what
has led to the belief that the first mentioned part of the ovum is only
a thickened portion of the latter.

473. Arantius, Hoboken, Warthon, Ruysch, Malpighi, and many
other old writers; Wrisberg, Reuss, MM. Lobslein, Meckel, &c.,
among modern ones, have made many attempts to unveil the nature
or structure of the placenta. It might be supposed that in this
respect science has nothing more to desire; but in turning over the
most esteemed works on the subject, one's opinion is soon altered,
on perceiving that twenty different sentiments yet have their antago-
nists and defenders.

Warthon, opposed by Arantius, was one of the first to say that
the placenta consists of two halves, one uterine or maternal, and the
other membranous or foetal. If Warthon, and those who have
adopted this division of the placenta have not taken the ovum of the
rodentia as their model, 1 am unable to discover in the human after-

182' APPENDAGES OF THE FCETUS.

birth any appearances that could account for their mistake; which
besides has been imitated by many of the moderns.

It is sufficient to cast a glance on the porous surface of any pla-
centa, to be convinced that one of its halves has not remained ad-
herent to the uterus; to remark that this surface is smooth, and
covered with a thin lamella, noticed even by those who admit the
double layer, in order to see that the fact is not so, and indeed can
not be so, &c.

474. This membranule,* which covers the fungous surface of the
placenta, admitted by Arantius, Littre, Hunter, MM. Lobstein,
Chaussier, Meckel, and most of the modern anatomists; rejected
by Ruysch, Mery, Rouhault, &;c., seems to me to have been gene-
rally ill understood: some, contrary to the opinion of Wrisberg,
have thought it to be only a thin portion of the caduca; according
10 most observers, it contains many vessels; many authors state
that it passes directly from one lobe of the placenta to another
without dipping dow^n into the interval between them; a still great-
er number, on the contrary, pretend that it dips down, also, between
the cotyledons, between each bundle, and every vascular filament,
to which it furnishes a kind of sheath. Lastly, there are some who
believe in its existence during the whole period of pregnancy; while
others say they have only met with it in the three or four last
months.

As long as the placenta does not form a compact mass, that is,
until about the twelfth week, there is not a trace of the pellicle in
question; as soon as the tomentose groups of the chorion become
entirely agglomerated, it appears, as if to cover their summits, and
soon afterwards is found to be continuous and confounded with the
reflected edge of the anhistous membrane.

It certainly contains no vessels, and the idea of a circular venous
sinus, whicli according tfif the reports of certain anatomists exists
along the circumference of the placenta, can only be the result of a
careless observation.

The utero-placental pellicle is here disposed in the same manner
as the arachnoid is on the brain: on the top of the projections and
protuberances it adheres intimately; whilst opj)Osite to the spaces
betwixt the lobes it may be easily separated, in the shape of a deli-
cate, transparent lamella; like the arachnoid, it also remains on
the surface, and in general does not penetrate into the parenchyma.

* It has been called the placenta serotina and is supposed to be formed at a late
period and to increase with the increase of the placenta. — M.

PLACENTA. 183

Its nature is similar to that of the pellicles, which soon after their
formation cover almost all sorts of fibrinous concretions. It is
not a tissue; it is destroyed by placing it in water, and after a few
hours dissolves as readily as all the other membraniform concretions.

475. A coat of deposit, much thicker, more fragile, and not so
smooth as the preceding one, surrounds all the vascular trunks;
this is what has given occasion to the belief that the vessels of the
placenta ramify in the very substance of the caduca; that the chorion
is composed of several coats; that the anhistous membrane lends
one lamina to the external and another to the internal surface of
the placenta, and that the delicate pellicle of the latter is doubled
down between all the fibrillae of its lobes and lobules. The lamellae
of which it is composed appear to me to be a concreted product
of a peculiar exudation from the womb, the chorion, and its to-
mentose portion. In this respect there is some analogy between
them and the caduca; but they differ from it in this, that they are
not to be seen until a long time after the ovum has reached the
uterus, while the anhistous sac forms immediately after fecundation;
and also in this, that one is very soft and somewhat elastic, while
the others are dry, hard, and break almost as easily as glass.

476. The glandular bodies, to which Blancardi, Malpighi, and
Littre attributed important functions in the placenta, are no longer
admitted by any body to exist; those anatomists probably allowed
themselves to be deceived by the primitive and natural granulations
of the chorion. Notwithstanding the assertions of Warthon, Cruik-
shank, Mascagni, Wrisberg, Michaelis, and Schroeger, it is now
pretty generally agreed to deny the existence of lymphatic vessels
in the after-birth. The same is the case as to the nerves which
Verheyen, MM. Ribes, Home, and Bauer tell us they have seen.

477. However, Dr. Lauth has recently published a work tending
to prove that a great number of lymphatic filaments of a peculiar
kind pass from the placenta to the uterus. It is true that when we
carefully separate the ovum from the womb we perceive an infinite
number of small whitish threads, extremely easy to break; but it is
also certain that similar threads are to be seen when separating the
caduca from the surfaces which it lines, the amnios from the chorion,
&c., that these are merely gelatinous or mucous tracts, but not
vessels, nerves, nor even cellular filaments.

478. The blood vessels therefore compose the fundamental ele-
ment of the placenta; these vessels are but expansions or ramifi-
cations of those of the cord, and like those of the navel string
are not developed until after the third week, and then by intus-
susception and gradually.

184 APPENDAGES OF THE FCETUS.

Previously to this period, the villous matter of the chorion does
not contain any of them, and this villous portion may until then be
compared to the hairy part of the roots of plants. It contains, in-
deed, spongioles, radicles, and articulated filaments analogous to
those described by MM. De Candolle, Correa and Dutrochet; if it
does take up any fluids from the surrounding parts, it must imbibe
or absorb them after the manner of vegetables. At a later period,
vascular channels are formed, as happens in new tissues. Being at
first much smaller than the radicles with which they are surrounded,
they do not seem to extend throughout the whole length of the
chorion, even at a pretty advanced period of their growth. I have
injected them with colored alcohol, size, spirits of turpentine, &c.,
at the third and fourth months, and afterwards examined them with
the microscope, and although the injection had passed into vessels
finer than those of the choroid, it always stopped at a considerable
distance from the extremities of the villous branches. This portion,
which cannot be injected, has always appeared to me to be, like the
primitive tomentum, unprovided with any central channel, to be of a
spongy nature, and to absorb only by means of imbibition.

The bands and solid white filaments that are found in the placenta
even after delivery, and which are attached to the chorion, are not,
as some contemporary authors too confidently assert, obliterated ves-
sels: they never were hollow, and remain solid, as they were at the
commencement. They are similar to those which connect the re-
flected portion of the anhistous membrane to the villous coat, and be-
long to some primitive branches of the villous coat of the ovule, in
wiiich no vessels were developed.*

Do the venous capillaries appear before the arterial capillary ves-
sels ? Is the contrary the case ? The assertions of Beclard, of
Meckel, of Lobstein, &c., concerning this point in anatomy, are any
thing but conclusive: having always met with arterial at the same
time with venous branches, I am disposed to believe that both these
kinds of canals appear together; and how could it be otherwise ?
If the blood enters in one, must it not return by the other kind of
vessels?

* I maintained this opinion in the year 1823 (Archiv. Gen. de Med. 1824),
and have ever since continued to inculcate it in my public lectures on midwifery-
I am, therefore, not without reason surprised to see MM. Breschet and Raspail
who have confirmed it by some recent microscopical experiments, endeavoring
to attribute it to themselves, or refer it to Carus, who never spoke of it before the
year 1827; M. Breschet should have recollected, however, that while examining
the granulations of the chorion with a lens in his study in February 1824, we
discussed this subject, and that he was not then of my way of thinking.

PLACENTA. 185

Each vascular branch, in separating from the outer surface of the
chorion, is composed of a single artery and a single vein, which are
already twisted in a spiral manner; the trunk soon divides into two
branches of each sort, and these again into two others, so that these
dycotoraic ramifications go on almost ad infinitum: being pressed
together and united to each other by means of the fibrous layer,
these divisions and subdivisions constitute a lobe, or cotyledon of the
placenta. In ruminating animals, particularly in the cow, these lobes
being very remotely separated from each other, form so many dis-
tinct placentfe.

All the vessels of one lobe communicate with each other; but the
experiments of Wrisberg, which I have repeated, prove that they do
not in general communicate with those of a neighboring lobe.

479. When any of these lobes separate from the others, and are
at some distance from the placental disc, they form a small distinct
placenta, and this has assuredly been the reason which has on more
than one occasion led to the belief that there were two placentae to
one single foetus. Each one unites to those about it, as the different
lobules of the same cotyledon are united among themselves, and
their adhesion, which takes place in the tliird month, may easily be
broken up at full term : being thus disposed, they constitute the
parenchyma of the placenta, so that this parenchyma is e-itirely
composed of vessels, of solid filaments, of granulations, and a fibri-
nous matter which serves as a common bond of union for them, but
not of any cellular basis analogous to that of other organs.

480. MM. Dubois and Biancini state that they have injected the
arteries, and probably the veins also, which pass from the uterus to
the placenta, and vice versa; Reuss has given a drawing of them,
and Albinus had already noticed them; I have vainly sought for these
utero-placenfal vessel in a great number of subjects, and the condi-
tion of the parts has convinced me that if they do sometimes exist,
they are far more frequently wanting. I can assure the reader that
whenever I have examined the ovum in the uterus after the third
month, its surface, as well as that of the womb, was smooth through-
out its whole extent, and that not a single vessel served to maintain
the connection between these two parts.* Might not the learned
authors whom I have mentioned have been deceived by some ano-
maly, some pathological stale, or some false appearances? Could I

* I have carefully witnessed the anatomical separation of the ovum from the
womb at full term, and could never see the smaikst vessel passing from one to
the otiier. I do not believe that there is any utero-placental circulation ap-
preciable by the senses. — M.

17

186 APPENDAGES OF THE FCETUS.

have been mistaken myself? Time and additional facts alone can
resolve this question, which I leave for the curious.

Development. Anatomists have all treated of the formation of
the placenta; but only a few of them have studied it methodically,
even since Hunter made us better acquainted with the nature of the
decidua. It has been said, that when the ovule reaches the womb
there appear on its external surface certain branching villi which
penetrate through the anhistous membrane so as to come in con-
tact with the womb, and that the placenta is formed in this man-
ner; that these villi, at first regularly disseminated over the entire
surface of the ovule, soon begin to collect in groups and to assemble
together at one point, but becomes every where else smooth and
transparent; that the placenta cannot be distinguished until after the
end of the second month; that it then covers two-thirds or at least
one half of the ovum, and that its proportional breadth becomes less
and less as the pregnancy advances, &;c.

481. The following is an account of what we do observe: after
gliding betwixt the inner surface of the womb and the caduca, and
becoming attached to the organ destined to contain it until the end
of pregnancy, one half of the villous vesicle is necessarily in contact
with it, while the other half pushes away the anhistous membrane.
From this moment one disc of the ovule is left in direct contact
with the living surface, without the interposition of the deciduous
membrane, and here the placenta is developed: this is the only spot in
the womb at which the germ can take up the principles of its nu-
trition, resembling in this respect a vegetable inclosed in a vessel,
and having no communication with the earth save by a small open-
ing at the bottom.

It is then evident that the placenta in some sort begins to grow
as soon as 1,he ovule reaches the uterus, and not merely afier the
two first months of gestation; that the relative dimensions of it and
the whole ovum are about the same from first to last; and that
it is consequently incorrect to say that it covers more than one
half of the chorion at the second month, but at a later period only
a third, a fourth, &c. I have reason to believe that it constantly
augments in the same proportion as the suiface of the womb with
which it is in immediate contact; so that its width at birth depends
upon the size of the uterus or the dimensions of the point left ex-
posed by the decidua at the commencement of gestation.

482, It is well known that the placenta may be attached either
to the fundus, the front, the back or sides, and sometimes to the
neck of the uterus; but hitherto the cause of these anomalies has
not often been inquired into. Those who say that it attaches itself

PLACENTA. 187

to the most vascular part of the uterus, make an assertion that is
void of sense; for, admitting that the ovule is at first entirely con-
cealed in the centre of the decidua, as several authors have stated,
and still continue to assert, who is to tell the villi that the womb is
more favorably disposed for their reception in one place than in
another? Since observation proves that the vdli at first cover the
whole vesicle, instead of growing on one portion of it, why should
not the placenta occupy more or less regularly the whole superficies
of the ovum instead of covering only one-fifth of it?

Had Osiander, Stein, and some other writers, reflected more care-
fully upon the subject, they doubdess would not have advanced the
opinion that the point of insertion of the placenta depends upon the
specific weight of the fecundated ovum, and consequendy, on the atti-
tude assumed by the woman immediately after impregnation. Indeed,
two remarks suffice to overthrow this system: 1. As the vivified
ovule does not leave the tube for eight days, it is manifest that until
then, the attitude of the woman is a matter of indifference as to the
point in question; 2. Be the time what it may that is considered
necessary for the germ to pass from the ovary to the womb, it is
clear that it will find the woman on foot more frequently than in any
other posture, and if the idea of Osiander were correct, that the im-
plantation of the placenta over the cervix, instead of being very rare,
ought on the contrary to be the commonest of all.

483. I think I have discovered a much more natural explanation
of this phenomenon, and shall venture to submit it to the examina-
tion of naturalists; upon entering the womb, the ovule necessarily
meets with the anhistous sac, and can proceed no farther without
detaching it; now, if the adhesion of this sac is the same throughout,
the vesicle follows its original direction, glides along the fundus of
the womb, which, with the assistance of the decidua, seems to pro-
long the channel of the tube to that of the opposite one, or else it
stops as soon as it issues from the tube, and then the placenta at-
taches itself to one of the angles of the uterus. If the adhesion is
stronger above than it is below, we may conceive that the ovum will
descend more or less towards the cervix; if the adhesion be strongest
in front, it will be directed backwards, and so of the other points.
This hypothesis is further confirmed by direct observation; of thirty-
four women who died while pregnant, or soon after delivery, at the
Hospital de Perfectionnement, 1 found upon examining tlie parts, that
the centre of the placenta corresponded to the orifice of the tube in
twenty cases, it was in front of it in three cases, behind it in two,
below it in three, and in six cases only, towards the front of the
uterus.

188 APPENDAGES OF THE FCETUS.

The mode of union betwixt the placenta and the womb is another
point that has occupied much of the attention of physiologists: Noor-
thwyck, Astruc, Haller, Mery, and Baudelocque, thought that the
large venous trunks of the womb were uninterruptedly continuous
with those of the placenta.

Warthon, Reuss and a great many of the moderns suppose that
the part of the womb which is in contact with the ovum at the com-
mencement of gestation becomes fungous; that these fungosities,
which constitute the uterine placenta, intermingle and unite with
those of the chorion, from which arises an intimate adherence, which
the womb must tear off before it can expel the after-birth.

It even appears that Professor Dubois argues from this rupture
that the milk fever is really a traumatic fever.

According to Stein the lobes of the placenta are impressed into
the womb like a seal into soft sealing-wax, and the ramifications of
its vessels are implanted into the largest vessels of the womb, pretty
much as the roots of a shrub are implanted into the earth. Asdru-
bali thinks that the placenta adheres to the womb in the same man-
ner as the pulp of a peach clings to the stone. Leroux maintained
that it is in the same way as a leech attaches itself to the skin;
others have said that it is like the graft of a tree, that it is effected
by means of an accidental cellular tissue, of peculiar vessels, &c., &c.

484. It appears to me that what I have said above concerning the
structure of the external surface of the placenta, proves that none of
these hypotheses are rigorously correct. I may repeat with Ma-
dame Boivin, that in several women who died whilst pregnant, the
membrane which covers and unites the lobes of the placenta ap-
peared to me to be the only bond between it and the womb. I have
remarked, further, that the adherence of the ovum was the same
every where, that it may be destroyed with the handle of a scalpel
without the least difficulty, and without rupturing any thing save
some mucous tracts like those found between the amnios and cho-
rion, between the croup membrane and the membrane that secreted
it. The error of the authors upon this subject manifestly depends
upon their having but few opportunities of examining the ovum in
the womb, and especially upon this: viz. that in women who die a
few days after delivery, the internal surface of the last named organ
remains swelled and fungus-like at the part that corresponded to
the placenta.

485. Double ova. After what I have said heretofore of the dif-
ferent parts of the ovum, I may dispense with entering into any con-
siderable details relative to double pregnancy. If two ovules reach
the womb, each by a different tube, or if they attach themselves to

PLACENTA. 189

it at a certain distance from each other, they will each have a dis-
tinct placenta, chorion and amnios, and sometimes even an epicho-
rion, until a certain stage of the gestation. If, on the contrary, they
had already contracted some adhesion together previously to leaving
the Fallopian lube, or if they happen to remain very near each other
in the uterus, it may be that they shall be enclosed in one single leaf
of the deci.lua, and that their villi, as well as their chorion, shall be
early confounded together. In this case it may be that the septum
formed by their conjunction, shall give way, and cause the two
foetuses to be found enclosed at birth in one single bag of membranes,
numerous instances of which are related in the scientific collections,
and of which one of the most authentic has been recently laid before
the public by Madame Boivin. Nevertheless, such a circumstance
is of very rare occurrence, for in double after-births, I have always
succeeded in tracing the chorion and amnios to the intermediate
septum, where the two membranes were more or less promptly con-
founrled, and in a more or less intimate degree. In general, the
vessels of the two placentae do not communicate with each other,
any more than the vessels of the different lobes of the same placenta;
but it is easily conceived that the contrary may take place some-
times, as seems to be demonstrated by facts carefully examined.

ARTICLE II.
Of the Foetus.

486. The ancients retained the name yovri, seed, for the product
of conception for the first six days. During the next nine days they
called it xnjjfta, then embryo for twelve days, after which they made
use of the term ■cahvov, to designate the fcetus until the forty-fifth day,
and these four supposed periods were characterised by them in the
two following verses:

Sex in lacte dies, ter sunt in sanguine terni,
Bis seni carnem, ter seni membra figurant.

At present it is generally agreed to give to the germ, when with-
out its membranes, the name of embryo, until the third month of
pregnancy; or according to some, until its several parts can be dis-
tinguished from each other; it is afterwards called /tt/ws as long as
it remains in the womb, and the term child is not applied to it until
after its birth. Although this division is entirely arbitrary and diffi-
cult to justify, I feel bound partially conform to it in this work.

17*

190 THE FCETUS.

SECTION 1.
Development of the Embryo and of the Fcetns.

487. The period at which the embryo first appears in the uterus
is still enveloped in darkness, and vain attempts have for twenty cen-
turies been made to penetrate the mystery with which it is sur-
rounded. At the sixth day, says Hippocrates, the semen is changed
into a transparent bubble, in which a very small point appears, which
is probably the navel. According to Haller and most of his pupils,
the embryo is not perceptible until the fifteenth or twentieth day. Of
those authors who, with the ancients, suppose that fecundation takes
place in the womb, a part maintain that the embryo is formed first,
and the membranes afterwards; others, with Hippocrates, Mauper-
tuis, de Buflbn, &c., teach that the membranes, on the contrary, ap-
pear first; yet no one has succeeded in showing on what day the em-
bryo begins to be visible. Again, the ovarisls and animalculists are
in the first place far from agreeing with each other; and we cannot
perceive that the proofs they adduce in support of their assertions
are much more satisfactory than those of the partisans of the an-
cient hypothesis. Finally, the opinion of Haller, which had been
generally adopted as the most probable, has been lately very much
shaken by the publication of a fact which has been supposed to be of
a nature to dissipate every uncertainty; I allude to the case recently
made public by Messieurs Home and Bauer at London.

However, the sensation produced in the scientific world by this
case, seems to me as extraordinary as it is difl[icult of comprehension,
and can only be explained by the urgent desire that is felt to escape
from the uncertainty that still prevails in science upon this interest-
ing point in natural history.

What! shall we dare to conclude, because a servant girl returns
sick to her master's house, and eight days afterwards dies with con-
vulsions and delirium, that she became pregnant the day she went
out? Because the sexual organs of a woman whose menses are sup-
pressed are not in a natural state, it is thought possible to assert that
she was pregnant! Further, even admitting this last point, which
certainly proves nothing, what right have we to maintain that the
corpuscule which was found in the midst of a mass of coagulable
lymph, was a germ rather than any thing else? Let those who feel
interested in this subject, take the trouble to examine Mr. Home's
note and the accompanying plate, [Philos. Trans. 18]7, page 252,)
jet them weigh all the circumstances, and then say whether such
men as Beclard and M. F. Meckel ought to modify their opinions
upon such a case.

EMBRYO. 191

488. The experiments of R. de Graaf and Nuck, repeated by
Duverney, Haighton and Cruikshank, if they are accurate, have long
since demonstrated that the product of fecundation in animals is a
vesicle, and that this vesicle takes up some days at least to pass
from the ovary to the womb. It is true we are ignorant whether
the time that elapses between the vivification of the germ and its
arrival in the womb is always the same in the same animal, or
whether there is any fixed and certain time for the different species;
but it appears that this term is three days in rabbits, and according
to MM. Prevost and Dumas, who have lately made numerous re-
searches on the subject, that it is from six to seven days in the bitch.

489. Strato, as Macrobius informs us, supposed that the foetus
does not begin to assume the human form until about the thirty-fifth
day, when it is as large as a bee. Aristotle teaches that at forty days
the embryo is of the size of a large ant; and that we can distinguish
its limbs and all its parts, even the penis, if it be a male. It has been
stated by others, but less correctly, that from the fifteenth to the
twentieth day the embryo is vermiform, oblong, or tumid in the mid-
dle. M. Orfila, in speaking of the primitive state of the foetus, is
very wide of the truth. The same may be said of M. Meckel when
he asserts " that the part that first appears corresponds almost ex-
clusively to the trunk; that we only remark at its upper part a small
projection, separated from the rest by a notch, and whose thickness
is not near equal to that of the middle portion of the body; that the
embryo is almost entirely strait, &.c." Ph. Beclard by reproducing
the ideas of the celebrated German anatomist, has fallen into the same
mistake; nor has M. Adelon been more fortunate in admitting that
the embryo exhibits no traces of a head at three weeks, and that the
belly appears under the form of a conical projection resting on the
inner membrane of the ovum. Nor do I understand why Madame
Boivin affirms that " at the tenth day, the embryo is merely a grayish
semi-transparent flake, easily liquefied, and of a form difficult to de-
termine." It is also certain, that when comparing it to a lettuce
seed, or grain of barley, as Burton did, or even to the malleus of the
ear like Baudelocque, they could have had before them only preter-
natural specimens.

§. I. Of the Smbryo in General.

Previously to the end of the first week, there is a striking resem-
blance between the human embryo and that of some of the serpents,
putting aside the proportional length. It is a curved body, form-
ing nearly a complete circle, which in this state may be two or
three lines in diameter, but which if straight would be at least four

192 THE FCETUS.

or five. It may be compared to some of the animalcules figured
by MM. Prevost and Dumas, particularly to the animalcule of the
dog; that is to say, one of its extremities is bulbous and rounded,
and the other terminates in a point: which gave rise to a belief in
the existence of a primitive tail in the human species. Being hol-
low and semi-transparent, this stock seems to be filled with a limpid
fluid, in the centre of which may be seen, even with the naked eye,
an opaque filament, of a white or yellowish tint, which represents
the cerebro-spinal system.

490. Numerous observations made on very young embryos seem
to me to prove: that the rachis is the fundamental part of the body;
that it appears previously to any of the other organs; that for a
considerable time it exists alone; that its form does not essentially
differ from that which it possesses during the remainder of its intra-
uterine life; that for twenty days, or a little longer, the embryo is
neither straight nor enlarged in the middle, that the head and neck
constitute at least one half of its total length; that the younger it
is the more does its curve approach to the form of a circle; that
the appearances of its external circumference differ very little at
first from what they are at a subsequent period, while its interior con-
tour or concavity merits the most serious attention, on account of
the changes it must undergo.

491. In fact, the organs appear in succession upon this concave
surface; at first the difierent parts of the face, then the limbs, and
between these latter the thoracic and abdominal viscera. Nothing is
so admirable as this development; it might be called a real vegeta-
tion; the lower jaw, the members, the mass that is to occupy the
abdomen and the breast, increase and come forwards, like buds
springing from the branch of a tree, or axillas of a plant.

The spinal circle thus fills up by degrees, the forehead becomes
farther removed from the coccyx; the thoracic and abdominal por-
tions of the original stock are forced to become straighter; the
head remains constantly inclined upon the breast, but in such a way,
however, that the chin at last takes the situation previously oc-
cupied by the forehead. The coccyx does not retire backwards
until a very late period; it is moved in that direction by an ex-
tremely simple mechanism; to wit, the development of the pelvis
and lower extremities.

492. From seeing that the lateral and anterior portions of the
body do not become manifest for a considerable length of time af-
ter the vertebral frame, I have more than once been tempted to be-
lieve, with MM. Tiedemann and Meckel, Serres and Geofi'roy St.
Hilaire, that the organic evolution really takes place from the sides

EMBRYO. 193

towards the median line, and with M. Richerand, to say that the
embryo is at first only a groove, the edges of which vegetating
from behind forwards, can only unite by a species of suture upon
the anterior median line. But attentive and frequently repeated ob-
servation compelled me to abandon this hypothesis; in the median
line of the face and neck I never could discover any void; I have
found it to be as completely closed at the twentieth as at the six-
tieth day; nor have I even seen the thoracic organs entirely expos-
ed, although the mass from which they grow seems to be covered,
as far as the belly is concerned, only with a very delicate tissue; the
parieles of the chest nevertheless exhibit their natural appearances
as soon as they can be discovered.

§. II. Of* the Kead, and Org^anis oi* the Senses.

At the beginning the head resembles a very long club; its subse-
quent growth is proportioned to that of the rachis; but the appear-
ance of the abdomen and thorax soon occasions it to lose a portion
of its apparently enormous size. As neither the face nor chest
exist at first, there is in fact no neck at the commencement of
embryo life. At five weeks the face is very distinct from the cra-
nium, and the head, quite isolated, no longer resembles a mere pyri-
form enlargement; and its cranial portion also permits us, most
commonly, to discern in the vesicle which it constitutes, the general
arrangement of the encephalon. Its facial portion is already quite
opaque.

483, The mouth. The mouth is the first organ of the senses that
can be perceived: I have found it in the youngest embryos that have
fallen under my notice; consequently, it exists at the twentieth day,
and then forms a very large, elliptical or triangular opening; as the
upper jaw is very projecting, while the lower one, on the contrary,
is very short, it follows that the mouth of a human embryo bears a
striking resemblance to that of a young snake. Anatomists have
never altered the ideas they had formed as to the manner in which
the lower lip is constitu;ed; they have all supposed that it was pri-
mitively composed of two lateral portions, which at length united at
a middle line, like the two bony pieces which support it; but it is
not so with the upper lip. As long as it was thought that the upper
jaw consisted only of two pieces, it was supposed that the corres-
ponding lip must be also formed of only two pieces. But since an
intermaxillary bone has been discovered in the human skeleton, it is
generally agreed that the lip is formed of three portions, one middle
tubercle and two lateral parts, which by their union give birth to
the two columns, or naso-labial ridges. This is the theory upoa

194 THE FGETUS.

which modern writers account for the formation of simple or double
hare-lip, which according to them, should never be met with exactly
in the middle of the lip; finally, still improving upon these divisions
which are already too numerous, it has recently been asserted that
the upper lip is developed from four separate points. I think I may
venture to affirm, that such ideas could only have arisen from obser-
vations not attentively made, or too rarely repeated. In the course
of the period I am now examining, the lower lip begins to be per-
ceptible; the chin causes the middle of it to project forwards; but
its loose edge, which is pretty thin, is not interrupted by any slit,
and represents a very regular semicircle; it is longer, and has a
deeper curve than the other; but in embryos of six weeks, and in
some a little above twenty days old, I have found the edges of both
lips perfectly formed, and without any division whatever.

494. The nose. It is incorrect to say that the organ of smell
cannot be recognised until towards the sixth or eighth week. At
thirty days it is often in our power to distinguish its anterior open-
ings, which are round, situated immediately above the mouth, look
directly forw ards, and resemble two blackish spots. However,
neither the nasal protuberance properly so called, nor the naso-
palatine vault exist as yet. It is true, nevertheless, that, in several
embryos of from five to seven weeks, the orifices of the nose were
not very evident to me, while a very decided eminence already occu-
pied its place.

495. The eyes. The organs of vision appear at the same time
with the mouth, if not earlier. I have distinguished them in em-
bryos not exceeding four lines in length, and they are never sought
for in vain in the course of the fourth week. At this period its
structure is surprisingly simple, if compared to what it must become
at a later period. Without lids, canlhi, or lacrymal apparatus, re-
sembling a circular disc half a line in diameter, and slightly convex,
the visual bulb is separated from the surface only by a slight, super-
ficial and very narrow groove, which can only be found by searching
for it with a needle. Two spots seem to constitute it entirely: one
of a yellowish white composes the centre; the other, of a black
color, exhibits the appearance of a circle, on the one hand enclosing
the former, and on the other continuous with the integuments. The
central spot is at first much larger than the black circle that sur-
rounds it, but in general the latter seems to me to exceed the former
in size towards the end of the sixth week. The whole indubitably
represents the sclerotica, and the transparent cornea, which is still
comjiletely opaque, and se^ms not to differ from the nails, except
in regard to color. It might in fact be called a portion of skin or

THE FCETUS. 195

epidermis that becomes modified according to the wants of the sys-
tem. Far from being directed in front during this period, the eyes
are, on the contrary, turned very much to the sides of the head, as
is the case in a majority of quadrupeds. I have no need to say
that they are neither separated nor surrounded by any projecting
portion of the face, for the orbitar arches and root of the nose are
not as yet apparent.

496. The ears. The ear also appears very early; it is distin-
guishable on the thirtieth day at the latest, and undergoes no re-
markable changes until the sixth or seven week; at first it looks
like the simple orifice of a cutaneous follicle, or a shallow and nar-
row pyramidal depression; some days later it might be mistaken at
a first glance for a leech bite, excepting that it has four angles in-
stead of only three. There is no trace nor rudiment of the auricula;
its opening is on a level with the skin, and like the eye, the organ
of hearing appears to be only a modification of a point on the tegu-
mentary surface; from the fifth to the sixth week the inner angles
of this crucial or rhoinboidal depression begin to rise above the level
of the skin; the tragus appears first, then the anti-tragus, and after
that the rest of the concha. All these parts grow by a sort of ex-
centric vegetation; and it is some time before they incline towards
the head, and dispose themselves in regular order.

§. III. Of the ITfeinbers, and tower Parts of
the Trunk.

I have in vain endeavored to learn which of the members appears
first. Whenever I have been able to distinguish the thoracic ap-
pendages; the pelvic extremities were equally visible. Neither have
I found in their dimensions such great disproportions as are men-
tioned by authors: at first there is only a small interval betwixt
them; the former emerge from the anterior part of the lateral bands
of the spinal trunk, at about an equal distance from the top of the
head and the point of the coccyx, supposing the embryo to be
straightened out; the latter are seen about one line above the coccyx,
which is curved from behind forwards, and concealed as it were in
the space between them.

As long as none of the abdominal or thoracic organs are yet de-
veloped, they are not so near to the convex as to the concave sur-
face of the spinal circle; but the roots of them seem to be fartlier
backwards, as we pass farther and farther beyond the fourth week.

The hand is seen first in the shape of a sort of pallet with a loose
and thin but undivided edge; the foot does not sensibly differ from
it; these two parts have a slightly concave surface, which is turned

196 THE FCETUS.

towards the median line; their edges, which are somewhat inclined
towards each other, look chiefly in a forward direction.

497. From the thirtieth to the fortieth day the fore-arm and the leg
are visible, and the points of the fingers begin to emerge. At forly-
five or fifty days the elbow and arm begin to detach themselves from
the breast to which they had been before attached by means of a mem-
brane. The heel and knee also become evident; nevertheless, the
thigh appears very short, as well as the arm, which doubtless depends
upon its notbeing as yet completely detached from the sides of the ab-
domen. All the fingers are very distinct, and the gelatinous substance
which unites their base no longer extends as far as their ends, the
foot ceases to resemble the hand; the toes are arranged difl"erenlly
from the fingers; in one word, these two organs exhibit nearly the
same characteristic appearances they are to have at birth. It is
manifest that one is designed for the purpose of standing, and the
other to be used for the prehension of objects. This peculiarity alone
might serve completely to expose the absurdity of those sophists who
have insisted that the primitive mode of walking, in man, was simi-
lar to that of brutes.

498. Coccyx and genitals. From the foregoing it will have been
seen, that during the three first weeks the trunk terminates by a ver-
miform extremity, and this sort of sacro-coccygeal tail, which is bent
very much forward, becomes straighter as its cavity becomes more
filled up. I ought here to remark, that its edges soon become con-
tinuous with the abdominal mass, or are concealed by the roots of
the pelvic extremities. The space between it, the insertion of the
umbilical cord and the feet, the extent of which, until the fifth or
sixth week, scarcely exceeds a line or a line and a half, retains for a
considerable time the appearance of an excavation; it is subsequent-
ly filled by the gradual growth of the genito-urinary organs; and the
development or concentric increase of the abdominal parietes and
sides of the coccyx and sacrum at last complete it.

499. Towards the fortieth or forty-fifth day a black point is dis-
tinguishable in front of the coccyx, and indicates the situation of the
anus; a little more tow-ards the umbilicus may be seen a conical tu-
bercle, with a groove on its inferior part, constituting the rudiment
of the clitoris, or penis, according to ihe sex of the foptus. A slit
which is of sometimes greater and sometimes less breadth and depth
extends from one of these points to the other. In several instances,
however, I have thought that the intervening space in well formed
embryos was smooth; so that, up to its period, there is nothing to
point out the difference between the sexes: we are tempted to sup-
pose that every fcRtus belongs to the male sex, for there are in

THE FCETUS. 197

fact neither labia nor scrotum, and the sub-pubic prolongation is alike
in all specimens.

500. The umbilicus. Properly speaking, there is no navel until
the thirtieth or fortieth day, and the cord merely proceeds to be
lost beneath the visceral mass of the abdomen. However, the
parietes of the abdomen, gradually increasing towards the omphalo-
placental stem, soon afterwards give birth to it.

501. After the sixth week, or the fiftieth day, the organisation of
the embryo becomes rapidly perfected. The eyes become more
convex; a very distinct palpebral circle soon afterwards surrounds
them; the two extremes of the vertical diameter of this circle, by
gradually approaching each other, soon give it the form of an
ellipse, and thenceforth the two angles of the eye are observed to
exist. In nine or ten weeks at latest, the edges of the eyelids are
in contact, and so closely in some specimens, that several authors
have supposed that adhesion had taken place between them. Pre-
viously to coming in contact they were thin and sharp; but their thick-
ness now exceeds that of the eyelids themselves; they completely
cover the front of the eye, but are so transparent that its color
may be easily distinguished through them. The central spot before
mentioned grows yellow and enlarges; one is easily convinced that
it constitutes the cornea, and that its posterior surface is in contact
•with a substance of the same color. The blackish circle is also
enlarged, and being extended farther backwards, is found to belong
to the sclerotica, and that its tint depends upon the substance that
lines it internally.

502. The nose, particularly, undergoes remarkable alterations:
the protuberance which it forms above the lip, increasing by degrees,
forces its anterior opening to incline gradually downwards. Its in-
ternal surface, which until the fifth week composes a part of the
buccal cavity, begins in the course of the sixth to be separated from it.

503. The mouth does not undergo any essential change; its
depth increases; the tongue grows larger and thinner, the lower
jaw projects more, which renders the anterior cervical notch more
manifest; the lips are more distinct, more isolated, but their form
is the same.

504. The external ear, reduced to the appearance of a leech
bite, in an embryo of four or five weeks, soon acquires its proper
characters. Every part of its concha is unfolded. After the tragus
and anti-tragus, we observe the slit of the helix to appear, and con-
sequently the concha. The lobule soon manifests itself as well as
the rest of the helix, with which it is continuous; and lastly, the
anti-helix itself is visible as early as the seventieth diay. Although

18 -

198 THE FCETUS.

all these parts are formed behind the meatus auditorius, the ear
nevertheless seems to extend forwards during this whole period,
and to approach much nearer to the angles of the mouth and
eyes.

505. The members very early reach the form of their perfect
state; in eight or nine weeks the fingers are all separate, or only
adhere to each other by a transparent gelatinous substance; their
three phalanges are distinguishable, and tend already to bend to-
wards the palmar surface of the hand; the last phalanx exhibits upon
its dorsal surface a spot which must be considered as the rudiment
of the nail; certain opaque lines indicate the situations to be occu-
pied by the bones of the metacarpus. The proportional length of
the arm and thigh, as respects the fore-arm and leg, is no longer ex-
traordinary. The germ of the shoulder and hip cannot be over-
looked.

506. The coccygeal point is more completely concealed by the
pelvic members, and projects less than it does a fortnight later.
The anus ceases to exhibit the appearance of a blackish depressed
spot; at sixty days it forms a small conical projection, not perforated,
and of a more or less intense yellow color. The genital tuber-
cle continues to increase in length, and its base is surrounded by
a very thick cushion; at some distance from its extremity is seen a
circular groove which corresponds to the corona of the glans.
The channel along its inferior surface is in a great many embryos
entirely shut, but in some it is still prolonged in the form of a slit
to within one line of the anal tubercle. The development of the
perineum, of the pelvis, and hypogastrium, occasions the cord
which in the first period appeared to be inserted betwixt the roots
of the inferior extremities very near the coccyx, to remove to a
considerable distance from those parts, as it approaches nearer to
the centre of the abdominal protuberance. The circle of the um-
bilicus at last unites so intimately with the cord which passes
through it, that there is no longer any line of demarcation between
the teguments of the one and the membranous sheath of the other.
Then if, as until birth, the size of the belly appears to be enormous,
it must be attributed in part to the circumstance that the organs con-
tained in the pelvis on the one hand, and in the thorax on the other,
do not attain their perfect development until a very late period.

507. Dimensions of the foetus at different stages of pregnancy.
As the embryo is curved forwards while it remains loose in the
centre of the ovum it seems to me that it ought always to be placed in
this situation when we go about to measure its length. How can we
otherwise obtain determinate results? If, during the first six weeks,

THE FCETUS. 199

we should attempt to straighten it out for the purpose of measuring
the distance from the vertex to the os coccygis, the front of the neck
and the abdomen would rarely fail to be lacerated; at two months
the firmness of the parts mostly enables us to avoid such an accident,
but as the foetus may be either more or less straight, there will arise
numerous discrepancies in the results. The habitually flexed state
of the lower extremities renders it too difficult to extend them so as
to comprise their length in a rigorous admeasurement of the embryo.
Authors not having informed us which of these methods they
adopted, it is useless to look further for the reasons of the discre-
pancy observable in their accounts of this subject. It is true that
the most minute precautions will not permit us to specify within one
line, the length of a foBtus more than a month old; but happily, such
a degree of precision can be a matter of small moment in the eyes
of the observer. In the present instance, the measurements that I
shall point out must in general be understood, as applying to the
foetus in its naturally curved position, that is, the space extending
from the occifiut to the coccyx; and I believe this diameter never
exceeds eighteen or twenty lines before the end of the second month.

508. The skin of the human embryo has no real existence until
at a pretty advanced period of its growth, while the sort of circle
which it at first constitutes, is nothing more than a homogeneous
gelatinous substance of slight consistency; the epidermis cannot be
distinguished from the skin until after the second month.

509. At three months the teguments are distinct, but still gelati-
nous and of a rose color. The eye-lids and mouth remain shut,
the nose is very projecting, the head very large; the costal arches
and bones of the fore-arm are visible through the transparent sub-
stances in which they are enclosed. The fingers and toes are per-
fectly distinct, and covered on the dorsal surface of their extremities
with a reddish plate which possesses the shape of the nail; from the
vertex to the coccyx the fostus is three inches in length.

510. At four months the skin is much firmer, and at certain
points is furnished with adipose granulations. The head begins to
be covered with down; the scrotum, or the greater and lesser labia
are formed; the anus is open; and if in the measurement we comprise
the lower extremities, which, notwithstanding the common opinion
to the contrary, are as long as the thoracic members, the foetus
will be from five to six inches in length.

511. At Jive months a little down and some particles of seba-
ceous matter are observable upon various portions of the skin; the
hairs begin to grow, but are still white, or without any determinate
color. The teguments are less transparent, although still of a rose

200 THE FCETUS.

color, and but slightly extensible; the nails are evident; the umbili-
cal cord far removed from the penis or clitoris. No pupil can be
distinguished, and the foetus is from six to seven inches long.

512. At six months, the period of viabilite, the down and the
sebaceous deposit are visible, at least in the axillae and groins. The
hairs of the head may be easily distinguished from those that grow
upon other parts of the body; the eyelids are no longer transparent;
it has been said that there is at this period no pupil; but it has ap-
peared to me, on the contrary, to be extremely large; the xiphoid
cartilage occupies the middle of the great axis of the foetus, whose
whole length is from eight to nine inches.

513. A.t seven months the hair is longer, and not so pale, the
down and cutaneous induitus more generally diffused; the skin is
less colored; the nails are large; the raembrana pupillaris bursts,
according to the authors; but it is by no means certain that this
membrane really exists in the manner usually understood: I have
reason to think that the iris originates at first as a simple ring, which
grows concentrically, so as at least to leave the opening commonly
called pupil or apple of the eye. The navel is still below the middle
of the foetus; the external genital organs are all apparent, except the
testicles in the male, and the foetus is about ten inches long.

514. At eight months the foetus is only distinguished by its greater
maturity; its length is about eleven inches. Its hair is more or less
colored; its skin, covered with sebaceous matter and down, is thick,
and not so smooth as before; the lower jaw, which at first was very
short, is now almost as long as the upper one, and the nails exhibit
a certain degree of consistency.

515. M term. The development and weight of a well formed
foetus, at term, are far from being alike in all cases. The knowledge
of them, however, even if approximative, is so important in the
practice of midwifery, that their extremes and average ought to be
sought for with great care. At this period, the length of the occipito-
coccygeal diameter is twelve inches, but the average length of a
foetus straightened out and taken from the heel to the vertex, is
eighteen inches, according to the very multiplied experiments of
professor Chaussier; seventeen, sixteen, nineteen, twenty, and even
twenty-two inches, are also pretty common measurements, but it is
rare to meet with only twelve inches, or to find twenty-three. The
instances of children twenty-six, twenty-eight, thirty, and even thirty-
six inches in length, or of only ten, eight, or even six inches, which
we find in old scientific collections, instances which the common
people always receive with cordiality, may be boldly classed among
other popular stories.

THE FCETUS. 201

516. The weight of a foetus is generally six pounds, frequently
six and a half or seven, sometimes eight, and rarely nine or ten
pounds. Among four thousand children, born at the Maternite at
Paris in a given time, Madame Lachapelle never met with one
weighing as much as twelve pounds. Baudelocque, who had a case
where the child weighed twelve pounds and three quarters, main-
tains that it is incredible that a larger one was ever seen; the weight
of the child also, according to Chaussier, is frequently only five,
four, and sometimes three, or two and a half pounds; but in the
latter instances, it seems to me evident that pregnancy had not
reached its full term.

517. Out of the profession, we daily hear of children weighing
fifteen, eighteen, twenty, twenty-five, and even thirty pounds at birth:
those stories too, which may be found in many authors of the six-
teenth, seventeenth, and even of the eighteenth century, are owing
to the fact, that persons who will not take the trouble to weigh such
children, very easily attribute a weight of twelve or fifteen pounds to
children that actually weigh only seven or eight. In fact, a new
born child of eight or nine pounds is enormous; the persons sur-
rounding the lying-in woman, when they see such an one, rarely fail
to cry out that it is a child of twelve or fifteen pounds; and it is
very likely that, in order to render the fact still more curious, four or
five pounds will be added to its weight after the fifth or sixth repeti-
tion of the story. In order to reduce such fables, which are founded
upon gross errors of observation, to their real value, it is only neces-
sary to reflect that thirty pounds is the weight of children of from
two to three years of age.*

518. If the absolute length of the foetus is subject to such great
varieties, it is easy to conceive that the relative length of difiierent
parts of it cannot be more precise and determinate. Nevertheless,
we are sometimes obliged in medical jurisprudence to have recourse
to it in order to determine the age of a given foetus. According to
Chaussier, taking eighteen inches as a mean term, there are ten
inches and four lines from the vertex to the navel, and seven inches
eight lines from the navel to the sole of the foot; eleven inches nine
lines from the pubis to the vertex; six inches three lines from the
pubis to the sole of the foot; two inches three lines from the clavicle

* Nevertheless, I beg leave to affirm, that new-born children weighing 10
pounds are by no means rare in the United States. I have weighed many at 11^
pounds and several at 12 pounds. A few years since a lady in this city gave
birth to a child of 13^ pounds, carefully weighed by me. She died a few days
afterwards with puerperal fever. I have already noted a case of twins the sum
of whose weight was I62 pounds. — M.

18*

2p3 THE FCETUS.

to the lower end of the sternum, and six inches from the extremity
of the sternum to the pubis. From the top of one acromion to the
other we find four inches and a half, which may be easily reduced
to three inches and a half by squeezing the shoulders together.
The greatest antero-posterior thickness of the thorax is four inches
and a half, while there are only three inches from one crista of the
ilium to the other.

§. IV. Of the Foetal Head, at Term.

519. The head, being of all parts of the foetus, the largest and
most incompressible, ought to be studied with the most particular
care. The bones of which it is composed, its articulations, its
diameters, its motions, and the degree of reduction it is susceptible
of, ought to be perfectly known to the practitioner who desires not
to be more dangerous than useful in applying the assistance of the
art to cases of dystocia. It is composed, as in the adult, of the
cranium, which is its most interesting part, and of the face, which is
as yet but little developed, and whose pieces consist of the ossa nasi,
the ossa malarum, the ossa raaxillaria superiora, the ossa unguis,
the ossa palati, the ossa spongiosa inferiora, the vomer, and the os
maxillare.

520. Form. The head of the foetus, chiefly remarkable from the
flexibility of its vault, exhibits in its ensemble the form of an oval,
the attitude of which has occasioned a sort of literary quarrel be-
tween MM. Capuron and Van Solingen: the former of these authors
insists that the large extremity of the head is turned backwards,
while the latter, who is also followed by M. Duges, places it, on the
contrary, in -front. If the external occipital protuberance occupies
the centre of the strait in labor, it is diflScult not to agree with the
Dutch accoucheur, that the large extremity of the oval is represented
by the face; but when we take hold of the head by the chin its large
extremity is undoubtedly to be found posteriorly. In this case, as
in many others, the dispute is rather about words than things; both
sides are right, and both are wrong in some respects. However,
by reflecting that all the diameters of the posterior part of the head
are three inches and a half in length, while the longest of those of
the face is only three inches at most, it will be evident that we ought
to adopt the opinion of our countryman, and say that the large ex-
tremity of the foetal head is formed by the occiput,

521. Diameters. The axes or diameters of the head are imagi-
nary lines, which pass through it in determinate directions. They
may be multiplied ad infinitum; but those only that are liable to be
placed in certain relations to tlie axes or diameters of the pelvis, de-

THE FOETUS. 203

serve our attention. I think that it is sufficient to describe seven;
1. The occipito-mental, five inches in length, extending from the
most projecting part of the occiput to the point of the chin, also
called the great or oblique diameter, and which M. Flamant de-
nominates the sur-occipito-mental ; 2. The occipito-frontal, about
four inches long, which extends from the occipital protuberance to
the forehead, and which is also called the straight or antero-posterior
diameter; 3. The bi-parietal, or transverse diameter, reaching from
one parietal protuberance to the other, and which is three inches and
a half ; 4. The bi-temporcd, or smallest diameter, measured from the
root of one zygomatic apophysis to the opposite one, and whose
length is two inches and a half; 5. The vertical or trachelo-breg-
matic, which passes through the head perpendicularly, descending
from the vertex to the anterior part of the occipital foramen, and is
about three inches and a half; 6. The fronto-rnental, or facial, whose
name sufficiently indicates its situation, and whose extent is three
inches; 7. Finally, the occipito-bregmatic, the most important of all,
whose posterior extremity is situated between the occipital protube-
rance and foramen magnum, and proceeds to terminate at the anterior
fontanelle; its length is nearly three inches and three quarters.

522. Circumferences. These various diameters are accompanied
with an equal number of circumferences, which should receive the
same names, and whose lengths are equally various: 1. The occipito-
mental or great circumference, which divides the head into two late-
ral halves exactly similar to each other, passes at the same time over
both extremities of the occipito-mental diameter, and which, when
multiplied by three, equals the length of the circumference, and also
over those of the fronto-mental, occipito-frontal, vertical, and occipito-
bregmatic; 2. The facial circumference, which passes over the fore-
head, the chin, and the cheeks; 3. The circumference of the vertical
diameter, which passes a little in front of the parietal protuberances,
and thus divides the head transversely; 4. That of the occipitofron-
tal diameter, which at the same time embraces the extremes of the
transverse diameter, and separates, horizontally, the vault from the
base of the cranium; 5. That of the occipito-bregmatic axis, which
is also the special circumference of the bi-parietal diameter, and the
most important of all, for in all natural labors it is found in relation
with the circle of the pelvic straits; 6, Finally, the circumference of
the bi-temporal or smallest diameter should pass also over both ends
of the vertical or occipito-bregmatic; its existence ought not to be ad-
mitted except in the greatest possible degree of reduction of the head;
a knowledge of it then becomes of the highest practical interest, for
by comparing its line of tension, that is to say, its bi-teraporal axis

204 THE FCETUS.

with the vitiated diameters of the pelvis through which the child has
to pass, we can ascertain whether delivery will be practicable or not.

523. Varieties. It is not necessary for me to observe that these
measurements should be taken merely as mean terras, and that there
is no more uniformity in the size of the foetal head than in the other
parts of the body; but I ought not to fail to remark, that they are
susceptible of various degrees of reduction or elongation, whether
by means merely of the uterine contractions, or by the mechanical
action of the instruments that are sometimes employed in midwifery.
Thus the occipito-frontal diameter, when compressed at its extre-
mities, may be shortened several lines,' by the over-riding of the
corresponding edges of the frontal, parietal, and occipital bones.
The same is true of the transverse and occipito-bregmatic axes,
whenever the pressure bears chiefly on the two opposite points of
their circumference; but in order to form a clear idea of the changes
that the head may undergo in this regard, it is indispensably neces-
sary to obtain correct notions as to the arrangement of the bones of
the head at birth.

524. Bones of the skull. In the foetus at term, the eight bones
of the skull, the frontal, occipital, the t7X)0 parietal, the tivo tem-
poral, the sphenoid, and ethmoid bones are far from possessing the
same firmness as those of the adult; those of the vault are still quite
flexible, and separated from each other by membranous spaces of
greater or less size; the frontal is formed of two symmetrical pieces;
the thin or flattened portion of the occipital and the squamous portion
of the temporal are pretty frequendy separate from the petrous and
condyloid portions respectively; the basilar apophysis, the body of
the sphenoid; the petrous portion of the temporal, and the several
pieces which constitute the base of the cranium, are on the contrary
almost completely ossified, or at least form with the cartilages which
unite them an incompressible mass.

525. From the above arrangement it follows, 1. That the diame-
ters of the vault of the cranium alone are reducible in labor; 2.
That whenever the diameters of the pelvis are smaller than those of
the base of the foetal skull, delivery is physically impossible without
the aid of art; 3. That in this way the medulla oblongata, the
pons varolii, the tubercula quadrigemina, and the peduncles of the
cerebrum and cerebellum, are completely protected, while the cere-
bral and cerebellar lobes, which are almost unconnected with the
maintenance of the vegetative life of the foetus, are alone liable to be
slightly compressed.

The numberless varieties of which the dimensions of the head are
susceptible has long since convinced accoucheurs of the necessity

THE FCETUS. 205

of discovering some means by which to ascertain what they are in
the foetus while still contained within the maternal organs; but it must
be confessed, notwithstanding M. Flaraant's opinion, that all attempts
of the sort have been hitherto fruitless. But while I release the
reader from a tedious description or even enumeration of all the
different methods that have been proposed at various periods, it
seems indispensably necessary for me to say a few words on the re-
searches of one of my former fellow students upon this subject.

526. Mensuration. By measuring a certain number of dried
heads, M. Fouilhoux ascertained, 1. That a line drawn from the
fronto-nasal suture to the edge of the upper alveoles, represents,
very nearly, one half of another line, drawn from the superior angle
to the great foramen of the occipital bone; 2. That the space be-
tween the fronto-nasal and fronto-parietal sutures is equal to that
which extends from the posterior edge of the coronal, and the point
of the occipital; 3. That by adding five or six lines to the occipital
arch we obtain the length of the sagittal suture; 4. That the bi-
parietal diameter is six lines longer than the sagittal suture; 5. That
the facial line multiplied by three also gives the length of the trans-
verse diameter; 6. That the occipito-frontal diameter exceeds the bi-
parietal by nine lines. So that if we can succeed during labor in
measuring, with any degree of precision, either the fronto-maxillary
line, or the naso-parietal arch, or the occipital arch, or lastly, the
sagittal suture, it is afterwards easy to determine the antero-posterior
and transverse diameters of the cranium.

527. The assertions of M. Fouilhoux, subjected to pretty nume-
rous experimental tests, have appeared to me to be, in general,
correct; but I have also found that the proportional differences
which he endeavors to establish are too variable to admit of their
being very usefully employed in practice. Even were they to prove
constantly and rigorously correct, how shall we ever be able to dis-
tinguish through the soft parts, and within the maternal organs, the
precise length of the occipital arch, or the frontal arch, or even the
facial line? The thing appears to me to be impossible.

528. The sutures of the fostal cranium are more numerous, more
moveable, and wider than those of the adult. As they, together
with the fontanels, serve to mark the positions of the head, it is
very important for the accoucheur to have them always present to
his memory.

The sagittal, straight, or antero-posterior suture extends from
the root of the nose to the superior angle of the occipital bone, and
may be divided into two portions, the naso-parietal, which unites
the two pieces of the frontal bone, and the parietal portion, which

206 THE FCETUS.

is formed by the conjunction of the two parietal bones at their supe-
rior edges. The fronto-parictal, coronal, transverse or anterior
suture crosses the one above mentioned at right angles, at the place
where its two halves unite. The occipito-parietal, lambdoidal, pos-
terior or occipital suture seems to be only a bifurcation of the
sagittal: as the squamous, or temporo-parietal sutures are con-
cealed under a thick layer of soft parts, they hardly deserve to be
mentioned in a work on midwifery.

529. The lambdoidal suture, so called from its resemblance to
the Greek A is perhaps the most frequent cause of error, as it may
be mistaken for the fron to- parietal. It differs from it, however, be-
cause its iwo branches, which are oblique to each other and to the
sagittal suture, really form two distinct and independent sutures, while
the two moieties of the anterior suture are only continuations of each
other, and constitute but one and the same line.

530. There are usually found at the points where these sutures
cross or terminate, certain membranous spaces called fontanels or
fountains of the brain.

The anterior or frontal fontanel, which is sometimes called the
bregmatic fontanel, because it in fact answers to the bregma, forms
the common point of union of four bony angles, viz. the superior angles
of the two portions of the frontal bones, and the two antero-superior
angles of the parietal bones; it is larger or smaller accordingly as these
angles are sharper or rounder; it is of a lozenge shape, and generally
extends much farther between the two portions of the coronal than
of the parietal bones.

The posterior, or occipital fontanel, which forms a part of the
summit of the head, is situated at the spot where the sagittal loses
itself in the lambdoidal suture; it is always very narrow, and in
some subjects scarcely distinguishable; its triangular shape pre-
vents it from being mistaken for the one before mentioned; but as
a middle suture sometimes divides the occipital bone into two
pieces, and as the superior angle of this bone is sometimes wanting,
it must be remembered that only three branches issue from this fon-
tanel, or if there should be four, the two lateral branches proceed
obliquely towards the mastoid processes, and do not cross the other
at right angles, as is the case at the anterior fontanel. This is the
most important fontanel, since it indicates the presence of the sum-
mit of tbe head.

The inferior or lateral fontanels, four in number, two on each
side, are found at the points of termination of the anterior and pos-
terior sutures, and are of no use in the practice of midwifery.

531. The head is further divided into five regions or ovals: one

THE FCETUS. 207

superior, in which is to be observed, the summit behind, the bregma
and sinciput in front, the vertex in the middle, and which is bound-
ed below by the occipito-frontal circumference; another, inferior,
which is represented by the base of the cranium and posterior part
of the face; a third, anterior or facial, which is enclosed in the
fronto-mental circumference; the two last, lateral or temporal,
which comprise whatever is left out by the other, and whose dimen-
sions have reference, in labor, to those of the occipito-mental
diameter, which renders presentations of them highly disadvanta-
geous.

532. The articulation of the head with the vertebral column
merits the most serious attention; for want of a careful study of it
a vast number of accoucheurs and midwives bring children still born
into the world, who, a few minutes before, were strong and full of
vigor.

The union of the atlas with the occipital bone is a very close ar-
ticulation, which scarcely admits of any motion except flexion and
extension; that of the atlas with the axis is a rotatory ginglyraus,
so arranged, that if the pivot motion of the head is carried beyond
a quarter of a circle, the articular surfaces immediately separate
and the spinal marrow is at the same momeat compressed, torn, or,
even entirely broken off; so that, if the chin of the foetus turns so
far as to pass behind the point of the shoulder, death ensues im-
mediately. On the other hand, it is in the occipito-vertebral articu-
lation that we find the cause of the so frequent presentations of the
vertex rather than the face. In fact, when seen in an antero-poste-
rior direction, the head resting on the top of the spine represents
a lever of the third kind: during the efibrts of parturition, the power
being evidently represented by the vertebral column, the points of
rest and of resistance must necessarily be met with at the extremi-
ties of the occipito-mental diameter. Now, if the occiput almost
always descends first, while the chin descends but very rarely, it
depends upon the more advantageous action of the power upon the
occipital than upon the opposite extremity of this lever, the condyles
being nearer the former than the latter of these points.

§. V. Of the Attitude, and Position of the Foe-
tus during Pregnancy.

533. During the whole course of pregnancy the foetus is bent
forwards, so as to form a kind of circle, more or less complete; at
full term it is found with the head bent forwards, on the breast, the
feet turned up to the front part of the legs, the legs against the hind
part of the thighs, the thighs on the anterior surface of the abdo-

208 THE FCETUS.

men, the heels crossed and very near the ischia, the arms applied
to the sides of the thorax, the fore-arms bent, and crossed in front
of the sternum, as if to support the chin betwixt the two hands.
It therefore forms an oval mass whose large end is represented by
the pelvic extremity of the trunk, and its apex by the cephalic ex-
tremity. In this state its great or occipito-coccygeal diameter is
only ten or twelve inches in length, and may even be shortened one
or two inches by pressure exerted upon its two extremities.

534. It may be affirmed, in general, that the laws of gravity de-
termine the position of the foetus, until the last stage of gestation;
suspended in the centre of the ovum by means of the umbilical
cord,* loose and very moveable in the amniotic liquor, it necessarily
falls to the lowest point of the cavity in which it is contained; the
cord being inserted much nearer to the coccyx than to the occiput,
renders it necessary for the cephalic extremity of the foetus to fall
to the lowest part of the womb: therefore, since, even when the
woman is lying down, the neck is lower than the fundus of the
womb, it is clear that the head must naturally be turned towards
the superior strait in a great majority of cases, as is proved by daily
experience.

535. However, the ancients entertained a different opinion; ac-
cording to them, the foetus has its head upwards, the pelvic extremity
turned towards the margin of the pelvis, and the hinder part of
the breech resting against the sacro-vertebral angle, until about the
seventh month; then, by means of certain quick and somewhat
convulsive motions, it turns over, performing a somerset; so that
the forehead comes to take the place of the breech, and vice versa.
This hypothesis, generally adopted until the time of Baudelocque,
and since that period still defended by several authors, principally
in Germany, is now abandoned to the vulgar, who also are begin-
ning to give it up.

536. If a pregnant woman dies before the seventh month of ges-
tation, the head of the foetus is found turned towards the neck of the
uterus, just as it is at the full term. I have opened the bodies of
three women who died between the third and sixth months of their
pregnancy, and in these three cases the occiput was below. Who
has not seen the foetus come head foremost in abortion as at the
full period? From October 1823 to the month of April 1826,

* It is hardly correct to say that the fetus is suspended, &c. by means of the
umbilical cord: that cord is twenty inches in length; and as the whole length
of the womb is only twelve inches, it follows that the child is not suspended
by the cord. It is connected with its parent by it. — M.

THE FCETUS. 209

eight miscarriages of from four to seven months took place under
my care at tlie Hospital de Perfectionnement; I have observed nearly
the same number in my private practice, and at my public lying-in
ward: but in all these cases I found the breech presenting in only
two instances. Further, it is not uncommon to find the neck suffi-
ciently softened before the seventh month to permit the finger to
pass in so as to touch the naked ovum in the womb, and we almost
always find that the head is downwards. Another reason advanced
by the moderns as decisive, but which if taken singly would not ap-
pear to me to be very conclusive, is derived from the length of the
foetus, compared with the dimensions of the uterine cavity. It lias
been said, since the fcetus after the sixth month is from ten to
twelve inches long, it is physically impossible for it to turn after that
period in the cavity of the womb, whose transverse and antero-
posterior diameters do not exceed six or eight inches: no doubt;
but they forget that the foetus is doubled up in the amnios, and in-
stead of twelve, its long diameter is only six or eight inches long;
they also forget, that even at full term the child sometimes changes
its position during labor, and that even at the period of its greatest
development, the diameter passing from its occiput to the coccyx
does not always exceed the length of the horizontal diameter of the
womb.

It is not therefore correct to maintain that the proportional'
dimensions of the uterus and fostus raise an insurmountable barrier
to the somerset motion; if this transposition has no exsitence, it is
because the relative weight of the head renders it unnecessary.

§. VI. Of 8uperfoetatioii.

537. The name of superfoetation is given to the vivification of a
germ, in a woman who already contains a fecundated ovule in some
part of her generative system.

The existence and the possibility of this fact, admitted and denied
by turns by the physicians of all ages, constitutes a question upon
which modern naturalists have not as yet decided. The ancients
have handled it so slightly, that it is really useless to oppose them.
According to Aristotle, " cases of superfoetation have been seen in
women, and twelve foetuses have been seen to come away in a single
miscarriage in this manner. When the two fostuses have been pro-
duced soon after each other, they are born as if they had been twins,
as the poets tell us of Iphicles and Hercules." The philosopher
also cites, as an instance of superfoetation, a woman who brought
into the world two children, one resembling her husband and the
other her lover!
19

210 THE FCETUS.

538. Almost all the cases we have of superfetation seem to me
to be referable, 1. To twin pregnancies, in which one of the chil-
dren, having died long before the full term, has been preserved
within the membranes, not to be expelled until the other which con-
tinued to live; 2. To pregnancies of twins unequally developed or
born at different periods; 3. To cases of extra-uterine pregnancy,
which did not interfere with natural gestation; 4. Lastly, to cases
of double uterus.

539. Nothing is more common than to see, in compound preg-
nancy, one of the foetuses lose its life, and when born exhibit the
appearances of a foetus of from two to six months, although in fact
it is nine months old, and every body knows that most monsters are
met with in company with a well formed foetus.

A lady of la Varenne, near Tours, was brought to bed of a stout
boy in 1819; with the afterbirth, Mr. Mignot, her surgeon, received
another foetus enclosed within the same ovum, but without a head,
neck or arms.

A lady of the fauxbourg Saint-Germain was delivered in 1824 of a
vigorous and very stout child; Madame Forbet, the midwife, brought
me the afterbirth, and at some distance from the umbilical cord I
found, supported by a pedicle two inches in length, a fleshy mass,
in which were the evident remains of a foetus. In March 1827, M.
Baroilhet had the kindness to give me a monstrous product, which
possessed neither head nor members, and which was expelled to-
gether with a healthy foetus, &c.

In 1824, at the Hospital de Perfectionnement, I received at the
same time with a full grown foetus, a dead one, which as to develop-
ment had not passed beyond the third month. M. Defermont has
shown me a similar instance. In the month of October 1826, Ma-
dame Badinier, a midwife, brought me two foetuses, one of which,
quite deformed, appeared to be of about two months, and the other
of five or six; they had both escaped from the same ovum, and be-
fore the full term. Bauhin speaks of a woman who gave birth on the
same day to a foetus at term, and to an embryo as long as the finger,
both enclosed in a single envelop. Ruysch saw the wife of a sur-
geon of Amsterdam delivered, with an interval of two hours, of one
child, full of life, and of an embryo which could not have been of
more than three months growth, with its cord full of hydatids. Percy
speaks of a woman who, after giving birth to a small but lively boy,
brought forth, surrounded by a black fungous mass, a female foetus
of the fourth month, in a pretty good state of preservation. Lau-
rette, says Zacchias, was delivered, eight months after the death of
her husband, of a badly formed male child, which never gave any

SUPERF(ETATION. 211

signs of life. One month and one or two days after this she was
delivered of a second child, which was in good health, and which
lived.

And the authors conclude that these were cases of superfcetation !

540. 2d. When two foetuses are contained within the uterus, one
may grow more rapidly than the other; one may be expelled before
its full time, and the other not be born till some time afterwards, &c.

To this class belongs, if indeed there be not a good many belong-
ing to the same category, the case of a lady named Dupuis, at Saint-
Germain-en-Laye, who had a miscarriage at four months and a half,
and four months after that brought a healthy boy into the world;
the case which MM. Desgrange and Fodere look upon as decisive,
and in which B. Franquet was delivered of a healthy foetus five
months and sixteen days after she had miscarried of a seven months'
pregnancy; the case of Madame Bigaud, who on the 30th of April,
1748, brought forth a living male child, and notwithstanding that,
was delivered on the 17th of the following September of a second
foetus quite as strong and lively; another communicated by M. Rexain,
in which one of the children was born three months after the other;
those of M. Delmas of Rouen, of M. Pignot of Issoudun, of M.
Wendt of Breslaw, of Dr. Fahrenhost, &;c.

541. The two cases by B. Franquet and Madame Bigaud, the one
mentioned in the Recueil de la Societe de Medecine, in which it is
stated that a woman at Aries was delivered of a full grown child in
1796, and of another, also at full term, five months afterwards, in
1797; another by Dr. Stearns, in which a negro woman was de-
livered of a black child in about the eigiith month, and a few hours
afterwards of a white fostus of about four months, which exhibited
signs of life, are beyond dispute the most difficult to understand.
But as it is not impossible that they might at Lyons have supposed
a foetus to be seven months, when in fact it was not more than five
months old, while the one last born might have exceeded the ninth
month of gestation; and as they might have made the same mistake
at Strasburgh; and as the signatures of notaries do not constitute evi-
dence in such cases, we may be permitted to suspect that some error
has crept into these stories,

542. 3d. When an extra-uterine conception takes place, the womb
sometimes swells and becomes filled with concrescible matter, as in
an ordinary conception; in such a case superfcstation appears to be
impossible: but if the womb remains in the same state as before
fecundation, it is clear that a new conception may take place during
the existence of the first gestation. In support of these assertions,
I may refer to an instance of extra-uterine pregnancy which lasted

212 THE FCETUS.

for three years, during which time the woman conceived and brought
forth a well formed child; and another case for which we are in-
debted to M. Cliet, in which it is said, that in a woman who died
suddenly, one foetus was found behind the womb in the excavation
of the pelvis, and another in the cavity of the womb itself.

543. 4lh. When the womb is divided into two cavities by a perpen-
dicular septum, and these cavities open separately into the vagina,
it is evident that two germs may be fecundated at intervals more or
less remote; in a word, that superfcetation may take place. This
is the way in which the following fact ought to be understood, which
has been cited by M. Cassan, and collected by Madame Boivin: a
woman forty years of age was delivered of a little girl on the 15th
of March 1810; the cavity of the uterus, which was already con-
tracted, ivas examined without any thing being found in it; and
yet this woman, whose abdomen had remained pretty large, gave
birth to another child on the 12th of May of the same year.

544. We ought also to admit the existence, or at least the possi-
bility of another kind of superfcetation. A woman at Charleston
gave birth on the same day to twin children, one of which was black
and the other white, and accounted for it by stating that after leaving
the arms of her husband in the morning, one of his negroes, armed
with a pistol, came and compelled her to have connection with him.
A negro woman at Guadaloupe brought forth two full sized boys,
one a black and the other a mulatto, and confessed she had had
connection on the same evening with a negro and a white man.
Another negro woman had three children at a birth; one black, one
white and the third a cabre. A white servant girl in Montgomery
county brought into the world at the same lying-in a white girl and
a boy that was perfectly block. A negro and a white servant both
disappeared upon learning that the girl was pregnant. According
to M. Gardien, M. Valentin has related a case similar to the one
above. A mare foaled a colt and a young mule at an interval of a
quarter of an hour; she had been covered by a horse, and five days
after that by an ass.

545. Granting all possible authenticity to these observations, and
supposing their correctness to be demonstrated, the ideas of physio-
logists that prevail at the present day admit of their easy explana-
tion. Two ovules may become impregnated, one after the other, in
a woman who grants her favors to two or more men on the same
day or in the space of two or three days, that is to say, up to the
moment when the excitement of the first fruitful coition occasions
the eff'usion of that coagulable lymph in the cavity of the womb
which afterwards becomes the membrana caduca.

SUPERFCETATION. 213

546. Of two germs vivified by the same copulation, one may not
descend into the uterine cavity until a considerable time after the
other; the maturity of the two ovules may not have arrived at the
same degree of perfection at the instant of their union with the
principle furnished by the male; one of the germs may happen to
be disengaged with difficulty from the ovary, remain adhering to it
without growing with the same rapidity as its congener, and not
escape from the vesicle, nor pass into the tube until after a greater
or less lapse of time.

547. I am astonished that^modern physiologists, and even some
medico-jurists, among whom should be mentioned M. Orfila, have
admitted the existence of superfcetation up to the moment when the
ovule reaches the womb, while they deny the possibility of its occur-
ring after that period. It ought to be equally rejected in both cases.
The concrescible lymph or anhistous membrane is fully as capable
as the ovum itself of intercepting all contact between the seminal
principle of the male and that of the female. To conclude, super-
fcetation may take place; 1. In the case of extra-uterine pregnancy;
2. In that of a double uterus; 3. Where a woman has had com-
merce with two different men the on same day, or even at short in-
tervals with the same man; 4. and lastly, while the uterine cavity is
not filled with any substance, and the orifices of the tubes remain
perforate.

SECTION 2.
Functions of the Foetus.

§. I. Of the ]\ourishiueiit of the Fcetus.

548. Few questions in physiology have occupied so much of the
attention of the learned, as that of the nourishment of the foetus.
Different authors have by turns placed its source in the liquor amnii
and in the placenta, in the umbilical vesicle and in the ailantois, in
the gelatine of the cord, and in the caducous membrane.

549. What I have elsewhere (410) said of the anhistous mem-
brane and its fluid seems to me to prove at least that that tunic can-
not concur in the development of the ovum longer than during the
first fortnight of its existence: If Chaussier and some others have
entertained a different opinion, it is because they had acquired false
notions concerning the caduca, and its nature.

550. The gelatine of the cord, which by Warthon, Rouhault,
Lobstein and Beclard, has been supposed to play a part in the

19*

214 THE FCETUS.

matter, has no more to do with it than the caduca, and it is not true
that it becomes less abundant in quantity as the foetus grows larger.

The idea of making the foetus live upon the fluid with which it is
surrounded, is the most ancient of all, and apparemly the most na-
tural; it gives rise to two very distinct theories; by one the water of
the amnios is supposed to be swallowed and digested; according to
the other it is absorbed in various ways.

551. In order to prove that the water of the amnios serves for the
nourishment of the foetus, the old writers, particularly Harvey and
Diemerbroeck, have treated at great length on its nutritous qualities,
and on the lactescent matter which in their opinion it always con-
tains; later authors have relied upon the assertion that small animals
plunged in it live longer than they do when plunged in common
■water; on its being more abundant and fuller of nutritive principles,
in proportion as pregnancy is less advanced; on the diminished
power of absorption in the cutaneous surface of the foetus, as it ap-
proaches nearer to the full term; and on certain cases of foetuses
being born alive without any umbilical cord.

552. Without stopping to refute these various propositions one
by one, it may be remarked that previously to drawing practical con-
sequences from them, their correctness should have been ascertained;
but it has never been proved that the liquor amnii is more nutritious
at the beginning than at the close of pregnancy; or that the foetus
absorbs more at one time than another. As to the observations of
Van-der-wiell, of Dennis and Littre, on the absence of the umbilical
cord, and on the rupture and cicatrisation of its divided extremities,
they are too improbable, and accompanied with details far too vague
for them to deserve the least credit.

Nothing, positively nothing, warrants our believing with Alcmaeon,
Boerhave, Buff'on, and Van-den-Bosch, that the waters are taken
up by the cutaneous surface. The last author, it is true, tells us he
saw the lymphatic vessels full of a fluid resembling the water of the
amnios, and that they became fuller in the limb of a cow's fcBtus,
strongly bound round with a ligature and plunged in the liquor of
the membranes; but even admitting the experiment to be correct,
what conclusion can we draw from it? Are not the lymphatic ves-
sels habitually filled with serosity? Do they ever fail to become
distended when a mechanical obstruction prevents the free passage
of the blood through a part, or the whole of a limb?

553. Founding on the opinion of Hippocrates, of Harvey, Rud-
beck, (fcc, and on some facts of his own, Diemerbroeck maintains
that the fostus is nourished by the mouth. His reasons are, that the

NOURISHMENT OF THE FGETUS. 215

child's stomach is always filled with a lacteous matter; that there
are excrements in its buvvels; that immediately after birth, or pre-
viously to sucking, it frequently vomits a whitish fluid; that it sucks
a finger if put into its mouth, even while still within the sexual or-
gans; and that its stomach would not be able to perform its diges-
tive function immediately after parturition, if it were not previously
accustomed to it. If asked whence the foetus derives this nourish-
ment, he answers that it is at first from the seminal fluid, and sub-
sequently from the lacteous juice contained in the amnios.

Haller, Darwin, &c., add to the reasons of Diemerbroeck and
La Courvee, that the amniotic liquid has been found in the stomachs
of many foetuses; that in a pregnant cow that had been frozen, Heister
found the mouth, oesophagus and stomach of the foetus filled with an
icicle which was continuous with the waters; that many observers have
met with silky hairs in the meconium, and they conclude that all these
matters could not have got into tlie digestive passages by any other
means than deglutition.

More recently, this opinion has been strengthened by the case of
a foBtus in which the bowel was completely divided near the caecum
and contained meconium in the portion connected with the stomach,
wliile the larger intestine was almost completely obliterated; by an-
other case mentioned by M. Dubois, in which the alimentary canai
being contracted near the pylorus, contained meconium only in the
part above tlie contraction; and lastly, by the fact that Beclard
having colored the liquor amnii with ink, in a bitch that he ex-
perimented on, found some of it in the oesophagus and stomach of
the young.

554. None of these proofs are conclusive; most of them do not
even deserve to be seriously combated. The presence of hairs ia
the intestines, might, in fact, be explained in another way; but the
cases of that kind that have been reported are far from authentic.
To the facts noticed by MM. Desgranges and Dubois, may be op-
posed one published by M. Piet, and in which the intestine, though
separated from the stomach, is said to have been, nevertheless, filled
with meconium. I have myself dissected a foetus, at full term, whose
cesophagus upon reaching the diaphragm ended in a completely im-
pervious blind sac, notwithstanding which its colon was full of me-
conium. While enclosed in the membranes, the mouth of the foetus
is closely shut, at least until a pretty advanced stage of pregnancy:
to swallow, either by suction or deglutition, it should be able to per-
form the motions of inspiration and expiration, of elevation and de-
pression of the larynx. Acephalous and astomatous foetuses, and those
which come into the world with all the openings of the mucous

216 THE FCETUS.

membranes occluded, are not on that account less completely de-
veloped, and their alimentary canal, according to the reports of
certain observers, does not contain less of meconium or of hairs.
It does not necessarily follow from the circumstance that liquor

amnii has been found in the stomach, that the fcetus swallows and
.* . . .

is nourished by it; would it be right to infer that a swimmer natu-
rally drinks water, because we find some of it in the stomachs of
drowned persons? Finally, ought it not to be enough to decide for
ever the question as to the nutritive properties of the liquor amnii,
to observe, that Bartholin and M. Morlanne have seen the fostus
continue to live in the womb more than a month after the complete
evacuation of the waters.

555. It is therefore superfluous to inquire whether the water of
the amnios, after passing into the intestines, is simply absorbed from
them, as was thought by La Courvee to be the case, or whether, as
Diemerbroeck, Boerhaave and others pretend, it must undergo a
previous digestion in those organs; neither is it necessary to refute
M. Lobstein, who is not far from making it pass in, partly, by the
genital organs of the foetus; nor Osiander and MuUer, who make
out, that it is absorbed, then modified by the breasts, to be subse-
quently carried to the thymus gland and thoracic duct; nor, finally,
Schurigius, David, Roederer, Scheele, Winslow, Heroldt, Beclard
and M. Geoffroy Saint-Hilaire, who believe that it penetrates into
the trachea and bronchia, in order to be there elaborated, or serve
in some way for the purposes of the foetal nutrition.

Notwithstanding the importance attributed by some writers to the
water of the amnios, all the authors, except La Courvee and a few
others, have confessed that the placenta performs the principal part
in the nutrition of the foetus, at least during the latter half of the
period of gestation.

There are some who, with the ancients, suppose that the placenta,
by means of some peculiar lymphatics, takes up a milky juice, a
real chyle, for the purpose of modifying or transmitting it to the
organs of the fcetus.

556. Others have asserted that the placenta takes nothing from
the womb except the oxygen, that it performs the functions of a respi-
ratory organ, that it is the physiological lungs of the foetus, and that in
this view the uterine arteries represent, in some measure, the bronchia
and trachea. In a figurative sense these assertions are not wholly
without foundation, as I shall remark further on; but when taken in a
literal sense, as they have been by an infinite number of physiologists,
they become valueless.

557. A majority of writers maintain that the fcetus is nourished

NOURISHMFNT OF THE FCETUS. 217

and developed by blood furnished to it by the mother; this is another
disputed point: is it real blood, or only some of its principles?
Does it pass directly from the vessels of the mother into the circu-
latory system of the fcstus? Is it merely poured into the sinuses of
the placenta? Must it, or must it not be subjected to some prepa-
ratory elaboration before it reaches the placenta?

558. Galen, Aristotle, Vesalius, Columbus, Maurocordatus, Hil-
danus, Haller, and a majority of accoucheurs have been of opi-
nion that the blood passes directly from the mother to the fostus;
the partisans of this hypothesis, which has been combated in detail
by Diemerbroeck, rely upon the existence of vessels passing from
the womb to the placenta; on this latter body having been seen, as
by M. Ribes, to grow and live after the expulsion of the foetus; on
the circumstance, that the detachment of the placenta, whether
during pregnancy or after delivery, always gives rise to hemorrhagy;
that uterine hemorrhages cause the foetus to die exsanguious; oa
blood having been observed to flow from the placental end of the
cord so as to constitute a dangerous hemorrhage; on M. Magen-
die's having found the odor of champhor, and the colormg matter
of madder in the young of animals fed on those substances, on the
presence of large orifices observed by various authors on the internal
surface of the womb; on the fact, that the best mode of arresting
flooding is to compel the womb to contract: and above all, on the
passage of various substances, when injected in the uterine vessels;
into the organs of the foetus.

559. None of these reasons are demonstrative; we have seen,
above, that it was necessary to imagine the existence of vascular
anastomoses between the ovum and uterus: supposing the placenta
does sometimes remain adherent to the uterus, and continues to live,
that does not at all prove that there is a direct sanguine circulation
from one to the other; it is false to say that the detachment of the
placenta always occasions hemorrhage; and even if it were true, it
would no more militate in favor of than against the idea of im-
mediate anastomoses, for the blood in that case may just as well be
poured out by exhalation, as from ruptured vessels. If it be true
that the heart and vessels of the foetus are emptied of their blood
when the mother dies with hemorrhage, Wrisberg proves that the
contrary has been very often observed; besides, it does not follow,
because a child is born anemic after a uterine hemorrhage of several
weeks duration, that the blood passes unchanged to the cord, for if
the woman be for a long period anemic herself, it is very natural
that the fruit of her womb should also be feeble: further, it seems
to be forgotten that many of those heraorrhagies, as those that depend

218 THE FCETUS.

upon insertion of the placenta over the cervix, may come from the
vessels of the placenta, and consequently, from the foetus, as well as
from the mother. When blood flows from the uterine end of the
cord that has just been cut, it is not at all because the circulation
continues to go on from the womb to the placenta, but it is simply
owing to the contraction of the womb and of the vessels of the
placenta itself, and of the cord; it is the after-birth disgorging the
fluids it contained, and not new blood coming from the woman. The
presence in the foetal organs of medicinal or alimentary substances
taken by the mother, is explained by the laws of imbibition or by
absorption, quite as satisfactorily, as by an uninterrupted continuity
of the vascular systems of the ovum and uterus.

560. Still there are the anatomical injections: they have been in
vain attempted by Ruysch, Haller, &;c., but as a thousand negative
facts do not destroy a single positive one, these injections are con-
stantly appealed to in support of the hypotheses in question.

561. M. Dubois formerly exhibited to the Academy of Surgery,
a specimen he had prepared, and in which the injection passed into
the placenta, through what he denominated the placento-uterine
vessels; Chaussier succeeded in impelling Mercury into it; Beclard
and M. Duges have succeeded with colored oil. In the body of
of a pregnant woman prepared for examination, M. Deneux saw the
uterine sinuses completely filled with injection, and continuing
without any line of demarcation into the placental sinuses, which
were also filled with the same material. Mr. D. Williams has re-
cently performed some experiments, from which it appears that
linseed oil, injected into the aorta or hypogastric arteries, penetrates
into the organs of the foetus; and M. Biancini, who has performed
experiments on one woman who died whilst in labor, on another
Avho died in a week after delivery, and on a third who died with
flooding, as also on cats, rabbits and cabiais, assures us he obtained
the same results with size and with mercury, which he thinks,
answer better than oil; in addition to the utero-placental arteries,
the Italian physiologist describes a set of veins of a corresponding
character.

562. But it seems to me there is a strange misconception of the
value of such experiments. How happens it that they have not
been regarded as but little applicable to the explanation of what
takes place in the living female? How long has the passage of
foreign matters from one vessel to another proved incontestably
that the same thing takes place with the natural fluids during the
life of the individual?

563. When a pretty fine injection is thrown into the arteries of

NOURISHMENT OF THE FCETUS. 219

the belly, the matter readily escapes from the internal substance of
the intestines; when thrown into the vena portas, it returns not only
by the veins and the hepatic artery, but also through the excretory
bile ducts; when thrown into the emulgent artery, it soon passes
into the emulgent vein, as also into the pelvis of the kidney, and the
ureter. Notwithstanding the above, we do not conclude that the
blood during life is continually transuding into the alimentary canal,
nor that it passes from the vessels of the liver into the hepatic ducts
or from the kidneys into the tubili uriniferi and ureters; the oil,
glue and mercury employed by Chaussier, and Messrs. Williams and
Biancini, are of too penetrating a nature not to go wherever it
may be desired to send them; but whether the passage in question
does or does not take place, it will certainly never serve to resolve
the problem at issue.

564. Hunter and several modern physiologists expect to get rid
of the difficulty by admitting that the uterine sinuses pour their
blood into the sinuses, or interlobular anfractuosities of the placenta,
whence it is subsequently taken up by the numerous capillary ori-
fices of the umbilical vein. This hypothesis, although more specious
and rational than the preceding one, is not therefore less difficult
to adopt; without referring on this point to what I have already said
(478) concerning these pretended sinuses, and their adaptation, I
remark: 1. That such an arrangement cannot be admitted to take
place in extra-uterine pregnancies; 2. That until the second or
third month, the placenta being composed of merely agglomerated
filaments, there can be no sinuses betwixt its lobules; 3. That a
placenta, although attached upon a fibrous polypus, or upon some
indurated portion of the uterus, has nevertheless been found to sup-
ply all the materials required for the fcetal nutrition; 4. That I
have seen the uterine surface of the afterbirth hard, coriaceous,
and without any orifice throughout almost its whole extent, in women
who were delivered of children that, although weak indeed, were
nevertheless living; 5. That the large vessels of the womb, said to
be continuous with the vessels of the placenta, are, by the very parti-
sans of the doctrine, admitted to be veins; 6. That the uterine veins
being, like the veins of all other parts of the body, the vessels of a
convergent and not of a divergent circulation, as they should be, con-
sistently with the views of that party, it follows that they are pleased
to get venous and not arterial blood from the mother into the pla-
centa.

565. Should it be insisted upon that the foetus receives completely
elaborated blood from the mother, it could only be possible, at the
utmost, to say, as indeed it has been said, that that fluid enters the

220 THE FOETUS.

placenta, through simple pores, by a sort of imbibition which might
be explained by a mere contiguity of surfaces. To this I can only
object, that the blood, as such, does not appear to pass in any way
into the ovum. It certainly does not pass there at least in the early
periods; for the villous portions of the chorion do not contain ves-
sels until pretty late, and besides, its filaments are never hollow quite
to their extremities (475). On the other hand, both Autenreith's
and my own experiments demonstrate that the blood of the foetus
does not present the same aspect as that of the mother: it is at
first of a rose color: it then becomes redder, then blacker, and
does not exhibit any difference of color in the veins and arteries.
Tiedemann and others have found that it contains a much larger
proportion of serum than the blood of an adult, and is less coagulable;
in fine, every thing proves that its chemical composition is very dif-
ferent from that of the mother. Even although chemistry had not
been able to ascertain for us these differences, would it be right to
believe that this fluid need not have, like our aliment, a due relation
to the period of our life, whether extra or intra-uterine, and that the
blood of an adult woman would not be, in some sort, a poison to so
frail and delicate a being as the embryo, or foetus ? Were it worth
■whi'e to insist upon this point, I might add that according to the
microscopical observations of MM. Prevost and Dnmas, the blood-
globules are so small in the foetus, that it would be impossible for
those of the mother to pass through the same canals or same orifices
without destroying the equilibrium of all the functions, and producing
sudden death.

If, therefore, the blood is poured into the caverns of the placenta,
or taken up by the pores of that organ, it must at least undergo
some elaboration, some important modification before it reaches the
umbilical vein; but what is the nature of that modification? I know
not.

566. In conclusion, the nourishment of the ovum is dependent on
various sources; at first it is a mere vegetable, which imbibes the sur-
rounding moisture. The villi of its superficies, real cellular spon-
gioles, acquire, in the tube or in the womb, the nutritive principles
required for the development of the embryo vesicles; after which the
embryo is nourished after the manner of the chick in ovo, or rather
like the young plant, which is at first evolved at the expense of prin-
ciples contained in its cotyledons. It gradually exhausts the vitel-
line matter contained in the umbilical vesicle; the emulsive substance
of the reticulated body or allantois is also gradually absorbed. It
reaches the end of the second month; the vessels of the cord are
formed; the placenta soon begins to show itself, and suffices to keep

NOURISHMENT OF THE FCETUS. 22f

up the evolution of the foetus, by its contact, the spongy cake takes
up from the womb the elements of reparation, and operates on them,
forming a fluid more or less analogous to blood, which is then ab-
sorbed by the radicles of the umbilical vein. The placenta absorbs
in the uterus, so as to form the fluids of the fogfus, as the liver, the
kidney, the seminal gland, Sic, take up from their own vessels the
materials from which to form the bile, the urine the prolific liquor,
&c.; as trees and plants absorb from the ground the principles of the
numerous compounds they contain: and I see nothing in all these
actions very difiicult of comprehension.

§. n. Circulation of the Fcetus.

Whatever may be the manner in which blood or other fluids reach
the placenta, it is, notwithstanding, necessary for them afterwards
to traverse the various organs of the foetus for their noUlishment ;
however, their circulation does not in all respects resemble that
which takes place after the birth of the child.

567. In the adult, the septum that divides the two auricles of the •
heart is complete, and separates them from each other perfectly; in '
the fcetus, on the contrary, this septum has an opening through it,
called {he foramen ovale, which is largest in the early stages of preg-
nancy. Previously to birth, instead of two large trunks, the pulmor
nary artery furnishes only two small branches to the lungs; but it is
prolonged, under the name of the arterial canal {ductus arteriosus)
as far as to the aorta, into which it opens below the left subclavian
artery. The hypogastric branches of the primitive iliacs send only
small branches to the pelvic organs, which are as yet scarcely de-
veloped; but they rise along the sides of the bladder and urachus,
under the name of umbilical arteries, and proceed to the umbilical
ring and to the cord. Unlike the adult, the foetus also has an umbili-
cal vein, which, upon entering into the abdomen, proceeds back-
wards and upwards, and somewhat from left to right, so as to pass
into the longitudinal fissure of the liver, through which it passes, giv-
ing off" here and there a branch to the right and left lobes of the liver.
Having reached the under surface of the liver in the transverse fis-
sure, the umbilical vein divides into two trunks: one, which is called
the venous canal [ductus venosus), and which, like the ductus arte-
riosus, grows smaller and smaller as the term of gestation approaches,
appears to be a continuation of the primitive vein, and proceeds to
open into the trunk of the vena cava, below the diaphragm; the other,
which constitutes the right branch of the vena portae, penetrates into
the liver, where it at length anastomoses with the radicles of the he-
20

222 THE FCETUS.

patic veins, which, as in the adult, proceed to open into the vena
cava a little above the ductus venosus.

568. Course of the blood. From the above arrangement of the
circulatory organs, it is evident that the course of the fluids must be
much more complicated than in the adult. From the smaller branches
of the umbilical vein, the blood passes into the larger ones, and soon
afterwards into the great trunk of that vessel, it then passes along the
cord through the umbilicus, and divides beneath the liver into two prin-
cipal currents, one of which follows the venous canal so as to go and be
mixed with the blood of the inferior cava, while the other proceeds
along the umbilical branch of the vena portae, to be ramified in the
right lobe of the liver, and taken up by the hepatic veins, which pour
it into the trunk of the cava as it passes through the diaphragm.
There it forms three columns; that of the venous canal, that of the
hepatic veins, and that which is brought by the cava from the lower
half of the body, which unite, and together enter the right auricle,
thence passing through the foramen ovale into the left auricle; from
the latter, the blood falls into the corresponding ventricle, which
forces it along the aorta towards all parts of the body, but chiefly to
the head and upper extremities, by means of the brachio-cephalic
trunk, the left carotid, and the subclavian.

569. After losing among the tissues the nutritive principles with
which it was charged, the blood is brought back by the jugular and
the axillary veins to the subclavians, and thence to the superior cava,
which also receives that of the azygos; the superior cava carries it to
the right auricle, the auricle to the right ventricle, and the latter to
the pulmonary artery, which directs only two small columns of it
to the lungs, and causes the rest of it to pass through the arterial
duct to the descending aorta, where it meets with a part of what the
left ventricle had already expelled. That portion which reaches the
primitive iliacs is in part distributed to the lower extremities by the
external iliacs; but by far the largest portion of it returns along the
umbilical arteries, through the cord, and at last to the placenta, from
whence it set out.

570. In the heart. Haller, Wolf, Sabattier, MM. Portal, Riche-
rand, &c., supposed that the blood of the two venae cavae does not
mix at all in the right auricle, that that of the ascending or inferior
cava passes entirely to the left, and that of the superior cava entirely
into the right ventricle.

571. Bicliat was opposed to this view of the subject, and M.
Magendie does not adopt it; it is difficult, say they, to understand
how two columns of fluid can pass into the same cavity without being

CIRCULATION OF THE FCETUS. 223

mixed together; the two auricles contract simultaneously, and not
one after the other; it is not probable that the vivified blood fur-
nished by the umbilical vein passes wholly to the superior half of
the body, and that the venous blood alone is expended in the re-
maining moiety. But seeing that the vena cava inferior,.surmounted
by the Eustachian valve, seems to be continuous wUh the foramen
ovale, rather than to open merely into the right auricle, and that the
cava superior opens opposite to the orifice of the right ventricle, and
on a plane which is rather in front of the inferior cava, it appears to
me we may conceive that the blood of the two vessels may really
pass into the left auricle and left ventricle, without necessarily mixing.
The simultaneous contraction of the auricles does not seem to oppose
this transfer; the blood of the inferior cava does not pass through
the foramen ovale during the contraction of the organ, nor does that
of the superior cava get into the ventricle during that action; if they
are both full of fluid at the moment the systole commences, what is
to prevent their passing it, without mixing, into the corresponding
cardiac ventricle?

I believe, therefore, that Sabattier's theory is the best founded,
and that only a very small quantity of the blood poured into the right
auricle by the two cava? respectively is mixed there.

572. However, it must not be supposed that the head and limbs
receive none but the blood brought to the heart by the umbilical
vein and its branches, nor that the abdomen and inferior extremities
are nourished only by the blood of the superior cava; on the one
hand, it would be absurd to suppose that that which is driven by the
left ventricle into the arch of the aorta, passes on into the carotid
and subclavian arteries, without some of it descending along the
thoracic aorta; and on the other, even were that the case, this blood
is no longer as pure as it was on leaving the placenta, for it is neces-
sarily mixed with the venous blood of the lower extremities and
abdomen. Further, the blood that passes along the aorta descen-
dens is not merely the blood of the ductus arteriosus, but with it
also is mixed that of the inferior cava.

573. In the placenta. Some persons have supposed that tlie blood
brought back by the umbilical arteries is taken up by the uterine
veins, and proceeds to be revivified in the lungs of the mother, before
returning to the ovum; others have thought that only a portion of it
is absorbed, while the rest passes immediately into the capillaries of
the vein; that there is in some sense two circulations, one great cir-
culation, completely under the influence of the heart and lungs of
the mother, and one lesser circulation, the only one really belonging
to the foetus. What has been said above will, I think, suffice to

224 THE FCETUS.

cause such opinions to be appreciated at their just vakie; I shall
content myself with remarking here, that in order to admit of what
is called a great circulation, the pulsations of the foetal must be iso-
chronous with those of the maternal heart. But the mode of aus-
cultation introduced by M. Kergaradec proves, as it had indeed
been before remarked by Diemerbroeck, that there is no such iso-
chronism, and that the fcetal heart beats one half oftener than that
of a majority of women.

574. If it were true that the blood of the umbilical arteries is
poured as pretended, into the placental sinuses, it evidently would
mix with that of the uterine arteries, which, according to the same
theory, is also deposited therein; if so, we must be compelled to
believe that the absorbing mouths of the umbilical veins have the
faculty of choosing the arterial blood out of this mixture, while the
uterine veins take up only venous blood: such an idea is not to be de-
fended. Besides, as the matter of injection, even the coarsest, pass-
es with an astonishing facility from the arteries to the veins of the
placenta without being effused on its uterine surface, it appears tome
that we may with certainty conclude that the blood of the foetus is
not taken up by the womb.

575. This does not, however, imply that the blood from the arte-
ries re-enters the umbilical vein without undergoing any changes;
but rather, only that these changes, purely molecular, are effected
in the placenta itself. This elaboration is not the less undeniable
because its essence is not understood. It may be compared to that
which is effected after birth in the general capillary system; and to
that which occurs in the secretory organs, and in the lungs themselves.
The fluids of the ovum are brought into contact with those of the
mother, and at that instant a change of principles is effected between
them, as takes place in the bronchia between the atmospheric air
and the venous blood of the lungs; but here all our information is
limited.

576. In the liver. The truly enormous size of the liver during
the intra-uterine life, long ago gave rise to the supposition that it
was an organ of hematosis, or that it modified the blood in some
manner. M. Lobstein appears to be still of this opinion. Fourcroy
says that if this modification does take place, it must consist in a
kind of decarbonisation and dishydrogenisation. More recently
still, MM. Prevost and Dumas thought they had observed that the
first blood globules of the foetus appeared in the liver. If, says M.
Geoffroy de Saint Hilaire, the liver receives so great a quantity, and
exhibits such a considerable size, it is, that it may secrete a great
quantity of bile, which, being poured into the small intestine, occa-

CIRCULATION OF THE FCETUS. 225

sions the formation therein of an abundant quantity of mucus that
the foetus digests, and on which it grows. Finally, Dr Lee of Lon-
don has just performed some new experiments, whence it results that
the use of the liver is to secrete an abundant albuminous and nutri-
tive matter; that this substance fills the hepatic ducts, the duodenum
and small intestines; while in the stomach we find only an acid fluid,
and meconium in the large intestines.

577. Of these different uses, not one is matter of demonstration;
those indicated by Fourcroy, M. Lobstem and M. Geoff"roy, are even
based upon mere suppositions, that are easy to overthrow; and
although the theory of Dr Lee and Dr Front is supported by some
facts, it seems to be the dictate of prudence that we should wait
before we decide, and admit that at present we do not know what
influence is exerted by the liver on the foetal blood.

§. III. Of the Respiration of the FcBtiis.

578. Air being indispensable to respiration, it seems quite natural
that that function should have no existence in the foetus; but on the
other hand, as absorption of air or oxygen seems to be indispensable
to the maintenance of life in all organic beings, attempts have been
frequently made to prove that all animals respire during their foetal life.

571). As to the human species, it has been said that the placenta
receives oxygen from the blood of the mother at the same time that
its own parts with certain heterogeneous principles, as, for example,
a portion of its serum: this opinion, which is of an ancient date, has
been latterly defended by MM. Lobstein, Meckel, and Muller.

It is true, that in order to explain the changes undergone by the
blood in passing through the placenta, we may compare that work
to respiration, but to accept such a comparison in the very letter,
would be most strangely to wrest the analogies. The blood which
re-enters the umbilical vein is doubtless modified, but it is not red-
der than it is in the arteries; the change it has just experienced
does not therefore in the least resemble that which occurs in its
passage from the pulmonary arteries into the pulmonary veins of the
adult.

580. Some other persons, and particularly M. Geofl'roy de Saint
Hilaire, have admitted that the foetus absorbs air or a vivifying gas
from the whole surface of its body, by a kind of trachge like tliose
of insects, or even by the pulmonary passages, which might in such
case be compared to branchiae, and that it respires after the manner
of fishes; but I have already stated that the gas obtained by M. Las-
saigne in his first experiments was only a compound of carbonic acid
and azote.

20*

226 THE FCETUS.

581. Some, however, have persisted in maintaining that tlie Inng
exerts a certain action on the water of the amnios; that it separates
air or some other principle from it; in a word, that it exercises a
sort of respiration: on this subject reliance has been placed on
some researches made in Denmark by Scheele, Wiborg, Winslow,
Heroldt, &c. ; experiments that tend to prove that the liquor amnii
fills the trachea and bronchia of the foetus; on those of Beclard,
who saw the same thing; and further, that the young of a bitch, still
enclosed in the membranes, executed the motions of dilating and
contracting the alae nasi, and of the chest; lastly, on the fact that
the foetus has on more than one occasion been heard to cry while in
the mother's womb.

582. But it has been seen, farther back, what ought to be thought
of the presence of liquor amnii in the gastric or pulmonary passages
of the dead foetuses. De Buffon and Autenreith, who got the foetuses
of animals to live in that fluid; Wrisberg and Osiander, who have
both seen the human foetus live ten and fifteen minutes out of the
womb with the membranes unruptured, did not see the respiratory
movement mentioned by Beclard; I too had an opportunity, in 1825,
of witnessing a fact that was very curious, and well adapted to
illustrate this point; a woman at the Hospital de Perfectionnement,
and who said she was six complete months pregnant, was suddenly
delivered at five o'clock in the morning of the 23d of August; the
ovum, which came away whole, was received by M. Lafond a resident
student at the hospital. The specimen was immediately brought to
me, and I placed it in a large bowl of tepid water. The foetus did
not appear to be of more than five months and a half; I left the
membranes whole; I carefully examined the nose, the mouth, the
abdomen and thorax of the foetus, which continued to live in this way
for thirty six minutes, but I discovered no motion in the thorax,
except the slight throbbing occasioned by the action of the heart.
"We were also able to convince ourselves that the water of the amnios
had penetrated neither into the trachea nor the stomach.

583. Uterine vagitus. As to the cries generally known under
the title of vagitus uterinus, examples of it may be found in Albert
Legrand, Libavius, Solinus, Camerarius, Sennertus, Bartholin, Deu-
singius, "Vellhusius, Boyle, and Needham himself; but these ac-
counts being given only upon the hearsay of old women, do not de-
serve the trouble of being repeated. The subject has come up
again in our own day: Osiander affirms that he heard these cries
in two different women; M. Zitterland cites an instance of it which
he himself witnessed, after having taken all proper precautions to
avoid being deceived; MM. Henri and Jobert have observed the

RESPIRATION OF THE FOETUS. 227

same thing at Paris, in an incontestible manner, in 1825, accor(^ng
to the report of M. Marc; M. Hesse has related a fifth case; and
M. Lesauvage assures ns that he very distinctly heard the cries of
young puppies while still in their mother's belly.

584. When the membranes are ruptured and the watery discharged,
when the orifice is dilated, and the child's face engaged more or
less deeply in the excavation, we may conceive, indeed, that the foetus
might breathe and utter some cries before its complete expulsion;
but still the state of compression and constraint of the thorax ren-
ders the possibility of such an occurrence very doubtful; but when
the ovum is entire, as in the case given by M. Lesauvage, the fact is
so improbable, that we are not authorised to draw any conclusions
from it.

It is sometimes so difficult to avoid all the causes of error,
all subterfuges, not to be deceived by strange and unexpected
noises, such for example as are often produced by air in the
intestines, that before we admit as positive a phenomenon which
it is impossible to reconcile with the laws of physiology, the
same person should have ascertained its existence repeatedly; in
the mean time, I may say with Fontenelle, that, since learned and
credible men have heard it, I will believe it, but I should not believe
it if I had heard it myself.

585. Further, if the foetus really breathed; if air passes through
its lungs, they would be permeable and spongy, while at birth they
are, as is well known, quite compact, and as heavy as a slice of mus-
cular tissue.

§. IV. Of the \*iability of the Foetus.

586. The word viability, derived from via, is employed in medi-
cal jurisprudence to express the possibility of passing through the
various phases of' human life. To render a child viable, it should
possess at birth an aptitude to live independently of its mother;
from this definition it will be perceived that a foetus at term, as has
been remarked by M. Billard, may be born not viable, provided it be
affected with some faults of conformation, or with certain diseases,
as also that a foetus may be born viable although dead when passing
from its mother's womb.

At what stage of pregnancy is viability possible? Although
debated by accoucheurs and physicians in all ages and countries, this
question has continued until this moment undecided. The foetus
which according to some persons is viable at four months and a half,
does not, according to others, really enjoy viability until the seventh
month.

228 THE FCETUS.

587. The law having determined that a child born before the one
hundred and eightieth day after marriage may, if it is pronounced to
be viable, be disowned by the husband, implicitly declares that viabi-
lity commences with the seventh month. As a legislative measure,
this decision is extremely wise, and could not be more just; but it
does not by any means prove that a foetus is never viable before the
end of the sixth month, nor that it is always so at the commence-
ment of the seventh. The determination as to the viability of the
child ought to depend on the degree of perfection attained by the
fostal organs, and not on the stage of pregnancy. But, as the evo-
lution of the foetus is not always in the same ratio, it follows that an
eight months' fcetus may be less viable than one of seven months.

588. Should we refer on this head to the cases related by various
authors, we might have examples of children that were infinitely
small, of some born at four months or four months and a half, and
nevertheless became robust and vigorous men. Who is unacquainted
with the history of the celebrated Fortunio Liceti, related by Van
Swieten? His mother, frightened by the roughness of the sea while
passing from Reco to Rapallo, brought him into the world before
the sixth month of her pregnancy; he was not bigger than a hand;
his father had recourse to the heat of an oven to bring him up, and
notwithstanding all that, Fortunio lived to be seventy-nine years old.
An abortion, says Brousset, was born in 1748, at the fifth month of
pregnancy, and lived to the ninth month, without sucking, without
producing any excretion, or performing any other motion, save to
swallow a few drops of milk; but, four months after its birth, it sud-
denly cried, and sucked, and moved its limbs, so that at sixteen
months old it was stronger than children of that age commonly are.
To be sure, one ought really to have been, like Brousset, a witness
to such a miracle to be able to believe it. Thebesius also pretends
to have seen a foetus, born before the seventh month, which could
not cry until the ninth, but which was still very weak after the lapse
of a year. Pleissmann cites another such case, quite similar to that
of Brousset, except that the foetus was born at a more advanced stage
of the pregnancy. The daughter of P. Soranus, according to Car-
dan, came into the world at the sixth month: to nourish her they
were obliged to pour milk into her mouth by means of a funnel,
which did not prevent her from running a long career.* Millot, who,

* Spigelius speaks of a man who was born at the commencement of the sixth
month, and who was obliged to be kept wrapped up in cotton for more than six
weeks. Montus says that the cup-bearer of Henry III was born at five months;
Avicenna, Diemerbroeck, Vallcsius, and Men;^ speak of facts nearly similar» and
quite as authentic.

VIABILITY OF THE FCETUS. 220

In the matter of proof, does not seem to be very difficult, speaks of a
certain Julius Modie, born in the year V, at five months and a half,
and who was so small and weak that at first he could not suck at all.
This child, however, grew very well. Have we not also had, as
proof of anticipated viability, the history of the famous Bebe de
Nanci, who only weighed one pound at birth, whose first cradle was
a sabot, says the Count de Tressan, and of which there is a wax mo-
del in the caljinets of the school of Medicine at Paris. But I ask,
what conclusion can we draw from observations so imperfectly sub-
stantiated, from facts encompassed with so many marvels, and -cita-
tions so improbable.

589. While admitting with Chaussier, M. Orfila, and some others,
that none of the facts related by the authors demonstrate beyond
reply that the foetus is viable before the seventh, month, I cannot,
however, agree with them that the thing is impossible. A woman
came in 1825 to be delivered at my amphitheatre, after she had had
a fall; her last child was six months and three days old; she sup-
posed herself to be only five months gone with child, and if she had
had commerce with her husband fifteen or even twelve days after
her lying-in, it was at any rate impossible for her to have entered
on her seventh month. Now this woman brought into the world a
little girl that weighed two pounds, which beside presented all the
appearances of a fcetus of about five months, whose cries were so
weak they could scarcely be heard, who notwithstanding breathed,
and lived in this state for four days.

590. In the course of the same year, a young woman miscarried
at the Hospital de Perfectionnement; having been delivered of a child
at term five months and twelve days before, in the same hospital, it
was impossible for her to be more than five months pregnant. The
foetus she brought forth weighed only one pound and a quarter, its
skin was of a bright rose color, and had on it no down nor seba-
ceous matter; its length from the vertex to the sole of the foot was
only nine inches. Notwithstanding this, my attention and that of the
pupils was attracted to it by some stretchings and slight movements
of its limbs; we wrapped the delicate creature in cotton, and placed
it near its mother, who was told to pour a few drops of milk into its
mouth from time to time; but as she thought such an abortion could
not live, she did not judge it proper to do any thing to prevent it
from dying. It expired in fact the next morning, twenty-eight hours
after it was born.

591. My object is not by any means to maintain that these foetuses
were viable; I merely wish to show that it is not strictly correct to

230 THE FCETUS.

say in a positive manner, that a child born previously to the last three
months of the pregnancy must be reputed not viable.

592. A foetus is viable when sufficiently developed to move its
limbs, and when it really does move them; when it cries and breathes
freely; when its head is covered or begins to be covered with hair;
when its skin is no longer transparent, is covered with down and
coated with sabaceous matter; when the bones of the cranium touch
along the greater part of their edges, and the sutures "and fontanels
are consequently very much closed; when it passes off its meconium
and urine; when the proportions and dimensions of the different
parts of its body are not too far removed from what is observed in
foetuses at term: and not because it is exactly seven months old or
more. For the same reason it ought not to be declared not viable
because it is born before the three last months of gestation, but rather
because the absence of its cry, a respiration scarcely discernible,
very feeble motions, inability to take hold of the nipple or finger, to
void its meconium and urine, softness and separation of the bones of
the head, the absence or fewness of hairs, the transparency and red
color of its skin, the want of a sebaceous deposit, the thinness of
its nails, &c., prove that its organs are still far from the degree of
perfection necessary for the maintenance of its exterior life.

593. Hippocrates and many other physicians of antiquity taught
that the foetus is more viable at seven months than at eight. At first
view, such a proposition appears somewhat absurd; all other things
being equal, a fostus likely to live at the seventh month, will, a for-
tiori, be viable if not born until the eighth month. The very strong
movements of the fostus about the seventh month, and which gave
rise to a belief in the somerset, rendering premature delivery much
more common at that period than at any other, the ancients drew
from it the conclusion that the seventh month is a natural term of
pregnancy, and that if the foetus over-passes that, it could not be
born without danger until the end of the ninth month. It is difficult
to understand how they should have made a double mistake on this
subject, unless, with M. Dubois, we admit as a fact, that if labor
takes place in consequence of the lively agitation of the fostus, as
pretty often happens at the seventh month, the cervix dilating with
its accustomed gentleness and regularity, the child will be exposed
to less risk than if born at eight months, when delivery is provoked
by a fall or some other external accident. In the former case, in
fact, early parturition is in some sort natural, while in the latter, it
is only a kind of abortion.

VIABILITY OF THE FCETUS. 231

ARTICLE III.

Of Abnormal Expulsions of the Human Ovum.

SECTION 1.
Of Abortion.

594. When the expulsion of the ovum takes place within the first
six months of pregnancy, it is called an abortion, miscarriage, or
blessure.

According to Aristotle, " if the fostus comes away before the
seventh day after the conception, the accident is called a show; at
a later period, but before the fortieth day, the woman is said to be
wounded.'''' In the former case it is an efflux; according to Bonac-
ciolus, effluxiones, quae, intra diem seplimum; in the latter it is an
aborsus; aborsus qux primis mensis; or an abortus; abortus qux
intra quadragesimum. But these arbitrary and insignificant dis-
tinctions have been neglected for a century past, both by physicians
and accoucheurs.

595. Frequency. In twenty-one thousand nine hundred and sixty
cases of pregnancy, Madame Lachapelle informs us that she observed
one hundred and sixteen abortions. According to that author, mis-
carriages are more frequent at six months, then at five, then at three,
than at any other period of gestation. M. Desormeaux, in accord-
ance with almost all the ancient authors, with reason, and with my
own observation, thinks, on the contrary, that it is the more com-
mon as pregnancy is less advanced. If Madame Lachapelle men-
tions a diflerent result, it is evidently because abortion in the early
periods does not occasion so much inconvenience to women as to
cause ihem to go to the hospital; which is not the case after the
first half of pregnancy has been passed through; or perhaps because
in the first six weeks, the ovum and the embryo, frequently confound-
ed with clots of blood, occasion the woman to suppose that she has
only had a return of the menses, while at a later period she cannot
make such a mistake.

596. Morgagni was of opinion that he had noticed more abortions
of female than of male fostuses: M. Desormeaux is of the same way
of thinking, and says that if the vulgar think differently, it is owing
to the circumstance, that in the early stages it is very easy at a first
glance to mistake a girl for a boy. This remark, which had been

233 THE FCETUS.

previously made by Morgagni, is very just, provided it be applied
only to the first two or three months. Madame Lachapelle has seen
more female than male embryos, and more male than female foetuses.
Upon the vehole, abortions of females seem to exceed those of males
in proportion to the nearness to the period of conception; and if it
were true, as it is in Germany said to be, that the two sexes are at
first confounded, or that the creation of the female sex depends
merely upon an arrest of the growth of the genital organs, the female
abortion ought to be the only one at the early stage.

597. Causes. It appears that the causes of abortion have been
till lately but ill understood, and the labors of M. Desormeaux, of
Madame Lachapelle, of M. Duges and Madame Boivin could not
have come more opportunely to throw some light upon this matter.
They may be divided into remote and proximate causes; or into
efficient and determining causes. The proximate or efficient causes
are constituted by the contractions of the womb, assisted by the mus-
cular eflTorts of the woman; the determining causes may be divided
into predisposing and occasional.

The predisposiiig causes may be connected with the state of the
woman or of the ovum; relatively to the woman, some of them de-
pend on certain general dispositions of the economy, and others on
a special state of the sexual organs only.

598. General state. Women who are plethoric, who menstruate
abundantly and regularly, who are irritable, excessively sensitive,
nervous, hysterical, lymphatic, of a fair complexion, weakly, sickly,
who have large eyes and a bluish sclerotica; persons affected with
syphilis, scurvy, rickets; those who have a badly formed pelvis,
some organic lesion, or any chronic disease; those who are asthmatic,
dropsical, affected with cancer; those who are badly nourished, and
those who compress their bellies by lacing, or wear their clothes too
tight, miscarry more frequently than others: and the reason of it may
be easily conceived. Marshy and unhealthy countries; certain at-
mospheric constitutions, formerly mentioned by Hippocrates, and
frequently observed since his day, and which render abortions really
epidemic at some seasons; watchings, and fatiguing occupations are
also classed among the predisposing causes of miscarriages.

599. Affections of the sexual organs. On the part of the sexual
organs these are, all the chronic diseases to which they are subject,
adhesions, deformity, displacements; alterations, whether scirrhous,
eneephaloid, or hydatiform; sub-inflammation of the ovaries and all
the disorders that it occasions; organic alterations of the Fallopian
tubes; fibrous, polypous or other productions in the tissue of the
womb itself, or the neighboring parts; preternatural adhesions of

ABORTION. 233

the broad or round ligaments, or of the tubes or ovaries to the sur-
rounding parts, or to each other; chronic metritis and all its con-
sequences; anteversion and retroversion; scirrhus and cancer; trans-
formations and afTections of whatsoever nature; in fine, whatever
may interfere with the easy and regular enlargement of the womb
during pregnancy.

600. This genus of causes, formerly noticed by several authors,
amongst others by M. Delpech, has lately been well discussed by
Madame Boivin in a memoir ad hoc, which in fact deserves the at-
tention of every accoucheur; its mechanism and frequency may be
easily conceived of by reflecting on the affections that take place
in a multitude of women at the period of puberty, before or after
the occurrence of that revolution, and indeed at all periods of their
lives; afTeclions that are most generally occasioned by a material
lesion of some portion of the generative system; and do not com-
monly disappear without leaving behind them the indelible traces of
their existence. Sometimes it is a tumor in the excavation that
prevents the enlargement of the uterus; at others it is an ovary that
has degenerated or been transformed into a cyst, and become lodged
in the recto-vaginal fossa, a case of which came under my own no-
tice; sometimes the right tube is glued to the ligament of the left
ovary, and vice versa, and even, besides, so as to adhere behind the
cervix, of which I saw an instance in a woman who died when about
three months gone with child; more frequently, there are encepha-
loid and scirrhus masses, either occasioned by the pregnancy, or
whose germs existed previously to the conception, which, by affecting
the ovaries, the tubes, the pelvic peritoneum, or the substance itself
of the womb, oppose an invincible obstacle to the changes of structure
and dimensions indispensable in these organs for the completion of
gestation, of which I have collected pretty numerous examples, &c.

601. Leucorrhcea, hydrometry, irritability; too great a degree of
contractility; rigidity of the fibres and even of the vessels, and if we
may believe Hauenschild and Loder, of the peritoneum of the uterus;
and a laxity or atony of its neck, (on which M. Desormeaux rationally
insists,) are also admitted among the number of the predisposing
causes of abortion; but for the most part their action is far from
being so evident as the preceding. The same may be said of a want
of extensibility of the uterus, occasioned by a too great firmness of
its fibres, a firmness on which many authors lay so much stress.
According to their statements, abortion is to be feared because the
womb does not yield with facility to the effort which tends to dis-
tend it. In this respect their language, always similar to that of
the ancients, who supposed that the ovum acted mechanically upon

21

234 THE FCETUS.

the womb, would lead us to suppose that there is a sort of contest
between the containing and the contained; however, nothing of the
sort takes place: the womb enlarges in consequence of the unfolding
of its fibres, and the affluxion of fluids into its vessels; the ovum
ceases to grow as soon as the organ that contains it ceases to de-
velop itself, and abortion may follow as a consequence thereof, but
without our being able to accuse a distending power which it by
no means possesses.* By rigidity of the uterus we ought to under-
stand a want of disposition in it to imbibe, to soften and distend, in
consequence of the accumulation of fluids in the insterstices of its
tissue, and not any resistance it may oppose to the swelling of tlie
ovum.

602. Diseases of the ovum. The foundation of an abortion in a
majority of cases is laid in some peculiar disposition of the ovum
itself, and I am astonished that authors have paid so little attention
to this predisposing cause: like fruits that perish before they have
attained their full growth, and separate and fall at the slightest shake
of the branch on which they grow, so the embryo or the foetus in ani-
mals must become detached and soon afterwards expelled from the
womb when it has ceased to live.

603. The alterations capable of bringing about the death of the
foBtus are extremely numerous, and so much the more so, in pro-
portion as the pregnancy is advanced. Since I began to pay regu-
lar attention to the subject of embryology, I have carefully observed

* M. Velpeau asserts here that the growth of the womb depends upon the af-
fluxion of fluids into its vessels, and denies virtually, that the growth of the ovum
is the cause of that of the uterus. I do not pretend to know by what means the
liquor amnii is formed; but it is evident that the development of the foetus, and the
increase in quantity of the liquor of the amnios are the causes of the enlargement
of the organ that contains them; that that organ enlarges because of their en-
largement; and that it ceases to augment its capacity when they cease to increase
in bulk.

The womb contracts soon after the rupture of the ovum and discharge of the
waters. This contraction takes place at any period of pregnancy when the wa-
ters are broken — is not this evidence enough to show, or rather prove that the
womb depends for its increase, not upon a power inherent in its own tissues, but
upon an antagonist force, to wit, the force which augments the bulk of the child,
while it at the same time distends the membranes more and more by dailyaddi-
tions to the stock of liquor of the amnios?

I do not agree with M. Velpeau in the sentiment which he has expressed. I
prefer to regard the ovum as an independent existence; which, like a parasite,
draws its materials of subsistence from the surfaces to which it may be attached,
and which compels those surfaces to augment pari passu with its own necessities
as regards space, and surface for absorption. For an expression of my opinion
on this subject see the Philad. Pract. of Mid. p. 104. — M.

ABORTION. 235

one hundred and fifty products that had not gone beyond the term
of three months; now I can assert that of this number at least one
half were diseased.

604. Sometimes the disease commences in the membranes; the
chorion thickens, becomes opaque, and is covered with rugosities
on its internal surface; the granulations on its external surface
swell, and give birth to hydatids-in-bunches in the womb, and to
the hydatiform mole, which Madame Boivin erroneously regards as
a dependency on the amnios, &c.; the latter undergoes alterations
that are nearly similar, is disorganised, or contracts adhesions with
the surrounding parts; the placenta is not formed, or is irregularly
developed, is transformed into hydatic granulations, and becomes the
seat of all sorts of degenerations.

Sometimes, and perhaps most frequently, the disease attacks the
umbilical vesicle or its duct; in others it affects the cord or the em-
bryo itself, and in this respect the forms and degrees of the altera-
tions are exceedingly various.

605. Almost all the diseases to which the child is liable after
birth, may manifest themselves during its intra-uterine life. In an
embryo of two months I have seen adhesion of the whole length of
the members to the trunk, I have seen ulcerous destruction of the
head, belly, hand, &c. in subjects quite as young as the above-
mentioned; also, manifest alterations in the lungs, the liver, the peri-
toneum, and other parts of the body as early as the third month; I
have found the umbilical cord in a state of atrophy, and its vessels
either quite or almost obliterated, at every stage of its development.
In several specimens the umbilical vesicle was hard, and as it were,
stony; in others it was full of a clear limpid fluid, and in two cases
it was not of a natural size, nor had it the other appearances that
naturally belong to it. In some embryos the head alone was atro-
phied and deformed; in others the same state was observed in one
or more of the limbs, the breast or the belly; most commonly, the
atrophy, or the disorganisation is general, and in some cases the
embryo at last wholly disappears. In such instances the amnios is
most commonly destroyed also; I have many times found the ovum a
mere sac, filled with an albuminous, limpid and viscid fluid; I could
almost believe with Walter, Burns, Beclard, and M, Diiges that
such ova, composed merely of the caduca and chorion, had never
contained an embryo; that they might be compared to those eggs
without germs, that are laid by pullets, that have never been fecun-
dated by the cock; but as in several of them there were still to be
found the traces of an amnios, an umbilical cord, or of the foslus
itself, it was necessary to renounce such an idea at once.

236 THE FCETUS.

606. I have, besides, certain proof that most of the cases of mon-
strosity, even those which in our times are so complacently ac-
counted for on the theory of an arrest in the process of evolution,
are nothing more than the results of disease in some part of the
ovum; but I reserve the development of these assertions for another
work; let it suffice to remark in this place, that the human embryo,
a mere vegetable during the first months of pregnancy, is surrounded
with too many causes of destruction to be able always to resist them
successfully; that nothing ought to be more easy to ascertain than
the disease and even the death of a being whose existence is so frail
and precarious; and finally, whenever the ovum is diseased to such
an extent as to cause the death of the embryo, abortion is in some
measure one of its necessary consequences.

607. I will not, with Madame Lachapelle, say, that after the death
of the foetus, the womb becomes the seat of a congestion, because
the blood, which previously passed into the placenta, surcharges it
by stagnating in its vessels; nor that this embarrassment, definitely,
is the cause of abortion. Such a supposition does not appear to me
to be tenable, and I should not have alluded to it, had not M. De-
sormeaux seemed to lend it a new force by the strength of his au-
thority. As soon as the ovum ceases to live, it becomes only a
foreign body in the uterus; thenceforth the organism tends to
throw it off", as it does whatever interferes with its operations, as a
thorn for example, but not because the blood primarily destined
for the foetus is compelled to re-enter the torrent of the maternal
circulation.

601. Weakness of the foetus, its convulsive motions, the super-
abundance, or too small quantity of the liquor amnii, circumvolu-
tions of the cord around its neck, &c., knots in it, its shortness, its
excessive length, cysts, or any accumulations of fluids between the
membranes, effusions of various kinds, whether diffuse or circum-
scribed, in the substance of the placenta or caduca, are also causes
capable of bringing on abortion, but not inevitably, like the affec-
tions I spoke of just now.

609. Occasional causes. The predisposing causes alone would
very rarely fail to bring on the expulsion of the ovum; they in fact
frequently do produce it, and in these cases the abortion is said to
be spontaneous; however, it is almost always attributed to some
accident, some particular circumstance, which, in the eyes of the
public, and even of many physicians, passes as the only and principal
cause of it. The generality of people being unable to conceive, and
professional people having scarcely imagined that the principle of
abortion might reside in the ovum itself, it has followed that a thou-

ABORTION. 237

sand insignificant causes have by turns been brought to its explana-
tion; that the slightest actions, those capable of effecting the smallest
change in the economy, have been classed amongst its occasional
causes.

610. Such for example among others are yawning, pandiculation,
the act of going to stool, of voiding urine, of coughing, great ex-
ertions, disappointments, joy or grief, the odor of the snuff of a
candle, the impression of any strong odor whatever, an hysterical
fit, epilepsy, coitus, dancing, sleeplessness, diarrhoea, tenesmus, and
all tlie causes that might occasion uterine hemorrhage during
pregnancy.

611. I do not wish to be understood, however, that none of these
causes may give rise to abortion; but only, that without the ante-
cedent existence of one of the predisposing causes above enume-
rated, they would scarcely ever determine it, and that they most
commonly are merely coincidences. The same may be said of the
acute diseases of the woman, of asphyxia, of all sorts of inflamma-
tions, of crying, of singing, of the jolting of a carriage, of vomiting,
of the use of certain medicines, of falls, blows, violent motion of
what part of the body soever, of any thing that might shake or shock
the uterus.

612. It has been generally thought that these causes act by de-
taching the placenta; but when it is remembered that the ovum fills
the womb exactly, and is itself perfectly filled with the liquor amnii
and foetus, it is evident that motions impressed on the womb by ex-
ternal shocks are as incapable of separating the placenta from the
womb, or the chorion from the amnios, as they would be to separate
two bladders, one contained within the other, and the inner one full
of fluid; th6 most active and imprudent women, those who give
themselves up to the most violent exercises, do not on that account
fail, most generally, to go their full time; while many others are
found to abort in spite of the most minute precautions, and the most
persevering attention. A woman, says Mauriceau, who was seven
months gone with child, in order to escape from her chamber, which
was on fire, got out of a third story window; fear soon made
her let go her hold, and she fell on the stones, and fractured her
fore-arm, but her pregnancy was not disturbed. A young midwife
mentioned by Madame Lachapelle, who was pregnant, and affected
with deformed pelvis, threw herself from the top of a stair into a
deep cellar, with a view to bring on abortion, and thereby avoid the
Caesarian operation; she died a few days afterwards of her wounds,
but there was no abortion.

613. Medication. Bloodletting, baihs, emetics, purgatives and

21*

238 THE FCETUS.

emmenagogues also enjoy a great reputation among the women, as
abortives, which happily is but little deserved. Disease? are daily
met with in practice which require repeated bleedings, whether ge-
neral or local, and for which the tartar emetic is administered, as well
as drastic purgatives and other equally active substances, without the
pregnancy seeming to suffer from them. Mauriceau speaks of a
woman who was bled from the arm eighty-six times in one preg-
nancy, and who notwithstanding was at the end of it delivered of a
fine large child; he mentions another who was bled from the foot
ten times without experiencing any inconvenience. Delamotte has
seen the most powerful evacuants produce gastritis, enteritis, perito-
nitis and even death itself, without being followed by the expulsion
of the ovum. I had the care of a young person who, with a design
of concealing the proofs of her dishonor, had produced a violent
abdominal inflammation by taking medicines to promote abortion;
she died on the eighth day without any symptom of abortion having
appeared. I was consulted for another person, who had, with the
same view, taken fifteen grains of tartarised antimony; it produced
most violent efforts at vomiting, but the progress of the pregnancy
was not interrupted.

614. It ought not however to be concluded from the above facts that
bloodletting, particularly from the foot, or the application of leeches
to the vulva, or that baths too frequently repeated, &c., can never
be injurious to pregnant women; I merely wish to say, that except
in case of some peculiar predisposition, these measures most com-
monly produce no effect, and that they may be had recourse to if
circumstances require them, just as if the woman were not pregnant.

615. M. Desormeaux had already pointed out the fact that abor-
tion is frequently preceded by a state of irritative congestion of the
uterus, a general febrile excitement, the train of symptoms which
constitute the molimen hemorrhagicum. Very recently Madame La-
chapelle and M. Duges have strongly insisted on this condition to-
wards which, in fact, almost all the predisposing and occasional
causes of abortion tend, previously to bringing into play the con-
tractile powers of the womb; but it was an error to regard it as the
primitive cause of almost all miscarriages; it is commonly only a
secondary phenomenon, an effect of some other external or internal
cause, and not a necessary result of any of them; however, there are
some women who exhibit it in an evident manner at each menstrual
period throughout the wliole course of gestation; whence it follows,
that it may suffice to detach the ovum, especially within the first
three or four months, and that Klein, as approved by M. Desor-
meaux, Madame Lachapelle and M. Duges, had a right to say, that

ABORTION. 239

abortion is never more common than during the menstrual periods;
besides, it plays in this case the same part it does in the causation of
floodings.

61 G. Periodical abortion, or that which in the same woman recurs
at nearly the same period from conception, is one which appears
to be most evidently connected with a menstrual or spontaneous
molimen. It may, however, also depend on a special state of the
womb, either congenital or acquired; for example, upon the womb
being incapable of distension beyond a oertain degree. On this
point the influence of habit or hereditary constitution is commonly
referred to; the cases of many women are cited whose mothers were
subject to al)ortion, and never able to carry a foetus to full term.
Observation has proved that miscarriage is so much the more to
be apprehended in proportion as the individual has been previously
subject to it; the case is mentioned of a young girl who, having by
criminal methods several times procured abortion of her fostuses,
could never carry one to the full term after she became a married
woman.

617. The mechanical causes, or certain manceiivres, recommend-
ed by some authors, in cases of deformity of the pelvis, and which
in the midst of our refined society are also employed by degraded
wretches not less criminal than the unnatural women who are not
ashamed to submit to their disgusting ministrations, must be arranged
amongst the same class with emmenagogues and drastic purgatives.
Those who make use of them most frequently fail of attaining their
object, and succeed only in seriously injuring the womb. I once
prescribed for a female, in whom such attempts had brought on a
flooding which conducted her to the verge of the grave; she suffered
horribly from pain in the interior of the pelvis for two months, not-
withstanding^which abortion did not take place, and she is now a
prey to a large ulcer of the neck of the womb. I opened the body
of an unhappy creature who suffered from the like attempts, which
did not succeed any better than the one above mentioned. M. Gi-
rard of Lyons mentions a similar instance. Very recently, also,
(October 1828,) a young woman, who became pregnant against her
wishes, succeeded by such manoeuvres only in producing an oro-anic
lesion of the uterus, which, after frightful sufferings, led her to the
commission of suicide.

618, Signs. After protracted disease, and within the first two or
three months, the expulsion of the ovum is often effected without
being accompanied by any particular symptoms, and does not sen-
sibly differ from Wihat takes place at a somewhat painful menstrual

240 THE FOETUS.

period. But at a more advanced stage it can only give rise to the
ordinary phenomena of a natural labor; yet it is most commonly
preceded by lowness of spirits, a general depression, by lipolhymia,
syncope, a feeling of coldness in the epigastrium, palpitations, pale-
ness, fetid breath, flaccidity of the breasts, and a major part of the
rational signs indicative of the death of the fostus. Ordinarily, as
has been before remarked by Roderic a. Castro, MM. Fodere and
Desorraeaux, Madame Lachapelle and M. Diiges, the woman at first,
for one or more days, has rigors, horripilation, a hot skin, thirst,
want of appetite, increased movements of the heart and arteries, a
feeling of weight in the pelvis, about the fundament or loins, and a
general lassitude of the limbs, as if threatened with some severe dis-
ease; next appears hemorrhagy, accompanied with pain of greater or
less severity, and all the symptoms of real labor: but, amongst all
these signs, scarcely any, saving hemorrhage* and pain, afford any
certainty previously to the dilatation of the cervix, and the presence
of a portion of the ovum in the upper part of the vagina.

619. Hemorrhage itself is not invariably followed by abortion, as
is proved by the observations of Mauriceau, Raymond, de Boer,
&c.; nevertheless, there is good reason to fear it when that symptom
once takes place. But before we accord to it any value, we should
know how to distinguish it from the menstrual discharge, which
sometimes continues throughout the whole of pregnancy. I have
already at another place (312) hinted that this discrimination is at
the beginning very difficult, and must here repeat that this kind of
abnormal menstruation, to which Madame Lachapelle appears not to
give much faith, is notwithstanding not of very rare occurrence; I
could add two instances to those related by Portal, Deventer, A.mand,
Baudelocque, &;c., and I can affirm that in these two women the
catameniae had never occurred with greater regularity.

620. As to the pains, it is important that they should not be con-
founded with the colic, or with those uterine pains that are also

* A patient under my care lost in the fourth month, by uterine hemorrhage,
more than twenty ounces of blood in the course of one day and a half, notwith-
standing which, she continued to the end of the ninth month in tolerable health,
and then gave birth to a very healthy child. It is certainly a very rare case, to
meet with a patient who does not miscarry after losing four or five ounces of
blood, as early as the end of the fourth month.

I have now under my care a patient in the sixth month, who has had several
very considerable attacks of hemorrhage, and who has not been without more
or less of a show for two months past: the placenta is not near the cervix uteri,
and the child, as learned by auscultation, is in good health M.

ABORTION. 241

occasionally met with during menstruation; for this end, reference
should be made to the signs indicated in regard to the pains of
labor.

621. The discharge of a certain quantity of brownish matter, or
of serosity, the softening of the cervix, the rupture of the men-
branes, the formation of the bag of ivaters Avith pains extending
from the navel towards the excavation, constitute the most conclusive
signs of miscarriage; nevertheless, M. Desormeaux has known all
these signs to be present after a fall, and yet abortion did not ensue.
M. Morlanne relates the case of a woman who was not delivered
until six weeks after the discharge of the waters; there has also
been recently mentioned the case of a woman six months gone, in
which the bag of waters was formed, and then ruptured, so that the
arm of the child engaged in the vagina; after which the labor was
arrested, the foetus returned to its proper position, and the preg-
nancy proceeded in its natural course! The author of it saw and
felt: we must believe him.

622. The fluid that escapes from the cervix may besides come
from an hydatic cyst, or from between the membranes; in such a
case, it is very evident that the pregnancy might not be necessarily
disturbed; it may also proceed, in double pregnancy, from the rup-
ture of one ovum, while the other may not sufl'er the least alteration;
but with the exception of these anomalies, it appears evident that
the rupture of the membranes, followed by the discharge of the
•waters, positively indicates miscarriage, or at least the death of the
fostus, if it is not soon expelled.

623. The child having ceased to live, is generally soon thrown
out by the uterus; but in some cases, its expulsion does not take
place for a pretty considerable period. I have seen it not take place
until the twenty-eighth day in a woman who was seven months with
child. In another woman, the pregnancy, which was ascertained by
hallottement, and active motion of the fostus, suddenly stopped at six
months; all the signs of the death of the child supervened; the belly
gradually lost one half of its size; from this period eight months
elapsed; the cervix remains closed, and nothing indicates that mis-
carriage is about to take place soon. M. Prout gave me an oppor-
tunity of seeing a fostus of from three to four months, which was not
discharged for five months after the first symptoms of abortion, and
numerous authors have mentioned similar instances.

If the membranes are not broken, and the air does not get access
to their interior, the foetus may be preserved without change for
several months, or even several years, which has given rise, I -pre-
sume to the supposed pregnancies of fifteen, twenty, or thirty months

242 THE FCETUS.

duration, &c., that are spoken of in the scientific collections. This
occurrence is met with, particularly in compound pregnancy: one
of the foetuses dies at two or three months; the other continues to
grow; and at the lying-in, the practitioner is astonished to receive
both a full grown child and an abortion. I am in possession of a
great number of facts of this sort; MM. Bouvier, Colombe and
Defermont, have each communicated one to me, and many of the
instances of superfoetation that have been most insisted on, are no-
thing more than such as these.

At other times it is decomposed, putrefies, passes into the state
of adipocire, and then the pregnancy goes on as indicated when
we were upon the subject of extra-uterine pregnancy (363). In
the first months it may become atrophied, and when the ovum is
thrown off, only exhibit the dimensions of an embryo of four or five
weeks, although the woman was three or four months gone. It
may also dissolve in the waters, and then the ovum is found to be
transformed into a real mole. If the membranes give way, the
fcstus generally escapes first, and the membranes follow soon after-
wards. M. Trelat, however, has seen a case in which the foetus
was not discharged until twelve days after the expulsion of its in-
volucra.

624. Although the foetus may no longer be in the womb, its
coverings may still stick there by means of some adhesion, and con-
tinue to live and grow. The caducous membrane soon acquires
a considerable degree of thickness; the amnios disappears; the
cavity of the chorion by degrees contracts, and the mass comes at
last to be a reddish fleshy tumor, in the centre of which is most
commonly, but not always, found a small serous cavity. In this way
are formed most of the fleshy moles, or moles of generation. The
placenta may continue to grow alone, or it becomes infiltrated, and
when at last it is expelled, it exhibits no resemblance to its original
form or nature.

625. Sometimes the ovum comes away whole; indeed, this is
most frequently the case until the end of the second month; but
after this its size does not admit of its being so expelled, in a
majority of instances, and so much the less, as the gestation
is at a more advanced stage; however, I saw an ovum of full six
months expelled at the Hospital de Perfectionnement, which was
not in the least broken. M. Larrey sent me another of five months
and a half, which was also quite whole. In the first months of
pregnancy; instead of coming away with all its appendages, the foe-
tus is sometimes expelled with the amnios alone, or with its amnios
and chorion only.

ABORTION. 243

626. Prognosis. A miscarriage is generally more dangerous
than a labor at term, and those authors have erred who find fault
with Hippocrates for having uttered this opinion; the former is a
disease, while the latter is only the termination of a natural function.
But to speak correctly, abortion is sometimes not such a serious
matter in itself considered, but because the causes which induce it
and the accidents which accompany it generally constitute important
diseases; because the pregnancy, which is terminated by it, has re-
called to the genital organs the germ of affections whose existence
was not suspected, or which perhaps would have never reappeared
but for it. The prognosis ought therefore to vary according to cir-
cumstances. If it appears to draw in its train a variety of nervous
affections, pains in the hypogastrium, chronic inflammation of the
womb, ulcers, degenerations, and all sorts of organic lesions, it
frequently is so because these alterations existed previously to the
miscarriage itself; excepting always those cases of abortion produced
by the direct agency of mechanical causes.

627. The least dangerous abortion is that which is determined by
a disease of the ovum, and the most serious is that which a violent
occasional cause, unaided by any predisposing one, has given birth
to; moreover, all other things being equal, a spontaneous abortion
is less to be dreaded than a forced one, and in general, so much the
less, in proportion as it is effected with gentleness; the danger, which
for the woman is greater in proportion, to the degree of advance-
ment of the pregnancy, is, for the foetus, the same at all stages of the
gestation.

Where the cervix is naturally soft and relaxed, while the rest of
the womb retains its ordinary density, the miscarriage is both easier
and less serious to the woman than in the contrary circumstances;
when produced by a very decided molimen, if there are no compli-
cations, it may terminate as favorably as the most simple case of
parturition; but as this hemorrhagic effort is, most frequently, merely
the first degree or the symptom of a more or less extensive inflam-
mation, there is reason to fear, especially if fever attends it, either a
metritis, an acute peritonitis, or some other phlegmasia equally
dangerous. Some authors have contended that abortion may liave
its advantages, as for example, to render menstruation regular,
or restore fecundity; but it is evident from her miscarrying, that
the woman was not sterile; and besides, if the menses sometimes
resume llieir original type after an abortion, tliey would have done so
with more certainty after a complete pregnancy.

6J8. I can conceive of only one case in which abortion could be
of advantage by being frequently repeated, and that is where the

244 THE FCETUS.

womb is not sufficiently permeable, or too dense to dilate in pro-
portion to the wants of the ovum; then one miscarriage must ne-
cessarily diminish this abnormal rigidity a little; a second one dimi-
nishes it still more; and finally, a third or a fourth may completely
overcome it so as at last to render it possible for the woman to con-
duct the fostus to delivery at full term.

Treatment. The practitioner should turn his attention to the pre-
vention of miscarriage, for when it has once commenced, all he has
to do is to hasten its termination.

629. The preservative treatment must necessarily vary according
to the nature of the determining causes we have to remove or com-
bat: if the woman is irritable and very sensible, we must do all in
our power to protect her from moral commotions; she should be
kept out of large cities; travelling should be recommended to her
for change of scene, &c. Those who are weakly and lymphatic,
should follow an analeptic regimen, and keep quiet, or at least en-
gage only in agreeable exercise: in some cases a tonic medicine may
be administered. Should there be a disease of the uterus or of
some other organ, its nature should be carefully inquired into, so as
lo apply the suitable remedy. When signs of plethora or of con-
gestion are present, blood is to be taken from the arm, which may
be repeated once or oftener if circumstances require it, particularly
in women in whom each menstrual period is marked by an evident
molimen.

Bleeding is certainly one of the best means of preventing abor-
tion; but it would be dangerous to conclude with the vulgar, that
it is useful in all pregnancies indiscriminately; where no particular
circumstance calls for it, it may be injurious to pregnant women as
well as to other persons, and too much fault cannot be found with
the habit that some fall into of being bled once or twice during their
pregnancy without knowing whether there is any real need for it
or not.* *

630. As soon as the signs of abortion become manifest we ought
to act in the manner I shall point out in the article on uterine he-
morrhagies; in general the most absolute rest, horizontal posture,
cold acidulous drinks, external revulsives, applications of ice itself,

* Dr. Pliysick told me that he was accustomed to order an anodyne enema
every night at bed time for such of his patients as were prone to abortion. Fifty
drops of landanum and a wineglassful of flaxseed tea was thrown into the rec-
tum regularly at night, with a view to obviate any too great tendency to uterine'
contraction. I have in several instances happily succeeded in conducting tlie
woman to full term by this method of treatment — I have also sometimes found
it to fail.— M.

ABORTION. 245

and antispasmodics and composing medicines, if there is any agita-
tion and tendency to convulsions, will be successively tried; blood-
letting is still the most powerful resource to be made use of, but
nevertheless it is not to be employed without reserve and caution, for
as it does not always prevent miscarriage, it is liable to be charged
with the production of an accident which it was impossible for it to
prevent; bathing the feet and the hands, and the whole bath, should
be avoided while there is any hope remaining oC being able to avoid
the expulsion of the ovum; otherwise they may be used with ad-
vantage.

631. Where the hemorrhage is of an alarming character, we
have a precious resource in the tampon, which has been too much
neglected by the moderns; it not only often arrests flooding, but be-
sides this, it does not always hinder pregnancy from going to its full
term, as noticed by Gallandat; M. Desorraeaux and Madame Lacha-
pelle. Denman, Kok, and Kluyskens have spoken highly of its em-
ployment in such circumstances; and like M. Hervez de Chegoin
who makes frequent use of it, I for my part have nothing to say ex-
cept what is wholly in favor of its employment. Perhaps also the
ergot might be efficacious in such cases; but as it favors the ex-
pulsion of the ovum, it would not be prudent to make use of it until
after having tried all other means. Finally, when abortion is once
decided, it requires the same cares as hemorrhage, properly so
called, or as convulsions.

632. To promote the expulsion of the product of conception,
when the impossibility of retaining it in the womb is once ascertain-
ed, we continue the use of the same means; if the woman is strong
we recur to blood-letting; but rest and the horizontal posture are
less indispensable; baths and ergot may be administered without fear.
Opium administered internally if the pains are very strong; seda-
tive ointments, or ointment of belladonna applied to the cervix, if that
part is painful, an(^ in a state of spasmodic constriction; and emol-
lient injections into the vagina may be of use in some cases. If the
ovum is too long in passing through the cervix, it may be of advan-
tage to insert the finger into that part and thus assist in the expul-
sion; but we should not determine to remove it with the pinces a
faux germe of Levret, the placenta hook of Dewees,*'hor any other
instrument, unless there should be a pressing necessity to deliver
the woman at once, for we run the risk of not getting the whole
away, and of being unable subsequently to reach the remaining por-
tioiTs which could not be seized at first.

633. After the escape of the foetus, every thing returns to its na-
tural-state, just as it does after a lying-in. The deliverance of the •

22

246 THE FOETUS.

placenta, the milk fever, and the sequelae of the labor require the
same cares, particularly if the pregnancy have exceeded the fourth
month, and even in the first months, when the ovum comes away
whole; but if the membranes are left behind after the expulsion of
the foetus or embryo, as they compose the chief portion of the pro-
duct, the consequences do not always terminate at once; in such
cases we can never feel secure until after their complete expulsion,
and it would be wrong not to extract them as soon as it is possible
to seize them in the vaffina.*

SECTION 2.
Of the Term of Gestation, and of Retarded Births.

634. The natural duration of gestation in the human species is
generally nine months, or- rather two hundred and seventy days.
" Man only," says Aristotle, " is born at seven, eight, nine or ten
months; the last named period is the most common; sometimes,
however, pregnancy lasts until the commencement of the eleventh
month." According to Pliny, gestation may continue a whole year.
Riolan thought he had seen pregnancies of twelve, thirteen, four-
teen, fifteen, and even of eighteen months. Kiperus, according
to Millot, and Chanvalon pretend that the duration of pregnancy
varies according to climate. Heister thinks we may establish
that the term of nine months is the most ordinary one, and that
the time fixed by nature is that which elapses from the seventh to
the eleventh month. Sennertus thinks that every birth should be
deemed regular that happens within one year. Blancard, Hoff"-
mann, Mauriceau, Schenk, and De la Motte have related cases
confirmatory of the opinion of Heister. Levret contents himself
with advancing that the woman most- commonly carries the child
nine months, that many exceed that term, but that few go beyond
the tenth month.

635. In a cause that was pleaded by the celebrated lawyer Gerbier,
the duration of pregnancy suddenly gave rise to some very animated
discussions, about the middle of the last century.

Haller, Bertin, Lieutaud, A. Petit especially, and Lebas, Vicq-
d'Azyr, and Roussel, who were partisans of protracted pregnancy,
were vigorously opposed by Bouvart, Mahon, Hebenstreit, and
Louis. The latter author had no difficulty in demonstrating that
the numerous histories of protracted pregnancies mentioned by his

* See the article on Delivery of the Placenta.

DURATION OF PREGNANCY. 247

antagonists prove nothing in the present case, and that women scarcely
ever know the precise period at which they were fecundated; but he
was wrong to appeal to the immutability of the laws of nature, and
the necessity of not interfering with social order. " If," cried he
in his enthusiasm, " you add to the means women already possess
of deceiving those about them, the faculty of giving posthumous chil-
dren to their husbands whenever they choose, what will become of the
order of succession, and even of the entire social order?" As if, in
the natural sciences, we ought not to seek after truth rather than
concern ourselves about social conventions! On the other hand,
Petit and Lebas too complaisantly admitted as proved what was not
even in every instance probable; so that in spite of the numerous
analogies with which they fortified their opinions, the question re-
mained undecided both by naturalists and physicians.

636. At present the state of the case is changed; the antagonists
of Petit relied chiefly on the circumstance that, according to Aris-
totle, " the period of gestation in animals is limited to a fixed space,
and the term at which they bring forth is not subject to any varia-
tion." But as Buflfon had before pointed out, this assertion is wholly
false; Millot speaks of a cow which brought forth its calf five
days after the term, and of a cat that kittened nine days before the
regular period. Besides, M. Tessier, member of the Academy of
Sciences, a man whose honor and good faith cannot be called in
question, has removed all doubt upon this subject.

He found that, of one hundred and sixty cows, which commonly
carry their young nine months, as women do, only three brought
forth on the two hundred and seventieth day; that fifty of them
went from the two hundred and seventieth to the two hundred and
eightieth, sixty-eight from the two hundred and eightieth to the
two hundred and ninetieth; twenty to the three hundredth, and
that five of them did not calve until the three hundred and eighth
day, which is thirty-eight days beyond the term. On the other
hand, fourteen of them calved from the two hundred and forty-first
to the two hundred and sixty-sixth; so that we find sixty-seven
days betwixt the two extremes.

Of one hundred and two mares, whose term is eleven months,
three of them foaled on the three hundred and eleventh day; five
from the three hundred and tenth to the three hundred and thirtieth;
forty-seven from the three hundred and fortieth to the three hundred
and fiftieth; twenty-five from the three hundred and fiftieth to the
three hundred and sixtieth; twenty-one from the three hundred and
sixtieth to the three hundred and seventieth; and one on the three

248 THE FOETUS.

hundred and ninety-fourth day, which gives a latitude of eighty-three
days.

637. Thus, far from being fixed, the duration of pregnancy in
brutes is, on the contrary, extremely variable, and as the habits and
constitutions of women render them incomparably more liable to
impressions than any of the inferior species of animals, it is evident
they must be liable to the same irregularities. Besides, the follow-
ing proof taken in the human species, and admitting of no reply, is
related by M. Desormeaux. A lady, the mother of three children,
was seized with insanity in consequence of a severe fever, and all
the resources of hygiene and therapeutics had been exhausted upon
her case in vain; a physician thought that a new pregnancy might
perhaps restore her intellectual faculties. The husband consented
to note down in a register the day of each sexual union, which took
place only once every three months, so as not to interfere with any
still imperfect conception. Now, this lady who was watched by her
servants, and who was moreover endowed with very severe princi-
ples both of morality and religion, was not confined until the lapse
of nine months and a half.

Being agitated anew in a celebrated cause before the house of
Lords, at London, in 1825 and 1826, this question was decided in
the affirmative; but the physicians did not agree upon a fixed term
which must be always admitted. Out of twenty-five who were ex-
amined, seventeen said that pregnancy terminates about the thirty-
ninth or fortieth week, or betwixt the two hundred and seventieth
and the two hundred and eightieth day; but some of them did not
consider the case of Elizabeth Adderly, the wife of lord Hyde
Gardner, who was brought to bed on the three hundred and eleventh
day, as impossible. Dr. Blundell mentioned one pregnancy of two
hundred and eighty-seven days. Dr. Merriman said he had seen
several of two hundred and eighty-five, and two hundred and eighty-
seven days; two or three of two hundred and ninety-six, one of
three hundred and three, and one of three hundred and nine days.
Dr. Dewees relates one where the woman was not delivered until
the two hundred and ninety-third day, &c. To these testimonials
I may add a case which fell under my own notice. A woman in
her fourth pregnancy computed that she was four months gone
when she came to my amphitheatre. I distinctly felt both the active
and passive motions of the foetus. Appearances of labor took
place at the end of the ninth month, were soon suspended, did not
return for thirty days, languished a whole week, so that in fact the
delivery did not take place until the three hundred and tenth day.

DURATION OF PREGNANCY. 249

638. We may therefore conclude that tardy births are incontesta-
ble; but that in the present state of our knowledge it is not possi-
ble to affix to them any precise limits. Moreover, since the French
code, in order to do away any thing arbitrary in the decision on such
cases, has determined that the legitimacy of a birth may be con-
tested when it occurs after the three hundredth day, or the tenth
month, this point of physiology has lost much of its importance; for
at present what is essential for the physician to know is, whether a
child can or cannot remain longer than nine months in the womb.

SECTION 3,
Of Precocious or Early Births.

639. If fruits ripen sooner in certain climates and years than
others, if the appearance of flowers, if vegetation generally may be
more advanced; if the hatching of the chick varies from the nine-
teenth to the twenty-first day, or even from the eighteenth to the
twenty second; if some cats who carry their young only nine weeks,
may bring them forth nine days before their term ; if out of one
hundred and sixty-two cows, fourteen of them calve from the two
hundred and forty-first to the two hundred and sixty-sixth day; if
out of one hundred and two mares, six of them foal from the three
hundred and eleventh to the three hundred and twenty-sixth day,
while their natural term is three hundred and thirty days; if sows,
rabbits, &c., exhibit the same variety, wherefore may not the dura-
tion of human pregnancy be also advanced or abridged in the like
manner? I do not see that any thing reasonable can be objected
against the possibility of precocious or early births.

640. Every body knows that one foetus is sometimes better grown
and stronger at six months than another at seven or more; that a
child at term is sometimes not so stout nor tall as another which is
only of seven or eight months gestation; that on this point the de-
velopment of the ovum exhibits varieties that are' almost infinite ;
that the changes that take place in the organisation of the womb,
from the period of fecundation onwards, tend to develop it in a force
similar to that which directs the action of the muscles; that, except
in case of accidents, parturition is not effected until this force attains
such a degree as that the uterus may contract with the utmost force
of which it is susceptible; which necessarily takes place sooner or
later, according to an infinitude of circumstances; all these things are
known, I say, and shall any one dare to maintain that precocious
births are impossible !

22*

250

CHAPTER V.

Of Labor,

When gestation has passed through all the stages, when the ovum
has attained its last degree of maturity, and tlie organism of the foetus
is sufficiently perfect to anable it to live independently of the mother,
the birth of man takes place, and this is the phenomenon, the fifth of
the great function of reproduction, which is called labor.

It has been recommended at different times to replace the word
accouchement derived from ad and cubare, placed near to, by that
of parturition, derived from partus, partio, parturire, or by that of
child-birth, puerperium; but as custom cannot give place to a false
or erroneous acceptation, these different substitutes have not been
adopted.*

Definitions. Levret has defined labor as a natural operation, truly
mechanical, and susceptible of geometrical demonstration; which is
neither figuratively nor really true. Astruc, imbued with the same
notions, thought he could reduce the art of delivery to the solution
of the following problem: " An extensible cavity of a certain capa-
city being given, to extract therefrom a flexible body of a given
length and size, through an opening which is dilatable to a certain
extent." As if it were a matter of indifference whether the foetus
should be extracted artificially, or whether its expulsion should be
left to the powers of nature ! Bandelocque also has said that labor
is a purely mechanical operation, subjected to the laws of gravity
and motion; as if it were possible to make precise calculations of
organic actions, by reasoning upon the laws that govern the physical
■world! In asserting " that labor is nothing more than the passing
of the child and its appendages from the womb," M. Maygrier also
employs a faulty definition, inasmuch as it does not express the ac-
tion which occasions this passage. Neither is it correct to say with
Madame Boivin, that labor is the emission, expulsion, or excretion
of a living child at full term, together with its appendages, occasion-
ed by the contraction of the uterus, and the disposition of the genital

* la France.

OF LABOR. 251

organs of the mother. This definition, in the first place, is incon-
venient, in being too long; and then it comprises only natural labors,
and does not embrace either precocious or retarded births, nor cases
in which the child is dead in utero. According to M. Desormeaux,
who has properly felt the insufficiency of the principles of Levret,
Astruc and Baudelocque, " labor is a function which consists in
the expulsion of a fcetus from the womb, in which it grew during
the whole time of gestation." By substituting for the words opera-
tion and escape those of function and expulsion, this able practi-
tioner has rendered his definition incomparably better than any that
existed before. However, were it of any great consequence in prac-
tice to adopt one definition rather than another, I should prefer
simply to say, that labor is a function that consists in the expulsion
of the ovum from the mother'' s organs.

641. By making use of the word operation, physicians have gra-
dually become accustomed to see in labor a phenomenon almost
wholly foreign to the economy; and thence their eagerness to ter-
minate an action which did not require their assistance; by admit-
ting, on the contrary, that labor is a function, we feel ourselves natu-
rally prompted to let nature act, whom we assist, but whose place
we carefully abstain from taking, except in cases where we have
beforerhand ascertained with mathematical precision that the re-
sources of nature are incompetent.

642. Classification. Many plans have been proposed for the
classification of labors; Mauriceau, adopting the sentiment of Hip-
pocrates, calls those natural labors in which the child's head pre-
sents, and which terminates without assistance; all others he calls
preternatural. Peu makes use of the word laborious instead of
preternatural. De la Motte describes them as natural, non-natural,
preternatural and untoward. Soon afterwards were admitted, under
the title of natural labors, all those in which the head or the breech
presented; under that of laborious, those which, notwithstanding the
favorable position of the fcetus, are so long protracted that we are
obliged to assist them; all those were called preternatural in which
neither the head nor the breech presented to the strait. Smellie
modified this classification, and said, " I call that a natural labor in
which the head presents, and the woman is delivered by her pains
and the assistance commonly given: but should the case be so tedious
and lingering that we are obliged to use extraordinary force in
stretching the parts, extracting with the forceps, or (to save the
mother's life) in opening the head and delivering with the crotchet,
I distinguish it by the appellation of laborious: and in the preter-
natural, comprehend all those cases in which the child is brought

252 OF LABOR.

by the feet or the body delivered before the head." Smellie's divi-
sion, taught at the same time by Astruc, adopted by Solayres, and
propagated by Baudelocque, is still followed by a majority of French
accoucheurs.

643. There are few authors, however, who have not attempted to
show its incorrectness, and readily succeeded in doing so; but as
those which have been proposed as substitutes are not less incon-
venient, it has preserved at least the advantage of being more gene-
rally known than any other.

It would be quite as well to follow it, for example, as with Millot,
to admit of a division into natural labors, properly so called (the
child presenting the head); irregular natural labors (the child coming
breech foremost); artificial labors (those which require the em-
ployment of the hand, either alone, or armed with some instrument,
but without any necessity for dividing the mother's parts); pre-
ternatural labors (where it is necessary to make an artificial passage
for the child); or, with M. Gardien, to admit of mixed labors
(where the position of the foetus only requires to be changed); or
with MM. Maygrier and Gardien, and Madame Boivin, to make
a division of artificial labors (preternatural and laborious labors);
with M. Capuron, mechanical labors (where recourse is had to
instruments); or manual labors (the preternatural of Baudelocque);
or to make along with Denman a fourth class, under the title of
anomalous labors; or with Burns, to establish seven classes to con-
fuse every thing: 1. Natural labor; 2, Premature labor; 3. Pre-
ternatural labor; 4. Tedious labor; 5. Instrumental labor; 6. Im-
practicable labor; 7. Complicated labor. In fact these accoucheurs
have only changed the acceptation of the terms they employ, or
the new ones they propose are still more faulty than the old ones,
and I cannot perceive that the modifications adopted by MM. Her-
man of Berne, and Dewees of Philadelphia, obviate this inconve-
nience. Besides, there is no such thing as a labor purely artificial,
and the student cannot at a first glance understand the difference
between a manual and a mechanical labor, any better than that be-
tween preternatural and laborious labors.

The division that I prefer approaches very nearly to the one in-
dicated by Mauriceau. All labors that terminate under the sole
influence of the powers of the organism, after the manner of M.
Lebreton, I call spontaneous, fortunate or simple; those, on the con-
trary, that present difliculties of what nature soever, and which in
any way endanger the life or the health of the mother or of the child,
I call difficult, troublesome or complicated; and each of these great
classes may in turn be divided into orders, genera, species and varie-
ties, if the wants of the science call for it.

OF LABOR.

253

TABLE L

DIVISION OF LABORS.

BAUDELOCaUE.

5 Classes.

1. Natural labors. Re-
quiring no assistance.

2. Preternatural labors.
Requiring the use of
the hand.

3. Laborious labors.
Requiring the use of
instruments.

f I. Positions of the vertex.

i 2. Positions of the feet.
.3. Positions of the knees.
4. Positions of the breech.

L Faulty positions.

2- Accidents during labor.

L Faults of the female organs.

2. Monstrosity of the fcetus.

3. Want of power of the organs.

MM. Dubois and]

Desormeaux. '.Like those of Baudelocque. Presentations of the face are
Mesd. BoiviN and [ classed among the natural labors.

Lachapelle. J

The Author.
2 Classes.

i 1. The vertex, i
rl. Eutocia. ^2. The face. }
f 3. The pelvis. ^
("L Hemorrhagic.

12. Convulsive.
3. Aneurismal.
4. Hernial.
5. With procidentia.
[^2. Dystocia, ■{ 6. From disease of the J-
woman.

7. From narrowness of
the pelvis.

8. From wrong positions.
[_9. From exhaustion, &c.

All labors that terminate
spontaneously.

1

AU labors re-
quiring as-
sistance.

ARTICLE L

Of Labor in General.

644. Labor is said to be at term or timely if it takes place at the
ninth month of pregnancy; tardy or retarded, if the pregnancy ex-
tends beyond this period; advanced, hastened, precocious ov prema-
ture, if it takes place between the seventh and the ninth months;
and it is called miscarriage or abortion if it occur previously to the
seventh month. As it is in some sort produced by the same causes,
and accompanied with the same phenomena in all cases, I shall first
examine it in a general manner before entering into the details upon
each class in particular.

254 OF LABOR.

SECTION 1.
Of the Causes of Labor.

645. It is common to divide the causes of labor into proximate
and remote, or also into occasional or determining, and efficient or
immediate.

§. I. Efficient Causes.

646. The efficient causes are those which effect, or properly speak-
ing, constitute {font) labor; the)r have greatly occupied the atten-
tion of physiologists and accoucheurs in all ages; they have by turns
been attributed to the foetus, the womb, the abdominal muscles, the
diaphragm, and sometimes to all these parts together. Hippocrates
and most of the ancients thought that at the end of gestation the
foetus tears the membranes, extends itself like a spring, and pushes
with its feet and breech against the fundus of the uterus, while with
its head it presses upon the cervix so as to dilate it, pass through it,
and then escape from the genital organs. This opinion, which still
prevails amongst the vulgar, was founded upon what takes place in
birds, where the little chick, for example, breaks the surrounding
shell with its beak, when it reaches the period of hatching; upon
the circumstance that children that die while in the womb are born
with more difficulty than those who are strong and vigorous; and
lastly, on the fact that children have been frequently known to
escape spontaneously from the womb after the death of the mother.

647. Nevertheless, it has never been generally admitted that the
foetus is the sole agent, the sole efficient cause of delivery; indeed,
the wisest authors believed that it played an important part in this
grand function; but that it could not come forth without calling
other powers to its aid. In this respect the opinion of the moderns
is entirely opposed to that of the ancients. During the process of
its birth the foetus does not exert in any way an active power; the
analogy which it was attempted to trace between child-birth and the
hatching of a chick cannot withstand the very weakest objection: in
most cases the death of the child does not affect its expulsion at all;
besides, the slowness of the labor in such a case is explained by
the fact that the foetus when dead is flaccid, and cannot present to
the womb the same firm resistance as if it were alive; that if putre-
faction have commenced, the irritability and contractility of the
womb often receive a mischievous influence therefrom, and to a
greater or less extent lose their natural vivacity; finally, that the

CAUSES OF LABOR. 255

vitality of the fostus being generally proportioned to that of the organ
in which it is contained, it is quite natural that the labor should be
more prompt and easy where the child is robust and healthy than
where it is feeble or diseased.

648. Those labors that sometimes take place after the death of
the woman, and form the principle argument of the partisans of the
ancient hypothesis, furnish on the contrary a decisive proof in sup-
port of the opposite doctrine. In these cases the children have
always been found lifeless between the mother's legs; it might even
be affirmed that they died first. They escape from the womb by
means of a power wholly extrinsic to them; after death, the organs of
the life of relation, especially the muscles, become relaxed, while
those of vegetative life continue for some time in possession of their
contractility; sometimes the abdomen becomes filled with gas with
surprising rapidity; so that if the labor is far advanced when the
woman dies, it is not a surprising matter that the uterus, being me-
chanically compressed from without, meeting with no further resis-
tance from the perineum, and still retaining the power of contraction,
is enabled completely to expel the ovum without any necessary par-
ticipation on the part of the foetus. This was evidently the nature
of the case with the woman named Homer, who gave birth to a dead
child, thirty-four hours after she had herself ceased to exist.

649. In the second place, observation has demonstrated that de-
livery takes place pretty nearly in the same manner whatever be the
period at which it happens: now, where abortion takes place in the
first half of the period of utero-gestation, it is evidently impossible
for the foetus to make the least efibrt to escape from the organs.
How can so delicate a creature be supposed capable of dilating an
opening, through which the most vigorous man might vainly essay to
pass his hand? Who does not know that until the fourth or fifth
month it is scarcely capable of making a ^ew motions; that it is
rarely strong enough to be born alive, or at least to live over a few
minutes after birth? Were it to act of itself in labor, it would com-
mence by rupturing the membranes: however, the bag of waters is
not broken until the last stage of labor; in some cases it does not
break at all, and the ovum comes away whole; besides, the very
moment when the bag of membranes presses upon the cervix in
order to engage in it, is the time when the foetus retires from it,
instead of pressing upon it. If it be true that the birth of a dead or
very feeble child is generally effected more slowly than that of a
foetus that is strong and full of vigor, it is also true, that the differ-
ence between the birth of a living and dead one is not sensible.
In all cases, the after-birth comes away at last, and we are compelled

256 CAUSES OF LABOR.

to agree that the action of the foetus has nothing to do with that.
Let the head, the trunk, or any separate part be left in the womb,
and it will be expelled, just as if the fostus were whole, and living.
The placenta, the membranes, the clots, the whole after-birth, a
mole, a fibrinous concretion, a polypus, and all kinds of bodies,
in short, that are met with in the womb are incapable of any spon-
taneous action, and yet their expulsion is effected by the same laws
and announced by the same phenomena as those of the most robust
and the healthiest fcetus. It is therefore undeniable that the foetus is
not the efficient cause of labor; that instead of performing a part
essentially active in this process, it is on the contrary completely
passive from the beginning to the end of it.

650. This cause should be sought for in the organs of the mother,
Avhich was not done until in the last century. Galen, J. Fabricius,
Gelee, Harvey, Levret, &c., had, it is true, already maintained that
delivery is effected under the influence of the contractions of the
uterus, the abdominal muscles, and diaphragm; but this opinion, being
"vaguely expressed, did not have any effect on the theory of partu-
xition. Besides, Haller thought that the womb is but a secondary
agent, and that the abdominal muscles and diaphragm are the chief
agents. To A. Petit was reserved the glory of demonstrating be-
yond dispute, that the efficient cause of labor is essentially consti-
tuted by the contractions of the uterus, and partly by those of the
muscles of the abdomen and thorax.

65 1 . Essential effident cause. We acquire by direct observation
the proof ^that the contractions of the uterus constitute the efficient
principle of labor. By applying the hand upon the epigastrium
during a pain, the womb is felt to grow hard, to shrink, to lessen
in size, in one word, to contract; the finger, when introduced into
the vagina, perceives the orifice to become stretched, to grow thin,
and dilate or contract according to the stage of the labor. As
soon as the pain ceases, nothing of this sort can be perceived; all
the parts become relaxed; as soon as it returns, all the phenomena of
contraction reappear; but it is particularly when we are compelled,
in performing some operation, to introduce the hand into the interior
of the womb, that we abandon all doubt as to the important part
which it performs in the expulsion of the ovum. It pretty often
happens here that the operator is obliged not only to suspend his
progress during each contraction, but he also sometimes loses for a
short space all sensibility, all power to act, and the hand, which is
benumbed, and as it were paralysed, becomes incapable of distin-
guishing the objects it touches. What practitioner has not had
occasion to see that it is not posssible, during a pain, to pass through

CAUSES OF LABOR. 257

the OS uteri? Who does not know, that when passed up to search
for coagula, the placenta, or the foetus itself, the hand is soon
forcibly expelled, together with the foreign body it was designed to
remove?

652. Strictly speaking, the contractions of the uterus might suf-
fice for the expulsion of the child; in several cases of complete
procidentia of the womb, such as those reported by Peu, Jalouzet and
Madame Lachapelle, the pregnancy has been found to go to the
full term, and the labor to terminate spontaneously; many women
have been unconsciously delivered during an attack of lethargy, of
asphyxia, or in a deep sleep, into which they had fallen in conse-
quence of criminal attempts. Women weakened by protracted dis-
ease, a hemorrhage, or exhausted by suffering unconnected with
childbirth; those who are affected with ascites, inflammation in the
chest, delirium, or madness; those whose abdominal muscles, thin
and pale, have lost almost all their contractility; such as are pusilla-
nimous, timid, excessively irritable, or of a very marked lymphatic
constitution; and lastly, all such as from debility, disease, want of
courage, excess of sensibility, or want of power do not bear down
at all, and who, on the contrary, employ all the resources of their
volition to arrest the least effort of their muscular system, are deli-
vered notwithstanding. The womb alone in such cases bears the
whole burthen of parturition.

653. Accessory efficient cause. Nevertheless, the womb in most
cases requires to be sustained by the action of the diaphragm and
abdominal muscles. The concurrence of this action is so evident
in most women that no observer has thought of denying its exist-
ence, and that it is sufficient to announce it as a simple proposition;
but its importance has not been understood in the same way by
all authors. According to Haller, the womb contracts only for
the purpose of preventing the child from being pressed together
into a confused mass, to force it to present one extremity of its
occipito-coccygeal diameter to the straits; by their contractions,
the abdominal muscles support the womb in front and on its sides,
so as to prevent it from deviating, or from abandoning the direction
of the axis of the pelvis, or bending in any direction, and make it
in some respects resemble a straight canal, continuous with the
pelvis. The descent of the diaphragm then bears wholly upon the
fundus of the uterus; the cervix, being unsupported, yields to the
effort; and the foetus, being forced from above downwards, passes
through the genital organs as an inert and solid trunk, passing out of
a long canal with inflexible parietes.

23

258 CAUSES OF LABOR.

654. By carefully noticing the proceedings of nature, it will be
perceived that the idea of Haller expresses very well the mode in
which the diaphragm and abdominal muscles operate; but it is in-
correct, inasmuch as it attributes to tlie uterus only a secondary
part, whereas it is a matter of demonstration that its contractions
constitute the chief cause of delivery. Upon this hypothesis, the
expulsion of the ovum is almost wholly submitted to the volition of the
woman, but no one is ignorant of the fact that parturition is almost
entirely involuntary. Further, it was not so much Haller himself,
as his commentators, who desired to limit in this way the importance
of the uterine contractions; for that great man says positively, that
the efforts of the woman are not always indispensable to the termi-
nation of the labor.

655. On the contrary, far from acting with so much power on the
womb, the diaphragm, as has been remarked by M. Bourdon, only
serves as a firm point cVappid for the abdominal muscles. When-
ever an effort is made, the chest dilates, the lungs fill with air, after
which the glottis closes; the diaphragm gives to the base of the tho-
rax, which is moreover supported within by the distended lungs, a
degree of immovableness and solidity, which affords to the muscular
powers a fixed point that they could not otherwise have obtained;
whence it follows, that it is not by pressing the viscera from above
downwards, as is generally supposed, that the diaphragm assists the
uterus, but rather by giving to the chest the power of resisting the
contractions of the abdominal muscles, which contractions are thus
rendered effective upon the body to be expelled.

656. Tn most women the uterus is the first and only part to con-
tract until the foetus has reached the excavation of the pelvis. From
this moment a sense of weight, of straining, or of tenesmus, irre-
sistil^ly invites the concurrence of the contractions of the abdominal
muscles. Whilst the sole object of the womb is to dilate its neck, it
needs no aid; but when the orifice is sufficiently large, the foetus
must next be forced through a firm and very narrow canal, greater
powers become indispensable, and the uterus, redoubling its efforts,
rarely fails to solicit the action of all the muscles of the body. The
head and limbs being first fixed, the chest dilated, the diaphragm
depressed, the lungs filled with air, and the glottis closed, permits
the abdominal parietes, firmly attached to the pelvis and base of the
thorax, to contract from before backwards, as well as laterally; the
viscera, being unable to raise the phrenic septum which separates
them from the lungs, transmit directly to the fundus of the womb the
lively impression they have received; the latter organ, also sustained

CAUSES OF LABOR. 259

on all sides, now efficaciously employs all its powers to expel the
foetus through the cervix, the only point which now offers no resist-
ance, and upon which all its efforts comes to operate.*

657. This is the way in which the process takes place in a natural
state, but the organism is sometimes obliged to take another course;
the woman is not always capable of effecting this combination of ac-
tions. In certain cases the uterus, compelled to suffice for itself,
sometimes succeeds in producing the desirable result without any
difficulty; but in other cases, being too feeble, either in consequence
of over distension, which destroys its tone by reducing the thickness
of its walls, or of contractions too long continued or too frequently
repeated, or because its function is interfered with by some modifica-
tion of the natural state of its structure, it yields in importance to the
muscles, which, if directed with a vigorous and courageous will, are
sometimes able to expel the foetus with but a feeble co-operation on
the part of the womb.

658. In this sense only may labor be regarded as in some cases a
partly voluntary function, like the excretion of stool, and the emis-
sion of urine. Doubtless, a woman who bears down, as it is called,
who enforces her pains, no matter how feeble soever they may be,
■will get rid of the product of conception sooner; and that another
may, to a certain extent, protract its expulsion by preventing as much
as possible the contraction of her muscles.

659. A woman presented herself at Baudelocque's amphitheatre,
to be delivered there; the labor at first went on very regularly; the
pupils were assembled; the dilatation of the orifice was suspended,
and a whole night passed away without its making any progress;
the spectators, who were fatigued, now dispersed; the pains soon re-
turned, and the dilatation went on; the young people being notified,
re-assembled; again the phenomena of the labor ceased. Baude-
locque, suspecting the cause of these irregularities, gave a hint to the
pupils, who all left the apartment with an injunction not to go far,
and to return upon the first signal; the woman immediately began to
bear down, and the child's head roon reached the vulva; the pupils
were then called, and the labor, which it was no longer in her power
to suspend, soon terminated. I witnessed a nearly similar case in
1825. One of the first women that came to lie in at my amphithe-

* Hence it is that women, who are urged by the bystanders to bear down dur-
ing the grinding pains, find themselves unable to do so. The contraction of the
accessory or abdominal muscles, can be of no assistance until the child, and the
womb itself, have sunk so far down into the excavation, that those muscles be-
come able to act upon the fundus uteri, so as to fix it firmly, while the contrac-
tion of the uterus propels the head against the resisting points. — M.

260 CAUSES OF LABOR.

atre, had pretty smart pains, and the neck of the uterus dilated regu-
larly and promptly as long as there were only a few pupils present.
When they had all assembled, she continued to complain in the same
manner, but the labor did not advance at all; the whole day and
night passed in this manner; in the morning all the witnesses went
away to get some sleep; the dilatation began again; about noon it
was quite advanced; the pupils returned, and the phenomena were
immediately suspended; at nine o'clock in the evening she was left
alone, and as I was going out, I said it would be well to assemble
again between eleven and twelve o'clock at night. A k\v minutes
afterwards, the pains were accompanied with a sensible dilatation,
and the efforts directed with so much force, that the child passed the
inferior strait at ten minutes before eleven, just as two of the students
entered the room. Before she left the ward this woman confessed
that her object was to get rid of the students, and to disembarrass her-
self as soon as they were gone. But these are exceptions which do
not hinder us from establishing it as a general rule, that the will has
scarcely any influence on the progress of labor, except that exerted
by means of the abdominal muscles and diaphragm.

§. 11. Determiniii^ or Occasional Causes.

660. When it is remembered how much time was required to
acquire correct notions concerning the efficient causes, no surprise
ought to be felt at the vagueness of opinions at the present day in
regard to the determining causes of labor. The ideas first enter-
tained varied in accordance with the predominant medical hypothe-
ses of each particular period ; and then according to the notions
entertained by accoucheurs upon the efficient causes : sometimes
they were referred to the fcetus, and sometimes to the womb or other
parts of the mother. They may be divided into natural determining
causes, and accidental determining causes. The former necessarily
have their origin in the ovum, or in the economy of the woman;
they exist therefore in every case, and belong to labor properly so
called. The latter are derived from without, are foreign to the or-
ganism, depend upon a disease of the ovum or womb, or upon some
particular predisposition, &c.; they are, strictly speaking, the causes
of abortion: I shall, therefore, not treat further of them in this place.

661. Believing that the fostus itself opened a passage for its
escape, certain authors imagined that the waters of the amnios be-
come so acrid and irritating, as at last to produce a painful excita-
tion of the skin; that the bladder and rectum, fatigued by the pre-
sence of the urine and meconium, caused the child to feel a neces-
sity of passing off those matters; that the too elevated temperature

DETERMINING CAUSES. 261

of the uterus forced it to come forth and seek in the air the means
of refreshment ; that it could not hve without respiration ; that it
Avas affected by the obliteration of the utero-placental canals, and of
a part of the vascular system of the placenta itself; that it no longer
received sufficient materials for its growth; that its weight and ma-
turity led it to detach itself, as a ripe fruit falls from the limb of a
tree; and that the circulation could not be longer performed without
the action of the lungs. At a first glance, it might seem superfluous
to repeat all these various opinions, since it is actually demonstrated
that the child is not the active agent of its own escape; but as it has
been on the other hand pretended that it only puts the uterine con-
tractions into play, under the influence of the same causes of uneasi-
ness, embarrassment or necessity, I thought it best not to pass them
over in silence.

662. In the first place, all this scaffolding is supported on mere
suppositions. As has been said by A. Petit, no fluid in the animal
economy is less acrid than the liquor of the amnios; if it ever does
acquire any irritating properties, it happens as often at six, seven,
or eight months as at nine, and it has never been shown that the
pregnancy in such cases was advanced one single day.

663. The child is so little disturbed by the necessity of voiding
its meconium or urine; that it sometimes remains several days after
birth without discharging them ; who told it that outside of its
place of habitation there was air for it to breathe, and to cool the
heat of its blood? The temperature of the uterine cavity is the same
as that of the rest of a woman's body, and a thermometer placed
there during labor, would not rise any higher than one held in her
mouth; moreover, the experiments of M. Edwards prove that, far
from being burning hot, the temperature of the foetus is two degrees
lower than that of the mother, as long as it remains in the womb;
it is not true that the anatomical disposition of the utero-fcetal vas-
cular system is at child-birth sensibly different from what it was a
few weeks previously; nor is it more true that the ovum is permea-
ble by fluids, or less adherent at the end than about the middle, or
even the commencement of gestation; it is an ingenious metaphor
to say that it separates like a ripe fruit, but nothing like explanation
has been thereby gained.

664. But if it be true, that the sudden, violent and convulsive-like
movements of the child sometimes force the labor to come on be-
fore the natural term, it is not less true that that is an accident
which ought to be classed among the causes of abortion, and that
labor most frequently comes on without any thing of that kind being
noticed. Neither can the contraction of the ductus arteriosus, the

23*

262 DETERMINING CAUSES.

ductus venosus, and foramen ovale, as they do not take place to the
same extent in every foetus, be the cause of a phenomenon whose
period very rarely varies, and with which variations it has besides
no correspondence.

665. An anonymous author, who was for a long time opposed by
Millot, speaks of a vacuum that takes place in the sac of genera-
tion, in consequence of the transudation of its waters, and pretends
that the uterus, obeying its natural elasticity, closes up so as to re-
move this void; but it is easy to perceive that this author mistakes
the effect for the cause, and has misunderstood the question.

666. Steinzel and others have referred the occasional cause of
parturition to the periodical nisits of each menstrual period. But
in the first place many pregnant women are met with, in whom the
habit of menstruation has never been exhibited. Now the influence
of habit is felt so much the more powerfully the nearer we are to the
itstant when it was left off. Yet, in the hypothesis of Stein, pre-
cisely the contrary is remarked. Besides, in order to see at once
the futility of such a theory, it is merely necessary to advert to the
fact, that the ninth catamenial revolution takes place in some
females at the commencement of the eighth month, in others at
the seventh, often at the end of the tenth, and that a good many wo-
men do not menstruate more than two or three times a year, while
the differences observed in the duration of pregnancies are so few,
that many persons still doubt as to their existence.

667. MM. Lobstein and Chaussier seem to admit that this cause,
which has been so much sought for, is found in the completion of
the organisation of the womb, which waits until the muscular
character of its fibres is fully developed before it contracts. But
miscarriages and premature labors fully demonstrate the insuffici-
ency of such an explanation.

668. According to Loder the extensibility of the womb is con-
fined within certain limits; the fibres of the womb fatigued by a
long continued state of distention, being unable to yield any further,
react, at the end of the ninth month, upon the body that had kept
them so long extended, and thus decide the act of parturition; but
upon reflecting that the development of the womb is not a passive
phenomenon, that twin pregnancies, or those where the ovum from
some cause attains to very great dimensions, do not terminate any
sooner than those where the womb acquires but a very small size,
we are compelled to reject this hypothesis also.

669. The opinion of Levret and Baudelocque, entertained also
by M. Desormeaux, has at the present day the greatest number of
partisans. Founded on the arrangement of the uterine fibres, and

DETERMINING CAUSES. 263

upon observation of the phenomena of pregnancy, it has appeared
to be more satisfactory than any other. It is said — if the cavity of
the body of the womb, only, enlarges during the four or five first
months, and that of the cervix afterwards dilates by degrees, frorn
above downwards, and confounds itself with the former, it depends
upon the circumstance that the fibres of the body and fundus, placed
lengthwise, and being the softest and most extensible, distend and
yield more easily than those of the neck, which are circular, denser,
more compact, and situated transversely. Between them is estab-
lished a kind of balancing or contest, which results in the induction
of labor: those of the body must be looked upon as so many loops
which embrace the ovum in their concavity, while their extremities
are attached to different points of the circles of the neck; the former
at first yield without difficulty, and even without re-acting upon the
latter; but about the middle of pregnancy, by elongating, they stretch
the fibres of the neck, whose circles disappear or are thus drawn in
succession into the body of the organ; so that at last the canal of
the neck no longer exists, but merely an orifice with a circumference
of greater or less thickness. There is then an equilibrium between
the neck and body of the womb; but as the looped fibres have now
no other resistance to overcome but the circular fibres, they triumph
over the os uteri with great facility, the equilibrium is soon broken,
and labor commences.

670. According to this view of the circumstances, I should define
the determining cause of labor to be, the tendency of the fibres of
the body of the uterus to contract; a tendency or effort which pro-
duces no real and sensible effect, until from the moment when the
cervix ceases to furnish any further materials to the enlargement of
the womb.

671. A. Petit expressed himself upon this subject somewhat dif-
ferently: " It cannot be doubted," says that author, " that the deter-
mining cause of the uterine contractions is the irritation experienced
by the uterus when pregnancy has reached its full term. I consider
the cervix as a magazine in which nature has placed in reserve the
quantity of muscular fibres which she needs, to furnish by their de-
velopment materials for the expansion of the womb during the course
of gestation. In the natural state this expansion, when once begun,
proceeds pari passu with the growth of the foetus; every thing is
proportioned, fixed, so that when the latter is sufficiently developed
to bear the action of external agents, and employ them for its own
benefit, all the fibres of the cervix have yielded, and the magazine
is exhausted; labor will therefore take place when all the fibres that
had been placed in reserve in different parts of the womb, and chiefly

264 DETERMINING CAUSES.

in the substance of the cervix, shall have been employed. As long
as any of them remain, the womb may go on increasing, and no irri-
tation will be occasioned; a simple development is not capable of
producing it."

672. This explanation is more rational than the version given of
it by Baudelocque. The idea of a struggle between the fibres of
the different points of the uterus is doubtless ingenious, but the fact
which it expresses has no existence in nature. To me it seems evi-
dent, that by imbibing fluids during the pregnancy, the organ of
gestation is enabled to unfold its fibres in an active manner; that this
unfolding takes place first in the body and fundus, because there
the ovum is lodged in the commencement; that it afterwards takes
place in the neck by the same mechanism, that is, by the accumula-
tion of liquid molecules, which gradually separate the constituent
molecules of the fibres; that this unfolding being brought to a con-
clusion, and the womb besides having acquired the complement of
its muscular organisation, enters upon its contractile state for the
purpose of expelling the body that fills its cavity, and that now be-
gins to produce in it a more lively state of irritation.

673. Miscarriages, and premature labors, as well as protracted
gestation, &c., might be rigorously accommodated to this mode of
interpretation; but another one is required for extra-uterine preg-
nancy. Where the ovum is developed in the tube, or in the abdo-
men, or substance of the womb, what in fact becomes of this balance
betwixt the action of the fibres of the neck and body, this magazine
held in reserve, this unfolding of the fibres, which at a first view
gives so satisfactory a solution of all the other cases? Let us then
frankly confess that the deeper we search into the question of the
determining causes of labor, the greater will be the number of ob-
jections against the explanations that have been given; but do we
any better know the determining causes of the contraction of the
heart, and of an infinity of other actions which like it must be ad-
iriitted as facts?

SECTION 2.
Of Labor.

674. The name labor or travail is given to the collection of phe-
nomena which constitute child-birth; or, if we choose, child-birth
gives rise to a series of phenomena, local or general, which are em-
braced under the one title of labor.

675. As the phenomena of labor are numerous, and appear in

OF LABOR. 265

succession, it has been frequently attempted to group them, to form
different bundles of them, so as to class them better in the memory;
but as these divisions have never been established otherwise than
upon arbitrary or purely conventional data, it has happened that
they do not resemble each other in any two books. A. Petit, for
example, admits three, without saying any thing of the limits to be
allowed to each of them. Stein describes four, and that too, not
less vaguely than the former. Millot also thinks that labor ought
to be divided into four stages: the first, which he calls the secret
stage, because the women are scarcely conscious of it, comprises
the different symptoms that manifest themselves in the four, five or
six days immediately antecedent to the term of gestation: the second
extends from the first appearance of the pains to the discharge of
the waters; the third begins after the rupture of the membranes;
and the fourth when the child is on the point of being delivered.

676. Millot's secret stage is classed among the precursory signs
by Madame Boivin, who, like Chaussier and Adelon, admits five
stage?; four for the labor itself, and the fifth for the delivery of the
after-birth, but without indicating any very well marked line of dis-
tinction between them. M. Maygrier also reckons four stages, as
Stein does, and does not circumscribe them either. Denman seems
to have been the first to lay the foundation of a good division of
labor: according to him the first stage commences with the first
pains, and ends with the complete dilatation of the neck, or with
the rupture of the membranes; the second extends to the complete
expulsion of the fostus; and the third comprises the delivery of the
after-birth. In this way each stage forming a period rigorously
determined, it becomes no longer possible to extend or limit as we
please, the acceptation of the terms made use of. We might also
after the example of Burns, describe only two stages, properly so
called, and make the delivery of the secundines a separate labor,
which appears to me to be rational. M. Desormeaux, who was
fully sensible of the advantages of Denman's method, has done better
by carrying the first stage to the complete dilatation of the os uteri,
without regard to the rupture of the membranes. I shall adopt this
course myself, and divide labor only into two principal stages: one
which terminates when the dilatation is finished, and another which
begins at that moment, and ends with the delivery of the child.

Nevertheless, I shall add, as an independent period, what Millot
calls the secret stage, or what Madame Boivin describes under the
title of precursory signs.

§• I. Precursory Signs, or Preliminary Symp-
toms of* Labor.

266 PRECURSORY SIGNS.

677. Labor sometimes comes on suddenly, and without any
preliminary symptom; however the organism, which rarely pro-
ceeds to the exercise of its smallest functions without some pre-
lude, is most commonly true to its accustomod march, whenever the
question is upon terminating the great act of reproduction.

From two to fifteen, and even twenty days before the period, na-
ture in some subjects seems to try her forces; the belly diminishes
in size sensibly; the fundus, and even the Avhole mass of the womb,
subsides; the motions of the child are felt more than in common;
the infiltration and the varicose condition of the lower extremities
increase or now become manifest, if not previously present; the
labia pudendi in particular become swelled, softened, and occasion-
ally painful; the digestion is better performed; the nausea, vomit-
ing, and curious appetite are done away with, if they had not long
before ceased to exist; the respiration is not so short, nor so im-
peded; the women regain their habitual gaiety and lively humor,
are not so sleepy, more disposed to exertion, more active, and often
induced to believe, at least in first pregnancies, that their term is
further oft than they had before supposed. They have a sense of
weight in the pelvis, or, as they say, at ihe fundament, with jnore
frequent disposition to stool, and to void their urine. It is then, par-
ticularly, that all the articulations, all the ligaments of the pelvic
cavity become softened and relaxed; which renders walking, and
even standing itself more difficult, more fatiguing, and sometimes
even absolutely painful, although the woman is more disposed for
them. The secretion of mucus in the genital passages becomes
more active, and glairy matter in more or less abundance escapes in
flocks from the vagina and vulva; it is not very rare to find the
womb in an altogether peculiar state of fibrillar contraction, which
may be regarded as a passage from its state of rest to that of its
real contraction: that is to say, by touching the os uteri, we feel
that it is from time to time in a state of slight tension or constric-
tion, and by feeling of the body of the organ above the pubis, a
hiovement is found to take place in it; so true is it, that the point
of departure of labor cannot always be precisely determined.

078. These diflerent phenomena, which necessarily vary in num-
ber, progress and degree in difl^erent women, are in general of good
augury, provided they are not converted into symptoms of disease.
They announce that nature is collecting her forces, uniting her re-
sources, and making all suitable dispositions to accomplish the func-
tion she has been so long preparing for. As to their explanation, it
is perfectly natural; they all refer directly or indirectly to the change
of position of the womb. By plunging down into the excavation,
this organ necessarily presses with more or less force upon the rec-

PRECURSORY SIGNS. 267

turn, the bladder, the nervous plexuses and the blood vessels; thence
come the tenesmus, the bearing down, the lymphatic or sanguine
engorgement of the lower limbs and vulva, the relaxation of the
symphyses, the formation of mucus, &c. By sinking lower down,
and removing to a distance from the epigastrium, the womb leaves
the stomach and liver more unconstrained; the diaphragm, being
less elevated, permits the lungs to dilate more, whence more freedom
in respiration, circulation, the digestive functions, and consequently
in the exercise of the intellectual and locomotive faculties.

§. II. First Sta^e, or Period of Dilatation.

679. After these preliminaries, labor at length begins; its origin
is marked by pains, and short and slight colicky sensations, recur-
ring at considerable intervals. The external parts of generation
become moist, and the secretion of glairy mucus, provided it had
not appeared before, is added to the number of precursory symp-
toms. When the colic pains are present, the womb hardens, be-
comes rounder, and its summit sinks into the excavation, it dimin-
ishes in all its diameters, in one vi^ord, it contracts: the lips of the
OS tincae are effaced, and in an evident manner grow thinner; the
orifice stretches, and from the same cause loses its thickness, assumes
more decidedly the form of a circle, and manifestly contracts; by
introducing the finger into it, the membranes of the ovum will be
found endeavoring to engage in it, they are compressed by it and
forced lower down, they grow harder, become tense, very elastic,
and difficult to indent. The woman is now frequently tormented
with sinister forebodings; she becomes low spirited, and despairs of
safety, says she is going to die, loses all her courage, and is over-
whelmed with gloomy thoughts, and a sadness which nothing seems
able to dispel; she weeps, is agitated, or remains motionless, and in
some instances feels horiipilations all over the body. Animals them-
selves, a very remarkable circumstance, also fall into this state of
lowness at the commencement of labor; they refuse to eat or drink,
seem to be tormented with fear; and to be occupied only with the
dangers that threaten them.

680. The pains, which gradually increase in strength and severity,
at the same time become longer and more frequent; reddish or
bloody striae are soon found to be mixed with the mucous discharges,
which are also found to be increased in quantity; the mouth of the
womb begins to open, and dilates by degrees; the lower segment of
the ovum passes through it, and under the title of bag of waters,
projects into the upper part of the vagina; as the pains grow more
severe, the general irritation becomes more considerable; the inter-

268 STAGES OF LABOR.

val between the contractions is not calm; the woman is touchy, cross,
impatient, difficult to control; she cannot keep in one place, is dis-
contented with every body, and has an extreme susceptibility; every
pain in some degree resembles a paroxysm of fever; it is preceded
with a rigor and sometimes even with a tremor and rattling of the
teeth together; the quickness, frequency and hardness of the pulse
and temperature of the body augment; the skin is higher colored
and becomes moist; the mouth and tongue dry; the teeth and lips
are encrusted, become fuliginous, as in an adynamic fever; a great
thirst comes on; she has nausea, vomiting and cough; she wanders,
and the intellectual derangement is often carried to such an extent
as to resemble delirium. In irritable women, the anguish and rest-
lessness are sometimes carried to the highest degree; and the hardest
heart could scarcely resist a feeling of compassion and pity at the
sight of these unhappy beings, who with dishevelled hair, blackened
mouths, flushed countenance, burning skin and haggard eyes, can
only become mothers at the cost of so many sufferings and dangers.
When a contraction is over, every thing returns to its natural state;
the resdessness ceases; the pulse recovers its ordinary type; the
mouth becomes moist; the skin regains its natural color and habitual
temperature; if an examination be now made, the membranes,
having returned within the cavity of the womb, feel flaccid and
wrinkled, and the bag of waters cannot be felt; the edges of the os
uteri, which during the pain were hard, thin and sharp, are supple,
thick, and rounded immediately after it. The nausea, is suspended,
but the belly, particularly the epigastrium, most generally remains
very tender. Each pain reproduces the same series of phenomena
and is succeeded by a more and more complete remission, which also
grows shorter and shorter. The os uteri, which represents the re-
sistance to be overcome, gradually yields; its dilatation at length
becomes so complete, as that there is no contraction betwixt the
uterus and vagina. Thus is terminated the first stage of labor, the
longest and most fatiguing period of parturition, but not the most
dangerous or difficult.

§. III. l§ieconcl 8ta^e, or Period of Expulsion.

681. In the first stage the womb performs almost the whole duty
of the labor; it dilates the cervix, and forces the apex of the ovum
to engage itself therein; it either does not solicit at all, or but very
feebly, the contractions of the muscles, whose concurrence has not
as yet become indispensable. In the second stage, the contractions
in the first place become stronger, last for a longer period of time,
are not so far apart, and yet are followed, by a more decided calm;

STAGES OF LABOR. 269

the courage returns, the sadness is dissipated; some women, op-
pressed with the want of rest, sleep quite soundly during the short
interval between the pains; I once attended a lady in labor, who,
having been three days and nights in the anguish of a most painful
travail, slept several times on the morning of the fourth, notwith-
standing that the contractions were carried to the highest degree of
intensity, and there was scarcely more than one or two minutes be-
tween them. A feeling of weight and bearing down, by some re-
ferred to the pressure experienced by the cervix, but which depends
rather upon that of the rectum and bladder, soon compels the woman
to second her pains; and almost in spite of herself, to contract 'the
abdominal muscles and make the most violent efforts.

6H2. The bag of waters, the only portion of the ovum which is
not compressed externally, having no support whatever in the supe-
rior part of the vagina, bursts in the midst of one of the most vio-
lent pains; the foetus, forced downwards by the same contraction,
immediately takes the place occupied by the segment of the mem-
branes, and by engaging in the passage like a stopper or plug, pre-
vents the escape of the rest of the waters; and the head, if it be the
presenting part, is then said to be at the crowning (couronneraent);
the void thus produced in the womb is the reason why the labor
seems to slacken for a little while; but when this void disappears, and
the uterus is recovered from its astonishment, (I hope the expression
will be pardoned,) the pains recover all their energy, and succeed
each other with greater rapidity. Each one is ushered in with a gene-
ral shiver; the severest ones are often preceded by another which is
milder, and serves as a prelude to it; on other occasions we observe
one stronger and one weaker, alternately, regularly, and without
our being able to regard one as a sequel to the other. When they
come on, the woman lays hold of any thing solid in her reach, plants
her heels upon the mattrass, seizes with her hands the sides of the
bed or bolster, or the persons around her, to secure z point (Pappici;
she then throws her head back, draws a long breath, and all the le-
vers of her skeleton being thus fixed, contracts, with all her power,
the muscles of the belly, Avhile the diaphragm, and all the muscles of
her body act with the same energy; the neck and face swell, are en-
gorged with blood, and become purple or livid; the jugular veins ac-
quire an enormous size; the carotids beat violently; the thyroid gland
becomes engorged, the eyes sparkle, grow red, and seem to start
from their orbits; all the symptoms of cerebral congestion become
manifest; the general circulation is strongly excited; sweat some-
times pours from the skin, but only about the head, breast and ab-
domen, for the lower extremities, receiving less blood than common,
24

270 STAGES OF LABOR.

not unfrequently remain below their ordinary temperature; at length,
when the contraction is just about to cease, this agitation gives place
to rapid sobs, which soon restore calmness to the functions.

683. After a certain length of time, generally very short, another
pain comes on, accompanied with the same anguish, and followed
by the same phenomena. -As it begins, a small quantity of liquor
amnii is seen to flow off, because the child does not exactly fill up
the cervix during the interval between the pains: but by forcing the
presenting part to engage in the utero-vaginal orifice, the uterine
contraction soon puts a stop to this discharge, which re-appears
towards the close of each pain, because the foetus, ceasing to be
pressed downwards, returns into the cavity of the womb. If the
pains be somewhat strong, the head soon passes through the cervix
into the upper part of the vagina, which gradually dilates to receive
it, and it descends into the excavation, exerting an increasing pres-
sure on the rectum and bas-fond of the bladder; the bearings down
are now redoubled, strangury comes on, and cramps are felt in the
thighs and legs; if any fsecal matters are contained in the rectum be-
low the superior strait, they are mechanically forced out; the ampli-
tude of the vagina increases in every direction by the unfolding of
the wrinkles, always, except during labor, observable on its interior.
The head approaches the inferior strait, the coccyx retires back-
wards, the anus projects; the whole perineum is elongated, and be-
comes thinner as the inferior angle of the vulva is carried forwards,
and the plane of this opening at last comes to be almost parallel with
the axis of the body, instead of representing, as before, the plane of
the lesser strait of the dried pelvis ; the labiae being put on the
stretch are undoubled, and even drag a portion of the skin of the
thighs towards themselves: the mons veneris is lessened in size;
but it is false, entirely false, to say that the nymphae are also unfold-
ed : at length a pain, which is stronger than any preceding one,
which forces the woman to utter cries of despair, and which is com-
posed of two pains of unequal violence, for which nature seems to
have rallied all her remaining muscular power, triumphs over all re-
sistance; the most powerful contraction that has yet occurred brings
the parietal protuberances on a level with the tuberosities of the
ischia ; one more last degree of power is about to force them
through, but that power is just about to diminish; nature, who has
almost overcome all obstacles, seems to be ready to fail in her last
effort; just as she is about to attain the object of so many exertions,
she is seen ready to yield once more to the reactions of the peri-
neum; but one more attempt of the organism gives rise to anew
pain which comes to the assistance of the preceding one before it

STAGES OF LABOR. 271

has quite ceased, as if to sustain it, and the head finally escapes
through the vulva. In consequence of the vacuity which has just
occurred in the womb, provided the body of the child does not im-
mediately follow the head it is not commonly expelled until after a
calm of a few seconds or a few minutes, when a short and moder-
ately strong contraction occasions its escape, together with that of
the remainder of the liquor amnii.

684. The labor is finished. One of the most melting scenes, a
scene most adapted vividly to affect the human heart, is presented to
the eyes of the philosophical accoucheur. To those piercing cries
and violent agitation, to those transports of despair, those excessive
efforts, those inexpressible agonies, those dilacerating pains, which
seem to be intolerable, instantly succeeds a delicious calm, full of
charms, says M. Desormeaux, and interrupted only by the happy
idea of being a mother. The new born child cries, and all the suf-
ferings of the mother so courageously borne are forgotten; pas-
sionate expressions of satisfaction are substituted for those of pain,
sobs of happiness succeed to the sobs of despair; and this sudden
transition from the extremest dread, from a frightful state of anxiety,
to the height of joy and of the tenderest affections, is, in sensible and
amiable women, one among those appearances which most imperi-
ously demand our admiration for a sex whose other claims to it are
so numerous!

685. Duration of labor. There is no occasion for me to remark
that this general picture is far from being applicable to all women
or even to all the labors of the same woman; most of these nu-
merous phenomena are to be met with, chiefly among those who
are robust, vigorous, young, and in labor for the first time: in
others, they exhibit very varied appearances. Their development
requires a lapse of time which also presents very great variety in
different countries and in different women.

The duration of labor is, according to the reports of travellers,
much shorter among savages than among civilised people; among
the Negroes and Indians of America than among Asiatics and
Europeans; in hot climates than in cold countries; in Italy, Spain,
and Portugal, for example, than in France, Russia, and Germany;
in women who have passed their lives in luxury and idleness, than in
those who live in the country, and are obliged to labor hard for a
support. In general, labor lasts from four to eight or ten hours
in Holland, England and France; it is about the same in Switzer-
land and Germany; so that Haller was evidently deceived when he
stated that the duration of a labor is from an hour and a half to

272 STAGES OF LABOR.

two hours. The mean term of this function, therefore, as is remarked
by M. Desormeaux, is about four hours.

The four most constant and essential phenomena of labor are,
as may have been above seen, the contraction of the uterus, or
pain, the dilatation of the cervix, the formation of the bag of waters,
and the discharge of glairy mucus.

§. IV. Of liabor-Pains.

686. In midwifery, the word ,pain is synonymous with uterine
contraction; nevertheless, it should not be forgotten that this is only
conventional language, employed by physicians to make themselves
understood by the vulgar, and that these two things are essentially
distinct. It is true that pain is connected with contraction of the
womb; that they begin, progress, decrease, and cease together,
that the energy of the one is most commonly in a direct ratio to the
acuteness of the other; but it is very certain, also, that the contrary
may be met with, so that no labor can be concluded without the
contraction, while many may be cited as having taken place without
pain. Every body has observed, like M. Flamant, that in most wo-
men the contractions come on a good while before the pains.
Nevertheless, it is by the pain that we estimate the contraction and
its strength; the former is the sign of the latter. However, there
may be numerous shades of difference in the intensity of the pains,
without the strength of the contraction being on that account
necessarily different. In a nervous and extremely irritable woman
a very slight contraction sometimes produces the very severest pain;
on the contrary, a woman of a lymphatic temperament, indifferent
as to small matters, and who has but little sensibility, scarcely suf-
fers at all, although the womb contracts powerfully; some women,
from an excess of timidity, fear, or pusillanimity, cry out aloud upon
the slightest contraction of the womb, while courage and resigna-
tion lead others to bear the strongest contractions without complain-
ing. Finally, there are a few, who, for the purpose of securing more
attention or inspiring more compassion and pity, scream and worry
themselves in a most extraordinary manner, although they, in re-
ality, suffer but very little. There are also those who arm themselves
with artificial courage, who resolve beforehand not to complain nor
cry out, no matter how strong the pains may be, and at the ex-
pense of life make the most incredible efforts to impose silence
upon the most violent sufferings, and refrain from the most legitimate
outcries; so true it is that charlatanism and ostentation find occa-
sions for exercise even in human infirmities! It may also happen

LABOR-PAINS. 273

that the presence of strangers, or of persons displeasing to the wo-
man in labor, of whom she is afraid, or with whom 'She naturally
has no familarity, restrain her, and prevent her from giving free ex-
pression to the sensations she experiences.

687. At the commencement, the pains are so weak and super-
ficial, that they have received the title of flies (mouches), doubtless
in allusion to the slight sensation produced by the bite of that insect,
or that occasioned by its creeping on the skin. They are then
called, also, preliminary pains, little pains: characterised by a sort
of shuddering of the body of the womb, they arise in the umbilical
region, and are lost therein, or spread, so to speak, over the whole
hypogastriuni and flanks. At a more advanced stage, when the
labor is fairly set in, the pains, which are longer, stronger, nearer
together, and more decided, are c2L[\ed preparative; never was epithet
better applied; their business is, in fact, to prepare for the expulsion
of the ovum, or preside over the dilatation of the cervix; from the
neighborhood of the umbilicus they generally extend towards the
sacro-vertebral angle, or to the centre of the strait; this is the period
during which the woman is most impatient, cross, sad, worried,
difficult to govern, and utters the sharpest cry, which perhaps de-
pends upon the womb acting alone, and leaving to the woman the
free exercise of her general sensibility.

At the end of the first stage, and more particularly in the second,
the pains visibly change their character, assume the denomination
of bearing or expulsive pains, and in fact announce that nature is
employing all her resources for the expulsion of the fiBtus. These
pains, which are also designated as the great pains, are much
stronger, longer, and more complete than those of the first stage,
and are, besides, characterised by being separated by intervals more
perfect, better marked, and more calm, by giving rise to strangury
and tenesmus, or a sense of weight which brings the abdominal
muscles into play, force the woman to bear down, and make exertions
to assist the uterus. Notwithstanding their severity, they do not excite
her irritability so much, and are borne with more resignation and pa-
tience. The women who seem carefully to avoid every preparative
pain, are, on the contrary, anxious for the return of the expulsive
ones; they invite and solicit them; they converse, are tranquil, and
during the intervals between them, are even lively, and forget the
dangers, a sense of which had previously caused them to be so down-
cast. Their cries are difl'erent from those they uttered in the first or
second stages. The cries which accompany the first are sharp, and
resemble those occasioned by any other species of sufferino-. Those
of the second stage, on the contrary, seem to be suppressed like those

24*

274 LABOR-PAINS.

of a person carrying a heavy burthen. The former are free and open,
and take place during the act of expiration; the latter are restrained
by the closure of the glottis, and can scarcely be heard except during
inspiration; the former are expressive of suffering, the latter of exer-
tion.

688. When the labor approaches its termination, the pains, which
are sometimes of an extreme degree of violence, are pretty frequently
accompanied with a kind of convulsive trembling, during which it
seems as if the bones of the pelvis are about to separate or break,
and all the genital organs threatened with immediate laceration, have
been denominated dolores conquassantes, a barbarous and ill-sound-
ing term, but strongly expressive of the state of the case; their only
special character, however, is their high degree of intensity, for they
do not otherwise differ from the expulsive pains, properly so called.

689. As has been already seen, the direction of the pains is not
the same in every stage of the labor; they most frequently follow
the great axis of the womb, or the occipito-coccygeal diameter of the
foetus, and consequently terminate at a point which is so much the
nearer to the centre of the vulva, in proportion as the foetus is nearer
its passage through the inferior strait; whence it follows that an an-
terior obliquity of the womb is one of the most evident causes of
those disagreeable pains that are called pains in the back, and to the
consideration of which I shall return in another page.

Causes. The pains of labor are occasioned by the contractions of
the uterus: but what is the nature of their mechanism? At the time
of labor the womb is a muscle; but, in the natural order of things,
muscular contractions are not at all painful. The heart, the dia-
phragm, the stomach, the intestines, the rectum, and the bladder
give rise to pain by their contractions. The most violent contrac-
tions, even, of the muscles of the abdomen, in labor, are not painful;
we cannot therefore look to the fleshy structure of the womb for
the cause of the pain. Stein says that women would doubtless
bring forth their children without any pain, were it not for the power-
ful resistance offered to the passage of the foetus by the inferior seg-
ment of the womb and the neighboring parts, which by their antago-
nism give rise to pain. According to Levret, Asdrubali, &c., there
is not the least doubt that the seat of labor-pain is in the very orifice,
non vi cade guestione alcuna che in esso orijicio e il luogo positivo
ove si articolano i dolori del par to, &c., and not in the body and
fundus of the uterus, as supposed by most accoucheurs. Denman,
in speaking of labor-pains, does not attempt to define their seat; he
is satisfied with stating that, in labor, the degree of power can only
be estimated by the resistance, the resistance by the pain, and the

LABOR-PAINS. 275

pain by the expression. So that his opinion, which is adopted by
most of the English practitioners, and which Hoplvins characterises
as the most rational one, is very nearly the same as that of Stein and
Levret.

Hay and M. Bilon have endeavored to prove that the seat of
labor-pain is in the cervix much more than in the body of the
womb; their principal argument is, that the former receives its
nerves from the sacral plexus, which is one of the divisions of the
cerebral nervous system, while the latter receives its supply from the
hypogastric plexus, which belongs to the ganglionic system, and
which has no communication with the brain. Madame Boivin, who
speaks from what she has experienced in her own person, advocates
the same idea, and thinks that the contractions of the body and fun-
dus of the womb are not more painful than those of the abdominal
muscles and bladder.

690. If it be true that the cervix is endowed with a more acute sen-
sibility; receives a more abundant supply of nerves than the rest of
the organ, and is powerfully stretched by the contractions, and that
all the efforts of the uterus are directed upon that point, it is not
less so, that, during the strongest as well as the weakest contractions,
the pains are equally felt throughout the whole extent of the womb.
If the pressure of the foetus and the tractions exerted upon the cer-
vix were the only causes of pain, women ought not to suffer at all
after the dilatation is completed; yet, notwithstanding, their most
violent sufferings are experienced from that very period; and durino-
the delivery of the placenta, is it in the neck that we are to place the
seat of the pains?

691. Others have asserted that the pains of labor are owino- to the
compression of organs contained within the pelvis, of the nervous
plexuses, for example. But when the lumbar or sacral nerves are
compressed, pain is felt in the limbs and not in the excavation. The
pains extend from above downwards, both at the beginning and end
of the process, and occupy the whole hypogastrium, and not mere-
ly the lesser basin; as long as the head remains above the superior
strait, where the foetus presents transversely, or when it comes by the
feet, we cannot refer the pains to this kind of compression. To
maintain, with some writers, that they depend on compression of the
nervous branches distributed upon the inner surface of the womb, is
only to advance one of those numerous assertions, hazarded without
proof, which are but too often met with in medical works.*

* If, during labor, the finger be hooked in the dilating circle of the os uteri
and drawn so as to put it on the stretcli, a pain is produced, resembling that

276 LABOR-PAINS.

Thus the essential cause of labor-pain is wholly unknown; it is
a question in physiology which deserves and requires new research-
es. What is demonstrated by observation is, that all parts of the
womb, either unitedly or singly, may be the seat of pain during la-
bor; that in certain cases, the stretching of the neck concurs, perhaps,
more than all other causes in its production, and that pressure upon
the neighboring parts is not always unconcerned in it.

682. There is another long debated question relative to the in-
tefmittence of the pains of labor. A. Petit says, that were not the
pain to cease after it had set in, or if there were only one single pain,
the woman would sink under it, and could not bear it; whereas,
being reduced as it is into fragments, the sum of her sufferings is real-
ly lessened; in other words, the pains of parturition are intermittent
because they are not continuous, for that is all the explanation given
by A. Petit. A physician whom Millot opposes with much warmth
has entered more deeply into the question, asserting that the cause
of the intermittence of the pains is found in the resistance offered
by the ovum to the contractions of the womb. Others have since
endeavored to explain the facts as follows: when the womb contracts
with much force, say they, the nerves between its different strata, or
even on its inner surface, being compressed by the external surface
of the ovum, soon produce a degree of numbness in them, that neces-
sarily puts a stop to the contraction.

But the pains, in these cases, ought to be very long and very near
to each other at the commencement of the labor, instead of being
so fugacious and far apart, as the contractions are then extremely
feeble; on the other hand, they ought at the close to be shorter and
less frequent, inasmuch as the compression is then sudden and
most violent; nor are the pains that accompany the delivery of the
secundines, or the after-pains that follow delivery, and which still pre-
serve the intermittent type, explained in a manner at all more satis-
factory, under this hypothesis.

693. Buffon thought that the cessation of each pain was due to
the detachment of ihe placenta; that is to say, according to this
celebrated man, the object of each contraction of the uterus is
to detach a small portion of the after-birth, and as soon as this de-
tachment takes place, the pain, like the contraction, must cease for
a moment. Two remarks suffice to show the litde value of such a
supposition. The placenta sometimes comes away before the fostus,
and the pains are not on that account less intermittent until the labor
is concluded. In other cases the placenta retains its adherence even

which is felt during the grinding pains. — The most intense pain of parturition
is the result of the extension of the vagina, the perineum and labia. — M.

LABOR-PAINS. 277

after the delivery of the child, which does not change the intermit-
tent character of the pains.

694. In stating that the cause exists in the cessation of the con-
traction of the muscular fibre, as insisted on by Millot, who thinks
he has made a great discovery, we fall back again to the petitio prin-
cipii for which A. Petit has already been censured, above: this is to
displace and not to solve the problem.

695. During the contraction the blood is forced back into the
torrent of the general circulation, says Dr Dewees; the womb
grows pale, and the contraction ceases; a new affluxion takes place,
and the contraction immediately returns. Sic; but this explanation,
which in fact is perfectly similar to the one which I have been just
now opposing, is liable to the same objections, and not at all more
admissible.

696. In conclusion, we do not know the cause of the intermit-
tence of the uterine contractions, any more than we do that of the con-
tractions of the heart, the intestines, and the muscles in general,
or that of all imaginable intermittence, whether functional or
organic. Inasmuch as we cannot grasp a body strongly in the
hand without being soon obliged to relax it, wherefore should it be
supposed that the contraction of the womb does not require to be
alternated with relaxation? The nature of the phenomena is simi-
lar in each of the cases; its cause must be identical, and I cannot
perceive why we should with so much ardor seek for it in the one,
when we have, in some measure, agreed to abandon it in the other.
It is a question which will doubtless long remain unsolvable, but
which belongs much more to general physiology than to tokology
in particular.

§. V. Of the Dilatation of the Os Uteri.

697. Pain is the first symptom of labor; but it is neither the
most essential nor constant one; for, as has been pointed out by
Levret, Denman and Hopkins, it may be conceived, that there may
be cases in which it is possible for women to be delivered without
any pain, whereas it is materially impossible for her to be so with-
out the dilatation of the os uteri. This process of dilatation, which
is wholly subordinate to the power of the uterine contractions, re-
quires to be well understood. It is slow and not very preceptible
at the commencement, but is effected with great rapidity towards the
close of labor. It generally requires more time to enlarge it to
the size of a crown piece, than to complete its dilatation, when its
diameter is about three inches. The orifice, which is for the most
part very thin and somewhat sharp, when touched at the beginning,

278 LABOR-PAINS.

especially in a first labor, communicates an impression like that
which would be felt upon touching a ring of fine cord slightly-
stretched. In the latter half of the first stage it becomes, on the
contrary, thicker, and sometimes forms a kind of roundish cushion,
which seems to yield before the child's head, but gradually disap-
pears when the head passes or engages in the strait. The very con"
trary of this is remarked in women who have had many children;^
the lips of the os uteri, which at first are soft and supple, still some-
times retain a thickness of several lines, even although the labor
may be somewhat advanced; it is, however, only at a later period,
when the bag of waters begins to form, that they begin gradually
to grow thinner.

698. In both the above cases', the diminution in thickness is far from
taking place with the same regularity on every point of the circum-
ference of the circle. I have often seen its posterior half as thin as
the edge of a sheet of paper, while its anterior semi-circumference
formed betwixt the head and pubis a cushion from three to four
lines in thickness. This inequality, which is in some sort natural,
and almost always to be met with in various degrees, ought not to
be overlooked, whenever we attempt to determine the duration of
the labor: by touching the anterior half of the cervix without car-
rying the finger far back, one might be led to prognosticate a pretty
tedious time, while another person, after having explored the opposite
side, would announce that the labor is just about to come to a
conclusion.

699. The shape of the os uteri during the process of dilatation is
no less variable than the thickness of its lips. It is pretty nearly
circular where it corresponds to the centre of the pelvis; but more
commonly it is oval, with the broadest part turned backwards, or to
one side, right or left, according as the fundus is inclined in this or
that direction; sometimes elliptical, especially when the child pre-
sents in a transverse direction, it exhibits, in other ' cases, certain
inequalities which depend upon its different points not having the
same consistence nor the same extensibility.

700. All those authors who have maintained that the foetus is the
efficient cause of delivery, have necessarily also admitted that it is
the cause of the dilatation of the os uteri. The common people,
mostly, still reason in this way, and Vigarous seems to be of the
same way of thinking; but since it has been ascertained that, in the
expulsion of the whole or part of a dead foetus, the os uteri dilates
just as it does for a living child, this opinion, now become superan-
nuated, has been completely rejected. We have, says A. Petit, one
decisive proof that the foetus does not dilate the orifice, in the fact,

LABOR-PAINS. 279

that if we place a finger on the point of the ovum where it tends
strongly to engage in the opening, we find that the head of the
foetus, instead of pressing into it, actually retires from below up-
wards, being repelled by the fluids which pass beiwixt it and the
womb in order to fill up the bag of waters.

This however does not imply that the child has nothing to do with
the production of this phenomenon, but merely that it is not the
active cause in it, and can only concur in it by being under the in-
fluence of some other power.

701. The real cause of it is to be found in the contractions of
the womb. It is of the essence of fleshy fibres to shorten themselves,
and tend to approach a straight line, when they contract; the womb is
composed of curved fibres, the most numerous and strongest of which
occupy its fundus and body, and are principally placed lengthwise;
the cervix is the weakest part of the whole organ; the ovum is an in-
compressible body. Now, it is ma'iifest that with such a disposition,
the dilatation of the cervix must commence with the contractions of
the womb. The vertical and oblique fibres, by their two extremities,
which are their movable points, draw the horizontal fibres to which
they are attached, or with which they are interlaced, upwards to-
wards their middle, where is to be found the real fixed point. The
transverse fibres, in contracting upon the ovum, a smooth oval body,
necessarily tend to slide towards its apex or towards its base; but as
tliey are at least as numerous above as below the middle transverse
zone, it follows, that the circular fibres of the inferior portion of the
uterus will, in any general contraction, be found to resist, alone, the
eflx)rts of all the longitudinal and circular fibres of its superior half.

On the other hand, as the ovum can only be pushed by the con-
cavity of the uterine fibres towards the least resisting point of the
organ, it engages in the partly open orifice, and becomes a powerful
though secondary cause of the dilatation of the os uteri, and in this
case acts like a wedge: it is an inert force which acts in aid of a vital
or organic force. Thus it may be admitted that the ovum is de-
pressed while the os uteri is raised upwards; in other words, that
these two parts, under the influence of the same power, the uterine
contraction, slide one upon the other, and that the latter must dilate
in the direct ratio of the force which causes the former to descend.

At the commencement of labor, when the os uteri just begins to
open, it is known to contract instead of dilating during the pain, but
in such a way, notwithstanding, that it remains larger after the pain
than it was before it. At a more advanced stage, when the bag of
waters begins to form, we observe, on the contrary, that the os uteri
dilates considerably during the contraction, and contracts somewhat

280 LABOR-PAINS.

as soon as it is over. The cause of this peculiarity is easy to be
understood: at tlie commencement, the fibres of the neck still resist
with great energy the action of the fibres of the body and fundus;
as the womb contracts at all points at the same time, and not in one
or another of its planes, as A. Leroy supposed, or in different por-
tions of its substance alternately, as taught by some others, the ori-
fice, instead of dilating so as to allow the membranes to engage, on
the contrary contracts, as if to prevent their passing out; whereas, at
a more advanced stage, when it is sufficiently open to permit the
point of the ovum to lodge in it, the bag of waters unites in assisting
the uterine contraction to force them to distend.

702. Immediately after the discharge of the liquor amnii, the head
of the foetus occupies the situation of the bag of membranes, fulfils
its uses, and acts upon the neck in the same manner; nearly all
practitioners think this part less favorable for the dilatation than the
segment of the membranes, inasmuch as it is not so even, as it does
not form a tumor so equally stretched; but we shall see, in examin-
ing the subject of the premature rupture of the ovum, that upon this
subject observation requires to be consulted anew. It is principally
from this very moment that the uterine circle is converted, in first
labors, into a circular cushion of various thickness, and that the dila-
tation seems sometimes to diminish to such a degree as to impress
us with a belief that the labor is retrograding instead of advancing.

§. VI. Of the Discharge of Glairy HIuciis.

703. The term glairy or mucous discharge is given to certain
flakes of matter of a very clear yellow or greenish white color which
escape from the sexual organs during labor; this glairy matter occa-
sionally resembles white of eggs slightly cooked, and differs from the
mucus of the nostrils by being less adhesive and by forming masses
or lumps which are less coherent and more albuminous. It escapes
in masses or flakes which tremble like jelly, come away especially
during the contractions, appear in some instances several days before
the onset of labor, of which they constitute one of the most certain
preliminary signs,* become more and more abundant as the dilatation
progresses, and at last, in a majority of women, become tinged with
blood.

704. Nothing is more variable than the quantity of this discharge;
sometimes a few lumps only are observed, and at others very large
quantities of it escape with each pain ; when in small quantity

* In a great many animals, both domestic and wild, parturition is also pre-
ceded by a discharge of mucous matters, which is sometimes very abundant.

DISCHARGE OF GLAIRY MUCUS. 281

or wholly wanting, the labor is said to be a dry one; when abun-
dant, it leads us to believe the labor will be soon terminated.
Where red strise are mixed Avith it, the woman is said to have a
show, and the bystanders think it a good sign; or a proof that the
labor will be quickly over. This notion, although not without some
foundation, for it is generally observed about the close of the first
stage, is far from being always correct ; because there are cases
where the red colored mucus does not appear at all, while there
are others in which it occurs with the first pains.

705. Some authors have supposed that this semi-fluid matter
escapes by transudation from the membranes, and upon leaving the
ovum becomes thickened in consequence of the increased tempera-
ture of the parts of generation; as if there was the least resemblance,
either as to nature or appearance, between the water of the amnios
and the mucous discharges! Others have believed that the fluids
brought to the external surface of the ovum, meeting only with vessels
of extreme tenuity whereby to penetrate within the amnios, decom-
pose, become in some measure filtered, and that their finest and most
subtle particles pass through the membranes to form the waters; while
their grosser principles remain without, accumulate in the vessels
nearest the internal surface of the womb, whence they are expelled
during the contractions to give rise to the glairy discharges; but such
an hypothesis need only be mentioned in order to show its futility.
The glairy matter is furnished by the mucous membrane, and I cannot
conceive why its source should have been looked for any where else.
The vagina is lubricated with it every moment during the lifetime
of the individual; many women discharge pretty large flakes of it
at the approach of the catamenise; it is not uncommon to find the
womb filled with it in women who die in the unimpregnated state; in
leuchorrhcea and other diseased states, it sometimes exhibits the same
characters, and runs ofi" in as large quantity as during labor; finally
if it be of the very essence of organs lined with mucous membranes
to secrete mucus, is it surprising that 'some of it should be formed
in the sexual organs during labor?

706. The blood mixed with it comes neither from a rupture of
the utero-placental vessels, for these vessels have no existence, nor
from slight lacerations of the cervix, at least, most generally; for it
is very common to find the bloody mucus appear before the cervix
has been at all stretched: the mucus is colored with blood in the
same manner as the sputa in cases of pulmonic irritation, or as the
mucous excretions of the nose in cases of irritation seated in the
schneiderian membrane, &c. Whether this blood be derived from
the interior of the womb, or even from some cracks in the cervix

25

283 DISCHARGE OF GLAIRY MUCUS.

uteri, it may be conceived that though it ordinarily goes only so far
as to redden the mucus, it may nevertheless go to a much greater
extent, so as to constitute a real hemorrhage.

707. The use of the glairy matter is to moisten and lubricate the
parts over which the child has to pass, to increase their suppleness
and extensibility, and make it more easy for the ovum to slide over
the surfaces. Where the discharges fail to take place, the dilatation
of the OS uteri is always more painful, slower, and the organs more
disposed to become inflamed; their superabundance, in general, in-
dicates great softness of the tissues, weakness and a disposition to
inertia; so that this phenomenon really deserves great attention in
practice, and the accoucheur ought carefully to study its progress
and its particular modifications.

§. VII. Of the Bag of TVaters.

708. The name of bag of waters is given to the protuberance
formed by the membranes in the upper part of the vagina during
labor. A true segment of a sphere, or of an ovoid figure, which
was compared by A. Petit to a tymhal, this sac varies, however, in
respect to its shape, for it is generally moulded upon the opening
through which it tends to escape. Round, globular, and even, where
the OS uteri corresponds to the centre of the pelvis, and dilates in a
regular manner, commonly elliptical, where the child presents trans-
versely, wider behind and to the right or left in cases where the
•womb is strongly inclined in the opposite direction, it sometimes
presents the appearance of a cone, somewhat elongated, or of a
portion of intestine, or, as it is called, the shape of a saussage or
blood pudding, particularly when the foetus presents by the feet, or
also where the os uteri is very hard at the same time that the mem-
branes exhibit a great degree of extensibility; it has, finally, been
seen to enlarge beneath the orifice and become pyriform.

709. During the presence of a pain the bag of waters is hard,
tense, and elastic; after the contraction is over it becomes wrinkled
and contracts or disappears. Constituted like the rest of the ovum
of the anhistous membrane, the chorion and amnios, its formation,
according to some persons, depends upon the elongation of the
membranes; but A. Petit has fully refuted this opinion, by demon-
strating that the fcetal tunics are scarcely extensible; according to
some other writers, and particularly the last named author, every
contraction causes a small quantity of water to exude from them out-
wards; a vacuum is gradually effected in the amnios; and the ovum
being powerfully pressed in all directions, gradually engages, through
the orifice, in the upper part of the vagina; but if this transudation

BAG OF WATERS. 283

really took place, the surface of the bag would become" covered Avith
small drops of water, or a kind of dew, in a word, it would become
moist, during the pains, whereas, it is never drier than it is during the
very strongest contractions; besides, it has already been seen that
there is no analogy between the liquor amnii and the glairy dis-
charges, into the composition of which A. Petit gratuitously sup-
posed them to enter so readily.

710. The bag of waters, like the dilatation of the cervix, is pro-
duced by the contractions of the womb, and by a mechanism equally
easy to be understood: by acting upon the periphery of the ovum as
upon the throat of a pulley, the uterine fibres compel it to descend,
while, on the other hand, the cervix, by dilating, is obliged to ap-
proach nearer to the fundus, and to leave a more or less considerable
segment of the membranes outside of the orifice; the point of the
foetal ovoid, lubricated with mucus, forces the orifice to open a little,
as the finger, when previously covered with a peach skin turned in-
side out, will force the fingers of the other hand to open when we
try to push it betwixt them. It would, notwithstanding, be wrong
absolutely to deny the extensibility of the tunics of the foetus. On
the contrary, every thing proves that they may sometimes extend to
a considerable degree, and that it is in consequence of this elonga-
tion that the bag in certain cases aflects the form of a cone or of a
pear; I merely wish to say that this property is in general very slight.
Even if it be true that the amniotic lymbal is almost always curved
upon a cord that is shorter than the rest of the ovum, it is also true
that this peculiarity, which seems to demonstrate that the membranes,
have yielded at that point, is owing to another cause; any one who
has had occasion carefully to open a pregnant womb, has had an
opportunity of being convinced that the mere weight of the ovum is
sufficient to flatten it very considerably, as soon as it ceases to be
exactly supported by the surrounding organs: therefore, it is quite
evident that a portion of the membranes may in this state of relaxa-
tion engage very well in the os uteri, and in a very small volume,
without undergoing any real elongation.

711. After having wholly, or in part, dilated the os uteri, the baw
of waters, now become very large, and besides, ill-supported in the
upper part of the vagina, yields to the impulsion of the liquid, and
breaks; the contained fluid escapes, and the head of the child beino-
at the same moment pushed forwards by the same effort, stops up
the passage to the rest of the liquor amnii. But this rupture is far
from always taking place at the same point, or under the same de-
gree of dilatation, or at the same stage of labor in all women. The
membranes may be too dense, too thick and too resisting, or too

284 BA.G OF WATERS.

thin and fragile; the os uteri itself, which is sometimes very hard,
rigid and difficult to distend, is, on the contrary, in other cases ex-
tremely soft. In the most natural and regular state of things, the
sac gives Avay about the end of the first, or commencement of the
second stage; but it may open at the beginning, or not till the end
of the labor. It happens also, sometimes, that the membranes burst
either one or several days before the appearance of the first pains,
or that they do not rupture, at all, the ovum being forced to pass
whole through the straits of the pelvis.

The perforation commonly takes place in the centre, and in that
case the sac becomes instandy empty; if it happen near the edge
of the orifice or high up, it collapses only imperfectly, or appears
again with each return of the pains, and the fluid escapes in small
quantities only. When the tumor does not open until it nearly
reaches the vulva, and the rupture does not take place in the centre,
the head carries a segment of the membrane along before it, and the
foetus escapes covered with a sort of hood, and is born with a caul.

712. It was formerly predicted that a child born in this way
would be lucky or unlucky according to the color of the caul; that
if it swallowed its caul previously reduced to powder, or always
carried it about its person carefully enclosed in a box, it would be
fortunate and always happy; that if it lost it, it would be unhappy
in every thing, perhaps epileptic, constantly tormented by phantoms
or infernal spirits; whence it follows, says Diemerbroeck, that the
midwives seize upon this portion of membrane as a matter of right,
in order to frighten the parents, and get more money from them by
selling it to them at a dear rate. How many good women in the
country are still imbued with this absurd prejudice! Should the
caul extend over the mouth and nose, it might, strictly speaking,
hinder respiration from taking place, and perhaps cause the death of
the child, as some authors have supposed; but to justify such fears
as these, the lying-in woman herself must be supposed to be insen-
sible, and to have no body with her: this, therefore, is one of those
possible misfortunes of which we are as yet in possession of no ex-
amples.

EUTOCIA. 285

ARTICLE II.

Of Eutocia, or Simple, Fortunate, or Spontaneous Labor
{natural labor of the French writers).

In order that labor may terminate without foreign aid, a conside-
rable number of conditions are required.

713. On the part of the ivoman, there must be no fault nor de-
formity in the pelvis; no serious affection of the womb, no scirrhus
nor old cicatrices; the organ must enjoy a certain degree of energy;
the general powers of the system must not have been exhausted,
either by a profuse hemorrhage, or any long continued disease;
there must be no affection, making it dangerous for the woman to
give herself fully up to the efforts she is compelled to make, and no
accident must supervene during the labor.

714. On the part of the child, it is important that the occipito-
coccygeal axis should present one of its extremities to the straits,
that the fostus should descend with the head, the feet, the knees or
the breech foremost; that it should not be hydrocephalous, gibbous
or ascitic; not of a size disproportioned to the capacity of the pelvis;
that there be not two heads attached to a single trunk, or two trunks
to a single head, nor two children united together in any manner
whatever.

715. Notwithstanding the number of these conditions, it is a rare
thing for them not to be met with; for spontaneous child-birth forms
a large proportion of the sum total of labors. We find in Merri-
man's Synoptical Table, that out of 1800 cases 1746 might have
terminated spontaneously, since the child presented by the vertex in
1654 instances, four times by the lower extremities, twenty-three
by the face, forty-two by the hip, and that in twenty-three cases the
labor was only regarded as dystocial because they were multiparous
pregnancies. 20,357 labors took place at the Maternite at Paris
from 1797 to the end of 1811; of these 20,183 were natural. Out
of 1897 that took place under the superintendence of Dr. Bland,
1860 were brought to a conclusion by the hand of nature. It is seen,
therefore, that at the Maison d'Accouchement at Paris, difficult la-
bors have occurred in the proportion of one to sixty-two; and at the
Westminster Dispensary and Middlesex Hospital, according to Mer-
riman and Bland, out of forty-three labors, forty-two terminate spon-
taneously.

Madame Lachapelle, in her new tables, divides the labors that
have fallen under her notice into two periods; the first, extending

25*

286 EUTOCIA.

from the 1st Germinal, year IX, to the 31st December 1811, com-
prises 15,662 cases, of which 15,380 were spontaneous, and two
hundred and seventy-two difficult; the second, which extends from
the 1st of January 1812 to the 31st December 1820, comprises
22,243 labors, of which 21,974 terminated without any artificial as-
sistance, and two hundred and sixty-nine by the assistance of art.
According to Boer, there were 958 cases from September 1787 to the
same period in 1790, in the Obstetrical School of Vienna; and of
this number seventeen required turning, the forceps, or the perfora-
tion of the head; from September 1790 to September 1791, there
were eighteen cases of dystocia out of 950 labors; from September
1791 to September 1792, out of 1015 labors, there were eight re-
quiring turning, and seven the forceps; from the 1st January 1801 to
31st December 1802, among 2234 labors, thirteen were concluded
by turning, eight by forceps, and two by the perforation of the head;
from January 1st, 1803, to December 31st, 1805, out of 2,399 la-
bors there were five cases of turning, eleven of application of the for-
ceps, and three of perforation; in 1806, out of 2030 cases, seven re-
quired turning, two the forceps, and one the perforation of the head.
At Heidelberg, out of 1296 labors mentioned by M. Nsegele, 1230
were natural, and sixty-four not natural; which gives the proportion
of one to twenty, while the view by Boer exhibits, upon a total of
9590 only 102 requiring turning, the employment of the forceps, or
the perforation of the head; which makes about one case of dystocia
in ninety-five. But these proportions must be understood only as
showing the practice of the authors who have published them, and
not practice out of the public establishments. The discrepancies
now existing in reports on this head are already sufficiently great; as
may be evident upon reference to the London and Paris reports, and
those of M. Boer, and those of the clinic at Pavia, for, according to
M. Lovati, out of sixty-seven labors, twenty-two required to be as-
sisted. However, the proportions found in private practice are still
more variable, for, in great cities as well as in the country, the re-
sources of art are called in, at least in one case in six, by some indi-
viduals, whilst others employ them only once in ten, twenty, or
thirty, or even sixty, eighty or one hundred cases.

716. Admitting the result of the last period mentioned by the
Vienna professor, as the farthest possible limit, as the last term, and
beyond which nature cannot pass, we ask, can we rely upon enjoy-
ing equal advantages ? On this subject I think it important that
we should not confound the possible with the useful. Although
Boer's work proved that only one case out of one hundred and
Ihirty-two labors was terminated by the assistance of art, it does

EUTOCIA. 287

not by any means prove that it would not have been better to have
had recourse to it in some other of the hundred and thirty-one cases.
Is it not certain that in many cases where parturition may, rigorously
speaking, take place spontaneously, nature would, by a proper kind
of assistance, conclude the function more happily both for the mo-
ther and the child ? As to Merriman and Bland, who mention one
case of dystocia out of forty-five, it is not proved that they were not
in a hurry to act in many cases where the organism, if left to itself,
would have fully sufficed for its own welfare; besides, every body
knows that patience is not the prevailing quality of English practi-
tioners. Be this as it may, if the results obtained in the hospitals
of Vienna and London be taken as the two extremes, it seems to
me that we may admit those of the Maternite at Paris to be the
mean term, and then it will appear that the active co-operation of
the accoucheur will be useful in one out of fifty or sixty cases.

717. Now what is the reason that a different result is found to
occur in private practice? Ought dystocia to be met with more
frequently in women in easy circumstances, who live well in their
own families, than in the poor, who are tormented with fear or re-
morse, and who go to the hospitals to be confined? No, doubtless;
for every thing concurs to increase the number of difficult labors
in the hospitals, and diminish it in private practice. Deformed pel-
vis and all sorts of diseases of the genital organs are mosi frequendy
to be met with among the poorer class of women; many women,
who would otherwise have remained at their own houses to be de-
livered, go to lie-in at the hospital, because they are of a bad con-
formation, or because they are fearful of having a dangerous labor;
many others go there while in labor, because they are found, by the
person originally called in, to need the assistance of art, and because
they will have an opportunity of receiving that assistance better than
they would at home.

718. But in the hospitals none, in general, except skilful persons,
are appointed, who do not act for the mere pleasure of doing so,
who repose in nature all the confidence that she deserves, and do
not vainly interfere to assist her to do better; who know how to
apply in proper season, and only where they are indispensable, or
at least evidently useful, the resources of an art whose fundamental
principle is, always to preserve, and never to destroy, except in
cases of absolute necessity. But out of those public institutions, how
many imprudent, ill-timed, unskilful, or rash manoeuvres! Here it
is an ignorant midwife, whose audacity and effrontery supply the
place of knowledge, who cannot remain unemployed about the un-
fortunate women who are so thoughtless as to confide in her; there.

288 EUTOCIA.

it is a practitioner not less inept and more dangerous than the old
woman, inasmuch as he inspires confidence; such men, who are,
unfortunately, too numerous, who call themselves accoucheurs, be-
cause they are incapable of becoming any thing else, take a pride
in the number of difficult labors that they have terminated; they
resolve to deliver by force, without giving nature, who is wiser
than themselves, time to finish her work; and so that they may but
seem to be necessary, fear not to obstruct, interfere with and tor-
ment the organs, so as to convert the most natural labor into a
dangerous one!

There again, it is an impatient practitioner, who, being in too
great a hurry to wait, needlessly applies the assistance of art, so
as to be sooner at liberty to pursue his occupation somewhere else.
Sometimes it is a timid young physician, who, led away by the cries
of the patient, her relations, and assistants, rather than lose the
confidence he wishes to inspire, decides on resorting to measures
he knows to be useless. Finally, on other occasions, there are
wretches, equally criminal and despicable, who, in order to obtain
reputation among the people, make haste to operate wherever they
suppose they can profit thereby, without thinking upon the dangers
to which they expose both mother and child. Such scandalous
conduct as this, to the shame of the authorities, the laws, and of
the estabUshments for instruction be it spoken, is daily observed far
more in the large cities than in country places.

719. " I feel compelled," says Diderot, " by the interest that every
honest man ought to feel in the birth of the citizens, to declare, that
being urged by curiosity, I caused myself to be conducted one day
to one of those midwives who take in pupils, and that I there wit-
nessed samples of inhumanity which would be almost incredible
among barbarians; these midwives, in hopes of attracting a greater
number of spectators, and consequently of peasants, would cause
their emissaries to announce that they had a woman in child birth, and
that the labor would certainly prove preternatural; the spectators
collected, and in order not to deceive the general expectation, they
returned the child into the womb, and brought it down by the feet!
I should not dare to state this fact if I had not several times been a
witness to it, and if the midwife had not the impudence to confess
it to me. I therefore charge those who are appointed to watch
over the disorders of society, to keep their eyes upon this one."

Would to Heaven the fact related by Diderot had never been re-
peated since, and that it had never been witnessed except among
midwives! But let us draw a veil over a kind of conduct which
lends but too much support to the idea of Denman, " that the abuse

EUTOCIA. 289

of art produces evils more numerous and serious than the imperfec-
tions of nature."

Such, doubtless, are the chief causes that render dystocia more
common in private than in hospital practice.

720. However, it must be confessed that the proportions between
the different kinds of labor must of necessity vary from circum-
stances wholly accidental. Thus, of two practitioners who are
equally skilful and equally circumspect, one may attend several
hundred labors without being obliged to give any assistance to na-
ture; while the other may be several times obliged to have re-
course to the artificial means. Since I began carefully to notice the
facts that have fallen under my own observation in tokology, I have
found a very great difference between what has occurred at my
amphitheatre and in my private practice. Out of five hundred and
fifty labors that took place in the Hospital de Perfectionnement
while I had charge of it, and in my own amphitheatre, only eight
required 'any assistance; in my private practice, on the contrary,
out of less than three hundred cases, I had thirty cases of dystocia;
which gives for the former only one difficult labor in upwards of
sixty, and for the latter, so to speak, one for every eight labors.
Such a disproportion is, however, not difficult to account for; at
my public hall, and at the hospital, we received without distinction
all the women who presented themselves, without any of them, ex-
cept two, having previously undergone any examination; while the
cases of dystocia that fell under my notice elsewhere, were almost
all procured for me by my brethren, or by midwives, who, from ex-
cessive timidity, or for want of practice in the use of instruments, pre-
ferred calling on me rather than to attempt to deliver the women
themselves.

SECTION 1.

Of Natural Eutocia {simple or spontaneous labor, the head of the
child presenting).

721. What I have said concerning the attitude and position of the
fostus in the womb, makes it sufficiently evident, that the child ought
properly to present its cephalic extremity to the straits of the pelvis,
and that the cases where it descends in any other way should be re-
garded only as anomalies. It was correct, therefore, in Hippocrates
and most of the ancient authors, not to give the tide of natural la-
bors except to those in which the head of the child came first, and
to call all labors where the feet, the breech, or knees presented, non-

290 NATURAL EUTOCIA.

natural. The moderns having rejected this doctrine depends upon
their having misconceived the acceptation of the terms: the word
natural is admitted by them to be synonymous with spontaneous,
and consequently that labor where tlie pelvic extremity presents
ought to belong to the class of natural labors.

722. There is no doubt that tlie principles taught by the father
of medicine have been the cause of important errors in practice, by
leading practitioners to deliver by the head when it did not origi-
nally present, and in denying the possibility of a labor terminating
alone, where the feet present; but, although they abandoned these
ideas, have not the authors of the last century replaced them by
others equally incorrect? Is it right, with Dionis, and A. Petit, to
say that the fostus may be extracted with as much or more ease by
drawing it away by the feet, than if it descends with the head fore-
most; and that it is almost a matter of indifference as to the result,
whether the cephalic or pelvic extremity presents? I do not think
so, and I dare to say that such a way of thinking would be scarcely-
less dangerous in practice than the ancient doctrine. There is no
position of the child in which the labor has not sometimes termi-
nated alone; and yet it has entered into no one's head to call a shoul-
der presentation, for example, a natural one. If a dystocia takes
place, it is not because the chiW is in this or that position, but be-
cause the interference of art becomes indispensably necessary; a la-
bor may be fortunate, and simple, or spontaneous, although the foetus
presents with its pelvic extremity; but strictly speaking, the posi-
tions of the head are alone natural or normal.

723. Delivery by the encephalic extremity contains two very dis-
tinct genera: in the first the summit of the head presents; while in
the second, the face or some other part of the head offers at the
straits.

§1. Presentation of the Tertex.

1664 times in 1800 cases (Merriman); 1792 times in 1897 cases
(Bland); 19,780 in 20,357 cases (iMadame Boivin); 14,677 times
in 15,652 cases (Madame Lachapelle); 20,098 times in 22,243 (Id.);
1210 in 1296 cases (Ncegele); 61 in 67 (Lovati); 392 in 400 (Hos-
pital of the Faculty).

724. The presentation of the vertex is incomparably more fre-
quent, as may be seen above, than all the others. Is any thing fur-
ther wanting to prove that it is the only natural one, that which the
organism always tends to produce, when nothing arises to interfere
with the regular accomplishment of the grand act of reproduction?
In this presentation the posterior fontanel tends to place itself in the

TABLE II.

Positions of the Foetus according to different Authors.

Vertex.

Face.

Feet.

Knees.

Breech.

\l
[I

\-

L4.

\l

f\. Front of the legs behind the left acetabulum.
J 2. Front of the legs behind the right acetabulum,
j 3. Front of the legs behind the symphysis pubis.
l_4. Front of the legs before the sacrum.

fl. Sacrum behind the left acetabulum,
j 2. Sacrum behind the right acetabulum.
I 3. Sacrum behind the symphysis pubis.
1^4. Sacrum in front of the promontory.

Occiput behind the left acetabulum.
Occiput behind the right acetabulum.
Occiput behind the .symphysis pubis.
Occiput before the right sacro-iliac symphysis.
Occiput before the leit sacro-iliac symphysis.
Occiput before the sacrum.

Forehead upon the symphysis pubis.
Forehead upon the sacro-vertebral angle.
Forehead upon the left ileo-pectineal eminence.
Forehead upon the right ileo-pectineal eminence.

Heels behind the left acetabulum.
Heels behind the right acetabulum.
Heels behind the symphysis pubis.
Heels in front of the sacrum.

Trunk.

'Posterior surface.

Anterior surface.

^Lateral surface.

f ] . Occiput.
I 2. Neck.
\ 3. Breast.
I 4. Loins.
l_5. Sacrum.
rl. Face.
I 2. Neck.

Sternum.

Abdomen.

Genitals.

Neck.
i 2. Shoulder.
■{ 3. Thorax.
I 4. Flank.
L5. Hip.

1

^3.
I 4.
15.
fl.

1. Head in front,

2. Head behind.

3. Head left.

4. Head right.

O

f Vertex.

Face.

J Feet. .

' Knees.

Breech.

Trunk.

Same as BAUDELOcauE.

rl. Forehead left.
J 2. Forehead right,
j 3. Forehead front.
1^4. Forehead back.

f 1. Heels, legs, or sacrum left.
J 2. Heels, legs, or sacrum right.
I 3. Heels, legs, or sacrum front.
1^4. Heels, legs, or sacrum back.

f Lateral surface.
\ Posterior surface.
(^Anterior surface.

1

No subdivisions,

l.Head left.
Head right,
j 3. Head front.
(.4. Head back.

' Ver

tex.

Face,

g I Feet.

^ Knees.
Breech.

Trunk.

TABLE 11.— Continued.

'1. Left occipito-cotyloid.

2. Right occipito-cotyloid.

3. Right occipito sacro-iliac.
_4. Left occipito sacro-iliac.

Same as Gardien.

' 1. Left calcaneo-cotyloid.

2. Right calcaneo-cotyloid.

3. Right calcaneo sacro-iliac.

4. Left calcaneo sacro-iliac.

< Same relations.

j" Anterior surface. ] g." Sst
■{ Back. — No subdivisions

I. Lateral surface. <J 2. Shoulder.

sions.
t L Hip.
{ 2. Shoul
f 3. Ear.

1

J-o' >SameasGARD.
J 4 J

Fieriex.

Fee*. .

Knees.

Breech:

Face.

I Trunk.

1. Left occipito-anterior.

2. Right occipito-anterior.

3. Right occipito-posterior.
(_ 4. Left occipito-posterior.

f 1. Left calcaneo, tibio, or sacro-anterior.

J 2. Right calcaneo, tibio, or sacro-anterior.

I 3. Right calcaneo, tibio, or sacro-posterior.

^4. Left calcaneo, tibio, or sacro-posterior.

f 1. Chin behind and right.

J 2. Chin behind and left.

) 3. Chin in front and left.

L 4. Chin in front and right.

-Posterior surface.
Anterior surface.

)i.

Occiput.
Back.

1. Face.

2. Breast.

I T>- i,i 1 i c C Side of the
j Right lat. surface. > j^^^^^

t Left lat. surface, f Shoulder.

1. Head front & left.

2. Head front & right,
J" 3. Head back & right.

4. Head back & left.

Vertex.

Face. .

Feet. .
S ■{ Knees.
^ Breech.

I Trunk.

Like Gardien.

rl. Mento-sacral.
J 2. Mento-pubic.
} 3. Right mento-iliac.
[^4. Left mento-iliac.

Like BAUDELocauE.

'Sternal surface. — Like Baudelocciue; but no subdivision.
fl. Cervico- sacral.

Poster, surface. J f g^'-y'^o-P"!'^'^-.,.

I o. Right cervico-iliac.

t4. Left cervico-iliac.

{1. Costiil region. fl.")

2. Region of the 1 2. I Like Baud.
shoulder. j o. {

3. Region of the ear. l_ 4. J

o

Vertex.

-5 Face. . ,
Feet. . .
Knees.
Breech. '
Shoulder.

TABLE II.— Continued.

'1. 1st of Baudelocque.

2. Ide7n.

3. 4th of Baudelocque.

4. 5th of Baudelocque.

5. Occiput to the left.
l_ 6. Occiput to the right.

1
I
y Like Baudelocque.

I
J

f Moreover there are intermediate,
I imperfect, and inchned posi-
■{ tions.

I

(_ No other position of tlie trunk.

Vertex.

1. Occipital fontanel above the left acetabulum.

2. Occipital fontanel above the right acetabulum.

3. Occipital fontanel above symphysis pubis.

4. Occipital fontanel above right sacro-iliac symphysis.

5. Occipital fontanel above left sacro-iliac symphysis.
I 6. Occipital fontanel above sacro-vcrtebral angle.

1 7. Occipital fontanel above left iliac fossa.
l_8. Occipital fontanel above right iliac fossa.

Breech. . Eight species, like those for the vertex.

Trunk.
4 surfaces.

fl. Face.
fAnter. surface.! 2. Throat,
) 3. Sternum.
l_4. Abdomen.

1. Nucha.

2. Back.

3. Loins.

Poster, surface.

(.Lat. surfaces.

l_4. Sacrum.
fl. Cheek.
J 2. Neck.
) 3. Shoulder*
L4. Hip.

1. Head to the left.

2. Head to the right.

3. Head in front.

4. Head behind.

' Vertex 4 positions, like MM. Maygrier and Capuron

el. Loins to the left. 1

„ , . J ■.• ! 2. Loins to the right. I

^^'"»« 4 positions.^ 3_ Loins in front. |

l_4. Loins towards the back.

Face 2 positions. ^ q"

Right shoulder. . 2 positions. < ^

. Left shoulder. . 2 positions. < ^

Vertex to the left.
Vertex to the right.
Back in front.
Back to the rear.
Back in front.
Back to the rear.

Making
}■ in all 14
I species.

I
I

J

.-» o '^

I Vertex.

Face.
J Feet.
j Knees.

Breech.

Trunk.

^

>■ Like Baudelocque.

Like Baudelocque, except the subdivisions.

26

TABLE 11.— Continued.

< i

Head.
2 species.

Vertex.
2 species.

I 1. Occip.-ant. 3 var. <
I 2. Occip.-post. 3 var. <

^ Face. Onlyl

one spe- | Mento-pubic. 4 va-
cies at Y rieties at the su-

the inf. j perior strait.

(_ strait. J

1. Left occip.-acet.

2. Right occip.-acet.

3. Occip.-pubic.

1. Left fronto-acet.

2. Right fronto-acet.

3. Fronto-pubic.

[ 1. Right mento-iliac.

J 2. Left mento-iliac.

] 3. Mento-pubic.

L4. Mento-sacral.

L Feet.

2. Knees. ^■ 2 spec. ■{

3. Breech. \

Lower end ")
of the I
trunk, only ^3 shades,
one kind : j
the Pelvis, J

(1. Lateral surface. One species.
I The shoulder. 2 varieties.
J 2. Posterior surface. One species,
j The back. 2 varieties.
I 3. Anterior surface. One species
l^ The breast. 2 varieties.

t^ 2. Sacro- (
post. <
3 var. f

!i

Trunk.
3 genera.

1. Sacro-
ant.
3 var.

2. Sacro-
post
3 var

1. Head

2. Head
\. Head
2. Head

1. Head

2. Head

L Left.
Right.
Pubic.
Right.

2. Left.

3. Sacral,
left,
right,
left,
right,
left,
right.

Besides these, there are inclined positions of the head, L The temple;
2. The forehead; 3. The occiput; and of the breech there are, 1. The
hip; 2. Sacrum; 3. The parts of generation.

PRESENTATION OF THE VERTEX. 291

centre of the pelvis. The principal diameters of the straits are
adapted to the occipito-bregmalic and bi-parietal diameters. The
occipito-mental diameter, and the occipito-bregraatic circumference
should be parallel to the planes of the openings of the excavation,
and to the axes of the straits. These general relations are always
to be observed in regular positions of the vertex; but the occiput is
far from looking to the same point of the pelvic circle in all cases,
whence have arisen the various positions at present admitted in to-
kology.

Antecedently to the time of A. Petit, Solayres, and Baudelocque,
accoucheurs were content to say that the occiput had come in front
or backwards, that the face was turned towards the sacrum or
towards the pubis; and this old method of considering it, which
M. Delpech defends, is still generally adopted in England, in Ger-
many, and in most foreign countries. It is therefore in France
particularly, and almost only in France, that attempts have been
made to subject labors to the methods followed in natural history.
But upon this, as upon all other subjects that are merely matters of
convention, it has happened thai the same fact has not been looked
at in the same light by all observers. In the opinion of some we
ought to admit six positions of the vertex; according to others, the
number may be extended to twelve and even to twenty-four; many
think that there should be only four, and some not more than two.
Again, those who agree in respect to the proper number differ in
regard to the proper method of counting them or locating them.
For example, Madame Lachapelle, who like Baudelocque admits
of six positions, does not adopt the two antero-posterior positions of
that author, but in place of them establishes two transverse positions,
&c.; so that it is a pretty difficult matter for students to make a choice
in such a conflict of authorities.

In a theoretical point of view it cannot be denied that the vertex
may present itself to every point of the circumference of the superior
strait, and consequently, that an infinite number of positions may be
established if we choose; but the question is, how many of them
would it be useful to adopt in practice, which are those we ought
to study with particular care, and not how many we might admit.
In the first place, it is evidently superfluous to suppose there are
more of them than there are points corresponding to the ends of the
four principal diameters of the pelvis; therefore it seems that the
number established by M. Flamant, and which unites the classifica-
tion of Baudelocque with that of Madame Lachapelle, might be
considerably reduced. In fact, the occiput scarcely ever presents in
more than two ways to the inferior strait; in one it looks forwards

292 NATURAL EUTOCIA.

and lodges under the arch of the pubis; in the other, it is turned
backwards, and presses the anterior edge of the perineum forcibly
backwards.

Agreeably to this observation I have thought that all the presenta-
tions of the vertex might without mconvenience be referred to two
fundamental positions: one, in which the occipital protuberance
answers to some one point of the anterior semi-circumference of the
superior strait; the other, where the same part is turned to the
opposite portions of the strait. This modification, although slight,
and in itself considered of very little importance, answers, notwith-
standing, all the wants of both theory and practice; it enjoys the
great advantage of not excluding the other classifications, and of
accommodating itself to all the various doctrines.

The occipito-anterior position comprises the three first positions
of Baudelocque, or the two first of MM. Maygrier, Capuron
and Duges, and of Mesd. Boivin and Lachapelle. The occipito-
posterior position naturally includes the fourth, fifth and sixth of
Baudelocque, or the third and fourth of the authors just now men-
tioned. As to the lateral positions established by Madame Lachapelle
and M. Flamant, they are at least very rarely, if ever to be met with.

It is evident that the first, second and third have one common
termination, and that their mechanism is in almost all respects
similar. It is also undeniable that the fourth, fifth and sixth do not
differ more than the others. I do not perceive, therefore, the utility
in any way, of admitting these varieties, otherwise than as so many
shades of the two fundamental positions, to which all others must
of necessity be at last reduced. As to these, I think that no one
ever attempted to confound them; their mechanism is so different,
that the English accoucheurs, such as Burns, Merriraan and Bland,
bestow the title of natural labor only upon the occipito-anterior
position, while, according to them, the occipito-posterior position be-
longs to the class of preternatural labor.

1. Occipito-anterior Position.
1634 in 1800, Merrirnan; 19,370 in 20,517, Madame Boivin; 14,253 in 15,652
20,268, in 22,243, Madame Lachapelle; 60 in 67, M. Lovati.

Many foreign practitioners think that the occipito-anterior position
is the only one we ought to abandon to the resources of nature.
The causes of its great frequency are wholly physical and easy to
be understood. The head is the heaviest part of the foetus; the
plane of the neck of the womb is always lower than that of the
fundus; the head therefore ought to incline constantly towards the

PRESENTATION OF THE VERTEX. 293

cervix uteri. The posterior half of the head is much more weighty
than the anterior half. The weight of the hinder part of the trunk,
during the intra-uterine life, is much greater than that of the an-
terior portion. When the woman is standing up, sitting down, or
kneeling, and even when lying on her side, the anterior wall of the
womb is much more inclined towards the cervix than its posterior
wall; the back of the fnetus wdl therefore more frequently be found
turned towards the front of the motlier than towards her back. In
quadrupeds, the young are oflen found to have their bellies down-
wards, and almost always come head foremost, although the womb
is lower than the vulva; but it is to be observed that the abdomen
in these species weighs most, and the head least. Another no less
powerful cause of the frequency of this position is found in the pro-
portional dimensions and inclinations of the head and pelvis; the
abdominal strait being much larger in front than behind, and strongly
inclined towards the pubis, it is quite natural that the occiput should
commonly assume this direction, &c. The cause which so often
directs the occiput towards the anterior semi-circle of the strait, is
therefore not more difficult to understand, than that which occasions
the head to descend first; hence physicians were wrong to abandon
their researches in relation to it.

A. First Variety.
Left occipilo-acetabular position.
1st position of Baudelocque, Maygrier, Mesdames Boivin snd Lachapelle;
15,809, in 22,343, Madame Lachapelle; J 5,693 in 20,517, Madame Boivin; 36
in 67, Lovati.

In this position the back of the fcetus looks towards the front and
left; its abdomen towards the back and right. The occiput is placed
behind the corresponding ileo-pectineal eminence much more fre-
quently than behind the acetabulum, and the top of the forehead or
the anterior fontanel, rather than the forehead properly so called,
looks towards the right sacro-iliac symphysis; the right side is to
the right and in front, and the opposite one is behind and towards
the left. Its great frequency seems to depend upon the rectum be-
ing in pregnancy commonly filled with faeces, which forces the fore-
head to incline towards the right side; such at least is the opinion
of accoucheurs in the present day: an opinion which, besides, seems
to be sustained by. direct observation, since M. Duges has seen the
foetus in Baudelocque's second position in two women who had
the rectum on the right side: but this point is worthy of new re-
searches.

26*

294 NATURAL EUTOCIA.

725. In this position the head of the child does not pass through
the pelvis without undergoing four particular motions. 1st, flexion;
2d, rotation; 3d, extension; 4th, restitution.

Flexion. Immediately after the rupture of the membranes, the
uterine contractions must necessarily press the several parts of the
foetus upon each other; being pressed from above downwards, the
spine causes the head to bend forwards so that the occiput sinks
towards the centre of the pelvis, and the chin is squeezed more or
less firmly against the breast. This flexion movement does not
seem to have been well understood, even by the most esteemed
authors. They teach us that antecedently to the very first contrac-
tions of the womb, the head should be, disposed in such a manner,
that its occipito-frontal and bi-parietal diameters should be parallel
to the oblique diameters of the strait; whose axis would then be re-
presented by the vertical diameter of the fcetus. According to them,
the object of the flexion motion would be to alter all these relations;
that is to say, to compel the occipito-mental and occipito-bregmatic
diameters to assume the places of the vertical and occipito-frontal
diameters, which would be much more favorable. In order that the
above might be correct, it would be necessary for the chin, during
pregnancy, to be kept habitually remote from the breast, which it
would not approach until the period of labor, otherwise the occipito-
frontal diameter cannot be parallel to one of the diameters of the
pelvis; but, it is well known that the fostus, in the natural state, is
always doubled up, and that its chin is pressed upon the sternum.
The flexion motion therefore really takes place long before the
commencement of labor, and instead of being wholly eflfected, is
only a little increased during labor.

726. In this way the occiput by being depressed, soon corresponds
to the centre of the superior strait; the occipito-bregmatic diameter
is then parallel to the oblique diameter, which extends from left to
right and from front to rear; the bi-parietal diameter represents the
other oblique diameter; the occipito-mental diameter is parallel to
the axis of the pelvic circle, and the occipito-bregmatic circumference
corresponds to the plane of the strait.

727. Rotation. In this state the head is disposed in the best pos-
sible manner to pass without difficulty through the upper strait; by
successive pains it is forced to descend a little; it reaches the excava-
tion, and being soon stopped by the floor of that cavity, it executes
the rotation or pivot motion; that is to say, it turns upon its great
axis, the occiput sliding upon the left anterior inclined plane, from
behind forwards and from left to right, so as to place itself behind
the symphysis or under the arch of the pubis, while the forehead

PRESENTATION OF THE VERTEX. 295

slides from right to left and from before backwards on the right pos-
terior inclined plane, so as to get into the hollow of the sacrum. This
is the moment when the sacral plexuses are most forcibly compressed,
and when most women are affected with cramps in the legs and
thighs.

728. Extensioyi. Hitherto the flexion of the head has gone on
increasing; henceforth it diminishes: the extension movement is
about to begin; as it approaches the inferior strait the occiput rises,
and by degrees causes the chin to abandon the front of the thorax;
instead of continuing to bend forwards, the head lends to turn
over backwards, in order that the occipito-mental diameter may
be brought into parallelism with the axis of the inferior strait,
without hindering the rest of the trunk from still following the course
of the central line of the superior strait; the rectum and neck of
the bladder being now more forcibly compressed than before, give
rise to a straining, and tenesmus; the womb and abdominal muscles
contract more violently than ever; the perineum distends, elongates,
grows thin, and in this way prolongs the posterior wall of the pelvis
to an extent of from three to four inches. The head being once
engaged in the inferior strait, is no longer in the same relation to
the diameters as before. Yet, it is well to observe that its great
diameter and occipito-bregmatic circumference have not undergone
any change of this sort, and that below as well as above they still
represent the plane and axis of the strait. But instead of being
&ituated obliquely, the bi-parietal and occipito-bregmatic axes are
so situated, that the former corresponds to the direction of the bi-
sciatic diameter, and the latter to that of the coccy-pubal diameter;
which is the reason why at the end as well as at the beginning of
labor the great diameters of the occipito-bregmatic circumference are
always found to correspond to the largest diameters of the pelvis, and
why the chief end of the rotation motion is to establish these favor-
able relations.

729. As the rotation takes place only at the expense of a twist
of the child's neck, and not of its whole body, the shoulders retain
their primitive direction at the superior strait, so that their great
diameter is parallel to that oblique diameter which proceeds from
left to right, and from behind forwards.

730. The efforts of the woman are now redoubled, the head
gradually engages in the vulva, its back part being forwards, and
slides down the plane presented by the anterior surface of the coccyx
and extended perineum, which plane is strongly inclined forwards;
the great labia are slowly effaced, and grow thin from their perineal
commissure towards their pubal extremity; the nyraphae are forci-

296 NATURAL EUTOCIA.

bly pressed in an upward and lateral direction, but they do not un-
fold; they could sooner be torn and separated from the inner sur-
face of the vulva; sometimes even the skin of the upper part of
the thighs yield, so as to assist the pudendum and perineum in
forming the sort of casque, with which the head remains partially
covered until it escapes entirely from the pelvis; the parietal protu-
berances at length pass through the bi-sciatic diameter, and the head,
now arrested by the resistance of the soft parts only, is soon com-
pletely expelled. Whilst it is passing through the vulva, the pos-
terior end of the occipito-bregmatic diameter, continues to rest under
the symphysis pubis, as upon a transverse axis, and rolls from be-
hind forwards, as the occiput, the sagittal suture, the parietal protu-
berances, the anterior fontanel, the frontal bone, the orbits, the nose,
the mouth and chin are seen to emerge in succession. When the
occipito-bregmatic circumference is expelled, the anterior edge of the
perineum, being drawn backwards by its natural elasticity, slides
over the face, which affords it a plane inclined obliquely from the
forehead to the chin, and approaching near the coccyx goes after-
wards to place itself on the fore part of the neck, forcing meanwhile
the head to turn over upon the mons veneris.

731. Restitution. 'I'he head, now freed from all constraint, and
incapable of retaining the twist which had brought it under the arch
of the pubis, soon recovers its natural relation to the shoulders and
rest of the body, which had been temporarily changed; that is to
say, its antero-posterior diameter again crosses the transverse diame-
ter of the shoulders at right angles, as it did when at the superior
strait. In one word, the occiput turns towards the left groin, while
the chin is directed towards the opposite sub-iliac space, and the
title of act of restitution has been given to this rotation.

732. After a calm of a few seconds or minutes duration, the
shoulders descend into the excavation, and perform a pivot motion
upon the anterior right and posterior left inclined planes; the right
shoulder being directed behind the symphysis or under the pubic
arch, and the left on the front of the sacrum, forces the head to un-
dergo a similar motion, which places it entirely crosswise, the occi-
put being to the left and the face to the right. In this direction they
engage in the inferior strait. The right appears first under the pubis;
the child's body bends on its right side so as to accommodate itself
to the pelvis; the left shoulder comes down upon the perineum; the
vertical axis of the thorax is parallel with the axis of the perineal
strait; the vertical axis of the abdomen represents ihat of the superior
strait; they pass the vulva together, and the rest of the body, render-
ed very slippery by the liquor amnii and sebaceous matter, and now

PRESENTATION OF THE VERTEX. 297

representing only the point of a cone whose base has already es-
caped, is expelled by the power of the same effort, and the labor is
terminated.

B. Second Variety.
Right occipito-ace tabular position.
2d position of Solayres and Baudelocque; right antero-lateral of Madame Coi-
vin; right occipito-anterior, Dug6s; 3682 in 20,517 cases, Madame Boivin; 4659
in 22,282 cases, Madame Lachapelle.

733. Admitting that the situation might determine the occurrence
of the first variety, the same cannot be said of the second. M. Duges,
it is true, mentions two cases, where, in this last named position, the
bowel was transposed, being found on the right instead of tlie left,
side; but anatomical observations in daily repeated dissections show
that auch an anomaly does not occur once in every three or four sub-
jects, as ought to be the case were it the only or even the principal
cause of the position: and besides, when it has been met with, was
it not rather an efiect than a cause; and is it not more rational to at-
tribute the second position to the contractions of the womb itselH
If it be true, for example, as several facts carefully examined might
lead me to believe, that previously to the commencement of labor,
the occiput has no determinate position, and does not properly belong
to one anterior variety more than to the other, may we not suppose
that the uterus, being inclined to the right and in fror-t,is more dis-
posed to push the head towards the left than the right side of the
pelvis? The impulse received by the foetus in this inclination of the
womb is necessarily directed from right to left; in which case the
forehead, being arrested by the musculo-vascular edge found in the
apex of the triangle represented by the abdominal strait in the living
subject, must compel the occiput to yield alone to the movement,
and go to place itself opposite the leftilio-pectineal eminence. With-
out attaching any great importance to this idea, I should find it an
easy task to advance a considerable number of reasons in support of
it, and I think it deserving of the attention of those practitioners
who love to give an account of what they observe.

734. However it may be, as to the causes of the right acetabular
position, it is twie that its mechanism differs but little from that of
the preceding one; the child is impelled by the same power; the
head executes the same movements, presents the same circumference
in the different planes of the pelvis, and offers the same diameters
to the principal diameters and axes of the straits, &c. But the occi-
pital fontanel is turned to the right instead of the left; the occipito-
bregmatic diameter, instead of proceeding from left to right, goes

298 NATURAL EUTOCIA.

from right to left, and takes the place of the bi-parietal diameter; dur-
ing the act of rotation its extremities slide upon the right anterior,
and left posterior inclined planes, to conduct the occiput under the
arch of the pubis, and the forehead in front of the sacrum.

735. At the inferior strait and vulva there is not the least differ-
ence remaining betwixt the two positions; but after the escape of
the head, the occiput in its act of restitution turns to the right in-
stead of inclining itself towards the left; the left shoulder, and not
the right, comes under the symphysis pubis, the right side, and not
the left, slides along the sacro-perineal curve; the face and whole
anterior surface of the foetus look towards the inside of the woman's
left thigh, instead of turning towards the right; but nothing of all
this process changes the proportional relations of the foetal head to
the maternal pelvis.

736. This variety is considered as less favorable than the other;
some have said that it renders tlie labor slower and more fatiguing;
when the forehead is turned towards the right sacro-iliac symphysis
it is separated from the parietes of the pelvis only by fat and a layer
of peritoneum, on which it slides without any difficulty, while in the
second position, the rectum shortens the opposite oblique diameter
a little. When in the first position, the occiput and forehead rest on
two regular planes, equally solid and smooth; while in the second,
the anterior part of the head depresses the rectum from above down-
wards, pushes it along before it, and folds it so as soon to form a
kind of cushion, whose thickness is also increased bjT^ the foscal mat-
ters contained within it; it at least follows, that the left posterior
surface of the basin is too soft to allow the head to glide rapidly
down into the lower part of the excavation. The foetus might here,
to a certain extent, be compared to a solid straight stick, one end
of which is applied upon a smooth hard plane, as for example a
plate of glass, or on the other hand upon an uneven or spongy sur-
face, such as a woollen cloth or a mattress. In the former case,
the stick would slide along without tlie least obstacle and under the
slightest impulse, while in the latter it would not slide at all, or with
difficulty. Further, it may be conceived that this state of the plane,
on which the forehead is obliged to descend, may in the same way
interfere with the act of rotation or the pivot motion, &c. All this
may doubtless be true, but upon looking at the subject a little closer,
we soon perceive that much is to be retracted of these pretended
difficulties; for, 1. The thickness of the rectum when compressed
by the head is reduced to a very small degree; 2. The matters with
which it is filled are or may be evacuated at the very beginning of
labor; and 3. The forehead in every case presses on the rectum,
through the parietes of the womb, which does not rise in folds.

PRESENTATION OF THE VERTIX. 299

On this subject I think I ought to point out a contradiction found
in the authors on midwifery. On the one hand, they say that the
right-acetabular position is determined by the presence of the rec-
tum on the right side of the sacrum, and on the other, that this same
position is rendered less favorable by the friction of the head on the
bowel on the left.

Remarks. The act of rotation in these two positions has not been
interpreted in the same way by all authors. Madame Boivin and
some others account for it by referring it to the contraction of the
muscles that line the excavation. But it is evident that such an ex-
planation is inadmissible; for, 1. This rotation sometimes takes place
when the head is still above, and most generally does not occur
until it is below the muscular bundles, to whose contractions it is
attributed; 2. If the pyramidal and internal obturator muscles, by
their contractions, could make the head revolve on its own axis, they
would carry it across the pelvis, and not from front to rear. By
referring it to the action of the sterno-mastoid muscles of the foetus
itself, an opinion has been advanced still less worthy of being com-
bated than the preceding one.

Besides, what need is there for us to look for the cause of this
movement, either to the muscles of the pelvis, or of the child's neck?
The occiput turns towards the pubis, because it finds a vacant space
there, while it is strongly resisted on the sides; it deviates from its
original direction for the same reason that the forehead turns, at the
superior strait, towards the sacro-vertebral angle. The form of the
pelvis and the laws of mechanics give a perfectly clear account ef
this peculiarity: the anterior wall of the excavation, which is much
shorter than the posterior, being deeply notched and somewhat
hollowed out, any salient part of the head, when strongly urged by
the contractions of the womb, could scarcely fail to engage in it, not
only without the assistance of the contractions of the inclined planes,
but even in spite of those contractions, were they really to take
place.

C. Third Variety.

Occipito-pubic position.

The 3d of Solayres, Baudelocque, &c.: 6 in 20, 517, Madame Boivin.

737. The ancients regarded the occipito-pubic as the most fre-
quent position, because they did not distinguish the two antero-
lateral ones, and only judged from what is observed at the inferior
strait. Baudelocque admitted it rather for the purpose of filling
up his plan than from the testimony of his senses. Since his time

300 NATURAL EUTOCIA.

MM. Gardien, Dubois, Flamant, Dewees, and Desormeaux, as well
as Madame Boivin, have continued to describe it, at the same time
admitting it to be very rare. In fact, out of twenty thousand five
hundred and seventeen children, six only were found to present in this
manner. MM. Maygrier, Capuron and Duges have argued against
the possibility of its occurrence, and Madame Lachapelle affirms
that she never observed one single instance of it in more than
thirty-six thousand labors.

The question therefore is, whether it is proper to retain it in a
regular classification. The labors and researches of the moderns
are almost the only ones that can be usefully consulted for the pur-
pose of deciding upon this point; for as Baudelocque found no ob-
jections that he thought it worth while to combat, he neglected to cite
any particular facts for the purpose of demonstrating the possibility
of its occurrence. It is objected by MM. Maygrier and Capuron,
that the forehead, being a solid and round part, cannot maintain itself
in front of the sacro-vertebral angle during the expulsive contrac-
tions of the womb; that two round and equally salient bodies cannot
slide upon each other without turning off to the right or left; in one
word, that previously to the close of pregnancy, or at least at the
very commencement of labor, the forehead of the foetus is neces-
sarily repelled by the promontory towards one of the sacro-iliac
symphyses.

738. Without denying the force of these objections, I may, not-
withstanding, be permitted to observe, that in the recent pelvis the
sacro-iliac hollow is to a great degree effaced by the psoas muscles
and iliac vessels; that the vertebral projection is thus considerably
diminished; that the entrance to the excavation is then not so large
behind as it is in front (72); that the womb being directed in con-
formity with the axis of the superior strait, rather than with the axis
of the spine, and the head of the child habitually bent upon its breast,
the forehead, at the commencement of labor, ought to correspond
to the anterior surface of the first piece of the sacrum, and not to
the sacro-lumbar projection, properly so called; and therefore that
it does not seem impossible for the head to descend in a direct posi-
tion. I add, with M. Desormeaux, that authors have reasoned upon
this case as if the pelvis were always the same, always regular.
Where the vertebral angle is but slightly expressed, or thrown back,
the sacro-pubic diameter is sometimes longer than common, without
the cavity of the pelvis being really vitiated; in such a case the third
position, far from being impossible, should, on the contrary, be the
most natural and the easiest, inasmuch as the head, in engaging,
always strives to place the great diameter of the circumference that

PRESENTATION OF THE VERTEX. 301

presents parallel to the greatest diameter of the pelvis. Although
Madame Boivin states on the one hand that she has met with it six
times in twenty-five thousand five hundred and seventeen cases, on
the other, Madame Lachapelle affirms that it is never met with.
These contradictory assertions at least prove that the situation of
the head at the commencement of labor has not always been recog-
nised with certainty at the Paris Maternite. And how could it be
otherwise? By the confession of all practitioners, it is very often
impossible, previously to the rupture of the membranes, to tell
whether the occipital fontanel is in front or behind, and o fortiori
whether it is to the right or left, rather than in the middle of the
strait. Now, it is probable that Mesdames Boivin and Lachapelle
could, themselves, have touched each of these thirty-six thousand
women before the head had engaged in the excavation? To con-
clude, although it be true that the occipito-pubic position, three very
authentic cases of which are mentioned by Dr. Dewees, is of very
rare occurrence, it is not less true that we are not, in the present
state of the science, authorised to deny its possibility; and as its
mechanism is not altogether the same as that of the occipito-aceta-
bular positions, I think it right to say a few words in regard to it.

739. When at the superior strait, the occipito-mental diameter
and the occipito-bregmatic circumference are placed as in the two
first positions, and always correspond to the axis and plane of that
opening; but the bi-parietal diameter is situated transversely, and
the occipito-bregmatic from front to rear, instead of being parallel to
the oblique diameters; the pivot movement is not necessary and does
not take place; the direction of the various axes of the head is the
same at the end as at the commencement of the labor; as the shoul-
ders look towards the iliac fossae at the commencement, it is uncertain
which way the act of restitution will take place; in fact, there will be
none, because there was no previous act of rotation; however, as it
is a rare occurrence for the shoulders not to place themselves one in
front, and the other behind, before they pass through the inferior
strait, the occiput, after a few moments of indecision, turns to the
right or left, but without our being able to know beforehand which;
after that, there is nothing peculiar in the rest of the labor.

740. Remarks. It cannot be denied that these three positions are
in fact but shades of each other. In all three cases the head begins
by flexing itself strongly down upon the breast, and ends by extend-
ing itself as it passes out under the arch of the pubis; the occiput, a
projecting part that always comes out first, never has more than two
inches, or at most, two inches and a half to pass over before it
reaches the arch of the pubis, and in escaping from the pelvis, it
27

302 NATURAL EUTOCIA.

slides on a surface that is plane and even convex, but not at all
concave. Although in the first variety every thing is disposed in
the most advantageous manner, the presence on the one hand of
the rectum, and on the other of the bladder and sacro-vertebral
angle, cannot after all, render the second and third any more diffi-
cult or dangerous.

2. Occipito-Posterior Position.
320 in 35,895 cases, Madame Lachapelle; 203 in 20,517, Madame Boivin.

741. Of far less frequent occurrence than the occipito -anterior
position, the occipito-sacral position is also much less easy, and less
natural. In order to emerge first, the occiput is compelled to tra-
verse the whole extent of the anterior face of the sacrum, the coccyx
and perineum, that is to say, a surface of from seven to eight inches
in length; while in the other position it escapes after passing over not
more than two inches. The posterior wall of the pelvis is deeply
excavated, while its anterior half circle is rather convex than con-
cave; the summit of the head falls nearly at right angles upon each
point of that wall, and the occiput meets a new resistance at every
effort; which is not the case when it is turned in front. The vertex
cannot present itself at the vulva until a considerable part of the
breast has descended into the excavation; so that it is no longer
merely the occipito-bregraatic diameter, but it is a line drawn from
the anterior fontanel to the posterior part of the thorax that is re-
ferred to the antero-posterior diameter of the lower part of the ex-
cavation. Here the vertebral column is so strongly curved that it
cannot but lose a considerable part of the force impressed upon it
by the womb, before that power can reach the head. The head
and trunk both together, and not the head alone, traverse the exca-
vation and inferior strait; and finally, the forehead is commonly too
broad to fill up the top of the pubic arch accurately, and the coccy-
pubic diameter may on this account lose as much as half an inch of
its length.

742. The causes that occasion the posterior position to occur are
little understood; it is better frankly to avow our ignorance than
vaguely to refer them to this or that shape of the pelvis, to the direc-
tion, or disproportioned dimensions of the womb, to certain habits
of the woman, to uncommon movements of the foetus, &c. The
only thing that can be affirmed about them is, that it is pretty com-
mon to meet with them several times in succession in the same
woman. Besides, this is a question that requires some careful re-
searches before it can be decided. Although the three principal

PRESENTATION OF THE VERTEX. 303

varieties of this position differ only by slight shades from each other,
I nevertheless think, but merely for the purpose of not deviating too
far from generally adopted opinions, that I ara bound to give a suc-
cinct explanation of its peculiar mechanism.

A. First Variety.

Left fronto-acetabular position.

4th position of Baudelocque, Gardien, Dubois, Desormeaux, Lebreton, Fla-

mant, Madame Boivin: 3d of Maygrier, Capuron, Dug6s, and Madame Lacha-

pelle: 109 in 20,517 cases, Madame Boivin; 164 in 22,343 cases, Madame La-

chapelle.

743. The left fronto-acetabular position is the most common of
the three posterior varieties. It unites all the most favorable condi-
tions of its species, and in this respect it excels all the others. The
back of the foetus being turned backwards and to the right, the ab-
domen towards the front and left, its left side to the front and right,
and its right side behind and towards the left side of the womb,
engages in the superior strait in such a way that the occipito-mental,
bi-parietal, and occipito-bregmatic diameters, and occipito-bregmatic
circumference are parallel with the oblique diameters, the plane, and
axis of that strait, respectively, as in the first anterior position.
There is this difference, however, that the frontal extremity of the
occipito-bregmatic axis occupies the place of the sub-occipital ex-
tremity, that the left extremity of the bi-parietal diameter has assumed
that of its right extremity, that the anterior fontanel glides behind
the ilio-pectineal eminence, instead of descending before the sacro-
iliac symphysis, and that the posterior fontanel, instead of being
slightly inclined in front and towards the left, is, on the contrary,
turned more or less backwards and towards the right, which, as is
evident, does not at all interfere with the proportional relations of the
head and pelvis, and prove, that so far the posterior are not more
unfavorable than the anterior positions.

744. After the dilatation of the neck and the rupture of the mem-
branes, when the occipito-bregmatic circumference has passed the
superior strait, the head, meeting with a deep excavation behind, is
rapidly urged to the very bottom of the excavation, and at first the
labor seems to progress more rapidly than in the very opposite posi-
tion; but, from this moment, the difficulties mentioned above become
more and more manifest. Instead of being gradually replaced by
the act of extension, as in the anterior positions, the flexion still
continues to increase with every pain; whilst the forehead is arrested
behind the pubis and the occiput is abutted against the front of the

304 NATURAL EUTOCIA.

sacrum, the coccyx and perineum, which resist so as to force it to
move forwards, the breast engages in the excavation, shdes in some
measure behind the face, opposes the turning of the chin towards
the centre of the pelvis, and makes it very difficult for the occipito-
mental axis to become parallel with the central line of the inferior
strait, and especially with the axis of the vulva. The vertebral
column being too much curved loses a part of the power impressed
upon it by the womb; as it presses upon the head at an angle which
becomes more and more acute, it cannot urge it onwards with the
same degree of energy, even although the same degree of force
might be em.ployed.

The pivot movement takes place, nevertheless, and the forehead,
or the bregma, sliding along the left anterior inclined plane, comes
from left to right, and from behind forwards, to place itself under
the arch of the pubis, whilst the vertex, or occiput, moving upon the
right posterior inclined plane, proceeds from before backwards and
from right to left, into the hollow of the sacrum; but this rotation
is effected with some difficulty, because the forehead is too wide to
adapt itself accurately to the sub-pubal notch; because, beneath the
superior strait, the lateral regions of the hinder half of the pelvis are
made up of soft parts, which do not repel the head with sufficient
force towards the median line; lastly, because the extremities of the
occipito-frontal diameter and its circumference, and not those of the
occipito-bregmatic, roll in inverse directions upon the planes of the
excavation, as is the case in the occipito-anterior position.

745. Notwithstanding so many unfavorable circumstances, the
occiput descends, by bearing strongly upon the sacrum, the coccyx,
and perineum, and the foetus finally passes the strait. In this situa-
tion it is upon the posterior commissure of the vulva, and not upon
the inferior edge of the symphysis pubis, that the occipito-bregmatic
diameter now presses, slides, and reverses itself from above down-
wards and from before backwards; so that the posterior fontanel,
the sagittal suture, the anterior fontanel, the parietal protuberances,
the frontal protuberances, and the several parts of the face, are seen
to appear in succession in front of the perineum. As soon as the
chin is disengaged from the summit of the pubic arch, the act of
restitution takes place; the face inclines towards the left groin, and
the occiput towards the right sub-ischiatic notch; the left shoulder
proceeds in front, under the symphysis; the right shoulder reaches
the concave surface of the sacrum; the head, governed by the move-
ment of the trunk, places itself crosswise; and the rest of the labor
is concluded as it is in the right occipito-acetabular position.

PRESENTATION OF THE VERTEX. 305

B. Second Variety.
Right fronto-acetabular position. ' .

5th position of Baudelocque, Gardien, Dubois, Desormeaux, Madame Boivin,
&c.; 4th of Maygrier, Capuron, Duges, Madame Lacliapelle, &c.: 92 in 20,517
cases, Madame Boivin; 66 in 22,243 cases, Madame Lachapelle.

746. The right fronto-acetabular position, although rather more
rare than the preceding one, is, notwithstanding, more co'mmon,
relatively to the opposite fronto-acetabular position, than the right
occipito-acetabular is when compared to the left occipito-acetabular
position. This peculiarity comes in support of the opinion I ad-
vanced when detailing the causes of the first position of the vertex:
it may in fact be conceived, that if once placed behind, at the supe-
rior strait, the occiput may descend almost indifferently to the right
or left of the median line, while, if turned forwards, it must be most
frequently repelled towards the left side.

In this position the back of the foetus is directed to the left and
backwards, the right shoulder to the left and forwards; the bi-parietal
diameter represents the left antero-oblique diameter; the occipito-
bregmatic is parallel with the right antero-oblique; and the lesser cir-
cumference and occipito-mental diameter are parallel with the plane
and axis of the strait. The head, when engaged in the excavation,
revolves a half quarter of a circle upon its vertical axis. The occi-
put, sliding upon the left posterior inclined plane, proceeds to lodge
in the hollow of the sacrum; wliile the bregma, rolling upon the
right anterior inclined plane, is directed to the symphysis pubis.

Upon emerging from the vulva, when the act of restitution takes
place, the occiput gradually turns towards the inside of the left thigh,
and not the right, as in the fourth position. As to the rest of the
labor, it is terminated like the former, except that the front of the
foetus at last looks towards the right, and its right side directly in
front, whereas in the other variety, dirgctly the reverse is observed.
Moreover, it is said to be rather more difficult, in consequence of the
presence of the rectum, which must retard the progress of the occiput.

747. M. Nsegele maintains that the fourth position of the vertex
is much more common than the second, and that the French ac-
coucheurs did not perceive it, because, being led away by the autho-
rity of Baudelocque, they did not perceive that the former of these
two positions commonly converts itself into the right occipito-aceta-
bular position, as soon as the head gets through tlie superior strait.*

* My own experience in midwifery is in perfect accordance v/ith M. Naegele's
assertion on this point. — M.

27*

306 NATURAL EUTOCIA.

These assertions of the German professor ought to be taken into
consideration, not that they are perfectly correct, for even provided
the very numerous observations collected at the Paris Maternile could
not be cited as proofs of the contrary, the form of the pelvis and the
specific gravity of the foetus would alone prevent the admission of
such an opinion, until its correctness had been irreversibly demon-
strated by multiplied facts; but they should be taken into considera-
tion, because it appears certain, that when the occiput reaches the
bottom of the excavation, it does, in fact, in some instances turn to-
wards the acetabulum instead of proceeding towards the posterior
median line. I have already observed and pointed out to many stu-
dents the reality of this phenomenon, so as to leave no doubt upon
the subject. Upon passing the pelvic circle, the head by degrees in-
clines to one side, and places itself exactly cross-wise, soon after it
descends into the excavation. This pivot motion continues, under
the influence of the uterine contractions; if it be the fourth position,
the posterior fontanel gradually reaches the arch of the pubis, by
gliding from behind forwards, and from right to left, along the right
anterior inclined plane, and on the other hand from left to right for
the fifth, &c.

748. I am ignorant of the causes to which such anomalies ought
to be attributed; I have never found any thing peculiar in the con-
formation of those women who have exhibited them; the labors have
progressed regularly, and there was nothing unusual in the weight
of the children; I think I have only noticed that from the very begin-
ning of the labor, the antero-poslerior diameter of the head was much
nearer to the bis-iliac than to the sacro-pubic line of the strait, and
that the pubis, being slightly depressed above, seemed to favor the
anterior rotation, by the hoUowness of the arch, and by the distance
to which the acetabula were separated.*

749. The knowledge of these conversions ought not to be over-
looked in practice: in the first place, because, as they are favorable,
we may in some instances be enabled to promote, and even to enforce
them whenever such a thing is possible; in the next place, because
they afford a very natural explanation of the mistakes, which we
have been heretofore compelled to attribute to the ignorance of those
who committed them. For example, it pretty often happens that

* I have in a good many instances observed the fetal head to change its posi-
tion during labor, so as to bring the occipital fontanel from the left acetabulum
quite over to the right one, and then go back again to the original position.
In an ample pelvis the child has power to change the position of its head very
readily, until it is fairly within the vagina, where it is held too firmly to admit
of such spontaneous rotations. — M.

PRESENTATION OF THE VERTEX. 307

two accoucheurs, called to the same woman, one at the commence-
ment of the labor and the other at its close, announce, each, a differ-
ent position; that one announces an occipito-anterior, and the other
the contrary position, and that upon seeing the head emerge, one of
them remains convinced that he had been really deceived. Notwith-
standing, both of them may have been right, for the fourth or fifth
position might really have existed, although the labor terminated in
the second or first. It would be wrong, however, to generalise this
remark too far, and apply it to all cases where the escape of the fcetus
contradicts the diagnosis established by the practitioner from whom
tlje woman first receives attention: it would be too convenient a re-
source for the concealment of real mistakes, and one of which the
inept and ill-taught would not fail to avail themselves at the expense
of truth.

C. TJtird Variety.
Fronto-pubic position,
fith position of Baudelocque, MM. Gardien, Dubois, Desormeaux, Madame
Boivin; occipito-sacral of MM. Flamant, Lebreton; is rejected by MM. May-
grier, Capuron, Madame Lachapelle. and M. Dug6s.

750. All the arguments advanced by authors against the possibility
of Baudelocque's third position apply equally well to the sixth. If
the forehead cannot maintain itself upon the sacro-vertebral angle
it is, a fortiori, impossible for the occiput, which is much narrower,
to maintain itself in that situation and not to deviate either to the
right or left. But as the impossibility of the occurrence of the
occipito-pubic position is far from being a matter of demonstration,
so also is the same thing to be admitted as regards the opposite
position.

Sometimes the sacro-vertebral angle, in the living subject, projects
but very slightly, a fact to which suflUcient attention has not been
paid, and it is evidently wrong to reason as if the head were not al-
ready flexed upon the breast from the very beginning of labor, and
as if it were the occipito-frontal, and not the occipito-bregmatic dia-
meter, that is at the very commencement parallel to the antero-pos-
terior diameter of the strait.

751. If it be true, as we learn by the touch at our amphitheatres,
that, in many women, we can readily feel the most prominent part
of the foetal head over the centre of the pelvis, quite above its abdo-
minal opening, long before the commencement of labor, I cannot
perceive how the sacro-vertebral angle can constitute an insurmouu-

308 NATURAL EUTOCIA.

table obstacle to the sixth position. It must therefore be admitted,
at least, as a possible shade, if not as a real variety.

752. Its mechanism, moreover, scarcely differs from that of the
two oblique varieties; the posterior surface and occiput of the
foetus being, from the beginning, turned directly backwards, there
is no occasion for the head to perform its pivot movement in the
excavation, so as to engage in the inferior strait; the shoulders pass
through the superior strait parallel to the bis-iliac diameter, and there
is no act of restitution without, any more than there is an act of ro-
tation within the pelvis, and if the face comes at last to turn towards
one of the thighs and the occiput towards the other, it happens so be-
cause the trunk, in revolving on its vertical axis to place the shoul-
ders in an antero-posterior attitude, necessarily carries the bi-parietal
diameter in the same direction.

It is less favorable than the corresponding oblique positions, only
because it renders the forehead and face more liable to be turned
downwards, and to permit the great diameters of the head to become
parallel to the smallest ones of the pelvis. When they attributed
the difficulties accompanying it to the friction of the face behind
the pubis, accoucheurs of past ages, doubtless, had not reflected
on the state of flexion in which the head is found to be placed; for
it would have been easy for them to see that it is the anterior ex-
tremity of the oceipito-bregmatic diameter, and not that of the occi-
pito-frontal diameter, that must rest upon the hinder part of the pubic
articulation.

753. Remarks. Besides these six varieties, there would be a great
many intermediate ones, provided the occiput were obliged, in each
of them, to correspond to some indicated point of the pelvic circle:
in effiect, if there be some of them that we can bring in relation with
the extremities of the four principal diameters of the strait, I cannot
perceive why eight others might not be established betwixt those just
now mentioned; and this number once agreed upon, there is no rea-
son why we might not add sixteen others, and so on ad infinitum.
But it is quite enough to make a particular position of all the cases
where the occiput looks towards any portion of the left anterior quar-
ter-circle of the pelvis, another for the right, and a third and fourth
for the posterior half of the pelvis; since these varieties, which dif-
fer more in degree than reality, ought, after all, to be considered as
mere shades, constantly changing, before the close of labor, into
occipilo-anlerior, and occipito-posterior positions: so that, in fact, the
four diagonal positions of the superior strait, when reduced to the
two antero-posterior ones of the inferior strait, constitute the whole of

PRESENTATION OF THE VERTEX. 309

those, the study of which is really important. We are not, how-
ever, on this account to deny the existence of the directly anterior
and transverse positions established by Baudelocque, M. Flamant,
and Madame Lachapelle.

754. I have treated in greater detail of the occipito-pubic and
sacral positions than of the occipito-iliac positions, because their
mechanism presents some peculiarities which it is well not to be
ignorant of, for the doctrine of Baudelocque being extensively
known, it might be attended with some inconvenience, were I to over-
look positions admitted by that author to exist, which, though they
are of rare occurrence, yet really do occur, and substitute for thera
others equally rare, and which, moreover, soon become confounded
with the oblique ones.

755. When Madame Lachapelle says that the occipito-iliac are
more frequently to be met with than the fronto-acetabular positions,
she must surely be misled by some preconceived idea. Previously
to the descent of the head into the excavation, it is often difficult
to say whether the occiput looks exactly towards one of the ex-
tremities of the transverse diameter, rather than a few lines for-
wards or backwards of it, or to know whether it constitutes a trans-
versal position, rather than an oblique one very much inclined:
further, as the author herself admits that the head remains but a
short time thus directed towards the iliac fossae, either the occiput
or forehead soon deviating in front to gain the pubic arch, and the
left occipito-iliac position being the most common of the two it is
manifest that the transverse positions are completely converted into
the corresponding oblique ones, and that they do not deserve a par-
ticular description.

756. Anomalies. In some positions of the vertex the movements
of the head seem to deviate wholly from the ordinary march of a
labor; for example, it may happen, and indeed it does happen
pretty often, that after having passed obliquely through the superior
strait, it places itself transversely in the excavation, where it re-
mains for a longer or shorter time previously to performing its pivot
motion; in other cases this motion is not performed at all, or but
imperfectly; the head, therefore, passes the inferior as it did the
superior strait diagonally, or even emerges from it in a transverse
position, so as to bring the occipito-bregmatic, into parallelism with
the bi-sciatic diameter. In some other instances, the occiput upon
escaping from the vulva turns in a direction directly contrary to that
it ought to pursue, provided the restitution were regular; it was in
this way that Solayres and Baudelocque saw, and that I myself have
seen, the face, in a left occipito-acetabular position, turn towards the

310 NATURAL EUTOCIA.

woman's left thigh, as it ought to do in the second position, and
vice versa; so that from the commencement to tlie close of labor,
the foetus performs about half a spiral turn, from behind forwards,
and from left to right, or from right to left, according to the posi-
tion. Baudelocque was mistaken when he attributed this irregu-
larity, on the one hand, to the smallness of the fcetal head, or on the
other to the excessive amplitude of the pelvis; I have had occasion
to notice it in women whose labors were very slow, and whose
pelves were not larger than necessary for the transmission of the
child. Might it not depend upon some peculiarity in the form of
the inferior strait or excavation, some anomaly in the uterine con-
tractions, or rather of the impulsion originally communicated to the
foetus; and which, after having first produced the common act of
rotation, might be strong enough to compel the head and shoulders
to turn so as to perform a complete semi-circular turn? In the
present state of tokological science it is impossible to answer this
question.

§. 11. Presentation of the Face.

4 in 1800 cases, Merriman; 5 in 1897, Bland; 74 in 20,517, Boivin; 103 in
22,243, Madame Lachapelle; 58 in 6,555, Boer.

757. It never until lately entered any one's imagination to trust
the delivery to the hands of nature, where the face of the child pre-
sented at the superior strait of the pelvis; it is true we find in Mau-
riceau, De La Motte, and Smellie, cases of spontaneous termination
of the labor where the face presented; P. Portal and Deleurye also
maintained that these positions are not in general very dangerous;
Roederer and Petit even agree that some of them may terminate
without any assistance; but Baudelocque and Stein having professed
that they cannot possibly terminate spontaneously except where the
foetus is very small or the pelvis very large, it has happened that
MM. Maygrier, Gardien, Capuron, &c. continue to class them
among the preternatural labors.

758. Such was the state of the subject when Madame Lachapelle
laid it down as a principle, that this sort of labor is nearly as easy
and as natural as that by the vertex, and affirmed, that out of seventy-
two cases of this kind, forty-two were concluded without danger
either to the mother or child. M, Desormeaux ranged himself on
the side of the midwife in chief of the Maternite; and the same ideas
are found in the work of Boer, who, after saying that delivery by the
face is very simple and very natural, describes its mechanism in the
following manner: Caput foetus , ex quo supra in margine pubis

PRESENTATION OF THE FACE. 311

hseref, per illam ita transmovetur, utfrons sensim inincurvaturam
ossis sacri vergat. Utque fades aperturse infra appropinquat,
mentwn propemodo admittitiir sub pube, simul atquefrons cum ver-
tice sKpra perinfeiwi protruditur. £n facialis omnis partus exor-
dium, progressus dc finis!

M. Chevreul expresses himself in nearly the same manner: " I
can enumerate eighteen labors, says he, that occurred since 1792,
either in my private practice, or at the Maternite at Angers; where
the children presented the face, and ivhich terminated naturally. Ml
these children were of the common size; fifteen of them were born
alive; three were dead, but appeared to have been so previously to
the commencement of labor."

However, a distinguished professor, M. Capuron, has recently
come out with great vigor in opposition to this doctrine, endeavor-
ing to demonstrate upon geometrical principles, that delivery by the
face, according to the mechanism pointed out by Boer, is generally
impossible, provided the woman does not receive any artificial aid.
But no geometry can hold good in this case; as numerous facts
exist, they are evidently possible. I have myself seen seven cases
of face presentation; the children were born alive and well; I trusted
the cases to nature, and no particular difficulties were observable.

This kind of labor, therefore, is not only possible, but also for
the most part quite easy. M. Capuron and many others have thought
otherwise, because they did not perfectly understand its mechanism,
and were misled by the idea that the breast in such cases must ne-
cessarily pass the strait at the same time with the head, which is
wholly incorrect. It is clear, when the head presents at the superior
strait, with the chin towards the pubis and the forehead towards the
sacrum, that the fronto-mental diameter, which is only three inches,
or if prolonged to the anterior fontanel, three inches and a half, is
parallel with the sacro-pubic diameter, equal to four inches and a
half, and that it occupies the situation that belongs, in vertex pre-
sentations, to one of the diameters of the occipito-bregmatic circum-
ference. So far there is no disadvantage in a face presentation.
But at a later period, when the head descends, the chin gets below
the pubis before the occiput reaches the excavation, and the breast
is still at the superior strait while the face is actually engaging in
the inferior pelvic circle; then, the front of the neck, being stopped
by the lower edge of the symphysis pubis, compels the vertebral
column to react upon the posterior part of the head, which it urges
from behind forwards, so as to force it through the vulva, by pre-
senting to that opening a series of circles, whose principal chords are
measured by the vertical diameter of the head. The laws of me-

312 NATURAL EUTOCIA.

chanics, therefore, in accordance with facts, permit us to class face
cases among the spontaneous labors.

759. According to Deventer, the causes of this presentation are
to be sought for in the obliquities of the uterus, which, from the very
beginning of its action, cause the extremity of the occiput to lodge
upon the margin of the strait, and thus oblige the face to descend
first. According to M. Gardien, the cause lies much more in the
inclination or obliquity of the foetus itself, than in that of the organ
which contains it. Madame Lachapelle, who rejects both of these
hypotheses because she saw the face presenting at the upper strait
in two women who died previously to labor, attributes it to the cir-
cumstance that the anterior obliquity of the womb being very com-
mon, the weight of the occiput must in such cases prevent the chin
from remaining applied against the sternum, and must bring the
mento-bregmatic diameter into parallelism with the sacro-pubic
diameter from the very commencement of labor. It seems to me
that all these opinions have some foundation, but that none of them
suffice to explain all the facts, and that it is for the most part impos-
sible to say why the face and not the occiput presents.

760. The face positions being in fact only reverted vertex posi-
tions, it is plain that we must for both admit the same number of
species and varieties. Authors, however, have generally described
only four; and they have rarely agreed as to the manner of arrang-
ing them. Some make them correspond to the four oblique posi-
tions of the vertex; others, as Smellie, Stein, Baudelocque, and
MM. Gardien and Desormeaux, dispose them transversely, and from
front to rear, and admit a right mento-iliac and a left mento-iliac
position, as well as a mento-pubic, and a mento-sacrcd position.

Perhaps, in studying the subject, there is some advantage in this
latter mode of classifying them; but it is important in practice to
know, 1. That the antero-posterior positions are rare, so much so,
that Madame Lachapelle has never seen a single case of that kind,
although Rcederer, Deleurye, Stein, &c. admitted them as very
common, and as the easiest; 2. That if they do sometimes occur at
the commencement, as in one case that I saw, they soon become
converted into lateral positions; 3. That the mento-sacral position,
which Stein gives as the best, and of which one case is related by
Smellie, is altogether impossible without this conversion; and,
4. That in the iliac positions, the fronto-mental diameter is more
frequently directed obliquely than transversely.

761. It ought also to be known that the face does not always
present in full; that the forehead often sinks lower than the chin;
that the contrary obtains in other cases; that in some instances,

PRESENTATION OF THE FACE. 313

also, it descends with one of the cheeks foremost, &c., and that
these anomalies constitute the varieties pointed out by Madame La-
chapelle; and which may be either primitive, that is, they may exist
from the very commencement of labor, or secondary, that is, not
become manifest until after the first efforts, and even at a very ad-
vanced stage of parturition; and that the last case ought to be con-
sidered as possible, for example, in vertex presentations with the
occiput backwards, or where the pelvis is very large, and also where
the sacrum is too concave.

A. Right Mento-Iliac Position.
3d of Baudelocque, M.Gardien, Madame Boivin; 53 cases in 22,243, Madame
Lachapelle.

762. In the right mento-iliac position, which evidently is a devia-
tion of the first or fifth of the vertex, and ought therefore to be, and in
fact is the most common (41 to 31; 58 to 45), the face comes down
transversely into the excavation; but as the length of the neck would
not allow the chin to get down to the level of the tuberosity of the
ischium without dragging the upper part of the thorax through the
superior strait, without throwing the occiput forcibly backwards on
to the chest, without putting the whole length of the vertical diame-
ter of the head, protracted as far as the sternum, into the situation
that ought to be occupied by the fronto-mental diameter, a rotative
movement soon takes place, and changes the relations of all these
parts: the chin and front of the neck slide from behind forwards upon
the right anterior inclined plane, and lodge in the top of the arch of
the pubis, while the bregma slides in an opposite direction, upon the
left posterior inclined plane, and proceeds to occupy the anterior
surface of the sacrum. Then the forehead, followed by the sagittal
suture and occiput, passes gradually down the plane presented to it
by the anterior surface of the coccyx and perineum, in front of which
all these parts are in succession disengaged. As it emerges from
the vulva, the chin rises, by degrees, towards the mons veneris, the
hyoidian region, or lower extremity of the vertical diameter, really
forms the centre of the semicircle described by the head as it clears
the strait, and the rest of the labor terminates as in the corresponding
positions of the vertex.

B, Left Mento-Iliac Position.
4th of Baudelocque; M. Gardien, Mesdames Boivin, Lachapelle, etc.; 31 to
41; 45 to 53.
28

314 NATURAL EUTOCIA.

763. Where the chin looks towards the left iliac fossa, the posi-
tion of the face answers to the second or fourth of the vertex. It is
rather more frequently met with than the preceding one, but does
not differ from it except that the chin slides on the left anterior in-
clined plane, and the bregma on the right posterior one, so as to
place the head in an antero-posterior direction, in order to pass the
perineal strait; and that the act of rotation must be somewhat easier,
if, as is asserted, it be true that the presence of the rectum may im-
pede that of the right occipito and fronto-acetabular positions of the
vertex.

It IS said that the head has been, but very rarely, seen to emerge
from the vulva in a diagonal or even transverse position, but it does
not appear to me certain, that, in these cases, the observers were
not deceived by an incipient act of restitution.

C. Mento-Sacral Position.
1st of Bandelocque.

764. The third position is extremely rare, 1. Because the occipito-
pubic position, which must give rise to it, is itself not very common;
2. Because if it be true that it does sometimes or even pretty often
exist at the very beginning of labor, the contractions of the womb
soon transform it into a diagonal or transverse position, 3. Because,
if it should maintain itself for any length of time, the chin, which is
too prominent not to lodge against the sacro-vertebral angle, would
force the occiput to descend, or swing towards the centre of the
pelvis, and at last place itself in the third position of the vertex; 4.
Because it is evidently impossible for the chin, which must always
appear first at the vulva, to descend in this attitude as far as the an-
terior edge of the perineum, unless, as M. Desormeaux remarks,
the fo3tus be an abortion ; for the breast would then be entirely
within the pelvis at the same time with the head, and Stein would
have satisfactory reasons to maintain, with the ancients, that face
labors cannot, without danger, be abandoned wholly to the powers
of nature.

In fine, all the face positions may be reduced to one fundamental
one, a species which comprises two, or three, or five varieties, right
and left mento-iliac, mento-pubic, and if it be preferred, two diagonal
ones, all of which have, for a last result, the arrival of the chin under
the arch of the pubis, in order that the head may pass the inferior
strait without obliging the breast and shoulders to descend antece-
dently thereto into the bottom of the excavation.

765. Remarks. In practice we also meet with certain positions

PRESENTATION OF THE PELVIS. 315

that belong neither to those of the occiput, nor to those of the face,
properly so called. The head sometimes descends, half turned over,
so that neither the occipito-bregmatic nor fronto-mental diameters
correspond to those of the straits, but it is the occipito-frontal diame-
ter or circumference, or even, in some cases, the occipito-mental
diameter that assumes that relation; sometimes, on the other hand,
the head too ranch flexed occasions a part of the nucha to present
together with the occiput. It pretty frequently happens also, that
one of the parietal bones, or the ear, or the temple, being nearly
parallel with the horizontal plane of the pelvis, engage first. Lastly,
in this respect there are an infinite number of shades of difference,
which I do not think it necessary to speak of at great length, because
it suffices to indicate them merel)^ to show that they are referable to
some one of the correct vertex or face positions; or again, because
they most commonly become causes of dystocia.

SECTION 2.

Of Unnatural Eutocia (presentations of the pelvis).

611 cases in 20,517 Madame Boivin; 1390 in 37,895, Madame Lacbapelle;
65 in 1800, Merrinian; 54 in 1897, Bland; 194 in 6555, Boer; 61 in 1296,
NaBg6le.

766. The pelvic extremity of the foetal ovoid comprises the feet,
the knees, and the breech; when it presents first at the straits of the
pelvis, the labor can most generally be terminated alone, as has
been noticed by practitioners in all ages; but this does not warrant
us in saying with the moderns that these presentations are natural.
Without pretending with the ancients, that delivery by the feet is
always dangerous, or that we should endeavor to bring the head to
the strait, in preference to letting the foetus escape feet foremost;
without referring with Avicenna to the examples of Agrippa and
Nero, or that of Richard of England, &c. to prove that children
born in this way necessarily become tyrants, criminals, or wretches
who ai^e a disgrace to human nature, I think we shall be at least for-
ced to admit, with Celsus, Moschion, Pare, De Saint Germain, &c.
that this kind of labor is less favorable than that where the other ex-
tremity of the occipito-coccygeal diameter presents. It would surely
be both a very erroneous and a very dangerous doctrine, to say, with
Rhodion, Dionis, A. Petit, and Bounder, that delivery by the feet is
easier than by the head.

767. All accoucheurs agree that the child is oftener born dead in

316 UNNATURA.L EUTOCIA.

pelvic presentations than in those in which the vertex descends first.
At the Paris Maternite, out of eight hundred and four children expel-
led in this manner, only five hundred and eighty-one were born liv-
ing, whilst out of a sum total of twenty thousand six liundred and
ninety-eight vertex presentations only six hundred and sixty-eight
were still-born.

768. After the rupture of the membranes, the pelvic extremity of
the foetus never presents the same evenness, the same resistance, or
the same rounded form as the head, to the openings of the pelvis;
it consequently acts to much less advantage on the cervix to finish
its dilatation. When the head presents, the uterine contractions act
upon it, through the medium of the spinal column, as upon a solid
body; while the pelvic extremity, on the contrary, being soft,>up-
ple, and flexible, yields, and is in some measure crushed down. In
vertex presentations the most voluminous part, that which is best
calculated to bear all sorts of pressure, escapes first. In pelvic pre-
sentations, on the contrary, the point of the cone advances first, so that
the foetus progresses more slowly in proportion as the labor advances.
In the former case the remaining parts of the child are delivered
immediately after the abdomen, and neither the thorax, nor abdo-
men are in danger of suffering any injurious compression; in the
latter, the belly and the thorax being obliged to overcome the re-
sistance of the cervix, can rarely support such a degree of pressure
beyond a few minutes without the greatest danger; the liver and
other viscera of the abdomen must react upon the great vessels;
the circulation in the cord, which is pressed against the breast, and
the action of the heart, cannot but be very much impeded, if not ab-
solutely suspended. In delivery by the head, the spine represents a
long handle of a lever, to which the womb applies itself forcibly,
until the termination of the labor; in presentations of the pelvic ex-
tremity, before the head has completely passed through the superior
strait, it is in a great measure beyond the influence of the uterine con-
tractions; at the very moment where the greatest amount of uterine
power is wanted, all the benefits of it are lost. Finally, the pressure
sustained by the parts, in succession, from below upwards, necessarily
drives the blood up towards the head, and determines that state of
congestion so often met with in children that are dehvered footling,
and which Osiander and M. Flamant erroneously attributed to the
action of cold air upon the child's body previously to the delivery of
its head.*

* The view taken here of the causes of death which so frequently operate ef-
fectually on the foetus, in pelvic presentations, omits one of tlie most considera-

PRESENTATION OF THE PELVIS. 317

These disadvantages cannot be denied, or unknown by any well
informed practitioner: it would be wrong, however, to conclude from
the above, that the assistance of art will be always required merely
because the pelvic extremity of the child presents; on the contrary,
I think that we should always, in such cases, abandon the labor to
the resources of the organism, except an opposite conduct should
be imperiously demanded by some peculiar circumstances. If the
rupture of the membranes does not occur until after the complete di-

ble, and which appears to me to be readily conceived of in the following man-
ner. When the vertex descends first, in any woman, the child begins to
breathe as soon as the mouth and nostrils are exposed to the air, and it general-
ly cries before the shoulders are born; but, when it is enabled to reach the air,
it becomes instantly a matter of indifference, as to its security, whether the after-
birth be detached or not. Now, it most generally happens that the afler-birth
is wholly or partially detached, by the constriction of the womb long before the
hips and legs of the child are expelled; for the womb, is by this time, grown so
small, that the placental superficies of it can no longer hold the placenta — This,
as I have said above, is a matter of indifference to the child as soon as it can
communicate with the atmosphere.

In a pelvic presentation on the contrary — it is a matter of the greatest conse-
quence to the child's safety, that the detachment of the placenta should not take
place so early, for, although the feet or the breech is born, the child's head hav-
ing no access to the air, it perishes with a real, I might say a double asphyxia,
to wit, its placenta is separated from the mother, and its lungs receive no air. I am
far from asserting that the placenta is dctaclied in all cases at so early a stage of
labor as that which I have indicated, though I am free to utter my opinion that
in the vast majority of cases, the placenta is separated by the time the head
is fairly born, in ordinary vertex cases.

Such are my views of the principal causes of death of the foetus, in breech and
footling cases. — It follows from the premises, that in all such labors the child
should be withdrawn so soon as it can be conveniently done.

I am sure that in my own practice the results are far more favorable than
those cited by M. Velpeau. I do not think that one tenth of the cases of pelvic
presentation under my care, prove fatal to the foetus — and I attribute this success
to the custom which I have adopted, of procuring my forceps in good time, so
as to have them at hand, wherever the first examination discloses the existence of
a pelvic presentation.

I make very slight tractions on the shoulders in order to facilitate the expul-
sion of the head — and as soon as I find that the head is not likely to come down
I grasp it in the forceps and deliver it at once. I have safely delivered a num-
ber of children who I think would have been born dead, but for such a pre-
caution.

In a breech case, the life of the child will be lost by a few minutes delay in
the delivery of the head, and the tractions which are effected by pulling by the
shoulders, can never be of very considerable force, without injuring its cervical
spinal marrow. Hence, whenever, any considerable extrinsic force is required,
it should be applied by means of the forceps. — M.

28*

318 UNNATURAL EUTOCIA.

latation of the os uteri, if the position is regular and the pains good,
the foetus will, indeed, pass out without running much more risk
than in a delivery by the head; but if the membranes give way
very early, if the least traction be employed under the pretext of
hastening the delivery, it is certain that difficulties will be infi-
nitely multiplied, and the life of the child seriously compromitted.
This is a point which young students, as well as practitioners, ought
never to lose sight of. This, also, is one of the motives that have
induced me, both in my lectures and in this work, to deviate from
the ideas generally received among us in relation to pelvic presenta-
tions of the foetus.

759. Previously to the time when de la Motte, Petit and Bau-
delocque had demonstrated that the somerset motion described by
their predecessors was a mere chimera; as long as it was supposed
that the fostus naturally remained squatting on the sacro-vertebral
angle until the end of the seventh month of pregnancy, there was
no difficulty in accounting for the presentations of the breech, knees
or feet; to explain their occurrence, it was sufficient to say that
something had prevented the somerset from taking place; that the
child, either through forgetfulness, weakness, or something else, had
allowed the opportune moment for performing this pretty feat to
elapse; but at present, when we cannot resort to this subterfuge, we
are brought to confess that the causes of presentations of the pelvis
are but little known.

770. It is probable that, about the period when the length of the
occipito-coccygeal diameter of the foetus begins to exceed that of the
transverse or horizontal diameter of the womb, it may happen that
the head of the child, being carried upwards by some sudden move-
ment, by the decubitus of the woman; or some other cause, cannot
resume its original position. It has been observed at the Maison
d'Accouchmens at Paris, and I have had occasion myself to notice
it, that presentations of the pelvic extremity are much more common
in abortions and in twin pregnancies than in simple labors occurring
at full term; and this remark might perhaps be used to sustain the
above explanation; but how can we refer the cause of this anomaly
to the foetus, or to mere peculiarities of attitude in the mother, in
those tolerably numerous cases, where all the deliveries of one in-
dividual terminate in this way, and when it is well understood that
a woman having once been delivered of a breech presentation, war-
rants us in fearing that it will happen so to her again? Would it
not, rather be reasonable to seek for this cause in the conformation
of the womb or pelvis in such a case?

771. The positions of the pelvic extremity may, like those of the

PRESENTATION OF THE PELVIS. 319

head, he divided into regular and irregular or deviated ones. In the
former, the thighs are applied against the abdomen, the legs are bent
upon the thighs, and the breech and feet present together at the su-
perior strait, and the great oceipito-coccygeal axis is parallel to the
axis of the pelvic circle. In the latter, the fcetus is more or less
inclined to the right or left, forwards or backwards; the posterior
surface of the coccyx, or one of the tuberosities of the ischia, or the
forepart of the legs and the sexual organs, correspond to the centre
of the pelvis; most generally, the latter are reduced to the former
as soon as the waters are gone off; in other instances they maintain
themselves for a much longer time, retard the labor, and, in certain
cases entirely prevent it from terminating spontaneously.

772. The regular positions may also become irregular, especially
after the rupture of the membranes, either because the feet continue
to descend pressed against the breech; or because one of the legs
rises up on the anterior surface of the trunk, while the other is
extended, and descends first; or because one of them becomes
situated transversely, so that the knee and heel press on two oppo-
site points of the strait; or because one knee descends together
with a foot or a buttock, or one of the legs is turned up in front, and
the other back; or lastly, because this last mentioned condition is
met with concurrently with one knee, one foot, or a foot and buttock
together, &c.; but in general, they remain frank until the conclusion
of the labor. The two legs and thighs then extend, and the feet
escape first. At other times, again, the legs rise upwards and the
child comes away doubled, or by the breech properly so called. In
other instances, the knees alone descend together, the feet continu-
ing to be applied to the ischia, which constitutes presentation of the
knees: whence it results, that there are really no primitive presen-
tations of the feet nor of the knees, and that until the rupture of the
membranes, there are no other positions except those of the breech.
Thus these various kinds of positions ought to be considered only
as shades of a single and even fundamental species, the presentation
of the pelvic extremity of thefcetus.

773. Instead of six, Baudelocque proposes only four positions
for the breech, feet and knees; in the first the back looks forward
and to the left, forwards and to the right in the second, directly
forward in the third, and directly backwards in the fourth. MM.
Capuron and Maygrier have rejected the two latter, and substituted
for them two diagonal positions, which renders their classification
of the pelvic positions in all respects similar to the one they thought
proper to establish for the head. Madame Lachapelle has acted dif-
ferently; she retains Baudelocque's third and fourth; but in place

320 UNNATURAL EUTOCIA.

of the first and second, she admits two others, in which the back
looks directly towards the right, or towards the left side of the
pelvis.

One thing seems to me to be proved by this discrepancy: it is,
that we might, strictly speaking, establish, as M. Flamant has done,
eight positions of the breech. But, on the subject of the pelvic
extremity, I shall repeat what I said in relation to the cephalic ex-
tremity: disagreement has arisen on the subject, because, instead of
seeking every possible number and kind, we ought to endeavor to
ascertain only such as.it might be useful to know.

774. Admitting that it were not perfectly correct to say, with
Mauriceau, Dionis, De la Motte, and Levret, that the loins are, in
breech cases, most generally turned backwards, MM. Capuron,
Maygrier, Duges, &c., would not be less in the wrong to assert that
they as well as the sacro-anterior positions are purely hypothetical:
Asdrubali, who has noticed them, partakes the opinion of Mauriceau,
and of Smellie; and the tables published by Madame Lachapelle
show that, out of 1390 cases wherein the pelvic extremity pre-
sented, there were thirteen anterior, and twenty-six posterior ones.

775. Thus the direct positions, either anterior or posterior, are
possible, as well as the diagonal ones, and the breech may present
in as many ways as the head. Like those of the head, too, these
positions may be reduced to two principal ones: the one sacro-an-
terior, and the other sacro-posterior. This is the way the ancients
understood them, and if Baudelocque could be satisfied with one
position for the posterior semi-circle of the pelvis, I see not why
the three positions of its anterior semi-circle should deserve a more
special description. In tlie first, second, and third positions of that
author, whether the hips engage just transversely or somewhat ob-
liquely, it always happens that one of them looks to the left and the
other to the right, exactly as in the three posterior varieties. In
the first case the occiput always ends by placing itself behind the
pubis; in the second it proceeds to lodge on the fore part of the
sacrum, as is observed to happen in the corresponding positions of
the vertex. The anterior position differs essentially from the pos-
terior one; but the two last being admitted as possible, it is quite
useless, as to practice, to establish others, except as shades of them.
Notwithstanding, out of respect for received opinions, I shall not fail
to point out the particular mechanism of each one of these shades,
and instead of uniting all the positions of the pelvic extremity in one
single genus, I shall for the same reason continue to examine sepa-
rately those of the feet, the knees and breech.

PRESENTATION OF THE PELVIS. 321

§. I. Presentation of the Feet.

538 out of 37,895, Madame Lachapelle ; 23 in 1800, Merriman; 18 in 1897,
Bland; 68 in 6555, Boer.

776. What I have stated in relation to the dangers of delivery by
the pelvic extremity, applies strictly to presentations of the feet. In
that case the child resembles a cone or a very sharp wedge, descend-
ing from its point towards its base; the bag of waters being generally
less regular in shape, more elongated than in other positions, and al-
most always rupturing before the dilatation of the neck has had tim6^.
to be completed, it follows that the pressure upon the foetus constant'
ly increases from the root of the lower limbs up to the superior part
of the chest, and that the viscera are violently repelled from beloviT
upwards; in one word, the parts of the woman are dilated, and a pas-
sage for the head opened by the hips, the belly, and the thorax. If
the abdominal and thoracic cavities were formed of bones as solid,
and if their horizontal diameters were of length equal to those of the
head, they would bear the pressure of the os uteri with quite as little
inconvenience, and the child would not run much more risk in one
way than in the other; but this is not the case, and I cannot too
strongly insist upon the disadvantages of such presentations.

1 . Calcaneo-Anterior Position.

347 in 37,895 cases, Madame Lachapelle.

• ■ A. First Variety.

Loins in front and towards the left.

1st position of Baudelocque, Gardien, Maygrier, Capuron, Madame Boivin and
M. Desormeaux.

777. In the first position of the feet, the anterior surface of the
foetus looks backwards and to the right of the womb; the right hip is
turned towards the left sacro- iliac symphysis, and the left hip towards
the right acetabulum; whence it follows, that if the presence of the
rectum were the principal cause of the great proportional frequency
of the first vertex position, the first position of the feet ought to be
more rarely met with than the second; however, the contrary is ob-
served to happen; for, by the statement of Madame Boivin, in a total
of 234 labors by the feet, the left calcaneo-acetabular position alone
occurred 135 times.

778. The heels, which previously to the rupture of the mem-
branes are more or less near to the tuberosities of the ischia, do not
actually engage within the os uteri, until the moment v/hen the

323 UNNATURAL EUTOCIA.

waters run off, and sometimes even much later than that. If the
amnios does not give way until after the orifice is properly dilated,
the legs and thighs follow the feet immediately, and the hips, which
traverse the superior strait in a diagonal position, soon reach the
vulva. Ill the contrary case, all these parts descend slowly, and by
degrees, with each returning pain. The frelal pelvis, before it en-
gages into the inferior strait, generally performs a rotation upon the
right anterior and left posterior inclined planes of the excavation;
the left hip occupies the arch of the pubis, Avhile the right hip goes
to fill up the hollow of the sacrum. The whole child bends upon its
anterior or left side; the belly next passes through the os uteri; the
elbows, pressed against the ribs, or somewhat in front upon the
breast, yield to the contractions of the womb, and descend along
with the thorax into the excavation. The shoulders follow the
chest through the abdominal opening of the pelvis, where they re-
main in the same direction they affected at the commencement of
the labor, that is to say, diagonally, the right before the lefi sacro-
iliac symphysis, and the left behind the right acetabulum. When
below the strait, they are subjected to the same pivot motion as the
hips, and like them, are soon placed in the antero-posierior direc-
tion. The head, strongly flexed, follows the upper part of the breast;
the ovoid which it represents engages with its apex foremost; its
occipito-mental diameter is parallel with the axis of the strait, the
plane of which soon becomes parallel to the occipito-bregmatic cir-
cumference; the bi-parietal and occipito-bregmatic diameters mea-
sure the oblique diameters; in fine, the relations of the head to the
upper pelvic circle are absolutely the same as in the first position of
the vertex; there is only this difference, that the small, instead of
the large extremity of the cone represented by the head, videl. the
chin, the face and base of the skull — instead of the superior oval and
occiput — advance foremost.

779. The root of the umbilical cord, the abdomen, and the lower
part of the thorax are now emerged; the left elbow appears at the
top of the pubic arch; the right elbow, arm and shoulder slide gra-
dually along the sacrum and perineum, and successively appear in
front of the posterior commissure of the vulva, which strongly raises
the trunk of the foetus up towards the mons veneris; so that the
shovdder that is in front does not commonly disengage itself until
after the other, although the corresponding elbow had appeared at
the vulva first. Immediately after this, if not supported, the child
falls backwards again by its own weight, and rests on the anterior
edge of the perineum; a kind of movement of restitution which
again carries the left shoulder to the right, and the right one to the

PRESENTATION OF THE PELVIS. . 323

left side, ?oon lakes place, and the bis-acromial again crosses the
occipito-bregmatic diameter at right angles.

780. When fairly in the excavation, the head revolves on its
occipito-mental diameter, so as to carry the face directly backwards,
and the nape of the neck and occiput directly in front; the two ex-
tremes of the occipito-bregmatic diameter slide from right to left,
and from before backwards, on the right posterior inclined plane,
and from left to right and from behind forwards, on the left anterior
inclined plane, as in the first vertex position, so as to become parallel
to the coccy-pubal diameter. The womb can now no longer act
immediately upon the head, which is entirely or partly in the vagina
but the disposition to straining, produced by the pressure now ex-
perienced by the rectum and bladder, soon compels the woman to
gather up all her powers and redouble her courage, and the contrac-
tions of the abdominal muscles soon come to the assistance of the
powerless womb for whose forces they are now the substitutes.
From this moment the occiput receives the whole weight of the ex-
pulsive power: in order that it may become parallel to the axis of
the perineal strait, the occipito-mental diameter gradually executes
a see-saw motion, which brings the anterior fontanel near to the
anterior surface of the hollow of the sacrum, and causes the chin to
thrust the breast towards the symphysis of the pubis. Finally, the
nape of the neck, bearing upon the summit of the arch, as upon a
fixed axis, permits the head to describe an arc of a circle, the radii
of which seem to have the lower edge of the articulation for their
centre, and to be composed of the occipito-mental, occipito-frontal
occipito-bregmatic, and vertical diameters; so that we see the chin,
the forehead, and the anterior fontanel appear in regular succession
at the vulva, after which the occiput escapes from above downwards,
and emerges thus from the pelvis to put an end to the labor.

B. Second Variety.
Loins forward and to the right.

2d position of Baudelocque, Gardien, Capuron, Maygrier, Desormeaux and
Dugd?; 8() limes in 234 feet presentations, Madame Boivin; 175 in 37, 899 la-
bors, Madumc Lachapelle.

781. In the right calcaneo-acetabular position, the soles of the
feet, the fore parts of the legs, and the whole anterior surface of the
foetus look towards the left and back part of the mother; the right
side is towards the front and left of the mother.

The feet and legs as in the preceding position, are not mechani-
cally stretched out, are not really pushed into the orifice, until after

324 UNNATURAL EUTOCIA.

the perforation of the membranes. The hips, arms, and shoulders
pass through the straits, and present themselves at the vulva in the
same way; that is to say, diagonally at the superior strait, and
antero-posteriorly at the inferior strait; but the act of rotation takes
place from left to right instead of from right to left, as before: both
the right hip and right shoulder, and not the corresponding parts of
the left side, proceed to lodge in the arch of the pubis; the abdomi-
nal surface turns towards the left, and thus takes the situation of the
posterior surface, which now looks towards the right iliac fossa;
the occipito-mental and bi-parietal diameters, and the occipito-breg-
matic diameter and circumference, preserve the same relations with
the axis, the oblique diameters and plane of the superior strait, and
with the coccy-pubal and bi-sciatic diameters of the inferior strait;
but the face and forehead are obliged to descend along the front of
the sacro iliac symphysis, and the pivot motion occurs along the
right anterior and left posterior inclined planes; in one word, the
second position differs no more from the first than the left hand does
from the right; and the mechanism of the one is so similar to that
of the other, that it would be really fastidious to enter into any longer
details concerning it.

C. Third Variety.
Loins directly in front.
3d position, Baudelocque, MM. Gardien, Maygfrier, Capuron, Desormeaux,
&c.; 7 in 254, Madame Boivin; 6 in 235, Madame Lachapelle.

782. It is true we find undoubted instances of the third position
in Mauriceau, Smellie and Levret, &c.; but as these authors, as well
as de La Motte, Deleury, and Asdrubali, did not distinguish them
from the two preceding ones, we cannot ascertain in what propor-
tion they met with them. Be this as it may, we do not perceive
that the form of the strait can in any way prevent such a presenta-
tion from taking place; the pelvis is wide enough in front to admit
of the two hips engaging in it transversely; the sacro-vertebral angle
might very well lodge betwixt the thighs or legs of the child, whether
flexed or extended, the belly and breast are too easily depressed to
occasion the least difficulty in this respect; and the shoulders them-
selves would pass transversely through the strait as easily as the hips.
As to the head, although in penetrating to the excavation it would
not experience more, or might have even less difficulty, than if the
vertex were presented in the third position, it notwithstanding rarely
fails to deviate to the right or left side of the promontory. It is easy
to see that in this respect there has been more dispute about words

PRESENTATIONS OF THE PELVIS. 325

than things. In fact, if those accoucheurs who reject the third po-
sition of the feet, admit under that title only those cases where the
middle line of the child's back glides along behind the symphysis pubis
to the very close of labor, they are no doubt partly right, and such
a labor must be extremely rare; but if, on the contrary, in order
to constitute such a case, it suffices for the child to descend in this
way until the arrival of the head only, we are not permitted to be
ignorant not merely of its possibility, but also of its very great
frequency.

During the progress of the labor, then, this third position almost
always converts itself, a little sooner or later, into the first or second;
sometimes it lasts only until the arrival of the hips at the superior
strait; sometimes it maintains itself until the shoulders engage;
sometimes it is not converted into a diagonal position until the breast
has descended quite into the excavation; finally, it may happen that
it does not become converted at all, and then one of two things is
observed to take place: either the hips, the shoulders, and the head
do not turn upon their axes at the abdominal strait, in the excava-
tion, nor at the inferior strait, and the child's back continues to look
to the front of the mother both out of the pelvis and inside of it, and
there is no pivot movement within the pelvis, nor restitution nor
rotation outside of it; or, on the other hand, the hips and shoulders,
which were engaged transversely at the upper strait, place them-
selves in an antero-posterior direction to pass through the vulva — in
which case the head is the only part that does not turn on its axis.

2. Calcaneo-Posterior Position.
4th position of Baudelocque, MM. Gardien, Desormeaux, &c.; 10 in 538, Ma-
dame Lachapelle; 6 in 234, Madame Boivin.

783. Under the title of fourth position, Baudelocque comprised
all the cases where the dorsal surface of the foetus looks towards
any point of the posterior half of the superior strait, and not merely
those in which it is turned directly backwards, as we might be
tempted to believe from reading a great number of modern works.
In this respect he has only imitated Mauriceau, Dionis, De La
Motte, Portal, Smellie, Asdrubali, &c.

In the usual folded state of the foetus, the soles of the feet, the
fore parts of the legs, and the forehead and abdominal surface of
the child are directed forwards. The lower limbs being more or
less rapidly extended and elongated by the uterine contractions,
they pass through the vagina, and reach the vulva; the hips soon
follow, and sometimes pass the superior strait in the direction of the
29

S26 UNNATURAL EUTOCIA.

bis-iliac diameter, more frequently in that of one of the oblique ones,
or at least, after being slightly inclined, one forwards and the other
backwards, provided they were previously quite transverse. When
in the excavation, they are observed to engage in the perineal strait;
sometimes parallel with the bis-sciatic line, at others by following
the oblique diameter, and most frequently, after one of them has
been placed behind the symphysis pubis, and the other in front of
the sacrum.

784. The arms and shoulders present themselves in their turn,
and act like the hips, with the exception only, that they more rarely
fail to execute the pivot motion before they pass through the vulva,
even though they had previously affected a transverse position;
being repelled by the anterior edge of the perineum, these different
parts, as they emerge, are raised upwards towards the mons veneris;
to accommodate itself to the curve of the pelvis and genital parts,
the foetus bends in the shape of a very long arc of a circle, convex
behind and concave before, as it does in an anterior position. The
elbow that is below the pubis shows itself first at the upper part of
the vulva; but the opposite arm and shoulder, more particularly
urged by the efforts of the womb, proceed from behind forwards
along the posterior median line, and actually are the first to escape
from the pelvis; the edge of the perineum immediately afterwards
retires upon the neck, as if to permit the trunk to fall back towards
the anus, and the other shoulder to disengage from beneath the pubic
symphysis ; the back then turns back again, as by a sort of move-
ment of restitution, M'hich replaces the shoulders, the one to the left
and the other to the right, or diagonally. The head cannot become
engaged without being strongly flexed; on the one hand the occiput
almost invariably deviates towards one of the sacro-iliac symphyses;
on the other, the occipito-frontal diameter, or even the entire head,
represents a lever of the first kind, whose anterior extremity more
particularly supports the action of the expulsive powers; the chin,
although more or less prevented by the breast, ends however by be-
ing depressed, and the occipito-mental diameter by finding itself al-
most parallel with the axis of the strait; the forehead and anterior
fontanel come, one after the other, to hide behmd the symphysis of
the pubis, and thenceforth the occipito-bregmatic circumference is in
correspondence with the plane of the pelvic margin, as in all the an-
terior positions.

785. When in the excavation, the head rolls on the inclined planes,
replaces itself in an antero-posterior direction by means of the pivot
motion, and afterwards glides with much more diflUculty than when
the occiput is forwards; the breast, which is situated in front, opposes

PRESENTATIONS OF THE PELVIS. 327

the lowering of the chin; the occipito-bregmatic diameter, which is
three and a half inches long, not being able to place itself in corres-
pondence with the antero-posterior diameters of the excavation and
apex of the pelvis, has its place occupied by the occipito-frontal
diameter, which has an extent equal to at least four inches. The
face, and particularly the forehead, are too broad and ill-disposed to
fit the form of the pubic arch so exactly as the nape of the neck and
occiput do; finally, the shoulders hardly emerge before the chin pre-
sents itself at the vulva.

Nevertheless, immediately after the expulsion of the thorax and
upper extremities, the upper and hinder part of the neck rolls from
before backwards upon the anterior edge of the perineum, as upon
an axis, and the nose, the forehead, the anterior fontanel and remain-
der of the head successfully disengage, by forcing the breast back-
wards.

786. Remarks. The mechanism of this position, as now seen, is
very unfavorable, and much more difficult than that of the calcaneo-
anterior positions; if the chin or forehead lodge upon the upper edge
of the pubis, the act of flexion of the head is prevented or destroyed,
and the occipito-mental diameter, or the occipito-frontal diameter and
circumference, occupy the situation of the occipito-bregmatic diame-
ter and circumference; then the labor cannot be terminated without
assistance.

It would, notwithstanding, be wrong to conclude that art must of
necessity aid the economy in all the posterior positions of the feet:
attempts to change them would favor the reversion of the head, and
most frequently produce just the state of things which it is desired
most carefully to avoid. Besides, nature, when left to herself, gene-
rally succeeds better than any foreign power in flexing the head and
placing it diagonally at the superior strait.* In a very great majority
of cases this position spontaneously converts itself into an anterior
position, either suddenly, after the head has got into the excavation,
or, on the other hand, gradually, in proportion as the hips, the shoul-
ders, and the head itself present.

* The best position for the woman, in this labori is that on the left side, with
the thighs strongly flexed. As soon as the shoulders are delivered, the body of
the child should be turned back towards the woman's buttock, so as to give
greater facility to the flexion of the head. At the same time that the child is
pressed backwards, the edge of the perineum should be pushed towards the coc-
cyx, in order to let the nape of the child's neck retreat as far as possible. When
this can be done, a fing-er in the child's mouth will easily depress the chin, and
thus eftect the desired degree of flexion. I have succeeded in this way several
times without any difficulty. — M.

328 UNNATURAL EUTOCIA.

787. In a case of this kind I have seen the hips emerge trans-
versely from the vulva, turn in the direction of the oblique diameter
that extends from behind and right to the left, then place itself in the
antero-posterior direction, as the shoulders became engaged, then
continue their rotation movement after the escape of the latter, and
at last turn quite across, with the back in front, yet the head escape
as in a direct anterior position. Now, this is what almost always
happens if the accoucheur is skilful enough to do nothing, to content
himself with sustaining the fo3tus, as it passes the vulva, without em-
ploying the least traction.

788. If the loins are sometimes turned directly to the left or right,
which cannot be doubted, inasmuch as Madame Lachapelle informs
us that she had seen it so, we may be at least allowed to suppose
that in this direction persons have been often deceived by the oblique
position that approaches most nearly to it. But for this, the cele-
brated midwife would not have said that out of 1038 labors by the
feet, there were found to be 347 left iliac positions, and 175 right
iliac positions; moreover, by the admission of Madame Lachapelle
herself, the really lateral positions almost always convert themselves
into anterior or posterior, diagonal or direct positions.

789. In all the feet positions, the hips and shoulders ordinarily
execute a rotation movement, previously to engaging in the inferior
strait; according to Baudelocque, this movement may, however,
possibly not take place, and the parts may therefore continue parallel
to the bi-sciatic diameter; according to most of the modern accou-
cheurs, on the contrary, the hips and shoulders almost never pass
the vulva otherwise than parallel with the coccy-pubal diameter.
To reconcile these two extremes, there remained one intermediate
opinion, and Madame Lachapelle embraced it, maintaining that the
pelvis and upper part of the thorax pass through the inferior strait,
in an oblique or diagonal direction, and not in a directly transverse
nor antero-posterior direction, strictly so called. For my own part,
if I can believe my own eyes, both parties are right, an error is found
only in the exclusion by which each party endeavors to put down
the other.

790. All the accoucheurs, both ancient and modern, have main-
tained, that in delivery by the feet, the arms rise along the sides of
the neck and head. Wiedemann was one of the first to oppose this
doctrine, and he pretends that they always remain applied against
the breast, if no tractions of any kind are exercised upon the foetus.
M. Desormeaux and Madame Lachapelle adopted this opinion also.
In the deliveries by the feet that have fallen under my notice, the
forearms and elbows did not abandon the breast, and always escaped

PRESENTATIONS OF THE PELVIS. 329

before the shoulders, when the woman was left to her own powers,
and nothing more was done than to support, without pulling at the
trunk until the expulsion of the head.

791. Though so many authors have professed the opposite opi-
nion,^ which still prevails very generally, it depends solely on the
circumstance, that the persons who assist lying-in women, rarely
consent to remain inactive in a footling delivery; they lay hold on the
members that spontaneously present, and the very natural, and in
itself considered, laudable desire to put an end to the sufferings of the
mother, causes them to pull with more or less force upon the child,
and a phenomenon which is produced merely by art, is then very
readily mistook for a natural one. Where the womb, assisted by
the muscular contractions of the abdomen, is alone charged with
the duty of expelling the ovum, all the parts of the child are pushed
down simultaneously, and so folded and pressed together, that it is
very difficult for one of them to rise upwards while the others are
descending; as the uterus does not contract from its fundus towards
its cervix only, but also circularly, from above downwards, by a sort
of vermicular or peristaltic movement, the elbows or arms run no
risk of lodging against the upper edge of the pelvis.

792. If, on the contrary, the foetus is extracted and not simply
expelled, as the tractions come to act ultimately upon the breast and
head, it follows, that these parts only are dragged downwards, while
the arms, retained in their position by the womb, remain where they
were, and can only descend in a direction extending from the shoul-
ders towards their free extremities.

Nevertheless, I do not believe it right to deny, as Madame Lacha-
pelle does, the possibility of the phenomenon admitted by the older
accoucheurs to take place in every spontaneous delivery. We may
conceive that the arms, when once they have reached the excavation
along with the shoulders, being no longer directly urged by the
uterine efforts, may rise upwards by sliding along the sides and
fore part of the breast, or rather, that the head, supporting from this
moment, the whole action of the expulsive powers, may cause the
face and breast to descend into the inferior strait, without necessa-
rily carrying the elbows along with them. It must be so, further,
since M. Gardien affirms that in many labors terminated by the feet
without any assistance, he has seen the arras rise along the sides of
the neck and head, and since M. Deneux told me he had observed
the same thing.

Presentation of the knees.

4 in 20,517, Madame Boivin; 9 in 22,243, Madame Lachapelle.

29*

330 UNNATURAL EUTOCIA.

793. The position of the knees being in all respects like that of
the feet, it is useless to give the mechanism of it apart; in fact,
whether the legs have descended, or remain bfent upon the thighs,
the lower extremities traverse the os uteri and straits of the pelvis
with equal facility. Perhaps they descend with rather less facility
in the second than in the first case mentioned, provided the mem-
branes give way when the neck is still incompletely dilated; but the
knees scarcely reach the vulva before the legs become extended, and
thenceforth every thing proceeds as if it had been a footling case.

The knees present first, because they have been reversed, either
mechanically or by muscular action, in the cul de sac formed by the
apex of the ovum, at the moment when the membranes are ruptured,
or because the rush of fluid forces them along with it, rather than
the feet, which may be farther from the orifice; or because the breech,
which, presented first, mounts upwards again along with the feet,
under the influence of the contractions of the womb, so that the
knees only can be depressed into the opening of the neck; or yet
again, because, after the discharge of the waters, the legs are situated
crosswise above the uterine orifice, or have beeen arrested against
two opposite points of the strait. Moreover, we may conceive that
they may both descend at once, or only one of them along with one
foot, without that circumstance changing the progress of the labor;
and it was entirely wrong to attribute more danger to delivery by the
knees, than to those that take place by the feet.

Presentation of the breech.

837 in 37,895, Madame Lachapelle; 375 in 20,517, Madame Boivin;]42 in
1800, Merriman; 36 in 1897, Bland; J 26 in 6555, Boer.

794. Presentation of the breech has always been regarded as
more dangerous, difficult and unnatural than that by the feet or
knees. It was thought that the size of the buttocks would not admit
of the expulsion of the child without the neck of the womb as well
as the perineum being violently contused or extensively lacerated;
but even had experience not pronounced upon the value of these
exaggerated fears, a moment's reflection would have shown how
unfounded they were. It is merely necessary to recollect the di-
mensions of the foetal pelvis, to be instantly convinced that, even to-
gether with the thighs, the size of the breech could never form an
insurmountable obstacle to delivery, unless there were some faulty
conformation of the straits. When the child comes doubled, the
pelvic extremity is too supple, too flexible, and accommodates itself
too easily to the form of the openings it has to traverse, for it to

PRESENTATIONS OF THE PELVIS. 331

expose the neck of the uterus and the perineum, any more than the
head does, to the lacerations of which we have spoken.

795. In presentations of the feel or knees, the bag of waters is in
general more elongated, tears more readily, and the os uteri has less
need of being so largely dilated. With the breech, on the contrary,
the amniotic sac is as large as in a head presentation, and does not
open until it has produced a considerable dilatation; the buttocks •
and hips, which have to open a passage, react without inconvenience
against the resistance of the neck; the belly and breast pass the straits
and vulva without the risk of a very violent pressure; for, excepting
the head, the hips exceed, as to dimensions and firmness, any other
part of the child.

796. In breech cases it is true that the labor, in general, goes on
very slowly until they have passed through the cervix, and sometimes,
even until they have traversed the vulva; while in feet or knee pre-
sentations, it seems, at first, that the process of child-birth is going
to be extremely prompt. But these differences are all in favor of
breech positions; for in the second case, the phenomena then suc-
ceed each other, producing so much the less effect as the body is
nearer being completely expelled; while in the first case, where the
hips have once descended into the vagina, the rest of the body
emerges with much less difficulty. I dwell upon this idea because
it is well calculated to show how imprudent it may be, in a presen-
tation of the pelvic extremity, to bring down the feet artificially, with
the sole view of hindering the breech from engaging first before the
dilatation is completely effected.

797. Baudelocque admits four positions for the breech, as he does
for the feet, and divides them in the same manner; M. Flamant
reckons eight of them, and MM. Maygrier and Capuron, four, as
for the head, &c.

798. Without speaking of the cases where the fcetus engages
squatting, having the heels glued, as it were, against the ischia, cases
in which art is almost always required for the assistance of nature,
I must say that in women endowed with but little moral and mus-
cular energy, the softness and flexibility of the breech will absorb
the greater part of the motion communicated to the spine of the
child by the womb, which often ends by falling into a state of
inertia, and that the labor cannot then be always abandoned ta
itself without danger; besides, in the three anterior positions, the
external organs of generation of the male sex are exposed to fric-
tions more or less violent against the promontory; and it is also by
no means rare to find black and contused echymoses in new bora
children that come by the breech.

332 DIAGNOSIS.

Whether the buttocks have passed the upper strait in a transverse
or oblique direction; whether the back is in front or rear, it is not
less a rare thing for them to fail to place themselves in an antero-
posterior direction in the excavation; being strongly pressed against
each other they swell; in boys, the scrotum becomes puffed and in-
filtrated; as they curve towards the pubis to gain the vulva, they dis-
tend the perineum almost as much as the head does, the form of
which they partly simulate; they are next seen to disengage of them-
selves, and then every thing goes on as in a footling labor.

SECTION 3.

Of the Conduct of the Accoucheur during Labor.

799. When called to a woman who supposes herself to be in
labor, there are two ways in which the accoucheur may behave,
accordingly as he may have for a long time enjoyed her confidence,
or as he may never have been much acquainted with her before.

In the former case he should examine at once, in order to ascer-
tain whether the labor has really commenced; in the latter, it is often
necessary to be not quite so much in a hurry, unless indeed the la-
bor seems to be very far advanced.

He may begin to talk about one of the thousand subjects of futile
conversation that every body understands, and which admits of only
a gradual approach to the principal object; in this way time is
allowed for quieting the agitation commonly occasioned in most
women by the presence of a stranger, and particularly an accou-
cheur; during this parley, he should endeavor to possess himself of
the shades of character, the caprices, tastes, and habits of the person
he is called upon to direct, in order to adopt such a plan of conduct
as is most likely to inspire her with great confidence in her attendant;
the subject of her pregnancy is soon brought up, the symptoms
that have accompanied it, the peculiarities that have marked it, and
its term; he may ask whether she has had several pregnancies, or
whether this is the first; he can ask about the general state of her
health, the inconveniences and diseases that she has heretofore suf-
fered, after which he may be allowed to think of the labor properly
so called.

§. I. or the Diagnosis.

800. Nothing is easier, in the opinion of by-standers, than to say
whether a woman is in labor or not; but this is not the case with

DIAGNOSIS. 333

the well-instructed physician. As women in their first child-birth
lack a term of comparison, they very frequently deceive themselves
in regard to the sensations they experience; even in the second,
third or fourth pregnancy women deceive themselves sometimes.
How often have the neighbors, relations, the widwife or accoucheur
been seen to fix and arrange every necessary preparation for the
birth of the child, and the supposed labor cease for a whole month
or six weeks, just when the bed had been made up for the reception
of the woman, and when the clouts, the ligature for the cord, the
scissors, the caps and other clothes of the child were only waiting
for the arrival of the stranger to be applied to it ! How often have
even still greater mistakes been committed ! Who does not know
how poor women have been kept for days together on the child-bed,
even by physicians, and at last found that their pregnancy was seve-
ral months ofi" from its close, or even that they were not pregnant at
all ! A young woman in her ninth pregnancy was seized with pain,
and thought herself at term; several accoucheurs were called in suc-
cession. One said that the bag of waters was formed; another, that
the head was about to engage; a third, that he could not find the os
uteri; a fourth, that the forceps must be applied. This poor creature,
in despair, sent for me on the fifteenth day; I found the cervix as it
is at the seventh month ; there was an anterior obliquity of the
womb; I stated that labor had not begun, and would not take place
for more than a month — and applied a broad bandage round the ab-
domen. In a month, a student, who staid by her, came to tell me
that the os uteri was dilated, and delivery about to take place. I re-
paired to her, found no symptom of labor, and in fact, the child was
not born till a month afterwards.

When persons who are strangers to the science of medicine are
deceived in this way, the public only laugh at them; but what con-
fidence can an accoucheur inspire who is guilty of such stupidity?
It imports us therefore to be on our guard against such causes of
error, and it is easy for those who have any positive knowledge of
tokology to do so.

801. The pains of labor, the true pains, are intermittent, sepa-
rated by intervals more or less short, progressive, return at regular
periods, are not accompanied with tenderness of the abdomen nor
heat of the skin nor fever; they begin in the neighborhood of the um-
bilicus, and end in the pelvis or flanks.

Pains foreign to \2b0r, false pains, are, on the contrary, vague,
irregular, sometimes more, sometimes less acute, do not entirely
cease, increase under pressure, and are, most commonly, accom-
panied with fever or some kind of functional disturbance; they an-

334 DIAGNOSIS.

nounce a lesion of the stomach, the bowels the liver, the kidneys,
the bladder, or some other organ contained in the abdomen, and
have been called false because they are entirely unconnected with
parturition, appear in pregnant women as they do in those who are
not pregnant, or as they do even in persons of the other sex. No-
thing, therefore, but the greatest want of reflection, can cause them
to be confounded with the true pains — those which depend upon the
contractions of the womb.

802. I, however, ought not to omit speaking of a state that might
render this discrimination very difllicult, and a mistake at the same
time highly dangerous: if an inflamed point be established in the
neighborhood of the womb, in that organ itself, in the bladder, rec-
tum, (fee, just as labor comes on, the pains of child-birth will pro-
gress just as those of the disease do, and if it were absolutely neces-
sary to decide from the testimony of the pains alone, the most skil-
ful person might be led into a mistake. But the science possesses
other means of ascertaining the existence of labor. If, when the
suffering is at the height, the hand, placed upon the hypogastrium,
feels the womb grow hard, contract, and become rounder, it is de-
cided that child-birth is about to take place, and, in this case, the true
pains may exist alone, as they may also be met with in conjunction
with false pains.* If the hand discovers the womb to be unmoved,
without action, and without connection with the cries uttered by the
patient, it may, to a certain extent, be affirmed that the labor has not
begun.

803. In fine, we are by the touch enabled to solve the question
without any fear of being deceived. While ever the cervix is still
uneff'aced, while it retains some few lines of length as a canal, we
may, in general, assert that the woman is not at full term; only we
must avoid mistaking the lips of the os tincae for the cervix itself,
and remember that in persons who have had several lyings-in before,
it is now and then found to be extremely soft and very wide, several
days or even several weeks previously to the end of pregnancy; and
that in such women the orifice frequently forms a cushion or an
edge several lines in thickness at the commencement of labor. If

* Let not the inexperienced practitioner be led by this statement into the mis-
take of supposing that where the abdomen, in these pains, grows hard, and then
relaxed, again to become hard upon the recurrence of the pain, the labor is actu-
ally begun. M. V.'s remark is true as applied to the hardening or contraction
of the womb itself; yet, in some cases of false pains, I have observed that they
were connected with a spasmodic constriction of the abdominal muscles, which
yielded to the touch a sensation closely resembling that of the womb under con-
traction. — M.

DIAGNOSIS. 335

it be a first labor, the cervix does not begin to gape antecedently to
the appearance of the true pains, and if it feels like a tubercle, pier-
ced through its centre, we may be satisfied that there have been as
yet no uterine contractions; where, on the contrary, it is thin, hke
a sharp circle, the gestation is necessarily at its term, and if the par-
turition have not commenced, it is almost a matter of certainty that
the labor will not fail to show itself within a few days.

To obtain a decisive proof on this point, we have, at most, only to
touch during a pain; if the finger feels, in such a way as to admit
of no doubt, that the membranes become tense, that they try to en-
gage in the os uteri, which manifestly becomes thinner, contracts, or
opens a little, to return immediately afterwards to its primitive con-
dition, nothing further is wanting, the labor has begun; if nothing
of all this is observed, we may be content, the moment for lying-in
has not arrived.

804. However, I cannot quit this article without calling the at-
tention of young practitioners to a peculiarity in the diagnosis, that
is not sufficiently known, and which might lead them to deceive
themselves, after what has been above said. Modern accoucheurs
have with one accord rejected, as among apocryphal or ill-under-
stood facts, the very numerous cases tending to prove that labor
may begin, the contractions of the womb be brought into evident
play, and that, after having continued for several hours, the labor
may be suspended so that delivery shall not take place for a whole
month afterwards: such anomalies as these have been cited chiefly
on occasions of protracted gestation, and as proofs of superfoeta-
tion; it has been pretended that such powerless efforts as the above
had masked the natural term of gestation, and that the time that
elapsed betwixt their cessation, and the real labor, was an excess
over nine months. But I have acquired the conviction that this in-
complete labor, or, as Levret calls it, false labor, is not a mere
chimera. In March 1824, I was called to a woman in the rue
d'Orleans, in her second pregnancy, and who had been in pain for
about twenty-four hours; the pains were regular, weak, and sepa-
rated by pretty long intervals; the os uteri, which was very soft,
and wide enough to admit of the introduction of three fingers, was
not completely eff'aced; the point of the ovum had already begun
to engage within it, and when the pains came on, the membranes
were on a level with the top of the vagina, and became smooth and
tense, while, on the other hand, I felt the orifice and body of the
womb harden and contract with a certain degree of energy. It
was ten o'clock at night; I announced that the labor would not
terminate for several hours. I returned home after giving orders to

336 DIAGNOSIS.

send for me as soon as the waters should break; not being sent for
the next day, nor the day after, I supposed they had had recourse
to the advice of some other practitioner, and thought no more of it.
Six weeks afterwards, being called upon again, I confess I was sur-
prised, for I supposed the woman had been delivered long before.
This time the symptoms persisted, and delivery took place. M.
Nivert has published in the Clinique des Hopitaux a case of the
same kind which he met with at my amphitheatre. MM. Gerdy
and Tanchou assure me that they have witnessed cases nearly simi-
lar, and I have, myself, since met with two others.

§. II. To determine the Position.

When the existence of labor is no longer doubtful, we must en-
deavor to learn in what position the fcetus presents.

805. The vertex is in general easily known by its round and
regular shape, by the posterior fontanel, and occipital point, by
the anterior fontanel; the sagittal, transverse, and lambdoidal su-
tures, and by the parietal protuberances; however, when the head
has been for a long time engaged, the teguments occasionally
form so large a tumor upon its summit, it is itself sometimes
so elongated, that one has need of some practice in order not to
mistake it. It is in many cases so movable, and particularly so
high up, as to render it difficult to distinguish it with certain-
ty from any other part. As long as the membranes remain un-
broken, we ought, besides, not to try to reach it except in the
absence of the pains; otherwise we should be liable to rupture
them prematurely. We can, therefore, best judge of the presenta-
tion of the fcetus, at the moment when the waters come off; the
upper oval of the head may then be touched throughout its whole
extent; the integuments are not yet swelled, and the bones have
not had time to ride over each other. In the three varieties of the
occipito-anterior position, the posterior fontanel approaches more or
less near to the pubal semi-circumference of the pelvis, and is be-
hind one of the acetabula or the symphysis pubis, while the frontal
fontanel is more or less elevated behind, and looks towards the op-
posite point of the pelvic cavity; in the varieties of the posterior
position the fontanels are disposed of in the inverse directions. Al-
though it approaches very near the centre of the straits, the pos-
terior fontanel, notwithstanding, almost never corresponds to it ex-
actly; both in the anterior and posterior positions, this fontanel is
always placed upon a much lower plane than that occupied by the
anterior fontanel. In order more correctly to distinguish the dif-
ferent varieties of the vertex, we should endeavor to recognise the

DIAGNOSIS. 337

sutures; by adding their direction to the notions we derive from the
particular situation of the fontanels, it is commonly easy to avoid
confounding the anterior with the posterior varieties, and to attach
to each shade of one and the same position, those characters by
which it is separated from all the others.

806. The face is so different from every other part, that, at a first
glance, it seems impossible to mistake such a presentation: this is an
error; the proof of the contrary is contained in all the collections of
cases, and is daily met with in practice; ihe chin may be mistook for
the elbow, the shoulder for the heel, or the knee; the mouth for the
anus, the nose for the sexual organs, and the cheeks for the tube-
rosities of the ischia. Lest the testimony of an infinite number of
learned observers should not suffice to demonstrate the possibility of
such mistakes, I will relate a well known anecdote of a former pro-
fessor of midwifery at the Ecole de Paris: being a man of a rather
decided character, he had just touched a woman in labor, and sup-
posing he had found a face presentation, he asserted with great ges-
ticulation that such a position could in no case be confounded with
one of the breech, not perceiving that his finger, which was covered
with meconium, was giving him the lie, in the faces of the students,
who could not help bursting into loud laughter.

It is chiefly in cases where the soft parts of the face have had time
to swell and puff up, that we may be readily deceived, especially
when the mind, pre-occupied with such or such a position, receives,
with a sort of avidity, the most equivocal signs as certain proof of
what we had predicted. With proper attention, however, we shall
be enabled, without difficulty, except in a few very rare cases, to
recognise the face whenever it presents, and the rupture of the
membranes, allows us to examine it naked; the eyes and eye lids,
the nose and lips, the alveolar arches and tongue, the chin and ears,
which are found near at hand, possess characters too decided for the
positions of the face not to be always clearly ascertained.

807. The feet cannot deceive the accoucheur when they pre-
sent: the heel, to be sure, has some resemblance to the elbow, and
the toes some similarity to the fingers; but when we remember the
difference of length between the latter named parts — that the one
are arranged upon the same line and short, that the others are of
unequal lengths and much flexed; when we reflect on the form of
the ancles and legs, one must be very careless to compare it with the
fist and fore-arm, and not to distinguish the feet from the hands, ex-
cepting when these parts are still above the superior strait.

808. The knees might indeed be mistaken for the elbows or
shoulders, although rounder than ihe former and smaller than the

30

338 DIAGONSIS.

latter. But as two elbows cannot, any more than two shoulders,
present at once at the strait, we may be sure that they are the knees,
from the mere fact that there are two such tumors together in the
strait at the same time; and as a single knee is generally accom-
panied with one foot, or ;at least with the breech, it will always be
easy to satisfy ourselves that we are touching some part of a lower
extremity, and not one of the. arms. There is, notwithstanding, one
circumstance that seems as if it might impose upon us; I mean the
simultaneous presence of a knee and an elbow. But besides the
rarity of these coincidences, we learn, by penetrating a little further
with the finger, that these parts, instead of approaching towards each
other at their origins, separate farther and farther from each other.

809. Presentations of the breech have, more frequently than
others, led into error on this subject; where the buttocks have had
some difficulty in getting through the os uteri or the strait, they
swell like the vertex; the crease that separates them may be mis-
took for the sagittal suture; the coccyx and space in front or on
the side of it, for the occipital angle, the posterior fontinel, and
lambdoidal suture; and lastly, the ischia may be mistook for the
parietal protuberances; but this same crease, being a slit and not a
fold, the movableness of the coccyx, the presence of the anus and
of the genital parts, the roots of the members, &c., soon bring the
accoucheur back to the knowledge of the truth, when he has de-
parted from it for an instant. The anus and genital parts might be
mistook for a face presentation, were we not to remark that the
mouth, bordered with thick lips, contains a conoidal, movable, and
fleshy body, the tongue, and that the finger, when withdrawn from
the rectum, is found to be covered with meconium. Still, another
circumstance might deceive us. I shall give the particulars, because
the authors have omitted to mention them. Having been called
upon by Madame Lebrun, the midwife, to terminate a preternatural
labor, I thought I could feel the feet, the buttocks, the coccyx, and
anus; but my finger penetrated into an opening, bordered by thick
lips, at the bottom of which I felt a tubercle similar to the tongue.
Disconcerted by this combination of signs, I for a moment thought
I had to deal with a monstrous child; I again introduced my hand
further; I brought down the feet, and the emergence of the hips
soon put an end to my uncertainty. It was the vagina that I had
mistaken for the mouth, and the cervix uteri, which is very salient
at that age, had made me suppose I felt the tongue. In order to
obviate all hesitation in such a case, it is merely requisite to remem-
ber that the mouth is open behind, so as to be continuous with the
pharynx; whereas the vagina ends in a cul de sac, at the bottom of

DIAGNOSIS. 339

which the os tincse is to be found, in the shape of a tubercle, more
rounded, shorter, and particularly, less movable than the tongue.

§. III. Of the Prognosis.

810. After having established the diagnosis, a new question natu-
rally presents itself to the mind of the accoucheur, while it is very
soon propounded to him also by the patient herself or her attendants.
Will the delivery be prompt and easy, or slow and difficult? When
will it take place? The answer here is an extremely delicate mat-
ter, and ought only to be given after maturely weighing it, and then,
with the greatest reserve. The duration of labor is so variable
depends upon circumstances so diverse, and sometimes so unex-
pected, that it is often impossible for the most skilful practitioner to
fix it beforehand, even approximatively. On the one hand, it would
be necessary from the very beginning to know the proportions of
the foetus and pelvis, with how much energy the womb shall con-
tract, and how often the pains shall succeed each other; on the
other, he ought to be able to affirm that the progress of the
labor shall or shall not be interfered with by a hemorrhage, an
attack of convulsions, a prolapsion of the cord, or some other acci-
dent; that the fairest and best position shall not be converted to an
abnormal one; that the membranes shall give way at such a particular
period, and not at any other; that there shall or shall not occur a
spasmodic resistance of the cervix, &c. Now, none but ignorant
women or impudent quacks can pronounce upon all these points, and,
in spite of so many uncertainties, say at what hour the labor is to
terminate.

811. All that we are permitted to promise in a general way is
the following: the child is well situated; the pelvis is neither small
nor deformed; the genital organs are healthy and well disposed;
the OS uteri soft and very dilatable; the pains occur regularly and
with constantly increasing force; the woman is courageous and well
constituted; therefore the termination of the labor will be prompt
and fortunate; a little less prompt if it be a first labor; a little
more so if she have had several children before, and still more so,
even too rapid, if the pelvis be possessed of excessive amplitude.
On the other hand, the position of the foetus, without being posi-
tively bad, is not, however, one of the best, or perhaps it may be a
very large one; the pelvis is slightly contracted; its axes are too
much or not sufficientlyJnclined; the os uteri is hard, or covered
with cicatrices; the woman is of a delicate, nervous, or lymphatic
constitution; in all these, we ought to fear that the labor may be-
come a long one, and that the resources of art may become neces-

340 PROGNOSIS.

sary. We can also, to a certain extent, judge of the duration of the
present labor by her former ones, and particularly by the effect
produced by each pain upon the dilatation of the os uteri, and upon
the progress of the fcBtus through the pelvis. In fine, when all the
phenomena occur in their most common order, we may, by calcu-
lating the time that has elapsed since the first pains, tell, within a
few hours, how long the woman has still to suffer. If, for example,
only two or three hours were required to bring the dilatation of the
OS uteri to the size of a five franc piece, it is extremely probable that
not more than that will be necessary to complete the expulsion of
the child; but this is the highest degree of precision to which we
can pretend, and those who pique themselves upon the possession
of more exact knowledge in this matter, either impose on the public
or deceive themselves.

812. The accoucheur who, for the purpose of making a parade
of vain knowledge, thinks himself able to announce the precise term
of delivery, not only exhibits his own ignorance or bad faith, but he
also compromits the dignity of his profession and the safety of the
woman. If indeed it be true that chance is often on the side of
impudence and quackery, it often happens that the predictions of
ignorance or rash vanity are not realised; but, if promises, gene-
rally made with much emphasis and assurance, are not fulfilled at
the appointed time, that alone is enough to give rise to the liveliest
solicitude, in the minds of relations or assistants, and especially in
the patient herself, who never fails, afterwards, to think either that
her destruction is certain, or that she is to have a bad labor.

§. IV. Of the Attentions ]¥ecessary for a Wo-
man in liabor.

813. Inasmuch as spontaneous parturition is a natural function
and not a disease, are we thence to conclude that the art of the
accoucheur is unnecessary, and that women in labor have no need
of assistance? Some physicians, misled by mistaken philanthropy,
have thought so. In animals, say they, pregnancy brings no incon-
veniences, and delivery is almost unattended with pain. The wives
of the Osiiacks, who are still strangers to the refinements of Euro-
pean civilisation, are delivered of their children upon the spot where
they happen to be, and immediately resume their accustomed occu-
pations, or continue their march, if they happen to be on a journey.
Those of the island of Amboyna, who live under a directly opposite
temperature, behave in the same way. The aborigines of certain
countries in America bathe themselves in cold water and return to
their work as soon as the child is born, while the husband goes to

PROGNOSIS. 341

bed and plays the patient for a week or two! Parturition is a mere
nothing to country women, who cannot spare time to drag them-
selves, methodically, from the bed to the sofa, and vice versa. Who
has not seen soldiers' wives bring the most robust and finest children
into the world, withput in any respect deviating from their active
modes of living, or without ceasing by forced marches to follow their
regiments? Even in the large cities it is not uncommon for poor
women to go on foot to a midwife while the pains are upon them,
and return home the next day in spite of Hygieine, their poverty not
allowing them to attend to themselves for more than three or four days.
I, like Roussel, have seen a yoimg girl who found means to conceal
from her parents both the humiliating proofs of her weakness and
the operation that delivered her from it. What practitioner is there
who has not had an opportunity of making the same observation?
The pregnancies of these poor creatures being illegitimate, it would
seem as if they had no right to be sick. But these remarks in no
wise prove that women ought to be left to themselves during partu-
rition. In the first place it is false to say that parturition in animals
never requires any assistance, arid is never accompanied with serious
accidents: sows, mares, cows, &;c., are even, in general, quite ill in
bringing forth their young, and country people are by no means ig-
norant of the fact. Does it follow, because some women, when com-
pelled by imperious motives to deliver themselves in private, or
without taking the least precaution, escape from the serious dangers
with which they supposed themselves to be threatened, that all
others may imitate them without exposure to more imminent perils?
If there are some whose health is not disturbed by such painful
experiments, how many others are there who become the victims of
their temerity? Because one man falls from the top of a roof with-
out breaking his bones, does it follow that we should advise others
to go to the house top to have the pleasure of tumbling down to
the ground? Will people never be tired of referring us back to a
period of primitive nature, that every body talks about, and that no-
body understands? By attempting to substitute the exception for
the rule, we inevitably fall into absurdity, and that is what happened
to the elegant Roussel. If, in order to avoid the dangers of abuse,
it were always necessary to forego the use, what would become of
the human race? The business of the accoucheur, doubtless, is
not to put himself in nature's place where a labor is natural; but some-
body ought to be with tfie woman who is able to give her proper
directions, to foresee accidents, to recognise them, and to remedy
them when they do take place; to apply the resources of art when
necessary, and at the opportune moment; who, by the confidence

30*

342 PROGNOSIS.

he inspires, calms all her fears, and gives courage and resignation,
hy tranquillising her in regard to the future; but who differs more
and more from the mere spectator, in proportion to the extent of his
knowledge and skill.

814. Hygienic treatment. The chamber and every thing con-
nected with it should be first attended to. In great cities a back
room should be preferred, or the quietest and best aired apartment
of the establishment. It is important that this chamber should be
sufficiently spacious, well lighted, and so constructed that its tem-
perature may be easily altered. Too great a degree of heat would
promote sweats, cerebral congestions, convulsions, nausea and vomit-
ings, to which women are already but too much predisposed during
the efforts of labor; cold would not be less injurious, both by the
disagreeable sensations it would be sure to excite, and especially by
hindering the expansive movements of the fluids.

815. Odors, even the sweetest, , are also not without inconve-
niences. During labor the nervous irritability of the woman is
generally of the highest grade, and the senses become excessively
excitable. The most valuable perfumes are sometimes borne no
better than the most disagreeable odors. It would not, for example,
be always safe to place a woman in labor in an apartment filled with
the emanations of muse, amber, lilies, orange flowers, or roses. I
have seen a lady fall down insensible and with convulsions upon
entering a room containing a pot of reseda. I am acquainted with
another who, without being pregnant, is seized with syncope or
lypothynia whenever a fresh rose is brought near her.

816. The regimen of ihe patient requires the most careful super-
intendence of the accoucheur; indiscretions in respect to it may give
rise to the worst consequences. In regard to this point, attention
must be paid to the probable duration of her sufferings, to her con-
stitution, and habits: if the delivery may be expected to take place
within from four to six hours at farthest, all kinds of aliment are
hurtful, by loading the stomach, whose digestive power is tempo-
rarily suspended. If, on the contrary, the labor progresses slowly,
she may have broths or some light kind of potage; but she ought
to refuse coffee and chocolate, usually preferred by women in large
cities, as well as bread, fruits, vegetables and meats of every de-
scription, which are best liked by country people; coffee has too
much influence upon the innervation and circulation, and chocolate,
bread, and meats are too difficult of digestion to be given without
some fear in these circumstances. All this, however, ought to be
understood only in a general way; a woman who is healthy, but
rather feeble than strong, whose, digestive organs are in good con-

HYGIENIC TREATMENT. 343

dition, may without inconvenience, and sometimes even with ad-
vantage, take a breakfast of coffee or chocolate at the commence-
ment of her labor, especially if she has been long in the habit of
using them, just as we see stout, vigorous country women, as well
as robust women of tlie laboring classes, eat one or several cutlets
without being at all incommoded by them. It ought to be known
that these exceptions are numerous, for by proscribing food in all
cases indiscriminately, we just favor the evil we wish to avoid; no
matter how absolute the threats of the accoucheur, it is not uncom-
mon for them, to be disregarded, and if no bad consequences follow,
the woman, emboldened by impunity, no longer submits to advice,
relates her story to her acquaintances, and as all beings are not less
alike in their liability to illness than in shape, the punishment
of her indocility fails not to fall upon some of those who have had
the imprudence to listen to her. I was called to a woman in her first
confinement, in the month of March 1824: this lady's mother had
had thirteen children; she had never omitted to drink a bottle of wine
and eat one or two cutlets during or immediately after her travail; in
spite of my remonstrances the daughter must follow her example,
but the unfortunate lady expiated her mother's imprudences with her
own life! We must therefore allow to some what we would rigorous-
ly refuse to allow to the far greater number, and content us with
laying before the most obstinate the dangerous risks they run, and
then leave them at liberty to do as they like.

817. Drinks. Where the duration of a labor does not extend
beyond the most ordinary limits, the woman herself is pretty often
the first to perceive that she ought not to eat, that food would do
her harm. This is not the case as to drinks; the excess of heat
observed during the strong pains has the effect of drying the
organism, and loudly demands the introduction of fluids into the in-
terior. Those that may be allowed are innumerable; the infusions of
mallows flawers, ofmarshmallow roots, of linden, of violet, ofbugloss,
and borrage; decoctions of barley, of dandelion, liquorice, &c.
either pure or edulcorated with sirup of sugar, gum of honey, capil-
laire, cherries, or marshmallows, may be given almost without distinc-
tion, as well as all imaginable ptisans, provided they do not exert
any evident action upon the organism, and are not acid; for it is the
water and not the medicaments that is here demanded by the organs.
Lemonade and acidulateddrinks would suit as well or even better
than any other; but the stomach does not bear them well because
they increase its tendency to acidity. Wine and water produces the
same effect; the other ptisans often diminish the thirst very litde, par-
ticularly if the woEian does not like the decoctions of barley, dande-
lion and liquorice, which are more refreshing, though they happen

344 HYGIENIC TREATMENT.

not to suit or be agreeable to her taste; if pure cool water is taken
"vvith more pleasure and satisfaction, I see no reason why it should
be refused to her, taking care always to correct its crudity with a
few drops of orange flower water, or sirup of cherries in very small
quantity. In the country, and among the lower classes, where the
disembodied relics of old medical doctrines ordinarily take refuge,
hot wine and roties-au vin sucre are still given, with the view of sus-
taining her strength, and eaii de carmes, and a hundred other more or
less heating compositions to accelerate the labor whenever it ap-
pears somewhat tedious; but these incendiary measures, which in-
flame the already irritated organs, disturb all the functions, and some-
times excite fever that no means is capable of allaying, and produce
a dreadful hemorrhage much more commonly than they do any good
in hastening the delivery, begin to go out of fashion, and, let us at
least hope, will before long cease to enjoy any favor. Madame Mal-
ville, a skilful and prudent midwife, was on the night between the
20th and 21st of January 1828, called to a poor woman, and though
all the phenomena succeeded each other with the greatest regularity,
all she could do was insufficient to prevent the administration of hot
wine; a hemorrhage came on; new doses of wine were taken; the
blood flowed still faster, and wine was again given to obviate the faint-
ness; the child nevertheless was expelled, but a frightful discharge
took place immediately afterwards, and but for the coolness and firm-
ness of the midwife, the poor creature, pale and exhausted, and un-
able to turn her head upon the pillow without falling into syncope,
must have inevitably lost her life.

It is only in cases of weakness or languor, depending upon old
diseases, or the peculiar constitution of the woman, that it is oc-
casionally found useful to give a few spoonfuls of good red or white
wine; but there must be no counter-indication, arising from the
state of the digestive organs, nor a state of excessive nervous exci-
tability.

818. The state of the alvine and urinary excretions will also re-
quire the attention of the practitioner. The constipation, which is
so common during pregnancy, causes the rectum to remain inac-
tive at the approaches of labor; its contents may prevent the
head from gliding downwards, irritate the sphincter and mucous
membrane in the neighborhood of the anus, occasion too violent
a straining, and promote the formation of hemorrhoids, which are
naturally of too common occurrence in parturition. Consequently,
provided the woman does not feel the necessity of going to the close
stool, an injection of a decoction of marshmallow root or flaxseed,
or simple tepid water should be given.

819. Provided no discharge of urine takes place before the head

HYGIENIC TREATMENT. 345

. becomes engaged in the superior strait, the emission becomes more
and more difficult, in consequence of the compression which the
bas-fond of the bladder soon suffers; it may therefore be supposed
that if the delivery is protracted, the retention of the urine may be
followed by a painful distension of the bladder, and that the woman,
who is restrained by the fear of increasing her pain, will cease to bear
down, except very moderately. The action of the abdominal mus-
cles, as it can then be transmitted to the womb only through a
stratum of fluid, ceases to be so efficacious, or if the woman gives
herself up without reserve to the whole force of the exertions she
is capable of making, there may be reason to fear a rupture of the
bladder, a terrible accident, which is almost necessarily mortal.

The woman should therefore be advised to evacuate the bladder
while she is still able to do so, and if the natural efforts are insuffi-
cient to effect the object, the catheter should be employed for that
purpose. We are in such cases sometimes obliged, in consequence
of the shortness and slight curve of the female catheter, to make
use of a male one; but if we take care to push the fundus of the
womb backwards with one hand, whilst we try to introduce the in-
strument with the other, I do not think that the flat catheter which
is recommended by some of the English physicians, can ever be in-
dispensably necessary.

820. The period of labor is, without contradiction, one in which
the moral state of women demands the greatest attention; conse-
quently, we ought with all possible care to abstract whatever may
be disagreeable to them, or likely to vex them, and to respect even
their caprices and the oddities of their characters.

None should be permitted to remain in the room except those
persons who are indispensably necessary; that is, one, or at most,
two friends, the nurse, and accoucheur. More than these would
render the air impure; some could not bear the spectacle of suf-
fering without reflecting the impress of it from their countenance^
others could not keep their tongues still, would always have a sup-
ply of stories of dreadful cases, and a thousand imprudent things
to say; at one while, that Mrs. such-a-one was delivered of a mon-
ster, or neighbor such-a-one died with convulsions ; at another,
they delivered Mrs. so-and-so with instruments, &c. ; from ten-
derness or real interest or affectation, they grow quite sad, and la-,
ment over the possible consequences of the lying-in; and whisper
or talk in a low tone, or at least they sit gloomy and silent, and
merely throw a furtive glance of pity towards the woman in la-
bor, who, as she is almost always disposed to make an evil inter-
pretation of all that is said and done about her, every moment

346 HYGIENIC TREATMENT.

looks for her sentence of death in remarks only half heard, in ges-
tures, or in the expression of sadness and compassion she observes
in her attendants.

821. Parturition is a function that seeks the shade, that may be
obstructed by indiscreet looks, and which as far as possible is made
a mystery of by modest women. The accoucheur ought to under-
stand that the mother, the aunt, grandmother or sister, are not always
considered as the most agreeable attendants in this painful moment.
As a discreet as well as a circumspect and prudent interpreter, he
ought to dismiss without distinction every one whose presence is not
desired by the woman. How careful should he be himself! impas-
sible and firm, of an imperturbable coolness, he must, notwithstand-
ing, know how to compassionate the distress of which he is a wit-
ness, encourage, console, amuse; inspire her with boundless confi-
dence, and great familiarity, by the affability of his conduct, by rea-
sonings that everybody can understand, by his patience, the amenity
of his temper and the gravity of his manners; he should be able to
procure obedience without constraint, and by all the means which
are suggested by moral philosophy, his own understanding and
education, incessantly combat the discouragement and dread of all
sorts, and the sadness and alarms to which the most resolute as well
as the most timid women sometimes give way.

822. The dress of a woman in labor was formerly a matter of
great consequence; there were gowns, jackets and head dresses
devoted to this purpose alone; every country, each province, and
even each family, had its peculiar fashion; a woman of good family
would think she could not lie-in decently without her gown and
other lying-in clothes; at present these old customs are no longer
to be found, except in a few countries or families, where, out
of a mistaken feeling of respect, people obstinately resolve not to
live differently from the mode adopted by their ancestors. To this

^e accoucheur has nothing to say, provided the form of the dress
and its arrangement are not of a nature to interfere with the free
exercise of any of the functions, provided there be no constriction
of the abdomen, the breast or the neck, that the motions of the
limbs are left free, that the materials are light, neither too hot nor
cold, and that the circulation does not suffer from their employ-
ment.

833. The bed for child-birth, which is also called lying-in bed,
bed of labor, bed of pain, bed of misery, little bed, &c., is also a
matter of fashion or custom, which has singularly varied as to its
form, according to times, places and whims. There are some wo-
wen who will not make use of them, and who are delivered stand.

HYGIENIC TREATMENT. 347

ing up, the elbows resting on a mantel piece, the back of a chair,
a table, a bureau, or some other piece of furniture, or even leaning
on the shoulder of some friend. Some women place themselves on
their knees upon the floor; others place themselves on their hus-
band's knees, with their legs much bent and elevated. Tl>e ancients
made use of a peculiar kind of seat or elbow chair, a lying-in- chair,
having supports for the arms, a movable back-piece, with notches
in a piece to keep it at different degrees of elevation, a support for
the feet, and a pierced seat ; so as to be converted at will, either
into a real bed, or an arm chair. These chairs, still made use of in
Germany and Switzerland, and very good drawings of which may
be seen in the works of Stein and M. Hermann, are no longer em-
ployed in France, notwithstanding M. Rouget has lately attempted
to revive them by presenting to the Academy, and to the administra-
tion of the hospitals of Paris, a new lying-in bed of his own inven-
tion. They are not wholly destitute of advantages, but as they can
"without inconvenience be replaced any where by other means more
common, and always at hand, no person feels the necessity of resort-
ing to them; and it would be too ridiculous to see a surgeon, as in
former times, always followed by his lying-in bed, when proceeding
to visit a woman in labor.

824. The best bed is one with a sacking-bottom, tight, of a mid-
dling size, and so placed that the upper end may rest against one
I of the walls of the chamber, and leave room to pass conveniently
all round the rest of the bed; one mattrass is laid on this sacking-
■ bottom, and a second one, bent double in the middle, is arranged up-
on it in such a way that the edge of one of its extremities may sup-
port the buttocks, while its folded portion supports the back and head;
a piece of cloth, some oil cloth or some cushions, pillows and bol-
sters, to supply an inclined plane for the head and breast, complete
the preparations.

We may also be content with a cushion, to be slid under the
middle of the first mattrass, so as to raise the pelvis up and leave!
the perineum naked; the head of the bed is then formed with one or
two common chairs, turned downwards, with the legs against the
wall, and the upper edge of their backs towards the woman's breech;
the rest of the arrangement is completed as before, and the second
mattrass is not wanted.

A single mattrass, without any cushion, will also answer; it is to
be doubled; the head of it is to be raised with chairs; all that por-
tion of the sacking-bottom that is to be in front of the pelvis is left
uncovered, and by means of some cloths to receive the discharges
upon, we may avoid soiling any part of the bed clothes. Some per-

348 HYGIENIC TREATMENT.

sons add a slick, fixed cross-wise to rest the feet against during the
expulsive pains; but this fixture is more troublesome than useful, the
hands of an experienced nurse answer much better, for they can fol-
low the different degrees of flexion and extension of the limbs. In
the country, a bed is often made by placing six or eight chairs face
to face and laying a mattrass upon them.

Indeed, a strong and well formed woman may be delivered in any
posture, on a chair, on the floor, a bundle of straw, on foot, and on
all the kinds of beds that have been proposed; so that it is only in
the cases where nothing interferes with the accoucheur's prescribing
just what he thinks best, that he ought to attach some value to the
composition of the lying-in bed; further, the only essential matter is,
that the woman should be as comfortable as possible, that she be not
incommoded, neither during the pains nor the intervals between them,
and that the perineum may have room to dilate.

825. There is not, neither can there be any fixed period at which
all women should place themselves on the lying-in bed: some women
feel the necessity of going on to the bed as soon as their pains get
to be pretty strong; others not until a much later period, and most
women may be guided in this matter by what agrees best with their
own particular feelings; as long as they keep on the bed, or on foot
either, because they are more comfortable in either case respec-
tively, and not for the sake of gratifying some preconceived notion,
they ought to be indulged; it would be absurd to compel them to
remain on the bed from the beginning to the end of a labor, while
the only means of alleviating their distress consists in moving about
from place to place; on the other hand, by compelling them to keep
up till the close of the labor, their courage and strength are exhaust-
ed to no purpose, they are exposed to the danger of bringing on
flooding, to the prolapsion, and overturning of the womb, laceration
of the perineum, and to the too prompt and precipitate escape of the
foetus.

Therefore, in regular labors, where there is no special indication
to be fulfilled, it is useless for the woman to lie down previously to
the rupture of the membranes, unless it be for the purpose of resting
when she feels fatigued. When on the contrary, the dilatation of
the OS uteri is complete, and especially when the head has descended
into the excavation, it is better, but not always indispensably neces-
sary, for her to lie down on the bed in readiness for it. Where the
pains are weak and far apart, and where the membranes give way
early, or the head remains very high above the superior strait, and
the OS uteri, although soft and very dilatable, opens with difficulty,
she ought to keep up and move about as long as her strength will

MANAGEMENT OF LABOR. 349 .

permit. Again, she should be persuaded to lie down early if her
pelvis be a very large one, and the membranes do not give way,
though the os uteri be dilated, when the labor progresses too rapidly,
and when there is a threatening prospect of hemorrhage, or when
there is an obliquity of the womb. Women affected with curva-
ture of the spine, asthma, hydrothorax, ascites, or some other ab-
normal disposition, are sometimes constrained not to lie down at all,
and are oWiged to be delivered while standing up, or seated, or on
their knees, (fee, while there are others wl^o could not leave their
beds before the termination of the labor without difficulty. But
these are cases of exceptions Avhich do not belong to the class of
eutocia.

826. When the woman is on the bed, she should, during the pains,
be on her back with the legs and thighs half flexed, and the feet
resting on the mattrass or sacking. This posture, which is so natural
that women assume it of their own accord, and if they have changed
it for a moment, always return to it as soon as the pain returns, is
particularly necessary where the womb is strongly inclined forwards.
But in the intervals of the contractions it would be as ridiculous as
it would be cruel to exact any determinate attitude; the woman
ought then to be left free to choose a position that is most agree-
able to herself, on either side; a being, when suffering unavoidable
pain, at least hopes by changing*its situation and trying various
positions, for some alleviation of its distress; to deprive it of such
a resource, would be a real act of barbarity. Moreover, the atti-
tude on the back is very rarely necessary except in cases of very
decided obliquity. Most of the English and American women lie
on the left side, with the breech near the right edge of their com-
mon bed, which is properly prepared, the legs and thighs flexed, the
knees separated by pillows or cushions, and nol\%ithstanding; we do
not find that childbirth is much more dangerous in England than in
France. However, it is evident that such an attitude must be very
uncomfortable and unfavorable to the muscular contractions that
occur during the pains. The British accoucheurs who recommend
it, think it admits of their supporting the perineum more effectually,
of employing the touch more freely, and, which I cannot understand,
of operating more readily with the forceps, the hand, or any instru-
ment whatever; but when we remember to what extent the modesty
of the English ladies is carried, and reflect on their extreme delicacy,
and the reserved character of their manners and customs, we are
rather led to think that the lateral position, which prevents them
from looking the accoucheur in the face, has been chosen to gratify
and save them from unpleasant feelings.
31

350 EUTOCIA.

827. The accoucheur places himself to the right of the bed; he
is there most commodiously situated to touch, to follow the progress
of the labor, and support the perineum; all of which may be done
under the bed clothes, for it is with the finger or hand, and not with,
the eye, that he must here act and ascertain the state of the parts.
As the will and the courage of the patient exert a great influence on
the progress of parturition, it imports him to know how to direct
their powers. We daily meet, in practice, with women who hear
down, and endeavor to make the most of their pains, as soon as
they become somewhat strong; the old women, the midwife, and
sometimes the accoucheur himself encourage them to act in this
way, by persuading them that they will be the sooner delivered.
Such conduct is extremely blameable, and can only be the fruit of
ignorance or want of reflection. Where the os uteri is not dilated,
the membranes unbroken, or at least, where the head is not as yet
engaged in the superior strait, efforts to hasten the delivery only
serve to exhaust the woman to no purpose whatever; until the end
of the first stage, the action of the muscles is not solicited, the womb
does not demand their aid, and they can be of no use.

But as soon as the foetus penetrates into the excavation, the os
uteri being dilated, and the membranes ruptured, and the sense of
weight about the fundament, tenesmus, and strainings are felt, they
occasion a desire to bear down, and compel the muscular contrac-
tions to come on stronger and stronger in aid of the womb, in pro-
portion as the child is nearer the moment of expulsion. The womb
now compels the eflTorts to take place, independently of the woman's
will; the thing is, to know how to make the best use of them, and
there are many women who do not know how to do it — who do not
know how to deliver themselves; who, with the expense of a con-
siderable degree of power, cause the labor to advance but very little;
the accoucheur should teach them their apprenticeship, if I may-
use such an expression, should teach them that when the pains are
regular, they should not employ their voluntary efli'orts until the con-
traction is fairly begun, or until the muscular action is positively-
solicited; then, by pressing the pelvis, feet, and hands upon the bed
or upon the persons stationed to support them, they should bear down
with all their might, as if at the stool; as soon as the womb itself
ceases to act, all efl!brt ought to be suspended, and the woman
should be strictly directed to rest, and be as still as possible, never
losing sight of the fact, that the muscles are not intended to force the
foetus downwards, but only to aid and support the contractions of
the uterus.

828. The pains are sometimes so acute, so intolerable, when the

MANAGEMENT OF LABOR. 351

head reaches the inferior strait, that instead of bearing strongly on
the pelvis, and pushing downwards, the woman, in spite of herself,
draws it upwards as if to avoid the pain. In this she is doubly dis-
appointed; in the first place, because nothing can save her from the
distress she endures, and because she in this way voluntarily pro-
tracts the period of her deliverance; and then, far from being an
evil, violent contractions are what she should above all things de-
sire, for upon them depends the prompt termination of the labor. The
same thing often takes place in women who are too pusillanimous,
too nervous or timid; they are restrained by the fear of making
the pains too sharp; they are restless, and toss about from place
to place, and rather than assist and make the most of their pains,
do all they can to hinder or suspend them.

829. Some of them fall into the opposite kind of excesses, give
themselves up to such immoderate efforts, that unless care were
taken, very serious consequences might ensue, such as a great con-
gestion of the brain, and even an apoplexy, the sudden swelling of
the thyroid body, and the rupture of the large veins of the throat,
the formation of hernias of all sorts, temporary paralysis of the lower
limbs, &c. The dangers to which they expose themselves by
inconsiderately bearing down in this manner, ought to be painted
in strong colors and exhibited to their view, and all the means of
persuasion and control should be skilfully employed in order to
oblige them not to give way so completely to their feelings. If
reason, intreaty and gentleness do not succeed, a firm and even
menacing tone, properly adapted, sometimes becomes necessary.
There are a thousand means to be made use of to quiet them, to
inspire them with dread, and restrain them. Thus, Baudelocque,
after having in vain exhausted all his resources, thought of bringing
two lawyers dressed in their robes into the chamber of a woman in
labor, by which she was so intimidated that she thenceforth became
reasonable, and submitted to the counsels of her accoucheur.

830. The touch is performed at different periods of labor, for
the purpose of ascertaining the position of the fietus, the degree of
dilatation of the neck, and to learn how far the head has descended.
Rigorously speaking, it would be sufficient to touch three times dur-
ing a labor: once at the commencement, to learn certainly whether
the womb is contracting; a second time, just as the waters break,
to make ourselves positively sure of the position; and a third, when
the pains and eflforts have acquired a certain degree of strength, in
order to see whether the parts engage properly in the excavation;
but, generally speaking, unless the vulva and vagina are very sensible
and irritable, we may repeat this operation much more frequently,

352 EUTOCIA.

and that without any ill effect. Provided the touch were never
practised but for the purpose of learning the progress of labor, it
would rarely be followed by any other inconvenience than that of
annoying the woman and wounding her scruples, how often soever it
might be repeated, always excepting the cases where it is made an
object of study, as in our public halls, where a very great number of
students touch the same woman in succession. But there are ac-
coucheurs who resort to it with very different motives, who, furnished
with an apron, the coat off and shirt sleeves tucked up, seat them-
selves betwixt the woman's knees, and perform what they call her
lesser labor, and forcibly dilate the vulva and os uteri, under the
pretext of accelerating the progress of the case. The poor crea-
tures who submit to such procedures, and are even the first to ask
for them, do not know to what dangers they are thereby exposed.
We might pity those who put them in practice through ignorance or
temerity, but what ought we to think of those who make use of them
as a system, in order to appear more skilful and important in the
eyes of the vulgar?

831. If it be sometimes useful or even permissible to introduce
one or more fingers into the vagina, so as to aid in the dilatation of
the parts, it is only in cases where rigidity or an irritated condition
of some point in the vulvo-uterine canal indicates that it would be
well to introduce some mucilage or soothing ointment, such as
Galen's cerate, or the cucumber ointment, and not oil, as recom-
mended by Consell. When the head, in engaging in the strait, and
even in passing through the excavation, pushes the cervix before it
like a cap, there may be some use in supporting the circle with the
end of one or more fingers during the pain; but if it is not always
dangerous, it is at least always useless to try to overcome its resis-
tance by artificial means.

832. To support the -perineum. When we reflect on the form of
the pelvis and the direction of its axes, it is easy to perceive that
the perineum, which is a continuation of the sacro-coccygeal wall of
the pelvis, but much less solid, must be violently distended, and run
the greatest risk of being torn, as the head emerges from the lower
strait. Hence all accoucheurs have recommended some mode of
preventing this accident from taking place. Some have supposed,
with Mesnard, that it is only necessary to push the coccyx back-
wards, or to place two fingers between the head and perineum when
the occiput reaches the vulva; others, that the object may be better
attained with the assistance of Roonhuysen's lever, or a wide piece
of whalebone; lastly, some practitioners are content with the appli-
cation of the hand to the exterior. But inasmuch as, in spite of all

MANAGEMENT OF LABOR. 353

these precautions, the perineum sometimes tears, certain modern
surgeons have concluded that it is wholly useless to support it in any
way. If 1 can give credence to several young German and English
physicians, the accoucheur of the public establishment at Gottingen,
and the one who in 1834 directed the lying-in hospital of Dublin,
are of this opinion, and I am assured they even go so far as to think
that the precautions recommended on this head are all dangerous. As
success here depends less upon the means employed than upon the
hand that employs them, it is likely that a long time must elapse
before every body can be of one accord as to the value of those that
have been proposed.

833. However this may be, the conduct recommended by reason
and experience is the fohowing; the hand, either naked, or what is
better, wrapped in a linen clotli, is applied transversely, so that its
cubital edge may correspond to the point of the coccyx, and that its
radial edge may be below the anterior commissure of the perineum,
the ends of the fingers may lodge between the labia and the thigh, or
extend on to the thigh, while the finger and thumb being separated,
are placed between the other labium and opposite thigh. In this
Avay we convert the inclined plane that the head has to pass over in
emerging from the soft parts, into a firm wall ; the hand is placed
there as if to continue the concave surface of the sacrum and coccyx,
and as to compel the head to adapt itself to the axis of the vulva; the
power that we employ must therefore act from behind forwards, from
the coccyx towards the pudendum, and not in the opposite direction
nor laterally. We must force the occiput to turn upwards towards
the pubis, and not hinder it from descending; besides, it is only at
the moment when the head begins to distend the vulva with a cer-
tain degree of force, that it imports us to act; previously to this
period the operation would be without object, and the accoucheur
would prove merely that he is ignorant of its mechanism. By trying
to bend the fingers a little, as has been recommended, for the pur-
pose of bringing the soft parts towards the median line, the hand is
rendered too concave, and does not support the head sufficiently,
and we thus promote exactly what we wish to avoid; by placing the
hand, as others recommend, in a state of supination, vertically, with
the fingers towards the coccyx, and the wrist towards the vulva, we
again miss the object, for our efforts are then directed with more
facility in front than behind, while the contrary is what we wish to
do. Finally, to prevent, as certainly as possible, any laceration
from happening, we may, after the manner of M. Flamaut, take
hold of the skin on the buttocks or posterior part of the pelvis
with both hands, and draw it forwards as much as possible; it is

31*

354 EUTOCIA.

proper, it is even important, as soon as the parietal protuberances
have passed the level of the tuberosities of the ischia, to engage
the woman to moderate her efforts, instead of exciting her to bear
down more and more, as is too commonly done. This is the moment
that the parts, being surprised, or astonished, are lacerated, if the
head, pressed too rapidly forwards, does not give them time to yield
and mould themselves by it. Therefore, the slower the progress
of the head, the greater will be the chance of preserving the perineum
uninjured.

I am far from saying that laceration of the perineum is in all cases
a serious accident; on the contrary, I believe it to be very rarely
dangerous; but the accoucheur ought nevertheless to do all he can
to prevent it from occurring; and I cannot too strongly condemn the
negligence, in respect to it, of which most of them are culpable.
If it be not in our power to prevent the woman from suffering, it is
at least a duty to preserve the natural form of her organs as far as
possible. The wound will heal up, no doubt; but the dimensions
of the external orifice of the vagina remain too large, and we cannot
divine what distress may be indirectly produced by this accident,
though in appearance a slight one.

834. To support the head of the fcetus . As soon as the head has
passed out of the vulva, it should be supported by both hands; the
fingers being separated, are applied under the occiput, the ear, and
lower jaw on each side, being careful not to prevent the act of re-
stitution from taking place. Rigorously speaking, we might dis-
pense with any tractive effort; for the remainder of the foetus is
often expelled with the same pain that delivers the head; or else
another pain soon comes on to complete the delivery; however, as
there is no advantage to be derived from retarding the termination
of the labor, and the woman has nothing so much at heart as to
be prompdy delivered, it is best to follow up the impulsion given by
the womb, and whilst it is still contracting, to draw very prudently
and moderately upon the head or armpits, in the axis of the inferior
strait.

The conduct I have just above indicated is particularly applicable
in the three true varieties of the occipito-anterior position. It may,
and indeed ought to be slightly modified in most of the other presen-
tations.

835. Occipito-posterior position. When the occiput looks to-
wards the back part of the pelvis, delivery being in general more
difficult, it is natural that we should profit by its tendency to turn for-
wards, in order that we may by degrees convert it into an anterior
position, in which we may sometimes succeed by imitating the na-

MANAGEMENT OF LABOR. 355

tural processes. When the head sinks into the excavation ahnost
immediately after the evacuation of the waters, we endeavor to
make it deviate to the right or left, in the intervals between the con-
tractions, by passing two or three fingers up in front of the sacrum.
During the pain, we prevent it from returning to its original posi-
tion, by leaving the fingers, with which we displaced it, betwixt it
and the median line; these attempts are repeated as often as they
may be deemed necessary, and if we cannot always succeed in con-
verting the fourth or fifth positions of Bandelocque into the first or
second, we are at least sure that we occasion the mother and child
both, no additional hazard where the maneuvre is properly execut-
ed. The perineum is in more danger of being lacerated in this than
any other position; in order to support it efficiently, we should take
care not to incline the hand too much forwards, for the point of the
head would fall almost perpendicularly upon it, and would rather
turn backwards towards the anus than glide in the direction of the
vulva. This is the situation in which M. Flamant's precept is espe-
cially applicable.

836. Face positions. Although the face positions do not render
delivery much more difficult than those of the vertex, yet, as they
are less exactly according to nature, it is always prudent, where it
appears easy to do so, to change them into positions of the vertex.
It can no longer be thought of after the head has once reached the
excavation; it should be attempted while it is still movable at the
superior strait, and that in two difierent ways: we may either try,
with two fingers, to push the chin towards the breast by acting on
the forehead, or we may endeavor to hook the occiput, to draw it
down and produce the same effect. In both cases we leave the
fingers in place until a contraction comes on, so as to transfer to
the occipital branch of the lever represented by the head, the power
that previously acted upon the facial or anterior branch of it.
It would be particularly important to efliect this conversion in the
mento-sacral position, if it should ever be met with. Further,
where the face emerges first, it is not so easy to support the peri-
neum as it is in the vertex positions; but the rupture of the peri-
neum is the less to be feared, because the front of the neck, and not
the bregma, presses against the lower edge of the symphysis, while
the upper oval of the head passes along the perineum to reach the
vulva. The hand ought therefore to press but moderately, and not at
all until the forehead is without; otherwise we might increase the dan-
ger to which the foetus is exposed, or at least interfere with the ter-
mination of the labor.

837. Inclined positions of the head. When the whole forehead,

356 EUTOCIA.

or one side of it, the anterior fontanel, one of the parietal protuber-
ances, the upper part of the nucha, the chin, or one of the cheeks
is substituted for the frank vertex or face positions, they do not
always prevent the delivery from being spontaneous, because the
woman's efforts generally succeed in causing the occiput or face to
descend. Nevertheless, as these intermediate or bastard positions
may to a certain extent embarrass the progress of the pains, or of the
labor in general, we ought, as soon as they are discovered, to attempt
to change them to the regular positions to which they correspond.
As long as the head continues at the superior strait, and the womb is
not too strongly contracted upon the body of the child, we might
hope, by introducing a couple of fingers behind, in front, or on the
sides of the occiput, to bring it back to the centre of the strait, or at
least, if we could do no better, force it to enter fairly with the face
in the opening.

838. Presentations of the feet. In maintaining that footling labors
commonly terminate without assistance, I did not mean to have it in-
ferred that we must never touch the foetus in any way until it is com-
pletely expelled; but merely, that it is unnecessary, and even dan-
gerous, to exert any tractive force upon it.

As soon as the legs appear, they should be supported, after wrap-
ping them in a napkin; the same is to be done with the hips, the
arms, the breast and shoulders; when only the head remains in the
excavation, we place a couple of fingers on the chin, in the mouth,
or what is still better, on the sides of the nose; two or three fingers
of the other hand are slid under the symphysis pubis, so as to sup-
port the occiput, and as soon as the least contraction comes on, we
draw the whole downwards in the direction of the axes of the in-
ferior strait and vulva, as if we were trying to turn the child's back
up over the mons veneris, and upon the hypogastrium of the mo-
ther.

839. The head now having nothing to pass through except the
perineal strait, is beyond the influence of the uterus, and may be
extracted without difficulty; but while ever it has not traversed the
uterine orifice, or the abdominal opening of the pelvis, the least at-
tempt to accelerate its escape could tend only to produce a case of
real dystocia. As to the perineum, it is easily managed, since it
depends upon the accoucheur to pull the head with more or less
force, or to incline it more or less forwards, as it passes through the
vulva.

840. Presentations of the knees. The knees present very ievr
peculiar indications; if they present in a regular position, they should
be allowed to come down of themselves, and when they reach the

MANAGEMENT OF LABOR. 357

vulva, all we have to do is to assist in disengaging the legs. If one
of them assumes a bad direction, lodges against some part of the pel-
vis, or is arrested by the cervix or some fold in the vagina, it is com-
monly disengaged without difficulty, and brought alongside of the
other one. For the remainder we are to act as in feet presentations,
taking care not to pull unnecessarily.

841. Presentations of the breech. AVhen the buttocks descend
first, and the feet tend to engage at the same time, it is sometimes
well to push the latter back, and keep them somewhat raised during
several pains; if not, there is nothing to be done until they get to
the bottom of the excavation. It is in this state improper to pull at
the breech except during the contractions of the womb ; if, how-
ever, its size is very great, and there should be some difficulty in its
passing through the vulva, the finger hooked into the groin that is
towards the sacrum may be of some service by enabling us to give
timely assistance to the woman's efforts. The hips are scarcely
delivered before the constriction they had experienced is transferred
to the child's belly. It is important then to pull on the thighs and
legs, which should be extended in order to diminish this dangerous
compression; the management of the rest of the labor is in all re-
spects similar to that required where the feet or knees present. As
the buttocks are escaping from the inferior strait, they sometimes
distend the perineum as much as the head does when it comes first;
but as they are much softer, and the flexibility of the trunk admits
of their accommodating themselves much more easily to the direction
of the axes as well as to the forms of the spaces they are obliged
to traverse, they much more rarely occasion a laceration; so that
in such cases it is not always indispensably necessary to support the
perineum.

842. In oblique positions of the breech we must act as in \\\e in-
clined positions of the head; we must endeavor to restore them to
a correct state : if the posterior surface of the coccyx and point
of the sacrum are in the centre, the woman should be directed to
lie down early; she should be made to lie as much as possible on
the back, while the hand applied to the hypogastrium pushes the
womb backwards and upwards; if this precaution should not suffice,
we might, with a couple of fingers of the other hand, hook the
isohia and draw them down into the strait. If one of the buttocks
engages alone, with or without the corresponding hip, it should be
raised up during the absence of the pains, or we should try to reach
it directly, by passing some of the fingers up along its external sur-
face.

Where, instead of one buttock or the coccyx, we meet with the

358 EUTOCIA.

genital organs or fore part of the legs in the centre of the dilated
OS uteri, it is generally easy to bring the legs down in place of the
breech; and this ought to be done whenever both the breech and feet
present at the same time, for it would evidendy be too difficult to
compel the former to engage alone.

843. Obliquities. Anterior inclination of the womb may be said
to be the only one that demands attention during labor. When it
does exist the foetus always engages with difficulty; the abdominal
muscles being too much curved, contract with but little energy; if,
nevertheless, the child's head engages in the excavation, the back
part of the cervix rises, while its fore part, which becomes thin
and distended, covers the head like a cap, and descends beneath the
strait.

This state of things, moreover, cannot fail to embarrass young
beginners. It may lead them to suppose that the dilatation is com-
plete in some cases where it has scarcely begun; finding no os uteri,
they most generally begin to dream about anomalies, or else know
not what to think about it. Here is what one of my young brethren,
"who had been practising in the capital with distinction for three
years, wrote to me on the 3d of January 1827. "I have been all
night with Madame de S. A., the labor appears to go on regularly,
but I cannot find the os uteri; I have passed the finger up towards
the promontory, then towards the iliac fossae, and also up behind the
pubis; at all these places I have reached the cul de sac formed by the
upper extremity of the vagina, but I have found no cervix; what must
I do, what does it mean?" The truth was that the orifice had gone
so far upwards and backwards behind the tumor that projected into
the excavation, it was necessary, in order to reach it, to crook the
finger quite forwards.

Whenever I have met with this peculiarity, which, I repeat it, is
very common, the labor has gone on very slowly until the end of the
first stage, but I have always found it afterwards to progress with
much energy, and to require no particular management.

844. Tedious labor. In former times, every physician and every
midwife had an oxytocic* remedy, some sure means of bringing
labor to a prompt termination; upon this head all the arcana and
amulets have had their share of pufis. Some put a bit of precious
stone, as jasper, topaz, emerald, &c.in a small bag, which was
suspended from the woman's neck; others advised her to hold a
piece of loadstone in the right hand; sometimes an eagle's plume
was fastened to the thigh, or the first feather of the right wing of

* From o^uf quick, and roxof child-birth.

MANAGEMENT OF LABOR. 359

that bird was secured to the sole of her corresponding foot; some-
times again she was to have the belly rubbed with viper's fat and
snake's gall, or the navel was covered with a very hot snake or rabbit
skin; finally, some saffron placed on the hip, some cabalistic sentence
on the forehead, the breast or pit of the stomach, and a thousand
other absurdities of the same kind, were also frequently made use of.

As M. Desormeaux remarks, it would be almost puerile to make
the least mention of such nonsense, provided we were not oblio-ed,
from a human respect, to reply to certain folks who hold ihem to
be great secrets, and in certain cases to show, like Van Swieten,
some condescension for the weaknesses of females. These reme-
dies at least will do no mischief, and may perhaps prevent the ad-
ministration of some less inoffensive remedy.

The aromatic waters, as balm and mint waters, the tinctures of
canella, of cloves, all sorts of compounds, and all sorts of alcoholic
elixirs have each had their day, and many women who used them have
fallen victims to their imprudence. Purgatives and emetics have
had great vogue even among medical men, and are not yet wholly
forgotten by the vulgar. Preparations of manna, or of senna, to
■which, by way of corrective, was added lemon or orange juice, were
very much used in the time of Mauriceau; but, without denying
that such preparations may possess the faculty of restoring the pains
in some particular cases, and without fearing their action on the
alimentary canal, so much as some physicians of our day do, it is
notwithstanding, manifest, that, if they ever may become dangerous,
it is chiefly to women in labor that they are likely to be so.

845. Purgative articles, given in the form of clysters, are not
attended with the same disadvantages, and, in fact, they appear to
have been employed in this way with some advantage; amongst
others, the decoction of senna, whose operation is generally accom-
panied with smart colic, is perhaps not to be wholly neglected. It
is at least certain that I have, at the Maternite of Tours, seen it im-
press upon the contractions an energy that could scarcely be attri-
buted to mere chance. Bleeding, baths, antispasmodics, opiates,
borax, and many other articles, are, in the opinion of some persons,
possessed of very decided oxytocic properties; but in order not to
be misled in this manner, we should be careful not to confound
what depends on time, circumstances, or chance, with the real
effects of the means employed, and never lose sight of the possibility
of those singular coincidences which often put to flight the most skil-
ful combinations.

846. Labor sometimes progresses with extreme slowness, and
mav last from two to five or even eight days, without there being

360 EUTOCIA.

any thing particular to be done, and that in two opposite cases;
1. In young nervous women at their first lying-in, and who are of
a rigid and excitable fibre; 2. In those of a delicate, feeble, and
l)'^mphatic constitution, or where the os tineas is very soft for some
time before the full term. In the former, the labor can with diffi-
culty set in fairly, because the orifice is too resisting, or of too great
a degree of sensibility; here a small bleeding, if warranted by the
state of the pulse, and the strength and habitual coloration of the
patient, a tepid bath, unctions with belladonna ointment, and slightly
narcotic and soothing drinks may sometimes be employed with advan-
tage; in the latter, it seems as if the womb were in a state of uncer-
tainty, as if it were assaying its strength, as if under the necessity of
preparing in silence before entering openly into action; I have seen
some remain two, three or four days in this state; but when the con-
tractions once acquire a certain degree of energy, the labor termi-
nates in general with an extreme rapidity, which singularly contrasts
with its former slowness; indeed, it is to this circumstance that a crowd
of remedies are indebted for the vogue they enjoy. Nature, here
has no need of assistance, this slowness is necessary for her, and it
ought not to be disturbed in any way; we are merely permitted to
support the strength by giving some analeptic aliments, or a few
spoonfuls of wine, repeated from time to time, and always with the
greatest reserve.

847. On other occasions, the pains, after having been regular
and pretty smart, begin to return only at long intervals; sometimes
this is owing to the general weakness of the woman or the fatigue
of the womb, sometimes, on the contrary, it must be referred to ill
directed efforts of the womb, or to its not possessing a great share
of excitability. In the former case, rest, and some broth, if there be
any appetite, a little wine if there be not too much thirst and heat,
and resignation, are all that we can recommend. In the latter, we
also recommend rest if the woman is much fatigued, but otherwise
she should be advised to walk about; for it cannot be denied that
walking about and a vertical posture positively accelerate the pro-
gress of labor.

Time and patience are here the great remedies; but this is a sad
resource for one who is in a state of suffering, and the accoucheur
must expect the most multiplied solicitations, and all sorts of proposals
and entreaties from all the by-standers. As long as they are satis-
fied with amulets and inert topical applications, and do not insist on
giving active substances internally, they should be allowed to say
and do as they like; it is one way to amuse the women; while they
see us busy in regard to their suff'erings, they bear them more cou-

MANAGEMENT OF LABOR. 361

rageously. Should the practitioner be compelled, for the sake of quiet,
to prescribe some remedy, he should follow the advice of Mauriceau,
and, in the first place, make a bargain with the patient, obtain
from her as much time as possible, and promise her that, if at such
an hour the pains do not return, he will then cause them to begin
again; then, when the hour agreed upon arrives, if the pains continue
to be still weak, take care that the article to be made use of cannot
be procured except from some considerable distance; that the person
sent to bring it be a dull messenger, who will be apt to lose his way;
let it be some sort of wood, or bark, or root, or at least some hard
substance. When the remedy at length arrives, it must be pul-
verised or rasped for a long time; after Avhich it should be boiled
for several hours. In the next place the liquid must have time to
cool; it is next passed through a piece of linen, something more is
to be added, and then it should be boiled over again; at last it is
given to the patient, and as three or four hours are necessary for it
to produce its effect, it is easy to see that we may in this way gain
more than half a day, and that within that interval the pains will
rarely fail to resume their natural course.

848. In certain cases the labor becomes slow, because the con-
tractions are difficult, extremely painful, unequal or' partial. The
first mentioned case ordinarily depends upon plethora, either local
or general, which is the cause why the uterine fibres, engorged with
blood, and as it were stupified, cannot contract with suitable energy;
women who are sl,rong, robust, sanguine, and very muscular, are
most liable to this state of things, which is known by a feeling of
general uneasiness, weight and distress felt in the hypogastrium and
pelvis, a highly colored skin, and especially by the pulse, which is
either strong and large, or contracted, small and hard; in this case,
bleeding frtim the arm, by means of the depletion it occasions, fre-
quently succeeds in restoring to the pains all necessary activity.

The second case may be met with alone, or concurrently with the
former; and as its cause is an exalted sensibility, whether natural
or accidental, of the whole economy, or of the sexual organs in par-
ticular, it is proper after bleeding, if that has been deemed useful,
to have recourse to baths, to the mildest anodynes, and even to the
thebaic preparations.

The third ease is of much more frequent occurrence tl^an the gene-
rality of practitioners suppose, and I can hardly comprehend why
the authors make scarce any mention of it in the treatise put into the
hands of students. The work of Wigan, which is highly esteemed
in the north, proves that these contractions have fixed the attention
of the German accoucheurs in a very special manner: among us
32

362 EUTOCIA.

hardly any body but Madame Boivin speaks of it; but Burns and
Devvees treat it somewhat more at length. Sometimes it is the fun-
dus of the womb that contracts thus spasmodically, while the rest of
the organ hardly contracts at all; sometimes, again, it is one of its
angles, a portion of its anterior wall, of its posterior wall, or one of its
sides; the pains are not less acute than they would be if the whole
organ contracted, they may even be more severe, but they are in
pure waste, or at least, far from having as much influence on the
progress of the labor as the regular contractions. If the parietes
of the belly are not too thick, we can, by applying the hand upon
the hypogastrium, feel that the uterine ovoid is not even, that there
are lumps or inequalities, and that, too, independendy of the form
of the fcfitus. Wigan, who gives to this disposition the appellation
of tetanus, appears to me to have made too many divisions; practice
can derive no benefit from it, and theory gains by it nothing but con-
fusion.

Whenever the general state of the patient does not contra-indicate
it, we must here also have recourse to bleeding, then to baths,
and next to simple anodynes, diffusible anti-spasmodics, opiates,
&c. I, for example, use with success a potion composed in the
following manner: R lettuce and wild poppy water giv, orange
flower or mint water oj> syrup of pink or white poppies 5j> or syrup
of marsh-mallows, §j, with extract of opium gr. i, or laudanum, from
grs. V to grs. x. Simple frictions on the belly, long continued, also
succeed pretty often. They are sometimes performed with the hand
alone, or with a flannel, either dry and hot, or wet with oil of chamo-
mile, camphorated alcohol, or cologne water, &c. Although nature
herself frequently succeeds in restoring the natural order of things,
this state is, notwithstanding, not to be overlooked, in the first place,
because it indefinitely prolongs the labor, and in the next because
it may be looked upon as a morbid state, or at least as evidence of
great predisposition to diseases, or to inflammation of the womb.

849. Spasmodic contractions of the os uteri have also been ob-
served, and I have several times seen its dilatation completely ar-
rested, or considerably retarded for hours together by this irregularity,
which in general requires the same treatment as the preceding.
In some instances, the os uteri is at the same time very sensible,
dry, hot, highly irritated and painful, although regular in shape; a
valuable remedy in such a state of things, and far more efiicacious
than hip baths, and emollient, mucilaginous, or narcotic injections,
or various sorts of ointments usually recommended, is found in the
belladonna ointment, proposed by Chaussier and Dr. Conquest, and
frequently made use of by Madame Lachapelle at the Maison d'Ac-

MANAGEMENT OF LABOR. 363

coucheraent at Paris. Its employment too is followed with no incon-
venience; when I have occasion for it, I direct one drachm of the
juice or extract of belladonna to be triturated with one ounce of
cerate or hog's lard; with the fingers I easily introduce a portion
of this ointment, as large as a filbert, up to the os uteri, the whole
circumference of which is soon anointed with it. The belladonna
acts here as it does upon the iris, when applied betwixt the eye lids
a few hours previously to performing the operation for cataract, and
often with a promptitude that is really surprising.

In the spring of 1825, a young woman of good constitution was
seized with labor pains at five o'clock in the evening; the labor went
on regularly all night. The next morning, at six o'clock, the os uteri
was as large as a three livres piece at least; from that time the dilata-
tion progressed slowly, although the force of the pains did not di-
minish at all; a vein was opened in the arm; the agitation of the
patient went on increasing, and the orifice continued in nearly the
same state. M. Ribail, who had the care of the woman, sent her
to the hospital, where I saw her at half-past six in the evening: the
OS uteri was a little larger than a five franc piece, and formed a thin
circle, almost sharp, hot, and extremely sensible; the pains still
continued; the ointment was applied at seven o'clock, and before the
clock struck eight the delivery was completed.

Conclusive as was this result, it nevertheless appeared to me dif-
ficult to attribute it exclusively to the action of the ointment, but
since then I have used it in five diff'erent cases, and in all of them
the efl^ect has been, if not altogether as prompt, at least quite as un-
deniable.

850. I have elsewhere said in what manner the premature rup-
ture of the membranes or their too long continuance in an unbroken
state, might retard a labor or render it a bad one. In tlie former
case we ought to do every thing in our power to favor the dilata-
tion of the orifice without increasing the power of the uterine con-
tractions, for it is important to relieve the foetus as soon as possible
from the dangerous compression it has to suffer; to fulfil this indica-
tion, it appears to me to be proper to direct the woman to walk
about, to moisten the parts in some way, and especially to have re-
course to the ointment of which I have just been speaking.

In the latter, that is, where the point of the ovum is too slow in
giving way, it must be ruptured. To be done without inconveni-
ence, this little operation requires the combination of the following
conditions: 1. That the dilatation shall be, at least, very much ad-
vanced; 2. That the pains shall be maintained, without any threat-

364 EUTOCIA.

enings of inertia; 3. That the child shall be in a good position;
and 4. That there shall be no other obstacle to the delivery.

851. Should the os uteri not be largely dilated, we should be ex-
posed to the inconveniences connected with a premature rupture of
%e membranes; if the womb should cease to contract, or contract
only a little, we might give rise to complete inertia and all its con-
sequences; were the foetus badly situated, we should increase the
dangers of the presentation, and should the resources of art become
necessary, their application would be far less easy. But it should
be well understood that these general rules are not without excep-
tions: for instance, where the fluid enclosed in the amnios is in too
large quantity, it may be allowed to escape even although the open-
ing of the cervix is not considerable; the same holds, too, where
the position of the child is not fixed, where the hips, shoulders, head,
or any other part is found to present by turns at the centre of the
strait. In this case we seize the moment when the head is well
situated to rupture the membranes, because, were this rupture
left to nature, it might as well take place while it is unfavora-
ble as while the position is favorable. Where the bag of waters
does not retain the shape of a segment of a sphere, is very much
elongated, or pyriform, its presence being no longer of any use as to
the progress of the dilatation, it should be broken without too much
regard to the degree of the dilatation. The same principles guide
us in respect to the strength of the pains; their absence ought not
always to deter us, for the rupture of the membranes is often the
best, and sometimes the only means of restoring them.

852. To effect this rupture there are a thousand different modes
of proceeding: the point of a bistoury, of a pair of small scissors,
of a common sewing needle or a knitting needle, of a pin, directed
by the pulp of the fore finger, has often been found sufficient, and
perhaps been employed with advantage; for one must be very un-
skilful or careless seriously to wound the mother or foetus with
either of those instruments; however, at the present day we proceed
generally in a different manner : the membranes are scratched
through with the finger nail, while they are tightly stretched; or we
endeavor to burst them with the end of the finger by suddenly
pushing upon the tumor from its point towards its base; and if
the first attempt does not succeed, we make a second, a third, &c.,
always during the height of the pain; or again, and the method is a
better one, we firmly pinch a fold of the membranes, while in a
state of relaxation, and in such a way that the next contraction of
the uterus in essaying to form the bag again, does not fail to rupture
them.

MANAGEMENT OF LABOR. 365

Where the membranes have given way spontaneously very high
up above the cervix, and the tumor that had engaged in the vagina
does not disappear, and seems to interfere with the progress of the
natural phenomena of the labor, we ought most generally to per-
forate them as if nature had not yet effected it. Lastly, when the
membranous sac does not permit the liquor amnii to escape until
long after the dilatation of the orifice, as it is generally found that
the rest of the labor proceeds with great celerity, the woman should
always from the time the rupture takes place preserve a horizontal
posture.

853. Another cause of protracted labor is the weakness, whether
absolute or relative, of the uterine contractions; this is almost always
the cause that is kept in view by the authors of oxytocic remedies;
nevertheless it is far from being the most common one, and as the
means proper to overcome it are most generally hurtful in the other
cases, it is easy to explain the discordance met with in the works
on the effects of substances employed to accelerate the process of
parturition.

When the inaction of the womb is evident, and depends neither
upon general nor local fatigue, when it prevents the labor from pro-
ceeding, and the attention and regimen which were spoken of at the
commencement of this article have been tried in vain, and especially
when, instead of diminishing, it goes on increasing, hour after hour,
those substances that seem to exert a special action on the gestative
organ should be tried. This is the case in which small injections of
senna are indicated; in which stimulants in general are indicated;
in which the borate of soda, extolled by the ancients, by Romberg
among others, and in our own day by M. Lobstein, might be suc-
cessfully administered; but a substance is now known that seems to
deserve a preference over all others, and of which I am about to
speak in more detail.

854. The ergoted rye, clavus, secalinus, secale luxurians, calcar,
secale mater, (ble farouche, ble noir, ble cornu, ble ivre, ergot, seigle
eperone, clou de seigle, seigle de matrice) seems to have been used
from time immemorial by the old women, and by some country mid-
wives for the purpose of hastening delivery; it was mentioned in the
Acta Natur. Curios, for 1688, and the title of ivomb-rye which was
adopted by the Germans shows that this idea was not a new one.
These traditions of the vulgar at length attracted the attention of the
profession, and M. Desgranges published his first researches upon
the oxytocic properties of the ergoted rye in the Gazette de Sante
for 1777. Since that period numerous observations have been col-
lected and made public in the American, English, and French jour-

32*

366 EUTOCIA.

nals, &c., (fee. Stearns, Prescot, Chapman, Bordot, Goupil, Chev-
reul, Legras, Bigeschi, Gendrin, and especially M. Villeneuve, have
collected an infinite number of facts that prove decisively that the
ergot of rye is capable of restoring the contractions of the womb
during labor. However, MM. Desormeaux and Capuron do not
appear to have much confidence in it, and Madame Lachapelle has
published a long series of experiments, which tend to show that it
enjoys no property of the kind, whether given in fine or coarse pow-
der, in infusion or in decoction, in extract or in syrup. In the last
four years I have used it more than twenty times; M. Delanglar and
M. Terreux have also used it at my solicitation, and in every case
its action has appeared to be evident, undeniable. It forces the
uterus to contract in a few minutes, in a quarter of an hour, or, at
most in twenty minutes after it is exhibited. I have very recently
had another most convincing proof of its efficacy: to a young wo-
man who had been twenty-four hours in labor, I gave three doses in
the space of forty minutes; within five minutes after the first one, the
pains, which had for several hours been very feeble and slow, sud-
denly became strong and very frequent, but soon relaxed again; the
second dose brought them back in the same way: they diminished a
second time, and it was not until after the third dose that they were
maintained until the complete expulsion of the foetus, which soon
took place.

I prescribe it in the quantity of fifteen or twenty grains in a spoon-
ful or half a wineglassful of sweetened water, and repeat the dose
two or three times, at intervals of fifteen or twenty minutes. Per-
haps a larger quantity may be safely given: Parmentier took half a
drachm of it; MM. Lapre and Campernon a drachm, and a drachm
and a half, for several days together, without experiencing any sensi-
ble effects from it; its use might therefore be continued for a long
time and in large doses, before any well grounded fear of inducing
ergotism could be entertained.

855. It is to be hoped that the chemists will ere long separate the
essentially active principle of this substance; MM. Desgranges and
Lapre have already observed that four or five grains of the bark
produce a greater effect than twelve or fifteen of the entire grain.
I have no doubt that a preparation will be discovered ere long, whose
energy shall be uniform; but, meanwhile, a fine powder made of
the entire grain appears to me to be preferable to the decoctions,
extracts, &c.

856. In order that the ergot of rye may be given with some chance
of success, and without any danger, it is necessary, 1st, that there
should be no manifest tendency to hemorrhage from excess of irrita-

MANAGEMENT OF LABOR. 367

tion; 2d, that it be possible for the delivery to take place through the
natural passages; 3d, that the child be in a good position; 4th, that
the cervix be soft and dilatable; 5th, that the general irritability be
not too great; 6th, that the digestive organs be in a good state, and
7th, that the weakness of the uterine action shall depend upon the
want of irritability of that organ. M. Legras advises that it be
given also, for the purpose of steadying the head at the superior
strait previously to applying the forceps.*

ARTICLE IIL

Of Dystocia, or Difficult Labor [preternatural labor, la-
borious I., mechanical I., manual L, artificial I., 8fc.)

857. Labor ceases to deserve the title of spontaneous, whenever
by leaving it wholly to the powers of nature, it threatens to become
dangerous either to the mother or child. These kinds of labor
were for a long time designated by the simple epithets of preterna-
tural or laborious: but the distinct acceptation that was attempted
to be given to each of these qualifications being quite arbitrary, too
much confusion has ensued among the authors who adopted them not
to make it desirable to replace them by others. As the term dystocia,t
employed by Hippocrates, Sauvages, and M. Desormeaux, expresses
all the cases that require the assistance of art, it appears to me the
most proper one, and will doubtless be preferred at a future day as a
generic term.

858. As to the subdivisions to be established, it is contrary to the

* Many children perish in this country from the improper use of ergot. The
power of the article ought not to admit of further doubt: it excites, generally
■within thirty minutes after its exhibition, a contraction of the womb which
does not wholly cease until the child is born; or in case of any insurmountable
resistance, until the strength of the uterus is exhausted. The ergotic pain is a
single pain; hence, if the parts are not in a state to admit of the proper dilatation,
the ergot destroys the child by causing a contraction or spasmodic effort of the
womb which presses the placenta so firmly and so long against the fcetus, that
the utero-placental intercourse is as effectually destroyed as it would be, were
the after-birth detached. The child which is killed by ergot, dies therefore by
asphyxia from the compression of its placenta. Where the os uteri is well di-
lated and yielding, and the vagina and vulva in a similar condition, no danger
can ensue upon the use of this powerful and valuable article. — M.

t From Jy?, an inseparable article which imports difficulty, trouble, misfortune
and Toxs;, child birth.

368 DYSTOCIA.

rules of reasoning to found them upon the nature of the means that
are employed where nature is insufficient for us any longer to con-
form to the principles laid down by Solayres, Baudelocque, &c. The
faults of such a method are too evident for it to be necessary to
enumerate them; it should suffice us to remember that by follo\ying
them, the same cause of dystocia, the same accident, for example
a hemorrhage, may by turns cause the same fact to be classed by
turns among the preternatural, laborious, mechanical, mixed, manual,
&c. labours, according to the ability, or good pleasure of the
accoucheur.

It is, therefore, infinitely better to base them upon the causes that
may give rise to difficult labor. This plan, which has been adopted
by Merriman and M. Desormeaux, exhibits real and indisputable
advantages; it readily applies to all possible cases, enables us to
reduce or multiply genera and species without in any way interfering
with the general classification, and, besides, can combine with all the
Other methods proposed by the various authors. After all, difficult
labor is characterised by the accident which complicates it, and not
by the kind of assistance required in it.

859. The causes that render labor difficult depend either upon the
mother or the child. Some of them are unforeseen, or do not occur
until the moment of parturition; the tide of accidental may be appro-
priated to them. Others exist beforehand, and render the labor
necessarily difficult: they merit the denomination of pre-existing
causes.

The accidental or unforeseen causes are: any serious disease, such
as inflammation of the brain or its coverings, of the lungs or pleura,
of the peritoneum or uterus, &c. which takes place during labor:
any hemorrhage sufficiently abundant to endanger the life of the
mother or her oflfspring; convulsions, syncope, laceration of the
womb, the premature escape of the cord, hernia, aneurism, asthma,
great debility, &c., and some positions which do not become bad
until after the first pains.

The pre-existing causes are: deformities of the pelvis, malfor-
mation or disease of the organs of generation, calculus in the blad-
der, fibrous or other tumors in the excavation, deformities in respect
to height, transverse positions, monstrous conformation, and diseases
of the foetus.

As these different causes are in reality only complications of
labor, it follows that dystocia comprises all cases of complicated
labor, as eutocia comprehends all simple labors.

HEMORRHAGIC DYSTOCIA. 369

SECTION 1.
Accidental Dystocia.

§. I. Of Hemorrhagic Dystocia.

Whether the hemorrhage be an epistaxis, an hemoptysis, an he-
matemesis, a hematuria, or a metrorrhagia, any one may conceive
that the efforts of child-birth must to a considerable degree augment
the danger which accompanies it. In the five first named cases we
are to act as we should do in relation to all hemorrhages in general;
and if the blood still continues to flow, we should begin to think of
terminating the labor as promptly as possible; the sixth-named case,
uterine hemorrhage, is met with so frequently, constitutes an acci-
dent of so serious a nature, that it becomes necessary, in this place,
to examine it, not only as a complication of labor, but also as one of
the essential and distinct diseases of pregnant women.

860. This hemorrhagy is called internal, latent, or concealed he-
morrhage, when the blood that flows from the vessels is retained in
the womb and does not escape from the genital organs; it is, on the
contrary, denominated external, apparent, when the sanguineous
fluid escapes from the genital organs as fast as it is poured out by the
mouths of the vessels. It is owing to two kinds of causes: efficient
causes, and occasional or determining causes.

861. From the time of Puzos, accoucheurs have generally placed
the efficient cause of flooding in the detachment of the placenta;
they state that the placenta separates itself from the internal surface
of the womb, and thenceforth the blood flows abundantly from the
large and numerous vessels which open on it; this opinion appears
to me to be ill-founded. Puzos and his partizans have mistaken the
effect for the cause. It is not the detachment of the placenta that
produces the hemorrhage, but the hemorrhage on the contrary that
detaches the placenta: blows, falls and great shocks may certainly
affect the womb and its contents; but as the ovum constitutes a full
bladder in immediate contact with the whole extent of the cavity of
the organ that contains it, the most violent commotions would not
be able to detach it. While ever the membranes remain unrup-
tured, it cannot be conceived how the adherences of the placenta
can be destroyed otherwise than by the efforts of a fluid endeavor-
ing to effuse itself into the cavity of the womb. It is astonishing
that such a doctrine should have been maintained so long by so
many celebrated men; for even admitting a previous detachment of
the placenta, we should still have given no explanation of floodings.
In fact this detachment takes place every day, either wholly or par-

370 DYSTOCIA.

tially, from the middle stage of the most natural labor, and notwith-
standing there is no hemorrhage. Besides, an anatomical disposi-
tion that has no real existence is relied on here, the ovum is merely
struck (plaque) on the inner face of the womb, and not intimately
united to it; the placenta and organ of gestation communicate with
each other only by means of pores, and not by means of large vas-
cular mouths.

862. The efficient cause of flooding seems to me to be analogous
to those of all other hemorrhagies, to that of epistaxis, for instance.
The sanguine exhalation takes place in the womb as it does in the
nose, under the influence of a local congestion, an affluxion, a pe-
culiar state of irritation, of the molimen hemorrhagicum so much
talked of by Stahl. When this affluxion, or molimen, exists to a
certam degree, the blood transudes with greater or less force, and
from a more or less extensive surface, as happens during the pre-
sence of the menses; only, it requires a stronger impulsion, because,
during pregnancy, the ovum that it is compelled to detach in order
to effect a passage, necessarily presents a certain degree of resistance
to it; moreover, it seems to me, that in respect to its intimate me-
chanism, an uterine hemorrhage that does not depend upon any trau-
matic lesion, is always the same, at whatever period and in whatever
condition it may occur, as well during gestation as during and after
parturition.

The idea which I now set forth, and which is nearly similar to that
which has already been taught by Costa, M. Desormeaux, Madame
Lachapelle and M. Duges, merits the most serious attention, and
ought to have great influence on the therapeutics of flooding, and
upon some other points of tokological science.

The determining causes are as numerous as they are diversified;
they may be referred to a general state of the woman, to a peculiar
state of the sexual organs, and to external accidents.

863. General state. StoU, Finke and other observers have re-
marked that during the prevalence of certain epidemics, all the
bilious affections were accompanied with metrorrhagy; it has been
stated that verminose diseases, various lesions of the alimentary
canal, and all those indispositions that are accompanied with sympa-
thetic reaction upon the womb, are capable of giving rise to it.
Fatigue, frequent attendance at balls, plays, whole nights passed
without sleep, an exciting regimen, heating liquors, purgatives, the
warm bath, substances used to produce abortion, moral commotions;
in fine, whatever tends to render the menstrual flux more abundant
and more precocious, is also capable of giving rise to the flooding;
to these causes may be added an ulcer, a polypus at the neck of the

HEMORRHAGIC DYSTOCIA. 371

womb, fibrous and other tumors in the substance of the parietes,
or in the neighborhood of the external surface of the uterus, cri-
minal maneuvres, and every thing calculated to produce a determi-
nation of fluids towards the pelvis; violent exertions, the jolting of a
rough-going carriage, riding on horseback, efforts to carry or lift a
heavy burthen, coughing, vomiting, shocks communicated to the
trunk of the body by falls upon the feet, the knees or seat, blows
on the abdomen or pelvis, diseases of the rectum and bladder; in
one word, all conditions, whether of temperament or of disease, all
circumstances, whether natural or eventual, that are capable of
producing a sanguine congestion, a raptus towards the vessels of
the womb, and all the causes of abortion; so that pregnancy and
labor in themselves constitute one of its most powerful causes.

804. In some particular cases, an entirely special cause of hem-
orrhage is superadded to the preceding ones, and may of itself pro-
duce the flooding; I mean the implantation of the placenta upon the
cervix uteri.

Whether the placenta corresponds to the orifice by its very cen-
tre or by some point more or less near its circumference, there re-
sults nevertheless a hemorrhage whose distinctive character is, that
it occurs only in the last months of gestation, or from the period
when the cervix uteri begins to dilate from above downwards. The
authors who attribute it to the rupture of the utero-placental vessels
have certainly been deceived by theoretical prejudices, or false ana-
tomical appearances. I offer the following as the results of several
observations collected with great care.

When the placenta is inserted upon the neck of the womb, these
two parts proceed together in their development until about the fifth,
the sixth, the seventh, and sometimes even until eight months and a
half; but from that time forwards, the environs of the orifice are so
rapidly withdrawn from the centre, that a constantly increasing por-
tion of the ovum necessarily remains without any adherence to the
womb, and this portion, which is soft, vascular, and constantly on the
stretch, may crack or even tear, and thus give rise to a hemorrhage
which puts the child's life much more at hazard than the mother's.
On the other hand, this displacement does not in general take place
without the inferior portion of the womb being more or less irritated
by it, and soon becoming the seat of an affluxion, a more or less
decided congestion, and thencefoth, the general efficient cause of
floodings is superadded to the peculiar cause constituted by the
presence of the placenta on the cervix. Is it necessary for me to
remark that these two causes, the rupture of some vessels of the
placental parenchyma, and a state of congestion of the uterus, may

372 DYSTOCIA.

exist separately; that although the former almost always super-in-
duces the latter, it is not, however, impossible for it to exist alone,
and that the latter may pre-exist, or even exist to such an extent as
to give rise to the most imminent danger, without necessarily com-
bining with the other? Besides, it is well known, that blows,
shocks, vivid emotions, and all the othes causes of ordinary uterine
hemorrhage are equally fitted to produce it where the placenta is
inserted over the orifice; it therefore follows that both these kinds
of flooding depend on the same proximate cause, the hemorrhagic
molimen, and upon the same occasional causes; but that the presence
of the placenta upon the cervix constitutes a peculiar determining
cause, which rarely fails of being in itself sufficiendy powerful to
produce it.

865. Vessels of the cord. It is at present pretty generally be-
lieved that the vessels of the umbilical cord may break during labor,
and give rise to one of the most serious kinds of hemorrhage.
Doubdess, it would not be wise to deny the possibility of such an
accident; but it must be confessed that the observations relied upon
to prove it are any thing but conclusive. The one mentioned by
Lamotte was evidendy only a case of ordinary hemorrhage: the
blood had begun to flow previously to the rupture of the mem-
branes; the woman rapidly grew weak, and the author believed that
the hemorrhage took place from the cord, because he found one of
its vessels to appear as if eroded to such a degree as to admit of the
transudation of blood. Levret's case, when carefully analysed,
proves nothing more in favor of the opinion of the surgeon of
Valogne; and the case by Baudelocque, who at first refused to coin-
cide with the opinion of Leviet, certainly ought not to have induced
him to change his views. Had the rupture of the cord been the
cause of the hemorrhage, the foetus would not have been born alive
in the cases reported by De la Motte and Baudelocque. In the
example cited by Levret, the foetus, it is true, was dead born, but
the forceps had been employed, and the meconium continued to
come away while blood was still flowing. In fine, in all three cases,
the mothers became so weak as to excite the serious alarm of the
accoucheur; which seems to me clearly to demonstrate that the
blood came from the uterus and not from the child. Did the nature
of this work admit of it, it would be an easy matter for me to show
that none of the reasons invoked by these authors are capable of
demonstrating the correctness of the opinion they desire to support:
let it suflflce me to say that in the actual state of our knowledge, the
hemorrhage from the cord, as understood by De la Motte, Levret,
and Baudelocque, can only be admitted as possible, and not as

FLOODING. 373

proved. In this respect, moreover, I am completely of accord with
Mesdames Boivin and Lachapelle.

866. Nevertheless, the umbilical vessels, and their branches rami-
fying upon the foetal surface of the placenta, are sometimes subjected
to rupture; I am in possession of several examples of the kind; but
it is because they were previously in a diseased state, and that too
generally in the early periods of pregnancy. Then, the foetus dies
promptly, abortion takes place, and the hemorrhage is not discovered
until the ovum comes to be examined. I have very often found
embryos of six weeks, two months, &c., still enveloped in the mem-
branes, separated wholly or partially from their cord, close to which
were discovered one or more small clots of blood; at other times
small varicose or aneurismal sacs, sometimes upon the cord, some-
times upon the secondary divisions of its vessels, the walls of which
are exceedingly thin, and liable to be ruptured by the slightest effort.
In an after-birth at full term, I have seen some of these dilatations
that had been ruptured, and which communicated with a large clot
covering a part of the placenta, and which had not lacerated the
amnios; but it is easy to perceive that this kind of accident is but
indirectly similar to those spoken of by authors.

867. Diagnosis. Uterine hemorrhages have certain common
symptoms and certain peculiar signs; among the general signs, there
are some which announce the approach of hemorrhage, and others
which accompany or succeed it.

868. Precursory signs. Although in some women the flooding
appears on a sudden, and without any precursory symptoms, it is
not the less true that this accident is almost alw^ays preceded by a
more or less decided disorder of some function. Thus, one or more
hours, or one or even several days before the appearance of the
blood, the individual has a sense of uneasiness, restlessness in the
limbs, weight, fulness in the pelvis, alternate flushes and chills
throughout the body, and rather more thirst and less appetite than
common; flushes of heat ascend to her head; she has fits of giddiness,
and becomes much redder or paler than in her habitual state; the
pulse acquires strength, frequency, and quickness; there is, pretty
commonly, a degree of febrile action.

869. Signs of flooding. When a quantity of blood sufficient to
excite alarm has flowed, the pulse loses somewhat of its strength and
hardness, soon becomes irregular and tremulous; the face grows pale
and the skin cooler; dimness of sight, ringing in the ears, and weak-
ness of the stomach, which induce the woman to ask for some kind
of aliment; yawning, pandiculation, nausea, lipothymia, syncope and

33

374 DYSTOCIA.

even convulsive movements appear in succession, and sometimes
with frightful rapidity.

In external floodings, the precursory symptoms are succeeded by
a discharge of blood from the external organs, and this characteristic
is too evident for it to be needful to indicate any others; neverthe-
less, it has appeared to be difficult to some persons, not to con-
found, at times, a real flooding with a simple monorrhagia. Bau-
delocque did all in his power to clear up this point of diagnosis:
according to him, menstruation occurring during pregnancy differs
from metrorrhagia, properly so called, in respect that it takes place
without any pain, without effort, without any notable disorder of the
health, without any antecedent molimen; in respect that the fluid
which escapes is serous, very slighdy colored, and does not coagu-
late; in that it is very small in quantity, terminates in two, three, or
four days, appears at the ordinary epochs of the menstrual flux, and
that far from debilitating, it is, on the contrary, followed by an im-
proved state of health, and greater freedom in the exercise of the
functions; while the very opposite circumstances are observed in a
real hemorrhagy. But, in looking a little closer at the subject, it is
soon found that these characteristics are for the most part quite illu-
sory. In the first place, it is a fact that, in many women the menses
are frequently preceded by the same symptoms as the most danger-
ous floodings, and that the blood of the menses, far from being fluid
and colorless in all cases, is on the contrary sometimes charged with
cruor and very coagulable; besides, flooding is not always accom-
panied or announced by the general signs heretofore indicated; it
may be very moderate in the beginning, and formed of serous blood,
or blood charged with fibrine, and coincide with one of the catamenial
epochs; indeed, as the mechanism of menstruation is the same with
that of metrorrhagia, I do not see that it is possible to distinguish
the one from the other by any special signs. Moreover, this diffe-
rential diagnosis leads to nothing; while the flow is slight, the pre-
cautions prescribed by art are incapable of interfering injuriously
with the menstrual function; and as soon as the blood escapes in
sufiicient quantity to require more active interference, it would be
almost ridiculous any further to seek to discriminate between menor-
rhagia and metrorrhagia.

870. In internal flooding, admitted by Mauriceau, De la Motte,
Levret, Baudelocque and Merriman, who have related cases of it, the
blood tends to accumulate between the placenta, or membranes, and
the corresponding part of the womb; a lenticular coagulum might in
such case form with variable rapidity, depressing the ovum in au

FLOODING. 375

eccentric manner on the one hand, and on the other compelling the
uterus to distend mechanically, so as to receive the fluid that is efTused:
I am aware, that in presence of facts, argument ought to be silent;
but then, those facts ought to be incontestable, well noted, and pro-
perly interpreted: now can these conditions be recognised in a ma-
jority of those that have been mentioned in favor of internal floodings?
Is it quite certain that the blood in some instances found betwixt
the placenta and the womb had accumulated there during life, rather
than immediately after death; that that which escaped in torrents as
the membranes gave way was not efTused before hand in the interior
of the amnios? How, indeed, can we conceive that the blood which
escapes from the uterine vessels in somewhat considerable quantities
is capable of dilating beyond measure, and almost instantaneously, tlie
cavity of the womb, instead of running between the gestative organ
and its contents, so as to escape outwards, or of rupturing the mem-
branes and becoming eff'used within their cavity? How can we
admit that the adherences of the placenta, which are habitually so
weak, could resist the effort of the blood, tending to form a new
cavity for its own reception, more powerfully than the uterus, which
yields with so much difficulty?

Until these various questions shall be solved rigorously, I shall
continue, with Mesdames Boivin and Lachapelle, to think that the
existence of internal flooding, such as it is generally understood,
ought not to be admitted, except under pretty numerous restrictions,
and also, that what has been hitherto said in relation to it needs con-
firmation.

It should in all cases be accompanied with the same symptoms as
external hemorrhagy, from which it should be distinguishable only
by the absence of blood flowing externally, or by the natural size of
the womb or abdomen.

871. Flooding ivith implantation of the placenta over the cervix.
According to Rigby, floodings produced by the attachment of the
placenta in the vicinity of the orifice, ought to be of extremely fre-
quent occurrence, for, in one hundred and six cases, he met with
it forty-three times; and Madame Lachapelle goes so far as to say
that uterine hemorrhage occurring in the three last months of preg-
nancy, depends almost upon no other cause. Be this as it may, this
kind of flooding is distinct from other species, in that, it never takes
place before the fifth month; that the blood at first flows in small
quantity, and stops of its own accord, to re-appear in greater
abundance after a week or two; in that, it pretty often comes on
without any assignable cause, or precursory symptoms ; that it
returns after shorter intervals, and is in greater abundance as the

376 DYSTOCIA.

stage of pregnancy is more advanced ; in that, during labor, the
blood flows especially during the contractions, and not in the inter-
vals, as in the other species. When it commences early, as the
blood flows in small quantity, the woman becomes exhausted but
slowly, the muscles become oedematous, the face is bloated, the lips
grow pale, and the skin soon assumes a dull yellow tint, the color of
wax, through its whole extent. These, however, are only rational
signs, which may even not be met with near the commencement of
the flooding; whenever, therefore, it becomes desirable to remove
all doubt upon the subject, recourse should be had to the touch. The
orifice is, in general, very soft, and somewhat dilated; instead of the
membranes, a spongy body is felt, engaged, as the point of a cone
"with a large base might be, in the upper part of the cervix; but care
should be taken not to mistake a coagulum of blood for the placenta,
and in order that the operation should not be performed unnecessa-
rily, to recollect that this exploration may possibly reproduce the
hemorrhage, by disturbing the concretions by means of which the
economy had succeeded in suspending it.

872. Instead of following the course that I have just indicated as
the most general one, the hemorrhage sometimes pursues a very
different one. M. Duparcque has seen a case which came on as early
as the sixth month, which ceased spontaneously, and did not retura
until the appearance of the labor. M. Desormeaux has met with it
once in the tilth month; and it became su profuse in the sixth, that it
was found necessary to deliver the woman. I have seen a case where
it did not appear until the end of the ninth month, in a woman to
whom I was called by M. Baroilhet, and where it did not become
serious until the approach of her confinement, although the centre
of the placenta was situated over the orifice. In other cases, espe-
cially in first pregnancies, and where the uterus is very much in-
clined in front, the os uteri is sometimes so little opened, and so high,
up, that the blood may accumulate below it, to a certain amount, and
in some sort produce an internal hemorrhagy. Did the flooding de-
pend upon the rupture of some of the vessels of the placenta or cord,
it would be characterised by causing the sudden death of the foetus,
and by debilitating the mother secondarily. Moreover, it would
doubtless produce, as in cases where the blood is effused into the in-
terior of the membranes, a feeling of weight in the pelvis and hypo-
gastrium, with dragging in the loins, the groins, and about the pit of
the stomach.

873. Prognosis. The dangers that follow in the train of uterine he-
morrhage necessarily vary according to a multitude of circumstances,
according to the species and amount of the flow, the stage of the

FLOODING. 377

pregnancy, and the ability of the prescribing attendant. In the
early stages of pregnancy it is rare for the woman not to be saved,
for abortion is nearly an invariable consequence of it. In the last
three months, on the contrary, the life of the child is pretty frequently
preserved, while that of the mother is exposed to much greater risks.
Upon this subject it may be established as a general rule, that for
the woman, the danger is the greater as the pregnancy is the more
advanced, and that the converse is true in respect to the child.
External hemorrhage is always less redoutable than internal; be-
cause in the latter, the evil, when discovered, is often beyond the
resources of art, while it is easy to recognise the former from its
very commencement. Where the flow takes place from tlie cord
or placenta, the life of the foetus is more seriously menaced than that
of the mother, and vice versa as to uterine hemorrhage, properly so
called.

The danger is not to be estimated by the quantity of blood that is
lost, but rather by the effect produced by it upon the system in gene-
ral. There are women, who, other things being equal, are led to the
verge of the grave by the loss of a pound of blood, while others lose
double or triple the quantity without being seriously incommoded by
it; and it is not requisite for me to say that those who are strong,
sanguine, and robust, suffer from it less than such as are lymphatic,
weakly and anemic.

874. Even although we should be so fortunate as to allay the
storm, and prevent the death of the patient in a case of profuse flood-
ing, there would still be reason to dread relapses that would become
more and more dangerous, general or local infiltrations, chronic in-
flammations of the womb, peritoneum, pleura, and pericardium, and
nervous affections of all sorts; as to the dangers of the moment they
are estimated by the severity of the symptoms under notice at the
time. While ever the debility is not great, while the pulse retains
some strength and hardness, and the color of the skin and features
of the countenance remains without any too evident alteration, the
flooding need not excite our alarm; on the contrary, there is not a
moment to lose where the face grows pale, the extremities become
cold, the sight dim, the pulse weaker, tremulous, and irregular; final-
ly, but little hope remains where lypothymia, syncope and convul-
sions supervene.

875. Notwithstanding that the death of the foetus is one of the or-
dinary consequences of hemorrhage occurring in the four or five first
months of pregnancy, and that at later stages it becomes most gene-
rally necessary to empty the uterus, it would however be wrong to
conclude that a happier termination of it can never be obtained.

33*

378 DYSTOCIA.

Indeed, all observers have remarked that slight floodings, especially
those occurring in the first stage of pregnancy, when arrested by a
well understood mode of treatment, sometimes permit the ovum to
continue its evolution, and the foetus to live and grow until its natu-
ral term; the blood has been seen to flow even to the extent of ex-
citing fears for the woman's life, and yet abortion not to take place
(460); I attended a young lady who was seized with a profuse he-
morrhage in the third month of her second pregnancy, who lost more
than two pounds of blood in the space of thirty-six hours, and not-
withstanding did not miscarry; M. Desormeaux mentions another
case, where the blood flowed with such force that it was necessary
to have recourse to the tampon, and where the pregnancy, neverthe-
less, went to its full term.

876. Uterine hemorrhage is cured in three ways.

1. The blood that escapes externally sometimes becomes itself
the remedy of the evil it constitutes, disengorges the uterus, destroys
the molimen, removes the congestion, and permits the equilibrium
to establish itself naturally; here, the flow may have been efl^'ected
at the expense of the cervix, the vagina, or the inferior portion of the
womb, and may not have destroyed the principal adherences of the
ovum, which remains uninjured, and thus is but slightly disturbed in
regard to its development; or the placenta, although partially detach-
ed by the blood that exudes from its external surface, continues to re-
sist, the hemorrhage stops, and, as in the other case, the child's life
is preserved.

2. In other cases, the flooding, after if has continued for a longer
or shorter time, ceases; the ovum, although detached and more or
less altered, is not expelled, and remains in the uterus for a period
that is variable.

3. It most frequently happens that the contractions of the uterus
are brought into play, and, in these cases, we can rely only upon
abortion, delivery, turning, or the forceps, to save the patient from
dangers with which she is threatened.

Puzos has maintained that, when the flow is once arrested, the
parts may contract new adhesions: a case by Noorthywck, that of
his own wife, has been supposed to confirm this opinion; but upon
careful reflection, numerous doubts soon occur to any impartial and
unprejudiced mind as to the value of this fact.

According to Pasta, whenever the union of the ovum with the
womb is destroyed by the flow of blood, it is impossible for it to be
re-established, and when abortion, or labor, or at least the death
of the foetus do not follow flooding, it is because the hemorrhagic
excitement takes place in some part beyond the limits of the placentat

FLOODING. 379

877. The following is what observation has demonstrated: while
the blood is endeavoring to glide towards the os uteri, a more or
less extensive portion of the placenta or anhistous membrane be-
comes fully saturated with it; first one clot forms, then a second, then
a third; and these several layers, of various thickness, soon become
sufficiently numerous, provided the energy of the hemorrhagic af-
fluxion becomes diminished, to exert such a degree of pressure as
to retain the blood within its own vessels; it is not by stopping up
large openings, by filling large vascular trunks, but by being plas-
tered against the pores of the womb, that coagula are enabled to sus-
pend a hemorrhage; the same mechanism by which they succeed in
putting a stop to epistaxis, when they accumulate within the cavities
of the nose.

878. Provided these coagula are not very extensive, the ovum
continues to live, like a tree from which one or more of the roots
have been removed: the fluid part disappears by means of imbibi-
tion, and the fibrinous layers becoming drier and drier, and less and
less evident, remain, sometimes, until labor takes place, although
the points which they separate are not re-united. At the Maternite
at Tours, I saw a young woman who was thrice seized with slight
flooding, at intervals of a fortnight, in the two last months of her
first pregnancy. There was nothing peculiar in her labor; but
there were found on the surface of the placenta, three distinct layers,
about the size of a three livres piece; one of these layers, which was
very near the edge of the placenta, was composed of a clot that was
still red, of a lenticular shape, and with difficulty separable from the
after-birth; the second was composed of a fibrinous concretion, much
firmer and scarcely colored at all; the third looked more like a
sort of cicatrix. Is it not evident that these three points correspond-
ed to the seat of the three hemorrhages that had taken place antece-
dently to the occurrences of the labor?

879. Treatment. It may be said with truth that the uterine
hemorrhages of pregnant women, are diseases which require, on the
part of the practitioner, the greatest coolness, knowledge and skill;
indeed, in presence of such accidents, a few seconds, more or less,
often decide as to the life or death of two beings, equally dear; such
are the cases where it imports us to know how to choose the remedy
and apply it properly, and where a distrustful timidity might become
equally fatal with imprudence and rashness.

The means to which we can have recourse are extremely nume-
rous; some of them are, to a certain extent, applicable to all cases
indiscriminately, and others are to be employed only under peculiar
circumstances. '

380 DYSTOCIA.

880. Rest, low diet, a horizontal posture upon a hair mattrass,
rather than upon a feather bed, in a chamber which ought to be
darkened rather than too much lighted, quiet and not noisy, cool, and
well ventilated, rather than hot and close, with diluting or cold aci-
dulous drinks very frequently suffice when early recourse is had to
them, in moderate cases of hemorrhage: if the woman is strong or
sanguine, and especially if there have been precursory symptoms, if
there are rigors, and the state of the pulse warrants it, six or eight
ounces of blood may be drawn from the arm. When these slight
succors do not succeed at once, and where there has been no pre-
cursory molimen, and the woman is naturally weak, we have re-
course to revulsives, and to external refrigerants. We prescribe
manuluvia, either simple or containing mustard, dry friction of the
arms, the breast and along the spine, and apply large cups to the
breasts; aspersions are made upon the abdomen and inner part of
the thighs, with cold water, either alone or with the addition of vine-
gar, ether, or ammoniac, &c.; compresses wetted with the same
liquids, or with iced water, may also be applied to the same parts.
Burns praises the effect of alum; Duncan and Rigby seem to have
derived great advantages from the use of opium and sugar of lead
(acetate of lead), which had previously been recommended by Et-
muUer, &c., and is frequently employed by Dewees; the digitalis is
also recommended by many of the English physicians; but these va-
rious articles are rarely made use of in France. Rhodion, Hamilton,
and some others have recommended the application of tight ligatures
to the limbs. A practice that seems to me to deserve the attention of
practitioners is the application of a sinapism between the shoulders;
I have made use of it often enough, and in cases sufficiently various,
to enable me to affirm that it is one of the most powerful and most
useful revulsives that can be recommended. MM. Trastour, La-
roche, Nivert, and several young physicians who had seen me em-
ploy it, or put it in practice themselves, have already made mention
of it in their theses. I have elsewhere stated the anatomical and
physiological considerations by which I was led to its employ-
ment. I resort to it both in the first months of pregnancy and
during labor, as also in the interval betwixt these periods; and the
effect has always been extremely prompt. A young woman, nine-
teen years of age, was brought to the Clinique Externe of i\ie School
of Medicine towards the close of 1825; she was about three months
gone with child, and had been flooding for twelve hours; we tried
the remedies indicated higher up, but the flow continued neverthe-
less to increase until evening; being then alarmed by her extreme
weakness and the appearance of approaching syncope, I applied a

FLOODING. 381

mustard cataplasm to her back; in a quarter of an hour the dimi-
nution of the hemorrhage was evident; it soon became a mere
draining, which continued until the next day, when the ovum was
expelled.

There ought to be nothing surprising in such a result, when we
reflect with what ease people in the country sometimes put a stop
to epistaxis, by placing a key, or some pieces of linen, or the like,
wetted with cold water betwixt the shoulders, and with what rapidity
sympathetic irradiations are brought into play by the action of mus-
tard. Nevertheless, it would be unreasonable to think that the action
of this medicament is infallible, and that it ought to be employed
in all cases. Reason indicates that it would be injurious rather than
useful where the flooding is attended with a general reaction of the
system, and the symptoms of the hemorrhagic efibrt continue in full
force; both in pregnancy and during labor, as the placenta is to a
great extent detached, and its expulsion is inevitable, it might serve
to diminish the impetuosity of the affluxion; but there would be little
wisdom in relying upon it to completely suppress ahemorrhagy that
had already become serious and alarming.

881. The tampon. Doubdess one of the first ideas to occur to the
mind upon observing a flow of blood from the womb, was to stop up
the orifice of that organ; however, notwithstanding what Costa says
upon tho subject, thp use ol the tampon was hardly mentioned in the
science until since the times of Madame Bourgeois, of P. Fortal. F.
Hofflnann and Smellie. If we may confide in Leroux, the tampon is
an heroic remedy, which is almost always followed by success; ac-
cording to the modern classics, on the contrary, it is rarely an useful
and most frequently a dangerous remedy, that ought to be proscribed
from sound practice. Amongst others, M. Demangeon, who has
been well combatted by M. Gardien, has expressed himself strongly
against the tampon, which, in his opinion, can only serve to augment
the dangers of the disease. Rigby and Merriman scarcely make
mention of it. Specious arguments, theoretical prejudices, excep-
tional cases generalised, and false reasonings, comprise, notwithstand-
ing, all that has been brought to bear against the innumerable facts
that have been reported by an infinite number of authors: in fact, it
is not possible, after reading the work of Leroux, to participate
in the fears that are attempted to be awakened by the antagonists of
the tampon, or in common with Burns, Mesdames Boivin and La-
chapelle, and Dr. Dewees, not to consider it as one of the most pow-
erful means of rescuing women from the dangers of a serious attack
of flooding.

882. It ought not upon this account to be said that it never can

382 DYSTOCIA.

be injurious. The tampon, like all important therapeutic resour-
ces, is a weapon of protection in the hands of a skilful practitioner, but
it may become a murderous one in those of an ignorant person. For
example, it would be imprudent to make use of it at the commence-
ment of a flooding, before the symptoms of plethora have been dis-
sipated, or where the blood is being effused within the interior of
the membranes with the uterus in a state of inertia; for in such a
condition it could not fail to augment the excitement, or by retain-
ing the blood in the womb, favor the indefinite distension of the
parietes of that organ. Nevertheless, it has not as yet been very-
positively demonstrated, that even here it would not be more fre-
quently useful than hurtful; reasoning, which accords with a pretty
considerable number of facts, leads me to believe, along with M.
Chevreul, that it affords, perhaps, one of the surest means of forcing
the uterus to contract, or arouse it from its lethargy; this is the pro-
perty, even, which renders it redoubtable where we are fearful of fa-
cilitating the expulsion of the ovum, and which makes it improper to
resort to it until afier we have ascertained the inefficacy of other
modes of treatment.

883. It is composed in very various ways: many persons content
themselves with filling the vagina with tow, lint, old linen, sponge
&c. Dewees says it is never necessary to carry the tampon as far
as the OS uteri; there are some who prefer a small baff. or sort of
purse, filled with astringent substances: but the simplest method,
which also is that adopted by M. Desormeaux, consists in making
a kind of sac with fine linen well greased with cerate, and which is
introduced empty as far as the os tincae, to be afterwards filled with
little rows of lint or tow, or some such substance, and then secured
with a T bandage. The oil in which Burns advises us to soak the
tampon appears to me to be of no other use but to favor its in-
troduction. Vinegar, and oxycrate, recommended by others, are
of less doubtful value, although their styptic action is soon annihi-
lated by the coagula, and by the flow of the blood; moreover, it
is a mechanical barrier and not a pharmaceutic substance by
which we attempt to oppose the hemorrhagy. It is a real stop-
per, which, by closing up the passage to the blood, compels it to
coagulate by little and little, and as it becomes concrete, to compress
and shut up the exhalent orifices that furnish the fluid; on the other
hand, by its quality as a foreign body, it excites the cervix, and chan-
ges the vitality of the womb, whose contractility it arouses, whose
reaction it recalls, to such a degree as soon to occasion the expulsion
of the ovum.

If it is to succeed, the blood ceases to flow from the vulva, the

FLOODING. 383

general symptoms are gradually allayed, the liypogastrium becomes
more firm without increasing in size, and provided the womb is not to
be emptied, the woman only experiences a feeling of tenesmus, strain-
ing and weight in the pelvis, and sometimes slight colic pains; while,
in the opposite case, pretty smart pains, and real contractions of the
womb supervene; in consequence of w hich the clots, the tampon,
and the product of the conception are all expelled one after another
from the genital organs.

In some women it is followed by such a degree of uneasiness,
even although there may be no uterine contractions, that they insist
upon its being removed; in general, their entreaties should be re-
sisted, provided no evidences of internal hemorrhage are discovered,
unless, indeed, the pain is so acute as to give rise to certain nervous
aflections, or convulsions; complaints in these cases are rather to
be desired than feared. After some time the functions are seen to
return to their natural state; and, in order to avoid the risk of a
return of the flooding, the tampon is left in situ as long as possible,
at least for several hours, or even a whole day; then, when it is
no longer considered to be indispensably necessary, the T bandage
only is removed, for the tampon, being no longer kept in the organs
by an external force, it escapes spontaneously and gently.

884. Dilatation of the os uteri, and rupture of the membranes.
Before proceeding to forced delivery, Puzos recommends the trial
of a practice which is, in his opinion, much more simple, and par-
ticularly much more consonant to the nature of the organism; in-
troduce, says he, first one, then two, then three fingers into the
orifice, Avhich you should titillate and irritate, but very gently; and
you will often find that this alone will suffice to stop the hermorrhagy,
and to induce the womb to contract. If this does not suffice, begin
to dilate it, enlarge it with all the care and gentleness that the seve-
rity of the symptoms will admit of your using, and if you still do not
succeed, perforate the membranes, and the vacuum that will take
place in the membranes will rarely fail to be followed by the expul-
sive contractions of the womb. You will have, it is true, a prema-
ture delivery, but which will be less dangerous both to the mother
and the child than if the practitioner had undertaken to deliver the
foetus.

885. This conduct is particularly adapted to cases where hem-
orrhage takes place during labor, or where the pregnancy is very
much advanced, and the placenta is not attached near to the neck.
Notwithstanding, it is evident that with the exception of the rupture
of the membranes, the tampon fulfils pretty nearly the same indica-
tions, and that where the flooding is violent it would be wrong to act

384 DYSTOCIA.

with so much reserve, and not to terminate the delivery as soon as
possible.

Forced delivery. When a labor proceeds with a certain degree
of regularity, notwithstanding the hemorrhage may continue, and the
powers of the woman may diminish too rapidly, it generally suffices
to accelerate the contractions as hath been mentioned, and to en-
gage the women to keep up her courage and use her best efforts to
enable the womb to get rid -of its contents as well as to put a stop to
the flooding. Provided, on the other hand, the infrequency of the
pains does not permit him to rely upon the powers of the economy,
the accoucheur should hasten to deliver the child. If the head be
already engaged in the superior strait, and the os uteri sufficiently
open, and a fortiori if it have already reached the excavation, it
should be seized with the forceps: otherwise the child should be
turned; but in order to admit of the hand being carried into the
womb, the orifice must have reached a certain degree of dilatation,
or at least be in a very dilatable state. Therefore, it is only in the
last stages of pregnancy, and where nature or the means hereto-
fore pointed out have forced the labor to begin, that we may
resort to this method, which is particularly applicable to cases of
hemorrhagy from implantation of the placenta over the cervix uteri.
Happily, when there is a flooding; the orifice is commonly very soft,
and admits of a ready passage. Moreover, it is manifest that \yhere
the danger is pressing, it would be better to make use of some
violence in overcoming the resistance, than to abandon the woman
to the so frequently fatal chances of an overwhelming flooding.

886. The termination of the labor should never, under any pre-
text, be left to the powers of nature, when the hemorrhagy is in-
contestably occasioned by the insertion of the placenta upon the os
uteri.

In this particular case, many practitioners have recommended,
that as soon as the fingers have got within the os uteri, we should
try to find that part of the edge of the placenta that is nearest, so
as to pass up the hand in that direction; others have thought that
in difficult cases, or where there is no time to temporise, it would be
better to neglect this minute research, and to perforate or rupture
that point of the ovum that corresponds to the orifice, so as instantly
to lay hold on the child's feet. The former of these two modes of
practice would occupy too much time; and the latter would not
fail to augment very greatly the violence of the hemorrhagy, and
seriously endanger the life of the foetus, should its extraction hap-
pen to be tedious or difficult. Besides, the child would have to be
withdrawn through the opening in the placenta, which, being pulled

FLOODING. 385

downwards by the shoulders or head, would necessarily raise great
obstacles to the operation.

The method followed by P. Portal, M. Dubois, &c. is in all re-
spects to be preferred. Without any regard to the edge of the
placenta, the hand, after reaching the os uteri, is to be tirst carried
in front, and then to the right of the woman if it be the left hand,
and to her left if it be the right hand that is made use of, and in
less than a second, the membranous part of the ovum is reached,
and must be perforated; the feet are now prompdy seized, and the
fcEtus may be delivered before the after-birth.*

887. In the other species of hemorrhagy, when the turning has
been effected, and the hips are at the vulva, it seems to be wise, pro-
vided there be no inertia of the womb, to leave the closing of the
labor to nature, whereas, in cases of implantation over the cervix,
when the operation is once begun it cannot be terminated too soon.
The reason of this difference strikes us at once: in the first mention-
ed case, as the omphalo-placental circulation continues to go on, the
life of the child is not compromitted, and that of the mother is no
longer in danger as soon as the blood ceases to flow; in tlie second,
the functions of the placenta ceasing, a few moments of delay might
occasion the death of the fcetus.

Is it necessary for me, in closing, to state that the reader must look
to the articles on abortion and delivery of the placenta for the details
which I cannot introduce here?

§. II. &f CoaavsiSslve Uystocia.

The agitation, the agonies of a woman in the midst of tlie most
violent labor pains are sometimes carried to such an extent, that to
have been witnesses of them is sufficient to make us feel diat such a
state borders closely upon the convulsive afTections, and convince us
that convulsions must be frequently met with in women in labor.

The convulsions of pregnant women, like those of other women,
may be general or local; affect only one or all the limbs; the face or
any other part separately; or they may bring into play all ilie mus-
cles of the life of relation: most commonly none but the muscles that
are habitually subject to the will are afiecled; but in certain cases,

* I saw a patient in labor with placenta previa, under the care of Dr. R. M,
Huston of this city. The hemorrhage which had been very great was arrest-
ed before my arrival, by means of a tampon, w^hich he introduced. In the
mean time the pains continued to dilate the os uteri more and more, until, infer-
ring that the organ was sufficiently dilatable, he removed the tampon, and then
successfully delivered by turning. — M.
34

386 DYSTOCIA.

those viscera which contain a muscular membrane are also seized.
Thus the pharynx, the oesophagus, the stomach, the intestines, the
bladder, the uterus itself, the heart, and especially the diaphragm, are
at times violently tormented by them.

Hysteria, epilepsy, catalepsy, and the convulsions produced by
some material lesion, such as a phlegmasia, or any disease of the
encephalon or its meninges, or of the general nervous system, ap-
pear pretty frequently, and sometimes become aggravated during the
course of pregnancy: but it is to be observed that the three first rarely
manifest themselves during labor. Moreover, in these cases the dis-
ease is complicated by the state of gestation, and that is not what is
generally understood by the convulsions of pregnant women.

888. Puerperal convulsions, also called apoplectic convulsions,
hysterical apoplexy, milk apoplexy, sympathetic apoplexy, eclamp-
sia of labor, differ from other diseases, in that they are evidently con-
nected with the state of pregnancy, which they complicate.

889. Their proximate cause is always located in the brain, and,
consequently, I do not perceive the use of dividing them into sym-
pathetic and idiopathic convulsions. This proximate cause doubt-
less, is an irritation, or stimulus, which reacts upon the whole ner-
vous system, but whose nature appears to be extremely variable:
sometimes it is a precedently irritated point in the brain which in-
vites the fluids into that organ, which thus becomes a centre of
fluxion; sometimes, on the contrary, the fluids themselves, by being
determined towards the brain in too large quantity, produce a state
of congestion therein, and in consequence thereof, a convulsive re-
action. In this, as in the other case, the remote causes are very
numerous. There are predisposing and determining causes. Al-
though eclampsia is observed at all seasons, at every age, in all
classes of society, and under all temperatures, it is, notwithstanding,
true to say, that strong persons, those who are plethoric, of a dry
fibre, very animated countenance, short neck,* abundantly and fre-
quently regulated, nervous, delicate, irritable, subject to nervousness,
and young women in the first pregnancy, are more liable to them
than others.

Air that is impure, charged with odors, and too rarely renewed;
the summer heats, too high an artificial temperature, anger, grief,

* In Dr. Collins' cases, amounting to 16,654 labors, there were 30 cases of con-
vulsions. Five of the women died.

In all the cases of convulsions that have come under my notice, the women
were small,' thin, with long necks. I have seen only one fatal case. It has been
ray good fortune to have met with few samples of this dreadful malady. — M.

CONVULSIONS. 387

/

vexation, some unexpected news, joy, and all the vivid emotions;

loss of sleep, freq\ienting of balls and theatres; laboring at night;
the abuse of baths, of hot drinks, of coffee, tea, spirituous liquors,
and spiced or high-tasted dishes; a succulent regimen, and whatever
increases the afflux of blood towards the head; the presence of a
great quantity of water in the membranes, or of several children in
the womb; rigidity or extreme sensibility of the fibres of that organ;
hardness or spasmodic contraction of the neck of the womb; the
pressure which it exerts upon the surrounding vessels and nerv§s;
the thrusting of the stomach upwards; coition; the suppression of
an issue or any habitual discharge; the use of corsets, and too tight
dresses; and want of exercise, &c., have been ranked among the
causes of eclampsia. To these have been also added, infiltration of
tlie [imbs or leucophlegmasia, livmg in hot countries, indulging in ^
too much sleep, leisure, the use of alcoholic elixirs and tinctures; the
habit of lying long in bed, atmospheric vicissitudes, and almost. all
the common causes which the authors never fail to recall upon the •
occasion of each disease they describe, those causes which seem to
produce all the evils because they do not necessarily create any one. -
of them.

890. No one can deny that such circumstances have sometimes
produced eclampsia; but it is also undeniable that it often comes on
without its being possible to assign any satisfactory reason for it.
Convulsions appear most commonly towards the end of pregnancy,
and their most common occasional cause is labor; they may then
depend upon some obstacle which by obstructing the escape of the
foetus, soon produces a general disturbance of the system; or upon
a simple irritation that re-acts upon the whole economy; or, also, a
repulsion of the fluids towards the interior of the body, occasioned,
by the efforts which the woman is compelled to make. They may
also be the consequence of an attack of hemorrhage, or of exhaus-
tion, or the symptom of some rupture, &c. Many practitioners,
among whom are M. Desormeaux and Madame Lachapelle, have
observed that eclampsia sometimes prevails almost epidemically.
" When one of our women had been seized with convulsions, we
rarely failed," says Madame Lachapelle, " soon afterwards to have
several others in the same state." A tendency to imitation would
be here insuflicient to account for the fact, and, besides, could not
be applicable to cases occurring out of the public establishments, in
private practice, or in those singular epidemics that have been so
often observed.

891. Signs. The attack of eclampsia is, in some women, an-
nounced by various precursory symptoms, such as flushes of heat

388 DYSTOCIA.

about the head, giddiness, confusion of ideas, hallucinations, indis-
position to move, uneasiness in the limbs, a dull or frightened look,
redness of the conjunctiva, or of the whole countenance, headach,
vertigo, stammering, vivid brightness of the eyes, irregularity of the
pulse, slight convulsive motions of the muscles of the face, subsultus
of the muscles of the extremities; but it is often, also, found to appear
in a sudden and unexpected manner, and to attack at once, with the
most alarming symptoms. The woman suddenly becomes insensi-
ble, and seems to revive for a moment only to fall again into the
most violent agitation; the limbs writhe, contract, become flexed and
ex-tended with astonishing strength and celerity; the body is bent
backwards, as if the head and heels were about to approach each
other; the hands are powerfully directed towards the breast or the
epigastrium, which they strike, and sometimes appear to tear with
rage; the features of the face become distorted and convulsed; the
lips, which are drawn in various directions, move in the most sin-
gular manner; the eyes roll, are agitated and turned up under the
orbits; the pulsation of the carotids and temporal arteries is seen
through the skin; the jugulars swell; the throat and face become
tumid, and almost purple; the eyes seem as if they would start out
of the head; the moulh fills with water, which is spirted sometimes
to a great distance upon the assistants; the tongue, irregularly agi-
tated, is often pinched, and even violently bitten by the grinding of
the teeth and the spasmodic motions of the jaws. In these terrible
moments the woman is truly a frightful object, and highly deserving
of pity; the diaphragm by its rapid contractions gives rise to sobs,
and an appearance of suffocation, and forces from the mouth and
nostrils the substances accumulated in them. The stomach and
bowels, the bladder and uterus itself, when they become the seats of
such motions, produce vomitings, involuntary expulsion of the faeces
and urine, and sometimes of the ovum, with an extreme promptitude;
in fine, it might be said that all the viscera participate in the disor-
dered movements of the limbs. At other times, the face and rest of
the body pass, so to speak, with the rapidity of lightning, from this
state of agitation and vivid color into the most perfect calm, and fall
into a mortal paleness; at last, and more or less promptly, the con-
gestion of the brain brings on coma, which generally succeeds the
attacks of syncope and insensibility.

892. The duration of an attack is not less variable than its inten-
sity; it lasts in some cases only from ten minutes to a quarter of an
hour or half hour; whilst in others it continues half a day or even
twenty-four hours; if coma supervenes, it may prolong the insensi-
bility for several days and terminate in a complete and prompt restora-

CONVULSIONS. 389

tion to health; but it is also found lo assume all the characters of
apoplexy, and occasion the death of the patient. It also sometimes
happens that certain of the functions remain in a perverted state
after the cessation of the convulsions; sometimes the sight, or hear- ■
ing, or smell, or some one of the intellectual faculties appears to have
sufTered the severest pressure of the disease; at others, tliere are
found internal lacerations or particular effusions, that occasion a de-
viation from the natural state of the organism, &c.

AVhen the woman comes to herself, fatigued and worn out, her
limbs bruised, as after long and violent exercise, astonished at the
situation in which she finds herself, she is, sometimes, ignorant of
every thing that has taken place, can scarcely believe what is told
her, and has no knowledge of the extraordinary movements executed
by all parts of her frame, or the violent cries she has uttered; some
are mentioned, even, who have been delivered without knowing it,
and after the attack was over could not understand that they were
really delivered!

On the parts that have been struck with considerable force we
afterwards find blackish spots, Avhich are real contusions, attended
with more or less pain.

Where the woman recovers her senses in the intervals of the
paroxysms, the convulsions have been denominated epileptiform;
in the contrary case, and especially where they are accompanied
with stertor and coma, they are called ajjoplectiform or edampsic.
This division can be of use no further than this — viz. that the
former which are more easily confounded Avilh epilepsy or hysteria,
are rarely so dangerous as the latter; but in fact they are only differ-
ent shades of the same affection.

893. The examination of the body after death is far from always
giving a satisfactory explanation of the severity of the symptoms.
A small quantity of serum in the ventricles of the brain; the veins
and sinuses of the brain more or less engorged; the meninges and
cerebral substance somewhat red, or of a natural appearance; in
some cases evident traces of congestion, or a slight extravasation
of blood; but, most generally, no appreciable lesion, is what the
unprejudiced observer finds within the cranium. Neither have the
other splanchnic cavities exhibited any alterations, that constantly
occur in these cases; the heart is flaccid and almost empty; the
lungs choked up or pale; a few ounces of citron-colored or reddish
serum in the serous cavities, are the principal traces left by the dis-
ease in the abdomen and thorax.

"Without being rare, eclampsia is, notwithstanding, not a disease fre-
quently to be met with, since Madame Lachapelle met with it only

33*

390 DYSTOCIA.

sixty-fiive times in nearly forty-thousand pregnant women; the progno-
sis is in general unfavorable, for by the admission of that lady, in
spite of the most rational and careful treatment, one third of the cases
proved fatal. It is more frequent in the last three months and during
labor than at other periods, and is less dangerous when it occurs after
delivery, or previously to the sixth or seventh month of gestation.
Not so serious, cseteris paribus, when occurring during labor, as be-
fore it, it is less so in proportion as the labor is more advanced at the
moment of the first attack.* As the emptying of the uterus is often
the only means of putting an end to the convulsions, it is evident
that the danger arising from them will be in a direct ratio to the
difficulty of effecting that object; if the neck of the womb and the
head of the foetus are disposed in such a way as to make it an easy
matter to extract the child, the disease may be considered as less
alarming than if the orifice is still hard and undilated. Those cases
that attack women who are hysterical, epileptic or endowed with
great nervous susceptibility, or whose form exposes them more par-
ticularly to these two affections; those in whom the paroxysms are
short, or separated by well marked intervals of calm, and of restora-
tion of all the functions, are always less to be dreaded than such as
possess no analogy with an anterior nervous state of the woman,
which supervene in women who are sanguine, plethoric, or whose
organs are all surcharged with serosity ; which are accompanied
with apoplectic phenomena, as coma, stertor, or complete insensibi-
lity during the intervals of the paroxysms; and also of such as are
only the symptoms of organic disease of longer or shorter stand-
ing, seated in the brain, the lungs, the heart, or any other important
organ, aud which had been greatly aggravated by pregnancy.

894. The child runs scarcely less risk than the mother; in the
first place, it often dies in the midst of the extraordinary motions
that mark each paroxysm; and then, wherever abortion takes place,
its life cannot be preserved; the same thing often takes place when
premature delivery cannot be avoided; and even in forced delivery

* I am of opinion that convulsions are more to be feared in labor where the
pains are violent, but ineffectual, than in those where the pains are feeble and
of short duration. The violent efforts of the abdominal muscles in consent with
the energetic contractions of the womb, and the strain upon the respiratory or-
gans in the bearing-down, cannot but press tlic uterine globe very strongly
against the aorta, and the great arterial trunks in the belly; hence, an increased
determination of blood to the head. Hence the swollen and flame colored coun-
tenance, the extraordinary activity of the innervation; and lastly, the convulsive
attack. Hence too, an additional motive for emptying the womb as soon as
practicable, in order to obviate one of the causes which, having produced, will,
if unchecked, continue to aggravate the cerebral causes of the convulsion. — 31.

CONVULSIONS. 391

also, at full term, the foetus is often lost; neverthelsss it is incorrect,
■with some authors, to state that the loss of the child almost always
occurs where the attack of puerperal convulsions is somewhat
severe. Mauriceau, De la Motte, Levret, Smellie, Baudelocque,
the cases gathered or collected by MM. Bouteilloux, J. C. Bau-
delocque, Madame Lachapelle, &c. afford proof enough of the
contrary.

895. Treatment. A disease exhibiting itself under forms so
diverse, and in such various degrees, cannot be cured by a treat-
ment that is alike in all cases: it is therefore not astonishing that
we have so many boasted remedies for it. There are few sub-
stances among the anti-spasmodics, the sedatives, the narcotics, the
revulsives and the anti-phlogistics, which have not had their vogue;
but as there is always too much disposition to generahse, in thera-
peutics as Avell as in the other branches of medicine, facts have not
been wanting to prove that such or such an article, puffed beyond
measure by different physicians, is more injurious than useful in
eclampsia.

Ether, balm water, orange-flower water, and mint water, mixed
in various proportions with infusions of linden flowers, wild poppies,
orange leaves, lettuce water, &c. and with some sedative syrup, are
not to be neglected in a number of cases where the convulsions have
more analogy with hysteria or epilepsy than with apoplexy, especi-
ally if the patient is nervous, very excitable, or lymphatic rather than
plethoric and sanguine.

In these cases, also, the syrup of clove pinks, of white poppies, of
diacodium, pills of cynoglossus, the extract and tinctures of opium,
may be usefully given, either alone, or added to the above mentioned
vehicles, or under some other form, and combined in some other
manner.

896. Rigidity, scirrhous induration and spasmodic contraction of
the OS uteri being sometimes the only, or at least the principal cause
of convulsions, we ought not to omit to examine it carefully. Pro-
vided that it should seem to be the point of departure for the disease,
we should apply to it some of the opiate cerate, from which M.
Schweighaeuser asserts that he obtained very successful results, or
what is better still, the belladonna ointment. Were it really too hard
to be overcome by the efforts of the womb, I do not see that it would
be possible to dispense with incising the neck. Upon this subject
the fears of Madame Lachapelle are, to say the least, exaggerated: for
I have not learned that the passage of the head, after this operation,
has in any case enlarged the wound, so as to perforate the peritoneum.
However, notwithstanding what has been said by M. Bodin, it is a

392 DYSTOCIA.

resource not without danger, to which we should not under any pre-
text resort, except in case of indispensable necessity.

897. Bleeding has always enjoyed much favor among obstetric
physicians: Mauriceau, De la Motte, Puzos, &c. have repeated it
six, eight, ten, seventeen and even as much as eighty-six times
in one pregnancy in the same woman! The loss of blood is al-
ways useful where there are signs of congestion about the head, a
strong pulse, or any signs of pletliora. The blood is sometimes
drawn from a superficial vein, sometimes by means of leeches or
cups, and at others by all these means together. Except where
there is some particular counter irritation, we commonly begin with
a general bleeding of six, eight, ten, twelve, or even fifteen ounces,
according to the severity of the disease, and the constitution of
the woman. After this first venesection, if it appears to produce
some amelioration, it is repeated a second time, a third, or even a
fourth, at intervals more or less considerable, always remembering
that in this way the strength of the woman is rapidly exhausted.
"When the general bleeding can no longer be repeated with the hope
of obtaining any decided advantage from it, leeches may be applied to
the number of fifteen, twenty, thirty, forty, or fifty, behind the
ears, or on the neck, or even in the neighborhood of the vulva,
provided there should be any appearances of irritation or evident
congestion in the pelvis. Should the coma be very profound, and
blood not to be got except in very small quantity, scarified cups on
the nape of the neck, or on the mastoid apophyses, ought also to be
tried. As to bleeding from the temporal artery, or even from the
radial artery, proposed by some persons, I do not think that it de-
serves any preference over venesection: but which vein ought to be
opened?

In the prevaling theory of blood-letting bleeding in the foot passes
for being essentially revulsive, while bleeding from the neck is rather
derivative, and that from the arm merely depletive; but these dis-
tinctions are scarcely justified by practice: Baudelocque has seen
bleeding from the saphena aggravate the affections that were inva- '
riably diminished by opening a vein in the arm, and other practition-
ers have observed the inverse. In eclampsia the object is to disen-
gorge the vascular system, and when bleeding is deemed necessary,
I think it matters little whether it is taken from one vein rather than
another. If the cerebral congestion is fixed and too great, should
the opening of the jugulars appear to be indicated, leeches or cup-
ping might be regarded as preferable, considering that bleeding in the
neck is not always an easy nor even practicable matter, especially in
a person laboring under convulsions.

CONVULSIONS. 393

Another reason of the same kind will long continue to render bleed-
ing in the arm much more general than bleeding in the foot; it is al-
ways, or almost always possible, no matter how agitated the patient
may be, for us to open a vein in the bend of the arm, whereas as
much cannot be said as to the veins of the legs: by bleeding in the
arm, we act at the instant, when we please, and how we please, and
we take much or little, and that without any difficulty. By bleeding
in the foot, on the contrary, various preparations are required; we
must take advantage of a moment of calm, the vein is often found
to be too small or too deep-seated, and it frequenUy happens that
enough blood is not obtained.*

898. Tepid baths allay irritation, whether sympathetically by
their soothing action on the skin, whether by diminishing the excit-
ing qualities of the fluids by the water which they occasion to pass
into the circulatory system, or by diminishing the force of radiation
of lieat. They are administered with success where the symptoms
of apoplexy do not predominate; but they ought not to be prescribed
until a bleeding has been premised, provided the state of the patient
is such as to admit of her losing blood without danger; otherwise it
might favor the affluxion and congestion in the brain; they should be
rejected in cases depending on flooding, a serous plethora, and where
there are any threats of inertia: the woman may remain immersed
in a bath for half an hour, an hour, or even longer, according to the
relief she derives from it.

899. The application of cold water to the belly, according to the
recommendation of Sigaud, has not a sufl[icient number of facts in
its favor to enable us to recommend it in this form as a general pro-
position. Ablutions, and ice-water to the head, either used alone, or
whilst the rest of the body is plunged into a hot bath, which Den-
man and most of the English authors, as well as M. A. C. Baude-
locque, Madame Lachapelle, &c. have boasted so much of, appear
as if they might indeed be usefully combined with the other rational
means where there is reason to fear a lively reaction in the brain;
nevertheless their employment seems to me to require a great deal of
prudence and circumspection.

* M. Velpeau does not dwell with sufficient emphasis upon the use of
blood-letting in these convulsions. In this country the amount of blood drawn
for the cure of puerperal convulsions is determined only by the ability of the pa-
tient to bear its loss. — I should be more pleased if M. Velpeau should recommend
instead of 15 ounces, the abstraction of twenty or 40 ounces; for, whatever, may
be the cause of the attack, it is attended with so great a determination to the
brain that no time should be lost in reducing it by the promptest mode, videlicet^
by Blood-letting.— 31.

394 DYSTOCIA.

900. Oily or irritating injections of all sorts are frequently used
in England, and not without success. In France, they prefer ex-
ternal revulsives, sinapisms or sinapised cataplasms, to the feet, legs,
or thighs, a large blister on the back of the neck, and dry frictions
along the spine, and on the limbs. Madame Lachapelle, who does
not place much confidence in them, and is even afraid of them where
there is a threatening of inflammation in any one of the organs, also
rejects the employment of digitalis and camphor, to which Hamilton
attributes very great virtue, and blames the condnct of our transma-
rine neighbors, which consists in a recourse to purgatives and even
to emetics, after bleeding. Without charging myself with the de-
fence of the accoucheurs of Great Britain, I cannot, however, omit
to observe, that out of twenty-two women treated by bleeding, calo-
mel in purging doses, neutral salts given by the mouth or by injec-
tion, and lotions made with liquid acetate of ammonia or spirit of
rosemary, to the head, Merriman lost only six, while in spite of the
energy of the practice employed at the Maternite, they have almost
as many deaths as cures in that institution.

The digitalis purpurea, which is recommended by Hamilton, may
be tried in convulsions preceded by oedema of the limbs. The seton
in the back of the neck, as advised by M. C. Baudelocque, ought
not to be employed until all other remedies have been found insuffi-
cient; raoxas and scarified cups are not likely to be at all more suc-
cessful than leeches and the common revulsives.

901. To conclude, bleeding from the arm, the foot, or the jugular
vein, is useful, and oftentimes even indispensable, in the convulsions
of pregnant and puerperal women, whether of a slight or severe
character, where the patient is young, strong, and of a good consti-
tution, and not exhausted by preceding hemorrhages. Local blood-
letting is the only kind we can resort to where the convulsions super-
vene upon a flooding, or in persons who have been debilitated in any
way, or those of a lymphatic constitution, &c. In that case, if they
occur after delivery, and the lochias have ceased to flow, leeches may
be applied to the labia or to the groin, as recommended by M. C.
Baudelocque, otherwise they should be applied to the mastoid apo-
physes, according to the counsel of Chaussier.

When the vascular system has been depleted, if the state of the
patient admits of it, a tepid bath should be prescribed; if irritation
or spasmodic contraction of the os uteri appears to be the cause of
the phenomena, some opium cerate, or belladonna ointment should
be applied to it. After a flooding, or a painful or fatiguing labor
or delivery of the placenta, some analeptic broths and a iew spoon-
fuls of sound wine will occasionally be found the best remedies that

CONVULSIONS. 395

can be made use of. Where the woman is delicate and nervous,
we have recourse to sedative infusions and waters, narcotic prepa-
rations, &;c. Sinapisms, blisters, scarificalions and other revulsives
are, in severe cases, particularly useful as accessory in effect to
blood-letting, or as supplementary to those evacuations, where they
are themselves inadmissible. Finally, should there be manifest
symptoms of disordered stomach or bowels, without any of the signs
of inflammatory irritation, I do not perceive that there wouhl be any
temerity in promoting either the vomiting or the alvine evacuations
by means of gentle emetics and purgatives; but during the labor, the
best remedy beyond dispute is the delivery of the child.

902. Where the disease comes on before the end of the sixth
month, we ought to do every tiling in our power to succeed without
soliciting the expulsion of the fcBtus, its viability being at a later pe-
riod possible, there is no longer any need for so many precautions
on this head.

To admit of the child being delivered, either with the hand or
with the forceps, it is necessary that the dilatation of the cervix
should be very advanced, or at least that the os uteri should be soft
enough to admit of the womb being entered without the employment
of any great degree of force. However, if a trial have been ineffectual-
ly made of ointments, injections and baths; if the woman or the child
were in imminent danger, and a forced delivery the only means of
safety; and in a case where the os uteri should be thin, but hard and
undilatable, and obstinately resist the contractions of the womb, there
ought to be no hesitation in following the counsel of M. Bodin, to
make one or more incisions into its concave edge, or in resorting to
what has been called since the time of Simson and Lauvergeat the
vaginal-cesarian operation.

§. III. Dystocia caused toy the Premattwe De-
scent of the Uintoilical Cord.

903. Although not a rare occurrences, procidence of the cord is
not very frequendy met with, for it was observed to happen forty-
one times in 15,652 labors, at the Maternite at Paris; its being more
frequently met with in private practice seems to depend upon the
hasty maneuvres of the persons who assist the lying-in woman,
rather than any other cause: Black has even asserted, but it is evi-
dent erroneously, that the descent of the cord is always the effect
of attempts to hasten the delivery. A woman was brought to my
amphitheatre while I was delivering a lecture; she was compelled
to wait half an hour at the porter's lodge; no one examined her,
and when she was brought up to the ward, the cord formed a loop

396 DYSTOCIA.

of several inches hanging out of the vagina, although the os uteri
was but very little dilated. Moreover, there are but few accoucheurs
in large practice who have not had several opportunities of observing
the same thing.

904. The causes of this accident may be referred, 1. To the ex-
cessive quantity of the liquor amnii; 2. To too great a length of the
cord; 3. To the too sudden escape of the waters upon the rupture
of the membranes.

905. The procidence of the cord has always been noted by
authors as a dangerous accident. Not because it renders the labor
more difficult, or causes the woman to run any greater risk, but be-
cause the fcEtus is thereby exposed to the hazard of dying before it
can be delivered. Its death in this case is indisputably produced
by the cessation of the circulation of the blood through the cord,
and all the reasons collected in the memoir by Thouret are in-
sufficient to weaken this proposition; but the obstacle to the cir-
culation has not been understood in the same way by all accou-
cheurs.

Until the time of De la Motte, Avho did justice to this notion, it
had been generally supposed that the blood, from becoming chilled
by the external temperature, coagulated, or became concrete in the
loop of the cord hanging out of the vulva.

At present, the accidents attending it are attributed to compression
alone. In fact, as soon as the waters are all gone off, if the cord
descends before the head, the breech, &c., its vessels are almost
necessarily flattened during the expulsive efforts. Nevertheless, if
the pelvis be very large and the foetus small, and the cord is placed
near one of the sacro-iliac notches while the forehead or the occiput
is towards the opposite one, the compression of its vessels may be
so slight as not to prevent the blood from pursuing its route.

906. Death takes place from an excess of blood, or apoplexy, if
M. Chambon is to be believed; from anemia or syncope, according
to Baudelocque, MM. Capuron, Deneux, &c.; from asphyxia, or
want of oxygenation of the blood, according to Muller. But neither
of these three hypotheses is correct. It is impossible to maintain
with Freteaux, that the vein is less compressed than the arteries, or
with others, that just the contrary happens. All three of the ves-
sels are compressed alike, and the death of the fcetus is to be ex-
plained not upon the quantity, but the quality of the blood, it re-
ceives.

907. Prognosis. If the cord is cold, without pulsation, shrunk,
and greenish, the death of the child is indubitable; if the labor is
still far from its termination, the head strongly engaged, and it is

PROLAPSED CORD. 397

difficult to alter its position, the prognosis Avill be very unfavorable.
On the contrary, if the pulsations are kept up with some degree of
force, and the labor goes on rapidly, even althcJugh the cord be lank
and shrunken, its premature escape maybe followed by no unpleasant
effect.

908. Treatment. There are different ways of remedying this
procidence. If the chdd presents transversely, by the shoulder, or
by the hip, and the os uteri be not sufficiently dilated to admit of an
attempt to turn, we must try to return the loop into the womb; where
the labor is pretty well advanced, we have to seek for the feet, and
it would even be dangerous, whenever the pulsations of the cord are
found to grow sensibly weaker, to wait for a complete dilatation be-
fore we act.

Where the pelvic extremity of the fcetus presents, as soon as the
contractions become sufficiently strong, we have to favor their effect
by pulling downwards in a proper way upon the lower extremities.
But it is, particularly, where it escapes before the head that the cord
requires prompt assistance.

In such cases the ancients confined themselves merely to pushing
it up again, and keeping it wrapped up in a linen rag in the vagina;
modern surgeons make use merely of their fingers, or of a piece of
whalebone surmounted with a sponge or with a ring. Ducamp has
recommended a species of pincers, enclosed in a canula, in most
respects similar to the porte-noeud of Dessault; M. Dudan thinks
we should be satisfied with a gum elastic catheter, No. 9, furnished
with its wire, which serves to fix the end of a ribbon passed through
one of the eyes of the instrument. With this ribbon M. Dudan sus-
tains the cord at the end of the catheter without compressing it, and
returns it into the cavity of the Avomb, where he afterwards leaves it,
first withdrawing the wire, and then the catheter itself. The canula
a charniere, proposed by Wellemborg, would in fact be more dange-
rous than useful, and I doubt whether any accoucheur will be ever
tempted to make use of it. It has also been advised to introduce
and fix graduated compresses or bits of sponge betwixt the head of
the fcetus and the parts of the modier. Finally, Mr. Croft finds, it
more expeditious and more safe to carry the whole hand into the
womb, so as to hook the loop of the cord over one of the limbs of
the child.

Doubdess, most of these means might succeed; but there is not
one of them that ought to be adopted exclusively; for the condnet to
be pursued will necessarily vary according to the state of the cir-
cumstances.

909. When the child is dead, the presence of the cord requires no
35

398 DYSTOCIA.

particular manceuvre. If it be living, the head may be, 1. Upon the
point of clearing the inferior strait; and in that case we need only-
urge the woman to bear down upon the pains as hard as she can;

2. In the excavation, and the labor may go on but slowly; the re-
duction is here impossible, and if, after trying it, we find the pulsa-
tions of the cord diminishing, we must hasten to apply the forceps;

3. Lasdy, scarcely engaged; here we take hold of the cord, and roll
it up into a kind of ball which we endeavor to return by pushing it
up by the side of, or even above the head, if possible, and if there
is any tendency for it to fall down again, it should be kept there until
the contractions have firmly fixed the cranium in the strait. Pro-
vided the introduction of the fingers were found too difficult, or in-
sufficient, some mechanical means might be tried; such as the instru-
ment of Ducamp, or Dudan's, or what is still better, the portecordon
in the shape of a fork, invented by M. Guillon. Rather than pro-
ceed to turning, recourse ought to be had even to the method recom-
mended by Dr. Croft.

On this subject Madame Lachapelle, as well as many other mo-
derns, says that the precept of the English surgeon ought not to be
followed, inasmuch as, where the hand is introduced, it would be
quite as speedy to draw down the feet. For my part, I am not of
that way of thinking; the life of the child is too much endangered in
forced delivery by the feet, for us not to prefer delivery by the head
whenever it is possible.

When compelled to extract the fcstus by the hand or by the for-
ceps, it is important to conform to the precept of Boer, which is, that
previously to acting either upon the feet or the head, we ought not the
less to endeavor to return the cord, which, without such precaution,
could scarcely fail to be very much compressed, either by the hand
of the accoucheur, or by the hips, the shoulders, or some other solid
part of the child.

§. IV. dystocia from Excessive lieng^th or
Sliortiaess of tBie UBM^jJUicai Coi'cl.

910. Shortness. Until the time of Baudelocque it was supposed
that the delivery of the foetus might be prevented, or at least con-
siderably retarded by a very short cord. When the placenta is
attached to the fundus of the womb, if the cord is less than six or
eight inches in length, says De la Motte, the head, which is forced
towards the inferrior strait during the contractions, is found to rise
upwards again during the intervals between the pains; the occiput
is seen to engage in the vulva, to be on the point of clearing the
strait at every effort made by the woman, and then, as soon as the

THE CORD. 399

pain is off, it re-enters the passage; and this continues for several
hours.

The circumstance really takes place, but is altogether independent
of the umbilical cord; it is chiefly to be met with in young women
who are strong and robust, and at their first confinemeni. It de-
pends upon the elasticity of the perineum: this flooring of the pelvis-r
gives way while the womb, assisted by the abdominal muscles, urges
the head onwards and makes it project from the parts; but as soon as
the contraction ceases, its natural rpsistance returns the vertex into
the interior of the pelvis.

However, it would be incorrect to assert, as Baudelocquef does,
that a cord's being too short cannot in any case interfere injuriously
with delivery; in such a case the placenta is liable to be prematurely
detached, wliich might facilitate the occurrence of inversion of the
womb, give rise to hemorrhagy, and bring the child's life into dan-
ger, should the labor be prolonged; the strain arising from it might
weaken, or even arrest, or at least disturb the contractions of the
womb, and suspend the labor; but in no case can the mere shorlness
of the cord mechanically hinder the expulsion of the child.

911. Excessive length. When the cord is, on the contrary., too
long, it generally has a strong tendency to procidence, and particu-
larly to the formation of one or more loops around the limbs or
body of the fiEtus. These turns are frequendy met with in prac-
tice, and oftener round the neck than any where else; where there
are many of them, that portion of the cord that remains free may be
really too short, whence the same accidents as under the former
head might be feared. It has also been thought that they might
obstruct the passage of the blood in the jugular veins, and act like
ligatures, so as to produce a state of asphyxia. I have seen many
chddren born with turns of the cord about the neck, and it has never
seemed to me to be productive of danger in any case. Besides, in
strangulation, death is produced by the stoppage of respiration, and
death cannot take place in that way in the fostus: again, I do not
see how the cord can be drawn so tighdy as to obliterate the inter-
nal jugulars or the carotids; therefore, at most, only the umbilical
vessels are liable to be interrupted. It would appear, however, that
these turns of the cord may exist for several months before the pe-
riod of delivery, and thus give rise to some very curious anomalies.
A fact lately observed by M. Monod, a resident pupil at the Mater-
iiile, proves that they may, like a branch of ivy round a tree, leave
very deep grooves, and produce strangulations, &;c., from which
even the bones do not wholly escape. Moreover, it is fortunate
that these causes of dystocia either do not exist at all, or but very

400 DYSTOCIA.

rarely, for it is impossible to discover them until the head has
passed the inferior strait; except in certain cases of breach presen-
tation, in which the cord may be felt tightly stretched, either betwixt
the thighs, around one of the limbs, or merely up along the abdo-
men, we can suspect the existence of these turns only upon conjec-
tures that are too uncertain and vague to deserve the least confidence.
If, however, it should be ascertained that the cord is too short, it
ought to be immediately cut, provided there should be any danger
to the child, and the labor still far from its termination; care should
be then taken to deliver the woman as early as possible, either by
the hand or with the forceps. When it" is not discovered until the
escape of the head, it is in general easily to be remedied: if the
turn be a very loose one, and the cord very long, the birth of the child
is most generally not at all obstructed by it, and nothing need be done;
in the contrary case, we must either disengage or cut the loop, so
that the respiration may not be long in becoming established.*

§. V. AmeMrisiiaal ©ystocia.

912. An aneurism within the splanchnic cavities, or even in one
of the great external arteries, is always a serious disease; but it is yet
rendered still more dangerous by the efforts of labor. The con-
tractions of the muscles and the repulsion of the blood consequent
thereto might readily occasion the rupture of a sanguine tumor, if
haste were not made in emptying the womb. In such cases, there-
fore, the patient should be advised to assist her pains as little as pos-
sible, and as soon as the orifice is sufficiently dilated or dilatable,
the child should be extracted either with the hand or the forceps.

§. VI. Bystocia fi'osit Asthma, Myclrothorax,
Gibliosity, ©ropsy, &c.

913. All diseases that render the respiration difficult, may make
it necessary for us not to trust the labor to the mere resources
of the organism. It is well known that asthmatic persons are soon
threatened with suffocation when under any state of violent exer-
tion; and that the same holds good of those who are laboring under
some effusion in the chest, or in whom the free expansion of the
chest is restrained by a deviation of the spine, &c. All wise prac-
titioners therefore have recommended that in these circumstances

* Dr. Smith, who relates a case of inversion of the womb, produced by the
shortness of the cord, recommends, witli reason, that we should draw down a
portion of that which is connected with the placenta, and then slip the noose
over the shoulders, and not over the head of the child.

ASTHMA, HERNIA. 401

the efforts of the woman should be controlled, and that she should
be artificially delivered as soon as the stale of the parts admits of
the child's feet being brought down sufely.

914. The same precept has been given where the labor is com-
plicated by the presence of some large tumor in the abdomen, or
Avith a dropsy in that cavity; and that, because here, as in the, pre-
ceding cases, the efforts of the womb might give rise to a fear of
asphyxia, or at least might be followed by a dangerous collapse.

915. However, I ought to remark that many dropsical women go
through their labors almost as easily as those who are in the enjoy-
ment of perfect health. I saw at the hospital de Perfectionnement,
in 1824, a woman laboring under ascites who had been tapped
thirty-six times, and who was, notwithstanding, delivered very natu-
rally after a labor of a few hours duration. Another one came
to the same establishment in 1826, who had been dropsical for four
years, and whose labor lasted only two hours, although her abdo-
men was enormously large, and although from ten to fifteen litres
of fluid had been several times drawn off from the belly by tapping.

Nevertheless, as the abdominal muscles are generally very much
weakened, and separated, in ascites, by a thick stratum of fluid, their
mediate action can be possessed of but little energy in the expulsive
part of labor.

§. VH. Merraial ©ystocia.

916. When the hernia, of whatever species it may be, is reducible,
it should be returned to its proper situation before the pains become
very strong, and then during each contraction its escape is to be
prevented by holding the tluimb, a compress, or the hand, upon the
opening through which it passes outwards. This manoeuvre is to
be attended to by the accoucheur, or at least by an assistant fit
to be trusted, and not by the woman herself. When it is an old
and irreducible one, we must be content to support it exactly,
so as to prevent it from becoming strangulated, or receiving an ad-
dition of new portions of viscera to those already contained within
the tumor. Beyond this, the labor requires no particular assis-
tance, and we should confine ourselves merely to moderate the dis-
position of the woman to improve her pains by bearing down; never-
theless, should the violence of the efforts be such that nothing could
prevent the descent, or if there should be strangulation and tlie
labor far advanced, the child should be extracted with all suitable
precautions as soon as the dilatation of the os uteri admits of it.

§. vni. Dystocia from Syncope.

35*

402 DYSTOCIA.

917. Some women are so delicate, or so irritable and nervous,
that they fall into syncope from the least pains; in other cases the
syncope and fainting are due to the extreme distension of the uterus,
to the force of the contractions, to inanition, to an attack of hemor-
rhage, &c. In a lady who was pregnant with twins, M. Desor-
meaux found them to last throughout the whole interval of the con-
tractions, and the woman only came out of them while the womb
was reacting with violence upon its contents. Antispasmodics and
opiates, either applied to the os uteri or taken internally by the
mouth or anus, cordial tinctures and other such articles, a few
spoonfuls of sound wine, or of broth, light food, &c. may be tried
in succession or by turns; but, says M. Desorraeaux, provided the
life of the woman be threatened, we cannot wait for the effects of
remedies, no matter how well chosen they may be: under such cir-
cumstances, to temporise, would be a serious fault; we should ter-
minate the labor as soon as possible, in order to prevent a fatal
exhaustion.

918. It is uncommon for weakness, properly so called, to render
a labor difficult; every day, valetudinary and phthisical women are
met with who can scarcely stand, and yet bear their children without
difficulty. Others are not prevented from being delivered naturally by
a state of lethargy, of asphyxia, &c., and on more than one occasion
the womb has been found to retain enough contractility in dying wo-
men, or in those who had just expired, to effect the expulsion of the
ovum. There are two principal reasons why our succors are most
commonly unnecessary in these cases; 1. Although the muscles and
the uterus have to a great degree lost their contractile faculty, the soft
parts of the pelvis and the perineum also offer much less resistance;
2. The feeblest women, even those who seem to be upon the point
of expiring, ordinarily recover an amount of courage and energy that
forms a striking contrast to their extreme exhaustion.

919. Notwithstanding, it is not a rare thing to see these momen-
tary efforts followed by an oppression and sinking, from which the
women recover only after having run the greatest risks; many of
them even are scarcely delivered till they fall into a morbid collapse,
or sink gradually into death after a few hours, as if, in acting with
some degree of violence nature's only object had been to terminate
the great act of reproduction happily, at the risk of exhausting in an
instant the small remaining strength still belonging to the organs!
A young woman six months gone with child, who had been labor-
ing for thirteen days with an attack of phlebitis, and who was in a
decidedly adynamic state, was seized with the pains of abortion at
four o'clock in the morning; at ten o'clock the os uteri was soft, and

SYNCOPE. 403

of the size of a three hvres piece; at each contraction her cries, an-
guish, and agitation restored an appearance of strength, the existence
of which was not suspected a few hours before; the poor woman
was urged to redouble her courage, and make the utmost of her ef-
forts; in fact the child was delivered at about eleven o'clock, but in
an hour afterwards she was no more.

Consequently, as soon as the os uteri is sufficiently dilated where-
ever there is reason to fear too great a degree of exhaustion, prudence
requires us to have recourse to a forced delivery. The forceps should
be preferred in such cases, provided turning be not absolutely indi-
cated, inasmuch ^s it is less fatiguing for the woman.

SECTION 2.

Essential Dystocia.

Labor is essentially difficult where the passage of the foetus requires
the interference of art, from its being rendered impossible, or greatly-
obstructed from some mechanical obstacle. Of these obstacles, some
depend upon the woman; others, on the contrary, depend upon the
foetus itself.

§. I. Dystocia Occasioned l>y the State of the
Female Organs.

The difficulties that arise in the organs of the female are some-
times referred to the soft parts, and at others to the hard parts of
her structure. The former alone will occupy our attention here,
for as much as the latter were treated of in the section on deformed
pelvis.

920. Various tumors have been observed in the pelvic excava-
tion, and on more than one occasion, great difficulty has arisen from
them in regard to the birth of the child.

They are pretty frequently found to occur in the perineum, or in
the recto-vaginal septum; being variable as to size, consistence,
nature, &c. they are far from always requiring the same kind of
treatment; when not very large or capable of being flattened by-
pressure, if other circumstances are favorable, they do not always
prevent the spontaneous delivery of the child; scirrhous or fibrous
masses connected with the ovary, the intestines or epiploon, when
sufficiently moveable to sink down and lodge betwixt the uterus and
sides of the pelvis, present a peculiar indication; they require to be
displaced and carried above the superior strait; for this purpose, the
woman must be placed upon her back or side, in such a way that

404 DYSTOCIA.

the pelvis may be higher than the breast, and all the muscles in a
state of relaxation; then by means of tlie hand or fingers, we at-
tempt to push the tumor out of the passage; finally, when all at-
tempts at reduction have proved to be fruitless, it may become indis-
pensably necessary to extract the tumor by making incisions through
the vagina or rectum, or even to have recourse to the cesarean
operation.

921. Sarcomatous, scrofulous, fibrous or other tumors that are
situated in the cellular tissue of the pelvis, and that cannot be dis-
placed, are much more dangerous than the foregoing ones; by resist-
ing the head of the child, they expose the Avomb and other organs con-
tained within the excavation to contusions, perforations and lacerations
that it is not always an easy matter to prevent; they also induce iner-
tia and exhaustion, and pretty frequently excite hemorrhagies, con-
vulsions, or various kinds of inflammations.

922. Those of the recto-vaginal septum are, most generally, sim-
ple encysted tumors; this at least seems to result from the observa-
tions of Plenck, of M. Pelletan, and a case recently noticed by M.
Roux at La Charite at Paris. The woman has sometimes succeed-
ed in expelling them, either through the anus or through a laceration
in the perineum. In some cases they have been ruptured by the
muscular eftbrls, and that without any ill consequences, when the
fluid they contained was permitted to escape into the rectum, the
vagina, or even to be effiised in the surrounding cellular tissue. But
they may also end in abscess, gangrene, or a mortal peritonitis, if the
laceration extends into the peritoneum. It is, therefore, most pru-
dent to empty them or extract them as soon as they are ascertain-
ed to be capable of hindering the escape of the foetus, or rendering
it dangerous. In such cases, it is not always an easy matter to dis-
tinguish an hydatid or encysted tumor from such as are solid; but, as
has been pointed out by M. Desormeaux, a puncture with a small
trocar will suffice to remove all doubts upon the subject.

923. Calculi in the bladder. It is evident that a large stone
might, during labor, become situated directly behind the pubis, so
as to shorten the antero-posterior diameter of the pelvis. But a stone
being violently pressed from above downwards, by the child's head,
would almost necessarily give rise to contusion or laceration of the
bladder or of the recto-vaginal septum, as well as the pain that would
ensue thereupon. It would be easy, at the commencement of labor
to push the stone upwards, and retain it above the symphysis pubis,
until the head could get below it. Should the practitioner arrive late,
and find the stone coming down before the head, he should, notwith-
standing, endeavor to raise it above the strait. AVhere it is impossi-

^SJ^

URINARY CALCULI. 405

ble to get it up, there is one resource left, which is ro cut down on
the stone through the anterior side of the vagina, or to perform va-
ginal lithotomy.

924. The labia or nymphfe may have become agglutinated pos-
teriorly to the fecundation, and either wholly or partially close up
the vagina. The hymen may be hard, fibrous or cartilaginous, to
as to leave but a small orifice, and thus interfere ^vith the escape of
the child (143). Delivery is not in such cases impossible: such fee-
ble barriers are incapable of counterbalancing the energetic contrac-
tions of the uterus; but it is better to divide with an instrument those
parts that have to be separated, than to expose the woman to the
risk of ruptures and irregular lacerations whose limits cannot be pre-
scribed, and which might go to a dangefous extent.

925. Where the vulvar extremity of the vagina is completely
obliterated, no conception could possibly have taken place by the na-
tural passages; but it is not uncommon to meet with bridles or par-
tial contractions in some part of the canal. Where these frena are
not very old, or very hard, they ordinarily become softened and yield
to the mere progress of the labor; where they resist, so far as to
awaken a fear of laceration of the womb, inertia, convulsions, ex-
haustion, or their own rupture, they should be divided by making a
few small incisions on their anterior edges. A woman who was in
labor of her third child, and who two years previously was delivered
by means of instruments, was brought to the hospital de Perfection-
nement, by M. Dubourget, after having been three days in travail: I
was about to apply the forceps, but was soon arrested by a large cres-
cent shaped bridle, which was hard, and as it were, fibro-cartilaginous
which was two inches above the vulva, and on the free edge of which
I found it necessary to make three incisions.

926. When the vagina opens into the bladder, fecundation being
on that account evidently impossible, it is therefore useless to class
this deviation among the causes of dystocia.

Several authors, and among others Barbaut, and still more recent-
ly M. Marc, have made mention of women in whom the vagina
opened into the rectum, who notwithstanding became pregnant, and
yet were delivered without any artificial aid.

Stegmann relates the case of a girl whose vagina opened above
the pubis, and Morgagni speaks, after Gianella, of a case in which fe-
cundation nevertheless took place: in such a case it would be neces-
sary first to try, like the Italian accoucheur, to dilate the preternatu-
ral opening, and should that prove insuflacient, to make several eccen-
tric incisions upon the orifice, not losing sight of the proximity of
the peritoneum and bladder.

406 DYSTOCIA

Scirrhous or fibrous tumors capable of affording an obstacle to
delivery, and requiring serious operations, rarely occur in the vulva;
but chronic or acute phlegmons are met with that might be singular-
ly aggravated by the passage of the foetus, and it is important, there-
fore, that they should be very energetically treated in vt^omen who
are approaching their term.

The labia are, at times, the seat of bloody tumors, of a particular
kind, that I have long mentioned in my lectures, which Dr. Dewees
also has described in the American journals, and to the consideration
of which I shall return when I come to treat of the accidents of par-
turition; for the present, I shall content myself with stating, that
where they are sufficiently large to interfere manifestly with the birth
of the child, or expose the mother to very acute suffering, I should
not hesitate about plunging a bistoury into them, so as to empty them
completely.

927. Some women, though in other respects robust, are aflected,
towards the close of pregnancy, with a considerable infiltration in
the lower limbs, and even in the whole body. The cutaneous and
mucous folds of the vulva may in such cases attain to an enormous
size, and completely close the vagina; the termination of a labor
is thus rendered, of necessity, much more difficult, and above all
much more painful ; it cannot be dissembled, that by leaving na-
ture to herself here, there will be reason to fear the occurrence of
gangrene, or of more or less extensive lacerations; unhappily, al-
though threatened with such dangers, there is little that the accou-
cheur can do; some punctures, the application of emollient and se-
dative lotions, and care in relation to the disposition of the parts and
to the muscular efforts of the woman, afford all the materials for his
counsel.

928. Inversion of the vagina may take place during pregnancy
and even during labor. I was called last spring, by Madame Beva-
let, to see a woman who had been suffering for thirty hours without
being delivered. The head of the fostus was quite down in the ex-
cavation; but the vagina, which was entirely inverted, exhibited out-
side of the vulva, the appearance of a fungous and livid cushion
larger than two fists. It was necessary to apply the forceps for the
delivery of the patient.

929. Much has been said about the obliteration of the os uteri of
women in labor; but if it is not wholly certain, it is at least highly
probable that the authors who have mentioned it were misled by
some deviation affecting the os tincae. I have already seen so many
practitioners, even experienced ones, affirm that there was no os uteri
at all, in cases where it was merely raised up towards the sacro-ver-

TUMORS. 407

tebral angle, that it seems to me very easy to refer a great majority
of the cases of supposed obliteration of the os uteri to this mistake
alone. It is evident that nothing less than some severe disease, some
acute inflammation, could thus close up the mouth of the womb, be-
twixt the fecundation and the term of gestation; but in that case the
parts would necessarily be affected with concomitant alterations of
structure, sufficient to remove all doubts; the anamnestic signs would
have attracted attention precedently, and abortion could rarely fail to
take place.

However, if authentic examples be wanting of complete oblitera-
tion at the period of labor, we at least possess several instances of
coarctation, partial or total induration, and still more numerous ones
of stricture in some other portion of the os uteri.

Were the canal closed by a spongy or polypous mass, like those
met with by Denman and M. Evrat, we should wait for its descent
into the vagina, to attempt its extraction, after which we should pro-
ceed as in any other case of parturition.

930. A scirrhous induration, of partial extent, might require no
particular assistance. In a case mentioned by M. Desormeaux, the
whole dilatation took place at the expense of only two-thirds of the
circumference of the orifice, and the escape of the ovum was scarcely
retarded; but if the whole of the cervix uteri were involved, either at
its vaginal extremity, or at a point near the cavity of the uterus, the
vaginal-cesarian operation would be indicated, it being well understood
that a forced dilatation with the fingers or the speculum, either could
not be attempted, or had been vainly tried.

931. A fibrous tumor, a scirrhus, a polypus, cicatrices, an ulcer,
an abscess in the substance of the womb, or even upon its internal
substance, would also require particular precautions, provided it were
possible to ascertain their existence. In the first place, the diseased
point does not in general partake in the extension of the organ during
pregnancy, or does not contract again after delivery; in the next
place, it deranges or interrupts the contractions daring labor, and in
that way favors the occurrence of convulsions, laceration of the womb,
hemorrhage, inertia, and general exhaustion. In order, therefore, to
protect the woman as far as possible from such dangers, it would be
necessary to extract the child, without waiting too long, either by the
hand or with instruments.

932. Labor is also sometimes rendered very difficult, and even
wholly impossible, by means of displacements and deviations of die
womb.

There are instances of complete prolapsus which did not prevent
the woman from being fecundated ; witness the peasant woman

408 DYSTOCIA.

mentioned by Morgagni. In other cases, the falling of the womb
occurs during pregnancy. In both cases, provided the gestation
goes to its full term, it is possible for the womb, which here cannot
be seconded by the abdominal muscles, to deliver itself alone; but
it is also possible that the pains should prove to be insufficient, and
thenceforth prudence requires us to make use in succession of de-
coctions, mucilages and ointments of an emollient nature, and resort
to the dilatation or incision of the edges of the orifice, and afterwards
bring down the child's feet.

Sennertus and Ruysch have related cases of hernia of the womb,
where the women have, notwithstanding, become pregnant; but every
consideration leads to the belief that mistake here has more than on
•one occasion arisen from a very decided anterior obliquity of the
womb.

This kind of displacement forms, in the opinion of several authors,
an insurmountable obstacle to the spontaneous termination of labor;
so that, under such circumstances, they have thought of no better
counsel than that of resorting to the cesarian operation; however,
this last recourse will hardly be taken by a man who is fully ac-
quainted with the resources of the animal economy. Provided the
reduction be possible, the accoucheur will attempt it: in the con-
trary case, he should be content with recommending the horizontal
posture, and advising the woman not to bear down. During the
contractions, and even during the intervals .between them, it is pro-
per to press the uterus backwards, with the two hands applied to the
epigastrium, as if to make it re-enter the abdomen; by means of
these precautions, which are not even always indispensable, the os
uteri dilates, opens, and the labor most frequently terminates without
further assistance, and without danger, even in cases apparently the
most difficult. An accoucheur at Copenhagen was called to a woman
who had for a long time had a crural hysterocele, and who exhibited
some symptoms of pregnancy; the period of delivery arrived, the
surgeon had given the most unfavorable prognosis, and thought he
should be under the necessity of performing the operation of hyste-
rotomy. But nothing of the kind happened, and the labor terminated
spontaneously. Ruysch and Simon relate two cases of uterine
hernia equally remarkable; in one of them the cesarian operation
was performed and the woman died; in the other, nothing was done,
and both the mother and child were saved!

Simple deviations of the womb may also interfere with the pro-
gress of parturition and require some particular care. Upon this
subject I ought to remark, that it is far more important than writers
seem to suppose, not to confuse deviations of the cervix with those

DISPLACEMENTS OF THE WOMB. 409

of the womb strictly so called. In fact, although the deviation of
the orifice pretty frequently coincides with that of the fundus of the
organ, it is nevertheless undeniable, that one is often met with, with-
out the other.

933. When the womb is inclined laterally or backwards,, no great
difficulty can arise as to the delivery of the child, provided there
should be no other cause of dystocia. In tiie anterior obliquity, on
the contrary, especially when it is to a great extent, the assistance
of art may become indispensably necessary. The woman should
be directed to lie down at the very beginning of the labor, and told
to remain in a horizontal posture taking care to keep the hips con-
siderably elevated; the hypogastrium is to be pressed backwards,
while by means of one or two fingers introduced into the vagina we
attempt to draw the os uteri to the centre of the pelvis. These last-
mentioned tractions, which are useful where the orifice is found
raised upwards towards the sacro-vertebral angle, need not be tried
in cases where the womb, instead of being inclined by a see-saw

■ motion, is bent forwards on its anterior surface, like a chemist's
retort? But in that case we should direct the woman to moderate,
or even to suspend, her eflA)rts; for, during the pains, the action of
the diaphragm and abdominal muscles tends constantly to augment
the obliquity, and thus to annul the efforts of the practitioner in a
contrary direction. In the spring of 1825 I was called by M. Ma-
jeste to a woman whose labor had been at a stand for several hours,
notwithstanding the pains were very severe. The womb, bent into
the form of a retort, was so disposed that at each contraction its pos-
terior surface became quite horizontal. I showed the patient that
her efforts were not only of no use, but also that they were sufficient
to prevent her labor from coming to a conclusion. She was obedient
to the counsel I gave her, and resisted, as far as she possibly could,
the sensations that excited her to bear down. It was not long be-
fore the womb rose up of its own accord during the contraction, the
head soon engaged, and in two hours afterwards the child was born.
There are, therefore, certain cases of inclination where the labor
ought to be abandoned almost entirely to the mere contractions of
the womb.

934. Doubtless, Moschion and Deventer were wrong in maintain-
ing that obliquity of the womb most frequently produces a transverse
position of the foetus; but it would be quite as unreasonable to main-
tain that this effect never does take place. If the inclinations of the
womb do rarely suffice to produce real transverse or shoulder pre-
sentations of the foetus, they, at least, seem to me to be very fre-
quently the causes of presentations of the face, the forehead, the

36

410 DYSTOCIA.

nucha, the parietal protuberances, the hips, &c., and in this respect
to deserve the attention of the accoucheur.

935. I ought in this place to mention a kind of deviation that I
have never met vv^ilh but once, of which I have been unable to find
any cases described by the various authors, and which ought not to
be confounded with anterior obliquity. In a woman who came to
be confined at my amphitheatre in the month of May 1828, the
fundus of the uterus was rather inclined backwards than forwards;
the head of the foetus formed above the strait a considerable projec-
tion, which descended nearly to the vulva, and was at last situated in
front of the symphysis pubis; the os uteri, which was on a level with
the superior strait, seemed to be scooped out of the substance of the
posterior wall of the womb, which made it much longer behind than
before; in order to reach the orifice and penetrate towards the head
of the child, I was obliged to bend my finger so as to make it pass
almost horizontally above the pubis. Such a state of things sur-
prised me, and I mentioned it to the students, who easily satisfied
themselves as to its existence. The progress of the labor was so
much retarded by it, that after seven hours of pain and pretty strong
contractions, the os uteri, although very soft and very dilatable, was
scarely open at all. M. Desonneaux, whom I invited to see this
remarkable case, said that he had never noticed one like it, and
agreed with me that by means of position and the assistance of the
hand properly combined, I ought to try to carry the head to the
centre of the superior strait, by making it slide from below upwards
and from before backwards over the pubis. I began to execute
this manoeuvre at half past eight o'clock, and continued it alternat-
ing with several of the students until nine o'clock. From this time
there was no longer a tumor in front of the symphysis, and the
labor progressed so rapidly that in less than an hour the child was
born and the placenta itself expelled.

Such a state of things seems to depend: 1st, on a posterior
inclination of the womb; 2d, on excessive inclination of the supe-
rior strait; 3d, on some deviated position of the fostal head, and,
perhaps, upon the thickness, or the unequal density of the walls of
the womb; to this displacement should be referred the positions
described under the name of siir-pubal by Madame Lachapelle aud
M. Duges.

936. I have many times found the orifice turned so much back-
wards or to the outside, that its plane was almost parallel to the axis
of the woman's body, although the rest of the womb was scarcely
deviated at all. Excessive amplitude of the pelvis, great inclination
of its superior strait, and presentations of the vertex, are probably

DISPLACEMENTS OF THE WOMB. 411

the causes that most favor its obliquity. la touching, we feel,
sometimes almost at the bottom of the excavation, and at others
rather higher up, a tumor, generally very even, and which consists
of the child's head covered with the anterior wall of the distended
cervix of the uterus. This state of things has to me seemed to im-
press upon labor a peculiar character of tediousness, and often
coincides with what is called pains in the reins. The ablest wri-
ters, and Baudelocque himself, recommend, as a remedy, that we
should hook the os uteri with one or two fingers, draw it towards
the centre of the pelvis during the intervals between the paihs, and
keep it there during the contractions; or also, have recourse to
vaginal hysterotomy, the only means of avoiding gangrene or rupture
of the womb, &c. Were I to depend upon my own experience in
this matter, I should be led to think that the interference of art, in
this slate of things, is rarely necessary, and that in more than one
case there has been too great haste in acting, to the great detriment
both of the mother and child. I for a long time conformed to the
precepts laid down in the books, I pulled at the os uteri, and did
all I could to bring it back to the centre of the excavation; it is true
I succeeded, but pretty often not until I had remained several hours
with the woman. I was one day obliged to leave a student as my
substitute, who neglected the directions I gave him; after an ab-
sence of three hours I returned, found the os uteri completely
dilated, the membranes ruptured, and the head strongly engaged.
From that time I have never interfered in such cases, and tiie
organism has always succeeded in restoring things to their natural
state. My design is not to conclude from this, that we must never
do any thing but wait, but merely to observe, that, excepting in a
small number of cases, nature herself may suffice, and that a resort
to bloody operations ought not to be lightly resolved on.

937. Gibbosities and acute diseases do not become a cause of
dystocia, excepting as they often do not allow the woman, without
danger, to give heiself up to the efforts needed for the delivery of a
child; but there is another very remarkable cause of difficult labor
which no author has mentioned. A strong, robust woman, pregnant
with her first child, in the forty-fifth year of her age, had been in
labor for forty hours, when M, Morisse sent for me to see her.
The presentation was good, the head had been in the excavation for
twelve hours without advancing, in spite of the energy of the uterine
contractions. The skin on the fore part of the thighs and abdomen
was all covered with old cicatrices, which were hard and fibrous,
and confined the lower part of the hypogastrium, so that the womb
was as if strangulated immediately above the pubis, and the child

412 DYSTOCIA.

could not descend. I applied the forceps, and the child was brought
away living.

' §. II. dystocia clepessdm^ ou the Foetws. Mon-
strosity.

938. Excessive volume. There is no doubt, says M. Duges, that
where the child is very tall it may render a labor more tedious,
painful and distressing, especially if the passages are not soft and
small, as in a first labor; but it is not yet proved that great size in
a well formed child at full term has ever alone constituted an insur-
mountable obstacle to spontaneous parturition.

If it be true that Baudelocque, Chaussier, M. Capuron, &c., have
seen children born, weighing near thirteen, twelve, or even ten
pounds, it is, nevertheless certain that we no longer see them reach-
ing to the weight of fifteen, twenty, and twenty-five pounds, nor any
■whose length exceeds from twenty-two to twenty-three inches. But
as it is an easy matter to ascertain that the head of a foetus of twenty-
two inches will not be quite four inches in its occipito-bregmatic
and bi-parietal diameters, it is at once evident that, even in case of
extreme size, spontaneous delivery is not impossible. It should be
remarked, however, that in that case the least narrowness of the
pelvic cavity, especially in the perineal strait, must promptly become
the cause of dystocia.

On the other hand, the practitioner ought to know that under such
circumstances, version by the feet is never proper. Indeed, where
the head presents, although its shortest diameter and smallest cir-
cumference are almost always in relation with the largest diameters
of the pelvis, it is rarely that in extracting the child by the feet the
occiput is not forced to turn over more or less upon the back, while
the occipito-frontal, which would be nearly five inches long, would
take place of the occipito-bregmatic diameter, perhaps it might even
be the occipito-mental that would be thus situated, and that would
be at least five and a half inches in length.

The best course is to confide in the resources of the organism, and
where it is indispensably necessary to act, to attempt the application
of the forceps rather than venture upon turning; and should it be a
presentation of the pelvic extremity of the ftetus, either originally or
by turning, every precaution should be employed to prevent an arm
from becoming locked behind the neck.

939. Infiltration of the integuments of the head, and sanguine
tumors, sometimes evidently increase the size of the head, but rarely
to such an extent as to furnish any real obstacle to delivery. Har-
nier, to be sure, has remarked that where thrombuses and infiltra-

MONSTROUS FCETUS. 413

tions are of such magnitude as to deserve any particular attention,
by engaging in the space under the arch of the pubis, such tumors
prevent the rotation movement which the head ought to execute in
order to clear the inferior strait.

940. Hydrocephalus constitutes a much more real, and particu-
larly much more serious cause of dystocia; it is recognised by va-
rious signs: the finger feels a broad and tense tumor; the bones of
the head are evidently separated and very moveable; the dimen-
sions of the fontanels are very considerable; sometimes we meet
with Wormian bones of various sizes in the midst of spaces that are
completely membranous; as to the infiltration of the limbs and hypo-
gastrium of the mother during gestation, ascites, hydramnios, ana-
sarca, the lymphatic constitution, and the rational signs, that have
been supposed derivable from the size of the head, tongue, and fore-
head of the woman, they can give rise only to conjectures that are
wholly useless in the establishment of a positive diagnosis. More-
over, it is necessary to take care not to be imposed upon by an
accidental deficiency of ossification, by a fontanel, by abnormal
sutures, or a great degree of flexibility of the bones, and to recollect
that hydrocephalus during intra-uterine life is so rare,* that according
to Madame Lachapelle and M. Duges it was only met with fifteen
times in 43,555 labors.

941. In order to comprehend the dangers of this species of dys-
tocia, it should be well understood that serous fluids may accumu-
late in various quantity in the cranium, and that if the head is soft
and its size not very greatly augmented, the mere energies of the
woman in general suffice for its expulsion. When its size is not
excessive and the womb threatens to fall into inertia, recourse is had
to the forceps, taking care to make use of a moderate degree of pres-
sure, so as not to burst the head, nor allow of the instrument's slip-
ping. Where the child is dead and the head is too large to get
through the straits, cephalotomy becomes a last resource, which we
are obliged to employ.

Notwithstanding, 1 ought not to conceal that this subject has been
and still is the subject of a very important question among practi-
tioners. Where we have a certainly that the child is dead every
body is agreed; but in the contrary case, it has been asserted that
we have no right to kill it, and that it would be better to perform
the cesarean operation or symphyseotomy. Others have objected
that a child ought not to be the assassin of its mother; that as
hydrocephalous children die very soon after their birth, it would be
contrary to humanity as well as to morality to sacrifice a sound
and healthy woman for a being whose existence is so precarious.

36*

414 DYSTOCIA.

These reasons are, in my opinion, of the highest authority; for
although, as M. Duges asserts, it be true that a slight degree of
hydrocephalus ought not necessarily to occasion the death of the
child, does not alvvaj's prevent its viability, and may sometimes be
cured, it is equally certain, that in case the head is not so large as
absolutely to require the operation, and that where even the disease
is so advanced as to render the delivery impossible, we have no
ground to rely upon the viability of the child. But how is the liquor
amnii to be evacuated? Should it be done with Smellie's scissors,
Stein's perce-crdne, a common bistoury, or is it better, like MM.
Maygrier and Duges, to be content with a simple trocar? Since,
according to Holbrock, Vose, &c., the puncture has been success-
fully performed after birth, and as large lacerations are not required
to give issue to the serum of hydrocephalus, I perceive no inconve-
nience likely to arise in pursuing this last named course, inasmuch
as it at once satisfies the indications of prudence and the wants of
practice. But if the head should not be thereby emptied sufficiently
to render its escape easy, I should not hesitate about plunging one
of the other instruments into the head.

After the operation of cephalotoray has been performed, the con-
tractions of the womb generally suffice for the expulsion of the head;
but if this should not be the case, recourse is had to the forceps, to
turning, or to the crotchet.

942. I do not know that hydro-rachis has ever proved to be a real
obstacle to the termination of a labor. It is a dangerous disease to
the foetus, and that is all; besides, nothing could be easier than to
empty the tumor by pushing a trocar into it, should it appear to
interrupt the progress of the labor.

943. It is rare also hr ascites, and particularly {or kydrothorax, to
be of such extent as to furnish considerable obstacles to the delivery
of the child, as appears from the remarks of Baudelocque, M. Lamou-
reux, andM. Duges. In all cases those lacerations and eviscerations
that were practised by Deventer should be avoided, as well as the
mode recommended by Mauriceau, of perforating the navel or the
neighboring parts with the finger; simple punctures, made with a
trocar or a bistoury, always suffice to produce the eflect which it is
desirable to obtain.

944. Solid tumors developed upon certain parts of the trunk,
or any decided deformity, like the case related by Baudelocque, and
another one published by M. JNivert, might require some peculiar
attention; or even render delivery wholly impossible. Cases of this
sort are particularly untoward, inasmuch as it is, generally, quite
impossible to ascertain the circumstances until after delivery. Thus,

MONSTROUS FCETUS. 415

in the case that fell under M. Nivert's notice, the foetus had a very-
solid and projecting gibbosity which lodged above the pubis; the for-
ceps was applied, but without effect, for it became necessary to empty
the head; still, it was only by means of the crotchet and by employ-
ing the utmost strength, that he succeeded in extracting the trunk
of the foetus. Who could have suspected the existence of such an
obstacle? and even had it been understood, what could have been
done? Ought turning to have been attempted? Would any advan-
tage have been derived from pressure suitably applied to the lower
part of the hypogastrium? It belongs to future experience to solve
these questions.

945. The simultaneous presence of several foetuses in the womb
is far from always being a cause of dystocia, especially when they
are independent of each other, and are each enclosed within a
separate amnios. But this is not the case where they are contained
within the same set of membranes, or have contracted any adhesions
that compel them to present simultaneously at the straits of the
pelvis.

In the latter case, the union of the children may be in very vari-
ous degrees. Sometimes they are connected together by a very
circumscribed point upon the inferior, middle, or superior part of the
back, sometimes by almost the whole back, side, or front; at others
they are conjoined at the head, or placed end to end at the breech.
The fusion is in some cases much more complete: or, there may be
only one single trunk to two heads and two or four arms; or, on the
contrary, there may be only one head to two trunks, with limbs more
or less completely isolated.

946. The signs of these monstrosities are so vague, that they
really do not deserve to be repeated in this place; there can be no
certainty, nor even probability, of their existence, except in so far
as certain portions of the foetus are already emerged; and even then,
it is for the most part very difficult to characterise the nature of the
monster we are about to receive.

We have enough of cases of monsters from excess of parts, born
living and under the mere resources of nature, to warrant us in not
acting too hastily in such circumstances. If a double foetus with
a single head presents by the vertex, or even by the feet, provided
the conformation of the pelvis be good, the delivery will not require
any particular interference; the same would be the case with two
foetuses attached to each other by their extremities, either the head
or breech, as is proved by the cases mentioned by Meckel, Palfyn,
Duverney, Home, &c. Further, M. Duges saw one born without
assistance, though it was completely double, at full term, and of large

416 DYSTOCIA.

size. But again, the observations of Plenck, Smellie, &c. demon-
strate that monsters of a much smaller size have, on more than one
occasion, rendered delivery very distressing, both to the mother and
the accoucheur, particularly where there was a great desire to have
them born alive.

947. When there are two heads to a single trunk, provided the
one that is in front succeeds in engaging first, the second may fol-
low without any extreme difficulty, and being forced downwards,
they will clear the vulva, almost as easily as if there had been but
one. When such a monster presents by the feet, the posterior head
ought to descend first into the excavation, whilst the other remains
above the pubis; the woman may exhaust herself in vain efibrts,
and the intervention of the accoucheur may become indispensable.
But, previously to operating, several questions present themselves
to the practitioner; is the monster dead, or is it living? In the lat-
ter case, are we to act upon the woman, or upon the foetus! I
know that a double child, or one that is simply bi-cephalous, may
live and grow after birth; that several have lived for seventeen, or
twenty years, and even to a very advanced age; that a fostus seen
by Everard Home that was born in the East Indies, and which died
at three years of age of the bite of a serpent, grew as regularly as
the best formed child, though it had two heads united together at the
vertex. Who is unacquainted with the history of the monster
noticed in China, and of which an account was laid before the
Academie des Sciences last year? I do not wish therefore to
maintain that such beings are of necessity unlikely to live; but is it
true that they have the same rights as any other foetuses to our care
and solicitude? Is their life so valuable, that with the view, and
under the few chances of preserving and raising them, we are bound
to perform on the mother a most dangerous and too commonly
fatal operation? I am aware that by the cesarian operation we
may save the child, and not cause the mother to perish; but is it
not well known that one half of the women who submit to it lose
their lives, and that almost all the fostuses soon undergo the same
fate? I do not hesitate to say, and I believe in conformity to the
sacred laws of humanity, that if I were obliged to choose between
hysterotomy and the murder (meurtre) of a monster, I should not
vacillate a moment, I would sacrifice the fcetus. Happily, the skil-
ful acooHcheur can scarcely ever be subjected to this distressing
alternative; manoeuvres well arranged, and performed either with
the hand, the forceps, or the lever, almost always succeed in disem-
barrassing the woman through the natural passages, without injuring
the child.

MONSTERS. 417

948. The turning and delivery by the feet resorted to by Pen,
Walter, Walgen, M. Evrat, M. Brez, Regnoli, &c., and recom-
mended by Asdrubali, MM. Desormeaux, Duges and others, whe-
ther the child be exactly double or merely bi-cephalous, living or
dead, and at any stage of gestation, will suffice in nine cases out of
ten, at least, where there are no other causes of dystocia present.
It ought therefore to be tried in all cases. However, if one of the
head should be already so far engaged, that it could not possibly be
returned, we might, after the manner of Plenck, try the application
of the forceps. Should the forceps prove insufficient, there would
be a last recourse, the removal of the parts that had descended into
the excavation, that is to say, of the head alone, or the head and
arms; after which the feet could be brought down so as to deliver
by turning, as was done by M. Retel, in 1818, in such a case.
There would be less to fear in such a case, as the foetus generally
dies long before we are reduced to tliis extremity. The difficulty of
separating two children, united to a certain extent, outside of the
womb, and the danger to which by such operations they are exposed
clearly show how imprudent it would be to follow the advice of
Sraellie, and attempt to do so, in the interior even of the uterus.

949. When, in twin pregnancy, two fostuses present simulta-
neously at the straits, the intervention of art almost always becomes
necessary, and sometimes indispensable. If it be found that both
the heads tend to engage at the same time, which is excessively rare,
it is proper to push up the rriost moveable one with the fingers, so as
to let the other advance first; the same procedure may be adopted
for the feet, the knees or breech; if the children present across, or
in any other way except by the head or the pelvis, recourse must be
had to turning; but it may happen that one of them comes by the
head, whilst the other descends by the feet, and that upon reaching
the superior strait the chin of the latter hooks in with the chin of
the former, so that the two heads at length become immovably fixed,
each opposing an insurmountable resistance to the other, and con-
stituting one of the most embarrassing cases in the practice of mid-
wifery; neither turning nor the application of the forceps can be
thought of; even the cesarean operation itself, which has been re-
commended by some authors, would not always enable us to disen-
gage the fcetus; so that the detruncation of the one that is without,
constitutes almost the only resource left to us for the safety of the
mother and one of the children.

418 DYSTOCIA.

SECTION 3,

Dystocia from Wrong Presentations of the Fcetus.

It has been seen in another article that the presence of one of the
extremities of the occipito-coccygeal diameter of the foetus at the
superior strait is one of the first conditions of eutocia. All the cases
in which any other point than the head or pelvis presents ought
therefore to be classed among the cases of dystocia. I will add that
to them should be conjoined all the deviated positions of the head or
breech.

§. I. Deviated Positions of the Head.

Under this tide I comprise the positions of the sides of the head,
of the ears or of the temples, admitted by Mauriceau, Deventer, De
la Motte, and Baudelocque; and those of the occiput, in so far as
they really exist, as was understood by the last named author: as to
the forehead and face positions, since they do not, in general, pre-
vent a labor from terminating without assistance, I shall say nothing
about them in this place.

950. Positions of the occiput or upper part of the nucha are rare,
and scarcely occur except in very decided anterior inclination of the
womb. Then the vertex may be turned towards some point on the
circumference of the pelvis instead of corresponding to the centre
of the strait; should pushing the womb backwards, keeping the wo-
man on her back, or the mere efforts of the organism prove to be
insufficient to re-establish the natural position, it would be necessary,
with the fingers, the lever, or one of the blades of the forceps, to
hook the upper part of the cranium, and draw it down towards the
centre of the excavation, upon which the labor would return to the
natural order.

951. The lateral positions of the head, being nothing more than
slighdy modified positions of the vertex, are the same in point of
number with them; they are marked by the presence of the ear, of
the angle of the jaw, or the parietal protuberance: they are distin-
guished from each other by considering to which point of the strait
the posterior edge and lobule of the ear are turned; they are, more-
over, rare, and generally end in conforming themselves, spontaneous-
ly, to the corresponding positions of the vertex or shoulder.

We ought, consequently, to trust to the efforts of the womb, as
long as the os uteri continues to be sufficiently dilated; if they then
persist, we must, as in positions of the occiput, endeavor to bring

WRONG PRESENTATIONS. 419

back the vertex to the centre, by means of the fingers, the lever, or
one branch of the forceps; or, where it is a shouUler that is too far
advanced, the child should be turned and delivered.

§. II. Deviated Breech Positions.

952. The pelvis may, like the vertex, incline in any direction, and
give rise to what have, by the authors, been denominated positions
of the hips, sacrum, front of the thighs, and genital organs. Pro-
duced sometimes by the inclination of the child no longer agreeing
with the vertical axis of the womb, and sometimes, which is more
common, by obliquities of the uterus, the deviated positions of the
breech do not always prove insurmountable obstacles to spontaneous
delivery. Nature often succeeds, alone, in transforming them into
direct positions, so that if the labor progresses in other respects regu-
larly, the assistance of art rarely becomes necessary.

However, we must not, for fear of acting unnecessarily, remain
inactive under accidents or sufferings which it would be easy to pre-
vent or alleviate by a skilful manoeuvre. Whilst the membranes con-
tinue unruptured, all we ought to do is to restore the womb as far
as possible to its natural attitude, either by pushing it with the hand
into the axis of the strait, or by causing the woman to assume such
or such an attitude, according to circumstances. But if, the mem-
branes being ruptured, the os uteri, although soft, should dilate with
exceeding slowness; if the pains should be directed with great force
towards the reins, or the strength appear likely to be exhausted; or
lastly, should any accident supervene, the accoucheur ought to wait
no longer: he should try to reach the deviated part with his fingers,
or even with the lever, if it be the hip or sacrum, and restore it to
the centre of the pelvis; or he may proceed at once to seek for the
feet or the knees.

§. III. Positiosis of the Triisik of the Body.

It is incontestable that the trunk sometimes presents at the supe-
rior strait otherwise than by the head' or pelvis; this has been ad-
mitted by practitioners in all ages, and has been a thousand times
proved by observation. But it is true that these presentations ex-
hibit shades so various and multiplied as has been asserted by the
authors? In the first place, it is possible for positions that are frankly
transverse, to take place either before or after the discharge of the
liquor amnii, when the foetus is at full term and well grown? For
that end it would be required that the transverse diameters of the
womb should exceed the perpendicular; but even should such a dis-
position exist before the commencement of labor, can we conceive

420 DYSTOCIA.

that it could maintain itself under the contractions of the gestative or-
gan? Would not those contractions necessarily compel the head or
the breech to descend towards the os uteri? Mauriceau, Deventer,
Smellie, Roederer, &c., have given drawings representing such po-
sitions, it is true; but none of them is said to have been taken from
nature, and a mere glance suffices to satisfy us that they are all
fancy-pieces. If the ideas of these authors have in our own day been
reproduced, with additions, is it not rather in order to be conformable
to the notions of the ancients than from direct observation? Could
Solayres and Baudelocque be fit judges of a question never precedent-
ly agitated, particularly as they had such motives to retain it as it had
been laid down, in order to magnify the importance of a classification
which in a great measure constituted their reputation and their glory?

I desire that, here, as well as in the succeeding articles, no one
will misconceive of my intentions, and that I may not be charged
with want of reverence for so many celebrated names; I merely ex-
press my doubts, and do not pronounce judgment; but, were it ne-
cessary to combat the opinion and the arguments of those accouch-
eurs, whether ancient or modern, who have admitted the existence
of transverse positions, by means of authorities not less respectable
than they are, I would suggest, without any allusion to my own ex-
perience, that out of more than forty thousand cases noticed by
Madame Lachapelle, and twenty thousand mentioned by Merriman,
not one of these presentations was observed; finally, that M. Du-
bois and M. Duges reject them as chimerical or superfluous.

953. Is it, then, demonstrated that the chdd may present either of
its three principal surfaces at the entrance of the pelvis, and that in-
clined positions of the side have not been mistaken for positions of
the dorsal or abdominal surface? A multitude of cases are found in
books, which, if taken according to the letter, would lead to an af-
firmative answer to these questions; but, upon analysing them with
some degree of care, they are soon found to be accompanied with de-
tails not sufficiently circumstantial to serve as incontrovertible proof
of what their authors have averred to be the facts. According to
Madame Lachapelle, positions of the anterior and posterior regions
never do take place, and those of the side are the only ones that we
can conceive of, except it be in some abortions; she maintains that
positions of the dorsal surface would not fail, under the influence of
the uterine contractions, to be soon transformed into positions of the
shoulder, should they not result in being reduced to some positions
of the head or pelvis; that those of the abdominal surface would re-
quire a reversement of the occiput, of the lower extremities and spine,
incompatible with the life of the fcetus. For my own part, I think

POSITIONS OF THE TRUNK. 421

that the hack and the anterior surface of the fostus may present at
the superior strait; that these positions have been observed; that
proofs of them are contained in the works of Deventer, De la Motto,
&c., but that they are rare, and differ so little from the positions of
the side, as to require only very slight modifications in the manoeu-
vres appropriate to these latter.

954. Baudelocque admits, further, that in the posterior surface
we should distinguish the occiput, the nucha, the back, the loins,
and the posterior surface of the pelvis; and that the anterior and late-
ral surfaces require the same subdivisions. But while we admit
that the foetus may, indeed, present by these diflerent points, it would
be, nevertheless, useless to adopt such numerous positions, for they
are of no practical application, overload the memory without any ob-
ject, and only serve to discourage die student.

955. The simple good sense and observations of Denman and
Madame Lachapelle, prove that the nucha cannot maintain itself at
the superior strait, that it would soon give place to the head or
shoulder, and that positions of the hips or loins could not f;id to be
soon transformed into a direct or inclined position of the breech.

It is, then, evident that a position of the abdomen has often been
supposed present, when, in reality, it was only an inclined position*
of the breech, feet, or knees, complicated with one of the arm, or
with a premature escape of the umbilical cord. Madame Lachapelle
thinks that the throat would not, under the contractions of the womb,
be long permitted to remain at the orifice, for the pains would bring
the face there far more easily. I am in possession of no facts to
militate against the opinion of this author, and know that on this
point many practitioners might have been deceived by the touch;
however, I can conceive that, where the occiput is very much re-
versed backwards, the chin may lodge upon some part of the pelvic
circle, and compel the anterior part of the breast and neck to fix it-
self at the orifice, while the breech, although retaining'its natural re-
lations to the abdominal members, remains at the fundils of the ute-
rus. In order, therefore, to avoid the reproach of abandoning one
Extreme for the purpose of falling into another, I shall admit the po-
sitions of the back, and of the anterior face of the thorax, as at least
possible occurrences.

956. As to presentations of the side, they are too frequently
met with, for their existence ever to have been the subject of a doubt;
but the classification of Baudelocque, although recently brought for-
ward again in America by Dr. Dewees, one of the most distinguish-
ed accoucheurs in the new world, here requires the same reform as
in the anterior and posterior surfaces. The sides of the neck form
37

422 DYSTOCIA.

too deep a notch betwixt the shoulders and head, not to yield a pas-
sage to one of these parts; the side of the chest being less round,
and particularly not so smooth as the point of the shoulder, could
not hinder the latter from engaging in the os uteri; lastly, the flanks
would soon bring about a hip or breeeh position.

957. Causes. Inclinations of the womb or of the straits of the
pelvis, sudden and irregular movements of the fostus, certain atti-
tudes of the woman long persisted in, are the principal causes to
which, in the present state of our knowledge, we may attribute the
bad positions of the foetus.

958. Hippocrates was the first one to say that the foetus in utero
was in some degree situated similarly to an olive or a cork in a long
necked botde; that in order to escape from the genital organs, it must
present one of the ends of its long diameter; and that any other pre-
sentation was dangerous, rendered delivery impossible, and imperi-
ously demanded the assistance of art.

This doctrine, which has been republished by all the authors since
the father of medicine, and against which no one has made any ob-
jections even in our own days, is, notwithstanding, not free from all
doubt.

The comparison instituted by Hippocrates is not correct, except
in so far as the foetus remains in a normal position; in the other
cases, the child represents neither an oval nor a cone placed trans-
versely or obliquely: whilst the head turns on one of its sides, be-
hind, or in front, whilst the shoulder, the breast, or the back tend
to engage, the remainder of the trunk continues, notwithstanding,
in due relation with the vertical axis of the uterus, whenever the
contractions are somewhat energetic; and thenceforth the foetus is
in no respect like a cork that presents crosswise in the throat of a
vial.

959. No doubt the hand of the accoucheur is often necessary, and
even indispei'ksable, when it is neither the head nor pelvis that pre-
sent; but it is also certain that the organism alone would, in many
cases, triumph over this obstacle were the labor left to itself. Peo-
ple have in practice reasoned as if the positions of the trunk, when
once determined, could never change. But daily observation proves
that the difl^'erent points of the fostus, though very remote from each
other, may, during a labor, present alternately at the orifice; that po-
sitions of the back or shoulder may be converted into positions of the
head or breast; that positions in appearance the most unfavorable
might sometimes be replaced by normal positions, were all accou-
cheurs sufficiently ivell informed to know how to ivait.

9G0. Those passive movements undergone by the fostus in utero,

SPONTANEOUS EVOLUTION. 423

which Denman has mentioned under the title of spontaneotis evolu-
tion, and which M. Murat calls spontaneous version, have been care-
fully observed by Madame Lachapelle, and noticed by Garthshore,
Martineau, &c. Neither were the ancients wholly unaware of them,
since they advise that, for the purpose of bringing the head back to
the strait, the woman should be shook or assume certain positions.
Most modern authors have also remarked them, since they have laid
it down as an established rule, that the position of the child, while
still enclosed in the membranes, is so variable, that, in order to fix it,
it becomes necessary to rupture the ovum, choosing a moment when
the head corresponds to tlie centre of the pelvis; but upon this, as
upon all those phenomena that have not been the objects of special
study and attention, little thought has been given to the practical con-
sequences that might follow it.

961. Allhougli the spontaneous evolution takes place most fre-
quently where there is a superabundant quantity of liquor amnii,
where the foetus is not large, where the womb is very much inclined,
or where the pelvis is badly formed, it may, nevertheless, be some-
times observed in the directly contrary conditions. Although it
more commonly and easily takes place before the rupture of the
membranes, it is, notwithstanding, found to occur after the evacua-
tion of the waters: a young woman, in her second pregnancy, was
admitted into the hospital of the Ecole de INIedecine, at ten A. M.
in the month of August, 1825. The os uteri was then but little
dilated ; nevertheless, I discovered that the shoulder presented in
the second position. The waters were not discharged until three
o'clock in the afternoon; four students, who were aheady well ad-
vanced, touched and recognised tlie presence of the shoulder, as I
had done. I did not wish to bring down the feet; the pains were
neither very strong nor very frequent, and I had some confidence in
the assertions of Denman. At eight o'clock the shoulder was found
to be evidently moved towards the left iliac fossa, and I could easily
feel the ear to the right. At eleven o'clock the temple was nearly in
the centre of the orifice: the energy of the contractions was greater,
and the os uteri completely effaced. At midnight the occiput came
down, and in the space of an hour the child was expelled in the right
occipilo-acetabidar position.

962. It appears to me that the explanation of spontaneous evolu-
tion is an easy matter: the head of the foetus, which is its most
solid, voluminous, and regularly rounded part, and on that account
its most slippery portion, naturally tends towards one of the two ex-
tremities of the great diameter of the uterus, and towards the cavity
of the pelvis; if, under the influence of any cause, it has assumed

424 DYSTOCIA.

any other position, it is very natural that when pressed by the organ
in which it is enclosed, it should gradually, and without much diffi-
culty, reassume the situation it occupies when in its natural circum-
stances. When the womb contracts, if the foetal ovoid is well situ-
ated, it becomes compressed equally in every direction, but if, on
the contrary, it is in a deviated position, its extremities support
almost alone, the whole effort of the contraction, and but for the
shoulder, which is from its salient form apt to be arrested at the
strait, either the head or the breech would be almost always brought
to the strait.

For this consequence to fail taking place, which is almost impos-
sible, the middle of the child's body ought to correspond exactly Jo
the centre of the pelvis, so that, of its two extremities, one should not
be more disposed than the other to slide up towards the fundus, or
down to the orifice of the womb; besides, the difference of the shape
of the head and breech would render tliis equilibrium extremely
difficult. There is nothing very extraordinary, therefore, in the evo-
lution or spontaneous version of the child; it is quite a natural phe-
nomenon, easily explained by the action of the womb and its rela-
tions to the form of the ovum and fcetus. The mechanism of this
evolution explains why the anterior and posterior positions of the
trunk are so rare, and shoulder cases so common. If, when some
point on the dorsal or abdominal surface of the child offers at the
strait, the head of the pelvis are too far removed from it to be
brought back again, the pains never fail to act with a certain degree
of force upon the two extremities of the bis-acrimonial diameter,
which then becomes inclined, and one of the shoulders is soon com-
pelled to engage in the open part of the strait.

963. To conclude, from the above details I think it follows:

1st. That all those positions of the trunk that cannot be referred
to those of the shoulder, the back, or the anterior part of the thorax,
ought to be classed among the inclined positions of the head. 2d.
That shoulder presentations are, so to speak, the only ones that re-
quire particular attention, inasmuch as all others are naturally reduced
to them. 3d. That the child is never situated completely crosswise
in the womb, and that the most untoward positions may sometimes
be expected to be reduced to those that are most favorable. 4th.
That there are a good many cases, in which the interference of art
is any thing but indispensable, although the fcetus may present by
neither end of its great diameter.

964. The indications to be fulfilled in cases of faulty position of
the child necessarily vary according to a great variety of circum-
stances. Until the waters are discharged, nothing is to be done.

SPONTANEOUS EVOLUTION. 425

We should wail for the dilatation of the os uteri; if the uterus is
obliquely situated, we must endeavor to restore it to its natural at-
titude; should the head project over the hypogastric notch of the
pelvis, it should be pushed backwards over the edge of the strait;
when the fcstus is so movable that the head, the shoulder, or some
other part come to present successively at the orifice, it is proper, as
has been said, to rupture the membranes without waiting too long,
and choosing the exact moment when the head happens to be over
the strait.

But if the OS uteri is already sufficiently dilated, if the membranes
are already ruptured or on the point of giving way, it is important
to decide at once, whether or not the hand is to be carried into the
womb. Denman tells us that we may dispense with doing so in a
majority of cases, seeing that the womb, most generally, will bring
about the spontaneous evolution, and that if the child should really
come down doubled, its escape would not, on that account, be wholly
impossible. The French accoucheurs think, on the contrary, that
we ought to act immediately in all cases; for, say they, the longer
we wait the more will the womb contract, and the more difficult will
it become to enter it and eflect the turning.

The conduct of Denman in this case does not appear to me to be
of the very wisest; by imitating him, it is true, some foetuses that we
deliver by the feet might come away spontaneously, but many more
of them would fall victims to such an expectant mode of practice,
and which might be saved by operating in good time. As to de-
livering the fojtus double, it is manifest that it must be very difficult,
that it will most generally not lake place at all, and that the woman
will be exhausted with useless efforts, and may lose her life; that
even under the most favorable conditions of this kind, the child gene-
rally dies long before it is born, at least if we may judge from
Denman's own cases, since out of thirty of them only one was bora
living.

Thus, although spontaneous evolution may lake place, and rigo-
rously speaking, some women may be delivered without it, it is
nevertheless more conformable to the dictates of prudence and hu-
manity to turn the child, or apply the forceps. To this rule an ex-
ception should be made of those cases where the shoulder is not
fully engaged, those where the vertex or the pelvis is near enough
to the orifice to allow us to rely upon a fortunate transmutation, and
lastly, those where the introduction of the hand is so difficult that it
would not be more dangerous to wait than to proceed at once to the
operation.

37*

TABLE III.

•

^normal Presentatiom

' of the Foetus. — Tokological

' Operations.

Authors.

o ^

O O

12;

03

o

m

c

1

a,
o

ha

B

'H

3

1

"E.

O

Boer

6,555

126

68

58

—

38

39

10

Bland

1,897

36

18

5

—

—

9

9

10

Merriman

1,800

42

23

4

—

—

12

29

7

Madame Boivin. . . .

20,517

363

234

74

4

96

96

218

16

Madame Lachapelle. . .

22,243

492

203

103

9

118

76

174

12

M. Naegele. .....

415

15

—

4

—

2

15

3

1

M. Naegele

1,296

61

—

—

18

41

19

4

Total,

54,723

1135

546

248

13

234

287

491 60

427

CHAPTER VI.

Of Obstetric Operations.

ARTICLE I.

Of Turning.

965. The word turning, is, in tokology, applied to the act of
turning the child with the hand, and bringing one of the extremities
of its great diameter to the superior strait. There are two kinds
of turning; in one the head, and in the other the feet are brought
down first.

Hippocrates has a few words upon the subject of turning, but
only of version by the head. Celsus advises that the feet should be
drawn down where it is too difficult to get hold of the head, but he
dares not perform this manoeuvre except when the child is dead.
Aetius and Paul of Egina are the only ones among the ancients who
have applied the idea of Celsus to the living fcetus; although it is
mentioned in Wolf's Collection, and though Franco and Pare have
treated of it as a common practice, we must come down as late as
the time of Guillemeau before we can obtain any circumstantial de-
tails concerning it. Previously to the time of this last mentioned
author, all those practitioners who were either ignorant of, or refused
to adopt the operation of turning by the feet, were reduced to the
necessity of bringing away the child piece-meal from the womb,
after having allowed it to perish, or else to extract it with the crot-
chet or some other instrument in all cases where they thought it not
possible to bring the head to the strait. Besides, until then there
never had been any question about bringing down the feet, except
as a remedy for faulty positions, as positions of the body for exam-
ple. It is only since Guillemeau's day that it has been recommend-
ed to bring down the feet and make a complete version and delivery
of the child, in cases attended with some accident, the head being al-
ready at the strait.

428 DYSTOCIA.

SECTION 1.

Of Turning in general.

The necessity of acting with the hand to change the position of
the fcEtus or assist in its expulsion having been clearly ascertained,
it should be communicated to the relatives or friends of the woman,
and they should be informed of the dangers to which the child is
exposed. Provided the case be at all doubtful, or if the family have
not implicit confidence in him; if his age, or above all his reputation
do not place him beyond the reach of the envenomed shafts of envy,
it is well for the safety of all parties, that the accoucheur should
request a consultation with one or more of his brethren, best known
by their experience and knowledge.

966. As to the woman herself, she ought to be informed of the
advantages of the operation, and of the evils of retarding it or of not
performing it; but it is important that she should be kept in ignorance
of the risks the foetus is about to run, and the sufferings to which
she is exposed herself. These precautions being taken, we should
next think of what period of the labor we should choose for the ope-
ration; of the position most favorable for the woman and for the ac-
coucheur, then of the position of the child, and lastly, determine
which hand should be introduced.

967. The time for acting. As long as the membranes remain
whole, and the orifice undilated, we may wait: if the labor is diffi-
cult only in consequence of the faulty position of the child, and the
woman is in danger, it suffices that the orifice be soft and dilatable,
we may operate. In all cases where the membranes are ruptured,
there is not an instant to lose;* however, where the womb has been
for a long time contracted, where there are great irritation, heat,
fever, or any symptoms of inflammation, these epiphenomena ought
to be first combated by bleeding, baths, sedatives, ointment of bella-
donna, &c. according to circumstances.

* M. Velpeau says " in all cases where the membranes are ruptured there is
not an instant to lose" — Let not the young and inexperienced practitioner em-
brace tliis doctrine. — The rule is, that we may turn whenever we can do so with-
out violence to the os uteri. All prudent authors concur in opinion that it must
never he forced — gentle attempts to dilate, may be made from time to time —
but as to absolutely forcing open an undilated and rigid os uteri — the attempt
would be worthy of condemnation — Hence in fact, the operation must be deter-
mined by the judgment of the attendant — always using as his watch-word no
violence. — M.

TURNING. 429

Upon the whole, the most favorable moment for turning is jnst
when the membranes are whole and the os uteri completely dilated.
This period ought, therefore, always to be chosen if possible, and if
there be no counter indication present.

968. Position of the woman. Should it be necessary only to
bring back the head or buttocks, in case of deviated position of those
parts, to the superior strait, we might indeed leave the woman upon
her common bed; or in the situation she had occupied on her little
bed during the pains; but whenever it becomes necessary to seek
after the head or feet at some distance from the vulva, we ought to
act differently; however, the essential point on this subject is that
the vulva and perineum shall be completely at liberty, and that
nothing about the pelvis shall be left to interfere with the move-
ments of the accoucheur, and that the muscles shall not require to
be put in tension for the support of some other parts of the body.
Thus, she may be placed on her side, conformably to the precepts
of the English and American practitioners; on the edge or foot of
the bed; on the knees of some strong person; on a chair, a settee,
a table, or any piece of furniture suitably prepared for her. Upon
the whole, her attitude ought to be like that of a patient during the
operation of lithotomy.

969. At the Maternite at Paris, and the Strasburg Hospital, one
side of the lying-in-bed is placed against a wall; as soon as an ope-
ration becomes necessary, the woman places herself crosswise upon
it, with pillows under her head and shoulders, towards the wall;
the sacrum rests upon the free edge of the bed; an assistant is
placed on the outside of each leg, and charged with the duty of
keeping them separate, and the legs and thighs flexed, while a third
is prepared to hand any thing that may be wanted during the opera-
tion. If they can be disposed of, other assistants secure the pelvis,
and prevent those disorderly movements which the sufferings of the
woman sometimes deprive them of the power of controlling.

970. The same conduct may be followed in private practice, but
it appears to me better to slip the mattrass down so that the folded
edge may correspond to the foot of the sacking-bottom. The wo-
man is then in exactly the same condition as before, and the assis-
tants can more easily move round about her. It should be observed,
that many women are so courageous that it is not necessary to sup-
port either the legs or the head, and indeed, two chairs or two stools,
fixed so as to support the feet, might serve instead of assistants to
hold her legs, if assistants are wanting.

There is no fixed rule as to the height of the bed; but it is well
to pay some regard to the stature of the accoucheur, the degree of

430 DYSTOCIA.

inclination of the axes of the straits, and perhaps also to the stage
of the labor.

971. Position of the Accoucheur. If the bed be a low one, the
accoucheur may sit down or kneel upon the floor. Nevertheless, a
standing posture is unquestionably the best, and whenever there is
a necessity for using much power it should be preferred. The pre-
cept of Levret on this subject has long been forgot, which was thus:
" the accoucheur should stand up, with his legs separated at an
angle of forty-five degrees, one foot being placed forwards and the
other backwards; that he should have the spine bowed, and lean
with the hand that he does not operate with upon some solid sub-
stance."*

All this, says Roussel, may be called mechanics and geometry by
an operator who wishes to shed lustre on his art, but certain it is,
that a simple midwife, by relying upon her native dexterity, absolving
herself from the constraints of a prescribed position, and executing
all the motions that may be required by circumstances rather than
those demanded by the rule, will operate better than an accoucheur
no matter how gravely he may straddle his forty-five degrees.

972. Taking off the coat, rolling up the sleeves, and putting on
an apron has seemed too grotesque to many moderns, who think
that the woman might be frightened by so many preparations, &nd
they ought therefore to be dispensed with; people may declaim after
this sort as much as they please in the study, but by the lying-in
bed it is otherwise.

In fact it is not merely for fear of spoiling it that the accoucheur
ought to take off" his coat, but because, unless he does so, the move-
ments of his arms would not be free enough to permit him to ma-
nosuvre conveniently, and penetrate to the fundus of the womb. As
to the apron, it may doubtless be dispensed with: but what harm
can it do, and why is it more frightful here than in a surgeon making
his visits, or preparing for an operation?

Some cloths to put under the feet, some napkins to wipe his
hands and arms when they become soiled, warm water, Cologne-
water, some vinegar, and a little good wine, in case the woman

* If a woman lie upon her back for this operation, the practitioner has equal
access to the uterus with the right or left hand, the former of wliich is to be used
in occipito-posterior positions, and the latter in the occipito-anterior. If she lie
on the left side, the left hand is applicable for the occipito-anterior, and the right
for the occipito-posterior positions. But the right side is equally convenient if
we use the left hand for the occipito-posterior, and the right one for the occipito-
anterior position; it is of little consequence, therefore, which of the tliree atti-
tudes is taken by the patient.— 'M.

PRESENTATIONS OF THE FCETUS. 431

should be likely to be ill, are also necessary previously to con-
mencing the operation. Moreover, the condition of the fa3tus must
be attended to, its position ascertained, and the hand to be introduced
to be decided upon.

973. The christening or provisional baptism is only applicable to
a living child, and that, provided it be not a monster. Where there is
ground to fear that it is dead, we should say, " Child 1 baptise thee
&c. if thou art living;" and where there is reason to suspect it of
being a monster, we substitute for if thou art living, the words if
thou art ivorthy of being baptised. In order to baptise, some part
of the naked surface of the child should be touched, if not with the
fingers, at least with the water of christening, which it is sometimes
necessary to inject to a considerable distance.

This precaution, which, as is manifest, belongs to the dogmas of
religion, ought never to be neglected with persons who make of it
an article of faith. Whatever be his personal belief, the physician
ought to respect the opinion of the families he attends, whether
they agree with his own or not; and to me nothing seems more
blameworthy than those pragmatical practitioners who, under pre-
tence of reforming consciences, openly revolt against every custom
that does not square with their own way of thinking.

274. To ascertain the positson of the fcetus. The positions of
the head, the feet, the knees, and the breast, having been charac-
terised in the article on eutocia, I have now to attend only to those
of the trunk.

Presentations of the shoulder, whether frank or inclined, will, if
the arm have not come down, be ascertained by the rounded form
of the tumor in the orifice, by the presence of the clavicle, the
ribs, the scapula, and one side of the neck.

When the arm escapes first, it not only indicates that the shoul-
der is at the superior strait, but it also teaches us to which side of
the pelvis the vertex and also the face are turned. The thumb cor-
responds to the summit of the head, while the palm of the hand an-
swers to the abdominal surface. However, it is important to kftow,
that instead of being in a state of supination, or even of slight pro-
nation, the hand and the whole limb may be twisted in a contrary
direction, and especially into forced pronation; so that previously
to giving a definitive judgment, it is best to slip some of the fingers
into the vagina, along the cubital edge of the arm, as far as the arm-
pit so as to make sure of its relative situation.
. If the back should stop at the centre of the strait, the range of
the vertebral spines and the ribs would suffice to point it out. The
absence of ribs in the lumbar region, or on the one hand the hips,

432 DYSTOCIA.

and on the other the scapulae and back part of the neck, might
serve to show which way the head is directed.

The sternum, the ribs and clavicles, above which we can also
sometimes feel the front of the neck, indicate presentations of the
anterior face of the thorax.

Where the os uteri is largely dilated and the membranes ruptured,
and the presenting part is not too high up in the pelvis, and has not
had time to swell and alter its shape under the influence of the ute-
rine contractions, it is in general prettj' easy to distinguish the differ-
ent positions of the trunk from each other; it is at least always pos-
sible to avoid confounding them with those of the head or pelvis;
but in the contrary circumstances the most consummate experience
is sometimes deceived, and it is often impossible to establish a cer-
tain diagnosis until after having carried the hand into the womb.

975. Choice of the hand. Where the bag of waters is still un-
broken, or the foetus retains a considerable degree of mobility, it is
useless to delay about the choich of a hand to operate with: the one
that is most easily used is to be introduced, or the one which habi-
tually brings down the child in the least unfavorable position;
where the position has not been ascertained, or is merely a matter
of doubt, the practitioner ought to act in the same manner, or may
make use of the hand commonly employed in operating for those
positions most frequently met with; if, however, there should occur
any difficulty after reaching the womb; it is best to withdraw it and
introduce the other hand.

In cases where the presentation is well determined, we may
know at once which hand is most favorable to the success of the
operation; this is moreover liable to vary according to the kind of
manosuvre about to be executed, or which it is indispensably neces-
sary to attempt,

976. For those inclined positions of the head and breech which
do not require immediate version by the feet, the left hand ought to
be preferred. Whenever the deviated parts correspond to some
portion of the right half of the pelvis; the right hand, on the con-
trary, in the opposite deviations, and either of them, indifferently, if
the deviation takes place directly front or back. The cephalic ver-
sion ought to be subjected to the same rule of practice.

977. For the feet, knees, or breech, those positions in which the
posterior surface of the foetus looks towards the left side of the pel-
vis, are best operated on with the left hand, and the inverse posi-
tions with the right hand, although it may be most frequently in our
power to do just the contrary if we please.

978. When the vertex presents first and we have to bring down the

TURNING, CHOICE OF THE HAND. 433

feet, the left hand is most suitable, in left occipito-pelvic positions,
that is, the first and fifth of Baudelocque. (First and fourth of Mx\I.
Maygrier, Capuron, Duges, &c; first, fourth, and fifth of Madame
Lachapelle; left-occipito-acetabular, and right fronto-acetabular of
]M. Gardien.) The right hand, rigorously speaking, is only for the
diametrically opposite positions; but as it terminates a labor in the
first position of the feet, as it is more handy from customary use,
and as it manosuvres as well as the other in median positions, it
ought to be selected for all the right and antero-posterior positions.

979. In shoulder presentations we may lay it down as a general
rule, that the left side requires the use of the left hand, and that
the right hand should operate in the positions of the right shoulder.

980. Lastly, we ought to make use of the right hand in presen-
tations of the sternum, or back, whenever the head is not turned to
the left, and of the left hand in the opposite case.

981. These general rules appear to me to be simple, applicable
to all cases, and easy to be understood. Baudelocque, Madame
Lachapelle, M. Duges, M. Desormeaux, and very recently, M.
Major, of Lausanne, also, have advised us to introduce that hand
which, when in a state of serni-pronation, will have the palm turned
towards the front of the child, and the fingers toivards its lower ex-
tremities; but this rule is too vague, and liable to too many excep-
tions for it to be used in practice. It is not perfectly exact, either
in positions of the pelvis, or those of the back or shoulder, and in
positions of the head and sternum it is only suitable in the first stage
of the operation.

Those who have recommended the introduction of the hand that
is naturally turned towards the side of the pelvis where the feet are
situated, did not observe that it most commonly happens, even in
shoulder positions, that the feet remain up towards the fundus of the
womb, without being sensibly inclined to one side more than to the
other; neither did they remark that precisely the contrary rule is
followed where the pelvis presents first.

When M. Gardien says that the right hand is required in all
those cases where the feet are to be brought down in the first, and
the left where they are to be brought down in the second position,
he has approached nearer to the truth, although his assertion is not
correct either, except for positions of the head and trunk; but he has
rather expressed a fact than endeavored to lay down a rule, which,
however, naturally follows from the principles that I have indicated
above.

Dr. Breen advises us always to use the left hand, inasmuch, says
he, as the right is infinitely more commodious in assisting the action
38

434 DYSTOCIA.

of the other in pressing upon the hypogastrium. M. Major thinks
that we can mancEUvre with the same hand in all kinds of positions,
but always in conformity to the rule indicated above. For this end
we have only to vary the posture of the woman, to place her on one
side or the other, or on the back or abdomen, accordingly as the
abdominal surface of the foetus, for example, looks to the right, to the
left, in front, or to the rear; but I do not see what advantage such a
course can have over the one generally pursued in France.

983. Now the hand being chosen, in order to let it slip easily
through the passages, render its introduction easy, and guard against
the infection of contagious diseases, we should cover it with some
fatty or mucilaginous substance. It may be immersed in oil or
mucilage, greased with butter, lard, or the white of eggs, &c. may
be used: whichever of these substances is selected, it seems to me
right always to follow the counsel of Roederer, that is to say, only
to anoint the back of the fingers and hand, which alone exert
any friction upon the parts of the mother, while the other surface
of the hand has to do only with bodies that are already but too
slippery. The forearm ought also to be greased as far as its upper
end: if the part of the child we are to pull by were at the vulva,
or not high up in the vagina, this precaution might be rather injurious
than useful, and the hand should be applied quite dry.

SECTION 2.

Version by the Head.

983. Long imbued with the idea that the positions of the head
were the only ones which admitted of a fortunate delivery, physi-
cians only thought, in the first place, of restoring that part to the
straits, when the child presented otherwise than by the head: the
precept of Hippocrates was followed, and they endeavored to bring
down the head not only in positions of the shoulder and other
regions of the trunk, but also in those of the breech, knees, and
even of the feet themselves, which were then looked upon as very
dangerous. Celsus showed that the foetus might escape with its
lower extremities foremost; but version by the head was not the less
regarded as the safest and most practicable process, until the time
of Franco and A. Pare. Since the time of Guillemeau, on the
contrary, it has been almost wholly abandoned, and at present the
standard authors scarcely mention it, except for the purpose of con-
demning it. Notwithstanding what a few modern authors have said
about it, no person in France has felt it a duty to put it in practice.

TURNING. 435

The objections urged against it are the difRculty of its execution,
the sraalhiess of the hold afforded by tlie head to the hand that at-
tempts to seize it, and the impossibility of bringing it back to the
strait, where the womb is ever so slightly contracted upon the
child; that even in the most favorable cases, where turning is once
effected the hand cannot assist in the delivery, which must be left
to the powers of nature unless recourse be had to the forceps ;
"whereas, by acting upon the feet, it is an easy matter to extract the
foetus without employing any instrument but the hand that brought
them down. Lastly, that as delivery by the pelvic extremity is
almost as natural as by the head, it is evidently preferable to turn
and deliver by the feet; and that it is the only method that ought to
be attempted where it becomes proper to change the position of the
child.

984. To the above, I answer; 1. That it is not always very difficult
to take hold of the head while it is in the womb, not to exert a con-
siderable degree of power on it where that may be required; 2. That
unless the waters have been long discharged, we may often succeed,
without much difficulty, in laying hold of the occiput, and bringing
it down to the strait, no matter how far it may have been removed
therefrom; 3. That in this operation we have not so much to catch
hold on the head and compel it to descend, as to push up the part
that has engaged in its place; 4. That far from being a simple and
desirable case, a delivery by the pelvis, on the contrary, exposes the
child to the greatest danger, while that by the vertex, even when
assisted by the forceps, is rarely dangerous. M. Flamant seems to
have been the first to introduce it in our day; notwithstanding what
Osiander says about it, who has attempted to divide the credit of it.
In fact, the German professor did not describe it until 1799, whereas
it was taught at Strasburgh in 1798; since that time much attention
has been paid to it in the north of Europe, and MM. Labbe, Eckard,
Wigand, Schnaubert, Siebold, d'Outrepont, M. Wenzel, Busch,
Carus, Ritgen, Schweighaeuser, Toussaint, Vallee, Deroche, and
Ubersant, have expressed themselves more or less at length upon
turning by the head, and endeavored to diffuse the principles laid
down by professor Flamant.

Cephalic version may, therefore, be attempted, 1. In a well formed
pelvis, where no other accident has happened except the vicious
position of the foetus, and the head is found in an inclined position
in the vicinity of the strait; 2. In presentations of the shoulder, back,
or anterior part of the thorax, provided the arm is not prolapsed, and
the uterus not too much contracted. Lastly, it seems prudent to
try it whenever the feet are farther removed from the strait than the

436 DYSTOCIA.

head is, and where it is probable that the labor would terminate
spontaneously if the head were at the strait. Moreover, after having
attempted to perform it in vain, we are not prevented from still pro-
(;eeding in search of the feet, which can be as readily found after
as before the attempt has been made: if the head seems disposed to
come down, we may endeavor to bring it down; if not, we have
only to direct the hand towards the feet. I do not think, however,
that this kind of turning ought to be preferred in the inclined posi-
tions of the pelvis, nor, a fortiori, where the breech presents fairly.
MM. Flamant and Schweighaeuser wish it to be preferred in all
cases, even where there are accidents on the part of the mother, be-
cause, when the head is once brought to the strait, it can be laid hold
of with the forceps. Perhaps they might be imitated with advantage
in some cases where the fcBtus is very movable in the uterus; but I
doubt if it be possible where the waters are gone off, and the womb
strongly contracted on the child.

985. Thus, the woman being placed as has been directed, the left
hand is introduced if the head is to the right, and the right hand, on
the contrary, if to the left; and either one or the other almost indif-
ferently, if the vertex is turned in front or directly behind.

In the first place, the part that is engaged is to be pushed up-
wards; we should try to remove it from the strait, snd direct it to-
wards the iliac fossa that is opposite to the one occupied by the
vertex; in this way the womb is enabled to exert its power on the
head and return it to the centre of the pelvis. After having thus
raised up the shoulder, if the head does not descend, it must be
sought for with the hand, and taken hold of with all the fingers,
which draw it down as with a crotchet, and at the same time en-
deavor to make it assume, in preference, one of the occipito-anterior
positions. When the head has been brought to the centre of the
pelvic circle, it is left there, and the delivery requires no further as-
sistance, provided there be no other accident in the case; if the con-
trary should happen, the forceps should be immediately substituted
for the hand.

Wigand, in speaking of cephalic version, says that we may often
succeed in operating without introducing the hand into the genital
organs; he thinks that by acting upon the womb through the abdo-
minal parietes, and assisting it by the posture of the woman, we may
most commonly bring back the head to the superior strait. Before
I was acquainted with the doctrine of the German professor, I had
already followed this precept, and have in conforming to it found
.that it is, in fact, sometimes possible to restore to the vertex its na-
tural position; but I do not think that this manceuvre can ever be of

TURNING. 437

much use where the waters have been long discharged, and the womb
strongly contracted on the child.

SECTION 3.
Of Thrning by the Feet or Pelvis.

The mancHuvre in turning by the feet consists of three principal
stages. It is necessary, 1. To introduce the hand; 2. To change
the position of the child; 3. To assist in the expulsion of the ovum.

These three stages are never found together in turning by the
head, where, as has been already seen, the action of the hand is of
no further use after the head has been properly placed at the supe-
rior strait; in some of the feet positions the manoeuvre is almost
wholly confined to the stage of extraction.

986. Introduction of the hand. Many authors advice us to pene-
trate into the vagina at the very moment of a strong uterine contrac-
tion; in this way, say they, the pain produced by the operation be-
comes confounded with the pain of the contraction, and the woman
does not distinguish them apart; then also the vagina is both enlarg-
ed and shortened by the temporary descent of the womb, which in
some sense comes down to meet the hand. In theory these asser-
tions may be very correct; but in practice they certainly do not au-
thorise the precept which it has been attempted to draw from it, and,
like M. Desormeaux, I think, from my own experience, that the
hand should generally be passed through the vulva in the intervals
between the pains.

Whatever mode be adopted on this point, the fingers being placed
side by side, must first be introduced in the direction of the length
of the vulva; after which they are brought together in such a way,
that their palmar surface forms a kind of gutter, in which the thumb
is lodged, so that the whole may form a very long cone, the base of
which is found at the place of the metacarpo-phalangial articulations.
The hand thus gets into the vaginal cavity, following the direction
of the axis of the inferior strait.

987. In order to penetrate through the os uteri, it is absolutely ne-
cessary to choose a time when the pain is off, so much so, that no-
body has ever dared to prescribe the contrary. Otherwise, in-
deed, it would often be impossible to get into the uterus; there would
be a risk of lacerating the orifice; in fine, it would be voluntarily to
create a thousand difficulties, and to expose the woman to numerous
dangers.

If the dilatation is very much advanced, the fingers, which are at

38*

438 DYSTOCIA.

first held together, should be almost immediately more or less sepa-
rated, so as to accommodate them to the form of the part that pre-
sents, and allow them to slip easily between it and the parietes of
the womb. In the contrary case, they are to be introduced one after
the other, and the cone formed by their junction is soon reproduced.
They are then gently passed onwards, taking care to stop upon the
recurrence of each pain, and always move in the axis of the supe-
rior strait. Here it is above all important not to be in a hurry: for
the movements and the efforts require the greatest gentleness; in-
stead of pressing forwards to dilate the os uteri, it is sometirhes bet-
ter to separate the base of the fingers moderately and by degrees, or
at least the portion of the cone already introduced into the orifice.
During this manoeuvre the other hand should be applied to the pa-
tient's hypogastrium, for the purpose of supporting the uterus, and
inclining it backwards or to one side if necessary. As soon as the
roots of the fingers have passed through the os uteri, the whole
hand enters without difficulty into the uterine cavity, and thenceforth
the intromission is effected.

988. Period of exploration. Before proceeding any farther the
state of the case must be ascertained; we must be sure not to be
deceived as to the position of the foetus, not to confound the arms
with the legs, to see if any part is twisted out of its proper position,
and endeavor to learn where are the feet or breech after having first
recognised the head. Then, to get hold of the child for the pur-
pose of extracting it or changing its position, it is essential to re-
mark, that several points of its body could not bear the degree of
pressure which it is sometimes found to be necessary to exert. For
example, we ought to avoid pressing the ends of the fingers upon the
sutures, the fontanels, the abdomen, and sides of the thorax; for the
purpose of pushing up, turning, or extracting the foetus, we ought to
apply the hand only to the forehead, the occiput, the temples, the
parietal bones, the shoulders, the spine, the sternum, the hips and the
limbs.

989. Mutation. After having ascertained the part that presents,
it is pushed up to free the superior strait, taking care to apply the
fingers to a surface as extensive as possible; then the feet should be
sought for, seized and brought to the orifice. The fostus must never
be brought down otherwise than in conformity to its natural flexures;
that is to say, it must be rolled up, on its anterior surface. By turn-
ing it over backwards, it would necessarily be brought in the direc-
tion of its extension; it would soon become an inflexible trunk, or
arc of a circle, which most generally would render the remainder of
the operation impossible; the uterine cavity would not be sufficiently

TURNING. 439

spacious to admit of the evolution, and the least force would hazard
the luxation or fracture of the limbs, the rupture of the spinal mar-
row, and would give rise to extremely severe pains on the part of
the woman, and perhaps even to lacerations of the uterus.

Whilst engaged in exploring, and turning the child, it is not less
essential to support the womb outwardly than it is during the time
of intromission. The hand that is held applied to the hypogastrium
may aid also by suitable pressure in causing the head, the shoulder,
or the limbs to descend, which renders the turning in all respects
easier aud surer; but for this precaution, the accoucheur would be
liable, when compelled to exert a certain degree of force, and par-
ticularly where the liquor amnii has been long discharged, to pro-
duce dangerous stretchings, to separate the vagina from the cervix, to
rupture the womb itself at some weak part, or at those points where
the womb is most strongly contracted on the projecting and solid
parts of the fostus.

These mancBuvres ought always to be executed in the intervals
between the pains; they would be excessively dangerous if performed
during the contractions, and would generally occasion fatal lacera-
tions to take place; besides, it is often impossible at those times to
move the foetus; the hand soon becomes so compressed that it is
quickly benumbed, and completely loses all its powers of sensation
and motion; as soon, therefore, as a pain appears, all exertion is to
be suspended; it should not be begun again until the contraction has
ceased, unless, however, some serious circumstance necessitates a
very prompt termination of the labor.

I ought, also, to warn the young practitioner, that in order to reach
the fundus of the womb, the arm must be introduced much farther
than he would at first suppose, and that to get into the axis of the
superior strait, the hand should be much more inclined forwards
than would be imagined upon the inspection of a dried pelvis.

Most accoucheurs have recommended and still advise that the feet
should be seized, and not any other part of the limbs; in fine, the
feet are the only parts by which we are advised to pull, in the kind
of turning under consideration. Nevertheless, it is possible, it is in
many cases even advantageous, to follow the counsel given first by
Burton, reproduced by Delpech, and very recently again by Dr.
Breen — that is, to take hold of the knees* or hams, rather than the
feet.

* It is quite as well to turn by the hams as by the feet — I, at least, have found
it so. It should be remarked, that where any considerable difficulty is expe-
rienced in the exploration for both feet, it is perfectly safe to draw down only
one, the turning is easily effected and the foetus is actually safer, because if only

440 DYSTOCIA.

990. Extraction. When the mutation has been completed, and
the child reduced to one of the positions of the extremities of its
great diameter, we may stop, provided the pelvis be well formed and
the womb retains sufficient energy to terminate the rest of the labor.
This is the way we are compelled to act in all cases of version by
the head, unless we choose to apply the forceps; but when the feet
are brought down, ought they also to be abandoned after they are
placed in a situation which no longer prevents the spontaneous de-
livery of the child? To authorise this advice it has been supposed:
1. That pulling on the child ought always to be avoided when not
absolutely necessary; 2. That tractions force the arms to rise along
side of the head, which prevents its advance, and that they almost
always place the occipito-frontal or occipito-mental diameters in the
situation that ought to be occupied by the occipito-bregmatic; 3.
That in rapidly passing through the os uteri, the belly and breast of
the fcEtus are subjected to too sudden a compression; 4. Lastly, that
the womb, being too suddenly emptied, may become inverted, fall
into inertia, and give rise to hemorrhage, &lc. All these inconve-
niences are real, and nothing would be so easy as to enlarge the list:
but on the other hand, it should not be overlooked that the woman
submitted to the operation only for the hope of being soon delivered;
that her family and attendants cannot be satisfied until the child is
completely expelled; that, in case of abundant hemorrhage, of syn-
cope, of lypolhymia, convulsions, premature descent of the cord and
exhaustion, we have no right to wait; that inertia ought rarely to
occur in such circumstances, seeing that the manosuvre is better cal-
culated to remedy than produce it; that the compression of the ab-
domen, when the hand has been previously introduced into the
womb, ought not to inspire any great alarm; that, at least, it is scarcely
more to be feared where we draw the foetus down by the hand, than
where it is simply pushed down by the efforts of the mother; lastly,
that it is possible to avoid one extreme without falling into another,
and that, it is as dangerous, in the practice of midwifery, not to act
apropos, as to do so without any necessity.

A well informed and prudent man will therefore preserve a just
medium, and proportion his manoeuvre to the circumstances of each
particular case. If not pressed by any important circumstance, he
will wait, and excite the uterine actions so as to draw the child down-
wards concurrently with them, for the two actions ought to be so

one foot is employed for the mutation and extraction, the other one is folded up,
on the child's body, which makes of the case a sort of breech presentation. The
head is extracted more easily the greater the dilatation of the parts effected be-
fore the head comes to the opening. I speak from experience. — M.

TURNING. 441

combined as to constitute, as it were, but one; at each pain the
womb ought to commence before the hand, and finish after it. By
pursuing this course we imitate a spontaneous delivery; the arms
sometimes descend before the head, which continues bent down upon
the breast, and the occipito-bregmatic diameter does not lose its
natural relation to the straits of the pelvis; it is in no case indispen-
sably necessary to pull hard enough to rupture the spinal marrow
or detruncate the foetus. If, on the contrary, there should be no
other chance of safety either for the mother or the child, than in a
prompt delivery, and should the contractions of the womb be too slow
and feeble to admit of his relying upon them, the tractions performed
by the accoucheur ought not only to assist, but they should more or
less become the substitutes of the powers of the woman: there can
be no hesitation in such a case; of two unavoidable evils we must
choose the least. I need not repeat that in the former as well as
in the latter case the tractions ought to be performed with great cau-
tion; never by jerks, and always in the axis of the straits.

To conclude, extraction may be considered under two principal
points of view: 1. As a mere accessory power added to that of the
womb, and which hastens the termination of a painful function;
2. As a principal, or even sole resource, in cases where the organism
is powerless, or where it is of importance to empty the uterus within
a few minutes. This distinction being once established, I do not see
how any discussion can afterwards arise as to whether the child may
or may not be pulled downwards after it has been turned. As long
as the tractions are confined to the part first assigned to them, it is
evident they can be only of service, and no well informed man will
ever make use of them in the other way without a clearly understood
necessity for so doing.

§. I. Of BriBi^lii^ DoiFn the Feet iv'heii the
Head is at the Orilice.

Relatively to turning by the feet, the positions of the head ought to
be reduced to two: the left occipito-iliac, to which we bring the first
and fifth of Baudelocque; and the right occipito-iliac, which com-
prises the second and fourth of the same author, to which also we
ought to bring the occipito and fronto-pubic positions, should they
be met with.

991. The first of these requires the left hand, and the right hand
is preferable for the second.

A. Left Occipito-iliac Positions.

992. The left hand enters the vagina in a state of pronation,

442 DYSTOCIA.

passes along the anterior face of the sacrum, penetrates into the
orifice, and if the occiput is turned directly to the left, remains in a
state of semi-pronation, approaches a state of supination if the ver-
tex is in the first position, but must be held quite prone if the ver-
tex is turned backwards and to the left, &c. The head is to be taken
hold of and held in the hand, and not merely with the points of the
fingers. The thumb is placed on the right temple, or parietal pro-
tuberance, and the other fingers, being more or less separated, are
applied to the face and opposite temple.

At first this part is thrust upv/ards and along the axis of the supe-
rior strait, that is to say, upwards and forwards; it is afterwards re-
jected towards the left iliac fossa, taking care to favor this movement,
with the right hand, which, being placed upon the hypogastrium,
sustains the fundus of the womb, and inclines it more or less back-
wards and to the right.

993. Now is the time to go in search of the feet; for this end the
hand may pass along the anterior surface of the child, and arrive di-
rectly at the knees, or at the roots of the thighs; this is the shortest
route; but by following it we are liable to several errors, in short
to mistake the elbow for the knee, the foot for the hand, the arms
for the legs, and the safest way is to act in the following manner:
we begin by extending all the fingers, and the thumb also, towards
the left side of the head; they ought to be placed side by side, and
extended in order to occupy the least possible space; they are then
passed over the whole of the left lateral surface of the child, by
sliding along behind the neck, the shoulder, the breast, the flank and
the hip; during all this time the anterior part of the wrist supports
the forehead and prevents it from descending again into the strait; the
other hand pushes the womb backwards as much as necessary or
possible, and endeavors to bring the parts we are trying to get hold
of as near as possible to the fingers.

994. If the legs are in their natural state of flexion, we endeavor
to carry the whole hand, flattened, above and behind the breast,
turning it more and more into a state of pronation as we proceed;
if they are on the contrary turned out of the way or displaced from
their natural positions, if it appears too difficult to envelop their
posterior surface in the palm of the hand, we should take hold of
both of them if possible, or at least that one which is nearest the
posterior surface of the womb, embracing their root with the thumb
which is fixed in the groin, and with the fingers whicli are kept
upon the posterior surface of the thighs. Should they be twisted
or crossed; should one of them be found flexed, and the other ex-
lended; finally, if we have attempted in vain to get hold of them

TURNING. 443

both together, and should be obliged to bring them down one after
the other, we should at all events carefully try to bring down the pos-
terior limb first, even although it should be the most distant one from
the orifice.

995. In the first case, to continue the operation, the hand has
only to slip along behind the thighs and legs, which it pushes before
it, extending them as they come down; in this way the feet can
neither escape nor deviate, and may be conducted without difficulty
to the superior strait.

In the second case, more difficulty is generally met with; we are
sometimes obliged to act successively on the thigh and leg as if they
were levers of the first kind; while we are searching for one foot
the other escapes, and it is always a difficult matter to draw them
both down together, unless we have been so fortunate as to get hold
of the hams with the fingers and thumb at the commencement of the
search.

In the third case, that is to say, when the limbs are far removed
from their natural attitude, and always when we are obliged to bring
them down one after the other, we act as we best can; only we
should, while pulling at the leg first got hold of, endeavor to make
it approach the opposite limb; by abducting it, which is naturally a
very limited motion, and which would expose the child to the risk
of luxations or fractures, we should also have the disadvantage of
fatiguing the uterus far more than by following an addnctive move-
ment for its free exercise, also, the last named movement requires
much less space than the other.

996. However it may be, when one of the feet has reached the
vagina or the vulva, it should be secured by means of a fillet pre-
viously to going in search of the other; not with a view of hindering
it from mounting upwards again, as some of the ancient authors
imagined, but only that it may be found again, when wanted. This
precaution being taken, the left hand is again carried into the womb;
and that it may more readily reach the other foot, it should follow
along the inner and posterior surface of the one held in the fillet;
by conforming to this rule we necessarily meet with the crease of
the breech and sexual organs, the thigh we are in search of cannot
now be mistaken, and we thus avoid a good deal of tiresome feeling
after an object. It ought to be well understood that this foot is
to be brought down in adduction, by following the anterior surface
of the foetus, and the side of the other leg.

After having succeeded, in any way, in extending the legs, and
bringing them down into the excavation, we place the index between
them above the inner ankles, while the thumb and the other fingers

444 DYSTOCIA.

are applied to their outer surfaces, and in such a way that the heels
lodge in the palm of the hand. If the head, forced down by the
womb, or ill supported by the wrist, should have approached too
near the orifice, we should, before we pull the feet down, and with-
out letting them go, push it up again towards the left iliac fossa
with the thenar.

997. The first object of the tractions now to be performed, is to
turn the child, to compel the head to rise up towards the fundus of
the womb, whilst the pelvis is drawn into the superior strait, and to
convert one of the left positions of the vertex into one of the right
positions of the feet; that this mutation may yield all the advan-
tages we are authorised to expect from it, the back of the child
must always turn to the right, then a little in front, but never back-
wards. Consequently, the operator will carefully avoid inclining
the hand in supination, after he has begun to pull on the legs; he
should keep it in serai-pronation, to reduce to the second position of
Baudelocque; and even if that should not suffice, he ought to try to
get the right foot, which is in front, with the right hand, and draw
down solely, or almost solely, by it, until the tendency of the back
to direct itself backwards shall have been overcome.

998. As soon as both of the feet have passed through the vulva,
they should be wrapped in a dry cloth so that they may be held
more firmly. The hips soon pass through the orifice, and present
at the inferior strait. As the limbs come forth, the hands, which
are applied, the right one in front and the left one behind, ought
to extend along them towards the vulva, so as to hold them by as
large a surface as possible; the thumbs are therefore placed behind;
the two last fingers on the anterior surface, and the index and medius
extended on the outside of each leg. or each thigh, until the hips
shall have been born.

999. Before proceeding any further, it is proper to attend to
the umbilical cord, to see that it be not stretched, by carrying the
index and the thumb, or two other fingers of the right hand, towards
its insertion on the belly of the child. If it should be found tense,
a loop of it of sufficient length should be brought down by pulling
the placental portion, but never by pulling its abdominal portion; if
it is found not to be stretched any about the navel it may be let
alone; if it should proceed from the navel down betwixt the thighs
and then mount up along the child's back, so that the circulation
should appear to suff"er, it ought to be disengaged, and even divided,
should the danger appear to be pressing, and no other means of
disengaging the limbs be discoverable; but after that the labor ought
to be terminated within a very few minutes.

TURNING. 445

1000. We continue the tractions obliquely downwards and back-
wards, that is to say, in the axis of the superior strait. As the
hips are disengaged they are in turn taken hold of, the left or pos-
terior one with the left hand, and vice versa, but in such a way
that the fingers are not applied higher up than the cristse of the
ilia, so as to avoid pressing upon the abdominal viscera. The belly
and the breast soon follow; this is the time that the arms rise up-
wards, that the shoulders engage, and that it is essentially important
to combine the efforts of the accoucheur with those of the woman,
in order to avoid a departure of tlie chin from the breast. What-
ever resistance may be met with in engaging the shoulders in the
excavation, we ought never to imitate those routine practitioners,
who, while they are pulling tiie child downwards, can never think of
any thing better than to make it revolve on its axis, or make its
whole body perform a more or less extensive movement of circum-
duction; neither should we move it alternately from the internal
surface of one thigh to that of the other, nor raise and depress it by
turns from sacrum to pubis and vice verso; such manosuvres could
not do any good, and would stretch the dorsal or cervical portions
of the spine too dangerously; when it is found insufficient to draw
downwards in the direction of the straits, it may be barely proper
to try the effect of diagonal tractions, that is to say, we may pull
downwards towards that oblique diameter, which at the superior
strait corresponds to the greatest diameter of the shoulders. In the
first place, while continuing to pull gently, we raise up the child's
pelvis, as if we intended to carry it towards the mother's left groin;
it is then depressed towards the right sacro-sciatic notch; afterwards
we continue to raise and depress it, until the shoulders, which in this
way engage one after the other, and receive the greatest part of the
force employed, are near enough to the inferior strait to be easily
got hold of; when the child has advanced thus far, we must attend
to the extraction of the arms.

1001. When the child is small or the pelvis very large, the pre-
sence of the arms offers but a small obstacle to the escape of the
head, and we ought, properly, to abstain from disengaging them ;
but, in all other cases, they could not fail to embarrass the rest of
the operation, and prudence, if not an indispensable necessity, re-
quires that they should be brought down. Some authors have said,
that when applied alongside of the neck, they facilitate the passage
of the head, the dilatation of the vulva, that they obviate the contrac-
tion of the uterine circle, and the strangulation of the foetus, and that
they are never so large as to prevent the delivery from taking place;
but as this opinion is not founded on any plausible reason, it does no

39

446 DYSTOCIA.

deserve the trouble of being opposed, and at present no one follows
the practice.

The member nearest the sacrum must always be extracted first;
should we begin with the other, we should meet with great difficulty,
and when we had succeeded, the other arm would not be found to be
at all more free.

1002. The trunk, which should always be wrapped up in a cloth,
is supported by the right hand, as it is performing the oblique trac-
tions. The left thumb, in a state of pronation, is placed in the hol-
low of the corresponding axilla, while the index and medius are
applied to the outer and anterior surfaces of the arm, as far as the
bend of the elbow, as if to form a tackle for the humerus. We
then act upon the whole arm as upon a lever of the third kind; the
thumb represents the fulcrum, the fingers the power, and the re-
sistance is found in the forearm of the child. While we are thus
acting on the arm to bring it down, it must be carried in the direc-
tion of adduction, so that as it sinks down it may slide over the fore
part of the breast. If we should be content with hooking it with
one or two fingers, we would run a risk of fracturing the bone, or at
least of exerting the force only upon the shoulder-joint. When
the whole shoulder is much elevated, it is sometimes found advan-
tageous to follow the advice of Baudelocque, which has been re-
peated by almost all the accoucheurs of our own day, namely, to
divide this little operation into two stages, to put the hand, at first
in pronation, so that the thumb may for an instant take the place of
the other fingers, and operate in succession upon the whole limb,
beginning at the root of it; but this precaution is most frequently un-
necessary, and I have had no occasion to repent of having generally
neglected it.

The arm having been brought down, it is to be extended along the
side of the thorax; the right hand deposits the trunk of the child in
the left hand, and then proceeds to disengage the anterior or sub-pubal
member, according to the method indicated above.

1003. Instead of following their natural tendency to rise up along-
side of the head, the arms are sometimes turned backwards, and
that in two different ways: 1. One of them, or both, but generally
only one, and especially the one that ought to be found in front, is
fixed behind the neck, so as to arrest the progress of the occiput;
2. Previously to rising upwards, or even while in the act of rising,
they get behind, and cross each other upon the back, below the
shoulders, which may occasion their being luxated, or even frac-
tured, and greatly increase (he difficulties of the manoeuvre, provided
it be not remedied in good time.

TURNING. 447

In the first case, we commence by disengaging the arm that is not
deviated; we then push the trunk up a little, so as to compel the head
to rise, and as far as possible to diminish the pressure upon the
other arm; after which the fingers and the thumb ought to be ap-
plied as has been already directed, and act upon the same principles,
but with rather more gentleness. If the arm resists, we attempt to
make it rise up above the occiput, and the blunt-hook proposed by
M. Dubois ought not to be employed until all other attempts shall
have proved to be insufficient.

In the second, even although the forearm should have passed
quite across to the opposite side, as seems to have happened in a
case under the care of M. Duges, and even though it should have
risen as high as the nucha, it ought always to be hooked with the
middle and fore finger to draw it down along the child's back, and
bring it out of the vulva; it is generally pretty easy to succeed in this
manoeuvre, but the breast has sometimes to be pushed strongly up,
or the trunk more or less considerably rotated, before it can be ef-
fected.

1004. Should the exertions of the accoucheur have been well
seconded by the contractions of the womb, the head ought now to
have descended into the excavation, or at least be considerably en-
gaged within the superior strait, so that the occipito-bregmatic and
bi-parietal diameters would be found to be in proper relation to the
oblique diameters of the pelvic circle.

In that case, the right hand, passing along the front of the breast
and throat, penetrates in a flattened and half-supine position quite
into the vagina; the thumb and two last fingers are placed on the
sides of ihe throat, the index and medius should be directed on to
the chin, or in the mouth, or what is still better, on each side of the
nose, for the purpose of keeping the head in its natural stale of flex-
ion, and approximate the facial extremity of the occipito-mental di-
ameter as much as possible to the sternum; after having placed the
right hand properly, the foetus is to be laid on its belly upon the an-
terior surface of the corresponding arm, which is then much depress-
ed towards the perineum, without, however, pulling, for the object
at that moment is merely to disengage the vertex from the pubic
arch. In the next place, two or three of the first fingers of the left
hand are to be carried under the occiput, to sustain it, and prevent it
from engaging before the chin; the thumb, the other fingers, and the
rest of this hand are applied naturally behind the neck, and we at-
tempt to push the head upwards in the axis of the superior strait, so
as to cause it more easily to perform its pivot-motion.

When we have succeeded in getting the face into the hollow of

448 DYSTOCIA.

the sacrum and the occiput beliind the symphysis, we should wait
for a pain; the woman should be told to bear dowii, and the two
hands being fixed as has been seated, we immediately begin to exert
some tractive force on the head, which is gradually drawn down in
the axis of the straits, while at the same time the trunk of the child
is gradually raised upwards, as if we were going to turn it over on to
the hypogastrium of the mother.

1005. When the efforts of the accoucheur have not been sufhcient-
ly seconded by the contractions of the womb, or when, after the de-
livery of the shoulders, the head has not performed its flexion move-
ment, and is found to be arrested at the superior strait, it is some-
times very difficult to reach it, and still more so to get it down; how-
ever, until we can reacli it, all tractive force on the trunk is to be sus-
pended, for it would only tend to reverse it still more. The hands,
placed as before, should be carried further up. At this juncture it is
particularly useful to apply the fore and middle fingers to each side
of the nose; for by applying them to the inside of the mouth, there
would be a risk of depressing the lower jaw only, or of luxating it or
straining it to an injurious degree; but in this case also it is most dif-
ficult to reach this part of the face; and further, it must be confessed
that when we have reached it, if a good deal of force is required, the
fingers slip and get off from it with surprising facility; so that we are
mostly under the necessity of fixing them on the most movable part
of the face, a part the least calculated to bear the force necessary to
make the head turn forwards.

1006. It is therefore indispensably necessary to stimulate the ac-
tion of the womb or that of the abdominal muscles; as the efiorts of
the woman oblige the anterior or mental branch of the sort of lever
represented by the head to descend first, the least pulling at the jaw
in a direction from above downwards is then very efficacious; those
tractions, on the contrary, which the accoucheur exerts on the trunk
of the body, being more particularly transferred to the occiput, tend
naturally to produce the inverse effect of the one we wish to obtain.
It is therefore essential not to pull, except upon the face, whether
there be any pains or not, until we have brought the occipito-bregma-
tic diameter of the head to correspond with one of the diameters of the
pelvis.

1007. To the inconvenience of a reversion of the head there is
sometimes added another that never fails to be embarrassing; instead
of looking backwards and to the left, or directly left, the face is
sometimes found to turn more or less in front, or directly backwards,
so that the neck is twisted round on its own axis. In this state of
things all tractions on the trunk of the body would be dangerous.

TURNING. 449

Previously to doing any thing of that sort, we ought, in the absence
of a pain, to push up the breast, and take hold of the chin with two
fingers of the right hand, disengage it and direct it towards the sacro-
iliac symphysis, while with the left hand on the hypogastrium we
favor, first the rotation, and then the flexion of the entire head; after-
wards we proceed as in the former case.

B. Right occipito-iliac position,

1008. In the third and sixth positions of Baudelocque, we might,
strictly speaking, use the left hand with the same facility as the right;
but the latter is preferred because it terminates the delivery in the
first position of the feet, which appears to be rather more advanta-
geous than the second, and because we can generally manoeuvre with
it better than with the other hand.

1009. Whether, therefore, the occiput be towards the pubis, the
sacrum, the right acetabulum, or the right sacro-iliac symphysis, the
right hand ought always to be made use of, in a supine position in
the first case, prone in the second, half supine in the third, and in a
state of semi-pronation in the fourth. By placing the thumb on the
left temple, and the fingers on the opposite temple and side of the
face, we can embrace the head in the hand, raise it up in the axis
of the superior strait, push it towards the right iliac fossa, and then
reach the ear of the same side, so that the hand may be supine, and
the thumb brought close to the radial side of the index finger; the
hand, being then flattened out, may slip all along the child's right
side, and as it becomes prone, get hold of the feet, and act in all
respects as the left hand does in a left occipito-iliac position.

1010. When the face presents first, the manoeuvre does not sen-
sibly differ from that which is used for the positions of the vertex.
The right hand is always to be introduced where the chin is to the
left, in front, or to the rear; or to speak more generally, and perhaps
also more correctly, the right hand is to be employed in all cases
where it seems easier to push the forehead towards the right iliac
fossa than towards the opposite one — and the left hand in all other
cases.

1011. The other inclined positions, that is to say, those of the
temples and posterior part of the occiput, when they cannot be early
reduced to the corresponding ones of the vertex, are classed among
the positions of the trunk of the body, whence it manifesdy follows,
that in turning by the feet there can be only two positions of the
head; therefore, as these two positions themselves, as to iheir prac-
tical indications, differ only in one requiring the right hand more
particularly, and the other the left hand, and as it is only necessary

39*

450 DYSTOCIA.

to transpose to the right hand the rules already laid down for the
government of the left — it is clear, in point of fact, that all the manosu-
vres of the head are naturally reduced to a single one, and that by
multiplying them, we naturally fall into fastidious repetitions, evi-
dently of no use, and fit for nothing but to overload the memory of
the student.

§. II. Of Turning by the Feet in Presenta-
tions of the Trunk.

1012. Although it may not be certain that no case has been seen,
in a well formed pelvis, where the trunk of the foetus was so situated
that the head was turned directly backwards; although it is difficult
to conceive of such a phenomenon, an error was committed by those
who maintain that the same holds good of the anterior part of the
pelvic circle. The ossa pubis being lower than the sacro-vertebral
angle, and the soft parietes of the abdomen being very distensible,
the posterior concavity of the symphysis does not, like the projection
of the spine, repel the head towards the sides of the median line,
and admit of its fixing itself directly in front.

1013. Besides, this last mentioned position has been many times
met with. To the proofs already in possession of the profession on
this subject, I might add several more; but I shall content myself
■with citing only one. A woman, in her fourth pregnancy, and
whose former labors had exhibited nothing peculiar, continued seve-
ral days in labor at my amphitheatre; she was carefully attended
to by the students, and all of them had an opportunity of satisfying
themselves that the right shoulder was at the orifice, while through
the remarkably thin parietes of the abdomen the head could be felt
almost naked, above and in front of the symphysis pubis. How-
ever, as these positions are rare, and do not at all alter the funda-
mental rules of the manoeuvre, I shall refer all the presentations of
the trunk, as I have done those of the head, to two principal ones:
namely, a left-lateral one, comprising the first and fourth of MM.
Maygrier, Capuron, Duges, and Madame Lachapelle; and a right late-
ral one, to which the second and third of the same authors must
be reduced.

In fact, what does it import to the hand with which we operate,
whether, in presentations of the side for example, the head is a little
nearer or a little further off" from the anterior or posterior median
line of the pelvis? If we wish to take hold of the posterior surface
of the child's legs, we shall still be obliged to deliver in the first
position of the feet if we use the right; and in the second if we use
the left hand; as we always have to bring the child as near as pos-

SHOULDER POSITIONS. 451

sible to a transverse position, in turning there will be rather more
difficulty in those cases where it is farthest removed from that posi-
tion, and rather less where it is nearest to it; but there is no other
difference, and surely that is not enough to justify the importance
attributed by modern writers to the question, whether the cephalo-
anterior positions of the trunk ought or ought not to be admitted.

1014. I have already pointed out the reasons that induce me to
admit the possibility of presentations both of the anterior and poste-
rior surface of the foetus; although they in reality require the same
manoeuvre as those of the lateral regions, I shall say a few words
about them notwithstanding, and successively pass in review the
positions of the side, the posterior and anterior surfaces, taking care
meanwhile to dwell only upon those to which a major part of the
others ought to be reduced in operating.

A. Positions of the Shoulder and Side.

1015. By following a numerical order in indicating positions, so
much confusion has been introduced, that it is almost impossible for
students to understand each other if they happen not to have studied
the same books. Thus, to speak only of positions of the trunk, in
Baudelocque's first the head is in front, in front and to the left ac-
cording to Maygrier, and directly to the left according to M. Gar-
dien: now, as this mode of proceeding is entirely arbitrary, and as
nothing can prevent one accoucheur, if he chooses, from calling that
a first position which another chooses to denominate the third, I have
thought I might arrange all the shoulder presentations under the titles
of dorso-pubic, dorso-sacral, and right or left dorso-iliac. This is
the way to avoid all ambiguity, and reduce to their just value the nu-
merous classifications which have successively appeared in France
since the time of Solayres.

1. Positions of the Left Shoulder.

1016. Dorso-sacral position (3d of Baudelocque). In this po-
sition, the head, which is on the left side, may be stopped above the
foramen ovale, the sacro-iliac symphysis, or even the iliac fossa;

being referable to the corresponding varieties of the vertex positions,
its different shades require to be operated on like the left occipito-
iliac position. Only, instead of the head, it is the shoulder that is
to be pushed up, and instead of placing the thumb and fingers on
the temples, they are to be applied to the back, and to the fore part
of the thorax; in fact, turning, in this case, differs from that in ver-
tex positions, only in respect that the head is already raised or re-
versed, and that the first stage of the operation is effected by natural
means.

452 DYSTOCIA.

1017. The left hand is to be introduced; the thumb is to be press-
ed on the anterior face of the shoulder or the sternum; the other
fingers slip behind the scapula or chest, and the little finger remains
turned towards the child's occiput.

To conform to this rule, the hand ought to be introduced half
supine, or in a more or less complete state of supination or pronation,
accordingly as the vertex happens to be near the symphysis pubis,
the sacro-vertebral angle, or the iliac fossa; after having raised up the
shoulder, taking care at the same time to push it backwards, so
that the anterior surface of the fcEtus may look somewhat down-
wards, we should endeavor to push the head towards the middle of
the iliac fossa, provided it were at too great a distance from it be-
fore, which often requires a skilful combination of the efforts of the
hand that presses upon the hypogastrium with those of the one which
is operating in the womb. The thumb then abandons the sternum,
is placed alongside of the index, and for the remainder of the pro-
cedure we act as was directed in speaking of the left occipito-iliac
position.

1018. When the head is found completely in front (left dorso-
iliac position), or even somewhat near the right acetabulum, we may
proceed as above; only that in order to get hold of the right shoul-
der, the hand is in a forced state of supination, and that after having
lifted it up, the head is to be carried from right to left, as far as pos-
sible, towards the iliac fossa, by acting chiefly with the thumb exact-
ly applied to the sternum.

In cases where it is situated very near the posterior median line
(right dorso-iliac position), it is very difficnlt to bring it back to the
left extremity of the great diameter of the pelvis, because the thorax
only moves, whereas the head retains its primitive position. To
overcome this difficulty, we are to support the upper part of the
chest with the thumb and fore finger, while the others are extended
as far as the occiput, and thus serve to push from behind forwards,
and from right to left, as if we wished to tilt it over from the occiput
towards the chin.

1019. Borso-pubal position (4th of Baudelocque). The maceu-
vre is generally much more difficult in this than in the preceding po-
sition, for it can scarcely be terminated without first being converted
into a left cephalo-iliac position, or into a position of the right side.
But, in either of these cases, the change we are obliged to make in
the situation of the foetus is so great, that if it be somewhat com-
pressed by the uterus, its life is often found to be exposed to the
greatest dangers. This is certainly a case where it would be proper
to bring the head to the orifice, and afterwards apply the forceps, in-
stead of turning and delivering by the feet.

SHOULDER POSITIONS. 453

1020. However this may be, provided the waters have not been
long discharged, if the membranes are not ruptured, and lastly, if
the child is to a certain extent movable in the womb, the best prac-
tice is to reduce it to a dorso-sacral or left dorso-iliac position: this
may be effected in two different ways.

Unless the head happens to be nearer to the sacro-iliac symphysis
than to the right acetabulum, we might, by turning the hand into a
very forced state of supination, get hold of the shoulder, as in the
cases heretofore treated of, that is, so that the thumb may tend to
reach the sternum whilst the fingers remain behind the thorax, the
little finger being towards the head; then we act by raising it up-
wards a little, the vertex in front; the hand afterwards assumes dur-
ing the operation an attitude of pronation, which is more and more
complete in proportion as the occiput moves more towards the left
iliac fossa.

1021. Should it be too difficult thus to move the cephalic extre-
mity of the child, from right to left, over the major part of the an-
terior semicircle of the pelvis, we might, after raising the shoulder
and head above the pubis, go immediately in search of the feet or
knees, proceeding along the left side. Having got hold of the legs,
the act of turning would compel the head, which, besides, is already
repelled by the forearm within the uterus, to rise upwards and take
a situation in tlie fundus of the womb. But in this case special care
should be taken not to permit the child's back to turn to the poste-
rior surface of the womb.

Should the shoulder be so disposed of that the head were to be
found above the right sacro-iliac symphysis, that is to say, in the
third position of Maygrier, or still nearer to the sacro-vertebral an-
gle, the left hand, introduced in a forced state of pronation, might
attempt to raise the shoulder, and move the head from the right sacro-
iliac symphysis to a situation above the left sacro-iliac symphysis;
but although this manosuvre may sometimes be found rather easier
than the former one, it should be stated that it is perhaps a more
dangerous one; for provided the two or three last fingers should not
act with force upon the occiput while the thumb and index are push-
ing against the upper part of the chest, there is a risk of doing no-
thing more than effecting a retroversion of the head on to the back
while endeavoring to displace it.

Should the membranes have been long ruptured, the womb strongly
contracted, and the child not to be moved but with very great diffi-
culty, there is a third manoeuvre that ought then to be preferred, and
which perhaps it would be well to employ in other cases; it con-
sists in pushing the shoulder up with the right hand, from behind

454 DYSTOCIA.

forwards, as if to make the spine turn upon its own axis; then trying
to reach the right side by passing along the front of the chest, while
the womb is forcibly pushed backwards with the left hand; lastly,
in taking hold of the feet, the right one first, so as to bring them
down in the first position.

1022. In conclusion, all the positions of the leftside may be ma-
ii03uvred with the left hand. By not losing sight of the rule that the
thumb should always correspond to the sternal surface, the fingers to
the dorsal surface, and the cubital edge of the hand to the child's
head; by remembering that previously to going in search of the
feet, the head ought to be moved as near as possible to the left iliac
fossa, the practitioner will be aware of every thing that it is essential
to know concerning the manoeuvre for the left lateral surface. Should
he make use of his right hand, as his first object would be to raise
up the left shoulder, so as more readily to reach the right shoulder
and side, the case would evidently be converted into a right shoulder
position, properly so called, which I am now about to treat of.

2. Positions of the Right Shoulder.

1023. What I have now said of the left shoulder positions bein^
strictly applicable to those of the right shoulder, it would be super-
fluous to enter upon new details concerning the latter. I shall merely
remark, that in the present case, the right hand performs the part
which was entrusted to the left in the former case; that the head is
to be moved towards the right iliac fossa previously to searching
further for the feet; lastly, that the foetus should be delivered in the
first and not in the second position of the feet. After all, to save
the necessity of particular description, in shoulder positions it is
enough to remember that the right hand always goes to the right
side, and the left hand to the left side, and that in all cases, tlie
fingers ought to be situated in regard to the foetus as has been
already mentioned.

I will, however, observe, that these rules cannot be absolute; that
a knowledge of them merely renders the operation rather easier
that they may be modified in a great variety of ways; that they are
principally established for young physicians who are as yet insuffi-
ciently enlightened by experience, and wiio require a certain num-
ber of clues to lead them through the labyrinth of practice; lastly, I
will state that in cases where the hand is carried into the womb pre-
viously to the rupture of the membranes whether the child presents
with its right side or its left side, and in any position of the shoulder
whatever, we may arrive at the feet directly, and almost with equal
facility with either hand.

SHOULDER PRESENTATIONS. 455

B. Presentation of the Sternvm.

1024. The cephalo-pubic position (1st of Baudelocqiie) of the
sternum might, rigorously, be as well reduced to the left cephalo-
iliac, as to the right cephalo-iliac position; but it is generally reduced
to the latter, because it terminates it in the first position of the
feet.

1025. In the right cephalo-iliac position (4th of Baudelocque) the
right hand must be made use of; it is to be introduced supine if the
head is in front, prone if in the contrary situation, and betwixt these
two attitudes provided the head be fairly to the right. The part that
is engaged must always be pushed back until the trunk of the foetus,
instead of being convex on its anterior face, shall become concave;
then the operator should endeavor to reach the right shoulder be-
hind which the fingers are to be applied, while the thumb rests on
the anterior surface of the thorax; afterwards, nothing more remains
to be done except to swing the bis-acromial diameter, so that its pos-
terior extremity may turn downwards, by acting upon it as upon a
lever of the first kind, whose fulcrum is represented by the thumb,
and the power by the fingers; this being done, the position difl'ers
in no respect from the corresponding one on the right side, and is to
be managed in the same way.

1026. In the left cephalo-iliac position (3d of Baudelocque) the
left hand does what the right should do in the opposite position; it
pushes up the breast, gets hold of the left shoulder, draws it down
a little, and if the head were too far from the iliac fossa, it brings it
nearer to it, obtains a dorso-sacral position of the left shoulder, and
the rest of the manoeuvre presents nothing of a special character.

C. Presentations of the Back.

1027. Right cephalo-iliac position. If the head is to the right, in
front, or to the rear, in positions of the back, the right hand is to be
made use of as in positions of the sternum, and according to the same
rules. Consequently, it is introduced half prone, supine, or more or
less completely prone, accordingly as the head looks to the right, in
front, or to the rear; but in such a manner that the thumb may al-
ways pass in front of the right shoulder and breast, Avhile the fingers
rest upon the dorsal surface. In the first place, this shoulder is to be
brought down so as to make the other rise; it is then to be repelled,
by acting on it as upon the end of a powerful lever, which the thumb
tends to move and to oblige the foetus to turn on its great axis, until
the position of the back is converted into a corresponding or dorso-
sacral position of the right shoulder.

This movement requires great care, for if the head does not go

456 DYSTOCIA.

with the trunk, the cervical portion of the spinal marrow runs the
greatest risk of being lacerated, or violently twisted in the second
stage of the operation; this danger is to be avoided as far as possible,
by pushing the chest very far backwards and upwards, so as to give
great depth to the curve of the anterior surface of the foetus; or if it
should be absolutely necessary, by getting hold of the head itself to
force the face to turn forwards and downwards.

1028. Left cephalo-iliac position. The left extremity of the bis-
acromial diameter is taken hold of, the fingers on the back, and the
thumb in front of the left shoulder or sternum, and the cubital edge
turned towards the occiput; while the trunk is turning on its oc-
cipito-coccygeal axis, we should endeavor to comprise the head ia
the movement, and, if necessary, bring it near to the iliac fossa. In
one word, the left hand here acts as the right hand does in the oppo-
site positions; it converts positions of the back into positions of the
left side, which it afterwards terminates by delivery in the second
position of the feet.

SECTION 3.

Of the Manoeuvre in Presentation of the Pelvis.

The manoeuvre in positions of the pelvis reduces itself in some
sort to that of the last stage, or stage of extraction, in the head or
trunk positions; I need therefore only add a few words to what has
been said farther back, in order to conclude all that concerns it.

1029. Although, strictly speaking, the right hand might be easily
made use of in all the positions which it is proper to terminate by
the first of the feet positions, and the left only in the opposite cases,
it is, notwithstanding, better to do the very reverse. We can, with
the right hand, in all the right dorso-pelvic positions, push up one
buttock, or even both of them towards the right iliac fossa, reduce
inclined to central positions, and take hold of the limbs by their an-
terior surfaces, without being obliged to assume an awkward atti-
tude; whereas with the left liand the breast could not be raised with-
out difficulty, and it would be still less easy to reach the feet, if they
were not at some distance from the orifice. Lastly, by using the
hand that corresponds to that side of the mother's pelvis towards
which the child's heels are to be turned, while coming down, a half
prone position brings the palmar face of the fingers in front and on
one side; the operator is consequently in the most favorable condition
to prevent the back of the foetus from moving towards the sacro-iliac
symphysis, and on the contrary, to compel it to turn towards the

PELVIS PRESENTATIONS. 457

acetabula; the operator can also pull with all the force that circum-
stances may require, an advantage not to be obtained by adopting an
inverse order in the application of the hand.

Whenever, therefore, it is intended to deliver in the first position
of the feet, that is, whenever the child's back shall look more or less
towards the left of the pelvis, or even directly towards the pubis or
sacrum, the left hand should be introduced; and the right hand in all
the other cases.

A. Positions of the Feet.

1030. Inasmuch as the positions of the feet previously to the rup-
ture of the membranes, are scarcely distinguished from those of the
breech, there can hardly be any question concerning them until after
this rupture. The accoucheur then may be called under two diffe-
rent circumstances, which it is important that he should not confound
with each other: either the feet have not cleared the vulva, or the
trunk has more or less completely emerged.

In the former case, if the two feet present together at the orifice or
in the vagina, all he has to do is to take hold of them and draw them
down so as immediately to extend the legs, and that the hips may
soon arrive at the inferior strait; provided only one of them can at
first be found, some attempts should be made to discover the other,
which it is rarely difficult to do; should the attempt not succeed, the
first one should be brought down, then secured by a fillet, and made
use of as a guide to the second, which may perhaps be found reversed
towards the breech, moved off far in a state of abduction, or with the
leg and thigh doubled up on the belly, &c.

In the latter case, the presence of the feet offers no particular
indication; nothing is to be done, as was mentioned in speaking of
turning in head positions, but to pull the different parts that are
still unexpelled downwards.

A very necessary precaution, when extracting a child by the feet,
is, to act in such a way that at the moment when the child is passing
the straits, the occiput may look towards some part of the anterior
semicircumference of the pelvis. The thing is easy; and no skilful
practitioner will ever fail in bringing it about, when he goes in
search of the feet in a head or trunk presentation. But it is no
longer the case where the pelvis presents spontaneously at the supe-
rior strait; mistimed or unskilful tractions may have been instituted
in his absence, or when he reaches the bed-side of the patient the
hips may have been already expelled and the face turned in front.

1031. The position of the feet where the child's dorsal surface
looks backwards may give rise to three particular cases: 1. The
40

458 DYSTOCIA.

feet are still at the superior strait, or in the vagina; 2. The delivery,
if left to the natural powers, may be complicated with no accident,
or give no evidence of requiring the assistance of the hand, until the
lower extremities, or even the hips are born; 3. Turning has been
attempted on account of some position of the head or trunk, the
feet have been brought down, but the operator has failed to make
the occiput turn in front.

1032. Let us here suppose the first hypothesis: after having got
hold of the limbs in the manner heretofore mentioned, the back
ought to be directed first towards the sacro-iliac symphysis or iliac
fossa, then towards the acetabulum; with each pull, as the hips
approach the perineal strait, they are taken in both hands, and in the
interval betwixt two pains the whole trunk is pushed upwards again,
as if we wished to make it mount up above the superior strait; as
soon as the womb, which is thus momentarily distended, appears t%
be about to contract, the pelvis should be suddenly pulled down,
•while at the same time we endeavor to make the body of the child
revolve on its axis; in this way, says Baudelocque, the cavity of the
womb is first enlarged, and as we endeavor in the next place to
empty it suddenly, the organ is in some measure surprised, and can
not contract so fast as to prevent the head from following the turn
we give to the body. These attempts are to be renewed from one
to ten and even fifteen times, according to the necessity of the case,
that is, until the anterior position has taken place of the posterior
one, or until the impossibility of effecting the change is ascertained;
when the attempt proves unsuccessful, no particular difficulties re-
main, and the rest of the manoeuvre is the same as in feet presenta-
tions in general.

When all hope of succeeding is abandoned, we must even be
resigned to let the face came along uppermost; we must redouble
our precautions against letting the chin depart from the breast; the
arms should be disengaged, the hindermost one first, by pulling, them
from behind forwards, and in a direction from the head towards the
thorax; immediately after this, two or three fingers of each hand
should be applied to the two extremes of the occipito-mental diame-
ter; we should endeavor to push the head upwards, or raise it so
as to give it more freedom, and finally, make it execute a pivot
movement, by which the face is gradually carried backwards.

Supposing it should be found impossible to turn the occiput in
front, the shoulders and chest should be pulled downwards, and
rather backwards than forwards, so as to deliver the chin, the fore-
head, and anterior fontanel before the occiput; if these tractions
should prove incompetent, the forceps should be had recourse to.

PELVIS PRESENTATIONS. 459

1033. In the second case, provided the head has not as yet arrived
at the straits, we should act as in the first case, that is, the fcetus
should be pushed upwards every time we wish to give the body a
turn; but we must expect to succeed still more rarely.

1034. In the third, these attempts are of no use; we may ne-
glect them altogether, and immediately disengage the arms if it be
not already done; we then conform, as to the head, to the principles
established higher up: some of the fingers must be applied to the
chin, which we endeavor to turn from right to left, while with the
other hand we act on one of the shoulders or the occiput, so as
to favor the complete rotation of the head and trunk, and then
proceed to deliver.

B. Position of the Breech.

1035. As the knees occasion no difhculty, by their presentation
merely, in delivering a lying-in woman; as their presence does not
at all alter the principles, nor even the practical details of the ma-
noeuvre; as one or more fingers are all that is required to disengage
them, or give them a regular position when in the vagina; and lastly,
inasmuch as, where this presentation does not return into the class
of breech presentations, it is always an easy matter to reduce it
among the presentations of the feet, I shall not devote a special arti-
cle to the consideration of it, but shall pass at once to the considera-
tion of breech presentations.

1036. The left hand should be preferred in breech presentations,
as in those of the feet, whenever the back is turned more or less to
the left, and vice versa for the right hand. The child being doubled
up, with the thighs and legs raised up along the abdomen, if the
hips have cleared the orifice of the womb and descended into the
excavation, or even to the inferior strait, the groin that is most
backwards should be hooked with a finger or two, while the thumb
of the same hand is applied to the outer surface of the anterior hip.
If any resistance is experienced, there will be some advantage in
substituting one or two fingers of the other hand for the thumb,
and if that will not answer, the blunt hook should be made use of.
As soon as the hips have cleared the vulva, it is generally very easy
to extend the limbs, and the rest of the process is merely a footling
delivery.

1037. Previously to the rupture of the membranes, and where
the breech is not yet so far engaged as to render it impossible to
push it up again above the superior strait, whether the fcetus be dou-
bled up or merely in a squatting attitude, we should always endeavor
to bring down the feet.

1038. In order to push the breech up, the hand is placed under it

460 DYSTOCIA.

and along the posterior surface of the thighs; the thumb is placed on
the anterior and the fingers on the posterior hip; or, where the foetus
is still very movable, and very high up, it is enough to apply the
thumb under one of the ischia, and the fingers under the other; the
pelvis is then pushed towards the iliac fossa that corresponds to the
hand that is made use of; then by passing along on the outer surface
of the limb that is nearest the sacrum, the feet may be got hold of
and brought down, so as to allow us to embrace the forepart of the
legs with the hand, and deliver, as in a corresponding position of the
feet; that is, in the first if the left hand is used, and in the second po-
sition if it is the right hand.

1039. In conclusion, the raancEuvre of the pelvis presents us but
two particular indications: 1. To draw it down with the fingers or
blunt hooks, when it is too low down to be pushed back again; 2.
To displace it whenever the thing is possible, so as to let the feet
pass down first. In both cases, when we employ only one hand, the
palm of which is directed so as to slide up along the child's abdo-
men and breast, we surely require for our guidance only the follow-
ing rule; that the fingers shall always be applied to the ischium or
hip that is opposite, and the thumb to the ischium or hip that corres-
ponds to the hand that is operating. Were the limbs found to be rever-
sed upon the dorsal surface, instead of being turned towards the abdo-
men, the thighs, should be acted on as we do on the arms, when dis-
engaging them at the inferior strait; the thumb fixed in the groin might
serve as a point d'appui; the fingers being moved along towards the
ham, would represent the power, and the knee would be obliged to
descend, drawing the leg along with it. The two limbs ought thus to
be brought either together or in succession, to their natural position.
In whatsoever way they may present, it is always better to make
them descend together, than one by one; however, where too much
difficulty is experienced, it would be imprudent to persist in endea-
voring to make them descend simultaneously. If one of them should
have already escaped, the anterior one for instance, and it should
be impossible to get the other one down, the delivery, in most
cases, would not be rendered on that account much more difficult:
it should be made use of to draw down by, while the index and
medius fingers, or a blunt hook, should be applied to the posterior
groin, as has already been mentioned. If, on the other hand, the
anterior member only should be retained at the superior strait, it is
still more important than in tlie former case to draw it near the other
limb, because we cannot so readily reach the groin in this situation,
and especially because the action of the blunt hook is not so advanta-
geous.

1040. Remarks. In concluding this article, I shall take the liberty

PELVIS PRESENTATIONS. 461

of again suggesting to students and young accoucheurs, that if, in
turning by the feet, they wish to avoid the risk of often killing the
foetus, they ought never to lose sight of the fact that the head cannot
rotate on the spine more than a quarter of a circle, without luxating
it, or straining the spinal marrow, in a very dangerous way; that, in
general, it does not follow the motion of the trunk of the body, by
means of which attempts are made to rotate it; that it is impossible,
in any case, to affirm that it has rotated, merely on the ground that
the back, for example, has been turned from behind forwards; conse-
quently, that in any species of manoguvre whatever, we should com-
mit a very great error if we caused tiie child's body to turn more
than a quartor of a circle, without being assured that the head ac-
companies it in its movement.

1041. Neither can I leave this subject without returning for a
moment to the consideration of the manoeuvre recommended by
Baudelocque for bringing the child's back in front, and which was
spoken of some pages back. It would, in my opinion, be wrong to
rely upon such attempts. If the womb is but slightly contracted,
it is useless to act in that way; when, on the contrary, the foetus is
forcibly compressed, the force which we exert upon it from below
upwards, seldom extends as far as the head, and even then it cer-
tainly does not change the general disposition of the womb, so as to
render the child at all more movable. This is not all; if it be not
certain that we shall be enabled, in this way, to render the rotation
of the occiput easier, it seems to me manifest that the abdomen, the
thorax, and even the cervical portion of the spine would not always
safely bear the various kinds of pressure and the twists to which
they will necessarily be subjected; lastly, to express my unreserved
opinion, I will say that this precept of Baudelocque seems to me to
be more the fruit of imagination than of observation, and that mo-
dern writers ought, previously to copying it, at least to have called it
in question and submitted it to a new examination.

SECTION 4.

Presentation of the Arm.

1042. The premature escape of the arm does not, of itself, con-
stitute a position, and forms only a complication of other positions,
particularly that of the shoulder. Both arms have been seen, but
rarely, to present together at the vulva; unless brought there by
inconsiderate manoeuvres, they could not both thus descend except
in back or sternum positions. It is said that they have been both

40*

462 DYSTOCIA.

felt at the orifice at the same time with the feet, and it is at least
certain that they may precede the head at the inferior strait ; so
that, although the presence of the hand commonly indicates a posi-
tion of the shoulder, it may also happen that it is only a complica-
tion of a head or pelvis position.

1043. Until, in the last century, nothing was deemed more dread-
ful than the appearance of the arm in the course of a labor; and
in our day, the common people still look upon such an occurrence
as extremely dangerous. But these fears are explained by the
fact, that until the time of Levret it was not thought possible to
penetrate into the womb without having previously returned the
prolapsed member into its cavity. In reflecting upon the dangers
occasioned by the ridiculous or barbarous measures adopted in cases
of this kind, could it be believed that physicians would have seriously
recommended that a piece of ice should be put into the child's hand,
that it should be pinched or fdlipped, to make it pull its arm back!
Others have invented a sort of forks, or crutches, &c. to push it up
with, by acting upon the chest; the more timid pushed it up to the
top of the vagina, and sometimes succeeded in returning it into the
cavity of the womb; but their attempts were generally in vain, and
the arm, if somewhat swelled seemed to them to constitute an
insurmountable obstacle to the introduction of the hand into the os
uteri. Under such circumstances, the old women, and even the
physician himself, could imagine no alternative save pulling at the
arm until the child yielded and came away doubled, or until the
arm was torn off. Pare advises that the soft parts below the
shoulder should be first cut round, and that we should then resort
to sharp pincers to cut the bone with; De la Motte recommends us
to twist the limb round like the limb of a tree that we might wish
to tear off from the trunk; lastly, the most timid were satisfied
with making deep sacrifications in the tumefied part, so as to lessen
its size.

Happily, at the age in which we live, such a dreadful doctrine is
held by nobody. Baudelocque and his successors did it justice long
ago; and at present it is not without a sentiment of indignation, that
we still hear from time to time of practitioners who dare to conform
to it in practice. I should not even insist upon this point, had not
certain persons had the inconceivable audacity to renew this revolt-
ing practice of late years in Bretagne, Normandy, Champagne,
and even in the environs of Montpellier, almost at the same time;
particularly, had not these practitioners found some defenders in the
capital; had not certain persons had the hardihood to publish, in
1826, 1827 and 1828, various pamphlets to justify a conduct so far

ARM PRESENTATIONS. 463

removed from tokological doctrines, and had they not anew appealed
to the authority of A. Pare, Mauriceau, Deventer, De la Motte,
Puzos, Mesnard, Levret, &c., as if the modern accoucheurs had not
overturned, without exception, all the reasons advanced by their pre-
decessors in favor of the amputation, or tearing off of the arms!

1044. I do not intend to deny that it never has been necessary
to separate from the trunk a member prematurely escaped, in order
to penetrate more readily into the womb; I merely assert that I can-
not conceive of such a necessity; that it is impossible to admit of it
except where the child is dead; that no matter how much the arm
may be infiltrated or swollen, a skilful accoucheur will always be
able to carry his hand into the womb without mutilating any thing;
lastly, that without being able to say how far the Norman surgeon
may have departed from sound rules, we must at least admit, that
the reasons and proofs cited by M. Roux for his excuse, would be
dangerous if taken in the very letter.

1045. In order that delivery may be effected, the child's head
must pass through the os uteri: but the hand of the physician and
the arm of the child can never be equal in size to the volume of the
child's head. Therefore, the presence of an arm is incapable of pre-
venting the hand from passing into the uterus, even although there
should be infiltration and tumefaction of the labia; and after that, it
becomes completely useless to return the arm previously to going in
search of the feet.

Therefore, when a hand appears at the vulva, and it is impossible
to ascertain certainly that the corresponding shoulder is at the supe-
rior strait, far from becoming alarmed, and pushing it back, it is, on
the contrary, best to secure it with a fiUei; the fillet being fixed, the
shoulder is next pushed up, and we proceed to get hold of the feet,
just as if there were no complication whatever. As we draw the
lower extremities downwards, the arm mounts upwards, and the fillet
serves to pull it along at the same time with the feet after the version
is complete.

1046. Although the descent of the arm along with the head is
not a serious cause of dystocia, there are, notwithstanding, cases
where the course of the labor is really embarrassed by such an oc-
currence. Consequently, we may get rid of the complication if pos-
sible. If called before the superior strait has been passed, there is
no difiiculty in returning the child's hand into the uterus, and re-
taining it there by means of a few fingers until the head is well en-
gaged. If called at a later period, great difficulties are sometimes
experienced; in some instances the thing is impossible; we must,
under such circumstances, endeavor to make the hand slip along the

464 DYSTOCIA.

forehead towards the sacro-iliac symphysis or obturator foramen of
the side where there is the least pressure; but should some new diffi-
culty arise, rendering the immediate termination of the labor neces-
sary, the forceps would be applied, without regard to the presence of
the arm.

In case the hands should present at the same time with the feet,
they doubdess would not long maintain their position; the contrac-
tions of the womb would soon force them to rise, by urging the
breech down. Besides, in order to obviate all cause of alarm, it
would be merely necessary not to confound them with the lower
extremities, and to pull upon the latter until the hips had come
down.

Pean and Deleurye have advised, where an arm and shoulder fill
up the orifice too exacdy to allow the hand to reach the child's foot,
that we should begin by bringing down the other arm, so as to en-
able us to penetrate more easily into the womb. This precept has
been the object of much criticism: it has been said that two arms
must necessarily occupy more space than a single one; that by bring-
ing a second one alongside of the first, instead of overcoming the ob-
stacles, we should only increase them; and that, if the hand may be
carried up as far as to the arm that has not yet escaped, there is no
reason why it could not reach to the feet themselves.

I have had no occasion to repeat the practice of Deleurye in this
respect; nevertheless, it seems to me to have been proscribed pre-
viously to being sufficiently examined. Baudelocque is, assuredly,
deceived, when he maintains that it is always as easy to reach the
feet as the arm that is still retained above the orifice of the womb;
the arm may be near enough to be seized with two or three fingers,
whilst the feet always require the whole hand to be introduced, and
most commonly to a great depth. By pulling upon the second arm
we tend to make the engaged shoulder mount upwards, and to con-
vert a position of the lateral surface into one of the sternal surface,
or dorsal surface, and I can conceive that in some cases there would
result an increased facility of passing the hand and of performing
the remainder of the manceuvre.

But what shall I say of Dr. Davis, who recommends us in certain
cases of arm presentation to terminate the delivery by means of em-
bryotomy! of Douglass, and of Sims, who profess the same senti-
ment; and above all, of Dr. Lee, who, to spare the mother, sepa-
rates the arm from the body, perforates the thorax, fixes a crotchet
upon the pelvis or inferior part of thefcetal spine, and by means of
sufficient force thus extracts the child J as if this operation were
not an hundred times more dangerous, even for the woman, than the

TURNING. 465

most painful and complicated version! Who shall say how far the
temerity of certain persons shall carry them? Has not a surgeon in
one of the colonies lately had the hardihood to perform the hypo-
gastric cesarian operation simply because turning appeared to him to
be too difficult in an arm presentation, and what is still more sur-
prising, to boast of his conduct, as a model to be followed? It is
only by remembering, that, in the sciences, where men are always
to be found who invariably substitute for the bounds of the possible
the limits of their own knowledge and capacity, that we are enabled
to conceive of such scandalous practices.

As long as the accoucheur is not in possession of certain proof of
the child's death, he has no right, under any pretext, to mutilate it;
and if ever the presence of the arm could really prevent the intro-
mission of the physician's hand, it would be far better to follow the
advice of Bodin, and perform the vaginal cesarian operation, than
to have recourse to embryotomy. Even although the child be dead,
we should proceed in the same manner, and, in the first place, put in
requisition blood-letting, the bath, injections, ointments, indeed all
sorts of relaxing and sedative measures.

General Recapitulation on the Manoeuvre.

1047. In the manceuvre, all the positions of the head may be re-
duced to two; all the positions of the side belong to the second stage
of the man(Buvre for the head positions; all the positions of the back
and of the sternum should be reduced to shoulder positions; and all
positions of the shoulder are at first converted into positions of the
feet. In turning, therefore, there are, in fact, but two positions which
it is essential to study profoundly, and consequently but two manoeu-
vres which it is indispensable to know well: further, as these two
manceeuvres differ only in requiring the employment of a different
hand, as in reality the right hand does not manoeuvre differently from
the left, it follows that the whole manoeuvre in labors is reduced to
the rules which were laid down in speaking of version by the feet in
positions of the vertex. I am aware that, as thus proposed, the
question will not be always exactly understood; but I also doubt
whether those to whom these general rules will not suffice, will be
able to make much out of the most elaborate explanations. In the
detailed applications there are an infinity of shades which words can-
not describe, but which are easily guessed at by an intelligent man,
or which practice alone may teach him to discriminate.

466 THE FORCEPS.

ARTICLE II.
Of the Forceps.

SECTION 1.

The Forceps in itself considered.

1048. The forceps is an instrument with which the child, while
still within the organs of the mother, is seized and drawn forth. It
is not very precisely known who was the first inventor of this sort
of pincers, nor at what period it was first made mention of. It is
true that in the time of Avicenna certain blades with teeth in them
were made use of for the extraction of the dead foetus; Ruelf also
speaks of a pincers he made use of to extract the separate bones of
the cranium, but what comparison is there between these clumsy in-
struments, which no one would have ventured to apply to a living
child, and the forceps employed at the present day?

1049. The Chamberlains were for a long time in possession of a
secret for terminating difficult labors. One of the members of that
family came to Paris for the pupose of convincing the French of the
value of his instrument; but as he was not successful in his first at-
tempts, and was ill satisfied with his reception in France, he return-
ed with his secret to London. Chapman and Gifl'ard, who pretend
to have been acquainted with the means employed by Chamberlain,
pubhshed a description of it at the commencement of the eighteenth
century, and asserted that it consisted of a forceps for taking hold of
the head with; a surgeon of Brentford, whose name was Drinkwater,
is also spoken of as the author of a similar forceps; but it is really
impossible to determine whether the Chamberlains made use of a
forceps or a lever, or some other instrument, nor whether the' hands,
which Palfyn says he first thought of, and the invention of which
was claimed by Ledoux, were any thing else than the instrument
used in England.

1050. However this may be, it was about this time that the use of
the forceps was introduced into the practice of midwifery. At first,
formed of two blades, either full or fenestrated, which were intro-
duced separately into the pelvis, and which were but slightly curved,
they soon received the addition of a double notch, to admit of their
being crossed. Smellie made them an extremely simple instrument,
the application of which is as easy as possible; this accoucheur even

THE FORCEPS. 467

thought it would be well to have two forceps, one very short, to be
applied to the head when already down in the excavation, and the
other rather longer, having a concave edge, for the purpose of pene-
trating as far as the superior strait.

Levret, on his part, introduced such important modifications of
the forceps, that he in some sort made a new instrument of it,
which is still known in the science as Levrefs forceps. Like all
tlie others this forceps is composed of two branches: one called the
male branch, which I ])refer to call the left branch, and the other the
female branch, which I shall call the right branch; the blade of each
is largely fenestrated, has a bead or blunt crest on the circumfer-
ence of its concave surface, and on one of its edges exhibits a
curve which corresponds with the curve of the axes of the pelvis.

The handles, which are entirely metallic, and not quite so long as
the blades, terminate by a flattened hook. At the place where they
cross there is a flat surface, a pivot and a mortise, which admit of
their being firmly united, and prevent them from sliding on each
other when they are once applied;

1051. Since the time of Levret and Smellie the forceps has un-
dergone numerous changes, without speaking of those of Roederer,
Crantz, Walbaum, Johnson, Fried, Stein, Leake, Plenck, and an
infinity of others, the figures of which may be seen in the treatise of
MuUer. We have the jointed forceps of Saxtorph, which in other
respects very closely resembles SmelUe's instrument; that of Cou-
touly, also jointed, but at the same time much more complex than
the former, and which admits of various shaped blades beir^ fixed
to the same handle, according to circumstances; another one, by the
same accoucheur, for the handle of which there is substituted a trans-
verse metallic hilt, and which, in consequence of the manner in
which the branches are united, must act like a lever of the third kind;
that of Baudelocque, or Pean, Avhich differs from Levret's only in
being rather longer; the forceps of Thenance, the branches of which
need not be crossed, and which unite near to the curved end of the
handle, and is thus converted into a lever of the third kind, like one
of those of Coutouly. The two forceps of M. Dubois; that of Bru-
latour, jointed by a peculiar mechanism; that of Bruninghausen, the
pivot of which is replaced by a sort of round-headed nail, and with
very small fenestres in the blades; then the forceps of Meryen, which
is also jointed; then that of Doctor Guillon, also jointed, and which
has no need of a movable pivot in order to be united, and contains
in its handle a pelvi-cephalometer, blunt hooks, sharp crotchets, a
perforator, and an extractor. Lastly, MM. Capuron, Maygrier,

468 THE FORCEPS.

Flamant, Colombat, and Prout have also thouglit proper to propose
some modifications in the construction of the forceps, so that the
profession is now in the possession of near an hundred species.

1052. There is not, strictly speaking, one of these forceps with
which the principal object proposed, viz. the extraction of the fcstus,
cannot be attained; but at the same time, not one of them presents
more real advantages united than Levret's. Its inventor, who ap-
plied it so often, Baudelocque, whose practice was so extensive,
Mesdames Lachapelle and Boivin, who must have assisted the de-
livery of so many women, MM. Desormeaux, Gardien, Evrat, &;c.,
never felt the necessity for modifying Levret's forceps, and M.
Dubois himself has long since rejected in his own practice several
alterations in them introduced by himself.

It is well to remark, besides, that most of these pretended im-
provements have been proposed only by young men, who had had
no opportunity of convincing themselves that in this, as in all other
surgical operations, much less reliance is to be placed upon the
form of the instrument than upon the address or skill of the ope-
rator.

1053. The Levret forceps, made somewhat larger according to
the views of Pean, deprived of the bead upon its concave surface,
and file-polished, in the way directed by Professor Flamant, termi-
nating in blunt hooks, containing a pique, as recommended by M.
Dubois, without any shoulder near the joint, and without a sliding
plate to secure the pivot, is the one I prefer. A correction that I
would willingly adopt, provided it could be efTected without weaken-
ing the instrument, would consist in having hinged joints, so as to
permit them to be doubled up, and thus rendered more portable;
but up to the present time this has been attempted in vain, and an
examination of the forceps lately made by M. Colombat, leads me
to think that that ingenious surgeon will not be more fortunate in
this respect than his predecessors.*

* I cannot omit this opportunity for saying that I consider the obstetric for-
ceps of Dr. Davis, of the London University, as the most convenient and safe in-
strument that has as yet been constructed — Its fenestra is so large, that a con-
siderable part of the parietal region is prominent through it — its new curve is so
admirable that it is scarcely practicable to injure the anterior sacral nerves or
other tissues with it, and its length is also so well adapted for delivering from
above the superior strait — Its lightness, not inconsistent with all needful strength
is a high merit in this excellent instrument — I satisfactorily employ it in pre-
ference to the Baudelocque forceps or that of Siebold which are so generally ap-
proved of in our country. — M.

USE OF THE FORCEPS. 469

SECTION 2.

Of the Use of the Forcejis.

1. The cases that require the employment of the forceps are nu-
merous, and may be divided into two classes: in tlie one, no other
means except the forceps can be had recourse to; in the other, it
would, strictly speaking, be possible to have recourse to turning, or
to rely upon some other means of succor, should it be desirable to
avoid applying the forceps. Antecedently to the invention of this
instrument, all those labors, that could not be terminated by the hand
alone, were treated by embryotomy, or by some serious operation
upon the mother; at present we are rarely reduced to the necessity
of thus sacrificing the child, and of equally compromitting the safety
of the mother, because the forceps generally suffices to obviate this
destructive practice.

1054. It has been laid down as a general rule that the forceps
must be applied, 1. Whenever the head is too large, either relatively,
or absolutely, to pass through the passages without exposing the
woman to the hazard of exhaustion, or other dangers; 2. When the
womb is in a state of inertia, and efforts to restore its contractility
prove to be in vain, and the head is found to be so far engaged that
it is impossible to restore it to the superior strait; 3. When any
accident renders the extraction of the fcetus indispensable, and the
head has already descended into the excavation.

1055. Too large a head. If, as is already proved by the experi-
ments of Baudelocque, and some other authors, the head of a new
born child, when squeezed so as to bend a forceps of the best con-
struction, is reduced in diameter not more than three or four lines
at the utmost, it is evident that when taken hold of within the pelvis,
where it is already more or less compressed in various directions, it
would not be prudent to depend upon any greater degree of re-
duction; and besides, to obtain a reduction to that amount, it would
be necessary for the instrument to be applied exactly to the two ex-
tremes of the bi-parietal diameter. But when we come to reflect
upon the difficulty of fixing the blades exactly upon the points de-
sired, and that each of them are a line and a half in thickness, it is
difficult to believe that a head too large to pass through the pelvis
under the influence of the powerful contractions of the womb and
the well directed eff'orts of the woman, could derive any great assis-
tance from the application of the forceps.

1056. Weakness of the organism. Inertia, or want of contrac-
41

470 USE OF THE FORCEPS.

tions of the womb, is one of the cases for which the forceps is most
frequently applied. When the head passes with difficulty through
the straits, and the woman is exhausted with vain efforts, the efficacy
of this instrument is not contested by any one; but this is not the
case where there is inertia only, without any narrowness of the pas-
sages. Here every thing should be tried with a view of restoring
tlie action of the womb, and the forceps ought not to be made use
of until after the ergot has been tried in suitable doses.

1057. Accidents. When the child presents by the vertex or by
the face and one of the complications pointed out in another article
renders it necessary to deliver the woman without delay, one of the
two following conditions will necessarily exist: 1. The membranes
have been ruptured and the waters discharged for a long time; the
womb is strongly applied to the foetus, and the head has reached
the excavation, or it is at least pretty firmly engaged in the superior
strait; in which case nothing can supply the place of the forceps;
2. The OS uteri is dilated, the head is engaging, the membranes are
ruptured: strictly, the forceps might be applied: but the child is
still sufficiently movable to admit of our going in search of its feet.
In this case practitioners are not agreed as to the best mode of pro-
ceeding; some think, with Levret, Smellie, Plenck, and especially
with M. Flamant, that the forceps promises greater advantages than
turning; others, along with Madame Lachapelle, M. Desormeaux,
and almost all the modern practitioners, are of a contrary opinion.
I think there is error and reason on both sides. M. Flamant speaks
the truth when he maintains that the forceps is much less dangerous
for the foetus than turning by the feet, and that it is to be preferred
in all cases where too much difficulty does not arise in its applica-
tion; but he relies too much upon his personal address, and certainly
inculcates a dangerous principle when he affirms that turning and
delivering the child by the feet is almost never necessary; and that,
however movable and high up above the abdominal strait the head
may be, the forceps is always to be preferred.

1058. Every accoucheur knows that if the head is still movable,
it will displace itself during the introduction of each branch of the
forceps, and most generally is difficult to get hold of; that as the
blades of the instrument cannot in reaching it be accompanied by
the fingers, unless, as is M. Flamant's practice, the whole hand is in-
troduced into the pelvis, they are in some measure introduced at
hap-hazard into the uterine cavity; that it is most generally impossi-
ble to say, exactly, whether ihey embrace the occipito-frontal diame-
ter, rather than any other; finally, that the woman is exposed to a
thousand dangers, whereas the feet may be brought down with far

USE OF THE FORCEPS. 471

less difficulty, and at a much smaller risk of accidents; but it is
also undeniable, and it appears to be too much overlooked at the
present day, that although the woman runs incomparably less risk in
turning, the same is not true as to the child, which too frequendy
becomes the victim of this manoeuvre, while it scarcely suffers at all
under the methodical application of the forceps.

1059. It is therefore wisest to pursue a just medium betwixt these
two extremes, to prefer the forceps, when we are much accustomed
to handle them, when they can be applied without too much diffi-
culty, and without any fear of injuring the woman; on the con-
trary, to have recourse to the hand to draw down the feet, under
the opposite circumstances, that is to say, when the head is too high
up, or too movable to be easily got hold of, and where there is no-
thing to prevent the artificial evolution of the fostus.

2. The forceps should only be applied to the head of the foetus;
Smellie and others were wrong to advise their being applied upon
the foetal pelvis; for should even a small amount of force be em-
ployed, they would crush the bones of the hips; the upper ends of
the blades would contuse or lacerate the abdominal viscera, and in-
evitably kill the child; besides, the blunt hook or fingers would
always advantageously supply their place here; the head is the only
part upon which it can act or be placed without inconvenience, and
for which it was constructed.

1060. From Levret and Smellie down to the most modern ac-
coucheurs, the French and English authors have all recommended
that the forceps should be applied so that its two claws should cover
the two extremes of the bi-parietal diameter; that its long axis should
be parallel to the occipito-mental diameter, and its concave edges
turned towards the occiput, excepting always those cases where
the head is delivered in an occipito-posterior position; it is true,
that Deleurye and Baudelocque had admitted that where the head
is locked transversely at the superior strait, it might at first be
grasped by the occiput and forehead, so as to make it descend into
the excavation, to be afterwards laid hold of in a more advantageous
manner; but as far as I know, nobody has followed this advice, es-
pecially as the case supposed by Baudelocque has, perhaps, never
occurred.

1061. The practitioners of Germany, Prussia, and Russia, fol-
low quite a different rule; they pay no regard to the position of the
head; the pelvis alone guides them; according to them, if the con-
vex edges of the blades look toward the iliac fossae, they are well
placed; the reason they assign is that we can very rarely before-
hand determine what is the exact situation of the occiput; that even

472 USE OF THE FORCEPS.

supposing we could ascertain it, it would not on that account be ne-
cessary to change the mode of application of the instrument, inas-
much as, in the diagonal positions, the mere power exerted in fixing
and uniting the blades brings the forehead in front of the sacrum or
behind the pubis; that completely transverse positions are exceed-
ingly rare, and would render the application of the forceps, too diffi-
cult, if the design of embracing the parietal protuberances were ob-
stinately persisted in; lastly, that by conforming to their doctrine the
operation is always extremely simple, and that the head almost al-
ways ends by placing itself, if it were not so already, in an antero-
posterior position; so that, after all, the same result is obtained, only,
by conforming to the principles generally adopted among us.

1062. Without denying that there may be somewhat of truth in
this view of the subject, which, it seems to me, has not been suffi-
ciently attended to by the French, it may, nevertheless, be objected,
that as a general proposition, it will always be better to pass the
blades of the forceps immediately upon the temporo-parietal regions
of the head, than always to introduce them along the sides of the
pelvic cavity; that if it is rare to find the head situated directly across
the pelvis, it is at least common to find it turned towards one of the
acetabula, or sacro-iliac symphyses; that it is not only good, under
such circumstances, to have the forceps turned somewhat to the right
or left; but also, that it most commonly assumes that direction spon-
taneously; and, so to speak, in spite of the operator, provided the
head be pretty firmly fixed in the passage. Let us observe, further,
that by grasping the two ends of the occipito-frontal diameter, the
head is prevented from flexing; it is forced to descend transversely,
to present one of its longest diameters to the different passages, and
that if taken hold of in this situation, it cannot pass through the infe-
rior strait.

1063. To conclude, inasmuch as the occipito-bregmatic and oc-
cipito-frontal diameters always turn more or less directly from front
to rear when they reach the excavation; as in cases where the head
has not yet cleared the superior strait, the occiput or forehead al-
most always looks towards one of the cotyloid cavities; as the clams
of the forceps, after their introduction, naturally incline towards
the sides of the head, or when it opposes but little resistance to the
force exerted upon it, cause it to turn on its vertical axis, it may
be said that the difference between our practice and that of the
Germans is greater in appearance than in reality, and that, in fact,
it does not appear that it can ever be indispensably 'hecessary to
place one of the branches of the instrument in front and the other
behind.

USE OF THE FORCEPS. 473

1064. Thus the forceps may be applied to the head when the ver-
tex or the forehead comes first, and even when the trunk escapes be-
fore the head.

To render this application indispensable, it is necessary: 1. That
the head shall not require to be reduced more than two or three
lines, or that it shall be possible to displace it, and direct it more ad-
vantageously through the straits; 2. That there shall be a pressing
need for terminating the labor without delay, or that no further re-
liance can be placed on the powers of the woman in the expulsion of
the child; 3. That the head shall be engaged so far that it would be
impossible without difficulty to return it and proceed in search of
the feet; 4. That the membranes shall have been ruptured and the os
uteri completely dilated for a greater or less period of time.

1065. Previously to commencing the operation the same precau-
tions should be taken as for turning: the woman should be situated
in the same manner; however, there may be circumstances in which
the accoucheur need not alter her position; for example, in case of
convulsions, hemorrhage, or extreme debility, indeed any circum-
stances which would render any shock or movement dangerous;
but then the head must have cleared the abdominal strait, in which
case a short forceps may be made use of, such as Smellie's, for ex-
ample.

The posture on the side adopted by the English for spontaneous
delivery is also preferred by them as most favorable for the applica-
tions of the forceps, which I can hardly conceive of.

As it is wrong to iutroduce the forceps into a woman's organs,
without advertising her of it, I think the best mode of quieting and
reassuring her is to show her the mechanism of the instrument.

There should be in readiness some warm water to attemper the
instrument; and some butter, oil, or mucilage, to make it slip more
easily over the surfaces; when every thing is properly disposed of,
and the position of the head has been ascertained, nothing remains
but to introduce the blades; but as there is some difference in this ma-
noeuvre, according as the occiput is directed in this or that manner, as
the head descends before or after the trunk, I shall now proceed to
examine these different cases.

§. I. Occipito-anterior Position.

1066. This position, the most advantageous, and most frequent of
of all, requires that the left branch should be introduced first. Two
or three fingers of the right hand, in a flattened position, are to be
passed up betwixt the left side of the vagina and the parietal protu-

41*

474 use OF THE FORCEPS.

berance, so that their extremities may touch the os uteri; the instru-
ment is then taken by the left hand, as a writing pen is held, and the
handle is first raised up high in front of the woman's right groin, so
as to bring the other extremity in the line of the axis of the vulva or
inferior strait: as for the introduction of the hand, the interval be-
tween two pains must be chosen; it is introduced gently, without
force; in proportion as it enters, the handle is by degrees brought
from above downwards and from right to left, towards the median,
line; after this it is frequently necessary to place the thumb above
and to the right of the pivot, instead of leaving it beneath it; it
is thus moved onwards, making it follow the left posterior inclined
plane or front of the sacro-iliac symphysis, rather than the left side
of the pelvis properly so called, until its entablement shall have ar-
rived between the labia; after which the handle is brought near the
internal surface of the left thigh, depressing it more or less accord-
ing to the depth to which the blade has been carried.

During this introduction the point of the clam, held very strictly
betwixt the head of the foetus and the parts of the woman, ought
never to deviate from the curve of the excavation. By deviating
from the axes of that cavity, it would be arrested by the vagina,
which it turns up in folds, or might lacerate; if inclined too much in
front or to the rear, it would involve the bladder or rectum in the
danger of being wounded. On the other haad, by turning too much
inwards, which almost always happens in using a forceps with a very
concave blade, it abuts against the child's head, and is soon stopped
by the folding up of the scalp; so that in any way it would be dan-
gerous to introduce it by force.

Whenever, therefore, any resistance is experienced that does not
appear to be natural, instead of pushing it on with too much vio-
lence the instrument should be withdrawn a little ways so as to dis-
engage it, and afterwards slip it up in a more favorable direction.

Where the head has passed through the os uteri, as long as the
forceps does not abandon the fingers that are in the vagina, one must
be very awkward to go amiss; but this is not the case where the head
is almost inaccessible, and where the circle of the orifice still enve-
lopes it in the shape of a crown fitting more or less tightly. The
greatest attention is necessary here: if the end of the clam deviates
from the cranium, it slides over the outer surface of the os uteri, and
gets into the cul de sac, or circular groove formed by the vagina,
where it is attached to the neck of the uterus. If the accoucheur
should not perceive this deviation, it is easy, without pointing them
out, to comprehend the havoc and danger that might ensue. How-

OCCIPITO-ANTERIOR POSITION. 475

ever, in order to avoid them, it suffices never to make the instrument
penetrate beyond the parietal protuberances without being previously
assured of the position and state of the os uteri.

1067. When we are sure that the left branch is well placed, an
assistant takes hold of it and keeps it in contact with the thigh while
the physician introduces the other.

This one is to be taken in the right hand, and guided by the
fingers of the left, to the right side of the pelvis, or corresponding
sacro-iliac symphysis; to make it enter, we are to act exactly as
was just now directed, in speaking of the left branch. If the occi-
put is inclined to the left, we endeavor to move the blade forwards
behind the right thyroid foramen. If it be a right occipito-acetabu-
lar position, on the contrary, we leave it in front of the sacro-iliac
symphysis, while we endeavor to get the left branch behind the left
acetabulum.

1068. In order to be able to unite the two branches of the for-
ceps, they must both be at the same depth in the pelvis; the mortise
in one must correspond exactly to the pivot in the other; their place
of crossing must not be more to the right than to the left, and their
handles must be sufficijently depressed. When the occiput is behind
the symphysis pubis, it is sometimes difficult to fix them exactly
upon the sides of the pelvis; they incline towards each other at their
convex edges, while their concave edges tend to separate, which
doubtless depends upon the head being no't so thick towards the
forehead as towards the occiput. This difficulty may be overcome
by taking a firm hold of the blunt hooks of the forceps, so as to use
them as a bent lever of the third kind, but we should be very sure
that the obstacle depends upon no other cause. By following this
precept, the concavity of the blades comes to be applied over the
paiietal protuberances when the occipito-frontal diameter is in line
with the sacro-pubic, and, in the oblique positions, the vertex is dis-
placed, and promptly directs itself to the top of the arch of the pubis.

Further, it is evident that when the head is too firmly fixed, one
of the branches of the forceps will, under efibrts of this kind, resist
less than the other, and place itself under the corresponding anterior
inclined plane of the pelvis; so that the three occipito-anterior po-
sitions, so far, do not sensibly diffijr from each other as regards the
application of the instrument. The hand generally suffices to turn
the pivot, otherwise the kind of lever called the key of the forceps
is had recourse to.

1069. In the next place, we ascertain that the head is the only
part embraced by the blades, and that the os uteri, the womb, or some

476 USE OF THE FORCEPS.

other part of the woman is not taken hold of; the mode of acquiring
a degree of certainty upon this point, consists in moving the instru-
ment gently from handle to handle, in the direction of the axes of
the pelvis. If it moves readily, and without making the woman
suppose that she is getting torn ox pinched, there is nothing to fear;
in the contrary case, it is almost certain that some fold of the genital
organs has got pinched in the clams of the instrument, and until the
head shall have been more properly embraced, all pulling and every
species of pressure should be carefully avoided.

1070. In operating with a view to lessen the size of the head, a
loop of ribbon, of thread, or of a fillet is fixed on one of the blunt
hooks of the forceps; a turn is then made over the other branch, and
the handles are brought as near together as is deemed necessary; the
fillet is then carried over the first handle, then brought back over
the second, and so in the form of a figure 8 until it is all used;
it being well understood that the pressure exerted must be greater or
less, according to the degree of reduction which it is desirable to
obtain.

1071. Where the passage is capacious and the forceps is only
had recourse to for the purpose of speedily delivering the woman
this compressing method may indeed be dispensed with; neverthe-
less, as it is always well to have both hands disposable, so as to be
able to rest them from time to time, it seems to me better to apply
the fillet as recommended in all cases, with this difference, that
under the circumstances now supposed, it is employed solely for the
purpose of keeping the branches of the forceps in a fixed and pro-
perly approximated situation.

After having wrapped the handles in a napkin, the right hand is
placed near the blunt hooks, above as long as it is necessary to pull
in the axes of the superior strait, and below, on the contrary, when
the head is at the inferior strait; the left hand is applied at the roots
of the blades, beyond the pivot, below when the right hand is above,
and above when it is underneath.

1072. The forceps being properly held, and the head firmly
grasped, before we begin to pull downwards the occiput must be
directed diagonally, provided it be still at the superior strait; if it
be in the excavation, it is brought behind the symphysis pubis. To
compel it to descend to the centre of the pelvis, and to prevent the
forehead from descending prematurely, it has been recommended to
sustain the latter with a couple of fingers of the left hand; but I think
it would be wrong to place much dependence upon this precaution,
which, besides, deprives the accoucheur of a great portion of his

OCCIPITO-ANTERIOR POSITION. 477

power. I prefer trusting to the depression of the handles, to such an
extent as to keep the blades in the axes of the superior strait, and to
tractions performed in the same line of direction.

1073. If the head is locked, or too firmly fixed at the superior
strait, we first attempt to start it as we start a cork in a bottle or a
nail that we want to draw: it is then to be pushed up so as to oblige
the occiput to deseend in a more favorable manner. We are to
pull obliquely downwards and backwards until the strait is com-
pletely cleared; as soon as the rotation movement is efi'ected, and
the head is in a direct anlero-posterior position, we ought, in pulling
to move the handles of the forceps alternately right and left, until
the parietal protuberances have passed the ischiatic strait. These
tractions ought to be at once powerful, slow, and moderate; should
there be no reason for haste, we need not pull except during the
uterine contractions, which besides, rarely fail to become very ener-
getic and frequent, as soon as we commence the operation; but
when the very moments are counted, or the womb in a state of in-
ertia, it would be useless or dangerous to wait; we ought to act
immediately.

1074. When the head reaches the vulva and is retained only by
the soft parts, we leave off" pulling from handle to handle. We
ought even not to pull at all, provided the womb appears to have
preserved a sufficient degree of energy to enable it to terminate the
labor; for at this juncture it is highly important not to proceed too
rapidly, and to be assured that the best way of managing the peri-
neum is to retain the head as long as it may be at the vulva. In-
stead, then, of engaging the woman to bear down, and pulling at
the same time with great force, as we had previously done, she is
urged to be careful of making strong efforts; it is often best even
to withdraw the instrument, which, if the head be born, requires no
particular precaution, while, in the contrary case, the blades are re-
moved one after the other, holding them in the same way as when
they were introduced, and beginning with the right branch, which is
uppermost. Should it be afterwards necessary to exert any tractive
force, it might be effected by placing the fingers upon the temples or
under the arm-pits of the foetus, as is done in some cases of spon-
taneous delivery.

1075. Authors have expressly advised that the noise made by the
striking or rubbing of the two branches of the instrument together
should be avoided, because, say they, this noise might frighten the
woman. It would doubtless be imprudent to take no precaution on
this head, and to clash the blades together as we would the foils at a
fencing match; but I can perceive no reason for the minute precau-

478 USE OF THE FORCEPS.

tions that are indicated in relation to the matter in the latest publica-
tion on midwifery.

§. IL Occipito-posterior Position.

1076. The forceps ought to be introduced and fixed in the same
manner as in the former position; only, it is unnecessary to depress
the handles so much while drawing down: as the occiput, which
however ought to emerge first, constantly tends to lodge against the
anterior face of the sacrum and coccyx, which is very long and very
concave, more numerous difficulties must be expected, as well as
greater dangers to the perineum. But the operation would be still
more dangerous and difficult, if, as has by some been advised, the
concave edge of the instrument should be turned backwards instead
of looking towards the pubis. In the first place, to conform to this
precept, it would be necessary to change the posture of the woman;
and then it would be impossible to grasp the head at the superior
strait, otherwise than in a line from the anterior fontanel to the nucha;
in the third place, as the forceps would no longer be parallel with
the curve of the pelvis, its concave edge would, during the tractions,
of necessity press the vagina and bladder with violence against the
pubis, while the ends of the blades would operate in the same man-
ner, and still more certainly upon the soft parts behind. If, on the
other hand, the head should be grasped only with the view of turn-
ing the occiput round to the front of the pelvis, as it would be nearly
impossible to act at the same time upon the trunk of the foetus, we
should succeed only in wringing the child's neck. In this, as in
the occipito-anterior position, the forceps ought therefore to be so
placed that its concave edge may look forwards, even though it may
be turned towards the child's forehead, and not towards the occiput,
as the general rule would require.

§. III. Left Occipito-iliac Position.

1077. It does not appear to me that such a position, in the exca-
vation, is admissible; but should it ever be met with at the superior
strait, and require the application of the forceps, I do not see how
■we could dispense with following the precept of the German accou-
cheurs, unless indeed we should imitate M. Flaraant, and proceed
beforehand to take hold of the head with the hand and place it in a
more convenient position; a proceeding much easier to recommend
than to execute, in a majority of cases. The sacro-vertebral angle,
the coccyx and the perineum would not admit of the instrument being
placed transversely; at least, it would be absolutely impossible to ex-
tract in the direction of the axis of the superior strait.

PELVIS POSITIONS. 479

1078. Admitting, however, that the case may occur, this is the
advice given by the authors: the right branch of the forceps is to be
introduced first, and conducted with the ordinary precautions, in
front of the right sacro-iUac symphysis, as high up as the forehead;
then the ends of the first fingers of the left hand are placed under
its convex edge, and in concert with the right hand move it from
behind forwards and from right to left, until its concave edge is
turned towards the left iliac fossa, and the blade has arrived upon
the right parietal protuberance. The handle, strongly depressed,
is then given to an assistant, who holds it against the woman's left
thigh.

1079. The left branch is held in the left hand, and passed up
along the posterior part of the pelvis until its point is above the su-
perior strait, and the pivot even with the mortise that is in the other
branch. After having joined them and dislodged the head, if it be
still in the superior strait, and forced the occiput to descend into
the excavation, provided it were not already there, the concave
edges of the instrument are gradually brought to the front, and the
remainder of the operation is conducted as in the occipito-pubic
positions.

§. IV. Ri^ht Occipito-iliac Position.

What I have just now said of the left occipito-iliac position is en-
tirely applicable to the right occipito-iliac position; they only differ
from each other in regard to the application of the forceps, in doing
which the left branch is to be introduced first.

§. V. Positions of the PelTis.

It may happen that after the child has been drawn down by its
pelvic extremity, great difficulty shall be experienced in attempting
to disengage the head. The same thing may be met with at the
close of a pelvis labor which up to that moment had exhibited no-
thing peculiar; if the fingers and hands do not suffice for the deli-
very of the woman, it will probably be found that it is occasioned by
a contraction of the pelvis, more or less considerable, in which case
the forceps may be of little avail. However, it must be tried, rather
than resort to symphyseotomy or the cesarian operation, particularly
provided the head is below the superior strait.

If the occiput is in front or a little to one side, an assistant should
raise the trunk upwards, and first the left branch, then the right is
introduced, following the same rules as if the head had descended
first.

If it is behind, and it be found impossible to turn it round to the

480 USE OF THE FORCEPS.

front of the pelvis by means of the hands, the foetus is to be turned
back over the perineum, and the branches of the forceps are still to
be introduced as before.* But in extracting the head we should en-
deavor to act with sufficient force upon the forehead and chin to
make those parts descend early under the symphyses of the pubis.

Lastly, should it be found on one side, the trunk ought first to be
moved to the right or to the left, and then we should proceed as has
been directed for the corresponding positions of the vertex.

Thus, in all cases, the trunk is to be turned towards the direction
in which the occiput looks, and the forceps introduced along the
sides of the head, in such a way that the concavity of its edges may
be towards the front, or shall be brought there in the progress of the
operation.

1080. It is easy to perceive that the presence of the trunk must add
to the difficulties that are experienced in head presentations. Still,
many practitioners have thought, that under such circumstances the
fingers might be beneficially substituted for the forceps, and that it is
entirely useless to attempt its application where the head has not
yet reached the excavation.

This seems to me to be dangerous doctrine. I know very well
that a skilful accoucheur will generally triumph over the difficulties
presented by this position without having recourse to the forceps; I
am also aware that the forceps, here, cannot easily be applied to the
head at the superior strait; but it is also undeniable that the head
may be arrested at the superior strait by such a degree of contraction
that the best combined efforts of the hand shall be insufficient for its
extraction; but, why should not the forceps oflfer the same advan-
tages in this case as in the positions of the vertex? Moreover, ex-
cepting symphyseotomy, what other means is there of extracting the
fcEtus alive? I will add, that, the trunk being without, and the head
in some measure beyond the reach of the uterine contractions, any
force exerted upon the body with the hand, and sufficient to enforce
its passage through the organs, will generally act on the spine of the
child to the extent of seriously compromitting its existence, whereas
the forceps does not expose it to the same dangers.

1081. Consequently we may have recourse to the forceps, in pel-
vis presentations, 1. When the head is stopped by the inferior strait
only, and we are convinced that the powers of the hand alone

* The woman should lie on her back, with the perineum projecting over the
foot of the bed. If the body of the child be now supported in a vertical position
by an assistant, it will be found that there will be space enough to introduce the
forceps on each side of the face. I have, in general, found the application of the
forceps quite as easy in a footling or pelvis case as in any vertex presentation. — M..

DETRUNCATED HEAD IN PELVIS. 481

would be insufficient, or too dangerous; 2. When the same part has
not cleared the superior strait. But then, it must be engaged in it,
or at least the face must be chiefly in the excavation, and it must be
possible to reach the os uteri with some of the fingers. It is well
understood, moreover, that in both cases, the chin must have been
previously forced to descend, the head must have executed its rota-
tion movement, and the shoulders must have been disengaged.

§. VI. The Child is completely or partially
Double.

1082. In cases where two children are united to each other at
their anterior or posterior surface, and where two large heads are
supported by a single trunk, it is possible that the efforts both of the
woman and the accoucheur, although properly combined, may be in-
sufficient to effect the delivery without the aid of the forceps.

If the trunk or the two trunks have escaped, it will be necessary,
in order to admit of the application of the instrument, that one of the
heads shall be in the excavation; nor, provided the monstrous foetus
should present by the vertex, ought this instrument to be reject-
ed, although neither of the two heads should have cleared the supe-
rior strait. In the former case, that is to say, where the trunk is de-
livered, the head nearest the posterior plane of the pelvis ought to
come down first, and in the latter, on the contrary, that one which is
naturally turned towards the pubes.

Finally, the operation, if conducted agreeably to the general rules
indicated higher up, would require no other precaution than that of
raising the handle of the forceps forcibly upwards at an early
period, and to pull, almost from the commencement, in the line of
the axis of the vulva. This would be the only way to avoid forcing
the second head, still contained in the womb, to reverse itself, or to
remain hitched, as it were, above the pubis or the sacro-vertebral
angle.

§. VII. The Head, separated from the Body,
remains alone in the Pelvis.

1083. Formerly so litde care was taken in regard to the extractive
force exerted upon the fostus, when it was deemed necessary to de-
liver it footling, that it was not very uncommon to see the neck sepa-
rate from the head and the trunk, being torn off during the violence of
the exertions. At the present day this accident could happen only
to the most ignorant or thoughtless practitioner; for it is never
allowable to employ a force with the hand alone, sufficient to pro-
duce the occurrence. It is only where one of the passages, of size

42

482 USE OF THE FORCEPS.

sufficient to admit of the transit of the trunk, is so contracted as
completely to arrest the head, that it might perhaps become useful to
separate the portion of the cliild that is without from that which
remains enclosed within the genital organs.

But admitting that this necessity does exist in some cases, it still
must be very rare, since the delivery of the body does not absolutely
prevent the application of the forceps to the head; nevertheless, as
we unfortunately meet with a good many persons who undertake the
practice of midwifery without possessing the least knowledge of the
subject, it would be imprudent for the educated practitioner not to re-
flect upon what he would do if called to a woman whose foetus had
been thus detruncated, either voluntarily or involuntarily, by immode-
rate pulling or by means of an instrument.

1084. In the first place, the head must be placed in a proper
situation, that is to say, its occipito-mental diameter must be adapted
to the axes of the pelvis, and the face turned backwards.

When in the excavation, it is almost as easy to get hold of it as
if it were not separated from the body. At the superior strait, the
operation is often found to be one of the utmost difficulty, and appears
to be even impracticable, when the womb is scarcely contracted,
and the face and occiput are not yet engaged. When the head is
firmly fixed by the contraction of the uterus, or when it can be kept
still with the hand so as not to slip out of the grasp of the instru-
ment, we are to proceed just as if the body were still attached; only,
in order to make surer of its not turning so as to put the occipito-
frontal in place of the occipito-mental diameter during the process
of extraction, we should endeavor to steady it by applying a couple
of fingers of the hand that holds the root of the forceps near the
vulva, to the face or chin.

§. YIH. Recapitulation, on the Employment
of the Forceps.

In bringing this article to a close, 1 think it a duty to repeat the
following corollaries:

1. The forceps ought never to be applied without an evident
necessity, because, although it might not be mischievous to the
child, the mother may receive the greatest injury from it.

2. In the practice of good accoucheurs the forceps is scarcely
employed once in two hundred labors;* and as every thing tends to

• Dr. Collins, page 10, tell us that during his mastership of the Dublin lying-
in Hospital, in 16,414 deliveries the forceps was used only 24 times, and the lever
three times, making 27 cases in all, or one case in 608 deliveries. It is to me
inconceivable, that, viewing the class of the population which resorts to that insti-

DETRUNCATED HEAD IN PELVIS. 483

show that the ergot will be advantageously substituted for it in a mul-
titude of cases, its employment will doubtless continue to be more
and more rare. Most of those who make a more frequent use of it
are not wrong merely because they perform an operation that is use-
less, but also, and especially, because they needlessly derange the
progress of a natural function; and because they voluntarily expose
themselves to the risk of complicating the sequel of delivery, even
admitting they are sure of not wounding any organ.

3. The forceps cannot be beneficially applied, except to the head,
either when it descends foremost, or when it follows the trunk of the
body.

4. It is much more to be relied on for the purpose of grasping, and
extracting the head, than for diminishing its size.

5. It is not allowable to introduce it into the wonib until the orifice
is sufficiently dilated, and the head ceases to be movable and loose
above the superior strait.

6. As far as possible, the blades of the forceps ought accurately to
embrace the two sides of the head in the direction of the occipito-
mental diameter; nevertheless, where some difficulty or doubt is ex-
perienced, it is more convenient and more prudent to pass them up
along the sides of the pelvis.

7. Except in the right occipito-iliac position, if it ever does occur
and we should wish not to grasp the head by the occiput and fore-
head, the left branch must always be introduced first, because it is
the undermost.

8. In whatever manner the branches are introduced, their concave
edges must be ultimately brought in front; but if the head had been
seized by the ends of its occipito-frontal diameter, and had not, while
descending, rotated between the clams of the instrument, it must be
abandoned at the inferior strait, to be taken hold of more advantage-
ously, should the forceps still continue to be necessary.

9. The extraction should always be performed in the line of the
axes; always with gentleness, never precipitately, nor by jerks; the
tractions from handle to handle are of no use after the head occupies
the vulva, and if performed while it is at the superior strait, would
sometimes be dangerous.

10. It is not only because it has become useless that the instru-
ment should be taken off" when the head, at the lower strait, is only
resisted by the soft parts, but also, and chiefly, in the view of avoid-

tution, many more examples should not have occurred requiring the application of
the instrument. Perhaps, had the forceps been less timidly resorted to, the ratio
of cures or recoveries already so honorable to that house, would have been still
more creditable to it. — M.

484 THE LEVER.

ing laceration of the perineum, and allowing the vulva to dilate more
slowly and regularly.

ARTICLE III.
Of the Lever.

SECTION 1.
Of the Lever in itself considered.

1085. Herbiniaux, and Denraan, the British Baudelocque, have
decidedly maintained that the lever is incomparably superior to the
forceps; and notwithstanding that it has not been so highly thought
of in France, it has occupied much of the attention of the physicians
of our country since the middle of the last century.

1086. Its inventor is no better known than that of the forceps.
Was the idea of it derived from the uncus of Celsus or the curette
of the lithotomists? Is it the instrument made use of by the Cham-
berlains, as Mulder pretends, or the spoon of Palfyn, or one of the
branches of Smellie's forceps, variously modified? Still it is true
that Roonhuysen, who made a secret of it, acquired celebrity as an
accoucheur, by means of a peculiar instrument, since used under the
title of Roonhuysen's lever. This instrument, which, from Roon-
huysen passed into the hands of Bruyn, was purchased and made
public by De Vischer and Van de Poll in 1753; but, as was the case
with regard to the forceps, a great number of very discrepant ac-
counts of it appeared in the course of a short time; there was soon
a lever by Boom, another of De Bruyn, a third by Titsing, one by
Palfyn or Heister, one by Cole, one by Griffith, a lever by Wathen,
one by Aitken, &c. There was no less discrepancy upon its mode of
acting: according to some it was to be applied to the occiput, potentia
agit in os occipitis, was the family secret; according to others it was
to be applied to the temples. Titsing directed it to be applied to the
mastoid process; and lastly, others thought it should be fixed upon
the side of the chin. As to its advantages, if De Bruyn was to be be-
lieved, they were immense, no difficulty could withstand it, whether
the head were reversed, arrested or locked, the lever triumphed over
them all, and by means of this marvellous instrument, the Dutch ac-
coucheur pretends to have unlocked eight hundred heads in the course
of forty -two years. The French authors have, on the contrary,

THE LEVER. 4^5

maintained that it is only useful in correcting the positions of the
head, in compelling the reverted occiput to replace itself at the centre
of the pelvis.

1087. However this may be, instead of a bar of steel about ten
inches long by an inch and a half in breadth, curved at each end like
a spatula, enveloped in adhesive plaster, according to De Bruyn, or
chamoy leather, as Boom says; instead of a simple spatula or kind
of flat spoon, the handle of which was terminated by a broad ring,
which constituted the lever of Titsing, the modern lever, such as it
appeared when modified by Pean and Baudelocque, is nothing more
than one of the branches of Smellie's forceps, very much elongated,
without its notch, and very little curved. This stock, the blade of
Avhich is very widely fenestrated, and the root supported by an ebony
handle, has also been itself modified in a great variety of ways by
the moderns, either in regard to its length, or the degree and shape
of its curve, or because some have added a joint in the stock, so as to
bend and make it more portable.

SECTION 2.

Use of the Lever.

1088. Subsequently to the idea originated by the axiom of Roon-
huysen, and which has particularly been adopted among us, it was
generally agreed that the lever is not destined to supply the place
of the forceps, that at most it can but serve to restore the flexion-
movement of the head, by hooking down the occiput; thenceforth its
employment necessarily became much restricted, for under those cir-
cumstances the fingers almost always suffice, and if, after all, any in-
strument were necessary, one of the branches of the forceps would
answer as good a purpose as the lever itself.

But this is not the view the English accoucheurs take of the
subject, nor that taken by its inventors, nor indeed is it a correct
one.

1089. The lever is an instrument that is applicable to two diffe-
rent objects: on the one hand, it may be employed for the purpose
of restoring or reducing the head to its natural position; and on the
other, it is possible to make use of it, as we do of the forceps, to
extract the head when it has descended into the excavation. In
the former case, the fingers, or one branch of the forceps, might,
strictly speaking, in most circumstances, be substituted for it: but, in
the latter, I am convinced that it is susceptible of advantageously
taking place of the forceps, and that pretty frequently. In the first

4JJ*

486 THE LEVER.

case it acts upon the occiput, or on a parietal protuberance like a
simple crotchet; in the second, it really performs the office of a
lever of the first kind.

As a crotchet, the'lever offered for sale by the different cutlers in
the vicinity of the Ecole de Medecine, and which is very nearly the
instrument modified by Pean and Baudelocque, leaves nothing to be
desired; as a lever, I prefer one that is rather shorter, and that may
shut up by means of a hinge joint, which does not at all diminish its
strength; further, it ought to be strait from the extremity of the
handle to within about three inches of the end of thS blade; the
latter should be broad, oval and ending in a long flat root, which
narrows, gradually, to continue into the handle; its curve should be
considerable, at least greater than that of the forceps; with the ex-
ception of the middle part, its concavity, that which ought specially
to bear upon the head, it ought to be very well polished; and lastly,
in the construction of such instruments the best steel ought to be
selected.

§. I. Use of the Lever as a Crotchet.

1090. If then it be intended to make use of the lever in con-
formity to the principles of the French authors, it must be taken
hold of with the right hand for the right occipito-iliac position, and
with the left hand in a case of the left occipito-iliac position, and
with either hand in the antero-posterior positions. Introduced with
the same precautions as if it were one of the branches of the for-
ceps, it is passed up between the surface of the genital organs and
the child's head, until it gets beyond the occipital projection or pari-
etal protuberance, and in such a way that its concavity may be easily
applied to one of the parts above mentioned; as, in the occipito and
fronto-pubic positions, it is impossible to pass it up directly behind
the occiput, it must be at first carried a little to one side, and after-
wards conducted on the part which it is intended to depress; when
it is well placed, the hand that directed the blade takes hold of
the root of the instrument; in order to make sure that it shall not
slip, and that the back of it shall not rub against the soft parts of the
woman, the operator should employ the extracting force with the
hand that holds the handle, in a direction backwards, forwards, or
sideways; in short, in a direction opposite to that pointed to by the
protuberance which he wishes to depress. In general, the intervals
between the pains is to be selected for acting and as soon as the ver-
tex has reached the centre of the pelvis, the operation is complete;
the instrument is to be withdrawn, and the labor abandoned to itself;
or, if necessary, other means of assisting it are resorted to.

USE OF THE LEVER. 487

§. II. Of the Ijcver used as a I^ever,

1091. The use of the lever after the manner of the Dutch and
English accoucheurs, that is, as a substitute for the forceps, is very
simple as to its mechanism: in the first place, it is best that the head
should be in the excavation; then that it should have already, or at
least chiefly executed its pivot-movement; in the third place, that
there should be but a slight degree of contraction of the inferior
strait, or that the retardation of the labor should depend solely upon
a want of action of the womb, or of the woman herself. What-
ever may be the position of the head, the right hand must be
made use of for extracting with, at least in all cases where the ac-
coucheur is not left-handed; for the purpose of introducing it, we
have recourse to the right hand, if the lever is to be passed upon
the right side of the pelvis, and to the left hand in the contrary
case.

1092. Where the occiput is in front or somewhat to the left, the
left hand introduces the lever, as if it were the right branch of the for-
ceps, in front of the right sacro-iliac symphysis; when it has passed
up sufficiently far, the action of the two hands is combined so as to
guide the concavity of its blade on to the right temporo-parietal re-
gion, that is to say, in the direction of the occipito-mental diameter,
and on the same parts that would be embraced by the corresponding
blade of the forceps. The left side of the vertex is supported by the
fingers of the left hand; the thumb, placed near to the vulva, em-
braces the back of the lever, to which, conjointly with the right side
of the pubic arch, it serves as 2. point d'appui; we are now to wait
for a pain, and then draw down slowly but strongly, as^ if we were
making a lever of the first kind swing from below upwards, and from
left to right; the head 'generally yields readily; it is gradually drawn
down in the axis of the inferior strait, which it clears as it executes
its extension-movement.

In this way the force exerted upon the head acts in a direction
from the chin towards the occiput, or in that of a line drawn from
the angle of the right jaw to the left side of the vertex; so that, as
it is supported elsewhere by the left side of the pelvis, there is no-
thing surprising in the circumstance that it allows itself to be so
easily extracted.

1093. Should the occiput be on the right side, in the second posi-
tion for example, the lever ought to be introduced with the left hand
but then it must be changed, as above, and the right hand seizing the
handle of the instrument, should also extract in the same manner,
with this difference only, that the see-saw movement should take
place from right to left, and not from left to right.

488 THE LEVER.

Should the vertex be turned backwards instead of towards the
front of the pelvis, the lever ought to be applied to the temporo-
parietal region, in the direction of the occipito-bregmatic diameter,
and the see-saw should be performed in such a way that the occiput
which ought here to support the principal effort, may escape first, in
front of the perineum, and be strongly raised towards the centre of
the vulva; this position is less favorable than the other, without
doubt, but still, it is not very difficult.

1094. I know that what the lever effects under these circum-
stances could be equally well done by the forceps, and perhaps with
more certainty; and indeed, it is not my design to substitute the
former of these instruments for the latter; I have merely wished to
show, that among us, the mechanism of the lever has been generally
misunderstood; that its employment, without being indispensable,
is perhaps not to be despised; and that its application is too simple,
too harmless, as compared with that of the forceps, for it not to
be had recourse to where the head presents at the perineal strait, and
appears to be arrested only by want of action of the woman's organs;
I will even add that its introduction will often be attended with the
great advantage of exciting the uterine contractions, as well as those
of the abdominal muscles, and thereby of accelerating, at least in-
directly, the termination of the labor, without exposing either the
woman or her child to any danger; I am happy, moreover, in find-
ing myself supported in almost the whole of this doctrine by M.
Desormeaux.

ARTICLE IV.

Of the Fillet.

lt)95. The noose consists of cloth, thread or silk, wool, leather,
or cotton, sometimes strengthened by the addition of bulrushes,
whalebone, brass-wire, or plates of iron or steel, variously inter-
laced and worked, and which was formerly applied to different parts
of the foetus, so as to effect its extraction. The employment of
these means is of a very ancient date, and doubtless extends back as
far as the age of Hippocrates. Previously to the discovery of the
forceps and lever, the noose and fillet were the only instruments
made use of for the extraction of the child, where there was some
hope of preserving its life. Avicenna recommends that they should
be applied to the trunk; but it was particularly with a view of fixing

THE FILLET. 489

it upon the head that Mauriceau, Pugh, Smellie, Burton, and others
thought of a sort of purses, sheaths, or caps, slings, and little bands,
which are now wholly forgotten. If the forceps is a substitute for
all the various nets that were formerly applied to the head, turning by
the feet, which is better understood, and especially better executed
than it was previously to the last century, also renders superfluous
all the fillets which certain accoucheurs used to apply to the trunk
for the purpose of extracting it artificially; so that at present the
noose is merely a strip of linen, silk, or worsted, about an ell in length
and an inch wide, by means of which a limb that has escaped from
the organs is secured, while we proceed to search for the other one,
or the rest of the foetus. Some persons, however, still make use of
it for the purpose of employing extractive force upon the ham, the
groin or the axilla; but as the blunt hook or fingers always offer us
greater advantages, they are really useful only when applied to the
V7rist or ankle in arm presentations or in turning and delivery by the
feet.

1096. In order to apply it, the strip is in the first place to be
doubled; then a slip-not is made upon it and held apart with the
end of the thumb and two or three of the fingers of the hand which
is to take hold of the foot or hand of the foetus; after this, it is slipped
up and secured with the other hand, the noose being fixed above the
articulation of the tarsus or carpus; it is then given in charge to an
assistant who is to hold it, but witliout pulling it, while the operator
proceeds to search for the other parts that he wishes to bring down
to the inferior strait. When both of the lower limbs have been
brought down there is no further use for the noose, provided it had
been secured upon the leg; if it is upon the wrist it may still be of
service in keeping the arm extended along the body, and conse-
quently in favoring the delivery of the corresponding shoulder. To
conclude, the noose is a means whose application at the present day
is confined within extremely narrow limits, and whose mechanims
is too easily understood for it to be needful that I should say any
thing further about it here.

ARTICLE V.

Of the Locked-Head.

1097. According to Peu, who was the first writer to speak of it, the
head is locked in the passage whenever it is firmly held betwixt the

490 LOCKED-HEAD.

pubis and sacrum, without being able to advance or recede, and so
that it is almost impossible to apply the instrument to it. Accord-
ing to De la Motte, the head, when locked, is griped by the bones
of the pelvis, like the key stone in an arch. Roederer presents
another view of it: he thinks that in order to constitute locked
head, the head must be so embraced in the strait, or in the excava-
tion, by every point of its circumference, that a lamina of metal or
the smallest probe cannot be passed between it and the organs of
the woman. Baudelocque says that the head is locked, whenever
it is fixed at the superior strait by the two extremities of one of its
diameters, so that it can neither advance under the influence of the
natural powers, nor be forced back by the hand of the accoucheur.
Baudelocque's definition, which has been adopted by all modern ac-
coucheurs, and slightly modified by M. Desormeaux, is without con-
tradiction the most correct, and may be construed as follows: the
head is locked in the pelvis whenever two diametrically opposite
points of its superficies are so compressed that it cannot possibly
descend under the influence of the expulsive power alone, and when
it cannot be pushed up without the very greatest difiiculty. The
locked-head, according to the view of it presented by Roederer, or
paragromphosis, cannot possibly occur. Madame Lachapelle will
not even admit the existence of any species of it, and thinks that all
that has been written under that title ought to be referred to vicious
conformations of the pelvis, to bad positions of the head, or, lastly,
to powerful and permanent contractions of the uterus.

1098. However this may be, locked-head has become very rare
at the present day, and De Bruyn, who pretends to have met with
eight hundred cases of it in the course of forty years, Berkman and
Titsing, who cite two hundred and sixty-two cases in nineteen
years of practice, must have had a different idea of it from ours.
It is to me evident, from the accounts given by Camper on this sub-
ject that the Dutch accoucheurs gave the denomination of locked-
head to all cases in which the head, from being arrested in any way
in the pelvis, makes the employment of Roonhuysen's lever necessary;
so that what they have said concerning locked-head has almost no
connection with what has since been written by Baudelocque under
that title. Dr. Dewees, who treats of locked-head upon the princi-
ples of Baudelocque, is astonished that he scarcely ever meets with
it, and thinks that the circumstance depends upon the American wo-
men having better formed pelves than the European women; but he
would probably hold a different language if he knew that Madame
Lachapelle never met with it at all, and that but a few instances of
the kind are met with in the course of a year.

LOCKED-HEAD. 491

1099. In the first place, the case where the head is simply fixed
at the superior strait, because the liquor amnii has been long dis-
charged and the womb is closely contracted upon the body of the
child, must not be confounded with locked-head, nor that case where
it stops in the excavation, betwixt two very contracted straits, and
after having with great difficulty cleared the superior pelvic circle,
nor those in which its escape is prevented by the resistance of the
perineum or narrowness of the inferior strait.

1100. The head can scarcely become locked except between the
pubis and the sacrum, at the superior strait; further, in order that
it may happen at all, the conjunction of a great number of condi-
tions is required; 1. That it shall present in a direct manner;
2. In a well formed pelvis, it must be of enormous size; 3. The
narrowness of the pelvic cavity shall not exceed a certain degree;
and there shall be a space of two inches and a half between the
sacrum and pubis for an antero-posterior position, or three inches
for a transverse position; for, locked-head cannot take place except
where the head can get as low down as the level of its greatest
thickness; 4. The uterine contractions must have been energetic.

Among these conditions there is one upon which I must dwell
for an instant. I find a difficulty in conceiving how the occipito-
frontal diameter can really get fixed in this way in the sacro-pubic
diameter. The ends of the lever, which it may be considered to
represent, are too unequal for its occipital portion to fail to come
down first, especially when the efforts of the woman react violently
upon it through the intermedium of the vertebral column; it seems
to me, then, much more probable that it is the occipito-bregmatic
diameter that becomes locked, and that the head may be retained
betwixt the sacrum and pubis, as well by any one of the other dia-
meters of the occipito-bregmatic circumference as by the bi-parietal
diameter alone.

We may further admit, along with M. Desormeaux, that locked-
head may sometimes take place in the excavation, when the sacrum,
flat, or nearly flat, makes the head pass along a canal that gradually
diminishes in size, as it descends, until at last it cannot turn upon
its axis, nor advance nor recede, beyond a few lines, tovvards the
superior strait.

1101. Tumefaction of the lips of the os uteri and external organs
of generation, and extreme degree of swelling of the hairy scalp and
over-lapping of the cranial bones, have been given out as signs of
locked-head; but most of the phenomena may take place without
the locked-head, and are therefore no sufficient basis for a sure
diagonisis.

492 LOCKED-HEAD.

The pathognomonic sign, in these cases, is derived from the fixed-
ness of the head, which, in spite of the energy of the pains, makes
no advances for several hours together. While the pain is present,
it seems to advance a little; but immediately afterwards it rises again
up to the same point it occupied before; if the accoucheur endeavors
to push it up again with his hand, he finds that it is immovable, and
cannot succeed in dislodging it but with the greatest difiiculty. It
should also be understood that, by elongating, the head may appear
to descend, and approach near to the vulva, although its position
does not really undergo any alteration. This circumstance must be
what has so often deceived the accoucheur, making him suppose that
the superior strait was cleared, while in fact the occipito-bregmalic
circumference was not as yet engaged in it. An examination is
made; the vertex is found a few lines from the vulva, whence the
conclusion is drawn, that it hag descended into the excavation: to
avoid this mistake, and understand it, the practitioner should re-
member, 1. That the symphysis pubis is only from eighteen to
twenty-four lines in depth, and, consequently, that the swelling of
the cranial integuments may easily bring the vertex down even with
the vulva, although the parietal protuberances are still at the superior
strait; 2. That the finger must be carried backwards, especially, and
not merely in front, when we wish to ascertain what part of the pel-
vis is occupied by the head; and, 3. That the locked-head may take
place below the superior strait.

1102. There are several degrees of this cause of dystocia: some-
times the disproportion between the head and pelvis is so small that
it only results in a somewhat slower labor and more fatigue for the
■woman; at other times it is so great as to render the delivery exces-
sively diflScult, but absolutely impossible without assistance, provided
the contractions are well sustained; again, lastly, it is so great, that
nature is absolutely unable to triumph over it, and the resources of art
become indispensably necessary.

In the case first mentioned, the locked-head is not very dangerous,
and ordinarily is accompanied only by a slight degree of irritation
and disposition to inflammation.

In the second arid third, it constitutes a serious accident, both as re-
gards the mother and the child. The pains, which follow each other
to no purpose, though strong and frequent, at length end in a state
of general exhaustion and inertia, should the woman even be so for-
tunate as to escape an attack of inflammation of the womb or perito-
neum, a flooding, or convulsions. The bladder the rectum, the va-
gina, the urethra, and other soft parts in the pelvis, from being long
and severely compressed, may become contused, ulcerated, or gan-

LOCKED-HEAD. - 493

grenous, and give rise to fistulas that are too commonly incurable,
or to some other alteration equally terrible. The compression of
the nerves, and of the vessels in particular, may give rise to para-
lysis, tumefaction, and the infiltration of the lower limbs and vulva;
the symphyses themselves, from being violently distended, occa-
sionally run some risk, where the expulsive efforts are vigorously
sustained.

The long continuance of the labor after the discharge of the
waters, and the direct action of the contractions upon the body of
the child, expose it, in the first place, to the same accidents as all
long and difficult labors, that is to say, to asphyxia and death.
Again, the head, particularly where the pelvis is badly formed, as
tlie sacro-vertebral angle is very salient, cannot adapt itself to the
straits or excavation, as in a mould, without the brain itself under-
going a dangerous, and sometimes fatal compression. It may also
be followed by fractures, and external or internal extravasations,
lacerations, &c.

1 103. It is clear that, in order to avoid so many dangers, the prac-
titioner ought promptly to interpose for the assistance of the power-
less organism; but by acting speedily there is risk of acting unne-
cessarily; by waiting he may lose the opportune moment; how then
are these two extremes to be avoided? The well-informed physi-
cian will readily succeed in this difficulty by taking care not to lay
it down as a principle, as has been recently done in some medical
journals, doubtless from oversight, that he must make haste to ex-
tract the child with the forceps, whether the head is locked or not,
whenever it has remained an hour or two in the excavation; the
woman ought never to be assisted in this way until there is a cer-
tainty that the head will not pass the passages spontaneously, or that
the delivery will not take place without exposing the patient to the
accidents heretofore indicated.*

1104. Turning by the feet, as recommended by the ancients,
must not be performed merely because the head is really locked;
the slings, bandages, and fillets would in such cases be wholly in-
sufficient, and are at present no longer recommended by any body.
The lever, the spatula, and the separate branches of the forceps,
so much lauded by the accoucheurs of the last century, were suc-

* From reading this sentence one might infer that the forceps are applicable
only for the safety or comfort of the mother; but, surely, the security of the off-
spring demands a share of our attention, and the legitimate uses of the instru-
ment are as frequently connected with the infant as with the parent. Many
children are rescued from death by speedy delivery with the forceps, the instru.
. ment being employed solely in their behalf. — M.
43

494 LOCKED-HEAD.

cessful only because they were employed in cases very different from
those which are understood to be locked-head at the present day.
Roonhuysen's instrument is manifestly incapable of compelling the
head to descend, where there is a disproportion between it and the
straits; it might, at the most, serve to dislodge it and give it a more
favorable position, and in that case it would not be absolutely locked.

1105. It is otherwise with the forceps, which admits of the ef-
forts of the accoucheur to be conjoined with those of the womb and
abdominal muscles. However, as the clams can be applied only
upon the sides of the pelvis, some practitioners have objected that
by compressing the head in a line from right to left, this instrument
might augment the pressure already experienced from front to rear,
instead of diminishing it; that it is better calculated to give rise to
locked-head than to relieve it; and consequently, more dangerous
than useful; but these fears, inspired by a theoretical view of the sub-
ject, must yield to facts; besides, it is not correct to say that the
diameters of the head gain by compression in one way what they
lose in another; I repeat that I am certain the forceps succeeds in ex-
tracting the locked-head far more by compelling it to traverse a circle,
which acts upon it like a ring, than by reducing it by means of a di-
rect pressure.

Should it not succeed, and the child were ascertained to be dead,
recourse should be had to cephalotomy, and then to the crotchet; but
if the foetus were still living, the operation of symphyseotomy would
be indicated, and ought to be preferred to the cesarian operation,
which, in such a case, can never be necessary.

ARTICLE VI.

Of the measures rendered necessary hy narrowness of the

Pelvis.

"When the pelvis is so deformed as to render delivery impossible,
even with the assistance of the means I have now passed in review,
there remain only three kinds of resources for the delivery of the
woman: 1. To act upon the foetus so as to lessen its size; 2. To in-
crease the size of the pelvis; 3. To extract the child by an artificial
passage. As these three modes of delivery are excessively dan-
gerous, whether to the mother or her offspring, it is necessary, pre-
viously to putting them in practice, to determine in what cases they
are really indispensable.

TOO SMALL A PELVIS. 495

1106. To attain this object, the accoucheur ought to know the
exact dimensions of the head and pelvis, in those diameters which
correspond to the diameters that correspond to each other in the
different stages of labor; also, to know how far the head is capable
of being reduced, and what amount of courage and energy are likely
to be exhibited by the woman; but these notions can only be ac-
quired approximatively. Notwithstanding the numerous cephalo-
meters proposed by various authors, and in spite of the means re-
cently indicated by M. Fouilhous, we must still depend upon the
finger for the most certain result under such circumstances: and,
with the exception of M. Flamant, what practitioner is so bold as
to dare to pronounce that the dimensions of a head he has just
examined are, within from two to three lines, of precisely such or
such an amount? The degree of solidity of the pelvis, the form of
the contracted strait, and the direction of its axes, also deserve the
most serious attentions: for example, the symphysis may be soften-
ed to such a degree as to admit of the bones sliding one over the
other, so that one os pubis may extend in front, while the opposite
coxal bone falls backwards, which would render the corresponding
oblique diameter so much longer. According to Deventer and Ma-
dame Lachapelle, the two hip bones may also be both carried for-
wards by the forcing of the sacrum into the space between them,
and thus give rise to an unexpected augmentation of the sacro-pubic
diameter. If the superior strait is of the shape of a figure 8, or if
the contraction occupies only one side, the head being situated trans-
versely, with the occiput towards the widest part of the pelvis, may
sometimes traverse the canal notwithstanding a considerable degree
of contraction.

Where the axis of the strait approaches that of the spine, the two
extremities of the bi-parietal, or the occipito-bregmatic diameter will
be compelled to engage at the same time, and will require a space of
about three inches. Should it, on the contrary, be very much in-
clined to the front, one of the parietal protuberances might engage
before the other, so as to give a gain of three or four lines in the act
of passing through the pelvic circle.

On the other hand, a head that is very flexible, and energetically
urged onwards by the uterine and muscular contractions of a vigo-
rous woman, may be elongated and moulded in the passages, be con-
siderably reduced (Denman says, to one-third of its original vo-
lume), and, according to Baudelocque, attain to the length of eight
inches, while its thickness is proportionably diminished; it may be-
come so much flattened as to pass through a strait of two inches
and a half, and recover its ordinary volume within the excavation,

496 TOO SMALL A PELVIS.

if we may give credit to the assertions of De Boer; and, in all cases,
admit of the child's being born alive. Lastly, how many women are
there who have been fortunate enough to bring their children into
the world without any aid, when in their previous confinements they
could be delivered only by symphyseotomy, the cesarian operation,
or embryotomy! Here, then, the operator stands in need of all the
integrity of a sound judgment, of prudent and sage counsels, of
attention to a thousand diversified circumstances, and of proceeding
only with extreme caution, if he desires not to compromise the dig-
nity of his art, or the safety of those beings who look to him for the
conservation of their existence.

1107. Instead of accommodating itself to the form of the open-
ings, the head may be fractured, or the brain mortally compressed.
Long continued pressure upon the foetus, and particularly upon the
umbilical cord, which most commonly gets down into the excava-
tion, rarely permits it to escape with its life; the woman herself
soon becomes exhausted; the bladder and other soft parts, against
which the head presses with great violence, may inflame, be lacerat-
ed or perforated; the womb, violently irritated, by its repeated con-
tractions, may be ruptured, and death ensue. The softening and
separation of the symphyses often leave behind them a movable
state of the articulations, and a degree of lameness which are at least
very troublesome, and where the distension is carried to a great ex-
tent, are often followed by caries and abscesses, which sooner or
later terminate in the death of the patient. There are, therefore,
two evils, which it imports to avoid with equal care; there is a just
medium we should endeavor to secure.

1108. Let us suppose that the application of the forceps and
turning have been attempted in vain, or that the pelvis is so deformed,
that no greater confidence is to be placed in those means than in the
efibrts of the woman, one question presents itself; on whom shall we
operate — the child or the mother? Where there is a certainty that
the pelvis is so contracted as to render the delivery of a mature and full
grown child either dangerous or impossible, have we a right to bring
on abortion, either at at an early stage of pregnancy, or only between
the seventh and eight months. Would it not be possible, by means
of regimen, or of a debilitating treatment, to oppose, to a certain ex-
tent, the development of the foetus, so that at full term it shall be of
a very small size?

TOO SMALL A PELVIS. 497

SECTION 1.

Of Regimen, as a means of enabling women with contracted pelvis
to be delivered without the assistance of any surgical operation.

1109. Were it true that the strength of the fetus while enclosed
in its involucra is always in proportion to that of the mother, nothing
would be more natural, nor better indicated, than to weaken a de-
formed woman during tlie progress of her pregnancy. But as the
most robust women do not always bear vigorous childien; as those
■who are naturally feeble and sickly often give birth to very stout
and large ones; it is to be feared that the severest diet and most
abundant sanguine evacuations, would only serve in such a case to
incapacitate the woman from supporting the operations that would
notwithstanding be requisite when she should fall into labor. I
know one person who, having been delivered twice by means
of art, was bled ten times, and confined to a vegetable diet dur-
ing her third pregnancy, with a view of retarding the growth of
the child; this lady was, it is true, exceedingly weakened by it, but
the foetus did not appear to have been afl!ected, and in parturition she
required the same succors as before. Another woman who had
two very fatiguing pregnancies, and could not be delivered until
after three days of painful labor, and then by means of the for-
ceps, also became pregnant for the third time, found herself less in-
commoded than usual, and was, nevertheless, delivered without as-
sistance, and without difficulty, of a child sensibily smaller than the
preceding ones. I am well aware that practitioners worthy of credit
assert that they have obtained directly contrary results, and I can
well conceive, as a general rule, that by exhausting the woman,
the growth of her offspring will be retarded. But there are so
many exceptions to this rule, and what we gain on the one hand
so disadvantageously compensated by the loss of resources of which
we deprive ourselves on the other, that I would scarcely venture to
recommend such a course except to persons affected with a very slight
degree of contraction, and in whom delivery might, in fact, take place
spontaneously, should the head of the foetus not be very large.

SECTION 2.

Of Abortion, brought on for the purpose of rendering symphyseo-
tomy or the cesarian operation unnecessary.

1110. It was about the middle of the last century that the most

43*

498 NARROW PELVIS.

distinguished physicians of London decided that, in women affected
with deformity of the pelvis, it is proper to solicit delivery as soon
as the viability of the child is well established; according to the
statement of Kelly, Macaulay was the first person who had recourse
to this operation which resulted favorably in his hands ; since
then, Dr Barlow has published a memoir in which he essays to prove
that artificial abortion ought to be substituted for the sigaultian and
cesarean operations in all cases. Ramsbothan says he brought on
abortion three times with success in a woman in whom the perfora-
tion of the foetal head had been deemed necessary in a preceding
pregnancy; Drs Davis, Clough, Wigand, and very recently. Bang,
and Dr Blundell, have supported the doctrine advanced by Barlow.
M. Costa has even inquired whether it is proper to resort to it in the
cases of women affected with aneurism of. the heart.

1111. Li France, this question has been considered under a point
of view which has not admitted of its value being discussed. It has
been said that no one has a right to destroy a living fostus, even in
the first months of its existence. But delivery, when provoked pre-
viously to the seventh month, kills it inevitably, and rarely fails to
cause its death in the seventh and eighth. Besides, if it must be
destroyed, why not wait for the term of labor; by so doing we shall
at least not destroy the few chances we have of seeing the labor
come to a favorable conclusion.

For my own part, I confess I cannot possibly balance the life of a
foetus of three, four, five, or six monhs, a being which so far scarcely
differs from a plant, and is bound by no tie to the external world,
against that of an adult woman whom a thousand social ties engage
us to save; so that in a case of extreme contraction, if it were ma-
thematically demonstrated that delivery at full term would be impos-
sible, I would not hesitate to recommend abortion in the first months
of gestation.

But the case is different whenever there is a space of two inches,
and a half, at least, between the sacrum and the pubis: as in that
case the ovum has been seen to come away without assistance, and
the foetus born alive, the honor of the art and humanity combine to
forbid the employment of any destructive instrument, or any attempt
that must end in the death of the child.

1113. The inducing of labor at the seventh month would be par-
ticularly applicable where the pelvis is two inches and a half at least
and two inches and three-quarters at the utmost, because it is clear,
from measurements taken by Madame Lachapelle, that at seven
months the bi-parietal diameter is at most not over three inches,
and may be much less in extent; Avhich gives the same chances as

ARTIFICIAL ABORTION. 499

if the delivery were to take place at term, and through a strait of
three inches and some lines. But how are we to learn accurately
whether the foetus is viable? If, for greater security, we should de-
fer the operation till two weeks latter, what assurance could we
have that the head is not already too large to pass through the straits?
And if it can clear them at eight months, it is not probable that it
will succeed equally well at the end of the ninth?

I am far from thinking that the difficulty consists in penetrating
as far as the membranes so as to rupture them; nevertheless, wounds
of the uterus are so dangerous, that we should always dread to in-
troduce an instrument into its interior: and then it would be a
strange misconception to suppose that abortion brought on in this
way is not more dangerous, cseteris paribus, than a delivery at full
term: without mentioning the hemorrhagies, convulsions, or inflam-
mations of the peritoneum, that are but too frequently the results of
the operation, we ought also to expect the fcetus to perish either
before or soon after birth, in a large majority of cases. Being
scarcely viable, it is too feeble to bear the contractions of the uterus.
Although, after the membranes are perforated, the womb, some-
times, enters powerfully into action, it also happens that it remains
two, three, and even as much as fifteen days, before it begins to re-
act upon the product of conception; besides, its contractions are
generally slow, feeble, and too far apart to expel it when its size is
considerable.

Unless a very slight value is attributed to the life of the fcetus, this
recourse is, then, of small advantage; at least, previously to making
a general precept of it, it deserves to be maturely considered by un-
prejudiced men, and in a more philosophical way than seems to have
been done hitherto in England and in Germany.

1113. Signs of the death of the foetus. There is no doubt that
the fc3tus is still living if it moves, or if auscultation enables us to
hear the movement of the heart; there is, also, no doubt of its being
dead when portions evidently belonging to its structure, and in a state
of putrefaction, escape from the organs; but with the exception of
. these cases, which leave not the slightest uncertainty upon the sub-
ject, the question of life or death is, here, one of the most delicate
subjects in physiology, and one of the most difiicult of solution of
any in tokology. The same thing takes place in regard to the death
of the fcEtus as occurs in relation to the question of pregnancy; it is
announced by numerous signs, but they are extremely variable and
never certain. How could it be otherwise, inasmuch as it is some-
times impossible to pronounce upon the state of the fcetus that has
just been born, and that is before our eyes?

500 NARROW PELVIS.

However it may be, the signs of death may be divided into rational
and sensible, like those of gestation. The rational signs are observed
before or during labor.

1114. Previously to reaching the full term the woman has had a
fall, or has made some violent movement or strong effort; she has
struck her abdomen against some solid body; she has used too much
ardor in coition; she has abandoned herself without reserve to vivid
impressions of a moral kind; she has had a severe attack of disease,
lias taken very active medicines; in fine, she has exposed herself to
some one of the causes that are capable of producing abortion; in
which case there is some reason to presume that the child is dead;
provided she should, shortly after the accident, have had rigors, nau-
sea, a sense of weight above the middle of the pelvis, disgust, horri-
pilations, or a sense of coldness in the belly; if the breasts are en-
larged, full of milk, or shrunk; if the womb tends towards the lowest
part of the body, and moves to the right, left, or in front, like an
inert mass; if the fcetus has ceased to exert any active power; if the
abdomen cease to enlarge; if the mouth exhale a putrescent odor; if
there be a general uneasiness, or a constant febrile state, it becomes
extremely probable that the foetus is dead.

1115. During labor the death of the fcstus- is announced by the
escape of the meconium; by the entire absence of motion; by a pu-
trid odor that escapes from the vagina, or rather from the uterus,
along with the waters; by the diminution of the labor pains, and by
most of the phenomena which I mentioned just now. There is
reason to fear it, especially, where the amniotic fluid has escaped
prematurely, or at least where it has been long evacuated, and where
the position is bad; or where the contractions of the womb have in
any way borne directly upon the fcetus itself. The sensible signs are
not appreciable until some portion of the ovum itself can be touched
with the finger. Among them is classed the premature descent of
the cord, and the absence of its pulsation; inability to excite motion
in the foetus, although it be raised up in the womb; the escape of
shreds of the cuticle; the want of a soft elastic tumor on the head;
mobility of the cranial bones; the slight resistance offered to pressure
by the thorax or any other part; the absence of pulsation in the
heart, Slg.

But it must be confessed that, perhaps, not one of these signs,
taken singly, would be to a prudent man, a sufficient warrant to
pronounce unhesitatingly on the death of the foetus; indeed very few
of them deserve much consideration. It is only when united, when
constituting a whole, that we are sometimes warranted in drawing
pretty rigorous conclusions: the swelling of the breasts and their

DEAD FCETUS. 501

subsequent shrinking away may occur, although the child continues
to live; but this sign will, notwithstanding, be very important, if it
coincide with a majority of the other rational signs, because, says M.
Dubois, when the child dies, its deliverj^ regarded as the completion
of the great act of reproduction, is, in some sort, effected for the sake
of the economy, and the secretion of milk tends to take place just as
if the ovum were expelled. The same may be said as to the disa-
greeable load felt by the woman in all her movements, and the sense
of weight which she experiences in the bottom of the pelvis.

The waters may have been evacuated for three, four, ten, fifteen,
thirty, and even fifty-seven days, according to Bauhin, Boer, and M.
Morlanne, without being necessarily followed by the death of the
foetus; but the contrary will, however, much more commonly be met
with. If the meconium escapes, and the pelvis is not the presenting
part, there is great reason to fear that it is dead, although more than one
case has been seen where, under such circumstances, the foetus has
been born after several hours, strong and healthy: when the breech
comes down first, there is nothing unnatural in the discharge ^f the
meconium which is occasioned by the pressure experienced by the
belly as it passes through the os uteri, or the straits; it is altogether
a mechanical effect. But when the head is the presenting part,
the same cause no longer exists, and, in general, the bowels are not
evacuated, unless the sphincters, by being weakened, like the other
muscles, relax so as to oppose no resistance to the action of the
womb, which will scarcely take place unless the child is near ex-
piring. Lastly, the practitioner ought not on this subject to let him-
self be imposed on by the muddy appearance or greenish color of
the waters; for this is an appearance often assumed by them without
the meconium having any thing to do with it.

1116. A living foetus sometimes suddenly ceases to move alto-
gether, and may remain several days or weeks, or indeed until its
birth, without moving, and yet may not have incurred any danger;
on the other hand, the woman often supposes she feels it move after
it has really been dead for a long time, and I could relate many
cases of the kind, one of which I very lately saw with Dr. Leseble,
in a young woman who gave birth to a child that had been dead at
least four or five days, although she told us an hour before the de-
livery that she felt it move. But this does not prevent the sign from
being a very important one to the practitioner who knows how to
estimate it, and when, in the course of a long and diflScult labor, the
motions of the child are found suddenly to cease after having been
agitated with more or less violence, and, as it were, convulsively,
there is good reason to fear for its safety.

502 NARROW PELVIS.

Portions of the epidermis, and some of the hair, might, indeed,
become detached from some inflamed, gangrenous or ulcerated point,
without the child being dead: if this sign depended upon putrefaction,
it could in no case occur until after life had long ceased; in fine, I
can scarcely believe that any one could be deceived who should pay
a careful attention to all the circumstances.*

1117. The odor that escapes from the vagina has always seemed
to me to have but little significancy, as long as the membranes are
unruptured; but after that, I regard it as one of the most certain
signs; it incontestably depends on the circumstance, that the air, by
gaining access to the uterine cavity while at a high temperature,
under ibe influence of the uterine contractions, actively promotes
the putrefaction of the liquids still remaining within the membranes;
this odor at times is rapidly manifested, and may, in the course of
a few hours, become almost insupportable. It would be difficult to
confound it with any other odor, such, for example, as that ex-
haled from an ulcer, or a suppurating surface of any kind; and up to
the present time I have never met with it where the child did not
afterwards come dead into the world.

1118. As to the swelling of the hairy scalp; since it is produced
by the accumulation of fluids beyond the point of the head, which is
strictured more or less violently and for a longer or shorter period
by the os uteri, or the strait of the pelvis, it is evident that it will not
form, provided the child should be dead previously to the rupture of
the membranes; but, if the child should not die until after its forma-
tion, it might then continue, just as if death had not taken place; I do
not speak of the over-lapping and movableness of the cranial ^bones,
because they may too easily lead us into error, and also because
these two phenomena may depend upon causes far too diverse.

Where it is possible to reach the umbilical cord, we can easily de-
termine whether it continues to pulsate or not; and I cannot readily
conceive how this sign could deceive a well informed practitioner,
as to the real state of the child; I know that the vessels of the cord
may suspend their pulsations, during each effort made by the womb
or by the mother, without the fcetus really running any great risks;
but we should not decide upon the child's death simply because we
have examined the cord during the presence of a pain, or because

* Yet Baudelocque was near being deceived by such a symptom; he was on
the point of using the perforater, because a sloughing tumor on the scalp gave
him this very reason to suppose the foetus dead. By a sort of miracle of good
fortune, he was induced to lay aside the perforater, and resort to the forceps,
with which he delivered the woman of the cliild in perfect health with the ex-
ception of the gangrenous portion of the scalp. — 31.

DEAD FCETUS. 503

we have for a moment felt it to be without pulsation. It is only-
after having satisfied himself that the pulsation is entirely abolished
for several minutes, and equally during the presence and the absence
of the pains, below, as well as above the head, either free or com-
pressed, that the accoucheur is at liberty to pronounce without fear
upon the state of the foetus. To be still more certain, if the head
had not cleared the superior strait, I cannot see why the hand
might not be passed up more or less into the womb, so as to ascer-
tain whether the heart continues to beat, and to touch the umbilical
cord nearer its root, or at some point where it should be free from
all compression.

1119. If then the combination of all these signs, or the chief of
them, were always to be met with where the child is dead, there
will rarely be any embarrassment in giving a decision; but they fail
so often when it is indispensable to proceed to action, when there is
no time for temporising, that it is easy to imagine how practitioners
have been led to the performance of serious and even mortal opera-
tions on the mother, although the child was actually dead; and that
at other times, the child has been cut to pieces while still full of life.
Hitherto, medical men have made only vain efforts to escape from
so distressing a position, and may God grant that the method lately
proposed by MM. Bermond, Baudelocque, Jr. and Toirac, may
not deceive the expectations of its inventors. These three physi-
cians seem to have thought, at the same time, and without each
other's knowledge, that by bringing the two extremes of an electric
circle, in the womb, in contact with some given part of the child, or
merely upon the belly, that its muscular contractions would necessa-
rily be brought into play, provided it were not dead. It is a fact,
that both reason and analogy are in favor of this idea; but upon so
difficult and serious a subject we ought to wait for a longer experi-
ence and not pronounce lightly.

1120. The foetus is alive, and to keep it so, we have either to en-
large the openings through which it has to pass, or make new ones:
at the commencement of the last century, even when accoucheurs
met with a case of pelvis so deformed as to render delivery im-
possible, they preferred to sacrifice the child rather than perform
any operation upon the mother. Some of the boldest of them, like
Mauriceau, had immediate recourse to embryotomy, or at least to
cephalotomy; while others, as Delamotte, being more timid, and.
more humane, in appearance, but in reality more barbarous, pa-
tiently waited until the child was dead before they would proceed
to cut it to pieces. At the present day, inasmuch as spmphy-
seotomy and the cesarian operation have been successfully performed

504 SYMPHYSEOTOMY.

a great many times, the operation of embryotomy is not admissible
until every thing announces that the foetus is dead, or that it cannot
live.

SECTION 3.
Of Symphyseotomy.

1121. Historical. Being persuaded that the articulations and
even the bones of the pelvis were capable of being softened during
pregnancy, Fernel, S. Pineau, and many other old writers, con-
ceived that it would be useful to favor their softening, in cases of con-
tracted pelvis, and that this might be effected by means of embroca-
tions, cataplasms, and topical or general bathing ; founding their
opinion upon these vulgar traditions, which are spoken of by Riolan
and Pare, and which induce the common people to believe that in
many countries there is a practice of breaking the os pubis in young
girls as soon as they are born, for the purpose of rendering child-
birth more easy for them; upon what Galen, in speaking of the pel-
vis, says, viz. non tantum dilatari, sed et secari, tuto possunt, ut
internis succurratur, some modern physicians have supposed that
the operation of symphyseotomy must have been conceived of in the
remotest antiquity; it is true that CI. Delacourvee* mentions a de-
formed woman who died previously to delivery, and in whom, after
death, he divided the symphysis pubis for the purpose of enlarging
the pelvis; Plenck acted in the same manner in 1766 upon another
subject; but it is proper also to state that no one had formally thought
of proposing the performance of this operation in the living subject
with the view of facilitating delivery, when Sigault, who was still a
medical student, made it the subject of a memoir, which he presented
to the Academy of Surgery in 1768.

1122. The idea of symphyseotomy is, therefore, really due to this
surgeon; the Academy was hardly willing to hear the first proposal
of it, and Louis, who communicated it to Camper, treated it as a
ridiculous project, engendered in a young brain that was as yet in-
capable of any reflection; but not so the celebrated Hollander, who,
after performing several experiments upon the dead subject, replied
to the secretary of the academy, that at some future day it might be
advantageously resorted to. On his part, Sigault was not discon-
certed, and reiterated the same idea in his thesis at the school of
Angers in 1773. Four years afterwards he performed his operation

* De Nutritione Fcelus in utero paradoxa. Dantisci, 1655.

SYMPHYSEOTOMY. 505

in presence of A. Leroy, upon a woman named Supiot, and was so for-
tunate as to save both the mother and the child. This success gave
rise to an extraordinary degree of enthusiasm; the hundred tongues
of fame, seemed insufficient to celebrate the glory of the author
of so brillaint a discovery. The faculty of medicine at Paris thought
they could not reward him too highly by passing a solemn decree,
and causing a medal to be struck in honor of him; so that this same
Sigault, whom the academy of surgery would not deign to hear,
a few years before, was soon proclaimed the greatest benefactor to
humanity, and almost equal to the gods. Such exaggeration as
this soon gave rise to a lively opposition amongst the surgeons,
and was the signal of a combat, in which a great number of the
medical men of different countries felt themselves called on to take
a part. The Academy of Medicine warmly supported the opinions
of Sigault; the Academy of Surgery, as much perhaps out of spite
for not having retained them in its own bosom as from conviction,
continued to reject them with no less ardor. Both parties were
unjust: the dispute became scandalous; libels were published, per-
sonalities were not spared, and being divided into Symphysians
and Cesareans, as they were then called, the accoucheurs, actuated
by inveterate hostility to each other, were not ashamed to keep up
this controversy, equally curious and extraordinary, until the com-
mencement of the present century without coming to an understand-
ing. Plenck, Siebold, A. Leroy, Baudelocque, Saccombe, Giraud,
and Ansiaux, descended into the arena, but without perceiving that
the question was illy stated. Sigault in fact was wrong to propose
symphyseotomy as a substitute for the cesarian operation; every
body would have been on his side, had he only proposed it as a
new resource, fit to enrich the art, an operation attended with its
own peculiar applications, advantages, and dangers, and which at
least renders cephalotomy and the cesarian operation more rarely
indispensable.. Weidemann and Desgranges were the first to view
it in this light, and by imitating them, Thouret and M. Gardien have
at last put an end to these disgusting polemics, which served as an
excuse and screen for the jealousy and envious rivalry of all the little
spirits of the period, to blacken the fame of a great many most re-
spectable men.

But at the present day, when all the passions awakened on the
occasion of this quarrel have become extinct, it is an easy matter to
estimate the operation of symphyseotomy at its just value.

1123. Mechanism. "When the inter-pubal fibro-cartilage is divi-
ded either after death or on the living subject, the bones generally
separate about one inch, of their own accord, and this separation
44

506 SYMPHYSEOTOMY.

might, rigorously speaking, be carried artificially to the extent of
three inches, without disorganising the posterior articulations: when
the cartilage is divided, the coxal bone somewhat resembles a lever
of the first kind; the centre of motion is found at the posterior part
of the articular facette of the sacrum; the posterior branch of this
lever, very short, and formed by the tuberosity of the ilium, is drawn
backwards and towards the median line by the posterior sacro-iliae
ligaments; its anterior branch, which is very much bent, (coudee)
separates (from the corresponding pubis) in proportion to its excess
of length over the branch, which represents tlie power; the fore part
of each posterior symphysis becomes somewhat open; the fibrous
tissue which covers them yields, is elongated, stretched, and detached
the elastic cushion which is behind them becomes relaxed, and the
sacrum compressed from behind forwards, tends to escape towards
the interior of the pelvis. When the surgeon adds still more to the
separation of the pubes by pressing upon the cristas of the ileum,
the power is transferred to the anterior branch of the lever, and it
is evident, that thenceforth no very violent effort would be required to
tear away all the bonds of the posterior articulations. This is the
situation, particularly, where the displacement of the sacrum in front
must cause the increase of the length of the antero-posterior diameter
to disappear as fast as it tends to take place. In the empty pelvis and
upon pieces of paper this is really the case; but in the living subject,
while the pubes are separating, the child's head pushes the sacrum
backwards, beyond its natural limits, rather than admits of its
advancing into the excavation. Nevertheless, it would, in most
women, be dangerous to separate the ossa pubis from each other
more than one or two inches: we could not go beyond that without
lacerating the loose and abundant cellular tissue of the excavation,
the anterior sacro-iliac ligaments, and part of the posterior ones,
without giving rise to the most violent pain, and causing the most
redoubtable inflammation, unless the symphyses should happen to
be already very much softened beforehand, under which circum-
stance it is not likely that symphyseotomy would ever be required.
Since you agree, say the antagonists of the operation, on the one
hand, that it is not prudent to attempt a greater degree of separation
than two inches or two inches and a half; and on the other, that
the antero-posterior diameter is never enlarged more than two lines
for one inch, four lines for two inches, and six or eight lines for
three inches* of separation, it is manifest that you can depend upon

* Boer even asserts that, when carried to the extreme, this separation can
never give more than three lines additional to the antero-posterior diameter.

SYMPHYSEOTOMY. 507

only three or four lines of ampliation of the pelvis: now, is it right
that we should perform so serious an operation for the purpose of
gaining only three lines, and perhaps not more than two? This
argument at first seemed almost unanswerable: then it was said in
reply: doubdess we obtain an elongation of only three lines for the
antero-posterior diameter, but by engaging in the void space between
the separate pubes the parietal protuberance or projecting part of
the occiput will abstract at least three or four lines from the diame-
ters of the head, so that we gain at least half an inch. In speaking
after this fashion, authors have forgotten that the occiput or the
parietal protuberance is commonly found behind the body of the
pubis or acetabulum, and not behind the posterior face of the sym-
physis. But, further, this last disposition, in its turn, gives great
advantages in the operation,,and I am astonished that the authors
have scarcely mentioned it. I mean that, if the antero-posterior
diameter is augmented only two or three lines, the oblique ones will
be increased by at least six lines; and as the occipito-frontal breg-
matic and bi-parietal diameters are not directed from front to rear,
but obliquely, it follows, in fact, that the section of the symphysis
appears to be less limited in its applicability than has been generally
imagined. The researches of M. Desgranges prove that it permits
the oblique and transverse diameters of the pelvis to enlarge to the
extent of near an inch; that at the inferior strait particularly, it would
procure a considerable ampliation, and that upon this subject there
is, such is my opinion, a want of some additional experiments.

1124. Advantages and disadvantages. The operation of sym-
physeotomy, therefore, seems to be applicable in all cases where an
increase of space to the amount of four, five, or six lines would per-
mit the head to pass; for example, in all cases where the forceps is
insufiicient, and where, nevertheless, the smallest diameter of the
strait exceeds two inches and a half. But as it is seldom possible,
in the living subject to ascertain how far the head is susceptible of
reduction under pressure, and whether the strait is two inches and
eight lines rather than two inches and a half, it has happened that
the accoucheur, finding a difficulty in marking the point where the
section of the pubes becomes indispensable, and that where it can
no longer suffice, has generally decided in favor of the cesarian
operation, whenever the absolute necessity of doing something to
save the child's life has been ascertained. As to the dangers of the
operation, it appears to me difficult to prevent them, where the volume
of the head requires a considerable separation of the pubes, and
wherever the pelvic articulations are naturally very little relaxed.
Even could we dispense with acting on the hips or thighs, the child

508 SYMPHYSEOTOMY.

nevertheless must pass through, and, whether we extract it with
the forceps or by turning, or whether the contractions suffice for its
expulsion, nothing seems able to hinder the head, as it passes through
the contracted strait, from violently distending the posterior articu-
lations, and even lacerating them if its dimensions exceed those of
the circle through which it must traverse.

I am, however, far from thinking, along with Denman, Lauver-
jat. Hunter, Osborn, and Dr. Dewees, that it ought to be rejected in
all cases; I merely wish to show that its partisans, in their represen-
tations, have singularly lessened its dangers, and exaggerated its ad-
vantages.

It is the only means of safety that can be resorted to: 1. Where
the head is locked in the excavation, after having passed through a
very contracted superior strait; 2. Where the head has cleared the
OS uteri, and is arrested by the narrowness of the inferior strait; 3.
Where the trunk is delivered, the life of the child unquestionable,
and it is impossible for the head to get through the natural passages.
In these three cases, it is preferable to the cesarian operation, even
after the death of the woman; and that, because it would be almost
impossible to avoid killing the child by attempting to extract it by the
abdominal opening.

1125. Further, it offers unquestionable advantages wherever the
contraction affects the transverse and oblique diameters; where it
exists at the inferior strait; when it depends on barrure, an exosto-
sis, any solid tumor situated laterally, or on a protuberance of the
acetabulum; the same holds good of locked-head, whether of the spe-
cies called by Roederer paragomphosis, or whether the head is pinch-
ed at the two extremities of its bi-parietal or occipito-frontal diame-
ter, or in any other way that prevents it from descending, and from
being easily pushed upwards; and lastly, whether this locked-head
be understood after the manner of Baudelocque, of Madame Lacha-
pelle, or of M. Desormeaux, provided always that the inferior strait
be not extremely contracted; it is manifest, further, that if the elon-
gation of the sacro-pubic diameter, produced by the section of the
pubes, must be so much the greater in proportion as the contraction
of the pelvis is so much the more considerable, as maintained by Gi-
raud and Ansiaux, the very contrary may also happen, as has been
well observed by Boer and by Madame Lachapelle.

1126. To perform this operation, it is necessary: 1. That the
ftEtus shall be living; for, notwithstanding what M. Gardien says,
where symphyseotomy is indicated, should the child be dead, we
ought to prefer the operation of cephalotomy, which would always
suffice in that case; 2. That the presentation shall be natural, and

SYMPHYSEOTOMY. 509

that, as far as possible, we shall not be compelled to extract the fetus
by the feet, because turning too frequently occasions its death; 3.
That the os uteri shall be largely dilated: for otherwise there could
be no certainty that the operation is indispensable, and moreover, we
might, after performing it, find it impossible to terminate the deli-
very with the necessary rapidity; 4. That the woman shall be
young enough to obviate all fears in relation to anchylosis of the
pelvis.

1127. Manner of operating. The patient, being placed upon an
operation table, or on the bed, in the same manner as for the ap-
plication of the forceps, having her thighs and legs slightly flexed,
and pi'operly separated, an assistant must hold her shoulders, and
two others take charge of her knees, while a fourth stretches the skin
of the belly, and a fifth is prepared to hand the operator whatever
may be required.

1128. Situated to the right or betwixt the legs of the patient,
the surgeon, with a convex and very sharp bistoury makes an inci-
sion, which should commence a little above the symphysis and ex-
tend close to the clitoris; this incision divides the skin, previously
shaved, and all the soft parts that compose the mons veneris; being
parallel to the median line, it ought to fall as nearly as possible upon
the centre of the articulation; at its lower part, however, it is well
to give it a slight inclination to one side, between the top of the
greater and lesser labium, and, even to separate one of the roots of
the clitoris from the ramus of the pubes, for the purpose of avoiding
dangerous lacerations at a later stage of the process. There can
be none but very small arteries to tie, unless the internal pudic
should be divided by incautiously carrying the incision too far down-
wards. For the purpose of dividing the cartilage, some have re-
commended that we should act from below upwards, others from
above downwards, and several from behind forwards, or from within
outwards, and most writers from before backwards. There are
some who have made use of a bistoury, a sort of scalpel en ron-
dache, of the pliable knife of Aitken, of a probe-pointed bistoury
or a common bistoury, the point of which M. Gardien recommends
to be covered by the point of the nail of the left fore finger, so as
to prevent any injury to the internal organs. In such a case every
man ought to be allowed to choose the instrument that pleases him
best; for my own part, I think that in this, as in other cases, regard
is rather to be paid to the hand that acts than to the shape of the
bistoury, and that the only essential quality of the operating knife
is strength and sharpness. The safest way is to cut the sym-
physis from above downwards, and from the cutaneous surface to

44*

610 SYMPHYSEOTOMY.

the pelvic surface of the symphysis. The incision ought to be ex-
tended upwards half an inch, or even a whole inch, along the linea
alba. To avoid the risk of wounding the bladder, or urethra, as
has happened with some surgeons who went at one stroke quite to
the head of the child, through the bladder and womb, I think it will
always suffice to hold the blade of the bistoury at some distance
from its point with the left finger and thumb, while we make its cut-
ting edge act with the right hand: with the view of still more cer-
tainly avoiding the bladder and urethra, the catheter should be intro-
duced early, or at least previously to commencing the second stage
of the operation. By this means the bladder is emptied, and the
catheter serves to push the urethra a little to the right, while the in-
cision is inclined slightly to the left side of the sub-pubal ligament.
When the ligamentous matter is almost divided, the precautions are
to be redoubled; the cutting should now be done almost wholly by
touches with the point of the knife, and it is to be laid aside as soon
as we find no more resisting and elastic material to divide.

1129. Frightened with the imaginary disorders which might be
produced by the access of the air into the articulation, Alphonse
Leroy advised that the operation should be divided into two stages:
for that end M. Lescure, his pupil, thinks that an incision of nine
or ten lines should first be made through the skin, then, after having
divided one-third of the cartilage with extreme gentleness, that we
should return and prolong the section of the ligaments as far as the
clitoris, and afterwards proceed to divide the remainder of the carti-
lage, " without minding the blood that escapes from the small ex-
ternal pudic vessels, this section is performed, says he, very slowly,
and by carefully feeling the cartilage."

Others have supposed they could more certainly attain the same
end, by dividing the skin only above and below the symphysis, or,
even only to the extent of a few lines opposite its middle portion,
which would surely render the section of the ligament very difficult;
but at the present day these ill founded fears are dismissed: it is uni-
versally known that the accidents that too often follow the operation
of symphyseotomy are unconnected with the action of the air upon
the cartilage; and further, that such modifications in the mode of con-
ducting the operation would in no wise prevent it.

1130. Previously to commencing, it is important to make sure of
the spot occupied by the articulation; for when the pelvis is deformed,
it is not uncommon to find it deviated so far to one side as that the
operator has on more than one occasion fallen on the body of the
bone, instead of uncovering the cartilage itself.

Should it so happen that the symphysis is found ossified, as in the

SYMPHYSEOTOMY. 511

pelvis mentioned by Wiedemann and Lauverjat, and as "Boer and
Madame Lachapelle inform us is often the case, there would be so
small a chance of obtaining even a tolerably large opening, that in-
stead of sawing the articulation, as was done by Siebold, I should
prefer to have recourse to the cesarean operation. By applying the
saw beyond the symphysis, upon the very body of the bone, accord-
ing to the counsel of M. Desgranges, the operation would not be ren-
dered either more or less dangerous; for the difficulty exists behind,
in the sacro-iliac articulations, and not in front.

1131. Immediately subsequent to the division of the cartilage,
the posterior branch of the bent lever, formed by the coxal bone
being acted on by the elasticity of the posterior sacro-iliac ligaments,
occasions a separation of from six to twelve lines between the pubes.
This separation must necessarily vary, according to the degree of
contraction of the pelvis, and the rigidity or softness of the sym-
physes: if it is sometimes effected in equal proportions by both
of the bones, there must also be cases where one is much more con-
cerned in it than the other. Be this as it may, I find it difficult to
understand how it can go, spontaneously, to such an extent as to
prove dangerous, or that it is worth while to restrain it by securing
the hips previously to the conclusion of the operation. On the
contrary, to carry it to a sufficient extent, it is almost always requi-
site slowly and moderately to press the hips from within outwards,
and from before backwards, or carefully to separate the woman's
thighs.

1132. Unhappily, when the operation is terminated, the delivery
is still far off. If the contractions are energetic and well sustained,
the delivery is entrusted to the natural powers, to which also it
would doubdess be better to refer the care of separating the divided
symphysis to the required extent; but if the womb does not react,
if the labor grows languid, or any circumstance arises demanding
the prompt extraction of the fcetus, we are obliged to apply the for-
ceps, or turn the child, and that conformably to the principles that
have already been laid down; remembering, further, that turning
causes the child to incur the greatest risks, and that it was for the
preservation of its life that the mother was subjected to the section
of the pubes.

I should so greatly fear to bring down the feet in such a case,
that, unless they had originally presented, I would without hesitation
give the ergot to excite the uterine contractions, and would attempt
the employment of the forceps, even should the head, still engaged
in the superior strait, be found to be situated transversely. During
this part of the operation, it would probably be necessary to support

512 SYMPHYSEOTOMY.

the hips or whole pelvis, either with the hands or a suitable bandage,
so as to prevent the articulations from being too much lacerated by
the eccentric pressure of the fogtal head or the efforts of the ac-
coucheur.

1133. Dressing. When the delivery is complete the woman is
to be cleansed; the pubes are brought into contact with each other;
some lint, spread with cerate, and some compresses are to be placed
over the womb; a body bandage passed round the pelvis keeps every
thing in place, and should be sufficiently tight to prevent, at least to a
certain extent, a new separation of the bones from taking place; the
patient being now put to bed, ought to lie on her back, and be kept
in a stale of the most perfect rest; her thighs especially ought not
to move for six weeks or two months, a period of time which is in-
dispensably necessary for the consolidation of the symphyses; she is
also to be kept upon the regimen proper in serious operations, and if
any accidents make their appearance, they must be vigorously com-
bated.

The discharge of the lochite must be carefully attended to, and if
they threaten to disappear too scon, emollient or detergent injec-
tions should be thrown into the vagina, and the woman should be
advised, if she can, to suckle the child, and care must be taken to
preserve the lips of the wound in constant contact. When the term
of cure approaches, motion, and particularly walking, should not be
allowed except with great reserve. Should there still remain any
mobility and pain in the pelvis, recourse must again be had to rest
for a longer or shorter period, and it often happens that walking and
standing cannot be permitted without danger for three or four months.
Doubtless nothing can be more desirable than the consolidation of
the divided symphysis; but there have been women in whom it
could not be obtained, and who were notwithstanding able to walk,
stand, and leap, without sensible inconvenience, which is to be ex-
plained upon the supposition that the posterior symphyses had ac-
quired a great degree of firmness. MM. Mansuy and Dubois have
each related a case of this sort. A. Leroy and M. Lescure even go
so far as to say that it ought to be promoted by omitting any ban-
dage round the pelvis; they say, and perhaps they are not wholly
wrong, that the space between the symphysis fills with a cellulo-
fibrous tissue, which does not prevent the articulation from being
firm, and also allows the woman to bear children subsequently with
much greater facility.

1134. Results. Upon the whole, when we consider that out of
forty-three women who have undergone the operation of symphy-
seotomy fourteen died; that several remained crippled for life, par-

SYMPHYSEOTOMY. 513

ticularly the two spoken of by Madame Lachapelle, and who were
operated on at the Maternite; that in some of thera the operation
was not indispensably necessary, since, as we find in Baudelocque's
work, that they were afterwards delivered without assistance or
difficulty; that most frequently the child has not been saved, and
that, in fact, it must in a majority of cases perish under the opera-
tion of turning or the forceps, which we are almost always obliged
to try; lastly, as observed by Lauverjat, that in eighteen operations,
twenty-one individuals, mothers or children, perished; that in two
cases it was found necessary to have recourse to the cesarean opera-
tion; that five were followed by incontinence of urine, and one by
claudication; that in the thirty-four cases mentioned by Baudelocque,
only eleven children were saved; when we consider, I say, all these
dangers, and compare them with the advantages derived from it in
the most successful cases, it is difficulty not to concur with M. De-
sormeux in regarding the section of the symphyses as being in fact
scarcely less serious than the cesarean operation, and that its em-
ployment ought to be restricted within pretty narrow limits.

1135. Catolica's operation. If I understand correctly what was
told me by Professor Vulpes, it would appear that Dr. Catolica of
Naples has substituted another operation for that of symphyseotomy,
which, properly speaking, is but a modification of the one already
proposed by M. Desgranges of Lyons. Instead of dividing the car-
tilage, he proposes that the body and ramus of the pubes on each side
should be divided between the two oval foramina, as was recom-
mended by Aitken. In this way, the sacro-iliac symphyses remain
uninj ured; no risk of wounding the bladder or urethra is incurred;
the cellular tissue of the pelvis is scarcely stretched, and the conso-
lidation is easily obtained; there is no fear of abscess, caries, fistulas,
claudication nor peritonitis, and a considerable ampliation of the
sacro-pubic diameter is obtained. I am not sufficiently acquainted
with the reasons of the author to enable me to combat or approve
the operation, and until I shall have become more fully informed,
shall content me with the little I have now said concerninsf it.

SECTION 4.

Of the Cesarean Operation, [Hysterotomy, Hysterotomotocia,
Cesarean Delivery, Gastro-Hysterotomy).

The denomination of cesarean section is given to an opening
made into the belly and womb for the purpose of extracting the
foetus when it cannot be delivered through the natural passages; since

514 CESAREAN OPERATION.

the time of Simon its application has been further extended to the
incision or incisions which it is sometimes necessary to make in the
cervix of the uterus, with the view of facilitating the passage of the
head through it.

1136. Historical. Being lost, as it were, in the night of time,
the origin of this operation has not as yet been precisely ascertained
by any one. In the fabulous ages, it was said that a foetus, the
son of Jupiter, was extracted from the belly of Seraele by Mer-
cury. The Romans made the same statement concerning Escula-
pius, who was extracted from the belly of his mother by Apollo,
after she had been already placed on the funeral pile destined to
consume her. Virgil also says that Lycus came into the world in
the same manner. These vague traditions, a passage in Pliny, and
certain Roman laws, induce a belief that the cesarean operation
must have been employed in the most remote ages. M. Mansfield,
in a work, an extract of which is contained in the Bulletin des
Sciences Midicales, attempts to prove that it was practised even by
the Jews. It is said in the Talmud and the Mischajoth that a child
born by a section of the belly has not the rights of primogeniture.
Jaschi has described it in his commentary on the Nidda, and says
that women who have undergone it are not compelled to perform^the
forty-days purification. There is, however, no certain proof that it
was performed upon a living woman anteriorly to the year 1520,
unless we admit as authentic the case of the lady at Craon, who,
according to the statement of Goulin, was subjected to the section
of the belly in 1424, and, as well as her child, survived the operation.
The ancient Greek and Latin physicians make no mention of it
whatever. Guy de Chauliac, who, seems to have first described it,
founding his opinion upon the following passage of Pliny, {Jluspica-
tins, enectd parente, gignuntur, sicut Scipio Jifricanus prior natuSj
primusque Csesus, Cseso matris utero, dictus; qua de causa, CaesO'
nes appellati. Simili mode natus est Manlius qui Carthaginem
cum exercitu intravit,) believes that it took its name from Julius
Caesar; others, on the contrary, think that the general and his family
took their name from the operation. Bayle remarks that Aurelia,
the mother of Caesar, was still living when he went to Britain, and
consequently that the story related by Pliny ought to be rejected as
fabulous; the researches of Weidemann and those of Sprengel hav-
ing given no satisfactory solution of this problem, we are obliged to
confess that the etymology of the cesarean operation is no better
known than its origin.

1137. Rousset was the first author who dared to maintain that it
may and ought to be had recourse to in the living subject; after

CESAREAN OPERATION. 515

having cited various experiments and numerous analogies, he men-
tions severi women who had been subjected to the cesarean operation
with complete success; but can we rely upon the authenticity of the
case of the woman named Godon, who was operated upon seven
times; upon that spoken of by the surgeons Lenoir and Lebrun, who
operated upon the same subject three times; the recital of Alibax,
of Sens, of Colot, or the story of the woman who had a long scar
upon the right side of the belly, and who said she had a child ex-
tracted through the part seven years before? Ought we to receive,
according to the very letter, what G. Bauhin says of the person
called Alipaschie of Siergershensen in Germany, who was operated
upon by J. Nufer, a spayer of cattle, after she was given over by
several midwives, and who recovered so happily, that several years
afterwards she was delivered, without danger, of two other children?
What are we to think of the other fact mentioned by Pare and
Schenk relative to Nicola Berenger? How happened it that this
woman was delivered two years afterwards of a girl, and subsequent-
ly of a boy, if there was any necessity for her to undergo the cesa-
rean operation? The same may be said of the case of Elizabeth
Turgois, who subsequently gave birth to four children, by the na-
tural passages, according to the report of the same Bauhin. Lastly,
it is certain that of the sixty-odd cases related by Rousset, Bauhin ,
and Simon, only a very small number are quite conclusive, and that
Pare, Guillemeau, Marchant, Mauriceau, and all persons who were
unwilling to be convinced except by well established facts, were pos-
sessed of excellent reasons for combatting the assertions of Rousset.
1138. Be this as it may, according to Baudelocque himself, the
cesarean operation has been successfully performed twenty-four times
from 1750 up to the commencement of the present century, and
without counting the two cases of Lauverjat, which are unquestion-
able, it has been since performed at Nantes twice upon the same
woman, by Bacqua, once by M. Lemaistre of Aix, once by M.
Dariste at Martinique, once by Vonderfuhr, in 1823, at Dahlen, once
by the physicians of the hospital of Florence, on the 18th of May
1827, twice by Schenck, once by Bulk, once by Grcefe, once by
Leuch, once by Buren, another time, recently, in one of the colo-
nies; so that we cannot refuse to believe that at least some women
may possibly be saved by means of the cesarean operation.*

* Let us add that it has been twice performed by Professor Gibson on M. R.
in Philadelphia, saving, in the first instance, a daughter, and, in the second, a son,
both of whom, as well as the mother, are still in good health. It has also been
recently performed in Germany, with perfect success, for the fourth time, on the
same woman, by Michaelis. For an account of Dr. Gibson's operations, vide the
Amer. Journal of the Med. and Phys. Sciences. — M.

516 CESAREAN OPERATION.

1139. The danger attending it cannot, however, be denied.
Boerhaave and Boer were doubtless wrong in stating, that scarcely
one successful case could be found in fourteen operations; but it
is at least certain that it has been performed four times within
the last twenty years at the Paris Maternite, and that the wo-
men all perished; that out of seventy-three cases cited by Baude-
locque, forty-two were followed by death; that of one hundred and
six cases reported by Sprengel, forty-five were unsuccessful, and
that of the two hundred and thirty-one operations mentioned by
Kelly and Hull, one hundred and twenty-three were incompetent to
save the lives of the women; let us add that all the successful cases
have certainly been published, and that there is a great number of
them whose authenticity may justly be called in question; whereas,
according to all appearances, the same thing has not happened as to
the unsuccessful cases, of which perhaps the greater proportion
may have been passed over in silence. It may be stated, there-
fore, that, up to the present day, the cesarian operation has proved
fatal in at least one out of two cases, and that Tennon was mistaken
in asserting that, since the time of Bauhin, it has been performed at
the Hotel Dieu on seventy women, who recovered. By the report
of J. Burns and S. Cooper it appears that not a single well at-
tested case of its successful performance has occurred in Great
Britain, although the number of operations amounts to fifteen or
twenty.

I think these details will suffice to exhibit this operation to young
practitioners in all its importance, and to prevent them from resorting
to it in any case save where the necessity is absolute.

Nevertheless, it is difficult to conceive a priori that it is of so re-
doubtable a character. The wound which it is necessary to make in
the abdomen is indeed very large, but the parts divided are not very
delicate; there are no arteries, no large nerves, and nothing of any
great importance to guard against; the peritoneum is wounded, but
the digestive organs may be easily avoided; besides, how often have
the largest and most complicated eventrations, and penetrating wounds
of all kinds been seen which yet gave rise to no very serious con-
sequences, and admitted of the recovery of the patients; is not the
serous membrane of the belly laid open every day, without our
being alarmed about it, in subjects affected with strangulated hernia?
Would the wound of the uterus alone prove dangerous? but every
thing in this organ indicates that it possesses but a slight degree
of irritability, a slight tendency to take on inflammatory action, and
has the most favorable conditions for a sure and prompt cicatrisa-
tion. Are there not several cases of women who underwent the
cesarian operation successfully, subsequent to rupture of the womb,

CESAREAN OPERATION. 517

and particurarly the one recently made public by Doctor Frank?
The wound, which is at first very large, is soon reduced to one-fifth
or one-sixth of its original size, and when the organ is free to con-
tract, the hemorrhage ceases too quickly for any alarm to be felt in
relation to it. Lastly, is it not possible by proper precautions to
prevent the liquor of the amnios, the blood and other fluids from
being poured out into the peritoneum during and immediately after
the operation?

1140. It would seem then that it is not so much upon itself, as
upon the peculiar state of the woman at the time, that the serious
nature of the cesarian operation depends. Consequently, I can
scarcely refuse to admit the idea, that if we were to act as soon as
the indication becomes positive, without waiting until the person be-
comes exhausted with vain efforts, the uterus in a state of inertia or
on the point of becoming inflamed, if not already so; until peritonitis
or enteritis has become imminent, or existent; or lastly, until the pa-
tient's life is in danger — the cesarean operation would not be near so
often fatal, as, unfortunately, it has hitherto been found to be.

In support of this view of the subject, I hope I may be permitted
to allege a sentiment of Dr. Hull, who attributes the unfortunate
results obtained by his countrymen to the circumstance that they
never operate, in England, except in desperate cases, whereas upon
the continent they are willing to have recourse to it at an early
period.

1141. When the smallest diameter of the pelvis is less than fifteen
lines, be the foetus dead or alive, the operation of hysterotomy is the
only chance of safety that we can propose to the woman. When
this diameter amounts to from eighteen lines to two inches and a
quarter, it is equally indispensable, where we do not wish to act
upon the child; but in this case, the child must be alive, and further,
it remains for us to decide whether it is belter to follow the English
doctrine and destroy the foetus, than to expose the mother to the
danger of losing her life. Lastly, it may happen that we shall be
compelled to resort to it, even although there should be two inches
and a half or two inches and three-quarters at the smallest passage,
provided the forceps, turning, or the section of the pubes shall have
been deemed useless, or have been tried in vain.

1142. Not only ought the cesarean operation to be performed
upon the living subject, but it is also a rule of practice to subject those
to it who perish after the seventh month of pregnancy without being
delivered.

The child does not always cease to live at the same moment with
its mother, although most frequently it dies first. We might even
45

518 CESAREAN OPERATION.

believe, admitting as trne what has been written upon the subject,
that life may be maintained in the ovum more than twelve, twenty-
four, or even forty-eight hours. The princess of Schwartzenberg,
who died at Paris in consequence of a burn, could not be opened
until the next day, and the foetus was, notwithstanding, found to be
living. Another woman, mentioned by M. Gardien, was not ope-
rated on until after forty-eight hours had elapsed, and the child
was found to be still alive. Flajani, Veslingius and several other
authors relate cases of a similar character; but may we give credit
to the assertions of Cangiamila, when we find him afRrming in his
Sacred Embryology that in the space of twenty-four years, twenty-
one children were saved in this manner at Montereali, thirteen at
Girgenti, and that the cesarean operation was performed under these
circumstances twenty times at Syracuse in the course of eighteen
months.

1143. Be this as it may, the Roman law, lex regia,* which is re-
ferred to Numa Pompilius, ordered the physicians of that period to
open the bodies of all women who died pregnant, with the view of
preserving citizens for the state. To fortify this ancient usage, with-
out compromitting the lives of women who might be only in a state
of apparent death, the senate of Venice issued a decree in 1608 and
1721, which ordered severe penalties upon those members of the pro-
fession who should operate upon a person supposed to be dead with-
out the same degree of care as if she were actually living. In 1749,
the king of Sicily made another law, by which he inflicted the pen-
alty of death upon physicians who should omit to perform the cesa-
rean operation upon women who should have died in the last months
of pregnancy.

It is very useless, no doubt, to think of preserving the life of a
foetus previously to the end of the eighth month; but in Catholic
countries there is a desire at least to baptise them, and that the opera-
lion should be performed, in fact, if the woman has passed through
one half of the period of pregnancy.

1144. As to the necessity of acting, immediately subsequent to
the death of the mother, with the same precautions as if the woman
were known to be living, no one will entertain a doubt — in view of
the difficulty of ascertaining with certainly that life is irrevocably ex-
tinct, and of the promptitude with which we ought to act under such
circumstances. Precipitation might really produce a decease which
might possibly be otherwise avoided, and the time required to esta-
blish the certainty of the woman's death would more than suflice to

* Digest, lib. IX, tit. viii, L. 2, et lib. I. tit. v. &c.

CESAREAN OPERATION. 519

ensure the loss of the child, which, in fact, is never extracted alive,
excepting in a few cases, appertaining somewhat to the miraculous,
unless the extraction be effected during the first moments that suc-
ceed the death of the mother.

Van Swieten and Baudelocque mention three cases of women,
supposed to be dead, on whom the cesarean operation was about to
be performed, when they recovered from their lethargic state. Pen
relates an instance far more calculated to excite alarm : he com-
menced his incision, when the woman gave a shudder, accompanied
with grinding of the teeth and a movement of the lips. Rigaudeaux
has related another one not less remarkable: he was sent for, two
leagues from Douai, to see a woman whose labor had excited great
uneasmess; when he arrived she was believed to have been dead for
two hours. Instead of opening the abdomen without any examina-
tion, he explored the genital organs, found the pelvis well formed,
and proceeded to turn and deliver the child by the feet, which was
born in a state of apparent death, but which with great exertion was
brought to life in about two hours. The limbs of the mother pre-
serving their suppleness, he forbid them to bury her until the abdo-
men should have turned green; after a few hours this woman reco-
vered so completely from her insensibility, that she came herself, four
years afterwards, to inform Rigaudeaux that she was not dead !

Thus, when called to a woman who has lately expired, the first
thing to be done is to ascertain the state of the pelvic passages, and
whenever they are sufficiently capacious, an attempt should be made
to extract the child through the natural passages. In the second
place, if hysterotomy is found to be indispensable, it is to be per-
formed according to the same rules, and with as great care as if the
Avoman were living. By acting in this manner, whatever may chance
to occur, we have nothing to reproach ourselves with, and nobody is
liable to be blamed.

1145. When the cesarean operation used to be performed only
upon the dead subject, the incision was made upon the left side of
the abdomen; "Zef the woman be opened with a razor along the left
side,'''' says Guy de Chauliac, '■'■inasmuch as that part is freer on
account of the liver.'''' But since it has been attempted upon the
living female, it has been subjected to rules formed on a better foun-
dation. Among the various methods proposed by different accou-
cheurs, there are five which have attracted special attention: in one
the incision is made upon the median line, and parallel to the axis
of the body; in the second, the cut is made outside of the rectus
muscle; in the third, the abdominal parietes are divided transversely,
upon one of the sides; in the fourth, the wound is made immediately

520 CESAREAN OPERATION.

above the Fallopian ligament and parallel to that fibrous band; and
lastly, the fifth is made at the level of the crista of the ilium.

1146. Mauriceaii's method. Solayres, Henkel, Deleurye, &c.,
are wrong in attributing the idea of cutting down upon the median
line to Plainer, to Guerin, or to Varoquier. Mauriceau had ex-
pressed himself in the following terms: " Most persons direct the
incision to be made on the left side of the belly, but the opening
will be better in the middle, between the recti muscles, for in that
part there is nothing but the integuments and muscles to be cut."
This proceeding, which is preferred by Baudelocque, and now gene-
rally followed in France, England, and Germany, permits us to avoid
the muscles, and to act only upon the linea alba; only a slight de-
gree of gain is produced; no artery can be wounded, and moreover,
the uterus is incised parallel to its principal fibres. But it has also
been said that this method exposes us to the hazard of inflicting a
wound upon the bladder, and that the discharge of the fluids, whether
during or after the operation, cannot be effected without difficulty;
the wound occupying none but fibrous tissues, is slow in healing, and
the uterus being laid open throughout almost the whole extent of its
anterior wall, instead of tending to approximate the lips of the divi-
sion, rather separates them by its contraction.

1147. Method of the ancients. In operating upon the side of
the abdomen, the ancient accoucheurs generally chose the left side,
and made sometimes a straight, sometimes a slightly oblique incision,
or one of a crescent shape, but always immediately outside of the
rectus muscle. According to the statements of the physicians who
employed it, this method has over the preceding one the advantage
of avoiding all danger of wounding the bladder, of permitting the
cicatrisation to be easily effected, and of rendering the issue of mat-
ters that must escape from the wound far more easy. As the womb
almost always undergoes a twist upon its axis, inclining to the right
or left, it has been supposed that by making the incision along the
median line, it would fall nearer to its left edge than to the middle of
its anterior region; this also is one of the considerations from which
it has been recommended that the operation should be performed
upon the side towards which the uterus has naturally deviated.
Even admitting all these advantages to be real, they would, neverthe-
less, be compensated, it seems to me, by the risk of wounding the
epigastric artery or some of its branches; of having a wound, the
lips of which it would be almost impossible to keep in contact, on
account of the retraction of the oblique and transversalis muscles,
and by the impossibility of obviating the absence of parallelism in
the two wounds of the abdomen and womb.

CESAREAN OPERATION. 521

1148. Method of Lauverjat. To avoid the disadvantages con-
nected with these two methods, Lauverjat, who had at first admitted
the great superiority of hysterotomy at the median line, attempted
to methodise a procedure which had already been resorted to by
some practitioners, and recommended a transverse incision about
five inches in length, between the rectus muscle and the spinal co-
lumn, somewhat below the level of the third false rib, and more or
less so, according as the fundus of the womb is more or less remote
from it. By proceeding in this manner the fibres of the transverse
muscle are rather parted than divided; the epigastric and lumbar
arteries are avoided; we fall upon the fundus of the womb, whose
cavity forms a sort of funnel, which renders the discharge of the
lochia very easy, both by the vagina and hypogastrium; the parallel-
ism is easily maintained; the suture is not required; mere position
suffices to keep the wound in exact apposition; lastly, the external
angle of the cut occupying a low situation, extravasations into the
abdomen are incomparably less to be dreaded than in the other
methods. But it may be objected that the fibres of the external and
internal oblique muscles are necessarily divided; that the least ef-
fort must force the viscera out; that the womb being divided at its
fundus, where its vessels are largest, soon removes to a considerable
distance from the external opening, and that its fibres, by contract-
ing, must rather hinder than promote the approximation of the edges
of the inner incision; so that, notwithstanding the two successful
cases of Lauverjat, and the preference apparently given to him by
Sabatier and M. Gardien, this method is evident scarcely less dan-
gerous than the two former ones.

1149. Method of M. Ritgen. Dreading above all things the
wounding of the peritoneum and of the body of the uterus, Ritgen
has of late recommended that the attachment of the broad muscles
of the abdomen should be divided above the crista of the ilium; that
the peritoneum should be detached as far as the superior strait, and
that the neck of the womb should be divided to a sufficient extent
to admit of the extraction of the child. In the first place, I cannot
perceive how it would be possible to incise the apex of the womb
without cutting the serous membrane with which it is enveloped;
then, the difficulties inherent in this proceeding, added to the detach-
ment, which would be produced in the iliac fossa, do not appear to
me to be of a nature to render the operation at all less serious than
those which have been mentioned; besides, as far as I know, at least,
the operation is as yet only a project, and no one has put it in prac-
tice in the living woman.

1150. Method of M. Baudelocque, Jun. Attributing the princi-

45*

522 CEASAREAN OPERATION.

pal dangers of the cesarean operation to the double wound of the
peritoneum; and further, regarding wounds of the uterus as almost
essentially mortal in their character, M. Baudelocque has proposed
a new method, which in both these respects appears to him to be
infinitely preferable to all others, and which in fact differs from them
very considerably.

The incision is commenced near the spine of the pubis, and ex-
tends, parallel to the Poupart's ligament, beyond the antero-superior
spine of the ilium. He selects the left side, on account of the in-
clination of the cervix, when the womb is oblique to the right, and
the right side where there is a left lateral obliquity. After having
divided the abdominal parietes without touching the epigastric
artery, he pu&hes away the peritoneum from the iliac fossa quite
down into the excavation, and detaches it from the upper part of
the vagina which he opens; through this opening, which ought to
be sufficiently free, the finger is conducted into the os uteri, which
is now to be drawn up towards the wound in the abdomen, while
the fundus is at the same time pressed in an opposite direction, so
as to make it turn over more readily. When the operator has suc-
ceeded in bringing the orifice of the womb opposite to the opening
made in the abdominal parietes, the delivery is entrusted to the
uterine contractions, or provided it should be absolutely necessary,
the orifice might be dilated with the fingers, and the foetus extracted
either with the hand or the forceps.

1151. The idea of this method, which the author denominates
elytrotomy, is certainly ingenious; he has performed on the dead
subject, both pregnant and not pregnant, a number of experiments,
which have confirmed him in the favorable opinion he had previ-
ously formed concerning it, and which have sufficed to induce some
practitioners to suspend their judgment in relation to its value.
Nevertheless, I can scarcely believe that it will be found practicable
in a majority of cases, or that the laceration of the vagina in addi-
tion to the disturbance necessarily occasioned in the iliac fossa or in
the excavation would be less redoubtable than the simple and metho-
dical incision of the peritoneum and womb, such as may be per-
formed in ordinary hysterotomy. I may further add, that M. Bau-
delocque himself has very recently been obliged to have recourse to
the ceasarian operation, properly so called, after having tried the
operation of elytrotomy in the case of a woman who had long been
imder his supervision, and in which he was assisted by M. Hervez
de Chegoin. I am aware that one single fact does not warrant us
in drawing rigid conclusions; but this, which is the only one we
have in regard to the living subject, seems to me to lend great force

CEASAREAN OPERATION. 523

to the distrust of the author's notions, derived, a priori, from
reasoning.

1152. Method of Dr. Physic. Another mode of operating, which
is somewhat like that of Professor Ritgen, and also is not very diffe-
rent from that of M. Baudelocque, appears to have been proposed,
almost at the same time, by Dr. Physic. After having remarked that
in pregnant women, the peritoneum is easy to separate from the
bladder and parts about the os uteri, this surgeon conceived that by
making a horizontal incision immediately above the pubis, the os
uteri might be reached and opened without interesting the peritoneum:
but notwithstanding what Dr. Horner may say concerning it, this
operation is but little worthy of its inventor, and does not deserve
the trouble of being discussed.

1153. Previously to commencing the operation, it is proper to
soothe the mind of the patient by inspiring her with the greatest
possible confidence; a good condition of the general strength, and
of the womb in particular; an obtuse, rather than a lively sensibility;
a great degree of resignation such as are pretty often observed in
country-people, is most of all to be desired; if the child is incur-
ring any risks we should make haste; otherwise, bleeding, baths,
purgatives or any other proper means may be sometimes made use
of; and lastly, the conduct here in relation to the preparations, is the
same as in all the great operations.

Jf the bag of waters is not ruptured, ought it to be torn, as Plan-
chon advises, previously to making the incision into the womb, or
must it be let alone, as most other authors advise? By empty-
ing the membranes the escape of the liquor amnii into the perito-
neum is prevented, and there is less reason for fear as regards he-
morrhage and inertia of the womb. But these are not the most to
be dreaded of all the occurrences that may take place during the
operation; we are much more frequently embarrassed by the con-
traction of the womb than by its inertia. When the ovum is whole,
the child can be much more easily extracted; the wound in the
uterus, at first more extensive, is however reduced at last to much
smaller dimensions; lastly, there is less irritation excited in the
womb, and upon a careful consideration of all the circumstances, I
believe, in common with M. Desormeaux, that it is better to preserve
the membranes whole.

We should never omit to empty the rectum and bladder, especially
if it be intended to follow the method of Mauriceau. The appa-
ratus consists of a convex bistoury, a straight probe-pointed bistoury,
pincers, scissors, suture-needles, thread, quill-barrels, adhesive strips,
lint in rolls and in pledgets, of pieces of linen spread with cerate, of

^24 CESAREAN OPERATION.

compresses both oblong and square, a bandage for the body, small
and large sponges, a syringe, canulas of gum-elastic, to be used in
case it should be necessary to make any injections, water, both cold
and warm, and vinegar; wine and. cologne- water are also necessary.

If possible, the patient should he laid on the bed that she is to oc-
cupy during the first few days after the operation; her position
ought to be an easy one. She should be placed on her back, with
the legs and thighs very slightly bent, and assistants are charged to
watch against any sudden movements which the pain might compel
her to execute; two intelligent assistants must apply their hands upon
the sides and fundus of the womb, so as to circumscribe it very ex-
acdy, in order that no organ may happen to slip betwixt its surface
and the abdominal parietes, and so that it may compose with the
latter parts but one single mass. For this purpose the naked hands
seem to me less suitable than they would be if applied upon pieces
of broad flat sponge, as advised by Dr. Hedenus.

1154. "With the convex bistoury the surgeon makes an incision
through the integuments, from near the umbilicus towards the pubis,
in length from five to six inches, without its being necessary, or
always even possible, to pinch up a large fold of them, as advisedby
Levret. The sub-cutaneous layer, the aponeurosis and the muscular
fibres, as well as the cellular tissue, provided we do not operate upon
the median line, are successively divided in the same manner and
to the same extent. This incision ought not to be carried too near
to the pubis, on account of the bladder, and because the abdominal
parietes are generally very thick in that situation. It would be
better to extend it above the umbilicus, taking care to pass to the
left of it, so as to avoid the umbilical vein, and more particularly,
the anastomosis which may exist between it and the epigastric vein,
an anastomosis which has latterly been noticed by M. Mesniere,
Clement, and Martin.

After having opened the peritoneum so as to admit of the intro-
duction of the left fore finger, to serve as a conductor for the in-
strument, the wound in that membrane is to be enlarged by means
of the probe-pointed bistoury, to the same extent as the wound in the
skin.

The womb is now exposed; it is to be incised layer by layer, and
slowly, until we reach the surface of the ovum; then, in order to
retain for the cervix as much of its length as possible, the assistants
are told gently to press the fundus of the uterus downwards and
make it turn somewhat in front; we might, indeed, like Dr. Kluge,
hook the lower angle of the wound of that organ with the finger, so
as to favor such a movement, which by affording a facility for ex-

CESAREAN OPERATION. 525

tending the section very far upwards, permits us to guard the cer-
vix. In order to avoid the risk of wounding the vessels of the
placenta, it is better to use the probe-pointed bistoury to finish the
incision, than to have recourse to the grooved director to guide the
bistoury with. Further, I can conceive no objection to letting the
point of the finger detach the placenta and membranes to a certain
extent.

This is the moment, and not before the commencement of the
operation, that it would be perhaps well to follow the advice of Plan-
chon, and rupture the membranes by passing the finger up the
vagina, either with the fingers alone, or with the instrument of Sie-
bold, as is generally done in Germany; supposing, which appears
to me preferable, that the membranes should be pierced from the
incision, it will be necessary for the assistants to redouble their care
to prevent the parietes of the abdomen from abandoning the womb;
in this way the effusion of the waters into the cavity of the perito-
neum will be obviated, and the tendency of the viscera to escape
outwards will remain ineffectual.

1155. The extraction of the child ought to take place without
delay; when it presents by the head or by the breech it is drawn,
away in that position, and to favor its escape, the assistants are told
to press gently upon the sides of the womb through the parietes of
the abdomen; if it be situated otherwise; the feet must be got hold
of, and the extraction performed with the same precautions as in de-
livery by the natural passages, special care being taken not to bruise
or stretch the lips of the wound in the uterus.

1156. As soon as the foetus is withdrawn, the practice recom-
mended by Planchon might be adopted, viz. by means of a sound,
the cord might be repassed through the wound, for the purpose of
removing the after-birth through the vagina, but no beneficial effects
would be ultimately obtained by it, and the celerity of the operation
would be sensibily lessened; after all, the retraction of the womb,
which would most generally render this operation impossible, soon
forces the placenta to engage in the wound, and thus points out the
route we should select in extracting it. In order that it may present
less volume and less resistance, one of its edges even may be taken
hold of, if possible, rather than pull it away by the cord only. As
to the membranes, they must be carefully twisted into a rope as in
a natural delivery, to prevent any of them from remaining in the
uterus. Should any blood have been lost and formed into clots, they
ought to be removed with the hand. It would be well, moreover,
to cleanse all the parts by means of an injection of warm water; but
I do not think that for the purpose of keeping the os uteri open, it is

526 CESAREAN OPERATION.

of any advantage to place in it the tent recommended by Baude-
locque, nor the cierge pertuise of Ruleau, nor the tent of Rousset,
nor the sound of M. Tarbe, nor any species of canula whatever;
these means would not prevent the os uteri from closing, and would
augment the irritation to no purpose. The finger introduced from
time to time suffices to keep it free enough, should it cease to give
issue to the matters, which, after all, nothing can prevent from pass-
ing wholly or partly out at the wound.

1157. The operation being terminated, we must next think of
putting a stop to the flow of blood. In the lateral operation, and
especially in that of Lauverjat, several arteries may have been
divided; they should now be tied, provided they should not have been
secured during the progress of the operation. During the operation,
the principal orifices of the uterine arteries have been closed by the
fingers of the assistants; there never can arise any question about
obliterating them with the ligature; but it has been recommended
to cauterise them with vitriol, and generally, to trust them to the
contractions of the womb, which is to be solicited, provided it be
slow in taking place, by irritating the cavity of the organ or the lips
of the wound with the fingers, or linen moistened with vinegar and
water; after a few minutes the length of the incision in the womb is
reduced to from one to two inches, and thenceforth hemorrhage of
any kind becomes impossible.

1158. In England, in Germany, and also in France, the wound
in the abdomen is generally closed by the interrupted or twisted
suture, because, it is said, that is the only means of keeping the lips
in contact, and of preventing hernia of the viscera. Sabatier, how-
ever, thinks it ought to be dispensed with, and says that unless the
whole thickness of the abdominal parietes be included in each stitch,
which would be dangerous, the adhesive strips will do as much as
the sutures, without compromitting, in the same manner, the safety
of the patient. But notwithstanding the reasons urged by that
learned author, it seems to me to be preferable to have recourse to
the suture, even where Lauverjat's operation has been adopted.
In all cases the lower corner of the wound should be left free to
allow the matter to escape. Besides, the sutures do not prevent the
application of adhesive strips over their intervals, nor the favorable
action of the uniting bandage, and a proper position.

The wound is then covered with a piece of linen, perforated, or
with strips spread with cerate; two long and broad compresses are
placed on the sides; some pledgets of soft lint, common compresses,
and a body-bandage well applied, will complete the dressing.

Previously to leaving the woman, the linens soiled during the

CESAREAN OPERATION. 527

operation should be removed; she is to be placed in the middle of
her bed, taking care to move her as little as possible, and we should
endeavor to place her so that her muscles may be all in a state of
relaxation.

1159. Some antispasmodic potions, slightly opiated, to calm the
nervous agitation; some precautions to ensure the discharge of the
lochia by the vagina instead of their escaping into the peritoneum;
diluting drinks, bleeding and leeching as soon as any symptoms of
inflammatory action become manifest, and the greatest repose, both
of mind and body, are all that the surgeon can recommend to the
patient to obviate the dangers which threaten her.

SECTION 5.

Vaginal-Cesarean Operation.

1160. According to the reports of authors there are a great num-
ber of causes which may necessitate the performance of the vaginal-
cesarean operation: an obliteration, with fibro-cartilaginous indura-
tion of the OS uteri, as in the case related by Simson, and also in
that other case spoken of by Van Swieten; violent convulsions
which endanger the life of the woman while the orifice is too tense,
and still insufficiently dilated to admit of the introduction of the hand,
as is observed in the cases by Dubosq and Lambron; an extreme
obliquity of the orifice backwards, while the head of the child at the
same time forces down into the excavation, and even as low as the
vulva, the anterior portion of the womb, which it distends, renders
thin, and would at last rupture, provided an incision were not soon
made, as was done by Lauverjat — such are the occurrences which
have most frequently rendered it necessary; it may also become use-
ful where the uterus, having escaped from the pelvis during preg-
nancy, has never been reduced, and where its orifice cannot be di-
lated by means of the fingers, although there may be danger in
delaying the delivery, as in the examples cited by M. Thenance,
Jacomet, and a surgeon at Vaux mentioned by M. Bodin; but it has
been proposed more particularly in cases of scirrhus, and where the
orifice presents such a resistance to the contractions of the womb
that the woman is exhausted in vain efforts without effecting its dila-
tation; lastly, it would be equally well indicated, as M. Bodin has
attempted to demonstrate, in cases of arm presentation, should it
ever in any case be found really impossible to proceed in search of
the feet, and if no other means of avoiding the amputation of the arm
could be availed of.

528 VAGINAL-CESAREAN OPERATION.

1161. Although generally attended with but little danger, the
accoucheur would be blameable who should perform it without a well
ascertained necessity; I cannot therefore but condemn in decided
terms the temerity of those practitioners who do not hesitate to
employ it, simply because the os uteri happens to be somewhat
tense, and does not dilate according to their impatient desires; and
according to what I said when speaking o{ deviations of the os uteri,
I have no doubt that it has often been performed when it might have
been easily dispensed with.

In all cases, if there is an orifice, nothing is easier than to per-
form this operation; the speculum, employed by some persons is of
no use; a probe-pointed bistoury, wrapped round with a narrow
strip of linen to within eight or twelve lines of its point, is passed
up upon the index finger; in this way we carry it without difficulty
within the os uteri, provided it be not too far distant from the centre
of the pelvis; in the contrary case. Pott's curved bistoury should be
substituted for the straight one. Strictly speaking, one incision
might be deemed sufficient; but as it is important that it should not
be too deep, it would be preferable to make several of them, at a
small distance from each other. At a first view it would seem that
the passage of the head could not take place without enlarging such
wounds so as to extend them to the body of the womb, and lacerate
the peritoneum; but in fact this does not happen, and they com-
monly remain limited to the substance of the os uteri. In operating
for a scirrhous or fibrous induration, but a very few ounces of blood
are found to flow from the wound. M. Duges is, in my opinion, right
in recommending that all the diseased parts should be removed at
once, instead of merely incising them.

1162. When the anterior wall of the uterus is divided without
extending the cut down to the os uteri, we are obliged to make use
of a straight, or convex, and not a probe-pointed bistoury, to begin the
operation with, which is always a more delicate one than the pre-
ceding. Too much care cannot be taken to avoid wounding the pre-
senting part of the fcEtus while making the incision. But, when
the womb has been once penetrated, the forefinger becomes a sure
director, and the instrument may enlarge the wound as much as
necrpssary, without any danger; let us however observe that there
is less hazard in extending the incision backwards than forwards,
on account of the bladder, and also, that it is useless to make it very
large. After the delivery, the wound contracts very rapidly, and it
often happens that not a half day elapses before the os uteri recovers
its natural situation. If the blood should flow in too large a quan-
tity, it would be easily arrested by injections of oxicrate, and by th©

CEPHALOTOMY AND EMBRYOTOMY. 529

tampon; and the cautery, which is easy to apply; will rarely be
necessary in such cases. As to the lochia, they escape either from
the wound or from the orifice of the uterus, and in these respects the
woman requires only such cares as are common after an ordinary
parturition.

SECTION 6.
Of Cephalotomy and Embryotomy,

1163. In England the perforation of the cranium or reduction of
the foetus, by removing successive portions of it, even where it is still
known to be living, is generally preferred to the cesarean operation.
Wigan, combatted by Busch, maintains the same sentiment in Ger-
many. In France the operation of cephalotomy is not performed
except where the death of the child has been certainly ascertained
or at least become very probable, and where the delivery by the
natural passages is altogether impossible. When the pelvis has a
diameter less than fifteen lines, or the whole hand cannot penetrate
into the womb, the cesarean operation is preferred, even though the
child be dead. Upon this subject I will remark that our neighbors
too rarely have recourse to hysterotomy, and that they are too ready
to sacrifice the child, for fear of compromising the life of the mother;
that here we fall into an excess of quite an opposite kind, and
which, is perhaps, scarcely less blameable. In a case where every
circumstance announces that the foetus is still in full vigor, and that
it is robust; there is no doubt that, instead of sacrificing it, as is done
in Great Britain and at the north, it ought to be extracted without
endangering its life, by means of operations which indeed are severe,
but not always fatal to the woman; there is also no doubt, in my
opinion, that cephalotomy ought to be preferred when there are good
reasons for fearing the child's death, or for believing that it cannot
continue to live. It would be too cruel, after performing the cesa-
rean operation, to be able to present only a corpse, or a feeble, mise-
rable being, which must perish in a few minutes or hours, to the
unhappy mother as the price of all her sufferings and dangers! But
it would be a great mistake also to suppose that embryotomy is wholly
unattended with danger to the mother; it is, on the contrary, one of
the most redoubtable and revolting operations in tokology, whenever
it extends beyond the mere operation of craniotomy.

1164. To sum up, the operation of cephalotomy is indicated
1. When the foetus is dead and the passages are too much con-

46

530 CEPHALOTOMY AND EMBRYOTOMY.

tracted to permit its extraction with the forceps or by turning;
2. When it is very probable that the child is dead, or at the point
of death, and when it cannot be got away whole without the per-
formance of the operation of hysterotomy; 3. When the head alone
remains in the pelvis and cannot be extracted by the hand, the for-
ceps, or crotchet. It would be useless, dangerous, and ought to be
proscribed even in case the foetus were dead, provided the small dia-
meter of the inferior strait were less than eighteen or twenty lines
in extent.

1165. Embryotomy, that is to say, that operation which consists
in introducing a cutting instrument within the cavity of the womb,
for the purpose of lessening the size of the child, dividing, and re-
ducing it to small pieces, so as to be afterwards able to extract it
piece-meal, was frequently employed by the ancients, who had no
other resource, and did not confide enough in the powers of the sys-
tem; but at the the present day the forceps, the lever, turning, sym-
physeotomy, and the cesarean operation, properly appreciated as to
their respective value, render it almost wholly useless; it is therefore
no longer performed at the present day, except by certain country
medicasters, who are as ignorant of the art of midwifery, which they
disgrace, as they are of the plainest principles of the other branches
of medicine.

1166. Even the operation of craniotomy must very rarely be ne-
cessary or indispensable, since out of a total of more than twenty
thousand labors Madame Lachapelle has indicated only three instances
of it.* In performing it, Avicenna and Mauriceau made use of sharp
extractors in the shape of a crotchet; Levret, Denys, Fried, and
Ould, made use of sheathed perforators; Simson boasted of a ring-
scalpel; spear-pointed perforators have been recommended and modi-
fied in an infinite variety of ways; but at present a simple bistoury
is employed, or the scissors of De la Motte, improved by Smellie
and by Walbaum, are made use of when it is necessary to penetrate
to a great depth within the organs, and to exert a certain degree of
force to perforate the bones.

1167. The woman should be placed as for the application of the
forceps; the bistoury, wrapped with a small linen roller to within a
few lines of its point, which Baudelocque guarded with a small ball
of wax, is directed along the palmar surface of one or two fingers
of either hand, previously introduced into the vagina, and so on to

* Dr. Collins, of Dublin, states that 79 cases of delivery by lessening- of the
head, occurred out of the whole number of cases during his mastership of the
Lying-in Hospital. — The whole number is 16,414 cases, or one in about 206 la-
bors.—M.

CEPHALOTOMY AND EMBRYOTOMY. 531

the head which is to be opened. To insert the scalpel, a fontanel,
or at least a suture, is to be selected, when the vertex is the pre-
senting part: where the trunk of the body is delivered we may be
obliged to perforate the bones themselves, in which case we ad-
dress the instrument to the forehead, or even to the base of the oc-
cipital bone. When the head is left in the pelvis, we ought also to
endeavor to find one of the membranous spaces; but it is not always
easy to reach them, and the accoucheur must then choose the bone
which offers the least resistance, and which his finger can touch.
During this operation, if the head be somewhat movable, an assistant
ought to embrace the womb with both hands, as advised by Celsus,
and push it down towards the strait, so as to steady, as much as
possible, the parts about to be divided. On the other hand, the
point of the instrument ought never to move, while within the ma-
ternal organs, without being guarded by covering it with the point
of one of the fingers. When it is once plunged into the cranium,
the incision is prolonged as far as possible, at least to the extent of
an inch; most commonly, we should not be satisfied with making
only one incision; we ought to make a crucial opening, through
which the finger may be passed so as to break up the brain, which
may also be lacerated with the cephalotome itself.

If Smellie's perforator is selected for the operation, it is to be in-
troduced and shut with the same precautions pointed out when speak-
ing of the use of the bistoury; when closed it resembles a common
cephalotome; but as the two branches of which it is composed are
sharp on their outer edges, when they are opened, it necessarily en-
larges the incision at first made by its introduction, in direct propor-
tion to the degree of the opening; it is then shut, to be opened again
in another direction; after which it may be made use of to reduce
the brain to the consistence of gruel.

If the disproportion betwixt the child's head and the pelvis is not
considerable, and the womb still retains its energy, the remainder
of the labor is confided to the efforts of the woman, and terminates
with much rapidity; in the contrary case, we are obliged to resort
to the employment of the forceps, or crotchet. The forceps would
be always preferable where it could be applied, and when the head
is still somewhat firm; and provided it were not so liable to slip and
lose its hold, upon the application of some degree of extractive
force.

532 THE CROTCHET.

SECTION 7.

Of Crotchets, and their Use.

Crotchets were formerly employed in almost all the cases that are
now happily terminated by means of the forceps, and in an infinity
of others, which, by means of turning, or the skilful use of the hand
are capable of being brought to a favorable conclusion; but their em-
ployment becomes more and more rare, as the knowledge of obste-
trics, extends, as well as that of all the other destructive instruments
which .were so much abused by the ancients.

1168. Crotchets are of two kinds: one, terminated by a blunt
and rounded extremity, or else of an olive shape, and more or less
bulbous, which are proposed as substitutes for the fingers or the
fillet, do not divide the parts of the child, and are applied either
while it is living, or after its death, upon different parts of its body.
They are constructed of various forms. It has been recommended
that they should all be replaced by the one which terminates the
handle of the modern forceps; but the best ones consist of a long
piece of steel, supported by a wooden handle, and curved into an
arc of a circle, the sinus of which is sufficiently open to embrace
without difficulty the groin, the ham, or the axilla; when only bent
at a right angle, as advised by Madame Lachapelle, they slip too
readily; if bent into the shape of the letter S, or contracted in too
acute an angle, they will not fit accurately to the part on which they
may have to be applied; Baudelocque, Steidele, and most of the
accoucheurs of the present day, have imagined that the two blunt
crotchets of the forceps might be united, so as to form a pincers
with a curved end, and to be applied to both groins at once; but it
does not appear that such a modification can ever be wanted. A
single branch commonly suffices, and, with the exception of a ievf
cases, the fingers are a very good substitute. The utility of the blunt
crotchet, however, can scarcely be doubted when from any cause
whatever the head has be^gn separated from the trunk, which cannot
be extracted except by acting upon the axilla; in such a case, as in
breech and knee positions, the only rule that it is important to follow
is, always to act upon the bend of the limb that looks to the back
part of the woman's pelvis, and in drawing down, not to lose sight
of the axes of the pelvis.

1169. The point of the sharp crotchet is sometimes round, as in
the olive of the forceps, sometimes flat and triangular, as in Mauri-
ceau's and most of the ancient instruments, so that the entire in-
strument is nothing more than a cephalotome with a bent blade.

THE CROTCHET. 533

This point, which is single in some and in others double, may be
continuous with a straight or with a curved stem, or it may resem-
ble a hook of a chain, of greater or less length, like what is seen in
Scultetus's Armamentarium; the point, which in most of the speci-
mens is fixed, may however bend, and also open as in the instru-
ments of Aitken and Saxtorph. Forceps or pincers with sharp
crotchets have also been constructed; Mesnard, Levret, Smellie, Bau-
delocque, and many others have boasted of the value of the crotchet-
forceps, a model of which is to be seen in the Museum de la Faculte,
and which are nothing more than Smellie's small forceps without
fenestres in the blades, which are terminated by a triangular, sharp
and bent point. The forceps •\vith wolf-teeth of Avicenna, and the
dentated pincers of Rueff ought also to be classed among the sharp
crotchets.

J 170. After the performance of craniotomy, if the powers of na-
ture are insufficient, Burns thinks that we ought to wait twenty-four
hours before we resort to the triple forceps of Levret, and more es-
pecially to the sharp crotchet; he founds this doctrine on the circum-
stance, that the foetus, passing rapidly into a state of putrefaction,
softens, and becomes much easier to extract the longer we wait, even
admitting that it shall not be spontaneously expelled.

This practice, although recommended by Kelly, M'Kenzie, Den-
man, Osborn, Boer, Simson and Asdrubali, does not appear to me
to be one that ought to be followed; I agree with M. Duges that
it is useless to protract, in this way, the patient's anguish; and be-
sides, a labor that is already tedious cannot be with impunity pro-
tracted for twenty-four or forty-eight hours longer; and were there
no other reason than the necessity for renewing the preparations
for a forced delivery, which are always frightful, it ought to be re-
jected.

1171. The sharp crotchet is to be applied to one of the most solid
parts of the cranium, for example, to the occiput or the mastoid pro-
cess, when the head comes foremost; upon the lower jaw, in the or-
bit, or upon the forehead, when it descends after the trunk; in short,
in such a way as to prevent, as far as possible, the occipito-mental
diameter from abandoning the line of the axes of the pelvis, and to
retain it in its natural state of flexion. It may also be applied inside
of the cranium, by fixing it on the petrous portion or the basilar
apophysis; but in that case it is of essential importance that it shall
not slip, that it shall not act upon one of the bones of the vault of
the cranium, for by pulling them downwards it might pass through
them and injure the organs of the woman. Like the perforator, the
sharp crotchet ought never to be plunged into the foetus without be-

46*

534 THE CROTCHET.

ing guided, in some sort protected, or even covered by the accou-
clieur's finger; when fixed either on the interior or exterior of the
cranium, the stem must be supported by the thumb, while the fingers
remain firmly applied to the opposite side of the head, and the other
hand applied to the handle exerts the requisite extractive power. In
this way it cannot let go its hold without the accoucheur's perceiving
it at once; both the hands also act in concert, their efforts may be
exacdy combined, and the operation ceases to be dangerous. There
is no longer any danger of those dreadful slips, which chance alone
could prevent, when the operator is so rash as to pull, blindfold as it
were, with a single instrument.

1172. When one of the bones breaks or gives way, the crotchet
must be again applied, upon a firmer part. Some advise that the
point should be directed in front toward the pubes. Others have
directed it to be applied behind, for the purpose of more easily
drawing the head down through the superior strait; but it is not
easy to lay down general rules on this subject; we must act in either
way, according to circumstances. Should the head rise up again,
strongly, whenever we cease to pull with the crotchet fixed at the
back part, it would be well to follow M. Duges's plan and fix a
second crotchet in front, while the head continues to be held down
with the first; this may be got higher up, or a third instrument may
be attached while the head is kept as low down as possible with the
others.

To force the base of the cranium to clear the superior strait, we
sometimes meet with obstacles that are excessively difficult to over-
come. The bones of which it is composed do not bend like those
of the vault of the cranium, and the crotchet is quite as incapable
of lessening its size as the forceps; it is only by engaging it in an
oblique direction that we most generally succeed in extracting it in
cases where the antero-posterior diameter does not exceed two inches
or two inches and a quarter.

Perhaps the terebellum of M. Duges might be beneficially em-
ployed in such cases as these: this is a sort of cooper's turrel, which
is capable of perforating the bones and cartilages, of breaking up
the base of the cranium so as to render it flexible, and of acting as
a substitute for most of the cephalatomes.

1173. M. Baudelocque, Jun. has lately constructed a forceps, the
object of which is to overcome all these difficulties, and to render all
the perforators and most of the sharp crotchets superfluous. The
clams of this forceps are not fenestrated, and are but slightly
curved; so that by being closed they may pass through a strait that
does not exceed fifteen lines in its small diameter; through the

THE CROTCHET. 535

handles of the instrument passes a screw, which enables them to
be closed with such force that the head of the fcetus will be easily
reduced to any desirable dimensions without exposing the woman
to the least risk. This instrument appears to me to be an ingenious
one; but previously to forming a decided opinion concerning it, I
should like to have an opportunity of seeing it employed in a case
of labor.

1174. However, when the base of the cranium has reached the
excavation, the head may be taken hold of with the hands, and the
crotchet is of no further use, unless it should be applied to the trunk,
supposing, moreover, that the blunt crotchet when applied to the
axillae should prove incompetent to the extraction.

In this, as in all cases where the head is completely separated
from the body, there are only three points upon the tnmk which
can bear the action of the sharp crotchet: these are the spine,
the sternum and the ribs, and even the latter is a very insecure
hold, so that the whole of the ribs of one side are sometimes found
to give way one after the other, as soon as a certain degree of
extractive force has to be employed. It is therefore particularly
upon the vertebral column that we should endeavor to fix the point,
and then act as we should have to do provided it were attached
upon the head.

1175. There is one single circumstance which seems to me to
require the use of the sharp crotchet upon the trunk in a pelvis pre-
sentation; it is where the lower limbs have been separated from the
body, or where they are wanting in consequence of monstrous con-
formation, or where they do not admit of a hold being taken, suffi-
ciently firm to pull the body down by them. In such cases the
crotchet should be applied to the pubis, the crista of the ilium, or
what is still better, to the sacrum.*

SECTION 8.

Of the Extraction of the Head when it has been left alone in the
Genital Passages.

1176. When the head is separated from the trunk, and left in the

* The crotchet is a most detestable instrument, on account of the utter want
of security which every conscientious physician must feel, who is, by stress of
circumstances, compelled to make use of it. In a very bad pelvis, it is more dan-
gerous than in such as are not very much deformed; and the danger of its ap-
plication becomes enhanced by every degree of diminution in the pelvic diame-
ters. For my own part I abjure it, since I have employed the craniotomy for-

536 EXTRACTION OF THE HEAD.

pelvis, it almost always happens in consequence of its being badly
situated at the superior strait, or because the accoucheur was not
skilful enough to disengage it in time: in this case the detachment no
sooner takes place than the head becomes in some sort movable in
the womb, which soon brings it to the best possible situation; a few
pains then succeed in expelling it, and the assistance of art is, for the
most part unnecessary. In other cases the detruncation of the fcetus
takes place because, having been dead for some time, it is already
nearly in a putrid state. If we wait for a short time, under these
circumstances, the brain shrinks, the bones of the cranium become
very movable, may over-ride each other, and although at first the
pelvis might have been too narrow, the head nevertheless escapes
spontaneously at last; upon these results, and also upon the evils
that have often been found to follow upon unskilful attempts to
hasten the delivery, the English practitioners cited above found the
precept that the expulsion of the head should be confided to the
powers of nature alone; but as the labor has already lasted too long,
and as in some instances it would be necessary to wait several days
as the extreme irritation of the uterus would expose it to the hazard
of becoming inflamed, and the woman might die of exhaustion be-
fore the escape of the head it would be imprudent and unreasonable
not to give proper assistance. We ought not, says M. Desormeaux
to act with inconsiderate haste; there are cases where it is proper to
temporise; it may be necessary to restore the strength by means of
some aliment, a little wine, or other strengthening articles. Baths
and antiphlogistics, &c. may be required previously to any other re-
course in consequence of an incipient inflammation of the womb or
peritoneum, &c.

In cases where the hand alone may suffice, that is to say, where
the head is small, or requires to be placed in a better situation for
descending, an attempt should be made to get hold of the lower jaw,
then, after having brought the occipito-mental diameter into line with
the axes, it should be drawn down as far as possible, coincidently
with the eflTorts of the womb or those of the patient.

Next to the hand the forceps is the best and safest resource that
we have; but it is not always possible to apply it, while the head is
still at the superior strait, and in some cases its employment does not

ceps, described in the Pliila. Prac. of Midwifery, to which I beg to refer the
reader.— With the instruments there described and figured, I beheve it is quite
practicable to deliver, per vias naturales, whenever the diameter is not below one
inch and a half, and with a perfect assurance that the patient shall not suffer
from any wound inflicted by the instrument itselC It is manufactured by Mr.
John Rorer, North Sixth st., Philada. — M.

EXTRACTION OF THE HEAD. 537

always obviate the necessity of having recourse to craniotomy, or,
even to the sharp crotchet. It is true, that for the purpose of avoid-
ing the latter measures, a great variety of extractors [tiretetes) have
been proposed; but none of them can be regarded as good substi-
tutes. The double cross of Bacquie, the bascule of Levret, the ba-
siocester of Metzler, the sling of Mauriceau, the T of Stein, the nets
of Araand, the cap proposed by M. Desormeaux, Sen. the forceps
with three branches of Levret, the small piece of stick, to the middle
of which is attached a string, or the one made of iron fixed to the
end of the metallic rod in such a way that it may be introduced pa-
rallel to the rod, and after reaching the interior of the cranium, be al-
tered so as to stand crosswise to it, the invention of which is attribu-
ted to Danavia, and also to Assalini, and which has been too much
praised by many authors; all of these means have ceased to be made
use of at the present day. The crotchet planted somewhere near the
occipital foramen, in the upper jaw, or in some other firm part, whilst
the opposite part of the head is supported with the fingers, is in this,
as in some other cases, the last resource; but, nevertheless, it forms
the only really efficient extractor in all cases where the hand, the
common forceps, the toothed forceps, the extracting forceps with
three branches, or the crotched forceps, or the forceps of M. Baude-
locque, Jun. are either inapplicable or insufficient for the delivery of
the head.

CHAPTER VII.

Of the Natural Phenomena which folloio the Delivery of
the Fcetus.

ARTICLE I.

Of the delivery of the ^^fter-birth.

The placenta and the membranes are, after the birth of the child,
called the after-birth, and their expulsion, escape, or extraction is {in
France) called Delivery. Like child birth, this is a natural function,
and like it, this function may also be simple or complex, or, if the
expression be preferred, natural or preternatural, spontaneous or
artijicial.

SECTION 1.

Of simple or natural delivery of the After-birth.

All the phenomena of simple delivery are referable, 1. To the
detachment of the placenta; 2. To its expulsion from the genital
organs.

1177. First stage. The ovum becomes detached during the pro-
gress of a labor, and especially towards the conclusion, when the
waters have gone off. Being in some sort an inert mass, its adhesion
must necessarily be destroyed during the alternate contractions and
dilatations of the womb, unless the labor be so prompt as to require
almost no effort of the organism, or unless there be some preternatural
adhesions.

The cause of this detachment is found in the entire uterus, and
not merely in the orbicular muscle which Ruysch supposed he had
discovered. Sometimes the detachment takes place in such a way
that the foetal surface of the placenta presents first at the vulva, and
the l^lood, either fluid or coagulated, collects behind the spongy sur-

DELIVERY OF THE AFTER-BIRTH. 539

face of the cake, which is concave, like the bottom of a bottle;
sometimes it is effected gradually proceeding from the centre to
the circumference, or it may begin on the edge, and if the involucra
resist long, the smooth or internal surface may become the outer
one, and the blood being confined on the outside of the membranes,
does not escape until after the expulsion of the after-birth, the size
of which it sometimes surprisingly augments.

At. other times, in detaching itself, the placenta rolls up in the
shape of a cylinder or cornet cVouhlie. In that case it presents by
its uterine surface or by its edge to the several passages; the blood,
not being confined, flows out at the vulva as fast as it is poured into
the womb, and commonly ceases to flow as soon as the placenta is
delivered.

Second Stage. When once detached, the placenta presses upon
the OS uteri, engages in the orifice, which it irritates, and the womb,
which is irritated by its presence, becomes more and more con-
stricted, contracts, and soon forces it to pass into the vagina. When
there, it soon gives rise to a sensation of uneasiness, tenesmus, or
bearing down, which still solicit the contractions of the womb, and
bring into play the eflforts of the abdominal muscles. The diaphragm
and muscles of the belly react upon the abdominal viscera and
womb, as if for the expulsion of the foetus, and the placenta clears
the inferior strait.

Some persons, and among them M. Desormeaux, divide this pe-
riod of expulsion into two stages. It is true, that in order to pass
from the womb into the vagina, the after-birth sometimes requires
so considerable a degree of dilatation of the os uteri, that a particular
stage might be made of it, and that it may afterwards remain so
long in the passage that its entire expulsion really constitutes a dis-
tinct period; but as these two stages are far from being always so
distinctly marked, it appears to me that they may without inconve-
nience be confounded together. However, this is an affair of choice,
not of necessity.

If the labor have been a long one, if the woman be strong, if the
means of art have been applied for the extraction of the child, and if
the womb be in a state of considerable energy, the placenta falls into
the vagina and presents itself at the vulva almost immediately after
the delivery of the child. In opposite cases, the delivery of the
placenta does not take place for half an hour, and sometimes eveu
for several hours. It may also happen, that it shall not take place
for a whole day, or even for several days. This difl!erence is easily
explained: in the first case, the ovum which has been long detached
descends whole, along with the foetus. The womb, contracting

540 DELIVERY OF THE PLACENTA.

strongly in proportion as it empties itself, simultaneously throws
out both the child and placenta. In the second, the promptitude of
the delivery of the child is so great, that the womb has not had time
to break up the adhesions of the ovum, or to contract sufficiently.
Until the cavity of the womb becomes so diminished that tlie after-
birth fills it quite up, it may remain above the orifice. When the
child has just passed through the os uteri, provided the placenta be
detached at the time, and urged onwards by the uterus, nothing can
prevent it from descending: but if the orifice closes before the body
of the organ becomes reduced in proportion, the after-birth remains
shut up as it were in the uterine cavity, and cannot escape for a
considerable length of time, although its adhesions may have been
broken up from the beginning.

1 178. Although the organism generally suffices to finish the ex-
pulsion of the after-birth when it has reached the excavation, some
cases are, however, observed in which it would remain there for an
indefinite period, provided its escape were not promoted by artificial
means. It is on account of this tedious slowness, and to relieve
the woman of her fatigue and uneasiness of mind, that a natural or
simple case of delivery of the placenta is scarcely ever wholly aban-
doned to the efforts of nature. De la Motte, Deventer, Peu, and
some modern authors, are scarcely willing that we should wait for
it for half an hour: according to them, if we do not act at once, the
orifice closes, and may retain the after-birth, from whence accidents
of greater or less severity may ensue. Levret and Smellie, Baude-
locque, and almost all practitioners of the present day, advise us,
on the contrary, not to act until the placenta is completely detached,
and presents itself spontaneously at the orifice of the womb.

Both of these doctrines, if taken according to the very letter, ap-
pear to me to be equally incorrect. The practice of the ancients,
if followed without exception in all cases, would doubtless some-
times be dangerous; but I am induced to believe that at the present
day we have fallen into an opposite extreme; by endeavoring to
follow nature as closely as possible, the end which the accoucheur
ought to hold in view has been lost sight of.

Besides, if it is proper to act as soon as the placenta is detached,
I do not see wherefore the delivery should be so frequently deferred;
for except in a few cases, this detachment takes place previously to
the expulsion of the child. I can scarcely conceive, indeed, how
the womb can be reduced to a fourth or fifth part of its volume,
without destroying the delicate filaments which connect it to the
ovum. Most of the facts that are cited to show that the adhesions
of the placenta continue to exist after the birth of the child, are any

%

TABLE IV.

Labors observed by MM. Bland, Merriman, Dewees, Arnell,
Moore, N^ofcLE, Boer, Mesdames Boivin and Lachapelle,
and at the Dublin Lying-in Hospital.

o §

Ed

o ca

5

O

Q

Messrs. Dewees, Arnell
and Moore. . . .

Madame Boivin. . .

Merriman

Dublin Hospital. . .

Madame Lachapelle.

Naegele

Boer

u

About
35,000

20,517

1,813

106,766

37,895

415

15,608

or

6,555 ca

About
200

153

22

2,110

444

6

Uncer.
in
ses 92

Only
1

3

1

26

5

1

1

Uncer.
Uncer.

929
55,804
19,474

199
Uncer.
Uncer.

Uncer.
Uncer.

884
50,962
18,421

216
Uncer.
Uncer.

Uncer.

Uncer.

Uncer.

9,497

2,291

31

Uncer.

463

Total. .

224,569

3,027

37

1

76,406

70,483

12,282

Thus there were 3027 twins, 37 triplets, and only one case where 4 children
were produced at a birth in about 200,000 births.— 146,889 yield 76,406 boys
and 70,483 girls; and out of a total of 160,269 children, 12,282 were born dead.
M. Schweighauser reports a second case of 4 at a birth; the public papers have
mentioned a third instance in France of late years; Merriman speaks of a fourth,
which occurred in Worcestershire, in 1820; and Osiander says, according to a
letter, that a woman was delivered of 5 living children near Oporto in 1788.

47

DELIVERY OF THE PLACENTA. 541

thing rather than conclusive, and do not seem to have been properly
interpreted.

I know that w^hen the cord has been pulled at an improper time,
it has been found to occasion the inversion of the womb; but, in the
first place, this accident is a very rare one; and next, it does not
prove that the union of the placenta and womb was maintained at
the time; for, if such tractions are performed while the womb is soft
and uncontracted, whether the adhesions of the placenta be continu-
ed or not, they occasion the woman to bear down, and it is very
natural that the womb should then be inverted. The cord has often
been pulled so as to break it off, so as to give pain to the woman,
and make her feel a dragging sensation within, and the placenta,
notwithstanding, has not been moved at all. All this is doubtless
true; but without speaking of the pretended uterine cristae which
have formerly been so much spoken of, does the womb never con-
tract, except in a regular manner, upon the secundines? Does it not,
on the contrary, mould itself, in some sort, upon the anfractuosilies
of the placenta, so as to make its extraction somewhat difficult?
and then, are we sure that the extracting force has been applied in
the best possible direction, and exactly to the proper extent; have
not the faults of the accoucheur been mos commonly attributed to
the adhesion of the placenta? In my amphitheatre I have many
times seen the students leave off pulling at the cord from a convic-
tion that the placenta was not detached, whereas I had only to pull
in a rather more methodical manner than they did, in order to termi-
nate the delivery at once, and without difficulty, in their presence.
In a woman who came to be delivered^at the Hospital de VEcole
and who had a flooding, the cord had already been pulled so as to
break it off. I introduced my hand into the womb and found no
adhesion at all. Being called to visit a woman, in the Rue de la
Montagne-Sainte Genevieve, whose child had been born six hours, I
learned that all imaginable efforts had been made to bring away the
placenta. The physician had asked for assistance only because he
was convinced that the hand must be introduced into the womb in
order to destroy the adhesions of the placenta. He repeated his at-
tempts in my presence, and I soon found he would not succeed. I
now took hold of the cord, and found that there was no particular
difficulty in bringing away the after-birth. I have so frequently met
with these cases of supposed adhesion; I have so often introduced
my hand into the uterine cavity with the design of destroying them,
when I was informed that they existed, and when in fact they had
no existence; and from reasoning it is so difficult to admit them, that
I do not hesitate to look upon their occurrence as very rare. How

542 DELIVERY OF THE PLACENTA.

can We conceive, in fact, that they could give way so easily under
the feeble contractions that take place after the expulsion of the child,
after having resisted the violent efforts of the close of the expulsive
stage of the labor? I believe, therefore, that if it is not prudent to
deliver the after-birth immediately after the escape of the child, we
ought to look for another reason for the caution, than the non-detach-
ment of the placenta; that the object of the uterine contractions and
their effect is far more to push this body gradually through the os
uteri and into the vagina, than to break up its union to the womb;
that it is not indispensably necessary for the woman to have colic
pains and dragging sensations in the loins before the accoucheur de-
livers her; and that there are some disadvantages in not acting as soon
as a favorable opportunity presents itself.

Being (in 1823) still imbued with the prevailing ideas on this sub-
ject, I used to wait until the pains came on before I proceeded to act,
and I stopped as soon as I perceived the slightest resistance; and in
the short space of six months I was obliged to wait, on one occasion
ten hours, on a second twenty-four, on a third thirty-six, and on a
fourth forty-eight hours, before the placenta was delivered, and in the
last case, was even obliged after all to introduce the hand in search
of the placenta. Since that time I have never been obliged to wait
more than one hour: for me it suffices when the womb has contract-
ed and become hard, even although the woman have felt no pain, nor
dragging sensation, and up to the present time 1 have had good
reason to be satisfied with my mode of proceeding.

1179. Thus, after having given the first necessary attentions to
the child, we return to the mother, and if the hand applied to the hy-
pogastrium feels the womb contracted with a certain degree of force,
we assist the delivery of the placenta; when the uterine globe does
not form, we ought to wait, or make use of the measures proper to
remove inertia.

To favor the expulsion of the after-lairth, the cord is to be taken
hold of with the right hand, twisting it round the root of the mid-
dle and ring fingers, and then bringing it betwixt the thumb and
index finger; or it is merely taken hold of with the hand after
being wrapped in a piece of linen, and, always, as near as possible
to the vulva; two or three fingers of the left hand are then to be
slipped into the vagina, passing them under the symphysis of the
pubes to the orifice of the womb, or as far as the root of the cord;
as these fingers are to form a sort of gutter or pulley, I prefer
three rather than only two fingers, because as the medius forms the
bottom of the groove, the index and annularis easily prevent the
cord from slipping off to the right or left, whereas, if only two are

DELIVERY OF THE PLACENTA. 543

made use of, the cord almost always separates them, and therefore
it would be quite as well to place them crosswise, in the upper part
of the vulva, as is the practice with some persons.

The way to derive the greatest possible advantage from them is
to pass them up as far as the foetal surface of the placenta, even
should that be above the os uteri, and then make them act like a lever
of the first kind. The back of them rests against the top of the
pubic arch, and while the other hand is drawing the cord along the
axis of the inferior strait, they are pressed against the root of the
cord; then by a sort of see-saw motion, communicated by the gra-
dual rising of the wrist, they force the placenta along from above
downwards and from before backwards, towards the point of the sa-
crum, and in the axis of the superior strait.

This stage of the operation is the most delicate, the most impor-
tant, and most difficult to perform well. The womb is sometimes
so bent forwards that if the fingers do not push the cord almost
directly backwards, the placenta remains immovable; at other times
they must be directed a little to the left or right, because the os
uteri is deviated more or less to one side or the other; the axis of
the womb, besides, presents a thousand shades which it would be
necessary to apprehend, and which practice alone can enable one to
recognise. This is the reason why a delivery deemed by one ac-
coucheur to be impossible, will often be quite a simple case to an-
other person; and why this operation, in appearance so easy and un-
important, deserves, notwithstanding, the most minute attention from
those who desire to perform it Avell. Should the pulley (composed
of the ends of the fingers) be not well placed; should the lever re-
presented by the fingers not be well situated, or not act properly, the
after-birth, from being arrested by the upper edge of the pubes or the
posterior surface of the symphysis, would not come down; the whole
of the power would be directed upon the root of the cord, which
would certainly break, or upon some part of the uterine orifice,
whence that dragging and pain which give rise to the idea of preter-
natural adhesions.

Be this as it may, when the placenta has come down into the
vagina, the fingers of the left hand should be continued in the same
situation they occupied before, but merely so as to favor the escape
of the membranes which 'might not have cleared the os uteri, and
to form a sort of inclined plane, along the inferior surface of which
the whole after-birlh might glide while pulled by the right hand
along the axis of the inferior strait. In this way the hand that holds
the cord may be raised upwards without fear of being embarrassed by
the pubic arch, and we avoid being stopped by the inferior surface

47*

544 DELIVERY OF THE PLACENTA.

of the perineum; which is an inconvenience frequently met with
when the placenta is pulled along in what is properl)'^ called the axis
of the strait, rather than in that of the vulva.

As soon as the after-birth appears at the vulva, the left hand is
placed underneath it, crossvvays, and supine, in order to sustain it;
the right hand, in pronation, takes it with the ends of all the five
fingers, and rolls it four or five times round, drawing it moderately
and slowly downwards; without these rotatory motions the mem-
branes might separate from the placenta, and remain within the female
organs, while if twisted in this way they are collected together and
resemble a rope, and become easy to extract.

During these various manoeuvres, the womb rarely fails to contract
with more or less force, and seems to assist the accoucheur; the wo-
man herself is generally induced to make some efforts as soon as the
womb has descended into the vagina, and these efforts rigorously
speaking, would suffice to terminate the delivery, provided they al-
ways took place; but, in reality, they are not very necessary, and
may often be injurious: they only favor the expulsion of the placenta
indirectly, and are capable of directly producing the descent or in-
version of the womb; the woman ought therefore to be urged to
moderate rather than enforce them; it would not only be useless or
ridiculous, but also in some cases very dangerous to administer ster-
nutatories, or advise her to blow into a bottle, or in her hands, or on
to a grain of salt to hasten the delivery; for if ever such measures
have any effect, it is merely by occasioning certain succussions, or
those straining efl"orls that I just now was condemning.

The extracting force necessary in this operation ought never to be
carried so far as to rupiure the cord: if the placenta resists, the cause
of it ought to be sought for in the direction of the orifice, its closure,
&;c.; we should wait, or else pull in another direction, and be
assured that force is never necessary to enable us to triumph over
such obstacles.

1180. It is recommended that the after-birth should be examined
as soon as it is delivered, to make sure that no part of it is left with-
in the genital organs: it will be well to follow this advice, no doubt,
whenever the delivery has been attended with some difficulty, or any
peculiar circumstances; but in other cases, it would be puerile to
trouble one's-self about it, especially, considering that even should
some small pieces of the placenta or shreds of membranes be left in
the womb, we should not be authorised on that account to introduce
the hand in search of them.

COMPLICATED DELIVERY OF PLACENTA. 545

SECTION 2.

Complicated Delivery of the Sfter-hirth.

Inertia, hemorrhage, convulsions, syncope, the rupture of the
cord, preternatural adhesions, an encysted state of the placenta, ex-
cessive size of it, and a spasmodic contraction of the os uteri, con-
stitute a number of accidents which sometimes complicate the de-
livery, and require that we should hasten or protract the term of its
exclusion.

1181. Inertia of the womb, after delivery of the child, is more
particularly observed to happen in women who are weak and ex-
hausted by flooding or the fatigue of a protracted labor; it is also
met with after too sudden a delivery of the child, and in these dif-
ferent cases it requires a caution which is peculiar in each. Some-
times the proper remedy is a little good wine, sometimes a little
light and analeptic aliment, at others rest; but it is always useful to
excite the womb through the hypogastrium, by rubbing and pressing
it with the ends of the fingers, and even by compressing it with a
certain degree of force, alternately from above downwards, from
side to side, and from before backwards, as if with a view to m.ass
it, and oblige it to contract its dimensions. Pulling at the cord, if
attempted previously to the cessation of the inertia, would hazard
the production of an inversion of the womb, less perhaps, in conse-
quence of any remaining adhesions of the placenta, than from the
direct pressure of the abdominal viscera upon a soft and contracted
bag; transmitted to the internal surface of the gestative organ, they
might, also, invite an affluxion of blood to it, and give rise to hemor-
rhage. They must therefore be dispensed with, unless some d'erious
accident obliges us to act otherwise. Thus, inertia of the womb
ought to be classed among the complications which retard the de-
livery of the placenta.

1182. The volume of the after-birth is in some instances the only
cause that retards its expulsion. But this excess of size is often
more apparent than real, and depends on the blood being amassed
behind the membranes. Where the placenta is really too large,
moderate and skilful tractions almost always suffice; if not, we must
wait, and the natural retraction of the uterus at last renders its ex-
traction easy. In the second case, which is the most common, if
the contractions of the womb and force carefully exerted upon the
cord are inefficacious, the membranes may be torn, or the placenta
itself perforated with the fingers, and a passage made for the fluids
behind them.

546 COMPLICATED DELIVERY OF PLACENTA.

We should, moreover, have reason to suspect the existence of this
state of things should the womb be found to preserve a larger size
than common above the pubes, although not deficient either in firm-
ness or energy; were the after-birth already in the vagina, the diag-
nosis, and the application of suitable means would be too easy to be
spoken of at greater length in this place. Upon the whole, exces-
sive volume of the appendages of the foetus scarcely constitutes one
of the accidents of delivery, unless, indeed, it be coincident with
some other complication.

1183. I may say the same of the spasmodic contraction of the as
uteri. In fact, it is difficult to conceive that an opening, through
which a child has just passed, can contract spasmodically to such a
degree as to oppose the escape of the placenta. To admit such an
obstacle, we ought, which is not the case, to have some very authen-
tic instances of the kind.* Besides, as it is not a part of the nature
of spasm to persist, we might, should such a case occur, refer it to
the effect of time, and content us with administering some composing
or antispasmodic medicines, according to circumstances.

1184. It is evidently the natural, but somewhat precipitate closure
of the OS uteri, which has been qualified as the spasmodic contrac-
tion: considered under this point of view it is a circumstance de-
serving of attention. When the delivery of the child is completed,
the OS uteri in general contracts more speedily than the body of the
organ, and if in this case we endeavor to deliver the woman before
the fundus is prepared to overcome the resistance of the orifice, the
placenta passes through it with difficulty, which may induce a belief
that it is spasmodically contracted.

A bleeding from the arm where the woman is strong, and there
are any signs of irritation; emollient or slightly narcotic injections;
the belladonna ointment, or even a bath, if she is very nervous, not
strong, or has a vivid sensibility of the sexual organs, and there
are any indications of the approach of convulsions or flooding ;
patience, and gentle frictions upon the hypogastrium, should no acci-

* A spasmodic closure of the orifice of the womb after delivery, is a very com-
mon consequence of the use of ergot. It has so frequently followed the adminis-
tration of that medicine, that it constitutes for me, one of the objections to its
employment. I have, on several occasions, been obliged to dilate the os uteri
by the introduction of the whole or one half of the hand, in order to admit of the
escape of the placenta, which I found completely detached and compressed by a
contracted womb.

I may take this opportunity to say, that when the placenta does not come off
in an hour after the birth of the child, there is little hope of its discharge being
effected in two hours, or four, or six — and that it is belter to remove it at most
in an hour after the child is born. — M.

ENCYSTED PLACENTA. 547

dents appear; such are the measures that may be required by such
a state as we have indicated: it is only when pressing and grave
circumstances arise, that we are allowed to introduce a finger into
the orifice to dilate it, while with the other hand we pull gently at
the cord.

1185. The encysted state of the placenta, which Solinger calls
hernia of the after-birth, has not been understood in the same man-
ner by the difTerent authors who have spoken of it; Levret never
saw but one case of it, to which he was called by a midwife, who
supposed she was treating a case of rupture of the womb. Accord-
ing to that author the encysted state of the placenta is occasioned by
that portion of the womb which corresponds to the placenta re-
maining in a state of inertia, whilst the other parts of the organ con-
tract with more or less force after the birth of the child. Simson, on
the contrary, attributes it to the simple tendency of the womb to re-
cover its primitive shape, a tendency which causes the internal orifice
to produce, instantly, a real strangulation, above which is found the
after-birth enclosed within the cavity of the body, as if it were in a
small cell, while the cavity of the cervix remains open below. Pless-
mann has reproduced the idea started by Levret, but he has modified
it: according to his view the womb must be much more highly irri-
tated at those points which press directly upon the fcEtus than those
which only touch it through the placenta during the efforts of labor;
whence it follows that the former contract eooner than the latter, and
the formation of a separate sac for the after-birth is very easy to un-
derstand. Peu seems to think that the encysting depends upon a
peculiar conformation of the uterus; Leroux and Kok, that it most
frequently depends upon the rupture of the nervous filaments, which
occasions an afflux of humors, and, in consequence of that, a spas-
modic contraction of some portions of the organ. All these explana-
tions may be true in some particular cases; but Baudelocque prefers
Simson's theory; M. Desormeaux, resting on a fact related by
Meyeld, seems to be not far from adopting, at least in part, the view
taken of the subject by Levret and Plessmann,

An encysted state of the placenta is always the result of irregular
contractions of the womb, after the escape of the foetus, but I do not
think that these contractions can be explained upon the hypotheses
of Simson, Levret, &c. In a woman to whom I was called by Ma-
dame Bevalet, the internal orifice of the cervix offered but a feeble
resistance, whereas, a little higher up, I found a very decided con-
striction, and after penetrating into a cavity situated to the left of the
womb, in which cavity a greater part of the placenta was contained,
I was obliged to pass through another stricture, to get to the fundus

548 COMPLICATED DELIVERY OF PLACENTA.

and right side of the organ, where the remainder of the after-birth
was retained. In another woman who died at the Hospice de U
Ecoh, I found the uterus so moulded upon the placenta, that it was
divided, as it were, into five shallow cells, and which evidently de-
pended upon the protuberances formed by the corresponding cotyle-
dons of the after-birth. If the placenta were solid and even, like
the head, the womb in contracting would necessarily retain the form
of an ampulla; but the cotyledons in the process of the detachment
may separate from each other, and the placenta would then offer
more resistance in some parts than in others; so that the uterus soon
divides into several compartments or divisions more or less distinct
from each other, in the same way as it is found to accommodate
itself to the form of the head, of the shoulder, the breast, the pelvis,
and all the projecting or contracted parts of the fostus, after the
liquor amnii has been evacuated. Besides, what accoucheur of any
experience has not had an opportunity of observing, through the
abdominal parietes, the womb tuberculated, more or less uneven or
elongated, and not always globular or round, as it is too generally
said to be.

1186. However it may be, the cyst may be formed by the fun-
dus of the uterus, as supposed by Simsou and Baudelocque, and
then the organ approaches more or less to the shape of a calabash;
sometimes, on the contrary, it is found to be upon one side, as was
observed by Levrct; and, again, in front or to the rear, and at
points of different height. Le Roux says that in one instance the
placenta was encased in the fundus of the womb like a watch-glass
in the lid. But as such a case has not been noticed since, and there
is every reason to believe that the author might have been deceived
by some peculiar circumstances. M. Herbin must have been mis-
taken also, when he thought the after-birth was encysted in the
Fallopian tube, in a woman whom he was obliged to deliver artifi-
cially.

The placenta, moreover, may be enclosed wholly or only partially
within the accidental cell; it is sometimes strangulated by the circle
of the cyst; so that one portion of it may remain free in the cervix
while the rest of it is in some sort imprisoned above; in one or more
cells of the body or fundus of the womb.

1187. To have understood what has now been said in relation io
encysted placenta is sufficient to enable one to guess at the signs of
it. The treatment demanded by the case differs accordingly as it is
or is not accompanied with some complications. If there be any
complication, the contractions of the womb alone suffice to make
them disappear; these are to be solicited by means of frictions upon

ENCYSTED PLACENTA. 549

the hypogastrium, and judicious pulling at the cord. In fine, there
ought to be no haste; we must wait. If there is any threatening
appearance of hemorrhage, convulsions, &;c., or the safety of the
woman appears to be in any way compromised, we must, on the
contrary, make haste to act. The fingers are to be introduced one
after the other into the mouth of the cyst, which is to be dilated
gendy and carefully, and afterwards passed by the whole hand in
search of the placenta; should there be a second opening, it is Xo
be treated like the first, and in all cases the cord is a sure guide to
the after-birth, which is detached and separated by passing the
fingers, flattened, between it and the uterus, and which is lastly ex-
tracted by pushing it with the palmar surface of the hand down into
the top of the vagina. Should the placenta be found only partially
encysted, we might after dilating the mouth of the cyst, dispense
■with going any further, take hold of it with the fingers, and immedi-
ately extract it. But it is in general, both a surer and quicker
method to go into the very cavity of the cyst itself; it being well
understood that, during this operation, the hand that remains out-
side shall be employed in supporting the fundus of the uterus, in-
clining it to either side, and depressing it towards the one that is
within the organs.

1188. The rupture of the cord, in itself considered, does not com-
plicate the delivery of the placenta except by rendering the usual
tractions impossible: it may be prevented by ceasing to pull as soon
as there is any threat of its giving way; but it can only be remedied
by going in search of the placenta with the hand; and as long as
there is nothing to fear for the woman, this' recourse is unnecessary,
and we ought to trust to the organism itself. It is particularly apt
to lake place when the cord is inserted near the circumference of
the placenta, or when its vessels divide too soon, and separate like
the rays of an umbrella upon reaching the placenta. In the first
case the efforts concentrate almost wholly upon the root of the
cord, which yields before they can be transmitted to the after-birth;
in the second, the vessels are weaker than if they were united to-
gether; further, as the force cannot act equally upon them all, they
break very readily one after the other.

118'J. The morbid or preternatural adhesion of the placenta may
be either total or partial, slight or intimate. The ancients, Smellie,
and others, refer it to a scirrhous state of the womb or after-birth;
many modern writers have preferred to attribute it to inflammation.
But proofs are wanting on each side of the question. I have seen
the placenta hard, thick, and yellowish, having lost its spongy ap-
pearance, sometimes in a few points, sometimes throughout the

550 COMPLICATED DELIVERY OF PLACENTA.

whole extent of its uterine surface; I have seen it full of homogene-
ous masses, as large as nuts or partridge eggs, hard, and elastic;
but, in all these cases the adhesion, instead of being stronger, was
much weaker; although rugose and tuberculated, its surface was
smooth, and exhibited no trace of any laceration. I have also met
with the yellowish alteration, the placentas gras as they are called,
and almost all the alterations pointed out by M. Brachat of Lyons,
and M. Gendrin. But, in common with M. Desormeaux, I have
never observed any preternatural adhesion to accompany them.
Besides, I have not found, by consulting the authors, that scirrhus
has been noticed in the womb, exactly at the place where morbid
adhesions existed, and every body knows that ihe placenta generally
contracts a less intimate union with the fibrous tumors on which it
is sometimes attached and developed, than with the uterus itself.

1190. As to inflammation, it may be admitted as a probable
cause, in a certain number of cases; for example, when in conse-
quence of a blow on the belly, a dull pain and sense of heat are
found to continue for several weeks, in the corresponding part of
the womb, and an adhesion of the placenta to exist at the period of
delivery; but these phenomena often continue during the whole course
of a pregnancy without any adhesion taking place; and indeed ad-
hesions are most frequently met with without any such precedent
symptoms having been noticed. Moreover it is known that the special
character of inflammation of the mucous membranes is, to augment
their secretions, and to terminate but very rarely in adhesion of their
surface to the bodies with which tliey are in contact. Prudence,
therefore, requires that we should wait for some new researches,
before we pronounce upon this point of pathology.
^ 1191. When the adhesion is partial, it occupies sometimes one
portion, and at others the entire circumference of the placenta ;
sometimes, on the contrary, the edges of the cake are free, and it
adheres to the womb at one or more points of its surface or at its
middle. When the adhesion is general, a circumstance but rarely
noticed, but which has notwithstanding been seen by several practi-
tioners, and particularly by M. Desormeaux, it exhibits difllerent
degrees of the aflfection like the preceding case. It may in certain
cases be overcome by simply pulling at the cord, without our being
obliged to enter the womb; in other instances it is so strong that
the tissues seem to be confounded together, and it is impossible to
overcome it without tearing the parts.

1192. I will not, with M. Desormeaux, say that we can recognise
but that we may suspect, or have a right to suspect, the existence of
a morbid adhesion of the after-birth, when, notwithstanding the re-

ADHESION OF THE PLACENTA. 551

peated contractions, hardness, and globular shape of the uterus, we
find by passing the finger up through the os uteri that the placenta
does not present, and does not yield to tractions suitably exerted
upon the cord; by remembering, besides, what has already been said
viz. that a morbid adhesion is extremely rare, we ought to avoid con-
founding it Avith the cases in which the extraction of the secundines
is rendered difficult by some other cause.

1193. Two very diff'erent modes of proceeding have been follow-
ed by accoucheurs in cases of pathological adhesion of the placenta:
one party think it ought to be left wholly to the natural effbrts; the
others, on the contrary, think that we cannot too soon take mea-
sures to overcome it. On the one hand it has been thought that, by
allowing the after-birth to remain for an indefinite period within the
uterus, we expose the woman to the danger of flooding, or convul-
sions; that by becoming decomposed, by putrefying, this substance
must act injuriously upon the whole system, and particularly upon
the genital organs and peritoneum, giving rise to fever of a bad
character. On the other hand, it is asserted that these accidents
are far more the eflect of ill-timed manoeuvres than of the pro-
tracted presence of the placenta. Haller, Sandifort, and M. de
Saint-Amand, have reported cases of wombs that had been la-
cerated, inflamed, or gangrened, in consequence of attempts to
break up preternatural adhesions of the placenta; the after-birth
has been known to remain two, four, six, eight, fifteen or thirty
days, or for months together, Avithin the genital organs, without
causing the smallest accident; if it become putrid, the lochias wash
it away piecemeal, and its absorption may be easily prevented by
means of injections; in fine, the dangers which, it would seem,
ought to follow its forced detachment, have appeared to be much
greater than those that might be involved in its retention for a
greater or smaller period of time.

1194. There is reason on both sides of this question: although it is
undeniable that the placenta may in some cases remain for several
days in the womb without causing any accidents, it is very frequently
the cause of very severe ones. It has a thousand times been seen
to carry the woman to the very brink of the grave, and all the bad
symptoms disappear as by magic, immediately upon its expulsion:
were new proofs of it wanting, I could refer the reader to two cases
recently published by M. Goupil, and might cite those that have
fallen under my own notice. As a foreign body, it irritates the womb,
invites the blood to it, and is a constant cause of floodings, nervous
affections, and pains of all kinds; the acrimony which it contracts in
putrefying, and the odor which it developes, cannot be matters of

48

552 COMPLICATED DELIVERY OF PLACENTA.

indifference in a majority of women; the sanies and putrescence
which result from its decomposition, will not remain in contact with
the interior of the womb without penetrating, by means of imbibi-
tion or absorption, in greater or smaller quantity into the veins of
that organ; and who will venture to affirm that it would not under
such circumstances be dangerous? Although it has chanced that
the hand by being introduced within the uterus has sometimes lace-
rated the parts of the woman instead of detaching the placenta, it
must be attributed to a want of skill in the accoucheur, and not to
the operation in itself considered; besides, the question is not
whether we shall tear away or destroy, at all hazards, the intimate
adhesions of the placenta, whether we sha\[ peel it offzs the ancients
did, but merely whether we shall carefully separate it and extract it
w^henever we can do so without lacerating the uterus. Upon this
point I agree with M, Duchateau, and unless the child have been
delivered for a long time, it would be a mistake to suppose that the
introduction of the hand must be very painful and irritating to the
womb. Is it reasonable to fear any bad effects from the gentle fric-
tions of the fingers, or moderate tractions exerted with the hand
upon an organ that has been for several hours contracting without
any inconvenience, and with much violence before? Let me not
however be understood as recommending here the introduction of
the hand as soon as the placenta resists a little, and that I approve
of those who, by conforming to the advice of Kushler, never fail to
resort to it with the mere intention of removing coagula and other
substances that may be contained within the uterus. My opinion
is, that we ought to wait a few hours, and if there be no pressing
haste from any other cause, we may wait even longer, if the
woman is of a good constitution and has no troublesome disease of
any sort; but in the other circumstances we should act witlyjut
waiting too long.

1195. If the cord remains whole, we should pull at it in the way
indicated when speaking of simple delivery of the placenta; when
the cord is broken, we must attempt to hook a portion of the placenta
itself in the fingers. Levret, Baudelocque and all the moderns
insist very much on the necessity of drawing the cord down perpen-
dicularly to the plane of the placenta. Tlie following comparison
has been made use of. If you pull at a piece of wet paper in a
direction parallel to the plane on which it is applied, you will not
detach, but you will tear it, says Levret; but if you take hold of one
of its edges and turn it up, you may easily detach it without breaking
it. According to the last named author we must first endeavor to
ascertain the spot on which the placenta is seated, for if it be in

COMPLICATED DELIVERY OF PLACENTA. 553

front, we shall make use of the fingers arranged like a pulley, as has
been before mentioned, whereas, if it be situated on the posterior
part of the womb, this pulley becomes useless, and it must be car-
ried to the right or left, provided it be situated laterally.

This reasoning would doubtless be very correct, provided we
were acting in a free space, or if the placenta were not attached to
walls of the womb very much distended at the time; but it seems
to be overlooked, that the fingers only support the cord below the
mouth of the womb; that the after-birth touches the womb, both
by its spongy and its membranous surface; that, in whatever man-
ner we may take hold of it, the cord will always be parallel and
not perpendicular to the great diameter of the womb, from its very
insertion till it passes through the orifice of the organ; that by
pushing it strongly backwards, in front, or sideways, as is recom-
mended, we compel it to rub and slide on the corresponding point
of the OS uteri as on the groove of a pulley, without in any way
changing its relation of direction to the placenta itself. It is as
well, therefore, and even better, to place the three fingers in such
a way that they may act at the same time like a lever and like a
pulley, and draw the cord and rest of the after-birth down in the
longitudinal axis of the womb; but as this axis may vary, may differ
more or less from that of the strait, by inclining in front, to the right
or the left: as it may remain straight, or become curved, or even
zigzag, according to the position, form and direction affected by the
womb, it will be consequently necessary to pull sometimes more,
sometimes less towards the back or side, as I have already shown,
in speaking of cases of natural delivery of the placenta. It is not
until we have pulled at the cord, with all proper prudence, or where
the cord will no longer bear the requisite force to be applied, that
we may proceed to enter the womb in search of the after-birth.
Provided the cord is still not broken entirely off", we make use of it
as a guide; when it is completely separated, the hand will distin-
guish the placenta by its greater soflnpss, its unevenness, if the ex-
ternal surface be touched, and provided the fingers come in contact
with its foetal surface, by its polished and slippery feel, and the vas-
cular ramifications with which it is overspread; and in all cases
by the less vivid sensation experienced by the woman when the
hand is pressed on it, than when pressed on the womb itself.
There is generally no difficulty in this exploration for an experienced
person; but by carelessness it would not be impossible to mistake
the projections, sometimes presented by the interior of the womb
when it is irregularly contracted, for the reliefs of the placenta, a

554 DELIVERY OF THE PLACENTA.

mistake which in the hands of ignorant and unskilful persons would
be dangerous.

When found, we should endeavor to get hold of some point of
its circumference; if there is one which does not continue to be
adherent; it is then detached by turning it over towards its mem-
branous surface, or the advice given by Baudelocque may be fol-
lowed: the ends of the fingers flattened out may be slipped between
it and the womb; then by carefully moving them from side to side
it may be detached just as we would separate two sheets of paper
slightly adhering together: where the adhesion is found to be gene-
ral, the hand, disposed as before mentioned, is passed along the ex-
ternal surface of some portion of the membranes, and then gradually
to the circumference of the placenta; when there, it should act as
has been described. Should the circumference alone have con-
tracted morbid adhesions, as seems to have been noticed by Leroux,
and the middle portion of the cake be depressed by the blood, as
Baudelocque states to have happened under his own observation,
we might, after the example of that practitioner, penetrate through
the placenta, and then proceed as in the other cases. When its
separation is eflfected, the hand brings it away by pushing it down
before it; we ought to take care to leave no portion of it behind, and
at the same time remove all the coagula that may be contained in the
uterus.

1196. In acting thus, it very rarely happens that the adhesions
cannot be safely destroyed. However, they are sometimes so firm
that it is wholly impossible to make them yield. In such a case, the
plan pursued by Smellie, Levret, &c. should be adopted, namely, to
destroy the adhesions wherever they are not too firm, and tear and
bring away all that we can detach, and leave the remainder to the
natural powers. In peeling off the placenta we can go no further
than this, and it would be extremely dangerous to persist in endea-
voring to bring away the whole of it, and not leave the smallest por-
tion behind in the female organs.

1197. Sometimes the portion of the placenta which we have been
unable to detach separates spontaneously after a few days, and
escapes along with the coagula; sometimes it becomes decomposed
and comes away with the lochia; at others it is not discharged for
a long time; Smellie asserts that one of his patients did not expel it
until two months had elapsed, and it was then hard and quite dried
up; Kerkring relates another instance where it was not passed away
till full eight months. M. Prost has related two cases not less re-
markable: in one, the after-birth was not expelled until the five

COMPLICATED DELIVERY OF PLACENTA. 555

hundred and third day; and in the other, until eight months and a
half after the birth of the child. Although its presence may be
found not to give rise to any accidents, some precautions ought
nevertheless to be taken in regard to it: for instance, the fingers
should from time to time be introduced into the vagina to ascertain
whether it be detached, and extract it as soon as it tries to engage
within the os uteri; in case the fingers cannot get hold of it, recourse
might be had to the pince cifauxgenne of Levret, or to Dr Dewees's
crotchet; injections with mallows water, or barley water sweet-
ened with honey, or even with decoction of bark, may be daily
thrown into the uterine cavity, to cleanse it, prevent absorption,
and bring away the detritus of the after-birth as they separate or pu-
trefy.

It should not be forgotten, moreover, that these adhesions are the
result of a disease, and that after their violent destruction, the inner
surface remains in a pathological state calculated to excite some un-
easiness, and that they leave behind them a sort of suppurating
.wound that it imports us to cleanse and heal.

1198. Hemorrhage may take place before the delivery of the
placenta, as a complication of any of the accidents heretofore men-
tioned; but it is also observed singly; whether it depends upon iner-
tia, spasm, plethora, or irritation of the womb, it is always a dan-
gerous phenomenon, which we ought to make haste to combat;
if the presence of the placenta is not the only cause, it at least serves
to keep it up and aggravate it; we should, therefore, be diligent in
extracting it, even although there should be inertia. Some authors,
however, have thought that the delivery of the placenta ought not
to be hurried while the womb does not contract, unless there should
be a partial detachment of the placenta. M. Lacour has lately en-
deavored to show, that artificial delivery of the placenta can only
have the effect of increasing inertia, and consequently to that, of
producing flooding; but daily experience is opposed to this view of
the subject, and the contrary opinion is generally adopted. I
have no intention of repeating here what I have already said con-
cerning the causes, signs, and general treatment of hemorrhage; but
I must speak of it as one of the complications of delivery of the after-
birth.

1199. I am not sure that its mechanism has been well under-
stood; it is improperly attributed to the non-contraction of the
womb, in consequence of which the blood must flow in torrents
from supposed orifices that remain gaping upon the internal surface
of the organ; but is it not rather occasioned by the sudden cessa-
tion of pressure upon the hypogastric vessels, whereby the blood is

48*

556 DELIVERY OF THE PLACENTA.

allowed to rush into them with great force; or upon the circumstance
that the blood must in some sort accumulate mechanically in the
uterine vessels, which being no longer supported, pour it into the
empty space which a few moments before was occupied by the
ovum — or perhaps on the fact, that together with these dispositions,
there may be some irritating cause present in the cavity of the uterus
itself.

Upon this hypothesis, the best means of preventing a hemorrhage
would not be to rub the navel and the hypogaslrium with a spoonful
of brandy or cologne water, as advised by A. Leroy, but promptly to
apply a pretty tight bandage to the belly, and place the woman with
her head very low immediately after delivery.

1200. After having extracted the placenta, if the flooding continues
to such a degree as to excite apprehensions relative to the welfare of
the paiient, provided the womb remains soft and inactive, or a sina-
pism applied betwixt the shoulders has been tried in vain, we may
without hesitation introduce the hand into the organ. De la Motte
had well remarked that this is the most certain method of putting a
stop to the inertia; pressure made by the hand, and in various direc-
tions upon the hypogaslrium, which is lauded as an important dis-
covery in the Journal des Savans of 1722, can never be a complete
substitute for this means of relief.

Lijections of oxycrate, of pure vinegar or iced-water, which are re-
commended by Saxtorph; alcohol, and sulphuric or nitric acid di-
luted with water, with which Pasta advises us to cauterise the ute-
rine vessels; the introduction of a hog's bladder, to be afterwards
filled with air, water or astringent fluids, while within the womb, as
proposed by MM. Rouget and Vernet, would ofier much fewer ad-
vantages, and expose the patient to many more accidents, and are
not so easy of application as the hand; let us add, along with MM.
Pasteur and Evret, that Avhere we have any fear lest the hand alone
should not sufiice, we may always introduce, along with it, a peeled
lemon, or a sponge dipped in vinegar.

1201. But provided there should be no inertia, we ought to have
recourse to the treatment indicated at the article on hemorrhage in
general, that is, to revulsives, refrigerants, and even the tampon.
Perhaps it would be well, where the flooding is overwhelming, to
compress the aorta above the sacro-vertebral angle, while waiting
until other measures might be put in practice; immediately after the
birth of the child, the abdominal parietes are soft, and in many
women it would not be difficult to act upon the aorta with the
thumbs; so that without attaching so much importance to this mea-
sure, which has already been spoken of by Boer, Madame Lacha-

COMPLICATED DELIVERY OF PLACENTA. 557

pelle, M. Duges, &c. as is attributed to it by MM. Trahon and Bau-
delocque, Jiin., I would willingly have recourse to it, should an oc-
casion present.

1202. The ergot of rye, employed by MM. Balardini, Biges-
chi,. Bordot, Goupil, Villeneuve, &c. is said to put a stop to iner-
tia, to compel the womb to contract, and thus overcome the ad-
hesions of the after-birth, expel the placenta, and thereby suspend
the flooding. According to these practitioners, as the delivery of
the placenta has been always found to be prompt, and never accom-
panied or followed by hemorrhage in women who have taken the
oxytocic powder during labor, we ought to conclude that it must be
of great service in cases of preternatural adhesions of the placenta,
and flooding coming on after the birth of the child.

I would willingly exhibit the article in cases of adhesion, but
having had no opportunities of meeting with them, I am not in pos-
session of any facts of my own in relation to it. As to hemorrhage,
some physicians have thought that they have seen it produced by
the obstetrical powder; a young woman was seized with a violent
flooding after the birth of the child, although I had administered to
her a dose consisting of forty-five grains of ergot, during the labor,
and notwithstanding it had produced all the efi'ect I had anticipated.
I have also observed a very similar case quite recently, and am led
to believe that although the eigot may be useful where the flooding
is produced by inertia of the womb, it might very well be injurious
in the other cases, which are far more numerous than is generally
supposed.

1203. Another resource, which was first put in practice by Dr.
Mojon, then by MM. Hoff'mann, Taroni, Lemaistre, &c., consists in
injecting a coJd styptic fluid into the placenta, through the umbilical
vein. M. Mojon insists that previously to throwing in the injection,
we should draw the blood out of the vein and its branches by ex-
hausting with the syringe; but MM. Hoff'mann and Taroni have suc-
ceeded without using this precaution; the first made use of the oxy-
crate; the second employed brandy and water; and the last named
practitioner was satisfied with injecting cold water alone. In all three
of the cases, the womb, which had previously been soft and inert,
contracted immediately; the placenta was expelled, and the hemor-
rhage was arrested; but nothing, not eveji the fact recently related by
M. Sandras, proves that the placenta was still adherent, and that more
skilful tractions exerted upon the cord might not have produced the
same efi'ect; a case related a few days ago in a public journal would
even prove, were the journal and the author worthy of credence, that
these injections may be wholly ineflScacious.

558 DELIVERY OF THE PLACENTA.

1204. This remedy might be tried in a case of supposed adhesion,
with inertia and flooding, after having vainly employed the ordinary
resources, and previously to introducing the hand into the uterus.
Its action must be both mechanical and chemical; it unwrinkles and
swells the placenta, distends the womb, and occasions a sudden re-
duction of temperature, a contraction of the vascular mouths, and a
more or less powerful constriction, admitting, always, that the fluid
injected reaches as far as the uterine surface of the placenta. It must
in fact combine a part of the advantages attributed by certain authors
to injections thrown directly into the womb, or through bladders, and
to the tampon, so much lauded by Leroux, without having any of
the inconveniences.

1205. The operation is, besides, very simple: after having disen-
gaged the cord, the pipe of a syringe containing six or eight ounces
of very weak brandy and water, vinegar and water, or any suitable
medicinal liquid, may be introduced into the vein; the injection may
be pushed up with sufficient force to make it penetrate throughout
the placenta, and, to hinder it from escaping before it has produced
its effect, a ligature must be thrown round the cord. The woman is
soon seized with tenesmus and colic; the uterus and abdominal mus-
cles contract; the os uteri yields, and the after-birth is promptly ex-
pelled. M. Guillon recommends that instead of all these means, we
should inject some bouille, a sort of liquid cataplasm, astringent, or
emollient into the interior of the womb itself, and I see not why we
might not follow his example where the intervention of the hand is
not allowable.

1206. Convulsions, and repeated fits of syncope which come on
after the birth of the child, may, like flooding, be occasioned by
various causes; but the presence of the after-birth, being of itself
sometimes sufficient to produce them, we should begin by delivering
it in women so aflfected. For the remainder, we are to act as has
been advised in speaking of convulsions in general. The same is
true of the simple debility or exhaustion that sometimes supervene
upon a protracted labor, or succeed to other accidents. Provided the
after-birth seems to have any influence in occasioning this state, we
should make haste to extract it; nothing but the necessity of leaving
the woman in a state of quiet, or the fear of bringing back a flooding,
should induce us to temporise, in a case where no other accident was
at the moment present.

1207. In twin pregnancy the delivery of the placenta ought not
to be solicited until after the complete termination of the child-
birth. As the appendages of the two children always adhere to-
gether, at least by some of their points, the one could not be ex-

COMPLICATED DELIVERY OF PLACENTA. 559

tracted without detaching the other, not that this practice must in-
evitably occasion an inertia of the womb or bring on flooding, as
has been supposed by some persons, who found the opinion upon
the false notion that certain large orifices would remain, through
which the blood flows into the uterine cavity, but because it is al-
ways dangerous to destroy the organic relation of the foetus witli its
mother, unless it be on the point of expulsion itself. One single
circumstance might permit us to depart from this rule: it is when
the after-birth of the first child presents spontaneously at the orifice,
before the birth of the second, and then care should be taken not to
destroy the adhesions of the one that remains.

In general, the delivery of the placenta after the birth of twins,
is longer in taking place than in the common case, provided it be
not provoked by the accoucheur; which depends upon the uterus
having rather less tendency to contract, and perhaps also, upon the
fact that the size of a double placenta, is necessarily greater.

In order to assist it we may take hold of one of the cords, or
one of the placentae, and draw down the two after-births, one after
the other; but it is better, more prompt, and safer to twist the two
cords round each other, so as to make one siring of them, and then
act as in a simple case. The placentae, being almost never at the
same level in the organs, present at the orifice in succession, and not
both at once; besides, if the contrary should happen to be the case,
and their escape rendered difficult, it would be too easy to over-
come such an inconvenience for it to be necessary for me to enter
into any long explanations concerning it.*

1208. After an abortion, the delivery of the placenta is generally
not so easy as it is after a labor at full term; in the first three months
of pregnancy the ovum is almost always expelled whole, and there
is therefore no delivery, properly so called; but after that period, this
expulsion in mass becomes more and more rare and difficult. The
foetus escapes first; its involucra remain and are not expelled until
sometime afterwards, sooner or later. The cervix recovering its
original form and length, soon resists the necessarily feeble efforts of
the uterus; the after-birth having scarcely changed its relations to the
■ organs in which it is contained, cannot clear its orifice and fall into
the vagina, but with great difficulty. On the other hand, the cord

* Let not the student be led, from the above paragraph, to expect to find two
distinct placentae in all cases; on the contrary, most of the cases of twins are ac-
companied with a single oblong or oval placenta, the two cords springing from
the eccentric points. — In a case of triplets, under my care, there was one very
long oval placenta, with the three umbilical cords in a line, distant near two
inches from each other. — M.

560 DELIVERY OF THE PLACENTA.

is so weak that it will bear only slight pulling, and notwithstanding
retention of the placenta after abortion is scarcely a less serious
matter than after labor at full term.

As inertia, and inversion of the womb are not to be dreaded in
this case, the wisest course in my opinion is to make haste to effect
delivery before the cervix has had time to close, either by pulling
moderately at the cord, or by getting hold of the placenta with the
fingers if possible. But when we have waited too long, or have
been called too late, we are compelled to wait still longer and confine
ourselves to endeavors to promote the contraction of the uterus.
Should any accidents supervene, the hand could not be carried up as
far as the placenta, on account of the resistance of the cervix, and
the smallest extractive force would soon rupture the cord. I pre-
sume this would be the proper case to try the injections recommend-
ed by Dr. Mojon. If, however, the placenta should appear at the
orifice, or could be felt with the finger, and the tractions or the hand
should prove insufl[icient to extract it, an attempt might still be made
to bring it down with the pince a faux germes. Otherwise, its ex-
pulsion is to be left to the natural powers, and we must take care to
prevent the occurrence of accidents, or if they do occur, to combat
them as soon as they make their appearance. We may resort to
blood-letting, opiates, and baths, general and local; emollient or de-
tergent injections may be thrown into the vagina, and even into the
womb, so as to neutralise the effects of putrefaction; the woman is
to be confined to a strict diet, and as soon as the os uteri becomes
somewhat open, such portions of the after-birth as may present
themselves are to be removed.

Sometimes all these precautions are of no avail, provided the os
uteri has closed soon after the escape of the foetus, and the placenta
may remain in the uterus for a longer or shorter period without pu-
trefying; cases have been seen where the women in some sort forgot
it, did not discharge it until after the lapse of one or two years, when
they even became impregnated again, proceeded to their full term,
and then discharged it together with the new placenta. But the pla-
centa and membranes are most commonly expelled either piecemeal
or in one mass, in the course of the first week after the miscarriage,
or they are gradually discharged along with the lochia, or by means
of injections. It will be understood, further, that these difficulties
become more frequent and numerous in proportion as the abortion
takes place nearer to the middle period of gestation; that they are,
on the contrary, less severe, and more easy to overcome, the nearer
they occur to the natural period of parturition.

MANAGEMENT OF THE CHILD. 561

ARTICLE H.

Management of the Child.

The management of the child varies according to the state in
which it happens to be at birth, and accordingly as it is healthy or in
a diseased state.

SECTION 1.
Of the Foetus in a Healthy State.

When the child is born alive and in good health, which is known
by its cries and movements, after placing it properly between the
mother's limbs, the cord is the only thing that requires the accou-
cheur's attention at first.

As soon as the child passes from the vulva, it should be laid cross-
wise, upon its side, with the face turned towards the foot of the bed,
between the woman's thighs. In this situation it can breathe and
run no risk of being suffocated by the matters flowing from the va-
gina. Should the cord be found coiled round the body, it must be
disengaged; it should be freed from any portions of the membranes
that it may have brought along with it, and also from the mucus
which sometimes obstructs the mouth or throat; and lastly, we pro-
ceed to tie and cut the umbilical cord.

SECTION 2.

On Tying and Cutting the Cord.

1209. In the time of Hippocrates the cord was not cut until the
placenta was delivered. If the placenta was slow in coming away,
the child was placed upon a pile of wool, or on a leather bottle with
a small hole in it, so that by the gradual subsidence of the skin or
pile of wool, the weight of the child might react by almost insen-
sible degrees upon the placenta, and extract it without any kind of
violence. Deventer thinks the placenta should be extracted pre-
viously to dividing the cord; Dionis followed sometimes one plan,
sometimes another. Where the secundines required only gentle
pulling to extract them, he did not cut the cord until after they came
away, and pursued an opposite practice when he found it necessary
to introduce the hand in search of the after-birtli. Since the time of

562 MANAGEMENT OF THE CHILD.

Levret it has been established as a general rule, among accoucheurs,
to separate the child from the mother as soon as it has passed through
the vulva, and that it is never necessary to wait for the expulsion
of the fostal appendages. At first view the conduct of the ancients
appears to be more rational and more physiological than that of the
moderns; it seems that the placenta ought immediately to follow the
foetus, or at least be separated from the uterus before the cord can be
prudently cut; that before it is divided, the circulation ought to be
permitted gradually to take on its new type, which soon becomes
similar to that of the adult; but in reality it is not perceived that the
present mode of practice produces the least inconvenience to the
fcstus, and is certainly better for the mother. It would be in vain
to object that this conduct is not natural, for it is followed by most
of the animals themselves, who tear off the umbilical cords of their
young as they escape from the vulva. Not only should we not wait
until the placenta is delivered, but it is of no use to wait until the
pulsations have ceased, before we cut the cord, as recommended by
Denman and A. Leroy. Neither is there a general agreement as to
whether the cord should be cut or tied first.

1210. If we begin by applying the ligature, we have to do it
under the bedclothes; and on the lying-in bed, it is not so easy to
examine the umbilicus, and we deprive ourselves of the advantage
of disengorging the viscera of the blood with which they are some-
times overloaded. In fine, as soon as respiration is established, the
placental circulation becomes completely useless. If we cut the
cord before we tie it, we are at liberty to carry the foetus to any
convenient place, attend to it if it be not well, and examine it with
all desirable attention. However, it must be confessed that if the
child present nothing peculiar as to its condition, one of these modes
of proceeding is scarcely preferable to the other, and that each prac-
titioner is at liberty to adopt the one that pleases him best, without
its having any influence upon the result of his practice.

1211. The place where the cord is to be divided is altogether a
matter of choice. If it be cut at the distance of four or five inches
from the navel instead of nearer to or farther from the placenta, it is
done in order that what is left of the cord may not be troublesome
by its quantity, and may admit of the ligature being applied at a cer-
tain distance from the abdomen. Any cutting instrument may be
made use of, and the scissors are used only because they are rather
more convenient than a bistoury. Although a rusty instrument can
not possibly occasion any redoubtable accident, such as tetanus, as
A. Leroy supposed, it is nevertheless best to make use of such only
in cases where sharper ones cannot be obtained; on the other hand,

MANAGEMENT OF THE CORD. 563

there could be no advantage obtained by tearing off, bruising, or
sawing of the cord, as some authors have recommended, with the
view of more closely imitating the quadrupeds, even although we
intend to dispense with the use of a ligature.

1212. The cord being cut, it should be squeezed between the
fore finger and thumb, if there should be any disposition in it to
bleed, the other three fingers take hold of the breech; the other hand
is placed under the shoulders and nape of the child's neck, which is
thus removed from the lying-in bed, and commonly deposited on the
nurse's lap; there it can be examined at leisure. Previously to put-
ting on the ligature, we ascertain that no loop of intestine has got out
through the umbilicus, that there is not an omphalocele. Should such
a tumor exist, we ought to try to reduce it, or at least not to include
it within the ligature we are about to place on the cord, as happened
to some children under the notice of M. Sabatier and Madame
Boivin. In the time of Aristotle the midwives were in the habit of
forcing the blood contained in the cord into the belly of the foetus be-
fore they tied it, and pretended by means of this practice, which has
been revived at the commencement of the present century, to restore
strength and vigor to feeble children. Some again have maintained,
along with Rhazes and the other Arabian physicians, the Abbe Bi-
zance and M. Sarton, that this blood ought to be very carefully
squeezed out instead of forcing it in; that it is particularly necessary
to evacuate the kind of serosity or lymph, more or less of which is
contained in the cord, either by covering it with punctures, or squeez-
ing it with the fingers, either naked or covered with a piece of rag,
for they attributed to the retention of these matters the property of
producing the small pox, crusts on the head, tetanus, and convul-
sions. Levret, also, thinks that by squeezing out these humors we
may prevent the occurrence of infantile jaundice, that at least which
he compares to ecchymosis; but this opinion, which M. Desormeaux
seems to partake in some measure, cannot be maintained, and scarce-
ly deserves to be discussed.

In my opinion it is of very little consequence whether we take this
precaution or omit it: if it is sometimes of use, it is so because it
admits of the ligature being applied upon the vessels more exactly,
without its being so easy to cut them off, and admits of their drying
sooner, and without putrefaction.

1213. As to the ligature itself, De la Motte advises us to apply it
at the distance of one inch, Deventer, Levret, and the moderns at
the distance of two fingers breadth, others at three, four, five, six,
and even twelve inches from the abdomen. Some persons have re-
commended the application of two, and in such a way that the one

49

564 MANAGEMENT OF THE CHILD.

nearest the abdomen should not be so tight as the other. Sometimes
it has been recommended to draw it very tightly, at others very loose-
ly. One person is content with a single turn and a single knot;
another thinks there should be two turns and a double knot; a third,
like Plenck and M. Desormeaux, makes first one turn and one knot
and then bends the cord into a noose to tie another knot upon it. Some
would not dare to use any thing except tape, whereas wiser persons
make use of what they can find at hand; but in fact, is this liga-
ture really necessary?

No animal can have recourse to it. At the period of the con-
quest of Brazil travellers reported that the aborigines merely chewed
or tore off the cord with their teeth, and that they did not tie it up.
If a careful attention be paid to what happens after an ordinary birth,
it will be seen that the pulsations grow weaker, and soon disappear
in the cord, beginning at the placenta, and that after a few minutes
it may be cut without being followed by the least hemorrhage. This
remarkable phenomenon, which is attributed to the change of direc-
tion of the iliac arteries, and to the difficulty experienced by the blood
in passing into the aorta through the ductus arteriosus, and into the
cord through the umbilical arteries, always takes place where every
thing occurs in a natural and regular order, but in reality depends
upon the circumstance that the attractive force exerted by the pla-
centa upon the blood, is replaced by that of the respiratory organ; and
that the after-birth is no longer any thing more than an inert sub-
stance, without vitality, which is abandoned by the blood, as it aban-
dons a gangrenous or asphyxiated limb.

It is so independent of any mechanical change in the arrangement
of the vessels, that if, as was done by Vesalius, the belly of an ani-
mal at the full term of gestation be opened, the pulsations of the
cord are seen to continue as long as the fogtus continues to live
without respiring, and on the contrary, to cease as soon as the air
enters freely into the lungs. Beclard has seen the same thing in the
dog. I once received a human foetus, at the sixth month of preg-
nancy, enclosed within its membranes. The umbilical arteries con-
tinued to beat strongly as long as the membranes were unruptured;
but ihey fell into inertia as soon as the lungs and chest, upon coming
in contact with the air, attempted to perform some respiratory
movements. And do we not every day see the blood flow or stop
spontaneously in the same child, accordingly as the respiration is
free or embarrassed?

1214. Whatever may be the fate of the explanation, it is not the
less true, that if the cord were left to itself without any ligature, it
would not expose the foetus to any hemorrhage, or any accident,

MANAGEMENT OF THE CORD. 565

even although it should be cut off clean, and not contused or torn.
However, as the contrary may happen, as a mere compression of
the chest, or an embarrassed state of the function of any organ suf-
fices to disorder the general circulation and enable the blood again
to pass through the umbilical ring; as cases are reported of children
who have died from bleeding in consequence of the cord being not
well secured; and lastly, as there is no danger occasioned by the
application of a ligature, as it presents no difficulty, we are not au-
thorised to dispense with it; we should even be culpable to neglec*
it. Although the observations of Fautoni and Schultz prove that it
is not indispensable, those of Daniel prove, that it would not always
be safe to omit it even after a rupture of the cord; and the cautery,
made use of in Turkey, will always be less safe and more trouble-
some.

Further, whether tied or not, the cord constantly separates from the
abdomen at the same place, that is to say, at the spot where it joins
the skin, and consequently, a few lines beyond the surface of the
belly; and I do not think it my duty to combat the old women's no-
tion, which was derived from the physiology of the ancients, and
which requires that the cord should be cut very near the umbilicus
if the child is a girl, and very far from the abdomen if it is a boy,
such a mode of cutting it being supposed to exert a great influence
upon the development of the organs of copulation!

1215. I always make one turn of the ligature, which I tie with a
single knot sufficiently hard to close the vessels; I then carry the
two ends behind, cross them and bring them back again in front,
where they are secured by a double knot which is tied somewhat
more firmly. I pursue this method because it is very simple, and
because I have never seen it followed by any accident. But if the
cord were a very large one, I would willingly, for the sake of
greater security, imitate the conduct of M. Desormeaux and Plenck,
that is to say, that after tying the first knot, I would make a loop of
the cord, and secure it in the second turn of the ligature. Besides
this ligature, some practitioners apply one to the placental end of the
cord, to prevent, as they say, any hemorrhage from taking place
from the woman. But what I have said concerning the uiero-pla-
cental vascular system, proves that this is an unnecessary precaution
It can be of no use except in twin cases, and even there, to make it
necessary, the vessels of one placenta ought to communicate directly
with those of the other as appears to have been the case in two
instances met with by M. Mancel, but which must be a very rare
occurrence.

566 MANAGEMENT OF THE CHILD.

§. H. Of Cleansing the Child.

1216. Without undertaking to decide whether our first parents
took the trouble of removing the unctuous matter which covers and
soils the skin of the foetus at birth; without recurring to the question
whether, as is supposed by M. Richerand and most of the modern
physiologists, this substance is a mere result of the sebaceous secre-
tion, rather than a deposit of some principle contained in the liquor
amnii, as is supposed by the chemical physicians in accordance
with the sentiments of M. Vauquelin, I will say, notwithstanding
the ideas of Gaullier de Claubry, that none but beneficial effects
can follow its removal. If it were the intention of nature to retain
it upon the surface, why would the goat, the cow, and so many
other animals lick their young so carefully and sometimes so rudely
as soon as they are born! I know that no very serious inconve-
nience would follow should it be left adhering to the surface, and
that it would come off in a few days by sticking to the clothes, or
with the epidermis to which it adheres, and which always desqua-
mates within the first few weeks; lastly, I do not believe its presence
can have any great influence in producing scabs on the head, of
crusta lactea of the head in children at the breast, or crusts on other
parts of the body; nor, consequently, that it is absolutely necessary
to remove it with scrupulous minuteness, even to the very smallest
portion; but I think that none of it ought to be left except in certain
spots from which it cannot be readily got off.

Where nothing is made use of but a napkin to wipe it off, some
portions always remain adhering to the skin, unless it is rubbed so
long and so violently as to be sometimes dangerous; nor can we suc-
ceed much better by immersing the foetus in a warm bath, unless it
be composed of a mucilaginous or saponaceous fluid.

It should be first diluted and thinned with a little fresh butter or oil,
mucilage, or any kind of grease, or what is still better, the yolk of an
egg, which renders it miscible with water. A weak solution of soap
and water might also be made use of very properly, but the other
substances are preferable. This ceruminous substance is met with in
greatest abundance at the principal bends of the limbs, and on the
head and neck; when it is well detached from the body, it should
be gently wiped with a dry napkin; after which, in order to finish
the cleansing of the child we may first merely rub its skin with a soft
sponge dipped in warm water, or weak wine and water, and then
again with the sponge squeezed dry, to clean off any blood or other
matter adhering to it.

Some persons think the whole child should be plunged into a bath

CLEANING AND DRESSING THE CHILD. 567

and I do not see why the accoucheur should refuse this Utile grati-
fication to the parents when they desire to have it done; if I gene-
rally neglect it, it is because it takes up too much time, and assuredly
does not deserve to be made of so much consequence as is done by
some accoucheurs.

1217. It is difficult to conceive how certain grave authors can
defend the conduct of the ancient people of Germany, Britain,
Scythia and Greenland, and recommend the Lacedaemonian custom
of plunging the foetus into cold water or ice-water, or even to roll
it in the snow immediately after its birth, as appears to be still the
practice in some remote districts of the vast empire of Russia,
The vigor and the robust constitution of those people depended
upon their diet and the exercises to which they were accustomed.
If they had among them no weak and delicate children, that may
be accounted for, not by saying that the cold bath gives strength
and health to weakly children, but that those that were weakly
at first soon died, and that none remained but such as were endowed
■with more vigorous constitutions. This practice was quite a natural
test among a people who desired to have in their republic none but
strong citizens, and looked upon infirm men as more troublesome
than useful; but in our present state of civilisation the most robust
men are not always those who perform the most important parts in
the slate; it is no longer allowable to be careless of the life of any
individual, and every child, whether delicate or vigorous, has an
equal right to the protection of its parents and of society in general.

The foetus has enough to do to bear the inlemperature of the
atmosphere; and can any thing be more absurd than to wish to
make it pass at once from a temperature of 32° of Reaumur to
some degrees below zero? A transition so sudden as this in a
being so frail — is it natural? Even although it should be efiected
by degrees, las Rousseau wished, it would nevertheless be dangerous
and wrong.

1218. Medicated, alcoholic, or strengthening baths seem to me
to deserve the same reprobation, as a general rule: if they are
strong they deprive the skin of its suppleness, interfere with the
expansive movement of the fluids, and may give rise to the most
serious accidents; if weak, they at least do no good, and I should
not make use of them except where the foetus might be excited in
a general manner, so as to communicate a greater degree of activity
to its languid functions. Thus, except under particular indications,
lotions and baths of plain warm water are the only ones that pru-
dence permits us to recommend.

49*

568 MANAGEMENT OF THE CHILD.

§. HI. or Dressing the Child.

1219. The foetus being washed, cleaned and wiped dry, still re-
quires some attention; the accoucheur should direct its first dress-
ing; he should at least superintend the application of the belly band
and the dressing of the cord.

The form of this compress, in itself considered, is of little conse-
quence; Baudelocque directs it to be made double, and that a pretty
deep cut of a half moon shape should be made in the folded edge
with the scissors; that after splitting one of the halves from the
hole quite out to the end, the root of the cord should be lodged in
the space between; that the part not split should remain below, and
the two halves of the divided portion should be turned over and
crossed in front! There is another method. Let the compress be
placed at the upper and left side of the abdomen, rather than at the
right, on account of the presence of the liver; a second compress,
soft and of a square shape, covers the first; a band as wide as three
or four fingers, and long enough to go once and a half round the
belly, keeps the whole in place; this band is fastened at the side
rather than at the middle of the belly, with a pin which is far from
being so dangerous as some persons have supposed, or it may be
secured with a needle and thread. If drawn too tightly it would
do harm, if too loose, it would slip off and do no good. This
little apparatus, the object of which is to prevent the cord from
being pulled or stretched, and from sticking to the skin, ought to
be continued or reapplied until the cord drops off. It may even be
continued for some days, some weeks, or months afterwards, pro-
vided the navel projects too much, or there is any danger of an om-
phalocele taking place. The cord generally separates from the
navel about the fifth day; but in some children it takes place as
early as the second, while in others it does not happen until the
ninth or tenth day. It begins to dry at its loose end, as has been
correctly observed by M* Billard; the gelatin which it contains con-
tracts upon the vessels, which are soon somewhat strangulated by
it, as far as the umbilical ring, and not by the epidermis, as M.
Gardien supposed. Being reduced to a mere pedicle which grows
smaller and smaller, the vessels soon separate from the living parts,
so that the gangrene of which Haller speaks, the contraction indi-
cated by Gardien, the eliminative inflammation observed by Beclard,
Chaussier, and M. Orfila, as well as the kind of putrefaction noticed
by M. Denis, are merely accidental phenomena, and not the cause of
the fall of the cord. When a small wound is left after the separa-
tion of the cord, it generally heals spontaneously in from eight to

DRESSING OF THE CHILD. 569

twelve days. All the ointments and waters recommended by the
good women to force it to close sooner are of no use, and might
even produce an opposite effect. It is sufficient to cover it with a
piece of fine dry linen, or to sprinkle it over with a little flour or
powder of lycopodium.

1220. Previously to wrapping up the navel string, it was formerly
the custom to begin to dress the child and cover the head, arms and
breast. Thanks to the elegant pen of Rousseau, it is rarely neces-
sary for us at the present day to combat the employment of those
absurd swaddling bands, which render a new born infant an im-
movable mass, a sort of doll which could be taken hold of by the
feet and lifted up stiff. The reform upon this subject is carried so
far in England, that instead of the barra-coat they make use of a long
frock, a sort of sac of fine wool stuff, which serves for the dress of
the child. In France, they also put a shirt, or small woollen jacket,
provided with a soft chemisette, which is fastened behind with pins;
it is then wrapped in a linen barra and another made of wool or
cotton. These barras come up as high as the axillae, and go once
and a half round the body, and cross in front all the way down; the
end is then folded up so as to reach quite to the upper part of the
breast, and the corners are carried round behind, to the back, where
they are also fastened with pins.

However, all these matters belong rather to the women, and par-
ticularly the nurses, than to the physician. Provided that the child
is comfortable, free in its motions, the dress soft and warm, it is of
small consequence what shall be its form, nature, or arrangement;
every thing over and above these points should be left to the taste or
caprice of the family or assistants.

SECTION 3.

Of the Foetus in a State of Disease.

The foetus may be born weak, or even in a state of apparent death;
the treatment it shall receive under these circumstances should vary
according to the danger and the nature of the accident which com-
promils its life.

§. I. Of Asphyxia.

If the child is only weak without being actually sick, it should be
treated in the way that has already been directed; only we should
sooner attend to putting the finger in the mouth so as to cleanse it
from any mucus contained in it; great care is to be taken to avoid

570 MANAGEMENT OF THE CHILD.

cold; a little wine may be added to the water to be used in washing
it, and nothing is to be done that might in any way whatever inter-
fere with the freedom of its respiration.

But the weakness may be carried to the extreme; sometimes the
foetus neither cries nor respires, its skin is pale; the circulation is
languid, the heart scarcely beats; and but for the heat which remains,
and the obscure motion of the umbilical arteries and heart, the death
of the child would be evident.

1221. This is the state which is called asphyxia of new born
children, which M. Gardien prefers to denominate syncope, and
which others have denominated anemia; but which in fact differs
from those three morbid states in a great many respects, and which,
rigorously speaking, are much more nearly allied to the latter than to
the two former.

It is met with particularly after very precipitate delivery, where
the child has been turned, when it is born before the full term, where
there has been a flooding during labor or several days before it, espe-
cially that kind of flooding which is caused by implantation of the
placenta over the os uteri, or that which comes direct from the ves-
sels of the cord.

Its cause therefore is, on the one hand, a deficiency of blood,
which does not pass through the brain and lungs in sufficient quan-
tity to keep those organs in a state of action; on the other, the want
of incitation of the inspiratory muscles, and perhaps also, in some
cases, the presence of too great a quantity of mucus, or water of the
amnios in the trachea, as supposed by Heroldt and Scheele; M.
Desormeaux seems to agree with Freteau, that the compression of
the cord may also occasion it, by closing the passage for the blood in
the vein, whilst it leaves the arteries more or less permeable; but I
have elsewhere shown what ought to be thought of this view of the
subject.

Upon the whole, it seems to me that asphyxia of new born children
ought to be attributed to the affection suffered by the blood in the last
moments of the labor, its placental modification, and its having ceased
to be subjected to that sort of internal respiration which, under ordi-
nary circumstances, is kept up, until the real respiration becomes
positively established.

1222. Treatment. The first thing to be done is to remove the
viscid mucus from the mouth by means of the finger, or with a brush,
either dry, or dipped in a solution of common salt; there is no rea-
son to believe that it is either safe or useful to turn the foetus with
the face downwards to force the matters contained in the trachea to
escape therefrom, nor to suck them out into a tube as Heroldt and

ASPHYXIA. 57r

Scheele state that they have done. Where there is reason to be-
lieve that the placenta still maintains a part of its natural relations
with the womb, and especially where there is still some tremor,
some pulsation in the cord, we may follow the advice of Levret,
Sraellie, Freteau, M. Piet, Chaussier, &;c., not to cut it too soon;
but if the womb be well contracted, if the adhesions of the placenta
be evidently destroyed, it would be better to separate the foetus at
once from its mother. The fact related by A. Petit, wherein he
saw the child in some measure die and revive again accordingly as
the cord was compressed or free, to command our entire belief,
would require a fuller detail of all the accompanying circumstances.
Supposing that the secundines are either wholly expelled, or on the
point of being expelled, and that there should be still some pulsa-
tions in the cord, I should not object to keeping them for some time
in warm wine and water, as again recommended even in our own.
day by many authors, as MM. Beauchesne and Dorthal among
others; but in other cases I cannot perceive any advantages in act-
ing thus. As it is important for the foetus to preserve what little
blood it has, the cord should be tied previously to cutting it off; the
child is to be immediately taken out of the mother's sight; it should
be taken near a good fire, or it may be plunged up to the axillae ia
a warm bath, rendered somewhat exciting by the addition of a little
wine or brandy; we should give it slight shocks by slapping it with
the flat of the fingers upon the breast, the back, or the breech; the
cord should also be gently pulled in such a way as to move the dia-
phragm a little. Van Swielen speaks of midwives who applied the
mouth to the left nipple of the child, and derived great advantages
from suction performed on this or other parts of its body. Instead
of the mouth, a cup might be made use of. This practice, which
was reinstated by Saccombe, M. Desormeaux thinks may be of
some use, by exciting the action of the muscles; but it cannot pro-
duce, as is pretended, a real mechanical dilatation of the chest. The
temples, the nostrils, the forehead, the root of the neck, and the
spine, ought to be rubbed with the fingers dipped in cologne water,
alcohol, &;c., or with a pretty stiff dry brush; the inside of the mouth
and nose are to be stimulated by the introduction of vinegar, brandy,
or some other irritating liquor, or merely with the barbs of a dry
feather. I have, in imitation of M. Desormeaux, advantageously
employed a mouthfal of spirituous liquor, held a few moments in the
mouth and then spirted with force, in the form of a douche, or ablu-
tion over the breast of the child: the smoke of burnt linen or paper
introduced into the rectum has been beneficially employed in some
cases, some onion or garlic introduced into the anus, the mouth, or

572 MANAGEMENT OF THE CHILD.

the nose, produce nearly the same effect, and are not so dangerous
as ammonia or radical vinegar, which promptly act as caustics if not
largely diluted with water. The belly and thorax should be simul-
taneously and properly pressed so as to try to induce the diaphragm
to contract; and during all these processes the fetus should be always
kept very warm, for without this precaution the action of all the other
means will generally be inefficacious. We should persevere with
them for a long time, and not get tired, and redouble our patience as
soon as the least sign of life becomes manifest; sometimes the efforts
of the accoucheur are not crowned with success until after they have
been continued half an hour, an hour, or even two hours, and cases
are not wanting where children, after being several hours abandoned
as dead, have come to life, Avithout any other succor than the tem-
perature of the place where they were deposited.

1223. When these different means prove ineffectual, recourse is
to be had to inflating the lungs, which may be done either through
a quill-barrel, a female-catheter, or any kind of canula introduced
into the mouth and nostrils, or by merely blowing with the mouth
directly into the air-passages. The laryngeal-tube invented by
Chaussier, having the advantage of pretty exactly filling the glottis
when introduced into it, is better than the straight canula of Heroldt;
but a simple gum-elastic catheter, and instrument which may be
got any where, is almost as convenient; it is introduced through
the mouth, as far as the bottom of the pharynx; then, while it is
passed onwards, the point of it may be bent with the little finger,so
as to compel it to enter into the larnyx rather than the oesophagus;
when fixed right, the nostrils and mouth of the foetus are closed,
and the inflation commenced. However, if it should be admitted
that the experiments tried by Winslow, Heroldt, Scheele, Viborg,
Schmidt and Beclard, incontestably prove that the liquor amnii pene-
trates during intra-uterine life as far as the bronchia, it would per-
haps be useful to free the trachea from it by suction or otherwise,
previously to trying the effects of inflation; but there is still too
much uncertainty upon this point for it to serve as a basis for any
practice whatever.

1224. Curry, Chaussier, and others, had at first thought that by
blowing into the mouth none but vitiated or more or less changed
air was forced into the lungs of the foetus, and that it would be
better to make use of a bellows; but it was soon found that all these
precautions, were useless, that air, slightly warmed in the lungs of
an adult, and charged with a gentle humidity, would be more con-
genial to the lungs of the child than a drier and colder air. Besides,
Heroldt and others have proved, that the gas given out by expira-

ASPHYXIA. 573

tion, contains only one hundredth less of oxygen than atmospheric
air.

As it is important that the air should enter the lungs and not the
alimentary canal, an assistant ought to press his hand against the
larynx, so as to keep it against the cervical vertebra, and flatten the
CESophagus as much as possible.

1225. We should blow at first very gently. When the lungs are
sufficiently filled to lower the diaphragm and raise the sides of the
thorax, as is done in a natural inspiration, we must stop, and gently
compress the abdomen and breast in imitation of the act of expira-
tion. We then begin again in the same manner, and thus establish
a sort of artificial respiration, the advantages of which have certainly
been exaggerated by some authors: M. Desormeaux has been but
imperfectly satisfied with it, and in my hands it has succeeded in
but a small number of cases, and (according to the researches of M.
Leroy d'EtioUes) it is really dangerous unless managed with very
great care.

In fact, it is not the action of the lungs, but that of the respiratory
muscles that ought to be first put in play. But, as the very reverse
takes place in inflation, it follows, according to M. Leroy, that the
air generally stops in the large branches of the bronchia, and that we
can rarely succeed in forcing it into the air-cells, without the risk of
producing an emphysema, which of itself is sufficient to occasion the
death of the individual.

The operation of tracheotomy, proposed, in despair of any thing
better, by M. Heroldt, as it is very dangerous in itself considered,
ofl^ers no advantages superior to simple inflation, and ought to be pro-
scribed.

1226. Electricity and galvanism, which have been recommended
under these circumstances by Greve, Behrends, Boer, M. Gardien,
&c. might also be of great service either as a principal or accessory
cause in the treatment of the asphyxia of new born children. The
current should be directed through the breast, or from the mouth to
the anus. I must, notwithstanding, confess that I have twice tried it
without success, although I made use of a double battery of twenty-
one metallic plates, the action of which was very strong. The elec-
tro-puncture which was tried by M. Leroy on animals, might per-
haps be more efficacious, by permitting it to act directly upon the
diaphragm; but, so far as I know, it has never been applied to the
human foetus.

If we are to succeed, the pulsations of the heart and cord re-ap-
pear by degrees, the muscles gradually recover their natural firmness,

574 MANAGEMENT OF THE CHILD.

the skin becomes slightly colored, the heat returns, and then some
respiratory movements, feeble and irregular at first, then more and
more decided, soon make their appearance; cries are soon heard, and
the child is saved. It would, however, be imprudent to cry out vic-
tory too soon; I twice succeeded in restoring the motions of the
heart, and the respiration, for more than three hours, by means of
inflation and galvanism, in two children, which I nevertheless was
at length compelled to abandon.*

§. II. Of the Apoplectic State.

1227. Instead of coming into the world pale, anemic, or exsan-
guious, the child is sometimes born in quite a contrary condition;
its skin is of a bluish red or liver color, of various degrees of inten-
sity, especially on the face, and appears as if thickened. All the or-
gans seem to be the seat of a general congestion, the limbs are soft
and motionless; the circulation is suspended, either wholly or in part,
in addition to which, all the other signs just now indicated are found
to be present.

It should also be understood that the disease may exhibit itself
under various degrees of intensity, and produce various changes in
the interior of the body. Upon opening the dead bodies of such
children, fluid blood is often found extravasated between the menin-
ges or in the very substance of the brain. In other cases, and that
most frequently, the blood is not found to have escaped from the ves-
sels, or only forms slight ecchymoses in different parts; but it is in
excess in all the organs, which are engorged, and, as it were, soaked
in it.

The apoplectic state is met with, especially in strong children,
after long and difficult labors, the application of the forceps, and
pelvis labors, either spontaneous or artificial; where the child has
remained for several hours under the direct influence of the uterine
contractions after the discharge of the waters; where it has pre-
sented in a bad position; where it is too large to pass with ease
through the various passages; where a loop of the cord strictures

* There are a great many real resources for the recovery of the child, hut they
are often applied without success, because they are persevered in after the signs of
death are complete. In general, it is safe to abandon all attempts to resuscitate,
if there be no audible pulsation of the heart, no sensible beating of the umbilical
vessels close to the belly — if the child be without muscular tone or resistance —
and especially if the sphinctorian contraction is gone. — But no truce should be
allowed, while there remains the least sign of muscular action in any part of the--
body.— M.

APOPLECTIC STATE. 575

its neck, or is itself in any way compressed, and particularly where
any of these accidents occur coincidenlly with a previous pleihoric
state.

Its immediate cause is the compression or engorgement of the
brain; which, however, does not prevent a want of the revivification
of the blood from being an occasional cause of it, as well as of as-
phyxia; and M. Gardien, while opposing the sentiments of M.
Chambon, Courraut, and Capuron, is certainly wrong in maintaining
that compression of the cord is as incapable of producing the apo-
plectic state as it is capable of easily producing asphyxia.

1228. When a child is born in this state we should make haste to
disengorge its vascular system; by acting soon where there is no
effusion, the alarming symptoms may generally be soon dissipated.
Under the opposite circumstances, death is commonly inevitable; but,
as has been remarked by M. Desormeaux, inasmuch as it is impos-
sible, a priori, to distinguish a simple congestion from an encephalic
hemorrhage, the accouclieur would be reprehensible who should fail,
in any case, to bestow upon the child the same care as if the affec-
tion were known to be less seiious.

If the accident have been occasioned by compression by the cord
upon the jugular vein, the turns should be quickly cast off, or cut,
provided the foetus cannot be otherwise freed from their injurious
effects. In other cases it would be equally dangerous to wail for
the child to cry before cutting the cord, or to amuse one's-self with
immersing the placenta in a warm liquid. The section of the cord
is the first and chief remedy to be resorted to. The ligature is not
to be applied until after the disappearance of every bad symptom,
because the advantage of this section is, that it gives free issue to the
blood. To promote the escape of this fluid, it is sometimes requi-
site gently to press upon the breast, the abdomen, and the cord it-
self. As the blood flows, the cliiUI seems to revive; the livid color
of the lips is soon replaced by a purplish or rosy hue; the parts
about the mouth, and nose, the rest of the face, and the whole sur-
face of the body clear up by degrees; the respiration soon becomes
established, and in a few minutes the danger has wholly disappeared;
but the circulation is sometimes so much enfeebled and obscure that
no blood flows from the umbilicus. In such cases we are obliged to
resort to the remedies recommended for asphyxia, that is to say, to
frictions, stimulating baths, inflation, electricity, &c.; and as it is ab-
solutely necessary for the child to lose blood, provided it be impossi-
ble to obtain any from the cord, a leech should be applied behind
each ear to disengorge the brain.

1229. When the integuments have recovered their natural color,
50

576 MANAGEMENT OF THE CHILD.

the circulation has returned to its natural state, the respiration is no
longer doubtful, and the foetus cries and moves freely; the bleeding
must be stopped, provided it should not have stopped of itself. After
this we proceed as if the child had been born well. On the contrary,
should there still remain some obstruction in the pulmonary and cere-
bral functions, as have too frequently been noticed, especially where
we have been unable to procure a sufficient quantity of blood, leeches
ought again to be applied, and are almost the only agents upon
which we can place any reliance, in cases where congestion, a sort
of secondary apoplexy, does not come on until twelve, twenty-four,
or forty-eight hours, or even, as has happened, until three or four
days after its birth.

§. ni. ®f gome other Morbid States of the neiF-
born Child.

1230. It is not a part of my subject here to treat of the contusions,
wounds, luxations, and fractures which take place in certain difficult
labors; neither have I occasion to speak of what is called tongue-tied,
adhesion of the tongue, occlusion of the palpebrae or lips, imperfora-
tion of the urethra, vagina or anus, of jaundice, induration of the
cellular tissue, nor any of the faulty conformations or numerous dis-
eases to which the infant is subject; but I cannot pass over in silence
the deformity of the head and some other accidents which depend di-
rectly upon the compression of the head during its passage through
the straits.

1231. The depression of the parietal or frontal bone with or
without fracture, has been several times observed at the Maternite
at Paris by Chaussier, M. Duges, and Madame Lachapelle; there
is reason to fear its occurrence when the head rests against the
sacro-vertebral angle, and is for a long time subjected to violent
effiarts, when the strait is reniform, and when a pretty large head is
forced to mould itself to the form of the pelvis through which it
passes.

If the fracture or depression of the bones is not accompanied with
extravasation, nature ordinarily succeeds in restoring every thing to
its proper condition, and performs the .cure herself; otherwise, death
is the common consequence, or at least, there ensues stupor and a
very great tendency to convulsions.

1232. By moulding itself according to the contracted straits, the
head may be elongated without its bones being depressed or fractured,
but in such a way that their edges cross and over-ride one another,
more or less; in these cases they pretty often recover their natural
position after the delivery; but they may also continue to over-ride.

TABLE V.

Table showing the Mortality of Lying-in Women in different Countries and at
different Periods; from the Registers of the Dublin Lying in Hospital, MM.
De Chateau-Neof, Duces, &c.

Years. Labors Deaths Years. Labors Deaths

Dublin Lyixg-IjN HosriTAL

■\

1757

1758

1759

1760

1761

1762

1763

1764

1765

1766

1767

1768

1769

1770

1771

1772

1773

1774

1775

1776

1777

1778

1779

1780

1781

1782

1783

1784

1785

1786

1887

1788

1789

1790

55

454

406

556

521

533

488

588

533

581

664

655

642

970

695

704

694

681

728

802

885

927

1011

910

1027

990

1167

1261

1292

1351

1347

1469

1435

1546

5

4

9

6

9

12

6

3

11

16

8

8

5

4

13

21

5

7

7

10

8

5

6

6

15

11

8

8

10

23

25

12

1791

1792
1793
1794
1795
1796
1797
1798
1799
1800
1801
1802
1803
1804
1805
1806
1807
1808
1809
1810
1811
1812
1813
1814
1815
1S16
1817
1818
1819
1820
1821
1822
1823

1603

1631

1747

1543

1503

1621

1712

1604

1537

1837

1725

1985

2028

1915

2220

2406

2511

2665

2e89

2854

2561

2676

2484

2508

3075

3314

3473

3539

3197

2458

2849

2675

2584

10
19
20

7

10
13

8
10
18
30
26
44
16
12
23
12
13
21
27
24
43
62
25
17
18
32
56
54
50
22
12
59

M. Duces, at the Matcrnite J
of Paris. |

1799
1800
1801
1802
1803
1804
1805
1806
1807
1808

1364
1155

1209
1496
16.32
1662
1564
1625
1691
1690

100

120
25
13

108
59
60

114
72
57

1809
1810
1811
1814
1815
1816
1817
1818
1819

1795
1814
2395
2384
2346
2422
2800
2411
1528

66

71

108

127

149

46

63

152

187

M. De Chateau-Neuf, at
Paris.

t 1816
I 1817
( 1818

9,683
10,52b

«1
90

11,662 167

1819
1820
1821

11,5(!UI 100
11,6.34 228

11,481 1 223

f Wassend£t,in Sweden, 1 death in 62
J Berlin, .... 109 in 10,000
^^] British Hospital, .\ 1 in
(^ Manchester, . . '

1 in

50

128:

V

Hotel-Dieu, Paris, . . 1 in 15
J London, in 30 years, 820 in 10,000
^^] Strasburgh, ... 1 in 109
tPctersbursrh, . . . 7 in 100(1

DISEASES OF THE CHILD. 577

as occurred in one case under my own notice, and thus constitute a
perpetual cause of disease, particularly of convulsive affections.

However, in this, as in the preceding cases, art can do nothing, and
we are obliged to trust to the powers of nature.

1233. A more common, and fortunately less serious accident than
these, is a sort of subcutaneous effusion, a swelling of the hairy-
scalp, which is almost always met with, but in different degrees,
when the head has traversed the pelvic canal slowly and with diffi-
culty; this tumor is generally found on that part of the cranium which
occupied the open space in the pelvis during the labor; or one of the
points that was longest and most forcibly pressed against the sacro-
vertebral angle or pubis; it is composed in some cases of reddish
serum, in some of pure blood, either fluid or coagulated, in others of
a mixture of these fluids, and is of various size, from that of a nut up
to that of a hen's egg.

It may be diffused or circumscribed, and it may be fluctuating,
though generally elastic and dough-like, and commonly disappears
without any assistance; sometimes, however, it suppurates and is
converted into a real abscess, which may end in denudation and ne-
crosis of the cranial bones.

Being soft and compressible in the centre, and firmer and more
elevated about the edges, it has, on more than one occasion, been
mistaken for a fracture or depression of the bones, and excited use-
less alarm. But since J. L. Petit, Ledran and Levret have called
attention to this sort of mistakes, they have become more and more
rare.

1234. When the tumor is of a small size, it should be left to itself,
and disappears in the course of three or four days, leaving behind it
only a simple ecchymosis; but its resolution may, and indeed should
be facilitated, by keeping it covered with compresses dipped in salt
water, red wine, or brandy and water, some eau-bhmche or other me-
dicine of the same kind. Should it be fluctuating and not very painful,
it should nevertheless be resolved if possible; if the means above in-
dicated do not suffice, they might be replaced by a solution of half
an ounce of hydro-chlorate of ammonia in a pint of red wine; this
liquor, which is recommended by Siebold, and frequently employed
by M. Boyer for bloody tumors of the knee, has many times suc-
ceeded in dispersing collections which it had seemed indispensably
necessary to open.

However, should it not produce the effect expected from it, and
the fluctuation increase, recourse must be had to the bistoury; and in
such a case we ought not to wait too long, which would admit of the
skin becoming more extensively detached, and much thinner. The

50*

578 MANAGEMENT OF LYING-IN WOMEN.

wound should be dressed with lint, cerate, or cataplasms, that is to
say, as we would dress an abscess or any sanguine collection of a
common kind, and the wound generally heals very speedily.

ARTICLE III.
Management of the Lying-in Woman.

1235. The accoucheur being now satisfied as to the condition of
the child and delivery of the after-birth, has nothing farther to do ex-
cept to attend to the woman herself. After ascertaining that the
womb is well contracted, and every thing in a natural state, he clean-
ses (or orders it done) the vulva, the thighs, and all the parts that
have been soiled with blood, waters, or other substances during the
labor. Some warm water, either simple or mixed with a little wine,
provided the parts are soft and relaxed, is, with the addition of a piece
of sponge, all that is necessary in this little operation.

We next change the woman's clothes; the chemise may be
long, soft and wide, and either open in front, or not, and it should have
long sleeves, so that the arms may not be exposed. Over this
chemise there is worn a cotton shirt, and then a neck-handkerchief
round the neck, so that the upper part of the breast, which is gener-
ally exposed to the air, may be rather better protected than the rest of
the body. In summer, and whenever the weather is not cold, these
two pieces, together with the head-dress, compose the whole of the
woman's dress; otherwise she puts on a long wadded silk-gown open
in front all the way down; in this gown there is the double advan-
tage of being warm, and very light. However, like the dress of the
child, that of the mother is a matter which we generally leave to the
nurse; and provided the several pieces be sufficiently large, and their
number and thickness suited to the temperature of the weather, or
the habits of the patient, she should always be allowed to arrange
her dress as she pleases. The same may be said as regards the
head-dress, except that it would not always be safe to permit the pa-
tient, which she sometimes requests, to have her hair cut, or sprink-
led with salt.

The breasts do not require to be supported, or provided with wad-
ded cushions, unless they are very large, and where there is fear
of taking cold. The bandage which some women use for the pur-
pose of compressing them, and preserving their shape, produces
quite a contrary effect; besides, by impeding the action of the respi-

MANAGEMENT OF LYING-IN WOMEN. 579

ratory muscles, it may oppose the return of blood to the thorax,
give rise to apoplectic symptoms, as happened to two imprudent wo-
men mentioned by Baudelocque, and become the cause of a number
of diseases, each worse than the other; the astringent or repellent
cataplasms employed for the same purpose, and to prevent the secre-
tion of milk, deserve the same reprobation.

1236. I would say as much of the belly-bandage so much blamed
by De la Motte, were it used solely for the gratification of a vain
coquetry, but I think it useful in another way. In this, as in all
other things, we must take care not to confound the abuse with the
wise and reasonable use of things.

Doubtless, by strangulating the abdomen with a towel, to reduce
their size and prevent the formation of scars or inevitable wrinkles,
women expose themselves to great dangers, without any chance of
obtaining their object; but as has been advanced by Smellie, Bau-
delocque, M. Gardien, &c. a bandage that is moderately tight, or
simply gives a good support, may be of great service, and counter-
act the formation of many serious diseases. The suddenness with
which the womb empties itself, causes the abdominal viscera im-
mediately after delivery to be all at once relieved from a long con-
tinued slate of pressure; the abdominal parietes, as they do not fol-
low up the retreating movement of the uterus, no longer support
the digestive organs with the same power; a kind of vacuum is ef-
fected in the large vascular trunks, and the blood should be determin-
ed there with so much the greater force, as it had only penetrated
them with difficulty for some months; hence arises a greater ten-
dency to hemorrhage, inertia of the womb, inflammations and func-
tional disturbances of the liver and intestines. Hence, says Van
Svvieten, the syncopes that are so frequently met with in women re-
cently delivered, though M. Desormeaux thinks they often depend
upon hysteria; again, StoU thinks that this is the principal cause of
the puerperal peritonitis. Now, the bandage, as I understand it, is
intended to supply as far as possible, the action of the abdominal
muscles, to promote the concentric movement of the uterus, and pre-
vent tlie atilux of blood towards that organ and the engorgement of
all the other viscera: besides, it is easy to acquire an idea of its
utility, by reflecting upon the dangers that follow the operation of
paracentesis, where the surgeon omits the precaution of applying a
compressive bandage upon the belly, after the evacuation of the fluid;
for as to degree, the pressurj upon the parts contained within the
abdomen experiences nearly the same transition in a woman delivered
of a child as it does in a dropsical patient undergoing the operation
of tapping.

580 MANAGEMENT OF LYING-IN WOMEN.

It is true, that if not carefully applied, the bandage soon rolls up
into the form of a string, and becomes more hurtful than useful;
that, as M. Desormeaux remarks, most of those women who neg-
lect to apply it, are not evidently worse off on that account, and that
the use of it could not have entered into the original plan of the con-
stitution; but as, when placed so as to produce no uneasiness nor
pain, I cannot perceive how it can do any harm, and as in many
cases it is incontestably useful, we should by rejecting it expose our-
selves, without any motive, to see symptoms arise which at first it
would have been very easy to repress or prevent.

It is composed, first of a towel folded into a triangular shape,
which is placed on the hypogastrium with the point downwards, and
then of another napkin which is folded once or twice lengthways,
and passed round the body like a bandage, embracing the hips.

To prevent it from getting into folds the last napkin should be sup-
ported above by a scapulary on the two ends of a bandage arranged
like suspenders, and below by pinning the ends of her doth to it.

The doth, formed of a piece of fine linen folded three or four
times, and sufficiently long to cover the vulva, and go to be pinned
to the body bandage both before and behind, is designed to receive
the fluids that are discharged from the vagina, and to prevent the
bed-clothes from becoming soiled with them: when care is taken to
renew them frequently, and not to pin them too tightly, none of the
ill effects will ensue so justlj' attributed to the old fashioned doth,
of which some women still make use, and which consisted of various
tampons kept in the vulva, and which more or less strictly stopped the
passage of the vagina. Although it is not an indispensable article
of dress, it seems to me that it may safely be permitted as a means
of cleanliness to those persons who desire to have it, or who set any
particular value upon its use.

1237. The new heel, to which the patient is about to be transfer-
red, ought to be furnished with an oil cloth, if one can be had, and
with a sheet folded into four layers, or of any other piece of linen fit
to protect the mattrass. The bed-clothes, the coverlids, and the ar-
rangement of the bolsters do not require any interference on the
part of the accoucheur, and ought, like every thing else to be suited
to the season and the habits of the woman.

She is to be transferred to the new bed shortly after delivery, and
when the vagina is freed from the clots and the fluid blood which
commonly follow the expulsion of the placenta. She is then in a
state of agitation, and can without inconvenience bear the little shocks
which the transfer almost inevitably occasions. If we wait longer,
as some authors have recommended from fear of hemorrhage or

MANAGEMENT OF LYING-IN WOMEN. 581

convulsions, she would be in the situation of the traveller who, hav-
ing reached his post harassed and fatigued, can still take a few steps
while heated, but when he once becomes still and cooled, is quite
unable to walk. All this, however, is to be understood of cases in
which every thing has passed naturally; for if the womb should not
contract well, or should there have been any flooding or threatening
of convulsions, or any other accidents that commonly ensue from
a state of extreme weakness, the removal should be deferred for a
few minutes in order to allay the danger or give time for the func-
tions to return to their natural condition, while the woman is still
upon the bed whereon she had been delivered.

1238. Those who get up, and go without any support to get into
the other bed, run the risk of bringing on inversion, anteversion or
retroversion, prolapsion of the uterus and many other dangerous
complaints. They ought to be warned of it, and made to understand
that they should allow themselves to be carried; when they are
very weak, or any accident has supervened, which might be aggra-
vated or recalled by too much motion, the two beds ought even to be
placed side by side, for in this way the woman can be slid on the
clean bed without moving her much, by making use of the sheet on
which she laid during the labor, and which may be easily removed
afterwards.

When put to bed, it would be useless, and indeed not always free
from danger, to compel her to preserve an attitude that she is unac-
customed to, to make her bed represent an inclined plane for exam-
ple, (descending towards the foot), for the purpose of favoring the
escape of the lochia, or on the other hand, to keep her hips raised
higher than her head, with a view of moderating the fluxion of fluids
towards the genital organs; she will lie upon the back, with the legs
stretched out and close together, should that position appear more
convenient and not fatguing to her; but she ought not to be prevented
from turning on the side, and bending her limbs if she wishes to do
so. In all respects she should be allowed to consult her own ease,
and her own inclinations should be attended to. The fatigue and
weakness brought on by the constraint of a fixed posture, would of
themselves be suflicient to bring on some accidents, and constitute a
morbid slate, even in a healthy person subjected to them; and they
should, a fortiori, be dispensed with in women whose functions,
being temporarily disturbed, require so much care and caution for
their restoration to a natural state.

1239, All that has been said, in speaking of the management of
a woman in labor, relatively to the air which surrounds her, the
chamber, and her moral condition, is equally applicable to her dur-

582 MANAGEMENT OF LYING-IN WOMEN.

ing the subsequent confinement. It is important that she should
neither speak nor be spoken to, except when necessary. A calm
state of the mind and repose of the body are so indispensable, that
too much care cannot be taken to remove every cause that might
interfere with them. The value of this precept was so well under-
stood in ancient Rome, that the magistrates themselves had no right
to enter the house of a lying-in woman for the execution of any
sentence or decision whatever; and in order to secure the respect
of the citizens for her asylum, it was sufficient, says Juvenal, to sus-
pend a wreath at her door.

Foribus suspende coronas,
Jam pater es.

Most of the diseases which affect a woman in child-bed may be
attributed to the thousands of visits of friends, neighbors, or acquain-
tances, or the ceremony with which she is too often oppressed: she
wishes to keep up the conversation, her mind becomes excited, the
fruit of which is headache and agitation; the slightest indiscreet
word worries her; the slightest motives of joy agitate her in the ex-
treme; the least opposition instantly makes her uneasy, and I can
affirm that among the numerous cases of peritonitis met with at the
Hospital de Perfectionnement, there are very few whose origin is
unconnected with some moral commotion.

1240. After the delivery of the placenta, and putting to bed, the
woman is commonly seized with a rigor, which sometimes goes so
far as to occasion a rattling of the teeth together. Some physi-
cians and the public have on this account deemed it best to cover
her over with a weight of bed-clothes; but this rigor, which is suffi-
ciently accounted for by the changes that have just occurred in her
system, and which must not be confounded with the chill of perito-
nitis, lasts but a few minutes, and scarcely deserves any particular
attention.

It would, doubtless, be imprudent to cover the lying-in woman too
lighdy; but it would be equally dangerous to fall into the opposite
excess. By covering her with thick bed-clothes and surrounding
her with well closed bed-curtains, and, in fine, by keeping her too
warm, besides the headaches, floodings, and convulsions to wiiich
she would be exposed, we rarely fail to produce a more or less abun-
dant perspiration, which it is sometimes difficult to suppress; this
diaphoresis probably has a great deal to do in producing the miliary
fever, which is so uncommon at the present day, and which was
formerly so often met with in lying-in women.

MANAGEMENT OF LYING-IN WOMEN. 583

1241. Sleep being of the first necessity to a being worn out with
fatigue, there would be a sort of cruelty in not permitting the wo-
man to enjoy it: in advising that she should be kept awake for several
hours for the purpose of avoiding hemorrhage, De la Motte certainly
did not in this morbid phenomenon distinguish the effect from the
cause. Although women sometimes do fall asleep with all the ap-
pearances of health, and wake up soon afterwards in the midst of a
profuse flooding, there is a far greater number who owe their well
being only to the beneficent influence of a refreshing sleep. Be-
sides, these floodings were imminent, or had even begun at the time
the women fell asleep; the desire for sleep being one of their most
common symptoms; if they should be unsuspected at first, and the
woman yields to the necessity she feels, she in fact falls into a dan-
gerous sleep, and sometimes never awakes from it; but in this case
the sleep is the elTect, and not the cause of the disease; it is conse-
quently not contra-indicated by any thing; only, prudence requires
that the pulse should be watched, and that the hand should from
time to time be placed on the hypogastrium, to ascertain that the
womb has not fallen into a state of inertia.

After this first sleep, that is to say, after the lapse of two or three
hours, she should set up in bed and take a little broth; this position
serves to rest her, and allows the lochia which had accumulated in
the vagina to flow readily oflf.

In the following days her linen is shifted accordingly as she gets
it soiled; the external parts of generation should be often washed,
and cleansed with mallows-water, which may, without inconvenience,
be replaced by a decoction of chervil mixed with milk; constipation,
so frequenUy met with in these cases, is combatted by means of
mild clysters, without regard to the prejudice which decides that no
clyster should be given previously to the occurrence of milk fever:
smarting about the meatus urinarius, difficulty of making water,
hemorrhoids, and other efl^ects of the frictions which must be expe-
rienced by the bladder and rectum while the foetus is passing out, re-
quire emollient or slightly aromatic lotions, hip-baths, and sometimes
the use of the catheter.

1242. The regimen, both alimentary and medicinal, of lying-in
women, is a point deserving the whole attention of the accoucheur —
not on account of the number or energetic quality of the substances
Avhich it is proper to administer, but because there are no where else
so many vulgar practices to proscribe, so many ridiculous prejudices
to extirpate, as upon this subject.

Drink should only be given to satisfy thirst, and not for the mere
pleasure of making her swallow ptisan; the woman requires a drink,

584 MANAGEMENT OF LYING-IN WOMEN.

and not a medicine. In regard to this, her taste and idiosyncrasy
may be consulted. She commonly continues to use one of the ptisans
which she had been advised to use during her labor. When tired of
one, another is given to her, and provided they do not prescribe some
of those bitter, exciting infusions, or some active compound, of which
the old women are so prodigal, she may, in general be allowed to
take what pleases her best. Hot wine, aromatics, alcoholic tinctures,
coffee, tea, and chocolate are not more admissible after than before
her lying-in.

The food should be light, and given in small quantity: broth
given one, two, or three times a day, or some messes of potage, are
all that prudence will allow before the milk comes to flow freely.
Eichele has supposed that by abstaining even from the broth, and
making use of debilitating measures, the milk fever would be pre-
vented from coming on; but I have often had opportunities of proving
the absurdity of such an assertion. If the woman is to suckle her
child, it is not improper to allow her to have polages of a rather
more substantial kind the day after the delivery; in the opposite
case I give nothing but broth. Upon this subject, attention must be
paid to her state of health, her habits and constitution; we ought
not, for example, obstinately to restrict a majority of country women
to too severe a diet; for, although many of them may have fallen vic-
tims to the many imprudences they commit, there is a much larger
number who, without making any change in their ordinary diet, and
continuing to eat cutlets, bread, and all sorts of meats, and at times
very gross food, yet get up, walk about, and do their customary work,
in two days after child-birth, without any bad effects following such
a course.

1243. When the secretion of milk has taken place and nothing
unnatural has happened, she begins to return by degrees to her com-
mon mode of living; she passes gradually from soup and panada,
and semouilles and rice-milk, to boiled eggs, white meats, fried tish,
chops, and other common dishes; so that in from eight to ten days
the patient has no more need than any body else of being directed in
relation to the choice of her food. 'I'he same is true of her drinks;
from wine and water she proceeds gradually to the use of beer or
pure wine; in fact the ptisans may be laid aside after the fourth or
fifth day. Many women, however, particularly those who cannot
or will not suckle, would not think themselves safe were not certain
infusions and medicines prescribed for them previous to their resu-
ming their ordinary regimen. The canne de Provence, the. arundo
phragmyfes, and the lesser periwinkle, especially enjoy a great repu-
tation in this respect with the public. According to the statements

MANAGEMENT OF LYING-IN WOMEN. 585

of the nurses and old women, the decoction of these plants is a pow-
erful means of repelling the milk. The woman cannot dispense with
its use if she wishes to avoid tetters, swellings, pains and all the con-
sequences of the lait repandu, a common bug-bear even to the best
informed women.

The ptisan of canne is too insignificant and inoffensive for us not
to prescribe it for women who repose any confidence in it; the
arundo phragmytes is scarcely more active; but, according to M.
Desormeaux, the periwinkle injures the stomach, excites the pulse,
and ought to be proscribed.

1244. Whether these drinks have been made use of or not, almost
all women in child bed desire to be purged before they get up alto-
gether; they then use sometimes an anti-lactic purge, and at others
some one of the ordinary cathartics. Weiss's whey and sal de duobus
have long enjoyed great vogue among the former; while the latter
most generally use manna, or castor oil, sedlilz water or decoction of
senna.

I am aware that it would be dangerous to give such remedies
without discrimination to all women, as has heretofore been done;
but is it a much wiser course to reject them all, as a great many
physicians of the present day recommend to be done?

If the accoucheur fails to order them, he expose* himself to a
thousand reproaches, which I am sure are unjust, but which, never-
theless, cause him to lose the confidence of his patients; should the
woman be seized with headache or rheumatis.m, even ten years after
her lying-in, the milk is the cause of it; do any pimples, or efflo-
rescence on the skin, any fever, abscess, or any sort of inflammation
make their appearance, it is always owing to the milk; and upon
reaching a certain age it is still worse: if the features lose their
freshness, if the color of the cheeks and lips fades, if the eyes
cease to be brilliant and bright, she is very carelld not to accuse the
inexorable sway of time, but she refers to the lait repandu, and the-
blame necessarily falls upon the physician who did not drive out
that dreadful milk at her last confinement !

Such prejudices would doubtless not justify the employment of
purgatives, were they as dangerous as some persons choose to say
they are, and were they never of any use; but such are not the facts.
I have frequently administered them, and can assert that I have
never known them to produce any bad consequences; and that, in
a great number of cases, they have evidently hastened the re-estab-
lishment of the^ digestive functions. I should be afraid of their ac-
tion where the tongue is red and lanceolate, or where there are un-
51

586 MANAGEMENT OF LYING-IN WOMEN.

doubted signs of phlegmasia in the abdomen; I believe them to be
of no use where the strength and appetite return fairly and rapidly;
but where the tongue is broad, whitish, yellow, or greenish the
mouth bitter and clammy, and there is no appetite, even although
there might be present some degree of fever, tension and sensibility
of the epigastrium, a gentle purgative I have often found to be fol-
lowed by the very best effects. I have seen these various symptoms
disappear on the succeeding day ip most cases, and the health be
afterwards restored with a degree of promptitude that I had had no
reason to hope for. By freeing the intestinal canal of the mucous
deposit with which it is pasted over, the purgatives bring it into a
state better fitted for the performance of its functions; the abundant
secretions which they occasion to take place from the villous surface
of the digestive passages free the system from substances that could
prove hurtful only, and impress upon the other functions a sort of
shock by which nature profits.

I prefer the factitious sedlitz water, or from six or eight drachms
to two ounces of castor oil; tlieir effect is sufficiently certain, and I
have not seen them produce as much irritation as most other evacu-
ants.

1245. The time that a lying-in woman ought to remain in bed is
necessarily very variable, and the nine days, the period fixed by the
vulgar, can be adopted only as a mean or general term. Five or
six days are sometimes sufficient; but if the symphyses should seem
to have been somewhat strained, the •womb have a disposition to pro-
lapse or become inverted, or the health appear frail, we ought to
•wait, and instead of eight or ten days, we should rather require her
to lie still for two weeks. In all cases, it would be wrong to per-
mit her to return suddenly to her usual exercise, as some practi-
tioners allow their patients to do. The first day she gets up she
should remain half an hour upon a sofa, and an hour the next day;
the third she may take a few steps and remain out of bed for two
or three hours; and during the following days she should consult
her strength and the degree of fatigue, as the rule for going to bed
again. Soon after this she can go down and take a few turns in
the garden, or in the yard; but it would be dangerous to go to
church on the first occasion of going out. The churches are ge-
nerally large, cold, and very freely ventilated. In what is called
their Churching, the women should not keep long on the knees;
they are sure to be fatigued before they go out, and often contract
there the seeds of serious diseases. Real religion does not demand
such imprudences; the woman ought to recover some degree of

MANAGEMENT OF LYING-IN WOxMEN. 587

strength before she goes on foot to present herself at the altar; she
ought first to have tried her strength at home, and make sure that it
will not be injurious to her to go out into the open air.

1246. Another custom that the physician ought to watch over is
the baptismal repast, if it takes place within the first ten days after
child birth. In this family feast joy is not forbidden; they laugh
and they talk; she desires to hold out with every body; the father,
the mother, the godfather and godmother, the brothers, sisters, un-
cles, aunts, (fee. all talk to her in turn. She only takes a seat at
table out of form, to be sure, or to make more sure of her prudence
she keeps her bed; all the guests forbid her to eat or drink any
thing; but in the mean time they oblige her to take a mouthful of
this wine, a mouthful of that , then taste of this dish, and o? that, so
that it too often happens that at the close of the day she finds herself
seized with symptoms severe enough to conduct her rapidly to the
gates of death. It would be better, therefore, for her not to be pre-
sent, unless it be beyond the tenth or fifteenth day; and even then
she ought to be extremely cautious.

The Lochia, the After-pains, and the Milk-fever, three of the prin-
cipal natural phenomena of a lying-in, now deserve our particular
attention.

1247. The term Lochia is given to the substances that escape
from the vulva, from the moment of the delivery of the secundines
until the womb has recovered its normal size and consistence; the
accoucheurs distinguish three kinds of them; the sanguine, the
serous and the milky or purulent; or the red, the clear, and the
white. The first are observed on the same day with, and on the
day after the birth; it is blood nearly pure. The second appear at
the end of twenty-four, or thirty-six hours, are formed of serum
mixed with a variable quantity of blood, and do not last beyond the
period of ihe milk-fever. The third succeed these, and last until
the fifteenth, twentieth, or even thirtieth day, and are produced by
the suppurative process going on upon the internal surface of the
womb. Nothing, however, is more variable than their abundance
and duration; the red lochia may cease from the first day and re-
turn on the fourth; I have even seen them reappear on the ninth.
Sometimes the purulent lochia do not appear at all, and in other
cases they last so long that it is difficult to distinguish them from a
leucorrhoea; this anomaly is, however, very easily to be understood
by reflecting for a moment upon the cause of this evacuation.

Although freed from the child and the after-birth, the womb does
not immediately recover its size and the other qualities natural to it;
they do not return until the end of five, six or eight weeks, a period

588 MANAGEMENT OF LYING-IN WOMEN.

at which the menses reappear for the first time; the womb indeed
always remains a little larger than it was before the woman became
pregnant, and, in general, the more so, as gestation is more fre-
quently repeated. During this period an insensible process goes
on, by means of which the uterine parietes are disengorged of the
substances they had imbibed. These fluids are directed more espe-
cially towards the cavity, because in that direction the tissue is less
dense, and they find a freer issue. As long as the great uterine ves-
sels are not emptied, blood only flows; at a later period it is serum
combined with the detritus of the ovum and the raucous secretions of
the organ. But a real suppurative irritation is soon established, the
product of which, analogous in some sort to the non-contagious dis-
charges from the urethra, by mixing with the serosity and mucus
furnished by the womb, constitute the white lochia.

The lochia require only cleanliness; upon the access of the milk
fever they sometimes cease to flow, or at least sensibly diminish in
quantity; nevertheless it is not uncommon to see these two pheno-
mena proceeding together without interfering with each other.
When they stop either before or after the milk comes, it appears to
me to be generally useful to add, to the means employed to recall
them, the injection of emollient or slightly detergent fluids into the
uterine cavity.

1248. The uterine colics or after-pains commence soon after
the labor is over, and generally cease upon the appearance of the
milk-fever, and rarely last longer than the serous lochia: they are
more frequent and sharper in proportion as tlie labor has been
more rapid and easy, and are sometimes strong enough to fatigue
the woman considerably; being produced by the efforts of the
womb to contract, it is quite natural that they should be stronger
and more frequent in women who have had several children, than
in those who are in their first child bed. In effect, the womb, too
rapidly emptied in the first named case, does not contract soon
enough to prevent the formation of clots in its cavity, is obliged to
contract for their expulsion as often as they are reproduced, and
each one of these contractions gives rise to a pain. In the second,
having reacted for a long time upon the ovum, it is too much irri-
tated at the close not to resume rapidly its natural size, and not permit
the blood to accumulate within its cavity, and then there will be no
clots, no contractions, and no after-pains ; thus the presence of
clots determines the contractions, and as was the case during the
labor the contractions occasion the after-pains. I ought, how-
ever, to remark, that these pains must also vary in respect to their
intensity, the constitution of the patient, and the circumstances;

MILK-FEVER. 589

being stronger, for example, in nervous and delicate women, when
the womb is already sore, and in a state approaching to inflamma-
tion, than in those who are in an opposite condition, though in fact
the contractions are similar in both cases. It is by attending to
these particulars that we are enabled without difficulty to explain
their great severity in some women where there is nothing to be ex-
pelled from the genital organs, and their mildness in others, where
they coincide with the escape of large coagula; and how it happens,
that, instead of diminishing after the second day, they, on the con-
trary, continue to augment in some cases until the third and fourth
day, &c.

It is important not to confound them with an incipient metritis or
peritonitis, which however is a pretty difficult matter where they
reach a certain extent of great severity; having too often avoided
making this distinction is the reason why authors differ so much
on the subject of puerperal peritonitis, and the treatment adapted to
it; as long as the after-pains are clearly intermittent, and during
their intervals the belly is not sore, while there is no fever and they
have not been ushered in with a chill, there is nothing to fear and
nothing to do; they are frequently followed by a pretty severely
painful sensation at the hypogastrium, acceleration of the pulse,
thirst, and heat of the skin, and notwithstanding, are not followed by
any serious complaints. But we must in such cases pay attention to
them, and not forget that they may be the first symptom of a, mortal
disease.

When moderate they may be trusted to the resources of the
economy, or we may give one or two cups of a weak infusion of
chamomile, which rarely fails to make them disappear in the course
of a day or two; otherwise, it is sometimes useful to prescribe a hip
bath, and emollient or slighdy narcotic injections; to exhibit seda-
tives or antispasmodics internally, or to bleed the patient once or
twice, either from a vein or by topical means, while at the same
time the hypogastrium is covered with cataplasms, and this accord-
ingly as the woman is weak, nervous, or plethoric; it may be ne-
cessary even to introduce one or two of the fingers towards tite os
uteri for the purpose of assisting in the expulsion of a clot that may
adhere too strongly; but in the great majority, these cases require
no assistance.

1249. The Mllk-fever generally appears on the third day, some-
times on the first or second, or not until the fourth, fifth or sixth day;
I have seen it not come on until the eighth, in a young woman at the
Hospital cle la Faculte: headache, without chills, heat and dryness
of the skin are its common precursors; the pulse which is at first

590 MANAGEMENT OF LYING-IN WOMEN.

small and hard is soon developed; the breasts grow hard, swelled,
and so painful in the course of a few hours, as to interfere with the
motions of the arms and chest; first a moisture, and then a sweat
succeed this stage; the pain in the head ceases; the fever abates in
the course of six, eight, ten, twelve or twenty-four hours, and, the
reaction which produces the milky secretion is completed; but the
breasts remain swelled and painful much beyond this period, espe-
pecially in women who do not give suck.

While the fever continues, no broths, nor potages, nor heating
drinks should be given. Should it be too high, an attempt to mo-
derate its violence should be made by means of a small bleeding.
But in general it requires only the hygieinic treatment pointed out
higher up. The coming of the milk is pretty often preceded with
the suspension, or at least a sensible diminution, of the lochial dis-
charges, which soon return to their natural course. Sometimes these
two phenomena see'm to have no influence upon each other, the
lochia do nQt appear again at all after the milk-fever is gone off.

For an account of lactation in general, the diet of the foetus, the
choice of a nurse, the disease of the breast and nipple; for the his-
tory of fistulas, whether recto-vaginal or vesico-vaginal, or other
serious lesions which are the effect or consequence of certain labo-
rious labors, I can only refer to the general treatises on Physiology,
Medicine, or Surgery that treat upon them; particularly those of MM.
Bicherand, Magendie, Adelon, Leger, Sabattier, Boyer, &c., and to
the excellent articles by M. Desormeaux in the Didionnaire de
Medecine. But there are certain accidents of a less redoubtable kind,
concerning which 1 cannot dispense with saying a few words in this
place.

1250. Complete or partial Inversion of the womb is recognised
by the reddish or livid tumor which projects into the vagina or vulva,
by the absence of the uterine globe above the pubis, and by the pains
and syncope experienced by the woman, &c.; although none but the
grossest ignorance could confound an inversion of the womb with a
polypus in that organ, yet men are sometimes seen, even at Paris, to
commit this mistake, even though they are clothed with the title of
physicians. Haste should be made to reduce the displaced organ.
For this purpose the woman should be so placed that her hips may
be higher than her breast; then the hand being furnished with a piece
of fine linen spread with cerate, the external tumor "should be com-
pressed gradually and without shocks,* and in a steady manner, and

* This is the direction given by almost all the authors. — It is not good to
compress the womb; such an action only excites the contractions or after-pains,

MANAGEMENT OF LYING-IN WOMEN. 591

at all points, pushing it up along the axis of the straits until it has
regained its natural situation.*

1251. The Descent of the womb, which is pretty often met with
in the early periods of a confinement, in women who have a very
large pelvis, relaxed tissues, a lacerated perineum, or in those who
make improper exertions, scarcely requires any thing after the reduc-
tion except rest and a horizontal posture; it is allowable only to add
some astringent or styptic lotions, the use of small rags moistened
with red wine, for example, in cases where there is no. irritation.
Pessaries cannot be made use of until a much later period.

1252. The Anteflexion and Retroflexion, that is to say, the state
in which the womb bends like an elbow at right angles, so that its
fundus comes to rest upon the sacro- vertebral angle or behind the
pubis, a disease very well described by M. Ameline in his disserta-
tion, and an instance of which in the dead body was shown to me
by M. Comte, would be recognised by the same symptoms as the
anteversion and retroversion, and would require nearly the same
kind of treatment. *

1253. Lacerations of the perineum generally get well of them-
selves, with the assistance of the hip bath, by avoiding all motion,
and by obliging the woman to keep on her side, so that the pus aiid
lochia may not stagnate in the wound. They generally cicatrise
more or less completely from the anus towards the commissure of
the pudendum. The perineum may be perforated through and
through, and the cure not be rendered any more difficult, provided
that the anal and vulvar edges remain unhurt. I saw a case of this
perforation produced by the passage of a large child, which was en-
tirely cured by the eighteenth day, and did not hinder the woman at
all in her subsequent labors'. In some cases, however, it is neces-
sary to cut the bridles, apply the caustic, and take up certain points
with the needle, &c., but then the disease returns under the ordinary
surgery, and cannot be regarded as one of the simple consequences
of child birth. I shall say the same of lacerations of the vagina,

which may as well take place in an inverted womb as in one not inverted — the
womb ought not to be handled; by watching it carefully, at the moment when
most free from contraction, the fundus may be pressed with the point of a finger,
and indented like the bottom of a bottle; when that much is effected, the com-
plete reposition is sure, if only a continual pressure be made: the fundus will be
pushed up again through the os uteri and vagina, until the hand is found to be
high up in the belly, and contained within the cavity of the reposited organ;
— M.

* For a very good treatise on inversion of the uterus in general, see a thesis
maintained, Dec. 1, 1828, at the Faculte de Paris, by M. Ferrance-Demissois.

592 MANAGEMENT OF LYING-IN WOMEN.

of the cervix, body, and fundus of the womb; of rupture of the
psoas muscles, of the rectus muscles and those of the sternum, ob-
served at the Paris Maternite by Mesdames Boivin, Lachapelle, and
by M. Comte. Upon this subject the excellent memoirs by Madame
Lachapelle may be consulted, and in this book the article on extra-
uterine pregnancy. I have not treated of descents of the ante-ver-
sion and retro version as diseases, because they are observed solely
in women who are pregnant; lastly, in treating of hemorrhage, I
said nothing relative to transfusion of the blood, practised anew in
these latter times by Messrs. Blundell, Doubleday, Waller, Brigham,
Boyle, Brown, &c., because it is not yet proved that an operation so
dangerous ought really to be adopted by wise and circumspect prac-
titioners.

1254. Infiltration of the external genitals may go to the extent
of closing the passage of the vulva, and, consequently, of prevent-
ing the discharge of the lochia. If the swelling be purely lympha-
tic, and not painful, it will disappear upon making a few pretty deep
punctures upon the internal surface of the pudendum. Where there
is sensibility and any signs of inflammation, recourse should be had
to baths, embrocations, emollient cataplasms, and even to leeches, if
the case require it.

1255. The Thrombus of the labia pudendi, which was noticed by
Levret, forgotten by most of the modern writers, pretty well describ-
ed by Dr. Dewees, and of which I have seen seven or eight cases,
may appear at the moment the head is engaging in or clearing the
inferior strait, and even in the first two days after the birth of the
child, as in the case lately published by M. Wintringer. The tu-
mor sometimes involves both of the labia; more frequently only
one is affected. Although in some cases it is from the size of a nut
to that of a hen's egg, it is also found to assume in other cases
much greater dimensions; it rarely disappears by resolution, and
some women suffer from it horribly. Leeches and poultices are
generally insufficient for its cure, but 1 have always found it to be
promptly dissipated, and without any bad consequence, after a large
and deep incision.

THE END.

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