Full text of "King's Eclectic obstetrics"

'f-fCfAfT; 'GEY-jIff;

ECLECTIC OBSTETRICS

Rewritten, Revised and Enlarged

ROBERT C. WINTERMUTE, M. D.

I'UOFKSSOK OF OMSTKTKIC'S AM) DISEASES OF WOMEN AND CHILDREN* IN THE ECLECTIC
MEDICAL INSTITUTE OK CINCINNATI.

NINTH EDITION.

CINCINNATI :

THE OHIO VALLEY COMPANY.
1892.

Entered according to Act of Congress, in the year 1855, by

MOORE, WILSTACH, KEYS & CO.,
In the Clerk's office of the District Court for the Southern District of Ohio.

Entered according to Act of Congress, in the year 1S6G, by

MOORE, WILSTACH & BALDWIN,
In the Clerk's office of the District Court for the Southern District of Ohio.

Entered according to Act of Congress, in the year 1875, by

WILSTACH, BALDWIN & CO.,
In the office of the Librarian of Congress at Washington.

ROBERT C. WINTEBMUTE, M. D.,

1 33 W. Seventh Street, Cincinnati, 0. :

DEAR SIR When my feeble health, two years ago, compelled me
to resign my position as Professor of Obstetrics, I realized that I would
never have the strength to revise my book on Obstetrics. I had
felt the necessity for such a revision for several years, and the ques-
tion arose who would do it? Fortunately, you consented to under-
take the work, although already burdened by the duties of your
Professorship of Obstetrics and Diseases of Women and Children,
in my place, at the Eclectic Medical Institute of Cincinnati. Your
task for more than a year has been a difficult one, but your faithful
work has at last been completed, and I offer you my congratulations
on your success. I now feel that my confidence in you was well
placed, and that the new Obstetrics will be all that is required by
practitioners and students, especially in regard to the use of specific
remedies and therapeutics. . Yours, very truly,

XOUTH BEND, O., May 27, 1892.

3 7

PREFACE TO NINTH EDITION,

Ox being called to the chair of Obstetrics in the Eclectic Medical
Institute two years ago, my attention was at once called to the fact
that a new and revised edition of the text-book of the department was
badly needed. The broken health and advanced age of the author
rendered it impossible for him to undertake the work; it thus
devolved upon me to make the revision. Arrangements being com-
pleted with Dr. King, I at once set about the task of overhauling the
old and building up the new. The great advance that has been made
in the art and science of obstetrics during the past fourteen years (the
time since the last revision by Prof. King) has rendered necessary a
thorough and systematic rewriting of the entire work, in order to
bring it up to the present state of knowledge on the subject. I
assumed the responsibility of the work with a very keen sense of the
many difficulties and great labor involved in the undertaking.
Numerous and extensive additions have been made to every chapter
of the work. Especial attention is called to the treatment of the dis-
eases of pregnancy ; specific medication being substituted for the old
style of prescribing. Where reference is made to remedial agents, the
specific tinctures peculiar to the eclectic school of medicine are
understood.

For valuable suggestions from Prof. J. M. Scudder, and the late
Prof. HoAve, also cuts Xos. 50, 55, 76, and 81, kindly loaned me by the
latter, I must acknowledge my obligations.

This work is here submitted to the profession in the hope that, as
now issued, it may meet the requirements both of a text-book for the
student and a work of reference for the busy practitioner, as I have
endeavored to present a clear and practical description of the subject
in question.

R. C. WINTERMUTE, M.D.

CINCINNATI, July 1,

-73'

PREFACE TO THIRD EDITION,

IN presenting this new edition of the "American Eclectic Obstetrics "
to the profession, it may be proper to state that the work has been
subjected to a thorough revision. For the purpose of presenting a
more regular and systematic study of the subjects treated upon, some
modifications have been made in the arrangement of the First and
Second Parts of the previous edition, which it is believed will meet
with the approval of the reader.

Owing to the publication of the American Dispensatory, and various
other Eclectic works on Materia Medica and Practice, in which the
therapeutical agents pertaining to the department of Obstetrics are
fully and accurately described, it has been deemed advisable to omit
Part Six of preceding editions; this exclusion has permitted consid-
erable additions to the work without an unnecessary increase in the
number of its pages. Some idea of the additions made may be formed,
when it is observed that at least seventy pages of -the last edition have
been entirely excluded, the greater portion of which is, in the present
work (and independent of revisions and other additions), occupied with
new and valuable matter (about sixty-three pages). The recent prog-
ress in the Obstetrical Department of Medical Science has rendered
these additions very necessary.

It has been the Author's endeavor to render the work satisfactory,
thorough, and essentially practical for both practitioners and students,
and he confidently believes that it will be found at least approximat-
ing these qualities, and in no way secondary to its predecessors.

For the many favors and kindnesses received from Eclectics, and
from the medical profession generally, the author avails himself of
this opportunity to express his assurances of great regard and pro-
found gratitude.

JOHN KING.

CONTENTS.

PAGE

CHAPTER I. Woman 11

CHAPTER II. The Pelvis: "True" and "False" Difference between Male

and Female Pelvis : Pelvic Articulations, etc 16

CHAPTER III. Syniphyses and Ligaments of the Pelvis 23

CHAPTER IV. Straits and Cavities of the Pelvis The Pelvis as a whole 29

CHAPTER V. Deformities of the Pelvis 35

CHAPTER VI. Indications of Malconformation of the Pelvis 47

CHAPTER VII. The Fetus, its Divisions and Dimensions 54

CHAPTER VIII. The Female Organs of Generation 61

CHAPTER IX. The Internal Organs of Generation - 68

CHAPTER X. Of the Uterine Appendages -The Ligaments, the Fallopian

Tubes, and the Ovaries 81

CHAPTER XL Of the Corpus Luteum 88

CHAPTER XII. Theories of Impregnation 94

CHAPTER XIII. Menstruation Ovulation Conception 100

( 'HAPTER XIV. Development of the Human Ovum 109

CHAPTER XV. Of the Fetus and its Development 128

CHAPTER XVI. Position, Nutrition, Respiration, Circulation, Dimensions,

and Death of the Fetus Superfetation 142

CHAPTEU XVII. Changes in the Condition of the Uterus during Pregnancy. 156

CHAPTER XVIII. Of Pregnancy 171

CHAPTER XIX. Compound and Mixed Pregnancy. 178

CHAPTER XX. Signs of Pregnancy 190

('HAPTER XXI. Diseases of the Pregnant Female 209

( 'HAPTER XXII. Diseases of the Pregnant Female Continued 234

CHAPTER XXIII. Hemorrhage and Abortion 249

CHAPTER XXIV. Labor 271

CHAPTER XXV. Management of Natural Labor 285

CHAPTER XXVI. Attentions Required Subsequent to Delivery, during the

Puerperal Period 318

CHAPTER XXVII. Presentations and Positions 332

CHAPTER XXVIII. Mechanism of Labor 340

CHAPTER XXIX. On Difficult Labor First Stage 358

CHAPTER XXX. Difficult Labor Second Stage :'>77

CHAPTER XXXI. On Difficult Labor, from Tumors, Pelvic Deformities, etc.. 390
CHAPTER XXXII. On Difficult Labor from Faulty Conditions of the Child,

Mai-position of the Head, etc 407

CHAPTER XXXIII. On Preternatural Labor Pelvic Presentations 429

CHAPTER XXXIV. Of Preternatural Labor Shoulder Presentations 446

CHAPTER XXXV. On Preternatural Labor Transverse Presentations Pro-
lapsus of the Umbilical Cord Plurality of Children Monsters -168

10 CONTENTS.

PAGE

CHAPTER XXXVI. Complicated Labor Uterine Hemorrhage from Placenta

Prtcvia Puerperal Hemorrhage Placental Presentation 484

CHAPTER XX XVII. Complicated Labor Treatment of Placenta Prsevia

Syncope from Hemorrhage 491

CHAPTER XXXVIII. Complicated Labor Accidental Hemorrhage Con-
cealed Hemorrhage Hemorrhage After Placental Delivery Effects of
Loss of Blood . 502

CHAPTER XXXIX. Complicated Labor Retention of the Placenta Hour-
glass Contraction Morbid Adhesion of the Placenta Putrefactive
Absorption 522

CHAPTER XL. Complicated Labor Inversion of the Uterus Rupture of the.
Uterus Rupture of the Vagina Rupture of the Bladder Syncope
Thrombus 537

CHAPTER XLI. Complicated Labor Puerperal Convulsions Eclampsia

Hysterical Convulsions Apoplexy Epilepsy 552

CHAPTER XLII. Turning, or Version Cephalic Version Podalic Version
The Fillet The Vectis, Lever, or Tractor Blunt Hook Placental
Forceps 573

CHAPTER XLIII. The Forceps Davis' Forceps Hodge's Forceps Cases in
which to be used Cases in which not to be used Period for using
them 586

CHAPTER XLIV. Rules for Applying the Foi'ceps Mode of Applying the

Forceps in the Various Positions of the Head 602

CHAPTER XLV. Mode of Applying the Forceps at the Brim In Face Pres-
entations, and in Pelvic Presentations 615

CHAPTER XLVI. Craniotomy Perforator Crotchet Cesarean Operation

Symphyseotomy (i22

CHAPTER XLVII. Induction of Premature Labor (540

CHAPTER XLVIII. Puerperal Fever Peritonitis Puerperal Septicemia
Inflammation of the Uterine Appendages Metritis Uterine Phlebitis
Inflammation of the Uterine Absorbents Treatment of Puerperal
Fever 654

CHAPTER XLIX. Phlegmasia Dolens Crural Phlebitis Treatment of Phleg-

masia Dolens. 680

CHAPTER L. Phrenitis Puerperal Mania Treatment of Puerperal Mania

Intestinal Irritation Acute Tympanitis Diarrhea 691

CHAPTER LI. Inflammation of the Breasts Mammary Abscess Ephemeral

Fever Weed Miliary Fever Sore Mouth of Nursing Women 700

CHAPTER LII. Cyanosis Retention of Urine Red Gum Jaundice Infan-
tile Ophthalmia Flatulent Colic Constipation Umbilical Hernia
Excoriation of the Navel Hemorrhage from the Cord Hemorrhage
from the Navel Nsevus Materni Tongue-tied Hydrocele Swelling
of the Breasts Hare-lip 713

CHAPTER LIII. Aphthse, Thrush Trismus Nascentium Porrigo Larvalis,

Milk Scab . 722

KING'S

ECLECTIC OBSTETRICS.

THE ART OF MIDWIFERY, AND SCIENCE OF OBSTETRICS.

CHAPTER I.

WOMAN.

THE professional delivery of women has been an art ever since the
human race had a history ever since the race began and improve-
ment in methods took place as observation extended and experience
developed knowledge. During periods of savagery and barbarism
there may have been little progress in the rudest of arts, when knowl-
edge was traditional, and nothing was recorded for the instruction
of coming generations. The wives of the builders of the pyramids
and the bondwomen whom Moses led out of Egypt were delivered
with some degree of skill with the advantages to be derived from
experience ; yet enlightened obstetricy was evolved only as progress
developed in other branches of learning. Substantial progress is of
slow growth. Great discoveries do not spring from the brain of any-
body as fabled Minerva came from the head of Jove. The art of
delivering a parturient woman is merely a professional matter a de-
gree of tact acquired by the ordinary midwife, and not much improved
upon ; but the science of obstetrics pertains to the evolution of the
human race, and bears upon the origin and descent of mankind.
11

12 KIX(i's KCLKCTIC OHSTKTUICS.

The science <>f obstetriey takes j)l]ilosoj)hical cognizance of differ-
entiation in sex ; woman is to be studied in all her peculiar physical,
mental, moral, and sentimental peculiarities, and as a creature quite
at variance with man her companion and admirer. Woman is' not
originally xi<! </ntcrix, but spiritually peculiar. She is moved by sen-
timents her partner in life never feels; she is swayed by impulses a
man never experiences.

A French writer, Colombat de L'Isere, says of woman : " Feeble
and sensitive at birth, and destined by nature to give us existence;
and by means of her tender and watchful care to preserve us after-
ward, woman, the most faithful companion of man, may be regarded
as the very complement of the benefits bestowed upon us by the
Divine Being as an object fitted to excite our highest interest, and
as presenting to the philosopher, as well as to the physician, a vast
field for contemplation.

" What subject, indeed, is more worthy of our attentive meditation
than the series of changes physical, moral, and physiological that
accompany every stage of woman's existence. Through a long suc-
cession of modifications and revolutions, she discloses all the phases
of her constitution. In infancy she differs slightly from the male in
whose pleasures and amusements she participates, as well as in his
dispositions and tastes, his inconstancy and vivacity. At that early
period ignorant of her own sex, ignorant, so to speak, of her own
nature the blush of modesty does not mantle on her cheek : and her
eyes, which reveal no passions, seem to seek only what has reference
to her real wants.

"Although at this early epoch her body is but a sketch of the
forms it^is destined to assume at a later period, she always retains,
even after her entire development, some touch of the softness and
delicacy peculiar to her childhood, and does not depart so widely as
her playmate from the idea of her original constitution.

" The reproductive faculty divides the life of the female into three
very distinct periods or stages. In the first, this property has no ex-
istence: in the second, it is in full activity; and in the third, it has
become null again. The duration of the first, commonly decides that
of the two last periods; so as to establish the general rule that the old
age of woman comes earlier in proportion as her puberty has been
more precocious.

' The vital forces that regulate the organic system, and the organs
that constitute that system, gradually increase during the first period

WOMAN. 13

of life: they attain their perfect development; and diminish and be-
come extinct at the close of the third, whose term, like that of the
others, may be accelerated or retarded by different accidental causes and
circumstances, dependent on certain physical and moral conditions.

"Upon setting out in the career of life, the two sexes exhibit
.nearly the same physiognomical characters and the same delicacy of
organization. Their type and their character, as yet indeterminate, dif-
fer only by almost imperceptible modifications, and which it is not pos-
sible to trace out in full detail. Subject to the same functions and
wants, their isolated and individual existence fails, as yet, to reveal
the sympathetic relations that are in the end destined to establish Be-
tween them a state of reciprocal dependence. Subjects of the same
kind of diseases, they are principally liable to the convulsive affec-
tions, and especially to inflammation of the brain, because the head,
which in infancy has a proportional size greater than in any other age,
is in them a vital center, towards which almost all the efforts of the
organisms are directed.

" The shades of difference in the sexes soon assume a more decided
tone, and their peculiar characteristics become so much the more
marked as the development of each individual is more perfect and
approaches more nearly to the period when by a sudden change nature
reveals the completion of those preparations she has been silently
making.

"The interval between the tenth year and the age of puberty is a
period of transition, a sort of passage from childhood to adolescence,
which appears to be the happiest era in the life of a female. Her ex-
treme nervous mobility prevents her being too deeply impressed by
the grave sentiments that might be fitted to interfere with her happi-
ness. As this stage is for young women the period of gentle pleasures
and of the most unrestrained gaiety, it follows that imagination ex-
hibits every object under the most attractive colors, and that the exist-
ence of young females is agreeably varied by a piquant freedom of
action and a great mobility of tastes and affection. Exempt, at this
age, from cares and troubles, they sing, they weep and laugh at the
same moment; and, as their joys, so their pleasures and their griefs,
as well as all their impressions, are ephemeral; they proceed along a
flowery path up to the age when nature calls on them for the tribute
which they owe to the species.

"The young girl who, until now, was an equivocal non-sexual
creature, becomes a woman in her countenance and in all the parts of

14 KING'S KcLKtTir OBSTETRICS.

her body: in the elegance of her stature and beauty of her form ; tin
delicacy of her features; in her constitution, in the sonorous and me-
lodious tones of her voice, in her sensibility and affections, in her char-
acter, her inclinations, her tastes, and even in her maladies. Very
soon all the tracts of resemblance between the two sexes are found to
be effaced. The bud newly expanded blossoms among the flowers,
and tli is brilliant metamorphosis is signalized by the rosy tints of the
cheeks and lips, and the perfect development which discloses the*
arrival of the age of puberty.

"This important period, this first moment of triumph, in which
nature seems to renew herself, is announced by a sentiment of neces-
sity to multiply, within the principle of life and by various striking
and admirable phenomena which put an end to the social inertia, in
which the young girl has lived from the period of her birth. The
sexual system soon becomes a centre of fluxion; nature makes great
efforts to establish the periodical discharge, and the whole machine,
in its inmost recesses, experiences a succession, a violent commotion,
a general movement. The new energy of the womb imparts a pow-
erful impulse to the entire system of organs: their functions become
more active ; the body grows rapidly ; the various portions of the figure
become more expressed and bring out those graceful contours, that be-
long to the tender sex alone. At the same time other important changes
take place: the pelvis and the sexual organs, which were in a. merely
rudimental condition, now acquire their full proportions; the throat
rises and becomes more sensitive ; the breasts become rounded and full,
while they establish their correspondence of sympathy with the womb.
The mons veneris comes into complete relief, and clothes itself with a
thick down, which, like a veil covering the organs of modesty, seems
to announce that they are destined soon to become fitted to act the
important part assigned to them by the law of nature. The meshes
of the cellular tissue, becoming rapidly filled under the influence of
the uterine irradiation, soon impart to the surface of the body a volup-
tuous embonpoint, which lends the highest splendor to the attractive
freshness and beauty of youth.

" The physiognomy of the young woman has now acquired a new
expression: her gestures bear the stamp of her feelings; her language
has become more touching and pathetic; her eyes, full of life but
languishing, announce a mixture of desires and fears, of modesty
and love in fine, every thing conspires to excite, to caress, and to
incite.

WOMAN. 15

"Her tastes, her enjoyments, and her inclinations are likewise
modified; her most pressing want is to experience frivolous emotions;
she is passionately given to the dance, to show and to company; the
curiosity so natural to her sex acquires new force and activity; she
devours books of romance, or, niore than ever fervent in devotion, is
excited by the expansive passions, and particularly by religious piety,
which is to her a sort of love.

" At this brilliant period of life, her moral, which depends upon
her physical condition, undergoes great mutations. The young girl
becomes more tender-hearted, niore sensitive, more compassionate, and
appears to attach herself to every thing about her. The new sensa-
tions arising within her soul make her timid in approaching the com-
panions of her childhood; a strange trouble, a sort of restlessness and
agitation before unknown, are the heralds of a power whose existence
she does not even suspect.

"The action of the new forms of vitality established within the
sexual organs augments more and more, and reacts with energy upon
the whole system. Under the sympathetic irradiations of the uterus
the general sensibility becomes changed and even excited in a peculiar
manner. A new sentiment soon gives rise to desires which, as yet,
have no definite object, and to vague emotions, of an instinct that
seeks some object it knows not what. This rising want produces
the impression of a touching melancholy, a charming bashfulness,
whose principle is founded in ingenious love presaging new disposi-
tions, and announcing that the inclinations and habits of childhood
are exchanged for other sentiments. The young virgin becomes timid,
reserved, abstract, and dreaming. She sighs less for pleasure than for
happiness; the necessity of loving makes her seek solitude; and this
new want, that troubles her heart and engages it wholly, becomes, if
it remains unsatisfied, a source of multiplied disorders and derange-
ments."

Thus I have ventured to introduce the career of woman the ob-
jective feature of the art and science of midwifery. The next step
will be to depict the anatomical and physilogical peculiarities of such
parts of the female organism as are essential to reproduction. It is
said, that the boy is the father of the man : and with more propriety it
might be declared that the girl is the mother of the woman. The doll
is the ideal representative of the race.

KING'S ECLECTIC OBSTETRICS.

OH A I'TKR II.

THE PELVIS: "TRUE" AND " FALSE" DIFFERENCE BETWEEN MALE
AND FEMALE PELVIS: PELVIC ARTICULATIONS, ETC.

THE PELVIS, so named from its fancied resemblance to an an-
cient basin, is a bony ring-like structure, of conical shape, with the
base directed upward; situated between the last lumbar vertebra and
the lower extremities, receiving the weight of the body above, trans-
mits it to the lower limbs. It is formed by the union of four bones
viz: the two Ossa Innominate, the Sacrum, and the Coccyx. It is
divisible into two parts or cavities, an upper and a lower, the dividing
line being the liiica ilio pcctinea. The upper portion is the larger, or
False Pelvis, formed solely by the alae ilia. The lower is the smaller,
or True Pelvis, formed by the sacrum, ilium, pubis, and ischium.

FIG. 2.

ADULT MALE PELVIS.

The SACRUM is situated on the superior-posterior part of the
pelvis, immediately below the last lumbar vertebra, with which its
superior surface articulates, above the os coccyx, and between the two
ossa innominata, to each of which it is united by means of ligaments.
It is a large bone, pyramidal or triangular in shape, the base being

THE PELVIS.

upward ; its anterior face is smooth and concave, and its posterior
irregular and convex. The concavity of its interior face is from above
downward, and its depth, in a well-formed pelvis, is such, that a per-
pendicular let fall from a line, drawn from the apex to the base of the
bone, upon the deepest point of the concavity, will measure from nine
to twelve lines, or from three-quarters of an inch to an inch; this con-
cavity is termed the hollow of the sacrum; it may, however, vary very
much, and when too strait or too much curved, it presents an obstacle
to the easy passage of the child's head through the excavation.

FIG. 3.

A. The Sacrum.

B. The Os Coccyx.

C C. The Two Iliac Bones.
D D. The Two Pubic Bones.
E E. The Two Ischiatic Bones.
1 1. The Crest of the Ilium.

ADULT FEMALE PELVIS.

2 2.

The Anterior-superior Spinous processes
of the Ilia.

3 3. The Acetabula or Cotyloid Cavities.

4 4. The Tuberosities of the Ischia.

5 5. The Obturator Foramina.

6. The Promontory of the Sacrum.

During childhood, the os sacrum is composed of five distinct pieces,
termed false vertebrae, which become firmly consolidated at adult age,
and leave five surfaces nearly quadrilateral, and which are separated
from each other by four projecting transverse seams or ridges, at the
original points of separation. At the sides or lateral portions of these
seams, are a series of openings, termed foramina, usually four on each
side, which terminate outwardly in large grooves converging to each
other, and which are named the anterior sacral foramina and grooves^
2

18 KING'S ECLECTIC OBSTETRICS.

and which serves to lodge and transmit the sacral nerves coming from
the spinal canal. The nervous cords lying in these shallow grooves
are comparatively secure from injurious pressure during labor, yet it
is sometimes the case, that during the passage of the child's head, these
sacral nerves are exposed to much pressure, which, as in other instances
of compression upon a nerve, occasions a numbness, pain or severe
<-ramps in the parts to which they are distributed, as in the thigh, leg,
or foot. This usually ceases as soon as the pressure is relieved by the
expulsive progress of the head, but when the nerves have been severely
bruised or compressed, the unpleasant effects may remain for some time
after delivery.

External to these sacral foramina, and on the projecting cristae,
which separate the grooves, arise the asperities, which serve as points
of attachment to the fibers of the pyriform muscles.

The posterior surface of the sacrum is convex from above down-
ward, rough and unequal, presenting on the median line, four emi-
nences or spinous processes, which decrease in size as they descend;
on either side of these eminences, there are four openings or forimina,
smaller than those on the anterior surface, which are named the pos-
terior sacral foramina, and which transmit the posterior branches of
the sacral nerves. External to these foramina are a number of pro-
cesses, which serve as points of attachment to several muscles and
ligaments.

The lateral surfaces of the sacrum are rough, thick above, but
diminishing as they descend, and in the recent subject are covered
with cartilage, which unites them to the iliac bones. The superior
portion of each lateral surface, which articulates with the ilium, is
broad and irregular; and the inferior edges, are thin and nearly sharp,
and give attachments to the greater and lesser sacro-sciatic ligaments.

The base of the sacrum is about two and a half inches thick, and
about four inches in breadth and articulates with the last lumbar ver-
tebra in such a manner, as to form a projection at the superior strait,
called the promontory of the sacrum or the sacro^vertebral angle. At
the posterior surface of the base, is a triangular aperture, which is the
commencement of a canal, traversing the whole extent of the sacrum,
which gradually diminishes in size as it descends, and in which the
spinal cord is continued. The apox of the sacrum is small, having an
oval surface which articulates with the base of the coccyx.

The texture of the sacrum is spongy and cellular, and covered ex-
ternally by a thin lamina of compact tissue ; its length is about four

THE PELVIS. 19

and a half inches. The union of the sacrum with the ilia is so
arranged as to give great firmness and security to its position, so that
it may sustain without injury, any Weight from within outward, and
from above downward ; the sacrum entering the ilia like a wedge,
having its superior portion broader than its inferior, and its anterior
point of union broader than its posterior.

The OS COCCYX or cuckoo bone, so named from its resemblance
to the beak of the cuckoo, is the caudal extremity of the spinal column.
It is a small, single, triangular bone, the base of which points upward,
and unites with the apex of the sacrum by means of an oval articular
surface, which, it is said, admits of a backward motion of the coccyx,
when pressed by the fetal head, to the extent of half an inch. Yet
the firmness by which the coccyx is fastened to the ischia, through
means of the saero-sciatic ligaments, is unfavorable to any such mo-
bility, except by severe and continued pressure. The coccyx is flat-
tened, curved from behind forward, and bears some resemblance to the
sacrum, though it differs from it in being much smaller, about one and
a half inches in length, and in having no spinal canal. Its anterior
surface is slightly concave and rough, and supports the lower extremity
of the rectum ; its posterior surface is convex and unequal, is separated
from the skin only by the posterior sacro-coccygeal ligament, and has
inserted into it some of the fibers of the gluteeus magnus muscle. Its
lateral edges are rough, giving attachment to the small sciatic liga-
ments and the ischio-coccygeus muscle. Its apex, generally project-
ing in front, gives attachment to the fibers of the external sphincter
ani muscle. In childhood the coccyx is formed of three or more bony
pieces, but which become consolidated in adult age. The internal
structure of this bone is cellular, and covered externally by a very
delicate lamina of compact texture. It is called by the various names
of buckle, knuckle, or whistle bone, crupper bone, etc.

The OSSA INXOMINATA, or nameless bones, and sometimes
termed the haunch bones, are two in number; they are the largest and
most irregular of the pelvic bones, are of a quadrilateral form, con-
tracted in their central portions, and form the lateral, anterior, and in-
ferior portions of the pelvis. Each one of these bones consists, in
early childhood, of three distinct pieces, but which become firmly con-
solidated in the adult. These are called the os ilium, the os ischium,
and the os pubis, whose union takes place in the acetabulum or cotyloid

20 KING'S ECLECTIC OBSTETRICS.

cavity; the dividing lines of these three bones meet nearly in the
center of the aectabulum, giving the upper and outer two-fifths to the
ilium, anteriorly one-fifth to the pubis, and the remaining two-fifths
to the ischium ; these several bones entering into the; formation of the
acetabulum. For purposes of description, and as a matter of more
easy reference, the above division is preserved by anatomists.

The OS ILIUM, hip or coxal bone (one on each side of the sacrum,
and which form the upper and lateral portions of the pelvis), is the
largest bone of the os innominatum, is flat, broad, and nearly triangular
in shape. The base or body of the bone is situated at the thick and
narrow part which forms the upper portion of the acetabulum, and the
large expansion or wing which passes from it, upward and outward, is
termed the ala, and which aids in forming the cavity of the false pelvis.
The external or femoral surface of the ilium is convex, and is called
the dorsum il'd or gluteal region, having the three glutei muscles lying
upon it ; and presents below, in its inferior and outer part, a cavity
for the head of the femur, called the acetabulum or cotyloid cavity.

The internal or abdominal portion, called the ventor or costa presents
at the upper part a broad, smooth, concave surface, termed the internal
iliac fossa, on which the internal iliac muscle is situated, and which
likewise supports the large intestine; in one of these fossae, the child's
head is placed during the operation of turning. Below, is a prominent
ridge or curved line, running from behind forward, that is, from the
superior part of the sacro-iliac junction to the top of the pubis, forming
part of the lined ilio-pectinea, or ttio-pubic line which defines the
superior strait. The excavation above this ridge, which is also named
the brim of the pelvis, is termed the false, upper, or superior basin or
pelvis, while the cavity below is termed the true, lesser, or lower basin
or pelvis, or the pelvic cavity.

The superior or upper convex edge of each wing, is called the crest,
or crista of the ilium, and to which the principal muscles of the ab-
domen that are called into action during labor are attached, as the in-
ternal and external oblique, and the transversalis ; this crest is rough
and thick, for the insertion of muscles, is shaped like the letter/, being
thicker in front and behind than in the middle, and terminates in
front, in an anterior-superior spinous process, from which some of the
muscles of the abdomen and thigh arise, and into which others are also
inserted and behind, in a posterior-superior spinous process, under-
neath each of which processes is a semi-circular notch, terminating

THE PELVIS. 21

inferiorly in an anterior and & posterior-inferior spinous process ; all of
which processes serve as points of origin and insertion of muscles and
ligaments. The surface which articulates with the sacrum is rough
and irregular. Immediately below the posterior-inferior spinous pro-
cess is an arched sinuosity, forming at the union of the ilium and sacrum
the great sciatic notch, which is two inches in depth, and terminates
inferiorly, by an acute and sharp spinous process called the spine of
the ischium; which points backward and slightly inward.

The OS ISCHIUM, os sedentarium, or seat bone, occupies the
lower part of the pelvis ; its base or body forms the inferior portion
of the cotyloid cavity, and is very thick and strong. The internal
surface of this bone is smooth and slightly concave, and is called the
plane of the ischium; it is nearly an equilateral triangle, and is three
and a half inches in length. The planes of the two opposite ischia
incline toward each other, forward and downward, and which conver-
gence exerts an influence on the fetal head during labor, repelling or
deflecting the vertex toward the pubic arch, as the head approaches
the outlet of the pelvis.

The spine of the ischium, proceeding from the posterior portion of
the os ischium, furnishes a place of attachment for the lesser sacro-
ischiatic or sacro-sciatic ligament; beneath this process is a concavity
or no-tch, named the lesser ischiatic, or sciatic notch in which the tendon
of the obturator interims plays. Below this, is the inferior or lower
portion of the ischium, or that part upon which the body rests when
in a sitting posture ; it is rough, thick, and strong, and is termed the
tuberosity of the ischium; the great sacro-sciatic ligament arises on the
inside of this tuberosity, and its outside, inside, and central surfaces
give origin to various muscles.

Passing obliquely from without inward, and from below upward,
from the tuberosity of the ischium, is a flat process of bone called the
ramus of the ischium, which unites with the descending branch or
ramus of the pubis, and assists in forming the pubic arch. In the
female pelvis, the anterior edge of this ramus is beveled or turned
outward, thus affording more space for the passage of the fetal head
under the pubic arch. The opening in the anterior part of the pelvis,
formed by the ischium and os pubis, is called the thyroid, sub-pubic,
or obturator foramen, through which pass the obturator vessels and
nerves, and to its inner side is attached the adductors and the obturator
externus. This foramen is rounded in man and triangular in woman.

22 KINt.'s ECLECTIC OBSTETRICS.

The OS PUBIS, otherwise variously called the .shear bone, the
cross bone, the bar bone, or pecten, is situated at the inner and an-
terior part of the os innominatum, and is joined to its fellow of the
opposite side, by a union or articulation termed the symphysis pubi*.
It may be divided into, the body, a horizontal, and a descending
ram us or branch. The body, or base, of each os pubis is placed trans-
versely before the anterior part of the ilium ; and from the side of the
body proceeds the horizontal ramus, going outward to meet the ilium.
The superior face of the os pubis is flat, and upon its outer and an-
terior portion is its spiuous process, which gives attachment to Pou-
part's ligament, and from this process two eminences proceed, one pass-
ing outward to be lost in the acetabulum ; the other, running along the
inner margin of the horizontal ramus, is called the crest of the pubis,
or crista pubis. This ridge is sharp and elevated, and forms the an-
terior third of the linea ilio-pectineal eminence. The descending
ramus of the pubis passes downward to unite \yith the ascending ramus
of the ischium. As with the rami of the ischia, the anterior edges of
the pubic rami are beveled or turned outward, affording a sufficiently
large and free opening for the fetal head to pass. The descending
ramus is connected with its fellow of the opposite side, toward their
origin, by a ligamentous substance, called the triangular ligament,
which is a part of the interpubic ligament, binding the two tubes to-
gether, and rendering the arch of the pubis broader or lower, and also
stronger. The arch of the pubis is formed on the anterior and inferior
part of the pelvis, by the union of the two pubic rami ; it is much
wider in the female than in the male. .

The anterior face of the body of the os pubis is concave and rough,
for the origin of the adductor muscles of the thigh ; its posterior sur-
face is nearly flat and smooth, but contributing a little to favor the
general concavity of the pelvis. The largest or thickest portion of the
pubic bone is that employed in the formation of the acetabulum; the
next thickest portion is at the symphysis pubis, from which it becomes
gradually thinner as it extends toward the obturator foramen.

It will be seen that the ilium forms no portion of the inferior strait,,
but enters largely into the superior also that the ischium forms no
portion of the superior strait, but only of the inferior while the
pubic bones form a large portion of both straits. Hence a deformity
of the ilium would affect only the brim, or the false pelvis ; a deformity
of the ischium would implicate only the outlet; but a distorted pubes
would necessarily involve each of the straits.

SYMYHYSES AND LIGAMENTS OF THE PELVIS. 23

CHAPTER III.

SYMPHYSES AND LIGAMENTS OF THE PELVIS. '

THE BONES of the PELVIS are united together in such a man-
ner as to give to it great strength, the articulations being effected by
means of ligaments and the interposition of cartilage giving support
to the trunk and favoring the movements of the lower extremities.
The joints to be considered which have received the name of Sym-
physes: each symphysis being designated according to the bones which
form it are, the symphysis pubis, the two sacro-iliac symphyses, the
sacro-coccygeal symphysis, and the lumbo-sacral or sacro-vertebral
symphysis. They all belong to the class of joints termed amphiar-
throdial.

The SYMPHYSIS PUBIS, or pubic articulation, is formed by the
junction of the oval articular surfaces between the bodies of the
ossa-pubis. A thick layer of tough fibro-cartilage is firmly united to
the articulating surface of each pubic bone; this passes across from
one bone to the other, and is so strong as to admit rather of the dis-
ruption of the bone than of its own tissue. At the center of the sym-
physis, and toward the posterior third of the fibro-cartilage, are two
smooth, polished, oblong articular surfaces, covered by a cartilage,
and lined by a synovial membrane, which arrangement is difficult to
detect in man, or even in woman, except when she has died shortly
previous to, or soon after, parturition.

Some authorities doubt the existence of a synovial membrane in
the pubic joint. The ligaments which strengthen the pubic articula-
tion are four in number: 1, the anterior pubic ligament, lying on the
anterior face of the symphysis pubis ; 2, the posterior pubic ligament,
which is an expansion of the periosteum; 3, the superior pubic liga-
ment, or supra-pubic ligament, which supports the superior edge of the
pubis, and effaces all its inequalities; and 4, the inferior, or sub-pubic
ligament, which is remarkably strong and thick, and of a triangular
form; by some, it is considered as a continuation of the inter-pubic
ligament. It adds greatly to the strength of the articulation, and its
inferior edge constitutes the crown of the pubic nrcJi.

24 KING'S ECLECTIC OBSTETRICS.

The SACRO-ILIAC SYMPHYSIS, or junction, is the articulation
formed by the corresponding rough surfaces of the sacrum and ilium,
and of which there are two one on the right, and the other on the left
superior lateral portion of the sacrum. Each of these articulating sur-
faces has a covering of cartilage, which is thicker on the sacrum than
on the ijia, and between which exists a thick, yellowish fluid, which
serves to lubricate the parts; and in children and pregnant women
there is said to be a synovial membrane in each joint.

The ligaments which aid in strengthening this articulation, are
four in number: 1. The posterior sacro-iliac ligament fills nearly the
whole of the deep excavation comprised between the sacrum and the
two posterior spinous iliac processes; their union constitutes a pyra-
midal ligament, capable of immense resistance. This ligament arises
from the posterior and inferior spinous processes of the ilium, and
from the margin of the sacrum and coccyx, and passes outward and
downward to be inserted into the tuberosity of the ischium; it is broad
at its origin, but narrow and thick at its insertion. 2. The anterior
sacro-iliac ligament, which extends transversely from the sacrum to the
ilium, is an expansion of the periosteum of the pelvis, which passes
in front of the articulation, and adheres to it but feebly. 3. The
superior sacro-iliac ligament, which passes transversely from the base
of the sacrum to the ilium, is very thick and strong. 4. The infe-
rior sacro-iliac ligament arises from the posterior-superior spinous
process of the ilium ; its superior fibers being inserted below the third
sacral foramen, while the lower portion is inserted anteriorly into the
tubercle of the extremity of the edge of the sacrum, and posteriorly to
the great sacro-sciatic ligament.

The foregoing articulations are still further strengthened by the
following ligaments, which pass between the sacrum and ischium, and
which assist in completing the parieties of the pelvic cavity viz. : 1.
The posterior, or greater sacro-sciatic ligament, which arises from the
internal lip of the tuberosity of the ischium, and from its ascending
ramns; it is situated obliquely in the posterior-inferior part of the
pelvis, is contracted in its center and expanded at its extremities, and
passes upward and backward to be inserted into the margin of the
coccyx and sacrum, and into the posterior-inferior spinous process of
the ilium. 2. The anterior, or lesser sacro-sciatic ligament, is placed in
front of the greater sacro-sciatic ligament, which it crosses; it arises
from the free margin of the sacrum and from all the bones of the
coccyx, and is inserted into the summit of the spine of the ischium.

SYMPHYSES AND LIGAMENTS OF THE PELVIS. 25

These two ligaments convert the great sciatic notch into two openings
or foramina; the upper foramen is the larger, irregularly oval, and
transmits the pyriformis muscle, the great sciatic nerve, gluteal, ischi-
atic and internal pudic vessels and nerves, while the lower foramen is
of a long triangular shape, and gives passage to the internal obturator
muscle and internal pudic vessels and nerves.

The obturator, or sub-pubic ligament, may likewise be mentioned ;
it is inserted by its internal semi-circumference to the posterior face
of the ascending ischiatic ram us, and by its external semi-circumfer-
ence to the outline of the obturator foramen. This ligament (doses
the obturator foramen, with the exception of an opening at its upper
part, through which pass the obturator vessels and nerves. The obtu-
rator muscles are attached to the two surfaces of this membrane. '

The SACRO-COCCYGEAL SYMPHYSIS is the articulation be-
tween the apex of the sacrum and the base of the coccyx; it is similar
to the joints between the bodies of the vertebrae. The union is effected
by two ligaments, and strengthened by an inter articular jibro-cartilage.
1. The anterior sacro-coccygeal ligament, which arises from the inferior
extremity of the sacrum, extends over the whole anterior face of the
coccyx, becoming blended with the periosteum. 2. The posterior sacro-
coccygeal ligament, which arises from the last sacral bone, is inserted
into the posterior surface of the second bone of the coccyx. This
ligament closes in and completes the lower and back part of the sacral
canal.

The Jnterarticular Fibro-cartilage, interposed between the articu-
lating surfaces of the sacrum and coccyx, differs from the ordinary
intervertebral cartilage in that it is thinner and firmer; it assists in
maintaining the connection between the bones, rendering mobility, it
is claimed by some authors, impossible. This joint is undoubtedly
subject to slight motion under certain circumstances, which will be
noticed further along in the work.

There are, in early life, coccygeal articulations which unite the
several pieces of the coccyx with each other; their consolidation takes
place more rapidly in males than in females.

LUMBO-SACRAL SYMPHYSIS is formed by the articulation of
the fifth lumbar vertebra with the upper surface of base of the sacrum.
The oblique position of the bones forming this articulation results
in a projection anteriorly, at the superior strait, called the promon-

26 KING'S ECLECTIC OBSTETRICS.

tory of 1li<- Min-tnii, or the ^aero-vertebral angle. The ligaments of this
articulation, in addition to those commonly existing between the ver-
tebne, are two in number: 1. The lumbo-aacral ligament passes from
the lower j)ortion of the transverse process of the last lumbar vertebra
to the lateral portion of the base of the sacrum. 2. The lumbo-iliac
ligament passes horizontally from the tip of the transverse process of
the last lumbar vertebra to the crest of the ilium, covering the sacro-
iliac articulation. The intervertebral disk also contributes to the for-
mation and straightening of this joint, which is one of the strongest
of the pelvis.

The ilio-femoral articulation, or the junction of the femoral bones
with the ilia, in the cotyloid cavity, is a pelvic articulation ; it bears
no relation to parturition, however, and only needs a passing reference.

MOVEMENTS AT THE PELVIC AKTICULATIONS.

It has long been a question whether the articulations of the pelvis
are possessed of any motion. An examination of the method by which
the bones are united with each other, and the solidity of their union,
would lead us to consider them as perfectly immovable, at least in the
ordinary conditions of life. Yet, when we reflect that they are sup-
plied with synovial membranes, which are only found in movable ar-
ticulations, we may admit them to possess, under certain circumstances,
a slight degree of motion, as for instance, the shock of a fall from a
height, upon the feet, is much diminished in its influence upon the
body and brain, by a slight mobility. Dr. Laborie, from examinations
of the pelves of women shortly after delivery, is led to believe that
there is a mobility of these articulations tending to enlarge the trans-
verse diameter at the outlet; the other diameters being increased by
relaxation of the sacro-sciatic ligaments and the mobility of the sacro-
coccygeal symphysis; the sacro-iliac and pubic symphyses presenting
characters partaking partly of enarthrosis, and partly of ginglymus.

There is no doubt, but that during pregnancy or parturition, there
may be a relaxation, or separation of the symphyses; the symphysis
pubis especially being more frequently involved than the sacro-iliac
joints : any considerable separation however, favoring marked mobility,
is an uncommon event, and one which is seldom met with, being a
pathological condition dependent upon some disease of the parts them-
selves.

For, were it a circumstance common to parturient women, it would
be impossible for them to walk or exercise immediately previous, as

SYMPHYSES AND LIGAMENTS OF THE PELVIS. 27

well as subsequent, to confinement (acts which are accomplished daily),
from the fact that an appreciable degree of mobility would not only
render it impossible to walk, but likewise very painful to stand. The
tissues about the joints may, probably, become softer, and perhaps
more movable during pregnancy and parturition, yet any appreciable
relaxation or separation must necessarily be unfavorable, and owe
their origin to some disease not connected with these conditions.

\Vhen relaxation does take place, the symphyses become .swollen,
and sometimes dilate so much as to separate the bones which aid in
their formation, permitting them to glide over each other, and occa-
sioning uneasiness and fatigue in the movements of the female, with
difficulty of standing. Should labor come on, the auxiliary muscles
of the uterus, not having any longer a fixed point of insertion in the
vacillating bones of the pelvis, draw the symphyses apart, producing
great agony; and the female, dreading the pain occasioned by their
contraction, remains passive, and allows the uterus slow r ly and diffi-
cultly to expel its contents, unaided by her efforts. Instances of this
kind have taken place, and have always proved a source of much dis-
tress and suffering, causing more or less intense pain on motion, with
much difficulty in moving the lower extremities, and an inability to
stand.

Occasionally there is not only a relaxation, but likewise an actual
separation of the pelvic joints, giving rise to most intense suffering,
inflammation, peritonitis, and all the symptoms of simple relaxation
in a more aggravated form, greatly endangering life. This separation
may be accidental, resulting from the powerful efforts made by the
patient to expedite her delivery; or it may ensue from the employ-
ment of the lever or forceps in extracting the fetal head. Sometimes
it is congenital, and usually accompanies exstrophy or extroversion of
the bladder, of which it may probably be the result.

There is but little protection given by ligaments to the anterior
part of the sacro-iliac symphyses, the only ligament of any size being
the anterior sacro-iliac; the, principal ligaments are placed on the outer
edge of the joint, and any tendency to open at its inner margin is pre-
vented by the ligaments of the symphysis pubis. Hence, a separation
of the pubic bones will occasion a relaxation or separation of the sacro-
iliac symphyses; and when a separation takes place in consequence of
the pubic junction being cut or ruptured, the sacro-iliac symphyses
immediately open considerably, the effect of which is pain, inflamma-
tion, and, if not remedied, caries of the bone, suppuration of the parts y
and hectic fever.

JS KING'S ECLECTIC OIJKTKTRICS.

Decided separation of the pelvic symphyses may be diagnosed by
carefully examining the parts. When the pubic symphysis is involved,
it may be recognized by grasping the symphysis between the thumb
externally and one or two fingers within the vagina, with the patient
standing; an effort at walking will at once impart the degree of mo-
bility existing between the bones. Rupture of the sacro-iliac joints
may be determined by placing the open hands over the symphyses and
wings of the ilium, and directing the patient at the same time, to move
the lower limbs as in walking; the degree of mobility and separation
will at once become apparent. Relaxation or rupture of the pelvic
joints may develop during the last months of pregnancy, or not until
after labor, and is always attended with pain on the least exertion.
Inflammation is occasionally present, and may result in suppuration
and the evacuation of pus. Locomotion is usually impaired, and be-
comes impossible if there exists a decided degree of separation of the
symphyses.

TREATMENT. Rest is the most essential factor in the treatment
of either relaxation or separation of the symphyses of the pelvis. It
will be absolutely necessary for the patient to remain quiet, and in a
recumbent position for a long-continued period of time. The patient
must not be permitted to stand on the feet, or attempt to walk; walk-
ing, particularly, is likely to prove injurious, and excite inflammatory
action. Internal medication is uncalled for in the treatment of this
affection. Local agents, to control inflammatory development, and
anodynes to relieve pain, may be useful in some cases. The treatment
in the main, however, will consist in the application of dressings and
bandages, together with such mechanical apparatus as will favor the
support of the parts. The pressure of the bandage should be at first
gentle, but gradually increased. The bowels should be kept regular,
and the surface of the body frequently bathed.

The patient should be advised not to attempt walking too soon after
delivery, and when it is considered prudent to test her strength, it
must be done with great care. A well-padded leathern girdle should
be fixed around the hips, as tightly as the patient can bear, and kept
in its place by straps passed under the thighs; the upper part of the
body should also be supported on crutches, in order to lessen the weight
and pressure of the trunk on the articulations, which must, at first, be
unable to maintain its whole weight.

STRAITS AND CAVITIES OF THK PELVIS.

CHAPTER IV.

STRAITS AND CAVITIES OF THE PELVIS THE PELVIS AS A WHOLE.

THE union of the several bones already considered by means of
their symphyses or articulations, forms the Pelvis, which is of a con-
ical shape, with its base looking upward and forward, and its apex
pointing downward and inward. The internal surface of the pelvis is
divided into the upper basin, false or greater pelvis, located above the
superior strait, and the lower basin, true or lesser pelvis, more com-
monly termed the pelvic cavity or excavation, and which occupies the
space comprised between, the superior and inferior straits so called
because they are rather more contracted than the space between them.
The greater pelvis is bounded posteriorly b^y the lumbar vertebra?, lat-
erally by the ahe ilii, and anteriorly by the abdominal parietes; the
lesser pelvis is marked posteriorly by the sacrum and coccyx, laterally
by the ischia, and anteriorly by the pubes.

Between these two cavities is an aperture of an elliptical or curvili-
near triangular form, somewhat resembling the shape of a playing-
card heart, with its base resting on the sacrum, and at which location
a prominent ridge is observable, which has received the names of ilio-
pubic line, linea ilio-pectineal protuberance and brim of the pelvis; it
is formed by the crest of the pubis, and the ridge which is continuous
along the lower part of the alre ilii, and which, together with the pro-
montory of the sacrum, consti-
tutes the SUPERIOR STRAIT. Ill
a well formed pelvis its circum-
ference measures from fourteen
to sixteen inches. The diame-
ters of the superior strait are as
follows: 1. The antero-posterior
or sacro-publc, or conjugate di-
ameter (A A, Fig. 4), extending
from the superior- posterior edge
'of the symphysis pubis to the
promontory of the sacrum, DIAMETERS OF THE SUPERIOR STRAIT.

measures from four to four and A A ' Antero-posterior C C, Oblique Diameters.

Diameter. A C, Sacro-cotyloid Space.

a half inches. 2. The transverse B B, Transverse Diameter.

or bis-iliac diameter (B B, Fig. 4), passing from one ilium to the other,

FIG. 4.

KING'S ECLECTIC OBSTETRICS.

FIG. 5.

and crossing- the antero-posterior diameter, at a right angle, measures
five inches. In the recent subject, this diameter is lessened by the
psose and iliac muscles, which overhang the sides of the brim. 3. The
oblique di(tmcters* (c c, Fig. 4), passing from the ilio pectineal emi-
nence, just above the acetabulum, to the sacro-iliae symphysis of the
opposite side, measure, each, from four and a half to five inches. The
one passing from the right ilio pectineal eminence, to the left sacro-
ili:ic symphysis, is called the right oblique diameter; and that which
passes from the left ilio pectineal eminence, to the right sacro-iliac
symphysis, is called the left oblique diameter. 4. The sacro-cotyloid
space, or diameter (A C, Fig. 4), extending from the center of the
promontory of the sacrum, to the ridge just above the cotyloid cavity,
measures from three and three-quarters of an inch to four inches.
The articulation of the spinal column witfi the pelvis, is such, that

the axis of the superior strait is not
parallel with that of the body, the su-
perior-posterior part of the pubic sym-
physis being about four inches below
the level of the sacral promontory. If
a piece of pasteboard be accurately
cut and fitted to the pectineal line, or
superior strait, it will represent the
plane of that strait (c H, Fig. 5), and
will be neither horizontal nor vertical,
but will form, with a horizontal line,
an angle of about 54 to 56, varying
more or less according to the position
of the body. The axis of the superior
strait will, therefore, be an imaginary
line passing through the center of the plane at right angles (A B, Fig. 5),
and will be found to extend from the neighborhood of the umbilicus,
downward and backward, to the central portion of the coccyx.

The INFERIOR or PERINEAL STRAIT, also termed the outlet

* I am aware that many writers term the oblique diameters, right or left, accord-
ing to the sacro-iliac symphysis from which they commence their measurements.
I have always considered this an incorrect mode of measuring, one less readily
comprehended by the student, and consequently instead of taking the posterior
extremities of these diameters as the origin, I commence at their anterior extrem-
ities, and call the diameter right or left oblique, according as its extremity is sit-
uated anteriorly and laterally to the right or left side.

A B, Axis of the Superior Strait.
C H, Plane of the Superior Strait.
C D, Horizontal Line.
C D, Plane of the Inferior Strait.
E G, Axis of the Inferior Strait.

STRAITS AND CAVITIES OF THE PELVIS.

Fia. 6.

of the pelvis, is bounded posteriorly by the apex of the coccyx, laterally
by the inner edges of the ischiatic tuberosities and the sacro-sciatic
ligaments, and anteriorly by the rami of the ischla, and the inner edges
of the pubic arch. Its circumference measures between thirteen and
fourteen inches. The conformation of this strait is apparently very
irregular, but if a sheet of paper be applied to it, and its outline
traced by a pencil, it will be found of an oval form, with its large
extremity pointed backward, and broken by the projection of the
coccyx. The diameters of the inferior strait are as follows :

1. The antero-posterior diameter (A A, Fig. 6), extending from the
lower edge of the symphysis pubis
to the apex of the coccyx, measures
four inches, but in some women it
may be increased to five, in con-
sequence of the regression of the
coccyx. 2. The transverse, or bis-
ischiatic diameter (B B, Fig. 6), ex-
tending from one tuberosity of the
ischium to the other, measures four
inches. 3. The oblique diameters
(c C, Fig. 6), extending from the
center of the great sacro-sciatic lig-
ament of one side, to the point of
union between the ascending ramus
of the ischium and descending ramus
of the pubis, measure, each, from
four to four and a-half inches. At
the period of delivery, this diameter may be slightly increased, owing
to the mobility of the sacro-sciatic ligaments.

That which passes from the right lateral anterior region to the left
lateral posterior, is called the right oblique diameter; and that which
passes from the left lateral anterior region to the right lateral posterior,
is called the left oblique diameter.

An imaginary line extending from the lower edge of the symphysis
pubis to the coccygeal apex, will represent the direction of the plane
of the inferior strait (c E, Fig. 5), and a line passing through the cen-
ter of this plane, at right angles or perpendicular to it, will give the
direction of the axis of the inferior straits (FG, Fig. 5), which extends
from the center of the strait to the first sacral bone, and crosses the
axis of the superior strait near the center of the pelvic cavity, forming

DIAMETERS OP THE INFERIOR STRAITS.
A A, Antero-posterior diameter.
B B, Transverse diameter.
C C, Oblique diameters.

1. Base of the Sacrum.

2. Pubic Symphyses and Pubic Crest.

3. Anterior-superior Spinous Process of the

Ilium.
4 4. Obturator Foramina.

KING'S ECLECTIC OBSTETRICS.

FIG. 7.

at their point of contact a very obtuse angle ; it is parallel with the axis
of the body. The direction of tin- axes of the two straits, should be
well understood, as they determine the direction which the fetal head
takes in passing through the pelvis, and which course should be fol-
lowed whenever delivery has to be effected by instruments; the curved
direction of the two axes through the center of the pelvis, may be
considered as the true axis of the pelvis (G K, F'ty. 7).

In consequence of the arrangement of the pelvic bones, which
causes this variation in the direction of the axes of the two straits, the
pelvic contents are prevented from falling downward, which might
otherwise, be the result, either from their own gravity, or from the
pressure of the abdominal viscera above them.

The PELVIC CAVITY or EXCAVATION, includes all that
space occupied between the superior and inferior straits ; it is bounded
posteriorly by the sacrum, the coccyx, the sacro-iliac symphyses, and
a portion of the sacro-sciatic ligaments; anteriorly, by the symphysis-
pubis, pubic bones and the internal obturator fossa?; and laterally, by
the two inclined acetabular planes, the sciatic openings, and the sacro-

sciaitc ligaments. The canal of this
cavity possesses a curvature cor-
responding to the curve of the sac-
rum, and which gives to it a greater
extent than that of the straits. The
axis of this canal represents the
route taken by the fetus in its expul-
sion through the cavity, and should
be well understood by the practi-
tioner, if he expects to meet with
success in the operations which may
be necessary to effect artificial de-
livery. The axis of the pelvis is
not formed by two straight lines,
nor does it, as supposed by Cams
and others, represent the arc of a
circle ; but it has been well deter-
mined by M. Cazeaux, who ob-
serves (Fig. 7) :

" To form an exact idea of the
general disposition of the pelvic
cavity, it seems best to cut that canal by a series of planes, passing

A B, Plane of the Superior Strait.
I O, -Plane of the Inferior Strait.
Q', The point where these two planes would

meet, if prolonged.
M N, The Horizontal Line.
E F, The Axis of the Superior Strait.
G K, The Axis of the Pelvic Cavity.
P Q R S T, Various points taken on the Sacrum

to show the plane of the excavation at each

point.

STRAITS AND CAVITIES OF THE PELVIS. 33

from the point Q' (the point of intersection of the planes of the superior
and inferior straits), to the points r Q K s T, of the anterior face of the
sacrum. Each one of these planes will determine the opening of the
pelvic cavity at that point. Now, to determine with precision the di-
rection of the general axis of the excavation, it will be necessary to
erect a perpendicular to the geometrical center of each one of these
sections, and to draw a line ( K) along the extremities of the perpen-
diculars. This line (G K) is curved, and is called the general axis of
the pelvic cavity. It is easy to see that this line is nearly parallel
with the anterior face of the sacrum, and its extremities are lost in the
axes of the superior and inferior straits. This curve represents exactly
the axis of the whole excavation ; that is to say, the line which the
fetus traverses in passing through the pelvis."

The depth of the pelvic excavation, posteriorly, along the sacrum
and coccyx, is from five to six inches; laterally, three and a-half
inches ; anteriorly, along the os pubis, one and a-half to two inches.
Its diameters are:

1. The antero-posterior diameter, passing from the symphysis pubis
to the center of the sacrum, measures four and a-half inches, or
more.

2. The transverse diameter, extending from the plane of one ischium,
to that of the other, measures about four and a-half inches.

There is considerable difference in form and texture, between the
pelvis of a female and that of a male. (Figs. 2 and 3.) The female
pelvis is not so strong nor so thick as that of the male, and contains
less osseous matter; in the male, the long diameter of the superior,
strait, is from before, backward, while in the female it is from side to
side; in the male, the brim is more triangular; in the female, more
oval. In the female the ilia are more distant; the tuberosities of the
ischia arc also further apart from each other, and from the coccyx, and
the space between the pubes and coccyx is greater than in the male.
The sacrum of the female is broader and more curved than in the
male, and the superior articulations are more distant from each other,
occasioning a peculiarity in her walking, apparently rendering it
more difficult for her to preserve the center of gravity. The sym-
physis pubis is not so long in the female as in the male, and the ranii
of the pubes and ischia are smoother on their inner face, and have
their anterior edges turned more outwardly ; the obturator foramen is
3

34 KING'S KCLKCTIC OBSTETRICS.

more triangular in the female; and the cotyloid cavities are more
widely apart.

The following dimensions of the male and female pelvis are by
Meckel :

IN THE MALE. IN THK FEMALE.

Inches. Lines. Indies. Lines.
"The transverse diameter of the great pelvis between

the anterior-superior spinous processes of the ilia. . 78 8 (i

Distance between the cristse of the ilia 8 3 9 4

Transverse diameter of the superior strait 46 50

Oblique diameter of the superior strait 45 45

Antero-posterior diameter of the superior strait 4 4 4

Transverse diameter of the cavity 4 4 8

Oblique diameter of the cavity 5 5 4

Antero-posterior diameter of the cavity 5 4

Transverse diameter of the lower strait or outlet 3 4 5

Antero-posterior diameter of the lower strait or outlet. 33 44

" The latter may be increased to 5 inches, from the mobility of the coccyx."

The above dimensions of the straits and cavity of the female pel-
vis are assumed as the standard, and any considerable deviation from
these measurements, may present an obstacle to the progress of deliv-
ery, and the pelvis is then said to be vitiated or malformed.

It may be proper to make a brief reference to some of the vessels
and soft parts which cover the pelvis, especially those which occupy
its cavity. In the greater or false pelvis, we find anteriorly, the mus-
cles and the anterior parieties of the abdomen, which assist in com-
pleting this basin; laterally, the iliac fossa3 are filled with the internal
iliac muscles; and posteriorly, are the psoas major and minor muscles,
which pass downward along and on the sides of the lumbar column,
and along the pelvic brim, to be inserted into the trochanter minor.
These muscles, in connection with the iliac veins and arteries, are so
arranged as to contract the size of the transverse diameter of the su-
perior strait, to even an inch less than its true length, thus apparently
presenting its oblique diameter as the largest ; but these muscles are
capable of great compression, especially when they are completely
relaxed by flexing the thighs upon the pelvis, and hence in the ma-
jority of cases, they present but little obstacle to the passage of the
fetus.

The pelvic excavation is lined by fascia, which assist in diminishing
its diameters; it is also lessened posteriorly, by the sacral plexuses of
nerves, the pyriform muscles, the hypogastric blood-vessels, and the

DEFORMITIES OF THE PELVIS. 35

rectum ; anteriorly, by the bladder, the obturator nerves and vessels,
and the internal obturator muscles ; and in its vertical diameter, by
the floor of the pelvis or perineum, which is a muscular membranous
plane closing the pelvis inferiorly, acting in antagonism to the dia-
phragm and abdominal muscles, and on whose median line are the
urinary, generative, and fecal or anal orifices. Inclosed within these
soft parts are the vagina and uterus. The muscles of the perineum
are: the sphincter ani, surrounding the lower part of the rectum, and
which arises from the coccyx, and is attached to the center of the peri-
neum ; the sphincter or constrictor vagince, which arises from the body
of the clitoris, and is attached to the center of the perineum ; it is about
fifteen lines wide, and surrounds the anterior opening of the vagina,
acting as a sphincter to it; the erector clitoridis arises from the ascending
ramus of the ischium, covers the inferior face of the crus clitoridis,
and is inserted into the upper part of the crus and body of the clitoris;
it draws the clitoris downward and backward; and the transversalis
perincei arises from the fatty cellular membrane which covers the tuber-
osity of the os ischium, and is inserted into the perineal center; it keeps
the perineum in its proper place.

CHAPTER V.

DEFORMITIES OF THE PELVIS.

ANY remarkable deviation from the standard measurements of the
pelvis produces a malformation or deformity of it; yet it does not fol-
low that every slight variation should be viewed as a deformity, but only
those instances, in which it may so far depart from its normal form as
to render it extremely difficult, or even impossible to deliver the full-
grown fetus by the natural passage. A pelvis, the small diameter of
which measures three and a-half or four inches, may, in case there be
no unusual enlargement of the fetal head, admit of its safe passage at
full term with but very little difficulty; below this measurement, say
from three inches to three and a-half, the forceps will undoubtedly
be demanded ; if it be still smaller than this, the induction of prema-
ture delivery would be prudent and justifiable, and if the fetal head
should be unable to pass, the perforator would be required. In cases,

36 KING'S ECLECTIC OBSTETRICS.

however; where the measurement of the small diameter does not ex-
ceed one inch and ii-half, the perforator can not be used with safety, ;md
in these instances, the Caesarean section is recommended as the only
chance for the mother's life.

The more general causes of vitiated or malformed pelvis, are rick-
ets and mollities ossium. Rickets is probably the most frequent cause ;
this is a disease common to children, especially those of a strumous
diathesis, and is very seldom met with in adults. In this affection the
bones become very much softened, in consequence of the deficiency of
the calcareous matters natural to them, owing to their absorption or
non-deposition: and in connection with the disease there is most usu-
ally an arrest of development of the bones, in which the pelvis, instead
of becoming properly developed with the growth of the female, retains
its infantile condition, and thus presents a permanent obstacle to de-
livery. From these circumstances the bones curve unnaturally in vari-
ous directions, especially those upon which there is much pressure, or
upon which is exerted a long-continued action of the muscles; and the
pelvis in particular, which sustains the weight of the trunk, becomes
more or less deformed, according to the duration and severity of the
disease, and the deformity continues even after the disease has been
cured. Most generally, this disease commences in the bones of the
inferior extremities, and gradually extends itself to the pelvis, the
spinal column, etc.

TREATMENT. Children, affected with rachitis, will require both
hygienic and therapeutic measures to overcome it. Rachitic softening
of the pelvic bones in tlie female infant, demands the most careful
and pains-taking treatment the deformity following, results in after
life in the most serious consequences. The invigoration of fresh air
is one of the first essentials in the treatment of this disease. The
child should be taken into the open air every day, as the weather will
permit. While indoors, the child should be kept in a state of rest, in a
reclining position ; the apartment should be well lighted and ventila-
ted, also dry, and on damp days a fire in an open fire-place would be
advantageous. We should next advise the mother as to diet, and this
is of the greatest importance. During the first year, the child should be
nourished at the breast, providing the mother is in good condition.
If breast milk can not be furnished, cow's milk may be used, properly
diluted. After the age of weaning, the diet, recommended, in the Xew

DEFORMITIES OF THE PELVIS. 37

York hospitals, is meat soups, beef tea, peptonized beef the diet
being principally animal. The usual internal treatment consists in
supplying lime-salts to the system. Prof. J. Lewis Smith, in his
Treatise on the Diseases of Infancy and Childhood, recommends the
following formula, which he claims will be found useful in most cases :

R Olei morrhuae fgiv

Aq. calcis.
Syr. calcis lactophosphatis, aa fgij Misce.

Of this, one teaspoonful should be given four or five times daily to an
infant of one year.

Lime-water, codliver oil, the compound syrup of the phosphates
are recommended by most authors as valuable internal agents in the
treatment of this disease. The formula I have quoted contains these
ingredients in about the proper proportion. In moving the patient,
great care should be taken to prevent deformities : the softened and
yielding bones may be easily twisted or distorted. Children, and
especially female children, who are disposed to rickets, should never
be allowed to creep or walk at too early an age, lest pelvic deformity
occur as a consequence. Before exertion of lower extremities is
allowed, as standing or walking, the parts should be supported by stif-
fened dressings.

Mollifies Osslum, or Malacosteon, is the usual cause of those deform-
ities which take place during adult age, It also consists in an undue
softening of the bones, owing to the absence of their salts, especially
the phosphate of lime, and is usually connected with a gouty or rheu-
matic diathesis; sometimes it is the result of mercurial treatment.
This disease is gradual in its progress, and the deformity resulting
from it, may occur in women who have previously given birth to sev-
eral children, and who may subsequently become so deformed in the
pelvis, as to render delivery by the natural passage absolutely impos-
sible.

The cause of the deformity, in either rickets or mollities ossium,
is essentially the same ; thus, the sacrum being softened by either
disease, will, from the superincumbent pressure, be forced from its
natural position, occasioning an increase or decrease of the pelvic
diameters, at the superior strait, inferior strait, or in the pelvic cavity.
Or the oblique diameter of the pelvis, or its antero-posterior diameter
may be diminished, in consequence of the acetabula being driven in-

38 KING'S ECLECTIC OBSTETRICS.

ward; these alterations may exist singly, or may be variously eom-
bined.

In cases of Mollities Ossiutu, the TREATMENT will be similar to
that named for rickets, together with such other measures as may be
indicated; however, the disease is seldom cured.

Deformities of the pelvis may arise from other causes than those to
which I have just referred; thus, the very erroneous practice of forc-
ing children to walk, by means of go-carts, baby -jumpers, and the like,
may at an early age give rise to malformations which will continue
irremediable through life. When children are allowed to walk vol-
untarily, gradually perfecting this exercise as their locomotive organs
acquire energy, strength, and development, deformities rarely occur.
A child carried constantly on one arm, may cause a malformation, and
I am acquainted with a lady, who has a deformed pelvis, originating
from carrying her mother's children during her girlhood, constantly
resting them on the one hip. Carrying heavy burdens in early life, or
remaining too long in one position, before the bones have acquired
the necessary firmness, are very apt to cause this kind of malfor-
mation.

An old unreduced luxation of the femoral bones, caries of the
bones, exostoses, the result of syphilitic or rheumatic affections, im-
perfectly consolidated fractures, and pelvic tumors, may contribute
to deformity of the pelvis, or occasion a diminution in its capac-
ity. Sometimes, it is impossible to determine the origin of the de-
formity.

Pelvic deformity is more common to the females of Europe than
to those of this country which is probably owing to the fact, that our
countrywomen are better nourished, take more healthful exercise, and
are not exposed to the many causes, common to Europe, which con-
tribute to destroy health among the working and indigent classes.
Many of the cases, which are met with in this country, are among
females, whose early life was passed in some portion of Europe. But,
there is no doubt, that as our population increases, together with an
increase of poverty, factory-working, etc., these results will cease to
be uncommon among us.

The various forms, given to the pelvis by the above causes, are very
numerous, and must ever vary, according to the multitudinous local
accidents, severity and duration of the causes, etc.; and to enter into a
minute description of them, or to arrange them into distinctive classes,
is almost impossible ; nor, indeed, is such an attempt absolutely neces-

DEFORMITIES OF THE PELVIS. 39

feary. Some of the more common deformities have, however, been
classified by authors as follows: 1st. The abnormally large pelvis, or
where there is an excess of dimension ; 2d. The dwarfish pelvis, or
where there is a diminution of dimension ; 3d. The unequally con-
tracted pelvis ; and 4th. The obliquely distorted pelvis.

1st. The abnormally large pelvis (pelvis equaliter justo major], or
excess of the dimensions of the pelvis. This can not properly be
termed a deformity, yet its presence may give rise to many accidents,
which it is the duty of the accoucheur to prevent or relieve. Females,
in the unimpregnated state, in whom this condition exists, are very
liable to various uterine displacements, which often prove extremely
difficult to remedy. And during pregnancy, from the absence of due
support to the uterus above the superior strait, this organ readily de-
scends into the pelvic cavity, producing a sense of weight, with various
painful and unpleasant symptoms; as painful or difficult micturition,
constipation, obstinate tenesmus, hemorrhoids, pains, cramps, etc., the
necessary result of compression of the bladder, rectum, and the blood-
vessels and nerves which line the pelvis, by the enlarged and prolapsed
uterus.

Again, during parturition, and especially if the female should
exert herself by bearing down before the os uteri be sufficiently di-
lated, the uterus may be forced through the inferior strait; or, dilata-
tion being perfected, together with frequent and energetic uterine con-
tractions, the fetus, from the want of proper resistance, may pass
easily through the pelvic straits and cavity, and suddenly present
itself at the perineum, which has not yet been sufficiently distended,
and lacerate it. Or, should the- perineum yield without laceration,
precipitate birth frequently follows, rendering the female exceedingly
liable to hemorrhage, inversion, or other accidents. These inconven-
iences, however, may be readily obviated by a careful practitioner;
the recumbent position during the first months of pregnancy and dur-
ing labor, will generally overcome them.

2d. The dwarfish pelvis (pelvis equaliter justo minor), or diminution
of the dimensions of the pelvis. This deformity, although not very
common to this country, is occasionally met with. The pelvis retains
the proper form and dimensions externally, yet its internal cavities
are very much diminished in extent, varying from a quarter of an
inch to an inch, in each of the diameters. This kind of deformity is
not connected with rickets nor malacosteon ; nor can it be attributed
to arrest of development, as the pelvis is usually well formed, and

40 KING'S ECLECTIC OBSTETRICS.

bears no resemblance to the undeveloped pelvis of the child ; its causes
are not well understood.

The difficulty in giving birth to 'a child, depends entirely upon the
degree of deviation of the pelvic dimensions from the standard size,
and the proportions existing between the diameters of the fetal head
and the pelvis; yet a pelvis smaller than the average size, may occa-
sion no other difficulty than a tedious, disagreeable, painful, and per-
haps exhausting labor.

The diagnosis of this deformity is always difficult to correctly
determine, unless we have bad its existence indicated by a previous
labor, and in cases where we suspect its presence from the size of the
patient, a certainty may be acquired by an examination. All the di-
ameters of the pelvis are equally contracted in the dwarfish pelvis,
hence it has been termed " the equally contracted pelvis," and as no
favorable changes can be effected in consequence of the impossibility
of bringing the long diameter of the head to correspond with the long
and uncontracted diameter of the pelvis, as in the unequally contracted
pelvis, very great obstacles to delivery are presented, and most labors
result fatally to both mother and child.

3d. The unequally contracted pelvis, or partially deformed pelvis, in
which there is a great alteration c-r disproportion between the various
parts, so that during labor the female is subject to much suffering, and
even death, and the practitioner frequently becomes embarrassed. The
deformity may exist in the greater pelvis, the lesser pelvis, the supe-
rior strait, the inferior strait, or in two or more of these united.

FIG. 8. The most usual mal-

formations in the greater
pelvis are an exaggera-
tion of the curvature of
the lumbar column, pre-
senting a deviation or
projection of its anterior
surface ; or the wings of
the ilia, or the iliac fossa?
may be turned too much
ELONGATION OF THE ANTERO-POSTERIOR DIAMETER outwardly. These defor-
OF THE SUPERIOR STRAIT. mities do not materially

affect either pregnancy or parturition, although when excessive, they
undoubtedly influence the presentations of the fetus, and sometimes

DEFORMITIES OF THE PELVIS. 41

occasion a permanent obliquity of the uterus, which may prevent the
natural expulsion of the child. (Figs. 8 and 9.)

The lesser pelvis, or pelvic cavity, may be deformed by a deficiency
or excess of one or more of its diameters, and which must, conse-
quently, influence, in a greater or less degree, the diameters of the
superior and inferior straits more frequently those of the superior
strait.

The antero-posterior diameter of the superior strait may be affected
FIG. 9. by the advancement of the promon-

tory of the sacrum toward the cen-
ter of the strait, in which case we
usually find an excessive curvature
of the sacrum, which is sometimes
so great, that its apex looks up to-
ward the pubic arch, interfering

T, " with the antero-posterior diameter

DIMINUTION OP THE ANTERO-POSTERIOR r

DIAMETER OF THE SUPERIOR STRAIT, of tnc inferior strait; or, while the
AND ELONGATION OP THE TRANSVERSE base of the sacrum diminishes the
DIAMETER. antero-posterior diameter of the su-

perior strait, in consequence of its abnormal projection, its apex may
be thrown backward, and thus increase the diameter of the inferior
strait. Sometimes the sacrum may be unchanged, but the pubes will
be found retreating toward the sacrum, diminishing the antero-poste-
rior diameter of the brim ; at other times, both the change in the sac-
rum and pubes may exist simultaneously.

The transverse diameter of the superior strait may be diminished
in consequence of one side of the pelvis being much narrowed, or the
horizontal rami of the pubes may approximate toward each other, be-
coming nearly parallel, and with this there may likewise exist an ap-
proach of the iliac bones. The forward projection of the pubes caused
by this deformity, increases the antero-posterior diameter of the brim.
A diminution of the transverse diameter of the brim, is seldom accom-
panied by an increase in that of the inferior strait ; although it may be
present where the contraction is the result of an upward and backward
dislocation of the femur, drawing the ischiatic tuberosities and pubic
rami more distantly apart. The transverse diameters of both straits
may be lessened by improper pressure upon the pelvis at a time when,
in consequence of disease, the bones are softened.

The oblique diameter of the superior strait may be decreased by

42 KING'S ECLECTIC OBSTETRICS.

one side of the pubes projecting inwardly, while the other projects
outwardly, or the iliac bones may turn inwardly. If, in the first
deformity, the long diameter of the fetal head presents in the direction
of the great oblique diameter of the brim, and the transverse occupies
the diminished diameter, labor may terminate safely without artificial
assistance.

The superior strait may not be at all changed, while the inferior
strait is much diminished; thus, the antero-posterior diameter of the
inferior strait may be lessened by the apex of the sacrum turning
within and upward toward the pubic arch; or the coccyx may project
forward too much.

The transverse diameter of the inferior strait may be contracted in
consequence of the approach of the ischiatic tuberosities toward each
other, as well as of the sides of the pubic arch, which will render it
absolutely impossible for the head of the child to pass, or even the
hand of the accoucheur. This deformity is the most to be dreaded;
the head readily passes through the brim and pelvic cavity, and be-
comes arrested only at the outlet, and the practitioner, after delaying
for a length, of time, in hope of its expulsion, is finally obliged to
employ the forceps or perforator.

The oblique diameters of the inferior strait may be changed by the
maldirection of the ischio-pubic branches.

These malcoriformations of the two straits may exist singly, and
sometimes in combination, but in opposite directions; thus, if one
strait be contracted, the other will be enlarged. The consequences
which must arise 'from these various changes, will be evident to the
student who compares the diameters of the child's head with those of
the bony passages through which it must pass.

The pelvic cavity may be deformed, 1st, by a turning backward of
the pubes; 2d, by the abnormal length of the symphysis pubis, which
retards delivery by preventing the head from engaging in the arch of
the pubes; 3d, by the too great or small curvature of the sacrum; 4th,
by exostosis, and fibro-cartilaginous morbid productions. Various
other forms, than those referred to, may be assumed by the pelvis,
which, however, can not be satisfactorily classified, as they must ever
vary, according to circumstances.

4th. The obliquely distorted pelvis. (F/g. 10.) This deformity is
usually dependent upon an arrest of development of one or the
other side of the sacrum; more generally the right side, and which
occasionally extends to, and includes the ilium. Nseg6le was the first
writer who seems to have noticed this deformity, and of whose re-

DEFORMITIES OF THE PELVIS.

marks M. Cazeaux has given
us the following -in his work
on Midwifery, translated edi-
tion, p. 434:

" The peculiar characteristics
of these deformed pelves are
as follows:

" 1st. Complete anchylosis of
one of the sacro-iliac symphyses,
or partial fusion of the sacrum
and one of the iliac bones.

" 2d. Arrest of development,
or defective development of

the lateral halt of the Sacrum,

and defect in the amplitude of ^

the anterior

FIG

OBLIQUELY DISTORTED PELVIS,

In which the autero-posterior diameter traverses from

tor y * ^ sacrum to th left acetabuim;

the left oblique diameter is also lessened, while tho

sacral foramina of right is normal.

the anchylosed portion. '

"3d. On the same side, diminished length of the ilium, with diminu-
tion in the extent of the sciatic notches of this bone; that is to say, the
distance from the anterior-superior spinal process of the jlium, to its
posterior-superior spinous process, as also the length of a line drawn
from a point at the pelvic inlet, corresponding with the sacro-iliac junc-
tion, if it existed, along the linea innominata, and the linea ilio-
pectinea to the symphysis pubis, are shorter than (the same distances)
on the other side. But farther upon the anchylosed bone, the part
corresponding with the articular surface, which is continuous without
interruption, with the sacrum, is not so high, and descends to a shortei
distance than it does on the opposite side, and than it would do in a
bone normally formed; or to express myself more clearly, if on the
anchylosed side we suppose the ilium and sacrum separated, or reunited
only by the interposition of a nbro-cartilaginous disk, such as exists in
the normal joint, the articular surface or the reunion of the two bones
would be found less long, and would descend less low than it would
on the non-anchylosed side, or upon the pelvis normally constituted.

" 4th. Tho sacrum seems to be pushed toward the anchylosed side
and it is toward that side that its anterior face is more or less turned,
while the symphysis pubis is pressed toward the opposite side, a dispo-
sition which prevents the symphysis pubis from being directly opposite
the promontory of the sacrum, and gives it an oblique direction.

"5th. On the anchylosed side, as much of the internal surface of the
ilium as concurs to the formation of the pelvic excavation is flattened,

44 KING'S ECLECTIC OBSTETRICS;

and where considerable vitiation exists, it is almost entirely plane, so
that a line drawn from the middle or even from the posterior end of
the linea innominata, along the body and the transverse branches of
the pubis to its symphysis, will be nearly straight. We have never
seen at the lateral half of the anterior wall of the pelvis, of which we
now speak, any inclination inward, nor have we ever especially noticed
that sort of fracture of the horizontal branch of the pubis, which is
observed in pelves deformed from the effects of malacosteon in adults.

"6th. The other lateral half of the pelvis, that is to say, the one in
which there exists a sacro-iliac synchondrosis, also differs from the
normal condition. At first sight, in examining the pelvis under con-
sideration, and especially where the obliquity is considerable, it is easy
to induce oneself to believe in the normal conformation of the non-
anchylosed half; but this opinion is not correct ; thus, let us suppose
two pelves equally contracted, with this difference only, that in one
the left sacro-iliac symphysis is anchylosed, in the other, the anchylosis
is on the right side ; let a section of each be made so as to pass through
the middle of the sacrum and the symphysis pubis if now we under-
take to fit the right half of the first pelvis to the left half of the second,
so that the. cut surfaces shall cover each other, we will discover that
the pubic bones are separated by a distance of from eight to twelve
lines. Thus, the lateral half of the pelvis, which is free from anchy-
losis, participates not only in the abnormal situation and direction of
the bones, but also in their irregular form, in such a way that in meas-
uring this half, a line drawn from the center of .the promontory of the
sacrum, along the linea innorainata, and pectinea, to the symphysis
pubis, would be at its posterior half more curved, and at its anterior
half less curved than in a pelvis well formed.

"7th. It folloAvs from this, that the pelvis is obliquely contracted,
that is to say, in a direction which would intersect a line passing from
the anchylosed joint to the cotyloid cavity of the opposite side, while
the extent of the last-mentioned line is not diminished but may be
increased where the obliquity is very marked. In consequence of this,
the shape of the superior strait (that is to say, an imaginary surface '
passing along the linea innominata and the linea pectinea over the
sacrum), and the shape of the middle of the excavation (situated mid-
way between the superior and inferior straits, called the apertura pelvis
media), would both resemble, properly speaking, an oblique oval when
examined in front the transverse or small diameter of which would
be represented by the contracted oblique diameter of the pelvis, while
its great or longitudinal diameter would correspond to the other oblique

DEFORMITIES OF THE PELVIS. 45

diameter. On this account we may, as far as the form is concerned,
term this variety of pelvic deformity the obliquely oval pelvis.

"That the distance from the sacral promontory to the point corres-
ponding to the one or the other cotyloid cavity (the distance sacro-
cotyloid), as well as the distance from the obtuse point of the sacrum
to the spine of the ischium on either side, is less on the side where
the anchylosis exists.

"The distance from the tuberosity of the ischium on the side of the
anchylosis to the posterior-superior spinous process of the ilium of the
opposite side, as well as the distance between the spinous process of
the last lumbar vertebra, and the anterior-superior spinous process
of the ilium on the side of the anchylosis, are smaller than the same
measurements on the opposite side.

"The distance from the inferior edge of the symphysis pubis to
the posterior and superior spinous process of the ilium, when the
anchylosis exists is greater than that extending from the same point
of the symphysis pubis to the posterior-superior spinous process, of
the opposite side.

" The walls of the pelvic excavation converge, in a certain oblique
manner, from above downward, and the pubic arch is more or less
contracted, so as to give it a resemblance to the male pelvis. These
two conditions, as well as the contraction of the sciatic notch, the
diminution of the distance existing between the spines of the ischia,
and the one-sided and defective development of the sacrum, bear a
direct proportion with the degree of obliquity.

"Finally, on the flattened side, the cotyloid cavity is placed more
directly in front than is observable in the normally-formed pelvis,
while on the opposite side, it looks almost directly outward, in such
a way that when examining the pelvis in front the eye rests directly
upon the cotyloid cavity of the flattened side, while the edge of the
one on the other side can only be seen, or at least very little of its
cavity.

" In order to give to those who never have seen a pelvis of this
kind as accurate an idea as possible, we will remark that when first
seen they give us the impression that the deformity has been occasioned
by a pressure acting from above downward, and from without to with-
in, in an oblique direction upon one of the lateral halves of the an-
terior pelvic walls, and upon one of the cotyloid cavities, while, at
the same time, the other half seems to have been qpmpressed on its
posterior portion from without inward.

" Another peculiarity f this variety of deformed pelvis is, that they

46 KING'S ECLECTIC OBSTETRICS.

differ from each other only in the degree of their obliquity, and at the
point where the sacrum is soldered to the ilium, while in every other
respect (that is to say, in reference to the principal peculiarities of the
deformity), they resemble each other as much as two eggs. It is on
this point that a skillful person, not knowing this peculiarity,, would
be disposed to take two different specimens presented to his inspection
for the same, and it would be difficult to convince him of his error.

" The condition of the bones of the pelvis (exclusive of the varia-
tions already mentioned), as it regards their strength, their volume,
their texture, their color, etc., is exactly similar to that of healthy
bones, such as are observed in young persons exempt from all deform-
ity. It is for this reason that we find on these bones none of the
signs, either as it regards form, etc., which are met with, as the con-
sequence of rickets or malacosteon of adults. If we divest our mind
of the existing deformities, the pelvis which we have seen, would seem
to resemble, in general, the healthy pelvis. The majority of them
belong to the medium-sized pelvis, while the others are either under
or over the average size. In no case that we have specially noticed,
have we discovered the least sign of the existence of rickets; in none
have there appeared any of the phenomena, or accidents, or morbid
modifications, w r hich usually precede or follow the English disease, or
the mollities ossium after puberty. Nowhere have we been able to
establish the injurious effects of external causes, such as falls, blows,
etc., and never has there existed any antecedent pain. It has riot been
proved, in any of the cases which we have specially examined, that
there existed any lameness. In one case only, we thought in seeing
the person walk we observed a slight limp, but other connoisseurs
present at the examination, did not observe it, and the parents, and
all the family of the person in question, assured us positively, that
they never remarked any lameness.

"In the pelvis of this kind, with the lumbar vertebrae attached, the
vertebral column was strait in the lumbar region ; in other cases, it
inclined to the side exempt from anchylosis. In ail the pelves of our
collection, provided with lumbar vjertebrse, the anterior face of the
bodies of the vertebrae was more or less turned toward the anchylosed
side."

The anchylosis of the sacro-iliac symphysis, above-named, as a
peculiarity of this deformity, is usually so perfect, that the articulation
can not be discovered ; and the two bones appear as one, without any
perceptible line of demarkation between them.

MALCONFORMATION OF THE PELVIS. 47

CHAPTER VI.

INDICATIONS OF MALCONFORMATION OF THE PELVIS.

UNDOUBTEDLY, the greatest earthly happiness consists in a domestic
life, where harmony and co-operation can be maintained; and there is
nothing so truly calculated to embitter it, and render it a source of
constant wretchedness to husband, wife, and relatives, as a knowledge
of the existence of pelvic malconformation in the wife, rendering her
incapable of giving birth to a full-grown fetus ; and to determine such
conformation and capability, in the otherwise marriageable female,
physicians are often consulted. It is, therefore, highly desirable that
every practitioner should be thoroughly acquainted with all the symp-
toms and indications necessary to determine the presence as well as the
extent of a pelvic deformity, for should he decide incorrectly, from
lack of proper information, and thus cause the parties to engage in a
contract for life, the responsibility of the death of the female, accruing
therefrom, would rest solely upon him. Or, as is sometimes the case,
the pregnant woman may require his knowledge to correctly ascertain
the extent of malformation, that a course may be pursued to preserve
both the parent and child, if possible at all events the mother also,
whether there would be safety in allowing gestation to continue its
full term, or in the induction of premature delivery.

Various causes may give rise to a suspicion of pelvic deformity,
as the pre-existence of rickets, fractures, unusual shortness of the
inferior extremities, or an inequality in their length, as well as an
inequality in the height of the hips, etc.; a short female with long
arms, when compared with the rest of the body, projecting chin, and
short, crooked legs, has also been named among those disposed to
pelvic malformation.

In the investigation of this matter, the physician should make
himself as thoroughly acquainted as possible with the previous history
of the patient, even from her infancy ; the presence of scrofulous
symptoms, or rickets, or any lameness or difficulty in walking at
any antecedent period, any fall upon the sacrum, or carrying heavy
weights, must be carefully inquired into ; and if there should be found
any spinal curvature, or shortening, or incurvation of the inferior
extremities, the age at which these changes occurred should be noticed;
though it must be remembered, that pelvic deformity is by no means

KING'S ECLECTIC OBSTETRICS.

a constant accompaniment of either of these last named conditions.
In sixty-nine cases of spinal deformity, reported l>y M. Bouvier, there
were but twelve cases where pelvic deformity was present. Should
there be present an inequality in the length of the inferior extremities.
it must be ascertained whether this arises from dislocations, or im-
properly united fractures independent of rickets, or whether it be
owing to rickets, or mollities ossium.

The above indications, however, though they may occasion a suspi-
cion of some existing deformity, are, of themselves, insufficient to
give a precise idea of its extent or character; yet when they are pre-
sent, they afford competent grounds for further and more accurate
examination. For this purpose there are various methods recognized;
as the measurement of the pelvis by instruments designed therefor,
termed callipers, or pelvimeters; or by the employment of the hand.
The first is termed instrumental pelvimetry, the latter, manual pclvim-
etry; and by the term pelvimetry is understood, a process having for
its aim the measurement of the various diameters and extent of the
pelvis.

The principal object for which pelvimeters have been used, is to
ascertain the capacity of the superior strait, which is the fetal entrance
to the pelvis, and more particularly, the extent of its antero-posterior
-diameter, though the dimensions of other parts may likewise be deter-
F I0 . 11. mined by some of them. The pelvim-

eters most usually employed, are Cou-
touly's, Stark's, Baudelocque's, Mad.
Boivin's, Simeon's and Stein's; some
of which are for external pelvic measure-
ment, and the others for internal.

Baudelocque's pelvi meter is for ex-
ternal examination, and is most com-
monly preferred to any others yet in-
vented for that purpose. It (F'njiire
11) consists of two movable metallic
branches or arms, curved externally
in a semicircular form, and of sufficient
concavity to embrace the hips, or antero-
posterior diameter of the pelvis. One
extremity of these arms is straigl.'
for the distance of about five inches, and, at its superior portion, is
attached to its fellow by a hinge, while the other, or free extremity
terminates in a knob, or button. At the inferior portion of the

PEL.VIMETER.

MALOOXFORMATION OF THE PELVIS. 49

straightened arms of the compass, commences its curvature, and at
this point a graduated scale is attached, which moves in a groove, and
indicates the degree of separation of the free extremities. The instru-
ment should always be applied to the naked body. In an examina-
tion, one of the knobs must be placed on the first spinous process
of the sacrum, which will be found a short distance below the hollow
of the loins, and the other must be placed on the symphysis pubis,
or in the separation of the labia majora at the most elevated point
of the anterior commissure of the vulva; and in effecting this, the
skin must be carefully drawn upward, so as to reach, as nearly as
possible, the upper part of the symphysis pubis, or else an error of
several lines may be made. This position of the instrument indicates
the distance from the posterior edge of the spinous process of the
sacrum to the anterior surface of the symphysis pubis, which, in a
well-formed pelvis, will be seven inches. But, in order to determine
the precise extent of the antero-posterior diameter of the superior
strait, the thickness of the sacrum, two and a half inches, as well as
that of the symphysis pubis, half an inch, must be subtracted from
the external measurement, seven inches, and which will give four
inches as the length of the diameter sought.

From the fact, however, that the knob of the posterior extremity
can not always be correctly placed upon the first spinous process of
the sacrum, and that there is more or less variation in the thickness of
the soft parts over which the instrument is to be applied, as well as of
the bones, and especially in the latter cases, where there has been an
arrest of development, the measurement of the antero-posterior diam-
eter of the superior strait, obtained by Baudelocque's pelvimeter, can not
be depended upon as being definitely certain; neither can the instru-
ment be rendered useful in the detection of other varieties of mal-
formation, whether dependent on exostosis, projection of the sacral
promontory, or other causes. And although its use is recommended in
cases where minute accuracy is not required, and in those unmarried
females in relation to whose pelvic dimensions the physician is con-
sulted, in each of which instances its employment may aid us in our
diagnosis; yet a reliance solely upon its indications is, under all cir-
cumstances, exceedingly imprudent and hazardous.

These objections to Baudelocque's pelvimeter, occasioned the inven-
tion of Coutoufy's pelvimeter, which, unlike the former, is designed for
the internal measurement of the pelvis. It is composed of two straight
steel arms, parallel with each other, and which slide with equal facility,
the one upon the other; these terminate in two raised extremities, and
4

KING'S ECLECTIC OBSTETRICS.

FIG. 12.

when introduced into the vagina, one of the extremities is applied
against the symphysis pubis, and the other against the promontory of
the sacrum; the application of which, however, is exceedingly difficult
to effect with accuracy. To the horizontal branch is attached a scale,
which indicates the exact amount of separation of the two extremities.
The introduction of this instrument is difficult, always attended with
more or less pain, and rather disgusting to female delicacy ; all of which
render its employment very objectionable.

The pelvimeter of Coutouly has undergone several modifications,
though the same objections still remain. The improvement of this
instrument, by Prof. M. Van Huevel, at Brussels, is considered
superior to any other. The following description of it is given
by Tucker:

" This instrument is composed of two
metallic rods, A A and B B (Fig. 12), united
by means of a joint, so arranged as to allow
the extension of the rods at pleasure, at the
same time that this joint may be tightened
by means of a nut-screw. The rod A A, in-
tended to be introduced into the vagina, is
curved anteriorly, and flattened at its ex-
tremity in the form of a spatula; the other
rod, B B, is not so long, and is traversed at
one extremity by a rod, c, movable backward
or forward, by means of a screw. In apply-
ing this instrument, the female is placed upon
her back, with the legs and thighs well

, flexed, and separated as widely as possible.

VAN HUEVEL'S PELVIMETER. -,

The point on the skin corresponding to the

upper edge of the symphysis pubis, should be marked with a dot
of ink; at the same time, a similar mark may be made to desig-
nate the position of the ilio-pectineal eminence, for the purpose of
measuring the oblique, as well as the antero-posterior diameter of
the superior strait. This being done, one or two fingers should be
introduced into the vagina, and placed against the sacral promon-
tory ; when this has been found, the internal rod, A A, is to be
inserted into the vagina, and carried along the fingers to the pro-
montory of the sacrum, against which the broad extremity of the
rod is to be placed. In this position it may be firmly held by hook-
ing the thumb of the hand introduced into the vagina, over the
hook attached -to the rod A A. When this rod has been accurately

M A LCOX FORMATION OF THE PELVIS.

placed, the button extremity of the rod C, FIG. 13.

.should be fixed upon the dot of ink, indi-
cating the superior edge of the symphysis
pubis. When the point of union between
the two rods has been made firm, by tightly
screwing the nut, the instrument may be
withdrawn, and the distance from the ex-
tremity of the rod c to that of A A, may be
ascertained. But, in order to obtain the
length of the sacro-pubic diameter, we must
subtract the thickness of the pubis, and to
do this, it must be measured by reintroduc-
ing the instrument, as is seen in Fig. 13.
The distance first ascertained, minus the
thickness of the pubis, will give us the exact
length of the antero-posterior diameter of
the pelvic brim. VAN HUEVEL'S PELVIMETER.

"The length of the oblique diameter may be ascertained in a similar
manner. In this case, the extremity of the rod A A, must be placed
against the sacro-iliac junction, while that of the rod C will rest on a
point a little external to the iliac artery. If the sacro-iliac junction
can not be reached, we may measure, instead of the obliqu'e diameter,
the distance sacro-cotyloid, which will give us every measurement of
importance, since, where the oblique diameter is contracted, it is due
(except in some cases of exostosis), not to compression inward of the sac-
ro-iliac joint, but to that of the sacral promontory or the cotyloid cavity.

" This instrument may be employed also in measuring the pelvis
externally, but its application in this case is too simple to require
farther explanation."

The other pelvimeters, by Stein, Simeon, and Mad. Boivin, are
somewhat similar in construction to those just named, and are liable to
the same objections. The pelvimeter of Stark, is rather simple in its
formation, but is decidedly objectionable, on account of its application
requiring the introduction of the whole hand within the vagina, which
w\)uld be exceedingly improper in an unmarried female; beside which,
in a small or deformed pelvis, much pain and difficulty must necessarily
attend its use. Prof. Lazarewitch, of Charkoff, Russia, has devised a
pelvimeter which may be used for internal or external measurements,
or for these two combined ; it is in many respects superior to any that
have yet been presented to the profession, but has not been generally
received.

52 KING'S KCLKCTIC OKSTKTUICS.

All artificial pelviineters are liable to more or less inaccuracy, and
in some instances are of no use at all; still we should not omit their
employment in those cases which come before us for examination, as
they will usually afford some aid toward forming a correct diagnosis.
The hand, and, under certain circumstances, the index finger of the
accoucheur, when skillfully introduced into the vagina, is undoubtedly
the most certain and accurate pelvimeter we have, and can be employed
with all females, whether married or not. I am aware that writers
generally oppose the use of the finger in the examination of the un-
married, and would impress it upon all practitioners as a correct rule
by which to be governed, more especially in this country, where pelvic
deformities are rarely. to be met with; but when the female has arrived
at the marriageable period, and is about to enter into wedlock, yet
doubts are entertained as to the perfect formation of the pelvis, and
the other indications lead us strongly to suspect some defection, we
should not hesitate a moment in performing a manual exploration, con-
sidering the future health, happiness, and life of the individual of too
much importance to herself, her friends, and society, to be trifled away
by an unwise regard to customs or opinions, which are only strictly
applicable to the healthy, and those of perfect conformation.

In the manual examination, it is preferable to have the female
standing erect, with her shoulders against the wall; the index finger,
having been previously oiled, should then be carefully introduced into
the vagina, with the end of the finger pointing upward and backward
in the direction of the promontory of the sacrum. If, when the radial
portion of the finger has reached the lower edge of the symphysis
pubis, the sacral promontory can not be felt, we may safely determine
that this diameter of the superior strait, the antero-posterior, is not
deformed; but if the sacral promontory can be felt, a mark should be
made upon the finger, at its point of contact with the symphysis pubis,
(or the index finger of the other hand may be placed upon this part
and held there), and then withdrawing it, the distance between the
mark and extremity of the finger will give us the exact measurement
of this diameter, if we deduct from it six lines, for the thickness of
the symphysis pubis, and two or three lines for the obliquity of tlie
measurement.

But this is only useful where the pelvis is much distorted, or where
the antero-posterior diameter of the brim is less than three inches.
Other methods have been advised where greater accuracy is required,
such as the introduction of the whole left hand within the vagina, to
such a distance that the external edge of the little finger may be placed

MALCONFORMATION OF THE PELVIS.

against the inner surface of the symphysis pubis, and the first finger
against the promontory of the sacrum. As the FIG. 14.

hand must be opened, after having entered with-
in the vagina, the practitioner can ascertain both
the antero-posterior and transverse diameters,
by knowing whether the whole width of the
digital extremities of the hand can be introduced
into the space under investigation whether he
must spread his fingers to touch the extreme
limits of the diameters or, whether he can
only introduce two or three fingers. In the
first instance, the diameters will be equal to
the width of the digital extremities of the
hand; in the second, they will be more than
three inches, and perhaps four; and in the
latter, the measurement will be from one and MANUAL PELVIMETRY.
a half to three inches, according to the measure of the fingers intro-
duced. (Fig. 14.)

The distances between the ischiatic tuberosities can be ascertained by
moving the finger from side to side, or by means of a pair of compasses
applied externally. The finger can likewise measure the antero-pos-
terior diameter of the inferior strait, by applying its radial portion to
the symphysis pubis, with the extremity pointing toward the apex of
the coccyx. The transverse and oblique diameters of the superior
strait may also be ascertained, sufficiently accurate for all practical
purposes, by carefully examining the circumference of the brim with
the finger, in cases where this is practicable.
The length of the symphysis pubis, the curve
of the sacrum, the projection of the spine of
the ischium, the shape of the straits, the con-
dition of the lateral parietes of the cavity, and
the presence of any tumor within the pelvis,
can always be decided by the finger much
better than by any instrument. And in cases
where the fetal head does not advance during
labor, the finger can readily determine the space
existing between the circumference of the head
and that of the pelvis, and thus instruct us
whether the pelvis be sufficiently proportioned
or not.

In cases where the child's head is somewhat MANUAL PELVIMETRY.

FIG. 15.

54 KING'S ECLECTIC OBSTETRICS.

protruded into the pelvis, even when the brim is contracted, and the
hand can not in consequence be carried up to make an accurate ex-
amination, Ramsbotham recommends two fingers of the left hand
to be introduced within the vagina, the extremity of the first finger
being placed exactly behind and against the symphysis pubis, and the
tip of the second against the sacral promontory. If the examiner will
then carefully withdraw the fingers, keeping them steady, the distance
between their extremities may be measured on a scale of inches, or
otherwise, and thus give the exact dimensions of the antero-posterior
diameter. (Fig. 15.)

CHAPTER VII.

THE FETUS, ITS DIVISIONS AND DIMENSIONS.

IN order to understand the mechanism of labor, beside having a
knowledge of the pelvis and its divisions, it is likewise necessary to
become well acquainted with the dimensions of the various parts of the
fetus, especially those which, from increase of size, may render it diffi-
cult or even impossible for labor to progress. Accoucheurs generally
divide the fetus into three distinct parts, namely : the head, the trunk,
the extremities; some, however, in consequence of the peculiar manner
in which it is curved upon itself when within the uterine cavity, object
to this division, and prefer another, comprising, 1, the cephalic ex-
tremity, or head; 2, the pelvic extremity, including the pelvis and the
inferior extremities; and 3, the torso, or trunk, having reference to
the parts between the head and upper pelvis. But the first arrange-
ment is sufficient for all practical purposes.

The head is of an oval shape, and is the largest and least reducible
part of the fetus, and a familiarity with its obstetric divisions and
dimensions is highly necessary for the successful accoucheur. The
bones of the fetal cranium are the same in number as in the adult
head, but they are soft, and are not united by firm sutures as in the
adult; their imperfect ossification gives rise to membranous spaces be-
tween them of greater or lesser extent, called commissures or sutures,
from the Latin word suo, to sew, and which are often of much benefit
to the safety of the child during its passage through the pelvic canal,
inasmuch as in every delivery they admit a certain degree of com-

THE FETUS ITS DIVISIONS, ETC. 55

pression or reduction of the head, and even a riding of the bones over
each other. They also serve as indications by means of which the
position of the head in the pelvis may be correctly ascertained. There
are several of these sutures, but those which are the most important
are three in number the others are of no practical utility in an ob-
stetrical point of view.

1st. The sagittal or median suture or commissure, is situated between
the two frontal and the two parietal bones, and extends from the root
of the nose to the superior angle of the occipital bone, dividing the
anterior and superior portion of the cranium into two equal parts ;
anteriorly, it is crossed at right angles by the coronal suture, and ter-
minates posteriorly at the lambdoidal suture. Occasionally, but very
rarely, instances are found where this suture extends throughout the
occipital bone, dividing it into two parts.

2d. The coronal suture, sometimes called the transverse, anterior, or
fronto-parietal, crosses the sagittal suture at right angles, separating
the frontal from the parietal bones, and extends from the extremity
of the greater wing of the sphenoid bone of one side, to that of the
opposite side.

3d. The lambdoidal, or occipito-parietal suture, separates the upper
edge of the occipital bone from the posterior edges of the parietal
bones ; in shape it resembles the Greek capital, lambda.

At the points of intersection and junction of these commissures are
membranous spaces or openings, occasioned by the incompleteness of
the ossification of the angles of the bones. There are six of these
spaces in the fetal head, of which a knowledge of but two is all that
is required for practical purposes; they are technically termed fon-
tanelles from/ons, a fountain; they have also been called bregmas, from
a Greek word signifying "to sprinkle," each name originating from
an ancient idea that a moisture passed from the brain through these
membranous spaces.

The anterior fontanelle, also called the bregmatic, or frontal, is the
opening situated at the intersection of the coronal and sagittal com-
missures; it is of a quadrangular or diamond-shape, and may be dis-
tinguished by the four bony angles, the edges of which are soft and
smooth, being almost always tipped with cartilage. The opening is
of considerable size, which, however, varies in different heads, and
the finger can readily detect it by its soft, smooth, and yielding
character.

The posterior or occipital fontanelle, is situated at the center or angle
of the lambdoidal commissures at its point of junction with the pos-

56 KING'S KCLKCTIC OKSTKTKICS.

terior extremity of the sagittal commissure. In the immature fetus it
may he felt distinctly, but in the full-developed infant it consists of
merely a kind of triangle formed by the meeting of the two commis-
sures, and is frequently wanting. This fontanelle may be distinguished
by its triangular shape ; its narrowness, being much smaller than the
anterior fontanelle; having but three bony angles; and in consequence
of the more complete ossification of the edges of the bones, they im-
part to the finger, on pressure, a hard serrated sensation, which is
never possessed by the edges of the anterior fontanelle, and which,
therefore, will enable the practitioner to distinguish the one fontanelle
from the other. In many instances the posterior fontanelle is so small
that it can only be distinguished by the three commissure lines that
radiate from a common center.

It has been previously remarked, that occasionally the sagittal com-
missure continues throughout the occipital bone, dividing it into two
parts, and in instances where this occurs, four bony angles will be per-
ceived by the finger. The practitioner, however, can not err in this,
if he will recollect that the posterior fontanelle is always smaller,
and its edges rougher and harder than the anterior, and that
on the slightest compression of the head, the occipital bone al-
ways glides under the ossa parietalia. The anterior fontanelle is
invariably larger than the posterior, no matter how well marked this
last may be.

A thorough knowledge of the sutures and fontanelles is absolutely
required in the practice of midwifery for it is from them that the
position of the head within the pelvis is ascertained with certainty;
and in cases where interference is demanded, from a too early de-
parture of the head from its proper or flexed position, or from some
other cause, the educated accoucheur can at once render the necessary
assistance to bring the labor to a safe and prosperous termination. But
if he have neglected to inform himself on these points, his patient may
be subjected to much unnecessary suffering, and, perhaps, from lack
of timely aid, the death of both mother and child may ultimately
ensue. Hence, a peTfect acquaintance with these peculiar marks can
not be too strongly impressed on the mind of the student. It is from
these alone, that the situation of the head when in the pelvis can be cor-
rectly ascertained, and never by an ear, nose, or other part of the head.

There are four principal DIAMETERS belonging to the fetal
head, viz.:

1. The large, oblique, or occipito-mental diameter (A B, Fig. 16),

THE FETUS ITS DIVISIONS, ETC. 57

extending from the vertex or posterior F IG . 15.

fontanelle to the symphysis of the chin ;

its measurement is from five to five and

a half inches. It is important to recollect

this diameter, for if it enters the cavity with

either .extremity descending, it can not be

reversed, from want of space, but must

either be allowed to escape as it presents,

or be returned above the superior strait to

effect a change. This diameter may be

* i i .IT / .0, DIAMETERS OF THE FETAL

saielv elongated by compression ot the TJ

~ * HEAD.

cranium with the forceps or otherwise, to A B occipito-mcntai.
the extent of six or, ten lines, so that its D E - Occipito-fnmtai.

, C H. Cervico-bregmatic.

whole measurement may be six or seven T G . Tracheio-bregmatic, or vertical

inches A ^' F ron t- m ental, or facial.

2. The longitudinal, horizontal, antero-posterior or occipito-frontal
diameter (D E, Fig. 16), extends from the center of the forehead to
the occipital protuberance; its measurement is from four to four and
three-quarter inches.

3. The perpendicular, vertical, occipito-bregmatio or trachelo-breg-
matic diameter (Gi,Fig. 16), extends perpendicularly from the most
elevated point of the vertex, or top of the head to the anterior portion
of the great occipital foramen ; its measurement is from three and a
half to three and three-quarter inches.

4. The small, transverse or bi-parietal diameter (A B, Fig. 17), ex-
tends from the center of one parietal protuberance to that of the other;
its measurement is from three and a half to nearly four inches. This
diameter may, by compression of the cranium with the forceps or
otherwise, be diminished one-third or even three-fourths of an inch,
without any injury to the child.

In addition to these measurements of the fetal head, with which
the student must become familiar, authors have given several others,
a knowledge of which, however, is not necessarily important in prac-
tice ; they are :

1. The cervico-bregmatic diameter (c H, Fig. 16), whioh extends
from the back part of the neck to the center of the anterior fonta-
nelle; it measures from three and a half to three and three-quarter
inches.

2. The fronto-mental or facial diameter (A D, Fig. 16), extends from
the symphysis of the chin, to the center of the forehead ; it measures
from three to four inches.

KING'S KCLECTIC OBSTETRICS.

3. The post trachelo-frontal diameter, which extends from a point
midway between the occipital protuberance and the occipital foramen,
to the center of the frontal bone ; it measures from four to four and
three-quarter inches.

4. The prce-trachelo occipital diameter, extends from the hyoid bone
to the posterior fontanelle ; it measures from three and a half to four
inches.

5. The bi-temporal diameter (c D, Fig. 17), extends from the root
of the zygomatic process on one side to the same point opposite; it
measures from two and three-quarters to three inches.

6. The sub-occipito bregmatie diameter, extends from a point midway
between the foramen magnum and the occipital protuberance to the
anterior fontanelle ; it measures three and three-quarter inches.

In order that the diameters of the fetal head may, at one glance,
be compared with those of the pelvis, I present the following tables
after the manner of Cazeaux :

Diameters of the pelvis,
(in inches).

Antero-posterior.

Transverse.

Oblique.

Sacro-cotyloid.

Superior Strait

...4 to 4i

...5 to 5

.4i to 5

33 to 41 .. ..

.4 to 5

4 to 4J

Kxcavation

...4 to 5

4J to 4f

. 41

DIAMETERS OF THE FETAL HEAD.

I Occipito-mental 5 to 5 inches.

Longitudinal Diameters.... J Occipito-frontal 4 to 4f *'

( Siib-occipito-bregmatic 3|

Transverse Diameters ,

Vertical Diameters.

( Bi-parietal 3 to 3|

( Bi-temporal. 3

( Trachelo-bregmatic 3J to 3f

Fron to-mental 3 to 4

A comparison of the diameters of the fetus with those of the pelvis,
will be found of much utility, enabling the practitioner more readily
to effect a correspondence between the large diameters of the head and
the long diameters or axes of the pelvis, in all cases where such a
change may be required. From an investigation of these measure-
ments, it will be seen that at full term, the fetus, to be safely and
readily expelled must present one end of its long diameter (A or B, Fig.
16) ; and also, that if its occipito-raental diameter is parallel with the

THE FETUS ITS DIVISIONS, ETC. 59

plane of the inferior strait, delivery will be impossible; either the chin
or the occiput must descend first. It will likewise be observed, that
the most favorable position for the expulsion of the fetal head, is to
have it strongly flexed upon the body, so that its largest diameter, the
occipito-mental, shall correspond to the long diameters or axes re-
spectively of the straits and cavity, while its sub- j? IG> jy
occipito-bregmatic diameter, shall be parallel to the
plane of the straits, and the occiput shall, during its
passage, correspond to one extremity of an oblique
diameter, until the rotation ensues which places the
presenting extremity under the arch of the pubis.

Each of the diameters of the fetal head have a
circumference assigned to them, the largest of which
is the occipito-mental circumference, and which with
the occipito frontal or horizontal circumference, are
more important than the others, because during A B . Bi-Parietai.
labor they successively come into relation with the c D - Bi-Temporai.
pelvic parietes. The fronto-mental circumference passes over the
chin, cheeks, and forehead, and is consequently termed by several
writers, the facial circumference. The remaining circumferences are
unimportant.

The other diameters of the fetus are :

1. The bis-aoromial diameter, extending from one acromial process
to the other; it measures four and a half inches.

2. The dorso-sternal diameter, extending from the vertebral column
through to the sternum; it measures three and a half inches.

3. The bis-iliac diameter, extending from the crest of one ilium to
that of the other ; it measures three and three-quarter inches.

4. The bi-trochanterie diameter, extending from one trochanter to
the other; it measures three and a half inches.

The movements which the fetal head is enabled to execute with
safety; in consequence of the laxity of the articular ligaments between
the head and vertebral column, must not be forgotten. In head pre-
sentations the shoulders are usually expelled so soon after the head
has passed, that accidents are rarely met with ; but in breech or feet
presentations, or in cases of turning, in which the head may be re-
tained for some time within the cavity from mal-position or otherwise,
the careless or unskilled accoucheur may, by the employment of an
ill-directed force, occasion the death of the child.

The head may be moved in four different directions, termed flexion,

60 KING'S I'X'LKCTIC OBSTETRICS.

cxt 'ii*loii, lateral inclination, and rotation; and the extent to which
these movements may be carried, must never be lost sight of.

The movement of flexion, is that in which the head is thrown for-
ward and downward, so that the chin is depressed upon the neck or
upper part of the sternum, and to which extent this motion is limited.
By it, the occipito-mental diameter of the head is made part of the
long diameter of the fetal ovoid or ellipse. This movement of the
head should never be forgotten, as when it is incomplete, or there ia
too early a departure of the chin from the breast, during the passage
of the head through the pelvic canal, an attention to it, with the
proper manipulation to restore the flexion, as hereafter described, will
very much facilitate the expulsive progress of the head ; but a want
of care or knowledge in this matter may, in these instances, render
the labor tedious, painful, and even hazardous.

The movement of extension, is the reverse of the former; the head is
thrown backward; and the motion is limited by the occiput coming
in contact with the back of the neck. This motion takes place in
occipito-anterior positions of the head, in which the vertex becomes
placed under the pubic arch, while the forehead, face, and chin, leav-
ing their previous state of flexion, pass successively along the arch of
the sacrum, coccyx, and perineum.

The movement of lateral inclination is that in which the head is
thrown to one side or the other, and is limited by the side of the head,
meeting with the corresponding shoulder.

The movement of rotation is that in which the face of the child is
turned from one side to the other. All the.other motions are limited
in their extent by an opposing obstacle, but in this last there is none
presented, and if it be carried too far the life of the child will be
endangered. I have met with several cases of still-born infants, occa-
sioned by the midwife rotating the body of the child beyond its proper
limits ; and instances are recorded where the body has been made to
turn once and even twice, almost, if not actually twisting off the neck.
It must be borne in mind that the head can not be rotated upon the
neck, with safety, beyond one-quarter of a circle, or in other words,
the face of the child can not be turned to the right or left beyond the
corresponding shoulder; and this applies to the head when out of the
pelvis, and the body within, and likewise to the body out of the pelvis
and the head detained.

One thing may be adverted to here, which will be again noticed in
another place, and which is, that pulling the body of the child for the
purpose of extracting the head, or pulling with the forceps applied to

THE FEMALE ORGANS OF GENERATION.

the head, the body not being expelled, are not only improper but ex-
ceedingly culpable. I have known a practitioner, in his endeavor to
extract the head with the forceps, pull so forcibly and continuously, as
to almost tear the head from the body, at the same time lacerating the
soft parts of the mother in a most shocking manner.

CHAPTER VIII.

THE FEMALE ORGANS OF GENERATION.

HAVING referred to the
osseous portions of the fe-
male and of the fetus, in
their obstetrical relations, it
becomes necessary to briefly
notice the soft parts which
cover them, constituting in
the adult female, the organs
of generation, and which are
divided into external and in-
ternal. The external organs,
to which the term Pudendum
is applied, are situated on
the exterior of the pelvis,
where they may be noticed
by the eye, and comprise,
1st. The mons veneris ; 2d.
The vulva and its parts; 3d.
The perineum. The inter-
nal organs are more deeply
seated, and can not be seen
or studied except by dissec-
tion ; they are, 1st. The
vagina; 2d. The uterus;
3d. The Fallopian tubes and
ligaments; and 4th. The
ovaries.

The MONS VENEEIS,
or supra-pubal eminence, is

FIG. 18.

THE EXTERNAL FEMALE ORGANS OF GEHERA-
TION.

A. The Mons Veneris.

B. The Labia Externa, or Labia Pudendi.

C. The Fourchette, or Posterior Commissure of the Vulva.
D D. The Perineum, extending from the Posterior Com-
missure of the Vulva to the Anus.

E. The Anus.

F. The Clitoris.

G. The Preputium Olitoridis.

H. The Nymphte, or Labia luterna.

I. The Vestibulutn.

K. The Meat us Urinarius.

L. The Hymen.

62 KIN(;'s KCLKCTIC OIJSTKTinrs.

a triangular space situated at the lower part of the hypogastrium,
immediately on the lore part of the pubis, in front of, and just above,
the symphysis pubis. It presents a prominent rotundity, which varies
according to the quantity of adipose matter deposited, and of which
it is principally composed ; it is more prominent in young and vig-
orous virgins than in mothers and aged females, and is said to be much
more so in young females the natives of tropical climates. The cutis
or skin which covers this part is smooth in early life, but becomes
covere 1 with short curled hair or capilli at maturity, and is supplied
with numerous sebaceous follicles; a straight long hair is said to be
indicative of sterility, and also of a lack of energy of the reproductive
organs. Through the adipose and cellular tissue, are ramifications of
some branches of the external pudic vessels and nerves, and in it are
distributed some fibers of the round ligaments of the uterus.

The uses of the mons veneris during copulation are not satisfactorily
ascertained, though it is said to be more elevated when the female is
laboring under sexual excitement, and immediately previous to men-
struation. Moreau states, that in parturition, owing to the extensi-
bility of the skin, and laxity of the cellular tissue contained within it,
it assists in augmenting the size of the vulva. This part is sometimes
attacked with inflammations and abscesses which prove exceedingly
painful, and may suffer from the various forms of disease common to
the tissues entering into its formation.

The VULVA is the slit, or longitudinal fissure (fissura vulvce, or
genital fissure) , which extends from the mons veneris superiorly, along
the median line to the perineum inferiorly. The orifice of the vulva
serves as an entrance to some of the internal organs; it varies in ex-
tent in different persons; is very small in infancy, small and narrow
in girls, of greater width and extent in women, and during parturition
distends to a size which admits of the free passage of the child through
it. After copulation its size is usually double that of the vagina!
orifice; and in women who have borne many children, or who have
had laceration of the perineum, it most commonly remains quite
large.

Along the lateral portions of the vulva are two rounded folds, or
oblong eminences, or lips, which extend in a longitudinal direction
from the mons veneris to the posterior part of the vulva; these are
called the LABIA MAJORA, labia externa, or labia pudendi. As
they proceed from before backward, they diminish in thickness, which
renders them more prominent above than below; their superior ex-

THE FEMALE ORGANS OF GENERATION. 63

tremity is adherent, the inferior being free and rounded. Externally,
the labia majora are covered with the common skin, on which a few
hairs may be found, and which is supplied with numerous sebaceous
follicles; internally, it is covered with a beautifully fine, smooth, and
sensitive mucous membrane, of a florid color in young persons, but
which is lost on the approach of age. The inner, or mucous surface,
is supplied with glands that secrete a fluid preventing an adhesion of
these parts, as well as protecting them from the effects of friction.
By their approximation, the labia majora cover and protect the in-
ternal parts from the air and external agencies; and during parturition,
when the child is about to be expelled, by their elongation and almost
entire disappearance, they increase the capaciousness of the vulva.
They may be attacked with inflammation, abscess, hernia, serous in-
filtration, or other diseases, which sometimes interfere with their
functional activity, or occasion various accidents.

The point of union of the labia majora, at their upper or anterior
extremity, at the symphysis pubis, forms the anterior commissure of
the vulva; and at their lower or posterior extremity they form a kind
of bridle at the anterior edge of the perineum, called the FOUK-
CHETTE, frcenum, or posterior commissure of the vulva, which is
sometimes slightly lacerated during first labors, but which occurrence
causes no trouble. The posterior commissure is the most dense and
resisting point of the vulva, not yielding without difficulty.

On separating the labia majora, we observe several other parts; the
NYMPH.ZE, labia internet, or labia minora, which are two mem-
branous folds, located between, and running parallel with, the labia
majora, and which extend from the anterior commissure to about the
genital fissure; they are formed of cellular, as well as spongy tissues,
covered with mucous membrane, and contain many vessels and nerves
which render them highly sensitive. Their superior edge is coherent,
the inferior loose; and a little below the anterior commissure of the
vulva they unite, the anterior extremity passing around the clitoris so
as to form a hood, or prepuce to it, while the posterior is lost in the
corresponding labium pudendi. In young persons,their color is lively
red, they are firm, and their surface is not corrugated, but smooth; in
women who have had children they become darker and wrinkled.
Females of a phlegmatic temperament, and especially those laboring
under leucorrhea, have them pale and flaccid ; and in brunettes they
are dark, granulated, and sometimes quite long. They are furnished
with a sebaceous substance, which, if allowed to accumulate in quantity,
occasions a disagreeable fetor.

64 KI.NC's KCLKCTIC OHSTKTHICS.

In early life the nymphse are so long as to project beyond the ex-
ternal lips, or labia majora, which, however, usually disappears at
puberty. Occasionally, the labia minora have projected so far as to
produce much inconvenience, requiring an operation for their removal ;
and among the South Africans, especially the Bochisman women, this
elongation is found in an excessive degree, extending to eight or ten
inches below the margin of the labia, forming what has been named
the apron of the Hottentots.

The uses of the nymphse are unknown, although they are supposed
to add to the voluptuousness of copulation, and to amplify the vulva
during parturition, by becoming distended or effaced ; this last view,
however, does not agree with my own observations, as I have repeat-
edly ascertained their presence during the passage of the fetal head
into the world.

The CLITORIS is situated at the superior and median part of the
vulva, at the junction or origin of the labia minora, and just below
the anterior commissure of the vulva. It is a small red projection,
bearing some resemblance to the male penis, having two corpora cav-
ernosa, which are attached by crura to the rami of the pubes and ischia,
a spongy, cellular tissue, somewhat similar to the corpus spongiosum
in the male, two erector muscles inserted into the above named crura
rendering the organ erectile, and is surrounded with a fold of the in-
ternal mucous membrane of the labia, which forms the prepuce, or
preputium clitoridis. It is, however, imperforate, being without a
canal, or urethra. At its external termination is a round, red protu-
berance, which, from its shape, has received the name of glans clitoridis.

The clitoris is supplied with arteries and veins from several sources,
and its nerves, which chiefly arise from the sacral plexus [branches
of the pudic], endow it with intense erotic sensibility. Its length is
variable, and when uncommonly long or hypertrophied, has sometimes
occasioned doubts as to the sex of the individual. It is of no service
in parturition, but is considered as the principal seat of venereal
pleasure in the female ; the excision of this organ in the adult female
very much lessens the voluptuousness of sexual congress; and its
titillation alone will give completion to the venereal orgasm, as in in-
stances of masturbation. In infants, this organ presents an apparent
excess of size, projecting beyond the vulva, and which is owing to the
want of development of the proximate organs, especially of the labia
majora.

The VESTIBULE is a triangular space or depression, about an
inch in length, having the clitoris above, the meatus urinarius or ori-

THE FEMALE ORGANS OP GENERATION. 65

fice of the urethra below, and the nymphse laterally. The lower, or
inferior portion of this depression, is divided by a line or raphe, which
can be readily felt 'with the point of the finger, and which leads di-
rectly to the orifice of the urethra. It is supplied with numerous
mucous glands. Immediately beneath the vestibulum may be recog-
nized, situated on a line with the top of the pubic arch, a small bulb-
ous projection or cushion, which incloses the orifice of the urethra.
A knowledge of this arrangement will render the catheterism of the
female an easy operation.

The FEMALE URETHRA is a slightly curved canal, from one to
two inches in length. It is larger and more dilatable than that of the
male, and passes directly beneath and behind the symphysis pubis in
an oblique direction, upward and backward, having its concavity up-
ward, on the pubic side, and its convexity downward, on the vaginal
side. During labor or parturition, the urethra becomes elongated, and
its direction, as well as that of its orifice, changes, so as to create diffi-
culty in the introduction of 'the catheter. For instance, distension of
the bladder with urine, distension of the vagina by the presenting
parts, or the elevation of the uterus, may carry the urethral canal
high upward, and sometimes thrust it against the pubes, so that its
orifice will be brought behind the symphysis pubis ; in such cases, the
sound or catheter must be introduced behind and parallel to the sym-
physis. The urethra is lined internally with mucous membrane, the
folds of which usually run longitudinally and not transversely.

The external orifice of the urethra, called the meatus urinarius, is
situated below the vestibule, and immediately above the vaginal open-
ing; it is irregularly round, and is more constricted than the upper
portion of the urethral canal. A membranous swelling, or cushion,
abundantly supplied with numerous follicles, surrounds it; and in
ordinary cases, where the introduction or the catheter is necessary,
after having found this raised cushion, which, as already stated, is at
the lower part of the vestibule, directly under the symphysis pubis,
the orifice will be discovered in the center of it. The point of the
catheter should be directed perpendicularly to the surface of the ves-
tibule, introduced within the orifice, then by depressing the handle, the
point will turn upward behind the pubis and toward the bladder.
This tubercle or caruncle of the urethra varies in its development,
the orifice being sometimes very thin, merely membranous, and at
others very patulous and funnel shaped.

In instances where from long-continued pressure of the child's head,
or from other causes, the practitioner is unable to detect the meatus
5

B6 KING'S ECLECTIC OBSTETRICS.

urinarius, and it is absolutely necessary that the bladder should be
evacuated to avoid its rupturing, or the probable formation of a
fistulous passage between it and the vagina, it may be necessary
for the practitioner to expose the parts to sight, in order to in-
troduce the catheter; indeed, it is his duty to do so; but under
ordinary circumstances the patient should never be exposed for the
operation.

The urethra may be so severely pressed by the fetal head as to
occasion sloughing, resulting in urethro-vaginal fistula, which is a
very difficult malady to remove; and in operations with the forceps
or crotchet, the practitioner sho'uld be extremely cautious not to bruise
or lacerate this canal, as it is almost certain to result in permanent
stillicidium of urine. The urethra! mucous membrane is subject to
prolapsus, tumefaction, and occasionally polypus growths.

The HYMEN, also termed the virginal valve, vaginal valve, fios
virginitatis, claustrum virginale, etc., is a membranous fold formed by
the mucous membrane of the genital surface. It is situated about
half an inch within the vulva, at the orifice of the vagina (ostium
vagince), which it closes more or less perfectly, and is usually in the
shape of a crescent, with its convexity downward and adhering, and
its concavity upward and detached. Sometimes it is oval from right
to left, or circular, with one or more openings which allow the various
secretions and discharges from the vagina and uterus to pass out;
occasionally, it is imperforate, preventing the egress of these dis-
charges". Ordinarily, the hymen is quite thin and delicate, being
ruptured by the slightest causes ; sometimes it is soft and lax, yielding
without rupturing; and instances have occurred in which it was so
firm as to present an obstacle to copulation, or to embarass the
process of parturition; to remedy which, it has been found necessary
to make a circular or crucial incision in it.

The uses of this membrane are not well defined, nor can they be
of much consequence, since it is lost daily without injury. The pres-
ence of the hymen has long been regarded as a sign of virginity, but
when we reflect that it is sometimes readily ruptured in females of
undoubted chastity, even in the acts of laughing, coughing, sneezing,
lifting, etc., and again that it has been found entire at the time of
parturition, most convincing proof is afforded, that, as an emblem
of virginity, this membrane can not be depended upon under any
circumstances whatever; for its absence affords no evidence that
sexual intercourse has taken place, nor does its presence prove the
condition of chastity. It is often destroyed, during infancy, by care-

THE FEMALE ORGANS OF GENERATION. 67

less nurses who rub these parts roughly with a coarse towel. I have
met with seven instances only, of firm and imperforate hymen in
which it was impossible for the nuptial rites to be consummated,
and one in which it was present at the parturient period, and in each
of which the difficulty was removed by the bistoury.

Along the circumference of the orifice of the vagina, are several
small, flat, or rounded reddish tubercles, commonly numbering from
two to four, occasionally five or six. Sometimes they are pale, or
livid, and vary in firmness. They exist in pairs, the two posterior
being generally larger and longer than the anterior. These are termed
the CARUNCUL^E MYRTIFORMES, and are considered by some
anatomists as the remains of the ruptured hymen, while others view
them as existing independent of this membrane. I have in three
instances, witnessed the unrupturcd hymen simultaneously with the
presence of the carunculse. As they disappear during the expulsion
of the fetus, they may probably be designed for enlarging the capacity
of the vulva, thereby diminishing the risk of severe contusion or
laceration. When they become so large as to cause unpleasant symp-
toms they may be removed by the scissors.

Between the posterior commissure of the vulva, or fburchette, and
the hymen and the external orifice of the vagina, is a space or depres-
sion bearing some resemblance to the cavity of a small boat, which is
called the FOSSA NAVICULARIS, or concha. Its greatest extent
is six lines, or half an inch. It is found in girls and in women who
have not given birth to children, but is usually ruptured in a first con-
finement by the efforts made to expel the fetal head, and which is fol-
lowed by no serious consequences unless more or less of the perineum
be likewise involved. It is the most inferior part of the vulva, and
hence becomes a receptacle for vaginal and uterine discharges ; inflam-
mation and syphilitic ulcerations are frequently located there among
public women, which occasion obstinate and intractable difficulties,
not easy to cure.

The PERINEUM proper, includes the whole of the space between
the coccyx and the pubes, including the terminal orifices of the urinary,
generative, and digestive apparatus; but in Obstetrics, by the term
perineum, is meant the space lying between the posterior commissure
of the vulva and the anus. It is from an inch to an inch and a half in
length, and presents on its external surface, on the mesial line, a .prom-
inent, hard ridge, which is termed the raphe of the perineum. Exter-
nal ty,the ]>erineum is covered with the skin; internally, it consists of

68 KING'S ECLECTIC OJ:STJ:TKICS.

adipose cellular tissue, of fascia, aud of several muscles. In some
females it is thick, hard, and resisting; in others it is thin, soft, and
easily dilated ; conditions which render labor tedious or otherwise, by
retarding the passage of the fetal head when rigid and unyielding, or
allowing ib to pass by a ready dilatation.

In the last stage of labor, the perineum usually offers more or less
resistance, but eventually becomes thinner, elongates, and extends,
even to four or five inches, thus affording a passage for the child ; and it
is at this period, when the head is passing, that it becomes occasionally
lacerated, or more rarely, perforated through its center. This acci-
dent, however, may generally be avoided, by supporting the perineum
with the hand, making such firm but moderate pressure as will pre-
vent the head from advancing too rapidly, and which, at the same
time, will allow the tissues an opportunity to acquire the proper degree
of extensibility. Excessive and injudicious support will undoubtedly
effect more mischief than benefit. The condition of the perineum
should never be overlooked by the practitioner, as it frequently pre-
sents an obstacle to delivery far greater than the os uteri, the straits,
and the vagina together, owing to its unyielding resistance ; and
a labor which, under ordinary circumstances, would be finished in
from fifteen to thirty minutes after the head has reached this point,
may be continued for several hours. This rigid 'condition of the
perineum is often brought on by excessive meddling, frequent exam-
inations, etc. I have overcome several instances of obstinate resist-
ance, in a very short time, by relaxing the parts by means of a process
of dilatation, which may be produced by sweeping the finger through
the posterior commissure of the vulva. Rigidity of the perineum is a
condition which frequently retards the completion of labor ; support to
the parts as usually applied is a feeble agent in overcoming it; the
sweeping movement, however, if applied at frequent intervals, for a
brief period, will, as a rule, result in complete muscular relaxation.

CHAPTER IX.

THE INTERNAL ORGANS OF GENERATION.

THE internal organs of generation, belonging to the female, are, as
previously remarked, the vagina, the uterus and its appendages, the
Fallopian tubes, ligaments, and ovaries (Fig. 19).

the VAGINA is a cylindrical membranous canal, which con-
nects the internal with the external organs of generation; it is

INTERNAL ORGANS OF GENERATION.

located in the pelvic cavity, FlG -

being posterior to the bladder
and urethra, and anterior to the
rectum. Its direction is nearly
coincident with the axis of the
pelvis, which gives a curved form
to it, the concavity of which, is
on its anterior or pubic surface,
and the convexity on its posterior or
rectal surface. The walls of the
vagina are soft and yielding, and
slightly flattened from before back-
ward the anterior wall being
shorter than the posterior. In well
formed women its length is five or
six inches, and its width one; but
this usually varies according to age,
and the different circumstances of
life. In girls, it is longer and
narrower than in married women,
and especially those who have
borne children ; and in African
women it is -longer and wider
than in European. The middle
portion of the vaginal tube is larger than at the extremities, and the
lower or inferior orifice is more contracted than at its upper or superior
extremity. The walls of the vagina are generally in contact, when
undisturbed. As females advance in years, the vagina gradually con-
tracts its dimensions to nearly those found in young girls. It is com-
posed of a fibrous and mucous membrane; the first is placed exter-
nally, and consists of condensed cellular tissue, highly elastic, and of
.a reddish color.

The external surface of the vagina is united, in front to the bas-fond
of the bladder and to the urethra, by cellular tissue, which becomes
denser as it 'approaches the vulva; behind, to the rectum, by similar
cellular tissue, but which is less dense than in front; laterally, to the
broad ligaments and ureters above, and below to the umbilical arteries,
the sacral plexuses, the hypogastric vessels, the levator muscles of the
anus, and the pelvic cellular tissue; and superiorly, above and behind,
by a double fold of peritoneum.

The internal surface of the vagina is divided into an anterior and a

THE INTERNAL FEMALE GENITAL
ORGANS.

A. The Uterus, seen on its Anterior Face.

B. The Intra-vaginal portion of the Neck of the

Uterus.

C C. The Fallopian Tubes.
D. The flmbriated Extremities of the Fallipoan

Tubes.

E E. The Ovaries.
F. The Ligament of the Ovary.
G G. The round Ligaments.
H. The Vagina laid opun.

On the right the fimbriated extremity of the
Fallopian Tube is seen applied to the Ovary.

70 KIND'S r. LECTIC OBSTETRICS.

posterior wall. In the center of each of these parietes is a longitudinal
line or ridge, the one on the anterior being more distinct and prominent
than that on the posterior wall; these ridges are called columnar vaginae,
or columns of the vagina one, the anterior column of the vagina,
the other, the posterior column of the vagina. One or two tubercles
are generally found at their inferior terminations. These columns are
intersected at right angles by transverse parallel ruga?, folds or
wrinkles, which become more prominent and approximate more closely
as they advance toward the vulva; these ruga?, however, do not con-
stantly exist ; they are more distinctly marked in girls and in aged
women ; and during pregnancy, as well as for a short period after par-
turition, they are nearly eifaced. Some writers consider them as aids
to the enlargement of the vagina during labor ; others, that they assist
in the elongation which it undergoes during pregnancy, caused by the
ascent of the uterus ; and others again, that by multiplying the points of
contact between the vaginal walls and the male organs, the voluptuous-
ness of coition is increased.

The superior, internal, or upper extremity of the vagina, is attached
around the upper part of the neck of the uterus, being a little higher
behind than in front. The peculiar manner by which it embraces the
neck, gives rise to a circular fissure or groove, to which the name cul-
de-sac has been applied ; the one in front, being termed the anterior
cul-de-sac; that behind, and which is more distinctly marked, the pos-
terior cul-de-sac. These culs-de-sac are of greater or less depth, accord-
ing to the projection of the neck of the uterus. This portion of the
vagina is in immediate contact with the peritoneum, which separates
it from the abdominal cavity ; and it is here where injuries are most
commonly inflicted by the use of instruments, often resulting in in-
flammation and death ; hence, when operations are demanded, great
care should be observed by the operator.

The inferior, external, or lower extremity of the vagina, sometimes
termed the external or vuVvar orifice, which terminates below r the
urethra, is narrowed at its entrance, and, in the virgin } is usually par-
tially closed by the hymen.

The internal parietes of the vagina are composed of a mucous mem-
brane, which is the continuation of that of the vulva, and the internal
membrane of the uterus; inferiorly, this membrane is of a red or ver-
million tinge, and superiorly it has a whitish or grayish appearance.
Occasionally, it presents posteriorly, bluish or livid spots, which are
more or less irregular. It is furnished with numerous mucous follicles,
the secretions from which constantly keep the parts during health, and

INTERNAL ORGANS OF GENERATION. 71

especially during parturition, in a state of lubricity. If this organ
becomes dry and inflamed, while labor is progressing, a rigid and un-
yielding condition of it ensues, which must necessarily occasion much
distress to the patient; hence the importance of examining during
labor, as seldom as possible, because the frequent introduction of the
finger into the vagina not only removes the moisture of the parts, but
likewise irritates them ; beside frequent touchings are useless, deleteri-
ous, and immodest.

The part surrounding the orifice of the vagina, is termed the bulb
of the vagina or the plexus retiformis; it is a dense, compact, erectile
spongy tissue, somewhat resembling that of the corpus spongiosum
urethne, of a grayish or bluish color, about an inch in breadth, and
two or three lines in thickness. During the venereal orgasm, it con-
tracts the vaginal cavity, and thus increases its resistance. The
sphincter vagince or constrictor vagince muscle is formed by some mus-
cular fibers on the outside of this spongy tissue ; it contracts the
vaginal orifice, and depresses the clitoris.

The arteries of the vagina come from the internal iliac ; its veins,
which are numerous, form a kind of net-work called plexiform, and
flow into the hypogastrics ; its nerves arise from the sacral plexus,
and its lymphatics are lost in the hypogastric lymphatic plexus. The
contractility of the vagina is of the peculiar elastic character common
to all cellular structure. As soon as the fetus has been expelled, this
organ resumes its natural condition in a very short time, except in
cases where the head has been confined in the cavity for a longer
period than usual, when its contraction will not take place for one or
two hours ; and the hand may be very readily introduced within it for
some hours after delivery.

The vagina serves as a medium through which external bodies may
pass toward the uterus, as during copulation, and also through which
the* uterine contents and vaginal secretions may pass oif, as the fetus,
menses, etc. It is subject to inflammation, uleeration, eversion, inver-
sion, etc., the history and treatment of which, more properly belong
to a treatise on " Diseases of Women."

The UTERUS, or womb, is a hollow organ, whose principal func-
tions are to receive the impregnated ovum, as it escapes from the
Fallopian tube, to assist in its nourishment, growth, and preservation,
until the parturient period arrives, and then to act as the principal
agent in forwarding its expulsion. It is a yestative not a generative
organ.

72 KING'S ECLECTIC OBSTETRICS.

In shape, the uterus is conical or pyriform, usually described as
resembling a pear flattened from before backward, with its base turned
upward, and its apex downward. It is situated obliquely in the pelvic
cavity, below the small intestines, between the bladder and rectum,
and above the vagina; and is retained in its position by the round and
broad ligaments, and the vagina. Its axis or long diameter very
nearly corresponds with the axis of the superior strait. In very young
females its base is below the superior strait ; in adults it is nearly on a
level with it.

In childhood it is quite small, but rapidly increases in growth to-
ward puberty and adult age, and after the period of child-bearing, it
diminishes to nearly its infantile size. Its average length, in the adult
woman, is two and a quarter to three inches ; its breadth at the fundus,
one and a third to two inches, and toward the neck, including the os
tincse, one inch to one and a half inches; and its thickness from eight
to twelve lines, or from four to six lines for each of its walls.

Immediately previous to menstruation and during that term, it
usually becomes greatly augmented in volume, which may be mis-
taken for the commencement of a pregnancy. Its weight, in the
virgin female, is seven or eight drachms, and in those who have had
children, from twelve drachms to an ounce and a half, while in the
aged female it dwindles to one or two drachms.

The uterus is divided into three parts: 1, the base or fundus uteri,
which is only a few lines high, being confined to all that portion which
rises above the insertion of the Fallopian tubes; 2, the body or corpus
uteri, which is the largest division of the uterus, and includes all that
part of the organ situated between the fundus and the neck, or con-
tracted portion ; 3, the neck or cervix uteri, which is the contracted
and elongated portion found below the body, about an inch in
length, and which is embraced by the vagina, forming in its cavity a
projection of four to six lines, at the extremity of which is an open-
ing, termed os tincoe, from its fancied resemblance to the mouth of the
tench fish, also called os uteri externum. The orifice, at the junction
of the uterine cavity with the superior extremity of the canal of the
cervix, is termed os uteri internum. The uterine sound is frequently
checked in its progress to the uterine cavity at this point, from con-
traction, and generally with more or less pain ; but if the instrument
be held steadily, pressing lightly upon the parts, the contraction will
yield, and the sound pass onward. But this should not be persisted
in when severe pain persists.

Generally, the uterus is slightly inclined to the right, sometimes to

INTERNAL ORGANS OF GENERATION. 73

the left, or backward. Its position, however, is not constajit, being
determined by its own condition, as well as that of the neighboring
parts. Thus females, in whom the vagina is short, will have the axis
of the uterus approximating that of the inferior strait; sometimes the
fundus is thrown so far forward that the anterior wall is the most in-
ferior part, constituting an anteversion; at other times it may be the
reverse of this, the fundus being thrown in the hollow of the sacrum,
and the neck behind the symphysis pubis, producing a retroversion ;
or, the fundus may be thrown to one side of the pelvic cavity, with
the neck to the opposite side, which is termed lateral version; and
again, the body of the uterus may be bent on the neck, either behind
or in front, constituting an anteftexion or retrqflexion.

We distinguish, in the uterus, an external and an internal surface.
The EXTERNAL SURFACE is divided into an anterior and a
posterior face, a superior and two lateral borders, two superior angles,
and an apex.

The anterior face is smooth, polished, slightly convex, covered on
its superior two-thirds by a prolongation of the peritoneum, and is in
contact with the posterior face of the bladder, from which it is some-
times separated by some folds of the small intestine ; inferiorly, it is
united to the bas-fond of the bladder by loose cellular tissue, and
which adhesion may account for the involvement of the bladder in
many uterine displacements.

The posterior face is more convex than the anterior, and is covered
throughout its whole extent by a prolongation of the peritoneum ; it is
likewise in contact with the anterior surface of the rectum looking
toward the concavity of the sacrum. The superior border, base or
fundus, is convex, looking upward and forward, and is covered in its
whole extent by a prolongation of the peritoneum, and by the convo-
lutions of the small intestines. In the unimpregnated state it never
reaches the level of the superior strait, and can not, therefore, be felt
through the inferior abdominal wall, except by making considerable
pressure. The two lateral borders are irregular, being convex in their
superior half, and concave in their inferior; they are situated between
the two duplicatures of the peritoneum; which constitute the broad
and round ligaments, and which ligaments being attached to the an-
terior edge of the lateral borders, are consequently on the same plane
as the anterior face of the uterus. The two superior [grooved] angles,
or cornua uteri, are formed at the junction of the superior with the
two lateral borders, and from which point arise' the Fallopian tubes

7 4 KING'S ECLECTIC OBSTETRICS.

and ovarian ligaments; the apex is the inferior extremity of the uterine
neck, and is situated in the upper part of the vagina.

The CERVIX UTERI, or NECK OF THE UTERUS, should be
thoroughly studied by the practitioner, with regard to its form, size,
and consistence, in order to facilitate his diagnosticating the state of
pregnancy, full term, etc., as well as the many abnormal conditions to
which it is liable.

The neck of the uterus in the adult female, who has never borne
children, will be found to vary considerably from that of one who
has; it is from twelve to fifteen lines in length, cylindrical, flattened
from before backward, and fusiform; being about nine lines in its
transverse diameter at the center, and from four to six lines at its ex-
tremities. It is embraced by the vagina toward its upper portion,
leaving about two-thirds within the vagina, and one-third above the
vaginal adhesion. The inferior or vaginal extremity of the neck, is
of less volume than any other part of it, and is perforated in its center
by a transverse fissure or orifice, of one or two lines in length, to
which several names have been applied, as, os tinea:., os uteri, os inter-
num, mouth of the womb, uterine orifice, etc. In the virgin, this orifice
is completely closed up, and is sometimes difficult to find; the sensa-
tion conveyed to the finger in contact with it, is similar to that expe-
rienced by feeling the depression between the alse nasi, at the end of
the nose, with the pulp of the finger, and which sensation will assist
us in recognizing the opening. The os tinea? divides the apex into
two lips, an anterior and a posterior lip. These lips are smooth,
regular, small, firm, thin, and closely approximated; the one anterior
being slightly thicker and more prominent than the posterior. As
the long diameter o/ the uterus is nearly parallel with the diameter
of the superior strait, the face of the apex will be found looking to-
ward the lower portion of the sacrum, in an inclined position; from
which arrangement the anterior lip will be found a little lower down
than the posterior.

In the woman who has borne children, the uterine neck varies in its
extent, being reduced in length, according to the number of births, so
much so, that instances are recorded in which the mothers of nineteen
or twenty children had the portion within the vagina completely de-
stroyed; the orifice is usually deformed, gaping, larger, and less
regular, and sufficiently patulous to admit the introduction of the end
of the finger; the lips are thicker and softer than in the virgin, and
are filled with fissures or inequalities, which are more frequent on the
left side of the neck, and are the results of lacerations of the fibers-

INTERNAL ORGANS OF GENERATION.

which occur during the passage of the child's head through the os
uteri, and which have been prevented from uniting by the lochial dis-
charges. These fissures are of variable depth, and sometimes are so
numerous as to divide the lips into eight or ten small tubercles. These
differences are of much importance in legal medicine ; yet they may
occasionally be produced by other causes than parturition, or may even
be wanting in the mother.

The INTERNAL SURFACE of the uterus presents a narrow,
oblong, irregular cavity, with contiguous walls, which is divided into
two parts, the cavity of the body and the cavity of the neck. (Fig. 20.)

The cavity of the body is triangular in shape, flattened, and when
empty is not very extensive, being hardly large enough to contain a
split almond. At each of its three angles there is an orifice, the knver
or inferior one leading to, and establishing a communication with, the
cavity of the neck, and the two upper or superior ones forming the
entrance into the Fallopian tubes; the openings in these latter are
very narrow, and will scarcely admit a hog's bristle. Occasionally,
this opening is divided by a perfect septum, which may render super-
fetation possible, and very rarely there exists a congenital deficiency
of it. In the absence of the catamenial discharge this cavity is con-
stantly moistened by a sero-mucous fluid.

FIG. 20.

CAVITY OF THE UTERUS, AND THE FALLOPIAN TUBES.

A. Fundus of the Womb.

B. Cavity of the Womb.

C. Cavity of the Neck of the Womb.

D D. The Canal of the Fallopian Tubes

laid open.
E E. The fimbriated Extremities.

F F. The Ovaries. .
G G. The round Ligaments.
H H. The Ligaments of the Ovaries.
I. The Cavity of the Vagina.
6, H'. The Uterine Orifices of the Fallopian
Tubes.

The canal, or cavity of the neck, affords a communication between the
cavity of the body and the vagina; it is oval and cylindrical, about
twelve or fifteen lines in length, and five or six in its greatest breadth;
it is fusiform, flattened from before backward, presenting on its

76 KINfi's KCLKCTIC OIJSTKTKICS.

anterior and posterior wall several longitudinal and transverse rugae or
wrinkles, to which the terms arbor rifn mternus, palmce pUcatce, &nd
/icnnifonit r u gee, have been applied; they are formed by the lining
membrane of the neck, and which are so arranged as to represent a
fern leaf in relief; they extend during the dilatation of the mucous
membrane of the cervix in the uterine development from gestation,
an<! during parturition, and frequently disappear after delivery. On
the mucous membrane of the neck are a number of muciparous fol-
licles, more abundant about the os uteri, which were mistaken by
Naboth for eggs, and hence have been called ovula Nabothi, glandula
Nabothi, or the glands of Naboth. In the healthy uterus of the virgin,
these follicles can hardly be seen; but during pregnancy, or when dis-
ease attacks the parts, they enlarge so as to be readily recognized by
the eye, and when touched with the finger they feel like shot. During
pregnancy, they secrete a thick, tough, pellucid, gelatinous mucus, in
quantity sufficient to close up the cavity, and, thus prevent any com-
munication between the cavity of the body and the vagina. The in-
ternal surface of the neck is less vascular than in the body. ' Ciliated
cylinder epithelium is observed upon the mucous membrane of the
canal of the cervix, but, at its lower part, instead of cylinder there is
squamous epithelium resembling that of the vagina, and beneath which
are found verrucose or filiform papillae, containing one or two vascular
loops; those seated more directly in the neighborhood of the os uteri
apparently possess a peculiar sexual sensitiveness.

The character of the uterine tissue is very difficult to understand
in its unimpregnated condition, but becomes more manifest during
gestation. Its constituent parts are: an external peritoneal membrane,
an internal or mucous membrane, a peculiar tissue, and numerous
blood-vessels and nerves.

The external peritoneal membrane is furnished by the peritoneum,
which, after having covered the posterior surface of the bladder, is
reflected from behind forward, upon the anterior face of the uterus,
covering its superior three-fourths, and extending over the fundus
uteri and posterior surface of the uterus; it is then prolonged on the
vagina for a short distance, and from thence reflected upon the rectum.
In front of, and behind the uterus, this membrane forms four small
falciform folds; those which are in the space between the bladder and
uterus are named the vesico-uterine, or anterior ligaments; and those
situated between the rectum and uterus, being termed the recto-uteri in ,
or posterior ligaments. On the borders of the uterus the attachments

INTERNAL OUOJANS OF GENERATION. 77

of the peritoneum are quite loose, but become more intimate toward
the median line.

The existence of the internal, or mucous membrane, has been very
much doubted by many anatomists, as may be seen from the following
observations by Moreau : '

"On examination, we find the inner surface of the body of the
uterus to be soft, pulpy, having neither the brilliancy of the peri-
toneum, nor the whiteness of the mucous membrane of the vagina;
of a reddish or blackish brown color; it generally contains, whatever
may have been the circumstances preceding the death of the woman,
a brown or dirty gray fluid. When the uterus is macerated, or boiled,
or dissected soon after death, it is impossible to trace the mucous
membrane beyond the cavity of the neck. If, on the other hand, we
observe that all the hollow organs provided with mucous membranes,
such as the stomach, intestines, bladder, and the vagina itself, and which
are required, by their, functions, to change in size, present, when
empty, a rugose surface and folds more or less projecting, formed by
the lining membrane; that this membrane is furnished, moreover,
with numerous follicles, which pour out mucus intended to protect the
organ from the irritation of the substances or bodies they may contain,
or which may pass through them, we will see that no similar arrange-
ment obtains in the cavity of the body of the uterus; the follicles are
found only in the cavity of the neck; they are there disposed symmet-
rically, on four opposite lines, two on the anterior and two on the
posterior paries. If the uterus were provided with a mucous mem-
brane, could it bear the enormous enlargement resulting from preg-
nancy, without lacerations of its internal surface, such as frequently
occur in the vagina at the time of delivery, and of which traces
may be seen almost always in women who have borne children?
Moreover, in advanced age, we often find obliteration of the cayity of
the body of the uterus, as well as of the tubes. We have long
observed this fact, which is confirmed by the researches of Mayer,
reported by Breschet, and what is very remarkable, this obliteration,
the natural consequence of age, does not extend beyond the internal
orifice, at the point at which we have said the mucous membrane
terminates. In organs lined by a true mucous membrane, the cavity
always remains. In old cases of artificial anus, that part of the intes-
tinal canal below the accidental opening, no longer giving issue to
fecal matter, contracts, but never consolidates.

" We shall terminate these considerations by a single remark. The
serous and mucous tissues, evidently communicate by means of the

78 KIND'S ECLECTIC OI5STETUICS.

aperture of the Fallopian tubes. Is there a point at which these
ti>.-ui's change, and are transformed into each other? Undoubtedly
there is; l>ut \\here is it? Is the serous tissue suddenly arrested at
the dictations of the tubes? Does it line the cavity of the fimbiiated
extremity? Does' it extend along the tube as far as the uterus? Or
does the mucous tissue occupy the whole cavity ? Is the latter pro-
longed, as it is said, into the cavity of the tube? Does it terminate
;tt the fimbriated extremity, or extend beyond? This can not be
demonstrated. If it be impossible to assign the precise point at
which one of these tissues commences, and the other ends, is it not
reasonable to regard the cavity of the body of the uterus, and of the
Fallopian tubes, as respiratory surfaces, intermediate by their position,
organization, and uses, to the serous and mucous tissues; upon them
the transformation is exerted, but in a gradual, successive manner,
without being able to determine accurately the point of mutation.

" This opinion acquires more value if we observe that the exhala-
tions of the internal surface of the uterus are not identical over its
whole extent. Haller had already found in the cavity of the body,
a serous, whitish, muddy, and thin liquid, which, in the uterus of
a newly born child, resembled milk, while that in the cavity of the
neck was a thick, dense, and reddish mucus. The exhalations of the
cavity of the body of the uterus, present under various circumstances,
but normal for them, the characters of exhalation of the mucous
and serous tissues, alternately morbid and physiological. Thus, in
ordinary health, the matter exhaled by the uterine cavity, has a great
analogy with mucus. When this surface is excited in a special manner
by the act of generation, the fluid produced resembles more the serous
exhalations; it is a concrescible, plastic lymph, which becomes con-
densed, and quickly changed into a species of false membrane, the
caducci* When simply the seat of some fluxive function, as at the
menstrual periods, a phenomenon is manifested which belongs equally
to overexcited or highly inflamed mucous and serous tissues, a san-
guine discharge is. established, the affluxus is dispelled, and nature
resumes her usual course.

" We may hence conclude, that the cavity of the body of the uterus
possesses no mucous membrane ; or if it exists, it has undergone such
modifications as to leave no longer any resemblance to the same tissue
in other parts."

Cazeaux, likewise, observes in relation to this membrane : " To the
reasons already offered by Morgagni, Chaussier, etc., in favor of its
existence, we shall add those presented by Cruveilhier, which appear

INTERNAL ORGANS OF GENERATION'. 79

to us perfectly conclusive, viz.: 1st. Every organic cavity communi-
cating with the exterior is lined by a mucous membrane. 2d. Anatomy
demonstrates that the vaginal mucous membrane is continued into the
cavity of the neck, and then into that of the uterus, only it is deprived
of its epithelium in penetrating the latter. 3d. When examined by a
lens, the internal surface of the uterus exhibits a papillary disposition,
but the papillae are imperfectly developed. 4th. This internal surface
has follicles or crypts spread over it, from which mucous can b< j
squeezed out, and which, if their orifices be obstructed or obliterated,
become distended by the liquid, and form little vesicles. 5th. It is
continually lubricated by mucus. 6th, and lastly; the internal surface
of the uterus, like all other mucous membranes, is subject to sponta-
neous hemorrhages, to catarrhal secretions, and to the mucous, fibrous,
and vesicular vegetations, called polypi; and it is generally admitted
that, wherever there is an identity of action, there is also an identity
of nature."

That the inner membrane of the uterine walls is composed of a mu-
cous body or tissue, has, according to the recent microscopic observa-
tions of M. Coste, and others, been decided in the affirmative, and
which is probably continuous with the lining mucous membrane of the
vagina, and of the Fallopian tubes, but which has no submucous tis-
sue, being closely attached to the muscular coat. It consists of tubular
utricular follicles or glands, arranged perpendicularly with the surface,
simple or bifurcated, spirally contorted at the end, from one thirty-
third to one fiftieth of a line in diameter, their length being that of
the thickness of the mucous membrane, and consisting of very deli-
cate membrane and ciliated cylindrical epithelium ; the cilia vibrating
from below upwards, and thus very likely aiding in conveying the
spermatic filaments to the Fallopian orifices. The secretion from these
glands probably forms the decidua.

The peculiar tissue of the uterus, which is under the mucous mem-
brane, and is named the middle, fleshy, or muscular coat of the uterus ;
is very dense in structure, resisting, of a dirty grayish color, being
sometimes slightly pearly near the neck, crackles like cartilage under
an incision with the scalpel, and constitutes the greater part, if not the
fundamental structure of the organ. In the unimpregnated state of
the uterus, it is very difficult to determine the true character of the
uterine tissue, as it varies in color and density, its fibrous organizations
being concealed by the state of condensation of the organ. There has
been considerable difference of opinion upon this point, some viewing
it as belonging to the fibrous tissue, and others to the muscular ; the

80 KIXCi'K ECLECTIC 015STETRICS.

condition of pregnancy, however, removes all doubt and uncertainty,
and presents to us a true muscular tissue.

The arteries of the uterus come from the hypogastrics, or internal
iliacs, under the name of uterine arteries, and from the aorta, or renal
arteries, under the name of ovarian or spermatic arteries. The uterine
arteries penetrate the uterus by its lateral borders, and describe a num-
ber of flexuosities in the proper tissue of the organ ; the branches of
the same side frequently anastomose with each other, and unite on the
median line with those of the opposite side. They likewise commu-
nicate above and laterally with the branches of the ovarian arteries,
and terminate in the interior tissue, continuing into the veins, and,
probably, presenting orifices within the uterine cavity.

The veins follow the course of their respective arteries ; they are
very numerous, have no valves, and empty into the corresponding
trunks : the right spermatic into the inferior cava, the left into the
renal vein, and the uterine veins into the internal iliacs. The arrange-
ment of the veins, in the uterine tissue, is analogous to that observed
in the corpora cavernosa, and the erectile tissues ; and their orifices on
the internal surface of the uterus, are very large during pregnancy,
and become visible just after delivery.

The nerves are derived, one portion, from the sacral plexus of the
cerebro-spinal system, which more especially supplies the cervix with
nervous filaments, and, consequently, renders it more sensitive to the
touch than any other part of the organ ; the other portion, being des-
tined to the organic life alone, is from the great sympathetic nerve,
which supplies the body of the organ with filaments, and which will
explain to us how most of the vital organs of the body, especially the
brain and stomach, sympathize so readily with the uterus, both in dis-
ease and during pregnancy. The performance of the several functions
of menstruation, conception, and parturition, is, without doubt, chiefly
owing to the influence of the uterine nerves.

The lymphatic vessels are very numerous, and arise from different
parts of the organ, forming reticulations, branches, and trunks, which,
united in bundles, leave the uterus in three different directions. The
least numerous leave the abdomen by the inguinal canal, and are
distributed to the inguinal ganglia; others, united to the lymphatics
of the vagina, accompany the uterine and vaginal arteries, and ter-
minate in the hypogastric lymphatic plexus. But the most numerous
arise from the anterior and posterior surfaces of the neck and of the
body, run toward the lateral borders, follow their direction, are then
united with those of the ovaria, the tubes, and fundus uteri, ascend

THE UTERINE APPENDAGES. 81

the ovarian arteries and veins, in front of the psoas muscle, to
join the ganglia situated in front of the aorta, the vena cava, and in
the vicinity -of the kidneys.

All the above vessels, etc., are very small during the condensed or
unimpregnated condition of the uterus, but increase in size during
pregnancy, and at full term acquire an enormous size, supplying the
organ with torrents of blood. The lymphatic vessels, also, play a very
important par,t in the diseases of the uterus.

Sometimes the uterus is absent entirely, at others but slightly devel-
oped, or it mayjbe malformed, or in an abnormal position. It is liable
to hernia, prolapsus, retroversioii, anteversion, inversion, ulcerations,
inflammations, etc., the history and treatment of which may be found
in any treatise on the diseases of women.

CHAPTER X.

OF THE UTERINE APPENDAGES THE LIGAMENTS, THE FALLOPIAN

TUBES, AND THE OVARIES.

THE uterus is supported, in the pelvic cavity, by six duplicatures of
peritoneum two anterior, or vesico-uterine, and two posterior, or recto-
uterine ligaments, to which reference has been heretofore made ; also
two lateral, or broad ligaments, which are much larger and more im-
portant than the others, as within them we find contained the round
ligaments, the Fallopian tubes, and the ovaries (Fig. 19).

The BROAD LIGAMENTS are formed by two duplicatures of
the peritoneum, which, covering the anterior and posterior faces of the
uterus, are prolonged transversely, extending to the ilia; these two
folds rest against each other, and divide the pelvis into two cavities
the anterior cavity containing the bladder, and the posterior the rec-
tum. These ligaments are of a quadrilateral shape, and from their
supposed resemblance to the wings of a bat extended, have been
named the alee vespertilionis. Outwardly, and below, these ligaments
are continuous with the peritoneum that lines the excavation; their
upper, or superior border is loose, and extends from the angles of the
uterus to the iliac fossse, presenting three small folds, called a/ce,,<or
wings. The anterior wing is not distinctly developed, and is denied
by some anatomists ; it is occupied by the round ligament. The. mid-*

82 KING'S ECLECTIC OBSTETRICS.

die wing incloses the Fallopian tube, and the posterior contains the
ovary and its ligament.

The space between the two serous folds, constituting the broad liga-
ment, is filled by a loose and very extensible lamellated cellular tissue,
continuous with the fascia propria of the pelvis, and which is traversed
by the uterine vessels and nerves. As gestation advances, and the
uterus enlarges, the two laminaB of the peritoneum separate to receive
the uterus, assisting to cover its anterior and posterior surfaces, and in
consequence, during the latter month of pregnancy, the broad liga-
ments entirely disappear.

The ROUND LIGAMENTS, or supra-pubic cords, are two in
number, one on each side ; they are of cylindrical form, six or seven
inches in length, of a fibrous appearance, and of a grayish white color.
They arise from the lateral borders of the uterus, below and a little in
advance of the Fallopian tube, and are directed upward and outward,
following the direction of the pelvis ; they are enveloped in a cellular
tissue, and are covered by a prolongation of the peritoneum, to which
the name " Canal of Nuck," has been given. They enter the inguinal
canal on each side, traverse it, emerge by the corresponding inguinal
ring, and divide in front of and above the pubes into a number of
fibrous fasciculi, which are lost in the cellular tissue of the groins,
mons veneris, and labia pudendi. They contain a great number of
veins, which are liable to become varicose.

There has been considerable controversy as to the structure of these
ligaments, but the investigations of modern anatomists have ascer-
tained them to be expansions or prolongations of the muscular fibers
of the uterus, containing blood-vessels, nerves, lymphatics, and cellular
tissue.

The real uses of the round ligaments are not satisfactorily known ;
they are supposed to be, to retain the uterus in its proper position, and
to prevent its displacements. During pregnancy, chronic affections,
or uterine displacements, these ligaments are subject to inflammation
and engorgement, and which conditions may, probably, be the cause
of the pains in the groins, frequently experienced by women thus
circumstanced.

The FALLOPIAN, or UTERINE TUBES, (oviducts, vector ca-
nals), are two cylindrical canals, from four to five inches in length,
of a conical shape, flexuous and waving, and extend from the upper
or superior angles of the uterus to the ovaries; they are placed in the

THE UTERINE APPENDAGES. 83

thickness of the middle wing of the broad ligaments. The internal
cavity of these tubes is very narrow at their uterine extremities, but,
as they extend outwardly, i| gradually increases in size, but again con-
tracts just before opening at the fimbriated extremity. The internal
extremities of the tubes are inserted into the superior angles of the
uterus, where they open into the cavity of its body, their orifices
being named the internal or uterine. The external or free extremities
of the tubes, called the fimbriated extremities or pavilion, communicate
with the peritoneal cavity by an oblong, inverted opening, with digi-
tated or fringed edges, of which one is longer than the other, curved,
and inserted into the external extremity of the ovary ; the other hangs
loosely over the ovarium. The openings at these ends .of the tubes
are named the free orifices of the tubes; the orifice at either uterine
angle is called the ostium uterinum, that at either fimbriated extremity,
the ostium abdominale.

The tubes are enveloped by the peritoneum, which forms the outer
or external tunic or membrane ; the internal membrane is a prolonga-
tion of the uterine mucous membrane (which, however, is denied by
some authors), and is also continuous with the serous peritoneum; the
tubes are composed of two laminae of unstriped muscular fibers, the
exterior of which have a longitudinal direction, while the internal are
circular. Their vessels are derived from the ovarian arteries, and their
nerves from the great sympathetic. The middle layer or proper tissue
of the tubes, is a continuation of, and identical in texture with, that
of the uterus. The internal lining mucous membrane of the Fallopian
tubes is thin, in longitudinal folds permitting dilatation, and is covered
by ciliated cylindrical epithelium, the movements of which are directed
from the ostium abdominale to the ostium uterinum.

The Fallopian tubes serve to conduct the fecundating principle of
the male to the ovaries, and to seize the impregnated germ or ovule
of the female and transmit it to the uterus. At the moment of fecunda-
tion, the fimbriated extremity grasps the escaping ovum (morsus dia-
boli), and probably also at each menstrual period; a failure of this
action, or of the peculiar offices of the tubes, may, probably, be a
cause of extra-uterine pregnancy.

The OVARIES furnish the ovula which contain the rudiments of the
future animals ; they are situated in the thickness of the posterior wing
of the broad ligaments, behind and below the Fallopian tubes ; they
are two in number, oblong, oval, whitish, twelve or fifteen lines long,
and flattened from before backward, being about the size and shape of

84 KING'S ECLECTIC OBSTETRICS.

an almond. Previous to puberty, and sometimes in virgins and women
who have not borne children, their surface is polished and embossed;
but after puberty, owing to the escape of ^he ova, they become rough
and fissured. Their superior border is convex and loose ; their in-
ferior, straight, or slightly concave, and adhering to the broad liga-
ments, by which they are maintained in position, as also by a special
one, named the ligament of the ovary (ligamentum ovarii), a dense,
imperforate cellule-fibrous cord, which fixes the internal ovarian ex-
tremities to the uterus. The external extremities are joined to, or ap-
proximate, the fimbriated Fallopian extremities. The nerves of the
ovaries come from the renal plexus, and the blood-vessels which are
called the ovarian, have a similar origin with the spermatic vessels in
the male. The situation of the ovaries varies according to circum-
stances; in the fetus they are in the lumbar region; during gestation
they rise into the abdomen along with the body of the uterus, upon
the sides of which they are attached; and immediately after delivery,
they occupy the iliac fossae, where they sometimes continue through
life. It is not uncommon to find them p IG 2 i.

turned backward, and adhering to the
posterior uterine surface. They like-
wise vary in size, being larger in pro-
portion in the fetus than at maturity,
decreasing after birth, enlarging at pu-
berty and during pregnancy, and dwind-
ling away as old age approaches; they

frequently become the seat of organic

* EXTERNAL FACE OF THE OVARY

alterations. (Fig. 21.)

The external covering of the ovaries is obtained from the peri-
toneum, and is named -the indusium. Beneath this covering, the body
of each ovary is invested with a whitish, dense, fibrous membrane,
called the tunica albuginea, which is the proper tunic of these organs,
and- which may be considered as an expansion, or extension of the
ovarian ligaments. From the internal surface of this membrane
proceed prolongations which divide the ovaries into many small cells
filled by their proper tissue. The parenchyma of the ovaries, or tissue
proper, is of a reddish brown color, spongy, dense, and vascular,
bearing some resemblance to the erectile tissue, it is called the stroma;
in this tissue are found imbedded a number of small transparent folli-
cles or vesicles, varying in size from the smallest pin's head to that
of a large shot, the smaller being within the larger and better de-
veloped more toward the surface. These last sometimes produce small

THE UTERINE APPENDAGES.

FIG. 22.

elevations on the stroma, which give a rough or tuberculous appear-
ance to the whole ovary; they are called the ovisacs, or Graafian vesicles,
after De Graaf, who gave a,, description of them.

The Graafian vesicles number from fifteen to twenty in the adult
female, in, or near a state of maturity, but with the aid of a microscope
many more can be seen which gradually become developed as the others
perfect their function. They are hardly visible in children and old wo-
men, but are very distinct during the menstrual life. (Fig. 22.) Each
ovary at birth contains not less than thirty- five thousand ova. (Foulis.)

The vesiculaB Graafianse, consist
of two separate tunics ; 1. The ex-
ternal tunic or tegument, which is firm,
fibrous, and vascular in its character,
like the stroma or proper ovarian
tissue ; 2. The internal tunic, formed
of dense cellular tissue, but thin,
smooth, delicate, diaphanous, and
easily torn ; some consider it desti-
tute of vascularity, which is, again,
denied by others. From the close
approximation of these two tunics, it
is sometimes difficult to separate them.

The internal face or cavity of the A . The Ovule abou7i-i7a line in diameter.

inner tunic Contains the nucleus, COm- G '- The Granular Cumulus, or ProligerousDisk.

K. The Cavity of the Graafian Vesicle.

prising: 1. Ihe granular membrane, M. The MUCOUS surface,
which is a delicate membrane formed v - The vascular Layer.

F. The Fibrous Layer.

oi granules or cellules. I his mem- p. The Peritoneal Coat,
brane is exceedingly thin and very G " The Granular Membrane,
easily torn ; its thickest portion corresponds with the free side of the
vesicle, or that portion which is nearest the surface of the albuginea,
and here the granulations are more numerous, constituting the cumulus
proligerus, or discus proligerus. 2. A fluid either limpid, reddish, or
slightly lemon-colored, concrescible, and composed principally of albu-
men, as it is coagulated by heat, alcohol, and the strong acids. In
this liquid float, vitellary corpuscle, oil globules, and a great number of
small grains, which settle themselves, touching each other, upon the
inner wall of the vesicle, and form the above named granular mem-
brane. 3. The ovule or human egg, which is found in the center of the
proligerous disk. (A, Fig. 22.)

The OVULE, or HUMAN EGG was first discovered as a distinct
organ in the Graafian vesicle by Charles Ernest Baer, though DeGraaf
had suggested the idea previously. It is imbedded, as stated above,

THE

OVULE IN THE
VESICLE.

GRAAFIAN

KINGS ECLECTIC OBSTETi: ! -.

A NON-FECUN'DATED OVULE OB
HUMAN EGG.

Pur kin je, about 1-60 of a line in
diameter.

D. The Germinal Spot, from the 1-400 to
the 1-600 of a line in diameter.

FIG. 23. in the midst of the proligerous disk, and

is perfectly formed in the ovary during
the earlier years of life. It is extremely
minute and hardly to be seen by the
naked eye, but when examined with the
microscope, presents an opaque, rounded
appearance. Bischoff says : " The largest
human ovules I have seen and manipu-
lated, did not exceed the tenth of a line,
being barely perceptible to the naked
eye." As seen by the microscope, the
ovule is possessed of an exterior covering
called the vitelline membrane, transparent
zone, cortical membrane, or chorion; of a

A. The Vitelline Membrane, or Trans-

parent zone. substance denominated the yelk or vitellus,

B. The Vitellus, or Yelk. 3 t i '.i/u' A i n

& The Germinal Vesicle, or Vesicle of and f a Vesicle Within the yelk, termed

the germinal vesicle.

The Zona Pellucida, or vitelline mem-
brane, is an elastic, thick, hyaline, and
transparent membrane, without a determinate texture, whose external
and internal outlines assume the appearance of two circular lines
inclosing a transparent ring. (A, Fig. 23.)

The yelk or vitellus of the human ovum occupies the cavity of the
vitelline membrane; it is formed according to Bischoff, of a coherent
indistinctly granular, yellowish, transparent, and viscous mass, which
does not run out when the egg is cut or crushed; each portion of the
zone reserving its particular segment of yelk, or the latter escaping
altogether. It usually fills the interior of the viteliine sphere com-
pletely, though it is sometimes smaller, and its granulations are
placed in juxtaposition with its sole envelope, the transparent zone.
(B, Fig. 23.}

Within the yelk, or on one of the points of its circumference, is
discovered a slightly oval, colorless, and perfectly transparent vesicle,
consisting of a very delicate membrane, which incloses a clear and
transparent liquid, but which occasionally contains a few granulations.
This colorless vesicle scarcely measures the sixtieth of a line in diame-
ter, is surrounded by a mass of deep yellow, and is identical in
character with that found in the unfecundated eggs of birds. Fecun-
dation destroys it. This is called the germinal vesicle or the vesicle of
Purkinje (c, Fig. 23). The honor of its discovery is variously attrib-

THE UTERINE APPENDAGES. 87

uted to Purkinje, Baer, and Coste, though the latter is more justly
entitled to it.

If, according to Wagner, the germinal vesicle be attentively exam-
ined with the lens, at four or five hundred diameters, there will be
seen on some part of its periphery, a small, dark, round spot, which
consists of a collection or stratum of fine, small lenticular granules or
globules, and which stratum appears to be the true living .animal
germ, existing previously to impregnation. This is called the germinal
spot, and was cotemporarieously discovered and described by Professor
Rudolph Wagner, of Germany, and T. Wharton Jones, of England.
Two, or more germinal spots have been met with in the mammiferse.
(D, Fig. 23).

The ovule, therefore, previous to impregnation, is composed: 1, of
an exterior tunic, the zona pellucida or vitelline membrane, within which
is contained, 2, a yelk, which again incloses, 3, a vesicle, the germinal
vesicle, within which we find, 4, a dark spot, the germinal spot or germ
from which it is presumed the future man originates, after it has been
fertilized by the male semen.

The Graafian or ovarian vesicles experience considerable changes
during menstruation, conception, and after impregnation. The inves-
tigations of Gendrin, Negrier, Pouchet, Raciborski, Jones, Lee, Pat-
terson, Bischoff, and several others, have led to the belief, which
has been general among medical men, that the phenomena of men-
struation is owing to the development or maturity of these vesicles.
Until the period of puberty these ovisacs are hardly discernible, but
on the completion of this period, they develop themselves, maturing
periodically, in women once in every twenty-eight days. At each
period of ovulation or menstruation, a vesicle becomes much enlarged,
its upper segment rapidly rises above the surface of the ovary, forming
a prominence there about the size of a small nut (A, Fig. 24), and the
walls of the vesicle become less transparent in consequence of the
thickness of the internal membrane, and the hemorrhage that finally
takes place in the interior of the vesicle. The quantity of blood
effused within the vesicle adding to the amount of fluid it naturally
holds, distends it so much as eventually to lacerate or rupture its
walls, at a point about a line in extent, the situation of which can be
distinguished by its reddish appearance and its more elevated pro-
jection. The ovum and contents of the vesicle escape into the peri-
toneal cavity, or are carried down to the womb by the Fallopian tube :
the vesicular walls shrink up, their cavity holding a clot of blood

KING'S ECLECTIC OBSTETRICS.

FIG. 24

about as large as a cherry, which has oozed from the torn margins,

and which, as the vesicular cav-
ity diminishes, is gradually ab-
sorbed. The margins of the
fissure approximate, giving rise
to more or less cicatricula of
various forms, being sometimes
linear, again radiated, and at
others triangular; when recent,
they are red, but gradually be-
come brown, forming deep fur-
rows by their retraction.
DIAGRAM SHOWING THE OVARY, AND A __ . , . ,

GBAAFIAK VESICLE AT ITS HIGHEST BE- This rupture of the vesiclea
GREE OF DEVELOPMENT, AND JUST BE- not only takes place at the period
FORE ITS RUPTURE. o f impregnation, but also at each

A. The hypertrophied Vesicle iod f ovu l at i on . an d the

B C C. Radiated cicatrices left by previously rup- f

tured vesicles. scars which are left, instead of

being an evidence of so many previous conceptions, as was formerly
supposed, are merely the remains of ruptured ovisacs. (See Nidation.)

CHAPTER XI.

OF THE CORPUS LUTEUM.

THE term CORPUS LUTEUM, or yellow body, is applied to the
remains of the Graafian vesicle, after the ovum has been expelled from
it, whether from copulation or from menstruation. And as there has
been considerable discussion upon this body, regarding its presence as
a sign of conception, it becomes a matter of some moment, in a medico-
legal point of view, to determine its true character.

The corpus luteum is a peculiar glandular mass, varying in size
from that of a pea to half an inch in length ; it is of a dull yellow
color, friable in consistence, having a lobulated appearance, with
slight convolutions, somewhat resembling a section of the human
kidney, and very vascular ; according to Montgomery, an injection
through the spermatic artery will easily pass into its substance. The
true corpus luteum is found in the ovary of a recently pregnant woman,
and varies in size and appearance accord-ing to the period of gestation,

THE CORPUS LUTEUM. 89

gradually diminishing in size, and losing its deep yellow color, until
about the fifth month after full term, when it disappears, leaving a
small pit over the place it had previously occupied. So that the idea
that it is a permanent formation is erroneous. Dr. Montgomery, who
has bestowed considerable attention to this subject, thus speaks of its
appearance :

" Its center exhibits either a cavity, or a radiated or branching white
line, according to the period at which the examination is made; if
within the first three or four months after conception, we shall, I
believe, always find the cavity still existing, and of such a size as to
be capable of containing a grain of wheat at least, and very often of
a greater dimension; this cavity is surrounded by a strong white cyst;
and, as gestation proceeds, the opposite parts, of this cyst approximate,
and at length close together, by which the cavity is completely oblit-
erated, and in its place there remains an irregular white line, whose
form is best expressed by calling it radiated or stelliform. This is
visible as long as any distinct trace of the corpus luteum remains. I
am unable to state exactly at what period the central cavity disappears
or closes np, to form the stellated line. I think I have invariably
found it existing up to the end of the fourth month. I have one
specimen, in which it was closed in the fifth month, and another in
which it was open in the sixth later than this I have never found it.

" After the period of gestation has been completed, or the contents
of the uterus pi'ematurely expelled, so that gestation ceases, the corpus
luteum soon begins to exhibit a very decided alteration in all its char-
acters, until, at length, it is no longer to be found in the ovary. The
exact period of its total disappearance I am unable to state ; but I
have found it distinctly visible, so late as at the end of five months
after delivery at the full time ; but not beyond this period ; and the
corpus luteum of a preceding conception is never to be found along
with that of a more recent, when gestation has arrived at its full term;
but in cases of miscarriage, repeated at short intervals, it may.

" At the time of delivery the corpus luteum is neither so large nor
so vascular as at the earlier periods of pregnancy, except the woman
should happen, at the time of her death, to be laboring under inflam-
mation of the uterine system ; in which case the corpus luteum partakes
of the turgescence of the other parts, and, very remarkably, of their
increased vascularity, a striking instance of which is represented in a
preparation in the writer's museum, taken from the body of a woman
who died of inflammation of the womb, two days after delivery; the
central radiated white line is very distinct, and the vessels having been

90 KING'S ECLECTIC OBSTETRICS.

injected, the substance of the corpus luteum is quite crimsoned, and,
externally, the ovary continues to exhibit the superficial cicatrix, and
the alteration of form produced by the projection of the part contain-
ing the corpus luteum."

With reference to the corpus luteum, as a test of conception, there is
some diversity of opinion; some viewing the existence of a true corpus
luteum, so called^ as an infallible test; while others maintain that no
real distinction can be made between true and false corpora lutea, or
that which forms independent of impregnation. This question still
remains unsettled, though the observations of Dr. Montgomery, which
are corroborated by other investigators, as Haller, Pouchet, Haighton,
Jones, Lee, Raciborski, etc., seem to confirm the former view; he re-
marks : " I have seen many of these virgin corpora lutea, as they are
unhappily called, and have preserved several specimens of them ; but
not in any one instance did they present what I should regard as even
an approach to the assemblage of characters belonging to the true
corpus luteum, the result of impregnation, from which they differ in
all the following particulars:

" 1. There is no prominence or enlargement of the ovary over them.

" 2. The external cicatrix is almost always wanting.

" 3. There are often several of them found in both ovaries, especially
in subjects who have died of tubercular disease, such as phthisis, in
which case they appear to be merely depositions of tubercle, and are
frequently without any discoverable connection with the Graafian
vesicles.

" 4. They present no trace whatever of vessels in their substance,
of which they are in fact entirely destitute, and of course can not be
injected.

" 5. Their texture is sometimes so infirm that it seems to be merely
the remains of a coagulum, and at others appears fibro-cellular, like
that of the internal structure of the ovary; but never presents the soft,
rich, lobulated, and regularly glandular appearance which Hunter
meant to express, when he described them as ' tender and friable, like
glandular flesh.'

" 6. In form they are often triangular or square, or of some figure
bounded by straight lines.

" 7. They never present either the central cavity or the radiated or
stelliform white line which results from its closure.

"This latter peculiarity, in common with several others observable
in these spurious productions (whether .occurring in virgins or in other
women, but not the result of conception), even when they are connected

THE CORPUS LUTEUM. 91

with a Graafian vesicle, depends on their different mode of formation;
a circumstance which deserves especial attention, as pointing out the
essential difference between a very large class of these pseudo-structures
and the true ones.

" The history of their formation appears to me to be this : accidental
or morbid determination takes place toward a vesicle, in consequence
of which it is distended with fluid, and either bursts arid discharges its
contents (in which case there may be found an external cicatrix), or
the fluid is again absorbed ; but, in either case, there is often deposited
on the internal surface of the vesicle, a substance somewhat resembling
the corpus luteum in color, but in general not more than about one-
sixteenth of an inch in thickness, and entirely destitute oi> blood-
vessels : sometimes it is very much thinner even than this, amounting
to little more than a mere layer of coloring matter lining the vesicle.
In this condition I have often found them, the vesicle being enlarged
to three or four times its natural size, full of fluid, and its internal sur-
face of a bright yellow color; but when the vesicle collapses, either in
consequence of rupture of its coats, or the absorption of the contained
fluid, the inner surface of this new deposit closes upon itself, and forms
an irregular line of junction, which is generally darker than the rest
of the structure, and not unfrequently, they present the yellow color
only on the circumference, while their center is so dark as to be almost
black; but, from their situation, they are entirely without lining mem-
brane, to form either a central cavity or white stellated line, which, in
the true corpus luteum, is formed by the closure of the inner coat of
the vesicle; for the same reason also, these accidental formations are in
general much smaller than the others; and they are moreover totally
without vessels in their structure, so-, that, however minutely the rest
of the ovary may be pervaded by fine injection, not a particle of it will
pass into the bodies thus formed."

Among those who have not considered it as a test of conception, but
only as an evidence of perfect ovulation, may be named Hume, Blu-
menbach, Bischoff, Cuvier, Cazeaux, Prof. Meigs, of Philadelphia, etc.
This latter gentleman, in his "Treatise on Obstetrics," maintains that
the yellow matter found in a corpus luteum, "is of the same apparent
structure, form, color, odor, coagulability, and refractive power," as
the yelk of eggs. His views are based upon the following observa-
tions :

" 1. Equal masses of yelk and corpus luteum are equally yellow.

" 2. They alike fill the tube, before the focus is got, with a brilliant
yellow light.

92 KING'S ECLECTIC OBSTETRICS.

" 3. They alike consist of pellucid fluid, in which float granules,
corpuscles containing yellow fluid, oil-globules, and puuctiform
bodies.

'" 4. These bodies, placed on the same platine, and diligently com-
]>;iiv<l together, exhibit the same forms, size, tint, and refractive
power.

" 5. Yelk, boiled hard, is granular and friable ; it is coagulated by
heat.

" 6. Corpus luteum, boiled, becomes hard, granular, and friable ; it
is coagulated by heat.

" 7. Both substances, raw or boiled, stain paper alike of a yellow
color.

" 8. There is this difference : the crushed mass of corpus luteum
contains patches of laminar cellular tela, detritus, and blood-disks
forced out by the compressorium ; which can not occur in the yelk, as
that is contained within a vitellary membrane, in which its corpuscles
are free ; whereas, in the corpus luteum, they are confined by the deli-
cate cellular substance lying betwixt the concentric laminae of the
Graafian follicle.

" 9. They refract alike.

" 10. Projected on a live coal, they alike give out the odor of roasted

These opinions require further investigation, in order to establish
their correctness.

The formation of the true corpus luteum, is thus explained by
Ramsbotham : " It has been demonstrated that the Graafian vesicle
possesses two membranes : one. adhering to the substance of the
ovary, the other inclosing the fluid in which the ovule of Baer
floats. When a fruitful connection takes place, a great determination
of blood is made to that ovary which supplies the germ. The
gland becomes larger, rounder, and more vascular than the other ;
to the touch it feels fuller and softer. But the vascularity is con-
fined to one spot the neighborhood of the corpus luteum ; and the
increased size and softness result, not so much from an alteration in
the structure of the whole organ, as from the quantity of lymph and
fluid blood deposited between the membranes of the vesicle, which is
converted into the characteristic yellow gland-like mass. This effusion
causes the vessel to be thrown prominently out toward the peritoneal
surface; the attenuated coats burst, or rather an opening is formed by

THE CORPUS LUTEUM. 93

absorption, and the fluid, with the ovule previously contained within
them, passes into the tube."

The changes that occur in the ovisac take place with less intensity
when impregnation is not present, and hence the difference in the
appearance between the true and false corpora lutea. AVhen impreg-
nation has taken place, there' is increased vascular excitement in the
ovaries and uterus; and from the augmented accumulation of blood in
the generative parts, the changes in the ovisac occur with more slug-
gishness, because they are " conducted upon a larger scale and with a
greater abundance of materials."

Leishman, in his System of Midwifery, closes a very able article on
this subject as follows :

" What is called the Corpus Luteum is due to a deposit of yellow
fatty matter in, and hypertrophy of, the internal layer of the Graafian
vesicle (ovisac).

" The formation of a corpus luteum always succeeds the rupture of
a Graafian vesicle.

" Up to a certain point the changes in the Graafian vesicle are uni-
form, and have no relation to pregnancy. The corpus luteum of preg-
nancy may, however, be distinguished in its subsequent course by its
higher development and longer duration, its hardness, its vascularity,
and, at a later stage, by the formation of the white lining membrane,
and large central stellate cicatrix.

" The presence in the ovary of a corpus luteum is no evidence of
pregnancy, unless the characteristics last indicated are distinct and
unequivocal under which circumstance it is a certain sign.

" With reference to the above conclusions, it may be remarked that
much confusion has arisen from the employment loosely of the terms
'true' and 'false,' as applied to the corpus kiteum, in so far as they
are assumed to imply a distinction, which proves or disproves the oc-
currence of pregnancy.

" ' There is as little reason,' says Farre, with justifiable emphasis, ' for
the use of the last term as there would be for denominating a child a
false man. . . . These terms actually represent the same body,
only in different stages of growth or 'decay/

"During the whole of the child-bearing period of a woman's life,
the ripening and dehiscence of the Graafian vesicles are of periodic
occurrence. In those animals in which plural births are the rule, sev-
eral vesicles ripen and discharge their contents at, or near, the same
time; but in man this is exceptional, and we thus find that one vesicle

94 KING'S ECLECTIC OBSTETRICS.

only, as a rule, ripens at a time, bursts, discharges its contents, and
rapidly shrinks as it retires toward the centre of the ovary, to give
place, in a normal condition of the parts, to a constant succession of
vesicles, which, one by one, run a similar course after discharging their
ova. There is every reason to believe, further, that, during pregnancy
and stickling, while the uterine functions are in abeyance, those also
of the ovary are temporarily arrested, in so far as the development of
new Graafian vesicles is concerned the whole generative force being,
as it were, turned into other channels.

"The numerous lacerations which, in consequence of repeated rup-
tures, take place on the surface of the ovary, leave, in the process of
healing, corresponding cicatrices. On this account, the smoothness
of surface is soon lost, and it becomes more and more fissured and
wrinkled, until, toward the end of the child-bearing epoch in a wo-
man's life, the ovary is so irregular on the surface, as to warrant the
comparison which Raciborski has instituted between it and the kernel
of a peach. After this, the organ becomes atrophied, and, like the
uterus and other parts, is restored, in some measure, to the form which
it presented in early life."

The medical expert, if called upon to determine the existence or non-
existence of pregnancy, by the appearance of the corpus luteum in a
post-mortem examination, would undoubtedly find an extremely diffi-
cult question to decide. Every author cites numerous differential
characteristics, which I believe to be misleading ; also impossible to
diagnose pregnancy, beyond the peradventure of doubt, simply by the
appearance of the corpus luteum.

CHAPTER XII.

THEORIES OF IMPREGNATION.

GENERATION comprises those' several phenomena which are neces-
sary to the development or reproduction of organized bodies, and which
include, in the human family, the various functions of menstruation,
copulation, conception, gestation, and labor or parturition. The partic-
ular method by which generation is effected in the organic world,
varies according to the character of the organization, being more sim-

THEORIES OF IMPREGNATION. 95

pie as this approaches elementarity. Moreau has described the several
modes somewhat as follows:

1. Generation may be spontaneous, doubtful or unknown, as in case
of intestinal worms.

2. It may result from an individual, by division or separation of its
parts; a, by simple division of the individual, each fragment pro-
ducing a new individual, as in the instances ofjissiparce or vegetables,
cuttings of trees, and animal infusoria; 6, by separation of a vegetable
product, either on the exterior or interior of the individual, as with
the gemmiparce, or vegetables, buds of trees, and some polypi.

3. It may be effected by impregnation, requiring the connection of
the sexes, and varies according to the character of the sexes. 1st.
As in hermaphrodism, or where the sexes are united in the same indi-
vidual, and which may be divided into, , where the sexes are united
in a common envelope, in which instance one individual is sufficient,
as with many vegetables and some molusca; 6, where the sexes are
separated on the same individual, as in monoecious plants; c, with the
sexes separated in the same individual, but requiring the connection
of two similar individuals, and even reciprocal impregnation, as with
gasteropodous mollusca, and worms. 2d. When the sexes are sepa-
rated on different individuals, and which may be divided into, a, with-
out approximation, the parents and offspring remaining unknown to
each other, as with dioecious plants, and fishes ; 6, with approximation,
but without copulation, the parents knowing each other, but the off-
spring being ignorant of them, as with the batrachia, or reptiles, frogs,
toads, etc.; c, with approximation and copulation, as with the majority
of insects; the reptilia, chelonia, sauria, ophidia, birds, and mammalia.

4. This last method of generation by copulation and approximation,
offers great varieties, differing according to the mode of development
of the fecundated product, thus: a, by incubation, as with insects, and
the greater part of reptiles and fishes ; 6, by external incubation, as
with birds; c, by internal incubation in the parts of the mother, with-
out adhering to them, as with some of the ophidian, and ovovivipa-
rous animals; d, by an organ of gestation, to which the impregnated
product adheres, from which it derives the greater part of its nourish-
ment, and from which it separates after a certain time, as with all the
mammiferous animals. To this last and most complicated process
belongs the generation of man.

The mode in which fecundation is accomplished in the human being
belongs more especially to the physiologist's department to determine;

96 KING'S ECLECTIC OBSTETRICS.

but as the matter has long been a subject of inquiry, and presents a
field of interest to many, I will briefly refer to the various opinions
that have from time to time been advanced and maintained in the
medical world.

In the male, the semen, or spermatic fluid secreted by the testicles,
is undoubtedly the agent especially called into action in the function
of reproduction ; this is manifest from the fact that, removal of the
testes not only destroys all sexual propensity, but likewise renders the
individual forever after incapable of begetting offspring: The same
may be said in relation to the removal of the ovaries of the female ;
she loses all sexual inclination, the procreative functions are annihi-
lated, and all those graces, emotions, and feelings which distinguish
the sex, gradually disappear. Observations have likewise been made
in relation to this matter, of a highly interesting character, to some
of which a very concise reference will here be made.

Spallanzani, during his investigations, noticed, that as soon as the
female frog laid an egg, the male immediately cast a fluid upon it,
which soon impregnated it. He then confined the gentials of the
male frog in a silk bag, and ascertained that in this condition impreg-
nation could not occur. He, likewise, applied to some of the freshly
laid ova, a small quantity of the male semen or fluid which he had
previously collected, and impregnation was the result. He also insti-
tuted similar experiments on a bitch in heat, and which had been kept
confined for twenty-three days before heat commenced, in order to
prevent the approach of any dog ; the result was, that by injecting
nineteen grains of semen into the vagina, at 100 Fah., fecundation
followed, and, at the proper period, the animal gave birth to three
pups which bore a strong resemblance to herself and the dog from
which the semen was gathered. Prevost and Dumas arrived at simi-
lar results ; they expressed the semen from the testicle of a frog, and
after diluting it with water, they placed some ova upon it, which be-
came prolific. According to these gentlemen, it is important to dilute
the male fluid in order to have the experiment prove successful.

Sir Everard Home, in his " Lectures on Comparative Anatomy,"
vol. iii, p. 315, records a similar experiment on man, performed by
Hunter ; the husband was affected with hypospadias, which prevented
him from impregnating his wife; Hunter advised him to inject his
semen into his wife's vagina through a warm syringe ; the result was,
she became pregnant.

These experiments, with others of similar character, prove conclu-

THEORIES OF IMPREGNATION. 97

sively, that the agents engaged in the generating process, are the semen
furnished by the male testes, and the ova of the female. Spallanzani,
as well as Prevost and Dumas, determined from further and satisfac-
tory trial, that the fructification of the ova only took place when
brought into actual contact with the male semen ; thus refuting the
doctrine held by some physiologists, that impregnation did not require
this mutual junction, but was effected merely by the presence or influ-
ence of a seminal halitus or vapor.

Another point of inquiry among physiologists, was, the method by
which the spermatic fluid is carried to the ovaries; some contending
that impregnation was effected in the uterus, while others maintained
that the semen was conducted to the ovaries, and that fecundation was
possible even beyond the angles of the uterus; indeed, this fluid has
been found on the surface of the ovaries, by Adelon, Bischoff, and
other investigators. But by what means it reaches the ovaries, has
never yet been satisfactorily explained; for the male penis, certainly
has not sufficient power to throw it beyond the uterus.

Various views have likewise been supported at different periods,
relative to the manner in which the union of the male and female
principles necessary to the formation of a new being, is effected, and
how this new being, of whatever species, comes to bear the impress of
the mental and physical features of one or both parents. But the
solution of these particulars is still involved in mystery. The oldest
theory on this subject, is that of epigenesis, which holds that the new
being is created entirely anew, and at the moment of conception,
receives at once the materials necessary for its formation, one portion
being derived from the testes of the male parent, the other from the
uterus or ovaries of the female. Aristotle, Galen, and others, sup-
posed that the material furnished by the female was the menstrual
fluid; and Hippocrates considered that the female supplied all the
substance required for the development of the future being, while the
male fluid merely contained that vivifying principle necessary to im-
part vitality to the female materials. This theory of epigenesis, with
various modifications, was the prevailing one for many years, and was
for a time renewed by Buffon in the beginning of the seventeenth
century, whose views were entirely speculative and untenable. His
notion was, that the growth and nourishment of individuals during
youth, was effected by certain organic molecules common to both
sexes ; but which being required in less quantities for these purposes
at maturity, the predominance was emitted by the male testes with the
7

98 KING'S ECLECTIC OBSTETRICS.

spermatic fluid, and also by the ovaries, or female testes, as he termed
them, for the purposes of reproduction of the species. He imagined
that the body of each parent supplied each of these molecules with
atoms derived from its various parts, and that whichever parent af-
forded to the newly organized being the major portion of these mole-
cules, the resemblance to that parent would be the most marked.

During the sixteenth century another theory was originated, being
based upon investigations and discoveries of the physiologists of that
period, among whom may be named, Leuwenhoeck, Harvey, De Graaf,
and others. It is termed the theory of evolution; and was strenuously
supported under some form or other, during the whole of this century.
The adherents of this theory maintained that the germ of the new
being existed in only one of the parents, while the other furnished the
principle which communicated life to it. They were divided into
ovarists, and animalculists or spermatists. The ovarists, among whom
I may mention Harvey as the principal, having discovered numerous
small vesicles in the ovaries, which apparently decrease according to
the number of conceptions, held that these vesicles were the fetal
germ, which only needed the animating power of the male semen to
usher the new being into existence. But this view was objected to by
many, on account of its exclusiyeness, whereby the male fluid had but
a minor part to perform; beside which, if the semen merely exerted a
vivifying influence upon these vesicles, it did not explain why the
offspring so often resembled its male parent.

In consequence of these objections, a different opinion was supported
by those who were called animalculists, and which originated princi-
pally from the microscopic discoveries of Leuwenhoeck and other in-
vestigators, who found myriads of animalcules in the male semen.
These held, that after having been thrown into the uterus during copu-
lation, the animalcules perished, with the exception of one or two,
which entering the Fallopian tubes/ were conveyed through to the
ovaries, and there deposited and nourished in a nidus formed by the
ovum. As this spermatozoid progressed in growth, it ruptured the
nidus which inclosed it, and was again conveyed to the uterus to be
nourished and preserved until the period of parturition. To this
view, wherein the female merely supplies the nourishment for the
embryo furnished by the male, an objection similar to the one above
is suggested, as to the cause of resemblance, in many instances, to the
female parent.

Those who desire to have these several views more in detail, are

THEORIES OF IMPREGNATION. 99

referred to the several physiological treatises in which they are fully
related and discussed ; and as they have become at the present day
obsolete, a mere glance at them was deemed all-sufficient in the pres-
ent work. But, before terminating this subject, a reference to the
views of physiologists of the present day must be made, without which,
this portion of our work would be imperfect.

In Chapter X, will be found a description of the ovaries, Graafian
vesicle, ovule, germinal spot, etc.; these are the discoveries of recent
physiological investigators, and have been the means of eifecting a
revolution in relation to the views of impregnation, giving rise to a
theory, the ovular theory, which is, undoubdtedly, more in proximity to
the truth, than any of the previous doctrines which have been held on
this subject. The theory is, that the egg, ovum or germ, is supplied by
the female, in whom it exists in indeterminate quantities ; that at the age
of puberty, these germs commence maturing; at their period of ripen-
ing, they rupture the vesicular tissue in which they are contained and
pass from it, being accompanied by a sanguineous discharge, probably
from the uterus, called menstruation, the appearance of which is signifi-
cant of the fact, that the female has reached the age at which she is capa-
ble of giving birth to children ; these ovules escape either into the peri-
toneal cavity, or into the womb through the Fallopian tubes, and pass
off with the menstrual flow, or are retained in consequence of
fecundation.

On the other hand, the male supplies a fluid in which is contained
minute, round and granulated bodies, the spermatic granules, as well as
bodies possessed of motion, like the epithelial cells, which are not, how-
ever, animalcules, but, more properly, spermzoons or spermatozoids ;
these bodies, by means of ciliary movement, the result of wavy motion of
the ciliated epithelium lining the walls of the uterus and of the Fallo-
pian tube, assisted perhaps by a kind of peristaltic action of the latter,
are conveyed to the uterus, tubes, or ovaries, when coming into contact
with the nude, uncovered ovum wherever this may be, in the ovary,
the tube, or the uterus through some inscrutable agency, probably
an intermingling or mutual permeation of the male semen and female
germ, animalization takes place ; and a creature is brought into exist-
ence, which, possessing certain elements derived from each parent, will,
necessarily, present mental and physical resemblances to-either or both
of them. Ovarian and ventral pregnancy prove that the spermzoons
are conveyed even to the ovary ; but impregnation undoubtedly occurs
in the tube or in the uterus after the ovum has left its ovarian vesicle.

100 KING'S ECLECTIC OBSTETRK s.

How long a period is occupied between the emission of the ovum from
the ovary and its entrance into the uterine cavity is unknown, proba-
bly five or six days.

Repeated experiments on animals have proved, that any obstacle to
this contact of the germ and semen, will prevent conception. Martin,
Barry, Bischoff, and others have observed the spermzoons freely mov-
ing about in the transparent zone of recently impregnated ova of ani-
mals, and it is by no means improbable that a similar result occurs in
impregnation of human ova.

CHAPTER XIII.

MENSTEUATION OVULATION CONCEPTION.

AT a certain age, the female reaches the period of puberty, which is
made manifest by a sanguineous discharge from the uterus, occurring
periodically once a month, and which is called menstruation. It has
likewise many other names applied to it as menses, catamenia, courses,
terms, periods, monthly sickness, menstrua, flowers, monthlies, times, etc.
It is not a secretion, but an effusion or hemorrhage; very much resem-
bling venous blood, and is undoubtedly blood rendered impure by the
addition of mucus and epithelial scales with which it meets during
its flow.

Strieker, of Vienna, " has demonstrated the passage of red and
white blood corpuscles, through the walls of the capillaries of the uter-
ine mucous membrane. Some of these capillaries become ruptured in
the process. The blood oozes through the mucous membrane of the
uterine cavity, impregnates its epithelium, causing it to swell and be-
come detached, and passes on, mixed with epithelial debris, into the
vagina, and thence out of the body."

As a general rule, the discharge, in females of this climate, is estab-
lished at the fourteenth or fifteenth year, though it varies with some,
oftentimes appearing as early as the twelfth or thirteenth year, and
again not until the seventeenth or eighteenth. In the 'former instance,
it is termed precocious menstruation, and is significant of an unnatural
increase or development of certain organs, at the expense of others; it
is commonly followed by premature death, especially if an early mar-
riage, resulting in pregnancy, should take place, in consequence of

MENSTRUATION OVTILATION CONCEPTION. 1 01

these unseasonable and abnormal indications of puberty. In the latter
instance, the term tardy menstruation is applied, and which is usually
the result of some debility or disease, that may eventually destroy the
female.

Climate, constitution, education, modes of life, etc., affect the ap-
pearance of this discharge; it being earlier in warm climates than in
cold, and i-n city females, than in those of the country. It likewise ap-
pears earlier and more abundantly in females of a nervous tempera-
ment, than in those who are phlegmatic.

The advent of the menstrual discharge, is the chief external sign of
the approach of puberty; and is one of the most interesting periods in
the life of the female. At this time, a Graafiau vesicle for the first
time projects from the surface of the ovary, gradually developing to a
state of complete maturity, the maturation of which marks an impor-
tant epoch in the life of the female a transformation in which the girl
passes into womanhood and becomes capable of reproduction, a process
attended by growth and development of 'the peculiar organism of the
female by which a new life and individuality assert themselves.
Thus ovulation is established, which, at puberty, is usually concurrent
with menstruation, and is probably the immediate or exciting cause of
menstruation ; however, as will be seen presently, the two may exist
independently of one another. This interesting period, in the life of
the female, is ushered in by many symptoms and changes in her mental
and physical developments that manifest themselves gradually. A re-
markable advancement toward the perfection of the reproductive organs
is presented ; the ovaries rapidly enlarge, and change from their pre-
vious long, flat, and smooth condition, to one in which they are large,
oval, rounded, and embossed; the Fallopian tubes become elongated,
their fimbriated extremities widened, and the fimbriae enlarged; the
uterus becomes more fully supplied with blood, and its tissue more
florid; the body and fundus likewise obtain more rotundity and devel-
opment than the cervix, which appears proportionally shorter and nar-
rower; the vagina is widened and dilated, and its vascular structure is
supplied with increased quantities of blood, and its mucous folds aug-
ment in number. The pelvis becomes larger and wider, with a dimi-
nution of its inclination forward; the pubic region more prominent,
round and covered with hair; the labia pudendi more amplified, red,
and sensitive; the hips more projecting, and inclined outwardly; the
pelvic cavity enlarged ; and the breasts rounder, full, and prominent,
with the nipples projecting, more sensitive, and the areola of a darker

102 KING'S ECLECTIC OBSTETRICS.

hue. The whole person improves in grace and elegance, and the voice
becomes more sonorous and melodious.

Corresponding with these modifications of the physical system, are,
changes in the mental character; the gay, light-hearted girl loses her
playfulness, and assumes the dignity of womanhood ; she becomes more
reserved, more 'sensitive, and full of sympathy; she manifests strong
attractive feelings toward the opposite sex, and seeks to love, as well as
to be loved; the social and moral sentiments become of a purer and
more exalted character; a great fondness for children is displayed ; and
in her, we find the most perfect combination of modesty, devotion, pa-
tience, affection, gratitude, loveliness, and Christian virtue.

The menstrual discharge, being a sign of maturity and fertility of
the reproductive organs, does not appear during childhood, nor in old
age. It usually ceases at the ages of from forty to fifty, though occa-
sionally, it extends to a very advanced age. The period of its cessation
is termed the turn of life, the menopause, or the critical time of life ; from
which time, women cease to bear children. And on account of the vari-
ous unpleasant, and often serious symptoms presenting at this period,
its approach is much dreaded by nearly all of them.

The amount of fluid discharged, varies in females, averaging from
six to eight ounces; some -will lose only four ounces at each menstrua-
tion, and others twelve, and yet each will remain in health, because
the system of each is controlled and affected according to its individ-
ual wants, habits, strength, and activity. The discharge usually con-
tinues from three to six days, occasionally from eight to ten, and must,
as a general rule, have revealed itself before impregnation can take
place.

All cleanly women \vcar a napkin during menstruation, which is
placed, by means of a girdle, in a manner similar to a T bandage, for
the purpose of concealing their situation, which it does by absorbing
the fluid discharged; from four to twenty of these napkins will be
worn during one menstrual term.

In the consideration of menstruation and ovulation, many strange
theories have been advanced, that appear quite absurd in the light of
modern research; some authors use the terms synonymously. Physi-
ological investigation, however, gave rise to such inquiries as : What
is the cause of menstruation? From whence comes the hemorrhage?
To what extent does menstruation depend on ovulation ? Is the ani-
mal rut, or oestrus, and menstruation, analogous? And many other
questions that we need not notice here.

.MENSTRUATION OVULATIOX CONCEPTION. 103

Menstruation is believed by many to be merely the phenomenon of
that function which matures and discharges an ovum from the ovary
periodically. The prevailing belief seems to be, that menstruation is
co-existent with, or rather the result of, functional ovarian activity ; that
menstruation is an indication of ovulation. That ovulation occurred
only at the menstrual period, \vas generally accepted as a fact, until
within a few years. It is a special function, and consequently may oc-
cur independently of menstruation ; causes, of which we know nothing,
may hasten the development of a vesicle, or excite the bringing forth
of an immature ovum, and thus establish inter-menstrual ovulation.

The Jewish female furnishes, it seems, evidence indicating the occur-
rence of inter-menstrual ovulation. According to Rabbinical ruling,
intercourse is prohibited until twelve days after the appearance of
menstruation ; at the expiration of this time, the bath of purification
is taken, the Jewess scrupulously cleansing herself every part of the
body being immersed in the bath. Mosaic law has named this the
Micva. Not until now, does the wife receive the husband. These
women are surely as prolific as other females, and their impregnation
demonstrates the fact, that the maturation of the ova occurs at any
time.

A Graafian vesicle may rupture during sexual excitement, as during
coitus, or from the sequence of such excitement; and this is an ex-
planation why women may conceive at any time. That ova are dis-
charged at irregular periods from the ovaries, and not merely monthly,
about the menstruating period; that there can be no menstruation
except in connection with ovulation, though there may be oyulation
without menstruation, is now becoming the opinion of obstetricians in
general.

Mr. Lawson Tait says : " The growth and ripening of Graafian folli-
cles before puberty constitutes one of the many arguments in favor of
the view, that menstruation and ovulation are wholly distinct processes,
and abundant examples can be given of them being carried on each
independently of the other. The statement constantly made in text-
books that, if the ovaries are extirpated, or become atrophied, men-
struation does not re-appear, is not accurate ; and equally incorrect is
the assertion that the first ovular dehiscence corresponds with the first
appearance of the menses. It is perfectly certain, that ovulation is by
no means a periodic process, in the sense of being monthly; and the
fact that a periodic flow from the uterus is almost confined to the hu-
man race, is sufficient to show, that it is not in the ovaries that we

104 KING'S ECLECTIC OBSTETKK s.

have to look for the cause of this curious and objectionable phenome-
non, for which Johnson alone has so far suggested a useful purpose.
Where the cause does exist, we do not know ; but it is quite certain, that,
as it continues for months, in some cases, after the removal of both ova-
ries, it can not be in those glands. Nor is it in the uterus; for in three
cases in which I have removed the uterus, as completely as it can be
done, menstruation has persisted ever since in one of them for nearly
seven years. Removal of the ovaries alone, is followed by immediate
and complete arrest of menstruation in about fifty per cent, of the
cases. Removal of both tubes, with or without the ovaries, is followed
by the same arrest in about ninety per cent, of the cases; and I suppose
that in hysterectomy the arrest occurs in at least ninety-seven per cent.
But it is the exceptions, in such a case as this, which prove the rule;
and I suppose that we shall some day find a special nerve mechanism
which is the real cause and governor of the phenomena of menstrua-
tion ; and this is certain to be ganglionic ; for a ganglionic system gov-
erns all other rythmic phenomena."

As to the source of the menstrual discharge, strange and varied the-
ories have been advanced. The most recent is that of Dr. A. W. John-
stone, to which Mr. Tait calls attention in his work on Diseases of
Women and Abdominal Surgery viz: that it depends on the action of
a special nerve, which lies in the broad ligament, in the angle between
the tube and round ligament, close to the uterus. Some claim it has
its origin in the cervix and os uteri; others in the vagina, tubes and
ovaries.

Coste believed it to be a transudation through the walls of the cap-
illary vessels of the uterus, being chiefly venous. Dr. Farre advances
the theory, that there may be permanent vascular orifices through which
the blood escapes during the menstrual period; that these orifices are
closed during the inter-menstrual period, by the contractility of the
tissue surrounding them.

Pouchet claimed, that the greatest part of the mucous membrane is
shed at each menstrual period ; its separation from the uterine walls
involved a rupture of vessels, and thus the menstrual flow. The most
reasonable theory, however, is, that the tubes are the starting point of
the catamenial discharge; that the epithelial lining and a portion of
the uterine mucous add to the detritus, the blood being largely from
the uterine walls, the result of a process of diapedesis. A case of
chronic inversion of the uterus was recently reported before the Cin-
cinnati Eclectic Medical Society, in which this condition was clearly

MENSTRUATION OVULATION CONCEPTION. 105

illustrated. Menstruation has occurred regularly for many years; at
each period the mucous surfiace of the inverted uterus is bathed in
blood, prior to which many drops of blood, giving it a beaded appear-
ance, are noticeable; also the loosening and casting off of small shreds
of the epidermis the cause of the hemorrhage.

The fact of menstruation occurring after the removal of the uterus
and its appendages, may be due "to segments of the organs left at the
pedicle, either in hysterectomy or oophorectomy, or, perhaps, to the
existence of a supernumerary ovary.

Since the female among the lower animals will not cohabit with the
male at any period other than the rutting season, it would indicate that
the oestrus and ovulation are concurrent. I am aware, that doubts are
entertained by some, as to whether the oestrus and human menstrua-
tion are analogous; however, admitting that they are, this would not
be positive proof but that ovulation may exist irregularly and inde-
dendently of the rut.

By ovulation, is understood the functional action of the ovaries: at
which time occurs the escape of the ovum from the ovisac, from whence
it is either received by the Fallopian tube and transmitted to the uterus,
or is lost in the peritoneal cavity. The fluid contents of the ovisac
gradually increase with its development, until, at the time of complete
maturation, the distention is so marked that rupture is the result, fol-
lowed by the dehiscence of the ovum. The functional relation ex-
isting between the oviduct and the ovary, and the exact manner by
which the ovum, as it escapes from the ovisac, finds lodgment in the
oviduct through its fimbriated extremity morsus diaboli and is then
conveyed to the uterus, does not appear to be clearly defined. Numer-
ous opinions have been advanced as the subject has been studied and
investigated. Lusk, in his Science and Art of Midwifery, speaks as
follows, on the MIGRATION OF THE OVUM :

" The number of ova in each ovary has been estimated by Henle at
thirty-six thousand. Only a small proportion of them, however, meet
with the conditions requisite for fruition. It is probable, that many
ova perish while still surrounded by the stroma of the ovary. The
history of extra-uterine pregnancies teaches us that, in some instances
at least, the ovum, after its discharge from the Graafiau follicle, escapes
into the abdominal cavity. It, therefore, becomes an interesting subject
of inquiry as to the conditions which ordinarily determine the passage
of the ovum from the ovary into the Fallopian tube of the correspond-
ing side. It will not do to assume, as is usual, a peculiar erectility of

106 KING'S ECLECTIC OBSTETRICS.

the Fallopian tube, which enables it to apply its funnel-shaped extrem-
ity to the ovary just at the moment of the rupture of the Graafian
follicle. Setting aside the inherent improbability of the existence of
such a degree of intelligence in the fimbrire as would lead to the exact
adaptation of the tube to the precise point at which the ovum is to be
discharged, it has been proved that the Fallopian tube possesses none
of the characteristics of erectile tissue. Injections of its vessels after
death do not communicate to it the slightest change of form or place.

" Muscular action has also been often invoked to explain the assumed
manner in which the fimbrise seize the ovary; but galvanization of the
tubes, practiced upon criminals recently executed, produces only ver-
micular contractions, which do not affect the position of the fimbrise.
Indeed, w T hen we remember the position of the Fallopian tubes in the
pelvis, and bear in mind that they are at all times necessarily subjected
to the pressure of the intestines, it becomes difficult to understand how
they can execute any very extended movements.

" In the absence of direct experimental proof, the suggestion of
Henle, that the passage of the ovum into the Fallopian tube is due to
currents produced in the serum by the ciliated epithelium, which cov-
ers both the external and internal surfaces of the fimbrise, is, on the
score of probability, entitled to the most consideration. One of the
fimbrise (fimbria ovarica) is permanently attached to the lower angle
of the ovary. .

"It is likely that the ovum, discharged from a Graafian follicle, is
floated down by the peritoneal serum toward the lower and outer border
of the ovary, where a sufficient current is present to insure its being
caught up and conveyed into the infundibulum tubse. Failures on the
part of the ovum to reach its destination are, in all probability, not
uncommon. Support is given to the theory of the importance of the
cilia? in influencing the migration of the ovum by the observation of
Thiry, that in batrachians, which have the oviducts fixed to the ab-
dominal walls, and situated at a distance from the ovary ; during the
rutting period little pathways of ciliated epithelium form in the peri-
tonaeum, which collectively converge toward the openings of the tubes.

"While the ovum remains in tlie ampulla, or dilated portion of the
tube, its further progress is at first dependent upon the movements of
the cilia? ; but, after the isthmus is reached, an additional propelling
force is furnished by the circular muscular fibers, which possess a peri-
staltic action."

The attention of physiologists has recently been called to an adenoid

MENSTRUATION OVULATION CONCEPTION. 107

/unction of the endometrium and subjacent tissue. The cited evidence
of secretory power, in the lining of the uterus, is based on the develop-
ment of the decidual structure, which is always evolved as soon as
pregnancy occurs, and which not infrequently developed during nor-
mal menstruation. Such a membrane, or vascular meshwork, may be
exuded during ovulation the low grade of structure not depending
upon either menstruation or pregnancy. The decidual exudate de-
pends upon exalted vascular activity in the endometrium, and not
upon any secretory function. In fact, a membrane or vascular texture
can not be secreted any more than a tongue or an ear can be the result
of adenoid action.

It has been assumed and asserted by speculative physiologists, that
during inter-menstrual periods there is evolved from the endometrium
a membranous meshwork, which is to entrap or ensnare the fertilized
ovum when it emerges from the Fallopian conduit. If the ovum be
not fructified, it is not prevented from traversing the uterine cavity,
and falling into the vagina. In other words, the speculative net-work
developed from the endometrium is to be discriminative is to let the
unfecundated ovum pass the barrier, but to entrap and ensnare the
fertilized body. However, to get rid of discriminating power ascribed
to ,the deciduous membrane, the meshw r ork is to entangle the unim-
pregnated egg and take it out of the womb, but is to arrest the out-
ward course of the fertilized ovum. An objectionable feature of the
scheme is, that the inter-menstrual meshwork is to be denominated
nidus, a nest, and the entrapping is called nidation, or nesting, after
the manner of birds; when in fact the uterine exudate is more a net
than a nest. The endometrium does secrete mucus by means of crypts
and follicles in its free surface, and contributes to the exudative forma-
tion of the decidual structure, but it does not develop anything in
health except uterine mucus, which, in some respects in odor, for
instance is peculiar. In a normal condition between menstrual ac-
tivities the endometrium secretes or throws off endothelium, as the
mucous lining of the mouth does, or any other localized portion of a
mucous structure.

The mucous secretions differ to an appreciable extent. The secre-
tions of the urethra differ from those of the bladder and ureters. The
free surface of the endometrium is pale and smooth, except when men-
strual epochs are approached; the structure then attains a pinkish
flush of vascularity, and at length becomes so congested that corpus-
cles of blood burst through the alternated walls of the vascular capil-

108 KING'S ECLECTIC OBSTETRICS.

larics. The corpuscles mix with mucus and exuded lymph, making a
fluid which is decidedly sanguineous, but is never pure blood unless a
hemorrhage occurs.

Toward the end of a catamenial nisus, there is little blood and much
plastic lymph exuded, as in ordinary trumatism, and then the decidual
exudate or meshwork is elaborated. "Lining the fundus of the womb
as it does, it can not help ensnaring the ovum as it leaves the salpin-
giau canals, whether the egg be impregnated or not. If the ovum be
not fertilized, it passes off with the detached decidua; and if it be
fructified, the pregnant state excites uterine vascularity, and secures
the services of the, decidual membrane in fixing and nourishing the
developing ovum. The neoplastic membrane makes no discrimination
between the unimpregnated and the fertilized egg, but the condition
of pregnancy enforces the kind of action which is to result in a loss
of the structure, or in the utilization of its possible offices in the nutri-
tion of the ovum. It has been suggested, that the decidual exudate of
menstruation occludes the canal of the uterine cervix, producing me-
chanical obstruction membranous dysmenorrhoaa ; but as catamenial
pains are mostly over before the menstrual exudate is shed or cast off,
the theory has few substantial facts to sustain it. The womb in a state
of physiological hypertrophy pregnancy is augmented in weight
from ounces to pounds. Yet, in the enlarged state it is increased
mostly in muscular evolution; after parturition, the organs enter upon
rapid involution, so that in a few weeks it returns to normal weight
and size. In the manifestation of these great changes, there is no dis-
play of increased glandular action or adenoid activity.

The endometrium undergoes important transformations, yet does
not become appreciably glandular or adenoid. In ectopic gestation a
decidual exudate is always found upon the free surface of the endo-
metrium, as if ready to ensnare the fertilized ovum, but the function
of the membrane is not forced into use.

DEVELOPMENT OF THE HUMAN OVUM. 109

CHAPTER XIV.

DEVELOPMENT OF THE HUMAN OVUM.

IT will now be proper to notice those changes which occur, during
pregnancy, in the ovum, as it progresses in its development. Shortly
after conception, a layer of coagulable lymph lines the whole internal
surface of the uterus, which is at first of a soft, gelatinous nature, but
which soon becomes imperfectly organized, vascular, and of a reddish
color ; it is called the membrana caduea (caducous membrane), or
membrana decidua (deciduous membrane). Several other names have
been applied to it, as epichorion by Chaussier, epione by Dutrochet,
perione by Breschet, anhistous membrane by Velpeau, adventitious
lamina by de Blainville, nidal decidua by Aveling, etc. This mem-
brane is about one line in thickness, and is in contact with the whole
of the inner uterine surface ; its inner, or fetal surface is smooth and
polished, with striae and depressions which lead into canals, bearing
some resemblance to that of serous membranes, and its external or
uterine surface is rough and unequal, and closely adheres to the
internal surface of the uterus. It is not persistent in its character,
as it is formed only during conception, or as stated under nidation,
in the preceding chapter; and it is expelled with the ovum and its
membranes whenever this occurs. Within this membrane is a space
or cavity called the cavity of the decidua, which is filled with a limpid,
serous fluid, to which M. Breschet has given the name hydroperion.
This fluid is present simultaneously with the caducous membrane,
or perhaps with the impregnation of the ovum, increases in quantity
as the uterus enlarges, and continues to be secreted, according to
Breschet, until the caduea vera and caduea reflexa come in contact
with each other, or toward the fourth month ; it is supposed that this
liquid aifords nourishment to the embryo during the early months,
before a direct placental communication is established between it and
its mother.

The manner by which the ovum becomes enveloped in this mem-
brane is supposed to be as follows: having passed through the Fal-
lopian tube, until it arrives at its uterine orifice, it pushes before
it a portion of the membrana caduea, until the whole ovum is sur-
rounded and inclosed by this membrane (F. Fig. 25). The por-

110

KING'S ECLECTIC OBSTETRICS

A. The cavity of the uterine
Neck -

Fallopian Tubes.

C. External, or Uterine Ca-

duca.

D. Cavity of the Decidua.

E E. Angles at which the De-

tion of membrane thus covering the ovum, is
called the decidua ovuli, or reflexa (ovuline, or
reflected decidua), while that in contact with'the
uterine walls, is termed the decidua uteri, or vera
(uterine, or true decidua). As the ovum grows,
the decidua reflexa approaches nearer and nearer
to the decidua vera, the cavity of the decidua
diminishes, until, finally, at the third month the
cavity is obliterated, and the two decidua, coming
in contact, become agglutinated into one mem-
brane. The ovum, it will be seen, is not com-
pletely surrounded by the decidua reflexa, and at
THE CADUCA, AFTER that part of the uterus from which this membrane
was detached by the advancing ovum, the surface
is lined by no membrane whatever. At this un-
covered point a new structure is developed be-
tween it and the ovum, bearing some resemblance
to the membrana decidua, and which is called
decidua serotina, and here the subsequent forma-

igies at wnicn me ie- , n ,-> i , i i rr*i_

cidua vera is reflected tion of the placenta takes place. The uses of
by the advance of the the membrana caduca, are, according to Moreau,

F. chorion. " to prevent the ovum from floating loosely in the

G. Amnios. cavity of the uterus ; to maintain it in contact
with a fixed point of the parietes of this organ, until it has contracted
sufficiently numerous and firm attachments to enable the embryo, after
being developed during the first stages of pregnancy at the expense
of the surrounding fluids, to extract from the blood of the mother,
the materials suitable for its nutrition and subsequent growth ; to. de-
termine the place of insertion, form, and extent of the placenta ; to
prevent superfetation ; and, according to Lobstein, to transmit to the
chorion and amnion the vessels which furnish these membranes with
the elements of nutrition and exhalation."

The above is the description generally given by authors relative to
the caducous membrane; still, it is not a settled question, and much
diversity of opinion prevails in regard to it. Some consider it to be
a secretion, or exhalation from the internal mucous coat of the uterus,
effected by the peculiar excitement resulting from conception ; while
others view it as an exfoliation of this mucous coat, itself, which, from
a similar cause, has undergone considerable changes in its consistence
and vascularity. The former is the most commonly received opinion,
and, probably, the most correct one ; it maintains, that the excitement

DEVELOPMENT OF THE HUMAN OVUM. Ill

caused by a fruitful coition occasions the secretion of a plastic lymph,
\vhich coagulates and forms a kind of false membrane or caduca, anal-
ogous to those produced on inflamed surfaces by the exhalation and
coagulation of an albuminous fluid, and which is entirely distinct from
the mucous membrane, although it adheres, more or less firmly; to the
latter by numerous vascular villi, or prolongations, which frequently
* extend into the canal of the cervix, or Fallopian tubes. When the
adhesion of this false membrane is but slight, the ovum, upon entering
the uterine cavity, instead of pushing forward a decidua reflexa at the
orifice of the tube, may slip between the caduca and uterus, and form
an attachment at some other point, thus giving rise to the various pla-
cental insertions which are met with in practice.

The opposite opinion maintains that the utricular glands of the
uterus become elongated, augmented in size, and contorted, their se-
cretion increases, the vessels of the mucous membrane become more
fully developed in size and number, and a substance composed of
nucleated cells fills up the interfollicular spaces in which the blood-
vessels are contained. These changes produce a thickening and soft-
ening of the mucous membrane itself, with increased vascularity, thus
forming the deciduous membrane. But, as Prof. Meigs observes, " I
can not readily comprehend how, after all this structure is once thrown
off as a decidua, it can ever be reproduced for the service of subse-
quent pregnancies." Dr. Carpenter inquires, if the views relative to
the mucous membrane of. the uterus being the decidua, are well-
founded, how are we to explain the formation of the decidua continu-
ously over the upper orifice of the cervix uteri, and over the orifices
of the Fallopian tubes, as is frequently, though not always, the case ?

Again, it has been asserted by Dr. Lee, that this membrane is not
formed unless the ovum reaches the uterus, but in this he is evi-
dently in error, as there are, at least to my mind, a sufficient num-
ber of facts recorded to prove its presence independent of the
arrival of the ovum at the uterus. And, if I am not mistaken, Prof.
Meigs, as well as other investigators, have observed the decidua in
cases of extra-uterine pregnancy. Moreau states, that " it is even found
in cases of tubular and ovarian pregnancy, provided the pregnancy be
not too far advanced, and have not exceeded five or six months, for
we are inclined to believe that it disappears at a later period." Vel-
peau denies that the membrane is organized, hence, he has called it
anhistous; but there are sufficient proofs of its organization, as, for
Jnstance, its vascularity; it has also been injected by Ruysch, Burns,

112 KING'S ECLECTIC OBSTETRICS.

Lobsteiri, and others beside, it is liable to disease, and toward the
last becomes very thin, like serous or cellular tissue.

Hunter asserted that the deciduous membrane had three openings,
one at the inner orifice of the cervix, and one at each orifice of the
Fallopian tubes ; were this the case, no decidua reflexa would be formed,
but the ovum in entering the uterus, would at once pass through the
opening into the cavity of the decidua, from whence it could escape
out of the uterus through the opening at the inner orifice of the cer-
vix, and no conception would result. Such openings in the membrane
may occasionally be present, but according to the investigations of
many excellent observers they do not occur as a general rule. It has*
also been denied that the decidua reflexa is a mere reflected portion of
the decidua vera, as the texture of the two are said to be non-identical ;
and that the reflexa is probably formed by the agency of nucleated
cells from the plastic materials thrown out from the decidua vera, in
the same manner as the chorion is supposed to be formed in the Fal-
lopian tube, from similar materials secreted from its lining membrane.
More recently it has been advanced that the decidua is formed inde-
pendently of impregnation (see Nictation) ; that it consists of two dis-
tinct layers, one, lining the wall of the uterine cavity, and termed, the
decidua vera, d. uteri, or parietal decidua, the external surface of which
presents numerous filaments, while its internal surface is smooth,
shining, but presenting numerous elevations. The other, forms the
inner layer, is named the decidua reflexa, d. ovuli, d. chorii, and pre-
sents similar elements as the preceding, its internal surface being
studded with numerous pits, probably for the reception of the villi of
the chorion.*

*From recent investigations by Dr. Kundrat, of Vienna (Rokistansky's senior As-
sistant), and which are published in the Medizinische Jahrbiicher, 1873, No. 2, and
described in the Medical Times and Gazette, Aug., 1873, it appears that the generally
accepted description of the human Impregnated uterus and embryo, is only partially
correct. The purport of his observations are: The mucous membrane (mucosa)
of the recently gravid uterus is known as the decidua, and which has been commonly
divided into a decidua vera, d. reflexa, and d. serotina; at first, its structure bears some
resemblance to the uterine mucosa, in or before menstruation ; it is thickened, the
ghmds are dilated, elongated, and tortuous, and there is a great increase of intertubular
cells. In every respect the structure of the three portions of the decidua is very
similar. Inferiorly the d. vera abruptly terminates in an overhanging border at a
short distance from the cervix, this last taking no part in the formation of the fetai
cavity. During the entire period of pregnancy, the Fallopian tubes, as well as theii
inferior openings, are patent. Kundrat farther observes that when the impregnated
ovum reaches the inferior tubal opening, its progress is not obstructed by an adhesive
growth of the opposite mucous surfaces to each other, as some investigators believe

DEVELOPMENT OF THE HUMAN OVUM. 113

From this brief review of the subject, it will be seen that it is still
involved in obscurity, and those who desire further information re-
garding it, are referred to the various essays by Hunter, Lee, Chaus-

for no such adhesion exists. For the same reason the ovum does not push before it
and invaginate a portion of the nmcosa, which becomes the decidua reflexa. The
latter is clearly an outgrown and infolded portion of the decidua vera, possessing
glands on its deep or ovular surface, as well as on its free. The ovum is retained at
the fundus of the uterus by the swollen decidua. If the swelling is not very great,
the ovum may travel down toward the cervix; and it is for this reason that placenta
przevia is more common among multiparae. He does not believe that the ovum enters
the mouth of a gland, but that it develops on the irregular surface of the d. serotina.
As pregnancy advances the uterus enlarges, and the connection between it and the
ovum becomes more intimate and complex. At first the enlargement of the uterus is
out of proportion to the growth of the embryo, and a free cavity exists between the d.
vera and the d. reflexa, which is filled with a somewhat opaque mucoid fluid. The
embryo does not fill the uterine cavity until the fourth month, and the walls, which
were previously disproportionately thick, become disproportionately thin, while the
envelopes become transparent. In the fifth month the process has advanced still an-
other step, by the adhesion partial at least of the opposite walls of the uterine
cavity ; that is, of the d. vera and the d. reflexa.

As regards the connection between the chorion and the decidua, it has frequently
been stated that the processes or villi of the former pass into the glands of the latter.
Kundrat remarks that this arrangement was "but seldom" to be discovered. On the
contrary, the chorion-villi were found to be fixed in the grooves of the d. serotina and
on the sides of its elevations by a connective mass composed of mucus and degener-
ated epithelium. Other villi had buried themselves in the tissue of the d. serotina,
and formed a connection so intimate that any attempt at separation ended in rupture.
It is here that, the placenta is afterward developed. As gestation proceeds the changes
of the decidua are very considerable, and in the last months peculiarly interesting.
The d. reflexa becomes attenuated by pressure until reduced to a simple layer of the
transparent envelopes of the embryo, of which it forms the most external portion. On
the other .hand, the d. vera and the d. serotina remain as comparatively thick layers
of tissue, compact and cellular on the surface, but spongy in their deep portion from
the presence of the numerous ends of the dilated glands, which represent sinuses
lined by epithelium. As the termination of pregnancy approaches there occurs a re-
markable change on the lining membranes of the uterus. These, as well as the d.
reflexa, become whitish, dull, and of a pale yellowish or even yellowish-gray tint,
opacity replaces transparency, and the process, which is discovered by the microscope
to be one of fatty degeneration, passes into the deeper layers. This description, of
course, reminds us of t'he simultaneous fatty degeneration of the placenta. When par-
turition occurs, a portion of the membranes is expelled with the fetus, and it is inter-
esting to inquire what part, if any, of the envelopes is retained. Careful examination
certainly reveals that the superficial portion of the decidua vera is, as a rule, in-
cluded in the fetal membranes, while the deeper portion is retained, although this is
not always the case. During the first week post-partum the discolored lining mem-
brane of the uterus may be found, under the microscope, to present the characters of
the decidua vera, but the sinuses are full of blood, the superficial cellular layer gone,
the fatty degeneration extends to the deepest layers, and the tissue generally is infil-
trated with round cells and blood. The lochial discharge consists of such cells and

114 KING'S ECLECTIC OBSTETRICS.

sier, Breschet, Velpeau, Cams, Granville, M. Coste, Weber, Sharpey,
Farre, Priestley, Barry, etc.

At the period of full development of the ovule, it escapes from the
vesicle inclosing it, and passes into the Fallopian tube through the
agency of the fimbriated extremity of 'this organ, gradually traversing
its canal until it arrives at the uterine cavity. The modifications un-
dergone by the human ovule in its passage through the Fallopian
tube, are unknown, but are supposed to be similar to those which
occur in the eggs of mammiferous animals, particularly those of the
rabbit and dog. In these animals, the first change which has been
observed in the ovule after its escape from the ovary, is the entire dis-
appearance of both the germinal vesicle and germinal spot, while at
the same time there will be found a collection of granules in the cen-
tral portion of the ovum. During its travel through the first half of
the oviduct, the vitelline membrane becomes somewhat thickened,
while a layer of the granulations which formed the proligerous disk
of the ovule previous to its departure from the ovary, surrounds the
ovum, but which disappears as it traverses the second half of the
oviduct, having a layer of a transparent, gelatinous substance to occupy
its place around the vitelline membrane, and which albuminous layer,
as well as the thickening of the vitelline membrane, continues to in-
crease. While these changes are being effected, the yelk gradually
increases in density, forming a compact, homogeneous mass a trans-
parent fluid occupying the space existing between it and the interior
surface of the vitelline membrane ; finally, the yelk separates into two
regular spherical divisions ; these again separate, forming four spheres,
and this separation continues, until from the numerous small spherical
divisions which are thereby formed, the yelk presents a mulberry or
raspberry appearance. These spheres or granulations decompose as
the ovum advances toward the cavity of the uterus, and finally disap-
pear, being replaced by a clear and transparent fluid. They are sup-
posed to condense on the inner wall of the vesicle, forming there a
second vesicle which has been called the blastodermic or umbilical
vesicle or membrane, or germinal membrane or area. As this blastoderm

of products of disintegration. In the second week post-partum the process has still
farther advanced, and the epithelium of the exposed sinuses is found to be prolifer-
ating. Restitution now begins and advances, and soon there is found on the surface of
the muscular coat a fine layer of connective tissue, covered by epithelium and fur-
nished with young glands, to represent the mucosa of the uterus, which is again at
rest.

DEVELOPMENT OF THE HUMAN OVUM. 115

becomes developed after the arrival of the ovum in the uterus, the
albuminous layer surrounding the vitelline membrane disappears,
while this membrane diminishes in thickness. About the sixteenth or
seventeenth day will be observed a rounded, whitish spot, at some
point of the blastodermic vesicle, standing oat apparently detached,
and w r hich is named the embryonic spot, tache embryonnaire, or area
germinativa ; it is composed the same as the blastoderm, of cellular
granulations, and from it commences the gradual development of the
embryo. The blastoderm is composecj of two laminae, the external
animal, or serous layer, and the internal, mucous, or vegetative layer, the
former of which is supposed to give origin to the brain and spinal
cord, organs of sense, cartilage, bones, skin, and muscles, or organs of
animal life; and the latter to the lungs, liver, spleen, and digestive
tube, or organs of nutrition. A third layer has also been recognized
by some investigators, which is situated between the two just named;
it is called the middle or vascular layer, ancj is supposed to assist in
the development of the heart, circulatory apparatus, etc. The time
required for the passage of the human ovum from the ovary to
the uterus is supposed to be from eight to ten or twelve days,
and it is about this latter period, the twelfth day of pregnancy,
that we can distinctly observe the embryo, which then appears to
be a mere amorphous vesicle, measuring about three lines, while
the entire ovum measures six or seven lines. The envelopes of
the ovum are three, the CHORION, TUNICA MEDIA, or MIDDLE
MEMBRANE, and the AMNION; and its accessories are four, the UM-
BILICAL VESICLE, the ALLANTOIS, the PLACENTA, and the UMBIL-
ICAL CORD.

The CHORION is a thin, glistening, transparent membrane, very
analogous to serous tissues, quite resisting for its tenuity, and forms
the external covering of the ovum, passing also over the fetal surface
of the placenta and the external face of the umbilical cord, and may
be considered as corresponding to the internal lining membrane of an
eggshell. It is formed by the union of the vitelline membrane with
the albuminous envelope which this acquires while in the oviduct;
however, this is still a question among physiologists, some of whom
suppose it to be formed by the external layer of the blastodermic
vesicle and the allantois. It has two surfaces, an inner or fetal sur-
face, and an external or uterine surface. Both of these surfaces are
smooth at first, but at an early period, about the second week of preg-
nancy, the external surface presents minute granulations, which rapidly

110 KING'S ECLECTIC OBSTETRICS.

augment in length, forming numerous villi or velvety prolongations
with which the chorion soon becomes covered, and which penetrate
into the decidua, preventing the ovum from injuriously moving about.
These spongy, cylindrical villi disappear from the general surface
about the second or third month, but at the spot where the chorion
comes in contact with the uterus, and where the secondary caduca or
decidua serotina is formed, they enlarge and become vascular, giving
origin to the placenta. The vascularity of the chorion does not man-
ifest itself until after the development of the allantois, about the
second month, when it consists of two layers or laminae, the external
or primitive one of which is non-vascular, and is called the exochorion ;
while the other, the internal or allantoid layer, is highly vascular, and
is named endochorion.

In the early period of pregnancy the chorion is separated from the
amnion by an albuminous layer, which condenses into a thin web-like
membrane termed tunica media; and this albuminous fluid is more
abundant in the first weeks of gestation. In the midst of this fluid is
situated the umbilical vesicle, or yelk-bag. As the ovum matures, the
external face of the chorion unites with the decidua reflexa, while its
inner face comes in contact with the amnion after the second month ;
there have been instances, however, where at full term, a considerable
quantity of fluid existed between the amnion and chorion, termed false
waters; its escape has given rise to the belief that the liquor amnii
had passed off. When this fluid is discharged several times during
one pregnancy, it constitutes hydrorrhea (see page 180). The chorion
serves to envelope and protect the ovum during its passage from the
oviduct to the uterus, furnishes a sheath for the umbilical cord, assists
in the production of the placenta, and, probably through the attach-
ment of its villi to the decidua, nourishment is absorbed from the
maternal blood by which the vitality of the embryo is sustained ; at
the parturient period it assists, in connection with the amnion, to form
a bag containing the amniotic liquor, which materially promotes the
softening and dilatation of the os uteri.

The AMNION is the most internal covering of the embryo, around
which it forms a sac; it is very thin, smooth, and transparent, and
is more dense and resisting than the chorion, which it very much re-
sembles in structure and appearance. It is supposed to be formed by
the internal lamina of the fold of the external serous layer of the
blastoderm around the embryo (which forms the cephalic and caudal
hoods), and is continuous with the margins of the ventral opening of

DEVELOPMENT OF THE HUMAN OVUM. 117

the embryo; however, there are several other views concerning its
origin. Its internal surface exhales a liquid in which the embryo
floats freely ; its external surface is more or less separated from the
chorion, the space between them being filled with an albuminous
liquid. It apparently consists of condensed cellular tissue, in which
neither blood-vessels nor nerves have yet been recognized. As the
development of the ovum progresses, the space between the amnion
and chorion diminishes, the albuminous fluid found between them
gradually disappears, until finally the two envelopes come in contact
and adhere to each other. The amnion forms the outer coat of the
fetal face of the placenta, and of the cord ; and a division of the cord
shows us the chorion placed between the cord proper and the amnion.
Its uses are to furnish the liquor amnii, to aid in forming the mem-
branes, and bag of waters, and to serve as a covering to the umbilical
cord, the liquor amnii, and the fetus.

The LIQUOR AMNII, also known as the amniotic fluid, waters of
the amnios, etc., is a fluid contained within the amnion, and in which
the embryo floats ; by some it is supposed to be an exhalation or
secretion from the amnion, by others to be a product of the fetus, and
' by others again to be a secretion from both the fetus and its parent.
The probability is, that the liquor amnii proper is exhaled by the
internal surface of the membranes of the ovum, the elements of which
are furnished by the uterine vessels, and that it may be mixed or
adulterated with the fetal excretions, especially at an advanced period
of pregnancy. This fluid varies in quantity as well as in its proper^
ties ; during the early stage of gestation, when compared with the
fetus, it is proportionally greater, there being from half a fluidrachm
to a fluidrachm present when the embryo can hardly be seen by the
naked eye, and although it continues to increase until full term, yet
its relative proportion to the size of the fetus gradually diminishes, so
that at parturition, while the fetus may weigh from six to eight
pounds, the quantity of fluid will seldom be found to exceed a pint.
lu some few cases it may amount to quarts. Its appearance varies
from that of a transparent and limpid fluid, more commonly observed
in the early period of pregnancy, to that of a thick, slightly yellow,
green, or brown color, and which is more usual to the advanced stage.
It is soft and viscous to the touch, has a specific gravity of 1.004, and
emits an odor somewhat resembling that of semen, though occasion-
ally, especially when the fetus is dead, this odor is putrid and very
offensive ; its taste is saltish. Sometimes it becomes milky or clouded,

118 KING'S ECLECTIC OUST ETHICS.

and frequently contains white clots, which are detached pieces of the
fetal sebaceous covering ; greenish or dark-colored flakes, being por-
tions of undiluted meconium, are likewise often observed in it. Its
most common appearance at parturition is that of a dingy liquid, hav-
ing a tinge of yellow or green. Heat renders it cloudy; alcohol or
caustic Potassa causes a fleecy precipitate, with which nutgalls form a
brownish deposit, similar to a dilute solution of gelatin ; Nitrate of
Silver occasions an abundant white precipitate, which is insoluble in
Nitric Acid ; and the tincture of Violets becomes changed to green by
it. Analysis has found in it a large proportion of water, with albu-
men, albuminate of soda, chloride of sodium, carbonate of soda, phos-
phate and carbonate of lime, urea, and, probably, a peculiar free acid,
called amnic or amniotic acid. Its use appears to be to protect the
embryo from any severe compression of the uterine walls ; to protect
it from the effects of falls or blows ; to prevent any adhesion of the
fetus while in utero, and allow it free motion ; to protect the fetus,
during parturition, from the injurious effects of uterine contraction
upon its body, until all its parts are in a suitable condition to permit
its expulsion ; to aid in the dilatation of the os uteri, at term, by means
of the bag of waters, as well as to lubricate the parts through which
the fetus has to pass, thereby facilitating its delivery. Some physi-
ologists believe that it likewise aids in nourishing the fetus, pre-
vious to the formation of the placenta and establishment of the fetal
circulation.

. The UMBILICAL VESICLE, vesicula umbilicus, or vesicula alba,
yelk-bag ; is formed by the internal, or mucous layer of the blasto-
derm ; it is of a rounded, or pyriform shape, is situated in the space
between the amnion and chorion, and communicates by a long pedicle,
or duct, with the intestinal tube, upon which it lies. It forms
FIG. 26 . a sac, seldom larger than a small pea, and

contains a viscid, transparent, yellowish-white
fluid, in which may be seen a few globules
and numerous granules. It appears to be com-
posed of an external or vascular layer, and an
internal or mucous layer. The following account
of its formation, is given by Prof. Meigs :
"When the blastoderm has partly undergone
the morphological -changes that convert it into
SEGMENT OF THE SPHERE the earliest rudimental embryon, part of the yelk
OF THE VITELLUS. corpuscles still remained unappropriated ; and as

DEVELOPMENT OF THE HUMAN OVUM.

119

they are still contained in their original vitel-
line membrane, they constitute a small but
visible ball, called the umbilical vesicle.
Originally, the vitellus was a sphere, of
which Fig. 26 represents a segment. The
blastoderm is developed upon a segment of (\ I
this sphere as at A, in Fig. 27. When the
blastoderm doubles or folds its edges in-
ward, it pinches (or contracts) a portion of

the vitellary ball, as in Fig. 28. In a still

* BLASTODERM DEVELOPED UP-

further progress, as shown by Fig. 29, the ON THE SEGMENT OF THE
portion of the vitellary ball that remains out- SPHERE OF THE VITELLTJS.
side of the embryon is connected to the embryo by a delicate tube, or
vitellary duct." Velpeau states, that this duct opens into the fetal
ilium; Rigby, Ludlow, and Oker, consider FIG. 28.

the appendicula vermiformis as the re-
mains of it. As pregnancy advances, the
yelk having been transformed, the umbilical
vesicle becomes atrophied, and the develop-
ment of the amnion removes it further and
further from the embryo, at the same time
elongating its duct or pedicle, the canal of
which remains open till the sixth or. eighth
week of gestation, after which it is obliter- INWARD FOLDING OF THE
ated, and the umbilical vesicle becomes flat- EDGES OF THE BLASTODERM.
tened, diminished, of a lenticular shape and gradually fused into the cord,
and entirely disappears after the third or fourth month ; in a few rare
cases, it has been found at full F

term. Its use is supposed to
be to afford nourishment to
the embryo, until its pla-
cental connection with the
mother is established.

The external or vascular
layer of the umbilical vesicle
has ramifying over its pari-
eties two blood-vessels, an
artery, and a vein, which are
called the omphalo-mesenteric, or vitello mesenteric vessels, and which ac-
company the pedicle, forming a part of it. The omphalo-mesenteric
artery arises from the aorta, and as it reaches the summit of the intestinal

FURTHER PROGRESS OF THE BLASTODERM.

120

KING'S ECLECTIC OBSTETRICS.

convolutions, it gives off branches to the mesentery and to the intestine ;
then it extends to the pedicle, through which it passes until it reaches
the umbilical vesicle, upon which it is distributed. In the adult, that
part which supplies the mesentery is converted into a mesenteric artery,
all the rest being obliterated, as the umbilical vesicle disappears. The
omphalo-mesenteric vein, enters the abdomen, passes around the duode-
num, and opens into the umbilical vein just as this is emerging from
the liver. In its passage around the duodenum it gives off branches
to the stomach and intestines, and when it empties into the umbilical
vein, it sends a large trunk to the liver; the whole disappears with
the vesicle and its pedicle, except that portion which furnishes the

above branches, which remains
in the adult as the ventral, or
hepatic-portal vein. Profes-
sor Meigs admirably illustrates
the arrangement of the om-
phalo-mesenteric vessels, and
cord, by the following dia-
gram, Fig. 30 : " Let A A, be
a portion of the abdomen of
the embryo, and c c, the na-
vel, or umbilical ring; B B,
the navel string, or cord, laid
open ; D, the umbilical vein,
bringing back the blood from
the placenta, and passing into
the belly at the ring, to go to
the liver; E, F, the two um-
bilical arteries of the fetus ;
H, the umbilical vesicle, or
vitelline sac, whose pipe, con-
duit, or efferent-duct runs
along the umbilical cord to the navel, and passing into the belly
empties itself into the ilium, G G, which bends up to receive the dis-
charge ; K, L, represents the omphalo-mesenteric vessels."

The ALLANTOIS, or attantoid vesicle, is a small sac, or bladder,
which may be observed about the tenth day, and which arises from the
inferior part of the intestinal canal, or caudal extremity of the embryo ;
it is found near the umbilical vesicle, between the chorion and amnion ;
its growth is rapid, and soon becomes attached, by its base, to the

DIAGRAM OF THE OMPHALO-MESENTRIC

VESSELS.

DEVELOPMENT OF THE HUMAN OVUM. 121

inner surface of the chorion. On the parietes of the allantois are dis-
tributed the terminal branches of the two umbilical arteries and vein.
The uraehus, or pedicle of the allantois, is a cord, which is pervious in
early embryonic life, and which passes out of the fetal body at the
navel, being accompanied by the umbilical blood-vessels to the chorion,
which they pierce, sending branches into its villi, which increase in
size as these villi form the placental connection with the uterus.

The allantois rapidly disappears, so that in a few days after its ap-
pearance there can be observed only a cord of greater or less length,
passing from the embryo to the chorion, and containing the umbilical
vessels within it ; this cord, likewise, gradually becomes lost in the sub-
stance of the umbilical cord, only a portion of it remaining within the
abdomen of the embryo, to form the uraehus, at the rectal termination
of which is subsequently formed the urinary bladder. In consequence
of this early disappearance of the allantois, many physiologists have
denied its existence. The use of this vesicle, or membrane, is to con-
duct blood from the embryo to the chorion, or, as remarked by Prof.
Meigs, " the allantois may be said to be a bladder, or vesicle, upon
which the umbilical arteries climb toward the wall of the womb, to
attach themselves there." It is, likewise, stated to receive the urine
of the fetus, secreted in early uterine life. Dr. Carpenter makes the
following remarks in relation to this vesicle :

" With the evolution of a circulatory apparatus, adapted to absorb
nourishment from the store prepared for the use of the embryo, and to
convey it to its different tissues, it becomes necessary that a respira-
tory apparatus should also be provided, for unloading the blood of the
carbonic acid, with which it becomes charged during the course of its
circulation. The temporary respiratory apparatus, now to be described,
bears a strong resemblance in its own character, and -especially in its
vascular connections, with the gills of the mollusca; which are pro-
longations of the external surface (usually near the termination of the
intestinal canal), and which almost invariably receive their vessels from
that part of the system. This apparatus is termed the allantois. It
consists at first of a kind of diverticulum, or prolongation, of the lower
part of the digestive cavity, the formation of which has been already
described. This is at first seen as a single vesicle, of no great size;
and in the fetus of mammalia, which is soon provided with* other
means of aerating its blood, it seldom attains any considerable dimen-
sions. In birds, however, it becomes so large as to extend itself
around the whole yelk-sac, intervening between it and the membrane
of the shell; and through the latter it conies into relation with the

122

KING'S ECLECTIC OBSTETRICS.

external air. The diagram (Fig. 31), will serve to explain its origin
and position in the human ovum. The chief office of the allantois, in

FIG. 31.

E, GI F

DIAGRAM o? THE HUMAN OVUM AT THE TIME OF THE
FORMATION OF THE PLACENTA.

A. Muco-gelatinous substance blockiug up the Oi Uteri.

B B. Fallopian Tubes.

C C. Pecidua Vera, at 2 C, prolonged into the Fallopian Tube.

D. Cavity of the Uterus, almost completely occupied by the Ovum.

E E. Angles at which the Decidua Vera is reflected.

F. Decidua Serotina.

G. Allantois.

H. Umbilical Vesicle.

I. Arnnios.

K. Chorion, with the outer fold of Serous Tunic.

mammalia, is to convey the vessels of the embryo to the chorion ; and
its extent bears a pretty close correspondence with the extent of sur-
face, through which the chorion comes into vascular connection with
the decidua. Thus, in the carnivora, whose placenta extends like a
band around the whole ovum, the allantois also lines the whole inner
surface of the chorion, except where the umbilical vesicle comes in
contact with it. On the other hand, in man and the quadrumana,

DEVELOPMENT OF THE HUMAN OVUM. 123

whose placenta is restricted to one spot, the allantois is small, and con-
veys the fetal vessels to one portion only of the chorion. When these
vessels have reached the chorion, they ramify in its substance, and
send filaments into its villi ; and in proportion as these villi form that
connection with the uterine structure, which has been already de-
scribed, do the vessels increase in size. They then pass directly from
the fetus to the chorion, and the allantois being no longer of any use,
shrivels up, and remains as a minute vesicle, only to be detected by
careful examination. The same thing happens in regard to the um-
bilical vesicle, from which the entire contents have been by this time
exhausted ; and from henceforth the fetus is entirely dependent for
the materials of its growth, upon the supply it receives through the
placenta, which is conducted to it by the vessels of the umbilical cord.
This state of things is represented in the diagram (Fig. 31). The al-
lantois has a correspondence in situation with the urinary bladder ; but
it is only the lower part of it pinched off, as it were, from the rest,
that remains as such. The duct by which it is connected with the ab-
domen gradually shrivels ; and a vestige of this is permanent, forming
the urachus, or suspensory ligament of the bladder, by which it is con-
nected with the umbilicus. Before this takes place, however, the al-
lantois is the receptacle for the secretion of the corpora wolffiana, and
of the true kidneys, when they are formed."

The PLACENTA, or afterbirth, is a soft, spongy, vascular mass,
occupying about one-third of the external covering of the ovum, and
forming the principal connection between the embryo and the uterus.
It is a flattened, irregularly circular body, of a more or less intense
reddish-gray color, varying in diameter from six to nine inches, some-
times having one diameter longer than the others, about an inch in
thickness at its point of junction with the umbilical cord, from which
it gradually tapers off toward the circumference, which seldom exceeds
two or three lines, and weighing one or two pounds, depending,
however, upon its size and the amount of blood it contains. It most
usually has the umbilical cord inserted at its center ; occasionally this
passes into it, at or near the circumference, and with this disposition
the vessels of the cord will frequently be found to separate into
numerous branches before they reach the substance of the placenta ;
this is termed the battledore placenta. The placenta, umbilical cord,
and membranes, are collectively called the secundines.

The placenta presents two surfaces, an external or uterine, and an
internal or fetal. The fetal surface has a smooth, polished appearance,

124 KING'S ECLECTIC OBSTETRICS.

and is marked by the numerous radiations of the vessels of the umbili-
cal cord, forming a kind of network, which may enable us to dis-
tinguish the placenta in artificial deliveries ; this surface is covered by
the chorion and amnion, the former of which intimately adheres to
it, and sends processes between the lobules, while the latter is loose
and nearest the fetus. Each one of the umbilical arteries upon reach-
ing the placental surface divides into two branches, and this dichoto-
mous division is repeated until these vessels have diminished in size
to a diameter of about three-sixteenths of an inch, when they pass
through the chorion into the placental tissue, numerously subdividing
to form the ultimate villous tufts or ramifications ; the blood is then
conveyed back to the cord, by about sixteen veins, which run on the
placental surface along side of the chief branches just referred to, and
terminate in the one vein of the umbilical cord. The uterine surface,
when removed from the uterine wall, presents a uniform, but not
smooth appearance, and is slightly convex; it has a fleshy resemblance,
and is divided by deep sulci or furrows into numerous irregularly
shaped lobes, from half an incli to about an inch and a half in
diameter, which are connected with each other, at the bottom of these
sulci, by a loose cellular, or, according to Velpeau, lamellated, albumin-
ous tissue, which is easily lacerated. ' Upon an investigation, it will
be found that each of these lobes or cotyledons, is formed by the .
ramifications of one branch of the umbilical arteries and veins, on
their first separation, and that the vessels of one lobe do not anasto-
mose with those of another, and but slightly with each other. This
surface is not in direct contact with the uterine wall, but is separated
from it by the interposition of the decidua serotina or placental decidua,
an albuminous layer analogous in appearance to the true caducous
membrane, which is more firmly attached to the placenta than to the
uterus, and which enters into the fissures separating the lobes, when
not too deep, in which latter case it passes from one lobe to another,
forming a kind of membranous bridge, while a thick partition of
cellulo-mucous substance penetrates deeply between the lobes. The
circumference of the placenta is thin and irregular, and measures from
twenty-one to twenty-seven inches ; its margin is continuous with the
chorion, and is contiguous to the fold formed by the caduca when
passing over the ovum to constitute the decidua reflexa ; between this
fold and the placental circumference is a thickening or density of
substance, so disposed for the reception of the placental border as to
form a triangular sinus.

The earliest rudiments of the placenta are observed toward the

DEVELOPMENT OF THE HUMAN OVUM. 125

termination of the first month of pregnancy, which become gradually
developed until the third month, when the organ acquires its proper
character, and continues to increase in size with the growth of the
fetus. As soon as the ovule has reached the uterus, the chorion is
observed to be covered with numerous villi which give to it a downy
appearance, but those villi in contact with the decidua reflexa, proba-
bly from an absence of proper material for their development, become
atrophied and filamentous, serving merely as points of union between
the chorion and decidua; while those which are exposed to the uterine
wall, receiving nourishment from the exudation of lymph which takes
place on the surfaces of both the uterus and ovum, continue to
develop themselves, elongate, become converted into vessels, and
ultimately form the placental part of the placenta. (Fig. 31.) The
uterine portion of the placenta is the lymph above referred to, which
forms a thin, soft, delicate tissue known as the decidua serotina, and
which is furnished more copiously by the uterus, on account of the
superior size and vitality of this organ compared with those of the
ovum. At that portion of the uterus where the placenta is situated,
will be found large cells or sinuses which communicate freely with
each other, but which do not extend beyond the decidua serotina, this
membrane answering the purpose of a valve to prevent the blood in
them from passing into the cavity of the gravid uterus; these cells are
the uterine sinuses, and into them the blood is poured by the curling
uterine arteries terminating in a capillary extremity. The capillary
vessels of the fetus, covered by the thin decidua, insinuate themselves
into these sinuses, and, without any interference of the circulation
of either the fetal or maternal fluid, the change is here effected which
probably removes the effete matter of the fetal blood, while at the
same time this fluid absorbs oxygen from the maternal blood; and
these changes are brought about without the existence of any vascular
intercommunication between the mother and fetus, the action some-
what resembling that which takes place in the lungs of an adult,
between the venous blood and the atmospheric air Weber, Kolliker,
Turner, "Wincklen, and Delore, have demonstrated that the maternal
blood does circulate in the placenta, bathing the villosities of this
formation. And Dr. T. Snow Beck affirms that u the cavernous
structure of the placenta is in direct communication with the canals
of the sinuses or veins, and that these vessels carry the blood away
from the placenta, which is brought there by the utero-placental
arteries," and that there " is no such thing as a feeble wall or delicate

ll>|| KIN(.'s K( LKCTIC OI5STETKK S.

membrane, either at or forming the line of separation, nor, indeed,
structures of any kind that prevent the flow of blood direct from the
placenta into the uterine sinuses or veins."

The placenta may attach itself to any part of the internal surface
of the uterus, more commonly at or near the orifice of one of the
tubes, occasionally in the vicinity toward the fundus, rarely toward
the neck, and still more seldom over the inner os uteri; this latter
position is termed placenta prcevia, and is dangerous to both mother
and child on account of the hemorrhage which is apt to ensue as it
becomes detached from the uterine wall, during labor, by the dilata-
tion of the os uteri. These placental situations are supposed to be
determined by the character of the adhesion existing between the
caduca and uterine wall, as to firmness as well as to the degree of
resistance afforded by the caduca to the advancing ovule ; thus, if the
adhesion be weak between the decidua and uterine wall at the utero-
tubal orifice, the ovule may slip or pass down between them until
it meets with sufficient resistance to impede its further progress, and
at this point, where it is stayed, commences the formation of the
decidua reflexa, as well as of the placenta. And if the attachment
be so slight as to permit the fecundated ovule to pass out of the
uterus and through the canal of the cervix, conception does not take
place. It must be borne in mind, that the attachment of the placenta
is by apposition only, the decidua serotina being interposed between
it and the uterine wall; and when actual adhesion occurs, it is in-
variably the result of disease.

In cases where more than one fetus is present, we generally find a
separate cord, placenta, and set of membranes for each one, and though
the placentae may be joined together, forming apparently a single or-
gan, yet there will be no anastomosing of the blood-vessels, the circu-
lation of each child being perfectly independent, so that should one
die or become diseased in utero, the other may continue to live or be
healthy. In some few instances, there have been found exceptions to
this two children have been inclosed in one bag of membranes, or
when in separate ones, there has been a communication of their vas-
cular systems. The use of the placenta is to form the principal con-
nection between the embryo and the uterus in order to contribute to
the nourishment of the former. (Fig. 31.)

The UMBILICAL CORD, funis umbilicalis, or navel string, is a
long, flexible, and vascular cord which serves as a connecting medium

DEVELOPMENT OF THE HUMAN OVUM. 127

between the fetus and placenta. It has two insertions, a placental and
a fetal. The placental insertion is usually in the center of the placenta,
though it may occur at any point between the center and circumfer-
ence of this organ ; the fetal insertion is at the umbilicus. At birth,
its average length is from sixteen to twenty-four inches, though it fre-
quently varies from this measurement, having been found several feet
long, and again only six or seven inches. Its thickness is likewise
variable ; ordinarily it is about equal to that of the little finger ; when
it exceeds this it is termed a fat cord, and when it is smaller it is called
a lean cord. This variation in its thickness depends upon the larger
or smaller amount of a viscid, semi-transparent fluid which is infil-
trated in the cellular tissue of the cord, and which is named the gela-
tine of Wharton; this fluid is coagulable by heat and acids, and when
unequally distributed occasions swellings or nodes on the cord.

During the early weeks of pregnancy the umbilical cord does not
exist ; its first appearance is about the end of the first month, when
the embryo is fully separated from the blastodermic vesicle, at which
period it is composed of the duct of the umbilical vesicle, urachus.
omphalo-mesenteric vessels, and a covering of amnion and chorion.
It is now cylindrical, thick and short, but elongates in proportion as
the umbilical vessel removes and disappears. At about the commence-
ment of the third month, the umbilical vesicle, urachus, and omphalo-
mesenteric vessels being obliterated and amalgamated with the cord ;
this now consists of two arteries, one vein, fine areolar tissue, gelatine
of Wharton, and an external covering of amnion and chorion, which
elements remain until the termination of pregnancy. At first the cord
is straight, but after the second month, a torsion of the vessels com-
mences, the two arteries run uniformly and spirally ardund the vein,
usually in a direction from left to right ; the vein thus occupying the
axis of the cord.

The vein of the umbilical cord is of a thickness nearly, if not quite
equal, to that of the two arteries combined ; it has no valves, its walls
are thin but firm, and it performs the functions of an artery, carrying
the pure and vitalized blood from the placenta to the fetus. It arises
from the placenta ; the venous ramifications of each placental lobe
uniting on the surface of the placenta to form the cord, which passes
onward into the umbilical ring of the fetus, where it separates from
the two arteries and proceeds toward the liver.

The two arteries of the umbilical cord arise from the fetal internal
iliacs, of which they are branches, and proceed toward the umbilicus,

128 KING'S ECLECTIC OBSTETRICS.

where they separate and traverse the vein in a tortuous manner until
they reach the placenta, into which they give off numerous ramifica-
tions. The walls of the arteries are thick, resisting, and contractile,
and they pulsate strongly. The arteries perform the office of veins,
as they convey the adulterated blood from the fetus to the placenta.
It is very rarely that any different arrangement of the cord from the
above, has been observed ; a few instances have been related where but
one artery was present, and Velpeau has stated that two veins have
been met with. The colors of the blood in the vein and arteries re-
semble each other so nearly as to be scarcely distinguishable.

The cord is subject to abnormities and accidents, as, a division of
the vessels before having reached the placenta, a varicose or hydatidic
condition, a rupture of the coats, a closure of the vessels, an insertion
into some other part of the fetus than the umbilicus, or into a wrong
part of the decidua, and twists or knots r ^especially when the cord is
very long, which interfere more or less with the circulation and con-
sequent nutrition of the fetus. Any of these conditions may occasion
the death of the fetus, and abortion, though, some of them, when
slight, exert no important influence. The cord is most commonly
above the head of the child, yet there are often exceptions ; it has been
found coiled once or twice around the child's neck, or body, or a limb,
in some instances causing death by strangulation, or the loss of a limb ;
occasionally, it is found presenting before the fetal head. In cases of
twins, each fetus has its own cord, though instances have been met
with where there existed a communication between the cords of the
several fetuses.

CHAPTER XV.

OP THE FETUS AND ITS DEVELOPMENT.

THE ovule, or ovum, is the human egg previous to its impregnation,
though these terms are frequently applied to the embryo and the fetus;
as long as this is amorphous or of an undetermined form, it has re-
ceived the name of germ; from the period when a definite form can be
observed until the third month, it is called the embryo, from which
time until its expulsion from the uterus, the term fetus is applied to it.

THE FETUS AND ITS DEVELOPMENT. 129

After birth it becomes the child or infant, though either of these latter
terms are often used synonymously with fetus.

The study and investigation of the de- FIG. 32.

velopment of the. human embryo (Fig. 32),
is one which the student finds attended
with considerable difficulty ; for, notwith-
standing the many discoveries of physiol-
ogists on this point, there still remain much
obscurity and uncertainty attached to it, as
is evident from the various views which
have from time to time been presented to
the profession. Dr. Rigby, in his work on

Midwifery, has probably, given the clearest, SECTION OF A MORE DE-
and at the same time the most concise ^ELOPED OVUM, IN WHICH

. n ,. n. ,1 i 3 i THE TWO PORTIONS THE

illustration ot the researches and conclu-

EMBRYONIC AND UMBILICAL

sions of those who have investigated the VESICLE BEGIN TO APPEAR.
subject, as will be found in the following o. umbilical vesicle.

, i i -n T I- Internal laydr of the Blasto-

(^uotation, which will, I trust, prove ac- derma '

ceptable to all who are interested : E - External layer.

-, -r-r , mi i i V. Vitelline Membrane.

"Embryo. ihere is, perhaps, no de-
partment of physiology which has been so remarkably enriched by
recent discoveries, as that which relates to the primitive development
of the ovum and its embryo. The researches ot Baer, Rathke, Pur-
kinje, Valentin, etc., in Germany; of Dutrochet, Prevost, Dumas,
and Coste, etc., in France; and of Owen, Sharpey, Allen, Thompson,
Jones, and Martin Barry, in England, but more especially those of
the celebrated Baer, have greatly advanced our knowledge of the'se
subjects, and led us deeply into those mysterious processes of nature
which relate to our first origin and formation.

" These researches have all tended to establish one great law, con-
nected with the early development of the human embryo, and that
of other mammiferous animals, viz.: that it at first possesses a struct-
ure and arrangement analogous to that of animals in a much lower
scale of formation ; this observation also applies, of course, to the
ovum 'itself, since a variety of changes take place in it after impreg-
nation, before a trace of the embryo can be detected.

" At the earliest periods, the human ovum bears a perfect analogy
to the eggs of fishes, amphibia, and birds ; and it is only by carefully
examining the changes produced by impregnation in the ova of these
lower classes of animals, that we have been enabled to discover them
in the mammalia and human subject.
9

130

KING'S ECLECTIC OBSTETRICS.

FIG. 33.

SECTION OF A HEN'S EGO WITHIN

Periphery of the Yelk.

B. Vesicle of Purkinje, imbedded in the

Cumulus.

C. Vitellary Membrane.

D. Inner and Outer Layers of the Cap-

sule of the Ovum.

E. Indusium of the Ovary.

" As the bird's egg, from its size, best
affords us the means of investigating
these changes, and as in all essential
respects they are the same in the hu-
man ovum, it will be necessary for us
to lay before our readers a short account
of its structure and contents, and also
of the changes which they undergo,
after impregnation. In doing this, we
shall merely confine ourselves to the de-
scription of what is applicable to the
THEOVAR*. human ovum. (.%. 33.)

A.. The Granular Membrane forming the " The 6gg IS knOWU to Consist of twO

distinct parts, the vitellus or yelk sur-
rounded by its albumen or white; to
the former of these we now more par-
ticularly refer. The yelk is a granular
albuminous fluid, contained in a granu-
lar membranous sac (the blastodermic membrane), which is covered by
an investing membrane called the vitelline membrane or yelk-bag. The
impregnated vitellus is retained in its capsule in the ovary, precisely
as the ovum of the mammifera is in the Graafian vesicle. The whole
ovary in this case has a clustered appearance, like a bunch of grapes,
each capsule being suspended by a short pedicle of indusium.

" In those ova which are considerably developed before impregna-
tion, the granular blastodermic membrane is observed to be thicker,
and. the granules more aggregated at that part which corresponds to
the pedicle,, forming a slight elevation with a depression in its center,
like the cumulus in the proligerous disk of a Graafian vesicle. This
little disk is the blastoderma, germinal membrane, or cicatricula; in
the central depression just mentioned is an exceedingly minute vesicle,
first noticed by Professor Purkinje, of Breslau, and named after him ;
FIQ. 34. ' n more correct language, it is the germinal ves-

ick. (Fig. 34.)

" According to Wagner, the germinal vesicle
is not surrounded by a disk before impregnation ;
and it is only after this process that the above-
mentioned disk of granules is formed. By the
time the ovum is about to quit the ovary, the
vesicle itself has disappeared, so that an ovum
has never been found in the oviduct containing a germinal vesicle,

A. Vitelline Membrane.

B. Blastoderma.

From T. W. Jane*.

THE FETUS AND ITS DEVELOPMENT. 131

nothing remaining of it beyond the little depression in the cumulus
of the cieatricula.

"The rupture of the Purkinjean or germinal vesicle has been sup-
posed by Mr. T. "W. Jones to take place before impregnation ; but the
observations of Professor Valentin seem to lead to the inference that
it is a result of that process, and must be therefore looked upon as
one of the earliest changes which take place in the ovum or yelk-bag
upon quitting the ovary.*

" During its passage through the oviduct (what in mammalia is called
.the Fallopian tube), the ovum receives a thick covering of albumen,
and as it descends still farther along the canal the membrane of the
shell is formed.

"On examining the appearance of the ovum in mammiferous ani-
mals, and especially the human ovum, it will be found that it presents
a form and structure very analogous to the ova just described, more
especially those of birds. It is a minute, sphericle sac, filled with an
albuminous fluid, lined with blastodermic or germinal membrane, in
which is seated the germinal vesicle or vesicle of Purkinje. When
the ovum has quitted the ovary the germinal vesicle disappears, and
on its entering the Fallopian tube it becomes covered with a gelatin-
ous, or rather albuminous covering. This was inferred by Valentin,
who considered that ( the enormous swelling of the ova, and their
passage through the Fallopian tubes/ tended to prove the circum-
stance. (Edin. Med. and Surg. Journal, April, 1836.) It has since
been demonstrated by Mr. T. W. Jones, in a rabbit seven days after
impregnation. The vitellary membrane seems, at this time, to give
way, leaving the vitellus of the ovum merely covered by its spherical
blastoderma, and incased by the layer of albuminous matter which
surrounds it.

" From what we have now stated, a close analogy will appear be-
tween the ova of the mammalia and those of the lower classes, more
especially birds, which from their size afford us the best opportunities
of investigating this difficult subject.

"In birds, the covering of the vitellus is called yelk-bag; whereas,
in mammalia and man it receives the name of vesieula umbilicalis.
Its albuminous covering, which corresponds to the white and mem-
brane of the shell in birds, is called chorion: by the time that the

* We said, " one of the earliest changes." Mr. Jones considers that " the breaking
up of the surface of the yelk into crystalline forms," is the first change which he has
observed.

132

KING'S ECLECTIC OBSTETRICS.

ovum IKIS reached the uterus, this outer membrane has undergone a
considerable change; it becomes covered with a complete down of little
absorbing fibril l;i\ which rapidly increase in size as development ad-
vances, until it presents that tufted, vascular appearance, which we
have already mentioned when describing this membrane.

" The first or primitive trace of the embryo is in the cicatricula or
germinal membrane, which contained the germinal vesicle before its
disappearance. In the center of this, upon its upper surface, may be
discovered a small dark line:* 'this line or primitive trace is swollen
at one extremity, and is placed in the direction of the transverse axis
of the egg.' (Fig. 35.)

FJO. 35. "As development ad-

vances, the cicatricula ex-
pands. ( We are indebted
to Pander/f says Dr. Allen
Thompson, in his admirable
essay, above quoted, ' for
the important discovery,
that toward the twelfth or
fourteenth hour, in the hen's
egg the germinal membrane
becomes divided into two
layers of granules, the serous and mucous layers of the cicatricula ;
and that the rudimentary trace of the embryo, which has at this time
become evident, is placed in the substance of the uppermost or serous
layer.' . ' According to this observer, and according to Baer, the part
of this layer which surrounds the primitive trace soon becomes thicker;
and on examining this part with care, toward the eighteenth hour, we
observe that a furrow has been formed in it, in the bottom of which
the primitive trace is situated; about the twentieth hour this furrow is
converted into a canal open at both ends, by the junction of its mar-
gins (the plicce primitives of Pander, the laminae, dor sales of Baer) : the
canal soon becomes closed at the cephalic or swollen extremity of the
primitive trace, at which part it is of a pyriform shape, being wider
here than at any other part. According to Baer and Serres, some
time after the canal begins to close, a semi-fluid matter is deposited in
it, which on its acquiring greater consistence, becomes the rudiment of

Allen Thompson on the Development of the Vascular System in the Fetus of Ver-
tebrated Animals. (Edin. New Philosoph. Journal, Oct. 1830.)

t Pander, Beitragezur Entwickelungs-geschichte des Hunchens im Eie. Wurzburg,
1817.

A. XiauspareiH Area.

15. Primitive Trace.

THE FETUS AND ITS DEVELOPMENT.

133'

the spinal cord; the pyriform extremity or head is soon after this seen
to be partially subdivided into three vesicles, which being also filled
with a semi-fluid matter, gives rise to the rudimentary state of the
eucephalon. 3 ' As the formation of the spinal canal proceeds, the parts
of the serous layer which surround it, especially toward the head, be-
come thicker and more solid, and before the twenty-fourth hour we
observe on each side of this canal four or five round opaque bodies ;
these bodies indicate the first formation of the dorsal vertebrae. (Fig. 36.)

FIG. 36.

A. Transparent Area.

B. Lamina Dorsales.

C. Cephalic End.

D. Rudiments of Dorsal Vertebrae.

E. Serous Layer.

F. Lateral Portion of the Primitive Trace.

G. Mucous Layer.
H. Vascular Layer.

K. Laminae Dorsales united to form the Spi-
nal Canal.

" ' About the same time, or from the twentieth to the twenty-
fourth hour, the inner layer of the germinal membrane undergoes
a farther division, and by a peculiar change is converted into the
vascular mucous layers.' (A. Thompson, op. cit. ) It will thus
be seen, that the germinal membrane is that part of the ovum
in which the first changes produced by impregnation are observed.
The rudiments of the osseous and nervous systems are formed by the
outer or serous layers ; the outer covering of the fetus or integuments,
including the amnios, are also furnished by it. 'The layer next in
order, has been called vascular, because in it the development of the
principal parts of the vascular system appears to take place. The
third, called the mucous layer, situated next the substance of the yelk,
is generally in intimate connection with the vascular layer, and it is to

134

KINGS ECLECTIC OUSTKTRICS.

FIG. 37.

A. Serous Layer.
B C. Vascular Layer.

D. Mucous Layer.

E. Heart.

the changes which these combined layers undergo, that the intestinal,
the respiratory, and probably also the glandular systems, owe their
origin.' (A. Thompson, op. dt., p. 298. (Fig. 37.)

"The embryo is therefore
formed in the layers of the ger-
minal membrane, and becomes
as it were, spread out upon the
surface of the ovum: the
changes which the ovum of
mammalia undergoes appear,
from actual observation, to be
precisely analogous to those
in the inferior animals.
{Boer, Prevost, and Dumas.) From the primitive trace, which
was at first merely a line crossing the cicatricula, and which now
begins, rapidly to exhibit the characters of the spinal column, the
parietes of the head and trunk gradually approach farther and farther
toward the anterior surface of the abdomen and head until they unite ;
in this way the sides of the jaws close in the median line of the face,
occasionally leaving the union incomplete, and thus appearing 10 pro-
duce in some cases the congenital defects of hair lip and cleft palate.
In some way the ribs meet at the sternum ; and it may be supposed
that sometimes this bone is left deficient, and thus may become one of
the causes of those rare cases of malformation, where the child has
been born with the heart external to the parieties of the thorax. In
like manner the parietes of the abdomen and pelvis close in the linea
alb'a and symphysis pubis, occasionally leaving the integuments of the
navel deficient, or, in other words, producing congenital umbilical
hernia, or at the pubes a non-union of its symphysis with a species of
inversion of the bladder, the anterior wall of that viscus being nearly
or entirely wanting.

" The cavity of the abdomen is therefore at first open to the vesicula
umbilicalis or yelk, but this changes as the abdominal parietes begin
to close in ; in man and the mammalia merely a part of it, as above
mentioned, forms the intestinal canal, whereas, in oviparous animals,
the whole of the yelk-bag enters the abdominal cavity, and serves for
an early nutriment to the young animal. Another change connected
with the serous or outer layer of the germinal membrane is the forma-
tion of the amnion. The fetal rudiment, which from its shape has
been called earina, now begins to be enveloped by a membrane of ex-
ceeding tenuity, forming a double covering upon it; the one which

THE FETUS AND ITS DEVELOPMENT. 135

immediately invests the fetus is considered to form the future epider-
mis; the other, or outer fold, forms a loose sac arpund it, containing
the liquor amnii. While these changes are taking place in the serous
layer of the germinal membrane, and while the intestinal canal, etc.,
are forming on the anterior surface of the embryo, which is turned to-
ward the ovum, by means of the inner or mucous layer, equally im-
portant changes are* now observed in the middle or vascular layer.
1 In forming this fold,' says Dr. A. Thompson, ( the mucous layer is
reflected farthest inward ; the serous layer advances least, and the space
between them, occupied by the vascular layer, is filled up by a dilated
part of this layer, the rudiment of the heart.' (Op. Git., p. 301.)

" While this rudimentary trace of the vascular system is making its
appearance, minute vessels are seen ramifying over the vesicula um-
bilicalis, forming, according to Bae'r's observations, a reticular anasto,-
mosis, which unites into two vessels, the vasa omphalo-meseraica.
(British and Foreign Med. Rev. No. 1.) These may be demonstrated
with great ease in the chick ; the cicatricula increases in extent ; it
becomes vascular, and at length forms a heart-shaped network of
delicate vessels, which unite into two trunks, terminating one on each
side of the abdomen. (Fig. 38.)

" The umbilical vesicle now begins to separate
itself more and more from the abdomen of the
fetus, merely a duct of communication passing to
that portion of it which forms the intestinal canal.
The first rudiment of the cord will be found at
this separation ; its fetal extremity remains for a
long time funnel-shaped, containing, beside a por-
tion of intestine, the duct of the vesicula umbili-
calis, the vasa omphalo-meseraica (the future vena ^^ 7?^LZ
portse), the umbilical vein from the collected ven- wi' n which at A, is the

T i /> ,1 i n Fundus of the diminutive

ous radicles of the chonon, and the early trace of Human Aiiantois.

the umbilical arteries. These last named vessels c ; The Duct of the Vesi -

.n IT i n cula Umbilicalis, dividing

ramity on a delicate membranous sac of an elon- into two i ntes tinai P or-
gated form, which rises from the inferior or cau- tions ' and besldes this duct

X . _ , . are two vessels which are

dal extremity of the embryo, viz.: the atlantois; distributed upon the vesi-
whether this is formed bv a portion of the mucous cula Urabilicalis and fwiu

. a reticular AnactouioBM

layer of the germinal vesicle, in common with the with each other. From
other abdominal viscera, appears to be still uncer- Baer '
tain ; in birds this may be very easily demonstrated as a vascular
vesicle arising from the extremity of the intestinal canal ; and in
mammalia, connected with the bladder by means of a canal called

136 KING'S ECLECTIC OBSTETRICS.

urachux; from its sausage-like shape, it has received the name of
allantois.

" The existence of an allantois in the human embryo has been long
inferred from the presence of a ligamentous cord, extending from the
fundus of the bladder to the umbilicus, like the urachus in animals.
But from the extreme delicacy of the allantois, and from its functions
revising at a very early period, it had defied all*research, until lately,
when it has been satisfactorily demonstrated in the human embryo by
Baer and Rathke. It occupies the space between the chorion and am-
nion, and gives rise occasionally to a collection of fluid between these
membranes, familiarly known by the name of the liquor amnii spurius,
which, strictly speaking, is the liquor allantoidis.

" The function of the allantois is still in a great measure unknown.
In animals it evidently acts as a species of receptaculum urinse during
the latter periods of ge'station; but it is very doubtful if this be its
use during the earlier periods. It does not seem directly connected
with the process of nutrition, which at this time is proceeding so
rapidly, first by means of the albuminous contents of the vitellus, or
vesicula umbilicalis, and afterward, by the absorbing radicles of the
chorion; but, from analogy with the structure of the lower classes of
animals, it would appear that it is intended to produce certain changes
in the rudimentary circulation of the embryo, similar to those which,
at a later period of pregnancy, are effected by means of the placenta,
and after birth, by the lungs, constituting the great functions of res-
piration.

" In many of the lower classes of animals respiration (or at least
the functions analogous to it) is performed by organs situated at the
inferior or caudal extremity of the animal; thus, for instance, certain
insect tribes, as in hymenoptera, or insects with a sting, as wasps,
bees, etc.; in diptera, or insects with two wings, as the common fly;
and also the spider tribe, have their respiratory organs situated in the
lower part of the abdomen. In some of the Crustacea, as, for instance,
the shrimp, the organs of respiration lie under the tail, between the
fins, and floating loosely in the water. Again, some of the mollusca,
viz.: the cuttlefish, have the respiratory organs in the abdomen. We
also know that many animals, during the first periods of their lives,
respire by a different set of organs to what they do in the adult state ;
the most familiar illustration of this is the frog, which, during its tad-
pole state, lives entirely in the water.

" As the growth of the embryo advances, other organs, whose func-
tion is as temporary as that of the allantois, make their appearance :

THE FETUS AND ITS DEVELOPMENT.

137

these also correspond to the respiratory organs of a lower class of an-
imals, although higher -than those to which we have just alluded we
mean branchial processes, or gills. (Fig. 39.) It is to Professor
Eathke (Acta Naturce Curios., vol. xiv), that we are indebted for
pointing out the interesting fact, that several transverse, slit-like aper-
tures may be detected on each side of the neck of the embryo, at a
very early stage of development. In the chick, in which he first ob-
served it, it takes place about the fourth day of incubation : at this
period the neck is remarkably thick, and contains a cavity which com-
municates inferiorly with the esophagus and stomach, and opens ex-
ternally on each side by means of the above-mentioned apertures,
precisely as is observed in fishes, more especially the shark tribe;
these apertures are separated from each other by lobular septa, of
exceedingly soft and delicate structure. Rathke observed the same
structure in the embryo of the pig, and other mammalia : and Baer
has since shown it distinctly in the human embryo. It is curious to
see how the vascular system corresponds to the grade of development
then present: the heart is single, consisting of one auricle and one
ventricle; the aorta gives off four delicate, but perfectly simple
branches, two of which go to the right, and two to the left side : each
of these little arteries passes to FlG 39

one of the lobules, or septa, at
the side of the neck, which cor-
respond to gills, and having again
united with three others, close to
what is the first rudiment of the
vertebral column, they form a
single trunk, which afterward be-
comes the abdominal aorta. In
a short time these slit-like open-
ings begin to close ; the branchial
processes or septa become ob-
literated, and indistinguishable
from the adjacent parts; the heart
looses the form of a single heart ; a crescentic fold begins to mark the
future division into two ventricles, and gradually extends until the
septum between them is completed. It is also continued along the
bulb of the aorta, dividing it into two trunks, the aorta proper, and
pulmonary artery : at the upper part the division is left incomplete, so
that there is an opening from one vessel to the other, which forms the

A. Branchial Processes. D. Allantois.

U. Vesicula Umbilicalis. E. Amnion.

C. Vitellus. From Baer.

138 KING'S ECLECTIC OBSTETRICS.

duct us arteriosus.* A similar process takes place iu the auricles, the
foramen ovalc being apparently formed in the same manner as the
ductus arteriosus; these changes commence in the human embryo
about the fourth week, and are completed about the seventh.

"At first the body of the embryo has a more elongated form than
afterward, and the part which is first developed is the trunk, at the
upper extremity of which a small prominence, less thick than the
middle part, and separated from the rest of the body by an indenta-
tion, distinguishes the head. There are as yet no traces whatever
of extremities, or of any other prominent, parts; it is straight, or
nearly so, the posterior surface slightly convex, the anterior slightly
concave, and rests with its inferior extremity directly upon the mem-
branes, or by means of an extremely short umbilical cord.

" The head now increases considerably in proportion to the rest
of the body ; so much so, that at the beginning of the second month,
p G 40 it equals nearly half the size of the whole body :

previous to, and after this period, it is usually
smaller. The body of the embryo becomes con-
siderably curved, both at its upper as well as its
lower extremity, although the trunk itself still
continues straight. The head joins the body at a
right angle, so that the part of it which corres-
ponds to the chin is fixed directly upon the upper
DIAGRAM OF THE FE- P ar ^ ^ ^ ne breast; nor can any traces of neck
TUS AND MEM- be discerned, until nearly the end of the second
BRANES, ABOUT THE month. (Fig. 40.)

"The inferior extremity of the vertebral column,

A. Vesicula Umbilicalis, i_ i_ L .c 11 ^i T / j-i

already passing into wnicn at nrst resembles the rudiment of a tail,
the ventricular ami becomes shorter toward the middle of the third

rectum intestine at G. ,1 j , i /> i

B. Vena and arteria Om- montn , and takes a curvature forward under the

phaio-meseraica. rectum. In the fifth week the extremities become

C.Allantois springing from -Mil

the pelvis with the visible, the upper usually somewhat sooner than

D. Embryo* 8 ' Ane S ' the lower > in the form of sma11 blunt prominences

E, Amnion. the upper close under the head, the lower near the

-F rom ca. caudal extremity of the vertebral column. Both
are turned somewhat outward, on account of the size of the abdomen;
the upper are usually directed somewhat downward, the lower ones
somewhat upward.

In making these observations upon the formation of the ductus arteriosus, we must
request our readers to consider this as still an unsettled question.

THE FETUS AND ITS DEVELOPMENT. 139

" The vesicula umbilicalis may still be distinguished in the second
month as a small vesicle, not larger than a pea, near the insertion
of the cord, at the navel, and external to the amnion. From the
trunk, which is almost entirely occupied by the abdominal cavity,
arises a short, thick umbilical cord, in which some of the -convolutions
of the intestines may still be traced. Beside these, it usually contains,
as already observed, the two umbilical arteries and the umbilical vein,
the urachus, the vasa omphalo-meseraica, or vein and artery of the
vesicula umbilicalis, and perhaps, even at this period, the duct of
communication between the intestinal canal and vesicula umbilicalis,
the fetal extremity of which, according to Professor Oken's views,
forms the processus vermiformis.

" The hands seem to be fixed to the shoulders without arms, and thb

FIG, 41.

DIAGRAM OF THE FETUS AND MEMBRANES, ABOUT THE SIXTH WEEK.

A. Chorion. G. Communicating Canal between the Vesicula

B. The larger Absorbent Extremities, the Site of Umbilicalis and Intestine.

the Placenta. H. Vena Umbilicalis.

C Allantois. II. Arterise Umbilicalis.

D Amnion. K. Arteries Omphalo-meseraica.

E. Urachus. L. Ven Omphalo-meseraica.

E. Bladder. N. Heart.

F. Vesicula Umbilicalis. O. Rudiment of Superior Extremity.

P. Rudiment of Lower Extremity. From Cants.

feet to adhere to the ossa ilii; the liver seems to fill the whole abdo-
men ; the ossa innominata, the ribs, and scapulae, are cartilaginous.

" In a short time, the little stump-like prominences of the ex-
tremities become longer, and are now divided into two parts, the

140 KI.Mi's KCLKCTIC OBSTETRICS.

superior into the hand and the fore-arm, the inferior into the foot
and leg; in one or two \\vrks later, the arms and thighs are visible.
(/'///. 11.) These parts of the extremities, which are formed later
than the others, are at first smaller, but as they are gradually developed
they become- larger. When the limbs begin to separate into an upper
and lower part, their extremities become rounder and broader, and
divided into the fingers and toes, which at first are disproportionately
thick, and until the end of the third month are connected by a mem-
1 > numus substance analogous to the webbed feet of water-birds; this
membrane gradually disappears, beginning at the extremities of the
fingers and toes, and continuing the division up to their insertion.
The external parts of generation, the nose, ears, and mouth, appear
after the development of the extremities. The insertion of the umbili-
cal cord changes its situation to a certain degree; instead of being
nearly at the inferior extremity of the fetus, 'as at first, it is now
situated higher up, on the anterior surface of the abdomen. The
comparative distance between the umbilicus and pubis continues to
increase, not only to the full period of gestation, when it occupies the
middle point of the length of the child's body, as pointed out by
Chaussier, but even to the age of puberty, from the relative size
of the liver becoming smaller.

" Though the head appears large at first, and for a long time con-
tinues so, yet its contents are tardy in their development, and until
the sixth month the parietes of the skull are in a great measure mem-
branous or cartilaginous. Ossification commences in the base of the
cranium, and the bones under the scalp are those in which this process
is last completed.

" The contents of the skull are at first gelatinous, and no distinct
traces of the natural structure of the brain can be identified until the
close of the second month ; even then it requires to -have been some
time previously immersed in alcohol to harden its texture. There are
many parts of it not properly developed until the seventh month. In
the medulla spinalis no fibers can be distinguished until the fourth
month. The thalami nervorum opticorum, the corpora striata, and
tubercula quadrigemina, are seen in the second month ; in the third,
the lateral and longitudinal sinuses can be traced, and contain blood.
In the fifth we can distinguish the corpus callosum ; but the cerebral
mass has yet acquired very little solidity, for until the sixth month it
is almost serai-fluid. (Campbell's System of Midwifery.)

" About the end of the third, during the fourth, and the beginning
of the fifth months, the mother begins to be sensible of the move-

THE FETUS AM) ITS' DEVELOPMENT. 141

Dients of the fetus. These motions are felt sooner or later, according
to the bulk of the child, the size and shape of the pelvis, and the
quantity of fluid contained in the amnion ; the waters being in larger
proportionate quantity the younger the fetus.

" The secretion of bile, like that of the fat, seems to begin toward
the middle of pregnancy, and tinges the meconium, a mucous secretion
of the intestinal tube, which had hitherto been colorless, of a yellow
color. Shortly after this the hair begins to grow, and the nails are
formed about the sixth or seventh month. A very delicate membrane
(membrana pupillaris), by which the pupil has been hitherto closed,
now ruptures, and the pupil becomes visible. The kidneys, which at
first were composed of numerous glandular lobules (seventeen or
eighteen in number), now unite, and form a separate viscus on each
side of the spine ; sometimes they unite into one large mass, an inter-
mediate portion extending across the spine, forming the horseshoe
kidney.

" Lastly, the testes, which at the first were placed on each side of
the lumbar vertebrae, near the origin of the spermatic vessels, now de-
scend along the iliac vessels toward the inguinal rings, directed by a
cellular cord, which Hunter has called Gubernaculum testis : they then
pass through the openings, carrying before them that portion of the
peritoneum which is to form their tunica vaginalis.

" The length of a full-grown fetus is generally about eighteen or
nineteen inches ; its weight between six and seven pounds. The dif-
ferent parts are well developed and rounded ; the body is generally
covered with the vernix caseosa ;* the nails are horny, and project be-
yond the tips of the fingers, which is not the case with the toes ; the
head has attained its proper size and hardness ; the ears have the firm-
ness of cartilage ; the scrotum is rugous, not peculiarly red, and
usually containing the testes. In female children, the nymphse are
generally covered entirely by the labia, the breasts project, and in both
sexes frequently contain a milky fluid. As soon as a child is born,
which has been carried the full time, it usually cries loudly, opens its

*The vernix caseosa is a viscid, fatty matter, of a yellowish-white color, adhering
to different parts of the child's body, and in some cases in such quantity as to cover
the whole surface ; it seems to be a substance intermediate between fibrine and fat,
having a considerable resemblance to spermaceti. From the known activity of the
sebaceous glands in the fetal state, and from the smegma being found in the greatest
quantity about the head, armpits, and groins, where these glands are most abundant,
there is every reason to consider it as the secretion of the sebaceous glands of the ffkin
during the latter months of pregnancy.

14:2 KING'S KCLFCTIC OI-.STKTRICS.

eyes, and moves its arms and legs briskly; it soon passes urine and
fteoes, and greedily takes the nipple. (Xsegel&'s Hebammenbuch.')

"Tlm< then, in the space of forty weeks, or ten lunar months, from
an inappreciable point, the fetus attains a medium length of about
eighteen or nineteen inches, and a medium weight of between six and

.-rvril pounds."

CHAPTER XVI.

POSITION, NUTRITION, RESPIRATION, CIRCULATION, DIMENSIONS,
AND DEATH OF THE FETUS SUPERFETATION.

IT was formerly believed that the fetus in utero maintained a sitting-
position during the early months of pregnancy, and that as it pro-
gressed in its development, the superior weight of the head, effected a
revolution, so that at the latter period of pregnancy its position was
reversed, the head being downward ; but this is incorrect, the position
of the intra-uterine fetus remains unaltered from the commencement
to the termination of gestation, no matter what may have been its
primary or original position. Its usual position is with the head
downward, the most dependent part being the vertex; the head is
flexed forward so that the chin rests on the anterior superior portion
of the breast; the thighs are drawn up toward the abdomen, with the
knees apart from each other, and thrown upward so as to strongly flex
the legs on the posterior surface of the thighs; the heels approximate
at the posterior part of the thighs, the feet being usually crossed ; the
arms rest upon the sides of the thorax, Avhile the fore-arms are flexed
and crossed in front of the sternum ; the neck and back are bent for-
ward into a curve. In this position it constitutes an oval figure, whose
long diameter is about eleven inches, and forms a line nearly parallel
with the long diameter of the uterus; and we can not conceive of a
more easy and compact position for such an irregular and bulky body.

The cause of the dependent position of the head, which is by far
more common than any other, has given rise to much speculation; it
has been supposed to be the result of gravitation that the fetus being
suspended by the umbilical cord, its heaviest extremity, the cephalic,
would naturally fall downward. Again, it has been stated to depend
upon the instinctive will of the fetus itself, which assumes the position
as the most convenient for its intra-uterine existence, and as the most
advantageous for an easy expulsion. Various other reasons have been

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 143

given, but none of them are satisfactory, and the subject remains in as
much obscurity as ever.

The principal functions of the fetus while in its intra-uterine con-
dition, are nutrition, respiration, and circulation, upon each of which
a brief notice will be bestowed. In relation to the first, nutrition,
many hypotheses have been advanced; it is at present supposed that
during the early embryonic life, nourishment is accomplished by super-
ficial imbibition, or probably by absorption through the villi of the
chorion, and that its sources are, at first, the vitellus, or the liquid in
the umbilical vesicle, and perhaps the albuminous matter existing be-
tween the amnion and chorion; the amniotic liquid, after its formation,
is also considered to contribute much toward this end, as it contains
several nutrient principles. It is probably absorbed by the cutaneous
surface, for acephalous fetuses, and those with the natural mucous
orifices closed, as well as those which have been born without a pla-
centa or umbilical cord, have been, with these exceptions, as well de-
veloped as the perfectly-formed fetus. It has also been stated that
this fluid is probably swallowed, or conveyed into the digestive tube,
from the fact that hair and portions of epithelium have been found
mixed with it in 'the stomach; and the meconium is supposed to be
the result of digestion. It has also been suggested by Dr. Montgom-
ery, that the milky liquid in the decidual cotyledons, may assist in the
nourishment of the fetus. The placenta has likewise been thought to
assist during the latter months of pregnancy, but this is rather de-
signed for hematosis than nutrition, and acts as a substitute for the
undeveloped lungs of the fetus, somewhat in the manner of the gills
of fishes, whose blood is aerated by the water passing through them.
It must be remembered that fetal nutrition has continued in instances
where the liquor amnii had been evacuated for weeks, which would
seem to indicate some other source of nutrition; beside, although
meconium, hair, etc., have been found in the digestive tube, still it
appears to me that the function of deglutition must be very difficult
to perform in cases where inspiration and expiration are absent, as
with the fetus. It will thus be seen that the subject of fetal nutrition
is involved in great obscurity.

By FETAL KESPIKATION, is meant, not the inhalation and
exhalation of atmospheric air, such as takes place after birth, but the
phenomenon by which the blood in the placenta is modified to suit it
for the purposes of fetal life. As with the function of nutrition, this

141 KING'S ECLECTIC OBSTETRICS.

is also ;ui unsettled and incomprehensible subject. It is supposed, that
although the placenta may be the medium by which a vivifying prin-
ciple is taken from the maternal blood and conveyed to the fetal, yet
the materials which form in the latter and become unsuited to nutri-
tion, are not removed by the placenta alone, but principally by the
liver, which employs the superabundance of carbon and hydrogen to
fu nn bile, as well as to aid in perfecting its own development. Respi-
ration and nutrition appear to exist together, acting in harmony, with-
out disturbing each other, and both being probably performed through
a similar means, that of absorption.

In the FETAL CIRCULATION, there are several anatomical
peculiarities, not existing in the adult, which it may be proper to
notice: 1. There is a vein termed the ductus venosus, which is situated
at the thick edge of the liver, and communicates between the umbil-
ical vein and the vena cava ascendens or inferior vena cava; after
birth this vein contracts, closes on the seventh day, and becomes oblit-
erated. 2. In the center of the septum, between the auricles, is an
oval aperture, called the foramen ovule or foramen of Botal ; this is
furnished with a valve, which it is stated allows the blood from the
vena cava ascendeus to pass into the left auricle, without mingling
with the blood of the, vena cava descendens ; after birth, this closes,
rarely persisting beyond seven or eight days occasionally it remains
unclosed during life, giving rise to a morbid condition known as
morbus caruleus. 3. Soon after the origin of the pulmonary artery, a
branch is given off, which communicates between this artery and the
aorta, entering this latter just below its transverse arch ; it is called
the ductus arteriosus, and after birth gradually closes and becomes
obliterated. 4. The umbilical arteries and umbilical vein have been
already referred to.

The fetal circulation is entirely independent of that of the mother,
its blood resembles venous blood, being of a uniform dark color, and
becoming of a bright florid tint as soon as exposed to the atmosphere ;
it contains less fibrin than adult blood, but coagulates on standing ; no
difference can be perceived between the color of the fluid passing in
the umbilical arteries and that in the umbilical vein. Under the
microscope it presents corpuscles, resembling those seen in the blood of
an adult.

The course of the circulation is as follows : The blood is conveyed
from the ramifications of the umbilical vein in the placenta to this
vein; through which it passes, traversing its whole length, to the

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 145

umbilicus; as soon as it has entered into the abdomen through the
umbilical ring, it proceeds to the longitudinal sinus, or fissure of the
liver, where a portion of it flows into the ductus venosus which con-
veys it immediately to the vena cava ascendens ; while the remainder
passes through the vena portse into the liver, circulates through it, and
flows into the hepatic veins where it is collected and also emptied into
the vena cava ascendens just as it is traversing the diaphragm. It is
from thence conducted, together with the blood conveyed through the
ductus venosus, to the right auricle of the fetal heart, where it is pre-
vented from mixing with the venous blood from the vena cava
descendens by the curtain-like eustachian valve, which conducts it
through the foramen ovale into the left auricle, and then into the left
ventricle, which throws it into the ascending aorta, through which it is
distributed to all parts of the body, but especially to the head and
superior extremities. The venous blood carried by the vena cava
descendens into the right auricle is at the same time directed by the
eustachian valve into the right ventricle.

The arterial blood having supplied the superior parts of the fetus,
it returns from these parts through the jugular and axillary veins,
passes into the subclavians, and then into the vena cava descendens,
through which it flows into the right auricle, then into the right ven-
tricle, and, together with that portion which passed into the right
ventricle without having entered into the foramen ovale, is thrown
into the pulmonary artery, from which a portion is conveyed to the
lungs, while the major part passes through the ductus arteriosus into
the descending aorta, where it mixes with the blood from the left
ventricle, not required for the head and superior extremities, and
flows along with it to the descending aorta. That portion which
entered the lung through the pulmonary artery returns by the pul-
monary veins to the left auricle, and thence to the left ventricle, and
into the descending aorta, where it mixes as just stated above. A
part of the blood in the descending aorta is distributed to the viscera
and inferior extremities, while the larger portion returns to the
placenta, through the umbilical arteries, there to be revivified, and be
again taken up by the umbilical vein to traverse the same route as
before. (Fig. 42.)

From this arrangement of the circulation it will be seen that the
blood with which the head and superior extremities are furnished, is
nearly fresh and pure from the placenta, while that flowing through
the inferior parts of the fetus, having previously circulated through
the system, must be less pure ; and this may, probably, be a reason why
10

146

!:< I.KCTIC OBSTETRICS.

FIG. 42.

DAIQKAM OP THE FETAL CIRCULATION.

1. Umbilical Cord, consisting of the Umbili-

cal Vein, and two Umbilical Arteries.

2. Placenta.

3. Umbilical Vein dividing into three

branches.
4 4. Two branches of the vein to be distributed

to the Liver.

6. Ductus Venosus, or third branch of the
Umbilical Vein.

6. Inferior Vena Oava into which the Ductus

Venosus enters.

7. Portal Vein, which returns the blood from

thb Intestines, and unites with the
right Hepatic branch.

8. Right Auricle, through which the blood

passes to the left Auricle.

9. Left Auricle.

10 Left Ventricle, through which the blood

pastes to the arch of the Aorta.
11. Arch of the Aorta, from which the blood
is distributed, through its branches, to
the head and upper extremities.
13 18. The Arrows represent the return of the
blood from the head and superior ex-
tremities through the Jugular and Sub-
clavian Veins to

14. The Superior Veno Cava, to the right Au-

ricle, and in the course of the Arrow,
through

15. The Eight Ventricle to

16. The Pulmonary Artery.

17. The Ductus Arteriosus, a proper contin-

uation of the Pulmonary artery; the
commencement of the fight and left
Pulmonary Artery, are seen on each
side.

18 18. The descending Aorta, joined above by
the Ductus Arteriosus ; further down
it divides into the common Iliacs,
which become the Umbilical Arteries.

19. The Umbilical Arteries which return the blood along the cord to the Placenta, while the External

Iliacs are continued to the lower extremities.

20. The External Iliacs ; the Arrows making the return of the venous blood by the Veins to the In-

ferior Cava. (Neitt and Smith.)

the head and superior extremities are more rapidly developed than the
inferior portions of the fetus.

Previous to birth, the proper functions of the lungs are not
required, and they are small, dense, firm, and unaerated, being
nourished by small branches passing from the pulmonary artery;
but after birth, considerable change ensues, the lungs become more
or less inflated with atmospheric air, and pulmonary circulation is
established. The foramen ovale is closed by the valve perfected for
this purpose, which closure propels all the blood, entering the right
auricle, from the ascending and descending cava, immediately into the
right ventricle ; from thence it is propelled into the pulmonary ar-

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 147

teries (which increase in diameter), and passes into the lungs, where,
from the action of the atmospheric oxygen, it is converted into arterial
blood. The ductus arteriosus being now useless, gradually contracts
and disappears. The blood from the inferior extremities, not being
able to pass through the umbilical arteries, flows through the vena
cava ascendens into the right auricle and ventricle of the heart, thence,
as above, into the lungs, and the circulation becomes changed from
that of the intra-uterine to that of the extra-uterine or adult. In ad-
dition, other changes also occur, the liver becomes more active, the
excretory functions of the kidneys and intestinal canal become estab-
lished, and proper digestion of the food received into the stomach
takes place.

The dimensions, appearances, and weight of the fetus at different pe-
riods of its mtra-uterine development, have been somewhat accurately
ascertained by various investigators; and as it is not only a matter of
mere curiosity, but frequently, one of great practical importance, in a
medico-legal sense, to determine the age of the expelled fetus, it is
necessary that the student should be informed on these points. The
following summary of statements of various observers are therefore
presented :

The first distinct microscopic view which can be had of the embryo
is about the third or fourth week; it is oblong, swollen in the middle,
bluntly pointed at one extremity, obtuse at the other, and is slightly
curved forward ; it is semi-opaque, of a gelatinous consistence, grayish-
white color, varying from two to five lines in length, and weighing
one or two grains. It is surrounded by the amnion, and has a vermi-
form or serpent-like appearance. Its head appears as a small tubercle,
separated from the body by a notch ; its mouth is indicated by a cleft ;
its rudimentary eyes by two black points ; its caudal extremity is
slender, and a white line may be observed in it, which indicates the
continuation of the medulla spinalis. The members present nipple-
like protuberances ; the liver occupies the whole abdomen, the cavity
of which is opened in front to a considerable extent ; the umbilical
vesicle is very large ; the chorion is villous, the villosities being dif-
fused over its whole surface.

At the sixth week (Fig. 41), its length is from nine to twelve lines ;
its weight from forty to seventy-five grains; and all its parts are
distinct. The head has greatly increased, and is separated from the
thorax by the depression of the neck ; the eyes still appear as two dark
epots; the mouth presents a small, triangular orifice; the face is

148 KINii's KOI,ECTIC OKSTKTRICS.

distinct from the cranium ; the hands, fore-arms and fingers can be
recognized; the chiviclc and maxillary bone present a point of ossifi-
cation; the legs and feet are situated near the anus, which remains
closed ; the umbilicus, for the attachment of the cord, may be observed,
the cord consisting of the omphalo-mesenteric vessels, a portion of
the urachus, a part of the intestinal tube, and of filaments, which
represent the umbilical vessels; the formation of the placenta com-
mences ; the chorion and amnion are separated from each other ; and
the umbilical vesicle is very large. The divisions of the vertebra? can
be seen, also the imperfect interventricular septum of the heart, and
the lungs, which appear as five or six lobules, in which the bronchii
may be distinguished terminating in somewhat swollen culs-de-sac.
Extending from the lung to the bottom of the pelvis, along each side
of the vertebral column, may be seen two glandular structures ; these
are the Wolffian bodies, or false kidneys, and are constituted of an
excretory canal running through their whole length. Alongside of
this canal may be observed another, which becomes, according to the
gender of the new being, either the oviduct or the vas deferens. Both
of these canals empty below into the transitory pouch or cloaca.

In early embryonic life may be seen on each side of the neck four
transverse fissures; these open into the pharynx, are separated from
each other by fleshy bands, and are analogous to the bronchial arcs
of fishes. The aorta sends three or four branches to these fissures,
but which, together with the fissures soon become obliterated, but two
on the left side remaining, one of which becomes the arch of the
aorta, while the other forms the common trunk of the pulmonary
arteries ; the first branchial fissure of each side also remains, and is
converted into the external ear. The upper jaw is composed of a
pimple or piece on each side, which gradually approximate and form
a single body; the nostrils are each split down to the mouth, and are
separated by the incisive pimples, but approach each other, and assume
their proper form, as the pimples diminish in size ; and if the progress
of this development is arrested, hare-lip is the result.

At two months, the embryo is from one and a half to two inches in
length, and weighs from three drachms to nearly an ounce ; the head
forms about one-third of it, the eyes are prominent but not yet covered
by the lids, which are still rudimentary; the nose forms an obtuse
eminence, with rounded and separated nostrils; the mouth is gaping;
the elbows and fore-arms are detached from the trunk, and the fingers
are isolated, or adhere by a transparent gelatinous substance; the
rudimentary shoulder and hips are just observable; the penis or

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 149

clitoris is apparent, but can not readily be distinguished from each
other, on account of the length of the latter. The anus forms a small
conical projection, but is imperforate, and its location is marked by a
dark spot; the rudiments of the lungs, spleen, and supra -renal* cap-
sules are observed ; the ccecum is placed behind the umbilicus ; the
digestive tube is withdrawn into the abdomen; the urachus is visible;
osseous points are apparent in the frontal bone and in the ribs; the
ehorion commences to come in contact with the amnion at the point
opposite the insertion of the placenta, which now begins to assume
its regular form ; the cord is inserted low down in the abdomen, is
infundibuliform in shape, and four or five lines in length, and the
umbilical vessels commences their spiral twisting; its base contains a
portion of intestine. The umbilical vesicle begins to disappear. The
epidermis is distinguishable.

At ten weeks, the embryo is from one and a half to two and a half
inches in length, and weighs an ounce, or an ounce and a half; the
eye-lids are apparent and cover the eyes, and the lachrymal puncta
are visible ; the hips commence to develop themselves, and the buccal
fissure begins its obliteration. The parietes of the thorax are seen,
and the motions of the heart are no longer visible; the fingers are
distinct, and the toes appear as tubercles united by some soft sub-
stance; the cord assumes the spiral appearance, is longer than the
embryo, is less infundibuliform, is not inserted so low down, and still
contains a portion of intestine.

At three months, the embryo is from two and a half to five or six
inches in length, and weighs from an ounce and a half to three or four
ounces ; the head is voluminous, but bears a better proportion to the
rest of the body ; the eyelids are very distinct, and are in contact by
their free margins; the pupillary membrane is visible; the nose pro-
jects ; the mouth is closed but perfectly delineated ; the thorax is
well formed; the fingers are completely separated, and the nails pre-
sent the appearance of thin membranous plates ; the inferior extremi-
ties are of greater length than the rudimentary tail ; the clitoris and
penis are very long, but the sex may frequently be discriminated by
a longitudinal fissure, the edges of which form the labia pudenda;
the thymus gland, as well as the supra-renal capsules are present;
the ccecum is placed below the umbilicus ; the cerebrum is five lines
in diameter, the cerebellum four, the medulla oblongata one and a
half, and the medulla spinalis three-fourths of a line; the two ven-
tricles of the heart are distinct; the decidua reflexa and vera come
in contact ; the cord contains a little of the gelatin of Wharton, and

150 KIMi's K< LK'TIC OBSTETRICS.

umbilical vessels which twist and form long spiral turns; the placenta
becomes completely isolated, and the allantois, umbilical vesicle, and
omphalo-mesenteric vessels have disappeared.

\t four montlis, the embryo takes the name of Fetus. Its length is
from five to eight inches, and its weight from three to seven or eight
ounces. The skin is rosy, tolerably dense, and begins to be covered
with down ; and a sensible motion may be perceived in the muscles.
The fontanelles and sutures are very large, and sometimes whitish
hairs may be seen on the head; the face is elongated but imperfectly
developed ; the eyes, nostrils, and mouth are closed, and the tongue
and projection of the chin are observable ; the membrana pupillaris is
very evident ; the nails become more developed ; the sex may be re-
cognized ; the coecum is placed near the right kidney ; the gall-bladder
commences to appear ; meconium is found in the duodenum ; the
ccecal valve is visible; the umbilicus is placed near the pubis; the
ossicula auditoria are ossified ; the superior part of the sacrum presents
points of ossification ; the decidua serotina is formed ; and the chorion
and amnion are in close contact with each other. A fetus born at this
period might live for several hours.

At jive months, the length of the fetus is from seven to ten inches,
and its weight from seven to twelve ounces. The head is still large,
with appearances of hair ; white substance in the cerebellum ; the
nails are very distinct ; the skin is more consistent, frequently pre-
senting patches of sebaceous matter; the heart and kidneys are very
voluminous ; the ccecum is situated at the inferior part of the right
kidney; the gall-bladder is distinct; points of ossification are manifest
in the pubis and heel ; germs of permanent teeth appear ; the me-
coniurn has a yellowish-green tint, and occupies the commencement of
the large intestine ; the umbilical cord is longer.

At six months, the length of the fetus is from ten to twelve and a
half inches, and its weight from twelve ounces to a pound. The liver
is large and red, some fluid in gall-bladder. The hair is -longer and
thicker, white or silvery; the face of a purplish-red; the eyelids some-
what thicker but still in contact, the pupillary membrane also remains,
and the eyebrows are filled with delicate hairs. The skin is better
organized, presenting some appearance of fibrous structure, and
sebaceous covering; the nails are solid; sacculi begin to appear in the
colon ; the cord is inserted a little above the pubis; the scrotum is very
small, quite red, and empty, the testes being near the kidneys ; points
of ossification are developed in the divisions of the sternum.

At seven months, the fetus is from twelve and a half to fourteen

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 151

inches in length, and weighs three or four pounds. All its parts are
more perfectly developed and better proportioned; the brain possesses
more consistency ; the skin is rosy, thick and fibrous, with sebaceous
covering; the eyelids are partly open; the pupillary membrane disap-
pears ; the iris commences as a simple ring, which increases in a con-
centric manner, ultimately leaving an opening called the pupil; the
nails have not yet reached the extremities of the fingers ; a point of
ossification is observed in the astragalus; the left lobe of the liver is
nearly as large as the right ; the gall-bladder contains bile ; nearly the
whole of the large intestine is filled with meconium ; valvulse con-
niventes begin to appear; the coecum is placed in the right iliac fossa;
the testicles leave the kidneys and approach the inguinal ring.

At eight months, the fetus is from fourteen to sixteen or eighteen
inches in length, and weighs four or five pounds. The skin is very
red, covered with long down, and a quantity of sebaceous matter,
called the vernix caseosa, or smegma, which is a secretion of the fetal
skin, and is found more abundantly on some fetuses than on others ; it
is a fat, slippery, viscous substance, of a yellowish-white color, is in-
soluble in water, alcohol or oil, and only partially soluble in potash,
and is apparently of service, during labor, by aiding to facilitate the
expulsion of the fetus. The pupillary membrane disappears; convo-
lutions appear in the brain; the inferior maxillary bone, which was at
first very short, is now as long as the superior ; the nails are much
firmer, and reach the extremities of the fingers ; a point of ossification
is observed in the last vertebra of the sacrum ; no center of ossifica-
tion is presented by the cartilage of the inferior extremity of the
femur ; the testicles descend into the internal ring, and one is usually
contained in the scrotum; generally that on the left side; the hair of
the head is much darker and longer.

At full term, the fetus is from sixteen to twenty-three inches in
length, and weighs from five to seven, ten, and sometimes even twelve
pounds, the average weight being about six and a half pounds. The
head is covered with a greater or less quantity of hair, varying in
length from six to twelve lines; the white and gray substances of the
brain become distinct; convolutions well marked; tlie pupillary mem-
brane no longer exists ; four portions of the occipital bone remain
distinct; the external meatus auditorius still remains cartilaginous;
the os hyoides is not yet ossified ; the skin is deep red, and covered
with sebaceous matter, especially at the flexures of the joints ; the
liver descends to the umbilicus ; the testes have passed the inguinal
ring, and are frequently found in the scrotum ; meconium is found at

152 KING'S ECLECTIC OBSTETRICS.

the termination of the large intestine; the center of the cartilage at
the lower extremity of the femur, exhibits a point of ossification.

A full developed fetus is characterized by a ready movement of the
limbs, an ability to cry, and a capability of sucking; its mouth, eye-
lids, nostrils, and ears are open ; the hair, eyebrows and nails are fully
ilrvrloped; the cranial bones are firm, and the edges of the fontanelles
are not far apart, the body is of a clear red color; and the meconium
is discharged within a few hours after birth. The meconium is a semi-
fluid, of a dark green color at term, which is found in the fetal intes-
tines, and is a mixture of bile with the secretions of the mucous
membrane ; some suppose it to be digested amniotic fluid.

An immature fetus may be known by its feeble motions, its small
size, and incapability of sucking ; its head is covered with down or
sparingly with short hair ; the bones are soft ; the fontanelles widely
separated ; the skin is red with blue streaks ; the nails are not per-
fected; the eyelids and mouth are closed; and the urination and defe-
cation are imperfect.

As will be stated under Abortion, the fetus is liable to numerous
diseases, some of which may be independent of the condition of the
mother, while others occur secondarily through her. Cases of inter-
mittent fever have occurred to the fetus where the mother was laboring
under the disease; small-pox has attacked the fetus both where the
mother was suffering with it, and in other instances where she was en-
tirely exempt from it, and the same may be said of measles. Various
cutaneous diseases have also attacked the fetus in utero, as well as hy-
drocephalus, pleurisy, abscesses of the lungs, oedema, scirrhous indu-
ration, tubercles, lobular pneumonia, calcareous deposition in the
lungs, peritonitis, and enteritis. It is also especially liable to hyper-
trophy or atrophy, worms, calculus, dropsy, rickets, caries, and necro-
sis. Various forms of syphilitic disease are very apt to injure or
destroy it, when the system of one or both parents is contaminated
with the syphilitic virus. The heart, liver, kidneys, stomach, and
other organs may become organically affected, and it is by no means
uncommon to observe fractures and dislocations of various bones,
which took place previous to birth. Previous to the expulsion of the
fetus, it is impossible to detect any of these maladies, and even had
we the means of doing so, it is very doubtful whether any curative or
even palliative measures could be beneficially pursued; the greater
part of them may be ascertained after its death and expulsion, and all
the advantage to be derived from such information, at this time, is to

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 153

lead to the adoption of such measures as may prevent similar attacks
in subsequent pregnancies.

The signs by which we may determine the death of the fetus, are fre-
quently of great importance, especially in reference to the best time
for obstetric operations, when these have to be performed. There are
no signs upon which, separately, the accoucheur can positively deter-
mine a dead fetus ; indeed its diagnosis is extremely difficult, and must
be decided by the aggregate of symptoms present. These are named
by Dr. Churchill, in his work on Obstetrics, as follows :

1. The cessation of the fetal movements; but these may be suspended
for several days, and yet the fetus be alive. 2. The subsidence or
flaccidity of the abdomen; this varies much during pregnancy, less
tension being present in women who have had several children. 3.
The recession of the umbilicus ; but a dead fetus may remain in utero
for months without this sign. 4. The loose feel of the uterine tumor.
5. A rolling of the tumor in the abdomen, and a sensation of dead weight
and coldness; these may exist and yet the fetus be alive, the rolling
may proceed from a loss of tone of the abdominal muscles women
who give birth to a living child, frequently complain of the uterine
tumor feeling as a weight or foreign body ; again, there is no appre-
ciable difference between the temperature of a living fetus and that of
a dead one the coldness is a mere sensation that may be experienced
independent of fetal death. 6. The breasts* suddenly become flaccid,
and their secretions suppressed ; this rarely occurs from any cause save
the death of the fetus. 7. The health of the female becomes deteriorated;
but a dead fetus has frequently been retained for weeks or months
without any change. in the maternal health, beside the health may be
impaired from other causes. 8. Bad appetite, sunken countenance,
a dark areola around the eyes; feted breath, repeated rigors; these are
all minor signs, and may exist independent of pregnancy, or when oc-
curring during its presence may be owing to causes not connected with
the condition of the fetus ; yet taken in connection with other signs
they may become useful in aiding the diagnosis.

When the motions of the fetus have been very active up to the
fifth, sixth or seventh month, or longer, and suddenly subside, and at
the same time the breasts which had been firm and tense, become
flaccid and decrease in size, while the abdomen loses its previous tense
and rounded form, the uterine tumor becoming weighty and rolling
loosely in the lower belly, we have almost a positive proof of the death
of the fetus, which is rendered still more certain by the absence of the
beating of the fetal heart. But, although much assistance may be

154 KING'S KCLKCTIC OBSTETRICS.

derived from the use of the stethoscope, yet it frequently proves un-
certain, either from want of tact and experience on the part of the
aiiM-ultator, or because the position of the fetus may be unfavorable to
the transmission of sound to his ear, or the pulsations may be tem-
porarily suspended. If, however, the pulsations have been distinctly
heard on a previous occasion, and subsequently become suddenly or
gradually inaudible, the evidence in favor of the death of the fetus, in
connection with the other symptoms, is rendered unequivocal.

After the rupture of the membranes, there are other diagnostic
symptoms of a more determinate character. 1. The liquor amnii be-
comes dark, thicker than usual, fetid, and bloody, especially where the
fetus has been dead for some time; but it must be remembered that
these conditions have been present with the living fetus. 2. When
the death is not recent, having occurred some time previous to the
examination, the scalp will feel emphysematous when the finger is
pressed upon it, crepitating under the touch, and a portion of the
cuticle will peel off; where the death is recent, the bones of the skull
will overlap each other loosely, and the edges of the bones will convey
a sensation of peculiar sharpness. These, together with the absence
of pulsation at the anterior fontanelle, and its decrease from the col-
lapse of the bones, are considered conclusive signs.

In face presentations, the flabby lips, flaccid and motionless tongue,
and a slight swelling of the presenting part, are evidence of the child's
death. In breech presentations, the finger can be readily introduced
within the sphincter ani in case of death, which contracts and resists
the finger, if the fetus be alive ; the discharge of meconium is a symp-
tom of no value. In an arm presentation, the pulse at the wrist may
be imperceptible, the arm may become cold and livid, and yet the
fetus be alive; but if the epidermis peel off, the child is dead. In
prolapse of the umbilical cord, the absence of pulsation in it is usually
regarded as conclusive evidence of the child's death; but this has
occurred and the child been born alive.

Before closing this chapter, I will make a few remarks on super-
fetation, which subject has not been noticed in the preceding pages.
By superfetation is meant, a second impregnation and conception,
where the female is already pregnant. The early writers were
impressed with the belief, that such an occurrence was possible,
while among recent authors we find a difference of opinion. The
reasons which have been advanced in its favor, are: 1. Females, at
full term of pregnancy, sometimes give birth to a well-developed

POSITION, NUTRITION, RESPIRATION, ETC., OF THE FETUS. 155

fetus, and a blighted ovum at the same time; or, where the children
are living, one of them will be more matured than the other. The
disparity between them has aiforded ground for belief that they were
the products of different impregnations; but these cases do not prove
superf'etation, as it not unfrequently occurs that the development of
one of the twins is retarded, or it may die and be expelled while the
other is retained; and it is by no means uncommon for one twin to be
larger and more matured than its fellow.

2. Cases have been recorded where the female has brought forth, at
one parturition, two children, one of which was white, and the other
black, or mulatto. But these cases have, so far as I know, been the
result of two coitions, shortly succeeding each other, one with a white
and the other with a black person. There is abundant evidence to
prove that superfetation of this kind is possible at a very early period
of pregnancy; impregnation having taken place before the canal of
the cervix became closed by decidual membrane, or by the tough,
gelatinous secretion of the glandule Nabothi. But after the forma-
tion of these substances, which effectually prevents any egress into the
uterus, I do not believe that conception can occur, unless, indeed,
there be some other route through which the semen can reach the im-
pregnated ovum, independent of the uterine cavity, and Fallopian
tubes.

3. Instances have been related where from three to four months
after the delivery of a well-developed child, another child, fully ma-
tured, has been born. In some of these cases, the difficulty has been
removed by the discovery of a double uterus. But where these cir-
cumstances have happened with but a single uterus present, if such in
reality has ever occurred, the subject is involved in much obscurity.
It may be that the development of one fetus progressed much more
slowly than that of the other ; and that when this latter was born, the
uterine contractions not having destroyed the integrity of the mem-
branes of the former, nor destroyed its utero-placental attachment, it
continued to remain in utero, until its maturity again determined
uterine action. It has also been supposed in cases of single uterus,
that this organ may have been divided by a longitudinal septum, and
thus impregnation could be effected in each at different periods ; but
this is as difficult to my mind as in the previous instance, unless it -be
admitted in each, thai immaturity of the fetus favors protracted ges-
tation, and that the contractions of the uterus to expel a full grown
fetus, do not, necessarily, involve the immediate expulsion of another
in utero, but imperfectly developed.

156 KING'S ECLECTIC OBSTETRICS.

CHAPTER XVII.

CHANGES IN THE CONDITION OF THE UTERUS DURING PREGNANCY.

FROM the moment of conception, the uterus gradually undergoes a
series of changes, in volume, form, situation, and direction, a knowl-
edge of all of which is highly important to the accoucheur. These
changes occur both in the neck, and in the body, each of which I will
review individually.

CHANGES IN THE NECK OF THE UTERUS. As gestation
proceeds, the congestion and ramollissement of the substance of the cer-
vix gradually advances, until finally the whole neck becomes softened.

Toward the end of the first month, the lower or inferior portion of
the cervix commences to undergo this change, which is principally con-
fined to the mucous covering of the part, imparting to the finger a
fungous softness, but through which deeper pressure will detect the
firm consistency of the proper tissue. The softening always com-
mences below and advances upward, gradually progressing, so that
at the end of the third month, or commencement of the fourth, this
modification extends into the substance of the lips, softening them
through their whole thickness to the extent of a line and a half, and
increasing as gestation progresses, until at the sixth month it embraces
one-half of the vaginal projection of the neck. It continues to ad-
vance gradually upward during the last three months, until finally
the whole cervix, together with the ring of the internal orifice becomes
so softened, that at "term" it has occasioned, in the practice of the
inexperienced physician, much difficulty in discriminating it from the
vaginal walls. It may be proper for me to remark that, in five or six
cases, I have encountered a cushiony, spongy sensation of the inferior
portion of the uterine cervix, the patients not being pregnant, but
laboring under abnormal conditions of the uterus.

This ramollissement of the neck is an important indication of preg-
nancy, being present at an early period, and is found in all females
in whom the neck is in a normal condition ; it likewise renders
material assistance in determining the stage of pregnancy. But in
the investigation of this last point, it must always be recollected that
in females who have given birth to a number of children, the vaginal
.projection of the neck loses a considerable portion of its length, and

CHANGES IN THE UTERUS DURING PREGNANCY. 157

consequently, if one half of this projection has been lost, the softening
will not commence in the lower extremity of the remaining portion,
until the period at which it would have ensued, were the neck of its
original extent, or at a period proportioned to the amount of length
which has been lost. Thus, in a woman who has 'given birth to eight
or ten children, the neck will vary very much in the extent of its
softening at the sixth month, when compared with that of a female
at the same stage of gestation, who has borne only two or three
children. In primiparse, or women with their first child, this soft-
ening progresses more slowly than in multiparse, or women who have
previously had children.

Beside the softening of the neck, it undergoes other modifications.
During the early months of pregnancy it becomes thicker, with an
increase of its volume, more especially at its superior portion; it is
also found at a lower point within the vagina, inclined a little to the
left, with the os tincse looking more toward the pubis, and, as a larger
extent of it can now be felt and examined by the finger, it has given
rise to an erroneous impression that its length was likewise increased.
At the fifth month the cervix looks more toward the sacrum, and still
a little to the left, becomes more elevated and is difficult to reach;
this elevation of the neck gradually increases as pregnancy advances,
rendering it more and more difficult to reach, and which has, probably,
led to the mistaken views of several authors, that the cervix became
gradually shortened from the fifth month until "term," at which
period it was completely effaced. The fact is, however, that there is
no shortening of the neck until the ramollissement has occupied its
whole extent, rendering it yielding and incapable of resistance, which
generally commences in the last fortnight of pregnancy, and during
the last few days, both in primiparse and multipart, and then in
consequence of uterine action at the time of labor (pressure of the
bag of waters and of the fetal head) it dilates, shortens, and disappears,
forming, for the time being, a part of the uterine sphere. As the
neck ascends, looking backward and to the left, the fundus is nearly
always carried forward and to the right.

Perhaps, it would be proper to remark, that in primiparse, toward
the seventh month, there exists a slight diminution of the length
of the cervix, but which does not materially affect the correctness
of the above statement ; this shortening is occasioned by the spindle
shape assumed by the cervix at this period, or a bulging of its
central part, which necessarily causes a slight approximation of the

158

KINO'S ECLECTIC OBSTETRICS.

external and internal orifices of the neck. This does not happen in
multipart.

The form of the cervix is different in primiparse and multipart,
during gestation. Among the former it will be found more pointed
and contracted at its inferior extremity, and enlarged at its superior,
and the os tincse changes from a hardly perceptible transverse fissure,
to one of a circular form, though it is seldom, if ever, opened, until
dilatation occurs during labor. About the seventh month, the walls
of the neck having become softened, they readily yield to the pressure
of the secretions from their internal surface, and as the os tincse
remains closed, the central portion of the canal of the cervix is pressed
outward, which gives to the whole neck a fusiform appearance. The
external surface remains smooth and polished, and the os tineas
regular and rounded, without any roughness or inequalities ; the
circumference is sometimes soft, and occasionally, during the latter
FIG. 43. FIG. 44. FIG. 45.

These Figures show the softening and opening of the cervix uteri, as pregnancy advances ; also, how
the finger ultimately gets into direct contact with the naked membranes.

months, presents a sharp and thin border. Among multipart, the
form of the cervix is quite different, somewhat resembling a thimble,
with its small extremity upward, its orifice instead of being closed is
opened sufficiently to admit the extremity of the finger, and its
periphery is very irregular on account of numerous cicatrizations and
fissures, the results of previous lacerations. As the softening advances
upward, the opening of the os tinea? and inferior portion of the cavity
of the neck simultaneously continues to increase, so that each month
the finger may penetrate deeper into this thimble-shaped, and some-
times funnel-shaped cavity. Toward the ninth month, the second
phalanx of the finger can be introduced within this opening, its free
extremity being arrested by the closed and puckered ring at the internal
orifice, which finally softens and dilates, allowing the finger to pass
through the cavity of the neck, and to come in direct contact with the
membranes. At this period the canal through which the finger passes,

CHANGES IN THE UTEEDS DURING PEEGNANCY. 159

instead of being shortened, will be found to vary from one inch, to an
inch and a half in length. (Figs. 43, 44, 45.)

The softening and spreading out of the neck is said to be greatly
accelerated by frequent touchings or examinations .during pregnancy,
and occasionally the internal orifice opens at too early a period, even
in the seventh month, especially among those women who are subject
to floodings.

It is sometimes the case, that the presenting part of the fetus, in
engaging in the excavation, presses the anterior inferior portion of the
uterus before it, which, in a large pelvis, may even descend to the in-
ferior floor, occasioning much embarrassment to the inexperienced
practitioner, who not being able to ascertain the situation of the os
tincoe, might erroneously suppose it to be imperforate. It will be
readily seen that, as the portion of the uterus mentioned is pushed
downward, the neck will be carried behind it, with the os tincse look-
ing toward the anterior face of the sacrum, and much difficulty may
be experienced in gaining access to it; but when once reached, the
finger must be bent like a hook and introduced into its cavity from
behind directly forward, pulling the neck by its anterior lip down to-
ward its normal location at the center of the cavity, while at the same
time, efforts may be made with the other hand on the abdomen, or by
means of an assistant, to elevate or push the body of the uterus up-
ward and backward. While the womb remains in this mal-position,
it will be impossible for delivery to be accomplished until the above
change in its direction is effected; and when effected, if the female
has been long in labor, with evident symptoms of dangerous exhaust-
ion, the os uteri soft and dilated or dilatable, and the head at the
superior strait, my own experience is in favor of at once terminating
the labor by turning and delivering by the feet, at the same time
administering sufficient stimuli to sustain the sinking powers of the
system. This is the course I have adopted in three instances of simi-
lar character, and in each of which success crowned my efforts, with
the exception of one child being still-born.

PHYSICAL CHANGES IN THE BODY OF THE UTERUS,
etc. In the non-gravid state, the uterus may be said to be in an in-
active or dormant condition, from which it is suddenly aroused by
conception, and becomes more susceptible, with increased temperature
and swelling, from the greater sanguineous determination toward it.
The volume of the uterine walls increases in every direction, and the
uterine cavity enlarges, which enlargement is maintained by the new

160 KING'S ECLECTIC OBSTETRICS.

formation called the caducous membrane, and which is present long-
before the impregnated ovum reaches the uterine cavity. As soon as
the ovule has reached the uterus, the increase of volume or develop-
ment of the embryo, continues and progresses until the moment of
parturition, being more rapid in the latter than in the early months.

The shape of the uterus is not materially changed during the first
month of pregnancy, but subsequently, as its volume augments, from
being flattened from before backward, it gradually grows rounder,
assumes the shape of a pear, or gourd, then spheroidal, until toward
the termination of gestation, it becomes of an ovoid form, slightly
flattened in its antero-.posterior diameter, with its anterior face more
convex, and its posterior somewhat concave, to adapt itself to the pro-
jection of the lumbar vertebrse.

- The situation of the uterus must necessarily vary in proportion to
its increasing size and shape; thus, we find that during the first three
months of pregnancy it is lower in the vagina, or pelvic cavity, with
the os tincse a little inclined to the left, and thrown forward to the
pubis; but after this period it gradually rises from the excavation into
the abdominal cavity, pushing the opposing contents of this cavity
before it. From a knowledge of the various points at which the
fundus is located, we may, by palpation, be enabled to determine the
period of gestation; thus, at the fourth month, it will be found two or
three fingers' breadth above the pubis ; at the fifth month, it will be
found within one finger's breadth of the umbilicus; the hypogastrium
projects and is rounded, the vagina is elongated and narrowed, and
the motions of the- fetus are felt; the cervix is more elevated, is turned
upwardly, and is more difficult to reach; from the fifth to the sixth
month, the fundus passes the umbilicus, and, at the sixth month, is
found half an inch above this depression, which now begins to project
beyond the integuments ; the vagina still farther elongated and nar-
rowed, with only a few projecting wrinkles at its lower portion ; the
cervix will be found nearly on a level with the superior strait, softer
and larger than previously ; ballottement is now readily effected ; at
the seventh month the fundus will be found three fingers' breadth above
the umbilicus, with increased abdominal and umbilical projection, and
often pain in the groins, from distension of the muscles of the ab-
domen ; the neck is still farther softened, more voluminous, and more
difficult to distinguish ; at the eighth month the fundus extends into
the epigastric region, the abdomen is farther distended, and the skin
frequently cracks and presents livid marks or lines ; the ramollisse-
ment, or softening of the cervix is still farther advanced; during the

CHANGES IN THE UTERUS DURING PREGNANCY. 161

ninth month, the fundus still continues to ascend, but in the last fort-
night of gestation, there is an evident depression of the abdominal
projection, the fundus is on a lower level than before; the respiration
becomes more free, the woman more lively, and expresses herself as
feeling lighter; the cervix is entirely softened. This sensation of
sinking of the womb, is, probably owing to descent of the fetus, the
head of which can usually, at this period, be readily felt, presenting a
voluminous tumor within the pelvic excavation.

Although the above is the average of a number of observations, yet
they are not invariable ; as, in many females, the shape and capacity
of the pelvis and abdomen, and the resistance of the abdominal pari-
etes, will affect, more or less, the rapidity and extension of these
changes.

The direction of the uterus is altered by the changes which take
place in the organ during pregnancy ; while it remains within the ex-
cavation where it is supported by the pelvic bones, it holds its vertical
direction, but as it passes upward into the cavity of the abdomen,
where the soft parts alone sustain it, it inclines forward, following the
direction of the axis of the superior strait, and which may be owing
to the unyielding resistance of the lumbar prominence, and the yield-
ing of the anterior abdominal wall ; from the same cause it is made to
lean toward one side of the abdomen, most commonly the right, form-
ing the right lateral obliquity of the uterus. The reason of the greater
frequency of this right obliquity, is, according to Mad. Boivin, that
the round ligament of the right side is shorter, stronger, and more
abundantly supplied with muscular fibers than the left ; and as they
draw the uterus toward the right, they necessarily cause this organ to
rotate on its axis, carrying its anterior surface somewhat to the right
side, and its posterior to the left ; both of which changes are import-
ant to be understood.

The thickness 'of the uterine parietes has given rise to much contra-
dictory speculation ; some writers concluding, that in consequence of
the great distension of the uterus, its walls become very much attenu-
ated, while others consider that they become very much thicker during
pregnancy ; but the fact is, that at the period of parturition, if an ex-
amination of the uterine parietes be made, they will be found to vary
according to the portion examined, the neck being very thin, and the
body and fundus of the same thickness as when in the non-gravid
condition, with the exception of the part corresponding to the inser-
tion of the placenta, which is thicker than at any other place. As
there is, then, no diminution of the uterine walls during gestation,

162 KING'S ECLECTIC OBSTETRICS.

there must necessarily be a great augmentation of their bulk, which ia
ascri taiiH-d to -be the case, as at term, the uterus has been found to
weigh two pounds ; and in one instance, cited by M. Moreau, it reached
nearly four pounds. In a few rare instances, the parietes of this or-
gan have been found to be only a few lines in thickness.

The density of the uterine parietes likewise changes during gestation.
In the non-gravid condition they are hard, resisting, and of a consist-
ency approximating fibrous tissue, but in pregnancy they become
softer and relaxed, which condition is present even at the first month,
the walls, having a softness which gives a sensation on pressure, simi-
lar to that of an oedematous limb, or of caoutchouc softened by boiling
in water, and which is of some value in determining pregnancy. As
the parturient period approaches, this ramollissement and yielding
character of the walls continue to increase, so that the inequalities-of
the fetus may be felt through them, and its motions may not only be
distinctly perceived, but will often produce a momentary projection of
some part of the organ, and even of the abdominal parietes. In con-
sequence of this suppleness of the uterine fibers, the fetus can change
its position within the cavity of the organ during gestation, and thus
cause its diameters to vary according to the position assumed, shorten-
ing its normal long diameter, and lengthening its short ones. The
fetus is also protected from the evil results of blows upon the abdo-
men, or severe shocks received by the mother, which would ensue
were the walls more dense and unyielding.

VITAL CHANGES IN THE UTERINE TISSUES. The most
remarkable changes of the uterus, during pregnancy, are those effected
in its texture, especially that of its proper tissue, or middle coat. This
tissue, which, as I have heretofore remarked, is of a grayish color,
dense, and composed in the non-gravid womb of minute spindle-shaped
fiber-cells, with elongated oval nuclei, and which on account of the
great quantity of nucleated embryonic connective tissue, can be isolated
only with great difficulty ; during pregnancy these muscular fiber cells
become enlarged, their length being increased from seven to eleven
times, and their width from two to five times, while at the same time
new ones are formed. The uterus, in pregnancy, changes, therefore,
from a state of density to one of 'softness and elasticity, extending its
substance, enlarging, gradually assuming a reddish hue, having its
fibers gradually unfolded, elongated, and presenting unequivocal evi-
dence of its muscular nature.

Although the muscular character of the middle uterine coat has

CHANGES IN THE UTERUS DURING PREGNANCY. 163

been determined, yet the arrangement of its fibers is still involved in
uncertainty. Mad. Boivin, who has minutely examined the uterine
structure, has probably given us the most correct account of the dis-
position of some of these fibers ; still, there is much left to ascertain
on this point. She states, that there is an exterior plane of fibers,
running or radiating from the middle line, outward and downward, to
the lower third of the womb; upon this part they terminate, and aid
in forming the round ligaments located there, while the most superior
ones are distributed to the Fallopian tubes and the ovarian ligaments.
There is also an internal plane of fibers, the arrangement of which
varies considerably from the external, in being circular, and located at
the uterine superior angle; having the internal orifice of the tubes as
their center, they surround each of them, describing concentric cir-
cles, being very small and close toward the focus, but gradually sepa-
ting as they advance from this point, so that the last and largest are
found upon the median line, and extend in the direction of its length.
Other muscular fibers are found between these two planes, but they
can not be traced. At the inferior part of the organ is a semicircular
order of fibers, which commence at the median line of this region,
and reunite on the sides near the round ligaments.

"This structure of the uterus resembles that of all hollow organs,
having longitudinal fibers externally, and circular and horizontal ones
internally. The greatest development of muscular structure is found
in the fundus, which is part of the organ more especially concerned
in the expulsion of its contents, and this structure is so disposed that,
during contraction, the uterine surface approaches toward the center.
The least resistance, during labor, should be made at the inferior part
of the uterus, in which we find merely the horizontal fibers, form-
ing an arrangement which will bear some comparison to a sphincter
muscle."

Other anatomists have attempted to trace the uterine muscular fibers,
and have separated them into layers, planes, and fasciculi; yet, not-
withstanding all these attempts, there is so much irregularity and con-
fusion in the course and arrangement of these fibers, so many cross-
ings and intercrossings, and such an interweaving of them, that it is
impossible to demonstrate them satisfactorily ; we have presented to
us only an inextricable muscular network, rendering the uterus fully
capable of performing all its various movements of extension, con-
traction, dilatation, and shortening. M. Moreau observe^that "a skill-
ful dissector may give the fibers any direction he chooses, without the
possibility of proving the contrary." Farre observes, " Nothing like

1(54 KING'S ECLECTIC OBSTETRICS.

a continuous arrangement of muscular fibers in the form of circular or
longitudinal bands, surrounding or investing the organ can anywhere
be demonstrated by the aid of the microscope."

That the longitudinal and horizontal fibers are separate and inde-
pendent parts of the uterine structure, and probably all the other
fibrous arrangements, may be inferred from the fact, that we often
have one set of them powerfully acting, while, at the same time, the
other is contracting with but slight force, or even not at all. Thus,
in the hour-glass contraction, we have an example of forcible con-
traction, and a want of it at the two antipodal extremities. Again,
not unfrequently there appears to be a want of action o,f those fibers
which contract the organ in its longitudinal diameter, elongating the
uterus to such an extent, that, as ascertained by an examination through
the relaxed abdominal walls, after delivery, its length will be ten or
eleven inches, with the fundus elevated toward the epigastrium, w r hile
its transverse diameter will be only three or four inches, resembling
an intestine, rather than the womb.

A female during labor, as is often the case, may suffer intense pains,
and make the most vigorous efforts, without any advance, whatever,
of the child, although the pelvic formation is normal, and the uterus
sufficiently dilated ; may this not be owing to a want of simultaneous
action of the two separate sets of fibers, the horizontal being active,
while the longitudinal are slightly so, or altogether inert? This want
of synchronism in the movements of the fibers, may be owing to irri-
tation occasioned by protracted or severe labor, by rheumatism, by the
administration of ergot, or by officious intermeddlings, and which may
also result from extreme susceptibility of the nervous system. Gel-
semium will be the remedy if the irritation has developed spasmodic
action ; or Lobelia, by relaxation, may overcome the irregular action
in the two sets of muscular fibers. If the condition depends upon
rheumatism, think of Macrotys. In either case, to relieve this painful
condition, the internal use of Opium, Morphia, or Diaphoretic pow-
der, may be given as often as the urgency of the symptoms indicate;
the room must be freely ventilated, the drinks should be cool, and no
examinations per vaginam must be instituted until the contractions
become normal, and not then, without they are actually necessary.
Occasionally, under these circumstances, and where there have been
no previous violent contractions, in addition to the above treatment,
I have found firm, but moderate, pressure over the fundus to restore
the energy of the inactive fibers.

The serous, or external peritoneal coat of the uterus, during preg-
nancy, extends in. every direction, with a more active nutrition that

CHANGES IX THE UTERUS DURING PREGNANCY. 165

prevents any diminution of its depth, there being but little difference
in the thickness of this external covering, either in the gravid or non-
gravid womb. The serous covering is movable on the tissue which
unites it to the middle or muscular coat, this tissue being apparently
diminished in density.

The internal, or mucous coat of the uterus, about which there have
been so many discordant opinions, becomes very evident during preg-
nancy ; it is softer, more lax, and redder, is more distinctly denned
from the muscular coat, its vessels become more distended ; and be-
coming hypertrophied, it presents an increased and villous appear-
ance, and from its great development its nutrition undoubtedly be-
comes more active. Its follicles become more marked, with an increase
of their secretion. There are also glands found imbedded in the
thickness of this coat, which appear to enter into the internal mus-
cular layers; these enlarge after conception, and are viewed by some
authors as the principal elements of the caducous or nidal membrane.
These glands resemble small canals, and run tortuously within and
behind the mucous uterine coat, forming a kind of knot, throwing out
ramifications, and opening on the internal face of the inner mucous
layer : they have been called the utricular glands.

The blood-vessels of the uterus likewise undergo changes which may
be briefly noticed. In the unimpregnated condition the arteries are
small, flexuous, and very much contracted, but during gestation, as
they become less compressed by the uterine fibers, they expand, soften,
and describe more regular curves ; their caliber increases, the blood
circulates more largely and rapidly, and a more active and energetic
nutrition ensues. The arteries of the uterus, as heretofore stated, are
furnished by the spermatics and hypogastrics, the superior portion of
the uterus receiving chiefly the branches from the spermatics, and the
body and cervix those only from the hypogastrics. The arteries are
always tortuous, and when they arrive at the uterus, they do not run
any distance under the peritoneum, but immediately enter into the
muscular coat, pass toward the inner surface, and especially to the part
where the placenta is attached, ramifying and anastomosing freely as
they proceed; those branches which reach the lining membrane ter-
minate in the tortuous canals in the placental decidua, while those
which do not arrive at the inner surface ramify upon the coats of the
veins. The veins of the uterus are greatly dilated, much more so
than the arteries, and their points of communication with each other
are multiplied to that degree, that at the parturient term, an inextrica-
ble mass of venous vessels is presented, giving to the uterine tissue a
resemblance to that of the erectile. That part of the uterus to which

KINC'S i;ru:<Tir OIISTKTUICS.

the placenta is attached IB more abundantly supplied with veins; and
on removing the placenta, the veins which open into the uterine cavity
will be seen, presenting large, smooth-edged and oblique apertures.
There are no proper valves to the veins, so that if any fluid be injected
into the trunks of the spermatic and hypogastric veins, it will flow in
a full stream into the cavity of the uterus, which may afford some ex-
planation of the cause of the large quantity of blood discharged in so
short a time from the uterus during parturition, together with that
from the exposed arteries. The venous circulation in the uterus and
placenta may be readily interrupted by the various derangements of
function in the thoracic and abdominal viscera, and the removal of
these obstructions during pregnancy is an important point.

The lymphatic vessels, or absorbents, likewise, become greatly en-
larged during pregnancy: according to Cruikshank, the first who
observed them, they are as large as a goosequill, and are so numerous,
that when injected with mercury, they give to the uterus the appear-
ance of a mass of lymphatic vessels. Those of the neck run into the
pelvic ganglia, and those of the body into the lumbar ganglia. Cruik-
shank supposed their function to be that of carrying on a " copious
absorption in the uterus toward the mother," during pregnancy; but
Dr. Eobert Lee has suggested another very probable function ; he ob-
serves, "The sudden removal of the uterine structures after delivery
by absorption, is probably the most important 'office they perform, and
the cause of their enlargement to such a vast size during the latter
months of pregnancy."

The nerves of the uterus likewise become considerably developed
during gestation, for the undoubted purpose of furnishing the uterus,
during the parturient act, with all the nervous energy that may be
necessary. After delivery, the nerves, together with all the augmented
tissues and vessels of the uterus, return to their original size and
condition.

CHANGES IN THE PROPERTIES OF THE UTERUS. In

the unimpregnated condition, the vital properties of the uterus are
very obscure, so that it may be touched, compressed, pricked, or even
cauterized without causing pain or much uneasiness, unless it be mor-
bidly affected; at this time its properties are chiefly limited to its tonic
forces, or organic sensibility and insensible contractility, the separa-
tion of the principles of growth and nutrition from the circulating
fluids, and the elimination of de-vitalized or decomposed elements
which are no longer necessary to the maintenance of life.

CHANGES IN THE UTERUS DURING PREGNANCY. 167

It is true, that when the finger is brought into contact with the
neck, the female is conscious of the touch ; however, the sensation goes
no farther ; but during pregnancy the animal sensibility becomes much
more marked, and the female more readily recognizes the contact of
bodies with the neck, as well as the fetal movements, and which sensi-
bility becomes more developed as gestation advances, so that in its
latter stages even the touch becomes excessively painful with many
women, and during parturition the uterine contractions produce intense
agony. The introduction of the hand within the uterus, for the pur-
pose of turning, effects similar pain, and when the adhering placenta
is removed artifically, the woman experiences sensations as if she were
being eviscerated. This exaltation of animal sensibility is principally
confined to the neck, the body of the organ being nearly insensible ; there
exists, however, a relation between these two parts, from which irrita-
tion of the neck will influence the fibers of the body. And this
relation will account for the premature births effected by repeated
touchings, frequent coition, the irritations of the cervix from artificial
dilatation, or the use of agents which stimulate the cerebro-spinal sys-
tem. It occasionally happens, that the female will be unconscious of
any movements of the fetus until the latter months of gestation, or
even not until labor actually commences, owing to the slight develop-
ment of sensibility, but in the majority of cases it is the very reverse
of this.

The most remarkable property, however, which the uterus manifests
during pregnancy is its organic contractility, which either did not pre-
viously exist, or if it did, it remained latent. This property, precisely
resembles the contraction of a muscle, and is never manifested except
under some irritating or stimulating influence ; it varies in intensity
in different females, and is so marked and energetic in many instances
as to benumb the hand of the strongest man, when introduced to per-
form artificial delivery. It is this contractile power which effects the
expulsion of the fetus and its secundines, as well as other productions
which may be accidentally developed within the uterine cavity, and
which, likewise, causes the womb, as well as its various vessels, to
gradually return to the diminished condition in which they were pre
vious to conception. Should the organic contractility of the uterus,
from any cause, fail to manifest itself after parturition, a hemorrhage
would ensue that would prove rapidly fatal to the parturient woman ;
and, when such cases occur in practice, the most important indication
is to arouse this power of contraction, which is the natural remedy,
and which produces its beneficial results by closing and obliterating

168 KING'S ECLECTIC OHSTETRICS.

the large open mouths of the blood-vessels on the internal placental
surface of the organ.

In the human family the presence of these contractions is always
accompanied with more or less pain, which is never found among ani-
mals in a state of nature, and which exists among savages and domes-
ticated animals in only a minor degree. Accident or disease may,
however, be the cause of pain with these last when in labor; and we
have good reasons for believing that the excessive pains undergone by
parturient females of our own race, are the results of the enervating
influence of civilization and its various customs, habits, and refine-
ments upon the constitution. In 1842, I was called upon to attend
Mrs. D , about twenty years of age, a short, thick-set female, bru-
nette, and in apparent good health, with her first child; there had
been observed a discharge of the waters, " the show," together with
some singular and indescribable feelings, but no pain. From these
symptoms, together with the calculations made upon the matter, it was
presumed that labor could not be far distant ; and it was, likewise,
deemed expedient by the mother that the advice of a physician should
be resorted to. Having ascertained that no pains of any kind had
been experienced, I thought myself unwarranted in making any ex-
amination, but did so at the urgent request of the mother, when to my
great astonishment I found the head within the pelvic cavity, and upon
placing my hand upon the abdomen, I felt very distinctly the con-
tractions of the uterus as they occurred, but the patient complained of
no pain whatever. I now seated myself by the bedside to watch the
progress of labor, as well as to be ready for any emergency in so sin-
gular a case, and the whole process of parturition was effected without
any untoward accident, and without the least pain, if the asseverations
of the female are to be believed; during the latter stage she evidently
contracted the abdominal muscles and made bearing down efforts, not,
she stated, from any painful influences, but from a strong sensation or
desire to make them. Shortly previous to my visiting the West, I
again attended this lady in her second labor, when she suffered as se-
vere pains as I remember to have ever witnessed in the parturient
chamber. The cause of this anomaly I do not pretend to understand.
The female, as a rule, suffers more severely with the pains in her first
labor, than in subsequent ones; however, there is no law governing
this matter so far as individuals are concerned : each accouchment of
the same woman is peculiar unto itself. In prognosing the probable
outcome of a labor, the practitioner should not be influenced by for-

CHANGES IN THE UTERUS DURING PREGNANCY. 169

mer experiences with the same person. As in the case cited, the con-
dition of the woman may be so favorable, that delivery will be accom-
plished and she -scarcely experience any uneasiness whatever, and but
very slightly the pains peculiar to labor, while her next lying-in may
be characterized by the most severe pains, and suffering so intense as
to demand relief by the administration of remedies, in some cases ne-
cessitating the effect of an anaesthetic.

The exercise of these organic contractions ensues involuntarily and
without any dependence on the will, yet we sometimes find them in-
fluenced by mental impressions, so much so, that a violent emotion
may arouse them at a premature period, and it is not an uncommon
circumstance for the appearance of the accoucheur in the room of the
lying-in woman to cause a suspension of them for several hours, or
even days. They may likewise be suspended for some hours by the
administration of opiates, as well as excited by stimulants, or irritation
applied to the neck, or, ergot, strychnia, electricity, borax, and many
other agents internally administered. If the uterus is excessively
distended if the labor has been too rapid, or prolonged the con-
tractions are very apt to diminish become more slow and feeble, or
entirely cease. I have met with instances, in which the contractions
have been suspended for several hours, in consequence of an intoxi-
cating draught of hot gin or brandy sling having been given by the
nurse, to "ease the pains and give the woman strength."

These changes in the condition of the uterus, necessarily effect some
modifications of the neighboring parts. In the early period of preg-
nancy, as the uterus enlarges in the cavity, the vagina becomes short-i
ened, but as soon as the former rises above the superior strait, the
latter becomes narrower and longer; in its elevation the uterus carries
its surrounding peritoneum along with it, the folds of which, or the
broad ligaments, disappear, and the tubes and ovaries approach nearer
to the uterus, where they rest, nearly in a perpendicular position; the
round ligaments present short linear fibers, among which are prolonga-
tions of the muscular fibers of the uterus, and which contract with
that organ.

From the increased vitality of the re-productive organs, as well as
from the obstruction of circulation by the enlarged uterus, the veins
of the vaginal walls become more developed, with various appearances,
which are often recognized, toward the termination of gestation, by the
finger. The vaginal pulse, of Osiander, which he estimated highly as
a diagnostic sign of pregnancy, may be felt, at some portion of the

170 KING'S ECLECTIC OBSTETRICS.

vagina, and is owing to the excessive enlargement of the vaginal and
uterine arteries. About the seventh or eighth month, the vaginal
mucous membrane is frequently covered with granulations the size of
a pin's head, which not only line the whole extent of this canal, but
also the exterior surface of the neck, and even the interior. When
these are present, there is an increased vaginal secretion.

One of the important changes to be understood by the practitioner,
is that undergone by the bladder. This organ is gradually pressed
above the superior strait, the urethra] canal is elongated, and its orifice
will be found behind the edge of the pubic symphysis, so that in intro-
ducing a catheter it must be directed nearly if not quite parallel with
the pubic bone, with its concavity in front, and, in some instances, the
curve of the canal becomes so great, from the bladder being pressed
forward and above the pubis, that a male catheter will be introduced
with more facility. This compression on the upper part of the canal,
impedes the circulation in the lower parts, from which results tume-
faction of its whole length. Tenesmus of the bladder is often the
consequence of compression on the body and neck of this organ, occa-
sioning frequent, urgent, and ineffectual efforts to urinate. In not a
few instances the catheter will have to be used to relieve the irritated
and distended bladder.

OF PREGNANCY. 171

CHAPTER XVIII.

OF PREGNANCY.

WHEN the fecundated ovum becomes attached to some portun of
the uterus, conception is said to have taken place, and the peculiar
condition of the woman, from the moment of conception to the period
of parturition, is called pregnancy or utero-gestation ; this usually com-
prises nine calendar months, or two hundred and eighty days from the
last menstrual show, or one hundred and forty days after quickening
the time at which most females perceive the first motions of the fetus,
and which generally occurs about the twentieth week after conception.
Although this is the period which seems to have been generally
recognized from the earliest ages, yet it is not invariable, as it occa-
sionally terminates sooner, and again, may extend to even ten months,
of which there are well attested cases on record. The determination
of this subject is one of great difficulty, as we can seldom ascertain the
precise moment of fecundation, and yet it is one of immense import-
ance, from the fact that the legitimacy of the oifspring may depend
upon a correct decision.

The only method by which we can ascertain the commencement of
utero-gestation, is by reference to the period of the last menstrual
flow, as well as to the time of quickening; but even these means are
very uncertain, as conception may occur sometime during the inter-
menstrual period; beside which, the period of quickening varies in
different women. On account of these difficulties, laws have been
established in several nations, fixing the term within which legitimacy
is acknowledged by them; thus, in France, the "Code Napoleon,"
admits the legitimacy of a child born within three hundred days after
wedlock, divorce, or death of the husband; and if born after that
time, its legitimacy may be contested, though it is not to be viewed
as a bastard. In Prussia, three weeks beyond the usual time are
allowed, or three hundred and one days. In Scotland, ten calendar

172 KIND'S KCLECTIC OBSTETRICS.

months are considered the extent of legitimacy. In England and in
this country, the limit of gestation is not determined by law.

That the term of utero-gestation varies in many females is, I
believe, generally admitted by observing accoucheurs of the present
day, and the existence of the laws on this subject, in the countries
above referred to, are strong confirmations of the possibility of pro-
tracted gestation. Indeed, I have met with several instances in which
I had every reason for believing that the pregnancy had been pro-
longed to two and three weeks beyond the usual period ; and two, in
particular, in which I positively know that gestation was continued
for ten months. Drs. Blundell, Desormeaux, Hunter, Montgomery,
Rigby, Hamilton, Burns, Dewees, Velpeau, Merriman, Moreau, Simp-
son, Meigs, Atlee, and many others, have met with similar instance:?,
in which the term of gestation had extended from one to four weeks
beyond nine calendar months. Their reported cases, taken in con-
nection with investigations made on animals, as rabbits, sheep, cows,
mares, etc., that likewise are found to vary considerably in their
periods of gestation, certainly aiford the strongest evidence in favor
of prolonged pregnancy. Eelative to this subject, Dr. Montgomery
justly observes : " We can not imagine why gestation should be the
only process connected with reproduction, for which a total exemption
from any variation in its period should be claimed. The periods of
menstruation are, in general, very regular ; but who is there who does
not know, that as there are, on the one hand, women in whom the
return of that discharge is anticipated by several days, so there are
also many in whom the return is postponed an equal length of time,
without the slightest appreciable derangement of the health. Again,
menstruation and the power of reproduction in the female, very gen-
erally, indeed almost universally, ceases about the forty-fifth year, in
these countries ; yet occasionally instances are met with, in which both
are prolonged ten or fifteen years beyond that time of life ; and a
similar variety is observable, in the period of the first establishment of
that function in the system. If we turn our attention to brutes, the con-
ditions of whose gestation so closely coincide with those of the human
female, and are less disposed to have it disturbed, we can not Tor a
moment doubt the fact, that there is a great irregularity in the term
of gestation in different individuals of the same species."

Dr. Charles Clay, of England, has advanced the view that the term of
utero-gestation is regulated by the ages of the individuals concerned in
the act; that the younger these individuals the shorter the term, and, as

OF PREGNANCY.

173

age advances, the period of gestation is proportionately lengthened.
From what he has been enabled to glean, the term of gestation has
occurred as follows :

.... 264 days

274 davi

15 " "

.... 267 "

" 30 " "

276 "

" 15 to 15J " "

..... 267 "

" 35 "

278 "

" 15 to 17 " "

.... 270 "

" 44 " "

84 "

'( 19

.... 272 "

52 " "

290 "

But, he observes, the age must be calculated not by that of the
mother alone, but by the combined ages of both parents. Thus, if
the female be twenty, and the male thirty, a result must be expected
equal to an age of twenty-five, or, taking into consideration the earlier
maturity of the female, of twenty-four. If, however, the female be
thirty, and the male twenty, then the result would equal an age of
twenty-six. For the extension of inquiry on this subject, he remarks:
" It will be desirable in all cases to be recorded, whether in favor
or against the propositions here laid down, to secure the following
data : 1st. Date of conception arising from a single contact. 2d. Date
of parturition commencing. 3d. Age of the mother. 4th. Age of
the father. 5th. In statements of age, where the female is the
younger, it must be fixed at the year below the mean ages of the
two combined. 6th. Where the female is the older, the age must
be fixed a year above the mean of the two combined; by this rule
the average age on the [above] table will give the days of gestation
more correctly than by any other known rule." (The Complete Hand-
book of Obstetrics, Surgery, etc., by Charles Clay, M. D.) This hy-
pothesis of Dr. Clay's does really appear to be supported by the data
he advances, and is certainly deserving more thorough investigation.

I will give here a table which will be found useful for determining
the period at which menstruation, quickening, parturition, etc., may
probably occur. This table is so arranged that the dates on the
same line in the several columns are consecutively twenty-eight days
or one lunar month distant from each other. Thus, if a female
menstruates on the 7th January, her next period will occur twenty-
eight days subsequently, on the 4th February, the next on the 4th
March, then 1st April, and so on.

Pregnancy is usually dated from the last menstruation, on account
of the difficulty of determining the precise period of a fruitful coitus j

174

KING'S ECLECTIC OBSTETRICS.

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OF PBEGNANCY. 175

two hundred and eighty days after the last menstruation is the usual
period allowed for full term of pregnancy ; or two hundred and
seventy-five days from a fruitful coitus when this is known. Hence,
five days may be allowed in the calculation with the accompanying
table; thus, if a pregnant female had her last menstruation on 29th
July of any year, her period of confinement will occur at about two
hundred and eighty days, or ten lunar months subsequently, which,
upon counting, we find will be on the 8th April of the ensuing year;
or by allowing five days, we may expect her labor to come on between
the 8th and 13th of April.

Quickening is generally supposed to be first experienced at about
the one hundred and fortieth day of pregnancy ; hence, if a female
perceives quickening for the first time on llth August, by count-
ing along in the table for the balance of the period of pregnancy, that
is, one hundred and forty days, or five lunar months, we find that
labor will probably occur upon or about the ensuing 29th December.
I say, probably, because there is less certainty in this, as quickening
may be perceived at a much earlier period, or, at a more advanced
stage of the pregnancy.

.After December, the present year in question terminates, so that,
upon finding on what day in January, in the last or fourteenth column,
the counting along on the same line terminates, and it is necessary to
count on still farther, we must return to the same date of January in
the first column, as we left in the last or fourteenth column, and then
count along on the corresponding line as far as may be required.
Thus, if we desire to count nine lunar months from 1 8th October, we
find that three lunar months brings us to 10th January of the next
year in the last or fourteenth column we now find the 10th January
in the first column, and by counting along for the balance of the time,
six lunar months, it brings us to the 27th June of the subsequent year.

In leap year one day may be deducted from the ascertained period,
after having passed the month of February of the leap year ; thus, two
hundred and eighty days from 19th November would be 26th August
of the ensuing year but, if this be a leap year, it will be 25th August ;
again, two hundred and eighty days from 13th August would be
20th May of the next year, or, if le.ap year, 19th May.

By reference to the figures at the bottom of each column, counting
from the first column, we can always determine how many lunar
months or columns must be included within any number of days, and
vice versa. Thus, six lunar months or columns are equal to one
hundred and sixty-eight days then one hundred and sixty-eight days

176 KING'S ECLECTIC- OBSTETRICS.

from the 18th July would be six columns or lunar months, carrying
us to 2nd January of the next year. The reader may find various
other uses for this table.

Another point to determine, is the earliest period at which a child
may be born, consistent with its existence subsequently. This is like-
wise a subject of much moment, involving the reputation of a mother,
the legitimacy of oifspring, and the peace and happiness of families,
especially in those instances where the fetal developments exceed those
which are generally found at the various periods of pregnancy. I
remember an incident which occurred some years since, and which
I will relate here, to show the importance of prudence. I was called
to attend a lady who had aborted three months after her marriage:
the fetus presented all the appearances of one between the fourth and
fifth months, and on seeing it, I innocently remarked, " it is a good-
sized one." This imprudent remark occasioned much unhappiness in
the minds of the husband, the mother of the lady, and herself; and
they each inquired of me, in private, if I supposed there "was any-
thing wrong?" having reference to the wife's chastity. I had long
known each of the parties, before their marriage, and had no reasons
whatever for the most distant idea of want of purity and virtue, and
it was from this consciousness of undoubted integrity of character
that the observation was inadvertently made and I so replied to their
inquiries. About eighteen or nineteen months afterward, I delivered
this lady of a male child, at full term, which having been weighed on
the day of its birth, was found to exceed twelve pounds. Here was
an extraordinary development of size at full term, and a similar excess
of growth was undoubtedly the case with the previously aborted fetus.

The seventh month is generally viewed as the shortest period in
which a viable child may be born, yet there are many instances in
which it has occurred still earlier. These cases, do not however
militate against the general view regarding viability, and should be
considered exceptional, exerting no influence as to the justifiability of
inducing premature labor at the seventh month, in the hope of pre-
serving the life of the child. Dr. Dewees states, that he has known
instances of this kind : one " in which labor habitually occurred at the
seventh month, and two, in which it regularly took place at the eighth
month of pregnancy." In Scotland, a child born six months after
marriage, or after the death of the father, is considered legitimate.
Carpenter, in his Physiology, mentions an instance in which a child,
born twenty-five weeks after wedlock, lived between six and seven

OF PEEGNANCY. 177

months, and was declared to be legitimate by the Presbytery of Scot-
land. Dr. Dodd and Dr. Christian relate similar cases, as well as
many other physicians. Dr. "W. Hunter observes, that " a child may
be born alive, at any time after three months ; but we see none with
powers of living to manhood, or of being reared, before seven calen-
der months, or near that time. At six months it can not be." Beside
the many recorded cases where children, born previous to the seventh
month, lived for an hour to several days or weeks thereafter, it may be
interesting to refer to the following : M. Capuron mentions the case
of Fortunio Liceti, who, born after a gestation of four months and a
half, lived subsequently for eighty years. M. Devergie relates the case
of Cardinal Richelieu, who was born at the fifth month. Dr. Hamilton
cites a case where a child born only nineteen weeks after conception
lived eighteen months. Dr. Lavirotte, in Lyon Me'dical, April, 1873,
observes that viability does not solely depend upon the intra-uterine
age of a fetus, but likewise upon its volume, its weight, its muscular
force, the more or less advanced organization of its skin and nails, and
especially upon respiration, digestion, nutrition, and normal condition
of the heart and large blood-vessels. The fact that a child, born at
the seventh month of gestation, may subsequently continue to live, is
of importance in another point, viz.: the induction of premature labor.
Upon these various deviations from the most common course of
pregnancy, it is not my intention to offer any speculative views, as the
present work is intended to be, not one of theorizing, but of utility in
a practical point, to those who consult its pages ; I will, therefore,
leave this subject, by observing, that an opinion in these cases should
always be given very guardedly and reservedly, lest by a hasty and
improper decision we tarnish the reputation, and consequent happiness
of the innocent.

It sometimes happens that the ovum, after impregnation does not
reach the cavity of the uterus, but becomes attached to the interior
walls of the Fallopian tubes, abdomen, etc., in consequence of which,
from want of a proper and natural connection with the mother, the
development of the ovum is much retarded, is seldom perfected and
disease often attacks it; under these circumstances, a well-formed
living fetus could not be produced. I am aware, that some writers ob-
ject to these facts as being without foundation ; but the objections are
commonly presented by those who support the theory that the male
semen never extends beyond the uterine cavity, within which, alone*,

fecundation occurs. As before stated, the spermatic fluid has been
12

178 KINc's FCLKCTIC Ol'.STKTRICS.

found in the tubes, and on the ovaries of various animals by rigid in-
vestigators; beside, the fact that fetal formations, without the uterus,
do occasionally exist, is, in connection with the above, an evidence
tending, to say the least of it, to support a belief of the possibility, as
well as the probability, of fecundation occurring beyond the uterine
cavity.

When the impregnated ovum reaches the uterus, and is developed
within its cavity, it is termed a normal or uterine pregnancy, which is
divided into simple uterine pregnancy, when there is but one fetus ; com-
pound or multiple pregnancy, when there are more than one ; and mixed,
complex, or complicated pregnancy, when, with the existence of the
fetus, there is also, a mole, hydatids, or some morbid condition of the
uterus, or its appendages. When, instead of passing into the uterus,
the vivified ovulum becomes fixed upon the tubes, abdomen, etc., it is
called extra-uterine pregnancy, of which there are several varieties, ac-
cording to the place of adhesion of the ovum, and which I wilt refer
to in the ensuing chapter. To those pathological conditions which
simulate pregnancy, often misleading both the patient and her physi-
cians, and which occur independently of true conception, the term
false pregnancy has been improperly applied.

CHAPTEK XIX.

COMPOUND AND MIXED PREGNANCY.

COMPOUND or multiple pregnancy, are the terms applied to those
pregnancies in which more than one fetus exists within the uterus at
the same time. The cause of this peculiar disposition which some
women have to compound pregnancies, is a matter of mere conjecture,
and but little is known relative to it which is either satisfactory or
worthy of confidence. It has been attributed to the impregnation of
two or more Graafian vesicles during a fruitful embrace, and which may
happen either in one or both ovaries; again, and with some degree of
probability, it is stated that one vesicle may contain two or more ovules,
each of which becomes fecundated upon the rupture of the vesicle
during copulation. By some physiologists it has been supposed that
this anomaly is not the result of one act of impregnation but of two
or more, and this is undoubtedly true in many instances, as examples

COMPOUND AND MIXED PREGNANCY. 179

are 011 record of females having given birth to twins, one being white
and the other colored, the result of intercourse successively with a
white man and a negro. And previous to the secretion of the mucus
which fills the canal of the cervix during gestation, or to the appear-
ance of the membrana decidua, superfetation may be possible.

Cases of a marvelous and probably fabulous character, are recorded
where women have given birth to five, six, or even nine children at
one birth, but it is rarely the case that more than two are present
during pregnancy. In the course of a practice of thirty-one years, I
have met with but three cases of triplets, and one in which a woman
had four children at one birth, all closely resembling each other;
while of twins or couplets I have met with quite a number, averaging
about one in every eighty labors. From the want of sufficient vital
force bestowed upon them, triplets seldom attain adult age, and twins
rarely attain the meridian period of manhood.

As a general thing, in compound pregnancies, each fetus or embryo
is surrounded by its own proper membranes, the chorion and amnion,
so that the children do not come in contact with each other ; but have
between them four layers or laminse, the two amnios, and the two
chorions which touch each other. Sometimes} one chorion incloses
both ovules, each, however, being enveloped with its proper amnion,
and in which case there are but two layers or laminse separating them,
the two amnios which rest against each other. Occasionally, the
fetuses are all inclosed in one amniotic cavity; and very rarely, one
fetus is contained within the body of another.

In the first-mentioned variety, should the placentas be united, there
will be no vascular communication between them; and should one
child die while within the uterus, it will not necessarily involve the
life of the other; this will frequently be found to occur in twin and
triple pregnancies. The same labor may expel both children, or, if
permitted, one child may be born two or three days earlier than its
brother.

In the second variety, the chorion being common to each, there will
be two cords and but one placenta, and as in the first, one fetus may
continue to live independent of the death of the other. In this variety
the birth of the two children must take place during one labor, the
one being immediately expelled after the other.

In the third variety, one placenta will be common to each, with two
cords, which sometimes extend to the placenta, and at others bifurcate
from one common trunk at various distances from the placenta. In
these cases, we often meet with monstrosities or imperfectly-formed

180 KING'S i-:< ].}-.( TIC OHSTKTRICS.

children. The birth of the children must take place in this as in the
second variety, during one labor; and possibly, the death of one may
endanger the life of the other.

In the last form, monstrosity is frequently the result. One fetus
may be inclosed in the abdominal cavity of the other, which is termed
profound or abdominal inclusion; or, it may be merely surrounded by
the integuments of the other, forming an external tumor having no
communication with its internal cavities, which is termed the cutaneous
or exterior inclusion.

There are no positive signs by which we can indicate the existence
of twin pregnancy, although some have been noticed by writers.
Thus, an unusual development of the uterus but this may be owing
to an increase of the liquor amnii ; a flattening or longitudinal depres-
sion of the abdomen on the median line, in connection with the above,
might justly give rise to a suspicion of twins, but this could only
happen when the fetuses lie one upon each side of the uterus; two dis-
tinct shocks or motions, are sometimes felt at the same time in different
parts of the uterus, but no reliance can be placed upon this as a sign ;
again, ballottement is exceedingly difficult in compound pregnancies,
as one child must necessarily interfere with the ascent of the other.
Auscultation has been named as a mode of detecting twin pregnancies,
but we may err even in this, as the sound of the fetal heart can often
be distinctly heard in distant parts ; Cazeaux says, " Whenever the pul-
sations are heard at two distant points, the line between these should
be carefully sounded with the instrument ; for if they are produced
'by the presence of two fetuses, the pulsations will become feeble, or
almost disappear toward the center of this line; but if, on the con-
trary, they are due to a single child, they will be just as strong at its
middle part as at either extremity." The diagnosis is rendered more
certain if with these varied pulsations we ascertain them to be non-
synchronous in action, and with a different rhythm. However, it is
of little importance to determine the presence of more than one fetus
within the uterus during gestation, as a knowledge of it could be of
no utility whatever, until parturition had taken place, at which time
it can readily be detected.

Compound pregnancy, in consequence of the excessive development
of the uterus, frequently induces labor previous to full term, and it is
not uncommon in these instances to find the uterus contracting and
expelling its contents during the seventh and eighth months of utero-
gestation.

COMPOUND AND MIXED PREGNANCY. 181

In addition to the above there are, 1st, false pregnancies, improperly
o called, in which the uterus contains a false germ, mole, or hydatidi-
form o-rowths; and 2d, mixed pregnancies, where the uterus contains
both a fetus and mole.

Moles and hydatoid iormations, are undoubtedly the results of
some diseased condition of the ovum, by which it becomes destroyed,
or metamorphosed, into a growth possessing sufficient vitality to exist
and augment in size, until removed by the uterine contractions. It is
a true conception at first, but which becomes blighted by disease, and
degenerates into morbid development. The vesicular mole is more
generally met with, though it is rare to find it perfect, and in the ex-
amination of abortive ova, vesicular degeneration of the chorionic
tufts will very often be found, and in the membranes of fetuses born
at the full time a few stalked vesicles may be seen. (Fricker.} Other
moles may form from a hypertrophied condition of the membranes,
from hemorrhage between the decidual layers, or into the placental cells,
etc., and consist of a mass of solid substance. The disease occasioning
the vesicular form may commence with the ovum in the ovary; if the
solid mole be the result of an abnormal condition of the nidal decidua,
it may possibly occur without impregnation, or even copulation, but
such cases are extremely rare.

These false pregnancies are extremely difficult to detect. When the
uterus increases in size with greater rapidity than is natural under
ordinary causes, with nausea, or vomiting, and tendency to fainting,
more severe than with normal pregnancy, great constitutional irrita-
bility, occasional attacks of uterine hemorrhage, emaciation, quick
pulse, absence of the fetal-heart sounds, fetal movements, and ballotte-
ment ; a want of correspondence between the duration of the preg-
nancy and the rapid uterine development, occasional discharges of
portions of the mole, a presentation at the os uteri of a substance
somewhat like that of the placenta, but between which and the inner
margin of the uterine cavity the finger glides along without difficulty,
etc., we may be led to suspect the presence of hydatidoids ; and upon
a vaginal examination, if we find a soft mass in the cervix, which
upon being roughly pressed, bleeds, and discharges upon the finger
portions of aqueous vesicles, our suspicion becomes certainty. Under
these circumstances we must endeavor to promote an early expulsion
of them. The index finger may be passed within the os uteri suffi-
ciently far to reach the mass and break it in pieces; as soon as the
contractions of the uterus have removed the detached pieces, we must
examine again to ascertain whether any portion remains, and if any

182 KING'S KCLECTIC OIISTKTUICS.

are found, they must be again broken, and thus proceed till the whole
mass is discharged. If the finger can not be readily introduced for the
above purpose, a sponge-tent may be placed in the canal of the cervix
for the purpose of inducing uterine contractions, or ergot may be
administered. Dr. Lawson Tait's compressed carbolized sponge-tent
may also be used, or Molesworth'a uterine dilator.

The prognosis is not very favorable in molar pregnancy, as the
woman is exposed to death from hemorrhage, from the effects of the
operative assistance more generally required, and from remote acci-
dents; and, even should recovery ensue, she may suffer for a long
time from extreme debility, anemia, etc.

Hemorrhage to an alarming extent often accompanies a labor for
the expulsion of hydatidiform growths, for which, in the early months,
the tampon may be employed, or the os uteri and vagina may be
plugged by means of muslin torn into strips, or a sponge saturated in
a mild solution of per-sulphate of iron; together with other means for
arresting uterine hemorrhage referred to under the head of Abortion,
while at the same time the strength and general condition of the pa-
tient must be closely attended to. In cases where the practitioner is
thoroughly satisfied that the uterus does not contain a living fetus,
the previous symptoms of pregnancy having disappeared, and there
is a continued hemorrhage gradually reducing the patient, the safest
plan is to dilate the cervix, examine the uterine cavity, and at once
remove any form of molar pregnancy contained therein, or any dead
fetus; or, if it be a tumor that has occasioned the uterine develop-
ment, treat it according to the indications.

Mixed pregnancies are likewise very difficult to distinguish, and are
almost always a cause of abortion, at which time the practitioner must
be watchful of the hemorrhage which may ensue, endeavoring to check
it, if possible, that the fetus may be saved ; but, in any case, when the
hemorrhage is profuse, and does not readily yield to treatment, the safest
method will be to cause a speedy discharge of the uterine contents.

When the ovule becomes impregnated within the ovary, it is seized
upon by the fimbriated extremity of the Fallopian tube, through the
canal of which it passes until it enters the cavity of the uterus, in
which it becomes gradually and fully developed. Many writers be-
lieve that fecundation takes place only within the uterus, but the exist-
ence of extra-uterine pregnancies proves that it may ensue in the ovary
itself; and the idea advanced by some that the ovule after impregna-
tion may make a retrograde movement from the uterine cavity through-

COMPOUND AND MIXED PREGNANCY. 183

the tubes to the ovary or abdomen, is both absurd and opposed to
reason. Undoubtedly impregnation may take place in the ovary,
tubes, or within the uterus,- whenever the male semen comes in contact
with the matured ovum at any of its various points of discharge.
However, let it occur where it may, it is occasionally found that the
ovum does not reach the uterine cavity, but is arrested or diverted
from its route, and attaches itself upon some unnatural point, from
which it proceeds toward a partial development; these instances are
termed abnormal, or extra-uterine pregnancies.

The causes of extra-uterine pregnancy are involved in much obscu-
rity ; in some instances there have been found partial or complete ob-
literation of the canal of the tubes, either at some particular point, or
throughout their whole extent, but the occasion of these closures or
their period of occurrence, is not satisfactorily explained. Blows upon
the hypogastrium soon after conception, have been named among the
causes, though there is no certainty in relation to the subject, which is
still one of inquiry. Cases are recorded in which fecundation took
place, although the tubal canals were imperforate throughout, and
many others where it has occurred, without a rupture of the hymen,
eo that notwithstanding what has been advanced in relation to the mat-
ter of impregnation, much yet remains for investigation.

In the early period of extra-uterine pregnancy, its determination is
very difficult, if not impossible. At a later period, we may be led to
suspect the presence of extra-uterine pregnancy, when we discover a
premature enlargement of the abdomen above the symphysis pubis
when this enlargement is less uniformly developed, and more irregular
in its shape, than in normal pregnancies when the tumor or enlarge-
ment is foilnd. in one of the iliac fossae, or not central in the median
line, being easily felt through the parietes of the abdomen and when
upon a vaginal examination, the uterus is found not to have increased
in size, nor undergone any change from a firm, unyielding tissue, to
one softened and elastic ; and very often this organ will be found
pressed by the abnormal tumor against some part of the pelvic walls.
The cervix is apt to be patulous. Pain is generally present, especially
when the motions of the fetus can be felt, and which gradually be-
comes more severe as its development proceeds. The pain is some-
what similar to uterine pains, and at times it is constant, fixed, and cir-
cumscribed in the pelvis, groin, or umbilical region. We may be
positive of extra-uterine pregnancy when, having ascertained fetal
movements, fetal-heart pulsations, etc., the sound detects an empty
state of the uterine cavity. While it exists, some of the symptoms of

184 KINC'S K( !.!:< 'TIC <>l!STKTi;irS.

pregnancy, as cessation of menstruation, nausea, vomiting, mammary
enlargement, etc., may be present ; but in many instances these have
been absent. There is a discordance of opinions among writers rela-
tive to the membrana decidua, some of whom assert that the internal
surface of the uterine cavity becomes covered with it during extra-
uterine pregnancy, while others deny it; among the latter may be
named Dr. Robert Lee, of London. But the statements of M. Caz-
eaux, Prof. Meigs, Ramsbotham, and other investigators, tend to prove
conclusively, that the membrana decidua is formed within the uterine
cavity in abnormal pregnancies. Ramsbotham remarks, " It is a cu-
rious circumstance in the history of these cases, that if the child should
live until the term of gestation is completed, as soon as that time has
expired, the uterus takes on itself expulsive action, which is attended
with pain similar to the throes of labor, and during these pains the
deciduous membrane is expelled from the cavity, with a slight san-
guineous discharge ; the same also occurs on the death of the ovum,
provided that be premature." See Nidation* In these pregnancies
we will frequently discover an increase of the uterine volume, with
ramollissement, especially during the early stages, and will sometimes
find a thick, ropy, gelatinous substance or mucus in the uterine neck.
Great care is necessary not to confound extra-uterine pregnancy with
displacement of the normally pregnant uterus during the early months,
pregnancy complicated with fibro-myoma or cystic disease of the
uterus, and, after the death of the fetus especially, with pelvic hema-
tocele, ovarian tumor, dermoid cysts, cancer, fibro-cystic uterine dis-
ease, uterine hydatiform growths, and phantom pregnancy.

The duration of extra -uterine pregnancy is very variable; most
commonly it terminates in a few weeks or months ; seldom exceeding
five months; and occasionally it has continued through a series of
years, even as long as forty-six years. It is stated, that in those cases,
where it has continued during the full period of labor, there have been
at the termination of the ninth month, symptoms simulating labor, as
intermittent uterine pains more or less severe in character, a com-
mencement of dilatation of the os uteri, a discharge of muco-sanguine-
ous fluid, and true uterine contractions ; and where this condition has
continued for several years, these" phenomena have recurred at fixed or
irregular periods but they are by no means constant.

The most common termination of extra-uterine pregnancy, is by a
rupture of the cyst which incloses the fetus, and which may be effected
by a blow, violent exertion, or some similar cause, or it may ensue
slowly and gradually. This rupture is accompanied with several

COMPOUND AND MIXED PREGNANCY. 185

symptoms of a grave nature; at first, there will be severe pain for
several hours, and finally an agonizing pain will be followed by tran-
quillity and a perfect quiet from suffering, with a subsidence or flatten-
ing of the abdominal enlargement, or, perhaps, its entire disappear-
ance ; the abdominal cavity experiences an increased heat, and the
patient, if the development was of some months' date, will feel as if a
voluminous body had been displaced ; the skin grows pale, faintings
come on, the pulse becomes small and contracted, a cold sweat covers
the whole body, and frequently death follows, owing to the hemor-
rhage produced by the rupture of the cyst. Or, if hemorrhage to a
copious extent should not ensue, or it should be arrested, violent
peritoneal inflammation will be the result. The fetus in all these
cases is usually dead, which may have been the result of defective
nutrition or some other cause unknown ; and if a new cyst is formed,
which is sometimes the case, although very dangerous to the mother, it
is more favorable, because it may probably form an abscess from which
the fetus may be discharged, and thus save the patient's life, or it may
permanently hold the fetus while this undergoes several alterations, as
hardening, or passing into the state of adipocire, all the fluid parts
being absorbed, and the cyst becoming gradually a solid, non-malig-
nant tumor. Again, it may terminate in a sac containing pus, in
which the fetus putrefies, and is eventually discharged into the
peritoneal cavity, the intestine, or bladder, and which may give rise to
violent peritonitis ; or, it may become coated with a bony, earthy, or
semi-coriaceous crust, and remain comparatively harmless, producing
no distress, except that occasioned by its weight and bulk. Indeed
death is pretty certain in these cases, from peritonitis, purulent infec-
tion, or exhaustion from long continued suppuration.

Extra-uterine pregnancies have been divided into several varieties,
each variety being determined by the point of fixation of the ovule,
thus:

1. Ovarian Pregnancy, is that rare form in which the ovum remains
adherent to the surface of the ovary, and is of two kinds where the
ovule is found within the vesicle which held it previous to conception,
and where it is partly developed in the abdomen, and partly in the
substance of the ovary itself. It may continue for five or six months,
when, from the augmented size of the fetus, the cyst ruptures during; a
paroxysm of pain, and, as found after death, the fetus, with a large
amount of blood is expelled into the abdominal cavity. During the
presence of this abnormal pregnancy, most, excruciating pain about
the pelvis, is experienced by the patient from time to time, with con-

186 KIN<;'s K< LECTIC OI'.si I.IK'IOS.

stipation and dysuria ; and an examination of the uterus per vaginam,
detects it unaltered in size, form, and consistence. The pain is not
constant, but regularly or irregularly intermittent, with intervals of
ease. But after the rupture of the cyst, the pain becomes more severe,
with syncope and finally death from peritoneal inflammation. The
existence of this form of extra-uterine pregnancy, is denied by some
authors.

2. Tubar, or Tubal Pregnancy, is probably the most frequent variety
of extra-uterine pregnancy. An arrest of the ovule takes place in
some portion of the Fallopian tube, between its fimbriated extremity
and its uterine orifice, and at which point the imperfect placenta be-
comes attached to the inner face of the tubal canal, the walls of the
tubes forming the fetal sac. The growth and development of the
fetus proceeds for two, three, or four months, rarely seven or nine, when
the sac ruptures. In this form of misplaced pregnancy, there is an
early enlargement over the symphysis pubis, and a vaginal examination
will find the uterus unchanged in size, etc., and movable, but uncon-
nected with the mobility of the tumor. As the fetus continues to
grow, the female suffers severe pain in the pelvis, which is increased
after the rupture of the sac, and is followed by excessive prostration
and death. The fetus is most commonly discharged into the abdom-
inal cavity.

3. In Ventral, or Abdominal Pregnancy, the impregnated ovule fails
to reach the tube and falls into the abdomen, upon some portion of the
walls of which the placenta attaches itself. The pain, experienced by
the female in this variety of pregnancy, is situated in the abdomen;
the enlargement is found in the iliac fossa, at an early period; upon
an examination per vaginam, the uterus, as in the previous species, is
found unaltered, and more movable than in any other of the abnormal
pregnancies; and the fetal movements may sometimes be observed till
the ninth month. The sac, which incloses the fetus, gradually forms
adhesions with the surrounding parts, and inflammation most generally
occurs, at some period, followed by abscess, which discharges the fetus,
in fragments, through the w r alls of the abdomen, the vagina, the rec-
tum, or the bladder. Cases are reported in which the fetus has re-
mained within the abdomen for forty and fifty years, in a mummefied
or cretified condition, and others in which normal pregnancy occurred
during the presence of the first fetus in the cavity of the abdomen.

There are several other varieties named by authors, to which a brief
reference may be made, as, Sub-peritoneo-pelvic pregnancy, in which
the ovum is situated between the two laminae of the broad ligament^

COMPOUND AND MIXED PREGNANCY. 187

where it becomes developed, and which is, probably, the least danger-
ous of any, as its situation favors the spontaneous expulsion of the
fetal debris, and renders them more accessible, should their extraction
become necessary ; Tubo-ovarian pregnancy, in which the cyst sur-
rounding the fetus is party formed by the ovary, and partly by the
opening of the dilated tube, whose extremities have contracted some
adhesions with the ovarian tunic ; Tubo-abdominal pregnancy, in which
the cyst is partly made up by the walls of the tube, the placenta being
attached to their interior face, while the other portion of the surface of
the ovule is in the cavity of the abdomen, and in which cavity the fetus
is usually developed ; Interstitial, or parietal pregnancy, in which the
ovule penetrates into the midst of the uterine fibers, the cyst being
formed by these muscular fibers alone how this is accomplished, is at
present an enigma; Utero-tubal pregnancy, where the ovum is retained
partly within the tubes, and partly within the uterine cavity; and
Utero-tubo-abdominal pregnancy, in which the fetus is in the abdominal
cavity, the umbilical cord passing through the canal of the tube and into
the uterus, to the inner face of which organ the placenta is attached.

In all these abnormal pregnancies; ihe ovule retains its proper
membranes, as the chorion and amnion, by means of the first of which
circulation is effected *bet\veen the mother and embryo, and in those
cases where inflammation has been produced by the presence of the
ovum in the peritoneal cavity, a membraneous cyst is formed somewhat
similar to the caducous membrane of the uterus, but undoubtedly not
a true decidua.

TREATMENT. Diagnosis of extra-uterine pregnancy is always
difficult. Menstruation is apt to recur in a few months ; the peculiar
sensations of pregnancy usually experienced by the patient are not
always present, and a physician is seldom called until an advanced
period, and often only at the time when rupture of the cyst is about
to ensue. It is best determined by palpation of the abdomen, and
careful vaginal exploration ; and may be decided by exclusion, after
bimanual and pelvic examination, that the abdominal enlargement is
neither salpingian nor ovarian ; that it is not the result of hypertrophy
of the abdominal or pelvic viscera, but must depend, after excluding
every kind of swelling except that of abdominal pregnancy, on ectopic
gestation. The best treatment at this critical period is to execute lap-
arotomy and remove the fetus with its surroundings, as soon as dis-
covered, whether the ovum be dead or alive. Morphine, injected

188 KING'S ECLECTIC OBSTETRICS.

hypodermically into the fetal cyst, has been recommended to produce
the death of the fetus. It has also been advocated that electricity be
employed for the same purpose ; the object being to prevent the growth
of the ovum and ultimate bursting of the sac. If the dead i^tuo re-
main incarcerated in the abdominal sac, the woman will sooner or later
develop septicaemia the result of putrefactive gases arising from the
decomposing fetus. Infection always follows the death of the fetus,
though the poisoning in some cases is so slow that it has taken years
to wear out the victim. A process of ulceration may establish a fistu-
lous outlet, through which will pass the fetal bones denuded of flesh;
as the decomposing mass is cast off, inflammatory action develops, ad-
hesions exist between the pelvic viscera, intestines and sac, rendering
separation impossible, and the death of the mother soon follows as the
inevitable result.

In the execution of laparotomy, to remove the product of extra-
uterine conception, the same general rules should be observed as in
ordinary ovariotomy. The following instructions are given by one of
the best known writers on surgical subjects : The patient is to be in
a clean and comfortable room, on a table, and with clothing fresh ; the
abdomen is to be sponged, and it is well to have a rubber cloth cover
the skin, an aperture having been cut in the cover in the median line
to operate through ; pans of hot water or antiseptic fluids are to be at
hand, and scrupulously clean sponges; all instruments are to be un-
questionably aseptic, as well as the operator's hands and arms; the
patient is to be kept steadily under the anesthetic, and it is well to
have the limbs tied to the operating table, to prevent troublesome
movements of the body. The abdominal incision is to be along the
linea alba, just below the umbilicus, and extended enough to admit
the hand ; after division of the peritoneal lining of the abdomen, a
quantity of serum may escape, and the fetal envelope come into view,
appearing redder and more vascular than the sac of an ovarian cyst.
This is to be manipulated to determine the position of the fetus,, and
to find its connections with the Fallopian tube or with the peritoneal
surface of the uterus. Generally, the pedicle of the ovum is as small
as that of ovarian tumors in general, but it may be larger or more
extensive in its attachments. But, be the pedicle large or small, it
must be ligated and then severed with scissors on the distal side of the
knot. After the ligature is tied, the sac may be opened and the fetus
removed ; then the pedicle may be divided a half inch or more out-
side the line of strangulation. Adhesions are to be overcome before

COMPOUND AND MIXED PREGNANCY. 189

or after division of the pedicle, as the operator may choose, or as may
be convenient.

Scrupulous care should be exercised to arrest all bleeding from trau-
matic surfaces, and the long rubber drainage tube should be employed.
In other words, the management of the case is to be like that of hys-
terectomy or ovariotomy. If the peritoneal cavity could be made dry
and free from coagula, there would be no necessity for drainage tubes,
but there is no surety for such an aseptic state. There will be oozing
after reaction, and a consequent fermentation. The long drainage tube
does not irritate or even create perceptible worry, and is very efficient
to carry off septic fluids.

The wound in the abdominal walls is to be carefully closed with deep
sutures, the outer end of the drainage tube projecting from the lower
angle of the wound. Vomiting on the part of the patient is to be
allayed by taking sups of hot water. A hypodermic injection of mor-
phia is to allay great pain, yet is not to be employed unless there is
need of an anodyne. Nutritious enernata may be employed on the day
following the laparotomy. The drainage tube is to be removed in the
course of a week, or as soon as offensive flows cease. The abdominal
sutures, which may have been silver or silk, are to be cut and disen-
gaged as soon as the tenth, day, and adhesive strips put across the
wound to aid the sutures, may be renewed as a protection against ven-
tral hernia in the line of the incision.

The danger in the operation is from peritonitis, and that is caused
by septic fluids, which an efficient drainage tube carries away, espe-
cially if irrigation be coupled with drainage. Warm antiseptic fluids
are to be forced into the perforated tube in quantities to wash and rinse
the peritoneal cavity of the abdomen. Especially are the washing and
rinsing to be done when there is much febrile disturbance.

There is a condition that may be met with in females at almost any
period of life, and whether they have previously given birth to off-
spring or not, that has been termed false, apparent, or spurious preg-
nancy, and which has sometimes so strongly resembled pregnancy as
to deceive very experienced practitioners. There will be found in
these cases, cessation of menstruation, morning sickness, sympathetic
changes in the mammary glands, enlargement of the abdomen, with
other symptoms, even to a resemblance of the true pains of labor.
The patient is thoroughly satisfied that she is pregnant, and frequently
becomes indignant when this is doubted or denied; and cases are re-
corded in which the females even suffered from pains supposed to be

190 KING'S ECLKCTIC OBSTETRIC.

those of labor. And yet, when the symptoms present are closely inves-
tigated, there will be found some irregularity in their true character
and proper development, together with an absence of softening of the
cervix, of uterine enlargement, of development of the sebaceous areolar
glands around the nipple, of fetal pulsations, of ballottement, etc. A
tympanitic distension of the abdomen, when present, will give more
or less resonance on percussion. If the patient be placed under the
influence of chloroform by inhalation, the semblance of pregnancy will
promptly disappear.

But little that is satisfactory is known as to the cause or pathology
of this condition ; hysterical women, and those who >uil'er from ovarian
or menstrual functional derangements, are more subject to it, and a
tympanic distention, in the generality of cases, appears to be the cause
of the abdominal enlargement; but the origin of this flatus is yc-t un-
determined. Sometimes the symptoms will continue for a longer time
than that of normal gestation, and again they may disappear in a few
weeks or months. In all doubtful cases of pregnancy, a very thorough
and minute investigation should be pursued by the practitioner, espe-
cially of the ovaries, uterus, and abdomen, and any existing malady of
these organs be treated according to the indications, while at the same
time the general health should be attended to by proper hygienic and
other required measures.

CHAPTER XX.

SIGNS OF PREGNANCY.

PHYSICIANS are frequently consulted to decide the existence or non-
existence of pregnancy, in cases where it may be of immense impor-
tance in determining the reputation of a female, the legitimacy of a
child, or even the life of a new being, and in instances when a preg-
nant woman is condemned to capital punishment. Hence, a knowl-
edge of the signs common to pregnancy can not be too thoroughly
understood by the accoucheur. Women with illicit offspring, when
suspected and interrogated, will almost always endeavor to mislead us
by an obstinate denial, and even by an appearance of much indigna-
tion ; and this will usually apply to all females, whether married or
not, who desire to abort, or destroy their conception. We can not,
therefore, be too cautious in giving full credence to the statements of
any female upon this subject, unless we have a sufficient acquaintance

SIGNS OF PREGNANCY. 191

with her to justify implicit confidence in her assertions; and we should
always depend upon our own knowledge of the symptoms, rather than
upon any light we may elicit from the female.

Again, in cases where there is no desire or interest to deceive, as
when pregnancy is suspected from the presence of abdominal enlarge-
ment, suppressed menstruation, morning sickness, etc., it will often
require all the skill of the physician to diagnosticate correctly, and, if
an incorrect opinion is pronounced, it will frequently place him in an
extremely mortifying situation. It is not many years since, that a cele-
brated Professor plunged the trocar into the gravid uterus and shoul-
der of the fetus of a woman, whose condition he mistook for dropsy.
I know an instance where a female, supposed to have erred, was exam-
ined by two or three physicians, who decided that she was some three
or four months advanced in pregnancy; she denied the charge, but if
was of no avail ; her friends forsook her, and even her parents became
harsh, severe, and cold toward her; she pined away in secret, hiding
her grief from the world, and in a few months died. An investiga-
tion being held, a morbid growth within the uterus disclosed the true
cause of her symptoms. Many instances of similar character might
here be related, showing the value and importance of a full acquaint-
ance with all the signs which are to guide us in our investigation and
decision. We should exercise great discretion, and rely entirely on
the indisputable evidence of our senses; not forming our opinion on
one sympton, but on a combination of unquestionable symptoms, and
if the least doubt be entertained, we should unhesitatingly express it;
for it is much safer to remain in uncertainty, than to pronounce an
incorrect diagnosis. Females usually suppose themselves pregnant
when after iutercouse they find a cessation of menstruation followed
by an enlargement of the abdomen and fetal movements at a proper
time, and generally they are correct, yet all these signs may be appa-
rently without conception present.

To determine a recent conception is not only difficult, but as far as
the physician is concerned, absolutely impossible; yet many females
resolve this point very correctly, from certain 1 voluptuous sensations,
peculiar to each, individually, experienced during a fruitful copulation ;
and where they have previously given birth to children, having felt
similar sensations at the period of fecundation, we have on subsequent
occasions, when these occur, some grounds for believing them to be
again pregnant. Yet it is commonly the case that "cold women," as
they are called, are more easily impregnated than those warm, ardent,

192 KIND'S ECLECTIC OBSTETRICS.

amorous beings who, during copulation, enjoy exquisite voluptuous
.-(fixations, with spasms, and nervous agitation.

The dryness of the penis when withdrawn after an embrace, and the
retention of semen by the female, are looked upon by some persons as
undoubted evidence of 'fecundation. An anxiety or depressed condi-
tion of the woman a few days afterward, paleness of countenance, a dull,
sunken, languishing appearance of the eyes, with a bluish circle sur-
rounding them, spots on the face of various sizes, and swelling of the
neck, have all been enumerated as signs of early conception, but they
are extremely uncertain and doubtful.

It is only when pregnancy has somewhat progressed that we are ena-
bled to diagnosticate with any degree of confidence, and the more ad-
vanced this is, the more correctly can we decide. The signs of preg-
nancy are divided into the RATIONAL and the SENSIBLE; the
rational are again subdivided into general, local, and sympathetic,

The general signs are those which result from increased activity of
the nutritive functions, and from the modifications which take place in
the nervous system. The pulse is more frequent and strong, full, and
hard; occasionally, in the latter months, intermittent and contracted;
the blood is said to be buify and more plastic; respiration is more ac-
tive with an augmentation of the heat of the body; and all the secre-
tions are more abundant, with increased odor. The changes in the
nervous system are usually the greatest and most remarkable. The
sensibilities become more refined, the female becomes more susceptible
as well as more liable to moral and physical influences; sometimes her
nature appears completely changed, so that those who were kind, lov-
ing, and amiable, become peevish, irritable, jealous, and malicious,
and vice versa; the silent become loquacious, and the talkative become
taciturn; in some, the intellect becomes more active, and they are ren-
dered more subject to nervous derangements. If diseases are already
existing in the female their further progress is either retarded or more
rapidly hastened toward a serious termination. Pregnancy renders
the female system more liable to disease, constituting a condition called
puerperal, which is induced by conception is more fully developed as
pregnancy advances and reaches its maximum point at childbirth ; it
then gradually diminishes until after lactation, when it ceases ; mani-
festing itself again, in a greater or less degree, during every subsequent
pregnancy. It is owing to this puerperal condition that pregnant and
lying-in women are more liable to epidemic and other diseases, and
which are usually more rapid and severe at this time than during the
ordinary state and habits of the animal economy. Although these signs

SIGNS OF PREGNANCY. 193

are indicative of pregnancy, yet in the early months they are very
obscure, and when taken by themselves at any period, very uncertain,
affording very little aid in diagnosis unless associated with the others
hereafter mentioned.

Among the local signs, that upon which females place the greatest
reliance, is the suppression of menstruation ; this is, to be sure, a valua-
ble and most important indication, and one that is very common with
pregnant females, yet too much confidence must not be placed in it as
an unerring sign. It often happens that women fail to menstruate for
one, or several periods in succession, without conception being present,
and this may or may not be accompanied with an augmented protuber-
ance of the hypogastric region. This suppression may be owing to
cold, functional or organic disease of the reproductive system, or other
cause, which should always be carefully investigated with a view to a
correct solution. Again, there are many instances where menstruation
or a periodical sanguineous discharge is present during pregnancy
others, where females have conceived without any previous monthly
flow, and, occasionally, some menstruate regularly, or rather have a
periodical discharge of blood, only when pregnant. Usually, when
the catamenia have failed in non-pregnant females, there is a greater
or less derangement in the general health, but when the health con-
tinues in its ordinary condition, with a gradual enlargement of the ab-
domen, morning sickness, and the development of the glandular fol-
licles of the areola, we have strong reasons for suspecting pregnancy,
especially in the married woman. In the unmarried, where illicit
commerce is strenuously denied, the diagnosis will be involved in much
uncertainty and difficulty; yet the physician should not bestow a too
ready credence on the statements of his patient, but rather postpone a
positive declaration, until the other signs have advanced so far as to
give an undoubted indication of the true state of the case. When the
least doubt exists in the mind of the practitioner, he should be very
particular not to prescribe or administer any remedies tending to the
restoration of the monthly evacuation.

A change in the color of the vulva, from its natural pinkish hue to a
bluish tint, has been named as a sign of pregnancy ; but as this is prob-
ably owing to an obstructed circulation, pelvic tumors or other abnor-
mal conditions may produce it. It is usually more marked when the
female is in the erect or sitting posture, and disappears more or less
in the recumbent.
13

194 KIN(i's KCL&TIC OBSTETRK'S.

A change in the color of the skin, called cpliclix, and sometimes morph,
or mask, accompanies many women during every pregnancy. It is a
brownish, yellowish, or earthy colored stain or freckle, of greater or
less extent, usually occupying the forehead, cheeks, and even the neck
and breast, but is not a constant sign of pregnancy. It is a minor sign 2
and one, probably, more important among those females ^Yho have been
disfigured by it in previous conceptions. It often becomes permanent,
remaining after parturition, and occasioning considerable uneasiness to
the female. Efforts have been made to remove it ; success has been
reported in several instances, by employing, as a lotion, the saturated
aqueous solution of Sulphuret of Potassa, to be applied on the stain
three or four times a day, in connection with mild laxative agents to
regulate the bowels and restore the cutaneo-hepatic sympathetic rela-
tions; but a subsequent conception has always brought with it a return
of the dark spot.

Dr. Schlesinger, in an address before the Vienna Medical Society,
proposed to determine pregnancy in is earlier months by thermometry.
From several investigations, he has ascertained that between the axilla
and the vagina there is a difference in temperature of 0.21 C., and be-
tween the vagina and non-pregnant uterus of 0.16 C.; the cavity of the
uterus being of a higher temperature than that of the cervix. The
temperature of the fetus in utero is higher than that of the mother,
and which is imparted in a certain degree to the uterus. Hence, the
gravid uterus is of a still higher temperature than that of the non-
gravid. Pulse test: the pulse rate varies in health, from eight to ten
beats per minute, depending on the upright or horizontal position;
while in pregnancy it remains unchanged is not influenced by posi-
tion. This, it is claimed, is the result of an hypertrophied condition
of the heart, always existing during pregnancy. Recent observers
claim this to be one of the most reliable among the many signs of preg-
nancy. Further investigation should be made and reported.

Dr. A. Rasch has stated as among the important early symptoms
of pregnancy, the increased desire to void urine, especially at night, and
fluctuation, which has been detected as early as the seventh week of
gestation, but generally after the second mouth. Two fingers are to
be introduced into the vagina, the womb being steadied through the
abdominal walls with the other hand, and then alternately manipulate
the uterus with the two fingers. Sometimes the fluctuation will be
detected in one corner of the fundus, sometimes lower down ; after
three months, outward manipulation alone would feel it. When the
fingers have diagnosed an enlargement, the practitioner must, of

SIGNS OF PREGNANCY. 190

course, determine whether it be from hypertrophy, tumor, or preg-
nancy. When anteversion is present, as is more generally the case
in early pregnancy, the above manipulation is more readily performed
than in retroversion. Fluctuation, combined with increased tempera-
ture, softening of the cervix, and the areolar changes of the mamma,
is almost a certain symptom.

The sympathetic signs are usually confined to the digestive system,
and are only useful as means of diagnosis when taken in connection
with the more positive sensible signs; they sometimes become so
severe and troublesome as to require treatment, for which the reader
is referred to the chapter on "Disorders of Pregnancy, and Treat-
ment." Among the sympathetic signs are nausea, or morning sick-
ness, vomiting, anorexia, pica, malacia, acidity of stomach, heartburn,
and toothache, which are more common in the earlier months of preg-
nancy, gradually disappearing in the latter months, being followed by
constipation, hemorrhoids, and more or less headache.

All the rational signs, of whatever subdivision, are only important
when accompanied with the sensible signs, and when they occur
together, the diagnosis is rendered more easy and certain.

The SENSIBLE SIGNS are subdivided into the visible, the audi-
ble, arid the tangible.

The visible signs are those which may be recognized by the eye, as
enlargement of the mammae. The breasts, during the earlier stages of
pregnancy, acquire new life from sympathy with the uterus; the
lactiferous glands are aroused into action, the breasts increase in
magnitude, becoming round, tense, hard and tender, with frequently
a pricking sensation in them, which sometimes continues during gesta-
tion, and at other times the enlargement diminishes about the fourth
or fifth month, and may not appear again until near the period of
parturition, or even subsequently. Occasionally the axillary glands
enlarge.

Simultaneously with the augmentation of the breast, or about the
commencement of the third month, the nipples increase in size and
sensitiveness, and are sometimes quite painful, they become of a
deeper red, and it is often the case that a yellowish or milky fluid
can be obtained from them. The surrounding skin likewise becomes
tense, thin and more transparent, and the veins more conspicuous.
The enlargement of the breasts, and increased size of the nipples are
most commonly present during pregnancy, yet taken alone, they can

196 KINCi's K< LECTIC OBSTETRICS.

not be depended on as signs, for pregnancy often exists without them,
and again, they may originate from other causes, as ovarian or uterine
tumors, amenorrhea, etc.

The areola, shortly after conception, becomes changed from its
natural pink color to a deep brown, and which is a more valuable
sign in first pregnancies than succeeding ones, as in the latter it
would be difficult to decide whether the change was owing to the
former pregnancy, or the one under examination, especially, if only
a short time has elapsed between them. By some medical men,
especially Smellie, 'and Hunter, it was viewed as a positive sign of
pregnancy. Cazeaux says, "and I should diagnosticate the existence
of pregnancy, with a degree of confidence, in a young woman who
had never borne children, and whose breasts presented both a brown-
ish-colored areola, the tubercles (sebaceous glands), and the freckled
characters before described." But, notwithstanding, this sign has its
objections; it is sometimes absent during pregnancy it may be modi-
fied by the color of the skin, being more distinct in women with dark
hair and eyes, and less so in blondes and brunettes ; and it has been
present when conception did not exist, being induced by disease, as
amenorrhea, or organic disease of the ovaries, or uterus; all of which
should be considered during the investigation.

With this alteration of color, the papilla?, or sebaceous glands which
are seated under the skin of the areola, and especially near its margin,
become enlarged, appearing like small tubercles, and which is consid-
ered a more positive sign of pregnancy than the areolar discoloration,
and more especially so when these enlarged follicles contain sebaceous
matter.

The secretion of milk, is a sign of some value ; yet the accoucheur
must remember, that it has occurred in females who were not preg-
nant, likewise in children ; and that cases are on record, where milk
has been obtained from the breast of the male. In females, this
secretion may be present in consequence of the sympathy existing
between the breasts and the reproductive organs in a state of disease ;
instances of which are frequently met with ; consequently, this sign is
only of importance when attended with others of a positive character.
Beside, it must not be forgotten that disease may give rise to the dis-
charge of a fluid apparently resembling milk, but differing from it in
many respects.

Enlargement of the abdomen, affords to the public a strong presump-
tion of pregnancy, because it is an invariable concomitant of this con-
dition. Yet a mere dependence on this sign will often deceive us, as

SIGNS OF PREGNANCY. 197

it may be present from many other causes than pregnancy. Thus, the
accumulation of adipose matter in the omentum and walls of the ab-
domen, ascites, uterine and ovarian tumors, amenorrhea, tympanitis,
etc., will cause its enlargement. An appreciable increase of size, in
the abdomen, is commonly observed about the third month, and if
with it we have enlargement of the breasts, areolar changes of the
mamrnse, cessation of menstruation, increased uterine temperature,
fluctuation, with usual health, and previous morning sickness, the
inference is strong that conception exists; yet even these may mislead
us; hence, the necessity for great caution in forming a diagnosis on
this subject, can not be too strongly enforced.

Previous to the third month, or soon after conception, the ab-
domen generally becomes flat, its anterior wall retracts, and ap-
proaches toward the vertebral column ; but about the third month, it
commences to project, first on the median line, gradually increasing
and extending from the pelvic to the umbilical and epigastric regions,
reaching this last at full term, and leaving a sunken, or depressed ap-
pearance over the iliac fossa3. In women who have had several chil-
dren, the abdomen inclines more forward and downward, from laxity
of the parietes, while with those in their first pregnancies it is usually
less projecting, but larger and more uniform. The volume of the
abdomen, at different stages of gestation, likewise varies from several
circumstances, as twins, amniotic dropsy, etc. If, with the above
appearances, we ascertain that the umbilicus is sunken at first, and
then becomes gradually more prominent as the projection of the abdo-
men proceeds, our suspicions of pregnancy are still further corrobo-
rated. During the latter months of pregnancy the umbilicus may be
thrust forward from one-fourth of an inch to even an inch beyond the
anterior surface of the abdomen ; and this projection may also origi-
nate from the presence of pathological tumors within its cavity.

Quickening, a term applied to a fluctuation, or fluttering sensation,
experienced about the end of the fourth month, may be mentioned in
connection with the augmentation of the abdomen. By some authors
this is considered as the result of life being imparted to the fetus at
the time it is felt ; by others, it is viewed as being caused by the im-
pregnated uterus when rising from the pelvic excavation, etc. It is
undoubtedly owing solely to the fetal movements, which take place as
soon as the embryo attains size and strength sufficient to make its
motions felt by the mother, and which generally commences about the
eighteenth or twentieth week of utero-gestation. However, preg-
nancy may exist, and no quickening have been experienced by the

198 KIN<;'S KCLKCTIC ( U5STKTR K X.

mother; again, females often mistake other sensations for this symptom r
as a flatulent motion, etc.; yet, if the' sensation continues to increase
in strength, until the fetal movements can be distinctly felt, all doubts
will of course be removed. If, during the latter months of gestation,
firm and continued pressure be made by the fingers against opposite
sides of the uterus, it will produce such disturbance to the fetus, as to
make it move vigorously; or, if one hand be placed on one side of
the abdomen, and the same point on the opposite side be struck with
the other hand, the fetus is very apt to move actively. The motion.-
of the child, if it be alive, may likewise be determined, by dipping
the hand in a bowl of cold water, and applying it suddenly over the
abdomen. It must be borne in mind, that although the motions of
the fetus are a strong evidence of pregnancy, yet its absence does not
prove the reverse condition, as the child may be dead, or very feeble.
In the strict sense of the word, quickening really occurs at the period
of conception.

Among the visible signs, may be named a peculiarity observed in the
urine of some pregnant women, first described by M. Nauche, iii 1831,
and after him by several other gentlemen. The urine on being
allowed to stand in a glass for some twenty or twenty-four hours,
presents on its surface a number of brilliant, crystalline granules,
resembling small specks, or oblong filaments, irregularly isolated,
which often unite, forming a transparent layer or pellicle about a line
in thickness, which can only be seen in certain positions. After a few
days a portion of this pellicle gradually falls to the bottom of the glass,
forming a white, milky crust there. At one time this pellicle was
considered a positive proof of pregnancy, but the investigations of Dr.
E. K. Kane, of Philadelphia, have determined, that Mesteine, the
name given to this material, is not peculiar to pregnancy, but may
occur during the presence of milk in the breasts, especially if it be
not freely discharged from the mammae, and that its presence is rather
an indication of the existence of this mammary secretion, than of
pregnancy.

The audible signs, are those detected by the ear, with or without
the aid of the stethoscope, among which is, the placenta! sound, or
bruit de souffle, which is variously represented as resembling the blow-
ing of air, the cooing of a dove, the drone of a bagpipe, having a
peculiar rasping sound, similar to that which is heard in the carotid
arteries of chlorotic females, in varicose aneurisms, and in some car-
diac affections ; this sound is owing to the arterial and venous circula-

SIGNS OF PREGNANCY. 199

tion of the walls of the impregnated uterus, as well as to pressure
upon the arteries, and not to the utero-plaeental circulation; it is
always synchronous with the mother's pulse, and is occasionally heard
in the course of the linea alba, but more frequently on the sides of the
abdomen, over the course of the iliac arteries; sometimes it can be
heard over a large extent of surface. When the female is placed in
such a manner as to remove the pressure of the gravid uterus upon
the arteries, as upon her knees and elbows, this sound can n^ot be
heard; and there are cases in which it can .not be detected, although
the motions of the fetus may be distinctly felt. It is first heard about
the fourth or fifth month of pregnancy, though some writers profess to
have observed it even before the end of the third month, and becomes
more audible as gestation advances. This is neither a constant, nor a
positive sign of pregnancy, for it may be owing to various other
causes, as aneurism, abdominal tumors, or whatever may compress the
arteries, and has been heard even after delivery; hence, but little con-
fidence is bestowed upon it at the present day.

Dr. Verardini in an address before the Academy of Bologna, stated
that intra-vaginal auscultation is of the greatest importance for detect-
ing early pregnancy, and will enable us to avoid many possible errors.
The instrument, vagina-uteroscope, may be made of gutta percha, very
light, and of various shapes. By pressing the vaginal extremity of
the instrument against the cervix uteri, if pregnancy exist, a soft, pro-
longed sound is heard, similar to that heard in aneurismal tumors
when the stethoscope is pressed upon the arteries, this is the character-
istic utero-placental bruit. The examination may be made w r ith the
patient lying upon her back or side ; but if no sound be heard in this
position, the female should be placed in the knee-elbow position, when
the auscultator will succeed without difficulty. The bruit which is
distinctly heard during the first months, ceases at the commencement
of the sixth or seventh month. If the bruit be absent while other
symptoms common to early pregnancy are present, the diagnosis is
uncertain, as there may be uterine disease. In making the examina-
tion, it is important to be certain that there is no pulsating tumor or
artery in the vicinity of the cervix. If the bruit continues to be
heard after the seventh month, it is indicative of placenta prsevia.

The sound of the fetal heart, differs entirely from the placenta!
souffle; it closely resembles the ticking of a watch, and differs ma-
terially from the mother's pulse in frequency and rapidity, beating
from one hundred and twenty to one hundred and forty in a minute,
the pulsations being sometimes so rapid as to render it impossible to

200 KING'S ECLECTIC OBSTETRICS.

count them, but returning to their natural character, without any
cognizable cause.

The pulsations of the fetal heart are first perceptible between the
fourth and fifth months, and are more commonly heard on the anterior
inferior portion of the abdominal wall, just above the iliac fossa, oc-
casionally on the median line, and over an extent of two or three
inches; as the fetus advances in growth the pulsations become more
marked.

These pulsations, whenever they can be heard, afford positive evi-
dence of pregnancy, yet their absence is no indication of non-preg-
nancy, as the fetus may be dead, very feeble, or it may be in a position
unfavorable to the transmission of sound to the ear; or an excessive
quantity of the liquor amnii may destroy the sound. The presence
of twins, and even the position of the child in the uterus has been
attempted to be determined by the presence of these pulsations, but
from the discordant and contradictory statements made by authors in
relation to these points, no confidence can be placed in t them ; though
if the sound of the fetal heart should be heard emanating from two
different points, and especially when non-synchronous in action, or of
different rhythm, it would be of some value in the diagnosis of twins.
In auscultating a female suspected of pregnancy, especially during the
fourth, fifth or sixth months, it is advisable to have her lie upon her
back, with the thighs flexed upon the abdomen ; the bed should be of
a height sufficient to allow the practitioner to auscultate without stoop-
ing too much, which would render it impossible for him to hear any
internal sound. The stethoscope, and not the ear, should be applied
to the abdomen, which is less disagreeable to females, and it should be
placed, first, over the part where the pulsations are most commonly
heard, and then changed as may be required.

The tangible signs, or those which are ascertained by the touch, are
exceedingly important in assisting us in our diagnosis of pregnancy,
for by them we are not only enabled to determine this condition, but
also its degree of advancement; hence, every practitioner should fully
qualify himself to perform this operation of touching or manual ex-
amination.

The examination per vaginam or vaginal touch, is usually made by
means of the index finger, which is always preferable to the middle
finger, as recommended by some writers; occasionally, however, it
may become necessary to introduce both index and middle fingers at
the same time; this, however, is usually done for the purpose of reacb-

SIGNS OF PREGNANCY. 201

ing more deeply into the vagina, and the touching should be accom-
plished with the index finger alone, for if both are employed, there
may be a double perception, and an uncertain, confused idea of the
condition of the parts under examination. The practitioner should be
able to manipulate with either hand, as occasion should require, and
should be very careful that his finger nails are not too long or pointed,
in order to avoid giving pain or injury, as well as to render the touch
more easy, delicate, and certain ; long finger nails, in an accoucheur,
manifest negligence and carelessness, and are always inexcusable. The
finger, in order to admit of its easy introduction, should be anointed
with oil, lard, pomatum, butter, etc., and not with mucilaginous liquids,
as advised by many, because these last do not adhere so firmly to the
skin, and are less apt to protect the finger, especially if there be excor-
iation of it, from the absorption of any infectious virus which may be
present. As to the length of the finger necessary to become an ex-
pert accoucheur, that is of little consequence, as the shortest fingers
and smallest hands become, as perfect in this art, as the longer and
larger.

The female may be placed in the erect, recumbent, or sitting posture,
according to the circumstances ; thus, for ballotement, or for the detec-
tion of uterine displacements, the erect position should be assumed ; to
ascertain the advance of pregnancy, the size of the uterus, tumors, etc.,
the recumbent position is the best, with the female lying upon her back
or side; the latter is preferable in these cases, with the head and chest
elevated .and inclined forward and the inferior extremities separated and.
flexed as much as possible on the abdomen, so as to relax the abdom-
inal muscles, and consequently render the examination more easy. In
some instances where the erect position can not be maintained, or
where the recumbent would give rise to suffocation, as in debility,
dropsy, dyspnoea, etc., the sitting posture will be found the best, in
which the patient is so placed upon a chair that the weight of the body
rests upon the sacrum, the body being inclined backward and the vulva
being beyond the edge of the chair, so as to allow the operation to be
performed. If the patient be standing, the physician should -place
himself in front, resting on that knee opposite to the operating hand,
with the other knee, demiflexed, and placed between the limbs of the
female, to act as a support for the elbow to lean upon, thus preventing
the hand from trembling, and allowing the examination to be made more
easily. If she is in the recumbent position, he will place himself on
that side of his patient corresponding with the hand he intends to
employ, and should be seated on a chair of a suitable height. The

KIN(i's KCLKCTK' OUSTKTKK'S.

woman, in whatever position she may be placed, must not be exposed,
but have a proper covering over her.

The extended hand of the operator is now to be passed lightly and
quickly along the internal surface of the thigh nearest to him if she
lies on her back or of the lower one if she lies on her side toward
the nates, and as soon as it is arrested by the soft parts, and the fissure
between the nates recognized by the index finger, this must then be
carried forward toward the vulva. Some writers advise the finger to
be carried to the symphysis pubis and then moved downward and back-
ward; but in doing this, friction against the clitoris and meatus urin-
arius must necessarily ensue, but which should always be carefully
avoided. The practitioner must be careful not to commit an error by
introducing the finger within the rectum, instead of within the vagina,
indeed, this could only happen from inattention, or an inexcusable
carelessness. On finding the vaginal opening, the condition of the
external labia, its size and firmness must be ascertained by passing
them between the thumb and index finger, and the fourchette may also
be detected if there has been no previous labor, but if there has been,
it will be absent, and its place supplied with inequalities. The finger
is then to be pressed nearly backward with its palmar surface directed
toward the symphysis pubis, examining, as it passes along the urethral
canal, which is generally more swollen in pregnant women than others,
the condition of the mucous membrane of the vagina, whether smooth
or wrinkled, whether any abnormal conditions of its walls are present,
and the width and length of the vaginal canal.

When about one-third of the finger has passed into the vagina, the
wrist is to be strongly depressed, and the finger directed nearly verti-
cal, when the bos fond of the bladder, the vaginal cul-de-sac, and
cervix uteri may be examined. At this time of the operation the
thumb is to be extended and applied against the anterior face of the
symphysis pubis; the other three fingers will vary in position accord-
ing to circumstances, being generally extended on the perineum, press-
ing it upward, and sometimes flexed with the thumb, into the palm of
the hand, for the purpose of ballottemeut, or for examining the parts
on the anterior plane.

However, if the female lies upon her side, with her back toward the
practitioner, the positions of the fingers will be nearly reversed, the
palmar surface of the index will be looking toward the sacrum, and the
other fingers and thumb more or less flexed in the palm.

The same method of introducing the finger may be pursued for the
detection of malformations of the pelvis, the dilatation of the os uteri,.

SIGNS OF PREGNANCY. 203

the presentation of the fetus, etc. The various changes which the
neek of the uterus undergoes during pregnancy, have already been
described, and to which the reader is referred.

Abdominal palpation or exploration, may assist us in forming a cor-
rect diagnosis of pregnancy, and can be practised in all cases, with a
few rare exceptions, which may be owing to an excessive thickness of
the abdominal walls. In making this examination the female must be
placed in a recumbent position, on her back, with the hips elevated,
the head flexed on the chest, and the thighs on the abdomen, which
position completely relaxes the abdominal muscles. At first, both
hands are to be applied over the abdomen, to determine its size, form,
and hardness, more especially in the hypogastric region.

To ascertain the growth of the uterus, the practitioner will place the
ends of the eight fingers immediately above the symphysis pubis, and
make deep but gradual pressure until they feel the resistance of the
uterine globe ; and in this manner he will continue to ascend gradually
along the abdomen until the fundus is gained, which may be known
by the absence of any further resistance, and by the fingers sinking
deeper and gliding over the convexity of the fundus. If pain should
accompany the examination, or if the abdominal muscles be in a state
of great tension, further procedure must be postponed until a more
favorable occasion. The uterine globe invariably retains its oval form,
is circumscribed, presenting a resistance somewhat of an elastic charac-
ter, and which is firmer in the early months of gestation than during
the latter; and the practitioner will often be enabled to recognize
movable, irregular masses, and even the various parts of the fetus,
depending upon the period of pregnancy in which the exploration is
made. The elastic character of the uterine partetes is not so appreci-
able when the enlargement of the organ is dependent upon chronic
disease, and should it be owing to the presence of a mole within its
cavity, it will be impossible to decide, unless at an advanced period,
when the absence of the fetal movements, of the pulsations of the
heart, and of the fetal inequalities, may furnish grounds for such a
supposition.

The vaginal touch is usually practiced at the same time with the
abdominal exploration, especially in the earlier months of pregnancy.
The finger introduced within the vagina, is applied on the neck, or
against that portion of the uterus between the neck and the symphysis,
or between the neck and the sacrum, while the other hand is placed
above the pubis, pressing firmly to recognize the uterine tumor. The

204 KING'S K<M.K<TI<' OI-.STKTUICS.

womb being tnus located between the finger within and the hand with-
out, the degree of its enlargement may be ascertained, by instituting
a comparison between it and the non-gravid organ. Again, the finger
may elevate the uterus, which will be recognized by the hand, or the
hand may depress the organ, which will be felt by the finger, and thus
its condition and situation as well as any fluctuation, be determined.
However, during the first three or four months there are no unequivo-
cal .signs of pregnancy, and the practitioner will often be mistaken
should he depend on any of them at this time, yet he may, in nearly
all instances, satisfy himself of the unimpregnated condition of the
uterus.

Another mode of determining the presence of pregnancy, is from
the passive movements of the fetus in utero, and which is called bal-
lottement; these motions depend upon physical laws, and are entirely
independent of the vitality and muscular strength of the fetus, as they
are present whether it be dead or alive. As a certain size and weight
of the fetus is required for ballottement, it can not be produced in the
early months of gestation, or if it can, it is imperceptible. The sen-
sation of ballottement is, according to most writers, analogous to that
produced by striking a marble ball, which has been placed in a blad-
der full of \vater, or in a glass tube likewise filled with water sus-
pended in a vertical position, with the lower end closed by a dia-
phragm of bladder or parchment. The blow is to be given with the
palmar face of the finger applied just under the spot where the ball
rests, striking from below upward, when the ball ascends in proportion
to the force of the blow, and when this force is exhausted, it descends
and falls back upon the finger which displaced it, communicating a
shock to it, and which motion and sensation constitute ballottement.

To perform the ballottement, the female should be standing, with
her shoulders placed against some solid body, as a wall, to cause a
projection of the abdomen. The finger, properly oiled, is then to be
introduced into the vagina as far as the neck, and should be applied
anteriorly, on that portion of the uterus between the symphysis pubis
and the projecting portion of the neck, at which point a smart blow is
to be given, sufficiently strong to cause the fetus to ascend ; the blow
should be made from below upward, and from behind forward, which
last may be effected by suddenly flexing the first phalanx as the shock
is imparted. As the uterus is generally inclined forward with its long
diameter corresponding somewhat with the axis of the superior strait,
this last direction of the blow will be required to cause the fetus to

SIGNS OF PREGNANCY. 205

ascend in the direction of the uterine long diameter, otherwise, it will
merely be pushed against the posterior wall of the uterus, being dis-
placed without ascension. At the time the blow is imparted, the op-
erator should place his other hand upon the abdomen, over the fundus,
to firmly fix the uterus in its position, and a short time .after the shock
has been communicated to the fetus, he will press upon the fundus from
above downward, to hasten the descent, and thus increase the intensity
of the sensation to be experienced by the finger within the vagina,
which finger is to be held firmly and steadily against that portion of
the uterus which has been struck, until it has received the shock of
the descending fetus, or until a sufficient length of time has passed for
that result. Ballottement is best obtained when the woman is in the
erect position ; yet, there may be cases in which, from inability to
stand, the recumbent posture may be employed, when the operator will
have to place the finger at various points both anterior and posterior
to the vaginal projection of the cervix.

Ballottement may be effected at the fourth month of utero-gestation,
though it is frequently absent during this as well as the fifth month ;
at the sixth or seventh month it is very distinct, and conveys a sen-
sation similar to that of a solid ball inclosed in a fluid and falling
upon the finger, as above described. As the fetus continues to grow,
ballottement becomes less distinct, is hardly perceptible at the end of
the eighth month, and is impossible in the latter weeks of pregnancy.
During the early period of ballottement it may be advisable, in cases
where accuracy is absolutely required, and in which it can not be
recognized, to make several trials ; as from the fact that the small size
of the child allows it to easily change its position, this sign may be
present one day, and be quite impossible to detect at another.

By many authors ballottement is considered as a pathognomonic
symptom of pregnancy, being equally applicable to the dead or living
fetus, and, indeed, we know of no other cause to produce it, than the
actual presence of a child within the uterus. However, the practi-
tioner should always ascertain that there is no displacement of the
uterus which might create a mistake, as in anteversion, and also that
the shock communicated to his finger is not from stone in the bladder;
each of these conditions, has, heretofore, occasioned some difficulty in
determining true ballottement.

From what has been stated, it will be observed, that in order to
determine the condition of pregnancy with certainty, the practitioner
will be obliged to procure a delay until the motions of the fetus and

20G Ki.\(i's KCI.KCTIC <I;STI-:TI;I< s.

other signs :irc manifested with force and distinctness, and which
usually will beat the fourth or fifth month; though, from feebleness of
the fetus he may have to wait for a still longer period. In all difficult
cases, the physician, when called upon, should never positively aHiriu
the existence oil pregnancy, until he has distinctly perceived the pul-
sations of the fetal heart, ballottement, and the proper changes in the
condition of the uterus; in ordinary cases, an experienced practitioner
can form a correct diagnosis from these last uterine changes; the ra-
tional signs afford but little evidence of any value or certainty.

Occasionally, the physician is called upon to determine the stage of
pregnancy ; this is often very difficult. However, reference should be
had to the length of time which has elapsed since the last menstrua-
tion, the position of the fundus uteri, the condition of the cervix,
ballottement, auscultation, and the time of quickening, if it have
taken place, and from all which, an approximation to the period of
gestation may be obtained. As to the sex of the fetus in utero,
I know of no method of determining it ; Drs. T. J. Hutton and
Braxton Hicks have stated, however, that this may be determined
in most cases by auscultation practised toward the end of pregnancy.
If the fetal pulsations number from 138 to 144, the child is probably
a female; from 124 to 130 it is probably a male. Steinbach was
correct in 45 out of 57 cases examined by this method, and Franken-
hauser was correct in all the 50 cases which he examined. And Dr.
Hutton further remarks that if the uterus be divided into two equal
parts by an imaginary horizontal line, fetal pulsations heard below
this line indicate a presentation of the vertex ; above it, of the nates ;
and below it and to the right, of the second vertex position. Neither
is there any reliable mode of ascertaining the presence of twins,
further than already stated.

SYNOPSIS OF THE SIGNS OF PREGNANCY AT DIFFERENT STAGES.
During the First -and Second Months.

RATIONAL SIGNS. SENSIBLE SIGNS.

1. Suppression of the catamenial dis- 1. Increase in the size and weight of the
charge. uterus, with slight prolapsus. The cer-

2. Nausea, vomiting, ptyalisra, anor- vix uteri is directed to the left and toward
exia, etc. the symphysis pubis, fluctuation, increased

3. Unnatural flatness over the hypogas- temperature,
triurt.

CHANGES IN THE UTERUS DURING I'UKCXANCY.

207

RATIONAL SIGNS.

4. Tumefaction
mammae.

and tenderness of the

SENSIBLE SIGNS.

2. Diminished mobility of the uterus,
its walls soft like caoutchouc.

3. The os uteri round and regular in
primiparse, but in mnltiparse, irregular in
its circumference and more or less open.

4. Eamollissement and apparent oedema
of the mucous membrane, covering the
lips of the cervix uteri. The fibers of the
neck not vet softened.

During the Third and Fourth Months.

1. Suppression of the catamenia (an oc-
casional exception). '

2. Continuance of nausea, vomiting, an-
orexia, ptyalism.

3. Slight prominence over the hypogas-
trium.

4. Depression of the umbilicus.

5. Tumefaction of the breasts increased,
with prominence of the nipple, and a
Blight discoloration of the areolse.

6. Kiesteine in the urine. ?

1. The fundus uteri elevated rather
above the superior strait, at the end of the
third month. At the termination of the
fourth month, it rises two or two and a
half inches above the pubis.

2. Fullness, and dullness on percussion
over the hypogastrium.

3. Existence of a small tumor in the
hypogastric region, detected by abdominal
palpation, about the size of a child's head
a year old.

4. The direction of the long diameter of
the uterus is now changed, so as to cor-
respond with the axis of the superior
strait. At the fourth month the os uteri
is considerably elevated in the excavation,
looking backward and to the left; in-
creased temperature.

5. Ramollissernent of the inferior por-
tion of the cervix is more marked ; os
uteri more open in the multiparae, but still
closed and rounded in those who have not
borne children.

During the Fifth and Sixth Months.

1. Suppression of the catamenia. (Some
rare exceptions.)

2. Cessation of nausea, vomiting, etc.,
now usually takes place, though they may
continue throughout pregnancy.

3. Increased prominence of the sub-um-
bilical region.

4. The size of the abdominal tumor is
increased, it is round, elastic, and if the
abdominal walls be thin, the inequalities
of the fetus may be felt.

1. At the end of the fifth month, the
fundus uteri is within an inch of the um-
bilicus, and the same distance above it at
the sixth.

2. Movement of the fetus is now active.

3. The bruit de souffle and the fetal pul-
sations may now be distinguished.

4. Ballottement.

5. Between the cervix and the pubis z
tumor may now be felt, either soft and
fluctuating, or round, hard, and resisting.

208

KING'S ECLECTIC OBSTETRICS.

RATIONAL SIGNS.

5. The umbilical depression nearly ef-
faced.

6. Discoloration of the areolae more
marked, with an enlargement of the sub-
cutaneous glands.

7. Kiesteine in the urine. ?

SENSIBLE SIGNS.

6. Ratnollissement of the inferior half
of the cervix uteri ; increased tempera-
ture.

7. In the primiparse, the os uteri is still
closed, but in the multipart, it is suffi-
ciently open to admit the half of the first
phalangeal bone, although in each it is
softened to the same extent.

During the Seventh and Eighth Months.

1. Suppression of the catamenia.

2. Nausea, vomiting, etc., ordinarily ab-
sent

3. Abdominal tumor much increased in
size.

4. Dilatation of the umbilical ring, and
pouting of the navel.

5. Increased discoloration of the areolse,
with enlargement of the sebaceous folli-
cles, and increased prominence of the nip-
ple. The milk may be pressed from the
swollen mammae.

6. Discolorations on the skin of the ab-
domen.

7. Vaginal-granulations.

8. Kiesteine still exists in the urine.?

1. Increased size of the abdomen.

2. The fundus uteri, at the end of the
seventh month, has risen two and a half
inches above the umbilicus; at the eighth,
it is placed within the epigastric region ;
uterus commonly inclined to the right.

3. Movements of the fetus become more
violent.

4. The fetal pulsations and the bruit de
souffle still continue.

5. Ballottement perfectly felt during the
seventh month, but becomes obscure in
the subsequent months of pregnancy, on
account of the increase in the size of the
fetus.

6. The ramollissement of the cervix is
more extensive, and at the end of the
eighth month is nearly complete; in-
creased temperature.

7. In the primiparae, the cervix is ovoid
and apparently shortened ; the os uteri is
still closed.

8. In the multipart, the os uteri is co-
noidal and wide enough open to admit the
whole of the first phalangeal bone ; the
superior fourth of the neck still hard and
firmly closed.

During the First Half of the Ninth Month.

1. Reappearance of vomiting, not from
nausea but from pressure of the gravid
uterus against the stomach.

2. The abdominal tumor is increased
in size ; skin much stretched and tense.

3. Respiration difficult.

4. All the other symptoms remain and
are augmented in intensity.

1. The fundus uteri occupies the epigas-
tric region.

2. The movements of the fetus; the
pulsation of the fetal heart and bruit de
souffle are still present. At this time bal-
lottement has disappeared.

3. The whole cervix uteri is softened,
except the internal orifice, which remains

CHANGES IN THE UTERUS DURING PREGNANCY. 209

RATIONAL SIGNS. SENSIBLE SIGNS.

firm and closed. The os uteri in primi-
parse is slightly opened, though not suffi-
ciently to admit the finger, as in the case
in multiparse, although the softening is
equally extensive in each ; increased
temperature.

During the Last Half of the Ninth Month.

1. The vomiting ceases, as the abdom-
nal tumor sinks from the epigastrium.

2. Respiration less oppressed.

3. Considerable difficulty exists in walk-
ing, owing to the sinking of the presenting
part into the pelvic excavation.

4. Constant and ineffectual desire to
evacuate the bladder and rectum.

5. The hemorrhoids, the oedema of the
limbs and the varicose condition of the
veins of the inferior extremities are all
increased.

6. Pains in the loins, and colics.

1. The fundus uteri has sunk low down
in the abdomen.

2. The sensible signs still persist, except
ballottement, which is usually, though not
always, absent after the fetus has acquired
considerable size.

3. In multiparse, the internal orifice of
the cervix is softened and dilated, so that
the membranes may be felt. In the primi-
parae, the internal orifice is soft and di-
lated, but the external remains partially
closed. During the last ten or twelve
days, owing to the dilatation of the in-
ternal orifice of the cervix uteri, the
whole cavity of the neck becomes en-
larged, so as to increase the size of the
uterine cavity; so that in touching, the
finger reaches the membranes, in the
primiparse, after having passed the thin
and even margin of the os uteri. While
in the multiparse, this margin is thick and
unequal.

CHAPTER XXI.

DISEASES OF THE PREGNANT FEMALE.

BETWEEN the uterus, and every part of the body, a strong nervous
sympathy exists, owing to the intimate relation maintained between
the sympathetic and cerebro-spinal system of nerves ; and this sym-
pathy is more especially marked during the condition of pregnancy,
when the ganglia and plexuses of nerves, together with the blood-
vessels and absorbents of the uterus enlarge, and become roused
from a state of apparent inertia to one of energetic activity. This
change in the female system gives rise to many symptoms, which may
14

210 KING'S ECLECTIC OBSTETRICS.

be considered as indications of the healthy act of conception, a;;<l
which, as a general rule, should not be meddled with; but, when they
Ixrome unusually severe or protracted, they are then termed the "dis-
eases of i>n u'liancy," and require proper treatment for their palliation
or removal. As pregnant females are liable to the same diseases as
the unimpregnated, it would require a volume to treat separately upon
them ; I shall, therefore, confine this part of the subject to those con-
diti >ns more common during pregnancy.

When the female is supposed, from the presence of the ordinary
symptoms, to have become pregnant, certain measures are necessary
for her to pursue, as well for her own benefit as for that of her off-
spring. All compression upon the abdomen or around the waist, such
as stays, corsets, belts, etc., should be removed, modified or worn
loosely, and should not be resorted to until after parturition; an at-
tention to this point may prevent abortion, varices, oedema, uterine,
and other disease, on the part of the mother, which difficulties are
very apt to be the result of pressure and consequent obstruction of the
portal circulation, as well as of the great arterial trunks and veins of
the abdomen ; and on the part of the fetus, hydrocephalus, deformity,
or positions which may render the labor tedious and even fatal. She
should likewise be especially observant of her diet, selecting that
which is the most nutritious as well as most easily digested, bearing
in mind, that the gastro-uterine sympathy, as well as the gradually
increased volume of the uterus, tend greatly to diminish the energy
of the digestive powers. Stimulants especially, as alcoholic, vinous,
or malt liquors, fats, much acidulous food, and in instances where
they prove decidedly hurtful, tea and coffee, are to be avoided. The
use of farinaceous vegetables, ripe fruits, boiled or roasted meats,
water, and milk, may be named as among the best kinds of food and
drink ; and, though many females may have indulged their appetites
without any resulting unpleasant symptoms, yet such a course is more
apt to produce various difficulties than is generally supposed, especially
upon the future of the fetus. Moderate exercise in the open air, espe-
cially during the early months of pregnancy, should be very strongly
advised, with only occasional and not too prolonged bathing. Coition,
though commonly indulged in during pregnancy, is extremely unwise
and improper; and though often practiced with impunity, yet it is very
apt to be followed by metrorrhagia, abortion, or some defect in the
mental or physical organization of the offspring. Females subject to
leucorrhea, immoderate menstrual evacuations, abortions, as well as

DISEASES OF THE PREGNANT FEMALE. 211

those of a nervous or impressible temperament should be particularly
warned against cohabitation during pregnancy. If parents desire
physically and mentally healthy offspring, the sexual passion must be
permitted to remain dormant or undisturbed during the period of ges-
tation. The symptoms or diseases of pregnancy, which frequently
require medical treatment, are first, those which are the result of de-
ranged circulation and nervous sympathy; second, those originating
from the compression of the enlarged uterus upon the neighboring
organs; third, diseased conditions of the uterus or its contents; aod
fourth, accidental diseases.

Among those symptoms depending probably upon deranged circu-
lation and nervous sympathy, one of the most common, as well as the
earliest, is vomiting, or morning sickness, as it is usually termed. Vari-
ous explanations have been given from time to time as to the cause of
this phenomenon, but none of them are wholly satisfactory. With the
major part of females it is the first sign of pregnancy, commencing
usually about the fourth or sixth week, and sometimes immediately
after conception, and continuing for a few months, or even up to the
parturient period. It partakes of the character of sea-sickness, or of
that experienced by persons commencing to smoke tobacco. The
female experiences more or less nausea from the time of rising in the
morning, which may at first be removed by eating the morning meal,
but which soon becomes followed by vomiting of a greater or less
degree of severity and duration; occasionally, the vomiting becomes
exceedingly violent, everything being rejected from the stomach, and
if not checked, the female may die from exhaustion or starvation ; or
premature labor may ensue, followed by hemorrhage of an alarming
character. Where the vomiting occurs during the first three or four
months of pregnancy it is dependent upon gastro-uterine sympathy
is principally confined to the morning, lasts from ten minutes to an
hour or two, each day, and usually ceases in from two to four months;
the matter evacuated is thick, slimy, colorless, greenish or blackish,
frequently acid, and if the effort at vomiting be severe, a little bile or
even blood may be mixed with it. This sympathetic vomiting seldom
falls under the practitioner's care, unless it becomes very severe ; and
indeed, no especial means are required for its removal when not too
violent or prolonged, as it is merely a normal effect of conception.

When the vomiting occurs only in the morning, and is compara-
tively slight, it may be palliated by some aromatic infusion, and if the
discharges are very acid, magnesia, alkalies, with aromatics, or char-

212 KINO'S KCLKCTIC OBSTETRICS.

coal, will bo found efficient; sometimes these agents will exert but
little effect upon the acidity, in which cases, they will have to be laid
aside and acids employed, as Lemon-juice and water, a solution of
Tartaric or Citric acid, or acid wines. Should the discharges contain
much bile, mild cholagogue laxatives will be found beneficial, as a
combination of two parts of Rhubarb and one of Bicarbonate of Po-
tassa, administered three times a day, in doses of eight or ten grains
of the mixture, or sufficient to produce one or two mild alvine evacu-
ations, daily; may also use Citrate of Magnesia, or Seidlit/ powders.
When the vomiting is accompanied with much pain in the stomach,
Sp. Tr. Nux Vomica or Ignatia, with counter-irritation to the epigas-
tric region, may be employed with advantage ; and in severe and ob-
stinate cases of pain I have succeeded in giving relief, when other
means have proved inutile, by applying a hot fomentation of water
over the epigastrium, together with hot sponging, Chloroform, Aqua
Ammonise, or a Sinapism.

When the vomiting is violent and obstinate, various means have
been advised, all of which have at times proved beneficial; it must be
remembered, that while a certain course may produce a good influence
on one patient, it may have no effect whatever upon another, hence
the necessity of an acquaintance with these several means. As severe
vomiting is frequently accompanied with gastric or hepatic derange-
ment, Chionanthus or the small Podophyllin pill often controls it.
Macrotys will control a larger number of these cases than any other
single agent, and though it may fail in the beginning, I often pre-
scribe it again, after having exhausted the list of remedies, and in
this way frequently succeed; Pulsatilla is also a good agent, especially
when nervous excitation is present. They may be used singly, in
alternation, or together. Jn cases where the circumstances of the pa-
tient will allow, Champagne w r ine, according to Prof. Meigs, taken
during the meal (should vomiting occur after the meal) will almost
always prevent it. I have occasionally met with severe cases of vom-
iting, in which, after the employment of the usual remedies without
effect, Lobelia has produced the desired influence ; in such cases, I have
rubbed together one drop of Oil of Lobelia and thirty grains of Sugar,
and given one-sixth of the mixture for a dose, repeating it every ten
or fifteen minutes until relief ensued, which generally followed the
first or second dose, rarely requiring a third or fourth. Notwithstand-
ing all these remedies, it will happen, sometimes, that no relief will
be experienced, and the patient continues to suffer up to the fourth

DISEASES OF THE PREGNANT FEMALE. 213

month without any amelioration of her condition; yet, even in such
cases, the physician should not add to her suffering by giving up the
case as beyond remedial action, but should cheer her up, and endeavor
to fortify her spirits by the anticipation of better effects from the next
means to be used. In some instances food is only retained while cold;
and in others nothing will lie on the stomach but what is hot. Ice
will sometimes check it, and bismuth has a good effect. Effervescing
draughts have been extolled in attempts to allay the sickness, and will
often give satisfactory results, as Seidlitz powders, Soda or Mineral
water.

The use of peptics is to be commended.

Acidulated camphor water makes a pleasant drink, and will, in
some cases, control a rebellious stomach, where other agents fail;
Fowler's solution of arsenic, administered in drop doses on an empty
stomach, or with a restricted diet, .has been highly commended. I
have succeeded in overcoming obstinate cases, in several instances,
by the use of Macroty's and Fowler's solution in alternation. Prof.
Howe speaks of the alternate use of these agents, and says he has long
considered arsenic as the specific for the vomiting of pregnancy.
Many other agents have been used and recommended for this dis-
tressing symptom, as Bromide of Potassium, Creosote, Turpentine,
Salicin, Lime water, Oxalate of Cerium, and infusions of Peach and
AVild Cherry-tree bark, etc., etc. In fact, there is scarcely anything
considered remedial that has not been tried in the vomiting of preg-
nancy.

In persistent nausea, with inability to retain any kind of food on the
stomach, and having exhausted the list of internal remedies, I have
succeeded in subduing the trouble, temporarily, or until food could be
taken, by the hypodermic injections of Morphia. Dr. Girabetti states
that he has successfully treated obstinate cases of this character by
rectal injections of solution of Bromide of Potassium, commencing
with 90 grains of the salt the first day; 120 the second; and 150 the
third day and then lessening the dose in proportion to the effect.
Dr. Simmons has met with a similar success by rectal injections, morn-
ing and evening, of a solution in mucilage of 30 or 40 grains of Hy-
dro-chloral. We do not commend such heroic measures, however,
believing milder means to be more effectual. Carbolic acid, in the
dose of from one-fourth to one-half a grain, in a teaspoonful of glyc-
erine or mucilage, and repeated three times a day, has likewise proved
effectual in certain cases, especially when gastric acidity, flatus, or fer-

214 KING'S ECLECTIC OBSTETRICS.

mentive dyspepsia was present. In all these cases, the diet should be
of the lightest character, and if the stomach be found to possess less
irritability at any certain period of the day, this period must be selec-
ted for taking the principal meal. The practitioner must likewise
ascertain whether fluid or solid food agrees best with the stomach, and
advise the patient accordingly. The patient should not move about
too much, and, sometimes, rest in the horizontal position will be ab-
solutely required. Gastritis, indigestible food, constipation, certain
odors, etc., may likewise give rise to, or increase the severity of vom-
iting during uterogestation, all of which should be borne in mind
during treatment, that, if present as existing causes, they may be
removed. .

Where vomiting occurs only during the early part of the day, Prof.
Meigs recommends a cup of coffee with toast, to be taken by the
patient while in bed, after which she should, if possible, sleep again
for a short time ; upon subsequently arising no nausea or vomiting
will take place. I have tested this method, and found it to succeed
admirably in the majority of cases. Hot milk, or hot water, will
prove serviceable when preferred to coffee.

In some cases recently seen in consultation with other physicians,
where the usual remedies had been tested, I relieved vomiting by
local applications to the neck of the pregnant w r omb. A solution of
cocaine two grains to the fluid drachm of water I believe to be the
best local agent. The patient can wet a piece of lint with the solu-
tion, and carry it to the os uteri every six to eight hours. The fluid
extract of Veratrum viride,- incorporated with vaseline and applied to
.the os uteri, will, it is claimed, produce about the same effect as
cocaine. The local use of Tinct. Iodine, and the application to the
cervix uteri of colorless Iodine, have given very satisfactory results.
The practice of dilating the neck of the uterus has many able advo-
cates. The cervix is to be dilated to he depth of near a half inch.

Good results have followed in several cases, in which the cervix was
dilated by means of a small silk sponge saturated with the cocaine
solution.

The vomiting that occurs after the fourth month of pregnancy is
supposed to be owing to the pressure of the gravid uterus upon the
stomach, and is often very difficult to relieve ; indeed, palliation, as
the rule, is all that can be expected. Tonics, and antispasmodics may
be employed in these cases. I have frequently met with cases which
resisted all treatment, ceasing only at parturition ; and again, I have

DISEASES OF THE PREGNANT FEMALE. 215

considerably mitigated the severity of this distressing symptom, by
keeping the bowels in a regular condition preventing constipation, and
administering the small doss of macrotys ; relieving the irritable stom-
ach to such an extent, within a short time, as to retain light food.
The application of coacine becomes valuable, and more often called
for in sickness occurring after the fourth month, than before that time ;
and should be remembered as an agent soothing and kindly in its
action; often relieving when internal remedies are not tolerated.
Counter-irritation over the last dorsal vertebrse is often a valuable
adjunct to the treatment. In this form of vomiting, all food, or what-
ever is received into the stomach is generally rejected, and the patient
suffers from inanition; indeed, the principal subject of fear is, that
she may die from actual starvation. It should be our aim to discover
what variety of food best agrees with the stomach, and the period cf
the day in Avhich this organ is the least irritable, that advantage may
be taken of that period for taking a light meal. In some instances
where vomiting followed the reception of everything taken into the
stomach even in moderate quantity, I have succeeded in sustaining
the powers of the patient up to the period of parturition, by giving
half-teaspoonful, or teaspoonful doses of milk, cream, gruel, etc., every
hour or two throughout the day, occasionally with a few drops of
Brandy, or other stimulant added. In one case, ice cream was all in
the way of food that could be taken for a number of days, and proved
very serviceable in tiding the patient along until more substantial
nourishment could be taken. In extreme cases, where all forms of food
are ejected by the stomach, rectal alimentation may become necessary.
The whites of two eggs, in eight ounces of water, may be injected
every six or eight hours. In these cases, the less medicine the patient
swallows, the better will it be for her, except when imperiously de-
manded.

Frequently the vomiting becomes so excessive as to threaten the
life of the patient, as before observed, from starvation; for it is sel-
dom the case that abortion is produced by puerperal nausea, though
it frequently ensues from emetics. In such instances, after a fair and
patient, but fruitless trial of all remedies to overcome the difficulty,
and sustain the patient's strength, we may be compelled to resort to
premature delivery. This, however, is not to be thought of, unless,
the patient's life is actually endangered, and should never be under-
taken without having first consulted with one or more medical men.
Dubois, who in the course of thirteen years met with twenty fatal

216 KING'S ECLECTIC OBSTETRICS.

cases, advises never to perform the operation, even though the vomit-
ing be violent, when the patient, however feeble and emaciated she
may be, is not obliged to retain her bed, when a small portion of
aliment can be retained, and when intense and continuous febrile
action has not been induced; he also prohibits the operation when
signs of extreme exhaustion are present, as loss of vision, cephalalgia
coma, somnolence, and mental disorder. A timely interference is
advised, at a period characterized by an incessant vomiting, whereby
all food, and sometimes even a drop of water is rejected ; where
emaciation and debility are present, requiring absolute rest ; where
the least movement or mental emotion causes syncope; where .the
features become decidedly changed ; where there is severe and con-
tinuous febrile action, with excessive and penetrating acidity of the
breath, and a failure of all other means. Dr. Churchill considers the
pulse to be the best guide; and when this rises there should be no
hesitation in at once producing an abortion, lest the patient may
become so far prostrated, from a delay, as to render death certain.

When vomiting has been very distressing during labor, I have
frequently given prompt relief by the administration of the tincture
of Gelsemium, and would suggest its employment in these obstinate
vomitings during pregnancy.

Ptyalism or salivation, frequently occurs during the early months
of gestation, and seldom requires any treatment. Rarely, however,
it becomes very severe, resembling mercurial ptyalism, but differing
from this in the absence of tenderness of the gums and disagreeablei
fetor of the breath ; the fluid secreted is colorless and transparent, or
tenacious and frothy, with an unpleasant taste, commonly accompanied
with acidity, and often inducing vomiting. As a general rule, this
symptom needs no treatment. Phytolacca or Hamamelis, However,
should be thought of when treatment becomes necessary ; a good
plan is, to regulate the action of the bowels by mild aperients, and
wash or gargle the mouth and throat with Borax water. I have
never had this symptom to contend with, excepting in one case. I
succeeded in relieving it, after several agents had failed, by the admin-
istration of Sulphate of Atropia, hypodermically, the one-hundredth
of a grain once a day, until relieved. In cases of acidity, Lime-water
may be used with some advantage. The secretion, when profuse, may
be moderated, by constantly holding in the mouth some candied Sugar,
or a lump of Gum Arabic.

DISEASES OF THE PREGNANT FEMALE. 217

Anorexia, or a want of appetite, and a dislike for ordinary aliments,,
are symptoms frequently met with at various stages of utero-gestation.
These may be owing to the sympathetic actions existing between the
uterus and digestive organs, to a torpid state of the organs subser-
vient to digestion, or to an unloaded condition of the alimentary canal.
Usually, puerperal anorexia requires but little attention ; but where
treatment is required, it must be based upon the supposed cause of
it thus, if it be suspected as a result of nervous sympathy, Pulsatiila
or Macrotys will generally remove it; if it originates from torpor of
the digestive apparatus, Nux Vomica, or the compound tonic mixture
will be found useful ; and if it be induced by plethora, or an accumu-
lation of morbid matter in the alimentary canal, Ignatia may be used
or the first decimal trituration of Podophyllin, in two or three grain
doses; or if persistent, mild purgatives will be essential. Indeed,
I would remark here, that throughout the whole period of utero-
gestation, if the bowels be kept in a soluble condition by mild
aperients, or by the use of proper food, many of the distressing
symptoms common to this period will be avoided. Flatulence may
be removed by the use of Sp. Tr. Viburnum, or by compound spirits
of Lavender given in some sweetened water. To overcome these
difficulties, some authors recommend emetics, but I am decidedly op-
posed to their use : firstly, because milder measures will accomplish
all that can be desired ; and secondly, because emetics have a tendency
to produce abortion, and which may be avoided by other efficient and
less hazardous means. There are some practitioners who proceed,
apparently, as if they supposed every patient's stomach to be a strong
metallic vessel, capable of being acted upon by emetics, powerful stim-
ulants, drastic purgatives, etc., etc., without the least injury whatever,
but always with benefit ; such physicians, of all men, are the least
adapted to obstetric practice, and I might add truly, or any other.

Either with or without anorexia, the patient may have " longings,"
or a desire for certain articles, which are sometimes unnatural and even
disgusting. When these longings are not directed to unwholesome or
dangerous articles, there is no reason why they should not be indulged ;
neither is there any necessity for interfering with any particular dis-
likes which may have been produced in the patient's mind. In rela-
tion to these longings, and their influence upon the fetus in utero,
when ungratified, as well as to the effects of the maternal mind, gen-
erally, upon it, there is much discordance of opinion among medical
men, some believing that the embryo is acted upon by strong mental

218 KING'S ECLECTIC OBSTETRICS.

emotions of the mother, .while others deride the idea. I must confess,
that too much evidence, of a direct and satisfactory character, has been
at various times presented to me, to permit me for a moment to doubt
this point; and I am thoroughly convinced, that the fetus in utero is
subject to influences and changes, resulting entirely from the mind of
its mother, when under strong or continuous action. How, or why
this is produced, is as difficult for me to explain, as it would be to
account for the cessation of a severe labor-pain on the entrance of
the accoucheur into the puerperal room, or the sudden dissipation of
toothache upon obtaining a sight of the forceps, or to explain why one
man should be actively purged upon seeing another swallow a nauseous
dose of medicine. I know, " sympathy," and " imagination " are held
up as replies but if these are applicable to the latter cases, why not
to the former? A greater attention to the efforts of nature, as wit-
nessed in the human system, and less attention to speculative hypoth-
esis and dogmatic authority, w r ould tend much to advance the true
science of medicine. He who really desires a knowledge of the truth,
will not hesitate to receive it from any source.

There is no direct vascular communication between the mother and
the fetus, nor have physiologists been able to detect any nervous con-
nection between them, and, for this reason, some have denied the
mental influence of the mother upon the fetus in utero, and consider
the supposed effects of this influence as mere coincidences, and not
proofs. And yet, it appears to me, these coincidences, as they are
termed, have been too numerous, and often too prominently marked,
to admit of any doubt. It certainly appears to have been believed,
acted upon, and with successful results, in ancient times (Genesis,
chapter xxx, verses 30 to 41). It has heretofore been referred to,
that, notwithstanding the absence of direct vascular communication,
the fetus has been acted upon by medicine taken by the mother.
Nerves or their congeners appear to be necessary to animal life and
development, and yet how many most perfectly and astonishingly
made living creatures are there in whom not a trace of nerve-tissue
has been discovered !

Diarrhea may occur, and usually yields to the ordinary treatment
for this disease when independent of pregnancy. It may be owing to
intestinal irritation, which may be the result of constipation preceding
pregnancy, or it may be induced by the sympathy existing between
the intestines and the excited uterus; under either of these circum-

DISEASES OF THE PREGNANT FEMALE. 219

stances, the early administration of Aconite and Ipecac, in the usual
small dose, will, a.s a rule, give prompt relief. Epilobium is Prof.
Scudder's remedy. In some instances, the small dose of the first dec-
imal trituration of Podophyllin will be the remedy ; the base of the
tongue showing a dirty coat is the indication. And again, I have
found Sulphate of Quinia with essence of Cinnamon to be decidedly
beneficial. "When the diarrhea depends upon chronic inflammation of
the mucous membrane of the intestines, it becomes of a serious char-
acter, and unless treated promptly and properly, may terminate fatally.
In this case, Euphorbia, given in doses of from one to ten drops, will
relieve the irritation and promote functional activity hot fomenta-
tions should be applied over the abdomen, and mustard to the dorsal
and lumbar portions of the vertebral column. The soluble Citrate of
Bismuth (Liquor Bismuth) is a very good agent in overcoming diar-
rhea; one grain to a dram of water is the dose. In addition to these,
the ordinary treatment for inflammation of a similar character must be
pursued, meeting the symptoms as they present themselves. Much
benefit will be derived in these cases by the alternate use of tincture
of Aconite, and tincture of Ipecacuanha, in small doses, and in most
cases no other treatment will be called for. The diet should be light,
and small in quantity, consisting principally of boiled Milk, boiled
Rice, Arrowroot, etc. Diarrhea more often occasions abortion than
does constipation, in consequence of tenesmus, and which usually
occurs about the third month. As with all other affections during
pregnancy, care must be taken to avoid active or powerful catharsis,
whatever may be the agents employed in their treatment.

Heartburn, or cardialgia, is a distressing symptom, and may be pres-
ent during the early period of conception, not until the third or fourth
month, or may be entirely absent. It may be occasioned by sym-
pathetic action, by the use of certain articles of diet, and .by the pres-
ence of bile in the stomach, but most generally it arises from acidity
of the stomach ; it is also said to be caused by emotions of the mind,
and an affection of the eighth pair of nerves. There is heat or a burn-
ing sensation in the epigastric region, which extends upward along
the esophagus, with pyrosis or eructations of a clear, bilious, sour and
bitter fluid, and is frequently accompanied with a peculiar sensation of
dragging from the stomach toward the spine ; eating aggravates the
difficulty. There is generally no febrile or other constitutional dis-
turbance present ; the appetite is commonly impaired. This symptom

220 KINO'S ECLECTIC OBSTETRICS.

may usually be mitigated by an attention to the bowels, removing
acidity 1 y alkalies in aromatic infusion, by a rigid attention to diet,
which should be light, nourishing, and easy of digestion, and by the
use of moderate exercise in the open air. In very painful and obsti-
nate cases, counter-irritation, as sinapisms, etc., applied to the epi-
o-astrium will be productive of benefit. A long-continued use of
alkalies will injure the tone of the stomach. Sometimes alkalies will
fail to produce the slightest relief; in such cases a resort to acids will
often effect the desired result; solution of Citric acid, Tartaric acid,
or Lemon-juice may be used, or elixir of A r itriol. As soon as some
relief has been afforded, an attempt may be made to invigorate the
powers of the stomach, for which purpose I have met with much
benefit from very small doses of Pulv. Hydrastis Can. and Capsicum,
administered three times a day, near meal times. Nux Vomica and
Ipecac are good agents to tone the stomach. Generally females obtain
a temporary relief from this symptom, when not obstinately severe, by
taking Lime-water, or chewing Magnesia,. Chalk, or Peach-kernels.

Gastrodynia, spasm or cramp of the stomach, is frequently the
result of some error in diet, but may also be occasioned by cold or
violent mental emotions. Its attacks are often sudden, more transient
than heartburn, but far more severe. Violent pains of a neuralgic
character dart from the sternum through to the back or shoulders, being
accompanied with great distension, flatulence, restlessness and anxiety ;
it may be so severe as to occasion premature labor, or the death of the
fetus. The treatment should be prompt and energetic; warm fomen-
tations, or sinapisms, should be applied to the epigastrium. Colocynth
is a good agent where the pain is severe, or Viburnum where cramps
are present. In some instances of a severe and obstinate character, I
have succeeded in giving relief with the compound tincture of Lobelia
and Capsicum, also with the tincture of Gelsernium. When the attacks
are frequent, they may be overcome by keeping the bowels regular,
neutralizing acidity of the stomach, and administering small doses of
Nux Vomica several times a day. The diet should be light and
nutritious, avoiding fats, acids, and stimulants. Alkalies, aromatics,
and anti-spasmodics, are the only internal remedial agents generally
required.

Constipation is a common attendant of pregnancy, and is frequently
very obstinate and troublesome. It is caused by the compression of

DISEASES OF THE PREGNANT FEMALE. 221

the gradually-developed uterus upon the rectum, which diminishes its
diameter, as well as impairs its activity; constipation may also be
owing to digestive derangements, improper food, sedentary living, and
other causes calculated to lessen the energy of the intestines. Various
symptoms depend upon this condition of the bowels, as headache, or
a sense of fullness and weight in the head, sleeplessness, irritability,
pains in the abdomen, bloody mucous discharges, nausea, and, in the
latter period of pregnancy, false pains. Sometimes, notwithstanding
accumulation of fecal matter in the intestines, there will be small dis-
charges of a liquid character. Constipation is a symptom always to
be dreaded in the pregnant female, because of its liability to produce
abortion from the large amount of feces collected in the rectum,
requiring great expulsive effort to remove, as well as its tendency, at
the time of parturition, to cause protracted labor, peritonitis, or con-
vulsions. Piles are usually a consequence of constipation in the preg-
nant female. In the treatment of costiveness during pregnancy,
especially when dependent upon impaction of the lower bowel, or
pressure of the growing uterus, I prefer the use of warm laxative
enemas to active purgatives administered by the mouth, and for this
purpose an emulsion of Castor Oil, may be used daily, and after the
rectal accumulation has been removed, a daily enema of warm water
may be substituted for the previous one. If it be possible, it is
always decidedly better to overcome constipation by hygienic than by
therapeutical measures, which always occasion more or less debility,
or else some digestive derangement. If medicine is required, and the
tongue is broad and pallid, with a white coating, indicating an alkali,
I prefer small doses of Bicarbonate of Potassa or Soda, to any other
agent with which I am acquainted. Tincture of Nux Voniica, given
alternately with Tincture of Belladonna, or Pulsatilla, in very small
doses, has proved serviceable in cases where the constipation was due
to lack of nervous energy. Podophyllin is often called for in these
cases, and may be given, either in the form of the small pill or the
trituration, one part of Podophyllin to one hundred parts of sugar of
milk. Active cathartics are seldom required, and should al\vays be
used with great care during pregnancy, on account of their tendency
to produce premature labor; the secret of success consists entirely in
maintaining one daily alvine evacuation. I have recently tested
Glycerine Suppositories, with very satisfactory results, in constipation;
the action is prompt, and the effect pleasant. In diarrhea, the prac-
titioner should always ascertain if it was preceded by constipation,

K I Mi's ECLECTIC OBSTETRK -.

and should, this be the case, laxative measures must be the first
adopted. No female should he allowed by a, physician to enter the
parturient state -with constipated bowels; and in those instances where
the practitioner attends the patient previous to full term, he is highly
reprehensible if he neglects the proper attention to this condition.
The diet in these cases may be such as to assist very much in bringing
about the desired regularity, without the aid of physic, as brown
bread, mush and maple syrup, hasty pudding, oatmea'l, figs, stewed
prunes, dates, ripe fruits, and dried laxative fruits stewed, as apples,
peaches, plums, etc. Any irritability of the bowels which may follow
a removal of constipation can be allayed by some gentle sedative, as
Aconite and Ipecac or Sp. Tr. of Amygdalus Per.

Headache, or oephalcUgia, is of very common occurrence during
pregnancy, and attacks all temperaments, and as it is frequently a
premonitory symptom of convulsions or mania, the practitioner should
not fail to devote especial attention to its removal. The pain may be
constant or periodical, acute or dull, and may be located in one par-
ticular part of the head, or over the whole of it. Sometimes, espe-
cially when acute, it is also of a throbbing character, and not unfre-
quently there is an intolerance of light and sound. Usually it is
owing to some deranged condition of the digestive organs, and may be
readily removed by proper attention to diet, and prescribing such
agents as are specifically indicated. If characterized by periodicity,
Quinia, or Arsenicum, i* the remedy. If pain is localized, think of
Rhiis Tox. or Bryonia, and if the pain is throbbing, Belladonna. It
may, likewise, originate from mental emotions, fatigue, stimulants,
and coitus, requiring special sedatives, and quiet, with proper hygi-
enic measures; if anemia exist, some preparation of iron is neces>ary.
I prefer the Acid Solution of Iron, and suggest its use in this condi-
tion ; if albuminaria be present, treat as herea'fter directed. The
headache which occurs during the early months of utero-gestation is
of a nervous character, and is not regarded as a dangerous symptom;
while that which occurs during the latter months is owing to plethora,
is usually attended by evident signs of cerebral congestion, and must
be treated promptly and energetically, that serious results may not
ensue. This latter form, unlike the former, instead of being relieved
by the recumbent position is more or less aggravated by it, and is
frequently accompanied with a quick, full, strong pulse, flushed
countenance, suffused or heavy eyes, heaviness of the lids, and pho-

DISEASES OF THE PREGNANT FEMALE. 223

tobia; the carotids pulsate with unusual force and a sensation of
giddiness is present, which is increased on stooping. Belladonna is
the remedy for this condition. If this form of headache is permitted
to continue without relief it will almost assuredly terminate in con-
vulsions, more especially if albuminous urine be present.

The nervous form of headache may be removed, as before observed,
by regulating the bowels, and attending to the diet. I have derived
considerable advantage from Rhus Tox., Gelsemium, Ammonia Carb.,
and Bryonia, either separately or in such combinations as indications
direct, and, in some severe instances, counter-irritation to the sub-
occipital region, or behind the ear. This annoying symptom may
occasionally prove quite persistent, and after several days Pulsatilla
may become the indicated remedy, the patient showing symptoms of
fear. The administration of this agent at such times, will promptly
overcome the trouble.

The plethoric variety requires somewhat different treatment; the
bowels must be kept entirely free from any disposition to constipation,
counter-irritation must be intermittingly applied to the whole length
of the spinal column, and active diuretics may be safely and freely
given. Tincture of Nux Vomica, or tincture of Belladonna, in small
doses, will frequently remove the headache. If the urine contains
albumen, the means hereafter named must -be promptly resorted to.
In very severe cases cupping may be applied to the temples, or nape
of the neck. Moderate diaphoresis will likewise be found serviceable,
and should be effected by the use of the simple diaphoretics, without
the administration of any preparation of opium. Although local de-
pletion may act as a beneficial palliatory measure, yet general bleeding,
which is so frequently resorted to and recommended by certain
physicians and authors, must be specially guarded against, as it debil-
itates the female, rendering her liable to premature delivery, tedious
labor, perhaps requiring instrumental aid or hemorrhage after parturi-
tion, and frequently tends to the destruction of the fetus.

Convulsions often attend the condition of pregnancy; their most
usual periods of attack are in the latter months, during parturition,
or shortly after delivery. Those convulsions attended with or pre-
ceded by signs of general plethora, and cerebro-spinal congestion, and
commonly termed " puerperal convulsions," will be treated of in an-
other part of the work. At the present time, I would call attention
to a form of convulsions, which I have met with as early as at the

224 KIND'S KC I.KIT 1C OBSTETRICS.

second month of gestation, and which occurs much more frequently
than the true puerperal convulsions. They most generally occur in
aiuemic or hysterical patients, or in those whose nervous systems
have been exhausted by any depressing cause, and though when the
attacks are light no bad results follow, yet they frequently occasion
premature labor, or, by appearing at the parturient period, perplex,
embarrass, and, perhaps, alarm the -practitioner. They are, undoubt-
edly, of an hysterical character, and differ from the true puerperal
convulsions, in being often preceded or attended by the globus hyster-
icus and borborygmus, with a small, hard -pulse peculiar to ordinary
hysterical attacks; the motions of the limbs are likewise more violent,
the eyes roll or store with a wild expression, and though they may be
unnaturally brilliant, yet there will be no suffusion, and the pupil is
not insensible. Occasionally the ordinary concomitants of sobbing,
crying, or screaming will take place. Urine, of a pale color, is fre-
quently voided in large quantities. In the treatment of this form of
convulsion the greatest reliance was formerly placed on the officinal
compound tincture of Lobelia and Capsicum (Antispasmodic tincture),
in doses of from a fluid drachm to half a fluid ounce, and repeated
every ten or twenty minutes, nntil the attack was overcome. This
compound is probably one of our most powerful antispasmodics ; but
owing to its disagreeable taste, together with the large dose required,
it is not so generally used as heretofore. Gelsemium is now used quite
extensively in these cases, and in small doses frequently repeated will
prove quite efficient. Bromide of Ammonium is also a good agent,
and may be used either singly or in combination with Gelsemium. In
obstinate cases, Chloroform should be inhaled by the patient until
spasmodic action is overcome and complete relaxation produced. In
the meantime, dring the absence of these convulsions, the patient must
be placed upon a generous diet of an easily digestible character ; the
bowels must be kept regular, wine or ale may be allow r ed, with some
chalybeate preparation, the use of which should be continued during
the whole course of utero-gestation, unless otherwise contra-indicated;
all exciting influences should be removed as much as possible, quiet
should be enjoined, excessive depletion by diaphoresis, diuresis, or
catharsis are to be avoided, and coitus must be absolutely prohibited.
In these instances, I commonly leave some such agents as above
named with the patient, to be administered by her friends whenever
an attack occurs, and which effects its influence without the necessity
of my presence on every occasion. With this class of patients, the

DISEASES OF THE PREGNANT FEMALE. 225

practitioner should always be prepared to meet this symptom as a
complication at the period of parturition, for it not uncommonly hap-
pens that one or several attacks come on during the labor, as well as
subsequently. Occurring at this time, Chloroform should be promptly
administered, which will usually immediately overcome all convulsive
action.

When there is a tendency to epileptic convulsions, more or less
giddiness is apt to be present, and the urine will always be found to
contain a little albumen. Again, when albumen is continuously pres-
ent in the urine of a pregnant woman, there is always danger to fear
from puerperal convulsions, and more especially if this be associated
with a plethoric condition. It is, therefore, the positive duty of every
obstetrician to examine the urine of his patients from time to time
during pregnancy, and especially when oedema of the extremities is
present, and also in the latter months, to discover whether it contains
albumen, as well as a diminished quantity of urea, and thus enable
him to promptly resort to measures for the prevention of a convulsive
attack; though it must not be forgotten that puerperal convulsions
frequently come on without any previous albuminous condition of the
urine. Headache, dimness of vision, giddiness, are apt to be present,
and, sometimes even amaurosis, when albumen exists; and this con-
dition is often accompanied with oedema of the extremities and cellu-
lar tissue of the body, and appears to be more common with primipars&
than with multiparse. It has been attributed to pressure of the gravid
uterus upon the kidneys, and likewise, with much greater probability,
to sympathetic irritation of these organs. There is no doubt that not
only albuminaria, but often even true kidney disease, follow the renal
congestion kept up by the pregnant condition. In cases of albuminous
urine it will be found useful to produce derivative action by hot or
stimulating local applications, dry cupping or even cupping with scari-
fication over the loins and renal region; and even active catharsis.
We should, however, be extremely careful that the bowels are not acted
on to such an extent as to produce exhaustion, or that an irritation of
the intestinal mucous membrane is not excited that will prevent proper
digestion. The Spirit-vapor Bath is very useful in all cases. The in-
ternal remedies will depend entirely upon the general conditions and
surrounding circumstances of the patient; we would think of Macro-
tys, Rhus Tox, Bryonia, Gelsemium, Eryngium, or Belladonna, as in-
dicated. In some cases we find the urine alkaline, and we supply the
acids, Nitric acid being specially indicated. Again there are cases in
15

226 KING'S ECLECTIC OBSTETRICS.

which it is decidedly acid, and Bicarbonate of Soda becomes the indi-
cated remedy. Digitalis, Tannin, Bcn/.nic acid, Citric acid, Gallic
acid, etc., IKIVC each, been found advantageous when administered un-
der the proper circumstances. When there is a deficient oxygcui/ation
of the blood, Nitric acid, Nitrate of Ammonia, Peroxide of Iron, etc.,
are indicated. And after the albumen has diminished, with an in-
crease of urea and urine, blood restoratives as, the Acid Solution of
Iron, Citrate, Pyrophosphate, or Carbonate of Iron, with or without
Quin ia or other tonics, must be administered, together with a nutri-
tious, digestible diet.

According to Andral and Gavarret, the fibrin of the blood is dimin-
ished during the first six months of pregnancy, but subsequently be-
comes augmented, even to a considerable amount above the usual
physiological portion, assuming the characteristics of inflammatory
blood, and manifesting the buffy coat after venesection. In addition
to which, the quantity of the blood is also considerably increased be-
yond the usual normal proportion. These changes in the blood are,
very probably, due to an increased nutrition, by which chyle is formed
in greater abundance from the food, and conveyed to the blood-vessels.
This plethoric condition is a natural and salutary consequence of preg-
nancy, and under ordinary circumstances requires but little attention,
further than active exercise and moderate diet. But occasionally these
additions to the quantity and quality of the blood become so great as to
develop symptoms demanding prompt therapeutic treatment, which is
more especially the case with indolent females, those who live luxuri-
ously, and those of sanguine habit ; it may also be induced by constipa-
tion. These symptoms are headache, somnolence, flushed face, vertigo,
dyspnoea, full and frequent pulse, heat of the skin, depressed spirits, and
high-colored urine. Sometimes the general plethora gives rise to local
plethora, which may be followed by congestion of a serious character
in the brain, lungs, or uterus. This latter organ, during pregnancy,
is the most liable to hyperasmia, which may be known by a sensation
of fullness and weight in the pelvis, groins, and thighs, tension or
swelling of the abdomen, pain in the kidneys or loins and even symp-
toms of premature labor; and, not unfrequently, this condition of the
mother exerts an influence on the fetus, in consequence of which, its
movements become less frequent and weaker, or perhaps" cease alto-
gether, but which, if not allowed to proceed too far before giving re-
lief, will again appear with the removal of the local plethora.

DISEASES OF THE PREGNANT FEMALE. 227

Whenever the symptoms of general or local plethora become so
severe as to require remedial measures, and no symptoms of approach-
ing miscarriage have been manifested, it will frequently, but not always,
be advisable to commence the treatment with a cathartic, followed by
diuretics, which will be found to exert a safer and more salutary de-
pletory influence, than even general bleedings, which are so highly
recommended by many medical writers. Infusion of Digitalis, Sp. Tr.
Apis Mel. Asclepias, and Gelscmiuin will be found quite useful agents
in diminishing the plethoric condition. The hot water bath, and dry-
ing with a rough towel, will favor general depiction by stimulating
the action of the skin. Counter-irritation by dry cupping, sinapisms,
or other means should be applied to the upper portion of the spine;
the legs and arms may be rubbed or bathed with some stimulating
liquid, and, very frequently the wet sheet, or rather bandage applied
around the abdomen and pelvic region will effect much benefit; if the
case be very severe, tending to a miscarriage, cupping may be pursued,
applying the cups to the loins and over the sacrum. On no account
must large or small general bleedings be had [except when the urine
is found to be excessively albuminous, endangering an attack of con-
vulsions, in which case cupping upon the loins may tend to preserve
from such attack], for though they may occasionally be followed by
present relief, yet their after consequences are much to be dreaded;
beside it is a well-established fact at this day, that bleeding rather in-
creases than diminishes. the tendency to an inflammatory condition of
the blood. After the symptoms have been removed by the above
treatment, the subsequent measures should be light diet, moderate ex-
ercise,, regularity of the bowels, and use of Macrotys, or the Parturi-
ent Balm, which will be found a most excellent agent at this time,
with an occasional use of diuretics, and the use of a bandage or proper
support to the uterus, if necessary. Hemorrhage, or symptoms of
miscarriage, are to be treated as laid down elsewhere for these diffi-
culties.

I should observe here, that local congestion of the uterus, or of any
other organ is not necessarily connected with general plethora, but
may exist with a state of general anaemia; under which circumstances,
the nervous and vascular systems will be found in an extremely ex-
citable condition. In such cases, after the removal of the local hyper-
sernia, proper attention should be bestowed upon the existing anaemia.

Odontalgia, or toothache [facial neuralgia], is frequently a trouble-
some symptom with pregnant women; it may occur with or without

228 KINO'S KCi.ECTtr OP.STKTRICS.

caries, and may appear at any period of utero-gestation, often contirv-
uing until parturition; the pain is most usually intermittent, but is
occasionally continuous. Generally, it is owing to increased irritabil-
ity of- the nervous system, and at times to a sanguineous congestion
of the jaw. As the extraction of a tooth during pregnancy is fre-
quently followed by premature labor, it is not prudent to resort to this
expedient, even should caries be present; and it seldom happens that
any alleviation of the suffering follows the operation. However, should
the pain be owing to a carious tooth, the patient suffering severely
without any relief being afforded, and other means have failed, then
the tooth may be extracted by a skillful dentist, and probably the ad-
ministration of Chloroform would entirely prevent any bad influence
upon the generative system from the shock of the operation. The
proper treatment in these cases is the administration of Aconite, Ver-
atrum, Rhus, Macrotys, or Viburnum, as they may be severally indi-
cated. Where the pains occur periodically, Sulphate of Quinia should
be given; the bowels should be kept in a regular condition by gentle
laxatives; and as a local application, washing the mouth frequently
with cold or tepid water and salt will be found useful. In very
severe and obstinate cases, counter-irritation behind the ears will be
followed by excellent results, as a sinapism, or stimulating liniments.
Tinture of Aconite root, employed in friction beneath the ear, is said
to be a very effectual remedy, and is certainly deserving a trial in this
distressing complaint. Chloroform applied locally, either alone, or in
combination with equal parts of tinctures of Camphor, Aconite root,
and Opium, has likewise proved efficacious. If caries be present, the
cavity should be cleansed, and the following mixture applied on cot-
ton or lint, and frequently repeated until relief is obtained, viz.: Take
of Oils of Cajeput, Cloves, and Amber, each one fluid drachm, Camphor
one drachm, rub the Camphor with the oils until it is dissolved. Or,
Chloroform may be applied similarly. In the toothache of pregnancy,
the breath is very apt to be acid, and will redden litmus ; frequently,
when constipation is a concomitant, its removal will be followed by a
cessation of the pain.

It is frequently the case that the nervous excitement produced in
the uterus by the condition of pregnancy extends to the kidneys and
ureters, giving rise to spasmodic action of the ureters, attended with
severe pain along their course, and occasionally strangury, and which,
if not promptly relieved, may induce premature labor. In these in-

DISEASES OF THE PREGNANT FEMALE. 229

stances counter-irritation should be applied over the lumbar region,
and sedatives administered internally. The tincture of Gclsemium
alone, or combined with the tincture of Macrotys, will prove a very
useful remedy. Where strangury is present, Gelsemium and Lobelia
will prove valuable agents as relaxants. The inhalation of Chloro-
form may be necessary in some cases. The hot hip-bath will be found
a soothing means of relief in this complication. Constipation is usu-
ally present, and may be overcome by copious warm enemata.

The bladder may likewise become the seat of sympathetic nervous
excitement, especially the urethra and neck, giving rise to a constant
sensation or desire of urinating, and the urine passes in small quanti-
ties, frequently with pain and difficulty, and is likewise, with some
patients, attended with excessive irritability of the external genera-
tive organs, and more or less severe and distressing itching, which is
increased at night. The internal use of Aconite, Gelsemium, Rhus,
Apis and Eryngium are the remedies usually indicated ; hot applica-
tions over the region of the bladder may also be used as an additional
means of relief; sometimes, liquor Potassa may be advantageously ad-
ministered with other means. The bowels should be kept regular,
and the diet should be of a mild, not stimulating, character. In all
troublesome or obstinate cases the urine should be examined, and if
an excess of" uric acid, urea, or phosphates, etc., be discovered, the
proper treatment therefor must be pursued. For the itching of the
genitals, cold applications should be employed, and the parts kept well
cleansed. (See Pruritus of the Vulva.}

Occasionally, from pressure, or perhaps from an increased deter-
mination of blood to the uterus, which withdraws this fluid from the
immediate neighboring parts, there w r ill be found a torpor of the blad-
der, giving rise to a retention of urine and its difficult passage. This
is a more serious difficulty than the previous one, on account of its
tendency to produce retroversion of the uterus. Eupatorium Pur will
favor an increased flow of urine ; Apis in some cases Mall prove effect-
ual. Santonin, in two or three grain doses, exerts a specific action, by
stimulating contractions of the bladder. Acetate of Potassa should
also be thought of; the patient should be advised to empty the blad-
der often, if possible, by her own efforts, and should these means fail,
the urine must be removed by the careful introduction of a catheter;
w r hich operation must not be delayed for too long a period.

230 KINc's K< I.K< TIC OBSTETRICS.

Syncope, or Jit* o/'/i'mf//^ frequently attend the pregnant condition,
and may occur at any period from conception to parturition, though
more commonly during the earlier months; vertigo, or dimness of
sight, is also apt to be present, with sometimes tinnitus, and weakness
of the knees. These affections may be owing to debility from what-
ever cause, to extreme nervous susceptibility, or to plethora. Syncope
generally occurs while the patient is standing, is seldom of long dura-
tion, and very seldom causes any serious results. However, when
frequently repeated it may induce premature labor, which should be
carefully guarded against. The treatment should be that usually pur-
sued in syncope at other times; put the patient in a recumbent posi-
tion, in a place where there is a circulation of cool air dash cold
water on the face apply Ammonia, Ether, or Vinegar, etc., to the
nose, and after her recovery, should there be much debility, with cool-
ness of the surface, diffusible stimuli may be administered internally,
with frictions to the limbs, and, in severe cases, along the spinal col-
umn. When the attacks are severe, and occur frequently, Pulsatilla,
Gelsemium, Digitalis, and in some cases, Bromide of Ammonium may
be given with benefit. The food should be wholesome, and restricted
somewhat as to quantity, and if the patient be weak, tonics may also
be employed. When these attacks are frequent, Sulphate of Quinia,
or Strychnia will be efficacious ; if anemia be present, the Acid Solu-
tion of Iron.

Palpitation of the heart is not an unusual occurrence, during preg-
nancy ; it is a distressing symptom, and though by no means danger-
ous, it occasions i much alarm to the patient. It may happen at any
period of utero-gestation, and may be owing to mental excitement,
derangement of the digestive organs, pressure, flatulency, or sympa-
thetic nervous irritation. During its presence, it may be relieved by
the administration of an alkali, if acidity and flatulency are present;
by a mild laxative if the bowels are confined ; and under other cir-
cumstances, Digitalis, Lobelia, Cactus, Strophanthus, and in some cases
stimulants may be employed, according to indications. Four to eight
drops of the Sp. Tr. of Digitalis, given daily for some time after a
paroxysm subsides, may prevent a return of the same. During the
interval, some of the bitter tonics may be administered, and will often
be found beneficial in preventing a return of the palpitation, and
should the patient be of an anaemic habit, the proper chalybeate^
must be used in conjunction. The diet must be mild and stimulating,.

DISEASES OF THE PREGNANT FEMALE. 231

the patient should exercise moderately, her dress should be loose,
coitus should be abstained from entirely, and the mind should be kept
perfectly tranquil.

Dyspnoea, or difficulty of breathing, may occur, in the early months,
from sympathy, and at a later period from plethora, or from pressure
of the enlarged uterus; it may likewise be owing to derangement of
the digestive organs, thoracic disease, cardiac disease, tumors, etc. The
treatment will consist in the administration of antispasmodics, as Gel-
semium, Lobelia, Ether Carbonate of Ammonia, etc., attention to the
regularity of the bowels, and a course similar to that just named for
palpitation. When owing to organic diseases, or congestion of the
lungs, these must be attended to according to their indications. When
the difficulty is owing to the enlargement of the uterus, but little relief
can be expected until the delivery of the fetus, hence, there will be no
necessity for injuring the patient's system by the employment of
medicines.

Cough sometimes occurs, independent of cold or existing disease,
and which, in the earlier months, is owing to sympathetic action ; in
the latter to pressure. The cough is usually short, dry, hacking, and
constant ; occasionally very severe, with but little or no expectoration,
no febrile symptoms, and no change in the pulse, and is apt to cause
premature delivery. It may be treated by narcotics, antispasmodics,
rest, and regularity of the bowels, with a proper attention to diet.

In the latter months of pregnancy, when the cough is severe and
persistent, Belladonna, Pulsatilla, Sanguinaria, and occasionally an
anodyne may be employed.. Drosera, Bromide of Potassium, Trifolium,
Bromide of Ammonia, etc., are advised by Prof. J. M. Scudder. If
the cough be due to irritation of the diaphragm and lungs from upward
pressure of the enlarged uterus, but little can be done, except to keep
the bowel? regular, the urinary organs healthy, and during sleep to
have the head kept in a somewhat elevated position. The cough will
pass away after parturition.

Mastodynia, or a painful and distended condition of the breasts, is
very apt to attend pregnancy, especially with prirniparaB, and may be
owing to the rapid development of these organs and flow of blood to
them. When severe, relief is frequently afforded naturally by a thin,
colorless, serous discharge from the nipple. To relieve congestion,

232 KIND'S KCLKCTIC

aiul prevent inflammation, which are the principal indications, topid
fomentations may be applied, together with an anodyne liniment, as a
mixture of Oil and Laudanum; the bowels must be kept free, and all
pressure upon the breasts removed. The Sp. Tr. of Phytolacca Dec.
will be found exceedingly useful in these cases, in doses of one to two
minims, administered in some water, and repeated every three or four
hours, at the same time applying it locally. Tincture of Iri.s Versi-
color will also prove beneficial in many instances.

pain about the pelvis and hips, as well as the abdomen,
frequently accompany pregnancy; the cause of these pains is supposed
to be owing to pressure on the anterior branches of the sacral nerves ;
but this could only happen when there has been a descent of the uterus,
at the termination of utero-gestation, for prior to this period the uterus
is too much elevated for its inferior portion to compress these nerve-.
As these pains are more common after fatigue, they are probably de-
pendent on an irritable condition of the nerves of the painful muscles,
and should be treated principally by rest. In severe cases Macrotys
may be given internally, and stimulating liniments may be rubbed
over the affected parts, and the back; and the pain of the abdominal
muscles may be frequently relieved by the use of a bandage.

Mania, or insanity, usually attacks pregnant females of a hysterical
disposition, or those who are hereditarily predisposed to it. It may
occur at any period of utero-gestation, from conception to parturition,
and as a general rule, is not so severe as that which occurs in the
puerperal state, and ceases with delivery. The treatment must be
principally moral, meeting any symptoms which present themselves,
according to their indications; employing tonic means, where debility
is present; Pulsatilla, Macrotys, Stramonium, and the Bromides, as
they may be specifically indicated, where there is much nervous irri-
tability; and the means recommended for plethora, or albuminous
urine, should these exist. The application of cold to the head, stimu-
lants to the spine, and cups to the temples or back of the neck, should
always be employed, as may be indicated, to overcome any local con-
gestion. When the mania is acute, treat it in the manner recom-
mended for Puerperal Mania, which see.

Beside the several affections which have just been named, as owing
to nervous sympathy and deranged circulation, there will be found

DISEASES OF THE PTIPXiXANT FEMALE. 233

certain changes in the mental condition of the patient; thus .she may
become very despondent, or very irritable. The former, when severe
and obstinate, and accompanied with gradual loss of health, may
terminate eventually in puerperal mania ; the latter has nothing serious
in its tendency, and disappears after delivery. The first must be treated
by moral as well as therapeutical means; the patient should be kept
from all depressing circumstances, should be led into cheerful society,
where she will not hear of any wonderful or fatal accidents having
occurred to parturient women, and should be exhorted to overcome
the tendency to despondency as much as possible ; the therapeutical
measures should be Pulsatilla, Viburnum, the Compound Tonic Mix-
ture, cold to the head, diuretics, etc., if plethora exist; and chalybeate
tonics when an anaemic condition is present.

The second should be treated by the use of Macrotys, keeping the
bowels regular, and should wakefulness be present, the following may
be administered, Sp. Tr. of Aconite, Sp. Tr. of Hyoscyamus, Sp. Tr.
of Gelscmium, etc., as indications direct. The patient should take
moderate, but regular exercise daily in the open air, and the diet
should be of a non-stimulant and non-heating character.

Pruritus of the Vulca, Prurigo, or itching of the Genitals, occurs
during the early months of pregnancy, and is sometimes very distress-
ing; occasionally it continues during the whole period of utero-gesta-
tion, and disappears immediately after delivery. It may be caused by
uncleanliness, acrid discharges, and frequently, according to Dewees,
from aphthous efflorescence of the vulva ; at times, it occurs without
any known cause. In the treatment of this distressing symptom,
means must be employed according to its severity, and the pathologi-
cal condition of the parts affected. In the greater number of cases
a solution of Borax will be found efficient; if much inflammation of
the parts is present, a w r eak solution of the Sesquicarbonate of Potassa,
or of Nitrate of Silver may be applied locally, and as it subsides an
astringent infusion may be substituted, as of Geranium and Golden
Seal ; a compress of lint or soft linen should be moistened with these
applications, and placed between the labia immediately in contact
with the affected parts. A very excellent preparation is composed of
Carbolic acid five grains, Acetate of Morphia four grains, Dilute Hy-
drocyanic acid one fluid drachm, Glycerin two fluid drachms, distilled
Water a sufficient quantity to make two fluid ounces of the mixture;
moisten some lint with this, and apply it upon the part affected. In

234 KING'S ECLECTIC ORSTETRICS.

all cases the bowels should be kept regular, and the parts well cleansed.
Occasional tepid baths may be employed with benefit, and sometimes
the induction of diaphoresis will produce a favorable result. Inter-
nally, but little means are required; Rims Tox, Apis, or Eryngium
may be administered, if such agents are desired. If the pruritus pre-
sents characters pf periodicity, Sulphate of Quinine, Macrotys, or
Arsenicum, etc., may be administered, according to the indications
present. The Juniper Pomade applied on lint, I have found highly
successful in a number of cases; and in others, the disease has disap-
peared as if by magic, upon the local application of a lotion composed
of a saturated aqueous solution of Sulphurous Acid Gas one fluid
ounce, and rain-water three fluid ounces. The saturated solution may
be made by passing a stream of the gas through water, until this is
saturated. Wet a piece of lint or linen with it and apply to the part.
One part of Carbolic acid to fifty or sixty parts of water may fre-
quently be locally applied with advantage. If the itching be due to
pediculi, Cologne, or the above carbolic preparations, will remove
them without any necessity for the use of that filthy and undesirable
mercurial ointment.

CHAPTER XXII.

DISEASES OF THE PREGNANT FEMALE Continued.

THE symptoms or affections originating from compression of the
enlarged uterus upon neighboring organs are several. (Edema, or
serous infiltration into the cellular tissue of various parts of the body,
will be first noticed. It may occur in the early months of pregnancy,
but is most common in the latter months, and is generally attributable
to pressure of the enlarged uterus upon the blood-vessels of the pelvis,
thereby interrupting the circulation, and finally resulting in effusion.
It is not, however, always produced from this cause, as frequently the
size of the uterus bears no proportion to the extent of the oedema, but
is usually small; and, again, w r e frequently find the uterus enormously
distended, either by excess of liquor aranii or plurality of children, with-
out any accompanying oedema. In those instances where the swelling
is caused by uterine pressure, it is mostly confined to the lower extrem-
ities, but where it spreads over the whole body it is due to plethora,

DISEASES OF TJTE PREGNANT FEMALE. 235

or renal congestion, which may be known by the presence of albu-
minaria, and either of which is unfavorable. Convulsions are very
apt to succeed oedema from these latter causes. Ordinarily, no pain
accompanies this affection, yet, occasionally, it is very painful. Where
the swelling is confined to the feet and ankles, quickly disappearing
on assuming the recumbent position, but little treatment is required;
but where it becomes so great as to render the recumbent position
almost impossible, from dyspnoea, or where it is complicated with
effusion into any of the important cavities of the body, it becomes of
a serious nature, and requires energetic treatment. In the milder
cases, when confined to the lower extremities, and where treatment is
required, relief may be afforded by the administration of laxatives,
with cold applications to the cedematous part, at the same time sup-
porting the limbs with a bandage well applied. The rubber, or
elastic, bandage is more efficient in these cases than if made from
other material, as the degree of pressure can be regulated, thus pro-
ducing more uniform support. In severe cases, purgatives and di-
uretics will be beneficial, and it will often become necessary to induce
premature labor as the only means of saving the patient's life, who
can not possibly live up to the full period with an increasing infiltra-
tion. When oedema is not dependent upon some important organic
lesion, it usually disappears after parturition. When renal conges-
tion is a cause of the effusion, in addition to the above treatment cups
may be applied over the region of the kidneys, and, if obstinate, a
discharge may be maintained from this region by means of an irritat-
ing plaster. Puncturing and scarification of the cedematous limbs are
advised by some authors, but they should not be attempted, as they
are most usually followed by gangrene.

When, by pressure of the enlarged uterus upon the pelvic blood-
vessels, the circulation within the lower extremities is obstructed, it
gives rise to a varicose condition of their veins. This difficulty is a fre-
quent accompaniment of the latter months of utero-gestation, and is
more apt to occur in women of an advanced age, than in young females.
As they are owing to the impeded circulation in the extremities, their
cure can not be effected until the cause is removed, when they usually
disappear spontaneously. Sometimes they continue after delivery,
gradually increasing, and on each subsequent pregnancy augmenting
considerably in size, forming tumors which are more or less painful,
embarrassing the movements of the female, and often terminating in

*23<) KIN<;'s KCLKCTIC OBSTETRICS.

obstinate nlcerations. Rupture of these veins is the principal acci-
dent to fear, as it may prove fatal, and the practitioner's treatment
.should be especially directed to a prevention of its occurrence. The
patient should not be long at a time on her feet, but should keep in a
horizontal position, with the dress loose, and the employment of
properly graduated pressure over the veins by means of bandages, or
elastic stockings. The bowels should be kept free, the diet spare, and
the bandages may be kept moistened with cooling applications,
especially in severe cases. If the varices are situated in the genital
parts, as the vulva or vagina, compresses moistened with cooling
lotions may be applied, and continued for some time, or until the
enlargements disappear, in order to prevent rupture, which sometimes
happens, especially at the time of parturition, during the passage of
the fetal head through the pelvic canal. Within a year or so, new
modes of treating varicose veins have been suggested; one by Dr.
Linon, in which he thoroughly moistens a flannel compress with a
solution of six drachms of perchloride of iron in eight ounces of
water, applies this upon the varicose part, and holds it there for
twenty-four hours by means of a roller bandage of flannel applied
moderately tight. This application is to be repeated daily for ten or
twelve days in succession, or until the varices have disappeared, after
which the bandage may be continued for some days without wetting
the compress. This is stated to have cured enormous varices, accom-
panied with pain and dark spots; an improvement in the venous di-
latations will be observed from the first appplication. Dr. Rugge, of
Berlin, has met with success by subcutaneous injections of one or two
grains of Ergotin, repeated every few days, the varices gradually dis-
appearing from the first injections. Pain and infiltration followed
each injection, but were succeeded by no abscess, nor any influence in
provoking uterine contractions. The best vehicle is Glycerine, five
grains of the Ergotin to one fluid drachm of this fluid. Prof. Scudder
prefers the Hamamelis.

From a cause similar to the above, hemorrhoids, or piles, may be
produced, and more particularly if constipation be present. Occasion-
ally they are an attendant of diarrhea. They are similar in nature and
appearance to those occurring at other times, and require the same
local treatment. When slight, they may be removed by producing
regularity of the bowels by means of laxative medicines, with cold
and astringent applications to the parts. Although Magnesia, as the

DISEASES OF THE PREGNANT FEMALE. 237

rule, is contra-indicated in pregnancy, on account of its tendency to
accumulate in the intestines, the following preparation is stated to be
very beneficial in procuring daily soft alvine evacuations without
pain : take of Sulphate of Magnesia, Carbonate of Magnesia, Bitar-
trate of Potassa, Sublimed Sulphur, each, equal parts. The dose is
from one to three teaspoonfuls before breakfast, according to its action.
Internal agents may be administered, in the hope of overcoming the
trouble by stimulating the venous circulation ; Hamamelis and Col-
linsonia may be employed, either singly or in combination, for this
purpose, and will oftentimes effect a cure. Owing, however, to the
fact of this condition being the direct result of mechanical pressure,
therapeutic means do not always relieve ; the annoyance and suffer-
ing continuing until the cause is removed by parturition. If pain or
irritation exist, narcotic ointments, as Poke, Stramonium, etc., may
be applied with benefit, and where the tumor protrudes externally the
pain and iritation may be relieved by the application of Laudanum,
incorporated in Juniper pomade, or Glycerole of Tannin on absorb-
ent cotton. The removal of piles by an operation, during pregnancy,
is totally inadmissible and unjustifiable. Nor can a perfect cure be
expected until after parturition, when the pressure has been removed
by a return of the uterus to its nongravid condition. I have derived
considerable benefit, in this difficulty, from an ointment composed of
Stramonium ointment, one ounce, Alum, two drachms, Sulphate of
Morphia, ten grains; mix, and apply a small quantity on lint or
cotton. Another valuable local application is the Persulphate of Iron.
A solution of Borax, also, is a cooling application, and will relieve
the itching and burning ; the parts may be washed with it morning and
evening. An ointment composed of Tannin, ten grains, Acetate or Mu-
riate of Morphia, two grains, pure Lard, or Spermaceti ointment, one
ounce, has also been advantageously employed as a local application.
All these ointments should be applied two or three times a day, and
be carried well up into the rectum. Occasionally the pain and irrita-
tion become so excessive that the direct application of anodynes will
be called for. Cocaine may be employed ; a four per cent, solution
will usually mitigate the suffering. Many other remedies have been
employed in piles with benefit, and others may suggest themselves to
the mind of the practitioner, but whatever local means may be used,
it is of the greatest importance to keep the bowels regular, the diet
spare but nutritious and easily digested, and avoid too much exercise,
or even long standing.

238 KINGS KCLKCTIC OI'.STKTKK 'S.

Should hemorrhage l>e present, it must be checked, especially when
considerable, or it may occasion miscarriage; for this purpose astrin-
gents, cold applications, and compression may be employed. A prep-
aration composed of Stramonium ointment, one ounce, Styptic powder
(calcined Sulphate of Iron), two drachms, and powdered Alum, one
drachm, employed as a local application, and introduced as far as
possible into the rectum by means of the finger or otherwise, will be
found very valuable in all cases of hemorrhoids accompanied with
hemorrhage. Persulphate of Iron, diluted about one-half, and ap-
plied on cotton or lint, will also act promptly in controlling the bleed-
ing. Injections of warm water may be used for this purpose, when
other means are not at hand. Fluid extract of Witch-hazel bark,
taken internally, has also proved very useful.

Prolapsus ani is occasionally met with as a concomitant of piles, or
it may occur independently; it is often attended with excessive pain
during an alvine evacuation, together with distressing tenesmus, and
is usually produced by the same causes which occasion piles, viz.:
pressure. This symptom is exceedingly annoying and distressing,
and but little can be done toward a cure of it, until after delivery is
accomplished, when, as a general thing, the cause being removed, a
spontaneous cure is effected.

With this complication, the parts are usually relaxed to the degree,
that extrusion of a portion of the mucous membrane of the rectum is
produced by the slightest causes. It is cpaite likely to follow constipa-
tion ; in some cases every evacuation of the bowels is followed by a
return of the difficulty; straining at stool, and coughing are also ex-
citing causes. Temporary relief is all that can be expected in the
way of treatment ; whenever the prolapsus occurs it should be returned
as soon as possible. Place the patient in the knee-elbow position,
anoint the fingers before manipulating the parts, and endeavor care-
fully to return the part first, which escaped last. This is a simple
operation, and one the patient can execute after a short time, without
professional assistance. If painful, the protrusion can be painted with
a solution of Cocaine before an attempt is made to return it, after
which the parts may be supported by passing within the anus a pledget
of cotton, which may be saturated with Glycerole of Tannin, or other .
mild non-irritating astringents. The female should be instructed as
to the after treatment, in order to properly apply it in subsequent
attacks. Prolapsus ani is a very troublesome affliction during par-

DISEASES OF THE PREGNANT FEMALE. 239

turition, as every pain is apt to cause a protrusion of the bowel, ren-
dering it irritable and most acutely sensitive.

Cramps of the inferior extremities, sometimes extending as high as
the upper pelvic region, are occasioned by pressure of the gravid uterus
upon neighboring nerves; they may likewise be occasioned by stand-
ing upright for a long time, too much exercise, fatigue, constipation,
or extension of ligaments. They are sudden in their attacks, are occa-
sionally very frequent and painful, and mostly occur during the latter
months of pregnancy. Friction over the affected part, and change of
position will ordinarily remove them; and when they are frequent in
their attacks, relief can often be afforded, and this disposition to fre-
quency obviated, by an attention to the bowels, together with the use
of Macrotys, or Xanthoxylum. Viburnum will often overcome this
trouble, especially if the patient take the recumbent position during
its administration, and so remain, quietly, until the paroxysm sub-
sides. The application of a liniment composed of equal parts of Aq.
Ammonium, Turpentine and Olive oil, will be found quite serviceable
in relieving the spasm of the part. The soreness caused by the cramps
may remain for sometime after their cessation, and may be removed
by rubbing the parts with some Camphorated oil, or the officinal com-
pound tincture of Camphor. . Gelsemium may also be administered
with benefit.

The pregnant female frequently suffers from a deep seated pain in
the right side, which most commonly manifests itself after the fifth
month; it is unaccompanied by cough, or any febrile or inflammatory
symptoms, and is attributed to the fundus of the uterus pressing
against the concave surface of the liver. It is not present until after
the ascent of the uterus above the superior strait never occurs in left
lateral, or anterior obliquity of the uterus, but only in right lateral
obliquity, and is much relieved, after the eighth month, by the falling
or descent of the uterus into the pelvis. Permanent relief can not be
had until after delivery, yet when severe, the female may derive con-
siderable benefit from change of position, standing, lying on the left
side, stretching upward, and leaning to one side ; in addition to which
the bowels should be kept free. At least one evacuation should be
solicited daily. Regularity in going to stool will often correct any
irregularity in this regard. Proper attention to diet, and judicious
exercise should be advised. One drop of Nux in a glass of water

J4 KING'S ECLECTIC OBSTETRICS.

may be taken each morning, or mild laxatives, if they become neces-
sary. When the pain is excessively severe, cupping will sometimes
mitigate it. The diet should be light and non-stimulant.

Jaundice, occasionally occurs during pregnancy, and is owing to
pressure upon the gall-ducts by the neighboring viscera, which are
compressed by the gravid uterus, in consequence of which there is not
a free escape of bile; it is more severe when it happens during the
latter months, and is usually attended with dyspeptic symptoms. But
little can be done for this evil; though it .is proper to regulate the
bowels, and attend to the diet. Should it remain after delivery, it
must be met with the appropriate treatment.

Females who have given birth to many children are sometimes
annoyed with a lax condition of the abdomen, in which the abdominal
parietes, from their excessive looseness, do not afford support to the
enlarged uterus, thereby allowing it to fall in any direction. The best
treatment, in such cases, is a local application composed of astringent
and slightly-stimulant agents, together with mechanical support by
means of an appropriate belt or bandage, and the patient should as-
sume the recumbent position daily, for three or four hours at a time.

In opposition to this, we frequently meet with a very rigid condition
of the abdomen, in which its parietes do not give way in proportion to
the gradual augmentation of the volume of the uterus. This is most
common among primiparse, occasioning much distress, in consequence
of the tender and irritable condition of the parts, the skin over which
often cracks. This may sometimes be relieved by rubbing Sweet oil,
Almond oil, simple ointment, etc., over the part, and if very painful
or tender, it may be relieved by hot, or soothing applications, Cloths
wrung out of hot water, or a fomentation of Hops. If abrasions exist
the parts may be painted with a solution of Cocaine. Internal treat-
ment is useless.

There are other symptoms occasionally met with during pregnancy,
which are due to pressure, or nervous and vascular sympathetic de-
rangement, and \vhich deserve a passing notice. Thus, in the latter
months of pregnancy, females are unable to retain their urine, which
escapes upon the least exertion, and may or may not be accompanied
with tenesmus or a frequent desire to evacuate the bladder; this incon-

DISEASES OP THE PKEGXANT FEMALE. 241

tinence of the urine seldom admits of relief until the removal of the
cause the pressure of the bladder by the enlarged uterus by deliv-
ery; perhaps, some benefit may accrue by giving support to the abdo-
men. It is a very annoying symptoin, but is by no means dangerous.

Occasionally, pustules around the genital organs may appear, or
vaginal mucous discharges of a whitish color, tinged sometimes with
green, or blood. These symptoms disappear after delivery, and require
no other treatment than cleanliness, frequently bathing and injecting
the parts with Fluid Hydrastis, or solution of Borax, or other similar
combination. The practitioner must be careful not to injure his pa-
tient's reputation as well as his own, by pronouncing either of these
as syphilitic, on too slight grounds, for they are often the legitimate
results of pregnancy.

Pressure of the uterus is apt to occasion congestion of various
organs, especially of the lungs, or stomach, in consequence of which
hemoptysis or hematemesis may result from exudation of blood from the
mucous membrane. These hemorrhages may be treated by laxatives,
sedatives, astringents, and the means usually employed for them when
existing at other times. Should they, at the time of parturition, be-
come excessive, resisting the treatment employed, the delivery should
be hastened by artificial means.

There are likewise symptoms which occur during utero-gestation,
depending upon an abnormal condition of the uterus, its supports, or
its contents. Among the displacements of the organ, prolapsus or
descent, are the most common, and it usually takes place during the
first months, before the ascent of the uterus above the superior strait;
though it must not be forgotten that, during the early weeks of preg-
nancy, there exists, probably from an augmentation of the weight of
this organ, what may be termed a normal prolapsus; but when it
exceeds this normality it then becomes abnormal and demands treat-
merit. The patient will complain of a bearing-down sensation, with
pain and uneasiness in the sacral region, and frequently in the lower
part of the abdomen. The prolapsus will be more or less perfect ac-
cording to the capaciousness of the pelvis, and the laxity of the liga-
ments. Where there is an excess of pelvic dimension, a sudden
prolapsus may take place in an advanced stage of pregnancy, from
straining, over-exercise, or some unusual exertion. This displacement
not only occasions abortion, but is frequently caused by it, from the
16

242 KING'S ECLECTIC OBSTETRICS.

uterus being left in an inflamed or hypersemic condition ; it may also
be produced by straining, debility, and whatever circumstances would
give rise to it in the uuimpregnated state. This difficulty may give
rise to very serious evils, and should be promptly treated. Ordinarily,
the employment of astringent vaginal enema, rest in the recumbent
position, the wearing of external supports or bandages, and regularity
in the evacuations from the bladder and bowels, will answer the pur-
pose. In very severe and obstinate cases other measures may be
required; the rectum and bladder should first be evacuated; the pro-
lapsed organ should then be carefully placed in its proper position,
and retained there by a piece of fine sponge introduced into the vagina,
and the patient should maintain as much as possible the recumbent
position, until the increased volume of the uterus would prevent any
further prolapse. The sponge may be moistened with some astringent
lotion, if desired, and should be cleansed every two or three days.
Any accompanying symptoms, as debility, constipation, etc., must be
met by appropriate treatment. If the mechanical treatment, by sponge
or other pessary, occasions irritation, increased suffering, or pain, it
will have to be omitted, and the preceding measures be pursued.
AVhen we find an impaction of the uterus within the pelvis, render-
ing its reduction impossible, abortion will have to be induced.

Retroversion of the gravid uterus, is sometimes met with, as well as
in the unimpregnated organ ; in this displacement, the fundus is found
backward, at or below the promontory of the sacrum, while the os
tincse is carried forward and upward, either upon, or above the pubic
symphysis, and the vagina being dragged along with the os, its ante-
rior wall will be likewise carried forward and upward, while its pos-
terior wall will be considerably depressed. Retroversion of the uterus
may come on slowly or suddenly, it seldom exists in the latter months
of pregnancy, and usually takes place between the second and fourth
months. It may be owing to various causes; a very common one is
a retention of urine until the bladder becomes enormously distended,
which extending backward and downward, thrusts the uterine fundus
along with it in the same direction ; or a large pelvis may predispose
to this accident, but it is not an essential condition ; relaxed condition
of the uterine supports, augmented weight of the fundus with relaxa-
tion of the parts, great concavity of the sacrum, ovarian enlargement,
tumors, violent efforts, straining at stool, blows, falls, vomiting, poly-
pus, hydatids, etc., are each capable of effecting this displacement

DISEASES OF THE PREGNANT FEMALE. 243

under favorable circumstances. The symptoms accompanying retro-
version are, a partial or complete retention of urine, which often takes
place suddenly ; when it is partial there is a desire to urinate frequently,
the water passes off in small quantities at a time, but never in suffi-
cient amount to empty the bladder, and finally, it involuntarily drib-
bles away, and the enormous distension of the bladder creates a chronic
inflammation, or what is yet worse, it may become ruptured. Defe-
cation is also very difficult, the feces being flattened and passing in
small quantities; and both the dysuria and difficult defecation are in-
creased by any efforts at evacuation. When retention of urine is pres-
ent in the early months of pregnancy, the practitioner should suspect
retroversion, and adopt the proper means to satisfy himself in relation
to it. In connection with these two prominent symptoms, there w r ill
be an aching pain in the sacrum, thighs, and pubes, with weight in
the pelvis and disagreeable bearing-down sensations. When retrover-
sion is suspected in the pregnant female, an examination should be
immediately demanded, for if it be not promptly attended to, it may
occasion the death of both the mother and child, as may be readily
imagined, when an enlarging uterus becomes impacted in the cavity
of the pelvis, preventing micturition by its pressure upon the urethra,
causing irremediable constipation by compression of the rectum, and
intense suffering by pressure upon the anterior sacral foramina and
nerves. Upon an examination per vaginam, which must in all cases
be made, the uterine fundus will be found depressed below the prom-
ontory of the sacrum, with the cervix toward the bladder, and higher
than the crown of the pubic arch; in some instances, the os uteri may
be found in its normal position, with the fuiidus depressed, the cervix
being bent or flexed at an angle, in which the uterus is shaped some-
what like a retort; this is termed retroflexion, and is not common in
the pregnant condition. If this displacement be not relieved, the pains
continue to increase, vomiting takes place, with peritonitis, and the
patient dies from inflammation or sloughing ; and it must be remem-
bered, that the later the gestating period in which the retroversion
occurs, the greater is the danger.

In treating a case of this character, before any attempt at reduction
is made, the bladder must be emptied by means of a male elastic
catheter, bearing in mind that the displaced uterus, having elevated
the neck of the bladder, causes an elongation of the urethra. Some-
times considerable difficulty will be experienced in introducing the
catheter, which may be overcome by pressing the uterus backward,

244 KING'S ECLECTIC OBSTETRICS.

and thus liberating the urethra, until the instrument has entered.
Soon after the evacuation of the bladder it will often be found that
the uterus assumes its normal position without further interference;
should this not take place, the rectum must be unloaded by copious
injections, as an accumulation of fecal matter within it will very much
interfere with the attempt to replace the uterus properly. Though it
should be stated that injections have sometimes failed to produce the
desired effect, and instead of relieving has aggravated the difficulty.
The patient is now to be placed upon her face, or the operation may
be performed while she lies on her left side, with the nates near the
edge of the bed, and two fingers be passed into the posterior part of
the vagina along the curve of the sacrum, until they come in contact
with the presenting part of the depressed fundus, which must be pressed
cautiously and firmly upward and forward, in the direction of the axis
of the superior strait; for if the pressure be made in any other course,
no reduction can be accomplished. When the reduction is effected,
the womb assumes its position with a sudden jerk, and sometimes a
clicking noise. Sometimes this attempt will fail ; it will then be
proper to introduce one or two fingers into the rectum for the purpose
of pushing the fundus upward and forward, while a finger or two of
the other hand enters the vagina, for the purpose of bringing down
or depressing the cervix, and all these trials should be made steadily,
cautiously, and firmly. In very obstinate cases, the patient may be
placed on her knees, "having the pelvis elevated as high as possible,
while the shoulders rest upon the bed, table, or whatever she is placed
upon, and in this position, having the aid of gravitation, we may
undertake the last named manipulation; this posture is a favorable
one, inasmuch as it tends to overcome tenesmus and bearing-down
efforts. Various other means have been advised to reduce the retro-
verted organ as the use of Bond's instrument for retroversion ; Gariel's
India-rubber pessary, etc., and to produce a thorough muscular relaxa-
tion, the use of Chloroform, or Hydrate of Chloral.

Having accomplished reduction, the patient should be kept in a
recumbent state, until the ascent of the uterus above the promontory,
when its volume has so far augmented as to render any further dis-
placement of the kind impossible; and the bladder should likewise be
emptied every four or five hours . If necessary, anodynes or tonics
may be given according to the indications. Instances are sometimes
met with, in which, afcer the organ has been reduced, it will not re-
main so, but falls over again upon the slightest exertion, and the

DISEASES OF THE PREGNANT FEMALE. 245

operation will have to be performed again and again before the reduc-
tion will remain permanent. In these cases advantage has ensued
from the introduction of a thin gum-elastic air bag, of a fusiform
shape, into the rectum; the large end of this to be introduced, after
which it is to be distended with air, and constantly worn by the
patient, until no longer required ; it admits of easy removal at auy
time by permitting the inclosed air to escape, and then withdrawing it.

The reduction of the uterus may only be partial, so that although
remaining in the pelvis, a part ascends, giving the organ a deformed
shape, still an attention to the bladder and rectum may enable the
patient to reach the full term ; in these cases the labor may be com-
pleted without artificial aid, though it may be tedious and difficult.

Where retroversion has occurred previous to pregnancy, and the
organ is rendered almost immovable by adhesions, or where from
other causes, after a persevering attention to the bladder and rectum,
no permanent reduction can be obtained, it has been proposed to
induce premature labor as the only means of saving life ; but \ve must
be cautious in a resort to this expedient, and should never undertake
it without the opinion of a second or even third practitioner.

In anteversion of the uterus, the displacement is exactly contrary to
the last ; the fundus pressing forward toward the symphysis pubis,
near the level of the superior strait, while the cervix is thrown back-
ward and upward, the os uteri looking toward the hollow of the
sacrum. This may originate from severe exertion while the bladder
is empty, and is more apt to ensue when the ligaments are in a relaxed
condition from blows, falls, tumors, diarrhea, relaxed abdomen, fecal
accumulations, lifting heavy weights, violent exercise, etc. The symp-
toms are, a constant desire to pass urine, which is accomplished with
some difficulty and heat; constipation is frequently present, with
pelvic heaviness, hypogastric pain, and a distressing, dragging sensa-
tion, which is augmented by standing or walking. It is rarely present
during pregnancy, and w r hen it does occur is not so serious as retro-
version. The treatment is : after placing the patient on her back, to
elevate the fundus and pull down the cervix with a finger, or hook,
and afterward, if required, a bandage may be worn, with a compress
over the pubes ; the bow r els should be kept open, but the urine should
not be passed too frequently. The woman should remaiiwlying upon
her back for several days or weeks, as may be required ; though from
the debility following a prolonged confinement of this kind, I gen-

246 KING'S ECLECTIC OBSTETRICS.

erally advise more or less exercise, according to circumstances, the
uterus being held in place by a bandage, and proper support for the
time being.

An aqueous discharge, of a limpid, or yellow color, sometimes takes
place during pregnancy, being variable in quantity, at times passing
by drops, and again occurring suddenly and in large amount. It is
called hydrorrhea, or false waters. Usually this is not a serious affec-
tion, but occasionally uterine contractions of a severe character accom-
pany it, which, if not overcome, will result in the premature expulsion
of the uterine contents. As regards the source from which this fluid
originates, we have no satisfactory evidence ; authors vary in opinion
concerning it, some considering it to be the result of an uterine dropsy,
others to a transudation of the amniotic fluid through the membranes,
some again to a rupture of the allantois, or rupture of the chorion, and
caduca, etc. Most generally, the woman goes on to the full term of
utero-gestation. Where there is danger of miscarriage, the bowels
should be kept in a soluble condition by mild laxatives or injections,
the patient should be enjoined to keep in a state of rest in the recum-
bent position and agents administered to allay any uterine excitement,
among which I prefer the compound powder of Ipecacuanha and
Opium. As soon as any danger of premature labor has passed away,
the patient should take the Parturient Balm, or Macrotys, for the pur-
pose of imparting tonicity to the reproductive organs, in connection
with chalybeates if anaemia be present. When a symptom of this
character attacks a pregnant female, the practitioner should be careful
to ascertain the condition of the bladder, as not unfrequently a dis-
charge of urine may be mistaken for it.

Not unfrequentfy the uterus is attacked with spasmodic action the
organ may be felt rapidly moving from side to side, with frequent
convulsive movements, and will speedily induce premature labor if not
relieved. I find it the best treatment in these cases, to evacuate the
rectum by enema, and the application of heat to the part, as cloths
wrung out of hot water, while internally such agents as Macrotys,
Lobelia or Gelsemium may be given. Anodyne liniments may also
be rubbed on the abdomen.

The impregnated uterus is sometimes attacked with rheumatism,
commonly produced by the same causes which give rise to rheuma-
tism of other parts. It is most common to those of a rheumatic dia-

DISEASES OF THE PREGNANT FEMALE. 247

thesis, and is frequently a metastasis of the pain from some other part.
The symptoms are pain, augmented sensibility of the uterus, which
may be limited to only a part of the organ, or extend over the whole
of it, no contractions, pressure often increases the pain, which may
extend into the loins, groins, and thighs, or which may suddenly be
translated to some other part of the system. There is tenesmus or a
constant desire to evacuate the bladder and rectum.

To remove this last condition, Eryngium, Gelsemium, or Rhus, may
be employed, together with the hot hip bath. Rheumatism as a rule
will be attended with more or less fever; the treatment, then, should
begin, by selecting the proper sedative in combination with anti-rheu-
matics; thus Aconite and Macrotys may be called for, or the pulse
being full and strong, Veratrum should be used in place of the Aco-
nite, or one of the other anti-rheumatics being indicated, it replaces
the Macrotys. The anti-rheumatics in common use are the Macrotys,
Bryonia, Apocynum, Phytolacca, Sticta, Colchicum, Rhus, and Eupa-
torium; Acetate of Potassa and Asclepias are also useful in some
cases. Within a few years several new agents, derivities of coal tar,
have been introduced to overcome pain; they are known as Antipy-
rine, Antifebrine, Antikamnia, as well as several others; they should
be given with care, and their action studied ; they are positively
contra-indicated in weakened heart action. Quinia is often a useful
agent, administered after secretion is established. The alkalies and
acids often prove valuable anti-rheumatics, especially the alkaline
diuretics. Baths, in these cases, are usually more harmful than
beneficial.

The movements of the fetus in utero, are sometimes very violent, or
turbulent, not only occasioning alarm to the mother, but much uneasi-
ness, a sense of sickness, with general nervous agitation, sleeplessness,
febrile symptoms, and often local pain.

This may be owing to an irritability of the nervous system, or to
some preternatural susceptibility of the uterus. It may be removed
by an attention to the bowels, and the administration of Viburnum,
Pulsatilla, Macrotys, or Gelsemium, either singly or in such combina-
tion as indications may direct; the Parturient Balm will frequently
prove beneficial ; and when obstinate, a few doses of the compound
powder of Ipecacuanha and Opium may be given. However, the
practitioner should bear in mind, that narcotics should be employed
as seldom as possible, during pregnancy, on account of their deleteri-

248 KIND'S i-:< LKCTIC OBSTETRICS.

ous influence upon the nervous system of the fetus. The agents, as
named above, will, as a rule, act promptly in overcoming the trouble,
and should be used in preference.

Dropsy of the ovum usually takes place during the early months, and
may be suspected by an unnaturally great increase in the size of the
abdomen, which comes on suddenly, thereby differing from the gradual
enlargement in ascites, and which is rendered still more certain when
the pregnancy is positively determined. It is frequently, however,
very difficult to form a correct diagnosis, and some of our oldest and
most experienced practitioners have been mistaken in relation to it.
Abortion is the common result, the fetus generally perishing before
this accident occurs, especially if the collection of the fluid is great;
and should it be born alive, it seldom survives a few days, or weeks at
farthest. The only treatment, in this affection, is strict attention to
the health of the female, and an absolute avoidance of the operation
of paracentesis ; for no practitioner is justified in performing this
operation on a female who affords the smallest possible suspicion of
pregnancy ; at least until a sufficient time has elapsed for its determi-
nation by the positive signs, as revealed by auscultation, ballotteraerit,
etc. When the quantity of fluid is enormous, giving rise to serious
consequences, the propriety of inducing premature labor by evacuating
the amniotic liquid, may then be considered. Hemorrhage and Abor-
tion will be treated of in the following chapters.

The accidental concomitants of pregnancy, are hernia, tumors, syphi-
litic affections, calculus, deformed pelvis, and extra-uterine pregnancy ; the
latter two have already been treated upon, the others require no espe-
cial consideration at this place; they will be again referred to under
the head of Labor. The treatment for syphilitic affections will be the
same as pursued under other circumstances, independent of pregnancy.

HEMORRHAGE AND ABORTION. 249

CHAPTER XXIII.

HEMORRHAGE AND ABORTION.

WHEN the fetus is capable of continuing its existence, independent
of any uterine connection, it is said to be viable; and the period of its
viability, theugh not precisely fixed, is generally admitted as early as
at the commencement of the seventh month. There are, however, a
few instances on record where children, born as early as the commence-
ment of the sixth month have been reared, but these may be considered
as the exceptions to the general rule. A fetus may move at birth, but
this does not constitute viability. In cases where it is non-viable, or
incapable of sustaining an extra-uterine existence, that is, previous to
the seventh month, and is expelled from the uterus, owing to any
cause whatever, an abortion is said to have taken place. Its expulsion
at any time between the seventh month and full term, is a premature
delivery ; and the term miscarriage is popularly applied to either of
these, indiscriminately, and generally conveys an idea of loss of off-
spring previous to the ninth month.

As hemorrhage and abortion are intimately related, being generally
dependent on, or connected with each other, I will consider them under
one head. Hemorrhage may take place at any period of pregnancy,
and is owing to a greater or less detachment of the ovum from the
uterus, and the more extensive the detachment, the greater is the
probability of, or disposition to abortion. In the earlier months, life is
seldom endangered by hemorrhage, in consequence of the smallness of
the uterine blood-vessels, which tlo not admit of a large and rapid dis-
charge of blood ; but in the latter months, where these vessels have
become much augmented in size, there is always danger from the
hemorrhage which may then occur. It should be stated here, that
women, laboring under hemorrhage in the earlier months, are occa-
sionally lost, the flooding obstinately resisting all treatment ; this is
more usual with debilitated or anaemic individuals, especially those who
have had previous discharges, with large loss of blood.

Abortion may be spontaneous, accidental, or designed, and may
occur at anytime prior to the seventh month, but more frequently about
the third or fourth month, and generally at a period coincident with
what would otherwise have been a menstrual period ; this is undoubt-

ECLECTIC OI5STETKICS.

edly owing to the delicate connection existing between the ovum and
uterus at this time, Avhereby a separation of the former may ensue
more readily from even slight causes than in the latter months, when
this connection is more persistent. Abortion is not usually a serious
accident, as many females abort several times, successively, and few
women who bear offspring pass through their menstrual life without
aborting one or more times. The principal dangers are from excessive
hemorrhage, or the constitutional injury inflicted by a series of suc-
cessive abortions. The causes of this accident are numerqus, and have
been divided into constitutional, or depending upon the condition of
the maternal health ; ovuline, or attributable to some disease of the
ovum ; uterine, or originating from an abnormal state of the uterus
and its appendages; and accidental, or owing to circumstances not
immediately connected with the condition of the uterus, ovum, or
mother.

No particular class of females are especially liable to abortion ; it
occurs among those who enjoy the idle, sedentary, luxurious habits of
fashionable life, and among those who are obliged to earn their daily
subsistence by hard labor ; the most robust may abort as well as those
of a delicate and nervous disposition ; though it may, probably, be
more frequently observed among those who neglect an attention to the
rules of hygiene. Authors state that plethoric females, those who are
nervous or irritable, or extremely susceptible to external impressions,
and those of indolent habits, abort more frequently than others ; it has
likewise been stated that abortion may occur as an epidemic. The con-
stitutional causes are tuberculous diseases, as scrofula, anemia, phthisis,
and recent cutaneous affections, epilepsy, hysteria, abdominal tumors,
leucorrhea, diarrhea, dysentery, constipation, strangury, or, measles,
scarlatina, pelvic peritonitis, typhoid fever, small-pox, and other acute
diseases. Syphilis is likewise a common cause. Among these causes,
when they occur, probably, syphilis, epilepsy, small-pox, and scarlet
fever, are the most certain. Ascarides, piles, or other diseases of the
rectum, as well as of the bladder, ovaries, and kidneys, by the irrita-
tion they communicate to the uterus, may likewise become causes.

Females, during pregnancy, or even after a recent confinement,
should never be vaccinated, because in either case it exposes them to
great hazard ; this- is a point to which especial attention should be paid,
not only on account of the abortion which would very probably follow,
in the first condition, but, in either, violent fever or inflammation of
the veins, might be produced, resulting in death.

HEMORRHAGE AND ARORTIOX. 251

The ovuliue causes are numerous; thus, the fetus may be affected
with the parental diseases, as measles, small-pox, scarlatina, lead pois-
oning, mercurial salivation, typhus, etc., which may either occasion
its death, or cause its attachment to the uterus to become so delicate
as to render abortion unavoidable. Syphilitic disease may be commu-
nicated to the ovum by the male parent, as well as the female ; and a
seminal fluid vitiated by debauchery, or having its vitality enfeebled
by age, may also give rise to an unhealthy embryo, the result of which
will be an abortion. Atrophy, also hypertrophy of the placenta, may
so debilitate its connection with the uterus as to become a cause of
this accident. An effusion of blood between the placenta and uterus,
termed by M. Cruveilhier placental apoplexy, may separate the pla-
cental connection, and give rise to abortion ; placentitis, hydatids,
syphilitic or fatty degeneration of the placenta or chorion, rupture of
the umbilical vein, etc., will also produce it. Whenever the fetus is
dead, from whatever cause, it becomes a foreign body, excites uterine
contraction, and must inevitably be expelled, though frequently some
time may pass between its death and expulsion. Other diseases of
the embryo or its appendages as, hydrocephalus, pulmonary disease,
disease of the chorion or amnion, etc., may likewise occasion abortion.
Indeed, it is supposed, that the most common causes of this accident,
are those referable to the condition of the ovum.

Among the uterine causes are, prolapsus, retroversion, anteversion,
adhesions, uterine irritability, uterine congestion, fibroid tumors, poly-
pus, cancer of the cervix, diseases of .the tubes or ovaries, ulceration
of the cervix, corroding ulcer, etc. Madam Boivin found that, among
a great proportion of those females who habitually aborted at a regu-
lar period of utero-gestation, dissections revealed uterine adhesions to
the bladder, rectum, or other neighboring organs ; of course, if these
adhesions are considerable, there can be but little expectations of cure.

The accidental causes are falls, blows, coitus, severe exercise, lifting
heavy weights, working on sewing machines, rough motion on horse-
back, in carriages, or, in railroad coaches, or violent concussion of the
body from jumping; and the membranes'of the ovum may be so frail
as to rupture upon a very slight compression of the uterus, occasioned
by coughing, sneezing, extracting a tooth, or straining at the stool.
Abortion is also occasioned by emesis, drastic purgation, tight-lacing,
terror, grief or excess of joy, together with the criminal means fre-
quently employed for this purpose. It is unnecessary to enter into
a detailed relation of these causes, as they can seldom be obviated
by the practitioner, whose principal efforts will be directed toward

252 KING'S ECLECTIC OBSTETRICS.

preventing their results from becoming dangerous. Some women abort
from the slightest causes, while with others again, the most serious
accidents produce no influence of this kind. It is stated that abortion
has been caused by the mere smelling of a pungent odor, but I pre-
sume such instances must be very rare. Among newly-married
jxT.-oiis, abortions frequently occur from the abuse of coition, and this
will likewise prove a very fertile cause of the accident among child-
bearing females at any period, especially when they have some
displacement or disease of the uterus; and I am fully of the opinion
that what are termed, "abortions from habit," are chiefly due to this
act. A recent author claims that fully one-half the spontaneous abor-
tions 'are directly the result of excessive sexual indulgence during
pregnancy. As a general rule, it may be observed, that when the
ovum is healthy, and its placental connection is firm, the production
of abortion in a pregnant female will be found very difficult to effect,
except it be attempted by some mechanical means, when it will be
apt to assume its more serious character; but if the ovum be diseased,
the tendency to abort will be in proportion to the influence of the
disease upon it, and its placental connection with the uterus.

Abortion is undoubtedly produced by the mammary irritation result-
ing from continued lactation during pregnancy; and with many
females, conception, as well as menstruation, is retarded while the
child continues to suck. But whenever the menses appear during suck-
ling, the child should be immediately weaned, both for its own advant-
age as well as that of its mother ; and the same course should be
adopted when pregnancy happens. Frequently, a threatened abortion
may be checked, and the female be enabled to reach full term, by
immediately weaning the child upon the first appearance of pain or
bloody discharges.

The symptoms of abortion are very much modified by the causes
which produced it, and the period of pregnancy at which it occurs.
If it happens during the first days of pregnancy, it is accompanied by
little or no pain, and is often mistaken by the female for a difficult
menstruation ; and the ovum which usually passes away entire, and
accompanied by a greater or less amount of blood, is looked upon
merely as a coagulum or clot. When the pregnancy is more advanced,
and especially when the abortion proceeds slowly and gradually, vari-
ous premonitory symptoms may present themselves, as a feverish or
irritable condition of the system, loss of appetite, nausea, cold extremi-
ties, swelling of the eyelids, with lividity, mental depression, intermit-
tent pains in the loins, a sensation of weight about the vulva, frequent

HEMORRHAGE AND ABORTION. 253

desire to urinate or defecate, and flaccidity of the breasts; the pains
continue to increase in frequency and force; they extend over the
abdomen, running toward the coccyx, and finally assume the characters
of true uterine contractions. A sanious and bloody vaginal discharge
takes place, and, as the pains continue, the dilatation of the os uteri
progresses, the membranes protrude, become ruptured, the liquor
amnii escapes, and, sooner or later, the ovum, either entire or in part,
i.s expelled. As all these symptoms, with the exception of rupture of
the membranes, may occur in pregnancy without any subsequent abor
tion, the practitioner must be guarded in his diagnosis, unless he
knows positively that the fetus is dead.

Most frequently, however, there are no precursory or constitutional
symptoms; the first sign being the hemorrhage, which is more or less
abundant, and is followed by a cessation of the fetal movements,
diminished size of the abdomen, flaccid breasts, a sense of coldness in
the hypogastrium, uterine contractions or pains, and expulsion of the
fetus. If the fetus is dead, or the liquor amnii has been discharged,
abortion will almost certainly take place, sooner or later, though no
time can be positively determined after the death of the fetus, for its
expulsion.

Between dysmenorrhea and abortion there is considerable resem-
blance in the character as well as the seat of the pains; both are
intermittent, and both cease after expulsion of the uterine contents;
hence, it becomes the accoucheur to proceed cautiously in forming his
diagnosis. He must first endeavor to ascertain whether pregnancy
has. taken place ; failing in this, he must inquire into the character of
the previous menstruations, whether they were painful, accompanied
with much hemorrhage, etc. And he should never fail to examine all
the discharges, especially the clots, if they have not been thrown away,
breaking them down between the fingers, and among which he may
discover the entire ovum, or only a portion of it; indeed he should
require the nurse to save all the discharges during the progress of the
abortion, that he may, by this examination, not have a clot of blood
mistaken for the ovum, and every practitioner should perfect himself
in a knowledge of this kind, not only by an examination whenever
the opportunity occurs, but also by procuring, if possible, ten or
twelve specimens of ova at various periods of pregnancy, and preserv-
ing them, so as to accustom the eye to a familiarity with them; though
it must not be forgotten, that the ovum may pass away without having
been observed, or even be discharged in minute portions with the
sanguineous discharge, more or less hemorrhage continuing for some

jr>4 KING'S ECLECTIC OBSTETRICS.

time subsequently. If he ascertains that the former menstruations
were healthy, and that between the present difficulty and the last
menstruation, one or two months have been passed without any dis-
charge, these are strong grounds for suspecting abortion; if pregnancy
e\i.-ts, abortion is undoubtedly in progress. The blood in dysmen-
orrhea is menstruous, while that in abortion is sanguineous, and
escapes in larger quantities than is usual to the catamenia. The finger
should likewise be introduced into the vagina for the purpose of ascer-
taining the condition of the cervix, and if it be found shorter than
normal, its orifice patulous and sufficiently dilated to admit the end
of the finger, and especially if during a pain, the membranes are
found tense and protruding, the diagnosis becomes more certain.

The diagnosis of abortion is more positive as the period of utero-
gestation advances, because the development of the uterus can then be
readily ascertained, the pains will be more violent, the hemorrhage
more abundant, and the dilatation of the os uteri more easily detected.
After the fifth month the death of the fetus may also be more posi-
tively ascertained by auscultation, which will fail to detect the sounds
of the fetal heart, and if it has been dead for a few days, there will be
found an emaciation and flaccidity of the breasts, a diminution in
volume of the abdomen, with weight in the hypogastrium, dragging
sensations about the loins, and cessation of the fetal motions which
were previously observed by the female. In the early months of
pregnancy, if nausea, vomiting, or other sympathetic irritations con-
nected with this condition, and which are present with a patient,
beqome suddenly suspended, it affords grounds for suspicion of ap-
proaching abortion.

The prognosis of abortion varies according to its cause, as well as
the period in which it occurs; females who abort are always exposed
to more danger than when delivery takes place naturally at full term.
In a few cases, death takes place during the accident, but more com-
monly no immediate fatal effects happen, though they are very apt to
ensue as secondary results, being the consequence of some chronic
disease of the uterus, ovaries, etc., produced by the abortion. Females
at full term are more subject to acute maladies, which often prove
immediately fatal, while the serious results of abortion more commonly
manifest themselves at a remote period ; yet grave consequences may
occur speedily under either of these conditions. Abortion is very
generally unfavorable to the fetus, because its expulsion happens
during its stage of non-viability, and its death must inevitably take

HEMORRHAGE AND ABORTION. 255

place; or, the abortion may have been determined by its death. In
this latter ease, the fetus, acting as a foreign body, excites the uterus
to contractions : but this eifect may not take place for weeks and even
months after its death.

Abortion occurs with more difficulty, and is attended with more
danger, after the second month of pregnancy than before, on account
of the increased size of the ovum, and the unfavorable condition of
the cervix to dilatation; and the more advanced the pregnancy, the
greater is the danger from hemorrhage. Probably, abortions occuring
during the third and fourth months of pregnancy, are, as a general
rule, more dangerous than at any other period. If the hemorrhage is
profuse, abortion will be very apt to follow, though the practitioner
must bear in mind, that large and frequent hemorrhages may occur,
and yet pregnancy continue to the full term. If the pains occur at
regular intervals, with dilatation of the os uteri, and protrusion of
the membranes, the abortion almost always follows ; and if the mem-
branes be ruptured, it will certainly occur; though I know of one in-
stance in which, in order to effect an abortion, the membranes had
been perforated, and a large amount of fluid (liquor amnii) escaped,
and yet the woman went to full term with a living fetus. The death
of the fetus will likewise positively determine it, though a few in-
stances are related of an opposite character.

If the abortion be produced by constitutional, accidental or mechan-
ical causes, it is usually more violent or alarming in its results, than
when owing to the uterine or ovuline. When it occurs during acute
attacks, as measles, erysipelas, scarlatina, small-pox, typhus, etc., being
the result of the severity of the attack, it is very apt to prove fatal,
especially when it takes place before a mitigation or cure of the acute
disease has been effected. When produced mechanically, the principal
danger is from hemorrhage, peritonitis, or metritis. Usually, the more
slowly the abortion comes on, the less danger is there to fear from
hemorrhage, though the constitutional effects are more to be dreaded,
than when it is accomplished with rapidity. Previous abortions
always exert an unfavorable influence upon subsequent pregnancies,
predispo'sing to a similar accident, and which, of course, requires the
especial attention of the practitioner.

The ovum, in an abortion previous to the third month, is usually
expelled entire, but after this period it commonly proceeds as at full
term, the liquor arnnii being first discharged, followed by the embryo,
and sooner or later by the placenta. At the third and fourth months.

256 KING'S ECLECTIC OBSTETRICS.

the placenta has considerably augmented in size, and has likewise
formed close adhesions with the uterus ; and this latter organ, though
it may have acquired a degree of contractile power sufficient to expel
the ovum, does not possess the contractility of tissue as developed at
full term, and is frequently incapable of overcoming the attachment
existing between it and the placenta. In an abortion at this period, a
partial evacuation of the uterine contents, is very apt to be followed
by a closure of the os uteri, and a cessation of the symptoms, leading
the practitioner to believe that the abortion has happily terminated ;
but after several days the hemorrhage, generally preceded and accom-
panied with pains, again appears with increased severity, and if the
cause be not removed, the patient dies. The cause, in this instance,
is a retained placenta and membranes; the utero-placental adhesions
having been overcome, hemorrhage, and sometimes copious hemor-
rhage, follows the separation of the placenta from the uterus, which
remains detached in the uterine cavity, irritating the uterus and pre-
venting its complete contraction, thereby promoting an increased
hemorrhage, and causing a fatal termination, if the patient be not
relieved by art. And whenever hemorrhage occurs, several days
subsequent to an abortion, the practitioner should always suspect the
presence of the placenta and membranes within the uterus, without
regard to the statements that may be made to him, affirming that these
have been expelled. He should at once make a vaginal examination,
when he will probably find a partially dilated os uteri, with a portion
of the placenta protruding. Should the placenta be only partially
detached, the os may be slightly dilated, but without protrusion of the
placenta, depending however upon its situation and extent of separa-
tion. Occasionally, the placenta decomposes, the uterine discharges
become fetid, absorption of the putrid matter takes place, and an
irritative fever ensues, requiring all the skill of the practitioner to
overcome, or to avert its fatal eifects. Putrefaction of the dead fetus
takes place only when the membranes are ruptured, which admits the
air into the cavity of the uterus ; decomposition without putrefaction
ensues when the membranes are entire. Absorption of the placenta
has been observed, both after an abortion, as well as after a 'natural
accouchement. Sometimes an effusion of blood into the placenta may
occur, and by imparting to it a kind of organization, produce wha<
are known as " fleshy moles."

The TREATMENT varies according to the symptoms which are
presented the principal indications being, to prevent the abortion if

HEMORRHAGE AND ABORTION. 257

possible, and when this can not be effected, to assist the expulsion of
the uterine contents, and likewise to remedy any subsequent accidents.
When the pains are somewhat continuous, and are experienced pre-
vious to the hemorrhage which considerably mitigates their severity,
the case is very probably one of uterine congestion; but when the
hemorrhage is observed first, followed by pains increasing in severity
and with well marked remissions, abortion is about to ensue. In all
cases of abortion, the practitioner should carefully examine the con-
dition of the cervix, except in instances where the death of the fetus
has been positively ascertained; if it be of normal length nud thick-
ness, but slightly dilated, unfavorable to the speedy expulsion of the
ovum, and if the hemorrhage be not too threatening, an attempt may
be made to check its farther progress; but if it be dilated, short, the
os patulous, and attended with considerable hemorrhage, means must
be adopted w r hich will favor the speedy expulsion of the uterine con-
tents. And in making this examination, no roughness or violence
must be used, lest the symptoms of the abortion be aggravated.

In a great number of cases, whether abortion ensues or not, all the
treatment required will be, rest in the recumbent position, a cool,
hard bed, perfect quiet, avoidance of stimulants, and all excitement,
quieting of nervous fears or anxieties, cooling drinks and light diet,
with an occasional dose of the compound powder of Ipecacuanha and
Opium, say four or five grains repeated every two, three, or four
hours, for the purpose of subduing the pains. It is claimed by the
most recent writers, that to arrest uterine action, nothing can be com-
pared with Opium ; it is recommended in half-grain doses, repeated
in thirty minutes, if necessary, to allay uterine excitation and control
the pains. Laudanum may be used; a drachm in starch-water
enema. But where this course does not speedily effect a mitiga-
tion of the symptoms, there having been no escape of the liquor
amnii, Viburnum Prunifolium should be given; one or two
drachms to four ounces of water, in teaspoo^ful doses, will usually
prove efficient. A blister applied to the sacrum was formerly
much in use; it will likely prove beneficial in some cases, and should
be tested where other means fail. Should any displacement of the
uterus, or other affection exist, it must be treated as heretofore advised.
Nauseating with a preparation composed of three or four parts of the
tincture of Lobelia, and one of the tincture of Opium, has been rec-
ommended and successfully employed in some cases, but I deem it
inferior to the means above named; although it may be used, should
17

_'.">> KING'S ECLECTIC OBSTETRICS.

that fail. Care is required not to cause emesis, which might render
the abortion inevitable. The administration of Stramonium seed has
been highly spoken of, but I have never seen its action in such
cases, and can, therefore, say but little about.it. Tincture of Cannabis
Indica, in doses of five or six drops every one, two, four or six hours,
has also been advised as an anodyne as well as to arrest the sanguin-
eous discharge. If the hemorrhage be slight, it may not require any
special attention, but when it is considerable, effort should be made to
check it. For this purpose, cloths wet in cold vinegar and water, or
ice applied to the hyp9gastrium and pudendum has been recommended;
but the application of ice within the vagina, or cold vaginal injec-
tions, recommended by some authors, should be used with great
caution, lest they produce the accident we are attempting to avert.
Injections of water as hot as can be endured, will give better results,
and affect the patient more pleasantly. In cpnnection with these, in-
ternal means may be used, a few drops of the oil of Erigerou, or oil of
Erechthites may be given, in mucilage or on sugar, evey ten, thirty,
or sixty minutes, according to the severity of the hemorrhage ; or a
powder composed of burnt Alum and Sulphate of Iron, three grains,
Capsicum, one grain, may be administered as often as the urgency of
the symptoms demand; the burnt Alum and Sulphate of Iron form a
valuable hemostatic, and may be made by mixing together two parts
of Sulphate of Iron and one of Alum, and exposing them to heat in a
stone or clay dish, until the mixture assumes a reddish color. Other
astringents may be employed in the absence of those named, as Tan-
nin, Hamamelis, Gallic Acid, etc. An agent in common use as a
hemostatic is powdered Alum and Nutmegs; the late Prof. Meigs
recommended it in the proportion of five grains of the former to one
of the latter as a dose, to be repeated every half-hour or hour. It
will frequently be found that internal remedies derange the digestive
organs and occasion constipation, without everting any influence what-
ever upon the hemorrhage ; in such instances a soft sponge, or plug
of cotton wadding moistened with solution of Alum, Tannin, or Per-
chloride of Iron, and introduced within the vagina so as to slightly
press against the os, will promote coagulation and tend to arrest the
flow; and this application may be worn for several hours at a time,
changing it only as required. I regard the solution of Perchloride
of Iron, as just mentioned, as one of the most reliable agents at our
command, in controlling uterine hemorrhage, and have frequently
gotten prompt results from it, after other means have failed. It may

HEMORRHAGE AND ABORTION. 259

be used on absorbent cotton, after which all coagula resulting
therefrom should be removed by hot water vaginal injections.
A rectal enema, composed of Lloyd's Ergot, two fluid drachms,
thin Starch solution, one fluid ounce, retained in the rectum for an
hour, repeating it two or three times a day, if necessary, has proved
successful in some instances in arresting the pains and checking the
hemorrhage. It is not required that the patient should be confined
to the recumbent posture for more than the first two or three days,
and, subsequently, even though some flow be present, only occasion-
ally, according to the symptoms; a constant lying in bed will affect
the general health, occasion anorexia and nervous excitement, and
rather tend to facilitate instead of prevent the abortion. On the
other hand, should there exist any congestion or irritability of the
uterus, an erect position, or any bodily movements, increase the
liability to abort, hence, these conditions must be removed before
allowing the female to move about.

Should these means fail to arrest the hemorrhage, and there is no
doubt in the mind of the practitioner but that the expulsion of the
ovum must take place is inevitable the tampon or plug should be
employed. This consists of pieces of linen cloth, muslin, silk, or
balls of absorbent cotton. The tampon can, as a rule, be best applied
by using Sims' speculum. It is always well to wash the vagina out
with hot water; then, if the cotton is used, the balls may be carried
to the parts by means of dressing-forceps, firmly packing them around
the cervix. The first few balls should be sprinkled with lodoform.
If muslin is used, the pieces should be about, three or four inches
square, which are separately introduced into the vagina, until it is
completely filled and distended; these are to be kept in place by a
napkin or bandage, and may be allowed to remain for six or twelve
hours, but never to exceed twenty-four. Sometimes sponge is used,
but I think it inferior to the pieces just referred to. The first piece
introduced may be medicated with Tannin, Alum, or other astringent,
and the remaining pieces forming the tampon should be moistened
with Carbolized Oil, to admit of their ready removal, and to act as an
antiseptic. It must be especially borne in mind by the practitioner,
that the tampon is never, under any circumstances, to be used after
the fifth month of pregnancy ; because, the uterine capacity having
become much augmented, its cavity may become distended with
blood or coagula, and cause a fatal result. Previous to the fifth
month, however, it is incapable of containing an amount of blood

260 KING'S ECLECTIC OHSTHTKICS.

sufficient to prove fatal from a concealed hemorrhage. Upon the re-
moval of the tampon, a roagulum may be observed attached to its
upper part, in the center of which the ovum, or its remains, will gen-
erally be found. Cotton-wool was regarded by J. Marion Sims as
the best material from which to prepare a tampon. He advises that
it be soaked in some .antiseptic solution and then molded into small
disks; they are now carried high up, with the dressing-forceps, and
packed tightly around the intra-vaginal portion of the cervix, and so
on until the vagina is filled. This makes, probably, the most solid
tampon that can be used. When the tampon is removed, after
about twelve hours, the parts should be carefully examined, and, in
case the cervix is not sufficiently dilated to allow the ovum to pass,
then at once re-apply the tampon as in the beginning, and so continue
until dilatation follows. The tampon not only acts as a mechanical
agent in controlling the hemorrhage, but hastens the expulsion of the
ovum by exciting contractions of the uterus. Ergot is usually indi-
cated in cases requiring the tampon; and when associated they act
very well. The ovum, as a rule, is expelled entire in cases where this
treatment is used. Should the presence of the tampon induce dysury,
the bladder must be evacuated by means of a catheter ; and during
the whole treatment the female should be kept in the recumbent posi-
tion, and not allowed to arise until all danger from hemorrhage is
over. The tampon ought never to be used when there is any pos-
sibility of checking the abortion, as it is very apt to increase the ten-
dency to abort, in consequence of the irritation of the cervix produced
by its presence having extended to the fundus ; beside, the external
discharge of blood being suppressed, it continues to be effused inter-
nally, gradually separating the ovum from the uterus, until it finally
passes off, surrounded with a compressed coagulum. Neither should
it be employed after the expulsion of the ovum, nor when the os uteri
has dilated to an extent that will admit a finger to pass and remove
the embryo.

Females who habitually abort in the early months of pregnancy,
should, after the symptoms of abortion have been removed, be advised
to remain most of the time in the horizontal position, avoiding all
fatigue and violent exertion, until the uterus has risen above .the
superior strait of the pelvis. The employment of the lancet, in cases
of abortion, is recommended by some authors, but I can not perceive
its utility ; the detachment of the placenta from the uterine wall, which
is the cause of the hemorrhage, can not certainly be remedied by a

HEMORRHAGE AND ABORTION. 261

loss of blood from some other part of the system, for in all the cases
which I have witnessed treated by blood-letting, the separation con-
tinued to progress, with augmented hemorrhage, and the only result
gained was a degree of debility and disposition to disease, on the part
of the female, probably greater than would have resulted had the use
of the lancet been omitted. It is true, that in consequence of the
prostration of nervous and muscular force effected by its use, it may
overcome rigidity of the cervix, and favor the dilatation of the os uteri,
when the fulfillment of these indications is desired; but then we have
remedies which produce the same results without disposing a part or
all of the constitution to any of the after disastrous consequences so
common to blood-letting; as Lobelia, and still better, the tincture of
Gelsemium, from the relaxing influences of either of which the patient
will speedily recover. I am aware that bleeding, in many cases, may
arrest or modify the expulsive contractility of the uterus, but it is ef-
fected at a great expense to the constitution of the patient, and is by
no means a safe or desirable method of treatment; Opium, either alone
or combined with Lobelia or Gelsemium, will not only produce the
same results, but will succeed in cases where bleeding fails. As to
bleeding for the relief of plethora, or of a congested condition of the
uterus, the hemorrhage undoubtedly affords all the benefit that can be
had from venesection, especially in the latter condition; and the ordi-
nary means advised for overcoming or relieving either of these states
will be found fully efficient without a resort to the lancet though the
lancet saves time and labor, to the physician. For the purpose of
equalizing the circulation, it has been advised by some accoucheurs to
bathe the lower extremities of the female in warm water; with some
patients this course may be attended with benefit, but it should always
be employed with caution, as among many women it will be found to
facilitate the abortion ; it is only in hemorrhage after the expulsion
of the ovum where much advantage will be derived from this local
bathing.

If by the means employed the abortion is not prevented, or if it be
so far advanced that no hope for checking it can be reasonably enter-
tained ; the pains increasing together with the hemorrhage, the os uteri
gradually dilating, and the ovum being within reach of the finger, all
that the practitioner can do is to patiently await the efforts of nature,
and carefully watch and treat the hemorrhage ; as a general rule, any
artificial interference is highly improper, and might give rise to serious
consequences. The practitioner must be very careful not to rupture

262 KING'S ECLECTIC OBSTETRICS.

the membranes in the early months, for the purpose of facilitating
expulsion, as it is always desirable that the ovum be expelled entire,
for when the membranes are retained after the discharge of the fetus,
there is danger from hemorrhage; and when, in cases of such reten-
tion, it is found that the contractions of the uterus are insufficient to
separate and expel the membranes, the os being sufficiently dilated,
agents may be administered which will promote these contractions, as
Ergot, Macrotys, Pulsatilla, or Quinine. Creed's method will often
stimulate the uterus to increased -action. Agents of this class are not
to be depended on when the hemorrhage is alarming, but give way to
more radical treatment, as will be presently noticed. The fresh inner
bark of Cotton root, in strong infusion, will generally excite the uterus
to energetic action ; but this agent can rarely be had. So will pow-
dered or grated Nutmeg in teaspoonful doses; also a combination of
Borax and Cinnamon. If this does not produce the desired effect, and
the hemorrhage continues unabated, it will be proper for the practitioner
to introduce a finger within the canal of the cervix, as far as possible,
then bend it so as to resemble a blunt hook, and in this way remove the
membranes, and in doing this it may become necessary to introduce the
whole hand into the vagina ; or a wire blunt-hook, which will admirably
answer the purpose, may be made, by bending a piece of fine wire so as
to form two parallel strips nearly in contact with each other, the curved
end of which is to be again bent so as to .form a hook; this may be
introduced into the uterus, whenever hemorrhage is owing to retained
membranes, for the purpose of removing them. Other instruments
have likewise been recommended for this purpose, as Bond's placental
forceps, and Dewees' placental hook. But in the introduction of the
finger, or any of these instruments into the canal of the cervix, no
force must be employed, too much care and gentleness can not be
observed; no attempts whatever should be made, to effect dilatation,
nor should these means be employed at all until the cervical canal has
become cylindrical and sufficiently open for their free intromission.
And as the development of the uterus previous to the fifth month is
not such as to warrant any fears of a serious internal hemorrhage, the
tampon may be used, in conjunction with the other means, to check
flooding, if circumstances prevent the removal of the membranes.
The introduction of the tampon is sometimes attended with such dis-
agreeable and painful sensations that the patient can not endure its
presence for even ten minutes ; in such cases, as well as in cases w r here
it does not check the hemorrhage, the evacuation of the uterine con-
tents must be promoted as soon as possible. It may be proper to

HEMORRHAGE AND ABORTION. 263

remark here, that when the hemorrhage is such as to threaten the life
of the mother, every means must be employed to arrest it, even should
the means effect the death and expulsion of the fetus, as the safety of
the mother always demands s-uch sacrifice. When the death of the
fetus has occasioned the abortion the hemorrhage is not generally
excessive.

A very good rule to govern one's actions in cases of hemorrhage
from abortion is, after deciding it to be inevitable,to use the tampon
as has been suggested, in cases where there is no dilatation of the cer-
vix, and so continue together with the administration of Ergot, until
dilatation is produced. .Should the hemorrhage be alarming, and the
cervix already fully dilated and relaxed, then forcibly remove the ovum
by introducing the fingers or hand.

In the more advanced stage of pregnancy, when in consequence of
excessive hemorrhage or other cause it becomes necessary to facilitate
the expulsion of the fetus, the membranes may frequently be ruptured
with advantage, because at this period, the uterus has increased in size
sufficiently to receive two or three fingers, or even the whole hand,
should it become necessary to remove a retained placenta. And the
extraction of the placenta should always be effected, when the abortion
occurs at .a period of utero-gestation, in which the uterus will permit
the introduction of the hand within its cavity. Other means may
likewise be employed to favor the expulsion, as Ergot, Macrotys, in-
jections of hot water together with Creed's method. Cold applications
may be made to the pubes and hypogastrium, to aid in arresting 1 the
hemorrhage. At this period I usually prefer as an internal hemostatic,
the tincture of Cinnamon, of which from half a fluid drachm to a
fluid drachm may be given every ten, thirty or sixty minutes, as the
urgency of the case requires, in a wine-glass of sweetened water; ten
or fifteen drops of Laudanum or Viburnum may be added to each dose,
in case the pains are very severe. The Cinnamon and Ergot may be
administered together in doses of from fifteen to thirty drops of each;
the combination of the two agents exhibit more striking haemostatic
properties than either administered singly. After the embryo and its
membranes have passed away from the uterus, should hemorrhage still
continue, it must be treated in the same manner as recommended for
flooding after delivery at full term. Intra-uterine washings of a solu-
tion of Iodine after the evacuation of the contents, have been advised
both for its antiseptic and haemostatic effect.

A weak solution of Sulphuric Acid has been frequently employed in
hemorrhages occurring during pregnancy, as well as after delivery,

264 KING'S ECLECTIC OBSTETRICS.

with decided benefit. It is exhibited as a vaginal enema, ten or fifteen
drops of the acid being added to three or four ounces of warm water.
Care should be taken, however, not to employ it when it is desired to
check the abortion. Many persons use this injection with the criminal
intention of procuring an abortion.

In cases of excessive hemorrhage occurring several days after the
abortion has apparently terminated, and which, as previously stated,
are owing to a retention of the placenta and membrane, the wire
blunt-hook may be slowly and carefully passed within the canal of
the cervix, and the membranes extracted by means of a gentle manip-
ulation ; if this can not be accomplished, the practitioner will most
likely have to contend with the effects of putrefactive absorption.
The patient with whom there is a retention of the placenta is exposed
to hemorrhage, to septicaemia, to hydatoid degeneration of the placenta,
or to polypoid growths of which the placenta forms the nucleus ;
hence the necessity for not allowing it to remain too long within the
uterus, and especially when the flow is continuous or excessive. Putre-
factive decomposition may be known- by a fetid lochial discharge, and
absorption of the putrid matter gives rise to an irritative fever which
may prove dangerous. The fever must be treated upon general prin-
ciples, using Aconite or Veratrum as' indicated, and being careful to
support the strength of the patient; and the vagina must be frequently
syringed with water, as hot as the patient can endure, in which shall
be used Borax, Asepsin, Carbolic Acid, Distillate of Hamamelis, or
Fluid Hydrastis, as the practitioner may prefer, for the purpose of
removing the putrified material as soon as it forms; and for the pur-
pose of obviating putridity of the remaining portions of the placenta
or membranes, soft cotton wool has been recommended moistened with
diluted Carbolic Acid, or other antiseptic, and carefully introduced
within the canal of the cervix, (dilating this, if necessary, by means
of tents), removing it every two or three hours, and replacing it with
a new pledget. As a rule, I believe pledgets of lint should not be
introduced into the cervix at this time, as it might be an obstruction
to the free drainage of the uterus, and as a result of pent up purulency
thwart the very object we are trying to accomplish. Internally, to
lessen the dangers from septicaemia, such agents as Chlorate of Potash,
Baptisia, Phytolacca, dilute Nitro-Muriatic Acid, Asepsin and such
other remedies as would tend to eliminate the poison that might have
been absorbed by the system may be administered, as well as tonics,
good diet, etc., as indicated from time to time. I have in several in-
stances succeeded in preventing any serious consequences by adminis-

HEMORRHAGE AND ABORTION. 265

tering, in connection with the general treatment, Macrotys, Pulsatilla,
Phytolacca, together with direct sedatives, if there happens to be an
increased temperature, as Aconite, Veratrum or small doses of Digi-
talis. The Parturient Balm (Am. Dispensatory) as a uterine tonic is
a good remedy, especially during convalescence. The infusion of Digi-
talis is useful in some cases. Peruvian bark in Port wine has also
been used in a few cases with apparent benefit, where a tonic in called
for.

After an abortion, especially in advanced pregnancy, it may become
proper to apply a bandage around the abdomen, the same as after or-
dinary labor, and the patient should be kept for a few days in a state
of rest ; if there be much exhaustion from loss of blood, the diet must
be similar to that recommended in uterine hemorrhage, or flooding
after labor at full term. A lochial discharge, as well as secretion of
milk, is most commonly present, after abortion in the advanced stage
of gestation.

The sequelce, or after consequences of abortion, are irritative fever,
metritis, peritonitis, phlebitis, ulceration of the cervix, anemia, leucor-
rhea, menorrhagia, dysmenorrhea, organic disease of the uterus,
sterility, or phthisis, either of which, when present, will require the
treatment appropriate to such abnormal condition.

When an abortion has once taken place, it is very liable to recur
during the following pregnancy, and to prevent the occurrence of
which, the practitioner should endeavor to ascertain its cause, and
remove it, if possible, by the appropriate treatment pursued during
the intervals between the pregnancies, as well, as during pregnancy
previous to the manifestation of the aborting symptoms. It will be
still more efficacious, however, if the patient, while endeavoring to
become cured of her difficulty, will give the reproductive organs rest
by an absolute avoidance of sexual excitement, cohabitation, and
pregnancy, for a considerable length of time. Should it be owing to
tumors, diseased ovum, or other intra-uterine diseases, internal treat-
ment will be of little avail ; though in these cases the internal use of
alteratives, uterine tonics, proper diet, exercise, etc., may be adopted,
with a faint hope that good may follow. If a fissured os and cervix
uteri be the cause, as determined by a careful examination, and which
is often present in those cases of abortion that occur successively in
the same woman at the same period of gestation, the fissures must be
healed by local applications of Nitric Acid, Nitrate of Silver, Caustic
Iodine, or Chromic Acid, etc., being careful to apply these agents in

266 KING'S ECLECTIC OBSTETRICS.

a manner that will not destroy the tissues of the parts; at the same
time administering such agents internally as may be indicated to
relieve pain, remove anemia, or lessen uterine congestion, etc., \vhen
either of these are present. The trouble being a slight fissured con-
dition, it may often be cured, or at least benefited, by the direct
application of caustics; if, however, the cervix should be deeply
lacerated,- then nothing short of a careful operation, known as traehe-
lorraphy, will restore the parts and overcome the trouble. It is
necessary to remove all cicatricial tissue, after which the parts may be
sutured together. Uterine congestion, as a cause of abortion, requires
an avoidance of coition, diuretics, regularity of bowels, moderate diet
and exercise, and sometimes warm hip baths. If the uterus be dis-
placed, it must be restored to its normal position; should ulceration
of the cervix uteri be a cause, it must be treated by applying locally
concentrated Nitric Acid by means of a pine stick porte-caustic, Xi-
trate of Silver, solution of Sesquicarbonate of Potassa, solution of
Sulphate of Zinc, etc., the application to be made by means of a spec-
ulum. The patient must likewise be kept in a state of rest, and if
treated during pregnancy, no vaginal injections must be used. Dys-r
menorrhea is frequently a cause of abortion, and when present, the
functions of the uterine system must be attended to, administering
uterine tonics, Chlorate of Potassa, and pursuing the means generally
recommended in Eclectic teachings to remove the difficulty ; and so
in all other uterine derangements. In those cases of abortion due to
an enfeebled condition of the uterus, to a premature disintegration
and exfoliation of the decidua, or to morbid nervous excitability of
the reproductive system, I have found the Helonias Dioica, Pulsatilla,
Senecio and Macrotys to be excellent remedies, in combination with
Chlorate of Potassa; and, indeed, have even found it efficacious in
geveral instances where the cause of the abortion was quite obscure;
it is especially required in all these instances that the uterus have a
long period of rest. If the abortion is owing to a syphilitic taint of
the system, this must be remedied by the usual treatment for this dis-
ease, administered, in most instances, to both parents. The bowels
must be kept regular, the diet must be nutritious, avoiding fats and
acids, the surface of the body must be frequently bathed with a weak
alkaline solution, and too much exercise must be prohibited ; if the
male parent is contaminated with the disease, but little benefit can be
expected unless he is also placed under proper treatment. The ad-
ministration of Mercury, so highly recommended by some authors, is

HEMORRHAGE AXD ABORTION. 267

of no utility, as this agent will not only effect no cure of the disease,
but has a strong tendency to destroy the vitality of the fetus, and thus
add to the already existing cause of abortion. Any other disease with
which the patient may be affected, whether general or local, must, if
possible, be eradicated by the appropriate remedies, which may be
employed not only during the interval between pregnancy, but like-
wise when this condition is present. Fatty degeneration of the chorion
and placenta, detected by careful microscopic investigation, will re-
quire the same treatment pursued in similar degeneration of other
organs. Chlorate of Potash has been recently used, with marked
success, in a number of cases where women habitually aborted owing
to degeneration of the placenta, and, as a consequence, faulty nutrition
of the fetus. This^remedy, when further tested, will, I believe, prove
to be a specific in this diseased condition of the placenta.

Ansemic or chlorotic patients should be treated with vegetable
and chalybeate tonics, among which I prefer Acid Solution of Iron;
those who are plethoric require light and moderate diet, exercise, reg-
ularity of bowels, and depletion by diuretics; and coition should be
very moderate until pregnancy occurs, during which it must be pos-
itively prohibited. If the patient resides in a miasmatic district,
usually so called, a removal will in many instances be followed with
benefit ; though occasionally the internal use of Sulphate of Quinine,
Fowler's solution of Arsenic, or dilute Kitric Acid, will be found to
answer an excellent purpose. If she be giving suck when pregnancy
occurs, the child must be weaned; if there be any vesical or rectal
irritation, hemorrhoids, or a constipated condition of the bowels, these
may be overcome by an attention to diet, aided by laxatives, anodyne
and mucilaginous enemata, quiet, and an avoidance of all active med-
icines. As habitual abortions usually occur at a regular period of
pregnancy, the patient should at this period more frequently assume
the recumbent position, upon a hard mattress, in a cool room, and be
otherwise treated according to the peculiarities or indications of her
individual case ; and which treatment should be perseveringly pursued
until the aborting period has passed by.

When habitual abortion obstinately resists our endeavors to remove
it, it will ultimately destroy the constitution of the patient; and it
therefore becomes necessary on her part to pursue a rigid and self-
denying course. The indications are: firstly, to avoid pregnancy,
until the functions of the reproductive organs have been restored to a
normal condition; and, secondly, to effect this restoration. The only

2(5s KING'S ECLECTIC OBSTETRICS.

method by which the first indication can be fulfilled is absolute and
positive discontinuance of sexual intercourse for a year or longer or
for such a length of time as may be required to effect a healthy con-
dition of the generative functions. I am aware that various other
means may be suggested, or pursued, to prevent pregnancy, but, in
tin- cases under consideration, it must be especially borne in mind,
that not only is an avoidance of this condition required, but it is im-
peratively demanded that the sexual organs be maintained in a state
of quiet, entirely free from all excitement, and which can only be
effected by rigid abstinence.

The second indication is to be accomplished by bestowing a care-
ful attention toward both the uterine and general systems, employing
tonics, alteratives, and such other measures as may from time to time be
required. The tonics which I have found more commonly beneficial are,
Macrotys, Pulsatilla, Achillea, Aletris farinosa, Helonias Dioica, as in-
dicated; they are given either singly, or any two that are indicated
may be combined or given in alternation. Sulphate of Quinine will
sometimes be called for. The Parturient Balm (Am. Dispensatory),
as prepared by Lloyd Bros., I regard as an excellent uterine tonic also ;
indeed, the vegetable uterine tonics, generally, may be employed with
advantage. The agents which I term uterine tonics, and which are
described in the Am. Dispensatory, appear to exert an especial health-
ful influence upon the uterus, but of their peculiar modus opcrantli, I
am free to confess my ignorance. In addition to the special tonics
mentioned, it was formerly the custom of the earlier Eclectics to ad-
minister, in these cases, alteratives, so called, as compound syrups of
Sarsaparilla and Stillingia; together with Iodide and Bromide of Po-
tassium; at present these are seldom thought of. The general tonics,
however, may be used in connection with the special treatment, as the
practitioner may deem proper.

In conjunction with this treatment, the .bowels must be kept in a
soluble condition by the use of mild laxatives, so given as to produce
one, but not over two, alvine evacuations daily, approximating as
nearly as possible to the natural healthy discharges; and for this pur-
pose I prefer the trituration of Podophyllin, or the small Podophyl-
lin and Hydrastin pill; this may be omitted occasionally, and cold or
tepid enemata employed, as may be found to suit each particular case.
In many cases, a few doses of Cascara Segrada, or Cascara Cordial,
will prove useful, repeated once or twice a day for several consecutive
days at a time, according to its effect. Active purgation is invariably

HEMORRHAGE A.ND ABORTION. 269

to be prohibited, except in plethoric patients, when it may be resorted
to every week or two, if not contra-indicated. Bathing the surface
daily with cold or tepid water, and once a week with a weak alkaline
solution, and drying with considerable friction, will materially assist
in the restoration to health, by bringing about a normal condition of"
the skin, the functions of which will be found more or less impaired
in these cases ; the shower-bath has also been advised, either of rain-
water or salt water, and where it is applicable it will usually prove
beneficial ; its temperature should range between 75 and 85, and the
best time for using it is upon rising in the morning. Moderate exercise
will be found indispensable, and an avoidance of all indolent habits im-
perative, as lying in bed late in the morning, lying down after a meal-
to sleep, sleeping, on feather beds, etc. The diet should be light but
nutritions, using tender fowls, meats, etc., but always avoiding fats
and acids ; and very weak patients may use Port \vine, porter, or other
suitable stimulants, in moderate quantity, during the dinner meal.
Occasionally, a change of air will prove serviceable. All bathing
must be omitted during menstruation. By a perseverance in this
course for one or even two years, the most obstinate cases of habitual
abortion, when not owing to uterine adhesions, may be cured; and it
may be proper to remark, that should pregnancy occur shortly after
dismissing the patient as cured, it is very necessary that close atten-
tion be bestowed upon that condition, until five or six weeks have
passed beyond the previous aborting period, in order to promote the
certainty and permanency of the cure.

It may be briefly stated that when habitual abortion is due to a
morbid nervous excitability of the reproductive system, to premature
disintegration and exfoliation of the decidua, Helonias, Dioica and
Chlorate of Potassa are the remedies; when due to uterine displace-
ments, overcome the trouble by using supports, if necessary, and ad-
minister Aletris, Nux, Parturient Balm, and Belladonna; when to a
low grade of uterine inflammation, Aconite, Pulsatilla, and Macrotys;
to a hard, contracted condition of the cervix, with more or less irrita-
bility, Gelsemium, Aconite, Macrotys and Lobelia; to a neuralgic or
rheumatic aifection of the uterus, Aconite, Macrotys and Gelsemium ; if
there be a sluggishness of the circulation, lack of nervous energy, Nux,
Xanthoxylon, Gelsemium, and Rhus; to irritability of nerve centers,
Bromide of Potassium, Belladonna, Gelsemium, Conium, etc. < Any
constitutional disease under which either of the patients may be labor-
ing, will require the proper treatnient for such affection.

270 Kl.Ml's K< LIX'TIC OI5STKTIJH-S.

Before leaving this subject, I wish to refer to two things which may
occa.-ion .-nme trouble to the practitioner in the treatment for prevent-
ing abortion ; the first is, the difficulty in prevailing on some females
to keep quiet and confine themselves to the recumbent position for a
sufficient length of time. Xot feeling any sickness, nor suffering from
any pain, the patient will be apt to treat the advice of her physician,
in this matter, very lightly, unless it is especially urged upon her,
explaining to her the consequences of a different course of action, and
the advantages attending its observance, among which may be named
the diminution of the tendency to abort, by checking or overcoming
irritability or other morbid results due to the cause of such tendency,
and the strong probability of its permanent cure, when the habit has
been overcome in any one pregnancy. The practitioner can not be
too particular in regard to this matter. Though he must not forget
that too long a continuance in the recumbent position is apt to give
rise to morbid symptoms that may promote instead of prevent the
abortion. The second point is relative to the decided objections which
are frequently made to vaginal examinations. When a female, during
an abortion, objects to an examination of this kind, and the symptoms
are not very urgent, the physician will treat the case as well as circum-
stances will permit; but when the hemorrhage is great, and the serious
consequences that may happen from a persistence in the objection have
been explained, without effecting any change in the will of the patient,
it would be improper for the practitioner, so- far as his own reputation
alone is concerned, to assume the whole responsibility of the case.
He will, therefore, not manifest any irritation, nor abruptly leave the
patient, but will state to the friends, or the patient, that the case has
assumed a character which leads him to desire council, and then, should
any fatal result ensue from a continuance of such obstinaucy, this
course will free him from any subsequent imputations, of neglect,
malpractice, etc.

In a premature labor, the management will be the same as recom-
mended for labor at full term ; for as a general rule, during the last
three months of pregnancy, the hand may be introduced within the
uterus for the purpose of performing any manipulations which may
be required. But I would make one observation, that if the hand of
the practitioner be very large, and a manual operation is demanded
during the seventh or eighth month, it will be safer for the patient,
and very humane on the part of the medical attendant, to send for
some medical friend, with a small' hand. This is a point too little
heeded, and which, of itself, is frequently a cause of grave results.

LABOR. 271

CHAPTER XXIV.

LABOR.

LABOR, or PARTURITION, is that function by which the matured
fetus, together with its secundines, are expelled from the uterus; it
occurs at the end of nine calendar months and one week, or about two
hundred and eighty days from the last menstrual appearance, and about
one hundred and forty days after quickening. A few days, either
previous or subsequent to this time, constitute practically no material
difference. At this period, the hitherto inactive nervous and muscular
systems of the uterus become stimulated into action, causing contrac-
tions of this organ, which are always accompanied with pain, in a
greater or less degree, and which cease only when the uterus has
expelled its contents; as the contractions are invariably attended with
pains, the terms, labor pains, and uterine contractions are employed
synonymously. As a general rule, labor, though painful and exposed
to danger, may be expected to terminate favorably, and without arti-
ficial aid. The average duration of labor is six hours, or according to
some authors, four, but which depends upon the amount of power in
action, and the degree of resistance which is presented. Cases have
been known, in which labor has been completed in ten or fifteen min-
utes, while with others, again, from four to seven, and even ten days
have passed, before the fetus has been expelled into the world. The
investigations of M. Quetelet, Dr. Buck, and others, indicate that
more births occur at night than during the day, there being five chil-
dren born at night, for every four born during the day ; and also, that
the least number of births occur at midnight, and at noon. Yet
these day-births may, in many instances, require the attention of the
accoucheur during the night.

The immediate or exciting cause of labor, is not satisfactorily under-
stood, though physiologists of all ages have advanced various theories.
Thus, some have attributed it to a supposed struggling of the fetus, in
an endeavor to procure a more adequate amount of nourishment than
is received while within the uterus ; others again, have supposed it to
depend upon the motions of the fetus, in seeking to relieve itself from
its constrained position, to remove itself to a less elevated tempera-
ture ; or, to obtain access to the atmosphere for the purpose of breath-

272 KING'S ECLECTIC OBSTETRICS.

ing. But these, or any other theories which suppose the fetus to be
the principal agent in its own expulsion, are now known to be incor-
rect ; the fetus is merely a passive agent in parturition, and a dead one
is expelled as easily as one living. Some, viewing the uterus alone as
possessing the power necessary to effect labor, have supposed, that
when no further development of uterine fiber can take place, the con-
tractions ensue; others assert, that they commence as soon as the
antagonizing condition, which exists between the fibers of the cervix
and those of the fundus, are overcome, the latter having the prepond-
erance of action. Dr. Tyler Smith believes the expulsion of the ovum
to be effected by certain changes occurring in the uterus, and which
are due to ovarian excitement, the ovaries, in all cases of pregnancy,
assuming a regular periodical action at or near the tenth period from
the last menstruation. This hypothesis, however, is inconsistent with
the recent views concerning nidation. Cases have been recently
reported, also, in which the ovaries have been removed during
pregnancy without affecting labor in the least, which came on and
was perfectly natural at the proper time. Sir James Simpson has
advanced the opinion that parturition is the result of a separa-
tion between the deciduous membranes and the uterine walls, and
which is due to degeneration of the decidual structure occurring
toward the full 'term of pregnancy. But it is unnecessary to enter
into an explanation of all the views which have been promulga-
ted on the subject ; suffice it to say, that they are all unsatisfactory, and
we are compelled to admit that it is the result of an unknown natural
law, or, as expressed by Avicenna, an Arabian physician of the eleventh
century, " that at the proper time, labor comes on, by the grace of
God ;" or, as a medical man once remarked, " it is involved in as
much obscurity as the cause why peaches ripen in August, and straw-
berries in June." But though the researches of physiologists have
failed to discover the exciting cause of labor, they have established the
fact, that .as with all other uterine functions, periodicity exists in this
also ; as labor manifests itself at a period corresponding to that of
menstruation, and which, but for the conception, would have been a
menstrual term.

The principal agents, in the accomplishment of parturition, are the
contractions of the muscular fibers of the uterus, aided in ordinary
cases, during the second stage, by -the diapbragm and the abdominal
muscles ; the expulsory efforts of all these agents finally determine the
evacuation of the uterine cavity, which, when completed, the organ
returns to its non-gravid state, measuring from two and a half to three

LABOR. 273

inches in length, about an inch and a half in width, and a half or
three-fourths of an inch in thickness. The pain, which attends each
uterine contraction, is supposed to be owing to the pressure these con-
tractions exert upon the nerves of the uterus, and also to the constant
traction upon the circular fibers of the cervix, by the longitudinal
fibers.

The PREMONITORY SIGNS OF LABOR are several; a sub-
sidence, or sinking down of the uterus in the abdomen, is the first, and
probably most striking ; the uterus, which had previously extended to
the epigastric region, sinks lower, and appears to spread out laterally.
This symptom may occur as early as two weeks previous to the first
pains of parturition, but usually, it is observed only a few days before.
The mechanical impediment to respiration being thus removed, the
female experiences much relief, she respires with greater ease, feels
lighter, cheerful, and more comfortable, less apprehensive, and is better
able and more disposed to action and motion than she had been for
some time previously. The lowering of the uterus occasionally pro-
duces a puffiness and swelling of the lower extremities, rendering
locomotion difficult or impossible. In those cases where nausea or
vomiting was present, from mechanical pressure upon the stomach,
this subsidence at once relieves the patient from any further disposi-
tion to these unpleasant symptoms.

This falling of the uterus generally takes place gradually, so that
several days pass before the patient is aware of it sometimes it occurs
suddenly, or in a short time, as in ten or twelve hours. As the head,
covered by the cervix, must enter the brim, to a greater or less extent,
during the above sinking, this is looked upon as a symptom indicative
of a large* or well-formed pelvis ; being seldom observed in cases of
contracted pelvis. The sinking of the uterus is usually considered to
be the result of the complete softening of the cervix uteri, with a
relaxation of the uterine tissue, which permits it to expand laterally.
The late Dr. Meigs considered the womb wholly passive in the matter,
it being pushed downward by the action of the diaphragm and
abdominal muscles. In some females, this sinking of the uterus* is
followed by an unpleasant sensation of weight in the inferior part of
the pelvis, with an irritable condition of the rectum and bladder,
occasioning frequent and ineffectual desire to evacuate these organs,
with other unpleasant symptoms, and which are owing to pressure of
the presenting part upon the bladder, rectum, blood-vessels, etc. These
symptoms can not be relieved by treatment, though when dysury ia
present the patient may urinate freely, by placing herself upon her
18

274 . KING'S ECLECTIC OBSTETRICS.

hands and knees, with the hips somewhat elevated; tenesmus, when
severe, may frequently be relieved by an injection of starch, or elm
infusion, to which a few drops of Laudanum have been added, or the
support oi a bandage carefully applied might prove advantageous.

One, two, or three weeks previous to labor, contractions of the
uterus are frequently observed, to which the names of painless uterine
contractions, or fibrillar contractions, have been applied. The patient
experiences a squeezing sensation in the abdomen, which is unaccom-
panied with pain, and which occurs at intervals ; during its presence,
if the hand be placed upon the abdomen, the uterus will, be found hard
and well-defined. They occur much sooner in primiparse than in mul-
tiparae, and are supposed to be sometimes occasioned by the child's
motions ; it is believed that these painless contractions produce gradual
changes in the cervix and os uteri, before actual labor commences, and
may, possibly, assist in bringing about the subsidence of the uterus.

In connection with the above symptoms, the parts become somewhat
relaxed and soft ; though it is very doubtful whether any relaxation
of the pelvic symphysis occurs, as stated by some authors. With these
are frequently other symptoms, of a minor character, as cramps in the
lower limbs, swelling of the labia, increase of appetite, etc.; all of
which, collectively, indicate the approach of labor. But the symptom
upon which we may rely as an evidence that labor is close at hand, is
a muco-serolent discharge, called by nurses and midwives, " the show"
It is, usually, observed from twelve to twenty-four hours previous to
the commencement of actual labor, and consists of a greater or less
quantity of mucus, of a thin, or thick and viscid character, colorless,
until labor has commenced, when it becomes mixed with more or less
blood. The mucus is an exalted secretion of the follicles of the
vagina, and is not to be regarded as an indication of labor, unless
there be found mixed with it the gelatinous substance which had pre-
viously occupied the canal of the cervix ; and the blood arises from
the separation of the membranes, and the rupture of the blood-vessels
which pass from the cervix uteri to the fetal membranes. According
to Wigand, when the mucus is thick and viscid, it is mpre favorable.
It evidently prepares the passages for the exit of the fetus by lubrica-.
ting them. It may be proper to state here, that the show 4s frequently
absent, and also, it is sometimes observed for some days previous to
actual labor ; but these cases may be looked upon as the exceptions to
the general rule; for it is usually only when the dilatation of the os
uteri has commenced, with descent of the membranes, that the san-
guineous show is seen it is, therefore, a good sign of commencing
labor.

LABOR. 275

Some females suffer for a week or longer previous to labor, with a
restless anxiety, a wakefulness at night, pains of an irregular character
about the uterus, and a peculiar nervous irritability. Others again,
especially those of nervous temperament, are attacked with rigors or
tremors, of greater or less severity, but which are unattended with
any feeling of cold. These rigors are usually indicative of rapid dila-
tation of the os uteri, and require no attention, unless accompanied
with a sensation of cold. They frequently occur immediately after
labor, and are sometimes so severe as to create some alarm in the minds
of the friends of the patient, as well as of herself, and heating drinks
are often injudiciously administered. Some warm diluent drink, as tea,
and an extra covering over the patient will be all that are required.
" If these shiverings be followed by symptoms of fever, this must be
guarded against; if by severe pains in the head and abdomen,
evidently not proceeding from the labor, then you may suspect that
there is inflammation. If there be much flushing of the face, throb-
bings of the carotids,* and the pulse high, there is reason to apprehend
that convulsions may supervene. These accidents are rare, however ;
and when the rigors occur without the above accompanying symptoms,
it is indicative that the labor will be active and its termination
speedy." Blundell.

Dilatation -of the os uteri is frequently attended with nausea or
vomiting; these are not the causes, but the effects of the dilatation,
and have no weight in sustaining an erroneous impression once enter-
tained, that nauseants or emetics favor dilatation. The only agents
proper to overcome a rigid os uteri, and forward the dilating process,
are relaxants. The practitioner who, in the first stage of labor, meets
with a rigid os uteri, which seems disposed to obstinately maintain its
rigidity, notwithstanding the strength and frequency of the pains,
will observe that an attack of spontaneous vomiting is followed by a
softening, relaxation, and dilatation of the os, and is therefore a
favorable symptom. As a common rule, it seldom lasts any length
of time, occasions but little distress to the patient, and needs no treat-
ment. Occasionally it becomes very painful and obstinate, requiring
the aid of the physician; a few drops of Laudanum, or of tincture of
Gelsemium in a draught of Soda water, will usually prove sufficient
to check it; and should ^constipation be present, a laxative enema
must be administered. It is rarely that a sinapism is required over
the epigastrium ; vomiting during a protracted labor must not be
confounded with that just referred to; it is a very unfavorable sign,
and the matter ejected will be in large quantity, dark colored, and
often fetid ; it will be noticed under Rupture of the Uterus.

27(1 KI.\<;'s ECLECTIC OBSTETRICS.

Usually labor commences with pain, but considerable progress may
be made without any pain ; and occasionally the patient experiences
no pain until the os has become fully dilated, and the suffering attends
the expulsive effort only. True labor pains are intermittent in their
character, having an interval of ease between them; at first they are
short and weak, with long intervals, but gradually become stronger,
more frequent, with but little or no interval between them. They may
be suspended by many causes, as passions of the mind, anger, fear, sur-
prise, grief, etc.; sudden and unexpected news, or even the entrance
of the physician into the parturient room, has frequently suspended
the labor for hours. The administration of stimulating liquors, which
is rather common with some old nurses, is very reprehensible ; I have
known labor to be suspended for twelve hours, by a draught of gin-
sling, advised for the purpose of easing the pains. Anodynes, as Mor-
phine or Opium, act in a similar manner; a full dose of either will
overcome uterine contraction, and may result in the suspension of
labor for hours.

There are two kinds of pain recognized at the commencement of
labor, which arc termed true and false pains, and it is of importance
to the patient, as well as to the reputation of the physician, to be
enabled to discriminate between them. True pains are regularly inter-
mittent, and are confined to the uterine region, and during their con-
tinuance, if the hand be placed on the abdomen, over the uterus, it
will be found to contract and grow harder with the pain, and to
become softer as the pain passes off; upon making a vaginal examina-
tion, the os uteri will be found to contract during the presence of a
true pain, with a protrusion of the membranes, and to dilate during
its absence.

False pains, are more frequent in first pregnancies than in subse-
quent ones; they are irregular or constant, and exert no influence
whatever upon the uterus or os uteri, though contraction of the abdom-
inal muscles may attend them, and which it is important not to mistake
for uterine contractions. They are very apt to harass the patient
during the night, and disappear through the day; and may be dependent
upon rheumatism or congestion of the uterus, intestinal irritability,
constipation, overfatigue, etc., and are sometimes attended with febrile
symptoms.

True pains, commence generally in the back, pass around to the
front of the abdomen, as far down as the groin, recur at regular
intervals, gradually increase in frequency and power, and occasion
contractions of the uterus and os uteri, and protrusion of the bag of

LABOR. 277

waters. False pains, usually commence in the neighborhood of the
fundus, have a limited extent, are irregular, spasmodic, often quite
sharp, and exert no influence on the uterus or os. There appears to
be a disagreement among obstetricians as to the order of uterine action,
some believing it to commence in the os uteri and from thence to pass
to the fundus, while others assert that it begins in the fundus, passes
in an undulate manner to the cervix, and then returns to the fundus,
the uterus being firmly contracted all this time. As to the manner
in which peristaltic uterine action occurs, Leishman cites Wigand,
who has taught,, in so far as the contractions of labor are concerned,
as^follows: The earliest contractions always take place at the neck,
which grows tense. From this point the vermicular action extends
gradually upward in the direction of the fundus, from whence it
again returns toward the os, obvious mechanical advantages being
attendant upon this method of action ; my own observations lead me
to coincide with the latter opinion.

To remove false pains, we must endeavor to learn their cause; if
they be owing to intestinal irritabilitv, or constipation, a mild pur-
gative, or a purgative enema will answer; if from overfatigue, rest
must be enjoined, and an opiate may be administered, or, what is
better, Sp. Tr. Pulsatilla or Valerian ; if from rheumatism, the com-
pound powder of Ipecacuanha and Opium, with an occasional lax-
ative, will remove them, or specific tinctures of Gelsemium, Macrotys
and Aconite. -Ordinarily a few doses of compound powder of Ipecac-
uanha and Opium (Dover's Powder) will give relief. If the patient
is annoyed by a return or a continuance of the pains, I would recom-
mend half teaspoonful doses of the Parturient Balm three times daily.
This preparation has a direct and kindly action on the uterus, and
satisfactory results will follow its administration.

I have met with many cases, in practice, where the pains were sharp,
regular, occurring at short intervals, with dilatation of the os to nearly
the size of a silver half dollar, and everything indicating a speedy
labor ; when, after waiting a few hours, the pains ceased, and did not
recur again for several days ; the longest time I have observed to pass
in such cases, before the re-appearance of labor, was two weeks ; I do
not pretend to account for these anomalies.

Labor has been variously classified by different authors, for the
purpose of facilitating an acquaintance with it. The arrangement
which I have adopted, is one followed by several recent writers, and

278 KINO'S ECLECTIC OBSTETRICS.

will be found fully sufficient for all practical purposes; it divides labor
into four classes, viz.:

1. Natural labor, in which the fetal head presents, and where
delivery is effected within twenty-four hours, without the aid of any
artificial power.

2. Difficult labor, also called lingering, tedious, and protracted, in
which the fetal head presents, but where labor continues beyond
twenty-four hours, and may require some medicinal, manual, or instru-
mental assistance.

3. Preternatural labor, in which some other part than the head
presents, where there is a prolapse of the umbilical cord, or a plurality
of children.

4. Complicated labor, in which some serious accident occurs, not
connected with the presentation of the fetus.

From its commencement to its termination, natural labor is one con-
tinued process, marked, however, by certain peculiarities which have
led to a division of it, among obstetricians, into several parts or stages.
The most usual, and, probably, the most natural division, is that of
Denman, who describes labor as consisting of three stages. The first
stage, extending from the commencement of labor to the full dilata-
tion of the os uteri ; the second stage, occupying the period between
the dilatation of the os, until, and including, the birth of the child ;
and the third stage, including the delivery of the placenta. The time
which each of these stages occupies varies with different patients
according to circumstances.

In the FIRST STAGE OF LABOR, the stage of dilatation, the os
uteri will, at an early period, be found looking toward the sacrum, and
will gradually approach toward the center of the brim as labor advances.
The pains which are present during this stage, are of a peculiar character,
and are variously described by patients, as " grinding, cutting, or saw-
ing." They are entirely confined to the uterus, producing no sensible
change in the position of the fetus, but influence the condition of the os
uteri, dilating it that the head of the fetus may pass through. These
are termed the preparatory pains, and the rapidity with which dilata-
tion ensues, very much depends on their force and frequency.
Generally, it proceeds more rapidly during the latter half of the first
stage, and is effected more slowly in primiparse than in multiparse.

These pains commonly commence in the back, extend to the loins,
from thence to the front of the abdomen and pubes, a'nd terminate in

LABOR. 279

the neighborhood of the groins, or upper part of the thighs. Some-
times females are able, especially in the first part of this stage of labor,
to conceal these pains, but usual]}' they cause much suffering, obliging
the patient to suspend for the time whatever occupation she may be
engaged in, and forcing from her moans, or a short and fretful cry.
The pains are not attended with any bearing-down or expulsive efforts,
and the practitioner should be careful to caution the patient against
any of those voluntary bearing-down efforts during the preparatory
stage of labor, w^ich are so often unwisely advised by ignorant nurses
and midwives. As the pains proceed, they increase in severity, and
last for a longer time, having shorter intervals between them, and
when absent, the female manifests a certain degree of restlessness and
uneasiness ; the pain in the back may sometimes be relieved by
pressure, but not always, and when this is the case, the matter should
be left to the care of the friends, and not to the practitioner, who must
be careful not to fatigue himself at an early period, lest he be unable
to afford more important aid at an advanced stage, should it be
required. Sometimes each pain is preceded by a slight nervous tremor
or shivering, and it is not uncommon for nausea and vomiting to
attend the whole of the first stage. The vomiting in beneficial, in con-
sequence of its removing crude and indigestible substances from the
stomach, when they are present, and also from the relaxation of the os
uteri, which is certain to accompany it. When it is very severe and an-
noying, I have frequently checked it by administering a hot drink ; the
common tea or hot water may be used. Frequently the female becomes
irritable, restless, impatient or despondent, and may suy or do things
which are extremely unpleasant to the physician, but which good sense
will teach him to pass by in a pleasant, friendly manner, at the same
time endeavoring to console and encourage his patient. By an atten-
tion to the moans or peculiar cries of the female, her expressions, and
respirations, the practitioner can frequently determine the first from
the second stage of labor. Respiration will be free, or if the breath
be suspended, it will be for a few seconds only, without any straining
or bearing-down efforts, and which is the reverse of the second stage.
Generally, there is no increase of the temperature of the surface,
and no perspiration, especially during the first half of this preparatory
stage; and the pulse is seldom quickened until the second stage.
Hohl has remarked, however, that during the first part of a pain, the
pulse will be found more frequent, then remain stationary for a
moment, and afterward subside into its natural action. Upon auscul-
tation, just as a pain is coming on, there will l)e heard, a short, rushing

280 KIXc's KCLKCTIC OUSTKTKK S.

sound, apparently proceeding from the liquor amnii, and which ma} 7 ,
probably, be caused in a degree by the fetal movements, or the mus-
cular contractions of the uterus, at the same time all the tones of the
uterine pulsations become stronger and more distinct; sounds also, are
heard which were not noticed before, especially those of a piping,
resonant character, and which seem to vibrate through the stethoscope.
As the pain reaches its maximum, these sounds become gradually
dull or altogether inaudible, and return with the decline of the
pain, resuming the original character during the intervals between
the pains.

If we examine through the abdominal walls, during the pains, the
body of the uterus will be found hard and rigid, and thrown forward,
so as to place its long diameter in correspondence with the axis of the
superior strait, and without which the labor would progress w r ith much
difficulty ; as the pain ceases, the organ relaxes. An examination per
vaginam will detect the os uteri high up, looking toward the promon-
tory of the sacrum, and more or less dilated; most commonly, it will
admit the end of the index finger, at the commencement of labor.
If it be much dilated, each pain will cause a protrusion of the mem-
branes into the vagina, which is called the "bag of waters" and the
presenting part, if it be low down, will be found to ascend during each
contraction, but will resume its original position as the pain subsides.

This ascent of the head is due to the liquor amnii, which, being
compressed downward by the uterine contraction, must exert an action
that will cause any body floating in it to ascend, in accordance with
the laws of hydrostatics.

The bag of waters is the name given to that portion of the mem-
branes which protrudes through the os into the vagina during a pain.
Its shape is generally round or elliptical, and sometimes elongated,
like a sausage, and which is supposed to be owing to the nature of
the presentation. During a pain it is hard, and must be carefully
touched, as it frequently becomes ruptured from the slightest cause;
as the pain disappears, it becomes lax and wrinkled, and recedes into
the uterine cavity. It undoubtedly assists in the dilatation of the
os uteri. It usually ruptures at its dependent extremity, and when
the rupture occurs, that portion of the liquor amnii, situated between
the fetal head and the membranes, escapes, the head descends and
prevents the too rapid flow of the remainder, and delivery is soon
effected. Sometimes the rupture occurs high up, the waters escape
gradually, and the head being in immediate contact with the mem-
branes, the child may be born with a caul, especially when the

LABOR. 281

membranes in contact with its head remain unbroken. Rupture
of the membranes may occur at any period of the first stage of labor,
depending on their power of resistance ; if it should happen at an
early period, it will delay the delivery, and may cause a difficult labor.
Sometimes it is not ruptured at all, but the fetus is born enveloped in
the membranes, yet such cases are rare. It is important for the practi-
tioner, as a general rule, to retain the membranes entire, if possible,
until complete dilatation of the os uteri has been effected.

The os uteri may present several variations in its character during
the first stage of labor. Thus, it may be found thick, soft, spongy,
moist, dilated, or if not dilated, relaxed, and dilatable, which is a
favorable condition; or it may be thick, hard, rigid perhaps likewise,
hot, dry, and tender, feeling somewhat like cartilage, and which is an
unfavorable condition, generally indicating a difficult labor. Toward
the latter part of the first stage of labor it may be found soft, moist,
cool, sensitive to the touch, but not painful, and so thin that the
presenting part of the fetus can be distinctly felt through its substance ;
this is likewise a favorable condition. Or, it may be thin, hard, rigid,
perhaps tender when touched, with its edge tightly embracing the
presenting part of the fetus, like a piece of cord; this is an unfavor-
able condition, indicating, as with the former instance of rigidity, a
difficult labor. Rigidity of the os uteri will be treated of hereafter.

To return to the progress of the preparatory stage of labor; the
os uteri becomes thinner and softer as the labor advances, its dilatation
continues to increase, and usually, the head of the fetus passes the
superior strait, occupying a considerable portion of the pelvic cavity,
until complete dilatation having been effected, the os uteri is wholly
effaced, and the head passes through into the vagina. Sometimes,
however, the anterior lip may be felt, thick and somewhat cedematous,
between the fetal head and the pubis, requiring no interference, unless
the progress of labor be impeded by inefficient pains, but which is
more commonly encountered during the second stage. Generally,
if the membranes have not previously given way, they rupture at this
moment, and the liquor amnii escapes with a gush. Sometimes they
do not rupture but pass through the vagina and its orifice, upon the
external* parts, which they aid in dilating. With the full dilatation
of the os uteri, which may be accomplished in from four to eight
hours, the first stage of labor terminates. The duration of this stage,
however, varies with different women, and frequently with the same
women in different labors, and almost always occupies more time with
primiparse.

282 KING'S ECLECTIC OBSTETRICS.

Tlie os uteri liaving become fully dilated, the SECOND STAGE
OF LABOR the propulsive and expulsive stage now commences,
between which and the first stage, especially if the membranes have
ruptured, there is usually a short interval of freedom from pain; and
with some women, several hours of rest will follow without any pain.

A new order of things is now presented, the pains become much
stronger and more perfect, and change from the grinding character
to that of the expulsive, and it is only in this stage that the accessory
powers of the diaphragm and abdominal muscles are called into
action the rectus abdominis, the external and internal oblique, and
the transversalis. The action of these muscles is rarely witnessed
until the os uteri has retracted over the head, and then it commences
powerful and continued. The patient fills her chest with air, and
fixes it as a fulcrum for muscular exertion by closing the glottis,
which prevents the escape of the air; she then grasps any object near
her for support, fixing the feet firmly upon some immovable point,
and forcibly bears down. Any noise or outcry is usually suspended
until the termination of the pain, the breath being held until it is
over; though, sometimes when the pain continues for a long time,
a kind of half-breath with a short cry will be uttered once or twice
during the pain, apparently- for the purpose of more firmly renewing
the condition necessary for powerful bearing-down efforts. The tone
is not of the fretful, moaning character of the first stage, but is of a
straining character, sometimes terminating in a short cry and gasping
for breath, and affords a good test for the practitioner to determine
the second stage from the first. Between each pain there is a perfect
condition of repose, and should this stage be much prolonged, the
patient will frequently doze during the intervals. The dozing is
owing to fatigue, and partly to the congestion about the face and head,
the result of the suppressed breathing, and requires no interference,
unless it be excessive and attended with severe pain in the head,
which are the premontory signs of convulsions.

During the presence of a pain, and while the patient is so power-
fully exerting herself, the heat of the skin becomes increased, also the
frequency of the pulse, the eyes are bright, profuse perspiration takes
place, and during the suspension of respiration, the vessels of the head
and neck become congested from an arrest of the circulation, the face
being florid and sometimes purple. The patient manifests much agita-
tion, though she bears her sufferings with more patience and cheerful-
ness than in the first stage, and appears to have changed her fretful or
despondent condition to one of courageous determination. Vomiting.

LABOR. 283

occasionally occurs in this stage also, and is usually a favorable symp-
tom, unless it be dark, greenish, and fetid, with fever, suspension of
pains, and tenderness of abdomen, when it is a very unfavorable indica-
tion.

Upon making a vaginal examination, the head of the child will be
found in the pelvic cavity, each pain forcing it toward or upon the
perineum; the pressure exerted upon the head causes a wrinkling of
the integuments, and overlapping of the parietal bones; and if the
external parts are unyielding, the labor being protracted, a tumor,
caput succedaneum, will form under the scalp, owing to an effusion of
blood into the loose cellular membrane between the bones and integu-
ments. The head most usually lies in an oblique or diagonal position
in the pelvis, having the occiput looking toward the left acetabulum,
and the forehead to the right sacro iliac symphysis, the most dependent
part being the vertex. As the head is forced onward by the pains r
the soft parts of the canal through which it is passing become gradu-
ally dilated, rotation of the head ensues, the perineum becomes thin
and distended, and the occiput appears between the labia. On the
subsidence of the pain the head recedes, and the external parts resume
their natural appearance ; but on the return of another pain, the head
is thrust still further down, the distension of the perineum is increased,
the anus projects, and probably there may be, at this time, a discharge
of the contents of the rectum, as well as of the bladder. The patient
suffers most intensely, as manifested by her loud, piercing cries, or by
deep, suppressed groans. As the pains continue, the distension of the
perineum increases, it becomes thinner, tense, elongated, and widened,
the vulva begins to unfold, and the head advances to the external
labia ; with the subsidence of the pains the elasticity of the perineum
forces the head to recede upward, to be again thrust forward upon
their renewal. Finally, all resistance is overcome, a succession of
strong, expelling pains, called double pains, because they follow each
other so rapidly, that a new one commences before the previous 'one
has terminated, causes the head to emerge from the vulva, while, at the
same time, the female utters a sharp, agonizing shriek, which is fol-
lowed by panting and sobbing, and, after a short period of repose, the
remainder of the child is delivered. As soon as the head is born the
child commences respiring and crying, or if this does not immediately
occur, it will as soon as the mucus in the mouth is removed by means
of a finger.

Dilatation of the perineum, like that of the os uteri, is accomplished
in different cases, at various' periods of time, sometimes requiring sev-
eral hours before it is completed, especially in first labors, and as often

2X4 KIND'S ECLECTIC OBSTETRICS.

requiring only a few pains. Its distension is so great during the
passage of the head and shoulders as to endanger its laceration, which
must be carefully guarded against by the practitioner.

After delivery of the child, the female is relieved from all her suf-
fering and anxiety, and enjoys a greater or less period of repose, until
the THIRD STAGE OF LABOR or, supplemental stage, commences;
though, usually, she will be much excited or exhausted, with a rapid
pulse, flushed countenance, and profuse perspiration. The pains are
again renewed, but with less severity than before, and after one or two
have been experienced, the placenta and membranes are expelled.
Sometimes the placenta is delivered with the same pain that expelled
the child, but usually from a few minutes to half an hour or longer,
elapses before this takes place ; as the placenta is not, commonly, com-
pletely detached before the birth of the child.

The delivery of the placenta is usually followed by a variable
amount of blood, not to exceed a pint in normal cases ; and frequently
a shivering, with chattering of the teeth ensues, which, however, is
not the result of cold. When the placenta is not delivered within
an hour after the birth of a child, it must be managed as a retained
placenta. If the distance between the perforation in the membrane,
through which the fetal head passed, and the placenta, be ascertained
after their expulsion, it will give us the exact distance between the
placenta and os uteri, and thus enable us to estimate the situation of
the placenta in utero.

After the secundines have been expelled, the uterus contracts, and
gradually returns to its normal, unimpregnated condition, and it may
be felt through the abdominal walls, directly above the pubic sym-
physis, soon after the delivery, imparting the sensation of a hard,
round tumor, somewhat like a large ball. For a few days subsequently,
the exposed vessels of the uterus, at the placental site, discharge a
sanguineous fluid called the lochia, which changes to a greenish, or a
creamy hue, having a peculiar odor, and which gradually disappears as
the uterus resumes its. non-gravid state.

Professor Haughton, who has bestowed considerable attention upon
the subject, concludes, from his investigations, that the involuntary or
uterine effort during labor amounts to 3.4 pounds to the square inch,
while the voluntary or abdominal force equals 38.6 pounds to the
square inch, giving a total of 42 pounds. Now, if it be admitted that
the diameter of the fetal head is 4 inches, we have a propelling
power, exerted upon its surface, during uterine action, equivalent to
593 pounds. And as the voluntary force exceeds the involuntary more

MANAGEMENT OF NATURAL LABOR. 285

than ten times, it may readily be seen how the progress of labor must
be impeded by destroying the will power under the influence of anaes-
thetics. It will, however, become necessary in some cases of nervous
patients, to allay the suffering, to a degree, by allowing a few inspira-
tions of chloroform during the pain, withdrawing it during tho inter-
val between the pains, and so continue during the last throes of the
second stage. It is very probable, however, that the real force ex-
erted is less than .that named above, though we are aware it is very
great from the difficulty experienced, if not impossibility, of intro-
ducing the hand into the uterine cavity during a pain, from the in-
fluence of these pains upon the accoucheur's hand when within this
cavity, as well as from the force required in delivering the head with
forceps, in the absence of pains, and when the head is in the upper
part of the vagina.

CHAPTER XXV.

MANAGEMENT OF NATURAL LABOR.

IT must be remembered by the practitioner, that labor is not a
case of sickness, but a function natural to females, for which as com-
plete provision is made as for any other function of the system;
and all that he can do is, to carefully witness and superintend its
progress, without any improper, or uncalled for interference. Indeed,
the ma"xim of every obstetrician should be, "allow nature to pursue
her own course, without any officious intermeddling." But, sometimes,
as is the case with other functions, this of labor may fail from certain
causes, and it is only in these failures, when the natural powers are
insufficient to safely finish the labor, that the aid of the practitioner is
demanded ; and it is his duty to thoroughly inform himself relative to
all the circumstances which may require his assistance, as well as the
means of removing, or overcoming them, in the safest, gentlest, and
most successful manner. In a natural labor, nothing further is
required, after having satisfied one's self that the presentation and
condition of the parts are normal, than to patiently await the ex-
pulsion of the head, receive it and the rest of the child, tie and
separate the cord, and remove the placenta. But as the young
physician, especially, may be at a loss how to proceed in the manage-
ment of a case of this kind, I shall lay down a line of conduct, an
attention to which, I trust, will be found advantageous; for without

KIN<;'s KCLKCTIC MISTKTI: K 'S.

a knowledge of the proper course to be pursued, a very slight inter-
ference of an improper character, may convert a simple .case of labor
into a protracted or even dangerous one.

Having been engaged to attend a female in her confinement, the
physician should endeavor so to arrange his business, that, at the
expected time, he can readily be found by those who are dispatched
to summon his presence to the parturient chamber. He should obey
the summons as promptly as possible, not only that he may secure
the confidence of the patient and her friends, by displaying a readi-
ness, cheerfulness, and willingness to accord his services, but more
especially that he may be in time to rectify any accidents which may
occur, and to which all females are liable during parturition as,
presentation of the superior extremities, uterine hemorrhage, and (in
cases where delivery takes place rapidly, with but a few pains), an
encircling of the neck of the child by the umbilical cord. If he
reside in a city, it is hardly necessary to take along with him any
medicines or instruments, lest he be tempted to needlessly administer
the one, or rashly employ the other; beside, when either are required,
they can readily be obtained, and in sufficient season. Perhaps a
flexible male catheter, and some compound powder of Ipecacuanha
and Opium, may be the only exceptions to this rule. But with a
practitioner in the country, who frequently has to attend patients many
miles distant from his office, and where the delay occasioned by
sending for the requisite articles may prove fatal to his patient, the
case is entirely different. He should take with him, his instruments,
and several vials, containing compound powder of Ipecacuanha and
Opium, Ergot, Macrotys, some preparation for uterine hemorrhage,
as tincture of Cinnamon, and tincture of Gelsemium, or compound
tincture of Lobelia and Capsicum. He should likewise include an
.anaesthetic, as Chloroform, Ether, or a mixture of the two. The use
of any of these may not generally be needed ; but if one patient
among fifty is saved, or benefited, the physician will be fully repaid
for his attention to these patients.

On reaching the patient's house, he should have his arrival made
known to her before he enters the room, as it is frequently the ease,
especially in first labors, that the sudden introduction of the physician
has caused a suspension of the pains for some time ; beside, the female
may wish to have her room arranged before the entrance of the phy-
sician, or she may be very averse to his presence, requiring some time
for her friends to remove her scruples. But this can not always be
done, for with the poorer classes, who occupy but one room, he is

MANAGEMENT OF NATURAL LABOR. '^87

obliged to be ushered into the patient's presence at once, and his good
sense will teach him how to conduct himself in such cases. Unless
from the general symptoms and appearance of the patient, he suspects
the second stage of labor to be at hand, or where symptoms are present
which demand his immediate attention, it will be proper to remove
any embarrassment under which she may be laboring, and allow her
to collect herself, by entering into conversation with her upon any sub-
ject foreign to her situation. Should the pains come on, while thus
engaged, if they are of trifling importance, the practitioner may leave
the room, or occupy himself in conversation with some of the friends
present, and especially with the nurse, from whom he may gain infor-
mation as to the condition of the bowels, bladder, and previous charac-
ter of the pains. But if the pains are frequent and active, or occasion
much complaining, he may then inquire of the patient, herself, in a
low tone of voice, relative to these points ; and he may also form some
idea of the probable advance of the labor from the character of the
pains. He should likewise interrogate as to the general health of the
patient, and with multipart, the character of previous labors ; ascer-
tain the present condition of the pulse, skin, and tongue, and make
such other inquiries as may be necessary.

If the bowels are in a constipated condition, in the early part of the
first stage of labor, a mild cathartic may be administered, as castor oil,
or, whatever unobjectionable purgative the patient may prefer ; but if
the labor has advanced to nearly the commencement of the second
stage, or if this stage is already present, a laxative injection should be
used in preference, as being more apt to cause a speedy evacuation of
the rectum. And at all times, during the labor, whenever the female
desires to evacuate the bladder or rectum, the practitioner should leave
the room; indeed, it is proper that- he should request the patient,
through the nurse, or some friend, not to retain these discharges, but
to have him notified, whenever they are called for, while he is in the
room, that he may retire.

As soon as it is deemed necessary to make a vaginal examination,
and which should not be delayed for too long a time, the request must
be made of the patient, through some friend or the nurse ; the object
of such an examination is usually understood, but where it is not, an
explanation should be given, stating that it is " for the purpose of
learning the condition of the parts, the manner in which the child is
coming, and to know that everything is right to insure a safe deliv-
ery." Sometimes, an objection is made, especially by those in their
first labors, but by a firm and gentle course, representing to the patient,

L ; S,S KIX<;'s ECLECTIC OBSTETRICS.

that her own safety, as. well as that of her child, may depend upon an
early examination, the objections will generally be overcome. Should
the female be pettish, or fidgety, and notwithstanding these represen-
tations, persist in her objections, declaring that she will never submit
to an examination, and perhaps using harsh words to the physician, all
that he can do, will be to wait patiently until the pains have subdued
her caprices and antipathies, when the examination will be cheerfully
granted. Generally speaking, however, there will be found no diffi-
culty in obtaining the consent of the patient, if the request be delicately
made through a third (female) person.

One other reason for requiring an early examination, is, that the
accoucheur may not be detained for hours, waiting upon false pains.
I have known several young practitioners, who, having been misled
by these pains, and a delicacy as to insisting upon a vaginal examina-
tion, have been deprived of their rest for many hours, and were only
made aware of their error, when the loss .of confidence in their abilities
determined the patient to send for another medical man, who at once
explained the cause of the delay. Truly, a mortifying situation for
any one to be placed in! Again, it may be the case, that no pregnancy
exists.

It is not only highly proper, but it is a positive and imperative duty
of the practitioner, to conduct himself, throughout the whole course
of rjarturition, with firmness and kindness, but especially with de-
corum, using no language, arid manifesting no actions which might
offend the delicacy or modesty of the most fastidious. It will, there-
fore, be proper for him to observe the persons who are in the room,
previous to making an examination, prudently dismissing all but two
or three, whose presence as assistants may subsequently be needed ;
and unmarried females should by no means be allowed to remain, as
they can render but little assistance, or afford but a small share of con-
solation to the patient. The presence of relatives should always be
preferred, and if the husband remains it is an attention which many
men neglect to pay to their wives at this period, and should be rather
encouraged than condemned; his presence will tend to check the
obscene language of the filthy-minded, should any such be present.
No pure-minded nor well-meaning practitioner would hesitate for a
moment to perform all the necessary duties of his profession in the
presence of a husband, which he would do in his absence, or in the
presence of females. servant in attendance, to do the errands that
may be requisite, will be found a valuable acquisition, when one can
be had.

MANAGEMENT OF NATURAL LABOR. 289

Previous to the examination, the physician must see that the nail of
the finger to be introduced into the vagina is short, otherwise, it might,
by coming into contact with the tense membranes, at this early period,
rupture them, and occasion serious results. Indeed, a physician with
long nails, and kept in a state of uncleanliness, is not a very proper
nor desirable object for the parturient chamber. Filthiness of person,
in any respect, implies filthiness or carelessness in practice.

There are various positions recommended for placing the female
during an examination. Sims' position, in the early part of labor,
is the preference with many ; directing the patient to lie on the bed,
upon her left side, her back being toward 'the physician, with the
hips near to the edge of the bed, and the knees drawn up toward the
abdomen, and separated a little by a pillow or cushion placed be-
tween them. Other positions may be advised, as to lie upon the
right side, or upon the back, in which case the right or left hand
may have to be used ; but an accoucheur should accustom himself to
examine readily with either hand. I usually allow the patient to
take the position, in the beginning, that seems; most comfortable to
her. I find it more convenient, however, if she remain on the back,
to pass the hand, in making the examination, beneath the flexed
limb, etc. The position having been taken, the index or middle
finger is to be annointed with lard, sweet oil, pomatum, or other
unctuous substance, both for the purpose of an easy introduction and
that the parts may not be readily irritated by its presence, as well as
to guard against the contraction of disease, should any be present.
A cloth, or napkin, .should be at hand, as likewise a basin of water,
soap, and towel, for the subsequent washing of the hands. In all
cases, when possible, never make a vaginal examination unless in the
presence of a third person.

Having loosely thrown a sheet over the patient, for any exposure of
her person is unnecessary and reprehensible, the practitioner will seat
himself by the bedside in such a manner as will admit a ready intro-
duction of the 5nger into the vagina, that is, with his face looking
toward the head of the patient, and his side to the side of the bed next
the patient. As simple as this direction may be, an error or a hesita-
tion as to the proper mode of placing the chair, may destroy the
confidence of the patient or her friends. During the presence of a
pain is the period generally advised for the introduction of the finger,
hence, it is frequently termed "taking a pain." The sheet is now to
be raised, but without any exposure of the female, and the examining
hand of the accoucheur passed quickly upward toward the vagina; the
finger is to be carefully and slowly introduced along the posterior
19

KING'S K( I.KCTK' OBSTETRICS.

commissure, and into the vagina, carrying it along the posterior wall
of this canal, until its upper extremity is reached ; then, by bringing
the point of the finger toward the symphysis pubis, the os uteri will be
felt. The practitioner will be very careful, in this examination, not to
introduce his finger into the rectum instead of the vagina, a very
mortifying accident, and one which I have known to occur in the early
obstetric practice of some young medical gentlemen ; it will not be
likely to happen, if presence of mind is retained, with a freedom from
restraint and bashful diffidence. The advice to envelop the arms in a
towel, or cover them with oil-silk sleeves at this early examination, is
altogether unnecessary.

In this first vaginal examination, there are several conditions to be
ascertained, in effecting which, the physician must proceed carefully
and cautiously, and without undue -haste; nor must he remove his
finger, until he has positively satisfied himself in relation to the more
important symptoms. A great fault with young practitioners, is a
species of delicacy or bashfulness, which, although highly commend-
able, is very apt to prompt them to make a hurried and unsatisfactory
examination. The knowledge to be acquired is : 1, whether pregnancy
exists ; 2, whether the woman be in labor, and the progress it has
made ; 3, which is the presenting part of the child ; 4, whether the
membranes are entire, or have ruptured; 5, the condition of the os
uteri, vagina, perineum, and pelvic diameters; and the finger should
not be withdrawn until the pain has passed away, and a sufficient part
of the succeeding interval has been occupied in making the examina-
tion thorough and satisfactory.

The recommendation to ascertain the existence of pregnancy in a
female who declares herself pregnant, that she has felt the motions of
the child very sensibly, and that she is suffering from labor-pains,
may, at first sight, appear rather absurd, but when we reflect that
instances have not unfrequently occurred, in which the physician,
misled by the professions of the woman, who was herself deceived "in
regard to her condition, has remained in attendance for days and even
weeks, until the discovery was made that she was not even pregnant,
rendered him the mark for the jest and ridicule of all who heard of
his exploits; this caution will be deemed very proper and essential.
Many circumstances may occasion an enlargement of the abdomen, as
flatulency, an effusion of fluid in the peritoneal cavity, tumors, etc.;
and a near resemblance to labor-pains may be occasioned by spasmodic
action of different muscles, leading the female to believe, not only that
she is pregnant, but that labor has actually commenced. It will,
therefore, be readily understood, that the accoucheur can place no

MANAGEMENT OF NATURAL LABOR. 291

reliance upon any other source than a correct, personal examination.
The means by which pregnancy may be determined have already been
given in preceding pages; but it may not be amiss to call attention
to a few matters relating thereto. In many instances, the hand placed
on the abdomen for the purpose of detecting the contractions of the
uterus during the pains, the condition of the abdomen as to its softness
or hardness, and elasticity, the extent of the swelling, and its shape,
will frequently decide the question; but if there still remains am
doubt, the vaginal examination will be more likely to solve it. There
will be found, if pregnancy be absent, the protruding, unexpanded
cervix, with a close, undeveloped os uteri, and the uterus when poised
on the end of the finger, will, if not diseased, be found small, light,
and very movable; but, if pregnancy be present, and labor com-
mencing, the cervix will be found expanded, and the os uteri fully
developed, and perhaps sufficiently open to allow the finger to enter,
and detect the presence of the fetus. When doubt still remains, bal-
lottcment, auscultation, and the means previously recommended
should be resorted to.

The female may be pregnant, but not in labor, and this is to be
determined by the rules given in the previous chapter. This is a point
that must, as well as the preceding, be fully solved, or else the prac-
titioner may subject himself to much ridicule by waiting upon "false
pains" instead of true ones, a circumstance which has, unfortunately,
happened more than once in practice. Labor may be detected by the
true pains hardening the uterine globe; by the os uteri contracting
during the presence of a pain, and dilating during its absence; by the
bag of waters being tender, tense, and protrusive during the uteiine
contractions, and becoming soft and relaxed in their absence, receding
within the uterine cavity.

During the presence of a pain, a careful examination should be made
to ascertain the effect produced by it upon the os uteri ; whether this
is high up in the pelvis, or low down : whether it is thick or thin,
soft, and yielding, or thick, rigid, and unyielding ; and in doing this,
no pressure should be made upon the membranes, which are generally
tense and thin during the presence of pain, lest they rupture, and a
natural labor be thereby converted into a protracted one. Upon the
cessation of the pain, as soon as the os uteri has relaxed, and the mem-
branes have collapsed, and not before, cautiously introduce the finger
within the orifice of the os uteri, to ascertain whether the head pre-
sents, and should a pain come on, while the finger is within, graduallv
remove it as the membranes protrude, without exerting any pressure
upon them, and re-introduce it on the subsidence of the pain and col-

29'2 KING'S KCLKCTIC OUSTKTHICS.

lapse of the membranes. The head may readily be known by its
rounded form, its peculiar hardness, and its sutures. Tf the hard
edges of the parietal bones can be felt along the sagittal suture, there
can be no difficulty in determining the presentation. The endeavor
to ascertain the position of the head at the commencement of labor,
or previous to the rupture of the membranes and completion of the
first stage, is unnecessary, and exceedingly improper, and endangers
the rupture of the membranes; it is sufficient to know positively that the
head presents, and this information should always be obtained, before
withdrawing the finger, for it quiets any fear or anxiety on the part of
the practitioner, who knows, that nature is most generally capable of
overcoming or rectifying any improper positions of the head without
artificial interference. " Any attempt to determine in which of the
numerous positions described by some authors, the head is placed at
the brim of the pelvis, would only endanger the rupture of the mem-
branes, and disturb the regular order observed by nature in the process.
Indeed, I can not discover what benefit could result from knowing
during the first stage of labor, provided you can touch the vertex with
the point of the finger, in which of the six or eight positions of Bau-
delocque and other foreign authors, the head is placed, The import-
ance attached by some authors to a knowledge of these positions, some
of which are wholly imaginary, has probably arisen from the dangerous
practice of employing the long forceps before the os uteri is fully dilated,
and before the head has passed into the cavity of the pelvis. At this
early stage of the labor, no instrument of this description can be safely used,
and if the operation of turning were required, the position of the head
would have no influence upon the method we would adopt in turning.
Be sure that the head presents before you state this to the nurse or
patient, as they will not soon forget your mistake, if it should turn
out to be a case of nates presentation." Lee.

Should any other part present than the head, the practitioner, has
by the examination, gained information which will enable him to give
the necessary assistance at the proper time ; but by neglecting to
obtain this knowledge, he is highly culpable, as he not only runs the
risk of exposing his patient to much unnecessary suffering, but may
actually endanger her life, that of the fetus, or the lives of both. The
method of determining face, nates, and other presentations, together
with their treatment, will be described hereafter. I may state here,
that if the index finger fails to reach the os uteri, or feel the present-
ing part, two fingers, the index and middle, should then be introduced,
for it is imperative that the practitioner should decide the presentation
at as early a period as possible. It is frequently the case, especially in

MANAGEMENT OP NATURAL LABOR. 293

females of irritable habits, that the most cautious introduction of the
finger within the os uteri will occasion the uterus to contract ; and in
nearly all patients, the excitement produced by the finger being need-
lessly moved round to discover the position of the presenting part, will
induce contractions, which may, more or less suddenly, force the mem-
branes against the finger and rupture them, occasioning a premature
dischage of the liquor amnii, an accident always to be dreaded in the
early part of the first stage of labor. When the membranes are. entire,
the protruding bag of waters will be felt during the pain, and there
will be no dribbling away of the liquor amnii ; if they be ruptured,
the presenting part can be more readily detected, the hairy scalp puck-
ering up during the pain, and becoming smooth and even, when it
subsides ; while, on the contrary, the membranes are smooth and tense
while the pain is on, and lax during its absence.

The finger being withdrawn from the os uteri, the dimensions of the
pelvis and its conditions, should then be explored, for the purpose of
determining the probable character of the labor. The point of the
finger should be carried toward the promontory of the sacrum, as ex-
plained when describing the pelvic diameters, and if this be not
touched, the space is ample enough for the passage of the fetus, and if
deemed necessary, the other diameters may be ascertained by the rules
heretofore given. The condition of the soft parts, as to whether they
are hot or normally cool, dry or moist, soft and yielding, or hard and
unyielding, should also be observed the finger should then be with-
drawn, wiping it with a napkin, while still under the sheet; after
which, the hands may be washed.

As soon as the examination is finished, the patient and her friends,
being naturally anxious to know whether everything is right, will
interrogate the physician relative thereto. This is a very delicate
position for him to be placed in, for if the reply, or opinion expressed,
prove incorrect, the confidence which the parties repose in him, will be at
once lessened or altogether .destroyed, and another physician may be
sent for ; beside which, it may give rise to some apprehensions on their
part, that difficulty or danger in the case exists, not recognized by the
medical attendant. Consequently, a reply to such interrogations
should be very guarded ; the physician should never permit himself to
be betrayed into the expression of a positive opinion on this subject.
When the head presents, and everything appears to be in a favorable
condition, he may state this, and add, that if no unforeseen circum-
stances occur, and the labor progresses uninterruptedly, she will, prob-
ably, be delivered by such a time, naming the longest possible time
suggested by the examination ; and if delivery is eifected previous to

294 KI.\<;'s KCLKCTIC OBSTKTUK'S.

this time, it will prove anything but a disappointment to the patient,,
and will occasion no doubt of the accoucheur's skill or acquaintance
with his profession. The reasons for such a course are sufficiently
obvious ; for it frequently happens that a labor which commences
rapidly and with a prospect of speedy termination, becomes protracted
during its latter part ; and one that has a slow and tedious beginning,
may advance with rapidity during the second stage ; Reside, many cir-
cumstances may transpire during the progress of labor, which may
convert it into one of a protracted and even dangerous character. By
remembering the following points, which have been laid down by
accoucheurs, a pretty accurate estimate as to the duration of labor may
be formed, when not interfered with by unexpected accidents :

1. First labors are commonly more tedious than subsequent ones.

2. Labor advances more rapidly where the pelvis is of large
dimensions than where it is small.

3. In proportion to the softness and yielding of the soft parts, will
be the rapidity of the labor.

4. The duration of labor is always modified by the character of the
pains.

5. Labor will be accomplished at an earlier period when the os uteri
is dilated, or thick, soft, and dilatable, than when it is thin and firm,
even though somewhat dilated.

6. A soft and slightly dilated os uteri, moist and relaxed condition
of the soft parts, and regularity in the pains, are signs of a speedy
delivery. When these symptoms are present, and the os uteri is
dilated to a size corresponding in diameter to that of half a dollar,
most accoucheurs consider it improper to leave the patient, especially
if it be in the night and which will be found a good general rule to
adopt in practice.

7. Labor will be rapid where the vagina is large and yielding
throughout its whole extent; but will be slow where it is small and
unyielding. " If the entrance of the vagina is small, the neighboring
parts cool, dry, inelastic, and as if tightly drawn over the bones ; if
the finger, in spite of being well oiled and carefully introduced, pro-
duces pain upon the gentlest attempt to examine, we may expect a
tedious and difficult labor."

8. When the upper portion of the vagina is well dilated, and its
lower portion is rigid and contracted, the labor will be rapid during
its first half and protracted afterward; and vice versa.

9. Labor is almost always tedious in primiparse of advanced years.
10. Notwithstanding all the above points, unexpected changes may

occur which will materially alter the character of the labor, and hence

MANAGEMENT OF NATURAL LABOR. 295

the necessity of expressing an opinion, as to the duration of labor,
with a cautious reserve; for "no one can know beforehand, when a
labor shall be terminated," and no good practitioner ever makes prog-
nostics. Should the examination, at any time during the first stage of
labor, discover rigidity of the parts, it must be treated as described
under difficult or protracted labor. If the breech, an arm, or any other
unusual part presents, it should be made known to the nurse, or some
friend, but not to the patient, and the proper means should be pursued,
as hereafter laid down.

The examination being over, the condition _of the patient's bowels
and bladder must be attended to, if this has not been done previously,
using the catheter to evacuate this latter organ if required ; and it
must be recollected, that these are essential and necessary measures to
insure a safe and speedy delivery. Now is also the time to make the
proper arrangements for the delivery, as preparing the bed, and getting
in readiness the ligatures, scissors, bandage, etc.; an attention to these
little but very necessary matters, serves to secure the confidence of the
patient and her friends, a very important desideratum in obstetric
practice. The adjustment of the bed is usually attended to by the
nurse, still it is requisite for the practitioner to understand the method
of doing it, as he will frequently be called upon to give directions in
relation thereto. A cot, hair mattress, or straw mattress may be used,
but by no means a feather bed; and, if the patient have but the one
feather bed, it must be removed or rolled to one side, that the under
mattress may be used for her to lie upon. OveV this a folded sheet,
blanket, or any soft material, to protect the mattress or cot from the
discharges, must be placed, covering that part of it which will be
occupied by the .patient's hips. During the second stage of labor,
some recommend a piece of oil-cloth, or leather, or india-rubber
cloth these are all proper, but are not always at hand. Upon the
folded blanket, or material that is employed, ,the sheet upon which the
patient is to Lie, maybe placed. Care must be taken that in preparing
or guarding the bed, as it is sometimes called, no depressions or con-
cavities are formed, into which the pelvis might sink down; at this
point it should rather be elevated a little. Thus arranged, the bed is
ready for the delivery when it comes on.

A piece of narrow tape, or bobbin, or linen thread doubled, two or
three times, and a few inches in length, must be secured for a ligature.
I generally use two ligatures, and which, together with a pair of
sharp scissors, should be placed in a convenient position for the prac-
titioner to reach, when it becomes necessary to ligature the umbilical
cord and divide it; or these may be handed to him by one of the

296 KIN(;'S I-X 'LECTIO OBSTETRICS.

female assistants. Long and strong pins should also be held in readi-
ness, with which to pin the binder or bandage, after the delivery ;
but it will often be found that the female has a binder already made
which requires to be fastened and retained with a cord, like a corset
but these are generally troublesome and in the way, and I do not like
them as well as a good stout towel, or piece of unbleached muslin,
about a foot wide, and three or four feet long.

The room must be kept comfortably cool, and free from unpleasant
odors, the clothing of the patient should be light and loose, and the
diet, if any is required, composed of crackers, gruel, toast-water, tea,
and cold water; no stimulating articles of food or drink, nor meats
should be allowed, nor should any solicitations be used to induce an
appetite.

Everything having been thus attended to and prepared, nothing
else can be done than to wait patiently for the second stage of labor ;
the practitioner can do nothing to facilitate the progress of the first
stage, and any interference to dilate the os uteri, or passages through
which the child has to be expelled, or in any other way to hasten the
labor, is a mark of ignorance, and is fraught with serious consequences.
Even the too frequent repetition of the vaginal examination is im-
proper ; probably, another examination may not be required for an
hour or two, but this will depend very much upon the increased
strength and frequency of the pains, as well as the capaciousness of
the pelvis, and the yielding character of the soft parts. It is proper
to examine the hypogastrium occasionally to be certain that the bladder
does not become distended with urine, and this may be done at the
time of the vaginal examinations ; during a protracted labor, an atten-
tion to this circumstance is very important, that the catheter may be
used without delay, as soon as a necessity for it arises.

In reference to the condition of the bladder, the accoucheur should
always personally satisfy himself, for it often happens that he will
be told the urine passes freely, when, in fact, there is only a mere
dribbling of fluid upon the recurrence of each uterine contraction, and
which may be the liquor amnii, or a portion of urine forced out of the
bladder in consequence of its contraction by the abdominal muscles ;
this latter circumstance is an indication that the bladder contains a
large amount of fluid, which requires an artificial evacuation. In
introducing the catheter, the index finger of the left hand is to be
passed between the labia majora, and carried toward the vestibulum,
at the lower part of which, just within the lower angle of the pubic
symphysis, the meatus urinarius may be detected by a slight pressure
of the finger upon this part ; the point of the catheter should then be

MANAGEMENT OF NATURAL LABOR. 297

passed along the inner surface of the finger, until it reaches the
urethra] orifice, when a slight movement will cause it to enter. It
should be passed upward without force, until about three-fourths
of it has entered, being careful not to allow it to slip entirely into the
bladder ; some small vessel must be in readiness to receive the urine
as it passes. When the pelvis is occupied by the head, a flat catheter
will be preferable to a round one, as it does not take up so much space
in the antero-posterior diameter. Sometimes the introduction of the
instrument into the bladder will be facilitated by gently raising the
head of the child, during the absence of uterine contraction.

Some time may elapse before the commencement of the second
stage of labor, and a few suggestions relative to the mode of employ-
ing the time, may be of service, especially to the young accoucheur.
If the labor has just commenced, and everything is found right on
examination, there will be no necessity for tarrying at the house; the
practitioner may return home, or visit other patients, being careful not
to allow his absence to exceed one hour, as it may then become
necessary to institute another vaginal exploration. Much, however,
will depend upon circumstances; if it be a first labor, it will not,
probably, progress very rapidly ; if previous labors have been rapid,
too long an absence, from the patient is not advisable, and more
especially when the os uteri is dilated to nearly the size of half a
dollar, or is very soft and dilatable ; for it must be remembered, that
although it may have required several hours to obtain the above
degree of dilatation, the remainder of the process may be effected in a
very short time, and labor be completed by only a few more pains.
Should the physician conclude to remain with the patient during the
first stage of labor, and which is the course usually pursued when the
visit is late at night, it is not proper that he should continue all the
time in the parturient chamber, as it may prevent his patient from
attending to the fecal and urinary discharges, the calls to one or both
of which are apt to be rather frequent. He should retire to some
other room, generally, if possible, so situated that he can hear the
cries of the female, and thus be able to determine the progress of the
labor, as well as the necessity for another examination. Or, if this can
not be done, the room not being favorably situated for the purpose,
he will request the nurse to, inform him, from time to time, of the
advance of the pains, their frequency and strength. While thus
absented in another room, he may employ himself in reading, in con-
versation, etc., but should never permit himself to become so far
interested in whatever employment he adopts, as, for a moment, to
.forget his patient. Or, if there is a probability that the labor may

'2V$ KINti's ECLECTIC OBSTETRICS.

not require his immediate attention for a few hours, he may lie down
on a sola or bed, and enjoy ;i short sleep, until the nurse awakens
him, at such time as he may have requested. If there is but one room
occupied by the family, as is frequently the case with the poorer
classes, it will be proper for him to leave it occasionally to take a peep
at the stars, or a glance at the weather, or to inhale a little fresh air,
for the purpose of relieving a little dullness of feeling, etc., remarking
as he goes out, that he will return in ten or twelve minutes ; thus
giving the female an opportunity to attend to her evacuations. These
little attentions, and especially if performed wiih a degree of delicacy,
will always produce a favorable impression, which may subsequently
prove advantageous to the physician.

"While in the room with the patient, it is always proper to speak
encouragingly to her, and endeavor to cheer her up, occasionally
assuring her when such is really the case, that everything is going
right. But, above all things, avoid that very reprehensible and
demoralizing practice, which is too common among some persons,
of indulging in filthy and obscene convei'sation ; some individuals,
and among them I regret to say are found females, seem to select this
as the best time for the delivery of all the obscenity with which their
minds are filled, and vie with each other as to who shall bear off the
palm in such disgusting loquaciousness. This kind of chat has a
depressing and injurious influence upon the patient, beside polluting
the minds of all present ; and I have no doubt, but that the first
approach toward a departure from virtue, has, with many females,
commenced in the parturient room, where these coarse and indelicate
conversations were permitted. No gentleman, and certainly no lady,
would be guilty of such low and undignified behavior. It is the duty
of the physician, at all times, and under all circumstances, not only
to preserve and protect the health of his patient, but likewise to
preserve and protect the purity of her mind, and any one who pursues
a different course, should not be recognized as a professional brother
nor as a man worthy the confidence of community.

It is not necessary, during the first stage of labor, that the female
should retain the recumbent position, she may sit up, walk about, lie
down, and change her position, according to her inclination ; nor
should any bearing-down efforts be permitted during this stage, as
they exhaust the patient's strength, without effecting the least benefit
whatever, and may also cause a premature rupture of the membranes,
and thus convert the labor into a difficult one. It is onlv when the

MANAGEMENT OF NATURAL, LABOR. 299

os uteri is fully dilated, and the membranes have ruptured, that she
must assume the recumbent position, or make use of any voluntary
efforts at bearing down.

After the full dilatation of the os uteri, until the birth of the child,
the female should be required to remain in the recumbent position,
lest, while moving about, the child should suddenly be expelled upon
the floor, and the uterus, following the cord and placenta, become
inverted. But, in a prolonged labor, where there is no immediate
danger of rapid expulsion, she may be permitted to sit up at short
intervals, as well as to change her position on the bed. If, at the
complete dilatation of the os uteri, the membranes have not ruptured,
the head presenting, and the soft parts being yielding, the accoucheur
should rupture them ; but not under other circumstances, except those
referred to hereafter. Sometimes, the head emerges from the vulva
.simultaneously with the rupture of the membranes, but this most
commonly occurs in cases where the membranes are unusually tough,
and have been allowed to remain entire until the head has cleared the
os uteri and advanced considerably into the pelvic cavity.

During the second stage of labor, many practitioners pass a towel
around each fore-arm, without removing the coat, as a protection
against the discharges. The towel is doubled so as to form a triangle,
the base, or folded edge of which, is passed rather tightly around the
wrist, but not so as to interfere with its free motion, the rest being
folded with one end over the other, around the arm, and then pinned,
and which is usually done by some female present. Others, again,
have oil-silk sleeves for the purpose which they draw on over the coat
sleeves. Some, merely remove the coat, and roll up the shirt sleeves^
thus having a free, unimpeded use of the hand and arms, especially in
cases where manual assistance is required. This latter plan is the
one which I prefer; but the accoucheur may please himself in these
respects.

After the rupture of the membranes, the practitioner should make
no delay in ascertaining the position of tho presentation ; and an early
examination, at this time, is often of much importance, as any mal-
position may be more readily rectified than at a later period. The
situation of the head at the time of tho rupture varies; most com-
monly it will be found just within the brim, sometimes midway in the
pelvic cavity, or at the perineum, etc. The position of the head may
be determined by the rules heretofore named. During this stage
of labor, the patient should not be left by her medical attendant,
who will find it necessary to repeat his examinations every four, six.

300 KIND'S KCI.KCTIC nnsTKTKlrs.

or. eight pains, according to their frequency and strength, and the
rapidity with which the head advances; and after these examinations,
it is not necessary to wash the hands each time, but merely to dry
them on a napkin, secured for the purpose. It is also an excellent
plan for the accoucheur, by means of a flexible stethoscope, to examine
the condition of the fetal heart from time to time, both during natural
and unnatural labors, as the information thus acquired may prove
of great value in the management of the case, and save his patient
much suffering and danger. Should the patient suffer from cramps
of the lower extremities, they may be removed by frictions with the
hand over the part affected, or ligatures around it, or warm applica-
tions; pain in the sacrum, occasioned by pressure of the presenting
part upon the anterior sacral nerves, may be relieved by firm, counter-
pressure against the posterior face of the sacrum, during a pain, and
which should be made by the nurse, or some female present; the
practitioner should avoid any fatiguing exercise, or manipulation,
unless when imperatively required. If, however, the pain should be
very severe, and no relief be afforded by the counter-pressure, and
the efficiency of the pains be, at the same time, diminished, it may
become necessary to relieve the agony of the patient, by hastening the
delivery with the forceps. I have heard of a Professor of Obstetrics,
who informed his class, that he had relieved several instances of this
kind, by placing a folded handkerchief between the head and the
nerves. But it must* be remembered, that this would still further
diminish the diameter of the pelvic cavity, and be very apt to produce
irritation, dryness, and probable inflammation of the parts; perhaps
the Professor may have dreamed of these several cases, and forgotten
that they were but dreams.

The position which I prefer for the delivery, is on the back, having
the knees flexed toward the abdomen, and the feet resting against some
support, as the footboard of the bed ; and a sheet or towel fastened to
the bedpost, may he held by the patient, upon which she may pull
during the presence of the pain, or the hand of an attendant may be
used. In this stage, the auxiliary aid of the diaphragm and abdomi-
nal muscles are useful, and the patient may be advised to make bearing-
down efforts, when the pain is on. Her dress should be so far drawn
up underneath her, as to prevent it from being soiled by the discharges.
And until the period when the head presses upon the perineum, it is
not necessary for her to remain in one position all the time, though
she must not be allowed to get out of the bed. It is during this stage,
that many practitioners have applied an obstetrical supporter. As a

MANAGEMENT OF NATURAL LABOR. 301

general thing, supporters have notfbeen found so useful in practice a&
was at first supposed, and are seldom, if ever, made use of by the
obstetrician.

Various other positions for delivery, are recommended by writers,
and assumed by females ; as sitting, kneeling, leaning over a chair, and
lying on the left side. Females, generally, will assume the position
recommended by the physician, but where they obstinately prefer a cer-
tain position, and it is immaterial, so far so the delivery is concerned,
it is better to allow them their own way. Lying upon the left side,
with the knees flexed, and a pillow placed between them, is the posi-
tion most generally recommended in this country and England; but I
do not think that the delivery proceeds with so much ease and rapidity,
nor it so convenient for the practitioner in every respect, as when the
female is placed upon the back. Some writers maintain, that the
action of the uterus is frequently interfered with, and the progress of
labor impeded, when the female lies on her left side, in consequence
of an obliquity of the uterus, caused by this position ; also, that the
too close condition of the limbs, produced thereby, retards the labor,
and to overcome which the advocates of this position, advise a pillow
to be placed between them, which causes much unnecessary heat.
When lying upon the back, the limbs can be kept apart with ease, the
axis of the uterus is brought into a favorable direction 'for an easy
delivery, and the patient, being in a position requiring no muscular
exertion to maintain, can freely and more powerfully employ the
abdominal muscles.

"When the head has reached the perineum, the practitioner will take
his seat, by the bedside, in the position heretofore named, and as the
part begins to distend, he should keep his finger gently upon the head,
during each pain, so as to ascertain the proper period for supporting
the perineum, in order to protect it from becoming lacerated, and the
advance of the head must be determined, not by its condition at the
pubic arch, but at the perineum. As soon as the perineum is fully dis-
tended and protruding, and the head about emerging, and not before, a
folded cloth, or napkin, light and not too thick or bulky, may be
placed over it, extending from its anterior edge to the coccyx, and
which must be sustained by either hand, as the case may require, more
commonly the right. The pressure, made in giving support to the peri-
neum, must be moderate, it must not interfere with the advance of the
head, the part requiring firmer support toward the coccyx than at its
anterior edge ; and instead of making efforts to retract the skin over
the head, as it passes through the orifice, the perineum and the head

: JOl' KIN<,'s KCLECTIC OBSTHTHK S.

ghould be carried upward and forward in the direction of the axis of
tlie inferior strait; this action would press the fetal head toward the
pubic arch, and tend to elongate the perineum forward ly, thereby
diminishing the risk of laceration, by facilitating the movement of
extension of the fetal head. This pressure should not be long contin-
ued, nor should it be made at all, except when the pain is present, an. 1
it would be much better to leave the part entirely untouched, than t<
make improper pressure, which has frequently, of itself, occasioned tht
very difficulty it was intended to obviate. There is scarcely any
necessity for this support when the perineum is gradually yielding to
the normal advance of the fetal head ; .but when the head is rapidly
advancing, the perineal tissues not being sufficiently softened, support
of this kind may prevent laceration ; and it may also be useful in
oases of delivery by the forceps. Some authors advise to support by
pressing the bare thumb upon the anterior edge of the perineum, while
the index and second finger rest upon the vertex to check its too rapid
advance ; this, to my mind, is equal to no support at all, the object of
support being, in my opinion, to elongate, as it were, and aid in the
relaxation of the perineum, and at the same time to press the occiput
against the pubic arch and facilitate the movement of extension. '

My experience in this matter, leads me to believe, that laceration of
the perineum would be a rare accident, were the rule to support it
during the latter part of the second stage of a normal labor, entirely
dispensed with in obstetrical practice. Some writers recommend the
support of the perineum, not only during the passage of the head, but
likewise of that of the shoulders, from a belief that the perineum is
frequently lacerated as the bis-acromial diameter is emerging ; in some
instances, an attention to this point may prove serviceable, but I do not
regard it necessary as a general rule.

While the head is at the perineum, pressing upon the lower part of
the rectum, a great disposition to evacuate the bowels will be produced,
and the female will desire to rise and attend to the call ; but it must
by no means be granted, as a violent pain might come on, and the
child be delivered, and perhaps, destroyed, before the physician could
bestow the necessary attention. Beside, these desires generally dis-
appear with the delivery of the head, the pressure of which upon the
parts has occasioned the tenesmus. I have twice witnessed the delivery
of the child, and its reception into the chamber-utensil, where the physi-
cians had permitted the females to attempt an evacuation of the rectum,
at this stage of the labor. Again : should the bowels not have been
opened, early in the labor, and the probability is, that a fecal discharge

MANAGEMENT OF NATURAL, LABOR. 303

may happen, the patient must not be permitted to rise from the bed,
but must perform the evacuation on some old, useless cloths, to be
placed under her for such purpose, and which are then to be immedi-
ately removed.

It is sometimes the case, that the pains cease, or diminish in strength,
toward the close of the second stage, but they may be renewed by
making firm pressure with the left hand, upon the uterus, each time
of its contracting, or, by pressing firmly on the end of the sacrum.

As the head passes through the vaginal orifice, the leg on the side
toward the practitioner should be raised and flexed at the knee, to
facilitate its passage, and to enable the attendant to act with greater
accuracy and promptness ; the fetal head should be received into the
right hand, holding it loosely, so as to admit of the motion of restitu-
tion, and, at the same time, a finger should be passed around the neck
of the child to ascertain whether the umbilical cord is coiled around it,
and which commonly occurs when the cord is of more than ordinary
length.

If the neck be embraced by one or more turns of the cord, it must
be liberated by loosening it, and passing it over the head ; or else the
following results may ensue, especially if the cord be short : the com-
pression may arrest the circulation in the blood-vessels of the neck,
and prevent the access of air into the lungs by closure of the trachea,
thus destroying the child ; or, the expulsion of the child by a strong
pain, might cause inversion of the womb, or serious hemorrhage by
tearing the placenta from its uterine attachment. If the cord can not
be easily passed over the head, it must be loosened as much as possible,
so as to prevent strangulation of the vessels of the neck; for it must
be remembered, that ordinarily, even with two or three coils around
the neck, the cord will be sufficiently long for delivery to take place,
without any evil consequences to the mother. Sometimes, the cord is
so placed around the neck, that it has to be divided before the body
can be born, a ligature being applied as soon as possible; but this is
done only in those extremely rare cases, where the free portion of the
cord is rendered so short as to endanger inversion, should the child be
delivered. It is frequently the case, that an evacuation of the rectum
occurs with the expulsion of the head, but the compress at the peri-
neum serves to protect the hand of the accoucheur from being soiled
by it. The use of a napkin or compress in supporting the perineum
has been termed most absurd, the objection being that it absorbs the
great secretion of mucus designed to lubricate the parts and thereby
render the passage of the head more easy. I have never found any

;J04 KING'S ECLECTIC OBSTETRICS.

difficulty from this cause, which may be readily obviated by applying-
oil or lard upon the perineum, and, if necessary, also upon the com-
press. The principal object of the compress has just been referred
to the support can be given as well without as with it.

As soon as the head is born, the child commonly commences crying
lustily ; frequently, however, the presence of mucus interferes with its
breathing, and the practitioner should pass a finger into its mouth for
the purpose of removing any mucus or other obstruction that may
exist there. More commonly, simply wiping its mouth with a small
napkin, will answer the purpose, by removing any mucus that may
have accumulated around the lips.

No attempt, whatever, should be made at removing the body, unless?
much delay occurs in the natural process, or, the life of the child is in
danger. After the birth of the head a short interval generally fol-
lows, but if this is prolonged, serious consequences may result; under
such circumstances, a finger may be inserted into the axilla nearest the
perineum, and traction made in the direction of the axis of the inferior
strait, while, at the same time, pressure is to be made by the other
hand, or by an assistant, on the abdomen over the uterus. One
shoulder disengaged, the other follows, and the child is born without
any further trouble. I prefer, however, as the rule, to arouse the
uterus to act and expel the child, by making firm pressure, through
the abdominal walls, upon the uterine fundus, and which will also be
found to facilitate the delivery of the placenta. But, when the body
follows the head without requiring any assistance to expel it, the
right hand must be passed along with the head, supporting it as it
moves, and the body must be supported by the left hand ; and as soon
as the child is expelled, it should be laid upon its right -side with its
back to the mother's genitals, to prevent it from receiving any of the
copious discharge which follows, into its mouth ; or it may be placed
with its abdomen toward the mother, so that the mouth is protected
from the discharges. And in moving the child, care must be taken
not to make sudden or powerful traction on the cord, as the uterus may
become thereby inverted, or a portion of the placenta by being roughly
detached, may occasion alarming hemorrhage.

The expulsion of the child terminates the second stage of labor;
and it must be ever borne in mind by the physician, that in a case of
natural delivery, there is nothing for him to do in these two stages,
except to witness the progress of the labor, to console and encourage
his patient, and to receive the child after its expulsion. Any inter-
ference, in either the first or second stages, when everything i&

MANAGEMENT OF NATURAL LABOR. 305

proceeding favorably, further than I have just described, is exceed-
ingly improper and criminal.

I am aware that some writers advise, and many practitioners adopt
the plan of administering Ergot to all parturient women, in the second
stage of labor, for ^ the purpose as they say, of promoting the easy
expulsion of the placenta, and a subsequent uterine contraction, thereby
lessening the risk of hemorrhage; but, more for the purpose, as I
strongly fear, that they may the sooner visit another patient and
procure another fee, or, perhaps, from want of sympathy and patience.
I consider this a very unscientific and censurable practice, and have
witnessed many accidents resulting from it; indeed, when the influence
of the Ergot has subsided, the reaction that must ensue, would be very
apt to produce a condition of the. uterine tissue favorable to hemorrhage
from that organ. From a practice and observation of thirty years, I
am thoroughly convinced, that the administration of Ergot to cause
contractions of the uterus, whether indicated or not, occasions and
develops a greater proportion of diseases of the organ, than is generally
suspected by the profession. I have found Sulphate of Quinia, to
answer a much better purpose, when it is desired to keep up permanent
uterine contraction after delivery, though, as with Ergot, it sometimes
fails. It may be given alone, or in combination with powdered
Cinnamon.

A natural labor may be accomrlished in two hours, or it may con-
tinue for twenty-four or even longer, without any danger. The danger
is never to be estimated by the time which the process occupies, nor by
the severity of the pains, but by the symptoms which are present. So
long as the parts are in a proper condition, position and presentation
right, and the pulse unaffected, there is no necessity for haste, alarm,
or officious intermeddling, no matter how long the labor continues ;
the practitioner should appear cheerful, resolute, and confident, at once
check any complain cs or whisperings among the female attendants,
and use all means to sustain the patient's spirits, and preserve her from
a despondency, which may cause a suspension of uterine contraction,
and convert the labor into a difficult one. But, if the parts become
hot and dry, with more or less tenderness on being touched, and the
pulse accelerated, it is then necessary to interfere, calmly, deliberately,
without violence or rudeness, and employ the proper means to over-
come the difficulty.

Sometimes, after the delivery of the child, the female will be
attacked with violent pains, and forcible straining, or bearing-down
efforts ; as these may be owing to a disposition to inversion of the
20

:',();; KINO'S KCLKCTIC OHSTETUICS.

uterus, the practitioner should endeavor to ascertain their cause, and
remove it if possible, at the same time urging upon the female the
importance of resisting these efforts as much as possible, lest inversion
should be produced by them.

The third stage of labor commences after the birth of the child [the
placenta not having been expelled simultaneously with the child], and
may be considered the most important period of the process, for by far
the greater part of the accidents of labor occur at this time, either from
improper intermeddling, or from an ignorance of the correct mode of
proceeding. After having observed that the child is living, as made
known by its crying, it must be separated from its uterine attachment;
and this must be effected without any exposure of the mother a point
which I desire the reader especially to impress upon his mind as
many practitioners, at this stage, are very apt to needlessly expose
their patients.

As soon as the pulsation of the cord of the living child ceases
toward its placental extremity, say at a distance of five or six inches
beyond its abdomen, or, as far as can be reached by the hand without
introducing it into vagina, the accoucheur will proceed to cut the cord.
The child must be withdrawn from beneath the bedclothes, if the
length of the cord will permit; or if too short, the operation must be
performed under the bedclothes, raising them to effect it, taking
especial care, however, to previously place over the parts of the patient
a well-aired cloth or towel, that they be perfectly covered and con-
cealed.

The ligatures, which had been prepared in the early part of the
labor, are now to be used ; they should not be so thin as to risk cutting
through the membranes and vessels of the cord, nor so thick as to be
incapable of making firm compression, sufficient to prevent bleeding
after the separation. The cord is to be tied tightly with one of these,
at a distance of an inch or two from the umbilicus, care being had
not to include any portion of protruding intestine, which is occasionally
met with; as in these cases, the incautious ligaturing of the intestinal
protrusion would give rise to the most disastrous consequences. This
first' ligature is of importance, for if it be not tied securely, so as to
compress the vessels, the child may lose its life from hemorrhage ;
hence, when the cord is large or fat it may require considerable force
to ligate it properly ; and shortly after dividing it, it will be well to
examine and ascertain whether any hemorrhage is occurring from its
free extremity. The second ligature is to be applied two or three
inches beyond the first, and the division must be made between the

MANAGEMENT OF NATURAL LABOR. 307

two with the scissors, being careful not to excise, at the same time, a
finger, or a portion of the child's penis, if it be a male. In this
operation the practitioner should see whafrhe is doing.

I am well aware that many authors advise the application of but one
ligature, and consider the employment of the second superfluous, but
I prefer two in all cases, not from an erroneous impression held by
some, that the female may lose blood through the unprotected, open
vessels of the cord, but for the following reasons : In the first place, I
am well convinced, that, in many instances, by thus retaining the
blood within the cord and placenta, it acts as a provocative to uterine
contraction and insures a speedy detachment and expulsion of the
placenta; secondly, it is much more cleanly, and dispenses with the
pressure of the thumb and finger to prevent the blood from spurting
over the bedclothes, or even on the clothing of the practitioner; thirdly,
it is safe in case of twins, with anastomosed circulation in the placenta,
should the practitioner, as is frequently the case, have neglected to
place his hand on the abdomen to ascertain the size of the uterine
tumor, and the probability of the presence of a second child ; and
fourthly, should it be judged advisable not to have the second ligature,
it can very readily be removed, or another division of the extremity
of the placental portion of the cord be made.

It is sometimes the case that the child is born in a state of defective
vitality, asphyxia, or apoplexy. If the pulsation in the cord continues,
and the child does not breathe, some cold brandy sprinkled on the
region of the diaphragm, or suddenly dashing cold water upon its
back and chest, and perhaps a few light frictions made rapidly over
the body and extremities with a piece of warm flannel, will be all the
means required for its resuscitation ; previous to which, however, the
finger must be passed carefully into the mouth, as far down as possible,
.in order to remove any mucus which may be present, obstructing the
respiration.

Where these means do not suffice, it may become necessary to
produce artificial respiration, which will not, however, be found of so
great value in cases of congenital asphyxia (in which air has never
entered the fetal lungs) as in other forms; a flexible catheter, or laryn-
geal tube must be cautiously and correctly introduced into the larynx,
after which the angles of the mouth must be closed to prevent the
escape of air ; the practitioner will then apply his mouth to the free
end of the tube and slowly and gently inflate the lungs, simulating
breathing by making gradual pressure on the chest to expel the air,
which he continues to introduce for some time ; with these attempts

Kix(;s KCLKCTI

he may also sprinkle water or brandy over the face and chest, apply
warm flannel to the surface and administer an injection. Some
children are not resuscitated until after a persevering trial of an hour
or two. Respiration may also be excited by the Sylvester method,
which consists in lifting the child by its two arms and then lowering
it to a sitting posture, gradually carrying the arms to the correspond-
ing sides of the body ; these elevating and depressing movements are
to be continued alternately for some time; they tend to produce
movements strongly resembling those of natural respiration. Dr.
Harvey L. Bird, of Baltimore, advises an easy and speedy method in
asphyxia, which consists essentially in placing the palms of the hands,
(the ulnar edges being in approximation) under the back of the child
in the dorsal decubitus, the thumbs being extended toward the head
and extremities. Keeping the ulnar edges of the hands together, the
radial sides are simultaneously and alternately elevated and depressed
so as to raise and lower the child's body about forty-five degrees above
and below the horizontal line, the downward movement allowing air to
enter the lungs, while the upward facilitates its escape. These alternate
movements performed with gentleness and regularity, the child's head
being kept in the median line of the body, rarely fail in effecting
respiration in a short time, where life is not extinct. The first
symptom of returning life is a short sob, which increases in frequency
until respiration is established, after which, the child should be -kept
at a sufficiently elevated temperature, and in a state of rest and quiet.
Upon the first return of vitality, the warm bath used for a very short
time, frequently facilitates the restoration.

This condition of the child may arise from a premature detachment
of the placenta, from uterine hemorrhage, or from defective nourish-
ment, and is generally accompanied with little or no pulsation in the
cord, and but slight action of the heart, and as nothing is to be gained
by maintaining the connection of the fetus with the uterus, it will .be
proper to ligate and cut the cord ; but in all instances where the pulsa-
tion of the cord is distinct, though feeble, I deem it inadvisable to
make the division, until respiration has been fully established ; and in
those cases where the" placenta has been expelled, it should be Wrapped
in warm, damp cloths, and no separation be made until all pulsation in
the cord ceases.

Apoplexy may be known by the lividity of the face, blueness of the
surface, labored, or obscure action of the heart, and feeble, or imper-
ceptible pulsation in the cord; while, in the instances above referred
to, the color of the surface is natural, or pale. Apoplexy may result

MANAGEMENT OF NATURAL LABOR. 309

from prolonged labor, compression of the head by a narrow pelvis, or
from a delay in the expulsion of the body after the delivery of the
head, etc., and it must be treated by removing the cerebral and pul-
monary engorgement. In these cases it is recommended to cut the
cord without ligaturing it, and allow the escape of from half an ounce
to an ounce of blood, at the same time sprinkling tepid water over the
head, face, and chest. As in the previous instances, the mouth and fauces
should be freed from mucus, and artificial respiration may be attempted.
If recovery ensues, the surface becomes paler, or slightly rosy, the pulse
more frequent and stronger, and efforts at inspiration are made ; and
when these symptoms appear, the cord may be tied. In all these
instances, the practitioner should not become discouraged at too early
a period, and therefrom slacken his efforts, as almost hopeless cases
have been resuscitated after long, but patient and continued treatment.
When the pulsations in the heart and cord have ceased for several min-
utes, attempts at restoration will be useless.

The cord having been cut, the child is to be passed to the nurse, who
is generally ready to receive it in a small blanket, prepared for the
purpose ; but as its body is very slippery with the waters, blood, or
vernix caseosa, there may be danger of dropping it, if it be not taken
.hold of properly. To avoid any such mortifying accident, the prac-
titioner will seize it by the ankles, with his left hand, placing a finger
between the two ; and will have the back of its neck to rest in the
arch formed by the thumb and index finger of his right hand, resting
the upper portion of its back upon the palm of his hand, and placing
the points of the three remaining fingers under its right axilla ; thus
held, it can not fall. Some advise the left hand to be placed at the
breech, with one finger between the legs, the left thigh grasped by
the thumb, and the right thigh and nates resting on the remaining
fingers and palms at the same time making gentle pressure of the hands
toward each other, for the purpose of more firmly securing the child.
Either of these methods may be safely adopted.

The next thing is to ascertain, if it has not been previously done,
whether there is another child in the uterus ; this may be known by
placing the hand on the abdomen, when the fundus uteri will be felt
still in the epigastric region; and an examination per vaginam w r ill
detect the bag of membranes, and the presenting part. If, however,
the uterus be found small and hard like a solid ball, when grasped
through the abdomen; or small, but soft and doughy ; or small, but
becoming hard and soft alternately, no second child is present, and the
placenta has probably passed, either partly or wholly into the vagina.

310 KINC'S KCLKCTIC or,sTi"r uics.

If it be hard and nearly the size of the adult head, there is no child,
but a contraction of the uterus, upon the mass inclosed within its cav-
ity; and if it be thus large, but soft and doughy, contraction of the
organ has not yet taken place for the purpose of expelling the pla-
centa. The treatment of twin cases will be considered hereafter.
Having ascertained that no twin-child is present, the practitioner will
attend to the delivery of the placenta ; occasionally, the same pain which
expelled the child likewise ejects the placenta. But, usually, from five
to thirty minutes elapse from the birth of the infant, before the uterine
contractions are renewed for the purpose of removing the secundines.
The left hand should be placed on the hypogastrium, and if the uterus
be found hard and well defined, and the patient complains of some
pain, but not so severe as before, the organ is contracting and expelling
its contents, and the right hand should be ready to receive them as
they emerge. If, however, the uterus be found large, soft, and yield-
ing, or, if it be not felt at all, it may be caused to contract by gentle
friction and pressure on it, through the abdominal parietes, and as soon
as it contracts, the woman should bear down, and slight traction be
made upon the cord with the right hand in the direction of the axis
of the superior strait, which will carry the cord backward to the os
coccyx, and as soon as the placenta moves the motion will be recog-
nized by the hand, frequently, a crackling sensation, or as if tearing
a piece of thin silk. In the meantime, the left hand should continue
upon the hypogastrium, both for the purpose of exciting the contrac-
tions, as well as to admonish a cessation of the traction, whenever the
uterus grows soft, or manifests a tendency at some portions of the
fundus, to become depressed and follow the direction of the traction,
and thus, probably, be partially or completely inverted. "Whether the
placenta be in the uterus or vagina, if the soft condition of the uterua
continues, notwithstanding the means used, the labor may be compli-
cated with hemorrhage, to treat which, according to the rules hereafter
given, the physician must be thoroughly prepared. Crede's method
of aiding or forcing the delivery of the placenta is stated to be supe-
rior to any other, as it does not endanger the tearing away of the cord,
produces a tonic contraction of the uterus that diminishes the tendency
to subsequent hemorrhage or to severe after-pains, and aids in the pre-
vention of puerperal disease. It simply consists in grasping the
uterine fundus, through the abdominal parietes, with the hands, in
such a manner that the organ can be forcibly compressed from above
downward and backward ; and which, as the rule, causes the detach-
ment and ejection of the placenta. The operation is the more readily

MANAGEMENT OF NATURAL LABOR.. 311

effected the sooner it is employed after the delivery of the child. Of
course this method is inapplicable when hemorrhage is present.

When the placenta has emerged from the vulva, it should be twisted
or turned around several times, for the purpose of forming a cord or
string of the membranes, that, thereby, no portion of them be left
attached to the uterine surface, thus effecting a clean and perfect
delivery, and the accoucheur should always examine its uterine surface
to ascertain whether any portion of it has remained within the uterine
cavity. If a portion of the membranes be left within the uterine
cavity, it may give rise to unpleasant symptoms, as hemorrhage, putre-
faction, offensive discharges, etc.; or should portions of them pass-
away in a few hours afterward, they may occasion alarm to the patient,
or lead her to think that her medical attendant is not perfect in this
department of his profession.

It is always proper for the practitioner to ascertain as early as possi-
ble after the birth of the child, whether the placenta is detached, that
he may remove it, and this may usually be known by the absence of
pulsation in the cord, which becomes cold and flabby, and, generally,,
renewed but less severe pains with a slight discharge of blood; but,
unless there be flooding, or some other circumstance demanding the
immediate delivery of it, it is inadvisable for him to make any more
active efforts than above named, to bring about its expulsion when not
effected naturally, for at least one hour subsequent to the child's
egress ; then he will treat it as a retained placenta. And in all cases
of natural labor, it must be thoroughly impressed upon the mind, that
no force or haste is required in the removal of the placenta and mem-
branes, but they should be drawn forth slowly and carefully, to
prevent any tearing of the membranes, or cord, or other unpleasant
accidents arising from too hasty a removal of them from the uterine
or vaginal cavity.

The secundines being completely removed, the practitioner will
request the nurse to bring a basin or some other vessel, in which to
place them, covering them with a cloth, "for the sake of decency. "
Then he will ascertain, by placing a hand on the abdomen, whether
the uterus is small and contracted, or large and soft, which latter
condition indicates a tendency to internal hemorrhage, and the pulse
and countenance of the patient should be at once examined, as described
hereafter. The delivery of the placenta closes the third stage of
labor; a stage of the process which requires much judgment and
presence of mind, for the slightest mistake or misconduct might lead
to the most serious consequences ; and with ail diiTiculties which may

312 KI.\(;'S KCI,I-:< TIC OHSTETIJICS.

occur at this stage, as well as their treatment, the physician should be
thoroughly and familiarly conversant.

As soon as possible after the birth of the placenta, and especially in
cases where it has been found necessary to extract it artificially, the
practitioner should ascertain that there is no inversion of the uterus,
and, if it has not been previously accomplished, should likewise
examine the placenta and membranes to see that the whole of them
have passed away, and that no portion of them has been left within
the uterine cavity, subjecting the patient to severe pains, nausea,,
vomiting, and hemorrhage. In this examination both surfaces of the
placenta should be inspected.

Unless there are certain circumstances, or symptoms present, which
will be referred to hereafter, it is not material that the bandage or
binder should be applied until after the expulsion of the placenta. It
should be passed under the patient's back, carefully, being made to
embrace the hips and the whole abdomen, and without requiring any
efforts on her part to assist in its application; it should be pinned or
fastened from below upward, having that portion around the hips and
lower part of the abdomen, more tightly applied than the rest, or
sufficiently tight to occasion a very slight degree of uneasiness when
first placed on. If, however, there should be considerable of the
discharges present, so as to endanger wetting the binder, these must
first be removed, or covered over with dry cloths. When hemorrhage
is present, the bandage is in the way, and should not be applied until
this is overcome. Many writers consider the bandage of no practical
importance, but I am well convinced of its utility during the first
forty-eight hours after labor when it is carefully and properly applied.
When firmly applied, and pressing equally upon the anterior surface
of the abdomen, it promotes the regular contraction of the uterus, and
gives support to the viscera and to the suddenly relaxed abdominal
walls, thereby diminishing the risk of concealed hemorrhage, and
syncope, and also tends to prevent air from passing into the uterine
cavity; it likewise assists a return to the natural condition of the
abdominal parietes, preventing that lax state of the integuments
which causes a "pendulous belly," but if used simply for this purpose,
it can well be dispensed with. When, in dropsy of the abdomen, the
sudden removal of the pressure is effected by tapping, unless a bandage
is applied and tightened as the water passes off, syncope and nausea
are very apt to ensue; and fatal syncope has occured shortly after
parturition, from no other attributable cause than the omission of the

MANAGEMENT OF NATURAL LABOR. 313

bandage; the removal of the uterine contents in labor, whereby a
removal of pressure is speedily accomplished, is a somewhat analogous
case, requiring similar measures for relief. The binder may, if neces-
sary, be worn for a % few days succeeding delivery, not certainly to
exceed three or four ; and its longer employment, as advised by some
physicians, for two or three weeks, strikes me as being a useless
measure. A bandage applied too tightly, and especially when worn
longer than the first few days, would, in my estimation, very much
endanger some displacement of the uterus, paralyze or greatly weaken
the abdominal muscles, force the uterus into the pelvic cavity by
pressing the intestines upon it, check to a greater or lesser extent a
free circulation in the organ by compression of the vena cava and
pelvic veins, and greatly interfere with the accomplishment of involu-
tion. It should be applied so that the uterus will be pressed down-
ward rather than backward ; and, in some cases, it may be advisable
to place a sufficiently thick compress under it, in order to secure the
proper compression to aid in preventing uterine relaxation with flood-
ing. It will be observed from the above, that since the publication
of the last edition of this work, further and more attentive experience
has considerably modified the views therein expressed relative to the
binder. Generally, the binder is applied by the nurse or some female
friend, but the physician should understand how to apply it himself,
and should always ascertain that it is properly placed and tightened
before leaving the patient. He will, frequently^ be requested to place
the bandage on his patient, but, as a general rule, I consider it a
task entirely out of his province, and one which should be invariably
performed by a female. To be of the greatest service, the bandage
should be applied next the skin, and I can not conceive of any office
more offensive to female purity and modesty, and more repugnant to
the sensitiveness of a man of honor and refinement, than that of
bandaging a naked and exposed parturient woman. True, physicians
and females have often to be placed* in even more delicate and exposed
situations than this, but then it is only in those cases in which health
and life render it imperatively necessary, and in which, from the
dangers to the patient, modesty becomes a vice. She must be, truly,
an ignorant nurse, who is incapable of correctly bandaging a parturient
female. Although I consider the application of the bandage, the duty
of the nurse, yet it is the physician's duty to ascertain, after it has been
done and the female covered, whether it is applied properly. And in
those instances where he is desired to place the bandage, himself, and
no excuses will be received, he may adjust it over the body-garment

KINC'S K( LKCTIC

of the patient, and thus obviate the necessity for exposure. After the
application of the binder, some 1 warm, dry. cloths .should be loosely
applied to the vulva, for the purpose of absorbing the discharges, and
preventing them from soiling the dry clothes of the patient. These
cloths should be examined from time to time, while in the house, for
the purpose of aiding in the determination of the degree of hemor-
rhage; and for the same purpose, the hand may be placed upon the
abdomen occasionally, to learn if the uterus continues contracted ; the
pulse likewise ought to be felt several times, and inquiries be made
as to whether the patient experiences any sensations of faintness.

The " putting to bed," as it is termed, in which the patient is moved
into her regular bed, should take place as soon as circumstances will
permit ; in ordinary labors it may be accomplished in an hour after
the delivery, or, following the washing and dressing of the child ; but
if the labor has been tedious, or very painful, it must be delayed
according to the strength and circumstances of the patient. In the
process of "putting to bed" the practitioner must be very careful that
the patient uses no exertions on her part for the purpose of giving
assistance/ and that she be not removed from the horizontal position,
lest hemorrhage be thereby induced. The husband and two females
may carefully raise and remove her, or she may be carried in a strong
sheet, held by four persons,-- it matters not how the removal, or
"putting to bed," is executed, so it is with care, and an attention to
the above points. But, under any circumstances, the patient should
not be allowed to lie for any length of time with the discharges and
damp cloths around her, these must be removed as promptly as the
condition of the patient will admit, and in a manner not calculated to
unnecessarily expose her to any dangers.

As soon as the mother can be safely left for a short time, and the
nurse's attention to her can be dispensed with, the child, which had
been warmly wrapped up and placed in some safe location, must be
attended to. It must be washed and dressed. This is almost always
the task of the nurse, or some female present ; yet the practitioner
should understand how it is to be done, in case inquiry be made of
him, or he should be left in a condition where he would be required
to act the part of nurse ; a part, however, to which I most decidedly
object, except in imperative cases.

The body and limbs should be lubricated with Sweet Oil, fresh
Lard, or fresh Butter, which will assist in the more ready removal
of the sebaceous matter with which the skin of the child is covered
at birth; after which, warm Soap-suds will be the only application

MANAGEMENT OF NATURAL LABOR. 315

required. If the above substance is not thoroughly cleansed from the
skin, it may occasion painful and troublesome cutaneous excoriations.
Be careful that, in washing and drying, the tenderness and integrity of
the infant's skin be regarded, as too much pressure, or too much fric-
tion may bruise or abrade it; soft cotton, or linen should be used, both
in the washing and drying. Some apply cold water to the infant,
but this is wrong, and frequently injurious, requiring a very robust
child to pass through the ordeal with safety. The child has just
emerged from a situation of an elevated temperature, and a reduction
of this temperature too suddenly, or too soon after birth, would,
especially in those who are weak and delicate, be very apt to occasion
serious and even fatal consequences. In washing the child's head,
many nurses are accustomed to apply a small portion of warm spirits
of some kind, for the purpose, as they say, of preventing its taking cold ;
whether this accomplishes the intention or not, there can be no objec-
tion to the practice, if too great a quantity of liquor be not employed.
After the washing, the accoucheur will be called upon to dress the
cord; but previous to this, it will be proper for him to examine the
child, and ascertain that it is not malformed or blemished with nsevi,
and that its limbs, hands, feet, mouth, genital organs, etc., are perfect.
Some examine for this purpose, even before its washing. This having
been done, a piece of soft linen must be doubled, so as to form a square
whose sides measure six or seven inches ; this is again doubled and
folded in a triangular form, somewhat in the manner of preparing a
paper filter, so that its point, which will be the center of the square
when opened, may be applied to the flame of a lamp or candle, to form
an opening of sufficient size, through which to pass the- cord. I prefer
making the orifice by burning instead of cutting, as its edges are
thereby much softer and less liable to increase any existing irritation
of the parts in contact with it. This is then opened, and through the
orifice thus formed in the piece of linen, doubled, the cord is to be
passed. The linen may now be allowed to lie upon the abdomen, and
another piece placed over it and the cord, or the cord may be wrapped
up in the first piece. But whichever plan is adopted, the cord must
be placed upward along the abdomen, rather to the left, in order to
avoid any compression of the liver, and then be secured in this position
by a bellyband or bandage, passed, but not too tightly, around the
child's body. If any blood be found to ooze from the end of the cord
previous to dressing it, another ligature must be applied nearer the
umbilicus. The remaining piece of the funis umbilicalis dr,ies up,
and usually falls off in five or six days, though this may vary from

316 KING'S ECLECTIC OHSTKTIMCS.

two to sixteen days. It is not, commonly, necessary for the practi-
tioner to examine the cord at subsequent visits, for every time the
nurse bathes the child, she makes it a matter of duty to inspect its
condition herself, and from her any information relative to it, under
ordinary circumstances, can be obtained. As the cord shrivels and
diminishes in thickness, it soon has the appearance of a fine spider-
web, and which may lead the accoucheur to hasten its separation
by cutting it with a knife or scissors, but he must be careful not to
attempt this; I' have known such an operation to be followed by
severe ulceration, and also by hemorrhage. After the application
of the bandage, the child should be lightly and loosely dressed,
according to the season, and all cumbersome and tight clothes placed
aside, as injurious to its health and welfare.

The child should be placed to the breast as soon as possible, for, in
many instances, it will at once obtain a supply of the mother's milk ;
or if there be no milk present, the attempt at sucking is very apt to
be followed by its early secretion ; but should it fail to suck, or should
no milk have been secreted, there will be no necessity for feeding it
until several hours have elapsed. Some recommend it to be kept from
the breast for ten or twelve hours ; this may answer in cases where
there is much exhaustion, or where the labor has been protracted ; but
in ordinary instances I prefer placing it to the breast as early as possi-
ble; and this, not so much for the purpose of food, as to excite uterine
contraction and thereby prevent hemorrhage. I have met with many
instances in which, for several hours after the birth of the child, any
attempt made by it to suck, was instantly followed by more or less
severe after pains. Should it become advisable to feed the child, a
little warm milk and water, without sweetening, or some thin gruel,
will be the only food required [if, however, these articles must be
sweetened, it will be better to use sugar of milk, and not cane sugar] ;
but after it obtains the mother's milk, no other food, whatever, should
be allowed, unless, for some urgent reason.

The substance collected in the intestines of the fetus during utero-
gestation, is called " meconium," and if it be not removed soon after
birth, it will occasion gripings, colic, etc. The first breast-milk of the
mother, secreted after delivery, is the best agent for the removal of
the meconium ; it is called colostrum, and contains, in addition to the
common milk globules, numerous large cells, or granular corpuscles,
whose investing membrane is filled with oil, or common milk globules,
similar to those which are floating free in the surrounding fluid. This
colostrum appears to exert a laxative influence on the child, and is

MANAGEMENT OF NATURAL LABOR. 317

superior to any other agent for the above purpose ; if it can not be
had within a few hours succeeding delivery, some Sweet Oil, or Castor
Oil may be given, to effect the evacuation. I do not believe in dosing
an infant with medicine as soon as it is born, for, owing to the cus-
toms and habits of society it will become a charge to the physician
soon enough, without attempting medication from the moment of birth ;
therefore, care and prudence should be manifested in making use of
laxatives to purge off the meconium. And, above all things, for the
sake of decency and of science, forbid that nauseous, abominable, and
worse than heathenish practice, which some old. nurses have, of forcing
down the child's throat, a disgusting mixture of urine and molasses.

During these attentions to the child, the mother must by no means
be neglected; her pulse should be examined from time to time, and
other investigations pursued to ascertain the condition of the uterus,
and whether any disposition to hemorrhage exists. The practitioner
should NEVER leave the house for at least one hour after the delivery
of the placenta, and he who leaves earlier than this, is criminally
guilty of the loss of his patient, should she, shortly after his leaving,
die, from uterine hemorrhage. There is no excuse for him. If it is
absolutely necessary for him to leave the house, previous to the ter-
mination of the hour, let him have another physician called in, to
temporarily supply his place. If the labor has been a tedious one,
or the patient is much exhausted, or if the womb does not contract
properly, the house should not be left for even a longer period than
an hour, depending, however, upon the circumstances of the case.

When about to return home, the accoucheur should place his hand
upon the patient's abdomen, to learn whether the uterus is small, hard,
and contracted; he should examine the condition of the pulse, and
likewise request the nurse to show him the cloth which had been
placed at the vulva, that he may form some idea of the quantity of
blood discharged. He should direct a light, non-stimulating, but
nutritious diet, as, of toast and tea, gruel, barley-water, and similar
articles, favoring the patient's desires in this respect when they are not
decidedly objectionable, and positively prohibit the admission of friends
into the parturient room, for a period of at least twenty-four hours ;
the room must be kept comfortably warm, and properly ventilated
without exposure of the patient, and perfectly free from any noise or
excitement. Nervous irritation, fretfulness, feverishness, mania, and
even death, have followed the use of a diet not sufficient to afford the
nourishment and strength required during the puerperal period. He
should leave the most positive orders that the female shall not assist

318 KING'S K( I.I (Tic OBSTETRICS.

herself in anything, and especially that she continue in the horizontal
position, for the first twenty-four hours after labor, for even the
momentary semi-erect posture has frequently occasioned alarming
hemorrhage; and he should also ascertain that the bandage is properly
secured.

CHAPTER XXVI.

'ATTENTIONS REQUIRED SUBSEQUENT TO DELIVERY, DURING THE
PUERPERAL PERIOD.

IN about twelve hours the patient should be again visited by her
medical attendant, and even sooner than this, where the labor has
been tedious, or where there is a disposition to hemorrhage. As with
the process of natural labor, so with the puerperal state, when unin-
terrupted by accidents, no interference is required on the part of the
practitioner; the patient will gradually attain her normal condition,
unaided; yet as many females, who pass through their labors with
safety, perish in the subsequent puerperal condition from inflammatory
attacks, it is the duty of the attendant to superintend this condition,
that he may at once adopt the proper measures to remove any abnor-
mal symptoms that may arise.

The shock to the nervous system from labor, effects a derangement
varying from mere restlessness to absolute hysteria; in easy labors,
the patient soon recovers from it, requiring only a state of rest and
sleep. When severe, it is characterized by symptoms of exhaustion,
with an alteration in the appearance of the eye, an anxious counte-
nance, derangement of the brain, the sensibility of which is either
diminished or increased, and a disturbance of the circulating and
respiratory systems, as manifested by the pulse, which is slow and
labored, or rapid and fluttering, or alternating from slow to rapid, and
which must not be mistaken for the pulse of peritonitis, and also by
the hurried, panting breathing.

The pulse will be found to increase during the second stage of labor,
to diminish after this is completed, and to rise again on the secretion
of the milk. A pulse ranging from 100 to 110 in the puerperal state,
should be watched, though it is not always indicative of danger. A
quick pulse may be present when a large clot is in the uterus, it may
occur with diarrhea, gastric disturbance, or severe after-pains ; and
when found immediately after delivery, it frequently indicates hemor-

ATTENTIONS SUBSEQUENT TO DELIVERY. 319

rhage. A quick, feeble, fluttering pulse occurs in the collapse from
the nervous shock. There is a sensation of fatigue experienced in the
shoulders and in the muscles of the abdomen, which sometimes persists
for three or four days. It is occasioned by the muscular efforts made
during the second stage of labor, and which may be discriminated from
peritonitis, by the pulse not being increased, by no aggravation of the
pain on pressure, and by the absence of febrile symptoms. When
these symptoms are not very severe, they will subside upon keeping
the patient quiet, and free from excitement, together with a few hours
sleep. If severe, small doses of the compound powder of Ipecacuanha
and Opium may be administered with advantage. In some instances,
the indication for Sp. Tr. Xanthoxylum, Pulsatilla or the Parturient
Balm will be present. The support derived from the bandage will,
usually, quickly overcome any weakness that may exist in the abdom-
inal walls. Not unfrequently small doses of Sulphate of Quinia, Sp.
Tr. of Macrotys, of Aconite, of Golsernium, or even of Nux Vomica,
according to the indications, will prove efficacious. The diet should
be nutritious, the patient kept quiet, the visits of friends prohibited,
and for a few days nursing may be avoided. When symptoms of col-
lapse or great exhaustion are present, stimulants may be allowed, as
a moderate quantity of brandy and water, wine, or Aqua Ammonia, and
these may be given in conjunction with the compound powder of Ipe-
cacuanha and Opium. Special attention has recently been called to
Erythroxylon Coca, either in tincture, fluid extract, or infusion, which
will, in many instances, no doubt, be found decidedly beneficial. In
anemic conditions, small doses of the Acid Solution of Iron may be
associated with the other remedial measures. The stimulants may be
omitted as reaction comes on, for if continued beyond this, they will
be likely to produce mischief.

The vagina, notwithstanding its great distension, soon recovers its
normal size, and the heat and soreness speedily disappear, unless the
labor has been protracted during the second stage; or the lochial dis-
charge becomes acrid. The integuments of the abdomen do not so readily
recover their natural condition; they remain loose and flaccid for a
long time ; but if the bandage be properly applied, the only evidence
of pregnancy which they afford, will be the white streaks on the exter-
nal surface of the abdomen, linece albicantes. The contractions of the
uterus after delivery, not only reduce its size, but prevent uterine
hemorrhage, remove all substances from within its cavity, and diinm-

320 KING'S ECLECTIC OBSTETIUCS.

ish the caliber of its vessels and sinuses. The contraction, however
is not permanent, but is followed, after a short time, by an interval of
relaxation; and these alternate contractions and relaxations continue
for eight or ten days, during which time the organ can be felt and
examined through the relaxed Avails of the abdomen, after which it
becomes so reduced in size as to descend in the pelvis, when it can no
longer be distinguished through the abdomen. A day or two after
delivery, the lining membrane of the internal cavity of the uterus,
appears loose, somewhat softened, wrinkled, and covered, more or less,
with patches of decidua. At the placeutal site the part is raised, and
the surface is unequal, like a granulating ulcer, and its size is very
much reduced. The whole internal surface of the organ is of a dark
ash color, with a greenish or brownish discharge upon it, which has
been mistaken for a gangrenous condition. The uterine structure is
not so dense as in its natural state ; its fibers are more distinct, and
the sinuses are still evident, being, filled with clots of blood at the pla-
cental site. The os and cervix uteri appear bruised and ecchymosed,
and small lacerations or abrasions may sometimes be observed, which
occasionally degenerate into ulcers. The orifice remains open for
several days, closing gradually.

The contractions of the uterus, which ensue after delivery, are usually
accompanied with more or less pain, termed AFTER-PAINS, and
which are more common to multiparous women than primiparous;
being more generally absent in the latter. Females who are the sub-
jects of dysmenorrhea are said to be the most liable to these pains,
which vary greatly in their severity and duration. They commence
soon after delivery, say from half an hour to an hour, and continue
from twenty-four to sixty hours. No bearing-down efforts accompany
them, nor is the frequency of the pulse increased. These pains are
useful not only in reducing the uterus to its non-gravid condition, but,
by expelling coagula, pieces of membrane, .and the fibrinous clots
which plug up the sinuses, they also prevent irritative fever. They
are frequently brought on, or increased, upon applying the child to the
breast, which is an argument in favor of this being done at an early
period after delivery, in order to assist in promoting these contractions
and thereby lessening the risk of hemorrhage.

After-pains may be usually distinguished from peritonitis, by their
periodical returns, by being unaccompanied with fever or an excited
pulse, by the persistence of the secretion of milk, and the discharge of

ATTENTIONS SUBSEQUENT TO DELIVERY. 321

the lochia, and by not increasing in severity upon pressure, though it
must be recollected that the muscles of the abdomen may feel sore
when pressed upon. They require no treatment unless severe, wheii
they may be overcome by the administration of Sp. Tr. Macrotys, or
compound powder of Ipecacuanha and Opium, either singly or in
alteration; the mixture known as Diaphoretic Powder has been admin-
istered with benefit. Should the pains resist the use of these agents,
and which resistance will usually be found to depend upon retention
of coagula, the rectum should be unloaded by a purgative enema, and
hot fomentations should be applied to the abdomen, which will cause
a prompt discharge of the clots, followed by immediate relief to the
patient. The application of Hops, heated in a small sack or equal parts
of Hops and Tansy, made into a fomentation with Whisky or some
kind of Spirits, and applied over the abdomen warm, renewing it from
time to time, together with the internal administration of compound
powder of Ipecacuanha and Opium five grains, repeating the dose
every three hours, has, in my practice, afforded prompt relief in severe
after-pains that had obstinately resisted all previous treatment. Sul-
phate of Quinine, in doses of two to five grains, one, two, or three
times a day, alternating with Sulphate of Morphia, in doses of one-
eighth to one-fourth of a grain, will frequently check after-pains which
have resisted other means. The process of involution is greatly facil-
itated in a majority of instances by the use of Macrotys and Pulsatilla;
Phytolacca also seems to exert a specific influence in this regard, as
well as the Parturient Balm. Other remedies have been recommended
in this difficulty, but I have found the above all-sufficient in the nu-
merous cases which have come under my notice. There is a species
of pain, of a very excruciating character, which sometimes follows
delivery ; it does not intermit like the ordinary after-pains, but is con-
tinuous, and is located in the coccyx and extremity of the sacrum. It
may be relieved by introducing an opiate suppository into the rectum,
or by thejnternal administration of the compound powder of Ipecac-
uanha and Opium, or other mild anodyne.

Rheumatism of the uterus may render the retraction of this organ
after delivery, very imperfect, causing it to continue enlarged above
the superior strait. In this case the after-pains are prolonged and
very severe,' and the want of sufficient contraction upon the bleeding
vessels may give rise to profuse hemorrhage. This may be overcome
by pursuing a treatment similar to that named in another chapter.

322 KINO'S ECLECTIC OBSTETRICS.

In addition to the above-named conditions, there are several others,
which it is important to inquire into upon the first visit after delivery;
among these may be named the state of the excretions. During the
second stage of labor, perspiration becomes quite copious, diminishing
after the delivery, but not immediately returning to the ordinary
standard; sometimes it has a greasy feel, and a sickly odor, and the
skin is soft and flabby, gradually returning to its natural state.

Particular inquiry should be made as to the urinary discharge, and
on this point the practitioner should fully satisfy himself. It is
frequently the case, that the patient is unable to void the urine, or
it passes with difficulty, and in small quantity. This may distend the
bladder, giving rise to pains, fever, violent spasms, and, perhaps,
rupture of the bladder. Pressure of the head upon the bladder and
urethra, during its passage through the pelvis, usually occasions this
difficulty. Whenever there exists any want of free urination, the
bladder should be at once emptied by means of a catheter, which may
have to be used several times before the parts recover their tone
sufficiently to do without it. In attending to the evacuations during
the first twenty-four, or thirty-six hours after labor, the patient should
never be allowed to rise in the bed ; it has often been the case that a
sudden rising up in bed, within a day or so after delivery, especially
when this has been accompanied with hemorrhage, has been followed
by immediate death. The late Professor Meigs considered this to
arise from the "heart clot" emboly. The excessive loss of blood
disposes the remaining portion of this fluid circulating in the system
to a ready coagulation; consequently, if on rising, the debilitated
patient should faint, the activity of the circulation is impeded, and a
mass of coagulated blood forms in the heart, filling it so that the
circulation can not be re-established, and death must ensue ; or if this
does not supervene, restoration takes place very slowly, with symp-
toms of restlessness, difficult respiration, and a peculiar action of the
heart. Dr. Meigs says, that he has not seen a patient, struggling and
breathing violently, from the above cause, who has ever recovered.

The condition of the bowels should likewise be inquired into ; if the
patient is doing well, and had a thorough alvine evacuation previous
to delivery, there will be no necessity for any medication in two or
three days, if at all. But, if the bowels were costive, or if there are
febrile symptoms, restlessness, with slight pain upon pressure of the
abdomen, some mild laxative medicine should be administered. If
an enema can be given without worrying or exciting the patient it

ATTENTIONS SUBSEQUENT TO DELIVERY.

may be employed in preference to the internal laxative ; but on no
account should the patient be actively purged, as it increases her
already existing debility, favors absorption of any septic poison that
may be present, and may give rise to some uterine displacement.
Castor Oil is the agent most generally employed for this purpose, but
many females have an aversion to it, consequently other laxatives will
have to be used, as the compound powder of Rhubarb, calcined Mag-
nesia, or one of the mild aperient waters may bo substituted, as
Hunyadi. Small doses of Cascara Cordial is a favorite with many.
In fact, any one of the mild, non-irritating laxatives may be em-
ployed, when an agent of the kind is indicated. I have frequently been
called to patients, several days after their delivery, who were suffering
from pains in the abdomen, headache, restlessness, and febrile symp-
toms, caused by the medical attendant having neglected to evacuate
the bowels, and in whom all these symptoms disappeared, after the
action of a dose of mild purgative medicine. This inattention to the
condition of the bowels of the puerperal female, appears to constitute
a part of the practice of a certain class of physicians. It is, however,
a very reprehensible omission.

The LOCHIA is a discharge consisting of blood, broken-down
coagula, and decidual debris, which takes place from the partially
closed vessels of that part of the uterine surface to which the placental
attachment was formed, as well as from the naked surface of the
uterus deprived of its decidual membrane ; it generally lasts five or
six days, or longer, until the womb is restored to its normal size;
though with some females, the discharge continues until the re-appear-
ance of the menses. It is, at first, bloody, but in twelve or thirteen
hours becomes thinner and paler, changing to a discharge of bloody
serum. According to its color, the lochia is distinguished by the
names of sanguineous, sero-sanguineous, and purulent or puriform;
it exhales a peculiar, disagreeable odor, varying in intensity with
different women, which is called gravis odor puerperii. During the
milk-fever, the discharge generally ceases, but returns on its subsid-
ence, being then of a yellowish-white color; it varies in quantity,
being with some women very small, while others will soil from six to
fifteen napkins in the twenty-four hours; but this quantity gradually
diminishes, and the discharge assumes a greenish or paler color before
it ceases. The lochial discharge serves to relieve congestion, and to
lessen the chances of an inflammatory attack; during fever, it becomes

324 KING'S ECLECTIC OBSTETRICS.

checked, hence, its presence is indicative of the absence of fever. This
flow is considered to bear a relation to the expulsion of the uterine
contents, somewhat similar to that which exists between menstruation
and the discharge of the monthly formed decidua.

Generally, the lochia requires no interference ; it is only when its
condition affects the health of the patient, that medical attention will
be needed. Thus, it may be very small in quantity, but continue the
usual time without any unpleasant results, and which is apt to occur
after flooding; or it may be abundant, and cease at the usual time,
without any detriment to health ; or it may stop shortly after delivery,
without any evil consequences, as is frequently witnessed in the case
of still-born or putrid children. When this flow continues beyond
fourteen or sixteen days, it is indicative of existing ulcerations of the
cervix, of a check to the act of involution, or of both. Should these
conditions be found, upon examination, to exist, astringent solutions
may be locally applied to the vaginal walls and to the ulcerations, as,
of Tannin, Borax, Chlorate of Potash, Asepsin, Persulphate of Iron,
etc.; while, to forward uterine involution, agents should be admin-
istered internally that occasion contraction of uterine fiber, as, Ergot,
Sulphate of Quinia, Macrotys, Cinnamon, Strychnia, etc.

Sometimes, however, the discharge is very excessive, producing
much debility; in these cases, remedies must be employed which will
diminish the quantity of the flow, as well as strengthen the patient's
system. To check the discharge, astringents may be employed; Ma-
crotys, Aletris, Pulsatilla, or the Parturient Balm may be 'given, as
suited to each particular case. Perchloride or Persulphate of Iron
will often prove serviceable, in dilute solution. I have also gotten
good results from teaspoonful doses of a mixture of soluble Citrate of
Iron ; a drachm to the ounce of Port wine. As tonics, Quinine,
preparations of Iron, or some of the ordinary vegetable bitter agents,
may be used; the diet of the patient should be more nourishing, but
not stimulating, and. she should be kept in a state of rest and quietude.
If, with the excessive discharge, there is vascular excitement, as quick
pulse, heat of surface, furred tongue, pain in the back, etc., the patient
should be placed on a low, mild diet, with cooling drinks, the bowels
must be gently moved by Seidlitz Powders, or other cooling laxative,
and the febrile symptoms may be overcome by the administration of
Aconite, Gelsemium, or such other specific agents that may be espe-
cially indicated, prepared as usual, in the half-glass of water, and
given in teaspoonful doses, every one or two hours. Macrotys will

ATTENTIONS SUBSEQUENT TO DELIVERY. 325

be often called for, at which time the most satisfactory results will
follow its use ; it may be either given singly or with the sedative.
Beside the sedative and antiphlogistic influence exerted on the sys-
tem by these agents, we also obtain the peculiar tonic action of the
Macrotys upon the uterus, thus rendering the compound a highly de-
sirable one. The generative parts should be bathed with cool water,
three or four times a day. Should the increase of the flow be owing
to the presence of a portion of the placenta within the uterine cavity,
and which may be presumed if the discharge is offensive, with vomit-
ing, the vagina may be syringed two or three times daily with hot
water, in which may be used Chlorate of Potash, Borax,- Asepsin, or
diluted Carbolic Acid, one to fifty or sixty parts of distilled Water,
or, solution of Permanganate of Potash, one to one hundred or one
hundred and twenty parts, etc., and if the offending portion can be
easily removed it should be done, when the symptoms are very urgent.
Should it become necessary to apply any of these to the inner uterine
walls, it must be effected by a soft uterine probang, and not by injec-
tion ; the greatest circumspection and care must be observed in mak-
ing these applications. Generally, however, the uterus will evacuate
its contents with more safety when not interfered with by injections
or manual operations. ..-.

At times, the lochial flow, after having diminished in quantity, sud-
denly becomes increased and of a red color; this arises from the
patient sitting up too soon, or, at a later period, from too much exer-
cise, as of walking. Rest in the recumbent position will, usually, be
the only treatment needed; but should it prove obstinate, the red dis-
charge still continuing, secondary hemorrhage may ensue, for which
the practitioner must be prepared; Ergot, Cinnamon, Macrotys, Pul-
satilla, etc., are among the articles that may be used in these instances,
together with a confinement to the horizontal position. Some of the
astringent preparations of Iron may frequently be employed with
benefit in these cases.

The lochia may be checked, or deficient in quantity, from other
causes than uterine contraction, in which cases febrile symptoms will
be present; and if the discharge be not promptly restored, it may
form the basis of some fatal disease. The treatment which I have
found to be most commonly beneficial, is, to evacuate the bowels by a
mild purgative, after which the sedatives and other agents usually
indicated where we have febrile excitation should be given ; at the
same time bathing the groins, thighs, and inferior extremities with

326 KING'S ECLECTIC OBSTETRICS.

the officinal compound tincture of Camphor has been recommended.
Hot fomentations to the abdomen have also proved serviceable.

When the above treatment fails to remove the abnormal symptoms,
they may be owing to inflammation of the uterus, or other local in-
flammation, which will require to be treated upon general principles.
I would remark here, however, that the combination of the Sp. Tr.
of Aconite and Macrotys, above mentioned, with attention to the con-
dition of the bowels, and warm fomentations to the abdomen, have
been employed in my own practice very successfully. I have also
administered the tincture of Gelsemium, in these cases, with the most
remarkable results. A similar course may be pursued where the dim-
inution of the lochial discharge is owing to uterine rheumati-m ;
which is apt to be the case when the uterus is attacked by this
disease.

Sometimes the lochia has a very fetid odor, is acrid, and of a dark
color; this may be owing to putrefaction of retained coagula, or de-
composition of pieces of the placenta or membranes which have been
left within the uterus. An injection of hot water, with the addition
of an astringent, or of a very weak solution of chloride of lime,
passed into the vagina two or three times daily, will be found
sufficient to remove the fetor. Or, weak solutions -of Chlorinated
Soda, of Permanganate of Potassa, or of Carbolic acid may be
injected into the vagina, as well as sprinkled upon that part of the
bed in the vicinity of the reproductive organs. When the discharge
continues of a purulent character, long after deliver}', with lumbar
pains and sense of weight accompanying, it may be owing to ulcers,
or abrasions of the cervix or vagina, which will have to be determined
by the speculum, and treated accordingly. When the lochia is acrid,
an infusion of Elm bark and Black Cohosh root, may be injected into
the vagina, several times a day, with advantage.

With some women the secretion of milk is attended with considerable
vascular excitement; rigors, headache, pains in the back and limbs,
quick pulse, furred tongue, etc., are present in a greater or less degree.
This condition is termed milk-fever, and is by no means common to
every parturient woman ; it usually manifests itself in two or three
days after delivery; occasionally sooner, and sometimes later. It may
generally be avoided by placing the child to the breast as soon after
labor as is compatible with the strength and condition of the mother,
and by the early administration of a mild purgative. It commonly

ATTENTIONS SUBSEQUENT TO DELIVERY. 327

lasts for twelve or twenty-four hours, rarely forty-eight, and may be
overcome by the use of cooling purgatives, fomentations to the breasts,
if they are full, hard, and painful, and the frequent application of the
child. "When very severe, diaphoretics or sedatives may also be given.
When the rigors are very intense, or when the fever assumes peri-
odicity, febrifuges and antiperiodics must be administered, and the
practitioner should be on his guard lest it be attended with puerperal
peritonitis.

Milk-fever is often occasioned, or aggravated by too long a delay
in giving suck to the child, and which may arise from deficient, mal-
formed, or sore nipples. Where the nipples are deficient or mal-
formed, the milk will have to be extracted by artificial means, as the
breast-pump. The secretion of milk is liable to become diminished
when the uterus is suffering under a rheumatic attack; and this,
together with the severe pain, diminution of lochia, pain on pressure,
etc., may be readily taken for peritonitis. From recent investi-
gations it seems more probable that the symptoms, to which the
name of "milk-fever" has been applied, are in no w T ay associ-
ated with the secretion of milk, but are rather the result of a
mild form of puerperal septicemia arising from absorption of any
putrid lochia that may be present within the uterus or vagina, and
may be remedied by keeping up proper uterine contraction, with
cleanliness, antiseptics, and tonics or febrifuges as required.

Excoriation and ulceration of the nipplqs is a very common aifection
among nursing women, indeed, some suffer severely from it after every
confinement. It is, sometimes, so severe and painful that it is impos-
sible to bear the application of the child's mouth to the nipple, and,
in some instances, a persistence in suckling, gives rise to large, foul,,
painful, superficial ulcers, or deep cracks, which bleed upon every
application, of the child ; occasionally, the woman loses her nipple.
This difficulty may be obviated, by the use of artificial shields, or
prepared teats, which can be had in every drug-store; but frequently
the child refuses to suck with them, and the aid of the physician is
demanded. Whenever inflammation is present, it must first be subdued,
previous to the application of any healing salve or ointment. This
may be effected by a poultice of Elm bark, or Flaxseed, which should
cover the whole nipple and areola", after which any of the preparations
named below may be applied. Sometimes, the inflammation will be
so intense, as to require the application of a few leeches on the breast
outside of the areola, before any benefit will result from the emollient
poultices. The severe pain may frequently be relieved by a careful

328 KING'S ECLECTIC OBSTETRICS.

application of a solution of Nitrate of Silver to the excoriated parts
only ; the solution may be of the strength of from two to six Drains
of salt to the fluiclounce of water.

After the reduction of the inflammation, and in those cases where
it is but slight, the following applications have been recommended :
1. Take of Spermaceti Ointment, six drachms; Balsam of Peru, ono
drachm; mix together, and apply a small portion to the nipples, several
times a day. 2. Take of Mutton Suet, one ounce; Balsam of Peru,
two drachms ; Honey, Glycerin, of each, one drachm ; melt the Suet,
and add the remainder of the articles, stirring well together. I Rw
same as above. 3. Take of Balsam of Tolu, Balsam of Peru, Honey,
of each, fourteen drachms; Camphor, Opium, of each, two drachms;
Alcohol, two pints ; mix together and allow them to stand for seven
days, frequently agitating them. A piece of linen is to be moistened
with this, and kept constantly applied to the nipple when the child is
not suckling; if too severe, it may be slightly diluted with water. It
must be washed off every time previous to the application of the child.
I have used this successfully, in many cases. 4. Take of Beef-mar-
row, Olive Oil, white Wax, of each two ounces; Cherry Wine, made
of common cherries (Cerasus avium, C. vufgarus, etc.), two fluidounees ;
place the articles together in a vessel, apply it over a gentle heat, and
allow it to remain until all the wine has evaporated. This ointment
may be applied just previous to the child's suckling, and immediately
after. Should the child's mouth be sore, this will have a tendency to
heal it. It forms an elegant preparation, one which I have su<
fully employed in the most distressing and obstinate cases. And as
my object is to render this work one of practical utility, even in minor
difficulties, I do not hesitate to give publicity to these small details.
5. Take of Glycerin, Tannin, each, two drachms; mix, dissolve the
Tannin, and apply frequently. 6. Take of Gum Tragacanth, 8 to 15
parts; Lime water, 120 parts; Glycerin, 30 parts; Rose water, 100
parts ; mix, and employ in ointment or embrocation. The agents I more
commonly employ are, however, No. 3, of the preceding, and diluted
Carbolic acid, or Carbolate of Soda. I have frequently been called
upon to prescribe in cases of sore nipples, which had baffled the treat-
ment of four or five preceding medical attendants, but which yielded
at once to the course above named.*

* The above named form nlse are old; most of them are taken from the Am. Dis-
pensatory. They, however, will be found quite efficient, and may be used where
other means fail. A cure, in most cases, will follow the application of Glycerole of
Tannin.

ATTENTIONS SUBSEQUENT TO DELIVERY.

After having bestowed the proper attentions to the mother, and
Ascertained the condition of the bowels, bladder, uterus, lochia, pulse,
breasts, etc., the practitioner may then inquire concerning the child.
Whether it has had evacuations from the bowels and bladder, and
whether it sucks. In cases -where the urine is scanty, or where there
has been no urinary discharge, and the parts are natural, requiring no
surgical operation, a warm bath, cold water sprinkled upon the hypo-
gastrium, or the administration of one of the diuretic infusions,
will be very serviceable; if, however, these do not cause a copious
urinary discharge, and the hypogastric region be swollen from
accumulation of fluid in the urinary bladder, it may become neces-
sary to introduce a small flexible catheter, in order to remove the
urine, and which will be found a difficult operation, requiring great
care. If the bowels have not been evacuated, and there is no imper-
forate anus requiring the surgeon's aid, a mild laxative as before
remarked, may be given ; Castor Oil is usually preferred, though I
prefer Sweet Oil in almost every instance. The light should not be
too intense for the delicate eyes of the child, but should be kept sub-
dued for several days after birth, gradually accustoming these organs
to ordinary daylight. The clothing of the child should be warm, and
loosely applied, that it may be free in its motions; caps are to be
avoided as injurious; the dress should be high up on the neck, with
long sleeves ; and the diapers must be soft, and never allowed to
become dry and stiffen with the excretions, and thus give rise to
troublesome excoriations.

The only proper food for an infant, is its mother's milk, and when
this can be obtained, little else should be given it, for at least six or
seven months. All paps, panadas, gruels, and cordials are to be
avoided, and their use among infants, as food, can not be too severely
censured. Colics, diarrheas, green and watery stools, and severe
aphthous affections are the penalties of such unnatural practices.
When the mother's milk can not be had, from \vhatever cause, and
a wet nurse is not at hand, and it becomes necessary to feed the child,
a mixture of one part of water to two or three parts of cow's milk,
and warmed, forms an excellent substitute for the parent fluid. The
milk used should be procured from one healthy cow regularly, and bo
given as soon as possible after it has been milked out. The addition
of cane sugar to the preparation, as advised by some writers, I con-
sider uncalled for and pernicious, frequently producing diseases of
the stomach and bowels, which are attributed to other causes. If
sugar is at all desired as an addition, it should be sugar of milk alone.

330 KINGS ECLECTIC OB8TETBICS.'

The following table, by Simon, showing the mean of fourteen analyses,
made at different periods, with the milk of the same woman, and
which very nearly corresponds with the analyses of other investigators,
will conclusively show the folly of adding sugar to a preparation
intended to supply the place of breast-milk :

Water 883.6

Solid constituents 116.4

Butter 25.3

Casein 34.3

Sugar of milk, and extractive matters 48.2

Fixed salts 2.3

And as to the sugar of milk, it very nearly corresponds in quantity
to that of cow's milk, as may be seen by the following analysis of this
animal's milk, by Chevallier and Henri :

Casein 4.48

Putter 3.13

Sugar of milk 4.77

Saline matter 0.60

Water 87.02

It will be observed that cow's milk contains more casein and butter
than human milk, which may, probably, lead to the production of a
still better substitute for this last, than the one proposed above.

In feeding the child its artificial food, it should be done in a manner
to simulate, as closely as possible, the natural functions; that is, it
should not be fed with a spoon, but should be taught to suck from
a vessel, through some porous substance, by which means the saliva is
invited into the mouth to be swallowed with the food, which latter is
thereby rendered more easily digestible.

The parturient woman should be kept in a state of rest and quiet
for nine or ten days, in order that the process of involution may
progress uninterruptedly, or in other words that the uterus may return
to its non-gravid size, without hemorrhage, inflammation, or displace-
ment, and that the system may fully recover from the shock given
to it by the labor. The first two or three days, she must not be
allowed to remove from the horizontal position (though she may
move around in bed), especially if the labor has been protracted, or
if there has been hemorrhage ; after this time, if not contra-indicated,
she may be permitted to sit up in bed a few minutes at a time, or in a

ATTENTIONS SUBSEQUENT TO DELIVERY. 331

chair, while the bed is being fixed, and should from this time lengthen
the duration of sitting each day, until there is no further occasion for
remaining in the bed. But in this matter, the judgment of the
accoucheur based upon the conditions present must, after all, decide
the proper degree of motion to allow the patient; some strong, healthy
women may sit up and even walk about in a day or two subsequent to
labor, while delicate and weak females, or those who have been much
enfeebled by a prolonged labor, hemorrhage, etc., will require rest and
quiet in the recumbent position for three or four days, or even longer.
Too much rest in bed relaxes muscular fiber and weakens nerve
power, while proper movements tend to equalize the circulation, to
remove passive uterine congestion, and to excite the contractile power
of the uterus sufficiently to enable it to expel any putrid lochial clots
that may form within its cavity, and thereby tend to the avoidance
of septicaemia. Where there is a sense of fatigue, weariness, mild
stimulation will prove beneficial.

The room should be well ventilated 1 , but without exposing the
patient, and be kept clean, quite free from all unpleasant odors, and
moderately warm. The female should be kept clean, especially about
the genitals, which must be frequently bathed with lukewarm water,
or warm water and spirits; and her diet must be light, nutritious, and
of easy digestion, especially during the first days. Gruel, mush and
milk, toast, panada, arrowroot, rice, etc., are all that is usually per-
mitted until the fifth or sixth day, when, if she be doing well, the
use of soft-boiled eggs, oysters, and weak soups, may be allowed.
After the tenth day, and during the puerperal month, animal food,
fowls, and other diet of a nourishing but non-stimulating character,
may be given; if she be- weak, a little porter will be admissible.
However, it will more frequently be found that a compliance with the
desires of the patient, as to diet, will answer a much better purpose,
than any arbitrary rules that can be laid down, when such desires are
not morbid or otherwise contraindicated.

If the patient, previous to pregnancy, was afflicted with prolapsus
uteri, an intermittingly continued recumbent position [but not neces-
sarily in bed] for eight or ten weeks after delivery, together with
Sulphate of Quinia, Macrotys, Pulsatilla, Aletris, Strychnia, etc., in-
ternally, according to the indications [to improve the tone and con-
dition of the uterus], will contribute much toward a radical cure;
the medical man observing that the uterus is kept in position during
the intervals of sitting or standing.

The visits of the practitioner should be daily, for the first two or

332 KING'S ECLECTIC OBSTETRICS.

three days, or oftener, if required ; after which, a visit every second or
third day, made on two different occasions, will be sufficient in ordinary
cases. However, this is governed by custom ; in some places, after the
first visit succeeding delivery, no other is made, unless the physician is
sent for; in others, the visits are continued more or less often, as may be
required, until the ninth or tenth day. I consider the last-named plan
of visiting, the preferable one, both as regards the safety of the woman,
and the reputation of the accoucheur. If, after the fourth or fifth
week from parturition, the patient suffers from pains in the back and
loins, debility, profuse leucorrhea, irritable bladder, with more or less
straining and tenesmus, and perhaps some hemorrhage, we may be led
to suspect defective involution, and if examination confirms our
suspicion, we should at once pursue the treatment necessary to remove
the subinvolution, which consists, in some cases, of gently stimulat-
ing vaginal injections, together with uterine tonics, as Macrotys,
Pulsatilla, Aletris, Parturient Balm, etc.

CHAPTER XXVII.

PRESENTATIONS AND POSITIONS.

FOR the purpose of more clearly understanding the mechanism of
labor, it is necessary that a knowledge of the various presentations and
positions of the fetus, be had. By the term presentation, in obstetrics,
is meant the part of the fetus which occupies the pelvic superior strait
at the commencement of labor; while position designates the relations
which the presenting part assumes with the circumference of this strait,
or with some fixed point. Thus, if it is said the vertex present*, we
understand it to mean a presentation of the head, in which the head
of the child will be the part first delivered ; if it is still further said,
that it is in the left occipito-anterior position, we learn that the occiput
of the child looks toward the left acetabulum of its mother, while its
forehead is toward her right sacro-iliac symphysis, and the sagittal
suture will consequently be found running in an oblique direction in
the pelvis between these two points or, in other words, we have the
position in which the head presents.

There are two PRESENTATIONS recognized in obstetrics one

PRESENTATIONS AND POSITIONS.

333

Cephalic, the other Pelvic. The cephalic, is divided into vertex, face,
and shoulder presentations; the pelvic, into breech, knees, and feet.
Occasionally, some portion of the trunk may present, or perhaps the
ear and side of the head, but these are so extremely rare, as to form
exceptions rather than exemplifications ; and their management would
be similar to that recommended for arm or shoulder presentations.

The most common, as well as the most favorable presentation for
both mother and child, is that of the vertex or head, and which alone
constitutes a natural labor ; the others are only deviations. That this
is the fact may be gathered from the following statistics : Bland
records 1792 head presentations in 1897 cases of labor; Dubois 10,262
in 10,742; Kluge 257 in 298; Lovati 61 in 67; Mazzini 439 in 452;
Nfflgele 1210 in 1296; Pacord 49 in 53; Ramoux 266 in 275; Riecke
214,134 in 219,258; Siebold 132 in 137; Smellie 920 in 1000; and
Velpeau 392 in 400.

The relative frequency of the various presentions, are given in the
following table, taken from Churchill's Obstetrics,

Author.

Total No. of
cases.

Head presen-
tations.

Breech pre-
sentations.

Inferior ex-
tremities.

Superior ex-
tremities.

20 517

19 810

372

238

Mad La Chapelle

15652

14677

349

255

Dr Jos Clarke

10 387

9 748

184

DP Merriman

2947

2735

Dr Granville

640

619

Edin Hospital

2452

2 225

Dr. Maunsell

839

786

691

645

Dr. Collins

16414

15912

242

187

Dr Beatty...

1 182

1 105

4666

4 266

Dr Churchill

1 640

1 119

The POSITIONS of the two presentations and their divisions or
deviations, vary considerably, so much .so that some authors have
given one hundred and two distinct positions. (Baudelocque.} But
these have recently been so reduced and simplified by Nsegele, Dubois,
Stoltz, and other accoucheurs, that the whole of them may be com-
prised in sixteen positions, and which will be found fully sufficient for
all practical purposes. The many slight alterations and deviations
in position, which may occur with the several presentations, and which
have given rise to the numerous positions above referred to, may,
singly, either be reduced to some one of the distinct positions, here-
inafter named, before the termination of labor, or may hold such

334 KINCi'.S KCLKCTIC OI5STETRICS.

a close relation to it, as to require no material difference in its man-
agement.

In a VERTEX or CRANIAL PRESENTATION, although it
mav become necessary to determine the situation of the anterior and
|H.-ierior fontanelles, and the direction assumed by the sagittal suture,
in order to ascertain its position, yet it is the posterior fontanelle alone,
which distinguishes the situation of the occiput; and this fontanelle, in
all natural labors, is the most readily reached by the finger. A vertex
position is characterized by the relation existing between the occiput
of the fetus, and the acetabulum, symphysis pubis, or sacro-iliac sym-
physes of the maternal pelvis. Thus, then, the positions of a vertex
presentation, may be arranged as follows :

POSITIONS OF THE VEKTEX OR CRANIAL PRESENTATION.

1st. LEFT OCCIPITO-ANTERIOR, in which the occiput of
the child looks toward the left acetabulum of the mother, or anteriorly
and to the left of the pelvis. In this position the forehead of the
child, and consequently the anterior fontanelle, will be found toward
the right sacro-iliac symphysis, the sagittal suture running obliquely
across the pelvis anteriorly from the left, to the right posteriorly.
This position has also been called the' left occipito-cotyloid, or first
(oblique) cranial position.*

2d. RIGHT OCCIPITO-ANTERIOR, in which the occiput of
the child looks toward the right acetabulm of the mother, or ante-
riorly and to the right of the pelvis. In this position, the anterior
fontanelle will be found toward the left sacro-iliac symphysis, the
sagittal suture running obliquely across the pelvis anteriorly from the
right, to the left posteriorly. This position has also been called the
right occipito-cotyloid, or second (oblique) cranial position.

3d. OCCIPITO-PUBAL, in which the occiput faces the sym-
physis pubis of the mother, or is placed anteriorly without any lateral
obliquity. In this position, the anterior fontanelle will be toward the

* I see no necessity for .the changes in name which some authors have given for the
varions positions in which the head, or other parts of the fetus, may present. The
names which I still adhere to, and which originated with eminent obstetricians, appear
to me to convey a clearer and much better understanding of the positions than any
others that have yet been proposed as substitutes. Indeed, the new terms attempted
to be introduced by recent writers are not only more apt to confuse the student and
practitioner, but are, certainly to my mind, very unsatisfactory. The term left occipito-
anterior, will much better convey to the mind of the accoucheur the fact that the occi-
put is to the left anteriorly, than the term first cranial position. K.

PRESENTATIONS AND POSITIONS. 335

sacrum, the sagittal suture running in the direction of the antero-
posterior diameter of the pelvis. This position has also been called
the first (direct) cranial position.

4th. LEFT OCCIPITO-POSTERIOR, in which the occiput
looks toward the left sacro-iliac symphysis of the mother, or poste-
riorly and to the left of the pelvis. In this position, the forehead of
the child, or its anterior fontanelle, will be found toward the right
acetabulum, the sagittal suture running obliquely across the pelvis
anteriorly from the right, to the left posteriorly as in the second posi-
tion. This position has also been called the right fronto-cotyloid, or
third (oblique) cranial position.

5th. RIGHT OCCIPITO-POSTERIOR, in which the occiput
looks toward the right sacro-iliac symphysis of the mother, or poste-
riorly and to the right of the pelvis. In this position, the forehead
of the child, or its anterior fontanelle, will be toward the left
acetabulum, the sagittal suture running obliquely across the pelvis
anteriorly from the left, to the right posteriorly, as in the first posi-
tion. It has also been called the left fronto-cotyloid, or fourth (oblique)
cranial position.

6th. OCCIPITO-SACRAL, in which the occiput faces the sacrum
of the mother, or is placed posteriorly without any lateral obliquity.
In this position the anterior fontanelle will be found toward the
symphysis pubis, the sagittal suture being in the same direction as in
the third position. This has also been called the second (direct) cranial
position.

The student can readily master a knowledge of these positions, if,
taking the vertex or occiput as the guide, he will bear in mind, that it
may be placed either anteriorly or posteriorly in the maternal pelvis,
and that, commencing with its anterior position as the first, he has
merely to give to it the directions, left, right, and/row^. Thus, vertex
to the left anterior, vertex to the right anterior, vertex anterior, vertex
to the left posterior, vertex to the right posterior, and vertex posterior.
Professor Meigs simplifies the positions, the better to impress them
upon the student's mind, thus : " vertex left, vertex right, vertex
front; forehead left, forehead right, forehead front," and which
enumeration is, undoubtedly, as he remarks, " the easiest one to
remember." The importance of a knowledge of these positions, is,
that in cases where an interference is demanded, the accoucheur may
have a certain guide by which to govern his operations, with an eye to
the safety of the mother, as well as of the child ; and, without this
knowledge, any assistance which may be attempted, is more likely to

336 KING'S ECLECTIC OBSTETRICS.

effect mischief than benefit. And I hold a man, who is ignorant of
these matters, criminally responsible for any fatal consequences that
may follow his rash attempts to accomplish he knows not what. Nor
is the excuse, "that he has no malice or evil feeling toward his patient,
but was endeavoring to do the best he could for her," a valid one he
has no right, whatever, even with the authority of a diploma,. to under-
take a practice which concerns health and life, with an entire ignorance
of his duties; the very attempt alone, is, in my estimation, criminal.

More recently writers have given but four positions, the first or left
occipito-anterior;. the second or right occipito-anterior; the third or
left occipito-posterior; and the fourth, or right occipito-posterior.
The other positions, four in number, occipito-pubal or sacral, and left
or right transverse vertex positions, from their rare occurrence, and
from the fact that they must assume an oblique position before the
head can be born, unless it be very small as compared with the maternal
pelvis, are merely referred to. Yet as the first mentioned do sometimes
occur, I think it proper to recognize them. The transverse positions,
as far as my own experience is concerned, are nothing more than
positions which are incidentally encountered during the movement of
the head toward an oblique position.

When the head presents well flexed, it is a vertex presentation, but
when extension has occurred, it then becomes a FACE PRESENTA-
TION, in which but two positions are recognized. In the diagnosis
of face positions, the mentum or chin of the child, must be taken as
the guide.

Although the labor in face presentations is tedious, and more painful
to the mother, and somewhat more dangerous for the child than in
vertex presentations, yet we find that in the majority of cases they
terminate naturally, and without any artificial aid. From statistics
collected from French, German, and English authorities, it appears
that in 136,123 cases, the face presented in 640 or about 1 in 21 2|
cases, so that these deviations of the natural vertex presentation are
very rare. As to the labor, we have a record of 344 cases, in which
248 were delivered naturally, 42 required version, 20 the forceps, and
15 craniotomy. The mortality to the mother averages about 1 in 50 ;
to the child 1 in 7; and it has been found the greatest to both mother
and child in those cases where assistance was given ; so that the
necessity for interference is not so great as was formerly supposed.

PRESENTATIONS AND POSITIONS. 337

POSITIONS OF FACE PRESENTATIONS.

1st. LEFT MENTO-ILIAC, in which the child's chin is to the
left side of the maternal pelvis, and its forehead to the right side.
This is also termed the second or left face position.

2d. EIGHT MENTO-ILIAC, in which the chin of the child is to
the right side of the mother's pelvis, and its forehead to her left side.
This is also termed the^rs^ or right face position.

Some authors give two other positions, one the mento-sacral or fourth
face 'position, in which the chin is toward the sacrum or nearly so, and
the forehead toward the pubic symphysis, and the other, the mento-pubic
or third face position, exactly the reverse of the preceding one. The
former is said to be extremely rare, and I very much doubt whether it
can occur, except in children with very small heads, or in premature
labors. The latter is likewise seldom met with, although it is the
position which the two principal positions assume at the termination
of labor. For practical purposes the two positions above named are
sufficient. The right mento-iliac position is much more frequently
encountered than the left, and is commonly given by authors as the
first face position ; but, as I have commenced with the vertex presenta-
tion by giving the first position to the left, and the second to the right,
I have considered it better to adhere to this arrangement with all
presentations without regard to the frequency of any one position
among them, and which certainly presents more uniformity and less
complexity.

A SHOULDER PRESENTATION may be considered a deviation
of the cephalic presentation, and includes those of the arm, elbow, and
hand; according to statistics it has occurred 358 times in 93,398 cases,
or about I in 260f, and its mortality to the mother is about 1 in 9,
while of the* children rather more than one-half have been lost. There
are four shoulder positions; two for each shoulder, and the points by
which the practitioner is to be guided in his diagnosis, are, the head of
the fetus, and the ilium of the mother ; some authors name the back
of the fetus instead of its head, while others again have two dorso-
anterior, and two abdomino-anterior positions. The right arm or
shoulder presents oftener than the left, and in the majority of instances,
the back of the fetus will be looking toward the maternal abdomen.
First, is the distinctive term applied to the two positions of the right
shoulder presentation : and second, to those of the left.
22

338 KING'S ECLECTIC OBSTETRICS.

POSITIONS OF SHOULDER PRESENTATIONS.

FIRST LEFT CEPHALO-ILIAC, in which the right shoulder
presents, the head of the fetus being in the maternal left iliae fossa,
its face looking posteriorly, and its back anteriorly. This is likr\vi.M>
called the first dorso-anterior position.

SECOND LEFT CEPHALO-ILIAC, in which the left shoulder
presents, the head of the fetus being in the maternal left iliac fossa,
its face looking anteriorly, and its back posteriorly. This is likewise
called the^r.s^ dor so-posterior position.

FIRST RIGHT CEPHALO-ILIAC, in which the right shoulder
presents, the head of the fetus being in the maternal right iliac fossa,
its face looking anteriorly, and its back posteriorly. This is likewise
called the second dorso-posterior position.

SECOND RIGHT CEPHALO-ILIAC, in which the left shoulder
presents, the head of the fetus being in the maternal right iliac fossa,
its face looking posteriorly, and its back anteriorly. This is likewise
called the second dorso-anterior position.

The PELVIC, or BREECH PRESENTATION, is divided into
four positions, the sacrum of the fetus being the diagnostic guide. In
this presentation, the delivery is generally accomplished by the natural
powers, without the intervention of art, though it is slow, tedious, and
painful to the mother, and more dangerous to the fetus than vertex,
or face presentations; the mortality to the child is owing to pressure
of the os uteri on its body, which, by forcing the blood toward its
head, produces congestion of that organ; it may also be owing to the
tardiness of the labor, and the compression of the cord during the
delivery of the head. Why the breech should present, has not been
satisfactorily explained. Breech presentations have occurred, accord-
ing to statistics, 2,438 times in 129,117 cases, or about 1 in*52, and the
mortality to the child is recorded at 195 deaths in 678 cases, or about
1 in 3j. Those breech presentations in which the back of the child is
directed anteriorly, and which are more commonly encountered, are
termed first positions; those in which the fetal back is directed
posteriorly, are termed second positions. The other positions which
have been given by former writers, as, sacro-pubic, sacro-sacral, etc.,
I have wholly omitted, as I doubt very much whether they really
occur ; but should they ever be presented to the accoucheur, he will
be guided in their management, by the rules hereafter laid down
Knee and feet presentations are mere deviations from the breech, and

PRESENTATIONS AND POSITIONS. 339

are even more tedious and dangerous to the child than this, on account
of the delay in the delivery of the head, the maternal parts not being
so well dilated, as when the breech presents, with the extremities
flexed upward. Knee presentations are rare, occurring about once in
3,445 cases; statistics give 1,268 foot and knee presentations in '117,640
cases, or about 1 in 92f, and the mortality to the child is recorded at
210 deaths in 562 cases, or about 1 in 2J.

POSITIONS OF BREECH PRESENTATIONS.

1st. FIRST LEFT SACRO-ILIAC, in which the back or sacrum
of the fetus looks anteriorly and to the left; its abdomen posteriorly
and to the right; its transverse or bitrochanteric diameter occupying
the right oblique pelvic diameter.

2d. FIRST RIGHT SACRO-ILIAC, in which the sacrum of the
fetus looks anteriorly and to the right; its abdomen posteriorly and
to the left ; its transverse diameter occupying the left oblique pelvic
diameter.

3d. SECOND LEFT SACRO-ILIAC, in which the sacrum of the
Ait us looks posteriorly and to the left; its abdomen anteriorly and to the
right; its transverse diameter occupying the left oblique pelvic diameter.-

4th. SECOND RIGHT SACRO-ILIAC, in which the sacrum of
the fetus looks posteriorly and to the right; its abdomen anteriorly
and to the left; its transverse diameter occupying the right oblique
pelvic diameter.

In KNEE PRESENTATIONS, the feet are always to be brought
down, and the positions of the feet (corresponding with those of the
breech), are determined by the heel; thus, first left calcaneo-iliac , or
heels to the left and front; first right calcaneo-iliac, or heels to the
right and front; second left calcaneo-iliac, or heels to the left and
posteriorly; second right calcaneo-iliac, or heels to the right and
posteriorly. The position of the heels enables us more readily to
determine the position of the breech.

To briefly recapitulate, the presentations and positions are as follows :

Presentations. Positions. ' Presentations. Positions.

VERTEX.

1. Left Occipito-anterior.

2. Right Occipito-anterior. g HOULDER . .

4. Left Occipito-posterior.

1. First Left Cephalo-iliae.

2. Second Left Cephalo-iliac.

3. First Right Cephalo-iliac.

4. Second Right Cephalo-iliac.

5. Right Occipito-posterior. f j_ p irst L eft Sacro-iliac.

6. Occipito-sacral. , J 2. First Right Sacro-iliac.

It Sacro-iliar.
'lit Sacro-iliac.

. ccpito-sacra. j 2 . First Right Sacro-iliac.

-r,. _ f 1. Left Mento-iliac. 1 3. Second Left Sacro-iliar.

I 2. Right Mento-iliac. t 4. Second Right Sacro-ilia

340 KI.Nc's ECLECTIC OBSTETRICS.

.CHAPTER XXVIII.

MECHANISM OF LABOR.

IT has been heretofore remarked, that presentation of the vertex is
the most common of all the mechanism of which includes descent,
liexion, rotation, restitution aiid expulsion of the trunk; and among
the positions, the left occipito-anterior, or that in which the occiput is
directed toward the left acetabulum, is more frequently met with, oc-
durring, according to statistics, about 69 times in every 100 cases. In
.1,913 cases, reported by M. Dubois, 1,339 were left occipito-anterior,
494 right occipito-posterior, 55 right occipito-anterior, and 12 left oc-
cipito-posterior. Why the occiput is found so much more frequently
in front is difficult to determine; but its position at the left anterior
of the pelvis may be accounted for by the rectum on the left side,
which, being usually distended w y ith fecal matters, diminishes the
right oblique diameter, so that the head being forced to traverse the
most ample diameter, the occiput is thrown to the left acetabulum,
and the forehead to the right sacro-iliac symphysis.

As already remarked, vertex presentations are always more favor-
able for both mother and child, than any other. The occipito-posterior
positions are, however, less so than the occipito-anterior, in conse-
quence of the difficult descent of the head, the more frequent demands
for artificial aid, the greater liability of laceration, or perforation of
the perineum, and from the delay in the advance of the head often
creating sloughs, and urinary, or stercoral fistulse.

The presence of a vertex presentation may frequently be recognized
during the last few weeks of pregnancy, even before the finger can be
introduced within the os uteri; a regular, solid, rounded tumor may
be felt through the inferior portion of the uterine parietes, which can
be raised by the finger with more or less difficulty as the pregnancy is
more or less advanced. And when, at the commencement of labor,
the presenting part can not be easily reached, or the round, resisting
surface of the head is not encountered, .there may be some other than
a vertex presentation, and the labor should be closely watched during
the first stage, in order to determine, as soon as possible, the nature
of the presenting part, and be thereby enabled to rectify, at the proper
period, any accidents which may present themselves. Nseg^le states,
that various circumstances, independent of malposition, may occur,
which will prevent the presenting part from being felt at the end

MECHANISM OF LABOR. 341

of gestation; as in cases of multipart, where the uterine fundus is
-strongly inclined forward; in twin cases; in breech presentations;
where a large quantity of amniotic fluid is present ; where the uterus
is not oval at its inferior part; when there is a hydrocephalous head ; and
where the pelvis is narrow. As soon as the dilatation of the os uteri
has so far proceeded as to admit the introduction of the finger, during
the absence of a pain, the large, rounded, smooth and solid surface
of the head can be felt through the membranes, and if the dilatation
be sufficient, membranous spaces, answering to the sutures and fonta-
nelles, may be recognized; and if the head be pressed upon, a resist-
ance of a somewhat elastic character may be noticed. But great care
is necessary to prevent these examinations from prematurely rupturing
the membranes. After the membranes have ruptured, at the close
of the first stage, these diagnostic signs are more manifest.

After having correctly ascertained 'the presentation, the next thing
will be to determine the position, and this should always be done at
as early a period as possible, in order, the more readily to remedy
any difficulties which may occur. The diagnosis can, in many
instances, be effected previous to the rupture of the membranes;
but, most frequently, it will be impossible to arrive at it, until after
this has occurred, and then, it should always be accomplished without
<lelay.

Auscultation has been spoken of, as affording aid in determining
the position; thus, if the fetal heart is heard pulsating in the left
iliac fossa, the occiput is to the left, and if in the right, it is to the
right, etc. ; but there is too much uncertainty in this mode of
diagnosticating, to admit of its employment in actual practice ; the
examination per vaginam is the only one on which dependence
must be placed. The same may be said in relation to the active
motions of the fetus, whose anterior region is supposed to corre-
spond with the point of the uterus at which these have been
recognized for a long time. The practitioner may attend to these
symptoms, for the purpose of verifying their accuracy, or of leading
to a more positive determination of their real value ; but he should
not allow a labor to proceed solely upon the indications they afford.

In order to arrive at the position of a vertex presentation, the
accoucheur should render himself enabled to recognize at once, the
character of the fontanelles and sutures, a description of which has
already been given, and the exploring finger should be pressed with
sufficient firmness upon the head to enable it to detect them. He
must also bear in mind that, frequently, while the head is descending,

342

KINGS ECLECTIC ORSTETKK S.

the compression it undergoes, is such, that the bones are forced to
overlap each other, and the sutures, instead of a membranous sensa-
tion, convey to the finger, one of longitudinal ridges or prominences ;
and the distinctive character of the posterior fontanelle especially, is
lost, being recognized merely by the junction of the sagittal and
lambdoidal sutures, or rather the longitudinal prominences which
they present from the pressure.

IST. LEFT OCCIPITO-ANTEKIOR POSITION.

DIAGNOSIS. In this position, the finger, upon being introduced
into the vagina, or within .the os uteri, will first come in contact with
the boss or protuberance of the right parietal bone of the fetal head,
which is the most depending part, and not the posterior fontanelle,.
which latter will be found in the region of, and corresponding nearly
to the maternal left acetabulum ; the sagittal suture may then be
FIG. 46 traced running from

this triangular fon-
tanelle, obliquely
across the pelvis,
from below upward,
and from before
backward, and from
left to right, until
it meets with the
large, soft, mem-
branous, and quad-
rangular anterior
fontanelle, w h i c h
will be toward the
right sacro-iliac
symphysis. The
back of the child
will be toward the
front and left of the
mother's abdomen,
while its abdomen
will be toward her
back and right; its

right shoulder will be in front and to the right, and its left, back and
to the left. (Fig. 46.)

MECHANISM OF LABOR. -,4.>

MECHANISM. The waters having been discharged by the rup-
ture of the membranes, the expulsive contractions of the uterus force
the head, which presents obliquely at the superior strait, down into
the brim of the pelvis, its flexion upon the chest is increased, so that
.the neck is bent more into a curve, and the body of the fetus is more
or less compressed and rolled, as it were, into a ball, occupying much
less space than before. At first, the two fontanelles are nearly on a
level, but as labor progresses, and the head advances, one of them,
more commonly the posterior, will be found gradually descending, as-
the uterine contractions cause the vertex to sink. The flexion causes
a change in the relations of the head. Previous to the rupture of the
membranes, and the flexion of the head, the occipito-frontal diameter
of the fetal head was parallel to the left oblique diameter of the
superior strait, and the biparietal of the former coincided with the
right oblique of the latter ; but now, while the position of the latter
diameters remains unaltered, the former changes, the occipito-breg-
matic of the fetal head corresponding to the left oblique diameter
of the strait, in place of the occipito-frontal. The axis of the
pelvis, which, previous to the rupture, coincided with the trachelo-
bregmatic diameter of the head, now corresponds very nearly with it&
occipito-mental. If the student will compare the diameters of the
fetal head with those of the maternal pelvis, he will ascertain that this
movement of flexion, brings the smallest diameters of the head in cor-
respondence with the smallest of the pelvis, thus placing it in a position
highly favorable to its ready expulsion.

The descent of the head is due to the continuation of the uterine
contractions, which force it through the strait, into the pelvic cavity,,
and onward to the lower strait of the pelvis. In its passage through
the pelvic excavation, it undergoes great compression, the bones over-
lap each other, as above stated, forming longitudinal ridges along the
sutures, and sometimes, when the pressure is very considerable, a
tumor is formed upon the scalp, called the CAPUT SUCCEDANEUM.
The obliquity of the head at the superior strait is preserved throughout
its descent, with the exception that one fontanelle (the posterior) is,,
more commonly, lower than the other. The contractions urge the
head downward, the occiput descends on the left antero-lateral inclined
plane, while the forehead moves in the direction of the right sacro-iliae
ftymphysis, and the descent is wholly perfected, when the occipito-
bregmatic circumference coincides with the plane of the inferior
strait, or when the two protuberances of the parietal bones have
arrived at this level, and to attain which, the left protuberance, which

344

KINOES ECLECTIC OBSTETRICS.

is behind, must traverse the whole anterior face of the sacrum,
describing the arc of a large circle, while the right, which is anterior,
traverses a shorter distance, describing the arc of a much smaller
circle.

When the head arrives at the floor of the pelvis, its further progress.

is arrested by the perineum, sacro-sciatic ligaments, etc., etc., which

FIG. 47. form this part; but

the continuation of
the uterine contrac-
tions effects a move-
ment of rotation
from left to right,
in which the occiput
is passed behind the
symphysis pubis, a
little to its left,
while the forehead
rotates into the hol-
low of the sacrum,
remaining, however,
a little to the right.
(Fig. 47.) In this
situation the occip-
ito-mental diameter
of the head is al-
most parallel with
the axis of the in-
ferior strait, and
the sagittal suture

nearly coincides with the antero-posterior diameter of this strait. As
the resistance at the floor of the pelvis is gradually overcome, the
occiput continues to descend, passing under the arch of the pubis
until the neck comes in contact with it, when its further advance is
arrested. At the period when the occiput is engaged at the pu-
bic arch, the shoulders and upper part of the body engage in the
superior strait with their long diameters in the same direction as
was taken by the biparietal diameter of the head, viz.: its right
oblique diameter.

The neck being immovably fixed against the pubis, the contractile
efforts being always in a line with the axis of the superior strait, are
directed upon the chin, or that portion of the head which lies in the

MECHANISM OF LABOR.

rvr

Concavity of the sacrum ; the chin gradually departs from the chest,
while the occiput ascends, forming the FIG. 48.

motion of extension. (Fiy. 48.) During
this extension, with the neck fixed against
the symphysis pubis as a pivot for the head
to turn upon, the forehead and face pass
over the curves of the sacrum, coccyx, and
perineum, and as the head emerges, the
vulva becomes distended, the labia majora
are effaced, the nymphse are pressed up,
the perineum becomes thin, yielding, and
distended, and the sagittal suture, ante-
rior fontanelle, forehead, nose, mouth,
and chin, appear in succession at the
vulva, and the head is born. It must be
remarked here, that although the fetal head is impelled toward the
outlet during each pain, yet each remission is followed by a recession
of the head; and this may frequently be observed when the occiput,
which has appeared at the vulva during a pain, recedes within the
cavity during its cessation, having the labia closed over it. This
recession is of immense benefit to the woman, as the distension of the
parts is thereby relieved. Were the head to be forced onward without
any such relief, the circulation in the parts would be obstructed, the
vessels would be more or less strangulated, and inflammation, fol-
lowed by gangrene, would be very apt to ensue. From a similar
cause, it is likewise advantageous to the fetus, an undue and con-
stant pressure upon the head of which, would be likely to cause
its death.

The passage of the fetal head through the pelvic cavity is often
accompanied with cramps in the inferior extremities, which do not,
however, interfere with the action of the uterus or the progress of the
labor, but are sometimes so agonizingly painful as to demand a hasten-
ing of the delivery with the forceps : the cramps are owing to the
compression of the internal sacral nerves by the head.

A few seconds after the delivery of the head, it undergoes another
motion, called restitution, in which it becomes directed as it was pre-
vious to rotation, that is, with the face looking toward the internal
posterior surface of the right thigh of the mother, and the occiput
toward her left groin. (Fig. 49.) From a supposition that the rota-
tion was effected without any participation of the body therein, merely
occasioning a twisting of the neck, and that after the birth of the

346

KING'S ECLECTIC OBSTETRICS.

head, the neck untwisted, restoring the head to its natural relation*

FIG. 49.

with the body, the
term restitution was
applied to this last
motion. But, accord-
ing to Gerdy, this view
ig erroneous, for the
trunk does rotate with
the head in such a
manner as to bring the
long diameter of the
shoulders, which was
at first in the direction
of the right oblique
diameter, to nearly
correspond with the
transverse diameter of
the pelvic cavity. They
descend and reach the

floor of the pelvis in this transverse position, which presents their
bis-acromial diameter to the small, or bis-ischiatic diameter of the
inferior strait, rendering it almost, if not quite impossible for them to
be delivered. Consequently, the resistance offered to their further
advancement, at this point, by the uterine contractions, as was the case
with the head, establishes a rotation, which causes the right shoulder
to pass from the right side toward the pubic arch, while the left passes
into the concavity of the sacrum, and the bis-acromial becomes nearly
coincident with the antero-posterior diameter of the inferior strait, and
it is this rotation of the shoulders which causes the motion of the head
called restitution; it necessarily following the impulse impressed on
the shoulders.

Sometimes, however, the head executes a motion, a short time pre-
vious to its restitution, and which occurs immediately after its expulsion.
This appears to be owing to a slightly oblique position of the shoulders,
while the occiput is about passing under the pubes in an antero-
posterior direction, which imparts a slight twist to the child's neck,
and from which it is relieved, as soon as the head is delivered, and
free from the soft parts.

Shortly after the expulsion of the head, the shoulders having
executed the motions above named, the right shoulder appears at the
vulva and is fixed against the pubes, while the posterior or left shoulder

MECHANISM OF LABOR.

347

traverses the perineal cavity in the same manner as the face in the
delivery of the head, and after its disengagement at the anterior
commissure of the perineum, the right or sub-pubic shoulder follows.
During the birth of the shoulders, the trunk of the child becomes
curved laterally, so as to correspond with the curvature of the pelvic
excavation ; the concavity being on its right side, and the convexity
on its left.

Frequently, the right shoulder will be the first delivered; or both
shoulders may emerge from the vulva at the same time. After the
delivery of the shoulders, the remainder of the body is easily expelled,
describing in its passage, a more or less marked spiral movement.

Thus, then, in a natural labor, with an- occipito-anterior position,
we have the head to offer its smallest diameters and circumference to
those of the pelvis, and to perform the motions of flexion, descent,
rotation, extension and restitution. (Fig. 50.)

FIG. 50.

KINGS ECLECTIC oliSTETUlcs.

_'n. RIGHT OCCIPITO-ANTERIOR POSITION.

DIAGNOSIS. In this position, the finger will first come in con-
tact with the left parietal protuberance, which is the most depending
part, and the posterior fontanellc will be found corresponding nearly
.to the right aeetabulum; from this fontanelle may be traced the sagit-
o. 51. tal suture, running ob-

liquely across the pelvis
from below upward, and
from before backward,
and from right to left,
until it meets the ante-
rior fontanelle, which
will be toward the left
sacra - iliac symphy.Ms.
The back of the child
will be toward the front
and right of the moth-
er's abdomen, while its
abdomen will be toward
her back and left; its
left shoulder will be in
front and to the left,
and its right, back and
to the right. (Fly. 51.)
Madam Boivin re-
cords 3,682 instances of
this position in 20, -317
cases, or about 1 in 5-f cases. Nsege'le states that though more ca.-e.--
are terminated in this position, yet that its frequency as an original
one is .07 per cent. Between this and the previous position there
will be found but little difference in practice. Dewees states that on
account of the right lateral obliquity of the uterus prevailing so often,
and the rectum being occasionally impacted with hardened feces, this
position is less favorable than the first; but, he adds, we may control
the obliquity by placing the woman upon her left side, and can empty
the rectum by an injection.

MECHANISM. In the right occipito-anterior position the occip-
ito-frontal diameter of the fetal head is parallel to the right oblique
diameter of the superior strait, and the biparietal of the former coin-

MKCHAXISM OF LABOR. 349

cides with the left oblique of the latter; but, as in the first position,
when the membranes rupture and the head descends, the occipito-
bregmatie diameter of the head takes the place of the occipito-frontal,
the biparietal remaining unaltered. The flexion, descent, rotation,
extension and restitution are the same as in the previous position,
\vith the exception that rotation takes place from right to left, and
restitution directs the face toward the internal posterior surface of
the left maternal thigh, and the occiput toward the right groin. The
delivery of the shoulders is likewise the counterpart of the first
position.

3c. OCCIP1TO-PUBAL POSITION.

DIAGNOSIS. In this position the occiput, or posterior fontanelle,
will be detected behind the symphysis pubis, and the sagittal suture
may be traced [running parallel, or nearly so, to the antero-posterior
diameter of the pelvis], from before backward and upward, until it
meets the anterior fontanelle, which will be toward the sacrum. The
back of the child will face the mother's abdomen, while its abdomen
will be toward her back ; its right shoulder will be toward her right
side, and its left toward her left.

This position occurs but very rarely, though Nsegele considers it to
be the original one in all occipi to-anterior positions, these being
merely secondary transformations of it, and recognized only because
the examination is made at too advanced a period. Baudelocque met
with it twice in 10,329 cases; Madam Boivin 6 times in 20,517; and
Madam La Chapelle not once in 30,000.

MECHANISM. In the occipito-pubal position, the occipito-
bregmatic diameter of the fetal head corresponds with the antero-
posterior pelvic diameter, and its biparietal with the pelvic trans-
verse. The mechanism, when the head is small, as compared with
the pelvis, differs from the two preceding positions, in the head
executing only the motions of flexion, descent and extension; as rota-
tion is unnecessary, and the direction of restitution will depend
entirely upon which shoulder engages at the pubic arch, as rotation
of the shoulders must ensue before they can be delivered. The labor,
if not interfered with by any uterine obliquity which will remove the
head from the center of the pelvis, will be as favorable as in either of
the preceding cases.

Labor may be facilitated, when the head is in this position, making
but little advance, by changing it to one of the occipito-anterior

350

KINti's ECLECTIC OBSTETRICS.

positions, especially when the vertex is high up, and manifests no dis-
position to assume one of these positions after the occurrence of three
or four pains. To effect this change, the head may be grasped be-
tween the thumb and fingers, and the face inclined laterally; but the
operation must not be attempted until the os uteri is well dilated, the
soft parts yielding, and the head at the superior strait, not impacted,
but free and movable, and during the absence of pain. If the change
can not be effected, we must then wait until symptoms present them-
selves indicating the necessity of interference by forceps or otherwise.
Indeed, when the head is large, unless it be changed, either naturally
or artificially, to an occipito-anterior position, there will be but little
progress in the labor.

4Tii. LEFT OCCIPITO-POSTERIOR POSITION.

DIAGNOSIS. In this position the occiput is placed at the left

sacro-iliac symphysis, and the forehead at the right acetabulum. The

anterior fontanelle will
be found behind the
right acetabulum, from
which the sagittal suture
may be traced running
obliquely across the pel-
vis, from before back-
ward, and from above
downward, and from
right to left, until it
meets with the posterior
fontanelle, which will be
toward the left sacro-
iliac symphysis. The
right parietal protuber-
ance is the lowest in the
pelvis, and the finger
will come in contact
with it the first. The
back of the child will
be toward the back of
the mother and to the

left, while its abdomen will be toward her abdomen, and to the right;

its right shoulder will be toward her abdomen and to the left, and its

left to her back and right. (Fly. 52.)

MECHANISM OF LABOR. 351

This position is very rare, occurring, according to Noegele, in the
ratio of .03 per cent.; to La Chapelle of .04 per cent.; and to Boivin
of. 05 percent. It is more unfavorable than the right occipito-pos-
terior position, the labor being more painful and protracted; this
arises from causes similar to those named under the second position,
and may be remedied, to a certain extent, by the same means as
therein mentioned.

MECHANISM. If the examination per vaginam be made at an
early period, before the head has undergone much flexion, the oc-
cipito-frontal diameter will be found to coincide with the right
oblique pelvic diameter, and the biparietal with the left oblique.
With the descent of the head, the same as in the previous positions,
flexion takes place, which changes the situation of the head so as to
bring the occipito-bregmatic diameter in correspondence with the
right oblique diameter of the pelvis; and the occipito-mental diam-
eter of the head runs nearly parallel with the axis of the superior
strait. At first the anterior fontanelle will be found in the center of
the pelvis, but as the head becomes flexed and descends it rises, while
the posterior fontanelle, previously beyond the touch, descends, and
engages in the pelvic cavity. The descent occurs in the same manner
as already described in the preceding instances. When the head has
reached the floor of the pelvis, rotation, which is much more extended
than in the occipito-anterior positions, takes place, the occiput de-
scribes an arc from left to right, and is carried round to the symphy-
sis pubis, through the left side of the pelvis, when the head is deliv-
ered in the same manner as if it had been an original anterior position :
the first. This extensive rotation could not be effected with safety
to the child unless the body participated in the motion, and which
must, of course, require a long time to accomplish ; but w T hen com-
pleted the labor proceeds favorably, the right shoulder is soon, brought
under the pubic arch, and the left passed into the sacral concavity,
and the delivery is terminated as usual. The movement of restitu-
tion places the face of the child toward the internal part of the right
maternal thigh, and its occiput toward the internal part of the, left
thigh. It is often the case in this position, and especially in primip-
arous women, that, nature becoming exhausted, artificial assistance is
demanded.

The above method is the one in which delivery is most commonly
effected in the posterior occipital positions, but occasionally it occurs
in another ^way. W T hen the head arrives at the floor of the pelvis,

352

KINGS ECLECTIC OBSTETRICS.

the rotation places the forehead under the symphysis pubis, and the
occiput in the hollow of the sacrum. (Fig. 53.) In this position the
face of the child will be to the front of its mother, and its back to
her sacrum; the occipito-frontal diameter of its head will coincide
with the pelvic antero-posterior, and the biparietal will be transverse,
as well as the bis-acromial.

In this position, the uterine contractions still further increase the
flexion of the head, the occiput is forced to gradually traverse the
FIG. 53. sacral, coccygeal, and peri-

neal curve, the perineum
becomes greatly distended
and elongated, the occiput
passes over the posterior
commissure, and the head
passes out by its occipito-
frontal diameter. As the
occiput is passing outward,
the forehead rises behind
the symphysis pubis, thus
giving more space for the
head to pass through. Some-
times, after the delivery of
the occiput, the neck be-
comes fixed against the per-
ineum, and the forehead,
face, and chin of the child,
successively, emerge from under the pubic arch. Should the fore-
head descend so low that the eyebrows may be felt, it will, by pre-
senting an impediment to its elevation behind the pubic symphysis
at the time of the passage of the occiput over the perineal curve, very
much increase the difficulty of the labor.

Dr. Dewees states, "\Ve almost always have it in our power to
reduce this and the fifth " (when they occur with the occiput in the
hollow of the sacrum, as just described), "one to the second, and the
other to the first, and we should always do so when nature does not
do it for us. Nor is this change of position of the head an operation
of the slightest difficulty to the accoucheur; neither does it cause the
smallest pain to the patient, provided advantage be taken of the
proper conditions of the uterus, and head of the child, and state of the
labor. For the uterus must be well dilated, the membranes ruptured,

MECHANISM OF LABOR. 353

the head occupying the lower strait, and the' labor active. When
these prerequisites obtain, the point of the forefinger must be placed
against the edge of the sagittal suture either before or behind the an-
terior fontanelle, and, in the absence of pain, this part must be pressed
toward the left sacro-iliac symphysis,* and maintained there during
the subsequent contraction of the uterus. Should this attempt fail in
changing the position of the head, by bringing the posterior font-
anelle to the right acetabulum, the attempt must be repeated again
and again until it succeeds, which it will almost constantly do."

The expulsion of the head in the occipital posterior positions may,
in consequence of a premature extension, fix the occiput in the hollow
of the sacrum, and thus the face be forced downward by the contrac-
tions, delivery occurring as in face presentations; but, in order to
effect such a change in the pelvic cavity, the natural size of the head
must be considerably reduced, or the diameters of the excavation
must be very large.

In all the occipito-posterior positions there may be a failure of
complete rotation, a want of energy of uterine contraction, or exhaust-
ion, etc., either of which will require the interference of art.

STH. RIGHT OCCIPITO-POSTERIOR POSITION.

DIAGNOSIS. In this position the occiput is placed at the right
sacro-iliac symphysis, and the forehead at the left acetabulum, the
anterior fontanelle will be found behind the left acetabulum, from
which the sagittal suture may be traced running obliquely across the
pelvis, from in front backward, and from above downward, and from
left to right, until it meets with the posterior fontanelle, which will
be toward the right sacro iliac symphysis. The left parietal protu-
berance is the most depending part, and with which the finger will
first come in contact. The back of the child will be toward the back
of the mother and to the right, while its abdomen will be toward her
abdomen, and to the left; its right shoulder will be toward her back
and to the left, and its left to her abdomen and right. (Fig. 54.)

This is considered the most common of the occipito-posterior posi-
tions, and is stated by Nsegele to be the next in frequency, among the

*In the fourth position of the vertex, while attempting the above reduction, the fore-
head must be pushed toward the right sacro-iliac symphysis, which will reduce it to the
first position; in the fifth position, the pressure must be made in the direction toward
the left sacro-iliac symphysis, which will place the head in the second position. Author.

354

KING'S ECLECTIC OBSTETRICS.

FIG. 54.

vertex presentations, to the left occipito-anterior, occurring in the
ratio of 29 per cent. In 355 cases, related by Simpson, 256 were
in the first position, 1 in the second, 2 in the fourth, and 76 in
the fifth. Its frequency is supposed to be owing to the same cause

which gives rise to the
left occipito-anterior
position, viz.: the press-
ure of the rectum on
the left side of the pel-
vis, which happens
especially when, as is
common to women ad-
vanced in pregnancy,
there is an accumulation
of hardened feces. It
is a more unfavorable
position than the first
three, and the labor,
though generally ac-
complished by the nat-
ural powers, is more
tedious and painful than
with the occipito-ante-
rior positions.

MECHANISM.-
This is the counterpart
of the fourth position, and difficulties or changes may be encountered,
similar to those met with in that position. At the commencement of
labor, the occipito-frontal diameter will be found to coincide with the
left oblique pelvic diameter, and the biparietal with the right oblique;
the two foutanelles, as in the preceding case, being at nearly the same
level. As the labor advances, flexion ensues, and the occipito-breg-
matic diameter takes the place of the occipito-frontal, the axis of the
superior strait corresponding nearly with the occipito-mental diam-
eter. Flexion, descent, extensive rotation and restitution, occur as in
the preceding case, with the exception that the rotation takes place
from right to left, the occiput sweeping around the right side of the
pelvis, the left shoulder is brought to the pubic arch, and restitu-
tion brings the face of the child toward the internal part of the left
maternal thigh, and its occiput toward the internal part of the right

MECHANISM OF LABOR.
FIG. 55.

355

thigh or, as in the preceding position, rotation may place the fore-
head under the pubic arch, and the occiput in the hollow of the sac-
rum, as shown in Fig. 55.

BTH. OCCIPITO-SACKAL POSITION.

DIAGNOSIS. In this position the forehead or anterior fontanelle
will be detected behind the symphysis pubis, and the sagittal suture
may be traced [running parallel or nearly so, to the antero-posterior
diameter of the pelvis], from before, backward, and downward, until
it meets the posterior fontanelle or occiput, which will be toward the
sacrum. The back of the child will face the mother's back, while its
abdomen will be toward her abdomen ; its right shoulder will be
toward her left side, and its left toward her right.

This position is of very rare occurrence, so much so that its exist-
-ence is doubted by some accoucheurs, and, together with the third, it
is not classified as a position by several authors. In 20,517 deliveries
it was met with but twice. Boivin.

MECHANISM. In the occipito-sacral position, the occipito-breg-
matic diameter of the fetal head corresponds with the antero-posterior
.pelvic diameter, and its biparietal with the pelvic transverse. The
mechanism differs from the two preceding positions, in the head exe-
cuting only the motions of flexion, descent, increased flexion and

356 KINfi's ECLECTIC OBSTETRICS.

extension. The motion of rotation' is unnecessary, and the direction-
of restitution will depend upon which shoulder engages at the pubic
arch. If nature does not reduce this to an occipito-posterior position.
and the labor is slow and painful, it may be facilitated by effecting the
reduction artificially, in the same manner, and guided by the same
rules, as named, when treating of the mechanism of occipito-pubal
positions. The head may present in positions not exactly agreeing
with those just given, relative to which, Dr. Dewees very correctly
remarks : " Mathematical precision is not required in such cases,
especially as the mechanism of the labor is not altered ; for when the
posterior fontanelle is at all in advance of the sacro-iliac junction,
either right or left, it will almost always eventually place itself under
the arch of the pubes, and this is all that is necessary."

In may be proper to remark here that sometimes the movements of
the head do not occur exactly in the manner just described. Flexion,
for instance, will be found to occur previous to the descent of the
head, or simultaneously with it, or not until the head has reached the
pelvic floor ; and, occasionally, extension will take place so far as to
gradually place the anterior fontanelle in the center of the pelvic
cavity, flexion occurring, however, as soon as the descent is completed ;
this last irregularity is more usual with the occipito-posterior positions.
Again, Dubois has met with a few cases, in which excessive flexion
brought the posterior fontanelle to the center of the excavation (or
perhaps, an inclination of the trunk backward, may have effected it),
but which was restored to its proper situation upon meeting with the
resistance from the pelvic floor.

Rotation may also vary ; it may commence while the head is at the
upper part of the pelvic cavity, so that flexion, descent, and rotation
occur simultaneously; or it may not take place until the head has
almost passed the posterior commissure of the vulva. Rotation may
also be incomplete, or it may be so extensive as to carry the occiput,
not only to the pubic symphysis, but even beyond it, to the acetabulurn
of the opposite side ; in these latter instances, after a short period of
rest, it again places itself behind the symphysis, by a retrograde
motion. These irregularities are not easily accounted for, and though
they may render the delivery tedious, yet it will generally be effected
without any artificial interference.

Rotation of the shoulders likewise, offers some irregularities; it may
be wanting, or it may be incomplete, or it may be excessive, the sama
as with the rotation of the head.

MECHANISM OF LABOR. 357

The pressure upon the circumference of the head, produces a sero-
sanguineous engorgement over the part not subjected to the compres-
sion, and which is always the lowest or presenting part. This tumor,
caput succedaneum, may become so developed as to obscure the
diagnosis, or lead to the supposition of a breech presentation ; but, if
the finger be carried beyond its circumference, the bony resistance of
the head will determine the presentation. The diagnosis of the posi-
tion, may, however, not be so readily ascertained, as this engorged
condition of the scalp may prevent the detection of the fontanelles ; in
such cases, the delivery will require to be performed without inter-
ference, bearing in mind, that in vertex presentations, the major part
are delivered by the unaided efforts of nature.

This tumor of the scalp is an unerring indicator of the position
of the fetal head ; thus, in the left occipito-anterior position, it will
be found on the right parietal protuberance, and in the right
occipito-anterior on the left; in the occipito-posterior positions, it
is located about the center of the vertex, sometimes on the anterior
fontanelle, but, generally, to correspond with the part originally at
the os uteri, and subsequently with the part which presents under the
pubic arch.

It may be distinguished from a sanguineous tumor of the head,
which Nsege'le has termed cephalcematoma, by the following charac-
teristics : it is irregularly circumscribed, being larger in proportion
to the tediousness of the labor ; is always single ; is oedematous,
retaining the pit of the finger ; has no fluctuation ; and the scalp is
of a well-marked violet color. The cephalsematoma vary in size, from
a small nut to a hen's egg ; it is distinctly circumscribed ; possesses
a well-marked fluctuation, sometimes pulsations ; its center is some-
times so greatly depressed as to be mistaken for a perforation of the
bone ; its base is limited by a prominent osseous border, which, how-
ever, is often not developed for several days after the commencement
of the disease ; and the skin covering it is colorless. Again, the caput
succedaneum appears directly after birth, and disappears in from
twelve to forty-eight hours, while the cephalsematoma seldom appears
until some hours after the delivery, and lasts for several weeks.
Cazeaux.

358 ' KING'S ECLECTIC OBSTETEICS.

CHAPTER XXIX.

ON DIFFICULT LABOR FIRST STAGE.

DIFFICULT, lingering, tedious, and protracted labor, belongs to the
second class, and includes all labors where the fetal head presents, but
where they continue beyond twenty-four hours, and may require some
medicinal, manual, or instrumental aid. It is true, that cases will be
met with, in which artificial delivery may be required within the twenty-
four hours, and others, again, which may continue for a period con-
siderably beyond twenty-four hours, but these instances form exceptions
to the above definition. As a general rule, however, the one given
will be found exceedingly salutary and beneficial in practice, and an
attention to which, will be calculated to prevent the occurrence of any
mischief from a rash or premature interference of the practitioner.
This class of labor has also been termed unnatural, but as I can see no
especial reason for changing the terms usually applied to it, and which
in my opinion much better express the character of the labor, I still
adhere to the designation " difficult," which comprises every descrip-
tion of labor in which the process fails to be accomplished in a prompt
and regular manner.

The danger in a difficult labor depends entirely upon the stage in
which the delay happens ; thus, the first stage of labor may continue
for even sixty or seventy hours, with but little, if any danger, espe-
cially if the membranes remain entire, and there is a proper amount
of liquor amnii present, and no mechanical impediment exists. But
delay in the second stage, is always attended with danger, if it con-
tinues beyond a comparatively short time ; hence, in estimating the
necessity for interference, we are not to be governed so much by the
length of time occupied by the first stage, as by the interval which has
elapsed since the rupture of the membranes and the discharge of the
amniotic fluid ; and the experience of accoucheurs has demonstrated
that the danger is, commonly, in proportion to the duration of the
labor. From statistics of the Dublin Lying-in-Hospital, it appears
that when labor exceeds thirty hours, one woman in thirty-four dies ;
when it exceeds forty hours, one in thirteen dies ; beyond fifty hours,
one in eleven ; and beyond sixty hours, one in eight.

Difficult labors are more common among primiparae, and are, like-
wise, not unfrequent among multipart who have given birth to a large
number of children. According to the statistics of English obstetri-

DIFFICULT LABOK FIRST STAGE. 350

cians, 653 cases of difficult labor occurred in 23,758, or about 1 in 36 ;
and it will frequently happen, that a practitioner in his individual
private practice, may meet with even a much larger average than this.

The continuance of a labor beyond a period of twenty-four hours is
necessarily calculated to arouse the fears of the patient and her friends,
as to the cause of the delay ; and if the practitioner does not proceed
properly in such instances, the anxieties and doubts of the friends may
lead them to require the aid of a second accoucheur, or perhaps the
dismissal of the first. It is therefore always proper, when the labor
has continued thus long, to institute a careful investigation of the con-
dition of the patient, arid of all the presenting symptoms, for the
purpose of learning the cause of the delay, and at once applying the
remedy. " In estimating lingering labors, we calculate from the first
commencement of true uterine action ; but in estimating the length of
labor, in reference to the patient's strength and its effects on her sys-
tem, we principally take into consideration the time that has elapsed
since the membranes broke ; for it is reasonable to infer that no great
exertion has been sustained, consequently that little or no exhaustion
has appeared; and particularly, that scarce any injurious pressure can
have taken place on the soft parts within the pelvis, while the mem-
branous cyst remained entire, provided there be an ordinary quantity
of liquor amnii. Thus, when called to a case of lingering labor, in
considering the chance of injury from its duration, our mind should
be directed, not so much to the interval which has elapsed since the
first accession of uterine pains, as to the time at which the membranes
ruptured ; and that should be looked upon as the period when it was
possible for dangerous pressure to have commenced." Ramsbotham.

The management of a patient in difficult labor must be similar to
that required in natural labor. She should not be kept in one posi-
tion, but should be allowed to sit, walk, or lie down, as she may prefer,,
and more especially in the early part of labor ; in the latter stage,,
circumstances may require her to preserve the recumbent posture. She
must not bear down or make any efforts to assist the uterus during it*
contractions, as such efforts may cause the membranes to give way
prematurely, exhaust the patient's strength uselessly, or otherwise
interfere with the progress of the delivery ; and this is a point which
can not be too strongly insisted upon. It is only during the second
stage of labor, when the presentation and position are both favorable,
that the action of the muscles of the abdomen may be exerted with
advantage. The room should be kept cool and quiet, to prevent fever
and induce sleep. Bland, nourishing fluids, weak tea, or acidulated

360 KING'S ECLECTIC OBSTETRICS.

draughts, may be allowed, but stimulants and solid food must be pro-
hibited. Too frequent vaginal examinations are injurious, but the
condition of the bladder should be ascertained every two or three
hours, and much urine should not be allowed to collect in it. This is
of especial importance in difficult labors : the urine must be passed
often, either naturally or by catheter ; and in the use of the latter, no
force should be employed, and care must be taken not to permit it to
slip into the bladder. If the metallic instrument can not be intro-
duced, an elastic catheter must be substituted ; and although under
ordinary circumstances no exposure of the female is allowable, yet
there may be instances where, from the failure in introducing the
above instrument, and the condition of the parts, an exposure will be
necessary to accomplish the desired evacuation of the bladder. This,
however, must never be practiced, except under the most imperative
requirements. This class of labor may be owing to one or more of
several causes, referable to : 1, the uterus; 2, the parts or passages
through which the child passes ; or, 3, to the child itself, and which I
shall now proceed to designate and treat upon :

1. Among the abnormal conditions of the uterus, that may occur
during the first stage of labor may be named as a very common cause
of protracted labor, INEFFICIENT ACTION OF THE UTERUS,
in which the contractions are partial, feeble, or irregular ; they may
continue only for a few seconds, they may hardly be appreciable, or
they may occur at irregular and lengthy intervals ; and in each
instance, the os uteri may be soft and dilatable. This cause will,
in some cases, be owing to a torpid, inactive, and sluggish condition
of both mind and body, or a want of tone or proper nervous irrita-
bility in the constitution ; to some depressing action, as debility result-
ing from excessive discharges, previous disease, etc.; to sudden and
violent emotions of the mind, and other circumstances which exert an
influence on the brain and nervous system. Debility of the system,
or even the presence of serious disease, does not invariably occasion
inertia of the uterus, for we frequently meet with females laboring
under tubercular phthisis, hectic fever, etc., who pass through their
labors with great facility. With some females the tendency to difficult
or easy deliveries appears to be a peculiarity transmitted from parent
to child, and occurs independent of any abnormal conformation, or
habit of the system. A deranged condition of the digestive organs
will frequently influence the character of the uterine contractions, as
will likewise irritation of the os or cervix uteri. Cancer of the uterus,

DIFFICULT LABOR FIRST STAGE. 361

fibrous tumors, uterine inflammation, rheumatism of the uterus, etc.,
may also interfere with the uterine contractions, rendering them
deficient in dilating or expelling power, and irregular in their intervals,
but these causes are more apt to prove dangerous during the second
stage, and will, therefore, be more particularly noticed hereafter.

Females are often annoyed, at the -close of gestation, with false,
spasmodic, or irritable pains, which have no connection whatever with
the contractions in the fibers of the uterus, and which have, in some
instances, given rise to the absurd statements that labor has continued
uninterruptedly for one, two, or more weeks. Care should be taken
to distinguish these from the proper contractions of the uterus.

Inefficient action of the uterus may occur during the first or second
stage ; and, as before remarked, the danger is greater in the latter
than in the former instance. In the First Stage we may find the pains
feeble or irregular, and exerting but little influence upon the bag of
membranes ; yet if there is only a slight increase of the pulse, " with
the surface of the body cool, tongue moist, absence of thirst, no tender-
ness of the abdomen on pressure, no heat or tenderness of the vagina
and os uteri, and dilatation is advancing, however slowly, we ought
not to interfere, for many hours may elapse before this stage will be
completed, and yet the pressure of the fetal head upon the soft parts
will produce no evil effects if the apartment be kept cool, the posture
be occasionally changed, voluntary efforts at bearing down be avoided,
and nothing but mild nourishment and diluents be allowed."

TREATMENT. When there is considerable delay in the advance-
ment of the first stage of labor, the patient should be kept in as
cheerful condition as possible, and she may occupy the time by
walking about but not to cause fatigue by reading or sewing, by
frequently changing her position, etc.; and should be encouraged to
exercise patience, which virtue the practitioner will find equally
demanded on his part. If the bowels have not been freely evacuated,
a stimulating enema or a dose of purgative medicine may be given,
and which will frequently arouse the uterus to increased action. If
the pulse is weak and slow, and no heat, but rather coolness of the
surface, nor hemorrhage, some arrowroot, or gruel, or wine and water,
may be beneficial, but their use should be permitted with caution.
If, from the want of sleep, continued suffering, and anxiety of mind, the
patient should become fatigued or exhausted, a soporific dose of some
desirable agent should be administered, and natural sleep encouraged,
indulging her in rest and sleep for one or two hours; upon awaken-
ing, she will not only feel refreshed, but will very likely have a

362 KING'S ECLECTIC OBSTETRICS.

recurrence of the pains with increased energy. If an opiate is admin-
istered, it should always be preceded by a purgative when constipation
exists. In a number of instances I have succeeded in restoring nor-
mal power and proper intermittent action to the uterus solely by the
administration of Sulphate of Quinia in a five or ten grain dose.

If there is a plethoric condition of the uterus, or an irritated state
of the os and cervix uteri, this may be frequently overcome by the
use of the sedative, which will usually be Aconite, in addition with
the specially indicated agents, as Macrotys, Lobelia, Gelsemium, or
Pulsatilla, as they may be severally indicated, together, in some cases,
with the compound powder of Ipecacuanha and Opium. Plethora
of the uterine tissue may be known by the energy with which the
pains are at first manifested, but which soon diminish in frequency
and intensity. The cervix is soft and yielding, but the presenting
part does not engage during the pain; the pulse is hard and full, the
respiration laborious, and the pains are equally diffused over the whole
abdomen.

Sometimes the employment of warm diluent drinks, with frictions
over the abdomen, will frequently succeed in restoring or increasing
the contractions, without other aid being required.

When the pains which occur at very irregular periods are confined to
the uterus, and do not render the bag of waters tense, nor impart any
hardness to the uterus when felt through the abdominal parietes, the
pulse being quick and full, and the uterus unusually developed, the
inertia is owing to an Excess of Liquor Amnii, overdistending the
organ, or perhaps to the presence of Twins. In this case, although
the soft parts are relaxed and dilated or dilatable, the labor does not
progress any, the uterus being, from this cause, rendered incapable of
contracting sufficiently powerful to rupture the membranes, and the
patient becomes fretful and restless. The only remedy in this case, is
a discharge of the liquor amnii by an artificial rupture of the mem-
branes, which should be done during the absence of pain [the os uteri
being well dilated], and made as high up as possible, in order to avoid
a falling or washing down of the cord; though I would especially
desire to impress it upon the mind of the student that this procedure
is entirely unjustifiable in ordinary labors, and must not be attempted
unless it is well ascertained that there is no mechanical impediment,
that the head presents, and the os uteri is dilatable. A premature
rupture of the membranes, by discharging the bag of waters and-
bringing the hard and unyielding head of the child upon the sensi-
tive os uteri, may delay the labor by lessening the pains, or producing

DIFFICULT LABOR FIRST STAGE. 363

rigidity of the os. Still-born children are more frequently the results
of too early rupture of the membranes, and, probably, the use of in-
struments are likewise oftener required in such cases.

If the relaxation or cessation of uterine contractions depends upon
moral influences, the attendant, by ascertaining the trouble, may per-
haps, by a prudent and sagacious course, remove them ; but if this
is impossible, he will be governed by the effects produced, using
stimulants in case of depression, and sedatives where much nervous
excitement exists ; Pulsatilla is likewise an excellent remedy, espe-
cially where there are unpleasant sensations with the nervous excite-
ment, the patient complaining that "there is something n-rony ivith the
child." The induction of sleep, also, will frequently be followed by
uterine efforts.

I am decidedly opposed to the use of Ergot during the first stage
of labor, where the only difficulty is the inefficiency of the uterine
contractions, for, as a general rule, an attention to the various symp-
toms which may present themselves, during this stage, with their
appropriate treatment, will be all that is demanded. But, should
circumstances require the use of agents which exert a parturient in-
fluence upon the uterus, Macrotys, Aconite and Macrotys, or Pul-
satilla if the patient is nervous, will prove, as a general rule, more
salutary than the Ergot. Occasionally females will be met with, upon
whose uterine systems these agents produce but little if any influence,
and in whom, under imperious circumstances, it may become neces-
sary to administer Ergot, but I shall have occasion to refer to these
cases hereafter, as well as to others in which Ergot may be employed.
Usually, however, the remedies above noticed, both during the first
and second stages of labor, will prove fully as efficacious as Ergot,
without any of its injurious tendencies. As heretofore observed, I
have found that Sulphate of Quinia will frequently correct the ineffi-
cient action of the uterus. Want of pain, or tardy pains, are met by
Lobelia in some cases, which may be given with the Macrotys if there
is a fullness and oppression of the pulse.

2. RHEUMATISM OF THE UTERUS may be present during
the non-gravid condition of the organ, at an early period of gestation,
and at the time of labor during either of its stages. It is produced
by the same causes that favor the development of rheumatism in other
parts, as exposures to cold and moisture, insufficient clothing, sudden
changes of temperature, especially from a high to a low one, and

364 KING'S ECLECTIO OBSTETRICS.

occasionally, from a rheumatic metastasis; females constitutionally
disposed to rheumatism are more liable to it, though it frequently
r\i<ts without any other part of the system being affected by it.

"The most prominent symptom of this disease is pain, or a dis-
tresssing sensation, without any appreciable cause, and which may
involve the whole or only a portion of the uterus. The intensity of
the pain is variable, and the whole organ may suffer from it, or only a
part, as the fundus, corpus, or cervix. The location of the pain
depends upon the portion of the organ which is affected; thus if it be
seated in the fundus, the sub-umbilical region will suffer the most;
if in the inferior portion of the uterus, acute dragging sensations will
be experienced extending from the loins to the groins, thighs, and
external genital organs. Pressure upon the organ augments the pain,
and if the inferior part of the womb be affected, much suffering will
be caused by pressure upon the cervix during a vaginal examination.
Frequently the contractions of the abdominal muscles, or even the
weight of the bedclothes, will increase the pain. The pains, as with
all rheumatic affections, frequently metastasize, and pass from one
point of the organ to another, or to some other organ, and not un fre-
quently disappear suddenly. Remissions occur sometimes, during
which a sensation of weight in the part is experienced. Recto-vesical
tenesmus almost always accompanies the pain, and the evacuation of
urine is attended with considerable smarting and acute pain, and at
other times the evacuation of both the bladder and rectum is impos-
sible. The pain is usually attended with febrile symptoms, but some-
times these are absent. A repetition of the attacks of pain is very
apt to occasion uterine contractions, which may determine an abortion.

" When rheumatism of the uterus occurs during labor, it generally
impedes the progress of the labor, and sometimes, even prevents the
spontaneous expulsion of the child. Normal contractions of the
uterus only begin to be painful, when it has accomplished the greater
part of its task, and is in the act of distending and dilating the os
uteri; or in other words, true labor-pains begin only at the instant
when the energy of the corpus uteri overcomes the resistance of the
cervix. While in rheumatism of the uterus, the contraction is painful
from the first, and before any influence is exerted on the cervix ; so
that the cause of the pain is not in the violent distension of the os
uteri, but in the contraction itself, in the other morbid conditions and
in the altered relations of the nerves and contractile fibers of the
uterus.

" Again, in a natural labor, the contractions commence at the

DIFFICULT LABOR FIRST STAGE. 365

fundus, and are directed toward, and terminate at the cervix. In
rheumatism, instead of commencing at the fundus, they begin at the
painful part, and run toward the cervix in an irregular manner. The
rheumatic pains also exist before the uterine contractions, and under
the influence of the latter, they rapidly acquire a high degree of
intensity ; and sometimes their violence arrests the contractions before
they have traversed their ordinary cycle, in which case they are rapid,
short, and grow less and less frequent.

" Toward the close of the labor, when the action of the uterus
requires to be aided by the voluntary contraction of the abdominal
muscles, the female, for fear of augmenting her sufferings refrains
from contracting these muscles, thereby causing the labor to be ex-
cessively slow. She is in a state of extreme anxiety, with an increase
of the frequent pulse, the hot skin, the thirst, and urinary tenesmus.
When these sufferings are much prolonged, she falls into a state of
swooning, which frequently proves serviceable, as the pains are
suspended while it lasts; under these circumstances a profuse perspira-
tion has been observed, which has had a most salutary influence on the
rest of the labor. But, in other instances, the uterus becomes more
and more painful; it is rather in a state of permanent contraction
or fibrillar vibration, than of normal contraction ; the pulse being
accelerated, and the woman threatened with a metritis, which renders
the labor extremely painful." Cazeaux.

Uterine rheumatism is frequently mistaken for acute inflammation
of the womb, and as the symptoms resemble each other very much, it
is very difficult to discriminate between them. Rheumatism attacks
mostly very nervous and susceptible women, and may be more readily
suspected when the patient has had previous attacks of rheumatism or
neuralgia, in other parts. Cazeaux determined the disease by touch-
ing; thus, rheumatism and inflammation of the uterus are both painful ;
but in rheumatism, although the first touch of the womb is painful and
quick, yet upon gently and slowly raising it upward with the index
and middle finger, the pain either ceases altogether, or is much miti-
gated, by removing the tenesmus uteri ; while in inflammation the
touch becomes mo're painful the more it is prolonged.

TREATMENT. The means which may be adopted with benefit in
these cases are various. In the first place the bowels, if they have
not been previously evacuated, must be emptied by an injection ; if
the pain be not very severe, but troublesome and annoying, the com-
pound powder of Ipecacuanha and Opium may be given, in doses of
three to five grains, and repeated every half-hour or hour; other

366 KING'S ECLECTIC OBSTETRICS.

agents, however, will usually be called for, and among the first Ma-
crotys should be thought of, and in many cases will be all that is
needed. If the pain is attended by an excited circulation, Aconite
should be added, always observing the usual small dose. If the pain
is inclined to extend down the thighs, and to the region of the back,
Pulsatilla may be given with the Macrotys. If there are marked
remissions, Quinine may be given in doses of three to six grains, and
repeated as often as seems necessary. Fomentations of Stramonium
leaves, or other narcotics, may also be advantageously applied over
the abdomen, and, when the pain is very severe, much benefit will
be derived from the application of dry cups over the lateral inferior
portions of the sacrum. Should the disease manifest itself soon after
the sudden disappearance of a rheumatic pain in some other part,
revulsives or counter-irritants should be placed over the part pri-
marily affected, for the purpose of recalling the pain, if possible, to
that part.

Other means may likewise be used in some cases, in addition to
those just named; Lobelia may be indicated by the unpleasant sense
of weight and dragging in the abdomen and pelvis, or if the pains
are associated with a sense of muscular debility Nux Vomica will be
the remedy.

The disposition to uterine rheumatism at the period of labor
may, in most instances, be entirely overcome by the use of the
Parturient Balm during gestation. General venesection, although
it may afford relief, is never necessary, as its results are ultimately
more disastrous to the patient than beneficial, and a more per-
manent advantage is gained over the disease by the above course,
than could possibly be effected by the employment of the lancet ; and
by pursuing it, there will exist but little necessity for forceps, unless
other symptoms, not immediately connected with the rheumatic attack,
are present.

3. RIGIDITY OF THE OS UTERI, during the first stage of
labor, is a frequent cause of its protractedness. This may occur in
any case, but is more frequently met with in primiparse, in females of
an advanced age, and in instances where the membranes are prema-
turely ruptured. It may be occasioned by repeated and unnecessary
examinations, the use of stimulants, mental excitement, constipation,
or retained urine. It may also be owing to dysmenorrhea, or a dis-
eased condition of the os itself, either natural, or effected by the
improper use of pessaries or other mechanical aids to support the

DIFFICULT LABOR FIRST STAGE. 367

uterus, as well as the imprudent application of escharotics to the os,
for the removal of some real or imaginary affection.

Rigidity of the os uteri may be suspected in cases where the head
.presents and the pains are regular and,normal, but dilatation proceeds
very slowly, if at all ; the pains gradually lose their force, and the
patient becomes exhausted ; in addition to which, Madam La Chapelle
refers to another symptom, viz.: pains in the loins. On examination,
the os uteri will be found thin, resisting, hot, dry, and painful to the
touch, or, soft, cedematous, semi-pulpy, and undilatable, and which
must be carefully distinguished from the soft and flabby condition into
which the thin and rigid cervix must pass before it will dilate. Some-
times the rigidity is excessive, the os being unusually dense, feeling like
cartilage, with a stubbornly unyielding edge ; or if this be thin, the
same resistance will be met with, and a sensation is conveyed to the
touch, similar to that produced by a hole made in thin, extended
parchment.

Very frequently the rigidity will not be confined to the os uteri,
but will extend into the vagina and soft parts ; they will be found hot,
dry, swollen, and extremely sensitive to the touch, and if this condition
be not overcome, the patient becomes restless and feverish, the pulse
rises to 100 or 110, and finally, exhaustion of the vital forces mani-
fests itself. Occasionally the os uteri will be found to contract during
a pain, remaining rigid in the interval ; and in such instances a rup-
ture of the uterus may occur. Instances are recorded in which the
rigidity was so obstinate that the os uteri has been torn off and expelled
in the form of a ring.

TREATMENT. Formerly venesection, ad deliquum animi, was
considered the most successful and potent remedy in this difficulty,
and was the one on which the utmost reliance was placed by the
major part of the profession. I admit that bleeding will, in most
cases, have the effect of overcoming rigidity of the os uteri, but I by
no means admit it to be a proper or safe remedy. A female in labor
requires all the strength natural to her system, not only to sustain
her during its progress, but also to enable her to withstand and
quickly recover from the nervous shock. By the loss of an amount
ot blood sufficient to cause syncope, a debility of the nervous and
circulatory systems must ensue, producing a condition unfavorable
to either of these requirements; and a tedious second stage, with
subsequent hemorrhage or other evils, frequently followed a bleed-
ing practiced in the first stage, and which, no doubt, were aug-
mented, if not actually produced, by the venesection. Debility of the

368 KING'S ECLECTIC OBSTETRICS.

system, and more especially when sudden, persistent, and at the period
of parturition, is incompatible with a safe or energetic labor. Beside
the weakening influence of venesection upon the constitution, we have
an increased prostration of nervous and muscular force, produced by
the shock imparted to the brain and nervous system, as well as by the
lo.-s of blood which necessarily follows the birth of every child. In-
deed, it is impossible for any practitioner to determine what amount
of blood may be lost from the labor itself, independent of any artificial
discharge; and who can tell hew many precious lives have been lost
from uterine hemorrhage, or other fatal symptoms, in the practice of
believers in this treatment, which might have been preserved had the
lancet been cast aside? Indeed, so well were the adherents of this
practice satisfied of its danger to the parturient woman, that they
especially advised not to resort to it until the -parts become swollen
and tender, the pulse increased, with febrile symptoms, or a tendency
to cerebral congestion ; and even then to use it with great care. The
injurious tendencies of bleeding do not cease with the completion of
delivery, for, whether it be artificially effected by the lancet, or nat-
urally by uterine hemorrhage, not only is the puerperal month one
of slow, tedious convalescence, if this term can justly be applied to
it, but very frequently a life-time of irremediable suffering and dis-
ease is the inevitable consequence. Tartar Emetic was also a favor-
ite remedy of the champions of venesection, and was administered in
nearly every case of rigidity of the os.

In the treatment of this difficulty, u-e "have no occasion to wait for
the appearance of the above symptoms before attempting relief, be-
cause we have means to subdue it without the infliction of any imme-
diate or permanent injury to the system, and as soon as the evil man-
ifests itself, we at once apply the remedy, saving the patient a great
amount of suffering, and the friends and ourselves much anxiety and
alarm. And hence, we believe our practice has a vast advantage over
that which dare not attempt certain relief until after a lengthened
period of pain and distress, and when exhaustion of the vital forces is
about to commence. Promptness in combating this condition, as well
as many others, is the only method by which to insure certainty of
success.

In cases of rigidity, during the early part of labor, it will be neces-
sary to pay particular attention to the evacuation of the contents of
the rectum as well as of the bladder; if, after having waited for ten
or fifteen minutes subsequently, the rigidity still remained, the old
time treatment of eclectics was to administer at once the compound

DIFFICULT LABOR FIRST STAGE. 369

tincture of Lobelia and Capsicum, in doses of one, two, or four fluid
drachms, according to the urgency of the case, to be repeated in ten
or fifteen minutes should it be required; and, in the generality of
cases, this would effect a speedy and safe relaxation. In some cases,
in conjunction with the above, an injection of the same tincture was
employed, in the quantity of half a fluid drachm, or a fluid drachm
diluted with a similar amount of water, requesting the patient to re-
tain it as long as possible. In many instances this enema, it is claimed,
was sufficient to overcome the rigidity, without the administra-
tion of any medicine by mouth. This compound is not at present
used, to any great extent; it was, no doubt, a good antispasmodic,
and was an efficient means in overcoming the condition for Avhich it
was prescribed, and was only discarded on account of its disagreeable
taste and the large dose required. Lobelia, or Gelsemium, are the
specific agents now recommended for this difficulty. The emetic in-
fluence of Lobelia is not necessary, to produce the required result,
nor, indeed, is it always desirable that emesis should follow; much
more salutary and immediate results will ensue from nauseating and
relaxing closes and when vomiting has once occurred from its use,
without relaxation, it will frequently be found that smaller doses will
nob be retained sufficiently long upon the stomach to exert any relax-
ing influence. Lobelia is the remedy commonly indicated; its effect
is direct and certain, especially where the parts are full and doughy;
it not only overcomes the rigidity, producing dilatation, but at the
same time favors uterine contractions. It is, indeed, one of the most
valuable remedies in obstetrics. Gelsemium is likewise an efficient
remedy, and may be used in many cases with benefit. It possesses an
advantage over Lobelia, in not causing nausea or vomiting; but, as a
general rule, its influence is not so readily experienced as with that
agent. Gelsemium should be selected when the tissues are thin and
tense, want of secretion, the contractions are painful, the patient nerv-
ous, the vagina hot and dry.

In those cases where inflammation of the os uteri is caused by un-
equal pressure of the child's head upon it, the Gelsemium will be y
found a valuable remedy.

The induction of copious perspiration, by the spirit vapor-bath or
otherwise, has been advised, and will, probably, be found effectual in
some cases; but, on account of the trouble attending its application
during parturition, and the danger of chill subsequently, it is better
to employ it -only when imperatively required.
24

370 KING'S ECLECTIC OBSTETRICS.

The direct application of extract of Belladonna to the os uteri,
artificial dilatation, etc., have been recommended by various writers,
but I have never used them ; the above means having proved suc-
cessful in my own practice, as well as in that of others presented to
my notice.*'

* In relation to manual dilatation of the os uteri, which has been recommended by
some writers, under certain circumstances, it may be well for the student to acquaint
himself with the following rules, given by Prof. Dewees, which may prove serviceable
in the cases to which he alludes :

" 1st. When this part does not coincide with the direction of the uterine forces, and
the axis of the vagina. In this case, labor may become very tedious, for the want of
a correspondence of the axes; I therefore attempt to establish them, as directed in cases
of obliquity of the uterus.

" But I never attempt even the slight change here spoken of, until the os uteri is
yielding, and at the same time dilated, to the size of a dollar, and the pains in pretty
full force. By this method, not the slightest violence is committed, nor is even pain
excited.

" 2d. When the pains are powerfully protrusive, and the os uteri, though pretty
amply dilated, yet not sufficiently so to permit the parietal protuberances to pass freely
through it. In this case, much time and suffering are very often saved, by running
the extremity of the finger round the margin of the os uteri, and gently stretching it.
For, in many instances, if we gain an increase of half an inch in the diameter of this
part, it is all that is required, to enable the head to pass it.

"3d. When the head is detained by the anterior portion of the uterus being in
advance of it, and holding it as it were, in a sling. In this case, that portion of the
neck of the uterus, which is placed before the head, is obliged to sustain the whole
force of the uterine efforts ; in consequence of which, it becomes not only severely
stretched, but it very effectually opposes the advancement of the presenting part, and
gives rise to much unnecessary delay, as well as very much augmenting the sufferings
of the patient.

"This case is one of very frequent occurrence; and women who have ample pelves,
and especially those who have had several children, and are liable to the anterior obli-
quity of the uterus, are more particularly obnoxious to it. I do not know that any
writer has noticed this cause of tedious labor; and though this can not. strictly speak-
ing, be considered as an instance of rigidity, it nevertheless has all the effects of that
condition, as it creates delay, by a portion of one of the soft parts opposing the passage
of the head ; and may, therefore, with much propriety, be considered under the present
head of onr subject.

"We are every way satisfied, from long observation, that this situation of the uterus,
and of the head of the child, is one of the most common causes of delay when every-
thing else is favorably disposed, that occurs in practice at least in this country.
Whether this be so in Europe, where the remote causes, namely, large pelvis, are not so
reneral, we are unprepared to say; but we are certain, that the frequency of this
relation of the head of the child, and the anterior portion of the uterus, in this country,
render such labors more tedious, by hours, than they would be, if no such interposition
of the neck of the uterus took place.

"It is true, that the remora which the neck of the uterus offers to tjie passage of the
head when down before it, never of itself creates a serious difficulty ; the evil chiefly
consists in a painful and unnecessary delay ; but as the case is always manageable,

DIFFICULT LABOR FIRST STAGE. 371

Rigidity depending on disease of the os uteri may be removed by
the above plan, but it can not always be expected to answer. In-
cising the cervix lias been advised as a successful measure in those
cases which prove very obstinate and protracted ; but I have never
had occasion to attempt the operation. The inhalation of Chloro-

when it is proper to offer aid, it is certainly right to correct this deviation from a
strictly healthy labor, as early as circumstances will permit.

"The proper time to act is, when the head occupies the inferior strait and vagina,
completely; when the pains are active; and when the os uteri is sufficiently dilated
to permit the head to pass, if the axis of the head, and that of the os uteri were co-
incident.

"To relieve the head from this state of embarrassment, we must draw the prolapsed
edge of the os uteri by the point of the finger, in the absence of pain, toward the sym-
physis pubis, and maintain it there, until a pain comes on. At this moment, the point
of the finger is to be placed against the edge of the uterus, which is to be pushed
upward between the head of the child and the pubes. Should we be able to carry
the prolapsed portion of the uterus above the advancing portion of the head, the
former will suddenly withdraw itself from the finger; the vertex will apply itself to
the arch of the pubes, and the labor terminate almost immediately.

"It sometimes, however, requires several trials of this kind before they may succeed;
but the attempt must not be abandoned because it fails a few times, for the principle
is a correct one, and should, be acted upon perseveringly, should perseverance be
necessary. We have everything to gain, if we succeed, and nothing to lose if it fail ; a
disappointment, by-the-by, which can not well happen, if the process for the restoration
of the prolapsed part be properly conducted.

"We are convinced that we have seen very many labors, shortened by hours, by
acting as just proposed for such cases. It would be extremely difficult to determine, a
priori, the duration of a labor of this kind, if left to itself; as the resistance which the
margin of the uterus offers to the head, will for a long time be more than equal to the
power of the uterine forces ; consequently, the labor becomes stationary, and will con-
tinue to be so, until the margin of the uterus is obliged to yield, by its losing a part of
its power from attenuation, or perhaps by tearing.

" Nobody estimates the general rule, 'to let a labor alone that is advancing well,
and is natural in its general relations,' more highly than we do; we look upon it as a
most wholesome restraint when acted upon ; and is every way calculated to diminish
ignorant and mischievous officiousness. But this rule, like every oth_er general rule,
has its exceptions; and we may be even accused of violating it unnecessarily, when
we make the cases under consideration exceptions; but we should feel but little con-
cern upon this head, if the charge be even preferred against us, as we are certain that
we are justified in making them from ample experience.

"Many, nay, perhaps everybody (for we have said that we did not know that this
case had been noticed), will condemn what we have said upon this subject, and con-
sider our directions as unnecessary, if not mischievous, because they have never had
recourse to them, but have permitted the uterus to perform this duty unaided; there-
fore they say nature is competent to the work, and when she is competent, she is not to
be interfered with. Were this rule rigidly acted up to, there would be an end to
improvement, not only in the obstetric art, but in the whole range of practical medi-
cine. Our experience, however, teaches us not to heed this sweeping, indiscriminate
rule; for it is not sound practice to permit nature to struggle through difficulties,

372 KING'S ECLECTIC OUSTETKICS.

form is a very efficacious remedy in overcoming rigidity of the parts,.
and is used by many in preference to other means.

When the various means recommended to subdue the rigidity fail to
accomplish this result, and artificial delivery becomes necessary, it is
recommended to complete the labor with the forceps, provided the os
is fully dilated, and the fetal head has descended so low into the pelvic
cavity that an ear can be felt. But if the os is not fully dilated, and
the greater part of the fetal head remains above the superior strait,
and circumstances present, demanding prompt delivery in order to
save the mother's life, the perforator and crotchet must be employed,
for in such instances, the attempt to deliver by forceps would be rash
and unjustifiable; however, it will seldom happen, unless in cases of
diseased os, that the treatment above named will fail in overcoming
the rigidity.

The tendency to this cause of difficult labor, as well as of inefficient
uterine contractions, may generally be obviated by a proper course of
management through the gestating period, or at least during its latter
months, in all cases where the physician is aware of his selection as the
accoucheur. For a few months previous to the expected labor, he
should explain and impress upon his patient's mind, the necessity and
advantages to be derived from a proper preparatory course, especially,
if any circumstances exist, which might lead him to anticipate a diffi-
cult parturition. The course to be pursued at this time, and which has
proved generally successful, is, to keep the bowels in a normal condi-
tion by diet, if possible, otherwise, by mild laxatives; avoid fatigue,
overstimulus, and improper food, and administer once or twice daily,
a dose of the Parturient Balm, which exerts a healthy tonic influence
over the uterus, disposing it to act with proper energy at the time of
labor.

merely because it is supposed she can struggle through them; and to leave it for
some time a moot point, whether or not the case will eventuate in safety, when aid, as
certain, as safe, is always at command. Nor does this application of the finger ever
produce pain or other inconvenience, if properly and gently managed.

"Beside much delay is sometimes experienced from this dropping down of the
anterior portion of the uterus, by interrupting the pivot-like motion of the head, from
completing itself; especially when the head occupies pretty strictly the inferior strait.
In this case, the posterior fontanelle will remain for a long time stationary behind one
of the foramina ovalia; for its advancement toward the arch of the pubes, is prevented
by the prolapsed portion of the uterus interfering with the motion just mentioned, by
embracing too strictly the advancing part of the head.

" But the pivot-like motion of the head is almost always restored, the instant we
succeed in passing the depending portion of the uterus above the head of the child by
the point of the finger, as directed above."

DIFFICULT LABOR FIRST STAGE. 373

4. The proper position of the uterus is when it occupies the middle
of the abdomen, with its longitudinal diameter in the direction of the
axis of the superior strait ; but in persons of a lax and flaccid habit
of body, and especially with those in whom the walls of the abdomen
have become relaxed, it frequently inclines anteriorly or laterally,
which inclination is termed OBLIQUITY OF THE UTERUS, and
which may, by producing rigidity, or other symptoms, retard labor ;
the positions of the presentations are frequently affected by these
obliquities, and the deviations of which, continue, in many instances,
even after the uterus has been restored to its normal situation. There
are three varieties of obliquity : an anterior obliquity, in which, from
excessive relaxation of the abdominal parietes, the fundus uteri falls
forward, throwing the os uteri upward and backward in an unusual
degree ; a right lateral obliquity, in which the fundus falls toward the
right side ; and a left lateral obliquity, in which it falls to the left
side. Among these the left lateral obliquity is more frequently met
with. In an anterior obliquity, the female will be very apt to imagine
herself larger than usual, or perhaps, that she will give birth to
twins. These obliquities may be ascertained by observing that the
fundus of the uterus falls to the right, or left, or anteriorly, and that
the os uteri, instead of its normal situation in the center of the pelvic
cavity, is directed laterally to the right, or left ; and in the anterior
obliquity it will be found upward and backward, elevated to an extent
corresponding, relatively, with the anterior inclination of the fundus.
These obliquities, when excessive, especially the anterior, have fre-
quently given rise to the. idea that the os uteri was imperforate ; and
if not readily recognized and overcome, they may occasion more or
less serious accidents to both mother and child.

TREATMENT. This difficulty can be removed, by placing the
patient upon the side opposed to the obliquity, or upon her back in
the anterior variety ; and when the replacement of the uterus is ac-
complished, by applying a bandage firmly around the body, the organ
may be kept in its normal position. In the early stage of labor, it
will be found advantageous, in these cases, to keep the patient upon her
back, having the shoulders somewhat depressed, and the hips slightly
elevated. Any attempt to remove these obliquities by pulling upon
the os uteri is highly improper.

Sometimes there is an Obliquity of the Os Uteri only, and this is
more apt to procrastinate the labor, than when the whole organ is
inclined. Upon an examination, the os uteri will be found facing the
sacrum, and oftentimes being difficult to reach. Should this condition
remain for any length of time, without change, the expulsive efforts

374 KlXCi's KCLF.CTIC OHSTKTKK 'S.

of the uterus being necessarily directed against the anterior part of
the cervix, which occupies the open space in the pelvis, may, by
forcing the head downward, occasion a rupture at this point.

In a case of this kind the female should be kept in bed as much a>
possible, and as soon as it can be reached, the anterior lip of the os
should be hooked by a finger, brought carefully to the center of the
navity and sustained there until one or more subsequent contractions,
by pressing the head downward and into the opening, will thus pre-
vent the lip from resuming its previous abnormal position.

Labor is occasionally protracted in consequence of the Anterior Lip
of the Os Uteri being retained between the head and pubic symphysis.
either being caught thus during the dilatation, or occasioned by an
unequal dilatation of the anterior and posterior portions of the cervix.
This may delay the first stage of labor for several hours. It may be
overcome by the following operation, provided the head does not fill
the pelvis too tightly, and the lip of the os uteri is not cedematous
from the pressure, or inflamed, in which case, it is better to trust to
the natural efforts. The operation is, to gently push the anterior lip
over the crown of the head, during the absence of a pain, and retain
it there by firm and constant pressure, during one or two subsequent
pains, until it retracts and slips over the head. Not unfrequently,
this operation will prove unsuccessful, and the continued pressure of
the finger upon the lip and soft parts, will cause increased swelling and
inflammation; in the majority of cases of this kind, if the constriction
of the lip be relieved by pressing the fetal head more toward the pelvic
cavity, or toward the sacrum, and holding it thus during a few pains,
the lip will retract without any further aid. If the projecting anterior
lip be hypertrophied, these manipulations will prove of no utility.

Occasionally, at the commencement of labor, and especially in cases
where the fetal head is very small, or the pelvis uncommonly large,
the os uteri may descend with the head, as far as, or even through, the
pelvic outlet; this must be remedied by placing the patient upon her
back, with the shoulders depressed, and the hips elevated then by
gentle and steady pressure with the expanded fingers, return the pro-
lapsed organ to its proper location.

During the first stage of labor, the principal abnormal condition of
the parts through which the child has to pass, aside from actual disease
of these parts, is RIGIDITY OF THE VAGINA and soft parts in which it
may become necessary to employ vaginal injections, or to apply fomen-
tations to the perineum. A warm infusion of equal parts of Elm bark

DIFFICULT LABOR FIRST STAGE. 375

and Lobelia may be used in injection; and the same articles may be
used as a cataplasm or fomentation of the parts. These, however, will
not always be required, as the means recommended for rigidity of the
os uteri \vill generally likewise overcome the rigidity to the soft
parts. When the vagina is dry, harsh, and hot, Gelsemium is the
indicated remedy; or warm Lard Oil, or Lard itself, warmed into
a state of fluidity, may be injected into it with much advantage; but
the parts should never be anointed by friction.

Among the causes referable to the child or its envelopes, certain
conditions of the membranes may be named. As a common rule,
when the os uteri becomes fully dilated, the membranes are ruptured
by the internal pressure upon them; but there will frequently be
found exceptions to this rule. These exceptions are owing to: 1. A
RIGIDITY OR TOUGHNESS OF THE MEMBEANES, and
which render the labor protracted, by retaining the liquor amnii, and
thus hindering the uterus from acting with energy, after the os has
become fully dilated.

TREATMENT. In cases of this kind, the membranes should be
ruptured artificially, after which the contractions will become stronger
and more regular. But a proper degree of caution is required before
attempting this operation, because, if prematurely effected, it may
terminate in more serious results than had no interference taken place.
In the first place, there should be good ground for attributing the
delay to this cause ; secondly, before attempting it, the os uteri should
be fully dilated and the soft parts in a yielding condition ; and thirdly,
with primiparse, it should always, if possible, be postponed until the
first stage of labor is wholly completed. Feeble and inefficient con-
tractions for several hours, with softness and dilatability of the parts,
and the labor having nearly or fully terminated its first stage, are
among the symptoms indicating an artificial rupture. It is sometimes
difficult to effect a rupture of the membranes, especially when the
pains are feeble, and the use of a probe or sharpened quill has been
recommended; but we must be careful in using any cutting or punctur-
ing instrument not to injure the soft parts of the mother, nor the
presenting parts of the child. I have always succeeded with the
finger nail, pressing it upon the membranes during the pain, and
making a sawing motion with it from before backward, or from side
to side, and continuing it until the liquor amnii escapes.

2. The wedge-like pressure of the bag of waters is an important
mechanical agent in the relaxation and dilatation of the cervix and
os; but when the MEMBRANES HAVE RUPTURED PREMA-

376 KING'S ECLECTIC OBSTETRICS.

TURELY, either spontaneously or artificially, this bag is absent, the
fetal head then presses upon the os uteri, but is illy adapted to aid its
dilatation, and the result is a tedious and painful labor. The pre-
mature rupture may be owing to a weakness of the membranes, to
violence, or to a careless examination, and which last is perhaps a
more frequent occurrence than is generally imagined. An early rupt-
ure of the membranes is also an indication of a preternatural presenta-
tion, and whenever it occurs the character of the presentation should
be determined as soon as possible, that timely measures may be adopt-
ed, if required. When the membranes are prematurely ruptured, the
liquor amnii may be discharged in a very short time, or if the rent be
small, or the fetal head lies over its orifice, this fluid may slowly
dribble away, and add much to the discomfort of the patient.

TREATMENT. If the as uteri is dilatable, and the pains are
.active, nothing is required but a little patience, as the labor will
usually proceed with safety to both mother and child. If, however,
the os uteri be rigid and unyielding, this condition must be overcome
by the means already mentioned. If the liquor amnii passes off slowly,
the os being dilatable, and the pains feeble, the orifice in the mem-
branes should be enlarged, and the fetal head elevated, between the
pains, toward the sacrum, in order to admit of a free discharge of the
liquor, and which will be followed by active contractions. The dila-
tability of the os may be increased by Lobelia or Gelsemium admin-
istered internally, or by a rectal enema of the compound tincture of
Lobelia and Capsicum.

In closing this chapter on the causes which may protract the first
stage of labor, I desire to impress upon the mind of the student that
the mere fact of the tediousness of this stage does not justify any
attempts to hasten the labor. Delay in this stage seldom causes any
serious accident to either the mother or child, unless, from a want of
patience and prudence, it be unnecessarily or improperly interfered
with. True, the female may become worn out or exhausted, but this
is soon removed by an energetic uterine action in the second stage,
and in which stage only is the shock given to the nervous .system
which may produce unpleasant or serious results. He should, there-
fore, be very cautious and particular in ascertaining that artificial
assistance is positively required, before attempting to render it;
always bearing in mind the wholesome and oft-repeated saying of
Blundell, that " a meddlesome midwifery is bad" No interference of
any kind must be undertaken, unless it be desired to produce certain
results or conditions favorable to a safe labor, and which results or.
conditions we know are absolutely indicated, or required.

DIFFICULT LABOR SECOND STAGE. 377

CHAPTER XXX.

DIFFICULT LABOR SECOND STAGE..

THE SECOND STAGE OF LABOR may be protracted, even
when the first has progressed favorably, and may be owing to causes
not necessarily nor immediately connected with the first stage, or which,
although present in that stage, can not be determined until the com-
plete dilatation of the os uteri, and which causes, I shall consequently
consider under this head.

As before remarked, although labor may be delayed for a long time
during its first stage, without any hazard to the mother or child, yet
such is not the case in the second stage, for any procrastination beyond
a certain period is fraught with serious consequences to both, hence,
the accoucheur should allow no more delay in the labor than is abso-
lutely necessary, but should promptly and skilfully employ all measures
for facilitating this stage of the labor, that are compatible with the
health and safety of the woman ; to allow her to suffer unnecessarily
from a tedious, lingering labor, is to say the least of it, a very cen-
surable course. The development of bad symptoms may not take
place for some hours after the commencement of the second stage, or
they may occur within six or eight hours ; and, as a general rule, if
this stage of labor has continued for twelve or fifteen hours, symptoms of
constitutional suffering will manifest themselves. The pains, after hav-
ing continued regular and forcible for a time, gradually become more
and more feeble, occurring at less regular intervals, and causing little
or no advance of the head. They may return only at long intervals.
or the intervals may be alternately short and long, or they may be
regular, the pains gradually diminishing in force, until they are scarcely
felt. Or, the pains may commence each time of their occurrence, with
energy, but subside, almost suddenly, before they have reached their
maximum development ; or they may cease entirely.

This impaired condition of uterine action, is very frequently accom-
panied with several unpleasant symptoms, varying in degree : as severe
shiverings, frequently resembling light convulsive attacks; distressing
and frequent vomitings, of green, or bilious matter ; restlessness and
uneasiness of the patient ; the skin may be dry or moist, but in either
case it is hot; increase of pulse, ranging from 100 to 140; the tongue
dry and furred, with sordes about the teeth ; the mind despondent,
disturbed, and fearful ; the vagina hot, and with the os uteri, tender

378 KING'S KCLKCTK OHSTKTRIO.

to the touch ; the mucous discharge from the vagina becomes brown or
yellowish, and occasionally fetid or acrid; and urination is rendered
difficult, or altogether prevented by the pressure of the fetal head.
These symptoms usually occur in the order just given, and in all cases
of prolonged second stage, some of them will be present. If relief
be not afforded, they increase in severity ; the vomiting occurs more
frequently, with ejection of dark-colored matters ; restlessness increases,
with obstinate hiccough ; the abdomen becomes tender ; the skin cov-
ered with a cold, clammy sweat; the pulse rapid and feeble; the
tongue dry and brown ; stupor and low-muttering delirium ensues, and
death terminates the scene. Not only is the life of the mother endan-
gered in such cases, but also that of the child, by the delay of proper
interference.

The causes of difficult labor in its second stage may be referred to : 1,
the uterus ; 2, to the parts or passages through which the child passes ;
3, to abnormal conditions of neighboring organs; 4, to the child.

1. Among those attributable to the conditions of the uterus,
one of the most common causes of delay in the second stage, is a
CESSATION, OR INEFFICIENCY OF THE UTERINE CON-
TRACTIONS. As may have been observed in the previous chapter,
this is also a cause of prolonged first stage, but its effects are by no
means so grave in that stage. It may be owing to disease, sudden and
violent emotions of the mind, tumors, constitutional debility, etc.
Females of an irritable, nervous temperament, may have labor pro-
tracted, during its second stage, from this cause ; and those of debili-
tated constitution, frequently have a failure of uterine action in this
stage, and especially, when from prolongation of the first stage, great
exhaustion occurs.

TREATMENT. When attending a case in which the action of
the uterus becomes lessened, the pains short and inefficient, or at long
intervals, with no advance of the fetal head ; increased and irregular
pulse, restlessness, anxiety, and wakefuLness being also present, it will
become necessary for the practitioner to institute a very minute and
careful examination not only of the genital organs, but likewise of the
condition of the tongue, pulse, skin, head, and abdomen. By the
examination of the genital organs he will ascertain, if possible, the
cause of the delay, and determine by it the best method of affording
assistance ; and by the condition of these parts, in connection with
the general condition of the system, he will be guided as to the proper
time for interference.

DIFFICULT LABOR SECOND STAGE. 379

The cause of the delay can, of course, be learned only from the
examination. The best method of affording assistance, is, invariably,
that which readily and most easily terminates the labor, and with the
least danger to the mother and child, and which must vary according to
the causes and conditions present. Among these means may be named,
Ergot, Sulphate of Quinia, Macrotys, etc., the Vectis, the Forceps, and
the Crotchet ; each of which will be considered hereafter. The proper
time for interference, will depend entirely upon the symptoms; an in-
crease of the pulse, febrile symptoms, soreness and tension of the
abdomen ; exhaustion ; watchfulness, and anxiety ; a dry, hot, puffy,
or swollen condition of the soft parts, caused by the long-continued
pressure and interrupted circulation, and accompanied with a degree
of tenderness which renders a vaginal examination painful ; a retention
of urine, from pressure of the fetal head on the urethra and neck of
the bladder, requiring the use of the catheter, which can be introduced
only with difficulty ; and a change in the character of the vaginal
discharges, they becoming offensive are all symptoms requiring im-
mediate delivery. Indeed, as a general rule, it is good practice to
interfere, even before the local symptoms have appeared.

If, in cases of protracted labor from rigidity, the* constitutional dis-
turbance is excessive, with exhaustion of the vital forces, and determi-
nation of blood to particular organs, especially the brain, the prognosis
is very unfavorable. Fever, in either stage of labor, manifested by
chills, increased pulse, furred tongue, and flushed countenance, indi-
cates the want of artificial aid; and the case assumes a still more
serious aspect, if the pains gradually lessen in frequency and power,
the fetal head ceasing to advance, and the female becoming exhausted.
Sometimes, these symptoms come on very suddenly, requiring an
immediate interference ; the pains cease, the mind becomes confused
and wandering, a clammy perspiration covers the face and body, rest-
lessness with constant hiccough occurs, and the patient becomes so
completely changed in features and in tone of voice, as to be hardly
recognized by her friends. These symptoms may occur during the
first stage, but they will be more frequently met with in the second
stage, where the head has passed through the os uteri into the pelvic
cavity, and has been pressing for a considerable time upon the parts at
the inferior strait.

It is frequently the case that the contractile power of the uterus is
BO readily exhausted, that after having effected the first stage of labor,
the pains cease, or become very feeble in the second. In these
instances the pelvic diameters will be sufficiently ample, the soft parts

380 KING'S ECLECTIC OBSTETRICS.

in a yielding condition, and the head, in whatever portion of the
cavity it may be, will be found in a normal position. In such cases,
and under such circumstances, the labor may be readily terminated
by applying the forceps, but if it seems that the case needs no instru-
mental interference, but will probably result within a short time in
natural delivery, Macrotys should be administered, in the usual
small dose, every fifteen or thirty minutes; and if this fails, and
symptoms of exhaustion manifest themselves, it will then be proper to
administer Ergot, or apply the forceps and deliver at once; or if
having administered Ergot and it fails, within a reasonable time, to
stimulate the uterus to action, resort to the forceps without further
delay. And, indeed, this course may be pursued in all cases of ineffi-
cient uterine contraction, owing to mere debility or exhaustion of the
organ. Notwithstanding that Ergot has been so frequently employed
to facilitate labor, with no apparent immediate pernicious results, yet
the practitioner should ever bear in mind that it is a dangerous rem-
edy at best, requiring much judgment and discrimination in its em-
ployment. The dangers attending its use to the mother are, rupture
of the uterus, rupture of the perineum, inversion of the uterus, etc.,
to the child death, -and more certainly if the cord is around its neck.
And, although it has been employed with impunity in many cases,
where the only indication for its use was the impatience of the practi-
tioner a regard to his ow r n comfort and feelings, in preference to the
safety of his patient still, it is an agent whose action is always to be
dreaded; and the success attending its administration in the instances
just referred to have been the results of good luck, and not of any
superior skill or wisdom of its prescribers.

Ergot has, undoubtedly, a specific action upon the uterus, which
usually commences within twenty or thirty minutes after its exhibi-
tion ; and the character of the contractions produced by it are mate-
rially different from those of natural labor. They are stronger and
of longer duration, resembling a number of violent or spasmodic
uterine contractions continued into one another without intervals.
During a contraction, the circulation of the maternal blood in the
uterus and placenta must be interrupted; and when this interruption
occurs for a long continued time, as when effected by ergotic influence,
preventing the necessary changes in the fetal blood, we should anti^
cipate unfavorable results to the child, and not be unexpectedly
astonished upon finding it born in an asphyxiated condition.

As it is not uncommon to meet with individuals whose constitutions
are insusceptible to the specific influences of one or more drills, go

DIFFICULT L \IJOR SKCOND STAGE. 381

must we expect to meet with females upon whom Ergot exerts but
little or none of its peculiar action; and this want of susceptibility
may account for many of the failures which have been recorded by
authors. Another cause of failure has been, undoubtedly, the want
of a recent article; for an inferior preparation of Ergot, often
found on the market, does not possess the property of exciting
uterine action, and, no matter how carefully it may be admin-
istered, it being a worthless article, failure will follow. One of the
best and most reliable preparations is Lloyd's Ergot, the usual dose
of which is from thirty to sixty drops. This preparation has the ad-
vantage over others, in that it may be used hypodermically, being
free from Alcohol. In extreme cases it should be used in this way,
by means of the ordinary hypodermic syringe, the dose being from
five to twenty drops, repeated if necessary, governed by the effect
produced. As constipation, or a disordered condition of the digestive
organs, is frequently a cause of deficient uterine action, the practi-
tioner should never administer Ergot without having first unloaded
the bowels by enema, or by the administration of a mild laxative.

In the administration of Ergot to females during parturition, 'there
are certain rules to be guided by, which are based upon the recorded
experience and observation of many medical men, and which should
.be thoroughly impressed upon the mind of every individual who at-
tempts the conduct of a labor; they are, briefly, as follows:

Ergot should never be given for the relief or comfort of the practi-
tioner; where any deformity of the pelvis is suspected; where the
head is suspected to be disproportionately large; where the presenta-
tion is beyond reach, or can not be determined; wlrere there exists
an obstruction in the soft parts, as rigidity, etc.; where there is a
malpresentation ; where there exists increased excitement of the
nervous or vascular system ; . where there is a tendency to cerebral
symptoms ; afld w r here the os uteri is not fully dilated. It should never
be given while the woman's strength is greatly exhausted, lest the ex-
haustion produced by it be more excessive than her system can bear.

Ergot should be avoided, as much as possible, in first labors, lest
rupture of the perineum ensue.

Ergot may be given, ix CAREFUL HANDS, in multiparse, where the
sole cause of delay is deficient uterine contraction; where the head
presents and is low in the pelvis, the os uteri soft and fully dilated,
the soft parts yielding and dilatable, and the membranes have rup-
tured ; and the pelvis must be ample, with normal proportions be-
tween it and the fetal head. The patient must also be somewhat

382 KING'S ECLECTIC OBSTETRICS.

exhausted, but without any symptoms of fever or inflammation; I
must confess, however, that I prefer not to wait for any considerable
degree of exhaustion before administering this article.

Some authors recommend the administration of twenty or thirty
grains of Ergot in powder, or infusion, for a single dose; but in my
own practice, in all cases where I have considered its use indicated
and advisable, I have succeeded in arousing the contractions of the
uterus, in fifteen or thirty minutes, by the use of one of the fluid prep-
arations, either a reliable fluid extract or the specific tincture; my
preference, however, is the article previously mentioned, and known
as Lloyd's Ergot, in half to one drachm doses.

I would remark here, however, that among those practitioners who
are acquainted with the parturient virtues of Macrotys, the employ-
ment of Ergot for the purpose of inducing (spasmodic) contractions
of the uterus, is not so often required. . It might be well, in the cases
under consideration, to give this agent a fair trial before resorting to
the ergotic preparations; more especially as it may be exhibited with
greater safety, and at an earlier period of labor ; beside, the contrac-
tions induced bear a greater resemblance to those caused solely by the
natural powers.

It will sometimes be found that, although the contractions of the
uterus may be aroused by the administration of Ergot, they are not
of an expulsive character; in such cases the uterus contracts firmly
upon the part of the child within it, preventing its advance, and caus-
ing its death by the pressure maintained around it, unless timely
assistance be afforded by the employment of the forceps. Hence, it is
recommended by our best accoucheurs to have a forceps at hand when
this drug is exhibited. It must be recollected, however, that so long
as the pains continue, with an advance of the head, however slowly, the
pulse continuing good, no trouble in urinating, and no pain of the
abdomen on pressure, ARTIFICIAL INTERFERENCE is NOT REQUIRED;
but in debilitated patients, in whom symptoms of exhaustion and
fever appear, interference will be demanded, even though the head be
very slowly advancing. And by delaying the necessary aid, the
patient may die after delivery, from the shock of the labor, or from
hemorrhage and retained placenta, or, should life be spared, sloughing
of the uterus, vagina, bladder, and rectum may take place, rendering
her subsequent existence painful and burdensome in the extreme.

I have known Sulphate of Quiuia, in a dose of three to five grains,
to increase the expulsive action of the uterus in several instances, in

DIFFICULT LABOR SECOND STAGE. 383

which this action was inefficient ; and yet a large numoer of practi-
tioners have denied that it possesses such influence. In the cases
under consideration, where the diminution of uterine action has no
other cause than general or local debility, Crede's operation has been
successfully employed. The woman being placed on her back, the
accoucheur applies the palmar surface of his open hands upon the ab-
dominal walls, immediately over the fundus and sides of the uterus,
and, as soon as a pain commences, he makes firm pressure downward
and in the direction of the axis of the superior strait, ceasing his
efforts with the cessation of the pain and repeating them as soon as it
recommences, and so on, until the head is born. This operation should
not be practiced with violence or rudeness, and can only prove ser-
viceable in cases of normal vertex presentation, and where the mater-
nal pelvic diameters are sufficiently large. It increases the strength
as well as the duration of the pains.

2. PRECIPITATE LABOR may be due to violent or excessive
action of the uterus, to great relaxation of the maternal tissues, to an
abnormally large pelvis, to premature rupture of the membranes, or to
the child being quite small. AVomen who are subject to dysmenorrhea,
or who are well developed muscularly but at the same time excessively
nervous, are liable to powerful uterine action ; sometimes it appears
to be hereditary. Occasionally ovarian excitement, mental excitement
of any kind, and even hysteria, will give rise to an increase of the
labor paiu in the second stage. The dangers of such increased and
hurried action of the uterus are, injury to the child, rupture of the
cord, sudden detachment of the placenta followed by dangerous hem-
orrhage, inversion of the uterus, rupture of the uterus, vagina, and
perineum, and syncope, etc.; and from the continuous and forcible
straining of the w T oman, not unfrequently, subcutaneous emphysema
of the neck and head, as well as more or less cerebral disturbance. If
the practitioner is present at the time of this violent action, he must
promptly employ means to palliate according to the cause. The woman
must be kept constantly in the recumbent position, 'and, to lessen ex-
cessive uterine action, opiates, Gelsemium, compound tincture of
Lobelia and Capsicum, Chloral-hydrate, Bromide of Potassium, or
Chloroform, etc., may be used in full doses. All stimulus must be
avoided ; unnecessary examinations must be dispensed with ; the
bowels should be opened by laxative enema, followed subsequently by
sedative; and the woman should not be allowed to bear down, but

384 KING'S ECLECTIC OBSTETRICS.

rather encouraged to cry out loudly. When the pelvis is large, or the
head of the child small, the methods named under Abnormally Large
Pelvis may be pursued.

3. Very rarely, the labor is interfered with by an IMPERFO-
RATE OS UTERI, which may be suspected when .the pains are reg-
ular, increasing gradually in force, pushing the lower segment of the
uterus into the cavity of the pelvis, rendering it very thin, without any
opening of the os uteri being discoverable.

There may be an Agglutination of the Os Uteri, the result of some
previous inflammation of the part, and which may be detected by
finding an indentation, or depressed fold at the center of the os uteri,
without any opening; the pains will be regular, increasing gradually
in force, pushing the lower segment of the uterus into the cavity of
the pelvis, rendering it extremely thin ; or the Os Uteri may be oblit-
erated. These conditions are, however, rarely met with.

TREATMENT. It may be that the os uteri is merely rigid and
not dilatable, and the means recommended for this difficulty may be
pursued, whenever the os can be discovered. Sometimes the os uteri
is closed by agglutination, resisting the most powerful uterine con-
tractions; in such instances, Dr. Rigby remarks, "A moderate degree
of pressure against it while in a state of strong distension, either by
the tip of the finger or a female catheter, is quite sufficient to over-
come it; little or no pain is produced, and the appearance of a slight
discharge of blood will show that the stricture has given away."

If no opening, however, can be found, it will become necessary to
divide the presenting wall of the uterus, and form an artificial os
uteri, through which the child may pass. A crucial incision is to be
made upon the anterior-inferior part of the wall, as near the situation
of the os uteri as possible, by means of a sharp-pointed bistoury; this
knife is carefully passed along the left forefinger as a guide, and must
not be pushed too deeply into the uterine wall, lest the presenting
part of the fetus be injured. In performing the antero-posterior in-
cision, care must be taken not to extend it so far, either forward or
backward, as to injure the bladder or rectum. After the operation,
the delivery may be left to the natural efforts.

It must be recollected, however, that it is frequently the case that
from uterine anterior obliquity the os uteri will be higher up, perhaps
entirely beyond the reach of the finger, and looking toward the prom-
ontory of the sacrum, and in which position it may remain for several

DIFFICULT LABOR SECOND STAGE. 385

hours, retarding the progress of the labor, and a careful search should
always be instituted previous to attempting any operation. If it be
found thus elevated and inclined, the labor may be expedited by
drawing it downward and forward with one or two fingers, in the
direction of the axis of the superior strait, and holding it there until
the engagement of the head will prevent a return to its former in-
clination.

Sometimes the orifice of the os uteri will be found so minute or
contracted, from disease or other causes, that the head can not pass
through it, even when dilated ; for which the same course must be
pursued as named for cancer of the os uteri, being careful in all opera-
tions not to carry the incisions into the rectum or bladder.

I would remark here, that some of these latter conditions, existing
as causes of difficult labor, may be found present in the first stage of
labor, when they should be as promptly attended to as the circum-
stances of the case will permit ; preparing the parts, if possible, so
that no delay may take place during the second stage.

3. FIBROUS TUMORS of the CERVIX UTERI, are occa-
sionally met with, instances of which are recorded, where the labors
were finished without more than ordinary assistance, the mothers
recovering, but the children being still-born. In such cases it is bet-
ter to delay all operations, if there is the least possibility of the deliv-
ery being effected by the natural powers; but when this is impossible,
from the excessive size of the tumor, from the want of proper uterine
contractions, or from exhaustion of the mother, the child will have to
be extracted by means of embryotomy, or, if this be impracticable, by
the Cesarean operation.

4. A POLYPUS may arise from the body or neck of the uterus,
or it may be adherent to the walls of the vagina, and in either case
present an obstacle to the delivery. It may be known by its firm,
fleshy feel, its movability, its pear-shape, and its long, narrow neck ;
during labor it has sometimes been mistaken for the child's he;>d.

TREATMENT. If the tumor be detected at an early period of
labor, it m'ight be prevented from descending, by pressing it back
during the absence of a pain, and holding it thus until the head has
passed beyond it; but this is not practicable in all instances, and
especially when the tumor is very large. In every case of this kind
it will be proper to trust, for a time, to the resources of nature ; but
25

386 KING'S ECLECTIC OBSTETRICS.

when the parts become hot, dry, and swollen, and the uterine efforts
inefficient, interference is required, for a too protracted delay is
hazardous to both mother and child. The only operation necessary
is the removal of the tumor by excision, and not. perforation of the
child's skull ; for the danger from hemorrhage after the operation is
not so great as to justify the destruction of the child. "The polypus
should be drawn down as much as "possible by a forceps proper for the
purpose, a temporary ligature applied, and the stem cut through."
" It is not likely that the ovum could be brought to maturity, if a
large polypus occupied the cavity of the uterus; it is therefore fair to
assume, that when a polypus is found to impede parturition, it must
be attached to the mouth of the uterus, and therefore it can be the
more easily traced to its origin, so that you have every facility to
assist your diagnosis." (Murphy.) If the presence of a polypus in
the pelvic canal be discovered during the latter period of utero-gesta-
tiou, and its size be such as to possibly render labor protracted and
difficult, it should at once be ligated and excised, or it may be
removed by the ecraseur, when this can be done.

5. Other tumors may be present as impediments to the progress
of labor, as FUNGOUS, or CAULIFLOWER TUMORS, which,
from their spongy character and tendency to hemorrhage, may be mis-
taken for a placenta prsevia ; these may spring from, either lip of the
cervix, and when small may allow the birth of the child without any
artificial aid, but when large they may have to be incised, or entirely
removed by excision; iu either'case, there will be but a slight chance
for the mother's recovery. Embryotomy and gastrotomy have both
been performed in these cases, but generally with fatal results.

Among the causes due to the condition of the passages through
which the child passes, are: 1. RIGIDITY OF THE SOFT
PARTS, especially of the perineum. In such cases a resort to Ergot,
or the forceps, while the rigidity remains, is highly censurable. Oc-
casionally, during the advance of the fetal head, the os uteri, instead
of yielding, grasps the head during each pain, and prevents its further
progress; this is apt to alarm the practitioner, who, having ascer-
tained that the position of the head is correct, finds it to remain sta-
tionary, notwithstanding pain after pain continues with much force and
severity. A careful examination, as to the presentation and position
of the head, and its relative proportions with the pelvic diameters,

DIFFICULT LABOR SECOND STAGE. 387

in >y determine the cause of the delay. -The same cause frequently
prevents the head from rotating.

TREATMENT. Patience is required in these cases, in conjunction
with the means named for overcoming rigidity in the previous chap-
ter. In the instance of rigid os delaying the advance of the fetal
head, it will always be proper to correct any abnormal position of the
uterus which may be present, so that its longitudinal axis may corres-
pond with the axis of the superior strait.

The following abstract is taken from Braithwaite' s Retrospect :
"Dr. Washington has recently discovered that dry-cupping, applied
to the lowest part of the sacrum, produces dilatation of the os uteri ;
and, applied higher up, contraction of the uterus. In a case, where
the pains had endured fourteen hours without producing any per-
ceptible effect, in consequence of rigidity of the os uteri, Dr. Wash-
ington applied a dry cup as low down on the sacrum as possible, so
as to cover the origin of the nerves to the os uteri. Complete relaxa-
tion ensued; at the next pain, the head descended to the outlet; and
.at the second pain the patient was safely delivered ; and that in less
than ten minutes from the application of the cups. In tedious labor,
the cup should be applied first to the lowest point of the sacrum, and
if, in the course of ten or fifteen minutes, the patient is not delivered,
another should be applied higher up, so as to cause the uterus to con-
tract. The lower one should always be on when the upper one is applied,
so as to insure relaxation of the os uteri when the pains come on.

' "In retained placenta, the cups are to be applied higher up, so as to
cause the uterus to contract at once, the relaxation of the os uteri
being always sufficient after the fetus has passed. When Ergot is
administered, the woman is delivered by main force, without any
relaxation except that produced by the most fearful pains. By dry-
cupping, two or three pains are sufficient, and the amount of suffering
is not more than ordinary."

2. A CICATEIX IN THE VAGINA, will sometimes be met
with, which will present 'an impediment to the delivery; it is usually
the result of sloughing effected in a previous tedious labor, in which,
the healing of the ulcer which remains after the separation of the,
slough, occasions a diminution of the diameters of the vaginal canal.
An examination will detect, at some portion of the vaginal wall, a
.firm, unyielding band, which may occupy from three to six lines

388 KING'S ECLECTIC OBSTETRICS.

longitudinally, or which may present merely a very thin edge, the
thickness of a water. The difficulty will, of course, be proportioned
to the firmness and extent of the cicatrix, and is always a serious ob-
stacle to labor.

TREATMENT. In thesv cases we should not interfere prema-
turely, but always wait and learn Avhat the natural efforts can do;
strong and energetic contractions, with the pressure of the fetal head,
may overcome the difficulty. But where assistance is required, relax-
ation, effected by Lobelia or Gelsemium, administered by mouth, and
by rectal enema of compound tincture of. Lobelia and Capsicum will
usually produce the desired dilatability, and the head will advance
without any further delay. Where the cicatrix is of great extent, and
very firm and unyielding, the inhalation of Chloroform will in some
cases, relax the parts after the ordinary internal medication has failed;
anasthesia should be carried to the extent of producing complete relax-
ation. Occasionally it happens that the cicatricial bands are so firm,
that to induce dilatation more radical measures must be resorted to.
It is advised in such cases, by excellent authority, to slightly incise
the edges of the constricted part in three or four places, being careful
to avoid the neck of the bladder, the rectum, and the two uterine ar-
teries, which pass up from below on each side of the vagina; and for
this purpose the incisions should be made one behind each groin, and
one toward each sacro-iliac symphysis. The least snip is sufficient, as
the advance of the head will probably widen it. After the delivery,
a sponge or bougie, well oiled, should be introduced into the canal
and changed two or three times a day, so that as the part heals, the
diameters of the vagina do not again become lessened. The artificial
increase of the vaginal passage by incisions, should be attempted with
great care, and under the advice of counsel, for, however slight the
operation may be, the advance of the head may cause the cut to widen
and produce a much more extensive laceration than if the case had
been left to the natural powers. Indeed, I am somewhat inclined to
believe that the operation will very rarely be found necessary, where
the previously-named treatment has been faithfully pursued. Some-
times considerable hemorrhage follows, and cases have occasionally
terminated fatally. If the contractions of the uterus become inefficient,
or unfavorable symptoms present themselves, the labor may demand
a prompt termination by instruments, the use of which, in such cases,
even with the greatest care, is apt to produce more or less extensive
lacerations, and which are not without danger; and a knowledge of
this fact may lead to the practice of patience and caution.

DIFFICULT LABOR FROM PELVIC DEFORMITY. 389

Where the practitioner is aware of this difficulty at an early period
during gestation, or has reasons to suspect it, it is proper for him to
explain the matter to his patient, and request an examination, when
if the constriction be found very great, he may induce premature labor,
and thereby save the mother the hazards that she would run at full
period ; and the same course may be pursued with females known to
be laboring under Cancer of the Os Uteri. In. this latter condition of
the cervix, at ,full term, when the labor is delayed thereby, it may
become necessary to divide the diseased part sufficiently to admit the
passage of the child. But, as this operation is only to be 'attempted
for the child's safety, we must be certain that it is alive before per-
forming it ; the death of the mother is to be expected in such cases,
no matter what course is pursued. Cauliflower Excrescence may be
similarly managed.

3. IMPERFORATE or UNRUPTURED HYMEN, may pre-
vent the passage of the head. Impregnation may be effected without
lacerating the hymen, which will be found perfect at the period of
labor. It usually yields to the pressure of the head, but should it
resist for too long a time, a slight incision may be made into it by the
scalpel, taking care to prevent the laceration from extending into the
perineum, as the head passes through the external orifice, by giving
careful support to the perineum.

4._Where, from a continued DELAY OF THE CHILD'S HEAD

in the Pelvic Cavity, the circulation of the parts becomes interrupted,
the soft parts are apt to swell, thereby offering still greater opposition
to the advance of the head, and which may terminate in some structural
lesion of the parts, if prompt -and energetic measures be not adopted.
Dr. Campbell observes, " Unless a practitioner has had the manage-
ment of the patient from the commencement of labor, he is apt to view
this variety of diminished capacity, as arising from original defect in
the development of the bones themselves."

TREATMENT. This condition may be overcome, to a great
extent, by emollient vaginal injections, or injections of warm Lard or
Oil, and if necessary, relaxation may be produced by the adminis-
tration of Gelsemium or Lobelia. Should the pains be feeble, labor
may be facilitated by an injection into the rectum of compound
tincture of Lobelia and Capsicum, slightly diluted with water; or
Macrotys, Ergot, etc., may be exhibited according to the directions

390 KING'S ECLECTIC OBSTETRICS.

heretofore given, when treating of inefficient action of the uterus.
The forceps have been advised*, but I should, in these instances, fear
some injury to the parts from their employment. I have frequently
given the Gelsemium to cause relaxation, and when produced, have
followed it with Ergot, with the happiest results, in cases requiring an
expeditious delivery, where the pains were feeble, with a degree of
rigidity or tumefaction of the soft parts.

5. (EDEMA OF THE LABIA MAJORA, is sometimes so great
at the time of labor, as nearly to obliterate the vaginal entrance,
rendering the delivery difficult and very painful ; and the pressure of
the fetal head in its passage over the tumefied parts, may cause an
extensive rupture, or produce gangrene. The same treatment may be
pursued as in the preceding instance, but, if the tumefaction be very
excessive, or the labor considerably advanced, it is recommended to
puncture the engorged parts with the lancet, in different places, the
number of punctures depending on the extent and degree of oedema.
But it must be remembered that the parts after having been punctured
are liable to inflammation and sloughing.

CHAPTER XXXI.

ON DIFFICULT LABOR, FROM TUMORS, PELVIC DEFORMITIES, ETC.

6. THE capacity of the pelvis is occasionally diminished during
labor, by the presence of Tumors in its Cavity. These tumors may
vary in their size, consistency, and pathological characters ; 'they may-
be osseous, fibrous, adipose, steatomatous, sarcomatous or scirrhus, and
the difficulty occasioned by them, will depend upon their size and
degree of solidity. The history and surgical management of these
tumors, together with other details, are not within the province of this
work, in which I will merely refer to the diagnostic signs, and the
indications for treatment when they interfere with the progress of labor.

A hard, bony tumor of extremely rare occurrence, termed EX-
OSTOSIS, has been met with. It takes its origin from some portion
of the osseous parietes, more commonly from the sacro-iliac symphy-
sis, and sometimes from the first bone of the sacrum, from the last

DIFFICULT LABOR FROM PELVIC DEFORMITY. 391

lumbar vertebra, from the internal surface of one of the ischia, or
from some portion of the posterior face of the pubic bones: and may
be detected by its hard, knotty, and irregular feel, its insensibility to
pressure, its immobility, and its projection into the interior of the
vaginal canal, but always covered by the wall of this canal.

TREATMENT. If the presence of the exostosis be known at an
early period of gestation, it would be proper, according to circum-
stances, to effect an abortion, or induce premature delivery. At full
term, it may be possible, that when the tumor is very small, the labor
will progress without assistance, but when it is large, so as to mate-
rially interfere with the capacity of the pelvic diameters, the case
assumes a more serious aspect. As we can not remove this obstruction
by an operation, we must be governed by the nature of the case. If
there is a probability that the head may pass, it will be prudent to
wait until symptoms, demanding artificial delivery, present themselves,
when the labor may be terminated by the forceps, or perhaps the per-
forator. When the diminution of the pelvic cavity, from this cause,
is so great that the fetus can not pass through the vagina, the only
chance for the mother will be in the performance of the Cesarean
section, or the Porro operation, a description of which will be found
in another part of this work. Fortunately, these instances are rare;
I have never met with one.

7. Other osseous tumors may occasionally render a labor difficult,
as OSTEO-SARCOMA of the pelvis; this is very difficult to distin-
guish from exostosis ; it presents greater inequalities, has a semi-
cartilaginous softness, a degree of depressibility, and at some parts of
its surface crepitation may be observed. From the depressibility of
this tumor, the pressure of the head may flatten it, and effect a suffi-
cient amplification of the parts to admit of the passage of the fetus ;
and should the natural efforts fail, or symptoms appear requiring
interference, the labor may be terminated, according to circumstances,
as in the preceding difficulty.

Sometimes the pelvic cavity may be diminished by bony protuber-
ances, depending upon irregular consolidation of fractures in the part,
or perforation of a carious acetabulum by the head of the femur, etc.
In these cases, whatever may be the situation of the protuberance, the
indications for treatment will be the same as in pelvic deformities.

8. ENCYSTED TUMORS, may adhere to the cervix uteri, or to
the vaginal walls ; they are usually round, well-defined, movable,
elastic, and sometimes fluctuating, and require the same treatment as

392 KING'S ECLECTIC OBSTETRICS.

heretofore named for other tumors, as do also those of a Scirrhwt or
Phlegmonous character, Polypi, and various Excrescences, and Syphilitic
Vegetations which may be found on the external parts of the genera-
tive organs.

From the great fatality which attends the presence of pelvic tumors,
as obstacles to delivery, it must be regarded as a fortunate matter that
their occurrence is not very frequent. Perhaps, less fatality would
attend these cases, when known at an early period, and both mother
and child be saved, were the induction of premature labor accom-
plished ; although, it is by no means improbable, that even at the
seventh month, instances may be met with which will offer an obstacle
to the operation, and with these, the production of an early abortion
affords the only chance of safety for the mother.

As a general rule of action, in all cases of tumors at full term, the
first attempt of the practitioner should be to push the tumor up above
the superior strait, beyond the head, so as to remove its interference
with the advance of the latter. And the operator will be more likely
to succeed by placing the patient on her knees, with the pelvis eleva-
ted, and the breast on the bed, in a line with the knees ; this position
deprives the patient of any tenesmic, or bearing-down power, beside
causing the uterus to gravitate further from the pelvis, in a direction
toward the epigastrium, and thus affording greater space into which
the tumor may be placed. The manipulation may be conducted
according to circumstances, with the hand in the vagina, or one or two
fingers in the rectum, or both combined.

Where the tumor can not thus be placed out of the way, it is recom-
mended to puncture it with a trocar, and in case this fails, to perforate
the child's head, either of which operations do not always lessen the
danger to the mother. In relation to puncturing or incising the pos-
terior vaginal wall, in these tumor cases, Prof. Meigs remarks in his
valuable work on Obstetrics, " I do not feel at liberty to recommend
such an operation in this volume an operation which could only be
legitimately performed, upon due and mature consideration with the
most acute and able practitioners of the vicinity. They alone should
feel themselves vested with the authority to act under such terrible
circumstances. I merely remark, en passant, that an incision into the
posterior wall of the vagina, should it even have the good effect suffi-
ciently to reduce the size of the tumor, fearfully exposes the patient
to the risk of vaginal laceration from the subsequent distension by the
descending head, and the escape of the child into the peritoneal sac.

DIFFICULT LABOR FROM PELVIC DEFORMITY. 393

A small aperture in the thin posterior paries of the tube, is more
likely to yield and become a frightful laceration, than to resist the dis-
tending force of the advancing head." These remarks, from one of
the most eminent accoucheurs of America, are entitled to the serious
consideration of every medical man. Up to this period, I have met
with only one instance of tumor offering an impediment to delivery ;
it was a cauliflower excrescence of the cervix, in a female with her
fifth child, and terminated fatally.

DEFORMITIES OF THE PELVIS, are another cause of pro-
tracted and difficult labors, not unfrequently rendering the descent of
the child impracticable, and are much more common to the women of
Europe than to those of America. In another part of this work I
have referred to the character of these malformations, and the method
of determining them ; it now remains to speak of the management of
labor when they are present.

9._The ABNORMALLY LARGE PELVIS, can scarcely be con-
sidered a deformity ; but as the head of the child may meet with but
little resistance in its passage through the canals, the various motions
of flexion, rotation, etc., may not take place at all, or else be very
imperfectly effected, and thus modify the labor. The consequences
which may result in these kind of labors from deficient resistance,
have already been named. Where the labor proceeds rapidly, the
child may unexpectedly be expelled and fall upon the floor, even
before the practitioner has deemed it advisable to make the usual pre-
liminary preparations. In these cases, the best method of manage-
ment, when called in time, is, to prevent the head from being too
hastily expelled, by pressure upon it during a pain, giving firm sup-
port to the perineum until it is sufficiently yielding to allow the head
to pass without causing a laceration, and to guard against hemorrhage
by pressure over the uterine globe. After delivery, the patient should
be kept in the horizontal posture, for a longer time than usual.

10. The DWARFISH PELVIS, will offer an impediment to
labor, according to the degree of contraction present; the labor may
be accomplished by the natural powers, but it will be tedious, difficult,
and attended with much suffering, and perhaps, from the long-con-
tinued compression of the head, result in the death of the child ; or,
it may be impossible for the child to be born without assistance. And,
indeed, the same observations will apply to the Unequally Contracted
Pelvis, and the Obliquely Distorted Pelvis.

394 KING'S ECLECTIC OBSTETRICS.

The character of the labor, in these instances, will depend entirely
upon the amount of deformity which may be arranged as follows:
1st. Where the diminution of the pelvic diameters is not so great but
that the child may be born, after a long time, by the natural powers,
aided, in most cases, by the forceps, for the application of which there
will be found sufficient space. 2d. Where the diminution of the
pelvic diameters renders it impossible for the head to advance, and the
forceps can not be applied for want of space, and, consequently, the
only resource is the perforator. 3d. Where the pelvic canal is so
reduced in size, that even a mutilated child could not be extracted.

The difficulty of the labor will not depend so much upon the positive
size of the pelvic diameters themselves, as upon their adaptation,
relatively, to the diameters of the fetal head; for, though the pelvis
may be considerably contracted, yet, if the child's head be smafl, the
labor may progress with comparatively little difficulty. A pelvis,
whose small diameter is less than three inches, may generally be con-
sidered as one through which a living child can not pass ; on this
point, however, it may be proper to state, that accoucheurs vary in
their estimate, some placing the limit at two inches, some at two and
a half, and others at three, and even three and a quarter inches. In
instances where the small diameter is less than three, but exceeds two
inches, the labor will belong to the second arrangement or class,
as given above; in such cases the forceps could not be employed
advantageously, or if an attempt were made to use them, it would,
undoubtedly prove useless, and perhaps injurious the perforator and
crochet would be demanded here. Authors likewise vary in the limit
of measurement in these labors requiring the mutilating instruments,
some placing \t at one and a half inches, and others at one and three
quarters, and two inches. When the small diameter is below two
inches, the labor belongs to the third arrangement, and will, very
probably, require the Cesarean operation before the child can be
removed.

When there is a deformity of the pelvis, we are informed by Dr.
Rigby, that the uterine contractions are frequently irregular during
the first stage, of labor, exerting but little influence in dilating the <>s
uteri ; the head remains high up, does not descend against the os uteri,
and shows no disposition to enter the pelvic cavity beinir pushed
forward by the promontory of the sacrum, it rests upon the pubic
.syinphysis, pressing forcibly ag-.iinst it. The mode of determining
deformity a: the superior strait, has been already explained in another
part of the work. When the deformity is in the cavity or at the in-

DIFFICULT LABOR FROM PELVIC DEFORMITY. 395

ferior strait, it is detected with much less difficulty, as the parts are
more readily reached ; we will discover that the head makes no advance-
ment during a pain, and if the finger be passed around during the
absence of pain, the head will be found larger than the canal through
which it has to pass. When the labor is allowed to proceed without
interference in these extremely deformed pelves, various symptoms
may present, which are generally met with during the second stage,
as: inefficient contractions, exhaustion, and febrile symptoms, inflam-
mation and sloughing of the soft parts, the result of long and forcible
pressure of the head, and which may occur at either of the straits, or
in the cavity, and may, likewise, penetrate into the bladder, or rectum;
rupture of the uterus not unfrequently occurs in these cases. The child
may have one or more bones of the cranium fractured, or the pressure
may cause inflammation or sloughing of the scalp, or its death may be
occasioned by strong and continued compression of the head.

TREATMENT. This will depend much upon the class to which
the deformity belongs; no positive or fixed rule can be laid down; if
it be of the first class, a fair trial should be given to the natural powers,
and if they be found insufficient to effect the child's expulsion, or if
symptoms of exhaustion appear, assistance should be given with the
forceps, provided there be space enough for their application. If the
case belongs to the second or third class, I deem it advisable to operate
at as early a period as possible, before the system of the patient has
become exhausted from the long-continued exertion and sufferings of
the labor, thereby materially increasing the chances of a favorable
result. In instances w r here the perforator is indicated, the child is
generally dead from the pressure, before the symptoms have arrived at
a point demanding the operation. In alt cases where deformity of the
pelvis is suspected during labor, the practitioner should at once pro-
ceed by a careful examination to determine the character and location
of the distortion, and the method of .management should be decided
upon only after a consultation with experienced accoucheurs.

The following extract from Dr. R. Lee's Lectures on Midwifery,
relative to the treatment of pelvic deformities, will, no doubt, prove
acceptable to the reader ; he observes : " In cases of slighter distor-
tion of the pelvic, it is impossible to predict at the commencement
of labor whether the head will pass or not, and while it continues to
advance and no unfavorable symptoms are present, you ought not to
interfere wait patiently and see what nature can do. If the head
descends so low into the cavity of the pelvis that an ear can be felt,

396 KING'S ECLECTIC OBSTETRICS.

and the os uteri is fully dilated, and there- is room to pass up the blades
of the forceps without the employment of much force, it is always
proper, when delivery becomes necessary, to attempt to extract the
head with the forceps. It is necessary, however, to remember that
sloughing is apt to follow the use of the forceps where the soft parts have
been long pressed upon by the head, and that perforation of the head
is a much safer operation for the mother, when the distortion is con-
siderable.

"The employment of the long forceps, in cases of distorted pelvis,
has been recommended by Baudelocque, Boivin, La Chapelle, Capuroi>,
Maygrier, Velpeau, and Flammant, whose works contain ample in-
structions for its use, before the head of the child has entered the brim
of the pelvis; and the la"st of these writers has expressed his belief that
the instrument is more frequently required while the head of the child
remains above the superior aperture of the pelvis, than after it has
descended into the cavity.

"In thi country there are no practitioners of judgment and ex-
perience, who have frequent resource to the forceps, or who employ it
before the orifice of the uterus is fully dilated, and the head of the
child has descended so low into the pelvis that an ear can be felt, and
the relative position of the head to the pelvis accurately ascertained.
The instrument is very seldom used in England where the pelvis i.s
much distorted, or where the soft parts are in a rigid and swollen state ;
but it is had resource to, where delivery becomes necessary in conse-
quence of exhaustion, hemorrhage, convulsions, and other accidents
which endanger the life of the mother. It is used solely with the
view of supplying that power which the uterus does not possess."

Again, " Where there exists a great degree of distortion of the brim
of the pelvis, you may be unable to determine, positively, the distance
between the base of the sacrum and symphysis pubis; and it is not
necessary, for practical purposes, to do so with mathematical accuracy ;
but when it is under two inches and a half, you will readily discover,
if you have had considerable experience, on making the ordinary
examination, from the unusual manner in which the sacrum projects,
that it is impossible for a child at the full period to pass through it.
If labor has commenced at the full period of pregnancy, and you
discover, before it has continued many hours, that the pelvis is greatly
distorted, and that the child can not possibly pass alive, no advantage
can result from allowing the labor to endure till the patient is ex-
hausted, and you are satisfied that the difficulty can not be overcome

DIFFICULT LABOR FROM PELVIC DEFORMITY. 397

by the powers of the constitution. In such a case delay is dangerous,
and there is nothing which can save the woman's life but opening the
child's head with the perforator, and extracting it with the crochet.
But this should never be had recourse to without a regular consulta-
tion of experienced practitioners, and before it has been placed beyond
all doubt, by the most candid investigation, that the delivery can be
accomplished in no other manner, so as to preserve the mother's life.
" In the greater number of cases of difficult labor from a high
degree of distortion of the pelvis, which have come under my observa-
tion, where it has been the first child, the process has been allowed to
go on till the efforts of the patient had been nearly discontinued, or
had ceased entirely, and the favorable period for operating was lost.
In some cases, even when the duration of the labor, and the local and
constitutional symptoms, have made it manifest that such interference
was justifiable and necessary, I have unfortunately delayed too long to
deliver, in consequence of employing the stethoscope, and ascertaining
that the child was alive. In cases of extreme distortion of the brim
of the pelvis the proper practice is, to perforate the head as soon as
the os uteri is sufficiently dilated to admit of the operation being done
with safety, and afterward leaving the patient in labor till the head
has partially entered the brim, and the os uteri is considerably dilated.
There can be no doubt that, in some cases, it is right to interfere
before we certainly know that the child has been destroyed by the
pressure; but we have nothing here to do with the question respecting
the life or death of the child ; our conduct will be biased if we en-
deavor to solve this question. We have only to determine positively,
that delivery is absolutely necessary to save the mother's life, and that
it is impossible for the head of the child to pass, till its volume is
reduced. Pare*, Guillemeau, Mauriceau, Portal, Puzos, Levret, Smellie,
and all the best accoucheurs who have since appeared in Britain, have
performed the operation of craniotomy in many cases of distortion
from rickets and malacosteon, without reference to the condition of
the fetus. ( True religion and the common sense of mankind,' observes
Dr. Denham, ' appear to have nothing contradictory. The doctrine
they teach, of its being our duty to do all the good in our power, and
to avoid the mischief we can, is applicable to the exigencies of every
state, and we may be easily reconciled to it on the present occasion.
In, some cases of difficult parturition, it is not possible that the lives,
both of the mother and child, should be preserved. Of the life or
death of the mother, we can, under all circumstances, be assured: of

398 KING'S ECLECTIC OBSTETRICS.

the life or death of the child, there is often reason to doubt, when we
are called upon to decide and to act. The destruction of the mother
would not, in the generality of cases which may bring the operation
of which we are speaking under contemplation, contribute to the
preservation of the child ; but the treatment of the child as if it were
already dead, with as much certainty of success as is found in other
operations, secures the life of the parent. It then becomes our duty,
and is agreeable to our reason, to pursue that conduct which will give
us the most probable chance of doing good ; that is, of saving one life,
when two lives can not possibly be preserved.'

" 'The only means of effecting delivery/ observes Dr. Collins,
'where the disproportion between the head of the child and the pelvis
is so great as to prevent us reaching the ear with the finger, is by
reducing the size of the head and using the crochet. This is, how-
ever, an operation that no inducement should tempt any individual to
perform, except the imperative duty of saving the life of the mother
when placed in imminent danger. I have no difficulty in stating, that
after the most anxious and minute attention to this point, that where
the patient has been properly treated from the commencement of her
labor; where strict attention has been paid to keep her cool, her mind
asy; where stimulants of all kinds have been prohibited, and the
necessary attention paid to the state of the bowels and bladder ; that,
under such management, the death of the child takes place in labori-
ous and difficult labor before the symptoms bcome so alarming as to
cause any experienced physician to lessen the head. This is a fact
which I have ascertained beyond all doubt by the stethoscope, the use
of which has exhibited to me the great errors I committed bef