'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.
Copyright, 1892, by
THE OHIO VALLEY COMPANY.
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
9
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.
16
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.
17
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.
29
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.
30
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.
31
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.
32
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.
43
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 ^
th
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
48
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
50
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.
51
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.
58
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
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.
61
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.
69
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.
75
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.
85
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
86
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
88
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
8
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 
