(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "The Principles and practice of obstetrics"

This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project 
to make the world's books discoverable online. 

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject 
to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books 
are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. 

Marks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book's long journey from the 
publisher to a library and finally to you. 

Usage guidelines 

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the 
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to 
prevent abuse by commercial parties, including placing technical restrictions on automated querying. 

We also ask that you: 

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for 
personal, non-commercial purposes. 

+ Refrain from automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine 
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the 
use of public domain materials for these purposes and may be able to help. 

+ Maintain attribution The Google "watermark" you see on each file is essential for informing people about this project and helping them find 
additional materials through Google Book Search. Please do not remove it. 

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just 
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other 
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of 
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner 
anywhere in the world. Copyright infringement liability can be quite severe. 

About Google Book Search 

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers 
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web 



at |http : //books . google . com/ 



o 



00 



In 






^ 



tl 



IL^^MBI 



MEapiEm. 




iLiBflaM jiyr 




.N 



li 



THE 



PRINCIPLES AND PRACTICE 



OF 



OBSTETRICS. 



BT 



GUNSlIfG S. BEDFOBD, A.M., M.D., 



or OBtnnioi;, thx DitBAnB of womkh Aim oaiLDBXir, akb cukical oBsnraioi, n 
uvrmuTT o» jnw tobk ; aittbok of ** cuxical uotuus ox thb vmtMMM of 

WOKm AMD OBILDUX." 



inustTBlrl} bg Jout CoIortH l,it^ogrKp()(C 9Istn *n^ Ninrta«n{ur CSooH Sngribingg. 



Mnltom retrtat adhac operis, mnltnmqaa nstabit, tpc alU nato, 
post mille MBoala, pradndetor oocaaio aliqoid adjideuui 

Sexkoa, Lib. 



THIRD EDITION, CAREFULLY RBVISEO AND 




NEW YORK: 

WILLIAM WOOD & CO., 61 WAI.KER STREET. 

1863. 



'■^' 



Entered ftoeording to Aet of CongreM^ In tbe jear eighte«n hnndred and slxty-oae, bf 

GUNNING 8. BEDFORn, 

In the Clerk*! offloe of the District Conrt of the United States for tbe Svatbem District of 

New York. 



B. ORAIOnaADi 

PrbiUr, Stcrrotypcr. eiid Ktcetroiypar, 

Carton Vuiniing. 

81, S3, Mtd 83 CVnfrv StntL 



SiZ 



To 



THE ALUMNI AND STUDENTS^ 



WHO HAYB ATTENDED 



THE AUTHOR'S LECTUEES OX OBSTETEICS IN THE UNIVERSITT OP NEW lOM, 



AMD TO WHOSE UNIFORM COURTESY AND KINDNESS HE IS 80 



GREATLT INDEBTED, 



Vps 9oIttme is ^Sedtonatelg ^tbicakb. 



PREFACE. 



In writing a work on the " Principles and Practice of Obstetrics " 
I Lave had constantly before me one cardinal object — to be 
useful. I have endeavored to present to the Profession a practi- 
cal Book, one which will develop the phenomena of parturition 
in their various phases as they occur in the Lying-in nx^m. The 
anatomy of the Pelvis and Genitalia, and their special bear- 
ings on Parturition, have been dwelt upon with a minuteness 
to which they have a just claim. Abortion, the subject of 
Labor, its Divisions, its Mechanism and Management, its deter- 
mining cause, together with the forces engaged in the expulsion 
of the child, the treatment of the puerperal woman and her 
new-born infant, Flooding both ante-partum and post-partum, 
Placenta Pnevia, Puerperal Fever, Puerperal Mania, Anncsthe- 
tics, have all been considered with the fulness their importance 
demanded. Nor have I neglected the physiological disquisitions 
necessarily involved in the consideration of the numerous ques- 
tions connected with Menstruation, Reproduction, Pregnancy, 
Foetal Nutrition, Puerperal Convulsions, and other kindred 
topics. 

Manual, Instrumental, and Premature Artificial Delivery 
Lave received their share of attention ; they have been discussed 
freely and at length. On the subject of Instruments, I have 
spoken without reserve, and have not failed to raise my voice, 
in the most emphatic manner, in rebuke of what I believe to 
be oftentimes their unnecessary and reckless employment If 
what I have said on this point shall exercise an influence in 



PREFACE. y 

behalf of suffering woman, in the hour of her need, I shall 
indeed be happy. Touching the grave questions of Embryo- 
tomy and the Csesarean section I have suffered my mind to be 
governed by no predilection, but have examined, with the singl< 
purpose of reaching the truth, the substantial evidence both for 
and against these alternatives; my deductions are the results 
of what I believe to be a thorough and impartial analysis of this 
evidence. 

The arrangement of the work is rigidly systematic* the van- 
ous subjects following each other in what I conceive to be the 
proper order of their dependence. In one word, I have had in 
view the wants of the obstetric student; I have endeavored to 
aggregate facts, and dispense as far as possible with theoretical 
discussions. Throughout the work I have maintained strictly a 
Conservative Midwifery, as I have always done — and shall con- 
tinue to do — ^in my oral teachings in the University. It has 
also been my endeavor to inculcate upon the accoucheur a 
due reverence for the resources of nature, so that he may not 
thoughtlessly lapse into that too common error — "Meddlesome 
Midwifery." Among other things, it has been my special aim 
to bring the work fully up to the existing state of Obstetric 
Science in all its varied relations. For this purpose I have dili- 
gently consulted the ablest and most recent authors ; at the same 
time, I have not been unmindful of the obligations of our 
science to the early Fathers. May I presume to hope that the 
Book, both in its matter and arrangement, will not be unaccep- 
table to the general practitioner, or to the Professor of Obstetrics 
himself? 

In reference to the Illustrations, I have consulted quality 
rather than quantity, and have in every case endeavored to 
make them explanatory of some important practical lesson. 
"With this view, I have not hesitatc4^ where it could be done 
with advantage, to avail myself of the graphic delineations by 
Maygrier, Moreau, Montgomery, and others. The engravings, 
representing Forceps delivery, are the Daguerreotypes of my 
instnictions on this subject in the University, and I trust they 
may convey accurate rules for guidance on this impoilant and 
interesting part of the Accoucheur's duties. 



Vi FBEFACE. 

In order to facilitate the object of the reader, and place 
promptly within his reach the numerous subjects discussed in 
the volume, a Table of Contents, and, in addition, a full and 
carefully prepared Alphabetical Index have been provided. I 
have also added a list of authors to whom reference has been 
made, and this will give some indication of the labor expended 
on the work. 

The Book itself embodies ample internal evidence of failure 
or success in the accomplishment of the objects proposed. If 
that evidence, under a fair examination, shall lead to the decision 
that the design has not been carried out, it will be to me a 
source of the deepest regret. If, on the contrary, it shall be my 
good fortune to have my efforts approved by the Profession, 
then I shall be abundantly repaid for my labor, and may, with- 
out arrogance, exclaim — " Nee EgofmsiraP 

In conclusion, I cannot but cherish the hope that if this Volume 
should fall into the hands of some of my numerous pupils, residing 
in various portions of this and other countries, it may serve to 
awaken old associations, and bring back to memory the many 
happy hours we have spent together in the lecture-hall; and 
may these words be accepted as proof that their preceptor 
continues to entertain for them feelings of deep interest and 
altection. 



Vsw Toms, 66 Firm Amnm, 



PREFACE 

TO THE SECOND EDITION. 



An Author can covet no richer compensation for his labors 
than the endorsement of his Peers. It would, therefore, be 
aflTectation in nie to attempt to conceal the pleasure I experience 
in being thus early called upon for a Preface to the Second 
Edition of the ^^Prindplea and Practice of ObstetricsJ*^ But 
a little over four months has elapsed since the book was first 
issued from the Press. In view of the unhappy and disturbed 
condition of the country, and the consequent derangement of 
commercial as well as of scientific pursuits, I have, indeed, good 
cause for self-congratulation ; and I avail myself of this occasion 
to return my cordial thanks to the Profession for the counte- 
nance, which they have so promptly extended to my eiForts. 
The eulogistic notices of the Medical Press — both home and 
foreign — ^have imposed upon me an obligation not soon to be 
forgotten — an obligation I can cancel in no other way than by 
the pledge, that it shall be my earnest care to endeavor to 
render myself still more worthy of its good opinion. 

The present edition has undergone a thorough revision ; 
numerous verbal and typographical errors, more or less incident 
to a first issue, have been corrected. I again submit the work 
to the Profession, not without hope that it may continue to 
have awarded to it the seal of their approbation. 

Miroh, 1862. 



PREFACE 

TO THE THIRD EDITION. 



Again has the grateful duty devolved on me of returning 
thanks to the Profession for the continued — and I hope I may 
say without egotism — unexampled patronage extended to the 
" Principles and Practice of Obstetrics!'^ It is now but thirteen 
months since the book was first presented to the world, and my 
Publishers admonish me that a Third Edition is called for. To 
say that its reception is beyond my most sanguine hopes, and 
that I am deeply impressed with a sense of the obligation im- 
posed by this prompt recognition of my labors, would be but 
the reiteration of a self-evident truth ; and I may add, that both 
the pleasure and obligation are greatly enhanced by the fact 
that, in the short period which has elapsed since the work was 
issued from the Press, it has already been recommended as a 
Text-Book in nine of our medical colleges. What greater honor 
can an Author claim at the hands of his Peers — what higher 
incentive to future effort! These influences, if my life be 
spared, shall not be lost upon me. Again, also, I have most 
cordially to thank the Medical Press, here and abroad, for their 
continued commendatory and flattering notices. 

This Edition has been carefully revised and enlarged ; besides 
additions to the Text throughout the volume, it will be seen 
that a lecture on Phlegmasia Dolens has been incorporated. 

New York, 66 Fifth Avenue, Dec. 1862. 



CONTENTS. 



LECTURE I. 

POSITION AND BONES OF THJB PEJiYIS. 

Ifidwiferj an Exact Science— The Passage of the Child through the Maternal 
Organs is founded on the Principle of Adjustment — The Pelvis ; the Position it 
occupies in the Human Skeleton — Importance of its Position in Childbirth — The 
Direction of the Pelvis; its Variations — Bones of the Pelvis in the Adult and 
Foetus — Sacrum, CoocyZf and the Two Innominata — Auterior Sacral Plexus of 
Nerves ; its Influence in the Production of Numerous Pathological Phenomena — 
The Os Coccyx; its Importance in Childbirth — Dislocation of the Coccyx — 
Fracture of the Coccyx — ^The Spinous Process of the Ischium — How, when mal- 
ibrmed, it may interfere with the Process of Delivery i 

LECTURE II. 

USES, ABTICULATIONS, AXES, AND DIVISIONS OF THE PELVIS. 

Uses of the Pelvis — Articulations, or JointA of the Pelvis — Do these Articulations 
during Pregnancy become Relaxed ? — Is their separation necessarj', at the time 
of Labor, for the passage of the Child ? — Objections to the Theory of Separation 
— Pathological Changes in these Articulations— Form o! tlie Pelvis — The Greater 
and Lesser Pelvis — Straits ot the Pelvis— The Pelvis is a Crooked Canal ; Proof 
— Axes — Varieties of the Human Pelvis— Influence of Sex and Age — Contrast 
between the Male and Female Pelvis — Pelvis of the newborn Infant — The Pelvis 
in Connidxion with the Soft Parts — Its Measurements. . . - 12 

LECTURE III. 

DIVISIONS AND PRESENTATIONS OF FCBTAL HEAD. 

Foetal Head; its Regions, Diameters, Circumferences, Extremities, Sutures, Fonta- 
nelles — Sutures of the Adult and Foetal Head contrasted — Arch and Base of 
Foetal Head — The former undergoes Diminution during Childbirth, the latter does 
not ; Reasons for — Contrast between Diameters of Foetal Head and those of 
Maternal Pelvis — Deductions — Articulations of Fcetal Head — Two Movements, 
Extension and Flexion — Rotation. Presentation of Foetal Head; its relative 
Frequency — Presentation of Vertex— Circumstances which modify the Frequency 
of Head Presentations — Causes of the Frequency of Head Presentations — Differ 
epce between Presentation and Position— Six Positions of the Vertex by BaMde- 
locqne— BaLiiir^ Frequency oftbeee Foaitioua — NaSgeld's Division. . . • YI 



X CONTENTS. 

LECTURE IV. 

MECHANISM OF LABOR IN VERTEX PRESENTATIONS. 

Mechanism of Labor — Its Importance — Mechanism in the first Vertex Position — 
Left Occipito-acetabular— Position of the Fcetus— Relations of the Head to the 
Pelvis— Necessity for a Change in these Relations— Movements imposed upon the 
Head— Flexion, Descent, Rotation, Extension, and External Rotation— Object 
and Causes of these Movements — Proof that these Movements occur — Gerdy's 
Explanation of External Rotation — Mechanism in the Second Position — Right 
Oocipito-acetabular- Mechanism in the Third Position — Right Posterior Occipito- 
iliac, the Second in Frequency, according to Naegeld — Conversion of the Poste- 
rior Occipital into Anterior Occipital Positions — How this Conversion is accom- 
plished — Mechanism in the Fourth Position— Left Posterior Occipito-iliac— Ne- 
cessity of an accurate Knowledge of the Principles on which the Mechanism of 
Parturition is founded — ^The pracUcal application of this Knowledge at tlie 
Bedside 44 

LECTURE V. 

DEFORMITIES OF THE PELVIS. 

Pelvic Deformities, how divided— Evils of Increased Capacity — Case in Illustration 
— Dangers of Increased Capacity during Pregnancy and Labor— Diminished 
Capacity— Dangers of— Varieties of Pelvic Defonnities — Causes of — Rachitis, 
MolUties Ossium— Distortion of Spinal Column does not necessarily cause Distor- 
tion of Pelvis. Obstructed Labor from Polypus— Removal of Polypus, and subse- 
qu(*nt Delivery of Child by Forceps — Pubic Arcade — Congenital Deformity of— 
Craniotomy — The Space through which a Living Child can pass — Experiments 
of the Author — Discrepancy of Opinion among Writers— The Space through 
which a Child mny be extracted by Embryotomy. How to ascertain that Defor 
mities exist — In tlie young Girl — In the married Woman. Measurements of the 
Pelvis — Baudelooque's Pelvimeter — How employed — Its reliabilities — Objections 
answered. The best Pelvimeter, the Finger of the well educated Accoucheur — 
The " Toucher** — How conducted. . • 67 

LECTURE VI. 

ORGANS OF GENERATION. 

Organs of Generation — External Organs — The Mens Veneris, Iiabia Externa, Clitoris, 
Labia Interna, Vestibulum, Meatus Urinariua. and Uretlira — Secretory Apparatus 
of the External Organs — Sebaceous and Muciparous Follicles — Vulvo- vaginal 
Gland — ^Tlie Internal Organs — The Vagina, its Anterior and Posterior Relations 
— ^The Urethro-vaginal, Ve^ico-vaginal, and Recto-vaginal Septa — Vesioo-vaginal 
and Recto-vaginal Fistula; — How produced — Orifice and Superior Extremity of 
Vagina— The Hymen, its Absence no Test of Loss of Virginity — Its Presence no 
Evidence that Sexual Congress has not occurred— Retention of Menses mistaken 
fi>r Pregnancy — Blood-vessels and Nerves of Vagina — Uterus, Uses and Situation 
of— How divided— The Structure of Uterus composite — External and Internal 
Coat— Intermediate Tissue is Muscular— Is the Utems an Erectile Organ?— 
Bouget*8 BesMTches— Blood-vessels, Nerves, and LymphaUos of Ul«ni0— Recto- 



CONTENTS. XI 

uterioe Fossa, Importance of— Ligaments of Uterus— The Cervix, its Peculiaritiea 
before and after Pubertjr^Os Tines, Cicatrices upon, not alwa/s reliable as evi- 
dences of CbildbiPth^The FaUopian Tubes— The Ovaries, the Essential Organs 
of Generation — Structure and Uses of the Ovaries. 79 



LECTURE VII. 

MENSTRUATIOK. 

Functions of tne Uterus and its Annexse— Essential to Health, but not to Life- 
Forces in the Female Economy two-fold — Proof— Uterine Organs before and after 
Puberty — Indications of Puberty — Menstruation — Meaning of the Term— Age at 
which First Menstruation occurs— Influences which Promote and Retard it— Girls 
in the Country contrasted with those in the. Cily — Influence of Race on the Men- 
strual Function — Menstruation in young Children — Tardy Menstruation— Cause 
of Menstruation — Conflicting Opinions — The Menstrual Function dependent on 
Organic Development — Menstruation does not consist in the Discharge of Bloody 
but in the Maturity of the Ovules — Ovular Theory — Dr. John Powers's Claim — 
Periodicity of Menstruation — How explained — Is the Menstrual Fluid an Kxuda> 
tion, or Secretion? — Is it Blood?— Does it escape by Endosmosis? — The Source 
of the Menstrual Discharge, and its true mode of escape — Menstrual Blood in the 
Uterus and Vagina — Diflerence between— On what the Diflerenee ia depen- 
dent — Duration of each Menstrual Period, and Quantity Lost — Is Menstruation 
peculiar to the Human Female? — General Properties of the Menstrual Dis- 
charge — Period of Final Cessation— Why called the Critical Period — Aptitude 
in the Female for Impregnation — Case of Catherine de' Medici — Early Marriages 
in India 92 



LECTURE VIIL 

REPRODUCriOX. 

Reproduction — Its Importance and Necessity — Early Opinions concerning — Meambg 
of the term Fecundation ; in what it consists — Reproduction the Joint Act of both 
Sexes — The Female furnishes the " Germ-cell" — The Ovisac or Graaffiau Vesicle — 
Membrana Granulosa— Discus Proligerus — Zona Pellucida — Germinal Vesicle- 
Germinal Spot — Modifications in the Ovisac previous to its Rupture — Corpus 
Luteum — "Coagnlum" does not contribute to its Formation — Corpus Lufcnm not a 
Permanent Structure — True and False Corpora Lutea — Former connected with 
Pregnancy, Latter with Menstruation — Characteristics of each — True Corpus 
Luteum an Evidence of Gestation, but not of Childbirth— Can two " Germ-cells" bo 
contained in one Ovisac?— The Male Vivifies the " Germ-cell" — Spermatozoon, the 
True Fertilizing Element — What are the Spermatozoa ? — Contact between '* Sperm- 
cell" and "Germ-oell" necessary for Fecundation— How accomplished — Opinions 
oonoeming — Aura Seminalis — Electrical and Magnetic Influence — Doctrine of the 
Animalculists — Chemical Hypothesis— Mr. Newport's Experiments on tlie Frog — 
Deductions — Where does this Contact take Place ? — Experiments- of Bischoff and 
Valentin— Theory of Pouchet— Movements of Spermatozoa— Deductions from 
Analc^\— Experiments of Nuck and Haighton— -Fimbriated Kzlremity of Fallo- 
(iu Tabe»— Peculiarities oC \^' 



3U1 CONTENTS. 

LECTURE IX. 

DEFINITION AND DIVISIONS OP PREGNANCY. 

Pregnancy ; Definition and Divisions of — Is Pregnancy a Pathological Condition f — 
The Uterus and Annex» before and after Fecundation— Two Orders of Pheno- 
mena following Impregnation ; Physiological and Mechanical — IIow the Uterus 
Enlarges — Microscope and its Proofs — Development of the Muscular Tissue of the 
Uterus ; how accomplished— Solid Bulk of Uterus at Full Term— Meckel's Esti- 
mate — Increase of Blood-vessels, Lymphatics, Nerves, and other Tissues of Uterus 
— Nausea and Vomiting ; how produced— Influence of Nausea and Vomiting on 
Healthy Gestation ; the Explanation of this Influence — Blood — how Modified by 
Pregnancy — Is Plethora characteristic of Gestation 7 — Cause of this Hypothesis — 
Treatment of Acute Diseases in Pregnancy — Aphorism of Hippocrates on this 
Question — Increase of Fibrin in Inflammation — Deductions — " Buffy Coat" not 
always the Product of Inflammatory Action — " Bufiy Coat '* in Chlorosis, Preg- 
nancy, etc. — Kiestine ; what its Presence indicates — Blot's Experiments — Sugar 
in the Urine of the Puerperal Woman — Deductions — How are we to know that 
Pregnancy exists? Importance of the Question; its Medico-legal bearings; Illus- 
tration — The Proof of Pregnancy altogether a Question of Evidence ; how this 
Evidence sliould be examined. 131 

LECTURE X. 

SIGNS OP PREGNANCY. 

Ekridences of Gestation ; how divided ; their Relative and Positive Value — Suppres- 
sion of the Catamenia — Can a Pregnant Woman Menstruate? — Nausea and 
Vomiting material to a Healthy Gestation — Depraved Longings — Salivation of 
Pregnancy; how distinguished from Mercurial Salivation — Salivary Glands in 
Connexion witli the Mammjc in the Female, and the Testes in the Male — Sym- 
pathy between ; Illustration — Parotitis — Mammary Changes— Secretion of Milk 
not always dependent upon Pregnancy — Milk in the Breast of the Virgin, and in 
the Male— Mammary Metastasis — Illustration — The Areola; its Value — Color 
not its Rsj*ontial Attribute— Depo?it of Black Pigment and Excitement of the 
Sexual Organs — Connexion between — ^Tho True Areola; its Value — Areola 
around tlio Umbilicus — Discoloration of Integument between Umbilicus and 
Pubes — Dr. Montgomery's View of Areola — Can Pregnancy exist without the 
Areola? — Changes in Uterus and Abdomen — First two Months of Gestation, 
Uterus descends into Pelvic Excavation — Consequences — ^Vesical Irritation — 
Pain and Depression of Umbilicus ; how Explained — Impregnated Uterus at end 
of third Month— Gradual Ascent of the Organ — Right Lateral Obliquity — Pain 
in Right Side; how Explaired- Uterus at end of eighth Month — Cough and 
Oppressed Breathing; Reasons for— Projection of Umbilicus; its Value as a 
Sign of Pregnancy— Uterus at end of ninth Month — Contrast with eighth Month 
— ^Ascent of Organ in Primipara and Multipara ; Difference Explained— Bladder 
«Dd Urethra ; Change in Position — Thrombus of Vagina and Vulva — (Edema of 
TiOwer Extremities ; how accounted for. 143 

LECTURE XI. 

SIGNS OF PREGNANCY, CONnNUKD. 

ErlAenees of Pregnancy continned— -The Bffect of Fecundatk>n on Development of 
UteniB — Order of Development — ^Fundus enlarges first three Months— Body torn 



CONTENTS. Xlll 

third to sixth Month — Wisdom of this Arrangement — Shape of Impregnated 
Uterus— Modifications of Cervix in Pregnancy — Error of certain Authors- 
Uterine and Vaginal Extremities of Cervix — Cervical Canal — Relaxation ol 
Tissues of Cervix — Cervix does not Lengthen — Error of Madame Boivin — Promi- 
nence of Oa Tincae— Softening and Moisture — Mucous Follicles— Development of 
— Increased Mucous Secretion not a Pathological State— Uses of this Secretion — 
Cervix begins to shorten at its Uterine, and not at the Vaginal Extremity — 
Proof — Opinions of Stoltz and Cazeaux — Placenta Pnevia and Shortening of Cer- 
vix — Mod ideations of Cervix in Primipara and Multipara — Increased Development 
or Uterine Appendages in Pregnancy — How does the Cavity of the Uterus 
enlarge? — Ancient Theory — Increased Nutrition the true Caus&— Thickness of 
Utenne Wails: Opmions respectmg — Os Uteri at Time of Labor — Discoloration 
of Vagina as a sign of Pregnancy — Is ttiis Discoloration peculiar to Preg- 
nancy? 163 



LECTURE XII. 

QUICKENING, BALLOTTEMENT, AND PLACENTAL SOUFFLE. 

Evidences of Pregnancy continued — Quickening — Ancient Theory — Law of England 
in regard to Quickening — What is Quickening? — Opinions of Authors — Nervous 
and Muscular Development — Muscular Contractions of the FcBtus — Sensible and 
Insensible Muscular Contractions — Quickening not a Psychical Act, but the result 
of Excito-motory Influence — Spinal System — Its Physiological Importance — 
When does Quickening take Place ? — Does not always Occur — Delusive Quickening 
— Illustration — Contraction of Abdominal Walls mistaken for — Final Cessation of 
Menses and Supposed Quickening — Attempted Imposition — Queen Mary of Eng- 
land — Manipulations to Detect Quickening — Influence of Cold on Movements of 
Foetus — Illustration — ^Ballottement or Passive Movement of Foetus — Rules for 
Detecting — Positions of Foetus and Ballottement — Pulsations of Foetal Heart — 
Auscultation — Mayor of Geneva — Average Beats of Foetal Heart— Not Synchro- 
nous with Maternal Pulse — Auscultation, how Applied — Auscultation and Position 
of Foetus — Twin and Extra-uterine Pregnancies— How ascertained — Placental 
Souffle — Uterine Murmur — Kergaradec — Conflict of Opinions — Souffle not always 
Dependent upon Pregnancy — Uterine and Abdominal Tumors ; Cause of— Souffle 
no Evidence of Life of Foetus — Pulsations of Umbilical Cord — Dr. Evory Ken- 
nedj. 176 



LECTURE XIII 

EXAMINATION OF THE FEMALE. 

Examination of the Female to Ascertain the Existence of Pregnancy — ^The Thre& 
Senses, Feeling, Seeing, and Hearing, to be employed — The "Toucher;" what is 
it T — External Abdominal Examination ; its Objects ; how to be conducted — Va- 
rious Causes of Uterine Enlargement; how to be distinguished — Examination per 
Yaginam ; Rules for — The Vagina ; its Position and Relations — Position of the 
Female— Relation of the Vagina to the Cervix Uteri— Examination per Anum ; 
when indk»ted— Retro- Version of Uterus — Prolapsion of Ovary into Triangu^ai 
F oc a a Y minMl OvBriotomf-^Auscultation^The Metroacope; itaUsea. • \d% 



XIV CX)NTENTS. 

LECTURE XIV. 

EZTBA-UTEBINE PREGNANCY. 

BSxtra-uterine Pregnancy; its Varieties — Ovarian, Fallopian, Abdominal, and 
Interstitial — Characteristics of eacli Variety — Causes of Extra-uterine Pregnan- 
cy — Opinion of Aslruc— Objections — Progress and Phenomena of Extra-uterine 
Pregnancy — Placenta and Membranes ; tlie Germ inclof«ed in a Cyst — Exponent of 
the Uterus ; Cyst ; how formed — Cyst affords no Outlet for Foetus— Rupture of 
Cyst from Increased Growth of Fostus — iicmorrhage; how Produced — Enlarge- 
ment of Uterus — Extra-uterine Fcetation rarely extends to the Fifth Month — 
Exceptional Cases — Secondary Cyst; how Formed— Signs of Extra-uterine 
FoBtation — Areola and Tumefaction of Breasts — Illustration — Active Movement 
of Foetus; Cardiac Pulsations — Malpositions of Uterus from Position of Cyst — 
Intermittent Pain in Extra-uterine Gestjition— Dangers of this Variety of Gesta- 
tion — Hemorrhage firom Rupture of Cyst — Peritoneal Inflammation— Termina- 
tions of Extra-uterine Pregnancy ; Treatment— Gastrotomy ; when Performed — 
Gastrotomy and Csesarean Section — Fearful Hemorrhage in the Former ; why — 
Section of Vagina — Elimination of Foetus ; how aided. 203 

LECTURE XV. 

THE OCCASIONAL DERANGEMENTS ACCOMPANYING PREGNANCY. 

Pregnancy, although not a Pathological State, is occasionally subject to Derange- 
ments — These Derangements are both Physiological and Mechanical; Illustration— 
Dogmatical Doctrines of the Ancients in regard to the Therapeutics of Pregnancy — 
Bloodletting in Pregnancy; when Indicated — Cathartics and Emetics; are they 
admissible? — Nausea and Vomiting; how Treated — When Excessive— Ptyal ism — 
Constipiition — How Constipation is caused in the Pregnant Femaile; in part 
through Morbid Nervous Influence; in part fh>m Mechanical Pressure— Diarrhoea; 
its Dangers — Palpitation of the Heart and S.\ ncopo — Larcher's Opinion respecting 
Hypertrophy of the Heart— Pain iu the Abdominal Muscles ; how Treated — Pain- 
ful Maminee — Pain in the Right Hypochondrium — Pruritus of the Vulva ; Hemor- 
rtioids; how Produced — Varicose Veins — Cough and Oppressed Breathing. . 216 

LECTURE XVI. 

DISPLACEMENTS OP UTERUS IN PREGNANCY. 

Complications of Pregnancy from Displacements of the Uterus — Prolapsion, Ante- 
version and Retro-version of the Organ — Three Varieties of Prolapsion— Evils and 
Treatment of these Varieties— How Direction of the Urethra is Modified — Rules 
for Introduction of Catheter — Ante- version, Symptoms and Treatment of — Retro- 
▼ersion more frequent than Ante-version — Complete Retro-version occurs only 
during earlier Months of Gestation — Occasional Serious Consequences of tiiis Form 
of Displacement — Premature Labor sometimes the Result of Retro-version — Diag- 
Boeis of Retro- version — How determined — Symptoms — Retention of Urine — Punc- 
ture of Bladder, first proposed by Sabatier — Treatment of Retro- version— Plan of 
Bvrat. Halpin, and Gariel — Retro-version often mistaken for other Pathological 
Conditions — Prolapsion of Ovary in Triangular Fossa, and Fssoee in the Rectum— 
How distinguished from Retro-versioQ — Hernia of Gravid Uterui. .... 933 



CONTENTS. XV 

LECTURE XVII. 

PLACENTA AND ANNEXiB OF FCETUS. 

The Annexffi of tlie Foetus ; The Decidua — ^Hunter's Theory of its Formatloii ; The 
Decidua, an Hypertrophied Condition of the Uterine Mucous Membrane — The 
Reflexa ; how formed — Costers Views— Uses of the Decidua — ^The Chorion and 
its VilU — ^The Uses of each — Nourishment of the Embryo through the Villi— 
Professor Groodsir — The Amnion ; its Uses — The Liquor Amnii : Origin of— Is it 
derived from Mother or Foetus? — Casts of the Uriniferous Tubes found in 
Liquor Amnii — Uses of Liquor Amnii — Various — Does it contribute to Nourish- 
ment of Foetus? — ^The Placenta — Peculiar to the Mammiferous Class — How 
Divided, and Dimensions of— Two Circulations in Placenta — Distinct and Inde- 
pendent — Red Corpuscles — Difference in Size of in Foetal and Maternal Blood — 
When does Placenta begin to Form ? — What is the Connexion between Placenta 
nnd Uterus ?— Do the Blood-vessels of the * Mother penetrate the Placenta ? — 
Hunter's Opinion confirmed by Dr. Rcid and Professor Goodsir — Professor Dalton, 
his Injection of the Utero- Placental Vessels by Air — Fatty Degeneration of the 
Placenta — Is it Normal or Pathological ? — The Umbilical Cord ; how Composed — 
Its Usee — Nomenclature of the Anatomist and Physiologist— Difference between — 
Variations in Volume and Length of the Cord — Twisting of the Cord around the 
Foetus — Dr. Weidemann's Statistics of— Does the Cord possess any Trace of 
Nervous Tissue— Dr. Simpson on Contractility of the Cord — ^Scanzoni's Opmion — 
Virchow. 241 



LECTURE XVIII. 

NUTRITION, GROT\TH, AND DEVELOPMENT OF PCKTUS. 

Nutrition, a fundamental law of life — Objects of Nutrition ; Growth and Develop- 
ment — Development physiologically considered — Nutrition of Embryo; various 
Opinions concerning — Yolk Nutrition — Nutrition through Villous Tufts — Liquor 
Amnii; has it nutrient properties? — Does it enter the System of the Foetus by 
Cutaneous Absorption or Deglutition? — The Placenta and Foetal Circulation — 
Adult Circulation ; how it differs from that of the Foetus — How is the Impure 
Blood, returned by the Umbilical Arteries, decarbonized in the Placenta? — Endos- 
mose Action — Albumen cannot pass by Endosmosis; Opinion of Mialh(^ — Albu- 
minose — Influence of Parent upon Progeny — Transmission of Hereditary Disease — 
•Change in the Circulation as soon as Respiration is estabUshed — Puer Cajruleus — 
Does the Foetiw Breathe in Utero? — ^Intra-uterine Respkation not Essential to 
Development or Life of Foetus 254 



LECTURE XIX. 

ABORTION, 

Abortion— Its frequency — Loss occiision^d by it to the Human Family — Dr. White- 
head's Statistics— The Various Divisions of Abortion— Viability of the Foetus — 
The Case of Fortunio Liceti — At what Period of Gestation is a Female most 
likely to Abort?— The Opinion of Madame La Chapelle— Not sustained by 
general Facts— Abortion more frequent in the Primipara — Why? — Reflex Action 
—Whytt—Reid—Prochaska— Marshall Hall— Concentric and KccohItk ^w^oxia 



XVI CONTENTS. 

Influence— What does it mean ?— Kccentric Causea of Abortion— Hemorrhoidal 
StTRDguiy, Tenesmus, Sea-bathing, eta — How do they Produce Abortion ? — Irrita- 
tion of the Mammw and Premature Action of the Uterus — Cause and Effect^ 
How explained— Lactation, its mfiuence on early Contractions of the Uteru»— 
Gentrio Causes of Abortion — Antemia and Abortion — Exsanguiflcation and Con- 
rulaions— Experiments of Sir Ciiarles Bell and Marshall Hall — Experiments and 
Deductions c^ Dr. E. Brown-Sequard — Mental Emotions, Syphilitic Taint, Death 
of the FoBtua, all Causes of Abortion — Disease of the Placenta and Abortion — 
Abortion sometimes the Result of Habit — Phenomena of Expulsion in Abortion 
—The Pain and Hemorrhage of Abortion — How distinguished — Treatment — 
How divided — The Application of Cold — Its Mode of Action in Arresting 
Hembrrhage — Tampon and Ergot — When to be Employed — Two-fold Action of 
Tampon. — Extracting Placenta in Abortion— Exhaustion irom Hemorrhage — 
How Treated — Laudanum, its Efficacy in Exhaustion 266 



LECTURE XX. 

MOLAR PREGNANCY. 

Moles — Importance of the Subject — Moles variously Classified — Mauricoau's Defini* 
Hon — ^The Opinion of Femel - Practical Division of Moles — The True Mole always 
a Proof of Previous Gestation — Distinction between True and False Mole first 
made by Cruveilhier — Mcttenheinier and Paget on True Mole — Dr. Graily Hewitt 
— Case in Illustration of a True Molo— Can a Married Woman, if separated from 
her Husband since the Birth of her Cliild, or can a Widow, Discharge a True 
Mole from the Uterus consistently with lier Fidelity ?— False Moles, what are 
they ?— Substances expelled from tlio Womb of tlie Young Virgin — Fibrinous 
Clots — The Membrane of Congestive Dysmenorrhoea — The Hon lays an Epfg 
without the Tread of the Cock — Does tlio Membraua Decidua pass off at each 
Menstrual Period, or is it simply the Epitholial Covering?— The Testimony of 
Lamsweerdo, Ruysch, and Van Swieten as to the False Mole — The True Hyda- 
tids — Can they be produced in the Virgin Uterus?— The Case cited by Rokitan- 
sky — Importance of tlie Question — How are the True Hydatids to be distin- 
guished from the Hydatiform Vesicle ? 383 



LECTURE XXI. 

LABOR AND DURATION OF PREGNANCY. 

Labor —Multiplied and Unprofitable Divisions of; Classification of the Author into 
Natural and Preternatural ; Labor consists of a series of acts — IniporUmt Practi- 
cal Deduction connected witli this Succowsion of Phenomena ; Duration of Preg- 
nancy — When doesitTenninatuf— The Original Mode of Calculating Time- Calen- 
dar and Limar Months — Has Pregnancy a Fixed Duration? — The Gardner 
Peenige Cose — Coufiiciing Opinions; Testimony of Desormeaux — The C<Hle Na- 
poleon in reference to Turdy and Premature Births; Kxperiments of Teaaier* 
Tropical Heat and Vetfctation — How is the Period of Pregnancy to be ascer- 
tained ? — The various Modes of Calculation — Dr. Reid's Experiments in reference 
to A Single Coitus ; Xaijgele's Opinion ; Dr. Clay, of Manchester — Influence of ihe 
Age of the Parent on ihe duration of Pregnancy — Can a Female be Fecundated 
during lier Menstrual Period ? — Case ui Illustration. 2U6 



CONTJBNT& XTU 

LECTURE XXII. 

DKTBBlflNING OXVSR OF LABOB. 

Determiiiiiig Cwue of Laboiw-Meaning of the Term ; The BzfmlsiTe Forces— {Hi- 
BM17 end seoondMrj; Detennining Cause referred by some to the Foetusi by 
others to the Utems ; Opmion of Boffon with regard to the agenoj of tlie Foetus ; 
Ancient Doctrines; Utems the true Seat of the Detennining Cause of Parturi- 
tion; Antagonisro between kuscuUir Fibres of Body and Neck of Uterus; Change 
m Btmctore of Decidua and Placenta, as alleged by Prof. Simpson ; HaUer's 
Theory of the Decadence of the PUicenta; Objections to the Theory ; Dr. Brown- 
8^Qard*s Theory-<^arbontc Acid the Stimulant to Kusoular Contraction ; The 
Doctrine of Ovarian Nisuw, as propounded by Cams, Mende, and Dr. Tyler 
Smith; Objectioas to the Doctrine; Is Menstruation Peculiar to the Human 
Female? The Theory of Dr. John Power, adopted by Paul Dubois^ of Paris; 
Objections to the llieory; Explanation of the Author as to the Determining 
Cause of Labor ; Modifications in Structure of Uterus at Close of Gestation ; 
Peristaltic Movement of Uterine Muscular Fibre; Inherent Contractions; These 
Inherent Contractions independent of Nervous Force — Proof; Connexion between 
Inherent Contractions and Matured Development of Muscular Structure of Uterus; 
Irritability of Muscular Tissue of Uterus increases as Pregnancy advances — 
Deductions from this Fact; Modifications in Structure of Uterus after Child-birtili; 
Diminution of Musoulo-fibre Cells ; Fatty Degeneration, a Natural Change in 
certain Structures after they have completed their Functional Activity — sometimes 
• Pathological Result 309 

LECTURE XXIII. 

EXPULSIVE FOBCHS IN PARTURITION. 

Seat and Origin of the Expulsive Forces in Parturition— How these Forces are 
Modified — Spinal Cord — Its Influence— Parturition in part an Excito-motory Act — 
Exdtore of Reflex Action in the Uterus — ^What are they? — Difference in Uterine 
Contraction due to Inherent Irritability and Nervous Force — What is it that causes 
the Diaphragm and Abdominal Muscles to Contract as a Secondary Aid in La- 
bor f — ^The Contraction of these Muscles is not always an Act of Volition ; it is 
sometimes Reflex — Signs of Labor — Importance of— The Signs of Labor divided 
into Preliminary and Essential, or Characteristic — ^What are the Preliminary? — 
What the Essential Signs? — Labor Pain , how Divided? — Is Pain the Necessary 
Accompaniment of Parturition ? — What is the true Explanation of Labor Pain ? — 
Is it identical with Uterine Contraction, or is it the Result of Contraction ? — 
Change in the Physical Condition of the Uterine Muscular Fibre under Contrac- 
tion ; Deduction — ^True and False Labor Pain ; how Discriminated — Dilatation of 
Os Uteri; how Produced — Rigors and Vomiting during Dilatation; What do 
they Portend?- The Muco-Sanguineous Discharge during Labor; how Pro- 
duced — Formation and Rupture of the "Bag of Waters;" how the Formation is 
Accomplished — ^Usee of the " Bag of Waters " during Childbirth — Caution against 
its Premature Rupture— The '' Caul or Hood ;" What does it mean 7 . . . 321 

LECTURE XXIV. 

NATURAL LABOR. 

STatnral Labor: Conditions for — ^What is required on the part of the Mother ; what 
on the part of the Fcetos— Hippocrates and Head PrMentatioDS in Ij^aiural Lftboft \ 

B 



xrm OONTfiKTS. 

Fallacy of his Opinion— «Face Presentations in Katnral Labor; Mechanism of-^ 
Diagnosis of Face Presentations ; may be Confounded with Presentations of the 
Breech— Face Presentations in Dublin Lying-in Hospital — Error of Writers with 
regard to Version and Forceps Delivery in Face PresenUtions— Presentation of 
the Pelvic Extremities ; the Breech, Feet, and Knees— Opinion of Hippocrates ; 
his Direction for bringing down the Head in tliese Presentations — The Practice of 
A. Petit, Bounder, and others — Presentation of the Pelvic Extremities and Natu- 
ral Labor — Dr. Churchill's Statistics — Statistics of Dr. Collins ; Deduction — Dr. 
Hunter on Management of Breech Presentations — Diagnosis of these Presenta- 
tions ; may be Confounded with those of the Shoulder ; Prognosis — Are Breech 
Presentations necessarily Destructive to the Child ? — Do they in any way Com- 
promise the Safety of the Mother ? — Mechanism of Breech Presentations — Pre- 
sentation of the Feet ; Diagnosis and Mechanism of— Presentation of tlie Knees ; 
Diagnosis and Mechanism oC 387 



LECTURE XXV. 

DUnSS OP THE ACCOUCHEUR IN NATURAL LABOR. 

The young Accoucheur's Debut in the Lying-in Chamber — What he is to do, and 
what he is not to do ; his Cliat with the Nurse — The Examination per Vaginam ; 
how it is conducted, and wliat it should reveal — Is tlie Patient Pregnant? — Is 
she actually in Labor ? — Are the Pelvis and Soft Parts Normal or otherwise ? 
A Woman may imagine herself in Labor, and yet not be Pregnant; Illustration — 
What is the Presentation of the Foetus? — Is it Natural or Preternatural ? — What 
will be the Duration of tlio Labor ? — How this question is to be answered-^ 
When Labor has commenced, the Bowels and Bladder to be attended to— Quietude 
of the Lying-in Woman important; Loquacity of the Nurse — The Stages of 
Labor ; what are they f — Conduct of the Accoucheur during each of these Stages 
— After the Escape of the Head, Rule to be followed — ^When the entire Expul- 
sion of tlie Ftjetus is completed, important rule to be observed — ^How many Liga- 
tures are to be applied to tlie Cord f — ^Tho Author recommends but one — Reasons 
for — Trismus Nascentium, and Inflammation of the Umbilical Vessels ; Scholer's 
Opinion — When the Child is separated from the Mother, what is to be done f — 
Respiration of the Infant; Causes which Impede it — Asphyxia; Causes of— 
Treatment of Asphyxia — Marshall Hall's Metliod — Ability to resist Asphyxia 
greater in the New-Bom Infant than in the Adult— The Opinion of Brachet, of 
Lyons, Josat, and others, as to the Restoration of Life some time after the Pulsa- 
tions of the Heart have ceased — Death of the Mother not necessarily Fatal to 
•FcBtusin Utero; Why? — Brown-Sequard's Experiments. 851 

LECTURE XXVI. 

MANAQEMRNT OF THE PLACENTA. 

The Third Stage of Labor ; Expulsion of the Placenta— Mismanagement of Pla- 
centa— Dangers of— Function of Placenta, limited to a Certain Period— Natural 
Detachment of Placenta; How effected— What are the Evidences that the 
Detachment is going onf What that it is Accomplished ?— The Mode of Extract- 
ing the Mass after its Separation from the Uterus — Rule to be observed after its 
Removal — Retained Coagulum and Puerperal Convulsions ; Case in Illustration — 
After Extraction of Placenta, it should be carefully Examined — Retained Frag* 



CONTENTS. XIX 

Bwnto of After-birth and Irritative Fever — ^Tractions on Umbilical Cord before 
Separation of the Placenta — Dangers of— How Detachment of Placenta ia to be 
Aided when Uterus is Lethargic — Circumstances rendering it necessary to ex- 
tract After-Birth — Its excessive Volume — Spasm of the Os Uteri — Hour-glass 
Contraction — Morbid Adhesion — Convulsions — ^Hemorrhage— Opium and Bella- 
donna ; Difference in their Therapeutic Effects — How long after Delivery of the 
Child should the Extraction of the After-Birth be Delayed when there is no Com- 
plication ? — Permanent Retention of the Placenta, and Decomposition of the Mass 
— Does the Retained Placenta ever become Absorbed ? — Convulsions supervening 
on Retained Placenta ; The Indication to be Fulfilled — Convulsions in this Case 
are Traceable to Irritation of the Uterus, and are of Eccentric Origin. . . 37d 



LECTURE XXVII. 

POST-PARTUSI HEMORRHAGE. 

Management of Placenta in Flooding after the Birth of Child— Frequency and Morta- 
lity of Flooding — Statistics— Dangers of Post-partum Hemorrhage— What is Post- 
partum Hemorrhage, and how produced ? — How is this form of Flooding divided? 
— External and Internal Flooding — Causes and Diagnosis of External Hemor- 
ihage ; how distinguished from Internal — Duty of the Accoucheur the instant the 
Child has escaped through the Vulva— Treatment of External Hemorrhage; the 
entire object is to produce Uterine Contraction — How is this to be accom- 
plislied ? — Ergot not to be relied on as a Heroic Remedy in Perilous Flooding— 
Why ? — The Tampon ; objection to its use in Post-partum Hemorrhage — Pressure 
and Cold the two Reliable Remedies in Uterine Hemorrhage — the Cold Dash ; 
action of— A small piece of Ice introduced into the Vagina ; its reflex influence — 
Mammas and Uterus — Sympathy between and Deductions from — Pressure of the 
Abdominal Aorta — Electricity as a Remedy ia Hemorrhage; Objections to— 
Injections of Vinegar, Lemon-juice, eta, into Vagina, bad practice— Internal Ute- 
rine Hemorrhage ; how treated — Cephalalgia from Profuse Losses of Blood ; how 
treated ; how distinguished from Phrenitis — Transfusion as an Alternative after 
Excessive Hemorrhage — Dr. Blundcll first to resort to it in the Puerperal Woman 
— Average Success of the Operation — Prof. Edward Martin, of Berlin — How does 
Transfusion accomplish Reaction ? — Is it by the Quantity of Blood transfused, 
or by stimulating the Walls of the Vessels and Heart ? — Brown-Sequard's Expe- 
riments; Deductions from — Secondary Post-partum Hemorrhage; what does it 
mean 7 — ^Treatment of Secondary Hemorrhage. 388 



LECTURE XXVIII. 

TREATMENT OF THE PUERPERAL WOMAN, AND NEW-BORN INFANT. 

Management of the Puerperal Woman and her infant, during the Month — Applica- 
tion of the Binder; rules for — Object of the Binder; napkin to the vulva — Stimu- 
lants not to be administered to the newly delivered Woman ; why? — Ablution of 
the infant: rules for — Dressing of the Umbilical Cord — Examination of Infant to 
ascertain Existence or not of Deformity — Toilet of the Child ; pins not to be used 
— Afler-pains; how managed — Anodynes and Individual Idiosyncrasies — Bed- 
pan; motives for its use — Physicking and Cramming the Infant; Objections to — 
Argument from Analogy — When should the Child be put to the Breast? — Colott- 
tnim; uaesof UecoDium — A Flat Nipple; how remedied — First Visit atter ds^* 



COKTENTS. 

Terr ; when to be made— What the Aoooucheor Ls to do at thi« Visit — RetentifNi 
of Urine ; how managed— Retention and Suppreaaioo ; difference between— Th# 
Catheter; mode of tuiroduetion — ObPtacles lo PasMige of the Catheter; what ara 
UieyT—Incontiocnco of Urino; causes of— Veaioo^Taginal, aud Urethfo-vagioal 
FistiilflD — the Lochlal Dischiirge; what it ia; deinngemeni of — When Infiuii can- 
not take the brcaat, how lu bo Nourished — ^Sub«lJtut«» for the Coloetrum — Reteu- 
lionof ITritie in Infant; caui^ea of; Milk in Hreaslsof new-boni Intatita — Gubleir*! 
QbAurvHtiona — Milk Fev<;r — Blot's R4>3i"iifchesori Diminution of Pulse in Milk ¥er« 
— Coustiimiion of Infant; cauaea of^OcL'lu»ioD of Anuaj how ttiatiagod — Puru- 
lent Ophthalmia; cauaea of— Sore Nipples — Mammary A baoeaa— Paraplegia; 
cauaea of in recently dellTered women — Sloiifthini^ of Umbilical Cord — Pain ia 
UttTua when Child is put to the fireast; KxpUnatioo of— Thrombus of the Vulva 
— Weffd or Ephemeral Fever 404 

LECTURE XXIX. 

MULTIPLK PRfiGKANCY, AKD 8^P£RF€^ATI0N. 

Multiple PrefmaDcy; relative rVeqiteocy of; mortality of— Hypothesis In Kxplanft- 
tioii of Multiple Gestation— PI urn I Births apt to occur in certain F;imiliea— Signa 
of a Twin Pn^gnancy ; their vpIuo — Twin l^ibor not neceasarily Preternatural ; liow 
ijianngvd — Presentation of the Ftjutn-ses — When one Child is bora^ should 
Iho Mutlier bv tt>ld there is atiotht^r in Utero 7 — Delivery of the Placenta 
after the Birth of the first Child— Rulea for Delivery of Second Child— Discre- 
pancy of Opinion amou|^ Authors — Inlercstiog Twin Cn^ ; ejthibiting extraordt* 
nary pecuharilii'D — Can a Twiu Gealatlun exist with only one Amnion f — Super^ 
fcstatioo ; meaning of the terai — The PoHsibility of Supcr-fcBtation generally con- 
ceded by the early WriterM • not »o with the men of onr own times — The Case cited 
by Buflbo — The Case in the BrurJls^ by Dr. Lopez — la Super* foliation poaaible iti 
Animals; niustratioo— Can a Woman simultaneously carry aUterloe and Extni- 
uterine Foetus T-^Super-fcetation in a Double Uterus; the instance recorded in the 
Encjclographie Medicale— Objtctiona to Super*f<Btation examined — ^the Mueoua 
Plug ; is it on obatacle to a second lecundution ? — The Mucous Plug in Cervical 
Canal of the Pregnant and Un impregnated Female ; is lliero any differeooe 
between f^Dcmonstrut ions of the Microscope — The Membrana Decidua; does it 
prevent the entrance of the SpermatuKoon into the impregnated uterus! — Moral 
Consideratknis involved in the Qiieallon of Super^lcetation 431 

LECTURE XXX, 

I^VVEBSIOK OF TUB UTIIRCS. 

InTerston of the Uterus — ^Odt^n connected with Mismanagement of Placenta— 4^ 
Inversion occur in the Unimprefpualed Woman T^Caiues of Inversion — What are 
Ibcy? — Inversion most frequently the result of Carelessncaa or Ignorance — Dublin 
Lying-in Hospital StatiBlics — Inversion Complete or Tncomptete— Dlognosia of 
each— ChMnie Inversion, cot » founded with ProUpsus, Procidentia, and Polypus— 
How to be Distinguished — Treatment of Inversion when either Complete or In- 
complete— IkM» on Inverted Womb ever become Spontaneoiw^ly Restorer! ?— The 
case of Spontaneous Restoration cited by Bnudeloctiue — In Chronic Inversion, 
when the Organ cannot be rephiced, is Kxtir^iation of the Uterus Justifiable 7 — 
Importanccof IheQucslion— The Reconda of Succeasful Extirpation — Case of Mal- 
prncilco in which au^ Inverted Uleru? was forcibly torn frum the Person of the 
IMeitt^ Imring been mistaken for the Placenta. « . r . 446 



li^ 



G0KTEKT8. 

LECTURE XXXI. 

PBSTBRNATUSAL LABOR, PLACENTA PSiBVli, UKAYOroABLE HB- 

ICOBRBAGE. 

Fraternttorml Lftbor, divided Into Manual and Jnitramental-*Cau8e8 of Kannal 
Labor — llalpoaition of the FoBtos — How maj the Foetus be ICalposed? — Exhaus- 
tioii, bow Divided — Positive and Relative Exhaustion — ^Importance of the Dis- 
tiootion— Diagnosis of the two kinds of Exliaustion — Hernia, as a cause of Manual 
Labor — Protapsioo of the Umbilical Oord ; Relative Freqaenpy oP— Extremely 
Destructive to the Cliild, but not to the Mother— Predisposing Causes of Prolap- 
akm— Diagnosis of Prolapsion— How is the Death of the Child occasioned in Pro- 
lapsaooT — Is it the Coagulation of the Blood in the Descended Portion of the 
Oord T— Is the Arrest of the Circulation in the Cord a positive Proof of the Child's 
Death f— Dr. Ameth, of Vienna; bis Cases — At what period of Labor does Pro- 
lapsion occur? — ^Treatment of Prolapsion ; on what it depends — ^Various Contri- 
vances for Reposition of the Cord; their Value^Mode of replacing Cord in 
Vienna Hospital — Postural Treatment, as recommended by Dr. Thomas. Hemor- 
rhage, as a Cause of Manual Labor— Placenta Prsevia and Ante-partum Hemor- 
rhage—The Earlier Writers ; their views of Placenta Praevia — Connexion between 
Placenta Praevia and Hemorrhage— Unavoidable Hemorrhage. PUicenta Praevia ; 
Symptoms of— Diagnosis — ^Treatment of Placenta Pnevia before and at the time 
of Labor — ^The Tampon; when to be employed— Benefits and Dangers of the 
Tampon — ^Version in Placenta Praevia; Rules for — Dr. Simpson and Entire Arti- 
ficial Detachment of Placenta; Objections to-— Dr. Barnes and Partial Ajtificial 
Detachment — Ergot in Placenta Pmvia ; Abuse of; when to be employed — Rup- 
ture of the Membranous Sac in Placenta Praevia ; is it useful or otherwise f — 
Accidental Hemorrhage; how it differs finom Unavoidable Hemorrhage— The 
Pathology and Causes of Accidental Hemorrhage— Dr. Robert Lee, and a Short 
Cord as a Cause — Treatment of Accidental Hemorrhage during Pregnaucy, and at 
the time of Labor. . . . . • 457 



LECTURE XXXII. 

PUXBPEBAL CONVULSIOKS — ^BOCBNTRia 

Ptteiperal Convulsions, the different periods of their Occurrence— Muscular Actloii, 
on what is it dependent ? — Nervous Disturbance, Centric and Eccentric — Causes 
of Eccentric Disturbance— Modus Operandi of these Causes— Treatment of Eccen- 
tric Convulsions oftentimes empirical — Cases in Illustration — Irritation of Uterus 
as a Cause of Paetperal Convulsions during Pregnancy, at Time of Labor, and sub- 
sequent to Delivery — Convulsions during Pregnancy more frequent in the Primi- 
para ; why ? — ^Period of Life at which Ck>nvul8ionA are most apt to occur — ^Blood* 
letting and Opium oftentimes routine in Treatment of Convulsions ; just Distinc- 
tions essential — Opium.' when a Stimulant, and when a Sedative — Fatality of 
Stereotyped Practice— Excessive Blood-letting; how it produces Convulsions — 
Treatment of Convulsions based upon their special Cause— Sulphuric Ether as a 
Therapeutic Agent — Convulsions and Head Presentations; relation of— Artificial 
Delivery, when indicated in Convulsions — Divisions of Convulsive Diseases; Epi- 
leptic. Hysteric Cataleptic, Tetanic, etc. ; how distinguished— Hysteria much more 
frequent in earlier months of Pregnancy — SymptomSi Diagnosis, and Prognosis of 
Puerperal Convulsions. ^S 



CONTENTS. 

LECTURE XXXIII. 

PUXBPBBAL CONVULSIONS— CENTRIC. 

Paerpenil OonnilBioDs continued — ^Their Centric Causes ; divided into Psjchical and 
Pbjvioal ; how distinguished. Toxoemia, or Blood-poisoning — Albuminuria, its Re- 
lations to Convulsions — Causes of Albuminuria — Ed. Robin's Theory not sustained 
—A Change in the Composition of the Blood a Cause — Illustrations and Proo& — 
Secretion, its Objects— A Change in the Kidney, Structural or Dynamic, a Cause of 
Albuminuria ; Proofs — Pressure on the Renal Veins a Cause — Illustration — ^Albu- 
minuria more frequent in the Primipara; why?~>l8 Albuminuria a neoesaary 
Beeult orDiseased Kidney ? — Does it always exist in Pregnancy ? — Uraemia, what 
is itt — Dr. CarlBraun and Urffimic Intoxication — Is Albuminuria always followed 
by Ursmia?~Is Urea a Poison? — Carbonate of Ammonia and Urea — Frerichs^s 
Theory — Orfila's Experiments with Carbonate of Ammonia on Animals ; Result — 
Treatment of Unemia, on what it should be based — Therapeutic Indications— Col- 
chicum Autumnale and Guaiacum as Remedial Agents — Dr. Imbert Goubeyre and 
Bright's Disease In connexion with Albuminuria-— Anaesthetics in Ummia. . 604 

LECTURE XXXIV. 

MANUAL LABOR — DIVISIONS OF VERSION. 

Manual Labor — ^Version, divided into Cephalic, Podalic, Pelvic, and Version by Ex- 
ternal Manipulation — Diagnosis of Manual Labor; important that it should be 
made early — Prognosis, how it varies — Indications of Manual Delivery ; in what 
they consist — ^Time most suitable for Termination of Manual Delivery — Undilated 
Os Uteri, means of overcoming— Mode of Terminating Manual Delivery; the 
▼arioos Rules to be observed — Divisions of Manual Delivery —Rules for correcting 
Malpositions of the Head— What are these Malpositions, and how do they Ob- 
struct the Mechanism of Labor? 616 

LECTURE XXXV. 

RULES FOR PODALIC, PELVIC, AND CEPHAUO VERSION. 

Manual Labor continued — Ceruin Complications of Labor rendering Manual Inter- 
ference necessary — What are these Complications? — Podalic Version, or Turning 
by the Feet— Rules for Podalic Version— Should one or both Feet be seized? — 
Manner of Delivering the Child after the Feet have been brought to the Superior 
Strait— Rules for Extracting the Shoulders — Rules for Extracting the Head-* 
Appalling Consequences of Ignorance— Case m Illustration— Pelvic Version- 
Cephalic Version by Internal Manipulation — Cephalic Version by External 
Manipulation— Prerequisites for its Performance— Mattel and his Views; Objec- 
tions to — Version in Cases of Pelvic Deformity, recommended by Denman — Prot 
Simpson'sadvocacy of Version in Deformed Pelvis— Examination of his Opinion- 
Objections to Version in these Casea 630 

LECTURE XXXVI. 

MANUAL LABOR IN BREECH, KNEES, AND FEET PRESENTATIONS. 

Manual Delivery continhed — Presentation of the Breech, Slneea, and Feet; Manual 
Delivery in — ^The Indications in these Pelvic Presentations — Malposiikma of tht 



CONTENTS. XXm 

Pelvic Rxtremities — Excessive Size of tiie Breech ; how manag^ — Presentation 
of the Pelvic Extremities complicated with Hemorrhage, Exhaustion, Convul- 
sions— The Management of Pelvic Presentations in Inertia of the Womb— Iner- 
tia, how divided — Inertia from Constitutional and Local Causes — Importance of 
the Distinction in a Therapeutical Sense— Blood-letting in Inertia, when to be 
employed — Ergot, when indicated 64T 

LECTURE XXXVII. 

MANUAL LABOR IN TRUNK PRESENTATIONS; SPONTANEOUS EVO- 
LUTION. 

Uanual Delivery conunued— Trunk or Transverse Presentations, including the 
Abdomen, Chest, Back, and Sides of the Foetus— Presentation of the Abdomen : 
its Diagnosis and Treatment— Presentation of tlie Chest, Back, and Sides; how 
Managed — Shoulder Presentation with or without Protrusion of tlie Arm —Treat- 
ment of— Management of these Cases by the Ancients, barbarous and destructive 
to the Child, because founded upon Ignorance of the Mechanism of Labor — ^Their 
Management, Philosophic and Conservative in our Times — Spontaneous Evolu- 
tion — Meaning of the Term — Divided into Cephalic and Pelvic — Comparative 
Rarity of Spontaneous Evolution — Statistics by Dr. Riecke — Statistics of Dublin 
Lying-in Hospital — Fearful Fatality to the Child in Spontaneous Evolution — Dr. 
Denman's Exposition of the Manner in which the Evolution is performed, shown 
to be Erroneous by Dr. Douglass, of Dublin— Spontaneous Evolution not to bo 
relied upon when Artificial Delivery is indicated 655 



LECTURE XXXVIII. 

INSTRUMENTAL DELIVERY BLUNT INSTRUMENTS, FORCEPS. 

Instrumental Delivery — Instmments divided into Blunt and Cutting — Bhmt Instru- 
ments—What are they?— The Fillet and its Uses — The Blunt Hook and Vectis; 
their Uses — The Forceps — ^The Abuse of Instruments in Midwifery— Tlvcir too- 
General and Indiscriminate Employment — The Object of the Forceps— The For- 
ceps an Instniment for both Motlier and Child — Abuse of the Forceps— Case in; 
Illustration— The Forceps a Precious Resource when employed with Jiidgment — 
Statistics of Forceps Delivery — What is the true Power of the Forceps? — Is it a 
Tractor or Compressor? — The Forceps a Substitute for, or an Aid to, Uterine 
Effort— To what Part of the Child sliould the Instniment be applied?— The 
Advantages and Evils of the Forceps — How is the Head of the Cliild to be 
Grasped by the Instrument ?— Modification of the Forceps — Its Cranial and Pelvic 
Curves — The Author's Forceps — Indications for the Use of the Forceps — Time of 
Employing the Instrument — The Opinions of Denman, Merriman, and others — 
Objections to— The Justification of Forceps Delivery, a Question of Evidence to 
be Determined by the sound Judgment of the Accouolieur 565 

LECTURE XXXIX. 

PORCBPS DELIVERY, CONTINUED. 

Foroeps Delivery continued — Rules for the Application of the Forceps — The instni- 
ment may be employed when the Head is at the Inferior Strait, in the Pe»\Vv& 



ZZir CONTENTS. 

Oavitj, or at the Superior Strait.— The Head at the Ontlet, with the OoOpat 
toward the PaheB^ and the Faoe in the Concavity of the SaeniiiH— The Head at 
the OuUet in a Reverse Popition— The Head in the Pelvic Cavity diagonally, the 
Occiput regarding the Left Lateral Portion of the Pelvis, the Faoe at the opposite 
Sacro-Uiac Symphysis — ^The Head in the Pelvic Cavity diagonally, with the Occi- 
put at the Right Lateral Portion of the Pelvis, and the Faoe at the opposite Sncn • 
iliac Symphysis — ^Tbe Head in the Pelvic Cavity in Positions the reverse of the 
two preceding — Application of the Forceps, the Head being at the Superior Strait 
— Positions of the Head at this Strait— Difficulties of Foroeps Delivery when the 
Head in at the Upper Strait — Version, in such case, preferable — Case in Illustra- 
tion — Rules for Foroeps Delivery, the Head being at the Superior Strait— Locked- 
Head — What does it mean t— Want of Concurrence among Authors as to what 
Locked-Head is — Is Locked-Head of Frequent Occurrence t — Camper's Opinion — 
Dangers of Locked-Head to the Child and Mother — Under what Circumstan* 
«M may Locked-Head oocurf — Application of the Forceps in LodcedHead — 
Rules for. 696 



LECTURE XL. 

F0BCEP8 DEUVERT, CONTINUSD. 

Forceps Delivery continued — ^Use of the Instrument when the Head is retained 
after the Expulsion of the Body — Circumstances justifying the Forceps in these 
Cases — Application of the Instrument, tiie Head at the Inferior Siraitj witii the 
Occiput at the Symphysis Pubis, the Face in tlie Concavity of the Sacrum — 
Application in a reverse Position — When tlie Occiput is at the Left and Front of 
the Pelvis — Tlie Occiput at the Right and Front of the Pelvis — Use ol the Instru- 
ment, the Head resting at the Superior Strait— Tlie Foroeps in Face Presenta- 
tions—Under what Circumstances indicated — Practice of the Old Sciioolmen in 
Face Presentations — Objections to — When Version is to be Preferred to Forceps 
. Delivery in Face Presentations— The Manner in which the Faoe usually presents 
at thu Superior Strait — Right ICento-iliao Position-^Left Mento-iliao Poeition — 
Mode of Descent in these Positions — Manner and Difficulty of applying the For- 
ceps in Faoe Presentations at the Superior Strait — Use of the Instrument when 
the Face is at the Inferior Strait — Mento4interior Position— 'Mento-posterior Posi- 
tion — Comparative Rarity of the latter Position— The Oblique Positions of the Face 
at the Inferior Strait— How managed— Faoe Presentation and Ooovulsions— 0»e 
in Illustration. Wl 



LECTURE XLI. 

COmNG INSTRUMENTS — 6TMPHY8E0T0MT— <3JBSABEAN SBCnON. 

Cttttin^r Instruments — What they Involve— -Importance of the Qtiestkxi — ^Whak is 
the Smallest Pelvic Capacity through which a Livirfg Cliild can be made to pass, 
and wliat the Capacity throu^^h wliieh a Cliild mayl>e extracted piecemeal? — Dis- 
crepnncy of Opinion on these Questions — Sympliyseotomy, in what it consists — 
Sigault its Oriffinator— Tlie true claims of the Operation —The Question exa- 
mined—Comparison in8titut*>d between Symphyseotomy and the Cfesarean Section 
— Suitistios of each — Deduction — The CjBwirean Section— The Opinions in Great 
Britain and on the Continent of Europe as to the Merits of the Operation — Reasons 
M* the marked Difference of Opinion — Analysis of the Views of Authora touohing 



CONTENTS. XXV 

the Caniv« i SecCon— Statistics of the Operation-- How its Fatality may be 
Modified — Opinion of the Author as to the Advantages of the Caesarean Section 
over Craniotomy — What are the Bangers of the Operation? — ^The Benefits of 
Amesthenia in controlling the Shodc to the Nervous System — Post-mortem Cesar- 
ean Section, when resorted to— The Case of the Princess of Schwartzenberg — ^The 
Boman Law on the Subject of the Post-mortem Operation— Method of Performing 
the Caesarean Section; the Vertical Incision through the Linea Alba preferred — 
Why T — Should the Operation be Performed before or after the Rupture of the 
Membranous Sac? — How is the Child to be Extracted through the Opening in 
the Uterus? — Rules for Removing the Placenta — Dressing the Wound, and sub- 
■equeut Treatment— The Operation of £lytrotomy« as a Substitute for the Incision 
into the Uterus, proposed by Jorg and others — Merits of the Operation — ^Dr 
Christoforis and the Resectio-subperiostea of the Pul^ Bones— Researches and 
Statistics of M. PhiUn-Dufeillay 618 



LECTURE XLIL 

TAGD^AL HYSTEROTOMY — EMBRYOTOMY — CEFHALOTRIPSY. 

Vaginal Caesarean Operation, or Vaginal- Hysterotomy — ^Indications for this Openk 
tion — ^Two Cases in Illustration by the Autlior — Embryotomy — Meaning of the 
Term --Amount of Pelvic Contraction justifying Embryotomy — Dangers and 
Fatality of the Operation — Difference of Opinion among Authors as to the Circum- 
stances indicating Embryotomy— Tlie Case of Elizabeth Sherwood, as reported by 
Dr. Osbom — ^The Dangerous Precedent growing out of that Case — Evidences of 
the Cliild'j* Death in Utero — What are these Evidences ?— Conflict of Sentiment 
among Writers on this Question — Great Caution necessary in forming a Judgment 
— Analysis of the Evidence — ^Too General Use of the Perforator and Crotchet — 
Melancholy Results of this Fondness for Kmbryotomy — Case in Illustration —Mode 
of Performing the Operation of Embryotomy— In Hydrocephalus, what is to be 
done? — Decolhition — When to be resorted to — Evisceration — When indicated — 
Cephalotripsiy — Meaning of the Term — When to be employed. 644 

LECTURE XLIII. 

PREMATURE ARTIFICIAL DELIVERY. 

The Induction of Premature Artiflcial Delivery — Premature Artificial Delivery— 
How divided— When is the Foetus viable?— The Period of inducing Artificial 
Delivery with the hope of saving the Child — What was it that first suggested a 
Recourse to it f — The History of the Operation — First performed in Great Britain 
— Sutistical Tables showing the Diameters of the Foetal Head at Different Periods 
of Development — The Opinion of Dr Merriman and others, that Premature Deli- 
very should not be attempted in the Prim i para — Objections to — ^The Causes of 
Artificial Delivery — What are they f— Deformity of the Soft Parts sometimes a 
cause — Cnsc in Illustration — Excessive vomiting in Pregnancy and Artificial Deli- 
very — Examination of the Question — Statistics of Premature Artificial Delivery 
contrasted with those of the Ctt5wrean Section and Embryotomy — The various 
modes of inducing Artificial Delivery — Perforation of the Membranes— Ergot, 
Dilatation of Os Uteri by prepared Sponge, according to the method of Klugeand 
Bnininghau^en — Meissner's mode of Rupturing the Membranes — The Method of 
Kiwisch, or Water-douche — ^The Method of Cohen — Injection of Carbonic Acid into 
the Vagina as proposed by Dr. K Brown-S^oard ; its influenoe on contraic^Mffk oC 
Don-striatAJ taaacuJar Abrea^Iadactioa of Abortion — Is it ever )ast\&aV>\e\ . ^^4 



XXVI CONTENTS. 

LECTURE XLIV. 

PUEBPEBAL FEVER. 

Puerperal Fever — Synonyms; its Fatality most Fearfhl — ^What is Paerperal Fever f. 
— ^Is it a Local Phlegmasia? — Objections to the Hypothesis — Is it in its Nature a 
Toxemia, or Blood Poisoning? — Proofs in Demonstration of this Opinion. Humo- 
ral Pathology— Puerperal Fever not conEned to the Parturient Woman; it may 
attack Young Women, Pregnant and Non-Pregnant Women, New-bom Children, 
and tlie Foetus in Utero. The true Meaning of tlie Term Puerperal State — Divi- 
sioat of Puerperal Fever — Epidemic and Sporadic —Is it contagious ? Discrepant 
Views ; Proofs tliat it is a Zymotic Disease ; Contagion accomplished only through 
an Animal Poison — Prof Ameth's Account of Puerperal Fever in Vienna I^ospi- 
tal — Its Propagation through Dissections. The Question of Transmissibiiity 
through Decomposed Matter. Causes of Puerperal Fever. Symptoms — How 
Divided— Their Value — Anatomical Ijesions — Not UniformT-Sometimes the only 
appreciable Change is in the Blood. Diagnosis— With what Affections Puerperal 
Fever may possibly be Confounded. Prognosis — in the Epidemic Form gunemlly 
unfavorable ; the usual Preludes to a Fatal Termination readily detected by the 
observant Physician. Treatment — Divided into Prophylactic and Bemedial — Pro* 
phylactic— in what it Consists. Dr. Collinses Sanitary Measures in Dublin Lying- 
in Hospital — Results. Epidemic Puerperal Fever not always confined to li^'ing-in 
Hospitals ; its occasional Ravages in large Cities and Villages. Remedial Treat- 
ment — Depletory Remedies— When employed — Stimulants; when indicated. 
Opium Treatment ; the Veratrum Viride 680 

LECTURE XLV. 

PUEBPEBAL MANIA. 

Puerperal Mania ; its Pathology— Is it a Phrenitis, or is it essentially a Disease 
of Exhaustion and Irritation f — Opinions divided ; Nccroscopical Researches — At 
what Period of the Puerperal State is Mania most apt to Occur?— EsquiroKs Sta- 
tistics—Frequency of the Disease — Is Puerperal Mania liable to recur in a Subse- 
quent Birth f— The Opinion of Dr. Gooch and others on this Point— Causes of 
Puerperal Mania — Predisposing and Exciting ; Hereditary Influence — Symptoms 
— Rapid Pulse and Continued Restlessness — What do they Portend f— Diagnosis — 
Puerperal Mania and Phrenitis, Distinction between — Prognosis— Records of 
Hospitals for the Insane ; Records of Private Practice— Duration of Puerperal 
Mania— Is Permanent Aberration of Mind Probable in this Disease?- Treatment 
— Marshall Hall and Bloodletting— Opiates — Their Importance— Moral Treat- 
ment 699 



LECTURE XLVI. 

PHLEGMASIA DOLENS. 

Phlegmuyia Dok'us, although generally incident to the puerperal state, is not always 
so — It ma}' develop iu»eif in the non*puerperal woman, and aiw in the male sex; 
but little uiiderstfHHi by the early Kailier» — Maurieeuu the first to direct special 
attention to it — His Views of its Pathology— The Views of Puxos and Levret— 



CONTENTS. XXVli 

Hirtorical Sketch of the Diseaae— Mr. Wliite, of Manchester— Mr. Frye, of Glouces- 
ter— Dr. Kerrier- Mr. Hull— M. Albers— M Bouillaud— Professor Davis, of Lon- 
don— Dr. Robert Lee— Is Phlegmasia Dolens a Crural Phlebitis?— Dr. Macken- 
zie, of London — Is Phlegmasia Dolens a Tox»mia?—Svnonyftis— Causes of the Dis- 
ease; Symptoms— Why is (Edema a Symptom of Phlegmasia Dolens ?— Causes of 
Dropsical Effusion ; the relation between the cedema of Phlegmasia Dolens, and 
Obstructed Venous Circulation — Proof— Are the Veins Absorbents?— Lower's Ex- 
periments— Boerhaave ; Van Swieten, Hoff"man, Morgagni. Cullcn— Majendie and 
Booillaud— The CEdema of Pregnancy —How Explained— Which of the Inferior Ex- 
tremities is most liable to Phlegmasia Dolens?— The Causes of the Difference— At 
what Period after Labor does the Disease most usually occur? — Frequency of Phleg- 
masia Dolens— SUitistics— Diagnosis— Prognosis— Progress, Duration, and Termina- 
tion of the Di8ea«*e— Complications— What are they?— Purulent Collections— llieir 
Consequences— Peritonitis— Metro-Peritonitis— Treatment of Phlegmasia Dolens— 
Its Indications— Local Applications with the view of diminishing Pain. . . 708 

LECTURE XLVII. 

▲N.A8THETICS. 

Btberizatioii — Its Importance; Anesthesia — meaning of the Term — Anttsthetics in 
Midwifery of Recent Discovery- in Surgery, of Ancient Date ; The Anesthetic 
Agents now in use— Sulphuric Ether, Chloroform, and Amylene — Sulphuric 
Ether first employed as an Anaesthetic by Dr. Morton ; in Parturition, by ProC 
Simpoon; its first trial in America, in Labor, by Dr. Keep, of Boston— Chloroform, 
its Introduction by Prof. Simpson; Amylene; Dr. Snow— Comparative Safety of 
Sulphuric Ether, Chloroform, and Amylene— Cardiac Syncope and Paralysis of the 
Heart fh>m Chloroform — Indications for the use of Anaesthetics in Parturition — 
Should they be employed in Natural Labor? — ^Their value in Instrumental and 
Manual Delivery — Anaesthetics in Infancy — Influence of Etherization on Contrac- 
tions of the Uterus; on Mother and Child — Flourens on the Nervous System in 
Etherization — ^Time and Mode of resorting to Anaesthetics in Parturition — The 
Pulse; how affected by Etherization — Relaxing Effects of Etherization — Case 
in Illustration. 720 



LIST OF ILLUSTRATIONS xxlx 

CATALOGUE OF AUTHORS REFERRED TO AND QUOTED . . . amd 
ALPHABETICAL INDEX 729 



LIST OF nXUSTMnONS. 



UTHOGBAPHIC FLATXS. 



PItttes 1» 2, 3, 4, representiDg the Areola in Pregnancy, aa delineated by Dr. 

Montgomery Ufi, U9, .158; 161 

WOOD SNORAYINGS. 
now FAoa 

1. The bonea of the trunk 3 

2. The anterior surface of the oa sacrum 4 

3. The posterior surface of the sacrum ; 6 

4. The lateral surfaces of the sacrum 6 

5. The coccyx. 6 

6. The posterior surface of the coccyx 6 

7. The OS innominatum. 8 

8. The external surface of the os innominatum 9 

9. The adult female pelvis 14 

10. The adult male pelvis 16 

11. The foBtal pelvis 17 

12. The planes and axes of the pelvis 18 

13. The central curved line, or axis of excavation 81 

14. The course pursued by the foetus in its exit. 22 

16. Diameters of the upper strait of the pelvis 26 

16. Diameters of the lower strait of the pelvis 26 

1 7. The occipito-mental, occipito-frontal, and vertical diameters of the fcetal head 29 

18. The transverse or bi-parietal diameter, and fontanelles 29 

19. The coronal suture 30 

20. 21, 22, 23. Vertex presentations, as classified by the author 40, 41 

24. Flexion of the head 46 

26. RoUtion of foetal head 48 

26. Extension of foetal head 60 

27. External rotation of foetal head 61 

28. A peculiar deformed iielvis in the ^uthofs collection 62 

29. Oblique distortion of the pelvis 65 

80. The pelvimeter 68 

31. Method of vaginal exammation to detect deformity 70 

82. The uterus, as situated ui the pelvic cavity 80 

33. The uterus and ita annexa 81 

34. The arrangement of the extemal coat of the uterus 82 

86. Double uterus and vagina •..•...•. %% 



KXX LIST OP ILLUSTRATIONS. 

no. TAQM 

36. Continnitj of the fallopian tube with the cavitj of the uterus 90 

37, 88. The xnuflcular structure of the uterus ] 37 

39. The uterus in its natural state 1 67 

40. The uterus at the third month of gestation 167 

41. The uterus at the sixth month of gestation 169 

42. The uterus at the ninth month of gestation * 160 

43. The disposition of the hand for a vaginal examination 1 98 

44. Tlie amnios inclosing the fcetus 244 

46. The foetal surface of the placenta 247 

46. The maternal surface of the placenta 247 

47. The knotted cord 262 

48. Presentation of the face, first position 341 

49. Descent of the face 842 

60. Presentation of the face, second position 842 

61. First position of the breech 846 

62. 63. Descent of the breech 347 

64. Examination per vaginam — commencement of dilatation of oe uteri 863 

65. The OS uteri fully dilated — membranous sac unruptured 369 

66. 67. Manner of supporting the permeum 364 

68, 69. Removal ot the placenta. 376 

60. Hour-glass contraction of the uterus • 881 

61. Introduction of the hand in hour-glass contraction. 382 

62. Detacliincnt of the placenta in morbid adliesion to the uterus 386 

63. Placcntje in twin pregnancy 432 

64. Presentation in twin prepnancy 435 

63. Presentation of the left side of the head 625 

66-73. Illustrations of the manipulations in podalic version in vertex pre- 
sentations 631-534 

74. Kxtraction of the arm . . 636 

76. The production of the movement of flexion 637 

76. Delivery of the breech 649 

77. Delivery of the feet 661 

78. Delivery of the knees 651 

79. First position of the abdomen 566 

80. 81. Second position of the right shoulder with protrusion of the arm 661 

82. A ppUcation of blunt hook 667 

83-88. Author's obstetric instruments 679 

89. Introduction of the male branch of the forceps 587 

90. Introduction 'of the female branch 688 

91. The forceps locked 689 

92. Forceps applied, and disposition of the hands 689 

93. Gradual extension of the head in forceps delivery 690 

94. Complete extraction of the head 690 

96. Forceps applied after the extraction of the trunk 609 

96. Perforation of the cranium in hydrocephalus. 661 

97. Tlie curved instrument with an internal cutting border. 662 

98. Cephaloiribe or embrj'otomy forceps. . . .• 663 

99. Application of the cephalotribe 664 



CATALOGUE OF AUTHORS REFERRED TO AND QUOTED. 



Albens 710. 
Andrei, 106, 129, 183. 
Arneth, 462, 465, 686. 
Afftruc 206. 
AUee, 301. 

Bachetti. 213. 

Bailey. 42v). 

Balard. 722. 

Baly, 113. 

Barker, B. Fordjce, 543, 

630. 698. 
Bamefl, llobt., 271, 285, 

477, 576. 
Barry, Martin, 89, 117. 
Bandelocque, 86, 38, 69, 

146, 150, 452, 627, 641, 

657, 063. 
Beau, 697. 
Beck. Snow, 87. 
Becqiierel, 129, 134. 
Bell, >irC.. 271. 
Bemm 263. 
Bernard, 246, 262. 
Bidcltotf, 118. 184. 
Blot, 135, 508. 
Bhimeiibach, 151. 
Blundc'll. 400, 628. 
Boerliauve, 131. 
Boivin, Mad., 37, 126, 

158. 165, 240. 
Bouillatid. 86. 
Boulard, 87. 
Bounder, 343. 
Bowdiidu Dr., 429. 
Bowinun, 115. 
Braun. 272. 605, 515. 
Brenan, 696. 
Breschet, 104, 122, 205. 
Bretouneau. 220. 
Brierc de Boismont, 98. 
Broca, 116. 
Brodie, Sir Benj., 371. 
Brown-Sequard, 190, 271, 

812.319,331.371,401, 

507, 513, 678. 
Brucke, 136. 
BufTon, 310, 442. 
Burns, 67. 
Bu^row^ 502. 
BuscIh 67. 

Callisen, 712. 

Campbell, 515. 

Camper. 23, 151,602, 622. 

Capuron, 522. 

('urpenter, 91, 263, 510. 

Carriere, 716. 

Caruj. 312 

CHJseaux, 39, 127, 168, 

220. G6.3. 
ChMtUx, 6S4, i 



Charrier, 691. 
Chasraig^'ac, 426. 
Chn8tiM>n. 510. 
Churcbill, Dr., 83, 89, 339, 

344, 348, 390, 431, 442, 

444,461, 603,538,674, 

629, 667, 673. 
Clark, AloDzo. 697. 
Clarke, SirC. 155, 300. 
Clarke. Dr. Joseph, 27. 

67, 630. 
Clay, Charles, 221, 308. 
Cloetta, 87. 
Cohen, 678. 
CoUineau, 75. 
Collina, 339, 844, 437, 

496, 693. 
Coste, 83, 91, 115, 119, 

242. 
Cristoforis, 643. 
CroHse, 446, 449. 
Cruveilliier. 273. 
Cullon. 506. 
Cummiiigs, 417. 

Dalton, 91. 113, 250. 

Danyan, 694. 

Davis. 67, 204, 340, 576. 

DeGraaf, 318. 

Denman, 144, 465, 562. 

582. 
Depaul. 134, 682. 
Deviiie, 126, 127. 
Do wees, 67, 146,465,602. 
Dieffenbacli, 213, 401. 
Donne, 102, 116. 
Dougliiss, 563. 
DOutrepont, 98. 
Druit, 250. 
Dubois, 33, 35, 38, 96, 

131. 147,153,189,214, 

293. 314. 
Duges. 710. 
Dumas, 116, 401. 
Duncan, Matthews, 35, 

166, 306. 
Duparcque, 712. 
Duplay, 718. 

K^gert, 177. 
Elaasser, 144. 
Esquirol, 503, 700. 

Farr, Dr. W., 123. 

Farro, Arthur, 171. 

Faye, 96. 

Ferpu.son, 682, 683. 

Fcrnel, 284. 

Ferrier, 709. 

Fiffg, E. Garland, 638. 
Figueira. 667. 
FiiweJJ, 204. 



Flamant, 540. 
Flourens, 248, 485, 725 
Follin. 293. 
Frankenhauser, 187. 
Frerichs. 512. 
Frye, 7U9. 

Galen, 84. 417. 

Gardien, 46, 627. 

Gariel, 239. 

Gavarret, 106. 

Geoffrey St Hilaire, 266. 

Gerdy, 51. 

Geuth, 205. 

Godard, 116. 

Goo(!h, 300, 388, 701. 

Good. 712. 

Goodsir, 244, 249, 267. 

Goubeyre, 605, 615. 

Graves, 697. 

Gubler, 421. 

Guillemot, 267 

Guillot, 262, 422. 

Guthrie, 710. 

Haighton, 119. 

Hall. Marshall, 269, 370, 

485. 
Ilaller, 101, 115. 147. 
Haltnagrand, 555, 633. 
Halpin, 238. 
Hamilton, 67, 476. 
Hammond. 614. 
Hardy, 447. 
Harvey, 114, 150, 210. 
Hecker, 204. 
Heim, 213. 
Henry, 442. 
Hewitt, Graily, 285. 
Hewson. Addinell, 30. 
Hippocrates, 34, 131, 135, 

218,292,304,338,417, 

640. 
Hirschfeld, 87. 
Hodge, Prof., 686. 
Hoffman, 715. 
Hohl, 211. 
Holmes, 686. 
Homans. John, 429 
Huguier, 77, 165, 173. 
Hull, John, 709. 
Hunter, 87, 15.3,235,242, 

249, 345, 368, 444. 

Jackson, C. T., 721. 
Jacquemin, 75, 172. 
Jenkens, Conant, 429. 
Jobert, 86. 
Johnson. 340. 
Jones, Bencb, 510. 
Jones, T. Whaiton, 4^^ 
J6rg, 640, 679. 



ZXXil CATALOGUE OF AUTHORS REFERRED TO AND QUOTED. 



Kane, Rlinha, 186. 
Keating, 697. 
Keep, N. C, 709, 721. 
KeUler, 183. 
Keith, 662. 
Kennedy, 191, 240. 
Kergaradec, 189. 
Keyter, 632. 
Kiliaa 173. 
Kiwisch. 396, 677. 
Kluge, 173. 
Kohen, 117. 
K5]Jiker, 126. 
Krahmer. 302, 614. 

LaCb^polle, Mud, 33, 37, 

'ifis, 4:iL Cin2. 
Lamswecrde, 294^ 
Larcher. 325. 
Laaerre, 689. 
Liiwreiiee, 7 0* 
Le Blauc, 362. 
Le Cat. 101. 
LeGallois, 16. 
Lebert, 194. 293. 
Leconce, 136. 
Lee, Rob., 87, 476, 481, 

681. 
I^euoir, 19. 

Levret, 168, 449, 632. 
Liebig. 684. 
LcUiacb, 230. 
Lopez, 442. 
Loraiu, 685. 
Lower, 715. 
Lugol, 713. 
Macftii]i4t\ {i6a. 
Mnck^Dd*?, T, W.p 711. 
MartUi, Kd.. 400. 
Martin, M.. 417, 403*. 
Mattel, A., 517, 543. 
Miiu]i.*lII, (S'JH, 630. 
Mjiuriee.m. ^4. 283, 637. 
Mayor, 187. 
McClintock. 403, 447. 
Meckel 136. 
Meigs, Prof, 30, 91, 301, 

670, 686. 
Moisaner, 117, 676. 
Mende, 312 442. 
Merriman, 301, 438, 581, 

628, 668. 
Mettenheimer, 286. 
Mialh^ 262. 
MUla, Cb. S., 636. 
Minot, 429. 
Monro, 115. 
Motitgointfrv. 91, 115,119, 

Ift'i, I7iijM>5, 365. 
Mor^gnl 21^2. 
Morujii, \\\ T. G., 709. 
Mf^tt, Vakil tine. 688. 

Murphy, 301, 62a 
Murray, 240. 

Naeg^l^ 30, 38, 42, 4% / 



66, 188, 305, 842, 848, 

378. t8«; 
Naegel^ Jr.. 378, 716. 
Nauche, 185. 
Newport, 117. 
Neubert, 104. 
Nuck, 119. 
Ogle, 364. 

Osbom, 67, 619, 037, 653. 
Osiander, 410. 
Otis. 429. 
Ould. 627. 
Outrepont, 396. 
Ptiaret, 28*1 
r^oL, 96, 134. 
Pfllfytv, 598, 
Parcni'Diiuhatelet, 173. 
Petit. 343. 

Philaio DureilUy, 643. 
Pitcaim. 506. 
Pbter. 292. 
Porcher, 386. 
Pouchet 116. 
Power, Dr. John, 101, 

314. 
Priestley. 320. 
Prevost. 115,401. 
Puzos, 218. 

Querenne, 421. 
guL'telet, 2H. 

Racibflrnki. 98. 
RadHurd 476. 
Riiijrw Belomje, 717. 
EjiiriHrd. 73, 
Bain^b<itli4im. 39, 848, 

443 444. 562, 673 
Raver, 510. 
Read, 443. 
Hegnauld, 134. 
Reid. Jas , 305 
Ricker, 539. 
Ricord, 173. 
Riecke. 33. 
Rigby, 66, 360, 386. 
Ritgen 667. 
Riviere. 221. 
Roberton. 16, 96. 
Robin, Ch., 116, 149,194, 

262, 284, 605,611. 
Rodericus a Castro, 708. 
Rodier. 139, 134. 
Roger, 81. 

Rogers. Wm. C, 371. 
Rokilaiisky, 294. 
Rouget 83, 84, 90, 119, 

170, 262. 
Rousset. 633. 
Royston, 177. 
Ruleau, 632. 

Salomon, 386. 
Sankey, 717. 
Savonarola 136. 
Scanzoni. 34, 86. 67, 191, 
353. 348, 896, 461, 663. 
SclioJer, 367. 



Schwartz. 471. 
Schwerer, 639. 
Semmelweias, 686. 
Sharpey, 242. 
Siebold. 710. 
Sigault. 632. 
Simon. 633. 
Simpson, ProC, 28, 36, 89, 

1K4. 220, 253, 801, 313, 

435,471,476,514,644, 

722. 
Sinclair. 340. 
SmeUie, 598, 627. 
Smith, Stephen, 429. 
Smith. Tyler, 39, 392,812, 

433. 443. 467. 
Bnow, 722, 723. 
Spallanzani, 116. 
Stokes, (>97. 
Stoltz, 36, 38, 87, 168, 

666. 676. 
Storer, H. R., 678. 
Struve. 717 
Sydenham. 606. 
Szukiss, 97, 100. 

Tanner, 278. 

Tardieu, 682. 

Tamier, 685 

Tenner, A , 494. 

Tessier, 302. 682. 

Thomas, T. GaUlard, 464. 

Tiedemaon, 87. 

Todd. 115 

Touniie, 228. 

Trask, ProC Jas. D., 471. 

477, 57.3. 
Trousseau. 686. 

Valentin. 116, 117. 
Valleix, 7 1 1. 
Van Pelt, Jos. K. J., 30. 
Van Swie*«n, 131, 144, 

268, 294. 804, 641. 
Veit. Dr , 28. 
Velpeau, 24, 188. 
VerdeU. 262. 
Virchow, 88, 194, 304 

206. 353. 
Vogel, 691. 
Vogt,246. 

Von Glisczynski, 470. 
Von Ritgen. 373. 

Webb, Prof, 108. 
Weber. 243. 
Weidemann. 251. 687. 
WeUs, Horace, 709. 
West, 43. 453. 
White, J. P.. 452. 
White, of Manchetter. 

709. 
Whitehead. 266. 
Wigand. 542. 
Williams, J. B., 606. 
Wright. 641. 
Wyer, 717. 

I Young, *l\^ 



THE 



PRINCIPLES AND PRACTICE OF OBSTETRICS. 



LECTURE I. 



Midwifery an Exact Science— The Passage of the Child Uirough the Maternal 
Organs is founded on the Principle of Ac^ustment — The Pelvis ; the Position it 
oceuptee in the Human Skeleton — Importance of its Position in Childbirth— The 
Direction of the Pelvis; its Variations— Bones of the Pelvis in the Adult and 
Foetus— Sacrum, Coccyx, and the Two Innominata — Anterior Sacral Plexus of 
Nerves ; its InHuence in the Production of Nuiperous Pathological Phenomena — 
The Os Coccyx; its Importance in Childbirth — Dislocation of the Coccyx — 
Fracture of the Coccyx — The Spinous Process of the Ischium — How, when mal- 
formed, it may interfere with the Process of Delivery. 

Gentlemen — ^The science of Midwifery, so far as it relates to the 
expulsion of the child and its appendages through the matenial 
organs, is an exact science. Expulsion is both a physiological and 
mechanical act, and is the product, in part, if I may so term it, of 
a play of certain physical principles. What, in fact, is a natural 
delivery, but the operation of a motive-power acting on a body 
with the view of causing its passage through a given space ? This 
motive-power is the contracting womb ; the body is the foetus ; 
the space consists of the bony pelvis, and the various soft parts 
directly connected with the parturient effort. But. no force which 
the uterus can bring to bear will enable it to accomplish the delivery 
of the child, unless there be a proper proportion between the foetus 
and the organs through which it has to pass ; and, therefore, it 
may be asserted, that the natural expulsion of the child through 
the maternal organs is the result of adjustment ; or, in other words, 
of a correspondence between the various portions of the foetus, 
and the canal through which it makes its exit. 

If this be so— and the further we progress in the investigation 
of the subject the more convinced will you become of the truth of 
the proposition — it follows, as a necessary consequence, that the 
paramount duty of the obstetric student is to study nature, and 
understand the admirable mechanism she has instituted for the 
purpose of securing to the child a safe transit through the maternal 
passages. With a knowledge of this mechanism he will be euabledi 

I 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 



when nature is contravened by circumstances beyond her controlJ 

to act as her mibstitiite; and^ by judicioua interference, to sav 

the lives of both molher and child. Wilhont ihi.s krinwu^l^io, on 

the contrary, hi?^ iutorferenee wouhi be criminal; for it could lead 

to nothing short of disaster or death. Allow me, then, thus earh 

to urge upon you a profound respect for nature ; her temple is it 

proper place for the student of midwifery j there it is that sh« 

idi^scourses most elo<|uently, though silently, and the best obstetri- 

aans will be those who have worshipped the most zealously at her 

^thrine. Our science is but the portrait of nature^ and the fidelity 

of the picture is commensurate with the skill of the artist. 

As preliminary to a proper appreciation of the mechanism of 
labor, it will be necessary for you to become thoroughly acquainted 
with the anatomy of the human pelvis, both as regards its bony 
structure, and the various sofl parts directly connected with it 

The ffetus and its annexa?, togethetl 
with the uterus and its appendages,' 
will also constitute topics for attentive 
study. 

Before commencing a description 
of the Individ iinl bones of the pelvis, 
it may not be out of phice to direct 
your attention, for the moment, tQ 
the portion it occupies in the skele 
ton* It ifi situated at the inferior ex- 
tremity of the vertebral colunm, with 
which at its posterior and up|>er sur- 
flue it articulates, forming, at this 
point of union, an important projeo- 
tiou known as the aa^ro-vertehrat 
prominence, to which we shall have 
occasion, hereafter, more particularly 
to allude. The pelvis is supported j 
below by the two femoral bones, the | 
heads of which are ref«pectively ro 
j/ eeived into the neetabula. Thus, 

I it forms the lower boundary of the 

abdominal cavity, and at the same 
time affords aceommodation to th#i 
rectum, the bladder with its excretory 
duct, the uterus, etc. This position 
of the pelvis is not without interest^ ^ 
for you cannot but observe the Mgnal' 
! it imparts to the parturient woman, in the efforts nec^es- 
the expulsion of the child. In coni^ecjuence of the two 
Aportaat emunctories or outlets, the bladder and rectum, being 



Fia. 1. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 8* 

aituated within its cavity, nature is enabled, at the time of child- 
birth, to bring into active exercise, in addition to the contritions 
of the uterus, the various muscular forces employed in the expul- 
sion of the excrements from the system. 

By reference to Fig. 1, it will be seen fhat the pelvis, in the 
upright position, presents a marked obliquity to the horizon, form- 
ing what is sometimes described as the indinatian of this canal. 
The perpendicular line, exhibiting the axis of the trunk, instead of 
passing through the centre of the upper plane or strait, falls on 
the symphysis pubis, while the line which really represents the 
centre of the plane, intersects the perpendicular at an acute angle. 
When it is recollected that the usual position of the female is the 
erect one, the advantage of this inclination of the pelvis, during 
the period of pregnancy, will at once be appreciated ; for, if the 
axis of the superior strait and that of the trunk were identical, 
the necessary physical result would be the descent of the gravid 
uterus into the pelvic cavity, causing undue pressure on the adja- 
cent viscera, and other pathological derangements, which would 
materially interfere with the full development of a healthy gesta- 
tion. 

Bones of the Pelvis. — ^The adult pelvis is composed of four 
bones, viz. the sacrum^ coccyx^ and two ossa innominata. The 
two former constitute the posterior wall of the pelvis, while the 
innominata, one on each side, form the lateral and anterior bounda- 
ries of the canal. You will read in the books that, while the adult 
pelvis has but four bones, the foetal pelvis numbers fourteen. The 
reason of this difference is easily explained. In the system of the 
young subject, ossification not being complete, the sacrum presents 
very distinctly five pieces, and the coccyx three, making, for these 
two bones, eight pieces: while each os innominatum presents 
three divisions, making, for the two innominata, six pieces; so 
that^ five for the sacrum, three for the coccyx, and six for the inno- 
minata, give the fourteen of which the foetal pelvis consists. But, 
when the process of ossification is completed, which occurs about 
the time of puberty, these various divisions become consolidate ; 
so that, in adult age, the pelvis is composed only of four bones, 
instead of fourteen, as was the case in early life. 

The OS sacrum (Fig. 2) is triangular in shape, situated at the 
posterior and central portion of the pelvis, below the last lumbar 
vertebra, above the coccyx, and wedged in, as it were,' between 
the two ossa innominata. Its structure is mostly spongy, covered 
by a thin layer of compact tissue ; hence, proportionate to its size, 
it is remarkable for great lightness, which is increased by th« 
large number of foramina found on its surface. The five boneSi 
which originally composed it, are termed the false sacral vertelnw. 
It is well to mention, that occasionally there will be aiX) aad 



THE PRINCIPLES AND PRACl'ICE OF OBSTETRICS. 



ftotnetimes only four (lieces entering into the formation of thi? 
bone. The direction of the sacrum, in its connexion ^ivith the 

other pelvic bones, is 
obiique from beforo 
backward, and from 
ubuve downward, so 
that it furnis in front, at 
itsi juneiion with the 
la^t hiinbar vertcbni, a 
prominent obtuse angle. 
It is divided into an 
anterior surface, a pos- 
terior surface, two late- 
ral gui faces, a base, and 
a t^unimit, or apex. 

The ajitcrior surface 
(Fig- 2) prcsients some 
interesting points for 
the accoucheur. To- 
Fio. a. gel her with the coccyx, 

as has already been 
remarked, it constitutes the posterior wall of tlie pelvic cavity, 
being much more concave in tite female than in the male ; there 
are four transverse lines on this surface, marking tfie points 
of original separation between the five bones wliieli have now 
become consolidated into one mass. Just on the outer poilion of 
these Tmea, on either side, arc several foramina, usually fmir in 
number, called the anterior sacral foranuna, which aiford trarjKmi^* 
sion to the anterior giicnd nerves. This surface is occupied by the 
rectum, and what h known as the meso-rectum, which in nothing 
more than a foM of the peritoneum; blood-vessels, and the ante- 
rior sacral plexus* of nerves, together with a portion of the pyri- 
formi'i muscle, will also be found at this point. 

* Tlio anterior wiornl, or sthitic plcxua of nerve**, as if. is w>ii>etlni09 ctiHed, b 
formed by the tation r»r ilie four upper sncnil utid lii8( lutnbnr nenrps; the plvjeui ts 
ijlttJiUsl lit Uio «i«lc of tliij rectum, uoil rviaU on Uiu Antnriur eurfHce of iliu pjrHror* 
mw muscle. It la covered in front bjr tlio j*elvic tascia^ by which it la iM*piirnle4 
frotn the JKriJilic iiiid pudic brnnchon of the hypogiistnc artery, and nUo fmm the 
peWw viscera, I am quite conSddiit that EutHcient attention has not been ^ven to 
the influence of the Muionor micnil plexus of nenrpii lu producini; tnnny pnthologi* 
piiunouienM in worncRt •^'^►t on\y dunnp prej^imnry nnd ehl1dbirth» but aIso in 
ried wutnen vflio have never b<irne children, wnd especially in young girltL Tb© 
'itudcnt should remember the multiplied connejcions of this plexus, through ncr^ 
V0U8 diitributiont v^jlh other portions of ^he gy^tenj ; snd he will llien nppreciiilfl 
why an irriraiion of the anterior stucrol plexus, no mutter from what cause (nnd how 
often Is tt rectum, londcd mih fiecnl matter, the only source of tiiis irritation f), will 
oflentimes give rise U> anDoying disturbances in oUier portions of the fnrstein, whicti, 
imhAppily fur the pAtienI, an too frequontly regurded as idiopathic, or pricoAij 






IE PRINCIPLES AND PRACTICE OF OBSTETRICS. 6 

The posterior fluHiice of the sacrum (Fig. 3) is conyex and 
rough, Ibnning, in these particulars, a Btrikiug contrast with the 
anterior surface* Passing perpendicularly down the centre wi!I 
erved several Kmall eminencesi, the analog:ue8 of the spinous 
ses of the vertebral column ; on the sides of these emi* 
nenees will be seen the four posterior sacral foramina, for the 
passage of the posterior sacral nerves. This surface presents 
Dothiiag af special interest to us, except that it may be denomi- 



w 



J'*i 



Fio. a. 



Fm. 4 



a subcutaneous surface, as usually nothing intervenes 
tween it and the integuments but muscular aptmeuroses. This 
latter fact has a certain importance in the application of the 
peUiraeter for the measurement of the pelvis ; and we sliall again 
allude to it when speaking of pelvic deformities. 

The I wo lateral surtaces (Fig, 4) are broad and thick above, 
Eld tapering below; their upper portion presents an irregular 
articular surface, by which, through the medium of cartilage, 

wherciis they are bat symptoms or evidences of trouble clae where. In order that 
4b« pupil niDjr sec lh<> force of whut I have just stated, lot us ^ve a mnninpr out- 
Itoe €»t foine of the more imporUjit connexions of this plexus of nerves. The four 
But Anterior branches of the sacruJ ner\'eis bwiidea contHbuting to the forniAtioti of 
tli« mcml plexus conimuuicato with the siicriil gftnjrlia of the great syuipathelic, or 
tritpliiocbitic, which pre^^ides over organic Hfe, From this it is easy to uuder^tiind 
Iaow dJjftstlon, th« nutritiir© ftinctioos genemlly, and* in a word, any portion of 
oni^iiio exiat«nee, may become d<?ninged froon oripuftl irritntion of the »at*nil 
plifXtu. The flHh anterior Hacml nerve passes t4> tht^ sphincter, levator aul, and 
eoccr^oiia mutetos. Uuy we not, by rcmeniboriug thm latter fact, he oftcntimea 
onabtcd to explain tnnuy of ih© morbid phenomena occurring in these parts ? In 
additioQ lo the portions aln*Ady nimitMi us being supplied with nerves from the 
imcraX plexus, ir© muy state thut tlio tliree glutei muscles, and tlie lubLa extenm^ 
also derive uerres frooi the name aource. 



6 



THE PRINCIPLES ASV PRACTICE OF OBSTETRICS. 



,it is united to the corre8poniling iliac bone, forming the sac 
^ iliac symphysis. Posterior to this articular suHace are sever 
eminences and depressions, afibrding attachments to strong lig 
Bientoua fasciculi, which are inserted into the iliac bones. Th 
lower portions of the lateral surfaces, where they become thin and 
tapering, are eoveied by denne fibrous tissue, which contributes 
the formation of the greater and lesser sacro-ischiatic ligaments. 

The base exhibits a large articular surface, the direction of whi€ 

is oblique from before backward, and from above downward, an3 

which becomes united to the lant lumbar vertebra ; immediately 

I behind this surface is a triangular opening, the commencement of 

[the canal, which extends nearly along the entire length of iho bone, 

I and affords lodgment to the sacral nerves. 

The ape^, or summit of the sacrum exhibits nothing worthy 
attention, with the excepuon of an oval surface, which articulate 
with the upper portion or base of the coccyx. 

The eoccy^jc (I^^ig- ^) i» ^ ^rnall triangular bone, formed by the 
UDton of three, and occasionally of four small pieces; 

Tit receives its name from the resemblance to the bill 
of the cuckoo; it in Situated at the lower and posterioc 
part of the pelvic cunat, and articulates with the ape 
of the sacrum. Like the latter bone, the coccyx 
Fia. a. divided into an anterior and posterior t^urface, two 

lateral sui'faces, a base and summit. 

The anterior surfiice h concave, and receives the lower extremity 
of the rectum; on this surlace are seen transverse lines, which 
designate the original points of separation of the three or fou 
pieces of which the bone was originally composed. 

The posterior surface (Fig. 0)^ convex and irregular, afibrds 

attachment to some of the fibres of the large glut 

muHcles, and to the posterior sacro-coccygeal ligamenti 

The two lateral surfaces, thin and irregular, give 

attachment to the ischio-coccygcaj muscles, and lh«^ 

small sacro-ischiatic ligaments. 

ria, «. The base, slightly concave, has an oval surface, whiot 

unites with the summit of the sacrum. 

Tl»e apyx^ terminated by an osseous tubercle, which is occasion- 
ally bifurcatedj usually projecting forward, but sometimes laterally. 
or backward, gives insertion to the levator ani and external sphinc 
ter ani muscles. 

The coccyx o(\entimes exercises an important influence during 
childbirth, and especially in women who marry late in life, say fr< 
thirty to forty years. As I shall have occasion to mentioa, whe 
speaking of the articulations of the pelvis, the sacro-eoccyge 
articulation in the female is a movable one, and hence, during tl: 
passage of the child through the maternal organs, the cocc^ 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 7 

recedes so as to enhance, from one half to three quarters of an 
inch, and sometimes more, the antero-posterior diameter at the 
inferior strait of the pelvis. But, in women who do not bear 
children prior to thirty years of age,' this articulation is apt to 
become so consolidated as to offer great resistance to the efforts 
of the uterus, thus involving the necessity of instrumental deliveiy. 
Your attention shall be particularly directed to this subject in 
another part of these lectures. 

One more fiict in reference to the coccyx, and it is this : you will 
sometimes observe in practice, especially when the head of the 
fcetus is beyond the usual size, that the coccyx will be pushed so 
far backward as to form an inverted angle with the lower portion 
of the sacrum. The patient will complain of pain in consequence 
of this position of the bone, and I have known it in more than one 
instance to result in inflammation and ulceration of the parts, giving 
rise to a very unpleasant condition of things. The rule, therefore, 
for you to pursue in these cases, is at once, as soon as the delivery 
\s completed, to replace the bone, which is easily accomplished by 
taking a small piece of padded cotton in your fingers, and with it 
make gentle pressure on the coccyx, which will readily yield and 
assume its natural position. This may appear a very trivial sugges- 
tion, but it is one well worthy of recollection.* 

The OS innominatum (Fig. 7), known as the coxal^ or haunch 
bone, is the largest of the fiat bones in the skeleton ; it is irregular 
in shape, being contracted in its central portion, and, as it were, 
twisted on itself in opposite directions ; it forms, with its fellow, 
three-fourths of the circumference of the pelvic cavity ; it is situated 
between the sacrum and os femoris, and constitutes the lateral and 
anterior boundaries of the pelvis. The innominatum presents three 
divisions, or regions, the first of which, superior and posterior, is 
called the ilium ; the second, which is in front, the pubes ; and the 
third, situated inferiorly, the ischium. Though the bone is con^- 

* It will occasionally happen that the coccyx is fractured during delivery ; and 
this is apt to occur when the bone has become completely anchylosed to the sacrum. 
Under these circumstances, the head of the child, driven by the uterine effort against 
the •acro-coccygeal articulation, constitutes a force which the coccyx cannot resist, 
and it becomes fractured. The rude and unskilful use of instruments will also 
sometimes produce the same result In such a contingency, all that is necessary, 
as a general rule, will be to enjoin on the patient absolute rest ; let the bowels be 
in a moderately soluble condition, in order that the rectum may not become loaded 
with fsccal matter, which latter circumstance would induce irritation and interfere 
with the restorative process; and it must not be forgotten that an important featuro 
in the management of this case is to retain, as far as may be, the coccyx in the 
position it usually occupies with the sacrum ; for otherwise, by being allowed to 
project too far forward, it would necessarily, after the fractured surfaces had become 
oODSolidated, abridge the antero-posterior diameter of the inferior strait, thus, in the 
event of a subsequent pregnancy, entailiug on both mother and child some of thft 
perils consequent on a pelvic dehrmity. 



8 



THE PRINCIPLES AND PRACTICE OF OBSTETRICa 



soHctated into onti masfl in adult age, yet, io early life, as you linve 
been told, it is divided into thr*je distinct portions; these all iinit« 
at a eommoQ point, viz, ibe aeetabulumf or cotyloid cavity, wUlcb 



Tia, T. 

reopives the head of the thigh-bone, being an example of the arti* 
culation known as enarthroitis. 

I. Tlie ilhitn^ the largest of the three di^dsions, is nearly trlao* 
gulnr in shape, and has two Burfae-es, an eattemal and internal ; 
three bordori*, and three angles. 

The extenial surface (Fig. 8), slightly undnhiting, ia called the 
dorsum or back, and is occupied by the tlirec glutei mu&cles; there 
is nothinjx of obstclfic intporliinfe couiierted with it. 

TIk» internal surface is divided into an upper or anterior, a lower, 
and posterior portion. The anterior or u]>per surface is broad, 
concave, and smooth ; it is called the iUae fos^a or venter^ and ia 
occupied by the iliaeuH intrrnus muscle. This suriaee is sc[)arated 
from the lower portion of the bone by the linea-ilio-poctincji, a lino 
which parses along the brim or su[)erior contour of the pelvis; it 
is thii lower portion of the ilium which contributes to the fonna- 
tiou of twO'tiflhs of the acetabulum. The posterior surface is made 
\i] t(»ly bthind the iliac fossa, and 

vri' i|icct, of which there are two 

The supeiior is conc4»ve, 

viruic li;;r|nnenls, while 

intervention uf caxti- 



THE PRINCIPLES AND PRACTICE OF OBSTrFBHOa 9 

gfo — aij articulation kno\m as synetiondrosis — with the corre- 
an<ling JateraJ titirface of the sacrum. 
The »ufH>riar border of tfie ilium presents the figure of an italic 
S, and is sornetimtiS called the crest of the ilium ; it is the longest 



T*^^ 



of ihe three borders, and is divided into an internal and oxtemai 
Up, ftiid also into nn intermediate substance, the inteiistice. The 
intprnal lip affords attachment to the transversal is, quadratiis lum- 
borHm, and erector spinse muscles; while to the external lip are 
ttiohed the obliquns extennis, the latissimus dorsi, and femoral 
Ipottearosis; the obliquus intcrnus is inserted into the interstice. At 
the anterior extremity of the 8U]>erior border, is found the anterior 
ajieiior spinous process, the eeniral portion of which gives origin 
I the sartoiiiis muscle and Pou part's ligament, the outer portion 
to the tensor vaginiie femoris, and the internal surface to the iliacua 
intenius muscle. Posteriorly, the superior border is terminated 
by the posterior superior spinous process. 

The anttrior border commences at the anterior superior spinous 
process, and presents two notches, one of which is larger and less 
superficial than the other ; these notches are separated by the ante- 
rior inferior spinous process, into which is inserted the straight 
tendon of the re«'tus femoris muscle. 

The fx>stt^ior l>order is bounded above by the posterior spinous 
proce^ of the ilium, beneath which is a notch separating it from 
another projection, the posterior inferior spinous process ; below is 
iho great ischiatic notch. 



10 



THE PBIKCIPLES AND PRACTICE OF OBSTETRICS. 



The three angUs of the ilium arc nothing more than certain pro- 
jections resultini^ froin the junction of the three borders ; for 
example, the crest of the ilium fonns, with the anterior border* aii 
obtuse angle, the anterior superior spinous process; while the 
janetion of the crest with the posterior border fomns the second 
angle, the poisterior superior spinous process j and the third angle 
is represented by the union of the anterior and posterior borders, 
which, from its size, is sometimes described as the base of the ilium. 

2. The OS pubis is divided into two rami or branches; the hori- 
SEontat nimuH, sometimes called the body of the puhes, extending 
from the 8ymphyt*is pubis to the acetabulum, of which it contributes 
to form one tilYli ; this ramus affords the superior boundojy of the 
obturator foramen, while the descending ramus passing downward 
to unite with the ascending branch of the ischiutn, constitutes the 
internal wall or boundary of tljis same foramen. It is worthy 
of remark that the descending branch of the y^ubes does not 
descend vertically, but, on the contrary, forms, with its fellow on 
the opposite nide, a t^pace resembling an inverted V, known as I he 
pubic arcade; this latter is much wider in the female than male, 
for the obvious reason that it attords egress to the child, 

3. The OS ischium^ os sedenfarium^ or seat-bone, may be divided 
into two surfaces, two extremities, two borders, and a spinous process. 

The external surface is convex and irregular, and contributes to 
the formation of two-fifths of the acetabulum, ami also forms the 
external boundary of the obturator foramen. 

The inter/ial surface is smooth and slightly concave, and extends 
fVonv the superior to the inferior strait of the pelvis; this surface 
prcscuts a poiut of great value to the obstetrician, one which can- 
not too closely occupy his attention, for without an accurate know* 
ledge of its direction and uses, it will be impossible to comprehend 
the mechanism of labor* I allude to what is known as the incUntd 
plane of the ischium; its direction is from above downward, from 
behind forward, and from without inward ; it is on this plane, 
partly, that the head of the foetus rotates during its passage through 
the pelvic crivity. 

The Mtiperior extremity is thick and broad, and becomes oon- 
ounded with the base of the ilium. 

The inffirlor extremity is known as the tulterosity of the uchiitm^ 
that poiiion of the hone on which we sit; from the internal portion 
of the tuberojiity i*priugs the ascending ramus of the ischium, which 
unites with the descending ramus of the pubes. From the outer 
j)ortion of the tuberosity arise the quadratus and adductor muscles; 
^tnd from the iimer portion proceed the inferior geminus muscle, 
and great sacro-ischiatic ligament; the biceps flexor cruris, semi- 
tendino^us, and aemi-membranosus, arise from the central portion 
of the tuberosity. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 11 

The anterior or internal border aids in forming the obturator 
foramen, while the posterior or external border regards the sacro- 
ischiatic notch. About the inferior third of this notch is observed 
an eminence, extending obliquely downward and backward, known 
as the spinous process of the ischium. 

Under ordinary circumstances, this process does not possess much 
interest ; but it will occasionally exercise a very important influence 
on the progress of childbirth. For example, it is sometimes curved 
inwardly, exhibiting a sort of hook-like process ; in this case, as the 
head or presenting portion of the child descends into the pelvic 
cavity, it becomes arrested by this spinous projection. The uterus 
still continues to contract with great energy ; there is no progress 
in the delivery ; the life of the child is placed in serious peril ; the 
strength of the mother is becoming rapidly exhausted ; and the 
accoucheur is urged by anxious friends to do something to relieve 
the suffering patient. If, on a careful examination, he should 
ascertain the true cause of the difficulty, namely, the impediment 
offered by the abnormal condition of the spinous process of the 
ischium, he would proceed at once to overcome the obstruction, 
by introducing either the vectis or one blade of the forceps, for 
the purpose of liberating the head, or whatever portion of the 
fcBtus may present, from the antagonism offered by the malformed 
spinous projection ; and thus, by timely and judicious interference, 
he saves the lives of both mother and child. If, on the contrary, 
the practitioner, as unhappily is too oflen the case, should limit 
himself to an abstract view, and suffer his mind to be exclusively 
centred on the fact that the delivery does not progress^ nottoith" 
standing the strong efforts of the uterus^ he would most probably, 
under the circumstances, have recourse to the operation of em- 
bryotomy, which necessarily involves the destruction of the child, 
nrhile, at the same time, it places in serious hazard the safety of the 
mother. 

Let me, gentlemen, thus early in the course, caution you against 
this unjustifiable, nay, cruel tampering with human life. It will be 
my pleasure and constant aim, in the present series of lectures, to 
inculcate upon you an inflexible principle, namely, that the car- 
dinal object of the accoucheur, when he crosses the threshold 
of the lying-in chamber, should be a conscientious exercise of his 
skill to mitigate, as far as may be, the sufferings of his patient, 
and conduct her safely through the perils of her parturition. 

These objects can be attained only by a thorough knowledge of, 
and practical familiarity with the details of the science, the end ot 
which is to afford safety to both mother and child at the most 
trying, and, at the same time, the most interesting era of woman's 
life — when suffering the pangs of labor. 



LECTURE II. 

Utefl of the Pelvifi — Articulationa, or Jointn of the Pelvis— Do these Articulations 
during Pregnancy become Relaxed ? — Is their separation necessary, at the time 
of Labor, for the passage of the Child 7 — Objections to the Thbory of Separation 
— Pathological Cliangcs in these Articulations— Form ot the Pelvis — Tlie Greater 
and Lesser Pelvis — Straits of the Pelvis — The Pelvis is a Crooked Canal ; Proof 
— Axes — Varieties of the Human Pelvis— Influence of 'Sex and Age— Contrast 
between the Male and Female Pelvis — Pelvis of the newborn Infant — The Pelvis 
in Connexion with the Sott Ports — Its Measurements. 

Gentlembn — In the preceding lecture your attention was di- 
rected to the consideration of the bones of the pelvis ; and hav- 
ing described, in detail, the peculiarities of each of them, it now 
remains for me to show you in what way nature has provided for 
tlieir solid union, so that, in the aggregate, they may exhibit a 
power of resistance absolutely essential for the adequate discharge 
of their various functions. It is only necessary to reflect for a 
moment on what b required of the pelvis, to appreciate that, for 
the proper performance of its duties, great solidity is needed. In 
the first place, not to speak of its offices at the time of paiturition, 
it is the foundation of the trunk, sustaining, through the articu- 
lation of the spinal column with the sacrum, the superincumbent 
weight of the body, which, in the standing position, is transmitted 
to the inferior extremities, and, in the sitting, to the tuberosities 
of the ischia. The pelvis is also called upon to afford accommo- 
dation and protection to its viscera, viz. the uterus and its append- 
ages, together with the rectum and bladder. Another important 
office is to receive the attachments of muscles, the object of which 
is to produce different movements of the trunk and lower extremi- 
ties. Again : it has to sustain itself against the resistance offered 
by the lower extremities in the support they afford to the weight 
of the body. You see, therefore, without adequate provision for 
the proper binding together of the individual bones, how incompa- 
tible these duties would necessarily be with the integrity of the 
pelvis. 

Artictilationa of the pelvis. — ^The articulations are termed 
symphyses, and are as follows : The sacro-coccygeal symphysis ; 
the symphysie ptibia ; and the two scuro-Uiac st/mphysea. 

The aacro-coecygeal symphysis results from a junction of the 
j9ro oval surfaces, one of which is at the apex of the sacrum, the 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 13 

Other at the base of the coccyx ; the junction is through the 
medium of a fibro-cartilage, thus resembling the mode of articu- 
lation between the bones of the vertebral column. In addition, 
this symphysis is supported by an anterior and posterior sacro-coc- 
cygeal ligament, which, respectively, descend from the anterior and 
posterior surfaces of the sacrum, and distribute themselves upon 
the corresponding surfaces of the coccyx. The three or four 
bones, which constitute the coccyx, are also united through the 
mterposition of a fibro-cartilage, and it is alleged that the sacro- 
coccygeal articulation becomes anchylosed earlier than the first 
and second pieces of that bone. I need not repeat here what I 
have already stated, in the preceding lecture, as to the mobility of 
the sacro-coccygeal articulation, and its influence on childbirth. 

The symphysis pubis is formed by a union of the two pubic 
bones ; each of these bones presents an oval surface, slightly con- 
vex and mieven, the inequalities of which, however, are removed 
by the expansion of a layer of fibro-cartilage. In consequence of 
the convexity and peculiar direction of these surfaces, they are 
in contact only at their posterior portion, and for a small distance, 
so that superiorly, iiT front, and inferiorly, there is a space, which 
is occupied by the inter-pubic ligament. This ligament varies in 
thickness in the different points of its position ; for example, it is 
thickest above, while, as it passes in front and behind, it loses its 
volume ; below, it becomes suddenly increased, and, by its expan- 
sion, forms the sub-pubic or triangular ligament. In addition, the 
symphysis pubis is strengthened by the anterior pubic ligament, 
made up of two pliuies of fibres, one superficial, the other deep- 
seated. The former commingles with the fibres of the two recti 
muscles, separating into two bands, and distiibuting themselves 
over the descending rami of the pubes ; the latter extends from 
one pubic bone to the other, and becomes ultimately lost in the 
inter-articular fibro-cartilage. 

The sacro'iliac symphyses, one on either side, result from the 
union of the lateral surfaces of the sacrum, with the two corres- 
ponding surfaces of the ossa ilii, the sacrum being fitted in like a 
wedge between these bones. From the office of the sacrum, 
receiving through the spinal column the weight of the body, more 
than ordinary security is required in the arrangements by which 
the junction between this bone and the two ilia is effected. The 
union is accomplished in the first place through the medium of 
cartilage, which, it is said by some authors, is confined to the arti- 
cular surface of the sacrum alone ; while, by others, it is contended 
that the same material exists also on the articular surfaces of the 
iliac bones. In addition to this mode of union, these two articu- 
lations are strongly fortified by various ligamentous bands; for 
example: 1. The sacro-UidC ligaments, known as the anterior and 



14 



THE PRIKCIPLES AND PRACTICE OF OBSTETRICSp 



posterior ; they are simply an asseniblage of IigaiDentous fibres, 
ftliove, below, and at the postei-ior portion of the sacro-iliac junc- 
tion, but which, from the multiphcity of the fibres in close ajiprox- 
iinatioo, render Ihem efficient in ^ivin«^ 8trcnijth to thi* articu- 
lation. 2. The greater or posterior sacro^ciatlc ligament^ which 
U flattened and triangular, and occupies the inferior and posterior 
portion of the pelvis; besides strenfjthening the sacro-iUaiJ eymphy- 
818, it completes the wall** of the Icj^ser pelvis, and aid si in support- 
ing the weight of the viscera lodged vviihin the pelvic cavity. It 
aritiea from the tuberosity of tlie ischium, and is inserted into 
the lateral surfaces of the sacrum and coccyx, and also into the 
posterior inferior spinous process of the ilium. 3, The lesser or 
ariUTior saerosckttic ligaiuent, which is also triangular, is situated 
in front of the other, and answers the same uses. It extends from 
the spinous proces:) of the ischium to the sides of the saorum and 
coccyx. These two ligfimtnts convert the ischiatic notch into two 
foramina. Tin? 6rsL is the larger, and gives transmission to the 
pyrifurniis musele, the great ischiatic nerve, and also to the internal 
pudic nt'rvea and vessels; while the second affords pa^^sage to the 
intcmsd obturator tnnscle, and internal purlic tessels and nerves. 
,1 shall next cail your attentioti to one oiher articulation, viz. the 
rf^-f'ertehrai. It results from the junction of the base of the 
sacrum with the lower articalatiiig surface of the h\si lumbar 
vertebra. In the first place, the union ia formed by a tiViro-carti- 
lagc, which is much thicker in front than posteriorly, and this 
exfilaius in part the great prominence of thi* articulation ; secondly, 
there arc various ligaments which contribute .to its consolidation 
—the anterior and posterior vertebral ligameute, the inter^^apinous, 



Fio. f. 



together with the sacro^vertebral ligament. In addition to these, 
there are the ileo-lumbar and ileo-vertebral ligaments. 



THB PRINCIPLES AND PRACTICE OF OBSTETRICS. 15 

Helaaatian of the pelvic articulation — their separcUion at the 
time of labor. — In conneidon with the pelvic articulations, an ex- 
tremely interesting question arisen. Do these articulations, during 
pregnancy, become relaxed, and, at the time of parturition, sepa- 
rate ; and, if so, is this separation required for the properly carry- 
ing out of the reproductive scheme ? To show that this question 
is not unimportant, I may mention that it has not only attracted 
the attention of the learned in our science, but it has called forth 
earnest advocates both on the affirmative and negative side ; and 
it, therefore, is, in the strict acceptation of the term, a debatable 
subject. It was a favorite notion of the early fathers — ^and such 
was the belief entertained for a period of two thousand years — 
that the various pelvic symphyses did positively become relaxed 
during gestation, and separated at the time of labor for the pur- 
pose of affording increased facility to the passage of the child. 
Hiis opinion, it seems, was the universally accepted one mitil the 
sixteenth century, when, for the first time, it became the topic of 
controversy, and to this day it cannot be said to be settled. 

There can be no doubt that the symphyses do become more or 
less relaxed during the progress of gestation, and this relaxation is 
in perfect keeping with other phenomena, which occur at this 
period. As I shall have occasion to tell you, when speaking of the 
changes in the uterine organs consequent upon pregnancy, one of 
the lirFt of these modifications is an increased afflux of fluids to the 
parts, the result of which is a gradual relaxation and increase of 
the tissues composing the uterus. But this afflux is not confined 
to the uterus ; it pervades the surrounding structures, and, among 
them, the very structures constituting the bonds of union with the 
different bones composing the pelvic canal ; in this way, no doubt, 
the temporary relaxation is produced. 

Tliere are, however, in ray mind, two solid objections to the 
hypothesis that these bones separate at the time of parturition : I. 
There is no necessity for this separation, for the reason that, in a 
well conformed pelvis, there is absolutely more space than is 
required for the safe passage of an ordinary foetus ; and if the 
separation did really occur, it should be found much more frequently 
in cases of pelvic deformity than when the canal possesses its 
normal dimensions, which, as far as I know, has not been shown to 
be the fact; 2. It b not to be supposed that these bones could 
become detached sufficiently to increase the cavity of the pelvis, 
without entailing upon the parturient female the absolute necessity 
of retaining the recumbent position for weeks and months sub- 
sequently to her labor; which is contrary to all experience, 
for the great majority of women indulge in locomotion some six or 
seven days afler confinement, and without any perceptible difficulty, 
except the ordinary weakness incident to their condition. So much^ 



16 



TUJ2 PRINCIPLES AND PRACTICE OP OBSTETRICS. 



then, for the general fact touching the uniformity of this separiition 
of t lie pelvic bones.* 

On the other hand, it cannot bo doubted that the articntntiona 
of the pel via wiJl occasional ly become the scat of serious inflani* 
matory action, resulting in purulent engorgements, and other de- 
ran<rernents requiring consummate skill on the part of the |*raeti' 
tiotkor to rescue his patient. But this is a pathological condition, 
iind, therefore, j»rcsents no support to those who contend that 
separation of the pelvic bones is one of the phenomena of labor. 

The Greater and Lest^er Pelvis, — The general form or configura- 
tion of the pelvis h characterized by striking inegularity ; in order 
that you may have a comprehensive idea of thitt portion of the 
canal which bears directly an parturition, I ^hall describe to 
you respectively its two divisions, namely — the greater and kuer 
pelvis. 

The ffreater pdvis presents an irregular form, and ia hounded by 
three walls — two lateral and one posterior; tire lateral walls are 

formed by the two iliac 
fossie, while tlie posterior 
consists of the terujinal 
extremity of the f^pinal 
column, immediately be- 
licath which is the saero- 
V e rt eb r a 1 p r oi n i n en ce. Tlie 
anterior wal! is complete- 
ly wanting in the skeleton, 
while, ill the living or re- 
cent subject, it conjriists of 
the muscles and other 
structures constituting the 
front and lower portion of the abdomen. 

The kmer pi'ivf\% which i-^ directly below the greater, exhibits 
two opening's which have received the names of straits, for the 
siniple reason that they are narrower than the intermediate 
portion, whirh is called the cavity of the pelvis. These straits are 
denominated the superior, or abdominal, and the inferior, or peri- 
neal The superior strait, known as the brim, or inlet, consists of 
a prominent, irregular curved line; this line has a greater elevation 
posteriorly than in front. It commences in the middle of the sacro- 

* tt in well known, howereft that in ecrlaia miinmla there is a positive separation 
of 111© jMflvIc joints III the time of parturition ; fur exatuple, in the cow, one of the 
mdietitiuns of uppmaclung kbor will he a linking down of tlie on sacrum betweou 
tho (josieriiir surfucea of the oesft Uil Lc Gallois called ntteatioa to Ibo fact, ttiat a 
vAty remarkable nepamtlon of the njinpliysii pubin occurs in the gtiioea-pi^ ; and Mr. 
Robc-rtoii has aBcortiiined,43y actual experiment^ that Ihla aopiiraticm will take phioeto 
the exteol of one inch. 



Fro, m 



THE PRIKGIPLES AND PRAOTIOE OF OBSTETRICS. 17 

Tortebral prominence, and descends obliquely along the inferior 
border of the iliac fossae, ^hcre it becomes slightly rounded ; as it 
approaches the pulies, it is sharp, or cutting, and Anally terminates 
on either side of the symphysis of this bone — it is known as the 
linea ileo-pecHnea, 

It is difficult to describe accurately the form of the superior strait 
— some caU it a circle, some a triangle, and others say it is an 
ellipsis. Strictly speaking, it is neither one nor the other of these 
figures. But it is important for you to remember, in connexion 
with this strait, that there are six points, some of which have an 
intercf^ting bearing on the various positions of the foetus, as will be 
more particularly shown when treating of that subject. These 
points are three anteriorly, and three posteriorly ; the three foaner 
are the right and left acetabula and symphysis pubis ; the TOree 
latter are the right and left sacro-iliac symphyses, and the sacro- 
vertebral prominence. 

The inferior strait, or outlet, is much more irregular than the 
superior, and exhibits, as worthy of attention, three opening?, one 
anteriorly, and two posteriorly; these openings are separated by 
three bony eminences, one of which is behind, and the two others 
on the sides. The anterior opening, or notch, is called the sub- 
pubic arcade, for the reason that it is immediately under the pubes ; 
it is formed by the ascending and descending branches of the 
ischium and pubes, which present, as you have been reminded, the 
form of an inverted V, and slightly twist upon themselves forward^ 
and outward, so that their internal border is nearly in front, while 
their posterior surface is directed inward. The pos- 
terior openings are- called the sacro-ischiatic, because 
they are bounded by the sacrum posteriorly, and the 
ischium in front. The three bony eminences, which 
separate them, are the two tuberosities of the ischia 
on the sides, and the coccyx behind. '"'•• ^^ 

The lesser pelvis has four walls — one anterior or pubic, one 
posterior or sacral, and the other two lateral or ischiatic. The 
anterior wall is the length of the symphysis pubis, while the pos- 
terior is the extent of the sacrum and coccyx — so that the latter 
is two thirds longer than the former — a most important fact to note 
in memory ; for, as a direct consequence of this difference in extent 
of the posterior and anterior walls, there is to be deduced a prac- 
tical lesson of great value, viz. that when the occiput of the child's 
head is at either the right or left acetabulum, the labor, all things 
being equal, will be much shorter than when it continues at one or 
other of the posterior iliac symphyses ; and this ari^^es from the fact 
that, in the former case, the occiput has to traverse only one third 
the distance which it would be required to do had it to pass along 
the length of the posterior wall of the pelvic cavity. The twa 

2 




IS 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



lateral walls are formed by the lAchialio bones ; they extend from 
the superior strait to the tuberosities of the ischia, and, in ibeir 
widest portion, reach from the sacro-iliac symphysis on either side, 
to the posterior and middle portion of the corresponding acetabu- 
lum. 

The inclined planes of the pelvic cavity are worthy of a moraenlB 
attoDtioa, for tbey exercise an important influence daring I ho 
pa5i6age of the child through this caiial. Theee planes are four in 
number, two anterior and two posterior; and, in order that a 
definite idea may be had of them, it ban been suggested to make 
two vertical sections of the lesser pelvis, so as to divide it into four 
equal parts. Thui*, the two anterior planes would be represented 
by ^x>rtion of the lateral, and the entire of the anterior surface of 
ihe^tcavation ; while the sacrum and coccyx, together with the 
sciatic ligaments, and fiacro-iliac articulations, would constitute the 
two posterior planes. When spenking of the mechanUm of labor, 
we shall again refer to this subject, in connexion with the manner 
in which the f(Bt^l head h made to glide along these planea in its 
passage through the pelvis. 



\^ 



Pia.m 



4, B» PliBf of tDi^priAT ttnli E, F, PUn* of Infrrior itralt, K, K, Line T«pr#sctitifig horisAO. 
C« D, Axl» of laptiiior «tnlt. &f , O, K, Centml carved Hoe of flxetvstlon. 

Pkme^ of the Two Straits, — You have already been made 
acquainted with the fact of the obliquity of the pelvis to the hori* 
»on, in the standing or erect position, and this is demonstrated 
(Fig. 1) by placing a Uae on the summit of the cranium, and 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 19 

passing it perpendicularly downward, so as to represent the axis of 
the \yody. This line, in its course downward, strikes on the sym- 
physis pubis, which would not be the case if the pelvis did not 
occupy, relatively to the trunk, an oblique position. The peculiar 
direction of the pelvis involves the necessity of an exposition of 
what are known as the planes of the superior and inferior straits ; 
a knowledge of these planes, with a due appreciation of the 
characteristics of each, is one of the essential elements to a proper 
nndei-standing of the principles which regulate the passage of the 
child through the maternal organs. 

The plane of the superior strait (Fig. 12) is an imaginary super- 
ficies, extending over the brim of the pelvis ; and, in order that all 
confusion may be removed, let us suppose the strait to be closed, as 
happily suggested by Lenoir, by a sheet of paper perfectly adapted 
to its size and configuration. This sheet of paper will represent 
the plane of the upper strait, while that of the outlet, or lower 
strait, will be indicated by a piece of paper similarly applied. 
Here, then, we have the two planes, respectively, of the two straits. 
The true relations which these planes bear to each other, and to 
the trunk, together with the line of their axes, has formed the 
subject of much discussion, giving rise to very contradictory opi- 
nions. 

It would not be profitable to allude further to this controversy 
than simply to remark than Naegel^, in a memoir published by him 
in 1825, gives an interesting analysis of the various opinions 
advanced, and presents his own deductions, which have been gene- 
rally adopted. He has shown, by numerous and careful experi*> 
ments, that the inclination of the plane of the superior strait to the 
horizon is from 59^ to 60**, and that of the inferior from 10** to 11**. 
The sacro-vertebral prominence has an elevation of three and three 
quarter inches greater than the upper surface of the symphysis 
pubis ; and, if a line parallel with the horiason be extended from 
this latter point, it will reach the coccyx at the union between the 
second and third pieces of this bone. Again : the extremity of the 
coccyx is more than half an inch higher than the summit of the 
pubic arcade.* 

Axes of the Pelvis, — ^The axes are three in number, viz. the 
axis of the superior strait, the axis of the inferior strait, and the 
axis of the excavation. What is the true meaning of the term 
pelvic axes? They are certain imaginary lines (Fig. 13) which 
shall pass perpendicularly through the centre of the planes of this 

♦ It is, however, to be recollected that this elevation of the coccyx does not often 
obtain during tlie transit of the child through the inferior strait ; for, at this time^ 
the coccyx, owing to its mobility, is turned backward and downward, so that» in 
lieu of elevation, it becomes on a level with, and sometimes is even below, tho 
iaforior portion of the pubic symphysis. 



nu rtaciFLMs asp rmicncs csr 

lo order to apprecnte tke axis of tke wmpmor 
wifl Mippoie a fine whidi, wun^toag the niddle of the antero* 
poiterior diameter of thia strait at a right aogfe, aad being carried 
apward, will ftrike the oinbilieiii ; oo the cootrarr, if directed 
doiTDirard, it will &0 oo the coocjx. The axis of the iulerior 
strait will be represented hj a fine intersectbg the centre of the 
eocci-pabic diameter of this strait at a r%ht angle, which line will 
terminate superiorly below the sacro-vertebral prominence ; and its 
inferior terminal point, with the cocejx in position, will be through 
the centre of the bis-i«chiatic diameter, and, if carried through the 
soft parts, will pan to the anus itself. At the time of labor, how- 
ever, when the coccjx recedes, the direction of this axis will 
necessarily undergo a change ; for, in thb case, the lower extremity 
of the line would be slightly posterior to the anus, while xht 
upper extremity would commence a little in front of the sacro- 
Tertebral prominence. 

From what has just been said touching the axes, which reqieo- 
tiTcly define the direction of the two straits, it is evident that the 
junction of these two lines will represent an obtuse angle. This 
result, however, would prove a physical impos»bility, if the straits 
were on the same plane ; for, as you will readily perceive, in such 
an event the line passing through the centre of the upper strait, 
instead of terminating on the coccyx, would penetrate directly the 
centre of the lower strait ; or, perhaps, more properly speaking, the 
centre of the vulva. 

The axis of the pelvic excavation now claims our attention, and 
it is this axis which presents special interest to the accoucheur ; for 
the line, which ultimately describes it, indicates, with unfailing pre- 
cision, the direction purttued by the foetus in its passage through 
the canal. The axis of the excavation will be found by extending 
a line from the superior to the inferior strait, which in its course 
shall be equidiMtanl from the four pelvic walls by which the excava* 
tion is bounded. Now, if it be recollected that the posterior wall 
of the pelvic cavity is, under ordinary circumstances, not straight, 
but curved, and also two-thirds longer than the anterior wall, it will 
follow that the line which shall represent the axis of the excavation 
must be subjected to a corresponding curve. In one word, the axis 
will be described by a line in accordance with the curve of the 
sacrum and coccyx, and which is known by obstetricians as the cen- 
tred curved line of tlve excavcUian,* It is proper to mention here 
that this curved line is made up of a series of perpendiculars falling 

* It has already been obsenrcd, that change of posilion of the individual will 
effect a variation in the direction of the planes and axes of tlie superior and infisrior 
•traits ; but it slioukl bo distinctly remembered, as an important obstetric fact, that 
ih€ esnlro* curved tine (/ IA# txcavaiion is always identical, and in lo way influenoed 
by poeitioo. 



THE PRINCIPLES AND PRAOnCE OF OBSTETRICS. 



21 



on the naraerons planes in the eavitj of the leaser pelvis (Fig. 18) ; 
and it is also to be noted that the inferior extremit j of the curve is 
both elongated and broogfat forward by the distennon to whioh the 




Fia. 18. 
G,I>, Azisorraperiorrtrmit £, F, rUn« of inferior itnlt M,N,P, Central eiirTedlt]i«,«rfiz]fl 
of ttcaTation. 

perineum, vagina, and vulva are subjected during the parturient 
effort. 

There is nothing, gentlemen, more essential for you to remember, 
if yon wish to have a clear idea of the mechanism of labor, than 
the direction of the pelvic axes. They point out, in the first place, 
the course which the foetus pursues in its exit — (Fig. 14) showing, 
conclusively, that its progress through the maternal organs involves 
the necessity of its becoming curved upon itself as it follows the 
Knes of these axes, the concavity of the child*s curve regarding the 
symphysis pubis, the convexity the hollow of the sacrum. The 
appreciation of these axes is absolutely necessary, in all operations 
for the delivery of the child, whether manual or instrumental ; nor 
can you, for the purpose of extracting the afterbirth, or for any 
other object, attempt to introduce the hand into the uterus without 
subjecting the patient to the most serious hazard, unless guided by 
an accurate knowledge of the curves of the pelvis, and tho corres* 
pondence of the uterus with these curves. To this latter point we 
shall revert, when discussing the subject of natural labor. 



22 THK PB1KCIPLE3 AND PBACTICE OF OBSTOTBICS. 

Varieties of the Human Pelvis, — ^Thc human pel via presents cer- 
tain characteristic varietiesi, depending upon the sex and age of the 
iudividual. The adult female pelvis (Fig* 9), for example, exhibit! 
a striking contrast with the pelvis of the male. In the first plaoe, 
the former is wider and shorter ; the crests of the ilia, as also the 



\ 



\ 



\. 



\ 



"r L 



two anterior superior spinous processes, are further apart, which 
affords a greater capacity to the iliac fossie. The superior and 
inferior straits likewise present characteristic differences ; the con- 
tour of the upi>cr strait ii* larger and more rounded in the female, 
and the sacro-vertebral prominence is less markt'd than in the male; 
the two tuberosities of the Inchia are less thick, and are turned 
more outwardly* The sacrum is shorter and more concave, while 
the OS coccyx is further from the pubea, which gives a greater 
capacity to the inferior strait of the female in its antero-posterior, 
or cocci-pubic diameter. One of the most striking differences 
between the pelves of the two sexes is observable in the arrange- 
ment of the pubic arcade ; in the female it is capacious — in the 
male (Fig. 10), on the contrary, it is narrow. This arcade, you 
must remember, affords passage to the child during its progress 
through the maternal organs. 

It is impossible to contrast these points of difference without at 



i 



THE PRINCIPLES AND PRACTICB OF OBSTETRICS. 28 

ODce perceiving that nature, in the oonstmction and arrangement 
of the pelvb of the female, was influenced hy one cardinal object, 
namely, the adaptation of the canal to the necessities of childbirth. 

Bat, this peculiar construction of the female pelvis, while, all 
things being equal, it amply provides for the wants of parturition, 
brings with it certain inconveniences. For instance, I have shown 
you that, from the greater width of the pelvis, the anterior superior 
spinous processes of the ilia are further apart ; from this circum* 
stance, femoral hernia is more frequent in the female than in the 
male, and for the reason that Poupart's ligament, which you know 
extends, on either side, from one of these processes to the pubes, 
will necessarily present a larger space for the passage of the hernia. 
Again : in the female pelvis, the distance between the two acet»- 
bula is greater than in the male ; consequently, the inferior extre- 
mities, being more remote from the centre of gravity, impart to the 
female, in the act of progression, a vacillating, unsteady gait, 
resembling, in some sense, the walk of a goose or duck. These 
inconveniences, however, are insignificant compared with the great 
advantage she derives, in the discharge of one of the chief duties 
of her sex, from the peculiar configuration of her pelvis. 

If you inspect the pelvis of the new-bom child (Fig. 11), you will 
observe several remarkable differences between it and that of the 
adult. It is very much elongated, the superior strait looking down- 
ward and fon\'ard ; it is more or less in a cartilaginous state ; the 
sacrum is almost flat, and so elevated, that if a line be drawn hori- 
zontally backward from the upper portion of the pubes, it will 
strike the summit or apex of this bone. The iliac fosste are scarcely 
developed, while the iliac bones themselves are almost perpendi- 
cular at their upper poitions. From this peculiar arrangement of 
the pelvic bones in the foetus, it will be seen that the transverse 
diameter of the hips is less than that of the thorax, and also less 
than the bi-parictal diameter of the head, which is an arrangement 
advantageous for the safe passage of the child through the maternal 
organs. With a diflerent disposition, so far as their dimensions are 
concerned, there would, afler the exit of the head, be necessarily, 
from physical disproportion of the thorax and hips, a delay in the 
expulsion of these parts, which might involve oflentimes the safety 
of both mother and child. 

There is another interesting fact connected with the extreme nar- 
rowness of the pelvis in the new-born child, and it is this : the 
bladder, uterus, and its appendages cannot, for want of room, be 
accommodated in the pelvic canal, and are consequently, for the 
time, lodged in the abdominal cavity ; hence, the size and projection 
of the belly in the child and young animals.* 

The Pelvis in cwinexion with the Soft Parts, — In examinmg 

* Camper. 



24 



THE PRIKCIPLK3 XKO FRACrriCE OF OBSTETRtCS, 



the pelvis, in relatian to the soil parts with which it ia invested, 1 
iihall confine myself to the pelvic cavity, hrini, and outlet, for tliesa 
are the only portions of the canal wliich have an eesentiaj hearing 
on the passage of the fcctufi ; it is solely in reference to tbk latter 
pointy that it becomes necessary to advert to the soft strnctures at 
this time. On the lateral borders of the superior strait will be 
fontid the two psoaa muselei*, wliich pass down, from tht*ir origin, along 
the lowtT edges of the internal iliac muscles, and proceed nnder 
Puupart'H ligament to be inserted into the trodianter minor of tho 
femur. Ttie presence of these musdes, on the tJidus of the brim,* 
it will be well to roeollect, curtails ihe transvei*se diameter of this 
strait, half an inch on each eidc* Courting along the margin of the 
psoas muscles are the iliac arteries and veins, together with the 
crural nerves, and lymphatics. On the posterior surface of the 
excavation, you will observe the rectum, the pyriform muscles the 
internal iltae or hypogastric vessels, and the anterior sacral plexus 
of nerves, to whit^h allusion has already been made. Laterally and 
posteriorly, are the 6acro-6ciatie ligniiunts, with cellular tissue and 
layers of fascia. In front, the bladder, the internal obturator mu&* 
clcs, nerves, and vessels*, together with adipose cellular tihsue. 
Immediately behind the bladder, and in front of the rectum, will 
be found the uterus with its aauexie. 

At the inferior strait there are several small muscles, forming, aa 
it were, a double plane, which, together, constitute the luwer 
boundary or Soor of the outlet, sustaining both the pelvic ond 
abdominal viscera. This Boor, on its median line, presents three 
openings, which afford passage to the rectum, vagina, and urethra* 
The double muscular plane is composed, superiorly, of the levator 
ani and ischio<^oceygeal museles; inferiorly, of the sphincter 
imi, traufiversalis perinei, ischio-cavernous, and constrictor vagtuoa 
muscles. In addition to these, the boundary of the outlet is made 
up of aponeurotic coverings, a quantity of cellular tissue, the pudic 
vessels and nerves together with the integuments. The-^se parts, 
in fact, represent the perineum, which, during the passage of the 
child, undergoes an extraordinary distension, and, as has already 
been remarked, prolongs the parturient canal forward and upward, 
Measuretnenttt of the J^ehitt, — The pelvis has certain nieasure- 
Bnls or dimensions, w^hicli the student should clearly untlerstand, 
for it is upon the correspondenoe of these measurements with those 
of the foetal head that the fjurllity or diftleulty, the possibility or 
impossibility, of childbirth will oftentimes depend. Too close ation- 
iian, Uierefore, oannot be given to this subject, if you desire to 

I * U ifl 9uppo9(^d by Yolpoau, and others, thnt the iHteniul iliac flad paooii masdes 
\ Uie mAm of ilie brim, fonu o Bort of cushiou for tlie protection of the imprcgusiecl 
tigniiDtt the forc*o of conctisfiionA, and other iiijurit*« ; Aod Ihitt thU cuBhtcm 
JUcewim jurcveats uadue pivasure un the cnunl nenres. 



THE PRtKCIPLES AND PRACTICE OP OBSTETRICa 



25 



comprehend the beantifu! mechauHm, which nature has iriRtituted 
ft>r the purpose of accomplishing^ the expulsion nf the child ihrough 
ihe m:iternal organs. The diameters of the pi'Ivis may be divided 
into tho^ of the upper gtroit, lower strait, and c:ivity. 



Fta. 1& 

The upper sirnit (Fig. 15) presents the following: 1* The antero- 
posterior, sacro-pubic, or conjugate, each of these names being 
applied to this diameter ; it extends from the superior and internal 
portion of the ftyniphysjd pubis to the middle of the sacro-vertebral 
proniinenee^ and measures four iuehes ; '2, The transverse or bis- 
iliac di:iraeter, which extends from the prominence on the linea-ileo- 
peolinea (the line forming the contour or boundary of the brim) to 
the eorresponding prominence on the opposite side ; it measuren^ m 
the dried pelvis, iive inches, but, for practical pnrpoi^e!*, it yields 
only four inches, for the reason that it is abridged, on either side, 
half an inch in consequence of the presence of the psoas magnus 

Diu»*cle. You observe, therefore, that these two diameters, the 

itero-posterior, and transverse, make certain divisions of the supe- 
rior strait ; the former divides it, from before backward, into two 
fquihiteral portions; while the latter, the transverse diameter, 
separates this strait into two unequal portions^ an anterior and 
posterior; the reason of the inequality of this latter division is that 
the respective prominences to which the transverse diameter 
extiMids, approximate more nearly the sacrum than the pubes, 3, 
The other two di^imeters of the brim arc the oblique, and reach 
from the upper and posterior portion of the acetabulum, on either 

ide, to the oppo*»ite sacro-iliac symphysis ; each of these diameters 

fteasurcs four inches and a half. 

Let us now turn to the measurement of the inferior strait or out- 
let (Fig. 16). The diameters here are also four in number: 1. The 



26 



THK PBIKCIPUeS AKD PRACTICE OF OB3TETBI05. 



afitcro'postenor, or cocci-pubic, so called becaose it extends 
before backward, and from the summit of the pubic arcade lo^ 
extremity of tlie coccyx ; ita oaoal meisaremeDt is four iDcties ; butf 



FlQ. 11 

at ihe time of labor, owing to the retrocession of the coccyx, it \\i 
yield four inches and a h;ilf, and sometimes more ; 2. The trans 
verse or bis-ischiailc, receiving the latter name because il extend 
from the tuberosity of one ischium to that of the other; it meiisurt 
four inches; 3. The two oblique diameters, which reach from eacj 
ischiatie bone to the central portion of the opposite sacro-isctnati|| 
ligament ; they respectively measure four inches. The correspond 
ag dliimeterH of the pelvic cavity are all a fraction larger than thos 
of the t wo straits. 

Next we come to the measurement of the walls of the pelvis 
Tliese w^alls, you will recollect, are four in number — the anterior 
j»n^trrior, and two lateral. The tirst, niailo up of the symphyiiii' 
pti 1 1 i^ nieasurtja usually one inch and a half; the posterior wail^^ 
consisting of the sacrum and coccyx, is two thirds longer; the tw<i 
bitcral walls, which extend from the superior strait to the tuberosi 
ties oJihe ischia, measure about three inches* 

Tlie.Hc arc :ill the dimensions necessary for practical purposes j 
and you cannot but have observed, as we passed over iheni, one ofl 
two striking facts. In the first place, the longest diameter at the 
inferior strait 18 the direct, or cocci-pubie, while the longest at the 

sufterior slniit in the oblique ; ngain, the posterior w^all of the exca- . 

vation is two thirds deeper than the anterior wall. These ari|^| 
extremely interesting points, the ap[>Iic4Uion of wliich will be madd^^H 
when discus-ving ihc mechanism by which the child effects its exit 
through the maternal organs. 




LECTURE III. 

FoBtal Head; ita Regions, Dinmetera, Circamferenoee, Extremities, Sataran, Fonta- 
nelles— Sutures of the Adult and Fceial Head contrasted— Arch and fiase of 
Fcetal Head— The former undergoes Diminution during Childbirth, the latter does 
not ; Reasons for— Contrast between Diameters of Foetal Head and those of 
Maternal Pelris— Deductions — Articulations of Foetal Head— Two Movements, 
Extension and Flexion— Rotation. Presentation of Fcetal Head; its rulatiye 
Frequency- Presenution of Vertex— Circumstances which modify the Frcquencj 
of Head Presenutious — Causes of the Frequency of Head PresenUtions— Differ- 
ence between Presentation and Position— Six Positions of the Vertex by Baude- 
locque— Relative Frequency of these Positions— Naegele's Division. 

Gentlemen— Having described the normal pelvis, in relation to its 
bearings on childbirth, and called your attention especially to the 
measurements of this canal, which, you know, constitutes the space 
or passage through which the foetus makes its exit, the subject next 
in order is a description of the foetal head, with its various divisions, 
positions, etc.; and when this is completed, I shall proceed to show 
you the mechanism, which nature has contrived, according to the 
laws of adjustment, for the safe transmission of the child through 
the organs of the parent. The head being the most voluminous 
portion of the foetus, I shall limit myself for the present to a descrip- 
tion of it alone ; for, unless some deformity should exist, whenever 
the size of the head offers no impediment to its expulsion there will 
be found no obstruction in any other portion of the foetal body. 
This remark you may at first think strange; but the shoulders, 
chest, and pelvis of the foetus are so sofl and compressible, that they 
readily find egress, when the head has preceded them. 

Divisions of Metal Head. — ^The head of the foetus, for obstetric 
purposes, is divided into regions, diameters, circumferences, extremi- 
ties, sutures, and fontanelles ; and these divbions have, to a greater 
or less extent, a practical bearing on its passage through the pelvic 
canal.* The general shape of the head is that of an ovoid. 

* Dr. Clarke, of Dublin, was, I believe, the first to point out that the male foetus 
la, in size and weiglit. in every way larger than the female : with this proposition, 
now universally conceded, he attempted to show that the disproportion is the cause 
of a more protracted labor and a gpreater number of stili-Mrths in the case of male 
children. His paper, which will well repay perusal, under the title *' Observations 
on some causes of the excess of the mortality of males above that of females," will 
be found in the Philosophical Transactions of 1786, vol. Ixxvl p. 352. Prof Simp- 
ton has elaborated this fact, hrst propounded by Dr. Clarke, in a very mierwX\ii^ 



28 



THE PBINCIPLES AND PRACTICE OF OBSTETRICS. 



Megiona. — ^They are five in number: 1. Tlie vertex or summit; 
2. The face; 3. The two lateral regions; 4. The occiput; 6. Tlw 
base. Tliese various surfaces may present at the superior airsut 



memoir on the ** Sex of the Cbild," published in the Edioburgh Medical and Sur^ ' 
eaX Jonrnnl fur Octob<?r, 1844. 

The folJowing is an analyHia of the results at which Prof Simpson has arrived: — 
L A gre;itcr proportion of deaths oocurti m women who liuvu brought furth iimle 
children; 2. Tliere are more maJe sitJbborn children ihnn female; 3. OftheehUdre 
born alive and which Buffer from disease or injtihfs cotiBequent on piirturitiun, ihcii 
19 a ^eatcr proportUm nmong the mnlea thiui fomitlt^; 4. The number of HltM^ 
which dio in utero prior to labor, is »*bom equul among the innle and ftimalo; &. Fin 
laborw are more dangerous bolh to fnotht*r and child tlinn aubwqinnt ones; (?. Tb 
complic^liona of labor ore more fre\|ucnl tn thtj birth ol incite than ft-mafe chiMnm^ 
1. For the very marked diffcrenoefl between the difficultiea and perils of niulu 
compared with fernalo birth!^, there v% no other traceable chihw iu the meclmimiii i 
parturition thun tho lari^^er size of tbe bend of the tnttle child. 

It majr not be ortt of place to remark bercs, thitt iho fwurli deduction, tiz. *' lite 
umber <»f children whieh dio in utero prior to lubor in aboul equal among the ntale 
Fftnd female.*' if tfuc» is opposed to the ^nertil belief on the stibjeet; and il is to bo 
regretted that the learned professor hsid not more omi>lo data for llie opinkm 
expreaaed on lliis point. He i» in direct opposition both to Dra. Clarke and Qtiet^^ 
let: the former, in tbe paper already alluded to, observea, *' Aa the f^tamina of llu 
male are naturally constttuled to g:row of a gretiler ai&e, a greater supply of nour 
ment in utero will be necessary to hts growth than to that of Ibe feninle. Defec 
therefore, ofnouriahmeni proceeding from delicacy of constitution or diacoies of ihe-^ 
mother, niuat, of courBe» bo more injunout to the male sex." Quetelet, in bia admi* 
rable treatino on mati, Boy€^ ** It appears beyond doubt thai there ii a pufticulDrj 
CQUfc of mortnlity which attacks male children by preference before and immt^dialell 
«(ler Ibeir birth*' It ahoidd bo atuted in tliia connexion that the bills of mortal it^ 
in the cily of Hamburg [British and Foreign Medical Review, No. xxxvili.] give Ih 
proportion of the aoxcs In the caaes of prerouture ftiUl-boru cluldren as &2|^ male* 1 
47f females. 

In regard to the seventh deduction, arrived at by Prof. Simpson, it doefl aeem to mo 
that, while admitting the influenco of the Buie of the head as a cause of the incrended 
mortality among mule children, yet it ghouid not bo forgotten that pretematuml ] 
■eotationa are much more frequent among male than female oft'spnng. Concediq 
\\\\a to be so — and atatistica sustain the fact — it is, in my judgment, right lo refer I 
this character of pre^otatioD some portion of tbe acknowledged greater fatality \ 
male births. 

Dr. Vcit, of Prua^a [Britisli Aod Forcigo Hcdioo-Chirurgica] Review^ Jan. 1856^ 
p 2G8], has recently presented some interesting facts touching tl lis very subject. In 
his examlnatloD of Dr. darkens oplnioa, that the increani.'d mort4i1ity of male infant 
fa due to their greater si^ and weight, and ec>itHef|uently to the greatt r (iresaure up 
tbe bead, ho attempts to abow that this circumstance is not alone suRl- lout to iioo?iitU 
for tlie difference in mortality. He agrees with Casper, that the Ic' 
of the fL«ma1e sex has a detpor lyvlation Ui ihia quastion; and hti r< 
diffen*nc?o tn development b^twoon tbo aaxi'a ta too locon&iLi- r iln.' i 
marked an Inftiienee on iK* hi^ '*' «»i'i •IhUI In 'ITuM rl.Ililivr: I,. - i . 
tfneo oi weight bctwt 

0,22 of a dv' • ■' - 

six bnoa. 

inch. Pt. V I. 

girli are always ^t ^<i 



THE ?RiNCIFX.BS AND FKACTICE OF UBSTETKICS. 



29 



Fto. IT. 



the time of lubor ; and I need not state that tbe only circumstances 
under which the last re- 
gion or base is found 
there, will he when, either 
through an operation per- 
formed by tbeaccoaeheur, 
or through brutal manage- 
ment, the head has been 
separated from the trunk. 
_The region, which pre- 

ntn the most commonly 

the superior strait, is 
the vertex; and, when 
discussing tbe relative 
frequency of presentii- 
tious, your attention bhall 
be particuLirly drawn to this interesting fact. 

iJiameUn, — The dianicterti of the fa'tal head, which have a direct 

iring on its exit through the pelvis, are four in number ; 1. The 

ciplto-mental (Fig. 17), ftome- 
times called the oblique, because 
in position it is oblique to the axis 
of the body, is the longest diame- 
ter of tbe head^ and measures 
five Inches and a quarter; it 
extend^s from the central portion 
or }ux>minGDce of the occiput to 
the chin; 2. The nceipito-frontaL 
diameter, known a* the direct, 
ineaj5ures four inche?* and a quar- 
ter, and extends from the anterior ^^ 
portion of the frontal bone to ^fc s* / 
be occiput ; 3. The transveree or 
hparietal diameter (Fig, 18), 
su^nsares three inches and a half, 
reaching from the protuberance 
of one parietal bone to the corresponding protuberance oti the 
other; 4. The perpendicular or vertical diameter, which interseots 
tlio hi^parietal at right angles, and measures also three inches and 

i tbnmio Xuhxkl, m cotineoted with the duration of kibor, either in first or stibem. 

I jpryffoatK'ies, he pre«ent« the roUowing cnochisions: 1. Tbe dnng«r to the child 

m tXid htfth ia com|>k*t«! in twelve hours, ts only lialf aa ffre/it as when the labor 

I lo twt-uty-lour l>oijrs; and ihui further protniciion is still more dnoger 

- i!!' itunffer ti much incr(*iiBe<l when the socfwd frUifre of Inbor excpfda two 

' Wbon thi< duruttuu of thu eutiru Itil^or^ and tlie damtion eepefiall/ of the 

t^ an} cqujil^ the male sex is more eodangered thau the Tumale, 



Fio. IS. 



80 



THE PRINCIPLES AND PKACTICE OF OBSTETRICa 



a half; it extonds from the centre of the vertex perpendicnlarly w 
the base of the head** (^^S* 17,) 

Cirrum/erences. — The two circiimforences of the ftx-tal head are 
1* Tbe larj^er circiinii'erence, which separates the head iiito iwd 
e<^4«ihileral portions, and measures from thirteen to fifteen inches ; 
in commences at ihe symphysis of the chin, proceeds directly 
upward tklon^ tlie sagittal suture, and tfien down the central line 
of the occiput back to the chin ; 2» The lesser circumferenci 
which divides the head into an anterior and ]>osterior porti<m, am 
measures from len to twelve inches. It passes transversely across thi 
head, cumniencing at one of ihcprotnherances of the parietal bon 
J^Hr^mUie^* — The two extremities are ; 1. Posteriorly nm 
above, the promineuceof the occiput ; 2. In front and below, the chi 
Sutures. — The sutures may be said, for otir purpose, to be lliree 
1. The coronal; 2. The sagittal; 3. The lambdoidah The con 

nal suture (Fig, Id) is between 
the posterior edge of the fronts 
and the two anterior edges of 
the parietal bones. The sagittn 
suture (Fig. 18) extends froB 
the frontal to the occipital bone0 
and runs along the internal and 
superior borders of the two os 
parietalia. The lambdoidal sa 
ture, on the contrary, unites tfc 
]>ostcrior borders of the pane 
with the anterior borders of the" 
occiput. ^ 

Fhnlanrlhs. — ^The fontanelles 
Yuau, are two in number: 1, The an 

terior (Fig. 18), which is founj 
at the junction of the coronal and sagittal sutures ; it is quad 



4 



♦ Authors dlflfcr in their eetiTnat<? of the dmmclers of tho foetal head. It is 
eisy Ui Oo more Umn nppruxicDttt4) a tritt* nverugo of tliese measuremonts, and 1 
w© think we hiivo done in the ifxt Prof. Meigs, after an exftniinalion of one hu 
dred «ud fifty lieadss gives ibe following na Ibv rt'snit of hia observatioa: occipin 
tn^Tilai 5^ inehea; ofdpit/>'fronUil 4J". ; bi*p«ri(?tul 3jL 

In iho Amen Jour, of Wed Sciences for Jiui., I860, Jopeph K- J. Van Pelt, MJ 
flivts ineasurementa m«dc by hinus^lf of seven hundred foetal heads at term, 
tlib purjioao ho employed the cephalometr© of St*;in, In 646, lh« oodpito-menti 
diomelvr averiigi'd f>|J tnchr's; the occipito-froDtal 
bi- parietal diameter measured 3f J inches. 

Of 166 cranin measiired by Addinell Heniion, M*D., 
pir»i5.2r»: occipito-frooiaj, 4 68; bi-p«Hetiil, 3JJ0, 

It would, therefore, »eero, for aomo reason yet unexplained, thot authentic rneftp 
I'Mircmencs in thl<i country givo lar^r diumeteri for the roost part, especially the 
iDccIpito-frobtal and bi-parietal^ than foroiga meoaureiKiacta^ 



roeaaured 4^ bolies; tL« 
, the avernga oodpito-roenial 




THE PKINCIPLES AND PRACTICE OP OBSTETRICS. 81 

lateral in shape, membranous, and smooth. This fontanelle is what 
the old women call the " opening of the head." There is felt at 
this point a pulsation, which the ignorant oftentimes imagine to be 
the result of disease, but which is nothing more than an arterial 
throbbing. As ossification advances, this membranous expansion 
becomes consolidated into bone. 2. The posterior fontanelle (Fig. 
18), which is at the junction of the sagittal and lambdoidal sutures. 
It is usually, at birth, ossified — it is triangular in shape, and more 
or less rough. 

It is important to recollect the characteristic differences between 
these two fbntanelles, for they, as well as the sagittal suture, con- 
stitute the guides by which you are to distinguisli the individual 
portions of the vertex. For example, the respective positions 
of the fontanelles will indicate whether the occiput regards one of 
the anterior or posterior points of the pelvis ; while the direction 
of the sagittal suture will disclose whether the head rests obliquely 
or otherwise.* 

Sutures of Metal and Adult Head. — Although I have employed 
the term suture, yet you will at once perceive a striking contrast 
between the sutures of the foetal and those of the adult head. In 
the latter, they are serrated, and perfect in their organization, 
giving to the bones of the cranium a consolidation and immobility 
essential for the due protection of the brain. In the former, on 
the contrary, you observe a very different construction ; the sutures, 
instead of uniting the bones by a species of dovetailing, present an 
arrangement by which these bones — and this is more remarkable 
in the two ossa parietalia — are permitted to overlap each other. 
In this difference of arrangement in the adult and foetal head is 
exhibited another of those numerous evidences of design so con- 
stantly presenting themselves to the attention of the student of 
medicine ; evidences which, while they demonstrate the great truth 
that a supreme intelligence has directed the architecture of the 
human fabric, disclose the provident care which has been exer- 
cised in its adaptation to the special wants of the individual. When 
treating of that subject, we shall show you that the arch of the 
foetal cranium, during the passage of the head through the pelvb, 
oftentimes becomes diminished in its transverse diameter ; and this 
especially occurs in cases in which the head is a little larger than 
usual ; this diminution is accomplished, without detriment to the 

♦ An interesting fact haa recently been communicated, touching the occlusion and 
ossification of the anterior fontanelle, by Dr. Roger, physician to the Hopital des 
Enfans. in Paris. He is positive, as the result of his researches on this subject, that 
the cephalic souffle can be recognised only when there is no bony obstacle between 
the ear and the brain ; in the examination of nearly three hundred infurita, the fon- 
tanelle was never closed before fifteen months, and never found open afler the ag« 
of three years — [L*Union Medicale in 1859.] 



82 



THE PfdKCTPLES AND PKAGTICK OP OBSTETRlCfS. 



child or inoiiier, by the overlapping: of the two parietal lioiie 
You seo, ihereforu, I hat the lessening of the size of the heud coulj 
not be accompllsherl, if tfie sutures in the ftBtus were const ructe 
flimilarly to iliose in the adult. 

There is also anothnr interesting point connected with the diflfer- 
ence in the cotist ruction of ilie arch and l:>:ise of the fcrtal head 
Thi* former becomes, I have just stated, diininislied, and there isnc 
inconvenience from it, for the upper portion of the hrain is not 
essential to the maintenance of life ; the base of the ftutal skull is firni] 
in its coHi^t ruction, sufficiently so, at least, to resist pressure, and 
therefore, does not, like the arch, undergo diminution. If yc 
inquire why this is so, the answer is found in the injjiortant eircum 
stance that the base of the brain, especially the medulla oblongata, 
is so directly connected with life that it cannot be disturbed withou^ 
more or less haxard ; and hence this peculiarity of ronstruction. 

Tfiere is an essential practical fact, much insHted upon by 
Capuron, directly deducible from what has just been said t<mching_ 
the difference in the compressibility of the arch and base of thi 
fii?tal head ; and it is this — the difference in the whUh of the arcl 
and ba.'^e points out the exact amount of dimimition whirh it i 
possible fur the formt^r to undergo^ in order to facilitate delivery j 
for shotd<l the disproportion between the maternal pelvis and bas 
of the cratvium be such as to prevent the p;a5sage of the base, thf 
compression of the arch would result in no beiieBt, so far as tli 
delivery of the child is concerned. 

Diatnettrs of Fivtal Head and Pcivis. — Contrast, — In dci^cHl 
ing the respective diameters of the foetal head and adult femaM 
pelvis, you will have noticed a very interesting point, namely, tha 
the former presents one diameter, the occipito-mental, measuring 
^vc inches and a quarter, which is larger than any diameter of tli 
pelvis; and again, it has another diameter, the occipito-fronta 
yielding four incites and a quarter, which is also larger than th^ 
transverse and bis4schiatic diametei-s of the upper and lower 
straits, each of which measures only four inches* Here, then, is 
the head of the fcetus possessing certain larger dimensions tlian ll; 
maternal pelvis, the space through wliich it has to pass. Tliis 
once involves apparently the physical difficulty — of a larger boc 
iruf^crsinff a smaller space / nature, however, appreciates this difl 
culty, and has most effecttially — as wiU be shown in the succeeding 
lecture — renjoved it by the institution of a mechanism, not onlj 
perfect, but worthy of your profound admiration. 

Articfdations and Movetnents of FttUtl Head. — Before pro- 
ceeding further, it is important that your attention should be 
directed to the articulations of the fcetal head. It, like the adult 
head, enjoys two movements: L That of flexion and extension; 
2. That of rotation, or the lateral movement. In both the adiilt 



THE PRINCIPLES AND PKACTICE OF OBSTETRICS. 33 

and foetas, these movements are respectively the result of the same 
kind of articulation. The condyloid processes, on either side of the 
foramen magnam of the occipital bone, are received on the superior 
articulating surfaces of the atlas, or first cervical vertebra; this 
junction constitutes the articulation known as the occipito-atloidien, 
and it is through it that the head is enabled to perform the move- 
ment of flexion and extension. The second movement, that of 
rotation, results from the articulation subsisting between the odon- 
toid process of the second cervical vertebra — the vertebra dentata 
— and the internal surface of the atlas. This movement enjoys a 
much greater degree of latitude in the foetus than in the adult. It 
oftentimes extends beyond the fourth of a circle, but, in these 
cases, the excess of rotation is undoubtedly enhanced by the par- 
ticipation of the spinal column, which possesses much greater 
molality in the foetus than in more advanced life, for the reason of 
its cartilaginous structure.* The importance of these two move- 
ments you will more readily appreciate, when describing the manner 
of the head's exit through the pelvis. 

Frequency of Head Presentations, — In the Maternite of Paris, 
among 84,395 births, at full term, the head presented 82,164 times; 
and that you may appreciate the comparative frequency of the 
vertex or summit presentations, contrasted with the other regions 
of the head, in these 82,164 cases the vertex was found at the 
superior strait — 81,806 tiraes.f Dr. Churchill J says, in 327,802 cases 
collected by him, the head presented 321,502 times. In 219,253, 
reported by Riecke, the vertex presented 214,134 times. You 
observe, therefore, from these statistics, which, in the main, agree 
with those derived from other sources, that the head, out of all 
proportion to any other part of the foetus, presents most frequently 
at the superior strait. 

It is, however, a fact worthy of note that this extraordinary 
proportion refers only to the full period of utero-gestation ; for 
Dubois, in his researches on this subject, has found that of one 
hundred and twenty-one children, born before the seventh month, 
sixty-five presented the vertex, fifty-one the pelvic extremity, and 
five the shoulder. Thus, previous to the seventh month, the pre. 
sentation of the pelvic extremity is to that of the head as four to 
five, w^hile, at the completion of pregnancy, it is as one to twenty. 
It has also been shown, that the life or death of the foetus exercises 
respectively a decided influence on the kind of presentation. In 
ninety-six children, bom dead in the latter months of gestation, 

* It U stated by Madame La Chapelle and M. Dubois, that they have observed 
several instances in which the face was turned almost directly backward, such was 
the latitude of the rotary movement, without at all compromising tlie safety of the 
chUd. 

f Moreau, p. 146. } Churchill's Midwifery, p. 190. 

3 



84 



THE PRIKCIPLES ANll PRACTICE OP OllSTETRICa 



m'venly-two prefienled the bea<l, twenty -two ilie jielvic ext remit 
ttiul two the shoulder; so that the presentations of the pflvi 
extremity relatively to those oftlie head, were as one to three ai 
a quarter. In Ibrty-six^ dead untl delivered at the seventh mon 
twenty-one came by the head, twenty*one by the pelvic extremit 
and fbnr by the shoulder* In seventy-three living children, boi 
ai the seventh month, sixty-«:ine presented the head, ten the pel 
extremity, and two the shoulder. It would, therefore, appear th 
at the seventh month, in fa^tusen born alive, the presentation 
the head i^om pared with that of the pelvic extremity, was as six 
one, and when the ftetuses were dead, one to one. 

Again : according to Scaiizoni,* there were, in tlie Lying-lu 
Hos|uta[ at Prague, during a period of six years, 12,539 deliveri* 
of which twenty-one occurred previously to the seventh monttt] 
of these twenty-one, only six presented th© head^ while there we 
.fifteen pelvic presentations. In twenty-four eases of abortion, not 
'by Scanzoni in his private practice, fourteen presented the pelvi 
extrcniitieii. lie also observed that, in premature births, at a later 
period of pregnancy, pelvic presentations we^'e frequent, and mo; 
es|>Ciially when the fa»tus was born dead. 

Cause of the frequency of Head Prt»e7itation9. — ^ Various th 
ries have been suggested in explanation of the remarkable relati 
preponderance of this form of presentation; and Bome of 1 
cleverest mind* in the profession have, within comparatively a fe 
'years, been engaged in the disscussion of the question. The old 
theory, which, for a long time, was accepted as tlie true expositio! 
inculcated that the ftetus, until a certain period of gestation, s; 
the seventh mouth, remained in the uterus with its head upward* 
at tbitt time, it made a somerset, which resulted in bringing the' 
head to the oa uteris and placing the breech at the fundus of the 
organ. I^uch was the teaching of I Iij*po crates, Galen, and others 
In the sixteenth and seventeenth centuries, a new hypothesis vr\ 
advanced, giving to the fcptns a certain instinctive or voluntai 
-power, which catiHed it at the latter period of pregnancy to turn 
r1l.s head downward. One of the principal supporters of this view^ 
was Mauriceau. He maintained that the fcetus, toward the cloi 
of gestation, places its head in correspondence with the mouth 
the womb, in order that it may the more readily effect its ogress 

Without enumerating other conjectures in the attempted explan; 
tion of tlie general tact as to the frequency of head presentation! 
it may be stated that, in our day, there are three principal theori^ 
which have more or less occupied the professional mind on the bu' 

♦ lidirbuch der Geburtshllfe. 1856. p. 02. 

% L'eafaot tourno done de oette manl^e sa tdfce yers lea demien mois de la ^ro*- 




he 
ra. 



t iillri teulcmeut d'dtro dispos^ 6tre plufl facUement mia hora do la 
l6iiip« da raootMieheraent. — TraiU dt» MaJadici det Rmmu Gtomm, t. 1, p^ 164 




THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 85 

ject, viz. Physical gravitation, voluntary or instinctive action of 
the foetus, and, lastly, reflex or excito-motory movements of the 
latter.* These various hypotheses have been discussed with much 
ability by their respective advocates. The theory of physical 
gravitation has had many supporters, and a very interesting paper 
sustaining this view has recently appeared from the pen of Dr. 
Matthews Duncan, who, within the last few years, has made several 
important contributions to obstetric science. Professor Paul 
Dubois, in revival, as it were, of the notion entertained by Mauri- 
ceau and his school, published, in 1832, an essay* referring the fre- 
quency of head presentations to an instinctive or psychical influence 
exercised by the foetus. This essay has deservedly attracted much 
attention. Finally, we have the theory of reflex or excito-motory 
movements as the cause of the attitude of the foetus in utero, ably 
advocated by Prof. Simpson. f If I may be permitted to express 
an opinion on this controverted question, I should say that, in lieu 
of any one of these influences being per se suflicient to explain the 
podtion of the foetus in the womb, the fact is due to a combination 
of circumstances not yet, perhaps, properly comprehended. J 

The cardinal point, however, for you to remember is, that usually 
the head is found at the time of labor at the superior strait of the 
pelvis, and whatever may be the true explanation of the cause, 
whether vital or mechanical, you cannot fail to perceive in this 
arrangement another evidence of the wise provisions of nature. 
You have been told that, cceteris paribus^ the head is the most 
voluminous portion of the foetus, and hence the advantage of its 
preceding in childbirth the other parts of the foetal body ; it is, 
moreover, true that, in the presentation of the pelvic extremity at 
the time of parturition, as a general rule, whenever difficulty occurs 
in the delivery, it is not until the entire body has been expelled, the 
obstacle being due to the passage of the head. This will be shown 
more fully, when describing the mechanism of labor in pelvic pre- 
sentations. 

Presentation and Position, — It is not only important that you 
should appreciate the frequency of head presentations, but it is also 
necessary to understand in what manner the head may present 
itself at the upper strait. This brings me, for a moment, to the 
consideration of the difference between 2^ presentation 2iXi^ position 
of the foetus. In obstetric language, presentation signifies the par- 
ticular portion of the foetus found at the upper strait at the time 

^ M^moire sur la Cause des Presentations de la T^te pendant TAcoouchement et 
Bar les Determinations inslinctives et volontiers du Foetus Uumain. 

f Simpson's Obstetrio Works, vol iL, p. 102. 

X I should not omit to mention that Scanzoni refers the frequent presentation of 
the head to the shape of the uterus, and the mode of its development during preg- 
lumcj. 



36 



THIS PRlNCIPTiEa AND PRACTICE OF OBSTETRICS. 



abor, whetijer it be tlie lie^d^ feet, shoulder^ or any other ^ 
position^ on the contrary, is meant to deiine the particul 
Bl mil ion of the pre«*enling part. The distinction, you perceive, 
l>l»vio«s, and should bo borne in mcuiory, in order that what w 
shall now havt* to say touching the various positions of the vertex 
mny brcorae intelligible. I shall, for the present, limit myself to 
the positions of the vertex, reserving the other regions of tlie head 
for future consideration. 

Positions of tlie Vertex* — ^There is not only a remarkable dii 
orepaney among authors as to the number of verte^c positions, bti 

gaii^o as to the order of their frequency- If, for example, we are 1 
be guided by some of ihc^se writer?^, we shrdl find the vertex sit 
ated .It the superior strait, according to one of them in eight, to 
another in twelve, »nd to a third in sixteen different positions. Ai 
this is well enough, perhaps, for the closet, but it eunnot, in in, 
opinion, i-ubserve any pmctieal interest. It does seem to me, thai 
our great object »hould be to simpliiy, and not complieate scien 
by tietitious and useless classifications; they only tend to burdei 
the mind, and confuse thought. The accoucheur, in the lying-i: 
room, IS in need of substantial facts and wliolcsome principles j he 
ares not for barren hypothesis, fur he knows that it cnnnot i\i 
am in the hour of pi*ril. His mind should be stored with les'-oni 
of trnth, which will constitute so many guides to point out the 
ci:»uj'se to bo pursued, when embarrassed and cireuni vented by 
dithv^ulty. Hence, I shall not >^'eary you with an arniy of the 
numerous divif^ions which difterent writers have made of vertex 
positions, together with their varieties. My object is to econot 
mize your tinie, without, however, restricting your knowledge 
and it shall be my aim, in these lectures, to lay before you prlnci 
ple6, whicli you will recognise at the bedside of your p:itient, and' 
not idle away the hour in the vain and unprotitable ugitation of 
exude and nnartp|it>rted theory. 

I shall, therefore, limit niyself to the positions of the verte: 
with the relative frequency of each, as defmed by what may be 
tcrnuHl, touching this questioti, the two great obBtetric schools — 
the one represented by Baudelocque, the other by NaC^gelc, Paul 
Dubois, and Stoltz. Were I to continue the history of the divi- 
sions, as suggested by §ome other writers, it wotild, I am quite sure^ 
not only be without profit, but would, I think, atfoi d mitisfactory 

^evidence that these very writers had fidlen into a species of trail-, 
[^ndeutalism, which, for the healthy progress of science, and the 
?nc*fit of the sick-room, had, in my opinion, better have been 
avoided. Transcendentalism in our protessioo, like transc^'ndental- 
ism in religion, conimerce, or government, is not only an absurdity, 
but is oftentimes fraught with danger. 

7%€ School of Baudelocque. — According to Baudelocque, there 








THE PBINCIPLBS AND PRAOTIGB OF OB0TETRIO8. 87 

are six different positions of the vertex at the saperior strait; and 
in order that you may clearly comprehend them, I shall ask yott, in 
the first place, to recall to memory what we have already stated as 
to the anterior and posterior divisions of the pelvis, and the »x 
cardinal points foand in these two divisions of the pelvic canal. In 
drawing a line transversely across the saperior strait^ yon divide 
the pelvis into an anterior and posterior portion ; you have^ on the 
former^ the right and left acetahula, and the symphysis pubis; 
while on the latter, are observed'the three posterior points, namely, 
the right and leit sacro-iliac symphyses, and the sacro-vertebral 
prominence; now these sir points, taken in connexion with the 
occipat and os frontis of the foBtal head, will give the six vertex 
presentations as follows : 

In the first, the occiput corresponds with the left acetabulum^ 
and the os frontis with the opposite sacro-iliac symphysis. 

In the second, the occiput is at the right acetabulum, the os 
frontis at the left sacro-iliac symphysis. 

In the third, the occiput is at the symphysis pubis, the os fronUs 
at the sacro-vertebral prominence. 

In the fourth, the os frontis is at the left acetabulum, and the 
occiput at the right sacro-iliac symphysis. 

In the fiflh, the os frontis is at the right acetabulum, and the 
occiput at the left sacro-ijiao symphysis. 

In the sixth, the os frontis is at the symphysis pubis, the occiput 
at the sacro-vertebral prominence. 

You cannot have failed to notice, from what I have just said, that 
the fourth, fiflh, and sixth presentations are the direct opposites of 
the first, second, and third, and that, while the three latter are 
obtained by placing the occiput respectively at the three anterior 
points of the pelvis, you find the three former, by placing at these 
same points the os frontis. 

Let us next consider the relative frequency of these vertex posi- 
tions, in accordance with the statistics as recorded by Baudelocqae 
himself, and some of his disciples. In 10,322 vertex presentations, 
8,522 occupied the first position,- 1,754 the second, two the third, 
twenty-five the fourth, nineteen the fiflh, and one the sixth.* 

With Madame La Chapelle, in 20,698 vertex cases, 15,809 were 
in the first position, 4,659 in the second, 164 in the fourth, and sixty. 
six in the fiilh.f 

Madame Boivin states that, in 19,585 vertex presentations, the 
occiput was found at the left acetabulum (first position), 15,693 
times ; at the right acetabulum (second position), 3,682 times ; at 
the symphysis pubis (third position), six times ; at the right sacro- 
iliac symphysis (fourth position), 109 times; at the left saoro-ilia« 

• L'Art dea Aooouchemena. Par L L. Baudblocquib. Tome I, p. 306. 

t Pratique des Acooucbemens. Par Madame La Chapellk. Tomo ii.« p. 50^ 



38 



THE FKINCIPLKS AND PRACTICE OF OBSTXTKICS. 



nymphy^iA (fitUi position), ninety-four times; at the sacro-vertebnJ 
proTTiincnce («xlh po.sition), but twice. 

If thefiG statistics prove anything, they unequivocally establish 
that* ID vertex presentaiions, the very general rule is that the occi- 
put 18 either at the left or right acetabuhim (tirst or second posi- 
tion), and that when it is either at the symphysis pubis, the right 
or lefl sacro-iliac symphysis, or at the sacro- vertebral prominence, 
it is so, comparatively at least, as a rare exception. The authori- 
ties, iihieh I have cited in support of these data, are both eminent 
and reliable, and yet, when their deductions are contrasted with 
the statistic** of the opposite school — equally eminent and reliable — 
we shall be struck with the extraordinary, and apparently irrecon- 
eihible discrepancy in their conclumonn; and as illogical as it may 
at first sight seem, that two results, directly contradictory the one 
to the other, can both be right, yet I am disposed to think that the 
fact can bo demonstrated, lie tore, however, attcnijiting to recon- 
cile the conflicting statements, it is proper tluit the testimony of the 
other feidc should l*e presented. 

7716 School of Nae<felL — The opinion advanced by Baudelocque 
with reg:ird to the relative frequency of the positions of the vertex 
had received the very general concmTcnce of obstetric writers, until 
contestetl by Nal^gel^, who, in 1818, publi>hed his views on the 
niechaniitm of parturition. While Naegelfe agreed with Baude- 
locque as to the positive frequency of the firnt |>oHition of the ver- 
tex — the occiput in corresjjondence with the left acetabidum — yet 
he maintained that the second most frequent position was noi with 
the occiput to the right acetahulujn^ but to the right sacro-iliac 
sgniphysis. Here, then, was a remarkable discrepancy of senti- 
ment, and it was not long before it attracted the consideration of 
the learned in obstetric scieuce. Tlie distinguished Professor of 
Heidelberg, atler a rigorous examination of the subject at the bed- 
side, arrived at the following results: In one thousand instances of 
vertex presentation, for example, he found the occiput at the left 
acetabidum (first position) six hundred and ninety-eight times; 
at the right acetabulum (second position of Baudelocque) once ; 
at the right sacro-iliac symphysis (fourth positiou of Baudelocque) 
two hundred and ninety-eight times ; at the letl sacro-iliac symphy- 
sis (fit\h of Baudelocque) three times. 

Dubois and Stoltz, who were among the first to examine practi- 
caily the new view as propounded by Naegel^, have given the 
results of their investigation, which are radically in confirmation 
of those of the German Professor. Dubois, in 1913 preseutatioxia 
of the vertex, observed the occiput at the left ae^jtabuluni (first 
position) 1339 times ; at the right acetabuhim (second position) filly- 
five times ; at the right satTO-iliac symphysis (fourth position) fotir 
hundred and ninety-one times; at the left sacro-itiac symphysia 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 39 

(fifth position) twelve times. The material difference between 
Dubois and Nai^gel^, it will bo seen, is in the position of the occi* 
pnt at the right acetabulum, the latter making it but one in 1000, 
while with the former it was fifly-five in 1913. This, however, does 
not affect the main proposition, with regard to which there is an 
entire concurrence, viz. that the second most frequent position of 
the vertex is, token the occiput i$ turned toward the right sacro- 
iliac symphyaia (the fourth of Baudelocque). So much for France, 
in agreement with the opinion of Naegel6 ; and to the names of 
Stoltz and Dubois, mny be added those of Cazeaux, Jacquemier, 
and others. 

Next, let us turn to Great Britain, and see whether this revolu- 
tion of opinion — originated by the eminent German accoucheur — 
has enlisted any supporters in that commonwealth. Prof. Simp« 
son, in 1846, in a clinical lecture* on head-presentations^ sustains, 
with his usual ability, the views of NaSgel^. He says, very em- 
phatically, " I find that in one out of every three or four cases 
among my private patients, I meet with this position of the head — 
the occiput to the right sacro-iliac symphysis. It is so very fre- 
quent, that I have repeatedly seen two or three instances of it occur 
in succession." The statistics gathered by Dr. Martin Barry, 
House-Surgeon to the Edinburgh Maternity Hospital, present the 
following results : In three hundred and twenty-five cases of cranial 
presentations, carefully observed by him in that institution, the 
occiput was directed to the left acetabulum two hundred and fifty- 
six times ; to the right acetabulum once ; to the right sacro-iliac 
symphysis seventy-six times ; to the left sacro-iliac symphysis twice. 
It may also be stated that Naegel^'s opinion is concurred in by 
Drs. Rigby, Murphy, and Tyler Smith. Dr. Ramsbothamf admits 
that " the right posterior occipito-iliac positions are far more com- 
mon than before supposed." Lastly, Dr. Churchill,J the distin- 
guished representative of the Dublin School of MidwiftJk-y, observes, 
" The more closely the opinion of Na(3geI6 has been tested by expe- 
rience and careful observation, the more clear does its correctness 
appear." 

Now, with the deductions of the two schools before you, differ^ 
ing, as they do, so widely, the inference naturally is, that if one be 
right, the other b wrong. I think, however, that the discrepancy 
is due altogether to the time of labor at which these results were 
respectively reached. Baudelocque, for instance, judged of the 
relative frequency of the occipito-anterior positions, from the posi- 
tion ttie head occupied afler its descent to the vulva. Naegel^, on 
the contrary, began bis investigations at the very moment of par* 

• Northern Journal of Medicine, April, 1846, p. 216. 
f Ramsbotham^s System of Obstetrics, p. 206. 
X Cburcbiirs System of Midwifery, p. 203. 



TEE PMINCIPLES AND PRACTICE OF OBSTETRICS. 41 




Fia.ttL 




Fao^n, 



42 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



tnrition, when the head hud iiiidert^ono little or no departure from 
its original position. Bui the question arisen— admitting this differ- 
ence ol' time iLH to the period of iheir respective investigationa — 
how does it hap|*en that one school should find, at the eomnience»j 
ment of labor, t!ie occiput, seeond in frequency, in corresponilencol 
with the rin^ht sacro-iliac symphysis; and ilui other school, after the J 
descent of tfie head, fthonld recognise the occiput to be in accord- 1 
ance with the anterior section of the pelvis ? The solution of t>ii« j 
inquiry is a key to the problem, and will, I think, 8atiafactoril/| 
cxphiin it. 

Niiegel^, while maintaining that the riglit cjecipito-sacro-iliao I 
position U second in fre<:|uency, admits that it is so only as a primi- 
tive position-; and he shows that, as labor advances, the descent of I 
the head is such that, as a very general rule, both the right and left I 
posterior occipito-^acro-iliac positions become converted into one or ' 
other of the anterior-oecipitnl For example, the posterior light ia 
converted into the anterior right, while the posterior left is changed 
into the anterior left ; in other words, the hcarl undergoes a move- 
nient of rotation, which turns the occiput from the posterior to tlieJ 
anterior section of the pelvic canal. 1 

The tbllowing statistics, in proof of this conversion, are not with- 
out interest: In 1254 occipito-posterior positions mentioned by 
Naegele, in only seventeen inslance:^ did the occiput disengage' 
along the postcri^ir wall of the pelvis; and, in eacli of these, the 
exception could be explained by tlie greater capacity of the pelvis, 
numerous previous labors, or rupture of the ptirinuum. In twenty* 
six occipito-posterior positions, observed by StuUz, the occiput 
underwent tlie anterior conver>iion in alL In live hundred and three^ 
recorded by DuWs, the occiput was expelled posteriorly in thirty-^ 
nine. In the seventy-six cases as recorded by Dr. Martin Barry, in 
two only did the oocij»ut fail to rotate forward* The general senti- 
ment of obstetrioians, at the present day, appears to be in concur- 
rence with the views of Naegele* and his school, viz. that t!ie right 
posterior occipital position is the set^ond in the order of frequency 
Wily as a primitive position ; and with this concurrence I heartily 

cord. 

Author^ $ Vhssification, — In order to simplify the positions of \ 
the vertex, we »hall reject the third and sixth of Baudelocque, for 
the reason of their extreme rarity, and because, on this account, 
they should be regarded as altogether exceptional* and shall adopt ' 
the tbllowing c!aM4irication : 



•A liU) writer, however, R. tJ, Weet, M.D., in an wcoecdjiigl/ intereating 
menioir, eont45«t3 tim truth of Nau^ele's viuw9* Dr. West*s opinion \b foatided dU 
OtMervfttioas mudu by him in four lititicirtNl and ciglicy-ooe ddiveries. He agrees 
with the old achool uji Ui titer veriex poHttton^.'-CriA/iia^ PrtsmUktiom and CtMniol 
JUithnt, tftc By R. U. W^sr, M D. J/Judou, 1851. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 48 

Fir9t PoHtUm. — ^The occiput in correspondence with the left 
acetabulum, and the os frontis at the opposite sacro-iliao symphy- 
ns. (Fig. 20.) 

Second Position.* — ^The occiput at the right acetabulum, the os 
frontis to the left sacro-iliac symphysis. (Fig. 21.) 

TTiird Position, — The os frontis at the left acetabulum, and the 
occiput at the right sacro-iliac symphysis. (Fig. 22.) 

tbitrth Position. — The os frontis at the right acetabulum, and 
the occiput at the left sacro-iliac symphysis. (Fig. 23.) 

In the succeeding lecture, I shall describe the mechanism by which, 
in the four positions of the vertex, is insured the safe passage of 
the child through the maternal organs. 

* It must be distinctly borne in mind that tliis is the second position, not in the 
order of frequency, for it has already been shown that the third position (the right 
posterior ocdpito-iliac) is next to the first in frequency, but this classification ot 
first, second, third, and fourth, is made merely to avoid confusion. For example, thb 
oodput is placed first at the two acetabula. and afterwards at the two sacro-iliac 
symphyses, without reference to the relative frequency of its apposition with these 
various points of the pelvis, always excepting, however, the left occipito-acetabular, 
which, out of all comparison, is the most frequent of the four vertex positiooa. 



LECTURE IV. 

ICechanism of Labor— Its Importance— MedMoiism in tho firrt Tertez PomUoq— 
Left Occipito-acetabular — Position of the Fostua— Belationa of the Head to the 
Pelvis— Necessity for a Change in theso Relations— Movements imposed upon th« 
Head — Flexion, Descent, Rotation, Extension, and External Rotation— Object 
and Causes of these Movements — Proof that theso Movements occur — Gerdjr^ 
Explanation of External Rotation — Mechanism in the Second Position — Riglii 
Occipito-acetabular — Mechanism in the Third Position — Right Posterior Oodpito* 
iliac, the Second in Frequency, according to Kaegeld — Conversion of the Poite- 
rior Occipital into Anterior Occipital Positions — How this Conversion is touom* 
plished— Mechanism in the Fourtli Position — Left Posterior Occipito-iliac — Ne> 
cessity of an accurate Knowledge of the Principles on which the Mechaniflm of 
Parturition is founded — ^The practical application of this Knowledge al ttw 
Bedside. 

Gkntlemex — You are now prepared to Appreciate the interest- 
ing mechanism by which the transmission of the child, through the 
bony and soft structures of the parent, is accomplished. The me- 
chanism of labor may be defined to be a combination of movements 
founded upon the principle of adaptation, and intended, through 
the proper adjustment of the respective diameters of the fcctus to 
those of the pelvis, to facilitate the passage of the former into the 
world. In the whole range of obstetric science there is no topic 
more worthy of profound study — none certainly which involves 
more deeply the lives of both mother and child. One defective 
link in the chain of movements necessary to the perfection of this 
mechanism — unless promptly supplied by judicious interposition — 
and the saddest results may ensue. Therefore, I ask your attention 
while I endeavor to present to you, in the simplest j>ossible man- 
ner, the various stages of this adaptation, a knowledge of which ia 
OS necessary to the obstetrician as is the compass to the navigator. 
I shall, for the present, limit myself to a description of the me- 
chanism of labor as connected with the four positions of the vertex, 
reserving the other positions of the fcBtus to a future and more 
appropriate period of the course. 

Mecfianiain in the First Vertex Position — Left Occipito-cu^ta- 
tfidar, — In this position (Fig. 20), you will remember, the occi- 
put or ])osterior fontanelle corresponds with the left acetabulum, 
while the os frontis or anterior fontanelle regards the opposite or 
right sacro-iliac symphysis. The general relations of the foetus are 
such, that its dorsal surface is to the left and in front ; its anterior 



THS FlUNOIFLliS AND PRACTICE OF OBSTETRICS. 45 

plane to the right and posteriorly ; its right lateral surface to the 
right and forward ; its left later^ surface to the left and backward, 
with the pelvic extremities toward the fundus of the womb. For 
the proper understanding of what we shall presently say, it is abso- 
lutely essential that you should be under no error as to the exact 
relations, in this first vertex position, which the head of the foetus 
bears to the pelvis of the mother at the superior strait. In the 
first place, the sagittal suture occupies the lett oblique diameter of 
the pelvis ; the occipito-mental diameter is oblique to the axis of 
the snperior strait, and, at the same time, the perpendicular or ver- 
tical diameter is in correspondence or parallel with this same axis; 
the oecipito-frontal and transverse diameters of the head accord 
respectively with the two oblique diameters of the strait. 

I£f now, you attentively consider these relations of the foetus to 
the pelvis, it will at once become manifest that, for the head to pass 
teongfa the pelvic cavity, some change in its position is necessary, 
and for the following reasons : — 1. The occipito-frontal diameter of 
the headrmeasures four inches and a quarter, and to this is to be 
added the thickness of the scalp, hair, and walls of the uterus, 
which, together, will make up nearly, if not quite, a quarter of an 
mch — this increase, therefore, will give to the occipito-frontal dia- 
meter fonr inches and a half, or within a fraction of it ; as a conse- 
qnence, this diameter would hare, without alteration in the position 
of the head, to pass through the oblique diameter of the brim, 
which, it is not to be forgotten, measures only four inches and a 
half. This, then, would necessarily involve the physical objection 
of a body of four inches and a half traversing a space of precisely 
the same dimensions. 2. The occipito-mental diameter of the head, 
giving five inches and a quarter, is, in this first position of the ver- 
tex, oblique to the axis of the superior strait ; and as it exceeds any 
diameter of the pelvis, its descent into the pelvic cavity is impos- 
sible, unless through a change in its relations, which change, we 
shall show you, will be such as to bring it in parallelism with the 
axis of the upper strait, thus affording every facility for its passage 
into the excavation. 

Such, therefore, is usually the condition of things relatively to 
the foetal head and maternal pelvis at the commencement of labor ; 
and you plainly perceive the necessity for a modification in these 
relations.* Nature, cognizant of the difficulties just enumerated, 

^ It ibmetiraes occurs that the chin will be in more or less approximation with 
the sternum before the commencement of labor — but that this is the general rule, as 
is maintained by some writers, is, I tliink, altogether erroneoua The flexion of the 
bead, as I shall endeavor to prove, is the result of certain mechanical forces— and 
these are wisely brought into operation for the purpose of overcoming the physical 
disproportions between tlje head of the fuetus and maternal pelvis, as they ordinarily 
exist before the commencement of the parturient effort. It is stated by Jacquemier, 
thai^ so far from the head undergoing Uio movement of flexion, it DrequenUy descenda 



46 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS 



imposes upon the head of the child a sucoeBsiori of movemetkti, 
which, when completed, exhibit the mechanism of labor in all rtii 
perfection. These movements hre—flexiim^ descent^ rotalion^ 
exCennofh a^idi lastly, what is now denoniinatcd external rotaiion^ 
as a substitute for the term fonoerly einplored — restitution. 

Flexion. — Responsive to the con traction a of the uterus, the 
position of the head becomes changed ; the chin is brought in 
close approximation with the sterntim, constituting the movement 
of flexion,* and it is iutere*^tintr to contemplate how immediately 
the relations of the pelvis and head become moditied. As soon as 

the chin is thrown upo] 
the sternum, the oecipi 
mental diameter is madi 
parallel to the axis of thfl 
superior strait (Fig. 24), 
the oecipito-frontal is ol 
liquc to this same etm: 
while the perptndicu 
and transverse diamcte 
of the head are pi 
in apposition respect ivel 
with the two oblique dii 
meters of the brim. This 
simple movement, the; 
/ of flexion, does what 
Why, as you have ihi 
instant seen, it ko change 
/ the relations of the hei 

to the pelvis, that it not 
only removes the physical 
dithcultieH of which we 
have spoken, but, in lieu of these difficulties, it substitutes the 
greatest possible facility for the descent of the head, by placing 



»9 

LheV 




I 






to ll»p perineal stratt vmchanged, wtthnui OL^cunionitig^ any obst4icle to its cxpulaipi 
1 hoUJ i\m st^ti^'ment to be, aa a |<ciieml rule, altogether an il1u»r>Q : nor cau 
hcftd^ wiiliont the previoua raoveraent of flexioD, paas into iho pelvic cavity, c» 
v^liQti Ui« head itflelf ia unusuuliy dmall. or tho potviR UDUsUMlly cnpaeious. 

* Tlie hem), it Bboutd bi> recol]«ct<7d, prescntA ia tucU wiiy (hat^ iu^ti^d of the 
v«rU7X iieitig* as it were, p<?rfectlj plumb, it ia aligbtly torned or iitUet-led liit«mU/, 
9nt tliui nt tJju vtrry begittning oX \a\yoT^ aa soon at the head cuu he liiBtinclly re 
ulkhI, thut portion of it with which the fingt*r oomefl directly in contact ()ii#he t 
vi?riex position) will be the right o« p:irii^tAle, and the sdfiittiil suture will 
tietectod occupying the oblique diaineteTf but aJightly backwiird in the direction 
the wicrum. U iJi, 1 believe, generally tupposed that the credit of calUnjr iitU-n 
to thi« cireum.staDce, is dtie to Nailgeld; b»it he wna anticipated by that eotii 
obeervcr, Giirriieti, who dii^tioctly aaya, **iil the commencement ot lubor, one of the 
I ' ' i^m usually prt-aeota." If the iuclinatioa o( the lucis of the siipeiior 

I- »ii««^ a will be rnidily seen that the head, which is 10 acoom* 





THE PBINCIPLKS AND PRACTICE OP OBSTETRICS. 47 

imallest diameters of the latter in apposition with the largest at 
the snperior strait. What a combination of wisdom and intelli- 
gence in this movement of flexion, and how emphatically docs it 
demonstrate the ample provisions, when not intermpted, which 
nature is constantly making for the wants of the economy ! 

But you may be disposed to doubt that the head becomes flexed, 
or, at least, you may desire some demonstration of the fact. You 
have a right to asstftic nothing as granted which is susceptible of 
proof; if you pursue science by the assertion of this right, with an 
earnest demand for its fulfilment, the result cannot but be auspi- 
dous both for S(!ience and yourselves, for, under such circum- 
stances, the former will progress with a healthy growth, while you, 
instead of having your minds filled with rubbish, will have gathered 
iobstantial principles, which will guide you to truth. 

Now for the demonstration : if, at the commencement of labor, 
before the head has become flexed, you institute a vaginal exami- 
nation in the first position of the vertex, you will find the posterior 
fbntanelle or occiput at the lefl acetabulum, and the anterior fon- 
tanelle or os frontis at the right sacro-iliac symphysis ; the sagittal 
suture you will distinctly trace, coursing along the oblique diame- 
ter of the bi-im from lefl to nght, looking a little toward the 
sacrum, because of the slight lateral inflection of the right os 
parietale, to which allusion has already been made.* This, there- 
fore, is the condition of things at this time ; the pains come on, 
the labor has fairly set in, and is progressing ; afler the lapse of a 
little time, a second examination is made, and what do you dis- 
cover ? The occiput or posterior fontanelle, instead of correspond- 
ing with the left acetabulum, lies diagonally in the pelvic excava- 
tion, while the sagittal suture is not in correspondence with the 
oblique diameter of the brim from lefl to right, but is placed 
obliquely from below upward. Admitting, gentlemen, what I 
have just stated to be true — and the lying-in room will abundantly 
corroborate it — what, allow me to ask, could have accomplished 
this change in the relations of the head and pelvis, except the 
movement of flexion ? The next inquiry is, how is this movement 
of flexion produced ? 

modate itself to the direction of tliis axis, should itself describe an oblique line, and 
prenent one of itA sides, instead of being placed perpendicularly. " Dans le premier 
moment du travail, cVst ordinairement un des pari^taux qui se presente," etc. — 
Drain dPAuouchemens^ par M. Gardte^t, t it, p. 290. 

♦ The experience of the lying-in room will prove that the sagittal suture may be 
felt by the finger, but occasionally it will be impossible to detect either the anterior 
or posterior fontanelle ; therefore, under these circumstances, although the general 
fact will be ascertained, viz. that the head occupies an oblique position, yet it can- 
not be known thus early, whether the occiput is at the left acetabulum or at the 
opposite point of the pelvis, because the fontauelles are alone the proofs of this 
Ittterftct 



THE PRINCIPLES A2%D PEACT1C£ OF OBSTBTHIC^ 



You wU) Dot have forgotten the two articulations of the fcstii 
hend ; one for flexion and extenmon, the other for rotation ; anj 

you will rerall to memory thiit the condyloid proccsaes on either" 
Hide o( the foramen maipium occipiiale are not at t)ie centre of the 
base of tfie hi?nd, but arc rnorc posteriorly tban anteriorly^ thus 
uecegsurily glviug the same posterior direction to the occipito*j 
atloidien articubtion, on which the movement of flexion and extc 
aion depends. At the commencement of lab#, the nteriis, unde 
the influence of its contractions, exerts a forr-e, the object of whiel; 
is to cause the expuUion of the child through the pelviii ; the forc| 
is 80 displayed m to he ]»arallel, or nearly 8o» to the axis of th^ 
superior strait, and, consequently, more or lees pandlol to the axi| 
of the child's body, and that of the uterus itsflf. Tfiis force, yoq 
are to bear in mind, la concentrated upon the head of tlie f<ctu$ 
and, for a time at least, is re9i£ktcd by the neck of the womb, and 
to a certain extent, by the brim of the pelvi:j. If, therefore, yon 
will consider, for a munieut, thc^e circumHiunces, you will, I upprt 
hand, encounter no erabarra-^ment in comprehending the influence 
which contribute to the movement of flexion. They art?: 1. Tht"* 
contractions of the utenw ; 2. The position of the oceipito-atloidieo 
articulation ; .1. The resistance of the os uteri and [»elvic brim. 

I>esceni and Jkotation* — You have now seen iliat the firiit 
movement which the fcetal head undergoes is flexion, and you 

appreciate its causes and 
objects. As 800H a** the 
head becomes flexed, it 
occupies an oblique or 
diagonal position in the 
pelvic cavity (Fig. 24), 
and unless this be changed 
it will be iibysicaUy im- 
possible for it to make its 
exit through the vulva, 
beoruise of the dispro- 
portion between its dia- 
meters and those of the 
pelns. Hence, the uecc^ 
sity for another m«»v, 
ment, wliich in that of 
rotation, conKii^tiri-' -a' •» 
demi-spiral turtJ 
lin'j ' li 

a 1 > 
consequcnee of which is to ehnnge the po?«ition of 
instead of resting <liiigonally in the excavation 
the occiput is brought to the symphysis i 





THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 49 

the face directed to the hollow of the sacrum. The object, there- 
fore, of this movement of rotation is to overcome the physical 
difficalty of the head passing through the inferior strait, while con- 
tinuing diagonally, by placing it in the direct position, viz. with 
the occiput corresponding with the symphysis pubis, and the face 
with the concavity of the sacrum. You may, however, very pro- 
perly ask — how is this movement of rotation accomplished ? When 
describing the bones, your attention was particularly directed to 
the anterior and posterior inclined planes of the pelvis. After the 
movement of flexion has taken place, the head, urged by the impel- 
ling power — the contracting uterus — descends into the excavation, 
and, in its descent, the occiput is brought in contact with the 
inclined planes in front, while the forehead is in apposition with 
the posterior ; the contact of the head with these planes results, 
under the continued impulsion of the uterus, in the rotary move- 
ment to which allusion has just been made. 

I think^ therefore, it may be said, that the rotation of the head 
is due : 1. To the peculiar direction of the planes ; 2. To the 
resistance offered by the walls of the excavation ; 3. To the con- 
tractions of the uterus. Some high authorities are disposed to 
doubt that the inclined planes exert any influence in causing the 
rotation of the head, and maintain that tiie latter docs not undergo 
this change of position until it has reached the floor of the pelvis ; 
they refer, therefore, the rotary movement, not in part to the 
peculiar direction of the planes, but to the resistance offered to the 
head by the perineum and adjacent structures, together with the 
contractions of the uterus. 

To this view, there is, according to my experience, an insuperable 
objection, and it is this — rotation^ as a general ruley commences 
before the head reaches the inferior strait. The proof of this latter 
fact is within the reach of any practitioner at the bedside of his 
patient, provided he have experience and tact sufficient to recog- 
nise the evolutions of the foetal head in its progress through the 
pelvic canal. Again : if we deny the action of the inclined planes, 
how is rotation to be explained in certain cases in which, from 
numerous antecedent deliveries, or other circumstances, such, for 
example, as previous laceration of the perineum, there is such an 
amount of relaxation in the parts, as to render any attempt at resist- 
ance utterly negative ? 

Extension. — When the head has been rotated, the relation of its 
diameters to those of the lower strait is as follows : the bi-parietal 
or transverse diameter of the head, measuring three inches and 
a half, corresponds with the transverse or bis-ischiatic of the strait, 
which is four inches ; while the occipito-frontal diameter of the 
head, four inches and a quarter, rests in the direct or cocci-pubio 
diameter of the strait, which, imder ordinary circumstancea, ia four 

i 



60 



THE PRIITCIPLES AKD PRACTICK OF OBSTETRICS. 



X^^>^ 



Fio. U. 



mcbes, but, at the time of labor, owing to the n^^ression of tj 

coccyx, increnftts frci 
four and a half lo fi« 
iDcbcs« It is not diflicu 
to understand how 
head h made to extend 
From its peculiar pdsUiti 
at the lower strait, all« 
rotation is effected, ill 
posterior surface of tlj 
child's neck is ihrov 
closely against the syn 
physis pubis, which be- 
comes a point of resist- 
ance, so that the force of 
uterine effort, which unt 
this time had fallen 
llic occi|)Ut, is now 
cent rated on the chin ; tJ] 
result of this, change 
the direction of the in 
lulling power of the org 
h neceiisarilj to cause the chin gradually to leave the sternum (Fij 
20) mi til the movement of extension is completed. 

In tMintirmation of- the fact that extension does really tfike pla 
watch carefully the first case of labor you may attend, with 
occipito-anterior position of the vertex, and you will find the fa 
lowing to be the progress of the head as it emerges from the vulval 
Yoti will first perceive the coronal suture, ihon the anterior portic 
of the OS frontis, next the eyebrows, the eyes, the nose, the montl 
and finally the chin. Such is the order of the delivery of the 
yarlous p.irts, which is demonstration itself thnt the order is dn 
'altogether to the movement of extension, wh*icli the head is gradu 
ally undergoin*^, at this stage of the labor, during its passage int 
the world. Thus, the result of extension is to afford egre<.^ su 
c^ssively, through the antero-posterior or cocci-pubic diameter, ' 
the perpendicular, occijii to-frontal, and oc^jpi to-mental diameter 
of the head. It is at this period of the parturient effort that the_ 
perineum undergoes its maximum distension, so that the axis 
the inferior strait is elongated forward and upward, 'Hie nmmeulj 
however, the head has comjiletely freed itself from the oa ej'ttrfiun 
^thc anterior border of the perineum recedes, and comes direct Ij 
^ iti contact with the front of the child's neck. The immediate con 
pquencc of tins recession of the perineum is to cause the head 
which had previously been elevated toward the pubes, to fall bj 
It^ own gravity downward toward the poccyx* 



d 



TRK PRINCIPLES AND PRACHICE OF OBSTETRICS. 



Mxtcrnnl liotai ion. —The head ia liberated— it has niado its 
escape ihroiigh the vulva, and now let us trace its further progrcj^s. 
When it tin^t passes into the world— in this left orcipito ucetabular 
position— it i», aa you have seen, so situated that the occiput is in 
correspondence with the gymphysia pubis, while the lace is down- 
wani re*4urdin^ the coccyx. Almost immediately, hoM ever, afler 

i escape, it undergoes 
aotber change of posi* 
lion, which results in 
placing the occiput to- 
ward the led groin 
(Fig. 27), and the face 
in the direction of the 1 

oppo^itL* ramns of the 
Ls<'hinm. Until the 
]»uhliciiiiou of the paper 
of M. Gerdy, this tilth 
raovement of the head 
^'09 described as the 
movement of restitu- 
lioa, and the following 
la^ the explanation 
liven by Bnudelocque, ^.,,^ .^ 

u'ho. I think, was the 

first to direct attention to it — be supposed that when the bead 
rotated in the pelvic cavity, it did so at the expense of the body 
of the child — in other words, the body did not participate in the 
movement ; consccpiently, the head, ibr the lime being, was twisted 
or in a stale of lornion. The instant, however, it eflecied its egregs, 
it righted itself by the ini^titution of a parallelism between it and 
the body of the ftctus, which resulted in giving to the head the 
identical position it had previoui^ly occupied at the superior strait 
before nndergoing the movement of rotation. 

Tbii*, I repeat, was the generally received view until the appear- 
ftnr<? of M. iieidy's j»aper. He has contested this explanation, and 
maintain** that the rotary movement is not isolated — contined to 
the be4id — ^but participated in by the entire body of the feetus, I 
moHt confesH that, although formerly believing the old opinion to 
he the correct one, yet close attention to the suliject in the lying-iu 
chamber has convinced me that M, Gerdy is right. A« soon as 
iJic head has midergone rotation, the shoulders, instead of occnpy- 
tojr an oblique position, stretch across the pelvis transversely ; this 
ittld Dot be so, if they did not rotate feimultaneously with the 
pitmd. Agixirj; a very few seconds afler this latter has found its 
way into the world, the should cr« l»ecome diagonal in the pelvis 
from right to left, and it is this diagonal position which aceouwla 



62 THE FBIKCIPLES AND PRACTICE OF OBSTETRICS. 

for the change in the position of the head ; as the uterus contracts, 
the shoulders undergo another alteration of position, the right ODe 
being brought in apposition with the symphysis pubis, and the left 
with the hollow of the sacrum. This alteration in the direction 
of the shoulders necessarily imposes on the head another change 
in its position, so that now, in lieu of the occiput regarding the 
leil groin, it looks directly toward the internal surface of the left 
thigh, and the face is turned toward the right thigh. You see, 
therefore, that the changes in the position of the head, after its 
escape from the vulva, are but the results of the changes in the 
position of the trunk and shoulders of the foetus ; while, on the 
contrary, the rotation of the head in the pelvic cavity is the cause 
of the rotation of the trunk and shoulders. 

McpuUion of the Shoulders and Body, — Having pursued the pas- 
sage of the foetus to this [>oint, it will be proper to inquire in what 
way the shoulders and remaining portion of the child are expelled. 
When the shoulders have completely rotated, so that the right one 
b toward the pubes and the letl toward the concavity of the 
sacrum, they continue to descend under the hifluence of uterine 
contraction ; usually, the one which is behind is disengaged first;* 
sometimes, however, it will ha])pen that the one in front is the first 
to be ex})ellcd, and again, I have known both to make a simul- 
taneous egress. Still, ol>edient to the efforts of the utems, the 
remaining portion of the foetus makes its exit, and, as the body 
passes into the world, it is slightly curved upon itself, the concavity 
of the curve corresponding with the symphysis j)ul)is, while the 
convexity regards the hollow of the sjicrum. The reason of this is 
obvious; the pelvis being a crooked canal, the child, in its progress 
through it, must, of necessity, accommodate itself to its curves. 

Merhanis?7i in t/ie Second Ytrtex Position, — Right OccipiiO' 
acetahidar, — In this position (Fig. 21), the occiput at the right 
acetabulum, and the os frontis at the oj)posite sacro-iliac symphysis, 
the mechanism is jirecisely the Kime as in the first position, with 
the single exception that if the rectum be distended with faacal 
matter it may cause some little obstruction, during the rotary 
movement, to the os frontis, as it turns toward the concavity of 
the sacrum. In all other particulars the mechanism is identical, 
for the movements of flexion, descent, rotation, and extension, 
severally take place, and are accomplished in the same manner as 
in the first position. It may be well, however, to remind you that, 
arter external rotation is accomplished, the occiput, instead of turn- 
ing to the lell, will, on the contrary, pass to the right. 

Mechanism in the I'hird Vertex Position, — Eight Posterior 

• It may be remarked that thus will depend much upon tlie state of the perineum; 
for, if it Bliould have been lacerated in a previous labor, the anterior shoulder will 
be very apt to be expelled first. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 53 

(kcipiUhiUa4i. — ^This position, yon will recollect, according to 
Nafigel^ is the second in the order of frequency. The occiput is at 
the right sacro-iliao symphysis (Fig. 22), and the os frontis in appo- 
sition with the left acetabulum. This is the condition of things at 
the commencement of labor, and precisely the same phenomena 
occur in the progress of the delivery, as in the two preceding posi- 
tions. The peculiarity, however, of this right posterior occipito- 
iliio position is, that, during its passage through the pelvis, the 
occiput is rotated first from the right posterior to the right ante- 
rior section of the pelvic canal, and is ultimately brought, as in 
the two positions just described, in correspondence with the sym- 
physis pubis, while the forehead or face is directed to the hollow 
of the sacrum. The exceptions to this conversion of the occiput 
from the posterior to the anterior of the pelvis, are extremely 
lire — NaSgel^, as stated in the previous lecture, meeting with only 
seventeen instances, in twelve hundred and forty-four occipito- 
posterior positions, in which the conversion did not occur. 

Mechanism in the Fourth Vertex Position, — Left Posterior 
Oecipito-iliac. — (Fig. 23.) Here, again, the mechanism is the 
same, except that the occiput, under the influence of rotation, is 
brought first to the left anterior portion of the pelvis, and after- 
ward to the pubes. 

Deductions, — ^We have now completed the description of the . 
mechanism by which the child, in the several positions of the 
vertex, b enabled, with safety to itself and parent, to pass into the 
world. But all that we have said on this important and interesting 
topic would be, comparatively at least, of little avail, if we were 
not to pursue the subject still more closely. I suppose it may be 
assumed, without much fear of error, that you now thoroughly 
comprehend the different stages of the mechanism of labor ; and 
you are, no doubt, prepared to exclaim with me, how wonderful is 
nature, how exquisite this mechanism! The very exclamation, 
however, might possibly lead to wrong impressions ; for, if nature, 
it may be urged, be really so full of wisdom, and so bountiful in 
her provisions, she requires no assistance from science, being 
thoroughly adequate to the efRcient discharge of her duties. 
Here, then, is the point, and one, too, entitled to attentive con- 
sideration. Nature, it cannot be doubted, is, all things being 
equal, not only competent, but prompt in the accomplishment of 
her various offices ; but it will sometimes happen that she is con- 
travened in her arrangements by circumstances she cannot control, 
and, therefore, her relief must be found in the judicious interposi- 
tion of science. 

Allow me here incidentally to remark that, when you enter the 
lying-in chamber, your presence will involve one of two things ; either 
you will be there as a silent spectator, an admiring witness, if you 



fi4 



THE PRINCIPLES AKD PBAC3T1CE OF OBSTETRICS. 



ohootie, of the consiuttiniute skill displayed in the achievement of I 
parturient process, or it will devolve on you to give assisUnc 
because of the intervention of some influence which hxis paraly« 
nature, and lorees her to seek at your hands the needed succor 
How, permit me to ask, can yon render aid, with any well-founde 
hope of success, tinless your minds be previously imbued with th^ 
mechanism by which, w^ben not interfered with, the delivery of ifc 
child is accomplished ? In one word, gentlemen, in aflbrding tbii 
assistance, you become nature^s substitute ; but to be lier fiub8titut€ 
in truth and in edect, you must have been her di^^ciple, and learnc 
from her own teachings, the seriea of processes which, in the aggr« 
gate, make up what is known as ihe mechanism of labor. In tbi 
way only can you aid her, when subjected to influences which ahe 
herself cannot resist. 

In order that you may appreciate what I mean, and reoogniae 
the full force of the argument, permit me, by way of practice 
iilnstration, to imagine a catie of labor under the folluwhig circmi 
Htancesw A lady is attacked with bbor-paiiLS at six o'cluck iu th^ 
morning; the medical attendant is sent for; he arrives, and, on 
examination, ascertains that the head presents in the tirst po^itioa 
i>f the vertex — the occipnt at the left acetabulum, the os frontis 
the right sacro-iliac symjihysis j there is no deformity of the pelvig 
but tfie head may be a shade larger than nornud. Tlie pains con 
tinue with marked regularity; it h now nix in the evening; twelve^ 
hours from the commencement of the labor; but, notwithstanding 
the regularity and increasing character of the pains, t/iere is i 
profjrcfts whatever in the dtlwcry ; the bead is still at the superic 
strait, unchanged from its original position ; the mouth of the woml 
res|>ousive to the contractions of the organ, is well dilated, and thi 
''bag of waters" ruptured ; the i»ains now become more vigorousj^ 
the scalp of the chiUrs heiul iii corrugated or furrowed, a demon- 
stration that it is exposed to pressure, which, if protracted, must 
necessarily prove serious ; there is unusual heat in the vagina, and, 
in addition, (he Atrt^ngth of (he patient is giving icay, Tlie tVietidi 
become alarmed ; the accoucheur is closely interrogated as to tbi 
cause of the difficidty ; be assures them all m right, and offers wor 
of encouragement to the patient, telling her that, in a short time 
she will be delivered. 

Time stilt rolls on ; it is now eleven o'clock; no progreas wha 
ever; seventeen hours since the commencement of labor; the lad} 
is more exhausted, and the head of the child still the object of I 
intense pressure — the pains recurring with increasing force. In tbia 
condition of things, the doctor is emphatically admonished, that 
something must be done; in his embarrassment, he says to ihe hua^J 
band ; Sir, there is an impaction of the head, and, in order to save 
the life of your wile, it is absolutely necessary for me to 



THK PRIKCIPLES AND PRACTICE OF OBSTETRICS. 56 

the child ! This language forms a striking contrast with his pre- 
yioas assurances, and confidence in his judgment is so far shaken, 
that a consultation is demanded. Let us now. suppose that, in thib 
emergency, one of you should be selected as the consulting 
sccoueheur ; you reach the house ; learn the history of the case, and 
a vaginal examination enables you to detect, almost with the rapid- 
ity of thought, the entire cause of the delay. Nature has been 
vainly struggling to accomplish the movement oi flexion ; she has 
ikiled, and the consequence is that the head has been unable to 
descend into the pelvic cavity. After a brief consultation, you 
express your opinion, courteously but firmly, that there is no neces- 
rity for destroying the life of the child. The medical man in 
attendance differs with you ; or probably will make a strong per- 
sonal appeal, that there should be no difference of opinion, on the 
ground that he has committed himself to the family, having stated, 
without qualification, that the only alternative was the sacrifice of 
the infant ! It may, indeed, be that the instruments of death — the 
perforator and crotchet — are already on the table, awaiting only 
your sanction for their reckless employment. 

I need not say to you, gentlemen, that in circumstances like these, 
there is a paramount and sacred duty you owe the patient; all 
other considerations are of minor and insignificant import. There- 
fore, as there is but little time for argument, and death is at the 
very threshold, do all that you can as briefly as possible, to prove 
to your colleague that be is wrong ; if he be a man of heart, he 
will readily concur in your suggestions ; if without heart, and 
insensible to every influence, save his own selfish interest, the obli- 
gation devolves upon you to interpose, and protect from his mur- 
derous schemes both mother and child. Now, what is the sug- 
gci^tion you would make ? Why, obviously, to aid nature in doing 
what si.e has failed in accomplisliing ; that is, to produce the move- 
ment oi flexion. You may succeed, with a due degree of tact, in 
effecting this movement, as follows : gently grasp the head of the 
fcetus, during the interval of pain, and with the greatest possible 
caution, bring the occiput downward ; as this portion of the bead 
descends, the chin will, of course, approach the sternum ; this, in a 
word, is flexing the child's head. The whole difliculty of its descent 
from the' superior strait is now removed, and if the pains continue 
active, the labor will probably soon be terminated. 

Li what has this sin)ple, but most important manipulation 
resulted ? Why, it has not only saved the child, and rescued the 
mother, but it has converted a house of gloom into one of joy ; it 
has vindicated science, and made every member of that household 
your fast and abiding friend. Such, gentlemen, will be the precious 
results of true and available knowledge. Suppose, however, that 
mfter the movement of flexion has been accomplished, the strength 



56 THE PRINCIPLES AND PBACTICE OF 0B8TETBIGS. 

of the mother is so much exhausted, through previous effort, aa 
positively to indicate the necessity of immediate delivery. In suoh 
a contingency what arc you to do ? Before answering this ques- 
tion, allow me to ask what the precise position of the head is in the 
pelvic cavity after the movement of flexion has been accomplished ? 
It rests, of course, diagonally ; then, if immediate delivery bo 
necessary, tlie proper means of achieving it will be the application 
of the forceps ; but remember this essential fact, in the employment 
of tlie forceps, the head being in the diagonal position — after lock' 
ing the instrument^ and bf/ore making any extrcu;tive force^ the 
first thing to he done^ is gently to turn the forceps from left to righty 
far the purpose of producing the movement of rotation^^ which 
will necessarily change the head from the diagcmal to the direct 
position, by placing the occiput in apposition with the symphysis 
pubis, and the face in the concavity of the sacrum ; this being 
effected, you proceed to extract the head in the manner I shall 
point out, when discussing the subject of forceps delivery. 

* Many a child has bcM^n »icrificed, aiid tlio mother cruelly lacerated, from tlis 
tfiglect of tliis fundamental principle in delivery by furcepa. 



LECTURE V. 

Pelric Deformities, how divided — Evils of Increased Capacity — Case in Illustration 
— Dangers of Increased Capacity during Pregnancy and Labor — Diminished 
Capacity — Dangers of — Varieties of Pelvic Deformities — Causes of — Rachitis, 
Mollities Ossium — Distortion of Spinal Column does not necessarily cause Distor- 
tion of Pelvis. Obstructed Labor from Polypus — Removal of Polypus, and subse- 
quent Delivery of Child by Forceps — Pubic Arcade — Congenital Deformity of — 
Craniotomy — The Space through which a Living Child can pass — Experiments 
of the Author — Discrepancy of Opinion among Writers— The Space through 
which a Child may bo extracted by Embryotomy. How to ascertain that Defor^ 
mities exist — In the young Girl — In tho married Woman. Measurements of the 
PeU-is — ^Baudelocque's Pelvimeter— IIow employed — Its reliabilities — Objections 
answered. The best Pelvimeter, the Finger of the well educated Accoucheur^ 
The " Toucher** — How conducted. 

Gentlemen — I propose, in the present lecture, to direct your 
attention to the subject of Pelvic Deformities — a subject well 
worthy of your consideration, for the reason that these deformities 
not only exercise a very important influence on delivery, but 
oftentimes involve in serious peril the lives of both mother and 
child. A pelvis may be said to be deformed when its dimensions 
are either above or below the ordinary standard ; hence these 
deformities are divided into two classes: 1st, Increased capacity; 
2d, Diminished capacity. You might very naturally suppose that 
the larger tho pelvis, the greater the facility for the transmission of 
the child, and, therefore, perhaps, be inclined to doubt the propriety 
of denominating a pelvis, with increased capacity, a deformity. It 
is, indeed, true that, so far as the mere passage of the child is con- 
sidered, the facility of transmission is usually enhanced in propor- 
tion to the increase in the size of the pelvis. But this facility, it 
must not be forgotten, is too often purchased at a heavy cost, 
entailing upon both parent and offspring tho most dangerous 
results. I have described to you a normal or standard pelvis, and 
you now appreciate the provisions nature has made for the safe 
delivery of the child through it. Fortunate would it be if there 
were no departure from the natural dimensions of the foetus and 
pelvis, for then the paturient woman would be spared the anguish 
and danger incident to those disproportions, necessarily arising 
from an increase or diminution in size of one or the other. 

When a pelvis is deformed in consequence of an increased 
capacity^ the female encounters other troubles than those con- 



58 THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 

nccted with parturition. For example, as the direct consequence 
of an augmented space, she would be very likely to suffer from 
malpositions of the uterus, such as prolapsion, anteversion, or 
retro-version, and the bladder itself might become displaced. 
Occasionally, you will be consulted by ladies who will tell you that 
they are much annoyed either by a frequent desire to pass water or 
to evacuate the bowels; as either of these conditions may be 
traceable to various causes, it is of no little consequence that, in 
your investigation, yon should arrive at a correct of>inion, for the 
relief of the patient will necessarily depend upon the accuracy of 
the diagnosis. 

The following case is not without interest: In November, 1855, 
I was consulted by a married lady from the State of North Caro- 
lina, under the following circumstances: She was twenty-one years 
of age, and had been married two years ; no children ; her first 
menstruation occurred just six months previous to her marriage; 
about two months before the appearance of the catamenia, she 
began to experience irritation about the bladder, giving rise to a 
frequent desire to micturate ; and from that time until November, 
when I was consulted, this vesical irritation was more or less con- 
stant — being more annoying, however, a few days before her men- 
strual turns, and subsiding to a certain extent when these were 
over. This lady informed me that she had taken quantities of 
medicine, but without the slightest benefit. On an examination 
per vaginara, I ascertained the uterus to be in a state of prolapsion, 
but entirely free from disease of any kind ; and its inclination was 
slightly forward, pressing upon the neck of the bladder. There 
was now no difiiculty in accounting for the frequent desire to pass 
water — it was owing, as you at once perceive, to the mechanical 
pressure of the uterus against the bladder. In the vaginal exami- 
nation, I soon discovered that the pelvis was unusually large, con- 
stituting a deformity with increased capacity. This, then, was an 
interesting example of prolapsion of the womb, not from any 
increase in the volume of the organ, or from relaxation of the 
vagina, or from the effects of concussion, but simply a case of pro- 
lapsion from an augmented capacity of the pelvis. What, under 
the circumstances, could be done to relieve this patient, or was she 
doomed to suffer without any hope of benefit ? All that I did was 
to introduce into the vagina a soft India-rubber ball, for the pur- 
pose of giving gentle support to the uterus, and thus relieve the 
blatUler from pressure ; the result proved that nothing more 
was necessary.* Indeed, I do not know what else could have been 

• T am vt>ry partial to the Iridia-rubbor ball. It is soft and unirritaling, and has 
usually jrivou me great satisraction. Before introducing it, it is pierced with a small 
hole to allow the air to escape; you then fold it lengthwise, lubricate it with oil, 
and carry it into the vagina, being careful that the oritice looks downward toward 



THE PRIKCIPLES AND PBACTICE OF OBSTETRICS. 69 

done, as the support of the prolapsed uterus bj a pessary was the 
ouly indication to be fulfilled. 

There are one or two points of more than ordinary interest 
about this case. In the first place, the lady did not menstruate until 
she was eighteen years and six months of age ; and secondly, the 
first time she experienced irritation about the bladder was about 
two months before the appearance of the catamenia. The question 
now arises, why did she not for years previously suffer from the 
frequent desire to pass water? This is readily explained: the 
uterus, before the establishment of the menstrual function, is, phy- 
siologically speaking, dead to the economy — it is not only without 
office, but is comparatively insignificant in size — and hence, from 
this latter circumstance, there was an immunity from the vesical 
irritation, which only commenced when the advent of the function 
was at hand, and consequently the tissues of the uterus in a state 
of development. Again, this pressure was always more severe a 
few days prior to the menses, and diminished comparatively after 
their completion. The uterus, at that time, was more or less loaded 
with blood ; hence its increased volume, and, as a necessary result, 
its increased pressure agninst the neck of the bladder. 

During pregnancy, also, a deformed pelvis, from enlarged capacity, 
will involve more or less inconvenience from the various displace- 
ments to which the uterus is liable. One of the ordinary conse- 
quences of this species of deformity will be the descent of the foetal 
head into the pelvic cavity during the latter weeks of gestation, 
bringing with it the inferior segment of the uterus, which can 
readily be detected by the finger. From this circumstance there 
will arise various morbid phenomena, such as unusual bearing- 
down, constipation, troubles in micturition, either retention or a 
frequent desire to pass water, together with more or less distress 
in the thighs, the result of pressure on the pelvic nerves. But the 
greatest evils to be apprehended from an enlarged pelvis are more 
or less connected with the act of child-birth itself. For example, a 
too sudden expulsion of the fcetus may result seriously in several 
particulars, viz. inertia of the uterus, with flooding, may occur ; or, 
if the umbilical cord be naturally shorter than usual, or curtailed 
of its ordinary length by being encircled around the neck or other 
parts of the foetus, it may become ruptured in some portion of its 
extent, or torn from the umbilicus of the child, or from its attach- 

tlie outer opening of the canal ; the ball immediately becomes filled with air, and 
forms an admirable support to the uterus. A string should be attached to it, so that 
the patient may withdraw it for the purpose of having it cleansed, which should be 
done at least once in twenty-four hours. The patient should be taught to introduce 
it herself, which she can do without the least difficulty. Care must always be taken 
that the ball is of a proper size, neither too small nor too large ; in the former case^ 
it will fifdl out of the vagina; in the latter, it will be apt to irritate. 



eo 



TFE PRINCIPLES AND PRACTICE OF OBSTEmiCBi 



mcnt to the placenta ; if neither of these accidents should ensue, 
the plaof^nta it<^elf may be suddenly detached from the utcrns, or 
tliis latter or^an become inverted, in consequence of the reshtaoce 
uf the Mf\er-l>hih to the sudden traction of the cord< In jidditlunt 
there mny he the hazard of rnjiture of the neck of the organ, from 
its too rapid dilatation. Tlie occurrence of one or other of these 
accidL»nts would be followed by more or less peril. 

It is obvious, from what ha?* jiist been said, that a ]>atient willi 
this clftss of pelvic deformity should, at the time of labor, be strictly 
confined to the bed, and on no account permitted to walk about 
the rooTu, for the reason that I lie probabihty of any of these com- 
plit-ations would be i^reatly enhanced dniing the act of progrejssion. 
The patient should be in«tnicted to make no effort during a pain ; 
and the vigilance of the accouflieur will be nee<iod, in order that 
eiirly and efficient support be given to the perineum, to protect it 
against rupture from the sn<lden exit of the fcetus. 

Whatever may be tnihur the inconveniences or evils to b© appre* 
hended from a deformrd pelvis* with an inrrea^ed capacity ^ they 
are immeasurably insignilicaut in contrast with tho^e more foruii* 
dable ones, neces*«arily connected with a pelvis, whose capacity is 
diminif*hcd» In this latter east* oRentimt'S arise some of the most 
important questitmt* connected with the practice of midwifery — 
qncMions in whirh the judgment of the accoucheur will be severely 
tested, and bis feelings deuply touched. It is in instances like 
these in which you will be called tipon to decide the issue of Ut*e or 
death — ^whether u child known to be alive in its mother's womb shall 
be saciifieed, or whether, with a view of equalizing the chances of 
Burviviil between parent and offspring, the mother shall be subjected 
to an operation, which will necessarily involve her safety in the most 
alarming peril. These points, however, will be fully discussed under 
their appropriiilt* head, when speaking of operative midwifery. 

I ^ball nol, gentlemen — tor I do not think it necessary — enter 
Upon a minute description of the various pelvic deformities enume- 
rated by authors; I ]irefer to give you some general facts upon this 
Buhjcct, so that you may ^leduce from them ]>raclical lessons, which 
w*ill serve you in tlie lying-in chambtn-. Your minds cannot be too 
well stored with facts, provided they are tangible, and made sub- 
servient to your requirements in the hour of danger* Theory and 
sebolasrio classifications may appear well enough in books; but if 
thentt books be intended to aid the practitioner in the sick room, 
they would, in my opinion^ have more effectually accomplished the 
objcx't by elaborating what is really practical, and substituting for 
mere hypothesig and improtitablclore, sound and truthful prineiples, 
which will not only abide tlie test of the bedside, btit will consti- 

le fo rnaiiv li-'htH to guide lite medical man, when surrounded 
r loKt for the time in obscurity. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 61 

Varieties of Pelvic Deformity, — The pelvis may be diminished 
at the superior strait, at the interior strait, or in the excavation. 
This diminution may exist simultaneously in these three portions 
of the pelvic canal, or only one portion be curtailed of its usual 
capacity ; while the other two will present their normal dimensions. 
For example, the two straits and excavation may be so diminished 
in size, as to render it physically impossible not only for a living 
child to pass, but impossible, also, for the child to be extracted in 
fragments, when subjected to the operation of embryotomy. Again, 
there may be no deformity at either of the straits, but the excava- 
tion abridged by the growth of an osseous or fleshy tumor ; the 
excavation and upper strait may be normal, while there exists at 
the inferior strait a diminution, which will render it impossible for 
a living child to be extracted, or at least protract considerably the 
ordinary duration of labor. Now, the very converse of this will 
sometimes occur — the superior strait may be so curtailed as to 
prolong the labor at its commencement, while the inferior presents 
its usual dimensions, and will afford ready exit to the child. 

Let us suppose that you are attending a case of parturition with 
the pelvis exhibiting this latter deformity. If you be not exceed- 
ingly careful, and do not ascertain the fact of the deformity at the 
very advent of labor, you may possibly give an opinion as to the 
termination of the delivery, which will be likely to result in pre- 
judice to your interest. You make an examination, and finding 
the head presenting naturally, and the uterus beginning to con- 
tract, in reply to the inquiry either of the patient or nurse, you 
say " All is right," and you entertain no doubt that the labor will 
progress most favorably. Twenty hours may be required for 
nature to cause the head to pass through the abridged upper strait; 
finally she succeeds, and the head begins to descend into the pelvic 
excavation. You are closely pressed by the friends for your 
opinion as to the probable duration of the labor ; and it may hap- 
pen that you will assume as the basis of your calculation a very 
false principle — that is, you may argue in your own mind, if it 
needed twenty hours for the head to pass the superior strait, it will 
require at least the same time for it to escape through the inferior 
strait. This will prove false logic, and the result cannot but be 
injurious. The opinion, on the contrary, which would be given by 
the medical man, who had early discovered the deformity at the 
tipper strait, would be more in unison with the result of the case. 
He is at once able to account for the delay in the labor at the com- 
mencement, and knowing that there was no narrowing of the pelvis 
at the inferior strait, he would most naturally and intelligently 
conclude that, save the occurrence of some unforeseen accident, the 
labor would be completed in comparatively a short period. The 
young practitioner cannot afford to prove a false prophet iu tiv^ 



m 



THE PRINCIPLES AND FEACTICE OP OBSTETRICS. 



lyinft-in room ; his opinionB are weighed not itnfrernienlly in a 
capricious balance, an<l there are few things which will lend to 
injure him more eflTcclually ihan error in proj^iosis, whether aa 
regards the termination of disease or the duration of labor. 

Causes. — The causes of pelvic deformities are variouR; when the 
c^ipacity is increased, the deformity is almost uniformly congenital. 
This, however, is not always the case ; I now show you a pelvi* (Fig. 

28),w[ncfi, although ori- 
ginally w el Mbrmc<l, ex- 
hihits both in its upper 
and lower straits, a re- 
markable increa^ie of 
capacity. The defor- 
mity is tlie result of 
serious injury — the fo- 
male to whom it be- 
longed was crossing the 
street — she fell on her 
Pm^ 28L *<ide, and the wlicel of 

an omnibus passed over 
the lateral portion of the pelvis, causing a partial dislocation of the 
symphysis pubis, and also of the two sacru41iac symphyses ; theso 
diftlocalions, as you perceive, have produced an extraordinary sug- 
mentatton in tlie diameters of tlie pelvic straits. 

The eausei^, which usuall}- arc active in the production of defor- 
mity with dimini.shed capacity, are principally as follows; 1, Itachi- 
tiSy a diyeaf^e of infancy, the pathology of which is a deficiency 
of carlhy nuU<er in the botres, thus depriving them of their ability 
to resist superincumbent and other pressure, and consequently 
resulting in more or less distortion of the pelvic canal ; 2, MoUUiei 
099%nm^^ or, as it is termed l>y tlie Greek?;, Mala^^osteon^ which is 
also a softening of the bone; it is a disease incident to adult age, 
while rachitis originates in, and is peculiar to, infancy. Both of 
these pathological conditions usually exhibit their results first, in 
the spinal column, causuig various distortions of the vertebi'se ;f and 

• UotlitUt OflVtMm mrcly occurs in women who bavo not lK>me chndrc-n; and 
there la an iti(»rQ«Uiig cifeuinsiiinco of practical vnlue connected with this fuel — for 
exunnple, » fvnmlo nmy have brtmjrlit forth Bovernl children without difUculty; but, 
in ft future prfjrnuncj, a deformtlj, the effect of molltties ossiiitn, may t)ceur, which 
will render tMnbryotoroy or the ct^psareau section necessary. It would seem, there- 
(bre, thnt Hiild-birlh exercjaes more or U*8s intiuenco on this terrible mnlady, ti h'»d- 
injc: • rie of which is a rthoriening vf the sUtturt nf ih$ mdmduat^ owing to 

the L of the ^(liiial eohimn. 

f U »ii un^rtanl to recollect Unit distortion of the ipliml column dooa not tieom* 
aarily U^volve a defurmiiy of the fK*lvig, Without a kuowledfr^ of thia fiictt the 
practit)Ofier would 90iuelifnc3i V>o liable to error in forniing^ hta opinion Ska to the 
rxiatencc or non-existence of peMc dcfbrmitioa. It has, I am aware, been asterled 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 68 

you can readily understand why, in these affections, the superior 
Btrait of the pelvis should so frequently become the seat of defor- 
mity. The base of the sacrum receives the last lumbar vertebra, 
and, in this way, necessarilysustainsthe weight of the trunk; under 
these circumstances, when there is a softening of the bones, nothing 
would be more likely than a projection toward the symphysis pubis 
of the sacro-vertebral prominence, and necessarily an abridgment 
of the dimensions of the upper strait. In fact, either in Rachitia 
or MoUities ossiuniy as a general rule, the deformity of the pelvis 
will be in precise relation with the particular kind of pressure 
exercised on its different bones. If, for example, from disease or 
other circumstances, the individual keep her bed, and continue for 
a long time in a recumbent posture — if on her back, the deformity 
would 6e from before backward, because of the projection forward 
of the sacrum; if on her side, the deformity would be in the trans- 
verse diameter, because of the lateral pressure, thus causing more 
or less approximation of the sides of the canal. 

In addition to the causes already mentioned, there are others 
worthy of note, which will occasionally result in deformity of the 
pelvis — such as morbid growths, either osseous or sarcomatous, in 
the excavation,* fractures of the pelvic bones, ulceration of one or 

hj some writers that there is a necessary and constant relation between distortion 
of the spine, and distortion of the pelvic canal This, however, is not in accordance 
with facts. 

* Sometimes these morbid growths, such as polypoid and fibrous tumors, wiU 
curtail by their presence the dimensions of the pelvis, although there is actually no 
deformity in the bones of the pelvis itself— these growths being attached to the 
uterus, and sometimes, too, finding their seat in the vagina. Under these circum- 
stances, it becomes a very nice question, especially at the time of labor, to decide on 
the course to be pursued. The following case is in point: 

In September, 1853, I was requested to visit a patient twenty miles distant from 
the city, in consultation with Dr. James Ridley. She had been in labor with bor 
first child thirteen hours before I saw her. Previous to, and during her preg- 
nancy, she had been subject to severe floodings; the patient was in an anoemic state, 
and evidently suffering from strong labor pains. My friend, the Doctor, stated to 
me that he had made several attempts to reach the mouth of the womb, but failed 
in consequence of a tumor in the vagina. During the throes of labor, the tumor 
was pressed toward the vulva, accompanied by considerable haemorrhage. What 
was this tumor? At the Doctor's request, I made a vaginal examination, and, 
after some diflSculty. succeeded in directing my index finger along the posterior 
wall of the vagina, as far as the os uteri ; here, I very distinctly felt a stalk or pedicle 
attached to the posterior lip of the cervix. In bringing the finger toward the exter- 
nal orifice of the vulva, I could recognise a firm, uniform substance, increasing in 
volume as it extended toward the orifice ; it was insensible on pressure. The exami- 
nation developed, therefore, some interesting facts — viz., that the tumor was pedun- 
culated, the pedicle being upward, and the base downward, together with insen- 
sibility on pressure ; these are the very essentials of a polypus of the womb— and 
the other important feature of this character of growth waa present, viz. haemorrhage ; 
and in addition, as I have already stated, the patient suffered from bleeding both 
before and during her pregnancy. Br. Kidiey concurred with me in opVnioi^ Aft \o 



64 TH£ PKIXCIPLE3 AND PRACTICE OF 0B8TETBICB. 

other of the acctabula, permitting the head of the os femoris to 
pass into the pelvic cavity ; syphilitic disease and mercurial eachexj 
wOl also, in some instances, contribute to a modification and defor- 
mity of the pelvis. 

It sometimes happens that a pelvis will present a general and 
corresponding diminution in all its dimensions, the result of origi- 
nal conformation; and, in such case, the woman will frequently 
exhibit no indication whatever of disease — but, on the contrary, 
in every particular she bears the evidences of excellent health. 
Here, then, is an example of primitive or original malformation — 
consisting simply in a imiform curtailment of the respective diame- 
ters of the pelvis, not traceable to any special cause — but which 
may give rise to very serious obstruction during the passage of the 
child. Tliis species of defonnity, however, is comparatively rare. 

The pubic arcade of the female pelvis will occasionally constitute 
the only deformity ; in such case, it bears a striking analogy to the 
arcade of the pelvis in the male — the rami of the ischium and 
pubes, on either side, instead of forming the usual angle, descend 
perpendicularly, thus curtailing the outlet in such way as to render 
it physically impossible that a living child can puss, and, therefore, 
calling for the operation of embryotomy or the cajsarcan section as 
the ease may be. This 8j)ceies of deformity is, I think, extremely 
rare. On one occasion I met with it ; in all other respects, the pelvis 
was well formed: Dr. Xugent, of Long Island, requested me, in 
May, 1851, to see a lady under the following circumstances; she was 
in labor with her first child ; the pains had been regular and active, 
and everything progressed favorably until the head reached the 

tho nature of the tumor, and tho next important question waa— what, under the 
ciiX'umHtaiices, could bo done? The labor pains were well marked and regular-^ 
the patient was weak from previous and present losses of blood — the tumor so 
nearly filled up the vajciua, as to establish beyond peradventure tho uttor imposai* 
bility of delivL-ry without its removal. Without hesitation, therefore, I proposed 
this as the only alternative — with the concurrence of my friend, and, at hia request, 
I excise<l the tumor in the following manner: Directing my tinker upward as a guide 
as far as the posterior lip of the os uteri to which the pedicle was attached, 1 then 
intn)du(.-ed flatwise along my finger a probe-pointed bistoury, with which I sepa- 
rated the pc<licle from its attachment — tho linger and instrument were then with- 
drawn, and the next point was to remove the jwlypus from the vagina. This was 
acconi]>lish(.Hi by means of hooks placed on either side of the tumor, which, after 
some considerable traction, was brought into the world. Tho polypus was quite flrm, 
and wei^lutl six ounces. The pains of labor increased with tho extraction of tho 
polypus, and the patient, although much prostrated, bore her suflferings with remark* 
able heroism. It became, however, quite evident, after tho lapse of six hours from 
the removal of the tumor, that tho strength of the patient was fast giving way— the 
head had descended to the inferior strait, and the exhaustion of the lady l)ecoming 
more and mon» marked, it was juilged proper to have recourse to the forceps. At 
the request of Dr. Ridley. I applied the instrument, and extracted a fine living son. 
The mother and child are at this time both living, and in tho enjoyment of good 
health. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



66 



inferior strait ; at this stage of the labor, although the pains were 
strongly expulsive, there had been no progress for a period of eight 
hours ; the patient was becoming exhausted, and the head of the 
child encountered extreme pressure. It was under these circum- 
stances that I saw her ; on an examination, I found the pubic arcade, 
in its widest portion, measuring only two inches and an eighth. 
This contraction of the arcade at once accounted for the delay in 
the delivery, and there was no alternative but the operation of 
embryotomy. It was quite manifest that no force which the uterus 
conld exercise would be adequate to accomplish the exit of the 
child through such a contraction ; nor was there the remotest hope 
of consummating the delivery by means of the forceps. In such a 
contingency, delay would have sacrificed the mother ; and much as 
I am .opposed to this operation on general principles, yet, in the pre- 
sent instance, with the entire concurrence of Dr. Nugent, and at his 
request, having strong proof of the death of the child, I proceeded 
to remove it. The operation was accomplished without much 
delay, and the patient had quite an auspicious recovery. The 
deformity in this case was unquestionably congenital, constituting 
one of those anomalies in organization, which arc occasionally met 
with, but which cannot be explained on any rational principle. It 
was evidently in no way connected with disease of the osseous 
structure. The health of the lady had always been excellent. 

Oblique Distortion of the Pelvis — obliquh ovata. — Prof Naegel6 
was the first to direct attention to a peculiar deformity of the pelvis, 
which he denominated pelvis ohliqu^ ovata (Fig. 29). His mono- 
graph on the subject 
has been translated 
into French by M. 
A. C. Danyau, and 
discloses a vast deal 
of research. Na6gel6 
collected thirty-se- 
ven examples of this 
species of distortion, 
only two of which 
were in the male sex. 
The deformity con- 
sists in an abridgment 
or flattening of one of 
the lateral portions 
of the pelvis ; in the 

thirty-seven cases alluded to, the distortion was observed twenty- 
two times on the right, and fifteen times on the lefl side. On the 
affected side, there is complete anchylosis or fusion with the sacrum 
and innominatum ; on post-mortetn inspection, not the slightest trace 

4 




66 



THE PRlNCri'LES ASl> PHACTICE OF OBSTETRICS. 



of the feyncljondrosc articulation can be dbcornetl. The Professor 
Bupposes the fusion of the articuhition to be congenital ; othem, 
amontjf whom may be raentioned Dn liigby, attribute it to previous 
inflanimaiion of the part. This deformity is of extreme dangi»r at 
the lime of labor, for, as far as the results have be<;n obtnined, 
Naj^gel^ says they liave been fatal to both mother and child la 
every instance but one. 

What is the smaUent space through which a Uving child may 
be extrtxctid — and embrf/otomt/ practicable f — Let us novr eianiiae 
the most imporlatit question connected with the subjecit of pelvic 
deformities; for, after all, the ^reat point for us as obsletriciana 
is — what is the actual amount of curtailment, whicli will prevent 
the passage of the living fcDtus, and, therefore, call for an opera- 
tion which necessarily sacriiices the ebild^ or places in imminent 
peiil the siifety of the mother? There is much discrepancy of opi 
nion among authors, as to the !*pace required for the transmission 
of a living fcetus; and the name discrepancy, too, exists as to 
tthe extent of contraction through which it is possible to extract 
a child, fragment by fragment, in the operation of embryotomy. It 
gcems to me that these two questions are not matters of opinion — 
they are, on the contrary, questions of fact. Hypothesis here is 
of no possible avail, unless coniirmed by positive and ample expe- 
riment. In order to settle the argtimcnt for myself, not by theory, 
but through actual demonstration, I caused, several years sincei 
eix wocidcn pelves to be constructed with the following dimensions 
— l«t. The antero-posterior diameter of the superior strait meaauroA 
three inches, 

2d. The antero-posterior diameter meaaores two inohes aod 
three-quarters. 

3lI. The antero-posterior diameter measures two inches and one- 
eighth, 

4tlK Tlie antero-posterior diameter measures two inches. 

6th. The antero-posterior diameter measures one inch and three- 
quflriers. 

Cth. The antero-posterior diameter measures one inch and a half. 

With the pelves Nos. 1 and 2, I have experimented with a view 
of ascertaining whether it wiis possible to extract a foetal head, 
posseasing the ordinary dimensions at full term, without subjecting 
It to such pressure and injury as necessarily to destroy bfe; and, 
after repeated and ♦careful trials, I arrived at the conclusion that 
the smallest possible space, except in extremely rare instances 
through which a living foetus, at the cnA of gestation, can pass, is a 
diameter of three inches and an eighth antero-posteriorly — ^and 
oven with such capacity, there will necessarily be much delay in 
the delivery, and, to a certain extent, more or less danger to tht 
, child. 



J 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 67 

With the pelves Nos. 4, 5, and 6, 1 have repeatedly made the 
attempt, but unsuccessfully, to bring away the foetus piecemeal, 
and am satisfied that this cannot be accomplished — ^without the 
almost certain hazard to the mother of lacerations, which will more 
or less involve her life, or at least, entail upon her sufferiDgs, to 
which death itself would oftentimes be preferable — ^with a contrac- 
tion in the antero-posterior diameter of less than two inches and an 
eighth. These results,* gentlemen, may strike you as singular, 
especially as they are at variance with the opinions of men of high 
aatbority, who have been regarded as almost oracular upon these 
important questions.! But I am quite sure that I am right. This 
subject will be again referred to, when speaking of the operations 
to be performed on the mother and child, in consequence of 
> pelvic deformities. 

Measurement of the Pelvis, — You may be called upon to deter- 
•mine the measurements of the pelvis under either of the following 
circumstances : 1. In a young girl, who may be suspected, by her 
mother, to have a deformity, which, in the event of marriage and 
pregnancy, might peril her life ; and, therefore, your opinion will be 
required to decide this important question. You at once perceive 
how sacred the responsibility of such a position, and what delicate 
issues will necessarily be involved in your judgment of the case. 
2, A woman with a deformed pelvis may be in labor, and it will 
rest with you to determine what course is to be pursued — whether 
the deformity is such as to prevent the passage of a living child — 
whether the labor can be terminated by the forceps — or whether 
the alternatives of the caesarean section, embryotomy, or version, 
be indicated. 

These, gentlemen, are among the grave and trying points of our 
profession ; and their just solution requires sound judgment, ripe 
experience, and inflexible integrity. We will now suppose the case 
of the young girl. How are you to proceed in the examination to 
ascertain the condition of the pelvis ? Under these circumstances, 
an internal examination cannot be justified, nor is it at all necessary. 
You, therefore, conduct your investigation in the following man- 

* It may, perhaps, be urged that the deductions arrived at are not reliable, for 
the reason of the difference in the yielding of the natural and artificial pelvis ; but 
with the full recognition of this difference, and a proper allowance for it, I have faiUn 
in the results. 

f Busch, of Berlin, says, for a living child to pass, the antcro-posterior diameter 
muse measure from two and a half to three inches ; Scanzoni, two inches and threes 
quarters ; Bums, three and a quarter ; and Dr. Joseph Clarke, three and a half 
inclies. 

As regards the space through which it is possible to perform the operation of em- 
bryotomy. Bums says one and three quarters are required; Hamilton, one and a 
iiaif inches ; Osborn one and a quarter ; Davis, one inch ; Dr. Dewees would not advise 
the operation under two inches. 



68 TH£ PRINCIPLES AKD PRACTICE OF 0BSTETBIC8. 

nerr — In the first place, you will mform yourself of her early 
history — whether in infanry ^he was healthy; whether, during that 
or any subsequent periotl, tfiere waa any indication of ricketa, 
scrofula^ &c; examine into her present condition; is her nppt;tite 
good — how is her digestion — is she strong and mupcular — how is 
her sleep? Has the eatnmcnial fnnction appeared — if so, h it 
regular? Does she walk tirmly, or is there evidence of Limenesn? 
Thesie questions, if properly answered, will aid you materially iii 
arriving at a correct opinion. But, in addition, you can make lui 
external examination of the pelvis as follows : It is better, I think, to 
have the girl in the Rtanding position, with her back supported again^tt 
the door or wall^ — then with your hand introduced, t)ie chemise inter- 
vening between it and the pelvis, scrupulously avoiding all exposure 
of her f»crson^ you ascertain whetlier the sjraphysis pubis has its pro-' 
per shape, whether too prominent or too flat ; are the crests of the 
ilia natural, or do they approximate too closely ? How arc the ante-* 
rior-su])erior j^pinous processes — are they too nearly approximated, 
or do they maintain their natural position ? Then place your liand on 
the sacrum, and ascertain wlicther it is too projecting, or whether it 
recedes unnaturally. Tiiese are the special points to winch your utten- 



Atti. SO. 



tiOD IS to be directed in thi§ kind of exploration. You then have re- 
course to the pelvimeter, for the external measurement of the pelvis* 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 69 

Pelvimeter — haw used. — ^The best instrument, and most reliable 
one for this purpose, is the pelvimeter or callipers (Fig. 30) of 
Baudelocque. It consists of a scale and two extremities. In order 
to recognise the antero-posterior diameter of the superior strait, 
one extremity of the instrument is placed at the symphysis pubis, 
whilst the other is brought in contact with the superior spinoiis 
process of the sacrum. If the antero-posterior diameter be natural, 
the scale of the instrument should give you seven inches, and then 
yoa deduct two and a half inches for the thickness of the sacrum, 
and half an inch for the symphysis pubis, which will leave four 
inches, the measurement of the direct diameter at the superior 
stnut. For the measurement of the oblique diameter, one ex- 
tremity of the instrument is placed upon the great trochanter, the 
other upon the opposite sacro-iliac symphysis — the scale should, in 
this case, yield nine inches ; deduct two and three quarter inches 
£6r the thickness of the trochanter, neck, and head of the femur, 
and one and three quarters for the thickness of the sacro-iliac 
symphysis — this will make four and a half inches to be taken from 
nine inches, which will leave four and a half, the measurement of 
the oblique diameter at the upper strait. 

The pelvimeter of Baudelocque, I repeat, is an accurate and 
reliable instrument ; but I can readily anticipate your objections to 
it. You will ask me, for example, how this external measurement 
will suffice to prove that there is no abridgment of the dimensions 
of the pelvis internally by the presence of tumors, or other forma- 
tions ? The question is a legitimate one, and I will endeavor to 
answer it. If there be a curtailment of the pelvic capacity in con- 
sequence of the presence of tumors, whether osseous, fibrous, or of 
any other character, these tumors would unquestionably give some 
indication of their presence by certain pathological phenomena, 
such as irritation, more or les9, of the bladder or rectum, pain in 
the back, numbness of the lower extremities, a sensation of drag- 
ging, and pressure downward. Thei*efore, in the absence of these or 
other symptoms, I should be disposed to have faith in the develop- 
ments of the instrument. In order to become satisfied as to the 
configuration of the inferior strait, the pulp of the thumb is placed 
under the symphysis pubis, and the end of the index finger on the 
tip of the coccyx ; with the thumb and finger thus separated, the 
space between them is measured by a scale, and the result will 
show whether the cocci-pubic diameter be normal or otherwise. In 
the same way, the measurement of the bis-ischiatic diameter can be 
ascertained, by placing the thumb on the tuberosity of one ischium 
and the index finger on the opposite tuberosity. 

Internal Measurement. — Numerous contrivances have been sug- 
gested for the internal mensuration of the pelvis ; but, with all due 
respect for their inventors, I must, in candor, caution you against 



ro 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



their employment. Tbey cannot be resorted to without eubjeeting 
tbe female to more or less paiti ; and, moreover, they are wanting 
in precision in Iheir results. Id the married woman^ all instrnments 
may be dispensed with, for here we can employ whiit I consider the 
very best pelvimeter, because it h the most searching in its ex pi u ra- 
tions, and the most positive in its results — I mean the Jinger of 
(Jie well educated accoucheur. This brings me to a iew general 
observations on the important subject of vaginal examinauon by 
the linger, nr as it is termed by the Freni-li — the toucher. The 
patient should be placed either on her side or back — where there 
is no special oVyection, the back I think preferable^ — the accoucheur 
then places hi^ tluinib directly in the palm of his hand, and covers 
it closely with the middle, ring, and small fingers, so that the index 
finger may be free — this latter is the only one required for the 
vaginal examination ; and the directions just given, it* recollected, 
will frequently spare the practitioner much embarrassment, and hia 
patient no little annoyanee. 

1 have known instances in which the vaginsil examination bmi 
been attempted without regard to any rule or principle — the hand, 
with the fingers separated, carried toward the vagina, one finger, 
perhaps, finding its way into the meatus nrinarius, another press- 
ing upon the clitoris, while a third would probably be on the outer 
boundary, if, indeed, it did not penetrate the anus itself, consti- 
tuting in all truth a fun- 
damentai operation, and 
causing the patient to re- 
buke, in severe language, 
the operator for his stupid- 
ity and ignorance! The 
index linger being lubri- 
cated with oil, or some mu- 
cilaginous material, is intro- 
duced gently into the vat- 
gin a, at first from before 
ha^hicard and then from 
below vpward. A general 
sweep of the vagina is to 
be made during this exanii- 
nation, to ascertain the con- 
jJ dition of the excavation, 
whether its capacity is natu- 
ral or whether abridged by 
fiome foreign growth; tbe 
radial border of the finger 
is then placed under the 
symphysis pubis, and the apex directed toward the promontory of 



itt: 



fM. St 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 71 

the sacrum (Fig. 31). With the index finger of the other hand, 
placed on the radial surface of the finger in the vagina just 
outside of the symphysis pubis, the finger is withdrawn from the 
vagina, and a scale applied for the purpose of measuring it ; this 
will probably, in case of a natural conformation, give four and a 
half inches — ^but half an inch is to be deducted for the obliquity 
of the finger in its course from the symphysis pubis to the 
sacro-vertebral prominence, which would leave four inches the 
nonnal antero-posterior diameter at the superior strait. This 
mode of measurement has been objected to by certain writers 
on the ground, that, in some cases, the index finger could 
not reach the sacro-vertebral prominence. Well, it seems to 
roe that, admitting the objection to be valid, it demonstrates 
the very thing we desire, viz. that there is no contraction in 
the antero-posterior or direct diameter. The measurements of 
the inferior strait are to be conducted as we have already de- 
scribed in the case of the young girl. Some authors, and Yelpeau 
among others, recommend for the internal examination the 
introduction into the vagina simultaneously of the index and middle 
fingers, so that while the latter is extended toward the sacral 
prominence, the former may rest on the internal surface of the pubes. 
But I cannot see the necessity of this suggestion ; while, on the 
contrary, there is, in my judgment, a positive objection to it — an 
increased irritation of the vagina. 



LECTURE VI. 

Organs of Generation — External Organs — The Mens Veneris, I/abia Externa, Clitorifl^ 
Labia Interna, Vestibnlum, Meatus Urinarius, and Urethra — Secretory Apparatoa 
of liie External Organs— Sebaceous and Muciparous Follicles — Yulvo-vaginil 
Gland — Tlie Internal Orpins — Tlio Vagina, its Anterior and Posterior Relatione 
— Tiie Urethrovaginal. Vesico-vaginal, and Recto-vaginal Septa — Vesico-Taginal 
and Recto-vaginal Fistula; — How produced — Orifice and Superior Extremity of 
Vagina— The Hymen, its zVbsenco no Test of Loss of Virginity — Its Presence no 
Evidence that Sexual Congress has not occurred— Retention of Menses mistaken 
for IVegnancy — Blood-vessels and Nerves of Vagina — Utenis, Uses and Situation 
of — How divided — The Stnicturo of Uterus com posito— External and Internal 
Coat — Intermediate Tissue is Muscular — Is the Uterus an Erectile Organ 7— 
Rougefs Researclies — Hlood-vessels, Nor\'ea, and Lymphatics of Uterus — Recto- 
uterine Fossa, Importance of— Ligaments of Utenis — The Cervix, its Peculiarities 
before and after Puberty — Os Tincw, Cicatrices upon, not always reliable as eri- 
dences of Childbirth— The Fallopian Tub(?s— The Ovaries, the Essential Organs 
of Generation — Structure and Uses of the Ovaries. 

Genti.emen — The organs of generation in the female are usually 
diviiletl by authors into external and internal, embracing, under the 
former head, those which are situated on the outside of the pelvis, 
while the latter are contained within the pelvic canal. This division 
is not strictly correct, for we shall see, as we proceed, that the organs 
external to the pelvis are not in reality those of generation ; they 
are simply auxiliary to that act, and may, therefore, with much 
more propriety, be denominated the copulative organs. 

I need scarcely assure you that an accurate knowledge of those 
parts, both as regards their anatomical structure and relations, 
together with the numerous pathological changes to which they are 
exposed, is absolutely essential to the obstetrician. Without this 
knowledge, you will, in the practice of midwifery, be constantly 
liable to error, nor can you hope to diagnose or successfully treat 
the varied and important maladies occurring in these organs. I ask 
your attention, therefore, especially to this subject, and shall 
endeavor to be as brief as is consistent with clearness in descrip- 
tion. 

External Organs, — They are as follows : 1 . The mons veneris ; 
2. The labia externa ; 3. The clitoris ; 4. The labia interna ; 5. The 
vestibnlum; 0. The meatus urinaiius and urethra. !Mosi anato- 
mists comprehend these different parts under the name of vulva^ 
which is also given by some others to the opening extending from 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 78 

the mons veneris to the anas. The term pudendum is likewise 
occasionally employed to designate the external genitalia m the 
female. 

1. The mons veneris is situated in front of the symphysis pubis, 
and, at the period of puberty, is covered with hair. It is a sort of 
cushion, sometimes remarkable for its prominence, which is usually 
the case in fat women. Occasionally, too, this prominence is due 
to a projection forward of the pubic bones ; again, it presents a flat- 
tened aspect, which is observed more commonly in eipaoiated per- 
sons, owing to the absence or absorption of the adipose tissue ; and 
you will also find it receding inward, depending upon a recession 
of the bones of the pubes. In structure, the mons veneris consists 
of fatty or adipose matter, a fibro-filamentous substance, and cellu- 
lar tissue. It sometimes becomes the seat of active inflammation, 
which may terminate in abscess. Under these circumstances, it is 
important to give early and free escape to the purulent secretion ; 
othemise, much annoyance may ensue to the patient from the for- 
mation of fistulous or burrowing openings, which will not only 
result in much unnecessary sufleiing, but oftentimes occasion a 
tedious convalescence. 

2. The labia externa or majora are two duplications, commenc- 
ing at the central and inferior portion of the mons veneris^ at what 
is termed the superior commissure, and extending nearly parallel 
to each other downward to their terminal point, known as the infe- 
rior commissure. These labia have an external or cutaneous cover 
ing, and an internal or mucous investment, which is a continuation 
of tliat of the vagina, and is characterized by great delicacy and 
sensibility ; they are composed of an intermediate structure, con- 
sisting of adipose and filamentous cellular tissue like that of the 
dartos of the scrotum ; the round ligaments of the uterus expand 
themselves in the labia externa. Just above the inferior commis- 
sure, the labia are united by a small fold of integument, which has 
received the name of fourchette, and the little space comprised 
between the fourchette and posterior border of the vaginal orifice 
is called the fossa navicularis. The fourchette is almost always 
ruptured in the first labor, and neither it nor the fossa is of any 
special importance. The labia externa enjoy a remarkable elasti- 
city, which enables them at the time of childbirth to undergo, 
without laceration or injury, the necessary degree of distension. 
On their internal surface are mucous and sebaceous glands, which, 
in health, secrete a lubricating fluid, the object of which is to soften 
the parts, and j)rotect them against the consequences of friction. 
Occasionally, however, during pregnancy, and also in the unim- 
pregnated state, these glands, through some morbid influence, pour 
out an extremely acrid and irritating material, which inflames and 
excoriates the labia ; if the female be married, this acrid secre- 



74 THE PRINCIPLES AND PBACTICE OF OBSTETRIca. 

tion may produce in her husband a gonorrhoBa, so that a full nicifc- 
flure of vigilance will be required, on the part of the praciiiioner, 
not to confound it with a true syphilitic uffection* 

Do yon not» at a glance, appreciate the inevitable and melancholy 
consequences of error of judgment in a eai^e like this? Let us 
suppose an instance; and it is not so hj*pothetical that it may not 
present itself to any one of you, whcu you shall have bei-ome 
engaged in practice. You are, we will imagine, the family physi- 
cian — every coutidence is reposed iu your skill as a ]>ractiliuner, 
and in your honor as a man. The father of that family comes ta 
you, and says he wishes a sti ietly confidential interview ; he lella 
you he is in a state of much disquietude, and, for the hist four days, 
has not dared to give latitude to thmiglit, for the very suspicioa 
which has crossed his mir»d is woi"se to him than death. He saya 
he has suffered for a week past from an intense scalding iu mieturi- 
tion, and there is a discharge of matter from the |»enis. ** Allow me, 
my friend," you observe to him, *"- to examine the pHfts;'* he consents, 
you see the inflamed condition of the penis, and, in a jocose man* 
ner, you exclaim, *'0h 1 that's nothing; you have bei^n on a frolic 
— the next time, my friend, you must be mure careful — you have 
the clap, sir!" It may be that stich an opinion wil! be in accord- 
ance with facts, and no particular harm, therefore, will grow nut of 
this display of fkeetious mirth ; you cure your patient of hb dis- 
ease, and receive the equivalent, your fee, and there the tuatler 
terminates. But let us look at the other side of the question. This 
husband listens calmly to your optuion, and, perhaps, asks you if 
there be not a possibility that you mriy be in error as to the cause 
of his disease. *^ Oh ! no, sir," you re}>ly, ^' there is no more doubt 
about it than that two and three make Hve,''^ **Then, doctor, my 
hapjiincss ii* at an end ! If you are right I liave taken that disease 
from my wife !" Now, gentlemen, this inflammation of the urethra, 
and the scalding during micturition, may have been derived from 
Bcxnal intercourse with his wife, without the slightest violation ot 
conjugal fidelity. Afler the opiivion so hastily given, it will be too 
late to recall it ; that opinion has plunged a dagger into the heart 
of your patient; and though It may possibly be withdrawn, yet the 
wound is there, and it will continue to fester, and prey both upon 
his moral and physical health. 

The hifna externa^ in the young girl and in the unmarried female, 

are tii m, and usually closely approximated on their internal surface 

— but, as a consequence of matrimony and childbirth, \hcy become 

.relaxed, and ar© more or less separated. They are, occasionally^ 

^the seat of various pathological conditions,* such as serous inflltra- 



• For tbo full di?»cnptioo of these condiiiuns. ihdr caiksOA. treatment, etc., I miy 
nikr the rvHdef Uj my work on the Dijtm.te* of Women and Childnm. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 76 

tions, sanguineous and purulent engorgements, hernial protrusions, 
lipomatous* or fatty growths, chancre, and varicose veins — these lat- 
ter more commonly occurring during pregnancy, in consequence of 
the obstruction offered by the gravid uterus to the venous circulation. 

8. The clitorisy a small erectile body, is situated between the 
labia externa below the symphysis pubis, its lower or free extre- 
mity terminating immediately under the superior commissure, and 
known as the glans clitoridis ; there is a small fold of mucous 
membrane covering it, called the preputium clitoridis. This body 
is the analogue of the penis in the male, and is supposed to be the 
seat of the venereal orgasm. It possesses an erectile tissue com- 
municating with that of the bulb of the vagina, which is on either 
side, in correspondence with the ascending branches of the ischium ; 
these bulbs become united at the origin of the clitoris. This 
latter body sometimes becomes morbidly enlarged, so that it 
may be necessary for the comfort of the patient to excise it, 
which can be done without difficulty ; the operation involves no 
danger. When pretematurally enlarged, it has occasionally given 
rise to the supposition that hermaphroditism exists.f 

4. The labia interna or minora are situated just within the labia 
externa^ and extend from nearly the superior commissure to the 
centre of the vagina ; they are two membranous folds, and in shape 
have been likened to the comb of a cock ; they are composed 
externally of mucous membrane, a continuation of that of the 
vagina, and internally of cellular tissue ; they possess great sensi- 
bility. They are called nymphoe^ for the reason that they were 
supposed by the early writers to direct the course of the urine. 
These labia sometimes become morbidly developed, and, in such 

♦ On the 16th day of February, 1867, Dr. J. G. Hislop brought to my dinic an 
interesting case of tumor growing from the inferior portion of the outer surface of 
the right labium externum. The turoor was pediculated to the labium^ and made its 
first appearance nine years previously ; it measured five inches and a half in length, 
and its broadest diameter was three inches. The patient was a poor German 
woman, who was compelled to support her family by her daily toil, and the pre- 
sence of this tumor was a constant source of annoyance, interfering with prog^res- 
sion, and becoming ulcerated fVom ti'C friction against the thighs. On examination, 
I found the growth to be a lipoma, or fatty tumor, and with the concurrence of Dr. 
Hislop, and at the earnest request of the patient, I removed it before my class. The 
operation was quite simple ; the pedicle, which was about an inch in breadth, was 
detached by the knife, and the lips brought together by two sutures. The patient, 
in a few days, was well, and able to attend to her business with comfort. In one 
rear from the day of the operation, she was the mother of a healthy little daughter. 

f The opinion has prevailed that the clitoris becomes much more increased in 
volume in prostitutes than in married women, whose sexual intercourse is legitimate. 
Jacquemin and CoUineau positively assert, afler a full examination of the subject, 
that Ihe prostitutes of Paris reveal nothing remarkable, either in the form or dimen- 
sions of the clitoris. [De la Prostitution dans la ville de Paris, par A. J. B. Parent- 
Puchatelet, vol. L, p. 211.] 



re 



THE PIIINCIPLK3 AXD PRACTICE Of OBSTETRICS. 



case, may be removed* It has been very absurdly supposed by some 
authors, that the nymphae, during labor, iufircase the capacity of 
the vulva by their total di3:ippi*araaco ; but this h simply an hypo* 
the:»b without a shadow of truth, whicli can be readily verified in 
the first case of labor you may attend. They most likely augment 
the surface of secretion. In womL'n who have borne many children 
the nymph® become relaxed, and attain an increaise of volume^ so 
that they project ciaHiJerably beyund the labia externa. On one 
occasion, I was requested to meet a medical friend in considtation, 
in consequence of what he supposed to be a breech |>resentation. 
On examination, I fouud that not only there w:is no bretjJi presen- 
tation, but the OS uteri had just begun to dilate, and the head of 
the fa'lus was distinctly felt at the superior .straU. The error of 
my friend con3ii>ted in the fact that, in attempting to introduce hia 
finger into the vagina, he felt the relaxed and projecting nympUie, 
which he supposed to be the testes of the inlant. It will be well 
fur you to bear this mistake in memory. It may serve you at »ome 
future time, 

5, The vestibulum is a sn^all^ triangular space, with its apex 
upward and it« base downward ; it is bounded above by the clito- 
ris, on either side by the nympha?, and bt'low by the meatus ttri- 
narius, which you know is the outer 0|>errmg of the urethra. The 
vestibulum occasionally bec«>mr-s studded with small flesfiy excres- 
cences, which give rise to profuse mucous discharge j in such case 
the only remedy for the discharge will be the removal ufthe excrus- 
cen<'es» It also furnishes an important guide for the introduction 
of the catheter, as I shall more particularly state at the proper 
time. It is well to mention, that some authors describe the vesti- 
bulum as extending frmn the mons veneris to the hymen, 

0. T/te meattis urlnnrlus and rtrethra. — The female urethrA 
terminntes externally by an orifice caliotl the tncatiis nrlnarhis^ 
which is a small, rourjded opening; it is found immediately below 
the vestibulum. The urethra itself is about an inch and a quarter 
in length, slightly oblique from without inward, conical in shape, 
and exlrenu*ly dilatable ; it has neither a jirostatic nor bulbous por- 
tion ; in consequence of its shortness and great dilatability, urinary 
ealculus is comparatively rare in the female, fur the reason that the 
nucleus of the formation is, as it were, washed out of the bladJer 
at the lime of njicturition. The structure of the nreth ra consists of 
cellular tissue, together with muscular fibres; it in lined iuternally 
with a mucous covering in continuation with that of the bladiler. 
The inferior wall or belly of the urethra is united to the anterior 
wall of the vagina, and would necessarily be exposed to more or 
less contusion, at the time of labor, if it were not that it is fur- 
nished protection by the summit of the pubic arcade, in which it 
becomes lodgL-d during ihe [j issng:- of the foetus through the vulva. 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 77 

Instances are recorded, and which seem to have been accepted, in 
which sexual congress took place through the urethra. In one 
patient, on whom I performed the operation of vaginal-hysterotoray 
with safety to both mother and child, the urethra was so much 
dilated that I could introduce the index finger as far as the neck oi 
the bladder without producing the slightest uneasiness.* 

Olandular apparattis of the external genitalia. — ^This finishes the 
description of the external organs, which, however, would be 
moomplete without a reference to the very important contiibution 
made by M. Huguierf touching the existence, distribution, and 
pathological condition of the secretory apparatus of the external 
genitalia. The glandular or secretory apparatus of these parts is 
divided into the sebaceous and muciparous glands ; the latter 
present two separate varieties. Those of the first variety are 
distinct, and are found about the clitoris, vestibulum, and in dif- 
ferent portions of the external opening of the vagina. Those of 
the second variety, on the contrary, are united, covered by one 
envelope, and have, in common, but one excretory duct, thus con- 
stituting a veritable gland, to which M. Huguier has given the 
name of vulvo-vagvuzl gland. This gland was known to, and 
briefly described by some of the anatomists of the seventeenth cen- 
tury, but it seems to have been the good fortune of Huguier to 
have directed special attention to it within our own times. The 
period of its greatest development is between the ages of sixteen 
and thirty-eight years, its volume depending upon the age and 
habits of the individual. The vulvo-vaginal gland, one on either 
side, is utuated on the borders of the vulva and vagina, on the pos- 
terior and lateral surfaces of the latter, just above the superior 
edge of the hymen, in the triangular space formed, on each side, by 
the separation of the inferior fifth of the vagina and rectum. These 
muciparous organs, both in their distinct character as well as in 
their united condition, under the term vulvo-vaginal gland, are 
subject to various morbid conditions, to which too much attention 
cannot be given by the practitioner, and which I am sure are often 
mistaken for affections of the uterus and adjacent viscera. It would 
be out of place for me to refer, in the present work, more in detail 
to these pathological changes, but they are, in every way, worthy 
of your attention. 

Interned Genital Organs, — ^These organs are: 1. The vagina; 
2. The uterus with its appendages, composed of the broad and 
round ligaments, fallopian tubes, and ovaries. 

1. The vagina, the vulvo-uterine canal, as it is sometimes termed, 
measures from five to six inches in length ; it is curved, correspond- 

♦ See my work on the Diseases of Women and Children, p. 255. 
f Memoires de rAcademie de Medicine, vol. xv., p. 527. 



78 



THE PRI>XIPLES AND PRACTICE OF OBSTETRICS. 



ing with the curves of the pelvis, so that itn upper or titer 
extremity ia in relation with the axis of the superior strait, wlii 
the lower or vulvar extremity corresponds with the axis of th 
outlet — consequently, the concavity of the curve is in from, t| 
convexity behind. 

The anterior relations of the vagina arc with the urethra nn 
bladder; through the inediura of cellular tissue, it is in union wit 
the urethra, con.stituting the urethrO'Vaginal wall or septum, aa 
by the same mode of connexion it is united to tlte bladder, formic 
the maho-vaginal septum, Thei^o relations, it i'* important for yc 
to bear in mind, for they will enable you to understand why, i 
ceituin jirotracted labors where undue presj^ure liaii been made 
the fa'tua against one or other of theise septa, intlammation, in ill 
first place, and then ulceration may ensue, giving rLsc to either 
urelhro-vaginal or a vesico- vaginal fistula, the diagnosis of which : 
furnished by the fact that urine, instead of passing through th 
excretory duct of the bladder, is more or less constantly dribblin 
into the vagina, through one or other of these openings. It ha^ 
pens, too, that these fi^tultB are sometimes the result of instrument 
delivery, whether by the forceps or crotchet, but in such cases the 
are almost always the product of t-arelcssness or ignorance. 

The jt?o*/er /or relations of tlie vagina are also worthy of attentiofl 
III order that you may have an accurate idea of these relations, 
us divide the posterior surface into five fiflhs; the superior fifth 
floating, and encircles in part llie posterior portion of the os utcril 
the three middle fiilhs are in contact with the rectum, con8titutiii| 
the recto*vaginal septum, and the inferior tifkh is separated from tt] 
rectum by the interposition of the perineum* The recto-vagli]^ 
septum may jdso become the seat of ijijury, giving rise to a rect 
vaginal fistula, through which the ftrcal matter will pass directlj 
into the vaginai, entailing upon the patient the most loathsome, and 
oflenlimes rebellious malady. It, Hke the are thro- vagi rial an 
vesico-vaginal fistula;, is too frequently the result of ignorance 
neglect in the management of the delivery. 

in addition to tliese relations of the vagina, it is divided into it 
oit\fice or outer opening, and its superior extremity. The former, 
the orifice^ is be!ow and posterior to the labia interna; and, in th 
virgin, is nearly cloned by a delicate membrane called the /tt/men 
whicli i^ usually pierced by a smidl opening for the escape of the 
mensti'ual blood. 

It was formerly supposed that the presence of the hgmen was an 
undoubted proof of virginity, and, also, its absence a full demofl 
Btration that sexual intercoursL' bud taken place. Both of thea 
■"hypollieses are fonnderl in error, and are calutdated to lead, in sor 
instances, to unjust decisions. In the first place, well authenticat 
caiscs, about which there can be no doubt, prove incontesitably tha 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 79 

not only is it polssible for sexaal intercourse to take place without 
a rupture of the hymen, but that such* intercourse may be followed 
by impregnation ;* and the proof is furnished by instances in which 
the accoucheur, at the time of labor, has been obliged to iocise the 
hymen for the purpose of allowing the child to pass through the 
vagina* These, of course, constitute exceptional cases of extremely 
rare occurrence, but still they are of value in reference to the point 
under consideration. 

Again : there are numerous causes, other than sexual congress, 
capable of destroying the hymen, such, for example, as falls, blows, 
a sudden and profuse discharge of menstrual blood, disease, etc. I 
might here remind you that, occasionally, this membrane does not 
present any opening — it is completely closed, and, under such cir- 
cumstances, the catamenial fluid has no outlet ; it accumulates from 
month to month within the uterus and vagina, causing enlargement, 
thus giving rise to the suspicion of pregnancy. These are cases, 
which require all the vigilance of the accoucheur to enable him to 
rescue innocence, and shield character against erroneous judgment. 
We shall again refer to this subject when discussing the evidences 
of prc^ancy. 

Tbo superior extremity of the vagina is in contact with the neck 
of tb':; uterus, which it completely encircles; it passes a little higher 
on the posterior than on the anterior surface, which has led to the 
bjlief that the posterior lip of the os uteri is longer than the ante- 
rior, which, however, is not the case. 

The internal surface of the vagina is lined by a mucous mem- 
brane, which presents on its anterior and posterior portions, extend- 
ing from before backward, a median crest or column, from which 
appear to arise numerous transverse folds of mucous investment. 
These mucous folds or rugaB are more distinct in virgins, and are 
most numerous at the inferior portion of the canal ; in women, who 
indulge much in intercourse, they are less distinct, while they 
entirely disappear afler the birth of several children. Dr. Franz 
Kilian has shown, with the aid of -the microscope, that the mucous 
lining of the vagina is abundantly supplied with vascular papillas, 
and it also possesses a distinct tesselated epithelial covering, without 
glands or follicular openings. 

The vagina cannot be considered an erectile organ. The lateral 
boxmdaries of this canal afford attachment, above, to the broad 

* It may appear, at first view, incoasisteot to assert that pregnancy can bo 
accomplished without rupture of the hymen. But in this connexion let the student 
remember that the great act of reproduction consists essentially in two influences — 
one on the part of the female, the other on the part of the male. The female fur- 
nishes the egg or " cell-germ " — and the male imparts life to that egg, through the 
spermatozoon contained in the seminal fluid ; if these spermatozoa are thrown only 
on the outer portion of the vagina, they may find their way to the egg provided by 
the female. 



80 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 



ligaments, an<l correspond below witli the pelvic cellular tiaaue ani 
plexuses of veins. 

Bofiiiies a umcoua membrane, it is coniposcil of a gvcy tissue and 
iDUscnlar fibres, which are more fully developed nbout the urethrn, 
and alfto form the constrictor muscle of the vagina; the muneular 
structure of the organ is continuous with that of the uterus, an 
can readily be traced* The grey tif^sue ia extremely vascular, an 
is composed of elastic and lamiiions fibres mixed with tibro-ceU 
which become much increased toward the end of gestation, an 
assume a remarkable reddish color.* 

The vagina derives itn arteries from branches of the byj' 
and uterine; the venous plexusen^ which are quite numeroh 
nate in the hypogastric veins, and its lymphatic vessels pass to thi 
pelvic ganglia. 

The vagina receives nerves from the two great divisions of the ner- 
vous system — viz. those of organic and animal life; the furrner are de«J 
rived from the hypoga^stric plexus, tlie latter from the sacral plexoj 
2. The utertis^ although classed among the internal organs o1 
generation, is, in fact, simply an organ of gestatitm and nutritioi 
for the fti'tus. It is intended, as it were, i\» a sort of domieiU' 
lo>lging-i>lace for the f^rtus, affording it, at the same time, nLUin^nh 
ment, until it ha^ received sufficient development to prepare it for 
an extenial or independent existence. As a general rule, the 
of fecundation is consummated outside of the uterus, and th' 
fecundated germ is brought within its cavity, there to remain an 

become developi'd unt 
the corai)letion of uten 
gestation. It is very 
8ontiat that you should 
have a clear apprehen 
sion of the exact positioi 
and rehitions which th 
uterus bears to the adj 
cent organs. It i* sit 
ated in the pelvio exi 
vation {Fig. 32), with th 
bladder in front, the r 
tum behind, the Fmal 
intestines above, and tbftj 
upper extremity oi^ ih 
P,^ ^ Tagtna below ; the oe; 

vix of the organ is com 
pletely encircled by the va^na, which forms at this poiut a cuL| 
dc sac. 

DivhiofU ofi/ie Vterus. — The uterus is divided into its fundi 
body, and neck, two surfaces, three angles, and threo bordera. 



t^ 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



81 



Fundus. — ^The fundus consists of that portion above the trans- 
verse line, extending from the uterine extremity of one fallopian 
tube to that of the other. 

Body and Neck. — The body is immediately below this line, and 
reaches downward to the narrowing of the organ, at which point 




Fio. 88. 



is the commencement of the cervix or neck (Fig. 33), which ex- 
tends into the vagina, and is terminated by the os tinca3. 

Surfa4:es. — The two surfaces are the external and internal — the 
former is divided into two regions, one anterior, the other posterior. 
The anterior region is smooth, and slightly convex, while the pos- 
terior region presents a greater degree of convexity. 

Angles. — ^The three angles are two superior and lateral, repre- 
sented by the uterine extremities of the fallopian tubes, and one 
inferior, represented by the os tinccB. 

Borders, — ^The three borders are one superior, passing trans- 
versely from one superior and lateral angle to the other, imme- 
diately across the uppef* edge of the fundus ; and two lateral, 
reaching, on each side, from the superior to the inferior angles of 
the organ. 

Volume of the Uterus. — ^The size of t10 uterus varies. In the 
infant, it is small ; in the girl, toward the advent of puberty, it 
mcreases in volume, and continues to become developed until the 
child-bearing period. In the adult woman, its usual length is three 
inches, and, in its widest portion, about two inches and a half 
After the period of child-bearing has passed, it again becomes much 
less in volume, and not unfrequently exhibits a condition of atrophy. 
In shape, the organ is pyramidal, and an accurate idea may be 
gathered of its general form, by dividing a pear longitudinally, the 
upper portion of the section represent'mg the fundus, the lower 
the cervix. 

IStructure.—'bi structure, the uterus is composite, consisting of 

6 



82 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



an external coat, an internal coat, an intermediate or muscttia? 
tissue, blood-vessels^ nerves, and lymphatics. 

Metemal Coat — ^The external or serous covering is formed hf\ 



Ft«. 84. 

that imj)Ortant memhrane, the peritoneum, and i^ arranged in the 
jbllowing manner : It covers only the two superior thirds of the 
aoterior surface o( the uterus (Fig, 34), and then reflects upward j 
on t4ie posterior spuria ce of the bladder; this anterior fold of thoi 
peritoneum constitntes the anferior broad ligament of the orgsn^ 
The inferior third of the anterior surface, which is not covered byl 
peritoneum, is that particular jrortion of ihli surface which, throughj 
the miidium of cellular tissue, h in adhesion with the bas-fond of 
the bladder. Do not forget, therefore, that the bladder is in unioal 
with the lower portion of the uterus; for the recollection of thtfl 
fact will at ouce disclose the essential circumstance that displace-! 
ments of the uterus must of necessity lead, in greater or less degreei*! 
to cnsplacements of the bladder; and, again, it will remind you tha 
rhe direction of the urethra will be nnjililied^ during pregnancy, in^ 
■'onscfjueuce of the change in the position of the developing nterus* 

While only the tsvo superior thirsls of the anterior surface of the j 
uterus are covered by peritoneum, the entire of the posterior 8ur«^ 
facje is invested by it, and it even extends to a small portion of th< 
qpper anil fjosteriur t<iur|^* of the vagina ; it then becomes reflected^ 
■upward on the rectum, an«l thi-? posterior told, or ilupltcation, con- 
stitutes the posterior broad lif/ani'enf. You understand, therefore! I 
that the broad ligaments of the uterus are nothing more thaaj 
:uiterior and posterior duplieationg of the peritoneum, and contaifl 
mascular fibres, as described by Dr. Charles Rouget ; the pent 
:ietna in tu close and intimate adhesion with the subjacent tissue of 
the uterus, except on the lateral t»orders and posterior surface ol 
(he cervix, at which points it is comparatively loose. 

Trianguiar Fo9sa — Recto-utcrlthc Fo€8a, — Allow me, for a mo- 
ment, to direct ytnir attention to an important space, or fossa, situated 
between the posterior surfjie** of the uterus, and the anterior sur* 



THS PRINCIPLES AND PRACTICE OF OBSTETRICS. 88 

&oe of the rectum ; it is sometimes called the triangular fossa — 
I think a better name for it is the recto-uterine fossa, for the reason 
that this name explains its position, and the manner of its forma- 
tion. The important practical feature connected with this fossa is, 
that sometimes the ovary, and, at other times, the small intestines, 
become prolapsed into it, giving rise to much disturbance, and, 
therefore, requiring a prompt and careful diagnosis; it ^so is, 
occasionally, the seat of a bloody tumor — recto-uterine haamato- 
oele ; and there may, under certain circumstances, be a mass of 
&tty tissue in the fossa which might readily be mistaken for a tumor.* 
IrUemal Coat, — The internal or mucous lining of the uterus has 
given rise to much controversy touching its true character ; and it 
has been emphatically denied, by eminent anatomists, that it pos- 
sesses the attributes of a mucous surface. Now, however, since 
the admirable delineations of Coste, it seems to be very generally 
conceded that it is, in truth, a mucous tissue. It seems to me that 
all we desire to know for practical purposes is, whether, in health, 
this surface exhibits the functions, and, in disease, presents the 
pathological phenomena peculiar to a mucous membrane. That 
this is so, no one, I imagine, will pretend to deny. Therefore, it 
may be safely assumed that the uterus is lined by a mucous tissue. 
It is not uniform in its whole extent ; it is extremely thin toward 
the orifices of the fallopian tubes and the internal orifice of the 
oervix, while toward the centre of the cavity of the organ, it is 
remarkable for its thickness. It is in strong adhesion with the 
proper structure of the uterus itself; nor does there appear to be 
any sub-mucous cellular tissue connecting it with this structure ; 
hence the firmness of its union. Under the microscope, there is 
distinctly observed a columnar epithelium covering the membrane, 
and innumerable small openings, which are the orifices of the folli- 
cles so abundantly distributed over its surface. These follicles 
appertain both to the body and cervix of the organ ; in health 
tbey secrete mucus, intended to moisten and lubricate the parts, 
while, under morbid influences, they pour forth a muco-purulent, 
and, sometimes, an exclusively purulent discharge. The follicles 
Btnated in the neck of the organ secrete, in a normal state, a thick 
and alkaline mucus, which, remaining in and distending the 
cavity of the follicle, it is now understood, gives rise to those true 
cysts so improperly named glands of Neboth, to which we shall 
again refer when speaking of pregnancy, and the modifications of 
the uterus under its influence.f 

• See Diseases of Women and Children^ pp. 224, 297. 

f Aooording to Vircbow, the mucous membrane of the uterus is usually covered 
with ciliated epithelium; but during pregnancy ' the layer of ciliated cylinders is 
replaced by one of squamous epithelium. [Virchow's Cellular Pathology, 2d 
edit, LoDdoD, 1S60. p. 71.] 



84 



THE PRINCIPLES AND PRACTICE OF 0BSTETBIC3. 



Intermediate Tissue* — ^The true nature of the intermecliate 
of tlie wlerus was, in former years, also a, question of obatii 
debate; some maintaining that it waa muscular; others, on tb^ 
contrary, denying to it any of the attnbntL»s of muscularity, Al 
tliii pro-^eut lime, however, thin question is no longer one of con 
irover.ny ; science has decitled the point, and no one now donbti 
that the uterus possesses a muscular structure. The fact b denioii 
St rated by anatomy, physiologicai experiments, the phenomcni 
parturition, and chemical analysis — the latter showing, eonclu- 
ivcly, tfiat its components are those of muscular tissue. In a 
word, nothing, it seems to me, is better settled than tluit the uterua 
k endowed with thb stnicture, and that, in form and in action, it 
h essentially a hollow, or orbicular muscle. KocHiker, in hid 
recent researches, has proved that the nm^cular fibres of the uterui 
are, in correspondence with the fibres of all the other nmscles of 
organic life, composed of elongated cells, more or less adherent it 
each other. The uterus, therefore, in addition to affording accor 
nindulirm to, and providing nourishment for, the ffutus, during itd 
intrauterine or dcf»endent existence, accomplishes, at the [jrope| 
time, its birth through an expulsive force derived, in p.'ist, finial 
the contractions of its muscular tinsua. 

Is the Uterus an Erectile Organ f — Until the recent rcsi aiciiosj 
of Dr. Charles Uouget,* there war* more of hypothesis than of 1 
certainty, as to whether the uterus is entitled to be classed aniong4 
the ei^ectile organs. Admitting tlie generally conceded fact, thai 
the copulative organs of the mammiferous cla-^s of both eexc 
exhiViit, in certain conditions, changes of form, volume, and, some 
times, of position, due to the temporary disteusiou of bloc 
vessels,! which, under ordinary circumstances, are but incompletely | 
filled, this observer proceeds to point out the error of authors ii 
oiti>lanalion of these change**. He maintains that in employing th( 
terms erection, tnrgescencc, and sanguineous congestion, as moi] 
iiig the same thing, a cardinal blunder has been committed, for the 
reason that, while all the parts of the circulatory apparatus m*J 
become congested, those only, possessing the special anatomic 
di.Hpitwition of cavernous or spongy bodies, can be thrown int<] 
erection. On the other hand, anatomiists, forgetting that tb^ 
ereciile cavernous bodies are not merely an assemblage of niniw 
rous and largo veins, have described as erectile organs oer 
muscular formations, in which they have detected nothing but 
renous plexuses more or less abundant. This is a capital error. 
Rouget has proved that there is, in fact, no such thing as a specicii 

* Recherches Bar lea Orgaoea Erecliles de b Femmo, et imr I'Appttreil Muacu* 
\h\TH Tubo-oirarieOf par Dr. CuaeLes Kocgzt. Joumiil de la rUyskklog 
E. BU0WX-S«iU4BD. 1S53, p. 320. 

f A striking lUustratioa ia afforded by the penis and clitorii. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 86 

erectile tissue^ and that every erectile organ id, in realitj, simply 
a mascular organ, in which the blood brought bj the arteries may 
be temporarily retained in the capillanes, or veins, transformed 
into venous sinuses, and retiform plexuses. 

The first and most essential condition, therefore, in erectile for- 
mations is, that the dimensions and number of the vascular canals 
be such that their state of repletion, or comparative emptiness, 
may determine changes in the form, volume, or position of the 
organ. A second condition is the peculiar arrangement of the 
arteries and veins. The third condition, indispensable to the 
mechanism of erection, is the presence of muscular fasciculi, which, 
commingling with the vessels, become .the necessary agents of the 
erection itself. 

But the entire uterus is not erectile — this physiological attribute 
belongs only to the body of the organ, because of the peculiar 
distribution of the blood-vessels on that portion of the viscus, as 
will be immediately shown. 

JBlood- Vessels of the Uterus, — The arteries of the womb are 
derived from cwo sources, viz. the ovarian and uterine. The 
former usually pass from the aorta just below the origin of the 
renal arteries ; they descend along the vertebral column, behind 
the peritoneum, and in front of the psoas muscles and ureters ; 
they then pass between the folds of the broad ligaments, divide 
into several branches, and supply the cervix, body, and fundus 
with blood, anastamosing in the latter portion of the organ with 
branches of the uterine arteries. These latter, the uterine arte- 
ries, one on each side, are given off by the hypogastric or internal 
iliacs, proceed to the lateral portions of the uterus, and, in con- 
junction with the ovarian vessels, distribute themselves through 
the substance of the organ. Previous to puberty, these arteries 
are extremely small, and convey to the uterus but little blood, for 
tlie reason that this organ is without function, and needs no more 
blood than is simply necessary for its nutrition. Indeed, in this 
particular they may be regarded, in some sense, as analogous to 
the two branches of the pulmonary artery during foetal life ; these 
convey to the lungs of the foetus, which are also without function, 
just blood enough to maintain their vitality. As soon, however, 
as respiration is established, and the foetus commences its inde- 
pendent existence, the surplus blood, which before was carried 
through the ductus arteriosus to the aorta, passes through the 
right and left branches of the pulmonary artery, respectively, to 
the right and left lobes of the lungs, for the purpose of decarboni- 
zation. So, also, when puberty has been attained, the blood-vessels 
of the uterus have new duties to perform ; the wants of the organ 
are more pressing, because its specific function — menstruation — 
commences. Hence, there is a monthly sanguineous congestion 



86 



THE PEISCIPLES AXB PBACTICE OF OfiSTBTEIGS. 



of the cranes md uteriis* It is an ioteresting &et to benr t^^ 
mind, that the hodj of the aterus is maeh more sbmida&tly 6U^^| 
plted with hlocpd ihao any other porttoii of the organ — the arterial 
branches exhibiting theoiielTes in great nomber, and becomiD^ 
apinU, or tortnona. 

The veins, too, are very nomerons and large, both the arterii 
and veins presenting, on the bodr of the organ, that peculi: 
arrangement characteristic of erectile formations. The chief su 
pljr of the menstrual blood comes from the body of the nternSi 
and it is daring the catamenial periods that its erectile properties 
are developed. It is worthy of note that the uterine veins arc 
without valves ; and this dreajostanee^ together with the peculiar 
poettton of the uterus preventing the free return of venoi 
blood, is oftentimes a predisposing cause of nndue congestion 
the organ, thus exciting in it more or less disturbed action. 

Lymphatic Vessels, — The lymphatic vessels communicate wi 
the pelvic ganglia, and those of the cervix communicate, also, wi 
the lymphatics of the anterior portion of the vagina. Ton 
occasionally observe^ in carcinoma, and other affections of the 
vix uteri, engorgements of the inguinal glands ; and this may 
explained by the anomalous distribution of these lymphatics 
which attention has been directed by certain writers. In metrit 
an|)erveuing upon childbirth, the lymphatic vessels of the ote 
will frequently be found filled with pus. 

Nerves of the Uterus. — The uterus is supplied with nerves from 
the ganglionic and cerebro-spinal systems ; the former, the gan- 
glionic nerves, come from the renal and hypogastric plexuBes^ 
are di(?tributed throughout the structure. Tlie cerebro-spini 
nerves arc furnished by the sacral plexus, and distributed by an 
mosis through the orgim. It has been very positively denied th 
the uterus receives any nerves whatever from the cerebro^pir 
axis, and one of the most formidable advocates of this opinion 
il. Bouillaud. Jobert maintains that the projecting portion of the 
cervix uteri is entirely deprived of nerves, and is, under all dream- 
stances, insoiisible. 

As to the insensibility of this part of the cervix in some oases, lit 
H, |.»erha[js, not altogether wrong ; but to allege that it never be- 
comes the seat of pain is at variance with actual experience.* To 
the opinions of Bouillaud and Jobert may be opposed the researches 




* Tbero is no reaftcm to b« surprised at ibe faot, Ihnt the neck of the utents is 
deprived of leiudbility in a normal condition, Aod becomes verf senaitiTe in cases 
Lfif disease. Manj portioiui of the human structure exhibit the same peciiliaritf; 
flbr example^ the tendon^^ the periosteum, i}w dura mater, etc, are w^ithout sen^ 
eibtlity when in a norroal Mate, but wh^n ioflnmed* are exceedingly painful II 
need scarcelj be added, that Jobert is altogether mistaketi in slatiog that the 
of the uterua m deprived of nerves. 




THE PBIKCIPLES AND PKACTICE OF OBSTETRICS. 87 

of Haoter, and, in our own times, of Tiedemann, Robert Lee, 
Mailer, Ilirschfeld, Boulard, and others, who have positively 
recognised in the uterus — in the cervix as well as in other portions 
of the organ— distributions of the cerebro-spinal nerves. 

It is an important question whether the nerves of tiie uterus be- 
come enlarged and more numerous during pregnancy, or whether 
they retain the peculiarities, which marked them when the organ 
was in a state of vacuity. This question provoked rather a warm 
controversy between Dr. Robert Lee and Dr. Snow Beck. The 
former, after Tiedemann, endeavored to ])rove that the increase, 
both in number and volume, is considerable ; while Dr. Beck, afler 
J. Hunter, denies this altogether, and maintains that the increase 
18 only in appearance, predicating his argument on the revelations 
of the microscope, which, he says, show that the neurilema and 
certain fibrous bands connected with it, have been mistaken for 
nerves. However this question may ultimately be decided, there 
is one fiict, which, from analogy, would seem to give strength to 
the view of Dr. Lee, and it is this, that in hypertrophy of the 
mnscles of animal life — and the same thing is observed in hyper- 
trophy of the heart, first pointed out by Dr. Lee, and subsequently 
confirmed by an able German micrographer. Dr. Cloetta — there is 
actually an increase in the number and size of the nerve fibres. 

Cervix. — Before tenn.nating the anatomy of the uterus, I desire 
to say a few words with regard to the cervix or neck of this organ, 
because it has certain practical bearings well worthy of consider- 
ation. In the first place, the cervix is divided into two distinct 
portions; the 8U])erior and inferior. The former is called the uterine 
portion ; the latter the vaginal portion. The uterine extremity is 
that particular part, which unites with the body of the uterus, 
while the vaginal or inferior extremity is represented by that por- 
tion of the organ, which is found projecting into the vagina. I 
shall remind you, when speaking of the changes in the uterus con- 
sequent upon gestation, that it is not until about the fiflh month 
that the cervix begins sensibly to shorten, in order to afford accom- 
modation to the developing germ, and, also, that the shortening 
commences at the uterine portion of the neck, and not at the vagi- 
nal portion, as is maintained by Stoltz and others. 

With the recollection of this circumstance, is associated a most 
important practical fact, and it is this — in placenta praevia, women 
are very apt to have slight hemorrhage at the fifth and sixth months 
of their pregnancy, which may continue to increase, more or less, 
until the gestation is completed. The connexion between hemor- 
rhage at this time and placenta prsevia is explained as follows : as 
ioon as the uterine extremity of the cervix begins to shorten, it 
necessarily does so, by having its respective diameters increased; 
but this very increase is accomplished at the cost of one or more 



&8 



THE PiUNCIPLES AND PKACTICIS OF OBSTETRICS. 



of tbo utero-pl ace n till vessels, wlitch^ in placental presentation, i 
between the internal surface of the cervix and the placenta* I « 
not raean to bo understood that all women, who are attacked witli 
hemorrhage at the tifth and sixth months of gestation, have the3 
placenta unplanted over the mouth of the uterus ; there are other 
causes capable of occasioning bleeding at this period, such m-M 
threatened almrtion, severe concussions, etc.; but what I wi^U ic 
inculcate is, t)iat, in the event of hemorrhage occurriag, you tnhouid 
ive yonr attention awakened as to the possibility of it^ being eon* 

cted with placenta prtcvia. The trc-atment of this form of bleed* 
ing will be di?icU5iscd in a subsequent lecture. 

Vidumti and Form of Cervix, — The volume and form of tliecervu 
ai'o much modified according to the age of the individual, and 
these clianges are not without intere^st to the obstetrician. Bcfora 
puberty, it is extreuiely suuill ami dense, and presents a conical] 
shape; at the advent of pul»erty, on the contrary, when the nteruaj 
becouKs a new centre of action, as preliminary to the in%»titutioii| 
of thtj menstrual fnnction, there is a perceptible increases in 
ftize of the cervix, and its structure is marked by less density, Uni 
this period, the oii tinca> is only pintially dcvulupcd, and it is nolj 
until the age of eighteen or twenty that the cervix begins tu iti*| 
crease in its transverse diameter, so lliat, at this time, the two lips,] 
the anterior and posterior, become reailily recognised. 

I shall not at this time si>eak of the moditicati(»ns (»f the cervix! 
during t)ic progress of pregnancy, but it is well to rememl*er liiat^l 
aa a general rule, after childbirth, tlie cervix rarely resume?? its J 
original form and sijfie; it becomes shorter and larger, and there j 
will be fuand on the surface of both the anterior and posterior llpa] 
sm:dJ ii regularities, winch are nothing more than so mimy cica-J 
trices, reMuUing from the rupture of the mucous membrane of this] 
part at the time of the passiige of the feet us tli rough the os uterL] 
One word in reference to these cicatrices; although they may be said i 
to be the ordinary and characteristic results of childbirth, an<l aro 
held by some medical jurists as very positive evidences of previous ] 
pregnancy, yet it is my duty to caution you against a too implicit] 
reliance on these cicatrices in questions involving the oharaitor of J 
the female. Tliey will sometimes ensue from congestive dysmcs- T 
norrhica, and from disease of the cen'ix, such as hypcnemia, ulcer- 
ation, etc* I maintain, therefore, that, in all discussions in which 1 
the honor of the party may be involved, in the absence of other j 
and substantiid proof, these cicatrices should not be regarded as I 
of lintd wei^^ht, for the broad reason that the civil as well as the j 
moral law recognises every doubt to he the property of the accusod, 

T/te Mound Liffftment^, — The round ligaments, one on each side, i 
composetl of muscular fasciculi, arise from the sides of the fundus 
of t lie womb| in front of, and ju^it below, the uterine portion of the 



THE PKINCIPLES AND PRACTICE OF OBSTETRICS. 89 

fallopian tubes and the labia externa ; passing between the anteiioi 
and posterior duplications of the broad ligaments, they proceed 
outward, through the inguinal canal, and expend themselves on the 
mons veneris (Fig. 34). These ligaments, from their position and 
direction, afford support to the uterus against the encroachments 
of the distended bladder ; for, if it were not for them, the uterus 
would be much more frequently retroverted when pressed back- 
ward by the bladder iilled with urine. In proportion as the blad- 
der presses the uteinis backward the round ligaments constitute, as 
it were, a sort of antagonism maintaining the organ in its position ; 
and it is only in the event of the antagonism being broken up by 
a surrender of the force thus exercised by the ligaments, that the 
fundus of the womb is thrown backward, or retroverted. It was 
supposed by an ancient writer that the special office of the round 
ligaments is, during the act of coi- 
tion, to draw the os tincse down- ^ft^fe.^ ^, _— .^^ _^^5i 
ward, in order that it may be 
placed in juxta-position with the 
glans penis; but this hypothesis 
cannot he sustained, ibr the reason 
that if, during sexual congress, the 
round ligaments did, by their con- 
traction, influence the position of 
the uterus, the direct result of such 
influence, instead of causing the cs '°* * 

tincffi to descend, would be to draw it upward, because the free 
extremities of the round ligaments are more elevated than those 
which pass directly from the uterus.* 

The Fallopian Tubes. — The fallopian tubes, two in number, on- 
ginate from the lateral and superior angles of the uterus, with 
which organ they communicate by continuity of canal; they are 
from four to five inches in length, and form a communication be- 
tween the ovaries and uterus, transmitting the fecundating element 
to the ovaries, and, after fecundation has been accomplished, con- 
veying the germ to the uterine cavity (Fig. 36). These tubes 
terminate by a free or fimbriated extremity, to which we shall 
more particularly allude in the succeeding lecture. The structure 
of the tubes is, externally, a serous or peritoneal coat ; internally, 
a mucous investment without follicles, and covered by columnar 
epithelium with vibratile cilia ; and intermediately, a muscular tissue, 

» The utcnw will Bometimea exhibit a variety of malformations ; on the other 
oand, there are well authenticated instances in which no vestigo of the organ has 
been recognised. Occasionally, tliere will bo two uteri with but one vagina; 
while, «g;»in, there will be two distinct uteri (Fig 35) and two vaginre. This 
Utter variety ii» of especial interest because of the possibility of a siraultaueoua 
double fecundation, which might be mistaken lor superfoetatioD. 




90 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



airani^ed in circular and longfitudmal fibro-cells, thus causing, 
through their compound action, the tube to convey tho germ 
from the ovary to the uterus. The fibres of the tube reniaio 



W^ 



Fia. ««. 

distinct from those of the uterus, in the walls of which they can be 
easily detected. It may be mentioned, in passing, that, at the tini- 
briated extremity of the tube, sotnetinies called iht? morsua di*Abolu 
there is a meeting of the serous and mucous merabratres, the only 
example of a jnnuiion of these two tissues in the entire economy,* 

The Ovaries, — The ovaries are two almond-shaped bodies, hitiuited 
laterally to the uterus, with which they are connected by the uva- 
rian ligaments (Fig. 34). They are essentially the organs of gerie- 
ration in the female, and, hence, have been called the ti4te,a 
muliehres. Without tho ovaries, fecundation is impossible, for the 
reason that their t^pccial office is to provide the ovule or "germ- 
cell." This is well understood by farmers, who, when they wish 
to prevent breeding in their sows, spay them, or, in other words, 
t^xtirpate the ovnries. Tliese bodies are compOi^ed of a pecQUar 
structure; 1. A dense fibrous membniue, containing, according to 
lionget, some muscular tibres ; l!iis membrane — the tunica albu- 
giDaa — is t^losely invested by the peritoneum, excc[>t at one point, 
the /uY«5, through which nerves and blood-vessels enter the ovsk 
ries; 2. Tfie proper tisnie of the glind, known as the stroma, 
c^senli illy c(im|K>sed of areolar fibres and blood-vessels conmiinglcd 
with muscular fdjres, which are quite numerous; 3. The Giaaffiao 
Yeslcfen, in a'l the stages of their development, the largest cuu- 
tailing a lim]>id llnid and the ** germ-cell" ur ovule. Even in a 
newly bom itifanl, these vesicles are found in the ovaries, but they 
aet[uire ihcir full development only at the age of puberty, and then 

*ttb*it(liiK point, timt Oiero U r eoiimiintcrtlioit vriUi tlie peritoneal ciivltj, 
tliroagi) wlueti Ifijeetians thrown into the csnvUj of tlio iiiorus hare aomeiliim 
passet], Aiid oiused a (aia} pcrituuitia. TliU opvniiijc ia ciUed tiio ostium dl 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 91 

only do they contain ovules capable of being fecundated. When 
the ovule has attained its maturity, the ovisac opens, and affords 
an escape to the fluid which it contains, as well as to the ovule or 
" germ-cell ;" this latter, should it become fecundated, is conveyed 
by the fallopian tube to the uterus, where it awaits its preparation 
for external or independent existence. Should, however, fecun- 
dation not be accomplished, the ovule is equally conveyed to the 
uterus, and passes off with the menstrual fluid. As to this latter 
&ct, there is very little doubt entertained: indeed, it is now the 
generally received doctrine. 

Besides the true *' germ-cell," inclosed in the ovisac or Graaffian 
vesicle, there are, even in early childhood,* a number of immature 
ova observed in the ovaries. The escape of the ovule from the 
ovisac, whether fecundated or otherwise, gives rise to a peculiar 
formation known as the corpus luteum ; hence, there is the corpus 
htteum of pregnancy, and the corpus luteum in no way connected 
with that condition. The doctnne was formerly entertained that 
the corpora lutea observed in the ovary were always proportionate 
in number to the children born of the female. But the inaccuracy 
of this opinion has yielded to the march of science. According to 
the researches of Coste, the corpus luteum attains its maximum 
volume about the third month of pregnancy ; from this period up 
to delivery, it becomes atrophied, so as to present at that time 
about a third of its volume ; from forty to sixty days subsequently, 
it is reduced to a liard and small nucleus, which continues more or 
less.f The corpus luteum of menstruation is usually of small size, 
and completely disappears after a month. 

I may refer those of you who are anxious for some interesting 
scientific details upon this subject, to the researches of our distin- 
guished countrymen, Drs. MelgsJ and Dalton ; and, also, to Dr. 
Montgomery, of Dublin, who, in the second edition of his valuable 
work on pregnancy, has discussed the subject very fully and to the 
point. When treating of reproduction, in a future lecture, I shall 
again speak of the corpus luteum in its varied relations. 

* It appears that, during the period of childhood, there is a continual rupture of 
the ovisacs (or parent cells), and a discharge of ova on the surface of the ovarium, 
but these ova never attain so high a degree of development, as to render ihein fit 
for impregnation, the evolution necessary for this latter process not occurring until 
the period of puberty. [Carpenter's Elements of Physiology, p. 449.] 

f The exact period of its total disappearance I am unable to state ; but I have 
found it distinctly visible so late as the end of five months after delivery at the full 
time, but not beyond .this period. [Montgomery's Signs and Symptoms of Preg- 
nancy, p. 453.] 

\ Transactions American Philosoph. Soc. 



LECTURE VII. 

Fanctions of the Uterus and its Anncxic — Essential to Health, but not to Life— 
Forces in the Fomnlo Economy two-fold — Proof— Ut^^rine Organs before and after 
Puberty — Indications of Puberty — Menstruation — Meaning of the Term— Age at 
which First Menstruation occurs— Influences which Promote and Retard It — Girls 
in the Country contrasted with tliose in the Ciiy — Influence of Race on the Men* 
strual Function — Menstruation in young Children — Tardy Menstruation — Cauee 
of Menstruation — Conflicting Opinions — The Menstrual Function dependent oa 
Organic Development — Menstruation does not consist in the Discharge of Blood, 
but in the Maturity of the Ovules— Ovular Theory — Dr. John Powers'a Claim — 
Periodicity of Menstruation — How explained — Is the Menstrual Fluid ao Exuda- 
tion, or Secretion? — Is it Blood?— Does it escape by Endosmosis? — The Source 
of the Menstrual Discharge, and its true mode of escape — Menstrual Blood in the 
Uterus and Vagina — DitVt*renco between— On what the Diflerence is depen- 
dent — Duration of each Menstrual Period, and Quantity Lost— Is Menstruation 
peculiar to the Human Female? — General Proi)erties of the Menstrual Die- 
charge — Period of Final Ces.sation— Why called the Criticid Period — Aptitude 
in the Female for Impregnation — Case of Catherine de' Medici — Early Marriages 
in India. 

Gentlkmen— Having completed the anatomical description of 
the iilenis and its annexie, it is now proper that we should consider 
their special iimction'*, or i)hysiol()gical oflicea. It may, indeed, be 
said that these organs at tirst — so far, at least, as their pecidiar or 
special physiology is concerned — form only hi structure a ]>ortion 
of the economy ; in all other respect^ they are, as it were, lost in 
slumber, not being called upon to participate in the important 
movements of the system until the advent of puberty. Prior to 
this period, these organs receive their nutriment from the blood 
which traverses their tissues, but they do nothing in return, for tho 
simple reason that their time of action has not yet arrived. This, 
therefore, constitutes one great pectiliarity of the uterus and its 
appendages, and marks the differencre between them and many of 
the other textures of the hinnan mechanism. In strict truth, even 
after they have entered on the round of j)hysiological duty, they 
are not necessary to life, for this can bo maintained without their 
aid— but they are essential to health. This cannot be said of tho 
lungs, nor of the heart, an<l so, you j>erceive, the broad^ differenco 
between these viscera and the organs peculiar to the feniah* is this — 
that the functions of the i'ormer are material to lif«', and, therefore, 
commence at the birth of the individual ; while tho>e of the latter, 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS 98 

• 

not being essential to life, are not brought into exercise until the 
age of some twelve or fifteen years.* 

There is another interesting fact connected with this subject, too 
important not to be noted. The heart, lungs, etc., not only com- 
mence their offices at birth, but they are allowed no cessation, night 
or day. Through the whole period of existence they must be in 
constant and unbroken action, for the tenure of human life is the 
fidelity with which these offices are discharged. If the heart cease 
to beat, or the lungs to act, the whole mechanism, in its exquisite 
and wonderful arrangements, instantly becomes arrested, and in 
this arrest death finds its triumph ! Therefore, it is manifest that, 
in the human economy, there are two kinds of function — the one 
commencing at birth, and necessary to the maintenance o^life, is 
continuous ; the other, originating at a period remote from birth, 
though material to health, is nof^o to life, and is, moreover, as we 
«hall show you, periodical in its recurrence. 

Meciprocal Relations of the General and Uterine Systems, — 
Indeed, I am disposed to think that, without any infringement of 
physiological law, we may divide the forces which regulate the 
vital action of the female into two classes ; one of these will apper- 
tiun to the general system ; the other belongs to the uterine sys- 
tem. After puberty, and until the child-bearing period of the 
female has been completed, there is a reciprocal and necessary rela- 
tion between these two forces, which should never be permitted to 
escape the attention of the practitioner. Without an appreciation 
of this relation, he will be at a loss to account for the various con- 
stitutional disturbances so frequently dependent upon either organic 
or functional disease of the uterine organs. He will mistake 
phantoms for realities — he will treat symptoms for causes, and 
thus bring a blight upon his name, and discredit upon his profes- 
sion. 

By way of illustrating, let us suppose the following case : A 
lady is attacked with epilepsy, hysteria, or even mania. Now, I 
contend that either of these forms of nervous disturbance is, in 
nine cases out of ten, a product, or, if you choose, an effect, trace- 
able to its antecedent, or cause. It is, therefore, very rarely a pri- 
mary or idiopathic, but almost always a secondary or symptomatic 
trouble. Suppose you should be called to attend this lady, after 
others had in vain attempted to relieve her ; and, with a full and 
common-sense investigation of all the circumstances of the case, 
you should discover that, from cold, or some other cause, her men- 
strual evacuation had suddenly become suppressed, and that the 

• The period of tlie menstrual function is generally embraced between puberty 
and the time of its final cessation, and may be said to extend from twelve or flfleen 
to forty-five or,fifty years of age, which would, therefore, make its usual duration 
about thirty years. 



M 



THE PllINCIPLKS ASU PRACTICE OF OBSTETRICS, 



suppression was very shortly foHowecl by one or other of the al 
nervous aberrations? What, allow iiie to ask, with thia impoi 
light to gtiide you, would be your diagnosis — and what your pi 
of treatment ? You would see, with the rapidity of thought^ th 
the epilepsy, hysteria, or mania, was due to the 8U[ipresaion — nu 
as consistent men, your remedies would be directed^ not against tUi 
nervous disturbance, which b simply the phantom, or product, b 
against the suppression, which constitutes the entire c^um of ll 
derangement. 

But let us, by another illustration, see how it oftentimes happci 
that the uterine system itself is dependent, for its proper regul 
tion^ upon the force supplied to it by the general economy- He 
for example, is a girl seventeen yeai-s of age, who has never 
* St mated ; she is pale, leuco-phlegmatic, bloodless, presenting a tr 
picture of ana?mia. Why does she not menstruate ? Is the lun' 
norrlnx'a, in this ease, a cause, or an effect? If you be of opinion 
that it is the former, you will administer emmenagogues, and thus 
fritter awiiy, in the abortive Iiopc of doing goo<l, the little remain- 
iug strength of your patient. Hut if, as ftcnsiblemen, you perceiv 
at a glance, that the absence uf tl»e menHtrual function is simply 
result dependent upon a diL-ijadated condltioa of the general health, 
thus depriving ihe uterine organs of their proper supply of healthy 
nutriment, througli which they derive the necessary nervous stimu- 
lus fur the institution of the catamoniul function ; if, I repeat, you 
regnrd the anienorrhcea as the direct cftect of this broken-down 
condition of the general health, you will not address your remedi< 
to the uterus, but at once, by hygienic find other measures, end 
vor to im|>rovc the dige.stion, so that good bloud may be elaborated 
and sent tliroughout the economy imparting to every tissue nutri 
lion and development; in theaccornplishment of these latter objod 
the eatumenia become established, and the health of your patient 
secured. So murli for the reciprocal relations between the general 
and uterine systems, 

T/te Genital Organs at the Time of Puberty. — I have told yoi 
that, before puberty, the uterus and its annexaj are insignifican 
and form, only in structure, a portion of the general mcchaniai 
As soon, however, as this inipuriant era, puberty, has arrived, ne 
fires are kindled, new life imparted, new bi>pes created, and the girl 
enters upon a new mission. Her whole character is changed — ^shi 
has passed from childhood to wonianhoocL Instinct tells her that 
she is now an active member of the great human family, with, 
acred duties, and no less sacred obligations imposed upon her, 
bis change in her physical condition brings about corresponding 
changes in her moral bearing — she is no longer a child, sportive, 
rollicking, and irresponsible. If I may so term it, her sex is 
detined — and there is an inherent sense, which admonishes her tkat 




THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 95 

dignity and reserve are now to take the place of levity and childish 
confidence. 

As the period of puberty approaches, remarkable modifications 
will be observed in the physical appearance of the girl ; she gra- 
dually loses the form and figure of the child, and assumes, through 
the rapid and successive development of certain tissues, the full and 
comely aspect of the woman ; the uterine organs increase in volume : 
the pelvis receives an enhanced growth; the hips spread; the 
breasts enlarge ; the pubes is covered with hair ; there is a sensa- 
tion experienced in the generative organs to which the girl was 
previously a stranger, the direct consequence of the increased afflux 
of blood to them ; and it is not unusual, at this period, to find more 
or less mucus secreted, giving rise to a moisture, and, sometimes, a 
discharge from the vagina. The changes which I have just enu- 
merated are generally accompanied with more or less disturbance 
of the general system — such as headache, restlessness, constipation, 
loss of appetite, depression of spirits, neuralgia in one or other of 
its numerous forms, febrile excitement, hysteria, and other grades 
of nervous perturbation. Now, gentlemen, the interesting fact for 
you to remember is, that all these changes in the generative organs, 
this increased development of the tissues, and the constitutional 
derangements to which we have alluded, are but so many preludes 
to the institution of a function perhaps, in many respects, the most 
important in the economy of the female — I mean menstruation. 

Menstruation. — The term menstruation is usually, but improperly 
as we shall explain, defined to be a periodical or monthly discharge 
of blood from the vagina, commencing at the time of puberty, as a 
general rule, and continuing, except during pregnancy and lacta- 
tion,' throughout the child-bearing period. It has been attempted 
by certain writers to show that menstruation is the offspring of 
civilization ; but so far from this being so, the function occurs in 
women of every race, and in every condition of life; and, moreover, 
in the earliest written record it is referred to thus : "And Rachel 
said to her father — Let it not displease my lord that I cannot rise 
up before thee, for the custom of women is upon me."* When this 
function becomes established, it is ordinarily the silent, but emphatic 
declaration of nature that the female has attained her maturity, and 
is now prepared, by her physical development, to carry out one of 
the objects of her mission — the reproduction of her species. The 
age at which menstruation manifests itself for the first time is by no 
means uniform, and will be modified by various circumstances, such 
as climate, education, mode of life, temperament, constitution, and 
race. 

Climate, — ^The influence of climate on the early or late appear- 
ance of this function was, previously to the researches of Mr. 

* Genesiti, chap, xxx.1 



96 THE PRINCIPLES AND PRACTICE OF 0BSTSTRIG8. 

Roberton,* supposed to be very decided ; and the general opinion 
prevailed that girls, under tlie torrid zone, menstruated much ear- 
lier than those born in temperate, and higher latitudes. Mr. 
Roberton, however, has shown that the extreme difference in the 
time of the first menstruation in very hot and very cold climates is 
only three years ; thus, in Calcutta, the mean age is between 12 and 
13, while in Labrador it is within a fraction of 16. In Jamaica, it 
is 14 ; at Bombay, 15. At Christiania and Copenhagen, according 
to Dr. Faye, it is between 10 and 17; in Paris, and London, 
between 14.50 and 15; and at Lyons, 13. It, therefore, will be 
seen that the influence of climate is much less than was formerly 
supposed. 

The annexed table, derived from Dubois and Pajeot,f exhiUti 
some interesting data on this subject. It embraces observations 
made on six hundred women, in different climates, in reference to 
the period of the first menstruation : 

Warm Climate. Tempemte Climate. Cold Cllnuta. 

JSoHlh€rn AHn. France. Xorthsm Rmadm 

Age. Number of Women Menstruating for the first tinM. 

» jeara 3 

9 •* 9 2 

10 " 19 8 1 

11 " 8G 2« 3 

12 " 143 42 6 

13 " 135 G4 18 

14 " 9G 82 66 

15 •• f)2 99 114 

16 •' 25 96 lU 

17 '* 16 76 90 

18 " 3 fiO 78 

19 " 3 25 56 

20 " 2 18 SS 

21 " 1 6 17 

22 " 1 3 10 

23 " 1 1 3 

24 " 2 1 

Thus it .appears that the averai^e age at whicli menstruation first 
appears in warm climates, is 12 years, 11 months, and 21 days; in 
temperate cliniatos, 15 years, 3 months, and IV days; in cold cli- 
mates, 10 years, 7 months, and 27 days. 

Education and Mode of Life. — Girls in the country, whose 
habits are more in accorjlance with the ordinances of n.iture, men- 
struate later than those brought up in the city; and this difference 
is readily accounted for. The former are frugal in their habits, 
retire early, and ri.se with the sun ; they are independent in feeling, 
and in action ; their moral and physical education is usually calcu- 

• Essays and Notes on the Physiolojry and Diseases of Women. London, 1841. 
t Traite coniplet do I'Art des Accouchemens par MM. Dulwis et Pojoot, p. 325. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 97 

lated to improve the mind, and fortify the body. They live in the 
open air, and are more or less constantly in exercise ; in a word, 
their nervous system is strengthened, and they exhibit, not only in 
their personal appearance, but also in their very movements, the 
evidences of phy^cal health ; they, indeed, are the living portraits 
of nature's own daughters. 

How different is it with those bom and educated amid the tinsel 
and excitements of city life ! Look at our metropolis, New York, 
with its enterprise, its commercial prosperity, its immense wealth, 
its princely edifices, more like the palaces of the old world, than the 
impretending structures of an infant but mighty Republic — look, I 
say, at all these things — the products of successful enterprise, and 
indomitable energy — and then turn to the pallid cheek and wasted 
features of tl^se interesting creatures who are to do the honors,' 
and constitute the gems, of these magnificent domicils. In this con- 
templation, the philanthropist w411 find cause enough for lamenta- 
tion ; he will see that city life, with its rounds of excitement, its 
prurient books, and no less prurient dance, has forced into prema- 
ture action the nervous system of the young girl, and thus entailed 
upon her the melancholy results of this contravention of the laws, 
which nature has declared essential to health. The life of the young 
girl, moved and swayed by the constant and exciting currents of 
dty habits, is a life purely artificial ; it is without substance, 
destructive alike to health and happiness, and too often without a 
redeeming feature to relieve the retrospect. You appreciate, there- 
fore, why it IS that the catamenial function occurs earlier in girls 
surrounded by, and participating in, the follies and excitements of 
the metropolis ; these excitements tend directly to force into early 
development the nervous system, and under their prurient influence 
the sexual organs are stimulated to premature and sickly maturity ; 
hence there is, oftentimes, a premature and sickly exhibition of the 
menstrual function.* 

Temperament^ Constitution^ and Jiace, — ^Temperament and con- 
stitution, under given circumstances, will exercise their agency in 
the early or late appearance of this function. Girls of a nervo- 
sanguineous temperament and robust constitution, will menstruate 
earlier, all things being equal, than those of an opposite condition 
of system. The influence also, of race is very remarkable, and 
•appears to resist all the other circumstances kno^m to modify the 
late or early development of the menses ; for example, it has been 

^ Briere de Boismont, in his fuU and excellent paper on menstruation, states that 
in Paris* among the daughters of the wealthy, the age of the first catamenia is thir- 
teen years and eight months ; and, among the poor, fourteen years and ten months. 
It was observed in Vienna, by Dr. Szukiss, that in 665 women bom in the city the 
mean age was fifteen years eight and a half months ; while, in 1610 from the ooun* 
try, it was about sixteen years two and a half months. 

7 



98 



THE PRINCIPLES AND PKACTICE OF OBSTEraiCS. 



shown by Raciborftki find others, ihiit if a husbjiud and wifc, 
natives of New York for instance, should reside in the East Indaiis, 
aiid h:ive chihiron there, no matter how long the period of rcfii- 
denee, even if it extended to six or raore generations, the daughters 
will continue to menstrnate, not at the period usual for girU in die 
East, but in correspondence with the time at which this function 
usually occurs in the native homes of their parents ; and so^ also, tbe 
reverse of this i^ equally true. 

Precocious and Tardy Menstruation, — Ttiere are examples, 
recorded in the books, of inenHtruation occurring in young chil- 
dren ; but these, I think, should not be ac-cepted without ^ome 
qualificiition. One of the raost remarkable cases I have read of, \b 
related by Dr. D. Rowlett, of Kentucky;* *' Sally Deweese was 
bom in Butler Connty, Kentucky, Vth of April, 1823; at twelve 
months of age she meostniatcd, and continued to do m regularly until 
1833, when she became pregnant; on the 20th of April, 1834, ahe 
was delivered of a healthy female child, weighing seven and three 
fourth pounds." Other writers have also cited some extraordinary 
instances ; Briere de lioiamont mentions two crises ; in one, men- 
«tnmtion commenced at the third month, in the other at the third 
year. D'Outrcpont records one at nine months ; the infant had 
prornberant breasts, and menstruated every fanv weeks until her 
death, which occurred in the twelfth year of her age. Whatever 
credit may be placed on these and other recorded examples of 
menstruation in children, it is very evident that they should be 
regarded as extremely rare exceptions. Not so, however, with the 
cases of tardy menstruation ; 1 have known several examples of 
young women, in the enjoyment of good health, in whom the func- 
tion did not appear until the nineteenth, twentieth, and twenty- 
second year; there was one case of a female, who appeared at my 
clinic, and who, if her statements are to be relied upon — and after 
rigid scrutiny I could detect no motive for fraud — did not menstm- 
ote urrlil she wa^^ thirty-three years of age ; she married at thirty- 
five, and was delivered of a healthy living child sixteen months from 
the dj\y of her raamage. 

Causes of MefiMmat ion. — In referring to the various and oon^ 
flicting opinions advanced by mithors to explain the cause of the 
meriRtrual discharge, we cannot but be struck with two facts: 
1. The mjinifest want of agreement; and 2. The abaurditiea to 
which mere hypothesis will otYentimes lead its supporters. Some 
ascribe the menstrual crisis to the influence of the moon ; others 
«ay that it is produced by general plethora of the system ; while 
others, agjun, maintain that it is due altogether to local plethora; 
jmd so we might proceed to enumerate the diflerent theories whioh 



^ TnuujlvialA Joonuil oTMedicioe for Ootober, 1834 



TnE PHIKCIFLES AND PRACTICE OF OBSTETRICS. 



99 



have been projected on this subject — but cui bono f Women 
menstruate not only at every phase of the moon, but they men- 
struate every hour and day in the year. What, then, becomes of 
this supposed lunar influence — a doctrine, I may mentioU| of v<;ry 
ancient date, and which has been warmly defended by some of the 
eairly fathers. Again : you will occasionally see females in infirm 
health, the very opposite of plethora, have their menstrual turns 
with more or less regularity j but why should this be bo, if the 
mcnsiiraa) function be owing to general vascular fulness of the 
BjsTem — ft doctrine which, also, has had its elot^uent advocates ? If 
thl^ hypothesis of plethora be trne^ why could not menstruation be 
completely arretted by the abstraction of blood, upon the principle 
— causd suMatd toUitur ^ecttm; but we know very well, from 
practical observation, that, in certain engorged conditions of the 
economy, loss of blood, eitlier generally or locally, in aomctimes the 
most prompt and efficient remedy to bring on the catamenial flow. 
A trace to theory, and let us come to facts. 

When a girl menstruates, it is because »he has attained a point 
in her physical development, which enables her to perform thia 
function. Function, in a physiological acceptation, is the specific 
act accomplished by, and peculiar to, a given organ. For example^ 
the lungs decarbonize the blooil ; the liver secretes bile; the kid- 
neys urine ; the heart receives into its right cavities venous blooii, 
and throws from its left cavities arterial blood. These, together 
with numerous others, are functions which, more or less, commence 
with the birth of the child, and which also ar4.% more or less, directly 
connected with the maintenance of life. They, therefore, differ 
from the menstrual function in the broad fact that the latter does 
not manifest itself until some years atter the birth of the being; 
and while its periodical recurrence is material to the health, it is 
Hot, as I have before remarked, essential to the life of the individual. 
Kijw, it appears to me, that the true explanation of the cause of 
men>truation consists in the elucidation of the simple question, viz. 
Why Is not the function of menstruation, like the functions of the 
hings, heart, and kidneys, .simultaneous with the birth of the child? 

The solution of this hiterrogatory is, in my opinion, the only 
philosophical explanation of the cause of menstruation ; and we 
proceed, therefore, in a very few words, to answer it. As soon as 
tJie child is born, and its existence becomes independent^ the lungs 
commence their office of decarboniziation, simply because thehings 
are developed and prepared for this duty; the heart receivea 
TonQtt§ blood, and disposes of arterial blood, becaase the heart is 
developed and fitted for this office ; the liver secretes bile, and the 
kjilneys urine, for precisely the same reasons. But the difference 
with mentiiruatiou is this — it, like the other functions, is the oflp. 
•pring, if I may so speak, of organic development ; and the r^^asoa 



100 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 

that it ia not coexistent with birth, and does not become establisJjed 
until fi later period, is, tliat the organs, of which it is the speciiSc 
fiuiciion, have no physiological existence — that in, they lack physi- 
cal development, and, therefore, have not yet become participators 
in the acts of the system. These organs are the ovaries, the essen- 
tial and only organs of generation strictly so-called in the female. 
Tlie development of the ovaries occurs at the period of puberty, 
and then it is that their physiological action commences. 

At this time, yon will observe on the surface of these bodies^ 
the Graaffiau vesicle, containing the ovule, which, I have told you, 
escapes ordinarily with the menstrual blood* As these ovulea on 
the surface become matured, the ovary itself forms the centre of a 
sanguineous afBux, a veritable congestion, in wliich the fallopiau 
tubeij and uterus |iarlii'ipate ; this congestion, as a general princi- 
ple, results in the escape of juncns and of blood, which pass from 
the uterus through the os tincjB into the vagina, and thcnoe exter- 
nally ; this is popularly denominated raenstrnation. I have jugt 
flaid that, as a gencnd principle, the ripening of the ovulea— ovula- 
tion — is accompanied by a muco-sanguineous discharge ; but yoa 
tnnst bear in recollection that this miico-sanguineous discharge is 
not uniformly present ; the want of this distinction has, I think, 
given rise to more or less embarrassment. Menstruation doi*s not, 
be it remembered, essentially consist in the month ly evacuation, 
which usually occurs,* but in the cardinal physiological fact —thai 
one or more ovules reach their maturUy every month. With the 
appreciation, therefore, of this important truth, you can readily 
comprehend how, under certmn circumstances, a femalo may 
become impregtiated who, in the ordinary acceptation of the tenn, 
has never menstruated, examples of which we shall cite, wbeD 
treating of gestation-f 

* It is uniloubtedty true that, at ench cuiaDmnial period, ttiero ib osuallj a taa* 
gQlriCH)UH di^ii^rgc from the vagina ^ but this didcharppe^ ao fiir from roprcaetttitig tbo 
BBa&ncn of tho menslmBJ fuuctiofi, ia simply one of iho ordinary iinkjj in the dmin 
of pht*noiDena which occur at thiA time. The penodicol ovariiin tiifUH is npeesaftnlf 
aocornptinied with more or lean congest ton of the utenno orgnris, und thr pn^^snge of 
the blotsd Into tho world la nothing more thiin an c^»jrt of uature lo r*'he%<7 Xh» 
venaels from thetr hyperajtuic ccmditvon. If, however, oa will sointtimw ot^ur, thiA 
dinchnrjn^ of blood should not take plaoe^ numerous nenrous disturbADOca niur result 
from one of two cau5e»— either from the sojourn in the jrener«l gystein of tht^ noxioui 
elLMneiita cofitaioed in the roeniitnuil fluid, or from the irrication of tlie oviirian 8iuj 
uterine nerres id oonsequenoe of the continuod tngorged ecrndttlon of Uje uare- 
UertKl ve«seU. 

\ Dr Szukisftt of Vienna, during a period of fourteen je^irs, and in 9000 ciMi^ 
met with fourteen instv^nwH of lot^J nb^enee of mGnsirvwtion. In four of the«e la- 
fltftncc^a^ the women hud borne aeverii) children ; tlie other ten wore barren ; most 
of tliese, however, experienceii every three or four weeks. t)ie or^imury fiytnptom:^ 
or w&hfmna mmsirfmUmas, Jo none w«« tliere nn/ vicnnous meustruatioo ; Hit in 
two, tmpertoet development of the uteniB wils diaooverod. 



THE FBINCIPLES AND PRACTICE OF OBSTETRICS, 



101 



Lc Cat bas been the object of mych ridicule for having origiii- 
ated the theory that menstruation is the result of a voluptuotia 
oongestion of the uterine organs j but if, in his ignorance of what 
is now known in reference to ovulation, he could not more definitely 
exphiiu his idea than by employing the term voluptuous^ yet it is very 
evident that Ids nimd was in the right direction on the subject. 

The ovular theory of menstruation, which has recently received 
much attention, and been the subject of special research^ waii w^ell 

dertttood and described by a clever and logical writer as early 

1921 — I mean Dr. John Power. Indeed, I tfrink he is entitled 
to the oredit of having accurately delineated the ovular phenomena. 
In order that you may appreciate the basiis for this statement, I 
(]t]ote from him the following passage: "The generative powers of 
Uie human female are not limited to the production of a single 
ovum ; on the contrary, a number may always be detected in the 
ovaria, under different states of progress. The loss or disappoint- 
ment of one matured o%n.ira is followed by the maturation of 
another; this, in its ttirn, becomes disappointed, and thus an 
indetinite series is carried on throughout the period of generative 
capacity,"* I do not wish to be understood that this interesting 
subject had not been alluded to by writers prior to the time of Dr. 
Power; but, in my judgment, to him is due the credit of having 

I embodied in a clear digest what may, with some reason, be deno- 
minated the fragmentary notions advanced on the subject by his 
jffedecessors j and I think, too, that he has, in a measure, atitici- 
|pted ihe investigations of those who have succeeded him in tiiis 
field of inquir}*. 
J*eriodicit%f of Menstruation, — But why should meostruation be 
^riodical — that is, occur once in twenty-eight days, instead of 
being continuous and uninterrupted like most other functions of 
the system ? Haller inculcated the doctrine that the true explana- 
tion of Uie periodicity of the catamenla was, that nature required 
twenty-eight days to repair the loss of blood sustained at each men- 
strual crisis, and that it was not until this lapse of time that the 
v* in became filled so that they could pour out their contents. 

^^ Til man, and acciu'ate observer, however, was in error on 

^H thia question. JX you examine an ovary in its congested state^ yoa 
^H will observe on its surface the matured ovules of which I have 
^f spoken, or at leaat the remains of the ruptured vesicles from which 
' they have escaped ; exarniue the organ still more closely, and you 

wiU detect^ imbedded in the subjacent tissue, other ovules, which 
ara not matured, but which, as they approach the sur&ce of the 
ovary, become so, precisely as did the first ; so, in this way, there 
IM at each monthly crisis a constant succession of ovules, one or 



* KMays on Ft'tnale Kooaomf. Londoa, I82L p* I 



|02 



THE PRINCIPLES AND PRACTICTE OF OBSTETRICS. 



more of which either become fecundated by the seminal fluid of 
the male, or, in the absenco of such influence, e&capc witli the 
catamenial fluid. Thi^ periodical maturation of the ovules cod* 
finues ibom the period of puberty until the final cessation of 
menstrual function. 

There is a singular coincidence as to the physiological condition 
of the ovary before the age of puberty, and at the time the woman 
©eases finally to menstruate. Previous to puberty, the ovaries, aa 
we have already stated, are undeveloped, enjoy no action — ui a 
word, they are inert; after the function has ceased, these same 
bodies fall into a state of atrophy, and are no longer engaged in 
the aflairs of the economy. The similarity of condition in theae 
organs, before and after the menstrual crisis, is explained in this 
way: menstruation i>? the evidence which nature aff"i>rds that the 
female is susceptible of becoming- impregnated, that she is in Jh 
state to carry out the cardinal office of her sex — ^the reproduction 
of her fipecies. Menstruation, you have just been told, is but the 
result of the ripeninjr of the ovules, which the female is required 
to furnish in order that she may perform her part in the great work 
of increase. The reason, therefore, that her ability to perform thij 
latter duty is restricted to certain limits, is because it is only within 
tliesc limits — from puberty to the final terminatiouof the menstrual 
function — that the ovaries are capable of secreting ovules, which 
constitute the gifie qu4 non of procreation, so far as the female ia 
concerned.^ 

tSofirce and Nature of the Menstrual Fluid. — ^There Iras been 
much controversy, and very discrepant opinions have been ad- 
vanced, regarding the source and mode of production of the 
menstrnal fluid. It has been argued by many writers that the 
cat^amenia are simply an exudation ; others, on the contrary, say they 
are a secretion. It appears to me that the real cause of thu contJ*tt* 
dictory opinions, entertained upon this subject, is traceable to the 
circumstance that the prelimtiiary question— the one absolutely 
essential to the proper solution of the inquiry as to the truesotirce 
of the menstrual discharge — has not been sufficiently considereil. 
The question to which I allude is this: What is the menstrual 
fluid ? Is it really and truly bloody presenting all its elements and 
eharaeteristics, or does it, in its constituents, disclose that it is not 
blood ? Let us briefly examine this point. It has been very satis- 
factorily proved by Donn6 f and others, that the catamenial fluid 



* Several mstanceo Uiivo been recorded in which, afVer the nblfttion of the onriei^ 
the menstraal funciion entirely oeaned : but, perhaps, the most remarkable exAtn- 
pie ia the cue of the young woman mentionod bj Pott. In this caae^ both orariaa 
had been removed by Uje double opemtioii. The catamenlAf although prerioualy 
regtalar, uever re-appeared, 

f Doim4 has subjected the naeostruaJ fluid to a careful micToscoptc examinatiofDi 



THS PRINCIPLES Am> PRACTICE OF OBSTETRICS. 108 

in tlie Qterufl, and the catamenial fluid in the vagina, present a 
very important difference. In the nterus it is really blood, pos- 
sessing all its elements ; in the vagina, on the contrary, it loses its 
fibrin, for the reason that this latter product is dissolved by the 
vagitial mucus, which contains more or less acetic acid. 

You see, therefore, that the menstrual fluid, as soon as it passes 
into the vagina, becomes deprived, through the destruction of its 
fibrin, of its power of coagulability. It will, however, occasionally 
happen, that large coagula do pass from the vagina, and this occurs 
in certain forms of profuse menstruation, in which the loss is so 
abundant in quantity, that there is not sufficient mucus to dbsolve 
tiie fibrin. 

Therefore, if it be conceded that the catamenial fluid within the 
uterus contains red corpuscles — a necessary element of normal 
blood — it is very evident that it cannot pass from the vessels 
through endosmosis or percolation ; it can only escape through 
rapture of the engorged capillaries. Have you ever witnessed a 
oaae of profuse haemoptysis, or hromatemcsis ? If so, the inquiry 
may have suggested itself to you: Where does this immense 
quantity of blood come from, or, more properly, how does it pass 
firom the lungs and stomach? The mode in which the blood 
escapes, in these instances, either from the lungs or stomach, is 
precisely the same as in the case of the menstrual fluid. It is through 
rapture of the pulmonary and gastric capillary vessels. In answer, 
therefore, to the question, what are the source and mode of produc- 
tion of the menstrual fluid, it may be said that, at each catamenial 
crisis, the capillary vessels on the internal surface of the uterus and 
fallopian tubes become congested, and through their rupture afford 
escape to the fluid. The mucus, which is more or less commingled 
with the catamenial discharge, consists of an epithelial secretion 
from the mucous membrane of the organ. 

Duration and Quantity lost at each Menstrual Period, — The 
duration of each menstrual period is from three to eight days — and 
the quantity of fluid lost at each monthly turn will vary from one 
to eight ounces. It is well, however, to remember that both the 
duration and quantity lost will depend upon various individual 
circumstances, so that there is no fixed rule with regard to either 
of these points ; thus the extremes, which I have mentioned, may be 
normal, and in accordance with the general health. One female, 
for example, from some peculiar idiosyncrasy, will menstruate only 
for one or two days, and another for six or eight ; one will lose 
fiY>m four to six ounces, another only one or two ounces. The im- 

and presents the following as its constituents: 1st Ordinary blood globules, with 
their special characteristics, in large quantity. 2nd. Mucous globules. 3rd. Epi« 
dermic or epithelial scales detached from the mucous membrane of the uterua and 
Tagina. 



104 



THE PKINCIPLES AND PRACTICE OF OBSTETRICS. 



portant fact, wliieh you are to bear in recollection, mthb: llmttfae 
time and quantity of the mengtrnal discharge are always to be 
considered afi natural, and in harmony with the demand:^ of the 
economy, imlese cofisUtutional duturbances should /oUow ; iheite 
latler are the only evidences that the interposilion of the practi- 
tioner is necessary. 

Is Mensirualion Peetdiar to Woman f — ^The doctrine haa g«De- 
raUy been maintained that menstruation is peculiar to the human 
female. If, by this, it be intended to convoy the idea that the 
function, as it exhibits itself in woman, with all its phenomena, iU 
duration, etc., is exclusively recognized in her, then I can see no 
objection to the doctrine, itj perliapia, we except the monkey tribei 
for it is founded upon undeniable evidence.* If, on the contrary, it 
be argued that, during tlie period of heat^ which is* nothing Idsa 
than a jieriodical aptitude for procreation, certain of the lower 
TOammalia do not have any winguineous discharge, no matter bow 
slight or for liow short a time, then I object to the doctrbe, for it 
ia adverse to the evidence furnished us by accurate observation. 
Examine, for examj>le, the slut at the time she is about to take the 
dug (her period uf heM^^ and you will lind not only congestion of 
tho parts, but also a slight sanguineous show; and during tfus sea- 
son of h^Qt tlie sauie phenomenon is observed, so charactenstic of 
the menstrual function in women, viz. the «pontaneous maturation 
and escape of ovules, f 

Arc there Poisonous Elements in the Menstrual Fluid f — Al- 
though, as we have stated, the menstrual duid, while within the 
uterus, is essentially blood, yet there 8till exist differences of 
opinion regarding the uther properties of this discharge. The 
ancients entertained pectiliar views on this subject. It was sap- 
posed by some that it contained such concentrated poison, that its 
very exhalations would turn the jmrest milk sour, and throw a 
bliglit over the freshest and lovi'Iii*st tlxwers of the gardeu. In- 
deed, I atn not so confident that Pliny, and many of the writers 
among the Arabians, did not at least api»roach the truth when they 



^ It baa long been known thftt monkojs are subject to • poriodloftl sanfruineous 
discharge ; and some mtereettng details Iiavo recetUly bec'n prei8ented bjr M. Ncubort, 
of Stuttgart He lioa bud in liin ptisectsion, iiinee 1830, hny monkeys, in which h© 
fljoetly obuc^rvod tho phetiotneoa eoi]uect4»d with ihm diAcbHr^ MenstniHtioo was 
ragiiliir every Ibur weeks, as in women, nnd cpntiiiw(*d throe or four days; this oir 
canmtaaoe wm uoXl&yA in severtd different Hpwtesi Dunn)? the months of July and 
Auguat, however, the dow wan absent. The discharjco occurred whether tlio femalea 
lived aptti% or with the males; and it oonsed uf\er <eound»Hgiu Ail an exc«{)tioti, 
the roonlccya of Auatralia menstruate only twice a year, and tako the males only at 
theao penodfl [Moniteur dea Ttupktaux.] 

f Some interesting <letails will bo fofjnd on ihe suhjoct of meaatniation ia animals 
in a piper by Brest^'het, eitiitieil, Redi^rchca sur la gestation des quadrumaiMA, 
£M^moir«a di3 1'Aeadentie dea Sciences, t lU.] 



THE PBINCIPLES AND PRACTICE OF OBSTETRICS. 105 

advanced the opinion that the catamenial discharge incorporated 
certain noxious elements. These writers, it must be conceded, were 
fanciful, and some of their illustrations supremely ridiculous ; but 
laying these exuberances aside, I believe there is much truth in the 
aggregate of opinion they entertained on this subject. Most 
modern authors, however, are disposed to smile with something 
less than contempt at what they are pleased to terra the " crude 
notions" of the early fathers respecting the properties of the men 
Btrual blood. The smile might be pardoned, if those who indulge 
in it had given us something positive and well-defined touching this 
question, so interesting both in its physiological and pathological 
relations. 

I have myself no experiments to offer with the view of demon- 
strating that the menstrual blood positively contains noxious 
materials, but I argue the affirmative of this question from the 
pathological states which are observed to follow certain abnormal 
conditions of the catamenial function. For instance, in one hundred 
unmarried women, who may labor under suppression of the menses 
from the operation of any of the influences known to produce this 
result, such as cold, mental emotion, etc., it will be discovered that, 
in at least ninety-five, the suppression will be followed by more or 
less disturbance of the nervous system. In some', it is true, the 
symptoms will be slight and evanescent, but in others they will 
assume a more marked character, sometimes even producing mania, 
coma, epilepsy, catalepsy, or chorea. May not these phenomena 
be due to a species of toxaemia, or blood-poisoning, traceable to the 
poison of the menstrual blood upon the nervous centres ? * 

This opinion seems to be confirmed by the important fact that 
the nervous disturbances cease with the return of the function. I 
have enjoyed full opportunities for observing the effects on the 
economy of the various forms of menstrual aberration ; and I have 
also not failed to notice an extremely interesting and significant 
circumstance —a circumstance which certainly tends to corroborate 
the hypothesis that the derangements of the nervous system, under 
unnatural suppression of the menses, are owing to a species of 
blood-poisoning. The circumstance to which I allude is this : when 
the catamenial discharge, suddenly or otherwise, becomes abnor- 
mally arrested, the urinary secretion is usually diminished in pro- 
portion to the intensity of the nervous symptoms ; and what is still 
more significant is, that the nervous perturbation will yield in 
proportion to the effects of diuretic and sudorific remedies. There 

* The80 ncrvoiiB derangements may also be explained by the congested state of 
the spinal cord, as is shown in cases of paraplegia. A very decided proof that the 
menstrual blood contains more or less noxious elements is demonstrated by the cir- 
cumstance, that oftentimes gonorrhoea will be produced in the male if intercourse be 
had during the ciitamenml flow. This latter fact is beyond a peradventure. 



108 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



18 no error as to the fact — ^its truth is readily susceptible of demc»ii- 
Btratiou. * 

Critical Period, — The period at which the menstrual fuuetion 
finally ceases in tlie female may be said to vary between the ages 
of forty aud fitly yeai"s; although it will bo found that some cease 
to menstruate before the age of forty, while others will exceed the 
period of'fitYy years. I think we are warranted in saying that, as a 
general rule, the earlier the menstrtial function commence^t, the 
earlier it becomes suspended., and vice versa. The time of final 
cessation has been termed, very properly, I think, t!»e critical era 
of female life, for the reason that certain morbid nffections are apt 
to develop themselves at this period. You can readily unileri^tand, 
for example, that various diseases of the uterus may, through the 
monthly disgorgement effected by menstruation, be held irieasurably 
in check, although t lie re should be a strong predisposition to their 
development ; but when the important climsictcric arrives, and there 

19 no longer this periodical unhiading of the vessels, the elemcntt 
of trouble collect, and become embodied in one or other of the 
affections, more or less forjuidable, to which the organ in liuble. 

Again: diseases of the msimmie are apt to exhibit themselves at 
this period, having up to this time been controlled by the denvutive 
influence of the catamenial discharge. If to these facts we ad<l the 
various local congestions — sometimes of the brain, sometimes of the 
lungs, liver, etc., and comprehend, also, in this enumcmtion of mor- 
bid phenomena, the various nervous perturbations, which occur at 
the period of linal cessation, it cannot but be admitted that it is 
justly entitled to be denominated critical. 

There is one topic to which I cantiot too emphatically direct 
your attention, and wliich has a very important bearing in a practi- 
cal point of view. It is extremely common for women, as the 
period of final cessation approaches, to be troubled with metror- 
rhagia J and hence it will be your duty, in such cases, to distinguish 
between tins sanguineous discharge^ — which is oftentimes nothing 
more than one of the ordinary results of the struggle in which 
nature is engaged to terminate the menstrual crisis — and the di»* 
ebarge which is sometimes the prelude of carcinomatous disease of 

* la thia conaoxioa I mmj remind you of tho iQtorefltiDg liict recorded by Atidral 
and (Iitvarrul in ihviT reaeurclies uo pulmonary respiration ; they have ehoim duit, 
lu the male, from llic p<?ritKl of puberty lo Ihc* ago of thirty ycAfS, the con.*tur()ptUm 
of CJrUuj luoreases; while in ihe female, flrom the flrst mcnHtruiUion und during th© 
entirt' vUM be^trhii; p^rirni, the amouat of carbon consumed \s ulways the siimo. It 
would, iln it*njrt;, lippear Ihjit Ihta dillerenee in the doatniutiou of carbon, in lliu two 
■exoa. \» ilue to iho futiction of menstruation, whic-h, in thia respect, at k»a»t nmy b^ 
regarded as nti excn^lion llbemting the «yfitvro from a noxioiui element It Ihcro- 
fori9, th^ futtcHion be pretematurally arretted, uccttrdtnjyr to Uiis view the economy 
beo ^^>>tHl by li Mipembuadanoo of c^bon, and honce an ioflnity of pfttluh 

logj' irfia may ensue. 



TBE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



107 



the neck of the uterus. We are, if I remember correctly, indebted 
to Louis and Valleix for this latter essential fact* Therefore, in all 
ca^es iQ which, at the turn of life, metrorrhagia may occur, I would 
advise you to institute a vaginal examination for the purpose of 
aacertidning whether or not it is connected with organic disease. 

Should the female escape the dangers incident to this period of 
existence, she will, as a general rule, pass on, with the en^ "^yraent 
of health, to a ri|je old age. The spring-time of life is over, and 
she now lapses into the cold shades of winter. One of her great 
oflices has been completed ; she has fulfilled her destiny in the birtli 
and tender care of her children, and she now lives still to guide 
them by her counsels, and rejoice in their position as useful members 
of feociety. Such, then, are the three great eras of woman^s exist* 
ence, each marked by its own striking peculiarities, and each, too, 
surrounded by more or less peril — ^the era-s to which I allude are 
those of puberty, child-bearing, and the final cessation of the men- 
strual function. 

ApiUmie for Imprecation, — There is, in the human female, as 
in the various species of animal creation, a period in which the 
aptitude to become impregnated, is much greater than at others ; 
and it will be well for you to recollect tlie fact, for it may occasion- 
ally enable you, by judicious advice, to consumraate the happiness 
of the married by ble3?»ing them with oflT^pring, after yeai^s of p:itient 
but unrequited effort on their part. You know that, at the men- 
Irual crisis, there is on the surface of the ovary a matured ovule ; 
hhy as I have told you, either becomes deciduous matter, and 
pa>Kse8 away with the menstrual blood, or, if it (should have life 
huDarted to it by the seminal fluid of the male, it lives, becomes 
developed, and constitutes the future being. Indeed, the ovule, at 
this j*pecial |>eriod of its maturity, is not unlike the luscious peach, 
as it hangs in ftdl ripeness and flavor tVom the paretit tree — if there 
be no hand to pluck it in its tempting richness, it falls to the ground 
and decays. 

Woman, then, is most apt to become fecundated at this particular 
time,, when the ovnle, in all its development, lies on the surface of 
the ovary ; therefore, the simple suggestion, on your part, to the 
busband to have intercourse with his wife just before the catamenial 
crisis, will very likely result in impregnation. I am quite confidetil 
(hat I can refer to more than one instance in which I have suc- 
ceeded, in this way, in adding to the happiness of parties, who for 
yeai-s bad been honestly but vainly toiling for the accomplishment 
:>f .their hopes. It h a matter of historical record, that Henry II, 
of France, afler protracted disappointment, and almost desperate 
under baftled hope, consulted the celebrated Fernel as to the nwdua 
in qiio of impregnating his Queen, Catharine de' Medici; the king 
was advised to cohabit with her royal highness only at tb^ m<;iv%lTMial 



108 THE PRINCIPLES AND PRACTlCS OF OBSTETRIGB. 

evolution ; thk counsel was scrupulously observed, and the result 
was the birth of an heir to the crown. 

In India, young girls are made to marry immediately on their 
first menstruation, for the reason, that the doctrine is muntained 
there that, at each catamenial crisis, there is an ovule ready for 
impregnation, and if it be not fecundated, it becomes destroyed^ 
and, therefore, it is held that the party is guilty of child murder.* 
It appears that this has been the law for a very long period in 
India, and, as it is evidently based, in a measure, on the ovular 
theory of menstruation, it is quite manifest that this theory is not 
altogether of recent origin. You perceive, gentlemen, that, in 
discussing the general subject of menstruation, I have said nothing 
of the numerous pathological conditions to which the function, is 
exposed ; these I have treated of fully in my work on the Diseases 
of Women and Children. 

* " It was upon an ancient tlieoiy respecting generation, very much resembling 
oar own, that early marriages seem to h.ivo been instituted in India. It was said, 
that if an unmarried girl has the menstrual secretion in her father's house, he iDCora 
a guilt equal to tlie destruction of the fuetus ; that is, according to the doctrine of 
Pythagoras, and the theory of the ovarists, all the material of the new ovum, and 
the ovum itself is formed by the female : mcDStruation was, therefore, the loss of 
the ovum, or loss of the fuetus." [Dr. Webb, ProC of Militaiy Surgery, in tli« 
OoUege of Medicine, Calcutta.] 



.LECTURE VIII. 

BeprodncUon — Its Importance and Necessity — Early Opinions concerning — Meaning 
of the term Fecundation ; in what it consists — Reproduction the Joint Act of both 
Sexes — ^The Female furnishes the " Germ-cell" — The Ovisac or Graafian Vesicle— 
Membrana Granulosa — Discus Proligerus — Zona Pellucida — Germinal Vesicle — 
G^^rminai Spot — Modifications in the Ovisac previous to its Rupture — Corpus 
Lateum — " Coagulum" does not contribute to its Formation — (Corpus Luteum not a 
Permanent Structure — True and False Corpora Lutea — Former connected with 
Pregnancy, Latter with Menstruation — Characteristics of each — True Corpus 
Luteum an Evidence of Gestation^ but not of Childbirth — Can two " Germ-cells'' be 
contained in one Ovisac? — The Male Vivifies the " Germ-cell" — Spermatozoon, the 
Trae Fertilizing Element — What are the Spermatozoa ? — Contact between *' Sperm- 
cell" and " Germ-cell" necessary for Fecundation— How accomplished — Opinions 
concerning — Aura Seminalis — Electrical and Magnetic Influence — Doctrine of the 
Animalculists — Chemical Hypothesis— Mr. Newport's Experiments on the Frog — 
Deductions — Where does this Contact take Place ? — Experiments of Bischoff and 
Valentin — Theory of Pouchet — Movements of Spermatozoa — Deductions from 
Analogy — Experiments of Nuck and Hjughton — Fimbriated Extremity of Fallo* 
plan Tubes — Peculiarities of d 

Gbntlkmen — ^The subject next in order for our consideration is one ''^ 

which cannot fail to interest you, for it involves the important ^ "^ 
question — the origin and reproduction of the human species. To , Jt 
treat, therefore, of our own individual origin, and the mode by 
which the human family is propagated, is, it cannot be denied, to 
discuss a topic at once full of interest, and not altogether free from 
mystery. It would be somewhat out of place in lectures intended, 
as far as I can make them so, to be essentially practical, to speak of 
generation except so far as it relates to the production and develop- 
ment of the human foetus. It may, however, be observed, that 
'organized beingi can be perpetuated only through reproduction. 
Let the earth be covered, the waters filled, and the universal globe 
crowded with living beings, and yet how soon would life become 
•extinct, and the world a blank, were it not for the constant genera- 
tion of new beings to take the place of those who have run their 
race, and yielded to the inexorable demands of time. Look at the 
bills of mortality ; see what myriads of the human family are swept 
from earth every year by disease, and the natural decay of the 
system — and the same argument applies to all animated creation — 
and then tell me whether this prodigious waste does not require a 
oorrespouding supply. It is with all living things, as it is with the 



110 



THE PRIKCIFLE3 AKD FBACTICE OF OBSTETRICa 



4Siiitence of governments and nations ; both are to be perpetuate 
^lAfough the law of succession. Were it not for this great fact, how 
rapid and final would be the victory of death I 

The subject of roprod action has occupied the attention of m; 
from the very earliest period** of his history; and you will find th; 
in the remotest times of our science, hypothesis followed hypoihei 
in the earnest attempt to elucidate this profound and vexed problei 
If we are sometimes amused at the novel and Einnjular vie 
advanced by the early fathers in their explanation of this fnn^ 
mental vital act, it must be remembered that their theories am 
reasoning were the theories and reasoning of those, who had nothing' 
to guide them but their own obfiervation j they were lost, as ii 
were, in the darkness of the night ; they were without the tor 
lights, which the progress of science has furnished to the men 
modern times, through the development^of physiology, patholog; 
and chemistry. While, therefore, I honor the philosophers uf 
present and proximate ages, for their rich contributions of scien 
and bid them God-speed in their profound researclies, yet I canu" 
but look back upon the early apostles of our profession with fc 
ings of filial reverence. As pioneers, they have accomplish* 
much ; as accurate observers, they have given us many substantial 
principles, 

Meproduction — MeaninQ of the Tb^i, — Reproduction, in i 
strict physiological meaning, implies the development of a being, 
that it may be capable of an external or independent existence 
hence, it consists of a series of processes, which, when comideied, 
constitute the entire reproductive act. The first of these proce 
in the human species, is the contact of the two sexes, known 
copulation. The second process is fecundation, which consists 
the exercise of a vitalizing iuflueuce, through the male, on thi 
germ furnished by the female. This act of vituUs&ation, or Impai 
log life, gives rise to another process, conception. In strict physi 

Hogical truth, it may be said the male fecundates, and the fern 
aneeives. Then follows gestatiun, during which the embryo gro 

Pand becomes developed; and when its development has be' 
sufficiently accomplished, labor occurs, the object of which is 
expel it from the uterus. As soon as this is eifected, the enti 
relations of the new being are changed. It breathes, and, therefon 
has a circulation of its own. It is no longer dependent upon ii 
parent for the elaboration of its blof>d ; its lungs, which, befo 
birth, were without function, commence at once their round 
duty ; the first gasp of the infaut may bo considered its declaratloi 

'of independence. 

Its organic existence is now called into action ; it receives food» 
which, through the operation of its digestion, is converted into 
ohyle ; this latter passes through the thoracic duct into the venout 



lai 

I 




THE PBISCIPLKS AND PRACTICE OF OBSTETRICS. 



Ill 



^tjrsteni, whence, by the ascending: and descending venie cavre^ it is 
conveyed to the right cavities of the heart, and thence to the 
lungs, where, through the elaborative action of the»e organa, it 
becomes decarbonized, or, if you choose, arteriali^ed ; it ihen is 
taken to the left cavities, luid distributed, throu^^h the ram ifi eat ions 
of the aorta, to all portions of the system, imparting nutrition and 
development to every tissue. 

It is a physiological truth, that reproduction is the joint act of 
the two sexes, and it now remains for me to show you what science 
has disclosed as to the respective [jarts asaumer], in this woiiderM 
floheme, by the male and female. It would not be protitable to 

' array before you the numerous and coui3icting theories, which have 
"been maintained with more or less zeal on this subject; I prefer 
rather to present to you what I Vjelieve, at the present day, to be 
the accepted and recognised facts touching this interesting topic. 

The GemKelL — ^The female, in the act of reproduction, furnishes 
the ovule, or *' germ-cell," which, as you have already been informed, 
is a product of the ovary. Tiiis ovule hits no inherent j)ower 
of development beyond its mere growth as an ovule ; ami, as I 
have remarked to you, aiXer it has reached its maturity, if it be not 
vitalized by the male, it perishes and passes off with the menstrual 
Wood. The human ovum, like that in all vertebrated aninials, is 
contained witliin a sac, which, externally, is in appomtion with the 
substance or stroma of the ovary ; this sac, through courtesy to its 
discoverer is known, in mammals, as the Graafiian vesicle or ovisac. 
Its internal surface is supplied with a number of nucleated epithe- 
lial cells, constituting the membrana granulosa; th»4se cells 
hkewise furnish a disk-like coveriug to the ovum — the discus pro- 
Hgerous. The Gmaffian vesicle contains a quantity of fluid, and, in 
its centre, is observed the ovule. This latter, in the human subject, 
is extremely small, measuring not more than jj^th of an inch in 
diameter, and sometimes much less ; it has an external membrane, 
which, from its transparent character, is called the zona pelkicida, 
inclofiing the yolk or vitellus, the object of which is to furnish 
nourishment to the germ during the earlier stages of its develop- 
^inenL In the centre of the vitellus is the germinal vesicle, which 

iifegarded as the essential portion of the ovum; the nucleus of 
lll^ germinal vesicle is denominated tlie germinal spot. Although 
the ovum is at first in the centre of the Graaffiau vesicle, yet, in 
proportion as the contents of the vesicle approach maturity, the 
tendency of the ovum is to move toward the circumference of the 
ovisac, so that, jnst prior to its extrusion, it is quite near the surface 
of the ovary ; the advance of the ovum toward the outer portion 
of the ovary is one of the ordinary processes preparatory to its 
fecundation, and is supposed by Valentin to be due to the fact that, 
ifl the ovule progresses in development, there is elfused in tha 



112 



THE PRINCIPLES AND PRACTICE OF OBSTOTRIO, 



lower portion of the ovisac a fluid, which presses the discus 
proligeros K^fore it agaioat the opposite wall 

The Graaffian vesicle or ovisac, is said to be conipoacd of two 
envelopes or layers, and it is proper that you should have a dear 
appreciation of its structure. lu reality, the ovisac presents but a 
single vnscuhir tunic formed of lamiuouji ceUs, and of those so- 
called cdls of (he ovisac^ irregular and grainy. This ttinic in 
covered by a nucleated epithelium, and is immediately surrounded 
by the stroma of the ovary. You have been told that the ovule, 
when it has attained its maturity, escapes through rupture of the 
ovisac. But, previous to this rupture, it is interesting to noto the 
changes which occur in the ovisac itself; for example, there is a 
general increase in its vascularity and ati appearance of fatty celUi 
with an increased development of those of the ovisac, exhibiting 
a yellowish color, intended for the production of the corpus luteum, 
which is rcgardod by somd phy*!iiologists as a mere hypertrophy of 
the niembrana granulosa, or internal coat of the ovisac. When the 
ovum Ciicapes from the ovisac, the internal surface of the latter pr^ 
sents at iirst a sort of irregular ciivity, from the fact that ita 
epithelial liiiing is thrown into folds or wrinkles, the direct result of 
the contraction of the ovisac ; this cavity, however, soon begins to 
lessen in consequence, in the first place, of the increased develop- 
ment of the granular cells ; and, secondly, from the oontrat^tioti of 
the ovisac itself. Ultimately, the cavity is almost entirely obli- 
terated, and is represented by what has been described as the 
Btellate cicatrix. When the rupture of the ovisac is acoomplished, 
there is an effusion of blood in the remaining cavity, forming, of 
course, a coagulum; this sometimes becomes deprived of its color* 
ing mattt?r, and is absijrbod, assuming the attributes of a fibrinous 
clot ; at other times, the fibrine is absorbed at once, the red cor- 
puscles become grainy, and dis;ippear slowly; the clct maintaining 
its reddish color which is due to the hematoidine. 

77te Corpus Lydmm of PrcQnancy and of Menstruation, — ^Tho 
corpus luteum was at one time supposed, when recognised on the 
ovary, to be a positive indication of previous gestation, and the 
nundieroi these bodies represented the precise numl>er of child ro^ 
borne by the parent. This opinion, however, recent researches have 
ehcv^-n to be fallacious. In the first place, the error was no doubtf 
in part, owing to the circumstance that the corpus luteum was 
regarded as a permanent structure; and, secondly, that ita color was 
looked upon as its exclusiive characteristic. It has been very satia- 
fnctorily dcntonstrated that neither of these a^uroptions is coiTCct, 
for small yellow spots may exist on the ovary independently of im- 
pregnation ; while the corpus luteum itself which is the direct r^ult 
of gestation, disappears after a certain period, an d^ therefore, is not 
pemuuiefit. You must also bear in mind, that whenever there ia a 



THK PBnrCIFLES AND PRACTICE OF OBSTETRICS. 118 

mptare of the Graaffian vesicle, no matter from what cause, there 
wffl necessarily be, as the product of that rupture, a corpus lutcum. 

You have been reminded that, as a general rule, there is an escape 
of the ovule at each menstrual crisis; hence, there are two classes 
of corpora lutea, one the result of menstruation, the other of 
impregnation ; and, therefore, the division of these bodies into false 
and true— the former representing the corpus luteum of menstrua- 
tion, the latter that of gestation. This is an important distinction 
for the reason that, in more than one instance, the previous exist- 
enoe of pregnancy has been attempted to be proved by the recogni- 
tion, in a post-mortem examination, of these bodies on the ovary, 
their mere presence constituting the oi*ly basis for such an opinion. • 
It mast, therefore, be manifest, how essential it is to have a just 
idea of the characteristics of the true corpus luteum, and understand 
in what way it is to be distinguished from the one which is simply 
the offspring of menstruation. 

I need not tell you that upon this — as on many other questions 
of science — there is a difference of sentiment among writers, but I 
believe there is a sufficient concurrence, as to the general points of 
distinction, to afford reliable data for opinion.* Prof. J. C. Dalton, 
in an elaborate paper, gives the following summary as the result of 
his investigations on this subject : " The corpus luteum of pregnancy 
arrives more slowly at its maximum development, and afterward 
remains for a long lime as a noticeable tumor, instead of undergoing 
rapid atrophy. It retains a globular or only slightly flattened 
form, and gives to the touch a sense of resistance and solidity. It 
has a more advanced organization than the other kind, and its con- 
voluted wall is much thicker. Its color is not of so decided a yel- 
low, but of a more dusky hue, and if the period of pregnancy is at 
all advanced, it is not found, like the other, in company with 
unruptured vesicles in active process of development."! 

It is now, I believe, generally conceded that the corpus luteum, 
unconnected with pregnancy, and simply the product of mcnstrua- 

• After a careful review of the subject, the following conclusions have been 

«uced as being most likely to enable the observer to arrive at a just opinion : 
A corpus luteum, in its earliest stage (that is, a large vesicle filled with coagu- 
d bk>od, having a ruptured orifice, and a thin layer of yellow matter in its walls), 
affords no proof of impregnation having taken place ; 2. From the presence of a cor- 
pus luteum, the opening of which is closed, a»d the cavity reduced or obliterated, 
only a stellate cicatrix remaining, also no conclusion as to pregnancy having existed, 
or fecuudation having occurred, can be drawn, if the corpus luteum be of small size, 
not containing as much yellow substance aa would form a mass the size of a small 
pea; 3. A similar corpus luteum, of larger size than a common pea, would b(i strong 
preemptive eridence, not only of impregnation having taken place, but of pregnancy 
having existed during several weeks at least : and the evidence would approximate 
more and more to complete proof, in proportion as the size of the corpus luteum was 
greater." [Baly's Supplement to Milller's Physiology, page 57.] 
f Transactions of the American Med. Association for 1851. 



Ill 



THE PttlNCIPLES AND PRACTICE OF OBSTKTRICS, 



tion, is pelilom of greater volume than a small pea, while, iisuiiny, 
h is even less tlmji thi*^ ; from six to eight weeks H undergoes ^ikch 
rapi*l and positive diminution as to represent only a very small 
point on the surikee of the ovary; hence this latter will ordinarily 
i'Xhihit false corpora lutea, in greater or !e«s number, in Homeii 
who have their menstrual periods with Tecrularity. 

Tl»u corpus luteuni of pregnancy k cliaraeterixed by great vascu* 
larity, and this, no doubt, is explained by the fact that, at the tintie 
of fecundation, the uterine organs become the centre of an extra- 
ordinary aftiux of hlood, tar greater than during an ordinary nien- 
Ptrufil crisis. The size, too, of this corpus latenm is worthy of atten- 
' tion, as fonstituting a broad distinction liet ween it and the one 
which is TO e rely the result of menstruation. As a general rale, it 
will occupy from one-fourth to one-half the surface of the ovary, 
depending upon the particular period of gestation at which it may 
be inspected* It is usu:dly larger during the earlier montli^ gay 
till the third to the fouiih ; its volume, however, will vary, occa- 
sionally, even at given periodi* of gestation, in different hidividaals. 
As the completion of pregnancy approaches, the corpus tuteutn 
begins to decline in size, anrl undergoes a very marked alteration — ^its 
Tascularity rapidly diminishes, and its color becomes much lighter j 
alYer parturition, whether at the full tenn, or as the consequence 
t>f premature action of the uterus, this body begins to fall into a 
state of atrophy, atid so conj|detely loses its eh ai-act eristic* as to 
tTndur its recogijition next to imjiossible. It is admitted tliat two 
-or three months after delivery it completely disappears fix>m this 
ovary ; and it is now well agreed that a corpus luteum of a previotis 
conception (provided the ge?;tation arrive at the full term) is never 
■ft>imd to coexist with that of a subsequent leeundation. Atler the 
disappearance of the corpus luteum, its original site is usually noted 
by a small cicatrix, or line; and it is important to recollect that 
the^e cicatrices, like the corpora lutca themselves, are not perma* 
iient, but become, in the jirogress of time, more or less effaced. 

Au exceedingly interesting c|yestion now arises in reference to 
the presience of the true corpus luteum on the ovary, and it is well 
worthy of a moment^s thought. Is this corpus luteum ahvay^^^ 
'evidence of previous duldliirth, or is it only au evidence of previous 
impregnation ? That it is not an invariable proof that the female 
has borne a child, is demonstrated by the fact that there are well- 
Jiiithenticiitcd instinu'cs in which the coipus luteum of gestation has 
been recognised without previous parturition ; but, on a critical 
investigation, it bas been shown, in all these instances, that abortion 
bad occurred; so that the existence of the corpus luteum, althongh 
not an evidence of childbirth, must be regarded as a proof that 
fecundation had taken place. A multitude of influences may ope- 
rate to destroy the germ, after it has been fecundated, and C4iusc it 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 116 

to undergo such marked degeneration as to prevent its recognition. 
Therefore, it may be, in such instances, that the presence of the 
corpus luteum will afford the only evidence of the conception. 
Again : Is it possible for a woman to bring forth twins, and have 
only one corpus luteum ? The reply to this question is, that there 
are recorded examples of two ovules being contained in one ovisac, 
and, consequently, in such case, there would be but one corpus 
luteum.* It is quite remarkable that those clever observers, Todd 
and Bowman, in their late work on physiological anatomy, should 
hold the following language, which is certainly in direct conflict 
with well-observed facts : " In cases of twins, two corpora lutea are 
always present."f As regards the existence of the Xtj^ corpus 
luteum, and what it proves, it may, I think, be safely affirmed that 
the researches of modern science have demonstrated the truth of 
the aphorism long since put forth by that accurate observer, Haller 
— '* NuUus unquiim conceptus est absque corpore luteoy 

The Sperm-ceil. — While, as it has been stated, it is the office of 
the female to provide the ovule, it is the province of the male to 
impart to it life, so that it may attain, through successive develop- 
ment, its fcDtal maturity. But what is this vitalizing element ? The 
testes are, to the male, what the ovaries are to the female. They 
are glands which constitute the essential organs of generation — 
they secrete, after the period of puberty, a seminal fluid which, 
according to the experiments of Prevost and Dumas, consists of 
elements obtained from three sources: 1. The fluid which comes 
directly from the testicles; 2. The fluid which is secreted by the 
prostate gland; and, 3. That which is derived from the vesiculaB 
seminales. The two latter elements are, as it were, but mere vehi- 
cles for the seminal fluid of the testicles. This latter contains sper- 
matozoa, which constitute the real fecundating element ; they are 
small filamentous bodies, which enjoy the power of spontaneous 
motion, and hence they are regarded by some clever writers as 
veritable animalcula. It seems, however, to be shown that they 
are not animalcula, but partake of the character of the reproductive * 
portions of plants, which also possess a spontaneous movement as 

«n as they have been thrown from the parent mass ; and it is like- 
e conceded that the ciliated epithelia of mucous membrane will 
continue for some time in movement after their separation from the 
body. Among those who maintain that the spermatozoa partake 
of the character of animalcula may be mentioned Monro, Haller, 
Spallanzani, Valentin, Pouchct, and others ; while Coste, Charles 
Robin, and other observers believe the contrary. 

In man there are developed within the tubuli of the testicles 

* An interesting example of this kind is cited by Dr. Montgomery, in the seooiMl 
•ditioQ of his work, p. 375. 
t Page 861. 



116 



THK PRINCIPLES AKD PRACTICE OF OBSTETRICS. 



wlmt lire known as the spennfitic cell"j, withb each of whicli in a 
VOJ^iele of evolution,* aa it has been termed, an<l hi each vesicle 
thenj is a spermatosGoon. It is quite obvious that the sper- 
matozoon, tlie duty of which is so important, cannot boo^t of 
much magnitude — in tlie human bian!^ it fonslsts of u small, oval- 
»hny»od body, measurinjj, in Irriirtli, from jj^th to j^^th of a lino; its 
tJiil, termhmiing in a very ddi<*ate point, is from ^*jth to j^th of a 
line. Its power of moveiricnt, it appears, in chiefly thiough the 
ttn(lu1atlou8 of the tail. M, Godardf hm recently discovered in 
man a new sperieH of spermatozoon, with a very small head, and 
tlic tail is enduwi'd with much mure rapid and durable I^lovellR'nt^ 
than th^tail of the common and well-known spermatozoon. Tl»e 
esf?entia! fact to be recollected h, that the spermatoxoon represents 
the true fertilizln!;' element, and possesses the exclusive power of 
imparting life to ihe ovnie of the female. It luis been shown by 
Donne that the spermatozoa are deprived of all power of motion 
tinder peculiar conditions of the vaji^^inal and uterine seeretions — for 
in§tance, when there \s a morbid acidity of the vat^inal mucu», or an 
excessive alkalim' secretion from the uterus. Tins inability to move 
is, of course, tantamount to the destruction of the fecundating 
attribute now ao generally ceded to the spermatoxoon. Therefore, 
the practical fact is to be deduced that these morbid secretions of 
the uterus and vatrina may sometimes, throuirh their influence on 
the spermatozoa, be the cause of steiility* Wapier lias not found 
Bpcnnatozoa in the mule ; and it is well known that most hybrids 
do not produce otFsprin!^, Indeed, it was formerly suppoj^ed that 
ail hybrids failed in the fecundatinii: power. It has very lately 
bee!i shown, however, that there are «fune exceptions to this rule^ 
ThfiorittH of Ft'cundation. — It is curious to note the various and 
diseorilant theories, which have been advanced from time to lime 
in explanation of the true modus in quo of fecundation. For 
exam|>le, it was once iu>agincd that there passed from the Beminal 
fluid of the male a vapor — an aura seniinalis — and that it waa 
through the agency of this latter that life was imparted to the 
ovule; and, again, it was maintained that the fluid, after being 
deposited in the vagina, was absorbed, and reachetl the (>^b 
through the circulation. Electrical and magnetic influence^ have 
aUo been invoked to demonstrate the profound problem of viriflca> 
tlon. The animalculists, too, contended that each drop of the 
male sperm contained myriads of living germs already formed, and 
that, dunng coition, they are thrown into the uterus, and ull of 



" Wlitle Id RiAn there is but one ve«lcte aX evolutbn in each spennftlic ooll, in 
onimnls there ore several. 

f Etudea aur la Monopcliidle, etc. 1857. pp. T3, 74. 

% Memoiro sur THybn'dU^ en gcutrnl, etc. fij FxtL Broca. Jcnirno] de k 
Phytiiologio de THomme ct des Animaux. p. AM. 




THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 117 

them, with the exception of one, die ; the one which is fortunate 
enough to escape destruction passes through the fallopian tuhes to 
the ovary, and penetrates a small vesicle which has heen prepared 
for its reception — it then is brought back through the tube to the 
uterus, where it remains until its full development has been com- 
pleted. 

This doctrine of the animalculists is indeed fearful for the con- 
templation of the philanthropist — it implies a slaughter of human 
beings unexampled in the pages of history. There is nothing in 
the carnage of the battle-fields of ancient or modern warfare, 
which can approach this melancholy sacrifice of human life. With 
this hypothesis, the reproduction of one's species is no • trifling 
matter — conscience, in my opinion, must become veritably seared 
before engaging in any such enterprise ! 

On the supposition that the s|)ermatic fluid, like the blood, is 
chemically so constituted that constant motion is absolutely neces- 
sary for the maintenance of its fecundating properties, Valentin, 
Bischoff, and others, have advanced the hypothesis that the only 
object of the spermatozoa is, through their active movements, to 
preserve the chemical composition of the fecundating liquor. 

Carpenter, and other physiologists, are of opinion that Mr. New- 
port's* recent observations render it very probable that the contact 
between the ovule and spermatozoon causes the latter to undergo 
solution ; and that the essential act of fecundation consists in the 
passing of the product of this solution into the interior of the 
ovule, thus blending, as in plants, the contents of the " sperm-cell" 
with those of the " germ-cell." Indeed, it seems now conceded by 
the very best observers, that it is not simply contact between the 
"germ-cell" and "sperm-cell," but that actual penetration takes 
place at the time of fecundation. Among others, in confirmation 
of this view, I may cite the names of Martin Barry, Meissner, 
Kohen, and even Bischofl*, who for a long time had doubted the 
fact — all these have absolutely seen the spermatozoa penetrating the 
ovum. 

Seat of Contact betioeen the Germ and Sperm Cells. — In what 
pl^icular portion of the uterine organs does this contact between 
the " sperm-cell" and " germ-cell" take place ? Is it in the uterus, 
£illopian tube, or ovary ? There has existed, and there still con- 
tinues to exist, much difference of opinion upon this subject. The 
early fathers maintained that the uterus itself was the seat of this 

♦ In his experiments testing the mode of impregnation in the frog, Mr. Newport 
has shown that the spermatozoa become imbedded in the gelatinous envelope of the 
ovule in a few seconds after contact has been accomplished ; thence they penetrate 
the vitelline membrane, and pass to the interior of the ovule. These experiments 
of Mr. Newport have been fully confirmed by Bischoffl — [Philos. Trnnsac. 1863 
pp. 226, 281.J 



118 



THE PKINC1PLE3 AND PRACTICE OF 



contact — and, no matter how diiserepant their theories regarding 
other points touching the question uf reproduction, yet there 
appears to have been a very general assent to the fact — that the 
uierus constituted the special seat in which vivification was accom- 
plished. At the present day, however, some of the cleverest 
physiologists beheve that the " germ-cell" is vivified by the ** sperm- 
cell" very generally in the ovary ; and this opinion, it seems to me, 
is founded upon acceptable, if not irresistible, evidence, Biijchoff, 
Coste, Wagner, Barry, Valentin, and others, have positively reeog- 
liised spermatozoa on the ovary of animals killed soon after copvila- 
tion. The following passage from Bischoff is to tlie point : ** I 
had frequently observed spermatozoa in motion in the vaijina, 
womb, and fallopian tubes of bitches ; but, on the 22d of June, 
1858, it was tny good luck to perceive one on the ovary itself of a 
young bitch in lieat for the Urst time ; she was covered on the 2l8t, 
at seven o'clock, p.m., and again on the following afternoon at two 
o'clock ; at the expiration of lialf an hour, that is, twenty hours 
after the tii'st copulatitin, I killed her, and found several living 
spermatozoa, endowed with very active motion, not only in iho 
vagina, nterun, arnl tubes, but even amid the fringes of the latter, 
in the peritoneal pouch which surrounds the ovary, and on the 
surface of the ovary iticlt?' Valentin spenks as follows ; "" On 
ojjening the body of a female mammal, one or more days afler It 
has received the male, semen may be found, not only In the body 
and horns of the uterus, but also in the oviduets, and on the Mir- 
face of the ovary." 

Here, then, we have more than mere hypothesis ; we have posi- 
tive afhrraalion ; an(i this same cliaractcr of testimony could W 
much increased by other observers, but I do not deem it necessary 
to make further quotations. If, together with the essential fact that 
living spennatozoa have been seen, soon afler copulation, on the 
surface of the ovary, it be recollected that the existence of ovarian 
and ventral pregnancy has been satisfactorily demonstrated, it docs 
appear to me that it follows, almost as a necessary conseqiienee, 
that the seat of contact between the two germs is in the oms^tv. 
Nature rarely runs vagrant ; while she is abundant in her pro- 
Tisions for the wants of the system, yet she always exercises a 
-wholesome jurisdiction ; super tlnlty is not one of her faults ; on 
the contrary, in all her operations she is charactenzed by a prudent 
and conservative economy. Why, tlien, should living 8permat<»xoa 
be found on the ovary, soon after coition, if it be not in accordance 
with nature^s design ? Will it be said that this is a mere coinci- 
dence, nn exception to the general rule, as Pouehet has endeavored 
to show? This latter writer, I think, has signally failed in his 
theory upon the suV^jeet, He advances as an argument why the 
ovary cannot be the point of contact between the germs, that the 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 119 

peristaltic movement of the fallopian tabe is from within oatward, 
and that, on this account, it cannot convey the semen of the male 
from the womb to the ovary. It does not appear to me that there 
is much force in this reasoning, so far as the question at issue is 
concerned, for, admitting the truth of the direction of tlie peri- 
staltic movement of the tube, it does not, in my judgment, in any 
way invalidate the opinion that the fertilizing element of the semen 
reaches the ovary, and there vivifies the " germ-cell." You have 
been told that the spermatozoa enjoy a power of movement, and 
it is now ascertained that their progress is equal to one inch in 
thirteen minutes, I believe, therefore, that they find their way to 
the ovary in virtue of their own movement ; as soon as they 
are thrown from the male into the vagina they commence their 
jonmey. 

The experiments of Nuck and Haighton are quite conclusive as 
to the ovary being the seat of contact between the germs. You 
will remember that, in ])lacing a ligature, soon aflcr copulation, 
around the fallopian tube, and some time aflerward killing the 
animal, Nuck found that fecundation had occurred, and that the 
development of the ovum was going on in the ovarian extremity 
of the tube. Haighton, on tying the tube in rabbits, ascertained 
that fecundation did not take place on that side in which the 
ligature had been aj)plied. Indeed, the most recent observers seem 
generally to agree that the ovary is the place of meeting of the 
two germs. Montgomery says, "After the best consideration I 
could give to it, it is the conclusion arrived at in my mind." In 
connexion with this point, it may be stated that Coste has recently 
started a new theory in explanation of why the ovary must neces- 
sarily be the place of union between the sperm and ^erm cells. 
He says, the ovule, as soon as it passes from the Graaffian vesicle, 
undergoes alterations, which render it totally unfit for fecundation. 
In conclusion, I think it may be affirmed, without denying the 
occasional meeting of the germs in the uterus and fallopian tubes, 
that the union is most generally accomplished in the ovary. 

Hoxo does the Fecundated Ovule find Admission into the FaUo- 
pian TuMf — This question has generated numerous hypotheses ; 
but none of them are without objection. It has generally been 
supposed that the fimbriated extremity of the tube is made to 
grasp the surface of the ovary, through the contraction of its 
muscular fibres ; it is very evident, however, as Rouget has 
remarked, that it is the action of the longitudinal fibres only which 
could in any way afiTect the position of the free extremity of the 
tube ; but the immediate result of the contraction of these fibre? 
would be a diminution in the length of the tube ; consequently, 
instead of approximating its extremity to the ovary, the necessary 
tendency would be to place it more remote from that body. He^ 



120 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 

therefore, repudiates this explanation, and r«;fers the contact of tbe 
firobriitcd extremity of the tube with the ovary, at the time of 
ovulation, to the combined contraction of what he terms the 
ovarian-tubal muscular fasciculi. It is a veritable spasmodic con- 
traction of tins muscular apparatus, which consummates the contact. 

But the question anses as to the special influence, which origi- 
nates this muscular contraction, or, in other words, what is it that 
throws these fibres into action ? When the Graafiian vesicle has 
attained its development, and is matured, the distension of the 
muscular fibres proper to the stroma of the ovary begets a reflex 
movement, which is immediately transmitted to the tubo-ovarian 
muscular system. This latter contracts, and this brings the 
extremity of the tube in close contact with the ovary. The ovale 
is detached, and then conveyed through the vermicular movement 
of the tube itself to the uterus, where it remains sufficiently deve- 
loped to prepare it for an independent or external existence. 
Precisely the same thing takes place in menstruation ; so that 
whether the ovule be fecundated or not, it drops, as it were, from 
the ovary, and is received into the tube to be conveyerl in the 
latter case to the uterus, and pass off as a deciduous body with 
the catamenial discharge. The approximation of the tube to the 
ovary, at the menstrual period, is explaine<l upon the same principle 
as when fecundation occurs.* 

I have now, gentlemen, given you, very briefly, what may, I 
think, be considered the accepted facts of science touching this 
interesting question of reproduction in the human species. In the 
discussion of the subject, I might have entered into many import- 
ant details, elucidating propagation in the vegetable and animal 
kingdoms ; but, as I have already remarked, such details would 
not be in keeping with the practical tendency of these lectures. 

♦ In certain cases of local peritonitis, it will sometimes happen that, as the resoll 
of tho inHammation, there will bo an adhesion of the timbriated extremity of the 
tube so remote from tho ovary as to prevent contact at the time of ovulutton. Thin^ 
of course, would result in sterility, or in extra-utcrlDe foetiiiion. 



LECTURE IX. 

PregnaDOf ; Definition and Divisions of— Is Pregnnncy a Pathological Ck)ndition?-« 
The Uterus and Annezse before and after Fecundation— Two Orders of Pheno- 
mena following Impregnation ; Physiological and Mechanical — How tlio Uterus 
Enlarges — Microscope and its Prools — Development of the Muscular Tissue of the 
Uterus; how accomplished — Solid Bulk of Uterus at Full Term— Meckel's Esti- 
mate—Increase of Blood-vessels, Lymphatics, Nerves, and other Tissues of Uterus 
— Nausea and Vomiting; how produced— Influence of Nausea and Vomiting on 
Healthy Gestation ; the Explanation of this Influence — Blood — how Modified by 
Pregnancy — Is Plethora characteristic of Gestation? — Cause of this Hypothesis — 
Treatment of Acute Diseases in Pregnancy — Aphorism of Hippocratos on this 
Question — Increase of Fibrin in Inflammation — Deductions — " Biiffy Coat" not 
always the Product of Inflammatory Action — " Bufly Coat " in Clilorosis, Preg- 
nancy, etc. — EJestine; what its Presence indicates — Blot's Experiments — Sugar 
in the Urine of the Puerperal Woman — Deductions — How are we to know that 
Pregnancy exists? Importance of the Question; its Medico-legal bearings; Illus- 
tration—The Proof of Pregnancy altogether a Question of Evidence ; how this 
Evidence should be examined. 

Gentlemen — ^We shall speak to-day of the important subject of 
pregnancy ; in all its bearings it is fnll of interest, and whether in 
its normal, pathological, or legal relations, claims the profound 
thought of the practitioner. Pregnancy may be defined to be that 
condition of the female, which exists from the moment of foeiinda- 
tion until the exit of the child from the maternal organs. It is 
divided into ti^ue^ falae^ uterhiey extra-uterine^ and interstitial. In 
true pregnancy, there is really a foetus ; in false, the enlargement is 
dependent upon something other than a foetus ; when the product 
of conception is situated within the uterus, the gestation is called 
uterine ; when, on the contrary, the foetus is lodged externally to this 
organ, it is known as extra-uterine, of which there are three vari- 
eties, viz. abdominal, fallopian or tubal, and ovarian. In the first 
of these varieties, the embryo, under a rule of exception, does not 
reach the uterus, and becomes developed in some portion of the 
abdominal cavity ; in the second, in the fallopian tube ; and in the 
third, it receives its growth in the ovary. We shall hereafter have 
occasion to describe more particularly each of these varieties. 

There is another form of gestation in which, strictly speaking, 
the fa»tus is developed neitlier withiii nor without the uterine 
cavity ; and you may well ask — IIow is this ? It is called inter- 
stitial pregnancy, for the reason that the foetus does not re^l uudoi 



122 



THE PRIKCIFLES AND PRACmCE OP OBSTETRICS. 



cither the poritoneal or raucous coverings of the uterus, but 
found amid the meahes of muscular 6bros of the orgau, and hence 
ths propriety of its name — inttrHitial, There have been many 
attempted explannliona of the manniT in which the fceundate^ 
ovurti finds its way iiilo this intermediate f«tructure, but none of 
them are satisfactory, for they do not seem to be founded on cor- 
r«jct data,* The cardinal fact, however, that interstitial pregiinuey 
does sometimes exist, cannot be denied, for it has been m^og- 
nised by several trustworthy observers. 

In addition to the varieties already enumerated, pregnancy is 
divided into shnple^ compound, and complivated. In the tinst, 
there is but one fcutus ; in the second, there are two or more; 
while in the third variety, besides a foetus, the gestation may bo 
complicated with an abnormal growth, such as a polypus, tibrous 
tumor, or ovarian enUirgenient. 

Pre^j^natict/ not a Pathohgical Condition, — ^There htis beon a^ 
difference of opinion as to the true nature of pregnancy, so far as 
the general laws of the economy are concerned ; and contlieling 
views have been advanced as to whether it is or is not a patholo- 
gical condition. There ciin be no doubt that the general syj^tem, 
as the direct consequence of impregnation, undergoes numerous \ 
moditi eat ions ; and it is entitled to eonsi deration whether, ;ts a 
general rule, these modilicationa should be regarded as evidences 
of morbid action, or whether, on the contrary, they should not be 
aijcepted a;* testimony that nature is engaged in the attainment of 
an object, which she cannot accomplish except Uirough the opora- 
tion of certain changes, which, although not morbid, will neced- 
Haril)' encroach more or less on that integrity of function, or, if you 
prefer it, e*piillhrium of forces, which, in the un impregnated femolei 
la looked upon as the standard of heahh. It does seem to me 
that this question has been somewhat misapprehended by certain 
writers, and tliey have mistaken natural processes fur pathological 
phenomena ; they have regarded the workings of nature, under 
jx^culiar circumstances, as the manifestations of morbid influence; 
and hence, in their judgment, the important and interesting period 
of gestation is a period of diseased action. Even without invok- 
ing the aids of science, common sense, it seems to me, runs directly 
court ter to such an hypothesis. 

The destiny of wcunan would, indeed, be one of bitter anguish, 
if, in achiiiion to her other schtows, it were decreed that, wliile 
engaged in the great act of the reproductiun of lier species, ahd 

* Ono uathor, BreselK< snys, that if ony obstacle slioiiM oppo«9 Iho ovum iti ita 
entrntiec into the uteruss ii might ghde int^i iMmiu one (if i\m VL'iuma 9ifiiiae», which, 
be mHUiiiiiits, art^ found to ii|>t>u at the ori^n of tiie lallopiiiii lubes. The exisietio^ 
of three «iiiitMe» \\n% iieviT U?t«ti (ieuionairated, otid it ia now admitted Ujii& Ibif 

ameul atmiuriiiM wu.s in Liror 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 128 

sbonld necessarily be subject to the inconveniences and perils of 
disease. So far, then, from regarding gestation as a pathological 
state, we maintain that, as a general principle, it is entitled to be 
denominated a period of increased health. I am speaking now of 
the general rule, and not of the exceptions, to which we shall here- 
after have occasion to direct your attention. Indeed, some of the 
very best observers have declared — and the fact is well established 
by statistical data — that the probability of prolonged life is 
increased as soon as pregnancy occurs. Let us now take the con- 
verse of this proposition, and you will see, in its results, an addi- 
tional proof that gestation is not in truth a diseased condition ; 
look, for example, at those females who, either from choice or 
necessity, lead a life of celibacy, and see how much greater is the 
record of their mortality. Marriage* and pregnancy, therefore — 
however true religion and an earnest love for God may fill the 
cloister by devoted and self sacrificing ladies — should be regarded 
as among the covenants of nature, and the demonstration is found 
in the fact of the better health and greater longevity of those who 
keep these covenants inviolate. 

Pregnancy, although not a condition of disease, is one of excite- 
ment, in which the entire economy more or less participates ; and 
to show you how emphatically and promptly the system responds 

♦ It is worthy of remark that marriage is conducive to health and longevity, with 
certain qualifications. Some interesting facts have recently been presented by Dr. 
William Farr upon this subject, based upon statistics derived from the population of 
France ; these statistics receive additional importance from the circumstance that the 
returns extend over the whole of France, and include all grades of its population- 
According to the census of 1851, with a vidvv of showing the influence of the conju- 
gal relation, the population is divided into three classes: 

1. The married: 6,986,223 husbands; 6,948,823 wives = 13,936,046 married 
personal 

2. The celibates, or those who have never married: bachelors, 4,014,105; spin- 
sters, 4,449,944 = 8,464,049. 

3. The widowed : widowers, 835,509 ; widows, 1,687,583 = 2,523,092. 

It appears that, in France, marriage is legal for mules at 18, for females at 15; 
and it is shown that the mortality among the married women under 20 years was 
double that among the unmarried ; while the mortality among the married men at 
this youthful age was greatly in excess of that of the unmarried. The rate of deaths 
in the married women was 14.0 in 1000, and among the maidens it was only 8.0. 
In the married men it was 29.0 in 1000; in the unmarried 7.0. These facts carry 
with them their own comment, and should serve to admonish parents against the 
early marriage of their children, before the physical system is sufficiently developed 
to sustain the requirements of that state. From the ages of 25 to 30, the mortality 
of the unmarried is slightly in excess, being 9.2 to 9.0. From 30 to 40 the deaths 
among the wives were 9.1, and among spinsters, 10.3. After 40 years of age, the 
rate of mortality is still more in fiivor of the married in women, being, from 40 to 50, 
10.0, while in the unmarried it is 13.8. From 50 to 60, married, 16.3 ; unmarried 
28.5; and above 60, married, 35.4 ; unmarried, 49.8. 

It would seem, therefore, that, all things being equal, matrimony tends to the pro- 
motion of health and longevity. 



124 



THE PRIXCIPLES AND PRACTICE OF OBSTETKICS. 



to the changes induced by iriiprcgDation, it may V)c mentionetl tliat 
ol\entirae?*, with the quicknes-'^ of thought, const itutioinil #»ympa- 
thics, more or leas marked, supervene on the act of fceundatldn ; 
it is orjly necessary to understand why this is 60» in order t!i:it you 
may appreciate, and, at the same lime, see in these Bympathies an 
evidence, not of a pathological state, but an evidence that a new 
link has been added to the cbain of phenomena which nature 
recoguisos as rightly belongbg to her. 

It is interesting to note the considerate kindness with wliich 
the pregnant female was treated in ancient times. Indeed, she 
lK>camc the object of 8]>ecial attention and regard. Among the 
Jews she was, during the period of her gestation, permitted to 
partake of whatever ineaia she desired, no matter how strongly 
prohiliited by the Mosiiio cornmamJments at any other time* It 
was a recognised custDin, too, among the Athenians to absolve 
firotn punishment the murderer, whose hands %verc yet wet with the 
blood of his victim, if he atMiJit ^Ijelter in the houi^e of a womaa 
carrying her child* 

C^ui/if/es in the l/ferus thtring Pregnancy. — The uterus and its 

I annexie in the unim|iregnated female are, excejtt at the menstrual 
0riod% ill a state of quietude, and have but little participation in 

[the aftairs of the eeonomy, liut us tjoon ;ls feeundaliou has been 
eousummaled, and even before tlu* viviHed ovule reaches the wondj, 

[this organ is summoned upon active and continued duty, involving 
changes in its local comlition, which immediately awaken constitu- 
tional excitement, and IcekI directly to increased vital action.* The 
uterus now becomes u new centre; from a comparatively inert, 
poBsive organ it is sudderdy converted into one of the highest 
grade of activity — new duties now devolve upon It — it is no longer 
in a state of rest — it is converted into a domicile for the accommo* 
dal ion of the embryo ; but as this latter requires for its develop- 
ment something m<>re thiiu a place of temporary sojourn, and as, 
like all living beings, it can only grow by being nourishe<i, there is 
an afliux of fluids directed toward the uterus, freighted with ele- 
ments necessary for the nourishment of the germ. These duties 

^and changes incident to the organ, neeeasarily impart, to it increased 
structure and volume; and in pnjportion as these changes take 
place, two ordei-sof phenomena ensue — L Physioh)gical ; 2. Mecha- 
nical, The former class appertains to the transmission of influences 

[to the various potlions of the economy through the ganglionic 

r system of nerves ; the latter has special reference to the pressure 
and consequent disturbance exorcised by the developing uterus od 

• Unr?^y \im coin pared tlio suddoQ change otx:urr»ng in the uterus iVom itiiprog- 
nation to the lip of n cliihi mung by a bee, ** nempc ut pueronim Ubiu (<iiim iavoa 
depeeulnnlur, ut melhi li^uriniit) apum, spiculia icta, tumetit, tuflaramaQtur orlaqu^ 
llialtun JifCtiiDt," {Warw ExerdtAtio 08, p. 438.] 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 125 

tbe adjacent organs. We shall, when speaking of the symptoms 
of pregnancy, call attention in detail to these phenomena, and 
endeavor to give to. each one of them its true value. 

Development of Impregnated Uterus — Mucous Membrane. — The 
microscope has revealed some very interesting facts regarding th^ 
manner in which the uterus commences to increase in volume, as a 
consequence of impregnation. For example, the first change in the 
structural arrangement of the gravid organ is recognised on its 
internal or mucous membrane ; as early as the second week, it 
becomes notably thickened in its texture, and assumes a much 
more lax character ; its color is quite red, the result of increase in 
the contents of the blood-vessels, and folds or plicsB are now per- 
ceptible, so that it can be distinctly separated from the muscular 
coat of the organ. All these changes become much more apparent 
as the period of pregnancy advances, and the result is that the 
mucous membrane (except that portion lining the cervix) lapses 
into an hypertrophied condition, and constitutes the decidita vera^ 
to which we shall more particularly allude when treating of the 
envelopes of the foetus. 

Peritoneal or Serous Membrane, — It is only necessary to recollect 
the distribution of the peritoneal covering on the anterior and 
posterior surfoces of the uterus, together with its firm attachment 
to portions of these surfaces,* to appreciate the necessity for an 
increase in its elements so that it may, without undergoing lace- 
ration, continue the same relations with the gravid uterus, which 
are shown to exist between it and the unimpregnated organ. It 
was formerly supposed that the broad ligaments — simply dupli- 
cations of the peritoneum — were arranged in folds which, under the 
influence of gestation, expanded, and thus enabled the peritoneal 
membrane to keep pace, without involving its integrity, with the 
developing uterus. There is no truth in this hypothesis, and it is 
now admitted that the peritoneum, in common with the other tissues, 
really receives, as one of the results of pregnancy, an increase of 
elements, or, in other words, exhibits an hypertrophied condition. 

Muscular Structure.-^The muscular tissue of the uterus also 
undergoes important modifications, which result in a general 
increase in the volume of the organ. It is a well-established fact 
that this muscular tissue becomes developed in two ways : 1 . By 
an increase in the pre-existing elements; and 2. By a new formation 
of them. For the first five or six months of gestation there arc 
generated new fibres, and those which previously existed assume 
an extraordinary growth, their length presenting an addition of 
from seven to eleven times, and their width from two to five. 
The connecting tissue, which unites the muscular fibres, also pre- 

• See Lecture 6th. 



1S6 



THE PRINCIPLES AND PBACTTICE OF OBSTETRICS. 



Bents an increase, po tliat at tbe eu<l of pregnancy, distinct fibre 
can be recognised.* Such is il>e gradual development of the utern 
frntii tlie time fif f(*ctin<latiori until the completion of the period o| 
uteru-geatatiuii, that it« eoltd hulk has been estimated by ^lecke 
to tc, at the end of the ninth montli, twenty-four times greate 
than in the unimpregtiated organ. This excess of development 
princijially dne to the erdianced growth of the nmscular tissue^^ 
and, as ob8tctneian8, it is interesting for you to know' that, mjlil 
pthe sixth mouth of pregnancy, the walls of the uterus undergo a 

acceseive thickening, while the cavity abo becomes increa^d; 
"but, after tliis period, the walls diminish in thickness, and the are 
of the uterine cavity, in order to accommodate the lietus, U nil 
much augmented^ The seroui) or peritoneal covering, as haji ji] 
been remarked, also becojnes thickened; and there is, in fact,; 
increase in all the tissues of the organ; the blood-vessels and lyi 
phatics become larger and more distended, and the nerves, whelhe 
partly from the production of new nerve-Hbres or not, are enh;mc€ 
in length and width by the growth of their pre-eiddting elements^ 

Such, very briefly related, are some of the structural modifies^' 
tious jirodnccd i[k the uterus as the result of pregnancy; and you 
caimut fail to perceive that al! these changes are intended for thi 
accomplishment of two objects, viz. in the first place^ fur the! 
aeconnnodation of tlie growing embryo, thus affording it a place of 
temporary sojourn ; and secondly, for the provision of the element 
necessary to its nourishment. 

There has been much discrepancy of opinion as to the spccia 
arrangement or distribution of the nmscular tissue of the gravid"^ 
uterus. Madame Boivin, who gave much attention to the suyect, 
and whose fine delineations of this structure have commeudedj 
themselves to the highest consideration, recognises in the impreg-J 
nated womb three orders of fibres: 1. On the external surface of| 
the organ, there are planes of fibres, which proceed from thi 
median line obliquely downward and outward, toward the inferior I 
third of the uterus, pai^sing iu the direction (jf the round ligamentaif 
of which they constitute a large portion; ^ome of these fibres paaaj 
also to the fallopian tubes and ovaries; 2. On the internal surface, j 
there are observed circular fibres, and tlieir central point is the in*| 
ternal oritice of the tubes; 3. Between the two planes of fibres justf 
described, there is a third layer, which is regarded as inextricable.! 
On the other hand, Deville has quite recently en*!eavorcd to &howj 
that Madame Boivin was in error in her description. There are^l 
according to this observer, two orders of muscular fibre on the exter- 
nal surface of the organ — one transverse, the other longiludioAU 
The former are derived from the round ligament, fallopian tube. 



* Kftlhker's UicraaoopiCAl Anatomy, p, 650. 



THE Pl^INCIPLES AND PRACTICE OF OBSTETRICS. 



127 



ind ovary, and tiho from tlie wing of the correspondiog round liga- 
niant. Near the meilian line, these traus verse fibrei^ are inter- 
sected perpendicularly by a longitudinal band, describing curves 
more or less marked* This longitudinal baud originates, in front, 
near the uuion of the body with the neek of the uterus, ami passes 
from below upward to tlie fundus, and a^airi proceeds from above 
downward on the posterior surface, tcrniiuatiug a little below the 
junction of the neck and body of the organ. 

There h^ ho remarks, a poi*itive line of continuity between the 
trausverse and longitudinal fasciculi. The former, as soon as they 
api»roach the median line, become curved, some downward and 
others upward, so as to become longitudinal, and in this way do 
actually constitute the tnedian longitudinal fasciculus. This Is 
observed on both the anterior and posterior surfacest of the organ. 

On the internal surface, there is the same general description of < 
the muscular fibres as on the external aurtaee. In Figures 37 and 
aeT, taken from Cazeaux, who acknowledged his indebtedness for 
ihem to the courtesy of 3!. DevUle, the arrangement of the mus- 
cular etructure, as described by this anatomist, is graphically 
exhibited. 



J^w. 



Ha. 88. 



ConstUuthnal Si/mpathies, — The changes in the local condition 
of the \iteru9 arc promptly followed by more or less constitutional 
excitenaent. One of the very first organs in which this excited 
action is tnanifested is the stomach, as is shown by the nausea and 
vomiting, which, in many instances, so quickly, and, in the great 
majority of cases, so generally, supervene upon pregnancy. There 
is v*»ry little doubt, I imagine, now* entertained as to the manner 
in which the nausea and vomiting are produced. The uterus, you 
have seen, becomes, as soon as fecundation Is accomplished, a new 
and (ictive centre. Extraordinary changes of structure ensue ; all 
this necessarily induces more or less irritation from the uterus to 



128 



THE PRINCIPLES AND PRACTICK OF OBSTETRICS. 



the Stomach lljrough a rctiox action of the spinal cord; this irri- 
tation is transmitted to the stomjieh, and, as a conscqiienct*, unuscA 
ami vomiting are developed, Now^ I can readily understanrl that 
you may, at first sight, imagine this to be an argument against the 
asBuniptton that pregiianey cannot be properly considered a patho- 
logical or diseased condition. But tiuch an inference has no just 
basis, for I liold that the nausea and vomiting of jiregnancy, under 
ordiuary circumstances, instead of being regarded as pathological^ 
are, in truth, physiological phenomena; and it i»^ in my judgoient, 
precisely for the want of such distinctions that the error has obtained 
regartling the true condition of the female, while in gealalion. 

I do not think there is any fact, as a general fact, better esta- 
blished than that pregnant feinalefi, who escape nausea and vomit- 
ing during gestation, are excmdhigly apt (o mUcany, If this 
really l>e so — ^and your future observation ^vill, I am quite sure, 
abundantly corroborate the statement — there must be some im- 
portant connexion between this gastric irritability and a normal 
pregnancy — a connexion which holds the relation of cause and 
effect. What are the fads? As soon as impregnation take'< place 
the uterns become?^ suddenly congested, and this tendency of the 
blood toward the organ coniiniiea in unbroken currents until the 
completion of gestation. Without some derivative intinenee, in 
the earlier periods of pregnancy, to hold in salutary check thi« 
determination of bloud toward the uterus, its nervous structure 
would become so overwhelmed and irritated that premature action 
of the orgftti, and expulsion of its contents, would be the eon- 
sequence. In order, however, to guard against such contingencies, 
nature has found it necessary, in the plan of her operations, to 
institute two phenomena — nausea and vomiting — the dii*ect result 
of which is, for the time, to j^roduce relaxation of the general mus- 
cular tissue, and increased activity of that essential emunctory — 
the per^ipiratory surface. 

I need not exphiio to you how relaxation of the muscular system, 
and increased perspiration, necessarily tend to antagonize local 
congestions. This law, so well estabiishcd, constitutes the funda- 
mental basis for the therapeutic treatment of inflammatory affec- 
tions. Why are you tohl in aggravated attacks of inflammation 
of any of tlje vital organs — in pneumonia, for exampk* — to bleed 
to syncope l** Is it not because of the absolute necessity, in order 
that life may not be sacrificed, that an immediate and poweHuI 
impression be made on the system — and what so potent in its 
int!uen4^e t»» break up tfie Iwal congestion as the two immediato 
results of syncope — relaxation and free perspiration?* There is 

^ I am so well satisfied nf t)io iiti porta ooe, so far as o Itealthy gestsiion is con* 
osrned, of die two plieiiomcnA — iinasoft And vumUtJif^ — aud so trul/ do I n*gihnl 
lliiai IS neoeasary litiki! in tho chain of processes itistituted bjr nature lor th« soo- 



THK PRINCIPLES AND PRACTICE OF OBSTETRICS. 129 

another argument, I think, to show how necessary this gastric 
disturbance is to the completion of pregnancy, and it is this — as a 
general principle, it subsides about the middle period of gestation, 
the uterus, by this time, having become accustomed to its new 
condition, and, therefore, from this cause at least, in no danger of 
premature action. 

Changes in the Blood, — But, gentlemen, let us look at another 
modification resulting from pregnancy, and see how far, as many 
writers claim for it, it is entitled to the denomination — pathological 
— ^I allude to the change which the blood undergoes during gesta- 
tion. Through the researches of that clever observer, Andral, 
subsequently confirmed by the observations of Becquerel and 
Rodier, the important fact has been established, that, for the first 
five months of gestation, the absolute quantity of fibrin in the blood 
is diminished, and that the red corpuscles are also less in quantity. 
The amount of fibrin, they allege, after this period, is subject 
to variation; but it ordinarily becomes increased between tho 
sixth and seventh, and eighth and ninth months. It must bo 
remembered that this condition of the blood is not a more coin- 
cidence ascertained to exist in one, two, or three given cases of 
pregnancy ; but the value of the circumstance consists in tho broad 

cesaful accomplishment of the work of reproduction, that, when these pUcnoineDa 
are absent, I invariably have recourse to nnnute doses of i()ecacuanha for tire pur- 
pose of ioducing an irritable condition of the stomach. In more than one irtstanco. 
I have succeeded in this way, in carrying ladies to their full term, who had previ- 
ously miscarried — and in whom, on inquiry, there could be detected no cause for 
the miscarriage, eccep/ thai ihey had experienced neither nauxea tw^ vomiting. Id 
illustration, the following case, among several others, is not without interest : In 
November, 1851, I was consulted bv a lady from the State of Georgia, who imagined 
ahe was laboring under some disease of the uterus, which, as she supposed, had 
prevented her from bearing a living child, having miscarried twice successively at 
the third month of her gestation. After a very careful examination, I could detect 
no disease of the uterus, nor could I ascertain, on inquiry, that any of the ordinary 
■pecial causes had operated in the production of the miscarriages. On questioning 
her particularly as to tho state of her health while pregnant, she laughingly 
observed: "Why, sir, my health was, in both instancesy most remarkable; my 
appetite was surprisingly good, and I did not know what it was to have a rnornent*s 
side stomach." Judging that this was a case of miscarriage from the absence of 
the usual symptoms — nausea and vomiting — I so expressed myself to the lady, 
and enjoined upon her, as soon as she ag-ain discovered herself to be pre^ninnt, to 
commence with from a fourth to half a g^ain of ipecacuanha once, twice, or ilirico a 
day, as circumstances might indicate, for the purpose of producing nausea, thus 
simulating, as nearly as possible, the course pufsaed by nature, when not contra- 
rened by influences which she cannot control This treatment to be continued 
until about the fourth month of pregnancy, at which time, sometimes earlier, some- 
times later, the nausea and vomiting, usually attendant upon gestation, as a general 
rule, cease. My patient returned home, and, in twelve months afterward, I received 
a letter from her physician, Dr. Raymond, in wltich he remarked : " Your remedy 
has been attended by the hsppiest result. Two weeks since I delivered Mrs. H, of 
a fine aooJ' 

9 



ISO 



THE PHINCirLES ANI> PUACTICE OP OBSTETOICS. 



gro!iii<l that this is the general cliaracteristie of the blood (luring 
gL'StatJon; hence, a pregnant woman niay ha nau\ to be cbioro- 
anaBinit% sinmhiting, ^somewhat, the condition of chloro^tis, between 
the p!ithology of which and the blood of pregnancy there b a 
Btrikiug analogy. 

This seenis, indeed, to come in direct conflict with the very 
gencTfil f>pinion that pregnancy is usually accompanied by a?rtate of 
pU*lhor:i; and hence, under this latter impression, the too common 
pniotice is, tor any supposed fulness in the ht^id, or pain in the 
che>4t or abdomen^ the free abstraction of blood by the lancet. 
This is not only, in my judgment, empirical, bat it is oftentimes 
very pernicious practice. To the abstract practitrotier, pain in the 
head, etc, may indicate plethora, and, consequently, the wisdom 
of blood-letting. Not so, however, with the well-educated phyni- 
cian, who rejects the testimony of mere symptoms as tiUerly 
worthless, unless accompanied by a knowledge of the causes to 
whit'h they arc due. Who, for example, doe^i not know that one 
of the prominent accompaniments of an amemic or bloodless con* 
dition of tlie system is intense cephalalgia, with intolerance of light 
— and are not these, a!so, the two promitient and distressing symp- 
toms of that most fearful disease, [►hrenitis, or itiflammation of the 
brain? Tlien, gentlemen, in the name of truth, what is the value 
of symptoms, unless elucidated by their antecedents? In the two 
exam pies which I have just cited, you see precif^ly the same 
cKaracter of symptoms, but due to precisely opposite causes. In 
llie one, tonic an»l stimuhmt treatmeuL is indicated — while, in the 
other, ill e only hope of rescue is in the )>rompt and uucom prising 
use of tlic luiK^t, and other depletory measures. 

The opinion that pregnancy is accompanied by a plethoric coo- 
ditiiui of system is by no means of recent origin— and it seems to 
have sjH'ung fioni the belief generally entertained that, as during 
gestation there is usually a suppression of the catamenia, the very 
accumulation of this fluid in the system of the gravid female must 
necessarily induce a state of plethora. This, however^ is false 
reuMOning; for the qnafitky of blood thus retained can, by no mode 
of calculation, compensate for the amount provided by the mother 
lor the foptus and its annexte, during their intra-uterine develop- 
ment. So generally did the idea of plethoru and pregnancy 
f>ervade the teachings of many of the early schoolmen, that it was 
one of their injunetions to bleed the pregnant lemale at least three 
times while carry in j^ her child ; indeed, the observance of this 
maxim was regarded as essential to the safety of both mother and 
offspring. Unfortunately, the error has reached our own times, and* 
as a mere matter of tradition, ha^i a strong popular support. When 
engaged in practice you will appreciate the necessity of firmly resisting 
this delusion, which may almost be considered a popular superstition. 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 181 

Allow me here to remark that, as a general principle, if the preg- 
nant female observe strictly the ordinances which nature has incul- 
cated for her guidance ; if, for example, she take her regular exer- 
cise in the open air, avoid, as far as may be, all causes of mental or 
physical excitement, employ herself in the ordinary duties of her 
household, partake of nutritious and digestible food, repudiate 
luxurious habits, the exciting accompaniments of the dance, late 
hours, late suppers, etc. ; if, I say, she will steadfastly adhere to 
these common-sense rules, the reward she will receive at the hands 
of nature will be, general good health during her gestation, and an 
auspicious delivery, resulting in what will most gladden and amply 
repay her for her discretion — the birth of a healthy child, which is 
to constitute both the idol of her heart, and the study of her life. 
But if^ in lieu of these observances, the pregnant woman pursue a 
life of luxury, " eat, drink, and become merry," neglect to take he> 
daily exercise, and prefer her lounge — then the case is entirely 
reversed; she becomes plethoric, and, if not relieved by the 
employment of the lancet,* and other appropriate remedies, she 
oftentimes dies, having blotted herself from life by her own 
folly! You see, therefore, that pregnancy per se is not, in 
reality, a condition of plethora, but becomes so through the vio- 
lation of the laws prescribed by nature ; and this is equally true 
with regard to the general health of the female during her gravid 
state. 

It must, however, be borne in mind that gestation exercises no 
talismanic mfluence, nor can it constitute itself an ^gis by which 
to guard the female against the invasion of diseases incident to 
human nature. For example, a pregnant woman may be attacked 
with pneumonia, pleurisy, or other of the formidable phlegmasia ; 
in one word, she is liable to any of the numerous catalogue of 
human maladies ; and this brings me, for a moment, to the consi- 
deration of the treatment of these affections, when occurring in a 
state of gestation. Hifipocrates propounded the maxim that ^' an 
acute disease of any kind, seizing a woman with child, generally 
proves mortal" — mullerem utero gerentem morte quodam acuta 
leihcULf Van Swieten, the illustrious commentator of the no less 
illustrious Boerhaave, in speaking of this aphorism of Hippocrates, 
concludes that this unfavorable prognosis of an acute disease in 
pregnancy was necessarily deduced from what he held touching the 
abstraction of blood in gestation — "a woman with child, from open- 
ing a vein is apt to miscarry " — mulier utero gerena vend sectd 
aborteU It is very evident that neither of these maxims of the 

* It is Teiy probable that the plethora, in these cases, is due simply to an increase 
in the amount of water in the blood ; but, still, with this assumption, the advantage 
of the lancet, as a means of temporary relief, cannot be questioned. 

f Apbor. 3 torn., ix., p. 213. 



132 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS 



father of nieilicjne reecnves confirmation at the bedside, where, 
after all, ibeir true value is to be tested. 

In the first place, in certain coiiditioiift of plethora, brought on In 
the manner already indicated, accompanied by a bearing-dowii sen- 
sation, febrile excitement, and a bonndiu^ pulse, the abstraction of 
blood from the iirra will otVenlimes act like magic, imparting to the 
disturbed system quiet and calmness, such as the lulling of the tem- 
pest, and the falling of the waves produce on the bosom of tho 
ocean. Again; my own experience teaches me that acute diseaseSi 
if promptly treated, are as amenable to remedies as under any other 
circumstances J and, furthermore, their thei-apentic maiiagemeni 
fthould be characterized by the same degree of activity a* if 
pregnancy did not exist. Diseases of a high inflammatory grade 
are, 1 am <piite cindident, frequently fatal in the pregnant 
female for the reason that the practilioner is timid, his indeelxion 
growing out of fear that positive depiction may destroy the child. 
It seems to me that this is a very false philanthropy ; nor has it 
anything in science either to sustain or justify it. For instance, 
in a severe inflamuiation, tlie mollier will perish without prompt 
and eflicient depletion ; and, sjliould she die, what beeonics of the 
child she carries in her womb — es[)eciaily if it bhould not have 
attained a nterine dovelopnieul which will enable it to enjoy an 
independent existence, in which event, it is true, there is a remote 
possibility of saving it by a post-mortem Ctesarean section? 

13ut, gentlemen, will the active depletion, material to rescue the 
patient in cases of serious acute disease, necessiu-ily com promise the 
safety of the child, l*y depriving it of the noun>hment esseniial to 
its development? This h an exceedingly Interesting and im|>oriaul 
question, and one concerning which there is a divei*Sity of opinioa. 
It appears to me, however, tliat it is one <jf those points not to be 
determined by the fonim, nor by the disputations of tfie contro- 
versialist — it is simply a question of facts. The facts whicJi, to my 
mind, are conclus^ive on tliis subject, and which every observant 
accoucheur with a moderate field of practice will, from his own 
personal experience, be enabled fully to confirm, arc as follow<i ; U 
Pregnant women, aflfected with exhausting diseases, and in the last 
stage of phthisis pnhiumalis^ are oftentimes delivered of apparently 
healthy and w^ell-<levclopi'd children ; 2, In cases of exceasive nau* 
tea .and vomit infx — i*ontinuiiig nearly the entire period of gestation 
— thus preventing the female from taking her ordinary nourish- 
ment, the child exhibits no evidence of impaired nutrition ; 3* 
Wien pregnant women are over-fed, it often occurs, especially if 
they increase much in adipose tissue, t!mt they bring forth diminished 
children, instituting a striking contrast betw^een their condition and 
the corpulence of the parent ; 4. After convalescence from disea^kca 
which have needed prompt and bold depiction, during gcstationi 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 188 

the child exhibits no want of growth or development, but, on the 
contrary, usually bears the evidences of having been adequately 
nourished ; 6. The attempts made, in cases of pelvic and other 
deformities of the maternal organs, to cause a diminished growth 
of the foetus by restricting the diet of the mother have completely 
failed.* 

There is an interesting circumstance connected with the chloro- 
anffimic condition of the gravid female, to which it is not unimport- 
ant for the moment to allude. Andralf has demonstrated that, in 
all cases of acute inflammation, there is invariably an increase in the 
quantity of fibrin ; and, furthermore, that this increase is always 
proportionate to the intensity of the phlegmasia. In order that a 
clear understanding may be had of this practical point, and proper 
deductions made in other than inflammatory types of the system, 
the following table is presented as disclosing the ordinary variations 
in the quantity of the chief constituents of the blood in a state of 
health : 

Fibrin, . . . from 2 to 3^ parts per 1000. 
Red corpuscles, " 110 " 152 " " " 
Solids of Serum, " 72 " 88 " " " 
Water, ... •* 760 *' 815 " " " 

According to Andral, the increase in the quantity of fibrin is so 
unequivocal a sign of inflammatory action, that if more than 5 
parts of fibrin in 1000 be detected in the progress of any disease, 
it may positively be affirmed that some local inflammation exists.J 
It is also shown that, under the influence of inflammation, the 
maximum increase of fibrin is 13.3, the minimum 5, while the ave- 
rage is 7 ; and the important fact is proved that, in acute rheuma- 
tism and pneumonia, the greatest increase is recognised. Some 
practitioners are in the habit — and unfortunately the doctrine per- 
vades too many of the books now in your hands — of judging of the 
necessity of further depletion simply by the peculiar appearance of 
the blood after it is abstracted from the system — known as the 
" huffy coat." It would be a sad tale if the countless dead could 

♦ A prominent writer, M. Depaul, suggested in the Union M^dicale, 1 2th of Janu- 
ary, 1 850, the practice of repeated bleedings, together with restricted diet, during 
the latter half of pregnancy, with the view of arresting the full development of the 
fcetus. This suggestion, as is evident, was founded upon inaccurate data, and con- 
sequently proved valueless, so far as concerned the object for which it was intended, 

f See his admirable Essai d'Hiematologio Pathologique. 

X What a precious disclosure for the truly observant physician I How often does 
it happen that, with all the vigilance which can bo brought to bear, and all the 
soundness of human judgment, ho is baffled in his diagnosis — especially in what 
may be termed masked inflammatory action — whether the symptoms are really due 
to inflammation, or whether the disturbance may not be one of the ever-varying 
grades of neuralgic pain. In such case, the abstraction of a small quantity of blood 
will at once develop the mystery by ascertaining the relative proportion of its fibrin. 
iBuch, indeed, are the rich fruits growing out of scientific inquiry. 



134 



THE PRINCIPLES AKD PRACTICE OP OBSTETRICS. 



return to earth, and tell how thb error has led to thoir premature 
dosiruction I The '' buify coat,** while it is indicative, under ceilain 
cii'cumstancea, of intlannnation, is also one of the characteristics of 
anaemia; and it now seems to be the accepted doctrine that tta 
presence, under any circumstances, is duo to ono of two conditions: 
either a positive increase of the lihnn in the blood, in which case 
the amount of corpuscles may undergo no change ; or there is n)ereljr 
a relative increase, In which there ia a loss or diminution of the cor- 
puscles*. This, yon will perceive, is a very important distinction; 
for it is in the latter instimre, especially, in which the "huffy coat^^ 
will display itself, not because of the inflammation, but simply 
because otiidisproporfion between the fibrin and ccfrptiscle*. Now, 
iiuch disproportion is found to exist in pregnancy, in chlorosis, etc,, 
and, ns a consequence, both of these conditions of system are char 
racterixed by the ^^^ bufiy coat*^' * 

You see, therefore, gentlemen, how necessary it is, in the practice 
of our profession, to take an enlarged view of science^ — to collect| 
as it were, all ll*e fads, and not bo content with an isolated or frag- 
mentin'V consideration of a principle; rigid and searching analysis, 
and legitiniute deductions from well-established premises, are the 
elements which our science greatly needs, and they are the elements, 
too, which will consecrate lier discoveries as so many Irutlis, and 
give tht^m value and efticiency when applied to tlie amelioration of 
human sutTering, or to the arrest of disease. How often, in the 
clinic, have I had occasion to call yonr attention to the subject of 
chlorosis, and, in connexion with its patliology and management, 
to remind you that one of the characteristics of this affection, which 
is essentially a disease of debility, is the "biiffy coat." You have 
been told of the fatal err<*r of depletion in chlorosis — and yet this 
error is constantly committed by those who believe that the "buflfjr 
coal" is always the index of inHanmiatory action. It may surprise 
you — but still the tlict is susceptible of demonsi ration — tluit even at 
this day, amid the rich accessions which research and progress are 
daily contributing to our professional domain, and amid the lights 
which science is constantly shedding upon those who worship at her 
slirine, the gener.al belief, so far as practice is concerned, is that 
whenever the *' &vjf}/ coor' is recognued^ it is an urgent indication 
for the fiecessitt/ of further depletioti ! 

* The fibrin incrouMs during pr«*giiaiicy ; its gieneml ayerage quAntity in thia ood* 
ditkm ia H 40, but during: the Uuit two moutha \i ia 4.0S. Tlie blood of the pfregrumt 
wonttn alio undcrjEvx^a ti change m the proportion b of its albutuon, water^ and iroa 
Tlie iivcriig« quiiDiity of ulbumeit coDtaioed in blood ia 70^; yL Regnauld hat , 
siiown ttiAt tU>^ nveni^ of ttiia element durlog gestation ia 67.17. In ibe first seven 
months it is <S8.84; iu Lbc two last, 66.42, The increase in the water of the blood 
18 alao ahown by Ihe sarae observer. The average quantity of water is 791, 1 ; while 
during pregnancy it ia 817. Becquerel and Rodier have demonstrated that tliero la t 
i}ighi diminution in the quautity of iron. [Duboia and Pajeot^ op. citwj 



THE PRINCIPLES AND PUACTICE OP OBSTETRICS. 185 

ModiJiocUiona in the Urinary Secretion, — ^That the urine of the 
pregnant female undergoes certain changes, is by no means a dis- 
covery of our own times. The fact is alhided to in the writings of 
Hippocrates and other of the early fathers.* Within the last twenty 
or thirty years, special attention has been directed to an element in 
the urine — kiestein ; this name was, I believe, given to it by 
Nauche, who, together with numerous others, including our own 
countryman, Dr. Elisha Kane,t has made some interesting contribu- 
tions on the subject. Kiestein consists of a whitish pellicle ; and, 
when completely formed, its api)earance has been compared to the 
scum of fat, which is observed on the surface of cold broth. Dr. Kane, 
ID eighty-five cases of pregnancy, recognised a well-defined pellicle 
in sixty-eight; in eleven the pellicle was but partially formed, while 
in six it was absent. The pellicle will sometimes be detected thirty- 
six hours after the excretion of the urine, and again not until the 
eighth day. Kieslein has been observed as early as the fifteenth 
day after fecundation, and frequently at the second month. From 
the third to the sixth month, it exhibits its most marked charac- 
teristics ; from the seventh month, it gradually diminishes. 

Why should this element, kiestein, be found in the urine of the 
pregnant and parturient female? It is absurd to suppose that it is 
there as a mere coincidence; and we, therefore, are justified in ask- 
ing some explanation of its presence. Is the kiestein in the urine 
anything less than a demonstration, that nature is engaged in the 
elaboration of food necessary for the infant as soon as it is born-r- 
and is the passage of this substance from the system, throngh the 
kidneys, any less of a demonstration than its accumulation in the 
blood would be productive of injurious consequences? Both of 
these circumstances seem to receive confirmation from the import- 
ant fact, that, when the child takes the breast, and the secretion and 
excretion of milk through the mammary organs are in full operation, 
there is no longer any kiestein to be detected in the urine ; in addi- 
tion, among the constituents of kiestein is casein, which, you should 
remember, is an important element in human milk.J Again : 
recently Blot has announced to the French Academy of Medicine 
the interesting fact that sugar exists normally in the urhie of all 
parturiefit women^ of all nursing women^ and likewise in the urine 
of a certain number of pregnant voomen.% Here, then, are two ele- 

* In 1560, Savonarola spoke very particularly of the modifications of the urinary 
secretion conaequent on gestation, and his description of these changes would seem 
to indicate that the substance known as kiestein had actually been recognised by 
liim, altliough not under tiiat name. [Practica Canonica de febribus, pulsibua, 
urinis, Ac. By J. M. Savonarola, 1660.] 

\ The An»erican Journal of Medical Sciences. 1842. 

X Kiestem is not invariably Cund in the urine of the pregnant female, and may 
be produced by numerous pathological conditions of the system. 

§ It is proper to state that tlie announcement of Blot has been regarded as crro- 



136 



THE PULVCIPLES AND PRACmCE OF OBSTETRICS. 



ments, ca^oin and sugar, both components of human milk, found in 
the nniio, ami consequently must exist in the blood of the putrperal 
woman. 

In rcrtmn cases, the urine of the prejs^iant female ia fontid to roii- 
tain alhiimon in greater or less quantity, and it h «tiitt*d as an 
intereatirg fact that the alljinniiicius urine of pregnancy doe>» not 
produce redaction with the li<]uor of Eaniw il, while the same cha- 
racter of urine asssnmes a violet color, and produces a dark precipi- 
tate in cai^!cs of Hright's disease. 

Pregnancy, therefore, in a modified condition of the nystem, but 
not a diseased condilion ; and the type of the modificfition is, as a 
general rule, in exact relation with the demands of nature fur the 
accomprLshTnent of the great and mysterious object in which gho 
is engagtMl — the reproduction of the s|K»cie**. You are not, how- 
ever, to understand nie to say, that pregnancy is not oftcntimea 
complicated with disturbed action, anKHnTting to disease, which 
will reqvnre all your vigilance, and a ftill measure of skill, to arrest 
it. The very vomiting to which we have alluded as^ under ordi- 
nary circumstances, constituting one of tfic jiliysiohigical pheno- 
mena of gestation, sometimes ]4ucc?» m such imminent peril the 
safety of the mother, that it not unly refjitircs the interpo>ition of 
the accoucheur, but at the same time presents for consideration one 
of the gravest topics in the whole practirc of niiilwifery, via. prf- 
nutinre artijieiiii del t ran/ — which question we sliaJl fully di^^iisa 
under its appropriate head. 

Is (lie Female Pregtmnt f — With these general observations, we 
shall now enter upon the discuss^ion of the question — How are you 
to kfiotr t/iftt jfTtf/ttanrf/ exists ^ And here, gentlemen, we approach 
a sidiject which, in every respect, is entitled to your profound atten- 
tion* ^lany of you are, as it were, just on the threshold of life, 
igimrnul of the ways of the world, and, therefore, unable to appre- 
ciate, on the one hand, the srhenies of the deprave<1, and, on the 
other, the siid wrongs to which liie Innocent are oftentimes sub- 
jected. You will not be engaged in practice long before you will lie 
called upon to appreciate, in all llieir stirring truth, the solemn 
obligations to society, which your profession will necessarily imftose 
upon you ; nor can you form any adequate idea of the influence 
which you, as medical men, are destiue<l to exercise in the conmm- 
ntties in which you may respectively become resident. Touching 
this very question of pregnancy, your opinion will be invoked by 
the judges aiul the lawyers of the land; it may become your pro- 
vince to stay the ami of the law iu the execution of retributive jii»- 

neous hy lA'Crmte, who Iihs aeon thot (he qnantitjr of urio Acid i^ increnscil in tho 
UJiiio of Qurain^ womot^ whidi fact, he thiiikft is ih© oauiie of tho puppoacHi trror of 
Btol, Ou the other hAod Brucke mnmtaiitR that mxgiiff ^ye» really exist in m nou 
Ue mfumnl iu uuraing women. 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 137 

tice ; and, on the accuracy of your decision, may depend not only 
the well-being of society and the happiness of individuals, but 
human life itself will often be at your mercy. In most Christian 
countries, in accordance with the legislation of the Egyptians on 
this subject, the law obtains that if a female shall be convicted of a 
high oflfence, the penalty of which is death, the sentence shall be 
suspended, if it be proved that she is pregnant.* 

Who, in a plea of this kind put forth by the unhappy creature, 
in the hope that the day of her ignominy may be postponed, 
will be called upon to decide the truth or falsity of that plea? 
It is a question not within the jurisdiction of the learned courts — 
their province is to sift evidence as presented by witnesses on the 
stand, and, through the proper poising of the scales of justice, to 
protect innocence, and award to crime the decrees of the common- 
wealth. The plea, gentlemen, will be submitted to the decision of 
the medical man, and upon his testimony will the issue be deter- 
mined. Again : imagine the case of a woman, who, in the desire 
for gain, or urged on, perhaps, by some more malignant motive, 
charges the father of a family with having violated her person ; and 
thus, with a view to a successful issue of her scheme, feigns preg- 
nancy. In this case, too, the testimony of the medical man must 
decide the question. A woman who h:is strayed from the path 
of virtue, and whose abandonment results in impregnation, stu- 
diously endeavors, if not lost to all sense of propriety, to conceal 
her situation ; and when she approaches the medical practitioner 
for counsel, will have recourse to every art and subterfuge by 
which she may hope to delude his judgment, and accomplish the 
fiendish [)urpose of throwing a mantle around her own shame, by 
the destruction of the child she carries within her ! 

When engaged in the practice of your profession, you will fre- 
quently be consulted by persons of this description, and, if you 
suffer youf judgments to be dazzled, or your feelings to become too 
deeply interested, the most painful consequences may ensue. To 
distinguish between actual pregnancy, and the numerous diseases 
capable of simulating it, requires on the part of the accoucheur 
extraordinary circumspection ; and as he is, from the very nature of 
bis profession, the only earthly tribunal to which the final a])peal is 
made in cases involving the dearest interests of society, and the 

• It is marvellous that so enlightened a country as England should be guilty 
of the strange inconsistency of recognising ihe plea of pregnancy as a motive for a 
stay of execution, and ytt be so indifferent, in her legislation, as to the manner in 
which that plea shall be tested. In the decision of a question, involving such grave 
CODsequeiici'S to both the guilty parent and her innocent child, instead of submitting 
the arbitration to well educated and ex^wrienced mediciil men, the law calls for a 
jury of twelve ignorant women, and tho issue depends, not upon whether pregnancy 
actually exists, but upon whether or not the woman has quickened. This is, indeed, 
sioguhir legislation I 



188 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS, 



sacretl ri splits of iiKlividuaLs, it follows that the responsibility 
kn posed upon him is most fearful. 

A cn^e occurred some yeai-s since in this city, which i« woll 
calculated not only to arrest nttention, but to fix on the niirid the 
necessity of positive knowledge in obstetric medicine, and the value 
of accurate diagnosis in disease* A fumale a]>plied for proftH^ional 
advice ; she had for some time previoujjily labored under general 
derangement of health, and wag most soiicitons for relief. The 
practitioner whom she consulted^ being much embarrassied by the 
history of the case, requested the opiniun of j^everul medieiil friend**. 
The consultation resulted in the unanimous decision that the patient 
was affected with dropsy, and it wns proposed that the opi»raliun 
of paracentesis, or tai>pin^, siiould be peHbrmed. The medical 
gentlemen :L'4semhh'd, aceordiii<^ to appointment, and the iroear 
was thrust into the abdomen of the confiding woman ; no lluid, 
however, escaping; it was, indeed, lileraHy wlmt hasi been denomi- 
nated a ''dry tap," and you may well imagine the asioniHhment 
of the ppectators. A few days subsequently, the patent died from 
the etlects of inflammation, and the autoiny revealed tlie interest- 
ing but astounding tact, that the inj^trumeot, instead of pns'-ing 
into what wa:;* supposed to be an accumiilaiioti of fluid, wm ihmst 
into the very heart of a living fcetus! What greater misfortune 
could befall any one of you than an error like this — to f^nrvive it, 
would rcf^uire almost a lifetime, so far as your professional repii* 
tation is concerned, to say nothing of t!ie stinging rebukes of 
conscience. 

But. gentlemen, it "will sometimes become your duty to shield 
innocence against the suspicions of an unjust w orld, and vindicate 
purity against the assanlt.s of the base and heartless ; and it is in 
instances like these in which the question nf pregnancy, as a mere 
point of diagnosis, becomes invested with its highest degree of inte- 
rest. Can you imagine anyt!jing more luelandioly than the wanton 
destruction of character througli mere suspicion, unless, indeed, it 
be the tlestrnction of character through the cabals of the depraved? 
You will, lamsurCr pardon me, for meiitioidng the following touch- 
ing case, whii h occurred in my pmctice some years since ; and which 
carries with it its own sad moral ; it is worthy of meditation, and 
is a proper exponent of scenes, M'hich you may be called upon to 
encounter in your professional career. May it impress you with the 
fuhiL'ss nf your responsibilities as medical men, and cause you to 
ap|H'eciate tluf sacred oflices of your proI1^•^sion : 

I was reipiested to visit a lady, who was residing in the State of 
New Jei'sey, about ihiiiy miles distant from New York. I inime* 
diately repaired to her residence, and, on my arrival, was received 
by her father, a venerable and acc<mi[»lislied gentleman. He 
seemed broken in spirit, and it was evident that grief had taken 8 



THE PRI^'CIPLES AND PRACTICE OF OBSTETRICS. 



139 



erp hold of hb frame* On being introdiit^ed into his daughter's 
r^oom^ my synipatbit?s were at once awakened on beholding the 
wreck of beauty which was presented to my view. She was 
evidently Ulioring under that bane of human existence, conmtni lo- 
tion, and it was quite manifest from her wasted frame, that death 
had claimed his victim. My presence did not seem to occasion tha 
slightest disturbance^ and with the smile of an angel playing on 
her countenance, she greeted rao with these words ; " Well, 
doctor, I am glad to see you on my beloved father^s account, for 
he will not believe that I cannot yet be restored to health. Life, 
however, has lost all its charms for me, and I impiUiently long foi 
the repose of the grave." These words were spoken with extra- 
ordinary gentleness, but yet, with an emphasis, which, at once, 
gave tne an insight into the character of this lovely woman, 

Ilcr lather was a clergyman of high standing in the English 
church, and had a pastoral charge in England, in which he con- 
tinued until circumstances rendered it necessary for him to leave 
that country, and seek a residence in America. At a very early 
age, this young lady had lost her mother, and had been almost 
entirely educated by her father, whose talents, attainments, and 
moral excellence admira!>ly titled him for this important duty. 
When she had attained her eighteenth year, an attachment was 
formed between her ami a young barrister of great promise and 
respectability. This attachment soon resulted in a matrimonial 
engagement. Shortly after the engagement she began unaccotmt- 
ably to decline in health ; there wa« a manifest change in hei* 
habits ; she was no longer fond of society ; its pleasures ceased to 
allwre and prove attractive ; the friends whom before she bad 
caressed with all the warmth of a sister's love, now became objects 
of indifference; in a word, she was a changed being — her peisonal 
appearance exhibited alterations evident to the nio.st snfierlicial 
observer; her abdomen enlarged, the breasts fuller than usual, the 
face pale and care-worn, and the appetite capricious, with much 
gastric derangement. Many were the efforts made to account for 
this change in the conduct and appearance of the young lady in 
fjuestion. Speculation was at work, and inimerous were the sur- 
mises of her friends. The rumor soon spread that she W' as the 
victim of seduction, and her altered appearance the result of 
prei^nancy. 

The barrister to whom she was affianced heard of these reports, 

and instead of being the first to stand forth as her protector, and 

draw nearer to his heart this lovely ami injured girl, thus measur- 

ibly as.s\iaging the intensity of grief with which she was over- 

rhelmedi a<ldressed a ktter to lier father recpjesting to be released 

him his engagement. This was^ of course, assented to without 

atiun. The daughter, conscious of her own innocence, know- 



140 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



ing better than any one else, lier owu immaculate cbaracter, and 
relying on lieav«'« to guitle her in this her hour of tnbuijjtioii, 
requested that a physician should be sent lor, in order that the 
nature of hor ease u\ight be clearly a«certaineil. A medical man 
aeeortlingly visited her, arid, after an invealigation of her sym[). 
toms, iuformed the father that she was undoubtedly ]»regnant, and 
Buggef?ted timt mcan^ should be iuKtaully taken to keep the unplea* 
fiant matter secret. The father, indignant at this cruel imputation 
against the honor of hU clfdd, ttpollcss as he knew' her to be, 
Bpurncd the proposition, and instantly requested an additional 
consultation. TJ^is resulted in a contirmntiDn uf the opiidon previ- 
ously expressed, and the feelings of that parent cm be better 
appreciated than panrayed. 

Without deliiy, th;it good lunn determined to resign his pastoral 
living, gather u\i his Utile jnopiTty, and proceed with hi;* daughter 
to America, where, in a land of strangers, he hofieil for that conitbrt 
and pt*ace of mind, which had been denied him in his owu native 
home. On her passage to this eountry, the datighler Iwcnm© 
extremely ill, and there bting a jihy^ieian on bo:ird the vensiei, his 
iwlviee was requesied. After seeing the jiatient — sshe wa8 affected 
at the time with excessive vomiting from sea-sickness — he told the 
'father there was danger of ]iremature delivery. Such, therefore, 
was the general apfiearunce of this lady, that a medical juau, taking 
eimpfy appearances as his gnl^le, at oine comltnled she was |iregn;mt. 

This is about the substance of what 1 learned of thi^ interesting 
and extraordinary woman, and my nptnion was then reque!*ted us 
to the elinracter of lier njala<ly. 3Iy feelings were very naturally 
much enlisted in her behalf, niui I pntceeded with great caution in 
the investigation of her case. Without entering at this time into 
details as to the m:mner in which I conducted tlie examination, 
Bufliee it to say that, after a taithtui and critical survey, mg»t 
minntely made in reference to every point, I staled in broad and 
unef|nivocal language — that she was not pregnant. The only reply 
tbi« gentle creature made on hearing my opinion, was — **Doetor| 
you are right !'* These words were full of meaninijj, and their 
inifjort I could not but npi^u-eciate. They were uttered neither 
with an air of triumph, nor willi any feeling of unkindness toward 
those, who had so cruelly abused her. 

The father was soon made acquainted with the res id t of my 
fixaminaiion, but he indicut ed not the slightest emotion. His bearing 
was qMiet and JignitieJ, It was evident that he hud never lor one 
moment faltered in the belief of his daughter^'s virtue, nor did he 
require from ine or any other living being the assm^auce that his 
child had been shamefully wronged. He a&ked me with great 
solicitude whether something could not be done to restore lier to 
health, and I thought the old man's heart woidtl break, when I 



THE PRIKCIPLES AST) PRACTICE OF OBSTETRICS. 141 

told him, that his daughter* was in the last stage of consumption. 
It was the misfortune of this young lady, to labor under an affec- 
tion of the womb, which simulated, in several important particulars, 
the condition of pregnancy, and which the world, in its ignorance 
and undying thirst for scandal, might have readily supposed did in 
fiwjt exist : yet, there was no excuse for the physician, guided as he 
should have been by the lights of science, and governed by the 
principles of a sound morality. 

When I stated unequivocally, and without reservation, to the 
lady that she was not pregnant, I gave an opinion which I knew 
would stand ; my examination was conducted with the single object 
to reach the truth, irrespective of any other consideration ; my 
sympathies, it cannot be denied, were altogether with this afflicted 
girl; but they were not so irresistible as either to blind my judg- 
ment, or cause me to surrender what I knew was due both to 
science, and my own reputation as a medical man. The result of 
the investigation impressed me with the conviction, beyond any 
shade of doubt, that the entire train of symptoms, indicating 
gestation, was due to an enlargement of the uterus, altogether 
unconnected with pregnancy, produced by the presence of a large 
fibrous tumor occupying the cavity of this organ. This opinion, 
I admit, was not arrived at without some degree of caution — 
caution in every way justified by the peculiar nature of the issue 
involved in the decision. 

I left the father with the pledge that he would inform me of the 
dissolution of his daughter; and thus afford an opportunity, by a 
post-mortem examination, of testing the truth of my opinion. 
About four weeks from this time, I received a note announcing her 
decease, and asking that I would immediately hasten to the houso, 
for the purpose of making the examination. Dr. Ostrom, now 
practising in Goshen, at my request, accompanied me, and assisted 
in the autopsy. It may surprise you, gentlemen, yet it is an 
interesting fact to communicate, for it exhibits the true and 
unwavering character of the man, that, during the post-mortem 
examination, the father stood by and witnessed every stage of the 
operation ; his form was erect, his face pale and thoughtful, and 
so crushed was his heart that one tear, it seemed to me, would 
have broken the agony of his grief. As he stood before me he 
was not unlike the stricken oak in the forest, which, though 
stripped of its branches, was yet upright and majestic. The 
moment I had removed the tumor from the womb he seized it 
convulsively, and exclaimed ; " This is my trophy ; I will return 
with it to England, and it shall confound the traducers of my 
child !" 

Here, you perceive, both character and life were sacrificed by 
error of judgment on the part of those whose counsel had been 



X42 THE PRINCIPLES AND PBAOTIOE OF OBSTBTBIGS. 

invoked. Without a due appreciation of their responsibility, heed- 
less, as it were, of the distressing consequences which would 
inevitably result from the erroneous decision of a case in which 
character was so deeply involved, the medical gentlemen, unjust 
to themselves and to the profession of which they should have 
been in part the conser\'ators, rashly pronounced an opinion which 
consigned to an early grave a pure and lovely being, and broke 
the very heart-strings of a devoted and confiding parent. 

Let me, then, gentlemen, by every sense of duty, by the very 
love which should animate you to become, in these trying emer« 
gencies, the firm and uncompromising dispensers of rigid justice; 
let me, I repeat, by these considerations, urge you to a faithful and 
devoted study of the means by which alone you will be enabled 
to arrive at positive conclusions upon this momentous question* 
The entire investigation is simply one of evidence, and what is 
most needed, will be to separate true from false testimony; to 
bring yourselves to the consideration of the subject with but one 
object in view — ^the elucidation of truth. With preconceived 
opinion, or with prejudice, you have nothing to do. Let your 
minds, in the examination of this question, be ^^ like a sheet of white 
paper,'' with no bias for or against ; and let it be your inflexible 
resolution to decide by the testimony, so help you Ood I 

It shall be my purpose, in the succeeding lecture, to examine 
the nature and value of this testimony. 



LECTURE X. 

BTidences of Gestation ; how divided ; their Relative and Positive Value — Suppres- 
sion of the Catamenia — Can a Pregnant Woman Menstruate ? — Nausea and 
Vomiting material to a Healthy Gestation — Depraved Longings — ^Salivation of 
Pivgnancy; how distinguished from Mercurial Salivation — Salivary Glands in 
Connexion with the Mammae in the Female, and the Testes in the Male — Sym- 
pathy between ; Illustration — Parotitis — Mammary Changes— Secretion of Milk 
not always dependent upon Pregnancy — Milk in the Breast of the Virgin, and in 
the Male— Mammary Metastasis — Illustration — The Areola; its Value — Color 
not its Essential Attribute — Deposit of Black Pigment and Excitement of the 
Sexual Organs — Connexion between — The True Areola; its Value — Areola 
around the Umbilicus — Discoloration of Integument between Umbilicus and 
Pubes — Dr. Montgomery's View of Areola — Can Pregnancy exist without the 
Areola? — Changes in Uterus and Abdomen — First two Months of Gestation, 
Uterus descends into Pelvic Excavation — Consequences — Vesical Irritation — 
Pain and Depression of Umbilicus ; how Explained — Impregnated Uterus al end 
of third Month— Gradual Ascent of the Organ — Right Lateral Obliquity — Pain 
in Right Side; how Explained— Uterus at end of eighth Month — Cough and 
Oppressed Breathing; Reasons for— Projection of Umbilicus; its Value as a 
Sign of Pregnancy — Uterus at end of ninth Month — Contrast with eighth Month 
— Ascent of Organ in Primipara and Multipara ; Difference Explained — Bladder 
and Urethra; Change in Position — Thrombus of Vagina and Vulva — CEdema of 
Lower Extremities ; how accounted for. 

Gentlemex — ^The evidences of gestation may be said to possess 
different grades, and, therefore, we have, 1. Presumptive evidence; 
2. Probable evidence ; 3. Positive or unequivocal evidence. Each 
of these classes or grades of testimony has its own special source, 
and is due to certain special influences, which it becomes you as 
obstetricians thoroughly to comprehend. The presumptive and 
probable evidences may or may not be the result of gestation, for 
the important reason that they may be the product of various 
morbid conditions of the uterus or other organs of the system, 
with which pregnancy itself has no sort of connexion. But, on 
the contrary, the positive, unequivocal evidences are alone the 
offspring of impregnation ; so that, when this latter class of testi- 
mony is recognised, it is undoubted proof that pregnancy exists; 
it must be remembered that it is the only proof which will justify 
the opinion — when any important issue is involved in the decision 
— that a woman is really with child. You see, therefore, how 
essentially necessary it is, in the examination of this subject, to 
draw a broad distinction between certain and uncertain evidence ; 



144 THE PHIXCIPLES AND riUCTlCE OF OBSTETRICS* 

and, on no at'cmnit, to suffer your mhifls to Irfcnmo bewildered by 
falsu or l'oHhUM'uI issue^^* The point to be determijiod U Mtuply — 
Does jiregnariry exist ? It h precisely like any other ease, ihe 
decision of wliicb depends upon testimony ; the only difference 
being thrit, in eonrta of jnstiee^ the issues lire determined by luitnan 
or oral evidence, while with us, \\q have oftentiinc:^ nothing to 
gnide us in onr deliberations but the silent, yet eloijuent language 
which nature employs as the true exponent of the condition of the 
economy. 

Prr^jtmpttve EtHdetices : 

1. T/ic tSt/ppressixm of ihtt Caf amenta, — Avery nmrked belief 
has obtained that when a female becomes impregnated ^he i:eases 
to menstruate during the period of her gestation. An a general 
rule tldiS is undoubtedly true ; but there are so nifiny other €on- 
ditiona of the tiystem in \v?iich this function beeomes terajM)rariIy 
arrested, that, by itself, it is of little or no value a^ a sign of preg- 
nancy. It is strange that so good an oliserver iis Denman should 
have regarded the suppression of the catamenia as an unt?rring 
proof of gestation ; or, in other words, that a pregnant woman 
never menstrnates. It c^^n scarcely be necessary to enter into an 
argument to prove how unsup|>orted this o|>inion is by fact*. You 
have seen in the clinic more than one cuse, in which the function 
continued with regularity during the whole period of pregnancy.* 
I have attended a lady in tliis city in ftuir confinements, who has 
not had her courses suppressed during any of her jiregoancies, and 
who was never positively certain of her condition until the period 
of quickemng. Again : it is not uncommon for young married 
women to have a slight show for two or three jicriod;^ after their 
first impregnation;! and ignorance of the fact has often led to a 
false diagnosis*! 

It should be recollected, too, that the menses will occasionaHy 
become arrested soon alter marriage, and continue so for one or 
more months without the existence of gestation, the arrest of tho 
function in these cases being most probably due to the new relii- 
tions of the intlividual. It is necessary, also, to remind you — so 
univerAul is the jiopular opinion that when a woman becomes preg- 

• S<?© Bi«ea«<M of Women «nd Childreo, p. 171. 

I TUis circumRtAiKH? him^ius Uy iinve bt^u well anderitood bj Yui Swieien, who 
•Bjit *' llowever, niilit»ugh iiatarttlly the tncnAtnifh cetse in a woman with cliilili 
yet with flomo it Uft{jj)C(is ihAt during the first raonthfi of pregnancy thoy ahall 
oonttntto to iHav^ wiUioui injury to tlio fcciuR. but for tho most part in i •nudler 
quantity/' [Commontarie^ vol, viiL, p *Si*l ] 

^ Dr Elsas^^T, of the Stuttgurt Lying-in Hospitul, records flfly cases in whlct 
menstnifltion fiocurred during pregnancy, an follows i onco in tf, twice in 10, three 
limc« m 12, four in 5, live in C, eight in '*, and nine times in 3 iostiincca. It 
ooeurred most frequently in ovly pregnaocf ; fifteen were pHmipano^ Uiirty-tlvc 
multiparBt. 



PLATE I 




Vhu'd mondi 






AREOLA OK THIi: RHEA^ST 
Fourth month 



TOR PRLXCirLKS ANl 



VICE OF OBSTETRICS, 



145 



uant she ceases to have " her tunis" — that in cases in which a 
female desires to conceal her situation, she will sometimes mark 
her linen with blood, in the hope of iin| nosing upon the practitioner 
and othcre, in reference to her true condition. 

/^ Omtlathn incompaHbk with Gestation ? — It would seem in 
perfect keeping with the physiology of ovnlation that this function, 
as a genenil rule, shouhl cease as soon a^ fecundation has been 
accomplished, and its fiUp[>rcssion conliaued during the entire period 
of the gravid state. The rchitions of the uterus imd ovaries, when 
fecundation has been effected, become, for the time being, changed. 
The former constitutes a new centre, and there is a constant 
incre;ise of fluids toward it in order that it raiiy be enabled to 
accorapli^ih the nutrition and development of the foetus. The 
ov-arie*^ on the contrary, aUhotigfi they do actually become enlarged 
during pregnancy, surrender their sjiccial function — the periodical 
ri|jening of the ovules. This, I repeat, is undoubtedly the rule ; 
but* like all rules, it has its exceptions. The fact tliat a menstrual 
flow i« |>OBsilile in gestation necessarily involves the admission of 
OTulationi for the sanguineous discharge which ordinarily cha* 
ractenj^es the menstrual period is but the product of ovulation* 
At the same time it must l>e adraittetl that the regular catamenial 
ev^acuation througlj the term of pregnancy must be regarded as an 
extremely rare exceptional circumstance ; and when it does con- 
tinue after the early months, the discharge of blood can only pro- 
ceed from the cervix or upper portioji of the vagina, the cormex- 
ion of the ovum with the internal surface o\' the organ being 
such as to prevent any portion of this smrface from constituting the 
rce of the discharge. 

U menstruation, when it takes place during pregnancy, is most 
"apt to occur in the first two or three months, it might possibly be 
confounded with a threatened miscarriage; the distinction, how- 
ever^ would consist in the more or less regularity of its recurrence, 
and its peiiodieal cessation, together with the fact of an absence 
of any appreciable cause to which tho discharge of blood could bo 
ascribed* It sliould also be recollected that the appearance of the 
catamenia, in consequence of tho congestion accompanying it, 
would itself, in the earlier period of pregnancy, be likely to provoke 
miscarriage, lleuce, in c;ises like these, the importance of so mid 
judgment; let the patient, at the time, be kept quiet, and, if ple- 
thoric^ the abstraction of a small quantity of blood, with a sobible 
condition of the bowels, would be indicated. If, on the contrary, 
she be in an opposite condition — nervous and irntable^ — then the 
soothing influence of antispasmodics or anodynes is the resource. 

There are, however, other conditions of the uterus than a 
threatened miscarriage, which might possibly be mistaken for tho 
eataiaeuia — such .as a polypus, ulcerated carcinoma, or even a 

10 



146 



THE PRIKCIPLE3 AXD PRAOTiC 



fil>ran8 tumor developed within the uleririo cavit)% each of which 
would be aeeonijir»nit»d with mure or k^ss sanguineous discharge, 
and it maj also be added tliat the hemorrhage coiisequent npoD 
placetUa prapvia miijfht, under certain clrcuinstuneeB, lead to emUar* 
rassiiient in diagnosis* 

Mtnstntatlon only ilarlng Pregnancy. — ^The experience of 
DeweeH, Baudelocque, and others, seem fully to establish the eircuiti* 
itanee — and examples are given by these writers — iliat, as exceptional 
ea^^es, some women meriBtruate during their gestation and at no other 
time. Deventcr eiiei* a remarkable case in which menstruation 
occurred during gestatiun only, in four succesi^ive pregnaneieii. In- 
stauceii, well autiientioaled, are also recorded showing the possibility 
of impregnation before the first menstrual eruption, and also after 
the final cesi^atiori of tliis function, so far, at least, as the sanguineous 
discfiarge is concerned*, and, agfiin, you will meet sometimes with 
examples of pregnancy during the period of lactation before the 
reappearance of thocatamenia; so you see, gentlemen, that the cata- 
menia, whether present or absent, establis!ies notliing, ptr i^^ wa to 
the exi**tence or non-existence of gestation ; an<l 1 may observe, 
while yon remember the general rule, that pregnancy is followed by 
fluppression of the menses, you are also to bear in mind tlie name- 
xous exceptions, 

2. Naitsea and Vomit in ff^ with Depraved Appetite, — ^I have 
already renmrked to you that women, when they become pregnant, 
are usually affected with sick ntomach, and you have also been 
"infonned of the importance of this gastric irritability to a healthy 
gestation. It h an interesting fact that, in some females, nausea 
manifests itself almost sinmllancously with the act of fecandation, 
1 Ijave known Indies who, from this very circumstance, would 
positively atfirm that they were pregnant, and the result proved 
that they were right.* 

The nausea and vomiting of geatation are peculiar, and differ 
from idiopathic or primary vomiting in the important fact tlint. In 
.the latter, there is an indication of more or less ju-imary disejiw? of 
the stomach ; while, in the former, there i;* no Buch indication, nor 
are there any symptoms of general ilUhealth ; as t^oon as the oon* 
tents of the stomach have been ejected, the female is, for the lime 
being, quite comfortable- Ordinarily, the nausea and vomiting of 
pregnancy cease about the period of quickening, and frequently 
«arlien Sometimes, however, they will recur during the last two 

• Tliero ftre some eurioua casc« reported in mipport of i]MB opinion, ** I ir»i 
engHg^d to attiMid n Indv in her fourth lAbor, which gho told me? ftlio ex[>coted would 
l»ke place on the 12th uf No?iMnVs^r, eftrlj in tho mom'tDg of whidi day I was »ai 
lbr» ftod she fipav^ birth to a dnugfhter ; she told mo that iihe had olwnyt reckoned 
aiiM laoiiths trom tho ftrrt fooliog af aausQ«, mad had never been misUlcvD.* 
.pCoQlflomeiy, p, 90] 



THE PBINCIPLES AND PRACTICE OF OBSTETRICS. 147 

or three months of gestation, and this seems to be dependent upon 
mechanical causes. The uterus in its ascent at this period induces 
more or less irritation of the stomach through the pressure exer- 
cised upon it, and hence vomitmg, under these circumstances, will 
be more likely to take place immediately afler a meal, in conse- 
quence of the greater distension of the organ. I say that the irri- 
tability of the stomach in the latter periods of pregnancy is chiefly 
mechanical ; it is well to distinguish it from the nausea and vomit- 
ing of the earlier months, which I hold to be altogether physio- 
logical, and which has been explained, in the preceding lecture, to 
be due to a reflex action of the spinal cord from the uterus to the 
stomach.* 

It must, however, be borne in mind, that mere functional or 
organic disease of the utenis will oftentimes be followed by this 
irritability of stomach ; it is, indeed, a very common result of sup- 
pression of the courses from any of the causes, with which preg- 
nancy itself has nothing whatever to do. 

I am not a little surprised that so accomplished an obstetrician,f 
and so valued an authority as Paul Dubois, should say, that vomit- 
ing is not necessarily associated with gestation. Indeed, I regard 
this symptom as among the most constant accompaniments of preg- 
nancy, and its relation to this state, as a general rule, is based on 
sound physiology. 

3. Depraved Appetite, — A frequent consequence of impregna- 
tion is a depraved appetite— a longing for unnatural food — so that 
some of your patients will consume, with infinite gusto, chalk, slate- 
pencils, and other kindred dainties. Some become passionately 
fond of fruits ; I knew a case in which the lady exhibited such a 
passion for oranges, that the quantity she consumed is altogether 
incredible. On the authority of Tulpius,J salt fish will sometimes 
present irresistible charms. 

I attach more than ordinary importance, as a sign of pregnancy, 
to this depraved appetite, and am disposed to regard it, under . 
certain conditions, as quite a significant circumstance. For example, 
if a married woman, whose general health has been uniformly good, 
should suddenly exhibit this morbid taste, I should be much inclined 
to look upon it, all things being equal, as a strong presumptive 
evidence of impregnation. If you ask me to explain why, my 
answer is, I cannot, except as a matter of observation. But there 

♦ It was the opinion of Haller that the vomiting in gestation is occasioned by a 
putrid element in the seminal fluid of the male, which, becoming mingled with the 
blood, constitutes a sort of poisonous miasm; this may be classed among the 
iknciful notions not unfrequently met with in the writers of the past. 

f Traits Coraplet de I'Art des Aocouchemons, p. 503. 

j " I once saw a woman who, being with child, was so exceedingly fond of salted 
herrings, that before delivery she had eaten fourteen hundred, and this without any 
offence to her stomach, or prejudice to her health." [Art, Obstetric-compend., p. 6a] 



148 THE PRINCIPLES AND PRACTICE OF OBSTETRIGS. 

are many things, which I firmly believe, and yet cannot compre» 
hon<U except on the principle of faith. Man's belief would be 
sadly cartaUed if be rejected everything for which he coald not 
givo a satisfactory explanation. You believe in God, and yet who 
3»*: ;^^ yoa can c»->mprehend his infinite existence ? You believe in 
<fcc"::y. and where b the human intellect adequate to the compre- 
Ii-tc-i.c cf the vast theme? 

Sv "•.fT?-./*. — In cocneii''»a with lLi< depraved taste, it may be 
"jr^f': :?:a«fi :ha: 54; ce w-rcien, •larinj their pregnancy, will exlnbit 
■^i 7r-. ijsni or -ski-^r-irit}!:. md «ecrece e?»rmous quantities of saliva. 
?;; ' !tf 7C7TLa?:i -.'C 7c»f jiaacy iif^rj frc-ni that of mercur}* in the 
"itv*- lac "i^icr^ > 2«. Ti»ir:nr'!al :'2i.:r. zo *<:*reness or sponginess of 
r»v* :'i:n&. *ii»i r-rradra b^^l^ ':t:n±i»i*i •*> ibe salivary glands thcm- 
^'.^ • V !;;,£ j,jnw il- "T 'T.'i z^i Ti^nziTL, bj wiv of episodc, that these 
irs: •i.cvr:* s* if '•>: '^-r ' ;t< fiiri" id :':rh may, peradventure, 
>*«,**v-*,. :>i: T ••■ir rrj.rtaiiorj iriij :•- ii*h^ -r-^ less involved in the 
■:vv^■.^,^•;,c.^ : '/r.rm. I^n u« Kuj'jiOSr & as* 12 iHa^t ration : Mrs. A. 
w-.-^- r< **.r.o t-f y oi driring h*rr j»rf^jnaiirT : h^ bowels are tor|)id, 
^*.-\ t* 'Sk^^r.e 1 tlior n-a^in, yon jiid^e it Deowsfcry to order an aperi- 
<^.i . -.^.r.ohio. Sjon aft'-r tlii*? nhe l>ecoire? siI:vaieJ. You are at 
^•w;^*^* **V:.-*nrexl with having adrriifji-tfred merrrry; you are severely 
svv^.;rxsU and, in all j*rol/abi!ity, your exf^t will be very unceremo- 
r,;*"/.^-> furnished you, not with a God-f^j»eed invocation, but with 
aV. ?;v..iginable prejudice a;rain^t you and your skill as a physician. 
To '\ voung man just cornint-ncing i)rofessional life, and without 
iv^»iuation to sustain him, such a contingency would prove a severe 
|n>*K unless he could proinjitly and satisfactorily show that the 
ikitivation complained of was one of the occa4onal phenomena of 
j»ivj^nancy; and his justification would be fiilly established by the 
di;4gnostic evidences of this latter form of ptyalism, to which we 
htivo already alluded. 

The question of salivation during pregnancy, in a physiological 
Hollar, is interesting, for there can be no doubt of the sympathy 
i^viHting between the sexual organs, both in the male and female, 
Hud the salivary glands. In j>arotitis, or mumps, in which the parotid 
gland becomes the scat of inflammation, it is qidte usual, after a few 
it*iVH, for the testes in the male, and the mammaj in the female, to 
luiMuno enlarged and j)ainful ; as soon as this enlargement takes 
plaiMs the tumefaction of the parotid disappears. Instances, also, 
\^ ill Hiunetimes occur of malignant disease, developing itself in the 
fcuhmaxillary and parotid glands of women at the period of the 
tiiiul cessation of the menses. 

^'anges in the breasts— The Secretion of Milk— The Ar& 

\ general rule is that, soon after impregnation has taken 

breasts become the centre of an afflux of fluids, and con- 

^••^e ; the enlargement is accompanied by more or less 



PLATE IT 




Tiflh month 




r] 



\ 



AREOLA OF THE BREJAST 
Sixth mcnik 



A. 






>iir.'<r 



^••> 




TUE FKINCIFLES AND PKACTICE OF OBSTETRICS. 149 

of a pricking or stinging sensation ; they are much firmer to the 
touch, and enjoy a greater degree of mobility. This greater firm- 
ness and mobility are not usually observed in the manmiaB, when 
their increase of size is merely dependent upon the accumulation 
of fatty material. The nipple, in consequence of the tumefaction, 
is more prominent, and oftentimes painiiil. The veins, coursing 
along the breasts, become distended, and can be distinctly traced 
by the naked eye. The particular period after pregnancy at which 
these changes occur is variable ; sometimes they begin to develop 
themselves in two or three weeks, sometimes not until the lapse 
of two or three months, and, in women of delicate constitution, 
there will oftentimes be little or no change in the size of the mam- 
mae until the latter months of gestation. Indeed, I have seen cases 
in which, even after delivery, there could be detected not the 
slightest physical alteration, and generally, in such instances, the 
secretion of milk does not commence for several days after the 
birth of the child, and occasionally, there is not a drop secreted at 
any period after delivery, thus depriving the mother, whose heart 
is in the right place, of that most natural and sacred duty — the 
nursing her infant. 

The mamma) are really annexse of the generative organs in the 
female, and, according to the general law, have an important oflice 
imposed upon them — the elaboration of food adapted to the wants 
of the new-born child. Charles Robin has pointed out an extremely 
interesting I'act in reference to the true physiological relations of 
the mamma) to the uterus during the progress of pregnancy. He 
has shown that there is a correspondence in the development of the 
tissues of the uterus, and the glandular culs-de-sac of the mammary 
organs. These glandular culs-de-sac, ia a state of partial atrophy 
when gestation does not exist, become cognisable, and are lined 
with their epithelium at the time the fibre-cells of the uterus undergo 
an increase in volume. 

There are numerous causes, other than pregnancy, capable of 
giving rise to an increase of volume in the breasts. It is quite 
common for women to suffer more or less from tension of the mam- 
ma) at the time of the menstrual turns. In fact, this fulness of the 
breasts is sometimes the very indication by which the female becomes 
aware of the approach of her catamenial period. Again : nothing 
is more common than enlargement of the breasts following sup- 
pression of the courses — the same thing occurs, also, in various 
diseases of the uterus — more especially in cases in which there 
may be morbid growths, such as polypus, submucous fibrous 
tumors, hydatids, or other morbid developments. 

Milk in tlie Breasts. -The presence of milk in the breasts is 
regarded by many as a very important evidence of gestation ; but 
while it is one of the usual accompaniments of pregnancy, it. muati 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS* 

not be for|;otten that the secretion of milk may take place in vari- 
ous cuiiditions uf the system in wbieh impregnation has not occur- 
rexL The very mammary sympatbie^ to whicb we have just alluded, 
including the secretion of milk, so far from being necessarily due 
to pregnancy, are^ in fact, oftentimes the results of ovarian excite- 
ment,* no matter from what cause* Hence, milk will sometimes be 
secreted in disease of the ovary, and in the various menstrual aber- 
rations. It ia a well -established fact, that milk has been recognised 
in the breasts of young virgins, and also of nudes. An interesting 
ease is mentioned of a taithful young woman who, in order to quiet 
the infant of her mistreSvH, was in the habit of applying it to her 
breast, the consequence of which was a free secretion of milk. 

Perhaps one of the most extraordinary examples of this kind on 
record — and which is regarded as perfectly authentic^ — h that of a 
little girl, in France, eight years of age, deaf and dumb, who, by 
the repeated application to her breast of a young infant which her 
mother was suckling, had sufficient milk to nourish the child fur a 
month, during winch time the mother was unable to nurse it on 
account of sore nij^iles, Ttiis little girl was exhibited to the Royal 
Academy of Surgery on the Uith ot October, 1783, and had such a 
quantity of milk that, by simply pressing tlie breawts, she caused it 
to flow out in the presence of tho Aeailcniy; on the same dn}\ she 
ditl the stiine thing at the house of Baudelocque, before a large 
class of jiupils.f The ftxci may surprise you, but it is well known 
that virgins, old women, and even men, are ollen employed as wet* 
nuraea in the Cape de Verde Islands. In the lower animals, milk 
will occasionally be found in the teats as the mere result of sexual 
excitement — ^in some instances, in which coition has taken place 
"without fecundation, and in tjlhers, in whicli the female has become 
excited without intercourse with the male.J 

* Oq the llth of Mar, 18r>7, Mrs R. camo to the clmiofor proresaional advioe 
onder itio following circumiit4U>ceji: S})o had been nmmed iweoty-Uiree jeara; ini 
forty-two jcurs of age^ utid Uvr only clald wiis nineteen yeiir* old. With ibo excep- 
tioa of tlio period of pregnuocy and lactiitioii^ Ler (x>un»e8 Imd olwaya bt!>ea regular* 
auUl about six moiitha before sbe applied for advico; but she had within these fix 
months become much alarmed from thu oocaeloiiiil ftwelling of ono of her breaflta; 
and, on inquiry, it wn» oBc^rtained that at the time the cour»e« should hare appeared, 
the tumefaction of the breaal Invariably occurred, and subsided aa aoon as the oata- 
monial flow took place. There wae not the sH^^htest Indication of tumor or other 
disease of the mamma; it was simply an example of what^ perhaps, might be pro* 
perly tcrm<>d mamniary metastasis. The patient wns directed to have four leeches 
applied to i«Jtch groin a few days before the usnid time for the return of the fiiaiaM, 
, ^Hh a view of relieving the ovarian irritation. This simple suggestion had the 
effeot of rt'storing tho function, entirely removing tho engorgemeni of the mammik 
I huTo sijen »<3veral cases of hypertrophy of the brca^t^ following ameDorrhcaa, and 
tba hypertrophy has always yielded on the restoration of the mensinial fuQctioa. 

f Baudeiocque, L^Art des Aocouchemcna, torn, L^ p. 188, in 8v , Pans» 1815. 

I Harvey, In speaking of bitches which did not conceive after coiUon, and wkids 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 151 

TJhc Areola. — ^The next change in the breasts to which I shall 
allude, as indicative of pregnancy, is the condition of the areola — 
that peculiar circle which immediately surrounds the nipple. In 
the virgin, in a normal state, this circle is characterized by a beau- 
tiful hue, not unlike the tint of the budding rose. But I have seen 
it, even in the virgin, under certain conditions of morbid action, 
change this tint for a discoloration more or less marked ; it is essen- 
tial that you should understand the error, which seems to have 
been perpetuated by many clever writers respecting the color of th^ 
areola. According to them, the color is the principal or character- 
istic attribute. This, however, is not so, and the sooner the error 
be corrected and heeded, the better it will be for just opinions. 
Remember, gentlemen, I am now alluding to what may be denomi- 
nated the true areola, by which I mean the areola which, when 
recognised, is, in my opinion, a very solid evidence that gestation 
exists. 

There is no doubt that, under ordinary circumstances, when 
pregnancy occurs, there is a discoloration of the areola ; but as there 
are other conditions of the system in which this change of color 
takes place, it is quite evident that there must be some characteris- 
tics more reliable in order that a correct diagnosis may be arrived 
at ; in other words, if the areola be worth anything as a test of 
pregnancy, it must have some marked and peculiar developments 
dependent exclusively upon gestation ; and this is a question which 
we shall examine presently. Females who are subject to hysteria 
and the various menstrual aberrations, will occasionally have dis- 
coloration of the areola ; and I have observed it as by no means an 
unusual accompaniment of dysmenorrhoea dependent upon chronic- 
inflammation of the ovaries.* 

It is worthy of remark that the deposit of coloring matter, both 
in pregnancy and in undue irritation of the sexual organs, has been- 
observed in other portions of the system than in the areola of the 
nipple. For example, Blumenbach cites the case of a female peasant, 
whose abdomen became entirely black during each successive ])reg- 
nancy ; and a very remarkable instance is mentioned by Camper 
of a woman who, at the commencement of her gestation, began to 
tuni brown, and before its completion, became perfectly black; 
the discoloration, however, gradually disappeared after the birth 

at the time correaponding with the completion of their gestation, if they had been 
fecundated, appeared to be in great distress, says: "Some of them have milk in 
their teats, and are obnoxious to the distempers incident to those which have already 
pupped." 

• Besides the change in the color, sometimes observed in dysmenorrhoea and 
other menstrual aberrations, there are occasionally certain developments characteria-^ 
tic of the areola of pregnancy, such as slight turgcscence of the integument, and 
elevation of the follicles — but these developments are transitory, and disappear a* 
■oon as the menstrual excitement ceases. 



152 



THE PRINCIPLES AND PRACTICE 



iica 



of her child. These and other instances^ seem to prove, to a greater 
or less extent, a very marked relation Letween this depoaiit of black 
pigriieitt, and excitement of the sextial organs* Again ; it b not 
imii8ual to observe, around the umbllicas of the pregnant woman, 
a (lark areolar eui'face; and also a dark, Bometimcfl brown, Vma 
extending from the pubes to the umbilicufi. 

The areola has been studied with great attention hy Dr. Mont- 
gomery,* of Dublin, and bin de^cripuon of its true ehjiracteridUcs, 
flo far as bemg the result of pregnancy, is so faithful to natui-e, 
that I shall recall to you brit-ily what he says on the subject, *^ I 
caimot," Ije observes, *' say positively what may be the very earli- 
est period at which the changes may be observed, but I have 
recognised them at the end of the second month, at which time 
the alteration in color is by no means the most obvious circam- 
stance ; but the putl'y tnrge^cence (though as yet slight) not alone 
of the nipple, but of the whole of the surrounding disc^ and the 
development of the little glandular follicles, with the developed 
stato of the mammary veins, arc tljo objects to which we should 
principally direct our attentituj ; the color, at this period being, in 
general, little more ihau a deeper shade of rose, or flesh color, 
BliLrhtly tinged occasionaUy with a yellowisli or light brownish hne. 
During the progress of the next two or three months, the changes 
in \he areola are in generd j>erfected, or nearly so, and then it 
presents the following characters: a circle around the nipple whose 
color varies in intensiity, according to the particular complexion of 
the individual, being usually mudi darker in persons with Wvu^k 
hair, dark eyes, and sallow skin, than in those of fair hair, light- 
colored eyes, and delicate complexion. The area of this circle 
varies, in diameter, from an inch to an inch and a hidf, and in- 
creases in most persons as pregnancy advances, as does also the 
depth of color, 

** In the centre of the colored circle, the nipple partakes of the 
altered color of the pail, is turgid and prominent, its ai»ex being 
more or less covered with little branny scales, produced by the 
drying of a sero-lactescent fluid which oozes from the part ; the 
surliice of the areola, especially that portion of it more inmiedi- 
atcly around I he base of the nipjile, is rendered nnerjual by the 
ghmtlular follicles, which, varying in number from twelve to 
twenty, prqjeet from the sixteenth to the eighth of an inch ; and, 
lastly, the integument covering the part appears a little raised * 
emphysematous, turgesceut, softer, and more moist than that which 
surrounds it ; while on both, there are, at this j»enod, especially in 
women of dark hair and eyes, numerous round sfKits, or smiUl 
mottled patches of a whitish color, scattered over the outer part 



^ Signs and Symptoms of ProgQMicx. 2d EditloQ, p. 91. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 153 

of the areola, and for about an inch or more all round, presenting 
an appearance as if the color had been discharged by a shower of 
drops falling on the part. Dubois, referring to this appearance, 
applies to it the designation of secondary areola. This appearance 
is not recognised earlier than the fiflh month, but toward the end 
of pregnancy is very remarkable, and constitutes a strikingly dis- 
tinctive character, exclusively/ resulting from pregnancy ; the 
breasts themselves are, at the same time, generally full and firm ; 
and venous trunks of considerable size are seen ramifying over 
their surface, sending branches toward the disc of the areola; 
together with these vessels, the breasts not unfrequently exhibit, 
about the fifth and sixth months, and afterward, a number of 
shining, whitish, almost silvery lines like cracks ; these being most 
perceptible in women who, having had before conception very 
little mammary development, exhibit a rapid and marked enlarge* 
ment on becoming pregnant. When once formed, these lines con- 
tinue permanent, and, therefore, will not serve as diagnostic marks 
of a subsequent pregnancy, and sometimes they do not form at 
all."* 

Such are the essential characters generally belonging to, or con- 
nected with, the true areola, the result of pregnancy ; and I quite 
agree in opinion with Dr. Montgomery that when these peculiar 
features are recognised in the areola, they should be regarded as 
positive proof of pregnancy, no other condition being capable of 
producing them. The true areola, I repeat, in my judgment, and 
this opinion is founded on extended observation, is not recognised 
except as a consequence of gestation. 

The remarkable case which came under the observation of 
Hunter, it may be well to mention as an instance of his faith in 
this sign. It was chiefly on the presence of the areola that he 
founded his opinion of the existence of pregnancy in a young 
woman, who had been examined after death by his pupils, and in 
•whom there w\is an intact hymen ; and, therefore, the appearance 
of virginity. In laying open the uterus, it was found that Uunter 
was right. 

Let us for a moment look at the per contra of this question. 
Can pregnancy exist without the development of the true areola? 
In my opinion it can, and upon the principle of an exception to a 
very general rule.f I have already remarked to you that some 

• See Plates 1, 2, 3, 4, 6, transcribed from Dr. Montgomery's work, and which 
are most g^phic delineations of the areola in the difierent staphs of pregnancy. 

f In December, 1856, I received a letter from Dr. H. P. Ferguson, of Western 
Tirginia, who kindly sent me a patient, for advice, who had been under his profes- 
sional care for some months. The lady was twenty-seven years of age, had been 
married eight years, but had never borne any children, nor had she ever been preg* 
nant Her general health had always been good, and her menstrual tuma regular. 



154 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



women will pass through their gestation without the elightegt 
enlargement of their brea^^ts ; and you will occjisiioually raeet with 
cases in which the chancres in the areola do not commence thoir 
devt'lopment until the hitter months of gestation. It must also be 
recolleLtiMl that nursing women, who have recently miscarried, may 
present the peculiar attributes of the areola j no that it may de* 
volve on you to nhow, not only that the true areola is ab^olutelj 
the product of (irefj^nancy, but that the pregnancy of which it Ib 
the proiliu't, still exi«tg * 

Probahh m^nthnres : 

Changes in the Uterus and Abdomen, — ^You have already been 
told that, when fecundation takes place, immediate and remarkable 



until the June previous) to my a^cttig bcr. From that t'uno until December, when 
she Cnst consul ti?d nii?, her courses had been suppressed ; 8h« h;id mo»l of the urdi- 
Uftry symptoms of preKoancy^ except that theru was not tiie ftliji^hU'^t cUjittgu in the 
bre&Bta, nor any approjich to the formation of ttie areoU. Tbifi Indy had been niuch 
annojed by nausea and vomiting for four months after the menses became buji- 
preas4}d, and her appetite had been remarkably dcpmved ; her abdomen wks en- 
lugged oorrcsponding with u six months gestation— and yvt the breasts, which had 
Always bccQ smull, exhibited not the s)ight«-4t change in devchjptnent, Tht* pnttrnt 
Obeerved t^i me, in reply to my inquiry, \.\\&i slie liad not felt Any niuvem««nt ui her 
abdomen ; and, although she wna most anxious to be a mother, she suid she was 
qujt«? confldeot she was not pregnant. Dr FerguR»>u, in his kuer, remarks, ** Wrro 
it not tlmt the breasts remain unchanged, I should say that Mrs, L, is undoubtedly 
in gi^tntion; l\ave you over seen a case of pregnancy unaccompanied by the 
slightest mammary development?*' As this hidy was most anxious to have hef 
true situation oKcertaitied^ aud as she kad been rendered very unhappy by tbo 
apprehension that her enlarged size was oooasioned by the presence of a tumor, 
which would destroy her life, I proceeded to a very thorough invesiigaiiou of her 
case On a vaginiil examitiation, 1 soon discovered that the abdominal enlarge- 
ment was caused by the enbrgement of tlio uterus; applying one hand to the 
abdomen, with a view of gently grasping the uterus, and the index ^ugor of the 
other hand placi*d on the ^Kistenor portion of the eorvix uteri, with an alternate 
movement of ascent and descent made with the hands tlius applied, I very distinctly 
felt tlie pii«aive motion of the foetus* known by the French as the haihAtinient, and^ 
Bometimes described by the English under the term reptrcuasitm^ to which I shall 
have oeooston hereafter more particularly to allude^ when speaking of the vaginal 
cxploraiiona in reference to the diagnosis of pregnancy. So certain and unequivo- 
cal do 1 regiird the biiHotement as proof of gestation, that I at once^ without llio 
least uushtleation^ assured the lady alio was preguau*. This opinion seemed to give 
her grcnt pleoiiuro; and Nho very quietly, but pointedly^ asked me, ''Whether! 
wouhi stake my reputation on the opinion I had given/* I immediately n^plirHl 
that I was quite content to abide by the revelations of the future, and that *he 
would discover the fuitine would fully indorse my opinion. She led Kew York 
Janufiry 3d Tor her home in Vlrgiuia, hearing with her a letler to Dp. Ferguson, in 
which I expressed my positive conviction of her pregnancy ; all doubt in her mind 
WOB diRiipttted by tiio birth of a daughter on the 27th of the following March> 

* It will be observett that I tiave classed the art^ihi among tlie pfesiimptiv9 erl- 
denccs of f2;estalion. fur the rt*ttSon that I did not desire to separate it from the 
OOttsideratioo of the mammary sympathies At the same time, I regard tho true 
trtohi as among the most positive signs of (ireicnancf. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS, 



155 



changes begin to exhibit themselves in tbe nterus; tbese modifica- 
tions we now propose to examine, in order that they may receive 
their true value as evidences of geataiion. It is only necessary to 
remember the iniportaDt dntics which the uterus is called upon to 
discharge in the brief period of nine months— the accommodation 
and nutrition of the growing embryo^ — to appreciate the urgent 
necesiiity there is for marked and rapid idleration both in it* 
structure and functions. Almost simultaneously with the act of 
fecundation, and even before the product reaches the uteru?, this 
organ becomes tbe centre, so to speak, of an extraordinary fluxion. 
This concentration of fluids results necessarily in increase of vo- 
lume, because of the increase of tissues. 

Descent of the Gravid Vtents thiring the First Two Months, — 
Contrary to what might, at first view, be imagined, the tendency 
of tbe uterus for the first two months after impregnation is, not to 
ascend into the abdomen, but to descend into the pelvic cavity; 
and there are certain phenomena, during the earlier periods of 
pregnancy, consequent upon this depressed condition of the gravid 
organ, which it is important to remember : 

1, As the direct result of tlie descent of the uterus, there will 
be more or less frequent desire on tl»e part of the female to pass 
water, because of tbe pressure of the organ on the neck of the 
bladder;* sometimes, also, there will be a species of tenesmus, 
more particularly if the pressure of the uterus, instead of falling 
on tbe neck of the bladder, should, as sometimes will be the case, 
be directed against the rectum, 

2. It is only necessary for you to refer to what was said, when 
describing the relations of iho pelvic viscera to each otiier, to 
understand why an alteration in the position of the uterus must 
neoessarity affect, more or less, the position of the bladder ; so 
that, as the uterus descends into the pelvis, so measurably must tbe 
bladder ; tbe effect of this change of position in the latter organ, 
will be pain at the umbilicus, and a cup-like appearance of the 
cavity. Sir Charles Clarke claims to have been the first to direct 
attention to this pain at the umbilicus as a result of procidentia 
vesicae, and explains tbe connexion between cause and effect on 
very rational grounds. The superior ligament of tbe bladder, 
formeii by the remains of tbe two umbilical arteries, extends 
from the fundus of the organ to the umbilicus ; the bladder being 
prolapsed, the ligament is put upon the stretch, and hence the 
pain and increased cuji-like fossa. f 

^ This desire Ibr fVequent micturition us not cxdusivGly tho result of a meclmtiicftl 
GHIIOi il 19 \U Qart due to retlex iulluenee. 

\ I am dlsposi'd to attjich more than ordinary importaniNB to tlio pam nnd 
increMod excuvfliion of tJm umbilicua as early indicAtiona of prej^inncy, especially 
If thero have previously been no displacement of the uterus or bladder (hmi other 



% :-^^ 



IlIJv PIUNCIFLES AND PHACTICE OF OBSTETRICS. 



149 



of a prickiHg ur stinging seubutioii ; they are much firmer to the 
touch, aud eiyoy a greater degree of mobility. This greater firm- 
ness ftud mobility are not usually observed in the mammee, when 
their increase of size is merely dej^encleot upon the accumiilatioQ 
of tatty materiaL The uipple, in cuiisequenee of tlie tmaefactioii> 
is more prominent, aud uitentimes painful. The veins, coursing 
along the breasts, become distended, and can be distinctly traced 
by the naked eye. The paitieular jieriod after pregnancy at which 
these changes occur La variable ; sometimes they begin to develop 
themselves in two or three weeks, sometimes not until the lapse 
of two or three months, and, in women of delicate constitution, 
there will oilenlimes be little or no ehauije in the siaws of the mam- 
line until the latter months of gestation. Indeed, I have seen cases 
4n which, even after delivery, there could be detected not the 
iKghtest physical alteration, and generally, in such instances, the 
secretion of milk does not commence for several days after the 
birth of the child, and occasionally, there is not a drop secreted at 
any period after delivery, thus depnvtng the mother, whose heart 
LH in the nght place, of that most natural and sacred duty — the 
nursirig her infant. 

The mamma> are really annexaa of the generative organs in the 
female, an<l, according to the general law, liave an important office 
imposed ujion them — the elahonaiun of ioud adapted to the wants 
of the new-born child, Charles Kobin ha^^ pointed out an extremely 
intere>tiiig fact hi reference to the true phy^iulogical relations of 
the mamma* to the uterus during the progress of pregnancy. He 
has shown that there is a correspondence in the development of the 
tiiisiies of the uterus, and the glandular culs-de-sac of the mammary 
organs. These glandular culs-iJe-sac, in a state of partial atrophy 
when gestation does not exist, become cognisable, and are lined 
with their epithelium at the time the tibrc**cens of tlic uterus undergo 
an increase in volume. 

There are nmnerous causes, other than pregnancy, capable of 
^ving rise to an increase of volume in the breasts. It is quite 
(yommon for women to sufler more or less from tension of the mam- 
ma* at the time of the menstrual turns. In fact, this fulness of the 

easts is sometimes the very indication by which tiie female becomes 

^•ware of the approach of her catamcnial period. Again : nothing 

h more common than enlargement of the breasts following sup- 

aion of the courses — the same thing occurs, also, in various 

ea^es of the uterus — more especially in cases in which there 

may be morbid growths, such as pol^^us, submucous fibrous 

tumors, hydatids, or other morbid developments, 

Miik in tfie Breasts. -The presence of milk in the breasts is 
regarded by many as a very important evidence of gestation; but 
while it is one of the usual accom pan im cuts of pregnancy, it must 



158 



THE PBINCII 



PRACTICE OF OBSTKTaiCa 



developiuent, the fiindiis c»f t!je nlertis emerges from Un* pelvic, and 
i0 recogDUcd above the siiperiur strait, imparting to liie toucli the 
aensatioD of a round resijitinii^ tumor, occu]>yiug the lower and cen- 
tral portion of the hypogastric region- It will, however, require 
Bome tact and nieety of inariipulalion to detect the organ at this 
early period through the ahdomiual ualln, espet-ially in u primipura, 
and in women with niui-h adipose or fully matter. Am soon us the 
gravid womb has letl the pelvic ca\ity, and fairly entered the abilo- 
mon, the direction which it then [mraues is altogether changed; it 
now follows a line parulle!, or nearly 8o, to the axis of the superior 
strait; consequently, its course is upward and forward; and ihia 
alteration in its direction necessarily produces a change in the posi- 
tion of ita cen'ix, which becomes slightly elevated, and instead of 
inclining forward, looks backward, and frequently a little to the 
left. You pereeive that, as the uterus pursues the axis of the supe- 
rior istrait, it receives a point of support from the abdominal walla, 
the direct c-onseqnence of which is, that tlie pressure exercised poa* 
teriorly by the gravid organ on the aorta, ascending vena cava, 
ureter's, and npjier portion of the rectum, is much diminished, 

Jlhjht Lateral Obliquity, — It is afj interesting fact to note that, 
in tfie great majority of cases, the gravid uterus, after leaving the 
pelvis, becomes slightly oblique to the right in its long axis, cunsti- 
tnting what is known as the right lateral oblicjuity ; and varions 
theories have been suggested to account for the circumstance. 
Some, with Lev ret, have imagined that it was due to the insertion 
of ihe placenta on the right lateral half of the fundus uteri; but in 
order to make this ex)»lanation satisfactory, proof is required that, 
in all cases of this t^pecieh of obliquity, the placenta is actually in 
adhi'sion at this particular point of the organ ; this proof cannot be 
furnished, for it is directly adverse to facta, and, therefore, the the- 
ory is without a basis, Madame Boivin thinks that the obliquity 
is owing to the shortness, greater muscularity, and strength of the 
round ligament on the right si<ie. I have, myself, never been able 
to detect any difference in the length or structure of the two round 
ligaments, although I have had an opportunity of examining a 
largo number in autopsies. Again : it has been attemjited to show 
that the more frequent use of the right arm, and the greater diju 
position to recline on the right side, give rise to this obliquity of 
the organ. But this is not sustained by facts. Without alluding 
further to the various opinions of writers, allow me to observe that, 
although, perhfips, difticult satistactorily to explain, yet the fact 
itself is interesting and jmjjortant to be remembered. 

At the fourth month, the fundus of the organ is midway bctwoen 
the symphysis pubis and umbilicus. 

At the Bfth, it is on a level with the umbilicus; at this time tli6 
cervix is still higher in the pelvis, and inclined Diore backward. It 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS, 159 

is not unusual for the pregnant female to complain at iho fifth or 
sixth inonth of pain in the right side; this ia often occasioned b)r 
press:iire of the ivscending uterus against the liver. I have gene- 
rally been enabled to pulliate the p:iin with an occasional mercurial 
pill,' followed by a saline dniught. It will twiiolly, however, he more 
or less annoying until the birth of the ehilJ. 

At the sixth month {Fig. 41), the fundus is two lingers' breadth 



^^\ 



V 



N 



\ 



l\. 



•^ 



^■f- 



:.y' 



Fio. 41 Fio. 41. 

SixUi iftontb of goatifcloD. KLntb month of gxwUtiozL 

above the umbilicus \ and, at this period, the latter becomes partly 
inverted with a partial disappearance of its cup-Uke fossa, and forma 
a slight prominence. This peculiar appearance of the umbilicus ia 
worthy of recollection ; it has^ under ordinary circumsiances, Bomo 
value as a sign of pregnancy, although I have seen it aa the mere 
result of abdominal tumors and advanced ascites. 

At the seventh month, the fundus has reached midway between 
the umbilicus and the cui*ve of the stomach ; at this time the umbi- 
lical fossa has completely disappeared, and ihe umbilicus itself', in 
consequence of its inversion, forms a marked projection. The cer- 
vix is still more elevated and inclined posteriorly. 

At the eighth month, the fundus of the organ is high up in the 
epigastric region. There is now great prominence of the abdomen, 
with more or less oppression in breathing", in conijequeuce of the 
pressure of the ascending uterus against the diaphragm ; and it i» 
not unusual for the woman to be troubled more or less with a cough 



160 



THE rRINXnPLES AND PRACTICE OF OBSTETRICS. 



find jKilpitatio?! of the heart. It h just ns well ihv you to rcinem- 
ber in this eaiiucxioti, that the cough is iinaccompaaied wnih fever 
or an excited pulse; it w not the cough of infliimmatory action. 
It,, like the palpitation, ia simply tlie result of the mechanieaJ irrita- 
tiou expevienceil by llie lungs and heart, in consecpience of the 
greater elevatiini of the diaphragm, lima curtailing the usual eap*v 
city of the chest, I speak of tins in order that you may not, 
through erroneous diagnosis, subject your patient, for this cough 
anil [mlpitalion, which will yield as soon as tlie pressure is removed 
from the diu|ihragm, to tlie absurdity of antiphlogistic treatment.* 

Toward the close of the niuth month (Fig. 42), the uterus 
descends into the pelvic excavation, and, as a consecjuence, tliere 
will be more or less vesical irritation, and sometimes a feeling of 
tenesmus occasioned, in the former itistanee, by the pressure of the 
organ against the neck of the bladder, and, in the latter, ag:un8t 
the rectum. But this descent of the uterus, at the close of the 
ninth m<»nth, is followed by a circumstance which should not he for- 
gotten ; I me:in a diminished prominence of the abdomen, which 
will sometimes give rise to the appreHension, on the part of ifse 
female, that something is wrong j that she is oot i>regnant, or that 
her foetus is dead. Again : In consequence of the settling down 
of the gravid womli, the pressure is removed from the fliaj*hragm, 
and, hence, tlie respiration is freer, tlie congli disajipears, and the 
patient experiences a buoyancy of spirits, lorrning a striking con- 
trast with the oppression of the previous few weeks ; this she can- 
not account tor, but which you, knowing the cause oi" the i^hange^ 
can readily appreciate. 

Why does the impregnated uterus descend toward the end of the 
ninth month ? May it not be that, at this period, the organ increaees 
in its transverse diameter, and, at the same time, diminishes in 
length? But, gentlemen, if you ask me whether the descent of 
the organ at this puiiod l>e necessary, whether there be any special 
benelit derived, I ask you, in return, to retiect, for a moment, on 
the important work in which nature is so soon to become engaged, 
viz. the expulsion of the ftrtus from the maternal organs. The 
object, therefore, of this change in the uterus^ is directly connected 
with the birth of the child ; it is, as it were, one of the arrange* 
ments preliminary and essential to the important act of labor. 

These various changes in the position of the uterus, to which we 

^ Althouprtt it is true thflt tlicfle derangeiueots in the roMpiratory orgins. At the 
latter pi'riod of gc^tAtion, are usuailj traceable to the ascent of the iiapUmgtii ; yet 
it must [>e recollected Uiat tiieae phenomena will sometimoa develop tijeniselv«>» at a 
lea aclvancod period of pregnancy, and hero the dyspncea^ cough, «tc,, may b© dae 
to m nervous, or a congvfltiMl condition of the luue (possibly to redema of the orgati)i 
ihtt iKerapeutic iridiciilion will depend upon the special cou5te ; for ernmplo. if it be 
traced to DerTananeaSf liyoaeyamus, thirty or forty drops of Ui« tinctun* ; or If to 
ooogcstion, tli« Judicious intervention of the lancet. 



PJ-ATE JV 




AHKOLA OH- tjif; unF:,\.sr 

XnUh month 



•1 AFr ,\ 




• « 



THE PRINCIPLEiS AND PRACTICE OF OBSTETRICS. 



161 



xe thus briefly alluded, are liable to certain modifieationa. For 
example^ in a multipara — a female who has borne eevera! children 
— the uterns in its ascent usually does uot reach as biorh up in the 
abdomen in the latter periods of pregnancy as in a priuiiparu; and, 
at the same lime, the abdomen is much more protuberaut. These 
two circumstances arise from the fact, that previous preguaueies 
log so distended and relaxed the abdominal walls, the gravid 
womb, encountering but little resistance as it passes upward^ has 
a strong tendency to full forward, constituting a species of ante- 
version of the organ; whereas, in the primipara, its direction is 
more in accordance with the axis of the superior strait of the 
pelvis. In a fii-st pregnancy, the parietes of the abdomen undergo 
extraordinary distension, and conftequeutly become thin ; occa- 
sionally, there is a reparation of the two recti muscles; and you 
will remember an interestiug case, in the clinic^ of a female, who^ 
having been confined with twins, was allerwnrdis much amioyed by 
the protrusion of the intestines thiougli the space left by the 
iparati»>u of these mnscles.* 

Change in the Direction of ihe Urethra.— V\ hvn the gravid 
uterus leaves the pelvic cavity, and during its progress in the 
abdomen, very important changes are effected in the position of 
the bladder and urelhra; the ascent of the uterus necessiirily 
occasions the ascent of the bladder, which, of course, draws up 
the urethra in such a way that, instead of occupying an oblique 
position, as it docs under ordinary circumstances, it becomes more 
and more vertic^^l, so that, in the latter periods of gestntioii, it will 
be found almost parallel with the internal surface of the symphysis 
— a most important fact to be recollected in connexion with the 
introduction of the catheter, ignorance of which will oftentimes 
lead to results mortifying to the practitioner, and disastrous to the 
patient. The superior portion of the urethra will sometimes be an 
greatly pressed upon by tbe gravid uterus, that its lower extremity, 
in consequence of the impeded circulation, will become very much 
engorged, thus giving rise to an enlargement, whicli, if not nnder- 
fetood* might result in erroneous coucltisions. This condilitvn of 
the excretory duct is not unusual, particularly in first pregnancies, 
and arises simply from mechanical obstruction in the blood-vessels. 
It is of no sj^eeial import, except that without this ex[>lanation you 
might possibly, in making a vaginal examination, misaj^prehend 
the nature of the enlargement, and suppose it to be a foreign 
growth. 

(Edema of Lower Extremities. — The a-dema of the lower ex- 
tremiiies, as an ordinary accompanifuent of gestation, amounting 
sometimes to a fully developed anasarc^o, is also explained in tho 

* 8m DliCiiefl of Women and Chlldron, p, 9! L. 
II 




162 THX FanrciPLES and fbaohcob or OBsncTBiGs. 

Hunre way ; that is, obstraction, from preasnre of the impr^gnatod 
womby in the venous ciroolatioii,* thus preyenting the free paMage 
of blood from the low^r extremities to the asoending cava, and 
thence to the right cavities of the heart. In the same mamier 
also, do you account in part for the appearance of hemorriiiridsl 
tumors, so common in pregnancy ; I say in part, for they are like- 
wise due to the constipation, which is the usual accompaniment of 
tBis condition ; the constipation very frequently arising from the 
pressure of the uterus against the upper portion of the rectum. 
You have seen in the clinic several examples of enlargement of the 
veins in the vagina, traceable to the presence of various kinds of 
abdominal tumors ; and you have been told that these venous en- 
gorgements are simply the result of obstructed circulation. In 
pregnancy, also, you will occasionally meet with the same phe* 
uomena ; and I have known, under these circumstances, thromboa 
of the vulva, to produce fearful hemorrhage. In the latter cod* 
tingency, the great remedy is well directed pressure by means of 
pieces of sponge.f 

* There are other oauaes than obstruction in the venoaa oireolation. whScfa nuqr 
•ocaslonally produce oedema, or dropey of the cellular tiaane, during pregnanoji far 
example^ oiiganic diaeaae of the heart, the existence of albuminuria^ ansmiSi alo. 

f For an interesting case of thrombus of the Taginai together with its 1 
sstDiseaaes of Women and Children, p. 463. 




LECTURE XI. 



EvSdeooM of Ptegnaocy continued— -Tlie Effect of Fecundfltlotj on Development of 
Uterua — Onler of Development— Fundua enlarges firat three Moutlis— Body from 
Uiird to sixth Monili — Wisdom of thia Arrangement — Shape of Impregnated 
Utorua— Modiflcfltions of Cervix in Pregnancy — ^Error of certain Authors — 
Uterine and Vuginul Extremities of Cen'ix^^Cc^rvical Canal — Eolaxation of 
Tinsiies of Cervix — Cervix doea not Lengthen — Error of Madame Boivin— Promi- 
neoca of 0« TiDcas— Sofiening and Mol?^ture — Mucous FoUiclea— Development of 
— ^locretBed Macous Secretion not a Pathologicul State^Uies of this Sc^cretion — 
Cerrjx b<?giri8 to shorten at its Uterine, and not at tho Vaginal Extremity — 
i'roof — Opinions of Stoltz and Ca^eaux — Placcota Pncvia and Shortening of Cer* 
rix — Modifications of Cervix in Priroipora and Multiparu^Increased Development 
of Fterino Appendages in Pregnancy — How does tho Cavity of the Uteroe 
enlarge? — Ancient Theory — Increflstd Nutrition the true Cause — Thickness of 
Uterine Wall«; Opiniona reHpecting— Oa Uteri at Time of Labor — Discoloration 
d Vagina as a sign of Pregnancy — Is this Discoloration peculiar to Pregnancy ? 

GENTLEifKN — FroiTi the instant of fecuiiflaiioii until the accom- 
plish oient of the full term of utero-geatation, the womb ia con- 
stantly midergoing the process of development ; tbb iucrerise of 
tUsue and ca[mclty is in accordance with the growth of the embryo. 
In one word^ the exclusive and only object of these changes is to 
provide accommodation and suHtenaoce to the growing germ. But 
the development of t lie gnivid organ is not without order; in the 
arrangement, which nature has instituted for the successive in- 
crease in the volume and structure of the uterus, the obstetncian 
will find much of interest* The increase in the size of the organ, 
although successive, is not uniform ; as an evidence of tin?* fact, the 
growth of the uterus for the first three months U principally 
through the development of its fundus; the body of the organ 
undergoes striking changes from the third to the f^ixth month ; while 
it is not until the three last months of gestation that the cervix or 
neck contributes its share to the general accommodation of the 
embryo. 

You cannot, gentlemen, fail to perceive the wisdom of this order 
in the sucscessive developments of the impregnated uterus ; it is 
e&icntially conservative, and for the protection of both mother and 
chiKL Suppose, for illustration, the order were reversed ; and, 
bstead of the fundus, the cervix should be the fii^st to undergo the 
physical changes necessary for the re<|U!rements of the growing 
fcelus* Do you not perceive, at once, the inevitable results of such 



IfiB 



TEE PKINCIPLES AND PBACTICE OF OBSTETRIOB. 



To£rc4lier with those pcciiliiiritic*, which uanally accompany 
early pregimncy, there U a coii<lition of the abilotneii tit this prriml 
well worthy of attention. One would very njiinrally Bnp|>ose 
that, as soon as the imprognaled nterus began to increaste in hulk, 
there would neccssiiriiy be a corresponding deveh>pmcnt ami promi- 
nence of the nbdoinen. But tlua is not eo ; for the first two uioMlha 
after fecnndntion^ the abdomen^ bo far from heooinitjg prominetit, 
acttiolly recedes, and presents in the hypogafitnc region the a8|>eet 
of flatnesij. This fact had been well observed by the early writers, 
and hence the ancient aphorism ventre pfatj ettfitnt U y a — a flat 
belly denotes pregnancy. On the contrary, about the third montl 
there is ofientiiues quite a prominence of the hypogaijtric region, 
which, in a short time, becomes measurably Iciisened, and hence, 
a woman who in really pregnant may etipijose that she is not so^ 
for the reason that at the fourth month she will frequently be 
Bmaller than at the third. 

It is important that you should comprehend the oanse of this 
difference. At the third month, just as the gravid uterus begins to 
leave the pelvic excavation, it is not at all unusual for the small 
intestines, which rest, as it were, upon the fundus of the organ, to 
become more or less distended with flatus, and it is owing to thi« 
circumstaoce that the greater volume of the abdomen is due ; as, 
however, the period of the tburth month approaches, this distended 
condition of the intestines disapijears. What is it that produces 
the flatulent state of t!»e bowels at the third month ? May it not 
be due, in the first place, to the irritation experienced by the gan- 
glionic nerves of the uterus, and thus transmitted to the chylopoie- 
tic viscera ; and, secondly, to a reflex influence occasioned by the 
physical changes going on in the uterus itself? I am inclined to 
think that this U the ex[>latmtiun ; but you may urge the objection, 
if these Ciiuses should occasion the collection of flatus at the third 
month, why should they not also, d fortiori, occasion it duiing the 
entire period of the subsequent pregnancy ? I answer that it 13 
probably because the iligc?<tive mechanism becomes in a short time 
accustomed to these combined influences, and ceases as a eonse- 
quence to suffer any derangement. Be the explanation scitisfiictory 
or otherwise, the fact is worthy of recollection. 

I^osi(iort8 of the Gravid Uterus, — Let us now recall to memory 
the various positions of the impregnated uterus from the earliest 
moment of conception until the coni[>letion of the i^dl period of 
gestation. These gradual changes of position it is absolutely 
fjcccssar}' for you accurately to comprehend, for they have a x^ry 
important bearing, not only on the question of whether pregnancy 

flKom; for it must be recoll€«it43d that> to p.^1apBioii of either of Lbess viicer^ 
^ lllogelher tin connected with goetatiOD, the umbiliosa vrUI osuaUy ondergo the Mint 
laniSQt AB in pr^gimocy. 



THE PRINCIPLES AND PRACl'ICE OF 01 



157 



exists, bnt also a* to the particular period of the gestntion iti*Glf, 
For the first three months, the irapregoated organ is confined 
within the limits of the pelvic excavation ; this is ilje general rtile, 
but there are uecasionally exceptions to it» The ntenis, vvliile 
lodged in the pelvic e^ivity, continues to grow and increase in size, 
and Las a tendency to incline toward the hollow of the sncrnm, 
which %vill consequently cause the cervix to diverge slightly for- 
ward from the centre of the excavation ; and at the same time, 
becaose of the ordinary position of th** n-ctum to the left, the fun- 



y\ 






Third DKniUi of gceUtloti* 



dng and body of the organ are pushed to the right, which will 
necessarily induce a deviation of the cervix slightly toward the left 
of the pelvic excavation. Thus, you perceive, gentlemen, that, for 
the first three months after impregnation, for the rea'ions just 
stated, the direction of the neck of the u tenia present* three pecu- 
liarities, viz* downward, forward, and slightly to the left. I have 
repeatedly remarked, espeeially in a first pregnancy, that the 
patient would complain, in the earlier periods of gestation, of a 
sense of numbness and darting pains in the lower extremitie!?; and 
you see bow easy it is to account for these phenomena — the sacral 
plexQg of nerves, situated in the cavity of the pacnim, becomes, 
from the pressure of the uterus, more or less irritated, and thin irri- 
tation is immediately transmitted to the great Ischiatic and its tri- 
bntarie^, and hence the feeling of numbness and pain. 

At the third month (Fig. 40), in consequence of its progresaivo 



158 



THE PRINCIPLES AND PRACTICE OF OB3TKTRIC3. 



dcvelopnienl^ the fundus of the uterus emerges from the pelviH, and 
is recognined above the sjiiperior Ktrait, iinimrirng to the lourh the 
sentiatian of a routid re«istin*^ tumor, oecujiying the lower and c^i- 
tral portion of thtj ljypog:u5tric region. Il will, however, reqmrc 
some tact aud nicety of manifmlatiou to detect the organ at this 
early period through the nbdoiuirial walls, es})eeially in a priirdpnra, 
and ill women with much adipose or fatty matter. A«i 80011 as the 
gravid womb ha-?! left the pelvic cavity, aud fairly entered tlie abdo- 
men, the direction wliich it then |iuiiiues is altogether changed; it 
now follows a line parallel, or nearly so, to the axis of the superior 
Rtrnit; consequently, its course is upward and forward; and this 
alteration in its directiou necessarily produces a change in the posi- 
tion of its C4?rvix, which becomes slightly elevated, and instead of 
inclining forward, looks backward, and frequently a little to the 
left. You perceive that, as the uterus pursues the axis of the supe- 
rior striiit, il receives a point of support from the abdominal wall«^ 
the ilirect consequence of which is, that the pressure exercised pos- 
teriorly by the gravid organ on the aorta, ascending vena ca^^a, 
uretci-s, and upper portion of the rectuui. Is much diminished. 

Iltght Lateral OhUquity, — It is an interesting fact to note that, 
in the great majority of cases, ihe gravid uterus, after leaving the 
pelvis, becomes slightly oblique to the right in its long axis, consti- 
tuting what is ktiown as the right lateral obliquity ; and varioas 
thc^ories liave been suggested to account for the circumstance. 
Scune, witli Levret, have imagined that it was due to the insertion 
of the placenta on the right lateral half of the fundus uteri; but in 
order to make this explanation satisfactory, proof is required that, 
m all cases of this hpecies of obliquity, the placenta is actually in 
adhesion at this |>artieuhir point of the organ ; this i>roof cannot be 
furtiisheil, for it is directly adverse to facts, and, therefore, the the- 
OPy is without a basis. Madame BoiVin thinks that ihe obliquity 
is owing to the shortnesa, greater muscularity, and strength of the 
round ligament on the right side. 1 have, myself^ never !>een abJ© 
to detect any ditTerencein the length or structure of the two round 
ligaments, although I have had an opportunity of examining a 
large number in autopsies. Again : it lias been attem|jted to show 
that the more frequent use of the right arm, and the greater dis- 
position to recline on the right side, give rise to this obliquity of 
the organ* But this Is not sustained by facts. Without alluding 
further to the various opinions of writers, allow rae to observe that, 
although, perhaps, difticult satisfactorily to explain, yet the fact 
itself is interesting .and important to be remembered. 

At the fourth month, the fundus of the organ is midway between 
the symphysis pubis and umbilicus. 

At the fit\h, it is on a level with the umbilicus; at this time the 
cervix is still higher in the pelvis^ and iuclined more backward. It 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



159 



1 not tmiiMual for the pregnatit ft*male to comitl:iin at tlie tifth or 

^sixth motitb of paio in the right side ; this is otlen OL-ca^ioned bj 

presHure of the ascending uterua against tli© liver. I have geiie- 

Lrally heew enabled to pulliate the pain with an oueasional merenrial 

rpillj followed by a saline draught. It will iiftuiilly^ however, l>e more 

or less annoying until the birth of the ehilJ. 

At the sixth month (Fig, 41), the fiindua is two fingers' breadth 



L^x 



V 



} 



Fio. 4t Fio. 4f . 

Slitb mootl) of gMtitlon. Klstb tnooth of g«0tstlon. 

above the umbilicus ; and, at this period, the latter becomes partly 
inverted with a partial iliaappearancc of its cup-like fossa, and forma 
a slight prominence. This peculiar appearance of the umbilicus is 
worthy of recollection ; it has, under ordinary circumstances, some 
value as a sign of pregnancy, although I have seen it as the mere 
result of abdominal tumors and advanced ascites. 

At the seventh month, the fundus has reached midway between 
the umbilicus and the curve of the etomach ; at this time the umbi- 
lical fossa has completely disappeared, and the umbilicus itself, in 
consequence of its inversion, fornis a marked projection. The cer- 
vix is still more elevated and inclined posteriorly. 

At the eighth month, the fundus of the organ is high up in the 

epigastric region* There is now great prominence of the abdomen, 

with more or leas oppression in breathing, in consequence of the 

pressure of the ascending uterus against the diajihragm; and it ie 

, not unnaual for the woman to be troubled more or less with a cougli 



180 



THE PRIKCIPLES AND PKACTICE OF OBSTETRICS. 



and |):ilpitatiurj of the heart. It is }mi as well for you to reniem^ 
ber in tlib eonnoxiou, that the coagh is unaccompanied with i\*v6r 
or an excited pulse; it is not tlie cough of in flam mat cry nctton* 
It, like the palpitation^ U t^ira[)Iy the result of the mechanical iriita- 
lion expenencetl l»y the lungs imd heart, in consequence of tho 
greater elevation of the diaphrngm, thus curtailing the usual capa- 
city of the cliei^t. I speak of this in order that you may not, 
through erroneous diagnosis^ subject your patient, for this cough 
and palfutation, which will yield as soon as the pressure is removed 
from the dia[»liragm, to the absurdity of aniipfilogisiic treatment.* 

Toward tho close of t!ie ninth montli (Fig. 42), the uterua 
descends into the pelvic excavation, and, as a consequence?, there 
will be more or less vej^ica.1 irritation, and sometimes a feeling of 
tenef^mus occasioned, in the former instance, by the pic'^sure of the 
organ against the neck of tfie bladder, and, in the latter, against 
the rectum. But this descent of the uterus, at the close of the 
ninth month, is followed by a circumstance which should not be for- 
gotten; I uKian a diminished prominence of the abdomen, which 
will sometimes give lise to the appreTiension, on the part of the 
female, that something is wrong; that she is not pregnant, or that 
her foetus is dead. Again : In consequence of the settling down 
of the gravid womb, the pressure is removed from the diaphnigm^ 
and, hence, the respiration is fiver, the cough disaj^pears, and the 
patient experiences a buoyancy of spirits, forming a striking con- 
tract with the oppression of the previous few weeks ; this she caw- 
not account for, but which you, knowing the cause of the change, 
can readily ai>preciate. 

Why does the impregnated uterus descend toward the end of the 
ninth month ? ^lay it not be that, at this period, the organ increases 
in its transverse diameter, and, at the same time, diminishes in 
length? But* gentlemen, if you a^sk nie whether the descent of 
the organ at this period lie necessary, whether there be any special 
benefit derived, I a.sk you, in return, to reflect, for a moment, on 
the important work in which nature is so soon to become engaged, 
viz. the expulsion of the fa?tus from the maternal organs. Ilie 
object, therefore, of this change in the uterus, is directly connected 
with the birth of the child ; it is, as it were, one of the arrange- 
ments preliminary and essential to the important act of labor. 

These vanous changes in the position of tho uterus, to which we 

* AtthoufHi it is true that these derangemeaU in the rerplmtory organa^ at Iho 
latter period of ge«tAtlon, ore usually tmo««ibIe to the accent of tbe diAphragm ; y^ 
it roust b© reeoHectcd that these phenomena will eomotitut^s develop thcmselvc* at ft 
i««a advanced period of pre^ancj, and hero tJie dyspncua, cnuph, etc, may be duo 
to a nerroua, or a con^tested condition of the lunjf (possibly to <pderoft of tli« oi^pm); 
the Uierapoulic indicjitioa will de()end upon the «pfciiil cAUse ; for example, if it be 
timoed to uerToaaoeAs^ hvofiojamii^ thirty or forty drops c4' tho tincture; or if to 
OODgestion, the judicious intenrention of the Inneet. 



PLATE JV 



7 




A'/z/M month 



THE PRINCIPU:;S AND PRACTICE OF OBSTETRICS, 



161 



liave thus briefly alluded, are liable to curtain modificntions. For 
example, in a multipara^ — a female who has borne sc viral HiihlreQ 
— the otcrns in its ascent usually does not reach as higli up in the 
abdomen in the latter penods of pregnancy as in a primipara ; and, 
at the same time, the abdomen is mtieh more protuberant. These 
two circumstances arise from the fact, that previou*^ pregnancies 
having so distended and relaxed the abdominal walla, the gravid 
womb, encountering but little resistance as it passes upward, has 
a strong tendency to fall forward, constituting a species of anie- 
version of the organ; whcrea^s in the primipanL, ii^ direction is 
more in accordance with the axis of the superior strait of the 
pelvis. In a lirst pregnancy, the parietes of tiie abdomen undergo 
extraordinary distension, and consef^uently become thin ; oeca* 
f^ionally, there is a separation of the tvv'o recti muscles; and you 
will remember an interesting case^ in the clini*-, of a female, who, 
having been confined with twins, was afterwards much annoyed by 
the protrusion of the intestines tluough the sj)ace left l>y tho 
separation of tliese muscles * 

Change in the Direction of the Urethra. — When the giavid 
nterus leaves the pelvic cavity, and during its progresis in the 
abdomen, very important changes are effected in the position of 
the bladder and urethra; the ascent of the uterus necesjiarily 
occasions the ascent of the bladder, which, of course, draws up 
the urethm in such a way that, instead of occupying an oblique 
position, as it does under ordinary circumstances, it becomes more 
and more vertical, so that, in the latter periods of gestation, it will 
be found ahuost parallel with the internal surface of the symjihysis 
— a most important fict to be recollected in connexion with the 
introduction of the catheter, ignorance of which will oftentimes 
lead to results mortifying to the practitioner, ami di^^astrous to the 
patient. The superior portion of the urethra will sometimes be so 
greatly pressed upon liy the gravid uterus, that Itj? lower extretnily, 
in consequence of the impede<l circnlation, will become very mnch 
exjgorgcii, thus giving rise to an enlargement, which, if not tmder- 
stood, might result in erroneous conclusions. This condition of 
the excretory duot \s not unusual, paiticularly in tirst pregnancies, 
and arises Bimply from mechanical obstruct ion in the l>lor*d- vessels. 
It is of no special import, except that without this explanation you 
might possibly, in making a vaginal examination, misapprehend 
the nature of the enlargement, and suppose it to be a firreigu 
growth, 

(Edema of Lowttr Extremities. — The cedema of the lower ex- 
Ireraities, as an ordinary accompaniment of gestation, amf muting 
sometimes to a fully developed anasarca, is also explained in tho 



* Sa« Bl4eu€fl of Women iiiid Children, p. 211. 
11 




A or Tilt uitrjK^r 



L 



THE PRINCIPLES ASU PRACTICE OF OBSTETRICS. 

Save thus briefly alluded, are liable to certain modifications. For 
example, in a multipara^ — a female who has borne f^evtral chihlren 
— the uterus in its ascent usually docs not reach as high up in the 
abdomen in the latter periods of pregnancy as in a primiparu; and, 
at the same time, the abdomen is much more protuberant. These 
two cireum^tances arise from the fact, that previous pregnanciea 
having so distended and rehixed the abdominal walls, the gravid 
womb, eneountering but little resistance as it passes upward, has 
a strong tcndcnc}' to fall forward, coni*tituting a 8pecie8 of ante- 
version of the organs M'hercas, in the primipara, its direction is 
more in accordance with the axm of the Kupciior strait of the 
pelvi.s. In a first pregnancy, the parietes of the abdomen undergo 
extraordinary distension, and consequently become thin ; occa- 
sionally, there U a reparation of tlie two recti muscles; and you 
will remember an interesting case, in the clinir, of a female, who, 
having been contined with twins, was afterwards much annctyed by 
the protrusion of the intestines through the space left by tho 
separation «»f these muscles.* 

Change in the Direction of the Urtthra.—Whi'n the gravid 
uterus leaves the pelvic cavity, and during its progress in the 
abdomen, very important changes are etFected in the position o1^ 
the bladder and urethra; the ascent of the uterus necessarily 
occasions the ascent of the bladder, which, of course, draws up 
the urethra in such a way that, instead of occupying an oblique 
position, as it does under ordinary circurnstancLs, it becomes more 
and more vertical, so that, in the latter periods of gestation, it will 
be found almost parallel with the internal surface of the synqihysis 
— a most important fact to be recollected in connexi*m with the 
introduction of the catheter, ignorance of which will oftentimes 
lead to re«iult9 mortifying lo the practitioner, and disastrous to tho 
patient. The superior portion of the urethra will sometimes be so 
greatly pressed upon by the gravid utenjs, that its l(»wer extremity, 
in consequence of the impeded circulation, will become very much 
engorged, thus giving rise to an enlargement, which, if not under- 
stood, might result in erroneous conclnsions. This condition of 
the excretory duct is not unusual, |»articnlarly in iirst prcgnaiKiei^ 
and arises simply from mechanical obstruction in the blood- vesiselg. 
It is of no special in^ort, except that without this explanation you 
might poBsibly, in making a vaginal examination, misapprehend 
the nature of the enlargement, and suppose it to be a f(»reign 
growth. 

(Edema of Latter Extremities. — The adema of the lower ex- 
tremities, as an ordinary accompanintent of gestation, amounting 
sometimes to a fully developed anasarcji, is also explained in the 

• See Omeiises of Wamen and Children, p, ail« 

n 




i 



162 THE PBIKCIPLES AND PBACTICE OF OBSTETRIC!^ 

Bame way ; that is, obstruction, from pressure of the impregnated 
womb, in the venous circulation,* thus preventing the free passage 
of blood from the low^r extremities to the ascending cava, and 
thence to the right cavities of the heart. In the same manner 
also, do you account in part for the appearance of hemorrhoidal 
tumors, 60 common in pregnancy ; I say in part, for they are like- 
wise due to the constipation, which is the usual accompaniment of 
tilis condition ; the constipation very frequently arising from the 
pressure of the uterus against the upper portion of the rectum. 
You have seen in the clinic several examples of enlargement of the 
veins in the vagina, traceable to the presence of various kinds of 
abdominal tumors ; and you have been told that these venous en- 
gorgements are simply the result of obstructed circulation. In 
pregnancy, also, you will occasionally meet with the same phe- 
nomena ; and I have known, under these circumstances, thrombos 
of the vulva, to produce fearful hemorrhage. In the latter cod- 
tingcncy, the great remedy is well directed pressure by means of 
pieces of sponge.f 

* There are other caoses than obstruction in the venous drcnlation, which may 
eocaaionally produce oedema, or dropsy of the cellular tiasue, during pregnancy ; tof 
example, organic disease of the heart, the existence of albuminuria^ anspmia, et& 

f For an interesting case of thrombus of the vagina, together with ita treatniMiti 
see Diseases of Women and Children, p. 463. 




LECTURE XI 



Evidences of PTeg;naacy continued— Tlie Effect of FecuDdation on Development of 
Uterua — Order of Development — Fundus enlarges first ibree Moutlis-*Body from 
Ujird to sixth Ifonth — Wisdom of thia Arrangement — Shape of Impregnated 
tTtenifl— Modif)catioDs of Cervix m Prcgrnancj — Error of certain Authors — 
Uterine and Vogintil Extremities of Cervix — Cervical Canal — Helaxation of 
TiMsuei of Cervix — Cervix doea not Lengthen — Error of Madame Boivin— Promi* 
netice of Os Tinc»— Softening and Moisture — Mucotia FoUiclcB— Development of 
^-^locreflfled Mucous Secretion not a Pathological State — ^Uses of this Srcretion^ 
Oemx begins to shorten at its Uierine, and not at tho Vaginal Extremity — 
Proof^-Opinionfl of Stoltz and Cazeaux — Placenta Prajvin and Sliortenlng of Cer- 
vix — Modifications of C«rvix in Primipara and Multipara — Increased Development 
of Uterine Appendages in Pregnancy^ — How doea tho Cavity of the Uterus 
euUrge?-^ Ancient Theory — Increased Kutrilion the true Cause—Tbieknesa of 
Uterine Walls; Opinions respecting — Os Uteri at Tina© of Labor — Discoloratioa 
o( Tagina as a sign of Pregnancy — la this Discoloration peculiar to Pregnancy? 

Gextlemen — From the instant of fecundation until the aocom- 
plishment of the full term of utero-gestatton, the womb \s con- 
stantly undergoing the process of development ; this increase of 
tis«uc and cajmcity is in accordance with the growth of tho embryo. 
In one \rord, the exclusive and only object of the^ae changes is to 
provide accommodaiion and sustenance to the growing germ. But 
the development of the gravid organ is not without order; in the 
amuigement, which nature has iDstitnted for the successive iq- 
erea&e in the volume and structure of the uterus, the obstetrioiaa 
H-ill find much of interest* The increase in the size of the organ, 
although successive, is not uniform ; as an evidence of this fact, the 
growth of the uterus for the first three months is principally 
through the development of its fundus; the body of the organ 
undergoes striking changes from the third to the sixth month ; while 
H is not until the three last months of gestation that tlie cervix or 
neck contributes^ its share to the general accommodation of the 
embryo. 

You cannot, gentlemen, fail to perceive the wisdom of this order 
in the successive developments of the impregnate*! uterus; it is 
essentially conservative, and for the protection of both mother and 
duKt Suppose, for illustration, the order were reversed ; and, 
instead of the fundus, the cervix should be the first to undergo the 
physical changes necessary for the requirements of the growing 
foiufl. Do you not perceive, at once, the inevitable results of such 



164 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



an arrangement — preinaturi? ileliverv, and the consequent destruc* 
tion of the germ? Hut njitiirc, in this, us in all her other oyicra* 
tioDs, is con.stantly dl^clo.^ing to her disciples motive for every act 
ah© performs. For the first six months of gestation, in consequence 
of the increased vcjlume o£ the uterus being caused chiefly by tht; 
enlfir*Tement of the fundus and body only, the organ presents a 
peculiar shajie which has not been inaptly compared to that of a 
g&urd or bottle ; after this period, as the cervix begins to sbotten, 
the form of the uterus becomes more ovoid. 

Changes hi the Cerrfx. — Yon will find, in reading the various 
works on midwifery, tliat most writers have alluded to the moditi- 
cations of the neck of the uterus during pregnancy j but there is 
more or less discrepancy of opinion as to two important circum- 
stances connected with these modifications: 1. The degree of value 
to be attached to them so far a^ being guides in the diagnosb of 
the particular period of gestation ; 2. The manner in which the 
cervix commencfs and continues to shorten. I propose briedy to 
examine these questions, and to give to each of them, an far as I 
may be able to do so, its true bedside iujportance; for, after all, 
gentlemen, these questions, so practical in their bearing, must be 
decided by the revelations of the clinical room. In order that ycm 
may have a comprehensive and accurate idea of the phases through 
which the cervix of the uterus pa.ss«es during the entire period of 
prt^gnaney, I flhall divide it into three portions; 1. The lower or 
vaginal extremity ; 2. The upper or uterine extremity ; ^. It-* cnnal, 
being bounded respectively by tliese two extremities. 

Your attention has uheady been drawn to 'the important fact 
that fecundation constitutes the uterus an active centre ; this very 
centralization of forces, if I may so define it, toward the organ, 
im[iai*t9 to its physical condition a very rapid and remarkable 
c^nuige, and the most palpable appreciation of the nature and ex- 
tent of this change will be had l>y comparing the impiegnated 
organ of a primipara with the uterus of the matured but virgin 
female. In the latter, the organ presents a dense, resisting, and^ to 
all external appearances, homogeneous structure, it being inqiosss- 
ble to discern dis^tinctly with the naked eye any of the elements 
forming the components of the different tissues. Indeed, it may Ijo 
said with all truth, that so far as its physical nature is concerned, 
the characteristic of the virgin womb is compctcU^es^ ; while, with 
equal propriety, it may be affirmed, that the characteristic of the 
impregnated organ is so/teninr/ or looseness of structure, tihich b 
the direct result of the fluxion, of whieh it becomes so :u"tive a 
centre ; so that, in the earlier periods of gestation, the increase 
in the volume of the uterus is to be attrlbuteil, not only to nev^ 
formations^ but to the relaxing and spreading out, through thu 
agency of increased circulation, of its pre-exiriling elementJi. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



165 



For the first six months of ulero-gestation, the moditi cations in 
ihe cervir are more or less confined to a j^oftening, and consequent 
increase in volume of its two extreniities and canal ; and it is not 
until the beginninof of the seventh month that there is any percep- 
tible shortening of the cervical portion of t!ie organ, as we shall 
pre^iiently endeavor more particularly to show, Madame Boivin, a 
woman of extraordinary cleverness, and whose field for practical 
observation was vast, put forth the idea that, at the second month 
of pregnancy, the cervix titcri is so much increased in length that 
it measures two inches ; this opinion has been more or less adopted 
by her successors, more, I imagine, from the weight of her autho- 
rity, than from any conviction founded on actual investigation, that 
the ojanion is correct. I must confess I am somewhat surprised 
that Madame Boivin should have promulgated such a statement — 
accurate as she generally is in her deductions — for, as far as I have 
been enabled to test the point, from no limited observation, it is 
not in accordance with facts. Can it possibly be that this distin- 
guishetl woman may, for the moment, have forgotten tliat the 
tendency of the impregnated uterus is, for the first two months, to 
descend into the pelvic excavation, and thus Iiave confounded this 
^4toscent of the organ with the supposed elongation of its cervix ? 
Or is it ill at she may have mistaken a congenital elougiition for 
wh^t she iraagined to be a lenglhcning, the consequence of early 
gestation?^ Be it as it may, I am quite certain that the cervix 
does not increase in length during any period of pregnancy,f 

One of the very first changes observed by the vigilant accoucheur, 

fc<mnected with the general sorteniug of its structure, will be a 
Bght tumefaction of the anterior and posterior lips of the os tinea*, 
and at the same time the orifice begins to lose its transverse shape, 
and becomes more circulnr; this latter condition is in part owing 
to the increase in volume of the two lips, and also to the circum- 
stance that the anterior lip now Ijecomes more protuberant, bo that 
the two lips are equal in size and prominence. 

But there is another circuuiKtance connected with the condition 
of the OS tine* at this |)eriod of ge:4tation, which Ijecomes more 
marked as pregnancy advances; as far as I know, it has not been 
mentioned in connexion with the modifications of the cervix at the 
commencement of gestation. I aUade to a peculiar moisture of 
the two iip8^ whieh^ according to my experience^ is a constant accom' 

* The neck of the uterua will aometinaes exhibit an elongntion (Vom simple hyper* 

trophy of the pjirt, griviii^ ri^e to prolnpsui, ere. M. Ilujriiier has recently written 

»ii €Xcce<Uiip!y inten«tiug memoir on this subject, entitled, " Allongemeuts lljper- 

^r<^hi<|ties du en) da rtJterua.'* [Memoirus de rAcfldemio Imperiale de Medecine, 

' m XXili, p, 279 ] 

+ Hr M}*tltiewa Diincnn ja niso of iipinion that thr?re is rather an elonjration of 
the ec-rvix in Uia early period of utoro-|[e»ti»Uou» [Edinburgh Med. Jour., ILiroh, 
iU9} 



144 THZ T^iy^ZZFLES aSD PSACTICS OF OBSTRBICa 

puBii/ti'mf '/ofr'ptJiTi^y, Th^a ni«:-wcTrre » ocraakmed br the pour- 

mtr oa*: ir Tiii!-L-*. Triii:-! L^ n. trJn^ niore than the necesaaur result 
of an intrr"*!.^ in '.he -fize if zzie 3i7o>aft fblHciea, which you are 
awar» ir^ >;iir-..L in xor-j ir le^ ibfxii*iazice, on the intemml' sarfiice 
otKhe rerr-jL Tea ir- =i:c :•:• z:L«take tht* secretion of macns for 
a 3xor^iii •:r pariii Li:*rj!al ^.x:-* ■:■€ the partj — it is in erery way a 
naCTxnl in»x it?al:hj nn-.-tioc* in-L *iirjiz the entire progress of 
X»isazi*:n. :» -n-e!!':--! : : -"i'-ierre a ni«>^ impi?rtant purpose. Let 
;m -iX-i-iiJie -lis -•:!::• r- r i zi*:c:er,t. Aner the fall development 
of "lae r'sci:? has ":«f*?!: i«.**^:rr:p'L?he«L aa-i it » sufficiently matured 
ia L^* piTjs*:*^ rrrir.Lza-Vn *. ? -rna'-iie i: to live independently of its 
pur»;!T:. i -:e v triiz :z -cen^rii-rLa i* i::.<:tute»i, the object of which 
Ls :»: 5v«j'i-v ■•:? sii't -i:t"'i.-L«;'i zr a the mitemal system. Xow, in 
tab eAV.i >:''i:. - 7- s^xi L .—rv^-s ::i:l«c -z-f necessity be subjected to 
^f\:r:i«;r.:-.:Mry i-?cd sl mt. i.:.i :h-; :* Tit eri beo^me amply dilated ; 
:h^; H-i.'> :* ".:•.- ' 1^-- 1 i-r r.C'ii ir-a t'> ci"»ntribute largely, and 
*•? Ar« :h^f .:i". ■.:!. yi:.7«. -wzzh .x[i*::raraate forethought, and a 
pr>v:;er: a— i" j^f-n-r.: -* .nhy ?:* .-rir pri>tbund admiration, has 
taken ;ro«>i car»r : > ^-^r ltv: -./r-^ jr^iz? lor the great work of dis- 
tension. 

Tn-i Tr\i'-*-,z< :*■:■" :.*ei. *.: a'-- lir: ii the cervix uteri and vat^rina, 
are triv iri<r iT.e.-.:- w.:! •-. <-.- b-i:^ i? hv r aitl. As pregnancy 
advance*, ih^n^ :-!!:\r'» h-»r.'.:::e ni.-e aid tnore developed, and in 
f.r.ifKiftion to tLTir •:-•. •. ■-'•nir-.: wii; r-.* the secretion of mneos. 
Ti.i- wry rr;?! -j- --rvei *. : ::. i-v.-i aril relax the parts, and thus 
pn-par'^r* :hem l-r r.'.- ^rx —-ivv .i:<:.:-n-i n to whioh they are soon 
Vf }tf: -lihtj^rotr'l. In t'.- I i**er nionti'i-i or* ixestati^^n, the mucus is 
apt to Kfr'oni'.* *<j ab:i::'I:iri^ a^ 'o oaus*.- the female to imasrinc that 
sh#: ha- tfiat vntni-- unl iri':iv:i-.iri^ .l:-^.-a<t' the •'whites/'* She sends 
for hfir jnctWriii inari. :ii;.l l».j- }iini t«> pve her something to arrest 
thi** di-clinr<r<'. If th«- j»ra-titi<>rier l>.j iruided by the declarations 
of his pati«-rii — if In* j»hoiiM hivo no mind of his own— or if, in a 
word, he should not at onre ]»eri't-ive that this mucous secretion, in 
lieu of ronstitutinir a patholni^ical con«lition, is simply one of the 
wise provisions intended for the sueces^tul aeoomplishment of cer- 
tain ends, he would mo^^t likely prescribe some astringent injection, 
the tendency of which would be to arrest the discharge, and thus 
come in direct conflict with the purposes of nature. So you see, 
gentlemen, how essential it is to distinguish between healthy and 
morbid phenomena.f 

Shorteni7ig of the Cervix, — At the same time that these changes 
are going on in the two lips, there is a progressive increase in the 

♦ fJ*M» TMiwasefl of Women ami Children, " Ijcucorrhoea," p. 408. 

iMervinjr the cjuition Hujrj:cstcd, yet it is proper also to recollect that the 
laii may, under certain circumstances, bo aflectcd with a morbid dis* 
•*»ii«, which will need attention. 



THE PIIINCIPLIS AK0 PRACTICE OF OBSTETRICS. 



ler 



volume of the cervical canal, the tissues of which not only become 
softer, but there is also an augmented capacity in the canal itself. 
I cannot but think that authors have laborerl unrlcr a remarkable 
error in stating the mcnie an4 degrees of Bhortenin^, which the 
neck of the uterus undergoes during the various periods of preg- 
nancy. It is maintained by many that, at the fiflh month, it loses 
[>ne-third of its length, at the sixth, one-half, two-thirds at the 

eventh, three-fourths at the eighth, with an entire obliteration at 
the end of the ninth month, I believe this error is partly traceable 
to the circumstance that suffident importance has not betm attached 
to the fact that the cervix:, as one of the immediate results of ges- 
tation, becomes increased in volume, and this increase of volume is 
mistaken oftentimes for a diminution of its length. 

As far as I have been enabled to arrive at a just conclusion upon 
the subject — and no little attention has been given to the investiga- 
tion — 1 do not think there is any actual loss in tlie lengtli of the 
cervi^t until near the end of the sixth monti>^ and tliis brings us to 
the consjideration of the manner in which the shortening is accom- 
plished. You have already been informed that the order of deve- 
lopment of the gravid uterus is first an enlargement of the fundus, 
then of the body, and lastly of the cervix ; and it isruH until toward 
the termination of the sixth month that the cervix begins to contri- 
bnte its share to the general capacity of the uterus. At this time, 
the uterine portion of the neek commences to widen, from which 
there are two direct results: 1. A shoilening of its long axis; 2, 
An increase in the uterine cavity* 

Tills expansion of the uterine extremity of the cervix now pro- 
ceeds with more or less4 unifi>rmity, producing consequently a gra- 
dual shortening of the cervix, and at the same time a j^iadual 
increase in the capacity r>f the uterus, so that, at the eml of the 
ninth month, the cervix has so completely surrendered its length, 
that it presents simply a ring, which is known in obstetric language 
na its ol»literatioTi, If you examine a female in the fifth month of 
her gestation, on introducing your index fins^er into the vagina — 
ui the manner we shall hereafter point out— and passing it along 
the outer surface of the cervix uteri, you will very readily ascer- 
tain that its length is unchanged ; make this same examination at 
the seventh month, and, when your finger readies the uterine por- 
tion of the neck, you will at once recognise a remarkable alteration 
in the condition of things, viz. that this portion of the organ is 
more expanded, giving an increase to its various diameters, and 
then it i* that you will also appreciate the important circum- 

lance that the cervix commences to diminish in length, this dimi- 
•^IBtition, remember, beginning above, and not below — or, to be 
Tiore explicit at the uterine^ and not at tlie vaginal extremity 
of the part. 



1«8 



TUE ruiXClPLES AND PRACTICE OF OflSTETRICa 



I am thiiH ernphtitic upon thin point for the reason that a high 
authority in midwiteiy, llie learned Stollz, of Slrashurj^, main* 
tains that tho cervical portion of the uterus begins to lose iu 
lenjzth from below upward, and positively asserts that the ntt»ruic 
extremity undergoes no change nntil the latter part of the ninth 
month. This opinion of the distingnished profe»i*or is aUo par- 
ticipated in by Cancan x, who, a« a writer and observer, occu- 
pies deservedly a high position,* I cannot account for the opi- 
nion of these distinguished writers, I am confident it is foimdetl 
in error, and i^ altogether adverse to bedside experience. If I 
did not feel the strongest conviction — a conviction amply con- 
firmed by repealed investigation — that 1 am right in regard to 
this fpiesticMi, it would be with no little liesitation that I ?ihould 
thus ur»eqLiivocally» but yet most respectfully, doubt an oplnioa 
emanating from such valued authority. 

There is, in my judgmenti a very essential practical fact con- 
nected with the manner of the fihorlemng of the eer\'ix ; and it 
is strange that attention has not been more specially chilled to 
it, for it embodies a lesson of great value to the accoucheur, 
while it is of the deepest interest to the patient. It is as fol- 
lows: In the course of your practice you will occasionally be 
consulted by pregnant women in eonsequenee of more or lei%s dt*- 
charge of Ijlcnyd from the vagina ; this necessarily will j»roducc 
much discpjietude in the mind of the patient, and the loss of 
blood may result from the various causes capable of prom^uing 
a misearriage; sucli, for example, as blows, falls, or fright, 

Jlut the cause of the discharge of Ijlood to which I allude, in 
connexion with the shortening of the cervical portion of the ute- 
ni«, is of a very different kind, and traceable to a peculiar dr- 
cum^lance. In placenta pnevia, the placenta being attao!ied over 
the mouth of the womb, either centre for centre, or in a por- 
tion only of its cireuraierence, one of the most likely things to 
occur during the seventh, eighth, and ninth umnths of gesti^ 
lion will be flooding to a greater or less extent — and why? Do 
you not see the a! most necessary connexion between hemorrhage 
at the^e terms of pregnancy and placenta preevia ? What are 
the facts ? The atter-birtb is attached, throngh vascular and 
other connexiou)^, to the internal surface of the npper or ute- 
rine portion of the cervix ; you have just seen that, at the end 
of the sixth month, this portion of the cervix begins to w^ideu, 
for the purpose of giving increased size to the uterine cavity; 
now this very expaJisiou will be at the expense of some of the 
vascular connexions, to which wo have Just alluded, and hence the 
flooding. If, therefore, gentlemen, a patient without any as^igti- 

* Truitd Tli^nque et Pratique de TArt dea Accouchijmeiis. Pur P. CAOAtnL 
Oinqui^ttio Edition, p. d7. 



THE PKINCIPLES AND PRACTICE OF OBSTETRICS. 169 

able cause on her part, should, in the latter months of pregnancy, 
be attacked with a discharge of blood from the vagina, you may 
legitimately infer that it is because of the implantation of the after- 
birth over the os uteri. In such an event, the most judicious treat- 
ment will be called for; in a future part of the course, when dis- 
cussing the management of flooding, as connected with placenta 
pneviji, your attention shall be fully directed to the therapeutics 
of these cases. 

T7ie Cervix in the Primipara and Multipara. — ^\Ve have spoken 
of the two extremities of the cervix uteri, and you have noted the 
successive changes which occur in them ; you have also seen in what 
way the cervical canal commences and continues to shorten, until 
at the completion of utero-gestation it is reduced to a simple circle 
or ring. It now remains for me to point out certain diflerenoes in 
these modifications depending upon whether they occur in a primi- 
para or multipara, and it is important that you should understand 
the nature of these variations. In a primipara, all the changes to 
which we have alluded progress much more tardily than in the 
female >vho has borne one or more children. The softening of the 
utenne tissues is slower, so is the tumefaction of the anterior and 
posterior lips of the os tincaj ; and another essential characteristic 
of the OS tincJB in the primipara is, that it maintains more or less 
a conoidal form, and is not dilated so as to permit the introduction 
of the finger. Again : the internal suriUce of the two lips is uni- 
form, uninterrupted by elevations; and also in the primipara, the 
8hai)e of the cervical canal is fusiform. In the multipara, there is 
a more rapid development in the moditications of the gravid organ. 
Tlie li])s of the os tincie are more protuberant, and the linger can 
be readily introduced, for the reason that they never assume their 
original shape after childbirth; so true is this, that you will per- 
ceive a very striking contrast in the form of the vaginal extremity 
of the cervix when compared with that in the primipara ; in tne 
latter, it is more or less conoidal, while in the multipara it has been 
very properly compared to an inverted funnel. In the multipara, 
also, the internal surface of the lips is irregular; and this irregu- 
larity is owing to the circumstance that, during the passage of the 
child through the os uteri, there hrive been slight lacerations of the 
mucous membrane ; these lacerations heal, and form afterwards so 
many cicatrices, which are easily recognised by the touch. 4 

Development of the Uterine Annexoi and External Genitalia, — 
The general growth of the tissues, consequent upon fecundation, is 
not limited to the uterus; the appendages of the organ ])artieipate 
more or less in the eflfect of this incrc^ased nutrition ; the ovaries 
nearly double in size, with an augmented volume of their blood- 
vessels ; the same fact is observed with regard to the fallopian 
tubes ; and there is also a marked development in the muscular 



170 



THE PKTXCIPLES AND PRACTICE OF OBSTETRICS 



fibres of the broad and round ligaments ; the vagina and external 
organs likewise undergo important changes ; the former, as preg- 
nancy advances, becomes wider and shorter, and there is a very 

evident increase in its spongy tissue. The vagina assumes another 
nioJirtcation in the latter period of gestation, as ha>* recently been 
pointed out by Rouget. He has shown that distinct tiiuseiilar 
planes can be detected with tlie naked eye ; and thi« will at once 
explain the contractile power displayed by this canal during th© 
passage of the foDlus through it. The mucous follicles become 
larger, and pour out more or less mucus. There i» ati interesting 
circivni stance connected with this development of the mucoun fol- 
licles^ and it is this — in c4irrying your finger along tlie walls* of the 
vagitia^ you will occasionally have imparted to ii a sensation, as if 
you are touching nnmerous granulations; and if you do not recol- 
lect the reason of this temporary change iu structure, you might 
possibly confound it witii a very imj>ortar»t affection of the vagirta 
—granular vaginitis, first described by Deville. 

The external organs, especially as the fmal term of gestation 
approaches, are more or less engorged, and there is an evirlent 
relaxation of their tissues. In a word, gentlemen, you camnil but 
appreciate, as you contemplate these different modifications in the 
reproductive apparatus, the simple inuiivu, which has so obviously 
influenced nature— every change, you perceive, has been made 
tributary t<» the Huccessful accomplish men t of the great act In the 
reproductive scheme — the birth of the child. 

How does the Graind Uterus Enlarge ? — Thickness of its Wails, 
You have seen that^ as the necessary consequence of gestation, the 
cavity of the uterus enlarges in order to afford accommodation to 
the germ ; and the question arises, how is this enlargement of the 
uterine cavity e(r»'Cted ? The opinion entertained by the old school- 
men upon this subject was a i^ingulnr one — they taught that the 
cause of the inereaiie in the size of the organ was altogether 
tnechanical ; that, as the embryo gained in development and size, 
its pressure against the walls of the uterus occa>ioned a distension 
equal to its requirements. They, in fact, com[iared the gradual 
enlargement of the organ, and supposed it to be accoinplishcii upon 
the same principle^ to the dister»si«m of a liladflcr when tillcil by air 
or water,^ Hut the fallacy of ihi.H and kindred hypotheses must be 
apparent to all of you. The uterus grows and becomes developed 
through the same influence preci?*ely that imparts to the f(etus its 
growth and development — increased nutrition. Prior to the second 



• It b welJ io remember thnt this queation of the mnnner in which lb© prafid 
uterus tif^)ine8 eiiUrjf*^! w«« d<?temnned^ not by liumnn dissection, for \}m wnn on© 
of tlie ppt-cHiUfl elf menu oftnuaful inquiry from wfneh Ike fii)c}t>iit8 were di'bMmed; 
bill rrotn llic inspection of Chv tmpi-u^niit«Kl orjFnn in .iiiirDula, in Homo of wUicb* it 
\m GonceJtti, U)^ attfrus does enltun^ ilirough mechanical diateaaioo. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICa 171 



nionth^ the embryo is dependent for its nourishment on other 
sources, as we shall in the proper place indicate ; but after this 
period it derives its elements of growth from the placenta. The 
uterus, on the contitiry, becomes developed, because of the afflux 
of fluitls and increased circulation setting toward it from the 0rst 
moment of fecundation until the comjjletion of gestation* So you 
perceive, gentlemen, that both the uterus and the embryo it con* 
tains pass respectively through their phases of increase, by the 
simple agency of a more active nutrition. If any argument be 
recjuired to demonstrate the utter absurdity of the ancient theory 
of mechanical distension, you need only recollect the interesting 
eircurostance that, in extras uteiine pregnancies^ the cavity of the 
uterus undergoes more or less dilatation.* 

Thickness of (he Walh of (lie Gramd Uterus, — Tisere has also 
been much difference of opinion as to the absolute thickness of the 
walls of the organ during gestation ; some contending tliat they 
become extremely attenuated, while others maintain that they 
increase in bulk only at the disc on which the placenta is inserted ; 
and again it is affirmctl that the entire increase in the thickness of 
the parietes is due exclusively to the engorged state of the blood- 
vessels ; this latter fact being attempted to be demonstrated by 
the circumstance that, in women who have died of uterine hemor- 
rhage, the walls are always les*i in volume. Now, there is no doubt 
that the latter statement is truej but admitting its truth, what 
does it prove? Absolutely nothing, so far as the solution of the 
point in controversy is concerned ; for, while it cannot be denied 
that there is a relative increase in the thickness of the uterine walls, 
in consequence of the more active circulation, yet the cardinal fact 
for yon to remember is, that the principal cause of the increased 
bulk of the gravid uterus is found in the changes of the muscular 
tissue of the organ ; ami, as I have already remarked to you, in a 
previous lecture, these changes are brought about in two ways r 
1. By an enlargement of the pre-existing miLscular elements; 2. By 
a new formation of them. So that, while it may be conceded that, 
after fatal hemorrhage, there is a diminished thickness in the 
uterinu parietes, it must also be recollected that this loss is relative 
and not absolute, being proportionate only to the amount of dis- 
gorgement which the blood-vessels have undergone. 

As a general [irinciple — although there will bo more or less 
marked variations in ditferent women — it may be affirmed that, 
during the period of pregnancy, the thickness of the walb of the 
uterus is about the same as in the unimpregnated organ. It is 
greatest at the fundus, especially where the placenta is attai^hed, 

• For further d«?tails on this sabject, iho reader ni«jr con«u1t wiUi profit an elabo- 
rate paper on '*The Utcrua and it3 Appetid,'iges," by Dr. Arthur Forre (Cyclopnwllii 
of Antwiny *a<l Physiology , p. 64ft, London, 1858). 



172 



THE PRINCIPLKS AND PRACTICE OF OBSTETRICS. 



and gradually diminishes towards the cervical portion. Taking 
twelve lines to the inch, it raay be said that, at the fiindud^ the 
thieknesa is from four to ^ve Hne^, slightly le^is in the body, iind 
fi*om two to three Hues in the cervix ; another intere.stinpj tact ia, 
that* for the firnt five or dsc months of gestation, the iliitkne?*!! 
rather increases, and at^r tliis period its tendency is gnulually to 
diminish. 

Let me here direct your attention to an imftortant circumHtaDco 
with regard to the oa uteri at the time of labor. In making a vagi* 
nal examination, when labor ha^ fairly eommenoed, it will be aj^cer- 
rtaincd that the og is orteniimes chanuterized by extraordinary 
thinness; and it is this fact which, no doubt, has originated in the 
minds of some writers the idea that the entire aurface of the 
uterine walls participates in this attenuated condition. 80 much, 
you see, for determining a princifde by a Kingle circums-tance. It is 
bad logic, and has been fnntful in the wpread of unsound le&^on^ 
The whole of the te^^timony or none, is a fundamental maxim in 
law, and it is not without it^ application iu onr profession. 

lyUt'oioratlnn of (hr Vafjlnal WidU, — 'Among the changes 
occurring in the sexual organs ciuist^quent u|Mm pregnancy, much 
[importance has recently been attached by certain observers to a 
discoloration of the internal surface of the vagina; and men of high 
eminence are dispose*! to regard it a«* an evidence of very great 
value that ge*«tation ac^tually exists. There has been some differ- 
ence of opinion as to whom belongs the merit of having first c:illed 
attention to this pecnliarity in the color of the vaginal walla, but I 
tliink the credit is due to Jacqueniin, of Paris, whose op|»ortnnitie« 
fur investigatir»g this subject were of no ordinary limits, having 
beei» a)»pointiMl by the police to examine the generative organs of 
the pro^tittites i»f tlic French mctropolis^-certainly a wise regula- 
tion ; fin' if it bo an admitted princi|>ie thai, for tlve protection of 
the eomiunuily, prostituti<in tnusi be conntenancod, then, I say, let 
it be freed, as far as may be, from tlie dreadful sctuirge eninileci 
upon tlmse who indulge in it — [ mean the syphilitic taiut; and how 
C4in this be so etfoctua'.'y accomplisherl a^t through tire vigilant 
examinations, made under the police regulations, of the genitals 
of the prostitutes, who are to be found iu such fearful numbers in 
the great city of Paris. It would be well, indeed, if some such 
municipal law obtained in Now York, which is but the younger 
twin sister of I^aris in all that contributes to the formation of the 
true greatness of a people, and at the sjime time panders to the 
lowe^t and most degrading vices. 

Jae^piemin, in describing the discoloration of the vagina^ calls it 
a violet buu, not unlike the lees of wnie; and he broa^lly affirma 
that, irrespective of any of the other evidences of gcst.ation, this 
^ign .alone wotild bo suflicient for him to pronounce u[»on the 




THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 178 

existence of pregnancy. Kilian, of the University of Bonn, a good 
observer, and a man of much experience, regards the discoloration 
as one of the " most constant signs of gestation." This opinion is 
also sustained by Kluge of Berlin, Ricord, Parent-Duchatelet, and 
others. There can be no doubt that the color of the vagina, in the 
great majority of cases, does undergo a remarkable change during 
pregnancy, presenting a sort of bluish tint, and this is altogether the 
effect of the vascular congestion of the parts. 

Many of you, who reside in the rural districts, and who, perhaps, 
are more or less familiar with that primitive but honorable occupa- 
tion of man, agriculture, and its kindred pursuits, must recollect the 
practice usually resorted to by breeders with a view of ascertaining 
whether the female of many of the lower animals be in a state to 
receive the male — or, in other words, whether she be in heat. The 
practice to which I allude is to inspect the outer opening and 
internal surface of the vagina, which, in season of heat, wnll be found 
to exhibit a very dark color — and I am quite satisfied that this same 
character of discoloration takes place at the advent of the catamenia 
in woman.* 

I have closely watched this latter circumstance, and in the many 
vaginal examinations which I have made just before the menstrual 
eruption, I do not know that I have failed in a single instance, in a 
normal menstruation, to detect this discoloration of the vagina. It 
seems to me that the true way to arrive at the real value of this 
sign, as a diagnostic evidence of pregnancy, is to determine, in the 
first place, the two following inquiries: 1. Is the discoloration of 
the vagina a universal accompaniment of gestation ; 2. Is it ever 
present, when pregnancy does not exist ? I have no hesitation in 
stating, from my own personal observation, that pregnancy will 
occasionally pass through its various stages without the slightest 
cogiiizable change in the ordinary color of the vagina, and this is 
more likely to occur in women remarkable for pallor of skin, and 
especially in those whose pallor is traceable solely to an anaemic 
condition — whether the anaemia be dependent upon an original 
deficiency of the red corpuscles, or upon a sudden or long-continued 
drain upon the system. 

In reply to the second point, whether the discoloration is ever 
present without pregnancy ; or, in other words, whether any other 
cause can produce it, I am quite confident that there are numerous 
instances, which will amply support the affirmative of this question ; 
and it is with no little surprise that I find so valued an authority as 
Huguier positively, affirming that "this change of color in the 
vaginal walls is not found in any other condition of the uterus than 

♦ Some interestinj? facts as to the color of the vajrina in domestic animals at the 
time of Jieat and during gestation, have been recorded by M. Rainard [Traits complet 
de la partirition des principales femellesdomestiques] 



174 THE PRINCIPLES AND PBAGTICE OF OBaTET&ICa 

tliat of pregnancy/' Now, gentlemen, what are the facts ? In the 
first place, I have told you that the real cause of this bluish aspect 
of the vagina is vascular congestion, and consequent partial inter- 
ruption in the ordinary current of the blood. If this be true — and 
the fact is very generally conceded — ^it ^ould follow that whenever 
this vascular congestion is present, no matter from what cause, yon 
may very naturally look for the effect — discoloration of the vag^a. 
You will, therefore, notice the change of color in the case of intra- 
uterine tumors, in chronic sanguineous engorgement of the uterus, 
etc. In a word, it is one of the not unusual accompaniments of 
congestion of the uterus, whether from gestation, or from some 
morbid influence, with which pregnancy has no possible connexion. 
From what has just been said, it is very evident that the value 
of this sign as a proof of pregnancy, is subject to more or less 
qualification ; and it is also well to mention that delicacy on the 
part of the female will oftentimes prevent the accoucheur from 
availing himself of the means of ascertaining whether or not it be 
present. 




LECTURE XII. 



Evidencefl of PT©^ancycontioa«?d — Quickening— Ancient Th<*ory — Law of Knglaod 
in regard to Quickening — Wha^t is Quickening:? — Opmintisof AuUjora — Nervous 
and Muscular Development — Muscular Contrftctions of the Foetus — ^Senfliblo and 
Insenaibto Muscular Contractions^ — Quickening not a r^ycltica! Act, but the result 
of Excito-motory loflueuce — Spinal System — Its Physioloirical Importance — 
When does Quickening take Place? — Do<*s not alwoys Occur — Delusive Quickemug 
-^niiutmiion — Contraction of Abdominal Walls mistaken for — Filial Cessation of 
Utnam and Supposed Qulckening^Attempted Imposition— Queen Maty of Eng« 
land — ^MaoipulatioDa to Detect Qulckeoing — Influence of Cold on Movemetits of 
Fuetud — Illustration-^Ballottement or Passive Movement of Fcetui? — Rules for 
Detecting — Positions of F(Ktus and Ballottement — ruls^iliona of Foital Heart — 
Atiseultalion — Mayor of Geneva — Averngo Beats of Fcctiil Heart — Not Synch ro» 
nous with Maternal Pulse — Auscultation, liow Applied — Auscultation and PosiUon 
of Foetus — Twin and Extm-utcrino Pregnancies— How ascertained — Placental 
Souffle — Uterine Murmur — Kerguradeo-^Conflict of Opinions — Soulfle not always 
Dependent upon Pregnancy — Uterine and Abdominal Tumora; Cause of — Souffle 
no Evidence of Life of Foetus — Pulsations of Umbilical Cord — Dr. Evory Ken- 
nedy. 

Gkntlemen — We sliall now proceed to an examination of the 
evidences of gestation derived from other sources. Tims far we 
have considered those 8iG:n8 only, which are either so many sympar* 
thetic phenomena, or the direct result of increased vital action. 
Tlie order of signs, to which your attentif»n will now be directed, 

P^ia not only of special interest, but some of them, when recognised, 
i,r© conclnsive as to the existence of pregnancy. They may be 
numerated as follows: 1st, Quickening; 2d, The passive move- 

Ptnent of the feet us, termed by the French, Ballottement, by the 
English, Repercussion ; 3d, Pulsations of the fcBtal heart ; 4th, 
The Bruit placentaire, placental souffle, or uterine murmur ; 6th, 
Pulsations of the umbilical cord. 

Ist, Quickening, — ^This term is employed to designate the parti- 
cular penod of gestation at which, through the movements of the 
fcptus, the mother becomes for tho first time aware that she carries 

t'irithin her a living being. The ancient theory upon this subject 
ra* not only singular, but the very essence of absurdity ; it incul- 
cated the principle that qtnckening was tho simple evidence tliat, 
at that very moment, vitality was imparted to the foetus ; and that, 
therefore, prior to this event, the foetus was an inanimate mass, 
without Individ nality. In those days, when physiology was not a 
sdenoe, and when crude hypothesis oflentimes was Bubstituted for 



^ 



166 



THE PRINCIPLES AND FRACTHCE OF OBSTETRICS. 



fmniment qfpref/nanrt/. Tho moisture is occasioned by the pour- 
ing out of mucuft^ which U nothing more than the necessary result 
of an increase in the size of the mucous follicleii, which you are 
aware are found, in more or less abundance, on the internal surface 
of the cervix. You arc not to mistake this secretion of mucus for 
a morbid or pathological state of the parts — it is in every way a 
natural and healthy function, and, during the entire progress of 
gefitatioti, is intended to subserve a most important purpose. Let 
us examine this point for a moment. After the full development 
of the foetus haj* been accomplished, and it h sufficiently raatui'ed 
in its physical organizjition to enable it to live independently of ita 
parent, a new train of phenomena is instituted, the object of which 
13 to secure its safe expulsion from the maternal system. Now, in 
this expulsion, the sexual organs must of necessity be subjected to 
extraordinary distension, and the os uteri become amply dilated; 
the walls of the vagina are called upon to contribute largely, and 
so are the labia. Nature, with consummate forethought, and a 
provident arrangement worthy of our profound admiration, haa 
taken good care to prepare these organs for the great work of di»- 
tcnaion. 

The mucous follicle.^, so abundant in the cervix titeri andvasrina, 
are the instruments which she brings to her aid. As pregnancy 
advances, these follicles become more and more developed, and in 
proportion to their development will be the secretion of muouB. 
This very mucus serves to mnisten and rehix the parts, and ihiia 
prepares them for the excessive distension to ^hich they are soon 
to be subjected. In the latter months of gestation, the mucus 121 
apt to become so abun<lant as to cau;sc the female to imagine that 
she has that vague and u n meaning d iseasc the "whites."* She sends 
for her medical man, and bci^s him to give her something to arresi 
this dischnrgc. If the j>ractitioner be guided by the declaratioDS 
of his patient — if he should have no mind of his own — or if, in a 
word, he should not at once perceive that this mucous secretion, in 
lieu of constituting a pathological condition, is simply one of the 
wise provisions intended for the surcessful accomplishment of cer- 
tain ends, he would most likely [>reseiibe some astringent injection, 
the tendency of which would be to arrest the discharge-, and thus 
come in direct conflict with the purposes of nature. So you see, 
gentlemen, how essential it is to distinguish between healthy und 
morbid phenomena.! 

Shortening qf the Cervix. — At the same time that these changes 
are going on in the two Ups, there is a progressive increase iu the 

* See Dise«se« of Women ^nd Children, ** LeucorrtKca,** p. 408. 

f While ot)flervm|r the caution nuggiwled, yel it \s proper also to recollect that the 
pregtiADt womaa mny* under certain cinnimetaDQeSp be ftOected with ft morbid dir 
Qharge from Uie vit^ua^ which will need attention. 



THE PRlNCirLES AND PBACTICE OF OBSTETRICS. 



167 



volume of the cervical canal, the tissuea of which not only become 
softer, but there is also an augmented capacity in the canal itself. 
I cannot but think that authors have labored under a remarkable 
error in stating the mode and decrees of fihorteuini::, which the 
nock of the uterus undergoes during the various periods of preg- 
nancy. It is maintained by many that, at the fifth month, it loses 
one-third of its length, at the sixth, one-balf, two-thirds at tlie 
seventh, three-fourths at the eighth, with an entire obliteration at 
the end of the ninth month, I believe this error is partly traceable 
lo the circumstance that sufficient importance has not been attached 
to the fact that the cervix, as one of the immediate results of ges- 
tation, becomes increased in voltnne, and this increase of volume is 
mistaken oftentimes for a diminution of itfJi lengtlL 

As far as I have been enabled to arrive at a just conclusion upon 
the subject — and no little attention has been given to the investiga- 
tion — I do not think there is any actual loss in the lentjth of the 
cervix until near the end of the sixth month, and this brings ns to 
the consideration of the manner in which the shortening is accom- 
plished. You have already been informed that the order of deve- 
lopment of the gravid uterus is first an enlargement of the fundus, 
then of the body, and lastly of the cervix ; and it is not nntil toward 
the termination of the sixth month that the cervix begins to contri- 
bute its ehare to the general capacity of the uterus. At this time, 
the uterine portion of the neck commences to widen, from which 
there are two direct results: 1. A shortening of its long axis; 2* 
An increase in the uterine cavity. 

This expansion of the uterine extremity of the cervix now pro- 
ceeds with more or less nnifi>rmity, producing consequently a gra- 
dual shortening of the cervix, and at the same time a gradual 
increase in the capacity of the uterus, so that, at the end of the 
ninth month, the cervix has so completely surrendered its length, 
that it presents simjily a ring, %vhich is known in obstetric language 
as its obliteration. If you examine a female in the fifth month of 
her gestation, on introducing your index linger into the vagina — 
in the manner w^c shall hereafter point out — and passing it along 
the outer surface of the cervix uteri, you wull very readily ascer- 
tain that its length is unchanged ; make this same examination at 
the seventh month, and, when your finger reaches the uterine por- 
tion of the neck, you will at once recognise a remarkable alteration 
in the condition of things, viz. that this portion of the organ is 
more expanded, giving an increase to its various diameters, and 
then it is that you will also appreciate the important circum- 
stance that the cervix commences to diminish in length, this dimi- 
nution, remember, beginning above^ and not below — or, to bt* 
*nore explicit at the uterine^ and not at the vaginal extremity 
of the part. 



les 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



I HTTi ifms eTn|>hiitie iiijoii this f>oirit for the reason thnt a liigh 
authority in mi^hvifery^ the learritHi Stuh2, of Strasburg, iimiri* 
taiiia that the cervical portion ot the nierus begins to lose iu 
len^h from hdow up^rard, and fKwitively asserts timt the iilerinc 
cxtreniity undt^r^oes no t-hange imti! the latter part of the ninth 
moritli. Tiiis opinion of the di.stiu^mi^lieJ professor is ai^o par* 
ticipated in by C:izeaux, who, n^ a writer and observer, occu* 
pies deservedly a high position.* I oannot account for the opi- 
nion of these distinrrnished writerij, I am confident it is founded 
in error^ arid is nltou^ether adverse to bedside experience. If I 
did not feci tlie strongest conviction — n conviction amply con- 
firmed by repeated investigation — ^that I am right in regard to 
this question, it would be with no little hesitation that I sihould 
thus unequivocally, but yet most respectfully, doubt an opinion 
emanating from sueh valued authority. 

There is, in niy judgment, a very essential practical lact con- 
nected i?ith the manner of the shortening of the cervix ; and it 
is strange that attention has not been more specially called to 
it, for it embodies a lesson of great value to the accoucheur, 
while it is of the deepest interest to the patient. It is sm ful- 
low»: In the course of your practice you will occasionally bo 
consultcil by pregnant women in eonseqiivuce of more or less din- 
chiirge of blood from the vajrioa ; this necessarily will jjroiluce 
much disquietude in the mind of the patient, and the loss of 
blood may result from the various causL's c:i]Kdjlu of promoting 
a miscarriage; such, fov examjile, as blows, iidls^ or fright. 

But the eause of the disi^iargc of blood to which I allude, in 
conuexirni with the shortening of tlie cervical portion of the ute» 
1118, U of a very different kind^ and traceable to a peculiar cir* 
cumstance. In placenta pnevia, the placenta being attached over 
the moutli of the womb, either centre for centre, or in a por- 
tion ouly of its circumference, one of the most likely things to 
occur during the seventh, eiglith, and ninth months of gesta- 
tion will l>o flooding to a greater or less extent — and why? Do 
you not see the almost necessary connexion between hemorrhage 
at the^e IcTms of pregnancy ami placenta prtevia ? What aro 
the facta? The sfler-birth is attached, through vascular and 
other connexions, to the inlermd surface of the upper or ute* 
rine portion of the cervix; you have just seen that, at the end 
of the sixth month, this portion of the cervix begins to widen» 
for the purpose of giving increased sixe to the uterine cavity; 
now this very expansion will be at the expense of some of the 
vascular connexions, to which we have just alUided, and hence the 
flooding. If, tf»erefore, gentlemen, a patient without any assign- 

* TtmIi^ Tli4k»fiquo H Pmtiquo de TArt dea Accouchometit. Pjir P. C^kkaux. 
Oioqui^fne Kdjilon, p, 97. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 169 

able cause on her part, should, in the latter months of pregnancy, 
be attacked with a discharge of blood from the vagina, you may 
legitimately infer that it is because of the implantation of the after- 
birth over the os uteri. In such an event, the most judicious treat- 
ment will be called for; in a future part of the course, when dis- 
cussing the management of flooding, as connected with placenta 
praevia, your attention shall be fully directed to the therapeutics 
of these cases. 

T7ie Cervix in the Primipara and Multipara, — We have spoken 
of the two extremities of the cervix uteri, and you have noted the 
successive changes which occur in them ; you have also seen in w^hat 
way the cervical canal commences and continues to shorten, until 
at the completion of utero-gestation it is reduced to a simple circle 
or ring. It now remains for me to point out certain differences in 
these modifications depending upon whether they occur in a primi- 
para or multipara, and it is important that you should understand 
the nature of these variations. In a primipara, all the changes to 
which we have alluded progress much more tardily than in the 
female who has borne one or more children. The softening of the 
uterine tissues is slower, so is the tumefaction of the anterior and 
posterior lips of the os tinca> ; and another essential characteristic 
of the OS tincjB in tlie primipara is, that it maintains more or less 
a conoidal form, and is not dilated so as to permit the hitroduction 
of the finger. Again : the internal surface of the two lii)s is uni- 
form, uninterrupted by elevations ; and also in the primipara, the 
shape of the cervical canal is fusiform. In the multipara, there is 
a more rapid develoi)ment in the modifications of the gravid organ. 
The lips of the os tinea? are more ]>rotuberant, and the finger can 
be readily introduced, for the reason that they never assume their 
original 8ha|)e after childbirth ; so true is this, that you will per- 
ceive a very striking contrast in the form of the vaginal extremity 
of the cervix when compared with that in the primipara; in the 
latter, it is more or less conoidal, while in the multi|)ara it has been 
very properly compared to an inverted funnel. In the multipara, 
also, the internal surface of the lips is irregular; and this irregu- 
larity is owing to the circumstance that, during the passage of the 
child through the os uteri, there have been slight lacerations of the 
mucous membrane ; these lacerations heal, and form afterwards so 
many cicatrices, which are easily recognised by the touch. 4 

Development of the Uterine Antiexce a7id External Genitalia. — 
The general growth of the tissues, consequent upon fecundation, is 
not limited to the uterus; the appendages of the organ participate 
more or less in the effect of this increased nutrition ; the ovaries 
nearly double in size, with an augmented volume of their blood- 
vessels ; the same faet is observed with regard to the fallopian 
tubes ; and there is also a marked development in the muscular 



170 



THB PBTJiCTPLIffl AXB PBACTIOI OF 



filiTM of the broad mnd round It^ameots ; Um vapan aad extcmd 
afgsos likewise undergo importani ehaog^ ; ibe former, m pr^^ 
nukej advanoei, becomes vrider and fthorter, and Uien* b m Yerjr 
erident incrcrsse in it^ spongy tisftoe. The vihgioa Mntmes •fMnthtr 
iii4>dification in the latter period of gectaiioii, ft» hts reoentlj be«9 
jxrfoted oot by Kouget. He bas ibown th:it dbtincl mnpcatme 
plimea can be detected with the naked eye ; and thia witl ai uooa 
explain the contractile power displayed by this canal duricig^ the 
pamge of the fcetus through it. The muc^iM foUidei become 
burger, and ftour out more or le^ macus. There is an iutrrcftltng 
dreanifftance connected with this development of the mucous fol- 
HoieCy and h if thiit — in carrying your finger along tlie walls of the 
▼agioa^ you will occaiiionally have imparted to it a sensation, %< if 
yon are touching numerous granulations ; and if you do not rix*oU 
lect the retwon of this temporary change in struct ore, you rtiight 
pooatibly confound it with a very important affection of the vagina 
— granular vaginitis, first described by Deville, 

The external organs, especially as the final term of ge.«^taiion 
approaches, are more or less engorged, ami tlierc i* an evident 
relax at ian uf their tiesues* In a word, gentlemen, you cannt>l but 
appreciate, as you contemplate these difierent modificjiticm^ in the 
reproductive apparatus, the simple motive, which has so obviously 
influenced nature — every change, you perceive, ha^ been made 
tributary to the Huccessful uecompli'^hment of the great act in the 
reproductive scheme — the birth oftho child. 

JImit does the Gravid Uttrua Enlarged — Thickness of Us IVftlU, 
Ton have ween that, as the ncccs-sary consequenue of gestntion, the 
cavity of the uterus enlarge** in order to aiford aceommodaiion to 
the germ ; and the question ari?*e??, how h this cuhi^rgement nf the 
nteritu^ cavity effected ? The opinion entertained by the old school- 
men upon this subject was a lingular one — they taught that the 
can He of the iucrea«e in the size of the or^an was altogether 
mcchanii'al ; th;it, n^ the enjbryo gained in developnient and s^ize, 
its pre^Kure against the walls of the uterus occasioned a distension 
equal to its requirements. They, in fact, compared the gradual 
enlargement of the organ, and supposed it to he aecomplisheJ upon 
the Karne jirini^iple, to the distension of a bladder when tilled by air 
or water.* Hut the fallacy of this and kindred hyputhescs must be 
appurent to all of yon. The uterus grows and becomes developed 
thrftuu'h the same intluence precisely that imparts to the ftelus its 
growth and development^ — increased imtritiotK Prior to the second 

• It w well to remember tlmt tli'w qneation of the manner hi which tlie pxnni 
Utents bfOfmiea en]»»ri;<vl w«b dotrriniried, not by liiiitiftit difnectioiv for lhi« wmr ono 
of llti» phTiotw iAvnwuin oftruuirnl Inquiry from whtdi the nticjeTiU wt»ro deluiniMlj 
llttt from thi* liirtpection of the impre^nnunil orysrun in atiirauls. in nome of wUiuh, it 
* <>ce^vcl the atenjs dtHpM i«nlttf]p ihniugh mechaDtcai di«tuDiik>rt. 



THE PRIXCIPLES AND rRACTICE OP OBSTETRICS. 171 



month, the embryo is depcndfnt for its uourishmcDt on other 
sources, as we shall in the proper place indicate ; but ailer this 
period it derives its elements of growth from the placonta. The 
utenis, on the eontmry, becomes developed^ because of the afl9nx 
of fluids and increased circulation setting toward it from the first 
moment of fecundation until the completion of gestation. So you 
perceive, gentlemen, that both the utenis and the embryo it con* 
tains pass respectively through their phases of increase, by the 
simple agency of a more active nutrition. If any argument be 
required to demonstrate the utter absurdity of the ancient theory 
of mechanical distension, you need only recollect the interesting 
eircurastance that, in extra-uterine pregnancies, the cavity of the 
uterus undergoes more or less dilatation.* 

Thichtesjs of the Walls of the Gravid Uterus. — ^There has also 
been much difference of opinion as to the absolute thickness of the 
walls of the organ during gestation ; some contending that they 
become extremely attenuated, while others maintain that they 
increase in bulk only at the disc on which the placenta ij^i inserted ; 
and again it is affirme'd ihat the entire increase in the thickness of 
the parietes is due exclusively to the engorged state of the blood- 
vessels ; this latter fact being attempted to be demonstrated by 
the circumstance that, in women who have died of uterine hemor- 
rhage, the walls are always less in volume. Now, there is no doubt 
thai the latter statement is true ; but admitting its truth, what 
does it prove? Absolutely nothing, so fur as the solution of ilie 
point in controversy is concerned ; for, while it cannot be denied 
that there is a relative increase in the thickness of the uterine walls, 
in consequence of the more active circulation, yet the cardinal tact 
for you to remember is, that the principal cause of the increased 
bulk of the gravid uterus is found in the changes of the muscular 
tissue of the organ ; and, as I have already remarked to you, in a 
previous lecture, these changes are brought about in two ways r 
1, By an enlargement of the pre-existing muscular elements; 2. By 
a new formation of thera. So that, while it may be conceded that, 
after fatal hemorrhage, there is a diminished thickness in the 
uterine parietes, it must also be recollected that this loss is relative 
and not absolute, being proportionate only to the amount of dis- 
gorgement which the blood-vessels have undergone. 

As a genend principle — although there will be more or lesa 

umarked variations in different women — it may be affirmed that, 

during the period of pregnancy, the thickness of the walls of the 

Uterus is about the same as in the un impregnated organ. It is 

greatest at the fundus, especially where the placenta is attached, 

• For ftirther detaOs on thi-i subject, tho reader niaj consalt with profit ftu eUbo- 
ttkte paper cm " Tho Utenia and iu App<?ndriges," by Dr. Arthur Farro (rjyckipiedla 
ot Anatoniy and Phy&totogy, p. 645. London, 1856). 



172 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS* 



and ^jraduaUy diminishes towards the cervical portion. Takiujcr 
twelve lincH to tlie inch, it may be said that, at the fund as, the 
thickness is from four to five lines, sliglitly lesa in the body, and 
from two to three lines in the cervix ; another interestinj;^ fact i\ 
that, for the fii-s^t tive or 81 x months of gestation, the thickne^n 
rather increases*, and after this period its tendency is gradually to 
diminish. 

Let me here direct your attention to an important circumstance 
mth regard to the os uteri at the time of labor. In making a vagi- 
na! examination, when labor has fairly commenced, it will be ascer- 
tained that the os is oi'tentinieij characterized by extraordinai v 
thinness ; and it is this ll'Lct which, no doubt, has originated in the 
minds of some writerij the idea that the etitire surfiicc of the 
uterine walls participfltes in thi:* attenuated condition. 80 much, 
you see» i'or determining a pniiciple by a single circumj^lance. It is 
bad logic, and has been fruitful in the spread of nnsoimd Icssoniu 
The vvlu)Ie of the tc^limony or none, is a fundamental maxim in 
law, anil it is not without its appliiuiion in our profe.^sion. 

Dittcuhtration of the Vftfjinttl Walls,— 'Awunv^ the cininges 
occurring in the sexual organs cniisi/quent upon pregnancy, much 
irnporlance has recently been attached by certain observers to a 
discoloration of the internal surface of the vagina; and men of high 
eminence are disposed to regard it as an evidence of very great 
value that gestation actually exists. There has l)oen some diflcr* 
ence of opinion as to whom belongs the meiit of having lirst called 
attention to this peculiarity in the color of the vaginal wuIIjh but I 
think the credit is due to Jacquemin, of Paris, who^e opportuniiiea 
for investigating this subject were of no ordinary limits, having 
been ajipointed by the [tQlice to examine the generative orgitim of 
the prostitutes of the French metrof>olis5 — certairdy a wise regula- 
tion ; for if it be an adrnitte<l fvriikciple lliat, for the protection of 
the community, prosiitutiori must be countenanced, then, I tuiy, let 
it \w freed, as far as may ins from the clrcadful scourge entailed 
upon those who indulge in it — I mean the syphilitic taint ; and how 
can this be so elYectuaity accomplished a-* tlirough the vigilant 
examinations, made under the police regulations, of the genitals 
of the prostitutes, who are to be found in such fearful numbers in 
the great city of Paris. It would be w ell, indeed, if some such 
numicipal law obtained in Xew York, which is but the younger 
twin siller of Paris in all that contributes to the formation of the 
true greatness of a peojile, and at the sjime time panders to the 
lowe^t and most degcacling vices. 

Jacquemin, in describing the discoloration of the vagina, calls it 

a violet hue, not unlike the lees of wine; and he broadly affirms 

butt irresfwctive of any of the other evidences of gestation, this 

alone would be sufticient for him to pronounce upon the 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 173 

existence of pregnancy. Kilian, of the University of Bonn, a good 
observer, and a man of much experience, regards the discoloration 
as one of the " most constant signs of gestation." This opinion is 
also sustained by Kluge of Berlin, Ricord, Parent-Duchatelet, and 
others. There can be no doubt that the color of the vagina, in the 
great majority of cases, does undergo a remarkable change during 
pregnancy, presenting a sort of bluish tint, and this is altogether the 
effect of the vascular congestion of the parts. 

Many of you, who reside in the rural districts, and who, perhaps, 
are more or less familiar with that primitive but honorable occupa- 
tion of man, agriculture, and its kindred pursuits, must recollect the 
practice usually resorted to by breedei*s with a view of ascertaining 
whether the female of many of the lower animals be in a state to 
receive the male — or, in other words, whether she be in heat. The 
practice to which I allude is to inspect the outer opening and 
internal surface of the vagina, which, in season of heat, will be found 
to exhibit a very dark color — and I am quite satisfied that this same 
character of discoloration takes place at the advent of the catamenia 
in woman.* 

I have closely watched this latter circumstance, and in the many 
vaginal examinations wiiich I have made just before the menstrual 
eruption, I do not know that I have failed in a single instance, in a 
normal menstruation, to detect this discoloration of the vagina. It 
seems to me that the true way to arrive at the real value of this 
sign, as a diagnostic evidence of pregnancy, is to determine, in the 
first place, the two following inquiries: 1. Is the discoloration of 
the vagina a universal accompaniment of gestation ; 2. Is it ever 
present, when pregnancy does not exist ? I have no hesitation in 
stating, from my own personal observation, that pregnancy will 
occasionally pass through its various stages without the slightest 
cogifizable change in the ordinary color of the vagina, and this is 
more likely to occur in women remarkable for pallor of skin, and 
especially in those whose pallor is traceable solely to an anemic 
condition — whether the anaemia be dependent upon an original 
deficiency of the red corpuscles, or upon a sudden or long-continued 
drain upon the system. 

In reply to the second point, whether the discoloration is ever 
present without pregnancy ; or, in other words, whether any other 
cause can produce it, I am quite confident that there are numerous 
instances, which will amply support the affirmative of this question ; 
and it is with no little surprise that I find so valued an authority as 
Huguier positively, affirming that " this change of color in the 
vaginal walls is not found in any other condition of the uterus than 

* Some interesting facts as to the color of the vagina in domestic animals at the 
time of heat and during gestation, have been recorded by M. Rainard [Traits complet 
4e la part'iritioD des principales femelles domestic ues] 



174 THE PBINGIPLES AND PRACTICE OF OBSTETRICS. 

tbat of pregnancy." Now, gentlemen, what are the facts ? In the 
first place, I have told you tbat the real cause of this blaish aspect 
of the vagina is vascular congestion, and consequent partial inter- 
mption in the ordinary current of the blood. If this be true — and 
the fact is very generally conceded — it should follow that whenever 
this vascular congestion is present, no matter from what cause, you 
may very naturally look for the effect — discoloration of the vagina. 
You will, therefore, notice the change of color in the case of intra- 
uterine tumors, in chronic sanguineous engorgement of the uterus, 
etc. In a word, it is one of the not unusual accompaniments of 
congestion of the uterus, whether from gestation, or from some 
morbid influence, with which pregnancy has no possible connexion. 
From what has just been said, it is very evident that the value 
of this sign as a proof of pregnancy, is subject to more or less 
qualification ; and it is also well to mention that delicacy on the 
part of the female will oftentimes prevent the accoucheur from 
availing himself of the means of ascertaining whether or not it be 
present. 




LECTURE XII. 

Bvidenoea of Pregnancy continued — Quickening — Anclpnt Theory— Law of England 
in r^g&rd to Quickening: — ^What ia Quickening? — Opinions of Authors — Nervooa 
iktid Muscular Development — Muaculiu Contractiona of ilio Fcetus — Sensible and 
Itisenaibto Muscular Contractiona — Quickening not a Psychical Act, but tJie result 
of Exoito-aiotory Influence — Spinal Syateizi^Its Pliyaiolopical I m porta nee — 
When doea Quick entnp: take Place? — Does not always Occur — Delusive Qtiickening 
♦—Illustration — Contraction of Abdominal Walls mijitaken for — Final Cessation of 
Menses and Supposed Quicken in p — Attempted Imposition — Queen Mary of Kng- 
land — Manipulations to Detect Quickening — Influence of Cold on Movements of 
F«tu» — Illustration — Ballottemcnt or Pussive Movement of Foetus — Hahs for 
Detecting— Positions of FcEtua and BalloLtemcnt — Pkdsiitiotis of Futtiil Heart— 
Aitacuttation — Mayor of Geneva — Average Beats of Fictol Heart— Not Synchro- 
nous with Maternal FuU(? — Auscultation, how Applied — Au^icultation and Position 
of Foetus — Twin and Exlm-uterine Pre^unciea— How ascertained— Placetitiil 
SoufHi? — Uterine Murmur — Kerguradeo — Conflict of Opiinona — Bouffie not alwa^-s 
Dependent upon Pregnancy — Uterine and Abdominal Tumors; Cause of— Souffle 
no Evideno© of Life of Fcettis — Pulsationa of Umbilical Cord — Dr. Evory Ken- 
nedy. 

GsinXBHB^^' — We shall now proceed to an examination of the 
evidences of gestation derived from other sources. Thus far we 
-have considered those si^^ns only, which are either so many sympa- 
^ihetic phenomena, or the direct result of increa'ied vital action. 
The order of gigns, to which your attention will now he directed, 
Is not only of special interest, hut some of them, when recoguined, 
are conchisive as to the existence of pregnancy. They may be 
enumerated as follows: 1st, Quickening; 2d, The pasMve move- 
ment of the foetus, termed by the French, Ballottement, by the 
English, Repercussion ; 3d, Pulsations of the foetal heart ; 4th, 
Tile Bruit placentaire, placental souffle, or uterine murmur ; fith, 
Pulsations of the umbilical cord. 

1st. Qiiv:kening, — ^This^ term is employed to designate the parti- 
cular period of gestation at which, through the movements of the 
foetus, the mother becomes for tho first time aware that she carries 
^within her a living being. The ancient theory upon this subject 
i not only singular, but the very essence of absurdity ; it incul- 
cated the principle that quickening was the simple eviilenee that, 
nt that very moment, vitality was imparted to the foetus ; and that, 
therefore, prior to this event, the fcetus was an inanimate mass, 
without individuality. In those days, when physiology was not a 
science, and wheu crude hypothesis ollentimes was substituted for 



tffiy 



176 



THE PRINCIPLES AND PBACTICE OF OBSTETRICS. 



truthful nn<3 scientific research, it is not strange that sii«:h oj»iuiorji 
BhouiJ liave obtained. But that this hypothesis, fiilse, an»), in 
every sense, adverse to facts, should, almost in our own times, 
have been adopted by one of the moiat enlightened countries in the 
world, and made the basis of an important law, h a matter which, 
were it not for tlie unerring evidence of the Statute Book, would 
tw^arccly tall witfdii the range of credibility. The Ellenborough act, 
of 1803, holds the following inconsistent and unworthy language: 
''If an individual shall wilfolly or malieiously procure abortion in 
a wornar», not tiuiek with chihl^ the crime shall be declared felony, 
and the offender may be fined, imprisoned, set in the pllloryi 
publicly whipjjed, or transported for any term not exceeding 
fourteen years j l>ut if the oftence be committed after quicken* 
inff^ it shall he punishabk with death,^^ Now, gentlemen, allow 
mo to ask — Why this distinction in the award of punishnu'»»t for 
a crime which, as physiijlogists, you know to be nothing short of 
murda\ whether committed before or after the period of quick- 
entng f* 

Whrit is the difference between the ovule secreted by the ovary, 
which pa8Hc\s from the system wUh the menstrual bluod, and the 
ovule on which is exercised the speritic intluence of the spermatic 
fluid of the male? The broad, unequivocal, true physiological 
dilTerence is, that the former is dead, deciduous matter, and, like 
all tidngs dead, has no inherent power of development. The hater, 
on the contrary, is vitalized; the very act of lecun<latJon infusea 
life into it, and it proceeds on its mission of development until, 
prepared by successive increase for independent life, it is expelled 
from the organs of its parent. You ftee, therefore, physiologically 
speaking, the embryo is as mueh alive in the earliest stagt^s of 
fecundation as at any future period of its intraruteriue existence, 
Tho mould of the future being ia there, with all the necessary 
elements, through progressive development, for |>eH#ct pliysical 
organization. Like the little acorn, which, fulling from the parent 
tree, if it find shelter beneath congenial soil, antl be ahowed lo pursue 
uninterrupted its natural phases, will become matured into an oak 
as majestitt and sturdy as the one to which it owes its own exist- 
ence* Away, then, with the absurdity, and, in the exercise of your 
prerogative as mctlical men, whether in the chamber of sickness, 
or on the witness-stand in courts of justice, remember that he who, 

♦ Within a few yours, thi» law bus b<?cn modifletl. and slnnrli^ as followiJ: "Who. 
soffv^fl-, wiih llie ^^♦^ml to procure the miwarrmge of unj wnmAn, shalJ utiUiwf\iU7 
AdminttUrr to tH*r, or ciUfle to be Uken br her, tiny pi>isoii or otlicr noxious thio^^ 
Of diail unUwfully usa any inatniineiit^ or aiher mean.H whiita(.H?vcr, with ttif* lilc« 
inftel, iluiU bo fzruitty of fckiny, und beinj; coiivicliM] iht^rLM^r, shall be liublo, At the 
diflcrpimn of the CotJftT to bo trBiisported heyond the aotis for the terra of hk or her 
nftturiil liA», or for i\\\h Xfitm not Ip«! than fifteen yours, or b* Impnaoned tor «njr term 
not wtc««ding throo ywin.*' [I Viciorin, a Ixxjtv. %, 6.] 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 177 

from sordid motives, or with a view to conceal his own crime, shall 
produce abortion is, in the eye of heaven, equally guilty of 
marder, whether the act be perpetrated before or after quick- 
emng. 

The true Import of the Term Quickening. — Let us now inquire 
what it is that gives rise to the movement, known as quickening. 
Is it really the movement of the foetus, or is it attributable to 
movement of some other organ ? You will observe, in the course 
of your reading, various theories upon this subject. Some main- 
tun that the seat of the sensation of quickening is not to be re- 
ferred to the foetus, but will be found to be in the abdominal walls 
of the woman.* Others, with Royston, attribute it to the sudden 
passage of the uterus from the pelvis into the abdominal cavity ; 
while again, it is said that quickening is nothing more than the 
"evidence of the contractile tissues of the uterus being so far de- 
veloped, as to admit of the peristaltic actions of the organ." It 
really seems to me that much time has been uselessly wasted in the 
attempted explanations of a circumstance which, in my judgment, 
is in no way difficult of comprehension. 

The sensation first imparted to the parent, no matter how slight,. 
which makes her conscious that she is pregnant, and that the pro- 
duct of conception is alive, is a sensation traceable to nervous and 
muscular development. As soon as the nervous and muscular 
tissues of the foetus have received sufficient growth to enable them 
to enter upon their specific and legitimate functions, it is through 
the agency of one of these functions — muscular contraction — that 
the mother becomes sensible of her situation. Quickening^ then^ 
is nothing more than the ordinary result of progressive increase — 
in other words, the physical organization of the fcDtus has reached 
a state of development, which imbues it with the power of move- 
ment — a movement dependent upon muscular contraction. This 
contraction may be divided, for practical purposes, into two kinds 
— sensible and insensible. In the former instance, it is sufficiently 
strong to impart the sensation to the mother ; in the latter, so 
feeble that she does not become cognizant of it.. So you perceive, 
gentlemen, that while the sensible muscular contractions of the 
fetus may be said to constitute quickening, yet the insensible mus- 
cular contractions may take place some tinne previously to the 
period at which quickening usually occurs. Again, the accoucheur, 
with skilful manipulation, will occasionally be- enabled to recognise 
the active movements of the foetus before they have become ap- 
parent to the mother. I have met with more than one instance of 
this kind, and it is of importance to remember the circumstance. 

• Eggert says, the foetus has nothing whaterer to do with the movements known 
as quickening — they being exclusively confined to the abdominal and uterine 
nariotea. [Rust's Magazine ; vol. xvii., p. 62.] 

12 



178 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



T>r. !^roTit£»omery* states that he has had several fiimilar ejcninples; 
and the fact is confirrtied by other obsen'ens. 

I have just stated that the quickening of the fetas in uteroiB 
the result of muscular contractinn of the fa?tit8 itself. Tim h un- 
doubtedly true, but as intellif^ent students, who sbonld not be 
content with tite simple aflirmation of a fact, hnt who, in the true 
spirit of philosophy, have a right to seek its explanation, it is quite 
rea^^onable that you should ask what it is that gives ri«c to thin 
action of the muscular system. Is it the result of volition, or, in 
other wordn, is it a psi/chical net ; or does it depend upon flome^ 
thing beyond the control of the will ? The muscular movementa 
of the fa?tus in its niother''8 womb are reflex phenomena, the 
products of excito-raotory inflnence, an influence not dependent 
upon the brain, but traceable exclusively to what has been deno* 
minated the true spinal pystem, Tliis system h not only the nource 
of muscular movement, but it is the very fountain of life itself. 

Those of you whose attention has not been particularly directed to 
the sybjeet^ might, perhaps, ex]>ress surprise, if indeed you did not 
manifest more thau ordinary incredulity at the statement that an 
infant born without cerebrum or cerebellum, or without bolb^ 19 
capable of breathing, crying, taking its parent's broast and per- 
forming other acts connected with life. But while the researohes 
of tho physiologist have established the fact beyond a peradventure 
— they have gone further, and dL'tnonstrated that> without tho 
spinal cord, no matter liow perfect may be the cerebral masa^ life 
cannot be maintained, for the reason that the two essential fano- 
tions of the economy, respiration — and, consequently, circulation — 
on which the various organic functions depend, are the results of 
rel!i?x action of the medulla spinalis. You cannot, therefore, but 
appreciate tlie importance of this nervous centre, not only as the 
source of those forces constituting life, but also as the source from 
ivhich emanate, either directly or in direct ly, many of the disturbing 
influences, whidi derange and impair the human mechanism. I 
shall have occasion to call your attention to the physiology of the 
npinal system in connexion with the subject of parturition, and 
you will plainly see that child-birth is but another of those opera- 
tions f>f the physiological law, which are constantly presenting 
themselves to our observation. 

Period of Quickening, — A pregnant woman usually quickens 
about the middle term of pregnancy, say the fourth and a half 
month. But there is no uniform rule on this subject. 1 h.ive 
known quickening to occur as early as the tburth month, sometimes 
not until the end of the fiflh, and you will, in the course of your 
practice, occasdoiially meet with cases of gestation in which the 



• Signs ADd Symptooui of Pro^aanoy, pu IIS. 



THE PniNCIPLES AND PRACTICE OF OBSTETHICS. 



179 



mothers bnve experienced no sensation of life during the entire term 
of pregnancy, and yet bring forth heiilthy and fully developed 
infants. If you ask me to explain this, I must acknowledge that I 
cannot. It is no doubt due to isoine idiosyncriL<*y, either on the 
part of the parent or child^ which I da not comprehend, and which, 
therefoi^e, it would be useless to attempt to elucidate. It muy, 
perad venture, be that these f<Etusea are a species of " Lazy Law- 
rence," too indolent even to be made to move. We have many 
examples of this indomitable love of repose m both boys and men, 
who have long since left tlieir mothers' womb. They have no 
object in life — they simply vegetate and die, and history keeps no 
record of either their advent or departure, 

iSimulat€(i Quii^kening. — But, gentienien, what is especially inte- 
resting to you as acrouehenrs, and more urgently so in reference 
to the diagnosis of pregnancy, is, that married women, who are 
not in gestation, will sometimes imaghie they feel life, and this 
hallucination will occasionally be so marked that it may possibly 
convert you to their moue of thought, and lead to serious vvvot 
of judgment. 

On the principle that a medical man should be as ready to 
acknowledge his delinquencies as to proclaim Ins tiitnnphs, and with 
the sincere hope that the recollection of it may liereafter adniooish 
you of the necessity of caution, I shall cite the following intr rest- 
ing case, which occurred to me some years since : A married lady, 
the mother of eight children, came from Britisl* Guiana, for the pur- 
pose of placing herself nnder my professional care^ — her health had 
been quite iritirm for two years previousiy to my seeing her. On 
an examination of her case, I discovered that she was laboring 
under asthenic drojisy, from chronic disease of the liver. In 
communicating my opinion to her, she very courteously remarked 
that it was quite possible she was affected with dropsy, but she 
knew very well that sl»e was also pregnant. I asked her why slie 
thought 80, and how far advanced she imagined horself to be in 
gestation, to which she replied that f^he had, for six weeks pre- 
vioo-ly, very distinctly felt the movements of her child, and that, 
according to her calculation, wHiich had never failed her in previous 
pregnancies?, she was in her sixth month. Although I had suspected 
nothing of this kind previous to the positive declaration of the 
patient, yet such was her inexorable conviction on the point, that 
I immediately proposed t i institute an examination, for the pur- 
pose of satisfying my own mind. This she strenuously refused, 
nying that " It wouhl be nonsense, as she wa« a^ fully convinced 
of her situation as she \vas that she was a living woman.^' 

Under those ci re nm stances, I was content to submit the question 
of pregtianey to the future, and proceeded to do all in my power 
to relieve the formidable disease with which she was affected. So 



180 



THE PRINCIPLE3 AKD PBACTICE OP OBSTETRICS. 



dilapidated was hor general health, and such the character of her 
malady, that I found my efforts limited to the more temporary 
palliation of symptoms* She continued to increase in size, which 
circumstance she cor»slantly referred to her pregnancy ; and every 
day that 1 viaited her, she declared she felt more and more distinctly 
the movements of her child. She would otlen, as she reposed 
on her couch, take my hand, place it on her abdomen, and exclaim; 
'* There, Doctor, do you not feel it?" I tnu^t confess I never did 
feel it, but courtesy, contrary to conviction — so positive wan this 
lady of her situation— frequently wrung from me an equivocal, 
but reluctant assent* There was another conviction which had 
taken a strong hold of the mind of this estimable w^onmn, and it 
eonsisted in the full belief that, as soon as she should give birth to 
her child, bhc would regain her health. 

Well, gentlemen, things pai^sed on in this w^ay until, according 
to her own computation, she was, as it wvre, on the bordem of 
confinement ; and, at her urgent request, J engaged for her a monthly 
nurse, who immeiHately entered upon duty, A singular feature in 
the case was, that the very day correH|>onding with the period 
when she expected her labor, I was sent for in great haste, and on 
entering the raoni, my paiierit observed : " Doctor, you see I am not 
mistaken/' This lady asi^ured nie, and the statement was confirmed 
by the nurse, that for an liour previous to my arrival, hibor pains 
had commenced. On making a vaginal examination, you m%y 
readily imagine my embarraHsmeut on discovering that the uterus 
w:is unchatigedi and that no [iregnaney existed ! StUl it occurred 
to me that it might possibly be a case of extra-uterine fcBtatiou* 
I ftoon, however, after due exploration, decided in my own mtnd 
that this was not so. I need scarcely tell you that 1 stood self- 
rebukeil. I had neglected my duty. I was bound by every prin- 
ciplc of self-respect, by the very reasons I have so rej»eatodly urged 
upon you, to have insisted — ^wheu this lady first pluceil herself tuider 
my care, and disclosed to me her well-settled conviction that she 
was pregnant — upon an examination, which would h;ive errabletl me 
to decide the question; or, in the event of my failing to <tbtain her 
consent, it was an obligation which I owed both her and myself to 
withdraw from the responsibility of the case, for I maintain that 
the medicAl man, when denied jurisdiction, should not assume 
responsibility. I must confess, gentlemen, my conduct on this 
occ-asion Wiis not at all in keeping with ray usual mode of doing 
tilings, for I usually insist — and succeed too — as it is termed, ** in 
having my own way" in the sick room. But let us return to the 
patient. For the instant I was at a loss what to do. Knowing 
the ardent hope she entertained of her recovery as soon aa she 
should give birth to her child, and well aware, also, of the extreme 
inlirraity of her health, I was apprehensive that a sudden and 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ISl 

positive assurance on my part that she was not pregnant, would 
result most disastrously to my suffering patient. Accordingly, 
under the circumstances, I thought it most judicious to invoke 
counsel, and I requested my distinguishM friend, the late Dr. John 
W. fVands, to visit her with me. He, Wter an examination, corro- 
borated my opinion, and the lady was then made acquainted with 
the conclusion at which we had arrived. Such is the operation 
of mind upon matter, so sovereign the influence of the mind over 
the body, that, almost from the moment the disclosure was made 
to her, she began to sink, and in four days her sufferings were at 
an end. 

There are various conditions of system in which women will be 
apt to imagine they feel the motions of the foQtus, and, therefore, 
it requires more than ordinary caution on the part of the practitioner, 
in order that error may be avoided. For example, women of 
extreme nervous susceptibility, hysterical women, who are usually 
more or less annoyed by a flatulent state of the intestinal canal, 
will sometimes mistake a movement in the abdomen, dependent 
entirely upon a morbid condition, for the active movement of the 
child. Married ladies who have not bonie children, and who, at 
the approach of the period of the final cessation of the catamenia, 
usually enlarge in the abdomen from a deposit of adipose matter, 
will occasionally suppose themselves pregnant, and they will assure 
you that they have distinctly "felt life."* 

Again, women, from avaricious or other motives, will feign 
pregnancy, and, among their other devices, will attempt to impose 
upon the judgment of the practitioner, by simulating the move- 
ments of the foBtus, through the contraction of their abdominal 
muscles. When I held the Professorship of Obstetrics in Charleston, 
South Carolina, Dr. Bennett, of that city, kindly afforded me an 
opportunity of presenting to my class a very interesting case, in 
the person of an old colored woman answering to the name of 
"Aunt Betty." She was well-known in Charleston as "the old 

•Some ludicrous blunders have been made in these cases; females who have been 
married for many yeare^ and who, notwithstanding every legitimate effort on their 
part — faithfully aided, no doubt, by their devoted consorts — having failed in the con- 
■nmmation of their wishes — the production of offspring — are extremely prone to 
mistake, as the era of the final cessation advances, tlio phenomena usually accom- 
panying this important climacteric for so many evidences of gestation. The 
oessatioQ of the menses, the increased size of the abdomen, together with the 
numerous nervous perturbations consequent upon this transition state of the eco- 
nomy, are readily treasured up as so many indications that "hope deferred" is at 
last to be gratified ; and what is worth recollecting is, that it is generally extremely 
difficult to persuade these good ladies that what they have regarded as so many 
evidoDces of their pregnancy, are but the emphatic, yet sad declarations of nature 
that the springtime of life has passed, and they are about to lapse into the cold 
shades of whiter. 



182 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



woman who had been preg:nant for fifteen years,'' an^l T was informed 
that she Imd aeeumulated some money by showing thecuriooa how 
actively her little child '* jupped in the womb." 

She was in good health And qnite corpulent* As " Aunt Betty*' 
sat before inc, there was Considerable movement in the abdomeni 
whitih I very «oon noticed she should cause at pleasure. She wa» 
fitly-tivo years old^ and had not menstruated for ten yeara. Afiei 
presenting her to my claa**, and, under the full conviction that *he 
was not pregnant, I succeeded, with much coaxing, in obtaining 
ber consent that I should examine her, which privilege she pom- 
tively declared she had never previously granted nny one. The 
uierus was not enlarged ; she was not pregnant, and the deception* 
which had been practised on the credulous, w^as quite evident — 
ihe had, from long habit, accustomed hei-self to causi* the abdo- 
minal muscles to conlnict, which so closely simulated the move- 
ments of the ffEtus that she succesisfully carried out her scheme. 
Before I lefl Charleston, the good old woman died, and I was 
enabled, by a post-mortem examination, at which Dra* Francis Y. 
Poi'cher, J. B, Whit ridge, and Di\ Ben net t, were present, to coo- 
firm the accuracy of the diagnosis. There was nuthing remarkable 
revealed by the autopsy except that the i>tneiTtum wjis loaded with 
fatty matter, which accounted m part for the enlargement of the 
abdomen. 

Sometimes young, unmarried women will apply^ to you for 
professional advice, and beg yon to give them medicine to make 
them regular. They will tell yon, apparently, a very consistent story, 
h 18 not unusual for them to have a piotuberant abdomen, and if yott 
inquire about it, they vvill say, '*It is only a swelling they got prince 
they caugia cohl," or something equally satisfactory. Should yoii 
phice your baud on tlie abdomen, and recognise the movements of 
the fcptus— not unlikely to occur in aome of these eaaes — and aak 
the woman if she has ever noticed this peculiar motion, you will be 
surprised, gentlemen, at the ready coolness with which she will 
ollentimes reply, "Oh I yea, doctor, I am dreiidfully troubled with 
it — it is wind in my stomach !'** You must be on your guard — a 
woman who has fallen is generally well versed in the wily tricks 

•Dr, KeiHer reportGd to iUe Edinburgh Obstetrical Societj, MarcK 1850, tba 
fNirtioiibirs of a very remarkable ooao tK»t onl/ €»l' apurrooa pregoancy bat spurkms 
pttTUintion: 

*» He was sent for to what wnn regard*»d a veiy paiaful and protracted labor la 
wbtclii AccordtDg to the opinion of the attending accoucheur, the Oaaarean meUon 
iMi impcniiively detmiudi^ He was njitonlsliod to dnd that all the ajnipfcoisii of 
{nrinriiion wero fpuhou-s and the atenis waa uoimpreg-niited Tlie H-iends ridknilttd 
tJiO idea dint it wiia not real labor, aa the motions of the child could bd not otilf 
lelt. but »ccn through thw walls of liie distended abdomen, and the patient hamelf 
tnaiated iliat the child's movements were »o violent thai ahe feared ** it would leap 
througb lier aidi*."* The *ytnptot»s were relvrabk* in a gi\wil mtnisure to hysteria.** 



THE PRINCIPLES AKD PRACTICE OP OBSTETRICS. 183 

of life — and she will bring every subterfuge to bear in the hope 
that she may conceal from the public view the evidences of her 
own shame I 

Queen Mary, of England, is a striking example of how faf 
imagination, excited by the earnest desire to have issue, may some- 
times impose on good sense and moral worth. She was so 
confident that she felt the movements of the child in utero^ 
that public proclamation was made of the interesting circum- 
stance, and the intelligence sped with the wings of lightning 
throughout the courts of Europe. Eager, indeed, was expectation, 
and high the hopes of the Queen — her people rejoiced, and national 
oblations offered for the coming event, which was to make so many 
of her subjects happy. But, alas! the future threw a gloom over 
this cherished anticipation. The supposed quickening was but the 
result of impaired health and incipient dropsy.* 

i7ow can Foetal Movements he Excited f — We now come to a 
rery important question — llow can the movements of the foetus 
m utero be excited ? It is quite obvious that, in many cases of 
supposed or doubtful pregnancy, the accoucheur will be most 
anxious to decide the question by ascertaining, through certain 
manipulations, whether or not the chihl moves in its mother's 
womb. This fact being positively settled, places the existence of 
gestation beyond all contingency — it does more, for while it 
demonstrates that tlie woman is ])regnant, it establishes also that 
the child is alive. Most authora recommend, in this exploration, 
that the patient shall be placed in the recumbent posture, with the 
thighs flexed, and the chest gently elevated for the purpose of 
relaxing the abdominal walls. In my own judirment, it is much 
better, for the object will be more readily attained, to allow the 
abdominal muscles to be on the stretch, rather than in a state of 
relaxation, and therefore — ^although it may sometimes be incon- 
Tenient to the patient — I would prefer conducting the examination 
either in the standing or sitting position. If, in the latter, the 

• Haroe makes the following allusion to the case: "The Queen's extreme desire 
to have issue had made her family (rive credit to any appearance of pregnancy ; and 
when the legate was introduced to her, she fancied she felt the embryo stir in her 
womb. Her flatterers compared this motion of the infant to that of John the 
Baptist, who leaped in his mother's belly at the salutation of the Virgin. Dispntches 
were immediately sent to inform foreign courts of this event; orders were issued to 
give public thanks; great rejoicings were made ; the family of the young Prince was 
already settled, for the Catholics held themselves assured tliat the child was to be a 
male; and Bonner, Bishop of London, made public prayers. lie said that heaven 
would pledge to render him beautiful, vigorous, and witty. But the nation still 
remained sortiewhat incredulous, and many were persuaded that the Queen labored 
under iniirmitiea, which rendered her incapable of having children. Her infant 
proved only the commencement of a drop-sy, which the disordered state of her health 
had brought upon her." [History ol England, ch. xxxvi.j 



184 



THE PftlXClPLKS AKD PRACTICK OF 01 



jmtiont sIiotiM pliice Jiersflf upright in the chair, with her hca*! 
and fihoiiMors inclined sli^rhtly backward. Now, gentlemen, lot lis 
understand oursdves — what is it you wish to discover ? Simply 
whether the child moves In utero. I have told you that the move- 
ment \H an fxCiUh-tnotory act ; it it* obvious, therefore, that you will 
be most likely to succeed in your inve^Jtigaiions by having reco?in*e 
to those means best calculated to promote the physiolo^^ieal or 
excito-raotory influence. 

^Xi'ito-fJiatori/ action, in physiological language, consists of two 
distinct influenees — one of these indnenees coniinences at th© 
eircuniference, and travels to the centre, from which enianates, and aa 
a consequence, an action called reflex. The phentmiena are pro- 
duceil exclusively through nervous agency. You know very well 
that a capital remedy in severe uterine hLemorrhage is the cold 
dash applied to the abdomen — it is capita!, because it will very 
generally produce contraction of the womb, and thus arrest the 
flooding. But, what is the ttiodu^ in quo of this agent thuB 
applied — ^oii what principle does it cause uterine coniraetion ? On 
the principle clearly of rcHex or excito-motory influence. For 
example, the peripheral extremities of tlie nerves distributed upon 
the abdominal walls become primarily stimulated by the cold; thifi 
impression is instantly conveyed, throuq-h these nerves, to the 
medulla spinalis, which imparts to the motor nerves pnasing from 
it to the titcrus a new impulse; and it is to this impulse, transmitted 
by these nerves to the muscular tissue of the uterus, that the con- 
tractions of the org^m are to be referre^l. Upon the same principle 
precisely, will you somelimes observe the magic effects, in uterine 
haemorrhage, of a piece of ice placed in the vagina. I have nmny 
times had recourse to this simple remedy, efficient only on the ground 
of a sound ]»hysiologicid principle, and with the happiest results. 

Now, then, for the movements of the f<Pttis — they may be excited 
in various ways. Sometime?*, the plncing of the hand on the 
abdomen of the mother, and gently jjressiug it, will answer the 
purjM^se, At other times, place one hand flat on one side of the 
abdomen, and, with the fingers of the other, percuss the opposite 
«de, as yitu would in atteuiptiiig to detect fluctnaiion. Again, 
thrust the hand into a vase of ice water, and suddenly apply it to 
the abdomen. It is necessary here to state, as has been pointed 
out by Prof, Sitnpson and Hischoff, that tlie movement's wliich 
occur on the application of the cold hand to tl»e abdomen, are 
movements in the first place of tlie uterus itself through a reflex 
action; but this very movement of the wnmb causes it to pi*««3 
against the foetus, and thus inibices action in the latter.* 

• It itiiould lift rcmembereiJ tlmt these roovonicrUs of t!io uterus may txy ol 
lM?for<? llio fivttaji C4UI move, or evi*ti afler ii» il«?Hili: nittt also in caBi*a of 
enlxirgurtif'Ut ri*om i\\^ presence of sortie niurbid i^rowUi,. 




THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 185 

Some women will tell you that, on experiencing pain in one point 
of the abdomen, they will make pressure on the affected part, and 
immediately feel the movement of the feet us. This pain is often- 
times produced by the pressure of some portion of the fcetus against 
the abdominal walls, usually one of the extremities, and as the 
mother, to relieve herself, pushes the extremity from the painful 
part of the abdomen, she excites the movement of the child. If 
any of you have ever witnessed an arm presentation when the arm 
has passed from the uterus into the vagina, you, perhaps, have 
noticed that on touching the protruding hand the child will move. 
This is an interesting example of reflex or excito-motory action. 
An old author, whose name I do not now recollect, recommended 
as a sovereign remedy in arm presentations, to prick the palm of 
the hand with a needle, which, as he alleges, will cause the child to 
withdraw its arm into the uterus. No doubt, the recommendation 
was based upon the circumstance I have just stated ; but it will 
prove utterly nugatory so far as the effect mentioned is concerned ; 
and I may also remark that the author who suggested the remedy 
was entirely ignorant — for the physiology of reflex action was then 
unknown — of the true explanation of the movement following the 
pricking the palm of the hand. 

2d. BaUottemetit or Passive Motio7i oftheFcetua, — Ballottement 
or repercussion means nothing more than the passive movement of 
the child in utero — and ditters, therefore, from quickeninff in the 
eFsential fact that the latter is the result of muscular contraction, 
while the ballottement is purely passive^ a movement in no way 
connected with any inherent action of the icetus itself. For example, 
when a pregnant women suddenly turns from one side to the other 
in the recumbent posture, she may tell you she distinctly feels 
something fall, as it were, to the side on which she reclines. This 
is the fcBtus which, obedient to the laws of gravity, and floating in 
a quantity of amniotic fluid, follows the impulse given to it by the 
change of position assumed by the mother. The ballottement, 
when recognised, possesses great value as a sign of pregnancy. As 
a geneml rule, it does not occur earlier than the fourth month, and, 
according to my experience, it is most readily detected between 
the sixth and seventh months. Later than this, owing to the 
increased growth of the foetus restricting its playground, it is 
more or less diflicult of recognition. It is worthy of recollection 
that sometimes it evades the most skilful manipulation, during the 
whole course of pregnancy; and I am inclined to the opinion that, 
in such cases, one or two circumstances will exist to account for the 
failure — either an unusually small quantity of liquor amnii, or a 
cross presentation of the fcetus. This is not a mere speculation of 
mine — it is substantiated by accurate and well attested data. I 
have on several occiisions failed in detecting the passive movement 



180 



TSS PSDKJIFLI8 MXD FBACItCB QW OJMJCIHICS. 



of the focus; sod, in acqjmmciog mjsdf witli Ihe aetuAi btstoiy of 
tfe« CMe« St Uie tne of partitrttioii, I liare &ad one or Qthcr of 
llie abore drcttiadtaiiOtf to be jiceieiiL Tbe IbOowii^ eaaet I tbisll^ 
is n poiBt : 

A kdj Ironi Korth Csroltxia, cocisiilted om in Beceinber, 18SS| 
for whja ibe Bap|KMed to be s morbid growth b her wr^nib. She 
hid been msrned eleiren jesra, was 39 jreara of age, and hsul ti4*ver 
beoome pregnant. Her menses had always been regular as to time, 
bat not free in quantitj, nntil Jnljr previons to seeinjc^ her. With 
a werj thoroagh examination of her case, although I failed com- 
plete! j to detect the ballottement, af^er repeated and cireluJ trials, 
I prouoanced her pregnaoL Hy opinion was based upon unuxccp* 
ttonable testimony. 1st. The actiire ntovements of the child. Sd. 
The presence of the true areola. The lady would not believe that I 
was right in my opinion — but being an inlethgtnt womun, die 
aocepted the compromise wliieh I proposed to her — if, at the end of a 
few months, she did not prove a mother, that I would ctin^»nl to be 
denounced^ not only as a falt^e prophet, but as wnworiliy of all 
confidence. The emphatic and positive manner in which I s|>oke 
tended to remove her doubts, aud she soon surrendered her previous 
conviction. She returned to Carolinn^ and, on the 1 5lh of the fullov- 
ing April, wm delivered of a herdlhy living son, for the safiay of 
which &he was indebted to the skill of her physician, Dr. IShepperd, 
who wai* compelled to perform veisiun in consequence of a shoulder 
presentiition. It waj* tliia form of presentntion, no douljt, nhi^-h 
prevented my recbgniising the ballotternent. 

Mode of Detectinfjf BaUottenient* — ^The rules for detecting 
this movement are simple. In the first place, the exiiminaliuu 
may be made either in the erect or recuinbent position. 
The index finger of one hand is to be introduced into the 
v.iginu, and carricfd u[>ward nnd backward to the portion of 
the ulerus at which the neck and body of the organ unite — 
the other hand is to be applied expanded over the aV>domeu» 
for the purpose of grasping the fundus of the womb. You aro* 
then gently and suddenly to press with the index finger IVom 
b^hw upward, and from hfhind forward^ agiiinst the Ijody of the 
uterus; ihii pressure will nsuuHy cause a momentary ascent of the 
fcptUM, which immediately again descends, and rebounds, as it were, 
ngain^t the finger. This sensiition, once experienced, is quite con- 
firmatory of the condition of the female ;* for you must remember 



* I watt rLH]ni**UHl by a nuHlicjil jretilll'miin ot thiH citjr to Tifiit hts wife, in CQlEtul- 
Utiott with IjIh (nifid iiihI fniuily plivwidmi, Dr. Fneeiimn. The Lidy hail euCTered, 
X>f* FrtH'tnun iulWincd im?, for nioro tliiin a your from ovarian diivemio; for two 
nimUlii previoua to my ecH^ing licr, ohe lind lKH.*n voiding? iiuiiritiiic*a of pii9 per 
n*ciuia T}ie p«tu»»»l w«« muHi t?irud*«ltfJ from this circumstance. On «n ex«mi» 
OaUoHj I f^^uiid Ui« Hifht ovnry inuuii eiiki^edi and it wus evident Lbwt tt liad Ukeo 



THE PRINCIPLES AND PR4C3TICE OF OBSTETRICS, 



187 



that the relation of the embryo to the uterus is peculiar ; though 
lodged within the womb, yet it enjoys great capacity for motion^ 
either Jiclive or paftKive, for the reason that it is surrounded by more 
or los8 amniotic fiuidj which enables it to rebound to any impulse 
which it n\:\y receive, I know of no other condition of the uterus, 
either healthy or morbid, other than pregnancy, capable of produc- 
ing thia sensation of rebound, and therefore, when the hitter is 
really recognised, it is an indication of pregnancy of vury great 
import, 

3d. Puhation^ cf Foetal Heart. — ^One of the striking evidences 
of the progress of science, developing, as it proceeds, new facts, 
calculated, by their proper application, for the benefit of tlie human 
family, is exhibited in the discovery published in 1818, by M. 
Mayor, of Geneva, that, by the aid of auscultation, the heart of the 
foetus can be distinctly heard to beat in its parent's womb. What 
a precious discovery, and how inestimable its value in many cases iu 
which the true condition of the female is shrouded in mystery — and 
hf»w important, too, in instances in which, from pelvic or other defur- 
mities, the alterative of choice between the Ca?sarean section or 
embryotomy may depend upon thc^ solution of the question — Is the 
child alive or dead ? The piils^itions of the ftrtal heart are not in 
accordance, or, in other words, synchronous with those of the mater- 
nal heart. While the maternal heart will average from seventy-five 
to eighty beats in the minute, the former will vary from one hun- 
kdred and ten, to one hnndrcd and sixty,* This latter variation in the 
TCDtal pulsationii, may be asfribed to some occassional diHturlirmce 
experienced by the mother, in her circulatory and respiratory func- 
tions Jind thus transmiited to the child through the influence of the 
changes in the maternal blood. AlYcr these pulsations have been once 
ietectcd — and they are usually not recoii^niscd until between the 

irth and lil\h month — they will be found gradually to increase in 
/orce; but a-^ the period of gestation approaches its close, there will 
be a marked diminution in their frequency, Cazeanx maintains the 
•contrary of this ; I think he is in error, Tyler Smith describes them 



jm tuppuralive action, the matter pMiing out throuGrl] the rectum, i» cotisoquoncc of 
smtlon, an will Bometimes htipp«n in ibese c««e8. In addiiiou lo ilie euUrged 
jr» I thouffhi I (ii«covert:d alfo^ a» entargtrinent of the uterus — Aiid om luaking a 
Dt2:]uul examination, I very distinctly detected the bnllottomcnt. I at once pro* 
rili>(in<>.Mj tht* lady pregnnnt ; her condition bad never l>een mjftpected — her raenalmo- 
tiao hud been uniform and regular ; and no viigin«l examination had been previously 
m«de. far the reiiscm tliat its neccfifiity was not indientcd. This lady was placed 
upi>n tonic; treatment, viritli a riew of meeting the waftte from ibe onustant diachargQ 
of mutter. In four monlha after I aaw her, she was delivered by Dr. Freeman of a 
healthy httle girl, nnd what is extremely interesting entirely recovered her heuhh. 

* According to Frankenhauaer, in the male foitoa the heart beats one hundred and 
twenty four, and ia the female one hundred and forty <fbur ia a minute on an 



188 



THE PRINCIPLES AND PRACTICE OF OBSTETRtCSL 



aa det'lininj^r in tVt^quencyaiid contiianous with the diminution whS 
folio \V8 aflcM' birth.* 

Auscidfaiioft, — The douUle action of the fojtal heart — for in it^ 
as in iht? adult, there are two distinct sounds, iineijual in duration 
^is aHoertaint'd by meams of anscuitation. This, you are awnre^ 
is dividoil into m^dia(*i and immediate. In the former, the gtetho- 
soope r* employed ; in tho lattei\ on the contrary, the eiir is applied 
directly to the part at which the gouiid is sought tor. It is quite 
evident that the f<etal pulsations cannot readily be mistaken for any 
other »pecle« of vascular action, for tho imj)ortant reason that, on 
counting them, it will he found there \a no correspondence in fre- 
quency between them and the throes of the maternal heart, la 
havinjT recourse to auscultation^ tho patient may assume either the 
recumWnt or standing posilion. It is not neeeasary to expose her 
person ; the chemiHC may intervene— although the ear or sietho- 
BcojH?, applied directly to the naketl abdomen, wouKl be more likely 
to be followed by a succesi^ful investigation. Tlie chemise should 
be made as smooth as pos^sible, and perfect silence observed in the 
room; after the seventh month, the ear may be employed, if found 
desirable; but previotis to this period, the stethoscope it?iclf will he 
more advantageous. At wliat portion of the abdomen will the 
pulsations of the ftrtnl heart be most frequently found ? To answer 
this question it will be necessary to revert to what we have said, in 
a jin'vious lecture, touching ihe relative frequency of the VArtoiui 
presmtalions of the l<i?tus. 

The heiid is^ out of all comparison, most commonly f\mnd to pre- 
sent with the occiput either in correspondence with the lell or right 
acetahuhun ; the former eonsiitntlng the Hrst, the latter, the second 
presentation of the vert ex, f In these re^pective presentationa, 
you are to ask yourselves with what portion of the maternal abdo- 
men b the Rpine of the foetus in relation, for it is to ho borne in 
mhid that the beats of the heart will be more easily detected by 
auscul tilling on the back than any other part of the fut?tal surface — ' 
and for obvious reasons, as suggested by Velpeau ; in the first pL'Lce, 
tho natural curve of the ftetal b«jdy is on its anterior plane, thus 
moving the cardiac region further from the abdomen of the mother, 
while at the same time ihe upper extremities are usually folded on 
the chest; rmd secondly, the anatomical relations between the spine 
and heart afford another motive for selecting the back of the fa?tos 
in this character of exploration. It, therefore-, follows from what 
hiis been anid of the relative fiequency of cranial positions, that the 
back of the fcetus will be found most eonnuonly either on the letl 

♦ P. 143 

f Tlio fitudeiit BKould Dot forget wliAt lias alreftdy beim auid id rftg^rd to the 
ehaDfn? (^^ the Iteiid, as indioiti.'d by Nib^gol«, from the right sacro^Uiac symphyik to 
the right tiovtabuJum. 



THK PRINCIPLES AKD PRACTICE OF OBSTKTHIC3. 



189 



or right lateral portion of the abdomen, at some point between 
Poupnrt\s ligament and the umbilioim. Occasionally, however, in 
oonsequence of change in the attituJe of the foptns, the pulsations 
may be detected in various portions of the abdominal cavity. Of 
course, in pelvic presentations, the sound will be recognised in the 
upper portion of the uterus. 

The focility for recognising the pulsations will be much enhanced 
by the escape of the liquor amnii ; as soon as this passes off, tiio 
walls of the uterus coming in close contact with the body of the 
fo&tus, there is, if I may so term it, a more positive directness given 
to the sound, and con.«eqiiently an incre^ised power of jjerccption 
to the auscnltator. In addition to the proof of pregnauey and the 
life of the child, these pulsations, when recognised, will al-^n indi- 
cate the position of the fa?tus in titero. If, in your exploration, 
you should hear the beatings of the foetal heart in two distinct por- 
tions of the abdomen, the irresistible conclusion will be that it is a 
.ease of twin pregnancy; and again, after detecting the pulsations, 
^if, on a vaginal examination, you should ascertain that the uterus 
has undergone bnt slight enlargement, it is very manifest that it 
cannot contain afcEtus, and, thereforen^ the gestation is extra-nterine. 
Sometimes, with the best directed eflbrts, and with all the skill you 
can bring to bear, it will be impossible to recognise the action of 
the heart, and yet the woninn may be pregnant ; and, at the full 
term, bring forth a well -developed and healthy child. So you see, 
gentlemen, that while the pulfiations of the fcetal beait, once posi- 
tively heard, cons^titute an nnernng evidence that pregnancy exists, 
their absence is by no means a proof that the female is not preg- 
nant. 

4th. Mntit Pla^entaire^ Placental Souffle^ Uterine Munnur. — In 

1923, Kergaradec called attention to what he denominated the 

^ JJnt it placenta ire — ^ihe placental souffle — a peculiar sound which he 

maint;uned was disclosed during pregnancy through auscultation, 

and which he attributed to the passage of the blood from the uterus 

into the placenta — the ntero-jilacental circulation — and hence the 

^lianie placental souffle. Since that time, however, although the general 

ffect is almost univei^sally conceded that a peculiar sound is emitted, 

yet authors differ as to its cause and seat. Some agree in opinion 

with Kergaradec, while others maintain that the sound Is produced, 

not by the utcro-placental circulation, but through pressure exer- 

I cised upon the adjacent blood-vesseln by the gravid uterus, 

l>ubois restricts the cause and seat of the souffle to the circulation 

going on in the substance of the uterus itself. It is quite evident 

that the opinion of Kergaradec is not tenable, and, among others, 

for the following reasons : 

1st. This sound is sometimes heard after the birth of the child, 
and expulsion of the plaeenta. 2d. It is not contined to any given 



190 



THE PRINCIPLES AND PRACTICE OF OBSTCTRlCa 



point of tiie uterus, but will be heard in almost every portion of its 
surface at different tinier, 3d. It will oftentimes he recoguiscd 
when pregnancy does not cicist, in crises of abdominal or uterine 

tumnri^. The uterus, during pregnancy, U in an extremely liyper 
iBtnic condition, the vessels are turgid with blood, and consequently 
the local circulation will be more or less labored; may not tliiK be 
the ^imple explanation of the uterine murnmrdurinjifjjest-ation — ^and 
when it is heard ailer delivery, ntiay it not be explained upon the 
hypothesis that the sudden emptying of ilie womb has left the vas- 
cular and other tissttes of ilie oigan in giuh a relaxed stale, thai 
the eirt^ulation, for a short period aller parturition, eontinuea to be 
slug^dsh, or, if you choose, labored, and hence the murmur ? When 
you detect, through auscultation, the bellows sound in the heart, i« 
it not accounteil for on the principle that the circuhitlon, through 
valvuhir or otla^r disease, is interrupted in its ordinary round? 
But how, you may ask, is this soufiie produced when pregnaucy 
does not exist — in cases, for example, of abdominal or uterine 
tumor^^ ? 1 Lave no donbt it h the res^iult of |»red!iure upon some 
of the surroimdin^ vessuls. The hyj>othesis has obtained that the 
souffle may be occiisioncd by the peculiar condition of the blood in 
pregnancy, producing, as is sometimes the case in chlorosis, certain 
abnormal suuruls. Tliat distinguished phy^io^Jgist, Dr, Brown- 
Sequard^ suppoges tliat these sounds in dilorosLs occasionally ema^ 
nate from a tremor of the muscles peculiar to weak and aged fier- 
80ns; and he has shown that there is a sound produced in thegiavid 
ntcruH, which is generally mistaken for the placental souffle, and 
which is evidently due to the muscular sound; it co-exbts mth the 
local ctm tract ions of tlie in eras. 

Tliere is much diversity of opinion as to the paiticular period of 
pregnancy at wfiic!* the souftie can be first recognised. Some say 
they have detected it at the eleventh wx^ek, ot tiers at the third 
montfi. Hut you will tind, gentlemen, that these early periods, 
admitting tlierc is no error, constitute rare exceptions to a very 
general ruk\ It is more, I am sure, in accordance with correct 
observation, to say that it is not until the expiration of the fourth 
month that it can be detected. The souffle differs in one important 
particular from the pulsations of the i'oBtal heart — it is synchronous 
witli the maternal pulse, and, tlierefore, is connected with the blood- 
veifflcls of the mother. It possesses rather a coquettish jjropeujtity 
— after being once heard, it will sometimes bid detiance to the most 
aocomprLshed auscuUatoi\ and will so completely intermit, tUrt 
several days will often elapse be lore it again reveals itself Occa- 
sionally, the whole period of [jreguancy will pa^s without its ever 
being detected. Fiom what hju been said, it is manifest that its 
value as a sign of pregnancy i;* not of a high order, for it may 
exist where there is no gestation ; and while its presence is no 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 191 

indication of the life of the foetus, it may be detected when the 
latter has ceased to live. 

5th. PuUcttiona of the Umbilical Cord, — Dr. Evory Kennedy, 
who has written so well on the subject of utcro-foetal auscultation, 
says that he has been enabled distinctly to feel, through the abdo- 
minal walls of the mother, the convolutions of the umbilical cord, 
and also, by aid of the stethoscope, to hear its pulsatiods. But 
it has only been, he states, in cases in which the walls of the abdo- 
men and uterus were characterized by unusual thinness. I have, 
after repeated attempts under the circumstances indicated by Dr. 
Kennedy, never succeeded in attaining either one or other of these 
objects. If the cord were distinctly felt, or its pulsations heard, it 
would certainly be unequivocal proof of pregnancy. But it seems 
to me that if the pulsations alono were detected, it would be diffi- 
cult to demonstrate that they proceeded from the cord and not the 
heart, inasmuch as they, like those of the latter, are not in cor- 
respondence with the maternal pulse. It is true that the beatings 
of the cord might, from its extent, be heard in different portions 
of the uterine surface — but this, again, would be apt to give rise to 
the suspicion of Twin-pregnancy.* 

* A Funis wuffie is sometimes heard. Five instances, in five hundred cases of 
labor, have been reported by Scanzonu The source of the souffle docs not appear 
to be clearly establisbed, but its presence is supposed to be, indicative of danger to 



LECTURE XIII, 



Bxatn illation of the Female to Ascertain the Exislenoe cH" Ppefrnancf— Tbe ThfM 
SeUHca, Feeling, J:>eeing, and Hearing:, to *>« eriiphjyeU — Tb*j *'Tguch<?r;" wli»l to 
itT^Kxtornal AUiominal Ex»»)itidtion ; its Otijects; how to be conducted — Va- 
rious Causes of Uteriuo Knlargcment; how to be diMtiiigtiiHlieil — fixaniinotioti por 
Vftginmra ; Rales for — The %'iigiaa ; iU Position iind KelAtion^ — Positioa of the 
Fcma]t< — Relation of the Vagina to the Cervix Uteri — Kxamlnntion per A&um ; 
when indicui ted— Retro- VefHion of Utenis — Prolapsioo of Oranr into Trifln^pakr 
Fodsa — Vaginal Ovariotomy — Auscultation ^Tlie Metroscope; ita Uses. 

GxKTLEMKN — ^The examination of a female, for the purpose of tmcer- 
tmning whether or not she ia pregnant, requires on the part of tlie 
accoucheur, in the first place, a thorough knowlLilge of the various 
eviilencf^of gestation, together with a full appreciation of the mor- 
bid phenomena known to i<iniulate this ei»tuljtion; and, second ly, 
lie must bring to the examination a fivcility of tuct, which can onljr 
be acquired by a long and weH-cultivated experience. To arrive 
at a just diagnosis on this subject will otlen times constitute, from 
the complication of the surrounding circumstances, one of the .most 
diflicult duties in the entire curncuhira of the physician^s practice. 
But, great as is the embairassment, it may be overcome by an 
enlarged knowledge and due attention. 

In our discussion of the numerous signs of pregnancy, you will 
not have failed to notice that they are of different grades, and pre- 
sent various shades of valne. The great majority of them are, to 
say the least, only equivocal, and will not, therefore, when any 
important interest, such as life or character, is involved in the 
decision, fiirm data sufficiently broad to eualilc you positively to 
aflirm tliat gestation exists, 1 admit that a married woman, e^i^i^e- 
mskWy if slie have previously borne a child, will generally be enabled 
to understand that she is pregnant, from the symptoms which 
onlinarily ac4*ompneiy this state, such as the suppression of the 
catanienia, moining sickness, mammary sympaihics, and other 
phenomena. But these signs, as I hey may be dependent on other 
influences than pregnancy, are titterly insufficient in numerous cases 
in which the counsel and judgment of t lie physicinii will be hivoked, 
and npoti whoso opinion must dejiend all ttiut is sacred to tbe 
inilividuaL 

The accoucheur, in his analysis of evidence, will have to bring 
into requisition the three senses, /eelinff^ 9t€ing^ and hearing} 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 198 

therefore, his means of exploration are divided in obstetric lan- 
guage into — 1. The toucher; 2. The revelations made by the eye; 
8. Auscultation. The adroit application of these resources, and a 
judicious appreciation of their deductions, will rarely fail in enabling 
the practitioner to evolve an opinion in accordance with the truth. 

The toucher consists of an external and internal examination — in 
the former, it is restricted to an exploration of the abdominal walls ; 
in the latter, the finger is introduced into the vagina or rectum, for 
the purpose of sundry investigations, to which we shall presently 
more particularly allude. 

The eye is more especially employed in examining the state and 
peculiarities of the mammae, while the ear is engaged in testing the 
various auscultatory phenomena. 

1. JSxtemal Examination, — In this examination, the chief objects 
are to ascertain whether there is any abdominal enlargement, and 
if 80, on what it is dependent ; also to recognise, if possible^ the 
movements of the fcetus. If from distension of the uterus, the 
increased volume of the abdomen will usually be more or less in the 
centre of the hypogastric region, pyramidal in shape, with the base 
upward and the apex downward ; and the enlargement will present 
to the touch uniform hardness, while on the sides there will be an 
absence of fulness, and the abdominal walls at these points will 
yield more or less to pressure. The upper portion of the ]wramid 
will represent the fundus of the organ. By causing the aMoniinal 
muscles to relax, which can readily be done by flexing the thighs 
on the pelvis, and gently raising the head and shoulders of the wo- 
man, the hand is enabled to grasp the fundus ; this will deternjine 
the point of its ascent in the abdominal cavity, and thus enable you 
to approximate, all things being equal, the period of pregnancy. 

But, gentlemen, supposing the uterus to be distended, how do 
you know that it contains a foetus ? You will ])robably answer me, 
by means of the ballottement, quickening, or the pulsations of the 
foetal heart. These phenomena, however, cannot be detected in the 
earlier months of gestation^ and sometimes — although pregnancy 
may exist — the accoucheur fails altogether in recognising them dur- 
ing the whole period of the gravid state. Your diagnosis, there- 
fore, must be determined by other circumstances ; and this brings 
us briefly to consider the different causes, other than gestation, 
capable of inducing enlargement of the uterus. They may be 
enumerated as follows : A. Intra-uterine growths, including fibrous, 
polypoid tumors, and hydatids ; B. Hydrometra, or dropsy of the 
uterus ; C. Retention of the menses ; D. Physometra, or a flatulent 
distension of the organ ; E. Hypertrophy ; scirrhus. 

A. IntrorUterine GrototJis. — ^These, constituting pathological 

. states of the organ, are usually accompanied by phenomena which, 

to the intelligent observer, will unmask their true character. For 

13 



194 



THE PIUKCIPLKS AND PRACTICE OF 



example^ in eases i>f an iritra-uterine tumor, wbetUor simply fihroq% 
occ«i»ying the oiilire cavity of the orpiu, or polypoid, and pedien* 
lato<l to a given point, tliere will ahaost always be bemorrliage 
with more or less beariniT.do\vn pniu — ^ihe bleeding and pain gen#- 
rally increasing about the advent of the catamenial e\at*uatioiu 
Again : in these formations^ the growth of the tnmors is orilinarily 
»lower^ and in tins way, too, they may be distingnishod from preg- 
nancy, which you know is rapid in its development^ for the reason 
that there are but nine months allotted to the riccoinplishrneut of 
that ch^^ (P^mvre of niiture — the perfect organiy,ation of the era- 
btyo \ Oecnsiionally, when the uterus is enlarged from aa intra- 
uterine growth, auscultation will reveal a sonftie;* this may be 
mistaken for an evidence of pregnancy ; but if this latter condition 
really exist, in addition we slroul*! recognise the pulsations of the 
ftptal heart, together with the movements of the fcetus itself. Kor, 
in this eomiexion, should it be forgotten that these growths will 
liometimes coexist with pregnai»cy* 

Pathologists arc not of accord as to the special stroeture ot*the96 
tumors; it has been generally eaid that they are composed of a 
fibrous tissue ; recently, however, Lebort and C. Robin seem to 
have demonstrated that they consist of a simple hypertrophy of the 
fibrn^ninscnlar clement of the uterus, Virehow is also of this 
opinion, maintaining that the tibrous or fibroid uterine tumor pos- 
eo^es in every respect the same structure as the walls of the 
hypertrr»phicd uterus, consisting not only of fiVjrous connecting 
1is*iue and vcsi*els, but nleto of muscular fibre cells, f 

In uttrine hydatids there will also be occasioruU bearing-down 
paiiis, and more or less discliargc of blood ; and, in addition, there 
is a symptom which I consider pathognomonic of these growths, 
viz. a periodical discharge of water per vaginam* 

B. Jlydroinetra^ or Ihopsyj of the Utertis.-^ln this affeetion the 
constitution is usually more or less irjvolved, it being rarely a local 
disease ; and, in percussing, distinct fluctuation will be revealed. 

C. Retention of the Olenites. — ^This is a most important derao^^ 
ment of the female, and has more than once resulted in false and 
erucl opinions, aflecling nut only the happiness, but leading from a 
liroken heart to the death of the individuah Retention of the 
menses is that peculiar condition in which the menstrual blood is 
poured out regularly every month into the uteiine cavity; througb 
jt« aocumulalion, it gives rise to distension of the organ and certain 
sympathetic phenomena, w^hich have someiinves been mistaken for 
pregnancy, and formed the basis of most erroneons decisions. See 

* Tite suuflle \b not iil nil itMiomj^ialtblu with iin ittint-uteritic Hbrpua growth. Cor ii 
■My TvHuli tVom tliti f:ict of the tumor being aitiuikd ovrr tUo aortA or other lurgt 
vesicJa ; and samotifnes, ntiio. Uic increcmed viucularity of the utenm may produce it 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 195 

how easy a thing it is, by a careful examination, to arrive at the 
trath on this subject. Why is the catainenial fluid retained in 
utero ? Simply because there is an obstruction to its free passage ; 
and this obstruction may consist either of an oechided os tincae or 
an imperforate hymen. Therefore, if either of these be found to 
exist, your diagnosis is at once arrived at.* 

D. Physometra, — ^This is a rare affection ; it consists in the 
accumulation of flatus within the cavity of the uterus, and I believe 
is almost always traceable to the extrication of gas from some 
decomposed substance within the organ — such as a retained pla- 
centa, mole, or foetus. In physometra, there will be revealed, 
under percussion, a sound of distinct resonance, and the uterus 

• Among several cases of retained menses in which I have operated, the follow- 
ing is not without interest : A respectable woman, the wife of a thrifty mechanic, 
married about six weeks, requested my professional advice, ller husband, a 
mouth after marriage, had begun to treat her cruelly in consequence of suspicious in 
regard to her fidelity. When I saw her, she had the appearance of being about five 
months pregnant; she remarked that some of tlie female relatives of her husband 
had impressed him with the belief that she was pregnant when he married her; henco 
bis cruel treatment. The poor woman was in deep distress, and supplicated me to 
satisfy her husband that she had been true to him, assuring me, at the same time, 
that she would cheerfully submit to any examination I miglit suggest. She informed 
me that she was twenty -seven years of age, and had never menstruated ; her health 
had been wretched from early girlhood. On visiting her the following day, I ob- 
served there was an indistinct and circumscribed fluctuation perceptible at the 
anterior portion of the abdomen, and extending upward within one inch of the 
ombilicua. The finger being introduced as far as the cervix, I soon appreciated an 
entire absence of the os tinciB, the lower and central portion of the cervix being quite 
smooth and uniform on its surface. With the other hand applied to the abdomen, I 
grasped the fundus of the womb, and thus embraced this organ between the hand 
externally, and the finger introduced into the vaarina. The diagnosis was plain ; 
viz. that the fiuctuation was the menstrual blood contained within the uterus; in 
consequence of there being no outlet, this fluid had accumulated, causing a dis- 
tension of the womb, and giving rise to the suspicion of pregnancy. I stated my 
opinion very fully to the husband — told him his wife could bo relieved by an opera- 
tion, at the same time assuring him that his suspicions were without the slightest 
grounda 

Having obtained his consent, assisted by two of my office pupils, Drs. Burtsell and 
Morris. I introduced a speculum into the vagina, and brought distinctly to view the 
cervix-uteri. This I penetrated at iis lower and central portion. Soon, not leas, I 
am sure, than two quaris of grumous blood were discharged from the uterine cavity. 
It is as well to niention that the perineal strait of the pelvis was somewhat contracted 
in its transverse diameter. The operation was attended with very little pain ; the 
uterus assumed its ordinary size, and the patient recovered in a few days. I was 
much gratified with a visit from both herself and husband, the latter appearing truly 
contrite, while the former assured me of the happiness she experienced in being 
restored to his confidence and affection. Nearly thirteen months from the day of 
the operation, I was ©illed to attend her in her confinement*; after a severe labor 
of twenty-eight hours, I deemed it necessary to apply the forceps, and delivered her 
of a fine living son, assisted by two of my pupils, Messrs. Meriweather and Whipple, 
of Alabama. 



106 



THK PRINCIPLES AXD PRACTICE OF OBSTETRICa 



will lie found chanu5terize<l by unusual lightneg*, Itn volume, too, 
will be a|Jt to vary in consc([uencc of the occasional escape of 
flatuiii through the 03 tinc^e. In addition, tho antecedent bintory 
of the ra^ti will aid essentially in a correct diagnosis. 

E. Ift/iwrtrophi/ and SclrrluM of tfut Uterus, — ^Hore, too, the 
history of the case, besides the peculiar Juirdness of ^uiThusi 
impart (id to the touch, will cthilile the practitioner to avoid all 
doubt. 

I may also, at this time, mcntiosi some of the ordinary cau^e?* of 
abdominal enlarcfenient, wliic^h mi^ht possibly, through unpardon- 
able negligence, be tiiiHtaken for pregnancy — such as abdominal 
tumors \nthout tlie ulern^ whether simply libroua, pediculuted to 
the external surface of the organ» or in the form of a steatomatous 
ni:LSf«, encysted dropsy, tymjianitcB, ascites, etc., etc. 

Ahdonihifd 7\(mor8, — Fibrous growths, attached by a peiltclo 
to the outer portion of the uterus, are, according to my ex[>erience, 
by no means uncommon. Usually, there are several of them ; thrlr 
gi'owth is sometimes rapid ; most generally, however, alow. They 
an* not malignant, and when they destroy life, they do 80 in cun- 
sequence of their pressure on the digestive apparatus, 8t> as to 
interfere with the healtliy and necessary play of the nutritive func- 
tions* I have seen them from the size of an c*^g to the weight 
of thirty pounds. In my museum, yon have examined scvePal 
extremely interehting j»|>eeinK'ns of this character. These tutuorti 
are generally characterized by great mobility; and, mider ordiniiry 
circumstances, they caii bo made, by judicious manipulatioa^ to 
revolve slightly upon their axis, which consists of the pedicle by 
wliich they are att:icUed lo the external surface of the uterus ; and 
if you gently press the ulnar portion of tfie hand downward, you 
will frequently be enabled to pass* it between ihe^e tumors, shoviiug 
at once their separate and individual existence, and also proving 
how entirely they are unconnected w^lth increase of the abdoroeOf 
the result of gestation. 

JSidargcment of the Oirari/, — An enlarged ovary has ofleiitimes 
given rise to the suspicion of pregnancy ; imd while, with proper 
attention, it is not dirticult to make the neces^sary distinction, yet 
it must not be forgotten that occasionally this form of tumor 
coexists with, and constitutes one of, the complications of gesta- 
tion,^ In these latter eases, more than ordinary vtgilaneo will be 
needed to elicit the truth. It would be proper to inquire whether 
a tumor had been observed in the ai>domen i'o%* »ome time before 
the suspected pregnancy. But as a means of diagnosis iti thc^e 
ca4>e«, you will tinti auscultation, perhaps, the most efficient, pro- 
vided you can Duoceed in detcirting the pulsations of the festal 

^ Par AS mtere«titi||[ exjimpto of tlila kitid, see Diadttaei af Wodmki and Quldreoi 



THE PHINCIPLES AND PRACTICE OF OBSTETRICS. 



197 



heart. In siriiple ovarian i*nl argument, you will discover, on inquiry, 
that tlie tumor eomnienc^d not in the lower and central {lortion of 
the abilonien, as is the case in enlargement of the uterus, but in 
one or other of the iliac regions ; and for the very substantial 
TQoaon that this 'ha the location of the ovaries in their nattiral and 
healthy state. As the tumor increases in develojiment, its ascent 
in mora or less oblique ; and, on a vaginal examination, the uterus 
will b€ found to have increased, ii* any, but very slightly in volume, 
Shoald it be a case of dropsy of the ovary, which is by far the 
most common form of uiorbid action assumed by this body — 
percussion will enable you to ascertain the fact, for lluct nation, 
more or less distiuet, will be recognised. This form of dropsy is 
called encysted, because the fluid is contained in one or more 
cysts — in the former case, known as uuitocidar ; in the latter, 
multllocular. 

Ti/mpanit€8. — The abdomen will not unfrequently become dis- 
tended from a collection of flatus witliin the intestinal canal ; and 
this is apt especially to occur in nervous, liysterical women. One 
of the prominent diagnoHiic evidences of this character of disten- 
sion is the alternate increase and diminution of the volume of the 
abdomen — and thb depends ujion the quantity of flatus which 
escapes, either through the ccsophagus or rectum. In tliese cases, 
too, the uterus will not be enlarged. 

Aacite^. — Ascites, or peritoneid dropsy, cannot well bo con- 
fouu«led with pregnancy, if the ibllowing diagnostic guides be 
borne in mind : L It is the result of some previous derangement — 
inch, for example, as inflammation, disease of the liver, kidneys, or 
beart ; 2. In welUdeveloped ascites, tliere is always more or le^is 
lisstinct fluctuation — and the fluctuation in this differs from that in 
bydrometra and encysted ovarian drojisy, in the important fact 
that it is not contined to any one portion of the abdomen, but is 

^general ; 3, The uterus, unless as a rare complication, will be found 

^ unehauged in size. 

Ph€mtom Tumors — Accumulaiion of Fwcal Matter. — In hys- 
terical and nna^mic women you will sometimes meet with what are 
^»nned phantoin tumor^i, the pathology of which api>ear8 to be an 

[irregular contraction and relaxation of the jibdoniinal walls. A 

"careful vigilance will prevent the possibility of mistaking these 
enlargements for pregnancy ; so also with regard to the occasional 
distension of the abdumen from accumtdated faeces, 

2. Internal £,jfami tuition per Vagi nam, — It needs no little tact 
to conduct this examination \n a manner at once acceptable to the 
patient, and profitable to the accoucheur. Indeed, I know of few 
puitilions more embarrassing to the young practitioner than to be 
called uptm to institute this kind of exploration, without due 
knowkdge and experience. It can scarcely be necessary, gentle* 



198 



THE FRINC1PLE3 AKD PttACTICK OF OBSTETRICS, 



meti, to remind yon that your patient is always entitled to i 
meatfurc of delicacy and refinement — ^it should never be forg 
that it is at a heavy sacrifice that she consents^ to have you by hd 
side in the hour of her triiil^ — and the richest equivalent, therefor 
you can offer her for this micritiee is the high-toned bearings whic 
every cukivated gentleman knows so well how to cxercbe towi 
a female nndur these circumstances. 

You Bhould accustom yourselves to conduct this examination with 
either hand, and whichever one you employ the index fini^er onli 
IB required. It should be extended fully, the thumb brought inl 



Fig. la 

the palm of the hsunl, and 4»overed by the other three finger 
(Fig. 43.) If you have a i^cratch or sore on ihe finger, never intf 
duce it into the vagina, for you incur the serious hazjird o( inocQ 
laling yourself witfi the venereal poison, if any exist ; or the 

■ absorption of acrid teucorrhoal niniter may prove disastrous. The 
finger shotiKl always be lubricated with some mncilaginoas or oilj 
material ; what I find to answ^er every purpose is a little soap an 
water. Unless there be some ]»er8onal or other objection to it^ I 
usually prefer making this e\airiifiation with the pulient on h€ 
back, and in the recuii>hent position ; the ablominal walls should 
be in a state of relaxation, as in the external examination, in ordi 
to facilitate the accoucheur in his manipulations — for, if they 
tensL* and resisting, he will be unalile to feel the uterus with ih 
hand a))plied externatly, A very proper and necessary precautic 
b, to precede the examination by causing the bladder and rectuii 
to be evacuated of their contents. A neglect of this preuautia 
will be apt to interfere more or less wiili the thoroughness of tl: 
explomtiori, and add no little to the discomfort of the patient. 

Preliminaries to ihe E^amittatiim, — You are to remember thai 
there is not the slightest necessity for, nor will any thing juiitiJ 
the exposure of your patient. Your coat and shirt sleeve shou 
be turned over at the wrist, and a napkin properly pinned ov€ 

vthem, so as to protect you from any mucus or other f^ecretion* ic 
iho vagina— and besides, it is more in keeping with neatneJW and 
relineraent, two attributes always appreciated in her physician by 
a ilelicate and cultivated feuiale* IIow are you to find the vagina? 
This may appear to you a very lumecessary qaesiion — but, geotle 



THE PBIN'CIPLES AND PRACTICE OF OBSTETBICS. 



19» 



moo* It is full of gterlhij^ import to you as practitioners. What 
wouM Ue tht* me;i**ure of your tnorl ideation if, io attempt in«^ an 
examination of this kiiid« the patient* afler more than Ohri^tiaa 
furUfaiance, fthould exclaim* ** Dot-tur^ what are you about; do you 
M<»t know l>cUer than that ?■' und you should discover that the 
rubuke was promplt?<J Vjy itie painful ciremut^tance that, instead of 
the vagina, you had introduced the finger into the anus ! And 
yet, gentlemen, &trar>«re a» it may seem to you, this blunder haa 
Ik'cu oiuiniiited, for want of proj^cr knowled**e, much to the 
chagrin of the pi*actitioni.«r, and the uutraged feelings of the imtieut. 
It i* with a view, therefore, of guarding you against the possibility 
of »ucb an €rror, that I shall proceed in a few words to point out 
in wfiat vTAy it may be avoided. The hand, arranged aa I have 
ah^eady deikjribed, is to be [ilactM^l under the sljeet, and, willjout the 
consciousness of your patient, you should at once carry the index 
finger lo the central and inti^rnal surface of the knee corresponding 
with the side of the bed at which you are sittine; ; then coutluct 
the tinger carefulfy ah>ng the median line on the internal surface 
of the thigh :i^ tar as the vulva ; lids will bring your finger to the 
ceutiinl jiortion of either the right or left labium externum, and as 
»oon 118 it has reached t!uH point, all tliat i» necess^ary will be to 
pu»h the finger a little to the rigfit or Icfl, depending upon which 
lalaum it may be, and it is at once In the vagina, 

MeiatfonA of tJm Vaffina — Deductions. — As the finger [la^^aes 
into the vagina, ahvayn have its radial border looking toward the 
symphysis pubis. Now, before proceeding further, let us pause 
fW a nioraent, and make one or two observations with regard to 
the shape and anatoinica! relations of the vagina. It is, you know, 
called the vnlvo* uterine canal* because it extenda from the vulva 
to the ntcrns, receiving, as it were, into its up|>er portion the cervix 
of the latter organ* The vagina jMiiiteriorly, in its three uiiildle 
tafths is in relation, through the medium of cellular tis**ue, with 
the i-ectum, giving rise to the recto-vaginal septum ; anteriorly, it 
fonnis through the same sort of intervention* a union with the 
urethra and bladder, ihua eonsiituting for tlie accoucheur two 
imjiortant ncpta, viz, the urethro-vaginal, and vesico-vnginal. In 
addition to these relationt^, it must be bome in mind that the 
vagina is a crooked canal, with its concavity forward, and its con- 
vexity backward ; so that it corresponds with the curves of the 
elvi*, the upper extrendty being parallel to the axis of the superior, 
rhile the lower is iu relation with the axis of the inferior ntrait; 
the ordinary position of the utertis is such that Its long axis is more 
or le!*« in correspondence with the axis of the upper sti-ait of the 
pelvis; and it, therefore, follows, that the junction of the upper 
portion of the vagina nuil cervix of the organ will form with the 
outer opening of the vagina an angle of about 45 degrees. Tho 



200 



THE PKINCfPLfelS AMI PRACTICE OF OBSTETRICSL 



abject (»f my dirccUng attontiou to these import nnt facta i», in 
they may serve* as a guide far the direchon of the finpjer aiYer ti 
ha* reached the vagina. Without spoeLU attention to the «uhjeo4 
the young praetitiotter — I do not think I eacngj^erate it^ — in ninet] 
ea060 out of one hundred, will, as srmn as the linger entern thfl 
vagina, direct it from before baekward ! In doing thin ho will n<] 
succeed in reaching the os uteri, winch is one of the importaiil 
objects of bis search, either in ex[>lorjng for the evidenoea of pr 
nancy or at the time of labor — and hence his examinntian i* with 
out profit, he forms no diagnosi?*, and is stultified by bii* owi 
ignorance ! In rarr) ing the finger from before baekward, h€ 
reaches, not the os uteri, but the rectum — and if it 8hotUd rhanc 
to bo filled with masses of fiecal matter, by pushing and poking- 
as he would be likely to do — it is not iiniiOHsiUe that he might 
mii^take the pieces of excrement for some anomalous condition of 
things — perhaps a presi^ntatloii of the nates su[i[>ot*ing the tuuvabN 
lumps to represent the testes — and in his confusion, he woitM 
reveal his diagnosis, and request an immediate consultation I 

In order, therefine, to avoid all error on the subject, as soon as 
the finger has pnssed about three inches into the vagina, the wrig 
is immediately to be depressed, and an opposite direction imparte 
to the finger — and for the obvious reason that, at first, the direo 
tiun should be jiarallel to the axis of the inferior straits 

Yon will sometimes meet with easL»s in which tin* cervix uteri if 
situated so high up that it will be extremely dillicidt to reach \i 
with the finger. Under these cireumstanceR, you will find it gom 
practice to examine your patient in the standing [wWition ; ui thtd 
way* by giving the uterus all the advantage ijC gravity, the dif 
eulty will geueridly be overcome,* 

Well, you have reached the neck of the uterus — what next) 
You are now to ascertain its exact position; ia it nornial ? Has 
it descended lower into the pelvic excavation than usual — is the " 
tinea? tumid and moi?.t — is there any shortening of the cervix — h 
the Iwjdy of the organ enlarged — does the enlargement indieat 
disease, or is it the residt of pregnancy? Can you distinguish ihl 
foptus by the ballolienjent ? These, gentlti-men, are so man] 
inquiries which will necessarily present themsHves to the at ten 
tion of the accoucheur in etuiductiiig an examination with a vien 
of ascertaining whether or not pregnancy exists. 

I should have mentioned that, during this exploration, the othe 
hand is to be applied to the ubdcninMt of tht* female tor the pur 
po9C of gently gras|iing I he fundus of the womb, imd thus Judginj 
of its volume and exact p>sitinu in the ah4imiinal cavity. 

* In QAMw, »hu^ 111 w|ik;li, frain dtHenfw or oth^rwin^, ihe Iiri'tittiing of the patii 
becoiiu<fl aaitH?ted in the reciintbefit posture, slio sliuuld be exuimuod in Uw tt^ 
potitiotL 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 201 

The vaginal examination, if properly conducted, will reveal to 
the observant practitioner much interesting information, uncon- 
nected with the mere question of pregnancy. For example, he can 
ascertain the existence of i>elvic deformities ; the condition of the 
«oft parts, whether normal or otherwise, and thus decide between 
a pathological and healthy condition of the parts he traverses with 
his linger. In one word, gentlemen, the examination per vaginam 
is a precious resource for the well-educated practitioner; it is a 
field rich with disclosures, which may serve as his guide in an 
infinity of ways. 

3. Internal Examination per Anvm. — Under certain circum- 
Btances, it may become necessary to examine the female per anum; 
for instance, in cases in which there may be exquisite sensibility, or 
much contraction of the vagina ; where there are tumors developed 
in the posterior wall of the canal ; or in cases of retroversion of 
the uterus complicating gestation ; or where there has been pro- 
lapsion of the ovary or small intestines into the triangular fossa, 
bounded anteriorly by the posterior surface of the uterus, and pos^ 
teriorly by the anterior surface of the rectum — sometimes called 
the recto-uterine fossa. This is a mode of examination extremely 
repugnant to the female, but, when indicated, it is fruitful in light 
to the practitioner. 

You will sometimes be consulted by women, who will complain 
of extreme and painful pressure on the rectum, giving rise not 
only to great physical suffering, but oftentimes interfering seriously 
with the act of defecation. This pressure may arise from two 
very dilTerent conditions : either from retroversion of the uterus, 
or a prolapsion of the ovary into the triangular fossa. In either 
event, an examination per anum will greatly assist in elucidating 
the true nature of the case. The ovary, too, may be distended, 
exhibiting an example of encysted dropsy of the organ. Suppose 
such a case to complicate labor ; you see how important it would 
be to arrive at a proper diagnosis, in order that prompt and efli- 
cient means might be devised to overcome the obstruction to the 
passage of the child. In such case, the remedy would be to per- 
forate the ovary through the vagina, with a view of allowing the 
fluid to escape, and thus diminish the bulk of the tumor.* 

4. Auscultation. — It has already been stated that the pulsations 
of the f(rtal heart and uterine murmur are to be sought through 
auscultation ; and this i>» accomplished either by the ear or stetho- 
scope. It requires much tact, patience, and experience to become 
an efficient auscultator. Xauch some years ago suggested an instru- 
ment — the metroscope — which he introduced into the vagina for 

• On '.no occasion I performed the operation of vaginal ovariotoniy in a young 
girl under exlrenioly di?«trossing circunQstances. Se« Diseases of Women and Chil- 
dren, p. 297. 



202 THE PaiNCIPLES AND PRACTICE OF 0B8TETRIGB. 

the purpose of detecting, as early as the third months the fetal 
moYement, and he also affirms that he has been able to satisfy him 
self with the metroscope of the important fact that the placenta 
is attached over the mouth of the womb. The instrument consists 
of a wooden tube flexed nearly at a right angle ; one extremity is 
introduced into the vagina, and carried to the cervix uteri, while 
the other is applied to the ear. It can scarcely be necessary to 
remark that the metroscope has not met with much favor, and la 
now but little used. 



LECTURE XIV. 

Bxtra-uterine Pregnancy; its Varieties — Ovarian, Fallopian, Abdominal, and 
Interstitial — Cliaracteristics of each Variety — Causes of Extra-uterine Pregnan- 
cy — Opinion of Aslruc — Objections — Progress and Phenomena of Extra-uterine 
Pregnancy — Placenta and Membranes; the Germ inclosed in a Cyst — Exponent of 
the Uterus; Cyst; how formed — Cyst aftbrds no Outlet for Foetus — Rupture of 
Cjrst from Increased Growth of Foetus — Hemorrhage; how Produced — Enlarge- 
ment of Uterus — Extra- uterine Foetation rarely extends to the Fifth Month— 
Exceptional Cases — Secondary Cyst; how Formed — Signs of Extra-uterine 
FoetMtioh — Areola and Tumefaction of Breasts — Illustration — Active Movement 
of Fuetus ; Cardiac Pulsations — Malpositions of Uterus from Position of Cyst — 
Intermittent Pain in Extra-uterine Gestation — Dangers of this Variety of Gesta- 
tion — Hemorrhage from Rupture of Cyst — Peritoneal Inflammation — Termina- 
tions of Extra-uterine Pregnancy ; Treatment — Gastrotomy; when Performed — 
Gastrotomy and Caesarean Section — Fearful Hemorrhage in the Former; why — 
Section of Vagina — Elimination of Foetus; how aided. 

Gextlkmex — When fecundation has been consuraraated, and the 
vitalized germ does not reach the uterus, it is because of some 
derangement, which has contravened nature ; the development, 
therefore, takes place not within the uterine cavity, but at some 
point external to it ; hence, this form of pregnancy is denominated 
extra-uterine. Pregnancy out of the uterus is unquestionably of 
rare occurrence in the human female ; yet, on the other hand, 
there are well authenticated cases, which give to the subject an 
interest well worthy the attention of the practitioner.* Authors 
have made numerous divisions which, it appears to me, are more 
calculated to perplex than aid the student in his investigation of 
the subject. In lieu, therefore, of arraying before you this long 
and varied classification, I shall content myself with presenting, for 
your consideration, four different kinds of extra-uterine gestation, 
which, for practical purposes, will embrace all that science properly 
recognises: 1. Ovarian; 2. Tubal, or Fallopian ; 3. Abdominal; 
4. Interstitial. 

1. Orartan Preffnancy. — When the embryo becomes developed 
in the ovaiy, it is called ovarian pregnancy ; in reading upon this 
point, you will observe much discrepancy of oj)inion, arising out 
of the question whether it is possible for fecundation to take place 
before the rupture of the ovisac? Those who maintain that it can- 
not, deny the fact of ovarian gestation, for they say that true 
ovarian pregnancy is where the embryo becomes developed within 

• This variety of gestation has also been observed in the rabbit, sheep, and bitch. 



204 



THE PKINCIl'I.KS AND PRACTICE OF OBSTETRICS. 



the ovary, and this cmi only occur by llie spermatozoon pcnett'ai 
the ovisac, without disnirbino; itt* integrity^ and vilulizinj^ th<? ger 
But, a-s they contend that this mode of tecun<lation cannot be ac- 
complished, they reject, as a consequcnoe, the possibility ofovariaa 
gestation. Now, gentlenicn, it is very evident that thi^j in a niei*e j 
play of wordi^ ; it U a 8|>ecie8 of transccndeiitiil logic, which b not 
calculated either to advance the true interests of science, or subserve 
the requirements of the ]jhysician who, iu questions of this nature, 
ij% in want of well-established facts, unaccompanied by any of tlie 
refinements of the sophist, or the theoretical niceties of the dis- 
putant. What you winh to understand is simply this — i^ it po.^sihle 
for the fecundated germ to become developed, so iia to const jtute, 
in Init h and in substance^ an ovarian pregnancy ? The fact is proved 
beyond al! perad venture, for the fa-tus has been found, in a stato of 
progressive growth, in intimate relations witli tiie organ; so that 
the cp J est ion is not whet her the development is within or without 
the ovisac, but whether, not occurring in the uterine cavity, it is 
posHble for ti to liike phiee in eoimexion with tlie ovary« I repeat, 
science furnishes weli-authenticated examples of this species of extra- 
utcrine gestation.* 

2. I'^ufml or Ftdhpian Pregnane*/, — Tlii^ has usually been re- 
garded the mo^t frcqnent (orni of abnormal pregn:mcy, and is aaid 
to bear to the others* the proportion of nine to three. Prof. ]IeckeT 
has recently shown, from earefnlly eoUeeted tables, that this is not 
80,f For example : in all the casen of extra-uterine fa*tatiou, wliich 
he ha»» been enabled to gather from various sotircea, he has ascer- 
tained that, %vhile abduminal ]tregnancy occurred in one hundred 
and thirty*two inslaiices, the t;illof>ian variety was observed only 
aixiy-t'Mur liines. These sixty-four cases, with one exception, ler* 
minati'd fatally ; the exceptional example lian been rejtorted by Prof. 
Virchow. It b ala«i inlerej*ting to note that llecker^s retsearches 
have fully confirmed the ojnnit^n, which has for a lung lime pre- 
vailtHK viz. that tallopiaii pregnancy i^ more frequent in tlie lell tliao 
in the right tube. J Aeeording to his record, it occurred thirty- 
seven linres hi the forn*er, and only twenty-seven in the hitter. It 
shou1<l be remembered that, under the term abdominal, Prof. Iletv 
kor incbides also, ovarian gentation. 

• An inltTt'stiri}? aiee of ovarmn ^«tntion haa recently been recofUed by J. HaU 
Davtiv M,L> J in which the left ovnry wa* developed into a cyst, iiiid cf>titjiined a dc* 
CJiTcd tctixxL [Trunsnetioiig ol'the Ob^tetrieal Society of l^miXmi^ ISttO, p. 241.] 

f Moni»t«ichrift fur (»eJitirtxk«mde, T-ef. 1 869* 

J t)r Kill 111*11, of New York, rvp<jrt8 iu iho New York Jounjiil of Mi*didiie for 
Murch, 1857, nu mti*rt*i$tMi(; enso of HiUopinn projrimnt'y on the r\fihl Hide. Th» mine 
gvtitleiiimi has recfiiily m\.i with it M(>efii)d ^I'^rAiiiple of ihe ^iiie vnricty ofgeiKlBtinti 
tlio ofi Urn r\*fht ftidt*. Few niedidil men in thin eountry hove enjoyed moro «X- 
teitditl cip)¥>rmnitiea of purHsuitiif Bi]to[j«ir*al cMnniimiiHms thiiti Dr. FittndU* u Idii 
numerous r^jjoru to the N>w York rnlbuluglcid Soc-iciy will isliuw- 



THE PRINCIPLES A^D PKACTICE OF OBSTETRICS. 



205 



3* Abthminal Pntpiancy, — In t]iis case, the germ becomes i 
depositeii in some portion of the abtlomiiial cavity, and passes 
through certain stages of development; the i^urest guide as to the 
irticular part of the abdomen in whicli the development pro- 
jresses* will be the att itch men t of the placenta. This \\it^ been 
varitiiisly found on the broad ligaments, in the recto-uterhie f^msa, 
oil the mesentery, in the iliac fossae, on the internal surface of thd 
anterior wall of the abdomen ; in a word, more or less on all the 

►dominal viscera, I might cite well-accredited instances of these 
Sfierent point:* of attachment of the placenta, but, as they are 
generally accepted as truths, I scarcely think it necessary to con- 
§ume time in their narration. According to Prof. Heoker, there is 
a very marked difference in the mortality of this and the tubal 
species; while in the latter, one In &ixty-fbur survived, in the former, 
amoug one hundred and thirty -two cases, there were only litly-six 
deaths, giving a mortality of but forty-two per cent.* 

4. Inttrstitial Pregnancy.— T\\<& embryo here is developed 
neither dri*ectly under the peiitoneal nor mucous coverings of the 
uteru.% but becomes located in the meshes of the muscular fiTires of 
the organ, and there receives its growth. The question naturally 
arises, how is it conveyed to that particular piortion of the uterus, 
nd become eiubedded in the midst of its very substance ? Several 
bypolheses have been advanced to ex|)lain the circumstance, but 
they are as yet simple liypotheses, without the support of any reli- 
able data. It was the opinion of Bresehet — w^ho in 182't was the 
first to describe this %sanety under the form ffraviditas in uteri 
aubstantia — that the embryo, as it passed into the uterus, I'ell intOi 
the opening of some of the venous sinuse'4, which he 8up[»osed 
to exist near the uterine eitremity of the fallopian tube, and 
thus found its way into the substance of the organ. But repeated 
attempts have failed to discover these sinuses, and, without the 
proof of their existence, it is in accordance with true philo.^ophy 
to doubt their reputed functions. Only twenty six ca^es of this 
species of extra-uterine fcetation have been recorded ; it is as flital as 
tubal gestation, and, like this latter, it was observed more frequently 

♦ A voiy remarknble exiynple of extm-abdomtnai pregnRocy has been reported 
by Dr. Geuth* Tlie feraftle, fmm early childhood, had a amall movable tumor at the 
^teriutt Rljdomimd nng^. After ninrriaj^, slie liad borne three cbildreo- Sonic time 
ef tlie binh of the third child, the eataraenia cuased, and the tumor began tf> ea- 
lai^. Sixteen and a half weeka after the nienatrual suppr edition, the tumor e(^ii{Ulc(| ■ 
the vtilume of two fists; it extended, by a pedicle, into the inguinal canal. Th© j 
Hieut aiiffered greatly, and became much enft;ebled. The tumor was hiid open, ^ 
bd contained a fustua and placenta of between four and tiro months. The patient 
r«owered« and has subsequently become pregnant. Dr. Geuth's opinion is thut this 
w«a an Instance orifrlnfllly of hernia of the ovary and fallopuin tube, and that 
pregnancy occurred wilhoul lb© abdomen* [Verhadl der Gea. fiir Geburtik. Bei^^ 



206 



TB^ PRINCIPLES AND PRAOnCE OF OBSTKTRICa 



on tliG left than od the right side, m the propovtioii of neveoteeii" 
twenty-four. 

Catties of Extta^uterlne F(xtation. — Various theories have been 
aclvimcecl In cxplaTintion of tixtra-uteriiie gentation. It was coo- 
teniJe«J by A at rue that it in mach more frequent in hi do w a and 
unnmrried women** Upon this ai^suntption he proposed the theory, 
that often times fright, from being detected in the very act, deter- 
mined the error loci of the germ. But how, with this hypothesiii^ 
are we to understand the occurrence of extra-uterine fa^tation in 
married women, wfjo have not only a ri^ht to be pregnant, but are 
most r^nxious to become mothers, and who, therefore, so far from 
experiencing alarm .or mental emotion, enter into the act of inler- 
course with all the earnestness and pleasure, which an honest con- 
viction of right can insjjire? Again : how is it contiltftent with tbe | 
well-known fact that Bome married women become pregnant, MiA 
bring forth healthy living children witliout the slightest ap[>roach to 
anything abnormal, to whom sexual intercourse i« most repugnant, 
and whose constant hope is that they may not prove mothers ? la it 
not ronsonable to siqipose, that in these there would be Htroog 
meiitul emotion, bordering on well-developed tright, at the time of 
cohabitation ? 

In my opinion, a more plausible explanation is found in tho 
theory, which, I believe, was tintt proposed by Prof Virchow, He i 
ha8 observed that thi-* form of firognancy is frequently accompanied 
by ndhe^ions of the ititernal genital organs, caused by tiilse mem- 
branes; these adhesions are mostly on the lefl side. He, therefore, 
attributes to their presence an important influence in the produc- 
tion oi the pregnancy itself, and also explains why it is that extra- 
uterine gestation is mure frequent on the left than on the right 
side. It may bo mentioned, en jxtsaant^ that adhesions of this 
kind are sometimes the real, but occult cause of sterility. 

Pro^r^sB ami Phenometm of Extra-uterine Fc^tation. — In a 
practical sense, it is essential for you to understand the |>rogrefls 
and phenomena of this species of [jregnancy, in order that you may 
bo prepared, when it occurs, to render the necessary as^istance to 
your patient. The development of the foetus and its ap|)endageis 
proccc<is nearly in the same manner as when the germ Is located in tho 
uterus, although, as a general rule, the cotyledonous element or ]i»b€!8 - 
of the placenta are more abundant. In closely examining an extra- 
uterine foptation, you will be able to recognise the chorion and 
amnios; the uterus is more vascular, its fibres and mucous cover, 
ing are in a hypertrophied fetate, and the entire organ notably I 
enlarged. 

It is an interesting fact, and in strong illustration of tho hartnony 

* Ktiiericiicc proves thnt e3ctm-ut«rino preprniiiicy, m th© majoriljof oMCi^ oooan 
ui women wJio bnvo previously bome childrvu. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 207 

of principle which characterizes the operations of nature, that 
very soon after the passage of the fecundated germ to whatever 
part of the maternal organs is to constitute the seat of its growth, 
there will be observed in that part an increase in the action of the 
blood-vessels ; this, no doubt, is owing to the vital activity, which 
is BO marked in the ovule as soon as fecundation has been accom- 
plished. So true is it that the vessels become congested, through 
an afflux of fluid necessary for the wants of the embryo, that if, 
from accident or otherwise, these vessels should become ruptured, 
a fatal hemorrhage may ensue even in the very first few weeks of 
the gestation. 

The germ is inclosed in a species of cyst, which is composed 
differently in the different classes of extra-uterine foBtation. For 
example, in ovarian pregnancy, the cyst is made up of the fibrous 
and serous tissues of the ovary itself; while, in tubal pregnancy, it 
consists of the muscular tissue of the tube, in conjunction with its 
peritoneal tunic. In abdominal pregnancy, on the contrary, the 
cyst is composed almost exclusively of an exudation which, from 
its plastic character, forms a bond of union between the ovum and 
the surface with which it may be in contact. The cyst represents 
the uterus ; but, unlike this organ, it has no outlet for the passage 
of the foetus into the world ; and this is even so in fallopian preg- 
nancy, for, in this case, the tube will be found obliterated on each 
side of the cyst. As the embryo increases in development, one of 
the dangers to be encountered is the rupture of the cyst, which 
often results in the death of the mother from hemorrhage, and it is 
not, I think, improbable that this may sometimes be the real, but 
concealed cause of death, in cases in which females, in apparently 
good health, suddenly sink. 

In extra-uterine pregnancy, the uterus, as said before, undergoes 
more or less enlargement ; and this circumstance occasionally com- 
plicates the diagnosis. Frequently, in consequence of the increased 
vitality of the lining membrane of the organ, the membrana decidua 
will be recognised. It is comparatively rare that this variety of 
gestation reaches its full term ; it seldom i)asses beyond the fifth 
month, although sometimes it attains the ordinary period ; and 
there are instances recorded of its duration continuing many years. 
In these latter cases, the foetus is found in a degenerated state — it is 
either exsiccated and shrivelled, or will present a stony hardness, 
and sometimes a mere mass of adipose or fatty matter. The 
degeneration into a stony hardness is more apt to occur in cases of 
abdominal pregnancy, and then, as also when the foetus is dead in 
utero, and becomes converted into a calcareous mass, it is called 
Uthopoedion, Even when the gestation reaches the full time, it is 
extremely rare for the foetus to be alive — it almost always dies from 
want of sufficient nutrition. 



208 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



I have told you thnt rupture of the cyst, containing the fcBtus, ! 
nsually followed by fatal consetjuencefi — thin, ho\vovi*r, is no| 
always so ; occaisionally, after the escape of the embryo through th€ 
rupturc^ — if the patient survive the hemorrhage — she may sink froml 
peritout^al inflammation^ which is extremdy apt to fulluw the] 
egress of the firtus from the cyat. Should, however, the iiiflaiii 
matiou bo subdued by prompt treatment, then there will generally 
be the formation of what ia called a secomiafy cyst, in which iht 
fcrtna becomes int-losod, and which is the product of the €XudaiJOQ^ 
consecpient upoii the influumiatory action. 

The fcDtus, tUuH embraced within its secondary cy8t — luid the 
same tldng may occur while in its primitive envelope — will, some^j 
times, from it a weight, or other circumstances, cause milammatioR|l 
which may result not only in its own destruction, but also in that! 
of the cyst, involving the neighboring parts in ni ore or less ulcer 
tion, so that there may follow n fistulous communication externallyil 
either through some portion of the abdomen, rectum, bladder,! 
or vagina, and through this opening, the fcetus, in a stale of ( 
decomposition, may be dischargtMl fragment by fragment. This 
result is likely to compromise the life of the mother. It is, indeed,^ 
stated that portions of the embryo have been ejected by vomittn^ 
fmm the Htoiuach. h\ therefore, in tfie course of \« rUct%L 

you should lie called upon to give tm npiiiion as totht' i i \ of I 

the passage of t'aHal fragments, through tlie channels ment]oned,| 
you ciui, without hesitation, state that such a condition of thing! 
mjiy result from an extra-uterine pregnancy in the munncrl 
indicati'd, 

^l/mptotng and Diagnosis of Mxtra-uterine FcBtation, — How 
are we to know that extra-uterine pregnancy exists? Here, as in 
ntenne-gcstation, wo have nothing sjjccially to guide us in the eora-j 
mencemcnt ; menstruation may or may not become interrui)ted ; inl 
the only case of exti*a-uterme gustation, which Ikir tallcn under mjrl 
personal notice, in which 1 was consulted by Dr. Cyrus M* Thomp*] 
flon, of the Stale of Maine, tlie same phenomena occurred in ih« 
breasts, whicli are u«ual in ordinary uterine gestation, and tho" 

Bohi, especially, was fully dcvelojied with its characteristld 
attributes. The abdomen was more or less enlarged, but thero 
wad no suppression of the menstrual evacnation.* It is maintained,. 



^ Tlviii wiki tho cMiee of n lady, who mniried when »he was tlurty*three jeart of \ 
tge» D^riiif*^ her inuidentiood she enjo/ed exoetle&t hoalth. and continued lo do m' 
lor 1 jcnr oAiT UMrriagt.^ ; at thu period, however, ahc 5U0ered wore or leca f 
dofwigcmcnt of Uic system ; her abdomen enlarged, the breasta became tumid, iiud 
Ibere was ntmsen with rxtxisionul vomiting. Her mensea were quite re^litr, tiotli 
•ft to time imd qusuitiU; alie hnd a cough, with purulent expectoration, and a piiln 
at llU, It wiu! under ihe»e ciRMimstaficcs thnt she vij^ited the city of Kew Yorki 
bhsijftiJg with her a letter froni Iter i!uiuily physicino, Dr. Thompson, who regtmlwli 



TH£ PBINCIPLES AND PRACTICE OF OBSTETRICS. 209 

by aome writers, that the breasts undergo no change in this form 
of pregnancy, and that there is no secretion of milk. I cannot 
!mder8tand on what this opinion is founded. The phenomena, con- 

• mj opinion as to her case. The doctor had fullj made up liis miDd as to the hroad 
meaning of the cough, purulent expectoration, and accelerated pulse — they were 
ttio unmistakable eridences of a serious trouble, which had already marked this 
lady as a Txitim to that relentless enemy of our race— consumption. She, however, 
did not appear at all conscious that the cough indicated any such fiital issue, and 
her whole attention was concentrated upon the abdominal enlargement. Her own 
conviction was that she had a tumor, wlilch would destroy her life ; she did not 
bdieve it possible she was pregnant, for the reason that her menstrual flow was 
regular. I made a very critical examination of the case, and soon became convinced 
of two fiicts: First, that the uterus was enlarged, correfiponding with a three 
aaoitths* gestation; second, that commencing in the leA; iliac fossa, and extending 
obUquely upwards in the direction of the right hypochondriac region, there was 
evidently a growth independent of the uterus. 

On inquiry, the lady infonned mo that, just six months before I saw her, she 
oommenced to experience irritability of the stomach, and there was also an increase 
in the size of the breasts. Soon eSter this, she felt a sense of pain in the abdomen, 
which haa oontinued more or less at intervals, and which, within the last two or 
three weeks, had occasioned her not only mudi physical dii«tress, but caused a great 
deal of mental anxiety, from the apprehension that she labored under some serious 
affection, which would destroy her life. Here, then, were two conditions, which, 
on examination, I had distinctly recognised, viz. : In the first place, an enlargement 
of the uterus; and, secondly, an enlargement of the abdominal cavity altogether 
independent of the uterine development. What could tin's latter bu ? A very 
natnral presumption was— that it miglit be au ovarian tumor. During my manipula- 
tiona on the abdomen, I very distinctly felt a movement— at first I was nr)t quite 
iitiafled of its nature. I again recognised it, and so distinctly, that it could not be 
mistaken — it was evidently the movement of a fuetus. I then had recourse to 
auscultation, and, after some time, the pulsations of the foetal heart were detected ; 
the sounds were emitted about two inches above the umbilicus, and to the right. 
There was no mistaking them. My pupil, Mr. F. B. Bates, a relative of the lady, 
heard them, and also recognised tlio movements of the foetus. From the point of 
the abdomen at which the pulsations were detected, I came to the conclusion that 
the breech presented obliquely do wit ward corresponding with the left iliac fossa. 
Here, then, was clearly a case of pregnancy. What was its true nature ? It was 
fuite obvious that it was not a case of uterine gestation, for this organ, although 
enlarged, had not yet left the pelvic excavation. I decided, after a full considera- 
tion of all the circumstances, that it was unequivocally an example of extra-uterine- 
foBtation. I have already obsen'ed that the areola was well marked, presenting it8> 
troe characteristics. 

In reply to the most anxious inquiry of the patient regarding her condition, I 
told bor she was pregnant, but concealed the fact of the peculiar variety of gestation- 
under whicli she labored. I was unwilling to add anything to her cup of sorrow, 
which was already full to overflowing ; and more especially as I had good reason to 
believe that the period of her dissolution was near at hand. She appeared 
delighted with the opinion, and returned homo joyous and happy, little dreaming 
of the sad future, which was so soon to remove her from earth I In all truth, she 
verified those trite but expressive words of the poet : 

** When ifTDorance is bliM, 
Tls folly to b« wise.'' 

I gnve my opinion to Dr. Thompson in writing ; and I received a letter frooL him, 

14 



210 



THE PRrNCIPLES AND PRACTTlCfi OF OBSTETRICS. 



sequent upon ordinary gofltation, are entirely sympathetic, resttl 
iDg from the changes going on in the uterine organs; snul thej 
RViDpatbeiic phenomena are the results of that close allianee, wbie 
lA Vnowix to suWist between the Ijveasts, the uterus, anil its apf« 
diigen. It does eeem t(^ rue, that the fire, bo to speak, kimUed 
these appendages and in the uterus itself — for we have Keen that I 
also undergoes increase of volume — is sufficient to evoke cor 
spending exeitcmetit in the matnmse. 

As I linve already mentioned, the fact of the enlargement of tf 
uterus tends to complicate the diagnosis; but in extra-uter 
pregnancy, besides the increased size of the organ, there will be 
discovered on orjc or other portion of the abdomen, usually on th 
Bide, an enlargement, and the patient will occasionally complain 
a sense of pain at that point. Here, again, ihh may be confonndti 
with a tumor of the ovary, or a tumor of some other de 
tion. 

It is obvious that, for tlie first three or four months of < 
utcnne f(rtalion, there is nothing to guide us in the expression of 
positive opinion as to its existence; and the only means of arrivifl 
at a just decision will be the active or passive movements of tb 
fa>tus, and the cardiac pnlsjitions. These, well recognised, place i 
doubt at an end* I should mention that, although the uter 
increases in volume, yet it docs not exhibit the ehanges which 
have described as cliaraeteristic of uterine gestation. For cxaniplij 
the cervix does not undergo any sensible diminution in its leugtl 
iior, under ordinary eireumstances, does the position of tiie cerv 
ten<l backward towar<l the s^icrum, as we know is the coaq in trti 
gestation, in proportion as the uterus ascends in the abdoiniuf 
cavity *, and, moreover, by a proper abdominal examination, yon 
will be enabled to recognise whetlier the tumor is the enlarged 
trterus J but all doubt upon the subject will he dissipated by placing 
the finger of one hand on the cervix, and the other hand on I 
jibilonnnal portion of the tumor, thus completely grasping 

two tnonthji dterwnrd, atinoiincing the dcnib of hU patient, undor tho fbltowio 
ptiinAjt circumstaDoea : On her return liotne, nhe rallicMl for the first week or two 
her whole thoughts being occupied with the h»pjiy antteipation ot aoon bc«coraiu^ { 
nuther; she quickly, however. rdapBrnl into iter former cotidition — the oough 
I increajsiug, the pulse reaching lUO, witlj copious oxp4>ctoriilioQ »nd great liysa qf_ 
fleali. Just one month Irom tbo tirao she left New York ishe was atUM.'keti wi! 
profuse hsinoptysK which was followed by profound prostration: iho lueraopiyij 
again recurred m two weekjs, tnd two days afterward she aank fhirn exhaoatio 
Tho following is a hri^f extract fh>m the doctor's letter: 

*' In a post-mortem examinatioD, your dittgnoais of this case w«b fully cotifi 
Tliere was an extra-uterine ra?tua» npparenlly al>oul seven nioutlia devotoped. 
was partly decomposed, having, 1 huve no doubt, succumbed a few days befofw the 
mother. Tljere was nbout n pint of blood in the peritoneal 8nc« which must ha¥» 
added groatly to the protttrutiou of our unfortunate patient. Aa far aa I could 
dctenntDC, it was a case of ovarian extra-utenne pregnancy/* 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 



211 



WlweeD the two hands ; and^ in this wny, yoti can readily detect, 
by an alternate movement of the hands, whether it be the uterufl 
or something foreign to it. 

The paiticular positiun of the cyst, inclosing thefa*t«8, 'ftill some- 
iiniej* exercise an impottaiit intlnence on the [>oaition of the womb ; 
id thk should be borne in mind, otherwise it might lead to the 

abarrassment of ruii^taking extra-uterine pregnancy for sira|>ly a 
disjj lace meat of the uterus. If, for example, the cyst shonld alUieh 
itself jiosteriorly to the nterns, in the recto-uterine fossa, for 
iftstanee, it might ]>o.'<sibiy be mistaken for retroversion of the 
organ* - Bnt, a moment's thon^bt qn the part of the practitioner, 
together with a vaginal ex:ni»'i\ ition, would soon reveal the error. 
The fundus and body of the uunii.s, instead of being retro verted, 
would be in directly an opposite condition ; they would be pushed 
forward, consiituting what h known as an anteversion ; and the 
cer%'ir* in place of being. forwar*l, as is tlie case in retroversion, 
would be turned backward ; tliis malposition w*ould be apt also to 
produce more or less irritation of the lilatlder. 

The presence of the cyst in the recto-uterine cavity might mislead 

on in other respects in your din gnosis; for, w^e have elsew^here 
(larked, that this tbssa is occasionally the seal of a prolapsed 
ovary, or of a portion of the &m:dl intestines. But adequate care 
your examination, with a knowledge of the antecedent circum- 

RBOCJ, will generally avail in enabling you to arrive at a correct 
"opinion. Moreover, those who have recorded examples of this 
peculiar location of the cyst, say, that on an examination per 
vagi nam or anum, the tcetus can be recognised by the sense of 
touch* Suppose, however, the cyst tihould occupy a reverse posK 
lion, and be found just in front of the uterus. The result, in this 
case, would most likely be retroversion of the uterus, aud more or 
less vesical irritation ; this latter woukl be the eftect of two forces 
— in the first platre, the presence of the cyst; and, secondly, of the 
neck of the uterus, which, in retroversion, would be tbund turned 
toward the lower extremity of the bladder. 

The female, in extra-uterine pregnancy, will, at flifferent periods, 
experience more or less pain, marked by distinct intermittence* 
When the cyst is composed of miiscular tibres, as is the case in 
interstitial, fallopian, and ovarian gestation, these pains will closely 
simtdate labor puins, and are tlie result of the contractions of the 
muscular tissue of ihe cyst. The uterus itself otlen participates in 
iliese contractions, aud adds to the severity of the pain.* 

• Profesfl^jr HobI reports an intcresliug case of abdominal pregnancy^ in which ha 
reoognised the contractintis of tho cyst. Tho cyal was bobiiid tbo posterior cul de 
toe of the vaginn, and nenr tho posterior wall of the pelvis* He could distinctl/ 
fi»e1 it, and during the pains, Ihe contractions of Tho cyst were quite apparent. Aflef 
defith, there were many organic muscular Gbr»?« dek'Cted in ihe coat of the 07Um. 



212 



THE PRIXC1PLE3 AXD PRACTICK OF OBSTEfBICS. 



77i^ Dangers of jErfni-uferine Fixtaiion. — Let t» 110W9 genH^ 
mrnt brietly examine in what daefly eoiiKixi the true iliifigefs <if 
extr^'UteriDe fcptatlon. It is an important question* ani] ombodei 
Home interestting practical beanngn. It bus ALreiid3r been remarked • 
to you^ that this fonii of gi^stntion may temtimite in one of two 
wayx : First, In rufiture o( the cynt, wlitch in gi^neniUy the restatt 
of the increased rlevelopmont of the r<rtns, allhonglt not aivrajs 
io, for the laceration may be caused by blowR, falls, etc ; S^ooiidiy^ 
In tfje death of the fa-tus, the ^ae rrmaiuin^ nndbtnrbod. Theaei 
I bt'lievr, mav be snid to be the two orditian' modes of temdoiP 
tion of this upecies of gestation; an»l there are conikeqiiences to ihv 
mother growini^ ont of each, which it is e^asenUal for the pnieti* 
tioner to appret'inte. In very rare instances, the mother e«ciipc« < 
tlie iwiml fatal fonscfpienrtsi of rupture of the cy^t, becanse of the 
formjition of what i^ known a« the secondary sac, the uatnre of 
which we have already explained to ypti^ But the immediaie 
dangur of the rupture is d**aih from hemorrhasre; and fatal re»iiltJi 
ensue in at h'fi^t two-thinis of the cases in whirh rupture takei 
pbeo. 'file laceration is usually [^receded by pain in wjme fKjint 
of the ttbdoTuinal cavity, quickly followed by aymptoms of marked 
prostration— cold extreniitiei*, |»allor of countenance, clammy fier- 
Bpinition, vt»nHtinfr, and flickerintj pulso, Tldi* may occur at JMiy 
period uf the piegiiuney, even in the tirst month. In these caj^ 
a post-mortem examination will reveal mure or les** cfiWton of blood 
in the peritoneal cavity — ^the etfusion being the result of the ruf>- 
tureof the blood-vessels tmmeilintely concerned in the devcU^pnicnt 
of the foi'tus and itn arinexa\ Should, however, the feniale eM?apo 
the ordinary cc^n^erpiencei* cif rupture, she incurs I be serious fH*ril 
of peritoneal ir»f1amniat1on, caused by the irriUilion of the fcctos on 
the KTOUu linirjg after it has lell the cyst. So you ser^ the two 
iinmeiUatc dantrei*s of rupture of the sac arc: 1. Death from 
hemorrhage ; 2. Death fioui inflammation. 

If, however, the cyst be n«it ruptured, the ftetus may cootioite to 
live to the eompkHion of the fall term of gestation, whicli facrt will 
be recognised by its Tnovoineiils and the puliutions of it^ heart; or 
it mny have peri^heil, and Mtill coniiinie to l»e inclosed in the sjic. 
In either case, as ha?* already bt-en slated, tliere will be intennitteut 
pains simulating the throes of labor, but altogether ineifeclual ^ 
fiir \\» the expulsion of the fnptus is concerned. It, therefore, ref»ultt 
that the ftetus may sojourn in the system of the female^ and its 
prt*Heuce give rise to the fiillowing conditions : 1, It may destroy 
the life of the mother by intlammalion ; 2, By the derangement 
which itfl presence and pressure may occasion in the digestive and 
Other functions; 3. By its decomposition, and passage from the 
maternal system, through the vagina, rec-tum, abdomen, blarblrr, 
etc,» aa have already been indicated; 4. It may degenerate into a 



THE PRIXCIPLES AND PRACTICE OF OBSTETRICS. 



213 



I 



ilonf, flhrivellecl mass, and remain for many years in tlie system, 
witUoQt resulting in anything serious* 

Tr^KttnmnL — With thisbrief reviewof the principal circnmstances 
t'oujrected willi extra-uterine precn'^incy^ the question has, I have no 
doubt, fuggested itself to your minds — What can he tlorie in these 
ca-^9? Doe:* seience afford us any means of relief? These quea- 
tion^ gentlemen, concern us as medical men deeply ; for the great 
objeet of our profession is to arrest, if pO!?»ible, the shaft of death; 
and when we fail in thi^4, to do all in our power to soothe the 
anguish of human suffering, and make as iight ai* may be the pro- 
gress to the grave. We will suppose that your disignosis as to the 
exi,^tence of eaLtra-uterine pregnancy is either beyond all perad ven- 
ture, or that it is a matter of great dowlit.* In the latter instance, 
to attempt any ]*lan of treatment would be the sheerest folly, for 
the substantial resison that there can bi_* no indication as to any 
ftpecial medication^ a^ long a'l you are ignorant of the true nature 
of the case. You would not, I imagine, deem it wise^ because a 
patient complains of pain in the cliest, to take it for granted that the 
pain is necessarily the restjlt of fmeumnniaor pleurisy, and, therefore, 
plunge your lancet into the arm and abstract blood ad deliqulmn I 

But we take the former example — the proof of the pregnancy is 
live. In this ca«e, some very nice considerations present them- 

:Ves; First, the mother^s life is placed in great jeopardy, in the 
%'arions ways already indicated ; Seenndly, TI*o death of the ftetus 
is reduced almost to a moral ceit^unty. These, then, are the naked 
and indisputable dangers of an extj'a- uterine pregnancy, if letl to 
pursue its own course ;f and the important question for the jiracti- 
taoner is — Does science possess any alternative by wluch the danger 
ta the mother may be lessened, or the chances of safety to the child 
increased ? 

I jLssume, as a fact, am|ily sustained by the experience of the 
profession, that, as a general rule, the certainty of extra-uterine 
go«t:itiori (*annot be arriv<*il at betV>re the period of quickening; 




Sjiiit' yjTHV^ errors iinire kxN^ri (>«immitted with regard to \X\& exJ3t«nee of Uiij 
I of prc^sl;rt<Kln; n enfw* nhicli fK'Ourn.'d in licrliii is not witliout \i» monil: In 
ltiiriiRi» 1S2S, (>r. flLnni. wlio, with othor eminent gcnilefLien, had agre^ Uiat a 
pAtietit Wiia t!i« ^uUjoot of cxtm uteri no fa?tation, requuat4?d Pi-oC Diefifenbacii to per- 
form tlie CiPfnrvan section, Tho ^fportirioii wiis accordingly pernimied, but to ttie 
tjtuixemf'tit of tiU pri^otn, ihero wtns uti pfegnancr of any kixid. The woman, how- 
cvrsf, furtiirijiuty reoovoffd. [Or, Hoiui'a Vormiiclite MedidDiache Sduifka. p. 402. 

f U hM<i riH*ently bpoti iiii^'|ij:(«1et| by Dr, Bai^>liettl, of Piflo, to fittempt the dostrucs 
tkm of Iho enibrvo at uii c-nriy period, wo tliat tho mother miiy be protected from 
hnnii, tlmtngl) an iirrcut of \\n dr'v^lopnietit, Ue recorda a eaiw^ tif thU kind in whirh 
h« tiicc<.*i_«di.Ht ill hitt o):)j(^><;t by elt?ctro-pinK.'lur0, He iinplanU^d two no€>dIed into the 
tiiQiiif, and iheti dirt^'Unl into the? latter an electroniagQoUo current. [L'Uuloa Mo- 



14 



THE PBmClPLES AND rRACTICE OF OBSTKTItlCS. 



lerefore, anterior to this period, the question of treatment will noi 
fttsually arise. There is a difference of o|>inion a^ lo the course lo 
jhe pursued after the life of the child lim been fully recognbed. 
Some recommend gastrotomy, which oon»Uta in an inciHion of the 
ahdominal walb for the |iur|H>^e of ejctracting the fa:*tug, and thua 
equalizing the chances of life between it and it« parent. Now, thia 
is a mode of procedure wliich should not be resorted to without 
deliberate reflection, and it^ jastifieation banetl upon the reaaoniiblfp 
aai^urance that, taktrrg all the surrounding cireumstances into con- 
aideratiott, it preaenta the greateat chance of salety lo both uiother 
and efiild. 

There is one speciid danger in the operation of gastrotoiny in 
extra-uterino pregnancy, which does not apply to the Cajtsareaa 
aeotion in uterine gesstaiion, and it \s this : In gastrotomy, besidea 
the dread of ir^flammation and shoek to the nervous «y»tcni— com- 
mon to it and the Oesarcan operation — there U the cardh^l dmifftr 
qf hemorrhage^ and for the fi>llovving reason : As soon aa ih© cyst 
is op»cned, and the integrity of the blood-vessels encroaehetl upon^ 
profuse bleetling ensin'S — ihe cyst, especially in abdominal 49itiii* 
uterine pregnancy, pussrssin^ corufaratively such flight power of 
contraction, tor the reaijon that its muscular tissue is not abundant ; 
in the Ca?i*arean section, on the contrary, the uterus speedily cfin* 
tracts, and arrests the flooding,* The records of^gastrotomy, the 
child being alive, are certainly adverse to the operation, for it has 
almost always proved fatal. 

If, however, you should have decided that the extraction of the 
fcrlus iH justifiable, it may sometimes happen that it will be more 
advisable to make an incision into the vagitta, luid remove it through 
this pa*i«iige ; and tliis will be more particularly indicjited in cases 
in which the fretus can bu felt distinctly pressing down upon the 
vagina. Should the hea<i present, the child may be delivered after 
the incision, by means f»f the forceps or version, as occurred in the 
practice of Dubois. He felt tlie head of the fwtus through the 
vagina — made an incii^ion into the vaginal wall, and also into the 
cyst, with a view of terminating the delivery by means of the 
forceps. He soon found, however, that there were flrrn and resist- 
ing adhesions between the he»ad and sides of the cyst, which mused 
him to abandon the operation. In the course of a i'ew days an 
extremely putrid odor was emitted through the opening, and the 
t^i^tus, having undergone decontposition, came away in fragments ; 
Jie I)ony structures being aided in their pa'jsage by means of small 
[►inccrs, and repeated tepid injections. The mother was coovaleff- 
cent in two months from the time of the operation. 

* In Uie mk'fTitttijil i&txl rnllnphin viinott<^« of oxtni-utcrlne ri£tAtlOD» tha Oytl ll 
RuppUod with rau^ctilAf 3brt^«m the furmor, (htm tho uterua itself; in the latter, 
trom tji0 miutoular cool of the tabo. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS, 215 

There is another condition in which the operation of gastrotoroy 
may bo resorted to. Suppose, for example, after having carried 
the foetus beyond the ordinary term of gestation, the mother should 
manifest much suffering from its presence, and her health exhibit 
evidences of approaching decline from this cause. Under these 
circumstances, the question would legitimately arise whether it 
would not be advisable to extract the foetus for the purpose of 
increasing the chances of life to the mother. Here, again, gentle- 
men, it is but a question of expediency, which is to be determined 
by sound judgment, and with but one motive to govern that judg- 
ment, viz. the greater welfare of the parent. I might hero mention 
that Mr. Adams, of the London Hospital, and Dr. Stutter, of Syden- 
ham, have recently succeeded, by gastrotoiny, in the extraction of 
dead extra-uterine foetuses, several weeks after the completion of 
the full period of gestation. In both instances, the mothers sur- 
vived.* 

Should you discover, at any time, an incipient abscess in the 
abdomen, vagina, or rectum, etc., occasioned by the death and 
decomposition of the fictus, I need not tell you that it should bo 
promoted by warm fomentations, and, if necessary, opened, so that 
a passage may be afforded to the foetus ; and its extraction assisted 
by the various instruments necessary for the purpose. Dr. Camp- 
bell, f in an excellent memoir on the subject, presents some inte- 
resting details. lie s:iy8 it is well proved by experience that, when 
the suppurative process is established, or a breach is actually 
formed in the parietes of the abdomen, the integuments may, with 
laiety, be largely incised or the pre-existing aperture freely dilated 
with success. He records thirty cases in which gastrotoniy was 
performed, or the breach dilated, and of these, twenty-eight 
recovered. In twelve cases of gastrotomy, resorted to after the 
mppurative process was well advanced, ten were successful. In 
Dine cases operated on, when the foetus was still alive, or soon aft^er 
ito death, all were fatal. 

* Medical Times and Gazette, London, July, 1860. 

f A Memoir on Extra-uterine Gestation. Edinburgh, 1S40. 



LECTURE XV. 



mil 
K mn 

I 



I 



prcgTLincT, although not » Pathologic«d Btat€, is occBuion&ltjr nilrfect to DerBRg»* 
iTieuta — Tbeac DerangemetiteAre lx»lh rhy»iotogica) nml Mectmnk^l ; ni'j«tr»ttin>— 
I>tjgjiiiaical DuctriiULS of the Ancli'iiU Uj n^ard lo ih* Thcmpotitics of Preg: nancy — 
Bl4x»dtelting in Pregiumcy; when Iiidjc?iit*?d — Cnihartlcs wid Krut»li«a; ure thc?^ 
ndmiwihU*? — NiiUHe^ iir»d VomiHiijf; howTreulinl — When Kxitwire — ^rtrnlisru — 
0<>ii>ti|«nioij — llnw Coiii*ti|iutioii i« eniued io the Pr<'g»mrd KciiudL* ; in jttwt 
tlirytigh Morbid Nerrous IiiHuence; in pint fWnn Mcehiuiicid Prewnrc — IMiinhcB«; 
ita Danger*— Pill pita tion cif Ihe Heuit and Svikx»p<j — Lnrchi^r'^ Opitduu i^(i|iv<ting 
HyiKTtmplijr ollhc Heart— P;ilr» in tbt; AUI^uiiiuul MiLsden; how Tr«ni ted ^ Pain* 
ful Mumm<t*^Pam in the Hi^ht Hypoch«>ndriuni — PruHtna of tlse Vuly»; liemor* 
rhoidj} ; how Produced — Vuritxjee Veiiift — '^ough mid Oppn?i»ed Bri'tlhUig. 

GEXTi.KMKJf — I have remarked, in a previous lecture, that preg- 
nancy cannot, strict ly speakiiisr, be rogardeil iiJi a ptithologicstl or 
diseoM^^d BtiiU\ Hut wliilc this fact w conet,^de*i, yet, on the other 
hujid, it is not to be forgotten, that many of tho Byrnp!itlietlrt 
phuiiotnetm characteristic of gestation will ftometintes, through 
exaggerated action, assume a tnorbid eharacter, calling for thi» 
intervention of science. Indeed, the derangetuentH of prejonmncy 
may, with propriety, be <livided into physiologicjil and <!:d. 

10 not nntsunderKtand me; a true and cornph*te [i ^ical 

ion tH nothing more than a natural function, and while it keeps 

ithin the particular sphere of duty asi^igned to it in the mecha^ 
iiisni, it cannot, by any const ruction, be denominated morbid. It m 
only when the physiuIogi<vd fnricrr«>n ceases to he recognised by 
nature a** a f^ouud link in the chain of forces, which make up the 
entire workings of the system in health, that it becomes oon%*ertpd 
into a pathological result. 

Let us illuijtrate thin point. Yo»i know very well, that the im- 
j>ortant office of tfie kidneys is lo secrete urine, through which 
efteto rnjitter is more or less constantly passing from the ftysteni; 
60 long as lids secretion is perfofTued nonnallyi it const itutca a 
necessary ami precious element of ht^alth. Bit, sup|>ose that, in 
lieu of the oriliuary action of the kidney, there s^hould bo an 
increased secretion of urine, giving rise to that dangerous, and 
oftentimes fatal malady — diabetes. In tliis ea^cs we should clearly 
ha%*e substituted a patholc»gtcal stale fur what, under ordinary eir- 
eurnHiances, is **trictly a physiological function. The same thing 
occurs fmptently in pregnancy. For example, there is s^'arcely a 
■f mpatlif evoked in the economy as the con«^equenee of fecundatioOi 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 217 

which may not, in the manner just described, become morbid, and 
thus need the attention of the practitioner. Again : as tJie result 
of mere mechanical pressure, there may occur various plienomena, 
which, from their disturbing influences, are entitled to be termed 
morbid, and which, therefore, are legitimately objects of medical 
treatment. 

The digestive, vascular, and nervous systems may all become 
more or less disordered, as incidental to gestation, and these de- 
rangements will assume various types. The nausea and vomiting, 
ptyalism, depraved appetite, constipation, diarrhoea, etc., are all so 
many consequences, which, under certain circumstances, may require 
therapeutic management. 

Bloodletting in Pregnancy. — I have already alluded to the dog- 
matical and dangerous lessons, inculcated by the early fathers 
regarding the management of the pregnant woman ; and these les- 
sons have, I fear, ripened into a maxim which, even at the present 
day, is too often regarded with scrupulous fidelity. The old- 
school men taught that pregnancy is a peculiar state, calling for 
periodical medication ; and that the only security for a safe and 
healthy gestation was the strict observance, on the part of the 
practitioner, of certain prescribed rules of treatment. In fact, so 
fiir from regarding pregnancy a natural condition of the system, 
they described it as an abnormal state, and hence were predicated 
upon this basis their views of its management. For examj)le, the 
doctrine very generally obtained, that one of the universal charac- 
teristics of gestation is plethora ; and hence the maxim that blood 
should be abstracted from the arm of the j)regnant woman in the 
fourth, seventh, and end of the ninth month — these being the 
respective periods in which the gravid uterus is most disturbed by 
this vascular fulness of the system. You have seen that plethora 
is not necessarily an accompaniment of pregnancy, and, therefore, 
any rules of treatment founded upon such an assumption, cannot 
be sustained according to the laws of rigid analysis ; and, more- 
over, if you were to act in blind obedience to this precept, you 
could not fail to do a vast deal of harm. It oftentimes happens 
that many of the phenomena of pregnancy, which are 8upi)osed to 
emanate from plethora, are directly traceable, not to an engorged 
condition of the vessels, but to an exalted vitality in the uterine 
organs, and its transmission to the various portions of the economy 
with which these organs are more or less in close sympathetic alli- 
ance. 

Then, gentlemen, so far from teaching these crude generalizitions 
of the ancient school, which all bedside experience proves to be 
erroneous, I shall enjoin upon you the sound f)rinciple, that you are 
to employ the lancet in pregnancy, not because of the fiict that 
pregnancy exists, but because of the incidental occurrence of some 



218 



THE PBINCII'LES AND PRACTICE OF OBSTETRICS. 



eifciim.'^tance conipricating that condition, wliich broadly indie 
the necessity of ]o9» of bh)o<i. For instance, in all acute di&ea 
\n eases of actnal pk thorn, as nhown by the bounding pulse, flushe 
countenance, headache, etc.; in threatened abortion, with markc 
weight and nneusincj^s about ibe hip?*, aocompiinied whh fuhiess of ^ 
the system, blood may be abstracted in quantity, according to ih 
judgment of the practitioner, with good effect, 

CatharfJcs, — It was a favorite maxim of Hippocrates, that catha 
tics should be administered to the pregnant female only from lUi 
fourth to the seventh month, and that, in all caM»j*, the admiiiistf 
tion of the cathartic should be preceded by the aVistracliou of blood *^m 
and, again, it was maintained by Puzos and other*, that purgulivc 
were essentially necessary during the ninth monlh of gestation, fori 
the reason that they protected the female from many of those post 
partmu difficulties, which were tsu[jposed to be due to a const ipalcd 
state of the bowels* The only remark I shall make on tlie subject] 
is, tliat, unless there sboidd be some special reason, such as th^l 
presence of inflammati<m, the necessity for preceding a catl^artic byJ 
the use of the lancet is one of the fanciful notions fouudi^d apoiil 
nothing stable in therapeutics; and iis to limiting cathartic medi- 
cines to the fourth, sevenlh, ninth, or any other pei-iod of gestational 
ia about as philosophical as to enjoin upon a navigator, starling frotnf 
Kew York to Liverpool, tfie absolute necessity of steering noih^j 
east, s<niilieast, or due east, on stated days. Like the ^kiltul | 
navigator, the physician nuist be governed by circumstances; andj 
when, in his judgment, cathartics are indicated, they must be giveQ|| 
not according to any stereotyped rule, but for the special object j 
which may present itself at t!»c time. 

£iii€tics. — You will lind, in the course of your future experience, I 
that there is a very general prejudice e.visting, not only among theJ 
profession, but also in the public niiud, against the employment of I 
emeticj* during gesiatiou ; and this prejudice is founded upon the I 
apprehension that thi'ir direct tendency is to produce contraction j 
of the uterus, and, therefoi-e, premature expulsion of its contents. I 
It might appear, a priori^ that this aj^prehension is not without * 
force; but it seenm to me that, in reality, it is not entitled to mnoli 
consideration* T have piid some attention to tliis qtiestion, and 1 1 
am clearly of opininti that the prejudice against the use of emetics) 
ID pregnancy isi not only uutbunded in fact, but has occasionally 
been productive of bad consequences, I do not kfiow hoiv I can 
better illustrate the truth of this latter remark, than by the brief 
narration uf au interesting case in point, which came under mj^ 
observation a few months since : 

A nuirried lady, ngrd tweoty-seven yoars, on© year married, was! 
ia her seventh month of gt»statiou. Her health hail always beett ' 
good, and particularly so since her marriage. Nothing of any imi*^ 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS, 



219 



portance occun-^d durinrr her pregnajicy, with the exception of the 
ordinary phenomena incident to this condition, until the night of 
Dec. 23d, when, being in her 8evenlh month, she was suddenly 
attacked, while in bed, with vertigo, tVpllowod by I088 of oonsdoua- 
ncsfs and stertorous breathing, Bnt a lew niinutcft elapsed before 
I w:is by her side. Here, evidently, was a case of apoplexy. What 
was to be done? In the hurry of the moment, and his mind fixed 
upon the two ]>romiuent symptoms — the loss of consciousness and 
fttertor — the physician would most likely plunge his lancet into the 
arm for the [»urpose of relieving the brain of its pressure I He has 
read in the books, and heard, ex cathedra^ that, in apoplexy, blood- 
letting is the heroic remedy. Thi^ is a eaj^e of apoplexy, and, 
tlierefore, he bleeds. Now, gentlemen, this may be a syllogistic 
argument, and so far as the logic of the schools is concerned, it may 
have impressed upon it the seal of approbation. But the question 
is too naked — it is too abstract. In one word, it lacks the necessary 
collaterals for the medical man iu the sick room ; and it is precisely 
this want of completeness which otWntimes paralyses science in its 
praclicfti ministrations, and exjjoses both practitioner and patient 
to the brondest cm)>iricism. It is very true that, in many instances, 
prnmpt and ftdl bleeding is the remedy for npoplexy — but not 
always. We have, for example, npoplexy from gastric repletion — 
the stomach is tilled with indigestible tbod, ihTis causing luechmiical 
obstniction to the circulation. In this case, bleeding would be so 
much time lost, and the last spark of life might become extinct 
during its performanre. 

Aa soon as I approached tlie iied of my patient, I observed, on a 
chair, a basin, in wliich I was informed she had several times at- 
tempted to vomit. I noticed in the 1)asin some smalt pieces of salad, 
which had evidently been ejected from the stomiich. On inquiry, I 
learned that she had spent the evening at a frieud*s house, and had 
partaken very freely of lobster salad and ice cream. Without do- 
lay, I mixed twenty gmins of ipeeacnanhain half a tumbler of warm 
water, and, with some little ditiiculty, caused her to swallow it. In 
.A few moments it took eftect, ami you would have been amazed to 
Bee tbe quantity of nmligested food thrown tVom the stomach. As 
Soon as this offensive mateiial was ejected, the patient evinced 
marked and gratifying evi<lences of returning reason — the stertor 
ceased, and her consciousness was shortly in full play. She went 
on to her full term ; and I h:id the pleasure, in two months from 
that time, of presenting her with a line little boy, alive and in good 
he:dlh. One moment's hesitation, on my ])art, or the too ready 
adoption of the routine practice of bk^eding, would have s:\ciificed 
two lives, and thrown into the deepest grief a tlevoted husbuid, 
whose anxiety on the occasion bordered almost on bewiMemient, 

To show you that emetics arc not incompatible with a healthy 



220 



THE PRINCIPLES AND PHACTlCK 0¥ ODSTETRICa 



gcBtation, and do not nercsftarily provoke premature action of the 
uterus, I may recall to your recoilection a very comuion pracricc, 
among young unmarried women, who,titidiiig themselves preguant, 
have recourse to these substances in the hope that they may rid 
themselves of thi*ir Vanden, and thus, lhrout,^h the difHtruclion of the 
evidence of their j^juilt, find shcltt*r against the withenng storm of 
pn}>lie opinion. But their hope most frequently ends in disapjioint- 
ment — the remedy has tiot the desired effect. Again: how often 
are pregnant women exposed to timt unearthly sensation, 8ea-«iek- 
ness, and yet to miscarry under tiie mo**t violent and repeated 
attacks of vomiting, is hut an exception to the general rule* There- 
fore^ I have no hesitation in slating, that emetics, during pregnancyi 
are to he em[jloyed, when indicated) with as little reserve aa under 
any other circmTistances. 

I sluiU now briefly allude to some of the disorders of pregiiMQcy, 
which %vill, oeeasionnlly, call for the interposition of science: 

1. Xitujiea find Vomit if*r/.—]i is conceded thut naiisoa and Vnuiit- 
ing are the usual, and, so to speak, the natural sympathetic accom- 
paniments of gestation* nmi^ therefore, \indcr ordinary eireumstaii- 
ces, do not require the attention of the pliysician ; but somelimeii, 
it raay become necessary to resort to remedies for the purpose of 
keeping ihem within lensnnnble limits. A great variety of agcnta 
has been suggested fur ihis purpose. Opium, in its various prepart^ 
tionSf may be given internally, a qnarler or half a grain at a dose; 
two or three drops of the solution of morphia, in a teaspoonful of 
rohl water ; small pieces of ice internally, or a piece of ice laid on 
tl I e e 1 ii gast ri c re gi f »n , w i 1 1 som et i m es ha ^' e ^oo*! e ft ect . D r. Si m pson 
sj^eaks favorably of the inhalation of laudanum from a small fiber 
inhaler, hot water being used to protnote evaporation, I have,, 
ocea^-ionalfy, derived much benefit fri»m the application to tbo 
epigastrium of a cloth salnrafed with laudanum: chloroform, em- 
phiyed in tlie same way, has lu'en found useful. Equal fMirts of 
lemon juice and cold water, say a tablespoontul of each, or the same 
quantity of lime water and milk, two or three times a day; two or 
three dro[>8 of tincture of nux vomica, every two or three honr^» is 
a remedy much extolled by Lt«bach ; Imt, he observes, that atVer the 
arrest of the vomiting, severe ciamps are apt to er»sne, which, how- 
ever, readily yield to the tincture of tlie acetate of copper, one drop 
each hour, gradually increasing to six drops an hour* 'Flic extract 
of belladonna, in ointment, applied to the cervix uteri, first (sug- 
gested, I believe, by Breton ncau and Ca/.eaux, is sonietiraes very 
efficaeious. I have employed it with very striking benefit. Its 
strength should be 3 j. of belladonna to % i, of adejis; a small por- 
tion to be smeared on the cervix onco or twice a diy. as may lie 
indicated. It sliould l>e applied with the linger, and not through 
lIio siieeulum, for the rejison that this instrument may, e^ix^eially 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 221 

in sensitive women, induce premature action of the uterus. The 
llUowing, known as the potion of Riviere, has been in much repute, 
md may be resorted to oftentimes with advantage : 

IJ. Acid Citric gr. xxxvj. 

Syrup. Sacchar f. 3 viij. 

Potassas Bicarbonat gr. xxxvj. 

AqusB Destillat , . f. ^ iv. 

The citric acid to be dissolved in one half of the water, and then 
add the syrup ; the bicarbonate of potash to be dissolved in the 
remaining portion of water, and a tablespoonful of each adminis- 
tered successively. Should the vomiting be aggravated by a con- 
stipated condition of the bowels, which is oflcn the case, though it 
may elude the vigilance of the practitioner, one or two of the fol- 
lowing pills may be given as occasion may require : 

9. PiLColocynthComp.,) ga gr. xxiv. 

Extract Hyoscyam., ) '. 

Pil. Hydrarg gr. xij. 

Ft. Massa in pil. xxiv. dividcnda. 

Dr. Simpson commends highly the nitrate of cerium in one or 
two grain doses in water. If the patient should eject bile or vicious 
secretions from her stomach, then a slight emetic will be indicated ; 
nothing better, perhaps, than 10 or 15 grains of ipecacuanha. 

Tou will occasionally, gentlemen, meet with cases of rebellious 
Yomiting, accompanied by a distressing weight in the vicinity of 
the uterus, with flushed countenance and an excited pulse. In 
these cases, you will find the abstraction of blood from the arm, 
from ij. to iv. ounces, repeated as may be necessary, a most efficient 
remedy. Indeed, if it be not had recourse to, miscarriage will be 
very apt to follow.* 

2. JPtyalism. — Salivation cannot be said to be a very common 
attendant upon pregnancy, yet it does sometimes occur, and will 
occasionally give rise to annoying consequences from the more or 
less constant dribbling of saliva, and in quantities so great as to 
weaken the patient. I have seen but few cases of excessive ptyalism 
daring gestation, and, although there are many remedies recom- 
mended, I have not found anything so effectual as occasional small 
doses of Epsom salts — sriy, a teaspoonful in half a tumbler of water 

♦ Dr. Clay, of Manchester, calls attention to increased pain and tendeniess of the neck 
of the worab as an occasional cause of persistent vomiting in pre^ancy ; the increased 
pain and tenderness being the result of inflammatory action. The slightest irritation 
of the part induces violent vomiting, and this is arrested as soon as the irritation is 
removed. Tie recommends such a position of the patient as shall relievo the cervix 
ftom direct pressure by the head ; and, if necessary, a resort to leeches, to reduce 
She inflammation. Tlis treatment was adopted with complete success in three < 
[Midland Quarterly Journal, Oct 1857.] 



222 



THE PRIXCIPLES AND PRACTICE OF OBSTETRICS. 



every altornatG morning ; or, if neceswiry, daily. It prodticrs %eron 
discharges from the bowels, and thus to a certain extent aulagouiz 
the excessive secretion of saliva. 

3. Constipation. — I think it may safely be affirmed thiit re^ 
lariiy of the bowels during gestation is the exception, while a Wi 
ilency to constipation is the general rule ; and if ihi^i be so, the trti 
reason of this circumstance h certainly worthy of a momunl^ 
thought. Not to speak of those examples of constiprition, wbicli ar 
to be attributed simply to carelessness^ on the part of the female 
there are numeroun others contiimally occurring during the preg 
natit state, which need some other explanation. The uterus, it 
admiited, under t!»e influence of gestation awakens in the econoi 
varitpus !^ymf>!itliit's, and the^e cannot be evoked without aeciisiofl 
ally bringing about more or less derangement in the healthy 
natural functions of the particular organs with which they are coo 
nectt'd. For example, ive have seen that nothing is more commc 
10 prcLrnanry than disturlianc*- of the 8tomaeh; so likewise do tli 
heart, lungs, livor, ki<lneys, and tliu ncu'vona centres, etc, bccofi 
more or less deranged in their ri»8(K?ctive funrtions. These sympi| 
thctic iiirtueuces are produced through the ganglionic system 
nerves, vvhich, becoming to a certain extent the seat of irritation 
the utt'rns, trarisuiit tins initntiou, iltrough the ganglia and ptexuse 
to other orgrms of the system, 

I believe that, to a certain degree, tlie constipation of pregnane 
may be exphnncil in the same way — the regular action <if the inte 
tinal canal being moditied in consequence of a want of liealthj 
nervous (lower from the gar*glioT»ie nerved ; this, at all events, in mj 
opinion, is tlie true explanation of the torpor of the bowels in 
earlier months of gestation. But, at a later j>eriod, there is nn 
additional cause brotight iiilo operation, viz. pressure of the uterti 
agairist the intestines ; this »levelops it^ielf more sensibly during til 
last fom* months of gestation ; for, at this time, the uterus eon 
presses the large intestine just n^ it passes from the lefl iliae fo« 
to the sacrum, and hence tljere is more of less obs^truction at thil 
point to the descent of the fieecs into the reetum. You may ver 
naturally ask W'hy, when the impregnated uterus becomes largelj 
developed in the abilominal cavity, the whole intestinal e^nal tloe 
not suffer from compression ? The simple reason is, tliat the int€ 
lin^s above the pelvis enjoy great mobility, and are, therefore, froii 
this cause, enabled to accommodate themseJves to the distended 
uterus. 

It is very desirable to assist nature, during gestation, in removin 
the usual torpor of the intestinal canal ; for, if it be permitted 
continue, headache, fever, and loss of appetite will be iipt to ensu^ 
For this purpose, 1 am in the habit of ordering a simple enema 
warm water early in the morning, or what will frequently unswi 



TRK FKINCIPLES AND PRACTICE OF OBSTETRICS. 



223 



. M gr. xij. 



an excellent purpose, a tumbler of cold water dnmk as goon as the 
patient leavea the bed. Sometiraes it may be necesaary to give a 
little manna dissolved in water, and again one or two of the follow 
iog pills may be administered according to circumfitanoes : 

IJ , Mass® Hydrarg., 
Saponis, 

Assafa?tid!i% gr, vj. 

Ft, Massa in pil vj. dividetula. 

Ton will sometimes find that, in the attempt to administer oq 
aema, the fluid is immediately returned. Tliis wilt probably be 
owing to the circumstance that the rectum h elugged up with lumps 
of fiecal matter, which will be likely to give rise to varioiLs local 
syniptora8, such as more or less bearing down in the back passage 
and tenesmus, which, if continued, may resnlt in premature deli- 
very ; pains throughout the pelvis and lower limbs, with indications 
paraplegia from undue pressure on the sacral plexus of nerves. 
('ow, this is a very important condition of tilings, and a little 
inattention on the part of the accoucheur may re.snlt in serious trouble 
to the patient. Therefore^ in all such caseSj I would advise you 
particularly to inquire how long a time ha^ elapsed since the evacu- 
rUtion of the bowels; whether the p.'iin and tenesmus have continued 
for several dayn; and if you have reason to believe the rectum to 
be tilled with fjjcces without the ability to expel them, it will be 
your duty to proceed at once to reinove the offending masses. Tliia 
may be done in one of two ways — ^eilher introduce the index linger 

to the rectum, and thus giving it a hook-like form, bring away, 

ece after piece> the ficcal matter, or, if you prefer it, you may 
intro«lnc^ a small sjiatula, and thus rid the rectum of its contents. 

4, Diarrluea, — Pregnant women are occasionally subject to an 
opposite condition of the bowels, viz., diarrhcca; and it is well to 
remember that the same causes capable of producing diarrhcea, 
when pregnancy docs not exist, may also display their action during 
this state, such as improper food, cold, etc, ; and agiiin, diarrhcea in 
pregnancy, as in other conditions of the system, will sometimes be 
the direct consequence of constipation. Have you never, for 
example, seen a ease of protracted constipation followed by severe 
diarrhcea? If you have not, such instances will undoubtedly occur 
to you in practice* In these cases, the intestinal canal becomes 
irritated by the presence of faecal matter, and more or less jirofuse 
diarrhcea will be the result. One word as to the treatment of this 
latter form of diarrha^a. Give an astringent, and you will most 
probably destroy your patient. On the contrary, administer a good 
cathartic medicine, sweep the whole intestinal canal, remove the 
offending cause— tiie accnmulated fiecal matter^ — and you will not 
only arrest the diarrhcoa, but restore your patient to health. There 



224 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 

k, however, ^entk'raen, what may be trilled tbe tUnrrhfr^ //- 

nanvy — ihni is to say, it svjII somutimes sn|»erveiic U[»on i _ - <'y 
almost aiiiHihanct^usly with ihc* Ineeptiou of this stutt*, prtHiure*! by 
a peeuUur condilioa of the pingUoiiic nerves ; ho that, although far 
leas tVeqtient thnii r.otistipulion, yet dlurrlia-a may be refr?irdL"d an 
occasional acconipanimout of trestatiou, and may, by debilitaling 
the system, give rise to mipleaaaiit results ; but what is most to be 
apprehended iV ii^ tendenei/ in toomen of great nervous suscepti- 
biiifi/ fo produce fnisearrlftge. The diarrha^a must be treated on 
general [inrieiples ; t^hould it result from improper food or consti- 
pation, a purjjative will Ije iudleated; if tlie food be sliU in the 
fitomach, adtninii^ter ten or fifteen grains of i[>eeacuunha ; if from 
nervous irritability, calming enemata, etc. A tablespoonful of tho 
following mixture may bo given with good efiect two or three times 
a day: 

5- CretfiD Misturie, f | vj, 
Tinct, Opii, j 

" CjUechii, [ftaf3j, 
'* Kino, ) 

M. 

5- Palpitation of the Heart. — In women of groat nervous soft- 
ceptibility, palpitation of the heart is wot an unusual attendant upon 
pregnancy during the earlier month i*. It sometimes resolves itself 
into quite a disturbing symptom, and will need attention. If not 
controlled it may lead to misearriage. When it is found to be due 
simply to nervous irritability, gentle tonics and antispasmodics 
judiciously employed will be tbllowed by good results. Small 
doses of quinine with nouri^hitig and dige<^tiblc food; and, as an 
antispasmodic, thirty or forty dropsi of the tincture of hyot^cyainus 
will prove valuable. If the palpitation, as will i^ometimes be tha 
case, should be occasioned by a plethoric condition of system, the 
broad indication h the lancet, together with the nse of salitie 
cathartics and moderate diet. The quantity of Uood lo bt 
abstracted must rest with the judgment of the practitioner. In the 
latter months of gestation the female will oftentimes complain of 
dbtressing palpitation, which arises neitiier from nei'vous irritability 
nor plethora, but from the mechanical pressure of the elevated dia- 
phragm, thus encroaching upon the capacity of the chest, and, 
therefore, giving rise to functional disturbance of the heart. The 
most certain remedy in this case will be patience, for the difficulty 
will terminate with the delivery. But somcilang may be gained by 
position ; the patient usually experiences more or less relief in the 
sitting or demi-recumbent posture. It is highly important that the 
bowels be kept in a soluble state, for constipation will tend to 
aggravate this particular form of palpitation. 



THE PRINCIPLES AND PRACTTCE OF OBSTETRICS. 



225 



Larcber* Has endeavored to show thnt» during pregnancy, there 
IS a norma] hypertrophy of the heart, which consists in a thicken- 
ing of the left ventricle, the walls of which are increased in vohime 
from one-foil rth to one-third over their ordinary dimensions ; thb 
increase is confined exchisively to the lefl ventricle, no other por- 
tions of the organ participating in it The statement of Larcher is 
deduced from several hundred po^t-mortem examinations. The 
Interesting practical fact connected with tliia opinion is, that the 
liypertraphy of the left ventricle will expluiii the hcllows soimd bo 
frequeiUly detected in gestation, and which » therefore, is not to He 
regarded, in this case, as necessarily connected with fatal organic 
lesion of the organ. 

6. )Si/ncop€. — ^Young married women, in their first pregnancy, 
are very apt to be attacked with syncope. Indeed, according to 
my experience, this is much more frequent than is generally 
admitted by writers. I have known it to occur as early as the 
second sveek of gestation. It is usually confined to the earlier 
months?, but in some cases it exhibits itself at the time of quirken- 
ing. It will develop itself in women of good health, as well a* in 
those of delicate constitution. Sometimes, its duration is quite 
brief and evanescent, while again it will contiuue ff>r a longer 
pei-iud, producing mnch disquietude on llie part of friends. It 
may take place at any time, and without the slightest premonition. 
Syncope cannot, I think, as a general rule, be regarded a dangerous 
complication for the mother. I have never seen fatal consequences 
ensue from it, except in one case, where it was well ascertained 
that organic disease of the heart had previously existed. f It is, 
however, not without danger, under certain circumstances, to the 
child ; for example, when the syncope is long continued, the inter- 
ruption of the proper supply of healthy blood to the foetus may 
result in its destruction. Allow me, here, to call your attention to 
an important distinction between syncoj)e, strictly speakings and a 
feudden loss of consciousness, unaccompanied by suspension or dimi- 
nution in the heart*s action ; this latter seems to have an analogy 
with epilepsy; and, of coui-se, its treatment must depend, as far i\s 
may be ascertained, upon the particular cause producing it. 

In an ordinary case of fainting, the treattnent is simple ; the 
patient should be placed instantly in the recumbent position, /ter 
htafl on a plane wifh her Ifody^ in order to facilitate the passage of 
btcod to tiie brain ; the dress loosened, fresh air admilte»l, cold 
jvttler dajs^hed in the face, and, if necessary, salts of ammonia 
ied to the nose. It should also be recollected that simple 

shamcal excitement of the heart by marmal pressure is a valu- 

* Gazette M^dicalo de Pam 1857. p. 258. 

f It is proper to mention tliiii there are nome few eases recorded of fiiidden death 
I from ^'i)C<;p6 during pi^egntincj, I he eyntn^pe being Lho result siniply of emotion. 

15 



226 



THE PRIXC[PLKS ASV VliACTlCE OF 01 



able means of re-estiil*!ishin^' Us rhnhmica! movement. It 
scarcely be necessary to remnrk that a proper gnpervision shou 
be exercisetl by fiieiid*! io cases in which the female becomes eiit 
ject to these fainting turns, 

7- Pain in (he Ahdomlnal FaHetes. — ^In women with iheir fir 
ebildren, more especially, there wil! occasionally be expericncedcstc 
stve pain in the abdominal walls from the sixth to the ninth uion^ 
of getitation. The true cause Is, no doubt, the great distension 
which these parts are subject, and the firmer resistance which the 
oifer in a primipara. Sometimes, the pain amounts to intense %n 
fering, and tbe practitioner must be careful not to confound it witi 
intlanimation. The diagnosis is very clear — in mere pain of tfc 
abdominal muscles from distension, there is no fever j pressure 
ifrietions relieve, instead of aggravating, the distress. In infla 
maiion, on the contrary, tlie filightest pressure increases the ] 
and there i-^ high fever, with an accelerated and hard pube. 
have found in these cases of severe abdominal pain much benel 
from the application, by means of gentle friction, of equal partii of 
laudatium and sweet oil ; soap liniment, or camphorated oil is alfl 
useful. For the purpose of x*elaxing and soothing the stretcbe 
integuments a large slippery-elm poultice, applied warm, will be 
very scrvi cable. 

8* Rckfxntion of the AMominnI Pariefes.—Yon will, in wom« 
who have borne several children, oftentimes observe an opposil 
condition of the abdominal parietes. Instead of being excessive 
tense from distension, they will present an aspect of relaxation, bein 
absolutely as it were, flabby, and utterly unable to afford ll: 
fiecesAary support to the developing uterus. This nece&saril 
exposes th^» gravid organ to the displacement known asanteversit 
which, if not remedied, will, during the pregnancy, occasion mnd 
disturb'iuoe abotit the bladder, and at the lirne of labor preseil 
Kerio»<s obstruction to the delivery of the child, us will be motj 
parU'jnlarly mentioned when sipeaking of the causes of ob^tructc 
delivery. The remedy for this relaxed condition of the abdomfa 
wUii> is proper support ; it can be afforded by the employrnent of 
broad elastic belt wliicli, if properly adjusted to the person, wl 
prove <piitesuf!ieient in pri'venting the displacement to whieh I have 
referred. Before af>]Oying it, the jiccoucheur, if the uterus be 
already anteverted, should gently grasp the fundus of the organ, 
through the abdominal coverings, and direct it upward and back- 
ivard with a view of restoring it to its normal position. 

9. Ptnn/ul Mamm(F, — The breasts, particularly in the primipar 
sometimes become the seat of du^tresi^ing pain. As pregnane 
advances, they enlarge^ the lacteal glands and ducts undergoiq 
more or less constant development^ — the consequence is, oceanc 
great local distress, producing at times fever, and othbT 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



227 



tntional disturbanoe. In these cases, you will find, t'fipecially if the 
bowels be confirmed, much benefit from the derivative action of 
Epsom salts given in mnall quantities in solution, and as circuiu- 
itunces may indicate. Benefit will also be derived from local appli- 
miiojis; gentle frictions with some liniment, camphorated oif, 
laudmmm and sweet oil, or a poultice of crumbs of bread, saturated 
with a small quantity of tincture of belladonna. If the patient be 
plethoric, the abstraction of a few ounces of blood will be of ad van- 
tage ; and I have known great good accrue from tolerant doses of 
UirUirixed antimony. 

10. jFain in the Right Side, — - About the sixth month of pregnancy, 
women are often attacked with pain in the right side, which may 
poi>isilily, tlirough iiKidvt-rtence, lie mistaken for inflammation. The 
jiain usually ari.ses from the fact that the ascending uterus begins to 
exercise a pressure on tlie liver. As a general rule, the pain will 
continue more or le^s until afler delivery, although it may be miti- 
gated by the occasional use of a mercurial pill at night, followed in 
the morning by oil, or Epsom salts. 

11, Pruritu9 of the Vuha, — A most distressing itching of the 
external organs wHll sometimes manifest itself during pregnancy, 
and, in its aggravated form, it will constitute one oi' the most pain- 
ful affections with which the pregnant female has to contend, cuusi- 
ing her literally to lacerate the parts by the constant scratching to 
which she has recourse in tlie hojKj of temporary relief. lTlcei"?itionii 
often result, requiring very nice attention oil the pan of the prac- 
titioner. You will meet with pruritus of tlie vulva in other oasea 
than pregnancy, but when it is fmind to complicate gestation, it 
calls for more than usual vigilance, for, if not controlled, it may 
lead to abortion. The female, from motives of delicacy, otlentimes 
conceals the fact of her suffering, and, on tins account, the physi- 
cian is generally not consulted until the malady has reached one of 
its most aggravated phases. The characteristic feature of the 
disease is intense itching ; sometimes small vesicles, containing & 

»rO'*anguineous Huid, Mill be observed on the inner surface of the 
"parts, where, in some cases, deep ulceration will be provoked. 

I have just slatted that other causes than pregnancy will produce 
pruritus of the vulva; such, for example, as the final cessation of 
the menses, inattention to |)ersonul cleanliness, the presence of what 
are termed the pediculi pubis, known as the smnl! parasite insects, 
rhich occasionally infest these |>arts, diHcfiarges froni the vaginaj 
ftcarides in the rectum, etc. In some instances the worms will 
jjASei from the rectum to the vagina, and two cases have recently 
been published by Dr. Vollez, in which pruritus pudendi resulted 
from the pre^^ence of asc^irides exclusively in the vagina, none hav- 
ing been tbund in tlic reutuni. In these histances, mercurial oint- 
ment will prove an cthcient retnedy. 



228 



THE PRINCIPLES AND PRACTICE OF OBSTETKICS. 



JWaiment, — Tiie treatment of pruritus nm»t ilepend upon tli« 
particiilar condition of tbo parts, and also upon iha cause lo whtcb 
it is trace;ilile, When there are no ulcerations, I have geoerally found, 
if tht*re be nothing to contra4m3icate it, the abstraction froni 3 iv- 
to 3 vi. of blood from the arm, together with saline cathartics, ancl 
a lotion applied freely of 3 i. of the bonite of f^oda to Oj. of water, 
with Z i. of M age n die's ftohitioii of morjihia, lo be followed by good 
result!!^. When the parts are ulcerated, I always touch the ulcerated 
arface with the mVhl nitrate of silver, and this should bo repealed 
ivery fourth or fifth day, m may be indicated by the progress of 
the disejise. The f)art8 to be cleansed with Castile soap and water, 
and, lis far as possible, rest enjoined on the patient. Thia malady is 
apt, especially when suffered to continue for some time, to result in 
emnciiitiou, and in Ruch case, if you limit your remedies to local 
aj>|«ri cations voii will fail in affording relief Tonics, toL,'ether with ' 
nutniious diet, will he indicated. 

Tltere will occasionally be developed a form of pruntug of tbo 
genital organs, assuming the character of eczema, which b extremely 
ilitlicuJt to manaixe, often proviiifij obstinately rebellions to remedies , 
In thiis paiticnhir condition of things, the following treatment baj^ 
been proposed by M* Tournie, and which I liave found very cHicient 
for the purpose. He recommends, as topical applications, calomel 
ointment, and a powder of camphor and starch. Should the parts 
be covered with scabs, eniullient jtoultiees are fiii<t to be employed i« 
when the scabs are removed, the ointment m to be applied twice a1 
day, 3j* of calomel to ? j- of lard; after each a] ♦plication, a powder^ 
cousiisting of four parts of starch to one of finely powdered C!:Mn- 
phor, lo be freely usecL 

12. Ilemorrhoids. — Hemorrhoidal tumors, or piles*, arc not 
uncommon during preguinicy, and frctjucnlly give rine to much 
distress. When large, they may, by the excessive pain they inducts 
occasion premature action of the uterus. In the pregnant woman 
there are two causes in ofKTation which tend directly to the form) 
tioo of these tumori;: in the tirst place, pressure exerted by the 
gravid uterus on the venou?i trunks, thus obstructing the free return 
of blood to the heart, and secondly constipation, w4iich is so fre- 
quent an attendnnt upon gestation. These hemurrhuidal tumor 
nifiy be either external or internal ; in either circumstance, thc-y ar 
exceedingly apt to be .accompanied by much pain and initaiioiu 
If they bleed, which is sonietiines the case, the patient, for th« time 
being, is relieved, for their disgorgement is .always ft^llowed by n 
diminution in their vokirae, and consequently a lessening of the irri* 
,t3tion and pressure. Occasionally, how*cver, the bleciiing will 

frequent as senously lo affect the health, resulting in an aiiiemic 
'condition of tlie system, and imposing upon the fenuile the varioa 
nervoUB and other derangements consequent upon ibiJ* bloodJi 



THE PHIKCIPI-ES AND PJUCTICE OF OBSTETRICS. 



229 



I 



ilate. In such cnse, too prompt attention cannot be directed 
torw^ard the arrest of the hemorrhage. 

One of the iir§t indications to engage the attention of the practi- 
tioner in hemorrhoids* is to overcome the constipation, and keep, if 
possible, tfie bowels soluble, for, as lonsf as llie torpor continues 
there will be but httlc hope of beacfit from local applications; tlie 
recumbent posture will also be uf service in measurably removing 
the amount of pressure exercijsed by the uterus* If the tumurg be 
large, and from their tension occ;ision much Buffering, one of the 
most eftectuul remedies will be the application of from two to four 
leech e**, depending upon the juilrfujeut of the pi"^ctitioDer. An 
efficient remedy, also, will be an injection, night and morning, into 
ibe rectnm, oi half a pint of cold w*ater, and the introduction, for 
two or three hours each day, of the metallic rectum* bougie. I 
regard these latter nieann of very great valiae in the treatment of 
hemorrhoids, especially when they are internal. 

When it agrees with the stomach, sulphur will be found an exeel- 
lent medicine to administer internally — ^a teaspoon ful may be mixed 
with honey or mola^es, and triven once or twice a day. It is gen- 
tle ID its operation, and will, in many cases, exercise a happy in tin- 
dice in diminisihing the volume of the hemorrhoids. Let me here 
enjciin upon you a most important direction, the neglect of which 
oftentimes I f*n* sure, leads to mticli unnecessary suffering on the 
of the patient; the direction to which I allnde is this; always, 

it each evacuation of the bowels, instruct the female to intro- 
duce the protruding piles within the rectum; this can usually be 
aecompli!<hed without difficulty, except in cajses in which the tumors 
liave att.iined a large size. You per**eive at once the advantage of 
the praiiice. If tlic* tnnmrs remain external to the anns, the conse- 
quence in they become subject to the tuU presstire of the external 
sphincter musde, and it is this very pressure which so often aggra* 
vatea the intensity of the suffering. Mut:h vesical irritation ^vill 
sometimes ensm* from the prcHcnce of the piles, and, utiless your 
nttention be specially directed to the circumstance, you wmII fail in 
giving relief ii> the bladder, for the reason that, in lieu of regarding 
the irritaiion ns simply symptomatic, you will most likely mistake it 
for, and treat it as, an idiopathie or prijiv^ry affection. The remedy, 
uf course, is the relief of the piles, 

13. Varicose Veins, — Women, during the period of their gesta* 
lion, are subject to enhirgement^ or a varicose condition of tlie 
veins of the lower extremities. It is the result of the met^hsinieal 
pressure exerted by the uterus. This enlargement of tlie venous 
trunks is, however, not always conlincd to tlie lower limbs. It will 
iometimes be observed in the lower portion of the abdomen, vulva, 
and vagin.'i, Tliese varicose veins are most likely to develop them- 
selves during the latter four months of pregnancy, when the prea- 




230 



THE PRINCIPLES AND FRACTTICE OF OBSTETRICS. 



flure m greatest ; hnl they will also be observeti ^hiring the ♦ arfr r 
Tiionths, particularly in case?* in which, as will sumeliiuea h:»jif.« ti, 
there is a preilisposiiion to their formation. The great remedy bi u 
miif(»rin and well-directed pressure, in order that due support may 
bo given to the diijtended trunks. A properly-adjusted lact^^tock- 
ing will be fotmd well adapted for this purpose, or an onlinary 
roller bandage^ coiirmencitig at the toes and continuing up to the 
knee. In cases of fulness of habit, the occasional abstraction of 
bloody and salinu cathartics will be indicate*!. It is always advU* 
able in these canes to allosv the patient, as much as possible, to avail 
herself of the a*! vantage of position — hence benefit will be derived 
from tlie recunibent posture and, even when sittir»g, she should he 
directed to place her limbs on a chair, so that they may be on a 
level, or nearly so, with the plane of the body. 

14. Cough and OpprtHsed Breathing, — Some women, ami thiJ 
is more ej*pecia!ly the ease in nervous, irrital>le constitutions .ire 
very apt to he troubled with a cough in early pregnancy. This 
cough is peculiar, and is wel! w orthy tfie attention of the prnetl* 
tioner; it may, in strict irntb, be diinjominaied a nervouB cough | tl 
is usutUly dry, unaccompanied by exjjectorntion, except in some 
instances there will be a sliijht scro-niiicoiia discharge; it is parox* 
ysmal, without fever, and, on an ex|tloratioti of the chest, there will 
be an entire absence of all the physical signs, indicating organic 
lesion of the |>ulnuiriary apparatus. Now, wlmt is this cough, and 
how is its [u'cscni-e t*» be explained ? It is, unnuestiouubly, one of 
those examples of sympathy evoked in distant organs, by irritation 
of the uterus, to which your attention has been so repeatedly 
directed. This character of ecuigh will sometimes continue rebel- 
lious to all niedication during the whule period of gestation— at 
other times, it will spontaneously become arrested at tlie tliird or 
fourth month. In cases in which the irritation of the utenw iavefj 
marked — as will be evinced by local pain, bearing down, and gene- 
ral unea^iiness about the hips, I have tbund either the injection of 
laudanum into the rectum, thirty di ops to a whie-glass of lepid water, 
or the application of belladonna ointment to the cervix uteri, in the 
proportion of 3 j- of the extract to 3 j. of lard, very efficient in 
relieving the cough. The internal administration of the tincture of 
hyoscyamus, thirty or forty drops in half a wine-glass of cold 
water, as occasion may require, is also a good remedy. 

But, gentlemen, duiing the hitter period of pregnancy, especially 
in the two last months, there will frequently be a cough of a difPi^r- 
ent kind — it arises from the mechanical pressure of the uterus 
against the diaphragm, thus encroaching upon the capacity of the 
chest, and resulting in irritation of the hmgs, which, of counie* 
occasions more or less cougli. Accompanying it, there will, alaNi, 
be a feeling of oppressed respiration. Patience here is the most 



THS PRINCIPLES AND PKACTICE OF OBSTETRICS. 2S1 

oertiun remedy, for these symptoms will cease as soon as delivery 
is accomplished, and frequently in the last two weeks previous to 
labor, because of the descent of the gravid uterus into the pelvic 
excavation, thus removing the mechanical disturbance from the 
diaphragm. However, both the cough and dyspnoea may be pal- 
liated by keeping the bowels in a soluble state, and if the patient 
should be disposed to plethora, occasional abstraction of blood will 
be serviceable. 



LECTURE XVi. 



Compllcfltions of Prejfiiancj from Bisplncementii of the TTtetti^^PtDlipskm, . 
▼ersion and Retrckversion or the Oriran — Three Varietief! of ProlapftioQ — BHtol 
Treatment of these Vftrielies— How Direction of th© Urethra is Modified — ^Rtila 
for Introduction of Cttliietcr — Ante-vt?r8ioo, Sj'inptoms and TrBatment of — Rciro- 
verHion mr»ro frequent than A nt(^ version — Complete He tro* version occurt only 
daring' eurlitr Months of Ge«*tation — Oceaaional Serit^us Con9eqijenees(»rt)itt Tiwm 
of Dispfncement — Premature Lnlior somctimc'H tlic Result of Retro-vfrsion^Dlag 
ntma of Retro-verakm — How deterTuined — Symptoms — Retention of tTrin**^ — Pu 
ture of Bladder^ first proposod by Sabjitier^TrwUnient of Relrt»-ver84c>n^ — Plan of^ 
Errat, Balpin, and Gariel — Retro-version often mistaken for otiier Patliologiotl^ 
Conditions — Prolnp^ion of Ovary in Trinnjrular Fown, and Ficces in tito Bectizm^ 
Uow dislittguishofl from Retro-version — ^Hernia of Gravid Cteru& 

j6K5TtKMJ£jf— Tn the previous lecture, mention has been made 
ne of llie ordinary dlHorders of pregnancy, arisin|r more or k 
t'om sympathetic niul mechanical influences, e\*f»rcisc<l by the gravidi 
uteruH on various ortjnns of the ecotjorny, Wc shall now iltrec 
your attention to the cnnsideratitui i»f other compliratiotis of «restivJ 
tion, t!ie re.sult of displacemeut of tlie uterus itself You are well 
aware that this organ, from its peculiar situation and relations 
enjoys a remarkable degree of mobility, and ts, therefore, ILibltt|l 
espt*eially in its unimprcgujited state, to various dlsplaci'mentj) ;] 
examples of the^e you have had repeated opportunity of observing 
in the Clinic. 

Tfie uterus is, also, subject to mali>ositions during the period of 
pregrianry. and these, although intK*h less frequent than wlien 
taiion does not exist, are yet attenth^d by more serious consequences,! 
There are three forms of displacement to which the gravid woml 
lA exposed, and it is proper that you sho'dd understand their par 
ticular bearing upon gestation: 1. Prolapsus; 2. Ante-i^ersion A 
3. JietrO'f*erstfm, 

1, Prohpsuji Uteri, — ^There are three degrees of prolapsua iQJ 
pregnancy, as there are in the unimpregnated condition'; in tbi 
first, t!»e uterus has fallen slightly below its normal positiim ; in tbi 
set^ond, it has passed to a levL-l with the vulva; and, in the tbinl, it] 
is completely out of the vulva, conslitutitig a veritablG procldeiiti 
The causes of either of these vjirieties are numerous — such a* re1ax»«l 
tion of tlie va'^ina, or ligaments of the uleros, the preseuet* of tumorsl 
in the abdumen, habitual constipation, falls, or blows. When] 
^pemklng of the changes produced in the uterus in early pregnancy^] 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 288 

you will remember we noted very particularly the important cir- 
cumstance that, for the first two months, the tendency of the organ 
is to descend into the pelvic excavation ; and this very descent, 
which is one of the ordinary phenomena of early gestation, may act 
as a predisposing cause to either of the varieties we have named. 
As a general rule, the uterus, in the first two varieties, usually, 
about the fourth month, undergoes spontaneous restoration, by the 
gradual ascent of the organ into the abdominal cavity. Sometimes, 
however, this is not the case ; and when the uterus presses on the 
vnlva, serious inconveniences will result. For instance, the rectum 
becomes irritated, giving rise to constipation, and an annoying 
tenesmus; the bladder, also, is affected. Sometimes, there will be, 
more or less, a constant desire to pass water; at other times, there 
is complete retention of urine, requiring the introduction of the 
catheter. 

In these cases, it is of great importance to attempt the replace- 
ment of the uterus, for the obvious purj)ose of removing the pres- 
sure from both the rectum and bladder. With this view, the 
practitioner should gently grasp with his fingers, previously lubri- 
cated with oil or lard, the cervix of the organ, and make uniform 
pressure, at first a little backward, and then upward, in a direction 
parallel to the axis of the superior strait. The patient should be 
kept in the recumbent posture, and a sponge-pessary introduced, 
which may be retained in situ by means of the T baiidage. It 
should not be forgotten to have the sponge removed at least once 
a day for the purpose of cleansing it. After the fourth month, its 
use may generally be dis])ensed with, for the uterus, having as- 
cended above the superior strait, will usually remain in the abdomi- 
nal cavity, without the necessity of support. The tenesmus may be 
partially relieved by the use of injections of warm soap suds into 
the rectum, and, in order to facilitate the admission of the fluiil, the 
practitioner will sometimes find advantage in the introduction of 
the hidex finger into the intestine for the purpose of gently pressing 
the uterus forward, so that the pipe of the syringe may meet with 
DO obstruction. 

Introduction of the Catheter, — For the relief of the bladder, suf- 
fering from retention, resort must be had to the catheter. You 
will readily understand that, in the second variety of uterine dis- 
placement — the cervix of the uterus pressing ui>on the vulva — the 
natural position of both the bladder and urethra will be modified — 
the blad«ler, of course, is prolapsed, sometimes protruding slightly 
beyond the vulva, and the urethra, instead of being oblique from 
below upward, will be so 'changed in its direction, that, from the 
meatus to a little beyond its central portion, it will be horizontal, 
while its vesical extremity will be diawn downward. You per- 
ceive, therefore, that without a recollection of this circumstance. 



S84 



THE PRI>'CIPLKS AXI> PaAClICE OF OBSIETRICS. 



the successful Lntroductiou of the catheter woulil not be an eMf 
thing to accomplish, to say nolhiiig of the scriutiii eons«*quenoei 
which would most likely ensue from a forced attempt to overcome 
the difficulty. The catheter, under these circumstances, should be 
introduced at first horizontally, from before backward, and then the 
outer extremity of the instrument elevated, while the internal ex* 
treinity h correstpondingly depressed, for the jiurpose of following 
the altered direction of the urethra, and thus entering the cavity of 
the bladder, which you must remember ig downward and forward^ 
and not upward^ as it is in its normal posUitm ; it muf>t also be 
remembered that, in this case, the convex border of the instrument 
should be turned upward^ and its concavity downward. 

When ihc gravid uterus is in a state of complete procidentia, the 
complications become much more aggravated. The difficulties 
abont the rectiim and bladiler are ne<'essaril_v much increase*!, and 
the patient is exposed to additional tiuflering. There aio well- 
authenticated instances of w<imcn having passed the pentMl of 
gestation with the uterus protruding beyond the vulva. You i-an 
readily imas^inc the distress and danger coUHctjuent u|>cjn ^ucli .1 
condition of things. When piocidentia of the gravid uterus ex- 
ists, tfie tirst duty of the practtti«ni«r U to attempt its red ut lion, 
by gripping it gently with the lingers, ant I making pressture from 
before imckward, (larallel to the axis of the inferior, and then 
upward in the direction of the axis of the superior strait. Whi-n 
reduci'd, it should be relaineU in place by means of the sponge-pe!*. 
gary and T bandage. 

It may, in cases of procidentia of the impretmited womb, become 
ft question how far it is jnslifiuble to promote prLinature delivery; 
and this question will ncce^saiily present itsi-lf in instances^ in winch 
the hjcal irritation or constilulional disturbance is sucfj as to involve, 
in more or le&s hazard, the safety of the patient. The nltimato 
derision must depend upon the accompanying circumHtances of eiich 
indivi<lual case, and tlie sonud judgment of the practitioner, 

ir, Anie'VersioH* — Ante-veision of the uterus is comiiaralively 
of rare occurrence in early pregnnncy ; although you occasionally 
meet with it m women who have borne many children^ and whose 
ftbdominal walls are consequently so mucli relaxed as to be inado- 
'quate to afford the proper support to the ascending organ, :u)d it, 
therefore, liills forward, giving ri!*e to two condilions: 1st, Anle- 
ver^ion; 2d, An increased |»romiiieoce to the ahdomen* If ante- 



• There la n brond diflcrenco between anUf-versioii nnd aiite-llextun of Ui« 
ttt«ru)v hi tilt* lulk*r. tlio iikTus i«, as it wen.', cyrved ott iuulf in gticli wa/ ttmt 
the ivvu U|i|>t*r lliirJ.i of live orj^yii are ttirown torvvunl on the bluilder, but the o^rvix 
it uiitiHturboU in its rfliniona with the p^^vic cavity. 80^ iilso, iu r^tro-ticxioa. 
w\u\i* ttie stiiKTior pitriinrm uf the iitonis lire curvM buckwanJ ikw pueitkn of thb 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



235 



irersion occur in early gestation, before the uterus has left the 
pelvic excavation, it can readily bo replaced by passing the finger 
tiito the vagina, and pressing the anterior surfoce of the organ 
backward ; sometimes, it may be reduced to \in normal position by 
gently drawing the cervix forward, the temleiifV of which will be to 
place the body and funriu.^ in a position parallel to the axis of the 
superior strait of the pelvis. In a more advanced peiiod of gesta- 
tion, when the uterus is ante-verted, because of relaxation of the 
abdominal pariete^ the practitioner should, in the tii-st place, 
restore the organ to its normal position by righting it with the 
palm of his hand applied to the abdomen, making the pressure from 
below upward, and from before backwanl ; and secondly, an ab- 
dominal brMce, or bandage, i.s to be applied for the purpose of 
retaining the uterus in situ* 

IIL J^etro-version^-^Ketvo-reirsion is much more frequent tbaii 
ante-version, and may occur in the virgin, in the married w*omatif 
who la not pregnant, and it may also complicate pregnancy itsol£ 
It is most common when the uterus is in a stale of vacuity. It is 
quite obvious that this fomi of displacement must take place during 
the eai^ier months of gestation, for, after the fourth and tifth 
months, the longitudinal diameter of the uterus is ^ much in excess 
of the anten>]iOHterior diameter of the superior stnilt, that it is 
physically imposdble for the organ to become completely retro- 
verted. 

Retro-version of the uterus implies a displacement of the organ, 
by which it rests more or less horizontally in the pelvic excavation, 
the fundus being ♦lirected toward tlio sacrum, and the cervix 
regards the internal surface of the pubes. This displacement, when 
complete, divides, as it were, the cavity of the pelvis into two com- 
partrnents, an upper and lower — for tlie former, it constitutes the 
floor, and fur the latter, the roof or superior boundary. The term 
retro- version was, I think it is generally conceded, first applied to 
this eharacter of mal-position by Dr. Wm, Hunter, 

There are numerous causes capable of pn>ducing retro-version ; 
among which may be enumerated an enlarged pelvis, a relaxed con- 
dition of the Ifgaments of the organ — the rounrl and broad ; undue 
prfSHure whether against the anterior surface of the uterus, or upon 
its fundus; the efforts of vomiting, straining in the attempt at 
defecation, a distended bladder, and any sudden or violent move- 
ment may also produce it, Ketro-version will, sometiines, bo con- 
genital ; it is almost always, however, the result of accident. 

Il is sonietimes very gradual in its occurrence, and again it is 
quite sudden. In the latter ca,^e, it is the consequence of some 
exti'aneous physical violence experienecd by tfie female, sueh as a 
fall, blow, or the lifting of a heavy weight. When this displace* 
mont has taken jilace, it is accomimnied by symptoms, which, to the 



236 



THE PRINCIPLES ASD PRACTICE OF OBSTBTRICS. 



vigilant practitioner, will generally indicate iti natnro — for ^xsmp1«, 
there will be more or \em uneii«ness expeneneed jiboiit the loiun, 
and oftentimes a dragefing sensation, irritation of tli© bladder and 
rectiini, \cith difficulty in evacuatincr eitlier ; sometimes, it will be 
almo«*t impossible to cvanmto ibt* rectum in consequence of Xh* 
extr»»rne pressure exercised upon it hy the retro-vertrd urpnii. 

All ibe^e results are very inueh iucrL^a^ed in ibe gravid ntcnig, 
and occasionally fatal conHcquencea cn*iie from it« complete lum- 
24>nial impaction between the sacrum and imbeds, giving rise, in tbo 
iii*sr pL'icc, to seven* pressure, resulting' suhsecjncully in iutfammib- 
tion, ulceration^ and its t'onsequencct*. Iij lhi« ea^e, altn^ there uuiy 
bi3 rupture of the bladder tVorn the continued retention of urine, ami 
the imp08>ibility of dmwing it off by means -of the catheter.* Tha 
rectum, hxided with fiecal matter, will occasion a tenesmus which, 
provoking on the jmrt of the female excessive effoils to expel I ho 
contents, may re;*ult in rupture of the vagina, thu» causing iho 
fundus of the womb to jirvHs through the opening, A case of thiti 
kind, which ]»roved fatal, is mentioned by Dubois, as having baen 
conmiunicated to him by Dr. >Lnyor. There are examples of thia 
displacement, in which dealli occurred from the severe local inflam- 
mation, and consequent constitutional disturbance, resulting from 
pressure of the retro-verted womb. It will Roraetimes happen that 
the utfriLH, from the serious irntntion to which it is expo^^cil, will 
be thrown into prejnntnrt^* artinn, thus ridding itself of it!* cunt^nls, 
ThiA, in canes in which ir, becomes impossible to reduce the mul- 
po9cd organ, shoultl be regarded as a most foitunato issne^ for it 
will |uvive the meanft of suvirrg the life of the mother, and enable 
the practitioner lu restore the iitcru« to its normal |K)sition. In* 
deed, when this early evacuation of the uterub is not accomplished 
by nature, it lis, under certain circumstances, the only resort left for 
tlie accoucheur. 

The diuffno^iH of a retro-vertt*d wotnb is, ordinarily, not diiricult^ 
In addition to the loe!il disturbance, to which allusion ha;^ already 
been »nade, a vaginal examination will soon dissipate all doubt. 
The finger will readily recognise a change in the position of tho 



• A WCIIQII11, agfHl thirty live y©fim. harl emorrnons dbto*>el<ni of tlie fi)jclom«>n« 
wbich* on exAiiiiJirttiuii, li^d all the clmrMiic^rs nf H^cites; llicnj whs diiliitM^ nv<^r 
UH*{rn*iilor pnrt of Uii? oiivity.exuinding liigli up ubovo ihe umUUcuii, nuU cvldeiiUy 
due ^» ili*» prt^fuoi? uriUiid A iivnllcal pniotitiou^r had b^ou on th© poiiil of ^hst* 
fornilntr |«rtrneefir.e<ir» st» ai'iruiit wmm her diBtress. Korlmiati»lv% Ihia wus dt'rTr»-»<l 
Aitd «tio was i*ik«n to lite WestmiiHU^r UtT^piul. Oq inquirmif into hor hiatttn, i| 
WHS MntuU ttitit «tt4^ Wmm thrfi* nioii(ii« prcirnimt A cntnt'tcr coulij tint tM} mUio 
duOlNti ^tiU tm exuiiuimiiort, n retro vei^iuii iif the womb w»k iti^LocitMl, which luid 
prahahty existed iUtise wwk^ the dumtimj or the i*w*eirnig. A T-w ouocea ot urine 
dfibbknl iiw:iy tkiily* Th*« fumiviH of ihti wumb whs piishtii up. uiul imfTit*iliiii© rt*Uwf 
given. U)iwrtrd<) (if a pilhiti tif urmc tluwiiig uwiiy without tlio hIU of Uic C(Uit<^ter, 
Hie i^amao recovcrCTl flx)t*d. Lantft, April SO, l859d 



TITE PRINCirLES AXD PRACTICE OF UllffVi'RiCS. 237 

orgtiit, the cervix being in fvoni^ an<l the fundui* behind, pressing, 
more or less, upon tbo rectmti j and, iu complete retro-vemon, the 
posterior surilice of the orsj^Art will form the upper boundary of iho 
pelvic exeavfition, bcinj^ distinctly felt by the fiDger, extending 
horixnnltilly from before backward. 

When pregnancy does not exist, retro-rersion of the nteriis can- 
not be said to be a dangerous complication, although it ii* one of 
mneh annoyance to the patient, and ollentimes, from the difficulty 
of retaining the organ in situ^ of embarrassment to the accoucheur. 
Very <lifterent, however, is the case during the period of gestation, 
jbr here, as you have just seen, the most formidable and, oGca^sion- 
ally, lata! results ensue. 

Two of ilie earliest, most constant, and distressing symptoms of 
this dinplacement will be irritation of the bladder and rectum ; and 
this very irritation is iVequently the lirst indication that tlicre is 
anything wrong. 

Having told yon in what retro-version consists, and spoken of the 
consequences of this form of displacement, the next point for con- 
sideration is as to the remedifis to be employed. One of the most 
imperious demands will be tlie evacuation of the bladder and rectum, 
more es[*ecially the former. But this is not always readily accom. 
pli4ied» for the rensnn that the distended bladder ascends obliquely 
upward into the abdominal cavity, and so changes the position of 
the urethra as sometimes to render it physically impossible to intro^ 
dttco the catheter. 

This constitutes one of the most serious and painful complications 
of retro-version ; and, under such circumstances, as death will bo 
inevitable without relief to the bladder, the very important question 
2in»ea: What is to be done? We hiive the authority of Sabaiior, 
in these ca^^es, to perforate the bladder above the pubcs ; and, if 
the necessity of the operalion be indicated, I should not hesitate to 
have recourse to it; for the doulile reason that relief must be had, 
and, secondly, the operation itself does not necessarily involve any 
danger. The rectum should be evacuated by means of enemata, or, 
if required, the fsBces may be scooped out with a Bcnall spoon or 
spatula* 

These two viscera being emptied of their contents, an effort 
•hould next be made to restore the uterus to its proper position ; 
for this purpose, various plans have been suggested. In the event 
of inflammation having arisen from the severe pressure of the 
uterus against the adjncont organs, any attempt at reduction sljould 
l>e prreciled by means best calenlated to remove inflammatory 
action, such as leeches, hot fomentations, and emollient injections 
into the vagina. Minute doses of tailarixeii antimony, given to 
tolerance, will frerpicntly be followed 1>y go*xl elfects in subduing 
the loc^ excite meut. This being aceompUshed, efforts may be 



238 



THE PRIlffCIPLES AND PRACTICE OF 01 



tiitiAc to reduce the organ to its usual axis. For thin purpose, the' 
index finger of one hand should be iatroduced into the rectum, with. , 
the view of pressing the fundus of the womb upward and forwanl ; 
at the same time, the finger of the other hand is to be carried 
through the vagina to the cervix of the organ, and a movement 
made precisely counter to the other — that is, the cervix shouM be 
brought a Hitle downward and baekward* Thi!^ simple tnanipiiU' 
tion, adroitly peHoi-med, will BometimeB res^ult in the restortttioii 
of tile retro* verted uterus, but not alway*^. Huch will sometimet 
be gained by the position of the patient ; for example, if either on 
the back, or resting on her left miL\ you should fail in accomplish- 
ing the object, it will be found useful to direct your patient to place 
herself on her knees and elbows — this will tend to facilitate the 
attempt at reduction ; luit the position is an unpleasant one, and 
oftentimes there will be ol*jection nmdo to it. 

Evrat suggested tlie introduction into the rectum of a taTOf>on 
prepared in the following manner : a small rod about twelve inches 
in length has fastened to one extremity a sort of mop made of tine 
old lifien, and well »!^nic:ired with oil or fresh lard; tUh tauipcm ht 
then gently introduced into the rectum; of course, it U soon 
brought in contact with the lower surface of the iual|>u8ed orj^n, 
and witli a uniform Vnit jndi<'ious upward and forward preasnre-, 
Kvjat an»l uiheii* have succeeded in giving to the uterus its natural 
position. It ii*, however, to be recollecled that, while pressure b 
made upward and forwanl by meuns of the tampon, the finger of 
the accoucheur should be introduceil into ifie vagina for the pur- 
pose of niuking downward and backward traction on the cervix. 

If it prnve impossible to reduce the organ, then it hits been pro» 
poned to pcHbrate ilie uterus through its posterior wall witli a view 
of affording escape to the fupior amnii, and with the hope of s^o far 
diminishing the bulk of the pravid uterus as to facilitate the nrnluo 
tii«L Tills, however, is a dangerous expeilient, and should nut be 
resorted to excci>t in those cases in winch it is absolutely impos,Hiblo 
to rupture the membranes through the eer\ix, which, although 
diflienlt in this form of mal-position, may, with due care and porse- 
veratice, be accnni|ilislied. 

It has been suggested by Ilalpin,* in eaAes which have remsied 
the ordinary attempts at reduetiun, to pass into the vagina aa 
Instrument, the object of which shall be the exercise of a uniform 
pressure simultaneously on the entire lower Rurface of the uterus. 
Thus he contends, by means of a Itladiler, he can completely till tho 
pelvis, and elevate into the abdominal cavity the different vi^^era 
contained within the excavation. For this purpose, he places an 
empty bladder between the futidus of the womb and rectam ; he 



• Arcli. 0«ii. 1840, p. ga. 



THE PRINCrPLES AND PKACTICE OF OBSTETRICS, 



239 



then cautiously inflates it, and, as the bladfler becomes distonded, 
the rc'troverted lUenm h replaced. A i>lan very similar lo this haa 
been sujjf,'ested by GariuL He introtlnecs one of his vnlcanized 
■ intlia-rubber pessaries iruo the reetum ; it consists of a dilatable 
air i^essary, with an air reservoir, and a tube, to each of whieli are 
attached small taps. The collapsed pessary, having been previonsly 
placed in warm water, is Introduceil by means of a probe into the 
Ifeetnrn, immediately behind thu nterns ; then the tube of tbc pes- 
liary is adjusted to the air reservoir; the taps are opened, and by 
simple pressure of the hand the air is made to escape from the 
reservoir into the pessary ; in this way the pessary presses npon, 
and raises the retro-verted uterus from the hollow of the sacrum; 
thus the natural position of the organ becomes restored. This is 
an ingenious contrivance, but tfie profier applieation of the instru- 
ment requires much care in order that it may prove efficient. 

It is not at all uncommon for the inattentive practitioner to sup- 
pose that retro-version exists, when, in fact, there is no displace- 
ment whatever; and, I think^ I shall perforui an acceptable service 
by directing your attention briefly to the causes of error. I have 
more than once been consulted by medical p^entlemcn, wlio have 
treated their patients for this s\ipposed mal-position» whi^n, upon 
examination, I have discovered that the sym]>toms, which ba(i beou 
mistaken for those of retro-versiou, were due to circumstances with 
which dislocation of this viscus had no sort of connexion. Two of 
the most prominent causes of error will be : 

1st, A collection of fa?cal matter in the rectum; 2d* A prolapsion 
of the ovary into the recto-uterine fossa. You will perceive that 
either of these continj;irencies will necessarily, to a greater or less 
extent, give rise to the same local disturbances, which usually 
characterize a retro-version of the uterus — such, for example, as 
pain about the hijKS, distressing pressure on the rectum, with fre- 
quent desire to defecate, together with tenesmus. How, then, is 
the diagnosis to be determined — and in what way is the trtie nature 
of the difliculty to be ascertained ? If it be a collection of flecal 
matter in the rectum, this can readily be apj>reciated, almost in all 
instances, by a vaginal examination. Let the accoucheur, as he 
passes it into the vagina, run his finger carefully nlong the track of 
the rectum, with a view of ascertaining, whether or not it Is unusu- 
ally distended — if the distension be due to liecal matter, he will be 
tjrabled to recognise the lact by slightly pressing uj*on the rectum, 
which will enable him to separate the diflferent pieces of hardened 
fa?ees, and thus become satisfied that it is their presence, which has 
caused the symptoms lo which we have just alluded. Again, in 
retro-version, while the fundus is thrtiwn backward into the liollow 
of thi* sacrum, the cervix of the uterus inclines toward the |mbes; 
this will not be the caxe when the rectum is simply loaded with 



240 



THE PRIXCIPLES AND PRACTICE OF OBSTETRICS. 



excrement. But, in order to remove all doubt on tlie 8iibject of 
the diagnosis, let the rectum be freely evacuuied hy cnemata; if 
this cannot be accoinplislied by these means — as is sometimes the 
case — then tlie finger, or a smull .spatula, should be introduced, and 
the fieres brought away, as has l»een previously su^jj^ested. The 
peetuuj being relieved of its distension, it will foUow, as a neceasarj 
result, if there be no retro-vension, that the patient will, at aocCr 
ejcperience an absence of the disiresaing local disturbanceii. 

Ilnw are we to proceed in our diagrioifls cjf prolupMed ovary? 
In this ea^e, if the ovary have not undergone enhirgement from 
diiieaj»e, it will not be ditMcult to displace it frotu side to ^i<ic by 
meant* of the iinger, indeed, in some inataneeH it may be |fu?;hed 
upward without diHieuIty, but as soon as the tinger is withdrawn, 
it again prolapses ; the rno8t positive demonstration that it i^ a 
prohipsed ovary, will be the introduction of the uterine sound. 

Let the accoucheur carry the sound into the uterus, which miiftt 
always be done with great caution ; as soon as it is sufliciently 
intro<bii-ed, the uterus, should it bo retro*vertod, will, of course, 
while the t^ourul is within its cavity, become righted in iu position; 
if, under these circumstances, the linger of the accoucheur be intro- 
ducifd into the vagina^ he will not feel anything ptessing ttpoti the 
rectnm^ — but, on the contrary, if, after the introduction of the 
sound, the tumor be felt, then it is evidL'ut that it is occasioned by 
the presence of the ovary in tl»e recto-uterine fossa, 

Jlcrnia of (he Gravid l/lerus, — Hernia of the impregnated or- 
gan is extremely rare ; fettll there are fiome recorded e;cample8 of 
it, Dr, Evory Kennedy, in his work on obstetric ausoultaiion, 
cites the instance of an umbilical hernia of the uterus in a female, 
whti had previously borne several children. It appears that whilo 
in labor with her second child, she \v/is attacked with an ordinary 
umbilical hernia ; this continued gradually to increase, wijen, in a 
subset pient pregnancy, the gravid organ passed completely out of 
the abdominal cavity through the umbilical opening, so that, M the 
end of the ninth month, it extended to the knees, J&Iadoine Boiviu 
has recorded a case of ventral hernia of the impregnated womb, the 
organ j)as.sing out through an opening above the pubcs, which 
openit»g was the result of a large abscess. Other varieties of hernia 
have also been mentioned as having occurred, such as inguinal and 
crural.* 



♦ I find, in the Ob«tctrical Tmnsactiona of Lottdon, for ISfiiS, p. 77, tiio (ollowbf 
inkMVMting dtw cit itiiibiliml protrusion of the impregniiteil orgiui^ linving (xxmrnnl tn 
tlic pfftf'tice of Mr O. C, P. Marray : Mrs. M. A. J., thirty yeiirn old, roothtT of tlirw 
dtil^roii, obarrveil some bhxMi Lssutng: from her navel ; on uxamtniniBf tho atxlomen, 
Mr. Miirmy pbservcU a latige tumor the mte ofii gmviil utenm in the liitt«r tnontbt; 
Ilio hofiU of « taiXn» wuJd be cli*tiiM?tiy feh. nt the right umi upper porUou ot the 
umbiJJoitJ lutuor, tli<« bxly of llie fuelua «jct«siidiiig Uowti>vArd on tht4 left »id» Theft 



LECTURE XVII. 

The Annexa: of the Fcetus ; Tlio Decidua— Hunt3r's Tlieory of its Formation ; The 
Decidua, an H^TXjrtrophied Condition of the Uterine Mucous Membrane — The 
Reflexa ; how formed — Coste's Views— Uses of tlie Decidua — The Chorion and 
its Villi — The Uses of each — Nourishment of the Embryo througli the Villi — 
Profi»89or Goodsir — The Amnion; its Uses — The Liquor A mnii : Origin of — Is it 
derived from Mother or Foetus? — Casts of the Uriniferous Tubes found in 
Liquor Amnii — Uses of Liquor Amiiii — Various — Does it contribute to Nourish- 
ment of Fcetus? — The Placenta — Peculiar to the Mammiferous Class— How 
Divided, and Dimensions of — Two Circulations in Placenta — Distinct and Inde- 
pendent — Red Corpuscles — Difference in Size of in Ftjetal and Maternal Blood — 
When does Placenta begin to Form ? — What is the Connexion between Placenta 
and Uterus? — Do the Blood-vessels of the Mother penetrate the Placenta? — 
Hunter's Opinion contirnied by Dr. Reid and Professor Goodsir — Professor Dalton, 
his Injection of the Utcro- Placental Vessels by Air — Fatly Degeneration of the 
Placentu — Is it Normal or Patlujlogical? — Tlie Umbilical Cord ; how Composed — 
Its Uses — Nomenclature of the Anatomist and Physiologist — Difference between — 
Variations in Volume and Length of the Cord — Twisting of the Cord around the 
Fcetus — Dr. Weidemann's Staii-stics of — Does tlie Cord possess tyiy Trace of 
Nervous Tissue — Dr. Simpson on Contractility of the Cord — Scanzoni's Opinion — 
Virchow. 

GEinxEMEX — We shall to-day speak of the annex je, or appen- 
dages of the fcetus. These consist of the membranes, the liquor 
amnii, placenta, and umbilical cord. Each one of these appendages 
has its own special duty to ])erforra during the progress of the 
reproductive evolution ; when this latter is comj)leted, their presence 
ceases to be necessary, and they are, therefore, expelled from the 
uterus at the time of childbirth. The membranes are three in num- 
ber: 1. The decidua, or caduca; 2. The chorion; 3. The amnion. 
These three membranes constitute so many concentric layers, and 
form the coque, or, if you please, the shell of tho foetus. The- 

was still excoriation of the skin around the navel, but no division of the linea alba 
whatever, the continuity of tho ring being perfect. The coverings of the hernia were 
composed of skin, fascia, and peritoneum. Tho tumor consisted of more tiian two- 
thirds of the uterus, the lower part lying within the grasp of the umbilicus. The 
patient being placed in the most favorable position for reduction, ^^n^ manipulation 
was exercised, after which, to the astonishment of those present, the whole pro- 
tmding organ was returned, with comparative facility, into the abdomen, the ring 
yielding equally all round to allow of tlie return of the hernial mass. No portion of 
intestine hud protruded with the uterus. A bandnge was applied to the seat of the 
hernia, which acted well; the patient went on to the full time, and, after a fiivor 
able labor, gave birth to a healthy female child. 

16 



242 



TUK PRI>rci?LES AND PRACTICE OF OBirTETRtCS. 



mode of their orirrm» together with their particular usea, b oot 
unworthy of attentioiK 

1. Memhrann Decklua. —XJniiX quite recently, it W!i« very gene* 
rally coueeik'd that the meinbrana deritlua was jiroduced lu the 
manner orighiaHy explained by Dr. Wilhaiii Hunter. He maiiH 
tjiiiK'd that this menibrane was a new formation, and resulted in 
the following manner: At the time of fecundation, the iiitermil sur- 
face of the uterus bceonies the seat of increased vital action, which 
resnhs in the exudation of eoatjulahle lymph ; tlils coa^julable lymph 
constitutes a closed s.ic, and is the veritable decidua, or, a» it i* 
Bometimea called, caduea; this membrane Dr. Hunter termed llie 
decidutt vej*s, in contnidistincliou to another ft»hl, the deeidua 
reHexn, 'Vhh latter is produced, according to bis theory^ a« fol- 
lows* : the cadtica vera forjning a closed sac, and occupying the 
entire cavity of the utenis^ it tbliows that the three openings of the 
uterine cavity are completely occluded ; these throe opening* being 
the o^ tincje, and tlic two superior and lateral an;rrle^, wliicli are 
continuous with the two f:i!lopiitn tubes. Under thin arrangement, 
it would become a necessary eon.<ieqtience that nothing cotild cuter 
the cavity of the uterus^ unless it cither perforates or pushes before 
it thb cUised sac^ or niembranji vera. Hunter, therefore, attempted 
to ifhow that, as the fecundated ovule is impelied by the fallopian 
tvd>e toward one or other of the lateral and superior angles, as »oou 
a« it reaclR^s this an^le, it secures its entrance into the uterus by 
pushing before it a fold of the membrana vera, and it is this fold 
w hich he has denominated the membnuia reliexa. This was the 
exfiosition of Hunter ; and, as I have already remarked^ until withui 
a very short time, it was the accepted theory. 

Such, however, is the progress of mind, as is constantly clove- 
kipedin the revelations of scientific research, that what wa8 formerly 
regMt'ded fw the true description of the decidua, is now found to be 
nrterly at variance with facts. It has been satisfactorily demon- 
strated by Coste, Professors E. H, and Ed. Weber, Sharpey, and 
athers,* that, so far from thia membrane being the product of a uew 
forrnation, it is simply the result of a modified or hypertrophied 
condition of the mucous lining of the uterus. They have bhuwn 
that the decidua is not a closed sac, bnt is continuous with the 
mucous covering of the fallopian tubes ; and still more, that its 
structure is similar to that of the mucous membram? of the ut«iruii 
ild<df, coutaiuijig the ^ame glands and the siimc layers; and, there, 
fore, Hunt<'r\s theory of the retlexa is as iallacioua as b that of th<i 
original formation of the decidua vera itscUl 

A very short lime ailer fecundation, the tubular surface of thti 
mucous membiane of the uterine cavity becomes thickened, and it« 



• UuUfra Skmiouti of PhjAiolog^*, pfi Ibl^-m. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



243 



vascularity niuch increaaed. The entire intoraal surface of the 
organ is covered with a soft, pulpy tissue, in which may be observed 
numerous cellular elements. It is in this peculiar tissue that the 
avum becomes imbedded ; and it is this modified mnoous lining, 
which constitutes the deeidua vera. 

Under the microscope, the mouths of the tubes can be distinctly 
recognised, as also their white epithelial lining. The follicleg 
become much enlarged, and there is poured out from them into the 
cavity of the uterus a fluid, which serves, as w^e shall afterward 
see* through the absorption of the villi of tlie chorion, for the 
nutrition of the embryo during the earlier periods of its exiBtence, 
previous to the formation of the placenta, 

J>eri(ltfa r^Jfexa, — There has been much difference of opinion as 
to the mode of origin of the deeidua re6exa. It is now adniitted, 
I have told you^ that the explanation of Dr. William Hunter is 

bi the correct one ; and, perhaps, the view*s of Coste upon the 
pjbject are the most reliaVjle of any that have been advanced within 
lale years. According to hirn, as soon as the ovum enters the 
uterus, it becomes parti:illy imbedded in the soft, pulpy mucous 
membrane*, constituting the deeidua; the pniticular portion of the 
deeidua with which the ovum thus conies in contact is immediately 
the mat of inereased nutrition, which causes it to grow or spring 
up around the ovum, not unlike tho flesliy granulations, which are 
observed to arise around the pea put into an Issue for the purpose 
of increasing the purulent discharge. This increase of a small part 
of the deeidua vera continues tintil the ovum is completely enve- 
loped by it; and this growth is what Coste denominates the refloxa* 
Thesp two layers of deciduii, the vera and refiexa, approach nearer 
to each other as the ovum increases in development, so that, 
at idmnt the end of the third month, there is absohite contact 
between them, torn ring but one membrane. At the time of partu- 
rition, the mcmbrnna decidQa is exfjclled from the uterus, and hence 
its name. The bhiod-vesseh of this membrane gradually cease to 
be supplied with blood, and, at the period of delivery, the quantity is 

> exceedingly slight, ihut no hemorrhage accompanies its expulnion. 
Ukes c^f the Decidtta, — There can be no doubt that the chief 
uses of the deeidua are to provide^ as it were, a bed for the ovum 
in the earlier periods of its development, and, through the nume- 
rous glands di><tribuled on its surface, to afford the necessary 
nourishment previous to the organization of the placenta, which, 
we shall tell you, has no ejcistence at the commencement of gestation* 

n. The Chorion, — It has just been showTi that the membrana 
deeidua is nothing nnu'e than a niodiflcation in structure of the 
macoua investment of the uterus, and, therefore, it is, strictly speak* 



♦ Conipt<^ R^ndufi, 1847 



244 



THE PRIKCIPLKS AKD PBACTTICE OF OBSTETRICa 



iiig, furnished by the molher- The chorion^ on the coo 
together with the amnion, appertains excI^^ively to the funii 
hence, these membranes arc, with propriety, denominated its pr 
per tunics ; the ehoriun is the most external membrane of the oviii 
and tonus one of its cunstituents from the ear h est appreclab 
moment of tueundation. It la a thin, transparent investment, n0 
unlike a small hydatid ; it piiiiiiie^ over the fcetal &»urface of the yh 
eenta, and also affords an external sheath to the umbilical cor 
The chorion is intended to discharge, in the earlier periods 
embryonic life, a most important and necessary otlice, whieh is 
nutj iiioij of the embryo itself; and, hence, for tlds purpose, one 
the iirst changes it undergoes is the production over its collall 
surface of villous prolongations, giving to it tlie peculiar sbagj 
[appearance, wliidi forms, in the tirat periods of com^eption, one < 
'its prominent ehanicieristies. These villi conntitute so many absorl 
ing radicules, through which the lluids furnished by the jiarent 
conveyed from ibe decidua vera to the embryo, thus supplying 
latter with iLe necessary elements of development; and this moil 
of nutrition eoniiuues, as I have told you, until the formatiou oft 
place ntJi. 

It has been demonstrated by Professor Goodstr, that each one < 
these villi or tufts is composed of numerous nucleated cells in diffel 
eni stages of develupinent, inclustd within a layer of bai*eua*i 
membrane. At first, the chorion and villi liear no evidences 
vascularity, being entirely composed of cells, covered on the 
external surface by a delicate structureless membrane; soon, hoi 
ever, vessels, conducted by the allantois, give rise to vascidar loo( 
in these villi. On that portion of the chorion, from which en 

nates the placenta, the vU 



J^:^ 



>■ 



The Amnio* «nclti«iiif Ui» Partas, 



increase very much in nun[i^ 
while on the other portion th€ 
preserve their original com] 
tion. Each of these placotii 
villi b 6U])|ilied with a va^cull 
loop, between whieh and tl] 
umbilical vessels there i-^ a dire 
continuity ; and the blood of tb 
feet us is forced through the ve 
sels ill the villi by the agency i 
the f*JBial circulation, 

111. 77ieAfnnios.—Thh\Blh 
moHt internal membrane of tij 
ovum ; it is mnuoth and tr 
parent (Fig, 44), and is in liUgll 



lAdhef?ion with the chorion, by means of the mucous filament* cover* 
bg it^ outer surface. The iutemal surface of the amnios is sep mmted 



TUE PRINCIFLES AND PHACTICK OF OBSTETRICS. 



245 



from the foetus throusfli the intervention of a fluid — the iKjiior 
aninii — to the origin^ and special uses of which we shall presently 
refer. Like the chorion, this membrane passes over the fcetal por- 
tion of the placenta, and also aids in forming the sheatb of the umbi- 
lical cord. 

Barf of Waters. — ^These two membranes, together with the 
decidua, constitute the envelopes of the fcetus during the term of 
gestsition, and, at the time of j parturition, ther possess an import- 
ance w*ell worthy the consideration of the acconeheur For exam* 
fk% they, in eonjunclinu with the li<|nor anmii, form what is known 
_ nhe membranous sa(\ or, in more popular phraseology, the "bag 
of waters." This '^ bag of waters," as wo shall have occasion to 
explain when speaking of the phenomena of natural labor, dis- 
charges a very important oftice ui the influence it eontribntes 
toward inducing a proper degree of dilatation of the month of the 
womb. As a general principle, it is not characterized by mudi 
power of resistance, au<l, consequently, bec<)mes ruptured at the 
proper time by the simple contractile cficirts of the uterus, But it 
will occasionally happen that, owing to a greater degree of tenacity, 
it proves rebelhous to every eflbrt of the contracting womb, and 
the siccoucheur is called upon to rupture it with his finger during a 

in, and sometimes, indeed, it will be necessary to incise it, such 
sing the nature of its resiaiance. 

The Liquor Amnii. — The origin of this fluid is a question, w^hich 
baa called forth much diflTerence of opinion. Some observers main- 
tain that it is the production of the ftstus ; others, that it is fur- 
liiahed by the mother; and, agairi^ there are some who argue that 
it is the joint production of mother and ehild. It Is admitted that 
ihc quantity of liquor amnii is relatively greater in the earlier 
months than at the latter periods of gestation ; and, in addition, it 
is well to remember that the general quantity of this fluid at the 
time of childbirth is subject to remarkable variations. Sometimes? 
alter the rupture of the membranes, the escape of fluid w^ill be so 
slight that this circumstance gives rise to what the old women 
cicnominate a "dry labor j" at other times, there will pass from the 
utcruji several quarts. In these latter cases, it will have been 
obtierved that the patient suffered during her gestation from more 
than ordinary distension of the abdominal wall^. This sudden gusli 
of fluid has more than once struck terror into the young practi- 
tioner, causing him to mistake the discharge of the amniotic liquor 
for a case of fearful fluuding; ami, occasionally, under this delusion, 
inducing him to request a constdtalion, imagining the patient to be 
in imminent danger I With a moment's forethought, all embarrass- 
ment will at once cease, for it is only necessary to make a slight 
exanunation of the clothes to ascertain at once that the dischaige, 
in lieu of blood, is colorless. 



246 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



Source of the Liquor AmniL — ^The true source of the liquc 
amtiii appears to be derived from the parent ; aud it is claimed 
be notliiii^ more than an exhalation, cir, as Velpeau terms it^ n Tit 
imbibition, requiring no special canals for its passage. Thin fluid 1 
found, at times, mixed with meeonium, and there is no doubt, Uu 
tiiere is an excretion of urine from the feet us commingrmg with ll 
liquor amnit. Under the microscope, besides other Qiatcrials, clen 
transparent, elongated cylindricjd bodies — the casts of tho ur 
feroua tubes of the kidney of the fcBtus — ^have been distinctly recc 
nised, and the detection of these substances is very conctumi 
evidence that there U a mixture of the urinary secretion, and 
amniotic liquor. Again : there are facts recorded upon pcrfectif 
reliable authority, in which tlie death of the fcetus, whiJo in utero, 
was occasion etl by rujiture of the bladder froin over distension, 
consequence of an imperforation of tlie urethra, tlius preventing il 
escape of the urine. 

According to Vogt, the liquor amnii contains common ftaU 
lactate of soda, albumen, sulphate and phosphate of lime; and tvi! 
tlie presence of urea has been detected in it; Bernard ha^ recenllj^ 
observed glucose in this fluid. Vogt has also shown that the elo^ 
mentd vary during the diiferent periods of ge!«tation ; for cxamph 
the chloride of sodium is in greatt*r pro[;ortii>n iluring the fir 
niunths, being the period when cell-development and gruwlh are 
more active, Wlielher the liquor amnii be engaged in afibrdl 
nourishment to the embryo, we shall cxalnine wheo speaking i 
nutrition of the fcetu^. 

Uses of the Liquor AmuU, — ^Thc uses of this fluid are va 
1. During gestation, it serves to protect the foetus against tlie cfl^e* 
of any sudden concussion, wliich may befal the mother ; 2. It pr 
vents the adhesion of thoj*e parts of the fa?tus, which are inti^idc 
to remain separate ; 3* It affords facility for the fojlal movements i 
ntero; 4. It protect^ the umbilical cord from undue pres- 
ensuring a free circulation of blood from the fcBtus to the | 
5. At the time of labor, the liquor amnii performs the ira|>uria 
double office of aiding materially, by its uniform and gentle pr^ 
8ure^ in the dilatation of the mouth of the womb, and, after th 
rupture of the ** bag of waters," it lubric^ites the vagina and vulv| 
thus facilitating the ultimate distension which they are so soon 
undergo. 

Placenta, — The placenta, or ailer-birth, the latter name boin 
given to it for the reason that, as a general rule, it U expelled fro| 
the uterus after the fcetu^ i^ a ll'it, spongy mass, generally circull 
in shape, but sometimes assuming the oval form. It is the mcdiu 
of cx>mniunicalion between the mother and child — its special ot 
being to supply nourishment to the fictus, during its intra-UtQ 
existence. The pluceata i^ peculiar tu the mamailferoua das&, bui J 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



247 



the&e it presents much vanatioiu boili in its form and dimensions. 
In the ruminating animals*, it assumes the appearance of small 
urtequal masses, and is consequently inulti|>le. In the mare. It 
ihibils a reddish, granular layer, which is found to cover the entire 
irfaee of the chorion. We, however, are to examine it as it pre- 
senls irself in the human subject. The term placenta i^ derived 
from it^ 8U|»posed re*;eml»lance to a flattened cake — this name hav- 
ing hiifn af>plied to it by Fallopius, It usually measures from six 
to eiuhr inches in diamettM*, aiKl, at its C(*ntre, is from one inch to 
one inch atul a half in thickness, gradually becaming' less so toward 
its border or circumference. But while these may be considorod 
the standard measurements, it must be remembered that there are 
occasionally exceptions ; for example, the after-birth at full term 
will sometimes greatly exceed those dimensions, while again it will 
fall 8hort of them, 
I>lvisiam a/ the J^tacenta,~T\w placenta is divided into two 
iirfaces — the fcrtal and maternal. The fojtal surface (Fig. 45) is 
>nietimes called the membranous, because the chorion ainl amnioji 
both pass over it ; it likewise has received* the name of arbores- 
cent, ft^r the reason that the distribution of the two umbilical arte- 
ries, and one vein, give to it that peculiar appcarnnce resembling 
the branches of a tree. This surface of the i>laoenta is smooth, 
and, as it were, glistening. The maternal p<jrtiou, sometiraes 



■^r^ 



irw. 46* 



Fig. 4B, 



ilcnominated uterine, w in contact with the uterns ; and, while the 
integriiy of the contact is preserved, this surface is also sniofith, it? 
lobes or cotyledons being more or less in close j!ixtajvo4tiort. But^ 
if the after-birth be examined, eiibsequently to its detachntent from 
the titerus, tlie maternal surface will exhibit an irregulur, liroken 
asjicct* and di.'^tinct separations recognised among the various lubea 
composing it. (Fig. 4*i.) 
Bho&^e^HU of the Plarmta, — Physiologically speaking, it raay 



24S 



THE PRfXCIPLES AND PltACTICE OF OBSTETRICS. 



be* sriMl that thi' plieenta w divided int^i two dlsthu't porlions ; on 
afj|iertainini^ to the ftEtiLS, and the otlier to the mother ; for^ ha 
proceed further in the exdtninatiou of this subject, it will be shoi 
that there are two distinct, independent circulations in the orjgraril 
one on the fa?tal surface, cunipoHed of thi* vchsuIs In tljc* umliilic 
conl; tl»g other, on the xnaiernal mirface, composed of the uter 
placental vessels. Between those two orders of vessels there exia 
no continuity of canal, and, therefore, the two circulatioiis afi 
inik'pendcnt of each other. I think there is no fact better e»i$ 
blishcd tiian this absence of continuity of vascular conn cacion belwc 
the parent and fiems. A contrary opiiiiun has been attempted ti 
be proved by the result of inJ€M?tiuns thrown into the vessels of tlw 
umbilical cord, and which have been alleged to pass directly int 
the blood-vessels on the maternal surface of the placenta ; but 
a close analysis of these ex[>eriments, it has been most ^atif^factoriW 
shown that, in every case in which the injection has been recog 
nised in the vessels of the ni oilier, it was throujih wniple extrav 
satiun. An additional proof, if one be necessary, is furnished 
the fact of the marked diftcrum-e in the sijse and relative numb 
of liie red corpuscles, and, also* in the amount of fibrin and 
men, as found in the blooil of the parent and fcetus. 

These circumHtances, now accepted as well*denionstr;ited 
gurely prove the want of continnity between the vessels on th< 
malerrjal and fojtal stirfaces of the [jliicenta; un<i the fjict, ihn 
established, involves an important consideration connected wit 
the passage of blood from the system of the mother to the faytna 
to which your attention will be directed under the head of the foetal ' 
circulation. Flonrena and others, it may here he stated, haV6_ 
recently shown that if madder be given to a pregnant animal, il 
bones of the Caausejs become colored by it as nuu'h, if not mor 
than those of the mother, thus proving the permeability of 
maternal and fa*tal blood-vessels in t)jc placenta. 

Il is not until the second month that the fonnation of the pb 
centa commences. 

Although the circulationa on the ffptal and maternal snrfiiccs ' 
this body are not carried on through continuity of canal, yet it 
must be borne in mind that these two portions of the ovum ar 
mingled, the one with the other, in close alliance throughout the 
whide substance ; and, in this respect, the human at\er-birth diflTen 
e»>enliallv from the placenta of some of the lower classes of 
mals, in which the uterine or mnternal portion ronsi»l« of 111 
hypertrophied decidua, while the fcrtal surface is composed of the 
v;i3cMdar \u\\a of the chorion, which, a^ it were^ are ftMUid to cll| 
down into the thickened deeidua. So that, in this Utter 
iicre h no ditfl<ulty in separating these two ptu'tions of the orgai^ 

J^hitai and Uirrine Surfaces of t/ie Plamnta* — According to %k 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 249 

most recent observations, the following appears to be the mode of 
origin of the foetal surface of the placenta: The villous tufts, which 
spntig from the chorion, and to which allusion has already been 
made when speaking of this latter envelope, are composed, accord- 
ing to Prof. Goodsir, of numerous nucleated cells. There is 
observed at the terminal extremity of each of these villi,^a sort of 
bulbous expansion, and, through the development of additional 
cells, the villi become elongated, and dipping down into the 
decidua, absorb from it nourishment, which is earned to the germ, 
this is what occurs in the earlier stages of foetal development, for, 
at this time, as the villi contain no vessels, the nourishment is 
derived simply through the process of absorption. But soon the 
villous tufts are supplied with a vascular apparatus ; each villus is 
furnished with one or more capillary loops, which communicate 
with an artery on one side, and a vein on the other. In this way, 
through the increase and extension of the vascular villi of the cho- 
rion, the foetal portion of the placenta is formed ; while the maternal 
or uterine originates from the enlargement of the vessels in the hy- 
pertrophied decidua, between which, as has already been remarked, 
these villi dip down. Prof. Goodsir says, ** these vessels assume the 
character of sinuses ; and at last swell out (so to speak) around 
and between the villi ; so that, finally, the villi are completely bound 
up or covered by the membrane, which conslilutcs the walls of the 
vessels, the membrane following the contour of all the villi, and 
even parsing, to a certain extent, over the branches and stems of 
the tufts. Between the membrane or wall of the large decidual 
vessels, and the internal membrane of the villi, there still remains 
a layer of the cells of the decidua."* This, then, appears to be 
briefly the mode of origin of the matenial portion of the placenta. 
But a very natural question now arises — how is the blood con- 
veyc<l from the system of the parent to the uterine surface of the 
after-birth, and what is the particular mode of union between this 
latter and the uterus itself? It is brought through what are termed 
the ciirling arteri^^s of the uterus, and deposited into the placental 
cavity, and it is afterward returned through the large veins, gene- 
rally called the sinuses.f 

• Anatomical and Patlioioorical Observations, p. 60. 

f It has bet^n, for a long time, a controverted point, as to the particular mode of 
connexion whk*h exists between the internal surface of the uterus and the mater- 
nal portion of the placenta. It is quite evident however, that the original opinion 
of Dr. William Hunter has been lully demon.strated by the experiments of Dr. 
Reed and Prof Good.sir Hunter maintained that the blood-vessels of the uterus 
passed into the substance of the placenta, and formed a portion of its mass; but 
repeated attempts have been made to siiow that his opmion was erroneous, founded, 
as it was. upon the injections, which were made to pass from the utenne vessels 
into the maternal portion of the placenta — it being allefred that these injections 
reached the placental mass, not through continuity of vessels, but because of extra- 




mn, i^ontleinen^ you have seeii that tfie jilacvrila «ot only 
sents two suriiiees — one beloiighin^ to tlie tiptiis, and the other 
the mother — but you have also observed that these two surfaces |>oft- 
sc^ two dreiilalionSf distinct nnd ittdepcndent ; tlic one carried oi 
by the two arteries and one vein of tt>e unibilical cord^ the oth 
by the rn.'iternal artenes and veins, sometimes designateil the uteri 
placental vessels. Under this arrangement, the icetns derives fro 
the placenta the elaborated blood necessary for its nourish nietil aQi 
growth iri the mariner we shaJl presently expbin. 

J'atft/ Detjenenttion of (he Plactnta,—h i« worthy of note ih 
as prepiancy draws toward its close, the placenta beeon»e^ mo 
baril, and its enpillary vessels undergo a peeuliar alteration, whicl 
consists in the ap{)earaneG of numerous oil globules in titv eoatu oj 
the vessels, constituting what is tenued fatty degeneration of ihi 
ftDlal tufts. This change in the physical condition of the [4acco 
has been regarded as m\ evidence of diseased structure ; but recci 
observation proves that, in tlie great majority of cases, this fatt; 
substitution occurs In the placenta as one of tlie pha?*e8 thtougl 
which it tinally passes* \)\\ Druit and others have called spet?i 
attention to this hubjecL Sound pathology has un(picstiouabl 
demonstrated that fatty degeneration Is ofieuiiines the result ul 
morbid action ; but it must also be recollected, that it con?*titni 
one of the peculiar pnx'esses to which ti.ssues are subjocied, ai\ 
their functiottal activity is at ati end, and jjrior to their absoq] 
tion, This is well illustrated in the case of the* muscular libri'^cell! 
of the impregnated uterus^ when the org;m» having accomplish* 
I he purpose for which it underwent increase, is about to return 
its original size. 

Dr. Barnes, of London, has recently given the profe^sion two 
extremely interesting papers on the subject of fatty dcgcm 
tion of the placenta, in connexion with tiie pathological changes 
which ihi.» nniss is liable ; and he has jKuntcil out very cleverly 
relation between this nietamorpliosis of the placenta and a 
tion.* 

Umbilical Conh — The cord is the direct channul of eommnnl 
lion between the atler-birth and fcDtus. One of the extremitit;s 
attnched to the placenta, while the other is in connexion with th 
umbiiicliH of the chiM, It is composed of three vessels, two arti 
rics, and one vein — the artenes are branches of the hy|»ogiistric 
internal ilincs, and bring the invpure blood from iho fcrtus to ih 
piacenm ; the vein originates in the Icetal portion of the iilacent: 



two 



vo^iitum Beccfiilyi Prnf. DalUin, in an mtere»tlng piipcr rond before tin* Xew To 
Ac»td*Mny t»f Midioiite, UxWj outit)niis rlnj views of lluiilor. bj niea-us uf iiir ti»it»i 
tt^nn Ww ilividmi ves^ctfli^r Uit' niusculur wuUh uf ilie uteruti into tlie pkcvulA J 
&90 AniiUJiiiy of tUe Pliiceiita. by Jiio C\ Djiltoin M.P. 
• ile«liou-Cb4rargic»iJ TmuwfcctiuiiJs vols. ;H-3D, 



THE PRINCIPLES XNI) PRACTICE OF OBSTETRICS. 251 

and conveys arterial blood from this organ to the system of the 
fcBtus. The student is sometimes apt to become confused when told 
that the vein contains arterial blood, and the arteries are the chan- 
nels through which is conveyed the impure or venous blood. But, 
it must be remembered that the nomenclature of the anatomist is 
not the nomenclature of the physiologist. The former designates 
every vessel an artery, without regard to its office or function, 
which proceeds from the heart toward a given point, and applies, 
in the same way, the term vein to every vessel whose direction is 
toward the heart. The physiologist, on the contrary, considers an 
artery a vessel for the transmission of arterial blood ; and a vein, 
the channel through which passes impure or venous blood. As the 
science of anatomy is much more ancient than that of physiology, 
and, as its nomenclature consequently enjoys the precedence, it is 
right that the distinction, to w^hich we have just alluded, should 
not be forgotten. 

In addition to its three blood-vessels, the umbilical cord has a 
sheath composed of reflections from the amnion and chorion, and 
a pulpy gelatinous material, known as the gelatine of Wharton. 
As a general rule, the volume of the cord equals in thickness that 
of the small finger; but, sometimes, it will be much greater, and, 
again, it will be less than this size. When the volume is increased, 
it is usually due to an infiltration of fluid, and by no increase of 
size in the vessels themselves, although this latter circumstance has 
occasionally been observed. 

On the contrary, when the cord is very small or slender, it is 
because of the entire absence of this infiltration. The ordinary 
length of the umbilical cord is from fifteen to twenty inches, which 
is about the average length of the foetus at full terra. But there 
are occasional exceptions. For example, cases are recorded in 
which it exceeded in length five feet, and again it has measured not 
more than from four to six inches. In the former instance, although 
the length of the coid is actually far in excess of the normal or 
average standard, yet it may become comparatively shorter in con- 
sequence of being coiled around some portion of the foetus.* In 

* According to Dr. Weideraann, the funis was found twisted around the child 
337y times in 28,430 deliveries. In these 3379 instances, it was coiled around the 
neck 3230 times, and 149 limes around other portions of tlio body. In the 3'270 cases, 
2546 consisted of a simple coil, while in 684 instances, there were several coils. 

As regards the causes of the coiling of the funis, it is related that in 1788 cases, 
occurring at the Marburg Midwifery Institution, the cord was, in 80 instances, less 
than 15 inches in length, and in 183 over 25 inches; in 54 cases, the liquor amnii 
was small in quantity , in 41 it was copious. In 165 the child weighed less thau 
five pounds, and in 28 it exceeded eight pounda Therefore, it is deduced, that 
among the ciiuses tending to the occurrence may be mentioned a long funis, abun- 
dance of liquor aimii, and a small child. 

Among 2^30 diildren born at Marburg, 182 were dead, and 251 were still-bom. 




tlte Utter case, in consequence of the extreme conjt,^enital ebor 
of the iirabilical cord, there will be more or less hazard of its sudd 
rupture during the throes of labor in eonrjo portion of its extent, oi 
of its being torn from the umbilicus, givinjj riae to furious, if not 
fatal, bcmorrhnj^c. If neither of these accidents should occur, there 
would ^itill bo danger of suddenly detaching the placenta from thii i 
uterus, or, if llie adhesjun bu ^tronj^ enoUjEfh to resist the traction, 
the next evil in tho order of sequence woidd possibly be Inversion, 
or turuing: inside out of the uterus itself, a contingency full of dao*^ 
ger to the mother, as will bt? ex])Iained when treating more par- 
ticularly of this form of utLMine difliculty. 

You will fiouietimes recognise knotted cords, that is, there wUU 
be observed in the extent of the funis one or several knots, aodl 
these are more particularly noticed in eases in which the cor4 1 



Fm. 4T. 



exceedii its ordinary length* (Fig. 47.) It is supposed that tlib 
laltc-r circuniKtatiCLs togHher with the movements of the fosttis, 
prcili>pos»cs to the formation of these knots, I have several tioies 



Of 723 born with coiled tm\.% 43 were deud. and 12 sttil-bora. Among UtQ 45 
dead*b(>rii. in tlie 125 e:xHmpk8 of coiling, in 18 only could ilje death be rvfttrred to 
thiR Irittcr ctrciimstAneo alouc. 

Fri>m nuEiulta doHvcd Irom Iho Mtdwift^iy IriAiituUotui at Dresden, Gottingefi| ] 
Wtjiv.i>iiit;, BiM'itti, muj Mnrbufif, it tippenna tliut of 13,7*20 ttcw-boni infanU, 903 ' 
were Iwrn dcml; while in 1217 inMiiuces of coiling of the Amis. $\ ehiUlrpn wero 
bora dc^id. whosi' deitlh could bo uHcriVwd to tlpit eireuTnitt^int^, giving h pr\>portton \ 
of ]''%9 Ut the eoiltn)z«, und li!> to the tmuiber b('»rn dead. 

Thu!^ «ta the sixUxMUh chiid uranii}^ new-boni ci»ildrcu» in (fcucMul « vrtfW at 1 
«mon^ (hoM* ill which the c<jrd ii fiuiml twi^^ied, is born di^nd ; m» tli^ twdAh ehiUiJ 
ainoii^ Ih*; (leW'born, in trvaeml, »nd ihi; tenth Aan^nj^; those arovind wiMeh the fuoia J 
wooiied, Im 9titUl)orn; mid, as in one el*ii% Ui forty only can this C!»>iunir bo rcjemrdod J 
Aa rciiliy the c^tu^c of death, it rollows ihat linn 'iocident ii not oulllled to |»n>iiLlaeal 
coiutid^nitiiHi. [MuuiKSBchrift fur Gi^biutddrndc] 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 253 

met with them, but in no instance have I known them to interrupt 
the circulation between the mother and child. 

The placental extremity of the funis is usually attached to the 
central portion of the afler-birth, although occasionally it will be 
found inserted near the edge or border of the organ. Cases are 
recorded in which it is alleged that the foetal extremity of the cord, 
in lieu of entering the umbilicus of the child, was observed attached 
to the limbs, head, etc. But these instances do not come to us with 
the seal of good faith, and I should be strongly induced to doubt 
the statement unless in cases of extraordinary monstrosities. 

la there Nervous Tissue in tlie Cordf — Does the umbilical cord 
possess any vestige of nervous tissue ? This is an extremely inte- 
resting question from the fact that it is now well known that both 
the vein and arteries, composing the cord, are capable of contrac- 
tion. An interesting paper on this subject, demonstrating that 
these vessels are really imbued with contractile power, was pub- 
Hshed some time since* by Prof. Simpson. In that paper, he does 
not admit the presence of nerves in the funis, but contents himself 
with the bare hypothesis that elementary nervous tissue may in 
some form exist in it. Scanzoni f says, " Isolated nerve branches 
from the plexus hepaticus for the vein, and from the plexus hypo- 
gastricus for the arteries, are described by Schott and Valentin, and, 
according to the latter observer, they extend three or four inches 
from the umbilicus, as is revealed by the microscope." Virchow, 
however, does not admit these views, because he has never suc- 
ceeded in detecting nerves in the umbilical cord at any period of ita 
development. 

♦ Edinburgh Jour, of Med. Science, May, 1851, p. 494. 
f Lebrbuch der Geburtshilfe, p. 104. 



LECTURE XVIII. 

KutriUon, a fundamental law of lifo— Objects of Nutrition j Growth fend IVtelo^ 
iijfcut — DevcJopracnt phyaiolopricajly considered — Nutrition of Embryo; vurlom 
Opinions cortotminj^ — Yolk Natrition — NiUrition tlirougti Villous Tufta — liquor 
Amnii; has it nutrient properties? — Dcx»s it enter the System of the Fu*Iijb bjr 
Cutntieoufl Absorjition or Dep:lmition? — ^Tbo PIftcenta and FtBtol Circulttlion— 
Adult UrevUaiion ; how it difleni from ihut of the Fcetus — How la the Iiiipum 
Blood, returned l>y the UmbihL'al Arteries, decarbonized in tlie Pliicftitfi? — Endoe* 
moso Action— Alburoeu cannot pa«i by Kndoflmoais; Opinion of Midhe — Aihu- 
TTiiiiose — InJiuenw of Pjiretit upon Prtng-cny — Transmiasion of Hereditary Diftc^aso— 
CliMU^ in liie CirculMtian Jia »oon a^ Hesplrution \r efitabltshed — ^Puer Cffruk'Ua-- 
Does the Fcetus lireiHlje in Utero?— Intra-uterinc Ilegpirtttion not E^tieniial to 
Development or Life of Kci5tu«» 

GifixiXEifJEK — Nutrition, whether iii the vegetable or animal kiujif- 
doni, is one of the nb^oltile lunl t\indarnental necessities of lif*^ ; to 
pursue the topic of ilevolopineut, throiijrh the |)roeej*s of nutrition, 
in the varions eonditiorjs and phases of aniinsitcd nature, would 
provo, if not foreign to the finqiose of these lectures, a mogt 
interesting ini|uiry. Such a diKeussion, however, would divert us 
from onr present ohjrrt, nod we j^lmil speak, therefore, siuTply of 
the arrmi*reruents instilnit.M] liy nature lor ihv notirislnnent of the 
hitman cmhryo, from the earliest moments of fecundation until the 
final aceomplishment of intra-ulenne existence. 

77<e Objects of NntritioN, — Xntrition has no siucrle purpose; 
you are not to ^suppose that it i< for the promotion of mere 
growth. If this were so, the re^inlt would be nimply an aggregation 
of the priinordiiil elements, without form or symmetry — the archi* 
teetnre af tho sy&tem wouhl bo defective — thiit beautiful and perfect 
meehanism, composed, as it is, of multiplied li.HSues and organs, 
would fail to exi^t^ and in lieu of all lliis there would be substituted 
a SKMt of anomalous tn;u4s, without order or arrangement. You see, 
therelbre, that, besides growth, nutiition, in order that the great 
object of nature may be carried out, roust subserve another most 
important purpo.se, viz. development. Development, in a physio- 
logical sense, may Ix? said to be tlie proper adjustment or distribit* 
tion of growth matter for the formation of the varioit^ tissues and 
organs of the economy ; so that, when growth and de\'tt)opment 
have completed the structure of the various jiarts of the humaQ 
system, it may then be said that nutrition has efficiently performed 
a portion of it-s work. It, however, has something more to ^o* 



TUE PRINCIPLED AN'r) PRACTICE OF OBSTETRICS, 



255 



Tlie human system, like all living things, is constantly nnfJergo'mg 
change — eveiy hour thai we live there is waste of sirueturt^^ — thb 
waate, if not supplied by new matter — whieh can only be done 
through nutrition^ will lead to Oisintegnition and decay. In a 
word, it may be affirmed, that the ohjert of nutrition is ihree-fokl: 
1. Growth; 2. Dcvelojnnent ; 3. liepnir of waste. 

Beginning with the si in pie cell, the original nucleus, if I may so 
term it>, of the embi*}'0, we perceive, through the Buceessive sUiges 
of growth and development, the transmutation of that comf>ara- 
tively inmguiticant cell into a type of the most perfect organiswUion, 
as is disclosed in the mechanism of man I 

The subject of embryonic nutrition has called forth many con- 
flicting opinions; and even in our own day, with all the lights 
which science lias furnished, tijere still exists more or less dis- 
crepancy among observers. There is one fact, however, not only 
full of Interest, but well worthy of observation, and it is this — that, 
throughout the whole life of mnu, there is no period in which 
nutrition results in such rapid growth and development as during 
iutra^uterinc existence; and this is still more marked in the first 
half of fcBtal life. But when nature is unchecked in her operations, 
this rapid development interferes in no way with the perfection of 
the work in which she is engaged. In the brief period of nine 
mouths, the small cell, through successive increase and develop- 
ment, is converted into the full-grown foetus. What an extraordi- 
nary achievement, and bow demonstrative of t!ie power of ILiui, to 
whose infinite wisdom all things earthly are due I 

Jfodee of ^MtrUion. — In order to present the suliject of fcetal 
nutrition in the simplest possible form, and to convey to you what 
I believe to bo the accepted upiuions, at the present day, on thia 
stubjecti I shall briefly eonsi<ier the ovum in three different aspects ; 
I, From the moment of fecundation until its arrival within the 
uterus ; 2, From its entrance into the uterus, until the Ibrniation 
of the placenta j 3. From this latter period, until the completion of 
the ordinary term of utero-gestation. These, then, are three dis- 
tinct periods of development, each one requiring a supply of 
elements necessary for the nourishment and growth of the new 
being. 

From tlic period that the fecundated ovule becomes detached 
from the ovarian vesicle, until its entrance into the uterine cavity, 
it may be said to he dependent upon what is known as yolk nour- 
itdiment. But this particular species of nourishment soon becomes 
exhausted in the case of the human embryo, so that when the latter 
is lodged within the cavity of the uterus, a fresh source is found 
necessary, which is promptly provided, through the absorption of 
juices from the deciduji by uieans of the villous tufts on the exte- 
rior of the chorion, to which allusion has already been made, TluB 



266 



THE PRINCIPLES AND PHAmCE OF OBSTETRICS. 



tufl nutrition is in more or less aolive exerdso nniil tlie sfcon^l 
monlfi, when h new arrangement is made tliraii^h ibe vai^cular 
connexions, which ftubsist between the embryo and uterus, na a 
connei^nence of the fonnation of the placenta and umbilical cord, 

Doe^ the Liquor Amnii contain A^titrient Properties f — A very 
anci< ril rlactrine touchin|3^ the nutrition of the ffEtun, and main- 
tained with much xeal, referred the source of nuurishiaent to tbe 
liquor amnii; the advocates of this opinion were divided into two 
fleets, as to the mode in which tbe amniotic fluid entered tbe system 
of tbe ffrlui*, with tbe view of affording it the necessary nounub* 
ment. One declaring th:it it was through cutaneous absorption, 
tbe other through the a^^t of deglutittun. It ia not imprubable that 
tbe liquor amnii does in reality contribute a share, dunng tbe 
earher jj<*rio<k of etnbryonic existence, to its nouriBhment ; fur it is 
well a^ccrtaified that it contains nutritious elements, such as albu* 
men, salts, etc, Nor is it beyond possibility that some portion of 
the amniotic fluid may be swallowed by the fcetus. On the other 
hand, there arc welkiuthenticated instances in which this fluid has 
been iceognised ifi the stomach and intestines, in cases of acepha- 
lous f'liilJren; anil also where there existed, Irom malforniaiion, no 
comnumieatiou between the trsopbagus and stomach. These latter 
facts, it has been alleged, strengthen the hypotlicsis of cuLmeoUd 
abtiorptiori. Hut it i^ quite evident that tbe cutaneous absorption 
of the liquor amnii cannot be sn stained by any such testimony. In 
tbe tir.st place, even in acephuhms children, the amniotic fluid may 
reacii the stomach through tbe ccsopliagu^} ; and, secondly, in caaca 
in which there is an occlusion of this tube, the liquid found in the 
Btomacli cannot he the amniotic, for the important reason that, if it 
be ahsorW*! by the skin, it will cotmningle with the blood, and not 
be taken to the stonmclh 

Whatever influence tnay be exercised by the liquor amnii in 
aflfoi ding nourish nieut to the embryo, it must be admitted that this 
influence is toutined to the earlier ]*enods of embryonic life; far^ as 
Boon as the placenta is formed, all the wants of the foDtuis as we 
shall see, are abundantly provided for through this vascular oon- 
iiexion, 

Kntrition hy tfui Placenta. — The placenta, as yon know, is cbm- 
posed of a maternal and fcetal portion, each of these surfaces having 
its own particular order of vessels, through which a distinct circu- 
lation is c^arricd on. Tlie utero*placental vessels are engaged in the 
distribution of blood on the former, while the circulation on tbe 
latter is conducted by the vessels of the cord, viu., the two umbilical 
arteries and one umbilical vein* The blood is brought from tbe 
By»t(-in of the parent, and circulated through the maternal or 
uterine surface of the placenta liy the utero-|dacental arteries — ^it ia 
eoQveyed bacJc to the system of the mother by the uteroqdacental 



THE FBINCIPLES AND PRA^CTICE OF OBSTETRICS. 257 

veiiis. Prof. Goodsir has shown, as already stated, that the uterine 
arteries proceed from the walls of the uterus through the hyper- 
trophied decidna ; and, during their progress through this layer of 
membrane, they take a sort of tortuous or serpentine direction, and 
hence they have been denominated the " curling arteries " of the 
uterus. These arteries convey the blood from the system of the 
mother into the cavernous structure of the placenta, and the blood 
is Again returned to the general maternal circulation through the 
large veins, which have received the name of sinuses. 

Thus, you perceive, nature has abundantly provided the maternal 
8iir&oe of the placenta with blood from the system of the parent ; 
but, as yet, you do not understand, in the absence of all continuity 
of canal between the two orders of vessels on the foetal and uterine 
portions of the after-birth, in what way the foetus is benefited by 
this suf^ly of blood, or, in other words, how it finds passage to the 
fetal system for the purpose of providing it with necessary nourish- 
ment. This, however, it will be our purpose to elucidate before we 
complete the present lecture. 

Adult and Ifletal Circulation, — Allow me now to call your 
attention to the foetal circulation. This circulation is marked by 
certain characteristic differences, which are' not found in the case 
of the child or adult ; and these differences are owing to the im- 
portant fact, that, in the foetus, existence is a dependent one — it has 
no power of elaborating the blood essential for its maintenance — 
tills is done by its parent. Oi\the contrary, in the healthy, well- 
oi|pinized child, and in the adult, where life is independent, and the 
individual elaborates its own blood, there is a peculiar arrangement 
in the mechanism of the vascular and pulmonary systems adapted 
to this condition of life. 

You will, perhaps, have a more accurate idea of what I mean by 
a brief contrast between the circulatory apparatus as it obtains in 
the adult and foetus. In both, there is a great central organ — the 
heart ; and in both, also, there are two orders of vessels, viz. arte- 
ries and veins. In the adult heart there are four cavities, two on 
the right side, and two on the left. On the right side there are an 
aaricle and ventricle, which communicate with each other, and 
which are intended for the reception of venous blood ; and on the 
left side there are also an auricle and ventricle, communicating with 
each other, and containing arterial blood. These four cavities com- 
municate with each other only through the auriculo-ventricular 
openings. 

Now, then, let us turn, for the instant, to the arrangement in the 
foetal heart. Here, as in the adult, there are four cavities : two on 
the right and two on the left, commnnicating, as in the case of the 
adult, by means of the auriculo-ventricular openings. But, in 
addition, in the foetal heart, the right auricle communicates with 

17 



258 



THE PRINCTPLES AND PRACTICE OP OBSTETRICS. 



ihe left auricle, tbroiigb fi small opening known ns the fornnti 
ovale. The only diiference^ then, in the arrangement of the hea 
proper, as it presents itself in the adult and fanua is^ thfit» bc*id 
the annculo-ventrieular openings, there is in the fceiu** the forntrn^ 
ovale, which is the point of communication between the right and 
left auricle. 

In the adult, the following is the route of the circnlation^ — ti 
veins return from the nftpcr and lower extremitie!? the blood whid 
has been distri billed ihronghout the system for the parpouc 
nourishment, but which, in its round of circulation, has beeonic 
less charged with oxygen, and contains more carbonic acid, nni 
therefore, is in need of renovation. The vein^s, I «ay, return i\ 
blood from the upper extremities to the descending vena cava, an 
from the lower to the a^^^cending vena cava — these two vessels, tt 
descending and ascending cava% empty their contents into the ri^ 
auricle of the heart; thence it pas<*es, through the aiinculo-ve 
tricular opening, into the right ventricle ; from the right veniricfc 
It is conveyed by the pnlmcmsiry artery, which bifurcates into 
I right and U.'ft branch, into the Ittngs; and here, in consequence 
the absorption of oxygen and the exhalation of carbonic acid, tl 
Tenons blood is converted into arterial, which is conveyed throujj 
the jiulmonary veins to the lefl ventricle ; Aom the latter, it passed 
into the aorta, through the ramifications of which it is conductc 
to every portion of the economy, imparting sustenance to 
tissue and organ.* As soon as it has completed its circuit, it i 
Tet]uireH renovation, and for tViis putr[»ose is returned to the lungs — 
and so tbe work of elaboration continues, in more or less perft*ctic 
from the first moment of independent existence until the final clc 
of life. This, gentlemen, is briefly the circulation in the adult < 
'the child, whose life is independent of its mother. 

Let us now follow the course of the blood in the system of 1 
fcBtus. Besides the |>eculiaritius already pointed out in the circnl 
lory apparatus of the latter, there is the ductus arteriosus, whti 
appeal's to be nothing more than an extension of the pulmonn 
artery, and which conveys alt the blood, except the small quautii 
going to the lungs, from the right ventricle to the arch of fl 
Itortii. Then, there are th« umbilical vein, and two umbilic 
arteries. 

The blood is conveyed from the placenta to the fcetna in the 
lowing TTTanncr : llie iirteri:d or elaborated blood is carrieil by tl 
umbilical vein, w^hii'h enters I he system of the f<rtus at the umbi] 

* Re«))ji ration ccmsistji rt&aonliitllf in the «b!Kjrptioa of oxygcQ Rod ilie oxhftlAti 
of cnrbouic add; but iim bttor is not fomje<l, n» wns onw supposed, hy the c«< 
biruUlcin ofcjirlion and oxv^i?n in tlif^ lungs; n small nmoutit ofcurbontc Acid is ] 
^duced ill tlitf luuiffl hy Ihe decompmitioti of cnrbotiHlef, hut its chief 
Ukta place hi tiie Uaaues — the mujicltsai nenre-centres, etc 



rnS PRINCIPLES AND PRACTICE OF OBSTETRICS. 



259 



cuflL When this vein penetrates the umbilical opening, its eourse 
is at first from before backward, then from below upward^ and 
from left to right. As soon as it reaches the inferior portion of the 
liver, it gives off a branch which distributes blood to the right lobe 
of this vi?<cus ; this same blood is afterwards eoiiveyed through the 
hepatic vein, and deposited in the ascending vena cava. In order 
that you may not be led into error, and with the view of avoiding 
all confusion, I beg you to remember that the instant the umbilical 
vein sends off the branch to the Uver, it takes the name of ductus 
venofrtis. This latter vessel, then, h nothing more than the original 
umbilical vein, the name being changed as soon as it has parted 

irith the branch, whose duty it is to carry blood to the right lobe 
the liver. The ductus venosus throws its contents into the 
ascending vena cava ; and you must bear in mind that the blood 
thus depoi«ited in the ascending cava comes directly from the pla- 
cental, and is therefore pure, fitted to the nutrition of the tVetus, I 
have just mentioned that the hepatic vein also deposits its contents 
in the ascending cava* Hence, then, there are three columns of 
blood all commingling with each other: L The blood, which is 
derived through the ductus vcnosos directly from the [)lacenta, 
and which is pure ; 2. The' blood, which has circulated through the 
iivi-r, and which is returned to the cava by tlie he[)atic vein ; 3, The 
blood which is brought from the lower extremities, and ultimately 
deposited in the ascending cava; the latter column of blood is of 

jnrse le-^s pure than the other two, for the reason that it baa 

Jready been distributed to the lower extremities. 

Well, this volume of blood, derived as you have jtist seen from 
three different sources, is conveyed by the ascending vena cava 
into the right auricle of the heart. But the U[>|jer portion of the 
cava>, as it enters the auricle, is, through the arrangement of the 
Eustachian valve, rendered idmost coniinuous with the foramen 
ovale, so that the blood it conveys into the right auricle, instead 
of mingling with that brought by the descending cava into the 
same chamber of the heart, passes almost entirely through the 
foramen ovale into the lct\ auricle. Thence, through the auriculo- 
veniri* ular opening, it is conveyed to the left ventricle, and from 
this cavity it passes, throutj^h the aorta and its branches, to the head 

Qd upper extremiiies. The branches to which I allude, originate 
*lit the arch of the aorta, and are the brachiocephalic trunk, or arteria 
innorninata, the left primitive carotid, and left subclavian* 

The blood, af\er being distributed through these channels to the 
tip[»er parts of the body, suffers a diminution in its nutritive pro- 
peitics, and, therefore, needs elaboration ; hence, it is returned by 
the jugular and axilhiry veins to the Ruhclavians, which, together 
with the axygos vein, empty their contents into the descending 
vena cava — this latter conveys it into the right auricle, from whick| 



260 



TEE PRINCIPLES AND PRACTICE OF OBSTETRICS, 



thrc»iig}i tbe auriculD-ventricular opening, it passes into the 
ventiiolc, and from tbla latt«ir cavity it enters the pulinc 
artery. The pulmonary artery conveys to tbe lung», during fcDt 
Ute» but a very sraull tjuantity of blood, only sufficient to Buppl]( 
them with nutnmeut, far tbe reason that they have no power ot^ 
elaborating tbis fluid, as ia the case in the lunga of the adolt. Some 
[jrovisiou, tborefore, is needed by which the surplus blood from lH«j 
rigbt ventricle may be disposed of; for thid purpose there is thi 
duel us arteriosus, whose office it is to convey all tbe blood fix»i] 
the right ventricle, not passing to tlie lungs, to the arch of thi 
aorta. This latter blood is then transmitted through the dei^cend 
ing aorta, and, with tbe except ion of the portion of it which 
di>triliuted by the external iliacs and their branches to the low< 
extremities, is conveyed thronpb the two umbilical arteries to tt 
placenta, for the purpose of undergoing fresh renovation- The tw<! 
umbilical vcBsel^, you will not forget, are formed by the inter 
iliac or liypogastric arteries. 

Before calling your attentiou to the special arrangement in tl 
plaeeuta for the elaboration of the blood, returned to it by ih 
umbilical arteries, I wis^h, for the moment, to allude briefly to on 
or twu |uiints cunnected with tbe route of the circulation in ill 
ffftiis. You cannot have liiiled to notice, in the distribution 
blood tlirough the system of the latter, t!ie important fact thati 
to a certain extent, tbe head and upper extremities are suppUe 
with purer blood than the lower portions of the body. Tlie hea 
and superior extremitii^s do in reality receive blood almost as put 
as tlmt whiub comes directly from tbe placenta, an<l for the reasofl 
that their development is required to be in advance of that of ifi 
lower portions of tbe system. For example, a part of the bic 
which is derived directly from tlic placenta passes through 111 
ductus veuosus into the ascending cava, thence into the Hgh 
auricle, and through the foramen ovale into the left auricle — froil 
this hiller chamber it is sent to tbe letl ventricle ; from the IcJ 
ventricle it is conveyed throu!T:h the arterial brancbea given off at 
Jie arch of the iiorta to the bead and superior extremities. But 
|?ou ale to bear in mind that, as the blood passes from the lefi 
frentricle into the aorta, a small portion of it must, of necwwity, 
levcend and thus commingle with blood emptied into this cbantirl 
by I be ductus arteriosus, and which you will recollect is brought 
|tljere from the right ventricle^ after it has been returned from th« 
apl>er portions of the body, Tbe blood thus conveyed from tbe 
ri^ht ventricle, through the ductus arteriosus, to the arch of lli« 
aoitji, has, through its circuit, lost more or less of its nutneni 
elements; but yet, you perceive, it receives a small supply of pure 
blood from the left ventricle in the descending aorta — and therefore, 
although it is true that tbe blood which circulates through tlie bend 



THE PRIKCIPLES AND PRACTICE OF OBSTETRICS. 



261 



md upper extremities is purer, because a portion of it comes 
directly from the placenta, yet it must be recollected that the lower 
part of the body is not exchi»ively dGi>endeiit for its supply upon 
the blood from the right ventricle — and whicli has already partly 
exhausted itself in its circulation to the head, etc. — but it also 
JHCeives a colutnu of pure blood from the letl ventricle M it passes 
to the aorta. 

JSlaborafion of the Blood in the PlacenUu — Next let us examine 
how it is that the impure blood, which is returned from the system 
of the fcBtus to the placenta through the umbilical arteries^ receives 
a fre^sh supply of nutritious matter; or, in other words, bow It is 
that its decarbonization la accomplished. One of the theories 
brought forth to elueidate this question was based on the supposi- 
tion, that the blood-vessels on the fiPtul and maternal «urfaceH of the 
placenta were continuous with each other ; and, on tiiis assumption, 
it was maintained that the impure blood was conveyed directly 
iVom the faUus to the system of the mother — thence to the mater- 
nal lungs, from which, after havio*^ lost its wirhonic acid and 
receiving oxygen, it was rftnrned to the j^laccnta, whence, through 
the umbilical vein, it again made its circuit in the system of the 
fcfittis. The deductions from this theory are utterly fallacious, for 
the assumption on whicli it is predicated, as I have already pointed 
out, is without foundjitioti. The vessels of the fcelal and maLcrnal 
iuriaces of the jilacenta do not enmmunicate with each other — they 
are distinct and independL-nt, and t^o are lh<.'ir circtUations. How, 
then, you may very legitimately inquire, if the blood from the fcBlus 
be not returned to the circuhition of the mother, does it become 
purilied? The answer to this question is quite cfisy, and it may be 
regarded as one among the accepted truths of physiology. 

During intra-uterine existence, the aeration or decarbonization of 
the blood is accomplished altogether in the placenta; and this 
organ may, in strict physiological meaning, be denominated the 
hings of the f(BtU8 • Tlie following is tlie process of elaboration. 
The impure blood, as you are aware, is brought from the system of 
llie fa»tus to the placenta, through the umbilical arteries; these 
arteries ramify, atid communicate by continuity of canal with the 
radicules of the umbilical vein on the ftetnl surface of the placenta; 
although there is no direct connnunication between the vessels 
reepectively, on the two placental surtacea, yet there is a cod* 
tiguity; and, in fact, these vessels may be said to be, as it were, in 
juxtajK)8ition, so that the im|uu'e blood in the umbilical arteries 
becomes liberated of its carbonic acid, and is supplied with oxygen 
from the blood of the mother by an cndosraotic action — that Is, the 

• As rcpurda llio fiinctiona of ihe plncotita, it must be remembered Ihnt tliia htnif 
k it Uie same time, the represcntJitiv© of the iligeBiive and rcsplmtoiy oripins of tbt 
tdiilt 



262 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 

oxygen percolating the walls of the canals, displaces the carbon 
acid which passes into the maternal system through the same ki| 
of endoBmotic process ; thus, you ptfrcelve, one of the first renii 
produced upon the blood of the foetus is to afford an escape of i 
deleterious element, the carbon, which, in the form of carbonic i 
passes into the vessels of the mother, which it can do with iinpuoil 
to her health. 

The parent, however, h not content with recelvini; iiito her o^ 
Bystem this element, no longer fitted to sojourn in that of 
offspring; she does more — she transmits, through the sauie prc^ce 
of percolation, from her own blood, an element necessary for t}^ 
continued sustenance of the fetus* What is this element ? Son 
aay that it is albumen, which is known to be essentia! to fcDtal 
nutrition. But Mialhe has shown that pure albumen cannot pa 
through membranes, and he has developed the interesting fact, ih 
it is a substance, called alhufninose^ whieh has the power of 
eclating membranous tissues ; it is this substance which passes frc 
the blood of the mother to the fcettis, and from which the lat 
derives its nourishment, llobin and Verdeil have demonstra 
that wlint was su|v|msed by Ciuilli)t, Le Bbinc, and others, to be 
casein in the blood of preifnant women and nurses, is essentia 
albiimiuose, which, after all, is strikingly similar to casein an 
kiesteine. 

As soon as these chanjres have been effected in the blood brougli 
to the placenta by the umbilical arteries, the elaborated fluid 
immediately taken up by the radiculcs of the umbilical vein, an 
again cnnveyed to the system of the fa?tus, and there distributed ! 
the manner already indicated, In this simple but efficient way hi 
nature provided, by the eoustant escape of deleterious, and tlj 
constant adtlition of nutritimis matter, for the growth and develop 
ment of the fcBtus, In addition to the otiice which tlie plaoen^ 
performs toward the ftrtus, of giving albuminose in exchange fo 
carbonic acid, it is supposed, by some observers — and the hypothesis 
is not without a degree of probability — that it also discharge^ to j 
eei'tain extent, the duty of im excreting organ, by removiuj 
through the raaternal blood, excrementitious material, which, 
permitted to remain in the system of the feet us, would pro% 
destructive to its existence.* With this supposition, it is easy 
comprehend how the system of the mother may become conta 
Dated by disease derived from her husband; and how, also, th| 



• Eeniiird Iim rocentlj attempted to show, thot there exiBts, in ibe pliofQtft 
Uio mumrninirout ctAfli^ a peculiar funetifjiu whidi beretoHire b^w hevn QfiknowD, i 
which iipjK'urs to supply tht; ^lycogyjaic ACtioii ol'the liircf during tbe MHlor ] 
of embryonic exiAU^noo. Indeed, ho and Ch. Eouget havo demoDfltnieed that % y 
cv$Cf?nic riuiU^r cxbts not only in the plncenta and nmtilon. but also in all tb« 
ciflU l(» \\w various tiaaoea of the embryo, especially in Iho epiiheliul oella. 



THB PRINCIPLES AND PRACTICE OF OBSTETRICS. 263 

disease may be transmitted to offspring begotten by a different 
&ther.* 

Transmission of Disease. — ^The transmission of disease, from 
parent to offspring, presents a most interesting subject of inquiry 
to the practitioner of medicine. That this hereditary transmission 
is more or less constantly taking place, is a fact, unhappily, too well 
established, and it constitutes a veritable blight upon the race. 
Scrofula, syphilis, phthisis, carcinoma, etc., all of which I hold to be 
constitutional taints, may be transmitted either by the mother or 
father ; and this will, of course, depend upon whether the former 
or latter be affected with the malady thus transmitted. For exam- 
ple, a scrofulous mother will pass the disease to her child, through 
the ovule which she furnishes — that very ovule being a part of her 
system — containing either the elements of health or disease, just 
precisely as the case may be. Again : all the soluble elements in 
the blood of the mother — salts, fibrin, etc. — pass freely into the 
blood of the foetus. Suppose, again, the mother be free from all 
taints of scrofula, syphilis, etc., yet, under these circumstances, 
either of these affections may be propagated by the father, should 
he have the misfortune to labor under the affliction of either of 
them, or of any other constitutional malady capable of transmission ; 
and it is propagated through the spermatozoa, which he emits 
during sexual intercourse, and which, as you know, are the true 
essential fecundating elements of the spermatic fluid, f 

From what has been said of the placental circulation, it must bo 
evident to you that when the blood of the pregnant female is im- 

■ Attention has lately been directed to a very curious class of phenomena, which 
riiow, that whore tho mother has previously borno offspring, the influence of the 
iather may be impressed on her progeny afterward begotten by a different parent;. 
«s in the well-known case of the transmission of quagga marks to a succession of 
colts, both of whose parents were of the species horse, tlie mare having been once- 
impregnated by a quaggu male ; and in the not unfrequent occurrence of a similar 
'phenomenon in the human sp'^cics, as wiien a widow who marries a second time, 
^bears children strongly resembling ijcr first husband. Some of these cases appear 
Teferable to the strong mental impression left Vjy the first male parent upon the 
ifemale: but there are others, which seem to render it more likely, that the blood of 
the female has imbibed from liiat of the foetus, through the placental circulation^ 
mome of the attributes which the latter has derived from its male parent; and that 
the female may communicate these, with those proper to herself, to the subsequent 
offspring of a different male parentage. This idea is borno out by a great nuniber 
of important facts; and it serves to explain the circumstance well known to practi. 
tioners. that secondary syphilis will often appear in a female during gestation or 
4ifter parturition, who has never had primary symptoms, while the father of the child 
flhows no recent syphilitic disorder. For if he has communicated a syphilitic taint 
to the fojtus, the mother may become inoculated with it through her offspring, in the 
ananner just described. [Carpenter's Human Physiology, p 781.] 

f The reader will find some interesting facts touching the transmission of disease 
to the fcjetua in an able Report on the Influence of Marriage and Consanguinity 
apon Offspring, by S. M. Bemiss, M.D., 1858. 



THE I'laN'CirLKS AND PHACTICE OF OIJ 

pure, cither from the aooitmulntion in it of bile, or any other 
poisonouH matter, the fcBtu.s, which is nourishetl by thm blood, 
must necessarily be exposed to more or less danger. There is 
iiitother interesting feature connected with the oondhion of the 
blood during gestation, and it is this: It is not uncomnmn to flud 
women, attacked with eclampsia or puerperal ctinvul- iitg 

forth dead children j sometimes when the child is not d'. ^ :, it 
will itself have convukions immediately After birth* I hare sven 
several remarkable cases of this kind. With the doctrine thtl 
convulsions are oftentimes Init t!ie resnlts of irritation npon tho 
spinal cord, cither through poisonoiis blood or some other iudueoce, 
the explanation of the t^l^ismi^sion of the convulsive movement 
to the fa?tU8 is not difficult. The poisonous elements ojutained in 
the mother's blood are communicated to the embryo ihmuifh the 
act of percolation, of which I have spoken j and thci^e elemeoia 
will produce, coBteris pdribntt^ morbid cifecti* in the latter, prtMSsdy 
similar to those observed in the system of the mother. 

Chmif/e in the Ctreukitlon after Birth, — As soon aa the chttd 
if born, and after its very tirst inspiration, the whole current 
of the circulation, as it previously existed, bei^omes suddenly 
changed. The bloorl no longer passes to the plaoenta; on the 
contrary, it is tran«<mitied ir» lar^i^e quantities froui the right ventri- 
cle to the lungs, and these organs are theu culled upon to perform 
active and uninterrupted duty, viz. the decnrbonizati*>n of tho 
venous blood ; in this way, it is converted into arterial blood, which, 
through the pulmonary veins, ia coriveyed to the lefl ohaniber!* of 
the htart, and distributed to the entire system, jw has al really been 
described. Tije consequence of this change lu the route* of tho 
blood is the re^luction of the ductus vcnosus and ductus arteriosus to 
mere ligamentcui^ matter, while the foramen ovale becomes doaieil, 
mid ceases to afturd an opening for tlio tran'^mis^ion of blood from 
the right to the left auricles, as was the case during fojfal existence* 

liut, occiisionally, it will uocur that, tliruugh imperfect devolo|>- 
ment or other circumstances, the foramen ovale does iicit bei*ome 
obliterated, and tho consequence will be more or let*8 imperffctkm 
in the circulatory function, giving rise, among other phonomensi, 
to a disease, known as pun^r ctvrulens^ or blue dlsea^ic, .*•© c:dleil 
from the circumstance of the defective passage of the blood, Suoh 
n result, however, from imperfect closure of tfio foraman ovale, im 
not uiiivors;il, for it has been shown by Dr J. W. Ogle, and othern, 
that in marty uduhs the foramen still exists, without oci^yir.niiig 
any trouble, 

Do€s the Fisttia Breathe and Cry in Utero? — ^It is ipittr - 1 uuin 
that the chihi cannot introduce ;ur into its (ungs if there be no :iir 
to be introduced ; nor can it cry without the respiratory iuave> 
meuL Under ordinary eircmnstonces, the fcEtus is deprived of tho 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 265 

access of the atmosphere during its sojourn in uterp, and, conse- 
quently, breathing and crying are out of the question. But there are 
some exceptional cases recorded on undoubted authority in which 
these phenomena have really been observed before birth, and they 
are explained in this way — the membranes having been torn, and 
the mouth of the child in communication with air, either in the 
vagina or at the neck of the womb, respiration and crying have 
ensued. It was the opinion of Geoffrey St. Hilaire that the fcetua 
absorbs air from the entire surface of its body, but a fundamental 
prerequisite for this theory is the presence of atmospheric air in 
Qtero. 



LECTURE XIX. 

Abortion — Its flrequency — Loss occasioned by it to the Human Familj — Dr. White- 
head's Statistics — The Various Divisions of Abortion — Viability of the Fcetus^- 
The Case of Fortunio Liccti — At what Period of Gestation is a Female most 
likely to Abort? — The Opinion of Madame La Chapcllo — Not sustained by 
general Facts — Abortion more frequent in the Primipara — Why ? — Reflex Action 
— Whytt— Reid — Prochaska — Marshall Hall — Concentric and Eccentric Nervous 
Influence — What does it mean ? — Eccentric Causes of Abortion— -Hemorrhoidal 
Strangury, Tenesmus, Sea-bathing, etc. — How do they Produce Abortion? — Irrita- 
tion of the Mnmmie and Premature Action of the Uterus — Cause and EflTect — 
How explained — Lactation, its iuliuenco on early Contractions of the Uterus- 
Centric Causes of Abortion — Anwniia and Abortion — Kx sanguification and Con- 
vukions— Experiments of Sir Cliaries Bell and Marshall Hall — ExperimenUt and 
Deducti(ms of Dr. E. Brown-Stjquard — Mental Kmotion?, Syphilitic Taint, Death 
of the Fwtus, all Causes of Abortion — Disease of tlie Placenta and Ab<»rtion — 
Aborti<m sometimes the Result of Habit — Plienoinona of Expulsion in AUirtion 
— ^Tho Pain and Hemorriiago of Al)<>rti(m — How distinguished — Treutment^- 
How divided — The Application of (Told — Its Mo<le of Action in Arresting 
Hemorrhage — Tampon and Krgot — When to be Employed — Two-fold Artion of 
Tamp(m. — Extracting Placenta in Abortion — Exhaustion from Hemorrhage — 
How Treated — Laudanum, its Efficacy in Exhaustion. 

Gentlemen — I shall to-day speak of an interesting affection, 
one which shonld claim at your hands special attention, for the 
double reason that it is, in tlie lirst place, fre(|nent ; and, secondly, 
it is apt, under certain circumstances, to involve the female in 
more or less danirer — I mean abortion. There is an additional 
interest stirroundinir this subject, and it will be found in the extr^i- 
ordinary waste of life it occasions throui^h the destruction of foetal 
existence. There can be no doubt that the h>ss to the human 
family from premature cxj)ulsion of the fecundated ovule is very 
great, and more ])articularly, when we take into account the 
numerous instances in which tlie loss caimot be positively Jiscor- 
tained ; such, for exam])le, as in very early ])regnancy, when the 
discharge of blood attcndini; the miscarriai^e is otlentimcs judged 
to be nothing more than a late return of the menstrual flow. 

Frt'tpu'W'tj of Abortion. — Dr. \Vhitehea<l,* in his work, gives, 
as the result of his observation in a certain number of cases, the 
following statistics : ' 

In 2000 married women, in a state of pregnancy, admitted into 

♦ Dr. Whitehead on Abortion and Sterility. 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 267 

the Manchester Lying-in Hospital, he found their average age to 
be a fraction below 30 years. The sura of their pregnancies 
already terminated, was 8681, or 4.38 for each, of which rather 
less than one in seven had terminated abortively. But, as abortion 
occurs somewhat more frequently during the latter than in the 
first half of the child-bearing period, the real average will, conse- 
quently, be rather more than one in a dozen. Of these 2000 
women, 1253 had not at the time of the inquiry suffered abortion. 
The average age of these was 28.62 years. The number of their 
pregnancies 3906, or 3.11 for each person. The remaining 747 had 
already aborted once, at least ; some oftener. Their average age 
was 32.08 years. The sum of their pregnancies was 4775 or 6.37; 
that of their abortions, 1222, or 1.63 for each person. 

From these statistics, it would appear that more than 37 out of 
100 mothers abort before they attain the age of 30 years ; but as 
30 years may be considered comparatively young for the child- 
bearing woman, it is estimated that abortion occurs in nearly 90 
per cent, of those females, who continue in matrimony imtil the 
final cessation of the catamenia. This is sufficient, gentlemen, to 
show you that abortion is by no means of rare occurrence ; and 
the very circumstance of its frequency should impress upon you 
the importance, as well as the necessity, of thoroughly compre- 
hending its nature and management.* 

Divisiofis of Abortion. — You will find in the books various 
divisions of this subject; for example, one will tell you if the ovum 
be expelled from the uterus, prior to the third month, it is a mis- 
carriage; if between the third, and end of the sixth month, it is an 
aboition ; and between the seventh, and before the expiration of 
the ninth month, it is premature labor. Again : a recent author, 
Guillemot, divides the subject as follows: 1. Before the 20th day, 
he calls it ovular abortion ; 2. If before the third month, embryo- 
nic; 3. From the third to the sixth month, foetal abortion. And 
80 I might pursue the subject, arraying before you the multitude 
of divisions and subdivisions, not forgetting one of the most 
ancient of all, viz. if the ovule be expelled before the tenth day, 
it was denominated simply an eflluxion. But we shall leave these 
refined minutiae for those who like them, and give you what we 
think to be more in accordance with practical observation. 

AVe shall, therefore, consider the expulsion of the fecundated 
ovule from the uterus at any period from conception before the 
termination of the sixth month — an abortion, and from the seventh 
month, prior to the expiration of the ninth month, premature 
labor. This division is* founded upon what I conceive to be a 
rational basis. 

• Tn 41,699 deliveries, there were 530 premature births, or 1 in 78f (Churchill, 4th 
London Edition, p. 167.) 



THE PBINCIFLE3 AKD PBACTICE OF OBSTETRICS, 



It 19 now geoerally admitted that the fcptua is incapable of 
indepiindent existence — in the event of its being t1irf>wn Ironi the 
utenw — previous to the terniinjitioii of the sixth month ; so that 
the law of France on this subject, and I niaintain thsit it is a just 
law — although it will, undoubtedly, oftentimes afford a mantle lo 
conceal guilt — Is, that a child born 180 d:iys aller wedloek/filiall bo 
considered not ortly viable, but legiljraate, and entitled to alt iti 
legal and social rights. At the same time, it must be reniarked, 
that, under peculiar circumstances of constitutional development. It 
ifl possible for a child bom previous to this period to live, but tbe 
oharice is so slight, that tbe law — wisely, I think — makes no recog- 
nition of it, I shall not enumerate the instances recorded by 
authors of extraonlinary precocious viability — they do not carry 
with them that weight of testimony nec^^ssary to substantiate 
them as accepted truths. One of the most remarkable, however, 
may be briefly alluded to ; it is the case of Fortonia Liceti, men- 
tiouc'l by Van Swieten. He was brought into the world befcire 
the hiKih month in cun?^eqiience of a fri^lit his mother cxpericticed 
at sea ; when born, he wiis the size of a hand, and he was put into 
an oven by Ins father, for the purpose, no doubt, of making him 
rise, Fortunio, we are told, attained his seventy-ninth jear.* 

77ie period of Pregnancy at which Ahoriion is most /requfnt. 
—There seems to bo no little difference of opinion among writers 
as to tlic particular period of gestation at which the female is mojit 
likely to abort. A good observer, anil a clever woman, 3(adame 
La Chapelle, annouueeil, us the result of her exj^erience in the 
MateruiitJ of Paris, that abin*tiona were more frequent at the mxlh 
month than at any other time. Now, it must be recollected that 
Jladauii^ La Chapelle exercised a remarkalile influence as a writer. 
Her litati'monts were regtirded with mueh favor, and, therefore, 
it can readily be conceived why it was that the opinion advance<l 
by be I* on thi^ <j nest ion should have been so generally adopted by 
her contemporaries, ami perpetuated by those who have succeeded 
her. It is not improbable that Madame La Chapelle was quite right, 
60 fiir as the experience of the 3Iateniite enabled her to decidts 

•October 10. 1841 I foquoBted two of my pupiK Dn* Arondell nud Uof7v% to 

, altend iluriti^ hot \ahnr Jlra. II ♦ who wua <me of rny clinic patients «nd whom I IaJ 

I jircvioi»s!y ()tu*udi'd in thrtti coiitiuciiii;nU. A Ibwr Loura aflcr the goQtlcuici* 

freiicli^ her bouw, »\w was delivered of h lemate inftuit, which wciphwl two fwiimln 

[nine oiiTicf«; i\w mirfttoe of its boil/ ^:i9 nf a w^rlcl hue : nntl lf««n? wii* i*vrry 

Mndiciition tjf iia binng^ prcmjiluneL It breathe«d, aitd iti a ihort time ii(\«t iU birth 

'^(4 fri'trly, I ordered it to be wrapped in soa eottoii w<^ll biV>ric*tt^l with w^r^ 

«Wfi»t oil It WHS nourishud with llie mother's milk, by hfiving n f*>w drnps al m 

time put into i\s moiiUi. At first it Inbarod under jfrcot difflcnll}' In fwnlloiring ; 

but fffiidually it Buceocded in talcing suffloioiit to nourisli it, and it is now ti vlfeofoys^ 

HcoUhy younj^ wonuin. Tndei»eiidenUy of the evi(Jt»nce nfTordi'd by the pliyvlori 

I mpp«^rtr7moe of thh infunt, 1 aio sntiaflM], fjnom other circumstiinoeft, tliftt the motbli 

Ud not have cumplotcHl hi?r lixth month of pro^ancy. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



269 



tbla point. But that experience is not sufficient to establUli the 
general fact, and for the obvious rcxison that women, in a stnte of 
pregnancy, are not, as a gencnil rule, admitted into the Maternit^ 
in tlie earlier raonths of their gustation ; so that while it niny be 
true the records of that establishment do show^ that the perio<l at 
which women most frequently abort is about the sixth month, yet 
these statiiitics, admitting their entire accuiracy, are very far from 
proving the major pruposilion — that pregnant women are more 
liable to suffer abortion at the sixth month. 

Indeed, all correct observation isj, in my judgment, directly 
adverse to the fact ; and I think the results of practice will very 
conclusively exhibit that, mter is paribus^ abortion is mo,st fret^uent 
during the earlier inonthss huv fnnn the iirst to the thinl ; and 
the reason for this i^ no doubt fannded on t!ie important circum- 
stance that, at this early period, Uie uttathments of the embryo 
to the ntenne surface are comparatively so friable, that they are 
more liable to be broken up, thus ending in tiie premature 
expulsion of the product of concept ion. I also think that the 
priaiip:u'a is more disposed to abortion than the female who has 
already borne several children. In the former, the uterus, for the 
first time becoming the seat of those rapid and extraordinary 
changes consequent n[ton impregnatioa, will be more likely to 
awaken, through reflex or other in Hue nee;*, irritation calculated to 
terminate in abortion ; and this is particularly observed hi two classes 
of patients, presenting two opjiosite conditions of system, viz., 1, 
In the excessively nervous ; 2. In thuse characterized by unusual 
plethora. 

Causes — Abortion sometifnes occasioned by Reflex Movement. — 
The great fact that irritation of the spinal cord may be induced by 
tlie excitor nerves, had midoubtedly been demonstrated by Whvtt, 
Redi, Prochaska, and others; but it must lie conceded that, with- 
out the practical application made by 3Iarshull Hall of this impor- 
tant pliysioh^gical truth, its benefit to science would have been 
extremely restricted. To him, therefore, is due the merit of having 
fiuthfully and pei*8cvcringly insi^ited not only upon itH value, but 
its indispensable necessity for the accuriite diagnosis and treatment 
of disease. Previously to the discovery of reflex movement, it 

IS supposed that all nervous aberrations producing irritation of 
lithe spinal cord, were centric, or in other words, the result of an 
influence applied directly to the cord ; but now that the action of 
the incident excitor nerves is miderstood, we have another division 
of nervous disturbance, viz, eccentric^ in which an irritation is 
produced un the peripheral or terminal extremity of one or more 
nerves; the impression thus made is conveyed by the nervous 
irnuks to the spinal cord and the medulla oblongata by which, and 
without the interference of mind, an impulse is reflected back, 



270 



THE PRINCIPLES AND PHACTICE OF OBSTETRICS. 



through the motor nerves, to certain rauacles, at»d hence a m6V€ 
inent U produced. This is physiolog;ically — r^tx movement, 

I have purposely called your attention, incidentally at th| 
present time, to this subject, in order that you may h,ive a clc 
understanding of the true modus operandi^ through reflex infliienc 
of ceitain causes in the production of abortion. For erample, 
IS not diflieult to comprehend why it is that hemorrhoids, a collec 
tion of fiecal matter in the rectum, irritation of the vagina, eta^l 
will be likely to provoke early action of the uterus. Among the 
caust's of abortion, from excito-motory influence, may abo be, 
mentioned excessive sexual intercourse in the newly married. 
caloulus in the bladder, or strangury produced by the absorptioal 
of e.mlharides frotn a blister, as also the tene^^mus of dy^entt-ryj 
m:iy he enumerated among the causes of abortion ; ail these infla*' 
ences act ufjon the same principle, by reflex movement, bringin^fl 
into play the excito-motory system of nerves. I have known al 
lady miscarry from bathing in the ocean. Is it difficult to expluinj 
the relation of rause and eftert between the rold bath and! 
abortion? It in but another illustration of reflex irjfluence. ft ifl| 
well known, as Marshall Hall observes, that cattle made suddenly 
to ford a creek, will, almost as soon as they feel the im|>re8siiia of 
the chilled water, evacunte bolli the bladder and reclmn. 

ThesL*, gentlemen, are imiK>rtanl iaets; and I might proceed 
illustrate this great principle of reflex actiofi as one of thp eatt 
more nv less constantly at work in the production of aVjortic 
Why is it that a piece of ice put into the vngrna will often arreait 
feariul flooding? Why is it tlnit tilillalirtg the uiuutli of tbi 
uterus with the finger will fretiucntfy arouse this organ from 
State of inertia to one of positive contraction ? In the ofieratic 
of turning, soon after the hnnd has passed into the titerutf, ili4 
accoucheur will experience the most painful sensation, this bi4ti| 
the resnlt s^imply of the firm grasp of the cervix uteri around hll 
wrist. 

You have had cases before you, in the clinic, of women, 
after parturition, ex|»eriencing severe pain in the uterus from thd 
application of the infant to the breast. This is nothing more thfl 
another example of reflex influence ; and so true is this connexic 
between the uterus and mammje, that JScanzoni has recommendc 
miction of the Ijreasts for tho pur|K)U' of bringing on conlraotic 
of the uterus in cases in which, tVom justifiable motives^ it become 
desirable to induce premature delivery. 

Lactation itself is an active, but, I think, not a sufficiently re 
nised cause of abortion ; and it is inipo! tant, therefore, for this ; 
well as for other reasons, to direct a female, engaged in snckltnj 
her infant, who may suspect herself to be pregnant, to wean her 
child. This advice, if followed, will oftentimes insure her the. 



THE PRINCIPLES AND PnACTTCE OP OBSTi?rt!?f«i. 



completion of her gestation. The well-known sympathy existing 
lietween the tiisimmas and uterus will, I think, in part explain why a 
nursing woman is liable to abort; the traction of the child's mouth 
on the nipple being oftentimes an excitor of uterine action. Dr. 
Barnes* has written an able paper on this subject, and has shown 
that in a given number of instances, abortion occurred in 1 7 per 
cent, of cases in which the female became fecundated during lacta- 
tion, and in only 10 per cent, when impregnation occurred at other 
times. Women will occasionally abort from the extraction of a 
tooth ; in ihh case, the particular pair of nerves more immediately 
connected with this result is the iit\h, or, as it is called, the trifacial, 
Disea>?e-S of the cervix uteri, such as ulceration, hyjjertrophy, irulura- 
tion, etc., aUo deserve to be ranked among the influences occasion- 
iDg premature action of the uterus; and these, too, produce their 
effect ujion the principle of reflex movement. 

The iriiport^nt deduction I wis>h you to make from what has just 
been said in reference to this particular class of causes of abortion 
is, in all instances, to exercise a due degree of vigilance by endea- 
voring to ascertain in a given c^ise the particular influence, whioh 
may be in operation at the time, and, by successfully removing it, 
render to your patient a substantial service, as far as may be. 

Centric Causes of Abortion. — ^Tliere is, however, anotlier dis- 
tinct class of causes, capable of inducing premature contraction of 
the uterus; and they diftVr from those already named iu the impor- 
tant particrilar that they are centric, that is, their intirinnce is 
exercised primarily on the medulla spinalis itself, and irot secondarily, 
a« is the case in the operation of the eccentric causes, wdiich yoti 
know is through a reflected, and not a dirc^ct action. To illo^lrate : 
suppose a pregnant woman receives a blow on the spine, foil u wed 
by abortion. Here, tlien, h an example of a centric cause, tor the 
reason, that its primary influeuce is upon that great nervous centre 
— the medulla spinalis. A bloodies or aniemic condition of system 
is not an unusual cause of abortion ; and this should explain to you 
why it is that women who have suffered excessive depletion, either 
from the lancet, or as the conserjuenee of a long-continued drain, 
will be exposed to miscarriage. But you may desire to know what 
connection there is between abortion and anemia. It has been 
shown that when an animal is b!ed to death its dissolution is pre- 
ceded by convulsions. 8ir Charles Be!l and >[arshall llall both 
maintained that, in such cases, the convulsions are the result of 
loss of blood sustained by the spinal cord. It remained, however, 
for ilmt eminent physiologist, Dr. E. Brown-S6quard,f to demon* 
ftrate by numerous experiments that the convulsions, in these caseSj 



• London Lancet for 1863. 

f Kxperltnent«l Reaetrebea ftppUod to Physiology and Pftlhology. 
U7. 



1858. p. 



272 



THE PKINCIPLES AND PRACTICE OF OBSTETRICS. 



are nut tlu^ to ihe amtunic condition of the cord, but to the 
incrc:isn3 of carbonic acid in the blood, whicU U proportionate lo 
the instifficicncy of th© respiratory movement — the carbonto acid, 
tinder these i-i re u instances, boeomet* an excitant to the cord, aad 
is the true catme of the convuliaioiis. The yanie observer Km alao 
shown iliat carbonic at^id m an exeitor of the muscular system, and, 
in this way, is to be explained the relation of cause and efiect 
between a bloodless condition of the economy and eontractioua of 
the uterus. 

Albuminuria in pregnant women is oflen tbo can8e of abortion 
(Rayer, Martin, SoIoih Caheji), of premature parturition (Rayer), 
or of the death of tlie e!u!d (Cahen). Bratni Bays, in onc*fourth 
of the c;ises of albnininuria during precfnancy, there is abortion or 
premature labor. Mental amotions, M'hcther i right, an^jfer, depres- 
sion, sudden and excessive joy, etc., are all so many eircnmstanow 
capable of giving rise to abortion ; and the Influenee of these may 
be said to be throuirh centric action. 

Other Causes of Abortion, — A prominent and qaite commoil 
cause of y>renjatnro action of the gravid utcru!«, is a hypersemto or 
plethoric condition. This organ may be congested, as a eooie- 
qnence of the general vascular state of the system ; or it may be 
the result of some special local influence. For example: midjtosl^ 
tions of the uterus, or any other abnormal condition, inducing an 
obstruction to the free circulation of the blood; the abttse of 
cmmenagoguc medicines; intlammation, either of the extenud 
geidtalia, or of the organ itself. The syjihilitic taint an*l the abuM 
of mercury arc al>^o to be euunierated amor»g tfie causes of abortion* 

Syphilis may be transmitted from the mother to the child in 
utero ; or, it may be derived from the father, through the feeaiK 
dating liquor. In either case, abortion may occur in one of two 
ways. In the first place, from the death of the embryo ; or, secondly, 
it may be occasioned] by disease of the placenta, terminating in its 
early detachnjcnt, and consequent expulsion of the ovum. Small- 
pQX may produce aboilion, and in one or other of the modes jtt»t 
explained. 

Death of the feet us, no matter how produced, is to be regarded 
as one of the most certaiti of all the causes of abortion ; and with 
a momonrs thought you will perceive boAV fortunate this proviaott 
ia; for the continued sojourn of the embryo in utero, after its 
death, would necessarily involve, ibrough its decomposition, tbd 
safety of the mother, and hence the necessity for its early ejection. 

You can readily understand the connection between abortloa 
and disea!«e of the placenta. This latter organ is called upon to 
perform a must necessary oOice ; and even its partial separation 
cannot occur without exposing the embryo lo serious hazard. The 
maladies to which the after-birth is liable are various ; somett»ieB| i 



TEE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



273 



It will become indurated; at other times, it will pass to a state of 
hypertrophy or atrophy ;* occasionally, it will become the seat of 
calcareous formations, hydatid developments, uniHual fatty dege- 
neration, etc. ; it may aho be invaded by inllammation, or over- 
whelmed by an afflux of blood, con&titutinp; what has been so well 
deaeribed by Cruveilhier &» placental apoplexij. 

Habitual Abortion. — It is an interesting feet, that some women 
abort several times sut-eessively^ and this ig called the abortion of 
habit. A knowledge of this fact inculcate;^, in the first plare, the 
necesHityof the practitioner enjoining on hi^ ]:>atient, in her lirst preg- 
nancy, the great necessiiy of avoiding all those causes which are 
known to favor a jirematun* expulsion (if the ovum ; and secondly, 
in the event of a miscarriage, to exercise more than ordinary 
vigilance in the snbse^^uent pregnancies; and what I have fi»und 
an excellent expedient iu such cases i« — as soon as gestation takea 
plsice^ to interdict sexual intercout^e until after the fifth months 
for if the pregnancy pass beyond this period the chances of almr- 
tion will, I think, lie much dimiuiahed. 

These oases of habitual abortion are oftentimes exeeedingly 
djfiioult to manage, simply for the reason that sufficient caix* is not 
exercised in aseertiiniug the true source of the diftieulty. It is fi 
fact, fully indorsed by all sound experience, that abortion is very 
apt to be followed by chronic affections of the nterine organs, 
jach 08 displacements, or enlargements, and these are frequently 
the true cause of the early expulsion of the ovum. In sueh 
iostanreft, the obvious indication is, thiou^h ajipropriate treatment, 
to remedy the displacement, and subdne the enlargement. If it 
be apparent, that the source of the trouble is plethora, the remedy 
will be the diminution of that state by judicious depletion, together 
with saline cathartics, and restricted diet ; and here, If thorc be an? 
absence of nausea — one of the ordinary and important phenomena 
of gestation — ^give tolerant doses of ij>ecacuanha, say from one- 
aixth to one-fourth of a grain every two or three honrsi^ for tho 
purpose of exciting action of the stomach. The ix^ason ior this 

Wer treatment has been explained in a previous lecture. It is 
ential that the patients avoid all excitement, either mental or 
physical ; and it is a rule with me to enjoin more or losa quiet in 
the recumbent position nnlil the expiration of the Mil monlh. I 
need scarcely remark that if the cause of the abortion be tracod to 
exeesiiive nervous irritability, this condition must be allayed by 
timely recourse to anti-spasmodics and anodynes; at the same time, 
the general health should be improved by tonics aad appropriate 
dieL Dr* Tanner speaks highly, in these cases, of asaafcBtida,* 

• One ofllie be«t agents with which I am acquainted in the trwihlosomo ca^ea of 
npMtud miacHrriugii, occurritig iu wo»k HUtl irritable women, iu whoiu theri;? is aa 
■Imnco of vnaculAf congestion and aiiy JtpeciJic diseaae, is AaaaftBtkiiw Tbe dotft' 

18 



274 



TUK PRINCIPLES AND PRACTICE OF OBSTETRICS. 



Whatever may be the particular cause of* the abortion, tha 
phenomena connected with the expulsion of the ovum resemble 
more or less closely those of an ordinary labor. The eipuUive 
force is the same, viz., the contractions of the uterus. As a general 
rule, unless the membranes t^hould be ruptured by the rode maiii- 
]>u!atious of the accoucheur, previously to the expiration of the 
third month the ovum is usually expelled entire with its envelopes. 

Si/mptoms of Abortion, — ^They may be embraced in the Iwa 
terms pam and hemorrhage. When a female is threatened mrilh 
premature expulsion of the embryo, these two phenomena — |mto 
and hemorrhage* — will almost always, to a greater or le» extent^ 
be present. 

DlaffnoaU, — The diagnosis of a threatened abortion needs some 
little attention. In the first place, a pregnant woman may suppose 
herself menaced with abortion, simply because she has pain* But 
this is not sufficient — ^the pain of abortion, like the f»*in of labor, 
19 peculiar — it is recurrent, paroxysmal, marked by distinct inter- 
vals, (tnd ctmtring toitanl the hina and hypogaMric region. It ii^ 
in a word, notliing more than the contractions of the uterus, either 
raa*!ked or fully developed, and which, you know, are not C4>nti* 
nuons, but intermittent, when engaged in the exjiulsion of the 
ovum, whether at full term or at an earlier period. The pain, 
which the female may mistake for labor p:un, may result from 
colic, indigestion, or various other circumstances, wbich bave no 
possible connection with any specifie action of the utcnis. You 
see, therefore, it will be for you to determine as to the character 
of the pnin, ami whether it portend danger to the mother and 
embryo, or whether it be transitory, and will yield to the aduilnis* 
tration of a(ipropriate remedies. So far, then, as either the psia 
or hemorrhage is concerned, it is incumbent to ascertain, ia the 
first place, whether they really proceed from the ntenis ; and, 
secondly, if so, does the uterus contain an ovum, or, in other 
words, is tl>€ woman pregnant ? The blood, although di^nv^d 
from the uterus^ may not positively indicate an abortion, and so 
likewise with the pain, for both of these phenomena may exist 
without gestation. For example : they may be the result of a 
polypoid 'growth, of carcinoma, &c. ; the bleeding and pain may be 
altogether unassoeiated with the uterus itself, and may proceed 

which I UAUDlIr adtDitiist<?r \b about five graios of the extmct every night nl bed* 
time, and 1 g^neraUj take care that tb& p&tient altall havo had from lhn*e lo jlif# 
(imeium liefon* ftrrivinf ivt that period of her pregnancj at whieh sbo h«a fonncfff 
itoorted, [Sigms ond Diacaacs of Pregtiaacy. By Thomaa Bawkea TaoDtfr, ILB^ 
F.LvS,. p. 257.] 

* The b)«NHliij^ in early gesUtion may ariao from seretTi] cimimatatiopa^mcb ai 
m|>ture of ttie vi^as^Ss conneetmg the ovum to the uterus; or there may he a giving 
wiy of the Gcrpeniine Vi^ssek which distribute ihornselves in the uloriaa waUi^ and 
Wt^ then poor iheir contente into the caTity of the orgno. 



THB PRINCIPLES AXD PRACTICE OP OBSTETRICS. 



275 



exclusively from tionie abnormal condition of the vagina. The 
diatinction can be arrived at only by a thorougli examination. 

Again : a pregnant woman, especially in the earlier months of 
her gestation, may have a discharge of blood throngh the vagina 
without being at all threatened with a miscarriage. This discharge 
may be nothing more than menstruation, which, you are aware, 
sometimes occurs in pregnancy, several examples of which you 
have seen in the clinic. As a general principle, you will be enabled 
to distinguish menstruation tlom the hemorrhage of miscarriage, 
as fallows: 1. Its occurrence wilt usually accord with the mei*- 
fitrual periods previous to the pregnancy ; 2. It is unconnected 
with any of the causes of miscarriage ; 3, The patient is in good 
health ; 4, The flow is not profuse, lasting generally but two or 
three days ; 5. The pain in menstruation precedes the flow, and 
iisually ceases as soon as the discharge occurs ; 6. In miscarriage, 
whether before or immediately after its completion, the os uteri ia 
moreor less dilated and softened ; such \h not the case in menstruation. 

JProynosls. — As a general rule, a tavorable opinion may be 
expressed. The danger from losses of blood is much less in the 
earlier months, for the reason that the blood-vessels are less deve- 
loped ; it is rare to observe any serious puerperal complications 
follow an almrtion — such as intlamniation or fever. 

Treatment of Abortion, — Let us now consider hoto a mis- 
carriage h to be managed—^ most important point both for the 
pntteiit and practitioner. When summoned to a female, who 
supposes herself menaced with an abortion, the first and obvious 
duty of the iiccoucheur is to ascertain whether she be in fact 
menaced, or wlietber her fears are without foundation. Thii<, of 
necessity, will involve a just discrimination of her condition^f she 
have pain, whether it be the offspring of uterine effort ; an<l, if 
there be discharge of blood, whether it be the restilt of premature 
action of the orgati. If it be discovered that the patient is really 
threatened, his duty will be confined to the attainment of one of 
two cibjeets — cither the prevention of the miscarriage; or, if this 

mot be ncconipljshcd, he must limit himself to those measures, 
'hich will the most efficiently enable him to conduct his patient 
safely through her trouble. 

With regard to the prevention of a threatened miscarriage, I 
wish very emphatie^illy to remark that it can otleii be accomplished, 
even when apparently there no longer exists any hope (»f attaining 
this desirable object ; and yon must allow me to iuipress ujion you, 
not only the necessity, but the high moral obligation imposed on 
the practitioner, of employing, in the most faithful manner, those 
means best calculated to arrest the early action of the uterus. It 
U proper, at this time, to examine in what these means consift. 
The prevention of a threatened miscarriage is not to be achieved 



976 



THE rBlNCIPLES AND PRACmCK OF 0B8TETRtG§. 



by any act ofempirlcusm— it is, cm the contrary, to bo aoocMn| 
in the tir^t place, by a rigid appreciaiioii of all the mrcuiBitttHoei Iqf ^ 
wbicli eacb individual case may be surrounded; and, secondly, by 
a propur adaptation of remedies to the peculiar condilioD of the 

system at the time. 

Wi* will now imaE^ine you are at the Ix^dside of a pregnant 
feuntle, who h:ift both pain and a dischargee of blood from the 
vaccina, and that you have satisfactorily jiacertained, through a care- 
fully instituted examination, that these two phenomena are posi- 
tively cuimeeted with a threatened miscariiage — what is the first 
thing to be done? Certainly not, for the mere sake of appearing 
to do homelhing^ to be urged on to precipitate and unprofitable 
interference ; but the judicious physician will take a survey of tbo 
condition of his patient, fur the purpose of ascertaining some of the 
following points: Is *?he laboring under marked plethora? Is *ho 
of an extremely nervous temperament ? Has she been ex]>osed to 
any sudden emotion, such as fright, anger, or depresnion of ppiril«^ 
Has she experienced violence from a blow or fall? lias hbe beea 
aubjeet to previous abortions ?* These arc some of the principal 
inquiries, which a vigilant practitioner would naturally iri.stitut© in 
his own mind. 

You must remember that, in the management of a mist ;. i il. , 
no matter what may be the cause whit-h has determined it, '< 
reM must be tr\}omed. This is a sine qud non to the success uf the 
remedies to which you will necessarily be obliged to resort. TImj 
patient should be placed in a recun»bent position with her hips 
alightly elevated. Acidulated drinks, such as lemonade, may bo 
given, or a c;ipiLal compound under these circumstances will be the 
infusion of ro.nes with dilute sulphuric acid, say f, 3 \-iij. of the for- 
mer to f 3 ij. of the latter^ — a tablespoonful every half hour. Th« 
room shouM be cool, and tlie covering light. The acetate of lead 
and opium may be resorted to, either in solution or pill, and often- 
times with much bencBt, under either of the following formu- 
laries: 

Acetat. plurabi, 3ij, 

Aquae destiUat. i\ 5 >j, 

Tinct, opii, f. 3 ij- 

Ft. sol. 

A tablespoon ful every third hour. 

Acetat. plumbi, gr. xxx. 
Pulv* opii, gr. iij. 

Divide in pil. xij. 
One pill every two or three hours. 

A most important adjuvant, under these circumstances, will be 
the application of cold, by means of cloths wrung out of ice-water, 



TEB PKINCIPLES AND PRACTICE OP OBSTETRICS. 



277 



md applied to the fuicram^ around the loins, and to the vmlva itself. 
Cold, remember^ is the rooat povrerful and efficient agent to pro- 
duce directly and locally — and indirectly at a distance^ by a reflex 
action— contraction of the blood-vessels. It excites contraction of 
the blood-vessels of the uterus much more readily than it aflects 
the muscular tissue of that organ ; in this way, it will arrest the 
hemorrhage, and also cause a diminmion of the congestion, which 
U an excitant to uterine action. Another valuable remedy is bel- 
ladonna. It is well known that it exercises a marked influence on 
ilie blood-vessels of the uterus, as upon those of the iris, intestines, 
et4!«» causing them to contrac^t, and t'orjsequently relieving them of 
their congested condition, I have repeateilly had recourse to sup- 
poRitories of the extract introduced either into the vagina or reo- 
timi — the latter is preferable^ for ihe blood will be apt to remove 
the Huppos^itory from the vagina— and I can very confidently com* 
mend it to your attention, as oftentimes one of the most effectual 
means of arresting a menaced abortion. 

Supjiose, now, that your patient is plethoric, w*ith more or less 
tbrile excitement ; what in tliiH case should be done, es^pecially if 
liere be a hope of preventing ihe expulsion of the ovum ? Why, 
obviously to reduce the plethora, which you will find not an uncom- 
mon predisposing cause of abortion. For this purpose, general 
blood-letting is the great agent. I much prefer it, under these 
circumstances, to local dejiletion. The quantity to be taken must 
depend upon the sound judgment of the practitioner. Two, four, 
six, or nine ounces may be abstracted, and repeated as events may 
suggest. It is well to bear in mind that, in these cases, the draw- 
ing of blood is not for the purpose of corubating an active inflam- 
mation seated in an important organ, but the object is simply to 
diminish the momentum, if I may so term it, of the circulation, 
and thus protect the uterus from the afflux setting toward it. In 
addition to the abstract ion of blood, give ten grains of rdtrat. 
potassiis in a tumbler of water, with vj, gtt. of tinct. digitalis. 
Let this be repeated every four or six bours, together with abste- 

It may, however, be that your patient is not laboring under 
plcthf^ra, but she is of an extremely nervous temjierament. What 
in ihi^ case is indicated ? Certainly not the abstraction of blood, 
for this would only tend to aggravate the nervous irritability ; but 
on the contrary, the employment of such remedies as will calm 
and ftjrtify the system, sucli as the various antispasmodics, nei*^ 
vines, etc. In these instances, I have experienced much benefit 
from ihe injection into the rectum of thirty drops of laudanum to 
a wine-glass and a half of water; lubricating the os tinea? and 
vacina with the ungt. belladon. (3j. extract belhidon. to 5j uf 
jd»/p>^), and the Lntrf eduction of opium suppositories mto the 



278 



THE PRINCIPLES AKD PRACTICE OF OBSTETRICS. 



rectum, Internally, a tnble-spoonful of the folio wingr rnUture nuy 
be given every half hour, imiil the object be attaiued: 

Syrup, papav. f. 3 ir, 
Mueil. acac. f f iij. 

SoK sulpb. morphia (MajenJie) gtt. xx. 

Ft. mifit. 

In all cases of threatened abortion, the attention of the practi* 
tioner should invariably be directed to the condition of the riMjtutn ; 
far it will not un frequently happen that a collection of tfecal mat- 
ter in this intestine is the starting point — the original exciting 
cause of the difficulty. If this should be so, the firbt thing to bo 
done is to evacuate the bowels by means of an enema. It mm}% on 
the contrary, be that the patient is aflected with hemorrhoida. 
If these be external, they should be carefully introduced within 
the rectum so that they mny be relieved from the confiliiciion of 
the external sphincter. The removal of the hemorrhoidal tumora, 
under the ci re nm stances, cannot for a moment be thought of, for 
the operation itself would almost certainly provoke the coDtractioii 
of the uterus. 

As I have mentioned to yon, in a preceding lecture^ the preg* 
nant femidc is to be sedulously guarded agninht torpor of tho 
bowels, and this d i recti on « too, is especially applicable in ca^es of 
threatened abortion. E]»^om salts in small quantity, a seidliu 
powder, manna, the compound rhubarb pill, are all well adapted la 
this end. 

Allow me to make one remark in reference to the impregnated 
uterus in the case of the primipara* You will find, as a gciieral 
rule, that women of an excessively nervous temperament, who 
may, in tact, be termed very impressionahley arc more apt than 
others to miscarry in their first gestation^ and the circumstance is 
readily explaineJ. In prlmiparce^ the uterus distends with lest 
facility than in subsequent pregnancies ; and in women of great 
nervous susceptibility, the very diiliculty encountered in the dis- 
tension of the organ, freqiieully tends to premature action of tho 
uterus, and the expulsion of the ovum. In such cases, even before 
the elightest manifestation of trouble, I have been in the habit 
of recommending to foment freely, but without using friction, the 
hypogastric region with warm sweet oil and laudanum. This, I 
am %M\% will often prove an efficient remedy in these instances, and 
I can speak of it, from no Umited success, with much confidence. 

But let us present to you another view of miscarriage. The 
treatment which we have thus very summarily suggested, is Intended 
for the prevention of this trouble, when it is njerely threatened. 
I shall now call your attention, for a moment, to those remedm 
indicated in cases in which it becomes impossible to mresl Ihs 



THK ntlNClPLES AND PRACTICE OF OBSTETRICS, 



279 



expnlslon of the ovum, and in w liich, therefore^ the duty of the 
jiracliuoner will be limited to saving the life of the mother. 

The true danger to the mother in abortion b the fearful hemor- 
rhage, and examples are not few in which she; baa simk frtiTn loss of 
LIooJ« When^ then, it becomes nn ascertained fact that the mis- 
cirnage cannot be controlled, the obvious duty of the practitioner 
is to |>romote, by ju<licious inter posit ion, the termination of the 
dcUvcry ; and yon are also to bear in mind, whenever the hemor- 
rhajje is such as to endanger the safety of the mother, all rc^^ard 
for the embryo nmst be suKperuled ; no maUrr what may be the 
possible or probable chances of arrestinf^ the miscarriage, every 
consideration must yield to the liigher claim of the parent. It is 
an extremely nice point always to determine when tlie hemorrlnigo 
13 so profuse as to render it essential to imlnce the expulsion of the 
ovum, and, also, when it is certnin that the abortion cannot be 
prevented. In some instancen, it is true, this question may be 
decided without trouble; when, for example, a poniou of the 
ovum — which will sometimes h:jppen — has been thrown off; and, 
in, if the ovum be dii^tirictly felt protruding through ihe dilated 
'. is unequivocal evidence that its expulsion cannot be controlled. 
As to the question of tlie amount of hemorrhage which will not 
Mnly jnsitify, but absolutely call for the prompt action of the 
ceoueheur to i»romott? the evacuation of the contents of the 
uterus — this, I repeat, is a qnestion of jndgrnent to be determined 
by the evidence which nniy present itself at the time. Permit me, 
however, to make a single remark on this point, / ham known 
io ivse immense fjnantUies of blood in a threatened abor- 
, and to be apjxtrentlf/ moribund fn^fn erMtfu/uijicaticm^ and 
l/et (h^t/ hare raUCed^ and gone mi to the ftdl term. These latter 
examples, however, are exceptions to the genei*al rule. 

Well, w hen there is no longer any hope of restraining the abor- 
tion, or when the wnman is flooding so profusely as to en<!anger 
her life, the mouth of the uterus will be in one of two conditions 
— it will be either sufficiently dilated to enaljle you to fee! the 
ovum, or it will not be so dilated; and again, the ovum will also 
be in one of two conditions : it will either have pfirtially extruded 
through the cervix, or it will still be within the cavity of the uterus, 
»lIow, let us examine each of these )>oints. 1, Should the uterus 
»<j far dilated as to permit the introduction of the finger, I 
should recommend you, by all means, gently to increfise the dilata- 
tion — and this is reatlily accomplished by pressing the finger alter- 
nately fbrw^ard and backward — this very motion of the finger 
evokes a strong reflex action, winch oftentimes results in the prom]>t 
expulsion of the ovum. 2. If the os uteri have not undergone 
dilatation, and tin* hemorrhage so profuse as to occasion alarm 
for tho mother^ then thf> remedies to be employed are the follow- 



280 



THE PRINCIPLES AND TRAOnot Of OBSTBTBICa 



ing: l.Cold; 2. The tampon; S. The secale cornutiiiti. Herei 
you perceive, the oViject is to bring on, as speedily and effi- 
ciently as possible, contraetiona of the utc»ru«, tor it is on the effi- 
cienC contractions of thi« organ that you are to rely for the arn^i^ 
of the liemorrhage, 1 have told you that, when a misciirriagc b 
merely threatened, anrl, therel'ore, it becomes the duty of the 
medicsil miin lo do all in }m power to prevent it, the npplieiiiion of 
cold by means of clotlm to the vulva, faeruni, and loiiie^ is of great 
benefit, because of the eontraction it produces in the blood- ve«*clf 
of the uterus. Titer e is now, however, profu»e hemorrhage, plaiv 
m^ in more or less peril the safety of the woman ; and here, too, 
cokl, i>roperly resorted to, will jirove one of the mo^t pos^itife 
remedies. If you dash cold water — it would be better if It were 
iced — upon the abdomen, you will often times, in theto cases, cause 
a prompt artion of the uterus; or a simall piece of iee introduced 
into the vagina, will occasionally act like m;igic* In either io&iatto% 
the uterus in made to contract in consecpience of retlex action. 

The tampon is a valuable agent in this form of hemorrhage. It 
Bhould consist of small pieces of tine sponge, or linl, which idiotlltl 
be carefully introduced into the vagina, as far as the os uteri, until 
the j*assage is completely tilled up. The whole Lh then lo be k«pt 
in place by a compress and bandage. It may happen that tb« 
pressure of the tnmpon against the urethra, or netik of the bladder, 
will prevent the flow of urine ; in this cahc, the catheter mui*l be 
used, I would advise you not to allow the tampon to remain^ at 
any one tirae^ in the vagina for a longer |>enod than four hours; it 
should be withdrawn at the end of this lime, and replaced, if found 
Ufcessiiry, by another ; tins is an important direction, for the long- 
continued use of the same one will be apt to offc:i5iion putreiiiction 
of the tluids which necessarily, lo a greater or less extent, saturate 
it. The tatnpon acts, if I may »o say, in a two-fold capacity. In 
the tirst place, it arrests, for the time being, the hemorrhage j aiid^ 
fieconilly, the irritation priwluced by it on the mouth of ihi^ ulorus 
provokes contractions of tho organ, and thereby facilitates the 
object in %*iew. 

Another efficient remedy in these cases is ergot — ^tbe 9$c€U€ corwi#* 
turn ; and it is efhcienl because of its action on bolh the blooi]* 
vessels and mliscnhir tissue of the uterus. It is now adnvitled 
Uiat this drug :iffe«^ts the vessels and mu&icular tibrea of tlie 
organ on precisely the same principle; it ads* upon the smooth 
fibres of the uterus ; it acts also on the smooth fibres of the btuod- 
Te^aelH. It, therefore, is true that ergot arrests uterine hemorrhage 
in a tvvo*fold mnnner: I. By producing c<nitraction of the blood* 
vessels; 2. Contraction of the muscular strueturt* of the c^r^a. 
Ergot i« not a stimulant of any portion of the nervous jRystcm, mod 
inay, therefore, be regarded the antagonist of strychnine. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 281 

I should not hesitate an instant, in any urgent case where the 
strength of the mother is giving way from the loss of blood, and 
the mouth of the uterus still undilated, to introduce with my index 
finger as a guide, a female catheter or bougie — I prefer the former — 
into the os uteri, and thus hasten the dilatation by promoting 
efficient contractions. 

Let us now suppose the ovum is partly protruding through the 
OS uteri : in this case the proper practice is to terminate without 
delay its expulsion, by introducing the finger, and making gentle 
tractions upon it. If, on the contrary, the ovum be still within the 
uterine cavity, and it be desirable, on account of the hemorrhage, 
to hasten its delivery, then the means already mentioned — cold, 
tampon, and the ergot — will be indicated ; and what you will find 
a capital means in addition, for the purpose of promoting strong 
nterine eflfort, will be a drastic cathartic — say for example, a couple 
of aloetic and myrrh pills — or from one to two ounces of the com- 
pound tincture of aloes ; or if the case be urgent, requiring prompt 
contractions of the organ, a drastic enema may be administered. 

If abortion should occur before the expiration of the first three 
months of gestation, and the ovum come away piecemeal, the pla- 
centa will sometimes be retained, giving rise to much uneasiness on 
the part of the patient, and causing no little embarrassment to the 
young practitioner. These are the .cases in which various con- 
trivances have been projected for the jiurpose of extracting the 
retained mass — such as the tenaculum, the small slender forceps, 
hooks, etc. These instruments are, in my judgment, not only unneces- 
sary but fraught with danger. The best extractor is the linger. Let 
it be carefully introduced within the cavity of the uterus, and by 
skilful manipulation, with the other hand placed upon the abdomen 
depressing the fundus of the womb, the remaining portion of the 
ovum can, generally, without difficulty be removed. At a later 
period the uterus will be large enough to admit the introduction 
of tlie hand, and in this way the after-birth may be extracted. It 
is a curious and interesting fact that the retained placenta in cases 
of abortion does not, as at the full period of gestation, undergo 
decomposition, and, therefore, if it cannot be readily secured, sliould 
cause no disquietude. It will often pass off spontaneously, even 
after all efforts to remove it have proved unavailing. 

The patient, after an abortion, should, as in an ordinary labor at 
term, be kept quiet, and preserve the recumbent position. Her 
diet should be light, the bowels soluble, and all excitement avoided. 

In the event. of alarming prostration from loss of blood, there is 
no remedy more efficient in bringing on reaction than tea-spoonful 
doses of laudanum and brandy in a wineglass of strong coffee, 
every ten, twenty, or thirty minutes, according to the re(|uirements 
of the case. Be not afraid of this remedy, it is the sheet-anchor 



282 THE PRINCIPLES AND PRACTICE OF OBSTSTRICS. 

of hope in cases in which the patient is almost binking from exhaus- 
tion consequent upon profuse hemorrhage. But, of all things to be 
remembered, see that the uterus is well contracted, and not in a 
state of inertia, for it would be the essence of folly to attempt to 
control the exhaustion while the waste gate is still open. In abor- 
tion, as in delivery at full term, flooding is always one of the results 
of inertia of the uterus. 

In all cases of abortion, an important direction for you to bear in 
mind, is to examine carefully any clot or substance which may be 
thrown off from the uterus ; and this rule should be observed from 
the very commencement of the discharge. The object of the 
examination is to be assured whether the embryo has been expelled; 
and this necessarily su<^gests the discussion of the question of moles, 
or, if you prefer it, molar pregnancy, to which subject the succeed- 
ing lecture will be devoted. In conclusion, I would remind you 
that you will sometimes meet with cases in which there is more or 
less oozing of blood after the entire expulsion of the ovum ; and 
this will ordinarily occur in women of a leuco-phlegmatic tempera- 
ment, with a flaccid, muscular fibre ; the hemorrhage in these 
instances is almost always of a passive type, constituting what may 
be termed passive or atonic metrorrhagia. When called upon to 
treat a case of this kind, you will recognise great benefit from the 
injection, night and morning, into the rectum of a half pint of 
water, cold from the pump, together with the internal administra- 
tion three times a day, as may be indicated, off 3 j. of the tincture 
of ergot in half a wineglass of cold water. 



LECTURE XX. 

Holes — Importance of the Subject — Moles variously Classified — Mauriceau's Defini- 
tion — ^The Opinion of Femel— Practical Division of Moles — The True Mole always 
a Proof of Previous Gestation — Distinction between True and False Mole first 
made by Cruveilhier — Mettenheimer and Paget on True Mole — Dr. Graily Hewitt 
— Case in Illustration of a True Mole— Can a Married Woman^ if separated from 
her Husband since the Birth of her Child, or can a Widow, Discharge a True 
Mole from the Uterus consistently with her Fidelity ?— False Moles, what are 
th«»y ?— Substances expelled from the Womb of the Young Virgin — Fibrinous 
Clots — The Membrane of Congestive Dysmenorrhcea — The Hen lays an Egg 
without the Tread of the Cock — Does the Mombrana Decidua pass off at each 
Meuatrual Period, or is it simply the Epithelial Covering? — The Testimony of 
Lanisweerde, Ruysch, and Van Swieten as to the False Mole — ^The True Hyda- 
tids — Can they be produced in the Virgin Uterus? — The Case cited by Rokitan- 
sky — Importance of the Question — How are the True Hydatids to be distin- 
guished from the Hydatiform Vesicle ? 

Gentlemen — In the course of your practice you will observe, 
more or less frequently, examples of anomalous substances thrown 
from the uterus, and this, too, both in the married and unmarried ; 
hence you at once perceive how much will necessarily depend upon 
the sound jud<^ment of the physician in order that character may 
not be unjustly assailed, or wantonly destroyed. These substances 
have been differently named and classitied ; and there has existed no 
little discrepancy of opinion as to the particular cause of their 
origin. 

In a question so vitally important as is the one now before us, it 
ippears to me there is great want of accuracy in the arrangement 
and description, which the older authors have given of the various 
matters discharged from the womb; hnd this want of definite 
arrangement will, I think, account for the marked conflict of opi- 
nion entertained as to the true source of these expelled masses. 
One of the great masters of obstetric science is constantly quoted 
in proof of the alleged fact, that when a female expels from her 
uterus a substance — known under the vague name of mole — she 
could only have done so in consequence of intercourse with the 
other sex. I allude to the learned Mauriceau, who, in one of his 
aphorisms,* says, "Les femmes n'engendrent jamais des moles, si 
elles n'ont use du coi7." In order to prove the fallacy of this apho- 

* Traits dee Maladies des Femmes Grosses. Aphorism, 105. 



284 



THE FBIKC1PLE3 AND PBACTTCE OP OBSTfiTBtCS. 



rlsm, and consequently the wronsj of Ixn adoption, I have had 
ciinosUy to examine for myself the actual delinttiori which lht» *Ha 
iinguished man has given of a mole, I find the following to be hi 
language : " La mole n'est autre eliose i[uHme masse charnue mni^ 
OS, sans articulations, et unnn distinctions des memhrej«, engendr 
contre nature dans hi mat rice eiisuit*^ du coit, des semenceii eur 
rompues de Thonime et de la femme/** Here, then, according t< 
this detinitiun, a mole is Bimjily a fleshy moas, bearing none of th< 
evidences of the product of a previous coueefjtion ; and, therefore 
with ihis restricted signific^ilion, we are called npon to pronounc 
sucii subhtances as uuqualiHed evidence of Boxual iiitercoursi, — 4 
iieory at once cruel and unjust, as we hope to demonstrate befor 
completing this lecture. 

Another high authority, the celebrated Fernel, phymcian to Henr 
II,, originated the following maxim, which is ali^o fi equently referred 
to in confii'matioQ oi the o[ union subsequently advanced by MauriJ 
oeau: ^^^ Nnsquam vi^a ei»t nxnlier molam sine mare conccpisH%"j| 
I might, indeed, cite many other authorities in conHrmation of thi 
wne view, but this is nut necessary. I prefer rather, in the fac 

i'such testimony, to urge the abs*)lute duty imposed upon yon of 
examining most scrupulously the grounds for this sweeping decla*! 
ration, and i»f repudiating its adoption, unless convinced by positive 
proof of its truth. The opinion bears too directly ujiou chara<'te< 
and tlie beM interests of tiociety to receive a tacit concurrence, aucj 
therefnre, become a (uinciple of guidance in case^J m whieli it dec> 
eioti k to be arrived at, involving the injportant question of chaplitjl 
or infidelity, either in the married or nnmarried* What I object 
in tho authors just cited is their want of precision in the detiui 
tion lit' wljat u mole really is; for assuredly, in order that w^e maj 
tjuve a correct judgment as to the true origin of these e^cpeltcd 
ubstaneo^, wo should first have some standard of compariAoa 
'which science recognises, as the only means by whiclj we are to dia 
tinguisli between what is and wliat is not a mole — the ofiVpiing of 
31 previi)us conception, or, if you please, a blighted ovum. 

Therefore, for practical purposes, the suVistanoes expelled free 
the uterus may he (bvide«l into two distinct orders or chisses; 
Those, which arc the product of a diseased or degenerated oviiu 
and consequently iniplics a previous fecundation — ^known as 
moles. 2. Those the origin of which has no sort of connexion wit 
sexual intercourse, but wfiich is due to causes altogether foreign 
l\m inrtuenoe, known n^/ahe moles. 

The Tru^ MqUb— Vesicttlar or Jlt/Jatiform Moles, — It has be< 
very satisfactorily demonstrated by Charles Kobin, and other 
that an nltemtion in the envelopes of the ovum, with un auomalou 



• Tome i. p. 6Ut> 



f Fernel, tuiue u \^ &99. 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



285 



enlargement of tlie choiial villosities, is the only origin of a true 
mole, thus essentially connecting t!»e eonrco of this charaeter of 
njole with a previous conception. The hydatiform* or vesicular mole 
, has recently occupied much attentaon. Cruveilhicr, it 15 now ireue- 
rsUy admitted, was the first cleurly to point out the absolute differ- 
ence between the vesicular or hydatiform mole^ and what is under- 
stood, in patholopficjil Inngunp^e, an the true hydatids, which are 
occasionally found in the heart, liver, spleen^ and other organs. 
Whether, under any cireumstatice?i, these true bydatide, the oriijin 
of which is of course unconnected with pregnancy, can exist iu the 
Qtorus, we shall examine in the course of this lecture. 

Various theories have been advanced to explain the special 
changes the chorial villi undergo preliminary to their transforma- 
tion into the hydatiform bodie^^. It is supposed by Mettcnheimer 
and Paget that the change consists essentially in tbo conversion of 
oertain of the cells in the villi of the chorion into so many cysts ; 
on the outer anrtace of these new-formed cysts, a new vegetation 
of villi sprouts out, being identical in atrncturc with the proper villi 
of the chorion ; and in these last villi there commences a new deve- 
lopment of cysts, and so on ad infinitum. The opinion of Paget 
ami Mettenheimer is opposed in a recent paper by Dr. Graily 
Hewitt,! who maintains that, in the hydatiform mole, there is not a 
new formation, but simply an alteration and degeneration of previ- 
ously existing structures. This writer also dissents from the opi- 
nion, now generally admitted, that the starting-point or oauso of 
the transformation is disease of the chorion, while tho effect is the 
destruction of the embryo. Dr. Hewitt, on the contrary, endea- 
?onj to show that the degeneration is the result of the death of 
llic foetus. His paper ombodit^s much interest, and will amply 
repay perusal. Dr. Barnes J ha^ presented an elaborate res ft me of 
the whole question with his acctistomed ability, and the reader will 
find much of profit in his valuable contribution. 

You were told^ when speaking of reproduction and pregnancy, 
that certain phenomena arc absolutely essential to the formation and 
ultimate development of the embryo ; these phenomena have 
already been pointed out in detail. The moment the act of fecun- 
dation baa been consummated, then the work of growth and deve* 

^ Tlio hydatiform mole m usually thrown off before tho completion of th© ordinary 
term of pregriancy. If not ruptured during its expulsion, the mole wlU be found 
to exhn it a cavity full of a serous liquid, tn which are neter observed the Rmall ^ra- 
nuUr iKxlk's (cii!hiiiooi>et"i) tirst described, I belie%T, by Rudoiphy, and which otwaya 
9Xigt m true hydatida or aocphslo-cygta. Should tho molta be cxpeUed soon after tho 
death of the ymmg emhryf\ portions of the latter may bo detected in its cavity j 
but if it pass off long alter its dt^truction, then tho mole assumea more or kaa the 
upcct of tho plnceuta, nod thferc rvmtiins but little of the cavity, 

f Obstetrical Transnctions. Loudon, voL I, i860, p. 24d. 

j HriL ami For. Medtco-Chifurgicai Review, 1854-5. 



286 



THE PRINCIPtES AND PBACTIOE OF OBSTETRICS. 



lopniont coramcnceg — these two latter phenomena being the resaltJ 
of a healthy uutrition. It wilt, however, sometimes happen thsit, 
after the vitalized germ is deposited within the uterine carity, some 
morbid influence may arise in the germ itself, which w\\\ compro- 
mise the progress of a normal gestation, and lead to the destrao- 
tic»n imd degonenition of the ovnm ; so that, in lieu of fcetal devts 
lopmeiit, the product of conception exhibits a more or Ie4« anooia* 
Joiifl nmsa, in which, with a duo degree of care, there will be reoog- 
nised the alterations of tlie ehorial villosities, if not with the miked 
eye^ at least under the power of the microscope — and M/*, remetn' 
ier, t« ih^ conclusive affirmative proof of tfu true nwle* \n other 
instances, and they are not rare, the fcetus may be expelled normal 
and fully develojied, while tlie placenta will exhibit a partial hyiift> 
tiform degeneration in its villosities. 

It is an interesting fact to bear in memory, that, as a general rale, 
Boon after the death or metamorphosis of the ovum, the uterus be- 
comes intolerant of its presence, and expels it. This result^ however, 
la not nniveraal; the exceptions arc not h\\\ and the degenerated 
ovnni wiH occasionally remain for a long lime in the uterine cavitj. 
The latter circumstance may involve character in one of two ways 
— for instance, a lady may bring forth a healthy living child at fell 
term; in three, six, or twelve months Huhsctiuenily she may have 
expelled from the womb a true mole» Tiiis may occur in a die 
in which the husband has been absent during the whole f^»eriod<Vom 
the birth of the chiUl until the expulsion of the mole. Again: the 
same circumstancea may Ije observed in a widow, some considerable 
time at\er the decease of her husband. 

In instances like these, wlhit is to protect the fair fame of the 
parties but the testimony of the medical man that such occurrences 
may be entirely consistent with individual purity? In order to 
illustrate this point, let us suppose, in the former instance, that the 
female is pregnant with twins: in an early part of the gestation 
one of the germs dies, and the other reaches its full term of deve* 
lopment. The germ which survived for so shoit a period is trans* 
formed into a degenerate ma^sa, and continues in the uterus for 
some nmntha after the birth of the living child. In the second 
case^ the female becomes impregnated before the demise of her hus- 
band, but the germ, instead of progrcsiJiing through its various 
phases of development, from some cause or other becomes changed 
into a molar body, and may continue its sojourn within the nterna 
for months after (he widowhood of the female. When, therefore^ 
I tell you that such contingencies have occurred, is it not import* 
ant that wc should be somewhat reserved in the expression of a 
prejudicial opinion in either of these citations, without sotne 
broader foundation tbati the isolated circumstance — that a mole has 
been expelled? 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



287 



WillioiU yieliiin^ the slightest endorsement to the fanciful pio 
lure^ dmwn by some authors of tlie striking resemblance between 
uterine moles and ceitain animak^ such as lizards, screech-owlii, 
monkeyi*, frojpfs^ etc., yet it h well to remember that the mole is not 
of a uniform aspect, but will assume a variety of «bapes and tigurea, 
and Htill exhibit all the evidences of a true mole» 

Tlie folJowini^ interesting case, in which I |>erformed, almost in 
extrtmUj an important operation, may not be without instruction, 
as having a beaniig^ on the question now under consideration ; 

On Wedncf^day, April 7, 184^, Mr. D, requested me to pay a 
professional visit to his wife. She had been attended for several 
weeks by two medica! gentlemen wlio, on the day before I saw her, 
had volntxtarily withdrawn their attendance under the conviction 
that her case \vaa without remmly, and with the opinion fully 
eJE pressed to Mrs. D. and her friends that, in all probability, she 
would survive but a few houra. Her husband, in his interview with 
me remarked, that he was without the slightest hope, he and bis 
friends having watched with the sulfering patient t!ie two previoua 
nights, expecting her death at any moment. With such a repre- 
sentation of the case, I frankly told him I thought a visit from me 
useless, but if it would afford him any gratification I would cheer- 
fidly accompany him. He repeated his desire tliat I should hoc his 
wile. On being introduced into her chamber, I foimd her lying on 
her back, her face pale and emaciated, with every indication of 
extreme prostration; the expression of her countenance also gave 
evidence of great suffeiing. Her pulse was thready, and beat one 
hundred and twenty to the minute. Such was her exhaustion that 
when I addressed a question to her it became necessary for me to 
place my ear to her lips to distinguish her answer, and even then 
the arliculaliou was almost inaudible ; in one word, the appearance 
of the patient wai? that of a dying woman. Her respiration was 
labored, and the abdomen as much distended as is usual at ihe ninth 
montli of gestation. 

On percussing the abdomen, I difltinctly recognised fluctuation; 
m attempting to introduce my finger into the vagina, with a view, 
if poHsibk*, of ascertaining tlie character of the enlargement, I felt, 
at the opening of the vulva, a soft, elastic tumor, projecting through 
the mouth of the womb, which was dilated to the size of a dollar 
piece. The parietes of the os uteri thus dilated were extremely 
Itenuated, and did not appear to be thicker than common wriiing- 
psper. I found no difficulty in introducing my finger between the 
tumor and internal surface of the cervix, the adhesion being so 
delicate as to yield to the sligfitest effort. I satisfied myself that 
there w*as no action in the womb; the patient had not experienced 
atiy thing like labor pmns, a!id the dilatation of the cervix was the 
result merely of mech:iniral pressure produced by the tumor within 



4 



288 



THE PIUNCIPLES AND PRACTICE OF OBSTBl'KICS. 



the litems. Wbile pressing gently with my finger on the mfiiov 
ns it |ire!*c»iited at the mouth of the womb, aijtl grasping wiiJi tho»J 
other hand, the abdominal enlargement, I conld si second tlnii 
distinctly feel fl actuation* Again: in placing my fmgcr on the^ 
outer portion of the posterior lip of the uterus, rmd seizing wit li the*] 
iher h;ind the upper surface of the tumor through the uhdominal^ 
rails, altoruulely elevating and depressing the two handf^ it wafJ 
evident that I embraced the womb itself, which was immenfldji 
distended by the growth of the tunn>r. In making an ex 
per rtrfum^ the enlarged uterus was detected without diflieultjT. 

The?ie circumstances^ together with the important fact, that tbi 
abdominal enlargement was uniform on its surface, possessing 
nothing of the features usually attending extra-uterine groirlbSi 
such a-H ovarian and fibrous tumors, caused me to arrive at the ooi^ 
elusion that J in the present ease, the tumor was exclusively inlira- 
%tttrine. It will be perceived that, on this decision, depended the 
remote hope of giving to the suflTcring and almost dying patient even 
temporary relit^f from her agony. Ha\ing, therefore, formed mfi 
jmlgnu^nt as to the seat of the turnor, and partially as to its natnref 
I stated to the husband that, denperate as the case was, and immi*^ 
nently perilous as would of necessity be any attempt to remove thckl 
tumor in the exhausted and nearly hopeless situation of his wife,! 
yet, it wjis my ojvinion that it could be removed, although th«1 
serious hazard was^ that tM patient would sink under the opertkm^\ 

tiofu 

This opinion was given empliatically, without reserve, and anae- 
npanied by a word of comment, calculated to urge consent to i 
perntion, which presented but little prospect of permanent relief] 
and coedd only be justified by the reasonable expectation that, if 
the patient bhould survive tht! removal of the tumor, her suffering 
wotdd be mitigated, and her progress to the grave renilered cou 
parativcly comfortahle* Tlie opinion was communicated to th4k| 
patient by her hushaml, and she expressed an unqualified de^re tl 
the operation should be performed without delay, remarking ihatJ 
she was prepared to encormter everything, even deatli itself, with ' 
the remote hope of temporary relief from the agony occasionetl bj 
the pressure of the tumor. The husband and friends aeqaiesciikg 
in this appeal of the unhappy patient, I left the house for ilt« 
necessary instruments, promising to return in half ati hour and 
form the oj»cration. On my return, I was accompanied by Dr»J 
Detmohl and two of ray pupils, Messrs, Woodcock and Burgees,' 
These gentlemen heard with me the following particulars of tlie 
case, as related by the husband and sister of tlic patient: 

Mrs, D» was forty-seven years of age, and married in 1832* Sooil 
after her mamage she was attacked with cholera ; during her ooiK 
valcscence from this disease, she miscarried. Her health had beeifc 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 



289 



more or le^s infirm for tbo last ten years. Her menstrual periods 
hfttl always been regular, with the exception of the last year, dunng 
which time they occurred onee in two or three mouths, and then 
not freely* This !*he imputed to ehmige of !{fe^ find the eircum- 
Btnnce <lid not attract any special attention. Her abdouieu had 
l»egun to enlarge in July, 1849, and continued to do so to the 
pi-'esent time. In January last, she suflered greatly from distension 
of the bladder, and could not void her urine except in small 
quantitieis accompanied by excessive pain. For this she consulted 
a medical man, who found it necessary to introduce the catheter, 
from time to time, to relieve the bladder. She commenced as early 
as January to be constipated, and defecation was attended with 
excrnciatmg suffering. These difticulties about the bladtler and 
bowels continued to increase, and for w'eeks befori* I saw h^r, she 
repeatedly passed over ten days without an evacuation —medicines 
having no effect, and injections, per rectmn, immediately returning 
without biiDcinir away any faecal matter. Her urine was voiiled in 
very small quantities, not more than two tablespoontuls ut a times 
imd it was nearly the color of blood. It was itufiossible for her to 
evacuate the bladder, except when resting on her elbows and 
knees; this position, howT^ver, occasioned so much fatisjue, that, in 
her present exliausted condilion, she could not avail herself of it. 
In a word, the agony of this unhaj^py sufferer was induced .almost 
entirely by the pain consequent upon the attempt to evacuate either 
the bladder or rectum. 

With these facts before me, together with a knowledge of the 
position and bearings of the tumor, it was not diflicnlt to arrive at 
the import .ant conchision that the pain and distress in the hlatlder 
and rectum were due to mechanical pressure of the intra-uterine 
growth. At my request, Ur. Detniold examined the patient, and, in 
view of all the circumstances of Ihc case, concurred with me in 
opinion that, without tin operation s/ie cotdd sunn re but a few 
hotiTB f lehile if she did not sink under the attempt to remove the 
tumor^ her distress would be sensiH*/ palliated^ and her life possibly 
jnged, 

^"With the understanding, therefore, of the uncertainty and im- 
mediate danger of the operation — an understanding fully appreciated 
by the fiatient and her friends, I proceeded to remove the tumor in 
the following manner: 

^A mattress was arrangeil on a table, and Mrs. P, placed on her 
ek, her hips being liroaght to the edge of t!ie mattress, the 
thighs flexed on the pelvis, and an assistant on either side to sup- 
port the feet and Und)S. I then introduced the index finger of the 
right hand into the womb, steadying the tumor with the other 
band applied to the abdomen, and aticcee«led in directing my finger 
its full length between the tumor and cervix of the uterus; this 

19 



290 



THE PRINCIPLES AND PRACTICE OP OBSTETRICS, 



was done with great canlioTi, for the parietcs of the cervir were 90 
extremely thin, that indiscret^t manipulations would almost 
tainly have produced rupture of the organ. With a vieir, the 
fore, of obviating such a rosolt, I thought it more desinible 
bi't'nk up the adhesions of the tumor siraply with the finger tha 
incur the hnxard of inlroducing instruments into the uterine c&vtt] 
1m ]»roportion as the adhesions yielded, I grasped the tumor, an 
without much effort was enabled to remove it with my baud 
jfrfigmeutH. Having brought riway in thi*i manner all the solid por 
Hions, nud carrying my hand well into the cavity of the womb, ! 
distinctly felt a sac pressing, as it w*ere, against my finger, I in 
raedralely ruptured this, and there escaped, by measurement, tlu 
quarts of fluid whieh resembled in all its physical qualities, with the 
exception of the smell, pure pus. This fluid was collected in a vade 
as it passed from the womb, and half an hour ai\erward on examin- 
ing it, we found it no longer liquid, but presenting a solid maaa, 
pearly, like hardened lard. It was evident, therefore, that the 
temperature of the body kept this substance in a fluid state. As 
goon as the fluid had escaped, I introduced my hand still higher, 
and felt something in touch resembling human hair. It wus^ : 
feet, a mass of human hair malted together^ with no other vestlg 
of an embryo^there was no trace of scalp or anything else save ' 
hair. I grasped this body, and removed it from the womb ent 
it being so compact as not to separate in fragments. 

The uterus, thus freed of its contents, contracted, and there i 
4\o loss of blood. After the solid parts of the tumor bad been 
r^xtractod, there escaped from the bladder an incredible quantity of 
liigh-coltirod urine, which gave such relief to the patient that it 
caused her to exclaim, in simple, yet emphatic language, "Doctor, 
I am in Heaven I" It may here be asked why the catheter bad not 
been introduced before commencing the operation. In answer to 
this very prtq)er question, I would merely remark that every legiti- 
mate attempt had been made to effect this desirable object, bat 
was found physically impossible — without inflicting serioua injc 
on the patient — from the pressure of the tumor on the neck of tht 
orgnn. 

Mrs» D. bore the operation with a heroism which greatly surprise 
tis; and although it became necessary to suspend all manipnlatioc 
to mlly her from tainting, whieh occurred three different times, 
yet, considering her extreme prostration, it may well be deetned 
4 matter of amaxement that she did not sink. The operation being 
completed, the patient was placexi comfortably in her bed. Iji the 
course of half an hour, her breathing became easy, the pulse fell ton 
Veat-s in the minute, and there was an expression of composure 
about Iter countenance, which gave sincere joy to all of us, feeling, 
\ "wc did, an intense and unaflected anxiety as to the immedu 



THE PRINCIPLES AND PHACTICE OF OBSTETRICS, 



291 



sue of tho case, Withoiit the aid of an anodyne, she fell into a 
sleep wliieli lasted six hours, the first repose she had enjoyed for 
many Jong mghu of agony. 

When she awoke, she appeared greatly refresliedt and, althoit^b 
extremely prostrate, seemed to take pleasure in gazing on her 
friends, to eaeh of whom she gave a look of recognition. In the 
morning after tiie oj>eration, her bowels were spontaneously and 
freely moved, a large quantity of hard Ikcal matter passing away. 
Subsequently, injections, simply of warm w^ater, Nufficed to afford 
her a daily evacuation, and tlie mine was dischargeii ireely and 
without obstruetion. 31rti. D. continued to improve in appetite, 
digestion, and strength; and, although her friends were admonished 
not to be too sanguine as to her recovery, yet they regarded the 
fear of any aiber issue as utterly groundless. On the 22d of April, 
fifteen days at\er the operation, she began to fail,* and in defiance 
of everything which could be brought to bear in her case, she cson- 
tinned to sink, and expired on the 25th of April, having survived 
tho operation eighteen days. 

I have no doubt the anomalous mass found in the womb of tliis 
patient was the product of a blighted ovum^ and it nuvy be rea«oa- 
ftbly asked wlietfier her chances of recovery would not have been 
greatly enhanced if the tumor had lieen removed at an earlier 
perit)d, before the powers of the system had become exhausted by 
long-eoutinued and uninterrupted sidrering. The adhesions, it wiU 
be remembered, of the shapeless mass to the internal surface of the 
womb were slight. 

The stearine, winch escaped after the sac wa-s ruptured, I ix^gard 
as nothing more than tho fallal brain, and other liitty portions of 
the system, in solution. These eireumstances, together with the 
quantity of human hair removed from the uterus, and iho fact that 
the tumor wtxs eoniparatively of rapid growth, are, in my judgment, 
conclusive proof of [uevious conception. 

FaUe Moks — Molw Spurice, — These wull embrace all the sub- 
stances formed in the uterus, in no way connected with impregnar 
tion — such as polypoid and fibrous growths, blood clots, the mem- 
brane of congestive dysmenorrho^a, and, perhaps, the true uterine 
hydatids denominated aeephalacysts. It may be mentioned here 
that the mucous polypus has oft^n been confounded with the mole 
due to a previous fecundation. 

Young girls will sometimes, after extreme local suffering, expel 
substances more or less solid from the uterus ; in eases like these, 
the medical man cannot be too much on bis guard^ — a shade of 
doubt expressed by him will immediately be interpreted adversely 
to character; and rumor, with her thousand wings, will soon eon- 
sign to infamy the purest and most f^potless. Remember, gentle- 
men^ that the young girl who has become tlje object of suspicion la 



202 THE PRINXIPLES AND PBACTICE OF OBSTETRICS, 

worse than the withered flower — n:iy» she is the npas of society — 
her v<?ry presence is avoideil, for tfie reason that soriiil contact witU 
lipr begetj*, as it were, an atmosphere of pestUeiice, cleAtruetlve 
alike to all who breathe it ! A man may be gnspeetetl of forgery, 
AUtl vol, by a chain of irresistible evidence, he njay prove bb inno- 
cenc(% and become restored to soriety. So may one of yon bo 
charged with the high cnrne of jnnrder, and yet it may be in yoiii 
power to demonstrate with mathematical certainty that yon art 
unstained with the allt*ged victinrs blood. But how different wilb 
womnn, whoso tlKistity is onvv quest toned ; no eloquence can 
appeaBC the eredtilous in her bebalt^— no proof can emancipate lirr 
from the damning influence of snspii'ion — ^tbere she is, repulsed aad 
scorned, althongh as irnrnaenhite as purity itself I 

Look to it, then, aud see that yon do not sacrifice character by 
hasty and unju!*t tleeision^?. 

Even in the days of Hip|>ocrates it was admitted that substances 
will sonietimea be expelled from the uterus of strong, plethorie 
young girls^ aud this, too, in f perfect keeiiiug with iheir cha:nity» 
That elever olmerver, Guku, to whom we are irult-bted for so tnucb 
that is sound and practical, contended that, as hen$ will occasion* 
ally lay eggn without the tread of the cock, in tli© same way will h 
be |x>f<silile for femules to generate moles independently of sexual 
intercourse,* I ifuagiue there can be very little doubt that tht 
subhtances alluded to l)y Ilippoerate^, as being thrown from tlie 
uterus in robust and plethorie young girl*t, are identical wilb what 
will be observed ofientimes in congestive dysmenorrhtpa. 

I have, yrni will recollect, when speaking of " menstrualioD, 
reiniuded you that the eaiameuial fluid conHista of two distinct 
elements, viz, blood and epithelial mucus. Some writers, among 
Others, Dr, T^ler Smith,! nndutain that the mucous membrane 
itselJ' passes off at each menstrual tnru ; but this I think h not so. 
As a general rule, it is aiuiply the epithelium, the surtace covering, 
as it were, o( the mtieous lining, which is expelled from the organ 
With the menstrual fluid, and the epithelium is again reproduced, 
only to pass off at the following monthly evacuation. On the other 
band, however, it inunt be conceded that the mucous membnin« 
itself has oecasiunafly been recognised in the expelled miiss. Plater 
long MLUCc published a case of tins natnre in a paper entitled, Molm 
incipie«Ui9 frequcfis dejcctio / and Morgagni has described, with 



* The hd of hens and birds occasiooaHj throwing off ciggs wtttiout tlw Imd if 
Iba Qock, is phyiiioUygicany cxtrcmoly intereaUug. These e^Kga are luH Uie resull <f 
ilQundfltioii, but merely the oQVipring of exciteiiienC. They am diN^idiioua, uiut eaa- 
aot bo Lacubtited, for tlio ix^ason that tliey Imvo not been vilntiryed by tho RMku 
Tliere is a strict antilogj between these eg^s sind the ovules, whleh pass wilh tiM 
^Uitnbuud fluid from tlu* huniiiii lemiile nt each meiistrufll liun. 

f Lectures on Obgtcirica, Gai-dner a edition, p. 95, 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



293 



n*nt minuteness, a meraVvrmie thrown from the uterus, which pos- 
sed all the characteristics of the mucous covering of that organ.* 
Ill the congestive type of dysmenorrhcea, it not unfrequently hap- 
pens that, in consequence of the extraordniary afHux of blood to 
the mucous lining of the uterus, there h poured out a qujmtity of 
oosgulahle lymph, analogous to what occurs on the internal surface 
of the larynx in the membranous Ibrni of croup. This exudation 
of coagulable matter becomas so to f^peak^ a foreign substance 
within the uierine cavity; its presence stimulates the uteruf? to 
contraction ; and, hence, there will be recurrent pains, simulating, 
in tlieir general character, but in a much less exaggerated degree, 
the throes of labor. Finally, this substance Ls expelled from tho 
uterus, and the pain subsides. 

Xuw, gentlemen, thin is not at all unlikely to occur in a young 
girl whose purity is beyond suspicion. Yet the phenomena to 
which I have just alluded may blast that girl's character if you are 
not prepared to show that they are in f»ei'fect accordance with 
chastity, and are the result himply of a pathological condition of the 
menstrual function. This coagulable lymph will sometimes be dis- 
charged in shreds or patches, and again it will assume the form of 
a sac or membrane, exhibiting a complete cast of the uterine cavity. 
In the Gazette Medu'ule^ of Farii*, | there is recorded by Dubois, of 
Neufchatel, an iuterestintij case of a young woman who, at each 
menstrual period, expelled a hollow, membranous body, correspond- 
ing precisely with the shnpi' «>f the uterus. 

Besides this menibrane, iheiewill sometimes be thrown from the 
virgin and iminipreijjnated female, other substances; such, for 
exjiniple, as small, fibrinous masses, which appear, at first sight, to 
he organised, but oftentimes are eimply coagnla of blood ; and 
.fgaiJU there will be observed scales of epithefurm, which, by possi- 
%Hity, might comj>romise tlie ehariicter of the woman. Therefore, 
in all such cases, where suspiiion is on tlie aleit, it is your duty, 
by a careful examination of these substances, to decide as to their 
tniG nature, so that, by the strength of your professional opinion, 
you may at once do justice to the girl, whu has not only selected 
you as the guardian of her health, but at the same time the pro- 
l£utor of her honor. In the ease of the discharge of epithelial 
fragments, either from the uterus or vagina, the microscope will 
readily enable you to recognise the scales or squama*, which consti- 

* FoIHn, L^bort »rid others hAve reoognised In the dyfunenorrhoMil membrine the 
Iblbwing p«>ciiliiiriLieg, known to cxi«t in the mucous tissue of thu uterus: 1, Cou 
ftidcmblc tlMckneaa, grt?aler thiiti ihnt of any of tlie raucous surfaces of the body. % 
Tubiiknjs fflanduk*^, tvadily detectcii witli a leoA, and visible even to the iiaked eye 
3. Tht^e g^lMud tiles art^ united to each other by a fibro-plastic tiasuo and blood*vo9- 
fil^ which to}jr«.nher ctinstitute the demfis of rouooys metsibraziea 

f See Gazette Medicale, p. 7^9. 1817. 



294 



THE TRINCIPLES AND PRACTICE OF OBSTETRICS, 



tttte their characteristics ; and »o, too, with regard to the tibrinoufl 
concretions ; these are usually small, alraond -shaped bodies, with ftn 
Uf>defined central cavity, and a smooth exterior* In none of these 
Bubstancc*, of course, will there be the slightest vestige of any of 
the fiptal annex£P, such, for example, as the villi of the chorion, 
fragraenls of the placenta^ or umbilical cord ; and for the b<M 
possible reason, that their production is entirely independent of 
fiexua! intereoui^se, and consequently of pregnancy. 

T conld very readily multiply authorities on this question, b»l 
sludl content myself with the following: Lam«iweerde* dindcua 
moles into two kinds — one he calls the mole of generation, the 
other the mole of nntrition ; in reference to the latter, ho nffimu 
that a fleshy tnmor may spring in the virgin womb from the matter 
of nutrition — ** 3foia nutritionis.^* This author i?»sists that, for tlie 
production of tlie mole of generation, coition is absolutely ncce<8ary, 
Ruysch, t spcalcing of false moles, says, *' Such moles have been 
forced out by virgins, or, at b:fast, by such as were not suf^pected of 
being otherwise/' The following is tlie language of Van Swieten :J 
** It is certain tliat all tln«se mnsses called moles, which coniajd a 
hnman embryo, and those whieh are formed by the corruption of 
the little placenta left in the womb, cannot be produced without 
coitioiK But it in equally certain that the sarcomas of the womb, 
and the masses that t^pring from clutted Vilood^ may be generated 
without any coition. But as these are comprised underthe general 
name of moles, it is evident that the name of moles should be used 
with great caution, lest untnluted virgins and chaste widow's should 
be branded with the infamy of incontinence f" 

Can Tntt Ilydatkh form i«, and be es^peUed from the Ui^- 
rusf — It has already been remarked, that what are known as tnie 
hydatids have no connexion whatever with a previous conception; 
they arc entirely independent in their origin of any such influence. 
Therefore, it is a question of vmqualified interest to inquire whether 
it be i>ossible for them to be generated within the uterus. It is true, 
science has but slender evidence recorded of the true hydatids 
being discharged from the utertis; and tlie general belief is, that 
they cannot originate in that orgaru Rokitaneky,^ certaijdy a good 
authoiity, says, *^ Cysts are very nirely formed in the uterus; we 
have not met with a single example in Yienna, and I myself have 
only inspected one case of uterine acephalocysts." Here, then, 14 
an admission that, in one instance, at least, the true hydatids have 
originated in the uterus, Tlic admission, therefore, of thi» one case, 
while it proves the extreme raiity of the oecurreooei ooDclusivelj 

• Hiator. Molar, Uteri, cup. 1, p. 13. 

f Obaervat Atmtomia Clumr.f p. &4. 

J ComineDlari^t on Apho» oTBoerhmave, vol xlv,, pi. 180. 

g rntliologicul Anatomy, vol, iL, p, 291. London, 1S49< 



THE PRINCIPLKS AND PRACTICE OF OBSTETRICS. 295 

establishes the fact of the possibility of these formations. Indeed, 
I do not understand what there is in the anatomical structure of the 
womb at all incompatible with the growth of these acc})halocysts ; 
it is universally agreed that they are found in other portions and 
structures of the economy — why not, also, under certain circum- 
stances, may they not originate in the uterus? 

But a most material question is this: Have we any reliable 
means of distinguishing the true hydatids from the produota 
originating from the degenerated villi of the chorion ? This ques* 
tion may be answered affirmatively — under the microscope, and 
sometimes with the naked eye, when true hydatids exist, it will be 
observed that the cysts are inclosed one within the other; on the 
contrary, in the hydatitorm vesicles, these latter, which may be 
rounded or oval shaped, are attached to each other by slight 
pedicles, and have not been inaptly compared to a string of beads.. 
These distinctions are now recognised as ample to prevent any 
possibility of confounding the one with the other. The conclusion^ 
therefore, is manifest, that, in all cases, in which these bodies, of 
either class, are discharged from the uterus of an unmarried female 
or widow, no deduction adveree to the party should be drawn- 
except upon the evidence just mentioned; for science fully justifies 
the evidence. 



LECTURE XXI. 



Labor— Multiplied and UnprofitaViIe DWieinoB of; ClAssificHtlon of th© Aothor ieto 
Natural nnd I'reUTiiuturai ; Labor consmta of a Beriei of ecte — lm|>ortMni Practi- 
cal Di'^uctioii e<muecle(i with i\m Sueoeiiision of Fljtjtioiiiciiit ; Dumtiun o( Freg* 
nancy — Wlten docs it Tenuinale f — Tliu Original Mcxie of Ctilcitlulttig Time; CaloU' 
dar and Lunar Montlis — Ua& Prct;n«iicy ft Fixed Durntiim? — The (•iifUaer 
Peempc Case^ — Confliciing Oi«iuona; Testimony of I>esormouux — Tlie DkI« S^ 
poleou io reference to Tardy and rremnlure Births; Kxperlmcnla of Tnaler; 
Tropical Heat and Yei^taiioD — How ia the Period of Pre^^nancy to be MOtr- 
tawed 7 — ^The various Modea of Calculation — Dr. Reid'a Kxperitnentd in reteretkm 
10 4 Single Coitus ; Kaegele's Opinion ; Dr, Cliiy. of Munch eat c^r — Inlliieucv of tka 
Age of the Parent; on the iJiiration of Prej^riijncy — Can a Femalo be KcKTiUMlaled 
during her Menstrual Period ? — Case in Illustration. 

^•fntlemex — We have now^ in the order of succession of sttbjccts« 

reached an important aiul itUercRlinfX topic — one Avhich will neecftaa- 
rily ilertjaitd iiiiich ftltfiition, for it ismoni intimately conrieoteil with 
your duties in the lying-in ehamber — I mean labor. I am wcil a 
little surprised at the singular inid niiiltiplit'd divlMons, wltirli dif- 
ferent auliiurs have given of parturition* Itk my lioni*Ht judgment, 
these divisions tend more to eom plicate than siniplify the mibjeou 
Wilhonl, iherefot*e, embarra?i8ing yf»u with what I am dispof^d to 
tei*m imiit^cessarily niinutL* dassilicatious, I shall present yt»u with a 
very f^itniile divisjuri of htbor, which, I tliink, you will reoogobe to 
be in entire accordance with the revelations of nature. 

J}ivhhn8 qf Labor* — Lubor^ for all practical pur^Kisi^s, is cither 
natural or pre fertiat a raL Niittiral labor, we drtiominale that furm 
of parturition in which delivery h effected by the unaided efforts 
of nature ; or, in other wordsi, without the assistance of art. But, 
in order that nature rnay be thus adequate to the discharge of this 
duty, certain ecuiditionii are demanded botfi as regards the mother 
and child» and these c'ouditioiis we shall emmierate in detail hereaf- 
ter. Preternatmal hilior, on tlie other hand, as its name iinplieti, 
is contrary to ihe natnnd ]>roees^» and therefore, needs the intur- 
position of seteuce. It may be divided into matvutl and inatru- 
menttil ; in I fie former, the introduction of the hand is necessary to 
overcome the obstacle; in the Inuer, the hand being in»u1tiejent^ 
the employment of ins^trnmertts i-^ iu<Jicated, Instead, therefore, of 
calling labor teiliotis, com plicated, laborious, or di0ieuU, after the 
cxam|jle of tnost writers on this subject, we propose to discujts the 
vjirioua topics and dutiet» connected with human parturitio*!, under 



THE PUINCIPLES AND PRACTICE OF OBSTETRICS. 297 

the two divisions of natural and preternatural labor — divisioDS 
wbicli will not only be recognised as just in the lying-in chamber, 
but which will embrace every possible contingency that may arise 
during the parturient effort. 

Natural labor, when accomplished, may be said to be the separa- 
tion of the mother and foetus ; it is the transmission of the latter 
through the maternal organs, in order that it may enjoy an inde- 
pendent existence, for which its previous uterine development has 
prepared it. Its organization is now so complete, that, when 
thrown into the world, it can breathe, and elaborate its own blood ; 
it is no longer dependent upon the functions of the placenta ; in a 
word, its birth constitutes it physiologically an independent being. 
This expulsion, however, of the foetus and its annexje from the 
parent womb is not a sudden and abrupt act — on the contiary, it is 
a deliberate effort on the part of nature — made up of a series of 
successive processes which, when in completion, constitute parturi- 
tion. It is this very succession in the order of phenomena, which 
guarantees safety to the child, and immunity to the mother; so 
that, under ordinary circumstances, natural labor may be regarded 
as one of the functions of the female economy, in no way necessarily 
compromising human life; and I am quite certain that it is to 
"meddlesome midwifery" that much of the fatality of the parturi- 
ent chamber is to be imputed. 

The usual processes to which I allude as connected with the 
accomplishment of labor are, in the order of sequence, as follows: 
1st. The uterus contracts, the result of which will be to dilate the 
mouth of the organ ; 2d. The membranous sac or ''bag of waters'* 
is formed, and becomes ruptured, affording escnpe to the liquor 
amnii; 3d. Afler the escnpe of the amniotic fluid, the uterus grasps 
more firmly the body of the foetus, resulting in an increased expul- 
sive force, which acc'omi)lishes its delivery ; 4th. The placenta and 
its annexaj — the cord and membranes — are then expelled ; 5th. 
There is for some days a discharge from the vagina, known as the 
lochia. These, therefore, make up the chain of acts, or processes, 
which, in the aggregate, constitute child-birth, when accomplished 
by nature herself. Does not this very order of })henomena inculcate 
upon the obstetric student the order of his duties? It should 
empliatically impress upon him the necessity of studying nature in 
her own inimitable ways, so that when she is embarrassed by cir- 
cumstances, which she cannot control, he may be there to act as 
her substitute, and render the needed assistance. 

Duration of Pregnancy, — As preliminaiy to the consideration 
of your duties in the lying-in room, it is ])roper that we should 
examine three interesting questions — the period, the causes, and 
the signs of labor. The period at which labor commences, neces- 
sarily involves the discussion of the duration of pregnancy; for it 



298 



THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 



IB evitlent that the termination of pregnancy is but the adycni of 
labor. The duration of pregnancv, you must at once perceive, u a 
question of no trifling import; for the honor as well as the nghlft 
of individuals will oftentimes depend upon a just decision of thi« 
point. The popular opinion, endorsed by the general voice of tho 
Profession, is, that the human female carries her infant nine months. 
Now, then, the question anses — can a female be sfjontamrously 
delivered before the expiration of this period — or can nhe retain the 
foetus beyond the nine months conmstently with fidelity to htT hus- 
band, anil the civil and social ri^^hts of her child? 

The term nine months is too indefinite — it is wanting in preei^ion, 
and for the very obvious reason, that between calendar and bmar 
months there is a fixed difference; so that nine bmar months or 
nine calendar months represent an important difference in time. 
Each lunar month embraces a period of 2S <lays — so that ten lunar 
months are equal to 280 days or 40 weeks. Nine calendar months, 
on the contrary, including February, represent 273 days, Of 39 
weeks. It is, therefore, pcrha]*s, better, as many authors have 
done, to fix the period of human gestation, not at nine months, but 
at 40 weeks, or *^80 days. There can be no doubt that, as a gene- 
ral rufe^ 40 weeks ciiustitute, with the exception of two or thnMi 
days, the true period of fcrtal existence. But is this rule so gene- 
ral — in a word, is it so universal, that it admits of no oxcepiions ? 
This is the plain putting of the question — and we shall now [»rnreed 
briefly to examine it, fur on its just doei*iion must depend the high* 
est social and legal interests* On this subject — as on many others — 
there is a dii!erence of o|union* It has been much discuMcd, and 
the advocates on either side — earnest in pursuit of truth, rJKCept 
when animated more by love of victory than of justice— ai*e arrayed 
against each other in the emphatic spirit of uncompromising eon* 
tro\ ersy. 

Tl-osc who contend that gestaiitui has a universally fixed dura- 
tion, and consequently reject the possibility of protracted or prema- 
ture births, found their opinion on tho following arguments; 1st, 
The uniform and immntab!e law^ of nature in the reproduction of sdl 
living beings^a law which defines, with unerring precisian, the 
periotl of gestation for each species of animal, 2d, Against the po#- 
sibility of protracted gestation, they invoke the aid of physical 
intlucnfe, for they maintain tliat the sojourn of the f<rtus in ulero^ 
beyond the alTotled time, would result in such an increase of vol- 
unie ixs, to render its safe tleUvery imfmssiljle. Tf*ese, I think, aro 
the chief arguments of^writei-s, who oppose the idea of a defmr 
ture from what they conceive to be tlje invariable standard of 
nature. 

In order that you may understand that this difference of opinion^ 
on the interesting question now under consideration, was not eon 



T&E TRIKCIPLffl AND PRACTICE OF OBSTETRICS, 



299 



fine«l to tlie men of the past ages, I sliall cito the following impor- 
tatit Cttse, which w.as tried m the House of Lords in 1825, known 
as the ct4eb rated Gardner Peerage Case : 

Allen Legge Gardner,, the son of Lord Gardner, by his second 
wife, petitioned to have his name ioseribed as a Peer on llie Parlia* 
ment Ro!K The Peerage, however, waa claimed by another person 
—Henry Fen ton Iadi» — who alleged that he was the son of Lord 
Gardner by his first, and subsequently divorced wife. It was con- 
tended that the latter wast illegitimate; and in order to establish 
this point, the evidence adduced was partly medical, and partly 
moral. Lady Gardner, the mother of the alleged illegitimate child, 
Barted from her husband on board of his ship on the 30th of Junu- 
ry, 1802. Lord Gardner went to the West Indies, and did not 
again see bis wife until llih of July following. The child, whose 
legitimacy was disputed, was born on the 8th of December of that 
year. Therefore, the plain medie:d question, taking the extreme 
view, was, whether a child born 311 days (fortt/'/our weeks and 
three days)^ after intercourse (from January to December), or 150 
dayjj {twenty-one weeks and three daya)^ from July to Decetiiber, 
could be considered to be ihe child of Lord Gardner. If these 
questions wereans^vered in theafhrniative, then it followed that this 
must have been a very premature or a \ery protracted birth. There 
was no pretence that this was a premature case, the child hnviug 
been mature when bonu The quesition, then, was reduced to this: 
Was this alleged protracted gestation consistent with medical 
expei-ienee? Many me<lical witnesses, comprising the principal 
obstetric practitioners of Great liritain, were examined on this 
point. Their evidence was very conflicting— five positively main- 
taining that the period of gestation was fixed; and therefore, 
denvnng ihe possibility of such a protraction. The other eleven 
flUHtained the affirmative side of the question, and concurred in 
opinion that natural gestation might be protracted to a period 
which would cover the birth of the alleged illegitimate child. On 
the moral side of the question, it was clearly proved, that Lady 
Gardner, ai>er the departure of her husband, was living in open 
adulterous intercourse with a Mr. ladis ; and, on this ground. Lord 
Gardner ob tailed a divorce from her after hiis return. It was con- 
tended that the other claimant was really the son of Lady Gardner 
by Mr. ladl^. The decision of the House was, that this claimant 
was illegitimate, and that the title should descend to the son of the 
lecond Lady Gardner.* 

There are two interesting points in this case: Ist. The extraor* 
dinary difference of opinion among the medical witnesses; 2nd, 
The undoubted proofs of adultery on the part of Mrs. Gardner, on 



♦ Tiijlor*fl Medical Jurisprudenoe» 5tti edition, p, 686. 



soo 



THE PRINCIPLES ANI> PRACTICE OF OBSTETRICS, 



which ground alone the case was decided against her illegilinuito 

offiipnijg. 

On this memorable occanion, the following was the opinion 
delivered by Sir Charles Clarke, certainly a roan of no doubtful 
reputation; "/ Aare nrvrr^^^ he said, ^^ iteen a slnfjh iust-afWf in 
which th<s htw» of nature have heen chanffed^ beftevinff the iaw oj 
nature to b€^ (hat parturition should take place forty weeks ajter 
eoncepiion.^^ There is an exelusiveness, might I not say, without 
meaniDf^ any dijire^ipi^rt, an arliitrary posiiiveness in lliis opinion, 
which is more in keeping with the dictum, of an ancient Uomaa 
Emperor, than with tlic requirements of scit^nce. But Sir Charles 
Clarke was not afone in \m views ; l»e was sustained* in his general 
asaum|>tion, by Prof. Davis, Dr. Gooch, and others of equal emi- 
nence, who maintained that women never exceeded the ordinary 
period i»f gc8tation, Stranj:;e to say, however, as nnanimous at 
the«e gentlemen were as to the cardinal point^ — the inimutability of 
nature with re^^^ard to the period of human gestation— yet there 
was an extraordinary want of concurrence among them as lo what 
measure of time thsit }icrio<l really is I 

Whether upon the witnesses stand, or in the professorial chairi 
the opinion of a 'medical man \^ worth nothing except when in 
accordariec with facts* Hypothesis Is one thiny:; rh:nr and well- 
established iaets anolher. It seems to nu^ that if human testiniony 
13 to be regarded, under any circumstnnee^t, a-s a guide for opimun* 
the possibility of protractetl as well as premature jrestulion is placed 
beyond a perad venture. There arc so many well-nuthcrjlieated 
cases, ihonnii^lily and es**enti illy truthful, in eonfirmntion of this 
Btaternent, that I cannot understand liow a contrary sentiment can, 
at least nt the pre<tent day, pre v nil. I think a most satisfatiorj 
and irresistible evidence of the possiljilify of a gestation protracted 
beyond 40 weeks, or 2Ka d:»ys is to be derivt*d frtxn the interesting 
ca!<c reeorded by the learned Desonneaux» and it afford** me much 
pleasure to advert to it, for the reason that, independently of his 
high ch'iraeter im- learning and moral worth, I fee! that I owe much 
to hiH perstiual kindfies;*, tor It was through his partiality that I wm 
admitted, for a perii»d of nearly tw<» years, into the 3Iaternll5 of 
Paris during which lime I had abund.int op|K>rttmity of witnejs&ing 
his ta<'t and skill. After remarking, that " Observations well 
attested, eonchisively show, tlint the term may be |)rolonged beyond 
the usual [ii^riod/' he iiitroduces the fallowing oaae as having 
occurred within Ikis own ex|ierience: 

** A lady, the mother of three children, became deranged after a 
severe fever. Xh^r physician was of ofiinion that |»regnancy miulit 
have a benefieial etfeet on the meiilnl disease, and |»erndlted her 
husb.nid to visit her; bat witl» the restrietion thnt there should Iks 
an interval of thre^ montha between each visits in order that, If 



THE PRIKCIPLES AND PRACTICE OF OBSTETRICS. 301 

ConcepUon took plaoe, the risk of abortion, from further interconrao, 
might be avoided. The physician and attendnnts made an exact 
nolo of the timo of the huabfind's visits. As soon as evidenecs of 
pregnmicy begnn to exhibit themselves, the visits were discontinued, 
Tlie lady was closely watched duri tjg the whole period by her 
fetnrile attendants. She was delivered at the end of nine ealentlar 
months and a fortnight, and Desonaeaux attended her* If the 
nine caJendar months were those of the smallest number of days, 
they would have cqiialicd 273, in addition to which mn^st be taken 
into account the days of the fortnight, which ^vill make 287 da}*^; 
but if the calendar nionth^ were not of the shortest peri<xl, there 
would be 276, to whicfi are to be added 14, giving an aggregate of 
290 days.'' 

I cite this case to show that nature does sometimes exceed the 
ordinary period of 280 days, or 40 weeks ; and it does seem to me, 
if it be demonstrated that, undi'r certain circumstances, nature dis- 
closes a dej>arture from t)ic usual pci'iod of gestation, it ia a con* 
cesaion amply sutlictent for science, without involving the necei*sity 
of showing on wliat this departure ia founded, or the conditions 
which regtdate it. There are numerous other cases recorded by 
authors of equal probity, exhibiting not only the occasional pro- 
traction of gestation, but proving, beyond a shade of doubt, that 
women will vsometimes bring into the world living children before 
the expiration of the 40 weeks. 

Let me here remind you that one of the most enlightened coun- 
tries of Europe, after a scrtipulons investigation of all the facta for 
and against the question, has enacted, by legislative decree, in the 
Code Napoleon, that a child born 300 days after the departure or 
death of the hus^baml, or 1 80 days allcr nuirringr', shall be considered 
legitimate, and, therefore, entitled to all its social and legal rights. 
It may, indeed, appear at lirst sight, that tlii^ enactment is one of 
too mtu'h latitude, and will often times afford a mantle for tho 
guilty. Be it so — but is that a jnstitiablo reason fJjr destroying the 
chanicter of the pure and innocent? Indeed, there are cases re- 
ported upon authority which we have no right to question, in which 
human gestation has been retarded many days beyond the period 
sanctioned by the Code Xapolcon. Dr. Simpson records, as having 
occurred in his own practice, cases in which the period reached 33G, 
392, 324, and 319 days. Dr. Mcrriraan, 298 days; and Prof. Mur- 
phy, 297 days. Dr. Atleo reports two caies which nearly equalled 
85tt days each ; and Prof. Meigs publishes a case, wliicb he deems 
entirely trustworthy, of 420 days. 

It is not for me to say that there was probably a misealculatton 
in some of these extreme cases ; but admitting the error, which I 
do not think at all unlikely, yet with such acute observers, and with 
no motive to subserve but that of truth, it must be conceded that, 



m 



802 



THE PRINCIPLES AKD PRACnCE OF OBSTETRICS. 



wiib a liberal niargm for error in computation, these examplea 
Bhould hi' accepted as un<loubted evidences of the fact that pivg- 
nariry will, occasionally, cxti^rid beyond 300 days. 

If the main proposiiioi) bo accepted, that the ordinary term of 
260 daya ia not the universal term of gestation, and of thift thei^ 
can bo no doubt, it appears to me an extremely difficult problem to 
fix the jKirtieuIar period of time, in which nature may be found to 
depart from her iisuat tstandard. After all, it must be adnutted, 
the only important point in the discu fusion is this: Is naturt, as 
r^gardif the period of human gestation governed by angJUed and 
iiHmuUd>it law^ or is the rule ichichnhe ohaerv^nt otdg a general on€^ 
^ultjef't to 0€Qas tonal ejKeptions / That the latter is true is moat 
jj^rfeetly demonj^t rated. 

If we turn, for a moment, from the evidence deduced from the 
observations connected with human gestation, and ejcamine the 
record of reprod^iction as it occora iu the lower animals, we shall 
find fKit only substantial, but very convincing testimony that nature is 
not governed by any uniform law as regards the particular period 
of pre^irtiancy. The experiments of Te&^ier, made with great care, 
and with every eilbrt to guard against the possabiliiy of t»rror, 
continued, too, for a jn^rlod of years, have revealed some extremely 
interesting facts. His experiments embraced various animals — 
cowij, mares, sheep, rabbits, &c^ ; and it should be remembered 
that the results gathered from these experiments are the more 
satisfactory, for the rea^ou that tlicy were not liable to the ^llacy, 
or exposed to the possible error contingent upon this species of 
observation in the human subject.. In 577 cows — and it h impor- 
taJit as well as interest ir»g to recollect the usual penod of gestatios 
in this animal i« the same as in woman — 20 calved beyond the 29dlh 
day, some reaching the 32 1st day— amounting to a departure from 
the ordinary term of within a fraction of six weeks. In 447 mari*s 
— ^the )>eriod of gesLation is 335 days — it was noticed that 42 foaled 
between the 35Dth and 41£»th days, so that in them the grt*atest 
excess wwi 84 days. In the- sheep and rabbits the same dis- 
crepancy was recognised ; while iu the hen, it was remarked tlmt 
the period of incubation was often protracted for three days* 
These results have been amply confirmed by other observei-s. 

The following are the observations of Prof. Krahmer, of Ualle^ 
made on the cow, and it will be seen that they accord, in their 
general results, witfi those of Tessier : 



J2 cows oalved in Uic 3Slli week. 



21 cc\v9 ctilred In llie 44th week. 
9 ** '* " 45th »' 
3 " '* *^ 46Lh " 
5 ** " ** 47th '■ 

4 48th ' 

1 *i " - Bigt - 



THE PHIXCIPLKS AlsD PliACTlCE OF OBSTETRICS, 

But, gentlemen, it kh iilioi;ether imnt'i*essary to acciiimiJate proof 
in su[»|»ott of the atHniifilive of tlie question. There van be no 
doubt that, in tlie great reproductive scheme, the general type is 
found to prevail throughout auitiiated nature ; and it niu8t abo be 
eonc'ccled that this type h !*uhjet!t to ocorisloual variations, which, 
becau^ic they cannot be adequately explained, shoulil i\ot, therefore, 
be rejected. In the vegetable kiugdoni, the inflnence ot cliniate 
and seasons is invariably admitted. Under the genial ray 8 of a 
southern sun, the earth sends forth its frnits with a precocity 
unknown to the more northern latitudes. i\Iay it not be that there 
is mme kindred, yet occult intlucnce exercised upon the human 
system which, in one case^ leads to a premature devetapmeut of the 
germ, while in the other, it retards the reproductive processes of 
nature ? This hypothesis, it appears to me, is about all that the 
present state of si'ieuce can furnish in explanation of premature and 
protracted births. 

I might have mentioned that Dr. Chai^les Clay, of Manchester,* 
w^hose name is so honorably interwoven with the operation of 
ovariotomy, iti which he has had must remarkable succciis, has pro- 
mnlged the suggestion that the duration of pregnancy may bo 
influenced by the age of the parents, and from the observation of 
rcases, which have occurred in his own practice, he believes that the 
younger the mother, the shurter is* the period of gestation. This 
theory corresponds with the very general lielief that the older 
the anima! the more protracted will be the duration of preg- 
nancy. 

From all that w*e have said on this subject, we may, I think, 
afely arrive at this conclusion — that the precise duration of prtff^ 
is fiQi positive^ Imt simpft/ relative. 

Period of Prtfjrtanty. — How is tiie period of pregnancy to be 

ascertained — or, in otlier words, is there any rule by whii-h the 

|term of an ordinary gestation can be i*8ti mated ? This inquiry is 

lone of more than usual interest, and will have a hearing on your 

duties as practitionei*s of midwifery; for you will often be qucs- 

joned by your patients in regard to the particular period of their 

station wnth a view of knowing when they may expect their 
approaching confinement. There are various modes of calcuhitioD, 
and I think they may be cJassified as follows: 1st. The peculiar 
sensations experienced by the female at the moment of conception ; 
2d. The period of quickening ; 3d. From a tingle coitus ; 4tK 
From the Inst menstrual period. Let us now examine brietiy, and 

order, each of these tests, 

I. Peculiar Sensatiotis, — Tire notion that a woman is made con- 
scious of the instant of her fecundation by a sensation, characteristic 



^ OhtWTAtioDs OQ tb€ Term of Utero-Gestation. By Chariea Clay, Ul>*^ p. 0. 



304 



TOE PRIKCIPLES AND PRACTICE OF OBSTETRICS. 



and pe<^uliui% is uot one of modoni origin. Tliis opinion has pre- 
Miik'd fur a lon^ tiine; indeed, it can be traced back tu UtppoeraU^ 
himself who, in speaking of conception, observed : *'Liqnido autem 
constat harnm rernm periti^ qnod miilier, uti concepit, statim 
inhorrescit, ct incalcscit, ac deiitibus stridet, et articalum reliquutn- 
quc corpus convulsio prehendlt et uleruni torpor, idcpie ii«^ qtins 
purai sunt, accidit,''* which may be rendered into our own tongue 
thus: It 19 well imderBtood by those Bkilled in these matters that 
the instant a woman conceives, she expcrieneoa a general shivering 
and heat; her teeth chatter, and the articulationi^ with other por- 
tions of the body are tfirown iiito convulsive movement, while tho 
uterus itsdf is attacked with numbness, and this occurs even to 
women quite pure. Van Swieten says, **From many obftervatiomi, 
we nre assured that women, m the act of copulation, when they are 
impre;4nnted, enjoy a more than ordinary degree of plea^^ure; thifl 
change in the female organ^s apprcq)ri:itcd to generation m aJj^o, with 
good ren.**nn, thouglit to be greater at the time of conception, thaa 
wlien coition is performed, without impregnation immediately fol- 
lowing/* f There is one insuperalile objection to thin theory of 
scns;itions as :\ guide for computation, and it i?*, that whatever may 
occur in individual caf*es, the fact is abundantly establtslied tliat oeoi^ 
sionally women will conceive who do not experience the slightest 
feeling id' sexual pleasure — they are as inanimate as the lied on 
whicli they repose; and, under such ci re imi stances, I have known 
ladies continue iQcreduloHs as to their true condition until the very 
approach of their labor, so fully were they imbued with the iHipular 
conviction that sexual enjoyment and impregnation bear to each 
other the necessary relation of cause and efieci. I am awaro thai 
some modern authors concede to this theory of sensations a very 
marked value; and, while 1 am willing to admit that, in certain 
ea«es, from some peculiar feeling, more readily experienced than 
explained, a woman may become satisfied that she has been fecun- 
dated, yet, as a general principle, the evidence is deceptive, and 
presents, tlierefore, no claims as a reliable test. 

II. 77tc Ptrhd of Quirkcmnff, — It is recommended by some 
writers to take the time of quickening as a rnle for caJcnlation, and 
they assume that, as the woman quickens at the fourth and a half 
month, it is quite easy to ascertain tfje termination of her pregnancy 
by the addition of four and a half months to the time at which she 
first felt life. The fidlacy of this rule must be obvious, if it be 
recollected that the time of quickening is by no means a fixed one. 
Some women feel life at four months, others a little earlier, othen 
not utitil the tit\li mouth ; again, in some instances, the euuro term 



D<» Camibu5k cap, 8, torn, v. p. 30!l. 
f CommentMrici up<m AphoriAQU <4' BoerUaavo. vul. 13, p. 369. 



THE PEmCIPLES AND PBACTICB OF OBSTBTRICS. 305 

of pregnancy will pass without the slightest consciousness on 
the part of the female that she carries within her a living being.* 

in. From a Single Coitus, — Efforts have been made to deter- 
mine the duration of pregnancy by calculating from a single coitus ; 
but it is very evident, that this mode of computation is liable to 
much deception, for the reason that the majority of such cases 
would most probably occur in the unmarried, who, of course, to 
diminish the measure of their shame, would very naturally refer 
their impregnation to a solitary intercourse. Some interesting 
statements, however, founded upon researches conducted with 
every care to elicit truth, and guard against the possibility of error, 
have been made by Dr. James Reid, in regard to the question of a 
siDgle coitus. The following table, embracing forty-three cases, 
collected by him of conception, supposed to have resulted from a 
ringle intercourse, exhibits features not unworthy of attention : f 
260 days after single coitus, delivery occurred in 1 

263 " ** " ** " 1 

264 «* «* tt u « 2 

265 " " «i w •* 1 

266 " ** " " " 2 
270 ** '* " " *' 1 
27]^ " <( « «( « 2 

272 " " " " " 3 

273 " " " " " 1 

274 « « <( t( « *7 

276 '* " " ♦* " 2 

276 " " " " " 6 

278 " " " " " 1 

280 " '* . " " " 3 

283 " " " " " 2 

284 " " " " " 1 

286 *' " *' " " 1 

287 " " " " " 2 
291 " " " " " 1 
293 " " " " " 2 
296 *• *' « « "1 
300 *' " " " " 1 

According to this table, the duration of pregnancy, dating from 
a nngle coitus, will average about 275 days; and Dr. Reid deduces 
the fact that, from a single coitus, the time will be 39 weeks, while 
in calculating from the last cataraenial turn it will be forty ; and he 
accounts for this difference of time on the supposition that from two 
to six days will probably elapse after the last catamenial evacuation, 
before fecundation is consummated. Dr. Montgomery presents an 
analysis of twenty-five cases of gestation, dating from a single coitus, 
the average duration of the pregnancy being 274 days. Dr. Ma- 
thews Duncan, in an interesting paper on the subject, holds the 
average interval between insemination and parturition, to be 275 

♦ See Lecture XIL * London Lancet, 1850-3. 

20 



308 



THE FRINCIPLES AKD PRACTICE OF OUSTETRICB. 



days. Thia average he obtained frora the obftcrvatiou of forty- 
six ca.^e«.* 

IV, From the Last Menstrual Period — A very common modt9 
of calculatron^ both among the protesaiou and women theTn^clvc 
IB to take the last catanK'nial turn as the itarting point* Sow 
date from Xhe last day of tlie nienstniaJ evacuation, others from iv 
weeks subsequently. In either of these modes of compuiatioti, ther 
will necessarily be more or Iqss want of preci.-^ion, I think the fmi 
is very generally conceded, that the most likely time for a feroali 
to become iceundated is immediutely after a menstrual crisis; bat, 
it is equally well established, that impregnation will ocoaidoiyilljr 
occur just before the cataraenial period, :u»d sometimes during 
menstrual How, while, on the other hand, it must not be ibrgott 
that conception h possible at any time between the two menst 
turns, f It is very evident, that, this bt;ing the case, there wij 
8om«^times be a considerable diHcrepancy in time in the varic 
conclu!*ions attempted to be deduced. I have, for several yean,^ 
adopted a rule which, I believe, was originally suggested by the 
celebrated Naegelo; with some exceptional^ 1 have found it geu^ 
rally quite reliable, and far more salislactory in it8 results than any 
plan whicli has yet been proposed. Imagine, for examf)le, the 
termination of the last menstrual period to be on the 10th day of 
Jariuiiry ; then count back tiiree months, which will correspond 
with tlie 10th day of October ; now IVom the 10th of Oct(*ber, add 
seven days — this will bring rou to thu 17th day of October — tlia 
day on which the labor will commence. This, I rei>eat, ha>s accord 
ing to my observation, proved a mtj^^t satisfactory test; and 
tlieretbre, commend it to you with much contiilence. Accordiu 
to this mode of computation, the short and long months are Lakti 
promi8cuout»ly together, and the addition of seven days coustitute 
the average difference in the time. 

Many authors have tliought it diiBcutt to compute the period 
pregnancy, because, they allege, it is not known what particuli 
time elapse* from the moment of fecundation until the gen 
loaches the uterine cavity. But I cannot perceive much force 
Uiis argument ; and, in my opiidon, it matters not whether one or 
ten days are needed for the transmission of the fecundated ovum 
the uterus ; the true mode of calculation is from the moment 
iecundation, and hence the vaUie of Dr. Keid*s tables, which ^how 
that the ordinary duration of pregnancy, from a single coitus, is 

• Monthly Journal of Med. ScL, Maix'li, 18&4. 

f M RacilMifski baa paid vorj particiiUr Attention to the irubject of meattmatiQn 
It connected with fecundatioa ; and ho hns shown thiit the gctierul rule la, tlial ' 
3ien beoome impregnated immediately before or after, and even during menairt 
and that iho exceptions to tbia law are not more than six or eeren per eenL 
Bome interesting fiicti bearing on this quetition, the student maj oonaolt witfa \ 
Ilia work, *'Sur la Poote des Mamniiferef}/' 



THE PRINCIPLES AND PKAC11CE OF OBSTETRICS. 



807 



:>ut two honored and seventy *five days ; «nd this, I think, is con- 
RSrmatciry of what we have endeavored to show in a previous lec- 
ture^ that the particular point at which the ovule of the female and 
the fipermatozoon of the male meet h the ovary iti^elt^so that, yon 
perceive, the entrance of the germ into the uterus is one thing, and 
the fecundation of the ovu!e h another. The instant contact be- 
tween the ovule and spermatozonn occurs, the work of growth and 
development eommenccH ; and it i;^ not imjirobabic that it is to a 
for<retfu!ne8s of this fact that much of the discrepancy in the calcu- 
lation of the duration of pregnancy is to be attributed. 

I have told you that conception will aometitnes be accoraplished 
during the c^itamenial period; and I have now, in my mind, a ludi- 
crous, yet painful case, in corroboration of this tact. Xot a veiy 
long time ago, a gentleman called upon me, with the request that I 
would visit his wife professionally at one of the hotels in this city. 
The appointment was made, and I was there at the hour named — 
nine o'clock in the evening. As I was approaching the office of 
the hotel, for the purpose of sending my name to the lady's room, 
I felt a gentle^ but what I thought nervous tip on my shoulder, and 
looking round at once recogui>ed the countenance of the gentle- 
man who had arranged the appointment with me ; the ex|)ression 
of that countenance was fit for the study and development of the 
inimitable Hogartfi, and it, indeed, seemed pregnant with the 
details of the future. Pale and haggard, he hurriedly took me by 
the arm, and in a sort of whisper, observed, **This way, Doctor." 
After ascenditig two Hights of .stejis, which was accomplished in a 
marvellously brief period, impelled on us I was by my restive com- 
panion, he took a key from his pocket, with which he unlocked the 
door, and requested me to enter. I had, perhaps, seen darker 
night* than that, but, I doubt, wftether I had ever been thus unce- 
remoniously thrust into a darker room. Tl»e moment we had 
entered, he locked the door, and though I had not uttered a sylla- 
ble, he hafrtily remarked, '' Doctor, Ik* quiet !'* 

Well, 1 thought the whole thing very droll, and really it was 
aasuming something more than a broad farce ; and, without a 
momenl*s delay, I very emphatically observed: '*8ir, instantly do 
one of two things, either unlock this door or give me a light I" 1 
ad scarcely made the demand before my cumpanion in tlie dark 
pplied a match to a ga.^-buruen I will not attempt to describe the 
scene disclosed through the influence of that hitle loco-foco match ! 
Suffice it to say, that a female, gh.istly pale aTul almost bloodless, 
ky on the bed. My nervous companion imploringly asked mo to 
da something to save her life, which was fast passing away. I t^oou 
ascertained the true cause of the patient's extreme prostration. Shu 
was not married, and there tore not the wife, as had been alleged, 
of the gentleman who had requested my services. 



S08 



THE PBIKCIPLES AXD PRACTICE OF OBSTETRICa 



Tlje victim of a cruel BC*diiclion, ftlie had been brotinrht to Xcw 
York for tlio iiiir[>ose of getting ritl of tho eviilcnee of Ijer !*li:imi*; 
and with this view her s^eJucer Koaght the nid nf one of thone 
im\ny wretches wiih whom our city is iinhapjiily but too abutidantly 
fiUfj|iUed, always ready £oy the peqietralioa of cTitne, no in:itter 
bow munsitrous, iirovided the waives of their ^Mi — the iiiooey— 
can lie had. I learned thai one of tliese self^niyled " Doctor*'' biwl, 
for tlio last three days, been at work on thi^ tinhafipy girl, aod after 
inflicting on her great suffenng, had left her in her present tridan- 
cboly condition. You will scnreely credit it, but I ho fact is iie^^^^r- 
tbcless tio, that this poor creature, afYer endurin'4 extraordinary 
agony, both moral and physical, was abandoned by this tntiBcker 
in human life, to die ! lie had received the wageii of his sin, mod 
he was content ! The abortion liad been produced, and the f<rtiM 
removed from the house, but the afierbirih was still within the 
Uterus. Kow, under these circumstances, what w;i8 the course for 
me to pursue? Could I, with any moral justification, abandon thi« 
j»oor girl in tlie hour of her need ? Could I allow her to sink for 
the two reasons, first, tfiat she had Vieen seduced, and secondly, 
because she hatl been attended by an aboiliouiHt? It would be the 
refinement, not to say the absurdity, of casuistry^ to admit aitiy 
Ruch principle of guidance an iliis fur tho pliysician, who \Wh that 
one uf the great objects of \m profession is tu heal the nick and 
give succor to the distressed . As well might it be argued lliat the 
surgeon should refuse to dre»s the woundi* of a niau fehot in the act 
of burglary, I imagine that strict ethics exonerate the physician 
from nny of the antecedents of such example!* — his duty is to bind 
up tho wnund8, and ndministcr to the suffering patient, regnrdlcM 
of all extraneous circumstances. Seeing, therefore, the dtrfilorable 
condition of this uuibrtunatc young woman, I did not be&tUitc to 
proceed at once in the discharge of my duly as a medical man. 1 
gave her the stricte>t professional attention, and, in a short timei 
she entirely recovered frum her illness. 

My object in introducing the case to your notice is, tor the pur- 
pose of directing attention to a statement maile by the pretended 
husband. He declared to me most positively that be had never 
had intercourse witli the girl, txcrpt during /termenntrttation / and 
he mentioned the fact on the ground that he had always heard iXwl 
u woman could not conceive while she had "lier flow upun htjn** 
I rem:irked to him that I ihuuglit his personal experience was now 
amply suthcient to demonstrate the error of lliat theory. With 
cool eflTroutery he remarked, '* Doctor, I lliink you know all about 
H, and if you will only tell me how it is possible to avoid having 
children, I will make you a substantial present!'* ** Sir,** I 
remarked, *'thc only remc<iy for your case is, that you immediately 
consent to become an altered man!" He saw th« point of the i 
advice, and said nothing more t^n the subject. 



LECTURE XXII. 

Determining Cause of Labor — Meaning of the Term; The Expulsive Forces— pi i- 
mary and secondary; Determining Cause referred by some to the Foetus, by 
others to the Uterus ; Opinion of Buffon with regard to the agency of the Foetus ; 
Ancient Doctrines ; Uterus the true Seat of the Determining Cause of Parturi- 
tion ; Antagonism between Muscular Fibres of Body and Neck of Uterus ; Change 
in Structure of Decidua and Placenta, as alleged by Prof. Simpson ; Ilaller's 
Theory of the Decadence of the Placenta ; Objections to the Theory ; Dr. Brown- 
S^quard's Theory — Carbonic Acid the Stimulant to Muscular Contraction ; The 
Doctrine of Ovarian Nisus, as propounded by Cams, Mende, and Dr. Tyler 
Smith; Objections to the Doctrine; Is Menstruation Peculiar to the Human 
Female? The Theory of Dr. John Power, adopted by Paul Dubois, of Paris; 
Objections to the Theory; Kxplanation of the Author as to the Determining 
Cause of Labor; Modifications in Structure of Uterus at Close of Gestation ; 
Peristaltic Movement of Uterine Muscular Fibre; Inherent Contractions; These 
Inherent Contractions independent of Xervous Force — Proof; Connexion between 
Inherent Contractions and Matured Development of Muscular Structure of Uterus; 
Irritability of Muscular Tissue of Uterus increases as Pregnancy advances — 
Deductions from this Fact ; Modifications in Structure of Uierus after Child-birth ; 
Diminution of Musculo-fibre Cells ; Fatty Degeneration, a Natural Change in 
certain Structures after they have completed their Functional Activity — sometimes 
a Pathological Result 

Gentlemen — Having, in tlie preceding lecture, called your atten- 
tion to the period at which labor occurs, we now approach the 
consideration of a question which has called forth numerous theo- 
ries for its explanation, both from the older and more modern 
writers — I allude to the deternninifig cau.^e of parturition. Before we 
proceed further it should be clearly understood what is intended to 
be conveyed by the determitiing cause of labor. It means nothing 
more than this : that peculiar influence which first excites the mus- 
cular fibres of the uterus to contraction. In order that you may 
have a precise and comprehensive view of the question, let us sup- 
pose that the impregnated uterus has passed through its various 
phases of development, the fa*tus has attained its maturity, and the 
time for its transmission into the world has arrived — what principle 
is it which gives the first impulse to that series of muscular con- 
tractions which, when completed, accomplish the expulsion of the 
foetus and its annexai ? This is the simple, yet interesting question 
before us, and one in every way worthy of thought. There can be 
no doubt that the exi)ulsive forces, which result in the delivery of 
the child, are two, which obstetricians have divided into, Ist, the 



310 



THE PRINCIPLES AND FBAOriCK OF OBSTETRICS. 



primary, or efficient ; and 2d, the seconJary, or anxiiiary. Tlie 
former, the primary, are the contractile eflorts of the uterus j tlie 
latter, the secondary, the contractile efforts of the diaphragm and 
abdominal muscles. But what we are now in search of i« — tAcU 
peculiar someth'mff^ tchkk u the origifial startiny-poini of ihe^e 
tico vhs8€S of forces. In one word, what i