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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 
Focaa    YminMl  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,  0  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 0 0 

9  •* 9 2 0 

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  " 0 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  sepmmted 


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  is  it  that  givea  the  origi' 
nal  impulse  to  the  parturient  effort  ? 

/*  the  Determining  Cause  in  the  J*hUus^ — As  I  have  already 
observed,  there  in  a  remarkable  discrepancy  of  opinion  on  this  0<ib- 
ject— 6orae  refer  ring  the  determining  cause  to  the  action  of  the 
fetus,  while  others  maintain  that  it  originates  in  the  uteroj  iuclf 
It  was  the  opinion  of  the  great  naturalist,  Huffou,  that  the  i\i*iuB 
is  the  agent  of  its  ow^n  expulsion ;  and  thb  idea  was  no  doubt 
derived  from  the  supposed  analogy  between  the  himiAn  embryo 
and  chick — the  latter,  as  is  well  known,  breaking  iij*  shell  an  w*on 
as  tlie  period  of  its  incubation  hat^  been  completed.  This  hypcilh*^ 
mni  of  the  distinguished  Naturalist  will  not  abide  the  teat  of  exatni* 
nation  ;  indeed,  it  is  utterly  at  variance  w^iih  facta.  If  the  drier* 
mining  cause  of  labor  lie  due  to  the  action  of  the  foetus,  how  does 
it  happen  that  the  hitler  is  expelled  tVom  tlie  uterus  after  it  hai 
ceased  to  live  f«ir  days,  and  sometimes  weeks,  previously  to  the 
termination  of  pregnancy  ?     Again,  how  is  the  placenta  expelUni  ? 

The  doctrine — that  the  fa?tus  c.iuses  its  own  exit  from  the  uterine 
cavity — did  not,  however,  originate  witfi  Buffon  ;  on  the  contrary, 
it  is  a  very  ancient  notion ;  and  it  is  unnising  to  read  the  varioua 
explanations  given  w  hy  the  developed  embryo  is  Induced  to  ti<^ 
and  accomplish  its  entrance  into  the  world.  It  was  alleged,  on 
the  one  haml,  that  tlie  fat  us,  at  the  period  of  its  full  uitra-utenoe 
growth,  suffered  frotn  want  of  adequate  nourishment;  and  hunger, 
therefore,  prompied  it  to  leave  its  parent.  It  was  maintidnedf  also^ 
that  the  space  in  which  it  was  confined  was  too  limited — it  felt  an 
instinctive  longing,  I  fiup|iose,  to  extend  the  area  of  its  liberty; 
and  the  opinion  likevviHe  prevailed,  that  the  desire  to  paas  it3  water, 
and  evacuate  the  inlestinal  canal,  were  among  the  causes  wbicli 
moved  it  to  change  its  place  of  abode.  It  can  scarcely  be  neocs- 
sary  for  me  to  point  out  the  fallacy  of  the»e  view^s;  they  may  be 
ranked  among  the  fancies  of  the  good  old  fathers,  having  nothing 
in  truth  to  sustain  them.^ 

Is  the  Ihiermining  Cause  in  the  Uterus  -?— It  ia  very  generally 

♦  Harvey  tnniDtAiD^d  that  ** la  the  birth  of  living  cr&nturcfi,  the  chief  oiiiio «1 
birth  ifl  in  Ibe  lietus;  t  mean  ns  to  its  efrort,  not  to  ila  weight,  m  Fftbridis  Myi^ 
Jtc. ;  the  fctitua  itfielf  ruii&  \tA  liead  ag:*itii!ft  the  inclosures  of  Uie  womb|  optns  then 
by  its  own  atreagthf  and  strujrgles  into  daylight/' 

"In  vivipararum  ynTia  pnt'cipuatn  ua^^ccndi  causam  fo&tui  deberi  MoUititalp 
inciuam,  ejua  oon  autem  ponderi  iit  Fubridus  voluit,  kc, ;  ipse  fti^tua  prnoQ  eaplte 
Uteri  chuistra  aggreditur.  eudc^mque  propriis  viribua  redudit ;  et  in  luoem  eliiol»> 
lur,"    [De  Oeuemt,  AnimaL,  pp.  366-IJ 


nre  pRmciPLE3  and  practice  of  obstetrics. 


311 


€4>iicede(l,  that  the  determining  canse — whatever  it  may  be^residet 
in  the  uterus  itself,  the  ftptns  being  in  no  way  concerned  in  the 
orijnna!  impulse  to  conlrariile  effort ;  and  hero,  again,  we  have 
theory  iipoti  theory  promulgated  in  explanation  of  this  peculiar 
tnrtnence,  known  as  the  excitant  of  ntenne  eon  ti  act  ion.  It  would 
he  needless,  and  totally  unprofitable,  to  enumerate  these  various 
hypotheses  ;  I  shall,  therefore,  content  myself  with  n  simple  allusion 
to  a  few  of  the  more  prominent  of  them.  A  theory,  whirh  Jiag 
obtained  much  countenance  from  the  profeHsion,  refers  the  deter- 
mining cause  of  labor  to  a  cessation  of  antagonism  between  the 
muscular  fibres  of  the  neck  and  body  of  tJie  uterus— the  evidence 
that  this  antagonism  no  longer  exists  being  furnish ed  by  the  tact 
llml  the  length  of  the  cervix  has  entirely  disappeared,  and  exhibits 
nothing  more  than  a  circle,  or,  as  it  is  s^jmctimes  termed,  a  ring. 
This  exphinaticm  finds  no  Buppoil  at  the  bedside;  for  how  fre- 
quently docs  it  happen,  tn  eases  of  ahortion,  ibr  example,  that  the 
uterus  is  thrown  into  contractif»n  before  tlie  slightest  shortening 
of  the  cervix  can  be  detected  ;  and  again,  the  cervix  will  occasion- 
ally have  k>st  iU  entire  length  for  several  days,  and  even  weeks, 
before  the  contractile  efforts  of  the  uterus  manifest  themselves. 

Processor  Simpson  has  recently  suggested  the  idea,  that  the  pri- 
mary impulse  to  uterine  contraction  is  due,  in  the  first  place,  to  a 
change  in  the  structure  of  the  decithia  and  phicenta,  and,  secondly, 
to  a  loosening  or  separation  of  these  bodies  from  the  internal  sur- 
face of  the  nterus — the  modifications  of  structure  being  the  result 
of  the  maturity  of  the  tivum.  This  view  is  kiTulred  to  the  opinion 
of  Halter  and  others,  who  likened  the  placenta  to  the  srem  of  th© 
fruit,  and  arguetl,  that  as  the  matured  fruit  falla  from  the  parent 
tree,  because  of  the  decadence  of  its  8tem,  so  does  the  placenta^ 
when  gestation  is  com|>leted,  detach  itself,  and  thus  become  the 
exciting  or  determining  cause  of  parturition.  The  idea,  if  true^ 
would  necessarily  imply  that  the  primary  link,  in  the  chain  of  phe- 
nomena constituting  labor,  is  the  detachment  of  the  jJacenta  from 
the  uterine  surface;  but  to  admit  such  an  assumption  would  be 
directly  contrary  to  what  really  occurs — it  w*ould,  indeed,  be  con- 
founding the  cause  with  the  effect. 

The  placenta,  except  under  certain  circumstances  of  disease 
affecting  it^  or  in  cases  of  sudden  concussion,  becomes  detached 
from  the  womb,  not  through  any  decadence,  but  simply  througli 
the  force  of  uterine  contraction.  If  this  were  not  so,  if  the  lirst 
effort  of  childbirth  resulted  from  the  separation  of  this  body,  the 
necessary  consequence  would  be  hemorrhage,  more  or  less  profuse^ 
How  often  does  it  necur  that  some  minutes  elapse  :ifler  the  expul- 
sion of  the  IcBtus,  before  theaflerbirth  is  separated  from  the  womb? 
It  may  be  safely  said,  I  think,  tliat,  as  a  general  rule,  the  |>laccnta 
ins  in  adhciiion  with  the  uterus  until  the  child  has  been  thrown 


812 


THE   PRINCIPX.ES  AND  PRACTICK  OF  OBSTETRICS. 


into  i\n^  world ;  or,  to  speak  raore  properly,  as  the  child  is  pas4i$%^ 
ihroii(/h  die  mdva^  thti  work  of  separation  is  going  on„  jsh  thai 
Vfhen  f/*€  egress  of  the  fcetiu  has  been  accffmjtli^hftiy  if  the  uttruM 
should  he  felt  in  tJie  hypogastric  region^  Jirm  and  contract td^  this 
afford fi  veri/  n^idmfautial  eriden^'e  that  the  aftcrhirth  in  no  longer  in 
eofmexion  with  tht-  iralU  tf  the  organ.  What  in  tlic  true  exp1aii»- 
tiou  of  heniorrlmge  iu  cliiltlhirth  ?  la  it  not»  except  in  ujust^  of 
placenta  proma^  the  direct  result  of  inertia  of  the  womb  after  a 
partial  or  complete  delat'htnorit  of  the  placetita?  If  thin  be  «> — 
and  wlio  will  doubt  it — with  this  theory  of  the  early  ftcparaliuu  of 
the  alterhirtli  na  ihe  deteriuiiiitifj  cause  of  hd>or,  how  few  parturi- 
ent women  would  eseai>e  the  dangers  of  flooding? 

Dr.  Brown-Seqimrd*  fliiys,  **'Tlie  utenis,  in  pregnancy,  becomes 
more  and  more  irritable  every  day  ;  and  when  its  irritability  hai 
arrived  at  a  very  high  degree,  then  the  slight  excitation  produtsed 
by  the  carbonic  acid  normally  contained  in  the  blood,  U  sufiicieisl 
to  put  it  in  action/' 

Let  ns  next  turn  to  what  ban  been  denominated  the  OTarao 
theory  of  }mrLurition.  Dn  Tyler  Smith,  in  aecordnnce  with  the 
opinion  of  Canis?,  IVIende,  and  others^  Uim  attenipled  to  show  that 
the  determining  cause  of  parturition  i,^  but  the  product  of  ovarian 
excitement.  He  holds  that,  during  the  entire  term  of  geKtatioOi» 
the  ovary  becomes  the  seat  of  reenrreiit  excitement,  correspomling 
wntb  the  ordinary  catamenial  periods;  and  moreover  aflirniH  that, 
in  conHeipience  of  this  local  congi'iition  of  tlie  ovary,  there  is  uioro 
or  le»s  tendency  to  abortion  nt  each  of  these  returns.  It  will  be 
[lerceived  that  thi»  hypothesis  clearly  refers  the  entire  act  of 
uterirjc  coutrartion  to  that  inn>ortant  and  interesting  principle— 
reflt'X  influence  ;  the  ovarian  nerves  being  tin*  excitors^  whieJi,  cim- 
veying  the  stimulus  of  irritation  to  the  medulla  Kpinalij^,  can»e  thii 
latter  to  infuse  into  the  tnotor  ntMVes  of  the  uterus  an  ]mfud>u% 
whirh  result s  in  eontrat^ion*^  of  the  organ, 

Tiie  tfieory  of  Dr.  Smith  i«  not  without  objection.  In  thu  fifirt 
pkioe^  I  do  not  i-egard  it  m  at  nU  settled  that  ovulation  goes  im 
dut*ing  prPiTiianry,  and  without  this,  wliy  should  the  ovary  become 
the  ^ent  of  a  periodicd  piiaua^}  Sr-condly,  while  it  cannot  be 
denii^d  ilvM  the  duratiun  of  pregtiaiicy  is  usually  a  multiple  of  the 
mcnt*trual  intervaK  yet  this  is  far  from  bein^  neeessarily  the  eajie^ 
A  very  mibstantial  objection  to  this  hypothesis  is  dist^lo^icd  by  the 
feet  annomiced  by  l^rotessor  Sinrpson — he  remov€*ii  the  f>vartes 
during  the  latter  period  of  ]>reguaney  without  in  any  way  inter* 
feriug  with  the  ) phenomena  of  parturition.     But  it  seems  to  me 

•  Kxpt.'riuii*i>tnl  lk*i»earfhcs,  ^„  p    117, 

f  ScutvAtiuI  in  also  of  tJ|titiiou  tliitt  oruhitioQ  continues  during  irevtalifiQ ;  bait 
numcmiiji  atitujwies  by  Virolio\*%  Kussmiiiil.  mid  others,  prove  tlml  if  Uie  f^itietioD 
ftnlly  persist  m  wmn  womcQ,  it  must  Ic  n^Kurdcd  ub  a  rnrc  cxccptioiu 


THE  PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS.         818 

that  an  irresistible  and  conclusive  arc^uinent  against  the  theory  is 
this :  Dr.  Smith,  if  he  be  correct  in  his  opinion,  would  make  the 
parturient  effort  essentially  dependent  upon  nervous  influence,  or, 
in  other  words,  he  would  refer  it  to  reflex  action.  Before  con- 
cluding this  lecture,  we  shall  endeavor  to  demonstrate  the  fallacy 
of  this  proposition,  and  prove  that  the  uterus  enjoys  two  distinct 
forms  of  contraction — one,  inherent,  independent ;  the  other,  ex- 
traneous, dependent,  or,  more  properly  speaking,  the  result  of 
nervous  force. 

I  have  an  abiding  faith  in  the  analogies  of  Nature,  and  I  believe 
that  she  is  perfectly  consistent  in  them.  Indeed,  many  of  the  solid 
princif)les  of  our  science  are  derived  from  the  proofs  furnished  by 
these  very  analogies.  Now,  it  appears  to  me,  that  the  ovamn 
theory  of  parturition,  if  it  be  founded  in  truth,  should  not  only 
exhibit,  under  a  normal  condition  of  system,  a  universality  in  its 
application  so  far  as  the  human  female  is  concerned,  but  it  should 
also  disclose  a  necessity  for  its  influence  in  determining  the  partu- 
rient effort  in  animals  generally.  We  have  just  seen  that  if  the 
ovary,  under  any  circumstances,  be  capable  of  evoking  uterine 
contraction  at  the  close  of  pregnancy,  it  is  not  always  the  starting- 
point  of  this  phenomenon  ;  and,  on  examination,  it  will  be  readily 
understood,  that  the  truth  of  the  theory  is  not  borne  out  by  what 
is  observed  in  the  parturition  of  animals  ;  in  a  word,  it  has  not  the 
support  of  analogy. 

But  let  us,  for  a  moment,  examine  this  theory  under  another  point 
of  view.  The  doctrine  is  very  generally  maintained  that  menstruation 
18  peculiar  to  the  human  female.  If,  by  this,  it  be  intended  to 
convey  the  idea  that  the  function,  as  it  exhibits  itself  in  woman, 
with  all  its  phenomena,  its  duration,  etc.,  is  exclusively  recognised 
in  her,  then  I  can  see  no  objection  to  the  doctrine,  for  it  is  founded 
upon  undeniable  evidence.  If,  on  the  contrary,  it  be  argued  that 
during  the  period  of  heat^  certain  animals  do  not  have  any  san- 
guineous discharge,  no  matter  how  slight,  or  for  how  short  a  time, 
then  I  object  to  the  doctrine,  for  it  is  adverse  to  the  evidence 
furnished  us  by  accurate  observation.  Examine,  for  example,  the 
slut  at  the  time  she  is  about  to  take  the  dog  (her  period  of  heat)y 
and  you  will  find  not  ouly  congestion  of  the  i)arts,  but  also  a  slight 
sanguineous  emission ;  the  same  thing  will  be  observed  in  the  cow, 
mare,  and  other  animals,  which,  it  is  well  known,  will  only  receive 
the  male  at  this  time,  and  at  no  other ;  and  during  the  period  of 
heat  the  same  phase  occurs,  which  is  so  characteristic  of  the  cata- 
menial  crisis  in  woman,  viz.  the  maturation,  and  subsequent  escape 
of  ovules.* 

There  is  much  variation  in  the  period  of  heat  among  different 

•  See  Lecture  vil 


8U 


THE  PBINCIPLES  AND  PRACTICE  OF  OBSTETBlCa 


animals ;  in  the  slut,  for  instance,  it  takers  place  twice  in  the  yenr, 
and  contioues  about  fourteen  dayti  each  time ;  in  the  cow,  s^nd 
other  domestic  animals,  it  is  more  frequent  than  in  wild  nnimalfi, 
but  it  h  not  marked  by  any  definite  periodical  occurrence.  The ' 
duration  of  prct^naucy  in  the  cow  h  in  correspondence  with  that  in 
woman;  and,  at  the  completion  of  her  term,  the  animal  Is  thrown 
into  labor — but,  will  it  be  contended,  atler  what  has  ju.<4t  been  natd, 
that  the  determining  cause  of  parturition  in  the  cow  is  a  multiple 
of  the  menstrual  interval  ?  I  again  repeat  my  faith  in  the  doctrine 
of  strict  analogy,  and  I  believe  the  uterus  of  tlie  cow,  when  her 
gestation  is  completed,  contracts  in  obedience  to  the  same  iiitiuimcei 
which  constitutes  the  primum  mobile  of  paiturient  efF«»rt  in  lh« 
hnman  female.  What  this  inlluence  i«  we  may  or  may  not  be  tjoa- 
bled  to  explain  before  we  conclude  thin  lecture. 

Dr.  John  Power,*  «onie  forty  years  since,  suggested  a  theory  in 
explanation  of  the  determining  cause  of  labor,  which,  un doubted] j, 
possesses*  the  nient  of  jihuisibility,  and  whicli  h.iA,  of  late,  had  new 
strength  added  to  it  in  conscqut-nee  of  its  adoption  by  Prof  I*aul 
Dubois,  the  eminent  Parisiim  obstetrician.|  In  order  that  yott 
may  thoroughly  understand  Dr.  Power's  hypothesis,  I  shall  <|nute 
his  own  language: 

"  All  organ!<  which  are  inteniled  to  retain,  for  a  tiTue,  and  after- 
wards to  expel  their  peculiar  contentj^  are  ftirnislie<l  with  sphincter*, 
placed  at  their  evacuating  orillces.  Tlie  most  lemarksble  of  thene 
are  the  rectum,  the  bhuhler,  and  the  uterus. 

"The  sphincters  of  the  above  organs  are  possessed  of  two  dift* 
tinct  jjroperties — in  the  first  place,  they  act  as  valves  to  prevent 
improper  evacuation ;  and  secondly,  they  are  endowed  with  a  jH*cti- 
lliir  Bensibility  which  enables  them  to  regulate  the  necessity  or 
propriety  of  discharge  ;  and  for  this  latter  purpose  especially,  I  bey 
are  supplied  with  a  hirgi-r  (Kopoition  of  nerves  of  sensation  tlian 
the  bodies  of  the  organs  to  which  they  belong, 

**To  produce  the  evacuating  action  of  any  of  these  organ*,  the 
oxctting  stimulus  must  be  applied  to  the  sphincter,  Mhen  the  organ 
contracts  and  expels  its  contents. 

'*  The  existence  of  i*])hincters,  as  above  described,  is  universally 
admitted  with  res]>ect  to  the  rectum  and  bladder;  but  the  claim  for 
such  structure,  with  regard  to  the  uterus,  is  novel ;  and,  therefore, 
it  will  be  desirable  to  illnstrate  the  theory,  and  advance  proo^  and 
arguments  in  support  of  it, 

"  In  the  Hrst  j)lace^  I  sh.all  make  8orae  observations  respecting  tbd 

•  A  Tn^utis©  on  Utdwlfery,  developing  now  pnnciple&  By  John  Pgw«r,  MJK 
Loudoti,     tjvooiid  e<litton.     1393.     Pp.  23. 

t  The  TUei>ry  ot  Dr.  Power  lia^  ulao  received  the  codoraemcnt  of  Prt>f.  lt«Drf 
Miller.  M,D»  the  late  disonguiHhKl  Prfif.  at  Midwifery  in  the  Uiiivemity  ot  Look* 
liUc.     [Pritidpl*^  mni  Pmt'iieo  of  Obsi^tnos*  by  H^nry  Milter,  M  D.,  p.  300.1 


THE  PRINCIPLES  AND  PBACmCE  OF  OBSTETRICS. 


815 


analogous  action  of  the  rectam  and  bladder,  and  then  proceed  to 
poitjt  out  the  nature  and  effects  of  the  sphincter  of  the  uterus,  as 
explanatory  of  the  exciting  causes  of  labor. 

**^The  fajccs  received  from  the  colon,  are  protruded  forward 
along  the  rectum  until  they  arrive  at  the  sphincter  ani,  when,  in 
consequence  of  the  impression  made  upon  that  part,  the  action  of 
the  rectum  U  elicited,  and  they  are  expelled.  That  this  irritation 
of  the  sphincter  h  here  the  cause  of  expulsion  may  be  inferred 
from  the  t;ict,  that  if  the  motion  for  evacuation  be  attended  to^  the 
first  perception  of  it  is  always  at  the  sphincter,  and  rarely  felt 
under  the  earlier  periods  of  accumulation  in  the  rectam,  unlesa 
indeed  the  tieces  are  in  a  tiuid  or  acrid  state,  so  as  to  be  more 
readily  admitted  into  ctuitact  with  the  sphincter,  or  to  ]>roduee 
more  stimulating  effects  upon  it.  Thin  proves  that  the  expulsive 
action  is  the  effect  of  stimulation,  and  not  distension.  We  have 
equal  or  more  decided  evidence  of  the  8am e  principle  operating  in 
the  evacuation  of  the  bladder. 

"  I  shall  now  attempt  lo  show  that  tlie  cervix  and  mouyi  of  the 
womb  discharge  all  the  functions  whicli  have  been  above  a«;signed 
to  sphincters.  The  cervix  appears  anatomically  distinct  from  ilie 
body  of  the  uterus.  It  experiences  comparatively  little  change 
from  conception,  until  the  pregnauey  is  half  completed,  the  enhirge- 
nient  of  the  womb  having,  in  the  earlier  months,  evidently  pro- 
ceeded from  the  body  exclusively,  and,  it  is  most  probable,  that 
ibroughout  the  w^hole  term,  it  continues  to  be  derived  therefrom. 

^*The  cervix,  until  the  end  of  the  fifth  months  retains  its  former 
Uength ;  atler  this  time,  it  begins  to  experience  a  gradual  diTuiuu- 
tion,  until,  at  the  termination  of  pregnancy,  it  has  eniirely  disap- 
peared. The  contents  of  the  uterus,  which  the  intervening  cervix 
had  previously  kept  at  a  determinate  distance,  are  now  admitted 
into  direct  contiguity  with  the  oriHee, 

^*  When  we  take  into  view  the  manner  in  which  the  orifice  is 
supplied  with  nerves  of  sensation,  it  is  lair  to  infer  that  it  is  en- 
dowed with  a  peculiar  function^  and  a  high  proportion  of  fiensibility ; 
and  were  we  to  admit  that  a  stimulus  applied  to  it  would,  in  a  maimer 
analogous  with  the  above-reeited  production  of  fieeal  and  urinary 
evacuations,  have  the  effl-ct  of  exciting  parturient  contractions  of 
the  uterus,  it  must  be  allowed  tliat  a  necessity  exists,  during  the 
period  of  foetal  evolution,  for  the  interposition  of  a  valve  between 
it  and  the  uterine  contents,  to  prevent  their  ]>renmturc  expulsion. 
This  valve,  we  concluile,  is  found  in  the  cervix,  and  the  beautiful 
Bimplicity  of  the  contrivance,  as  well  as  the  undevf.Uing  and  admir- 
able manner  in  which  nature  gradually  resmnes  it  before  labor 
comes  on,  is  a  fine  illustration  of  the  providence  of  the  Divine 
Creator  to  prevent  the  generative  actions  from  being  rendered  abor- 
tive, and  secure,  at  the  due  time,  their  propitious  consumniation. 


m 


THE   PKINCIPLES  AND   PKACTICE   OF  OBSTETRICS. 


**TiuU  the  orifice  of  the  uterus  is  ibe  iiUMiium  tlirough  wiuch 
tlie  p;irtiinetjt  motions  are  cxcitetl,  ls  i*iroogly  confirmed  by  ihe  fact, 
that  contractions  of  the  uterine  libres  may  be  oociLsioned  by  aa 
mliHcial  stuiiulus,  applied  lo  llie  part  in  cjuestiou,  proving  that  the 
camtSi  presume  J  is  {vde<piate  to  produce  iJie  effect  usHij^ned  to  it. 

^''Another  proof  is,  that  a  defect  of  oriticial  irritation  will  W 
foJlowed  by  a  deliciency  of  parturient  coniracliou.  Thus  the  liiUor 
goeij  on  slowly,  or  is  suspended,  when  the  presenting  partu  are 
prevented  from  making  proper  excitinjjf  preasttre  on  tlie  orifice,  as 
in  cases  of  nml presentation,  malformation  ui^  tlie  child  or  pcliis,  or 
wluTc  the  head  recedes  in  consequence  of  rupture  of  the  woaib,  or 
where  the  belly  is  pendulous,  etc, 

*'  Labor,  liowever,  does  not  always  com©  on  as  soon  a^  the  cervix 
is  obliterated,  and  ocQasionally  takes  [>hjce  previous  to  that  eveuU 
These  circumstances  require  some  explanatiim* 

*' A  given  and  determiuate  impression  of  the  orifice,  differing  in 
degree  according;  to  the  const  it  mifm  of  ihc  individual  and  existing 
serisibilitjyr  of  the  part,  is  necessary  to  give  rise  to  the  uterine  con- 
tractions. Thus,  the  mere  ^gravitation  of  tlie  uterine  contents  in 
the  direction  of  the  orilice,  is  not  alone  sufKcient  to  produce  them;  thw 
pressure  and  tension  given  by  the  insensible  contractions  rniut  bo 
superadded.  If  this  is  vvantiiig,  or  weak,  labor  will  »till  be  post- 
poned. On  the  contrary,  if  it  happens  to  be*  strongly  or  prema- 
turely excited,  as  it  may  be,  by  evacuatini^  the  liquor  amnli,  nnd 
various  other  causes,  before  the  cervix  has  been  naturally  obUto- 
rated,  it  may  have  the  effect  of  eiLher  basteniug  that  event,  or  of 
Btimulatiug  the  cervical  parts  sutKcleutly  to  occnsiou  prcimature 
action. 

*^ The  gravitation  of  the  ccmtents  of  the  uterus,  doubtlei^sly  co- 
operates  in  proilucing  the  insensible  contraction,  while  the  latter 
tends  to  complete  the  cervical  obiiteration  ;  and,  it  is  probable,  that 
they  contitiue  in  giving  rise  to  the  uterine  contractions.  Thus,  as 
I  bi'fore  observed,  they  operate  as  cause  and  effect  to  each  other,'* 

1  have  given  this  long  extract  from  Dr,  Power's  clever  work 
because  I  wiis  tlesirous  that  you  should  read  his  own  words  in 
explanation  of  his  peculiar  theory — a  theory  which,  as  I  have 
already  remarked,  has  recently  been  accepted  as  the  truthful  exfK>* 
Bition  of  the  determining  cause  of  labor  l»y  one  uf  the  liighest  liv- 
ing obstetnc  authorities. 

It  is  quite  manifest  that  Dr.  Power  refers  the  original  movement 
of  jwiTlurient  action  exclusively  to  nervous  force,  brought  into  pby 
I  through  the  agency  of  reflex  intluetice.  With  him  the  starting^ 
point  is  irritation  of  the  excitur  nervas  of  the  cervix  uUru  rcsnlt- 
ing  in  a  reflex  impulse,  which  i>uts,  if  I  may  so  term  it,  the  wheel 
of  museular  contraction  of  the  uterus  in  motion.  I  may  Ik^  in 
error  but  it  really  seems  to  mo  that  Dr.  Fower^  in  his  attempt  to 


THE  PRINCIPLES  AND  PRACTICr  OF   OBSTETRICS. 


317 


sustmn  liis  ingenious  llieory,  hn»  himself  tunushecl  foncltjsive  objec- 
tions to  il — ihey  are»  in  fact,  the  very  objwtions  which,  to  my 
min*1,  are  entirely  *<tibver8ive  of  jilJ  his  reasoning.  You  are  eriti- 
cjilly  to  heuT  in  mind  I  hat  \m  mnin  propcwhion  ii*  this — thai  at  fht 
end  of  gestation  the  ceri^tx  ufrri  ha^ung^  through  the  procetts  of 
Mhorleninfi^  entirely  dhapptared^  *'  the  contents  of  the  organ^  tthirh 
the  intervening  cervix  had  previously  kept  at  a  determinate  din- 
tance^  are  now  admitted  into  fllreet  contlfpjifg  with  the.  orlftt*€.*^ 

It  is  thia  very  contiguity,  you  must  renien^l^cr,  which  causefl  the 
iinprfasion  upon  the  excitor  nerves  of  tlie  part.  Well,  for  argil 
ment*s  sake,  suppose  that  we  admit  the  truth  of  this  rea^nitig  in 
case!^  in  which  the  above  phenomena  occur,  viz.  the  obliteration  of 
the  cervix,  and  the  pressure  of  the  presenting  part  of  the  fci^tus 
against  it.  How  nhall  we  aatisfactorily  explain  the  detcnniinng 
cause  of  labor  in  instances  in  which,  notwithstanding  the  oblitera- 
tion of  the  cervix,  there  is  no  pressure  made  upon  it  ?  This  i«  the 
very  objection  suggested  by  our  author,  but  strange  to  say,  instead 
of  regarding  it  as  an  objection,  he  says,  *'  Another  proof  i^,  that  a 
defect  of  orificial  iri^tation  will  be  followed  by  a  deficiency  of  par- 
turient contraction,  ThUxS,  the  hibor  goes  on  slowly,  or  is  suspended 
when  the  presenting  parts  are  j»revented  from  making  proper excit* 
ing  presAuro  on  the  orifice,  as  in  eases  of  mafpresentatlon^  malfor- 
maiiofi  of  the  child  or  pelvis^  or  where  the  head  recedes  In  canse- 
qu^nce  of  rupture  of  the  womb^  or  tehtre  the  belli/  is  pendulous^ 

Do  you  not  see,  gentlemen,  that  tlie  language  wliieli  I  have  just 
quoted,  in  lieu  of  a  proof,  is  a  positive  upsetting  f*f  tlio  whole  the- 
ory; for,  in  cross  presentations,  in  which  it  is  pbysically  impossible 
for  the  presenting  portion  of  the  foetus  to  make  exciting  [pressure 
on  the  orifice,  labor  comes  on,  and  reguhir  uterine  contractiona 
supervene.  In  these  latter  instances  surely  tlie  theory  is  at  fault; 
for  it  cannot,  under  these  circumstanees,  explain  the  determining 
cause  of  parturition,  JFldsus  In  uno^  faUus  in  omnlj  is  a  sound 
miixim  in  law,  and  bears  with  ctjual  force  ou  the  question  now 
before  us, 

l}r^  Power  says,  "  Labor,  liowever,  does  not  aln'ays  come  ou  as 
Boon  as  the  cervix  U  obliterated ;  and  occasionally  takes  phice  pre- 
viously to  that  event,*'  Now  the  very  explanation  which  he  gives 
of  the  two  facts  eontaine«l  in  the  hist  ipiotation  militate^  in  the 
most  positive  manner  .against  his  theory,  for  he  remarks,  "A  given 
and  determinate  impression  of  the  orifice,  is  necessary  to  give  ri^e 
to  the  uterine  contractions.  Thus,  the  mere  gravitation  of  the  ute* 
rine  cMintents  in  the  direction  of  the  orifice  is  not  alone  8uf!jci«*rit  to 
produce  tfw  pressure  ;  and  tension  given  by  the  Insenslblr.  con t me- 
iions  must  be  superadded.  If  this  Is  tcantlng  or  weak^  labor  iflU 
stiU  b€ postpofud*^^    The  italics  here  are  my  own,  and  I  have  pur- 


818 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS, 


posely  made  them  in  order  that  you  may  see  the  language  thus  iti^ 
licized  is  a  surrender  ot  the  whole  argument.  If  it  have  any  mcaiK 
ing  it  Mgnifies  simply  this — that  the  mere  pressure  of  the  presenting 
portion  of  the  fcptus  against  the  uterine  orifice  m  not  iJways  ade- 
quate to  evoke  the  parturient  effort,  and  tlial  ^omelimoH  ibe 
''^  insensible  contraciions^^^  are  needed  for  iWia  purpose.  This  is 
nearly  my  own  opinion,  and  so  tirrn  am  I  in  this  belief  that  I  shjdl 
endravor  to  show  that  not  only  are  these  contractions  sometimes 
needed,  but  they  universally,  in  a  normal  state  uf  thingn,  pree^*d43 
any  reflex  or  nervous  force,  and  are  entirely  independent  of  ubai 
Dr.  Power  calls  **  orificial  irritation,'*  as  I  shall  no\ir  proceed  lo 
demonstrate. 

When  the  period  of  gestation  has  been  completed,  it  will  be 
observed  that  the  mnscular  fibres  of  the  uterus,  ns  the  very  first  vyc% 
in  the  parturient  process,  commence  a  sort  of  peristaltic  movement* 
This  movement  or  contraction  is  w*hat  may  be  denominated  a  pet 
86  movement— it  is  inherent,  indeneudent,  and  is  to  be  referred 
exclu-^ively  to  the  irritability  of  the  muscular  structure  of  the  utc- 
nis,  having  no  connexion  whatever  with  a  reflected  or  nervotts 
force.  These  contractions  are  similar  to  the  [)eristaltic  movements 
of  tiie  intestinal  c^inal,  which  are  admitted  to  be  the  result  of  ttihi>- 
rent  irritability,  and  totally  indoiiejulont  of  any  influence  derived 
from  the  ncrvoua  system.  They  are  whnt  may  be  regarded  ss 
indejiendent  contractions,  and  their  object  appears  to  be  the  exer* 
else  of  a  pressure  from  above  downward  on  the  f<j?tvis  toward  the 
0#  wfm  ;  these  irdicrent  contractions  of  the  uterus  will,  oceaMon- 
ally,  begin  to  develop  themselves  for  several  days,  and  even  weekai 
prior  to  the  setting  in  of  labor.  They  may,  indeed,  be  regarded  ss 
preli»ninary  to  the  concentrated  effort,  wdiich  results  in  the  expnl* 
giun  of  the  frjGtus;  and,  no  doubt,  one  of  their  purposes  is,  as  it 
were,  to  prepare  the  uterus  for  the  struggle,  which  is  so  close  at  b.ind. 

If  you  iisk  for  the  proof  of  this  independent  contraction  of  the 
organ,  I  w^ill  refer  you  to  two  important  Jacts,  which  establish 
l>eyond  a  perad venture  that  the  uterus  possesses  a  contractility  of 
its  own,  in  no  w^ay  dependent  upon  nervous  supply.  The  fact*  are 
these:  1,  The  foetus  has  been  exiielled,  in  virtue  of  the  inherent 
oontraction  of  the  organ,  after  the  death  of  the  mother,  when  ner- 
vous force  was  out  of  the  question  ;  audit  is  also  well  establisihed 
that  the  peristaltic  movement  will  continue  for  some  time  after  life 
has  become  extinct.f     2d.  Parturition  has  been  accomplished  by 

•  The  terms  **  in^eiisitU  c&ntracttons'^  are  oot  strictly  correct.  So  tnr  Ihim  helng 
irwnmfilf,  they  arv  not  only  felt  by  the  tuother,  but  oftentitnefl  give  rise  to  inor^  ot 
]««j|  distrcsi    They  should  rather  bi»  called  indipendeni  or  inhtrmt 

f  fko  Gr^f  liaji,  in  difiseeted  rabbity  obsenred  the  wcnnb  to  be  agitAted  bf  « 
Auctiuiting  and  periAtaltic  rootbtir  And  by  Its  own  foroe  to  ddve  out  the  fcetuii  [De 
Mulier  Oregon,  p.  'S2^,] 


THE  PRINCIPLES   AND   PRACTICE   OF   OBSTETRICS. 


319 


the  unauled  efforts  of  iKiturc  in  cases  in  which  the  lower  portion 
of  the  spinal  cord  has  been  completely  destroyed  ;  you  will  see  it 
go  oil,  too,  in  women  affected  with  paraplegia,  showing  that  the 
cord  is  without  function,  and  cannot,  therefore,  in  these  cases, 
miuiHter  to  uterine  contraction8.  Dr.  Brown-Sequard*  says  he  has 
seen,  hundreds  of  times,  the  uterus  or  its  corniia,  full  or  empty, 
oontracting  to  appearance  spontaneously,  after  the  death  of  rab- 
bits and  other  animals,  at  a  tiuie  when  the  spinal  cord  had  entirely 
lost  not  only  its  retiex  [lOWer  but  also  the  power  of  acting  on  mus- 
cles when  directly  excited  by  galvanism,  warmth,  or  rnechatiically. 
But,  gentlemen,  the  question  still  presses  ns — what  is  the  deter- 
mining cause  of  labor,  or  what  is  it  that  first  induces  these  indepen- 
dent movements  iu  the  muscular  tissue  of  the  uterus  ?  I  may  not 
be  very  lucid  in  the  exposition  of  my  notion  touching  the  question 
— but  it  does  seem  to  me  that  there  i^ a  necessan/ eontuyxion  between 
thisjirst  spontaneous  movemeni  in  the  muscular  icalh  of  the  uterus^ 
And,  if  I  may  so  term  it,  a  nicUured  development  of  ike  rmtneulur 
9fructure  of  the  organ  itself  What  I  mean  by  matured  develop- 
ment m  this — from  the  instant  of  fecundation  the  uterus  becomes 
an  active  centre,  the  effect  of  which  is  an  increased  nutrition,  which 
results  in  the  growth  and  development  of  the  various  structures 
conjpo^ing  it.  This  incre:ise  constitutes  one  of  the  processes  iu  the 
interesting  scheme  of  reproduction — and  so  essential  is  it  that, 
when  interrtipted,  failure  on  the  part  of  nature  to  consummate  the 
act  of  generation  is  tlie  consequence.  The  gradual  and  successivo 
development  of  the  museidar  tissue  of  the  gravid  womb  has,  I 
think,  a  marked  bearing  on  the  point  now  under  consideration. 
Here,  be  it  remembered,  we  have  tins  important  character  of  struc- 
ture, during  the  period  of  gestation,  csonstantly  receiving,  through 
increase  of  nutrition,  increase  of  volume,  and  consequently  aug- 
inented  ability  for  the  manifestation  of  its  j>eculiar  function — con- 
tractility.  It*  you  consider,  on  the  one  hand,  this  fact  of  increase 
in  development,  and,  on  the  other>  the  interesting  circumstancQ 
that,  as  pregnancy  approaches  its  termination,  the  uterioe  mus- 
cular fibre  is,  as  a  necessary  result,  proj»oitionately  gaining  in 
maturity  of  growth  and  devt-'Iopnient — if,  I  say,  yoti  cotjsider  all 
these  things,  does  it  not  seem  M*ithin  the  range  of  probability 
that,  under  the  constant  influence  of  nutrition,  and  repose,  so 
far  as  regards  its  functional  display,  the  muscular  tissue  of  the 
gravid  uterus  becomes,  as  it  were,  surcharged^ — in  a  word,  so 
fUll  of  contractile  power  that,  in  perfect  consistency  with  the 
general  laws  regtilating  the  animal  eoouomy,  it  commences  its 
series  of  acts  through  wliich  alone  the  exit  of  the  fcBtus,  afVef 
fiUl  intra-uterine  development,  can  be  accomplished. 


•  Sxpenmental  Reseftrchefl  ipplled  to  PhjEioIogy  and  Pathology,  p»  1(3$, 


320 


TBE   PRINCIPLES  AND   PBACTICK   OF   OBSTETRICS, 


If  I  be  correct  in  my  exposition  of  the  determining  eaiw©  of 
labor,  which  I  have  thus  briefly  presented,  it  seems  to  aie  it  must 
be  admitted  that  the  primnm  mobik  of  uterine  action,  when  gcstft- 
tiou  hns  been  completed,  \a  a  physiological  necessity,  tltidpr  any 
circumstances,  \vhetlu?r  tlie  theory  be  8ubstnntial  or  other \d?^c,  it 
will,  I  ihink,  prove  not  less  satisfactory  than  ihe  opinion  of  Avi- 
cenna — **  That  at  a  fixed  time,  labor  takes  place  by  the  grace  of 
God." 

Ftitfy  Defeneration  and  other  Changes  in  the  refetUly  dt^Uver^ 
XTterus, — It  is  conceded  that  tlie  uterus,  us  s^oon  as  its  contests 
have  been  expelled,  exhibits  new  chanties  iji  it»  ok?meniarj'  eoo9li* 
tution — the  bluod-vessels  find  nerves  which,  during  ges§tation,  were 
largely  developed,  now  diminish  in  volume,  and  soon  not  a  ves*tige 
can  be  detected  by  the  naked  ever  the  niuscuhir  ti<$sae  becomes 
much  less  conmderable,  through  the  diminution,  both  in  siie  and 
number,  of  its  elements — the  niiisculo-tibre  cells — and  passes  into  a 
gtate  of  f^itty  degeneration,*  so  well  demonstrated  by  Vircbow  and 
Kilian.  In  a  word,  the  organ  beconjes  invested  again  with  a  rudi- 
mentary character,  which  continues  until  stimulated  to  new  forma- 
tions, and  a  more  perfect  organization  by  pregnancy. 

Fatty  degeneration,  or  Rubstitution,  is  \mj  frequently  a  morbid 
or  pathological  conditlon^but  is  it  always  so?  Evidently  not — 
for  it  is  sonjetinies  a  perfectly  natural  result,  as  is  shown  in  certain 
atnictnres  prior  to  absorptirm,  when  they  have  accomplishcKl  the 
term  of  their  functionnl  activity.  This  is  well  illustrated  iu  the 
placenta,  as  has  been  jjointed  out  by  Dr.  Drultt,  Dr.  liubert  liamei^ 
and  other  observers.  The  vessels  of  this  body — the  placenta — 
midergo  fatty  degeneration  toward  the  close  of  gestiition ;  the 
remarkable  and  interesting  fact  is,  that  this  metamorphoaisof  stm^ 
ture  commences  in  the  tufts  or  vessels  at  the  circumference  of  the 
orgarj,  at  which  point  its  special  office  or  t unction  ceases  first. 
This,  then,  I  hold  to  be  strongly  corroborative  of  the  opinion  I 
have  advanced.  Fatty  substitutioDj  both  of  the  placettta  and  of 
the  muscular  tissue  of  the  uterus,  takes  place  as  soon  as  these 
iitructures  have  performed  their  particular  part  in  the  reproductive 
act;  and  this  change  in  the  tissues  is  not  to  be  regarded  :is  a  patho> 
logical  result,  but  as  one  of  the  natural  processes  of  the  economy. 

*  Dr  PrieaUoy  «iiy^  *'  He  haa  occasionally  seen  at  the  poet-moncm  examinatjoot 
of  women  who  had  previovialy  borno  cliildren,  tho  uterine  tbiuo  afll^clod  by  |*tty 
degenemtion^  and  so  soft  nod  friable  that  a  Bonnd  passed  iolo  the  utcduo  aivitj, 
during:  life,  as  a  meaoa  of  diagnosifi,  might  have  readily  hten  pushod  quttc  througb 
lh0  uleriu©  walk,  unless  the  greatest  car©  were  cjcercbied  \u  ita  niauipulaUoiL" 
[LoctuTOt  on  tbo  Development  of  the  Gravid  Uteres,  p.  lOJL] 


LECTURE   XXIII. 

Sett  tad  Origin  of  the  Expulsive  Forces  in  Parturition — How  these  Forces  are 
Modified — Spinal  Cord — Its  Influence—Parturition  in  part  an  Excito-motory  Act — 
Sxdtons  of  Reflex  Action  in  the  Uterus — What^are  they  ? — Difference  in  Uterine 
Oootraction  due  to  Inherent  Irritability  and  Nerv6us  Force— What  is  it  that  causes 
the  Diaphragm  and  Abdominal  Muscles  to  Contract  as  a  iSocondary  Aid  in  La- 
bor I— The  Contraction  of  these  Muscles  is  not  always  an  Act  of  Volition  ;  it  is 
■ometimes  Reflex — Signs  of  Labor — Importance  of—The  Signs  of  I>nbor  divided 
Into  Preliminary  and  Essential,  or  Characteristic — What  are  the  Preliminary? — 
What  the  Essential  Signs? — Labor  Pain ,  how  Divided  ? — Is  Pain  the  Necessary 
Aooompaaiment  of  Parturition  ? — What  is  the  true  Explanation  of  Labor  Pain  ? — 
Ib  it  identical  with  Uterine  Contraction,  or  is  it  the  Result  of  Contraction  ? — 
ChftDge  in  the  Phjrsical  Condition  of  the  Uterine  Muscular  Fibre  under  Conirac- 
tkm ;  Deduction — ^True  and  False  Labor  Pain ;  how  Discriminated — Dilatation  of 
Oi  Uteri;  how  Produced — Rigors  and  Vomiting  during  Dilatation;  What  do 
they  Portend? — The  Muco-Sanpuineous  Discharge  during  Labor;  how  Pro- 
doced — Formation  and  Rupture  of  the  "  Bag  of  Waters;"  how  the  Formation  \» 
Aoooniplished — Uses  of  the  •'  Bag  of  Waters  "  during  Childbirth — Caution  against 
its  Premature  Rupture — Tiie  "  Caul  or  Hood ;"  What  does  it  mean  ? 

GxMTLEMEN — Having  endeavored  to  explain  the  determinir>g  cause 
of  labor,  it  is  now  proper  to  discuss  the  seat  and  origin  of  the 
expulsive  forces,  which  result  in  the  delivery  of  the  foetus  aird  its 
appendages.  These  expulsive  forces  may  be  divided  into  two 
kinds:  1.  The  primary  or  efficient;  2.  The  secondary  or  auxiliary. 
Ton  must  recollect  that  the  peculiar  something  wliich  constitutes 
the  inception  of  utennc  action,  is  a  very  different  thing,  as  a  general 
principle,  from  the  power  through  M'hich  is  accomplished  the 
evaeoation  of  the  uterine  contents.  The  fact  is  generally  conceded 
that  the  primary  or  efficient  element  of  this  power  resides  in  the 
organ  itself,  and  consists  of  the  contractile  efforts,  which  manifest 
themselves  at  the  commencement  of  parturitioni,  and  continue  with 
more  or  less  impulse  until  the  delivery  is  consummated.  There  is 
a  striking  difference  in  the  grade  and  measure  of  force  exercised  by 
the  contracting  uterus  upon  its  contents,  and  this  difference  will  be 
fiiUy  recognbed  as  the  labor  progresses.  At  first,  and  until  the 
nedc  of  the  organ  becomes  so  dilated  as  to  experience  the  direct 
pressure  of  the  presenting,  portion  of  the  foDtns,  the  force  is  com- 
paratively moderate,  and  is  the^  result  simply  of  the  inherent 
mobility  of  the  organ  itself-— an  illustration  of  that  independent 
per  9e  contraction  of  which  we  have  spoken  in  the  preceding  lec- 
tore.    But  as  the  labor  advances,  and  when  one  of  the  conftequences 

21 


322 


THE   PRIXCTrLES  AND   PRACTICE  OF  OE 


of  this  advance — the  dilatation  of  the  o*^  uteii— l»a8  been  effecied, 
Xhun  these  moderate  efforts  undergo  a  marked  and  decided  ehangc — 
they  aB-*iime  an  expulsive  character,  which  increases  in  intensity  In 
prnporlion  as  the  head  or  presenting  part  of  the  fcetns  escape*  from  J 
the  ntcru!*,  afjd  makes  pressure  on  the  walls  of  the  vagina  and  vulva, ' 

Differethye  in  the  Parttirient  Force. — It  is  not  «uiHcieni  for  yoti, 
as  inteUigcnt  students,  to  know  that  there  really  exists  a  dilTereoc^s 
in  the  kind  and  amount  offeree  exercised  by  the  uterus  during  the 
parturient  struji^frle — you  require  fiomethrno:  more  ;  you  dc^ii^  the 
explanation  of  this  differeuee.     Childbirth  is,  strictly  speaking,  a 
jjhysiological  act,  and  its  physiology  is  of  the  most  gtnking  and 
positive  nature.      The  spinal  cord,  that  essential  nervous  cenln*, 
plavi?  an  important  part  in  the  general  movement,  resulting  in  the*! 
delivery  of  the  foetus  and  its  annexie ;  and  you  cannot  have  yoof  ^ 
attention  too  steadfastly  directed  to  this  interesting  fact.     It  »  [ler-  j 
fectly  correct  to  say,  that,  as  a  general  rule,  labor  is  in  part  accom- 
plished through  an  excito-motory  influence,  or,  in   other  worda, 
through  reflex  action.     For  the  production  of  a  reflex  movement,,! 
two  requisites  are  needed:    L  The  spinal  cord,  which  is  the  grett 
central  organ,  and  which  becomes  the  recipient  of  impressiaufi;  2* 
The  incident  exeltor  nerves,  which,  first  receiving  these  impression*, 
convey  them  to  the  medulla  spinalis,  and  this  latter  communicating 
to  the  motor  nerves  an  increased  vis  or  impulse,  an  influence  i^  thus 
extended  to  the  muscles  to  which  these  motor  nerves  arc  distnbuled» 
which  results  in  a  movement  known,  physiologically,  as  reflex. 

Ex<'itor8  of  Ilefl^x  Uttrlne  Aetkm — It  is  a  matter  of  great 
practical  ititerest  to  remember  that  there  are  various  excitors  of 
reflex  action,  so  far  as  the  uterus  is  concerned ;  and  it  is  the 
recollection  of  this  circumstance,  which  will  enable  you,  ofleotirae^ 
not  o?ily  t-o  control  morbid  influence,  but  will  be  f^n  '    ^  of 

miportunt  remedial  agents  in  cases  involving  more  or  ^      ^^  ha 

in  hemorrhage,  inertia  of  the  uterus,  or  excessive  uterine  cootinOiJ 
tlnn.     Some  of  these  exciters  may  be  briefly  alluded  to;  Wlien  a 
newly  delivered  woman  apjilies  her  infant  to  the  breast^  it  is  not  at 
all  unusual  for  her  to  eomphiin  of  more  or  less  pain  in  the  uterus'-^  . 
this  is  an  example  of  reflex  action,  traceable  as  its  primary  cnu^e  to 
rrriUvtion  of  the  excitor  nerves  of  the  mammse,  the  irritation  being 
induced  by  the  suction  of  the  chtUVs  mouth.     You  are  s«^metimcs  - 
told  tliat  irictions  on  the  abdominal  suriUce,  and  more  e^pedftlljf  I 
the   appUcatiou    of   cold,   will    evoke   uterine   contraction,     *rb#| 
fact  i«  undoubtedly  so— and  its  explanation  is  found  in  the  circum* 
Rtance  that  the  cutaneous  or  terminal  excitor  nerves  of  the  abdomeo 
beci^me  impressed  by  the  friction  or  cold,  and  hence  the   rrtlex 
movement  resulting  in  contraction  of  the  organ.     How  precioos  to 
the  life  of  your  patient  will  be  the  recollection  of  this  fiict,  in  feiu-ftU 
hemorrhage  of  the  uterus  after  the  birth  of  the  child — it  is  ou  ll 


THK   PRINCIPLES  AND   PRACTICE  OF   OBSTETRICS. 


323 


principle  just  explained  that  you  will,  with  sudi  prompt  and 
decided  effect,  use  the  cold-dash,  which  consbts  in  thi'owing,  with 
an  itnpulse,  a  pitcher  of  cold  w^ater  upon  the  abdomen.  When 
everything  looks  dreary  for  the  patient,  and  hope  is  almost  aban- 
doned from  the  iailure  of  other  remedies  in  these  instances  of 
abrming  flooding,  the  cold-dash  will^  otlenlimes,  y^rove  of  inealcuhv 
l>le  service  in  closing  u|*  the  flood-gates — ^the  mouths  of  the  utero- 
placental vessels — which  are  fast  exhausting  the  strength  of  your 
patient,  and  hurrying  her  with  rapid  pace  to  the  grave. 

But,  gentlemen,  there  are  other  important  excitors  of  uterine 
action  which  are  represented  by  the  numerous  terminal  nerves 
distributed  throughout  the  uterus  and  vagina,  and  these  constitute 
the  essential  class  of  excitors  in  the  parturient  act,  because,  as  eoon 

labor  commences,  they  are  brous^ht  more  or  less  into  o]>eration, 

.  will  be  presently  shown*  In  addition,  there  are  the  excitors  of 
the  rectum  and  bladder,  and  hence  you  can  understand  why  abor- 

yn  will  be  apt  to  ensue  in  cases  of  constipation,  or  from  the 

iministration  of  drastic  medicines,  winch  act  specially  on  this 
portion  of  the  intestinal  tube ;  and,  also,  I'roni  the  tenesmus  of 
dydcntery.  A  similar  result  is  equally  susceptible  of  explanation 
when  the  neck  of  the  bladder  becomes  the  seat  of  irritation,  either 
from  the  presence  of  a  calcidus,  or  from  the  absorption  of  cantha- 
rides  ftfler  a  blister  has  been  applied,  occasioning  strangury. 

Wo  have  spoken  merely  of  what  have  been  designated  the 
eccentric  or  indirect  influences  which  operate  in  the  production  of 
uterine  contraction.  It  must,  however,  not  be  forgotten  tfiat  there 
re  certain  centiic  or  direct  influences  equally  capable  of  bringing 
fcbout  the  same  result — influences  which,  uistead  of  exercising  their 
pnmary  irritation  on  the  terminal  or  incident  excitor  nerves,  pass 
directly  to  the  nervous  centre  iiself— the  medulla  spinalis, 

if,  as  I  hope,  I  have  succeeded,  so  far,  in  making  myself  under- 
stood, there  will  be  no  difliculty  with  the  data  just  presented  in 
comprehending  tlie  modus  ofjerandi  of  ihe  two  kinds  of  forces — ^the 
primary  and  secondary — which  determine  the  expulsion  of  the  feet  us 
and  Its  appendages. 

Pnmary  Forces  of  Parturition. — The  first  contractions  of  the 
parturient  womb  are  altogether  due  to  the  inherent,  independent 
irritability  of  the  organ ;  and,  as  h:ks  already  been  explained  to  you 
in  the  preceding  lecture,  this  inherent  action  of  the  uterus  will, 
under  cej-taiu  circmnstances,  suffice  to  accamjilish  the  birth  of  the 
child— showing  inconiestably  that  childbirth  is  not  essentially 
dependent  upon  nervous  agency.  These  flrst  contractions  continue 
at  irregular  intervals,  and  their  tendency  is  to  aid  in  the  dihitalioo 
of  the  OS  uteri.  When  this  is  accomplished,  and  even  during  the 
progress  of  dilatation,  the  contraction  increases  in  force,  and  here 
we  have  a  striking  illustration  of  the  conservative  care  and  per- 


824 


THE  PRINCIPLiea  AKD  PRACTICE  OF  OBSriTRICS, 


ferlion  displayed  by  nature  in  the  great  scheme  of  delivery.  Prior 
to  the  full  opening  of  tbe  mouth  of  the  uterus,  extraordinary  poivisr 
was  not  needed ;  but,  ae  soon  as  this  stage  of  the  labor  has  been 
completed,  an  increased  force  ia  called  for;  and  it  is  immediatdy 
furnished  by  making  the  spinal  system  of  nerves  Iribumry  to  the 
wtinlH  of  the  eeoufjuiy.  Hence,  you  will  find,  at  thb  period  of  the 
purturient  eftbrt»  xUni  the  irritation  of  the  inc^i^lent  excitar  nerve?* 
of  the  dilated  os,  caused  by  the  presaure  of  the  preAentiog  portion 
of  tftc  fcetua,  18  instantly  transmitted  to  the  medulla  spinalis  from 
which  lA  derived  a  responsive  impuUe  to  llie  mulor  nerves  of  the 
Uterus,  resulting  in  increat*ed  energy  of  the  contraction.  In  this 
way,  you  jjcrceive,  h  explained  the  primary  or  ellieicnt  element  of 
labor,  which  we  have  already  told  you  is  centred  in  the  utcms 
itself,  and  which  xa  of  a  two-fold  nature:  1.  Inherent,  the  result  of 
siiDple  ruuscular  irritability  ;  2.  Nervous,  the  result  of  reflex  aotkML 
Secondary  J'hrre^. — Let  us  now  turn  to  the  secondary  or  MixiU- 
ary  forces  of  childbirth,  and  see,  in  the  first  place,  what  they  are; 
and  secondly,  the  modus  in  quo  of  their  ]»roduction.  Thesu  auxili- 
aries consist  in  the  powerful  contractions  of  the  diaphragm  and 
abdominal  muscles,  which  undoubtedly,  although  in  a  seooodarj 
manner,  render  good  service  in  the  work  in  which  nature  is 
engaged*  As  soon  as  the  head  or  presenting  part  of  the  fcplus  hiui 
fairly  escaped  through  the  mouth  of  the  womb,  it  necessarily 
exercises  a  pofiiiive  pressure  on  the  distended  vagina— it  is  the 
pressure  on  this  surface,  which  chiefly  induces  irritation  of  the 
incident  excitor  nerves,  and  henoe,  through  reflex  influence,  the 
di:iphrngm  and  abdoininiil  muscles  are  uivakened  to  jjowerful  con* 
trnctiuns,*  When  ilie^e  Litter  commence,  the  labor  undergoes  a 
marked  change — it  is  then  what  is  denominateil  eJtpuUiv^^  and 
every  succeeding  contraction  ijf  the  organ  is  characterixed  by  aa 
increa!^c*d  impulse.  The  will  fre<|uently  has  no  control  at  this  linni 
over  the  muj^cular  contractions  of  the  diaphi^gm  and  abdominal 
walls — they  appear  inde[»endent  of  volition,  nor  can  they,  nnJer 
full  development,  be  restrained*  They  are,  under  these  cirutiOK 
Btances,  like  deglutition  and  mnny  other  phenomena  which  ara 
dependent  upon  a  special  local  irritation,  under  no  subjection  to 
tile  iudi vidua).  How  do  you  suppos^e  the  act  of  degbititioo  M 
accomplished?  Is  it  a  voluntary  movement!  You  ran  eadJy 
satisfy  yourselves  that  it  is  not,  for  you  will  attempt  in  vaan  to 
swallow  by  any  voluntary  act  of  your  own.    Deglutition  ia  a  pbiv 

*  1  think  it  rigtit  to  miv  ilmt,  altbougti  the  coatnctioo  c»r  tlui  diaphrfi«rni  sod 
•bdomiiiftt  muKlos  ia  fometifncs  reflex  during  ibe  parturient  effurt,  yei  it  Is  qaila 
Of^rtnm  that  tt  \b  frvqaenti j  roTuotJiry.  One  oT  the  most  fbrmidablo  tfCMilaks  wlHi 
wUlv'lj  the  ni^cticiil  tnait  has  to  contend  is  bvolanturj  ftd&on  of  the  dbpltm^ai, 
bofliiiiae  It  giTW  rbe  to  spusnni^  moro  p^rikms  Uuin  «kiy  Oftbtr,  idmudqcIi  m  Ibe^ 
dlnol  IMidaiiiiy  k  to  urest  tlio  nnfiiinitmy  moTcmcat 


THE  PRINCIPLES  AND   PRACTIGE   OF  OBSTETRICB. 


826 


nomenan  due  to  reflex  action  ;  ita  source  is  the  medulkt  oblongata  ,* 
iind  irritation  of  the  excitor  nerves  of  the  fauces  is  an  essential 
prerequisite  to  its  performance.  The  food^  during  a  repast,  is  the 
usual  irritant,  and  under  ordinary  circumstances  the  contact  of  the 
saliva  with  tiie  fauces  enables  you  to  consummate  the  act.  So  you 
perceive,  physioloiricaily  speaking,  deglutition,  so  far  from  being 
^fatiked  among  the  voluntary  phenomena,  ia  essentially  and  truly 

Uomatic  in  its  nature. 

From  what  has  been  said  in  explanation  of  the  primary  and 
secondary  causes  of  labor,  you  cannot  have  failed  to  observe  one 
iinal  feature,  viz.  that  the  force;?,  necessary  to  the  expulsion  of 
the  fcBtus,  commence  at  first  in  moderation,  and,  as  the  labor 
advances,  they  are  characterized  by  vastly  increased  impulse  and 
vigor.  You  not  only  understand  that  this  is  t^o,  but  you  are  also 
prepared  to  ap]jreeiate  its  necessity.  Of  course,  gentlemen,  you 
must  bear  in  mind  that  I  am  now  speaking  of  parturition  tnider 
ordinary  or  normal  circumBtancea,  and  not  of  those  exceptional 
cases  in  which  the  effort  commences  with  extraordinary  violence, 
and  is  complete<l  in  a  very  brief  period. 

Si{/ns  of  Zabor.— 'The  next  to]>ic  for  our  consideration  will  be 
the  signs  of  labor,  and  here,  peniiit  me  to  suggest,  we  touch  upon 
a  most  important  subject  for  the  student  and  f»vactitioncr  of  mid- 
wifery— a  subject,  which  if  not  wisely  understood,  will  frequently 
lead  to  serious  embarrassment,  if,  indeed,  it  do  not  subject  the 
medical  man  to  just  and  withering  rebuke.  How,  for  example,  are 
you  to  know  tliat  labor  is  at  hand,  or  has  really  commenced, 
except  through  a  proper  appreciation  of  the  signs,  which  indicate 
either  its  approach  or  presence  ?  It  is  a  question  altogether  of 
testimony,  and  that  testimony  is  made  up  of  signs  or  indications. 
It  is  for  you,  therefore,  to  be  careful  in  your  analysis  of  these  signs ; 
see  that  you  do  not  confound  true  with  false  evidence.  For  prac- 
tical purposes,  the  signs  of  labor  may  be  classified  under  two 
divisions,  and  I  think  they  will  embrace  everything,  which  it  ia 
bnportant  for  you  to  know  on  the  subject :  1.  The  preliminary  or 
precursory;    2.  The  essential  or  characteristic. 

Preliminart/  >SV^«^.— The  preHminary  indic*ations  of  labor  consist 
of  certain  pheno«iena,  whicsh  usually  exhibit  themselves  a  few  days 
previously  to  the  commencement  of  the  ]iarturicnt  act,  and  they 
may,  in  the  true  sense  of  the  term,  be  considered  as  preparatory. 
They  are  as  follows:  1,  When  laWr  is  near  at  hand,  the  fact  will 
be  broadly  indicated  by  the  peculiar  condition  of  the  neck  of  the 
uterus;  it  will  have  lost  its  length — it  will  be  more  orlcAs  circular — 
in  a  word,  the  neck  of  the  organ  will  be  obliterated  ;  on  an  exami- 
nation per  vaginam  tliere  will  be  recognised  a  eimj»le  orifioe,  which, 
in  women  who  have  already  borne  children,  will  usually  be  suffi* 
ciently  dilated  to  permit  the  introduction  of  the  end  of  the  index 


326 


THE  PRINCIPLES  AND  PRACTHCE   OF  0B6TETR1CS. 


finger,  while  in  the  primipfrrce  there  will,  as  a  general  rale,  be  au 
absence  of  rlilatatian,  2*  For  some  days,  and  occjisionally  for  tiro 
or  three  weeks  prior  to  the  commencement  of  actual  latx^r,  the 
female  will  complnin  of  a  sense  of  uneasiness  about  the  uterus;  and 
this  uneasineaa  will  probably  be  observed  several  liujes  during  llm 
day  and  nighl ;  if^  while  the  patient  compUins  of  thi«  local  <lb- 
turbancc,  you  should  place  your  hand  over  the  region  of  the  womb^ 
you  will  distinctly  perceive  that  the  organ  beiTomes  hard  for  the 
time  being,  and  ns  soon  a:^  the  uneasy  seiiHation  parses  away^  it 
again  becomes  relaxed.  These  are  what  are  known  as  the  inde- 
pendent contractions  of  the  uterus,  and  generally  develop  tbem* 

'  selves  earlier  in  the  primipara*  Tfiey  are  tiot  accompanied  by  m 
bearing-down  so  chnrjicteH'itic  of  true  hbor  conlracti<m<*;  they  tre| 
on  the  contrary,  but  the  result  of  the  muscular  irritability  of  iho 
organ,  and  are  to  be  regarded  as  sirni>ly  preliminary.  B©  carefill« 
and  do  not  confound  this  early  action  of  tlie  uterus  with  bibor 
properly  so  called.  The  sense  of  uneasiness,  due  to  these  ind^ 
|>endent  contractions,  will  ^ometime-"^  occasion  much  anxiety  m  the 
mind  of  your  pjitient ;  she  regards  it  as  the  harbinger  of  evil,  a^nd 
looks  upon  it  as  an  evidence  that  somethitig  is  wrong.  It  will  b^ 
your  duty  at  once  to  dispel  all  apprehen8!4>n,  and  a^aure  her,  which 
you  can  do  with  entire  tnith,  that  the  greatc^r  this  local  diyttirbaneu 
previous  to  the  eonimencement  «»f  the  |iartunent  effort,  the  nioro 
auspicious  will  be  the  doll  very.  This  is  really  so,  a«  a  general  mlCf 
for  thei^e  contractions  of  the  gra\id  uterus  are  not  only  preliiniitary, 
but,  when  of  a  decided  character,  exercise  a  very  happy  influcnoo 
in  preparing  the  os  uteri  for  its  sub<*eqnent  dilatation.  Indeed,  I 
have  remarked,  as  a  practical  fiict  worthy  to  be  recollected,  that,  aH 
things  being  equal,  labor  will  be  shortened  and  more  favorable  jo»t 
in  proportion  to  the  activity  of  these  contractions.  3.  For  aotiie 
days  [previous  to  the  completion  of  gestation,  there  will  be  ii 
remarkable  change  in  the  position  of  the  impregnated  utenw;  aod 
this  change,  as  you  will  presently  see,  will  result  in  what  may  \m 
termed  mixed  phenomena — some  highly  favorable  to  the  conditioii 

*  of  the  female ;  others,  again,  entailing  upon  her  for  the  timo  biiiigf 
more  or  less  distress. 

The  change  to  which  I  allude  in  the  position  of  the  orgsn  k 
this — the  fundus  of  the  womb,  in  lieu  of  pressing  high  up  in  the 
epigastric  region,  is  observed  to  descend.  This  is  wliat  may  b^ 
terme<l  the  riffhiing  of  the  organ ;  it  is,  as  it  were,  the  |>lm«ilig 
itself  in  readiness  for  the  struggle  in  which  it  is  bo  sc^on  to  tsfigtgv. 
If  yon  aak  me  why  the  gravid  uterus  dettcends  in  the  abdomiiud 
cavity  previous  to  the  commencement  of  labor,  I  must  acknowlwlg© 
that  I  cannot  satisfactorily  answer  the  interrogatory  in  anf  €»i}|«r 
ir»y  than  by  referring  the  descent  to  a  combination  of  tiiilianiea% 
inch  as  Increase  in  the  weight  of  the  organ,  and  of  the  fiBl«% 


THE  PBINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         827 

fiquor  amnii,  etc.,  together  with  a  softening  of  the  fibro-articular 
tinsues. 

Be  the  explanation  as  it  may,  the  immediate  effects  of  this 
descent  of  the  uterus  require  a  word  of  comment.  In  the  first 
place,  when  the  organ  descends  into  the  abdominal  cavity,  the 
pressure  of  the  fundus  being  retpoved  from  the  diaphragm,  the 
female  feels  much  lighter  and  more  buoyant;  she  can  breathe  free, 
and  is  relieved  from  the  sense  of  oppression  which  she  had  previ- 
ously experienced.  Secondly,  the  abdomen  becomes  much  less 
protuberant,  especially  in  the  epigastric  and  umbilical  regions.  Let 
me  here,  for  a  moment,  call  your  attention  to  some  of  the  tempo- 
rary inconveniences  of  this  alteration  in  the  position  of  the  uterus.-^ 
Just  in  proportion  as  the  fundus  descends  will  be  the  measure  of  . 
descent  of  the  opposite  extremity  of  the  organ  into  the  pelvic 
excavation ;  the  os  uteri,  which  before  was  high  up,  and  difficult 
to  be  reached,  is  now  much  more  accessible  to  the  finger ;  the  neck 
of  the  bladder  undergoes  more  or  less  pressure  from  the  presenting 
part  of  the  fcetus,  giving  rise  to  irritation  and  frequent  desire  to 
micturate,  and  sometimes  occasioning  a  retention  of  urine.  The 
rectum  may  be  unduly  irritated  by  the  superincumbent  weight  of 
the  prolapsed  organ,  and  hence  distressing  tenesmus  may  be  the 
consequence.  The  vagina  itself  does  not  escape  the  effects  of  this 
descent  of  the  uterus,  and  one  of  the  results  will  be,  through  irri- 
tation of  its  walls,  a  more  or  less  profuse  discharge  of  mucus. 

In  addition  to  what  have  just  been  enumerated  as  among  the 
precursory  signs  of  labor,  may  also  be  named  the  following :  — 
hemorrhoidal  tumors,  increased  cedemaof  the  lower  limbs,  with  an 
increase,  also,  Jn  the  venous  engorgements,  all  these  being  more  or 
le88  the  necessary  consequence  of  the  pressure  of  the  gravid  womb 
after  its  descent  into  the  pelvic  cavity.  Nor  should  I  omit  to  men- 
tion, among  the  indications  preliminary  to  the  advent  of  labor, 
various  neuralgic  pains  about  the  hips  and  loins ;  and  you  will  not 
fiul  to  notice  in  some  cases,  especially  when  the  presenting  portion 
of  the  foetus  has  thus  early,  as  it  sometimes  will  do,  passed  low 
down  into  the  pelvic  excavation,  that  the  female  will  complain  of  a  t 
sense  of  numbness  in  her  lower  limbs,  with  occasional  inability  to 
move  them  with  the  usual  alacnty — threatening,  indeed,  their 
entire  loss  of  power,  or  paraplegia.  This  condition  of  things  will 
necessarily  give  rise  to  much  alarm,  and  it  will  be  your  duty  to 
explain  to  the  patient,  not  only  the  cause  of  these  neuralgic  pains, 
and  of  the  menaced  paraplegia,  but  also  to  assure  her  that  both  one 
and  the  other  will  be  evanescent  in  their  character,  and  are  simply 
the  results  of  the  pressure  of  the  prolapsed  uterus  and  its  contents 
against  the  sacral  and  other  nerves  of  the  pelvic  canal. 

In  some  females,  you  will  remark  the  exhibition  of  great  anxiety 
— ^accompanied  by  remarkable  depression — a  short  time  before  the 


828 


THE  PRmCIPLES  AND  PRACTICE  OF  OBSTETRICa 


Betting  in  of  labor.    They  wili  become  cactremely  nervous  and  it 
table,  and  it  will  ret^nire,  on   yoar  part,  sound  judgment  in  yoii 
appeals  to  their  good  sense  not  to  eherihh  feeling*  of  desf^ondenc;^ 
I  Lave  generally  obj^erved  that  this  depression   nsually  tntmifei 
itiieir  in  women  of  a  naturally  morbid  irritability,  and  it  is  imfi 
tant  to  control  it,  as  far  as  may  be,  because,  beyond  certain  limit( 
it  may  exercise  a  prejudicial  intluence  on  the  continement. 

Such,  gentlemen,  are  some  of  the  mure  notable  of  the  indic 
tions  which  precede  the  commencement  of  labor,  and  which,  iher 
fore,  have  with  much  propriety  been  denominated  preliminary 
precursory.     You  must  not,  I  repeat,  confound  the  vesiciil  irrit 
tion,  or  the  tenusmuti,  or  the  increawd  discharge  of  mucus  fro 
the  vagina,  which  are  but  the  effects  of  mechanical  pre^fore,  will 
morbid  conditions  of  these  organs.     Suppose,  lor  example,  a  i 
ried  lady  should  send  for  you  a  few  days  before  her  confinenien 
and  Bay  to  you,  "  Doctor,  I  am  very  much  alarmed  about  myj*tli 
I  am  afraid  I  have  some  serious  disease  of  the  bladder.''     **  Whj 
do  you  think  so,  madfim?  '^     ^*  Because,  sir,  for  the  last  few  days^ 
have  had  ko  much   irritation  in  that  part ;  I  have  a  more  or  It 
constimt  desire  to  pass  water.'^     Now,  gentlemen,  it  woidd  boj 
very  tbolish  thing,  to  use  a  mild  expression,  to  mistake  this  irritj 
tion  of  the  bladder — eitnply  a  premonitory  symptom  of  appro 
ing  labor — for  disease  of  the  organ,  and  hence  subject  your  patient 
not  only  to  aseless,  but,  very  probably,  mischievous  medicatic 
Nor,  if  another  lady  complain  of  distressing  tenesmus,  must  y< 
hastily  conclude  that  she  is  afflicted  with  dysentery,  and  therefoi 
place  heron  the  sick  list,  and  eonvert  her  innocent  and  ui<    " 
stomach  into  a  veritable  drug  shop,  for  a  malady  which  ex 
in  your  own  imagination.     Yon  must  pardon  me  fur  calling  yon 
attention  to  these  matters,  but  I  am  most  anxious  that  you  shoulj 
when  you  enter  on  the  mission  of  duty,  bo  able  to  trace  eff.*cts 
causes,  and  thns  dislinguish  between  the  shadow  and  the  subHtanel 
In  these  cases,  the  irritation  of  the  bladder  and  rectum,  like  tl 
neuralgic  ))ain8  and  threatened  paraplegia — all  results  of  a  oommo 
antecedent^ — will  disappear  as  soon  as  that  antecedent,  throngh  th©^ 
termination  of  delivery,  has  been  removed  ;  and  so  you   must  tell 
your  patient.     She  will  find  you  a  true  prophet,  and  consequentl; 
ber  faith  in  your  skill  and  judgment  will  be  greatly  enhanced. 

Essential  Siffna. — ^Tiie  essential  or  charctcteristic  ftigiis  of  lal 
are  four  in  number:    1.  Pain;   2.  Dilatation  of  the  mouth  of  il 
wond>;  3.  A  muco-sanguineona  discharge;  4,  Formation  and  ru|i 
ture  of  the  membranous  sac,   or  **  bag  of  waters."     The»e  futi 
phenomena  constitute  the  elements  of  labor ;  and  do,  in  tuct^  mak 
up  its  diagnosis.     When  they  are  present,  ])arturition  is  undoul 
«dly  in  progress,  and  hence  they  aru  pro{terly  named  its  cJmr 
teristic  indications. 


THK  FBINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         829 

1.  Pain. — ^Under  ordinary  circumstances,  pain  is  the  inevitable 
penalty  of  childbirth.  "  In  sorrow  shalt  thou  bring  forth,"  is  the 
decree  of  Heaven,  and  it  has  always  seemed  to  me  that  the  suffer- 
ing entailed  upon  the  parturient  woman  but  tends  to  strengthen 
and  consolidate  the  undying  love  she  cherishes  for  her  offspring. 
The  progress  of  science,  through  the  application  of  anaesthetics, 
has,  it  is  true,  to  a  great  extent,  emancipated  the  lying-in  chamber 
from  the  anguish  incident  to  it,  but  it  may  be  a  question  whether 
thb  interference  with  the  r61e  of  nature  has  not,  oftentimes,  been 
productive  of  serious  consequences.  That  the  employment  of 
anaesthetic  agents,  notwithstanding  their  undoubted  value  under 
judicious  administration,  has  been  sadly  abused,  will,  I  think,  be 
conceded  by  every  unprejudiced  mind.  But  this  is  a  subject  upon 
which  we  shall  have  something  to  say  in  a  succeeding  lecture. 

Are  the  Pains  of  Lahor^  and  the  Contractions  of  the  Uterus 
Identical  f — ^Those  of  you  who  have  ever  attended  a  case  of  labor, 
and  witnessed  the  intense  agony  of  the  woman,  will,  perhaps, 
express  more  than  ordinary  surprise  that  certain  authors  should 
have  endeavored  to  show  that  the  process  of  childbirth  is  not  one 
.  of  suffering.  It  is  nevertheless  true  that  such  demonstrations  have 
been  attempted,  but  to  my  mind  they  have  failed  most  signally  in 
their  proof.  Again :  even  among  those,  who  admit  one  of  the 
characteristic  attributes  of  the  parturient  effort  to  be  pain,  there 
is  much  discrepancy  of  opinion  as  to  the  peculiar  manner  in  which 
the  pain  is  produced.  Some  writers,  and,  indeed,  they  constitute 
the  great  majority,  maintain  that  the  contractions  of  the  womb, 
and  the  pains  of  labor  are  identical — but  this,  I  think,  is  an  error, 
and  has,  no  doubt,  led  to  some  of  the  confusion  which  exists  on 
this  subject.  So  far  from  the  contractions  of  the  uterus  and  the 
pains  of  labor  being  one  and  the  same  thing,  I  shall  endeavor  to 
prove  to  you — and  I  hope  I  may  succeed  in  the  development  of 
the  opinion — ^that  labor  pains  are  the  direct  consequences  of  the 
contractions,  and  that  they  hold  to  each  other  the  relation  of  effect 
and  cause.  One  of  the  essential  conditions  in  support  of  this 
hypothesis  is,  that  the  contractions  must  precede  the  pain ;  and  do 
they  not  ?     Let  us,  for  a  moment,  examine  this  question. 

Sup[iose  you  are  attending  a  case  of  labor,  which  has  fairly  com- 
menced—what do  you  observe  ?  Your  patient,  who  may  have  had 
several  severe  pains,  will,  perhaps,  be  in  pleasant  conversation  with 
you,  when  suddenly  she  will  exclaim,  "  Oh,  there,  doctor,  I  am 
going  to  have  another  pain."  Properly  translated,  what  is  the 
true  import  of  this  language  ?  Why,  it  means  simply  that  the 
patient  becomes  cognizant  of  a  movement  in  the  uterus,  which  is 
nothing  but  the  incipient  contraction,  and  experience  has  admo- 
nished her  that  this  movement  or  contraction  of  the  organ  will 
immediately  be  followed  by  the  pains  of  labor.     Again :  place 


3S0 


THE  PRINCIPLES  AND   PRACTICE   OF  OBSTETRICS. 


yoiTT  hand  on  the  nlidomen  nf  the  patient  in  whom  partiintiftn  hai 
C5ominenciitl,  and  you  will,  by  a  tew  secondft,  aniicipale  the  coming 
on  of  a  [>tuti,  heoAuse  you  feel  the  uteriia  hariieti  under  your 
hand  ;  or,  witli  the  finger  introduced  into  the  vagina,  yon  will 
know  ihrit  ii  pain  is  about  commencing  the  moment  you  IWI  iha 
neck  of  the  womb  utiffening,  if*  I  may  so  term  it,  in  response  lo 
the  contractile  efforts  There  is  no  speculation  here ;  it  in  Ji  matter 
of  fact,  wliich  yoa  can  ascertain  for  yonr«elve*  in  the  vcrj*  firet 
ease  of  labor  which  may  present  itself  to  your  observatjoii — t»hoir- 
iag  couctusjively  that  the  contraction  precedes  the  pain — the  former 
being  the  cause,  the  latter  the  effect. 

But,  I  can  readily  imagine  you  to  say — ^well,  for  nrpument'i 
sake,  sir,  we  accept  the  hypothe»i!i  ihat  uterine  oontraciion  and 
labor  pain  are  not  identical,  and  are  truly  cause  and  eflcct,  Thia 
adniis^ion,  however,  you  properly  nrge^  does  not  explain  to  us  how 
the  contraction  produces  the  pain.  Well,  gentlemen,  I  nhall  now 
endeavor  to  satisfy  you  on  this  point.  In  the  fir?it  place,  yoii  most 
bear  in  mind  that  the  object  of  tbe  contraciian  of  the  gravid  uterus 
is  to  allurd  an  exit  to  the  iuiins  and  it»  appendages ;  andt  in  order 
to  accomplish  this  end,  there  muMt  of  necessity  be  an  opening  made 
by  these  contractions  in  i^ome  portion  of  the  organ,  through  whicb 
tlie  escape  of  the  fcrtns  may  be  effV'cted.  It  is  the  dilated  o»  uleii 
which  constitutes  this  <ipening,  and  the  dilatation  is  in^tinly  accom* 
plinhed  by  the  contraction  of  the  tongituJinal  muscular  tibres,  which 
paMS  trom  above  downward  parallel  to  the  lung  axis  of  the  organ, 
and  which,  therefore,  concentrate  their  whole  force  upon  a  giveo 
point,*  viz.   the  mouth   of  the   womb.     When   these  hi  '     d 

rtbres  contract,  as  a  necci^sary  cinisecpiencc  of  that   (■«  i, 

their  jirevious  physical  condition  tinderg«)es»  two  im]  tort  ant  chaugea; 
1.  They  Khorten  in  their  long  axis;  *2,  They  increase  in  volume  ta 
their  respective  diametera.  This  increase  in  the  diameters  ia,  of 
course,  the  necessary  result  of  the  dimlnuLion  in  the  length  of  tHo 
fibre. 

What,  therefore,  I  denire  especially  to  direct  your  attention  tg  is 
this:  When  the  respective  muscular  fibres  of  the  gravid  womb 
tindergo  this  augmented  volume,  they  miisl,  as  a  conRcijucncc, 
oxercisc,  fi»r  the  time  being,  an  unusual  preiisure  on  the  nerves  dia- 
tribmed  ihruughoui  this  very  tuuscular  ii?»8ue ;  and  it  is  thi*  proa* 
mre  which,  I  believe,  in  part,  Hatisifactorily  explains  the  phenomtiia 
of  labor  priin.  When  the  contraction  ceascii,  the  pain  eea-ie*,  (or 
the  reason  ihiit,  in  tlie  absence  of  the  contraction,  the  nerves  eujoy 

*  Tlitt  fUntJos  of  the  gniTid  womb  underg^oes  a  more  marked  d«velopmfrttt  than 
say  otIiHf  portutti  nf  (In?  orgTin ;  Jifu]  if  in  addition  to  thli  fsoti  It  bv  rvocUeetod 
thftt  thi<  lonffitudinA)  miiai.niUr  nbn«  ^viitC  in  (freattfr  nbuiulinios  Ibtfe,  H  ia  raay  to 
Itnagiiic  tlie  fct^blc  roaijttATYco  offi?n>d  by  itic  ocrvLx,  whidi  1%  not  only  IMS  dSTOtppS^ 
btti  t0ore  fpshngiy  provided  wiiU  tnuacuiar  fiasua. 


TEX  TBINOIPLES  AIO)  PRACTICE  OF  OBSTETRICS.         831 

sn  immunity  from  pressure.  While,  therefore,  I  am  disposed 
to  thiok  that  this,  to  a  certain  extent,  is  the  true  exposition  of 
labor  pain,  yet  I  am  inclined  to  adopt,  in  connexion  with  the 
theory  of  pressure,  the  views  propounded  by  Dr.  Brown-Sequard 
on  this  question.  He  maintains  that  the  pain  is  partly  due  to 
the  galvanic  discharge  caused  by  the  muscular  fibres  under  con- 
traction, and  when  they  meet  toith  resistance.  It  is  the  irritation 
of  the  sensitive  nerves  of  the  uterus,  under  the  influence  of  that 
discharge,  which  he  regards  as  a  principal  cause  of  the  pain.* 

However,  as  labor  advances,  the  increase  of  suffering  can  be 
traced  to  other  sources.  Such,  for  example,  as  the  pressure  of  the 
foetal  head  against  the  os  uteri  during  the  process  of  dilatation ; 
and,  when  the  head  has  passed  the  mouth  of  the  organ,  its  pressure 
on  the  walls  of  the  vagina  and  outlet  are  additional  causes  of  dis- 
tress; add  to  this  the  irritation  which  the  various  pelvic  nerves 
undergo  from  compression  during  the  egress  of  the  child,  and  you 
will  at  once  see  that  the  necessary  consequence  will  be  enhanced 
suffering,  the  susceptibility  to  which  will  depend  much  on  the 
peculiar  temperament  of  the  individual. 

Division  of  Labor  Pains, — Authors  have  divided  labor  pains 
into  true  and  false  ;  and  this  distinction  it  is  important  for  you,  as 
practitioners,  clearly  to  appreciate.  True  pain  is  the  offspring  of 
uterine  contraction ;  in  other  words,  it  is  synonymous  with  the 
existence  of  labor.  False  pain,  on  the  contrary,  has  no  connexion 
whatever  with  any  movement  of  the  uterus,  and  is  the  product  of 
some  cause  entirely  foreign  to  uterine  contraction.  It  may  be  occa- 
sioned by  flatus  in  the  intestines,  indigestion,  diarrhoea,  constipa- 
tion, disease  of  the  kidneys,  distension  of  the  bladder,  rheumatism 
of  the  uterus  or  adjacent  muscles. 

There  are  few  things,  gentlemen,  more  essential  for  the  accou- 
cheur than  a  just  and  prompt  discrimination  between  the  true 
and  spurious  pains  of  labor.  Without  an  accurate  diagnosis  on 
this  point,  he  will  be  like  the  ship  without  its  rudder ;  his  progress 
will  not  only  be  uncertain,  but  will  be  unsafe,  and  sometimes, 
indeed,  disastrous.  How,  for  example,  without  the  ability  to  dis- 
tinguish between  these  two  grades  of  pain,  can  you  know,  when 
summoned  to  the  sick-room,  whether  or  not  your  patient  be  in 
labor  ?  Failure  in  this  particular  will  lead  to  much  embarrassment, 
and  oftentimes  prove  perilous,  if  not  destructive,  to  your  reputation. 

True  Labor  Pains. — These  pains,  remember,  are  always  con- 
nected with  the  contraction  of  the  uterus,  and  are  slight  and  almost 
imperceptible  at  the  beginning  of  labor.  They  are  first  felt  in  the 
back,  and  usually  pass  on  to  the  thighs ;  they  are  distinctly  recur- 
rent— that  is,  they  are  not  continuous — but  come  on  at  intervals. 

*  London  Lancet.    1857. 


THE  PBIKCIPLES  AND  PHACTIGE  OF  OBSTETRICi. 


TUinMnay  be  divicled  into  two  kinds — grin«l'  m'^ 

firet;  ntter  tho  os  uteri  luis  advatKscJ  in  it-<*M  y 

ht$ann^  down  or  forcing  character.  Whon  the  true  \mn  is  prestftit^ 
th©  onlirt*  area  of  the  utexus  beeomes  hard ;  and  this  rlianjyt-  in  it« 
oondilinii  can  readily  be  reeajjjniHed  by  phicini?  your  hntid  on  iho 
abdomen,  A«  mvn  as  the  pain  subsides,  the  hanlcnin^  of  tho 
tttcrti!4  is  followed  by  rdaxiition ;  a;^ain:  if  during  the  piiin  tho 
finger  be  introduced  into  the  vagina,  and  the  09  uteri  dUatc*d^  Uie 
tnernbranes  will  be  felt  slij^litly  jirotruding,  in  re^  n, 

and  they  will  present  to  the  finger  a  sense  of  r*'  h 

the  dlscontinnanec  of  the  pjiin  they  cease  to  protruiie,  and  bocrynie 
flaccid.  Besides  the^e  characterititic  evidences  of  trtie  labor  poln^ 
the  patient,  during  its  presenee,  will  manifest  her  ^nffcringit  by  sup 
pres*^ed  groans,  or  in  some  more  marked  way.  A«  stvon,  howevtr^ 
as  the  pain  has  passed,  she  will  not  only  bo  free  from  ibstresft,  but 
will  join  in  agreeable  convers:uion  with  yon. 

SpKrimis^  or  Fifhe  Paiti^. — These,  as  I  have  already  y  '     |^ 

are  not  eunneeted  with  any  action  of  the  uterus;  for  cbr  s 

existence  the  organ  will  be  in  a  state  of  entire  tranquillity,  Th^jr 
ar*3  more  or  less  continuous,  depending  on  the  special  eauM  whlx*]! 
may  produce  them,  and  are,  therefore,  not  i*rcnrrent.  Il  can 
flearcely  be  neces?iary  fur  me  to  observe  that  the^e  i  h  %m\f 

«flfectu:dly  be  removed  by  tracing  ihein  t^  their  propi  .  For 

example,  if  from  eonstipiition  or  indigesticm,  .nj^eriems  will  \m 
indicated.  Should  they  bt*  due  to  spasmodic  action,  or,  aa  »oitie» 
times  will  be  the  case,  to  excessive  fatigue,  a  gentle  nno^lynr,  in 
some  form  not  inconsistent  with  the  idiosynera<«y  or  pern  f 

your  patient,  will  prove  the  remedy.     Tho^e  pains  will  i  »->- 

qnently  be  the  result  of  superabuiKlaneo  of  acid  In  the  primce  vi«; 
what  better,  under  the  circumstances,  than  the  employment  of 
antaeifls?  It  may  nlno  hnppen  that  inflammatory  attion  or  ftdirilci 
exei lenient  has  evoked  this  character  of  pain.  General  or  local 
bleeding,  with  a  jndiciouA  resort  to  purgaiiven,  dijiphon*rir*t,  t^u\^ 
wiil  constitute  in  these  cases  tho  elements  of  relief. 

II.  Dltaiation  of  the    Os    ^7/^1.— The  do<!trine   1  K 

and  indeed  it  has  among  its  suppurtei's  some  clever  n 
month  of  the  womb  is  opened  by  the  fanus  itself^ — that  this  lattitr^ 
as  it  were,  under  the  inHaence  of  a  peculiar  inatitiet,  desires  to  be 
Ubemted   from  its  accommodations,  and  therefore  spontaneonslT, 
and  upon  its  own  re^|  \\  makes  a  passage  for  its  escape.     It 

cannot  be  necesj^ary  i'  i»^trate  the  fallacy  of  this  propoMcioii 

— its  absurdity  rauAt  be  apjaarent  to  all  of  yoa.  We,  consequeniljr^ 
are  to  seek  for  s^otne  other  explanation  of  the  true  cause  of  xhm 
dilaUitioD,  which  is  so  ess^enttal  to  the  completion  of  labor.  Y€iii 
must  rcmend>er  that  the  cervix  of  the  uterus  is  well  supplied  with 
circular  musctdar  Hbres,  aad*  aa  a  generai  rule,  they  exerciM  m 


THE  PRmCIPLES  AKB  PBACTICE  OP  OBSTETRICS. 


S3S 


^_      tiiao 


species  of  guardmnslup  over  this  particular  portion  of  the  organ. 
Were  it  not  for  tbcm,  constituting  os  they  do,  a  veritable  sphincter, 
Ihe  closure  of  the  o8  would  be  impi^rfectly  nmintaincd.  But  asi  the 
object  of  labor  is  the  expulsion  of  the  fo&tuR,  there  la  a  iiecfs^ity 
for  an  opening  of  the  mouth  of  the  uterus,  and  consequently  a 
temporary  surrender  of  the  rigidity  of  these  circular  fibres.  When 
the  uterine  contractions  commence,  the  lougitudinal  muHculaf 
fibres  are  thrown  into  action,  the  result  of  which  is  a  concentration 
of  force,  directed  from  above  downward,  falling  on  a  common  point 
or  centre — the  os  uteri. 

The  only  resistance  to  tliis  force  will  be  the  circular  fibres. 
Through  successive  efforts,  however,  these  yield  to  the  more 
powerful  impube  of  the  longiludiniil  fibres,  and  the  result  is  dilata- 
tion. Muscular  contraction,  therefore,  may  be  regarded  jis  the 
primary  or  efficient  cause  of  the  dilatation  of  the  os  uleri ;  but 
there  are  also  two  secondary  or  anxiJiary  causes,  which  exercise 
their  influence.  The  firat  of  these  is  the  "  bag  of  waters ;''  ihu 
second  the  f<Dtal  head.  For  example,  when  the  dilatation  ha-^  fairly 
eomraenced,  the  membranes  with  the  liquor  amnii  will  be  forced 
through  the  opening,  and,  thus  protruding,  will  exercise  a  urdform 
and  gentle  pressure  against  the  orifice.  When  the  '^  bag  of  watei's," 
,^rough  successive  contractions,  is  rtiptured,  and  the  amniotic  fluid 
"ttcapes,  then  the  head  itself,  by  its  pressure,  forms  a  kind  of  wedge, 
which,  acted  upon  by  the  contractions  of  the  longitudinal  fibres, 
contributes  its  part  to  the  required  dilataticm. 

If  proof  be  required  that  this  U  the  process  through  which  the 
opening  of  the  mouth  of  the  gravid  womb  is  accomplished,  you 
wUl  find  very  substantial  evidence  of  the  fact  in  cases  in  which 
there  is  a  marked  want  of  parallelism  between  the  long  axis  of  the 
uterus  and  the  axis  of  the  superior  strait  of  the  pelvis.  For  in- 
stance: if  there  should  be  ante-version,  retro-version,  or  a  right 
lateral  or  left  lateral  obliquity  of  the  organ,  the  consequence  would 
be  that  the  os^  instead  of  corresponding  more  or  less  with  the 
centre  of  the  pelvic  excavation,  would  present  its  anterior  surface 
backward,  forwartl,  or  laterally.  In  such  case,  the  force  of  the 
contractile  effort  of  the  longitudinal  fibres  would  lose  its  concen* 
tration,  and  consequently  the  dilatation  would  be  greatly  retarded, 
it^  indeed,  it  were  not  altogether  prevented.  We  shall,  however 
have  occasion  to  allude  to  these  malpositions  of  the  uterus,  as  con- 
i^«cted  with  childbirth,  in  a  future  lecture.  There  is  one  important 
'^md  material  point,  in  a  practic4ii  view,  which  you  should  not  lose 
sight  of,  as  regards  the  dilatation  of  the  os  uteri,  and  it  is  this:  in 
•Jie  pnmipara  it  is  much  more  tardy  than  in  women  who  have 
already  borae  children  ;  and  again,  as  a  general  principle,  a  longer 
time  is  required  to  effect  an  opening  the  size  of  a  four-shilling  piece 
Uiao  for  the  completion  of  the  entire  process. 


THE    PRINCIPLES   AND  PRACTICE  OF  OBSTETRICS. 


Kerc%  allow  me  to  remind  you  that,  during  the  progress  ofdlbl* 
tat  ion,  the  female  U  not  un  frequently  attncked  with  rigors  or  «Atl- 
vering  fita^  as  they  are  sometimeja  called.  These  rigors  shoitld  crL*at« 
no  ftlartn  when  tltey  are  siruply  the  product  of  nterine  con  traction ; 
on  the  contrary,  I  arn  dinpo^ed  rather  to  regard  them  v^  fkvurable 
indieatious.  You  may,  under  the  eircurastance.H,  admiitUter  warm  lea 
or  griieU  ^^^  assure  your  patient  that  slie  need  teel  no  anxiety*  Bttl, 
gentlemen,  there  is  another  specnes  of  rigt^  in  the  lying-in  rciam, 
which  is  not  so  innocent,  and  which  may  be  the  prelude  of  trouble. 
I  mean  those  dwtres,<in<j  rhills,  whirh  flometunes  ocnur  in  Xf^ry  |irp- 
tracted  labors,  and  which  are  necanipanied  with  furred  lODgne, 
excessive  thirst,  oppressed  breathing,  ami  a  hard  and  ac^eUrated 
pulse.  ThesG  are  UJiually  rigors  of  danger,  and  will  require  all  the 
vigilanee  of  Uie  accoucheur.  They  point  to  serious  inlfammatory 
action. 

The  same  observation  applies  to  the  vomiting  which  occurs  during 
labor.  It  is  not  unusual  for  wonifu  to  be  affected  with  ***ick 
stomnoh  '*  during  the  stage  of  dilatation*  This  is  regarded  as  % 
roost  favorable  eircum«tance ;  it  portends  no  evil,  but,  on  the  eon* 
trary,  it  renders  a  material  service  through  the  relaxation  it  pro- 
duces, thus  facilitating,  among  other  things,  the  opening  of  the 
tnouth  of  the  womb,  There  is,  however,  another  kiml  of  vomiting, 
whic*h  will  oce:i^ionally  munifesjt  itself  alter  a  lung  and  tedious 
lal>or;  and  unfortiuiately  it  is  but  too  oflen  the  precursor  of  deaUl. 
Such  is  the  vomiting,  which  occurs  after  or  before  full  dilatatioti 
of  the  OS  uteri,  with  a  susfjension  or  entire  cessation  of  contraciioiifl 
— a  foublc  and  nipid  ]:uitH<%  great  [lain  on  the  band  pressing  the 
abdomen,  a  sunkfu  countenance^  with  extreme  pallor,  and  cold 
per8nii"ation.  Tlvi*  is  the  vomiting  indieative  of  rupture  of  t\m 
uterus,  one  of  the  most  alarmuig,  because  one  of  the  most  fatal  of 
the  coulingcncies  of  the  lying^iu  chamber. 

liL  A  Muco-JSatif/uui^oit4s  J}iite/iarffe. — Another  of  th«v  ly 

characteristic  signs  of  labor  will  be  this  disehargo  from  t  ti  i ; 

but  it  will  sometirnt»s  happen  that  there  will  be  an  absence  of  tbe 
disebarge  during  the  parturition,  :md  this  is  known  mn'^fttyiaborJ* 
The  mncous  secretion  U  derived  from  the  numerous  btlle  follicles  in 
the  cervix  and  vagina.  It  is  poured  nut  usually  in  great  abandftCHM 
Rt  the  close  of  gestation,  and  at  the  commencement  of  parturitlucL 
It  is  intended  to  answer  a  most  important  object — the  relaxing  luad 
lubrifating  the  pirts,  thus  farililating  the  approaching  distenstoit* 
Commonly,  there  is  committgled  with  this  secretion  of  mucut  m 
fihght  tinge  of  bloo<l,  and  it  is  known  as  the  ^/iow.  Some  woomq 
will  have  this  show  several  days  before  labor  commenct**.  The 
blood  probably  comes  from  rupture  of  the  mora  minute  vessels  of 
the  uterine  oritioe. 

IV.  The  Ihrmation  and  Jtupture  of  the  Memiranavs  JSac^  dt 


THB  PRINCIPLSS  AND  PKACTICE  OF  OBSTEAtlGS.         886 

Bag  of  Waters, — When  describing  the  appendages  of  the  foetus, 
and  their  relation  to  the  uterus,  you  will  remember  I  told  you  that 
the  most  internal  of  the  membrnnes  is  the  amnion,  and  that  this 
indoees  a  fluid — the  liquor  amnii — in  which  the  fcetus,  as  it  were, 
floats.  One  of  the  first  effects  of  the  contraction  of  the  uterus 
will  fall  upon  the  anmiotic  fluid ;  but  as,  from  its  very  nature,  this 
fluid  is  incompressible,  and  consequently  its  volume  cannot  be 
diminished,  the  impulse  it  receives  from  the  contracting  womb 
forces  it  to  some  point  of  the  organ  which  presents  the  least  resist- 
ance to  its  escape,  and  this  point  is  the  os  uteri.  As  soon,  there- 
fore, as  the  latter  begins  to  dilate,  there  would  be  no  obstacle  to. 
its  exit,  were  it  not  that  it  is  inclosed  in  the  membranes.  These 
membranes  constitute  a  sac  for  the  amniotic  liquor ;  and,  in  pro- 
portion as  the  OS  uteri  dilates,  the  lower  portion  of  this  sac,  dis- 
tended by  the  liquor  amnii,  protrudes.  Under  contraction  it 
becomes  hard  and  resisting ;  in  the  interval,  on  the  contrary,  it 
softens,  and  slightly  recedes.  This  sac,  as  has  already  been  stated, 
by  its  gentle  and  uniform  pressure,  assists  materially  in  dilating  the 
mouth  of  the  womb ;  and  you  will  observe  in  practice,  that  when 
the  OS  uteri  is  sufficiently  open  to  allow  the  head  of  the  foetus  to 
pass,  the  sac  becomes  spontaneously  ruptured.  It  will  sometimes, 
however^  occur  that,  owing  to  inordinate  resistance  of  the  mem* 
branes,  it  does  not  rupture.  In  such  cases,  when  the  os  uteri  is 
fully  dilated,  longer  to  respect  its  integrity  would  only  be  a  useless 
protraction  of  the  labor ;  and  therefore  it  will  be  your  duty  to  pro- 
ceed at  once  to  eff*ect  its  ru[)ture,  which  may  be  done  by  pressing 
the  point  of  the  index  finger  against  the  centre  of  the  sac  during  a 
contraction.  This,  however,  will  not  always  answer,  and  I  have 
occasionally  been  obliged  to  open  the  bag  by  grasping  a  fold  of  it 
during  the  interval  of  contractions,  between  the  thumb  and  fore- 
finger. I  have,  indeed,  met  with  crises  in  which  it  became  neces- 
sary to  pierce  the  sac  with  the  point  of  a  bistoury.  But  this  needs 
caution  for  fear  of  injuring  the  foetus  or  adjacent  sofl  parts. 

The  practical  fact  which  I  have  just  mentioned,  that  there  is, 
generally  speaking,  a  spontaneous  giving  way  of  the  "  bag  of  wa- 
ters" as  soon  as  the  mouth  of  the  uterus  is  sufficiently  dilated  to 
allow  the  head  of  the  child  to  pass — is  one  full  of  interest,  and 
should  admonish  you  against  an  officious  intrusion  on  the  laws  of 
nature.  How  oflen,  for  example,  is  a  labor  made  protracted,  and, 
as  a  consequence,  the  mother's  strength  exhausted,  and  the  life  of 
the  foetus  endangered,  through  the  officiousness  of  the  accoucheur 
in  prematurely  rupturing  the  sac.  In  doing  so,  an  escape  is  afforded 
to  the  waters  before  the  necessary  dilatation  is  accomplished,  thus 
entailing  upon  the  female  much  unnecessary  suffering,  and  involv- 
ing both  her  and  the  child  in  more  or  less  peril.  It  should  be  recol- 
lected, as  a  sound  maxim  in  midwifery,  that  to  rupture  the  mem- 


TUE  PRLVCIPLES  A>0   PRACTICE   OP  0B6TBTRICS. 


braf$es^  ejt^cpt  in  certain  cases  which  tPtli  be  nientioned  !^ereqfUf^ 
b4;/ore  the  os  uieri  isfuUy  dilated^  is  bad  practice.  Let  us  cxftmine 
this  point  for  a  moment.  When  tlie  sac  in  ruptured,  of  coumt!  the 
amniotic  fluid  in  more  or  less  quantity  escapes — tJicrefore,  in  this 
prtmuture  nijjturtj^  athl  eoiisequont  lusts  of  the  fluid,  nature  is 
deprived,  in  the  first  place,  of  an  important  auxiliary  in  siccomplisb- 
ing  the  dilatation  of  the  os ;  and  secondly,  as  there  is  Httlt*  or  no 
fluid  letl  in  the  womb  to  interpose  between  the  uterine  walls  and 
fcBtus,  the  latter  will  be  exposed  more  or  less  to  undue  jind  pro- 
tracted pressure;  in  this  way  the  umbilical  cord  is  in  danger  of 
compression,  thus  interrupting  the  feeto-plaoental  circulation,  md 
consequently  leading  to  the  destruction  of  the  child* 

In  certain  cases,  you  will  meet  with  an  exceedingly  unyielding  <M 
— it  will  give  but  slightly,  and  the  membranes  will  protrude  in  a 
conoidal  form,  stretching  down  in  this  peculiar  shape  to  tho  vulva 
itself.  Be  careful  not  to  be  deceived  under  these  circumslanoe^^ 
do  not  mistake  this  abnormal  form  of  the  sac  for  one  of  the  cxirp* 
mities**>f  the  child,  an  error  which  i»ns  been  committed^  and  Hhieh 
can  only  be  avoided  by  a  proper  dc*gree  of  caution.  Finally,  Xkm 
child  will  occasionally  come  into  the  world  with  a  portion  of  tbe 
membranes  over  its  head — this  h  known  as  the  caul  or  hood,  and  tt 
regarded  by  the  ignorant  a^^  a  circumstance  mo«rt  auspicious  to  tli6 
future  of  the  child,  for  it  is  supposed  that  the  caul  is  a  certain  pro- 
cursor  of  the  high  destiny  of  the  little  vtranger.  It  caniiot  be 
necessary  to  say  that  such  an  opinion  is  but  the  offspring  of  snpiff^ 
Btition,  and,  like  many  other  thing&y  has  no  foundation  but  in  ig09> 
ranee  and  morbid  imagination. 


LECTURE    XXIV. 

Kitaral  Labor:  Conditions  for — What  is  required  on  the  part  of  the  Mother ;  what 
<m  the  part  of  the  Foetus— Hippocrates  and  Head  Presentations  in  Natural  Labor; 
Fallacy  of  his  Opinion — Face  Presentations  in  Natural  Labor;  Mechanism  of— 
Diagnosis  of  Face  Presentations ;  may  be  Confounded  witli  Presentations  of  the 
Breech— Face  Presentations  in  Dublin  Lying-in  Hospital — Error  of  Writers  with 
regard  to  Version  and  Forceps  Delivery  in  Face  Presentations — PresenUition  of 
the  Pelvic  Extremities ;  the  Breech,  Feet,  and  Knees — Opinion  of  Hippocrates ; 
hia  Direction  for  bringing  down  the  Head  in  these  Presentations — Tlie  Practice  of 
A.  Petit,  Sounder,  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  Cora- 
promise  the  Safety  of  the  Mother  ? — Mechanism  of  Breecli  Presentations — Pre- 
sentation of  the  Feet;  Diagnosis  and  Mechanism  of— Presentation  of  the  Knees p 
Diagnosis  and  Mechanism  of. 

Gentlemen — ^Labor,  to  be  natural,  necessarily  presupposes  the 
existence  of  certain  conditions;  and  it  is,  thereforcy  proper,  that  we 
should  now  examine  in  what  these  conditions  consist.  Some  of 
them  refer  to  the  mother ;  others* to  the  foetus. 

I.  On  the  part  of  the  Jfother.— The  pelvis  must  be  well  con- 
formed, exhibiting  a  capacity  sufficient  for  the  exit  of  the  child ; 
the  mother  possess  strength  adequate  to  the  wants  of  the  delivery ; 
the  gravid  uterus  parallel,  or  nearly  so,  to  the  axis  of  the  sui>erior 
strait;  the  os  uteri,  vagina,  and  vulva  sufficiently  yielding  to  the 
forces  of  expulsion ;  and  these  latter  should  possess  the  requisite 
degree  of  efficiency.  It  must  be  quite  evident  to  you  that  these 
conditions  are  essentially  material  to  the  accomplishment  of  deli- 
very by  the  unaided  effi^rts  of  nature.  For  example,  if  the  pelvis 
be  so  diminished  in  size  as  to  render  it  physically  impossible  for  the 
child  to  pass,  the  interposition  of  art  will  be  called  for,  and  there- 
fore, in  such  case,  the  labor  ceases  to  be  natural ;  so  it  is  with  the 
other  prerequisites.  How,  for  instance,  could  the  expulsion  of  the 
foetus  be  effected  by  the  resources  of  nature,  if  the  uterus,  instead 
of  being  in  its  long  axis  parallel,  or  nearly  so,  to  the  axis  of  the 
brim,  should  be  in  a  state  of  ante-version,  retro-version,  or  exhibit 
a  decided  right  or  left  obliquity  ?  In  either  of  these  malpositions 
of  the  organ,  the  cervix,  in  lieu  of  regarding  the  pelvic  cavity, 
woald  be  ttimed  toward  the  sacrum,  symphysis  pubis,  or  to  one  or 

22 


838 


THB  PRINCIFLES  AJTD  PRACTICE   OP  0B3TETBICS. 


other  of  the  lateral  walls  of  the  pelvifi,  so  that  the  whole  force  of 
the  uterine  effort  would  be  negative  in  its  inttuetice,  becniwc  of  tbc 
refistanec  of  the  bony  struct  lire  of  the  pelvic  cjinal* 

11.  On  the  part  of  (he  Mittu^t^ — ^The  fcDtus,  in  its  parent'*  womb^ 
]«  doublet)  upon  itself  in  sueh  way  as  to  preserve  nn  ovoid  form; 
ihiH  ovoid  h  dividerl,  for  practical  purposes,  into  the  superior  and 
pelvic  extremities— the  eupeiior  ernbracini?  the  head — while  the 
pelvic  exiremiticH  irLclude  the  breoeli,  knees,  and  feet.  It  i-s  therr- 
fbre,  necessary,  in  natural  IhImis,  that  one  of  the  extrennties  of  the 
ovoid  should  be  present,  viz.,  eitber  the  head,  breceJi,  kneen  or  feet. 
In  either  of  the^e  presentations,  all  things  being  equal,  or,  in  otb^ 
words,  in  the  iibsenee  of  any  coniplicjation,  the  res^riurces  of  nature 
will  1x3  adoquate  to  accomplish  the  delivery.  I  am  a^vare  that  the 
presentation  of  the  pelvic  extremities  is  usually  reifjirded  »is  prcicr* 
natural,  calling  for  the  interference  of  the  accoucheur;  and  thia  lat- 
ter opinion,  I  am  sure,  has  often  led  to  hasty  and  tinn^eanry 
action,  reHultin<;  frefjuently  in  disaster  to  the  child,  and  tnore  orlm 
injury  to  the  mother. 

The  idea  that»  in  natural  labor,  the  head  must  present,  is  a  fenr 
lancient  one;  it  originated  with  Hijipocrates  himself  The  Father 
of  Medicine  very  aptly  illustrated  the  relation  of  tbc  fcetus  to  tbe 
womb  by  com[)anng  it  to  an  olive  in  a  long-neeked  bottle.  He 
r.aid,  that  in  order  to  afford  escape  to  the  olive  one  of  its  extremidei 
must  present.  This  is  perfectly  true,  and  applies  with  equal  fore© 
to  the  €xit  of  the  ftctus.  But,  strange  to  say,  with  all  the  tnithfiil- 
uesii  .of  the  comparinon,  he  taught  that  for  the  child  to  be  eirpelled 
hy  the  unMided  resourres  of  nuturt^,  consistently  with  the  safety  of 
Sf»!h  m^^ther  and  fietus,  an  essential  prerequisite  isM-that  its  head 
jho*di!  prest^nt  at  the  superior  strait,*  The  authority  of  the  inciiiiri- 
ous  Fr.lher  cf  Medicine  on  thi«  question  hns  not  been  without  tta 
«f»ffect ;  it  h'ls  if.lro4luced  bad  practice  into  the  lying-in  chaniWr;  i| 
has  caused  the  aoi^oucheur  to  be  ofBeious,  when  ho  should  trust  lo 
nature — >it  ha^.  in  a  word,  induct e<l  him  to  a  **  meddlesome  mid- 
wifery "  in  all  case:?  uf  pelvi:;  presentations;  for,  luider  the  eoovls 
^lon  that  this  pre«erta«ion  i^  contrary  lo  nature,  he  has,  a^  mKm  ae 
he  a>ceiTtained  its  exisi^i-ct,  proceeded  by  ill-adviser]  eflbfta  to 
ierminate  the  deliver  v. 


♦  Tln?e«  oblitjuitu's  of  ike  organ  mny  often  be  oorreoted  by  ciiaagQ  of  poaUlon  om 
4lio  |>iin  of  Uie  feiimlc,  at  Uttutigh  Uw  rkiltui  maoipuklioii  of  the  Aooouetivitr;  aal 
<whf! Dover  %i\oy  oxUt  so  eompietely  fis  to  emtMirnm  delivery^  pronipt  MilaiaBOt 
'^Itoulii  lH^  If  ndertMi  \n  order  to  rcmcvTc  Uietn. 

f  Ui  euiiii  iti  i\uia  in  ItK^yiUum  iin{ru«t«  oris  olivas  nudeum  imoiitut^  bune  itwe^ 
^tiiar  iuuic^uecro  nou  facile  eat ;  frSc  nmaa  muiiev i  est  gnr'a^  aflbctio,  ubl  f<BUw  tnue* 
<f«nHiriiiji  m^'Ht;  ftenim  ipiuin  cxire  per  afduum:  gniTe  Tero  Hiam  est  ii  la  f&im 
^lo^ieryi  el  jil«<rumque  mit  mntm  nut  |>oqU»  aut  ambcv  pemuiL  £ct  anttv  it 
hmc  magna  caiiaa  ciir  noti  fucile  exaat,  ti  moilyiii  aut  aidtrauii  aut  duplloatni  §t^ 
rit    [De  Mulier  Hark  iib.  I,  torn.  H] 


THE   PRINCIPLES  AND  PRACTICE   OF  OBSTETRICS, 


389 


Tills,  I  maintain,  is  all  wrong ;  nature,  tinder  ordinary  circnn:i- 
•tances,  being  quite  as  adequate  to  accomplish  tho  labor  when  the 
pelvic  extremities  present,  as  when  the  head  comes  firat.  At  th« 
same  time,  it  must  be  conceded  that,  as  a  general  principle,  delivery 
in  head  presentations  is  more  advantageous  for  botli  mother  and 
child.  What  I  wish  to  impress  upon  you  is  this — do  not,  t-iniply 
because  the  breech,  knees,  or  feet  are  found  at  the  upper  strait, 
therefore  conclude  that  interference  is  called  for. 

esldes  the  conditions  for  natural  labor  already  mentioned,  it  is 
ntial  that  there  Ijc  no  disproportion  between  the  dimensions  of 
the  ftpius  and  the  pehis  through  which  it  has  to  pass.  Agaiu  :  the 
adhesions  of  the  placenta  to  the  uterus  abould  not  be  such  as  to 
resist  the  efforts  of  the  latter  to  detach  it;  nor  should  the  umbilical 
cord  be  relatively  or  positively  too  short. 

Pte^eniations  of  Fhetus  in  Natural  Lfihor. — So  far  as  regards 
the  presentations  of  the  foetus  in  natural  labor,  they  may  be  enume- 
rated as  follows:  1.  The  vertex;  2,  The  face;  3.  The  breech; 
4,  The  fL^et ;  5.  The  knee<«.  In  either  of  these  presentations, 
therefore,  I  wish  you  to  recollect,  if  there  arise  nothing  to  compli- 
cate the  delivery,  nature  can,  by  her  own  resources^  accomplish  the 
ejcpulsion  of  the  child  ;  and  it  must  be  borne  in  mind  that  any 
other  region  of  the  head,  except  the  vertex  and  face,  is  preter* 
natural  ;  to  this  fact,  however,  your  attt^ntion  will  he  more  par- 
ticularly drawn  M'hen  treating  of  preternatural  labor.  We  have 
already  described  the  merhanism  by  which  the  head  is  made  to  pass 
through  the  jielvic  QiiniA  in  a  vertex  presentation,*  and  shall  now 

ik  of  the  interesting  subject  of  face  prcsentationa, 
^^Safhfics  of  Face  Presentations. — Instances  in  which  the  face 
j6  fuund  at  the  superior  strait  are  comparatively  rare ;  occurring, 
accordiitg  to  statistics  derived  by  Dr.  Churchill,  from  British, 
French,  and  German  sources,  1 167  times  in  200,817  cases,  or  about 
one  in  223^»f  The  majority  of  writers  class  this  presentation 
among  pretennatural  labors ;  but  I  cannot  understand  why — ^for  it 
is  a  matter  of  clear  observation  that  uatui-c  is  perfectly  competent 
to  effect  the  delivery  if  left  alone.  Indeed,  it  is  a  very  significant 
i^ct.  Well  worthy  of  retiection,  and  amply  proved  by  statistics, 
that,  in  face  presentations,  death,  among  both  mothers  and  children, 
is  most  frequent  when  science  uttempts  to  interpose.  This  is  an 
important  circumstance,  and  should  inspire  you  with  renewed  con- 
fidence in  the  ability  of  nature  in  this  species  of  labor,  lu  the 
Dublin  Lying-in  Hospital,  under  the  mastership  of  Dr.  Collins,  in 
[  16,654  births,  there  were  thirty-three  presentations  of  the  fiwe  ; 
these  cases  were  nil  submitted  to  the  natund  process,  and  all  the 
children  born  alive,  except  four,  one  of  which  was  acephalous.  J     Ib 

•  See  Lecliare  IV.  f  Churchill,  fourth  London  editiou,  p.  410, 

t  A  Proctical  Treaiiw  or*  MWwrifery,  by  Robert  OtlViuR,  M.D.,  p,  3% 


mo 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS. 


the  same  well-conducted  charity,  under  the  mancrship  of  Dr* 
Shekleton,  as  reported  by  Drs.  Johnston  and  Sinclair,  in  13,748 
deliveries,  the  face  presented  thirty-one  time?^,  all  the  children  bom 
alive,  except  six,  and  recovery  of  all  the  mothers  bat  one,  nhm 
having  died  of  peritonitis.  Of  the  fCix  children  born  dead,  one  wms 
an  acephalons  monster,  one  sunk  from  pressure  of  a  loop  of  tli# 
oord,  atid  the  death  of  another  was  ascribed  to  a  beating  to  whieb 
ita  mother  had  been  subjected.^ 

These  Btatisties  I  reifurd  most  interesting  in  their  praetioiil  benr- 
ings,  and,  to  my  mind,  are  irresiHtibly  eoneluHive — if  proof  be 
needed — as  to  the  propriety  of  classin^j  face  presentatiuni  atnoag 
those  of  natural  labor,  f  And  again,  they  demonstrate  ho^v  wtll 
nature  is  prepared  to  dii^charge  her  duty  when  not  enerosdied 
upon  by  unwarrantable  ofticiousness.  It  is  the  opinion  of  s*ome 
writers  that,  in  all  cases  in  which  the  face  presents,  an  attempt 
should  be  made  to  bring  down  the  vertex ;  others  recommend  in 
these  instances  ven*ion,  while  some  are  more  wedded  to  the  forceps 
as  the  only  means  of  terminating  the  ddivery*  These  various 
directions,  gentlemen,  du  well  enough,  perhaps,  in  the  books*,  but 
they  are  utterly  out  of  phice  at  the  bedside  of  the  partuHcnl  woman* 

J>iaffnosi9, — It  will  be  difficult,  under  ordinary  drouniatafHNEay 
jKi^ilively  to  decide  that  the  face  presents,  previously  to  the  rupttir© 
of  the  membranous  sac ;  but  after  this  has  taken  place,  an  altentivc 
examination  per  vaginam  will  soon  disclose  the  true  nature  of  ihe 
presentation.  The  first  circumstance  which  will  become  ubvioufi,  if 
the  marked  irregularity  of  the  surface  of  the  part  with  which  iho 
finger  comes  in  contact ;  then  the  different  features  will  be  felt  and 
roeogni'»cd,  such  as  the  eyes,  nose,  and  mouth.  Occasionally,  bow- 
ever,  when  nevere  pressure  has  been  exerted  by  the  uterua,  the 
general  character  of  the  face  will  be  «o  altered  V»y  the  tumefaelion 
it- has  undergone,  as  to  render  it  difficult  to  decide  at  cmce  the 
question  of  presentation.  It  is  in  these  cases  of  compression  of  the 
parts,  that  the  eye  nmy  be  mistaken  for  the  extenial  organn  of 
generation  in  the  female  feet  us,  or  the  nose  for  the  ]K*nis  in  the  tnsle. 

The  face  is  more  Ukely  to  be  confounded  with  the  breech  ihaa 
witli  any  other  [portion  of  the  fostus;  when,  for  example,  the  fitij^ 
reaches  the  malar  bone,  this  latter  may,  without  due  caution,  be 
mistaken  for  one  or  other  of  the  tuberosities  of  the  ischium ;  all 
doubt,  however,  will  be  at  an  end  if  the  finger  should  dhittacily  feel 
th©  mouth  and  gums  of  the  child.  Let  me  here  advise  you  uf  ibe 
importance,  as  far  as  may  be,  of  the  early  reoognltton  of  n  face 

*  Pnictlcal  llidw)fbr>'.     By  Drs.  Johnson  and  Sinclair,  |k.  76. 

f  In  lli«  doliv^M  tinder  my  direction  iti  tJitf  Royal  Ualertiitj  mm  > 
Uii* (iteo  |jf<ittttiti<ing  aloae  bavo  b€i'D  110;  ut  Xhvae^  \Q%  w«re  \%>n\  \v> 
naiuml  i*(r(»rt&     Of  the  eiglit  ptiU-bom  cbildreo^  in  the  above  uuni' 
itions,  (itio  wjis  in  o  putnd  atate^  and  bad  been  dead  kmg  bororr 
tnttOQS  of  DU&cult  l^nuritioD.  By  John  Hall  Davia»  ILD.   Loti^t  i*4^-v  Tj 


THE  PRINCIPLES  AKD   PRACTICE  OF  OBSTETRICS. 


841 


pre«eiitntioti;  repeated  vaginal  examinations  in  these  casea  will 
nocessaKly  expose  the  child  to  more  or  less  danger.  For  instance : 
tlie  eye  would  incur  the  rLsk  of  injury,  if  indeed  it  were  not 
defttroyed,  by  the  too  frequent  introduction  of  the  finger. 

You  might,  perhaps,  suppose  that  :i  positive  evidence  of  a  breech 
presentation  M'ould  be  the  discharge  of  meconium  ;  this,  however, 
IS  not  «o.  1  have  met  with  insti^nces  in  which  the  meconium  hua 
passed  into  the  vagina  in  bead  presentations,  and  this  may  occur  in 
cases  in  which  any  extraordinary  [treasure  is  exercised  on  the  body 
of  the  child  by  the  contracting  uterus. 

Proffnosis, — It  is,  I  think,  quite  consistent  with  the  results  of 
practice  to  say,  that  tlie  child  is  ordinarily  born  alive  in  presenta- 
tions of  the  face;  and  the  convalescence  of  the  mother  as  favorable 
as  in  an  ordinary  vertex  delivery.  It  is  not  unusual,  however,  for 
the  child  to  come  into  the  world  with  its  features  extremely  di.^- 
torted,  owing  to  the  general  swelling  of  the  face  ;  but  this  in  a  few 
days  will  disappear,  and  in  no  way  compromises  the  life  or  health 
of  the  infant. 

Looking  at  the  facts  as  they  exhibit  themselves  in  the  lying-iu 
chamber,  the  face  will  be 
found,  aa  a  general  rule,  to 
present  at  the  superior  strait 
in  one  of  two  positions,  al- 
though, occasionally,  there 
will  be  variations.  The  me- 
chanism, however,  by  which 
the    head  makes  its   transit 

^through  the  pelvic  canal  ia 
Bntially  the  same. 
Presentation  of  the  Mtee 
in  the  J'^rst  Position, — In 
this  position,  the  finger  being 
introduced  into  the  vagina, 
and  carried  up  to  the  mouth  of 
the  titerus,  will  feel  the  nose ; 
in  passing  the  finger  from 
the  right  to  tlie  left  side  of 
the  pelvisi,  along  tfje  dorsum 

1  or  back  of  the  nose,  the  coro- 

Inat  suture  will  be  recognised;  this  proves  evidently  that  the  fore- 
head of  the  f<rtus  is  toward  the  left  iliac  bone ;  and,  consequently, 
the  chin  will  regard  the  right  ilium  (F*ig.  48);  so  that  the  fronlo- 
mental  diameter  of  the  face  is  in  apposition  or  correspondence  with 
the  transverse  or  bis-iliac  diameter  of  the  sujjcrior  strait ;  while,  on 
the  contrary,  the  transverse  diameter  of  the  face  is  j>arallel  to  the 
ro-pubic  diameter  of  the  pelvis,  in  the  first  position ;  and  hence 


ritt.  4a 


S42         THE  PBINC1PLE8  AND   PRACTICE  OP  OBSTlTRiai* 

it  is  called  ilio  right  mento-iiifrc.     According  to  KaC^gel^,  in  tbti 
position  the  right  tide  of  the  face  is  slightly  lower  than  the  left* 

In  response  to  the  oontmctile  effbrts  of  the  womh,  the  h^acl  h 
made  to  di?sccnd  into  the  pehic  cavity ;  it  tliere  nnder|Bfoe»  a  rotJU^ 
movement,  which  »o  changes  its  relation  that  the  frf»nto-mc*ntaI 
diarnetf^r  of  the  face  accords  with  the  ri*^ht  oblique  diameter  of  the 
pclvia,  and  the  chin  is  opposite  to  the  right  foramen  o\'ale ;  the  chin 

is  next  brought  behind  the  nymphyntii 
pubis,  and  the  forehead  turned  into  the 
cavity  of  the  sacrum  (Fig.  -tU),  From 
whiit  has  just  been  said,  it  is  obvious  thut 
the  forehead  is  obliged  ki  travcn^e  the 
anterior  surface  of  the  sacrum,  whil<^  the 
chin  desoend!^  only  the  length  of  the 
symphysis  pubis,  in  order  to  reach  the 
inferior  stinit.  The  |>rogrc*s  of  the  face 
having  been  thus  far  accomplished,  %ht 
chin,  under  the  expulsive  intiaencM^  ol 
the  uterus,  is  made  to  pans  under  the 
symphysis  publ;*,  wliile  the  oeciptal  is 
***  ^'  pushed  downward,  and  ibo  flexion  or 

lisengagement  of  the  head  is  completed, 

Hfre  let  me  caution  you  to  guard  with  great  care  the  perimmm 
during  the  prngress  t>f  the  dt- livery,  fL»r  the  distension  which  it  is 
called  upon  to  undergo  in  the  descent  of  the  face  is  much  greater 

Uan  in  i  rertex  prestoui* 
tion  ;  and,  without  a  duis  de- 
gree of  vigilance,  ruptm« 
may  take  place,  always  an 
unpleasant  complicatioii  of 
chilli  birth,  and  sometimeii  ro^ 
suiting  seriouj!tly  to  the  nio> 
ther.  When  the  bead  hm 
poetaed  the  vulva,  the  Gscti  k 
t  u  m ed  u i» wan! .  As  the  deli- 
very  proceeds,  the  bead  Itti* 
dergoes  the  movemenl  of 
e^ctemal  rotation  in  thosatita 
way  that  this  movement  oo* 
curs  in  the  presentation  of  llbo 
vertei,  and  wtiich  bat  hcen 
described  in  a  prcTtoita  too- 
ture. 

Prt^miaiian  t^  th$  fkd§ 
in  th0  Seeanii  /*o*t/i<m*— In 
this  position,  which  U  precisely  the  reverse  of  the  first,  ibe  $(ao- 


THE  PRINCIPLES  AND  FRACTICB  OF  OBSTBTBICS.         84S 

Head  is  towards  the  right  iliao  bone,  while  the  chin  regards  the 
opposite  point  of  the  pelvis  (Fig.  50).  On  a  vaginal  examination, 
the  finger,  if  directed  along  the  dorsal  surface  of  the  nose  to  the 
left,  will  distinctly  feel  the  nostrils,  while  the  coronal  suture  will  hd 
found  to  the  right;  thus  showing  a  reverse  position,  and  consti- 
tating  the  left  mento-iliac  position  of  the  fact.  The  mechanism  of 
passage  in  the  second  position  of  the  face  is,  in  all  respects,  the 
same  as  in  the  first,  excepting  that,  in  consequence  of  the  change 
in  the  direction  of  the  face  at  the  superior  strait,  the  movement  of 
rotation  is  from  left  to  right,  instead  of  from  right  to  left. 

It  is  well  to  remember  that,  in  face  presentations,  the  duration 
of  labor  will  usually  be  more  or  less  protracted,  for  the  reason  that 
the  bones  of  the  face  not  undergoing  compression,  as  is  the  case 
with  those  of  the  cranium,  do  not  mould  themselves  to  the  form  of 
the  pelvis,  and  consequently  a  more  lengthened  duration  and 
greater  effort  are  necessary  for  the  transmission  of  the  parts  through 
the  pelvic  canal.  It  is  an  error,  however,  to  suppose  that  the  safety 
of  the  child  is  necessarily  dependent  upon  the  shortness  of  the  labor. 
You  will  sometimes  have  occasion  to  note  the  falsity  of  such  an 
opinion.  The  error  frequently  leads  to  officiousness  on  the  part 
of  the  accoucheur,  and  consequent  injury  to  mother  and  child.  In- 
deed, I  am  disposed  to  say  that,  all  things  being  equal,  sUao  births 
are  generally  safe  births.  Permit  me  to  enforce  this  upon  you  as  a 
maxim  in  the  lying-in  chamber ;  it  is,  as  you  must  perceive,  strictly 
conservative,  and  at  the  same  time  strictly  true. 

Presentation  of  the  Pelvic  Extremities, — I  have  told  you  that, 
when  either  of  the  pelvic  extremities  is  found  to  present  at  the 
saperior  strait,  nature  will  be  competent  to  achieve  the  delivery^ 
unless  something,  other  than  the  mere  presentation,  should  inter- 
fere, calling  for  the  assistance  of  the  accoucheur.  You  will  read 
in  the  books  some  very  contradictory  opinions  upon  the  subject  of 
these  presentations ;  and  you  will  be  not  a  little  surprised  at  the 
conflicting  rules  inculcated  for  their  management.  For  example,., 
as  has  already  been  stated,  Hippocrates  regarded  this  character  of 
presentation  as  contrary  to  nature ;  his  direction  was,  whenever 
the  breech,  feet,  or  knees  were  discovered  at  the  upper  strait,  to- 
introduce  the  hand,  and,  through  the  operation  of  version,  to  bring 
down  the  head !  Again  :  the  doctrine  has  prevailed,  and  been  sus- 
tained by  Antoine  Petit,  Bounder,  and  others,  that  the  most 
natural  presentation  is  when  the  feet  come  first ;  and,  in  keeping 
with  this  opinion,  it  was  suggested  that,  in  cases  of  head  presenta- 
tion, the  accoucheur  should  turn  and  bring  down  the  feet.  But, 
gentlemen,  it  is  not  necessary  to  refer  more  at  length  to  the  various 
opinions  of  authors  on  this  question.  The  substantial  point  for  you 
to  remember,  and  which  will  serve  you  when  at  the  bedside  of 
your  patient  is,  that  the  presentation  of  the  pelvic  extremities  i^.- 


344 


THK   PRINCIPLES  AND  PRACTnCE  OP  OBSTKTRICS. 


undonbteilly  entitled,  for  the  reasons  already  nioriiiunod^  to  be  obuifc 
fied  m  peifuctly  consistent  with  natural  Vjihor. 

I,  Prcitefitation  of  the  Breech, — ^The  iiaiee  or  breech  }ireaefil 
much  more  frequently  at  the  superior  strait  than  either  the  feet  or 
knees.  Dr.  Chm^chill,  with  his  nsiial  industry,  haa  funiijthed  m>0Io 
,  intere^Htintif  slJitiaticH,  louehintr  the  frequency  o^  breech  presenta- 
^  tion»,  taki'tt  from  the  records  of  Britbh,  French,  and  Geniiati 
praetii*e.  In  an  atrgregate  of  197,318  eases,  the  brec^eh  preHfultil 
S325  times,  or  about  1  in  5i)^ ;  and  in  1 148  easef^  all  he  hxfl  be^eti 
iible  to  eollect,  337  children  were  lost,  or  about  1  in  1*^.  At  I5m 
ttight,  this  would  appear  to  be  a  great  mortality ;  bnt  it  itiiiat  bo 
recollected  that  these  tables  are  derived  from  very  mixed  **>iiroe»— 
that  is,  in  many  instances,  no  doubt,  the  presentation  oi  the  breeoh 
being  regarded  as  prt4enmtural,  artiHcinl  ajil  wa«  had  reeoursc  to, 
and  in  this  way,  it  is  not  at  all  improbabh*  that  the  wifety  of  the 
I  child  was  compromiseth  In  order  to  sliow  the  actual  u^  well  aaUur 
felativo  fatality  to  the  child,  in  this  form  of  pre^enUttoiK  it  doiM 
•©em  to  me  that  an  essential  prerequisite  for  sticli  data  would 
be,  to  derive  our  facts  from  those  cases  whii-h  had  bei*n  enlirdy 
conrtded  to  nature,  and  where,  consequently,  there  had  been  no  id- 
terru|jtion  to  the  natural  proeesa  by  premature  or  unjuKttllabk 
interference.  We  sJiouId  then  ha  better  able  to  approximate  a  jii&l 
conifwirison,  all  things  being  eqnal,  between  the  pro}M)rtton  of 
children  lost  in  breech  and  vertex  presentations,* 

The  presentation  of  the  breech  Wiis  formcriy  regarfitnl  a*  one  erf 
great  danger,  because  it  was  supposed  that  the  child  thus,  as  it 
were,  doubled  on  itseU",  could  not  have  snflieient  i^pai'e  to  enabhi 
it  to  be  trunsmitted  through  the  pelvis.  This  opinion,  however*  ia 
without  foundation,  for  the  parts  composing  the  breech  are  f|Qtt« 
con»pix*i*sible,  and  will  yield  to  tlie  forces  of  the  uienis.  Baaed 
upon  the  apprelieiision  that  the  breech  eniild  not  pasa,  it  waa  m 
fiivorite  piaciiee  among  somp  of  the  English  aecotichenrs  always  to 
Interpol',  endeavor  Xo  push  it  upward,  and  tlien  search  ft>r  the  firet^ 

*  Dr  Collins,  wt>o  recommends  thitt,  In  tho  ubiiotice  of  iny  coniptio«Li(m.  tbffa 
illOQhl  be  aa  ialeiiU'eiio^  fn  brtech  fvranaljttioiii^  rvporti  thit  prMmtalfam  to  liava 
aefiomd  S48  linwa  in  IMU  ddiwm  Of  tlMM»  3«l  diiklrm,  13  w«to  elilUMni. 
of  whifh  A1  were  putritl  F<Mly  «>f  llie  242  wt^re  preiinituNj  lurlliiv  SS  cit  ithich 
wer»'  ftiilUlnini.  FtMirU'oii  of  iho  ^8  wcr\'  liuru  sit  the  cightb  moiilli ;  tweW«^  mt  i!it 
•oventJi ;  mie  at  the  f^x%\\ ;  mnJ  nnc  nt  itie  i\[\\\  Twetiiy-sixof  tl»o  28  werv  pfatrkL 
Twolvv  of  tlic  iO  pn'timtiire  cirildi\*n  wi^ns  lx»m  iilivt*,  **»/.,  twa  at  tlio  m%i\%  miuilh  ; 
wiren  Mt  tlii*  si*vi't)tti :  nrift  thn^  nt  th  t•i^tlrh  month  Thi^o  slAtkillefl are  «-xlreiii«|f 
ifitfirmtiiiir  Hriii  m  Ur  ns  tlK>y  g^t  4r«  (kHnil^'ily  in  Uyor  of  tho  pa«itioik  1  Umr*  «n 
iunK'd.  It  u  but  h\r,  I  tliirtk,  to  d(.<iluci  fnc^in  tU«  73  ulill^ljoni  mu^  ttie  tl8  prcftift* 
tun*  WifiUfk  whirb  were  bI»o  «t»JI*b*>rn»  ft»r  ns  26  i*r  the  28  wtm  jiutrid,  it  \n  litntQg 
pnMjftliui  thtfir  ilwith  waAalttip&tliwrmMV)rniectcU  wiih  the  pan  Iculur  fonii  uT  pn»aii» 
tJtl  .n.  Til  ri^''>rr,  Pr,  Mlins'  »lAiti8tic»  will  jrivc  u*  45  ffllU'U»rn  HiiUnii  tn  941 
)  mn,  or  iihitit  i  tu  5  \'*l  witidi  U  will  bo  perceived  diiir«r  vldil|f 

fr  lummlM^  by  Dr.  ChuroiiiU. 


THE  PMNCIPLES  A>T)  PRACTICE  OP  OBSTETRICS.         845 

and  deliver  the  child  in  this  manner.  Such  practice  was  not  only  bad 
practice,  for  it  had  no  justification  whatever,  but  it  was  most  destruo- 
Uve  to  the  child,  and,  at  the  same  time,  full  of  peril  to  the  mother. 

I  can  afford  you  no  better  admonition  upon  this  subject,  than  by 
reoording  the  experience  of  Dr.  Hunter,  who,  in  the  commencement 
of  his  professional  career,  became  so  imbued  with  the  prevailing 
opinion  at  that  time,  that  he  adopted  it,  but  soon  found  cause  for 
its  repudiation.  "  When,"  says  he,  "  I  first  began  practice,  I  fol- 
lowed the  old  doctrines  in  breech  presentation,  although  I  did  not 
like  them  ;  but  yet  dared  not  broach  new  ones,  till  I  got  myself  a 
little  on  in  life ;  cU  this  time  I  lost  the  ehilJ  in  almost  aU  the  breech 
eases  ;  but  since  I  have  Icfl  these  cases  to  nature  /  always  sue- 
eeedJ*^  There  is  much  good  sense  in  this  observation  of  Hunter, 
and  it  demonstrates  the  folly  of  blind  obedience  to  mere  opinion. 

Diagnosis, — It  will,  in  general,  be  extremely  difficult  to  recog- 
nise a  breech  presentation  before  the  rupture  of  the  "  bag  of 
waters ;"  but  after  the  escape  of  the  amniotic  liquor,  a  careful  ex- 
amination will  enable  you  to  detect  the  nates  at  the  upper  strait ; 
the  finger  will  feel  a  rounded  tumor,  softer  than  the  head,  and  im- 
parting somewhat  of  an  elastic  sensation ;  the  cleft  between  the 
nates  and  the  organs  of  generation  will  also  be  important  guides ; 
there  is  usually,  likewise,  in  this  presentation,  a  discharge  of 
meconium.  In  consequence  of  the  great  tumefaction  of  the  face, 
and  the  necessary  alteration  of  its  features,  errors  have  sometimes 
been  committed  by  confounding  it  with  the  breech  of  the  infant. 
Indeed,  under  certain  circumstances,  it  will  need  more  than  ordinary 
droumspection  to  avoid  the  blunder.  However,  as  has  already 
been  remarked,  the  recognition  of  the  mouth  and  gums,  together 
with  the  nose,  will  readily  dissipate  all  embarrassment. 

In  women,  whose  abdominal  walls  are  not  loaded  with  adipose  or 
fatty  matter,  and  which,  in  consequence  of  previous  births,  are  in 
a  atate  of  more  or  less  relaxation,  it  will  sometimes  be  possible  to 
feel  quite  distinctly,  through  these  walls,  the  head  of  the  foetus 
tamed  upward.  This  is  a  very  positive  indication,  in  case  of  a 
ringle  pregnancy,  that  one  of  the  pelvic  extremities  presents,  and 
which  it  is,  must  be  determined  by  a  vaginal  examination.  Again : 
a  Rtrong  evidence  of  this  kind  of  presentation  is  disclosed  by  the 
£iot  of  your  being  able  to  detect  the  pulsations  of  the  fcetal  heart 
on  a  level  with,  or  above  the  umbilicus. 

It  is  an  interesting  circumstance  that,  when  the  foetus  is  dead, 
the  anus  is  open,  so  that  the  apex  of  the  finger  may  be  introduced ; 
but  when  alive,  it  is  closed.  As  the  nose  is  an  important  guide  in 
face  presentations,  so  the  coccyx  is  when  the  nates  present,  not 
only  indicating  the  character  of  the  presentation,  but  also  the  true 
position  of  the  part.     It  is  possible  to  confound  the  breech  with 

•  Hunter's  Lectures,  M&,  1768. 


THE  PRINCIPLES  JlSD  PRACTICE   OF   OBSTETRICa 


Ae  shoulder,  and  it  is  essential  that  the  distinction  should  l»c  mtuU 
early,  for,  as  wo  shall  tell  you,  when  speaking  of  tho  manngcTncnt  »»f 
a§houUlor  preseutation,  it  is  very  important  that  a  correct  di  igno*!* 
Vo  arrived  at  before  the  labor  is  far  advanced.    The  acroniioo  pro 
eeso,  wilhouta  due  degree  of  care,  may  be  mistaken  for  the  tuberosity 
of  the  ischium ;  but  the  absence  of  the  ribs,  which  can  be  easily  fe!t 
in  a  shoulder  presentatiou,  will  remove  all  doubt  npun  the  .HubjtH  t. 
Prognosis* — Although  it  is  unquestionably  true  that,  wh*'n  the 
pelvic  extremities  present,  nature  is  competent  to  accomplish  the 
delivery,  yet  it  must  not  he  forgotten  that  the  mortality  to  the 
children  is  much  greater  than  in  vertex  presentations;  and,  I  am 
inclined  to  refer,  with  most  authors,  this  increased  mortality  to  the 
undue  pressure  exerted  on  the  umbilical  cord,  thus  interrupting  the 
circulation  between  the  f<jetus  and  placenta.     The  dc:ith  of  the 
child  may  also  be  the  result  of  delay  in  the  dulivery  of  the  h^ail, 
aflcr  the  other  poitiims  have  pa>ised  into  the  world.     Not 
standing  this  comparative  mortality  of  the  child  in  pelvic  prv> 
tioQs,  yet  it  cannot  be  denied  that  the  danger  is  much  enh.t 
and  the  fatality,  therefore,  augmented  by  the  offidousnea<i  u\  ifie 
accoucheur,  in  not  submitting  these  cases  to  nature. 

As  regards  the  mother,  there  is  no  more  danger  in  a  pi'lvic  than 
in  a  vertex  prcscutation  ;  and,  contrary  to  the  generally  rcc4*ivod 
opinion,  when  the  breech  pre^entju,  the  labor  is  usually  more  favor- 
able and  shorter  than  when  the  fijet  are  fciiind  at  the  superior  strait. 
It  13  not  difficult  to  exfjlain  this  eircurnMtance.  Ah  soon  aii  the 
nates  begin  to  descend  into  ll»e  pelvic  exea%\ation,  they  j^roduce 
upon  the  surrounding  parts  a  pres^Hure,  which  hnmediuit^Iy  eiills  into 
action  the  tributary  iutlueuce  of  the  spiird  eord,  thus  adding  vitfor 

and  efhcienoy  U\  the  coti-  < 

of  the  uterus.   This,  as  h  :, 

is  not  tlie  case  when  the  feet  (ure- 
sent  drH*,  for  tlie  reasim  thai  ttie 
diminished  volume  of  the  pre- 
senting parts  is  incapable  of 
making  the  degree  of  pretenra 
neeeHsary  to  t!vc»ke  tJie  roiflttz 
action  of  the  cord* 

The  breech*  feet,  and  koeei 
may  assume  four  diflTerent  pod> 
tions  at  the  sufwrior  st  ! 

we  shall  now  proeeed  i  » 

describe  the  mechani^^m  oi  trtuis* 
^1    f^i  mission  in  each  of  these  positions. 

J*^lrM  Panition  of  (ha  Urmch. 
— ^Tli©  sncrum  of  the  fcelus  reg;irds  the  MX  acetabulum  (Fig*  dl), 
constituting  the  l*^fi  anterhr  sacral  prmtion.     lien\   the   tiateS| 


THE   PBINCIPLE8  AND   PKACTICE  OF  OBSTETRICS. 


347 


baolc,  and  occiput,  correspond  to  the  left  anterior  portion  of^ 
the  uterus  and  pelvis,  while  the  abdomen,  cheat,  and  face  regard ' 
the  right  posterior  portion.  It  will  thus  he  seen  that  the  nates 
present  at  first  diagonally  at  the  superior  strait ;  but  as,  in 
response  to  the  contractile  eftorU  of  ihe  uterus,  tliey  are  made 
to  dei^cend,  the  right  la  turned  toward  the  sacrum,  the  con- 
cavity of  which  it  pursues  (Fig.  52),  while  the  letl  is  placed 
under  the  pubes,  forming,  as  it  were,  for  the  other  a  point  of 


Yig.  :>!  Fig,  6a. 

fupport.  During  the  process  of  the  delivery,  the  iiofht  hip 
ippears  first  at  the  vulva  (Fig.  53),  and  then  the  trunk  Is  expdled, 
being  sUgliily  curved  in  the  direction  of  the  pubes*  As  soon  as 
ie  breech  makes  pressure  on  the  perineum,  great  care  should  he 
lercised  in  giving  proper  support  to  the  latter,  in  order  to  prevent 
Tupture  ;  and,  :is  the  hips  pass  out  of  the  vulva,  a  loop  should  be 
made  of  the  cord,  by  drawing  down  a  small  portion  of  it.  If 
the  ptilsutions  be  found  to  grow  weak,  the  delivery  should  be 
hastened  by  tractions  on  the  body  of  the  child,  as  will  be  described 
when  speaking  of  preternatural  labor. 

The  arms,  because  of  the  resistance  oifercd  thera  by  the  brim  of 
the  pelvis,  will  occasionally  ascend  toward  the  face  so  as  to  become 
extended  on  the  lateral  portions  of  the  head  ;  the  shoulders  descend 
jiia^onally  at  the  superior  strait,  the  richt,  which  is  posterior, 
j>pearing  befrire  the  left,  which  is  in  front ;  in  the  pelvic  cavity 
they  undergo  the  movement  of  rotation,  vvhi('h,  of  course,  places 
them  in  the  direct  position  at  the  inferior  strait,  whence  their 
expulsion  Is  soon  followed  by  that  of  the  arms.  The  head  paeses 
from  the  su|jerior  strait  into  the  pelvic  excavation  in  a  flexed  con- 
dition, the  chin  being  approximated  ti3  the  sternum,  the  occiput 
turned  toward  the  pubes,  and  the  face  toward  the  t^acrura  ;  thus, 
[^'ith  the  neck  under  the  arcade  of  the  pubes,  and  the  face  resting 
ainst  the  coccyx  and  perineum,  the  chin  escapes  from  the  vulva, 
^id  tfie  delivery  is  completed. 

Seeond  Position  of  the  Jireeeh, — The  Bacrum  regards  the  right 
acetabulum — (he  right  anterior  mcral  position.  Here,  the  nates, 
back,  and  oeciimt,  are  in  front,  and  to  the  right ;  the  abdomen. 


848 


THE   PRLNCIFLES  AKD   PRACTICE  OP   OBSTKTRICa 


chest,  jind  l:t(x»  boKinrl,  and  to  the  left.    The  mechaiiUm  m 
poditiutt,  is  fundamentally  the  Rame  tm  in  the  first, 

Thinl  Poaidofi  of  the  Brt^ech, — The  sacrum  corresponds  wUI 
the  right  sacro-illac  symphj-.sis^^rAc  rhjht  posterior  sacral  positii} 
— the  breech,  hack,  and  occiput  being  buhiiid,  and  to  the  ri^ht 
while  the  abdomen,  chest,  and  invc  arc  in  front,  and  to  the  U'i\ 
This  position  m  the  reverse  of  the  first,  and  the  same  roeclianl^ 
causes  the  delivery  of  the  child.  The  head,  however,  will  expei 
euce  somewhat  more  difficulty  in  its  e^rresj^,  from  the  fact  that  the 
face  is  obliged  to  glide  aloni^  the  symphysis  [lubis,  while  the  ooci-^ 
put  k  passing  the  hollow  of  the  sjicnim,  llie  coccyx,  and  perineumJ 
The  head,  in  its  exit  from  the  vulva,  becomes  extended,  fto  thai  ihl 
chin  first,!  ^^"^^  ftttccessively  the  mouth,  nose,  and  forehcitd  emerge] 
from  under  the  pubes^J 

Fourth  Position  of  the  lireech. — The  sacrum  corrcfiponda  with 
the  left  sacro-iliac  sympliysis,  and  is  the  revei'se  of  the  fsecond^ — ike 
l^  jjosterior  sacral  position — the  hreeeh,  back,  and  occiput  sre 
behind,  and  to  the  left ;  the  abdomen,  chest,  and  visage  In  froBt, 
and  to  the  riglit«  Here  again,  tlie  meehaniHui  is  precisely  the  same 
as  in  the  preceding  position.  It  is  worthy  of  remark  that,  in  tbe^ 
various  breech  presentations,  the  inferior  extremities  almost  aJwuj 
remain  flexed  lengthwise  upon  the  trtmk,  and  usually  pass  out  of 
the  vulva  simultaneously  with  the  head. 

PreserUaiion  o/t/ie  Peet.^ — When  the  feet  prcseut^  it  b  pOBSil 

*  In  oddiiioUf  in  Ihese  posterior  sacral  positioDS,  the  lii^iid  of  I  ho  child  will 
vtfy  Apt  Ui  tiu  ol>8tructed  bj  the  cbtn  cfttchinj^,  n»  it  werc>,  upofi  the  niRiiM  of  th« 
putiea,  giv'm)i  viae  neceasarily  to  •  protract<?d  dtlay,  iind  mvolvitig«  in  mtfcc  or  h/m 
peril,  th<»  snfi'ly  of  th&  infant.  In  order  to  pr^voot  this  iliJSciilty,  as  mjoo  mB  iim 
hips  arr«  bvirt^  tli^i verted — if  nature  h.ive  not  ap^mtAneously  dmni^  thu  pa«|tiOQ^ 
which  she  aomctimeflv  thoutrh  rerely,  docs — ^the  hips  fhould  l>o  p^uiij  ftm^jtrd  bf 
tho  two  hntidii,  atid  i\w  body  of  the  cJiild  rotated  upon  ita  long  Kxi^  for  the  piirpoiQ 
of  C4jnv^rtii»^  the  fioi»ii^rior  sueral  into  quo  or  other  of  th<i  onU^rior  iMond  poflHIoiMi; 
tho  third  beiii)C  changed  into  tUtf  second,  Aud  the  fourth  into  the  tirit 

f  Ur  Kmm\yoiU»m  wiys,  "  I  behove  that  in  no  in»t«m».  if  Um  com  wm^  M 
cfitii^ty  to  tiitture,  prtividiHl  tliia  ciiiUt  iind  pelvis  wen.^  of  oomtnon  wmo  tad  fcffn, 
HPQuld  Uw  fice  be  expell*?d  under  tho  arch  of  the  pube^'*    This  i«  advem©  lainjrj 
cibiervNtion  on  tho  subject,  ond  in  certAiuly  not  consistent  with  tlio  ovid^tiev  ftir>i 
nistied  by  tho  tjin^ia  room.     [lUnubolhiiii'a  System  of  Obitetrict.      K«iiclai^% 
million    p  327  ] 

I  II  will  Nimetimei  hapj^en,  us  an  exceptional  circumfltAnce,  thftl  tho  fiio^.  laidar 
thn  inniii*rir.v  of  »  Atrong  <xmtniction  of  the  utcrun,  wtU  bo  turnod  from  ihi»  Krmpbjr* 
9h  pubis  into  the  hollow  of  the  Mcrurn.  nnd  the  body  of  the  child  wdl  atao  pAriiCi- 
pnte  id  tljiii  wnudreulur  movement  It  was  Na^l^  who  first  directi*d  oltt-ntioii  to  \ 
this  fact*  and  observed  it  to  oeeitr  only  when  the  fiistus  wa«  smnll,  and  not  nt  fUU 
time.  S?c«n/rOnt,  however,  records  two  ioiiances  of  this  oouver^lt^n,  in  whirh  It  ' 
tcx>k  pliKH^  when  liie  fi£tusea  were  large,  and  had  completed  iheir  lnini-merli»i!  lllSos. 

§  In  192.114  eaiet,  there  were  obnerred  1831  foot  or  Icnee  prewt-nlati'ma.  or  abotil 
1  In  lOo.  The  mortfllilr  to  lb«  ddldrea  1  la  3f.~[Churchiirg  IlidwifefT,  4th  ho^ 
40D  KdiUoQ,  p  427] 


THE  PRIKCIPLES  AND  PBACTICE  OF  OBSTETRICS.         849 

to  confound  them  with  the  hand  of  the  fcetus ;  and  this,  you  may 
readily  imagine,  would  result  in  a  serious  complicaticm  of  the  labor. 
For  example,  suppose  the  accoucheur,  always  in  the  habit  of  inter- 
fering in  these  cases,  because  he  believes  them  preternatural,  should 
seize  the  hand  at  the  superior  strait,  and,  mistaking  it  for  the  foot, 
make  traction,  and  bring  it  down  into  the  vagina.  It  would  then 
be  too  late  to  repair  his  error,  for  he  would  find  it  not  so  easy  a 
thing  to  replace  the  hand. 

Diagnosis, — The  diagnosis  of  a  foot  presentation  is  not  difficult ; 
it  only  needs  thought  and  judgment  to  make  the  proper  distinction. 
In  the  first  place,  the  foot  is  thicker  and  larger  than  the  hand  ;  the 
toes  ai-e  shorter  than  the  fingers,  the  great  toe  being  near  its  fel- 
lows, while  the  thumb  is  separated  from  the  fingers;  the  foot  is 
narrow,  the  hand  is  broad  and  flat ;  the  foot  is  at  a  right  angle 
with  the  leg ;  the  hand,  on  the  contrary,  is,  as  it  were,  but  an 
extension  of  the  forearm. 

First  Position  of  the  Feet, — The  heels  regard  the  left  acetabu- 
lum, and  the  toes  the  right  sacro-iliac  symphysis — the  left  anterior^ 
calcaneo  position.  The  breech,  back,  and  occiput  are  toward  the 
left  anterior  portion  of  the  uterus  and  pelvis  ;  the  abdomen,  chest, 
and  face  toward  the  right  posterior  portion.  As  in  the  case  of 
breech  presentation,  the  feet  cannot  be  readily  recognised  until 
after  the  rupture  of  the  membranous  sac. 

Second  Position  of  the  Feet, — The  heels  regard  the  right  aceta- 
bulum, the  toes  the  left  sacro-iliac  symphysis — the  right  anterior- 
calcaneo  position.  The  breech,  back,  and  occiput  in  front,  and  to 
the  right ;  the  abdomen,  chest,  and  face  behind,  and  to  the  left. 

Third  Position  of  the  Feet, — ^The  heels  regard  the  right  sacro- 
iliac symphysis ;  and  the  toes  the  left  acetabulum,  being  the  reverse 
of  the  first  position — the  right  poster ior-calcaneo  position.  The 
breech,  back,  and  occiput  behind,  and  to  the  right ;  the  abdomen, 
chest,  and  face,  in  front,  and  to  the  left. 

Fourth  Position  of  the  Feet, — In  this  position,  the  reverse  of  the 
second,  the  heels  are  turned  toward  the  left  sacro-iliac  symphy- 
sis, and  the  toes  toward  the  right  acetabulum;  the  left  posterior- 
calcaneo  position.  The  breech,  back,  and  occiput,  behind,  and 
to  the  left;  the  abdomen,  chest,  and  face  in  front,  and  to  the 
right. 

In  the  various  positions  of  the  feet,  the  mechanism,  after  the 
escape  of  these  latter,  is  precisely  the  same  as  in  the  breech  pre- 
sentations ;  and,  therefore,  it  is  unnecessary  to  repeat  what  we  have 
said  on  the  subject. 

FirstPosition  of  the  Knees, — ^The  tibiae  correspond  with  the  left 
acetabulum,  and  the  thighs  with  the  right  sacro-iliac  symphysis — 
Irft  anterior-tibial  position. 

Second  Position  of  the  Knees, — ^The  tibiae  at  the  right  acetabu- 


850 


THE  PROrCIFLES  AKU  FBACTIOi:  OF  0BSTETB1C8. 


lum,  Ihc!  thif;ha  at  the  left  Bacroilioc  Bympbysis — rigfU  anUricr^ 
tibial  pifsition. 

Third  Position  of  the  Knt^s, — ^The  tihire  to  the  right  nAcrcKiUiio 
fipnphysb;  the  thighn  to  the  left  acetabultun;  this  b  the  revetwi 
of  the  fi rut  i>osition — the  riffht  posteHor-tibiaL 

fourth  Pontion  of  th^  Knets, — The  u\nm  to  the  left  i^ero-Uiao 
synipliyais  ;  th^j  Uiighs  to  the  right  acetabulum^  the  rcveitc  of  the 
fti>c<>nd  position — the  ^ftpos(etior4ib(ai. 

As  soon  as  the  knees  are  expelled,  the  varion.^  poj«iiion»  Mr% 
reduced  to  the  corresponding  positions  of  the  feet  Without  carei 
it  may  be  possible  to  confuund  the  knee,  espL'ci;i]ly  when  only  one 
can  be  felt  at  the  superior  strait,  with  the  elbow  or  shoulder  In 
the  case  of  tbe  elbow,  the  olecranon  process  and  condylun  will  nervo 
IS  guides,  while  the  ribs  and  axilla  will  detortniiie  the  fact  ot  a 
aboulder  presentation. 

It  will  be  tieen  that  I  have  not  spoken  of  the  management  of 
pelvic  presentations  in  cases  in  which  the  labor  becomes  compltcaK^, 
and  in  which  consequently  it  will  be  necet^sary  for  tlie  accoucheur  to 
interpose.  Tins  sn!»ject  will  be  discusaed  in  a  future  lecture,  wh«a 
treating  of  preternatural  labor. 


LECTURE  XXV. 

The  joung  Acooucbeur's  Debut  in  the  Lying-in  Cbamber — ^What  he  is  to  do,  aiid 
what  he  is  not  to  do ;  his  Chat  with  the  Nurse — Tiie  Examination  per  Yaginam ; 
how  it  is  conducted,  and  what  it  should  reveal — ^Is  the  Patient  Pregnant  7 — ^Is 
she  actuall/  in  Labor? — Are  the  Pelvis  and  Soil  Parts  Normal  or  otherwise? 
A  Woman  may  imagine  herself  in  Labor,  and  yet  not  bePregpaant;  Illustration — > 
What  is  the  Presentation  of  the  Foetus? — Is  it  Natural  or  Preternatural  ? — What 
will  be  the  Duration  of  tlie  Labor  ? — How  this  question  is  to  be  answered— 
When  Labor  has  commenced,  the  Bowels  and  Bladder  to  be  attended  to — Quietude 
of  the  Lyingf-in  Woman  important;  Loquacity  of  the  Nurse — ^The  Stages  of 
Labor ;  what  are  they  ? — Conduct  of  the  Accoucheur  during  each  of  these  Stages 
— ^After  the  Escape  of  the  Head,  Rule  to  be  followed — When  the  entire  Kzpul- 
aUm  of  the  Fcetus  is  completed,  important  rule  to  be  observed — How  many  Liga- 
tures are  to  be  applied  to  the  Cord  ? — The  Author  recommends  but  one — Reasons 
for — ^Trismus  Nasccntium,  and  Inflammation  of  the  Umbilical  Vessels ;  Scholer*8 
Opinion — When  the  Child  is  separated  from  the  Mother,  what  is  to  be  donet — 
Respiration  of  the  Infant;  Causes  which  Impede  it — Asphyxia;  Causes  of— 
Treatment  of  Asphyxia — Marshall  Hall's  Method — 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  afler  the  Pulsa- 
tions of  the  Heart  have  ceased — Death  of  the  Motner  not  necessarily  Fatal  to 
Fcetus  in  Utero ;  Why  f — Brown-Sequard's  Experiments. 

Gentlemen — We  will  now  suppose  that  your  services  are  demanded 
in  a  case  of  labor ;  and  shall,  therefore,  proceed  to  speak  of  the 
daties  devolving  upon  you  at  the  bedside  of  your  patient.  The 
first  entrance  of  the  young  accoucheur  into  the  lying-in  chamber  is 
a  matter  of  no  little  importance.  In  the  first  place,  he  has  popular 
prejudice  to  contend  with ;  he  is  not  "  an  old  gentleman,  and  con- 
seqaently  knows  nothing  of  his  business."  The  only  means  of 
putting  an  end  to  this  prejudice,  and  of  demonstrating  that, 
although  not  a  patriarch  in  years,  yet  he  is  nevertheless  fully  com- 
petent to  the  discharge  of  his  duties,  is  his  conduct  after  he  crosses 
the  threshold  of  the  parturient  room.  One  mistake  in  his  debut  in 
obstetric  practice  may  exert  a  singularly  unhappy  hifluence  over 
his  future  prospects ;  should  he,  on  the  contrary,  make  a  favorable 
impression  in  his  first  case,  the  best  consequences  may  ensue  to  him. 
Something  more  is  required  of  the  accoucheur,  if  he  wish  to  suc- 
ceed, than  a  profound  knowledge  of  his  subject :  conjoined  to  an 
intimate  acquaintance  with  the  varied  details  of  the  sick-room,  he 
most  understand  human  nature ;  he  must  discriminate  between  a 
haimless  concession  to  popular  whim  or  caprice,  and  a  concession 


THE   PRINCIPLES  AKD   PRACTICE   OF  01 


which  may  compromise  \m  own  character  mid  thi^  ditr»»ity  of  his 
art.  In  a  u  onl,  he  is  constantly  to  bear  in  mind  the  full  mesumre 
of  his  rfispon 'nihility* 

Punctuality  and  promptness,  in   respondin);^  to  prof  '  *'*Wa> 

are  especially  luiportant  in  the  practice  of  ohstetric   i  .A 

messenger  has  arrived^  reipiesting  the  immediate  attefi(iance  of  the 
accoucheur*  The  hitter  proceeds  without  delay  to  the  re«*ideuee  at 
the  patient ;  he  ring.H  the  bell ;  he  is  admitted  ;  and  if  this  should 
bo  his  fi r^t  professional  visit  to  the  ianiily,  all  eye>^  will  naturally  be 
turned  toward  him,  surveying  him  with  marked  care;  if  he  fidtcr 
under  the  scrutinizing  gaze,  it  will  very  likely  be  attributed  to  wmot 
of  professional  ekill  I  Hii*  general  bearing,  as  soon  nn  he  enter*  the 
hon»e  of  hi.'*  patient,  should  bo  that  of  a  well-bred  gentleman ;  Im 
should  manifest  no  exritcment,  but  hi."*  conduct  be  such  m  to 
impress  the  conviction  that  he  is  accustomed  to  tbe^e  call*,  and 
understands  how  to  comport  himself  Soon  idler  being  introduoed 
into  the  parlor,  the  nurse  will  probably  leave  the  |iatient  for  tbo 
purpose  of  having  a  little  preliminary  chat  with  tlie  doctor.  In 
this  interview*  with  the  nurse,  if  adroitly  conducted,  much  cam  be 
learned  an  to  the  general  condition  of  the  patient — whether  it  U  her 
first  child — whether  the  labor  has  regularly  commenced,  whrthcr 
fihe  has  suffered  unusually  from  her  pains,  whether  she  in  uervoui 
and  irritable,  whether  nhe  h  agitated  at  the  doctor's  arrival. 

Tliese  preliminaries  over,  the  nurse  then  leaves  with  the  promise 
that,  in  a  few  minutes  she  will  return,  and  conduct  you  to  the  sick 
room.  When  you  enter  the  roonj,  your  patient  will  be  recliniug  on 
the  bed  or  sofa,  or  sitting  in  a  chair.  In  either  ca.H<',  you  approach 
her  gently  and  courteously,  and,  histcad  of  saying,  **  Well,  niailanLf 
you  are  about  to  have  a  baby — does  it  hurt  much?'*  or  some  such 
kindred  expression,  bearing  the  itiipress  of  a  vulgar  mind — 1  say*  \m 
lieu  of  surli  rudeness,  )uu  enter  into  conversation  with  her,  tnlktng 
of  any  and  everything  except  of  the  subject  directly  connected  with 
the  object  of  your  visit.  Talk  nf  Fraiice,  or  Egypt^,  or  Kamsehatka, 
or  the  marine  telegraph  ;  in  this  way,  a  little  professional  diplomacy 
will  enable  you  very  suecessfnlly  to  accustom  your  patient  tu  your 
presence.  The  first  interview  Ija^s  passed ;  she  finds  that,  after  all,  it 
is  not  such  an  embarrassing  thing  to  hold  converge  with  a  doctor, 
and  you  will  have  impressed  her  quite  favorably  merely  by  yaur 
manner.  She  will  rather  like  you,  atnl  will  be  apU  as  soon  aa  ooc*- 
sioD  presents  itself  to  say  to  the  nurse — "  What  a  clever  man  thai 
is;  he  is  so  very  agreeable.^*  ''Yes,  madam,"  replies  the  Uttrae, 
*'  he  know  s  what  he  is  about.'*  These  mutual  compliments  between 
patient  and  nur^e  give  you  a  substratum  in  that  family  ;  yoor 
autl>ority  will  be  hearkened  to,  and  you  will  have  achieved  an  early 
and  ImportaDt  victory.  Well,  thus  much  for  iho  first  aocna — wluM 
next  y 


THE  PRINCIPLES  AND   PRACTICE   OP  OBSTETRICS. 


353 


The  object  in  sending  for  you  was  of  course  to  have  the  benefit 
of  your  counsel  and  skill ;  as  8ood,  therefore,  as  you  hiivt-  fairly 
introduced  yourself  to  your  patient,  it  will  then  be  essential  to 
becorae  sau.sfied  as  to  her  true  condition  ;  to  do  this  it  will  he 
necessary  to  institute  a  vaginal  examination.  For  this  purjKise,  you 
ipeak  to  the  nurse,  and  tell  her  that  you  are  anxious  to  asccTtain 
how  things  are  progressing.  This  is  conimunieatetl  by  the  nurse  to 
the  patient,  and  her  assent  is  readily  obtained  ;  for,  as  a  general 
rule,  slie  will  he  found  most  solicitous  to  know  if  "all  is  rit^ht.'' 

Allow  me  here  to  call  attention  to  some  iew  details  in  reference 
to  this  first  examinrvtiou.  The  patient  shotild  be  in  the  recumbent 
position,  either  on  her  side  or  back ;  anil  whichever  j>ositiou  may 
be  assumed,  it  is  important  that  she  be  near  the  edge  of  the  bed, 
that  you  may  have  every  facility  for  conducting  the  examination. 
While  the  nurse  is  arranging  the  patic^nt,  you  will  generally  be 
requested  for  the  time  being,  to  walk  into  an  adjoining  room  ;  but 
if  not,  be  careful  that  you  occupy  yourself  with  something  else  than 
gazing  at  the  movements  of  the  parties;  take  a  sent,  and  turn  your 
hack ;  become  thoughtful,  jks  if  lost  in  the  aohition  of  some  great 
professional  problem  ;  or,  if  a  book  be  at  hand,  open  it,  and  improve 
your  mind.  When  everything  has  been  arranged,  you  then  proceed 
to  make  the  examination, 
the  mode  of  doing  svhich 
hm  already  been  pointed 
<>«t  in  Lecture  XIII.,  to 
which  I  refer  you.  When 
you  are  summoned  to  at* 
tend  a  lady  who  stipposes 
herself  to  be  in  labor,  the 
examination  which  you 
institute   will    have    the 

■Ufewing  objects:    1.  Is 

■be  pregnant  ?    2.  Is  she 

[actually  in  labor,  and  has 
the  OS  uteri  begun  to  di- 
late ?  (Fig,  5-4.)  n.  Are 
the  pelvis  and  soft  parts 
in  a  normal  conditioii,  or 
are  th  ey  deform  ed  ?    4.1s 

the   presentation    of  the 

foetus  in  accordance  with 

the  requirements  of  natural  labor,  or  is  it  otherwiee?    These  are 

ibe  points  to  be  ascertained  in  thiajexploration. 

I.  J}oes  Pregnancy  Exist  f — You  may  think  it  strange,  almost 
bordering  on  the  ridiculous,  that  your  services  should  be  required 
by  a  lady  who  imagines  her  labor  at  hand,  when  in  fact  she  is  not 

23 


Fia.  M. 


354 


THE   PRIXCIPLES  AXD  PRACTICE  OF  OBSTETRICS, 


in  gestation.  Bnt,  allow  me  to  tell  you  that  such  oerurreruity?  nrv 
now  a  part  of  liistory ;  and  it  would  be  a  aevero  bluw  to  your  vir^n 
aitpirations  to  be  fonnd  ministering,  for  fM2%  prnl  dayH,  to  tlie  wantu 
of  a  patient  supposed  to  be  in  parturition,  who  in  trulh  wj^  not 
even  pregnant.  Women  who  htixe  never  Inirne  children^  and  w}io«c* 
desire  it  baa  been  to  have  offspring,  are  sonieUme.<3  qwitc  Bpt  to 
imagine  themselves  in  a  state  of  gestation ;  as  I  liave  remarket]  in 
a  preceding  lecture,  the  accoucheur  ehould  never  rely  nficm  any 
stJitements  made  by  bis  patient  in  case«nfthi«  kind.     It  ty 

to  judge  for  himself,  irresfiective  of  all  adveniitioits  or  •  rUt- 

ences«  His  mind  must  be  free  from  bias,  and  his  decision  of  %ht 
case  based  up»on  the  evidence  which  maybe  presented  tu  hinsetiMiv 
Such  is  the  rule  of  conduct  I  wouh!  most  eaniestly  enjoin  oil  all, 
who  ntay  wi^h  to  discharge  their  trust  fearlesisly,  and  at  the  aaiiMi 
lime  justly. 

A  most  amusing  case  occurred  in  this  city  some  years  i»iooe,  aod 
will,  perhaps,  serve  more  eflectuiilly  to  illustrate  an  important  truth 
in  midwifery  than  any  argument  I  can  advance.  It  is  what  tnay  be 
-denominated  a  tangible  fiiet,  and  is  entitled  to  full  apfireeiation : 

A  lady,  aged  47,  married  since  lier  thirtieth  year,  had  rherisbed 
an  ardent  desire  to  become  a  mother,  but  had  not  succecnled  in  her 
wishes.  She  was  about  abandnning  all  b(»pe,  when,  of  a  nudiltm,  she 
noticed  that  her  abdomen  began  to  enlarge,  and  really  imagined 
herself  pregnant.  In  addition  to  other  symptoms,  she  thongbl  she 
distinctly  fell  tho  movementH  of  the  child*  Her  heart  was  full  of 
joy ;  she  received  the  congratulations  of  her  uumerooa  female 
friends,  w  lio  coni[ilimented  lit- 1"  on  lier  prowess,  and  tlie  Ijnal  aeoom- 
plishrnL-nt  of  her  hopes  afier  years  of  fniitlcss  eflbrt ;  alie  commi*tii3«d 
making  the  necessary  preparations  for  her  approaching  accooeheroeDI. 
Her  physician  wa*  advised  of  tht^  f>appy  circumstance,  and  informod 
that  hts  eservices  in  due  time  would  be  needed.  In  the  course  of  fl 
few  months  the  labor  comi]»enced  ;  a  messenger  hastened  to  apprise 
the  doclt»r  that  the  lady's  time  bad  come,  with  aJi  urgent  reqnetft 
that  ^e  would  be  prompt  in  reaching  the  bedside  of  his  deltgKted 
but  suffering  patient.  The  doctor  arrived — all  in  the  hoiiMC  Kra« 
confuHiuu,  and  in  high  e\ptvtation  ;  the  nurse  was  enchaiitf^d  ;  the 
husband,  in  a  spirit  of  humility,  couM  scarcely  realise  tlie  advent 
of  this  long  expected  era  in  his  life ;  the  patient  was  in  nettial  labor; 
the  pains  frequent  and  distressing.  The  physician  wa«  entreated 
by  the  good  nurse  to  lose  no  time  in  assisting  madam  ;  I  an 

examination  ;  the  silence  of  death  now  pervaded  the  lyln^  rn* 

ber  to  receive  from  the  lips  of  the  oracle  the  exact  facts  of  the  caa^^ 
the  friends  were  soon  made  joyful,  by  hearing  from  the  doctor  lliaS 
all  wji*  right — that  the  labor  was  quite  advanced,  and  in  a  very 
short  time  wouM  be  ccmipleted.  The  sufferings  of  t!ie  patient 
inerensed ;  she  was  urged  to  tnake  the  most  of  her  [»ain*« :  ^^  To  bear 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         856 

down  and  aarist  nature  " — ^when  lo !  in  the  midst  of  one  of  those 
powerful  efforts  to  ^^  assist  nature,''  there  was  heard  an  explosion, 
which  struck  terror  into  all  present,  the  doctor  included.  The 
patient,  as  soon  as  she  recovered  from  the  prodigious  effort  which 
had  occasioned  the  explosion,  exclaimed :  ^'  Oh  !  dear  Doctor,  it's 
all  over ;  do  tell  me  if  it's  a  boy !'»  The  explosion  was  nothing 
more  than  an  escape  of  air  from  the  bowels ;  the  patient  having 
mistaken  flatulence  for  pregnancy,  and  the  rumbling  of  the  gas  in 
the  intestines  for  the  motions  of  tlie  foetus!  Let  this  case,  there- 
fore, keep  before  you  the  recollection  of  the  fact,  that  one  of  the 
first  duties  devolving  on  you  in  the  examination  is  to  be  certain 
that  your  patient  is  pregnant. 

II.  J9^  Labor  Actually  Commenced  ? — ^You  have  only  to  refer 
to  what  we  have  said  in  Lecture  XXIII.,  regarding  the  signs  of 
labor,  and  the  mode  of  distinguishing  between  true  and  spurious 
pains,  to  be  enabled  at  once  to  determine  whether  the  parturient 
effort  has  really  begun.  If  you  find  labor  is  in  progress,  your  next 
car©  will  be  to  acquaint  yourselves  with  the  character  of  the  pains ; 
are  they  merely  commencing,  and,  therefore,  slight,  or  have  they 
already  assumed  a  degree  of  intensity  ?  What  is  the  condition  of 
the  OS  uteri  ?  Has  it  begun  to  dilate,  and  to  what  extent  ?  Does 
the  membranous  sac  protrude,  and  what  is  its  volume  ?  These  are 
important  questions,  for  they  will  aid  you  in  the  prognosis  as  to  the 
probable  duration  of  the  labor.  Has  your  patient  already  borne  a 
child,  or  is  she  a  primipara  ?  In  the  latter,  the  labor  is  usually 
more  protracted. 

in.  Are  t/ie  Pelvis  and  Soft  Parts  in  a  Normal  Condition  f — 
While  conducting  the  vaginal  examination,  you  should  not  fail  to 
assnre  yourselves  of  the  state  of  the  pelvis  and  soft  parts.  Is  the  for- 
mer natural  in  its  dimensions  ?  Is  it  deformed  ?  If  so,  whether 
by  an  increased  or  diminished  capacity  ?  Is  its  diminished  capacity 
such  as  to  involve  the  safety  of  the  mother  or  child,  or  will  it  only 
tend  to  make  the  labor  tedious  and  more  lengthened  ?  How  is  the 
uterus — does  it  preserve  its  parallelism  with  the  axis  of  the  superior 
strait — or  is  it  malposed,  so  as  to  exhibit  either  of  the  obliquities  to 
which  we  alluded  in  the  previous  lecture  ?  How  ar€  the  vagina 
and  vulva  ?  Are  they  contracted  and  rigid,  or  relaxed  and  dilata- 
ble ?  Is  the  bladder  distended,  or  the  rectum  more  or  less  filled 
with  &cal  matter  ?  These  are  so  many  points  to  be  ascertained  by 
the  accoucheur  in  his  first  exploration  ;  they  will  involve  no  diffi- 
culty on  his  part,  if  he  understand  himself — nor  will  they,  in  any 
way,  expose  the  patient  to  annoyance  or  suffering ;  the  index  finger 
carefully  introduced  will  be  all  that  is  necessary  to  arrive  at  just 
conclusions  upon  these  various  heads. 

rV.  Is  the  Presentation  of  the  JFhetus  in  Accordance  toith  the 
Mequirements  of  Nature? — Does  one  of  the  extremities  of  the 


THE   PRINCIPLES  AND  PRACTICE  OF   OESTETBIC& 


ovoid  present  at  the  superior  strait  ?  If  no,  which  ia  it  ?  Is  it  the 
heiidt  hrecchj  feist,  or  knees?  Ifllie  head,  h  it  the  %'ertex^  nr  face, 
and  whnt  position  doeti  it  asamne?  If  the  preMenttng  part  have 
bejjun  to  dcHceiid  into  the  pelvic  cavity,  is  its  Jesksent  cunKij^tenl 
with  the  mechanism  of  labor,  or  otherwise?  Instead  of  ooe  of  the 
extrcmilit's,  is  some  portion  of  the  trunk  of  the  (iBlwt  at  the  upper 
atrait,  constituting  a  cro*«8  birth  ?  In  addition,  tho  earofttl  aeooa- 
eheur  will  inform  himself  as  to  other  points ;  such  as  the  ti;nt^ni> 
ment,  disposition,  age,  moral  and  phy«ical  condition,  etc.,  of  bis 
patient.  Is  she  plethoric,  or  feeble,  and  nervous?  Ih  i*he  in 
good  health,  or  U  her  labor  comprieated  with  iK>mc  tscrions  dis- 
ease,  either  of  an  acute  or  chronic  form?  Is  »he  young,  or 
bus  ahe  already  approached  the  meridian  of  life,  and  yet  a  primi- 
paru  ? 

It  Clin  scarcely  be  nece^isary  to  impress  upon  you  the  importanoe 
of  becoming  thoroughly  and  promptly  cogniEant  of  these  vanoat 
conditions;  in  doing  8o,  you  phice  yourBclves  in  a  fitrong  and  iaie 
position  ;  you  know,  at  once,  whether  the  labor  is  natural,  or 
whether  the  interposition  of  science  will  be  called  for.  In  tnith, 
with  this  knowletlge,  you  will  bt*  not  unlike  tlje  skilled  gener;il  on 
the  battle  fields  who,  having  fully  informed  himself  of  iho  various 
points  of  the  field  itself,  and  of  the  strength  and  arrangement  of 
the  adverse  forces,  knows,  not  only  how,  but  when  tu  nmkc*  bis 
attack.  Under  these  circumstances,  his  charge  upon  the  enrmy 
will  Uiiuully  be  one  of  victory,  for  the  reanon  that  it  has  been  well  cot^ 
side  red,  and  based  upon  a  knowledge  of  circumstances  more  or  less 
isSHential  to  success.  So,  gentlemen,  will  it  Ik?  tn  the  ly  ing*in  chamber 
in  ea.^es  of  trouble,  if  you  will  early  inform  yourselves  of  th«  true 
nature  and  extent  of  the  ditTu-ulty  to  be  overcome. 

DHratiim  of  the  Z^iAor.*— Well,  the  examination  has  been  madai 
and  ytJU  are  in  posseshion  of  all  the  circumiitances  of  the  msm^ 
having  assoertiiined  that  everything  is  auspicious  to  a  tj  1j* 

very.  A  prcsttirig  quention,  which  will  be  urged  not  ut  ^  iily 
by  the  patient  and  friends,  as  soon  as  you  have  completed  the  euh 
miuation,  will  be  as  to  tlic  probable  duration  of  the  la1>or.  Much 
anxiety  will  be  evinced  for  a  prompt  reply  to  this  interrogatory,  aad 
the  friends  will  be  n)ore  or  less  ini}»orlunate  for  your  opinion,  Ko 
measure  of  experience  will  enable  you  to  give  an  unqualified  an* 
awer  to  this  inquiry,  for  there  is  a  vast  deal  of  capnoe  about  nature, 
and  although  we  may  af ►proximate,  yet  we  cannot  de^nitely  fix  the 
period  which  she  will  retjuirc  for  the  completion  of  her  work*  In 
order,  therefore,  to  relieve  the  very  natural  anxiety  on  this  poiat, 
and,  at  the  sjune  time,  avoid  a  positive  committal,  you  sbouhl  xay^-^ 
all  is  rights  and  everything  will  dejyend  upon  the  character  and 
efficifjioy  of  the  pains*      Thi-  inly  an  equivocal  :i  i  ut 

it  will  be  accepted  as  quite  tn  y,  and  will  serve  ;  \\^ 


THX  PBINGIFIiBS  AND  PBAOTICE  OF  0BSTETBIC8.         857 

yoa  from  the  conseqaences  of  naixuDg  any  particular  time  ia  which 
the  delivery  may  be  accomplished. 

Duties  of  the  Accoucheur  after  Labor  has  Commenced. — As 
soon  as  you  have  ascertained  that  your  patient  is  in  labor,  your  next 
care  should  be  to  conduct  her  safely  through  it,  and  with  this  view, 
we  diall  now  speak  of  certain  duties,  which  will  necessarily  devolve 
upon  you.  In  the  first  place,  if  the  bowels  have  not  been  evacuated 
for  one  or  two.  days,  and  more  especially  if  the  rectum  be  dbtendcd 
with  fsBcal  matter,  it  is  quite  essential  that  an  enema  should  be 
administered,  or,  if  preferred,  some  castor  oil ;  and  also  if  there  be 
an  accumulation  of  urine  in  the  bladder,  the  patient  should  be  di- 
rected to  attempt  to  relieve  herself;  if,  however,  she  should  be 
uiable  to  do  so,  the  catheter  must  be  employed.  You  will  not  have 
foi^tten  what  we  said  regarding  the  introduction  of  this  instru- 
m^it  in  the  latter  stages  of  pregnancy,  or  during  labor ;  the  posi- 
tion of  the  urethra  at  this  time  is  nearly  vertical,  being  more  or 
less  parallel  to  the  internal  surface  of  the  symphysis  pubis  ;  there- 
fore, the  direction  of  the  catheter,  in  order  to  reach  the  bladder, 
most  be  from  hdovo  upward^  describing  nearly  a  perpendicular 
line. 

Quietude  in  the  Chamber, — I  would  earnestly  suggest  that  the 
room  of  the  parturient  woman  be  kept  quiet,  and  that  she  be  saved 
the  perils  of  excitement  from  the  presence  of  persons,  who  can  ren- 
der no  assistance,  but  who  tend  to  contaminate  the  air,  and  often- 
times, by  their  frivolous  conversation,  disturb  the  patient.  The 
nurse  and  one  other  assistant  will  ^iiice,  under  ordinary  circum- 
stances, for  all  the  purposes  needed.  You  should  early  study  the 
character  and  disposition  of  your  patient — if  she  be  nervous  and 
timid,  and  full  of  despondency,  o[)en  before  Irer  vistas  of  hope  and 
cheerfulness;  encouragement  from  her  physician,  in  the  hour  of 
tribulation,  is  always  a  grateful  boon  to  a  confiding  woman,  and  it 
should  not  be  denied  her  at  the  time  at  which,  of  all  others,  she 
most  needs  support  and  comfort.  The  nurse,  if  loquacious,  and 
fond  of  recording  her  doleful  experience  of  "  horrible  cases,"  must 
be  promptly  checked.  There  seems  to  be  a  groTidng  and  morbid 
disposition  on  the  part  of  certain  unthinking  females,  to  indulge  in 
narrations  of  the  frightful  scenes  they  have  witnessed  in  childbirth, 
and  they  usually  avail  themselves  of  the  most  inopportune  occasion 
for  their  recital.  Nothing  of  this  should  be  allowed,  for  it  often- 
times has  a  most  pernicious  efiect. 

It  will  be  proper,  as  the  labor  is  progressing,  to  ask  the  nurse  if 
she  have  in  readiness  a  piece  of  tape  and  a  pair  of  scissors,  which 
will  be  required  as  soon  as  the  child  is  born  for  the  purpose  of  tying 
and  cutting  the  cord.  I  have  known  groat  confusion  to  ensue  from 
the  neglect  of  this  apparently  trivial  direction. 

Stages  of  Labor, — In  order  to  simplify  as  much  as  possible  the 


858 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS. 


questicjD  of  Datural  labor,  wo  shall  divide  it  into  three  ni 

shall  >ij>eiik  of  what  may  be  necessary  for  you  ro  do  in  ♦  >C 

them :  First  stage  consists  in  the  full  dilatation  of  the  cm  uicri,  and 
njpture  of  the  inembranons  ^ac;  aeconJ  i*tage»  the  deiteent  and 
expulsion  of  the  ftrtna;  third  stacfo^  the  delivery  of  the  plAcefita. 
Authors  differ  much  in  their  division  of  the  various  stages,  but  the 
one  just  piven  you  will,  I  think,  for  practical  pur)»osea,  he  fcmnd 
suJficiently  comprehensive. 

If*irat  Stage. — Tliis  I  have  just  told  yoa  is  occupied  in  the  dilsta- 
tion  of  the  os  uteri,  and  rupture  of  the  membrarHjui?  sac,  Durinc: 
the  commencement  of  thi^  ntage  of  labor,  the  )min.s(areat  finit  Kljsfbl 
passing  from  the  back  to  the  thighs,  and  arc  dcn<trainatcd  ♦^'rinding  ; 
It  b  not  until  the  os  uteri  becomes  %o  dilated  and  the  membraoousMo 
and  presenting  portions  of  the  foetus  begin  to  make  a  deri*l«l  prpt* 
fturo  upon  it,  that  the  pains  aa^unie  a  strongly  marked  bearing-«lowii 
character,  ll  h  well  to  note  the  change  in  the  iWmIr  as  soon  M 
thesie  latter  pains  are  in  full  development ;  at  this  lime,  during  a 
contraction,  6he  grasps  anytldng  within  her  reach,  and  mdcavoring 
to  iix  hor  feet  firmly  against  some  resiHting  object,  she  holds  her 
breath,  and  concentrates  all  her  efforts  on  the  uterus — ihi?  din- 
phrngm  and  alHlomiual  muscles  rontribnting  their  respecti%'e  aid  in 
this  effort.  This,  I  repeat,  is  what  you  will  ordinarily  ob!*erve  oa 
a  characteristic  difference  in  the  contrartions  of  the  iitenia,  during 
the  cornmenoenjent  and  completion  of  the  firht  stage.  You  cniinol 
but  perceive  that  this  very  diireretiee  inculcates  an  important  prACtiod 
precept,  \i«.,  not  to  urge  yonr4)tnient  to  make  any  effort,  or,  io  the 
ordinary  phrase,  'Mieardown''  while  the  ]iains  are  simply  grinding; 
for,  at  thi^  period,  no  effort  of  hers  can  avail;  on  the  contrary,  yon 
shouhl  caution  her  to  economize  her  strength  until,  when  the  os 
uteri  has  prog  ret*  sed  in  its  dilatation,  the  contractions  theni^lvis 
become  forcmg,  and,  consequently,  may  be  inatonally  aided  by  ihd 
efforts  of  the  female  herself.  The  more,  therefore,  she  endeavora 
to  assist  nature  at  this  period,  the  greiiter,  under  ordinary  circiim* 
sUmees,  will  be  the  facility  of  the  biith. 

Mupture  of  tlie  Membranous  Sac, — As  a  general  prineiple,  when 
the  OS  uteri  has  become  sufficiently  dilated  to  enable  the  h«^  of 
the  f<BtU3  to  pusj*  (Fig.  54),  there  is  a  spontaneous  rupture  of  the 
sac,  followed  by  the  escaj>e  of  more  or  less  of  the  amniotic  lUiid. 
You  have,  in  a  previous  lecture,  been  admonished  not  to  mpttire 
the  sac  prematurely  ;  for,  in  doing  so,  you  deprive  nature  of  fta 
imporUmt  adjimct  in  the  dilatation  of  the  os — the  uniform  and 
steady  pressure  of  the  sne  itself.  When  the  Uquor  airnili  es- 
capes betbre  the  proper  dilatation  of  the  mouth  of  the  utera% 
instead  of  this  gentle  and  effective  ]>ressure  of  the  sac,  there  b 
simply  the  hard  and  unequal  pres$9ui*e  of  the  ))e:id  to  iu>eompUsh  the 
object,  resulting  ordinarily  in  a  protracteil  delivery,  and  «oni€tiin<!« 


THE    PRIXCIPLES  AND   PRACTICE   OF   OBSTETRICS. 


Wu..  h^ 


~m  injury  to  both  mother  and  child.  There  are,  however,  circum^ 
stances  in  which  it 
mmy  become  essen- 
tial iy  necessary  for 
you  to  rupture  the 
**  bag  of  waters  *' 
early  in  the  labor, 
and  before  the  pro- 
per ilbgree  of  dilata-  wi^Hfevr '  i^j^ 
lion  h:is  been  accom-  l™l^^fe-r.  r  K 
plished.  Snppost*,  for 
example,  the  labor 
from  the  very  e*>tu- 
mencement  should 
be  extremely  rapi<l, 
and  that  you  ap}>re- 
bended  a  too  sudden 
expitli^iou  of  the  foe- 
tus aud  its  aiinexa? ; 
ill  a  case  of  this  kind, 
it  will  be  your  duty 
early   to   afford,   by 

rupture  of  the  sac,  ^  ""^"^  ^"^''J^  *i*'*^'^- 

e^cipe  to  the  auiuioiic  fluid,  Should  you  fail  to  flo  so,  the  rapiil  and 
brusque  tivarualitju  of  the  uteriue  coDtcnta  niit^ht  endanger  the  life 
of  the  miaher.  The  uterus,  under  -these  circuuisitnnccs,  would  b*j 
apt  to  be  thrown  into  a  state  of  inertia,  giving  rise  to  hemorrhage, 
which,  to  s!iy  the  least,  would  involve  the  SMfety  of  the  parent  in  a 
ter  or  less  degree  of  peril.     If  you  will  allow  me  to  say  s*>— i/ou 

'thmfUl^  flw  a  geficrtjl  ride^  regard  quick  births  as  dwigerons  btrfJis^ 
Position  of  the  Parturient  Woman. — Previous  to  the  rujiture- 
of  lbesa«*  of  waters,  the  jmtient  may  be  permitted  to  assume  what- 
ever position  may  be  most  agreeable  to  her.  It  is  a  great  mistake 
to  oontinc  her  to  the  bed  from  the  very  commencement  of  her  labor. 
In  the  first  p!aee,  it  is  uncalled  tor;  and  secondly,  while  it  etiervates. 
her  sinngth,  it  is  calculated  also  to  break  the  wing  of  her  s^iurit, 
and  occasion  more  or  less  depression.  Allow  her,  therefore,  the 
largest  liberty ;  siie  may  sit  in  a  chair,  recline  on  the  solii,  walk 
about  the  chamber,  or  get  on  her  knees.  In  one  word,  let  her  do. 
just  as  she  }>leases.'*^  liut  after  the  rupture  of  the  sac,  it  will  1*^ 
prudent  for  her  to  remain  in  bed.f 

♦  It  in  your  examinatkni  per  vaginam.  you  aHoertaiu  that  the  pelvis  is  unnsually 
capncioiia,  then  tt  will  become  Important  to  depnrt  from  tins  rule,  and  enjoin  upon' 
your  jmlieDt  to  contiuuo  in  the  recumbent  position  during  the  entire  progress  of  the 
or ;  otherwise,  from  tlio  cxci'Ssive  size  of  tlse  |>elvuj.  there  would  bi*  daiifrer  ot'  a  stid- 
idelivery  while  walklr.g about  thfc  rtxjni.  Siiuh  u  ctjnliujfency  mi^Vit  ru-Hult  (!udly. 
I  in  the  habit  of  ordering  a  ool  tti  be  placed  by  the  side  of  the  bed.  for  the* 


I!*>0 


TUB  PRINCIPLES  ASP  FBAOnCK  OF  OBSTETRICfl, 


Tlia  posiUcMi  amamed  by  the  female  at  the  time  of  delirery  rsriea 

'  in  cliflTurL-nt  t'ourjtnes.  In  Errglantl,  the  Usiuiil  position  in  *> 
8ii1e ;  in  France,  on  the  back — anii>  infleefU  throughout  *« 
with  the  exception  of  Vieiiiia  and  Heidelberg,  where  l)ie  Kttgliili 
custom  seems  to  fjrevml,  the  wornnn  is  ordinarily  delivereii  on  her 
biit^k.  In  j*onie  porlioris  c»f  Jrdancl,  it  is  Knid,  the  cuj«tom  nbtnin- 
of  havinf2:  the  birth  coni|»leted  wjlh  the  woman  either  in  the  -^ 
ing  poHltiun  cir  on  her  kncest,*  When  there  is  no  speeiiil  objt  ^ ,.  ,. 
on  the  part  of  the  patient^  I  am  in  the  habit  of  reeominendiii^  tlie 
poMlicin  un  iht;  bai^k,  because  I  think  »he  v:\u  jjivc;  htTuclf  tnueh 
more  efficient  support  than  when  on  ll»e  nde ;  anil,  in  all  cam*it  of 
operallve  midwtfi'ry,  wli ether  nuinuid  or  instrumrntjU^  the  bacdt  ik 
intitntely  preferable.  I^t  nie  here  remark  that,  in  tiome  iiisunceii 
ui  which  the  contractions  oi'  the  nft^rns  become  defcH*tircv  I  Idi%i9 
observed  great  advantage  from  allowing  the  female  to  plaee  herieU 
for  a  short  time,  on  her  knees  ;  this  cfiange  of  portion  will  of^eo- 
tiraes  e^timuUite  the  organ  to  renewed  effort* 

Improprleff/  of  Frequent  Vafjhia!  Ejramhiatiom.^^i  m*'  i^ii- 
lion  you  against  frequent  vaginal  examinatii>ns  during  thii*  ivtiige 
of  h>bor.  The  practice  of  constantly  introducing  the  fn 
the  vagina,  is  a  vicious  one;  nothing,  under  ordinary  eircuu.  :,-.-  :<» 
am  justify  it ;  it  is  both  annoying  and  injurious  to  the  palieot. 
U\er  vou  havo  i^atisfied  vourselves,  iis  fiir  .i*  miiv  be,  of  the  ^  ^^ 

if  things  in  the  exmnination  you  iriPlituted  at  the  ciunni'  > 

of  labor,  what  necessity  can  there  lie  for  more  than  one  or  two 
repetitions  mitil  al\er  flie  escape  of  the  waters,  when  it  becottitit 
neee-Hsary  agtiin  lo  explore,  and  inform  yourselves  as  to  the  prugreoa 
of  delivery,  and  the  precise  position  of  tJie  presenting  part? 

Dkf  of  iht  Pnrtttrkni  Woman. — The  patient  should  oceasianally 
l>e  pcrniittc<i  to  take  bland  nourishment,  such  n%  tea,  barley  wt^tm^ 
gruel,  light  broth,  etc.;  but  do  not  fall  into  the  pernio  i  *  '  ■-  *' 
recommending  wines,  sjuritR,  or  other  stimulants,  uj 
indicated.  They  excite  the  sys^teni,  anrl  almost  alway**  d*>  bdimi. 
lee  water  will  be  both  grateful  and  oflicient  it5  iv  drink,  partieuUrly 
if  there  be  a  degree  of  lethargy  in  the  eontraetiona  of  the  otenifi. 

Riff  id  iff/  (f  fti-e  0»  Uteri, — In  suvrno  ensea,  ililatation  of  I  be  o« 
uteri  will  be  eviremely  hIow  and  irki^>me,  and  this  may  be  ow  tng 
to  two  different  eonditionsi;  1.  To  extreme  dryr>e*5  of  the  parts  an 
ib§enee  of  the  mucous  seerefion,  which  we  have  already  Htmted 
luces  a  lubricating  intluence,  relaxing  and  preparing  Ibem  tor 


p\sr^t*$»  i»f  «)«4iv««riffff  tho  patimt ;  there  \m  much  ■drariUige  In  lbl%  ftir,  iifUr  tlic 
*\-  ntkUtttui  k)  li^r  aw II  ixiiri(brtat))«  bed,  whid^  htm  bevn  unllitr 

li  «  iho  hiMir, 

*  h\.  iU*,4tv  »^*>M,   "In  ioinc  remoic  purts  of  Irrknd  ■tod  nil •'  ; 

pdiiifut  nils  iipm  lh«  kfii*ri  of  «f}iJihirr  ponou.  kud  Uits  office  of  eul  •    tiv-e 

^Air  in  UBU»lljr  p<irfunn«d  by  hvr  buabniDd*" — ihfty*9  SyMUm  «/  ifwlip^rry,  p^  m. 


THS  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         861 

the  distension  necessary  for  the  transit  of  the  child.  In  sach  an 
event,  you  will  find  much  benefit  in  directing  your  patient  to  sit 
over  a  vase  of  warm  water.  This  I  have  frequently  resorted  to, 
and  with  signal  success.  Advantage  will  also  be  derived  from 
throwing  into  the  vagina,  at  intervals,  mucilaginous  injections,  or 
lubricating  the  os  uteri,  vagina,  and  vulva  freely  with  fresh  lard  or 
batter.  Here,  too,  the  application  of  the  Belladonna  ointment  will 
be  of  signal  service.  The  abominable  practice,  commended  by 
some  of  the  older  writers,  of  introducing  the  hand  into  the  vagina 
for  the  purpose  of  stretching  and  distending  it,  is  not  for  an  instant 
to  be  tolerated.  These  rude  manipulations  can  never  receive  the 
sanction  of  the  scientific  accoucheur.  2.  The  delay  in  the  dilatation 
of  the  OS  uteri  may  be  due  to  excessive  plethora  of  the  system, 
conjoined  with  unusual  muscular  rigidity.  Under  these  circum- 
stances, you  have  in  the  judicious  employment  of  the  lancet  an 
efficient  remedy.  Abstract  from  the  arm,  early,  just  so  much  blood 
as  your  judgment  tells  you  is  indicated — six,  eight,  twelve  ounces. 
The  effect  of  general  blood-letting  in  producing  a  softening  of  the 
OS  uteri  is  often  marvellous.  I  have  said  resort  to  the  lancet  early, 
and  for  this  reason — if  the  female  be  permitted,  in  this  state  of 
plethora  and  muscular  resistance,  to  continue  in  labor  for  some 
hours  without  relief,  she  grows  wearied  by  fruitless  effort.  The 
child  incurs  the  hazard  of  undue  pressure,  and  the  mother,  in  this 
hyperseniic  condition  of  system,  is  exposed  to  dangerous  congestion 
of  some  of  the  more  important  organs. 

Touching  the  subject  of  blood-letting,  allow  me  to  suggest  to  you 
an  important  lesson :  Whenever  you  are  summoned  to  attend  a 
lady  in  labor,  if  she  should  be  surcharged  with  blood,  as  will  be 
indicated  by  her  bounding  pulse,  flushed  countenance,  and  general 
physical  condition ;  and,  if  under  these  circtimatancea  she  complain  of 
more  or  less  intense  cephalalgia^  with  throbbing  of  the  temporal 
arteries^  and  an  approach  to  suffusion  of  the  eyes^  do  not  hesitate 
to  tie  up  the  arm,  and  abstract  blood  until  a  decided  impression 
has  been  made  upon  the  system.  A  neglect  of  this  precaution  has 
more  than  once  left  its  melancholy  trace  in  the  lying-in  chamber — 
either  in  the  production  of  puerperal  convulsions,  apoplexy,  paralysis, 
or  haemoptysis.  When  at  the  bedside  of  his  patient,  the  sa^cious 
practitioner  must  have  his  eyes  about  him,  and  be  prepared  for 
whatever  emergency  may  arise.  How  many  noble  ships  have  been 
wrecked  because  no  precaution  had  been  exercised  until  the  storm 
had  broken  forth  in  all  its  resistless  intensity. 

While  I  recommend  a  resort  to  the  lancet  during  labor,  when 
the  abstraction  of  blood  is  plainly  indicated,  yet  I  would  most 
emphatically  inculcate  upon  your  recollection  this  essential  obstetric 
troth — women  in  parturitio?i  are  always  more  or  less  liable  to  be 
attacked  with  flooding^  and^  therefore^  great  caiUion  is  to  be  observed 


Uch  ^^^"'I;vc  -^  e^-  °^  five  or  t^"  "^  \vec*^'^^''7a\\  "^^^"^ 


THS  PRIKOIPLBS  AND  PRACTICE  OF  OBSTETRICS.         868 

has  undergone,  be  more  or  less  swollen.  You  can  be  of  very 
material  assistance,  by  pushing  this  segment  of  the  cervix  gently 
upward  during  a  pain ;  or  if,  as  is  sometimes  the  case,  it  should  be 
more  toward  the  rectum  than  in  front,  the  same  thing  may  be  done 
also  in  this  case.  I  speak  from  no  little  experience,  when  I  tell  you 
that,  by  this  simple  manoeuvre,  if  dexterously  performed,  the  labor 
will  oftentimes  be  most  favorably  advanced.  Again  :  if  there  be  a 
sluggishness  in  the  contractions,  much  benefit  will  arise  from  care- 
fully insinuating  your  finger  within  the  dilated  oa  uteris  and  titil- 
lating it.  This,  you  at  once  perceive,  evokes  the  reflex  faculty  of 
the  spinal  cord,  and  imparts  vigor  and  eflSciency  to  the  contractions ; 
indeed,  the  introduction  of  the  finger  under  these  circumstances 
will  act  also  on  a  mechanical  principle,  for  the  dilatation  of  the  os 
uteri  is  both  vital  and  mechanical. 

It  is  during  the  second  stage  of  labor  that  the  patient  will  com- 
plain of  distressing  pain  in  her  back,  causing  her  frequently  to 
exclaim,  "  Oh !  my  back  will  break ;  Oh !  dear  doctor  I  my  poor 
back ;  what  shall  I  do  ?"  Great  relief  will  be  afforded  in  these 
cases,  by  twisting  a  napkin,  and  placing  it  under  the  back,  the  two 
ends  being  held  by  assistants,  one  on  either  side ;  during  the  pain, 
they  should  be  instructed  to  gently  elevate  the  patient,  by  raising 
the  ends  of  the  napkin,  so  that  firm  pressure  may  be  made  on  •the 
back.  This  is  an  old  suggestion  ;  I  do  not  recollect  to  whom  it  is 
due,  but  it  is  a  good  one.     I  often  avail  myself  of  it. 

As  the  head  of  the  foetus  approaches  the  vulva,  the  patient  will 
feel  an  urgent  desire  to  evacuate  the  bowels,  and  she  will  insist  upon 
being  permitted  to  leave  her  bed.  This  you  cannot  consent  to,  for 
it  would,  at  this  advanced  period  of  labor,  involve  both  herself  and 
child  in  danger.  The  desire  is  caused  by  the  pressure  of  the  head 
against  the  rectum.  Sh6uld  there  be  faecal  matter  in  this  portion 
of  the  intestinal  canal,  it  will,  however,  be  pressed  out ;  but  this  is 
matter  of  no  moment,  for  the  nurse,  if  experienced,  will  have  pre- 
viously provided  a  napkin  for  its  reception. 

Supporting  the  Perifieum, — ^The  head  having  approached  the  os 
externum,  the  perineum  now  becomes  the  seat  of  extraordinary 
distension,  and  the  anus  itself  is  more  or  less  open.  Support  must 
be  given  to  the  perineum  in  the  following  manner :  the  accoucheur 
will  place  a  piece  of  folded  linen  in  the  hollow  of  his  hand,  in  order 
to  constitute  it  a  plane  surface,  and  make,  during  the  contraction, 
a  firm  and  equable  pressure,  being  careful  not  to  have  the  radial 
portion  of  his  hand  above  the  inferior  commissure ;  for,  in  this  case, 
in  lieu  of  supporting  the  perineum,  he  would  press  more  or  less 
directly  against  the  head  of  the  foetus,  thus  antagonizing  the  expul- 
sive efforts  of  the  uterus,  and,  therefore,  incurring  the  liability  of 
rupturing  the  organ  (Figs.  55,  66). 

The  sufferings  of  the  patient  at  this  period  of  her  parturition  are 


864 


THE  PIUKCIPLES  AND   PRACTICE  OF^ 


fttCS. 


generally  most  intenjie ;  her  sht-iekA  are  terrifio,  ami  lo  an  iiuprMV 
tised  ear  will  be  any  tiling;  but  sweet  music.  l)u  not  alliiw  b«r 
cries  to  alarm  or  jjcrturb  you ;  and  while  I  would  not  sdvifle  yott 
to  dry  up  the  fomitaius  of  your  sympathy  in  thk  her  hour  of  db* 


.^ 


/ 


Ft|{v&IL 


tress,  yet  you  raust  be  firm,  and  at  the  ftanie  time  condolatory — 
givhitj  Iter  every  possible  encouragement,  and  assuring  her  in  (erma 
of  emphatic  kiridufS'*,  that  in  a  very  few  momenta  there  will  Lu  aii 
end  to  her  trihuhitiati*     Tlie  accouehetir  hiis  much  in  hin  |KJwer ;  if 


J^"  % 


Pli.  ftT, 


]ie  be  elever,  and  comprehend  human  nature,  he  can  prove  the  very   * 
balm  of  Gilead  to  his  patient ;  he  e:ui  make  her  &tih  in  him  lO 
strong,  tljat  it  will  tend  very  materially  to  break  the  inteiiscity  of 
physirnl  »nfTerinL%  and  remove  from  her  iniud  ibe  appn»hen«ioitt  of 
gloom  and  de«»pondenoy. 


THB  FRIKGIPLSS  AND  PRACTICE  OF  OBSTBTRICS.         885 

The  vulva,  during  these  last  throes  of  the  uterus,  becomes  greatly 
distended;  the  head  protrudes,  and  the  labia  externa  are  appa- 
rently so  tightly  drawn  over  it,  that  you  would  imagine  it  almost 
impossible  for  the  birth  to  be  accomplished  without  serious  lacera- 
tion. But  nature  is  so  conservative  that,  under  ordinary  circum- 
stances, the  exit  of  the  head  is  effected  without  injury  to  the  paits. 
Daring  the  interval  of  pain,  there  is  usually  a  slight  retrocession  of 
the  head.  It  is  not,  you  must  remember,  by  one  sudden  and  abrupt 
expulsive  effort,  that  the  delivery  is  consummated ;  on  the  contrary, 
it  is  through  a  series  of  consecutive  forces,  the  necessary  tendency 
of  which  is  gradually  to  prepare  the  parts  for  the  distension  to 
which  they  arc  subjected,  and  which,  for  this  reason,  they  can  sus- 
tain with  impunity. 

In  these  last  struggles,  just  as  the  head  is  about  making  its  final 
passage  into  the  world,  the  patient  will  sometimes  be  attacked  with 
nervous  tremblings.  They  are  entirely  involuntary,  and  she  has  no 
power  for  the  moment  of  controlling  them.  They  are  of  no  sort 
of  importance,  and  need  give  rise  to  no  disquietude.  When  the 
head  has  thus  escaped,  there  is  experienced  great  relief,  and  you 
will  be  asked  in  terms  of  kindness,  "  Oh !  dear  doctor,  is  it  all 
over?''  "  In  one  moment,  my  good  patient,"  you  will  reply ;  " the 
head  is  delivered,  and  the  rest  will  occasion  you  very  little  trou- 
ble." She  is  soothed  by  this  assurance,  and  is  fortified  with  hope 
for  the  remainder  of  the  birth.  It  is  proper  here  to  remark  that^ 
in  some  instances,  as  the  head  is  passing  through  the  os  externum, 
and  the  same  thing  may  occur  as  it  escapes  through  the  os  uteri, 
the  patient  will  lose  her  consciousness — she  will  wander,  and  if  it 
be  not  recollected  that  this  loss  of  reason  is  but  for  the  moment, 
mmecessary  alarm  may  be  excited.* 

Does  the  Cord  encircle  the  Neck  of  the  Child  f — ^There  is  at  this 
period  of  the  labor  an  important  duty  for  you  to  perfonn ;  and  you 
mast  be  careful  not  to  omit  it.  As  soon  as  the  head  has  effected 
its  transit  through  the  vulva,  you  should  immediately  introduce 
your  index  finger,  for  the  purpose  of  ascertaining  whether  or  not 
the  umbilical  cord,  as  sometimes  will  be  the  case,  is  around  the 
neck  of  the  child ;  if  so,  does  it  encircle  the  neck  tightly  ?    If  it  be 

*  Dr.  Montgomery  called  attention  to  this  temporary  loss  of  mind  during  labor 
some  years  since :  **  It  comes  on  suddenly  during  perfectly  natural  labor,  and  most 
fineqaently  at  that  particular  stage  of  the  process — dilatation  of  the  os  uteri.  It  is 
not  accompanied  nor  followed  by  any  other  unpleasant  or  suspicious  symptom ;  it 
occurs,  perhaps,  immediately  after  the  patient  has  been  talking  cheerfully,  and,  hay 
ing  lasted  a  few  moments,  disappears,  leaving  her  perfectly  clear  and  collected,  and 
returns  no  more,  even  though  the  subsequent  part  of  the  labor  should  bo  slower  and 
more  painful.  In  every  instance  which  came  under  my  observation,  the  patients 
were  conscious  that  they  had  been  wandering,  and  occasionally  apologized  for  any- 
tfaiog  wrong  they  might  have  said,  although  they  were  not  aware  of  what  the  exact 
nature  of  their  observations  might  have  been."     [Dublin  Journal,  vol.  v.  p.  51.] 


866 


THE  PBIKCIPLES  AND  PRACTIGE  OF  Ol 


loose  zind  excreta  na  compression,  let  it  aloQC.    SbouM  it,  j  r, 

be  found  eonstricling  the  neck,  yoii  ebould  endeavor  to  r^i  <» 

that  it  mny  be  gently  drawn  over  the  bead-  If  this  cairnoi  be 
a^'eonif>liFluHU  and  the  [>re^8ure  «o  groat  an  to  cau»e  you  to  appn^ 
hend  the  death  of  the  ehild  from  the  impossibility  of  atiiiofifiberic 
air  ]>a-*.sing  into  the  larynx  and  trachea,  then,  at  once,  uilli  - 

ger  as  a  guide,  introduce  a  pair  of  scis^or^,  and  make  a  *«  i 

the  cord;  or^  in  the  absence  of  scisftorH,  u  penknife  wiil  i  \»  r 
every  purpose* 

Generally,  as  eoon  as  the  bead  is  in  the  world,  the  child  will  gasp, 
and  jtrive  evidence  that  it  is  alive.  Unle!»8  something  nhould  u»di* 
cate  the  necessity  for  interference,  I  would  advise  you  to  mtbmit 
the  termination  of  the  delivery  to  nature,  except  ace  that  the  bed- 
clothes do  not  obstruct  the  mouth  so  as  to  interfere  with  tin?  func- 
tion of  respiration  ;  see,  too,  that  the  mouth  and  none  are  not 
obstructed  by  the  membranes. 

In  a  A>w  moment!!^  alYer  the  expulsion  of  the  head,  the  uterus 
again  contracts,  when  the  shoulders  and  entire  fcetns  are  expelled. 
DurinjT  tfie  passage  of  the  fthonldors,  the  perineum  must  be  oan^ 
fully  supported.  Some  practitioners  are  in  the  habit,  m  soon  mm 
the  head  has  made  its  exit,  of  making  traction  npon  it  for  the  pur* 
pose  of  expediting  the  delivery*  This  ia,  as  a  jyfeueml  rule,  bad 
practice,  for  the  sudden  evacuation  of  the  uterus  will  be  apt  to 
induce  inertia  aiid  hemorrhage. 

It  is  very  e^ssential,  the  moment  the  head  has  pan^^ed  the  vulir«, 
to  allow  a  fi-ee  access  of  air  to  the  face  of  the  child,  nnd  thb  can 
Ije  done  without  in  any  way  unnecessarily  expoalng  tlu?  pern*  i 
the  mother.  Infantts  are,  I  am  sure,  oftentimes  saeritiix-d  by  n  i 
ferenee  to  this  simple  but  fundamental  rule.  The  physiologrist  luw 
shown  that  respiration  is  dependent  u()on  the  excito*motory  sysit*m; 
or,  in  other  words  uj>on  the  spinal  cord.  It  is  an  excited  act,  and 
the  first  eticM-t  of  the  new-born  infant  to  breatlio  is,  p<.Thap«,  as  Mar* 
shall  Hall  has  deohired,  induced  hy  the  stimulus  of  the  atmc^jiphere 
actbig  upon  the  cutaneous  or  terminal  branches  of  the  trilkcial 
nerve. 

It  is  not  neceaaary  for  me  to  rcf>eat  here  what  I  have  alreadjr 
mentioned,  when  speaking  of  the  mechanism  of  laljor,  txr^pecting 
the  diflerent  movements  of  the  head,  shoulders,  etc.,  during  ihrir 
[lassage  into  the  world.    For  these  details  I  refer  you  to  Lecture  IV. 

Ait  soon  an  (/m  Child  is  barn  what  is  to  be  donef^UaU  gi'nile- 
men,  I  am  now  about  to  enjoin  npon  you  a  lesson,  which  I  hope 
you  will  not  fail  to  observe.  I  regard  it  as  imcof  the  mojst  import- 
ant connected  with  your  duties  in  the  lying-in  chamber.  It  is  thit ; 
the  nmmcnt  the  child  is  in  Ujc  world,  ])laee  your  himd  gently  upon 
the  hypogastric  region  of  your  patient,  for  the  purpose  of  bt^ing 
assured  that  the  uteriis  res|»onds  to  the  birth  :  thr  c\idi'nc*'  of  thii 


THE  PBINCXPLES  AND  PRACTICE  OF  OBSTETRICS.         867 

response  will  be,  that  you  will  feel  the  organ  gathered,  as  it  were, 
upon  itself,  occupying  the  lower  portion  of  the  abdominal  cavity, 
and  presenting  the  feel  of  a  hard,  contracted  object.  In  the  recog- 
nition of  this  circumstance,  your  mind  is  at  ease  with  regard  to  the 
fear  of  hemorrhage.  Suppose,  on  the  contrary,  instead  of  this  con- 
tracted condition  of  the  uterus,  you  should  find  the  organ  uncon- 
traded^  and  in  a  state  of  inertia^  occupying  more  or  less  of  t/ie 
abdomen :  this  state  of  things  would  at  once  admonish  you  of  the 
certainty  of  flooding ;  and  being  thus  admonished,  you  would  lose 
no  time  in  staying  the  current,  which,  if  not  promptly  checked, 
will  destroy  the  life  of  your  patient. 

The  subject  of  flooding,  with  its  causes  and  treatment,  will  be 
discussed  in  a  future  lecture. 

JDemands  of  the  Infant. — ^Let  us  now  turn  our  attention  to  the 
in&nt.  As  soon  as  the  child  has  escaped  from  the  uterus,  care 
should  be  taken  to  place  it  transversely  as  near  the  vulva  as  possi- 
ble, with  its  back  toward  the  mother ;  the  object  being,  in  the  first 
place,  to  prevent  laceration  of  the  cord ;  and,  secondly,  the  passage 
of  any  discharge  from  the  vagina  into  the  mouth  of  the  child. 
Should  the  cord  be  twisted  round  the  body  or  extremities  of  the 
infant,  you  must  not  fail  carefully  to  liberate  it. 

Usually,  if  the  labor  have  been  auspicious,  simultaneously  with, 
or  a  few  seconds  after  the  exit  of  the  child  from  the  maternal 
organs,  it  is  heard  to  cry,  a  proof  that  the  respiratory  movement 
has  taken  place,  and  that  the  infant  is  now  independent  of  its 
mother.  Under  these  circumstances,  you  should  place  a  ligature 
around  the  cord,  about  two  inches  from  the  umbilicus,  not,  how- 
ever, without  previously  having  assured  yourselves  that  there  is  no 
fold  of  the  intestine  protruding  from  the  umbilicus,  thus  constitut- 
ing a  species  of  congenital  hernia.  Should  there  be  this  fold,  it 
mast  be  carefully  pressed  back  into  the  abdomen  before  applying 
the  ligature. 

I  recommend  you  to  use  for  this  purpose  a  piece  of  flat  tape, 
which  exercises  an  equable  but  firm  pressure.*    After  the  ligature 

•  Dr.  Scholer,  in  speaking  of  that  very  fatal  affection  among  new-born  infants — 
Triamua  nascentium — Bays  that  in  eighteen  children  who  died  of  it  ho  discovered 
iDflammation  of  the  umbilical  arteries  in  fiAecn,  the  arteries  having  been  found 
swollen  at  the  point  at  which  they  approach  the  urinary  bladder.  The  same 
oboerver  has  failed,  in  all  examinations  of  infants  who  have  died  from  other  com- 
plaintB,  to  detect  inflammation  of  tlie  umbilical  vessels.  I  am  quite  disposed  to 
believe  that  there  is  much  truth  in  the  opinion  of  Dr.  Scholer,  that  trismus  is  caused 
by  this  inflammation  of  the  vessels ;  and,  moreover,  that  the  inflammation  is  owing 
to  the  rude  manner  in  which,  frequently,  the  cord  is  tied ;  sudden  an  i  undue  pres- 
sure on  these  vessels  by  a  round  string  being  apt,  I  think,  to  excite  inflammatory 
actioii,  which  is  soon  propagated  to  the  vessels  in  their  progress  toward  the  bladder. 
To  avoid  this  unnecessary  constriction,  therefore,  I  recommend  you  to  substitute  fbi 
the  round  string  a  piece  of  flat  tape. 


868 


THE   PRINCIPLES  AKD  PRACTICE  OF  OBSTBTRICS» 


has  been  properly  applied,  you  ^fiould  cut  the  cord  a  few  \uw»  b 
front  of  iho  ligature  wiiU  a  pair  of  acisftorH;  but,  in  doing  so,  be 
guarded  that  you  da  not,  in  your  confusion,  amputate  a  tUigur  m 
the  penis  of  the  unoffending  littl«  inlant,  both  of  which  bluuden 
are  matters  of  record. 

You  see,  gentlemen,  I  propose  but  one  ligature,  while  the  gcfie* 
ral  practice  is  to  employ  two,  and  separate  the  cord  between  ihetn.^ 
For  this  practice,  I  can  perceive  no  solid  reason ;  and  the  argil* 
ment  usually  advanced  in  ila  favor  i?*  full  of  error,  because  it  is 
fouuded  upon  a  false  hypothcsii*.  It  is  alleged  that  if  one  ligatare 
be  applie<l,  the  niutber  will  be  exposed  to  all  the  hazards  of  hooding 
through  the  untied  extremity  of  the  cord.  The  absurdity  of  this 
apprehension  I  have  already  pointed  out,  when  deaeribing  the  ani^ 
tomieal  arrangement  of  the  placenta,  and  the  foetal  circulation.f 

I  never,  in  single  births,  apply  but  one  ligature,  and  for  the  ful* 
lowing  reasons : 

1,  Two  arc  unnecessary,  because  the  small  cfuantity  of  blood, 
which  (lows  from  the  untied  extremity  of  the  corU,  conhUitii  mirrcly 
of  the  disgorgement  of  the  vessels  on  the  foDtal  surJuee  of  th€  afters 
birth,  and  does  not  come  directly  from  the  system  of  the  luoUi^; 
2*  This  very  disgorgement,  in  my  opinion^  asjiistd  in  the  more 
prompt  expulsion  of  the  placenta^ 

Tfufufcrrlnfj  the  Infant  to  the  Ulanket, — When  the  infant  haa 
been  separated  from  its  mother,  the  nurse  should  be  instructed  lo 
have  in  readiness  on  the  ^ide  of  the  bed  a  w^arm  flannel,  or  blanket, 
which  h  to  receive  the  Utile  stranger.  But,  remember  you  ar^  lo 
place  it  in  the  blanket  yourseh  eis,  and  not  allow  the  nurse  to  do  iOv 
You  luay  suppose  it  cpiite  unnecessary  for  me  to  sUile  any  ilinjo* 
tlons  as  lo  the  manner  in  which  you  are  to  remove  the  child;  bul 
sometimes  very  ludicrous  scenes  have  occurred  for  the  want  of  a 
little  foreihought  on  this  aubject.  If,  in  your  attempt  to  take  bold 
of  the  chihl  for  the  purpose  of  giving  it  to  tlie  nurse  yon  shoold, 
as  may  be  the  ca^sc,  allow  it,  from  awkwardness  on  )our  parti  la 
slip  out  of  your  hands,  you  would  very  justly  be  exposed  lo  Uie 
censure  of  those  around  you ;  or  if,  to  prevent  such  an  accidenl, 
you  shouhl  suddenly  jiress  it  toward  your  person,  thii  bliuidor 
would,  to  say  the  least,  w*ring  a  hearty  langh  from  the  witneasca  lo 
your  gaucheries,  in  seeing  your  clothes  besineared  with  the  albcQiii- 

•  U  tiiia  bcm  urippd  by  •onio  writer*  that  thoro  U  no  Dci?es9itT  for  my  fltr*tiirt^  aad 
Uih  apiiiiott  ii*  pfijdi(.nAt«<i  upc>o  the  fuel  fh»t  in  ibe  ciise  *tCy  *m  Is  no 

Ugaturo,  afui  nu  liLnnofrliag«.     H  was  iif.  lIuDter,  t  tlunk,  i  out  Um 

ennr  of  tLls  retiounin^  by  showing  Uimi  tho  parent,  in  dividing  liin  navel-niritig  la 
the  younir  nnuimt  rit.*cmuinlj  fiubjccts  the  VMivls  to  ii  degree  of  torsion,  w  iiith  jxm* 

t  See  L«turcs  XVIL  and  XVIR 

i  SJioold  then  b<»  twina,  It  woold  b«  flaTe  to  emplof  two  ligntum  boQuoMi  la  Hdl 
QMS,  there  migtU  be  «d  inoscuUUoa  of  blood-Tewfli  betworo  tb«  two  plBrtHl* 


THK  PBINOIPLBS  AND  PRACTICE  OF  OBSTETRICS 

sons  material  with  which  the  surface  of  the  new-bom  infant's  body 
is  more  or  less  covered.  Then,  to  prevent  any  blander  on  the  sub- 
ject, you  will  place  the  posterior  surface  of  the  child's  neck  in  the 
space  bounded  by  the  thumb  and  index  finger  of  one  hand,  gently 
seise  the  thighs  with  the  other,  and  in  this  way  you  remove  it  from 
the  mother,  and  give  it  to  the  nurse.  It  is  received  in  the  blanket, 
and  the  nurse  must  bo  directed  to  put  it,  for  the  present,  in  some 
secure  place,  either  in  the  bed  or  crib,  where  it  will  be  out  of 
harm's  way.  Sometimes,  through  carelessness,  it  is  placed  in  an 
arm-chair.  This  is  a  dangerous  practice,  for  it  is  very  apt  to  be 
crtulied  by  the  weight  of  some  good  dame  who,  in  coming  into  the 
Tooin,  seats  herself  in  the  comfortable  chair,  not  knowing  that  it  is 
already  occupied,  and  Aiat,  by  so  doing,  she  is  intruding  upon  the 
little  stranger's  rights  of  hospitality ;  at  the  same  time  giving  it  a 
pressing  welcome  which  may  be  anything  but  salutary  to  its  deli- 
cate physical  structuie. 

Ihe  Infant  does  not  breathe. — It  will  sometimes  happen  that  the 
infimt,  when  expelled  from  the  maternal  organs,  does  not  breathe  ; 
and,  under  these  circumstances,  it  will  require  prompt  and  efficient 
attention.  Its  want  of  respiratory  movement  may  be  due  to  various 
causes — ^for  example,  after  a  protracted  labor,  in  which  the  head 
may  have  been  exposed  to  long-continued  and  severe  pressure,  the 
brain  may  be  so  congested  as  to  occasion  an  apoplectic  conditioBp. 
In  snob  a  contingency  the  cord  should  be  instantly  cut,  but  ao  liga- 
ture applied,  for  the  reason  that  the  safety  of  the  child  wfll  depend 
upon  the  immediate  escape  of  a  small  quantity  of  blood  from  the 
untied  extremity  of  the  cord  ;  it  will  be  proper,  however,,  to  exer- 
cise a  discreet  vigilance  that  too  much  blood  may  net  be  lost.  The 
moment  you  perceive  the  evidences  of  the  congestion  to  have- 
passed,  which  will  be  made  manifest  by  the  change  in  the  color  of 
the  fiuse  of  tl\e  child,  and  a  return  of  vitality,  then  without  delay 
apply  the  ligature,  and  arrest  the  bleeding.  I  am  quite  confident 
that  many  an  infant,  coming  into  the  world  ui  this  apoplectic  state, 
has  been  sacrificed  from  the  neglect  of  this  simple  but  efficacious 
practice. 

The  child  will  occasionally  be  born  in  a  state  of  asphyxia — this 
term  I  think  a  bad  one,  for  it  does  not  convey  an  accurate  idea  of 
its  meaning.  It  is  derived  from  twe  Greek  words,  sphuo'is,  the 
pulse,  and  a  privative,  which  literally  signify  without  pulse.  You 
see,  therefore,  that  this  definition  of  the  word  gives  but  a  very 
inadequate  idea  of  its  true  im|)ort.  Asphyxia,  in  truth,  is  that  con- 
dition of  system  consequent  upon  impeded  respiration,  and  the 
respiratory  process  may  suffer  derangement  from  several  diffi?rent 
causes,  and  in  various  degrees.  Carbonic  acid  gas,  carburetted 
hydrogen  gas,  submersion  and  strangulation,  or  hanging,  are  all  so 
many  causes  of  asphyxia..    Again :.  we  may  have  asphyxia  in  a  case 

21 


870 


THE   PRI>'CIPLE3   AND   PRACTICE  OF  OBSTETHICS. 


m  winch  the  respiratory  process  has  never  been  etUblUbeti^  and 
tJiis  is  occasionaUy  exemplified  in  the  iiew*bom  infant.  We  shall 
no\i"  briefly  allude  to  its  inatiagemeiit  in  these  latter  circmnsianr*?*. 

1.  Examine  speedily  the  condition  of  tlie  mouiht  and  aitcertiuti 
whether  the  larynx  be  obstructed  either  by  a  collection  of  tnucttf^ 
en-  any  other  substance;  if  so,  remove  it  without  ft  momentV  delay* 
The  best  mode  of  doing  this  is  to  introdu<?e  into  the  month  of  the 
infant  the  small  linger,  and  by  a  gentle  scoop  you  will  be  rnmblMl 
to  clear  away  whatever  may  have  obstruct^  the  aocew  of  ai»i>- 
spheric  air  to  the  lungs. 

2*  If  there  be  no  mechanical  obstruction,  cold  water  ahonltl  bo 
dashed  on  the  f^ico  with  a  view  of  actinj^^  on  the  medulla  nbloagala, 
through  stimulation  of  the  terminal  branches  of  the  tif\h  pair  or 
trifacial  nerves,  thus  producing  a  motor  influence  fnuu  the  m«;'dt|[bi 
to  the  respiratory  muscles,  Should  cold  thus  applied  to  the  6ice 
not  suffice  to  accomplish  the  purpose,  thou  dip  the  entire  body  of 
the  child  alternately  into  cold  and  warm  water.    Tf  ttion  of 

w*armlh   and  cold  exercises  a  very  remarkable  n  on   the 

cntaneous  nerves,  by  imparting  to  them  a  decided  stimuloa.  It  is 
nece8!*ary,  however,  that  the  temperature  of  the  water  W  very  loir 
and  very  high — 35  and  100  degrees.  The  trunk  and  limbs  of  the 
infant  should  be  kept  in  the  warm  water  about  on*?  minute^  and  la 
the  cold  water  from  titleen  to  twenty  t^econds;  tVictiou  and  flagel- 
lattou  should  also  be  employed.  If  these  efforts  prove  aboni%*e, 
fhen  recourse  may  be  had  to  artilicial  respiration,  which  ocmsbCa 
mmply  in  blowing  air  from  your  own  lungs  into  the  month  of  tlio 
cIhM,  usbig,  at  thu  same  time^  the  precaution  of  ckmitig  the  nostriia 
ttC  the  child.  Al\er  each  inftation  the  chest  should  bo  genfly  rooH 
pressed  with  the  hand,  in  order  that  the  air  may  be  expelled  tfVooi 
the  lung*,  thus  simulating  the  action  of  the  expiratory  muscles,* 

The  extremities  are  to  be  kept  warm  by  means  of  jVietioi^  toge- 
ther with  hot  flannels  or  mustard  cat^iplasms,  rolled  in  fold*  of  old 
Unen  ;  and  while  these  points  are  b«iDg  attended  to,  it  will  be  uiefu) 


•  Dr.  Marsliidl  nail  a  ftw  \v«r«  mica  introduced  to  tins  nttentioo  of  lb<s  prefab 
«iMtiiin  rul«4  for  llie  !>.*«< liscit^tMJu  of  the  DSphj^xmtetl.  Tlic?iv  ruhvi  Htf;  now  hmom 
M  th(5  '^lieoiijf  MdhoU,"  nnil  tiAve  rt^iilUsd  in  v%*ry  ttitrki'tS  kucocm.  Hwktai  the  ' 
ulterimtkirt  of  tlic  hot  mid  c<:i1d  batli«  etc. — in  the  uso  of  Uio  butli,  tli«  ImiBBiita 
flUouM  b«3  nrnmendiry,  mid  the  altisniiitiLfti  ^ukk — In*  iosUti,  «■  oii#  iif  tti4»  yieg»»qttl» 
mtm  of  •Jiocvtfs  upcni  placing  the  chilr!  iti  the  pr^ime  porttioii,  and  ftltcmftirfy  tO 
lapldlj  chuij^fig  it  fn^m  ihia  po«ili<m  to  the  side,  and  vioo  vcrsn  TVTiiJc  m  ti« 
pitMio  pneiiion.  ahfi^bl  prcfl^urQ  is  to  he  made  along  tiir  back  and  Hba  Dr.  Hmk 
ilcdiK^»  the  fi^llowiDfT  trtilhs:  ExpermifriUi  iniitinienkhle  have  deiri«>n»trm(«d  Uus  If 
lh«  aubjeet  he  hiid  jir»n#,  and  prvaatini;  bo  brkklj  nmdo  on  tho  back,  ii.trM  m  ^rood 
•jplmlit}!) ;  aod  \Ut\{,  if  lite  proesurc  l>c  removed,  nnd  the  k>ady  tumc^i  ami 

It  litUt  m»r*,  lhcr<*  is  Rood  tnj^pirntioti ;  that  if  thia  prunath>n  «nd  prt.~-.». ..  »..>!  ihAi 
removal  of  tba  prvastjro  and  rotatioa  i»  ineiictnfi^l  t^ternatrly^  thoro  Is  good  frnpirm^ 


THE   PRINCIFLES  AND   PRACTICE   OF  OBSTETRICS, 


371 


to  tlirow  warm  water  into  the  rectum,  mixing  with  the  water  asaa* 
fcetida  or  brandy-  The  stimulating  efTeet  of  the  enema  ia  some- 
times followed  by  prompt  and  marked  benefit.  These  are  the 
directions,  which,  under  ordinary  circumstances,  you  are  to  pursue 
in  cases  of  asphyxia  occurring  in  the  new-born  infant. 

The  faculty  of  resisting  asphyxia,  that  is,  of  living  without 
breathing,  is  very  much  greater  in  the  new-born  infant  than  in  the 
adult;  so  that  if  a  child  should  not  breathe  for  an  iiotir,  or  even 
much  longer  after  birth,  it  should  not  be  abandoned  as  dead,  and, 
therefore,  considered  beyond  remedy.  Cases  are  recorded  in  which 
resuscitation  has  been  accomplished  by  some  of  the  means  alluded 
to,  even  after  the  asphyxia  had  continued  far  a  long  time.* 

Another  iniportant  fact  is  this;  a  iiev^iy4iorn  infant  afTected  with 
phyxla,  should  not  be  regarded  as  dead,  because  its  heart  has 
^einised  to  beat;  for  it  has  been  demonstrated  by  Bruchet,  of  Lyona^ 
Jo^t,  and  others,  that  life  may  be  restored  after  the  pulsations  of 
the  heart  bad  ceased  for  more  than  iive  minutcs.f  This  abihty  in 
the  new-born  child  to  resist  asphyxia,  explains  why  in  oases  of 
death  of  the  mother  it  may  be  extracted  alive  from  the  uterus, 
Uirough  the  Caesar ean  process,  even  after  the  parent  has  been  dead 
for  a  longer  period  than  half  an  hour.  Dr.  Brown-Sequard  has 
Khown  that,  in  tliese  instances  of  post-mortem  Caesarean  section,  if 
the  mother  die  when  the  body  is  quite  warm,  the  life  of  the  child 
is  in  more  danger  than  when  the  body  has  become  somewhat  cold 
previous  to  dissolution.  It  is  also  worthy  of  being  noted,  that  the 
asphyxiated  infant  should  not  be  kept  near  a  tire,  for  tlie  colder  the 
temperature  of  the  air,  the  longer  can  asphyxia  be  resisted. 


*  la  nn  mtereating  nrtlcl^  on  '*  the  EeauBciution  of  Cbtldren  boro^atOl,''  by  Win. 
C  Bog«T«»  M.D.,  of  Green  Island,  receutlj  deceased,  published  in  Ibe  American 
Miidieai  Uonikly^  for  February  1^60,  there  is  a  record,  collected  from  vanoua  sour- 
ce^  of  twenty-four  still-born  infiinta  resuscituted  by  artiticiid  respirutieri,  by  batha 
hot  «Jid  eoH  t>y  frictions,  and  by  Marslmll  Hall's  ready  raethad,  npplied  siDgly  or 
Jcjiolly,  fnjm  kn  to  ntnely  minHteji,  the  average  period  intervening  between  blrtb  and 
Iht*  wtAbliahmeut  of  respiration  being  thirty-Jiie  miimtfs,  thirty  atcond^.  In  tliui 
inicie,  also,  allusion  is  made  to  the  remarkable  case  reported  by  J,  Foster  Jenkena, 
ILI>.»  of  yonkers,  in  which  the  funis  waa  pukeless  lor  twenty-live  minutea  before 
delivery,  and  no  attempt  was  made  at  respiration  for  thirty  iniiiritea  after  birth  ; 
^  logf^Uiiiu  two  hours'  constant  attention  was  tieeei^sflrj'  to  preserve  the  child's  life. 

U  in  direct  eonrtict  with  tho  opiuloti  very  emphatically  expressed  some 
I  by  Sir  B.  Brodie,  who  wrote:  *'  If  the  action  of  the  heart,  by  which  the 
HfRitatiott  18  maintained,  shoidd  cease,  as  a  ooiifiequenoo  of  the  suppc  Jision  of  respirup 
lion,  ii  can  never  be  resuired.  This  I  positively  assert^  iifler  having  naade  it  the  Bub- 
J^t  of  ft  very  careful  investigation. "  [Lectures  oa  Pathology  and  Surgery.  1846, 
p.  81.] 


LECTURE   XXVI. 

Tbo  Third  Sta.ge  of  I^bor ;  Expulsion  of  the  PlacenU — Mi$EDandg«menl  of  Pis* 
oefiU — Dangers  of — FuDclion  of  PlaceoU,  limited  to  a  CertaiQ  Period — Kutitnl 
Detachment  of  Plueenla;  Hour  eflTected — What  are  the  Kvideoewi  that  th« 
Detachment  'm  going  onf  What  that  It  ia  Aoeompliabed  7 — The  Mode  of  ExtrKl' 
ing  the  Maafl  aAer  its  Separniion  from  the  Uterus— Rule  to  be  obaenred  alWr  iia 
Ketnova} — Hetaioed  C^iaguluin  and  Puerperal  CodtuIaIods  ;  Case  in  liluHlrBlioii— 
After  Kxlmction  of  Pluceuta,  it  slioald  be  carefiill/  Exjtniiried — Retained  Ffifp- 
roents  of  After-birth  and  Imtativo  Fever — Tractions  on  Dmbilieal  Cord  htton 
Scpnmtion  of  the  Placcntn— Dangeri  of— IIow  Detachment  of  Plaoeott  b  lo  ^ 
Aided  when  Utenjs  ia  U.4hargic — Circumgtancea  rendeKng  It  titfcommrj  to  «r- 
imci  After-Birth — Ita  exceaaive  Volume — Spaam  of  the  Oa  Uteri — ^Hintr-gi«« 
Contraction^— Morbid  Adheaion — Gonvulaiona — Ilemorrhago — Opium  acul  Hidla 
dnima;  Diflerence  in  their  Thempeuiic  En'e<*tij'- Hnvr  loug  afU-r  Dcdivcry  of  tht 
Child  should  the  Extraction  of  the  After-Btrili  be  Delaved  when  therfi  i^  nn  Cooi* 
plication?— Pennanent  Retention  of  the  Placenta,  and  DoeompoiitJon  of  iha  Maai 
— Does  the  Retaine<l  Pl»c*'iiifi  ever  iKJotwntj  Ab»orbts| ' — C-rjiavulsiotia  anpenrenlQf 
on  Retained  Placenta :  The  ludicalion  to  be  FuiUlled^i^otirulalotM  lu  tbk  Qam 
are  Traceable  to  Irritation  ol  the  UteruSf  and  are  of  Kcoentrio  Origttt. 


Gektlemkk — We  are  now  to  speak  of  the  lliird  sUige  of  hlior, 
which  consists  in  the  expulsion  of  tlio  placent.%  It  is  A  cairdiltal 
error  to  imagine  thai,  with  the  birth  of  iho  child,  the  ihtngcrs  of 
parturition  terminate.  So  far  from  tliii*  heing  so,  yon  will  dij^cover, 
when  engaged  in  pnictioc,  tliat  nome  of  the  moat  serious  complici^ 
iions  of  the  lyiog-in  room  are  more  or  less  eonnected  with  mis* 
mAnagoment  of  the  aAer-hirth— hemorrhage,  inversion  of  lh« 
womb,  prolapsiou  of  this  organ,  hiceration  of  the  pIa(^ent4^  or  nui- 
UUcsal  oordf  si^  all  »^o  many  accidonlSi  most  of  them  fearful  Iti  tlietr 
consequences^  resulting  from  this  catise.  I  think  one  o1*  tho  p*eai 
evil»  of  the  partitrient  chamber  is  a  dispo!iition  on  the  part  of  xhm 
accoucheur  to  be  officious  witli  regard  to  the  delivery  uf  Ihe  pla- 
centa ;  as  soon  as  the  child  is  born,  he  becomes  impatient,  and  pro- 
ceeds at  once  to  manipulations,  which  are  not  only  premature  and 
unneceMsary,  but,  «n*ler  the  circumstances,  altogether  without  ja» 
UgcatioD.  I  have  repeatedly  witnei^aed  the  sad  effects  of  tiik 
me<ldUng  with  nature ;  and,  tlierefbrc,  I  am  the  more  soliettoot 
plainly  and  di»tiuclly  to  [>oint  out  your  true  duties  upon  tliis  sul^ 
ject, 

J^'ufiction    of  Placenta — When    TermmaUiL — ^The     plaee«ifj^ 
joa  must  remember,  has  a  function  to  perform  only  for  a  oertain 


THE   PRINCIPLES  AND   PRACTICB  OF  OBSTETRICS. 


373 


period — ^tbis  function  consists  in  rcBpiration,  absorption  of  nutri- 
tious principles^  and  exoemosis  of  excretA  during  intra-utcrine  life; 
wheti  this  has  been  completed,  and  the  fcBtus  thrown  into  the 
world,  the  office  of  the  ulaccnta  bai  been  fulfilled,  and  it  becomes  a 
deciduous  mass,  which  is  no  longer  a  portion  of  the  living  mecha- 
Qismt  andt  therefore,  it  is  ejected.  The  mode  of  its  ejection  by 
nature  is  what  particularly  interests  uh  ;  and  when  once  thoroughly 
com preh ended,  it  will  induct  you  into  a  conservative  practice, 
which  cannot  but  result  favorably  to  your  patient,  and  spare  you 
much  unnecessary  embarrassment. 

Situation  of  the  Placenta, — The  placenta,  you  are  aware,  is  in 
adhesion  with  the  internal  surface  of  the  uterus,  usually,  as  was 
generally  maintained,  near  the  fundus.  According  to  the  investi- 
gations of  M-  Nai^geld,  Jr.,  it  is  found  most  commonly  on  the  left 
side ;  next,  on  the  right  side  of  the  organ.  In  two  hundred  and 
tbirty-eight  cases  out  of  six  hundred,  the  atethoacope  indicated  the 
placenta  to  be  attached  to  the  left  side ;  while  in  one  hundred  and 
forty-one  cases  it  was  at  the  rii^ht  side.  In  twenty,  no  sound  could 
bo  detected  ;  in  one  hundred  and  sixty  it  was  feeble,  and  so  diffused 
YtA  to  be  uncertain  ;  in  seven  instances,  the  placenta  was  attached 
tu  the  fundus ;  in  thirteen,  to  the  anterior  wall ;  and  in  eleven  cases, 
there  was  placenta  itrfcvia.  The  following  are  the  results  of  the 
researches  by  Dr.  Yon  Kit  gen  :  be  ascertains  the  seat  of  the  pla- 
oentii  by  measuring  the  distance  of  the  rent  in  the  mombraneSi 
made  by  the  passage  of  the  fa^tus,  iVom  the  margin  of  the  pla- 
cenLi ;  in  this  way  he  fuund  that  the  edge  of  this  body  n^ted  on 
til©  o«  uteri  in  twenty-two  cases;  at  one  inch  in  eight  cases;  be- 
tween one  imd  two  inches  in  twelve  cai^es ;  two  inches  in  seven 
CMcs ;  between  two  and  three  inches  in  sixteen  cases ;  three  inches 
in  five  cases;  between  three  and  four  inches  in  four  cases;  four 
indies  in  six  cases ;  between  ibur  and  five  inches  in  eight  eases; 
five  inches  in  three  cases;  six  inches  in  six  crises;  eight  inches  in 
tbree  cases.  It  would,  thereto  re,  appear  that  the  placenta  is  usually 
attached  much  lower  than  is  generally  believed** 
^  Natural  I/efac/tmenf  of  Placenta. — ^The  expulsion  of  the  ai\er- 
%irth  i^,  in  a  normal  condition  of  things,  preceded  by  its  detach- 
ment from  the  uterus,  and  tlie  manner  in  which  this  detachment  is 
accomiilishcd  is  through  the  contractions  of  tlie  uterus  itself.  Five, 
ten,  or  twenty  minutes — the  time  varying  from  different  inlbieucea 
— after  lht»  exit  of  the  child,  the  patient  will  complain  of  pain,  and 
the  pain  will  be  followed  by  a  flight  discharge  of  blood.  These 
two  cii'cumstances — the  pain  and  discliarge  of  blood — are  the  evi- 
dcnceji  that  nature  is  engaged  in  the  separation  of  tlie  placenta. 
The  pain  is  recurrent,  like  labor  pain — in  fact,  it  is  a  veritable  labof 


^  firiL  find  Fon  Med  Chir.  Rev,  i^p.  ia&§. 


374 


THE  PBINC1PLE3  AKD   PRACTICE   OP  OBSTETRICS. 


throe ;  it  is  n  natural  process,  and  raiisit  not,  thcreforp^  be  iDterfer^ 
with*  But  what  is  the  evidence  tlmt  the  detuchment  of  tho 
placenta  has  brcn  completed  ?  A  VQVy  important  qiiefltion,  tbt 
solution  of  which  you  inuftt  thoronghly  und^ntand,  for  it  hM  modi 
to  do  with  tlie  rogulition  of  yotir  roiidiitt  on  thiJ*  occaMOHp  Unilcr 
ordinary  circum«*tance«i»  when  the  afler-biith  in  eompletdy  delai^hed 
from  the  uterine  surtace,  it  will  be  found  resting  over  tho  month 
of  th©  womb,  either  centre  for  centre,  or  a  portion  of  its  eirontn- 
ference  will  be  felt,  sometimes  prolrudinijf  into  the  vaginm** 

The  direct  result  of  the  contractions  of  the  uterus,  after  lb© 
expulsion  of  the  foetus,  is  necessarily  a  diminution  of  \u  gvnenl 
volume — the  organ  becomes  shorter  and  narrower,  and  the  modus 
in  qua  of  the  separation  of  the  placenta,  under  the  influence  of 
the  contniciion,  i.s  easily  explained.  Each  successive  contrnrlion 
tends  to  dirniiiinh  ihe  respective  diameters  of  that  portion  of  ibo 
uterus  with  which  the  after-binh  is  in  adiiesion — but  the  diminisiioQ 
cannot  take  place  without  a  consequent  detachment  of  thia  bodjr^ 
and  this  is  the  true  exposition  of  the  manner  in  which  the  plmcenui 
becomes  Rcparated,  Again  :  there  is  another  intcrejitin^  f;irt  con- 
nected with  this  process — the  detachment  «f  the  alU'r^biilh  Ig 
usually  followed  by  a  clo?*ing  up  of  the  mouths  of  tho  ittera-pU* 
cental  veasel^ — and,  therefore,  nnder  these  cireumatiinoQBt  there  b 
no  apprehension  of  heuiorrhaf,a\ 

Removal  of  Placenta  tt^ftf^r  ita  JJrtnt^hm^nt, — There  are  two 
extremes,  which  you  are  sedulously  to  avoid  in  the  nianagerficnl 
of  the  placenta — the  one  is  prenuitare  and  officious  interferc^ee 
with  the  operations  of  nature,  the  other  a  hesitation  to  act  when 
nature  has  achieved  her  part  of  the  process,  and  call,-*  upon  yoa  to 
interpose.  This  latter  remark  has  special  reference  to  the  duly  of 
the  accoucheur^  after  the  t^lacenta  has  becf>me  detached  from  ihti 
uterus,  and  (his  organ  u  found  contracted  with  the  nfttr^Hh 
rtsting  ovtT  the  ctrvix^  or  p'otrnding  into  the  vaffina.  It  afleo 
happens  tliat  the  young  practitioner  remains  at  the  l^cdiftide  of  the 
patient  hour  alter  hour,  expecting  every  moment  the  expuMofi  oT 
the  afler-birth — this  does  not  lake  place,  the  patient  beoooieA 
alarmed  at  the  3elav,  and  the  only  consolation  sire  receives  is  the 
aasnrajice  that  it  will  soon  all  bo  riglit.  Another  hour  elap«cft«  simI 
no  expulsion.  A  consultation  is  now  proposed  by  the  frleiidiH^ 
this  18  of  course  acceded  to,  and  when  tho  consulting  phyajctan 

*  r  Imve  olr^fiiij  stuted  thnt  the  lictadimcnt  of  tho  »a«r*blnh  b  froquentlj  09m* 
p\Hv€i  ig  eoon  119  the  child  \n  uxpt^U^Kl  through  the  niatemsl  orgina^  mid  ttii*  ii  flM 
GMe  wtion  lhi»  titoni«,  in  n*ppc>i»»e  U>  Xha  ^x\x  of  ihe  fdjttas,  la  (Iiand  hart!  sod  Ctm* 
tnictc4  \xk  tho  hy{M)jt)i«the  n?^otj ;  whon  lhii«  detAclied  ffum  liii*  btcrtuil  siiHbo*  of 
tb«oipuu  and  wlicthc^r  re»thig  over  th^  c(»rvix,  or  pBr«ially  in  tho  VAgitm,  Vimm 
will  bo  inon?  or  Jf«a  nxnirn.'«fit  eooimction,  timulaiinf^  Ihc  tJ*ro«i  of  IjiHor^  t^  oen* 
tractiun  btfinf  Iriduoi'd  parti?  by  the*  pr«fse£ic«  of  the  m^pAmtinl  Afti^r-lnrih.  it  b«^g 
DOW  «  fore^^  tabsttiuce  tu  the  uteraii,  sod  ocouionlog  irnutiou  of  iu  p*rlft«iL 


THE  PRraCIPLES  AND   PUACTICE   OF   OBSTETBICS. 


875 


'■  m 


wnves,  he  proce^iU  like  *a  man  who  understands  his  business ;  he  finds 

that  the  uterus  is  contracted,  introduces  his  finger  into  the  vjiirina, 

feels  tbe  detached  mass  resting  over  the  os  uteri,  or  protruding  into 

the  v:iiftn:i,  and  extracts  it  without  delay  iu  the  following  m:tnnt*r: 

The  eud  of  the  cord  beiiJfir  enveloped  with  linen,  he  makes  two 

L«r  three  twLsts  of  it  around  two  of  the  fingers  of  one  band,  while 
lie    introduces    the 
adex   fiiii^er  of  the 

father  hathl  (Fig,  58), 

I  carrying  it  up  to  the 
mouth  of  the  uterus, 
if  the  placenta  have 
not  descended  into 
the  vagin;i ;  this  Hn* 
ger  then  seizes  the 
cord    close    to    the  C*^'*'  ^) 

after-birth,  and  makes  traction  downward  and  bnckwanl  toward 
tbe  sacrum  in  the  direction  of  thi.*  sujierior  Ktiait ;  wlien  the  pla* 
centa  has  escaped  from  the  womb,  the  extraction  is  to  be  made  la 
the  line  of  the  axis  of  the 
interior  strait,  always  re- 
memberirjg  to  withdraw  it 
by  rotating  it  upon  itself 
(Figt  59),  in  order  that  the 
membranes  may  l>e  twisted 
into  a  cord,  which  will  ena- 
ble them  to  resist  the  pres- 
sure  of  the  os  uteri  as  they 
pass  through,  and  thus  there 
will  be  no  fear  of  any  frng- 
mental  of  ihem  remainin:^  in  ^^*®*  ^  ^ 

the  uterine  cavity,  wliioh  wouhl  often  result  in  more  or  le^s  annoy- 
ance to  the  patieui'^such  as  increased  and  distressing  atler-pains, 
and  sometimes  hemorrhage.     When  the  placenta  is  found  ]»artially 

Iprotrudin^^  through  the  os  uteri,  it  will,  perhaps,  be  better  to 
seize  it  with  the  fingers,  and  thus  bring  it  away;  this  mode  of 
extraction  will  incur  no  risk  of  rupturing  the  cord,  which  possibly 

I  might  occur  in  making  traction  upon  it  when  the  point  of  its  iiiser- 

pilon  intcj  the  placenta  caimot  be  detected  by  the  tinger, 

Hehioval  of  Coaguki. — As  soon  as  tfie  delivery  of  the  afVer- 
hirth  has  been  accomplished,  the  finger  should  be  carefully  intro- 
duei<d    itita  the  vagina  for  the  purpose  of  bringing   away  any 

icoaguhi  that  may  be  there,  and  it  should  especially  be  ascertjirne<l 

^fc/usf/ur  there  u  a  clot  keeping  the  mouth  of  the  tcmnh  vpen  ;  if  so, 
it  must  be  immediately  removed.  I  have  known  very  great  dis- 
tress ensue  to  the  patient  from  the  neglect  of  Uiis  simple  preeau- 


376 


THE  PRINCIPLES  AND   PRAOnCB  Of  OB0rETBIG9. 


tlon,  in  consequence  of  the  s^Terity  of  the  conti'action9  indiicetl  hj 
the  irritalion  of  ihe  clot.  In  one  cii»e  which  I  have  now  in  my 
mind,  I  am  very  confident  that  the  presenoe  of  a  large  coagnJaiii, 
acting  tis  an  irritant  uf^on  the  08  uteri,  wiis  thn  eole  catiaie  of  con* 
rnlHons,  whicli  were  iioar  proving  the  dewlruction  of  the  patient. 
It  occtjrrod  in  I  ho  person  of  a  yonn*;^  primipani,  of  an  extrf^mely 
seTisitive  nervous  orn^anization ;  fihehad  been  in  labor  sixteen  liotsra, 
when  she  was  happily  delivered  of  a  healthy  living  son ;  soon  after 
the  expulsion  of  the  at^er-birth,  she  wm  attacked  tiolenily  with 
puerperal  convulsions^  altlion^h  there  lind  been  no  approai*h  to  m 
convulsive  spasm  during  the  progres^s  of  lier  labor.  Her  ph\*i«if3fttt, 
a  most  worthy  and  con»cientiousj  gentleman,  becoming  very  natu- 
rally much  alarmed  at  the  supervention  of  convulsions,  re<juait«d 
me  to  sec  the  case  in  consultation  with  him.  Before  I  arrived^  Ab 
had  uxperieneed  three  severe  attacks,  and  soon  after  I  reachctl  tbe 
house,  I  noticed  that  she  complained  of  distressing  bearing  down 
pain,  groaning  piteously,  and  placinuj  her  hand  upon  the  region  of 
the  utenw,  indicating  that  the  scat  of  her  suffering  was  there* 
While  the  uterus  was  thus  contracting,  she  w^'^s  again  taken  with  m 
rcmvulsive  nu^vement.  It  occurred  to  me  that  there  must  be  Bome* 
thing  abnortnal  about  the  organ ;  with  the  eoncurrence  of  my 
medical  friend^  as  soon  as  the  convulsion  ceased,  I  introduced  my 
finger,  and  discovered  a  large  coagulum  of  blood  ilislcnding  nod 
fretting  theos  uteri  ;  it  was  imnjediately  removed  by  gently  insinn* 
ating  the  finger  between  it  and  the  internal  surface  of  tho  dilated 
OS.  The  removal  of  this  clot  proved  a^mo^t  elfieient  remedy— for 
with  its  withdruwal  there  was  an  entire  cea«»ation  of  the  >  mi. 

Well,  you  may  desire  to  know   what  j>o^ible  conn  vm 

could  have  been  between  the  convulsions  and  the  preaenee  of  tho 
coagulmn*  The  connexion,  I  maintain,  was  that  of  efl\*ct  moA 
caui^e.  The  os  uteri  became  the  seat  of  a  positive  irritation  frami 
the  pressure  of  the  clot ;  this  caileJ  forth  an  nniluc  reflrx  aetion 
from  the  spinal  cord,  which  resulttKi  in  the  convulnive  niovemeiil. 
This  is  an  instructive  case^  and  I  hope  you  will  bear  it  in  miiicL 
But,  you  may  ask,  in  objection  to  the  explanation,  why  did  thu 
convulsions  not  occur  when  the  head  of  the  child  was  makiii^ 
pressure  on  tlic  mouth  of  the  uterus  of  this  delicate  and  tten^Uve 
lady?  I  reply^ — the  fact  that  they  did  not  occur,  is  the  meet 
decided  evidence  that  the  irritation  w:is  not  sufBcient  to  produce 
them. 

JCj'amitmtion  of  Placenta  qfUr  i(M  M^novoL — ^Yoo  should 
never  omit,  af^er  the  delivery  ot  the  placenta,  to  examine  it  eftre» 
fully,  in  order  that  you  may  be  assured  that  no  portioii  Has  bern 
left  within  the  uterine  cavity;  it  will  sometimes  be  laeefiat^Hl  attd 
divided,  s«i  that  fragments  of  it  fiill  remain  in  the  uterus.  Under 
•uch  circumstances,  it  will  be  your  duty  at  onin?  gently  to  i&iro- 


the:   PRIKCIPLES  AND   PRACTICE   OF   OBSTETRICS. 


377 


duco  tbt»  hand,  and  bnng  these  tragmetits  away ;  a  negluct  of  thig 
rule  will  otU'ruimes  result  in  more  or  less  trouble^BUch  as  abnormal 
coot  motions  of  the  woinb,  Hooding,  putrid  discharge  from  decom- 
position of  the  fragments,  and  irritative  fever. 

Damier  of  Ttaciions  on  the  CorcL — It  is  a  very  common  practice 
among  .nccaucheurs,  aeon  after  the  child  is  born,  to  seize  the  iirabi- 
Heal  cord,  and  make  tractions  more  or  less  forcible  upon  it^ hoping 
in  this  way  to  expedite  the  expulsion  of  the  after-birth.  This  is 
bad  pnitaice,  ami  should  never  be  had  recoime  to^  nnt  lithe  placenta 
U  dfUichedfrom  the  uterine  »ur/ace^  for  fear  of  the  following  acci* 
detils,  which  are  some  of  the  ordinary  insults  of  premature  trac- 
tions on  the  funis:  1*  Breaking  of  the  cord;  2.  Flooding  from 
sudden  ftt?[»uration  of  the  ])lacenta;  -T.  Inversion  of  the  womb, 
pulling  the  womb  inmde  out,  which  wouM  be  likely  enough  to  ensue, 
in  case  the  ailhesion  between  the  organ  nnd  plycental  mass  was 
suHiciontly  strotig  to  resist  the  tractions ;  4.  Prolapsus,  and  even 
procidentia  of  the  uleruB. 

The  rule8,  jtist  indicated,  apply  to  the  management  of  the  after- 
birth in  cases  of  natural  labor,  when  nature  detaclies  the  mass  from 
the  uterus,  and  the  duty  of  the  practitioner  is  limited  to  its  mere 
extraction. 

JSt/tft  (he  Ktpiilskm  of  the  A/ter-brrfh  may  he  Aided, — There  is 
one  fu'iitciplc,  connected  with  tlie  question  now  ur»der  consider  at  ion , 
which  ycm  should  keep  constantly  before  you — the  detachment  and 

a  eery  of  the  pl/wenta^  likt  (he  delivery  of  the  child ^  is  a  nntural 
c^^^,  and  should  not  he  hurried^  hut  submitted  to  nature^  unless 
certaifi  circum^tanfrs  call  for  tlie  intervention  of  science.  It  must, 
however,  be  admitted  that  in  some  cases  in  which  the  contractions 
of  the  uterus  are,  as  it  were,  lethargic,  and  not  sufficient  to  cause 
the  detachment,  the  accoucheur,  in  order  to  prevent  utmecessary 
delay,  can  be  of  signal  service;  thus,  he  may  place  his  liand  on  the 
abduminal  walls,  and  not  rudely,  but  gently,  grasping  the  uterna, 
resort  to  frictions,  which  will  have  the  effect  of  stimnluting  the 
organ  to  contra(*tlon.  As  an  import jint,  and  ot\cntimes  a  very 
efficient  auxiliary  to  the  frictions,  a  napkin  satnrated  with  Ice-water 
may  be  placed  over  the  region  of  the  uterus,  or  a  lump  of  ice 
applied  directly  to  the  sacrum.  This  latter  alternative  will  ocoa- 
lally  be  followed  by  very  prompt  and  happy  results.     In  these 

wn,  t«»o,  ergot  may  be  adminisstered  with  advantage. 

1  have,  however,  found  nothing  more  efficient  iu  these  instances, 
and  1  emphatically  commend  It  to  you,  us  deserving  both  of  recol- 
lection nnd  trial,  than  the  introduction  of  the  imlex  finger  within  the 
OS  uteris  for  (he  purpose  of  titillatin(f  it ;  ihu  movemi*nt  of  the 
finger  against  the  cervix  evokes  the  tnbtitary  and  important  action 
of  the  spinal  cord,  and  very  readily  accomplishes  the  object  you 
have  in  view,  viz*,  the  contractions  of  the  uterus. 


878 


THE  PmKCIPLIS  AND  PBACTICK  OF  0BSTKTB1C8, 


^r^  V  'ion  of  Pla<*enta, — Let  ««  now  consider  tooM 

of  llif  ^^  which  roay  render  it  incumbent  for  the  aoooil* 

cheur  to  interpose  iind  bring  away  tho  aller-birtb ;  or,  in  otliar 
worda,  tbo  circumstancpB  which,  making  ttborliv©  tho  ability  of 
nature,  and,  at  I  he  same  unie,  compromising  the  safety  of  tbe 
patient,  call  Ibr  prompt  assistance.  The  following  may  be  (rnam«- 
rated  among  the  more  proinineut  eoudiiions  requiring  artiticaal 
aesistance:  1.  Excessive  volume  of  the  placenta;  2.  Spasm  of  ibis 
OS  uten  ;  3.  Spa?m  or  irregular  contraction  of  the  upper  portion  of 
the  cervix,  or  body  of  the  uterus,  occAi*ioning  what  is  known  :uilhe 
hour-glass  contraction ;  4.  Murbid  jidheaion  of  the  after-birtli  to 
the  uterus;  5.  Convulsions;  0.  Hemorrhage. 

L  Excessive  Volume  of  (he  Placdfita. — You  will  sometimes  re* 
mark  that,  subsequently  to  the  birth  of  the  child,  nutw  i  litig 

the  vigorous  contractions  of  the  nteru^,  the  placenta d«H  uc 

away.  In  tliese  caies^  it  may  be  tliat  the  cause  qI*  the  delay  ia 
owing  to  the  excessive  ^izc?  of  the  after- birth,  or  the  in j readied 
volume  may  be  occasioned  by  tViw  body  being  dotibled  a\mu  itaidf^ 
or  by  an  accumulation  of  coagtda,  or  sometimes  of  the  liqiuramnii, 
pressing  down  ugalnst  the  after-birth,  and  cinsing  a  sort  of  »ac  iir 
pouch  to  present  over  the  os  uteri.  How  are  you  to  know  thattli0 
placenta  is  enlarged  either  positively  or  relatively?  The  di:ii:u»i«iis 
IB  not  difficult.  In  tho  first  place,  the  gunerid  volume  of  tho  ntt»ruji 
will  be  greater  than  under  ordinary  circumstances  ;  and,  ^ecrondly, 
on  introducing  the  finger  as  far  as  the  mouth  of  the  womb,  the  aticr- 
birth  will  be  felt  there  in  one  of  tw^i  conditions;  eitlier  with  a 
positive  increase  in  siste,  or  only  relatively  enlarged.  In  tbr*c  in* 
stances  of  increased  volyme  there  will,  ufteutlines,  bo  a  prolrarliKl 
and  uirnecessary  delay  iu  its  delivery,  and  tho  strength  of  tbo 
patient  becomes  exhansted  in  fruitless  efforts  to  expel  it.  The 
oourse  to  be  pursued,  is  at  once  to  introduce  the  hand*  grasp  Ui« 
after-birth,  and  carefully  bring  it  away. 

litit  never  fitrget  one  principle — in  all  cases  in  whiob  it  may  b©» 
oome  necessary  to  introduce  the  hand  into  the  womb  for  the  purpofe 
of  extracting  the  placenta — the  principle  is  thi^ :  Da  not  trinff 
awat/  Uu  maHs  until  you  Jind  die  ufrnts  httjinuuKj  to  conirud^ 
othenrise  yon  ^nll  expose  your  patlefU  to  heiuorrhagt^  If,  on 
reaching  the  os  uteri,  you  should  recognise  the  pouch  of  whicb  I 
have  just  s|>oken,  it  should  be  immediately  ruptured  for  the  escape 
of  the  coagula  or  liquor  amnii,  and  thus  the  diflicuUy  wUl  be 
removed* 

H.  S/MtA/n  of  the  Oit  UterL — Usually,  when  the  chihl  ha?«  pusacd 
into  the  world,  the  mouth  of  the  womb  will  be  quite  ^oH  and  relaxed, 
offering  little  or  t»o  reH^lance  to  any  attempt,  which  m:iy  be  niaJe 
to  introducM  the  linger  withiri  the  cavity  of  the  organ.  But  you 
wilt  somrtiiues  ob&iTVc  a  dejmrturc  from  this  slate  of  ibiags;  in 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         S7S 

lieu  of  relaxation,  there  will  be  such  a  contracted  condition  of  the 
08  as  to  render  it  extremely  difficult  to  penetrate  it ;  the  contraction 
is  irregular  and  spasmodic,  occasioning  more  or  less  suffering  to 
the  patient,  and  preventing,  of  course,  the  expulsion  of  the  placenta. 
These  are  the  cases  which  so  frequently  lead  to  embarrassment  on 
the  part  of  the  accoucheur;  the  womb  contracts,  the  female  suffers 
intensely,  but  there  is  no  progress  in  the  delivery  of  the  after-birth. 
Patience,  on  all  sides,  is  about  exhausted ;  the  doctor  is  puzzled, 
and  he  is,  indeed,  in  nuhihus.  The  question  very  naturally  ai*ises, 
is  there  any  necessity  for  the  embarrassment  ?  I  tell  you,  gen- 
tlemen, there  is  none  at  all.  It'  you  will  ascertain  that  there  is 
some  cause  at  work  to  interrupt  the  scheme  of  nature,  and 
what  that  cause  is,  you  will  have  no  great  difficulty,  under  ordi- 
nary circumstances,  in  applying  the  appropriate  remedy.  Sup- 
pose, then,  in  attempting  to  introduce  the  finger  into  the  os  uteri, 
you  discover  a  positive  resistance,  and  that  this  resistance  is  much 
more  marked  during  a  contraction  ;  also,  that  instead  of  a  uniform 
diminishing  of  the  uterus  while  under  the  influence  of  muscular 
effort,  you  find  the  effect  limited  almost  entirely  to  the  neck  of  the 
organ.  With  this  state  of  things  ascertained,  nothing  is  easier  than 
an  accurate  diagnosis.  The  Whole  difficulty  is  due  to  apcismodlc  cor^ 
traction,  or,  if  you  prefer  it,-  to  spasm  of  the  os  uteri ;  and  this  is 
the  true  source  of  the  delay  in  the  expulsion  of  the  placenta.  In- 
deed, until  the  difficulty  is  removed,  it  will  be  physically  impossible 
for  this  body  to  have  egress.  You  see,  therefore,  how  important 
it  is  for  you  constantly  to  keep  progress  with  circumstances,  as 
they  may  develop  themselves  in  the  lying-in  chamber.  While 
I  am  most  anxious  to  impress  upon  you  a  profound  respect 
for  the  consummate  ability,  which  usually  characterizes  nature 
in  the  discharge  of  her  varied  functions  during  the  parturient 
struggle,  yet  you  must  not  bo  delinquent  in  early  detecting  any 
obstacle,  which,  while  it  may  bid  defiance  to  all  natural  effort,  will 
the  more  urgently  indicate  the  necessity  of  prompt  action  on  your 
part. 

Well,  how  do  you  manage  a  case  of  spasm  of  the  os  uteri  ? 
Some  practitioners  are  in  the  habit  of  recommending,  in  a  sort  of 
stereotyped  way,  opium,  as  the  great  remedy  in  these  cases.  Opium, 
gentlemen,  is  one  of  the  most  precious  weapons  with  which  we 
may  hope  to  repel  disease ;  but  if  it  be  precious  and  efficient,  when 
judiciously  administered,  it  is  equally  injurious  and  fatal  if  given 
when  its  use  is  contra-indicated.  One  of  the  therapeutic  charac- 
teristics of  this  drug  is,  that  it  tends  to  cerebral  congestion  ; 
another,  that  it  stimulates,  through  centric  influence,  the  spinal 
cord  ;  another,  that  it  constipates.  Would  it  not,  therefore,  be 
madness  to  resort  to  opium  as  a  primary  remedy  in  cases  of  plethora ; 
and  would  it  not  be  equally  improper  when  the  trouble  with  the 


380 


THE   niTNClPLES  AND  PRACTICE  OF  OBSTSTRICa. 


patiout  is  linbit  uul  L'oniitipation  ?  So  much  for  the  routine  einplaj* 
ment  of  this  remedy. 

But  we  Imve  In  bt5lIa(lonna  an  cifitiient  thempeuiic  Agent  for  tbn 
difficulty  in  queiHiou;  and  it  i«  iiitereaiing  to  know  the  modug  in 
quo  of  its  net  ion.  Yon  mjjjht,  perhaps  suppose  tl»at  this  remedjr 
would  he  contra-indicated,  for  the  reason  that  one  of  its  esaentlml 
iittributcs  consists  in  its  power  of  inducing  muscular  contractioQ. 
Its  efficiency,  however,  in  npajsm  of  the  os  uteri  iii  due,  in  the  first 
place,  to  the  ikvi  that  it  diniinishoft  the  fk»ngiihility  of  the  parta  with 
which  it  cornea  in  contact;  and,  secondly,  it  le^tsens  the  reflex 
power  of  the  spiual  cord<  The  spasm  of  the  os  uteri,  remember, 
ig  a  ruflux  Bpasm.  Have  prepared  an  ointment  of  belladonnxi,  3  i. 
of  the  extract  to  5  »•  <>f  l*^***! — let  tlie  os  uteri  l>c  freely  smeared 
with  it,  and,  at  the  same  tijne,  attempt  gently  to  introduce  the 
finger  within  the  month  of  the  organ — ^if  you  sutx^eeti  in  thin  iafUir 
effort,  which,  with  proper  perseverance,  can  generally  bo  acoooi* 
pli^jhed,  my  advice  is4  to  allow  the  finger  to  remain  there  for  fiom9 
time,  with  a  view,  as  it  were,  of  fatiguing  the  nmHeulnr  fibres  of  the 
partf  and  thus  breaking  up  the  spn?<modrc  or  irregular  cnnlracUou. 
I  have  much  confidence  in  this  Intter  procedure.  Indeed,  I  have 
in  some  instances  succeeded,  without  recourse  to  any  other  means^ 
in  overcoming  the  ^pas^m  by  careful  insinuation  of  one  fingor  aftar 
another  into  the  os  uteri. 

An  important  remedy,  al»o,  in  the!*e  cases,  will  be  tolerant  dosci 
of  ipecacuanha ;  say  ^  to  ^  a  grwin  every  fifteen  minutes,  oji  elr- 
cumstnnces  may  indicate — it  has,  at  times,  a  powerful  effect  in  pro- 
ducing relaxation,  and  I  regard  it  as  one  of  the  most  certain  of  this 
antif^pni«rnodtc  ageutn.  If  the  patient  should  be  vascular,  with  a 
rigid  musiMilar  fibre,  and  a  l>ounding  pulse,  the  lancet  will  prove 
a  resoit  of  great  efticacy.  Take  from  tlie  arm  3  vi.,  §  viij*,  or  3  ju 
of  blo«>d,  as  the  peculiar  state  of  the  c.'ise  may  justify*  When  the 
gpn^m  is  removed,  then,  if  there  should  be  any  delay  in  the  delivery 
of  the  placenta,  the  projier  plan  to  be  pursued  is  to  introduce  ibo 
hand,  grasp  the  af^er-birth,  and  extract  it«  It  is  quite  rare  in  these 
instances  of  irregular  contraction  of  the  uterus  to  have,  as  a  coni- 
plication,  hemorrhage;  but,  in  »ni*h  an  event,  especially  when  iho 
hemorrhage  eiidangera  the  safety  of  the  patient,  the  premising  object 
is  to  arrcttt  it;  the  remeflies  for  this  purpose  we  shall  speak  of  ia 
the  succeeding  lecture* 

III.  iSpoitm^  or  Ifrf.ffu*€tr  Contraction  of  t/t€  Upprr  Piirttnn  of 
iAe  CfTf'ix  or  Boxhjofthe  Uterii» — Hour-glass  Contntction. — This 
is  a  peeuliar  condition  of  the  orgim,  to  which  it  is  neceKiary  to  make 
some  brief  allusion.  It  consists  essentially  in  such  an  abnormal  coii* 
traction  aji  to  occasion,  in  some  portion  of  the  long  axis  of  the  uteroa, 
a  narrowing — usually  occurring  at  the  upper  extremity  of  the  cervix, 
ar   in    the  body.      This  narrowing  neee^^sarily  divided  the  organ 


THE  PBIKCIPLES  AND   PRACTICK  OF  OBSTETRICS, 


381 


rx^l 


iDto  two  com  part  meDts  or  chambers,  aod  hence  it  has  been,  with 
some   propriety^   denominated    the    hour-ffkuB 
contraction  (Fig.  60). 

It  ia  not   an  common,  when   talking  with  a 
young  physician,  who  has  not  beon  particularly    ^i 

r  fatigued  by  an  extensive  practice,  to  hear  him 
exclaim,  in  speaking  of  a  case  of  midwifery, 
which  he  may  have  attended:  "Well,  sir,  I 
had  a  hard  time  of  it  the  other  day  ;  I  had  a 
case  of  hour-glass  contraction,  aod  it  bothered 

I  me  extremely,  but  I  succeeded  at  last  in  getting    1  v^^H\'^HV/J 
tlirough  with  it/'     This  language  is  not,  perhaps, 
eo  much  the  languatje  of  boast,  as  it  h  of  erro- 

I  neo  ns  j  udg  m  en  t .  H e  n  o  d  o  ub i  s  u  p po sed  th  at  b  e 
hadVentably  a  case  such  as  he  described,  and  if 
you  take  thejse  not  unfreqiient  recitals  of  the  in-  Fio^io. 

experienced  accoucheur  as  a  basis  of  opinion^  you 
will  very  naturally  be  misled  as  io  the  rehitive  frequency  of  this 
abnormal  condition  of  the  uterus.  The  more  you  see  of  practice,  gen- 
tlemen, and  the  more  familiar  you  become  with  the  revelations  of  the 
lying-in  chamber,  the  more  you  will  be  convinced  of  the  fact — that 
hour-glass  contraction  i^a  contparativelf/  of  rare  occurre^tce.  With  a 
fiiir  share  of  ob«<ervation  in  mid  wile  ry,  and  a  constant  desire  to  arrive, 
by  rigid  analysis,  at  just  conclusions,  I  can  posit ively  assert  that  I 
have  never  met  with  but  five  cases  of  the  true  hour-glass  conlrao 
Hon — two  in  my  own  practice,  and  three  in  consaltation.     While, 

I  however,  I  am  of  opinion  that  it  may  be  regarded  as  among  the 
complications  of  labor,  yet  I  would  guard  you  against  the 
tement  of  some  writers,  who  maintain  that  the  assumption  of 
hour-glass  contraction  of  the  uterus  is  altogether  without  fbunda- 
tion,  and  that  it  exists  irniy  in  imagination.  Rare,  however,  as  I 
believe  it  to  be,  it  is  material  that  you  ?>hould  undei-stand,  should  a 
ea^e  of  l)ie  kind  present  itself,  how  to  manage  it. 

The  uterus,  as  I  have  stated,  is  diviiled  into  two  chambers,  these 
chambei-s  being  separated  by  tl*e  narrowed  or  constricted  portion 
of  the  organ ;  the  placenta  is  lodged  in  the  u]>per  cbauiber,  while 
the  umbilical  cord  is  found  to  protrude  througli  the  striclured 
oriHce^  and  thence  into  the  vagina.  Now,  suppose  yourselves  by  the 
bedside  of  your  patient— the  placenta  is  retained;  you  institute  an 
examination  for  the  purpose  of  ascertaining  the  cause  of  the  delay; 
it  may  be  that,  not  reaching  the  placenta  with  the  finger  carried  as 
iifcr  as  the  os  uteri,  you  will  insinuate  the  hand  into  the  cavity  of  the 
organ  ;  then,  in  your  exploration,  following  the  cord  you  will  sud- 
denly come  in  contact  with  the  orifice  or  stricture  separating  the 
two  chambers;  you  feel  the  placenta  In  the  upper  chamber — in 
doing  so  you  tremble,  a  deadly  sickness  ccmies  over  you,  and,  with 


882 


TEE  PRIKCIPLES  AND   PBACTTICE  OF  OBSTETIUCa 


an  agitation  which  no  one  but  yourselves  can  i 
wilhdniw  your  hand;  the  nurae,  with  her  klm  i-  in 

your  haggard  countenance  that  something  ia  wrong.     Sh©  tske8 
you  one  side,  and  iii  reply  to  her  anxious  inquiry  you  rumark^ — OA, 
nurse^  tht  teomb  U  ruptured!    The  good  nurse,  difiVrcnt  from 
others  of  her  sex,  cannot  keep  the  secret,  atul  in  a  very  few  m<v 
mema  the   houi^ehohl   is   intbrmed  of  the   melancholy  disoorcfy, 
whic'}i  your  sagacity  has  enabled  you  to  make !     Instantly  s  coo-  i 
sullation  is  proposed;  in   a  brief  time,  some  man  of  cxperienc€ 
arrivoH;  on  examination,  he  find?i  that  what  you  hace  mhttik^n/or 
a  rupture  of  the  uterus  is  nothinri  more  than  the  opemn^  r^MuUiMg 
from  the  division  of  the  organ  into  two  e<>mparimenta!     Why  Ja  I^  J 
in  thitf  ianiitiar  manner,  call   your  att<;ntion  to  this  |>oiut  ?     Il  isl 
beeau.se  I  am  soliciioug  to  guard  you  against  so  gra%e  a  blunder  in] 
diagnosis,  and  at  the  same  time  to  admonish  yow  that,  witl)ouc| 
adequate  dti$crimination,  feeling  tlie  placenta  in  the  upper  chamberi 
might  lead  you  to  suppose  that,  through  a  laceration  of  the  orgaO|| 
it  had  es wiped  into  the  abdoniiuul  cavity,     A  moment's  retlcctiotil 
wouhl  serve  to  show  ynu  the  erri>r  of  such  an  opi»non — for  remem^l 
bcr»  that  whi'n  the  uturus  undergoes  rupture  during  partanitOll« 
the  evidences  of  this  appalling  complication  are,  not  only  waD 
marked,  but  they  are  a)uu>e<t  Hiniultaneou^  with  the  accident  itself— »j 
•nch  as  vomiting,  pallor,  and  f-inking  of  counieuauce,  cold  |»eri*pir 
tion,  with  a  rapid  and  liickering  pulse. 

The  treatment  of  hour-glass  contraction  consists  in  a  ri»ort  t< 
remedies  calculated  by  their  relaxing  effects  to  remove  the  iirtc 
lOfod  condition  of  the  uterus,  such,  for  ex  ^^c^etll 

Moouimended  iu  »pastn  of  thif  cervix.     As  I  hi         <      i  kc 

I  have  great  confidence,  with  a  view  of  removing  this  stricttiTO  ; 
r«itoring  the  uterus  to  its  normal  state,  in  the  eifioacy  of  fattiminjB 
lilt  Oiusoular  tibrcs,  and  for  this  puqK>8e  i  would  suggest  the  fol«J 

lowing  plan:  The  hand  should  be  in- 
troduced into  the  cavity  o(  the  organ  tm 
a  conical  form,  and  thLi  form  mainlatni?di 
while  the  hand  remains  within  the  eavity  ;l 
it  is  then  passed  up  to  the  cnnstrif*t)Ml  ] 
jHirtion  (Fig,  01)  ;  and  the  fingers,  reprt^^j 
senting  the  summit  of  the  cone,  are  ni»t1«  j 
-p,  to  push  gently,  but  firmly,  aijainst  iUal 
17  centre  of  the  <- 
and  continued  j 

break  the  force  of  the  9(|iasm  ;  the  sftric 
ture  is  overcome,  and  the  a^r*birth 
Fio.it  then  be  removed  without  diflScnlty.     It] 

will  occaHionally,  however,  happen  I 
tlic  liand  becomes  so  severely  crampcil,  and  the  reatStlUloe  of  \ 


THE  PRINCIPliES  AND  PRACTICE  OF  OBSTETRICS.         888 

oonstricted  portion  so  great,  that  the  accoucheur  is  under  the 
necessity  of  withdrawing  his  hand  without  accomplishing  the 
object.  Under  these  circumstances,  I  have  on  two  occasions  had 
recourse  to  a  method,  which  I  do  not  remember  to  have  seen  men- 
tioned by  any  author,  and  to  which  I  attach  more  than  ordinary 
importance.  It  is  this — take  a  small  piece  of  prepared  sponge,  of  a 
conical  shape,  well  enveloped  in  soft  linen,  and  completely  saturated 
with  olive  oil,  or  simple  cerate  ;  this  is  to  be  inclosed  in  the  hollow 
of  the  hand,  and  then  introducing  the  hand  into  the  uterus,  the 
apex  of  the  sponge  is  applied  against  the  constricted  orifice ;  by  firm 
and  properly  directed  pressure,  causing  the  sponge  to  act  on  the 
principle  of  a  wedge,  the  spasm  is  removed,  and  all  diflScuIty  at  an 
end.  I  submit  this  method  to  the  test  of  future  trial,  believing,  as 
I  do,  that  it  will  be  found,  under  the  circumstances,  to  subserve 
very  satisfactorily  the  object  in  view. 

rV.  Morbid  Adhesion  of  the  Placenta  to  the  Uterus. — ^This  is 
another  form  of  placental  complication  which,  if  you  are  to  rely  on 
the  statements  of  the  young  practitioner,  is  extremely  common. 
Bat,  gentlemen,  my  own  opinion  is  that  what  is  truly  understood 
by  morbid  adhesion  of  the  after-birth  is  to  be  classed  among  the 
very  rare  occurrences  of  the  parturient  chamber.  That  it  will,  how- 
ever, occasionally  be  met  with  is  unquestionable,  and,  therefore, 
there  are  some  points  connected  with  it,  which  it  is  necessary  for  you 
to  understand.  It  has  been  by  many  doubted  whether  there  exists 
any  such  thing  as  inflammation  of  the  placenta — placentitis.  But 
the  unerring  demonstrations  of  the  pathologist  have  abundantly 
shown  that  the  after-birth  will  sometimes  become  the  seat  of  inflam- 
matory action,  exhibiting  both  an  acirte  and  chronic  type.  One  of 
the  results  of  inflammation,  as  you  well  know,  is  an  effusion  of 
coagulable  or  plastic  lymph;  and  it  is  now  very  generally  conceded 
that  this  lymph  is  the  special  medium  through  which  the  morbid 
adhesion  of  the  placenta  to  the  uterine  wall  is  eflTected, 

The  adhesion  may  be  partial  or  complete.  In  the  former  instance, 
in  consequence  of  a  separation  of  a  portion  of  the  placenta  from  the 
uterus,  there  will  be  more  or  less  danger  of  hemorrhage.  When, 
however,  the  adhesion  is  complete,  there  will  rarely  be  hemorrhage 
unless  the  uterus  be  in  a  state  of  positive  inertia,  and  even  then  the 
bleeding  would  be  comparatively  slight,  for  the  reason  that  the 
mouths  of  the  utero-placental  vessels  would  be  protected  by  the 
contact  of  the  after-birth.  This  latter  may  be  in  cohesion  with  any 
portion  of  the  uterine  surface,  depending  upon  the  particular  point 
of  its  original  insertion. 

How  do  you  know  that  morbid  attachment  really  exists  ?  One 
of  the  evidences  will  be  the  fact  that,  notwithstanding  the  contrac- 
tions of  the  uterus,  the  placenta  is  not  expelled.  This  alone  is  a 
very  feeble  evidence,  for  the  non-expulsion  of  the  mass,  in  obedienoe 


TH£  PEOHCirLRS  AKD  PRACTICR  Of  0B9rETRIG8. 


to  the  rontractiJe  efforts  of  the  womb,  may  be  due,  not  to  morbid 
(uihe»ion,  hut  lo  one  of  the  conditiofi!*  wliicb  we  have  ailresiiljr 
eianiineil,  viss.  locreased  sise  of  the  placenta,  sipa^m  of  thr  o:^  iit«ri| 
or  the  bour-gl2&ss  contraction.  You  aee,  therefore,  you  iiiiiai  hare 
•oroe  more  reliable  testimony.  That  the  delay  is  not  c^Lis^^d  by 
exclave  volume  of  the  after-birth,  you  learn  from  its  absencts  over 
the  nirruth  of  the  uteruiii ;  that  it  399  not  9pasm  of  the  o^  will  be  mini* 
feflt  from  the  &cility  of  introdaciog  the  fijiger  \  and  that  therv  U  no 
hour-^la9«  contraction  is  ascertained  by  tlie  non*existeiico  of  the 
symptuma  charaeteristic  of  thin  condition* 

The  mo5*t  certain  evidence,  I  think,  for  an  accurate  din^iosis  willi 
regard  to  morbid  adhesion  of  the  placettta  will  bea^s  fuUows*;  K  Tbe 
Uterus  will  be  fijund  pref^cnling  to  the  hand  applied  to  the  abdamen 
a  hir;;cr  volume  than  when  tlie  ufler-birth  U  detached,  and  remains 
within  the  cavity  of  the  or«^an  ;  2.  The  failure  of  repeated  and 
vigorous  contractions  to  separate  the  alYer-birth  ;  3.  On  intr(»*loQing 
the  hand  into  the  cavity  of  the  uterus,  and  following  the  uuibilioid 
cord  UH  a  guide,  the  placenta  will  be  d'tJ^tiuctly  felt  in  CijnnejduB 
with  the  wurnb^  either  partially  or  completely.  Having  ihun  made 
tip  your  dia^noMs  as  to  the  real  slate  of  things,  and  aset^rtained  tbal 
the  delay  in  tlie  expulsion  of  the  placental  ma^  it  occasioned  by  ita 
morbid  attachment,  the  next  poujt  for  consideration  is — wh;i!,  uuiler 
the  circumHtauccs,  in  the  course  for  the  accoucheur  to  pursue  ^  This 
question  i^  very  important  as  well  as  interesting,  and  desonrea 
attention. 

The  plan  to  be  adopted  will  depend  upon  whether  or  not  thera  it 
hemorrhage — in  the  event  of  thi.i  latter,  should  it  be  *uch  Jta  Ul 
place  in  peril  the  safety  of  the  mother — the  treatment  must  be 
prompt  and  con^^i^t  of  those  remedies  of  whieli  we  shall  spe:ik  wbeti 
discujwirig,  as  wo  shall  do  iu  the  succeeding  lecture*  the  subject  of 
floodirij^.  It*,  on  the  contrary,  there  be  no  hemorrhA;Gti.\  or  com- 
plication  ciillitjg  for  the  imnMHliate  delivery  of  the  ^  then, 

the  ca8c  Wing  less  urgent,  there  ik  no  necessily  for  hi  ^  i^ttira. 
It  is  well,  however,  to  recollect  that^  although  there  may  be  DO 
pressing  motive  for  the  ]»rompt  contraction  of  the  after-birtli,  y»t 
there  U  a  certain  liniit  beyond  which  it  wouhl  be  nns^afe  in  sidlow 
this  mans  to  remain  within  the  uterus  without  reporting  to  lcgiti» 
mate  means  for  its  removal.  There  is  always  more  or  less  aajtiety 
on  the  part  of  the  patient  and  friends  until  the  delivery  of  the  |i1a* 
cenla  is  aoc^^mplished,  mn\  until  this  tnkcM  place  they  do  not  regard 
the  labor  as  complete  ;  in  this  opinion  they  are  right.  But,  gentle 
men,  iu  addition  to  the  anxiety  of  the  p>atient,  there  is  another 
reason  why  it  is  important  that  too  long  a  period  should  not  elapse 
before  the  extraction  of  this  body, 

'1^  Ha,  you  have  been  told,  is  called  upon  to  pi*rft>nii  only 

a  hui  iVi  its  function  ceasing  wMtli  the  birth  of  the  child.    It 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS. 


I  agi 


,  as  a  general  rule,  is  separated  from  the  uterus — its  vitality 
beeoRica  extinct,  and  it  ia  converted  into  a  deciduous  mass, 
constituting  no  longer  a  portion  of  the  living  eeonomr,  and  is  sub- 
ject, therefore,  to  the  mutation  incident  to  dead  structure^  viz,, 
decom]>osilion.  This  latter  condition  ma?  occur  sooner  or  later, 
depending  upon  various  circumstances;  in  the  event  of  sufh  a  con- 
tingency, the  pntient  would  be  unnecessarily  exposed  to  great  danger. 

The  rule,  which  I  would  suggest,  and  which  experience  has 
proved  to  me  to  be  the  safe  one,  is  not  to  allow — I  am  now  alluding 
to  cases  in  which  there  is  no  complication  intlicaling  prompt  intcr- 
ierence — more  than  tsvo  hours  to  ehipse  nftcr  the  hirth  of  the  child 
withotit  atiempting  to  biiug  away  the  al\er-birth,  and  this  applies 
to  any  case,  whether  of  morbid  adhesion,  hour-glass  contraction,  or 
whether  there  be  an  entire  absence  of  any  abnormal  symptoms. 
Again  :  I  would  enjoin  upon  you  another  rule,  and,  a!ihoui;h  it  may 
^^pinetimes  impose  rather  a  heavy  tax  on  time  and  patience,  yet  it 
irill  be  a  wi^^e  precaution,  may  save  you  much  enibarras<iTneut,  and 
prove  a  shield  to  your  patient  aj^ainst  serious  danger:  It  is  never 
to  le«tve  the  chamber  after  the  birth  of  the  child,  nntil  the  jtlaceata 
has  cotne  away.  If  two  hours  should  huve  elapsed  since  the  deli- 
very of  the  child,  and  you  have  discovered  that  the  delay  is  o>\;\*]ng 
to  morbid  adhesion ;  and,  if  frictions  on  the  abdomen,  or  lilillatii^g 
the  OS  uteri  with  the  finger,  s*houkl  ful  in  indticing  contractions 
suificient  to  break  up  the  adhesion,  nnd  detach  the  after-birth,  then 
the  broad  indication  is  not  to  wait  any  longer,  but  proceed  at  once 
to  extract  tt.  With  this  view,  the  hand  is  to  be  cautiously  intro- 
duced in  a  conoid  form  into  the  uterus,  and  following  the  cord  as 
a  guide,  it  will  goon  reach  the  placenta;  the  other  hand  shi*uld  be 
placed  upon  the  abdomen  over  the  site  of  the  placenta,  for  the  pur- 

;e  of  steadying  the  uterus.  This  body  will  be  either  in  com|dete 
ihesiou  with  the  womb,  or  will  only  be  partially  so.  In  the  latter 
case,  the  tingera  bliould  bu  insinuated, 
with  the  dorsal  surface  toward  the  uterus, 
between  the  latter  organ  and  placenta, 
cotmnencing  at  the  point  of  separation. 
The  hand  is  th*ni  made  to  glide  between 
these  two  surlaces  {Fig.  62),  and  by 
gentle  manipulation,  the  detachment  may 
be  accompliished-  After  the  placenta  has 
been  separated,  it  should  be  withdrawn 
Recording  to  the  directions  to  which  we 
have  already  alluded.  Should  it,  how- 
ever, occur  thnt  the  hami  cannot  detadi 
the  body,  then  it  should  be  brought  away  in  fragments,  and  at  the 
same  time  every  reasonable  attempt  made  to  extract  the  whole  of 
the  mass. 

25 


FjLi»  03. 


886 


THE   PRINCIPLES  AND   PRACTICE  OP  OBSTKTmca 


When  there  is  comf>lete  adhesion,  the  safer  practieo,  la  mfl 
opinion,  is  to  introduce  the  hand,  and  «tret<!hint^  the  fingers  over  i 
the  fcetal  surface  of  the  placenta,  n«  far  an  the  peripheral  ed|^, 
gentle  traction  should  be  nnade  upon  thi*  edge  by  drairin^  tli«J 
fingers  toward  the  palm  of  the  hand  ;  this  somewhat  sinmlatet  ih^\ 
mode  in  which  the  uterus,  under  the  influence  of  conlraiTttofi,  pro 
ceed^  in  the  separation* 

The  plan  just  sugi^ested  is  far  preferable  to  that  reoommendcd  by 
some  authors,  vti,,  to  tnake  tractions  upon  the  cord  with  the  hnp« . 
that  these  tractions  will  result  in  the  detaehment  of  the  ftfler4iirilt.l 
The  danger  of  this  practice  must  be  quite  evident  to  you,  conf^i^tinm 
in  liability  to  rupttjre  of  the  cord,  inversion  of  the  uterns,  etc.  For^ 
these  reasons,  it  shonhl  not  be  resorted  to,  and  I  trust  yon  will  not 
forget  this  atljuoniiion. 

It  will  occasionally,  however,  happen  that,  not  withstanding  the  bc«i-' 
directed  eftorts  of  the  accoucheur,  these  morbid  adhesions  tsanni)!  be 
broken  up  ;  and  there  is,  for  a  longer  or  (shorter  period,  retention 
of  the  aftur-birth.     This  i^  certainly  an  unfortimate  condition  of 
things;  but  like  many  other  contingencies  in  practice,  though  noid 
of  yotir  own  choice,  yet  they  are  to  bo  managed  in  the  be!<t  poascl- 1 
ble  way  circumstancea  will  permit.     One  of  the  principal  dangert 
of  retained  placenta,  as  you  have  been   informed,  consists  In 
decomposition  of  the  nia>s,  and  the  const  it  utional    diHturbance%^ 
which  are  so  apt  to  follow  the  absorption  of  the  decomposed  mutter. 
\Vht?u  diH'omposition  has  occurred,  much  of  the  material  passes  off 
per  vnginam  in  the  form  of  a  fetid  dis(»harge.* 

Af>strr//(iOH  of  retained  Placenta, — ^Some  writers  »  and 

nong  others  Naegcliy,  Salomon,  Rigby,  and  Porcher,  ii  »  jn 

sible  for  the  uterus  to  remove  a  ret^iinod  after-birth  througli  ihm 
process  of  absorption ;  this  is  the  explanation,  which  is  given  of 
tbose  aWi'ged  cases  in  which  the  placenta  has  been  pernianrolt] 
retained,  unaccompanied  by  any  of  the  constiuitional  or  loc^ 
dem:e«  ol*  decomposition.  You  will  find  in  the  books  several  h 
4ses  j-ecorded  of  retained  allcr-birth,  the  disappearance  of  vhiob 
iVoni  the  womb  could  be  accounted  for  only,  according  to 
«  riterjs  on  tlie  princn|ile  of  uterine  absorption.  I  have  never  knni 
n  case  tif  retained  atU«r-birth,  which  was  ni4  thrown  ofl',  in  jmrt,  at 
least,  afler  decomposition,  through  the  vagina  in  the  form  of  a^ 
putrid  discharge,  when  occnrring  at  full  time;  luui  I  am  iQclk 


*  In  ill  mmm^  wbetlier  the  placetiiJi  bas  been  reUiitidd  or  not.  In  whicK,  ilUr  i 
4Mfy,  Uie  dtiiobvfB  beoom<^a  rac*tid,  it  m  ver)'  important  to  order  ti>c  nunc  to  i 
itoe  vagina  IVeely  Kveral  times  a  Uoy  witli  lopiii  water,  and  tbt"  Budu  uuiiiis  of  < 

ac>ap;  nnti.  nlm,  ihc  CRVHsi'^unl  ujm?  <*r  tlj<*  dildrid^  of  Uim*  may  br  rftort^d  lu  in  I 

turoi  (if  itjjetHixjio.     If  thti  Ui>«cltarge  be  aliow4.^d  to  aecuiuulate  m  tiit*  tai;toai. 

ita  olfeii«ive  odor,  U  wlU  produce  mora  trleMi  rrrftatioD*  tad  prove exccinvtijr  i 

infi:  to  the  |mtiriit 


THE  PBINCIPLBS  AND  PRACTICE  OF  OBSTETRICS.         887 

to  regard  most  of  the  supposed  examples  of  permanently  retained 
placenta  as  apocryphal,  for  the  reason  that  sufficient  care  has  not 
been  exercised  to  ascertain  whether  the  mass  may  not  have  come 
away  during  the  absence  of  the  accoucheur,  either  in  a  solid  or 
fluid  state.  Still,  there  is  very  high  authority  on  the  other  side 
of  this  question,  asserting  most  positively  that  cases  have  occurred 
in  which  the  placenta  has  never  passed  from  the  uterus,  and  that  its 
subsequent  disappearance  was  the  result  of  absorption.  It  may, 
therefore,  be  considered  an  open  question — still  subjudice — to  be 
determined  by  the  accumulation  of  future  evidence. 

V,  Convulsions. — The  labor  may  have  progressed  and  terminated 
most  auspiciously ;  and,  a  few  minutes  after  the  expulsion  of  the 
child,  that  most  formidable  complication — convulsions — may  ensue, 
owing  to  irritation  occasioned  by  the  presence  of  the  after-birth. 

When  we  treat  in  detail  of  puerperal  convulsions  in  a  subsequent 
lecture,  we  shall  tell  you  that  they  may  be  produced  by  various 
causes,  and  among  these,  occupying  a  prominent  place,  will  be 
uterine  irritation,  either  prior  or  subsequent  to  the  birth  of  the 
child.  If,  therefore,  you  should  have  a  case  of  convulsions  result- 
ing from  irritation  of  the  uterus,  and  this  local  irritation  you  ascer- 
tain to  be  in  consequence  of  the  presence  of  the  after-birth,  there 
should  be  no  doubt  or  delay  as  to  what  is  to  be  done — t/ie  immedi- 
ate removed  of  the  afttr-hirth  is  indispensable.  It  has,  I  am  sure, 
often  happened  that  human  life  has  been  sacnficed  in  these  cases, 
by  mistaking  the  true  cause  of  the  convulsive  paroxysm.  I  need 
scarcely  remind  you  that  when  puerperal  convulsions  arise  fi-om 
irritation  of  the  uterus,  they  do  so  through  reflex  influence,  and 
are  eccentric  in  their  origin. 

I  may  here  mention  that,  as  soon  as  the  placenta  is  removed,  it 
will  be  proper,  with  a  view  of  calming  the  irritability  of  the  uterus, 
to  introduce  an  opium  suppository,  consisting  of  one  or  two  grains  of 
the  drug,  into  the  rectum,  or  from  forty  to  fifty  drops  of  laudanum 
in  half  a  tumbler  of  tepid  water  may  be  used  as  an  enema.  Bella- 
donna ointment  applied  to  the  os  uteri  and  vagina  will  also  render 
important  service. 

VL  Hemorrhage, — In  the  succeeding  lecture,  we  shall  speak  of 
the  management  of  the  placenta  in  connection  with  hemorrhage. 


LECTURE  XXVIi. 


Uanagcment  of  PlAceotA  m  Flooding  oftertho  Birth  ofChiki — Vrcqiaency  mnd  Mat^i 
lily  c>f  Flooding — Stiitiwtica — Dangers  of  Poet  (>iirtum  Uemorrhage — Wluil  ii  Po^^ 
pitftnrit  Hemorrhage,  and  how  prcnluceil  7 — tlow  is  ihiti  furrn  of  HiXidiiig  divitlnilTI 
^Kxtemjil  Mid  Inwrtml  Floodiitg— Cuuees  and  DktignoBk  of  Rxtenuil  Umi 
lia^;  botr  difitit)gmshi*d  from  Jntcnml — I>uty  of  tbe  Aocoucht^ur  the  Initaiil 
^  Child  Ims  escafXHl  through  the  Vtilvsi— Trentmvnt  of  Kxiemal  Homgrriiii|{«| 

Dtiro  oUj«^ct  is  to  pnxluco  ITierini)  Coiitmcttun — How  in  thin  to  bo  poei 
^lifiited '/—Ergot  not  to  be  relied  on  oi  a  Heroic  Remedy  in  r©rilouii  Floo4tiig-«| 
Wlijr? — The  Tampim;  objection  to  it  a  use  in  ront-pnrlum  Hemorrhage — Plnwrori  ] 
and  Cohl  U^e  two  Rcluible  Heiiiedicn  in  Uterine  HenK>frhngf> — the  ColiI  tlMJb^i 
action  of— A  iuiuU  jikav  of  Ice  IntrtMiuct-d  Into  the  VoginA:  it4  reHejt  in(liieiic»-«  1 
lHanima)  nud  Uteruf^^-Synipathy  between  and  Deductiona  &orn-^PrefB<iro  liT  lb* 
kAbdinnintil  Aort*— Khuiridly  a«  ii  Beniedy  in  HemnrHiJigt*;  Objectiom 
li\li*vlU)f\Ji  of  VinegiiiV  Ltiniim-juico,  etc,  into  Vnginu,  hud  |>r}iirttc«e^~  Jnlcimat  Uft^  ■ 
rine  HemorrhiJge;  how  treated — I'ephahilgia  from  Profuse  Li*««e«  of  iilood; 
■  Irented;  how  difllingiiinhed  fnr»m  PhrenitiB— TmnnfuEiion  im  nn  Altertiatiro  aAir!] 
^Exce^aiTe  Heniorrhiige  —  Dr  Blundell  first  to  n*«ort  to  it  in  the  Puer|*eml  Woomm  j 
—  Average  Buetv«a  of  tVio  Op^miiou — Pruf  K<Jw«nJ  Murttni  of  Herlin— UiiW  « 
TnitiMfuHum  Aa;ontftliHh  Heiu^tiun  7 — In  it  by  the  <^uantily  of  UU>*hI  tnifp«fVnt^J 
or  by  KimuliiHng  the  Wulh  of  the  Vi-sselii  and  Heart '! — Brown-  ; :  ip^  J 

rirneuta ;  Deductions  from — S^cotidnry  Po9t*panum  Heraorrtuigt  ^4  H  ^ 

meati? — Tn^attneot  of  Secondary  Hemofrhagv^ 

Gkntlbmkn — Next  ill  order  of  oonsideration  *m  the  tnanagvmieDI  of 
tbe  plftc<*nla  in  cases  of  horriorrhn^'e  or  flooding.  la  dlAcitaitng  lliQ 
qtic>4tit>ri  of  herriorrhjijre^  we  sJmll  limit  onrscJves^  for  ih©  prestnlf  t© 
thut  form  of  it  which  oceur*  subseqiteiilly  to  ibo  birth  of  llie  eUiIci, 
It  hnA  been  rvmarkcd  by  a  writer  on  midwifery,  that  no  phy^c4sii 
Rboiild  have  the  hardihood  to  cross  the  ihreiihold  of  the  Iying4fi 
ohumhvr,  who  ii^  not  |»rep;tre<l  promptly  and  t'iHcK'nt^  i-dwr  , 

the  tuHnled  Mervioe  in  the  iiioirvent  of  peril*     Thi;*  i*  (  j:ig« 

of  that  €*mphatic,  lucid,  and  practical  author^  I)r  (looch.     1  rcmpood  j 
moKt  heartily,  with  all  con»ciouf*iies8  of  jtii  truth,  to  the  value  ofihi! 
icnlimont;   and  I  would  sny  to  those  who  have  never  yet  Im*«d 
«ngat?ed  in  the  |»nictice  of  the  proft'f*!^ion,  that  if  there  be  any  ooc 
thini;  more  than  another,  in  the  whole  routine  of  profc.^sionaj  duty, 
ealeuJated  to  strike  terror  into  the  heart  of  the  praetitioDer^  It  iaa 
oaeo  of  flooding  after  the  birth  of  the  ehibb     One  moment  of  hi 
tat  ion  or  doubt^  and  dtfulh  npeedily  terminates  the  ^eene.     KatvTi  ! 
has  opened  her  flood-gates,  and,  if  they  be  not  ini^tantly  atid  «k9»j 
fully  cJoflcd,  all  chance  of  rescue  ii  at  an  end.    There  ia  no  time  for 


TEfi  PfiINClPLE3  XSJ)  PRACTICE  OF  OBSTETRICS. 


889 


eonsultation  here — no  time  lor  the  perusal  of  books  to  B6e  what  is 

be  done — that  inexorable  enemy  Death  is  pressing  for  his  victim  j 
Qd,  but  for  the  prompt  interposition  of  science^  the  chamber  of 
'rickness  will  be  converted  into  the  gloom  of  desolation  and  heart- 
fetricken  gJief. 

I  wish  I  had  the  power  to  portray,  with  graphic  truth,  tho 
lyiog-in  room  in  a  case  of  perilous  flooding.  There  is  your  patient, 
be  who  has  confided  her  life  to  your  custody — she  18  delivered  of 
a  healthy,  living  child— her  heart  is  full  of  a  mother's  love— and, 
while  ejctending  to  you  the  sincere  oblation  of  her  thanks,  and, 
perhaps,  in  the  very  act  of  receiving  the  tender  congratulations  of 
her  happy  and  devoted  husband,  she  is  struck  with  sudden  pallor — 
the  gentle  smile  and  beaming  eye  have  given  place  to  the  sunken 
and  ghastly  cheek;  she  is  speechless  and  unconscious;  she  knows 
not  the  countenance  of  the  agonized  husbimd,  who  bends  so  fondly 
over  lier;  his  voice,  once  so  familiar  and  welcome,  falls  without  its 
echo;  in  a  word,  that  woman  h  moribund.  And  all  this  change  is 
but  the  work,  as  it  were,  of  a  few  yecomin.  In  this  terrible  emer- 
gency, every  ey^  is  turned  toward  you;  the  liopes  of  that  husband 
rest  upon  your  instantaneous  action.  Overwhelmed  and  torn  with 
griel^  in  the  agony  of  his  distrea^  ho  will  exclaim,  in  tones  which 
will  reach  the  very  depths  of  your  heart :  "  Doctor,  doctor,  save 
my  wife!*'  Should  you,  under  tiiis  ajipeul,  prove  inadequate  to  the 
emergency  because  of  iguorance  of  what  to  do,  that  appeal  will 
untioue  to  ring  in  your  ears,  it  will  prove  a  withering  comment  on 

St  neglect^  and  cause  you  to  bewail  in  tears  of  blood  the  fntuity^ 
"which  urged  you  thas  wantonly  to  sport  with  human  life.  But,  on 
the  other  hand,  if  the  appeal  be  uuide  to  one,  who  is  not  only  fully 
impressed  with  the  sacredness  of  the  obligation  involved  in  tho 
responsibility  of  minister iug  to  the  sick — to  one  who,  when  W 
assumes  the  cares  of  the  lying-in  room,  feels  that  he  is  competent 
faithfully  and  promptly  to  discharge  his  duty;  and  if,  in  the  exer- 
cise of  his  knowledge^  lie  rescue  the  patient  from  her  impending 
danger,  and  restore  her  to  her  husband  and  child,  then  he  will 
have  accompltshcd  one  of  the  most  glorious  of  all  human  triumphs. 

In  tliese  scenes  of  distre^ss  you  must  be  careful  not  to  perujit  the 
heart  to  exercise  a  sovereignty  over  the  mind  ;  it  is  here  that  the 
heart  of  the  physician  must,  ibr  the  moment,  close  up  its  fountains 
of  sympathy.  There  will  be  no  time  for  you  to  commingle  your 
teal's  with  tbosfc  of  agonized  friends;  your  duty  will  be  to  arrest 
the  work  of  death.  The  danger  is  imminent ;  the  friends  are 
gathered  round  the  couch  of  the  dying  relative;  their  sobs  pene- 
trate the  inmost  recesses  of  your  soul ;  and,  in  looks  which  cannot 
be  misinterpreted,  ihey  say  that  you  are  the  only  being  under 
heaven  on  wlutm  their  last  ho[»e  depends !  It  is  in  instance-s  like 
these  that  promptness,  decis^ion,  and  energy  must  take  the  place  of 


THB  PRINCIPLES  AKD  PHACTICE   OF  OBSTETRICS. 

Byropalhy ;  and  although  your  promptness  may  subject  too  to  thd 
charge  of  being  rude,  and  your  decision  be  miataken  for  teriH»niy, 
yet,  if  thh  promptness  and  ded^ion  will  enable  you,  under  tb^-Mi 
trying  circumstances,  to  save  human  life,  restore  u  fond  mother  to 
her  weeping  children,  or  a  beloved  wife  to  her  husband,  what  eare 
you  for  the  construction,  which  a  selfish  and  heartlciw  world  msy 
place  upon  your  condiict  ? 

FVtqtienct/  and  Mortaliiy  of  F'looding, — Tlie  following  stutintica 
from  Dr»  Churchill  will  enable  you  to  appreciate  the  frequency  and 
iatality  of  hcniorrhage  in  childbirthf  under  its  three  forniit^  rii, 
post-partum^  acckhntal^  and  unavoitktbte.^ 

In  163,738  cases,  hemorrhage  occurred  1338  times,  or  about  I  ill 
122;  out  of  782  cases  of  hemorrhage,  126  mothera  wer«  lost,  or 
about  1  in  G ;  out  of  944  cases,  288  children  were  lost,  or  aboQl 
1  in  3. 

Further:  out  of  218  cases  of  accidental  hemorrhage,  32  prorod 
fatal,  or  1  in  6;  out  of  201  eases  of  unavoidable  hetiiorrhage,  71 
proved  fatal,  or  nearly  1  in  3^  ;  and  out  of  365  cases  of  flooding 
after  delivery,  25  proved  fatal,  or  about  1  in  14. 

Floodlit ff —  What  dms  it  3hmif — Before  speaking  of  the  raM^ 
dial  agents  to  which  you  are  to  resort  in  order  to  arrest  Hoodttig^ 
after  the  delivery  of  the  child,  let  us  first  enquire  what  is  flooiiiDg, 
or,  in  other  words,  how  is  it  produced?  This  is  a  very  important 
question^  and  it  is  abftolutely  essential  that  you  sfjould  have  no  loo»e 
or  undetincd  nntious  upon  the  subject,  but  positive  and  acctint* 
knowledge.  Well,  when  a  woman  has  profuse  hemorrhage  alUr 
tho  expulsion  of  the  child  from  the  uterus,  it  is  because  thin  ar|^mii 
in,  in  a  state  of  relaxation — a  state  known  as  inertia.  When  htertia 
of  the  womb  exists,  the  utero- placental  vessels,  instead  of  betit^ 
olosed,  iis  they  becunie  under  the  influence  of  uterine  contraction^ 
remain  open ;  it  is  these  very  vessels,  w  hieb  constitute  the  Hood* 
gates  to  which  w^e  have  alluded,  and  tliruu<^h  wliich  the  life*curretit 
of  the  temale  is  so  rapidly,  and,  if  not  checked,  so  fnlally  paming. 
You  see,  therefore,  if  it  he  true— and  there  is  no  fact  better  etia* 
blishcd— that  Hooding  is  the  necessary  result  of  inertia  of  the  utvmai 
if  there  be  any  force  in  logic,  the  irresistible  deduction  iS'-thaS  the 
only  means  of  arresting  the  hemorrhage  is  to  mmke  tJm  uiemt  com* 
iraci  for  the  jmrpom  if  closing  the  motUhs  of  the  niero^ntmmiol 
ve$$ele,  I  wish  you  constantly  to  keep  this  broad  lact  before  yoo^ 
and  you  will  find  that,  under  ita  full  appreciation,  the  dangers  aod 
anxiety  connected  with  a  case  of  uterine  hemorrhage  will  bovorj 
much  diminished. 

Divistohif  of  Flooding, — As  I  am  desirous  of  placing  thia  wbolt 
subject  o£  flooding  V>efore  you  in  thu  simplest  possible 


•  CkmxhiU*  Mdwifiry,  fourth  LoDdoD  «d.,  p.  46a» 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         891 

Stripping  it  of  everything  that  is  adventitious,  and  reducing  it  to  a 
positive  tangibility — before  telling  you  how  you  are  to  cause  the 
womb  to  contract,  I  wish  to  call  your  attention  to  two  very  essen- 
tia] divisions  oX  post-partum  hemorrhage — divisions  which  you  will 
recognise  at  the  bedside,  and  without  a  clear  knowledge  of  which 
it  wouid  Ihj  utteHy  impossible  for  you,  with  any  hope  of  success, 
to  attempt  to  af&)rd  the  required  relief. 

The  di\'isions  to  which  I  allude  are:  1.  External  hemorrhage; 
2.  InteiTial  hemorrhage.  When  the  hemorrhage  is  external,  the 
blood  passes  from  the  uterus  into  the  vagina,  and  thence  into  the 
worhL  When,  on  the  contrary,  it  is  internal,  the  blood  does  not 
pass  out  of  the  uterus;  it  is  retained  there  because  of  some  occlu- 
rion  of  the  mouth  of  the  organ — the  occlusion  being  caused  either 
by  the  detached  placenta  resting  over  the  05,  or  the  presence  of 
a  ooagulum  of  blood.  Now,  the  point  for  you  to  remember — and 
on  its  recollection  may  depend  the  life  of  your  patient — is  that, 
whether  the  hemon-hage  be  external  or  internal^  it  is  produced  by 
the  same  cause,  viz.  inertia  of  the  uterus ;  and,  moreover,  it  is 
equally  dangerous,  for  the  reason  that  the  blood  is  derived  from 
the  same  source — the  utero-placental  vessels. 

1.  External  Hemorrhage. — You  have  just  been  told  that  in  this 
form  of  fiooding  the  blood  passes  from  the  uterus  through  the 
vagina,  and,  therefore,  you  know  that  it  exists  from  this  latter  cir- 
cumstance, as  also  from  the  exhausting  effects  which  it  soon  occa- 
sions to  the  general  system.  One  of  the  most  certain  elements  of 
saceess  in  tlie  management  oX  uterine  hemorrhage  is  a  knowjedge 
of  its  very  inception.  When  death  ensues  from  this  cause,  it  does 
so  very  promptly  ;  and,  without  proper  vigilance,  the  work  of 
destruction  will  be  more  than  half  accomplished  before  the 
mccoucheur  is  aware  that  danger  is  at  hand.  Let  us  su]>pose,  by 
way  of  illustration,  that  you  are  engaged  in  a  case  of  midwifery; 
things  have  progressed  favorably,  the  child  is  born,  the  mother  is 
most  happy,  the  nurse  full  of  merriment ;  in  a  word,  there  is,  for 
the  moment,  a  little  gala  scene  in  the  lying-in  chamber.  You  apply 
the  ligature,  cut  the  cord,  surrender  the  infant  to  the  nurse,  and, 
taking  for  granted — it  is  too  often  a  fatal  assumption — that  every- 
thing is  as  it  should  be,  you  seat  yourself  by  the  fire,  have  your 
joke  with  the  good  nurse,  who  is  complimenting  you  upon  your 
■kill,  when  all  of  a  sudden  your  attention  is  attracted  to  your 
potient ;  she,  who  a  few  minutes  previously  was  calm  and  happy,. 
and  full  of  thanks  for  your  kind  ministrations,  is  moribund  !  With- 
out the  slightest  "suspicion  on  your  part  of  such  a  melancholy  epi- 
sode, you  find  the  poor  woman,  who  relied  on  you  to  conduct  her 
safely  through  her  confinement,  exsanguinated,  bloodless,  and  abso- 
lutely in  articuio  mortis  /  You  become  bewildered  by  this  sudden 
sod  unexpected  change;  reason  totters,  judgment  is  worthless;  at 


802 


THE   PRINCIPLES   AND   PRACTICE  OF  OBSTrfHICa 


the  vory  irioment  when^  of  all  others,  yoii  shouUl  be  firm  and  ^ 
leelecl,  you  are  refhiccd  to  a  mere  machine,  wilhont  thotigbt 
giiitie  yoii.  Uii(lt»r  th««»c*  painful  clrc-unwttuicca,  death  tttunaf 
and  revels  with  scornful  mockery  at  your  imbecile  j"  th 

check  lii»  pro^ret*8.  There  h  notlunpr,  gentlemen,  e\ 
this  picture;  it  m  but  too  faithful  a  (laj;juerrcoiy|K!  of  many  ft  i 
m»eue  in  which  the  heartstrings  of  aHecticm  have  been  broken,  a« 
the  doniestie  hearth  converte<l  into  a  domicile  of  unutterable  gric 
In  orders  therefore,  to  puaril  aj^uin«t  thi?<  Burprine,  and  bt!  pr€ 
pare<l  to  apj*ly  the  propi-r  renjctlics  the  instant  the  hemorrlmg 
commences,  remember  and  serupulouiily  carry  out  the  rule  1 1 
you*  U'hen  speak  in  jsf  of  your  duties  durin*^:  the  (la^^af^e  of  the  dii] 
through  tile  mntenial  orgauf*,  \'iz.  the  moment  the  fhihl  has 
its  esett  into  (/w  worlds  piiu,*e  yonr  hand  on  the  hi/pogasfrtc  re^an 
€ff  the  jtaiUnty  with  a  view  a/  tuterrtainiftff  whcthtr  or  nat 
uterus  is  etmtracted  ;  i/so^  ytm  nc^d  /mtt  ftofnar  of  ItnftorrAa^ 
if^  on  the  vontrart/^  it  be  not  rontraeterl,  but  m  rw»np  or  Uas^ 
this  is  an  ttud*tnce  of  inrrtiUj  ittul  thtrrfore  hemorrha*^ 
Under  these  circumstances,  instead  of  pennitting  time  to  paMi^  90 
precious  for  the  safety  of  your  patient,  you  proceed  without  delnjr 
to  arrcsit  the  bleeding  by  havirij^  recourae  to  tli©  means  moi^t  effi- 
cient iu  bringing  on  uterine  conttuctionf  and  can»equenUy  retnoY- 
ing  the  inertia, 

TreatmefU  qf  External  Ifrmorrhaff«. — Flooding  may  oeemr 
wlien  the  placenta  is  completely  or  jmrtially  detached,  and  yei 
withhi  the  uterine  ciivity,  or  iifter  this*  mass  ha*^  p.i.sj»ed  from  Umi 
organ.  It  m  a  very  t^ingular  fact  that  many  piactitionera  iioft^iie 
the  itiue  f/u4  non  of  i&uecc^^s,  in  the  management  of  hemorrbagv, 
be  the  removal  of  the  placenta ;  and  hence  in  these  csfles  ibn  vf 
first  thhig  attempted  is  to  extract  thin  body,  under  the  imprc 
that  vviili  its  deliviTV  the  flooding  will  cease.  There  never 
mure  perfr<a  dflunion.  Why,  gentlemen,  the  atter^birlh,  its  ftlrlot 
truth,  ha-H  nothing  to  do  with  the  hemorrhage,  it  i*  not  a  bk*c*dfnj» 
surface,  and  whether  it  be  within  or  without  the  uterxu*  h  a  iiiau%*r 
utter  indifference,  ko  far  as  the  great  object  i-^  concern^ — iMe 
ndueinff  uterine  contraetion.  The  praotice  h  founded  upon  tragm* 
and  indefinite  notions  with  regard,  in  Iho  ttinit  place,  to  %\po  %nm 
caufie,  and  secondly,  to  the  true  source  of  the  hemorrhage. 

Erffoi, — Another  frequent,  and,  in  vny  judgment,  ollentimwi  frntal 
wror,  is  to  rely  t»n  the  actititi  of  erffot  ;  hencCn,  a*  soon  as  il  U 
ascertained  tluit  hcmurrttage  exi^its,  thia  remedy  is  reiiortrd  to 
ttudcr  the  conviction  that  it  will  provoke  contractiofi,  and  ibm 
arreiit  the  flooding.  The  cardinal  objection  to  this  praclioti  1%  thju 
ahhongh  ergot  does  unquestionably  exercise  a  poMitive  and  marlciMl 
influence  on  the  muscular  action  of  the  uterus,  yut  it%  eftcei!*  arii 
not  ijpracdiatc  ;  frequently^  ten,  ti.tcen,  and  twenty  aiinutei^  claps- 


THB  FBHrCIPLES  XSJ>  PRACTICE  OF  OBSTETRICS.         898 

ing  before  there  is  the  slightest  therapeutic  manifestation.  With 
this  agent,  therefore,  as  the  sheet-anchor  of  hope,  death  will  often 
ensue  before  the  remedy  acts ;  and  I  have  no  hesitation  in  saying 
to  you  that  er^ot  should  not  be  classed  among  the  heroic  agents  in 
the  treatment  of  uterine  hemorrhage  after  the  biith  of  the  child. 
There  can  be  no  harm  in  adminiiHering  it,  but  do  not  let  it  take  the 
place  of  other  and  more  reliable  means,  to  which  we  shall  presently 
allude. 

Tampon. — Again  :  there  is  an  unfortunnte  and  far  too  common 
belief  that  the  great  remedy  for  hemorrhage  is  the  tampon;  with 
this  conviction,  many  physicians  have  recourse  to  it  the  moment 
they  are  aware  that  flooding  exists.  The  vagina  is  immediately 
plugged  up,  and  in  order  to  make  matters  doubly  sure,  a  T 
bandage  is  employed  for  the  purpose  of  retaining  the  tampon 
in  situ.  With  the  slightest  possible  reflection,  the  absurdity 
of  this  practice  as  a  remedial  means,  under  the  circumstances,  must 
be  too  apparent  to  need  comment,  for  do  you  not  at  once  perceive 
that  it  can  have  no  effect  whatever  in  producing  the  only  thing 
that  will  arrest  the  bleeding — contraction  of  the  uterus  ? 

But,  gentlemen,  there  is  something  more  than  absurdity  in  the 
application  of  the  tampon  in  these  cases ;  there  is  positive  danger, 
which  almost  always  results  fatally  to  the  unhappy  patient.  Look 
at  it  for  an  instant.  When  the  child  is  delivered,  and  the  tampon 
resorted  to  for  the  purpose  of  relieving  the  hemorrhage,  the  only 
eflTtCt  is,  by  occluding  the  mouth  of  the  womb,  to  convert  an 
external  into  an  internal  flooding.  It  is  true,  the  blood  ceases  to 
flow  through  the  vagina,  and  this  may  afford  you  momentary  con- 
solation, under  the  erroneous  impression  that,  because  there  is  no 
longer  any  external  sign  of  bleeding,  therefore,  all  danger  is  at  an 
end.  Delusive  and  fatal  hope!  It  will  not,  however,  be  long  that 
you  will  be  permitted  to  indulge  in  this  fiction,  for  the  evidences 
of  exhaustion  will  be  fast  accumulating;  the  strength  of  the  patient 
becomes  more  and  more  dilapidated,  and  you  will  soon  be  brought 
to  a  full,  but  melancholy  appreciation  of  your  folly,  by  seeing  her 
rink  at  the  very  time  you  imagined  you  were  rendering  a  most 
essential  service  !  My  advice  to  you  is — 9iever  resort  to  the  tampon 
as  a  means  of  checking/  hemorrhage  after  the  birth  of  the  child, 
for  the  reason  that  it  exercises  no  possible  good  in  accomi)lishing 
the  important  olgect  in  view — the  contraction  of  the  uterus — but, 
on  the  contrary,  its  direct  and  necessary  tendency  is  to  convert  an 
external  into  an  internal  hemorrhage,  thus  lulling  the  practitioner 
into  false  hope,  and  insidiously,  but  most  certainly,  destroying  the 
patient ;  for,  as  I  have  already  remarked,  whether  the  flooding  be 
internal  or  external,  if  it  be  not  checked,  the  tendency  is  the 
same — death. 

Pressure  and  Cold. — Having  disposed  of  those  measures,  which 


894      THE  PRmcrrLEs  aj^d  PRAcrfcE  of  obstetricsl 

have  an  unmerited  popularity,  and  which  nrc  not  the  measnrei 
eeience  can  recognise  as  the  weapons  fitted  for  iliis  terrible  conflict, 
I  shall  now  proceed  to  point  out  what,  in  my  juilgriaent,  are  tlie 
more  reliable  and  effective  means  to  be  adopted.  Keinetnber,  thrre 
is  no  time  for  compromiiie,  no  time  for  capitulation — ^the  vneray, 
with  bold  front,  and  intent  upon  destruction,  hiis  bid  hi«  grasp 
upon  the  victim,  and  the  issue  of  life  or  death  uill  be  di^tefw 
mined  by  the  promptness  and  character  of  the  resistance,*  There* 
fore,  what  you  are  to  do,  in  the  nmnagement  of  JiHuorrha^v  ii 
this — introduce  your  hnntl^f  without  a  moment's  dc!ay,  into  the 
uterus,  carry  it  up  to  t!iat  portion  of  the  organ  to  whii4t  tht*  pfai- 
centa  is  partially  attached,  or  from  which  it  ha»  bi*en  <  ^  '  ?y 
separated  ;J  willi  the  expanded  dorsum  of  the  fingers  tn  ;  !o 

but  uniform  pressure  agriinst  the  bleeding  utero-placenlal  %«'!k>rl% 
and  with  the  other  hand  ap[jlietl  to  the  abdomen,  make  counter 
preasure.  Should  the  womb  not  contract,  have  recourse  immedi- 
ately to  the  cold  dash — let  a  pitcher  of  ice  wafer  be  thro%i  n  from 
a  height — say  two  feet — *^uddenly  and  with  irnpfilN*  upon  tbe 
abdomen,  and  repeat  it  without  hesitation  shonhl  it  be  ne«^c*^ary. 

Such  are  the  heroic,  Rubstantial,  and  cotnnion-*»ense  rt-nuHlii^  In 
these  cases  of  desperate  hope,  and  they  will  of\en  serve  you  thith* 
fully  in  tlie  hour  of  need.  As  soon  as  the  uterus  begin**  t*i  wii>* 
tract,  g:il her  up  the  arterbirth  in  your  hand,  should  it  bt*  uithinlhe 
organ,  and  keep  it  firmly  in  your  grnnp  until,  by  powerful  contmc- 
tions,  it  togetlu^r  with  the  hand  is  expelled.  Striking  bt-ueJil  will 
he  derived  from  the  introduction  of  a  small  piivo  of  ivv  into  the 
vagina  or  uterus^— the  cornaet  of  cold,  thus  suddenly  a}<|)liiH],  will 
oftentinjes  ot-eaMon  immediate  contraction  of  the  organ,  by  the  sti- 
mulus itnparteil  to  the  excitor  nerves  of  the  part,  inducing  the  Mi 
influeure  of  reflex  movement.  Injections  of  iced  water  into  flie 
rectum    will  also  act  powerfully    uj»on  the  uterus  through   rrflex 

•  rt  munt  h^  undewtood  ihtit  I  am  tiow  Rjh^nkiriff  of  iltJit  fiffrn  of  proAviv  mmI 
pfrilfiiiM  ttiifKltng.  vfWich  ciiIN  for  llii^  rmv^t  iMiRiltvo  nnd  pmtnpt  rnt^imtuv^  te  wilt 
often  lui|»jx*ri  thai  lliero  will  bw  ii  pmUpariutu  Ium  in  ci>nRcq**<*nou  of  «rl»!it  r  uit  b« 
*lemicil  tlio  wafU  of  cnmptdv  cnnlnicllini  of  tlie  u tenia  ;  tb©  nr^n.  alt  lo 

S  *t»t4»  of  ^^rivfiil  Mifftbi,  hiis  h(»t,  «»  it  wer©,  |in>fH»rl/  rpppfMKlrHj  ii>  ili«  ..»^ 

dllld :  Mul  m  A  ciifist^queiK'e,  titcrc  mny  be  moro  or  \cm  hemorrliiiicc.  lu  tM»em 
OWie^  |;i*ntlo  frictloiiii  oti  Uh«  niKJimien.  the  iifiplicntinn  of  elolbit  wK  witU  cold 
WAt^r  lr>  il»c  iiMnmeti.  wu'rum,  »ruJ  vulv*»,  will  u.HUally  stiflUy*  ti>  i>>iitM  lUi»  l*lf«rdii^ 

I  It  ItnA  iwiMi  t>bj<H!tfi1  to  litis  pnictlcc  of  introduelrig  tlio  Imnil,  ff^  the  piir|in«w  ef 
aiAktiih'  |)n*«fluri\  ihiii  it  will  occusion  mHrUis.  1  liifvti  rrpouicdiy  ImiJ  frfimr^e  to 
llilfi  r^tfxnljk'iii,  iin<]  ill  r»o  in<iiUfic*i*  Iimk  iitJcli  h  mmiH  rollowvil,  .Idmiuttiir,  how^r^jr, 
the  Itirvr  ut  iJMt  iippfi'hcnDiofi,  wtiuid  it  not  b«  iH^ltcr  to  hicur  th«  haurd  </  UiMaa- 
tDAtliMi,  thdD  to  allow  tlic  pntiout  to  die  fhaai  exhamiion  t 

}  ir  tho  ptaceti^o  W  m  ]virtiul  »dhfitii>a  with  ilic  uierunt  roUowliift  iHe  oonl  vlll 
•ttnbk*  the  jifvout'tkcur  to  HMcvrtJim  itie  {^rtiruUr  \Aiiw  of  iu  utistdtm^iit ;  HI  nn  tte 
OfHitfiirv^  it  filiiiuM  ItiiTe  become  fsv  pimitcd  fmni  tia*  utcrintf  fturftiee,  tU»  muuitM  if 
llM  tttefo^placetital  veawli  wiU  MicKle  Hit*  poiut  of  i 


THE  PRINCIPLES  AKD  PRACTICE  OF  OBSTETRICS, 


395 


^  icy.  Iced  water  as  a  drink  will  occasionally  display  great  effi- 
cacy in  uterine  inertia,  causing  contraclion  of  the  organ,  ihrouffh 
its  iinpressioi^n  the  pneumogastno  nerve,  which  is  also  an  exeilor 
of  the  uterus* 

From  the  well-known  physiological  relation  between  the  iiiamm» 
and  uterus,  it  has  been  recomtnendecl,  with  a  view  of  arresting 
hemorrhage,  to  apply  the  infant's  mouth  to  the  nipj)U%  and  thus 
excite  an  action  in  tfie  spinal  nenes,  which  is  immediately  trans- 
mitted to  the  mednUa  sjunalh  ;  the  latter  bocomirig  the  seat  of 
ii'ritalion,  iruparts  to  the  motor  nerves  of  the  uterus  an  influence 
which  induces  contraction  of  this  organ.  This  may  do  in  moderate 
hemorrhage,  but  it  is  not  to  be  relied  upon  in  those  cases  iu  which 
life  is  menaced  if  the  flooding  be  not  promptly  arrested. 

Compression  of  the  Abdommal  Aorta. — Compression  of  the 
aorta  has  been  proposed  as  au  efficient  me:ins  of  checking  uterine 
hemorrhage;  but  it  seems  not  to  have  met  with  general  favor. 
Two  objections  have  been  urged  ,n gainst  it:  1,  In  women  loaded 
with  adipose  matter,  it  will  bu  difficult  to  make,  through  the  abdo- 
minal parietes,  the  necessary  pressure  ;  2.  Compression  of  ihc  aorta 
will  more  or  le^^s  obstruct  the  cireuliition  in  the  vena  cava.  Let  us, 
for  a  moment,  examine  these  objections:  as  to  the  fiiist,  it  is 
undoubtedly  true  that  it  will  be  difficult  to  press  u]>on  the  anrta 
through  tilt'  abdominal  walls  of  m^djc  women  ;  but  this  co  tninly 
has  nothing  whatever  to  do  with  the  apjilieution  of  the  rule  where 
the  objection  does  not  exist ;  and  secondly,  witli  the  simple  recol- 
lection of  the  relative  disposilron  of  the  aorta  and  vena  cava — the 
former  on  the  Iet>,  and  the  lattuc  on  the  right — it  would  be  rpnte 
€4i*y  to  avoid  making  pressure  on  the  vein,  Bnt  admitting  the 
poiisibiltty  of  pressure  on  the  vein  (which  would  never  be  comp'ete), 
it  would  in  no  way  prevent  the  success  of  the  operation.  I,  there- 
fore, regard  eom press! oji  of  the  aorta,  jtrovidcd  it  be  properly  made, 
as  a  sovereign  remedy  ;  not  merely  as  is  generally  supposeil  because 
there  is  no  more  blood  reaching  the  titerus,  but  for  another  reason 
which  has  been  demonstrated  by  the  experiments  of  Dr.  E.  Brown- 
Sequard,  ttiat  there  is  no  more  certain  mode  of  prndticing  contrao-^ 
tion  of  the  wondi  than  by  the  arrest  of  the  arterial  circulation, 

Lijection  of  Cold  Water  into  the  (JmbUmtl  Vein  and  Carity 
of  the  Uterus, — It  is  proper  to  njentitui  that  the  injection  of  cold 
water  into  the  umbilical  vein,  in  cases  in  which  a  large  portion  of 
the  placenta  is  still  in  adhesion  with  the  uterus,  has  been  resorted 
to  auccesst'uUy ;  the  water  should  be  injected  in  full  quantity.  The 
throwing  of  cold  water  into  the  cavity  of  the  uterus,  as  a  means  of 
arresting  hemorrhage,  has  been  seriously  opposed  under  the  appre- 
hension that  it  would  result  in  metritis  or  peritonitis.  On  the  other 
band,  we  have  the  authority  of  Scanzoni,*  who  says  he  has  employed 

•  Lehrbuoli  de»  Geburtshilfo,  p.  509.     1855. 


THE   PKIKGIPLIS   AND 


'4i9  •OSSTBTRICS. 


these  in jt*cUoijs  with  success  in  more  limn  one  hnrnln  J 
in  no  instiinrc  was  there   atiy  evil   reaulUn^,  or  au  ir|^ 
tnflannnatioii  either  of  th«  uterus  or  peritoneam, 

Varinus  other  remedies  have  been  sugccf^ted*     Electricity, 
example^  has  been  much  landed  by  eeitnin  English  a«tl)oritieii;  bat  | 
yon  mu«t  at  once  recognise  a  rery  serions  object  it  jii,  which  in  ibti 
delay  necessarily  connected  with  hn  application,  siiujily  for  the  res^ 
son  that  the  apparatus  h  nut  ui  hand,  and  oflen,  before  It  eould  \m 
obtained,  death  will  have  claimed  \m  victim.     I  need  ^^  ati» 

tton  you  against  the  unjusti liable  and  flaiijUferous  practice  \mi 

by  some  author?*,  of  injecting:  vinegar,  lemon  jtiice,  and  other  iiri* 
tfttin^  jiubstaneca  into  the  cavity  of  the  uterus  ;  they  aro  all  pfmi- 
clous  iu   their  tendency,   without   a   solitary  advantage  in   th«rl 
filTor.^ 

In  brief,  I  wi.^h  to  reiterate  in  the  most  emphatic  manner,  tlial  m 
cases  of  perilous  floodlnff^  the  tieo  ^ai  and  efficient  remedies  ar0^i 
ffrtamfrc  and  eoid^  lo  be  employed  a^  already  indicnied;  ami  1  will 
further  «tate,  that  if  my  ex]>erienee  be  worth  anything,  they  will 
prove,   if  ihoroughly  carried   out,  perfectly  tnisJl worthy,  even   in*^ 
instances  of  apparently  more  than  desperate  hope.     Allow  me  taj 
remind  yon  that  when  it  has  become  neeesisaary  to  rejiort  to  refrijj 
ronta  for  the  purpose  of  bringing  on  uterine  conttaetion^  the  mo*] 
ment  thi*  latter  object  has  been  aceoniplished,  and  cnn^equently  the] 
bcmorrhage  arretted,  no  time  ahotdd  be  lost  in  imparting  wtnrnih  \ 
by  thfi.  afipiication  of  littles  of  /tot  water ^  fearmjiumieh,  ete,^  but^  in  ^ 
doin*;  this  the  patient  in  not  lo  be  moved,  for  the  slightest  exrrlion  1 
would  be  likely  to  produce  fainting.     Let  me  here  enjoin  npcm  ywo  ' 
in  cm'j^  of  exfiuustion  after  Hooding,  to  make  it  a  rule,  without  an  j 
exception^  never  to  jienntt  the   patient,  even  for  an  Inatant, 
assume  the  upright  or  sitting  position.     More  than  one  example  ofl 
sudden  death  from  this  cause  could  be  reccirded,  the  t*xplanalt(iil| 
beitig  that,  the  brain  becomes  deprived  of  its  blood,  and  fatal  ajf 
oojKJ  is  the  result, 

TVcatmmt  of  Exhaustion  from  Ftoodinff, — ^We  will  now 
pose  that  you  have  succeeded  in  causing  the  nteruj*  to  e< m tract,  and f 
the   biveding  is  checked.     If,   with   the   attairnueut  of  theiie   t% 
reaults,  you  imagine  that  the  battle  is  over  and  vietory  complfte,| 
you  will  sometimes  find  yonrselves  sadly  in  error;  under  tbt'*  delo.^ 
sion,  your  patient  may  still  »ink  for  want  of  proper  attention  on 
your  part,    I'^rom  tfie  excessive  loss  of  blood  jtuMtnint'tl,  her  strengtli 
will  be  gone,  the  vital  powers  so  entirely  pro^irate  that  she 
exhibit  the  aspect  of  a  moriband  woman — deadly  pallor  of  oob 

•  AlthaugU  we  liave  the  high  authority  of  Outrepont*  Kiw'wcU.  and  oihet% 
liii^or,  in  mmQ  iofitAnecflt  of  emplov{ng  a  iolutiofi  (iT  tlio  niiiiUiUi  rif  Iron  wit>i  tliA  00 
water,  119  iia  tnj<?i'tion  into  the  cavity  of  the  utcrotr  yet  my  owa  opinion  i«»  that  tha 
cold  water  «lon«  will  be  cjqijally  efficicaL 


THE  PBINCIPLES  AND  PKACTIC£  OF   OBSTETRICS. 


397 


tenaiice,  co!d  surface^  no  puke  to  be  detected  in  the  radial  or  tern- 
portil  arteries,  the  beatings  of  the  heart  so  feeble  that  they  cannot 
be  appreciated.  In  these  cases,  whieb  so  closely  simulate  dit^olu- 
lion,  there  is  no  lime  for  inaelion  ;  every  second  ntiiraprovcd  for 
tJie  benetit  of  the  pntient  is  so  much  abstraett^d  from  her  chaucesj  of 
restoration.  Instead,  therefore,  of  regarding  her  as  beyond  relief^ 
and  participating  in  the  confusion  and  sorrosv  of  those  who  sur 
round  her  couch,  your  duty  is  at  once  to  have  recourse  to  those 
measures  best  calculated  to  produce  prompt  reaction.  For  this 
purpose,  the  various  f^timuhints  are  to  be  eni|>loyed — brandy,  milk 
punch,  strong  coffee  with  laudanum,  etc.,  but  a  due  degree  oH  care 
is  to  be  exercised  in  their  administration^  for  remember,  nller  a 
niomentfiry  revival,  the  patient  is  again  apt  to  fall  into  coHapse. 
It  is  as  it  were,  but  the  last  flickcnng  of  the  light.in  the  socket, 
there  is  but  one  spark  lett,  and  if  it  be  too  rudely  blown  it  brightens 
for  the  instant  only  to  become  for  ever  extinct.  When  reaction  ia 
etitablished,  tfie  strengtli  must  be  sustained  by  animal  broths, 
arrow-root,  tnpioea,  jellies,  etc.  Oji  the  otiier  hand,  it  is  not  to  bo 
forgotten,  that  the  reaction  in  these  eai^es,  growing  out  of  the  free 
UAc  of  stimulants,  will  sometimes  be  more  than  the  system  c:in  sustain^ 
and  hence  serious  congestions  may  arise  requiring  prompt  attention. 
Pressure  on  the  Jfain  Arteries  ef  (he  J£jrt remit ie$, — Alter  the 
hemorrhage  has  ceased,  and  with  a  view  of  rallying  tlie  sunken 
forces,  we  have  a  most  important  remedy  in  properly  directed  pres- 
iurc  on  the  main  arteries  of  the  limbs,  by  means  of  the  tourniquet 
or  hand.  In  this  way  a  large  amount  of  blood  is  kept  circulating 
in  the  principal  organs  of  the  body— the  brain,  lungs,  jmd  heart. 

2.  Internal  Htnwn^hage, — You  have  been  reminded  that,  when 
the  hemorrhage  is  internal,  it  is  bo  beeauae  the  mouth  of  the  womb 
is  closed  up  either  1>y  the  detached  ))lanenta  or  a  ctjagulum  of 
blood,  thus  eon.stiluting  what  is  descnbcd  as  internal  or  concealed 
flooding*  Whether  the  hemorrhjige  be  external  or  internal,  the 
object  of  treatment  is  preeii^ely  the  same — ^the  bringing  on  contrac- 
tions  of  the  uterus ;  and  tije  means  for  accomplishing  this  etid  are 
Jso  identical.  Internal  flooding,  I  have  told  you,  is  oftentimes 
asidious,  because  tliere  is  no  blood  escaping  from  the  vagina. 
The  practitioner  is  not  apt  to  suspect  that  anything  is  wrong,  and 
the  first  admonition  of  danger  will  be  the  exsanguinated  condition 
of  his  patient.  But  you,  who  I  trust  now  fully  appreciate  the  abso- 
lute necessity  of  guarding  against  a  surpnse  of  this  kind,  will  not 
Pom  it  to  observe  the  direction  of  ascertaining  whether  or  not  the 
uterus  be  contracted  after  the  child  has  made  its  escape.  It  may, 
however,  happen  that,  notwithstanding  the  birth  of  the  chiid,  the 
uterus  will  still  be  large,  and  yet  there  is  no  flooding.  This  may 
bo  in  consequence  of  a  second  fcelns  occupying  the  cnvify  of  the 
womb,  and  the  diagnosis  can  be  readily  made  out  by  carrying  your 


398 


THE  PBlNCrPI/ES 


fCE  OF  OBOTETRTCa 


finger  to  the  os  ulerL  In  the  event  of  a  Necond  child,  some  por- 
tion of  it  will  bo  felt.  If,  on  the  contrary,  the  uterus  he  enlarged 
In  consequence  of  being  distended  liy  the  accuinulntian  of  blood — 
intonml  honiorrhilge — the  organ  will  bo  found  more  or  t^ss  sort  oo 
prrf«ftiir(\  invpartitii^r  to  the  band  a  scnifation  as  if  pre^ng  upon  n 
pillow,  and  there  wilt  be  all  the  evidences^  too,  of  pi'osti'ation. 

The  folio  wing  case  is  not  without  instruetion  ;  the  recoljectioti 
of  it  may  serve  a  useful  lesson.  It  la  a  sorrowful,  raelaneholy 
tale,  and  well  do  I  rernen»ber  how  deeply  it  afteetcd  my  fi'ctiitgv, 
and  hfjw  freely  it  cau8ed  nie  to  synipatliize  with  thoi^e  who  were 
the  he:nt--stricken  witneases  of  the  harrowing  scene : 

Some  year§  since  I  waii  sent  for  in  great  ha^te  by  a  gentleman  to 
meet  him  in  eonsuttation  iu  the  case  of  a  lady,  who  had  just  brcn 
delivered  of  a^'hlld*  Ah  jioon  a«  I  reached  the  houne,  which  was 
done  without  delay,  he  inlbrrned  me  thai  shortly  before  my  arrival 
h©  had  delivered  the  patient  of  a  fine  son,  and  he  remarked  thit 
there  was  another  fietu«  in  the  womk  Finding  hifl  patit*nt  groir- 
ing  vv  e;ik^  he  thom;:ht  it  advisable  to  send  lor  aj^HiHtanee.  Thiii  waa 
all  lf>e  information  I  rccc^ived,  when,  on  heinir  introdnced  into  the 
i"Oijm,  I  witnessed  a  scene  which  I  have  not  language  to  describe. 
The  husband  and  two  female  relatives  were  standing  by  the  bisd* 
ude  of  the  dying  woninn;  her  two  tittle  children,  who  h:id  been 
asleep  in  an  adjoining  chandicr,  awakened  by  the  conftisioti,  b#» 
came  alarmed,  and  rushed  into  their  mother's  apartment*  Tbe 
moment  I  lieheld  the  patient  I  bcx*ame  eonvinc*ed  that  all  was  over  1 
There  »he  lay,  pulseless  and  speechless,  with  death  in  grapldc  let- 
ters written  on  her  eountenant'e.  In  jilaeing  my  haml  on  the  abdo- 
men, I  observed  it  immensely  distended;  it  was  soft  oo  pressurei 
and  in  an  instant  I  arrivetl  at  my  diagnosis ;  it  was  a  case  of  mfsr^ 
nal  hctHoirhage,  Without  delay,  I  introduced  my  hand  for  tbe 
purpose,  if  possible,  of  inducing  contraction  of  the  womb.  Tbe 
plaeetjta  was  detached,  :njd  r**i?ted  immediately  over  the  month  of 
the  organ,  thus  etfectually  preventing  the  esca|Ki  of  Idood  exteniallr, 
and  leading  the  practitioner  to  a  fatal  error  as  to  the  actual  condi- 
tion of  his  patient.  As  soon  as  I  had  introduced  my  haiid^  tbe 
nnhappy  lady  seemed  to  expedience  a  momentary  rcsuscitatian; 
she  upened  her  eyes,  \^  ildly  gaajcd  on  those  around,  uskud  fur  ber 
children,  and  instantly  expired  ! 

Ckmmient  here  cmi  sc^iroely  bo  necessary.  Error  of  judgment  aa 
to  the  nature  of  the  difficulty  had  thus  suddenly  swept  from  esirtb 
an  intervsling  wonnm — it  had  converted  a  house  of  joy  into  one  of 
mournhig,  and  deprived  the  young  and  hel|iless  of  a  motherV  love 
and  d<^votion.  Such  scenes  aro  indeed  agtmising;  they  are  cal- 
culated to  make  a  lasting  impression  on  the  minds  of  all,  who  fed 
tip  y  of  accurate  kTiowledge,  and  tlie  fuhiess  of  profeastond 


rc>i 


'ly. 


THB  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         899 

IVeatmefU  of  Internal  Hemorrhage. — ^The  manner  of  treating  a 
ease  of  internal  hemorrhage,  I  repeat,  is  precisely  the  same  as  when 
tfie  hemorrhage  ia  external.  Tlie  hand  is  to  be  introduced  into  the 
uterus  for  the  purpose  of  making  pressure  against  the  utero-placental 
vessels.  Pay  no  sort  of  attention  to  the  detached  afler-birth  or  the 
ooagulum  of  blood,  which  may  be  the  cause  of  the  occlusion  of  the 
moath  of  the  organ ;  but  carry  the  hand  up  at  once,  pushing  the 
plaoenta  or  coaguluni  one  side,  and  seek  for  the  bleeding  surface ; 
and  then  you  are  to  proceed  as  has  already  been  indicated  when 
.  speaking  of  the  management  of  external  flooding. 

There  is  a  circumstance  connected  with  profuse  losses  of  blood 
in  the  puerperal  woman  which,  in  a  practical  point  of  view,  is  of 
essential  moment,  and  I  do  not  think  sufficient  value  has  been 
attached  to  it.  I  allude  to  two  morbid  phenomena  which  may 
be  regarded  as  the  ordinary  sequelie  of  this  anaemic  condition  of 
system: 

Intense  Headache^  with  Intolerance  of  Light, — ^The  cephalalgia 
and  intolerance  of  light  are  features  associated  with  exhausting 
hemorrhages  in  every  way  worthy  of  consideration.  An  error  in 
diagnosis  here  will  be  at  too  heavy  a  cost,  and,  therefore,  in  such 
cases,  a  careful  judgment  should  be  exercised  that  the  truth  may  be 
developed.  In  order  to  illustrate  this  question,  and  present  it  to 
you  in  the  most  tangible  and  practical  manner,  let  us  suppose  that 
you  have,  by  prompt  and  efficient  action,  safely  conducted  a  patient 
through  an  attack  of  perilous  flooding.  When  you  make  yoin*  first 
visit  the  next  morning,  you  find  the  room  in  total  darkness,  and,  on 
inquiring  of  the  nurse  why  she  has  so  completely  excluded  the  light, 
she  answere :  "  Oh !  doctor,  madam  has  been  raving  with  her  head ; 
she  says  it  feels  as  if  a  knife  were  piercing  it,  and  she  has  made  me 
darken  the  room  because  the  slightest  light  almost  sets  her  crazy." 
You  approach  the  bed,  and  the  suffering  invalid,  in  a  feeble  voice, 
requests  you  to  do  something  to  relieve  her  head.  "  If  I  am  not 
relieved,  doctor,  I  shall  die."  I  have  more  than  once  heard  this 
very  language  ;  now  for  the  point.  The  two  prominent  symptoms 
which  occasion  so  much  distress,  viz.,  the  headache  and  intolerance 
of  light,  are  the  very  symptoms  of  phrenitis,  or  inflammation  of  the 
brain.  If,  therefore,  you  should  make  a  false  diagnosis  and  imagine 
that  your  patient  is  absolutely  affected  with  this  latter  disorder,  you 
will  proceed  with  your  antiphlogistic  course  to  arrest  it.  The  lan- 
cet, leeches,  purgatives,  and  blisters  will  be  called  into  requisition, 
and  too  soon  you  will  discover  that  you  have  been  attacking  a 
phantom,  and  the  sad  penalty  of  your  blunder  will  be  the  death  of 
your  patient!*    The  headache  and  intolerance  of  light,  so  far  from 

♦  It  is  well  to  bear  in  mind  that  slight  congestion  of  the  brain  is  not  always  inoom- 
pAtfble  with  more  or  less  profuse  losses  of  blood ;  and  the  vigilant  practitioner  will 
nonally  find  that,  when  the  exhaustion  is  not  extreme,  this  oongestion  may 


THE  rniKCIPLES  AND  FRACTICfi  OF  OBSTBTMCS. 

beinjr  tJic  productg  of  iniiamraation,  Are  the  re^nlts  simply  of  tbt 
exMiiguinatevi  »tat€  of  the  Hystem.  The  iiidicntion,  ihcrefore,  is  to 
restore  to  tho  blood  its  lost  albumen  by  sppropriate  tome  traal' 
ment,  such  as  nulnuoiis  diet,  small  clones  of  quii\ifie,  etc. 

Til  ronjnnotion  with  this  treatment,  a  mo«t  essential  object  10  to 
calm  the  IrriiabiUty  of  system,  reveahnl  by  llie  general  rejitles^meM 
and  nmre  or  less  jactitation  of  the  patient — what  she  most  needs  is 
gentle  sleep.     The  following  combination  I  have  found  efBtient: 

Pnlv,  opii»,  gr.  iii. 
Carbonat.  animoniie,  gr.  xij. 
Extract,  hyoscam.  gr.  xv. 
Ft.  roassa  in  piL  dividcnda,  vt« 

One  pill  every  two  or  throe  hours,  as  rircunistanccs  may  indicate. 

TV^vf^fusion, — It  will  be  proper,  in  connexion  with  the  (ptcstioB 
of  uterine  hemorrhage  and  its  results,  to  make  a  few  passing  iibs«r» 
vtttions  on  the  subject  of  transfusion,  whirh  consists  in  restoring  iho 
vital  energies  by  injecting  into  the  venons  system  of  the  patiesil 
blood  lakt?n  from  another  individual.  This  practice  is  not  tif  modc?ni 
origin,  for  you  will  find  it  both  spoken  of  and  adopted  by  some 
of  the  writej-s  of  the  sixteenth  century.  Dr.  Blundoll,  from  uufii»* 
roiis  experiments  on  animids,  convinced  of  its  ef!i<^ary  in  certain 
cases  of  cxhjuisiion,  dcst^rve**  iho  credit  of  being  the  lir)»t  to  fMOft 
to  this  Hlternative  in  the  puerperal  woman,  which  he  did  in  1825 
with  complete  success;  but  in  doijig  so  he  was  not  without  bitt«r 
oppositiiin.  There  are  a  number  of  cases  recorded  by  anthoni  In 
which  life  was  save^i  under  circumstances  where  every  other  eflbrt 
bad  failed  in  bringing  on  reaction.*  When  the  doctrine  of  traxuAh 
sion  was  first  suggested  in  the  sixteenth  century,  it  was  suppo^ied 

exist,  «ud  will  yield  to  thi»  ippliciition  of  two  or  three  leoch«a  to  tbo  tcmplM;  ar« 
whst  I  Imvp  Irird  with  gtHw]  eflecl— riry*ciippinj^  beliitid  llio  &eck. 

*  Tij  uti  ititere5itm(c  t»oj:ii>|crfi|>li  oti  triih^niMKin,  which  him  n-<}vtiilj  sppgaii^  tyjr 
Rdwanl  Manin,  FrofeAsor  of  Midwifi'ry  in  thu  University  of  Berlin,  it  is  *Xmu4  thai 
there  an?  flfly-H^^ht  known  cnnt-'H  in  which  thia  nlti^mAtivc  hni  bc«*n  had  f'wji>ufwi  to 
In  ^  ii  forty -« IX  of  which  f  -^mifAmfi 

rfii  'i'->ii  wvrv  sufii  iiii  to  itj  ,  ;»« irltftl- 

0V4.1  4  lUc  rcuiaiuuijf  twelve  qasos.  tho  (nUd  u«uw  v>Ai  tmcMbto 

to  li  ^  h.ivi(iR'ti<>c<nui«»Kl<iri  whnlt'vcrwiih  the  op^rntiwi.     Pip» 

tawr  M«{ii4>  Uiily  ol>»vrVi^  tlmC  thi'i*.^  Im«  boen  miicli  diflcii^iim,  tru^  '^rio 

h$yet  tiTi^i'frf  nl,  wlunh*»r  the  imntfiwixi   blood  neta  by  re«titnri(7n  h  <i^ 

plv'  blood,  or  by  ^timylnrintf  thi?  wnlls  of  the  vo  il^jr 

ihc  I  -  tr>  pnvlonji^  thn  arti%ity  ofUMS  luUer  unii)  lln  Mtal 

tlutd  ts  otiiurwlMM  |ir(Klu<,vtl     lit*  rnthc/  iitdiucs  io  iho  opiuicn  li  c4^  tXwm 

iuttt4vnc«^  may  b»i  ii>H?ribed  th<^  n^atoriitlve  result;   while  h<^  •'  vwof^thm 

stimuJjition  of  the*  whUa  of  the  ^-efisclf)  nntl  heart  i^  the  tnor<  for  thv  ffvmi 

Ihiit  the  8miili  ^unntity  of  bhunl  tninNfiiffed  Is  oUdfrclber   1  to  Acooonlte' 

liie  r«)]iction.  It  hns  ttHm  Ui-ii  proved  that  the  red  corpasck*f  of  Xht  blood  art  tifel 
proper  rcfltorauvc%  nUhougk  tlietf  aclioQ  la  tnntvrially  uni^  bj  lii#  M^fnm. 


THE  PRINCIPLES  AKD  PRACTICE  OF  OBSTETRICS.         401 

tbat  a  great  boon  bad  been  granted  the  human  family ;  the  old  men 
and  women  were  to  find  in  this  expedient  more  than  the  philoso- 
pher's stone ;  years  and  decrepitude  were  to  yield  to  this  wonder- 
ful discovery ;  and  you  will  read  in  the  writings  of  that  century 
directions  for  rejuvenation — for  example,  an  old  man,  in  order  to 
recover  his  adolescence  and  vigor,  was  advised  to  suck,  after  the 
fashion  of  the  leech,  blood  from  the  arm  of  some  youth.  With  the 
hypothesis  of  rejuvenation — about  as  difficult  to  aceomplish  as  per- 
petual motion — you  may  well  imagine  the  popularity  of  transfusion, 
and  the  wild  enthusiasm  with  which  its  advent  was  greeted.  But 
these  chimerical  notions  soon  died  away,  for  they  had  nothing  on 
which  to  rest  but  imagination.  Not  so,  however,  with  regard  to 
the  fact — that  the  throwing  of  blood  from  the  system  of  a  healthy 
individual  into  the  veins  of  a  patient,  exhausted  by  hemorrhage,  is 
really  a  means  of  saving  life. 

It  was  the  opinion  of  Dr.  Blundcll  that,  in  order  to  insure  perma- 
nent success  in  this  operation,  it  is  essentially  necessary  that  blood 
of  the  same  species  of  animal  shotild  be  employed,  lie  found  from 
experiment  that  a  dog,  bled  almost  to  death,  could  recover,  even 
if  blood  of  a  mammal  of  another  species  be  transfused  into  its 
veins;  but,  after  a  few  days,  death  always  ensues;  while,  on  the 
contrary,  in  employing  the  blood  of  another  dog,  the  animal  would 
be  permanently  restored.  Prevost  and  Dumas  have  also  con- 
tended for  the  same  priiu*ii)lc,  and,  indeed,  if  I  am  not  in  error,  this. 
was  the  prevailing  doctrine  until  very  recently.  That  eminent  and 
sagacious  physiologist.  Dr.  E.  l^rown-Soquard,*  who  is  now  so 
deservedly,  through  his  rich  contributions,  attracting  a  large  share 
of  attention  from  the  scientific  world,  has  made  numerous  e3q)eri- 
ments  upon  this  subject,  from  which  he  deduces  the  following 
important  conclusions : 

First, — That  arterial  or  venous  blood  from  an  animal  of  any  one- 
of  the  four  classes  of  vertebrata,  containing  oxygen  in  a  suflicient 
quantity  to  be  scarlet,  may  be  injected,  without  danger,  into  the 
veins  of  a  vertebrated  animal  of  any  one  of  the  four  classes,  pro- 
vided that  the  amomit  of  injected  blood  be  not  too  considerable. 

Second, — ^That  arterial  or  venous  blood  of  any  vertebrated  ani- 
mal,  being  sufficiently  rich  in  carbonic  acid  to  be  almost  black,  can- 
not be  injected  into  the  veins  of  a  warm-blooded  animal  without 
producing  phenomena  of  asphyxia,  and  most  frequently^  death,  after 
violent  convulsions,  provided  that  the  quantity  of  injected  blood  be 
not  below  one  five-hundredth  of  the  weight  of  the  animal,  and  also 
that  the  injection  be  not  made  too  slowly. 

Dr.  S^quard  observes,  the  reasons  why  Blundell,  Bischoff,  and 
others,  have  failed  in  securing  permanent  success  afler  the  transfur 

♦  Comptea  Rendus.    Nov.  1867,  p.  92&. 

26 


THE  PRIXCIFI*K  AX0   PBACTICK  OF 

mou  of  the  blood  of  am  ariifniU  of  ii  spedes  difimiit  from  tliat  of  ifcij 
tran^fu^^  one,  are:  1.  Tliat  the  blood  uaed  was  not  fresh  ;  2,  That 
it  ivfiA  in  too  larger  a  qnantitr ;  3.  That  it  was  injected  too  quicklr: 
4,  Tliat  it  WAii  too  rich  iti  carbonic  mdd^  aiid  too  pcior  in 
itu*  chief  canae  of  faUitre  being  the  faist  otie,  and  oext   \ 
quantity  of  blood. 

From  hj»  experiments,  he  has  arrived  at  the  conchision  thai  ibers 

no  danger  in  employing  the  blood  of  dog^s  catss  and   otbcr 
niammals  in  tranKfuNion  in  the  human  tipeeie»  ^  and,  moreovef«  ba 
agrees  with  Dieifenbacli  and  others  that  detibrinatetl  blaoc]  b^  jaat 
as  good  as  blood  containing  fibrin*     Four  or  five  oances,  be  ibinki, 
would  be  as  much  as  would  be  needed  for  an  adult  man  or  womaiL 
It  i»  not  necea^ary  to  warm  the  blood,  although  it  may  be  usefid  to 
do  ao  in  mme  in.stance^.     The  blood  to  be  transfused,  i*hhrr  that 
of  man  or  mammal,  should  be  received  into  a  large  open  va^e,  and 
immediately  whipped,  then  passed  through  a  thick  cloth.     If  ooi  j 
injected  at  once  it  must  be  either  whip^ied  again,  or  at  least  agl»i 
tuttnl,  to  recharge  it  with  oxygen  ju»t  before  transfusiuii,     Tbal 
injection  must  be  extremely  slow,  and  if,  after  two  or  tbree  c 
are  thrown  in,  lliere  is  great  increase  of  the  respiratory  movefneat^i 
it  will  he  proj»er  to  susf>end  the  operation  for  ten  or  tit\een  minaief  j 
Ijefore  completing  the  transfuMion* 

The  middle  ba^^ilic  vein  is  usually  selected  for  the  opemtioil* ' 
Thbi  vein  is  laid  bare  to  about  an  inch  in  extent,  and  iaolatisd  froia 
tlie  Eiurrounding  pans;  a  small  opening  should  be  made*  on  its 
anterior  wall,  and  the  end  of  the  syringe  carefully  introduet^d*  An 
ordiaar)^  bra^  syringe,  air-tigbt  and  in  good  working  order^  will 
answer  cxcvy  purpose. 

It  is  not  to  be  forgotten  thai  one  of  the  es^ntial  reqiiisttiea  fbr 
the  nhiiunlc  success  of  transfusion  in  cases  of  exhaustion  from  uterine 
hejnorrhage  is,  that  the  womb  must  first  be  in  a  state  of  cofitrao> ' 
tion,  otherwise  all  that  might  be  gained  by  the  operutiou,  would  be 
instantly  loit  through  the  open  mouths  of  the  utcro-plaoental 
vessels. 

^VlhiMon  [i:iN  already  Vieen  made  to  the  able  tnt 
Martin,*  of  Bei  liri,  and  I  think  I  shall  render  an  ; 
to  the  reader  by  incor|H:»rfiting  here  some  of  the  views  of  this  dl 
guisht'd  observer,  touching  this  interestifig  question.     He   tbinki| 
the  dangers  of  tiansfusioii   have   been   greutly  e  xugge  rat  * -d ;   aitd' 
insii»tH  that  only  hunuui  blooil  should  be  thrown  into  the  syHterii  of 
the  ejcsanguinjitcd  pnrrperal  woman ;  on  tlits  hitter  pt)int,  it  will  btf 
seen,  he  differs  from  Dr.  E*  Brown-Scquard.    Prof  Martin  regarda 
the  danger  of  death  frum  tlie  entrance  of  air  into  the  vc^ta«^  tf 


*  On  Transfusion  of  Blood  iu  Puorperml  Uicmorrluiges. 
1960. 


Vjr  Iskl,  Uartio.    BsHifl^. 


THE  FRINCIPIiES  AKD  PRACTICE  OF  OBSTETRICS.        401* 

veiy  trifling ;  nor  is  he  disposed  to  believe  the  coagulation  of  the 
blood  so  likely  to  occur  as  has  been  feared  by  some  writers.  The 
instruments  employed,  and  his  mode  of  performing  the  operation 
are  as  follows :  A  lancet  or  bistoury  for  the  incision  of  the  skin,  and 
a  glass  syringe,  seven  inches  in  length,  which  will  contain  fully  two 
ounces,  a  slightly  curved  trocar,  four  and  a  half  inches  long  (three 
of  which  is  handle) ;  the  end  of  the  silver  canula,  receiving  the 
point  of  the  syringe,  Hhould  be  funnel-shaped,  and  covered  with 
a  thin  plate  of  caoutchouc.  The  operation  being  decided  upon^ 
a  strong,  healthy,  and  willing  man  should  be  selected,  or,  in  the 
absence  of  such,  a  healthy,  resolute  female,  from  whom  to  abstract 
the  blood ;  one  or  more  intelligent  assistants  should  be  at  hand. 
Having  procured  a  basin  with  clear,  warm  water,  of  100"  to  104°  F. 
and  a  smooth  porcelain  cup  to  receive  the  blood,  lot  the  glass  synnge 
be  filled,  as  well  as  the  cup,  with  warm  water,  or  immerse  the  latter 
in  the  basin.  The  median,*  or  if  that  be  too  small,  the  cephalic  or 
basilic  vein  should  be  laid  bare,  by  means  of  a  cutaneous  incision 
extending  from  one  to  one  and  a  half  inches  in  length ;  the  trocar 
is  then  to  be  introduced  half  an  inch  into  the  vein,  in  the  direction 
towards  the  heart.  An  assistant  should  here  perform  venesection  on. 
the  arm  of  the  individual,  whose  blood  is  to  he  transfused ;  while- 
the  blood  is  falling  into  the  eniptiod  cup,  which  may  still  be  allowed, 
to  float  in  the  basin,  let  also  the  syringe  be  emptied  of  the  warnii 
water,  and  immediately  take  uj)  with  the  syringe  the  fresh  bloodl 
from  the  cup,  the  precaution  being  observed  that  the  blood  in  the- 
glass  is  liquid,  and  not  frothy.  Without  a  moment's  delay,  plat^e- 
the  point  of  the  filled  syringe  in  the  canula,  which  should  be  firmly 
held  in  the  vein  by  a  reliable  assistant,  afler  removing  the  stilet,. 
and  the  piston  is  then  to  be  slowly  pushed  inwards.  As  soon,  s^  the* 
syringe  is  removed,  be  careful  to  cleanse  it  immediately  with  wai'mi 
water,  unless  it  be  deemed  advisable  to  refill  it  at  once  with  die- still 
flowing  blood,  and  repeat  the  injection  without  delay. 

The  evidenoe  that  the  transfusion  has  been  successful  wtJI  be  dis- 
dosed  by  examination  of  the  pulse  and  heart,  together  with  the 
general  aspect  of  the  features ;  should,  however,  this  evi«!ence  not 
be  complete,  the  operation  is  to  be  immediately  repented,  not  for- 
getting to  observe  that  there  are  no  coagula  either  in  the  syringe 
or  canula.  Having  transfused  the  necessary  quantity  of*"  blood,  the 
canula  should  be  removed  from  the  vein,  and  the  wound,  drx^ssed 
precisely  as  afl;er  ordinary  venesection.f 

*  An  it  18  not  always  eaay  to  And  the  median  vein,  it  beinpr  coliapaed'  in  the  ex.* 
mnguinated  woaan,  it  may  sometimes  bo  necessary  to  look  feo  it  in  both  arms ; 
and  mstanoet  are  recordcnl  in  which  transfusion,  without  isilucious-  consequences, 
has  been  performed  successively  on  both  arms. 

\  Summary  of  Foreign  Medical  Literature  in  the  American  M^dloaLMontli^,  Jsa, 
1961.    By  L.  Elaberg,  M.D. 


402*       THE  PKINCIPLES  AKD  PBACTICE  OP  DBOTETRICS, 

Saeondaiy  Hmmorrhage. — There  is  a  form  of  boDmorrbago  coo- 
ueoled  with  childbirth,  to  vvhicli  as  yet  I  have  miule  no  special  allu- 
ijion.  It  may  occur,  at  any  lime  after  delivery,  from  two  hours* 
to  two  or  three  weeks,  and  has  received  the  name  of  **  Secondary 
Hajnunrhnge/'  Some  atuhorg  have  given  a  much  greater  hititiide 
of  time  to  this  character  of  floodijig,  and  mention  instatiees  in  which 
it  has  taken  place  as  hite  as  two  or  three  months  after  the  eipulwon 
of  the  faHus.  But  these  latter  cases  should  not,  I  think,  be  ri'garde^I 
as  connected  with  the  delivery.  Their  more  appropriate  phice  w^oold 
bo  under  the  head  of  passive  hajmorrhage.  When  **  Secondary 
Hcemorrhage ''  occurn,  it  will  generally  be  traceable  to  some  {lortion 
of  the  membranes,  phicenta,  or  a  coagnlnm  of  blood  having  been 
retained  in  utero ;  in  these  cases,  the  tirst  thing  to  do  is  lo  uscertain 
which  of  these  causes  may  exist.f  If  it  should  be  discovered  that 
the  flooding  is  due  to  one  or  other  of  them,  the  indication  is  to 
remove  the  substance,  whatever  it  may  be,  and  with  its  removal 
the  hiemorrhage  will  usually  cease.  Again :  the  bleeding  may  Ik; 
the  result  of  an  atonic  condition  of  the  uterus,  not  amoimting  te 
poijitive  inertia,  but  occasioning  a  partial  flaccid  state  of  the  organ, 
giving  rise  to  luemorrhage.  Under  these  circumstances,  you  may 
administer,  with  much  confidence,  ergot;  for  here  the  ilooding  Is 
not  so  profuse  as  to  require  the  more  heroic  treatment  of  which  we 
have  spoken  ;  in  connection  with  the  ergot,  a  capital  remedy  will 
be  the  injection  into  the  rectum  of  half  a  pint  of  cold  water  nighl 
and  morning.  In  plethoric  women,  the  bleeding  will  be  sotnclin 
due  to  cungestion  of  the  nterus.J  In  these  cases,  it  will  be  of  si^ 
bencrtt  to  abstract  a  hw  ounces  of  bluod  from  the  arm,  ad  miniver 
saline  cathartie^^  and  keep  the  patient  upon  strictly  abi^temiuud 
diet. 

In  ^yev^  case  of  "  Beeondary  haemorrhage,"  after  the  uterus 

♦  In  s<>me  Instaocea,  after  tlip  literas  has  contracted  suhsequt^utljr  to  the  birtli  i 
Itlio  child,  il  will  become  rel«xct|,  llie  eflect  of  which  wilJ  be  more  or  le^  bU 
Xhwe,  althou;rh  exeeptionnl  os^e^  RJiould  not  elude  the  vigihinco  oftlie  aooouchectr. 

f  TlitJ  presence  oJ*  uny  of  tlies©  Buh»tance«  iu  the  uterus  will  not  onij  gtvd  riia  lo 
Boc<Jiidury  bleeding,  boL  will  ultcQ  e1ud@  the  ultetttion  of  the  ficeouehcur  Hftfkoc 
the  uicyaslty  of  more  tlian  ordinary  yjgiliinco.  in  order  lliut  the  true  cniiso  of  tli« 
hstfiworrha^^t*  may  bo  prompU/  detected.  I  Imvo  on  more  than  one  (M*CM£ioci  bo«o 
ciiUtd  lo  CiJfl<?«  of  tliis  kitid.  iq  which  the  patients  hiive  bccu  nejirljr  exllllu»<tf^d  fttun 
tUo  graduat  oozing;  of  blood;  ah  soon  as  the  substances  were  removed,  the  lkBmaf> 
rhu^e  ceiiaod.  Dr  Collitis,  and  Madame  La  ClmpeUt^,  liave  both  reeonltHl  exaoiplcs 
of  bk*trding,  commencing  eight  uud  tea  days  afler  delivery,  oocaaioocd  by  c^taifoU  in 
the  viterus 

X  S«)nie  wTJtera  have  jitiributed  the  blee4itif^,  under  lUeao  ciroamBtainco^  to  what 
they  4i»TG  denominated  a  peculiar  mnlUntsi  hmmorrhogievm  of  Uie  iitoniit  »ti<i  in 
these  cu^es.  Ujo  bleeding  may  occur  without  the  »h^hte»t  ioertm  of  the  orgsti.  The 
ulerns,  under  the  iiiHucMice  ot  this  hieimorrbn^ic  mvliirwn,  will  be  found  9t^  M  I 
diatcndid  with  htood,  Tlieao  latter  conditious  may  l>e  regarded  aa  puLtiogtigiQOOiO  C 
tliia  fitate  of  the  organ. 


FRINCIPLES  AND  PRACTICE  OF  OBSTSTBICB.  403 

been  cleared  of  the  fragments  of  placenta,  membranes,  eta,  Ti^bich 
may  bave  remained  in  it  subsequent  to  delivery,  I  would  advise 
as  an  efficacious  remedy,  tbe  application  of  the  child  to  the  breast, 
for  tbe  reason  that  this,  through  reflex  influence,  will  impart  to  the 
uterus  a  marked  tonicity. 

You  will  read  with  much  interest  and  profit  an  excellent  paper 
on  the  subject  of  "  Secondary  Haemorrhages,"  by  Dr.  McClintock, 
ofDablin.* 

*  Dublin  Quarterly  Journal^  May,  1S31. 


LECTURE    XXVIII. 

Munii^pment  of  the  Fuerpeml  Woman  and  her  infant,  during  tb«  llofiCti^A]ipBab 
lion  ot"  lliL>  Binder;  nik-M  t^ir — Ohjeet  of  llie  Biiulor;  napkin  to  the  tuWm — 3liiMi<^ 
JjM't*  not  to  be  HdminTftcrcHl  to  the  newly  delircrwl  Womnn  ;  why  f — Ablution  U 
llitj  mfjiiit ;  m\€^  tor — Dn^sin^  of  llie  CrnbiHcM]  Conl — Kxiimmalicfn  of  Inlittt  t/i 
a«ttMt<im  Kxistence  or  not  of  Ix-formity — Toilet  of  ibo  Child;  piM  t>ot  to  be  w«^ 
^AfltT'piiini!;  how  rniinuf^fd — Anodynca  und  tndividuai  IdJoByncmM'-*— Bod* 
puh;  uiottviTH  for  ilM  ttm^x—rhyi^ickiiig  and  CrmnttniTtg  tine  InGini ;  t  i  j-^* 

Artf^imcnt  from  Annloj^y — When  <^honM  lljo  Chiid  be  put  to  tbo  iu  -i.i .  Aum- 
tnim;  iwwof  M<?conium — A  Fliit  Nipple;  how  remedied — Firvt  Vudl  aftct  4v1L 
v«ry  ;  wlien  Co  be  niHdt^^Whiit  tl»e  Accoucheur  is  Ut  do  jit  this  Ybit^ — HrC^ilksa 
of  Urine  ;  how  mounged — Reteulion  nnd  Stjpprf»it»n  ;  diffcrroec  between— Tli* 
CmiiL'tcr;  mode  of  ititroduetbn — Ob^tudea  to  PuDsagt?  of  the  C«ilh**»^  -  "»•!»•• 
thfy?— InoonUiivRw  of  Urine;  ciiu«e»  of— Vi.*»ici>v»fHnul,  nnd  I  aiil 

Fij<tiilAt— the  J^ichUil  DiAchnrge;  wh;itttiji;  dt*mn||femcnl  of—Whn*  i. 
noi  take  the  breaat.  how  to  be  Nourished — .^"ubfiUiutc  for  the  Cdoatnin 
li*ui  of  Urine  in  Infant;  cnu.'<«.*s  of ;  Mi]k  in  Brwu^tM  of  new-bwm  lri£jnU^»*uiM«T  « 
OliATVtiiionft — Milk  Fever — Bhjt's  Ri'MiirchcH  oit  Dlndnutiun  of  Pulm?  in  Milk  Tctm 
^Coiistipntion  of  Infiint;  CBtises  of— <3eeJu9ioQ  of  Auum;  how  tnnnaigttl— ^itru. 
lent  Ophtludmin;  uuutu*s  of — >Soni  Kippleii — MiminMrv  Abctoem— -rafapli^b; 
ciiuse»  of  iii  recently  delivered  womeri^ — Sloughin^^  of  Uinhilir*]  ComI — l^nin  in 
Uii»ru«  when  Child  la  put  to  iiie  Breost;  ExpkoiiUon  of — Thrombuii  of  th«  TuIts 
—Weed  or  Epbemefttl  Ftror 

Gkxtt.kmrn — Tlie  maimt^enieMl  of  the  puerperal  womau,  after  Ibi? 
birth  of  her  v\i\U\^  is  an  inien-stiiig,  and,  jit  the  same  linuv  a  xm^wj 
ini|ioiiant  subject.  It  is,  however,  so  chisely  interwoven  Miih  the 
muim^cmeiit  uf  tfic  new-born  infant  that  I  deem  it  ninre  c\|Hr4irtii« 
iu^iead  of  dii^cii8.sini^  tlio  two  quef^tjons  under  Uif^tluctheadis  to  pre* 
geiil  them  tu  ycKi  ronjoinlly ;  and,  with  lliisj  \iew,  we  »h:ill  now 
proec»«/d  to  point  ont  llic  wants  of  the  lying-in  ehamher,  diiring  ll»<? 
month. 

Application  of  (he  Hinder. — As  soon  a^  the  after-birth  is  rciitavetl, 
and  iUi.*  uterus  coiilracled»  the  abduininal  bandairt*  should  br  npt'lM. 
Soinepructitionera  arc  in  the  habit  of  using  the  binder^  a*  it  h  teirmod, 
tlie  nioint-ni  the  child  \s  in  the  world.  There  is  no  advfti]t.igi9  in 
thin  praetice»  but  much  inconvcnienee,  especiidly  when  there  in  diibij 
in  the  cxpulhiou  of  the  pLicenta,  for,  in  these  insiancejs  it  will  otivn- 
litni'ft  beeonie  neeci4»:iry  to  remove  the  l>inder,  and  thus  Mibject  the 
patient  to  addilio»»al  annoyance.  The  bandage  shonid  eonai^^t  of  ii 
double  fold  uf  linen  about  fourteen  inches  wide,  and  sudiiiently  Umg 
to  encircle  the  body  twice.  The  object  of  applying  it  al  M  h 
eimply  to  aflbrd  gentle  ar*d  eqttable  support  to  the  libdottiiiial 
parieteSf  w  hich  have  been  in  a  etate  of  great  distension ;  aud  now 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         406 

that  the  child  has  lefl  the  uterus  they  are,  on  the  contrary,  in  a 
remarkably  relaxed  condition.  I  am  generally  in  the  habit  of 
attending  myself  to  the  first  adjustment  of  the  bandage ;  it  is  a 
simple  matter,  but  still  there  is  sometimes  harm  done  for  the  want 
of  proper  care  in  its  application.  The  patient  should  not  be  per- 
mitted to  make  the  slightest  effort  to  assist  in  the  arrangement  of 
the  binder ;  she  should  be  turned  on  her  back,  and  the  bandage 
rolled  up;  you  then  unroll  a  small  portion  of  it,  which  with  your 
hand  you  gently  insinuate  under  the  back  of  the  patient  next  to  the 
naked  body,  at  the  same  time  instructing  the  nurse  to  stand  at  the 
opposite  side,  and  draw  that  portion  of  the  binder  toward  her.  In 
this  way,  without  in  the  least  disturbing  the  lady,  you  have  suc- 
ceeded in  the  first  part  of  the  operation ;  the  bandage  is  then  to  be 
arranged  so  that  it  comes  down  well  over  the  hips,  and  after  ehcir- 
ding  the  body  twice  with  it,  it  is  to  be  attached  by  moans  of  pins. 
The  almost  universal  fault  with  nurses  is,  that  they  draw  the  binder 
too  tiffhty  and  unfortunately  this  is  oftentimes  owing  to  the  direc- 
tions of  the  patient  herself,  who  is  most  anxious  that  hor  beautiful 
figure  should  be  preserved.  Little  does  she  think  that  this  earnest 
Bolicitnde  for  the  preservation  of  her  fine  figure  may  cost  her  the 
destruction  of  life,  the  undue  pressure  thus  exercised  on  the  uterus 
sometimes  giving  rise  to  inflammation,  which,  in  rebellion  to  the 
best  directed  efforts,  frequently  terminates  in  death. 

Napkin  to  the  Vulca. — When  the  bandage  is  arranged,  the  next 
thing  is  to  havu  a  warm  napkin  applied  to  the  vulva,  for  the  pur- 
pose of  protecting  the  patient  against  the  discharge  which,  in  more 
or  less  quantity,  will  necessarily  pass  from  the  uterus.  And  here 
allow  me  to  inculcate  upon  you  the  recollection  of  a  good  rule — let 
the  nurse  occasionally,  before  you  leave  the  chamber,  examine  the 
napkin,  and  tell  you"  whether  the  discharge  is  right,  or  whether  it  is 
too  profuse.  The  recollection  of  this  will  sometimes  save  you  much 
trouble,  for,  although  the  uterus  may  be  contracted,  yet  there  may 
be  too  much  oozing  occasioned  by  some  of  the  causes  to  which  I 
have  already  referred.  The  course  for  you  to  pursue,  under  the 
drcumstanees,  is  to  proceed  at  once  to  ascertain  what  the  true 
difficulty  is,  and  remove  it. 

If  the  patient  be  confined  on  a  cot,  I  do  not  suffer  her  to  be  dis- 
turbed for  at  least  two  hours;  at  the  end  of  this  time  she  will  have 
recovered  somewhat  from  the  fatigues  of  the  labor,  and,  perhaps, 
been  refreshed  by  sleep  ;  then  she  should  be  carefully  placed  in  her 
bed,  without  being  permitted  to  make  the  slightest  eftbrt  herself. 
Let  two  assistants  remove  her,  being  cautious  to  keep  her  in  the 
horizontal  i>osition. 

Toddies  and  Candl^.—lt  is  the  custom  with  certain  practition- 
ers, almost  immediately  after  the  birth  of  the  child,  to  have  re- 
course to  some  stimulating  drink  for  the  patient,  under  the  belief 


406 


THE   PRINCIPLES  AND   PRACTICE   OP  OBSTETRICS. 


that  it  is  ubsolulely  necessary*      Toddies  and  caudle  arc  the  &vorit« 
beverages.      In  my  ojiinion,  they  are  not,  as  a  general  princi|4e,  At 
all  needed,  and  they  olYenthnes  do  barm,     A  cup  of  tea,  or  som« 
warm  gruel,  laploca,  or  arrow-root,  are  far  mori*  in  1 
the  condition  of  the  patient ;  and,  unless  there  should  \i<  ; 

to  itidicate  the  use  of  wine,  etc.,  I  should  advise  you  not  to  hmv© 
recourse  to  it.  The  thing  a  nc*wly  delivered  woman  is  mo?t  ill  need 
of,  and  which  will  prove  an  efteetual  restorative,  is  repose;  ttotl, 
therefore,  she  should  be  stTupiilously  guarded  against  intruders  at 
the  time>  and  the  chnniber  kept  as  quiet  as  may  be  oonslstt^nt  u  ith 
circumstances* 

Washing  and  Ihrtsshig  the  Child. — Now  let  us  turn  our  . 
tion,  for  a  moment,  to  the  infant.  You  will  recollect,  whin  -  , 
rated  fr-om  its  parent  by  the  section  of  the  umbilical  cord,  it  was 
wrapped  in  flannel,  and  (>laced,  for  the  time  being,  in  a  spot  of 
eafety.  The  tirst  want  of  the  little  stranger  is  a  thorough  washing. 
The  nurse  should  provide  a  vase  of  warm  water,  some  Castile  soap, 
and  a  piece  of  delicate  sponge,  or  soft  flannel  She  should  thru 
seat  herself  in  a  low  chair,  and  commence  the  work  of  ablution. 
The  surface  of  the  new-born  infanTs  body  is  usually  covered  more 
or  less  with  an  unctuous  or  sebaceous  material,  and  in  order  to  have 
this  properly  removed,  it  will  be  necc^wary,  before  using  the  soap 
and  water,  to  direct  the  nurse  to  rub  the  entire  surface  gently  with 
frcfeb  sweet  oil,  or,  what  answers  a  very  good  purjiose^  ih©  yolk  of 
an  uncooked  egg.  As  soon  as  this  is  done,  the  M>ap  and  water 
should  be  well  applied  by  means  of  the  sjKmgc  or  flannel ;  but  \m 
careful  that  the  nurse,  in  her  ambition  to  perform  her  duty  wdl, 
does  not,  as  sometimes  will  be  the  case,  exceed  the  limits  of  pro- 
priety,  by  allowing  the  soap  to  come  in  contact  with  the  eyes  of  llie 
infant.  This  is  a  fruitful  source  bf  that  annoying,  and  oflen  diing«r- 
o\\^  ixf^QcixoUy  jntmUnt  ophthaimia.  When  the  ablution  has  lK*ffi 
properly  atte»ided  to,  the  child  should  be  carefully  dried  with  a 
warm  and  soil  linen. 

The  next  oliject  is  the  dressing  of  the  cord,  which  ia  done  ai 
follows,  and  which  should  not  h^  left  to  the  nurse,  but  attenilisl  to  y 
by  the  pmctitioner.  Take  a  piece  of  linen  three  inches  aqiiare, 
donbte  it,  and  cut  a  bole  in  the  centre,  through  which  the  cord  into 
be  drawn.  The  cord  is  then  enveloped  in  the  linen,  turned  onward 
and  to  the  left  on  the  abdomen.  A  circular  band  is  applied,  which 
will  retain  the  dressing  in  place,  and  also  aflTiud  romtbrtablo  mp* 
port  lo  the  child.  Ho  careful  that  the  bandage  is  not  too  light.  Tho 
common  practice  w*ith  nurses  \s  to  use  pins  for  the  purpose  of 
miiaching  the  infant***  dress,  I  much  prefer  the  nei*dle  and  thrnvd, 
for  the  pins  are  apt  to  become  loose,  prick  the  child,  and  may  tluui 
give  rise  to  serious  consequences,  evoking  convulsions,  or  olk«r 
troubles. 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         407 

It  the  Infant  deformed? — After  the  circular  band  has  been 
adjasted,  an  exaniiiiation  should  be  made  to  ascertain  whether 
there  is  any  deformity,  such  as  occlusion  of  the  anus  or  urethra — 
whether  there  exists  any  malformation  of  the  mouth,  which  may 
prevent  the  child  takini^  the  bre:tst.  It  is  proper  that  these  defor- 
mities, should  any  of  them  be  present,  be  recop:nized  at  this  time, 
in  order  that  prompt  mt>asures  may  be  adopti^d  to  remedy  them, 
and  not  delay  until  the  inflmt's  life  is  placed  in  })eril,  and  too  often 
without  the  cause  of  the  danger  being  oven  suspected.  Having 
become  assured  of  the  existence  or  absence  of  these  deformities, 
the  child  is  then  to  be  dressed,  which  may  be  done  by  the  nurse, 
without  nrach  supervision.  The  child,  its  toilet  being  completed, 
may  in  a  short  time  be  placed  by  the  side  of  its  mother,  if  she  bo 
awake ;  to  gaze  upon  it  will  cheer  her  heart,  and  prove  a  rich  com- 
pensation for  the  sufferings  she  has  encountered  in  bringing  it  into 
the  world. 

After-pains. — So  far,  then,  we  have  succeeded  in  making  the 
patient  comfortable ;  the  washing  and  dressing  of  the  child  have 
also  been  accomplished.  The  practitioner  has  not  yet  leti  the 
chamber,  nor  should  he  do  so  until  these  matters  have  been 
attended  to.  Soon  after  the  placenta  has  been  removed,  the  patient 
will  complain  of  more  or  less  pain,  closely  simulating  the  throes  of 
labor;  and  she  will  sometimes  become  alarmed,  imagining  she  is 
about  to  give  birth  to  another  child.  Those  pains  are  what  are 
known  as  after-jxthis ;  they  are  nothing  more  than  the  contrac- 
tions of  the  uterus  ridding  itself  of  the  fluids  contained  within  it, 
and  at  the  same  time,  through  these  contractions,  gradually  return- 
ing, as  far  as  may  bo,  to  its  pristine  state.  Altor-pains,  therefore, 
in  lieu  of  being  regarded  as  morbid  or  pathological,  are  to  be 
classed  among  the  usual  and  necessary  phenomena  of  childbirth. 
In  a  woman  with  her  first  child — a  primipara — these  pains  are  ordi- 
narily slight;  in  a  multipara,  on  the  contrary,  they  are  oftentimes 
severe  and  harassing.  The  reason  of  the  difference  is  that,  in  the 
former  case,  the  uterus  is  invested  with  vigor  and  tonicity,  and 
consequently  soon  becomes  restored  to  its  original  condition  ;  while, 
in  the  latter,  its  walls  are  flaccid,  and  the  contractions,  thereibre, 
more  protracted. 

Before  leaving  the  patient,  it  will  occasionally,  from  the  severity 
of  these  pains,  become  necessary  to  give  something  to  break  their 
intensity.  But,  unless  they  prove  so  annoying  as  to  occasion  much 
disquietude  and  prevent  sloop,  I  would  advise  you  not  to  interfere 
by  mcHlication  with  this  natural  process.  In  administering  medi- 
cines under  any  circumstances,  be  careful,  as  far  as  you  can  do  so,. 
to  ascertain  whether  or  not  the  patient  is  affected  with  any  striking 
idiosyncrasy;  I  mean  by  tins  whether  t-ha  is  morbidly  sensitive  to 
certain  remedial  agents.     You  have  no  right,  gontlemen,  to  assume 


PfUKCirLES  AND  PRACTICE  OF  OBOTSTRTCS. 

iiijr  tliuig  laodiiiig  the  peoidiiiiiliei  4if  tho^  wba  may  ^sytik  pmr 
pmbwdooai  mooned.  For  exftmjilt**  lei  o§  stippoae  iliat,  witlimiS 
olMitnrijig  |1h>  prfcmmion  to  which  I  huve  just  nUtidecl,  yoa  idianUI 
ordor  for  joar  palkfii,  in  euie  of  aftcT-paios,  ten  graioi  of  Dori»r*a 
poirder.  WeU,  the  puiciiptioii  b  fincil,  uttd  tbe  meiiicsoc  uik<*ti. 
In  m  vifrj  iliori  titne  ftftcrward  yoa  art*  dent  for,  axid  yoa  Mad  tlie 
pslient  deHrioQii,  slMotiiid^r  enax^  When  she  retnms  to  bor  «mi«a» 
Ibe  fir»t  thing  ahc  wiU  aajr  to  yon  will  be  something  liko  thmi 
**  Oh !  doctor,  why  *iid  yon  not  fell  me  you  haii  ordered  Dorei^ 
ponder  ?  I  tot>k  it  onee  and  it  nearly  killed  me r^  Then?lbr«« 
always  iorjtiire  whet  her  such  pet^uliartly  or^y»tem  exij^t^  re^ardiog 
any  remedy  which  you  may  propose  to  administer,  and  should  there 
bo  an  idio»yncnu»y,  suh^titute  in  iu*  niensi  something  eW.  If,  in 
your  judgmt»nt,  it  l»ei  ome  necestkiry  to  order  an  anodyne*  prrpap- 
ration,  any  of  the  followinjj  may  be  given  with  the  riniervalion  jitsi 
mentioned : 

IJ.   Syrup,  pup:iv,  ll  3  »v, 

Hucil  Ac*ncirt»  f  3  ij. 

SoL  Sulphnt.  Mor[4iiie  (^lagendie)  gtt.  xij. 
A  table^poonful  eviTy  half  hour,  until  the  su^erbg  m  mitigated* 
The  above  is  a  favorite  prfflcripiion  with  me. 
^,   Mistune  Cainphone  f.  3  ij. 

Syrup.  Simp.  f.  3J* 

Tinct.  Optics  j* 

The  balf  of  the  mixture,  and  if  not  relieved  in  an  hoar,  give  tbe 
remaining  portion. 

1|-    Pulv.  Dovcri,  3i. 

Divide  in  ehaitulas  ij. 

One  poudor  in  «ome  Hiriip,  nnd»  if  neeenaary,  the  second  in  an  hrmr 
or  two.  Or,  from  ten  to  tiHeeu  drop*  of  the  solution  of  murphta 
may  Ik-  given  in  a  de-isort-^ioonful  of  cold  wuti*r. 

I/irtrdoftii  to  the  Knrtt^, — Sfi  niui-li  Ibr  the  patient  an  to  con  tin* 
gent  remedies ;  but^  before  making  hie  adieu  aller  the  birth  of  the 
child,  there  are  some  other  direelionii  not  to  be  ni--'         '  '        '  l^ 
'praciitioniT.     The  nurse  muht  be  strietly  enjoincnl  fi<  e 

patient,  if  she  desire  lo  pass  her  Mater  or  evaeuate  her  bowd*,  to 
ait  on  the  ehaniber.^  A  bed-pan  nmst  be  used.  This  will  be  ^ome- 
what  inconvenient  at  firsts  but  m\y  annoyance  in  this  way  wiD 
bo  amply  repaid  by  an  immunity  fiom  thoHe  troubles  so  apt   to 


*  t  Imvv  ri^ieurodlv  uwi  wiili  cMteti m  whidi  1)^  iiftrir  pilni iiiRi ciliafiptaitidl  feij 
tti^tu^  V.vAii  t>i  Uiiiin  iikhiiMt^  nhil  tnice»lilu  ii>  the  pfa!K>noe>  of  a  ooafTilttm  ib  tfa^ 

ilic  eftw,  the  (lot  be  iek  by  th^  thi^^r ivirrird  to  ili« 
V  r»'movcU.     SltouW  the  oonguJum  he  oul  of  rmel^ 
f  Uijr<<tiim  (nto  fhv  U>w«I  will  ofleulinioa  «ld  Kti  Ita  expufadoo,  NDUr  m^A 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         40^ 

bllow  too  early  sitting  up  after  delivery,  such  as  prolapsus  uteri, 
procidentia  of  the  organ,  or  prolapsus  of  the  vagina. 

Physicking  and  Cramming  tlie  New-horn  Infant, — ^The  absurd 
and  mischievous  practice  obtains*  too  generally,  of  giving  the  little 
infant  oil  or  some  other  medicine  almost  simultaneously  with  its 
birth,  and  of  filling  its  delicate  and  much-abused  stomacli — a  sto- 
mach whose  powers  of  assimilation  are  extremely  feeble — with  food 
of  domestic  manufacture ;  and  hence  the  **  pap  bowl"  is  a  fixture  of 
the  lying-in  room.  This  practice,  which  is  one  of  the  products  of 
remote  but  regular  tradition,  is  fruitful  in  bad  consequences,  often- 
times proving  the  starling-pohit  of  disease  and  death.  Why,  gen- 
tlemen, is  it  not  strange  that,  with  all  our  boasted  intelligence,  we 
should  be  so  inferior  to  the  brute  creation  in  the  management  of 
the  young?  Do  you  see  the  slut,  with  nothing  but  instinct  to 
guide  her,  guilty  of  these  absurd  practices?  Here,  there  is  no 
medicine  given,  no  pap  forced  down  the  throats  of  her  innocent 
little  offspring.  The  pups  as  soon  as  they  come  into  the  world, 
seek  each  one  the  teat  of  its  parent,  and  from  these  teats  they 
extract  both  medicine  and  nutriment.  They  grow  and  become 
developed  ;  they  are  healthy,  and  rarely  do  they  need  the  services 
of  the  physician,  for  the  reason  that  they  observe  the  ordinances  of 
nature.  Learn,  then,  a  lesson  from  analogy,  and  remember  that  the 
identical  necessity  exists  in  the  infant  of  the  human  being  to  observe 
faithiiilly  these  same  ordinances.  My  rule,  therefore,  is,  as  a  gene- 
ral principle,  to  give  the  new-born  child  nothing,  for  the  reastm  that 
it  needs  nothing  but  the  material  which  nature  has  so  carefully  and 
elaborately  prepared  for  it;  and  that  material  is  the  mother's 
milk. 

When  should  the  Infant  be  put  to  the  breast  f — Instead  of  admi- 
nistering medicines,  and  cramming  its  stomach  with  food  it  cannot 
digest,  if  nothing  sliould  contra-indicatc  it,  have  the  child  put  to 
the  bre:ist  as  so(jn  as  the  mother  has  recovered  somewhat  from  the 
fatigues  of  the  labor,  say  in  two  or  three  hours.  Hut  you  may  urge 
as  an  objection  to  this  practice,  that  there  is  very  little  milk  at  this 
early  period  in  the  breast.  Well,  admit,  for  argument  sake,  the 
fact;  still  this  early  ai)plication  of  the  child  is  one  of  the  eliicient 
promoters  of  the  milk  secretion  ;  the  tnactions  made  u])on  the 
nipple  invite  the  milk  to  the  breasts,  and  the  child  at  this  early 
period  extracts  what  is  known  as  the  colostrum^  an  element  pos- 
sessing purgative  qualities,  and  which  readily  and  efficiently  removes 
from  the  hitestinal  canal  the  meconium — a  black  viscid  material 
found  in  greater  or  less  quantity  in  the  bowels  of  the  new-born 
infant,  and  which  a|)pears  to  consist  of  a  mixture  of  bile  and  pro 
ducts  secreted  by  the  intestinal  mucous  surface.  Let  me  here  enjoin 
upon  you  the  necessity  of  cautioning  the  mother  against  having  her 
infant  in  bed  with  her  while  she  sleeps.     It  is  stated  on  the  author- 


tio 


THK    PRINCIPLES   AND  PRACTICE  OP  OB8TSTRICS. 


ity  of  Osmnder,  thiit  in  England,  between  tlie  yoan*  1686  ami  1799* 
40,000  ehiUlren  wero  det*t roved  Uy  Wint^  overhiid  by  ihcir  paronU, 

A  Sunken  or  Fhi  Nippk — Uqw  Remedied. — One  more  dir inrtiaQ 
before  tftkinor  leave  of  ywiir  p  itiont,  and  a  very  esnentia]  one  it  H 
loo— let  ll»e  n^u'se  examine  tl>c  brej»5rt«,  nnd  tell  you  wlietlier  or  not 
the  i\\\\\A\i  is  well  forme<L  It  Bcnielinie^H  bappenfl  that  il  is  quite 
sunken  and  flat,  so  mnch  ro  that  it  will  be  irnpos^sililc  for  the  rhild 
to  grasp  it  in  its  month :  the  eun.«equenee  will  be  flmt  the  mother  in 
fretted  and  fiitigued  by  ihe  negative  efforts  of  the  infant  and  this 
hitter  will  l)e  defrauded  ctf  what  il  hst^  a  birthright  elaini  t*i— 4til 
natural  rjourishnient.  In  order  to  overeonie  the  diflleuliy  take  an 
ordinary  pint  bottle  with  a  hnv^  tieek,  fill  it  with  h*>t  wairr,  thru 
pour  out  the  waier^  and  apply  the  month  of  the  bottle  immeilLitelj 
over  the  nipple  ;  ns  the  b*ittle  eoo!s  there  is  a  tetideney  to  a  vaeiitim, 
and  tlHB  a  powerful  but  equable  suction  i«  produced,  which  result* 
in  elon^ting  the  nipple.  The  bottle  is  then  removed,  itnd  th©  cbtld 
applied. 

The  Fffsl  Visi(  after  Delivery. — ^Tliese  variotm  matters  having 
received  attention,  you  bid  good-day,  or  good-night,  as  ll*e  enac 
may  be.  Whenever  you  can  do  ?o,  it  should  be  your  geneml 
practice  not  to  allow  more  than  twelve  hotira  to  intervene^  from  tJie 
time  of  delivery,  before  you  pay  your  next  visit*  During  tlu^*  vinit, 
you  will  learn  how  things  have  progrcBsed  Rinee  you  lelh  11. »^  the 
patient  had  a  comfortable  Me<p?  Urn  she  been  much  annoyed  Uy 
the  aflrr*pains?  Has  she  pa-^s^ed  her  water?  How  is  her  |iul«e? 
Is  it  right,  or  is  it  accelerated  and  bounding,  indicative  of  infliun* 
matoi'y  action,  aiid  if  so,  where  »»  the  inflanniiation  ?  U  the  quick* 
ened  pulne  merely  the  renuU  of  your  pres^ence,  and,  therefore,  tran* 
gitory  ?  Is  there  pain  in  any  portion  of  the  alxloinen?  If  «o»  is  il 
constant,  or  U  It  recurrent  ?  If  consttaTit,  is  it  the  result  of  inflafB- 
mation,  or  of  illte^tlnal  flatus,  or  of  a  di^^tended  bladder?  I*  there 
any  tebvilc  exellement  ?  Thit*  i»  n  running  schedule  of  the  ques- 
tions, whioh  will  suggest  themselves  to  the  mind  of  an  intelli^iit 
and  vigilant  |)hysieian,  anxious  to  lie  prepared  in  time  in  the  event 
of  <binger,  and  equally  anxious  to  know  that  every  tlmig  is  |ifo- 
g^ressiug  an  he  \^  oiild  de!*ire. 

I'he  n\ir»c  may  tell  you  that  the  lady  has  suffered  a  great  deal  of 
pain  in  her  boivels;  and  will  also,  perhaps,  inform  you  that  the 
sligliiest  pressure  itgirravates  the  distresn;  the  nurse  at  the  natcM^ 
time  giving  to  her  agrc»ejible  roiinlennnre  a  Hort  at'  doleful  cx|»re** 
sion,  wishing  yi>u  to  understand  that  ^he  by  no  mean?*  Iikci*  the 
ftppearanee  of  mattrrs.  Now,  nnder  these  circumstances,  whal  mrt 
you  to  do?     Are  you  suddenly,  and  without  eaune,  to  1  :i 

converl  to  the  mi ja giving*  of  the  nurse,  and  alarm  your  p 
sad  oniens  and  a  long  face;  or,  as  a  con»cienttous  phyAieiaTi^  will 
you  nt>t  at  once  snbjeet  every  thing  connected  with  your  patient  lo 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         411 

a  searching  analysis,  and  ascertain  in  this  way  what  really  is  the 
matter — whether  there  is  a  substantial  something,  or  whether  the 
apprehension  of  the  nurse  is  a  mere  phantom. 

What,  then,  is  the  pain  in  the  bowels  ?  It  may  arise  from  the 
contractions  of  the  uterus,  and,  therefore,  it  is  simply  due  to  the 
after-pains;  it  may  arise  from  distended  bladder,  or  from  a  flatulent 
condition  of  the  intestinal  canal,  or  from  a  collection  of  foscal 
matter  in  the  lower  bowel  making  undue  pressure  on  the  uterus, 
or  from  inflammation  either  of  the  uterus  itself,  or  the  peritoneum. 

Diagnosis. — In  "  after-pains  "  the  distress  is  not  constant,  but 
paroxysmal  or  recurrent,  and  there  is  between  the  paroxysms  an 
interval  of  decided  calm.  The  pulse  is  usually  not  disturbed,  nor 
is  there  febrile  excitement.  If  the  difficulty  be  caused  by  distension 
of  the  bladder,  tire  organ  will  be  found  enlarged,  stretching  over 
the  hypogastric  region,  and  imparting  to  the  hand  a  sense  of  hard- 
ness. Ill  addition^  you  will  have  learned  from  tlie  nurse  that 
madam  has  not  passed  her  loater  since  the  birth  of  her  child. 
Sometimes,  and  I  have  seen  such  cases,  when  the  retention  of  urine 
is  complete,  so  that  none  whatever  escapes  from  the  bladder,  and 
this  state  of  things  has  continued  for  two  or  three  days,  the  abdo- 
men becomes  enormously  distended,  presenting  the  aspect  of  ascites ; 
in  these  aggravated  instances  the  pulse  will  run  high,  120  in  the 
minute  ;  and  there  will  also  be  coma,  more  or  less  j)rofound,  from  the 
accumulation  in  the  blood  of  the  urea,  which  should  have  been  ex- 
creted from  the  system  through  the  urinary  apparatus,  constituting 
a  case  of  blood-poisoning — uricmic  intoxication.  If  it  be  a  case  of 
flatus  in  the  intestinal  canal,  there  will  be  the  sound  of  resonance 
under  percussion,  together  with  distension  of  the  abdomen,  and  an 
occasional  eructation  of  gas  through  the  (esophagus,  or  a  passage  of 
it  per  rectum.  There  will  also  be  an  alternation  of  increase  and 
diminution  in  the  size  of  the  abdomen,  depending  upon  the  quantity 
of  flatus,  which  may  find  exit.  The  pulse  will  generally  be  undis- 
turbed. 

If  the  lower  bowel  be  distended  with  fajces,  you  will  have  good 
reason  to  suspect  that  this  is  so,  if  the  patient  informs  you  that  she 
has  been  more  or  less  constipated  during  the  latter  period  of  her 
pregnancy.  Lastly,  if  there  really  be  inflammation,  the  whole 
system  at  once  becomes  involved;  the  pulse  is  rapid,  120  to  130 
beats  in  the  minute ;  febrile  excitement,  excessive  tenderness  on 
pressure,  pain  constant,  pallor  and  anxiety  of  countenance,  with  a 
general  arrest  of  the  secretions.  Thus,  gentlemen,  you  proceed  with 
your  analysis,  and,  having  discovered  the  truth,  you  will  then  know 
w^hat  to  do. 

Retention  of  Urine. — ^This  is  not  a  very  unusual  attendant  upon 
the  delivery  of  the  child,  and  calls  for  the  proper  attention  of  the 
accoucheur.     I  desire  to  remind  you,  for  the  moment,  that  there  is 


«2 


THE  PHLVCIl'LES  AKD  FBACTTICS  Of  OB8TKTRICS, 


n  very  iiniiort.iiil  distinction  buaween  retention  and  nttjfftrtxxioH  of 
urine,  Tlio  ibrnier  implies  tliat  condition  in  which  tho  nrin©  ta 
BPCrc*ted  hy  the  kidnoyst,  mid  paitaea  through  the  ureters  into  the 
bhidilor,  and  there  b<'come»  retained,  acciimnlaiinpr,  and  thus  pro* 
dnrin*^  inordinate  distension  of  the  visciH*  In  8uppri*!*sion,  oif  ill© 
contrary,  it  i*  not  thi»  bfadder,  bnt  the  kidneys,  wliich  are  at  fault, 
there  being  little  or  no  urine  Hecretod.  With  thiu  di»tinctioti  biilbro 
yon,  what  would  rou  think  of  the  practitioner,  who,  lacing  aillvd 
to  a  ea^e  of  retention,  should  admhiiHter  dinreliea;  and  vet,  geu 
tlcmen,  this  \i\\ik  l>een  done,  anil  the  viciou?^  p  met  ice  will  con  tin  tie 
until  phy»^icians  are  brought  to  think  and  analyse.  Routine  |»rat*tic« 
is  one  tliinj? ;  bnt  the  tracing  of  effects  to  causes,  and  the  applica- 
tion of  npproju'iate  reinedie!*  to  those  cau!<<f»,  indicate  tho  scieutific 
prnetitioner.  A  very  coninion  cause  of  retention  of  urine  after 
chUdl)irth,  in  primlysin  tjf  the  bladder  almve  the  epiiineter,  thus  di** 
qurili  fy  ing  the  organ  from  contract  in  ir  suflicienlly  to  expel  It-*  con- 
ten  tn  ;  while,  on  the  other  hnrHl,  piirnlysis  i»f  the  aphiticier  ii*elf 
gi\*e,H  rise  to  an  opposite  condition — in  continence  of  urine.  The 
paraly**ia  in  either  ease  is  us»uaUy  not  of  long  duration;  and  will 
generally  pas^s  otf  in  a  few  days. 

The  object,  in  retention,  u  to  ttutoad  the  bladder ;  aiid  this  may 
be  done  souictinu'S  by  the  npplicati*>n  of  hot  clothn  to  tho  viilrn 
and  hypotra-^triutn.  I  somewljcre  resid  years  acjo  of  the  prnctiee  in 
theio  e^*i8eH  of  pouritig,  within  the  hearin;^  of  the  )»atient»  water  (Vooi 
a  vessel  slowly  into  a  pitcher ;  and  I  e:m  vouch  for  its  efHcai'y  in 
several  ea«e«  in  which  I  have  had  recourse  to  it.  Should,  howeviyr, 
this  cx|>edicnt,  and  the  w*artu  fomentations  fail,  then  we  have  a 
certnin  remedy  in  the  calheter.  It  irt  a  euriouf*,  but  iuterL*«itJig 
circuniMance  tlmt,  oceaaionally,  afler  the  patietit  has  inado  vwn 
attempts  to  ri'lieve  herself^  ami  after  the  failure  of  tho  ordituiry 
remedies  the  moment  the  areoucheur  sugge>it*  the  neccraty  of 
havin;>  recourse  to  an  instrumL-nt  for  the  purpose  of  drawing  off 
the  water,  madam,  alarmed  at  the  iilea  of  an  in**truracnt,  tells  the 
nurse  in  an  undertone, — **  Oh,  I  think  I  can  relieve  myself  now;" 
the  nurse  briuirt  the  bed-pan,  smd  sure  enouijh  the  bladd* 
evacuated.  Tins  is  a  strikintf  iUuj^tralion  of  the  operatiim  of  n, 
up*in  matter;  and  I  have  witnessed  its  happy  effects  In  more  thao 
one  instance. 

Mf*de  of  IfUrodttcing  (lie  Cath^ter^ — ^Tlns,  like  many  other  openi^ 
tions,  is  very  simple,  if  you  know  bow  to  iwrform  it;  but  ^mple 
an  it  iis  it  very  of^en  happens  that  the  practitioner  fails  in  hif 
attempt  from  jgoorunee  or  careU'!<sne«s,  and  such  f;iihire  is  not 
wilh<ml  «ad  consequences  to  his  reputntion.  The  tirst  point  in  the 
operation  is  to  find  the  fnealu^  trrinarhtn^  or  outer  opening  of  tho 
urethra,  and  this  should  be  accnmpH'*hed  without  in  any  way 
ex]k}sing  the  person  of  the  patient.     If  I  can  have  my  choi(*i-,  1  prvfor 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         418 

the  patient  on  her  back,  lying  near  the  edge  of  the  bed,  with  her 
thighs  slightly  separated,  and  flexed  upon  the  pelvis.  The  index 
finger  of  one  hand,  lubricated  with  oil,  is  then  directed  to  the 
vagina.  The  rules  for  recognizing  the  meatus  may  be  classed  as 
follows:  1.  Let  the  radial  surface  of  the  index  finger  be  carried  up 
to  the  anterior  portion  of  the  vagina ;  here  it  is  brought  in  contact 
with  the  lower  wall  of  the  urethra;  then,  taking  the  urethra  as  a 
guide,  draw  the  apex  of  the  finger  along  this  wall  in  a  forward 
direction  ;  this  necessarily  brings  you  to  the  outer  extremity,  or 
meatus  ;  2.  Place  the  apex  of  the  index  finger  at  the  superior 
commissure;  here  will  be  found  the  clitoris,  and,  in  drawing  the 
finger  perpendicularly  downward  along  the  vestibulum,  the  meatus 
will  be  reached  just  at  the  base  of  this  triangular  space;  3.  Place 
the  end  of  the  finger  on  the  summit  of  the  pubic  arch ;  very  near, 
and  a  little  below  this  point,  you  will,  by  gently  moving  the  finger 
about,  come  directly  in  contact  with  the  orifice  of  the  urethra.  If 
cither  of  these  rules  be  properly  observed,  there  will,  unless  in  case 
of  some  deformity  of  the  parts,  be  no  difiiculty  in  easily  recognizing 
the  meatus  urinarius. 

The  water-passage  in  the  female,  as  was  mentioned  when  de- 
scribing the  external  organs,  is  remarkable  for  its  shortness  and 
great  dilatability ;  and  its  direction  is  slightly  oblique  from  below 
upward.  Having  found  the  meatus,  keep  the  point  of  the  index 
finger  upon  it  to  serve  as  a  guide  for  the  introduction  of  the 
catheter.  This  instrument  is  constructed  of  various  materials, 
silver,  pewter,  or  caoutchouc.  I  prefer  one  of  silver ;  it  should  be  at 
least  six  inches  in  length,  and  slightly  curved.  Before  introducing 
it,  let  it  be  well  lubricated  with  oil,  and  this  iS  better  than  \i\rd  or 
butter,  for  either  of  these  latter  may  close  up  the  little  openings  on 
the  side  of  the  terminal  extremity  of  the  catheter,  and  thus  prove 
an  obstacle  to  the  free  passage  of  the  urine.  As  soon  as  the  instru- 
ment is  within  the  meatus,  I  would  advise  you  immediately  to  glide 
the  finger,  which  has  been  passed  as  a  guide,  within  the  vagina, 
keeping  it  on  the  lower  wall  of  the  m-ethra,  which  will  enable  you 
not  only  to  feel  the  catheter  through  the  wall,  but  also  to  prevent 
laceration  of  the  part.  One  point  always  bear  in  mind,  in  the  intro- 
duction of  the  instrument — 7iever  attempt  to  substitute  brute  force 
for  skill ;  and  when  you  recognize  an  obstacle  to  its  free  passage, 
you  may  depend  that  something  is  wrong,  and  that  wrong  is  not 
to  be  remedied  by  physical  force.  If  the  secrets  of  the  lying-in 
room  could  be  unmantled,  and  the  drapery  of  concealment  removed, 
among  other  melancholy  disclosures  we  should  have  many  a  tale 
of  sorrow  touching  lacerations  of  the  urethra,  bladder,  and  vagina, 
from  the  clumsy  and  unpardonable  employment  of  the  catheter. 

The  instrument,  then,  being  within  the  urethra,  a  very  gentle 
movement  is  to  be  imparted  to  it  obliquely  from  below  upward. 


THE  PRlliCrPLES  AND  PRACTICE  OF  OBSTSTEICS. 


The  catheter  bavins^  reached  the  bladder,  tijc  stiletto  U  wlthd 
arul,  us  a  gerseral  thing,  there  will  be  a  copious  flow  of  uriui*, 
where  will  iho  urine  fall?  Why,  on  the  bed,  without  n  question, 
oecAsiriuing  a  very  agreeable  and  inlerefitingcoudilion  of  thiugH,  If  yon 
nhouki  have  neglected  an  essential  point  in  the  opei^ation — bidding 
tiie  nurse  to  have  in  rejidiness  a  bowl  in  which  tlje  urine  is  to  be 
reet'ived  m  it  passes  through  the  catheter.  It  should  be  a  jtmall 
bowl,  placed  between  the  thighs  of  the  patient ;  as  aooo  lu  it  is 
lilled,  let  the  con  tenia  be  emptied  into  a  vase,  which  should  bti  At 
hand,  being  cnrernl  while  emptying  it  to  place  the  ilnger  oti  the 
mouth  of  the  catheter  to  check,  for  the  moment,  the  runnicig 
gtreanu  It  may  w>metinies  occur  that,  atler  the  catheter  in  ioiro^ 
duced,  no  urine  tlowd ;  this  is  an  embarraaaing  f^tate  of  tiiingi^  ftnd 
may  arise  from  various  causes:  1.  Although  yon  may  imagine  ihie 
catheter  to  be  in  the  bladder,  yet  it  is  not  there,  but  simply  in  Uio 
vagina;  2.  The  holes  at  the  eud  of  the  catheter,  or  the  body  of 
the  instrument  ilselt^  tnay  be  obstructed  by  docculent  matter  Of 
mucus  floating  in  the  urine;  3.  The  instrument  may  not  be  BilIB' 
cienlly  far  introduced,  having  passed  merely  to  the  neck  of  Um 
organ. 

OhstacUs  to  the  Ingress  of  ifit  Catf^ter, — There  njay  exist  cur- 
tain obstacles  to  the  free  ingress  of  the  catheter  into  the  blatlder; 
for  example,  the  various  malpositions  of  the  uterus.*  In  prolnjwitts, 
the  \jV)^\m  may  make  such  pressure  against  the  neck  of  the  bladder 
as  completely  to  prevent  the  pai«^ge  of  the  instrument ;  the  remedy 
19  very  simple — introduce  the  finger  into  the  vagina,  gently  elcvftii 
tb«  prulapsid  uterus,  and  then  with  the  other  hand  pas^i  th© 
catheter.  The  fundus  of  the  womb  may  be  in  a  state  of  ante-ver- 
sion, the  fundus  resting  upon  the  bladder;  this  also  is  to  be 
remedied  by  pushing  the  fundus  backward,  thus  liberating  \hm 
bbflder  from  the  pressure ;  or  the  uterus  may  be  rctro^crled,  lh« 
fundus  having  fallen  backward  ;  in  this  case,  the  cervix  of  the  orgftn 
will  be  thrown  forward,  and,  as  a  consequence^  more  or  less  |irQ§* 
sure  exercised  against  the  neck  of  the  bladder.  In  order  thai  Iha 
OAlheter  m:iy  p:iss  under  these  circumstances,  it  will  be  necessary  lo 
relieve  the  bladder  from  the  presifiure  by  pushing  the  cervix  of  die 
womb  backward  towanl  the  centre  of  the  pelvic  ejEcavation*  la 
procidentia  of  the  uterus,  the  organ  has  fallen  beyond  the  vagina, 
and  is4tuateil  between  tlie  thighs  of  the  pruient ;  when  this  mal- 
position of  the  organ  occurs,  the  bladder  w  ill,  of  course,  be  brought 
down  more  or  less  with  the  ntcrus,  and^  in  consequence  of  this 
latter  circumstance,  the  direction  of  the  meatus  utimtriuji  will  be 
so  changed,  that  it  w  ill  look  more  or  less  upward  ;  if  this  fact  be 
not  recollected,  the  practitioner  will  be  foiled  in  his  effort  to  intro- 

*  It  18  poflsible  that  srime  of  iliose  tn a) position ji  tnA)*  be  ooinddnit  with  a 
(ielirery,  iind,  therefur<*,  I  mt^tiLiun  Uteiit  in  thla  (xinnexioiL 


1 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         415 

duce  the  instrument.  An  attempt  should  always  be  made  to 
reduce  the  procidentia,  and  return  the  organ  within  the  vaccina ;  it 
should  then  be  retained  in  situ,  enjoining  upon  the  patient  the 
absolute  necessity  of  the  recumbent  position,  with  the  hips  slightly 
elevated. 

Incontinence  of  Urine, — After  a  protracted  labor,  it  is  not 
unusual  for  the  patient  to  be  unable  to  hold  her  water,  as  the 
phrase  goes;  and  this  is  almost  always  dependent  upon  the  severe 
pressure,  which  has  been  exercised  by  the  head  or  presenting  por- 
tion of  the  child  upon  the  neck  of  the  bladder,  producing  a  paralysis 
of  the  sphincter,  and  thus  incapacitating  it  from  retaining  the 
urinary  secretion.  Ten  drops  of  the  tincture  of  cantharides  in- a 
wine-glass  of  flax-seed  tea  twice  a  day,  will  prove  a  good  remedy 
in  these  cases ;  or  the  application  of  a  small  blister  to  the  upper 
portion  of  the  sacral  region  will  answer  equally  well.  I  need  not 
remind  you  that  the  modus  operandi  of  this  treatment  is  readily 
explained — the  cantharides,  whether  administered  internally,  or 
through  its  absorbent  action,  when  applied  as  a  blister,  has  often- 
times a  specific  eftect  on  the  neck  of  the  bladder,  producing  what  is 
known  as  strangury,  and  in  this  way  it  becomes  an  important 
therapeutic  agent,  when  it  is  desirable  to  stimulate,  through  nervous 
influence,  the  muscular  fibres  of  the  sphincter  vesica?. 

Here,  it  is  right  to  tell  you  that  it  is  possible  you  may  form  an 
erroneous  opinion  with  regard  to  the  ijicontinence  of  urine.  For 
instance,  the  nurse  may  inform  you  that  madam  cannot  liold  her 
water ;  well,  this  may  be  the  case,  but  there  are  other  conditions 
besides  paralysis  of  the  neck  of  the  bladder,  which  will  occasion 
this  difficulty.  A  vesico-vaginal,  or  urethro-vaginal  fistula,  consti- 
tuting rents  between  the  vagina  and  bladder,  or  the  urethra  and 
vagina,  may  be  the  cause  of  this  constant  dribbling  away  of  the 
urine;  under  these  latter  circumstances,  it  would  amount  to  no- 
thing short  of  stupendous  folly  to  hope,  through  the  action  of  cantha- 
rides, to  remove  the  difficulty.  Therefore,  gentlemen,  be  careful  in 
your  diagnosis. 

Flatus  in  the  Intestinal  Canal, — Women,  soon  after  delivery} 
will  occasionally  suffer  great  distress  from  an  accumulation  of  flatus 
in  the  bowels;  and  I  think  I  have  observed  this  more  particularly 
after  severe  floodings.  This  distended  condition  of  the  canal  has 
sometimes  been  mistaken  for  inflammation,  and  it  is  very  important 
that  you  should  understand  the  distinction.  In  tympanites,  slight 
pressure  will  produce  pain,  but  increased  and  long-continued  pres- 
sure will  afford  relief;  shoulfl  there  be  inflammation — and  this  is 
frequently  accompanied  by  a  flatulent  distension  of  the  intestines — 
the  greater  the  pressure  the  more  marked  and  severe  will  be  the 
pain ;  besides,  the  various  phenomena  indicative  of  inflammatory 
action  will  be  present.     Great  benefit  will  be  derived  in  cases  of 


416 


THE  PRINCIPLES  JlNB  PBACmCE    OF   OBSTETRICS. 


flatulence,  from  n  combination  of  turpentine  and  caHor  oU ; 
ounce  of  each   may  be   given  by  the    muuth ;    or  th«   foUc 
draught  may  be  ordered : 

Olei  Terebinth,,  t  z  »»• 
MuciL  Acaciffi,  t\  I  m. 
Tine.  0|ni  f.  3  S8. 
M. 

In  the^c  cases,  too,  relief  will  be  dt^rived  by  the  npplicatic 
the  fil«lonien  of  a  warm  flinnel  sprinkled  with  tnrjientine, 

A  Loaded  Condition  of  thf*  Lower  JJotccL — Thin  is*  unothc^r  nol 
unfre(|UL'nt  cau»e  of  distress  to  the  recently  delivered  woman,  and 
will  be  apt  to  lead  the  praetitluner  astray,  unleHS  he  exerci**  due 
vigilance  in  his  iiingnosis.  Most  women  nej^lrct  their  bo  web  yoder 
almost  all  eircumKtances,  and  this  very  neglect  proves  a  icevcri^tajl 
on  their  health ;  but  more  jiartioularly  are  they  carele««  in  the  lall 
tnontliH  f>f  ge^Htation,  and  lierice,  soon  after  the  birth  of  their  chh 
they  oftentiniea  huflcr  great  pain  from  an  aeeumulatioii  of 
matter  in  the  colon  and  reeium.  When  lhi><  Mateof  thinj^s  in  aJioer* 
tained  to  exbt,  immediate  reeoui*»e  should  be  had  to  an  enm 
whieh  will  hriug  away  the  mass*  of  excrement ,  and  thus  give  pr 
comfort  to  tl»e  patient,  and,  perhaps  **^ve  her  from  iterioas  siial 
tjuent  trouble,  A  jL^ooil  injection  for  this  piir|io»e  will  be  the  ft>n<! 
lug :  A  pint  urnl  a  half  of  inoa|>8ud8,  one  ounce  of  cjuanr  ail*  (out 
large  ftpoontula  of  molasfle^,  with  one  of  table  Halt.  Thi«  will  ^orn 
a  enpital  enema  for  the  occasicm,  Ynn  will,  I  am  aure,  cxeine 
while  u|»on  this  subject,  hi  callinvj  your  attention  to  a   "  "         i 

reality  u  very  imjKjrtant  point,  ami  it  h  this — you  ilir* 
to  administer  the  enema  as  alKJve  prepared,  she  does  so — ^ai  total 
the  thinks  she  doc>( — but  instead  of  throwing  the  content**  of  tko 
gyringe  into  the  bowel,  it  will  otU'Dtimes  happen  that  they  lodge  J 
the  hed,  and  for  tbe  reason  that  the  pi|>e  of  the   inHtnmient    hi 
merely  been  placed  in  the  vicinity  of  the  anus,  instead  of 
propvrly  introduced.     Thereforen,  when  this  praetiee  becomes  i 
aary,  unless  you  have  an  intelligent  and  reliable  nurse,  who  uni 
atand^  and   npprci'iates  the  diirerencc  between  right  and  wroi 

rr/Wm  the  vperafion  t/oitrdelves.     If  the  remedy  be  indicat^HJ,  it  if 
much   your  duty  to  see  that  it  is  properly  adminijfteretL,  a» 
would  be  in  apfdying  a  ligature  for  aneurism  to  be  aoro  that  y< 
had  embraced  \nthin  the  ligature  the  artery  insteail  of  thc^  nrrvr. 

There  is,  however,  another  form  of  constipation,  whieh  you 
flometimcs  meet  with  in  the  puerjieraf  woman,  well  worthy  of  attCQ 
ti(m.  It  will  resist  the  administration  of  cathartics  by  the  im»qt 
and  will  be  ctpially  beyond  the  control  of  enemata.  It  iai  eoimltpo* 
lion  Irnceablf  to  paralysis*  of  the  rectum — ^the  nerves  regulating  the 
functions  of  this  portion  of  the  intestinal  canal  having,  in  cooiicq^ 


THB  PRINCIPLES  AND  PRACTICB  OP  OBSTETRICS.         417 

of  a  protracted  and  severe  labor,  undergone  a  degree  of  pressure, 
which  deprives  them  of  the  ability  to  control  muscular  action. 
There  is  an  interesting  case  of  this  kind  reported  by  M.  Martin,  of 
Lyons,  in  which  the  faecal  matter  was  retained  for  a  period  of  more 
than  twenty  days.  He  was  compelled  to  introduce  into  the  rectum 
a  scoop,  and  thus  bring  iiway  the  masses  of  hardened  faeces ;  and 
it  was  not  until  the  lapse  of  twenty-nine  days  that  the  intestine 
recovered  its  tonicity.* 

The  Lochial  Discharge. — One  of  the  ordinary  accompaniments 
of  the  puerperal  woman  is  a  discharge  from  the  uterus,  which  con- 
tinues for  several  days,  and  sometimes  weeks,f  after  childbirth,  and 
is  known  as  the  lochia ;  it  is  nothing  more  than  the  oozing  from  the 
mouths  of  the  utero-placental  vessels,  together  with  the  passing  off 
of  the  decidua,  while  the  uterus  is  returning  to  its  original  condi- 
tion.{  At  first,  the  discharge  is  sanguineous,  and  it  may  assume 
this  character  for  two  or  more  days  after  delivery ;  then  the  color 
is  changed,  partaking  more  or  less  of  a  serous  nature,  and  presents 
a  greenish  hue ;  it  then  becomes  whitish,  and  ultimately  ceases 
altogether.  After  the  first  day  or  two,  there  is  a  sort  of  sul  generic 
smell,  and  which  I  have  remarked  striking,  or,  in  other  words,,  niwe 
offensive  in  women  of  dark  complexion,  hair,  and  eyes — the  brunette. 

The  lochial  discharge  will  sometimes  need  attention ;  and  you 
should  be  careful,  in  the  first  visit  to  your  patient  after  delivery,  to 
inquire  of  the  nurse  whether  or  not  the  discharge  be  right.  Tlu? 
nurse  may  tell  you,  to  use  lier  own  expression,  that  "it  is  vei*y 
scant,''  or  that  there  is  none  at  all.  This  state  of  things  will  be  apt 
to  give  rise  to  disturbance,  especially  in  plethoric  women,  and  in 

*  It  will  occasionally  happen  tliat,  after  a  labor  of  protracttd  duration,  and  more 
cqiecially  when  the  porinenin  has  been  subjected  to  long-continued  distension,  the 
muscles  of  this  part  will  become  partially  paralyzed — giving  rise  to  great  difficulty 
in  d^ecation,  from  embarrassment  in  voluntary  movement;  and  this  condition  of 
things  may  continue  for  months,  and  in  some  instances  for  life.  I  have,  in  two  case$> 
of  this  kind,  experienced  the  best  effects  from  the  internal  administration  of  minute 
doses  of  strychnine.  This  being  an  example  of  reflex  paralysis,  and,  consequently, 
not  traceable  to  congestion  or  injury  of  the  spinal  cord,  the  strychnine  constitutes  a 
valoable  remedy. 

f  Galen  taught  the  curious  doctrine  that  the  fnetus  appropriates  to  itsolf  the  best 
part  of  the  blood  for  its  own  nourislmient,  and  leaves  the  rest ;  and  tliis  is  the  reason 
why  pregnant  women  are  troubled  with  bad  humors,  which  are  thrown  off  after 
delivery.  The  following  is  his  language  :  "  Foetum  in  so  meliorem,  qua  uuiriatur, 
sanguinis  portionom  trahere,  deteriorem  relinquero;  quie  caiisii  est  praegnantibus 
cacochymice,  quam  natura  post-partum  evacuat.'*  This  po8t-|)artum  evacuation  ho 
describes  as  the  lochia. 

X  Hippocrates  held  tliat  when  the  infant  U  a  female,  the  lochia  usually  continues 
lorty-two  days ;  if  a  male,  thirty  days.  Nam  et  purgatio  a  partu  tit  mulieribus  ut 
plturimuQi,  in  puella  quidam  concepta,  duobus  et  quadragiota  diebus.  In  masculo 
▼ero  purgatio  diebus  triginta  contingit  2.  Do  natur  puer,  cap.  6.  Vol.  V.,  p.  314. 
It  is  needless  to  remark  that  this  is  simply  an.  opinion  wifthout  anything  substantial 
<br  its  basis. 

27 


418 


THE  PRIKCXPLES  AXD  PRACTICE  OF  OBSTETRICS, 


women  of  more  than  ordinary  nervous  snucoptlbillty.  In  the  for* 
naer,  occasioning  fever,  flushed  countenance,  headache^  a  boun  *:-  - 
pulse,  all  of  which,  if  permitted  to  pass  unchecked,  not  only  poi  ^ 
but  will  actually  result  in  mischief.  In  the  latter,  there  w\\\  be 
restlessness,  jactitation,  and  sometimes  even  eonvul^ve  movemrnt*. 
•  Again  :  the  lochial  evacuation  will  occasionally  be  too  profuse,  pros- 
trating the  patient,  and,  in  this  way,  laying  the  foundnlJun  of  fulun* 
trouble.  You  see,  therefore,  gentlemen,  how  important  it  ii  to 
have  an  eye  to  the  lochia.  When  it  h  scant  or  cntireiy  «nppr»?R»ed, 
I  have  found  much  beiieiit  from  a  warm  fhix-Aeed  poultice,  put  tutu 
a  flannel  ba^^,  with  which  should  be  incorporated  3  ii-  of  jiowdered 
camphor.  The  poultice  thus  prepared  to  be  laid  over  the  vm1v\, 
and  repented  every  hour  or  two,  if  necessary.  When,  on  the  CMn 
trary,  the  discharge  is  too  profuse,  a  teajajwonful  of  the  lhic?lure  of 
ergot  in  a  wine-glass  of  cold  water  twice  a  day  will  generally  be 
followed  by  good  eflVcts,  When  what  is  callecl  the  milk  fever 
conies  on,  whik'h  is  about  the  second  or  third  day  afler  deUvery,  the 
dischargu  usually  ceases  for  a  few  hours,  but  reluma  as  suotj  ^  the 
fever  passes  off.  The  nurtie  should  be  directed  to  have  the  vagina  pro- 
jierly  cleansed  by  injectiofis  of  tepid  water  two  or  three  time^  a  day. 

Affeftfi'ons  to  (he  Infant, — We  are  not  to  forget  the  little  infant 
in  this  first  visit ;  and,  therefore,  let  us  devote  a  few  moments  t«i  it* 
welfare.  Haa  it  been  put  to  the  breast,  as  you  directed?  Have  its 
bowels  been  moved,  an<]  has  it  passed  ita  water?  The  nurjie  will, 
perhajis,  say  that  everything  is  perfectly  right — it  has  taken  liie 
l»reast  freel}',  it  has  had  sevend  dark-coiore*l  evacuations — the 
meconium — and  it  has  passed  its  water.  Well,  all  this  is  as  \\ 
sliould  be^  and  of  course  renders  the  exercise  of  your  skill  tinnece^ 
^hY\\  On  the  otiier  hand,  the  child  tnay  have  been  put  lo  iIm* 
breast  ;  but,  in  ci^nsequencc  of  there  being  no  milk,  it  has  hstil  mi 
nourisihment ;  and  as  it  has  rtol  been  able  to  extract  from  the  breast 
the  colostrum,  its  naturtd  and  efficient  eatliartic,  H  has  not  Isreti 
imrt^ed  ;  it  may  also  be  that  it  has  not  passed  its  water.  Tlere^ 
4 hen,  is  a  state  ot  thlugts  winch  calls  fur  prompt  .act ion ♦  The  tir*t 
matter  to  be  attended  tu  is,  to  give  the  infant  a  tea^puouful  of  uli>f 
oil,  or  a  little  brown  sugar  dissolved  in  water,  or  <M|a.il  fiaru  of 
molasses  and  water.  Either  of  these  will  generally  Buffic«e  lo  priK 
duco  a  cathartic  efiect»  You  must  rememfier  that  if  tf 
be  allowed  t"  remain  tu  tlie  intestines,  bad  consequent 
and  I  am  quite  eonlident  that  oonvulsions  In  the  now-bcru  iDfanl 
are  ot>cn  the  result  of  this  neglect*  The  meconium  bc*comet  ati 
irritant,  and  in  this  way  is  the  cause  of  eccentric  nervous  disturb* 
ancc.     You  cannot  t«»o  faithfully  rcc(»llect  this  fact. 

Fccdhuj  the  Infant. — The  <:luld,  until  it  is  enabled  to  obtion 
fiourishment  froni  its  motli«r^i  breast^  may  b9  fed  with  dflatrd 
eow^s  milk.    This  is  a  near  approach  to  human  milk.    Shoald  k 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         419 

become  necessary,  from  the  indisposition  of  the  parent,  or  other 
oircnmstances,  to  bring  the  child  up  by  the  bottle,  as  it  is  termed, 
it  will  be  found  useful  to  restrict  it  exclusively  to  this  form  of  diet 
for  at  least  two  months.*  Its  powers  of  assimilation  are  extremely 
frail,  and  it  needs,  for  the  first  six  or  eight  weeks  after  birth,  the 
blandest  possible  nourishment.  After  this  penod,  it  may  partake 
of  farinaceous  articles,  such  as  oatmeal  with  milk.  There  is  one 
caution  especially  important  for  the  first  four  or  five  months — the 
food  should  be  thin  and  taken  through  a  teat.  This  will  prevent 
that  stereotyped  evil — stuffing  the  young  infant.     Be  careful,  also, 

*  In  the  American  Journal  of  Medical  Sciences  for  July,  1858,  Dr.  CummiDgs  has 
given  U8  an  interesting  and  practical  paper  "  on  Natural  and  ArtiJiAal  LacUxtum,^ 
fiom  which  I  make  the  following  extract: 

Cow*8  milk  contains,  While  human  milk  contains 

Butter      38.59  Butter      20.76 

Casein      40.75  Casein      14.34 

Sugar       63  97  Sugar       75.02 

Water    866  69—  Water     889.88 

"  Cow^s  milk,  therefore,  contains  nearly  three  times  as  much  casein  as  hanum 
mUk,  but  less  than  twice  as  much  butter.  In  cow's  milk,  the  butter  is  to  the  casein 
as  100  to  105;  in  human  milk  as  100  to  70.  If  then,  by  dilution,  we  reduce  the 
batter  to  20.76,  we  .shall  have  21.92  of  casein,  or  50  per  cent,  more  than  inhuman 
milk.  With  such  an  excess  of  casein  we  cannot  hope  to  succeed.  If,  by  a  f\irther 
dilution,  we  reduce  the  casein  to  14.34,  we  have  only  13.58  of  butter,  or  less  tlian 
two-thirds  of  the  proper  proportion.  Such  milk  may,  for  a  season,  seem  to-suit  the 
child,  but  before  long  it  will  be  found  that  it  does  not  thrive.  The  reason  is  plain. 
The  right  proportion  of  butter  is  20.76 ;  this  warms  a  child,  and  supplies  nervous 
energy.  But,  by  withholding  one-third,  you  lower  the  temperature  of  the  body, 
and  deprive  the  nervotis  system  of  one-third  of  the  special  nerve-food,  the  indispen- 
sable ledtiUn,  In  a  short  time  pallor  and  languor  supervene,  and  health  evidently 
declines,  Ac,  kc.  It  is  thus  evident,  that  by  no  mode  of  dilution  can  ordinary 
cow*s  milk  be  made  a  substitute  for  human.  There  will  be,  in  every  case,  an  excess 
of  casein,  or  a  deficiency  of  butter.  So  long  as  the  butter  is  to  the  casein  as  100  to 
105,  instead  of  as  100  to  70.  so  long  must  dilution  fail  to  adapt  it  to  the  wants  of 
the  child.  But  if  this  original  proportion  could  be  changed  to  that  existing  in 
hnman  milk,  we  might  have  hope  of  success.  And  we  proceed  to  show  how  this 
may  be  done.  If  we  leave  at  rest  for  four  or  five  hours  ordinary  cow^'s  milk,  and 
then  remove  and  examine  the  upper  third,  we  find  in  it  50  per  cent,  more  butter 
than  it  at  first  contained.  In  round  numbers,  its  butter  is  no  longer  to  its  casein 
as  100  to  105,  but  as  150  to  105,  or  as  100  to  70.  If  then,  by  dilution  of  this 
milk,  we  reduce  the  butter  to  20.76,  we  have  14.34  of  casein,  as  in  human  milk. 
By  using  the  latter  half  of  the  milk  furnished  by  the  cow,  we  have  54  of  butter,  to 
88  of  casein,  the  right  proportion  exists,  and  by  proper  dilution,  it  may  be  made  to 
resemble,  in  its  chemical  constitution,  human  milk." 

Milk.  Water.        Sugar. 

For  a  child  from  3  to  10  days  old,     .        .         1000  2643  243 

For  a  child  1  month  old,    .        .        .        .         1000  2250  204 

For  a  child  2  months  old,  .        .        .         1000  1850  172 

For  a  child  5  months  old,  .        .        .         1000  1000  104 

For  a  child  6  months  old,  .        .        .         1000  875  94 

For  a  child  11  months  old,        .        .        .        1000  626  73 

For  a  chUd  18  months  old,        .        .        .        1000  600  «3 


420 


THE  PKINCIFLKS  AND  PRACTICE  OF  OBSTETiaCB. 


l\yjki  tlie  nurse  does  not  flill  into  the  absurd  error  of  suppostng  ibat 
every  titne  the  child  cries,  it  is  hungry,  and,  therefore^  tnuflt  be  tM, 
If  we  could  have  the  correct  statistics  upon  this  question,  the  oob- 
verse  of  the  popular  belief  wonlil  be  found  to  be  true,  %'ijc,  tbjii  the 
child  far  more  frequently  dies  from  being  overfed,  than  from  the 
want  of  adequate  nourishment.* 

The  Li/ant  ha^  not  Passed  Us  Water,— ^Uie  little  stranger  hnB 
Dot  passed  its  water — at  least,  so  ^ays  the  nurse.  I  have  often 
been  told  this,  and  quite  oftt»n,  tuo,  found  that  the  nurse,  withoul 
intending  to  deceive,  was  altogether  mistaken.  In  these  alleged 
cases  of  non-micturition,  I  am  in  the  habit  of  examining  the  child*! 
diaper,  and  generally  1  have  discovered  the  evidencea  of  a  free 
stieani.  Would  it  not  be  cruel,  to  say  nothing  of  the  d^nger^  to 
subject  the  infant  to  medication  for  this  supposed  trouble,  when,  in 
fact,  it  did  not  exist  ? 

It  will  occasionally  be  the  cajse,  however,  that  mieturitiaii  bus 
not  been  accomplished ;  and  the  first  point  to  be  ascertained  U, 
wliat  is  the  cause  of  the  difficulty.  The  ititlmt,  like  the  adult,  may 
fail  to  pass  its  water  because  of  suppression  or  retention  of  the 
urinary  secretion  ;  and,  therutbre,  before  prescribing,  the  intelligent 
pmctitioner  will  be  careful  to  ascertain  to  which  of  theso  condi- 
tions the  trouble  h  due. 

Suppression  and  Jit  tent  ion  of  Urine  in  t/m  Infant. — Suppres- 
sion is,  I  think,  very  rare  in  the  new-bom  infant ;  for,  as  th«  kid- 
neys are  organized  at  comparatively  an  early  period  of  enibryotiie 
existence,  their  funeiion  is  alsti  early  developed*  Jietention,  on  llic 
contrary,  is  of  mme  frequent  occurrence,  and  may  aris^e  from 
various  circumBianccij,  such  as  congenital  nial formation,  a  coMection 
of  mucus  in  the  urethra,  spasmodic  contraction  of  the  neck  of  the 
bladder,  etc.  In  retention,  there  is  a  circumscribed  hanl  tumor 
in  the  hypogastrium  ;  while,  in  suppression,  there  is  no  mich  tumor, 
for  the  reason  that  as  there  is  an  absence  of  the  urinary  se^-rrtkni 
there  is  consequently  no  distension  of  the  bladder.  Occaiilofially, 
in  retention  of  urine  in  the  new-born  infant,  the  bladder  beenmet 
enormously  distended;  and,  in  this  alfeetion,  death  may  '  'm 

rupture  of  the  organ  or  uretei's,  inflammation  of  I  he  \  nm 

and  abdominal  viscera,  or  coma. 

In  suppression,  a  few  drops  of  sweet  spirits  of  nitre  in  a  little 
sweetened  water,  may  be  given  ;  or,  what  will  be  found  a  good 
remedy,  will  be  parsley  ter»,  to  which  the  nitre  may  be  added.  In 
retention,  the  treatment  will,  of  course,  depend  on  the  particular 
cause  which  produces  it.  If  the  urethra  be  obstruct ed  by  the  |ire- 
sence  of  mucus,  the  introduction  of  a  small  bougie  will  auflice  to 

•  When  the  infant  shows  evidence  of  wenkcpA!!,  or  indieate«  th  flcrofulotn  o  »«i4U*  -^^ 
ticm,  beoeDt  will  be  dimved  from  mmgliDg  with  lla  food  a  «ttuill  piece  of  butier,  or 
mattCMi  suet 


THE  PRINCIPLS8  AND  PRACTICE  OF  OBSTETRICS.         421 

remove  it ;  i^  as  is  sometimes  the  case,  the  obstruction  be  occa- 
sioned by  a  membranous  band,  incision  of  this  latter  VfiHl  bo  the 
remedy ;  should  it  be  that  there  is  a  spasmodic  stricture  of  the 
neck  of  the  bladder,  the  warm  bath  and  the  bougie  will  be  indicated. 
Milk  in  tlie  Breasts  of  the  Nevo^om  Infant, — ^There  is  a  circum- 
stance connected  with  the  new-born  infant  well  worthy  of  atten- 
tion. I  allude  to  the  presence  of  milk  in  its  breasts  ;  for,  without 
being  cognizant  of  the  fact  that  this  secretion  docs  really  exhibit 
itself^  you  would  very  likely  be  embarrassed  if  consulted  upon 
the  subject.  It  in  no  way  involves  either  the  comfort  or  health 
of  the  infant,  and  the  secretion  ordinarily  ceases  at  the  end  of 
the  first  month.  I  have  repeatedly  met  with  such  cases;  and 
all  I  recommend  is  to  protect  the  breasts  against  the  pressure  of 
the  dress,  and,  if  necessary,  to  lubricate  them  two  or  three  times  a 
day  with  olive  oil.  An  interesting  paper  has  recently  appeared 
from  the  pen  of  M.  Gubler,  entitled*  "  La  ^Secretion  et  la  Compo- 
ntian  du  Lait  cJiez  lea  Enfants  nouveau-n^  des  deux  SexesJ*^  M. 
Gubler  founds  his  memoir  on  observations  made  on  1200  new-bom 
children.  The  secretion  is  very  rarely  observed  in  notable  quan-- 
tity,  and  only  exhibits  itself  as  a  serous  fluid  for  the  first  two  or 
three  days  of  extra-uterine  life.  On  the  fourth  day  the  glands  are 
larger,  and  there  frequently  escapes  under  pressure  a  dense  and 
opaque  fluid.  The  number  of  infants  in  which  the  secretion  exists, 
as  also  the  quantity  of  the  fluid  itself,  gradually  increase  until  the 
eighth  day,  when  it  seems  to  ntthin  its  ninximum.  From  the  ninth 
to  the  tenth  day,  in  sixty-five  children,  there  was  one  in  which  the 
secretion  was  not  observed.  The  increase  in  tlie  volume  of  the 
breasts  and  the  secretion  usually  continue,  to  a  certain  degree, 
nntil  the  twentieth  day.  One  hundred  and  forty-nine  out  of  one 
hundred  and  sixty-five  infants,  from  twelve  to  twenty-one  days 
old,  exhibited  the  secretion  in  variable  quantity.  At  the  end  of  a 
month,  it  is  extremely  rare  for  the  secretion  not  to  have  ceased 
altogether.  In  four  instances,  however,  M.  Gubler  observed  it  to 
continue  for  two  months.  The  milk  of  the  new-bom  infant,  accord- 
ing to  this  writer,  assisted  by  the  able  chemist,  M.  Querenne,  is 
more  alkaline  than  the  milk  of  the  adult  woman  and  of  animals. 
It  would  seem  that  there  is  a  striking  identity  between  the  milk  of 
the  infant  and  the  ass.  The  following  is  the  analysis  of  M.  Que- 
renne: 

Milk  of  Woman.      Infant.       Ass. 

Butter, 2.00  1.40       1.40 

Casein, 3.90  2.80       1.70 

Sugar,  and  extractive  matter,  .     .     4.90  6.40       6.40 

Water, 88.60  89.40     90.50 

*  For  an  analysis  of  this  memoir,  see  "  Appreciation  des  Progres  de  la  Physiolo- 
gie^"  bj  K  Brovn-S^quard,  Journal  de  la  P4iy8iologio,  vol.  il,  p.  410. 


THE   PRINCIPLES   AND   PRACTICE  OF  OBSTETKICS. 


It  is  proved  by  this  analysis  that  the  liquid  secreted  ui  lite  bri*!u| 
of  the  infant  is  really  milk.     It,  therefore,  is  to  b©  regarJiHi 
dcnioiisl  rated  fact,  from  I  fie  comhined  observations  oi  M.  N,  Gatl 
lot,  Di\  BattLTsley,  of  Dublin,  and  M.  Giibler,  and  more  e?*f>tH-iiil!y" 
iVorn  the  amtlysis  of  M.  Querenne,  that  the  secretion  of  milk  in  th© 
"breasts  of  the  uew-bom  infant  is  a  physiological  act  of  very  gene* 
"■^Tal  occurrence, 

Miik  lever. — From  t^^enty-four  to  forty-eight  hoars  aft«r 
delivery,  the  patient  mny  experience  a  ehill,  followetl  by  more  or 
les<s  febrile  excitement,  with  headache  and  suppression  of  the  lochia* 
These  phenomena  nometinies  aiieompany  distension  of  the  maioirii9 
by  the  milk,  hence  they  are  classed  under  the  term — fnOk  /5»«r/ 
they  need  give  you  very  little  conceni ;  they  are  among  th<f  occa^ 
sional  sequents  of  childbirtli,  and  pas»  otT  in  the  eoui-st?  of  a  fei 
hcjurs.  Be  careful,  therefore,  not  to  lose  your  equilibrium,  and 
imagine  that  the  chill,  fever,  etc.,  are  the  sure  harbtngem  of  per 
toniti?*,  metritis,  or  some  other  seiious  malady.  There  i*  i» 
the  abdomen  on  prestiure,  and  although  the  pulse  may  ic| 

for  the  time  being,  it  is  not  the  pulse  of  intlammation  ;  nor  is  the 
that  anxiety  of  countenance  so  characterisiio  of  serious  ptter 
mflammatii>n.     Much  benefit  will  be  derived,  should  thi'ie  be  ci 
citement,  from  a  gentle  diiiphorc^i^s.     Far  this  fiurpuse,  give  er^ 
hour  or  two  a  tablespoonful  of  the  spirits  of  Mindereru»w 

Blot  has  ascertained  a  curious  and  interesting  fact — that  whc 
the  milk  begins  to  distend  the  breasts,  the  pulse,  instead  of  1»ela| 
accelerated,  frequently  diminishes  in  its  beatsi,  lieing  50,  55,  snj 
60  in  the  rninute. 

Cathartic  to  (he  Motlier, — On  the  third  day  afler  confmcmeQ^ 
it  will,  if  the  bowels  have  not  previously  moved,  be  neoeamary  U 
administer  »ome  aperient  medicine  to  the  mother;  and  in  <^  " 
it  will  be  proper  to  inquire  whether  she  has  any  prefer*  n 
what  you  ^ihall  prescribe ;  for  here,  as  in  the  example  of  the 
iync  to  which  we  have  made  allusion,  there  may  be  Komi*  ?*■- 

sy  of  system ;  and  it  will  also  be  prudent  to  inquire 
she  is  easily  alfccted  by  medicine,  or  the   reverse.     This  will   iodi' 
cate  to  you  the  quantity,  and  the  frequency  of  repetition,  whti 
may  be  necessary.     Half  an  otince  of  castor  oil,  to  lie  re|>eaf^  i 
four  hours,  if  necessary  ;  or  3  ss.  of  magnesia  with  3  ij.  of  < 
salts  in  half  a  tumbler  of  cold  water ;  or, 

]^     Sulphat.  MagnaiiiD  3  ij. 
Infus.  Senme,  f.  1  iv. 
Tinct.  Jalapfle,  f.  3  L 
Manna?,  3 1* 

M. 

One  half  to  be  taken,  and  repeated  in  four  hours,  if  needed ;  Of^' 


THE    PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS.         423 

Ihc  compound  rhubarb  pill  may  be  ordered.  If  there  should  be 
any  indication  of  he])atic  deranijement,  it  will  be  desirable  to  jL^ive 
a  live-grain  blue  pill,  followed  in  six  hours  by  one  or  other  of  the 
above  prescriplions.  You  will  find  stewed  prunes  a  valuable  ajieri- 
ent,  where  there  is  no  indication  for  more  active  medicine ;  they 
generally  agree  with  the  patient,  are  acceptable  to  the  taste,  and 
are  not  associated  with  the  drug  shop. 

Torpor  of  tlu  JBoicds  in  the  Infant, — You  will  have  cases  in 
which  there  is  unusual  sluggis>hness  in  the  system  of  the  infant, 
and  without  care  in  their  management,  much  harm  may  ensue. 
Here,  ^ov  example,  you  will  be  between  Scylla  and  Charybdis — for 
if  the  infant  be  permitted  to  continue  in  a  state  of  constipation, 
there  will  be  more  or  less  danger  of  convulsions ;  and  if,  on  the 
other  hand,  you  fill  its  delicate  stomach  with  physic,  you  awaken 
irritation,  which  may  be  the  starting-point  of  disease,  and  finally 
death.  How  often  have  I  been  consulted  in  cases  of  infants  a  few 
days  old,  because  of  constipated  bowels ;  and  it  would  severely  tax 
your  credulity  if  I  were  to  name  the  variety  of  remedies  pre- 
scribed for  these  poor  little  innocents,  without  subduing  the  diffi- 
culty, but  most  certainly  impairing  the  health  of  the  sufferers. 
There  are  two  modes  of  removing  constipation  in  the  nursing  child 
— one  is  by  direct,  the  other  by  indirect  medication.  In  the  for- 
mer instance,  the  medicines  are  administered  to  the  child  itself; 
in  the  latter  they  are  given  to  the  mother,  with  a  view  of  affecting 
the  child  through  the  changes  which  these  remedies  produce  in  the 
milk  of  the  parent.  Now  for  the  point.  It  very  often  happens 
that  the  constipation  of  the  infant  is  but  a  reflex  of  the  condition 
of  its  mother ;  she  suffers  from  torpor  of  the  bowels,  and  tliis  slug- 
gishness of  system  is  transmitted  to  the  chUd  through  the  milk« 
Under  such  circumstances,  it  would  be  absurd  to  expect  any  per- 
manent result  from  medicines  given  directly  to  the  child.  There- 
fore, permit  me  to  inculcate  this  important  ])recept — when  consulted 
in  a  case  of  constipation  in  a  new-born  infant,  let  your  first  inquiry 
be,  if  it  be  nursing,  as  to  the  state  of  the  mother's  bowels.  If 
these  be  torpid,  give  no  medicine  to  the  infant,  but  administer 
appropriate  remedies  to  the  mother;  make  her  bowels  right,  and 
you  will  thus,  through  the  modification  of  the  milk,  soon  find  that 
the  system  of  the  child  will  also  become  right. 

Occlusion  of  tJie  Anus, — ^There  is  another  condition  of  the  new- 
born infant  which  needs  a  word  or  two  of  comment.  Some  twelve 
or  fourteen  hours  after  its  birth,  you  will  occasionally  notice  the 
child  to  be  in  great  distress — it  moans  piteously,  refuses  the  breast, 
and  its  abdomen  is  greatly  distended ;  at  first  it  took  the  breast,, 
but  now  absolutely  rejects  it ;  it  will  not  sleep,  and  the  expression 
of  its  countenance  is  that  of  positive  anguish.  The  nurse,  in  reply 
to  your  question,  will  tell  you  that  it  has  had  no  p:issage  ^ince  its 


4S4 


THE   PRINXIPLES  AND   PRACTICE  OF  OBSTTrRIGS. 


biith  ;  and  she  will,  perliupH,  confess  that  nhe  li;is  given  it  oil^  ot 
somtftltirjg  eUt%  several  times  within  tlio  lust  two  or  three  hrkiirip 
but  the  child  ha»  invariably  thrown  it  from  the  stotnaeh.  It  hm 
pushed  itij  water  freely  and  often*  This  then,  gentlemen,  la  xhm 
case— what  do  you  make  of  it  ?  You  are  i^ent  for  to  prescribe  for 
thiK  lillle  i>aiieni,  and  the  motlier  is  most  anxious  fur  the  safety  of 
her  child;  she  imjrlures  yon  to  administer  soraethinij  to  relieve  IIM 
boweln.  Be  careful  bow  you  raahly  attempt  to  gratify  that  app^til 
without  having  previously  satisfied  yourselves  of  the  true  nature  of 
the  difficulty.  Doe*;  not  the  agg^regaie  of  the  circum^tanceji,  jiwl 
named f  lead  you  at  once  to  su spinet  why  the  bowelfi  have  not  bciefi 
moved  ?  lias  it  not  alroaily  occurred  to  you  that  the  cause  inmy 
be  mechanical  obstruction — ocnltialon  of  the  antuf  t  In  lieu*  thsre* 
fore,  of  routine  practice,  examine  the  infant  car efliU  '  ''        ir 

BUHpicions  be  confirmed,  do  the  only  thing  which  pruJi  o 

the  sufferer — remove  the  occluaiuu  by  an  opera tiun.  An  H*»on  iks 
the  mechanical  obstruction  U  overcame,  the  bowels  will  be  evmoQ* 
ated*  and  the  child  relieved. 

Congenital  occhisiun  of  the  anus  may  present  itself  in  vsrioiu 
forms  or  degree** ;  for  example,  the  of»eniug  may  be  *imply  doeied 
by  a  delicate^  fine  skin.  Sometimes  the  anal  ajierture  wUl  h9  well 
formed  for  an  inch  or  two,  and  the  obstruction  will  cominenee 
beyond  this  point;  and  there  are  eases  in  which  the  rectum  may 
terminate  in  a  blind  pouch  at  any  distance  Irom  the  sigmoul  tlet- 
ure  to  the  anus  iti*elf.  In  the  tirst  of  these  varieties,  a  him  pie  cm- 
oial  incision  will  suffice  to  remove  the  ditHculty ;  ttt  the  second  ftod 
third,  you  may  introduce  a  small  troc*jir,  followini*  the  con  in* 

Bncruni,  and  thus  penetrate  the  pouch*     It  may  become  ii  y 

afterward,  for  a  few  flays,  to  employ  a  small  tube  with  a  view  of 
preventing  the  closure  of  the  aperture. 

P undent  Ophthalmia— -Ophthalmia  Neonatorum, — The  infant, 
two  or  throe  days  after  its  Wirth,  will  oct^'isionally  be  nfiV  h 

influnnuution  oi  the  eyes;  and  let  me  here  cautiun  you  a-  tt 

danger  of  not  atternling  to  this  epecies  of  ophthalmia  at  ilii  very 
commencomenL  A  fQW  hours  of  progress,  without  proper  trwit* 
ment,  will  often  lead  to  the  destruction  of  the  eye.  On  the  otiicr 
hand,  if  prom])lIy  treated,  it  will  UMially  yield  without  trouble.  In 
ihi^  utrection,  the  tunica  conjunctiva  of  the  lid  is  first  att;icked, 
aoon  becoming  the  seat  of  active  inDammation,  resulting  in  oopioaii 
purulent  secretion  ;  and  if  the  inflanimution  be  not  .♦pttsdily  arrested, 
'the  cornea  is  next  involved — infilinuiou  of  pus  between  the  lafiilrt» 
ensues^  forming  what  is  termed  onyx — tfie  lamina*  them 
become  ulcerated,  and  the  eye  is  soon  destroyed  ibrough  ibt 
grcsj*  o^  the  ulceration, 

Camea. — Purulent  ofdithalmia  in  the  new-born  infant  may  ariM 
from  various  causes:  1.  Leucarrha*al  tnattcr  from  the  vagina  <if 


THB  PRINCIPLES  AND  PKACTICE  OF  OBSTETRICS.         425 

the  mother  at  the  time  of  birth ;  2.  Cold ;  3.  Exposure  of  the 
eye  to  a  sudden  and  bright  Hght ;  4.  Soapsuds  applied  to  the  eye 
of  the  infant  during  its  ablution. 

Symptoms. — The  symptoms  of  this  affection  are  easily  recog- 
nised. At  the  commencement,  one  or  both  eyes  appear  weak; 
there  is  a  slight  weeping ;  in  a  few  hours  inilamroation  sets  in,  and 
a  muco-purulent  discharge  is  observed ;  the  lids  become  aggluti- 
nated and  distended  by  the  accumulation  of  the  morbid  secretion, 
the  child  is  restless  and  feverish,  the  tongue  coated,  and  the  bowels 
UBually  torpid. 

Treatment, — ^The  mother  is  naturally  much  alarmed,  and  will 
urge  you  to  tell  her  whether  there  is  any  danger  of  the  child's  los- 
ing its  sight.  If  the  inflammation  be  confined  to  the  conjunctiva, 
you  can  very  safely  say  that  it  will  readily  yield  to  judicious  treat- 
ment, which  should  consist  principally  in  local  applications ;  but 
the  applications  are  not  to  be  confided  to  the  nurse ;  they  should  be 
made  by  the  practitioner  himself  in  the  fpllowing  manner :  The 
child,  being  on  its  back,  resting  in  the  lap  of  the  nurse,  the  practi- 
tioner, placing  its  head  on  his  knee,  and,  with  a  soft  sponge  mois- 
tened with  tepid  water,  cleanses  the  eyes ;  the  lids  are  then  gently 
separated,  and,  after  everting  them,  the  accumulated  matter  should 
be  removed.  The  eyes  are  to  be  washed  several  times  during  th# 
day,  with  the  following  collyrium  : 

IJ     Hydrarg.  muriat.  gr.  j. 
Sal  ammoniac,  gr.  iv. 
Aqua)  destillataj,  f.  3  vi. 
Ft.  sol. 

It  may  also  become  necessary  to  touch  the  inflamed  conjunctiva, 
by  means  of  a  camePs  hair  pencil,  with  the  following  solution,  once 
a  day: 

IJ     Nit  rat.  argenti,  gr.  ij. 
Aquae  destillat.  f.  3  j. 
Ft.  sol. 

When  the  child  falls  asleep,  with  a  view  of  preventing  their  agglu- 
tination, the  outside  borders  of  the  lids  should  be  smeared  with 
fresh  butter,  fresh  olive  oil,  or  what  perhaps  is  better,  the  red  pre- 
cipitate ointment.  The  bowels  are  to  be  kept  regular  with  castor 
oil,  or  flake  manna  in  solution  ;  and  above  all,  the  eyes  to  be  pro- 
tected against  the  light. 

This  treatment,  if  faithfully  carried  out,  will  effect  a  cure,  and 
should  not  be  surrendered  for  leeches,  blisters,  etc.  They  are  not 
only  rarely  indicated,  but  frequently  result  in  great  danger  to  the 
infant.  Remember  that  the  young  child  bears  the  abstraction  of 
blood  badly,  and  the  irritation  of  the  cantharides  is  oftentimes 
most  injurious. 


426 


TOE  PRINCIPLES  AXD   PRACTICE  OF  OBSTEXmCS, 


I  plioiild  not  omit  to  mention  here  the  means  employed  by  Cblt- 
gaignac ;  it  consiists  in  having  a  constant  current  of  water  ruiitiing 
Upon  the  eyes  for  several  hours  consecutively.  It  is  said  that  it  hms 
been  foUou'ed  by  much  success* 

S&rc  Nippie,H. —The^^  are  a  great  annoyance  to  the  puerperal 
woman,  and  utifoilunalfly  too  often  rt^bellious  to  treatment.  The 
outer  covering  of  the  nifiple,  the  mucous  membrane,  is  made  by 
the  tractions  of  the  child's  mouih  exquisitely  lender,  and  in  a  day 
or  two  ftubsequently  it  cracks  and  becomes  fissured.  Somcttnve«| 
however,  there  is  simple  excoriation ;  the  pain  which  the  tuother 
experiences  i^  most  intense;  the  nnrsinijf  of  her  infant  is  a  K*vere 
struggle  between  duty  and  pliysical  suffering*  The  true  difficidty 
of  relieving  the  sore  nijiples  is  this:  no  matter  what  reme<ly  yott 
may  apply »  every  time  the  child  is  put  to  the  breast  it  open*  the 
fissures  anew,  and  in  ihis  way  what  you  may  accomplish  in  one 
hour  is  undone  in  the  next ;  and  it^  on  the  other  hand,  the  child  be 
not  permitted  to  nurse,  the  breast ts  become  erigorge<l,  inflanunalioii 
ensuej*,  and  mammary  absces?^  is  the  consequen^re.  In  ihes«  casetk, 
numerous  remedies  have  been  suggcsred ;  but  I  have  fouui!  tiolhing 
answer  better  when  the  nipple  is  tissured  thnn  a  subitioii  of  the 
nitrate  of  silvei\  say  vj.  gr.  to  3  j.  of  water.  Let  this  be  applied 
several  times  during  tlie  day,  but  be  careful  that  the  nipple  is  well 
washed  betore  the  child  again  takes  it.  It  will  be  very  desirable 
to  use  the  nipple-shield,  and  allow  tlie  infant  to  nurse  through  it, 
thnn  protecting  the  nipple  from  the  immediate  irritation  of  the 
child's  mouth.  When  there  are  no  fissures,  but  simply  tendenvesB, 
borax  and  water,  equal  pints  of  brandy  and  water,  or  g}\  ii*  of 
Kul|ihjjte  of  zinc  to  5j.  of  rose  Avater,  etc.,  may  be  employ cnl  with 
advantage.*  In  crises  of  mere  excoriations,  the  tincture  af  cate- 
chu  will  oftentimes  be  serviceable, 

J/afuman/  Abset'M. — This  constitutes  one  of  the  banes  of  the 
lying-in  room,  iniliciing  iiporj  the  })atient  intense  snftenng,  and 
oflenliuics  lending  to  tedious  and  protracted  convalescence*  My 
own  opinion  is  that  ni.ammary  abscess,  in  nineteen  itistnnecs  out  of 
twenty,  is  the  result  of  carelessness.  It  may  be  produced  by  cold, 
or  a  sli[i;ht  blow  on  the  breast,  etc.;  but,  according  to  my  experi- 
ence, tlie  must  prolilic  cause  is  neglect  iji  not  having  the  breasts 
properly  drawn.  For  exam[>le,  the  child  may  be  delicate,  and  not 
able  to  extract  the  milk;  or  the  nurse,  bi  the  gratification  of  mme 
ancient  prejudice  derived  from  a  remote  ancestry,  dm-^s  not  think  It 
proi>er  to  allow  the  infant  to  bo  put  to  the  breast  for  two  or  Uiree  4 

*  It  ifl  0  good  rule,  especially  in  a  prixnipam,  to  enjoin  on  tim  pntlent  the  i 
«ilv»  durifjf^  )it?r  pregnancy,  of  mttkirjg  diiily  jr<*nl)<?  irnctlonti  on  iln'  ntpnli'%  wiili  1 
UugiT  and  tUnmb.     \n  thin  way  ilia  luueoim  (.Htvpriiig  b(<cofni^  tuirdened  And  1 
llmj9  euHlnin  with  iiitpunity  the  tViction  of  tli6  ehild*a  moutli.     The  tiacture  of  mj 
may  also  be  oceusiuuulJ/  used  with  benellt  * 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         427 

days  after  its  birth.  In  this  way  the  milk  ducts  become  greatly 
distended,  inflammation  ensues,  which,  if  not  promptly  arrested, 
terminates  in  suppuration.  If,  therefore,  the  child  be  not  able  suf- 
ficiently to  disgorge  the  breasts,  have  a  young  pup  obtained ;  this 
latter  is  worth  all  the  machines  ever  contrived  for  the  purpose  of 
drawing  the  mammse.  Gentle  friction  with  camphorated  oil,  and 
proper  support  given  to  the  breasts  by  means  of  a  handkerchief 
placed  under  them,  and  made  to  cross  the  shoulders,  will  be  very 
proper  aids.  The  moment  inflammation  of  the  breast  is  noticed, 
leeches  should  be  freely  applied,  warm  fomentations  and  poultices 
should  follow,  and  a  free  use  of  saline  cathartics,  together  with 
tolerant  doses  of  tartarized  antimony.  The  patient  should  not, 
while  the  breasts  are  engorged,  be  permitted  to  indulge  in  fluids. 
The  pup  should  be  applied  whenever  the  breasts  become  distended ; 
and  remember,  tJie  momejit  pus  is  formed^  make  a  free  incision^ 
and  afford  it  an  exit.  When  the  abscess  has  been  opened,  and  the 
purulent  secretion  finds  issue,  the  use  of  pieces  of  broad  adhesive 
plaster,  for  the  purpose  of  making  pressure,  will  materially  facili- 
tate the  process. 

Diet  of  the  Puerperal  Woman, — ^The  diet  of  the  puerperal 
woman  for  the  first  four  or  five  days  should  be  simple,  consisting  of 
gruels,  arrow-root,  tapioca,  boiled  rice,  tea  and  toast,  soft-boiled 
eggs,  etc.  If  everything  pass  on  favorably,  she  may  then  be  in- 
dulged in  meat  and  vegetables,  and  begin  gradually  to  resume  her 
ordinary  fare.  There  will,  however,  sometimes  be  exceptions  to 
this  restricted  diet ;  for  instance,  in  cases  of  anaemia  and  marked 
dilapidation  of  the  forces,  a  generous  nutrition,  together  with 
tonics,  will  be  indicated  from  the  first. 

Recumbent  Position  after  Delivery. — One  point  I  wish  strongly 
to  impress  upon  your  recollection — keep  your  patient  in  the  recum- 
bent  posiiio?i  for  at  least  ten  days  after  delivery^  and  she  will  subse- 
quently recognize  the  advantage  of  this  rule  by  finding  herself  free 
from  many  of  those  troubles  consequent  upon  too  quickly  "  getting  " 
np  after  child-birth  ;  such  as  displacement  of  the  uterus,  bladder,  or 
vagina.  Consider,  for  a  moment,  the  relative  conditions  of  the 
uterus  and  vagina  after  the  birth  of  the  child.  The  uterus  is  large, 
possessing  increased  weight,  while  the  vagina  is  relaxed,  and  inade- 
quate to  furnish  necessary  support.  Therefore,  if,  under  these  cir- 
cumstances, the  patient  rise  from  her  bed,  assume  the  erect  posture, 
or  walk  about  the  room,  what  are  you  to  expect  but  that  the  super- 
incumbent weight  of  the  enlarged  organ  pressing  upon  a  frail  found- 
ation, the  relaxed  vagina,  will  necessarily  lead  to  displacement  ?  I 
do  not  wish  you  to  understand  that  the  patient  is  actually  to  continue 
in  bed  for  ten  days,  but  she  should  maintain  the  horizontal  posture ;  let 
her  recline  on  the  sofa,  or  a  cot,  but  always  have  her  placed  there 
by  assistants,  and  not  be  permitted  to  reach  it  by  her  own  eflTorts, 


i28         THE  PRINCIPLES  AND   PRACmCK  OF  OBSTETRICS, 

T/irfifif(fial  Parnlt/giit  of  (hr  Lotrrr  Extrrinitirs^-^h  will  occii* 
eionally  happen  I  bat  vvljcn  tlic  patient  corameneeH  to  walk,  she  will 
cx|)eneuce  moris  or  less  hiabUity  to  move  her  lirnbfi;  ihero  will  bo 
a  feoliujj^  of  niimbiieHa^  with  diminished  seiisihility.  This  eonditioii 
of  tliini;^  will  very  naturally  give  ri>H?  to  nmcrh  anxiety.  'Hii*  inci' 
pm\t  puweHessfiejtA  of  the  hiwer  extrcmilies  in  nsually  acooin|)uuied 
by  severe  pain  iu  the  isehiatic  nerve  and  its  tributariea,  ami  al^M>  bj 
neuraigto  fieniuitionH  through  the  hifiM.  I  have  generally  ob^rved 
the  above  |>herioinena  atler  a  tetUous  labor,  and  more  -  v  tiJ%0r 

delivery  by  the  tbreeps* ;  in  the  great  majority  of  <i  -,  tbey 

are  the  resultu  of  pres§ure  on  the  saeral  plexus  uf  nerveii  dtirrog 
labor;  and  what  w  a  very  gratifying  drcumstanec  is — yon  maj 
ansttre  yonr  patient,  a^  a  general  rule,  tliat  they  are  irannitory  in 
thuir  character,  Sometimoft,  however,  they  arc  rnorc  pcrnianctit, 
refjuiring  the  ap[>lication  of  leeehes  over  the  region  of  the  ^erum, 
together  with  small  blisters,  for  the  purpose  of  removing  the  con* 
gested  »tate  of  the  parts. 

Yon  will,  however,  meet  with  cases  of  paraplegia  after  detiverf, 
in  which  there  is  not  the  slighteKt  approach  to  pain.  The  paraple- 
gia, in  these  instances,  is  traceable  to  some  morbid  intluenc<»  tntniM 
mitted  by  tlie  uterus  to  the  spinal  cord.  It  is,  ia  faet,  an  example 
of  simple  reiiex  paralysis.  The  treatment  should  consist  iu  tke 
admin  i.st  ration  internally  of  8lrychriiiu%  with  whieh  may  be  ad  van* 
tageously  conjoined  the  cold  shower-bath  ap|jlied  to  the  spine.  A 
very  practical  and  inieresting  history  of  this  form  of  paralyiis  an 
observed  during  gestatiiHi  and  alU*r  delivery,  hjis  been  pren^cited 
by  K.  Lerov  U'Ktiolles,  Nonat,  and  Dr.  Hrown-SoquanU* 

I'/w  Umfnlical  Cord, — From  the  third  tu  the  sixtli  tlay,  the  eon! 
will  slough,  and  become  detaeheil  from  the  nmbilieus  of  the  inliiBL 
Sometimes,  before  tliis  taken  place,  and  as  the  eoriHccpienee  of  th« 
sloughing  procoss  there  will  be  an  extremely  unple:vhant  smell  emit- 
ted :  the  I  ther  becomes  alarmeil,  sends  for  you,  an<l  says  ^hn  is 
afraid  her  child  is  mortifying!  If  you  eaiinot  at  ouee  readily  and 
satisfactorily  explain  the  cjiuse  of  the  fwtid  odor,  and  thus  relieve 
the  apprehensions  of  the  parent,  the  nnirtilieation  will  be  altugetlmr 
on  your  side,  should  a  praetitioncr  be  called  in  to  aid  yoo  in  your 
diagnosis  \  When  the  cord  becomes  detaeheiU  the  umbilicQs  b 
drei^sed  simply  with  a  piece  of  burnt  linen.  This  tsan  old  |>ni*cttco 
among  nurses,  and  it  answers  u.suidly  every  purpose.  Soanetlmm, 
however,  there  will  be  a  small  granulation  sprouting  from  the mvd, 
known  in  the  lying-in  room  as  proud  flesh  ;  the  sprinkling?  of  a  few 
grains  of  calomel  will  generally  suffieo  to  remove  it. 

Under  ordinary  eircumsianees,  the  puerperal  woman  Hiiouiil  be 
visited  at  least  once  every  day  for  the  hrsi  six  ilay.i  after  delivery, 


*  Itee  Leduiei  oa  Parsp)egi«,  by  Browa-&oqiiard«  Loadcxi  I^iioK  \^^- 


THE  PBINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         429 

and,  if  everything  progress  &vorably,  afler  this  she  may  be  seen 
every  other  day  for  a  week  or  so. 

UmbiliccU  Hemorrhage, — ^The  new-born  infant — ^fortunately  it  is 
of  rare  occurrence — is  liable  from  the  third  to  the  eighteen tli  day 
to  a  serious  hemorrhage,  which  is  connected  more  or  less  directly 
with  the  detachment  of  the  cord  from  the  umbilicus.*  As  soon  as 
the  cord  becomes  separated  from  the  navel,  it  will  sometimes  happen 
that  a  slight  oozing  of  blood  ensues,  but  this  is  of  little  or  no 
moment.  It  is  in  reference  to  the  more  formidable  variety  of  hemor- 
rhage from  the  umbilicus  that  we  propose  to  say  a  few  words  at 
this  time.  It  is  more  important  to  direct  attention  to  this  subject 
for  the  reason  that,  although  a  rare  complication,  yet  it  is  almost 
always  fatal.  There  is  far  from  being  an  agreement  as  to  the 
etiology  of  umbilical  hemorrhage ;  in  some  instances  it  may  be  the 
result  of  imperfect  closure  of  the  vessels  after  the  desiccation  of  the 
cord;  it  may  arise  from  what  is  known  as  the  hemorrhagic  diathe- 
sis ;  sometimes  it  is  accompanied  with  jaundice ;  again,  it  may  be 
connected  with  some  hereditary  influence ;  abscess  of  the  umbilicus 
may  occasion  it ;  sometimes,  too,  it  will  result  from  carelessness  in 
tying  the  cord. "  It  is  an  interesting  fact  that  this  form  of  hemor- 
rhage most  frequently  attacks  male  in  preference  to  female  infants, 
and  the  mortality  is  greatly  increased  among  the  former. 

The  treatment  of  umbilical  hemorrhage  will  consist  in  the  appli- 
cation of  astringents  and  pressure,  the  ligature,  caustics ;  and  in 
some  instances,  the  actual  cautery  has  been  adviscd.f 

Pain  in  the  Uterus  when  the  Child  is  Applied  to  the  breast, — 
Your  attention  will  occasionally  be  directed  by  the  mother  to  an 
excessive  pain  in  the  womb  whenever  the  infant  takes  the  breast. 
This  might  possibly  give  you  some  embarrassment  if  asked  to 
explain  the  relation  between  the  pain  in  the  uterus  and  the  trac- 
tions on  the  nipple  ;  but  with  a  little  reflection  you  will  be  enabled 
to  give  a  most  satisfactory  exposition  of  the  circumstance.  It  is 
another  interesting  illustration  of  reflex  influence;  the  traction  of 
the  child's  mouth  on  the  nipple  excites  an  action  in  the  spinal  nerves, 
which  is  immediately  transmitted  to  the  medulla  spinalis,  and  this 
latter,  becoming  the  seat  of  irritation,  imparts  to  the  motor  nerves 
of  the  uterus  an  influence  which  induces,  for  the  time,  contraction 

*  Although,  as  a  general  rule,  bleeding  does  not  take  place  until  the  separation  of 
■'re  cord,  yet  it  should  bo  remembered  that  this  is  not  universally  the  case.  Pro- 
fuse hemorrhage  may  occur  prior  to  this  period,  either  as  the  result  of  injury,  or  as 
An  idiopathic  bleeding. 

f  The  subject  of  umbilical  hemorrhage  has  received  some  able  contributions  from 
our  own  countrymen:  viz.,  Dr.  John  llomans  (Boston  Med.  and  Surg.  Journal, 
1849).  Dr.  Bowditch  (Amer.  Journal  Med.  Science,  1850).  Dr.  Bailey  (Amer. 
Journal  Med.  Science,  1852).  Dr.  Minot  (Ibid.  1852).  Dr.  Otis  (Vir.  Med.  Journal, 
1853).  Dr.  Stephen  Smith  (New  York  Journal  of  Med.,  1855).  Dr.  Conant  Jenkeni^ 
(TnioaactionB  Amer.  Med.  Asso.,  1 858),  and  others 


THE  PRINCIPLES  AND  PRACTICS  OF  OBSTETmca 


of  this  organ,  and  consequently  pain»     Bnt  you  may  aak,  do  all  | 
nursing  women  cumplam  of  ihi'i  pain?  By  no  mean«;  somi*  never' 
exponencc  the  s)it;htest  ineonveniencis  wliile  othe^f^  on  the  con* 
trary,  of  a  sensitive  nature,  suffer  for  someday*  after  delivery  mach 
annoyance.     An  eflicient  remedy  will  he  the  introdueliun  of  a  Kup»^ 
ponilory  of  belladonna  itito  the  vagina,    which  will  prevent  tilt 
contraction  and  consequently  the  pain  io  the  uterua. 

Thrombus  of  the  Vulva. — A  Thrombus  or  siMiguinoous  tatiior 
of  tiie  vulva,  aa  it  in  sometime*  called,  may  occur  as  a  conseqaenis  i 
(if  |iatfuiition.     It  results  from  an  extra vas:ition  of  blood  in  tb«l 
Burruumling'  cellular  lissuc,  dilfcring  in  this  respect  frotn  the  e^nri- 
coA^  tiimar^  the  blood  in  this  hitler  ca^e  being  containetl  within  tho 
vei«st?l8.     Thrombus  may  appear  in  Ih©  unmarried,  in  the  married 
who  liave  not   burue  children,  during  pregnancy,  at  the  tiin*  of* 
lab(H\,  and  i^ubseqiierttly  to  parturition*     It  i^  althotigh  cum|iaii^' 
tivttly  a  rare  atfcclion,  muf«t  commonly  connected  with  pri^gtmncy 
*nd  iabor,  and  this  arises  from  the  predisposition  of  llie«o  two  cuo^ 
ditiMUS  tu  the  formation  of  the  tumor — the  ubj<truettHl  ven%>iis  drcn- 
lation  no  engorging  the  vc^nels  as  to  provoke,  under  fkiine  clrcuin*^ 
stances,  their  rupture  frotn  i^light  caused.     It  may  happen  that  ibil 
rupture,  giving  rise  to  extravaaatioiu  may  take  place  during  labor, 
but  the  tact  may  escape  attention  for  some  days  after  delivery,  ^r 
tho  resison  that  the  head  or  j)resent»ng  part  o(  tlic  fa^tu-^  iiniy  bav#| 
temj^oiarily  acted  as  a  sort  of  tampon,  tlju«  preventing  tJie  itntn^ 
diate  formation  of  the  tumor. 

Cmaes. — ^These  are  both  )>redIspoaing  and  exciting — umong  (Ke 
former  may  be  ela«»ed  the  various  modiHeatiotm  incident  to  geti^ 
tion  and  labor;  a  contracted  pelvic,  deformity  uf  the  »ofl  |xarte, 
twin  pregnancy,  i^c. ;  the  exciting  causes  consist  in  fallft,  blowa, 
escternai  violeuee  of  any  kind,  rude  nianipulaliou?t  uti  the  part  o^ 
the  accoucheur,  ftircep:*  delivery,  or  undue  |irc8f*ure  of  the  pre^irut* 
ing  portion  of  the  IVrtua ;  coughing  or  vomiting  may  aUu  give  mft 
to  the  extravasation. 

iSt/tuptoms, — *^»*«i  of  the  tir«*t  and  most  prominent  symplonts  of 
thrombus  is  pain,  which  nn^jn  no  doubt  from  rupture  of  the  vcami 
an<l  also  from  pressure  on  the  adjoining  nerves.  There  i^  Itkowii 
more  or  Icms  tumefiu'tion^  .sometimes  l.'irge  at  the  very  eommriiiM^ 
rnent,  .and  again  its  deveJo|unent  is  not  complete  for  seveml  liaon 
or  days.  When  the  thrcimbus  hiis  4ittained  a  large  volume,  iimmf 
impede  the  birth  of  the  child,  or  the  expulsdon  of  the  placenta;  and 
casc«  are  reeordctl  in  whicii  retention  of  the  urine  and  i'v^x*  euMjed 
fmm  pres-iure  of  the  tumor  on  the  blajjder  ami  rectum.  Otutajfjoo* 
ally,  the  thrombus  may  suddenly  burst,  cauKing  profuxe  and  dan* 
gerons  h^BOiurrhage.  The  color  of  the  outer  covering,  noon  after 
the  aj'i  of  the  tumor,  will  present  a  livitl  or  bluisih  cast,  and 

this  i>^  rtaut  jioint  in  reference  to  the  diaguo^i^  of  thm  fomt 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.        427* 

of  sanguineous  engorgenK»nt.  An  interesting  fact  is  this — the  blood 
in  these  tumors,  mixed  more  or  less  with  purulent  matter  under 
inflammatory  action,  will  sometimes  emit  a  distinct  stercoral  odor, 
which  might  |)ossibly  lead  to  the  erroneous  opinion  that  the  throm- 
bus is  complicated  with  a  recto-vaginal  fistula.  It  has  been  well 
demonstrateil  by  the  surgeon — an  interesting  fact  for  the  accou- 
cheur—that in  abscesses  situated  in  the  vicinity  of  the  rectum,  it 
is  quite  usual,  without  any  communication  with  the  intestine,  for 
the  purulent  secretion  to  possess  the  odor  of  fajcal  matter. 

Dlag'nosis. — While  to  the  careful  practitioner,  the  diagnosis  of 
vaginal  or  vulvar  thrombus  presents  no  embarrassment,  yet  it  may 
possibly  be  mistaken  for  other  affections,  such,  for  example,  as 
incipient  abscess,  varicose  tumor,  osdema  of  the  labia,  hernia  of  the 
bladder  (vaginal  cysiocele),  omentum,  or  intestine,  inversion  of  the 
yagina,  or  uterus,  etc.  A  thrombus,  as  a  general  rule,  is  charac- 
terized by  rapid  developineut,  pain,  tlie  peculiar  bluish  color  of  the 
stdn,  and  hardness  of  the  tumor  when  the  blood  is  simply  infiltrated; 
on  the  contrary,  there  is  distinct  fluctuation  when  collected  in  the 
form  of  abscess. 

Prognosis. — The  pi'ognosis  of  this  affection  is  far  from  a  favor- 
able one;  when  death  ensues  it  is  most  frequently  caused  by  the 
profuse  hajmorrhage,  either  external  or  internal ;  sometimes,  too, 
by  the  exhausting  efft?cts  of  suppuration,  by  gangrene,  inflammation 
of  the  adjoining  organs,  and  more  especially  of  the  peritoneum. 

Termmatio9is. — The  terminations  of  thrombus  are  as  follows: 
Ist.  In  resolution ;  *2d.  In  suppuration ;  3d.  In  rupture,  and  conse- 
quent haemorrhage ;  4th.  In  gangrene,  and  sometimes  in  the  forma- 
tion of  encysted  tumors  of  the  vulva  and  vagina. 

Treatment, — The  particular  treatment  of  this  form  of  tumor  will 
necessarily  depend  uj)on  the  circumstances  attending  each  case ;.  for 
example,  should  you  meet  with  a  thrombus  during  labor,  of  such 
magnitude  as  to  interfere  with  the  birth  of  the  child^  it  will  obvi- 
ously be  your  duty  to  evacuate  the  effused  fluid  by  a  free  incision, 
and  then,  in  order  to  check  any  undue  bleeding,  the  tampon  should 
be  employed,  unless  the  child's  head  be  low  do-wn  in  the  pelvis,  in 
which  case  the  pressure  of  the  head  against  the  vessels  would  prove 
the  best  possible  hajmostatic.  There  are  instances^  however,  in 
which  it  would  be  judicious  to  attempt  the  resolution  of  the  tumor, 
either  during  gestation,  or  subsequently  to  delivery  ;  but  it  should 
be  remembered,  that  efforts  to  accomplish  resolution  would  be 
without  avail,  except  when  the  effusion  is  limited,  and  the  cover- 
ings unchanged  by  the  ])rogress  of  the  swelling.  The  remedies  most 
likely  to  effect  this  purpose  are  bloodletting,  repose  in  the  recum- 
bent posture,  and  evaporating  lotions. 

In  post-parCum  thrombus,  it  will  be  good  practice,  if  the  swelling; 
be  of  very  recent  origin,  to  make  applications  of  ice  to  the  part,  or 


428* 


THK   rRLNCIPLES  AND  PRACTICE  OF   OBSTETRICS. 


ell  <iirerted  pressure  with  spongea  wet  wilh  iee-walcr.  TIiiji  wiH 
&metiaiu8  be  t'olluweil  by  gt>od  results  in  iliiuiiilHhiug  the  tumor, 
ftiid  intiueing  rcH^ibition,  If,  however,  the  applications  fail  in  their 
j>urpoSL%  no  time  should  be  lost  in  operiin*2t  the  tumor,  auil  reutciv* 
in<^  the  eoagula;  should  this  be  followetl  by  much  htcmoi  rhnt»r,  lei 
injeciioiis  of  ict*-watcr  be  thrown  into  the  cavity,  or,  if  it  BhouM 
become  necessary  on  aecount  of  the  continuccl  blecclin!;»,  fill  tip  tho 
entire  cavity  witli  bulJs  of  Hut  or  sponge  well  Raturatt^l  with  a 
§otution  of  &u!phate  of  alum,  or^  if  at  hand,  a  decoction  of  oak 
bark. 

Weed  or  E/)hefnerai  I^er. — It  is  proper  that  I  Kbonld  here  nay 
a  few  words  touching  a  fever  which,  in  gnino  of  ivn  phenomena,  if 
kindred  to  ordinary  intermiltetit  fever,  and  which  ^OMietitoei 
attacks  the  puerperal  woman*  The  churacleri?<tie  of  thiit  di*<  iim?  in 
its  short  continuance,  and  henco  its  name,  ephemeral.  Whon  it 
occurs — it  is  by  no  means  a  frequent  visitor  in  the  lviiig4n  room- 
it  will  manifest  itself  abotit  a  week  after  dt livery,  rarely  earlier, 
8<»nietintes  later. 

Causes, — I  bcUcvc  there  is  no  jiredisposing  influence  morc^  di*ci- 
dedly  of»emtive  in  the  [iroduetion  cd'  weed  than  a  humid,  mla.Hrnalio 
atmoj^phere.  Cold,  however,  independently  of  any  niiuMnatic  flo- 
meni,  will  sometimes  oecjision  it*  Want  o(  rest,  mental  anxiety, 
and  laiigue,  may  be  enumerated  among  \U  exciting  eauHe"** 

Sf/mp(omg* — Tho  throe  principal  pheuonu-n.o,  which  mark  tlii» 
dise:i*«e  are— chill,  fever,  and  per<*j /nation.  The  chill  i-*  u^fially  one 
of  great  Ki'verify  and  loui;  continunnco ;  it  i-f  acconipnuird  by  nmrtt 
or  le!*»  pain  in  the  }i tad,  back,  and  exlrenrnie**;  the  connlenance 
becomes  change*!,  the  eyes  being  sunken,  and  the  feattire*  «lmwn 
or  shrivelled ;  the  surface,  notwiih*«tanding  tho  cold  ^lagl*,  l*  nnii* 
anally  h<it ;  the  fingern  present  a  bluish  or  livi<l  colnr,  as  i*  i*h'«.rrved 
during  the  cliill  of  ordinnry  intermittent  fever;  the  puUe  U  ^Iit;htly 
accelerated,  and  its  predoniinjint  feature  i*  feidilene^^at.  Tlie  ddU  iff 
followed  Ijy  fever,  and  thin  wnsond  stage  of  the  affection  is  aeemo* 
panied  by  a  general  increase  of  heat,  throbbing  of  ih^  Ivmplr*,  wilh 
increased  distress  rn  the  head  ;  the  eyes  bt'coinc  intolernnt  »»f  ftghl; 
the  tongue  i<  coated,  the  month  dry,  with  tlut-hcfl  face;  the  »rcn^» 
tions,  especially  of  the  breasts  and  kidney«i,  are  KUppreiwied;  and,  u 
n  gencnd  rvilr,  the  lochial  di^charL'e  is  arrested;  the  pulw  berotncai 
more  uniform,  auti  h  firmer  under  the  ftn^r.  There  m  often  a 
markei]  depression  of  spirits  in  ihin  sla^'e  of  the  dtsea**!*,  ami  the 
patient  is  despomlent,  che)i>hing  but  little  hope  of  recovery,  II 
may  hnpt»en  that,  in  tho  height  of  the  febrile  paroxYimiY  dcUrtiini 
will  «et  in»  The  hf»l  stage,  of\en  continuing  for  an  *'  ' 
in  ffillitwed  by  a  profuse  p*'rspiration  ;  this  «wc:nin_ 
a  prf»inf>t  inflinme**  ovc»r  (he  "lymploms  jtst  enumerated — ihe  pfit»e 
itt  isofter;  the  pain  in  the  head  »Mb>sides;  the  si'cretionj*  arc  fnti;  the 


THB  PBIKCIPLES  AND  PRACTICE  OF  OBSTETRICS.        429* 

tongue  and  month  moist;  the  lochial  discharge  returns.  In  one 
wordy  with  the  sweating  stage  the  disease  ceases ;  all  the  symptoms 
give  way ;  the  patient  is  no  longer  despondent ;  she  lapses  into  a 
gentle  slumber,  and  very  soon  recovers  her  wonted  health.  The 
disease  is  very  rarely  prolonged,  and,  under  judicious  therapeutics, 
does  not  return. 

Diagnosis, — It  is  possible  to  confound  this  affection  with  puer- 
peral fever ;  but  to  do  so  would,  I  think,  betray  great  carelessness- 
In  the  first  place,  tlie  severity  of  the  chill  is  different  from  the  ordi- 
nary chilliness,  which  is  usually  the  prelude  of  peritoneal  inflammar 
tion  ;  then,  again,  there  is  here  an  absence  of  the  rapid  pulse,  which 
I  cannot  but  regard  as  almost  pathognomonic  of  peritonitis ;  these 
two  circumstances,  therefore,  with  the  absence  of  abdominal  ten- 
derness, will  sufficiently  indicate  the  diagnosis,  and  thus  all  error 
will  be  avoided. 

Prognosis, — Weed  is  not  a  disease  of  peril ;  and,  unless  accom- 
panied by  some  serious  complications,  may  be  regarded  as  unim- 
portant so  far  as  the  safety  of  the  j)atient  is  concerned. 

Treatment, — The  phenomena  of  this  affection  very  clearly  point 
out  its  management.  During  the  cold  stage,  efforts  should  be 
made  to  break  the  intensity  of  the  chill,  and  limit  its  duration. 
The  patient  should  be  well  provided  with  additional  bedclothes; 
bottles  of  hot  water  to  the  extremities ;  hot  flannels,  or  even  a 
mustard  poultice  to  the  epigastrium,  together  with  warm  drinks. 
If  the  bowels  be  inclined  to  constipation,  I  should  advise,  even  at 
the  very  commencement,  a  searching  cathartic.  The  following 
may  be  ordered : 

3  Submur.  Hydrarg.  ^,  x. 
Pulv.  Jalap©,  gr.  xv. 
Pulv.  Antimonialis,  gr.  ii.     M. 

Let  it  be  followed  in  six  hours  by  f  3  i.  of  castor  oil ;  or,  if  there  be 
objection  to  the  oil,  3  i.  of  Epsom  salts,  or  the  following  draught 
may  be  administered : 

3  Sulpliat  Magnesiee,  3ij. 
Infus.  Sennje,  f.  J  iv. 
Tinct  Jalapaj,  £  3  i. 
Mannse,  3 1     Fiat  soL 

During  the  hot  stage,  a  diminution  of  the  covering,  together  with 
cool  drinks,  and  diaphoretic  medicines,  say,  f.  3  ss.  of  Liq.  Ammo- 
nias Acetat.,  every  two  or  three  hours,  as  circumstances  may 
indicate. 

After  the  copious  perspiration,  which  is  so  characteristic  of  the 
third  stage  of  the  disease,  the  patient  is  usually  left  in  an  extremely 
prostrated  condition.    Here,  it  will  be  proper  to  restore  energy  to 


480*       THX  PBIKGIPLSS  AND  FRACnCE  OF  0BBTETBIG8. 

the  system,  by  nutritions  diet,  quinine,  and  porter.  It  may  not  be 
out  of  place  to  remark  that,  as  an  exception  to  the  general  rale. 
Weed  may  assume  the  intermittent  type,  and  return  in  paroxysma 
precisely  like  ordinary  tertian  fever ;  in  such  case,  it  is  to  be  treated 
upon  the  same  principles  which  regulate  the  therapeutics  of  legiti- 
mate intermittent  fever. 


LECTURE    XXIX. 

Ifnltiple  Pregnancy;  relative  frequency  of;  mortality  of— Hypothesis  in  Kxplanft- 
tion  of  Multiple  Gestation — Plural  Births  apt  to  occur  in  certain  Families — Signs 
of  a  Twin  Pregnancy;  their  vplue — Twin  labor  not  necessarily  Preternatural ;  how 
managed — Presentation  of  the  Foetuses — When  one  Ciiild  is  bom,  should 
the  Mother  be  told  there  is  another  in  Utero  ? — Delivery  of  the  Placenta* 
after  the  Birth  of  the  first  Child — Rules  for  Delivery  of  Second  Child — Discre- 
pancy of  Opinion  among  Authors — Interesting  Twin  Case :  exhibiting  extraordi- 
nary peculiarities — Can  a  Twin  Gestation  exist  with  only  one  Amnion  f — Super- 
fcBtation ;  meaning  of  the  term — The  Possibility  of  Super-fcetation  generally  con- 
ceded by  the  early  Writers ;  not  so  with  the  men  of  our  own  times — ^The  Case  cited 
by  BufTon — The  Case  in  the  Brazils,  by  Dr.  Lopea — Is  Super-fuetation  possible  in 
Animals;  Illustration— Can  a  Woman  simultaneously  carry  a  Uterine  and  Extra- 
uterine Foitus  ? — Super-foetation  in  a  Double  Uterus ;  the  instance  recorded  in  the 
Encyclographie  Medicale — Objections  to  Supcr-fcctation  examined — the  Mucous 
Plug ;  is  it  an  obstacle  to  a  second  fecundation  ? — The  Mucous  Plug  in  Cervical 
Canal  of  the  Pregnant  and  Unimpregnated  Female ;  is  there  any  difference 
between! — Demonstrations  of  the  Microscope — The  Membrana  Dccidua;  does  it 
prevent  the  entrance  of  ti)0  Spermatozoon  into  the  impregnated  uterus? — Moral 
Considerations  involved  in  the  Question  of  Super-foetation. 

6entt.emen — We  have  not  yet  spoken  of  multiple  pregnancy,  or 
that  character  of  gestation  in  which  there  are  two  or  more  foetuses 
within  the  uterus.  Women  will  occasionally  bring  forth  two,  three, 
four,  and  five  children  at  a  birth  ;  and  there  are  recorded  instances 
of  a  far  greater  number  having  come  into  the  world  at  one  parturi- 
tion ;  but  these  cases  are  to  be  accepted  with  great  caution.  It 
would  seem  that  a  twin  pregnancy  occurs  in  the  varying  proportion 
of  one  in  sixty  to  one  in  ninety-five  cases.  Madame  La  Chapelle 
records  that,  in  37,441  births  there  were  36,992  single  deliveries, 
444  instances  of  twins,  and  but  five  of  triplets ;  and  it  is  an  inter- 
esting fact  that,  in  108,000  births  in  the  Hotel  Dieu  and  Maternite 
of  Paris,  from  the  years  1761  to  1826,  there  was  not  one  example 
of  quadruple  gestation.  In  129,172  deliveries  in  the  lying-in  Hospi- 
tal of  Dublin,  there  were  2062  cases  of  twins,  29  of  triplets,  and 
but  one  instance  of  a  quadruple  birth.  While,  therefore,  instances 
of  three,  four,  and  five  children  are  to  be  regarded  as  extremely 
rare,*  yet  it  is  quite  evident  from  these  tables,  amply  confirmed  by 
all  practical  observers,  that  such  is  not  the  fact  as  regards  twin 
deliveries.! 

•  **  Non  raro  femina  geminos  foetus  parit ;  rarius  paulo  tres,  neque  unquam  supra 
qiiinque."    (nailer's  Physiologia,  929.) 
f  Dr.  Churchill  presents  the  following  statistics :  Among  British  practitioners,  in 


432 


THE   PRIXCIPLES  AND   PRACTICE   OF  OBSTETRICS. 


There  have  bf  en  numerous  ihoones  promnlifated  in  the  attemptfid 
explanation  of  the  ciiuse  of  a  multiple  or  plnriil  progiinrv,  \mi  fier* 
hapji  they  may  all  be  summed  up  in  this  general  admii^aioti^thttl  it 
is  the  result  of  an  ext-essive  reproductive  |>ower,  sornctiines  pos^itritt- 
ed  by  thi?  male,  nnd^  at  other  tinier,  alone  the  attnbute  of  the 
female,  Tlie  procreation  of  twins  seemj*  to  hv  peculiar  lu  certain 
individual  and  families.  A  remarkable  ilhi^tmtion  of  the  truth  of 
this^  I  \vitnes!i«cd  in  the  case  of  an  American  lady  who  rtmrriidd  ji 
Genuau*  Thii*  lady  I  confined  three  tinier  successively  with  t^ins; 
her  husband  was  a  twin,  and  111$$  a\|nt  on  the  maternal  r<tde  \kni^  dcit* 
vered  twice  of  two  children  at  each  birih. 

Placenta  and  Membranes  in  MuUijyle  l^rcf/nmiry. — Tire  gtwr- 

ral  rule  i^thatf  ill  pla- 
ral  preL;nancyt  «Mb 
fceiu!t  posac«se>  tSa 
own  membrsiiiM  and 
'  nta  (F\g,  W), 
n  thin  pan icolsr. 
It  nimulaie.s  in  all  ns 
specie,  a  single  g«;ita* 
licm,  with  the  rjtotp- 
tion  thau  Homeiin>eA, 
there  will  be  an  ino«- 
culatioh  of  biuocl*v«a* 
McU  t>etwcen  the  dhf- 
ferent  placenta?.  On  the  other  hand^  Jt  will  oi  easitmaUy,  though 
rurely*  happen  iliat  there  k  hut  one  placenta  for  the  two  childreu; 
and  it  has  been  ^uggcnted  by  Dr.  T}  ler  Smith  that,  in  these  hillw 
instanceji,  the  one  ovule  hjis  eon tnined  two  yotka,  nod  two  germlfiil 
vesicles,  as  is  sometimes  obsened  in  the  ease  of  bird** — one  vgg  witi 
a  dotdde  yolk  producing'  two  individuals.  The  ftrtu^e^s  in  the  cam 
of  twins,  are  usually  smaller  than  when  there  is  but  une  chikl  in  the 
uterus,  and  there  is  also  astn>n^  predisposition  to  prcnjaluro  deli- 
very; when  there  are  more  than  two,  the  labor  is  still  rnori*  Apt  to 

257,935  bintifl  tliere  were  3431  cnaes  of  twins,  or  nhoMi  I  In  Tfi,  tiut  43  casit  <it 
tHpleta  or  1  in  5561 1:  among  tho  French.  In  39,409  there  wem  336  awos  ol  twto% 
or  1  lu  108,  Mnd  6  of  tripk't^  or  1  In  Ii568;  Anion;;  (he  Germcinfl,  in  3K9,O§0  tlMM 
wirru  i'i^t)  cAUcji  of  twins,  or  I  in  BT,  jiiid  38  tif  iHplrU.  or  I  hi  9T65.  TMlcitij^tbt 
Whob  wtt  ImvQ  600,4*14  co^a.  Atid  800S  of  twlni,  or  1  In  83,  und  hi  aum  of  tii)»i«Cl^ 
or  1  in  1443. 

Tlie  followini;^  he  givos  as  the  mlo  af  mottAlltj;  In  1308  cum  of  twlm  (C  c 
S690  ciutdreni  f>36  were  ]cm%  or  Al>out  1  in  4  ;  and  nut  of  1^  e«ie»  t€  tlipltti  {l  u, 
B$  chiMrrn)  n  were  lowt,  or  I  in  3,  Tliia  morUiUty,  however,  whtch  b  H^cfj  lifpk 
n»  Dr.  Church  til  properly  mnjirkH  inuMi  be  ^ujiIjII'hI,  bv  flllowing  for  tbe  gntti  wu^ 
ber  of  children  whow  dcntli  could  not  ht:  iittrihut«>d  to  th«i  l«bor. 

Tilt*  muiiality  to  the  mother  in  twin  cnma  hfui  been  computed  u  1  Ift  211,  (Qto» 
eUll'a  Midwaerjr,  tonrth  J^oudon  Kclitioii,  p.  443,} 


yxQ.  6S« 


THE  PBINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         438 

he  premature,  and  the  children  rarely  survive  beyond  a  short  time. 
It  must^  however,  be  admitted  that  there  are  weU-authenticated  ex- 
ceptional instances  of  the  reverse  of  this  latter  rule.  Dr.  Collins  cites, 
within  his  own  knowledge,  two  examples  of  triplets  having  arrived  at 
the  full  jieriod  of  utero-gestation,  and  were  reared  healthy  children. 

Signs  of  Twin  Pregnancy, — Much  has  been  written  touching 
the  ffigns  of  twin  pregnancy,  and  some  authors  are  of  opinion  that 
there  are  certain  indications  of  the  existence  of  a  compound  gesta- 
tion, which  are  entirely  reliable,  and  arc  as  follows :  A  greater  and 
more  rapid  increase  in  the  size  of  the  abdomen  ;  the  division  of  this 
latter  into  two  distinct  portions  by  a  sort  of  longitudinal  or  oblique 
fissure ;  the  movements  of  the  foetus  on  two  surfaces  of  the  abdo- 
men at  one  time,  with  a  general  increase  in  the  ordinary  accom[)ani- 
ipents  of  pregnancy,  such  as  gastric  irritability,  oedema  of  the  lower 
limbs,  etc.  It  can  scarcely  be  necessary  to  say  to  you  that  these 
symptoms,  as  a  guide  to  correct  diagnosis,  are  without  any  value ; 
for  there  is  not  one  of  them  which  may  not,  under  certain  circum- 
stances,  be  met  with  in  a  gestation  in  which  there  is  only  one  child. 

The  most  trustworthy  evidence,  prior  to  labor,  that  a  twin  preg- 
nancy exists,  is  the  fact  that  the  ]julsjUions  of  the  tcetal  heart  may 
be  detected  simultaneously  on  diiferent  portions  of  the  abdomen. 
But  the  recognition  of  this  evidence,  in  order  that  it  may  possess 
its  full  weight,  requires  a  degree  of  just  discrimination.  For  ex- 
ample: You  may  detect  the  pulsations  of  the  fa»tal  heart  very 
distinctly  at  one  point,  and,  on  apj)lying  the  ear  or  stethoscope  to 
another  portion  of  the  abdominal  surface,  you  may,  with  the  same 
distinctness,  likewise  have  the  pulsations  increased.  These  latter 
may  or  may  not  be  the  beatings  of  the  child's  heart.  How  do  you 
disdnguish  the  sounds  ?  When  speaking,  in  a  previous  lecture,  of 
the  foDtal  heart  as  positive  and  unequivocal  proof  that  the  female  is 
pregnant,  I  told  you  that,  between  the  throes  of  the  mother's 
heart  and  those  of  the  f(Ptus,  there  was  a  want  of  correspondence ; 
or,  in  other  words,  they  are  not  synchronous — the  latter  being 
much  more  ra|)id  than  the  former;  and  another  interesting  fact 
worthy  to  be  recollected  in  this  connection  is — that  there  is  also  a 
want  of  synchronism  in  the  pulsation  of  the  two  foetal  hearts  in  the 
case  of  twins.  If,  therefore,  you  should  distinctly  recognise,  through 
auscultation,  the  beatings  of  the  foetal  heart  on  opposite  portions  of 
the  abdominal  surfiice,  and  they  should  not  be  synchronous  with 
each  other,  it  is  very  conclusive  evidence  that  it  is  a  twin  gestation. 
More  than  ordinary  caution,  however,  will  be  needed  in  this  dia- 
gnosis, for  the  action  of  the  mother's  heart  will  sometimes  be  heard 
through  the  abdo<ninal  aorta,  and  when,  from  any  s|)ecial  cause,  it 
is  accelerated,  these  circumstances  conjoined  may  lead  to  an  erro- 
neous judgment. 

But,  after  all>  it  may  be  asked,  cui  bono  are  any  of  these  signs ; 

28 


m 


THK  PRlKCtPLES  AND  PRACTICE  OF  OBSrSTRICB. 


[for,  even  if  we  knew  lieyond  pcradTenturo  that  the  wonrnn  U 
fpregriaut   with   twins,  this  knowledge  woukl   in   no  wmy  «ii1  m 
provions  to  Ijilior.     Not  «o,  Kowrver,  in  a  twin-birth,  aftor  the  fir«t 
eljiM  has  been  expelled;  for,  ignorance  in  thi*  c:i»e  thai  there  U  a 
m<?conrl  child  to  he  dclivertnl,  would  not  onlr  plnce  t'  ir 

in  an  c*mb:in*as8itjg  pof^ition,  but  would  nt^oeaftsnly  hh  j  ra 

or  k-^  |>eril  the  siifcty  of  the  mother ;  the  dingnoias  is  so  idiBpIt 
th»t  error  would  be  without  justitieation.  For  example:  tMBOtmm 
the  fcetuB  paiiAeH  into  the  world,  the  uterus  will  continue  erilsrgcd, 
and  the  iruroduciion  of  the  finger  within  the  mouth  of  t)io  orgMm 
will  enable  the  prairtitioncr  to  feel  the  membrancji  of*  the  Hxond 
child,  or,  if  thc^e  Ih?  ruptured,  some  portion  of  the  fcptos  iuelf  woidd 
be  reoogiiiited.  Tticreforc,  in  all  cosca  of  hdior,  natisfy  jrcntrivlvQi 
the  moment  the  child  is  born  whether  there  i^oriK  not  a  second  <iQf 
tu  fullow.  Take  nothing  for  granted  in  the  lying-in  ehamWr,  whiek 
may  be  reduced  to  a  matter  of  certainty,  for  the  vagaries  of  Datiirt 
are  aonietlnieH  very  curioua,  and  not  uiifretpiontly  caprirnoufi, 

Twitui  not  ahrtty9  EfpiaUif  Devdoped.—Aw  case§  of  twin*  it  will 
occasion  ally  happen  that  one  fa*tU9  in  licalthy,  imA  pt*rferily  dcve- 
lo|>cil,  while  the  other  bcar»  all  the  evidences  of  an  efirly  arrc*!  in 
ilH  growth,  and  niuy  be  either  living  or  dead ;  thin'  fiM*t  i«  ttsty 
sati<^ factory  proof  that  the  livci*  of  the  two  children  are  quite  iwle- 
pendent  one  of  the  other.*  Agtiiu  :  both  children  may  be  fldlT 
developed  and  alive,  but  one  much  larger  than  the  other.  CiMV 
Kuch  IM(  I  have  just  mentioned  will  very  naturally  give  r\m  to  tlie 
idea  of  nuper-foftatiun^  and  have  been  attempted  to  be  ex|ilainetl  by 
»ine  write  Hi  exclu.sivcly  upon  this  hy|)oibe.^is ;  but  )«u|K*r>ffrtjilio« 
Ih  ntit  at  all  neces«ary  lor  the  explanation  of  the  phenomena — \^tf 
may  exi«t  independently  o^  any  such  infiucnce.  For  example :  Uiii 
ineipialiiy  may  be  due  either  to  Aonie  original  detWt  in  one  plactaUJi, 
or  funit,  oranc  fietus;  or  it  may  result  from  com  precision  cxrr*?*H>l 
in  uter©  by  one  child  on  tlie  other.  There  can  be  no  doubt  of  tbe 
oocasional  operation  of  either  of  these  influence*;  and  it  ts  proper 
that  you  ghould  bear  the  circumstance  in  memory. 

A  Twin  Prefinancy  not  Inf^ompntiide  with  NaturtU  Labar^'^A 
twin  pregnancy  dot!M  not  iieeetwarily  imply  that  the  labor  will  nol 
bo  natural;  on  the  contrary,  you  will  obm^rvc  in  pmctico  thai 
nature,  unless  there  should  be  aoine  complication,  such  a<i  malpiiM* 
tion  of  the  fiTtus,  <'tc,,  will  b«*  nd equate  to  acrompliikh  the  deBvcry 
thrimgb  her  own  resiource*.  The  hibor,  however,  as  a  getiCTBl  rule* 
will  be  more  protracted,  bec^iuso  the  nterus  having  tindergouc  n 

•  Tli<?Tc  b  no  dtfllciiHr  in  afciimiilntmjc  pnxif  of  tho  independeoor 
foi^lal  hvm;  ImU  thi»  roll<vwhi|t  in  rertntnly  »  tmmt  ini»r«»lin|f  dpRicmNt^ 
<*ct :  A  prcfTirtiH  woman  wm  anuL^kt^  with  iiiiiiU-pox  anil  rccoTwrd  , 
slier  tk*liverp4)  of  two  chiltlrvTi,  tK^  one  liavitit,^  iXHKMirtnl  the  stimll^pui 
.  s«ber  not    TUe  cavte  bss  tjc>en  re^oned  in  tliti  Joumsl  ds  Mi^Uoiatv  sttUcd  b/  V  j 


THE  PRINCIPLES  AKD   PRACTICE  OF  OBSTBTRICS. 


435 


greater  degree  of  distension  loses  in  proportion  itn  contractile  toni- 
city, and,  therefore,  a  longer  period  is  needed  for  the  achievement  of 
the  process.  And  again :  when  there  U  more  than  one  foetiia  in  utero, 
the  organ  cannot  eoncentrate  its  power  an  in  a  single  gestation. 

Tliere  is  much  variety  in  the  presentations  of  the  two  foetusea; 
but  it  is  eatimated  that,  in  about  two  thirds  of  the  cases,  each  child 
presents  the  head,  the  largest 
UHLiany  deseentling first.  Again : 
the  head  of  one  child,  and  one 
of  the  pelvic  extremities  of  tJic 
other  (Fig.  64),  will  be  found 
at  the  superior  strait.  These 
are  the  most  frequent  of  ilie 
presentations,  but  they  are  sus- 
ceptible of  the  same  variety  of 
modification  observed  when 
there  h  only  a  single  f«PtU8 
within  the  womb ;  utul  it  is 
also  w^orthy  of  remark,  that 
malpositions  of  the  fbtus  are 
more  fre<|uent  in  the  case  of 
twins  than  In  a  single  preg- 
Dancy. 

The  following  table,  exhibit- 
ing presentations  of  the  fcetus  in  808  labors  with  twin  children, 
has  been  coiLstructed  by  Prof  Simpson*  from  tlie  returns  of  twin 
births,  as  observed  in  tlie  Dublin  and  Edinburgh  Lying-in  Hospitals, 
and  among  the  jjatients  of  the  London  Maternity  Charity 


Fio.  04. 


Reporter. 

Total  number 

of 

Ca8<?a, 

Number  of 

Hwid 

PresentationaL 

Number  of 

Pelvic 

Presentations. 

Number  of 

transverse 

Presentationsp 

nirdjand  ) 
MoCliDlock  f 
KaniAbotliafUf 

Reitl 

123 

19a 
m 

30 

48 

73 
309 

122 

632 
23 
26 

63 
133 

03 

231 

7 

23 

7 
$ 

19 

1 

ToUl, 

1615 

1084 

498 

33 

Proportions  mnoog  twin  children, 

67  io  lOO 

lm3 

I  in  49+ 

FroportiDns  nmong  all  birtlia, 

96  in  100 

1  m  31 

1  m  224 

In  order  that  you  may  appreciate  how  it  la,  that  two  children 

*  Simpson's  Obstetric  Works,  vol.  it,  p.  133. 

f  Tbe  9Amu  tendency  to  matpresenUtioa  also  exists  La  the  c&ae  of  tripletA. 


436 


THE  PRTXCIPLES  AND    PRACTICE  OF   0BSTETKIC3. 


can  cotne  into  ihe  woHtl  without  involving  tbencecsaly  of  nrtifidd 
ifitarposition,  we  will  8up|>o§e  a  twin  on8c%  in  which  the  Le:iri  of 
«ach  iVttus  presents*  As  a  general  principle,  under  this  Ofimlition 
of  ihingfl,  one  of  the  cephjilic  extreniiiies  is  more  movculih*  than 
the  other^  and  its  tentleney  is  to  recede  8li<^hlly,  m  fia  to  nfTord  more 
tpaee  for  the  descerJt  of  the  head  of  the  other  liBtim;  iltiii  recesutiau 
being  innch  taiilitnted  by  tlie  smooth  and  nnctnons  state  of  thi* 
parts.  Hut  tfii^  ttiirreuder  of  pluce  on  the  part  of  one  of  the 
ehildn^n  docM  nrvt  universally  ooour,  and  wlien  it  <loes  not,  there 
will  ijeeeiisai*ily  be  more  or  leiw  obstruction  to  the  delivery. 

So  far  as  the  position  of  the  fcptiises  is  coneerat?d,  the  name  nrle 
applies  in  u  twin  gestation  to  which  we  have  already  alludcHl,  wb«ii 
discusjiinjj  the  ^.ubjcct  of  lat»or  in  a  single  pregnancy,  vi?*.,  in  order 
thiit  nature  may  expel  the  children  of  her  own  volition,  one  of  Um 
obstetric  extremities  must  present  at  the  upper  rtrait. 

It  i*honM  be  rceollec*ted  that,  when  the  fir!*t  ehild  prc^imU  tfc© 
head,  the  delivery  will  be  mmdi  easier  tlian  if  the  feel  should  pr^ 
scnt»  for  the  obvious  re:is<»n,  thnt  by  tlie  time  the  extremitieii  unA 
body  of  the  child  have  escaped  into  the  world,  the  uterun,  oeeuplcd 
with  the  other  ftptus*  will  not  Im-  able  to  throw  its  expulsive  fan»s 
so  etVieiently  ufion  the  he^id  as  it  ristn  iu  the  vagina,  and,  tonm- 
ipietitly,  from  thi^  cau**e,  there  will  be  more  or  Ic^s  delay  in  its  btrtl}, 

JI*ttt/i (feint' nf  of  a  Twin  Lahor, —  hvX,  us  now  inrpiire  how  a  twin 
laljor,  in  which  tliere  is  no  eonipliealion,  i«*  to  be  rombieti**!,     Yiwt 
are  at  the  bedside  of  your  patient  ;  she  is  in  labor;  the 
born;  you  observe  the  womb   to  be  still  enlarged,  mid  a 
examination  assures  you  that  the  titorus  contains  another  fanna.  In 
this  contingency,  will  it  be  proper  for  you   io  s:iy  In  your  pntiotl : 
**OJj!  madam!  I  congraiulate  you;  there  is  aniUher  baby  cotiiiiifr!*' 
There  is  much  ditferenee  of  opinion  among  author*  ii%  to  whclher 
any  such  disi-losuiv  shtmid  be  made,  until  the  birth  of  the  mreocid 
child  precludes  the  possibility  of  further  coiicc*nlmeiit.     Many  arr 
of  tlie  belief  that   an   announeement  <d'  this  kind   would  havt>  an 
injurious  et!\cl  on  the  patient ;  an<l  whether  it  would  or  would  O0I 
will  depend  very  tnuch  upon  eircumstances.     For  exam  pie:  noiae 
females  have  an  un  eon  troll  able  repugnance  to  become  mothcn; 
ihese,  however,  are  in  tlie  vast  minority;  olherss  again,  itiay  liave 
a  passion  for  children^  but  either  on  account  of  ill  hcaltli  or    ' 
peinmiary  means,  tliey  may  be  indii<[H>»ed  to  an  incream?   ^ 
Utile  responsibilities* 

In  snch  instaneci*,  tfie  accoucheur  will  be  called  upon  to  exerciiMe 
a  sound  judgment  as  to  the  profiiiety  of  prenuiimely,  and  uiihunt 
consideration,  announcing  the  approaching  ativent  of  a 
after  the  birth  of  the  fii-^l ;  for  without  some  little  d-  ^ 

his  ]mrt,  the  abrupt  iutelligencc  miglit  be  productive  of  tnom  or 
\t^  harm  to  the  patient.     On  the  contrary,  you  will  m^ifl  in  Umi 


THE  PBINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         437 

rounds  of  professional  life  with  women,  whose  great  ambition  it  is 
to  rear  large  families ;  and  every  additional  child  is  but  another 
link  in  the  chain  of  their  earthly  bliss.  Here,  then,  there  would  not 
only  be  no  objection,  but,  on  the  other  hand,  every  motive  for  a 
prompt  announcement  of  the  glad  tidings.  It  is,  therefore,  as  you 
perceive,  a  mere  question  of  expediency  as  to  the  course  to  be 
pursued ;  and  that  expediency  must  be  governed  by  the  peculiar 
drcnmstances  which  may  surround  each  case. 

Ma/nagement  of  th^  Placenta. — ^Tliis  matter  being  disposed  of, 
the  next  important  consideration  is — what  is  to  be  done  with  regard 
to  the  placenta  belonging  to  the  child,  which  is  already  delivered. 
In  the  first  place,  allow  me  to  remark  that,  in  cases  of  plural  deli- 
very, it  will  be  proper  to  deviate  from  the  rule  I  gave  you  in 
speaking  of  a  single  biith,  and,  instead  of  applying  but  one  liga- 
ture, two  should  be  employed ;  not  that  two  are  always  necessary^ 
but  as  there  are  very  frequently  vascular  inosculations  between  the 
borders  of  the  placentas  if  the  umbilical  extremity  of  the  cord 
were  left  open,  the  blood,  which  would  escape  through  it,  might 
prove  fiital  to  tlie  child  yet  in  utero.  What  are  you  to  do  with 
regard  to  the  placenta  itself?  My  advice  is  to  do  nothing.  Do 
not  attempt  to  extract  it ;  but  wait  until  the  birth  of  the  second 
child  ;  the  two  placenta}  are  then  usually  thrown  off  together.  The 
danger  of  making  any  eflbrt  to  deliver  the  placenta  after  the  expul- 
sion of  the  first  child  is  this — you  may  too  abruptly  detach  the 
other  placenta  from  the  uterus,  and  thus  incur  all  the  perils  of 
hemorrhage.  It  will  occasionally,  however,  happen  that  the  after- 
birth will  very  speedily  follow  the  delivery  of  the  first  child.  This, 
when  it  occurs,  is  all  right ;  it  is  nature's  work,  and  there  can  be 
no  objection  to  it. 

But,  remember,  there  is  another  child  in  the  womb.  What 
course  is  to  be  pursued  touching  it  ?  This  is  an  important  question, 
and  needs  some  little  consideration.  The  opinions  upon  the  practice 
to  be  ado])ted  are  by  no  means  concurrent ;  they  seem  to  embody 
two  directly  opposite  principles.  For  example,  you  are  told,  on 
the  one  hand,  as  soon  as  the  first  child  is  bom,  not  to  delay,  but  to 
proceed  at  once  with  the  extraction  of  the  second ;  and,  on  the 
other,  you  are  admonished  against  the  evils  of  interference,  and  are 
strictly  enjoined  to  commit  the  delivery  to  nature.  The  true  test, 
I  think,  of  the  wisdom  of  either  of  these  exclusive  rules,  is  to  con- 
trast them  with  what  really  occurs  when  nature  is  left  undisturbed, 
and  permitted  to  pui*sue  her  own  course  without  inteiTuption.  In 
the  great  majority  of  cjises  in  twin  births,  statistics  show  that  the 
second  child  is  delivered  by  the  resources  of  nature  alone,  from 
fifteen  to  thirty  minutes  after  the  birth  of  the  first.  In  212  instan- 
ces recorded  by  Dr.  Collins,  in  which  the  interval  is  accurately 
marked,  in  38,  it  was  five  minutes ;  in  29,  ten  minutes ;  in  48,  fifteen 


438 


THE   PBIKCIPLES  AXD  PRACTICE  OF  OBSTETBICS- 


minutes;  in  23,  twenty  mintites ;  in  30,  half  an  hour;  m  5,  fl 
qunrters  of  an  hour;  in  16,  one  hour;  in  8,  two  hours;  iti  a,  iKr 
hoars;  in  5,  four  hours;  in  1,  four  and  one  half  hours;  in  3,  liv^ 
hours;  in  2,  six  hours;  in  1,  seven  hours;  in  1,  eight  hoars;  in 
ten  hours  ;  and  in  1,  twenty  hours. 

It  iH,  therefore,  incoritestably  true  that  the  general  rule  in,  l\\ 
nature,  if  let\  alone,  will  (speedily  cause  the  second  child  to  folloii 
the  delivery  of  the  first ;  in  view  of  this  irapurtant  fact,  I  shoul| 
ndviHC  you,  unless  some  eomplication  such  a^  hemorrhage  or  coq 
vulhions  should  interpose,  to  wait  for  at  Ica«^t  half  an  hour  lH*for 
ftttL>mpting  any  thing  to  expedite  the  birth  of  tlie  second  cluldj 
f even  then,  such  interference  will  not  always  he  justifiahle;  for 
will  sometimes  occur  that  the  second  child— fur  instance,  iti  ihei 
of  a  premutnre  delivery — may  not  liave  reached  it;^  maturity  ;  an 
there  are  well  auihenticatcd  intitauces  of  thin  hitter  kind,  in  whie 
the  child  1ms  continued  to  remain  in  ntero  until  its  physical  or 
xaiion  was  so  far  completed,  as  to  render  it  capable  of  an  extenial  \ 
independent  existence  * 

It  is  very  geneially  recotnmended^  as  soon  an  the  fir>f 
delivered,  to  rupture  the  membranous  sac  of  the  second  fir 
a  view  of  expediting  its  expulsion.     I  cannot  concur  in  thtsopmion 
for  I  do  not  perceive  its  utility.    According  to  my  own  cxperieoc 
It  is  far  better  practice  to  commit  the  entire  management  of  th 
second  child  to  nature,  all  things  being  equal.     Wh:*t,  in  fact,  whe 
rigidly  analyzed,  is  a  twin  labor,  free  from  all  complications,  sn 
which,  consequently,  it  is  within  the  ability  of  nature  to  acoomi 
without  the  interposition  of  science  ?     Is  it  not,  in  strict  con 
tion,  two  successive  parturitions  developing  the  same  phenomen 
and  eonsummnted  by  the  same  means?     Both  require  contraction 
of  the  uterus,  both  demand  that  one  of  the  obstetric  extremities  ^ 
the  fmtus  shall  present ;  and  does  not  nature,  in  ordinary  labo^ 
prove  hei*self,   us  a  general   princi|»le,   competent   to  rupture 
membranous  sac,  and  does  she  not  usually  [jroduee  the  rnptarf  i 
the  oppmlune  moment  ?     Therefore,  unless  there  be  some  |)Ofut]^ 
Indication  for  so  doing,  I  would  urge  you  not  to  adopt,  as  a  st 
oty[>ed  practice,  the  plan  of  rupturing  the  membmues  of  the  i^eenQ 
f<rtus   immediately   n^er  the    delivery   of  the   first;    but   subii 
patiently  for  at  least  half  an  hour,  to  the  miniKt  rat  ions  of  natof 
herself;  and  if,  after  the  lapse  of  this  periocK  there  should  be  i 
manifestation  of  pr<>grej<s,  it  would  be  desirable,  by  gentle 
tions   over   the   abdomen,   to   endeavor   to   stimulate  the   otei 


*  Br.  Morritnafi  cites  the  (bllowinifr  oaee  r(^porte<I  in  \hn  MrfOttil  «mfi  Fh 
Jmgnutl  for  April,  1811,  vol  xxv.,  p.  :tll— iti  n  cmc  of  liridii,  iHo  Moomi  « 
fetaili^l  Tor  fuitrtri^ii  Unys  jiflvr  tiiu  biitli  of  the  first,  mud  tbo  wHier  i 
nnotlit-r  instjirice  hud  etmu-  to  his  ktiowl«igt%   it>   wliicli  dix   wwk«  ItmI 
boiwet'D  the  binh  ofihe  twtiiB. — [MerHmao  on  IHfUctUt  ParturiUott,  ]k  90] 


THE  PRINCIPLES   AND   PRACTICE  OP   OBSTETRICS, 


439 


increased  effort,  and  it  may  aim  be  proper  to  rupture  the 
membranes* 

There  can  be  no  objection  to  the  employment  of  erjjot  in  the^ 
casoi*,  provided  nlways  that  the  child  presents  naturally;  for  the 
uterus  is  apt,  thix)ugh  previous  eilbrt,  to  become  more  or  less 
defeetivo  in  action,  and  the  influence  of  ergot  will  oflen times  be 
very  mai-ked  in  evoking  itR  con(rat*tility.  Should,  however,  tiieae 
means  tail  in  producing  the  expulsion  of  tlie  fcetun,  it  will  be  proper^ 
after  waiting  two  houi-s,  to  introduce  the  band,  and  bringdown  the 
feet;  ov  if  the  head  have  desctiided  into  the  pelvif  excavation,  the 
forceps  should  be  had  rei:ot(rse  to  ;  the  nefCs^sity  as  well  as  the 
economy  of  this  mode  of  practice,  are  abundantly  sustained  by  the 
irapoiiant  iact  that,  according  to  accnratc  observation,  the  second 
child  will  usually  be  nacrifict^  if  more  than  two  or  three  hours 
e1a|i$<ie  afler  the  birth  of  the  fimt. 

In  twin  hibors,  it  is  important  that  the  accoucheur  should  not 
leave  the  room  of  bin  patient  until  the  delivery  of  the  second  eliild 
has  lieen  completed  ;  this,  as  a  general  rule,  sirould  be  scrupulously 
ol>served.  As  I  have  mentioned  to  you,  there  are  oecaf^ionally  some 
exceptional  cnses  in  whieh  a  comjdiance  with  thi;^  preee[>t  would 
not  be  practicable;  for  there  are  in^tancee  on  reconl  in  which  the 
second  child  has  not  been  expel leii  for  two,  three,  and  more  weeks 
subsequently  to  the  birth  of  the  ilrst,  Theref<»re,  while  in  the 
observance  of  the  general  rule,  it  will  be  well  to  benr  in  mind  the 
exceptions. 

The  following  is  an  interesting  and  instructive  case  of  twins,*  to 

wdtich  I  was  cjilled  some  tiu^e  since.     Mis.  K ,  aged  32  years, 

the  mother  of  thvuc  healthy  children,  eonsulted  me  on  the  0th  of 
October,  1855,  in  consennence  of  an  anxiety  she  ex]»enenced  in  not 
having  felt  for  the  preceding  week  the  motion  of  her  child,  she  then 
being  about  six  months  |«regnant.  She  remarked  that,  a  iew  day« 
befow  cons^dting  inc,  she  had  become  very  much  frightened  by  a 
horse,  and  since  that  time  had  not  felt  lift*.  With  the  exception  of 
words  of  encouragement,  and  suggesting  the  occat*ional  use  of  tbo 
tincture  of  liyoscyamus  witli  a  view  of  quieting  her  nervouwiess^ 
nothing  was  orderctl  in  her  case.  On  the  6th  of  Nov  end  ►er  follow- 
ing, the  husband  requested  me  to  visit  liis  wife,  stating  that  sho 
supposed  herself  in  labor,  and  waa  tiow  ing  very  profusely,  having 
lieeu  troubled  more  or  leas  in  thU  way  for  the  last  week.  In  an 
hour  from  the  time  I  received  the  nics^^igc,  I  saw  the  patii-nt, 
accom|>auied  by  my  son.  Dr.  llrnry  M.  Bedford,  and  found  her 

*  Placenta  previa  in  &  enAe  ortwiijs,  whicli  were  expL^lliid  froiu  ilie  iiti'ru»«,  altera 
icven  infnilba'  gt'stulion,  witli  on©  plocetito^  oue  nninlori  nnd  QUorkm;  bolli  erjruii 
iiiBerUHt  Into  the  |iliie<^TUu  nearly  in  juxtiiposiilun;  cnch  fcBtuH  pri.'»f!Uiiijr  cvult*ucH?t 
of  Incijiient  hydrLH^cphulus;  utid  eucli  beuriiiy:  miirkH  of  liiiviitfj^  Ijevii  iteod  for  ivo  of 
Uircii  wertfA     [See  Di^eu^e^  ot  Worweu  and  Children,  p.  liboj 


440 


Tllfi   PntNCIPLES  AND   PRACTICE  OF  OBSTETKlCa 


niakjtig  a  va^-inal  fxawtitisiticin^  I  dbcoveroti  thvos  nteri  dilaUHl  mud 
BolY^  nnd  flistinctly  M%  a  cloiii^liy  suliK^lanct:  presenting,  whk*h  I 
recognijsed  to  l»o  the  placenta,  tiud  wluch  at  once  aceonnled  for  the 
bcinonhni^i:.  Witli  I  fie  iirnotuit  nf  bloud  the  put  lent  wjis  lo»4ii<f, 
tojretlH'r  with  tlie  tuct  thai  the  niouili  of  I  he  womb  wilh  noft  and 
dihitubk%  it  vv:Ls  obviouslv  my  duly  to  lo?»e  no  time,  but  to  pnio^aed 
without  further  del»y  to  the  delivery.  In  aeeordanee,  thi^reftiiY, 
witii  this  objert*  I  carried  my  hand  to  the  nock  of  tlie  '<  irid 

separated  jd>out  one  fourth  of  its  atlm-hmeiil  to  tlie  plat  u  ^h 

enabled  me  to  feel  the  prcsentin*;  jmrt  of  the  IVpIuh,  which  I  6000 
reeogni^od  to  \yc  I  he  breeeh.  It  wtu  my  intention  ut  i»noi%  in  »ep»- 
ratinj^;  the  ptaeentiU  attaehTnents,  to  introduce  the  hand  into  ihm 
uterus,  and  terminate  the  ildivery  liy  brinuin^  down  the  fcttuii. 
As,  however,  the  uterun  contracted  with  tfreat  efticiency  nomi  afl^ 
I  had  ascertained  the  jireRentntSon,  tiiul  a^  it  wms  quite  evlclfnit  ihiii 
the  breech  of  the  ftetnn  was  desceudinsr  into  the  pelvic  excaiTatiois 
I  jinlii^ed  it  advisable  to  submit  the  birth  to  nature. 

Th«*  jiainii  in4Tea«ed  so  rapidly  in  force,  that  not  more  thiin  life 
niinutis  ehipined  before  the  expulsion  of  the  lU'tui^  was  aecumpliidied. 
An  the  child  ww*  pnmn^  into  thi*  world*  with  one  hand  npplie^l  to 
the  abdomen  of  the  mother,  I  soon  diseovt^red  that,  uJthou|rli  there 
waK  a  8i*nHation  of  fiardneH8  ini|iurted  to  my  hand,  tlie  uterus  wai 
but  Alif^htly  diminishe<l  in  volume;  at  the  sam<'  time  my  attrnlion 
wast  drawn  to  the  peculiarity  exhibited  by  the  undulical  oord,  II 
nccnrrod  to  mc,  at  first  view,  that  it  wa«  an  examph*  4if  what 
authors  Imve  describes!  m  the  knotftd  cord,  two  hifitaneeji  of  w  hich 
I  liave  ha<l  in  my  practice.  In  thin  ciiaracter  of  cord  there  arc*  dk- 
tlnct  knoti^  formed  most  probably  by  the  evolulioui*  of  the  f<eitL« 
tVi  Ht^o.  I  soon  ob»c  r V c  d ,  li  o  w  e v e r ,  t  h  a  t  n  o  »u ch  pec u  1  iarit  y  ex i^tcd 
In  the  [ux^ent  cane*  The  eidar^eil  iiterun  cau^*d  me  to  aii^|ief*t  tltti 
presence  of  another  fcetuss  imd,  in  carrying  my  hand  up,  nir  *««• 
picion  was  contirmed.  The  uterus  contracted  with  enerffy,  and,  ia 
WiLs  than  ten  luinuteM,  the  second  fietui*  wa»  expelled,  liotli  wc^e 
in  a  J^tate  of  dc<H>mposition. 

The  iiecufiarity  of  iht-  umbilical  cord  ih  explained  as  foUowa:  The 
cord  of  une  fa»tus  was  ciiimplctrly  twisted  around  that  of  the  othrr 
in  itJ*  whole  extent,  presenting  the  as|>ect  of  the  knottrtl  eord.  Oti 
tlie  vJcpuUion  of  the  f<(»cond  ftrtUH,  the  uterus  became  climmifihed  in 
aite,  and  was  ffit  in  the  hyjio^istric  ri'trion  well  contracted.  I  th«?fi 
{UIM!M'<1  my  hand,  and  renioviul  the  plaiXMita.  Titers  ifaj  Imt  \me 
after-birth  /  the  (iro  rorth  trtre  tnBtrttil  info  it  ttttarhf  at  M**  s*fmf. 
^Mtittt,  Thrrt  iras  but  one  ehnrioit^  and  ofte  amnion,  Th€  rifo 
fretttsea  rrrrc  afnmt  rquaUy  tUcK*mpo«td^  preumtintf  thr  ninmff  prO' 
hahilihj  that  thtir  th'ath  ^mn  t<iittftl(iiuttiiiA,     Abtiut  an  ^  *H 

JiuU'  iiii\:r  the  delivery,  the  fa»tm*ett  and  placenta  weit  ud 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         441 

examined  by  my  colleague,  Prof.  Van  Buren,  and  also  by  Dr. 
George  T.  Elliot,  then  resident  physician  of  the  lying-in  hospital. 
I  should  have  remarked  tliat  the  cord  which  was  twisted  around 
the  other,  having  its  length  curtailed,  and  also  decomposed,  became 
detached  from  the  placenta  on  the  birth  of  the  second  foetus.  Prof 
Van  Buren  immediately  detected,  by  means  of  the  blowpipe,  its 
place  of  attachment,  which  was  in  juxtaposition  with  the  other  cord. 

In  reviewing  the  circumstances  connected  with  this  delivery, 
there  are  several  points  of  interest  which  naturally  present  them- 
selves to  our  consideration,  and  when  all  the  peculiarities  of  the  case 
are  examined  they  certainly  do  present  an  aggregate  which  is  not 
only  unusual,  but,  in  my  opinion,  without  a  parallel.  What,  then, 
are  the  peculiarities  to  which  I  allude?  They  are  as  follows: 
1.  Implantation  of  the  placenta  over  the  cervix  uteri ;  2.  One  pla- 
centa, one  chorion,  and  one  amnion  ;  3.  The  insertion  of  both  cords 
into  the  placenta  in  juxtaposition;  4.  Each  fa»tus  exhibiting  evi- 
dences of  incipient  hydroce])halu8;  5.  The  probable  simultaneous 
death  of  the  two  foetuses.  These  constitute  the  peculiarities  of  the 
cise;^  and  I  repeat,  in  conclusion,  as  far  as  my  knowledge  extends, 
they  stand  alone.  But  what  imparts  special  interest  is  the  fact  of 
one  placenta  which  is  single  an<l  j)erfect  in  itself;  not  composed  of 
two  united  into  one,  the  points  of  union  easy  of  recognition,  as 
sometimes  happens  in  plural  gestation,  but  it  is  one  entire  placental 
mass. 

There  is  no  double  set  of  membranes ;  there  is,  on  the  contrary, 
one  distinct  amnion,  and  one  chorion.  In  fact,  there  is  here,  with 
the  exception  of  the  two  cords,  precisely  what  we  should  expect  to 
find  in  a  parturition  in  which  there  is  but  one  foetus.  Some  authors 
have  doubted  the  possibility  of  a  twin-birth  with  only  one  amnion, 
without  the  cohesion  of  the  embryos.  But  the  case  under  consi- 
deration is  an  unqnalitied  demonstration  that  it  is  possible  for  twins 
to  exist  with  but  one  anniion,  and  yet  no  cohesion  of  parts  ensue. 
Another  interesting  fact  connected  with  this  history  is,  that  al- 
though there  is  but  one  placenta,  and  both  cords  are  inserted  into 
it,  yet  the  umbilical  vein  and  two  umbilical  arteries  belonging 
respectively  to  each  cord,  have  a  distinct  circulation ;  or,  in  other 
words,  do  not  commnnicnte  with  each  other.  If,  to  this  circum- 
stance be  added  the  fact  that  there  was  not  the  slightest  evidence 
of  decomf)ositic)n  in  the  ]>lacenta,  but,  on  the  contrary,  an  aspect 
of  freshness,  such  as  exists  in  the  case  of  a  healthy  living  foetus,  we 
then  have  the  curious  coincidence  of  a  healthy,  fresh  placenta  coex- 
isting with  two  fcrtuses  bearing  the  evi<lences  of  having  been  dead 
for  some  two  or  three  weeks.*  This  certainly  presents  a  point  for 
physiological  discussion.     Again :  would  it  have  been  possible  in 

♦  There  are  caws  recorded  showing  that  the  amnion  may  also  remain  for  Rome 
time  wiUiout  undergoing  decomposition. 


THB  PB1KCIPLK8  AKD  PRACTICE  OF  OBOTKTBIC 


|[bia  iiiHtance  for  one  fcBtus  to  have  survived  the  other,  u  sometimci 
:>ccurs  in  twin  births?     My  opinion  is  deddedlf  In  favor  of  %k§ 

fnegntivo. 

The  itiather  had  a  prompt  recovery;  and  is  now  in  the  enjoymeal 
of  ^on«l  health* 

Sfjper-fititation. — It  will  be  proper,  at  this  time,  to  allude  brieHy 
to  the  subject  of  super-fcctntion,  whicti  irnplit<s  the  pcpssibiiity  of  a 
second  fecundation  !^iihAoquentIy  to  one  wliiuh  already  exists ;  or^ 
in  other  words,  the  possibility  of  a  woman  being  in  fL^eMlMifm  v^tUi 
two  foetuses  of  different  a^es,  and  consequently  generated  at  diffor- 
ent  periods".  Amutig  the  early  writers  tliere  wa^  u  general  cunetiT' 
renee  of  opinion  on  this  subject,  and  the  doctrine  of  super-fceUtioo 
was  accepted  with  ^ins<ular  unanimity.  Such,  however^  in  nol  lb« 
case  with  the  nier»  of  our  own  tinmen  ;  and  among  other^s  **'bo  iloitbl 
the  possibiliiy  of  KUi>er-fa^lali<)n,  may  be  jiiimed  the  diitingimbed 
authorities — Di*s.  Churcfull  and  llamsbotliani. 

There  can  be  no  doubt  that  two  fecundationti  may  take  place 
within  a  very  sliort  |>eriod  of  each  other ;  tliis  foitt  is  irre3*i'*tibly 
entabl idled  by  eascH,  the  authority  of  which  in  lieyond  all  tat'll. 
Some  of  you  are,  jx^rhapa,  familiar  with  an  eiEaniple  of  this  kind 
quoted  by  Buffon,  and  more  or  less  constantly  r*?ferred  lo  In  ob«ie- 
trie  works*  It  occurred  in  Siinth  Carolina,  A  white  woman^ 
immediately  after  receiving  the  embnicci*  of  her  buitbiuid,  was 
co<,'icc*i,  through  fear  of  her  life,  lo  have  intercourse  with  a  negro; 
the  iH^sult  being  that  she  gave  birth  to  two  children,  one  whtti%aiid 
the  other  mulatto.  In  the  Ainenean  Journal  of  Medicd  Scieiicei 
for  October,  JH45,  a  somewhsit  siniiliir  case  \^  mention<Kl  on  lhi» 
authority  of  Dr.  Lopez.  The  mother,  in  this  inMance,  wa»  a 
ncgrejtM,  fiiiA  having  had  in  succus^sion  iutereourHe  with  a  whttv 
and  black  man,  produced  two  children,  one  mulatto,  the  other 
black.  An  extremely  interesting  instance,  in  prur>f  of  the  pn«»ibi- 
lity  of  Hn|»er-fanation,  is  recorded  by  Dr.  llenry  in  hiit  valaahla 
monograph  on  thin  subject ;  it  occurred  in  the  Brazils*  Tilt 
natives  of  that  country  are  copper-colored,  but  among  them  am 
many  negroes  and  whites,  A  Creole  woman,  a  native,  brongbl 
into  the  world  at  one  birth  three  chiUiren,  of  three  tlifferent  eolonH 
white,  l>rown,  and  bbck,  each  child  exhibiting  the  fr^aturea  peculiar 
to  the  re-ipei'tive  i^aoes. 

But  such  freak*  of  nature  are  not  confined  to  the  human  titmi-;^ 
for  the  liarne  eircunistanee  bail  been  obi*orved  in  anitual^.  It  i 
related  hy  Mende»  that  a  marc  covered  lir^t  hy  a  stallion^  ai 
mhorlly  afterward  by  an  ans,  produced  at  one  parturition  a  hi^-t- 
and  a  mule;  and  you  will  tind  an  analogous  case  reported  by  Ij 
Read  of  Aridover,  with  the  Minple  difference  that  the  mair 
covered  first  by  the  ass,  and  in  two  or  tlircc  days  subseqneiH^ 
the  horse. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS. 


443 


The  cases  to  which  we  have  referred  may,  I  think,  be  safely 
regarded  as  indisputable  examples  of  siiper-fcetation ;  but  it  should 
be  recollected  that,  in  all  of  them,  if  human  testimony  be  worth 
anything,  the  procreative  acts  occurred  at  short  intervals.  Very 
different,  however,  is  it  with  tliose  reputed  instanct^s  of  a  wcll-deve* 
loped  and  mature  chiid  being  boru,  followed  by  another,  the  period 
of  time  varying  from  one  to  several  ttionthji.  In  these  latter  casea, 
in  the  absence  of  very  positive  evidence  to  the  contrary,  I  should 
be  d  its  posed  to  refer  the  phenomena,  not  to  super-fcetation,  but 
to  an  uriginal  twin  gestation,  in  which  one  of  the  fa?tuse8  was 
developed  at  the  expense  of  the  other,  the  retention  of  the  second 
being  necessary  for  its  proper  subsequent  maturity. 

A  very  remarkable  instance  occurred  in  Strasbourg,  the  particu- 
lars of  which  will  be  found  in  the  Il^cueildela  Socitt^ il" l*!mulation 
— a  woman,  ai^ed  thirly-Beven  years,  brought  forth  a  mature  and 
healthy  chihl  on  the  30tb  of  April;  on  the  IVth  of  September 
following  (about  one  hundred  and  forty  days  after  the  previous 
birth),  she  was  again  delivered  of  a  fully  developed  infant*  At\er 
her  death,  m\  autopsy  proved  that  ilie  uterus  was  single.  Dr.  Tyler 
Smith,  an  accuraic  observer  and  reliable  authority,  mentions  tlie 
fallowing  interesting  case  as  having  been  seen  by  him  in  company 
with  Mr.  Eardlcy.  I  <ptote  his  own  words :  **  A  young  married 
woman,  pregnant  tor  the  tirst  time,  miscarried  at  the  end  of  the 
fiflh  month,  and  some  hours  atterward  a  small  clot  was  discharged, 
inclosing  a  perfectly  fresh  and  healthy  ovum  of  about  one  month. 
There  were  no  signs  of  a  double  uterus  in  this  case.  The  pritient 
has  menstruated  regularly  duiing  the  time  she  had  been  i>regnant, 
and  was  unwell  three  weeks  before  slie  aborted.  She  has  since  been 
delivered  at  the  full  term.*'* 

The  twQ  examples  just  cited,  admitting  their  accuracy — and  I  see 
no  reason  to  doubt  it— are  very  strong  facts  in  favor  of  super-fceta- 
tion  resultirjg  from  remote  procreative  acts;  nor  do  I,  for  a 
moment,  think  them  explicable  on  the  ground  of  a  twin  gestation. 

It  is  now  well  established,  and  I  believe  tlie  fact  has  met  with 
nniversal  concession,  that  a  woman  may  become  impregnated  white 
she  is  carrying  an  extra-uterine  feet  us ;  that  is,  she  may  simulta- 
neously liave  a  uterine  and  extra-uterine  fcetation.  Horn,  Mende, 
Montgomery,  and  others,  cite  cases  in  proof  of  this  circumstance. 

There  are  also  examples  of  super-ftctation  occurring  in  a  double 
uterus;  one  of  the  most  notable  and  trustworthy  instuncos  of  this 
nature  is  recorded  in  the  Ennjdoifruphie  Medicale^  for  Fchruary, 
1849,  A  fenmfe,  a  native  of  Modena,  became  for  the  seventh  time 
pregnant  in  1817;  at  the  expiration  of  nine  motjtha,  she  was  deli* 
vered  of  a  healthy  and  fully  developed  male  inlant.     The  placenta 


♦  London  Liuicel,  1850,  for  August,  p.  131. 


444 


THE  PKINCIFLKS  AXD   PRACTICE  OF  OI 


was  properly  fxpellml^  and  ilii*  pfitierrl  soon  rei'overed  hrr  liemlth* 
It  was,  l)ow<*ver,  ohsorwMl  that  uim»  lialt"  of  the  alMJonien  ciiutifiued 
enlarcyud,  ami  the  luovenunilsof  a  lojlu^  were  vei*y  ili^int'lly  n^c^ig 
nized*  A  tnonth  subse^piont  to  her  last  pAfturlliou,  §ht«  agsuo 
liroiight  into  the  vvorhl  a  living  iimle  chiltl,  which  prustnitiHl  sill  thi» 
fvidt^nct'H  ot*  hf'iilth  niul  full  flevelupnienl*  Yeaj*^  alter wartl  tliU 
woman  dh^\  of  nf^oplexy;  an  autopsy  waA  had,  and  il»e  mterc^tUig 
circiitnfitunce  wa«  revealed  that  ther«  was  a  double  uterus  nith  m 

The  obje(»tion8  urn^ed  by  Drs.  Churchill,  RaiuHbothani,  and  otbenii 
against  a  true  and  nnt'ijuivoial  supfr4Vv latum  are  mainly  found tni  oa 
the  supposed  inT|>os.sibihty  of  a  ssieeond  icciindation^  while  the  utirw 
is  aln?ady  occupied  with  the  produet  uf  n  previous  one;  and  iboj 
maintain  that  thin  im[MJ8!*tliility  ari.He?^,  in  tlie  first  place,  fr<  \r\ 

that  the  OS  uteri  18  ehi>»ed  by  a  tenacioiu*  nim'on-s|tlug,  an»L  .y^ 

that  the  membraua  decidua  \w\ug  a  eoniplele  ku\  occbidinf?  the 
mouth  of  the  womb  as  well  ha  the  uterine  oritioes  of  the  fdloj^bui 
tubes,  the  Sfierniatozoon  camiot  p:ain  adnii^j^ion,  and,  tliereforv, 
feeundation  cauuot  be  eonsununaled.     Let  lu*  brietly  exn  ^e 

objections  i    1.      T/ic  muf^tntii  yVw^, — It    h   uuw   well    id  d, 

throtig^h  the  revelations  of  the  microscope,  that  thoro  im  no  e«(K$Ulial 
difference  in  the  fuucus  cvisting  in  the  cervical  caual  of  the  preg- 
nant woman,  and  that  ^'enerally  present  in  the  Kj*ine  caual  iu  au 
uniujjtreL'uated  ft*male  j  and  as,  in  the  latter  cane,  in  order  that  the 
fecundation  may  l»e  accomplished,  the  spermatozoou  must  of  necefr* 
sity  enter  the  uterus  throu^^h  this  mucus,  bo  uiuy  it  do  mj  whctj 
gestation  already  exists,  mnl  thus  genentte  a  second  (cetus.  2.  The 
ntrmhrana  dr.cidua. — Until  very  recently ♦  su*  has  already  boen 
rciuarked,  the  original  deseription  of  the  membrana  itccidua^  and 
uutmbnma  rellexu  a^  given  by  Hunter,  was  almo)»t  universcdlj 
ado]>ted  by  obsletricians ;  ami  with  I  hi;*  adoption,  it  would  at  once 
set'Oi  impossible,  after  llic  tbrnraiion  oi'  the  deeidua,  for  :i'  'y 

enter  the  cavity  of  the  uleruH,  without  tirst  pus^ljiug  the  i  u? 

before  it;  for  the  decidua,  as  described  by  llunter»  i»  veritably  a 
closed  sac,  and  coenpleteiy  occbuies  the  tliriv  openings  of  tlie  womh^ 
vi/*.,  the  OS,  an<l  tfu>  two  oriHees  of  tfie  fallopian  tul>cs  Hut  iluuii*r*s 
theory,  like  many  other  things  which  were  brilliant  iu  theirilay,  lus 
been  compelled  to  recede  before  the  lights  and  j»rogrcAs  of  science; 
mid  what  ouec  found  uuivenuil  concurrence  is  duw  thrown  adilc;. 

l*hysiologic^l  research,  aided  by  the  clever  microscopi&ia,  bat 
demonstrated  thnt  lIunior\s  view  wjks  little  less  than  a  lirtion;  and 
It  is  now  esiablinhed  beyond  a  perad venture,  that  the  niembrmna 
decidua  Ls  but  a  thickening  or  hypertro[ihied  couditiou  oiL  the  tnucoQft 
coating  of  the  uterus.  It  is»  ilu?rretbre,  uot  a  closed  iw,  and,  c^oil- 
secpiently,  oftVrs  no  impediment,  ,it  lea^t  during  the  early  '  if 

?Maliou,  to  the  ingress  within  the  uterine  cavity  of  the  :'> 


THB  PRTXCTPLES  AND  PRACTICE  OF  OBSTETRICS.  446 

soon — the  true  and  exclusive  fecundating  element.  These  objec- 
tions, therefore,  in  opposition  to  the  doctrine  of  super-foetation  are 
not  valid  ;  and  when  we  take  into  account  the  important  and  unde- 
niable evidence  on  record — irresistible,  and,  therefore,  conclusive — 
that  cases  of  this  description  have  actually  occurred,  both  in  the 
human  subject  and  in  animals,  super-fcctation  must  be  recognized 
not  only  as  within  the  range  of  possibility,  but  as  having  been  more 
than  once  practically  illustrated. 

Super-fcetation  in  a  Moral  Aspect, — There  is  another  view  in 
which  this  question  of  super-fa?tation  is  to  be  regarded  ;  and  it  will 
occasionally  need  the  soundest  judgment  and  discrimination  on  the 
part  of  the  practitioner,  in  order  that  8usi)icion  may  be  allayed,  and 
the  breaking  up  of  tlie  dearest  social  relations  prevented.  Let  us 
suppose  a  case.  A  gentleman,  shortly  after  the  impregnation  of  his 
wife,  is  compelled  to  leave  her  on  business,  which  will  require  an 
absence  of  a  year.  During  this  time,  she  brings  into  the  world  two 
children  at  an  interval  of  some  weeks.  Popular  opinion,  if  it  be 
allowed  to  poise  the  scales  of  justice,  will  undoubtedly  decide  against 
the  fidelity  of  the  wife ;  and  the  husband,  whose  heart-strings  are 
broken  by  this  unlocked  for  dishonor,  may,  perhapvS,  in  the  hour  of 
his  anguish,  apply  to  one  of  you  to  know  whether  it  be  possible  for 
a  woman  to  be  delivered  of  two  children  within  a  short  period  of 
each  other,  consistent  with  conjugal  purity.  If  the  case  just  hypo- 
thecated should  occur  to  me,  and  I  should  be  selected  as  the  arbiter 
of  that  man^s  peace  of  mind,  and  the  a?gis  against  the  suspicion  of 
his  wife's  chastity,  I  would,  without  hesitation,  unless  the  proof 
against  her  should  be  overwhelming,  decide  in  her  favor — and  upon 
the  broad  ground  that  the  two  births  were  the  result  of  a  twin 
gestation.  According  to  the  doctrine  of  chances,  the  presumption 
of  the  correctness  of  this  decision  would  be  twenty  to  one  ;  for,  as 
has  already  been  mentioned,  it  is  not  of  extremely  rare  occurrence 
in  twin  pregnancy  for  an  interval  of  days  and  weeks  to  elapse 
between  the  respective  deliveries,  for  reasons  which  we  have  pre- 
viously stated ;  whereas,  ou  the  other  hand,  super-ftctation  may  be 
properly  classed  among  the  exceptional  phenomena  of  life.  A 
broader  ground  still,  however,  on  which  such  a  decision  may  be 
based  is  the  Christian  principle — it  in  better  that  ninety^ine  guilty 
'  shoiUd  escape  than  that  one  innocent  be  co7idemne(L  Human  hap- 
piness and  a  wife's  honor,  I  hold,  to  be  too  precious  to  become  the 
sport  of  a  mere  contingency  ;  in  all  cases,  therefore,  involving  the 
sacred  rights  of  the  household,  look  to  evidence,  both  presumptive 
and  positive  ;  and  remember,  in  rendering  your  verdict,  that  humane 
maxim  in  law — a  reasonable  doubt  is  the  property  of  the  accused. 


LECTUKE   XXX- 


Jiif^nioa  of  the  TJtertiB — Often  connected  with  MtnisAQageitifliil  of  Pkoeiita^43n 
Xlivttfibfi  occur  in  the  Unimpre^nJiied  Woman? — CaiiMt  of  IiiT«reloti^ — What  an 
they?— Inveirinti  mmt  frequently  the  result  of  CarelBaatifiiW  or  lgp<iiniiio>  PoWia 
Lxinf^-'m  lU*ti^nu\  StatUtics — Inrcrsicm  Complete  or  tiiOQaiptft»-*tH«gsoiaa  «l 
eudi — Chmutc  Inversioo,  ooiifoandet!  with  Prolapnui^  Proddantiihi  atwl  Mypoa^ 
How  to  be  Dbtinji^uished — ^TV^atmcnt  of  Inrcnion  when  eiUitt  CcmpUt^  or  In- 
oomplete— Dortij  mq  luvertad  Wowti  ever  become  Spontaneoo'  "  ^  i?— Tl^ 
ca«a  of  Spontiuif^un  Reatofitioii  died  bjr  Baudelooque — In  twtkn, 

when  ihf  Oil  d,  b  Hxtirpotion  of  iho  Utcni*  J tiaiAft^bW T— 

I  m  iM^tUiiwe  ! ;  ecMnk  of  SuoctwTul  E  %^  rpation — €■»  of  Mai* 

pnic<tio<?  In  whii^h  uu  hivtrt'jtl  Uiuru^  wis  lbrdb[jr  tor&  ttom  the  Femoii  of  Ite 
Putieut^  liAvin{^  been  rtimUikeu  for  the  PUofOtft. 

GKNTi^RiTEN^It  remain«  for  us  now  lo  speak  of  an  accident  which^ 
thoTi<^h  rarf%  will  KomHimes  oomjilicntc  labor ;  and  it  is  very  apt, 
aJno,  to  be  accompanied  by  more  or  less  hemorrhitge — I  mean  inver- 
idon  of  the  uterus,  in  which,  when  complete,  the  organ  U  turned 
inside  out.  It  is  ej*pccia!ly  pi*oper  that  your  attention  t^honTd  be 
caliiHl  to  this  accident  at  the  present  lime,  for  the  reason,  that 
frequently  it  in  more  or  less  directly  connected  with  tjio  cxtniriiun 
t>f  tVie  placenta,*  In  his  excellent  £ssa9/  on  Intfergi&n  of  the  Vurm, 
the  late  Mr*  Crosse  f  remarks  that,  in  350  out  of  400  cusses  of  invert4rf 
womb,  which  he  liad  collected,  the  complication  was  a  ooiL^equenoe 
of  parturition;  of  the  remaining  fifty  cases,  forty  were  stapjn^f^^  ia 
hare  been  connected  with  the  presence  of  a  polypus  in  the  cavity 
of  the  organ. 

It  is  maintained  by  some  writers  that  inversion  of  the  womb  ii 
jMisMblv,  rind  has  actually  occurred  in  women  who  have  never  be*® 
impregnated,  ariti  when  the  uterus  is  in  a  state  of  entire  vacuity. 
The  accuracy  of  this  latter  opinion  I  very  much  donbL,  for  it  si»etBt 
to  me  phy ail-ally  inipjftsible  that  a  contracted  womb  i^bould  beeooie 
invcrtcfl  unless  it  contain  a  foreign  substance,  such,  for  e%amp]|i,M 
a  polypoid  growth,  in  which  case  the  accident  has  takm  place* 

One  of  the  pre-requisiiea  of  this  peculiar  form  of  di^ipLricenMint  is 
necessarily  more  or  less  relaxation  or  inertia  of  the  organ* 

*  It  i«  right,  faowerer,  to  state  that  Inveraion  of  the  atema  mmy  take  plaoe  ton* 
days  alter  the  ifeHvery  of  die  etiUtl,  And  tlie  reiaoral  of  tli9  fdaccBta.  Aiil  lad 
Tetlier  both  dtv  exaruplps  of  this  kind.  la  tbe  oaae  of  the  tiflMr,  H  • 
the  twelfth  day  ;  in  that  of  the  latter^  oo  the  teaih  day 

f  Fart  n.  p,  TO. 


Jim 


THE  PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS* 


447 


Causes,— Th^  causes  of  inversion  at  the  time  of  labor  arc  di- 
TQTse — such  as  the  sudden  and  rapid  expulsion  of  the  foetus;  undue 
and  forcible  tractions  on  the  cord,  while  the  ptacenta  U  elill  in 
adhesion  with  the  womb;  violent  cont?hing  immediately  after  the 
exit  of  the  ftetus,  etc, ;  delivery  in  thf  standing  position,  especially 
when  the  delivery  is  abrupt  in  consequence  of  increased  capacity 
of  the  pelvis.  It  is  likewise  alleged  that  too  »hort  a  cord,  either 
in  consequence  of  a  congenital  shortness,  or  because  of  its  encircling 
the  neck  or  body  of  tlie  child,  should  be  ennmernted  among  the 
causes  of  this  accident.  My  own  opinion  U  that,  admitting  the 
cord  ciccaaionally  to  be  extremely  short— and  there  are  instances  of 
its  measuring  from  six  to  ten  inches  only — it  cannot  with  propnety 
be  classed  among  the  causes  capible  of  producing  inversion ;  for 
admitting  the  funis  to  present  but  eight  inches  in  length,  this  would 
be  sufficient,  after  the  expulsion  of  the  head,  to  allow  the  escape  of 
the  remaining  portion  of  the  faetiis,  without  necessarily  involving 
the  inversion  of  the  womb,  through  tractions  on  the  cord.  Poly- 
ptiRj  whether  of  the  unimpregnated  uterus,*  or  as  an  accom[janiment 
of  gestation,  mny  result  in  inversion  of  the  organ;  tins  yon  can 
readily  understand,  for  the  weight  of  the  polypus,  especially  if  the 
uterus  be  sumewhat  relaxed,  would  naturally  tend  to  the  production 
of  the  accident.  Inversion  is  occasionally  spontaneous,  and  this 
would  be  more  liktly  to  occur  in  women  wlio  have  borne  many 
children,  in  whom  the  mti scuta r  parietes  of  the  uterus  are  verv  much 
relaxed,  and  the  labor  rapid. 

I  think,  however,  the  fact  must  be  conceded  that,  in  the  great 
majority  of  instances,  tiiis  form  of  uterine  displacement  is  due 
manifestly  citiier  to  carelessness,  or  gross  ignorance  on  the  part  of 
the  uccoucheur ;  as  an  evidence  of  the  truth  of  this  opinion,  you 
will  observe  that,  in  well  regtdatcd  lying-in  hosjntals,  inversion  of 
the  uterus  is  anitmg  the  very  rare  complications  of  labor.  It  is  an 
interesting  circumstance  to  record  that,  in  71,000  cases  of  delivery, 
which  occurred  in  the  Dublin  Lying-in  Hospital,  there  was  not  a 
solitary  example  of  inversion,!  We,  therefore,  arc  to  look  for  this 
accident  princi|>ally  among  the  records  of  private  practice.  There 
is  an  interesting  case  recorded  of  congenital  inversion.  It  was 
reported  to  the  French  Academy  of  3Iediciiie  by  Dr.  WiiIiams,J  of 
Metz,    The  girl  menstruated  with  regularity, 

•  Instances  arc  recorded  in  which  inversion  of  the  virgin  womb  has  occurred,  io 
coDscquenoe  of  the  presenoo  of  a  polypoid  tumor. 

f  No  example  of  acute  inversio  uteri  has  ever  fallen  undur  our  nntice^  and  the 
accuttiuLiteii  experience  of  Dra,  ClArke^  Labatt,  Collins,  Kenoedy,  and  JohD^wn,  in 
ih\a  lio8|)ital,  doe^j  not  furniali  ft  single  itiatanec  of  the  t»ccurrence  of  thia  aecidenti 
though  lUo  immber  of  women  delivered  during  their  united  miistershtps  amounta  to 
upwards  of  s«veaty-one  thousand.  [Hardy  and  HoClintocJ^^a  Practical  ObscnralioQi^ 
p.  223) 

t  DuhUn  Ued,  Prasa,  Nov.  1643. 


448 


THE   PRINCIPLES  ASD   PRACTICE  OF  DOSTSTRICS. 


Grmleft  of  InrtTitlon, — Thi?  utenm  itinT  be   cillier  ■  or 

corupk'lely  invcrteil ;  in  the  former  instance,  the  fiimln?*  i-  i  ,  ?t'«lf 
unci  tlie  internal  siirfnt'e  may  or  may  pot  reach  the?  o*  uteri ;  wli<rr(-si% 
in  foinpk'te  inversion,  the  inner  mirfhce  protnule^  through  tb« 
month  of  the  uteru;* — in  a  uonl,  the  on^un  is  tunieil  in^irk'  imi. 

When  thiH  iormi<liihle  Jiecident  prcsent?i  iUelf — and  it  i»  in  aO 
Irulh  ibrmidable,  oftentrme**  involving  the  Ule  of  ihe  mother — ^H  u 
of  cardinal  iiniionance  that  it  fthonld  be  promjitly  reeot^nised,  Ibr^ 
a*  He  jihall  remark,  wljen  H|>eak»n!^  of  tht*  ir<.'ulrni'nt,  the  ditHcuIfy 
of  restoring  the  organ  to  its  original  position  will  nj^niilly  iw  jrro- 
porllonate  la  the  time  whidi  han  elapsed  from  the  moment  i>f  iU 
di>»placcniont. 

J}htfjmmii, — If  yon  be  in  attendance  upon  a  femrde  hi  labor,  and 
inversion  oreiir,  tliere  can  be  no  exeune  for  your  i£(noraiiee  of  th<» 
eircunManee;  fur  yon  liave  been  tohi  niitil,  I  inn  sure,  the  n'|H*li* 
tjon  must  I  ing  in  your  eara,  that,  a«  the  child  is  pasaing  throngh  Xht 
maternal  organs,  your  duty  is  to  aseertam,  by  phi«  i  '  T«and  m 
the  hy[>oga«tric  regiorj,  whether  or  not  the  utenis  i  fit  the 

expulMou  of  the  ffPtus — in  other  wnrds  whetJier  it  isi  rontmrted. 
Suppose,  then,  in  observing  thi>5  rnle — and  to  neglect  it  would  b^ 
extremely  eulpnble^ — you  are  unable  to  feel  the  utcrua  at  thr  lower 
portion  of  the  alnhmien  ;  l:Mit»  in  lien  of  the  organ,  then  '  "  ?  )ie 
diMinelly  recognised  a  enj>[»eri-like  depres^irm.     Why,  ,  iild 

this  state  of  things  indicate?  If  there  be  any  truth  in  i»videiM?e» 
ihe  irresistilrk'  dedn<*tion  would  lie  that  the  womb  had  beeoiwj 
inverted  cither  ]»artially  or  compk'tely.  Whether  the  fbrrner  or 
latter,  would  soon  he  reveale<l  by  the  ahsrnee  or  pres*rnee  f^^n  large 
tumor  protruding  into,  and  i»onietinu»s  even  Ix-xind  the  vagina.  Ail 
doulH  as  to  the  tnie  nature  of  the  case  woiihl  be  promf«Uy  iBi* 
sipated  by  a  digital  examination  of  the  tumor  it-^elt  For  exofupk, 
if  the  inversion  be  ineornjik^te,  the  linge'r,  in  being  earrird  up  1o  tbi? 
OS  nteri^  would  distinrtly  feel  the  intenirvl  surface  of  the  organ 
throw  n  ilownwanl,  but  .still  within  the  uterine  cavity.  l)n  the  coi»» 
trary,  in  complete  inversion,  the  tumor  will  occupy  the  %'aghiii,  sod 
OfTaj<ionally  extend  Wyoud  it,  while  the  os  uteri  will  lit*  ihcmd 
above,  and,  as  it  were,  forming  a  t*|H'cies  of  fitrieture  arf»und  lh« 
upper  poilion  of  the  inverted  organ.  In  aildition  to  the**©  evt- 
denees  the  lunior  would  bo  sensible  to  the  touch,  and  the  plaooata 
attached  lt>  the  inverted  surface,  or,  if  separated  from  it,  the  (act 
of  its  previous  adhehion  would  be  manifest  from  the  peculiar  aa|H*cl 
or  fi'cJ  of  the  part. 

When  the  uterus  is  in  a  state  of  complete  inverv.ion«  the  fnllopian 
lubes,  ovaries,  and  uterine  ligaments,  are  rrrecs-iarily  drawn  tnfu  llit 
cui^ped-tike  or  funnol-^^hape  cavity  formed  by  the  depression  of  tli« 
external  surface  of  ihe  fundus;  and  thore  rui*  instances  recorded  lU 
which  the  small  intt  ,stiiir>,  thi'  hhiddi-r,  and  a  portion  of  tlu-  rectum. 


THK  PBlNCtPLEa  AND  PRACTICE  OP  OBSTBTRICS. 


449 


I 


fcnd  alsa  become  prolapsed  into  the  cavity.  But  the  descent  of 
these  latter  organs  must  rather  be  regarded  as  exceptions  to  the 
rule.* 

i*  f*  poisihh  to  mistake  Chronic  Inversion  for  Bonuthing  eJsef — 
In  a  case  of  recent  inversion,  I  repeat,  it  can  scarcely  be  conceived 
thil;  there  could  be  an  error  of  diagnosis ;  but  where  the  displace- 
ment has  become  chronic^  there  might  possibly  be  some  embarni«<8- 
tnent,  and  tbi^  leads  me  to  dwell  for  a  moment  on  certain  morbid 
phenomena  with  which  inversion  of  the  uterus  might,  without  due 
thought,  be  confounded — sudi  as  prolapsus,  procidentia,  polypus, 
and  other  tumors  connected  with  the  womb. 

In  simple  pix>!ap8us  of  the  organ,  the  apex  of  the  tumor  is  down- 
ward, the  ba8<?  uj>wai'd,  and,  besides,  the  os  tinc»  will  come  directly 
in  contact  with  the  finger* 

In  procidentia,  the  apex  is  downward,  the  base  upward,  there  is 
tUso  the  OS  tincA  at  the  most  pendent  portion  of  the  tumor. 

Ill  polypus,  the  base  is  downward,  the  apex  upward,  consisting 
of  a  pedicle  attnohod  to  the  uterus;  there  U  of  course  no  os  tine®, 
nor  is  there,  as  a  general  rule,  any  sensibility  on  pressure. 

In  inversion,  the  apex  is  downward,  the  base  npwjird,  and  there 
is  no  OS  tincie  to  be  recognised  at  tlm  lower  portion  of  the  tumor. 

H  therefore,  these  distinctive  differences  be  borne  in  memory,  it 
seems  to  me  that  an  errtmeous  iliagnosis  is  barely  possible ;  and 
yet  tken*  are,  unhappily,  autfienticotod  instances  in  which  a  ligature 
faas  been  applied  to  an  inverted  uterus  under  the  conviction  that  it 
waa  a  polypoid  growth,  and  the  life  of  the  patient  thus  sacrificed 
through  want  of  judgment.  Deaths  however^  is  not  always  the 
consequence  of  removal  of  the  uterus  by  Kgature^  as  wiU  presently 
he  shown  when  speaking  of  extirpation  of  the  organ. 

Inversion  of  the  utf-rus,  I  have  remarked^  is  a  formidable  compli- 
eation,  and  very  frequently  results  in  th»  de»^truction  of  the  patient ; 
death,  under  these  circumstances,  may  ensue  either  from  excessive 
hemorrhage,  or  from  shock  to  the  nervwis  system,  and  sometimes 
even  from  convulsions.  Yet,  on  the  otbe<r  hand,  the  chronicles  of 
obstetric  medicine  are  not  without  saiisfactory  evidence  that  women 
have  survived  for  many  years  this  displacement,  after  having  proved 
rebellious  to  every  effort  to  accomplish  the  restoration  of  the  organ 
to  its  original  position. 

JVIr.  Crosse  states  that,  in  soventy-two  oat  of  one  hundred  and 
nine  fatal  cases,  death  occurred  within  a  few  hours  j  in  eight 
within  a  week,  and  in  six  others  in  four  weeks;  of  the  remaining 
twenty-three,  one  died  at  the  fifth  month,  occasioned  by  an  operor 

*  Lcvret  reports  a  case  of  an  iDverted  uterus,  in  a  womati  s&voui^  ^reara  of  age, 
oonUining  a  portion  of  the  rectum,  bladder,  and  sniall  intestimes,  togetiVor  wirti  the 
fiilloptea  tubes  and  ovaries.  [Obiiervatioiis  sur  k  Curo  Kadicale  do  Plusieura 
Polypes  de  k  Matrico.     Ob.  8,  p.  133.     Paria,  1762.1 

29 


450 


THE    PRINCIPLES   AK0  PRACTICE  OP  OBaT£TIUOSL 


tion  ;  one  at  eight  months;  thr^e  at  nine  montbfiT  und  the  oUiersnt 
various  periodfi  from  one  to  twenty  yeari.* 

Treatmej«t. — Let  us  now  sti|ipo9e  that  yoti  have  a  caae  of  Inc 
plete  inversion*     How  is  it  to  be  managed?     No  time  nhovld 
lost  in  eflbrfs  to  red  nee  the  displacement.     The  pntlent  aiiuald  1 
a!)  the  advantage  of  position,  being  placed  on  her  hack,  aod  the 
pelvis  slightly  raised  above  the  plane  of  the  thorax  ;  it  is  e^pecbUjr 
important  to  remember  that^  in  this  form  of  iilerine  disphicomeiit " 
there  is  very  commonly  retention  of  urine  in  ronsequenee  of  I 
preitsnre  of  the  tumor  agains^t  tlie  neck  of  the  bladder.     Tbrr^or%^ 
do  not  omit,  as  a  preliminary  measure,  to  evaconte  ibe  vrioe  by  tint 
introduction  of  the  catheter*     If  the  placenta  be  still  ki  mi 
with  the  uterus,  do  not  on  any  account  make  an  c&'^^n  to  cUUidl  ill 
either  by  tractions  on  the  cord — for  these  would  only  lend  I9 
increase  the  inversion — or  by  manipulations  with  the  hmnA  emmei 
into  the  uterine  cavity.     On  the  contrary,  what  you  tboi:dcI  ilo  'm 
eautiously  to  introduce  the  band  within  the  mouth  of  the  iitcn%J 
and  w  ith  the  dorsal  surface  of  the  fingers  exert  gentle  but  m 
pressure  upward  against  the  inverted  portion  of  the  organ — smlis] 
this  way,  it  will  be  made^  generally  speaking,  to  resume  it»  po«ilioii| 
this  being  aceom  pi  lushed,  frictions  on  the  abdomen,  a  smalt  pice*  of 
ice  inirodueed  into  the  vagina,  or  the  administrntion  of  ergo^^J 
should  the  uterus  not  contract  with  surticiont  energy  to  sepanlt^ 
the  after  birth — may  be  resorted  to  with  a  view  of  evokiag  itih 
creased  action.     The  placenta  being  sefwirated,  it*  extrftt-iion  is  to 
be  accomplished  aec^ording  to  the  rules  indicated  iu  a  pr^vfaNM^ 
lecture. 

But  how  are  you  to  proceed  with  regard  to  tbt  DHUHigefMittt  of 
the  uterus  when  in  a  state  of  complete  inverwon  ?  In  ibis  < 
too,  prnmptneas  is  one  of  the  great  elements  of  suoociifl  ind^cd^lf  1 
even  a  tew  hours  lapse  after  the  accident,  it  will  be  extremolir  dM^i 
cult  to  effect  the  reduction.  Therefore,  retnember  th«l,  m 
liese   circtmistances,   action   simultaneous,   if   possible,   witb   ttei 

cident  will  prove  the  truest  economy.  In  complete  invert 
here  will  be  one  of  two  things — the  pUusenta  will  either  \m*  «*p»> 
rated  from  the  organ,  or  it  will  be  in  connection  with  it.  In  the 
former  in^tance^,  the  tumor  should  be  gently  grasped  by  the  luwd, 
and  ft  coTiiinued  but  cautious  pressure  made  in  the  dlreetion  of  tht 
respective  straits  of  the  pelvic.  T\m  pressure,  if  faithfully  |»ff- 
ciiited  in,  will  ol\entitnes  be  productive  of  the  luippiest  rt*«nlt*— 
restoring  the  utenis,  and  protecting  the  patient  against  the  annoys 
ftnee  and  dangers  of  failure  in  the  attempt  at  reductioo. 

When,  however,  the  placenta  is  still  adherent  to  the  Inviirtcd 
JMrgmi^  there  is  some  diftV^rence  of  opinion  as  to  the  proper  oooiM 


•  Op.  dt,  p.  110. 


THE  PRINCIPLES  AND  PRAOnCE  OF  OBSTETRICS.         461 

to  be  pursued.  Authors  are  divided  upon  this  subject,  some  follow- 
ing the  counsel  originally,  I  think,  given  by  Puzos  of  previously 
detailing  the  after-birth,  for  the  reason  that  in  so  doing  the  volume 
of  the  tumor  will  be  diminished,  and  the  possible  danger  of  its 
subsequent  extraction  avoided.  Others,  again,  maintain  that  the 
prelimioary  detachment  of  the  afler-birth  is  not  necessary,  and  they 
proceed  at  once  to  replace  the  uterus  without  any  reference  what- 
ever to  the  deciduous  mass.* 

I  should  advise  you,  gentlemen,  to  adopt  neither  of  these  sug- 
gestions peremptorily ;  it  is  not  wise — and  science  repudiates  the 
notion — to  have  stereotyped  rules  of  conduct  for  the  sick  room. 
You  should  have  stereotyped  principles,  but  the  application  of  these 
principles  must  be  governed  by  the  circumstances,  which  may  sur- 
round each  individual  case.  Therefore,  the  plan  which  I  suggest 
for  your  consideration  is  this — if  the  placenta  be  considerably 
detached  at  the  time  of  the  inversion,  you  may,  before  attempting 
to  reduce  the  displacement,  complete  its  separation,  and  then  imme- 
diately, in  the  manner  already  indicated,  proceed  with  your  mani- 
pulations to  accomplish  the  restoration  of  the  organ.  All  things 
being  equal,  it  is,  in  my  judgment,  far  more  desirable  to  attempt  to 
replace  the  inverted  uterus  while  the  placenta  is  still  in  connection 
with  it,  and  for  the  very  substantial  reason  that,  under  such  circum- 
stances, the  pressure  is  not  made  directly  against  the  womb  itself — 
which  must  necessanly  expose  it  to  more  or  less  injury — but  the 
pressure,  you  perceive,  is  directed  against  the  intervening  object — 
the  placenta.  It  may,  however,  be  that  the  size  of  the  afler-birth 
will  add  so  much  to  the  volume  of  the  tumor  as  to  render  the 
reduction  physically  impossible.  In  such  case,  of  course,  the 
proper  alternative  is  the  detachment  of  the  placental  mass.  After 
the  reduction  has  been  accomplished,  the  hand  is  not  to  be  suddenly 
withdrawn  from  the  uterus,  but,  on  the  contrary,  it  should  be 
continued  within  the  cavity  until  the  organ,  through  its  contrao- 
tions,  forcibly  expels  it ;  this  will  be  the  best  safeguard  against  the 
recurrence  of  the  inversion.  Should  every  effort  fail — and  such  in 
the  most  skilful  hands  will  not  unfrequently  be  the  case — care  should 
be  taken  to  return,  if  possible,  the  tumor  within  the  vagina  and 
sustain  it  in  situ  by  the  india-rubber  pessary,  or  a  piece  of  soft 
sponge,  and,  if  necessary,  with  the  addition,  also,  of  a  bandage. 

It  would  seem  that  after  the  reduction  of  an  inverted  womb, 
the  mortality  is  comparatively  slight,  for  in  fitty-two  cases  in  which 
the  organ  was  restored  to  its  position,  death  occurred  in  seven  only, 
or  one  in  7.3. 

Spontaneotia  BeducHon  of   the  Inverted   Uterus. — ^There  are 

•  Great  benefit  will  oflea  be  derived  from  the  administration  of  ether,  if  there  be 
nothing  to  contra-iudicate  its  use ;  its  relaxing  efiects  will  very  much  faciJitato  the 
repooition  of  the  organ. 


452 


THE  PRIKCIPLE3  AND   PBACTICE  OP  OBSTETRICS, 


several  cases  reported  of  spontaneous  restoration  of  the  tnre 
iiterusi,  after  resisting  every  attempt  at  rednction.     One  of  the 
ccurred  in  the  practice  of  the  renowned  Baudelocque,  on  irbo 
"authority  it  has  found  a  place  in  the  historical  archivoa  of  '* 
fession.     I  shall  present  it  to  yon  as  recorded  :  Madame  B*'>  a 

was  delivered  of  her  first  child  at  Cape  Francis,  in  1 782  ;  at  the  liniAl 
of  the  delivery  of  the  placenta,  effected  by  the  hand  introdncejf 
into  the  uterus,  she  complained  of  severe  pain,  and  felt  betw*^ett  I 
her  tliighs  the  protrusion  of  a  large  tumor,  which  was  iuitr 
returned  within  the  vagina.     The  lady  hecarae  almost  f 
natcd,  and  »o  prostrate  that  the  attending  acconcbeur  was  appr^  j 
hensive  that,  if  he  made  any  attempt  to  restore  the  or: 
would  die  in  his  hands.     After   seven  or  eight  years  of  ^ 
3Iad:ime  B.  visited  Paris  for  the  purpose  of  eon8ulun),^BaudeIuci|at% 
This  distinguished  accoucheur,  after  a  thorough  exaniinaliou  of  tht  J 
tumor,  decided  that  it  was  an  inverted  uterus :  he  made  neveral  | 
attempts  to  reduce  it,  but  failed.     He  prescribed  bathj^  ji 
On  the  evening  of  the  day  preceding  that  appointed  by  Daii-- 
for  another  a^empt  at  reduction,  Madame  B.  was  urged  by  »0tn#^ 
of  her  friends  to  walk  about  ber  room.     When  doing  so,  libc  feH 
suddenly  in  a  siltintj  position  on  the  floor ;  she  complained  of  an 
unusual  movement  in  the  lower  portion  of  the  abdoaierj,  and,  f^jr 
an  instant,  lost  her  consciousness.     Baudelocque  being  st?Dt  for,  was 
soon  at  the  house,  and,  on  examination,  could  detect  no  tumor — ^it 
having  spontaneously  been  restored.     From  this  time,  the  pitient 
improved  in  henlth.     Having  been  a  widow  for  several  yearsi  ifac 
married  again,  became  pregnant,  and  was  safely  delivered  at  full  tenn. 

This  case,  remember,  I  give  you  solely  upon  the  te**tiinony  of 
Baudelocque.  With  less  weight  of  anlhority,  I  should  be  disposed 
to  rank  It  among  what  may  be  termed  itiedical  delusions, 

Mtlirpation  of  the  Inverted  Uterm, — When  it  is  impo9;8ible  to 
return  the  uterus,  the  inversion  becomes  chronic  ;*  in  this  oondi* 
tion,  it  may  or  may  not  cause  much  inconvenience,  and  even  involve 
the  life  of  the  patient  in  danjjer.  For  example,  when  it  ii«ciitiiGi 
the  chronic  form,  the  system  may  be  gradually  drained  by  tl 
ooxing,  either  of  blood  or  mucus,  which  is  so  apt  to  ac*cofti|}a&]r1 
this  stage  of  the  displacement.  Again,  indolent  and  rebellious 
ulcerations,  induced  by  t!io  friction  of  the  dress,  may  etisaei  anil 


*  Them  firo  some  exoeptional  insUiTioea  reported  of  dironic  mversioa  of  tli#  j 
ut«ruB,  in  which  the  organ  ban  been  reduced  After  jeora  of  displnccmMit  Amoi 
otliers,  may  bo  mentioned  the  rcmnrkablo  ca«e,  wliicti  occurred  in  the  pmoUcir  of 
Pn>C  J,  P,  White;  the  orjniii  hod  been  inverted  for  fifteen  jeiiDi;  it  w«i  hdc ouMVittf 
rept>slit*d.  Th^  pftiient  died  sixteen  days  Btibsequeurly  of  peritanltia.  Dr.  Ty%ts 
6mah  reductni  an  inverted  uterus  of  twekeyeura'  duration;  pincnt  recorcftd,  \Tm 
detuiU  of  Prof.  Whitens  c»ae,  see  Am,  Joun  Med,  Sd.,  July,  1858,  p,  U.  f«r  Dr 
Smith's,  Am.  Jour  Med  ScL,  July,  1858   p.  2T0. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         458 

these  ulcerations  so  &r  compromise  the  safely  of  the  woman  as  to 
suggest  the  very  delicate  and  important  alternative — extirpation  of 
the  inverted  organ^  as  the  only  chance  of  safety.  In  the  whole 
range  of  obstetric  medicine,  I  know  of  no  more  momentous  ques- 
tion than  this  for  the  decision  of  the  accoucheur ;  painful,  indeed, 
is  the  responsibility  of  an  operation,  the  very  nature  of  which,  to 
my  mind,  is  horrid  to  contemplate ;  not  so  much  because  of  the 
danger  of  the  alternative,  as  that  it  absolutely  unsezes  the  woman, 
and  makes  her  existence  one  of  irreparable  sadness,  more  especially 
if  she  should  not  have  passed  the  child-bearing  period.  I,  there- 
fore, think  that  the  fullest  and  most  undoubted  evidence  that,  all 
things  fiiirly  and  deliberately  weighed  with  the  single  motive  of 
arriving  at  the  truth,  the  operation  affords  the  only  hope  of  safety 
—will  alone  justify  a  resort  to  it. 

The  following  table,  which  I  take  from  Dr.  West,*  gives  the 
result  in  fifty  cases  of  extirpation  of  the  uterus  for  inversion  con- 
nected with  parturition.  It  will  be  seen  that  thirty-six  of  the 
eases  were  sucxsessful,  twelve  fatal,  and  in  two  instances,  although 
the  patients  survived,  it  became  necessary  to  abandon  the  operar 
tion.  The  total  also  shows  the  results  of  the  respective  modes  of 
performing  the  operation — ligature  and  excision. 

Whole  number     -o..^^^^,^       tm^  Operation 

ofeaMt.  Keoovered.      Died.         .jiidomKL 

Uterus  removed  by  ligature  in  38  28  8  3 

"  "        "    knife  in  4  3  1 

•*  u        «i    knife  and  ligature      8  6  3 

60  36  12  3 

The  annexed  table  is  interesting,  as  it  indicates  the  influence  of 
the  period  at  which  the  extirpation  is  performed  on  its  fatality  : 

Pfttients  reoovered.       Died.  TMaL 


Under  1  month. 

4 

3 

7 

Between  1  and  2 

months, 

3 

3 

"      2 

"    6 

i( 

3 

8 

"       6 

"  12 

a 

3 

**     12 

"  18 

u 

"     18 

"    2 

^ears, 

1 

4«         3 

"    3 

M 

"       3 

"    4 

(i 

"      4 

"    6 

u 

"      5 

"    6 

u 

«       6 

'*  n 

« 

After  12  years, 

"    14    " 

1 

"    15    " 

1 

"    many  years, 

2 

35  11  46 

At  the  commencement  of  this  lecture,  I  remarked  that  it  was 

*  Lectures  on  Diseases  of  Women.   1858.,  p.  186. 


THE  PRIKCIPLES  AND   FRACTICB  OV  OBSTETRICS. 


more  particularly  in  the  walks  of  private  practice  that  we  if 
to  look  for  the  occurrence  of  inversion  of  the  womh,  and  thitt  U  u^ 
unha)>pily,  too  often  the  direct  result  of  ignorance  and  wanton 
bruuility.  The  following  metnneholy  case  will,  I  think,  suntain 
me  ill  this  opinion  ;  it  occurred  some  years  ago  in  tfiis  city,  aii4 
became  the  subject  of  legal  investigation ;  it,  therefore,  fonna  a 
part  of  the  criminal  calendar  of  New  York.  It  is  a  dark  pieturo 
in  the  affairs  of  professional  life  as  occasionally  exhibited  in  ibis 
metropolis,  and,  perhaps,  such  revelations  would  be  more  freqcteol, 
were  it  not  that  the  grave,  wbich  receives  the  victim,  too  oftes 
burieii  within  it  the  tale  of  woe  which  led  to  that  victim**  dei* 
truction  I 

A  poor  German  woman  Wiis  taken  in  labor,  and  sent  for  a  Dr. 
Septimus  Hunter,  to  minister  to  her  want^.    The  child  wia  deli*  ^ 
vered,  but  there  was  some  delay  in  the  expulsion  of  the  pbconla. 
It  was  proved  by  numerous  witnesses,  in  the  room  at  the  tiroe^  thttl 
the  doctor  had  made  the  most  powerful  e6rorts  to  bring  away  tlia 
after-birth,  nmid   the  heart-rending   screams   of  the    unforttinata ' 
patient,  and  the  most  fervent  appciila  btith  from  her  and  thofrinidi' 
who  surrounded  her,  that  he  would  dn^mu  and  leave  the  poor] 
sutlVrer  to  nature.     It  wtia  also  shown  that,  during  these  saragv  ^ 
manipulations,  the  blood  flowed  profui^ely  from  the  womb,  t^o  tlml 
there  were,  in  the  language  of  the  witnesses,  **  bi^j  pieces  like  liter 
upon  the  floor.'*    The  doctor,  intent  upon  the  accompU^hmeiil  of 
his  purpose —the  removal  of  the  placenta— paid  no  sort  of  attentioa 
either  to   the  agony  of  the  patient^  or  the  rernonHtrance  of  her 
friends,  but  continued  his  unholy  work  ;  hin  cruel  efforts  wi^re  in  I 
no  way  diminished,  but  the  shrieks  of  the  patient  hud  ceased  ;  sli0 
hiy  quiet,  and  without  a  murnnir ;   bracing  his  feet  agaiasi  tka 
bed,  by  one  herculean  graup  On  Septimus  Hunter  brought  away, 
as  he  supi'osed,  the  placenta,  but  u4th  it,  he  likewise  tore  from,  thfi 
body  of  that  dead  tooman — the  womb!!! 

There  was  necessarily  much  ejt citement  among  the  witncisea  of  ^ 
that  scene  of  blood;  a  police  officer  was  «ent  for;  Hunter  wai* 
arretted  ;  the  coroner  held  his  inquest— and  the  verdict  of  the  jury 
was:  "That  the  death  of  the  woman  was  caused  by  the  tearing  out 
of  the  womb  by  Dr.  Septimus  Hunter."     The  nterus  was  prvaefTod I 
by  the  coroner;  it  proved  to  be  a  case  of  inversion  of  the  organ,] 
whieh  this  trafficker  in  innocent  blood  had  mistaken  for  the  aAifwl 
birth»  and  thn^  coolly  and  deliberately  wrenched  it  from  her  person  t] 
After  the  finding  of  the  verdiet  by  the  coroner's  jury,  the  cum  wi 
submitted  to  the  Grand  Jury,  who,  after  a  full  hearing  of  the  evi- 
der*ce,  brought  an  indictment  of  murder  against  Hunter,     TImi  trial 
excited  much  attention  at  the  time«  and  the  interest  of  the  |irofes-' 
Sion  wa^  especially  elicited.     Several    medical  gentlemen  were  ei* 
amined,  and  there  waa  a  very  general  concurrence  among  Um 


TH£  PBINCIPLE8  AND  PRACTICE  OF  OBSTETRICS.         466 

that  the  deaih  of  the  tooman  toaa  occcuianed  by  the  tearing  out  of 
the  womb! 

It  was  my  good  or  bad  fortane — I  cannot  say  which — ^to  be  called 
aa  a  witness  on  the  occasion ;  and  I  unhesitatingly  gave  it  as  my 
opinion  that  death  was  not  the  result  of  the  tearing  out  of  the 
womb,  but  that  the  woman  died  from  flooding,  and  that  she  was  dead 
Ibefore  the  man  of  blood  had  wrenched  the  uterus  from  her  person  t 
This  opinion  was  regarded  as  a  very  singular  one — it  was  at  vari- 
ance with  the  rest  of  the  medical  testimony,  and  subjected  me  to  a 
searching  cross-examination  by  the  Hon.  Mr.  Whiting,  who  at  that 
time  held  the  office  of  District  Attorney.  The  examination,  able 
as  it  was,  did  not  cause  me  to  surrender,  in  the  slightest  detail,  or 
compromise  in  any  way  the  broad  and  emphatic  opinion  I  had 
given  under  the  solemnity  of  my  oath,  and,  I  hope,  with  a  full 
appreciation  of  my  duty  to  the  commonwealth.  Now,  then,  gen- 
tlemen, had  I  any  basis  for  that  opinion,  and  if  so,  what  was  it  ? 
iBt.  It  was  proved  by  numerous  witnesses — and  their  testimony 
was  not  contradicted — that  while  the  doctor,  in  defiance  of  the 
shrieks  of  the  patient,  was  engaged  in  his  brutal  work,  there  was 
profuse  hemorrhage  from  the  womb.  This  testimony  was  con- 
firmed by  the  coroner  and  jury,  M'ho  stated  that  when,  soon  after 
the  death  of  the  woman,  they  entered  the  room,  they  found  the 
bed  and  carpet  completely  saturated  with  blood.  2d.  It  was  also 
proved  that,  for  some  minutes  before  the  doctor  had  brought  away 
the  uterus,  the  patient  ceased  to  complain  ;  she  lay  quiet,  made  no 
manifestation  of  suffering ;  and  the  moment  the  doctor  had  achieved 
his  triumph,  the  friends,  in  ignorance  of  what  had  been  done,  sup- 
posing that  all  was  right,  spoke  to  the  patient,  told  her  it  was  all 
over — ^but  the  intelligence  reached  her  not — tfiat  woman  was  dead  I 
It  was,  therefore,  upon  this  testimony  that  I  founded  my  opinion ; 
for  it  is  absurd  to  imagine,  in  the  first  place,  that  the  woman,  if 
alive,  would  not  have  continued  to  exhibit  the  intensity  of  her 
saffering  during  the  butchery  to  which  she  was  subjected ;  and, 
secondly,  the  quantity  of  blood  lost  sustains  the  hypothesis  that  she 
*  had  expired  before  the  completion  of  the  horrid  deed.  It  was 
attempted  by  the  leained  counsel  for  the  prosecution  to  show  that 
the  bleeding  was  the  result  of  the  tearing  out  of  the  uterus,  and 
that,  therefore,  the  defendant  was  guilty  of  murder.  On  this  point, 
too,  I  underwent  a  protracted  examination,  and  all  that  legal 
acnmen  could  accomplish,  was  brought  to  bear  in  the  attempt  to 
elicit  from  me  an  affirmative  answer.  But  I  also  had  a  duty  to 
perform,  and  that  was  to  subserve  justice  as  far  as  I  was  able  to  do 
80.  My  reply  to  the  question  was — that  there  were,  in  my  opinion, 
two  reasons  why  the  hemorrhage  could  not  be  the  result  of  the 
forcible  pulling  out  of  the  uterus:  1st.  The  united  testimony  of  all 
the  witnesses,  that  the  blood  had  escaped  before  the  womb  was 


466        THE  PRINCIPLES  AKD  PRAOnCB  OF  OB8TITBIG8L 

removed ;  2d.  That  lacerated  veseeU  do  nat^  as  a  general  nde, 
bleed. 

My  testimony,  I  believe,  had  something  to  do  with  the  Terdicl 
rendered  by  the  jury  in  the  criminal  trial — instead  of  murder. 
Hunter  was  found  guilty  of  manslaughter,  and  sentenced  for  tw^re 
months  on  Blackwell's  Island.  It  was  my  duty  to  testify  to  the 
truth,  without  reference  to  any  collateral  issue ;  I  did  so ;  at  the 
same  time,  I  am  free  to  confess  that  if  I  had  been  governed  simply 
by  my  feelings,  and  the  award  of  punishmefit  had  been  left  to  mj 
discretion,  I  should  have  sent  the  man  to  the  State  Prison  fbr  life, 
in  order  that  the  bulky  walls  of  that  mansion  mig|it  protect  the 
community  against  a  similar  outrage. 


LECTURE   XXXL 

fMernatnral  Labor,  divided  into  Manual  and  Instraraental — Caoaes  of  Haniud 
Labor — Malposition  of  the  Foetus — How  may  the  Foetus  be  Malposed?— Exhaus- 
tion, bow  Divided — Positive  and  Relative  Exhaustion — Importance  of  the  Dis- 
tinction— Diagpiosis  of  the  two  kinds  of  Exhaustion — Hernia,  as  a  cause  of  Manual 
Labor — Prolapsion  of  the  Umbilical  Cord ;  Relative  Frequency  of— Extremely 
Destructive  to  the  Child,  but  not  to  the  Mother — Predisposing  Causes  of  Prolap- 
Bton^Diagnosis  of  ProUpsion— How  is  the  Death  of  the  Child  occasioned  in  Pro- 
lapsion ? — Is  it  the  Coagulation  of  the  Blood  in  the  Descended  Portion  of  the 
Cord  ?— Is  the  Arrest  of  \}\e  Circulation  in  the  Cord  a  positive  Proof  of  the  Child's 
Death? — Dr.  Ameth,  of  Vienna;  his  Cases — At  what  period  of  Labor  does  Pro- 
lapaion  occur? — Treatment  of  Pmlapsion;  on  what  it  depends — Various  Contri- 
Tances  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  Homor- 

'  rhage — The  Earlier  Writers ;  tlieir  views  of  Placenta  Prsevia — Connexion  between 
Placenta  Praevia  and  Hemorrhage — Unavoidable  Hemorrhage.  Placenta  Pnevia ; 
Bytnptoms  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  Prrovia ;  Rules  for — Dr.  Simpson  and  Entire  Arti- 
ficial Detachment  of  Placenta ;  Objections  to— Dr.  Barnes  and  Partial  Artificial 
Detachment — Ergot  in  Placenta  Previa ;  Abuse  of;  when  to  be  employed — Rup- 
ture of  the  Membranous  Sac  in  Placenta  Prsevia ;  is  it  useful  or  otherwise  t — 
Accidental  Hemorrhage;  how  it  differs  from  Unavoidable  Hemorrhage — The 
Patliology  and  Causes  of  Accidental  Hemorrhage— Dr.  Robert  Lee,  and  a  Short 
Cord  as  a  Cause — Treatment  of  Accidental  Hemorrhage  during  Pregnancy,  and  at 
the  time  of  Labor. 

OsMTLEMEN — We  shall  now  discnss  the  interestinij  subject  of  pre- 
ternatural labor,  by  which  you  are  to  understand  that  form  of 
parturition  in  which  nature  is  so  far  contravened  in  her  arrange- 
ments, as  to  need  the  interposition  of  tlie  accoucheur  for  the  accom- 
plishment of  childbirth.  Preternatural  labor,  we  have  already 
remarked,  may  be  either  manual  or  instrumental.  In  the  former 
instance,  the  introduction  of  the  hand  becomes  necessary  for  the 
termination  of  the  delivery ;  while,  in  the  latter,  a  resort  to  instru- 
ments is  indispensable. 

Manual  Labor, — ^The  causes  of  manual  labor  are  numerous,  and 
it  is  important  that  you  should  have  a  clear  appreciation  of  them,  in 
order  that  its  indications  may  not  be  confounded  with  those  of 
instrumental  delivery.  In  the  first  place,  you  are  to  bear  in  mind 
that  there  are  many  complications,  which  may  present  themselves 
during  the  progress  of  labor,  and  which,  therefore,  may  so  far  com' 


468 


THE  PBIXCIPLE3  AND  PRACJTICE  OF  OBSTETRICS. 


promise  the  safety  cither  of  the  mother  or  child  ha  to  call  for 
tlie  prompt  interference  of  the  nccoucheur — the  interfercuce,  how- 
ever, being  limited  to  the  introdiietioti  of  the  hand  with  one  of  two 
objects:  either  to  correct  a  malposition,  nnd  llien  commit  the  ter* 
mination  of  the  delivery  to  nature,  or,  if  the  fjeceflj*iiy  be  nrgenmo 
proceed  at  once  to  the  accorajilishment  of  the  biith  by  vcr^iorj.  It 
h  too  obvious  to  need  argument  that,  when  there  U  much  dispro*^ 
portion  between  the  foetns  and  maternal  organn,  manual  oid  will  bi 
utterly  inadequate  to  the  requirements  of  the  case;  under  iheit 
circumf«tance8,  a  resort  to  instruments  will  be  the  only  iUtcmatmu 
For  how  could  yon  hope,  by  the  simple  introduction  of  the  hand, 
cither  to  enlarge  a  contracted  pelvis,  or  diminish  the  »i»o  of  a  fa^tuM 
di»proportioned  to  the  passage  through  which  it  ia  to  make  il.-«  cjxtt  f 
In  strict  truth,  the  essential  cattses  of  manual  labor  will  V  1  in 

the  various  malpositions  of  the  fcelus,  thus  rendeiiu^  an  :i  ^  nni 
of  the  position  absolutely  necessary  in  ordor  that  the  chihl  nay 
pa£S ;  but,  at  the  same  time,  there  are  other  cumplicatiorm  lu  winch 
we  shall  presently  refer,  which  will  call  for  artificial  iuterpofiitioa; 
and  there  may,  also,  nri^e  the  question  of  allernulive  lif  clxiice 
between  instrumental  and  manual  delivery,  the  que^tioD  of  alter- 
native  being  determined  by  the  peculiar  nature  and  exigmtciw  of 
the  case. 

The  foetus  may  be  said,  so  far  as  the  possibility  of  natttrul  deB- 
very  is  concerned,  to  occupy  a  malpowtion  when,  instead  of  otve  of 
the  extremities  of  the  ovoid,  soaje  portion  of  the  trunk  pri*j«rnt«  dI 
the  superior  strait ;  it  is  also  badly  wtuated  if  the  head,  in  lieu  of 
the  vertex,  should  present  its  ocd[>ital  or  lateral  regiiins,  for,  in  this 
case^  the  disproportion  would  be  8uch  as  to  render  it  physically 
impossible  for  the  head  to  pass  without  a  previous  change  of  {lotft- 
tion ;  and  a^ain,  the  s^xnie  difKciilty  would  occur  in  proseutatioti  of 
the  lirccch,  knecis,  or  feet,  if  either  of  these  portions  should  \m*  to 
placed  against  any  part  of  the  upper  strait  a*^  to  become  initnM\ablc, 
nutwiihstandinr^  the  ccmtractions  of  ihe  uterus.  So  you  arc  to 
recollect  that  not  only,  in  order  that  labor  may  be  natural^  ia  il 
required  that  one  of  the  oksteiric  extremities  of  the  child  «4iall  |iir^ 
•ent,  but  it  muttt  present  properly,  and  in  accoidanee  with  thi 
ability  of  the  uterus  to  expel  it.  Besides  the  maI|>usltionti  of  iht 
fo^tuis  there  are  various  accidents,  which  may  so  far  complicate  Um 
safety  of  either  mother  or  child,  m  to  convert  a  labor,  which  wtvM 
otherwise  bo  natural,  into  one  of  manual  delivery*  or  .n  'wIq 

one  in  whiol*  it  nvay  become  necessary  to  delermiue  il 

wuul<i  be  more  judicions  to  resort  to  LnstrumentA,  or  lennmatc  ibo 
bibi)r  by  the  hand.  Th^tse  acct<1ents  are  us  follows:  t^JumstUm^ 
hernia,  prohpsion  tjf  t/te  umfnlical  cord^  hemorrhagt^  ctjikcidswH^ 

fstion, — ^Tbe  young  practitioner,  wboae  expefieoae  in 


THE  PRINCIPLES  AKD  PRACTICE  OF  OBSTETRICS.         459 

the  lying-in  room  has  of  course  been  limited,  must  be  on  his  guard 
touching  this  word  exhaustion  ;  it  is  a  very  equivocal  term  ;  unless 
properly  defined  and  thoroughly  appreciated,  it  will  oftentimes 
lead  to  erroneous  decisions.  In  order  that  you  may  have  a  clear 
understanding  of  its  true  import,  and  of  the  indications  it  involves, 
I  shall  divide  it  into  two  forms — relative  and  positive  exhaustion. 
For  practical  purposes,  this  is,  I  think,  a  sound  and  important  divi- 
sion, and  if  a  just  distinction  be  made  between  these  two  grades  of 
exhaustion  at  the  bed-side,  all  possibility  of  embarrassment  will  be 
at  an  end. 

Helative  .Ebshaustion. — I  have  scarcely  ever  attended  a  case  of 
labor,  unless  its  duration  was  extremely  brief,  in  which,  during  the 
throes  of  parturition,  and  more  especially  during  the  expulsive 
effort)  the  female  did  not  exclaim,  ^^  Ohf  lam  so  weaJc^  I  shall  die 
^  I  have  another  pain,^^  This,  or  something  kindred  to  it,  is,  I 
may  say,  the  stereotyped  language  of  the  parturient  woman.  Now, 
gentlemen,  if  you  give  this  phraseology  a  literal  translation,  if  you 
take  your  patient  at  her  word,  you  will  at  once  conclude  that  a 
storm  is  gathering,  and,  in  your  anxiety  to  do  something,  you  may 
be  guilty  of  officiousness,  which  will  be  quite  likely  to  compromise 
the  safety  of  the  woman  and  her  child,  and  do  no  great  credit  either 
to  your  judgment  or  skill. 

When  you  reflect,  for  a  moment,  on  the  severe  sufferings  occa- 
Roned  by  childbirth,  and  the  commotion  to  which  the  ner>'ous 
system  is  subjected  during  a  forcing  labor-pain,  you  can  readily 
conceive  why  all  this  should  beget  a  feeling  of  momentary  prostra- 
tion, causing  the  female  to  believe  that  the  recurrence  of  another 
pain  will  utterly  annihilate  her !  But  how  delusive  this  opinion  of 
the  patient,  whose  standard  of  danger  is  the  amount  of  physical 
suffering  she  endures.  Not  so,  however,  with  the  enlightened 
aocoucheur,  whose  duty  it  is  to  distinguish  between  fiction  and 
reality,  and  to  arrive  at  conclusions  not  from  mere  appearances,  but 
from  substantial  facts  as  they  may  present  themselves  to  him  in  the 
aggregate.  The  testimony  of  the  patient,  under  the  circumstinces 
of  which  we  speak,  is  the  testimony  simply  of  feeling,  and  not  of 
judgment,  and  therefore  it  becomes  useless  as  a  guide  for  practice. 
As  soon  as  the  pain  has  passed  over,  the  poor  woman,  who  a  moment 
before  was  admonishing  every  one  about  her  that  she  was  exhausted 
and  would  certainly  die,  not  only  becomes  tranquil,  but  engages  in 
conversation,  and  even  will  laugh  with  good  heart  at  a  merry  jest, 
which  the  accoucheur  of  tact  will  know  so  well  how  to  introduce 
for  the  purpose,  as  it  were,  of  detaching  her  mind  from  herself,  and 
giving  it  temporary  occupation  in  some  other  channel.  Again: 
the  pulse  is  good,  the  countenance  is  not  haggard,  there  is  no  evi- 
dence whatever  of  a  dilapidated  condition  of  the  vital  forces — ^in  a 
word,  the  prostration  of  which  the  patient  complained,  and  which 


460 


THE  PRIXCIPLK3  A?^D  PILiCTICE  OF  OBSTETRICS. 


she  Nuppofted  to  be  liie  harbinger  ot  iiicviUible  death*  h  bui  tha 
flittin'j;;  of  the  April  cloud  aver  ihe  sun,  cau^ng  for  tlic  insinnl  a 
slight  ob!«curity,  in  order  that  tlic  gloriotu  orb  may  become  still 
more  I'fi'iilgent.  This,  gentlemen,  18  what  I  term  rehittvc  eiluiii^* 
tion,  and  w  entitled  to  no  consideration  whatever,  so  far  as  being  on 
indic'jihon  for  interference  on  the  part  of  the  praetitionen 

Posttim  Kxhmistion, — Positive  exhaustion,  however,  is  alto- 
gether a  diflerent  thing,  and,  except  through  opportune  and  skilfiil 
iaterfereoce,  will  inevitably  lead  to  death.  Here  there  i»  no  imv 
gination,  no  fietiou — all  is  a  st:)leoin^  ein|)hatie  reality.  The  patient, 
after  a  pain,  does  not  rally-  The  sunken  countenance,  flickering 
pubi',  the  cold  and  clammy  perBpiration,  the  pallor  of  the  genenU 
surface,  indicate  w  ith  unerring  certainty  that  the  system  is  at  a  Joir 
ebb — tiiat  it  i»  fa^t  approaching  utter  dilapidation.  There  \%  no^ 
or,  if  aEiy,  but  a  momentary  rcnponse  to  stimulants.  The  foreei 
will  n<»t  react.  In  these  cjises,  which  fortunately  may  be  regarded 
as  rare,  every  successive  pain  has  a  direct  tendency  to  increaae  the 
prostration,  and  if  something  be  not  promptly  done  to  tneet  tht 
einer<^eney,  the  patient  biuks.  This  sometliiug  conftistK  in  delivering 
her  without  delay*  Should  the  head  of  the  child  havg  pnsmej 
through  the  mouth  of  tlie  uteruji,  or  be  in  the  pelvic  esccavatioD, 
recouitiu  should  be  had  to  the  forceps.  If,  on  the  contrary,  the 
head  be  stilt  at  the  superior  strait,  and  the  moutli  of  the  womb 
suftietently  dilated  to  permit  the  introduction  of  the  hand,  tha 
alternative  is  version.  The  pjirtieular  reasons  fur  this  ihoice  will  be 
fully  stated  when  we  speak  of  the  indications  and  rules  for  turoiDg^ 

JJeniia, — If  a  woman  in  labor  be  aftected  with  hernia,  whether 
it  should  have  pre-existed,  or  be  the  renuU  of  extreme  uterine  rfliirt, 
it  will  equally  need  the  attention  of  the  accoucheur.  For  example, 
sup{>o$e  a  C4ise  of  femoral  hernia:  each  successive  paiu  may  Jio 
increase  the  protrusion,  as  to  give  rise  to  the  appreheusioo  of  its 
beCTiming  strangulated.  This  latter  contingency  would  necesaarily 
subject  the  life  of  the  patient  to  more  or  less  hazard.  In  all  ctts<% 
therefore,  of  hernia)  protrusion,  one  of  the  firnt  duties  of  the  prao* 
titioner  should  be,  if  posiiible,  to  reduce  it,  and  then,  by  judicioua 
support,  to  prevent  its  return.  It*  however,  the  henna  become 
irreducible,  and  increase  during  the  pains  of  labor  so  as  to  place  in 
jeoparily  the  s:dety  of  the  patient^  common  sense  at  once  tells  yoo 
that  the  broad  indication  is  to  proceed  without  delay  to  artificial 
d«»livery,  according  to  the  rule  to  wdnch  we  have  just  referred  atider 
the  head  of  positive  exhaustion. 

ProiajMton  of  the   UntbiUcal  Cord, — This  a  very  serious  oom-  * 
plication  of  tabor,  not  that  it  subjects  the  life  of  the  mother  to  any 
hazard,  for  it  in  no  way  compromiaes  her  safety;  but  tt  b  of 
extreme  danger  to  the  child. 

Mortality/  and  ^rc^uaicy, — According  to  the  statistical  tables  of 


THE  PRINCIPLES  AlH)  PRACTICE  OF  OBSTETRICS.         461 

Dr.  Churchill,*  in  722  cases  of  prolapsion  of  the  funis,  375  children 
were  lost,  or  more  than  one  half.  Many  of  the  coses,  however,  it 
must  be  remembered,  are  taken  from  the  records  of  Hospital  prac- 
tice, and  as  a  large  number  do  not  seek  admission  until  some  time 
after  the  occurrence,  when  the  chance  of  a  safe  delivery  is  dimi 
niflhed,  and  some  not  until  the  cord  has  ceased  to  pulsate — it  follow 
that  this  mortality  cannot  be  regarded  as  a  true  exponent  of  the 
results  of  private  practice.  In  152,574  cases,  prolapsion  of  the  cord 
occurred  629  times,  or  about  1  in  218.  You  observe,  therefore, 
from  these  tables  two  facts:  1.  That  prolapsion  of  the  cord  is  hap- 
pily not  of  very  frequent  occurrence.  2.  That  it  is  extremely  fatal, 
proving  destructive  to  the  child  in  more  than  one  half  of  the  eases. 

Causes. — ^There  are  certain  causes,  which  strongly  predispose  to 
this  accident,  and  may  be  enumerated  as  follows :  a  pelvis,  which 
is  pretematurally  enlarged ;  the  insertion  of  the  placenta  near  the 
mouth  of  the  uterus ;  a  cord,  which  is  longer  than  ordinary  ;  the 
Budden  escape  of  the  liquor  amnii,  especially  when  this  latter  is  in 
unusual  quantity;  a  shoulder,  foot,  or  breech  presentation,  thus 
affording  more  space  for  the  prolapse  of  the  funis,  and  because,  .ilso, 
in  these  latter  presentations  the  fcetal  extremity  of  the  cord  is  nearer 
the  inferior  portion  of  the  uterus ;  a  contracted  brim,  preventing 
the  descent  of  the  head,  and  consequently  predisposing  the  cord  to 
pass  into  the  vagina.  To  these  may  be  added  obliquities  of  the 
uterus,  the  tendency  of  which  would  be  to  incline  the  presenting 
portion  of  the  foetus  toward  one  or  other  of  the  borders  rather  than 
toward  the  centre  of  the  superior  strait,  which  would  necessarily 
from  the  increased  space  predispose  to  a  descent  of  the  cord.  Pro- 
lapsion of  the  funis  is  more  frequent  in  women  who  have  borne 
several  children  than  in  the  primipara,  and  this  arises  from  the  fact 
that;  in  the  former,  the  uterine  walls  have  measurably  lost  their 
tenacity,  and  are  more  relaxed,  and,  therefore,  facilitate  the  pro- 
lapsion. The  above  are  some  of  the  more  prominent  causes,  which 
&vor  this  complication. 

JHaffnosis. — ^The  diagnosis  is  not  difficult,  and  may  occasionally 
be  determined  before  the  rupture  of  the  bag  of  waters,  although, 
as  a  general  rule,  it  is  more  readily  arrived  at  after  the  escape 
of  the  liquor  amnii.  In  the  former  instance,  the  cord  may  be 
felt,  during  the  interval  of  the  uterine  contraction,  through  the 
membranes,  and  the  fact  that  what  you  feel  is  the  cord  may  be 
ascertained  by  the  important  and  characteristic  circumstance  that 
the  pulsations  are  not  synchronous  or  in  accordance  with  those  of 
the  maternal  heart,  but  are  much  more  rapid .f    Consequently,  this 

*  Churchiirs  Midwifery,  4ih  London  Edition^  p.  454. 

f  Scanzoni  notes  an  interesting  circumstance  which,  without  an  explanation, 
might  lead  to  incorrect  diagnosis,  viz.  that  the  umbilical  arteries,  before  entering  the 
cord,  may  pass  for  a  greater  or  less  distance  along  the  membranes — inseriio  funiculi 


462 


THE  PRINCIPLES  AND  PRACTICE   OP  OBSTETRlCa. 


will  demonstrate  very  unequivocally  that  the  tieatings,  if  aiiy  b« 
felt»  are  not  connected  with  the  arterial  By»tem  of  the  niutbcr« 
The  same  rule  will  enable  you  to  distinguish  between  the  pnlan^ 
tions  of  the  umbilical  arteries,  and  those  ramiiying  on  the  lower 
j>ortion  of  the  uterus.  Ailer  the  rupture  of  the  mernbrarious  iisie, 
the  loop  or  fold  of  the  prolapsed  funis  can  be  distinctly  n^cognlxed 
by  the  touch,  and,  therefore,  all  doubt  aa  to  the  nature  of  the  diilk 
calty  will  bo  removed. 

Cause  of  Death  in  Prolapsion  nf  the  Cord. — What  \^  it  that 
cau«ie8  the  death  of  the  child  in  prol!t[xsion  of  the  funis  ?  Tliis  \m% 
question  about  which  there  ha«  existed  a  difference  of  optnioau 
Some  have  supposed  that  it  was  in  consequence  of  the  blood  becom- 
ing coagutate<l  in  the  descended  portion  of  the  cord  ;  but  tt  is  now 
very  generally  conceded  that  dc*ath  endues  from  the  conipreaaon 
exercised  upon  the  funics,  thus  interrupting  the  circidatioD  In^twt^a 
the  mother  and  child.  One  moment,  if  you  please,  upon  thii*  |>oiiil 
of  corupression,  anil  arrest  of  the  circulation.  You  are  not  hustily 
to  coTichido,  l*ccaU8e  the  circulation  is  arrested,  that^  therefore^  tlM 
child  must  necessarily  be  des^troyed.  It  will  sometimes  bappim 
that  Tro  pulsations  can  be  detected  in  the  cord  for  several  minute*; 
the  labor  may  advance,  and  by  a  change  of  position  in  the  prcMmt- 
ing  portion  of  the  foetus,  the  compression  will  be  removed,  and  the 
circulation  re-established.  It  is  well,  therefore.,  to  remcml>er  tliat 
compression  of  the  cord,  with  an  absence  of  pulsation,  does  iiol»  at 
an  inevitable  corjsequcnce,  imply  that  there  are  no  longer  imy 
throes  of  the  fcetal  heart.  Dr*  Arneth,  of  Vienna,  mentions  Hour 
cases  under  his  notice,  in  which  no  pulsations  had  been  detecii»ci  in 
the  cord  for  half  .an  hour  previous  to  delivery,  and  in  each  iustaiMse 
the  child  was  born  living* 

From  what  has  been  already  stated  touching  the  fatality  of  tlilt 
complication  to  the  child,  it  will  become  a  paramount  duty,  iti  all 
cases  of  funis  protrusiort,  at  once  to  announce,  not  to  the  patieat 
herself,  but  to  her  husband  or  some  other  relative,  the  apprebev* 
sioni  you  experience  as  to  the  safety  of  the  foetus.  In  doing  tlik| 
you  will  have  done  nothing  more  than  your  duty;  and  wbeibcr 
the  child  be  saved  or  perish,  you  will  have  liberate*!  yoiii^cl res  from 
all  r^*spon^«ibility,  which  concealment  of  the  fact  would  ba%'«  ini. 
pof^ed*  Fi-ankiiess  is  an  essential  and  very  nece-wary  element  io 
the  eharactcr  of  a  medical  man  ;  and  while  the  object  of  bb  pfO> 
fessi on  is  to  save  human  life,  and  palliate  human  suffering,  yet  it  b 
equally  incumbent  u}>on  him,  when  he  finds  himself  surronDdet]  by 
dangers  placing  in  inunincnt  peril  the  safely  of  his  patient,  can- 
didly  to  dijjolose  to. those  tuost  interested  in  the  issue  of  llie  cajve 
hb  doubts  and  fears. 

nmbilkalis  vthmento^a — eo  Utmt  their  pulsations  maj  be  foU,  aod  jot  tl»«  ootd  not 

be  prvJnjwed 


TRX  FBINOIPLES  AND  PRACTICE  OF  OBSTETRICS.         468 

At  what  Period  of  Labor  %8  Prolapsion  most  likely  to  Occur  f — 
Prdapmon  of  the  cord  may  occur  at  any  period  of  labor — before 
the  OS  uteri  is  much  dilated,  afler  it  is  fully  dilated,  or  before  and 
after  the  escape  of  the  liquor  aranil  The  tendency  of  its  descent, 
however,  is  greater  after  the  rupture  of  the  membranous  sac,  and 
this  circumstance,  therefore,  is  an  additional  motive  why  great 
caution  should  be  exercised  not  prematurely  to  interfere  with  the 
integrity  of  the  bag  of  waters. 

Dreatment  of  a  Prolapsed  Funis. — What  is  to  be  done  in  cases 
in  which  the  cord  is  prolapsed  ?  This  is  an  interesting  interroga- 
tory, and  is  worthy  of  consideration.  If  you  imagine  that  the 
mere  prolapsion  of  the  umbilical  cord  is  an  indication  for  inter- 
ference on  the  part  of  the  accoucheur,  you  will  labor  under  serious 
OTor,  and  be  quite  likely,  with  this  view  of  the  subject,  oftentimes 
to  do  mischief.  There  are  three  conditions  in  which  this  accident 
may  present  itself,  each  varying  from  the  other,  and  requiring  a 
different  kind  of  management : 

1.  There  may  be  no  pulsations,  and,  at  the  same  time,  irresistible 
evidences  of  the  death  of  the  foetus  from  incipient  decomposition 
of  the  cord. 

8.  The  pulsations  may  continue  strong  and  vigorous,  showing 
that  there  is  as  yet  no  undue  compression. 

8.  The  pulsations,  from  being  strong  and  vigorous,  may  become 
more  and  more  weak,  indicating  that  the  pressure  exercised  upon 
the  cord  is  endangering  the  circulation  between  the  placenta  and 
fotuii. 

If  you  will  bear  in  mind  these  three  conditions,  and  give  full 
appreciation  to  each  one  of  them,  your  duties  in  this  form  of  com- 
jAcation  will  not  only  be  simplified,  but  what  is  very  important 
they  will  be  well  defined.  In  the  first  place,  therefore,  if  no  pul- 
sations be  detected,  and  there  be  palpable  evidence  that  decompo- 
sition of  the  cord  has  commenced,  then  the  proof  is  positive  that 
the  child  is  dead.  Under  these  circumstances,  it  would  be  unne- 
ceasary  for  the  accoucheur  to  interfere ;  on  the  contrary,  the  labor, 
all  other  things  being  equal,  should  be  confined  to  the  efiforts  of 
nature,  for  you  have  already  been  told  that,  in  funis  presentations, 
the  only  danger  is  to  the  child,  the  safety  of  the  mother  being  in 
no  way  involved.  Surely  then,  the  important  fact  being  ascer- 
tained— the  death  of  the  child — ^it  would  not  only  be  uncalled  for, 
but  altogether  unjustifiable  to  have  recourse  to  artificial  delivery, 
unless  there  be  some  circumstance,  other  than  the  prolapsion  of 
the  cord,  rendering  interposition  necessary.  Secondly,  as  long  as 
the  pulsations  in  the  cord  are  strong  and  vigorous,  there  is  no  indi- 
cation of  peril  to  the  child,  for  the  reason  that  the  true  element  of 
danger  consists  in  the  interruption  of  the  circulation  through  com- 
pression.   While,  then,  the  force  of  the  pulsations  is  natural,  it  is 


404 


TIIK  PHIKCIPLE8  AND   PRACTrCK  OF 


nmnifest  that  there  is  no  undue  com pregsion  ;  lhrr«?for.  nn 

coi^Hary  to  do  more  than  merely  place  ibu  core] — il"  it  lai 

fiillen  heyond  the  vulva — high  up  in  the  vagina,  for  the  purptmo  «f  ^ 
protecting  it  from  exposure  to  the  atmosphere.    The  third  condl-  , 
lion,  however,  pre<ieiits  difierent  indicavtions,  and  something  nm 
be  attempted  to  prevent  the  effects  of  the  compreMsiorj,  which  am] 
shown  l>y  the  fact  that  the  pulsations  lose  their  ordinary  force,  and 
become  more  and  more  weak.     Here,  if  the  compres^un  coutaaiie, 
there  is  very  gcrious  haasard  to  the  child,  ami   now  the  qn^nioo  ^ 
arises — What,  under  the  circumstances,  is*  to  he  done? 

Jfueh  has  been  said  about  the  reyiosition  of  iVie  prolapsed  IM 
and,  with  a  vieTV  to  accomplish  this  object,  numerous  inatmnieiili ' 
have  been  constructed*  I  have  very  little  confidence  in  aay  of 
these  contrivances.  They  may  somelimes  sucreed  in  ileiLteftiOi . 
hand*,  but  very  frequently  they  fail ;  and,  more  than  lh!%  the  vmf^ 
attemf)t  made  to  replace  the  fallen  cord  is  otlentime*  followed  by 
injury,  not  only  to  the  cord  itself,  but  to  the  adj.ic^nt  soft  parla 
It  U  amusing  to  hear  some  persons  talk  of  the  facility  iritb  whicli 
the  reposition  of  the  funis  can  be  effected  by  the  aid  ut  these  001 
trivances.  Bnt,  gentlemen,  it  is  one  thing  to  talk,  and  cjalie  aooiber  ' 
thing  to  act.  I  have  known  many  a  jdauiiibU^  theory  to  give  way 
and  prove  utterly  negative,  when  tested  at  the  bedside  of  tka 
patienL  The  very  best  instrument,  in  my  opinion,  for  replacJOg 
the  cord,  is  the  dngerf*  of  the  accoucheur.  Let  the  middle  and 
index  fingers  bo  gently  introduced  within  the  mgina;  lh4sj  are 
thus  bronght  in  contact  with  the  fold  of  the  cord ;  this  latter  shoiild 
be  directed  toward  one  of  the  lateral  and  posterior  points  of  tli€ 
pelvis— most  frequently  toward  the  lell  sacro-iliac  syTDphyifui^  for 
the  reason  that  at  this  point  there  is  usually  more  space,  in  oonia* 
qucncc  of  the  greater  frequency  of  the  first  vertex  |»OMtioii  of  tha 
bead.  In  this  way  it  is  sometimes  po£tsible  to  replace  tha  cord 
within  the  uterus,  and  thus  remove  the  compresMon  to  whioh  it 
baji  heen  suhjoctcd.  If  this  can  be  done,  much  good  will  bata 
been  accomplished,  and  the  labor  may  then  be  committed  to  ibe 
resoui-ces  of  nature.  It  must  be  recollected  that  Uia  atl«in|il  la 
refilare  the  cord  should  be  made  only  when  tho  os  atari  ia  waB 
dilated,  the  bead  or  presenting  portion  of  the  foetiisat  the  mMfmot 
strait,  and  Dot  after  it  has  passed  into  the  pelvic  exeavatloii.  Ia 
this  latter  case,  we  have  a  more  efficietit  and  prompt  rmady  ia 
the  immediate  delivery  of  the  child  by  the  tbroeps.^ 


*  I  should  not  omit  to  nieniion  ati  iiigeakNis  piia,  woggmHieA  by  Dr,  T.  GftUkfi 
ThomuR,  lur  Uie  repcwiiJon  of  the  cortl.  It  ooosiBU  MisatiaUy  in  wbal  be  term 
p^turai  (tcattnetiL  The  wornuti,  iu  cnso  of  tunis  proUij;«kxi,  "  Is  ^^Mt4  fiq  Im 
ku4*«9t,  Willi  tho  bead  down  upon  tlie  bed  "*  Dr,  Tbomni  obsenrcs  "dmt  ib«  fssaai 
of  ihw  mridf'nl  (probpsion  of  Uio  cot4)  rvduoe  tbsowclvta  to  liro^  tb»  Alippei^ 
naiurv  of  the  dinjiLit^^  (lari,  ftnd  the  iodined  plsae  off^fvd  il  bjr  Um  Qlvnii^  1^ 


THK  PRIKCIPLSS  AND  PRACTICE  OF  OBSTETBICii.         466 
• 

According  to  Dr.  Ameth,  the  fanis  is  always  replaced  in  the 
Vienna  Lying-in  Hospital  when  the  operation  is  practicable.  The 
plan  adopted,  when  the  head  presents,  and  is  movable  at  the  brim, 
the  06  uteri  being  fully  dilated,  is  to  push  the  funis  upward,  and 
lay  it  in  the  hollow  of  the  neirk  of  the  child.  There  are  forty- 
threo  cases  recorded  in  the  hospital  register  of  this  reposition,  and 
in  thirty-eight  the  children  were  born  alive;  in  three  of  the 
remainder,  the  coixi  was  almost  pulseless  when  returned ;  in  one 
instance,  the  forceps  was  resorted  to  in  consequence  of  inertia  of 
the  uterus. 

Bat  suppose  the  reposition  of  the  funis  cannot  be  brought  almut, 
are  we  then  to  do  nothing  ?  To  remain  satisfied  with  the  failure 
to  replace  the  cord,  and  to  consider  the  abortive  attempt  as  the  full 
measure  of  your  duty,  when  the  evidences  of  compression  are 
beyond  all  perad venture,  would  be  to  consign  the  child  to  great 
peril,  if  not  to  certain  death.  Such  conduct  would  not  only  be 
highly  reprehensible,  but  would  very  properly  subject  you  to 
merited  rebuke,  urUesa  you  had  a  good  and  justifiable  reason  for 
nan-utterferefice.  There  are  two  alternatives  to  which  recourse 
may  be  had  in  a  contingency  of  this  kind — version  and  delivery  by 
the  forceps. 

It  is  extraordinary  that  there  should  exist  among  writers  on  mid- 
wifery 8uch  diverse  opinions  touching  the  propriety  of  these  two 
alternatives;  and  it  is  equally  unfortunate  for  the  young  accoucheur 
that  these  opinions  should  be  recorded  in  the  books,  which  are 
rapposed  to  contain  correct  rules  of  practice,  and,  therefore, 
regarded  safe  guides  in  the  hour  of  doubt  and  embarrassment. 
One  author,  for  example,  inculcates  the  necessity  of  proceeding  at 
once  to  the  termination  of  the  delivery  by  version  "  if  the  child 
be  living,  and  the  presenting  part  remain  high  up  in  the  pelvis." 
The  language  just  quoted  is  that  of  Denman,  whose  name  deservedly 
carries  with  it  great  weight.  Xo  less  an  authority  on  the  general 
question  of  obstetrics.  Dr.  Dewees,  of  whom  our  country  has  reason 
to  be  proud,  holds  that  "  Turning  may  be  had  recourse  to^  if  the 
Qtems  be  sufficiently  dilated  or  dilatable  for  the  operation,  the  head 
being  still  inclosed  within  the  uterus,  and  there  is  no  deformity  of 
the  pelvis."  I  might  array  before  you  the  names  of  other  dis- 
tinguished men  in  favor  of  the  operation  of  turning,  as  a  conserva- 
tive measure  in  prolapsion  of  the  cord.  But  to  do  so,  would,  I 
apprehend,  be  of  little  moment.  It  is  more  impoitant,  I  think,  to 
examine,  for  the  instant,  the  universal  propriety  of  the  rule  ineul 
cated. 

which  to  roll  out  of  its  cavity ;  and,  second,  that  the  only  rational  mode  of  treat- 
ment  would  bo  in  inverting  this  plane,  and  thus  turning  to  our  advantage  not  onl^ 
it^  but  the  lubricity  of  the  cord,  which  ordinarily  constitutes  the  main  barrier  to  out 
[Transactions  Now  York  Academy  of  Medicine,  Vol.  11^  Part  IL] 

30 


406 


ruM  FRficcipr.Es  axu  mxcncB  or  omrwrmm. 


The  r^teniiiblc  and  only  jmtti&i}>lr  argiiment  in  fnvor  of  rmmou 
in  ansoR  such  as  are  uow  uitder  cx^nsidei-atioiu  is  (hat  U  %mU  i^mrd 
the  frhfid  the  bfJtt  mearui  of  ito/ett/,  But  while,  on  tiio  other  tiand^ 
WQ  tiro  |>rom{>tetl  to  do  so  much  for  the  chtld,  we  are  not  to  forgol 
thai  the  safety  of  the  mather  has  c\ik\m^  equdly  urgent,  wbich 
irnnnot  he  lightly  regarded  by  the  accoiicheor.  How  often  ia  th«* 
life  of  the  mother  iuvolved  in  peril  in  the  operation  of  %'<£rpioa,  ami 
how  DiWn^  {Ua't,  docs  this  peril  tcrtiiinate  in  her  death  !  Yoo  f^ee^ 
therefore,  that  in  select ing  the  alternative  you  innftt  bo  goirerfif»] 
not  by  the  abstract  fact  that  tlie  funiw  is*  prohijiHcd,  but  by  a  due 
eon^idemtion  of  all  the  surrounding  circumstances.  Yon  Mrm  to 
consider  whether^  iji  full  view  of  all  the  facts  uf  the  t^m^  h/mi^ 
presents  tlie  greatest  promise  of  safety  to  the  child,  witluMil  eon* 
prominiug  the  life  of  the  parent. 

If  my  own  opinion  be  worth  anything  on  this  qnefrtion,  I  rilomld 
advise  yon,  no  matter  liow  imminent  may  be  the  danger  %o  lb* 
child,  tiever  to  have  recourse  to  versuon,  except  under  the  foUowiii|* 
conditions  :  ],  Tlie  heml  at  the  ^ujieriorMrait  not  having  de^sended 
into  the  pelvic  excavation ;  2.  The  mouth  oftfu*  ntt^nis  sof^  whI 
dilatable,  readily  permitting  the  introduction  of  the  hand  ;  3.  The 
painn  iiiiist  not  be  characterized  by  great  vigor,  for  thi*  wonld  not 
only  Ijc  a  serious  ol>stneJe  to  the  introduction  of  the  lianii,  Vtit 
would  prove  a  substantial  ground  why  version  should  not  ke 
attemj>ted,  for  the  reason  that  effieient  and  regular  contmctMMii 
would  be  likely  to  tern)inate  the  delivery  mort*  rapidly  than  It 
could  l>e  done  l:>y  turning;  4,  There  should  be  no  pelvic  deformllj^ 
4*r,  at  all  events,  vtTV  slight.     It  must  alt*o   l^^  in  mcmwry, 

that,  in  ver?4ioii,  the  child  is  not  unfrefiueiitly  ^  i,  and  oflen- 

times  its  death  is  traceable  purely  to  compression  of  the  oord  durii^ 
t\w  naaniputations,  necessary  to  the  accomf)li4iment  of  the  opef»> 
iioo.  If  the  hetid  kIioiiM  have  passed  into  the  j^elvic  caiily^  nod 
more  es[>eeially  if  it  !<))ould  have  rtaehetl  the  biferior  strait^  thin 
the  indication  would  olniously  be  to  deliver  vvithout  dehiy  by  ihm 
Ibreeps,  care  being  taken  so  to  adjust  the  Instrument  ns  not  to  maki 
yrt^ft'iure  on  the  cord. 

///'mf^rr/wi -7*'. —Hemorrhage  or  flooding  l>efore  the  birth  of  tikt 
child,  will  cor»^titute,  under  certain  circumstances,  an  impartaiit 
cause  of  artiticiai  delivery.  Your  attention  biet  already  ben 
dtreeted  to  hemorrhage  afU^r  the  birth  of  the  (li^tus;  wo  slttU  now 
•peak  of  this  accident  as  it  sonieiimo^  ,  •  "  v  to 

the  expulsion    of  the   child.      As  a^-  ihr 

question  of  ante-part ujn  flooding,  we  shall  proceed  to  couj*ider  that 
form  of  it,  which  is  more  or  less  directly  connected  with  placenta 
prtevia.  Uy  tlie  term  placenta  prievia,  you  are  to  undenttand  the 
insertion  of  the  at\er-birth  either  completely  or  partially  nrnr  ihi 
of  the  womb. 


THX  PBIKCIPLBS  AND  PKACTICE  OF  OBSTETRICS.         487 

The  almost  necessary  connexion  between  this  attachment  of  the 
placental  mass  and  hemorrhage  will  be  pointed  out  immediately. 
The  earlier  writers  promulgated  some  singular  views  in  explanation 
of  the  reason  why  the  placenta  is  occasionally  found  implanted  over 
the  cervix  uteri.  Some  of  them  maintained  that  this  wsis  not  the 
point  of  its  original  attachment,  but  that  when  found  over  the 
06  nteri,  it  was  the  result  simply  of  separation  from  its  former  place 
of  insertion,  and  the  consequent  gravitation  of  the  mass  toward  the 
neck  of  the  organ.  You  are  to  remember,  however,  that  this 
hypothesis,  absurd  as  it  is,  was  the  offspring  of  those  times  in 
which  physiology  w^as  scarcely  in  possession  of  a  name,  and  when, 
ooDsequently,  our  present  advanced  knowledge  of  embryonic 
devdopment  M'as  one  great  blank.  But  even  with  our  pi-esent 
knowledge,  there  is  not  a  general  concurrence  of  sentiment  as  to 
the  tnie  cause  of  placenta  praevia.  I  am  very  much  inclined  to  the 
opinion,  however,  recently  suggested,  that  it  is  owing  to  the  fact 
of  the  fecundation  of  the  ovule  ailer  it  has  passed  from  the  upper 
to  the  lower  portion  of  the  uterus  to  the  immediate  vicinity  of  the 
08  nteri.  This  explanation  at  least  possesses  the  merit  of  plausi- 
bility, and  is  due,  I  believe,  to  Dr.  Tyler  Smith. 

I  have  just  told  you  that  the  placenta  may  be  attacihed  to  the 
neck  of  the  uterus  either  completely  or  partially.  In  the  former 
instance,  the  aller-birth  may  be  said  to  rest,  centre  for  centre,  over 
the  dependent  part  of  the  organ ;  while,  in  the  latter,  only  a  portion 
of  its  border  is  found  there.  But  what  is  essential  for  you  to 
remember  is,  that,  hi  either  case,  there  will  be,  as  a  general  rule, 
more  or  less  hemorrhage.  Indeed,  were  it  not  for  the  flooding 
attendant  upon  this  form  of  presentation,  placenta  pnevia  would  be 
altogether  without  interest.  It  is,  therefore,  because  of  the  serious 
danger  in  which  both  mother  and  child  are  involved  from  losses  of 
blood  in  placental  presentation,  that  it  becomes  a  question  entitled 
to  your  fullest  consideration. 

I  have  endeavored,  when  discussing  that  subject,  to  portray  to 
yon  the  imminent  peril  of  the  lying-in  woman  in  hemorrhage  after 
the  birth  of  the  child ;  and  now  you  will  permit  me  to  assure  you 
that,  kindred  to  that  j)eril,  is  the  hazard  which  life  encounters  from 
the  hemorrhage  consequent  upon  placenta  previa ;  aor  must  it  be 
forgotten  that  the  danger  is  more  momentous  in  the  latter  case, 
from  the  circumstance  that  here,  in  addition  to  the  safety  of  the 
mother,  the  life  of  the  child  becomes  seriously  involved. 

Is  there  a  necessary  connexion  between  placenta  pnevia  and 
losses  of  blood,  and  if  so,  what  is  that  connexion?  This  is  an 
exceedingly  interesting  question  for  tlie  young  accoucheur,  and  its 
solution  will  at  once  ))oint  out  to  him,  not  only  the  true  danger  of 
this  form  of  presentation,  but  it  will  also  demonstrate  beyond  a 
peradventure  the  urgent  necessity  of  unbroken  vigilance  in  these 


4e8 


THK  PRINCIPLES  AND    PRAC 


caaen,  Fo  trying  to  the  intensu  of  boih  mother  and  child,  and  al  thm] 
same  litiie  so  h.iniisin^  to  the  practitioner. 

Well,  there  is  a  eonnestion,  and  it  is  dimply  thiB  :  th©  direct 
of  tht*  heriiorrh;iire  is  the  rupture  of  one  or  more  of  the  itt^rtKl 
plact'Utal  vcsseU*  in  consctpjence  of  the  widenirrg  or  dilatation  of  ^ 
llu*  lUeriue  extrfrnily  or  internal  orifice  of  the  cervix.     You  uril! 
remember,  ivlien  speaking  of  the  gradual  development  of  the  ntcrusi 
undur  the  influence  of  j^estation,  your  attention  wa»  speeially  ili- 
rec'ted  to  the  important  fact,  that,  for  the  iir«t  five  mm 
aec'onunodation  of  the  Rowing  embryo  is  provide<l  for  exr 
by  the  increased  eiipaeity  of  the  fundus  and  bo<ly  of  tlie  gtuvid 
womb;  and  it  is  not  until  after  the  fitlh  njonlh  that  the  cerilE 
of  tlie  orcran  beginji,  through  a  process  of  shorti'uinjr,  to  eontribiite 
its  propni'iion  of  Kpaee  to  the  wunts  of  the  firtus.     If  this  be  reanj*^ 
no,  and  I  think  there  is  no  doubt  of  the  fact,  you  will  at  oooe  peiv 
O0ive  how  irresUtibly,  aa  a  general  rule,  there  b  deduced  from  Uie 
recoUeetiun  of  this  circumstance  a  moht  important  practiced  priitei|ilai 
in  t  onnexion  witi>  the  question  now  under  consideration. 

The  (irinciple  lo  uhirh  I  allude  is  this:  that  in  jdfv^jtta  prtrriOf 
the  hcmorrhafje  mny  cf^nvmence,  not  necessarily  at  the  time  of  labor, 
but  at  tht  siitth  fnonth^  and  may  continue  at  iniertraU  in  mone  w 
IcM  qnanliti/y  until  thf  rompit^tion  a/  the  delivtiy  at  Me  j'  " 
Contniry  to  the  o|»inton  of  Sliilt/^  Caaseaux,  Dr.  Matthews  1 
and  others,  I  have  endenvored  to  show  you  that  the  sburieuttig  of 
the  neck  of  the  uterus  in  pri»gtnincy  crnnmrnmf  ai  fVn  ir/mwc,  and 
not  at  its  vaginal  ejttrttnity.     As  soon,  therefore,^s  this  lOiorteiiing^j 
conniiences,  it  will  generally,  to  a  jrreater  or  le^s  extent,  be  at  tll#] 
expense  of  the  integrity  of  some  of  the   utero*pl:icental  veiaelai 
which,   in  placcfda   /^rcrt^iot,   constitute   an   im|H>rtant   eonnoxtoci 
between  the  ufiper  portion  of  the  cervix  and  maternal  surfact!  of 
the  placental  mass.     I  say  ffcnmdly^  and  it  is,  in  a  |»raetical  |K»mt 
of  view,  and    more   |>artifnlarly  as  regards  a   correct   di 
imiiortant  that  you  should  bear  the  word  in  memory,  for  ;,    -  ^.-i 
sonnet ime^  m^t  with  exceptional  cast;^  in  wAiVA,  in  fyl^ictnta  prmtrk^ 
thar  tM  no  iif/n  of  henuirrhoffe  until  t/ic  commfncemmt  of  iab^  flf  . 
tke  fuli  term  of  ut^ro-t/estatitm. 

When,  however,  the  hle<Miing  commences  at  any  period  betweeO  \ 
the  8i\ih  and  end  of  the  ninth  month,  it  is  well  to  reeollect  that  ib^m^ 
is  nothing  fixed  or  regular  in  its  recurrence.  It  will  somrtiinct  bs  ' 
slight,  again  copious,  and  may  return  at  an  interval  of  a  f* 
nor  is  it  announced  by  any  premonitory  synjptoms,  its  ad v*  : 

ntore  or  leas  sudden.  In  some  cii&bs^  too,  strange  to  say,  throti^li  a 
salutary  dot,  and  the  closing  of  the  exposed  utjero-plaeenlal  v« 
the  woman  will  pass  on  to  the  completion  of  her  pregnancy  witli 
the  inicrpojiiiiioa  of  science.  But  these  are  extremely  rare  uiataDon^ 
and  shoidd  in  no  way  be  relied  upon  as  a  reason  for  inaction  on  the 


THK  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS. 


I 


part  of  the  accoucheur*  On  the  contrary,  it  will  be  his  imperative 
duty,  as  wc  shall  state  under  the  head  of  treatment,  promptly  to 
interpose  as  soon  as  he  becomes  aware  of  the  hemorrhage,  no  matter 
bow  slight  it  may  be  at  its  inception.  The  bleeding  in  cases  of 
pla<:eu(a  prmvia  has  not  been  improperly  termed  mmi^oidabk^  in 
contradistinction  to  another  form  of  hemorrhnge  during  gestation, 
designated  a^culentaL  In  t lie  latter  instance,  the  loss  of  blood  is 
due  to  a  sudden  and  partial  separutiou  of  the  placenta,  when  situ- 
ated in  other  portions  of  the  uterus  than  over  the  cervix,  and  the 
separaiion  is  traceable  mainly  to  falls,  shocks,  metital  emotions,  or 
sudden  congestions.  Tins  accidental  hemonhage  may  arise,  also, 
from  rupture  of  one  or  mure  vessels  of  the  umbilical  cord*  There 
is  one  point  essentiat  to  note  in  connection  with  p^e?i/a/>rcei'*a| 
more  particularly  when  the  after-birth  rests,  centre  for  centre,  over 
the  cervix  uteri,  iuid  the  point  to  whic!)  I  allude  is  this:  tM  ihemor- 
is  more,  profuse  at  the  time  of  labor  than  if  it  shouhl  occur 
fpftviously  to  the  full  term  of  gestation^  for  the  reason  (hat  (lis 
effect  of  a  labor-pain  is  to  detach  from  t/te  cervix  a  portion  of  t/ie 
ital  masjs^  and  comequenUy  &epo9€  a  larger  surface  of  the 
ro-placental  vessels  /  and  these  tdero-placental  vessels^  it  must  be 
refnetnbered^  ham^  at  the  compkitofi  of  gestation^  attained  their 
maximum  of  development  ;  and^  in  this  latter  fact  alsoy  will  be  seen 
ofi  additional  reason  for  the  greater  profusentss  of  theftoodifig  at 
the  period  of  ordinarg  parturitiofi. 

It  will  .Hometimes  happen  that  the  placenta,  through  the  sponta- 
neous efforts  of  nature,  will  be  expelled  previously  to  the  child;  in  this 
caae^  the  head  ot^the  fcetus,  responsive  to  the  contractions  of  tlie 
won»b»  may  act  as  a  wedge  against  the  bleeding  surface  of  the 
cervix,  and  thus  most  opportunely  arrest  the  hemorrhage.  Again  : 
if  a  woman  have  an  extraordinarily  capacious  pelvis,  and  the  con- 
tractions be  marked  by  great  vigor^  the  entire  ovum— child,  phu 
cenln,  and  niendjranes — may  be  suddenly  thrown  from  the  uterus, 
and  in  lias  case,  too,  if  the  vacated  organ  contract  promptly  there 
will  be  no  floo*rmg.  Tliese,  however,  it  is  to  be  recollected,  are  instan- 
ces contrary  to  the  general  rule.  But  as  they  have,  and  will  again 
occur,  it  is  incunil>ent  to  bear  them  in  memory.  When  the  expul- 
sion of  the  after-birth  is  preceded  by  that  of  the  child,  it  is  impor- 
tant to  recollect  that  this  is  the  result  altogether  of  the  strong  con- 
traetionsof  the  uterus,  which,  in  the  first  place,  have  been  sufficient 
to  detach  the  placental  masn,  and,  secondly,  to  throw^  it  into  the 
world*  In  these  instances,  if  one  of  the  extremities  of  the  ovoid 
should  present,  the  delivery  is  usually  accomplished  without  dcla), 
and  the  case  terminates  auspiciously,  for  the  simple  reason  that  ihe 
separation  of  the  placenta  and  the  subsequent  part  of  the  labor  has 
been  effected  in  accordance  with  the  natural  effort.  Malpositions 
of  the  foetus,  however,  arc  not  at  all  infrequent  in  placenta  pnevifii 


470         TUM  roiXCtPLES  AND  FRACTICE:  or  OBSTStRICa 


and  thw  uliould  be  rememWn^d^  in  order  Uial  i«l'  •' 

thuir  recugiiiiion  may  be  prompt.     Tin**  iorni  ofjn  ,  . 

irily  enhances  the  danger  to  both  mother  and  child* 
iSt/mpiom^.^U  t\  pregnant  remale   hfivc    hcniorrh^igR  fltnn 
ntcrus,  at  uny  time  between  the  ^ixth  and  ninth  month  of  cfeitalk 
and  on  inve^tigatian  it  be  ascertained  that  theie  is  nti  r^ 
fbr  the  bli*edint^^  tind  if  the  blood  flow  in  i&udden  g\\s\  nveiMl 

vala,  even  dnrittg  the  c)tiieiiii)e  of  sleep,  then  the  Appn'brQaion  iiuijr 
irific  that  the  hemorrhage  h  due  to  placenta  prrovia.  If  the  betttorw  i 
Tliage  ooeur  at  the  time  of  full  piuturltion,  und  there  \m  un  abeefi€#^ 
of  any  of  the  caa^es  of  accidental  bleeding,  and  if  the  discharge  of 
blood  become  more  profuse  as  the  labor-throca  JMlvance,  it  U  valoA- 
ble  f>ret<umptive  evidence  that  the  placenta  h  over  the  tnoutb  of  lb© 
utorns, 

JJktf^nosis, — ^In  order  that  all  nneertainty  may  be  at  an  eml, 

be  question  of  phiecnta  pneviti  placed  beyond  a  donbt,  it  u  wclllo 
collect  that  tliere  it^  one  means    by  which    the  accoudiaur  cam 
arrive  with  full  truth  at  an  accurate  diagnonis*;*  ami  tUb  ccm«sU  ia 
the  fact  that,  if  the   os  uteri  be  dilate<l  ^utficicntiy  to  admit  ibft,. 
introduction  of  the  finger,  he  can  feel  <piite  distinctly  the  pJUKTVtita. 
renting  over  it.    The  contact  of  the  tinger   with  liiii  tnaas  wlQ 
impart  a  8oi\,  doughy  scnsatinn.     It  is  pos!»ible,  howevrr,  trtlluiiti j 
due  caution,  to  mistake  tor  the  after-birtfi  a  clot  ur  eoagitlinii  i 
bloud.     If  it    be   the    latter,  it  will   be  fbnnd  movable,  and 
be  readily  brought  away  by  the  linger.      Tiiere  will,  ocea^itmally, 
exiHt  around  the  o«  tUtri  veg«?tntionfl^  cither  syphilitic  or  catiiwr«MH, 
and  thimv  too,  may   through  inattention  be  eontbunded  with  tlMl 
plncenta.     This  hitter  body  may  al«o  cornet inics  be  rcoognisinl  bjr  j 
the  tinger  through  the  pariclcs  of  the  cervix,  even  when  there  ij^iiii  ( 
^  y^latation  ;  but  to  accomplish  this  will  ret|uiro  great  niecty  of  loach, 

nd  a  large  experience  in  explorations  of  thiti  kind.  It  is  well,ali0^tj 
to  recollect  that,  in  pbu^cnta  piirvia,  the  v  '  T  the  %agiii»i 
become  greatly  engorged,  sympathizing  in  tin  t  with  Uioit' 

'  the  lower  ^gment  of  the  uterus^  and  these  arterial  palMttioiu  an 

larked  by  increased  force, 
IWatmtnt, — The  most  important  and  intereating  eirimtB«llsiQ9 1 
connected  with  f^aifenta  priJPvia  is  nnqnestionably  its  managciiWBl ; 


♦  A  ccorditifp  to  statistical  compibtbnn  from  the  joonml  oft 
St  BrPHbu,  tnadt'  by  Dr.  V«»n  GliRvytiS'kK  <Me*i  CcMir  Ztp.  \  S  l^ 

(&,)  iiluceutA  |mi:vii»  f^ceiirs  tiul  quite  ji»  nrcquLTUly  »»  fitnliM   l  r 

onsGfl  hnvrnir  tx-^'D  tlivre  ubservcd  in  10,440  dcliveji^'m,     The   t 
niAthei]  by  hemdrHuigt*,  iJuHnif  llie  ItitUT  third  of  prrgnnr 
Uie  fourth  or  hflU  HKmtb.     A  oertMin  diu^iiOtiiu  in  qoI  iKm^ 
osn  be  fcU.     T1m>  T-ct  tlmt  tliia  AbnomiUy  occum  ftlmost  lx 
1e«4s  to  the  hyp<ithc»i»  of  di?fe<;tive  rrorgjinijcaliun  of  Ihd  won 
pr«;ifii<inc)e«  fti]tuwing  eiich  other  ia  too  short  •  timt,  or  tlofo  itidiiimmhUjry  aimI  a^ktt 
iDorbid  contiUioui  of  the  ssmoi 


>l 


TBK  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         471 

for  ftlthongh  the  Iktality  of  these  cases  is  oomparatively  great  both  to 
mother  and  child,  yet,  through  prompt  and  judicious  treatment,  it 
may  be  much  dimhiished.*  Toa  may  be  called  to  a  case  of  this 
kfaid  at  any  period  before  the  completion  of  gestation,  or  at  the  time 
of  labor,  when  the  term  of  pregnancy  has  been  accomplished,  and 
parturition  regularly  commenced.  We  will  suppose,  in  the  first 
instimce,  the  former  case.  The  female  may  have  reached  the  sixth, 
seventh,  or  eighth  month ;  she  discovers  that  she  is  losing  blood 
from  the  vagina ;  it  increases  from  day  to  day,  and,  in  her  anxiety, 
riie  sends  for  one  of  you. 

What,  under  the  circumstances,  are  you  to  do  ?  The  first  inquiry, 
which  would  naturally  suggest  itself  to  the  mind  of  an  intelligent 
physician,  would  be — What  is  the  cause  of  the  bleeding  ?  Is  it  the 
result  simply  of  a  threatened  premature  delivery  ?  is  it  occasioned 
by  some  sudden  shock  or  injury,  thus  presenting  an  example  oi'acci- 
dmtai  hemorrhage  ?  or  is  it  traceable  to  the  fact  that  the  placenta  is 
inserted  over  the  neck  of  the  uterus  ?  These  are  the  questions  to 
be  determined,  and  on  their  solution  will  depend  the  special  treat- 
ment indicated.  If  you  be  of  opinion — judging  from  the  antecedent  as 
well  as  the  accoin|)anying  circumstances  of  the  case — that  the  bleed- 
ing is  due  to  jjlacenta  prcevia^  then  I  would  suggest  to  you  to  pur- 
sue the  following  course :  the  patient  should  be  placed  on  her  back, 
with  the  hips  slightly  elevated ;  she  should  repose,  not  on  a  feather 
bed,  but  on  a  hard  mattress ;  the  room,  if  in  winter,  not  to  be  above 
a  medium  temperature ;  if  in  summer,  the  windows  and  doors 
should  be  oftened,  in  order  that  a  pure  and  refreshing  current  of  air 
may  be  promoted. 

It  is  most  important  to  guard  the  patient  against  all  excitement, 
whether  of  body  or  mind.  If  fear  should  have  seized  her,  and  the  ner- 
vous system  become  in  consequence  much  disturbed,  one  of  the  best 
medicines,  under  the  circumstances,  will  be  the  comforting  assurance 
of  her  medical  man  that  he  will  carry  her  safely  through  her  tribu- 
lation. How  often  is  it  in  the  power  of  the  accomplished  physician 
by  a  dexterous  use  of  the  iufiuence  he  possesses  over  his  patient,  to 

*  Dr.  Schwarz,  having  examined  the  official  returns  made  by  Hesse  Cassel  prac^ 
dticNieni,  states  that  during  a  period  of  2U  years,  519,328  births  were  reported  by 
ISO  aoooueheurs,  and  among  tliem  332  cams  of  placenta  pnevia,  or  1  in  1564  labors :  the 
numbers  varying  from  8  to  28  per  annum.  The  mortality  depends  upon  the  degree- 
of  the  presentations  of  the  placenta,  and  also  u}x>n  the  mode  of  treatment ;  of  the  332 
cases  reported  by  the  Hes*o  pnictilioners,  86  dlt-d,  or  I  in  3*86.  These,  it  must  be  re- 
membered, embraced  every  variety  of  the  accident,  partial  and  complete.  This  cor- 
robomtcfi  in  a  remarkable  manner  ihe  statistics  of  Prof.  Simppon,  who  shows  front  data-. 
famfehed  by  lying-in  honpitals  and  practitioners  of  large  experience  that  the  general 
mortiUity  of  the  accidiiit  is  1  in  3  0.  and  also,  with  the  mortality  of  cases  onume- 
mted  by  Prof.  Trask  (Prize  ewwiy  on  placenta  prieviu,  Transactions  American  Medi- 
cal Association,  1855),  which  was,  237  deaths  in  938  cases,  or  I  in  3*95.  The  mor- 
tality after  turning,  according  to  Prof.  Simpson,  is  144  iu  421  cases  or  1  in  2*9;  thatt 
afforded  by  Profl  Trusk*8  record  is  1  in  3  4. 


472 


THE   PRIXCIPLES   AND   PRACTICE  OF  OBSTrTHlCa 


fortify  a  porturbcMl  »iiirit,  and  reaiilnijite  a  drooping  h«Art !  It  im 
highly  necessary  that  constipaiion  bltouitl  he  g^uurded  againjiit,  far 
the  very  act  of  draining  in  the  effort  at  ik^focation  will  have  a  Ion* 
(loncy  to  UHTenjic  the  hleoding.  Untler  the  circumstances,  fibottld  a 
iiiuvenicnt  W  Intiicated,  1  >jhi»iil«l  greatly  prefer  to  enemata,  the  fol* 
lowing  su)ulior^  a  tahlespoorifnl  of  which  may  bi5  taken  onee  in  two 
hourfi,  ualil  an  aperieut  aetioit  i«  pr.Mhuinl ; 

n 

Sulphat.  magrnesil©    5  '• 
Infus.  foL  RoKir.  f.  5  vUj* 

Ft.  soU 

This  h  a  combination,  which  1  have  employed  with  ufnial  advui* 
tage  in  cases  such  as  we  are  now  c:oTi8i<lerifiir.  Tlie  patient  iihoulJ  be 
reslrirted  to  cold  diinkt%  nothir»g  lK»tter,  if  it  agree  with  tttestomacli, 
than  tccil  lemonade.  The  diet  bland  and  unatimulating.  Atterlbv 
t>owels  have  been  gently  acted  on,  I  have  recently  experienced  in 
two  ai&L'f^  in  which  the  hemorrhage  occurre*!  at  the  sixth  aik] 
seventh  montht^  re«pei'tively  of  gestation,  decided  benefit  frotn  the 
adminiMration  uf  the  sulphate  of  the  pemxydc  of  irtm,  the  hieimK 
aiatio  pro^icrties  of  which  are  now  well  established ;  from  ftve  w 
tilYeen  drop!*,  three  times  a  day,  in  a  wine-ghr^  of  cold  water.  To 
prevent  injury  to  the  teeth  it  shouJd  l>e  taken  through  aglaim-labe. 
One  point  you  are  noi,  to  neglect— when  the  howeNare  to  bo  moved, 
or  the  urine  evacuated,  a  bedpan  must  be  employed.  On  oa 
account  its  the  patient  to  be  permitted  to  nm  the  chair ;  the  very 
eflort  may  l>e  folh»wed  by  serious  trouljle  in  eonsequetioe  of  i^ 
crea?»e<l  hemorrhage.  Well,  tliewe  are  the  preliminary  moa«an»  ta 
be  adapted;  but  suppose  the  bleeding,  notiviihstanding  lh«*e 
measure!*,  should  continue,  and  so  profusely  as  to  affet?t  the  J^lrengtb 
0f  the  patient,  and  involve  apprehensions  as  to  the  general  bmi^* 
Then,  in  addition  to  what  has  already  been  suggested,  h  will  b» 
proper  for  you  to  institute  a  c-areful  vaginal  examination  with  a  viev 
of  ascertain  if  ig  the  condition  of  the  oe  ulerl^  whirh  wiU  eitA^r  h$ 
girfficktttit/  di/afed  to  enable  yoiL  to  accomplUh  ddhtry^  or  it  %tiU 
not  fw  no  tlilaltd,  h\  the  hitler  ca»is  the  bleeiling  coiitinuing  in 
exhausting  prufu^encKS  and  the  os  nieri  not  at  all  or  but  alightly 
dilated,  you  have  an  important  remedy  in  the  tampon, 

I  cannot  nnderstand  why  some  clever  and  practical  authora  am 
opp«>sed  to  the  etiiployment  of  the  tampon  in  an  emergency  of  tUia 
kind,  lor  the  arguuienls  they  urge  are  certtiiuly,  in  my  judinnenl, 
without  the  slightent  basis.  As  a  principal  rd>jection,  they  main 6ttii 
that  this  instrument  will  be  likely  to  protluee  inlenial  hemnrrhage^ 
and  thus  destroy  the  patient.  Those  who  raise  this  objection  dono^ 
I   think,   without    sufficient    thought,  for   it   is   quite  c      '  tiai 

although  internal  flitodhig  might  posjsibly  follow  the  ent|     _         i  of 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         478 

the  tampon  in  accidental  hemorrhage,  yet  there  is  no  ground  for 
apprehension  that  it  will  ensue  in  placenta  prtevia,  for  the  reason 
that  the  bleeding  surface  is  below^  and  the  blood  does  fiot  accumu- 
late within  the  cavity  of  the  tUerus^  but  collects  between  the  tampon 
and  that  portion  of  the  cervix  from  which  tJie  placenta  liasj  in  part 
or  totaUy^  become  detached.  So  far,  thei'efore,  from  th w  agent  prov- 
ing injurious,  I  regard  it  as  one  of  the  most  efficient  alternatives 
to  which,  under  the  circumstances,  the  accoucheur  can  have  recourse. 
The  very  principle,  too,  on  which  the  tampon  exercises  a  salutary 
influence  is  one,  which  is  directly  opposed  to  the  occurrence  of 
internal  hemorrhage ;  for,  by  a  uniform  and  gentle  pressure,  it 
oanses  a  coagulum  which  acts  for  the  time  as  a  check  to  further  loss 
of  blood.  Thus,  you  see,  you  possess  in  this  agent  an  admirable  tem- 
porary remedy.  If  the  os  uteri  be  undiluted,  and  the  bleeding  con- 
tinue profusely,  the  patient  must  of  necessity  sink  unless  there  can 
be  something  to  hold  it  in  check.  For  this  purpose,  I  repeat,  my 
great  faith  is  in  the  tampon,  or  plug,  as  it  is  sometimes  called. 
Now,  an  important  question  aiises — How  long  is  the  plug  to  be 
employed?  My  answer  is  until  the  os  uteri  is  sufficiently  dilated 
to  enable  you  to  introduce  the  hand,  turn,  and  deliver. 

Version  I  hold  to  be  the  cardinal  remedy  in  placenta  prtevia,  if 
the  head  of  the  foetus  be  still  at  the  superior  strait,  and  the  mouth 
of  the  womb  will  allow  the  introduction  of  the  hand  ;  on  the  con- 
trary, if  it  should  have  descended  into  the  pelvic  excavation,  the 
indication  is  at  once  to  resort  to  the  forceps.  But  how  are  you  to 
know — if  you  employ  the  tampcm — that  the  os  uteri  has  undergone 
dilatation  sufficient  to  justify  artificial  delivery  ?  This  fact  can  only 
be  ascertained  by  occasionally  removing  the  tampon,  and  making  a 
digital  examination ;  the  time  as  well  as  the  necessity  for  doing 
this  should  be  regulated  by  the  frequency  and  character  of  the 
pains.  There  is  an  additional  advantage  in  the  employment  of  the 
plug,  and  it  is  this — its  very  pressure  against  the  lips  of  the  uterus 
will  excite  action  of  the  organ,  and  thus  promote  contractions 
which,  of  course,  will  tend  to  hasten  the  opening  of  the  os,  an 
object  so  desirable  in  cases  such  as  we  are  now  discussing. 

The  tampon  may  consist  of  small  pieces  of  old  linen,  or  fine 
sponge,  or  what  is  still  bvtter,  if  at  hand,  carded  cotton-wool — and 
they  should  be  gently  introduced  into  the  vagina,  piece  after  piece, 
until  the  entire  passage  is  tilled — the  whole  to  be  retained  in  place 
by  means  of  a  T  bandage.  There  are  several  n)odes  of  introduc- 
ing the  plug.  I  adopt  the  following :  the  index  finger  of  one  hand 
being  introduced  into  the  vagina,  the  palmar  surface  uj)ward,  I 
seize  with  an  ordinary  calculus  forceps  a  small  piece  of  the  mate- 
rial to  be  employed,  and  direct  it  along  the  finger  as  far  as 
the  OS  uteri,  against  which  I  exert  slight  pressure;  and  so  suc- 
ceeding pieces  are  introduced  until  the  canal  is  quite  filled  up. 


THE  PBINC1PLK8  AND  PRACTICE  OF  OBSTfiTRICS. 


When  neceflsary^  they  are  to  be  removed,  and  replaced  by  dJbcr 

pieces. 

An  efficient  tampon  will  be  iho  indta*^rubber  bag,  filled  with  io©- 
water  (iho  colpeurynter). 

Let  iti  nuw  ii(up|»o8c  that,  on  withdrawing  the  ping,  tt  iihoald  bt 
a«coiiHirud  tlint  ihe  moutli  of  the  womb  in  ftoft  and  dil '  vr 

miuir»g  tire  iiitroduclion  of  tlio  hmul  without  the  fe.ir  i>: 

how  Jire  you  to  proceed  with  the  doliwry  ? 

I  rec"Oiiimend»  in  case  you  should  undertake  xhv  \ri-jMn  <*  mu* 
fa?tu»,  to  proceed  aw  follows :  Carry  your  hatid  cautiously  thnmifh 
the  vagina  to  the  month  of  the  nteiu*  — here,  of  connse*  yi" 
in  eonUict  with  the  placenta,  which  b  resting,  more  or  lv>  , 
this  portion  of  the  organ.  In  a  word,  it  oecluden  the  of>eniiig 
thro\ii,'h  which  your  hand  is  to  enter  the  uterine  ruvrly.  Make  a 
slight  circuit  with  your  finger  around  the  dilated  o«,  and  if  you 
can  tind  a  portion  of  the  placental  Murfiice  wliieh  Unri  b«Hfiiii« 
detached  from  the  cer^'ix,  then,  without  hi-Bitation,  select  tliti  «» 
the  point  of  etFtnmct%  and  immediately  introtlnce  the  hand  (*»r  tbe 
purpose  of  bringing  down  the  feet*  But,  on  the  c»»itt3ary%  if  yo« 
cannot  iletoct  the  |uMnt  at  whirh  the  detachment  Inn  oerurrrd, 
then  my  advice  to  you  is  at  once  to  carry  the  hand  immediately 
through  the  body  of  the  placenta;*  having  thus  gained  admi«S3(iii 
into  the  cavity  of  the  uteiun,  i»tHk  for  the  fi-ei,  Lring  tLi*m  ilawn* 
and  thu«  terminate  the  di*llv<My,  What  it*  thi^re  object itmnble  ui 
tlm  practice  ?  You  mu^t  remember,  in  the  tir^t  place,  that  itvti  lii lef 
mte  in  Reriona  [KJtjl  — fiwuj  Any  f«  every fhimj^  and  tho  sooner  Urn  iltfr 
very  is  actHimpli^hed,  the  greater  will  be  the  chancer  of  t^afety  to 
both  mat  her  rin*l  *'l)i"d.  If,  therefore,  by  protnjit  and  sncecMful 
extraction  of  tlie  fcptun,  you  cause  the  uterti*  t«»  contract— and  IhU, 
under  ordinary  circtirnstancef*,  will  be  the  natural  result — have  yon 
not,  by  thus  efficiently  eloj^ing  the  mouths  of  the  iitero*placefifal 
ve*welK,  aehievinl  the  very  object  most  essmfud  to  the  safety  of 
mother  auil  child — the  i>€nnanent  arrest  of  t/te  hrmorrha^f 

As  I  liave  already  stated,  the  true  and  only  danger  of  pbcmto 
pmnia  is  in  the  losses  of  bhiod  it  oceanona.  Therefore,  if*  it  WO/i 
the  part  of  wind onu  the  moment  the  opportunity  ooeur^  to  do  that 
very  thint:  whi<'h,  under  iho  contingency,  \^  moj^t  lik*-!  id* 

pli»h  the  greatest  amount  of  g«Hxl — //j*  fjnmipt  tcUfuL  tlm 

/txtiM  frtnn  thr  utrrme  cavity  f     I  think  &o,  and  it  \»  for  thiii  %n\y 

•  I  om  »w«rc  thnt  in  thb  adTioe  I  illffor  with  montof  the  -  :liodlMi; 

IntI  f  iitn  qiitt4»  iiiirv«  T  am  ri>fl>t     TJie  oUJt^tbns  tir^Mj  bj  t  •  pr^eticv 

hietitciiini  Mr«  tWfHMd  :  l>»t,  Tli(^  dilticulty  ni  ptriu'if«ttiit^  lli»i  (limvuu*;  24,  TiM 
iuoreaac^  H«k  to  tlie  cKihl  t'mm  InccmtioiiA  uf  litis  body.  \n  reply  to  Urn  fffil  %^^^fa> 
iUm,  I  m*i5d  urily  »ay  Ihot  I  Itiivv  utK'Otiiit/'reit  vvTy  ltUl«^  irifScuhy  in  pfuc^imttftf  ti* 
mtkm  \  Rtiit  lu  Oie  (k^eotiU,  1  woiilii  aimpty  fi^niurk  ttiai  K\m  v\M  \»  «rX|iOiiMl  lo  Xkf^ 
Qirwt  kmmiQcnt  pcHl  by  dobiy,  ojid  thi^  bfct  altcnuitlre  In  ihcso  cftvm  b  '"i**rtftH 


THE   PRINCIPLES  AND   PRACTICE   OF   OBSTETRICS* 


476 


stantia)  reason  that  I  commend  the  practice  just  alluded  to.  With 
a  due  degree  of  caution,  the  well-instructed  accoucheur,  as  Roon  aa 
be  has  seiis^d  the  feet  of  the  child,  and  during  the  progress  of  hia 
tructions,  will  be  enabled  to  guard  against  inertia  of  the  uterus, 
and  having  accomplished  thedt^livery  of  the  fcctus,  he  will,  through 
proper  attention  to  hia  duties,  have  thy  gratification  of  txiiding  the 
source  of  tlie  hemorrhage  arrested  by  the  proper  contraction  of 
the  organ.  But  suppose  you  deem  it  necessary  to  thrust  your 
band  throngb  the  placenta,  or  you  sbould  be  enabled  to  detect  a 
portion  of  its  border  separated  from  the  cervix,  and  select  tliis  as 
the  point  of  entrance  into  the  uterine  cavity,  in  cither  case  the 
interesting  que«tion  arises— What  are  you  to  do  with  the  placenta? 
My  advice  is — to  pay  no  sort  of  attention  to  it  /  bring  down  the 
€t^  deliver  tht  child,,  and  then,,  if  the  expuhion  of  the  afttr-hlrth 
ioitld  not  prompthj  follow^  carri/  up  the  hand  and  bring  it  ateay* 
Artifidal  Detachment  of  the  J^laeenta, — It  is  proper  that  I 
should  here  allnde  to  the  plan  of  artificial  detachment  of  the  pla- 
centa, suggef^ted  ]>y  Dn  Simp<ion.  This  eminent  practitioner,  in 
cases  in  which  turning  cannot  be  bad  recunr.se  to,  inculcates  the 
practice  of  separating  the  aller-birth  from  its  surroiuKling  attach- 
ments ;  and  he  i*oenis  to  have  been  led  to  this  mode  of  procedure 
frr»m  contrasting  the  diminished  niortality  in  cases  in  whirh  the 
pbicc*nta  was  spontaneously  delathed  and  expelled  previously  to 
the  birtb  of  the  child — it  being  mueh  less  than  under  the  optTation 
of  version.  It  does  seem  to  me  that  Prof.  Simpson,  in  his  estimate 
of  artificial  separation,  has  not  taken  sufficiently  into  view  the 
wide  difference  between  spontaneous  and  artificial  deta(*fmicnt. 
The  former  is  the  work  of  nature— tbe  act  she  accora|»lishes  throngh 
the  force  of  uterine  contraction,  and  it  is,  also,  throngh  these  very 
contractions  that  the  mass,  after  being  spontaneously  detached,  is  in 
the  same  manner  expelled.  It  is  not  strange,  therefure,  that,  under 
these  circinnj^tanees,  thia  i^pontaneous  eflbn  of  nature  should  prove 
an  admirable  hiemostatic  adjuvant  in  the  profuse  bleeding  of  pla- 
centa pi-aevia.  Does  not  the  very  same  thing  occur  in  ordinary 
labor,  so  far  as  the  separation  of  the  after-birth  is  concerned  ? 
Pray,  bow  is  this  mass  detached,  no  matter  where  it  may  be 
situated  within  the  uterine  cavity,  except  through  the  successive 
contractions  of  the  organ  ? — And  do  not  these  very  contractions, 
because  they  are  in  pertect  consonance  with  the  mechanism  of 
nature,  guard  the  pai-turient  woman  against  an  attack  of  liemor- 
rhagc?  But  su[>iiose,  with  a  view  of  illustrating  this  point  more 
fully,  the  accoucheur,  after  the  birth  of  the  child,  should  attempt, 
by  prcmsiture  and  forced  tractions  on  the  umbilical  cord,  to  hun-y 
the  operations  of  nature,  and  tht^reby  cause  an  nrtitrcial  drtnch- 
ment ;  would  there  not,  as  a  necessary  consequence,  in  ninety-five 
eases  out  of  one  hundred,  be  more  or  less  profuse  bleediug  ?     XJn- 


476 


THK   PRINCIPLES   AND   PRACTICE    OP   OBSTBTRIC8. 


donbtedly  such  ivould  ha  tfie  result,  luid  there  b,  in  mj  jadguii;Ol» 
a  fit ri king  analogy  between  ibe  two  instances, 

Prntl  Simpson  is  alHo  of  opinion  thai  the  detadied  portioa  of 
the  phioonta  con&titutes  nhnofit  exch)siv(*ly  the  bleeding  surface, 
and  it  m  mainly  on  thi»4  hypotfie.His  that  is  founded  the  practirc  he* 
reconi mentis ;  but  if  he  be  right  in  thif*  conjecture,  how  are  wu  lo 
explain  the  oceurrenee  of  profuse  post-partuni  hemorrhage*  iitirr 
the  placenta  has  been  cxfK'lled?  Will  it  be  argued  that,  in  pbi- 
centu  y)rievia,  we  have  one  kind  of  bleeding  surfnce,  and  io 
hemorrhage  after  the  expulsion  of  the  after-bitth^  another?  Tb« 
great  bleeding-surface,  as  I  have  already  toUl  you,  ronM<«U 
essentially  of  the  mcro-[»laecntal  vessels,  and  is,  therefore,  strictly 
uterine^  and  not  [iTacental ;  at  least  it  ^eems  to  me  that  this  is  tbo 
main  nouree  of  the  hemorrhage  the  quantity  of  blood  paiFtiig 
from  the  separated  portion  of  the  after-birth  being  (juite  ui»igQlft<^ 
cant.  The  view  that  the  hemorrhage  is  derived  almost  entirdy 
from  the  detaehed  portion  of  the  ptacent:i^  and  not  from  the  tltrro- 
placental  vessels,  was  al><o  maintained  by  the  late  Professor  Ilami)* 
ton,  of  Edinburgh.*  It  is  proper,  however,  to  remark,  that  tl*a 
opinions  with  regard  to  the  ^oitree  of  the  hemorrhage  in  plat^eitm 
pripvia  are  conflicting,  although  the  geneml  belief  is  that  it  it 
derived  from  the  ntenn^.  Without  mentioning  other  aiitburtties 
it  may  be  well  to  state  thfit  Dr.  I^obert  Lee,  of  London,  \s  one  of 
the  sturdiest  udvcx'utes  uf  the  dnetnne  that  the  blood  pruectttl* 
from  the  uterine  sinuses,  while  Dr.  Had  ford,  of  Manchester^  belierei 
that  it  comes  both  from  the  ]>Iaeenta  and  uterus,  altbougli  (he 
larger  <[unntity  is  furnisficd  by  the  latter  organ* 

One  things  howe\er,  is  very  certain,  that  the  treatment  of  pla- 
oenia  pnevia— more  especially  ^inee  the  suggestion  of  PrckfeftMr 
Simji^on  of  detaching  the  |>laeunta  a**  a  remedial  resource — has  prcK 
voked  a  very  bitter  cmitroversy — indeed,  in  some  instances,  the 
contest  has  assumed  u»rrui>iakable  t^vidences  of  what,  in  phdn  lan- 
guage, may  be  en  lied  strong  personalities,  a  feature  always  to  be 
Avotiled  in  scicntiiSc  discussions.  lu  the  fierce  conflict  of  tlie 
political  arena,  such  episodes  are  more  or  less  in  keeping  with  tilt 
subject-matter,  but  they  t^hould  tind  !io  fmjlhold  in  a  profession  likt 
ours,  inten<led,  through  the  development  of  truth,  to  confer  bealtk 
and  blessings  on  the  human  family. 

Dr.  Dames,  so  well  known  through  his  important  oontHlmtJotis 
to  obMetric  science,  is  opposed  to  any  attempt  at  forced  effort  for 
the  purpose  of  detaching  the  placenta,  and  we  are  hni*py  to  tltid 
him  so  c<»nservaiivo  on  this  intei^sting  point.  Nothing,  in  my 
opinion,  will  justify  a  forcible  introduction  of  the  hand  into  the 
Qterine  cavity — for  violence,  under  these  circumstaooes^  will  tooiir 


t  Ptttotioal  ObienratioD^  fid  Ed,  p.  11% 


THE  PRINCIPLES  AllD  PRACTICE  OF  OBSTETRICS.         477 

the  serious  peril  of  rupture  of  the  organ — and  well  may  it  be  asked 
€ui  bono?  But  Dr.  Barnes,  while  opposed  to  artificial  detachment  of 
the  entire  placental  mass,  strenuously  inculcates  the  advantage  of 
partial  artificial  separation  as  a  means  of  arresting  the  hemorrhage. 
It  strikes  me,  however,  that  by  thus  increasing  the  area  of  the 
bleeding  surface,  we  must  necessarily  incre:ise  the  profuseness  of 
the  hemorrhage.  His  arguments  are  quite  ingenious,  and  his  essay 
well  worthy  of  attention  ;  *  but  it  does  really  appear  to  me,  after 
8  careful  perusal  of  his  excellent  monograph,  that  the  lesson  he 
teaches  is  not  without  objection.  At  all  events,  I  may  be  per- 
mitted to  express  the  opinion  that  the  views  of  Dr.  Simjison  with 
regard  to  the  entire  separation  of  the  after-birth,  and  those  of  Dr. 
Barnes  touching  its  partial  detachment,  are  questions  to  be  deter- 
mined, not  by  the  reasoning  of  clever  minds,  but  by  the  positive 
results  in  practice,  which  the  future  may  disclose,  either  afiirma- 
tively  or  negatively. 

The  plan  of  artificial  detachment  of  the  placenta  was  suggested 
to  Dr.  Simpson  from  a  consideration  of  the  high  mortality  of  the 
operation  of  turning  compared  with  that  following  cases  oi  sponta- 
neaus  detacliment  or  expulsion  of  the  j)lacenta  previous  to  the 
Mrth  of  the  child  ;  the  mortality  in  the  latter  case  being  but  one  in 
fourteen.  Cessation  of  hemorrhage  took  place  in  these  cases  imme- 
dLitely,  for  the  most  part,  upon  the  detachment  of  tlie  placenta ; 
and  believing  that  the  same  result  would  follow  its  artificial  detach- 
ment, he  suggested  this  as  a  resort  in  all  cases  of  labor  thus  com- 
plicated, in  which,  from  rigidity  of  the  os  uteri,  or  extreme  exhaus- 
tion of  the  patient,  turning  could  not  be  prudently  resorted  to. 

It  has  been  objected  to  Dr.  Simjison's  statistics,  that  they 
embrace  cases  not  adapted  for  comparison,  including,  as  they  do, 
cases  occurring  at  every  age,  subjected  to  every  variety  of  treat- 
ment, and  some  to  no  treatment  at  all ;  also  cases  complicated  with 
rupture  of  the  womb,  convulsions,  contracted  pelvis,  <fec. 

To  meet  this  objection.  Prof.  Trask,  in  his  essay  already  alluded 
to,  has  collected  all  the  published  cases  to  which  he  had  access, 
together  with  others  communicated  to  him.  He  has  analysed  them 
with  a  view  of  presenting,  as  far  as  possible,  the  influence  of  various 
irircumstances  and  conditions  of  the  patient  in  determining  a  suc- 
cessful or  fatal  result.  Anxious  to  give  the  reader  the  benefit  of 
Dr.  Trask's  researches,  and  of  affording  Prof.  Simpson  the  full 
benefit  of  his  conclusions,  I  sh.ill  briefly  allude  to  some  of  the  most 
interesting  and  important,  which  are  as  follows : 

"The  teachings  of  the  best  authorities  are  confinned,  that  the 
period  of  greatest  danger  is  between  the  seventh  month  and  the 
completion  of  pregnancy.  Of  the  presentations  in  the  353  cases, 
113  were  of  the  head,  or  the  head  complicated  with  descent  of  the 

*  The  Physiolugy  and  Treatment  of  Placenta  Pnevia.   By  Robert  Barnes.    1S5V 


478 


THE  PRINCIPLBS  AND   PRAOTICR  OF  OBSTCTRrOR 


funw  or  hand;  iil  of  the  superior  qxU'  're- 

mity,  luul  2  of  thp  urn biliciifl;  the  rem  '  ■         ^  'h© 

nto»t  part^  of  the  head,  but  the  proportion  of  titinfittiml  pfescmtatioDt 

rory  marked. 
From  Tiihk^  T,,  embracing  cases  «rthject«'d  to  ordinary  modc«  of 
treatment,  or  dyintc  undelivr-red,  we  lerirn    thrit  tbwc  wrore  141 
recoveries  and  59  denths,  or  a  mortality  of  1  in  3.4/* 

The  influence  of  bemorrbage  pin^vious  to  delivery  in  affoetiTiet  tbe 
rosnit  is  tbiis  sbo^vn  :  "  If  we  now  eoTnf»nrc  the  H4  case*  in  whbK 
the  hi*morrbago  wm  very  severe,  nmonpr  the  rfCf^ueries  ftfttrawf^' 
cM  ffeiivery,  with  the  12  in  which  it  wa?  moderate,  we  find  Xhe 
Qhsc^  of  *  mtiderate'  bear  to  those  nf  profuse  hemorrhage  tb<!  piti- 
portion  of  1  in  8  of  the  whole,  Amoni^  the /a tai  ca^e^  aflcr  anift- 
cial  delivery,  the  proportinn  of  rnnderntc  to  scver*^  hrr  "it 

3  in  47,  or  about  1  moderate  to  IH  severe*  Of  cases  rc^  _  rti* 
ficial  delivery  as  a  whole,  there  was  1  case  of  raodcrat©  to  1 1  of 
severe  bemorrhaee,  while  of  thoi«i*  delivered  upontaneouiily  tliin 
w\ift  I  moderate  to  5  J  j;evere.  Tiiere  i^  als«o  a  corrcspond««o» 
between  the  degree  of  pre^tetnation  and  the  nece^^sity  for  artificial 
delivery.  Among  rn^vs  of  ^pontnneons  expulsion  of  the  child, 
ihero  was  a  much  larger  proportion  of /wrfiei/ prewntations^  jMid» 
as  a  consequence,  less  hemoirhage,  and  therefore  a  lowi*r  rate  of 
mortnlity. 

"Adding  the  case.%  of  Dr^.  Lever  and  3Ierriman  to  the  eaeei  in 
the  tnlile,  we  get  a  totrd  of  96  saved,  and  160  lo«t,or  1  in  2.7  of  llw 
whole  saved*  Tfie  mnrtaiily  to  the  child  in  the  caws  of  the  practi- 
tioners of  lless(»*Ca^sel  i.i  rven  greatrr,  m5  having  been  born  lirli^ 
and  251  dend,  or  1  3.9  of  the  whole  #iavod* 

*' Table  II.  embraces  36  cases  of  spontaneous  expulsion  of  the  pW 
eenia;  in  these  but  2  deaths  are  noU*d,  both  from  diairhcpa  *aba^ 
qiient  to  hibor.'^ 

l>r.  Trask  add*  to  his  casps  others  rccordetl  by  I>r.  Slmp'ton,  and 
of  the  whole,  59  require<i  manual  assistance,  while  78,  or  57  per  ewit, 
were  ilelivered  by  natural  effort-.  Of  ca«es  embraced  in  the  inl 
table  only  17  pi*r  cent,  were  delivered  spoil'  nee 

is  that  ** cases  in  which  the  placenta  in  exj'  of 

the  child,  as  a  class,  «»^  charnctcriziH]  by  a  tonicity  of  the  wonib 
and  a  vigor  of  uierine  contraction  which  wc  do  not  find  in  ordiaary 
oascfl  of  the  accident*" 

There  were  HO  recoveries  and  11  deathn,  or  am  rabcmt 

1  in  M*     Dr.  T.  next  proceeds  to  inquire  what  suet  •  i blended 

artificial  detachment  of  the  plaeenta,  as  an  expedient  for  fyuttiiig 
an  end  to  hemorrhage.  '*  In  Table  IIL  are  recorded  thi  '  "  ^of 
M  cases.     The  mortality  of  cases  thun  treated  is  sta  ivc 

been  1  in  4.6.  The  gross  mortality*  after  its  perfonnancc  in  iba 
caac^  composing  this  tnble,  i^  ihureturc   some  what  lesa  Uian  Um 


THB  PRINCIPLfIS  AND  PRACTICE  OF  OBSTETRICS.         479 

goneral  mortality  under  ordinary  modes  of  treatment,  and  espe- 
cially after  turning ;  but  It  is  very  much  greater  than  after  sponta- 
neoas  expnlsion  of  the  placenta.  In  explanation  of  this,  our  author 
proceeds  to  show  that  the  proportion  of  complete  presentations 
was  considerably  larger  among  these  than  among  cases  constitut- 
ing the  first  table ;  that  the  proportion  of  cases  in  which  the 
hemorrhage  was  very  alarming  was  much  greater,  and  that  alarm- 
ing exhaustion  occurred  in  a  much  larger  relative  number  than 
among  cases  in  the  first  table.  In  other  words,  cases  in  which 
detachment  was  resorted  to  were,  for  the  most  part,  at  the  time  of 
the  operation  in  a  far  less  favorable  condition  for  recovery  than 
were  the  cases  in  which  artificial  delivery  was  resorted  to.  This 
drcnmstance  is,  of  course,  entitled  to  great  weight  in  comparing 
the  results  of  the  two  modes  of  practice. 

•*  About  one  in  three  of  these  cases  was  delivered  by  spontaneous 
expnlsion  of  the  child,  a  much  larger  proportion  than  among  cases 
of  the  first  table.  This  fact,  which  is  apparently  at  variance  with 
the  statement  as  to  the  unusual  severity  of  the  cases  we  are  consi- 
dering, receives  a  happy  explanation  in  the  following  facts.  In  the 
ipantaneous  deliveries^  after  fqyontaneoua  separation  of  the  placenta, 
the  child  followed  the  placenta,  in  more  than  half  the  cases,  in  ten 
minutes  or  less,  while  in  the  spontaneous  deliveries  after  artificial 
detachment,  the  child  followed  the  placenta  after  a  more  or  less 
protracted  interval.  In  the  first  case  the  contractions  of  the  womb 
expelled  placenta  and  child  nearly  together,  but  in  the  cases  of 
artificial  detachment,  the  hemorrhage  having  ceased  in  consequence 
of  the  detachment,  the  vital  powers  have  rallied,  and,  at  various 
intervals  from  one-half  hour  up  to  eighteen  hours,  have  expelled 
the  child. 

"  This  table  gives  abundant  evidences  of  the  hsemostatio  powers 
of  artificial  detachment.  Of  66  cases,  in  35  hemorrhage  ceased 
immediately  and  entirely,  and  in  the  remainder,  with  scarce 
an  exception,  it  continued  but  a  short  time  and  in  trifling 
degree. 

"  Fifteen  children  were  saved  and  thirty-two  lost,  or  a  trifle  less 
than  one  in  three  saved.  It  is  evident  that  unless  delivery  soon 
follow  this  operation,  the  life  of  the  child  must  almost  necessarily 
be  sacrificed.  The  result  here  given  does  not  difler  much  from  the 
results  following  turning  and  spontaneous  expulsion  of  placenta,  in 
which  a  trifle  less  than  one  in  three  were  saved.  It  is  quite  proba- 
ble that,  as  suggested  by  Dr.  Barnes,  the  detachment,  in  at  least 
0ome  of  the  instances  in  which  the  child  was  saved,  had  been  only 
partially  effected. 

"  The  plan  of  partial  detachment,  as  recommended  by  Dr.  Barnes, 
is  designed  to  meet  the  objection  to  total  detachment  which  arises 
from  the  peril  in  which  it  places  the  child;   sufiicient  connexion 


480 


TllK  PRINCIPLES  AND   PRACTICE  OF 


with  the  mottier  «lill  rcmmning  to  allow  of  charige«  in  tbe  blocNl  | 
required  by  tbe  child/' 

Ergot — the  eeeah  cornuh/m — is   a  remedy  mucli  cm;d»yr«l  Uy 
many  practitiora*!*!*  in  plactnta  prmvta*     The  well-known  iiiOiMiiK 
exerci.sv*!   by  tbi»  agtMit  in  the  product  ion  of  uterint*  eonlntrtloil^ 
lias  tanned,  I  fear,  a  too  jndi^criniinate  res^ort  lo  it,     I  have  greal ^ 
conHdi^nce  in  ergot,  under  its  jndiclons  admin istrnt ion,  bitt  I  inia 
protest  again j^t  its  enipiricfd  enijiluynienL     I  am  opposed  to  its  lui* 
in  placenta prtPr hi  m  the  following  coiidilions:   1.  If  rlie  njouth  of 
the  uteruH  be  8ijltiHeni1y  dilated  to  eii:iblu  the  aecoueheiir  to  tiav« 
reeonr^c  to  ailitleial   delivery^  the  administration  of  i*r^cft  will, 
throi]gh  the  increased  contraction  it  occaoion^,  setiousiy  inierfimi 
with  the  birth,  whelher  it  be  ucconiplished  by  version  or  this  lor-  ' 
ecps ;    2.  If  there  be  a  ero!i.spre»entation  of  tbe  fcrtUA,  ih^m  ibo 
remedy  .^thould  not  be  given,  from  the  very  fact  that  the  increftatd 
force  of  the  uterua  may^  under  ihc  circum^tanceB,  cauae  rufjiitreof 
the  organ.     On  the  other  band,  should  the  pre?«rntalion  1  ^     '  *\ 
and  (fi©  hemorrhage  continue,  not  withstanding  the  tampith, 
sometimes  may  be  the  ea:>e,  then  I  should  advocate  ergot,  amw  |^ 
f/wf  o&  uteri  tpere  rwt  dilated, 

Un<ler  ordinary  cireumstances,  one  of  the  fundamental  cooiU* 
lion**  ju^itify^ng  a  resort  to  tliis  drug  is — tlnit  the  mouth  of  the  womb 
shall  have  undergone  a  me*tsnre  of  dilatation.  But  in  the  caM 
under  dii^cussion  I  take  exception  to  this  rule,  and  fiH*  tlie  very 
obvitMis  reason  that  the  oj,  although  not  dilated,  will^  from  iW 
quantity  of  blooti  lost,  be  more  or  les?»  relaxed  and  dilatable;  and, 
therefore,  the  action  of  ergot,  in  lien  of  misfhicf,  will,  through  the 
inrre,'ise  oIl  contractile  effort,  promptly  aceomplii^h  the  rei|tiin!ii 
dilatation,  and  otlenlimes  most  happily  promote  ihe  ddivery. 

One  word  regarding  the  rupture  of  the  membranoui  aac  m  /ito- 
("fnta  pnwvla.  If  tbe  hemorrhaLre  be  ]>rofn3e,  not  controlled  by  the 
tampon,  and  tbe  os  uteri  unditated,  the  rupture  of  the  mrmbranet 
will  not  be  bad  practice;  for  here,  too,  the  oh,  thongb  not  dtbitodi, 
IS  more  or  les^  relaxed  in  o[>nse<]nenre  of  the  depletion  ;  the  encifMI 
of  tbe  amniotic  fluid  will  im[>art  activity  to  the  contr  irwl 

if  It  be  found  neeesMiry,  the  moment  it  can  be  dnn»v  iih  tbe 

hand  and  terminate  the  delivery;  or,  if  thehemi  should  have  {xuttt^l 
into  the  pelvic  cavity,  the  torccps  will  be  the  res^ource*  Uut  bow, 
in  placenta  jnievia,  with  an  undibile*!  us  uteris  is  the  kic  to  he  mp* 
lured?  The  best  mode  of  doing  this  \^  cantiouHly  to  penetrrue,  by 
means  of  a  j^mall  catheter,  the  plncentii,  and  allow  the  fluid  to  piL** 
oft  through  the  instrument, 

Acvid^Htal  Ihmorrhtigf:^ — ^Tbc  <'haracter  i>f  ih»odiniz,  n  hicU  \Kt 
have  ju^^l  been  describing,  is,  as  you  have  been  informed,  known  a« 
unavoidable^  for  the  reanou  that  it  is  in  clo^e  relation  with  tbe 
implantation  of  the  placenta  over  the  cervix  uu^ri.     AwtJemiS 


THB  PBINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         481 

hemorrhage,  on  the  contrary,  is  in  no  way  connected  with  placen- 
tal presentation,  but  occurs  when  this  body  is  in  union  with  other 
portions  of  the  uterus.  It  may  present  itself  at  any  period  during 
gestation,  or  at  the  time  of  labor.  We  have  already  spoken  of  this 
form  of  hemorrhage  in  the  earlier  months  of  pregnancy,  when  dis- 
cussing the  interesting  subject  of  abortion.  To-day,  we  shall  con- 
fine our  remarks  to  accidental  flooding  in  the  later  months,  or 
second  half  of  pregnancy,  also,  after  the  parturient  effort  has  com- 
menced. The  true  pathology  of  this  form  of  bleeding  is  a  partial 
or  complete  separation  ot*  the  placental  mass  from  the  internal  sur- 
face of  the  uterus  ;  and  the  causes  capable  of  inducing  the  detach- 
ment maybe  enumerated  as  follows:  premature  contractions  of  the 
uterus ;  external  violence,  such  as  falls,  blows,  carrying  heavy  bur- 
dens, etc. ;  mental  emotion,  sudden  congestion  of  the  womb,  or 
miduc  pressure  on  the  hypogastric  region  ;  riding  on  horseback,  or 
in  a  carriage,  esj)ecially  over  rough  roads  or  streets ;  among  these 
causes,  too,  we  are  not  to  omit  to  mention  the  fascinating,  but 
oftentimes  dangerous  polka  and  waltz. 

One  of  the  severest,  and,  for  the  time  being,  most  perilous  exam- 
ples of  accidental  hemorrhage  I  liave  ever  attended,  was  in  the 
person  of  a  lovely  young  married  woman,  who,  although  in  most 
other  matters,  a  sensible  and  refined  lady,  was  so  wedded  to  the 
dance,  that,  at  a  brilliant  reunion,  she  could  not  resist  tlie  tempta- 
tion to  "take  a  turn,"  though  nearly  seven  months  pregnant !  In 
half  an  hour  afterward,  she  was  attacked  with  flooding,  and  the 
scene  was  soon  changed.  She  was  transferred  from  the  gay  hall  of 
fashion  to  the  sick  chamber,  which  was  near  proving  to  her  the 
chamber  of  death !  By  constant  and  untiring  effort,  I  succeeded 
in  carrying  her  to  the  eighth  month  of  her  gestation,  and  then  w:is 
fortunate  enough  to  deliver  her  of  a  living  child.  I  doubt,  with 
the  sad  experience  of  her  folly,  whether  she  will  again,  under  simi- 
lar circumstances,  be  induced  to  "take  a  turn." 

It  will  occasionally  happen  that,  from  some  morbid  condition  of 
the  after-birth,  a  portion  of  it  will  become  detached  from  the  ute- 
rus, thus  giving  rise  to  hemorrhage.  I  have  met  with  a  fair  share 
of  such  cases.  A  good  observer,  and  an  eminent  practitioner.  Dr. 
Robert  Lee,  of  London,  maintains  with  much  positiveness,  that 
another  cause  of  accidental  hemorrhage  is  a  shortening  of  the  cord 
by  being  twisted  around  the  neck  of  the  child,  thus  inducing  a  i)ar- 
tial  detachment  of  the  placenta.  With  all  the  respect  I  entertain 
for  this  distinguished  writer,  and  with,  I  hope,  a  due  appreciation 
of  his  courtesy  on  my  visit  to  London  some  five  years  since,  I  must 
say  that  my  experience  does  not  accord  with  his  on  this  point.  I 
have  seen  many  cases  in  which  the  cord  encircled  the  neck  of  the 
child — indeed,  it  is  by  no  means  a  rare  occurrence — but  I  have 
nerer  known  a  single  instance  of  hemorrhage  arising  from  this  cir- 

81 


482 


THE   PRIXCIPLES  AND   PRACTICE   OF^ 


cumHtatJce,  Thc^  ihm<f^  I  admits  is  poftslbU*,  but  ticit  very  proljtahi^, 
and  for  this  reason,  perhfips,  it  mny  be  <»niimernted  among  the 
causes  of  ttte  accident.  ScansoDi  also  partieipaies  in  the  opinioQ 
af  Dr.  Lee  on  this  point. 

There  is  one  fact  to  ^^hU'^\  I  desire  especially  to  direct  att^ntiocia^ 
il9  an  a£ront  in  the  production  of  accidental  flooding,  and  to  which 
I  do  not  think  aitthors  have  attached  »u0icient  Import anr^.  I 
alUule  to  hjbitnal  and  obstinate  constipation,  I  could  viU*  murw 
thim  one  inslunee  in  winch  I  am  quite  sati^eil  the  violent  airainii 
induced  by  this  condition  of  the  bowels  has  occasioned  detach cninfi!! 
of  the  placenta  in  liome  portion  of  \t^  surfacf^  nm\  conmqtmn 
hemorrhage,  Ttiercforc,  remember  it  is  eftsential,  for  thb  nm 
as  for  other  reasons,  that  the  bowels  of  the  pregnant  female  be  | 
perly  regulated, 

Ifi  it  possible  to  confountl  accidental  hemorrhage  in  th«  bitter 
month!t  of  gestation  with  a  discharge  of  blood  altogetht-r  tsDeon* 
ne«*ti>d  with  a  detaelimcnt  <jf  t>je  afVer-birth  ?     This  que«(tion  ii  tioCJ 
witliout  interest,  and  needs  a  momenl^s  conBideraliun ;  it  neceMap-l 
rily  involves  the  inquiry,  whether  a  pregnant  w^oman  at  this  pc!rui4j 
of  gestation  can  lowe  bltjod  from  the  uterus,  and  the  ornm  prewr 
its  M\  integrity  of  union  with  the  organ*     There  can  hv  no  <1aiibt] 
thnt  this  nmy  occur;  you  have  already  been  told  that  some  womoo 
tncrstruate,  although  pregnant;  again,  certain  morlrid  conditioili 
of  the  uterus  may  give  rise  to  hemorrhage,  and   none  of  ntoro 
imfK>rtnnc«s  so  far  ns  a  correct  diagnosis  b  coneenicd,  than  polypnf 
or  a  std^ mucous  fibrous  tumor  of  the  organ.     I'Tie  diagnoKii  in 
mich  cnscH  would  not  be  drflicult,  and  it  is  scarci'Iy  necessary  for  itHi 
to  dwell  longer  upon  the  point  than  mcn»ly  to  remind  vim  i.f  tbfl 
'jios^iilnlity  of  such  contingencies. 

The  placenta  may  become  detached  in  two  ways,  even  \'  ^  i  lU 
separation  fmui  the  uterine  surface  is  only  part  id ;  for  rvij.jii, 
tiif  dc^tachmcnt  miiy  be  more  or  hnis  slight  at  some  point  of  itsi  cir- 
euinfercnce ;  this  is  the  ordinary  form  of  separation^  as  eonnet*t«l 
inih  accidental  hemorrhage,  and  the  bleeding  ia  usually  not  pn>» 
fuse;  it  nmy  nccur  several  times  during  the  r  ■'  an  iottfr* 

val  <&(  some  days,  and  it  is  generally  of  but  lir  h'!^  so  fiv 

aa  the  satl'ty  of  the  mother  or  child  is  in  question,  tn  these  rtif, 
rest  in  the  recumbent  povture,  and  a  quiet  mind,  together  with  coli! 
drinVs  at  the  time  of  the  bleeding  will  generally  suffice,  nnd  the 
patient  be  i^arried  to  the  completion  of  her  |*enf>d.  Yet  a  drtTenrtit 
state  of  things  occasionally  presents  itself  in  this  »j]>ena!  form  of 
phieental  detachment — the  hemorrhage  being  mofit  profuse, 
menacing  the  lives  of  both  child  and  parent,     IT  *  poa 

flhould  tiot  be  employed,  for  it  cannot  reach  tlie  h«  -hkI. 

tog»  and  its  only  tend<ncy  would  be  the  eon  version  or  an  eiieroal 
into  an  Internal  hemorrhage.     If  the  bUjeding  should  not  yidJ  ta 


THE    PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         488 

the  means  already  cited — ^rest  in  the  recumhent  posture,  elevation 
of  the  hips,  cold  drinks,  etc.,  then  there  should  be  no  scruple  as  to 
the  course  to  be  pursued — premature  labor  should  be  brought  about 

Sometimes,  the  partial  detachment  of  the  after-birth,  and  the 
consequent  hemorrhage,  will  be  the  result  of  premature  contraction 
of  the  uterus,  this  being  induced  by  some  moral  or  physical  cause. 
In  such  an  event,  the  attention  of  the  practitioner  should  be  directed, 
if  possible,  to  the  lulling  of  these  premature  efforts,  and  for  this 
purpose  opium  in  some  one  of  its  preparations  may  be  resorted  to. 
I  have  gi-eat  confidence  in  these  cases  in  an  opium  suppository,  one 
or  two  grains,  introduced  into  the  rectum,  or  thirty  or  forty  drops  of 
the  tincture  in  a  \^ine-gla8S  of  tepid  water  thrown  up  as  an  injection. 

There  is,  however,  another  form  of  accidental  flooding  connected 
with  partial  detachment  of  the  after-birth,  most  insidious  in  its 
inception,  and  at  the  same  time  fearful  in  its  results — I  allude  to 
that  condition  of  the  placenta  in  which  its  entire  peripheral  border 
continues  in  union  with  the  uterus,  atid  the  separation  is  limited  to 
its  central  portion.  Here  there  will  be  a  species  of  pouch  formed, 
into  which  the  blood  will  be  pouring  from  the  utero-placental  ves- 
sels ;  in  this  case,  however,  there  is  no  exteraal  evidence  of  hemor- 
rhage ;  the  blood  does  not,  for  it  cannot  pass  from  the  uterus.  It 
is  veritably  a  concealed  or  internal  hemorrhage,  and  the  work  of 
de.ith  may  be  accomplished  before  the  practitioner  even  suspects 
the  cause  of  the  danger.  Indeed,  I  am  much  dis})0sed  to  refer 
some  of  those  cases  of  sudden  and  supposed  inexplicable  dissolu- 
tion, which  occasionally  occur  in  the  latter  part  of  pregnancy,  to 
this  peculiar,  but  happily  not  common  form  of  hemorrhage.  As  I 
have  just  remarked,  the  blood  does  not  escape  externally,  and 
therefore  you  are  deprived  of  this  physical  proof;  the  only  and 
oftentimes  fatal  evidence  of  the  central  separation  of  the  placenta 
will  be  the  exhaustion  of  your  patient ;  the  face  grows  pale,  the  heart 
becomes  weak  in  its  pulsations,  the  countenance  presents  the  appear- 
ance of  serious  dilapidation,  and,  if  some  check  be  not  speedily  given 
to  the  bleeding,  the  patient  sinks.  In  instances  like  these  there  is  ne- 
cessarily much  embarrassment ;  and  it  is  difficult  to  know  M'hat  to  do. 

Usually  there  are  no  striking  premonitory  symptoms,  and  the 
connsel  of  the  practitioner. is  not  demanded  until  the  mischief  is  far 
advanced.  If,  however,  you  should  be  called  to  a  case  of  sudden 
prostration  in  the  latter  months  of  gestation,  unexplained  by  any 
antecedent  circumstances,  it  will  be  well  to  think  of  the  possible 
connexion  between  this  exhausted  condition  and  central  detachment 
of  the  placental  body;  and  if  you  should  be  satisfied  that  the  rela- 
tion of  effect  and  cause  really  exists,  then,  in  my  judgment,  the  only 
hope  will  be  in  the  prompt  evacuation  of  the  uterus,  in  order  that, 
through  efficient  contraction,  the  bleeding  vessels  may  be  closed. 
Under  these  circumstances,  I  should  not  hesitate,  at  once  to  intro- 
dace  a  catheter  into  the  uterus,  and  puncture  the  membranes  with 


484 


THE   PRINCIPLES  AXD   PRACTICE  OF  OBSTCTHlCSi. 


a  viow  of  allowing  ttie  liquor  amnii  to  paw  off,  ami  thus  eyoke  the 
needi'd  cfluri*  This  woul<l  probalily  W  the  promptt*!*!  and  mosi 
certain  method  of  accomplishing  the  object, 

Acchhmtal  ILinorrhnffe  at  the  Hmt  of  Jjahor, — If  thia  chantdsr 
of  hcroorrlinge  should  occur  during  the  proi^rcss  of  labor — ^it  eariJiol 
bii  regarded  a  fiXHiucnt  complication — it  uil)  need  alJ  the  atti*nljf»ii 
of  the  accoucheur*  If  it  be  j>r<ifuse,  and  eiumol  be  clieckcd  by  the 
apptication  of  cold  to  the  abdomen,  or  the  imroduction  of  a  small 
piece  of  ice  into  the  vajfiua,  or  injections  of  ice-vralcr  into  iho 
rectum  ;  and  it  be  aneenainod  tljai  one  of  the  extrenjities  of  tlui 
ftEtal  ovoid  firesenta,  the  clement  of  hope  will  lie  in  the  rupture  of 
the  membranous  sjic,  aiid,  if  thia  tihould  not  suffice  to  profu«ile 
(Strong  uterine  contniction,  recourse  may  be  hail  to  ergot.  HhoalJ 
the  hemorrhage,  in  doliaucc  nf  these  means,  biill  continue— a  rtre 
circumblanee — the  labor  muiit  be  termimited  artilicially  wither  by 
the  hand  or  the  forceps.  In  the  event  of  a  croft»-pre8etitatum, 
which,  as  I  have  just  ^uid,  would  contra-indicute  bolJi  ergot  and 
rupture  of  tlie  membranes,  the  finger  tihouJd  be  introducod  into  tl»« 
0.H  Uteri,  and  jxcrMle  eiforts  niatle  to  dilute  it.  Thin  i*|ieciej*  of  tiiil- 
lation  will  oftentimes  be  fi>lh>wed  by  the  haj>pie«t  effects  and  mori>* 
over,  it  must  be  recoUected  ihat^  in  these  <i\\^*%  of  Uik«  of  blo<Ml,  tbo 
rif^idity  of  the  muscular  tibre  of  the  uterus  is  very  n»uch  rc^luiH'd, 
and,  aii  a  getierni  rule,  the  dihitatioti  ot  (he  inuuth  of  the  organ  by 
jueans  of  the  fin<^cr  it*  more  or  lei»s  rciidify  accomprmhed;  llie 
cnomcnt  it  i»  sufliciently  open  to  permit  the  introduction  of  llie 
hand,  the  indication  ie  to  proceed  without  delay  to  turn  thi»  clril4 
by  blinking  down  the  feet ;  for,  the  earlier  vernion  ia  aitempUMl  b 
croSi^birtliH— all  lliin^  being  equal — tlie  greater  the  probability 
that  the  operation  will  be  successfuh 

8«jraetunes  when  the  fiemorrhage  continues  without  dilatation 
of  the  OS  uteri,  and' it  if*  not  ehuracterized  by  such  almndanetr  auto 
cumprorni^e  the  safety  of  mother  or  child,  gieat  lienefit  will  be 
deiivod  from  the  ju<liciouH  admiuih^tration  cif  unudynt*^  ii««thing 
better  in  thene  cases,  if  the  atomach  will  tolerate  it,  than  Dover"! 
powder,  \\\  five  grain  doses  as  circumNtunces  nniy  indicate*.  Sltould 
nausea  or  vomiting  lueclude  its  admini?itratiou,  morplii.i  or  opinio, 
should  there  be  no  contra4u<lication,  nmy  be  wubjttiiuted.* 

It  will  be  perceived  that  I  have  f^aid  nothing  touching  tlw  xxm^ 
stimulants  in  the  exhaustitm  so  apt  to  aceonipany  these  liMaea  dT 
blood,    whether  firom  placenta  pncvia  or  accidental  hem-     ' 
The  great  object  of  treatment  is  to  arrest  the  bleeding  by  ; 
OU5  mean^t  indicated  ;  at  the  same  time,  it  w  ill  be  nec*'?i«iry  to 
sustain  the  strength  by  a  judicious  employment  of  laudanum,  bmndyt 
milk  punch,  etc, ;  and  never  omit,  in  those  anaemic  cooditiott^i  by 
means  of  hot  6annels  or  hot  water  in  b<»tth  h,  to  preserve,  as  £ir  Mi 
may  be,  a  proper  temperature  of  the  extremities. 
*  Opium  wil],  l]4iw«T«r,  id  soiim  eaaei^  htvo  a  ttadency  to  iocnnM  tlit  tciai^l^ 


LECTURE    XXXII. 

Puerperal  Convulsions,  the  different  periods  of  their  Occurrence— Muscular  Action, 
on  what  Ls  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 — Irritiition  of  Uterus 
as  a  Cause  of  Puerperal  Convulsions  during  Pregnancy,  at  Time  of  Labor,  and  sub- 
sequent to  Delivery — Convtilsions  during  Pregnancy  more  frequent  in  the  Primi- 
pnra ;  why  ? — Period  of  Life  at  which  Convulsions*  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  \ipon  their  special  Cause — Sulphuric  Ether  as  n 
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 — Symptoms,  Diagnosis,  and  Prognosis  of 
Puerperal  Convulsions. 

Gentlemen — We  now  approach  the  consideration  of  one  of  the 
most  forniidable  and  perilous  complications  of  the  lying-in-chamber 
-puerperal  convulsions.  They  may  occur  during  pregnancy,  at 
the  time  of  labor,  or  subsequently  to  delivery.  Under  any  circum- 
stances, their  presence  is  fraught  with  more  or  less  hazard  to  the 
mother  and  child,  and,  therefore,  they  claim  the  earnest  thought 
of  the  accoucheur.  As  I  am  especially  anxious  to  explain  to  you, 
as  far  as  may  be,  the  true  pathology  of  convulsive  movement,  based 
upon  a  soimd  and  rational  physiology,  you  will  permit  me  to  recall 
to  your  recollection  two  great  fundamental  truths,  for  which  we  are 
indebted  to  the  researches  of  Flourens  and  Marshall  Hall.  The 
former  has  demonstrated  that  muscular  action  cannot  be  produced 
by  irritation,  either  of  the  cerebrum,*  cerebellum,  or  purely  cere- 

♦  There  is  no  doubt  that  strong  mental  emotion,  accompanied  by  cephalalgia, 
obscure  vision,  etc.,  will  sometimes  be  the  starting  point  of  convulsions  both  in  the 
pregnant  and  parturient  woman.  All  practitioners  of  observation  have  recognized 
this  fact;  but  it  must  not,  therefore,  be  concluded  that  the  convulsion  is  the  product, 
simply,  of  cerebral  irritation,  for  this  is  adv(frse  to  a  well-established  physiologiciil 
principle.  The  brain,  in  a  variety  of  way.s,  may  become  the  primary  seat  of  some 
irritating  cause,  whether  from  congestions,  slijrht  effusions,  or  some  toxaemic  influ- 
ence, such  as  unemic  intoxication,  etc.;  but  this  irritation  cannot  generate  a  con- 
vulsive movement,  until  it  has  affected  the  spinal  cord,  the  great  motor  centre  of  the 
ooooomy.  It  is  an  interesting  fact,  as  i)ointe<l  out  by  Andral  and  Browu-Sequard, 
that  rigid  spasms  sometimes  follow  intiammation  of  the  brain. 


486 


TH£  FfitNCIFLES  AND   PRACTICE  OF  OBSTrTRICSk. 


bral  nerveR,  if  the  irritation  be  strictly  confined  to  these  portiaos  of 
the  nervous  mass;  and  he  has  further  shown  that  mtvscular  mcnre* 
ment  h  the  product  of  irritation — either  direct  or  indirect— of  ibv 
true  spinal  cord*  and  muscular  nerves.  It  cannot  be  qtiesttoa«d 
that  this  ia  one  of  the  most  important  developments  of  modern 
phys-iology* 

This  j:freat  revelation,  however,  needed  one  more  fact  to  tmpsit 
to  it  it8  ftiU  interei^t,  both  in  a  physiological  and  pathological  tiBM^ 
The  fact,  as  I  have  before  remarked,  has  been  supplied  by  MarsUill 
Hall,  who  has  dL'mon&it rated  tliat  Irritation  of  the  spinal  cord  may 
bo  induced  through  certain  int-idi-nt  uxeitor  nerves.  V\  '  *  to 
the  disclosure  of  this  hitter  principle,  it  was  supposed  i  ucr- 

vons  aberrations,  involving  irritation  of  the  f^pinal  cord,  were  cm- 
(rit%  or,  in  other  words,  the  reiiult  of  an  influeoc4?  applied  directly  to 
this  nervous  centre.  I  may,  perhaps,  be  wrong  in  the  remark  thai 
Marshall  Ilall  was  the  fir>t  to  call  attention  to  this  intn  ict, 

fijr  the  L'ii  cnmstance  hail  been  previously  recorded  by  W  ^  .-hU, 
Prochaskn,  Unzer,  and  II.  Mayo;  l>ut  I  think  it  must  be  conceded 
that»  without  the  practical  appUeaiioii  made  by  htm  of  this  great 
phybiologicul  truth,  its  Ijcnellt  lo  science  would  have  been  extremely 
restncte<l.  To  him,  therefore,  belongs  the  honor  id'  having  Ciith- 
fully  and  perseveringly  in^istcil,  not  otdy  upon  its  imptjrtanee,  hat 
its  indispen^tble  necessity  for  the  proper  diagnosis  and  treat misnt  of 
disease.  Now  that  the  action  of  the  incident  exeitor  ner\t9  li 
understood,  we  have  another  divisiun  of  nervous  disturbance*  vii., 
t<X€ntrii\  in  whicli  an  irritation  in  produceel  on  the  peripher^il  extr» 
mity  of  one  or  more  nerves,  and  the  imp^e^«ion  thus  made  ii  eoo- 
Veyed  by  the  nervous  trunks  to  the  spinal  cord ;  the  irnpresiJiiont 
altogether  iudependent  of  mind,  beeomcH  a  sensation,  which  results 
in  a  motor  imjml^c  ;  this  latter  is  transmitted  to  cert;uu  mu»clei| 
and  heiioe  an  abnormal  movement  of  these  muscles  is  the  resoit. 
This  is  what  is  known  as  reflex  action. 

All  nervous  aberrations,  of  whatever  grade,  may  very  properly 
be  divided  into  two  classes — centric  or  eccentric  ;  and  you  will  find 
that  this  arrang«^ment  is  not  only  founded  upon  a  correct  physi- 
ology,  but  will  greatly  contribute  to  the  elucidation  of  that  ilnpo(^ 
tant  chapter  in  your  studies — nervous  diseases.  It  is,  therefunt, 
under  this  classification  that  I  propose  to  discus'i  the  impOriiBl 
question  of  puerperal  convulsions,  whether  during  :  y,  a^  t 

complication  of  labor,  or  subsequently  to  the  birth  ul  .  ild.  In 
either  of  these  aji^pects,  it  b  a  question  well  entitied  to  the  profotuid 
OOosideratioQ  of  the  medical  man* 


♦  It  must  alwafs  b«  bomo  in  mind  thftt  the  sptiial  our^J,  phj         ,     ,  *» 

dcnsd,  la  not  tlio  meduiU  jipiitolia  oC  the  MUHomiH;  on  ilio  coii^r ,  ,  -,  u  j  <  A 
oonl  coiuietj  of  the  niCiluJla  9jjiiittlj%  mwluUii  oblou{pciU«  poiM  Vnrulii,  crura  ccneMi 
ftud  till?  tuberLniln  quii^lng<*mma. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         487 

JEoeentrie  causes.  These  act  on  the  true  spinal  system  through 
excito-motory  influence,  by  the  transfer  of  an  undue  or  pathological 
impression.  These  causes  may  be  enumerated  as  follows :  1.  Indi- 
gestible food  in  the  stomach  ;  2.  Morbid  matter  of  any  description 
in  the  intestines,  whether  vitiated  secretions,  unassimilated  food,  or 
collections  of  faeces ;  3.  Irritation  of  the  bladder  or  rectum ;  4.  ?iTi 
tation  of  the  uterine  organs  and  vagina. 

It  is  important  to  bear  in  recollection  that  these  various  causes, 
under  given  circumstances,  are  capable  of  evoking  an  attack  of  con- 
vulsions ;  so  that,  when  called  to  a  case  of  this  serious  ner\-ous 
disturbance,  your  minds  may  be  prepared,  almost  with  the  quick-' 
ness  of  thought,  to  comprehend  the  relation  of  effect  and  cause, 
which  may  at  the  time  exist  between  the  convulsive  movement  and 
either  of  these  specified  agents.  In  this  way,  your  diagnosis,  sound 
at  the  very  start,  will  enable  you  more  successfully  to  meet  the 
therapeutic  indication.  There  is  a  vast  deal  both  of  routinism  and' 
empiricism  in  the  treatment  of  puerperal  convulsions,  and  this,  lam 
quite  confident,  is  mainly  to  be  attributed  to  the  fact  that  the 
practitioner  in  the  hurry  or,  perhaps,  alarm  of  the  moment,  suffers 
himself  to  regard  the  convulsion  as  a  primary  or  idiopathic  aflfection, 
instead  of  recollecting  that  in  ninety-nine  instances  in  a  hundred  it 
is  but  the  product  or  result  of  some  antecedent. 

1.  Indigestible  Food  in  the  Stomach, — Let  us  now  inquire  how  it 
is  that  indigestible  food  in  the  stomach  is  capable  of  producing 
convulsions.  It  is  not  sufficient  for  you  to  know  the  fact ;  on  the 
contrary,  you  should  be  content — when  demonstration  is  possible — 
with  nothing  short  of  demonstration  itself.  Therefore,  I  now  tell 
you,  as  a  principle  well  settled,  that  in  these  cases  the  irritation  is 
first  produced  upon  the  terminal  branches  of  the  pneumogastric* 
nerve,  and  is  thus  conveyed  through  that  nerve  to  the  spinal  cord, 
constituting,  as  I  have  already  stated,  an  interesting  and  striking 
example  of  eccentric  influence.  You  are  well  aware,  gentlemen, 
of  my  fondness  for  practical,  bedside  truths ;  in  contrast  with  mere 
hypothesis,  they  constitute  so  many  gems  for  the  medical  man. 
With  this  conviction,  you  will  pardon  me,  I  am  sure,  for  intro- 
ducing to  your  attention  the  following  instructive  case,  the  history 
and  sequel  of  which  are,  in  my  opinion,  the  best  comments  I  can 
oflfer  touching  the  treatment  of  convulsions  dependent  upon  gastric 
repletion : 

Late  in  the  evening  of  January  1, 1857,1  was  summoned  in  great 
haste  to  attend  a  young  married  lady,  who  was  then  in  the  eighth 
month  of  her  pregnancy — a  primipara;  the  messenger,  her  brother^ 
told  me  she  had  just  been  attacked  with  a  fit,  and  he  desired  very 
urgently  that  I  would  lose  no  time  in  hastening  to  the  house.     On 

*  The  physiologist  lias  stiown  that  tho  pneumogastric  is  an  excitor,  and,  at  tbu- 
time  a  mocor  and  ganglionic  nerve. 


THhl   PHl>'CIPr.ES  AKD   PRACTICE  OF  OBSTCTRICa 


my  arrival,  1  k*arnecl  glie  l*a<i  iKen  in  cjcrdlem  hotMi  up  lo  tbftt 
evening  tlinMi«;h<>irt  the  erttirc  period  of  her  fjestation  ;  bat  about 
hajf  an  boiir  before  I  reachtnl  t\w  bati^e,  slie  bad,  wbile  in  agrcN^^ldc 
con  vernation  with  her  hnnhnnt}^  been  attacked  with  eonvobionfi,  I 
ba<l  scarcely  eriteied  lier  njorn  bt*fon*  tinotbcr  paraxjMn  oecurrecl, 
developing  all  thr  onlinnry  jihenomerui  of  eclampwa.  The  finit 
quc*j«tioti  naturally  picsentint^  itwclf  in  my  mind  wili,  wbal  dot***  tbb 
mean,  or,  in  other  words,  was  there  any  special  and  eximaniitiary 
cau^'e  for  this  alannifig  state  of  f lie  putifnl?  ImnricdhtHy,  I  ifMid^ 
nmning  incpiinoH  a«  to  her  pre\  iou?*  !ii*alth,  etc,  which,  a«  1  hare 
jU8t  n^markcd,  had  \ivvTt  most  excellent.  On  ipie«tioning  th<n  bti«- 
baiid  do8ely,  he  informed  me  that  hiswitl*  had  partaken  of  a  hearty 
lea,  induljcinc:  freely  in  preserved  qntnces,  and  in  addition,  %\w  bad 
eaten  a  Iar|?e  f|nantity  nf  plum-i-ake,  PrecLftely  two  lionn*  after 
this  rcpa**t,  ihn  convulsions  cr»»ucd.  What,  gcntlcmeri,  with  th^m 
fads  before  yotu  would  have  been  your  judgment  of  the  caow  of 
the  paroxyjim,  and  what  your  treatment?  Won!*!  yon  havf 
applit'd  a  litratttrc»  to  ibe  arm  nr»d  abMrarird  bloml — the  remi^drof 
all  others,  in  the  opinion  of  some  writers,  which  ennfititulff  th« 
91  tie  qua  won,  the  very  sheet-anchor  of  hopo  in  jmerperal  <joo%iil- 
mons — or  would  you,  m  1  attempted  to  do,  have  taken  a  comoiofQ 
sense  view  of  the  eas^,  an<l  referred  the  perturllKilion  of  fV  '  M«i 

syKtem  to  the  presence  in  the  titotnaeh  of  thc'/wc^rrrfr/ v  md 

/)/*/77iw'ryA-€,  acting  aB  an  irritant  on  the  pneumogastric  nervci,  and 
thu«,  through  eecenlrie  agency,  causing  the  convulsion? 

This  was  my  diagnosis,  and,  a;*  you  will  pre**enrly  }mni,  wy 
thera|ieutics  wore  in  perfect  accordance  with  it.  Without  \o*^  of 
time,  I  adminifJtercd  twenty  grains  of  the  sulphate  of  jcine  in  half 
a  tua-cup  of  tejiid  water,  with  a  view  of  a  prompt  liberation  of  tb^ 
utomach  from  iii«  (tflVnding  contents.  In  Ics.h  than  three  mintitdi 
the  emetic  hegiin  to  take  c<fcct»  and  the  lurking  enemy,  nmler  tbo 
guise  of  quinces  atul  phim-cnkc,  was  very  ktiou  t*jceted.  Tfc<> 
quantity  of  these  subHtances  thrown  from  the  ftomaeh  nearly  Imtf 
filled  an  ordinary  washbowl.  The  effect  wa^i  all  that  eould  h$ 
denired;  I  remained  with  the  patient  f«uir  hours,  there  wan  no 
recurrence  of  the  convulsion,  atul  she  lapstnl  iulo  a  sweet  ami  undU* 
turbed  i*leep;  respiration  natural,  pul*«e  «oft  and  equable,  and  the 
countenance  indicative  of  tranquillity.  The  mO!*t  po!*itive  dire<TtJoiui 
were  giveu  :e*  to  the  necenf^ity  of  adhering  scrupulously  to  a  Mtiiple 
and  blind  diet.*    Thi»  lady  pji^scd  on  to  her  full  time,  when  I  had 

•  I  tnok  verjf  gofxi  mre — n  prtki'XWv  I  |jHVi»  l>ee!i  in  lUe  IuiImI  >  '  t*^ 

not  M  tr»<v  i>f  '  t     Tl»K  lh€»rt'rtrrc.  wius  nn  »  \\f 

4|ii«t*iii<m  urciHiviil^i  '  Atity  Uk*  ftilijwct  of  iinnuiiinurui. 


THE  PRINCIPLES  AND   PRACTICE  OP  OBSTETRICS.         489 

the  pleasure  of  presenting  her  with  a  fine  boy.  There  was  nothing 
whatever  untoward  dunng  the  labor,  and  her  convalescence  was  not 
interrupted  by  any  accident. 

Is  it  going  too  far  to  surmise  that,  without  the  prompt  action  of 
the  emetic,  according  to  every  Jaw  of  i)rofessional  calculation,  the 
patient  and  her  child  would  have  both  been  sacrificed  ?  I  think 
not.  But  what  prompted  the  administration  of  the  emetic  ?  Why, 
the  obvious  and  imposing  fact,  previously  ascertained,  that  the 
essential  and  only  cause  of  the  convulsive  movement  was  the  undi- 
gested mass  in  the  stomach. 

2.  Intestinal  Irritation, — Should  the  convulsions  be  traced  to 
intestinal  irritation,  either  from  collections  of  faecal  matter,  undi- 
gested food,  or  vitiated  secretions,  the  indication  would  be  speedily 
to  remove  the  oftending  cause  by  resoit  to  a  stimulating  enema  or 
a  brisk  cathartic. 

3.  Irritation  of  the  Bladder  or  llectum, — It  may,  however,  hap- 
pen that  the  true  cause  of  the  nervous  paroxysni  is  rrritation  either 
of  the  rectum  or  bladder.  An  ai^^irravated  case  of  hemorrhoids,  or 
a  collection  of  fa?ces  in  the  lower  bowel  may  give  rise  to  convulsions. 
In  the  instance  of  hemorrhoids,  my  adyice  to  you  would  be,  not  to 
hesitate  an  instant,  but  at  once  to  disgor<i:e  them  by  a  free  j)uncture 
with  the  lancet.  Xo  tampering,  negative  treatment  will  do  hero; 
the  life  of  your  ])atient  is  in  serious  peril,  and  every  returning 
paroxysm  makes  the  peril  greater.  In  the  event  of  the  irritation 
arising  from  masses  of  fieees  in  the  rectum,  they  should  be  dis- 
lodged by  the  aid  of  an  active  enema.  If  the  cause  of  the  con- 
vulsion be  traced  to  irritation  of  the  bladder,  the  first  object  of  the 
practitioner  should  be  to  make  a  just  discrimination  as  to  the 
spechil  chanicter  of  the  irritation,  for  it  may  be  tlu*  result  of  various 
influences — retention  of  urine,  or  its  extreme  aeiidity,  calculus  in 
the  bladder,  or  strangury.  The  indication  of  treatment,  therefore, 
would  depend  upon  what  might  be  ascertained  to  be  the  true  source 
of  the  disturbance.  The  following  case  has  a  ])ractical  bearing  on 
the  question  now  under  consideraticm,  and  I  shall  cite  it  as  an 
illustnition  of  the  necessity  of  thorough  vigilance  on  the  part  of  the 
medical  man : 

In  June,  1850,  I  was  requested  by  Dr.  B.  W.  .Tohnston,  of  Long 
Island,  to  visit  a  lady  with  him,  in  the  sixth  month  of  her  gestation. 
Four  days  before  I  saw  her,  she  had  been  attacked  with  pneumonia. 
She  was  a  strong  plethoric  woman,  and  the  disease  was  in  its  very 
inception  of  a  grave  character ;  tlie  doctor,  on  being  called  to  her, 
very  properly  resorted  to  the  lancet,  and  abstracted  3  xvj.  of 
blood  with  decided  temporary  benefit ;  it  became  necessary,  how- 
ever, to  re])eat  the  bleeding  in  four  hours ;  3  viij.  more  were 
drawn ;  the  patient  was  freely  purged,  and,  through  the  administra- 
tion of  minute  doses  of  tartar  emetic,  full  action  was  promoted  of 


400 


THE   PRINCTPLES  AND  PRACTICE  OF  OBSTETRICS^ 


that  important  emunctory,  the  cutaneous  suHUct*.  A  Wistoi  ivas  j 
applied  to  the  ct»crst,  mid,  in  twelve  hours  atler  its  applieation,  the 
patient  was  attacked  with  filight  convulsions.  It  wa^  under  thctd 
circumstances  that  I  was  requested  to  see  her.  When  I  vidted  her, 
the  intensity  of  the  pneumonia  was  broken,  and  so  far  li^  thml 
affection  was  concerned  the  patient  wa«  making  favorable  projjres 
But  a  new  phaj*e  had  developed  itself  in  tJie  guise  of  the  C4invubt]<Mi, 
whieh,  although  slight,  was  still  i^igniticufkt  of  portending  trouble. 
On  inquiry,  I  learned  I  hat  there?  had  been  no  indiscretion  of  ditt, 
nor  were  the  bowelffi  in  any  way  constipated.  Attention  wan  next ' 
directed  to  the  condition  of  the  bladder,  and  the  nurst*,  an  int<4ti- 
gent  woman,  informed  us  ihat^  for  about  an  hour  before  I  be  cod* 
vulsion^  the  lady  had  complained  of  much  smarting  about  tli« 
bladder,  and  would  call  for  the  chamber  every  ten  or  fifteen 
minuteii,  supposing  that  ihe  could  pass  water,  but  at  each  linic  not 
more  than  a  few  drops  were  evacuated,  aceom|>anied  by  tbe  tmist 
painful  scalding*  Now,  gentlemen,  what  do  yoti  vM  this  m ore  or 
less  cor»8tant  desire  to  micturate^  with  an  inability  to  pa,%ai  inon* 
than  a  {qw  drops,  accompanied  by  a  sensation  of  sc:ihling?  U  il 
not  strangury?  Unquestionably.  In  the  case  of  thi?i  )mtienl,  mn 
any  of  you,  from  the  treatment  of  the  pneumonia  already  debcrilMNl, 
be  at  a  lo^s  to  account  for  the  strangury  ?  There  is  not  one  of 
you,  I  am  quite  eonHder»t,  who  is  not  pre| tared  to  tell  mv  thnt  it 
was  produced  by  the  absorption  of  the  cantharidcH  of  which  lh<! 
blister  was  composed.*  As  soon  as  we  had  learned  the  exijitenci} 
of  this  vesical  irritation^  an  important  light  was  thrown  on  the 
cause  of  the  convulsive  mo\  i  n  eit.  I  had  no  doubt  mynt^lf,  and  in 
this  opinion  Dr.  Johtjston  fully  concurred,  that  the  nervous  jier^ 
turbation  was  occasioned  by  the  strangury,  atfording  a  tangibtv 
illustrution  of  convulsions  from  irritation  of  the  bladder.  With 
this  diagnosis  of  the  case,  I  suggested  the  ful lowing  mediclntr,  ooie 
pill  to  be  taken  every  fifteen  iniuutes  until  the  strangury  yielded: 

PuIt,  Doveri  J 

Extract  Ilyoscyam.    vaa.gr.  xij. 
Pulv.  Camphor.  ) 

Ft,  mas^a  in  piL  xij  dividenda*f 
The  patient  J  had  not  t:dien  six  pills  before  she  erprewjcd  lier^elf 
relieved  uf  the  strangury;  there  was  no  recurrenco  of  tlics  convul- 

*  8tr»n|,;ury  is  tioi  a  necowmy  oun»ttH|i)oticr>  of  ilie  appHoatum  cif  a  bU«tor.  wliflt 
ftt  the  aNRiQ  tlnio,  u  rnortf  or  lens  fk^iiently  ffssalta.  J  bit*  flNUi,  mp^tMf  H 
cbi)dri-m  wbo^  it  U  well  to  rccoUc^ct  ai  n  gpnemt  rub  sttsuin  blbtcf*  liadljr,  Il» 
ttofit  diMn«»ttHf^  Hiitrfriti^  fh»in  «r»ngtiry  proiliicetJ  t»  ll»i»  way, 

f  I  hii%x'  rt*|>^ikteclty  Umixd  tttb  an  adinimblo  cciriibtnatKiii  i»  ninmfnrf  tham  lh# 
absorption  (»f  eaiab'iriUos  nnvl  cjiii  rccomtncml  It  wall  inucli  contUtirucK, 

}  lu  lliU  cwic,  jiUo,  itiQ  uriac^  w»s  fXAiriined.  but  llivm  w«a  no  tmoo  of  allMiiiun. 


THS  FBINCIPLES  AND  FBACTICE  OF  OBSTETRICS.         491 

lion ;  but  I  subsequently  was  informed  by  the  doctor  that  she  was 
ddivered  shortly  afterward  of  a  still-bom  child,  bearing  the  evi- 
dences of  having  been  dead  for  some  days. 

It  is  not  of  rare  occurrence  that  the  child  is  defrt-roycd  in  utero 
daring  an  attack  of  convulsions,  and  such  no  doubt  was  the  fact  in 
this  instance.  When  the  death  of  the  foetus  takes  place,  this  latter 
acts  not  unfrequcntly  as  a  foreign  substance,  and  evokes  premature 
action  of  the  uterus —  a  most  fortunate  provision,  for  the  continued 
sojourn  of  a  dead  child  in  utero  could  not  but  seriously  compromise 
the  h<Milth  and  safety  of  the  moths*r. 

It  can  scarcely  be  necessary  to  remark  that  if,  on  examination, 
yon  asceitain  the  convulsions  to  be  occasioned  by  the  distension  of 
the  bladder,  the  remedy  will  bo  the  prompt,  but  cautious  intro- 
dncticm  of  the  catheter.*  I  have  mentioned  that  calculus  may 
Bometimes  be  the  offending  cause.  Here,  an  operation  for  the 
removal  of  the  calculus  is  out  of  the  question  ;  for  the  very  attempt 
would  most  certainly  aggravate  the  irritation,  and  thus  excite  the 
renewed  paroxysms  of  convulsion.  In  such  eases,  the  obvious  duty 
would  be,  if  the  thing  were  possible,  to  have  recourse  to  artilicial 
delivery. 

Irritation  of  the  Uterus  and  Vagina. — I  shall  now  speak  of  irri- 
tation of  the  uterus  and  vagina  f  as  a  cause,  through  eccentric 
action,  of  puerperal  convulsions ;  and  this  irritation  may  develop 
itself  during  pregnancy,  in  the  progress  of  labor,  or  after  the  birth 
of  the  child. 

Jhiring  Pregnancy, — It  is  an  interesting  question — Under  what 
circumstances  do  convulsions  most  frequently  occur  in  gestation  ? 
As  &r  as  statistics  can  establish  the  fact,  and  I  think  there  is  no 
fiust  better  proved,  they  are,  out  of  all  proportion,  more  frequent  in 
the primipara  than  in  the  mvltipara^  both  during  pregnancy  .and 
labor,  averaging  over  ninety  per  cent.  Then,  the  inquiry  neces- 
sarily arises,  why  is  this  ?  The  explanation  is  not  difficult.  In  a 
first  pregnancy,  the  female,  especially  if  her  nervous  system  be  deli- 
cately organized,  is  much  more  predisposed  to  nervous  pertui-bntions 
than  one  who  has  already  passed  through  that  process,  and  who, 
consequently,  becomes  to  a  certain  extent  accustomed  to  the  excite- 
ment, which  more  or  less  usually  accompanies  gestation.  Again : 
it  is  a  well-established  practical  fact,  that  there  is  much  greater 

*  It  18  always  necessary,  in  tho  introduction  of  tlie  catheter,  to  use  caution  and 
geDtleness ;  but  the  observance  of  this  rule  is  particularly  called  for  in  a  case  such 
as  we  are  supposing:,  in  which  convulsions  have  ensued  from  vesical  irritation ;  for 
the  sliKhtcst  injury  to  the  urethra  would  be  very  likely  to  renew  the  paroxysm. 

f  It  has  already  been  stated  that,  in  convulsions  from  undiprcsted  food  in  the  stomach, 
the  irritation  is  transmitted  to  tho  spinal  cord  through  tlie  pncumogastric  nerve ; 
bat  when  the  source  ot  disturbance  is  in  tho  intestines,  or  emanates  from  the  uterua 
itaelC  the  incident  excitor  nerve-fibres  of  tlio  spinal  and  sympathetic  uterino  neryet 
are  the  media  through  which  the  irritation  is  conveyed. 


498 


THE  PRIKCIPLKS  A^D   rBACHCE  OF  OBSTKTRICa 


rigMity  of  the  on  ntcri  in  tho  primipara,  whicli  necfssarily  rxfuw 
the  iricitlent-i*xcifor  iK*rved  of  that   |);irt   to   increasecl   IrriuiUoii*  ^ 
BvsidcA,  when  treating  of  albuminuria,  its  eau«es  and  i^ffects^  w# 
shall  tfl!  you  that  con<rp«!li<>n  ant]  uthiT  tierangemeiita  of  the  kid* 
ney«  are  far  more  frequently  met  u  ith  in  fir«l  than  in  !;u1>seqiteot ' 
pregniHitncs. 

Another  ques»tion  of  equal  Interest  nn»e» — Do  convn1i!iionff  mai^ 
fest  themm'lves,  aa  a  general  rule,  in  inidfUe  life,  or  at  an  earlier 
pcriorl  ?  Th(*  l)c»**t  ohftervation,,  and  ihe  most  nccurate  I  "  -how 
that  the  parlioular  period  of  life  nt  \\htt»h  they  are  '  to 

occur,  is  between  the  ages  of  seventwn  and  thirty-five;  and  it  may 
also  be  ntatuil  as  worthy  of  note,  that  if  they  develop  them!(4!lire« 
before  the  sixth  rnonth  of  gestation,  it  i«  an  exception  to  n  verw 
general  rule;  for  the  rale,  founded  upon  the  careful  obniTratMrn  of 
praolieal  men,  is  that,  as  a  eoniplic'ttion  of  pregnaney,  in  the  |;reit 
majority  of  iriRtanceH,  they  take  place  between  the  neventh  and 
ninth  months.^  This,  ton,  is  my  own  i*xpent'nce,  and  I  l^clievi*  It 
to  be  perfectly  Jii  aeeordanee  with  facts.  It  hm  hc^n  pO!*itkdY 
affirmed  by  Honte  wriTeri*  that  eonvtilf«ior»R  cannot  be  de%-eloped 
duiitig  pregnaney,  unle,*^,s  they  nre  preec*deil  by  contraction!*  of  tho 
uterufi.  Thi«)  ofunion,  how*ever,  is  at  variance  with  the  obaenratlGt* 
of  the  lyinp-in  room. 

7Watriicnf  of  Cortrtthlon^  tlurinff  Pf^fpmn*y, — Well,  gentkmeitr 
you  are  tjummoned  to  a  Iridy  in  corivul«tona  in  the  progrei*  of  her 
pregnancy,  and  labor  has  not  coinmenctHL  Wfiat  is*  to  be  dnnit? 
Your  action  ^vlll  depend  altogether  on  the  surrounding  otreiini- 
stances.  We  jmsume,  however,  that  thi?  convulsions  here  art*  iliti 
to  uterine  irritation  f^impty,  nn<l  are  not  complicated  with  uneiaM| 
of  which  we  «<ball  ftpejik  liereafter*  If  you  leave  this  univeratty  uiik 
the  conviction,  too  mdly  imprcftscd  upon  the  rfiindi  of  Aome  prac^ 
tltioners,  that  the  relird>le  remodiea  in  pueri>eral  convnlidoo*  aitf 
bloiriMetling  nml  opium,  it  is  reasoruible  to  suppose  that  one  or 
other  of  these  «geriiN  woulvl  be  iinniediately  re.*<orted  to.  1^4*t  «% 
for  a  moment,  pause  and  exanune  this  |*oint ;  this  examinalioa  may 

•  Dopaul  montions  a  c«fc  of  eonviiUfona  in  the  fourth  month  of  gvttatioik 

I  Thorc  prcx'ailo<i  mnnjr  ycors  ginee  a  very  general  opmion  ihat  {iutn»»fal  ro^tl^ 

A>ii«  wen*  n]\vnt>  c1ii«>  t/>  one  of  three  ottUtM:  confititutlonal  ir<  ieir^titlirr 

dr  tlu!  tit»'n»s  rrtim  nvi?rMtt»uort{iu)n,  Of  |^D«ni]  plclliorn;  ami  v  i*AL,ct^ 

wtiidi  \%M  biH'u  liAfidi-d  down  to  the  present  dwy,  Wf  Imve  Uih  cxphu:  i;  H 

Itiit  000  priu?tiuoncr»  who  refers  tlio  couvulMiuii  to  const) lutiori id  i.,,„,  .,  nfifl 

«aipk»y  opium :  »nuLhi<T,  who  cna  see  tiothincr  but  cxecwive  di8t**aflion  of  Ui*t  |(iftr1d 
^<,p.,i.  »^  (i,-.  f*'mR4t  of  thv  nervous  diilurbjioci*.  will  report  to  hiinicdiiUo  dtlifvrf; 
W:  1,  who  iiiwHja  a.«iociMli)!i  to  hb  tiiind  piK'rpon)  corirnltkMui  nid  fi^ 

Ihio.i,  >^>>.  [f>>iird  the  lancet  m  his  only  hope.  Th^  I  think,  will  iicomiiirt,  k>  ■ 
dc^rrre  at  1^A0t«  for  the  roun'no  pmctioc,  which  hnei  been  adopted  in  th«  mmtm§fftmmtt 
of  t)ti«  M^riouH  offeclion ;  it  fthowK  ii1m>  th«fullj  of  mere  hji'pcithentB,  nod  al  ikm  wamm 
Umo  th«  nuot'^itjr  for  a  ri^id  muiljiia  of  emah  cikM*  ««  it  trtny  prvMot  StMlf  In  llM 
tbeenrAtioQ  of  ihe  pntctitioncn 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         498 

St  some  future  timt>  serve  jou,  and  protect  your  patients  against 
the  fetal  consequences  of  stereotyped — I  know  no  more  emphatic 
term— practice.  Here,  then,  is  your  patient,  in  gestation,  and 
attacked  with  convulsions ;  the  instant  you  approach  her — true  to 
the  undying  instincts  of  routuiism,  you  call  for  a  bandage  and  basin  • 
the  bandage  is  arranged,  the  basin  all  in  readiness,  and  the  lancet 
plunged  into  the  vein.  The  blood  flows,  the  patient  faints ;  and 
Boon  after  reaction  comes  on,  there  ensues  another  convulsion  more 
marked  than  the  preceding.  You  have  not  taken  away  blood 
enough,  whispei-s  that  fatal  delusion — routhiism !  The  ligature  is 
again  applied,  the  orifice  opened,  and  slowly  runs  the  current! 
Syncope  follt)ws ;  the  spark  of  life  is  again  rekindled  by  a  feeble 
reaction ;  another  convulsion,  and  speedily  death  closes  the  s(*ene, 
thus  preventing  further  depletion !  The  practitioner,  who  has  an 
abiding  faith  in  blood-letting,  as  the  only  element  of  hope  in  puer- 
peral convulsions,  would,  if  consistent,  say  to  the  disconsolate 
friends,  "Oh I  if  I  had  seen  the  case  at  the  commencement,'! 
should  undoubtedly  have  saved  that  life !"  To  the  ignorant  and 
uninitiated  such  language  may,  ])erliaps,  prove  a  mantle  for  the  con- 
cealment of  reckless  and  unjustifiable  practice;  but  it  wull  fail  to 
appease  the  severe  exactions  of  science. 

So  far,  gentlemen,  from  depletion  being  indicated  in  the  case  just 
cited,  it  may  perad venture  be  that  the  resort  to  the  lancet  is  the 
true  cause  of  death  ;  and  I  will  explain  why  this  might  probably  be 
so.  Suppose,  for  instance,  the  patient,  from  antecedent  disease, 
hemorrhage,  or  from  any  other  cause,  should  exhibit  an  examj)leof 
ancemia/  in  such  an  event,  this  very  anaemic  condition  may  be  one 
of  the  essential  exciting  sources  of  the  convulsion.  What,  then, 
becomes  of  the  potency  of  blood-letting  in  a  case  like  this  ?  Its 
only  potency  consists  in  the  prompt  extinction  of  life,  through  an 
aggravation  of  the  anaemia.  There  is  no  fact  more  essential  to  be 
borne  constantly  in  mind  than  the  direct  connexion  which  exists 
between  excessive  losses  of  blood,  no  matter  how  produced,  and 
convulsions. 

When  an  animal  is  bled  to  death,  in  the  case  of  the  calf  or  sheep, 
for  example,  the  prelude  to  the  death  struggle  will  be  convulsive 
paroxysms.  How  often  do  children  succumb  from  convulsions 
induced  by  the  large  abstraction  of  blood,  either  by  the  lancet  or 
leeches ;  and  in  these  cases  ot  convulsion  from  exsanguification  of 
the  system,  the  result  is  almost  always  fatal.*  Be  careful,  there- 
fore, how,  without  due  consideration,  you  employ  this  remedy  in 
early  childhood,  for  its  abuse  will  readily  lead  to  serious  conse- 
quences. Brown-Sequard,  I  have  told  you,  has  shown  that  the 
cause  oflhe  convulsion  following  excessive  loss  of  blood  is  the  same 

*  Convulsions  from  anspmia,  whether  tlie  anaemia  arise  from  blood-letting,  homo^ 
riugOi  or  any  other  cause  are  to  bo  noted  as  of  centric  origin. 


4S)4  THE  PRINCIPLES  AND   PAACTICE  or  OBarTETRICa, 


jis  in  asphyxia — there  is  in  fact  an  insufficient  i  "       ••^rcv 

foiT,  the  airjoiint  of  c-arlionic  acid  increases  in  t  i  ii tiU 

cord  and  medulla  oblongata  become  extremely  sensitive?  to  the  irrit*- 
\lt^n  of  blood  containing  a  notable  quantity  of  carboriio  add,  and 
hence  the  con vnl hive  movement,* 

I  have,  I  ihink,  sjiid  Hufficient  to  show  you  that  the  if  n%i^ 

or  routine  practice  oC  resorling  to  the  lancet  in  »hc  ii  i  of 

cotivuUion!!,  is  not  otdy  unsound,  both  in  its  phy&iology  and  pattio*^ 
logy^   but  must,   of  nece.s.sity,    sometimes  prove  li  fatal    |ir]i«*lie9. 
Therefore,  gentlemen,  when,  in  these  CMseii,  you  |»lace  your  hope  id 
bhiod-ietiing,  let  it  be  a  hope  for  which  you  cran  exhibit  Mimr  ^uIh  i 
stantiol  basiH,     I  shall  presently  speak  of  the  indicatioiiN  tbr  then$*a 
of  thtH  heroic,  but  much  abused,  remedy. 

Let  us  now*  for  an  instant,  tvu-n  to  optum^  the  otiicr  routine  sig^ut. 
It  is  a  habit  with  some  practitioners  to  regard  convtilsions  Ascxelli*  - 
sively  traceable  to  a  disquietude  of  the  nervous  i^ystem,  without  U 
alf  tnki»»g  into  account  the  collateral  and  aecfmiparjying  clnriuD- 
stances ;  and,  w*ith  this  limited  view  of  the  patholosty  of  ilie  afleck  l 
tion,  they  administer  opium  for  the  purpowe  of  noott 
and  |>roducing  sleep.     In  order  that  you  may  fairlv 
pointy  and  fully  ap|>reciate  the  inevitable  iiazard  uf  thii^  liiiiJl*rd  md 
one-5«ided  view,  allow  me,  for  the  instant,  to  remind  youof  t*' ■  *--"i~ 
therapeutic  properties  of  that  important,  and  alno  much 
agcni — opium.     In  a  plethoric  condition  of  •ly^tem,  the  dii 
dency  of  this  drug  is  to  produce  ci»ngeMion  of  the  two  great  i 
centres — the  brain  and  Kjiinal  cord ;  and  it  is  a  welbestabrmhcd  Gurl, 
that  iongestion  of  either  of  these  important  organs  will,  t'  * 

centiic  influence,  prove  a  fruitful  cause  of  convulsions.  W 
prop(Jiiition  beftjre  you,  the  truth  of  which  is  nniversally  conceiird 
in  theory,  but  too  frequenily  forgotten  in  [Mactice,  do  you  not  «i 
ODoe  |»er€eive  the  extent  of  the  peril  to  which*  of  neces^ily^  you  will 
exptj}^  your  pntient*  in  the  use  of  this  medicine  as  a  remeily  in 
puerporal  convubiuns,  unless  it  l)e  atbninistered  with  judgnieot, 
and  with  a  due  regard  to  its  special  therapeutic  action  ?  Agftia: 
if  the  system  be  greatly  prostralinl  by  previous  looses  ;  if,  in  a  wonl, 
lh«  patient  be  in  an  ana?mic  stale*  then  opium  coujinned  with 
brandy,  ammonia,  or  cotfee,  U  a  valuable  remedy  ;  it  is,  indeed,  ia 
thi'se  cases,  oftentimci*  the  means  of  saving  human  life.  You  see, 
therefore,  that  thi^  medicine^  in  the  aftection  of  which  we  aro  now 
speaking,  ciin  be  regarded  as  appropriate  only  when  given  withdiM 
discrimiiiatioo  ;  and  the  same  remark  applies  with  e<jmil  force  to  all 
reme^llal  agents 

*  Tbc adniirvblc  nsenrcbea  of  KuBstnaul  nnd  A.  Tenner  on  t)i  ,  rit  oNBii 

hf  Ums«.«  of  Ulond,  woiiM   k*iid    to  the   opuikm  that  it  in  dn  v>a  oTIto 

tiMduIU  oUonipitM  and  ponn  %'»riiUu  mImcIi  induce  IIk-ik.' cxitivulfligua.  ^Jvunud  d«li 
Pbjriiotogio  de  T I  loin  mo  et  dit  Anifn«ux.     Tofn«  I,  p.  301.  J 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.  496 

In  the  treatment  of  convulsions  during  pregnancy  or  labor,  jon 
are  to  look  beyond  the  mere  paroxysm  ;  you  should,  as  far  as  may 
be,  endeavor  to  ascertain  the  cause  of  the  nervous  disturbance,  and 
not  blindly  have  recourse  to  remedies,  wliich,  too  often,  ha^e 
nothing  to  recommend  them  in  given  cases  but  mere  custom.  Just 
discrimination  is  a  very  necessary  and  essential  element  in  the  cha- 
racter of  a  medical  practitioner ;  he  should  school  himself  to  close 
observation,  so  that,  through  rigid  analysis,  he  may  be  enabled  to 
deduce  truthful  conclusions.  Therefore,  instead  of  having  your 
minds  fettered  by  preconceived  opinion  in  regard  to  any  particular 
form  of  treatment,  you  should  be  careful  to  subject  opinion  to  cir- 
camstances  as  they  may  develop  themselves  in  the  sick-room.  If 
you  do  this,  your  therapeutics  will  not  only  be  in  keeping  with 
the  philosophy  of  science,  but  the  results  will  be  likely  to  be  satis- 
factory. 

In  illustration  of  this  remark,  I  shall  now  endeavor  to  show  you 
under  what  circumstances  blood-letting  will  be  indicated  in  con- 
▼ulmons  during  gestation.  Suppose,  for  instance,  the  patient  should 
be  plethoric,  with  a  bounding  pulse,  and  flushed  countenance. 
Would  any  man,  in  his  senses,  hesitate,  with  these  premonitions 
of  danger,  as  to  the  course  to  be  pursued  ?  I  think  not.  Here, 
prompt  and  full  depletion  by  the  lancet  is  urgently  demanded  for 
two  substantial  reasons:  1.  The  vascular  fuhiess  may  be  the  cause 
of  the  convulsive  paroxysm,  in  consequence  of  congestion  of  the 
spinal  cord,  or  of  the  brain,  indirectly  affecting  the  cord.*  2. 
During  the  convulsion,  the  patient  will  incur  the  hazard  of  death 
from  apoplexy,  if  the  j)lethora  continue  undiminished.  The  bleed- 
ing, however,  to  be  of  value,  must  be  sufficiently  copious,  the 
quantity  abstracted  being  regulated  by  the  peculiar  circumstances 
of  the  case,  of  which  the  practitioner  is  to  be  the  proper  judge. 
Should  it  be  necessary,  let  the  operation  be  repeated  until  a  decided 
impression  is  made  on  the  system  ;  what  I  mean  by  a  decided  im- 
pression is  the  evidence  afforded  that  the  plethora  has  yielded  to 
the  depletion. 

In  all  cases  of  convulsions  with  vascular  fulness,  it  is  highly  im- 
portant that  there  should  be  a  prompt  and  free  action  of  the  bowels. 

•  It  has  been  bIiowd  by  the  pathologist,  in  tlie  autopsies  of  women  who  have 
died  during  gestation  or  hibor,  that  either  of  these  latter  conditions  is  usually  accom- 
panied by  what  is  termed  a  passive  engorgement  of  tlie  inferior  portion  of  the 
iplnal  oord.  This  fact  evidently  demonstrates  a  peculiar  predisposition,  both  during 
pregnancy  and  labor,  to  congestion  of  the  cord,  and,  consequently,  to  convulsions 
fivMn  this  centric  influence.  Yet,  notwithstanding  this  predisposition,  it  is  not  true, 
as  some  writers  have  attempted  to  show,  that  plethoric  women  are  more  commonly 
attacked  with  convulsions  than  those  of  a  debilitated  and  broken-down  condition. 
On  the  contrary,  women  who,  from  certain  pathological  influences,  have  suffered 
flrom  change  in  their  blood  constituents,  as  denoted  by  their  cachectic  and  hydropic 
■tstes,  are  the  very  women  most  likely  to  suffer  from  convulsions. 


496 


THE  PRINCIFLE8  AHU  PEAUTICE  OF  OBSTETRICS. 


Tills  miiy  hv  aecornplished  with  medicine  by  the  mouth,  or,  in  thi  I 
event  of  the  palioiit  not  boing  able  to  swullow,  hy  mcariJi  of  ft 
purgative  ctitMna.     A  very  guod  eatliartic,  niidcr  the  circaixu4aDoei| .] 

k  the  following  dmught : 

U 

InftH.  Seunoj  ^  S  iv 

2>Lilj>hat.  Magncsiie     3  U 

Mannas  3  i 

Tinct.  Jalapao  f.  3  ij* 

M. 
But,  gentlemen,  I  must  apprise  yoii  of  one  fact  never  to  beloit^l 
&ight  of  when  treating  convulsion;*:  it  U  this — delay  is  ojteniim 
tk^  cause  of  dtath  ;  and  I  regard  it  so  essential,  hi  connexion  with 
the  ahslniclion  of  blood,  to  have  a  pmmpt  movci 
bowels  th:it  I  am  in  the  habit  of  ret^ortmg  to  what  IhaN 
only  a  ]>niTn[»t  hut  an  eflicient  n^raedy — croton  oU,  Thure  ii,  I 
think,  an  unfounded  prejudi*;e  against  this  medicine.  I  have  heftrd 
pni<*titioncr»  object  to  its  iihh  beejiu.se  of  the  a])prehentiinn  th^  il 
wouhi  produce  /li^ptTcafhatJtifi,  or  excessive  purgirij^.  I  hrive  da- 
ployed  it  repeatedly  with  cldldren  and  adults  «nd  1  Ik'Ucvc  it  tl> 
be,  under  diacreet  adminifltrationf  a  safe  and  invaluable  Egeoi.  I 
have  on  several  occiisloiw  resorted  to  it  in  eonvulniouit,  aod  with. 
decidedly  good  effect : 

n 

Olet  Tiglii  gtt.  iv 

Sacchar.  Alb,      3  ij 

Mucil.  Acacias  f*  5  h 

M. 
a  tea-s|JoanfuI  every  fifteen  mintiteis  until  the  bowefii  are  fiiov«d* 

Here,  we  have  an  important   auxiliary  in  connexiou  willi  tfct 
lancet  and  eroiou  oil — I  mean  cold  ap)»liealions  to  the  htiid  •  thuf  ^ 
will  prove  of  very  material  service,  and  nhonld  not  be  Al 

an  adjuvant,  alAo,  in  thcge  ca*es,  we  have  an  admiral..  .  .4,  Jy, 
whiehlthink  wjw  first  introduced  to  the  attention  of  the  profeaaioOf 
in  tliL*  ircalnu'i»t  t>f  eonvulsjionH,  by  Dr.  Collins,  of  Dulilin*  lathide 
to  tartarixed  aiitiTnony  in  small  or  tolerant  do^ien,  the  libjcct  btingt 
uodur  itH  admin ist  ration,  to  keep  up  n  relaxed  condition  nf  tbo 
syMem,  Dut  the  remedy  of  all  others,  after  the  cireutatitm  hm 
been  brought  under  proper  control  by  thedne  abstractifm  of  btooil, 
etc.,  is  the  inhalation  of  ether,  not  admini.^tcred  so  tts  to  dealroy 
eonAcioustiesti,  but  merely  to  produce  a  sonthini;  iiditKtaco  on  tbe 
nervous  sygiem.  I  can  speak  of  ihia  agent — wliich  is  another  nf 
the  abuned  art  ides  of  the  materia  mediea — ^with  great  cr>T^^^  -- 
in  this  emcrgeney,  for  I  have  tested  it  in  the  most  sali 
maimer.  Its  chief  erticncy,  in  these  instances,  is,  I  thinks  tv  b« 
asciibi'd   Ui  Its  p«iUiM-  of  diminishing  redex  neuHibihty,     iVcvcr, 


THK  PRINCIPLES  AND  FKACTICE  OF  OBSTETRICS.         497 

hoimeoer^  have  recourse  to  it  in  cases  of  plethora  until,  by  the 
Judicious  use  of  the  lancet,  the  circulation  has  been  duly  equalized. 
In  cases,  also,  in  which  there  is  no  vascular  fulness,  and  the  convul- 
sion can  be  traced  simply  to  nervous  irritability,  ether  will  prove 
invaluable  from  the  first. 

If  the  convulsions,  as  will  sometimes  happen,  continue  in  defiance 
of  these  remedies,  then  the  question  presents  itself,  can  nothing 
more  be  done  ?  This  brings  us  to  the  consideration  of  exciting 
premature  action  of  the  uterus,  so  that  its  contents  may  be  expelled. 
IfJ  in  your  judgment,  after  weighing  with  due  care  all  the  circum- 
Btances  of  the  cajic,  you  should  be  confirmed  in  the  opinion  that 
delivery  is  the  only  alternative,  in  order  to  save  either  mother  or 
child,  then  I  need  not  assure  you  that  the  course  to  be  pursued  is  a 
very  plain  one,  and  without  delay  you  should  proceed  to  evoke 
uterine  contractions.  The  mode  of  doing  this,  and  the  various 
plans  suggested  by  authors,  will  be  stated  when  treating  of  prema* 
tare  artificial  delivery.  It  may  be  mentioned  in  connexion  with 
this  topic  that  if  the  child  should  be  ascertained,  through  ausculta» 
tion  or  other  means,  to  be  dead,  and  the  convulsions  still  continue, 
then  the  expediency  of  bringing  on  labor  is  the  more  urgent,  in 
order  that  the  life  of  the  mother  may  not  also  be  sacrificed ;  and^ 
moreover,  the  death  of  the  child  removes  the  only  iTilid  plea 
against  the  operation. 

During  Labor, — When  convulsions  occur  during  labor,  they 
may  do  so  at  the  commencement  of  the  parturient  effort,,  during 
the  process  of  dilatatiun,  or,  as  I  believe  most  frequently  takes 
place,  they  may  manifest  themselves  after  the  head  has  left  the 
uterus,  and  is  pressing  upon  the  vaginal  walls,  and  espechilly  during 
the  last  struggles  just  as  the  head  *  is  about  to  make  its  exit.  The 
treatment  of  convulsions  at  the  time  of  parturition  will  generally 
vary  according  to  the  ])articular  stage  of  labor  at  which  they  mani- 
fest themselves.  In  all  cases,  however,  where  there  is  an  evident 
plethora  of  system,  the  free  use  of  the  lancet  must  immediately  be 
resorted  to  for  reasons  already  explained  ;  the  therapeutic  principle, 
which  is  to  guide  you,  is  precisely  the  same  in  convulsions  with 
plethora,  whether  they  occur  during  gestation  or  at  any  stage  of 
labor. 

It  may,  however,  be  that  the  convulsive  paroxysm  commences 
soon  after  the  inception  of  labor  in  a  patient,  who  does  not  ex- 
•hibit  vascular  fulness,  but  whose  throes  of  parturition  are  severe 

*  It  is  aQ  interesting  fact  to  note  that  when  convulsions  occur  during  labor,  thej 
do  so  in  the  great  majority  of  cases  in  head  presentations ;  and  strange  as  it  may 
Appear  to  those  who  have  not  examined  the  subject,  they  are  extremely  rare  in 
malpositions  of  the  Aetus.  It  is  stated  as  tlie  result  of  the  combined  observation  of 
Dra  Clarke,  Labatt,  and  Collins,  in  the  Dublin  Lying-in  Hospital,  that  there  was 
but  one  case  of  convulsions  coincident  with  malposition  in  48,397  labors. 

S2 


498 


THE  PRIKCIPLES  AND  PRACTICE  OP  OBOTETWCS. 


anH  in  quick  surcrsstion.     It  rniijr  then  becnmc  «  question  wh<'lb€»r, 
utidtT  the  circunifttanet'S^  the  coiiviilsion!^  are  not  altogethi^  du<*  ta  lh« 
Tinusiially  rapid  auccei^^ton  of  thepAins.     If  «o,  I  know  of  no  rcrmMy 
equal  to  the  belladunna,*  for  I  am  quite  ftatlsHc^d  that  tt  |>o9»e«ifte9  , 
two  iinportant  ftllribirtt's,  one  of  which,  at  leiu*t,  hruv  [M^rlmpm,  not 
been  sufficiently  appreriated  in  the  prartioi?  of  midwifery :  t!it*!iOf 
attributes  are  (Ae  luUing  of  utrrinr.  contractirm^  ami  the profnoiiom  \ 
of  dilatation  vf  the^  mouth  of  (he  or<jan.     Therefore,  in  the 
we  are  now  speaking  of,  I  should  rernrnmend  you  to  bibrieaie  the 
OS  uteri  freely  with  the  bel  hid  anna  oin  intent  3  j  ^f  the  extftici  to 
5  j  of  adeps.     If  this  should  prove  as  elHcaeious  in  your  hands  aa 
it  ha3  in  mine  in  subduing  inordinate  eon  tractions  then  I  am  sunt 
you  will  unite  \>'ith  me  in  regarding?  it,  under  the  cireumsianoi'fK  n 
most  valuable  reTuedy,     In  casoss,  too,  in  which,  from  ant 
disease  or  other  conditions,  the  health  of  the  parturient  ftii.^.. 
become  mnch  disturbed,  leaving  her  in  a  atate  of  tnoro  or 
exhaustion,  it  may  beeonie  desirable  to  eheek,  for  the  time»  the  ao 
of  the  uterus,  more  c\sprcially  when  it  \fi  5ev*>rc  and  in  snch  qttidt^ 
tuccession  as  to  exhaust  the  strength  of  tlie  patient;  in  nuch  in- 
stances, you  possess  in  the  belladonna  an  efficient  means  of  fulfiUing 
the  indication* 

Miu-h  has  been  said  about  the  propriety  of  ruplurir 
b rat ieji  in  eases  of  c^mvulsiinns,   fi)r  the  purpoiic  of  ev u  .:  ih«  1 

liquor  amnii ;  and  the  suggestion  is  advanced  by  many  praetitioQera 
0U  the  ground  that,  on  the  escape  nf  ihe  anniiottc  fluid,  the  ntrnta 
becomes  diminisficd  in  ^^i^e,  the  tension  is  reniuved,  and  ciJH»«*  I 
qucaitly  the  uterine  irritntion  being  thus  sensibly  lessened,  ih# 

It  19  well  uufierstoof]  tlii^t  tho  coTiiructility  of  tliii  iiiorun  oiin  dUirr  b«  «xcit<4 
^4cpri:<;^K'd  ihroujyh  Ihe  nctiou  of  LvrL-iIii  jigvnts;  im*l  U  la  a  lrno»*Mjpo  «f  tliks  ^ 
let*  whk'h  oflc'iitlrm'8  «'nnblc?!t  iho  pracluicmcr  lo  ppiiijcf  w»"  u^  to  liii  « 

pttlionL     For  exfttfipkv  wp  know  tttnt  f^>VJ,  npn-tniii  cxeit4»miM,  ,  iilAliouoC 

tii«  m  tfterir  eloctrioitrt  etc.,  i«ro  »>  -  ncea  c»)ialitG  of  iuciUug  OMiitn4SlJ«iS>1 

M  th{>  orgrnn;  oii  the  other  hAod,  an  {'R^e^ion  of  nnmJ.  nnd  m»'fr  f^j^cMyf 

l>cl)udorina,  exhibit  wry  pensibj/  tiieir  puwer  lu  q»iictJiii|r  * 
wvty  iiilfnwtinif  i^xpvniufiiLs  luive  ht^n  made  by  Mr  T  ^ 
fo  fihov  tho  ^ltVt^L9  of  belUufoiiiia  on  thd  clrL"uI«tion.     Mi  h^   i  Hi,,ti 

mHxry  lu  the  web  of  n  fro^  cjtbibitod,  undrTtho  mien»oope,  i  f/nHinch'ni  «ti 
ollOOSl  lo  oblit^.Tniyon  oil  ttit*  itpplicntbti  of  IjrIUdonrui ;  wbiU\  »l  Um  aaiM  liai%1k«  , 
^lood  hi  Uie  cdfruiipriiidin)^  cnpiUnrks  ntid  veiio«ifl  mdiculofl  wha  iu  ft  iitato  I 
4K1  Btiif(U4t'ion.  It  WQuUl  SLK-m,  thon^furc,  that  this  rvniedy  dtxrs  not  ^v%  dirvuUy  on 
ilic  muaeular  flWrva  of  ibo  uterus,  but  excrta  its  luffuene©  tm  tb«  wails  ^-r  iJtf  >.)n«|. 
fMM*la  difltribuli.Hl  tbrntjg)imit  the  orgHn ;  uod  thiA  InHaenoe  cm  tlie  \  ot« 

explftinM  HA  follows:  tbo  iMfUmlonna,  it  is  said,  excitoa  tbo  t^^vit  -\  i,  ^ „.nr« 

Of  Uio  iinalt  nofvouji  Dlomctita  locompiinyinjy  the  vc«^  i  iitji  oxcitiemcii^ 

the  venelf  oontmct,  nnd  coniwqnctitly  "^  •  "  •-'-Tifr  <ir  i v  fi«cwiv«  bti«ir 

ffMlly  ]C9Mfl«<l,  tbe  uterus  ncciipie.^  H  »r  and  im  tijiftucfl  tKcooMi  4kiii^ 

iilab«d  hi  Jt<^cm)  volume.  But  U  must  U  ■> mui  n-a  ihnt  the  revvm  why  Uia  iitem 
fielax«9  when  tjellndoiina  iiiipplicd  i» — Ibnt  tb^  hI(MKt>veB»ek(  «iotnict.  uid  IbtlHMt 
^  tho  organ  tioC  nMoivtiif  blood  cmmikIi  Dccwuifily  booomrt  wft»ft»A. 


TEA  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIGS.         499 

oonvtdsions  will  c^ase.  I  can  see  no  force  in  this  argument,  and  I 
am  convinced  that  the  rupture  of  the  sac  before  the  proper  dilata- 
tion of  the  OS  uteri  is  bad  practice,  and  oftentimes  will  be  followed 
by  increased  paroxysms  of  convulsions,  for  the  reason  that,  as  a 
very  general  nUe^  the  contractions  of  the  uterus  are  marked  as 
soon  as  the  liquor  amnii  has  passed  away,^  If,  however,  the 
dilatation  have  been  accomplished,  there  can  be  no  objection  to 
affording  the  escape  of  the  waters  by  rupture  of  the  mcrnbranour 
bag.  It  must  be  recollected  that  ether  is  an  important  resource  in 
the  convulsions  of  labor,  as  we  have  shown  you  it  is  in  pregnancy 
where  parturition  has  not  commenced,  and,  with  the  restrictions 
previously  mentioned,  you  will  find  its  employment  most  satis- 
ikctory. 

When  it  is  practicable,  there  can  be  no  doubt  that  the  impor- 
tant indication — indeed,  the  very  best  practice  in  convulsions  at 
the  time  of  labor,  is  to  deliver  the  patient.  Some  authors  recom* 
mend  version  when  the  head  is  at  the  superior  strait,  and  the 
mouth  of  the  womb  in  a  condition  to  justify  this  operation.  With 
this  view,  under  certain  restrictions,  I  coincide.  If  you  will  permit 
me  to  express  a  positive  and  emphatic  opinion  on  this  point,  it  is, 
that  under  no  circumstances  should  version  be  attempted  in  puer- 
peral convulsions^  U7iless  the  patient  he  j^reviousiy  placed  under  the 
full  influetice  of  anaesthesia^  and  for  the  following  reasons  :  1.  The 
very  introduction  of  the  hand  into  the  uterus  constitutes  an  excit- 
ing cause,  which  would  almost  certainly  evoke  the  convulsive 
paroxysm;  2.  The  manipulations  necessary  to  accomplish  the 
delivery  would  so  irritate  the  organ  as  to  subject,  through  a  repe- 
tition of  the  convulsion,  the  life  of  the  mother  to  the  most  serious 
peril. 

The  tifo  next  alternatives  are  the  forceps  and  crotchet.  If  the 
head  be  well  down  in  the  pelvic  cavity,  there  should  be  no  hesita- 
tion in  using  the  forceps  ;  f  if,  on  the  contrary,  it  still  be  at  the 

♦  This  is  readily  accounted  for.  When  the  amniotic  fluid  is  evacuated,  tlie  uterus 
then  comes  more  or  less  in  direct  contact  witli  the  surface  of  tlic  foetal  IxKJy ;  this 
contact,  throufi^h  reflex  action,  tends  to  stimulate  tlie  muscular  fibres  of  the  oi^gan 
to  increased  eflbrt,  and  hence  the  marked  or  expulsive  force  which  follows. 

f  A  short  time  since,  I  was  requested  by  one  of  our  most  eminent  surgeons  to 
visit  his  daughter,  who  was  then  in  labor  with  her  first  child,  in  consultation  with 
Dr.  Sands,  Dr  John  Watson,  and  Professor  Camochan.  The  lady  was  in  delicate 
health,  and  she  had  been  in  labor  some  twelve  hours ;  she  had  three  convulsions 
before  I  saw  her.  On  reaching  the  house  I  was  requested  by  the  medical  gentle- 
men to  make  an  examination,  and  found  the  head  descending  in  the  pelvic  cavity. 
The  convulsions,  they  informed  mo,  had  not  developed  themselves  until  the  head 
had  begun  to  make  severe  pressure  on  thQ  os  uteri.  There  was  a  general  concur- 
rence of  opinion  among  us  as  to  two  points:  1.  That  the  convulsions  prooceded 
fhmi  irritation  of  the  utenis ;  2.  That  the  indication  was  to  place  the  patient  under 
the  influence  of  ether,  and  deliver  by  the  forceps.  They  kindly  reque8t<xi  me  to 
apply  the  instrument,  and  in  a  few  minutes  I  succeeded  in  delivering  the  lady  of  * 


500        THE  PRINCIPLES  AXD  PRACTICK  OF  OBSTmaOI. 


upper  strait,  I  should  achise  you  not  to  apply  thein,  vemioti  1  efaig 
preferable*  I  should  be  unwilling,  as  a  general  principle,  to  hsv§ 
recourse  to  the  crotchet.  If  the  child  be  living,  th«  usie  of  tb© 
instrument  would  be  without  justifiration,  and  if  it  !>c  do  iM 

be  tnneh  nioru  speedily  romf>ved  by  the  forceps,*     No  i  iw 

skilfully  the  crotchet  may  be  employedi  there  in  always  more  or 
less*  delay  in  the  delivery  by  this  nieatis,  and  the  irritation  to  which 
'the  pari«  are  exposed  during  the  operation,  is  an  exciting  estise  to 
a  return  of  the  eonvulaion. 

AjYer  Deiityen/. — You  will  ocoaRionally  meet  with  cam*8  in  wbiohi 
after  an  auspicious  delivery  of  the  child^  oonvulsions  will  ocxmr; 
and  it  is  right  that  you  j^hould  understand  the  contingencies  whieh 
may  produce  tlunu.  I  beliovo  they  may  be  enurueimted  as  followv  : 
K  Hemorrhage;  2.  The  dclarhed  placenta,  partially  throngh  tlM 
mouth  of  the  uterus,  inducing  irriiatiou;  3.  The  pre.HetiC4>  of 
coagula  of  blood  causing  distension,  and  consequent  irrltatioD  of 
the  OS  uteri;  4,  The  rude  introduetiou  of  the  hand  of  the  iicooci* 
cheur  into  the  vagina  or  uterus,  for  the  purpose  of  extracting  tbo 
placenta;  5.  Inversion  of  the  uterus.  These  may  be  n^gardt^  » 
the  chief  causes  of  couvuImous  mscurring  subsequently  to  the  bifth 
of  tlie  child  ;  it  is,  however,  to  be  recollected  that  posi*panum  eofi* 
vulniiius  will  mjmeiimes  be  but  the  continuation  of  iho  attack  prior 
to  the  delivery. 

I  have  already  called  your  attention  to  the  relation  whieh  mib* 
rists  between  excej*,4ve  losses  of  blood  and  convtrUions,  whether  ia 
the  [»uerperal  female,  or  in  the  young  child;  and,  then^fore,  it  ii 
not  necessary  for  me  again  to  nllude  to  it.  When  the  eonvobion 
IS  clearly  traceable  to  hcmon-liage,  the  broad  indicatiois  I*,  io 
endeavor  promptly,  alter  the  arrest  of  the  bleeding,  to  mtly  tli« 
dilapidaunl  forces,  and  for  this  purpose  I  know  of  no  fWitiefly  so 
certain  in  its  elHcacy  an  laudanum,  in  union  with  sttmulaoU;  a  lesh 
a[>oonful  each  of  laudanum  and  brandy,  in  a  wine^gbuii  of  watrr, 
repeated  every  ten  or  lidecn  miuutcs,  according  to  the  emergency ; 
or  a  spoonful  of  laudanum  in  a  wine-glass  of  coffee;  the  ^tretigtli 
afterwards  to  bo  gunrded  by  animal  b- 

What  connexion  is  there  between  a  1  afler-birtb  ptartialty 

through  the  mouth  of  the  uterus,  and  convuMonsf  This  is  n 
important  question,  and  its  solution  easy.  The  pre^^co  of  tin 
placei»ta  in^luies  irritation  of  the  incident-excitor  or  ieedttfit 
nerves,  and  hence  the  convulsive  paroxyam,  through  recetitrio 
influence^  as  h:Ls  beeti  already  explained  to  you.  The  rocue<ly  iti 
this  eas4«  is  to  remove  the  placenta  without  delay;  aiid,  if  tbm 

Mng  dilkL    Th«r»  wm  do  reearraiioa  of  the  ooamliiTe  paroxxna,  and  tkm  had  wm 
ampicioiM  oonvsJoiociooo. 
*  Ii;  bow«?er,  dftOOOiwdtSon  had  commenoe^,  »  trmi  the  forcc^  eonld  boC  §■!  ft 
,  than  llM  snM»^  as  a  RMiter  of  oeoMK^^  must  b*  1 


THB  PKINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         601 

be  no  contra-indication,  let  the  system  be  quieted  by  a  full  dose  of 
landnnum  and  brandy ;  or  the  inhalation  of  ether,  not  so  as  to 
destroy  consciousness,  may  be  practised  with  decidedly  good  effect. 
The  same  remark  is  applicable  to  the  presence  of  coagula ;  they 
should  be  instantly  removed,  and  repose  of  the  nervous  system 
induced. 

In  case  of  inversion  of  the  uterus,  every  care  should  be  taken, 
as  speedily  as  possible,  to  reduce  the  displacement ;  should  this 
&il,  and  the  convulsions  continue,  I  would  advise  the  free  use  of 
the  belladonna  ointment,  both  on  account  of  its  composing  and 
relaxing  effects.  When  convulsions  occur  after  delivery,  they  are 
usually  less  violent,  and  also  less  fatal.  But,  as  you  must  plainly 
Bee,  it  is  most  material  that  the  accoucheur  should  early  compre- 
hend the  true  cause  of  the  paroxysm,  in  order  that  he  may  at 
once  proceed  to  remove  it. 

Symptoms, — Puerperal  convulsions  may  be  said  to  present,  as  a 
general  rule,  two  orders  of  symptoms:  1.  The  precursory;  2. 
Those  which  accompany  or  characterize  the  attack.  The  former, 
or  precursory,  consist  in  more  or  less  uneasiness,  and  an  undue 
degree  of  nervous  irritability,  great  restlessness,  severe  cephalalgia, 
confusion  of  ideas,  loss  of  memory,  twitching  of  the  muscles  of  the 
&ce  and  extremities.  But  it  may  happen  that,  without  any  of 
these  premonitorics,  the  convulsive  movement  displays  itself  by  a 
gudden  exhibition  uf  the  symptoms,  which  are  really  pathognomonic 
or  characteristic  of  the  paroxysm.  It  is  only  necessary  to  witness 
one  case  of  convulsions,  with  all  its  frightful  cortege  of  phenomena, 
to  have  the  impression  indelibly  stamped  upon  memory.  It  is  one 
of  those  truthful  yet  terrible  portraits,  which  the  medical  man, 
even  if  he  would,  will  find  it  difficult  to  obliterate  from  recol- 
lection. 

Imagine,  for  instance,  that  you  are  at  the  bedside  of  your  patient, 
administering  with  kindness  and  skill  to  her  wants ;  the  labor  is 
progressing  favorably,  everything  looks  bright  and  promising,  and, 
without  the  slightest  premonition,  a  convulsion  commences,  usiiered 
in  by  the  following  symptoms :  The  face  becomes,  as  it  were,  sud- 
denly fixed,  with  twitchings  of  its  muscles ;  the  whole  expression 
is  altered  ;  the  eyes  at  first  roll,  and  then  become  stationary,  usu- 
ally turned  upward ;  the  pupils  are  dilated,  and  make  no  response 
to  the  light ;.  the  lips  are  drawn  in  various  directions,  and  exhibit 
rapid  movements  ;  general  distortion  of  countenance,  with  tume- 
fiiction  and  a  livid  hue ;  foaming  of  the  mouth ;  protrusion  of  the 
tongue  ;  violent  pulsation  of  the  carotid  and  temporal  arteries,  with 
marked  engorgement  of  the  jugulars ;  the  head,  in  consequence  of 
irregular  action  of  the  muscles  of  the  neck,  is  usually  drawn  to  one 
side. 

These  changes  are  also  accompanied  by  more  or  less  spasmodic 


603 


THE  PBINCIPLE3  AKB  PBACmCE   OF  OBSTETBICa 


C*>Titraetion  of  the  mii»cleH  of  the  iiriiw,  while  the  hands  are  finnly 
dosed  ;  the  lower  extrciuhies,  on  thi?  contrarj-,  are  more  or  len 
tree  from  movement;  aa  a  general  rule,  there  is  not  muob  jtictjia* 
tion,  so  that  it  dnes  not  become  necessary  to  hold  the  patient  to 
prevent  her  falling  from  the  bed;  the  respiration  ia  nhort  fii»d 
irregular,  and  sometimes,  through  contraction  oi'  the  f^lotUfli  mo*  i 
mentnrily  suspended  with  luterraittencc  of  the  heart**  oclaoii. 
During  all  this  lime,  there  ia  complete  loss  of  eonacioosueat ;  ocoft* 
flionally  there  will  be  involuntary  dischari^es  of  orinr  and  bmmi 
the  attack  is  followed  by  stertorous  breathing,  the  patitnit  prei«titr 
ing  the  general  condition  of  an  apoplectic ;  afler  a  certain  tiaMv 
the  Btertor  ceases,  and  consciousness  usually  returns.  There  ia  no 
fixed  rule  as  to  the  recurrence  of  the  attacks ;  they  may  cotne  on 
every  ten,  twenty,  forty  minutes,  and  hours  may  sometimes  mwet^ 
vene  between  the  paroxy^ms^  Such,  gentlemen,  is  a  brief  ioni- 
mary  of  the  principal  features  which  ordinarily  accompany  an 
attack  of  puerperal  convulsions,  and,  us  I  luive  told  you,  ooot  wk« 
ne»j4ed,  the}'  can  nut  readily  be  tbrgotten, 

J}faf/nnftis, — It  is  proper  to  remember  that  the  nervotw  ifVleHI 
may  bevariouHly  disturbed  during  pregnancy,  at  the  time  of  Imlior, 
and  sulweqnenily  to  delivery,  and  ihe&o  disturbances  may  amstiii* 
one  of  several  phases ;  for  instance,  either  hysteria,*  catale|i«y, 
oj)ilepsy,  tetanus*,  chorea,  or  the  puerperal  convnlHion  of  which  wo 
have  been  speaking,  may  originate  at  either  of  the»«  perioda;  It  k 
needltd,  therefore,  that  a  jui^t  cliMinetion  be  made  In  rtdbreiMWio 
these  different  grades  of  nervous  perturbation. 

In  hysteria,  consciousness  is  not  lost,  nor  does  either  coma  of 
stertorous  respiration  succeed  the  paroxysm  ;  there  is  great  rtJt 
lessiie^,  amounthig  to  violent  jactitation,  so  that,  unless  the  patient 
be  well  guanled,  she  will  throw  herself  from  the  bed  ;  uflefitiiocSi 
there  is  laughing  alternating  with  shrieking;  and  what  i*  atmoel 
always  a  prelude  to  the  attack,  is  a  sense  of  coi:  of  tiie 

ces^^jphagus,  occasioned  by  what  is  known  as  the  gl  ,    terieiM. 

Catalepsy  is  charaeterixed  by  one  striking  peculiarity,  vli.  ikt 
Wiifortn  jyersiatenc^  of  position  of  the  iimb§  during  tA§  pctrpaeymm^ 
HKmrei^pondlng  with  the  position  in  which  ih^  ttere  at  tA§  Hrm  ^ 
the  invasion, 

1  must  confer  I  am  unable  to  present  any  essential  oharaderistie 
difierences  which  will  enable  you  to  distinguisdi  with  positive  orr- 
tainty  epilepsy  from  puerperal  convulsions;  for  I  am  diKposed  la 
ri*gard  eclampsia  in  the  puerf>era1  woman  ai  lionjering  so  closely 
on  the  true  epileptio  convuhion  as  to  render  a  distinction,  to  ny 
the  least,  extremely  difficult*  If  there  bo  a  diUVronce,  it  may  be 
said  to  exist  in  the  coma,  which  uniformly  follows  eclampsia*  and 

•  tlfil^rb,  jiUhoufrh*  ■«  ■  nirw  exc?cption.  U  may  occur  ■!  ili*  tiiiMi  of  Ubor, 
BBiich  laare  uaoally  dort^lopf  itarlf  in  tbn  ILnit  llin^  inacilbM  of  pregasocj. 


THE  PRINCIPLES  AND   PRACTICE  OP  OBSTETRICS.         508 
which,  also,  occasionally,  but  not  universally,  is  a  sequela  of  epi- 


The  continued  rigidity  of  the  limbs  is  the  characteristic  feature 
of  tetanus,  and  leads  readily  to  an  accurate  diagnosis. 
'  In  chorea,  the  mind  is  undisturbed,  and  the  affection  consists 
principally  in  an  inability  to  control  muscular  movement. 

Without  some  judgment,  the  practitioner  might  possibly,  if  he 
saw  the  patient  during  the  stage  of  coma,  confound  this  condition 
of  things  with  apoplexy.  But  all  error  will  be  removed  by  a  history 
of  the  case ;  for  example,  the  coma  of  puerperal  convulsions  is  pre- 
ceded by  the  spasmodic  and  convulsed  action  of  the  muscular 
system ;  not  so  apoplexy ;  and,  besides,  in  this  latter  affection  there 
would  most  probably  be  hemiplegia — the  result  of  the  cerebral 
extravasation.  Again  :  it  is  well  to  bear  in  recollection  that,  even 
in  convulsions,  death  will  sometimes  ensue  from  effusion  of  blood  in 
the  brain,  constituting  a  veritable  apoplexy,  and,  in  such  case,  there 
will  of  course  be  hemiplegia  more  or  less  developed. 

Prognosis, — So  far  as  the  mother  is  concerned,  the  prognosis  can- 
not be  said,  according  to  the  best  observation,  to  be  favorable ;  and 
yet  I  cannot  agree  with  some  writers,  who  maintain  that  more  than 
one  half  die.  It  is,  I  think,  more  in  keeping  with  facts  to  say  that, 
under  prompt  and  judicious  treatment,  at  least  70  per  cent,  of  the 
mothers  are  saved.  Dr.  Churchill  states  that,  in  214,663  cases  of 
labor,  convulsions  occuiTed  347  times,  or  I  in  about  6I8|.  In  328 
oases,  70  mothers  were  lost,  or  about  1  in  4J.  The  mortality  is 
much  greater  among  the  children  ;  some  of  these  die  in  utero  during 
the  paroxysm,  and  many  of  course  are  sacnficed  by  the  operations, 
which  may  be  judged  necessary  for  the  safety  of  the  mother,  such 
as  premature  delivery,  version,  the  forceps,  and  the  crotchet.  It 
should,  however,  not  be  forgotten  that  our  prognosis,  in  reference 
to  the  safety  of  either  mother  or  child,  is  to  be  graduated  by  the* 
time  at  which  the  convulsion  becomes  developed,  its  duration,  the 
frequency  of  its  recurrence,  the  character  of  the  convulsion  itself,* 
and  the  condition  of  the  patient.  Occasionally,  although  death 
does  not  ensue,  there  are  some  serious  consequences  resulting  from 
convulsions,  such  as  loss  of  memory,  positive  mania,*  imbecility ;: 
and  these  may  continue  for  a  longer  or  shorter  period.  Cases  are 
recorded  in  which  permanent  amaurosis  and  deafness  were  the- 
results.  It  is  stated  by  some  authors  that  the  great  majority  of 
women  who  survive  the  invasion  of  convulsions  are  attacked  with 
puerperal  fever.  This  certainly  does  not  accord  with  my  ex])erience, 
nor  can  I  see  any  other  than  simply  a  coincident  relation  between* 
these  two  pathological  phenomena. 

*  Mania  and  other  forms  of  insanity  may  occur  aflcr  parturition,  even  when  the- 
labor  has  not  been  complicated  with  convulsions.  Ksquirul  perhaps  tiin  best 
autboritr  on  insanity,  suys :  '*  Tiie  number  of  women  who  have  become  insane  after 


LECTURE    XXXriT. 


PUerpeml  ConvnlMons  cotitinned — T?)dr  Centric  Ciiu*.'ji;  divnlr^l  trMo  I  -  r4 

Phyaloal ;  how  U(»»tiup:iiiiilied,    Toxjrruia,  iif  BU)*nJ-|M«sm»iinar — Alliunn;  :#. 

latKms  to  CouvulmoriH — C:im'H.>»of  Albimuiuirlo— Kd.  Hobin*  Tlieory  not  tiuUiocd 
— A  CUangC'it)  tbu  CompoHitioa  of  liie  Blootl  ii  Cnuse — Ijliintrntinn*  nud  l*fMofc 
&eciTtiotj>  il«  Objects — A  Cliunge  in  tht*  Kidtiej^  StnictuMl  or  I '  '  nmrn  of 

Atbamiuiiriii ;  rnx>r» — Preaaurt  on  the  RtfnAl  Vtiri«  a  C«u.«o —  i  ^-Albu*^ 

tnitiuria  mopo  frequent  iu  the  rrirnlpnrn;  why?— Is  AJburuUiuriH  a  uepvmmrf 
Uimitlt  orPi^ftuiBed  Kidney  7— Dt)ea  if  ajw«jr«  cxJat  in  rrf*pn«ncy  ?— tJfwtuia,  «1i«t 
\a  ilt — Dr  Curl  Brsiin  nud  UrjemicInmxiLnitiuii^I^  AlbiimmuriikftlwAjs  fcitiom^ 
by  rricfiiia?— Is  UrcNi  a  Potnon? — LVUmnU?  of  Ai&moiiUi  »iid  Urm^Frcfielvli 
Theor}- — OrliWs  Kxpcrim«i((«  wiih  C-urUjrtiiteor  AmitionUim  Animals;  Beittlt— 
Trtfiitmcut  of  Unciiuu,  on  wlitit  it  esbDMld  hv  Imsed — Thi«riip«\tlio  lutliciiiKktUN* 
Cotcliicura  Autumnalo  oijd  Gunuicum  us  Efiiiedhij  Agonti — [»r,  lmb«rt  Goub0jrf» 
«nd  Brig-ht'ti  Bi^i^ase  in  oounojtiou  witli  Alburaiiiurta — Anicsilitrtic»  m  Ufwmk. 

6K?rn.EirEN — In  tbe  preceding  lecture  w©  Imve  been  occupied  wlA 
a  consirk^ralion  of  the  ecrentrk  cfUiHcs  of  coriTulKioiif; ;  I  |>rupo9D 
to-flay  to  »|'ieak  of  iho^e  hjflucufCH  wbidi,  !lj rough  rentrir  '  i  r<i 

capaJilo  »o  far  of  ilihinrbin^  tlie  nervous  cijuilibrium  ns  r  -n 

thu  i^imvulHive  spiixm.  Tlie  caiiric  c:iu!k.*«  of  convul^iotii*  are  ili- 
v'uh'd  mto  psi/ehiral  uiul  phymctiL  Umier  tho  formt^r  head  are  in* 
dudctt  «*il)  oj)er:ition8  oti  the  tniiul,  kuown  hh  eniutiuntc,  go  thnt  tbe 
deprt'tiaiug  paaHiun?*,  such  an  grief,  or  tho  more  exciting  etDutioofti 
wich  MS  joy,  are  to  be  rrganled  as  among  the  p*iyehieal  csmstiai  ot 
thiti  affection.  The  })liymcal  coiimst  in  various  iiathologtcal  l*0OiB- 
tioni*  of  one  or  otiier  of  the  two  great  iiervoti  s  the  bmhi  lUid 

spirb't)  cord  ;  for  exai»jik\  pletliora,  by  indn^  jvgtion  ofllMStfe 

centres,  njay  provoke  coiivultsiutiis ;  an  anmmio  8tate  of  the  8y>t4;oi, 
as  ha^  been  already  explained,  may  do  the  same  thing;  diKcaMi  i^f 
the  brain  or  irplnal  cord^  whether  of  the  nubstancc  or  eoreriogi,  b 
jile^J  a  cent  He  eau^e. 

liiift  geiitlemi^n,  there  i»  yet  another  centric  agent  eapalile  of 
evokhig  convitlHtons,  to  which  I  desire  e<tpecially,  and  sonieurhjit  to 
detail,  to  direct  your  attention,  I  allude  to  an  impure  or  poisoned 
condition  of  the  blood.  Until  within  comparatively  a  »hort  prnofl, 
authors  were  silent  on  the  subject  of  certain  poiHonoii?*   \  es 

contained  in  the  urinary  secretion,  or,  at  least*  they  did  j  .rh 

tJiclr  cnTiftncmcot  S*  mo^li  gmil«r  ibun  gencmlly  »mpj»o<ied  At  tiio  116pittiil  £tel» 
P«tn  ino  twirtnh  itf  [he  inamae  women  we  rt'ccivnl  here  tt««ftni«  M  «liV 

ihtMr  (TraiU^  di-s  Hnladict  MmtMlvH.  vul   1.  ti,  230.) 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         505 

to  it  that  specific  interest,  which  late  discussions  have  excited ;  and 
hence  the  term  tooccemia,  or  blood-poisoning,  was  not  employed,  as 
it  now  is,  to  denote  a  very  peculiar  and  important  state  of  the  eco- 
nomy. While  toxcemia  is  the  generic  term,  there  are  various 
species  or  grades  of  blood-poisoning. 

This  question  is  well  deserving  of  attention,  particularly  at  this 
time,  for  it  has  recently  receiveU  prominent  consideration.*  In 
September,  1853,  I  published  a  paper  entitled,  "  Thoughts  on 
Urcemia^'^'*  which  was  generally  distributed  among  my  medical 
friends  in  this  city,  and  which  is  incorporated  in  my  work  on  the 
diseases  of  women  and  clnldren.f  In  that  paper  will  be  found  the 
following  language  in  reference  to  one  class  of  puerperal  convul- 
sions, and  I  trust  I  may  be  pardoned  for  quoting  it  here  :  "  Recently 
much  has  been  written,  and  questions  proposed  by  learned  acade- 
mies, respecting  the  connexion  between  albuminuria  and  puerperal 
convulsions ;  and  the  writers  are  almost  unanimous  in  the  opinion 
that  albuminuria  is  the  cause  of  these  convulsions.  Now,  I  con- 
tend that  puerperal  convulsions  are  frequently  nothing  more  thai\ 
ursemic  phenomena,  as  is  proved  by  their  causes,  symptoms,  dia- 
gnosis, and  pathology.  If,  then,  i)uerperal  convulsions  be  the 
result  of  urajmic  iiitoxication,  they  are  not  necessarily  produced  by 
albuminuria.  There  is  often  a  coexistence  of  puerperal  convul- 
sions, albuminuria,  and  a?denia,  general  or  local ;  but  each  one 
of  these  conditions  may,  and  has  existed  irrespectively  of  the 
other." 

Causes  of  Alhundnnria, — I  propose  now,  as  briefly  as  is  consis- 
tent with  the  interest  and  importance  of  the  subject,  to  examine 
the  true  relation  ot*  albuminuria  to  eclampsia^  and  also  the  ])oints 
of  relation  between  this  latter  and  Bright's  disease  of  the  kidney. 
With  this  view  I  shall  commence  with  the  consideration  of  the 
causes  of  alhumimiria.  Here  we  lind  various  o])inions :  Edouard 
Kobin  maintains  that  the  passage  of  albumen  into  the  urine  is  the 
result  of  imperfect  combustion ;  that  urea  is  produced  by  the  oxy- 
genation of  the  albumen  in  the  blood,  and  if  the  oxygenation  do  not 
take  place  the  result  will  be  albuminuria.  This  hypotliesis  possesses  the 
attribute  of  ingenuity,  but  its  demonstration  seems  to  me  difficult,  for 
the  obvious  reason  that  when  albumen  passes  into  the  urinary  secre- 
tion the  quantity  of  urea,  as  a  necessary  consequence,  should  not 
be  increased  in  the  blood.     It  is,  I  believe,  conceded  that,  although 

*  The  Urrcmic  Convulsions  of  Pregnancy,  Parturition,  and  Childbed.  By  Db. 
Carl  II  Braun,  etc ,  etc  Translated  from  Iho  German  by  J.  Matthews  Duncan, 
F.R.C.IVS.,  etc.,  ibOS. 

De  rAlbuminurie  Puorpvralo  et  do  ses  Rapports  avcc  I'Eclampsie.  Par  M.  LB 
DocrKUR  A.  Imbeht  Goubeyre.  Memoire  CourooDe,  dans  la  Stance  Publique 
Annuellc.     December,  1854. 

f  See  page  522 


506 


THE    PRINCIPLES   AKD  PRACTICE  Of  OB8TGTRIC8w 


albumen  does  occasionally  exist  in  the  urine  without  m  diminii* 
tiou  ill  the  fluid  of  ure:i,  yet  the  converse  of  this  i«  rery  oUtrn 
observed,  vix,  an  increase  of  urea  in  the  blood  coes^lmiiig  wUh  tilbm- 
miiniria*  This^  t!»erefore,  is  in  direct  conflict  with  th«  eirplaoitioii 
of  Rubin.  It  18  stated  by  Dr,  C.  L  B.  Willmms  that,  per  m^  •*  alb«ii* 
miiuiria  indicates  nothing  more  than  eon^resitefi  kidney.*'  1  cihalli 
on  the  contrary,  attempt  to  show  that  other  causes  thaa  simple 
congestion  of  the  kidney  will  occn>iion  nlbnininnrtu ;  andt  ill 
doincT  this,  it  will  follow  that  Dr.  Wiiliams**  opinioD  b  fiir  109 
cxchi^iive. 

It  is  quite  certain  that  the  (presence  of  albumen  in  the  nriii^ie 
not  IraceJible  to  any  one  in^ueiiee,  for  it  is  recxip^niscd  under  a 
great  variety  of  circumstances,  and  I  shall  endeavor  to  |>rove  that 
it  IS  due  to  one  of  the  following  causes  :  1,  A  ehnnqe  in  the  com- 
posititin  of  the  blood  ;  2.  A  change  in  the  kidney,  either  structurid 
or  dynamic ;   3»  Pressure  on  the  renal  veins, 

1,  Change  in  the  Composition  of  the  Blood. — It  was  n  t 
doctrine  of  the  old-school-men  that  the  blooil  contain **d 
deleterious  elements,  whieh  could  not  continue  in  the  s- 
out  p'enerating  dif^ease.     This,  too,  wa»i  the  opinion  o!  _    .    ., 

Pltcnirn,  Cullen,  and  others ;  and  the  ma^er-ndiidi»of  the  prei«eiit  tby, 
with  all  their  supposed  progresfS,  are  eonipcned  to  admit  '  '  -ri 
is  something   more   than   mere   conjeeture  in    what   w  dy 

termed  the  ^^peccarjt  humnrs*"  The  organs  through  w^bieh  theat 
humors  or  poisons  j)ass  Irom  the  economy  are  called  glands;  and 
each  gland  has  its  8i>ecitio  office  assigned  to  it — that  is*  uti«  of 
these  glands  fuminhes  an  outlet  for  one  character  of  mni  ihe 

blood,  ami  nnother  ghind  fi»r  a  different  subHtnnee.      i  itle 

thft  liver  is  engaged  in  the  secretion  of  bile,  etc,  and  ti.  i.  A  \mj 
water,  urea,  etc,  we  find  the  intestines  the  media  through  ulitdl 
cflTeto  matters  are  thrown  olT.  Tliese  various  otljci*s  are  perfortnod 
throtigh  what  is  called  secretion,  the  true  nature  of  whicli  lii  »tfll 
ittvolved  in  mystery.  It  is  true,  we  understand  certain  giminal 
principles  respecting  the  secreting  processes,  btit  it  cannot  be 
denied  that  we  are  unnble  to  exf»laijt  many  of  the  phenoftiena  eoo* 
necte«l  with  thi?*  fundamental  Inw  of  the  physical  nieehanUm.  At 
diough,  theivftire,  w  l*  are  ignurant  of  scimo  of  the  j»r<*eesst*s  oof>» 
neeted  with  glandular  elaboration  in  a  state  uf  health,  vft  it  does 
not  iVjDow  that  we  cannot  explain  many  of  the  causes  which,  intor^ 
fering  with  heallhy  serreiion,  rcHult  in  morbid  aeiion. 

In  order  to  ajuily  lliis  reasoning  to  the  ipiestion  beforo  nai  we 
will  suj>pose — what  will  f>ot  be  controvert ed— that  in  a  varitdy  of 
diseases  occasionally  accompanied  by  albuminuria,  such  as  eboleimi 
scarlatina,  diabetes,  c*to.,  the  ctmstiiuents  of  the  blood  becomo 
changtHl  by  the  introduction  either  of  a  poison  or  er  soIk 

atanre.     If  thi^  oceur,  it  is  (piite  manifest   thai  i  i   t^i  no 


THB  FBINOIPLES  AND  PRACTICE  OF  OBSTETRICS.         507 

longer  normal,  and  becanse  of  its  altered  condition  its  elaboration 
in  the  kidney  will  also  be  modified ;  so  that  in  lieu  of  the  ordinary 
elements  contained  in  the  urine,  we  shall  sometimes  recognise  albu- 
men, an  absence  of  urea  and  other  pathological  phenomena.  May 
this  not  be  satisfactorily  explained  on  the  principle  that  the  product 
of  endosmosis  will  be  modified  in  proportion  to  the  changes  in  the 
fluid  on  which  it  acts  ?  Again :  the  blood  is  changed  in  pregnancy, 
Tarious  circumstances  tending  to  this  modification,  viz.  the  forma- 
tion of  kiesteine,  the  secretion  of  milk,  the  quantity  of  blood  mate- 
rials passing  through  the  circulation  of  the  foetus,  together  with  the 
diseases  of  the  embryo  itself,  not  to  speak  of  its  excretions,  some 
of  which  we  know  enter  the  blood  of  the  mother.  These,  then, 
being  so  many  influences  capable  of  altering  the  constituents  of  the 
blood,  will  they  not  explain,  at  least  in  some  instaivces,  the  occasional 
presence  of  albuminuria  in  the  pregnant  female  ? 

2.  A  Change  in  the  Kidiiey^  either  Structural  or  Dynamic, — 
Every  structural  change  in  the  kidney  may  result  in  albuminuria, 
but  we  do  not  yet  comprehend  in  what  essentially  these  various 
ohanges  consist.  For  example,  though  it  may  bo  true  that  the 
presence  of  albumen  in  Bright's  disease,  in  scarlatina,  etc.,  may  be 
due  to  a  dosquamalion  of  Bellini's  tubes,  yet  this  cannot  be  said 
of  many  other  affections  of  the  kidney  in  which  albuminuria  exists, 
but  in  which  no  desquamation  takes  place.  Several  interesting 
experiments  have  been  made  to  prove  that  the  urinary  secfetion  is 
not  absolutely  dependent  upon  the  nervous  system  by  Segalas,*  and 
some  of  a  more  decisive  character  by  Dr.  Brown-Sequard  ;t  while, 
on  the  other  hand,  it  has  been  satisfactorily  shown  that  the  nervous 
system  may,  under  certain  circumstances,  exercise  a  marked  influ- 
ence over  this  secretion,  as  is  demonstrated  by  the  researches  of 
Brachet,  J.  3Iuller,J  and  Marchand.  The  latter  has  pointed  out  a 
very  important  fact  connected  with  this  subject.  He  produced  in 
%  dog  not  only  all  the  symptoms  of  urrcmia,  after  placing  a  ligature 
on  the  renal  nerves,  but  also  discovered  urea  in  the  blood,  and  in 
the  matter  vomited  by  the  dog. 

Kramer  is  said  to  have  detected  albumen  in  the  urine  of  animals, 
after  dividing  the  sympathetic  nerve  in  the  neck.  This,  however, 
seems  to  need  confirmation,  as  the  same  result  has  not  followed  the 
experiments  of  others.  Dr.  Sequard,  after  repeated  trials,  has 
fiuled  in  establishing  the  fact  mentioned  by  Kramer.  Budge  found 
albuminuria  after  a  puncture  of  the  cerebellum ;  and  CI.  Bemard§ 

*  Bulletin  des  Seances  de  TAcad.  do  Med.  do  Paris.  (Seances  dcs  27  A6ui  et  23 
Beptembre,  1844.) 

f  Experimental  Researclies  applied  to  Phjsiologj  and  Pathology,  Philadelphia. 
1S63-3.     P.  13. 

%  Manuel  de  Physiol.     Edit^  par  E.  Littre.     Paris,  1851.    P.  891. 

g  Comptes  Rendus  de  TAcad.  des  Seances  de  Paris,  t.  xxviii,  p.  393. 


608 


THE  rmKCIPLEB    vs'ii   PRACTICE  OP  OBSTETBIOS. 


occasionnlly  obtained!  the  saijiu  w^nli  from  a  puncture  of  the  mediilU 
oblongata.  In  uiKVition,  Jiawcvcr,  to  ihusv*  tJt^moiiHinititm?*,  wc 
littve  niinierous  insUinoc**  occurring  m  practice  illustrating  the  ioflo- 
cnce  of  the  nervous  centres — when  labui  ing  under  dtheaHe  or  Iran* 
malic  injury — over  the  urinnry  secretion;  and  it  iji  quite  po^i^bki 
that  the  irritiition  of  the  uterine  nerves  during  {ireguaney,  aoil  ta 
many  of  the  diseases,  both  organic  and  funeijonah  of  the  utrfcis 
itfli^f;  may^  through  retlex  action  of  tha  medulla  spinalis,  produce 
various  morbid  changes  in  the  uriue.  Again  :  it  does  appear  to  me 
that,  if  it  can  be  proved  that  «uddeii  emotions  shoekfi,  etc.,  baveaii 
influeuee  on  the  peculiar  processes  by  which  the  blood  is  continiH 
ally  ridding  itself  of  its  deleterious  materiaK  we  shall,  in  this  wiy, 
have  opened  to  uh  a  new  Beld  in  our  investigation  of  diseajee;  we 
shall  be  enabled  to  elucidate  many  morbi<l  phenomena  which  have 
herelofure  been  obscure,  and,  as  a  neeensary  consecpienct*,  dedtieo 
rational  therapeutic  princi files* 

3.  Prfssure  on  the  Ilcnal  \^einJi, — Wliatever  may  be  the  ollief 
causes  which  operate  in  the  production  of  albuminuria,  there  b  a 
mxss  of  irresis5tible  lestimtmy  to  demonstrate  the  pnsiii%e  inflttenee 
of  an  obstructed  renal  circulation.  O*  Robinson/  Meyer,f  and 
Frerichs,  have  abundantly  proved  that  a  ligature  tied  mon)  or  loii 
comjilotely  around  the  renal  veins  will  cauj^e  albumen  to  pasa  fhm 
the  blood  into  the  uriusiry  f^ceretion  ;  and  again  when  the  retaX 
veins  hafe  beeome  obliterated,  in  every  histancc  in  which  the  urttie 
was  examined,  albuminuria  was  detected,  Case«  of  this  natoie 
have  been  observed  by  Dnnce,  Rayer,  Dug^ii,  Velpeau,  R.  Lee, 
Cruveilfder^  Siokos,  Blot,  Leudet,  and  otheiii.  In  ge*tation,  and 
especially  in  priniiparti;,  albuminuria  m  often  caused  by  prea^ure  of 
the  impregnated  uterus  on  the  renal  vessels.  l>r.  Hoac  Cormaek, 
[  think,  was  the  lirst  to  rail  attention  to  this  subject.  Dr.  Brown* 
Seijuard  has  positively  a«»certained  the  influence  of  pressure  ttpon 
the  renal  ves<se!s,  rn  a  Indy  who  had  albumen  in  her  urine  during 
the  ninth  month  of  pregnancy.  He  placed  her  in  such  a  posit ioA 
that  the  pressure  was  much  diminished,  and  after  a  certain  time 
the  urine  ceased  to  contain  albumen.  When  the  ordinary  attitude 
was  resumed,  there  was  soon  a  reappearance  of  albumen  in  the  uriotw 

In  IOC  multipara^  Hlot  detected  albuminuria  in  eleven  instancet 
only*  while  in  uinetyninc  piimipariD  thiHy  exhibited  it.  The  pro- 
portion, therefore^  for  the  former  is  as  one  to  ten^  the  latter  ai 
one  to  three.  This  is  a  remarkable  diflTerence,  and  mu3*t  Vir<  due  to 
Bome  special  cause. J    It  u  t^uite  evident  that  albuminuria  is  of  ft^ 


*  Metlico-Chinirg  TrsDMa  of  Uie  Eojftl  Med.  Cliinirg  Soa  of  UmAcstu 
Tol  TUi,  I*  61, 

f  Gaz.  Med,  dc  PbH&     1844.     P.  4t9. 

%  Wotnon  ja  Uicir  flnrt  pfTjftt'*'**?^  prtjsent  •  fwy  difTerent  ci>f  '^e 

miiml  waU«  frum  tbose  wUo  liaro  already  bome  childreo.    lu  Um  .-«• 


ia4x 


THK  PRINCIPLES  AND  PKACTICE  OP  OBSTETRICS.         509 

qnent  occurrence  in  pregnancy,  and  oflentiraes  results  in  death. 
Imbcrt  Goubeyre*  states  that  of  sixty-five  pregnant  women 
attacked  with  albuminuria,  twenty-seven  died,  five  remained  albu- 
minaric,  and  thirty-three  were  restored  from  two  to  fourteen  days 
after  delivery.  The  frequency  of  puerperal  convulsions  in  albu- 
minuric women  is  very  great.  According  to  the  same  author,  of 
159  women  laboring  under  albuminuria,  ninety-four  were  attacked 
with  convulsions. 

Cahenf  and  others  have  endeavored  to  show  that  albumen  in  the 
urine  is  caused  by  disease  of  the  kidney.  It  cannot  be  denied  that 
disease  of  this  organ  may  coexist  with  gestation,  and  in  such  case 
the  albuminuria  may  be  traced  to  a  morbid  condition  of  the  gland; 
but  to  say  that  albuminuria  cannot  exist  in  pregnancy  other  than 
as  a  result  of  disease  of  the  kidney  is  in  direct  opposition  to  well- 
established  observation.  J 

As  a  point  of  diagnosis,  it  may  be  incidentally  mentioned  that 
when  albuminuria  in  pregnant  women  is  caused  by  Bright's  disease, 
there  is  frequently  some  degree  of  amblyopiag  and  even  amaurosis, 
while  in  simple  albuminuria  produced  by  pressure  of  the  womb  on 
blood-vessels,  the  retina  preserves  its  functions.     M.  Lecorche,  a 

are  firm  and  rcsistinj?;  in  the  latter,  on  the  contrary,  they  are  relaxed,  and  have  lost 
much  of  tlieir  original  tension.  For  this  reason,  in  primipara  the  impregnated  uterus  is 
more  perfectly  in  the  line  of  the  axis  of  tlie  superior  strait  of  the  \ie\vic  canal ;  while 
in  multipanc,  the  organ  is  disposed  to  fall  forward,  constituting  ante-version,  more  or 
leflfl)  of  the  fundus.  Precisely  in  proportion,  therefore,  to  the  inclination  of  llie  uterus 
forward  from  the  direct  line  of  ascent  will  be  the  probability  of  diminislied  pressure 
on  the  renal  circulation.  I  believe,  also,  there  is  anotlier  reason  why  albuminuria  is 
observed  less  frequently  in  multipara  than  in  primiparoi.  It  is  a  well-known  fact 
that  women  are  much  more  disposed  to  miscarry  in  a  first  than  in  subsequent  preg^ 
nancies ;  and,  caicris  paribus,  this  is  no  doubt  owing  in  a  measure  to  the  greater 
irritation  of  the  uterine  nerves  consequent  ui)<)n  a  first  gestation.  May  not,  there- 
fore, this  excess  of  irritation,  by  modifying  the  urin;iry  secretion,  bo  occasionally  a 
cause  of  the  more  frequent  presence  of  albuminuria  ?  I  think  so;  ai^jl  again,  when, 
under  these  circumstances,  the  pa.ss;»ge  of  albumen  into  the  urine  is  followed  by  urea 
in  the  blood,  as  is  often  the  case,  even  admitting  that  full  unemia  does  not  take  place, 
may  not  the  nervous  83'stem  become  so  much  disturbed  by  the  presence  of  urea  as 
to  induce  premature  action  of  the  uterus,  and  consequently  miscarriage?  If  there 
be  any  force  in  this  reasoning,  the  preventive  treatment  of  miscarriage  in  this  con- 
dition of  system  may  prove  far  more  successful  than  it  has  heretofore  been. 
*    •  Memoires  de  I'Academie  Imporiale  de  M^'decine.    Tome  xx.  1856. 

f  De  la  Nephnte  Albumineuse  cho7.  les  Femmes  Knceintes.     Th^so,  Paris,  1847. 

I  Blot  demonstrates  the  fact  as  follows:  1.  The  rapidity  with  which  albuminuria 
disappears  after  delivery  in  almost  every  case,  very  often  in  two  or  three  hours,  some* 
timcfl  in  one,  after  the  expulsion  of  the  child.  2.  Absence  of  the  symptoms  of  dis- 
eased kidney.  3.  Certiin  characters  of  the  urine  entirely  difierent  from  those  of 
Bright *s  disease,  as  for  instance,  increase  in  its  density,  and  the  presence  of  more 
salts,  and  particularly  urates.  4.  In  neven  women  who  died,  and  in  whom  albumi- 
nuria had  been  detected,  only  three  had  slight  pathological  alterations  in  the  kidney. 
[De  TAlbuminurio  chez  les  Femmes  Enceintes.     Th^se,  Paris,  1849.] 

§  From  afiPXos  dull,  and  oxp  the  eye. 


610 


THE   PRmcrPLES  XSV   PRACTICE  OF  OeOTETRICa 


pnpil  of  Rayor,  giv4?«  a  table,  shawiug  that  in  332  caao*  of  Bright't 
di^eiuHc^  tliere  \^m  eiilier  sinibtynpiu  or  luniiuro^b  tti  (>2  in^taticeft. 
The  coexiBtence,  thcretbre^  of  this  ej-mjitom  with  albnniuiam  in  thm 
pregTinnt  female  »hf>nhl  be  repinleil  mi  gravt*. 

Tfie  opinion  is  now  Wi41  settled,  and  concurred  ill  by  ft  grest  I 
majority  of  writers,  that  albnmiuum  1:^  in  many  c:i%tssy  »im|ily  tho 
result  of  an  active  or  passive  couge?ilion  of  the  kidney,  Anytbiog, 
therefore^  capable  of  obatrncting  tho  renal  circulation,  wlivtbvr  it 
be  an  enlarged  uterns  fjx>ni  prefi:nancy  or  diiseuse,  an  o%'iuiaii  tniEior, 
or  enlargement  of  the  abdomen  of  any  kind,  may  bo  enumerated 
among  I  fie  causes  of  albiiminnria,  Christisonj  Riiyer,  and  otlivrs 
maintain  that  the  diminution  of  urea  in  the  uriue,  and  consequetilly 
its  accumulation  in  the  blood,  b  in  proportion  to  the  (|nantity  of 
albumen,  but  this  doe;*  not  apj»ear  to  be  invn  ^     '      '  for 

Benee  Jones  has  recorded  an  instance  of  mollji  ucb 

he  ])resents  an  analysis  of  the  urine,  i^howUig  that  albumiiioiiaiiiftUcr 
may  exist  in  great  quantity,  while  tire  amount  of  urea  rrnrnlnit  p«^ 
feclly  natural. 

Is  Alhuminuria  alirat/s/olioired  hj  T'ritmmf* — ^That  the  pw* 
Bence  of  aJbiuuen  in  the  urine  is  not  neeessiirily  lollowed  by  unvmiati 
amply  proved  by  observation  ;  and  it  Is  important  that  thia  htA 
should  be  well  understood,  for  tho  reason  that  much  error  ha^  iiriiai 
from  the  opinion  enteitained  by  certain  writers,  that  there  \m  a  <£rMl 
connexion  between  urtemia  and  albuminuria.  Tfiis  error  i»  tioC  m 
much  owing  to  any  inherent  difticulty  of  the  Muhjt'et,  aat  it  b  to 
tliat  loose  appreciation  of  fact«,  or,  more  properly  speaking,  la  that 
want  of  heahhy  digeslion  of  well-settled  prind:  '  '  \  '  rtw* 
naiL'Iy,  too  oftL^u  charaoienzu^s  the  wniing«  of  i  rs* 

I  might  cite  a  long  list  of  observers  to  show  that  aibumrn  very 
ftrequenlly  exints  in  the  urine  w  ithout  any  deveh>ptuiait  of  um*t!iie 
intoxication,  but  I  ap[>rehend  this  would  he  unneeeaaary.  I  sliaQ, 
therefore,  limit  my^lf  to  two  or  three  undoubt  nei»ji,  Fnois 

Simon,  for  eiample,  saya  he  ha«  frequently  deh  HimiDitria  in 


^ri^idfmiioa,  ihift  %m 

^tlior  osiEia«  iMTliBli 
«nly  tncettlil»lolk» 


•  It  ts  important,  in  coniiexion  with  tho  siibjoct  imdt  r 
tfum  timnk  should  be  clcartj  undenEood.  tTnumi;i 
tho  two  tiprvous  centres — tho  bmiu  and  vpitml  cord- 
Of  e<^>nipleUii  criiiviiisive  pflroxy^ms;  t!>e  diisliirbaiioet* 
•Ctimi  offt  pectiUur  p(u«b>n  od  thcj^e  n<>rvoui  oetitrea  > 
or  together;  aad  iictico^  AcorjrdUi};'  to  Carpenter,  there  may  uo  tUro*  teni  cf  «f»Mh 
poiaonlnf :  1.  A  Atnto  of  Kiufxir  Rupervcnos  mthor  9iiddenly,  from  irliicli  Ih*  pstiiot 
Is  wirh  didieuUv  Ama>M«d,  soon  li>1Uiwi?d  hy  catiiptot*  coiiM,  «Hth  gyutoroUA  brMttiim* 
etc,  ua  in  orditiary  narcotic  {loi^onini^;  %  Cunvul«ioiui  of  an  i«tnUtitiu  dMiracM^ 
oCteo  aflvcUnjir  the  entire  rouacttlar  ayatom,  soddenly  occur^  but  i  of  cuo- 

•eiDts9tit«ii    3.  Omia  tiiid  onnirutsiotii  may  b^  ci:»mbiue(l    The  *  s.v^^gm 

hM  bfvrt  did^i^renUy  (^X(»tiiltitHi  bj  atuhi/r^;  for  exmnitlu,  ncimA  <x>ui(  ^  in* 

to  albuni^ti  in  the  uHnc,  oihors  Uifti  ti  is  c*ii«pd  by  iirt*  In  tli>'  .^^    wciia 

both  (if  thc8c«  opinioni  have  been  nyectcd,  and  n  new  one  udvn  rich%  tilb 

tliiit  nrn-ntiii  nntttlni  rmin  ihv  tmnttrontintiuit  oC  ur«>)i  into  ibo  curv 


jmjttmvri  \n 


THE  PRINCIPLES  wiKD  PKACTICE  OF  OBSTETRICS.         611 

persons  apparently  in  the  enjoyment  of  good  health ;  also  others 
have  observed  it  in  articular  rheumatism,  in  inilammation  of  the 
thoracic  organs,  intermittent  and  typhus  fevers,  in  measles,  cholera, 
and  in  chronic  affections  of  the  liver.  In  transitory  renal  catarrh, 
■ach,  for  instance,  as  occurs  in  erysipelas  nearly  as  often  as  in  scarla- 
tina, albumen,  together  with  the  well-known  epithelial  cylinders  of 
Bellini's  ducts,  is  found  as  constantly  in  the  urine  as  in  inflamma- 
tory affections  of  the  kidneys,  where  it  exists  in  connexion  with  the 
fibrinous  pings  from  the  same  ducts,  as  in  true  Bright's  disease.'*' 

Edouard  Robin  says  ^^  the  urine  becomes  albuminous  in  croup,  in 
aadtes,  and  in  cases  of  capillary  bronchitis,  with  emphysema,  accom- 
panied by  dyspncea ;  in  pulmonary  phthisis,  in  gestation  when  suffi- 
ciently advanced  to  occasion  a  habitual  congestion  of  the  kidneys ; 
in  cyanosis,  diabetes,  etc.,  etc."t 

In  order  to  prove  that  albumen  may  exist  in  the  urine  indepen- 
dently of  any  disease  of  the  kidney,  and  without  any  of  those 
nervous  disturbances  characteristic  of  uraemic  intoxication.  Dr.  M. 
T.  Tegart  mentions  the  following  interesting  and  conclusive  expe- 
riment upon  himself,  and  also  confirmed  in  the  person  of  one  of  his 
fHends :  He  made  for  some  time  a  portion  of  his  ordinary  nourishment 
to  consist  of  half  a  dozen  eggs,  and  albumen,  as  a  consequence, 
was  soon  detected  in  the  urine. J  Similar  experiments  have  been 
made  with  similar  results,  by  Bareswil,  CI.  Bernard,  Brown-Sequard, 
and  Dr.  Hammond  of  Baltimore. 

There  are  few  practitioners  of  careful  observation,  who  will  not 
endorse  these  statements.  Indeed,  I  consider  the  principle  to  be  so 
well  established  that  the  existence  of  albuminuria  is  not  necessarily 
connected  with  uraemia,  that  further  citations  can  scarcely  be  neces- 
sary to  demonstrate  the  fact. 

Is  Urea  a  Poison^ — Urea  was,  I  believe,  first  discovered  in 
17 VI,  by  Kouelle,  who  detected  it  in  the  urine.  It  owes  its  present 
name,  however,  to  Fourcroy  and  Vauquelin,  It  was  obtained  pure 
fior  the  first  time  by  Dr.  Prout  in  1817.  There  is  an  interesting 
droumstance  connected  with  this  production — it  is  the  first  instance 
known  of  an  organic  compound  being  artificially  produced,  and 
this  was  accomplished  by  Woler  from  cyanic  acid  and  ammonia. 

The  true  action  of  urea  is  variously  described  by  authors,  the 
general  opinion  being  that  it  is  a  poison.  Todd,§  Williams,|  Cor- 
mack,^  Simon,*^  and  others  regard  it  in  this  light,  and  contend  that 

%  Physiological  Chemistry.     By  Lehmann.    T.  I,  p.  345. 
f  Ed.  Robin,  London  Lancet,  January  24,  1852,  p.  96. 

X  "Thdse  BUT  la  Maladie  da  Bright"    Paris,   1845.    Gazette  Medioale^  Pari% 
1846.     p.  39. 
g  Lumleian  Lectures,  in  liOndon  Med.  Gaz.     1849-^0 
I  Principles  of  General  Pathology. 
^  London  Journal  of  Medicine.     1849.     Pp.  690-699. 
*B  Lectures  on  General  Pathology,  Amer.  Edit.,  p.  16L 


512 


THE   PHIXCIPLES   AXD   PRACTICE  OF  OBSTETRlGSr 


its  proijencu  in  iha  blood  will  occasion  comii,  conv  thsf^J 

nervous  phennnicna,     Indecri,  it  may  be  said  that  '  i  xhB 

geneml   oplnioa ;    it  is  profi^r,   therefore,   that  thin  opinloti    bo 
uxiimhicd.     If  urea  be  ft  poison  capable  of  prmincing:  ccinviiL^ooa, 
etc,  the  numerous  fX|>enmentH  made  on  livin*^  anin»aU  iij  m*  way' 
uslablish  tfie  tact,     AinoT»c^  others,  Prevent  and  Dumas,* 

Tiedeman,  Gnit-lin,  31iti*cherlich,  LI.  Bernard,  liareawil,  ^l / 

and  Frcriclis,  have  extirpated  the  kidneys,  and  have  never  knoim 
convulsions  to  ensue,     Tliir*,  it  may  be  ur*jfed,  is  ofily  nej^alive  prooC 
Negative,  however,  as  it  is,  it  must  be  admitted  that  it  is  tcstiinoiiy ' 
not  without  value;  and  to  it  may  be  abided  the  interesting  experi* 
inents  of  Biehat,  Courten,  Ga.npard,  Vauqueliii,  Segalaa,  Staiioiii% 
Bernard,  Brown-Seqtiartl,  Freriehs.J  and  i»ihcJ8,  who»  after  injiKi^J 
ing    into    tl)e  veins  urea   an4l   urine,   never   in    a   single   tuMJUioe  * 
observed  a  ease  of  convulsions.     Again:  Bright,  C'hrijitt)»on,  It<^ 
utid  Frenehs  have  cite<l  oas€S  in  which  a  largii  quantity  of  ureft 
existed  in  the  blood  of  man  unaccompanied  by  any  ofthe  f^ymptoou 
of  uraemia  ;  ami  Frerichs  says,  in  one  mslrmce,  in  whicli  lie  det%-ct«.*di 
the  greatest  amounl  he  had  ever  observed,  there  was  no  aj>p)oaMllj 
to  uriemic  disturlmnce.     Viiuquelin  and  8egii1as,  so  far  from  rc*gmrd-> 
ing  urea  zis  a  poison,  have  proposed  to  administer  it  aa  a  diiirettc. 
S<»me  recent  experimenters,  however,  espcK^mlly  Dr.  ITi  ' 

Mr,  Gallois,  aflirm  ihiit  they  iiave  observed  convuUiori 
after  the  injection  of  urea  into  the  veins.     But  there  w  ii 
that  it  was  the  urea  itself  which  caused  the  rcmvulsiotis»  in  j   h.'- 
Bome  other  principle  resulting  from  decoin position  of  thcs  injeirted 
substance. 

The  conclusions,  therefore^  from  those  facts  appear  irrNbtfldt 
that  urea,  to  say  the  least,  is  not  a  virulent  poison ;  Its  excels  to  ik$ 
blood  will  not  /^r  se  produce  tn*a^mio  ititoxiciitiou,  nor  will  it 
explain  the  numeruUM  phenomena  which  are  so  frequently  foond  %0 
aocumpjtny  its  jjresence  in  the  circulation.  J I  wii*  in  \\en'  of  aH  j 
these  circumstances  that  Frerichs  attempted  to  demonstrate  iImI 
urasrnla  depended  neither  upon  a  diminished  quantity  of  unm  in  llie 
urine,  nor  upon  an  excels  of  the  substance  in  the  blood,  nur  upon 
albuminuria;  btU  that  it  U  fraccabie  sokhj  to  carbonate  of  amm^' 
nia  in  the  systtm^  tfhich,  he  sa>fS^  is  formed  through  tht  agency  i^ 
a  ferment  from  the  urea  itself  In  other  wordsy  I'WHchs''9  thfiirhm 
is^  that  urmmia  is  exvlnsivcly  dur  to  the  tranttft/muitimi  nf  urem 
into  the  carbonate  of  ummofiia*     The  modus  in  fp4o,  ''  .  of 

this  imnsformation  is  not  clear;  there  is  no  proof  as  to    i  iin^r 

in  which  it  is  accomplished ;  but  the  major  point,  vis,  deptndmm 


•  Antmlee  do  Chimio  ot  <!o  Physique, 
f  Qaz.  Med.  do  Vhtvl     IS41      p.  |6£. 
%  Die  Bri^ht'«clio  Xicrenkmakoit,  Idfll. 
IU2.     pjin  XXV,,  p,  IS5, 


A&nlysed  in  Bmlthwaito'i 


THE  FBIKCIPLES  AND  PRACTICE  OF  OBSTETRICS.         518 

fjffurcunia  an  the  presence  of  the  carbonate  of  ammonia^  secmti  to 
rest  on  strong  and  cumulative  testimony. 

Many  years  ago,  Ordla  produced  convulsions  in  an  animal  by 
giving  it,  intcmnlly,  the  carbonate  of  ammonia ;  the  animal,  after 
becoming  convulsed,  died.  Brown-Sequard  has  published  the  fol- 
lowing facts  in  Tessier's  dissertation  ISur  PUremie^  Paris,  186tt: 
Carbonate  of  ammonia  injected  into  the  stomach  does  not  poison ; 
it  is  absorbed  slowly  and  passes  off  through  the  lungs  with  carbonic 
toid.  If,  on  the  contrary,  it  be  injected  in  a  certain  amount  into 
the  blood,  it  has  time  to  act  on  the  nervous  system,  and  to  cause 
convulsions  before  it  is  expired.*  CI.  Bernard  and  Bareswil  have 
detected  carbonate  of  ammonia  in  the  stomach  and  intestines  of 
animals  after  the  removal  of  the  kidneys ;  and  Lehmann  has  also 
observed  it  in  the  matter  vomited  by  patients  affected  with  cholera. 
Christison,  Jakehs,  and  others,  have  recognised,  under  certain  cir- 
cumstances, an  ammoniacal  odor  in  the  blood. 

Until,  however,  the  exposition  of  the  peculiar  views  entertained 
by  Frerichs  as  to  the  true  cause  of  unemic  intoxication,  no  siirnifi* 
cant  value  was  attached  by  authors  to  the  presenre  of  the  carbonate 
of  ammonia  in  the  exhalations.  Frerichs  states  that  he  has  nscer 
tained,  through  chemical  analysis,  the  existence  of  this  salt  in  the 
blood  in  all  cases  in  which  the  symptoms  of  in-a?mia  are  developed  j 
but  its  true  quantity  is  subjected  to  considerable  variation.  He 
further  remarks  that  the  two  following  propositions  he  hns;  provetl 
beyond  a  doubt :  1 .  That  in  every  case  of  nrcemic  irUoxicatlon^  m 
change  of  urea  into  carbonate  of  ammonia  takes  pUvce  ;  t?.  That 
the  symptoms  tchich  characterize  uraemia  can  ail  be  produced  by 
the  injection  of  carbonate  of  ammonia  into  the  blbod.  After  citing 
many  experiments  to  fortify  his  opinion,  he  says  he  has  frequently 
detected  the  alkaline  salt  in  the  expired  air  of  animals  deprived  of 
thdr  kidneys,  and  into  the  veins  of  which  he  had  injected*  urea; 
these  animals  remained  quiet  and  awake  as  long  as  the  expired  air 
was  not  impregnated  with  the  ammonia ;  but  the  moment  the  lat-  * 
ter  was  observed,  the  various  disorders  of  the  nervous  system 
characteristic  of  urromic  poisoning  developed  themselves.  ITiese 
views  of  Frerichs  will  necessarily  tend  to  tUe  settlement  of  a  vexed 
question,  which  has  called  forth  the  ingenuity  of  both  the  physiolo- 
gist and  chemist.  It  may,  however,  be  that  the  future  will  reveal 
the  existence  of  other  poisonous  materials  in  the  blood  which,  to 
the  present  time,  have  eluded  observation ;  and,  in  their  recogni- 
tion, we  may  find  additional  causes  for  the  production  of  tox:^emia. 
It  has,  indeed,  been  suggested  tlmt,  in  Brigbt's.  disease,  the  accu- 

*  Many  facts  have  recently  bocn  developed  in  France,  proving  that  the  phe- 
nomena of*  ursmia  must  be  due  to  some  Idnd  oC  poisoning  It  has  been  shown  by 
Pttxsret,  Tessier,  Picard,  Rilliet.  and  Barthez^  that  in  patients  who  have  died  (bom 
mcinta,  iliere  is  no  organic  lesion  of  the  nervous  centres. 

S8 


614 


THE   PRINCIPLES  AND   PKACTICE  OF  OB9TETK1C8L 


mulation  of  cxatlo  add  in  the  blood  will  develop  the  ayioploiiia  of 
urccmic  Intoxication, 

I  may  here  remark  that  Braun  attributes  the  dcatli  of  ehUdraii  to 
tlje  s^me  cause  as  that  of  the  mothers  In  caies  •  '  '  cH>BfJ 

volitions  from  uremia,  viz.  to  poisoning  by  cftrboi  'niaii 

Mch  poison  is  found  in  the  foetal  blood. 

TVeatment  of  UrasmiaJ^ — This  neoessarOy  involves  two  objectm 
L  The  immediate  restoration  of  the  principal  elimiuaturs  of  lltfti 
system,  such  as  those  of  the  kidney,  ekin,  and  Ixiwels,  with  a  view] 
of  diminishing,  through  these  outlets,  the  quantity  of  urtsa  «it4  j 
noatioua  elements,  which  may  exist  in  the  blood  ;  2,  The  prol« 
of  the  nervous  centres,  as  far  aa  may  be,  against  the  injimoiu  dEbct^l 
of  the  carbonate  of  ammonia. 

In  our  thempcutic  management  of  urtemia,  it  is  importanl  to] 
remember  that  the  skin  contains  an  immense  number  of  gltndi  ' 
which,  anatomically  speaking,  are  eimilar  to  the  oorpusde*  of 
Malpighi  in  the  kidney,  and  which  glands  secrete  water,  iiret»  Bod 
salts.  The  various  retnedies,  therefAro^  known  to  iocrejwe  tbfj 
cutaneous  secretion  should  be  employed  in  eases  of  urnimie  [K>tfoot| 
ing.  With  a  view  of  neutralizing  the  carbonate  of  ammonia  tn  iht  j 
blood,  Frerichs  has  strong  faith  in  benzoic  fici«l,  in  doses  of  (ive  OCi 
ten  grains,  together  witli  iced  acidulated  drinks. 

AntrMficHeB  in  Unimiia. — Chloroform  and  sulphuric  ether  1«V6 
been  repeatedly  employed  in  thei»e  castes  witli  very  favorable  rviiii)U| 
ami  I  btflicve  the  credit  is  due  to  Prof*  Simpson   of  an  injipfiiloiii 
explanation  of  the  mode  of  action  of  these  agents  in  urtemic  potsoci> 
ing.     Availing  himself  of  an   imjmrlant   fact  pointeil  out  by  tbi  f 
chemiHts,  that  chloroform  produces  a  Lem|Kirary  diabetesi  Kt3eUttti%  ' 
causing,  of  course,  the  appearance  of  sugar  in  the  orine^  aiid,  p«r« 
hapa»  also  in  tfie  blood  ;  and  that  the  addition  of  %  little  sugar  Mp 
nrtne  out  of  the  body,  prevents  for  a  time  the  decompoi^tioci  of  tli  I 
urea  into  carbonate  of  ammonia,  the  distinguished  ProfeaMNir  itag*  i 
gests  tliut  llie  ethciicy  of  anaesthesia  in  rc»itraiidng  and  ajresiilig  tilt 
ronvuUions  may  be  upon  the  ground  of  iu  preventing  thijft  decooi* 
potttion.f 

^  Dr.  Muclifim,  of  Kilinburgti,  bus  drawn  nttoiitioD  to  tlie  vjdue  of  ili«  calnlbi 
0u/iimnft/«  in  unomb  |iouiuning  The  exc4iHcnc«  of  xVm  rvroiMljr  oomkytii  141  ii»  po 
«r  h*ct(^if(hi|f  th(!i  nmouut  of  uita  in  thi*  urtnc.  This  foot*  I  belieffv  wm  flnl 
coVGnxl  by  Cluilius.  <£  Hei4e]l>er^.  Frareesof  KnihtD«r»  of  llalli,  hu  mtA^  «ib» 
'very  iQteresting  e36})chfnetit4  cm  the  subject  of  diurrCic  tutMlietnes,  Ao»»rtlixig  to  blav 
the  nvemgo  of  Ofea  Mcr otc4  during  tUe  day  in  hiMiltliy  urmc  is  19  C4  gpucimeR,  w^ili 
the  XMh\m  of  Bttcqncn*!  irive  IC  p^nvrtime^  Krahmer  has  »Howti  Uuil»  uaikr  t}« 
Influence  of  coldiicuitt,  the*  urea  is  iftciYx^ed  to  22.34  gnmmciii  and  tttnlir  dif 
•dminifftriftion  of  ^nUouni  to  2'i.74  gmnitne^  From  the  oxporlisculB  of  RtiltiDt^  , 
lll«t«forc,  it  flppt>iirs  tJmt  i»k:]ikniin  and  gwnincum  produce  n  grpftt^ff«pfittk>iiO(f  i 
HiMl  Biij  knov^u   reini^ieA      Hf.  Ilaaimnud  (Am^.Tiivm  Joum  ^    ScMo 

1859,  p.  275)  hAf»  iilKO  lv«tcd  the  superiority  «>f  iiukihKntni  uvvt  '^<  r  dhtfillii  * 

\  Siinp«oirt  OUi«trb  Wofka,  vol  vl  p.  I»37« 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         616 

Canchuions. — From  what  has  been  said,  it  appears  to  me  the 
following  conclusions  may  be  fairly  deduced : 

1.  Disease  of  the  kidney  will  often  produce  albuminuria,  but  in 
a  large  number  of  cases  albuminuria  exists  without  true  disease  of 
the  gland,  as  a  consequence  of  an  active  or  a  merely  passive  con- 
gestion, and  it  will  also  result  from  a  variety  of  nervous  disturb- 
anoes.* 

2.  Albuminuria  is  often  connected  with  uraemia,  but  is  not  the 
oause  of  it. 

3.  Ursemia  is  a  nervous  disturbance  arising  from  a  peculiar  blood- 
poisoning. 

4.  If  urea  be  a  poison,  the  quantity  of  it  which  accumulates  in  the 
blood  in  cases  of  extirpation  of  the  kidneys  in  animals,  or  in  sup- 
pression of  urine  in  man,  is  not  sufficient  to  produce  any  manifest 
deleterious  effect. 

6.  According  to  Frcrichs,  uraemia  is  merely  a  poisoning  by  the 
earbonate  of  ammonia,  which  is  a  product  from  the  decompoation 
of  urea, 

6.  The  treatment  of  unemia  must  consist  in  the  free  use  of 
diuretics,  sudorifics,  and  purgatives;  the  most  suitable  diuretics 
for  this  puriK>se  being  colchicum  and  guaiacum. 

♦  Dr.  Imbcrt  Gouboyre  (M^moires  dc  TAcad^mie  Imperialo  do  MMecine.  tome 
zz.)  maintains  that  there  ifl  a  puerperai  albuminuria,  and  tliat  it  is  fiymptomatic 
oT,  and  nothing  otiier  than  Briprht's  disease  of  tlie  kidney ;  tliat  there  is  a  puerperal 
Brighi*8  dieeaae.  as  there  is  a  puerperal  peritonitis,  etc  He  also  contends  that 
poerpend  eclampsia  is  actually  puerperal  Bright's  disease,  in  which  convulsions 
occur:  in  other  words,  that  the  eclampsia  is  but  a  symptom  of  albuminous  nephritis, 
or  Bright's  disease  Dr.  Carl  R.  Braun  (Unemic  Convulsions  of  Pregnancy,  Parturi- 
tion, and  Childbed)  defines  unemic  eclampsia  as  follows:  "Eclampsia  puorperalis  is 
an  acute  affection  of  the  motor  functions  of  the  nervous  system  (an  acute  nenroeis of 
moUhtjX  characterized  by  insensibility,  tonic  and  clonic  spasms,  and  occurs  only  as 
an  acoeaaory  phenomenon  of  another  disease,  generally  of  Bright's  disease  in  an 
acute  form  (diabetes  ulbuminosus,  nephritis  diffusa  scu  albuminosa),  which,  under 
certain  circumstances,  spreading  its  toxemic  eflects  on  the  nutrition  of  the  brain  and 
whole  nervous  system,  produces  those  fearful  accidents."  If,  then,  we  are  to  be 
guided  by  the  statements  of  these  two  distinguished  writers,  and  accept  their  opinions 
on  this  question,  we  must  believe  that  when  puerperal  eehmpna  occurs  it  does  to  03 
UtB  effect  of  BrighCs  discos  of  (he  kidney.  From  this  hypothesis,  too,  it  should  follow 
ttat  there  will  be  a  constant  relation  between  Bright's  disease  and  albuminuria,  and 
also  between  that  affection  and  eclampsia.  But  such  is  not  the  fact;  for  it  has  been 
shown  that  albuminuria  may  exist  w^ilhout  structural  alteration  in  the  kidney,  and 
also  that  the  variouii  forms  of  BrighCs  disease  may  be  present  without  the  detection 
of  albumen  in  the  urine.  (See  Begbie^  Brit,  For.  Med.  Chirurg.,  vol.  xii.,  p.  46.) 
Again:  acute  Bright's  disease  is  not  always  accompanied  by  ummia  and  eclampsia; 
In  100  cases  of  Bright'a  malady,  only  from  60  to  70  were  affected  with  unemie 
eclampsia ;  and  another  extremely  important  fact  is  this — Bright*s  disease  is  not 
uniformly  recognised  in  instances  of  fatal  eclampsia.  This  latter  circumstance  is  to 
mj  mind  a  very  decided  negative  to  the  necessary  relation  between  Bright*8  disease 
•od  anemic  convuLUoosi 


LECTURE    XXXIV. 

Ifsminl  IiJibor— Version,  dividtni  into  Gephnlic*  P<»d«lic,  Pelvic;  and  Vi^mion  by  I 
teni;it  Mniilputfilion — Dm^tiosis  of  Matiim)  l^iibor;  ipiiporlAnt  tliAt  it  shooM 
nindo  Mf Ijr— FrognosU.  tiow^  it  vurics — Iridlcutknr^  uP  Mcimuil  Dflivc^t  (»  < 
they  otMuiinl— Timo  mo8t  nuitublu  for  TiTiiiiriAtinn  of  MmiidjiI  LK^Uwr^-^Ut] 
0^  Ctcri,  itieAns  of  ovcrromiUK— Mcx1<?   of  TermUmtrnfC   Mntiual  DvliTtrj; 
varioui*  Hilled  to  be  oU«»ervecl— DivUions  of  Hxniutl  Deliv^^iy— HtUwilbf  ooffrtfllif  1 
Mii1|K)filtionii  of  the  ilend— What  Are  these  Matpoftiiloiui,  ond  how  do  tb^jr  Ob* 
atruct  tho  UecUanium  of  Labor? 


Okxtlemk!^— Your  attofiiion  having  been  ilireeted  to  tlie  variotif 
CJiii>=rji  r»t*  manual  interiercnce  \hr  the  terminitlion  at  fktl^v^rv,  yoa 
art?  now  prepreil  fur  the  discussion  of  the  qiie*<tion — i/i  i-' 
ia  fnttniud  labor  to  be  accompti&ked  t  Jiefurcv  however,  u  -  _; 
upnn  the  piirliculars  of  this  interesting  siihjeoU  It  will  be  proiwr  to 
make  one  or  two  preliminary  ohservalioiiH  touching  f'      "  r, 

it  is  sometimes  termed— ^*/rnm*7.     This  operation  con-  iiig 

inij  down  to  the  fiupenor  strait  one   or  other   of   the   ob^ieiri^i] 
extremities  of  the  f<etu*,  and  hence  it  is  divided  into  cephalic^  pdeic^ 
and  lyadaltc  vernion  ;  in  addition,  there  i*  version  by  external  mfmi- 
pnhition.     In  the  former  cane,  the  head  in  brought  to  thestraut ;  i 
pelvic  version,  the  nnte?*  or  breech;  In  podalie,  the  feel;  %  title 
externa]  cephalic  vermon,  of  which  we  slmll  more  part iciilarlyj 
hereafter^  an  nltempt  is  also  made  to  bring  the  head  down. 

Cfphftiic   Vrrstion, — In  the  earliest  period?!  of  our  jwirni^  this 
wa«  tlie  only  kind  of  version  adopted;  indeed,  niji;  xni'i 

bis  contemporaries  speak  of  no  other,  tuming  by  tlie  i  jg  m 

no  way  alluded  to  by  them,  and  com^equently  it  must  not  only  not 
have  been  practised,  but  altonjelher  imknown.     It  was  not  tintil  Uic 
sixteenth  century  that  version  by  the  feet  was  coiiimended  »o  tl»«1 
atti*ntion  of  the  profession,  a**  xi  Mibslilute  for  verMon  by  (■ 
and  although  writers  generally  refer  the  credit  of  the  suj^^i:  ..^  ..  .a  , 
Par^  and  his  pupil  Guillemeau,  yet  it  is  but  just  to  say  thai  Fraocoj 
preceded    them    both  in  the   suggestion.*     Guillemeau    wast  ilitj 
ini^trnment  in  the  seventeenth  century  of  i«preading  th*!  new  viifir,^ 
and  it  was  «oon  »doj>tod  by  Mauriceau,  the  great  obstetric  autbutity 
of  that  age.     From  that  period  to  the  preset* t,  podalio  vcr>«oo  l«ij 
been  very  generaUy  adopted,  while,  at  the  same  time,  il  miuH  \m^ 

*  Fntioo  woa  tb«  fli^  lo  dMcribe  tnd  reoommeiid  vorsioB  by  tlie  liwl;  whkk  It 
did  in  ItlA  Tnit^  dM  Honiia^  io  ISGt. 


THB  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         617 

admitted  that  version  by  the  head  has  found  its  advocates  even  in 
our  own  times.* 

Let  us  now  proceed  to  discuss  the  general  question  of  m<mual 
Uxbcr  under  the  following  heads ;  and,  in  doing  so,  I  shall  endeavor 
to  present  the  whole  subject  in  the  most  practical  manner :  1.  T?ie 
Diagnosis ;  2.  The  Prognosis;  3.  Ths  Indications;  4.  T?ie 
time  most  suitable  for  its  termination ;  5.  TJie  mode  of  termi- 
nating manual  labor  ;  6.  Its  various  divisions, 

1.  Diagnosis  of  Manual  Deliver g, — It  has  already  been  stated 
— and  it  is  important  to  recollect  the  fact — that  the  introduction  of 
the  hand  into  the  uterus,  or,  in  other  words,  manual  interference, 
can  only  be  useful  either  in  cases  of  malposition  of  the  foetus,  or 
in  the  event  of  the  super\'ention  during  labor  of  certain  accidents, 
such  as  hemorrhage,  convulsions,  etc.,  all  of  which  accidents  we 
have  fully  discussed.  It,  therefore,  is  manifest  that  the  duty  of 
the  accoucheur,  when  at  the  bedside  of  his  patient,  is  to  ascertain 
whether  the  relation  of  the  foetus  to  the  pelvis  be  such  as  to  enable 
nature,  through  her  own  resources,  to  accomplish  delivery ;  or 
whether,  in  consequence  of  malposition,  it  will  devolve  upon  him 
to  render  assistance.  For  example,  if  he  should  find  the  head  at 
the  superior  strait,  the  question  for  him  to  determine  is,  does  it 
present  naturally  ?  If,  on  the  contrary,  one  of  the  pelvic  extremi- 
ties, either  the  breech,  knees,  or  feet,  should  be  there,  is  the  posi- 
tion in  accordance  with  the  requirements  of  nature  ?  And  again, 
should  it  be  a  cross-presentation  of  some  portion  of  the  trunk, 
necessarily  involving  the  propriety  of  version,  its  exact  position 
should  be  ascertained  with  a  view  of  proceeding  to  delivery. 

It  may,  however,  be  that,  so  far  as  the  presentation  and  position 
of  the  foetus  are  concerned,  everything  is  perfectly  natural,  yet  the 
occurrence  of  hemorrhage,  convulsions,  or  some  other  complication, 
may  render  necessary  manual  delivery.  As  to  the  propriety  and 
time  of  having  recourse  to  this  alternative,  the  peculiar  nature  of 
the  case  and  its  exigencies  must  determine.  Is  there  any  special 
period  more  favorable  than  another  for  the  vaginal  exploration 
necessary  to  ascertain  the  true  position  of  the  foetus  ?  There  is 
undoubtedly — and  that  period  is  as  soon  as  possible  after  t/ie  rup- 
ture of  the  membranous  sac^  for  then  the  parts  are  more  or  less 
relaxed,  and  fitted  to  facilitate  the  object  in  view.  It  may  be  con- 
sidered, as  a  very  general  rule,  that  the  diflSculty  of  arriving  at  a 
con*ect  diagnosis  with  regard  to  the  presentation,  position,  etc.,  and 
more  particularly  the  difliculty  of  either  changing  a  malposition 

*  A.  late  writer,  Dr.  A.  Mattel,  is  quite  enthusiastic  on  the  subject  of  cephalio 
Tenion ;  he  says  he  invariably  adopts  it  in  preference  to  podalie,  unless  there  should 
be  tome  in8U{x?ni bio  obstacle;  and  ho  expresses  his  belief  that  cephalic  wiU  soon 
entirely  supersede  podalie  version.  [Essai  sur  Accouchement  Physiologique.  Fsf 
A.  katteL    Paris,  1855.     P.  183.J 


518 


THE   PRrSCIPLES  AXD   PRACTICE  OF  OBTTErRICS. 


into  ft  naturttl  one,  or  of  accomplishing  version,  will  be  enhanced 
in  proportion  to  (he  period  which  has  elapted  siuct  the  tsritp^  of 
ih^UqHOT  an\n\i  ;  tot  wliea  ibis  takes  pince,  thcfajtas  i#  cinbniecd 
more  i*]o^f ly  by  the  uterine  ^valle;  tlie  contrncitonit  a«  a  cofis^qiisiao 
become  more  cnergelio,  and  ihe  presenting  jiart  undergoes  mdl 
intense  prH«ssnre  a**  oftentimes  to  render  its  rc>co^ition  oxtr©mrtjr 
diflicult.  Tfierefore,  gentlemen,  1  cunnot  loo  emphatieHlly  liopreM 
upon  you  tfiat  there  i^  a  |>enod  of  election  for  thi«  kind  of  cvpto* 
ration,  and  if  yon  will  treiisure  the  ftict  in  memory,  it  will  fV^quetitJy 
aid  yon  in  rendunnt^  signal  service  to  both  mother  and  child. 

2.  Prognosis  of  Manual  Delivery, — Whtn  We  eoimlder  the  eoo- 
sumnmte  skill  displayed  by  nature — if  not  contravened— rn  lb© 
expulsion  of  the  child  from  the  cavity  of  t!ie  uterus,  and  the  nafeiy 
with  which  it  U  aceompli-'*hed,  we  cannot  be  surprised  that  tliti 
safety  is  t)eeesj$anly  greatly  dimiiiii^lied  wlien  ninnual  delivery  bhAfl 
roeouriie  to;  for  j*cience,  however  matured  and  complete,  caniMit 
equal  the  triumphs  of  nature,  when  undiatarbcd  by  adventitKHM 
influences.  And  again,  m  a  case  of  fearful  hemorrhage,  where  ibe 
powers  of  the  system  are  near  exhaustion,  or  in  convut«ort%  vbeti 
it  becomes  necessary,  aa  the  only  aliernulive,  loprooeefl  to  aitifidal 
delivery,  the  chances  of  life  either  to  mother  or  child,  from  all 
these  circumstr\nce5,  are  evidently  dimini^hi*d  if  cornpuretl  with  a 
natural  parturition.  Even  the  adjustment  of  a  ma]p«it<ition,  wiik  a 
view  ailerward  of  submitting  the  terminatioo  of  the  deliveiy  Ul 
the  resources  of  nature,  \iill,  to  a  certain  extent,  compi  nfe 
or  less  the  safety  of  the  mother  ancl  child,  and  the  (-(  of 
version  itself  is  by  nu  means  without  its  dangers,  as  I  ^huil  mm% 
particularly  rnennon  when  speaking  of  the  manner  uf  fHjrformiog  it. 

Therefore,  In  all  cases  of  manual  inierfetx-nce,  it  b  a  daty  yim 
owe  Your  fiat  lent,  yourselves,  and  science,  to  exercise  a  fVankness 
worthy  of  the  noble  profession  you  are  pursuing,  and  to  acquaint, 
not  the  patient  herself,  but  the  husband  and  friends  more  Immedi- 
ately interested  in  her  welfare,  thnt  what  you  propose  dolai;, 
although  it  is  an  alternative  fully  justified  by  the  ri  re  urn  stances, 
will  involve  in  a  certain  decree  of  hawinl  both  mother  arid  cbi)d. 
In  tlm  homrablc  and  hii^h-toned  course  you  lose  nothing,  bnl 
will  gain  much ;  for,  besides  the  approbation  of  your  own  eo«i- 
adince,  you  will  establish  a  reputation  for  candor  and  h«  r  ^  vro 

Cinential  attributes  in  the  character  of  a  physician,  an«{  .i ill 

always  yield  a  handsome  interest,  so  far  as  pub  ic  |iatronage  n 
concerned;  and,  al\er  all,  it  is  public  patronage  which  a  metlicml 
man  most  needs  ;  but  never  let  it  be  purchased  at  the  cost  of  tniih. 

3.  Indicadong  of  ManyalDtUvfry. — ^llie  indications  of  mftfioiil 
delivery  are  not  always  identie.'d;  for  example,  in  one  case  there 
?nay  bo  ainiply  a  malposition  of  the  head,  such  as  the  prettfiUOioi 
of  the  (iccipiial  or  parietiU  regions ;  this  malpoaition  may  ofteoiiiMa  i 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         519 

be  corrected  by  the  timely  and  skilful  manipulations  of  the  accon- 
ohear,  and  the  termination  of  the  labor  leil  to  nature ;  again,  it 
may  be  that  flexion  of  the  head  has  not  taken  place,  rendering  its 
desitent  into  the  pelvic  cavity  physically  impossible;  here,  the 
accoucheur  by  op])ortune  interferance  may  cause  the  necessary 
flexion,  and  thus  remove  tlie  obstacle;  should  the  ociuput  remain 
at  one  of  the  sacroiliac  symphyses,  it  should  be  brought  to  either 
one  or  other  of  the  acetabula,  with  a  view  of  curtailing  the  dura- 
tion of  the  labor,  thus  shielding  both  parent  and  child  froni  the 
dangers  of  a  protracted  parturition. 

Ill  a  presentation  of  the  breech,  knees,  or  feet,  it  may  also  become 
necessary  to  have  recourse  to  manual  intei*ference  under  either  of 
the  following  circumstances :  1.  In  case  the  labor  should  be  com- 
plicated with  any  of  the  accidents  to  which  we  have  alluded, 
placing  in  peril  the  life  of  the  mother  or  child,  and,  therefore, 
rendering  immediate  delivery  essential.  2.  If  either  of  these 
extremities  of  the  tcetua  should  present  at  the  superior  strait 
irregularly ;  for  exam[»le,  in  the  presentation  of  the  feet,  or  knees, 
if  one  foot  or  knee  should  be  so  situated  at  the  strait  as  to  resist 
the  contractile  effoit«  of  the  uterus.  Again  :  in  a  head  presentar 
tion  it  may  become  necessary  to  terminate  the  delivery  by  bringing 
down  the  feet,  thus  accomplishing  the  version  of  the  foetus ;  and, 
also,  when  any  portion  of  the  trunk  presents,  the  alternative,  under 
ordhiary  circumstances,  will  be  version.  I  am  thus  particular, 
g^tlemen,  in  the  details  of  the  indications  of  manual  delivery,  in 
order  that  you  may  at  once  appreciate  the  necessity  of  sound 
judgment  and  just  discrimination  in  the  management  of  these 
various  forms  of  preternatural  labor. 

4.  THmemost  Suitable /or  the  Ihrminatlon  of  Manual  Delivery. 
— One  of  the  fundamental  principles  in  midwifery,  which  should  be 
constantly  borne  in  recollection,  is — that  nothing  will  justify  a 
forcible  entrance  into  the  cavity  of  the  uterus;  therefore,  if  the 
month  oF  the  organ  be  not  so  dilated  or  dilatable  as  to  permit  the 
introduction  of  the  hand  without  violence^  the  operation  should, 
tinder  no  circumstances,  be  attempted.  So  you  perceive,  the  most 
saitable  time  for  the  accomplis'iment  of  manual  delivery  is  as  soon 
after  the  rupture  of  the  membranous  sac  as  possible  ;  or  before  the 
rupture,  provided  the  os  uteri  be  sufficit»ntly  dilated  or  dilatable, 
for  at  eitlier  of  these  periods  the  organ  will  be  in  a  condition  more 
or  less&vorable  to  tlie artificial  termination  of  the  labor.  Su]>poso, 
however,  that  manual  delivery  be  indicatetl,  and,  either  from  the 
length  of  time  which  has  elapsed  since  the  escape  of  the  liquor 
amnii,  or  from  other  causes,  the  mouth  of  the  organ  should  be  so 
firmly  contracted  and  rigid  as  to  preclude  the  j)ossibility  of  intro- 
ducing the  hand,  what,  undi-r  these  circumstances,  is  to  be  done  ? 
Are  you  to  allow  the  patient  to  sink,  or  the  child  to  be  sacrificed,, 


620         TUE   PRrNClTLKS  AND   PRACTICE  Of  OfiSTCrRlCa 

without  an  i*fibrt  to  snve  them  ?  Here,  fon  will  have  recount  to 
thoso  ngeril*  \tvsi  ca!cnl.itt»d  to  promote  ruUxtitiotL 

If  tho  patient  he  |»leihoric,  your  ^reat  remedr  will  be  th^  lancet; 
shouhi  blood-h'lting  bo  ifijM?mi».siblo^  tolerant  tloses*  of  UirLnr  rmt^ 
tic  or  i[»ecaeu:inh:i — the  former  is  preferable  becauM  more  reluible 
— will  be  found  essentijiUy  j^ervifcable,  W«rm  emoUirnt  iojifeliofiff 
into  the  vaij;ina  will  also,  in  iliese  oases,  olWniimes  have  the  bap- 
pieKt  efieet ;  and  if  it  ciin  he  rcmititsd  to  Mithoot  too  mtich  toooii- 
venience  to  the  patient,  the  warm  bi|>-bath,  or  merely  sitting;;  over 
the  va(>or  of  liot  water,  may  ri-»sfilt  most  bciielirially.  I  bare  ofi 
several  occasions  found  this  hitter  very  efficient.  Here,  loo,  yoo 
will  have  an  important  auxiliary  in  the  beUadunna  ointment  3  j.  of 
the  extract  to  ?  j.  of  adeps.  Let  it  be  freely  applied  to  the  moutb 
of  the  uterus,*  It  h  ivell  to  remember  that,  uh  exceptions  to  the 
general  rule,  canes  will  ocea^iortally  be  n\et  with  in  which  the  vm 
uteri  will  be  in  a  $tate  of  complete  relnxatiun^  although  the  rtipiiifii 
of  the  sac  and  es^rape  of  the  waters  have  occurred  w?veral  bouri 
previously, 

6.  IVie  Mode  of  t^rtniuati/if/  Jf initial  Zhlivery. — The  rnU^  to  bt 
observed  in  all  csiJ*e«  in  whicli  nirntmil  interlereiH!e  i?*  calUHJ  far  aro 
few  and  Hlniple,  and  Bhould  Im  faithfully  carried  out.  Il  ts,  I  mm 
quite  sure,  to  the  neglect  of  these  rules  that  we  arc  to  refer  inaQjr 
of  the  unfortunate  results  too  frequently  miccetjtling  manual  bbor* 
The  rules  are  as  follows: 

{a)  As  s»HUi  an  the  aocoucheur  has  decided  upon  the  ttocei^Mty  of 
interference,  lie  should  aciiuaint  his  patietit  with  the  fact;  ai>d,  in 
doh>^  8o,  care  should  be  taken  not  to  alarm  her  by  the  fligtitenl 
intim:uion  of  any  danji;er  involved  in  the  opeintton.  Tbe  probabi* 
UtioH  of  the  result  .should,  on  the  contrary,  a^  has  already  been 
remarked,  be  stated  frankly  to  the  husband  and  friend s.f 

*  It  wttl  »>metimc'B  hjippen  ilmt  tlic  os  uteri  resiitii  aII  the  mp»iMi  jiuC  isdleilii^ 
Mid  it  wiU,  itier^^fitre,  in  ouies  of  urgtMit  noccieitj,  t>e  |imf«er  to  liav*  rr<»mfiw  to 
wU'tt  is  ktiowii  as  urtillm)  dlUitation ;  lltU  is  to  bo  ofn?cti<t  in  ooe  of  two  W9j% 
«ii)»er  iltrou^h  the  Agi'iicv  ortlio  ntigiTH  or  nn  in^itrument.  Fur  the  fliniktr  tiurfeai^ 
<mo  i>r  two  tlngcrs  mm  be  CMiiliousljr  fiilnxlucx'd  into  the  on,  wliidi  trill  Act  botti 
nMciiuiiicttilr  »nil  phv»iub}ric»ii^  iri  Itio  HccmnplMhiiHira  ut  tho  ob}eot.  But  wilts 
tiie  Kileiy  uf  liio  iikiIIkt  or  child  dependji  upon  Ji  prom)it  dltatMiion,  1  ^icHild.  Iti  sudi 
Kn  i^iia-n^'iM'T,  prt'lVr  incising  tlio  oa  utori;  the  opt»nilic»n  i«  wiihout  dinifcrr,  aud 
U8ii  (i  by  rupid  dilulMtton.     bi  snying^  thi>^.  howeviT,  I  would  oiutNm  jrao 

(i^;i.,  ^  iTfHiiin)!*  In  \i  i*jtL^(»t  til  mMturict'M  of  fult  jtivtilfciitum.     Tlie  opKtm^itKk 

is  \nex\\ni%%¥\i  An  folhiwa  :  ilio  fjMticnt  on  hrr  buck,  in  bruuifht  to  Uie  <^d|plr  nflbf  hf4^ 
<ma  or  two  tirt^rs  »rc  then  Iniroduccd  into  the  vuirtDii.  «i  fur  a«  Iht*  cm  to  terro  m  a 
gutd(>  i^JT  ii»c  [mjbc- pointed  bli^toury.  with  which  four  or  Hvc  siiinH  bicMims  ir*  Im  bt 
mndi?  in  the  nnh-rtor  antl  po«t4rn<>r  \\\^  Should  ItcuicirrhM^  f'^Uow  — i*  vrrr  rvt 
<jin!«]rtiiituric«*— H;nj)H*ti(Jii>;  ofcfUd  wuti^  *\t  jhmall  ])1t^dj|^.*U  of  Ufil  will  n  i  a^ 

f  84Mnf«  excellent  aiitht^ritirA  rtN-oniineiid  whm  it  Ixvomcs  nca-      _  Am 

fVecmnNi  lo  MrtiUclnl   dehircry,  whether  mwnnnl  or  in*^trtimcntaL  In  do  fii  wtlhaiit 

miattatealilig  the  fjict  to  tbi*  putii*tit     In  nu  npttaou  Ibia  n  b^d  ikdviMH.  and  alMNild 


THE  PRINCIPLES  AND   PRACTICE   OF  OBSTETRICS.         521 

(J)  The  patient  should  be  placed  crosswise,  the  bladder  and  reo- 
tain  having  been  previously  emptied,  with  her  hips  brought  to  the 
edge  of  the  bed.  I  much  prefer  her  to  be  on  her  back,*  although 
many  recommend  that  she  should  rest  on  her  left  side.  If  on  the 
back,  a  fold  of  blanket  to  be  ])Iaced  under  the  hips,  to  prevent 
their  sinking  into  the  bed.  The  legs  flexed  at  a  right  angle  with 
the  thighs,  and  held  by  two  assistants  as  follows  :  let  the  left  hand 
of  the  assistant  on  the  right  side  be  placed  on  the  knee  of  the 
patient,  and  with  the  right  hand  in  a  state  of  supination  placed  on 
his  lap^  tlie  assistant  should  take  hold  of  the  foot  of  the  patient, 
holding  it  steadily  during  the  operation.  Precisely  the  same  thing 
should  be  done  by  the  assistant  on  the  other  side,  with  the  excep- 
tion that  he  should  place  the  riglit  instead  of  the  left  hand  on  the 
knee,  and  grasp  the  foot  with  the  left.  The  accoucheur  is  to  be 
seated  between  the  assistants. 

(c)  The  choice  of  tlie  hand.  This  is  important,  for  it  will  have 
mach  to  do  with  the  success  of  the  operation.  In  all  cases  in 
which  the  feet  present,  the  hand  should  be  introduced  correspond- 
ing with  the  heels  of  the  i'oDtus ;  when  the  knees  present,  the  hand 
corresponding  with  the  til)ia3 ;  and  in  a  breech  presentation,  the 
hand  which  corresponds  with  the  posterior  surface  of  the  thighs. 
In  a  head  presentation,  the  hand  corresponding  with  the  face,  for 
the  purpose  of  giving  the  natural  curve  or  flexion  to  the  body  dur- 
ing the  operation  of  version.  In  all  other  presentations,  the  hand 
corresponding  with  the  point  of  the  uterus  at  which  the  feet  are 
situated. 

(d)  The  hand  not  introduced  into  the  uterus  should  be  applied 
to  the  abdomen,  with  a  view  of  steadying  the  organ  during  the 
manipulation. 

(«)  The  hand  to  be  well  lubricated  with  oil,  fresh  lard,  or  some 
mucilaginous  material ;  and,  in  case  of  version,  the  coat  should  be 
removed  and  the  shii*t  sleeve  rolled  high  up  on  the  arm,  care  being 
taken  also  to  anoint  the  latter.  The  accoucheur  should  be  provided 
with  an  old  sheet  or  apron  for  the  purpose  of  protecting  his  dress. 

never  be  followed.  The  adroit  practitioner,  who  poiisesses  the  confidence  of  bis 
patient,  can  always  obtain  her  c^mscnt  to  submit  to  whatever  his  judgment  mn^i 
deem  proper.  Besides,  see  in  what  a  painful  position  ho  might  possibly  placo  him- 
self by  attempting  the  operation  without  having  previously  admonished  her  of  its 
necessity.  In  his  attempt  to  act  clandestinely,  there  would  be  more  or  less  risk  of 
rupturing  the  uterus,  to  say  nothing  of  injury  to  the  child,  through  the  movements 
of  the  mother  as  soon  as  she  became  cognizant  of  what  was  going  on.         « 

♦  I  have  on  two  occasions  been  obliged  to  deliver  patients  by  version  in  a  posi- 
tion not  altf>gether  convenient  to  them,  but  which  greatly  facilitated  the  operation — 
allowing  them  to  rest  on  their  elbows  and  knees.  In  boih  of  these  instances  I  had 
recourse  to  this  position  for  the  reason  that  the  feet  of  the  foetus  corresponded  with 
the  anterior  wall  of  the  uterus.  It  will  bo  at  once  seen  how  efficiently  the  position 
of  the  patients  removed  the  embarrassment  of  the  version. 


622 


THE   PUINC1PLE3  AND   PRACTICE   OF  OBSTITrRlCS. 


(f)  The  band  la  be  introduced  with  fin<ycr»  and  ihumb  j^^aibered 
in  a  cunoidal  form,  and  the  time  of  a  pain  to  be  selected  in  carrr- 
mg  l)w  hand  into  the  vagina;  it  should  at  fin*t  be  introduced  froai 
before  backward,  then  the  ellxiw  flhould  be  pfently  depre^Mid,  and 
the  finders  given  an  upward  direction  parallel  to  the  axi?*  of  tbe 
euperior  strait ;  b«t  the  hand  should  not  be  made  to  etiter  the  me- 
nia  except  during  an  interval  nf  pain. 

Iff)  When  the  liand  h  introduced,  it  should  pursue  thai  |»oit]oQ 
of  tl>e  f<rtus  corre?^fH>nclin*^  with  the  posterior  plane  of  the  titenai 
and  in  this  way  tlie  difficulty  will  be  avoided  of  conroimding  the 
shoulder  with  the  hip,  the  elbow  with  the  knee,  or  the  fingerB  with 
the  toes. 

(A)  As  soon  as  the  hand  has  reached  the  ft?et,  one  or  both  n^hottld 
bo  gently  seized^  and,  in  (he  absence  of  coniraetiofi^  brou«^ht  down 
to  the  superior  straits 

(i)  Tlie  version  of  tbe  ftrtus  should  lie  made  daring  freedom  from 
uterine  contraction,  and  the  patient  de?«ired  not  to  bear  down  or 
empltjy  any  eftbrt  until  the  feet  are  beyond  the  vulva.  The  opera- 
tion to  be  performed  with  great  caution,  **  Tarde  e(  ^eefire*^ — *slo¥rly 
and  »*ceurely  being  the  gf>vrrning  principle  in  theae  caneii. 

6,  Ditusionit  of  Manual  Dflit*erif, — It  seems  to  me  thmt  the  mnl- 
tiplied  division*  made  by  njost  auihurs*  of  mrumul  delivery  can 
have  no  other  ettect  than  that  of  cmifusin^  the  mind  of  tbe  flii* 
dent,  and  wearying  the  ]>atience  of  the  practitioner.    The  grMi 
objeet  in  teaching,  I  mnintain,  is  to  simplify  ns  tar  anil  m. 
port  with  the  nature  of  the  subject  di^cus'^ed,  so  that  tbe  cl 
of  all  inj^t ruction  may  be  accomplished,  viz,  to  be  nuefid.      Wnb 
thia  view,  therefore,  I  shall  present  to  you  the  fjllomng  elm^iSoi- 
tion  or  divisions  of  manual  labor,  wliieh,  while  they  will  embmee 
every  practical  indication  that  may  arise  in  the  !}(« 
I  trust*  commend  th(mselve»  to  your  nppretirition 
libernlion  from  unnecessary  and  complicated  details.     I  am  quite 
sure  that  the  utimerous  refinements,  if  I  may  so  term  them,  tnCe 
which  writers  enter  in  their  vaned  divisions  not  only  lead  to  i?<iB- 
fu54tiu,  but  so  perjilex  the  reader  as  to  cause  him  to  des|mir  of 
underKtandirjg   them.     To  obviate,  therefore,  this   difficulty^  iwd 
with  a  view  of  exhibiting  this  imjiortant  subject  in  a  manner  m 
ginip'e  ami  tnngible  that  all  may  appreciate  and  comprehend  tt,  I 
siibmrt  the  Ibllowing  claj*>iticuiiou  of  the  oireunmtancea  in  wbidi  it 
may  become  necessary  to  have  recourse  to  manual  interferenoe:* 

I'^irtt  I/ivt^ion^  embraiirig  bead  present  a  li<ms,  and  exhibitinf 
two  varieliei;  in  the  fir>t  variety,  simple  adjustment  of  the  ht?ad 
frum   .1  Mtion  brcnnies  ncee^ary ;    or  Mben  tbU  cannot  bt 

•civjmi  version  must  be  had  recourse  to;  in  the  eeoood  tjuv 

*  The  clmnM^mtion  \  pniprigtt  it  •ofm^wtml  kind  rod  lo  the  oo«  tdopt«d  bj  mf  M 
IMlti^  43ifQN)iV  M I  Uihik  b  more  atmpllflod 


T&E  FRnrClPLSS  AND  PRACTICE  OF  OBSTETRICS. 

eCy^  yenion  is  indicated,  in  consequence  of  the  occurrence  of 
hemorrhage,  convulsions,  or  other  complications. 

Second  Diviaiony  embracing  pelvic  presentations,  viz.,  the  breech, 
knees,  and  feet ;  this  division  also  exhibits  two  varieties ;  in  the 
first  variety  it  may  be  necessary  to  interpose  because  of  malposi- 
tion ;  in  the  second,  interference  is  called  for  because  of  the  com- 
plication of  some  acc^ident,  rendering  immediate  delivery  necessary. 

Third  Division^  embracing  trunk  presentations,  including  those 
of  the  shoulder  and  arm. 

We  shall  now  proceed  to  indicate  in  what  way  adjustment  is  to 
be  effected  in  the  following  positions  of  the  head,  embraced  in  the 
first  division  of  our  classification,  viz.,  1.  Occipital  region  at  the 
superior  strait ;  2.  Either  the  left  or  right  lateral  region  ;  3.  When 
the  head  is  not  flexed  ;  4.  In  occipito-antenor  positions,  w^^here 
rotation  is  not  effected ;  5.  In  occipito-sacro-iliac  or  posterior  posi- 
tions, where  rotation  is  not  effected. 

First  Division, — 1 .  Manual  Delivery  when  the  Occipital  Region 
presents. — ^Thc  occipital  region  may  present  at  the  superior  strait 
as  follows — and,  in  either  case,  i^  will  be  physically  impossible  for 
the  head  to  descend  into  the  pelvic  cavity  without  a  change  of  |»osi- 
tion:  1.  The  neck  of  the  fcetus  corresponds  with  the  lefl  acetabu- 
lum, while  the  vertex  is  in  apposition  m  ith  the  opposite  sacro-iliao 
symphysis;  2.  The  neck  regards  the  right  acetjibulum,  and  the 
vertex  the  opposite  sacro-iliac  symphysis.  3.  The  neck  is  at  the 
right  sacro-iliac  symphysis,  the  vertex  at  the  left  acetabulum ;  4. 
The  neck  at  the  left  sacro-iliac  symphysis,  the  veitex  at  the  right 
acetabulum. 

With  a  little  reflexion,  and  bearing  in  memory  what  we  have 
sud  respecting  the  fundamental  conditions  on  which  is  based  the 
mechanism  of  natural  delivery,  it  must  be  quite  manifest  that,  in 
either  of  these  positions  of  the  occipital  region,  there  is  an  urgent 
necessity  for  prompt  interference  on  the  part  of  the  accoucheur.  It 
is  in  cases  like  these,  in  which  the  proper  time  for  action  being  per- 
mitted to  pass  unimproved,  that  we  find  so  much  of  disaster  in  the 
lying-in  room.  Here,  for  example,  the  contractions  of  the  uterus — 
no  matter  how  vigorous — could  prove  of  no  possible  avail  in  accom- 
plishing the  delivery,  for  the  reason  of  the  physical  disprofjortion, 
caused  altogether  by  the  malposition,  between  the  head  and  mater- 
nal pelvis.  Therefore,  with  a  continuance  of  the  uterine  effort,  and 
no  adjustment  of  the  abnormal  presentation,  the  death  of  the  child 
would  be  certain ;  and  fortunate  would  it  be  for  the  mother,  if  she 
too  were  not  sacrificed,  from  either  exhaustion  or  rupture  of  the 
uterus !  Let  me  then,  in  connexion  with  the  case  under  considera- 
tion, again  enjoin  upon  you  the  necessity  of  early  acquainting  your- 
selves with  the  true  condition  of  things,  so  that  your  interposition 
may  be  opportune.     Delay  in  arriving  at  an  accurate  diagnosis  is 


624 


THE   nUXCIPLKS   AND   PRACrTlCB  OF  OB!4TETRlCa. 


ofleniimc'fl,  iti  the*ie  ami  kimlrt'cl  inst:ince»of  di^'priiporfiun  1>et%i*«M 
the  argnns  of  llie  mother  artd  tlie  preseniin*x  portion  of  the  fopto^ 
the  cause  of  embryotoinjr  or  other  opemtions,  which  woalil  tM>l 
have  bf*en  called  for  if  a  proper  degree  of  %*igiliitioo  hud  been  exer* 
ci8c?d. 

Siifiposing',  then,  that  a  cnrcful  vng^innl  examination  should  di«- 
close  the  fact  that  the  occipital  region  uf  the  chiJd*i*  head  pret^^nteil 
at  the  sufjerior  8iruit,  the  aceottclieur  will  be  compelled  to  do  one 
of  two  things:  cither  to  adjust  the  head  by  placing  it  in  n  iiomud 
poKitiun,  itr,  if  this  cannot  he  done,  he  niiii^t  resort  to  version* 
The  proper  time  for  a<lju«lin;^  the  head  will  be  when  the  pans  are 
soft  and  relaxed,  and  tlte  head  ctmscquently  more  or  less  movable; 
for  this  purpose  the  hand  shou'd  be  introdneed^  an  already  indi* 
eated,  and  the  vertex  brniiuht  in  projier  position  with  the  strait; 
this  being  accoinpllHhed,  shonld  no  accident  intervene  to  render 
immediate  delivery  necessary,  the  termination  of  the  labor  may  bt 
comnnttcd  to  the  eifurts  of  nature.  It*,  however,  it  become  iiiipot- 
Bible  to  right  the  head,  either  by  the  hand  or  lever,  the  coarne  to 
be  pursued  is  to  [»roceed  at  once  to  turn  and  deliver. 

2.  Manu€tl  DcUrery^  when  eithtr  of  the  Lateral  Regions  vf  thi 
Head  FresenU, — If  the  head  should  present  m  that  oDe  of  Ita 
lateral  re^jions  rests  across  the  t^iiperior  strait,  there  will  be  a  {4iyA* 
cal  impossibility  for  it  to  pass  without  change  of  poMlion;  fur,  in 
auch  case,  the  largest  diameter  of  the  head — the  occipito-meutal — 
meantning  5|  inches,  is  in  apposition  witli  one  or  other  of  \\m 
oblique  diameters  of  tlie  strait,  which,  you  will  recollect,  w  oidy  i^ 
inches  J  renderini?  it,  therefore,  out  of  the  question  for  a  body  of 
5J  inelici*  to  make  iti*  exit  through  a  space  of  4^  inches.  Here,  loo^ 
there  as  a  palpable  necessity  for  early  aHcertainitig  thia  cbamcter 
of  preAeniaiion,  for,  if  it  bo  permitted  to  remain  unchanged  uttder 
the  i»»tluence  of  strong  uterine  contraction,  serious  eon$cquencei 
may  ensue  both  to  mother  and  child ;  the  former  incuriiiig  the 
hasard  and  consequences  of  exhaustion  and  ru[iture  of  the  utenis; 
the  latter  the  serious^  if  not  fatal,  effects  of  undue  preasiLre.  Re* 
member*  also,  that  under  these  circmnstances,  if  there  be  laQDeeoa* 
sary  delfiy,  the  dreude*!  alternative  of  embryoloniy  may  become 
the  last  resotirce !  The  lateral  regions  of  the  head  may  pitsscol  as 
follows : 

Fitit  PoiUUm, — ^Tbe  vertex  is  in  apposition  with  the  left  sccta* 
bulum,  and  the  base  of  the  cranium  regards  the  oppotidU»  aacro> 
iliac  symphysis.     (Fig*  65.) 

Second  JPo^ition. — ^Tho  vertex  is  at  the  right  aeetabtdnm,  and 
the  base  of  the  eranium  at  the  opposite  saero-iliac  syraphj-^ia. 

Third  Position, — This  is  the  reverse  of  the  firsts  and  eofisfr 
quently  the  vertex  is  at  the  right  saero^iliac  M'm|*hys;a,  and  tbt 
base  of  the  craiiiutu  in  currei»poudence  with  the  leil  acetabuluisu 


TITK   PRINCIPLES  AKD   PRAC 


EtICS. 


526 


Fourth  Post t ion. —Thh  is  the  reverse  of  the  second,  the  vertex 
being  in  apposition  with  the  left  sacro-iliac  symphysis,  while  the 
l>ase  of  the  rranium  is  at  the  right  acetabulum* 

How  ran  these  four  positions  be  distinguished  in  a  vaginal  • 
exnmination,  so  that  you  may 
be  able  to  recop^ise  them 
individually?  This  is  very 
readily  accompVUhcil  by  dim- 
ply ascertnininnf  the  exact  pf> 
gition  of  the  oar  of  the  child; 
for  example^  in  the  first  posi- 
tion, if  it  be  the  right  side  of 
the  head,  the  concave  border 
of  the  ear  regards  the  left 
iliac  fossa ;  and  the  ricrht  iliac 
fossa  (Finr,  G5)  if  it  be  tlie 
left  side  of  the  brad.  In  the 
second  p*fsititHi,  the  relation 
of  the  ear  with  the  points 
of  the  pelvis  is  the  same  as 
in  the  fir.^^t  position  for  each 
side  of  tlie  head*  In  the 
third  position  of  tlie  right 
laternl  region,  the  concave 
border  of  the  ear  is  turned 
toward  the  right  iliiic  fossa,  whereas  the  convex  border  corres- 
ponds  with  the  ibssa,  if  it  be  the  lt?ft  lateral  region »  In  the  fourth 
position,  the  concave  border  of  the  ear  corresponds  with  the  right 
iliac  fossa,  if  it  be  the  right  lateral  region  ;  if,  on  tlic  contrary,  it 
be  a  presentation  of  the  left  lateral  region,  the  convex  portion  of 
the  ear  regards  this  same  fossa. 

Let  U8  now  suppose  that  you  are  in  the  lying-in  chamber  ;  your 
patient  is  in  labor,  and  you  have  ascertained  that  one  of  the  lateral 
surfaces  of  the  child^s  head  presents  at  the  supc^rior  strait.  The 
Ycry  knowleilge  of  this  fact  admonishes  you  that  natnre  is  at  fault; 
she  needs  assistance,  and  the  result  of  the  labor  will  depeml  very 
much  on  the  kind  of  assistance  rendered — whether,  for  example,  it 
be  opportune  aiid  ctiicient,  or  tardy  and  unskilful.  The  indications 
in  a  case  like  this  are  two-fold,  either  to  right  the  head  by  bringing 
the  vertex  to  the  strait,  and  then  committing  the  achievement 
of  the  delivery  to  the  natural  efforts ;  or,  if  the  adjustment  of  the 
mid  position  cannot  be  accomplished,  then  the  necessity  will  be  to 
terminate  the  labor  by  version.  With  a  view  of  righting  or  adjust* 
ing  tiie  heud,  the  hand  shonld  be  cautiously  introduced,  and  the 
attempt  made,  if  in  the  first  position,  to  raise  the  base  of  the  cra- 
nium from  the  right  sacro-iliac  symphysis  (Fig.  G5),  while  with  the 


FlQ.  S0. 


626 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICa 


Other  hand  appUed  io  tht^  nhilomen^  M:«^^ntiQ  pimsMtrtt  flipuhl  be 
directed  on  i\w  left  iliac  region,  for  the  purpoM^  if  |iombU%  gf 
depressing  the  vertex  in  proper  position.  But  if  all  atlempts  U» 
right  the  bead  fail,  then  the  indicatioti  in  at  oiiee,  if  th«^  paru  bit  Id 
proper  condition,  to  procce<l  with  the  ic^rsiori  of  tht*  f<rrtii«,  ttm 
details  of  wliich  operation  we  nhall  dUouss  in  a  wubp<equent  In^tuns 

Manual  Bellotn/^  Nntura  being  unable  to  accomplUh  Flexion,—* 
In  describing  the  niechanisni  of  natural  labor,  it  wa«  stateil  Ihftl 
the  head,  when  nature  is  not  interrupted  in  her  re»ource«^  utider^ 
goes  three  movements  |«re\iotm  to  its  expulsion,  viz.  L  Flexion; 
2,  l\otatiori  j  3.  Kxteniiiou.  The  objeet  and  modn  of  protluetiim 
of  these  movemefits  were  fully  explained  at  thai  lime,  WcU,  yoii 
are  attain  in  the  lying-in  room ;  the  head  pretieuta  in  the  mo&i 
natural  position,  the  potiterior  fontimelle  regai'  it* 

bulntn,  and  the  anterior  tho  opftonite  »acro-ii  ...  ^be 

oontractionsof  the  titeru;)  have  commenced,  and  inereajieit]  energy } 
the  OS  uteri,  under  their  influence,  dilate^  but  there  i*  no  diang* 
in  the  head  ;  time  passes  on,  the  contract  ions  lose  nothing  of  their 
vij^or,  but  rattier  increase  in  power.  On  a  vaginal  exatifiiuHJiin, 
you  a.'^certain  that  the  head  is  still  unchanged  from  iv*  prtmilivir 
relations  with  the  superior  strait;  there  ii  wiusual  h€<tt  In  lA# 
Vdijina^  the  itealjj  in  roiTugattd  vr  in  riihje»^  ami  tlit.  jHttiu*i*s 
gtrtftf/fh  is  f/iviuff  waf/»  Now,  gentlemen,  permit  me  to  a^k  jatt| 
w*hat  do  these  symptoms  disclose  ? 

Do  they  not,  in  the  most  emphatic  manner,  portend  tronble,  and 
inculcate  that  nature  ia  oppressed  by  some  obiiiacle,  which  tbr  b 
vainly  struggling  to  overcome  ;  and  do  they  not  tirgtuilly  ca^l  upcici 
you  lor  prompt  and  eflicient  succor?  Do  not  missiutei prt*t  ihti 
silent  but  eloquent  appeal  of  nature,  in  the  hour  of  her  tribulation! 
Deeision  and  pron^ptnei^s  here  will  enable  yon  to  save  human  lile^ 
and  draw  from  grateful  hearts  the  invocation  of  the  blemtn^ii  «f 
heaven  upon  you.     The  well-educated  accoucheur  will  at 

a  glance  the  true  nature  of  the   difliculty  ;  he   will   tvi  Am 

important  fact  that,  with  all  the  efforts  of  the  uterns,  the  flexion  of 
the  head  hns  not  been  accompli  shed,  and,  as  a  eonsoqnence  of  Ums 
failure  to  bring  about  this  tnovemcnt,  the  first  link  in  the  mecha- 
nism of  labor  is  wanting;  under  these  cireum stances,  the  ^fgomns 
uterine  contractions  have  been  lost  in  the  abortive  attempt  Ut 
accomplish  the  physical  impossibility  of  causing  a  body  of  lour 
inches  and  a  half  to  pass  through  a  space  of  only  four  inches  and 
a  half;  for  yon  w  ill  remetnber  that  the  occipit(»-fVtmtal  diameter, 
wbich  measures  in  the  clear  four  inches  and  a  qunrter,  receivi*.*  tli^ 
addition  of  a  quarter  of  an  inch  by  the  thickness  of  the  scalp,  liair, 
ajid  Mdes  of  the  uterus,  thus  making  the  aggregate  of  four  tnebei 
and  a  half  to  make  its  exit  through  the  nblique  diameter  of  llis 
su|jerior  strait,  which  j»rescnl8  these  ^ame  dimensions  £   Here,  thfes^ 


THE  PBINCIPLK3  AND  PKAOTICJfi  OF  OBSTETRICS.         627 

is  an  opportanity  for  the  exhibition  of  true  science,  which  is  erer 
in  sinking  contrast  with  ignorance  and  empiricism. 

One  of  two  contingencies  will  present  itself  in  the  case  such  as 
we  have  just  described ;  the  suffering  patient  will  have  by  ])er  side 
a  medical  man,  whose  previous  edudation  entirely  unfits  him  to 
appreciate  the  nature  of  the  difficulty,  and  who  consequently  will 
be  in  the  clouds  as  to  what  should  be  done  to  overcome  the  obsta- 
cle ;  or  it  will  be  her  good  fortune  to  be  attended  by  an  accoucheur 
who  has  studied  in  the  school  of  nature,  is  thoroughly  imbued  with 
the  principles  which  ordinarily  guide  her  in  the  parturient  struggle, 
and  who,  therefore,  is  prepared  promptly  and  efficiently  to  become 
her  substitute  in  the  hour  of  need.  In  the  former  case,  ignorant 
of  the  true  cause  of  the  delay,  the  medical  man  will  content  him- 
self with  assurances  to  the  patient  that  "  all  is  right ; ''  he  will  tell 
her  to  make  the  "  most  of  her  pains,''  and  soon  all  will  be  over. 
These  stereotyped  expressions,  the  language  of  ignorance,  may 
eerre  for  a  short  time  to  cheer  and  hifuse  hope  into  the  mind  of 
the  patient,  and  appease  the  anxiety  of  friends;  a  very  few  hours, 
however,  will  elapse  before  the  predictions,  so  confidently  made, 
will  be  proved  to  be  false ;  the  strength  of  the  patient  has  entirely 
given  way  in  consequence  of  the  unavailing  effort  of  nature  to 
cause  the  flexion  of  the  head — the  severe  pressure  to  which  this 
latter  has  been  subjected  has  resulted  in  the  death  of  the  foetus ; 
and  the  head,  from  the  long-continued  contractions  of  the  uterus, 
has  become  so  firmly  wedf/ed  at  the  superior  strait  as  to  render  any 
effort  to  move  it  impossible.  This  is  a  sad  picture ;  under  the  cir- 
cumstances, the  alternative  may,  perhaps,  be  craniotomy,  which 
will,  in  the  existing  condition  of  things,  most  probably  compro- 
mise the  life  of  the  mother. 

Let  us  now  reverse  the  scene.  Science  takes  the  place  of  igno- 
rance ;  the  well-instructed  accoucheur,  knowing  that  an  important 
part  of  his  duty,  in  the  lying-in  room,  is  opportunely  to  ascertain 
when  nature  is  defeated  in  her  plans,  so  that  he  may  at  once  be 
prepared  to  interpose,  will  not  remain  a  passive  spectator  of  her 
unavailing  struggles,  but  will  proceed  by  a  proper  examination  to 
inform  himself  of  the  true  cause  of  the  delay  in  the  descent  of 
the  head.  lie  soon  becomes  aware  that  the  efforts  to  produce 
flexion  have  proved  abortive;  and  in  lieu  of  waiting  until  the 
work  of  death  has  been  accomplished,  so  far  as  regards  the  foetus, 
and  the  life  of  the  mother  subjected  to  the  most  serious  peril,  he 
proceeds  to  do  for  nature  what  she  has  vainly  labored  to  accom- 
plish for  herself — in  one  word,  he  produces  the  flexion  of  the  head 
in  the  following  manner :  placing  the  patient  on  her  back — or,  if 
she  prefer  it,  on  the  side — the  accoucheur  gently  introduces  his 
hand  into  the  vagina,  steadying  the  uterus  with  the  other  hand 
placed  on  the  abdomen,  and  with  the  middle  and  index  fingers 


THK  PRINCIPLES  AND   PRACTICK  OF  OfiSTETBlCS. 

applied  to  one  os  pnrie^afe^  and  the  thumb  to  the  other,  ho 
liouHly,  during  ihu  absence  of  a  pain,  elevates  the  Ijice  and  dc?p 
ea  the  occiput,  wUk'h  necessarily  rcJ»uIl8  in  the  desirud  movement, 
vix.  flexion.  This  timdy  irjtcrference — founded  on  a  knowledge  <| 
of  tlie  prinriploji  on  which  rests  the  mechantfim  of  labor— -over* 
oonie^  the  ohstucle,  !recttrin<;  tsafety  to  bot!i  mother  aad  cbUd,  atnl 
ensiire^s  to  the  medical  man  the  enjoyment  of  a  con^ctousDeas  tbsl 
he  hris  performed  his  duty* 

4.  Manual  Ddh^en/  in  thf.  0^cipUih<mUri(jr  Poeifions  whm 
JRotatkm  is  not  rffVcteiL — The  contr:ictiona  of  the  uierusi,  we  nrlll 
suppose,  have^  m  they  ordhmrdy  will,  sufficed  to  eaiixe  tho  i]i;xioa 
of  the  hcud  ;  after  tlH8  rnovenient,  you  will  recollect  that  the  head 
restH  diasxonally  iti  the  pelvic  cavity^  and  crmttnue!«  to  do  so  until 
it  has  undergone  rotation,  the  effect  of  which  is,  In  the  occipiio* 
anterior  positions,  to  liring  the  occiput  under  the  symphyiii*  puhb, 
and  the  face  hito  the  hulluvv  of  the  s;icrum.^  But  it  will  e»ometiiii«S 
happen  that  nature  catuiot  eifect  this  rotary  movemeui — uitdo^ 
these  circuinstnnces,  the  s.mie  plicnoniena  will  [present  themii«*]v« 
na  in  the  case  of  uon-tlexion — undue  preasure  upon  the  head,  corni* 
gated  sicatfi,  exhaustinn  of  the  mother,  nnd  kcHouh  hazard  to  tiM 
child.  What  h  lo  be  done  ?  Intn*dtue  your  hand,  and  rotate  the 
head  ;  if  the  hand  he  not  suHitMcnt,  then  recounie  must  Ih>  had  to 
the  tbrceps ;  the  instrument  to  be  np[tlied  in  the  maimer  I  jliaU 
point  out  when  treating  of  uperative  midwifery.  As  »ooii  aji  it  hM 
properly  grasped  the  head,  the  movement  of  rotation  can  be  aooovn* 
pli^hed  withuut  difficulty.  Tliis  being  effected,  the  instrument  m^ 
be  withdrawn,  and  tho  termination  of  the  delivery  coafidetl  to 
nature;  t^hould  it,  howevei%  be  found  necessary,  from  the  eoudicioci 
of  the  mother  or  other  circumstances,  promptly  to  achieve  tfaii 
labor,  tilt-*  may  be  dune  by  the  forceps, 

5.  Manual  DcUvcri/  in  the  0ccipitO'Sacro4liac  Po^itionM  uAm 
notation  ii  nai  ^tct^d, — We  have,  in  speakjug  of  vertex  presentft* 
tions  and  their  relative  frequency,  directed  particular  attention  lo 
the  discrepancy  \}(  ophuon  as  to  which  i^  the  second  mo?t  fiequent 
positiot)  of  the  vertex ;  and  we  have  endeavored  to  account  for  thii 
dbcrcpancy  by  showing  that  authors  have  arrived  at  conftklilig 
fe«iQlts  for  the  rea<ton  that  the  basis  of  their  calculations  f!cp<sii4ed 
upon  the  eireurnstancc — that  their  cxtmiinalion  was  made  atdUTercal 
periods  of  hibor.  Befure  the  time  of  Navgele  the  very  geifevf^l, 
indeed  the  unt verbal  opinion  obtained  that  the  second  position  of 
the  vertex,  in  the  order  of  frecpieuey,  wa«  when  the  occiput  come- 
•ponded  with  tl»e  right  aeetal»ulum.  Na<*gel^,  however,  established 
the  fact  that,  ulthouj^h  it  is  true  the  occiptit  is  in  eorresjvoiidoiiot 
with  Uie  right  lateral  purticm  of  th<^  T'cK  i^  as  the  dftcotid  moit 


•  Lwltine  i  V  ,  p,  4S. 


THE  PfilNCIPLES  AND  PRACTICE  OF  OBSTETRICS.         529 

common  position  of  the  bead,  it  is  only  so  after  a  certain  progress 
has  been  made  in  the  labor.  He  maintains  that,  primitively,  the 
vertex  is  found  to  present  second  in  frequency  when  the  occiput  is 
at  the  right  sacro-iliac  symphysis,  and  the  forehead  at  the  left 
acetabulum ;  but  at  the  same  time  admiis  that  the  tendency  of  the 
head,  in  either  of  the  occipito-posterior  positions,  is  to  disengage 
itself  by  turning  the  occiput  toward  one  or  other  of  the  antenor 
lateral  portions  of  the  pelvis.  Indeed,  so  generally  does  this  spon- 
taneous conversion  take  place,  that  Naegele  himself  states,  in  1244 
ocdpito-posterior  positions,  in  seventeen  instances  only  did  he 
observe  the  labor  to  terminate  with  the  occiput  traversing  the 
posterior  wall  of  the  pelvis. 

So  you  perceive  that,  when  in  these  positions  the  change  into 
anterior  ones  does  not  take  place,  the  circumstance  is  entitled  to  be 
r^arded  as  an  exception  to  an  almost  universal  rule. 

It,  however,  you  should  meet  with  one  of  these  exceptional  cases, 
my  advice  would  be  to  do  what  nature  has  been  unable  to  accom- 
plish, VIZ.  bring  the  occii)ut  toward  one  or  other  of  the  anterior. 
and  lateral  points  of  the  pelvis,  depending  upon  the  particular 
posterior  occipital  position,  which  the  head  may  have  originally 
assumed ;  for  instance,  the  right  posterior  occipital  is  to  be  brought 
to  the  right  anterior  point,  and  the  left  posterior  occipital  to  the 
left  anterior  point.  There  are  two  motives  for  doing  tliis:  in  the 
first  place,  it  is  following  the  course  of  nature  wlien  she  is  not 
interrupted  ;  and  secondly,  it  will  render  the  duration  of  the  labor 
much  shorter,  for  the  reason  that,  in  the  occipito-anterior  positions, 
the  occiput  will  have  to  traverse  only  the  length  of  the  symphysis 
pubis,  while  in  the  reverse  positions  it  must  pursue  the  entire 
length  of  the  sacrum  and  coccyx.  This  increase  in  the  ordinary 
duration  of  labor  would  necessarily  expose  the  infant  to  the  danger 
of  protracted  pressure,  and  the  mother  to  the  evils  of  exhaustion 
and  other  serious  contingencies. 

THiis  embraces  the  first  variety  of  the  First  Division  of  our 
classification  of  head  presentations  in  manual  delivery ;  'and  it  will 
be  found,  I  hope,  both  simple  and  practical.  The  second  variety 
of  the  First  Division  will  be  discussed  in  the  succeeding  lecture. 


84 


LECTtTRE    XXXV. 

tfftDual  Labor  continued— Certain  Cors  ;  f  Lalxir  r>  -  '^  mual  fa 

feroiicc  nt^ct^saar)' — Wliumre  these  *  ant — Podul  c»r  ' 

by  the  Feet — Ruleg  for  PcKinUc  Veniiuu — 6liuuU  one  or  boih  l-ott  be 
Mamivr  of  DeHvpnng  Ih©  Child  nher  tli<?  Fwt  huvo  b«?en  br.nfTht  t^*  tfip  ^ 
StniU— Uuk'9  fi>r  ExtrHCtiii)Lr  tho  8bon]d*?r»— Kulf«  r*ir  K  {« 

AjipaJliug   CoiiaequenceB  of  I^nomwcc — C*ftfi  m  lllurtrnr 
Cephuhc   Version    by   iDtt^mid   Mniiipiiintion — Ccphidic  YefBtoii    bjr 
Muni|>uliitiori — rrertKjuytes  for  itK  iVrrurtnoncc — lifittct  ami  tik  View*; 
tioiiM  Ui — Yer»iou  in  Cii^eM  of  Pi*)vir  heformity»  ifoirnimMjdvii  by  D<y»injUh— f 
Simj«*(jri'8iidvocncyof  Vcman  ui  Defortoed  Pdvifl^Kxiuiiiuaiion  of  klfl< 
Objectiotii  to  Vcriioti  in  tiicM  Cbsca. 


GKmTKMKN — III  the  second  variety  of  oar  clasttificatiOQ  of 
[irrsL'Titatiuris,  in  iimivunl  delivt^ry,  are  to  bt*  incluck*cl  tIiu»«  c 
whk'h   the  tennirraltnu   of  the  bibor  h   ef!orii*ii   by  vcrsUm;  qO 
bccflusQ  of  any  malposition  of  thii  hcncl,  but  because  of  the  ocoiu* 
reiicu   of   some    accuknit    reridfiinpf   prompt   delivery  absioliiliil| 
ni'c<^*isaTy,  ehbcr  for  the  safi'ty  of  the  mother  or  eliild.     We 
iinagint%  f(»r  instance,  everything  is  proeeedirjg  tnost  auHpirloitsily — 
tiie  head  presjenis  in  a  natmal  position,  tlie  pain*  are  narmal,  aiML 
there  is  n  |>roper  correJ^poiulenee  between  the  niati*nial  or^.mi>i  titi4 
fti'tu**.     Under  lhe**e    favorable    eiri-nnrntaijeeis   however,   tlw;  »kj 
nmy  Iweome  suddenly  cloiuk'd,  inrlimting  a  storm,  and  the  M*venl| 
of  the  storm,  if  you  will  permit  m©  to  carry  out  the  ti^irc,  may  b« 
imagined  by  the  t-haraeter  of  the  cloud.     Let  ns  ilkirtrafc,     Snp 
pofte  any  of  the  aecideutj*.  In  iIiIm  favonible  ecmdltioa  of  iliir 
capable  of  cnmjilieatinr;  r»nturnl  hbor?^honld  occur — such  as  tienKi 
tUiigv  or  eoTivulsion.^,     Here,  tlie  nafety  of  the  parcfiit  and  ohit4  will 
«etH?"*«arily  be  Involved  in  more  or  loss  perils  and  the  degree  of  peril 
will  depemi  very  much  on  the  ^nivity  of  the  ronvtilKiomi,  lietnor^ 
rha*^e,  or  whatever  el»e  may  n*|)reH(*nt  the  c<»rn|*lioatifTrK     It  i^  !*» 
bo  borne  in   mind   that  artiticial  delivery  will    be  ii 
simply  because  the  parturkion  in  eorn|>licaied  with  8o.... 
but  because  that  accident — whatever  it  may  be — hm  a 
phase  wbieh,  without  an  iinmediftte  termiuatioD  of  the  ]; 
eotnprnmise  the  liveJ!i  of  mother  and  ehild.     We  will  nou      i 
that  fruch  a  case  presents  itself,  and  you  have  determined,  m  ibe 
most  ratiofli:il  alteniative,  to  resort  to  vcrwiofu 


THE  PRINCIPLES  AND  PRACTICE   OF  0BSTETBIC9, 


531 


1 


u 


Podalic  Version. — How  is  this  operation  to  be  performed  ?  lo 
the  preceding  lecture,  some  general  rules  were  given,  necessary  to 
be  observed  in  version ;  in  addition  to  what  was  then  satd,  we  shall 
now  call  yotir  attention  to  a  few  details  essential  to  be  recollected , 
when  the  operation  of  podalic  turning  is  indicated.  In  the  fir 
place,  I  hold  it  to  be  a  fundamental  principle — one  not  to  he  for- 
gotten— that  version  should  never  be  attempted  after  the  liead  has 
escaped  through  the  mouth  of  th^  uterus;  and  for  two  important 
reavsons;  1*  After  this  e»- 
cape,  it  will  be  impossible 
to  return  the  head;  2.  The 
attempts  to  do  so  will  incur 
the  serious  hazard  of  ru[> 
taring  the  organ,  or  the 
vagina  itself,  or  inflicting 
injury  on  the  head  of  the 
foetus. 

Again ;  should  the  head 
liavo  dcsccndeii  into  the 
pelvic  cavity,  although  still 
within  the  uterus — and  this 
will  sometimes  occur — the 
imlication,  as  in  the  former 
ease,  will  be  to  resort  to 
forceps  delivery,  in  prefer* 
enee  to  version. 

The  hand,  it  has  already 
been  stated,  should  be  in- 
Ltroduced    into   the   vagina 
rin  a  conoiclal  shape  during 
a  pain,  but  not  carried  into  no.  m. 

the   uterus  except  in   the 
al*f*ence  of  pain  ;  t!ie  other  hand  to  be  applied  to  the  abdomen  for 
the  p u  r J  lose  o f  s t e a dy i n g  t  h e  w o m  b . 

As  soon  as  the  hand  has  entered  the  cavity  of  the  organ,  before 
attempting  to  reach  the  feet,  the  first  thing  to  do  ii  cautiously  to 
spread  its  palmar  surface  over  the  face  of  tM  child^  and  endeavor 
to  />lace  tht  occipital  region  in  the  opposite  iliac  fossa,  bi/  gently 
eleratirifj  and  pressing  with  the  hand  thus  cjrjHUided  over  the  face, 
(Frg.  C6.)  This  is  a  very  material  rule,  and  you  cannot  but  appre- 
ciate the  great  advantage  it  affords  in  the  successful  performance 
of  I  he  operation. 

iJy  placing  tlie  head  in  one  or  other  of  the  iliac  fossae,  you  at 
onee  provide  autlicient  sp.aee  tor  the  ea^y  introdnction  of  the  baud 
and  arm  into  the  uterine  cavitv. 


'<J 


I 


C82 


THE   PRINCIPLES  AND  PRACTICK  OF  0BBTETBIC8L 


As  a 


I 


general  rule,  when  the  hand  has  entered  the  mouth  of  Uir 

orgftn^  i\m  hitter  t«  thrown 
into  more  or  lessi  violent 
oontrnction  ;  when  thi*  oe* 
cura,  the  hand  miut  remitiil 
quiet  nntil  the  eontrtieUofi 
has  oxi>ended  itself. 

As  t»oon  a^  the  uterna 
is  freed  from  the  contnK> 
tile  effort,  then  the  haiid« 
with  it*^  pnlmar  ^ttrfaco 
spread  out  on  the  fiitrfjie« 
of  the  chthK  IH  to  he  csrried 
upward  (Fig.  (37),  with  a 
view  of  searchinjBT  for  tbe 
knees  or  feet.  It  U  n  mk* 
take  to  suppose  thai  it  ti 
neeettsary  alwajra  io  mxo 
the  feet  in  podalic  Tersiion 
(Fig.  08) ;  if  yiHj  nin  gra^p 
iht'  kni*e?«,  either  o?je  or 
boili,  then  by  gentle  trao^ 
lion  on  them  you  trill  n^ 
dily  FuecHTd  in  linn^ptig 
the  ftH^i  ditwn  to  the  pm- 
perior  »tratt. 

Is  it  e!i9entta1  to  m^izr 
hoih  knee^,  or  h^ifh  fi*et  ? 
If  hitth  «»f  cither  of  ihe*^ 
extremiUL's  ran  1k»  eonv^^ 
nienily  gra«iped^  then  it  h 
well;  built  i3lb^  :  ,ni 

essential,  fur  wl,  la 

foot  or  one  knee  be  si'ixetl, 
it  should  be  brought  dovrn, 
and  the  other  will  sncin 
I  follow;  shotdd  It  not,  th« 
hand  van  readily  be  earHed 
up  again  ;  but  this  is  raraly 
necessary. 

When  the  extremtties 
are  gnwped,  tracliun  U 
not  to  be  made  except  dtl^ 
ing  the  ab^cneo  of  pab^ 
while  these  exlremitiesari* 
no.  as.  within   the  uterine   eaviij 


I 


I 


THE  PRINCIPLES  AND  PRACTICE   OP  OBSTETRICS, 


L 


(Fi^.  69*)  One  of  the  principal  dangers  to  the  cbild,  in  the 
operation  of  version,  is 
fiom  undue  pres.'«ureorthe 
umbilical  eord ;  therefore, 
great  caution  is  necessary 
in  your  manipufsitions  to 
a^'oid  coniprest^ing  the 
cord,  for  fear  of  interrupt- 
ing the  circulation  be- 
tween the  placenta  and 
foetus  J  and  be  careful,  too, 
nr>t  to  deiacli  the  cord 
from  the  umbilicus,  which 
might  possibly  happen, 
through  want  of  proper 
caution,  especially  if  it 
fihoukl  be  curtailed  of  its 
ordinary  length,  by  being 
coiled  around  the  neck  or 
limhs  of  the  child, 

Delimry  of  the  Lower 
Ecfremities  and  Drunk. — 
Well,  you  have  iiucceeded  Fio.  f9. 

in  bringing  down  the  feet  to  the  upper  strait  (Fig.  70),  or  within  the 
vagina,  what  next  ?  If  the 
in d icat  ion s  fur  i  m m edi ate 
delivery  be  not  urgent,  the 
termination  of  the  labor  may 
be  submitted  to  the  resour- 
ces of  nature;  on  the  con- 
trary, if  the  life  of  mother  or 
child  be  in  peril,  admitting 
of  no  delay,  then  you  are  to 
proceed  as  follows :  employ- 
ing the  hand  corresponding 
with  the  heeb  of  the  child, 
and  gently  seizing  the  lower 
limbs  above  the  ankle,  trac- 
tion during  a  pain,  h  to  bo 
made  downward  and  back- 
ward in  a  line  parallel  to  the 
axis  of  the  t«uperior  Ktr$ut  > 
fts  soon  as  the  limbs  have 
passed  beyond  the  vulva, 
they  should  be  enveloped 
in   soft    linen  in    order   to  ti«.  in 


6?,4^         T'E   ratNCnvLKS   AND  PRACTICE  OF  OBSTETKICS. 

protect  them  u^nin«t  injury  from  presearc  of  the  hand  ;  tht^ri  th(^  two 
iimbn  should  he  ^ebt'd^  reufjuctively,  taking  care  to  fjctemi  the  tlitimlit 
lengthwise  on  the  posterior  or  nnterior  surfaee  of  each,  as  the  trai*^  mar 
bo,  in  order  that  every  precaution  may  be  obserred  to  avoid  bniUsig 


Fm*, 


Fia.  Tl 


^ 


ihem  (Fig.  71);  the  tractions  are  to  be  continutHl,  combining  with 
them  a  movement  of  alight  elevation  and  deprcsj^ion ;    when  th« 

liip8  renc'h  the  vulva,  the  hand»  are 
to  be  placed  transversely  acftm 
them,  arul  the  same  moveim*fit  of 
alternate  elevation  and  depi^ea&ioii 
continued  (Kig*  72) ;  as  ao<iii  af 
the  hips  have  escaped^  tbc  cbOd 
should  be  9up|>orted  by  tb©  pal- 
mar 8tirraee  of  one  bund,  whik 
with  the  index  and  middle  fingetf 
of  the  other  carebiUy  introdoo^ 
along  the  abdomen,  the  aocoooli- 
cur  should  bring  down  a  loop  of 
the  cord,  in  order  to  pn^vetit  the 
possibility  of  Inferating  it  at  ihm 
umbilicus  during  the  protrreM  of 
the  den%*ery;  in  making  tht«loof>, 
traction  shouhl  beuWiJ  on  tlit»  f^la. 
cental  extremity  of  the  cord  (Fig. 
73).  ThiH  being  acoonjpli*bod^  th« 
^  ^  combined  movement   of  tmciioil 


\^ 


THE   PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS, 


'm 


Is  to  1)0  contimuHi  until  tho  tiitire  body  of  the  child  is  delivered 
cxc-cpt  the  shouh1ers» 

Ddivtry  of  the  Armt. — When  the  shoulders  reueh  llie  extern ;il 
or^^ns  it  will  be  necessary  to  attend  to  the  delivery  of  the  arms ;  the 
one  which  is  below  is  to  be  extraeted  fii*«t,  and  for  thin  purpos^e  the 
th.ld  l)cin^JC  sii|niorted  on  tlte  forearm  of  the  aecoucbenr,  lie  glides 
tin-*  iudt.'X  and  iiiiddk-  iintrers  of  the  right  hand  (if  it  be  the  first 
jiosiiiou  of  the  vertex)  along  Uie  arm  of  the  child  as  ikr  as  the 
buuieri>-euhital  artieulatiou,  anil  witli  the  thumb  iti  the  hollow 
of  the  axilljL,  the  arm  is  brongbt  successively  over  the  side  uf 
ihi*  htad,  the  face  and  the  neek ;  when  dehvered  it  will  he  on 
the  right  of  the  vwlva.  The  child  is  then  placed  on  the  rights 
arm  of  the  acconcheiir,  and  the  two  fingers  of  tlie  lefl  hand 
arc  introduced  for  the  pur|^u^e  of  extracting  the  otlier  arm,  which 
is  above^  the  mechanism  of 
which  is  precisely  the  saint*  as 
in  the  other  instance   (Fi^.  74). 

Ejttraction  of  ike  Had  — 
You  may,  |>erhaps,  8upp'»<L« 
that  after  the  entire  trunk  has 
been  liberated,  the  difficulty  is 
at  an  end,  iiud  the  successful 
terminahon  of  the  delivery  at 
hand.  But  such  is  nut  always 
the  case— indeed^  the  most  im- 
portant, and  ollen  times  diffi- 
cult part  of  the  operation  is 
yet  to  bo  acccnnplmhcd— I  mean 
the  extraction  of  the  liead ; 
and  here,  permit  rae  emphati- 
cally to  admonish  yon  tlmt  it 
Is  not  to  be  delivered  by  brute 
force,  l)ut  in  accordance  with 
the  hiw8  governing  the  mecha- 
nism of  labor  Unfortunately, 
the  recollection  of  this  fact  is 
too  of\en  nrdieedcd,  and  the 
most  dis:istrons  results  ensue, 

I  have  witnessed  some  appalling  \  j\\       ^^  \ '^^ 

examples  of  mismanagement  in 
thesi'  cases,  well  calculated  to 
make  the  medical  man  pause, 
and  retlcct  on  the  measure  of 
his  obligations  in  the  sick-room. 

In  order  that  you  may  fully  appreciate  the  importance  of  this 
question,  and  with  a  view  of  animating  you  to  a  just  consideratioii 


Fio.   T4, 


586 


THE   PRINCIPLES  AND   PRACTICE 


of  your  daties  when  science  is  needed  to  lake  the  place  of  naiaral 
effort,  we  will  supiKifte  tlmt  the  o|>eration  of  vemou  han  bc«n  jnw^ 
tbmicd,  and  tfie  entire  child  delivered  with  the  exception  of  iImi 
head.  After  the  shoulders  and  arms  have  been  extracted,  you  fttid 
some  obstruction  to  the  descent  of  the  head  ;  yon  make  tmcttoa  on 
the  iKKly  of  the  child^  hoping  in  this  way  to  overeurae  th'  '  y ; 

tfrere  is,  however,  no  reHfwnse  lo  these  eflbrts;  you  o  ^  ■ 

time  from  all  further  action ;  the  mother  beoomes  impalient,  Ihe 
friends  are  anxioti^  and  you  are  intportaned  to  do  someithing  Ut 
achieve  the  delivery.  Tractions  are  again  re»<jrted  tOy  but  withoui 
any  avail  except  to  augment  the  impatience  of  the  mother,  and  tbt 
anxiety  of  her  friends.  You  are  questioned  as  to  the  cau^e  of  Uit 
delay;  you  make  some  excuse,  as  unsatisfactory  to  yotinie1vefiia«U» 
thn.^e  who  seek  the  information  ;  time  still  rolls  on,  and  frtill  no 
delivery.  All  confidence  U  lost  in  you ;  silent  but  withering  evi- 
dences  of  rebuke  take  the  place  of  smiles  and  pleasant  wo/d«i;  a 
consultation  is  demanded  ;  i^otne  medical  man,  vended  iu  hia  at*ienoe 
and  adequate  to  the  emergencies  of  the  lysng4n  chamber^  is 
requested  to  meet  you. 

He  receives  from  you  a  history  of  the  case;  bo  examtitm  Umo 
patient,  di^'overs  at  once  the  real  cause  of  the  obtit ruction,  and 
proceeds,  with  your  concurrence,  to  remove  it.  In  a  very  few 
mrimenta,  he  aecomplt>hes  what  you  have  vainly  endeavored  for 
hours  to  do,  liiimply  because,  in  the  first  place,  he  pOKsee^es  the 
requisite  knowledge,  and»  secontlly,  brings  it  lo  bear  on  the  caj»e  in 
point.  What  is  it  Jie  does  f  He  supports  the  child  on  the  anlirrior 
wirfiice  of  his  arm,  and  with  the  index  fmger  of  the  eor responding 
hand  introduced  into  the  vagina  very  soon  aj^ccrlains  the  true 
nature  of  the  obstacle  to  the  descent  of  the  head — this  latter  ii 
refiling  obliquely  at  the  superior  strait  with  its  great  diameter — the 
oocipito-meutal,  mejisuring  ^\'e  and  a  quartiir  inehos — ov<»-  the 
oblique  diameter  of  the  tit  rait,  which  you  will  recoUoct  givisa  bat 
four  anit  a  half  inclies.  Vi>ur  t ructions,  therefore,  have  ittitm 
unavailing  for  the  reason  that  they  were  exhausted  iu  the  fmik 
attempt  to  overcome  the  physical  im|>ossibility  of  causing  a  biidy  of 
five  and  a  quarter  inches  to  traverse  a  apace  of  only  four  and  a 
half  inches!  But,  i\^  1  shall  presently  tell  you,  these  traction*  are 
occasionally  more  than  futile  ;  lliey  sometimes  reeult  in  the  de- 
struction of  the  child,  a  spectacle  almost  too  shocking  to  dwd 
upon  I 

The  nature  of  the  obstacle  being  clearly  aReorlained,  lhi»  aoooa* 
iheur  proceeds*  to  overcome  it  at*  follows:  he  places  the  index  and 
middle  tingei'^  of  the  hand  already  in  tho  vngina  just  below  tba 
orbits,  or  it  will  suffice  to  introduce  the  index  finger  into  tb«  mofith ; 
and  while  he  gently  makes  traction  downward,  with  th4!  eorma* 
ponding  lingers  of  the  other  hand  applit  d  to  the  occiput,  he  dcvatM 


TITE    PKINCIPLES  AND  FBACTICE  OF  OBSTETRICS. 


tins  latter  »o  that  tlie  combined  movement  results  in  approxiiimting 
the  cliin  to  the  stennnii,  or, 
in  other  words,  producing 
the  movement  of  flexton- 
(Fisr.  75)  J  this  being  accom- 
plished, ho  then  rotates  the 
hcnd  bringing  the  occiput 
under  the  symphysis  puliis, 
and  the  fsice  into  the  hollow 
of  the  sacrum ;  as  soon  as  the 
perineum  is  pressed  u|ion, 
he  htm  it  supported  by  an 
assistant,  and  with  a  com- 
bined lateral  and  extractive 
for<"e  delivers  the  head. 

The  .entire  operation  can 
oftentimes  bo  pei*formed  by 
the  aecompli.shed  aceou- 
cheur  in  the  bnef  time  I 
have  taken  to  de?4eribe  it. 
The  simple  question  now* 
arises — why  hns  lie  sne- 
cee<ied,  and  why  have  you 
failed?  llis  Huccess  h  the 
direct  offspring  of  know- 
ledge; while  your  failure  is  the  result  of  ignorance.  He  has  stu- 
died and  com|ireheuds^  the  mechanism  of  labor;  lie  knows  thai  the 
heari,  si  hetl»er  it  be  at  the  superior  strait,  firwl  or  lust,  must  undergo 
three  movements;  flexion,  rotation,  and  extension;  and  he  also 
understands  it  to  be  his  duty,  when  nature  is  contravened,  to  per- 
form these  movements  for  her. 

Let  us  now,  for  a  inoinent,  lookat  the  relative  position  uf  the  two 
metllral  men  so  tar  as  the  judgment  of  the  patient  and  her  friends 
id  ooticenied.  You,  who  have  been  inndetjuate  to  the  exigencies  of 
the  case,  will  be  scorned  as  utterly  unfit  for  the  requirements  of 
yotir  profession ;  and  Kealhing,  indited,  will  bo  the  eenstire,  should 
the  patient  exclaim— Doetnr,  you  eould  have  savetl  my  child  if  you 
had  underniood  your  business,  for  1  felt  it  move  tor  several  minutes 
atler  its  little  body  waa  in  the  world  1  Would  not  such  laui^uage 
to  a  medical  man,  whose  dereliction  ol*  duty  has  righteously  eulled 
it  fir^h,  be  the  very  cup  of  bitterness  itself  I  How  different  with 
him,  who  has  no  promptly  exhibited  the  proof  of  both  knowledge 
and  skill.  He  has  vindicated  s<ience,  and  imposed  n[)on  the  patient 
and  fiiends  an  obligation,  which,  if  their  heaits  be  in  the  right 
place,  they  never  will  believe  ean  be  cancelled. 

Came  in  Ilhistratioft, — I  could  cite  several  melancholy  examples 


Fig.  TD. 


538 


THE  PRINCIPLES  AND   PRACTlCfi  OF  OBSTETRICS 


of  barbarous  practice  in  tbese  cases,  to  which  I  have  lic?e«  ciiIU*fl, 
merely,  as  it  were,  to  bear  ti^stimony  to  the  mereiless  destnietioci 
of  human  life ;  but  I  prefer,  \iith  the  hope  of  impressting  upon  jrou 
the  saered  responsibilities  of  duty,  to  bring  before  yoti  a  ma«t  hi^rt- 
rending  instance,  mentioned  to  me  by  my  friend  and  colleajsnie, 
Prof.  Valentine  Mott,  as  having  occurred  in  his  practice  some  jv*t% 
since :  An  unfortunate  woman,  a  prostitute,  was  tnketi  in  luhor 
with  her  first  child*  A  physician  was  summoned  to  attend  her; 
finding  it  to  be  a  case  of  shoulder  presentation,  he  requeHted  acaii- 
sultation ;  after  much  delay  and  great  suffering,  version  wan 
effected,  Ttie  child  was  delivered  with  the  exception  c»f  ll>e  ht'iid; 
to  overcome  the  obstacle,  simple  brute  force  was  re#ioried  to ;  the 
child's  body  constituted  a  lever  upon  which  the  most  violent  tmo- 
lions  were  mad€%  but  all  without  avail ;  a  naf>kin  was  then  attached 
to  the  body,  and  with  ihh  double  lever  the  force  was  reneweil — tho 
two  medical  men  straining  every  effort  to  bring,  under  thi«  iocreiised 
pressure,  the  liead  into  the  world.  Nature  could  not  long  rvmt 
thi.s  combination  of  power,  and  the  rcsuh  was— the  body  wai  toni 
from  the  liead,  the  latter  still  remaining  mulelivorcd  !  Under  ihirfc 
circumstance'^,  Prof.  Mutt  was  sent  iov ;  he  found  the  patient  in 
abnost  a  moribund  state;  in  making  an  exainiuat  ton  j^cr  rcr^iWrn^ 
im  extensive  laceration  of  the  neck  of  the  uterus  was  difli»ovcred, 
through  w^hich  the  detruncated  head  had  ejjcaped  into  the  abdo* 
minul  cavity !  Here  was  a  case  in  wiiich  science  was  para1ys4Ml« 
for  the  dying  state  of  the  unhappy  sufferer  rendered  any  effort  to 
rescue  her  out  of  the  question.  This  woman,  prrmtituto  as  she  vras, 
and,  as  might  be  s»ij)]»oaed,  lost  to  every  sense  of  refined  feditig, 
exhibited  a  few  monjcnts  before  her  death  the  strongest  evidenoo 
of  a  phihinthropic  heart ;  evidence  which,  while  it  developed  nym* 
pathy  for  the  woes  of  others,  was  a  telling  rebuke  to  those  who  had 
participated  In  the  act  of  her  destruction.  Her  last  wonls  were 
the^e :  *'  /"br  (rOfPs  sake^  {loctors^  after  I  am  dead  examif^e  my 
body^  80  that  you  mat/  /ctiotc  koio  to  relieve  any  one  who  may  hcrt' 
€ffter  suffer  as  I  ham  done  /"  What  a  lesson  do  theiu*  words 
inculcate,  and  how  graphically  do  they  pottray  profesftional  respoo- 
sibility. 

Statistics  of  Pod^tlic  Version:  Freqitehcy, — Dr.  Churchill  ha^ 
collected  a  total  of  506,601  cases  in  which  version  wa»  performcnL 
4^\^Z  times,  or  about  one  in  1224^.  These  cases  are  tabulated  as 
follows ; 

JEfifjUsh  Practice, — 71,483,  version  247  timcs^  or  I  in  S47.* 


*  Mr.  R.  Garljind  ?i^  \mn  r^aftwtly  publii^hed  some  pupera  oo  the  sutiffei  of  ^Vi^i 
tfonwhk'ht  to  Bay  the  Jeast,  are  startling  in  Uie  views  thctjr  iticuloata     It  would  1 
rMlly  9(?em  ehat  tliis  ^jeotleinun  \\m  dij^t'overed  in  tbf  npfmtion  tjf  Turning  mi  •! 
ment  ofsttTv'ty  fur  the  pitrturient  womnii  fur  rnori^  n^iluble  iUah  anyittini^  3ii  tba 
leiouroea  of  outur^.     He  telLs  us  tliat  since  venting  the  papeni  aUiid^  to  h»  bai 


THE  PRINCIPLES  AND  PBAOnCE  OF  OBSTETRIOB.         589 

French  Practice. — 40,376,  version  451  times,  or  about  1  in  89j. 

German  Practice. — 393,823,  version  3,393  times,  or  1  in  116. 

Mortality  to  the  Mother. — In  2,939  cases,  in  which  the  result  to 
the  mother  is  specially  mentioned,  211  died,  or  nearly  1  in  14 ;  it 
must  be  remembered,  however,  that  this  result  is  merely  approz- 
iiyiative  so  far  as  the  operation  itself  is  concerned,  for  the  influence 
of  the  complications  of  labor,  such  as  convulsions  and  hemorrhage, 
as  also  the  duration  of  labor,  are  to  be  taken  into  the  account  of  the 
mortality. 

Mortality  of  the  Infant. — In  3,347  cases,  in  which  the  result  to 
the  child  is  detailed,  1,472  were  lost,  or  rather  more  than  1  in  3.* 

It  is  unfortunate  that  in  the  results  of  the  statistics  just  presented, 
no  statement  of  the  duration  of  the  labors  has  been  given ;  for  with 
a  knowledge  of  this  circumstance  we  could  the  more  readily  appre- 
ciate the  true  mortality  of  turning,  both  to  mother  and  child.  It 
cannot  be  denied  that  the  mortality  of  child-birth,  in  natural  as  well 
as  artificial  parturition,  is  materially  affected  by  the  duration  of  the 
labor.  This  we  shall  prove  under  the  head  of  instrumental  delivery. 
Prof.  Simpson  has  tabulated  twenty- four  cases  in  which  version 
was  performed  as  rej)orted  by  Dr.  Collins  of  the  Dublin  Lying-in 
Hospital,  with  the  following  important  results,  showing  the  influ- 
ence exercised  by  the  length  of  the  labor  on  the  death  of  the 
mothers.  Although  the  cases  are  comparatively  few,  they  are  quite 
significant  as  to  conclusions : 


Duration  of  Labor. 

Proportion  of  Deathf* 
of  Motliere. 

Below  24  houre. 
Above  24  hours. 

1  in  21  died. 
1  iu    3  died. 

Pehic  Version. — Some  authors  recommend,  in  lieu  of  seeking  for 
one  or  both  feet,  to  introduce  the  hand  and  bring  down  the  breech, 

attended  sixty  labort,  fifty-five  of  which  fie  terminated  by  turning/  He  has  had  but 
one  maternal  death,  and  that  "  occurred  five  days  afler  the  operation  by  inflamma- 
tion of  the  peritoneum  of  a  patient  who,  with  contracted  pclvLs,  had  submitted  to  the 
ordeal  to  produce  her  sixth  full-timed  dead  child."  Mr.  Figg  says  in  four  instances 
be  has  broken  the  arms  of  the  children ;  but  this  is  of  very  little  importance,  for  he 
advisee  not  to  be  *'  too  candid  to  Oie  rtlatives,  but  at  once  by  your  own  dictum  transulh 
McuUiaie  Hu  injurif  into  a  slight  sprain  received  by  tlie  infant  striking  its  shoulder 
{tffoinst  the  backbone  of  tfie  mother  while  actively  prosecuting  iL^  uterine  gambols  /'* 
Beally  I  cannot  approve  either  of  Mr.  Figg's  practice  or  hia  morality.  [See  London 
Med  Times  and  Gazette,  Nov.  13  and  20,  and  Dec.  25,  1858.] 

*  Ricker  reports  that,  in  the  Duchy  of  Nassau,  podalic  version  was  resorted  to 
2,473  times  in  304,150  cases  of  labor,  or  1  in  123.  The  result  to  the  mother  waa 
IT  6  deaths,  or  1  in  14,  corresponding  very  closely  with  the  general  mortality  given 
by  Dr.  Churcliill.  Nearly  1  in  2  of  the  children  was  lost.  According  to  the  sta- 
tistical record  of  Prof.  Schwerer,  version  was  performed  18*2  times  in  21,804  casee,  ot 
1  iu  119 ;  14  mothers  were  lost,  or  1  in  13 ;  93  children  lost,  or  1  in  2. 


540 


THE   PBINCIPLES  ANT>   PBACTICK  OF  OBSTETRICS. 


when  the  v\\\U\  otctipiea  a  |>oMlioti  in  which  the  breeeU  hi  ncuarcrthf 
superior  strait  ihan  ihe  head.  In  my  opinion,  however,  thin  prao* 
tice,  when  version  i»  really  ir»dicated,  will  be  fotitid  more  diifictilu 
and  ntlended  by  more  hazard  than  podallc  version ;  therefore^  I 
should  advise  you  to  give  preference  lo  the  latter  o{>eriitiuD. 

CtphuUc  Vera  ion  by  Internal  ManiptUation, — An  han  already 
been  remarked,  version  by  the  head  was  always  practised  by  the 
ancientH;  nowhere  can  I  tind  podalic  version  even  alluded  io  by 
them.     Their  prefi'renee  for  cephalie  turning  was  undoubtedly  dii9- 
to   the  doctrine   they  inculcated,  viz.  that  the  only  uatund  mA^ 
favorable  position  of  the  feet  its,  was  when  the  head  present^  at 
the  superior  strait.     Jlence  the  coun^iej  of  flippoci^te^,  in  all  caieti 
in  which  any  other  portion  than  the  head  pre»enteti,  was  to  diJ^placQ  < 
it,  and  subi^litutc  tlie  ee[»halic   e.vtremity,      lie   relied   much  oa 
changing  the  position  of  the   woman,  lor  the  purpose  of  brliigiDg 
the  head  down,  and  givea  paittcular  directi<ina  aa  to  thU  jioiat. 
For  instance,  he  recommends  to  place  taomething  under  the  hip« 
during  the  labor,  and  alMi  under  the  feet  of  the  bed,  »o  thai  thd  ( 
patlertt  may  be  raised  higher  toward  the  feet.     The  hi|:i9  jiro  to  W  \ 
more  elevated  than  the  head,  nor  lihoald  the  latter  have  any  bolater, 
lie  further  says  that  after  the  presentation  of  the  tcetas  luw  b««conii 
changed,  the  patient  is  no  longer  to  be  elevated  as  just  deneribed^.J 
and  a  pillow  should  be  placed  under  her  head,* 

Cephalic  version  had  for  a  long  time  fallen  into  neglect,  lea  tlial 
it  was  rarely  resorted  to ;  I  believe  it  18  generally  Gonce<Ied  thai 
the  credit  of  again  introducing  it  to  the  attention  of  the  proft*3«ioa 
is  due  to  M.  Flamant  of  Strn^burrfh,   who,  in  1705,  becanie  itt* 
earnest  advocate.     Since  that  period,  many  sucecsi^ful  casies  hart 
been  recorded.      M.  Uusch,  of  llerlln,  re]»orts  that,  in   15  ciiMi 
under  his  care,  he  delivered  14  living  children  ;  Ri(*cke  loxt  1  ebflil 
in  16 ;  while  Rieker,  of  the  Duchy  of  Nassau,  reports  10  oiaei^  of 
which  9  terminated   favorably  for  both  tnother  and  child.     OtlMr ' 
results  might  be  cited,  which  demonstrate  the  important  fact  llui 
all  things  being  equal,  crpfiallc  vemion  is  inBnitely  more  &Tormble  \ 
to  the  cliild  than  podalic,  for  in  the  41  cases  jutt  quoted  only  3 
children  were   lost,  or  about  1  in  14.     lu  podalic  venuon,  on  ike 
contrary,  the  lo«s  is  rather  more  than  1  in  3, 

The  conditions  jtistifying  a  resort  to  ce^^le  veimoci  may  be 
enumerated  as  follows: 

Ist,  The  |>elvis  must  possess  its  natural  dimension^*,  for  «  eoa- 
tracted   pelvis  would  present  positive  objections,  unless  il 
ascenained  that  the  head  is  tuioaually  small. 

*  Supinie  roclionUv  molla  quiddmn  cuxis  iubftienicro  oportet,  ftiqne  stSiii 
pcdtbua  Aliquiii  aupponera,  quo  altioroa  a  jiedibiia  dt'CUfntieiiUiii.  #•)#  i|iMiiat^ 
oosa  oipUa  alat  altiorat;  aullain  vera  onpiu  oenical  subalL    [Do  Mulkr.  Mofk 
Ub  I  ctpi  p.  K\ 


THB  PRmOIFLES  AND  FBACTICE  OF  OBSTETRICS.         641 

2d.  The  head  must  not  be  very  remote  from  the  superior  strait.* 

8d.  The  fcBtus  should  enjoy  a  certain  degree  of  mobility,  other- 
I  the  hazard  to  mother  and  child  would  be  greatly  enhanced. 
The  operation,  therefore,  should  be  undertaken  before  the  rupture 
of  the  membranous  sac,  or  as  soon  afler  as  possible. 

4th.  Cephalic  version  is  indicated  when  the  child  is  situated  trans- 
versely, or,  for  example,  in  a  shoulder  presentation. 

Mode  of  Performing  Cephalic  Version. — Having  previously 
aaeertained  the  true  position  of  the  head,  that  hand  is  to  be  intro- 
duced which  corresponds  with  the  poition  of  the  uterus  at  which 
the  head  is  situated;  the  other  hand  should  steady  the  uterus 
through  the  abilominal  parietes.  If  the  membranes  be  still  intact 
care  should  be  exercised  not  to  rupture  them  by  cautiously  gliding  the 
hand  between  them  and  the  internal  surface  of  the  uterus.  As 
Boon  as  the  hand  reaches  the  head,  it  should  be  grasped  by  the 
palmar  surface,  the  accoucheur  at  the  S^me  time  affording  escape 
to  the  liquor  amnii :  an  effort  is  then  to  be  made  to  bring  the  head 
to  the  superior  strait,  while  wnth  the  hand  applied  to  the  abdomen 
the  pelvic  extremity  of  the  fa3tus  should  be  elevated  toward  the 
oenml  line. 

Dr.  Wright,f  of  Cincinnati,  in  a  paper  on  cephalic  version  to 
which  was  awarded  a  gold  medal  by  tlie  O^io  State  Medical  Society, 
suggests  the  following  operation :  The  lingers  are  to  be  applied  to 
the  top  of  the  shoulders,  and  the  thumb  to  the  axilla,  or  to  such 
part  as  will  give  command  of  the  chest,  and  thus  afford  lateral 
foroe.  With  the  other  hand  upon  the  abdomen,  pressure  is  to  be 
made  so  as  to  dislodge  the  breech,  and  cause  it  to  ascend  toward 
the  centre  of  the  cavity.  Hence,  without  applying  direct  force  to 
the  head,  it  is  thus  brought  to  the  superior  strait ;  if,  however, 
this  &il,  the  head  may  then  be  grasped.  Dr.  Wright  states  that, 
in  all  the  cases  treated  by  him  from  the  commencement,  the 
children  were  bom  alive. 

Cq>Aalic  Version  by  External  Manipulation, — It  has  been  pro- 
posed, in  certain  malpositions  of  the  foot  us,  to  correct  them  by 
taming  the  child  and  bringing  the  head  to  the  superior  strait  through 
manipulations  made  on  the  abdominal  walls  of  the  mother.  That 
this  species  of  version  may,  under  some  circumstances,  be  accom- 
plished, I  have  no  doubt.  But  it  involves  certain  prerequisites — 
such  as  an  accurate  knowledge  of  the  exact  position  of  the  foetus, 

*  The  following  is  the  langaage  of  Van  Swieten  on  this  point,  and  embodies,  I 
think,  very  judicious  counsel :  "  For  while  the  foetus  is  disadvantageously  situated 
in  the  womb,  it  cannot  always  be  reduced  to  such  a  position  as  to  come  out  by  the 
besd;  this  can  be  effected  only  when  the  head  is  not  very  distant'  from  the  orifice 
of  the  womb,  so  that  it  can  be  easily  touched  by  the  fingers  of  the  midwife^  and 
moired  out  of  its  position."    [Van  Swieten's  Commentaries,  vol  xiv.,  p.  14.] 

f  American  Journal  of  Medical  Sciences,  July,  1855. 


542 


THE   PRLNCIPLKS  A^"D   PRACTK 


.OTtTiciurit  laxity  of  the  alMlominul  walH  aud  a  ripe  exporieiicv'  ia 
thi»  moJe  v(  iiiatii[HiIatioij.  In  c»rder  to  asrurtaiii  tlitj  pu^iii'iu  uf 
tbe  fcctu^,  rccoarae  must  be  hud  to  abduoiiiial  palpation^  auKulli^ 
lion,  auJ  the  **  toucher,"  One  of  the  latest  and  most  uncotwjiro 
niising  advocates  of  external  version,  Dr.  A.  >Iattou*  in  addaiom] 
to  t  raj  inverse  positions,  rccommen<ls  it  in  »11  case*  of 
of  the  breech,  which  he  considers  unnatural  and   dm  i 

contrary  to  the  physiology  of  parturition,     lie  ai)vii<H^  ihaf,  mi 
soon  as  it  is  ascertained  the  breech  is  at  the  su|ierior  fltrait^  efforts^ ; 
should  be  made  to  carry  it  up  to  the  fundus  of  the  womb,  aa<| 
briuLi:  the  head  down,  by  means  of  external   m  •  ui;   aadj 

t\m  he  says  is  his  general  praetice,  in  which  he  cIm:  :iva  been 

remarkably  successful.    The  time  at  which  this  coDvervioa  k  to  be 
made  is  from  the  sixth  to  tlie  ninth  month  of  r  -  t 

this  period  the  fcotus  enjoys  a  /Lfrcattr  degree  of  .  , 

and  hence  tlje  greater  facility  of  the  operatiun.     Thi-re  iir«-^  i  tbmk| ' 
Bonie  cardinal   objections   to   the   practico   recoTnmendeil   bv   Hf. 
Muitei  in  breech  cases : 

1,  The  difficulty  of  its  execution. 

2,  The  danger  of  provoking  the  uterus  to  premature  actio4i. 

3,  Nature^  under  ordinary  circumstances,   is  quite   capable  i 
A43hievhig  the  delivery  wken  the  breech  |>resenl?i,  although  It  mn 
be  recollected  that  the  child  incurs  more  hazard  thaii  in  a  hcftdjj 
presentation* 

4*  The  jxissibility  that  the  foetus  may  right  itself  before  the  com^] 
pletion  of  Uie  term. 

For  these  reasons,  therefore,  I  should  adrijse  vmu  jh»l  ; 
the  practice  in  the  |>resenLatioii  uf  llie  nates. 

External  manipnhition,  with  a  view  of  changing  tli  ^  v( 

the  fa*tus,  may  be  said  to  be  a  revival  of  an  ancient  ;  .    It, 

however,  met  with  but  little  favor  until  within  theprcc^ent  oeittiiry. 
It  is,  I  think,  conecnled  that  ifie  credit  is  due  to  Dr,  Wigiuni,  vt 
Ilaiuhurg,  for  the  impulse  which  tliis  operation  ha»  received  its  i>«f  * 
own  times,  and  m<»re  especially  in  Germany.     His  views,  .; 
in  full  iipprobation  of  the  niea5»ure^  have  the  endorsement  t .  .^,  ..... 
of  the  ablest  German  obstetricians,  among  whom  may  be  mcntJoi»i»il 
HuM'h,  Nn*}gele,  Kilian,  Scanzoni,  Arneth,  llohl,  autl  othen.     lo-, 
deed,  there  is  no  tloubt  about  the  very  general  adoptjoo  of  ibe 
practice  by  the  leading  men  of  the   German  school.     In  Ftmh^ 
loo,  Velpeau  and  Caseaux  recognise  external  mardptilataofi  aa  a 
proper  resource;  while,  a.^  I  have  already  stated  ♦  the  Caracaii  fihyKV 
cbtt,  Dr.  ^Fnttei,  is  jnore  than  unthu.Hiastic  on  t 
Urilain,  on  the  contrary,  it  has  failed  of  appr-  '  j 

country,  it  may,  I  think,  be  said  that  the  t|u<?stioQ  U  itttll  tubJudicB^ 

•  Emu  aur  I'AccoiiclMWitrr  Piir  A*  M*tici.     l\  tUX 

f  An  intufttqitiag  cimj  iif  r*  i  i  jhh^  lul*ur.  bv  »'Xl<«mAl  Iiuitttui33«t3c% 


'^E  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         5i8 

Let  US,  for  a  moment,  inquire  what  it  is  that  the  accouchear  pro* 
poses  to  accomplish  by  external  manipulation  ?  The  object  is  two- 
fold: 1.  To  change  an  abnormal  position  of  the  foetus  into  one 
which  is  natural ;  2.  To  avoid  the  necessity  of  introducing  the 
hand  within  the  cavity  of  the  uterus  for  the  purpose  of  bringing  to 
the  upper  strait,  through  internal  manipulation,  either  the  head  or 
the  feet.  This  is  undoubtedly  the  true  analysis  of  the  motive ;  and 
if  the  object  be  carried  out  consistently  with  the  safety  of  the 
mother  and  child,  the  operation  is  entitled  to  be  hailed  as  one  of 
the  greatest  benefactions  to  woman.  It  can  scarcely  be  necessary 
to  remark  that  a  fundamental  condition,  before  attempting  external 
version,  is  an  accurate  knowledge  of  the  position  of  the  fcetus  in 
H(ero/  it  is  this  knowledge  which  constitutes  the  entire  justification 
of  the  procedure. 

The  next  question  is,  how  is  the  position  of  the  child  to  be 
ascertained  ?  I  think  the  most  reliable  means  is  through  ausculta- 
tion and  abdominal  palpation ;  but  an  important  auxiliary  will  be 
found  in  the  "  toucher "  or  vaginal  exploration.  Auscultation, 
however,  may  sometimes  lead  to  erroneous  judgment,  as  in  the 
case  of  a  twin  gestation. 

Well,  we  will  suppose  that  the  diagnosis  of  position  has  been 
satisfactorily  determined,  the  next  question  is,  at  what  time  should 
the  oi)eration  be  had  recourse  to  ?  Some  writers,  in  agreement 
with  Mattel,  recommend  its  adoption  during  the  latter  months  of 
pregnancy,  say  from  the  sixth  to  the  ninth  mouths.  Without 
entering  into  any  special  argument  on  the  subject,  my  advice  to 
you  Ls,  not  to  attempt  any  interference  until  labor  has  commenced ; 
and,  as  a  gener.al  rule,  the  manipulation  should  be  made  before  the 
rapture  of  the  "  bag  of  waters,"  for,  it  is  to  be  recollected,  in  pro- 
portion to  the  escape  .of  the  liquor  amnii  will  be  the  diminished 
mobility  of  the  foetus,  and  the  consequent  difficulty  of  the  evo- 
lution. 

Mode  of  Perfortning  the  Operation, — ^The  patient  should  rest 
on  her  back ;  the  accoucheur  then  places  one  hand  flatwise  on  that 
portion  of  the  abdomen  corresponding  with  the  head  of  the  fcetus, 
while  the  other  hand  is  directed  to  the  opposite  point  at  which  the  • 
breech  will  be  found  ;  these  two  portions  of  the  foetal  surface  being 
thus  embraced,  the  one  hand  should  gently  dei)ress  the  head  toward 
the  pelvis,  and  a  movement  of  elevation  imparted  with  the  other 
to  the  breech.  The  tendency  of  this  counter-movement  will  be  to 
bring  the  head  of  the  child  to  the  superior  strait,  thus  converting 
it  from  a  transverse  or  oblique  position  to  a  cephalic  presentation. 
As  a  comparative  laxity  of  the  abdominal  and  utei'ine  walls  is 
essential  to  the  success  of  the  operation,  it  is  needless  to  remind 

with  safety  to  mother  and  child  by  Prof.  B.  Fordyco  Barker,  is  recorded  ia  the 
American  Medical  Times,  June  2, 18G0. 


644 


THE  PRmclPLES  AND   FRACnCE  OF  0B8TETR1GB. 


you  that  ihese  manipulalions  are  to  be  r       '  s^ 

of  the  bhor  priirm.     It  U  refommenrle^i  u  i  .,tO 

place  the  patii'Ot  on  the  side  corresponding  wiUi  the  head,  and  al 
the  s:ime  time  to  make  uniibrm  and  guartted  prefisuri?  on  thw  btter 
by  means  of  a  small  pUIow  or  cushion.  A»  !«uon  n«  the  pain  ec:u«^ 
thcj  pojiUian  on  the  baek  is  to  be  again  aHgunied,  and  iho  ftiait 
chai'acter  of  manipulation  conlinaed.  When  the  head  liaa  Ikmb 
made  to  descend,  it  will  be  disposed,  should  it  enjoy  much  tncibtltty, 
to  resume  more  or  leas  its  former  position;  to  4)bviat6  ibK  ibe 
membranoiH  sar  uhould  be  ruptured,  so  that,  with  the  escape  of  tho 
amnioiic  lluld,  the  bead  may  become  fixed.  It  hm  been  su^ge«4ed 
by  Kilian  and  others,  and  with  good  reason  I  think,  that  tbc$  rttctifi- 
cation  of  the  ehild'a  |)osition  18  not  exclusively  due  to  the  exttfrnsat 
pressure  of  the  hands;  btit  that  in  connexion  with  tbis  pre*tttni 
must  be  tnken  Into  aceount  the  influence  w^hich  it  exerci»ei  in  tbt 
correction  of  certain  obliquities  of  the  uterus,  to  wbtcb  theae  mat 
positions  of  the  f«etu-'§  are  ofYen times  due. 

If,  as  somctinu'i^  will  occur,  the  operation  abould  ppofe  uiiftii^ 
ceiMful,  the  ullernative  will  be  versitin  of  the  ehlM  by  t^  l:j©- 

tion  of  the  hand   into  the  nterns ;  or  the  pinn  prop*.  i>r» 

Wright  may  be  attempted.  If  the  hea<l  be  brought  down  to  tlm 
superior  strnit  or  not,  and  any  complication  present  itself  CAQiiig 
for  immediate  delivery,  podalic  version  will  be  the  resourcfj, 

Vernion  in  Pdaic  Dtfom%ity, — It  now  renniius  lor  me  to  call 
attention  to  the  subject  of  version  in  certain  cases  of  pdvio 
deformity,  as  recently  revived  by  Pruf.  Simp^^oci,  who  p^vem  It  tlie 
weight  and  authority  of  bis  name,  and  urges  it  m  a  »*n^  '  for 
craniotomy.     I  Ray  revived,  for  it  i**  well  known  that  i  uct 

was  advocated  by  Denmrm  and  some  of  his  t»onteniporarif»,  bitt 
had  fallen  into  almost  utter  oblivion  until  asrain  intruduct^!  to  tlt# 
attention  of  the  profengion  by  the  distinguished  writer  ju«l  naiatnL 
The  two  chief  argument -4  in  favor  of  version  in  pelvic  defomiiiy 
offered  by  Dr.  Simpson,  are ; 

1,  That  the  transverse  <1iametcr  at  the  base  of  the  fcetal  dciill 
(the  bi-mastoid)  h  \vm  than  the  corresponding  diameter  mi  lbs 
arch  of  the  crnninm  (the  bi^parietal). 

2.  That  the  head  tnay  be  extracted  confidently  with  the  life  of 
the  chihl,  after  the  body  has  been  delivered,  through  o  snuilhr 
space  than  is  needed  for  iu  passage  in  a  vertex  presentation,  and 
impelled  dimply  by  the  contractile  efforts  of  the  uterua. 

In  addition  to  these  two  main  propositions,  he  says  that  versioo, 
when  deformity  of  the  pelvin exists,  contrasting  it  %vith  eranioioroy, 
gives  the  child  a  chance  of  life ;  it  is  more  safe  to  the  mother, 
because  it  can  be  performed  earlier  in  labor,  and  more  speedily;  It 
eoables  us  to  adjuift  and  extract  the  hea<l  thr  'i*erfect 

pelvic  brim  in  the  most  advantageous  form  ati  .  bsiljr, 


THE  PRINOIPLSS  AND  PRACTICE  OF  OBSTETRICS.         546 

it  18  a  practice  that  can  be  followed  when  proper  obstetric  instru- 
ments are  not  at  h.nnd,  and  the  avoidance  of  instruments  is  generally 
advisable  when  it  is  possible.* 

The  importance  of  the  question,  and  the  high  authority  of  the 
gentleman  who  commends  its  adoption  to  the  profession,  will  justify 
an  examination  of  the  arguments  adduced  in  its  favor.  It  is  undoubt- 
edly true,  as  Prof.  Simpson  alleges,  that  there  is  a  difference  in  the 
respective  transverse  diameters  of  the  fcetal  skull  at  its  base  and 
arch  ;  for  the  former  measures  three  inches,  while  the  latter  gives 
three  inches  and  a  half.  When  describing  to  you  the  fojtal  head  in 
connexion  with  child-biith,f  you  will  remember  I  told  you  the 
characteristic  difference  between  the  base  and  arch  of  the  cranium 
is,  that  the  base  at  the  completion  of  utero-gestation  is  ossified, 
and  cannot  be  made  to  yield  to  pressure ;  and,  moreover,  I  pointed 
out  to  you  that  this  is  a  most  essential  provision,  for  the  exercise 
of  pressure  on  the  lower  portion  of  the  brain  and  medulla  oblongata 
would  most  likely  result  in  the  destruction  of  the  child's  life.  The 
arch,  on  the  contrary,  from  the  peculiar  construction  of  the  sutures, 
overlapping  each  other,  will  yield  occasionally  half  an  inch  in  its 
transverse  diameter,  and  the  temporary  pressure,  consequent  upon 
such  diminution,  could  be  sustained  with  impunity  for  the  reason 
that  the  upper  poniou  of  the  brain  is  not  essential  to  life.  It  would, 
therefore,  follow  that  if  the  contraction  in  the  antero-posterior 
diameter  at  the  superior  strait  wore  less  than  three  and  one  wghth 
inches,  the  delivery  of  the  head  by  version  would,  I  think,  be 
physically  impracticable ;  for  admitting,  for  argument's  sake,  the 
'Opinion  of  Prof.  Simpson,  that  the  head  can  be  made  to  traverse  a 
smaller  space,  after  the  delivery  of  the  body,  than  in  an  original 
vertex  presentation,  yet,  as  the  transverse  diameter  of  the  base 
measures  three  inches,!  and  undergoes  no  diminution,  it  will  need  a 
space  of  at  least  three  inches  and  an  eighth  to  enable  it  to  pass. 

But  again :  if  there  be  a  space  of  three  inches  and  an  eighth,  it 
is  possible  that  the  head  may  descend  in  a  vertex  presentation,  for 
the  reason  that  the  transverse  diameter  of  the  arch  will  occasionally, 
through  the  overlapping  of  the  bones,  yield  to  the  extent  of  half 
an  inch.  Therefore,  with  such  a  pelvic  deformity — such  as  we  have 
described,  it  is  f:ir  better  to  trust,  all  things  being  equal,  to  the 
resources  of  nature  than  attempt  delivery  by  version.  Although 
it  is  undoubtedly  true,  as  a  general  principle  in  mechanics,  that  a 
body  may  be  more  easily  drawn  through  a  space  when  its  apex  pre- 
sents than  impelled  through  the  same  space  by  a  vis  a  tergo  force 

*  Provincial  Medical  and  Surgical  Journal,  December,  185>7.     P.  6-47. 
f  Lecture  III. 

%  It  is  proper  to  state  that  in  the  six  cases  of  measurement  of  foetal  heads  g^yen 
bj  Prof.  Simpson,  the  bi-mastoid  diameter  (transverse  of  the  base)  varied  from  2f 
I  to  3]  inches. 

85 


546 


THE  TRINCIPLES  AND   PRACmCfi  OF  0BSTSTBIQ9* 


directe<3  aerainst  the  base,  yet  I  ilo  not  think  thi*  principle  ^ill 
Always  apply  iti  tlie  ease  of  child-birtb,  I  have  much  murt*  ounfi* 
denee  in  the  ability  of  nature  when  not  interfered  with,  thaji  I  have 
in  the  most  consummate  skill  of  man.  What  I  mean  is  tUh — Sq|»* 
posinfif  nn  inatance  of  pelvic  eurtaihnent  to  the  extent  of  three  and  ' 
an  eighth  inches,  I  shouhj  have  more  faith  in  the  efforts  of  nattiro 
80  to  diminish  the  transverse  diameter  of  the  arch  as  to  enable  it  to 
d^cend,  than  in  the  manipulations  of  the  accoucheur,  na  matter 
what  dexterity  he  might  possess,  afier  the  body  of  the  (cctuB  had 
been  delivered. 

But,  f^entlemen,  there  are,  in  my  judgment,  other  scriotifl  objec- 
tions to  verhion  in  these  eases.  You  have  been  told — and  the  fact 
is  perfectly  patent — that  turning,  under  the  most  favorable  circaio- 
etanccj*,  is  an  operation  of  peril  both  for  mother  and  child  ;  and 
just  in  proportion  as  the  natural  dimensiotis  of  the  pelvic  c4mal  are 
abridged,  the  peril  will  bo  enhanced.  Again:  another  aolid  argn* 
ment,  it  seems  to  me,  against  version  in  ^telvio  deformity  ta,  thm 
very  probable  contin^^ency^  after  having  subjected  parent  and  eibll4  i 
to  the  dangei*H  of  the  all eruu Live,  that  the  delivery  will  bo  rrquirod 
to  be  terminateil  by  craniotomy.  My  advice  to  you  ia  this — if  tlie 
antero-posterior  diameter  do  not  measure  mare  than  Uire#  and  an 
eighth  inches,  trust,  as  long  as  circumstances  will  justify  it,  i%t  Uit 
rei*our(*es  of  uutuie;*  if  these  be  found  inudef|uate,  and  liiert 
should  be  indications  of  peril  either  to  mother  or  child,  then,  in  limi 
of  veraion,  have  recourse  to  the  foreepi^  for  although,  a^  a  general 
rule,  when  the  head  is  still  at  the  superior  Rtrait,  I  prefer  taming 
to  forceps  delivery,  yet,  in  the  event  of  a  pelvic  deforn 
we  have  been  considering,  my  choice  would  be  tht 
The  safest  practice,  how^ever,  would  unquentionably  be  th^  indoo* 
tion  «>f  |»remature  delivery,  but  this  would,  of  course,  involve  tbo 
neceii.siiy  of  ascertaining  the  exiMtenee  of  the  deformiiy  at  aoiu<i 
time  prior  te  the  completion  of  utcro-gcstation.f 

*  TheffMnarees  of  uature  are  occiL^bnnlly  loo^t  extmorilitiarir  \n  orenxMntaf  a 
dlsproportiOQ  botwi>en  ttie  head  and  pelvis.  Tliia  fact  in  well  known  to  m;moeWiiBV 
wlio  htive  olMefvcd  well;  and  it  wou\d  be  more  (Vcqucotly  rcoogubwl  io  ptmBte^ 
WCfO  it  not  for  thiit  toa  |r©i»wiil  rIh—*'  miHldleaonit?  tikithvir»rr/' 

f  WheL  dUfCUislTig  thecubject  of  prfumturv  nrii:  ^y,  we  ihaQ  mtrnlkn 

Ibe  vMi«>u9  |pi4t!;a  ot  fte^Fie  •bridgmeut  in  which  IL  .    .ve  mill  be  jaa(lfl^bil& 


LECTURE    XXXVI. 

Manual  Delivery  continaed — Preflentation  of  the  Breech,  Knees,  and  Feet;  Manual 
Diplivery  in — The  Indications  in  these  Pelvic  Presentations — Malpositions  of  the 
Pelvic  Extremities — Kxcessive  Size  of  the  Breech ;  how  managed — Presentation 
of  the  Pelvic  Extremities  complicated  with  Hemorrhage,  Exhaustion,  Convul- 
■ions— The  Management  of  Pelvic  Presentations  in  Inertia  of  the  Womb — Iner- 
tia, how  divided — Inertia  fVom  Constitutional  and  Local  Causes — Importance  of 
the  Distinction  in  a  Therapeutical  Sense— Blood-letting  in  Inertia,  when  to  be 
empk^ed — Ergot,  when  indicated. 

OsNTLEMEX — We  now  proceed  to  the  consideration  of  our  second 
cBvision  of  manual  labor,  embracing  the  pelvic  presentations,  viz. 
the  breech,  knees,  and  feet,  and  which  also  has  two  varieties.  In 
the  first  variety,  you  will  remember,  it  may  become  necessary  to 
interpose  because  of  malposition  of  these  extremities;  in  the  second, 
interference  is  called  for  because  of  the  complication  of  some  acci- 
dent, rendering  immediate  delivery  essentisil.  It  is  important 
that  you  should  bear  these  two  distinctions  in  recollection,  aa 
they  will  be  the  guides  for  the  particular  kind  of  interference 
bdicated. 

Presentation  of  t/te  Breech. — I  have  stated  that,  under  ordinary 
eircnmstances,  natural  labor  may  be  accomplished  when  either  the 
breech,*  feet,  or  knees  present ;  but  it  may  happen  that  nature  is 
BO  fer  contravened  when  either  of  these  extremities  is  at  the  supe- 
rior strait,  either  from  malposition,  excessive  size,  or  from  the 
occarrencc  of  some  accident  placing  in  peril  the  life  of  mother  or 
child,  as  to  need  the  prompt  interference  of  the  accoucheur.  Let 
us  illustrate  this  interesting  practical  point.  You  are  at  the  bed- 
side of  your  patient,  labor  has  commenced,  and  a  vaginal  exploi-a- 
tion  has  satisfied  you  that  it  is  a  case  of  breech  presentation.  You 
are  content  with  the  abstract  fact  that  the  breech  is  at  the  upper 
strait ;  you  give  yourselves  no  further  concern,  and  rely  upon  the 
efforts  of  nature  to  terminate  the  delivery.  Pain  succeeds  pain ; 
time  elapses,  and  yet,  notwithstanding  strong  uterine  contractions, 
the  breech  does  not  descend  into  the  pelvic  cavity ;  the  reiterated 
efforts  of  the  uterus  have  made  a  decided  impressioYi  on  the  strength 
of  the  mother,  while  they  have  not  failed  to  exercise  a  pressure 
more  or  less  injurious  on  the  fostus  itself. 

*  For  the  diagnoais  and  positions  of  these  various  presentations,  see  Lectoie 

zzxv. 


648 


THE   PRINCIPLES  AND   PRACTICE  OF   OBSTETRlCa. 


In  tliia  state  af  tilings— arjimated  to  dutVt  pefliaps,  by  the  an]c*ni 
appeals  of  the  patient — yon  institute  another  exaroinatiun  for  the 
purpose  of  aseertaiiiing  why  the  breech  docs  not  c9«»oi*nd  in 
response  to  the  vigorous  efforts  of  nature ;  at  tbi^  late  hour^  after 
the  exliuu^ition  i»f  the  nioilier  from  unuvailiiig  struggles  to  advance 
the  labor,  and  the  danger  to  the  child  from  extreme  pressure^  yoa 
discover  that  the  eau»e  of  the  delay  is  due  to  one  of  two  encidl* 
tions— either  the  breech  docs  not  present  properly,  or  ila  great  sse 
prevents  its  progress  into  the  pelvic  eiinstU  Here,  you  pcrceWc,  tbe 
cardinal  error  eanwisiH  in  the  Diet  that  you  were  carele^ii  in  ttot  htr* 
ing  aswiiained  the  true  nntnre  of  the  obstruction  at  an  earJy  8tS|^ 
of  hihor;  »o  that  by  opportune  interfurenro  the  diffiettlty  ndght 
have  been  overcome,  thus  sparing  the  mother  the  posj*ible  fatal 
OonHcujuence»  to  be  iipprehencled  from  exhau«tion  and  a  protracted 
parturition,  u  hilr  the  cliild  would  have  been  protected  agaiu9«t  the 
injurious  effects  of  undue  pressure. 

It  in  a  great  priruiple  in  midwifery — one  to  be  kept  constantlv 
before  you^;/of  to  ihlatj  action  until  the  mot /tar  and  child  tirt 
sacrificed  J  hut  to  exhibit  the  nidM  tr/nV/i  Bcitr>^€  will  tinaljU  ifnn  iQ 
do  op/tortttnclf/^  and  in  time  to  save  human  life,  WIrat  would  lie 
your  judgment  oi  the  navigator  who,  iti  disregard  of  the  ft'arfitl 
atorm,  shoutd  remain  perfectly  passive,  and  awaken  to  a  con^lutt^ 
oess  of  |K*ri!  only  w  hen  \m  noble  vessel  had  lallcn  a  wrock  to  ibt 
howling  tempest  ?  'Flie  panillel  is  perfect,  so  far  aa  daty  ii  4^011- 
oertied,  between  the  captain  to  whom  is  intrusted  the  nafety  of  h 
ship,  and  the  medical  mau^  who  has  iu  custody  the  life  of  Ul* 
puli«.Mit, 

If  it  ^hould  be  found  U»at  the  obstruction  conststa  in  malpotittina 
of  thu  breech — in  other  words,  \\\  Instead  of  presenting  C4*ntris  for 
centre  at  the  superior  strait,  one  of  the  hips,  the  sai-rum,  or  |»o«le* 
rior  surface  of  the  thighs  should  rest  upon  some  portion  of  the 
opfK?r  contour  of  the  strait,  the  indication  is  obviously  to  bring  the 
breech,  without  delay,  in  a  position  parallel  to  the  h>ng  axis  of  tb« 
pelvis  so  that  it  may  be  made  to  respond  to  the  contractile  ^»flt>ils 
of  the  uterus.  Tfds  rectifying  of  the  position  may  be  efTected  fcy 
the  introduction  of  the  hand,  dunng  the  absence  of  pain,  endes- 
Toring  gently  to  elevate  the  breech,  and  place  it  in  pro|>er  rebUiiNi 
with  the  strait ;  i^^hould  the  hand  not  be  adequate,  it  may  beeono 
Oeee^^ary  to  resort  to  the  lever,  or  one  of  tlie  liratu'hfn  of  iht*  fof* 
oeps.  I  have  Icnowu  instances  in  which  change  of  attitude  in  the 
patient  has  sufficed  to  accomplish  the  object.  But  we  will  suppose 
that  these  various  expedients  fail ;  what  then  is  to  Ik?  done?  Tbe 
next  alternative,  about  which  tl»erc  sliould  not  be  a  moment**  hmh 
tatiou,  is  to  iutroduee  the  hand  and  bnng  down  the  fe«t,  IIm 
maaaer  of  doing  which  we  shall  explain  before  the  oioBe  of  thii 
kcttim. 


THE   FRINCIFLES  AND  PRACTICE   OF  OBSTETRICS, 


I 
I 

■ 
■ 


In  the  case  of  excessive  size  of  the  breech,*  the  accouclieur 
should  etideavor  to  place  his  index  finger  in  the  bend  of  the  tbigh, 
situated  posteriorly,  and  make  gentle  traction  downward  and 
backward  in  the  direction  of  the  axis  of  the  superior  strait;  in  the 
event  of  failure  to  accomplish  this,  the  blunt  hook  or  fillet  iimy  be 
substituted  lor  the  finger,  of  wliich  we  shall  speak  more  particu- 
larly under  the  head  of  Instrumental  Delivery.  If,  however,  all 
these  prove  negative,  then,  as  in  the  other  instauce,  the  feet  must 
be  brought  down  by  the  introduction  of  the  hand. 

It  may,  however,  happen 
tlmt  the  pelvic  extremities 
present  iu  the  most  natural 
manner;  but  owing  to  the 
occurrence  of  some  complica- 
tion, such  as  hemorihaget 
coQVul^^ons,  or  exhaustion,  by 
which  the  salety  of  the  mo- 
ther and  child  may  be  com- 
pruruisL'd,  it  will  become  expe- 
dient to  terminate  the  labor* 
Undi»r  these  circumstances^ 
you  will  procewl  as  follows: 
Suppotiitjg  the  breech  to  pre- 
sent iu  the  Itrtit  position  with 
the  jtacrum  rega ruling  the  left 
acetabulum,  and  the  posterior 
portion  of  the  thighs  in  cor- 
respondence with  the  opposite 
sncro-iliac  symphysis,  the  left. 
hand  is  to  be  carried  up  aa  far 
as  the  breech,  which,  by  a  gen- 
tle effort,  you  will  attempt  to  ^'°'  ^•' 
elevate  with  a  view  of  eujibling  yon  to  bnng  down  the  limb  which 
is  behind^  and  afterward  the  one  in  front  {Fig.  76) ;  the  delivery  is 
then  to  be  completed   as   if  the   feet   originally   presented^      lt\ 


■  TTi&  breech  will  sometiuas  hv  found  only  rdativthj  disproporttonnto  m  size,  and 
tlicro  19  a  very  ini portent  praciiciil  iiict  eormecled  witli  tli"«  circuinstaJiee.  Far 
exiimpk,  it  will  otxiasionHlly  liripiieu  tli«t  tlie  fe^t  present  at  ihp  miperior  strait 
fliinuttan^usly  witU  the  breech.  Under  theBo  drcumsmnces,  iu  consequence  of  tiie 
iocreiiat'd  v<»Uiiue  of  the  pre^eiilirt^  pjirls,  there  will  necei^Hrily  bo  mort^  or  lessdcltiy 
in  Uk*  d<jlivery,  and  very  genemlly  iiitorlercuce  will  be  calknl  for.  Some  auiliora 
rec*)U]meud  to  replace  the  feet  williio  the  ciivtty  of  the  uitfnia  in  onler  that  more 
space  m«y  Ik*  aUtnved  for  the  descent  of  tlie  breech.  I  ciinnot  rejcard  this  tts  judi- 
eions  pmctice,  ond  would  odvisc  you,  instead  of  retuniinj?  the  feet,  to  seize  one  or 
Uoth,  nnd  bring  them  doAvn,  thus  con  verting  tlie  uaso  into  one  of  foot  proseDttp 
aoii. 

f  See  Lecture  XX'XV 


648 


THE   PRINCIPLES  ASH 


or  OBSTETJUCa. 


Ill  tliis  state  of  Oiing^^ — animaled  to  duty,  perhaps,  by  the  anlfivl 
appeals  of  the  p.nieiit. — you  iiietitute  another  cxiiminatiun  for  the 
purpose  of  asccrtaiaing  why  the  breech  does  not  detoeiid  bi 
reH|Kinse  to  the*  vij^nroua  effort h  of  nature  ;  at  this  late  hour,  after 
the  exliauHtum  of  the  motlu'r  fr^nn  iitiavairhii^  utruggles  to  advance 
tho  labor,  nnd  the  danger  to  the  child  from  extreme  prt-»iire,  yoa 
discover  that  the  cause  of  the  delay  \»  due  to  one  of  two  enodi^ 
tiona — I'itlier  the  brc^ech  does  not  preseiit  properly,  or  its  great  mm 
prevents  its  prui;re*<s  into  the  pelvic  canal.  Here,  ynu  Jicreeivr,  the 
cardinal  error  etxi^ists  in  the  fact  that  you  were  cArcle**  in  not  liJii- 
itig  ascertained  the  true  nfitnre  of  the  ob.^truction  at  nn  rarly  sIai^ 
of  labor;  &o  that  by  opportune  interferenee  the  diffieuUy  might 
have  been  overcome,  thus  sparing  the  mother  tho  pos^ble  fatal 
oonse<juenee»  to  be  ajjpreheuded  from  exhau^tiim  and  a  protraetfd 
partutitton,  while  the  child  would  have  been  protected  agaiant  the 
in j  1 1  ri  u 1 19  elTe c t  s  of  undue  p ressti re. 

It  in  a  great  prineipfe  in  midwifery — one  to  be  kept  eon«iaiilly 
before  you — not  to  dtlaij  actifm  until  the  mofhrr  and  child  tlf$ 
itterijlced^  but  to  est/libit  the  aids  tthich  seiai^e  will  inaLU'  you  to 
do  opportuficit/^  and  in  time  to  save  human  life.  What  wotdtl  lie 
your  judgmetit  of  the  navigator  who,  in  disregard  of  the  fi-arfd 
storm,  shnujd  remain  perfeetly  passive^  and  awaken  t*»  .i»- 

ncjfi**  of  peril  only  when  his  noble  vessel  ?md  talK'n  a  u  \ht 

howling  temj>e9t?  The  parallel  ia  perfect,  «o  far  aa  daty  b  eon* 
cenied,  between  the  captain  to  whom  is  intrusted  the  safety  of  Ma 
ehip,  and  the  nKtliciU  muu,  who  han  in  custody  the  life  of  Ui 
patient. 

If  it  i^hould  be  found  that  tlie  abfttructiori  conmsts  m  malfiodjikiii 
of  the  breech — in  other  words,  if,  instead  of  prewinting  centre  Ibf 
centre  at  the  superior  strait,  one  of  the  hip!*,  the  sacrum,  or  po«te* 
rior  surface  of  the  thigli!*  should  rest  upon  some  portion  of  tJi€ 
upper  contour  of  the  stnut,  the  indicjition  is  obviously  to  bring  tSe 
brtfech,  without  delay,  in  a  position  parallel  to  the  long  axia  of  the 
pelvis,  !*o  that  it  may  be  made  to  respond  to  the  contractile  «*fr>rti 
of  the  uterus.  This  rectifying  of  the  position  may  be  effected  by 
the  iutroiiuction  of  the  hand,  during  the  absence  of  pain,  rtt^cs* 
yoriog  gently  to  elevate  the  breech,  and  place  it  io  proi>cr  relation 
with  the  strait;  should  the  hand  not  be  adequate,  it  mt^j  lMH*oai« 
necessary  to  resort  to  the  lever,  or  one  of  the  branches  of  ibo  for*  \ 
ccps,  I  have  known  instances  in  which  change  of  attitude  in  tJi©  1 
patient  has  snUiccd  to  accomplish  the  object.  But  we  will  0ii|»poM 
that  these  irarions  expedients  fail:  what  then  is  to  be  done?  Tb« 
next  alternative,  about  which  there  should  not  be  a  mn  ^  ^icd* 
tation,  is  to  ititroduce   the   hand   and   bring  down  i.  tte 

manner  of  doing  which  we  shall  explain  before  tho  oUwo  of  (Ul 
lecture* 


THE   PRINCIPLES  AKD  FRAOTICE   OF  OBSTETBICS. 


549 


I 


^) 


In  the  case  of  excessive  size  of  tlie  breech,*  the  accoucheur 
sliould  endeavor  to  place  his  iutlex  finger  in  the  bend  of  the  thighf 
situated  posteriorly,  and  make  gentle  traction  downward  and 
backward  in  the  direction  of  the  axis  of  the  superior  strait;  in  iho 
event  of  failure  to  accomplish  this,  the  bluiit  hook  or  fillet  may  be 
stjbstitntcd  fur  the  finger,  of  wincli  we  shall  speak  more  jmrticu- 
hirly  under  the  head  of  Instrumental  Delivery,  If,  however,  all 
these  prove  negative^  then,  as  in  the  other  instance,  the  feet  must 
be  bronght  down  by  the  introduction  of  the  hand. 

It  may,  however,  happen 
that  the  pelvic  extremities 
prciient  in  the  most  natural 
manner;  but  owing  to  the 
occurrence  of  some  complica- 
tion, »*nch  as  hemorrhage, 
convnifrions,  or  exhaustion,  by 
which  the  safety  of  the  mo- 
ther aud  chihl  may  be  com 
proniisL*d,  it  will  become  e\pe 
dient  to  terminal e  the  labor. 
Under  ihese  circurnstancea, 
you  will  proceed  as  follows: 
8upp(>Mug  the  breech  to  pre- 
sent in  the  first  position  with 
the  ^ncrnni  regarding  the  left 
acetabuhini,  and  the  posterior 
portion  of  the  thighs  in  cor- 
respondence wit  ft  the  o]>posite 
sacro-iliac  symphysi.*,  the  left 
hand  is  to  be  carried  up  as  far 
fts  the  breech,  which,  by  a  gen. 
tie  efibrt,  you  will  attempt  to 
elevate  with  a  view  of  enabling  you  to  bring  down  tlw  limb  which 
is  behind,  and  afU»rward  the  one  in  front  (Fig.  76) ;  tlie  delivery  is 
then  to  be  eoin[»leted   as   if  the   feet   originally   presented.f      If, 

•  The  br<?ech  will  Bometim»*8  be  found  only  r«iaiwdy  disproportionoto  in  si^e,  and 
^  t||i<re  is  a  very  imp<»rti4iit  pnieiiowl  fncl  coimccled  with  tliia  circumstttncf\  For 
exMtnpl)?,  it  will  occasionally  hnp|>en  thut  the  ft-et  present  at  ihe  Fuperior  strait 
utnuluneously  with  the  brccrh.  Under  these  circumsinncea,  in  consequence  of  the 
incrffiisi'U  voluuie  of  the  presenting  parij*,  iht to  will  iieee*«arily  bo  more  or  les«  delay 
ill  ihe  ddiverj,  and  very  generally  interfercnee  will  be  ciiiled  for.  Some  nuiliom 
reofiTumeiid  txj  rcpluce  the  fe<rt  willnn  the  Ciivity  of  the  utenia  in  onler  tlnit  more 
«piice  mny  be  «1  lowed  T\>t  the  ik*»Otfnt  of  the  breech.  I  cannot  re^rd  this  ns  jiidi- 
cxomf,  pructiec,  nnd  would  udvise  ywu,  iofilead  of  retuminj?  the  feet,  to  seize  one  or 
both,  and  briitg  ihein  down,  (Utis  uorivcrtiR^  Uie  cm^  inta  ono  of  foot  preseoUr 
tio», 

f  Se«  Lecture  XXXV 


Fio.  T«, 


560 


THE   PBINCrPLES  AND   PRACnCE  OF  OBSTBTWCS. 


however,  it  shoiiM  lie  found  impmcticable  to  succeed  m  this  wiTi 
recourse  must  be  hnd  to  tl»t3  blunt  hook,  by  placing  it  in  the 
groin  of  the  limb,  which  is  posterior,  and  making  downwArd  and 
backward  tractions  until  tlie  hips  approach  the  Tulva.  Tho  hsnd 
then  can  readily  complete  the  extraction. 

The  same  rule  of  conduct  is  to  govern  yon  in  either  of  th© 
other  three  positions,  remembering  always  to  introduce  the  hand 
corrrsj>ouding  with  the  posterior  surface  oi*  the  thighs. 

Presentation  of  the  Feet — A  presentation  of  the  feet  caonot  be 
regarded  so  favorable  to  the  safety  of  the  child  as  when  the  brceeh 
pri'sent*k,  and  for  the  following  rea!»ou8:  The  membranout  mc  is 
Oiade  to  protrude,  and  becomes  more  or  less  elon<,niied  tbrou^ 
the  mouth  of  the  uterus ;  it,  therefore,  is  unable  to  reach  lU  full 
development,  and,  m  addition,  it  is  liable  to  be  early  rupturod. 
Under  the  circumstances,  the  uterine  orifice  is  but  partially  dilated^ 
the  consequence  of  which  will  be  compression  more  or  less  seriooi 
of  the  fc&tus,  to  which  may  be  added  undue  pressure  of  Uie  nmUIMl 
cord,  and  not  unfrequently  premature  detachment  of  the  placenta, 
oil  of  which  are  so  many  influences  adverse  to  tlie  Kifety  of  ihw 
child*  On  the  contrary,  in  a  breech  presentation,  the  meiiibrDDoqi 
Kac  does  not  rupture  as  a  general  rule,  until  the  full  dibtatioti  of 
the  orifice,  and  consequently  both  the  f<ptus  and  cxjrd  are  pro^ 
tected,  at  least  measurably,  against  the  amount  of  comprc«9i0D  to 
which  they  are  exposed  in  a  footling  case.  The  life  of  the  chihU  It 
should  be  recollected,  is  always  more  endangered  wIr-h  tfie  {leivie 
extremities  present  in  a  priinipara  than  in  a  multipara,  for  the 
reason  that,  as  a  general  principle,  the  parturition  in  the  former 
being  more  protracted,  there  is  increased  risk  of  pressure  of  Uia 
cord. 

In  a  footling,  as  in  a  breech  presentation,  it  may  become  tiecii^ 
sary  for  science  to  interpose,  either  because  of  maljiosition  or  of  tto 
occurrence  of  some  accident  calling  for  prompt  delivery.  In  tbe 
ca>He  of  malposition,  before  anything  can  be  attempted,  the  finC 
duty  of  the  accoucheur  will  be  to  ascertain  the  special  character  of 
the  obstacle;  for  example,  the  feet,  in  lieu  of  being  so  t«itiulri  at 
the  superior  strait  as  to  become  responsive  to  thtf  contractions  of  iha 
uterus  ">ay  ^^^^y  ^^^  or  both,  on  the  anterior,  posterior,  or  lateral 
borders  of  the  strait,  thus  contravening  every  effort  of  the  woiub 
to  cause  their  descent.  Should  not  the  source  of  the  diflieulty  be 
early  ascertained  and  removed,  the  consequence  w*''  '  liau^iiyQ 

of  the  female  from  fruitless  efforlslo  overcome  the  }  *b»lm& 

tion,  and,  perhaps,  the  sacrifice  of  the  foetus  from  tho  electa  of 
long  continued  pressure.  The  indication  in  such  a  eontingeiiey 
would  be  without  delay  to  introduce  tho  hand  and  right  th«  feet^ 
by  bringing  them  in  proper  line  with  the  stniit.  In  the  event  of 
some   eumplication,  such   as   hemorrhage  or  convaWoiWi  artifioisl 


I 


delivery  must  be  accomplisheti  rt'membenng  to  introduce  the  hand^ 
whicfi  coiTe«[Jond8  with  the 
beds  (Fig.  77)  of  the  child. 

Allow  me  here  to  make  a 
augge^Uoii  not  to  be  forgot- 
ten,  and  it  is  thin :  whenever 
the  loea  are  found  to  corres- 
pond with  one  of  tlie  aute^ 
rior  and  latend  portions  of 
the  pelvis,  as  soon  as  the  hips 
are  p:isi*in:^  throu;^h  the  f)el- 
vis,  cure  should  buexerd^ed 
to  rotute  the  f<BtU8  in  its  long 
axi8,  so  as  to  bring  the  pos- 
terior plane  of  the  ehild*B 
body  in  apposition  with  one 
or  other  of  the  acetabula; 
if,  for  instance,  the  toe'*  are 
toward  the  left  cotyloid  ca- 
vity, the  back  of  the  fcetus 
ihonld  be  brought  to  the 
right  lateral  point  of  the 
pelvis;  if  to  the  right  coty- 
loid cavity,  to  the  left  lateral 
point  The  object  of  ihia 
movement  in  to  reduce  the 
posterior  to  the  anterior  po- 
sition^ and  thu«^  fadlitate  the 
delivery  of  the  head.  The 
aaioe  rule  nl^o  applies  in 
breech  presentation^*,  when 
the  Racrnm  is  at  either  of 
the  sacro-iliac  junction r. 

Prcaentatktn  of  the  lutres, 
— TiiiH  form  of  presentation 
ia  extremely  rare,  and  wIumi 
it  does  occur,  the  general 
position  of  the  fptus  is  the 
aanie  m  in  presentation  of 
the  feet.  Theindieatiori!?  are 
ako  identical  as  in  fiKiiling 
C'lses ;  if  there  be  malposi- 
titm,  it  mu**t  bf»  corrected ; 
and  if  the  labor  suflrL»r  from 
complication,  delivery  is  to 
be  accoinj>lished»     For  thia 


FiA^rr 


THE  PHIKCIFLE3  AND  FRJLCTICB  OF  0B3r£TRIC& 


however^  It  shotild  be  found  impracticable  to  suoceed  in  this  wsjt 
recourse  mu8t  be  had  to  tho  blunt  hook,  by  placing  it  in  the 
groin  of  tht5  limb,  which  is  po^erior,  and  making  downward  and 
backward  trnetions  until  the  hips  approach  the  viUra.  The  haad 
tl»en  c:m  readily  complete  the  extraction. 

The  same  rule  of  conduct  is  to  govern  you  in  either  of  tbo 
other  three  positions  remembering  always  to  introdneo  the  hand 
corresponding  with  the  posterior  surface  of  the  thighs. 

Presentation  of  (he  jFe€t, — A  presentation  of  tli  '  mnol  ba 
regarded  so  favorable  to  the  safety  of  the  cliild  as  ^  .  breach 

presents,  and  for  the  following  reasons:  Tlio  membranous  iflM^ii 
made  to  protrude,  afid  becomes  more  or  \em  elongated  throofcli 
the  mouth  of  the  nteruii ;  it,  therefore,  is  unable  to  reach  its  M\ 
di'vclopment,  and,  in  atidition,  it  U  liable  to  be  early  ruptured* 
I  nderthe  circumstancen,  the  uterme  orifice  is  but  pHrtially  dilated^ 
the  oonsequence  of  which  will  be  comprea&ioQ  more  or  lass  sarioitt 
of  the  fcetus,  to  which  may  be  added  undue  pre^isuro  of  the  ombilical 
cord,  and  not  unfrequenlly  premature  detachment  of  the  plal^•tltS| 
all  of  which  are  ^o  many  influences  adverse  to  the  safety  of  lh« 
child.  On  the  contrary,  in  a  breech  presentation,  the  raembranotiA 
isac  does  not  rupture  as  a  general  rule,  until  tlie  full  dthitation  of 
the  orifice,  and  consequently  both  the  fcotus  and  cord  are  pre- 
teetcd,  at  ha»t  measurably,  against  the  amount  oi'  rompresuoQ  to 
which  they  are  exj>osed  in  a  footling  caae.  The  life  of  the  child,  tt 
should  be  recollected,  is  always  more  endangered  when  the  |»«*lvio 
extremities  present  in  a  priuiipara  than  in  a  multijiara,  for  the 
reason  that,  aa  a  general  [triticiple,  the  parturition  in  the  former 
being  more  protected,  thoru  h  increajied  risk  of  presstire  of  the 
cord. 

In  a  footling,  as  in  a  breech  presentation,  it  may  beoome  jieoe^- 
sary  for  science  to  interpose,  either  because  of  malpositioQ  or  of  the 
occurreuee  of  some  accident  calling  for  prompt  delivery.  In  the 
ease  of  malposition,  lief  ore  anything  can  be  attempted,  the  fiml 
duty  of  the  accoucheur  will  be  to  ascertain  tho  specbl  chanurterDf 
the  obstacle;  for  example,  the  feet,  in  Heu  of  being  so  ri(tuit4Nl  H 
the  Huperior  Bivmi  an  to  become  reH[Rmsive  to  the  contractioiis  of  the 
uteruM,  may  rest,  one  or  both,  on  the  anterior,  posterior,  or  laief«I 
borders  of  the  strait,  thus  contravening  every  eflfurt  of  the  womb 
to  cause  their  descent.  Should  not  the  f^ource  of  ths  diffieoltj  be 
nirly  ascertained  and  removed,  tho  oonseciuenci*  will  be  exbanstlaii 
of  the  ft'male  from  fruitle*is  cfHirts  to  overcome  the  physical  obsini^ 
lion,  and,  perhaps,  the  sacrifice  of  the  fcetus  from  tho  effects  of 
long  continued  pressure.  The  indication  in  such  a  contingvtie; 
would  be  without  delay  to  intro<luce  ihe  hand  and  right  the  feet» 
by  bringing  them  in  proper  line  with  the  slniit.  In  tho  evoitt  of 
some   curaplicatton,  such   as  hemorrhage  or  couvuUions,  artlfiiial 


THE  PRINCIPLES  ANU   rKACllCE   OF  OBSTKTBIC8. 


551 


^S^.T 


delivery  must  be  accomplis1>eil  remembering  to  introduoe  the  handi 
which  correapond;*  with  the 
heels  (Fig.  77)  of  the  child. 
Allow  rae  here  to  make  a 
suggeHliort  not  to  be  targot- 
len,  and  it  is  this :  whenever 
the  toes  are  found  to  corres- 
pond with  one  of  the  ante- 
rior tiud  l:itei':il  poi'ticuiH  of 
the  pelvis^  tm  soon  as  ttie  hips 
are  pa^i^irig  tliroui^h  the  pel- 
vis, care  should  be  exerdsed 
to  rotate  the  feet  us  in  its  long 

CjjS  8o  a^  to  bring  the  pos- 
fior  plane  of  the  child'a 
body  in  apposition  with  one 
or  other  of  the  acetabnla ; 
if,  for  inntance,  the  loe^  are 
toward  the  left  cotyloid  ca- 
vity, tlie  back  of  the  ftjetus 
should  be  brouglit  to  the 
right  latei-al  point  of  the 
pelvis ;  if  to  the  n2:ht  coty- 
loid cavity,  to  the  left  laterftl 
point.  The  object  of  this 
movement  is  to  reduet«  the 
posterior  to  the  nnti^rior  po- 
sition, and  thus  facilitate  the 
delivery  of  the  heaii.  The 
Kime  rule  also  applies  in 
breech  presentatioris,  when 
the  sacrum  is  at  either  of 
the  sa'^ro-iliac  junctions. 

Prr  mentation  of  (he  Kneeff. 
— This  form  of  presentation 
is  extremely  rare,  ani  wlien 
ti  does  occur,  the  general 
position  of  the  f<3?tus  is  the 
i^aiije  as  in  preseutatiou  of 
the  feet.  Thelndieaiioi^  are 
also  identical  as  in  fmitHng 
eases;  if  there  be  malposi- 
tion, it  must  b»>  corrected  ; 
and  if  the  labor  suffer  from 
complication,  delivery  is  to 
be  iiccoraplished.     For  this 


FIS.TT 


l-Hi^  :tk 


652 


THE   PRINCIPLES  AND   PRACTICE   OF  OBSrrKTRlCS. 


purpose,  the  haml  should  be  introduced  which  corres]  h 

iKiltriiir  aurliicc  witli  ll»e  anterior  8iirtace»  of  the  ehihl  (i  •  i 

the  knues  being  brought  down,  the  same  piiueiples  arc  to  guid<*  vtJii 
as  ill  a  foot  presc nlation.  It  may,  however,  be  that  ihcre  will  hm 
iinusiiul  difiiculty  in  extricating  tfie  knees  with  the  haud ;  in  tluii 
ease,  the  fillet  may  be  advantJigeoiisly  em))loyed,  winch,  ticutgi 
placed  in  the  ham  of  the  leg  whieh  is  posterior,  downward  and 
backward  tractions  are  to  hti  made  unlil  the  knees  are  liberatc«it 
If  these  hitter  be  situated  so  high  up  as  to  render  the  application  of 
the  tillet  impracticable,  tlien  resort  nin»t  be  hud  to  the  blunt  hot>k, 
which,  being  carefully  inserted  into  the  ham  of  the  posterior  liinb^ 
will  enable  you  by  proper  extractive  foix-se  to  biing  down  tbekneea. 
Pehnc  PrestntcUions  with  Infi.rtia  of  the  Utents^-^X  have  i*sil1ed 
your  alteniion  to  the  management  t>f  |M_4vic  ]>resentalions»  under 
certain  complications  of  labor  ;  and  it  now  remains  for  me  to  Apeak 
of  thern  in  connection  with  inertia  of  the  uterus.  You  will  occa* 
iiionally  meet  with  cases  in  practice  in  wliich,  under  breech  pr^- 
^cntation?^— and  tlie  s'lme  thing  jnay  oc<;ur  when  the  vertex  or  any 
of  the  other  extremitien  of  the  ovoid  present — the  uterus,  after 
vigorous  effort,  ceases  for  fwirne  time  to  contract.  This  cessation  ui 
effort  on  tlie  part  of  the  organ  is  very  apt  to  be  regarded  m  the 
tmiform  result  of  inert  in,  iiu*l  hence,  with  this  abstract  view,  rcconrw 
IB  too  IVcquently  had  to  certain  8[»eeial  remedies,  which  are  known 
to  excite  uterine  action.  The  term  imrda  is,  I  think,  ofieiiiimejl 
misunderstood,  and  this  very  circnmstanee  leads  to  bad,  tf  wot 
dangerons  pi-acticc.  The  question  is  worthy  of  a  momeut^s  extuni- 
natiorj,  for  it  involves  an  important  principle  in  tlie  lying-in  room, 
In  order  that  you  may  conipjchend  wliat  I  ipean,  I  shall  regard 
inertia  of  the  v^'omb  in  ehiid-hirth  as  due  to  one  of  two  oonditions: 
either  to  constitutional  or  toc;i!  influence.  Kxamples  of  the  former 
you  have  irj  women  who  have  suflcred  from  antecedent  disease,  or 
from  exhausting  drains;  iueriia  may  also  be  traced  lo  a  naturally 
delicate  organizalion  ;  in  certain  susceptible  constitutions,  tncmial 
emotions  will  otn  asion  it.  Agaiti :  excessive  plethora  may  he  ranked  i 
among  its  causes.  If  this  view  of  the  suliject  be  correct,  it  ia  vet 
evidi  nt  that  oru*  ofthefurnlamenlal  [>rerequisiles for  judicious  trc!^i- 
mcnt  will  he  to  distinguish  the  particular  constitutional  circuuvsUmee 
to  which  tfie  imiction  of  the  or^an  is  lo  be  referred.  In  the  ai^eof 
inertia  from  previous  disease,  or  any  exhausting  influeneeA,  tbe 
remedy  will  consist  in  ihe  adininistnilion  of  stimulants  tfig<^hifr 
with  generous  ai»d  renovating  diet ;  if,  on  the  contrary,  it  be  dui*  la 
mental  influence,  resort  must  be  had  to  those  agents  best  c:Jculaie<l 
to  calm  the  mind,  and  infuse  It  with  the  invigorating  auxiliaries  of 
hope  ami  coutidenee.  If  the  (Kitient  labor  under  plethora,  tlien  tbtt 
abstraction  of  bfood  is  broadly  indicated — the  quantity  to  depimd 
upon  the  surrounding  circumstances  of  the  case, 


THE  PBINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         568 

Among  the  local  cau8es  of  inertia  may  be  enumerated  the  follow- 
ing :  increase  in  the  volume  of  the  uterus  from  an  excessive  quantity 
of  liquor  amnii,  which,  by  temporarily  paralysing  the  muscular 
fibre  of  the  organ,  induces  a  state  of  more  or  less  complete  inacti* 
vity ;  unavailing  efforts  of  the  uterus  to  rupture  the  membranous 
saCy  occasioning  exhaustion  of  its  fibre ;  unyielding  condition  of  the 
cervix  in  consequence  of  an  abnormal  induration  of  the  part ; 
departure  of  the  uterus  from  its  long  axis,  so  as  to  render  abortive 
any  effort  to  expel  the  contents,  thus,  as  it  were,  tiring  out  the 
organ  ;  inherent  debility  of  the  uterine  muscular  fibre  dependent 
upon  want  of  proper  nervous  influence. 

You  must  perceive,  gentlemen,  how  manifestly  essential  it  is  to 
examine  critically  into  the  existence  of  these  various  causes  capable 
of  producing  inertia  in  order  that  the  approi)riate  remedy  may  be 
employed.  If,  for  example,  you  should  be  satisfied  that  the  inactive 
condition  of  the  organ  is  traceable  to  excessive  distension  from  an 
unusual  quantity  of  amniotic  fluid,  the  indication  will  be  at  once  to 
rupture  the  membranes,  and,  by  the  escape  of  the  liquor  amnii, 
liberate  the  uterus  from  the  paralysis  to  \\  hich  it  has  been  subjected 
by  the  excessive  distending  force.  The  same  course,  also,  must  be 
pursued  when,  hi  consequence  of  the  prolonged  resistance  of  the 
membranes,  nature  is  unable  to  ru{)ture  them.  If  the  source  of  the 
trouble  be  found  to  consist  in  an  unyielding,  indurated  condition  of 
the  cervix,  benefit  may  be  derived  from  the  application  of  the 
bellarlonna  ointment;  if  this  fail  to  afford  the  necessary  reliefi 
I  should  not,  under  the  circumstances,  hesitate  to  incise  the 
cervix ;  and,  in  having  recourse  to  this  expedient,  I  would  advise 
you  to  make  several  small  incisions  on  the  anterior  and  posterior 
lips. 

Suppose,  however,  that  neither  of  the  above  conditions  of  the  organ 
be  present,  and  you  should  have  asceitained  that  the  inertia  is  due 
to  malposition  of  the  uterus,  constituting  a  want  of  parallelism 
between  its  lone:  axis  and  that  of  its  superior  strait,  thus  preventing 
the  uterine  effort  from  concentrating  on  the  centre  of  the  pehio 
canal,  and  consequently  wearying  the  organ  in  useless  struggles  to 
expel  its  contents.  It  can  scarcely  be  necessary  to  say  to  you  that, 
in  such  case,  the  indication  would  be  two-fold :  either  to  restore  the 
uterus  to  its  parallelism,  or  proceed  at  once  to  terminate  the  labor 
by  artificial  delivery. 

When  the  inertia  can  be  traced  to  inherent  debility  of  the  uterus 
consequent  upon  a  want  of  nervous  power,  then  you  will  find  an 
efficient  remedy  in  ergot.  If  there  be  nothing  to  contra-indicate 
its  administration,  it  may  be  given  in  infusion,  powder,  or  tincture. 
For  this  special  purpose,  I  prefer  it  in  the  form  of  infusion — say, 
3  ij.  of  the  powder  in  3  iv.  of  boiling  water ;  let  it  infuse  for 
twenty  minutes,  a  tablespoonful  to  bo  taken  at  an  interval  of  tea 


664         THE  FBIKCIPLES  AKD  FRACmCS  OF  0B8TETBIG8. 

minntes,  until  action  of  the  nterns  is  produced.  If  the  ergot  be  of 
proper  quality,  it  will  rarely  happen  that  it  will  not  have  the 
desired  effect  after  a  fbw  doses  are  administered.  In  this  hitter 
character  of  inertia,  I  have  found  repeated  drinks  of  ice  water, 
taken  in  small  quantity,  to  be  of  signal  service  in  promoting  uterine 
contraction;  warm  tea  or  gruel  will  occasionally  have  the  same 
effect. 


LECTURE    XXXVII. 


Manual  DeliireT7  oontinued— Trunk  or  TmnsvefBe  PreaentatioM,  iaeltiding  the 
Abdom^a,  Cheat,  Back,  and  Sides  of  the  Foetus — Fressentntlon  of  the  Abdomen  : 
its  DiMgrnofiis  iind  Treatment — Prest»ntattoa  of  th<?  Chesl,  Back,  and  Sides;  h  >w 
Managed '-Shoidder  rregtnitatjon  with  or  without  Protrusion  of  the  Arm— Treit- 
tit<*nt  of— Manage mt^nt  of  these  Cams  by  the  Ancitrnts,  barbarous  aud  destnictivo 
to  ibe  Child,  bi'caiise  founded  upon  Ignorance  of  tbe  Mechauitsm  of  Labor — Tbeir 
MMnagi^m^nt,  Fhiios^jphlc  and  Conaervaiive  tn  our  Timea — Spontaneous  Krolu- 
lion — Meaning  of  tbtj  Term — Divided  into  Cephidle  and  Pelvic — ^Comparattve 
Baritj  of  Spoutaneoua  Evolution — Statisties  by  Dr.  RIecko — Statistics  of  Dublin 
J^jiu^'m  Hofipital — Fearful  Fatality  to  the  Child  in  Spontaueoua  Evolution — Dr. 
Deumaii'a  Kacpodition  of  the  Manner  Sn  which  the  Evolution  is  performed,  shuwn 
to  h^  Erroneous  by  Dr.  Doujjrlasa,  of  Dublin — Spontaneous  Evolution  not  to  bo 
relied  upon  wlien  Artificial  Delivery  is  indicated. 

Gkntlesien — Our  tliird  ilivision  of  manua!  labor  embraces  trunk 
or  transverse  preaen  tat  ions  together  with  lliose  of  tlie  arm  and 
shoulder.*  It  h  quite  obvious  that  when  the  trunk,  shoulder,  or 
arm  presents,  it  will  be  pfjyaiually  impossible  for  the  child  to  pasi, 
except  througli  spontaueous  evolution,  for  the  reason  of  the  dispro- 
portion whiuii  must  necessarily  exist  between  it  and  the  ma-ternal 
organs.  Therefore,  the  alternative  in  this  form  of  presenlatioa 
will  be  to  cliange  the  position  of  the  child  by  version.  I  shall  firit 
tpeak  of  trunk  presentations,  and  in  doing  so  avoid  tbe  nunierous 
Bubdivisiuns  of  authors,  and  present  llje  sobjoct  to  yon  under  the 
following  heads:  1.  Presentation  of  the  abdomen  ;  2.  Presentation 
of  the  chest;  3,  Presentation  of  the  baek;  4,  Presentation  of  the 
sides  of  the  fa?tus,,  including  the  shoulder  and  hips. 

It  is  proper  here  to  remark,  that  I  sliall  recogniso  only  two 
positions  tor  each  of  the  presentations  of  the  trunk,  and  for  the 
8uV>stantial  reason  that  they  practically  etnbrace  the  various  divi- 
sions of  authors,  inasmuch  as  the  rules  for  their  terminatidn  are 
identieal.f 

Presentation  of  the  Abdomen, — ^In  this  presentation,  which  is 
extremely  rare,  the  child  is  in  a  j?tate,  as  it  were,  of  extension,  and 
consequently  tbe  risk  it  incurs  is  much  greater  than  in  either  of  the 

•  Indeed,  iome  clever  writers  comprehend  trnnsverse  presentations  under  those 
of  otie  or  other  shoulder^  believing  that  the  ubdomeu,  back,  and  sides  of  the  foBtus 
ftre,  when  found  at  the  superior  strait,  simply  varieties  of  the  shoulder  presentation. 

f  This  is  the  cbssidcution  suk^gested  by  Iliilmagrand,  and  others,  and  I  adopt  It 
beeaose  I  think  it  nut  only  rational,  but  eminently  practical  lu  its  results. 


556 


THE  PEIKOIPLES  AND   PRACTICE  OF  OBSTETRICS. 


^) 


Other  trunk  presentations.  When  the  alxlomen  ir  at  the 
strait,  the  tiict  will  be  uscL'rtaineJ  by  the  presence  of  the  n 
oord,  wliidi  Aonietinics  will  have  descended  into  the  vagina,  mid 
even  protruded  beyond  tlie  external  parts  ;  the  child  lies  no  com- 
pletely across  the  pelvis  that  its  anterior  snH'ace  is  in  relation  with 
the  mouth  of  the?  uterus  while  llie  dorsal  region  lookit  toward  ihi* 
fundus  of  the  organ.  Whether  the  head  be  at  the  left  or  right  mU 
of  the  pelvis — or,  in  other  words,  in  order  to  recognise  the  [tarticu- 
lar  iM:>sitton  of  the  f<jBtus,  the  accoucheur  will  readily  discover  iu 
dh'eeting  his  tinge r  fi  uui  rt»|ht  to  left^  with  which  side  of  the  pelvis 
correspond  the  borders  of  the  false  ribs^  the  crests  of  the  ilia,  mi 
the  organs  of  generation. 

I^irai     Position. — Ileiv 
the  head  is  in  relation  with 
the  left  iliac  fossa,  while  tbe 
feet    regard    tlie     opposite 
point  of  the  strait.     In  lias 
p,^8ilion,  the  lefl  hand,  pru* 
I  telly   i)re}>ared,    should   be 
introduced   into  the  menu 
(Fig.  V9);    it   should  then 
genily  pay^s  to  the  left  side 
of  the  cldld,  gliding  along  | 
the  entire  posterinr  iiurCiic6  I 
(»f  the  hody  uiuil  it  reached 
the  feet,  which,  being  sctzc^l, 
are  to  be  brought  down,  aodi 
converted   into   the  second 
position   of  the  feet.     Hie 
delivery  to  he  terminated  U'. 
if  it  were  oi  igitially  a  footUlig'' 
ca^e. 
Second  Positwn.—Thh  position  h  precisely  the  reverse  of  the 
preceding,  the  head  corres[>onding  wilb  the  right,  and  the  feet  vrilli 
the  left  iliac  fossa;  in  this  case  the  right  hand  should  be  - 
and  the  delivery  accompUshed  as  iu  the  former  po!*ition  ;  i  ^ 

however,  in  this  instance  will  be  converted  into  the  first  posttiuo^ 

It  may  hapium  that,  on  inlro<}ncing  the  hand,  only  one  foot  eao 
be  seized.  Under  these  circnmstances,  let  the  foot  which  h.*i3*  bc^n 
brought  down  be  attached  by  a  lillet,  and  retained  tn  position, 
while  the  hand  is  again  intro<luced  for  the  purpose  of  wcking  for 
the  other  extremity  which,  when  grasped^  is  to  be  placed  by  tbe 
side  of  the  foot  held  by  the  fillet. 

Presentation  of  (he  Thorax. — When  the  thorax  present «,  it  will 
be  readily  recognised  by  the  ribi?  and  stern nm,  as,  in  the  presenta- 
tion of  the  abdomen,  the  anterior  surface  of  the  cliUd's  body  ti 


Fio.  TO, 


THE   PRINCIPLES  AND   PRACTICE  OP  OBSTETRICS, 


557 


flown  ward,  and  tbe  ilorsal  plane  ia  npwnni.  Ht^re  the  }»eatl  is 
nnich  neircr  the  snperior  atmit  than  the  feut,  rendering  it  more 
difficult  to  deliver  by  the  feet  than  in  an  abdorninsil  presentation ; 
\or  tfii^  reJison,  it  hns  been  recommend t*d  to  hi  in:>  ttie  liead  in-tead 
of  the  fiH't  lo  the  strait,  and  then  tc »ntiil in ij  the  tuniiination  of  the 
labor  to  the  natural  resources,  unless  there  be  some  urgent  iiidlca* 
tion  for  the  immediate  extraction  of  the  child.  The  objection  to 
llie  practice  of  cephaUc  ver^ic}n  in  this  case  is  two-fold :  1.  It  is  very 
difficult  to  phice  the  head  of  the  child  in  proper  position  nt  the 
superior  stmit,  without  iuflicthiQf  upon  it  more  or  less  injin'y,  and 
incurrinf^  at  the  same  time  the  hazard  of  nipturini:^  tlie  uterus  ;  2,  If 
the  head  should  be  broutjjbt  to  the  strait,  and  ntit  placed  in  cor- 
respondence with  the  pelvis,  the  necessity  will  then  arise  of  having 
recourse  to  podaiic  version.  For  these  reasons,  therefore,  I  should 
advise  you  to  proceed  at  once,  in  case  of  thorax  ^iresen  tat  ions,  to 
seek  tor  the  feet* 

J^irni  Po8ifffjn> — The  head  is  Inrned  toward  the  left,,  and  the 
feet  toward  the  right  iliac  fossa.  The  left  liaiul  is  to  be  introduced 
in  the  same  njanner  as  indicated  in  the  first  position  of  the  abdo* 
men  ;  and  when  the  feet  are  grasped,  they  are  to  be  brourfht  to  the 
strait,  and  the  labor  is  terminated  as  in  the  first  position  of  the  feet. 

Second  PosHion. — ^The  head  to  the  rit^lit,  and  the  feet  re^arWing 
ibe  left  iliac  fossa.  The  right  !»:md  is  introduced,  the  feet  grasped, 
and  the  delivery  accomplisfied  us  in  the  first  j>osition  of  the  feet. 

Presaitatkm  of  the  Back, — When  the  back  pj'esents,  the  child 
is  not  sulijected  to  the  same  degree  of  danger  as  in  a  presentation 
of  the  abdomen,  for  the  reason  that,  instead  of  being  extended,  it 
is  flexe<l  on  itself.  There  is  no  diiliculiy,  with  a  dtie  degree  of 
attentiou,  in  rccognii^ing  a  back  presentation  j  the  evidences  are  :  n 
broad,  and  more  or  less  elastic  tumor,  the  l>orders  of  the  false  ribs, 
together  with  the  two  scapulas.  These  various  poiuts  will  also 
enable  you  to  ascertain  the  particular  positiun. 

First  Position. — The  head  is  in  correspondence  with  ihe  left,  and 
tbe  feet  with  the  right  iliac  fassa.  The  leil  hand  is  to  be  introduced 
in  a  state  of  supination,  and  the  fcetns  being  geutly  grasped,  its 
position  is  slightly  changed,  so  that  the  back  is  brought  toward  the 
symphysis  pubis;  the  hand  then  pursues  the  anterior  plane  of  the 
body,  and  alter  successively  passing  over  the  ubdoraen  and  thighs, 
reaches  the  knees  and  feet,  which,  being  brought  to  the  strait,  art 
converted  into  the  second  position  of  the  feet,  and  tbe  labor  is  then 
terminated,  as  already  indicated. 

Second  Position, — Here,  the  situation  of  the  child  is  reversed, 
the  head  being  in  relatioti  with  the  right,  and  the  feet  witii  the  letl 
iliac  fossa;  the  right  band  being  introduced,  the  same  rules  are  to 
be  observed  as  in  the  first  position. 
JPreaefUati&n  of  t/ie  Sides, — Under  this  head  will  be  embraced,  m 


658 


THE  PRlNCtPI.£8  AND  PRAGTICB  OF 


identical,  the  tiitenil  surfj^cs  rtinl  bip«i  of  the  eJilld,  ihft  rseogntlioo 
of  the  hitter  at  the  Btipei  tor  Mtrait  constituting  ibe  clhgiioM  of  tlM 
pret^eutation,  The  presence  of  one  or  other  }ap  will  be  nsTettlad  by 
a  a^nuill  rouiidod  tumor^  the  ssi^rum,  crest  of  the  ilimii,  and  iIm 
organs  of  generation. 

J*\rst   Pitaitwn  of  the  Hight  IIip,^~\n  this  pi  ^e  head 

regards  the  lellt,  while  the  feet  are  to  tlte  right  of  ■  ^  m ;  Um 
dorNftl  i»urface  of  the  child  is  in  relation  with  the  symphyak  pubK 
and  the  jinlerior  plane  with  the  promontory  of  the  sacrtim,  Tbt 
left  hjmd  h  ii»tro<lueed^  and,  after  elevating  the  ftctns,  the  feet  ara 
reaehcd  by  pin>uing  the  nnterior  surface  of  the  child  j  they  are  ibMl 
brought  to  the  strait,  and  the  delivery  terminated. 

ikmnd  Ponition  ttftht  Right  //*/?.— Ttie  head  to  tho  richt.  the 
feet  to  the  left  of  the  pelvis;  the  anterior  plane  is*  n  tlit 

posterior  behin<l.  The  right  hand  is  introduced,  and  m  ^  ion 
the  same  a«  in  the  former  eaae. 

First  Ponition  of  the  Lfjl  Hip, — The  head  toward  the  left  tliac 
fo»!ia,  the  feet  to  the  right.  With  the  left  hand  the  fo&tu8  is  t«>  be 
elevated,  ftTnl  aft<'r  pursuing  the  anterior  surface  of  the  body,  wliieli 
ie  in  front,  the  feet  arc  gra^^ped  and  brought  to  the  stnilt  :  \\w  pn»^ 
flentation  i»  reduced  to  the  second  position  of  the  feet, 

JSec^nd  Position  if  the  Left  Hip, — ^The  head  to  the   r in- 
fect to  the  left*     The  right  hand  iu  to  be  introduced;  th* 
ruh'j*  observed  as  in  the  previous  instance,  exoepi  that  the  feet  m 
reduted  to  the  first  position* 

Premntation  of  the  ShoiiUi^r, — In  calling  attention  to  sboulder 
presentations,  it  will  be  [»ri)|>er  to  divide  them  into  two  e]a«»t«:  1. 
Where  simply  the  felioulder  preM*nts ;  2.  Where,  together  with  llie 
shoulder,  the  arm  and  hand  protrude.  A^  we  proceed,  it  wPl  be 
seen  that  thi«  ift  a  very  important  division,  and  has  involved  «»• 
flicting  opinionH  in  reference  to  the  s|»ecial  f)racticG  to  be  adopted 
in  the»e  casc8.  It  '\n  a  point  of  much  nionicnt  to  rememWr  ikil 
always,  in  shoulder  preHeritation^,  it  is  esi^untial  that  an  aoourita 
diagnosis  be  made  cctr/y/  for,  generally  speaking,  precuHftly  iti  pro* 
portion  to  the  time  whtt:h  has  ejnpned  from  the  e»caf>e  of  the  liquor 
amnii  to  the  determination  of  the  diagnosis  will  be  the  diSeiiHjr 
of  operating,  and  ahno  the  d:mger  to  the  child.  Some  aare  wffl  be 
needed  in  distinguishing  the  shoulder,  for  it  may  be  coafoanded 
with  the  elbow,  the  breech,  liipfi,  or  knee.  The  true  dl^tiatttioaf 
the  one  which  make!<  it  certain  that  it  is  a  shoulder  pre^eiitatioiif 
eoiwisls  in  reeoguising  with  the  ^uger  the  ftcapula,  rlaviolev  and 
tlie  upper  ribs,  which  may  W  done  with  a  proper  iiegret»  of  eauttotL 

First  Position  of  the  Jiifiht  Shoulfier, — ^Thc  heml  is  to  the  left, 
and  the  feet  to  the  right  side  of  the  pelvis;  the  back  of  the  cliiMb 
turned  nlightly  upwnrd  toward  the  pubes,  wlilV   "  u»rior  ptase 

haa  a  posterior  aspect.     The  left  hand  being  itn  i,  llio  ahook 


THE  PRINCIPLSS  AND  FRACTICE  OF  OBSTETRICS.         569 

der  is  gently  raised,  and  the  feet  are  then  sought  for  by  carrying  the 
hand  along  the  anterior  surface  of  the  child's  body  ;  they  are  then 
brought  to  the  strait  of  the  pelvis,  being  converted  into  the  second 
position  of  the  feet. 

Second  Position  of  the  Right  Shoulder. — ^The  head  to  the  right, 
the  fcet  to  the  lefl ;  the  back  of  the  child  is  posterior,  and  the  ante- 
rior phine  is  directed  forward  and  upward.  With  the  right  hand, 
the  accoucheur  elevates  the  shoulder ;  and  seizing  the  feet,  in  tra- 
versing the  anterior  surface  of  the  body,  brings  them  to  the  strait 
converting  them  into  the  first  position. 

First  Position  of  the  Left  Shotdder. — ^The  head  to  the  left,  the 
feet  to  the  right ;  in  other  respects,  the  position  of  the  child  is  the 
same  as  in  the  preceding  example.  The  left  hand  is  introduced, 
and  the  feet  brought  to  the  strait,  converting  them  into  the  second 
pomtion. 

Second  Position  of  the  Left  Shoidder, — ^The  head  to  the  right, 
the  feet  to  the  left ;  the  posterior  plane  of  the  child  above  and  a 
little  in  front,  the  anterior  plane  below  and  slightly  backward.  The 
left  hand  is  carried  up  to  the  shoulder  and  trunk,  on  which  a  partial 
movement  of  rotation  is  effected  in  order  to  place  the  anterior  plane 
below ;  the  feet  are  then  brought  to  the  pelvis,  being  converted  into 
the  first  position. 

Presentation  of  the  Shoulder  with  Protrusion  of  the  Arm, — ^The 
treatment  of  this  compound  presentation  by  the  accoucheurs  of  the 
present  day  forms  not  only  a  striking  contrast,  but  exhibits  in  a 
most  favorable  manner  the  progress  of  obstetric  science  as  compared 
with  the  practice  inculcated  by  our  predecessors.  In  this  presen- 
tation, delivery  w^as  deemed  impossible  with  safety  to  the  child,  and 
hence  the  most  extraordinary  rules  were  instituted  for  the  manage- 
ment of  these  cases.  Indeed,  whenever  the  ann  protruded,  in 
aboulder  presentations,  the  accoucheur  in  former  times  regarded  it 
as  one  of  the  most  formidable  complications  of  the  lying-in  room ; 
but  one  thought  occupied  his  mind — the  destruction  of  the  child  as 
the  necessary  and  only  means  of  saving  the  life  of  the  mother. 
With  this  view,  numerous  expedients  were  resorted  to  ;  one  incul- 
cated the  practice  of  twisting  off  the  arm,  and  terminating  the  deli- 
very by  bringing  down  the  feet ;  another  suggested  amputation ;  a 
third  recommended  to  diminish  the  volume  of  the  arm  by  means  of 
scarifications  and  incisions.  Deventer,  with  the  hope  of  causing 
the  fcetus  to  withdraw  the  arm  into  the  uterus,  directed  the  hand  to 
be  pinched  or  pricked  with  a  pin  ;  for  the  same  purpose  ice  was 
employed.  Need  I  tell  you,  also,  that,  ignorant  of  the  principles  on 
which  rests  the  mechanism  of  labor,  the  absurd  and  reckless  prac- 
tice was  maintained  by  some  of  making  tractions  on  the  protruded 
arm,  under  the  conviction  that  the  body  of  the  child  could  thus  be 
delivered ! 


660 


THE  PHINCIPLEd  AND   PRACTICf:  OF  0BSTETR1G& 


Bui  a!l  tlicse  wer^  the  s-  n^  of  meii  wbo  h    '  ^rdS-j 

cicnily  stn«Jiod  in  the  schon!  «  ;  they  neilber  tni  ;  JeJ  < 

her  rt?8our€es  when  midif^turbcd  by  contravoninif  inflncncejs  nor  <lifl 
they  appreciate  the  ability  of  scit^iice  to  aid  her  in  the  moinwil  of 
waut.  No\\%  however,  thronijh  the  ndviinees  whieh  c/lwt*»tric  medi- 
cine hiiji  mndo,  thest*  minNlt^nius  allei-naiivcs  havi-  '  <  idotiril^ 
and  a  more  conservative  and  rationnl  jjraetice  hu  1,  TImi 
protrusion  of  the  arm,  in  a  ehouhler  presentation,  is  no  longvir 
reiyarded  as  necessarily  fsital  to  the  child  ;  and,  under  ordinary  cii*» 
cnmstances,  these  ea^t-ii,  with  a  projier  de<^re<j  of  rare,  caii  Im>^ 
nianairctd  with  siifety  to  both  nuither  and  fa*tU9,  There  an?,  Itow* 
ever,  it  i«  well  to  remember,  certain  conditions  connected  with 
form  of  presentation,  which  will  very  much  enhauee  the  daiigtir  to  | 
the  ciiild,  and  not  nnfretpietitly  involve  the  mother  in  mons  or  IcM  \ 
.  periL  If,  for  exainjile,  uuieh  time  have  ela|»^eil  wtnce  the  cfucsp^tif 
the  lirpior  amnii,  causin^jf  rigidity  of  the  os  uteri,  or  unduo  imiii- 
pulatiouH  have  been  prnctiiied  indneinuT  ^n  intlamed  at£ite  of  llifl 
niRlernai  organs  the  difiiculty  of  terminating  the  delivery  anwl  tiic 
dauL'er  w  ill  be  giratly  increased.* 

Jf^rjtt  Poitidon  of  the  Rhfhi  Should  ft  with  Protrunitm  ^f  cAt 
•4rm. — The  fact  that  the  arm  protrudea  in  a  nhoidder  prt!fiiCTitatioai 
heed  occasion  no  undue  alarm  to  the  practitit>ner,  for  the  drcttm- 
stance  will  neither  necessarily  involve  the  nafeiy  of  the  child,  Dor 
embarrass  the  operation  essential  to  its  delivery.  Indeed,  in  ibett 
case**  the  termination  of  the  labor  by  vernion  in,  all  things  iM^lag 
equal,  accomplished  w  ith  inorts  facility  than  in  head  prenentaiinns, 
for  the  reajHin  that  the  feet,  because  of  their  not  l>eing  i«il dated  so 
higf»  up,  are  more  readily  8eisct»d,  and  there  i»  aUo,  a«  a  g<eorril 
principle,  more  mom  for  the  introduction  of  the  hand.  In  thejkwi  , 
posUton  of  the  right  Mhouhler^  the  pelvis  of  the  fa^tuif  will  In 
toward  the  right  and  more  or  less  toward  tlie  upper  portioti  of  tlit 
titer  us  white  the  head  regards  the  leiY  iliac  fo$^%  l*he  fir*t  itlii^ 
to  be  done  is  to  attach  a  til  let  (which  conBisttii  of  a  ribbon  or  fileoi 
of  Itnen  one  inch  in  widths  and  twelve  inches  in  length)  aroaod  t&i! 
wrist  of  the  protruded  ariiu  The  fillet  should  at  tin*t  bo  cntrfssl«ii 
to  an  a^s^istant,  but  af^er  the  feet  are  brought  down  to  the  ^vnA^ 
the  accoucheur  Hhould  take  charge  of  it,  the  object  of  the  filkt 
being  not  to  prevent  the  accent  of  the  arm  into  the  atema  (wlueli 
will  take  place  a«  the  feet  are  brought  down)  btit  merelj  to  kmf 
the  arm  elongated  on  the  body  during  the  niauipolatioo.    Aa  milie 

*  Tlio  toQg^continiicKl  pressure  of  the  ooutnictiri|f  womb  will  f  ofy  luitumlljr  oooi* 
siuij  M  livid  liue  of  Uic  iirtii.  tuKvther  %\Hh  more  or  lem  iumcftxtiaUt  ifiwia^  r^  m 
lUo  belief  ihnl  Uie  chUii  h  Jemi,  ihm  inducing  ilii«  pmeUtJoDirr  to  a  rriort  ts  hotti^ 
meiits  to  disMXft  the  fa'tuit  for  the  purpose  of  exuactlttg  It  Tlili  wtXl  oftOtinii 
^vi^  %fntii\  i!m>r,  for  ihos»  physicnl  cbuigoB  miy  oeoor  wilbout 
IKOoaimlog  UiC  tifti  of  the  cLdiL 


THE   PRINCIPLES  AND   PRACTICE  OF   OBSTKTKICS, 


561 


mj9 


first  position  of  the  right  shoulder  the  feet  regard  more  or  less  the 
right  portion  of  the  uterus^ 
the  ]et\  hand  should  be  in- 
trodtK-ed,  and  carried  as  far 
as  iht"  lixilla;  it.  shouUi  then 
he  directed  along  the  ante- 
rior giirface  of  the  thild'8 
body,  until  the  teet  are 
reaeheil ;  these  are  to  be 
brought  dovvn  to  the  strait, 
and  I  lie  labor  terniinated  ua 
in  the  second  position  of  the 
feet, 

Seco/td  Position  of  th^ 
Might  Shoidckr  wiih  Protru- 
$tfni  of  tht  Arttu — III  this 
case,  the  fillet  is  to  be  at- 
tiurhcd  as  in  the  first  posi- 
tion ;  the  rit::ht  hand  is  then 
to  be  ill  trod  need  {Mg.  80), 

and  directed  along  the  ante-  ^^^  ^^ 

nor  anrihee  of  the  rhJld  with 

a  view  of  reiifhiiig  the  ftet;  these  are  brought  down  to  the  fitrait 
(Fig.  HI),  and  the  delivery  is 
lerininated  as  in  the  tiist  po- 
Bition  of  the  feet. 

JFVr,9<  Po/titian  of  the  Left 
Sliouldtr  with  Protmsion  of 
the  Arm^ — Here,  the  !eft 
hand  is  to  ho  introduced,  and 
the  same  niks  followed  as  in 
the  second  position  of  the 
right  shoulder,  except  tltat 
the  feet  are  reduced  to  the 
and  instead  of  tfio  tirst 
OBition. 

S^ond  Position  of  the 
Td^t  Shoulder  teith  Pro  frit' 
fion  of  th€  Arm, — ^The  right 
hand  to  be  introdnrcd,  and 
the  same  princijile  pursued  as 
in  the  Hrst  position  of  the  rigb# 
shoulder,  the  feet  being  re* 
duced  to  the  first  position. 

Sjx>ntaneou8  JEvointion^—Uaymg  now  spoken   of  the   general 
prineiples  which  are  to  guide  the  practitioner  in  cases  of  shoulder 

KB 


f 


If  ELT* 


Fio,  Bh 


562 


THE   PRI^^CIPLES   AND   PRACTICE    Of   OBSTETRICS. 


present  .it  ions,  either  with  or  without  firotnision  of  tlje  arm,  it  ii 
proper  llisit  I  Kliould  allude  to  two  other  qric^iions  in  connextoo 
with  thiganl>ject,  viz.  evLfcerafton  in  cases  in  which  version  iufoimii 
impnicticftble,   and   spofitatteQifs   evolufiofi.      Evisceration   of  the 
f(i?tnt^   will  enfi^aj^e  attention   in    a    future  lectnre,    when  irealiti^ 
of  instnimontal  delivery;   on  the   present  occn^ion  I  prnpofo  to 
nmkc  a  few  observations  in  reference  to  the  interesting  point  of 
Fpontaneotta  evolution.    This  term  iinfJies  the  ability  poii^essod  by 
nature  of  eausing  a  voltmtary  ehanjrc  lu  the  position  of  the  fofttisin 
utero,  so  that  a  part  of  the  fcrtal  body  origin  ally  more  or  ies8  remote 
from  the  superior  strait  may  descend  into  the  pelvic  exodTfltion,  and 
be  delivered  without  tlisplaeinsf  that  which  first  presented,     Spon* 
taneous  evolution  is  divided  into  cephalic  m\i[  jKltnc  /  in  the  form^, 
the  head  descends  to  the  superior  strait ;  in  the  latter,  the  pelvis. 
I  niuist  confess*  I  have  never,  in  the  course  of  my  observation^  ttmt 
with  an  iustnnce  of  what  may  be  properly  tei^med  spontaneous  evo 
lution  :  although  I  have  on  more  than  ont}  oe(»asion  heard  medira? 
gentlemen  speak  of  it  as  having  rc[)eatedly  ftlhni  under  their  notict;. 
I  am  inclined  to  tliink,  however,  that  while  they  intended  on  vio- 
lence to  truth,  their  opinion  was  founded  on  u  misapprehemfdon  of 
the  real  position  of  the  fa^tus.     There  can  be  no  doubt  that  thi* 
spontaneous  ehauf^e  will  sometimes  take  place  ;  for  practitioners  of  j 
conscience  and   high   moral    worth   have  testified   to   its   having 
iOeonrred  in  their  practice.     There  is,  however,  a  very  general  oon- 
ourreuce  of  opiniuu  on  one  point,  viz.  its  extreme  rarity.      It  b 
mentioned  by  I)r,  Kit  eke  that  it  wus  observed  oulv  10  timeji  m 
220,000  lubtirs  at  Wurtember^%  while  Drs.  Johnston  and  Sinclairi 
report  its  occurrence  twice  in  13,748  deliveries  in  the  Dublin  Lying* 
in  Hospitnh    In  the  Vienna  Hospital,  under  Dr.  Spaeth^  there  wai 
fcut  *one  instance  o{  spontaneous  pelvic  version  in  12,523  f 

Uibor.     Its  fatality  to  ifn*  child  is  most  fearful  ;  in  thirty  ca 
itionod  by  Denman,  but  one  child  snrvived. 

Some  of  the  older  writers  were  unquestionably  impressed  witkj 
the  idea  of  the  great  mobility  of  the  f<rtus  in  w/^o^and  it  Masaponl 
tliis  conviction,  no  doubt,  that  was  based  the  direction  of  cati»inji 
l!he  pregnant  female  frequently  to  change  her  position,  and,  indced|.i 
to  be  shaken  for  the  purpose  of  overcoming  a  m  alp  resent  a  ticm,  as 
directed  by  Hippocrates  himself.     But  it  is  to  Dr.  Denmai'    '  • 

are  indebted  for  the  first  full  account,  by  the  natural  pow< 
Hystom,  of  what  he  denominated  "  epontaneouis  evolution.''*     in  the 


*  Althougb  It  M  conceded  thnt  Dr,  Denman  wna  tlie  flmt  author  to  diffd  tp 
att4;utioti  to  tbe  6iibj(x:t  of  **8pontuneous  evoluiioo,"  yet  Ibe  possibiUty  of  its  < 
raoev  liitd  been  rveo|piified  previous  to  lils  thiie.     Dr.  Ratusl>ot]iiit|]  bjiji  Aoti 
K«'emrd  soeme  to  have  been  ihe  llrst  who  described  a  GA^te  of  "  spotitanouud  tvoila 
tkm."     It  happened  iti  his  o«'n  wife  s  thtrd  labc^r,  and  f\\e  tind  goue  to  lier  fti!l  I 
Tbe  book  in  which  Ilia  oase  b  mentioned,  a  Tory  aearoe  rimo.,  is  ootilled  JkifWl 


THE   PRINCIPLES   AND   PRACTICE  OF  OBSTETRICS, 


563 


course  of  his  extended  practienl  ohHervation,  he  had  noticed  the 
spontaneous  change  in  tfie  poHJiion  of  the  tbeius  under  a  shoulder 
presenlation,r  but  his  ex]iLaTiation  of  the  phenomenon  has  been  tihowa 
by  Dr.  Douglass  of  Dublin  to  be  erroneous.  Den  man  iuaii>tained 
tliat,  during  the  procL^ss  of  labor,  in  an  interval  of  uterine  repose, 
the  iihoulder  and  arm  receded  vviiliiu  the  cavity  of  the  organ,  and 
were  replaced  by  the  breech  of  the  child,  Douglas^,*  on  the  con- 
trary, dentonstrjited  the  fallacy  of  Denman's  opinion  by  proving  thut 
the  fcetus,  without  any  rece^^sion  of  the  superior  extremity,  descends 
hito  the  pelvis  dovjbled  on  itself,  and  is  then  expelled.  He  showed 
that  the  strong  cont  Tactions  of  tlie  uterus  at  first  press  the  shoulder 
and  chest  into  the  pelvis,  when  the  acromion  process  is  felt  under 
the  syuil>hysis  pubis;  as  the  loins  and  nates  descend  into  the  pelvic 
OJccavaiion,  the  apex  of  the  shoulder  passes  upward  in  tlie  direction 
of  the  mons  veneris,  thus  yielding  more  space  for  the  passage  of 
ihe  breech  iuto  the  cavity  of  the  sacrum ;  in  this  way,  after  sub- 
jecting the  perineum  to  extraordinary  distension,  the  nates  together 
with  the  shoulder  are  expelled.  With  this  explanation,  which  is 
now  generally  admitted,  it  is  evident  that  tlie  shotdder  becomes,  as 
it  were,  fixed  under  the  arch  of  the  pubcs,  this  hitter  being  made  a 
fnlcnini  on  which  the  foetus  revolves.  In  order  that  spontaneous 
evohuion  may  be  accomplislied,  it  is  es^^eiitial  that  either  the  fcetus 
be  relatively  small,  or  ihe  pelvis  more  than  ordinarily  capacious; 
and  it  is  aii  interesting  fact  to  note  that,  in  several  instances  in 
which  this  movement  has  been  cited  by  authors,  the  foetus  had  not 
reached  its  full  time. 

I  cannot  divest  my  mind  of  the  conviction  that  a  too  full  reliance 
on  tfie  ability  of  nature  to  effect  spontaneous  evolution  has  oden- 
tlmes  been  followed  by  bati  results  in  the  lying-in  chamber.  This 
rc-iaace,  in  cases  of  shoulder  presentation,  causes  the  accoucheur 
to  allow  the  proper  time  for  terminating  the  delivery  to  pass,  thus 
subjecting  the  mother  to  tnore  or  less  hazard,  and  the  life  of  the 
child  to  aknost  certain  sacrifice.  While,  therefore,  you  are  to  con- 
cede the  occasional  occurrence  of  the  phenomenon,  yet  my  advice 
to  you  is — nether  to  depend  upon  it  as  an  alternative  m  any  ease  in 
%chit*Ji  it  is  possible  to  tenninate  the  labor  by  the  introduction  of 
the  hand^  but  to  proceed  without  delay  to  briny  down  the  feet  as 

I  already  indicated^  the  instant  the  Jit  opportunity  will  justify  your 
inierferewe.  My  reasons  for  this  advice  are  as  follows:  1.  Spoil* 
taneons  evolution  is  among  the  extremely  rare  occurrences  of  the 
parturient  room,  2.  The  child  is  almost  always  sacrificed.  3.  The 
risk  of  rupture  of  the  uterus  from  the  necessarily  protracted  and 
JHniHffiKa  ITominis  Bndique  AnimaHa  Exi*rtus.     It  was  pnmted  at  Middleburgh  in 

•  An  Ej:phnation  tyf  the  Pmctm  of  the  SpmUanema  EwAtditm  of  iht  ihs^ttf,  e4a 
Bj  John  a  Dougbt^  M.D.,  etc^  Dublin,  Ibll. 


664 


MNCIPLES   AND   PRACTICE   OF 


increased  contractions  of  the  organ.  4.  The  great  dilEciilijr  and 
consequent  danger  of  tertninnting  the  delivery  after  the  sbcMiJd^r 
has  been  pressed  low^  down  into  the  pelvio  cavity,  in  the  eveoi  i»f 
natnre  being  unable  to  accomprish  the  Tiiovement. 

It  njny,  however,  happen  that  you  %vill  not  be  called  to  the  ease 
until  it  is  too  late  to  attempt  the  version  of  the  child,  And  that, 
under  ihase  circumstances,  from  the  length  of  time  which  ham 
elafKsed,  the  shoulder  ia  so  far  forced  into  the  pelvis  as  to  render 
the  eflurl  to  bring  down  the  feet  utterly  impracticable*  What,  iJi 
such  a  contingency,  h  to  be  done?  Here  you  will  be  compelb^d  to 
have  recourse  to  evisceration,  or  to  the  decapitation  of  the  child ; 
of  the  manner  in  winch  these  oporationa  arc  to  be  performed  wo 
shall  speak  under  the  head  of  €t7ibryo(omy.^ 

*  TUe  following  is  iin  mierc«iing  example  orpodalio  vertioa,  Qonneoled  vtlh  ml* 
position  of  the  uterus:  il  sliQUld  more  properly  hsvo  been  introduoed  vrben  lITiuiil 
ing  the  dL*4pbicenienLs  of  the  gnivifl  wornh: 

Slime  years  ait  ice  I  was  n-que^tted  by  Dr  Elwem,  of  tho  UniU^  States  Arm^^  l» 
visit  Mri  B.  «t  Fort  lUrniltoti,  Long  Jdond.  dlaUiDt  Iv^elvc  mU««  fh>cn  tbo  dljf,  I 
wiiM  itirurmed  hy  Drvi  rMrpeiiler  urid  IClwres^  the  former  of  ytYvom  Mir  hrr  •!  |Im 
ooiutJK>»cvnieut  ol  her  ^iokne^  that  »he  hod  been  in  Ubor,  not.  how(«rpr,  ocseoaipi* 
nled  by  very  strong  pain,  for  eight  day  a*  and  thut  the  Uqnor  iiumii  hiid  Ix'^n  piMPff 
frtm»  hf«rj  iu  nmjdl  qviimttiies,  ff>r  the  fuur  dnyw  pn^vioua  to  mj  viaitmg  liwf.  Dr. 
CarpcntiT,  who  wus  the  fniiiity  phrulcinn,  and  who  hud  tittiiiid«d  ht^r  ia  two  limwr 
aeeouchementSr  sintetj  U)»t  he  hnd  lieen  utinble  to  roiK*h  ti»o  motiih  of  iLu  viTiiiti^  and 
ttuil,  from  iho  conimeocement  of  her  Jnlior  op  to  the  pcHod  at  whidi  I  iiniifwl,  lit 
hud  been  completely  foiknl  in  evfTy  nitctupl  to  elfi'Ot  lliit  object  Dr  KIwc*  Wd 
6xperjfnoed  the  same  difllculiy.  At  the  reijtieat  of  thetio  gen[l*^iTHftt^  I  prooccikd  to 
mako  mi  oxomination.  Ou  introducing  my  finger  into  itio  vagina.  I  dtntrf^rfrtd  a 
Urge  resiHliiig  tumor,  which  t  rtHXtgrtised  to  L»e  the  head  of  the  fcrttis,  the  womk 
tatorventng  belwe^o  it  nnd  t!i«  ttugwr.  In  examining  very  caotioi)i  ly  Ure  Bitr6io»  «l 
tlie  tiuniiff  I  was  unable  to  diocover  tlie  o«i  tintic.  It  oocurttcd  to  me  Utat  that  mm 
A  cttao  of  retroversion  of  Uic  neck  of  tlie  womb,  nnd  in  genUy  iUdiiiff  my  fl^ftr 
ttuder  Uie  fcBtal  head,  and  carrying  it  towarrb  the  p<«Mtenor  part  of  lh«  |itivi%  I  fell 

the  Km  tincor^  which  woa  turned  8o  entirely  back  ward  oa  to  r»giird  t!i'^ 't  cf 

the  sucnim.     It  was  now  (|uilc  iippurent  why  Che  labor  luid  lioen  «o  \  atid 

t  wiw  eert^niri  tlial  wiiile  the  iiterun  retained  it«  present  povition,  delir^-nr  w  ariii  |fp 
out  <if  the  quealion.  In  conaequenee  of  tlie  malponiiLmi  of  tba  womb,  tlie  wIjuIv  ^Jtm 
of  the  uterine  ccmtnictioii  wu  directed  iti  sueh  way  as  to  reader  it  pliysuaillj  &mp«t- 
oible  (without  lacemtjoo  of  tliui  vSmub)  At  the  child  to  pani  Livrougli  the  pdvii. 
Thtf  pimiiion  of  the  uteruo,  under  ordinary  circumstancefv  i«  ^Mirallel^  or  neiiHy  lo.  la 
Ibe  nxia  of  the  wperior  stmit^  bo  tlmt  the  whole  force  of  the  contmctdo  rflbrt  btti^f 
directed  flt>m  above  downward^  it  is  evident,  should  them  be  no  Linpedunviit  lu  a 
Mtuml  delivery,  that  the  child  must  be  prfipelh'd  through  the  Qiatonml  p^lri^  fa 
Ihit  ciiae^  liowever,  in  cociieqiieiioe  of  tlic  malpogiLiori  of  Uto  womb^  tbo  loro*  qf  1^ 
oootroelkms  Wi«  cenlned  agftinot  the  poRtenor  wall  of  the  cervix  uteri,  and  tl*e  fokil 
of  rraiatAtiee  w^aa  fotmd  to  be  the  internal  aurnice  of  the  e^icrum.  Thii^  tliCR, 
ificounts  at  once  for  tlie  difficulty  of  the  hilxir,  and  shows  moit  conclusifrly  that  It 
ooutd  (IOC  hav«  bceu  otherwiJie  tbau  prutmctcd*  As  loOQ  oa  I  had  dtacovrrvd  ikm 
ponition  of  the  uterus,  and  thua  owurpd  myaelf  of  the  entire  wn^f*  nf  the  dtla^,  I 
wtilidrew  mj  hand,  and  tnjggesied  to  Drs.  Carpenter  and  £lwi'9>  n^g^^fiSm 

they  botla  coincided,  that^  in  my  upintun,  tliia  caoe  presented  tW'  i«,  lig^i 


LECTURE    XXXVIII. 

Instniinental  Delivery — Instruments  divided  into  Blunt  and  Gutting— Blunt  Infitni- 
menXs— What  are  they?— The  Fillet  and  its  Uses— The  Blunt  Hook  and  Vectia; 
their  Uses-  TIio  Forceps — The  Abuse  of  Instruments  in  Midwifery— Their  too 
General  and  Indiscriminate  Employment — The  Object  of  the  Forceps — The  For- 
eepa  an  Instrument  for  both  Mother  and  Child — Abuse  of  the  Forceps — Case  in 
lUustretion — The  Forceps  a  Precious  Resource  when  employed  with  Judgment — 
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 
£flbrt— To  what  Part  of  the  Child  should  the  Instrument  be  applied? — Tlie 
Advantages  and  Kvils  of  the  Forceps — How  is  the  Head  of  the  Child  to  be 
Grasped  by  the  Instniment? — Modification  of  the  Forceps — Its  Cranial  and  Pelvic 
Ganres — ^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— TIjo  Justification  of  Forceps  Delivery,  a  Question  of  Evidence  to 
be  Determined  by  the  sound  Jud<^raeut  of  the  Accoucheur. 

Gentlemen — "We  shall  now  consider  the  second  branch  of  preter- 
natural labor,  viz.  Instriwtental  Delivery — and  here,  permit  me  to 
•ay,  we  enter  upon  a  most  important  discussion.  The  instrumental 
recognised  in  midwifery  are  embraced  under  two  classes — blunt  and 
cutting  instrumefita.  The  foi-mer  are  applied  to  the  child,  and  do 
not  necessarily  involve  its  fife ;   the  latter  are  used  either  on  the 

lot.  To  rectify,  as  far  as  practicable,  tlio  malposition  of  the  cervix  uteri 

2d.  To  turn  and  deliver  by  the  feet. 

I  thould  have  remarked  tliat  the  mouth  of  the  womb  was  quite  soft  and  dilatable. 
It  will  I  apprehend,  be  unnecessary  for  me  to  enter  into  any  argument  to  show  the 
psramount  necessity  of  tlie  first  indication ;  and  if  it  be  recollected  tliat  the  patient 
was  in  a  state  of  dangerous  exliaustion,  the  propriety  of  the  second  will  be  evident 
But  wliy,  it  may  be  asked,  not  apply  the  forceps  ?  My  answer  to  this  question  shall 
be  brief  The  head  of  the  foetus  was  still  at  the  superior  strait,  and,  without  refer- 
ence to  the  opinions  of  others  on  this  subject,  I  can  aver  for  myself,  that,  where 
immediate  delivery  is  indicated,  I  should  always  prefer  (provided  the  parts  were  in 
a  proper  condition)  turning  by  tlie  feet,  to  the  delay  which  must  necessarily  attend 
deliTery  by  the  forceps  before  the  head  has  '>epun  to  descend  into  the  excavation  of 
the  pelvis.  Tlie  operation  benifr  agreed  upon,  Mrs.  B.  was  placed  on  h^r  back,  with 
her  breech  on  the  edge  of  the  bed,  her  legs  Hexed  on  her  tltighs,  and  her  feet  resting 
oo  the  hands  of  Drs.  0.  and  K.,  who  were  seated  one  on  each  side  of  me.  I  intro- 
duced my  rigiit  hand,  and,  with  the  other  applied  to  the  abdomen,  I  reached  tlie  oe 
tiDore:  I  then  succeeded  in  Axing  my  index  6nger  witliin  the  circle  of  the  anterior 
lip,  whk:h  was  cautiously  brought  toward  the  centre  of  the  pelvic  excavation,  at 
the  same  time  gently  pushing  back  the  fundus  with  the  hand  applied  to  the  alnlo- 
men.  In  this  way  I  succeeded  in  overcoming  the  malposition  of  the  uterus ;  and  in 
ftiUiUing  tlie  second  indication  I  proceeded  as  follows :  Before  determiniDg  on  whksh 


666 


THE   PRINCIPLES  AKB   PRACTICB  OF  OMTrtmCSL 


mother  or  chilch  When  employed  on  the  nioiher,  her  safety  will, 
u»  a  000*^01] ue nee,  be  i^Iai^eil  In  more  or  lc!**i  peril;  and  I  mrcd 
scarcely  remark  that  the  destruction  of  the  child  i«  the  inevitable 
resuh  of  their  U!«e  uf>on  it. 

MioU  IfistmmnUg, — llie^©  «oiiBtiit  of— U  TIio  Fillet;    JT,  The 
Blunt  Hook;  3.  The  Lever  or  Veetis;  4.  The  Forcepa. 

X.  The  i^iY^c^— ThU  is  simply  a  piece  of  ribbcm  or  linens  oat 
inch  in  width  and  twelve  hi  len^h.  It  may  be  applieil  under  Ibe 
folfcvving  eircnmstanees:  (^r)  In  a  breeeh  preaentatton  where*  in  eon* 
aeqnr'nee  either  of  ihe  great  siace  t»r  the  nates  o^  the  undue  »ln|f" 
gittljueHJi  of  the  Inbor,  it  becomes  neeessary  to  aid  nature  j  it  BbouJd 
be  pa!»>^ed  up  wiib  the  linger  tu  the  bend  of  ouq  of  the  thi|rha^  h>  as 
to  encircle  the  groin,  the  two  ends  of  the  fillet  are  then  sei&^'d  by 
ihe  mecotu'heur^  imd,  witli  welUdirtvted  tr.netion,  it  beeome«  a  rc^dy 
tneanci  of  bringing  down  the  bi-eceh*  (h)  In  eases  in  which  cKe 
trunk  i«  expelled,  and  there  is  unu-^ual  de!ay  in  the  det^oent  of  I  be 
shoulders,  the  fillet  heing  placed  under  the  axilla  will  be  of  tmni 
tial  use.  (c)  The  kuees  may  have  descended  into  the  pelvio  luco^ 
vation,  and,  fur  want  of  proper  ntertrie  effort^  rem:iin  tbere^  iboi 
protracting  unnecessarily  the  delivery;  heix?  agnin  the  lillet  carried 
to  the  bend  of  the  knee  l)ecomes  an  intpoit^ant  aid.  (ri)  In  ri^rtiton, 
when  only  one  foot  bus  been  hroitvrhl  down,  the  fillet  may  Ym 
attached  around  the  ankle,  while  the  aceoncheur  *eek»  for  theutlu^r 
foot,     (fl)  In  shoulder  prejientations  with  protrnffion  of  the  arm,  tbe 

iMind  to  ©mploy  In  ord«T  to  eflS?ct  0»e  version.  I  flmt  noqualnt^  tnrielf  with  thr  prw^ 
ei«e  sitiintion  of  the  f^fitiil  ht^wl,  ¥tUwh  I  fintod  to  \yts  pta€>«d  ui  tli^  wcon^  pnaitiw 
of  tlio  viTiex,  the  |)(j«tt<rior  foiitjiiii;i|0  otjrrt'vpniilltiiip  to  tlio  nirtii  »ci't«biilunk  leA 
the  ititvrtor  to  ine  bfk  »»cro-iii»tc  «yiiiphj?»i9:  L«jii9t*t|acDtIy  1  (fitnwiitrnS  lb«  rt|riit 
hiicid  fi»r  till*  purjjofie  of  pvrr<M'niiiitf'  tfie  version,  iti  order  tlutl  ttie  EiAtiimt  curw  aiiirftl 
be  ^ivcn  to  tin?  cliiUf ^  IxhIv.  Tlie  luiri*!  wm  curriiHl  up  to  tli«  imkimI  niBtmcr  wnvi 
Uie  reel  wcru  rcnehixl;  these  W4*ro  gftitly  ^Anfn-d  iitid  bmuitht  tiito  ths 
Tlio  pAticiit,  n%  thipt  limc^,  l^ivivpiii5  iilnrtnin^ly  cxhnuiii^d ;  ehi^  mtliod  under  the  1 
ence  of  n  Hnli*  t>rHiid,y  and  wi4ii»r,  Mud  t  prooeiMled  to  complete  the  delivery 
delnr.  The  diiUl  wun  nJive  and  v'igi>rt>itM,  Mtid  t>i»l1i  |:i«in?nl  nnd  oflkpHs 
ftom  vhi^ir  jiorduus  poflitioiif  mnd  are,  1  believe,  at  tlui«  liuw  hi  Ui«  tc^foifttiMilef  geoi 
hfilth. 

Tb«  aboTc  coi»  b  {at«n«tin|p  «ti  two  accounts.  In  Ih9  flna  ploee,  lint  tbs  cWM 
ihould  not  \mvo  tiei*ii  ftterittoM  bv  tho  pfiVMt  Un^rib  ot  ttiD«  Ur%,  B^  wai  in  Itftior; 
sad,  nrfxmdly,  tlie  possibility  of  mi«ukiog  the  n^trovrnuon  for  nn  ini|i0dbr«lt  cona- 
tion of  the  o«  ttncAK  CMum  nrv  rrcurdi^l  in  which  Ihc  orifloe  of  the  wnmb  wba  ptm* 
pt«leljr  nhUt4*niti^d  In  wonii»n  in  tftbor.  Tjt^ivf^rjiit'M  chph*,  Iu  ihiM  )>«niciihir.  b  inl^ 
r««ttng:  it  in  cit4rd  by  Sabiiuorin  hi»  ''  -  '(>«*mtoira     I^iivrrjttt  not  bttofpabli 

to  delect  the  mouth  of  iho  womb,  di  .  m  n  wotnun  pre^mal  Gar  Um  0I«I 

time,  made  »n  inciniim  ItHo  t1i($  pfiriuiti  t>i  i\w  utrruii  I'timvpundinir  wUh  line  oriAea 
Bl.  Oaulier,  a  Piirimnii  jiurgi-ou,  h^id  a  fiimihir  Cii!«e.  Iu■lJlIU^(»  of  Ui**  nfttno  kind  iN 
likewtBo  qtiottd  by  Ilummnoci  and  others.  Ami  in  oiiotlier  pnrt  of  thia  wnrk  1  wiD 
irive  lh<«  purlicutar^  of  two  v;%Ai»^  in  which,  in  (^imAeqitenco  of  itijfiH«A  inlDded  as 
Uw  o«  tinoHS,  it  bocomo  nccMWMry  for  rir^  ui  Ihe  iltne  of  Ubor,  to  Indss  Iht  4Nifie% 
whioh  nMulbed  favombly  to  botli  mother  uud  dtiUL 


fillet    Blionld   be   plnct'fl   amiiTid   the    wrist,   for   reasons    already 
explaincnj  when  treating  of  thi^  form  of  presentation. 

2.  The  Blunt  Hook, — This  instrument  is  employed  for  most  of 
the  purposes  for  which  tfie  fillet  h  used,  viz.  to  brinsT  down  the 
breevh  or  shoultlers,  rmd  also  to  faeilitate  the  delivery  of  the  knees, 
when  their  stay  in  the  pelvic  cavity  is  protracted.  The  mude  of 
usinr/  the  instrument  h  as  follows :  The  fingers  of  one  hnnd  being 
carefully  carried  to  the  pariieular  part  of  the  fcDtus  on  which  the 
blunt  hook  is  to  be  applied,  the  instrument,  previously  warmed  and 
oiled,  12}  made  gently  to  glide  along  the  hand,  w^hich  acta  as  a  dn^eo 


I 


Fie.  81. 


tor,  and  when  the  point  is  reached,  either  the  bend  of  the  thigh. 
(Fig.  82),  the  knee,  or  axilla,  as  t!«e  eui^e  may  be,  the  hooked  extre- 
*"  *f  the  instrument  is  to  be  cantiously  applied  to  eitljer  of  the 


668 


THE  PRINCIPLES  AND   PRACTICE  OF  OBSTETRfCB. 


purls,  and  tlieu  ilownwanl  traetton  exercised,  In  thii*  way;  tlwi 
Iceius  will  be  brought  down  witbout  injury  to  it  or  the  parent,  nnd 
the  delivery  promptly  terminated.  An  soon  as  the  part  rt'iieliei 
the  vidva,  the  instrument  &hoiiVd  be  withdrawn,  and  the  deliveryt 
if  nece^i^tiry,  terminate<l  by  the  hand. 

3,  l^he  I^ectr  or  Victim. — Thii*  instrument  Ua»  heeu  varioorif 
estimated  by  dittVrent  writers  on  midwifery;  some  claiming  far  il 
merits  of  a  high  order,  while  others  repudiate  its  use  akogethsr. 
It  has  been  nrg*.'d  that  the  lever  can  oftentimes  become  a  sub^titQtt 
for  the  forcfpH,  ituksnuich  as  it  may  be  made  an  instrument  nf  tJ-ac- 
lion.  It  dues  seem  to  me,  however,  that  under  no  circnmRlam-es 
should  it  be  resorted  to  as  a  tractor;  the  only  purpose  to  which  U 
can  be  legitimately  applied  is  to  correct  peculiar  malpositions  of  tf)t 
head.  For  example,  when  l!ie  ocriput  is  extended  b:i«  '  -  the 
lever  will   prove,   in  dexlerotus  hands,  an   impi»rtant    •  ;   in 

chan<xing  the  position  to  one  of  the  vertex*  Or,  in  ease  the  bead 
should  fail  to  rotate  in  the  pelvic  cavity,  and  the  hand  be  inade- 
quate to  accompIi.sh  the  movement,  the  veetin  may  bo  employod 
witii  good  eifect* 

Coutra»t  l^tmern  the  F*m^tp«  and  Lever,— \  do  not  flcroi  it 
necessary  to  institute  any  sf>eeiia]  contrast  between  the  eomporaUvt 
advatitages  of  the  forceps  and  lever,  m  some  actthors  have  done; 
for,  contrary  to  the  ojiinion  muintained  by  them,  among  whom  tntiy 
be  lueJiiinniHl  Bland,  Lowdcr,  Denniijon,  and  others,  I  bold  that  no 
compMrison  can  be  justly  made,  for  the  reason  that,  in  tfieir  opt*ra. 
tion,  they  are  entirely  different  instraments  — the  one  being  a  Irao* 
toi%  the  other  a  corrector  of  malpositions.  Whatever  may  be  mii 
in  refererKte  to  the  frequent  necessity  for  the  employment  of  the 
lever,  I  will  merely  state  to  yon  that,  in  the  Dublin  Lying4n  llcis* 
pital,  during  the  m:istership  of  Dr.  Collins,  in  sixteen  thcm^^and 
four  himdied  and  fourteen  deliveries,  the  lever  was  mued  but  three 
times;  and  in  the  n^ame  institution,  during  the  maHtership  of  I>r. 
8hcklcton,  as  reported  by  Drs*  Sinclair  and  Johnston,  in  thirteen 
thousand  seven  hundred  and  forty-eight  deliveries,  the  letet  wu 
resoited  to  but  once! 

Hfiw^  strangely  do  these  statistics  compare  with  what  we  are  te 
much  in  the  habit  of  hearing,  in  these  latter  days,  of  what  ooeom 
in  the  private  pnictict*  of  certain  medical  gentlemen,  w^ho  speak  of 
their  almost  daily  use  of  the  vcctis,  forcep,  or  en>tchet,  pritcisrlf 
as  if  a  man's  &kill  in  the  lying-in  room  U  to  be  measured  by  tl^e  fre* 
quency  with  whicli  ho  resorts  to  instruments!  1  believe  in  the 
converse  of  this  projmsition  ;  to  my  mind,  the  truly  skilfid  aeeouehear 
rarefy  (comparatively,  at  least)  employs  instrum<*nis  f<>rthc*»bviottf 
reiison,  that,  in  the  lii^  phu^,  he  is  thoroughly  imbued  with  a  kntiw* 
ledge  of  the  laws  by  which  nature  is  regulated  in  the  parturttal 
effort;  and^  se^xmdly,  he  is  cogtiixunt  tliat,  whvn  not  iuteffered 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  969 

with  by  officious  meddling,  this  8iim3  nature  is  generally  adequate 
to  the  proper  accomplishment  of  her  work. 

4.  The  Forceps. — I  shall  not  occupy  your  time  with  the  early 
history  of  this  instrument,  nor  with  the  various  modifications  it  has 
undergone  from  its  first  introduction  to  the  attention  of  the  profes- 
sion. Suffice  it  to  say  that  the  obstetric  arsenal,  so  far  as  the  num- 
ber and  kind  of  forceps  are  concerned,  is  not  only  a  vast  armory, 
but  has  really  become  an  institution  in  itself;  and,  indeed,  it  may 
be  asked,  with  some  degree  of  propriety,  whether  the  interests  of 
humanity  would  not  have  been  more  wisely  served  if  some  of  the 
time  employed  in  the  construction  and  modification  of  this  instru- 
ment had  been  given  to  the  proper  consideration  of  the  more 
important  question —  Under  what  circumstances  and  in  what  man- 
ner is  the  Forceps  to  be  Employed  t  If  this  question,  I  repeat,  had 
received  more  mature  deliberation,  we  should  have  been  spared  the 
numerous  appalling  examples  of  injury  and  death  consequent  upon 
the  unbounded  love,  which  some  practitioners  have  for  instrumental 
delivery.  It  is  time  that  [)lain  language  should  be  spoken  on  this 
subject ;  the  spirit  of  conservative  midwifery  seems  to  have  been 
lost  in  sleep;  the  ordinances  of  nature  have  been  disregarded, 
and  the  accoucheur,  with  instrument  in  hand,  rampant  in  hb 
desire  for  opportunity,  rushes  with  good  heart  and  unmeasured 
confidence  to  what  he  deems  the  scene  of  conquest ;  but  too  oflen, 
alas!  it  proves  a  scene  of  harrowing  agony  to  the  unhappy  pa- 
tient. 

One  would  almost  think  that  nature  had  become  emasculated  of 
her  power,  and  that  what  were  once  considered  her  own  admirable 
laws  had  been  so  changed,  and  she  so  utterly  deprived  of  resources, 
as  to  render  parturition  no  longer  an  act  of  hers — to  be  a(;com- 
pllshed  in  her  own  inimitable  way,  and  by  her  own  consummate 
ordinances — but  an  act  to  be  carried  out  according  to  the  peculiar 
caprices  of  the  accoucheur.  Nature,  gentlemen,  is  always  the 
same  so  far  as  her  own  fundamental  laws  give  her  an  identity ;  she 
is  now  in  this  particular  what  she  was  at  the- commencement  of  the 
world,  whether  as  represented  in  the  human  family,  in  the  animated 
tribes,  or  in  the  vegetable  kingdom.  I  claim  for  her  perfection  of 
dei'ign  and  unequalled  skill  in  the  display  of  her  own  efforts,  when 
not  contravened  either  by  morbid  influences,  or  the  officiousness  of 
man.  It  must,  however,  be  conceded  that  she  sometimes  needs 
assistance,  but  that  assistance,  in  order  that  it  may  be  serviceable, 
should  be  both  justifiable  and  opfiortune. 

Motives  on  which  Forceps  Delivery  should  he  Based. — In  the 
use  of  the  forceps,  I  cannot  too  emphatically  impress  upon  your 
recollection  the  necessity  of  keeping  constantly  in  view  two  cardinal 
principles:  1.  A  moral  justification  for  its  employment :  2.  Such 
a  use  of  it  as  shaU  secure^  as  far  as  may  he^  the  maximum  of  good 


670         THE  PBmCITLES  AKI>  PRACTICB  Of  QBSrnmclCSBw 

vi:  to  both  mfMer  and  rIdUlJ*      With  ibcMs  mn^ 

gu  the  accouchfjnr,  in  the  rotrofipoct  of  hw  pr^feafti  i 

will  find  nnthing  t'ur  8<>lf'^i^Uuki\  but  much  for  con^rnuoUitiijn  in  the 
cofivtction  tliat,  in  this  jmrticular,  he  ha*  faithfully  dijichargtMl  \m 
duty  to  those  h  ho,  in  the  hour  of  tnbuluti^m,  looked  to  hlro  iot  \ 
iMfltOfiee.  You,  who  havtt  attended  the  obfitfftrio  diaict  wbcftt 
you  enjoy  such  nbundunt  oppart unity  of  wiiucfwing  every  variety  j 
of  dirtea«e  incident  to  womi^n  and  children,  havo  on  mwr^  tltfici  out 
OOOMion  had  arrayed  before  you  ini^tances  of  Uio  fearful  resitlu 
flriaing  from  the  tinrii^cessary  usu  of  in!«tnimeut6;  lUk)  %rltit  iht 
hope  of  irnprrsMtig  you  by  exaiiipk*  an  wi4l  iiji  by  U'ord!^  I  sbaD 
take  tfto  liberty  of  refrei^hin^  your  recollection  with  a  brief  ALii«tricl 
in  referenee  to  the  melancholy  ease  of  a  married  nouinn,  who  in» 
brouc/ht  before  you  not  a  long  time  since,  in  whom  thit  ^pk 

plfit  oi^rlnsion  of  i/m  ftitatua  urlmirius^  with  jntrtiui  "  .;  ^ 

ih^  walli  of  the  ftpper  fourth  of  t/te  vaguui^  together  with  n  v^wiety 
vaghtai  fintHhv,^  produeed  hy  forceps  d^liven/.  The  fi^Uoiiiiij;  it 
the  ca'^e^  as  reported  in  my  woik  on  the  Di:»e:L!»et  of  \Vcftd«*n  and 
Children:! 

]Mr^,  11.,  aged  22  years,  mariried,  complains  of  inabilitj  tu  pern 
ber  water  in  the  natural  way,  and  nays  i(  runs  from  her  nearly  all 
the  time  through  the  front  p:yisajje.  **  llow  lo:ig,  mjiilara«  tiavi 
yon  bet*ri  marrie J  ?"  '^'^Just  twenty-six  months  ^i^■.*'  **  \Veif»  jim 
a  healthy  woman  bi'fore  your  muriajre  ?*'  ^  Ve*w  *»ir ;  I  msrrr  ItaJ 
a  tlay*ji  iiicknesis  thank  God  !**  "  You  have  had  a  child,  have  yo«l 
not?"  "*YeH»  air.^»  '*When  wa»  it  boni?'»  **Fit\eea  mciciilfei 
R^i,  sir/'  ''^llow  \nnrr  were  you  in  Iwbor?*^  ^*Three  diiya,  ait.*' 
"  Wan  your  labor  s*evere  ?"  **  No,  »ir,  but  it  wa*  liu;xering,''  **  IJail 
you  |iny  one  in  attcnul  you?'*  "Yes  sir,  there  were  two  dort<jf« 
with  me.*'     "Was  your  child  born  alive?"     "(ihl  no,  «!• ;  the 

*  Vrut  llotjri  *iiYn:  "Tlie  furtxp^  in  ihevhM'n  inMtfiitTHiii  I  tlitnk  tlie  rc^mcvt 
Profftiur  lit  ttij»p<>wd,  m  tliw  muxitii,  to  curuiil  the  fiilvariLri|CM  of  the  fitn^-i**  iti  • 
xnstiuer  not  et»<lrinMMl  by  llio  experience  of  ih<?  lyin};<iti  room.     S--  « 

0rom  circuiiimTibtng  \u  Wn^rtrA  to  lUe  in»rv  wif^fty  itf  t\w  Itifunt,  I  ttti^  »!• 

fbrrepn  u  an  injtirufncnt  far  both  ta&thsramd  tkOit  mid  iliCmt  ftmu^  orr/ii^^  .'  .uimmd 
mUff  mhrn^  IhrtniQh  opportune  app(kako%  U  tmtMm  tibe  dUMMiaAfir  to  mwb  tkt  itmm  ^ 
ftpii  p  *fmt  nnti  tiff'prtnrj, 

f  The'  emplii/mutit  of  the  fofc^iM  mfk\%  without  a  due  degree  of  v%r%  |Hr«  tlitl^ 
Te«ico  or  tiri'thnt-va^nml  fl!*tubia  for  tho  reaw>n  tlint  fotnctjinei  g:»vti  «0bn  «0  1^ 
niNHlefi  III  tm%*v  thtf  tipiiif  to  (t>-9Ct*tH!»  h^hx^  obRtnicUHJ  hi  itn  p«ampi  hj  the  avtMter 
waU  of  tUtv  iHitvU;  tltifl  <^JT(»rt  ncoeiuaril/  fUlb  mtjrti  or  l^nt  uii  tiia  bljhdd#rMd 
urrtTirt  pri>^!nrln;'.  tT  n^t  tl<<tiiloui  opeiiiiipt.  Uioootiaeuco  of  oniw  ttKxm  p«f^jrtlt 
of  r  -  il«9rnn|<viri4fubt,     Htill,  it  in  w<?il  tr*  r^e^uIliM  UtKl  llieiB  f«ry 

dull  Iroiu  Uj<>  Inn)^  del^r  in  n  tvatirt  tu  th<)  Ctimp\  and  «ii|' 

then  be  ti^rly  chiinrcablt?  to  lon^f-contiiJUpU  pressure  on  the  portly  termliMtjC^  m 
iiifl^intininim  nnd  uki^mitan.  From  ili(*«i*  iMttrf  ruuAes  will  nomHiniM  arl>#  ft  f*4to> 
rmKiiml  t!jiti4lii.  itioni  AvquetiUj,  t  thtiik,  thuii  from  tlie  um  of  tk*  laMntnoiL 


THE  PRINCIPLES  AND  PBACTICE  OF  OBSTETRICS.         571 

poor  little  thing  was  all  bruised,  and  its  head  was  a  good  deal 
injured."  "Why  so,  madam?"  "The  doctors  did  it,  sir,  with 
the  instrument."  "  Then,  you  were  delivered  with  instruments, 
were  you  ?"  *'  Yes,  sir,  indeed  I  was,  and  a  poor  sufferer  have  I 
been  ever  since !"  "  No  matter,  my  good  woman,  do  not  deplore 
the  past ;  you  have  been  cruelly  wronged,  but  we  will  endeavor  to 
do  something  for  you ;  at  all  events,  we  will  make  you  more  com- 
fortable." "  Thank  you,  sir."  "  Before  your  delivery,  had  you 
any  trouble  with  your  water  ?"  "  None  in  the  world,  sir."  "  How 
long  after  the  birth  of  your  child  did  you  experience  trouble  in 
this  way  ?''  "  Since  the  birth  of  my  child,  sir,  my  water  has  always 
troubled  me.  It  runs  from  mc,  and  1  cannot  help  it !"  "  Did  you 
call  the  attention  of  the  doctors  to  thiji  circumstance  ?"  "  No,  sir, 
for  they  never  came  near  me  after  I  was  delivered."  "Then, 
madam,  they  did  not  do  their  duty."  "  Indeed,  they  did  not,  sir.'* 
"  How  long  was  it  after  the  birth  of  your  child  that  you  left  your 
bed  ?"  "1  could  not  go  about,  sir,  for  nearly  six  months."  •"  Have 
you  had  your  courses  since  your  confinement  ?"  "  Only  once,  sir, 
about  two  months  ago,  and  I  thought  I  would  have  died  from  the 
forcing  pain  I  had."  "  Did  the  usual  (quantity  pass  from  you  ?'* 
"  No,  sir,  very  little,  indeed." 

This  cjiae,  gentlemen,  exhibits  another  of  the  many  instances  of 
professional  cruelty  more  or  less  frequently  occurring  in  this  popu- 
lous city;  and  it  is,  indeed,  needful  that  something  should  be  done 
to  arrest  the  reckless  temeiity  of  men  calling  themselves  physi- 
cians, who,  if  we  are  to  judge  them  by  their  acts,  place  a  very 
insignificant  estimate  on  human  life.  But  the  melancholy  feature 
of  the  whole  business  is,  that  these  assaults  on  health  and  life  are 
made  under  the  protection  of  a  diploma,  and,  therefore,  are  per- 
fectly within  the  record  I  No !  a  diploma,  though  it  may  serve 
the  purposes  of  the  holder,  is  insufficient  to  justify  the  moral  wrong 
of  the  sufferings,  the  details  of  which  have  just  been  narrated.  A 
diploma  without  knowledge  is  a  curse  to  its  possessor,  and  a  fearful 
instrument  of  destruction  to  the  comrannity.  With  knowledge, 
too,  must  be  conjoined  a  refined  morality  based  upon  that  Christian 
principle — "  Do  unto  others  as  you  would  wish  others  do  unto  you  /" 

This  poor  woman,  whose  health  was  her  only  capital,  whose 
daily  bread  was  the  product  of  her  daily  labor,  has  become  involved, 
either  through  ignorance  or  unpardonable  carelessness,  in  a  compli- 
cation of  maladies  which,  even  if  measurably  relieved,  will  cause 
her  more  or  less  di'^tress  during  her  entire  existence.  The  first 
question,  which  naturally  presents  itself  to  the  mind  in  viewing  the 
serious  afflictions  of  the  patient,  is  this :  What  has  produced  this 
Btate  of  tilings,  and  could  it  by  a  proper  exerdse  of  judgment  have 
been  avoided  ?  She  was  delivered  with  instruments,  and  to  their 
unskilful  and  unnecessary  employment  are  to  be  referred  all  hei 


672 


THK   PRINCIPLES   \SD   PRACTICK  OF  OB3TKTRICa 


present  iliflicukies*  Th<»rc  i»  no  evitlcncc  before  tia  thui  the  u-mj  ol 
instriinK*ut!§  wti'i  nl  nil  iridieateiL  Tlie  patient  oluwneil  that  **  li^r 
lubor  wa«  not  severe,**  it  was  "  only  lingering/'  Sh<?»  thtm^  ham 
^Deu  a  vtL'ilm  to  thiit  ^Miot  hasto,*'  which  nnfortnnately  too  often 
prevails  in  the  l\ in^-in  chamber,  or  to  tlml  undying  fuuitnt^MA,  H'tttdi 
Home  men  cherish  fur  operjilh'c  miihvifery.  Let  ihi»  cawj  W  a 
lesdon  to  you ;  think  of  it  In  your  hours  of  meditation^  aad  ma^  il 
prove  »  shield  to  ihoae  who  conBde  their  lives  to  yotir  euntody,  bi 
the  eye  of  Heaven,  murder  lose**  nothing  of  its  atrot-ity  becauM 
conee^iled  from  the  ken  of  human  observation ;  9o  it  is  wtlli  tlie 
dark  deeds  of  our  profession.  The  diploma  may  afford  a  nianite, 
8o  fnr  a>>  earthly  juriHiHetion  i-^  eoneerned,  Imt  the  time  of  reckofting 
will  come  with  aj>pa!lln;^  ret  ri  bin  ion  I 

You  iivQ^  however,  gentlemen,  not  to  misunderstand  me ;  I  i3i»- 
demn  only  the  abuse  of  the  foreeps^  and  desire  to  admonish  yott 
that  while  in  it  you  have,  wlien  projHTly  employeil,  a  meant  nf 
accomjjli*^hing  great  good,  yet,  in  reekle«»  and  unskilful  bamU»  il 
i2&  indeed  an  instrument  of  fearful  clestrnetifm.  On  the  one  haiid, 
it  will  enable  you  to  save  the  lives  of  both  mother  and  child,  ami 
rescue  them  from  the  dread  conj«equenee«  of  embryotomy.  On  iha 
Other,  it  will  oftentimen  lead  to  the  death  of  parent  and  o^pnin* ; 
or  if,  perad venture,  the  f<n-mer  should  survive,  she  will  love  etitailrd 
upon  her  troubles  to  which  death  ilsielf  is  fretjuenily  preferaUe— 
such,  for  instance,  m  vesieo  vaginal,  urethro-^aginal,  n'Cio-Tiigi»al 
fi8tula>4,  rupture  of  the  uleruM,  and  other  lacerations  of  the  soft 
part*<,  otlen  the  md  consequences  in  the  praetice  of  thiiae  geittVs 
men,  who  are  in  the  habit  of  reporting  to  ins^trumental  delivery 
without  cause  or  juslifiealicm. 

Prior  to  the  introduction  of  the  foreejts  in  operative  midwifery 
it  was  the  u^ual  praetiee,  in  all  ease**  of  difficult  parturiticm  ia 
which  the  hand  was  umdile  to  overcome  the  olwtacle,  to  deMroy 
the  child  atid  bring  it  away  piecemeal  by  means  of  hoak^  etc 
There  lore,  white  I  most  cordially  admit  that  I  regard  the  forecfit, 
nnder  proper  employmetit,  as  one  ot*  the  undonbted  boons,  vhidi 
ficlenee  has  placed  wiihiu  the  reach  of  the  eonseientious  and  akQriil 
accoucheur,  yet  it  would  be  an  interesting  iriquiry — if  the  stattftid 
could  1*0  fairly  gathered— whether,  in  consequence  of  its  reekltia 
use,  the  good  derived  from  the  employment  of  tht«  instiatsneat  liM 
not  been  more  than  counterbalanced  by  the  evil  it  has  inflicted.  Il 
is  a  ma^lm  of  the  assassin  that  **  dead  men  teU  no  (uUm  ;*^  is  it  nol 
equally  true  that  tho<ic  pr;ictitiouers,  who  destroy  their  patieota  by 
tlie  rude  and  unjustitiable  use  of  instruments,  are  very  maoli  dia- ' 
pos^*d  to  allow  their  deeds  of  blood  to  accompany  their  vtettms  to 
the  grave,  where,  mnid  the  silence  of  death,  they  may  find  »beh«r 
from  the  public  gaze!  Hence,  the  true  diflicidty  of  arriving  at 
reliable  htatijstic^  on  thij»  point* 


THE    PBINCIPLES  AND   PRACTICE   OP  OBSTETRICS, 


57? 


I  trnst  I  may  be  pardoned  for  the  plain  and  eniphatic  manner  in 
whicfi  I  write  on  this  important  question  j  but  I  feel  tliat  I  have  a 
sacred  duly  to  discharge  to  you,  and  also  to  those,  who,  after  you 
shall  have  left  thin  University,  will  look  to  you  for  counsel  and  aid 
in  the  lime  of  their  anguish.  But  a  short  while  since,  at  tlie  request 
of  one  of  those  truly  iz^ood  women,  *^a  sifter  nf  mercy /^  I  visited 
iti  a  miserable  hov*?l  a  poor  creatnre,  who  liad  been  attended  in  her 
confinement  by  a  medical  man,  who  futmd  it  neeessary  to  call  to 
\m  aid  two  of  his  professiona!  friiMids.  The  woman  had  been  in 
labor  only  six  hours,  when  it  was  deemed  nect^sary  to  resort  to 
the  forceps ;  she  was  delivered  of  a  dead  child  with  the  right 
OS  parkiaie  crushed,  and  the  correspon<ling  eye  forced  out  of 
the  socket !  The  unhappy  mother  ha*!  only  been  delivered  four 
hours  when  T  saw  her;  she  was  at  that  time  votnitmg,  her  face  pale 
and  ha^j^gard,  with  a  pulse  extremely  rapid.  I  requested  the  physi- 
cians to  be  sent  for,  but  they  could  not  be  found!  On  an  examiua- 
tion,  I  detected  a  rupture  of  the  neck  of  the  uterus,*  and  th?  poor 
creature  was  soon  released  from  her  aulferiuifs,  having  expired  jnat 
fourteen  honrs  from  the  time  her  labor  commenced  \\     What  better 

♦  I  may  refer  tlio  render  to  the  pri/o  essay  on  liupture  of  Vie  Womb,  by  Prof. 
Jamoft  D.  Traak,  M  D..  for  some  extrtraely  interesting  tucix  flw  moaoj^rnpti  la  the 
moat  complete  w©  have  on  the  subject.  l!ig  observatioua  are  bused  on  over  four 
hundreii  cuses,  which  he  has  variously  ctjllocted.  Tlie  paper  will  be  fourid  in  Ih© 
Americun  Journal  of  Medical  Science  for  January  and  April,  1848.  The  following 
extnict  touching  ilie  results  of  treiitment  in  Lliia  formidable  complication  will  be  reikd 
with  interest: 

We  fonnorty  ^howedl  that  the  average  dtiration  of  life,  aft^r  nipturei  with  lUoM 
delitTTcd^  wa.i  fwfmt^ufo  hours;  and  tlmt  of  the  unddivcrtd^  but  nine  lioura.  By 
adding  to  thoao  the  new  cascn,  we  find  thiit,  of  those  tL^livered^  fi/fy/QUr  per  ocnt. 
surrivud  beyond  twenitj-four  hours  -  while  of  thcwe  dying  undeltvvredt  tufenty  wven 
per  cenL  survived  beyond  the  same  period. 

Bitatwe  tucce»i  of  different  modet  of  Tteatmcnt  wftea  the  Head  and  the  wkoU  (ir  pari 

of  the  Body  has  craped  into  the  Poritoneal  Cavity. 

BUMMARY   OP  ALL  TBK  CASES, 

Gastrotomy  saved,   16,  loat^    4,  or 'iO    per  cent,  lost. 
Turning,  Jtc      ''      23,     "     50,  or  68.5         " 
Abandoned        "      16,     "     44,  or  75  •*  •» 

BMwe  aucuaa  of  diff^ent  modes  of  IVeatment  ichen  the  Pdvin  is  OoiUraded, 

fiUMMAar  OP   ALL   THE   CASKS. 

Gastrotomy  saved  i\  lost    3,  or    33  per  cent,  lost 

Perforation^  Ac.  saved  15,    **    30,  or    66         '*         *♦ 
Abandoned  "        0,    *'    11,  orlOO         "        " 

Adding^  tof^ther  these  two  daaaea,  we  get,  as  the  oomparatiTe  results  of  tha 
different  modes  of  Irealment— 

Gastrotoray  saved  22,  loHt    7,  or  24  per  cent  lost 

Turning,  perforation,  4<?,  saved  38,     *'    80,  or  tt8         "         " 
Abandoned  "       15.     "    05,  or  78         "         " 

f  This  woman  had  previously  borne  two  living  children  at  full  term;  her  parti 
were  normal,  and  her  mangled  child  preaenteii  the  ordinary  proportions ;  and  yet, 
■  a  labor  of  six  hours,  the  forceps  was  deemed  the  sheet-anchor  of  hope  1 


674 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSfSTRICB^ 


comment,  gentlemen,  can  I  m:ike  on  conduct  like  thin,  thnn  §ifB|ily 
cite  it  jisnn  a^lmonition  when  yon  sball  liave  entered  on  lite  missiefi 
of  pr.'jrtieal  iUitv,  and  become  renponsible  not  only  for  yoor  own 
reputations,  but  for  the  lives  of  your  pntients,  who  tnjiy  confide 
Ijoth  in  your  honor  nnd  akilL  I  will  not  weary  you  wiih  the  tiairs* 
tion  of  kindred  (»xamplcs  of  cnicHy,  wliich  I  have  w^iltieiised — Ibir 
the  heart  sickens,  and  the  mind  grows  restive  under  the  oontmnpl** 
tioM  of  such  deeds  of  initpiity. 

A  disliJiguished  profeHsional  friend  fron\  the  West,  ia  spctiiktfig 
of  the  monomnnia^  which  sometimeg  spreads  amonjf  medical  men  in 
reference  to  certain  pemlinrities  of  practice,  toM  me  that  -\m 

KhiCL*  rhei-e  prevailed  in  the  valley  of  the  Mississi[j|n  un  uni- 

veTHal  li^liefthat  cri/A/rr/iV*  constituted  the  great  remedy  for  the  mipc 
of  disease ;  in  accordance  with  thin  icjeneral  conviction,  a  dtictorwM 
ID  the  iiahit  of  placing  himself  on  the  hank  of  the  river,  and  m  tbt 
people |>ass(*d  by,  tfiey  weresnhitc<l  with  these  words  **  H  '^ar 

bowels  to-day*'"^     Indeed,  I  am  n<it  ao  confident  that  wr  14  a 

fn</ftom/mia  of  a  dittcrent  nort  among  us  here;  and  it  would  tMilw 
utrancfe  if  the  gravid  female  paR<H>ri*djy  should  one  of  ihe»e  dnyt  be 
greet  c<l  thus:  "Safe  delivery  in  soured  by  instrument*  I'^ 

Stf I ( Ut  ic8  of  I*htccps  Dt  It  V ert/ —  Pr^q uni  ey, — D  r .  Ch  n  i  t  et 

thefollovvini:  delaih:  Among  British  praciiiioiverH.  51M  !  ,ho» 

iu  167,648  laboi-H,  or  about  I  in  249. 

In  France,  330  forceps  rases  in  47,475  hilMns,  i>r   UMin  1  m  no. 

In  Germany,  7074  forceps  cases  in  756,50:^  hiburs  •^r  about  1  ta 
lOOJ, 

Taking  the  ajrgregate  of  these  cases,  the  forceps  wai  employed 
8007  times  in  850,713  eases,  or  Jibout  I  in  106 J. 

Morfalitf/  to  the  Mother, — A»  far  as  could  be  ascertained,  \n  %l% 
forceps  ilcliverics,  among  Britisli  practitioners,  .38  raothens  wcirv 
lottt^  or  1  in  21  J.  An)ong  the  French  and  Germaiiis  in  4911  caiwy 
142  mothers  were  lost,  or  about  1  in  34. 

Mortality  to  the  ChihL— In  Great  Britain,  in  004  Cfttea,  HI 
children  were  lost,  or  about  I  in  5  ;  iind  according  to  the  st^liKtiei 
gup|ilied  by  the  Continent  of  Europe  858  children  were  lo«t  in  5031 
cases,  or  about  1  in  5j. 

The  total  result  is  that,  in  5753  forceps  cases,  180  mothers  were 
lost,  or  about  1  in  32  ;  and  in  5731  cases,  98  children  were  bom  diAd, 
ur  abf»ut  1  in  5;  now,  if  we  turn  from  the  hirger  aggregat^^  a» 
fiirtii'^hed  by  Dr.  Churchill,  to  other  sources  confined  more  to  Indl 
vidua]  practice,  we  shail  have  very  different  results. 

In  the  Edinburijh  Maternity  Hospital,  there  were  1475  \i.  r^^ 
delivered  under  the  superintendence  of  the  Innlitution  |  amou|; 
tbeflc  were  58  luiscarriages  or  premature  labors,  being  1417  bbort 


*  Cburobill*!  MidwiCtry,  fourth  Lotuloii  Bditkin,  p.  MA. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         676 

at  full  term  ;  in  these  1417  cases  the  forceps  were  applied  3  times 
or  1  in  472.  Among  the  1475  women  delivered  under  the  superin- 
tendence of  the  hospital  (374  were  delivered  at  the  hospital,  and 
1101  at  their  own  homes),  there  were  11  deaths,  or  1  in  134.* 

In  the  Royal  Maternity  Charity  of  London,  Eastern  Division, 
nnderthe  supervi^iion  of  Dr.  Barnes,f  in  2416  deliveries  at  the  homes 
of  the  patients,  the  forceps  was  resorted  to  6  times,  or  1  in  401 ; 
deaths  7,  or  1  in  345. 

In  the  same  Institution,  Western  District,  under  the  charge  of 
Dr.  J.  Hall  Davis,  in  7371  deliveries  at  the  houses  of  the  patients, 
the  forceps  was  applied  6  times,  or  1  in  1220;  deaths  16,  or  1  in 
466.375.1 

It  is,  I  am  sure,  quite  unnecessary  to  refer  to  additional  statistics 
in  proof  of  what  I  am  anxious  to  demonstrate,  viz.  that  the  records 
of  private  practice  among  medical  men  of  judgment  and  skill 
exhibit  very  different  results,  both  in  the  frequency  and  mortality 
of  forceps  delivery,  from  those  presented  by  the  mixed  statistics  of 
hospital  and  out-door  deliveries. 

What  is  the  Tnie  Power  of  the  Forceps  f — Accoucheurs  are 
divided  in  sentiment  on  this  subject;  some  maintaining  that  it 
acts  principally  as  a  compressor,  diminishing  the  volume  of  the  head, 
and  in  this  way  facilitating  its  passage  into  the  world.  That  the 
forceps,  under  certain  conditions,  is  capable  of  diminishing  the 
transverse  diameter  of  the  foetal  skull,  is  a  question  about  which 
there  can  be  no  doubt ;  but  this  diminution  is  only  relative,  and 
cannot,  I  think,  exceed  more  than  three  or  four  lines  without  seri- 
oasly  compromising  the  life  of  the  child  ;§  so  that,  it  must  be  remem- 
bered that  the  forceps  as  a  mere  cowjW6^«or  becomes  deprived  of  much 
of  its  value  as  an  instrument  intended,  under  ordinary  circumstances, 
and  with  judicious  application,  to  save  the  lives  of  both  parent  and 
offspring.  Again :  the  great  majority  of  cases  in  which  the  use  of  the 
forceps  is  indicated  will  be  those  in  which  no  compression  is  needed,  as 
we  shall  more  particularly  mention  when  speaking  of  the  indications 
for  forceps  delivery.  Therefore,  I  think  it  right  that  we  should  refer 
the  true  excellence  of  the  instrument  to  its  extractive  properties. 

*  Simpson's  Obstetric  Memoirs,  vol  I,  p.  854. 

f  Dublin  Quarterly  Jour.  Med.,  Aug.  1859,  p.  99. 

X  Difficult  Parturition,  by  J.  Hall  Davis,  1858,  p.  272. 

§  When  describing  tlie  foetal  head,  I  told  you  that,  in  consequence  of  the  overlap- 
ping of  the  two  parietal  bones,  the  head,  during  its  progress  through  the  pelvis, 
oould  be  diminished,  without  harm  to  tlie  child,  to  the  extent  of  six  lines  or  half  an 
inch.  This  is  really  so ;  but  you  will  bear  in  memory  the  marked  difference  between 
the  two  forces  employed.  .  In  the  one  case,  the  force  is  derived  from  the  energetic 
and  continued  contractions  of  the  uterus,  gradually  accomplishing  the  desired  diminu- 
tion  in  certain  instances  of  relative  disproportion ;  in  the  other,  on  the  contrary,  the 
force  is  artificial,  and  cannot,  with  whatever  skill  it  may  be  exercised,  equal  in  aalu* 
tary  effect  ilie  eflbrts  of  nature  herselfl 


570 


TUK  rRlKC'irLES  AND   PRACTICE  OP  OBSTETRICSw 


It  is,  ifx^lced,  a  tractor  of  precioti^  value,  nnd  tliis,  in  mr  jucli*m<?iit, 
oonstitutes  its  chief  atlnbulo.  The  inHtrurneiil  Hliuul*]  hi?  re^nirdetl 
%B  simjjly  an  aid  to  nature^  for  it  is  only  under  one  df  t\ro  rircrnn- 
8lnneL«?=^  a**  I  shrdl  more  jmrticularly  Ktate  to  you,  that  its  ajjp'icatiuii 
becomes  justifiable,  vix,  I.  When  nature,  exhausted  iti  incffcrtiiAl 
efloit,  U  unable  to  aceotnpli&h  delivery ;  2,  Wlten,  in  conHe»|ui*mift 
of  certain  complicalions,  (he  lives  of  mother  and  child  unntd  h© 
com{)roiniaed  by  delay. 

In  one  word,  th<t  forceps  a/i  a  treictor  h^romrg^  ri,f  it  ^fu:rf\  v  Mi^^ 
stitiite  foi*  the  uteri n^i  cotitra.'tioti  nsresaari/  to  expel  thr  fnlL 
Therefore^  in  ftU  partirulars,^  it  ^hoiM  he  tnad^ftn  rig  idly  f*^  ;-  '^'f* 
blc  to  simulate^  through  e;ctntctiv€  forvc^  the  uterus  us  an  e-r^hiUar, 
I  think  lam  rl^ht  in  this  general  propoHition,  and  if  yon  wilt^  in  the 
first  plaec^  accept  it,  and,  secondly,  suffer  it  to  constitute  the  bad 
of  conduct  in  case.s  in  wliich  delivery  by  the  forceps  may  be  di*PiB«d 
advissablc,  I  hhall  predict  with  great  eoijfidenee  that  the  iiLHirumciit, 
in  your  hand^^,  will  cease  to  be  one  of  destruction,  and  will  prnroof 
abiding  service  to  your  patients.  There  is  one  other  advantage 
tjiTcrctl  by  the  forceps  which  I  >hoa!d  nor  omit  to  mention  :  Vtcddai 
eti:ili!ing  us  to  extract  the  child,  it  will  afford  thefaoility  of  cbaiigieg 
an  unnatural  into  a  natural  position  of  the  head. 

Dangers  of  Fhrctps  DeUt^^ry* — It  is  right  that  we  «»hoii]d  borf 
albi<b*  to  Hcune  of  the  evil  consequences  oecai^ionally  resultinir  from 
the  usie  of  tfie  instnmient.  Instances  are  reeonled  in  which,  t*p*?- 
cialJy  where  there  was  slif^^bt  contraction,  the  bones  of  the  pt^tni 
have  been  fractured  by  the  amount  of  force  employed,  or  a  s^eficira- 
tion  of  the   different  symphyses  tr^gcther  nnth   li  *   m  of  ilie 

ligamentft.     These  accidents,  however,  should  be  ri_  i-amonfr 

the  comparatively  rare  eonse«]uencea.  Injuries  to  the  foii  parts  aii» 
much  more  common.  Rupture  uf  the  uterus  or  vagina,  lacemtioQ 
of  the  fierineum-*by  no  means  unfreqtient  results  of  forcej»  difr 
very — thrombus  of  the  vulva,  pelvic  abacessea,  prolapsua  of  ilie 
womli,  etc.,  may  be  counted  among  the  sequels  of  the  txse  of  tilt 
iDStrument,  when  sufficient  care  has  not  been  developed  \n  it^  appli- 
cation. The  child,  too,  may  suffer  from  contusion,  fracture  of  tki 
boue^  of  the  cranium,  or  congestion  of  the  brain. 

7b  ^f^hnt  Part  of  the  Child  a/tould  the  Jn.ffrfiment  be  Appikdf 
— It  was  formerly  recommended,  afid  the  practice  atill  obtJiiii)i  wHb 
some  pmctitioners,  to  apply  the  forceps  in  certain  cnaes  of  brredl 
presentaiion—Smellie  and  Br.  Collins  were  two  earnest  supporttn 
of  thi^  practice.  I  must  confess  that  to  attempt  to  extract  the 
child  by  grasping  itJi  breech  with  the  forceps  nppears  to  me,  not  only 
unwise,  but  mo^t  certainly  calculated,  if  not  poiaiively  to  dfi^trof 
ita  life,  at  least  to  entail  upon  it  very  serious  injury*  To  beconit 
satlstied  of  thiB,  it  is  only  necesisary  to  remendx^r  the  AHfttoQUCal 
eoaformation  of  tbe  hips  of  the  fcrtus,  the  moi*e  or  liisa  oartilagiiiotti 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  577 

condition  of  its  pelvis,  together  with  the  want  of  correspondence 
between  the  general  physical  volume  of  the  breech,  and  the  pecu- 
liar shape  and  curves  of  the  forceps ;  the  recollection  of  these  cir- 
cumstances will  at  once  cause  you,  I  think,  to  appreciate  the  im- 
portant practical  truth  that  the  forceps  cannot,  with  due  regard  to 
the  safety  of  the  child,  be  employed  in  cases  of  breech  presentation. 
Besides,  even  if,  under  the  circumstances,  the  instrument  were  at 
all  admissible,  there  is  another  objection  to  its  use,  viz.  it  cannot 
present  the  ssame  advantages  for  the  extraction  of  tlie  child  as  either 
the  fillet,  the  blunt  hook,  or  the  finger  of  the  accoucheur  applied  to 
the  bend  of  the  thigh.  Therefore,  I  would  advise  you,  for  the 
reasons  just  stated,  never  to  have  recourse  to  the  forceps  in  this 
presentation.  When  the  instrument  is  used,  it  should  be  applied 
exclusively  to  the  head,  and  this  may  be  done  under  two  different 
conditions,  viz.,  1.  When  the  head  presents  first;  2.  After  the 
delivery  of  the  child,  the  head  remaining  in  the  pelvis. 

How  is  the  Head  to  be  Grasped  by  the  Forceps. — Except  in 
certain  extremely  rare  cases,  the  instrument  should  be  so  applied  as 
to  seize  the  head  thus:  the  internal  surface  of  each  blade  of  the 
forceps  (the  cranial  curve)  should  be  so  adjusted  as  to  be  in  cor- 
respondence with  each  os  parietale^  an<l  extending  on  either  side  in 
the  direction  of  the  ocdplto-tnental  diameter  of  the  head.  Seiied 
in  this  way,  there  will,  as  a  general  rule,  be  no  danger  of  injury  to 
the  child ;  and,  in  the  event  of  its  being  necessary,  the  proper 
degree  of  compression  can  be  exercised  so  that  the  parietal  bones 
may  be  made  to  overlap ;  and  what  is  extremely  essential,  the  head 
being  grasped  in  this  manner,  the  forceps,  under  the  judicious  mani- 
pulations of  the  accoucheur,  will  be  better  able  to  display  its  full 
power  as  a  tractor,  and  bring  the  head  into  the  world  in  accordance 
with  the  principles  regulating  the  mechanism  of  labor ;  for  remem- 
ber, the  forceps  beinff  a  substitute  for  the  7mtural  forces^  should^  in 
every  part  ictdar^  be  made  to  imitate  as  far  as  may  be  these  voy 
farces  when  7iot  disturbed  by  some  contravening  ivflueiice. 

Modifications  of  the  Fitrceps, — The  instrument,  as  originally  pre- 
sented, has  undergone  mnncrous  changes  depending  upon  the 
caprice  or  judgment  of  the  innovator;  I  shall  not  weary  you  with  a 
recital  of  these  multiplied  alterations,  but  shall  content  myself  with 
simply  remarking  that  the  forceps,  as  now  used,  exhibits  two  curves : 
one  of  these  is  known  as  the  (.ranial  curve,  intended  to  adapt  itself 
to  the  shape  of  the  child's  head ;  the  curves  present  two  oj)enings 
or  fenestra,  whieh  acconmiodate  themselves  to  the  parietal  regions 
of  the  foetal  cranium.  The  instrument  with  the  cranial  curves  is  the 
one  known  as  Denman's  or  the  short-strait  forceps ;  as  this  was 
intended  to  seize  the  head  only  when  it  had  well  descended  to  the 
inferior  strait  or  outlet,  the  one  curve  for  each  blade  (the  cranial), 
answered  the  purpose  well  enough  ;  but  it  was  soon  fovmd  \.VkaX,  xj^*^ 

37 


578 


THE  PRlNCU'LEii  AND   ritACTICK   Uf 


forceps  80  constrnctetl  wn»  not  udequnie  to  the  wsmts  of  the 
t'licur,  wherj  instrumfntul  ilelivfry  waacmlleil  for  hiffort*  Uic  dpsoeiil 
ifie  liead  lind  bet?n  iiccomplishcd  ;  imd  we  arc,  therefore,  mdcbtt^tl  f<] 
another  important  niodificalion  of  the  inhlrumetit  to  thoM*  diHtl 
guislied  accoucheurs,  Smeilie  auil  Levret*  The  modincatiou  to  whiub' 
I  nllufle  con&bta  in  an  additiouaJ  curve,  described  as  the  pelvic  ennftp 
the  conveJtity  of  vvliidi  regards  the  t»acnmi,  while  tin  \tj  ' 

turned  towards  the  puhes.     It  is,  tis  you  perceive,  in  j  ri 

pondence  with  the  two  axet*  of  the  pelvic  cavity,  and,  us  is*  manifc 
has  »fi€ci!il  relations  to  the  orgsins  of  the  mother  ;  tlie  cranial  carv 
on  the  contrary,  liu»  reference  to  the  child  only.    The  insttrutoi 
with  tho  curves  just  noticed  is  known  m  the  lonjj^,  the  me*i'  ll 

the  diort  tbrcept!(.     Tlie  hilLcr,  I  have  already  remarked,  s  I 

to  delivery  after  the  head  is  pressing  on  the  perineum,  while  the 
two  ibrmor  may  be  employe*!  ftir  tlie  extraction  of  the  head,  oo^ 
only  when  it  is  at  tlie  outlet,  but  in  any  portion  of  the  pelvic  cavil; 
or  at  the  i*u|K'rior  stniii, 

77ie  Author's  ObntetHc  Case. — I  preaent  my  own  obstelrie 
*>f  instruments,  consisting  of  the  forceps,  the  guard  crotduH^  tbo 
veetis,  and  pierce-crane  or  i»erforator.  Fig*  83  repreaetits  mf 
forcepii,  which,  1  bvlieve,  embodies  some  imjHjrtant  improvciueDt^ 
The  curve  of  tlie  blades,  their  lij^htnea^i,  and  thinneaa  (tiuflidrfitljr 
Btroii^i,%  however,  for  all  ordinary  purposes),  1  regard  as  a  \tVf 
esticiitial  improvement*  The  blades  of  the  forceps  are  usually  too 
thick,  uoiieeeiHarily  »o;  this  eircum»tance  frequently  |  'hM 

iutroduction,  especially  if  the  heail  be  more  than  ur«li  _  i^rgiv 
or  the  pelvis  Somewhat  eontmcted.  In  my  judgment,  therefore,  the 
thhmor  tho  blades,  consistently  with  the  litrcngth  required,  tli0 
more  advantageous  will  the  lustrunjent  be  found.  Inntead  of  ibe, 
pivot  lock,  I  hiLve  substituted  the  button  joint,  and  the  aiivstitags 
4»f  tlds  mode  of  articulation  over  lhe}nvot  will  be  at  once  coiieodcil 
on  testing  the  relative  fa4?iljty  of  locking  the  branches  of  tho  ioitni- 
mcnt.  It  ap])ear$  to  me  that  accoucheurs  genenilly  have  |imid  too 
little  altenlior»  to  the  handle  of  the  forceps:  I  certainly  do  attach 
itiucb  value  to  this  portion  of  the  instrument,  and  I  amsattKtit%]  tlaal 
tlie  indiliVrence  of  practitionere  to  it  has  oilentime»  led  to  Oulurt 
in  its  just  workings. 

In  c»rder  to  extract  the  head  of  the  fietili  ^ 
more  i^  needed  than  the  mere  adjustment  of  t) 
profier  traction  be  not  oiade,  aotl  proper  direction  given  to  tbe 
traction,  the  cldhl  will  frequently  bo  sacrificed,  and  more  or  lc«» 
aevere  injury  erinuc  to  the  sotlt  i^arts  of  the  mother.  To  obrblt? 
theikr  difiicultieM,  therefore,  and  to  furnish  every  facility  for  ll*« 
safe  extraction  ^f  the  child,  I  have  provided  a  handle  {Fig*  W) 
oi  Kufiicicmt  tcngtb  and  curve.  The  curve  at  the  exiretnity  of 
the  handle  w'di  afford  ^real^t  t^a^dXW's  Vc^  \U«  operator,  and  g;i%*«liiiii 


THE  PBINCflPLES  AND  PRACTICE  OF  OBSTETRICS. 


579 


more  power  than  any  forceps  I  have  yet  seen.  To  be  saliisfied  of 
this  fact,  it  is  only  necessary  to  lest  it  by  application  of  the  instru- 
ment on  tliC  manikiiL  The  length  of  the  handle  likewise  affords  a 
proper  lever  for  the  traction.    Tiie  two  rings  (Fig.  8a)  will  enable 


Fio^  ML       Fio.  61 


FukflOL 


Flo.  8dL        Fio.  6T.       Fni.  B& 


the  operator  to  give  proper  direction  to  the  force  employ ed»  and 
wiJl,  at  tiie  same  time,  facilitate  very  mnch  the  lateral  movcmentfi 
go  essential  to  impart  to  the  child*s  head  during  the  stages  of  its 
delivery.*  Fig.  85  roi>resent8  the  ordinary  pierce-crane  or  per- 
forator; Fig,  8ii  the  ordinary  vectis  or  lever. 

ITie  crotchet,  which  is  usually  employed  in  operative  midwifery, 
is,  in  more  senses  than  one,  a  murderous  instriiment,  and  has  been 
folliywed  by  melancholy  results.  Under  the  nio*it  favorable  eircura- 
etances,  aini  in  the  most  dexterous  hands,  it  often  does  barm.  It  is 
well  understuod  that  it  is  never  to  be  resorted  to  except  in  cases  in 
w*hieh  embryotomy  is  indicated.  Its  chief  danger,  therefore,  re- 
gards the  mother,  for  the  reason  that  the  purchase  which  this 
instrument  takes  on  the  child  almost  always  gives  way,  and  if  the 
acconchewr  be  not  particularly  circumspect,  the  soil  parts  of  the 
parent — the  nterus,  the  bladder,  rectum,  or  vagina,  will  be  more  or 
less  lacerated,  often  giving  rise  to  disastrous  consequences.     With 

*  ASler  loni;  trial,  I  ann  speak  with  mticli  confidence  of  tho  foroeps  described 
lu  the  text ;  and  [  have  the  aulbority  of  our  principal  iustruraent  makers  for  staling 
that  iliey  receive  more  ordera  Ibr  it  thaa  for  auy  other  fyreeps  moQufiictured  by 
iheiiL 


680         THE  PRINCIPLES   AND   PRACTICE  OF  OBSTETRICS. 


a  vicw^f  obviulhif?  ihU  ile»triictive  tenclcncv  of  the  instruoieiiU  I 
havo  causfJ  a  guanU^rulchct  (Fig.  87)  to  lie  con>*tnicte<l,  wbidt  I 
offer  ti)  ibi-'  atltMition  of  the  j^rafesjsiou,  allowing  iia  merits  to  rwit 
upoii  tlie  jn<lf»monl  they  nmy  forin  of  it»  uliliiy.     TIm 
of  this  tnstruiiieiit  la  tlie  |i;irik'iil:ir  imlifationt*  to  be  In 
um  of  the  crotehet  will^  I  think,  be  founrl  to  be  alt  thiit  C9fi  b9 
desired.     Fig.  S8  pre>*ent?i  a  from  view ;  in  the  centre  of  the  btado 
is  a  groove  for  the  reception  of  the  piunl,  w  hieh  U  tna<le  to  3*lide 
\vi\h  theility  to  the  poirjl  of  tlie  crotchet.     The  exireniiiy  of  Um 
guard  (Ki^.  87),  on  lu  external  snrface,  is  convex  and  smooth^  ami 
Ku  eompk»iely  conceals  the  sharp  point  of  the  crotchet  as  etittrdjr 
to  prote<*t  the  soil  j»arts  from  injury,  even  if  lire  in  ; 
slip  during  tlie  traeiionft  made  on  it  by  tlie  accout 
evenly  instead  of  tl»e  va;;iniv,  bhiddcr,  or  rectum  being  i  by 

the  point  <jf  the  eroichet,  they  will  suffer  no  injury,  fui  ....  ^.,.ooili 
surface  only  of  the  guanl  eonics  in  tiontaet  with  thrm*  It  nili  be 
(jeetj  that,  at  the  other  extremity  of  the  guards  there  in  i '  "    ttry 

blunt  hook.     This  h  iruportnnl  merely  us  a  matter  at* 

It  \$  due  to  myself  to  Plate  thai  the!*e  itifttrumenW  are  noi  jite- 
sentcd  from  any  foridnciis  I  have  for  fame  as  an  inventory  my 
undiiiion  lieii  in  a  different  direction.  But  they  are  the  ri^tilt  tk 
much  rellectioiu  antl  all  I  ask  U  that  they  may  receive  that  degree  i 
of  favor  to  which,  on  fair  trial,  they  mny  Ik*  IoutkI  h  •'inin.niidiy 
entitled. 

liidtcatkms /or  the    Cute   of  ilm   Junrrpff, —  in  cor:  ^li. 

imlicaliuns  for  the  emplovment  of  the  furceps,  we  jif  u» 

of  the  most  important  lopias  connected  witfi  the  entin*  ftcienci!  of 
midwifery  j  and  it  h  ri^ht  tliut  we  »hotdd  award  to  this  tiatdttion  a 
due  dc^jfrce  of  afipreciation.  As  one  of  the  Citrftential  piere<|!]intei 
for  a  resort  t(»  the  instrument,  it  is  ahwolutely  tjeei- 
Bhould  be  at  fault,  It,  therefore,  remains  for  n*»  i 
the  circumstances  are  which  so  far  contravene  lier  etVort«  as  to  iif^t 
the  UiterpoHili4»n  of  ficiencc.  These  circumfetaoce*  may  be  efmniie* 
rated  a;*  follows: 

1*  A  ronfracted  pelvis; 

2.  A  normal  pelvis  with  the  head  larger  than  nminl ; 

3.  Defrctive  parturient  action,  embraced  under  the  geiKMul  l^nn 
f  ineri  la ; 

4.  The  presence  of  some  serioti!i  complication,  »uch  .•!«  hinnftr- 
rha»r(»,  convnlsionn,  exliaustion^  beniia,  or  prolapsion  of  the 

5.  Hupture  i*f  the  uterti.%  the  head  bemg  in  the  pelvi«  Cftv..^^ 
fix<*d  at  the  superior  sti*ait; 

0.  Tfie  occurrence  dunng  labor  of  any  circmnstance  which  may 
plarp  in  jeopardy  the  life  of  the  motlier  or  child. 

With  regard  to  the  application  of  tlie  forceps,  hi  cAst*  of  tlvrfiMliTi 
ji^h  ic  capacity^  I  am  ded<WAW  *jC  o\>viiion  that  if  there  be  noi  i 


TIIK   PIUNCIPLES  AND   PRACTICE  OF  OBSTETRICS.         581 

space  of  three  inches  and  an  ciirhth  in  the  antcro-posterior  diameter 
at  the  upper  strait,  and  the  same  in  the  transverse  diameter  at  the 
lower  or  perineal  strait,  a  living  child  at  full  term  with  its  ordinary 
dimensions  cannot  be  exti-acted  ;  and,  moreover,  any  attempt  to  do 
80  would  more  or  less  seriously  compromise  the  integrity  of  the 
soft  parts  of  the  mother,  if,  indeed,  it  did  not  subject  her  life  to 
peril.  Some  of  the  most  melancholy  results  of  forceps  delivery  are 
to  be  found  among  those  instances  of  pelvic  contraction,  in  which 
mere  animal  force  has  been  employed  with  the  delusive  hope  of 
overcoming  the  physical  disproportion,  and  thus  accomplish  the 
labor. 

The  Time  of  Resorting  to  the  Forceps, — T  cannot  too  emphati- 
cally admonish  you  against  the  danger  of  blind  obedience  to  some 
of  the  lessons  inculcated  l)y  certain  distinguished  writers  as  to  the 
time  of  resorting  to  the  forceps.  You  have  just  been  told  that  the 
ase  of  the  instrument  will  sometimes  be  indicated  when  there  exists 
not  the  slightest  disproportion  between  the  fcDtus  and  maternal 
pelvis.  The  labor,  for  example,  to  a  certain  period,  may  have  been 
perfectly  natural,  and  all  things  have  gone  on  well  until  the  head 
reaches  the  inferior  strait.  At  this  stage  of  the  labor,  either  con- 
vulsions, hemorrhage,  exhaustion,  rupture  of  the  uterus,  etc.,  may 
occur,  and  render  immediate  delivery  absolutely  necessary.  It  is 
important,  therefore,  that  the  rule  for  artificial  delivery,  under 
these  circumstances,  should  bo  clearly  understood,  and  the  doctrine 
advanced  by  some  of  the  older  English  authonties  on  the  subject 
fiurly  examined.  I  cannot  but  regard  the  direction  given  by  these 
aathors,  with  regard  to  the  particular  time  of  applying  the  forceps, 
as  fraught  with  evil,  not  only  to  the  safety  of  both  mother  and 
child,  but  .also  to  the  reputation  of  the  medical  man. 

Dr.  Merrinian,*  one  of  the  ablest  accoucheurs  of  modern  times, 
observes — "  Ko  case  is  to  be  esteemed  eligible  for  the  application 
of  the  forcei)s,  unless  the  ear  of  the  child  can  be  distinctly  felt ;  so 
careful  have  the  best  professors  of  midwifery  been  to  guard  against 
an  improper  use  of  the  instrument,  that  it  has  been  laid  down  as  a 
rule  of  practice^  that  the  forceps  should  7}ever  be  applied  until  the 
ear  of  the  child  ha^  hee7i  within  reach  of  the  ojyerator^s  finger  for 
at  least  six  hours^  Dr.  Denman,  than  whom  no  one  has  left  a 
more  merited  reputation,  says — "  A  practical  rule  has  been  formed, 
that  the  head  of  the  child  shall  have  rested  for  six  hours  as  low  as 
the  perineum,  that  is,  in  a  situation  which  would  allow  of  its  appli- 
cation, before  the  instrument  is  applied,  although  the  pains  should 
have  altogether  ceased  during  tlie  time."  It  is  unnecessary  to 
enumerate  more  authorities  in  support  of  this  principle.  Suffice  it 
to  say  that  the  dicta  of  Denman,  Merriman,  and  others,  have  taken 

•  Synopsis  of  the  Various  Kinds  of  Difficult  Parturition.  Bjr  Samuel  Merriman, 
II.D.,  F.L.&    London,  1820,  p.  156. 


582 


THE   PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS. 


a  strong  hold  of  the  Englisb  school,  and  their  ofiinions  have  been 
too  generally  adopted.  You  will  permit  ine  to  say  that  cither  of 
the*  precept8  which  I  have  just  ciled^  if  univerftally  carried  out,  cao- 
not  bat  re^nlt  oftentimes  most  seriousiily  to  mother  and  child,  vii. 
that  the  ^*'mr  should Jir$t  be/eU^  and  that  the  head  shall  have  rttttd 
J\jr  ^tx  hours  an  low  as  the permeum,^*  In  the  first  place,  1  woald 
observe^  my  own  experience  teaches  me  tlmt  it  is  not  always  An 
ea«ty  thing  to  reach  the  ear^  even  when  the  head  \»  at  the  inferior 
strnit ;  and,  secondly^  not  to  interpose  until  the  head  nkiall  bapo 
pressed  upon  the  perineum  for  six  hours  w^ill  prove,  io  maiijr 
instances,  jieriiicions  practice. 

To  illustrate  this  point,  let  us  supposo  that  the  head  is  In  this 
pelvic  cavity ;  the  mother  suddenly  becomes  exhausted,  either 
from  hemorrhage  or  antecedent  eflbin,  or  it  may  happen  that  the 
labor  becomi»s  complicated  with  convulsions.  No  niulter  what  Um) 
special  cause  may  be,  we  will  hypotliceate  that,  from  the  irumineilfc 
danger,  imntediate  delivery  is  absolutely  indicated.  The  aecourhiror 
intruduces  his  finger,  and  endeavors  to  reach  the  ear^  he  does  not 
succeed;  Ihe  patient^s  situation  becomes  more  and  more  nlarming; 
he  again  makes  the  attempt  to  find  the  ear — he  faiU;  hia  own 
judgment  tells  him*  ifideed  everything  clearly  indicates  that  tbc» 
forceps  shoidd  b©  applied ;  l^iU  he  cannot  reufh  tha  earl  lie  delayi 
in  the  hope  that  ^^  tfie  head  may  conie  down  in  t/a  pehls  miffideniljf 
low  to  enable  him  to  ftrl  one  or  both  ears  distinrtit/J^  Aliul  lliii 
proves  fallacious.  The  assistants  sapplicate  him  to  do  sometbiog  to 
relieve  the  patient,  for  they  sec  alie  is  dying;  and  what  will  it 
avails  under  these  sad  circumstances,  for  him  to  exclaim  :  ^  I  ota 
do  tiolhing,/r>r  the  ear  of  the  child  cannot  befHt  /''  l/ct  it  not  be 
imagined  that  this  is  an  overdrawn  }»icture  ;  such  re»ti}t«  moit 
inevitably  ensue  from  nu  urlherenee  to  the  rule  to  which  I  h$?t 
just  alluded.  It  is  further  alleged  that  ^^  it  is  noceseary  to  retell 
one  or  borli  cars,  because  th'>y  becnme  the  gniilcs  to  tbe  proper 
adaptation  of  the  bbdes.^*  This  language,  I  must  eonfesft,  sorpriive 
mo  not  a  little.  If  there  be  any  meaiting  in  it,  it  is  simply  this^ — 
that  unless  the  ears  be  felt,  it  will  be  im{K>8sibIe  to  know*  how  to 
arrange  the  blades  of  the  inHtrument,  because  of  the  ignorance  of 
the  accoucheur  as  to  the  jKJsitiori  of  ihc  head*  Admitting  the  truth 
of  this  reaji<jning,  when  the  head  is  at  the  inferior  stiiut — whieh  I 
mo»t  unequivocjdly  deny — how  is  the  position  to  he  osccrtnined 
when  the  head  is  still  at  the  pelvic  brim?  Certainly  no'  '  "  img 
the  ears,  for  these  cannot  be  recognised  once  in  a  tho.  net 

p»cvioiisly  to  the  descent  of  this  head  into  the  cavity  of  the  ptilvb^ 
The  pusition  of  the  head  can  be  told  both  at  tiie  inferior  and  mpe* 
nor  ^traitift  by  the  direction  of  the  fontanellea,  ^gittal  suture,  etc*; 
and  thene  will  indicate  the  manner  of  applying  tho  forccpa,  an 
teizing  the  head  in  it&  bi-|)arietal  measurement. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         588 

But  again :  *^  The  head  has  not  been  pressing  on  the  perineum 
for  six  boarg  ;*'  what  is  to  be  done  in  this  ease,  when  the  life  of 
either  mother  or  child  is  menaced,  and  immediate  delivery  called 
for  ?  Are  yon,  with  watch  in  hand,  to  say  to  the  earnest  appeals 
of  surrounding  friends — "  Oh  !  I  cannot  interfere  yet ;  I  am  wait- 
ing for  six  hours  to  elapse !"  You  perceive,  gentlemen,  the  absur- 
dity as  well  as  the  dani^er  of  the  two  rules  to  which  I  have 
referred ;  and  you  will  allow  me  most  emphatically  to  enjoin  on 
you  to  pay  no  regard  whatever  either  to  the  ear  or  the  length  of 
time  the  head  may  be  in  the  excavation  ;  but,  if  all  other  things  be 
equal,  proceed  to  artificial  delivery  the  moment  the  safety  of 
mother  or  child  becomes  seriously  endangered.  The  very  essence 
of  forceps  delivery,  that  which  commends  itself  so  strongly  to  our 
consideration,  is  the  ability  with  which  it  oftentimes  enables  us  to 
rescue  both  mother  and  infant.  Therefore,  if  artificial  delivery  be 
indicated,  have  recourse  to  it  before  the  life  of  the  child  has  been 
MCLcr^iced^  or  the  vital  forces  of  the  mother  so  far  eoipeHded  as  to 
render  her  recovery  extremely  doubtful,  I  do  not  advocate  a  med- 
d.Iesomc  midwifery ;  on  the  contrary,  you  will  all  bear  witness  that 
I  am  essentially  conseiTative ;  but  I  do  most  strenuously  recom- 
mend, when  indicated,  such  an  opportune  application  of  th^  means 
put  into  our  hands  of  affording  relief  as  will  achieve  the  highest 
measure  of  good  to  both  parent  and  offspring. 

Perhaps,  you  may  think  it  important  that  I  should  enter  some- 
what in  detail  as  to  how  you  will  be  enabled  to  recognise  that  either 
the  mother  or  child  is  in  danger.  All  that  I  have  to  say  in  reply 
18,  that  the  accoucheur,  if  he  thoroughly  comprehend  the  principles 
of  bis  science,  will  through  ihe  proper  exercise  of  his  judgment 
readily  arrive  at  a  just  diagnosis  as  to  the  propriety  of  action.  For 
example,  he  must  distinguish  between  positive  and  relative  exhaus- 
tion; he  must  appreciate,  hi  an  attack  of  convulsions  or  hemorrhage, 
whether  immediate  delivery  be  indicated  or  not.  Is  the  pressure 
on  the  head  of  the  child  from  long-continued  effort  of  the  uterus 
such  as  to  compromise  its  safety,  thus  calling  for  interference  ?  In 
cases  of  funis  presentation,  under  what  circumstances  will  the  for- 
ceps be  justified?  If  the  uterus  be  ruptured  durhig  the  partu- 
rient effort,  and  the  head  in  the  pelvic  cavity,  would  not  delivery 
by  the  forceps  add  to  the  feeble  chances  of  the  mother's  reco- 
very ? 

All  these  are  questions  which  must  bo  determined,  not  in  the 
lecture-hall,  but  at  the  bed-side  of  the  patient ;  it  will  be  a  question 
of  evidence,  and  that  evidence  will  depend  upon  the  surroundings- 
of  each  case  as  they  may  present  themselves  to  your  observation.. 
Ill  one  word,  the  problem,  to  be  solved  is  this — can  nature  accom- 
plish the  delivery  consistently  with  the  safety  of  parent  and  child, 
or  will  the  interposition  of  science  be  needed  ?     Nee  temere^  nee 


584         THE   PHINCIPLES  AND  PRACTICE  OF  OBSTETRICS. 

timide — neither  raslily  nor  timidly — is  the  maxim  which  should 
govern  the  acrcoucheur  in  cases  of  lbrce]>s  application ;  and  while  I 
would  enjoin  to  its  fullest  extent  the  observance  of  camion,  yet  I 
caiHiot  but  impress  upon  ytni,  as  worthy  of  recollection,  that  so  far 
as  reirards  the  ;j:eneral  result  it  is  far  better,  in  dexterous  hands, 
that  the  histrument  should  be  Qn\\\oyQi!i  five  minutes  too  early  than 
five  minutes  too  late. 


LECTURE     XXXIX. 

Forcepe  Delivery  continued — Rules  for  the  Application  of  the  Forceps— The  instru- 
ment may  be  employed  when  the  Head  Ls  at  the  Inferior  Strait,  in  the  Pelvic 
Cavity,  or  at  the  Superior  Strait. — ^Tho  Head  at  the  Outlet,  with  the  Occiput 
toward  the  Pubes,  and  the  Face  in  the  Concavity  of  the  Sacrum — The  Head  at 
the  Outlet  in  a  Reverse  Popition — The  Head  in  the  Pelvic  Cavity  diagonally,  the 
Occiput  regarding  the  Left  Lateral  Portion  of  the  Pelvis,  the  Face  at  the  opposite 
Sacro-iliac  Symphysis — The  Head  in  the  Pijlvic  Cavity  diagonally,  with  the  Occi- 
put at  the  Right  Lateral  Portion  of  the  Pelvis,  and  the  Face  at  the  opposite  Sacro- 
iliac Symphysis — The  Head  in  the  Pelvic  Cavity  in  Positions  the  reverse  of  the 
two  preceding — Ap[)licati()n  of  the  Forceps,  the  Head  being  at  tlie  Superior  Strait 
—  Positions  of  the  Head  at  this  Strait — Difficulties  of  Forceps  Delivery  when  the 
Head  is  at  the  Upper  Strait — Version,  in  such  case,  preferable— Case  in  Hlustra- 
tion — Rules  for  Forceps  Delivery,  the  Head  being  at  the  Superior  Strait— Locl<ed- 
Head — What  does  it  mean?— Want  of  Concurrence  among  Authors  as  to  what 
Locked-Head  is— Is  Locked-IIead  of  Frequent  Occurrence? — Camper's  Opinion — 
Dangers  of  Locked-Head  to  the  (  hild  and  Mother — Under  wliat  Circumsian- 
ei*s  may  Locked-Head  occur? — Application  of  the  Forceps  in  Locked-Head — 
Rules  for. 

Gentlkmkn — We  shall  now  consider  the  rules  to  be  observed  in 
the  applicntion  of  the  forcej)s,  after  you  have  decided  that  the  use 
of  the  instrument  is  indicated.  Permit  me,  however,  to  premise 
that  forceps  delivery  may  be  resorted  to  under  the  following  cir- 
cumstances : 

1.  The  head  being  at  the  inferior  strait. 

2.  In  the  pelvic  cavity  at  any  point  between  the  two  straits. 

3.  At  the  superior  strait. 

4.  After  the  trunk  of  the  child  has  been  delivered,  and  the 
head  remains  either  at  the  brim,  in  the  pelvic  cavity,  or  at  the 
outlet. 

We  will  suppose  that  you  have  fully  determined,  according  to 
your  best  judgment,  that  the  alternative  for  the  safety  of  either 
mother  or  child  is  a  re.Kortto  the  forceps  ;  this  opinion  would  neces- 
earily,  if  it  be  a  just  one,  presuppose  that  you  had,  through  a  pro])er 
vaginal  examination,  become  informed  of  the  exact  relations  of  the 
head  to  the  pelvis.  ILivhig,  therefore,  decided  as  to  the  propriety 
of  artificial  delivery,  I  will  now  motitiou  what  I  deem  the  elements 
essential  to  a  successful  acc-om])lishment  of  the  operation  after  the 
head  has  descended  into  the  ]>elvic  cavity  : 

1.  The  full  consent  of  your  i»atient  must  be  had,  and  this  can 


586 


THE  PRINCIPLES  AND   PKACHCE  OF  0B9rETRI€8. 


readily  be  obtained  if  the  iiccourheur  will  only  ©iferci*c»  a  Witle 
adroitness.  There  is  a  cord  iti  woman'«  heart,  which  if  proj>rrljr 
touched,  will  ahvays  prove  responsive*  Talk  to  her  thus  :  Madam 
it  is  my  duty  to  say  to  you  that  if  your  delivery  be  hunger  dt^jtyej 
your  infant  will  incur  very  siTious  haacard  of  its  life,  and  the  tim« 
has  now  arrived  when,  if  I  act  promptly,  I  nhall  be  enabled  to  «ar« 
your  child,  and  spare  you  much  protracted  suflenng.  Oh  I  disir 
doctor,  but  will  not  the  instrument  destroy  my  poor  child  ?  So  far, 
my  good  friend,  from  hnrmlng  it,  i)»e  force[m  will  enable  me  to 
brinsj  it  into  the  world  without  intlicting  the  slightest  injury  iipcm 
it,  and  if  it  be  alive  when  I  commence  the  operntion,  of  which  there 
may  be  a  pojjsible  doubt  in  ion&equence  of  the  very  severe  pre^iift 
its  head  has  undergone,  I  think  [  can  very  confidently  promise  yiKi 
that  the  instrumer^t  will  bf  tht*  only  means  of  c«rial)ling  nio  to  Mive 
your  child.  Oh  !  doctor,  theu  do  not  delay.  I  will  Kubmit  to  say* 
thing  to  have  my  child  alive!* 

2.  The  position  uf  the  patient  is  of  much  importance ;  and  I 
greatly  prefer  that  she  remain  on  her  buck  rather  than  on  her  *idc* 
occupying  the  precipe  allitndc  which  has  already  heen  di*fic){bini 
w*hen  Rpeaking  of  version,  viz.  let  hor  hips  be  brought  to  ibt?  tJga 
of  the  bed,  placing  a  double  fold  of  linen  or  flannel  under  thcio  m 
order  to  have  them  on  a  plane  surface ;  an  as^ij^tant  sbould  hm 
seated  on  either  ^ide,  whose  duty  it  sliall  be  to  tlex  the  thigh  and 
leg  at  a  right  angle  allowing  the  foot  to  i-eston  hi*  knee,  oneof  ibe 
hand»  heing  [ituced  on  the  knee  of  the  patient,  while  the  otkar 
gently  seizes  the  loot,  for  the  purpose  of  Htead\iug  it.  The  aeooii-^ 
chenr,  with  an  apron  to  protect  his  dres»,  »eat!i  himself  on  a  laW 
chair  between  his  two  as«<i*tants.  The  bladder  and  rectum,  if  di^ 
tended,  shotdd  be  relievcfl  of  their  contents. 

3.  Tliere  is  no  necet»Kity  for  any  exposure  of  the  putlenCs  pacaoili 
and  this  injunction  should  be  gernpulouHly  observed. 

4.  The  08  nttri  fihould  be  suiBciently  dilated  and  relaxed^  aa  ds^ 
the  viigina  and  vidvu  to  allow  the  head  to  paiii ;  otherwise,  tbere 
would  be  the  serious  Iniziinl  of  formidable  and  drtuistrous  lanmk 
tions.  X^  attempt  to  introduce  the  blades  of  the  forocfw  into  an 
undilated  o*  would,  in  my  t)pini*»n,  be  but  the  probablo  pa»«pari  to 
the  death  of  the  patient;  ibr,  admilling  the  fro- 
duetng  tf»e  int*trument,  would  not  the  Iractionu  I              ^  Jdi* 

•  t  *»tn  \n  th<*  U«1»tt  of  UMving  recjouw©  to  a  irerjr  timpte.  and  at  the  avnie  tttn»Hlbci- 
uri!  ii|;  nil  ii]>pn«!iiMi8ion  Tnun  the  mitiil  of  Uio  incrtiicr  ta  ivfrrtttcvlo 

an  ^  at  iniitibtifiti  of  iliu  tnfufit  tttan  furci^ps  nppitcatifia.  U  miIbi:  1 

tt^k  iicr  it>  tUnMe  tivr  two  tmiKjs  t4)|in^ther,  und  F  then  pine* them  wiibin  tbc  bMes  oT 
frru-^trn  of  iha  insinmu'Hi ;  uow,  iimdum,  I  ttll  lipr.  roiir  Imnds  ttpphMnil  Uie  hmd 
of  titr  chilli ;  do  you  i^A  ativ  pnin  fVom  tlic'  iniilnimeiit  P  Koi  the  ilfffhinc  NvltlMf 
wUl  tntir  chitti  C'vt>eriorirei  nny  paiu  or  injury.  Wtiy,  doctor,  »lio  will  exdalM.  fmt 
Mtoui^U  iiic — I  lavvii ys  ttiim^tii  tttjit  whiii  InstnnncDt*  wero  amjikywl  tiia  ImmI  «f 
tilt  rf II hi  wri»  drtavUuWy  cru*V\<:<l  1 


THE  PBIHCIPLES  AND  PKACnC£  OF  OBSTETRICS. 


687 


▼ery  of  the  head,  be  alino«t  certainly  followed  by  mptare  of  .the 
cervix? 

5.  Previously  to  introduction,  the  blades  should  be  separated, 
placed  in  a  vase  of  warm  water,  and  then  properly  lubricated  with 
oil,  fresh  butter,  or  lard. 

d»  In  order  to  ensure  the  proper  application  of  the  forceps,  with 
out  injury  to  either  mother  or  child,  it  is  essential  that  the  instru 
ment  be  introduced  so  that  the  cranial  and  pelvic  curves  of  the 
blades  correspond  with  the  convexity  of  the  head,  and  the  concavity 
of  the  pelvis. 

7.  The  introduction  of  either  blade  should  always  be  preceded,  if 
the  head  have  not  entirely  escaped  beyond  the  mouth  of  the  uterus, 
by  three  fingers  gently  carried  into  the  vagina,  and  cautiously 
insinuated  between  the  head  and  uterine  orifice ;  this  I  hold  to  be 
one  of  the  fundamental  rules  in  forceps  delivery,  for  two  important 
reasons :  In  the  first  place,  you  will  be  enabled  by  this  rule  pro- 
perly to  adapt  the  blades  to  the  portion  of  the  cranium  to  which 
they  should  be  applied ;  and,  secondly,  there  will  be  no  risk  of 
injuring  the  cervix  of  the  organ  with  the  extremity  of  the  instru- 
ment, which  would  almost  certainly  be  the  case  without  the  precau- 
tion just  named.  If,  however,  the  head  should  have  completely 
freed  the  cervix,  and  rest  in  the  vagina,  then  it  is  not  neeci'sary  to 
carry  the  fingers  within  the  cavity  of  the  organ,  but  care  should  be 
taken  that  the  extremity  of  either  blade  be  so  adjusted  on  the  sides 
of  the  head  that  no  injury  be  done  to  the  mouth  of  the  uterus;  and 
to  accomplish  this,  let  the  fingers  be  carried  up  as  far  as  the  cei*vix, 
■o  that  this  may  be  guarded  against  violence. 

8.  Except  when  the 
oeciput  corresponds  with 
the  left  lateral  portion 
of  the  pelvis,  the  male 
branch  should  be  intro- 
duced first. 

9.  At  the  time  of  intro- 
duction, the  accoucheur 
should  gently  seize  one 
branch  of  the  instrument 
(the  male  branch  with 
the  lefl  hand,  the  female 
branch  with  the  right), 
so  that  the  thumb  shall  be 
applied  on  the  convex 
surface,  midway  between 
the  extremity  of  the  han- 
dle and  blade  (Fig.  89), 
grasp  the  branch  on  the 


Pto.  89. 

while    the   middle   and    ring 
concave  surface  just  below    the 


fingers 
ring* 


588 


THE   PRINCIPLES  AND    PHACTICK   OF   01 


^vitli  the  iiidev'  finger  applied  ui>ou  the  outer  portion  of  the  ring 

iuoit:* 

10.  The  int  rod  action  nmst  bo  madt*  during  the  inten*al  of 
ntcriiie  ooritnioti*)n  ;  imd  bufon*  tnakinj?  any  ailefWjil  to  introdnr^ 
the  branofi  Xhw^  seized,  I  am  in  the  hiihil  rif  pljicinj?  the  infttruriHitt 
ill  Riich  wjiy  that  it  nhall  In*  ursirly  jmrallel  to  the  nxi^  of  this  In^ily 
(if  the  male  branch,  the  paraMel  will  be  <»n  llic  right  »idc;  if  the 
Aimale,  on  the  left  aide) ;  then  the  extremity  of  the  blade  ii  to  Ue 
pressed  on  the  pidm  of  the  hand  already  introduced  into  the  Ttgioa 
(Fig.  89),  and  in  pnj|>ortion  a.^  it  ]n»netrate8  tfie  vagiria,  tl*  hiindle 
of  the  iiiHtrnmLMit  is  branrrht  t»>ward  tlie  operator. 

IL  l{enioml>er  that^  in  the  in  trod  action  of  the  forceps  nothbg 
will  justify  brute  force  ;  Kliould  there  bo  some  slit^ht  inipedimeilt  to 
its  passage,  let  llie  aecmieheur  employ  his  jud^rment,  and  not  vio- 
lence, and  wiih  a  Uttle  t^kilful  nmnipulatiiin  the  obslaclc  will,  mvdwt 
ordiuai7  circuiustanccs,  be  readily  removed. 

12.  The  head  ^hoold,  iS 
a  general  rule,  be  .^i-ixi-d  ia 
the  direction  of  iln  oceipilo* 
mental  diameter^  for  in  this 
way  the  greatest  {KtiNible 
fat'ihty  will  lie  nlforded  tSrir 
lis  wife  exlnu'tion.  It  in  a 
grave  error  to  nupp«we  thai 
the  blades  shtndd  iiivnrialifr 
bo  applied  on  the  Ndes  of 
the  pelvtH;  t^  is  the  /mm#- 
tton  of  th^  head^  as  will 
lierealler  be  abown,  •c\Ai^ 
f>  to  ihcide  the  /H>#ilian  qf 
the  UadrM, 

13.  When  >rh 
has  been  pr*»|  .  ro- 
duced,  it  U  to  be  intrortij 
to  an  aid,  who  t:ik«^  It  by 
the  hanille  (Kig.  00),  and 
bohh  it  steadily,  for  fbe 
^li^hte^t  movement  wfll 
of^enttmea    embarniaa    the 

operator.  The  other  braneb  i*  then  inlmduced  njion  promelj 
the  same  general  hush  (Fig*  00) ;  when  it  ha-*  embraced  the  bettd^ 
the  aeoonebeur  then  takes  the  handle  of  the  branch  which  Ima  htmt 
intrusted   to  the  assistant^  and  by  judieionn  uuinipubitioD  will  be 

•  U^t  i\\e  Biui\r\\i  MXiinUtm  liim»t'ir,by  ftrqucnt  triiil*  oo  tlii?  mnoikin.  to  iHat  Ite 
InnnifiK'iii  Ui  t*u'  nmiintr  <U«*cri>HKl,  Had  It*  will,  1  •m  ium  fluU  great  t 
Ibllowiaf  ll»n  ruW  til  i\i^  Urd^ldft 


Tuk  M. 


THE  PBINCIPLES  AND  PRACTICE  OP  OBSTETRICS. 


589 


enabled  to  bring  the  two  handles  in  juxta-position,  which  constitutes 
what  is  known  as  locking  tlie  forceps^  a  very  essential,  and,  in  my 
opinion,  the  most  important  part  of  the  entire  operation ;  for  if  the 
instrument  lock,  the  i)roof  is  positive  that  it  has  been  correctly 
applied. 

14.  After  the  instrument  is  locked 
(Fig.  01),  many  accoucheurs  recommend 
that  the  handles  should  be  kept  closely 
in  union,  and,  for  this  purpose,  they  re- 
sort to  a  napkin  for  the  purpose  of  bind- 
ing them  together.  Tliis,  as  a  general 
rule,  is  bad  practice,  and  should  be  had 
recoui'se  to  only  in  case  of  diminished 
pelvic  capacity,  when  it  becomes  im- 
portant to  lessen  the  volume  of  the  head 
by  more  or  less  powerful  pressure.  Fm.  oi. 

15.  The  force  employed  for  the  purpose  of  delivering  the  child 
should  be  compound,  consisting  oftico  thirds  lateral  and  one  thir 
eoUrctctive;  and  with  this  object,  the  right  hand  should,  with  its 


Fio.  92. 


dorsal  surface  upward,  be  made  to  seize  the  handle,  while  the  index 
and  middle  fingers  of  the  left  hand  (Fig.  92)  are  placed  in  the  two 
rings  of  the  instrument ;  occasionally,  in  the  absence  of  pain,  the 
fore-finger  should  be  introduced  into  the  vagina  in  order  to  ascer- 
tain the  progress  of  the  lieatl. 

16.  The  traction  is  to  be  made  only  dm*ing  a  pain,  or  while  the 
uterus  is  contracting;  ai\cr  the  contraction,  the  effort  should  cease 
until  another  recurrence  of  the  ])ain  ;  and,  during  the  interval  of 
pain,*  the  handles  should  be  slightly  separated  in  order  that  the 
head  may  be  liberated  from  any  undue  pressure. 

•  If  anirsthetics  bf3  Ij.id  rocourao  to,  the  pains  will  usually  he  more  or  loss  absent; 
and,  in  this  case,  th(?  rule  of  inakinj?  traction  only  during/  a  pain  does  not  obtain. 
There  will  also  l>o  an  exception  to  the  nile,  wlicn,  in  cfajseipn'iice  of  some  serioufl 
and  pressing  complication,  prompt  extraction  ot  the  child  \a  indicated. 


590 


THE   PRlxVCll'LES  AND   PRACTICE  OF  OBSTSTBIOB. 


17.  As  soon  as  the  heaiJ  bogins  to  pmtrude  at  the  vuh'fi  (if  xht 
occiput  eorre«i»ond  utth  the  s)  raphysis  pubis),  the  hanJk*  of  the 
forceps  should  be  suceesBiveiy  but  graduallj  debated  (Fig.  93),  for 


the  puTfiose  of  producing  the  movement  of  extension^  or  btiiigii^ 
the  chill  from  the  sternum,  bo  that  when  the  head  hun  complrtdjr 

escaped  through  the  vulva^ 
the  handles  of  the  trititrumcsil 
Will  describe  a  right  Aogk 
with  the  abflomcn  of  the  dmk 
ther  (Fig.  Oi).  Should,  bow* 
e\  er,  the  face  corre-sp^ind  willi 
the  symphysis  pubis,  tl>e  di- 
rection to  be  giver  la* 
8trument  will  be  }m  tbt 
reverse,  and,  conse<pifrntlj, 
the  head  being  delivered,  ibe 
handles  of  the  foreeps  will  hm 
at  a  right  angle  with  tlie  f|li> 
titil  cohimn* 

18.  Oare  must  be  taken  to 
make  proper  prosstirc  on  Ibt 
perineum,  as  soon  as  the  b«id 
begins  to  d intend  it. 

10.  When  the  head  bu 
been  extracted,  the  in^rti- 
ment  is  to  be  removed,  but 
this  needs  some  caution  ;  for  example*  the  fc>recp»  Hhofdd  be  un- 
locked by  directing  the  handle  of  the  female  brancli  n>wArd  ihe 
lea  thigh,  and  the  handle  of  the  male  bninch  toward  the  right 
thigh  ;  this  will  readily  enable  you  to  detach  the  bladeis  from  the 
head  in  corre?^pondenee  with  their  rci»pectivo  curved  aod  coqtu 
tfurfiices. 


Fi«.  S4* 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         591 

You  may,  gentlemen,  perhaps  imagine  that  I  have  been  unneces* 
sarily  minute  in  the  enumeration  of  the  above  rules  of  guidance ; 
but,  if  my  experience  have  not  deceived  me,  there  is  not  a  direction 
inculcated  which  will  not  be  of  value  to  you,  when  thrown  upon 
your  own  resources,  in  the  use  of  the  forceps.  Study  these  rules 
faithfully,  become  familiar  with  them,  and  what  is  most  essential — 
do  not  fail  to  appreciate  why  they  are  necessary  to  a  successful 
forceps  delivery.  Brevity  is  always  commendable,  but  it  should 
not  be  at  the  cost  of  an  important  fact. 

I  shall  now  proceed  to  demonstrate  the  mode  of  applying  the 
instrument  in  the  various  positions  assumed  by  the  head  at  the 
inferior  strait ;  in  doing  so,  I  shall  be  enabled  to  reduce  to  their 
practical  operation  the  different  rules  just  cited. 

First  Po8itio?i — T/ie  Occiput  regarding  the  Pubes^  the  Face  in 
the  Concavity  of  the  /Sacrum, — In  this  position  of  the  head,  the 
forceps  is  applied  with  more  facility  than  in  any  other  which  it  may 
assume ;  and,  indeed,  it  is  the  most  frequent  position  at  the  inferior 
strait  in  which  artificial  delivery  is  indicated.  Let  us  now  inquire 
under  what  special  circumstances  the  instrument  becomes  necessary 
in  this  first  position  of  the  head  at  the  outlet.  Here,  the  labor  may 
have  progressed  most  auspiciously;  the  uterus  has  contracted 
regularly  and  with  due  efficiency,  which  has  resulted  in  bringing 
the  head  completely  down  into  the  pelvic  cavity ;  but  at  this  period 
of  the  parturition  a  contre-tempa  may  arise,  such  as  convulsions, 
hemorrhage,  exhaustion  ;  or  it  may  be  that  there  is  a  slight  narrow- 
ing of  the  transverse  or  bis-ischiatic  diameter  ;  or  the  coccyx,  from 
rigidity  of  the  sacro-coccygeal  articulation,  will  not  yield  ;  or, 
again,  there  may  supervene  complete  and  rebellious  inertia  of  the 
aterus;  or,  peradventure,  rupture  of  the  organ  may  take  place. 
Any  of  these  occurrences,  therefore,  would  indicate  the  necessity 
of  interference ;  and  the  proper  time  for  the  interference  must  rest 
with  the  urgency  of  the  symptoms,  and  the  sound  judgment  of  the 
accoucheur. 

The  consent  of  the  patient,  we  assume,  is  had,  her  position  on 
the  bed  arranged,  the  mouth  of  the  uterus,  as  also  the  vagina  and 
vulva  are  adequately  relaxed  and  dilated,  the  bladder  and  rectum 
in  the  right  condition,  and  the  accoucheur  with  his  two  aids 
properly  seated.  The  blades  of  the  forceps  have  been  immersed  in 
warm  water,  and  well  lubricated  with  oil,  or  lard.  In  this  position 
of  the  head,  the  fingers  of  the  right  hand  are  carefully  passed  into 
the  vagina,  and  insinuated  with  caution  between  the  sides  of  the 
child's  head  and  the  internal  surface  of  the  mouth  of  the  uterus, 
should  the  head  not  have  completely  escaped  from  the  organ ;  the 
male  branch  of  the  forceps  is  seized,  as  indicated  (Fig.  89),  and 
placed  nearly  parallel  to  the  axis  of  the  woman's  body,  on  the  right 
side ;  the  extremity  of  the  blade  is  then  brought  down  so  as  to 


592 


TILE   PRINCIPLES  AND   PRACTICE  OF  OBSTETRICB. 


prv^i^  agahmt  the  palm  of  tho  hand  air*  'li« 

vugidiL,  atid  tlie  blade  is  theti  I'unJiictvili  (li  itn. 

trnctiufi,  iilong  the  iio^ers  to  be  adapted  to  tbe  lateral  nurfuise  of  tba 
child's  hcacl,  ihi?  Imndlu  of  tljt*  iiifitruniciit  Ix^inj^  iiii>dt*  ^--  *  "t  to 
approach  tho  uicdiati  lauf ;  when  the*  iritrt>ductiou  uf  the  1  n* 

pk*ted,  the  haiidlo  becomes  parallel  to  the  axis  of  tbe  irii  .il, 

]hit  how  nri!  you  to  be  asjjured  that  tbe  l>!ade  b.^  ,.  j.rljT 
granped  .the  beu«l,  and  that  the  extremity  of  the  fetiOHirum  in  uear 
the  inferior  toaxillary  bone?     This  may  be  n  A  from  tho 

fact  ilial  the  blade  hai  been  introduced  to  the  r  iWrciriivo 

inches,  that  it  ia  more  or  letts  Hrm,  antl  iu  making  gentle  traetjoQ 
an  tlie  instrument  in  a  ^trai^ht  line  from  within  <intward^  ibore  it  a 
slight  resist jiiire.  One  branch,  therefore,  being  ndjiiiitifd,  H  li 
intruHted  to  an  a^isiMant,  who  bohU  it  Hleadily  in  po^  j*?*  ©0); 

the  aeeoueheur  then  withdraws  bis  right  hand  froti)  '  ^ina^imd 

proceeds  to  introduce  the  other,  or  lemnle  bruiieh,  at  foIJowt;  iIm 
fingei-a  of  the  lefl  baud  are  carried  into  tbe  vagiuji,  to  be  injflti listed 
beiweHi  tlie  lU'ial  bea<i  and  on  uftTi  ^'  tbe  female  bhtd«<  is  next  to 
be  »eisted  by  the  light  hand,  precisely  as  wan  the  male  blmkr 
(Fig.  J#0) ;  and  its  introduction  to  be  conducted  upon  the  same 
principles,  remembering  that,  iu  this  ca«ie,  the  brancJi  munt  Ktrike 
nearly  a  parallel  with  tlje  hmg  nxh  of  the  patient***  bod^  l^ft 

Ride,  and  h  tt»  be  iutrudueed  over  and  noi  umicr  the  l-  eh 

lijis  been  already  adjusted.  As  &oon  as  the  Introductiou  luu  bvci 
aceomptished  a^s  tar  a^  the  lock  of  the  in!«trument,  the  hand  b  to  be 
withdrawn,  aiwl  the  accoucheur  then  take*i  hold  of  both  handle*  of 
tlie  tV)reeps  ibr  the  pnr[Hise  of  locking  it.  Here,  there  will  occjiiitatt' 
ally  be  experienced  B^mv  difticuky,  and  this  niiiy  ari>e  from  thu  ^Mt 
that  tho  Hr:!it  blade  introduced  haa  heeonie  deranged  tkrxKigb 
inattention  of  the  assifttant,  or  ii  may  be  that  the  !   '       tiM 

been  projierly  adjusted*     In  eitlier  ca.se,  tl»e  true  ^^tr 

ever  it  may  be,  must  be  renmved  betore  the  iiisrtntmeot  tain  bi 
maile  to  lock. 

We  will  now  suppo.He  that  all  is  eorr(^ct;  the  ACdmeheiir  tboi 
places  his  right  hand,  the  dorwil  su|iace  upward,  on  th*   "  ^f 

tbe  forceps,  the  midtlle  and  ring  lingers  of  the  other  ban  *i) 

being  insinuated  within  the  two  lings;  as  soon  as  the  pain  ctuii* 
niences,  he  begins  his  tnicticm,  wlii(?li  is  to  consist  of  a  Iwo  third 
laitnU  and  otte  third  t'xtractic6  force  :  this  compound  forcv  it  i» 
m<i>t  ef«!*ential  to  remember,  for  it  will  add  greatly  to  the  fiiciliiy 
of  tlie  delivery.  As  soon  as  the  contraction  vx'nm^  so  mast  tbe 
effort  of  the  accouohenr  bo  su^ipended,  eaae^  in  cases  m  iMicAi 
/^om  wiminent  d<trt(/cf  tjthr  io  the  mnthrr  or  childy  imtmaiktU 
d^livrrij  in  indtcaftd.  In  these  cxce[»tional  insraneeM,  tberdfbrOb  it 
h  Well  to  recoUeet  that  the  great  object  is  the  prompt  lermloatillfl 
of  the  labor 


THE  PBINCIPLES  AND  PBACTICE  OF  OBSTETRICS.         598 

Those  of  .you,  who  have  never  witnessed  a  case  of  forceps  appli- 
cation, will  be  amazed  to  leani  the  amount  of  force  sometimes 
required  to  achieve  the  delivery ;  the  strongest  arms  will  occasion- 
ally be  found  almost  surrendeiing  to  the  needed  effort ;  and  yet  all 
this  force,  if  it  only  be  tempered  with  judgment,  is  not  only  justi- 
fiable, but  will  be  quite  consistent  with  the  safety  of  mother  and 
child. 

When  the  head  begins  to  distend  the  perineum,  this  latter  must 
be  adequately  supported,  and  this  may  be  done  by  an  assistant,  or 
by  the  accoucheur  himself,  employing  for  this  purpose  the  left  hand, 
while  he  continues  hia  tractions  with  the  right.  In  proportion  as 
the  head  advances,  the  handles  of  the  histrument  should  be  succes- 
sively elevated,  with  the  view  of  bringing  the  chin  of  the  child 
from  the  sternum,  or,  in  other  words,  producing  the  movement  of 
extension  (Figs.  93,  94).  When  the  head  has  escaped  through  the 
vulva,  the  instrument  is  to  be  removed;  the  accoucheur  should 
place  his  finger  around  the  neck  of  the  child  to  ascertain  whether 
or  not  it  be  encircled  by  the  umbilical  cord  ;  if  so,  and  the  cord  bo 
drawn  tightly,  so  as  to  endanger  the  freedom  of  the  placeiito-foetal 
circulation,  one  of  two  things  should  be  done :  either  to  bring  a  loop 
of  the  cord  over  the  head,  and  thus  liberate  it  from  the  pressure ; 
or,  if  this  cannot  be  accomplished,  lose  no  time  in  making  a  section 
of  the  encircled  cord,  and  then,  if  the  uterus  do  not  immediately 
expel  the  child,  the  hand  should  be  introduced  for  the  purpose  of 
bringing  down  the  arms,  and  thus  expedite  the  delivery. 

Second  Position — The  Occiput  regarding  the  Concavity  of  the 
Saerum,  the  Mice  to  the  Pubea. — It  will  at  once  bo  seen  that  the 
head  here  is  completely  reversed  ;  and,  moreover,  in  this  position 
the  forceps  will,  in  the  majority  of  instances,  be  indicated  for  the 
reason  of  the  protraction  of  the  labor ;  for  you  are  not  to  forget 
that  the  occiput,  being  postenor,  must  have  traversed  the  entire 
length  of  the  postenor  wall  of  the  pelvic  cavity — consisting  of  the 
sacrum  and  coccyx — before  it  can  make  its  exit ;  and,  as  a  general 
rale,  the  increased  duration  of  the  labor  will  have  so  far  perilled 
both  mother  and  child  jis  to  render  it  necessary  to  resort  to  the 
forceps.  But,  in  addition,  any  of  the  accidents  already  mentioned 
would  constitute  another  motive  for  the  use  of  the  instrument.  The 
rules  for  the  introduction  of  the  forceps  are  precisely  the  same  as 
in  the  first  position.  It  is  well,  however,  to  remember  that  there 
will  be  more  difficulty  in  the  extraction  of  the  head  in  this  second 
position,  and  the  force  employed  should  be  more  guarded,  for  the 
&ce  cannot  be  brought  under  the  pubes  with  the  same  facility  that 
the  occiput  was  in  the  preceding  case,  because  of  the  greater 
irregularity  of  its  surface ;  again,  the  distension  of  the  perineum 
will  be  much  greater,  because  of  the  rounded  and  more  prominent 
configuration  of  the  occiput.    It  must  also  be  recollected  that,  in 

88 


594 


THE  PRINCIFLKS  AND  PRACTICE  OF  OBSTETBICSv 


ibis  position,  the  forcepfi^  its  soon  as  the  hea<l  hejrin«  i^1t|^htly^  to] 
protnide,  instead  of  being  elevated,  must  be  de^jres^ed^  for  th^ 
purpose  of  bringing  the  chin  from  the  slcmuni,  *o  that  whro  the 
head  l^  delivered  the  instrument  will  be  at  a  right  angle  with  ili« 
spinal  column. 

17urd  Position — The  Head  presenting  DiaffonaSy^  M#  Oocipid 
regarding  (he  L*{ft  Lateral  Portion  of  Oir  Pthiny  tfw  FUm  <ff  J 
Opposite  Sacro-ilicte  *St/mphi/»i3. — When  describing  the  rae 
of  natural  labor,  yon  were  told  that  the  head  undercfoes  three  mfl 
motits — fluxion,  rotation,  and  extension — before  ita  exit  thraogh  I 
maternal  organs  can  be  effected ;  but  it  will  sometimes  hsipf>cni1 
nature  ii^  80  far  contravened  in  the  completion  of  thi 
that  8he   will   need  the  assistance  of  art  f^jr  its  ac* 
Icre  then,  we  wilt  suppose  that  flexion  has  taken  place,  dud  tJii 
Miead  dejucended  into  the  pelvic  cnvity  in  its  diagonal  position ;  tlitj 
uteru>i  contracts  with  great  cflV»rt,  and  continues  to  do  so,  bnt  ill 
is  no  change  iti  the  direction  of  the  liead  ;  it  still  uecuplfn  llie  dii 
gonal  position  ;  the  strength  of  the  mother,  from  the  continued  boll 
ineffectual  eftorts  of  the  uterus,  begins  to  give  way  ;  tbn  brmln  of 
the  child,  also,  is  in  danger  from  severe  pressure,  as  is  cvinoed  fcfj 
the  extreme  heat  and  dryness  of  the  vagina,  and  the  corni| 
of  the  scalp. 

What,  under  these  circumstances,  is  to  be  done?  If  the  ticcon*"' 
cheur  content  himself  with  assuring  the  patient  that  tl*e  labor  ii 
progrensing  favorably,  that  it  will  soon  be  tcruunatc*!,  and  M  tftnlJ 
is  necessary  is  to  ^^  bear  doien^'*  and  **  make  the  most  of  ftetpains^ 
he  will  not  only  be  delinquent  in  duty,  but  will  find,  when  !<k>  1 
to  remedy  the  evil,  that  he  has.,  either  through  wanton  candle 
or  gvofis  ignor.inee,  alloweil  one,  and  [verhajis  two  lives  lo  be  i 
0ced.  Instead,  therefore,  of  such  passive  and  unpardonable  coimIvc 
he  should  at  once  proceed  to  ascertain  the  true  euu^e  of  tlie  ( 
in  the  delivery.  Let  him  inform  himself  why  it  is  Ihat  tb©  hmcl  I 
not  responsive  to  the  powcrfid  contractions  of  the  uterus;  why,  i 
a  word,  with  such  efforts  on  the  part  of  the  organ  the  labor  h  i 
ended*  As  soon  as  he  discovers  that  nature  ban  been  struggltD^  !■ 
vain  to  effect  the  movement  of  rotation,  and  recollecting  that  tbs 
head,  so  long  as  it  occupies  the  diagonal  position  in  the  pelvic  csvity, 
carmot  make  its  exit,  he  will  appreciate  the  cortaii^  '  >,t furtlitf j 

delay,  and  will  come  promptly  to  the  aid  of  the  m  ,>alient1 

doing  for  her  what  nature  has  been  unable  to  aocomplisb,  ri*. 
rotation  of  the  head. 

This,  then,  is  a  case  for  the  interposition  of  th«  forceps;*  b«t 
liow  15  it  to  be  introduced,  the  hea<l  occuj»yLng  the  diagooal  pMtioa 

*  Somelim^ii,  tbo  accoucheur  will  be  «ble  to  roUl«  tha  biM4  bf  ths  dopk  M^ 
dttction  of  the  \v.i\\\\ ;  vmi,  ^hm  thU  k  done;  if  tlvcr©  bo  no  urf«tit  ■imi—tfj,  tfcs 


THE  PRINCIPLES  AST)  PRACTICE  OF  OBSTETRICS.         595 

in  the  pelvic  cavity  ?  Assuredly  not  by  placing  the  blades  on  the 
odes  of  the  pelvis,  for  it  is  manifest  that,  in  doing  so,  the  lateral 
snr&ces  of  the  head  could  not  be  grasped ;  nor  could  the  object  for 
their  introduction— rotation — ^be  accomplished.  Here,  the  female 
branch  is  to  be  introduced  first,  and  for  this  purpose  let  it  be  held, 
as  already  described,  by  the  right  hand ;  and  with  the  fingers  of 
the  other  hand  carried  into  the  vagina  as  a  guide,  the  extremity  of 
the  blade  should  be  introduced  toward  the  right  foramen  ovale,  to 
the  distance  of  about  four  inches,  the  handle  of  the  instrument,  in 
proportion  as  the  blade  passes  along  the  parietal  region  of  the  head, 
being  depressed  and  inclined  toward  the  left  thigh  of  the  patient  in 
order  that  it  may  become  parallel  to  the  oblique  or  diagonal  position 
of  the  child's  head.  The  female  branch  thus  introduced  is  to  be 
confided  to  an  assistant ;  the  male  branch  is  then  insinuated  with 
the  left  hand  along  the  fingers  toward  the  left  ischiatic  notch,  for 
the  purpose  of  being  adapted  to  the  other  parietal  region  of  the 
head,  care  being  taken  to  cause  the  handle  to  approximate  that  of 
the  branch  already  introduced.  The  instrument  is  then  locked; 
the  hands  grasping  the  forceps,  as  in  the  first  and  second  position, 
the  first  thing  to  do  is  to  make  a  movement  of  the  instrument  from 
left  to  right,  the  object  being  to  rotate  the  head,  which  being 
accomplished,  it  is  no  longer  in  the  diagonal  position,  but  is  so 
placed,  that  the  occiput  is  in  correspondence  with  the  symphysis 
pubis,  while  the  face  is  in  the  concavity  of  the  sacrum.  The  ter- 
mination of  the  delivery  is  then  to  be  conducted  precisely  as  in  the 
first  position. 

Fourth  Position — The  Head  preaaitiyig  Diagonally^  the  Occi- 
put regarding  the  Right  Lateral  Portion  of  the  Pelvis^  t/ie  Face 
ol  the  Opposite  Sacro-iliac  Symphysis, — In  this  position,  the  head 
ifl  also  oblique  in  the  pelvis,  and  in  order  that  it  may  have  its  transit 
insured,  it  must,  as  in  the  preceding  case,  undergo  the  movement  of 
rotation.  For  this  purpose  the  male  branch  of  the  forceps,  seized 
with  the  left  hand,  is  introduced  first  along  the  fingers  of  the  other 
hand  in  the  following  manner :  Carried  into  the  vagina  under  the 
left  foramen  ovale,  it  is  gradually  depressed  toward  the  right  thigh 
of  the  patient  until  it  becomes  parallel  to  the  diagonal  direction  of 
the  head.  Tlie  female  branch  is  introduced  toward  the  right  ischi- 
atic notch,  and  the  handle  made  to  approximate  that  of  the  male 
branch.  The  instrument  is  then  locked  ;  here,  the  movement  must 
be  from  right  to  left,  so  that  the  occiput  may  be  brought  to  the 
symphysis  pubis,  and  the  face  in  the  concavity  of  the  sacrum.  The 
delivery  is  then  terminated  as  usual. 

It  is  well  to  remember  that  when  the  head  occupies  at  the  inferior 
strait  a  diagonal  position,  it  is  not  always  situated  as  has  just  been 
described ;  for  the  occiput,  in  lieu  of  being  at  one  of  the  anterior 
and  lateral  portions  of  the  pelvis,  may  be  turned  toward  one  of  the 


696 


THE   PRINaPLUS  AND   PRACTICK   OF  OBSTETRICS. 


pastcnor  and  lateral  enrfaoes  of  the  canal,  wliile  the  far 
will  jiroscnt  at  one  of  the  coiTefi|>onding  opposite  ai  ,    *:uIj 

For  example,  in  wlmt  are  termed  the  poMerior  occi{>ital  f>ofciti 
the  ncripiil  regards  one  of  the  imcro-iliac  junctions,  while  tb^  fi>r 
hi^ail  vvill  look  toward  the  oppuHiie  anterior  lateral  surfaee  of  thai 
prlvis.  Now,  iht*  fnct  which  I  wt^b  to  impress  upon  you  h  ihU 
no  matter  whether  the  occiput  be  anteiior  or  piisterior,  th©  Injadl 
still  occupies  n  diagonal  position,  and  consequently  t)ic  obstacle  to 
it*t  passai^e  is  prc<  i-ely  the  «ame ;  therefore,  in  cither  C3»e»  th©  •ppli-j 
cation  <»f  the  forceps  and  the  dtOivcry  aie  to  W  conducted  in  i 
anrc  wilh  the  i^arue  rnk\%  with  the  t^implu  exception  that,  io  the 
occipito*postci  lor  positions,  the  occiput,  instead  of  being  brought  to 
the  symphysis  pubiis  must  be  rotated  into  the  eoiieaviiy  of  tine 
sacrum. 

Apidication  uf  the  J^orceps^  (h§  Head  being  at  the  S*i§, 
Sfrait. — Precisely  the  same  indicntionB  may  present  thcnuftelvcn  fiir 
the  use  of  the  forccjiH,  the  head  being  at  the  brim  or  Qp|t€r  stroiti 
as  »t\i*r  its  descent  into  the  pelvic  cavity ;  for  example,  humoniiagc^  ^ 
convul^ions,  inertia,  exhaustion.     But  one  of  the  principal  causei^J 
cjdltn^r  fi>r  the  employ itient  of  the  Instrument  in  lhe*c  ia>e2*,  wU  Ml 
a  sliglit  disproportion  between  the  head  of  the  ffctus  and  the  hrim, 
whether  from  contraction  of  the  latter  or  an  increaseil  dt*ve1npm««|j 
of  the  former.*     When  this  di:i*pro  port  ion   really  exi^^tn,  uni 
antertj-posteriLir  diatneter  is  not  lesM  than  three  inches 
tlic  forceps  would  probf»bly  present  a  safer  mode  of  i         ^   tbafll 
version.    Yet,  I  am  quite  confident  that  to  apply  the  fbrcrpt  |ifl^ 
perly  at  the  upper  strnit  in  one  of  the  ino^t  diflicult  •  *  iit  f 

<»'.^tetric  surgery,  and  the  h:uard  of  injury  to  the  sot:  tli 

mother  is  vary  great;  for  here,  you  arc  to  remember,  b* 
difficulty  of  accurately  adjusting  the  instrument  to  the  bcv  .  .  ,  ...c 
oirdd,  there  is  the  danger  of  lacerating  the  cer^^lx  uteri  and  pcfi- 
n«'nm,     vVgain  :  the  safety  of  the  child  is  much  more  likely  to  bftJ 
ci>Tnpromii*ed,   in   consequence   of  the   more   protracted    tract* 
ncc<*Mriry  to  accomplish  its  delivery. 

But  you  may  a^k,  whut  is  the  true  difierence  in  tlic  d"*  "  '    f 
foroi'ps  application,  when  the  head  is  at  the  inferior  or  r 

strait?  A  moment's  thought  will  very  siitisfiictorily  exp  i-  i  .  • 
ditfcM'oncc.  In  the  former  case,  the  instrument  in  order  to  gtii-v  tie 
head  properly  is  required  to  pursue  but  one  axis  of  the  ptnal — tliii 
axis  of  the  lower  strait — while,  on  the  contrary,  the  head  b«*ing  i 
the  briut,  one  of  the  fundatneutal  principles  of  ftuccess  l\  titai  tUtl 


*  It  Itns  iilr«iidy  bp«a  elated  tlmt  Prof,  Stmpson,  id  ronval  <if  nn  nTd  practiet,  hm 

pu(rKv>t(.'d  the  flub^titutiou  of  Tension  for  the  fortwpB  tind  cnijii'  '  u  ^Lm  kmd 

MA  M  \hv  sup<?nor  ^iraK  mid  therv  is  u  contrscCion  of  tfio  briui .  'j  pi%/pf^0j 

hRil  tiUanlimv*  prsuHicJiWitiiy  of  such  BubfltitQikm  I  bar*  tn/  (kmb^  m  kai  bmm 

nifeaLioued  la  a  pr«fvioua  lcc«arew 


THB  PRIKCIFLSS  AND  PRACTICE  OF  OBSTETRICS.         597 

forceps  shall  be  introduced  in  accordance  with  the  two  carves  of  the 
pelvic  cavity,  viz.  the  curve  of  the  infenor  and  the  curve  of  the 
superior  straits.  Therefore,  I  should  advise  you,  whenever  you 
have  the  election  between  the  two  alternatives,  forceps  or  version-  - 
if  there  be  no  contraction  at  the  brim — to  prefer  version,  unless  the 
uterus  be  so  firmly  contracted  around  the  body  of  the  foetus  as  to 
render  the  introduction  of  the  hand  impossible ;  in  this  event,  it 
would  be  better  to  resort  to  the  forceps. 

I  have  on  several  occasions  been  obliged  to  apply  the  instrument 
at  the  upper  strait,  and  happily  with  safety  to  both  mother  and 
'child,  where  the  alteniative  of  version  did  not  exist.  It  will  only 
be  necessary,  however,  for  you  to  attempt  the  operation  once,  to 
become  persuaded  of  the  difficulty  and  danger  involved  in  it.  The 
following  case  is  in  point : 

I  requested  two  of  my  students,  Messrs.  Guernsey  and  Blodgett, 
to  attend  one  of  my  clinic  patients,  who  was  in  labor ;  she  was 
twenty-four  years  of  age,  healthy  and  robust,  and  pregnant  with 
her  first  child.  She  had  been  suffering  more  or  less  from  slight 
pains  for  two  days  before  these  gentlemen  visited  her ;  and  after 
the  lapse  of  twenty-six  hours  from  their  first  visit,  Mr.  Guernsey 
informed  me  that,  notwithstanding  strong  uterine  contractions  for 
the  last  eight  hours,  there  was  no  progress  in  the  delivery,  and  the 
friends  were  becoming  impatient.  He  also  remarked  (I  had  not  yet 
seen  the  patient)  that  she  was  strong  and  muscular,  with  a  bound- 
ing pulse.  I  suggested  to  him  to  bleed  her  to  the  extent  of  3  xij, 
and  inform  me  in  the  course  of  two  hours,  whether  any  progress 
had  been  made.  At  this  time  I  was  sent  for,  and  was  accompanied 
by  another  pupil,  Mr.  De  Coureey.  When  I  arrived,  the  gentlemen 
in  charge  of  the  case  remarked  that  the  head  was  still  at  the  upper 
strait,  and  that  the  pains,  although  severe,  had  occasioned  no  pro- 
grress  in  the  delivery.  On  making  a  vaginal  examination,  I  found 
their  representations  to  be  literally  true  ;  the  mouth  of  the  uterus 
was  dilated,  but  the  head  unusually  large  and  resisting  had  not 
begun  to  disengage.  The  occiput  was  toward  the  left  acetabulum, 
the  anterior  fontanelle  at  the  opposite  sacro-iliac  symphysis,  and  the 
head  in  a  demiflexed  position.  There  was  considerable  heat  about 
the  vagina,  and  the  scalp  was  evidently  corrugated,  showing  that 
unusual  pressure  (all,  however,  unavailing)  had  been  exerted  on  the 
head,  and  that  the  child  from  this  cause  was  in  more  or  less  danger. 
The  woman  herself  earnestly  supplicated  that  we  should  deliver  her, 
her  only  anxiety  being  the  sjifety  of  her  child.  It  was  no  easy 
matter  to  decide  upon  the  course  to  be  adopted  in  this  case ;  it  was 
evident,  however,  that  artificial  delivery  was  indicated ;  but  whe- 
ther by  version  or  the  forceps  was  a  question  of  some  delicacy  to 
determine. 

Under  ordinary  circumstances,  there  would  have  been  no  hesita^ 


598 


THE  PRINCIPLES  A^^>  PKACTICE  OF  OB9TETBICS. 


tion^  for  the  head  bein^^  at  the  Buperior  strait,  am!  interpostion 
being  uonessary,  version  would  be  preferable.  But,  in  thia  iotuuio^ 
the  hrnd  was  more  th:in  ordinarily  large,  and  turning'  would,  of 
course,  have  been  attended  not  only  with  much  difficulty  Uf  ihr 
0[>erator,  but  with  serious  result:^  most  prohahly  to  both  mother 
and  child.  Ad«l  to  thia,  that  tlu»  «teru«  wa*i  contraeting  with  grral 
ener^^y,  and  it  will  be  seen  that  the  question  naturally  arow — nHdcb 
would  afford  the  best  chance  to  the  mother  and  child,  the  forcqm 
or  turninf^?  I  decided  on  the  former,  and  in  eon»equ<*nce  of  ibo 
pecutiur  cireutustunces  of  the  caxe,  departed,  in  thin  preferencv, 
from  the  rule  which  I  hold  to  be  very  uenenilly  proper — io  twm 
jrath(^r  than  attempt  delivery  ht/ the /arcepi  wH^n  the  head  §4  at  th$ 
er  strait.  Proceeding  cautiously,  afler  some  little  difficulty  I 
succeeded  in  atlj listing  the  blades  of  the  insiriuuent,  but  found  it 
utterly  imf)ossible  to  approximate  the  handles  of  the  forcepa^  to 
con?*equence  of  the  size  of  the  head.  I  carefully  hekl  the  handbii^ 
guarding  asfainst  the  possibility  of  the  blades    '  and 

[icnced  my  traetiona  downward  and  backward,  cecded 

about  twetity  minutes  in  delivering  the  patient  of  a  vtgoroiif 
unusually  large  living  child. 

The  application  of  the  forceps,  the  head  bcin^  at  th©  ftttpennt 
strait,  h  a  modern  ex[>edient ;  and  the  credit  of  having  been  iIm 
fir«t  to  resort  to  this  measure  is  generally,  I  believe,  awardf4  to 
Palfyn,  who,  in  1723,  actually  applied  the  tniitmment  aitd  delivirtcl 
the  fcDtus.  Before  this  time,  the  long  forceps  was  not  in  mae^,  maA 
it  wa?*  with  the  view  of  imitating  the  example  of  PallVn  ffert 
Smellie  improved  his  fu reeps  by  adding  to  its  length,  and 
it  the  curve  on  its  border,  thus  causing  it  to  corr^potid 
two  curve-*  of  the  pelvis. 

Application  of  the  Fhreeps  at  the  Sfiperior  Strait^  tA 
reganling  the  Ptihee,  the  Fhrehead  the  Sacrthvertekrai  Pr 
— When   describing   the    position    of   the    fcetal   bead,   and   ihf 
mechanism  of  its  de/icent  into  the  pelvic  cavity,  yoti  werr  •   '  •  •     t 
it  is  extremely  rare  for  the  occiput  to  remain,  after  tho  00 
of  the  uterus  have  fairly  commenced,  either  at  the  pu'' 
ita  tendetiey  being  to  turn  either  to  the  right  or  left, 
ing  the  direct  into  one  of  the  oblique  or  diagonal  [losittattt^    Yil^ 
^  an  excejilion,  these  direct  positions  may  continue,  and  therefiirii 
it  in  proper  that  the  rules  for  the  application  of  the  forcsrpsv  ftnAfff 
thene  circumstances,  should  be  indicated.     Here,  the  iiial«  bnuidi 
is  intro<lnced  lirst ;  the  right  han<l,  with  the  exception  of  the  thtittib, 
ID  carrieil  along  the  vagina,  and  the  enda  of  the  0ngeri  oautioadf 
insinuated  within  the  cervix  of  the  utcnis ;  the  branch  of  tbt^  br 
merit  is  held  by  the  letl  han«l,  and  itilroJuced  on   the  loft  mn 
the  jK'lvis  with  a  view  of  being  adjusted  on  the  lateral 
of  the  chillis  head.     Tlie  branch  i^  carried  up  to  Ibe  disti 


THB  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         699 

seven  or  eight  inches,  so  that  the  look  is  brought  quite  near  the 
vulva.  In  proportion  as  the  blade  glides  along  the  side  of  the 
head,  care  should  be  taken  to  depress  the  handle,  so  that  it  may  bo 
brought  parallel  to  the  axis  of  the  upper  strait.  This  branch  being 
arranged,  it  is  to  be  entrusted  to  an  assistant;  and  the  female 
bi*anch,  held  with  the  right  hand,  is  to  be  carried  up  along  the  left 
hand  previously  inserted  into  the  vagina ;  as  soon  as  the  blade 
begins  to  pass  over  the  parietal  protuberance  of  the  head,  the 
handle  should  be  depressed  as  in  the  other  instance,  in  order  that 
the  two  handles  may  be  approximated  and  locked. 

This  being  accomplished,  the  forceps  is  seized,  as  previously 
indicated ;  and  now  there  Is  a  point  of  moment  to  be  recollected, 
otherwise  the  difficulty  of  extraction  will  be  very  much  enhanced, 
and  KO  also  will  be  the  danger  to  the  child.  The  point  is  this — 
before  employing  any  extractive  force,  the  first  thing  to  do  is,  by 
a  gentle  rotapy  movement  of  the  instrument,  to  bring  the  occiput 
in  apposition  with  thelefl  acetabulum,  thus  conveiting  it  into  the 
first  position  of  the  vertex ;  in  order  to  effect  this,  the  outer 
extremity  of  the  forceps  must  be  well  depressed,  and  direited 
toward  the  left  thigh  of  the  mother.  We  will  now  suppose  the 
rotation  to  be  effected ;  then  the  compound  force,  already  alluded 
to,  is  to  be  commenced,  and  the  tractions  made  in  a  line  parallel  to 
the  axis  of  the  superior  strait — caution  being  taken  not  to  injure 
the  pL-rineum  by  the  handles  of  the  instrument — until  the  head  is 
brought  down  into  the  pelvic  cavity.  Now,  you  are  not  to  for<i:et 
that  the  head,  from  the  time  its  position  was  changed  at  the  brim, 
occupies  a  diagonal  direction.  Therefore,  as  soon  as  you  have 
caused  it  to  descend  into  the  excavation,  all  extractive  force  must 
oease,  until  by  another  rotary  movement  you  place  it  in  the  direct 
position  by  bringing  the  occiput  to  the  symphysis  pubis,  and  conse- 
quently the  face  into  the  concavity  of  the  sacrum.  Having  done 
this,  the  delivery  is  to  be  terminated  in  accordance  with  the  rules 
already  mentioned  when  speaking  of  the  use  of  the  forceps,  the* 
head  being  at  the  inferior  strait. 

Application  of  the  Forceps  at  the  Superior  Strait^  the  Occiput 
regarding  the  Sacro-vertebral  Prominence^  the  Forehead  the  Sym-^ 
physia  Pubis, — One  moment's  reflection  on  the  relations  of  the 
head  to  the  pelvis  in  this  position,  will  serve  to  show  you  that  the 
obstacle  to  delivery  will  be  much  greater  than  in  the  former  case,, 
for  the  reason  that,  here,  the  face  is  directed  toward  the  pnbe» 
which,  as  has  already  been  explained,  will  cause  the  extraction  to 
be  both  more  difficult  and.  protracted.  There  has  prevailed  a 
difference  of  opinion  among  writers  as  to  the  management  of  this 
position  of  the  head.  For  example,  Smellie  advised  that  the  face 
should  be  turned  toward  the  concavity  of  the  sacrum,  either  before 
or  after  the  head  had  passed  the  superior  strait.    If  you  follow  this 


THE   PRINCIPLES  XKD   PRACTICE   OF  OBSTETRICS. 


direction — and  it  comes  from  very  high  atilhority — ^>'ou  will  tneor 
the  almost  certain  hazard  of  destroying  the  child  by  ihe  extrt^me 
torsion  to  which  yon  subject  its  neck,  amounting,  aa  yon  pcr<!eirc» 
to  one4mtf  of  a  circle.  Again:  it  has  been  r©eomme!ide«K  i«  this 
position,  to  phice  the  border  curve  of  the  forceps  in  correspondence 
with  the  Hiirrum. 

The  application  of  the  instrn merit  on  the  manikrn  will  »pe<HiHy 
<3onvtnee  you  not  only  of  theine<>nvenienco«but  the  utter  absurdity 
of  this  latter  precept*  In%te>i(i,  therefore,  of  adoptinpf  either  of  tbe 
above  rules,  lht»  fort^eps  »hoti!d  ht*  intn>diici*d  prccisrly  as  in  th« 
former  oa«e,  *m  the  isiJcs  of  the  p<4vi^,  and  miwie  to  gra«p  the  brad 
on  m  lateral  surfaei^s.  Alter  the  in^^irument  hiu  been  pruperljr 
adjusted,  a  gi/ntle  i*otary  movement  sliould  be  imparted  lo  tlit 
foreepn  for  the  jiiirpose  of  tuniiri!^  the  foreliead  lo\rartl  tl*c  Irft 
acetabiilmn  ;  then,  with  downward  and  backward  traction^  the 
head  Wiritf  bronjrht  into  the  pt^lvic  cavity,  it  is  aj^iiit  changed  from 
the  diagonal  to  the  direct  jxisition  by  bnn;^iffg  the  face  to  tlie  tyni* 
physiis  publn.  The  delivery  in  gub!*i*qnently  terminated  ms  baf 
already  been  deHciibf^d,  the  head  belfig  at  the  inferior  sitmjt  wilfc 
the  face  to  the  ptiben,  and  the  occiput  in  the  corjcavity  of  tlii 
sacrum* 

Appliattion  of  the  Fhrreps  at  t/te  Superior  Strait^  th4  OtX'ipiti 
re^farditiff  the  Le/t>  Acetafmium^  the  J*Wehead  the  opposite  Ara^ 
iVne  Stjmphi/sitt, — It  w  ill  Ih*  perci^ivctl  thjit  the  hend  occupi<«  in 
this  position  a  dirigoual  direction  at  the  upper  strait ;  and  the  for- 
ceps ii  to  be  so  introduced  as  to  seiae  the  head  in  it«  long  m 
occipito-rnental  diameler.  For  this  purpose,  llie  female  br&neli  b 
introduced  tii'st ;  it  is  held  by  the  riijht  hand  iind  glided  along  tlitt 
fingers  of  the  other,  which  are  carried  to  the  o§  uteii  in  tbe 
direction  of  the  right  sacro-iliac  sympliyMis;  the  lilade  of  lb*i  infitr»> 
ment  is  introduced  toward  this  latter  point  until  it  embraces  tbt 
forehcnd  ;  it  is  tfien  brouglit  over  the  teniph\  which  will  bo  found 
in  corre*ipondence  either  with  the  right  fitnunen  ovale  or  ftymphytb 
pubin,  depending  upon  whether  the  head  occupies  the  liiagoual  or 
tntnj«verse  position.  lu  proportion  a*  the  blade  beoornin*  adapted 
to  the  sHe  of  the  head,  the  handle  of  the  instrument  mu«l  \m 
gra«lu."illy  «lepres!*ed  toward  the  flov>r  of  the  pelvis.  Tidt  braiiell 
beirtg  thtn*  avijusted,  it  i»  to  be  confided  to  an  aid.  Tb<i  male 
bmnch  IS  then  hehJ  by  the  left  hand,  and  directed  along  tho  fingvn 
of  the  right,  which  are   inliodneed   into  the  vacrina  t  ^    The 

srtcrum  ;  the  blade  u  made  to  glide  along  the  hand  in  tl  uio 

of  the  front  of  the  sicrum;  at  fiiNt,  the  extremity  of  the  haml^e  is 
to  be  elevatel  with  an  inclination  toward  the  WX  >'ide  of  the  pubci ; 
in  proportion,  however,  an  the  b!ade  glide*  along  I  lie  sacrum  and 
under  the  head,  the  handle  is  gently  depreyjied  for  tbo  purpOM  of 
approximating  it  to  that  of  the  female  branch. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         601 

The  two  respective  branches  being  locked,  the  instrument  is 
seized  by  both  hands,  as  previously  indicated.  The  direction  of 
the  extractive  force  must  at  the  commencement  be  downward  and 
backward,  parallel  to  the  axis  of  the  superior  strait,  remembering 
to  keep  the  handle  of  the  forceps  inclined  toward  the  left  thigh  of 
the  mother,  in  order  to  bring  the  head  into  the  pelvic  cavity ;  when 
the  head  has  thus  descended,  do  not  forget  that  it  still  occupies 
the  diagonal  position.  Therefore,  all  traction  must  cease  until  the 
occiput  is  rotated  to  the  symphysis  pubis ;  the  delivery  is  then  com- 
pleted as  has  been  described. 

Application  of  the  Forceps  at  the  Superior  Strait,  the  Occiput 
regarding  t/ie  Right  Acetabulum,  the  ForeJiead  the  opposite  Sacro- 
iliac Symphysis, — Here,  again,  the  relations  of  the  head  to  the 
upper  strait  of  the  pelvis  are  the  same  as  in  the  former  position, 
and  precisely  the  same  principles  are  to  be  observed  in  the  applica- 
tion of  the  instrument.  The  male  branch  is  introduced  first ;  it  is 
held  by  the  left  hand,  and  passed  along  the  fingers  of  the  other 
hand,  which  are  carried  toward  the  left  sacro-iliac  symphysis ;  as 
soon  as  the  blade  embraces  the  forehead,  it  is  then  to  be  cautiously 
dirette<l  toward  the  temple,  which  will  be  found  to  correspond 
with  the  left  foramen  ovale,  or  symphysis  pubi^^.  The  handle,  in 
proportion  as  the  instrument  becomes  adjusted,  is  to  be  depressed 
toward  the  floor  of  the  pelvis.  The  female  branch  is  now  held 
by  the  right  hand,  and  introduced  along  the  fingers  of  the  other 
h:i.id.  It  should  be  directed  under  the  head,  following  the  ante- 
rior surface  of  the  sacrum.  The  extremity  of  the  handle,  which 
is  at  first  elevated  and  turned  toward  the  right  groin  of  tho  mother, 
must,  as  the  blade  advances  upon  the  head,  be  brought  downward 
or  depressed  for  the  purpose  of  uniting  with  the  male  branch. 
The  instrument  being  locked,  the  handles  are  seized  by  the  two 
hands,  and  an  extractive  force  exercised  downward  and  backward 
parallel  to  the  axis  of  the  superior  strait ;  when  the  head  is  brought 
into  the  pelvic  cavity,  a  rotary  movement  from  right  to  left  must 
be  made,  in  order  to  turn  the  occiput  to  the  symphysis  pubis,  and 
the  face  to  the  concavity  of  the  sacrum.  The  delivery  is  afterward 
completed  in  the  manner  already  indicated. 

Supposing  the  head  to  occupy  reverse  positions  at  the  brim,  viz. 
the  forehead  at  the  left  or  right  acetabulum,  and  the  occiput  at  the 
right  or  left  sacro-iliac  symi)hy8is,  the  application  of  the  foreei)s  is 
to  be  conducted  precisely  on  the  same  principlcjs,  remembering, 
however,  that  the  male  branch  should  always  be  under  the  symphysis 
pubis,  and  the  female  branch  in  front  of  the  sacrum. 

Application  of  the  Forceps  in  Ztocked-IIead, — ^The  term  locked- 
head  is  made  to  mean  many  different  things,  according  to  the  defi- 
nitions given  of  it  by  the  various  writers,  who  have  alluded  to  the 
Bubject.     Without  occupying  time  in  the  enumeration  of  the  con- 


THB  PRINCIPLES  AND   PBACTICE  OF  DB9TETR1CSL 


flicting  opioions  a?*  to  whiit  locketl-head  really  is,  it  will  he  KufTirtt'iit, 
for  all  practical  ])ui']>oftej*,  to  8tat(?  that  the  very  term  impiit-*  an 
immobility  or  fixedness  of  the  liead,  which  no  power  of  the  uterus 
can  overcome;  and  which  immobility  i«  in  part  demonstrated  by  Uit 
fact  that  the  head  cannot  bt*  mnde  either  to  amtend  or  deseeud  by 
any  manual  effort  of  the  accoucheur.  And  here,  I  may  be  p«f 
mitted  to  say,  that  I  do  not  believe  this  eonditiun  of  things  to  be 
pos^iible  in  a  well-conformed  pelvis,  the  bead  posseiisiog  it«  ordtDirf 
dimenmons. 

Loekedhead,  tbereforCf  when  it  does  occur,  isi  in  my jqdgiBtiil, 
the  result  of  a  disproportion  between  the  head  of  the  fcem^  and 
pelvic  canal,  whether  front  cxcc^ssivc  sisto  of  the  former,  or  dimi- 
nished capacity  of  the  latter.  This,  too,  is  the  opinion  of  Madams 
La  Chapclle,*  who^  in  her  vaj<t  experience  in  the  mateniiU  of  l*anii, 
never  met  with  an  exam]4e  of  locked-ltead  where  ther«^  waaaprt»per 
relation  between  the  fcptu^^  and  maternal  organs ;  morec^'er,  ihii 
dever  observer  is  incline*!  to  believe  tfjat  what  has  be4*n  !(Uppo^te<l 
by  most  writers  to  be  veritably  lot-kcd-head,  may  bo  explained  in 
another  way,  and  referriHl  to  deftjrnntics  of  the  pelvis,  t-  >m 

of  the  fiDtal  head,  or  to  strong  a»Kl  long-continued  ell  th« 

nterus.  It  is  quite  evident  to  my  mind,  and  amply  proved  by  pef*- 
Bonal  experience,  th;it  there  is  oftentimes  an  erroneous  dia^no^b 
arrived  at  on  this  question  in  thn  lyinir  jn  room,  I  have  more  than 
once  been  summoned  by  my  professional  friends  to  meet  ibem  ill 
counsel  in  cases  of  sufiposed  imuiobility  of  the  head  ;  and^  on  a 
close  ex:umnation  of  the  state  of  things,  I  have  found,  not  thai  llit 
head   was  immovable,  but  8iinf»ly  that  its  progress  tl  "     \ht 

pelviu  canal   was  «lut:)jtish,  n-quiriiii^  only  that  very  l-  ihiI 

too  frecpiently  neglected  renic*ly — jt^iiience^ 

There  exists,  also,  a  very  remarkable  difscrepancy  of  opiiuoii 
among  writers  as  to  the  relitivo  frequency  of  locked-head  com^ifired 
with   other  formidable  obstacle?*  c:iniug  for   the  inter'  of 

science.     For  exruitple,  while  it  i-i  conccfled  tb-it  it  is  ti(   ;  uf. 

rence  in  France,  our  own  distinguished  countryman,  Dr.  I>eir0««it 
avows  that  he  h.xs  never  recognise  Ian  exampL'  of  it  in  htapnu:lieO| 
whi<*h  circumstance  he  refers  to  the  fact  of  the  genendly  prevaiGng 
beallhy  or  normal  (telvio  conf*»rraation  of  our  American  womeo; 
yet  we  have  a  hijjh  authority^  Camper,!  assuring  us  that,  in  Hot 
land,  Kwke«l-hca  1  U  by  no  ineatis  among  the  rare  oeeurrenres  of 
the  parturicnl  eh^Jmber.     This  discrepancy,  it  seoms  t>^  *^«s 

frotn   the  circum^^tance  of  the  general  want  of  concui  to 

the  true  meaning  of  the  term  locked-hend ;  for  I  can  see  noiUbig 
in  th'*  women  of  Hollatid  so  mnrvellously  different  from  tho«io€ftli«r 
of  France  or  America,  which  could  rationally  account  for  the  very 

♦  Pmtiqii«»  il<>i  Aocoiie»i<»rnPiitji,  p.  130,  f  8yrtom  or3Xldirt(iBrf. 

I  Aciid.  do  Clilruf;^.,  toroc  v.  p.  4A0. 


THE  PRINCIPLES  AND  PRACTICB  OF  0BSTETBIC8.         608 

extraordinary  alleged  difference  in  the  relative  frequency  of  the 
oomplication  under  discussion.  Therefore,  I  repeat,  lockcd-bead  is 
one  thing  in  Holland,  another  in  France  and  our  own  country 
This  leads  me  to  remark  that  statistics  on  any  given  subject,  in 
order  that  they  may  possess  their  true  value  as  reliable  data,  should 
have  a  common  basis. 

Let  us  now  examine  in  what  the  real  dangers  of  this  complica- 
tion consist,  so  far  as  regards  the  welfare  of  both  child  and  parent, 
assuming  the  true  practical  definition  of  the  term  locked-head  to 
be — an  immobility  in  resistance  to  tht  most  powerful  contractions  of 
the  titerusj  or  the  best  directed  manual  efforts  of  the  a/icoucheur. 
It  is  manifest  that  these  dangers,  if  there  be  any,  should  be 
thoroxighly  and  opportunely  comprehended,  for  on  the  early  recog- 
nition of  this  positive  immobility  of  the  head  must  depend  the  issue 
of  weal  or  woe  to  mother  and  child. 

1.  Dangers  to  the  Child. — When  there  is  complete  immobility 
of  the  head,  notwithstanding  the  vigorous  contractions  of  the 
uterus,  it  is  too  plain  to  need  comment  that  the  life  of  the  child  is 
exposed  to  the  most  imminent  peril  from  one  or  other  of  the  fol- 
lowing circumstances:  undue  compression  of  the  brain;  depression 
and  fracture  of  the  cranial  bones;  the  formation  of  excessive 
epicranial  sanguineous  effusions,  or  even  the  detachment  of  the 
Bcalp  itself,  which  may  ensue  from  powerful  and  protracted  pressure 
of  the  contracting  uteru*. 

2.  Dangers  to  the  Mother, — The  continued  resistance  of  the 
head  to  the  impulsive  efforts  of  the  womb,  may  result  disastrously 
to  the  mother  in  several  ways :  for  example,  there  may  ensue  con- 
vulsions or  rupture  of  the  organ  in  som<5  portion  of  its  area ;  undue 
pressure  on  the  bbidder,  urethra,  rectum,  or  vagina,  giving  rise  to 
vesico- vaginal,  ure thro-vaginal,  or  recto-vaginal  fistulte,  abscesses  or 
sloughs ;  and,  also,  the  excessive  compression  of  the  sacral  plexus 
of  nerves  may  terminate  in  paraplegia,  and  other  formidable 
derangements  of  the  nervous  system.  If  to  these  accidents  be 
added  the  possibility  of  sudden  congestions,  not  at  all  unlikely  to 
occur  under  the  circumstances,  of  the  brain,  lungs,  etc.,  we  shall 
have,  I  think,  a  picture  of  contingencies  well  calculated  to  awaken 
the  attention  and  excite  the  vigilance  of  the  conscientious  accou- 
cheur. 

Under  what  circumstances  may  locked-head  occur?  I  have 
already  stated  that  I  do  not  think  it  possible,  except  in  cases  in 
which  there  is  a  disproportion  between  the  foetus  and  pelvis ;  and 
conjoined  with  this  must  be  the  prerequisite  facts:  1.  That  the 
disproportion  is  not  such  as  to  prevent  the  head  from  a  partial 
descent,  so  that  it  may  become  absolutely  locked ;  2.  There  must 
be  contractions  of  the  uterus  adequate  to  cause  this  partial  descent. 
If  what  I  have  just  said  be  true,  and  I  refer  you  for  the  demon- 


604 


THE    PRINCIPLES   AND    PHACTICE  OP  OBSmmCS. 


Btratlon  to  the  bedside,  it  manifostly  follows  that,  although  dUpixK 
portion  m?iy  exht,  yel,  wllhotil  sutficient  contractile  I'orcct  l<*ckod* 
head  cannot  ennue ;  for  it  is,  as  yon  will  not  fail  to  rei-oUecl,  the 
continued  impelling  action  of  tht;  uterus,  which  wedgeM — I  knov 
no  Ijelteir  term — the  head  of  the  fcDtu«  into  the  conlracfed  *p?*«'e. 
Therefore,  the  real  causes  of  this  conipliciilion  may  he  di  ^i 

the  predisposing  and  exciting;  the  former  refers  to  the  ix  ^  ^  r- 
tion  between  the  pelvic  can:ii  and  IcDtu,^ ;  while  the  latter,  the  tx- 
citintf  cause*  will  be  the  effort  of  the  utema. 

DiagnosiB  of  Locked-hmih — ^The  head  may  become  loek«d 
etthfr  at  the  superior  strait,  or  in  the  excavation.  In  citiier  event, 
it  will  be  in  one  of  two  positions,  vix.  it  will  present  directly  or 
tmn^versely.  In  the  former  case,  the  occiput  will  regard  the  pubes 
and  the  fac«  the  sacrum,  or  mce  versd  ;  in  the  latter,  the  head 
boinix  in  the  transverse  direction,  one  of  the  ossa  parieUilia  will  lie 
in  front,  the  other  behind.  Before  describing::  the  means  of  reme- 
dy in  t,^  this  difliculty,  and  thus  protecting  the  mother  and  child 
agaiu^t  the  dangers  of  the  compliciitlan,  it  may  not  be  unppufitJibU 
to  inquire,  ibr  the  moment,  in  what  the  true  diag^nosis  of  li>rkefl- 
he^id  consist!*,  and  whether  it  may  not  be  likely  to  mistake  some- 
thing else  for  it.  The  solution  of  this  inqtiiry  is  essentially  mat<rrial, 
undtT  the  circumstances,  to  the  proper  duty  of  the  acuoucheur; 
and  here,  allow  me  to  impress  upon  you  the  necessity  of  a  just  di** 
ti  net  ion  between  what  is  and  what  is  not, 

I  am  quite  sure  that  want  of  proper  judfijment  has  oflentimes 
induced  the  inexperienced  practitioner  to  i»i:igirie  that  he  had  jt 
csasu  of  impacted  or  locked-head,  when,  in  fact,  this  state  of  thing* 
had  no  sort  of  existence ;  the  error  has  arisen  in  this  way :  he  Uan 
recognised,  by  a  digital  examination,  a  more  or  loss  hard  tumefao- 
tton  of  the  scalp,  a  thick  and  swollen  condition  of  the  neck  of  tho 
uteru's  together  with  unusual  engorgement  of  the  vagina  and  vulvs, 
ttud  thes*»  phenomena,  too,  accom[ianied  by  strong  uterine  eon!ni6« 
tiotis;  now,  the  ijuestion  is,  do  these  ftymptoms  positively  indicate 
locked-hoad?  By  no  means;  for  the  testimony,  in  order  to  ht 
compKne  and  of  value,  n(*eds  one  more  circumstance,  which  cr^mrti* 
tntes  the  essential  and  only  positive  proof  of  theht?ad  being  louked, 
via.  iU  immobility  nat withstand ifuj  tht  vigoro^u  efforts  of  fh€ 
fiteriis,^  Therefore,  before  detcrmirdng  that  thij  compliealioa 
exists  it  must  be  first  asi.ertained  that  the  head  is  not  app&nmtiy, 
but  really  lixed,  or,  in  oihur  words,  immovable. 

A  just  diagnosis  on  this  esseuti  d  point*  will  be  the  tnettoa  of 
preventing  interference  otlenlimes  not  callt*d  for.  There  are  few 
accoucheurs  of  evtensive  pra^^lice,  who  will  not  concur  in  this 
opinion  that  nature  is  frequently  enabled  to  accompfuh  delivery  hj 

*  It  mny  b«  tn^mion4Hl  in  thU  conni>>rion  lluit  rpcmion  of  tbe  iHnd  iMtHMB  ISn 
\  \»  dc*ctsiYe  evulijuce  UmL  itn(uictiua  doo«  Dot  ci,isfc. 


THE  PRINCIPLES  AND  PBACTICE  OF  OBSTETRICS.         606 

her  own  resources  in  oases  in  which  all  the  symptoms  above 
described,  except  the  immobility  of  the  head,  are  present ;  and 
hence  you  will  occasionally  see,  in  the  course  of  your  observation, 
examples  of  an  extremely  elongated  head,  the  result  of  the  extra- 
ordinary pressure  it  has  undergone,  and  yet  the  child  born  alive. 
This  goes  to  show  the  conservative  care  of  nature,  and  how  ade- 
quate she  is,  oftentimes  under  the  most  unfavorable  circumstances, 
to  perform  her  duty — if  not  officiously  intruded  upon — consist- 
ently with  the  safety  of  both  mother  and  child.* 

But  we  will  assume  that  all  doubt  as  to  the  existence  of  locked- 
head  is  at  an  end,  and  the  diagnosis  complete ;  what,  then,  is  to  be 
done?  The  object  to  be  accomplished  is,  unquestionably,  to 
deliver  the  child  as  speedily  as  possible,  for  every  moment  which 
elapses  from  the  time  the  head  has  become  immovable  is  so  much 
against  both  mother  and  child.  The  mode,  however,  to  be  adopted 
in  the  delivery  will  depend  upon  whether  the  child  be  alive  or 
dead ;  and  this,  under  the  circumstances,  I  hold  to  be  an  important 
distinction.  If  the  child  be  still  living,  recourse  should  be  had  to 
the  forceps.  On  the  contrary,  if  it  be  dead,  I  should  recommend 
the  perforator  and  cephalotribe  as  the  most  available  means  of 
terminating  the  birth. 

Amplication  of  the  Forceps  in  Locked-IIead^  in  the  Direct  Post' 
tion^  tJie  Occiput  at  the  Pubes^  the  Face  totoard  the  Sacrum, — 
Before  introducing  the  instrument,  the  true  condition  of  the  head 
must  be  fully  comprehended ;  here,  for  example,  resting  as  it  does 
with  the  occipito-frontal  diameter  in  accordance  with  the  direct  or 
antero-posterior  of  the  pelvis,  it  is  evident  that  the  lateral  surfaces 
of  the  head  correspond  with  the  sides  of  this  canal ;  consequently, 
the  rule  is  to  introduce  the  blades  of  the  forceps,  one  on  the  lefb 
and  the  other  on  the  right  side,  in  order  that  the  head  may  be  pro- 
perly grasped  laterally  in  the  direction  of  its  occipito-mental  dia- 
«neter.  The  manner  of  introducing  the  instrument  is  the  same  as 
has  previously  been  described  in  this  position  of  the  head  when  it 
is  not  locked  or  immovable.  The  blades,  we  will  suppose,  are  pro- 
perly applied,  and  the  handles  in  juxtaposition.  What  is  next  to 
be  done  ?  A  moment's  thought  will  remind  you  that  the  forceps 
has  grasped  a  head,  which  is  completely  immovable  in  the  pelvic 
canal.    Therefore, the  brain  of  the  accoucheur  must  be  slightly  exer- 

*  In  these  cases,  however,  of  more  than  ordioaiy  difficulty,  it  becomes  the  accou- 
oheur  to  exercise  a  constant  and  judicious  vigilance ;  otlierwise,  serious  consequences 
may  ensue.  If;  for  example,  he  should  recognise  a  giving  way  of  the  mother's 
strength,  or  any  other  circumstance  likely  to  compromise  iicr;  or  should  he  find  that 
the  pressure  to  which  the  head  is  subjected,  is  such  as  to  place  the  life  of  the  child 
in  peril,  then,  of  course,  it  will  be  his  duty  to  interpose,  and  terminate  the  delivery. 
However,  what  I  desire  to  inculcate  is  this  :  as  long  cu  Vie  head  is  known  U)  respond 
in  its  progress  to  the  contritions  of  the  titeruSf  aU  other  things  being  equal,  the  labor 
should  be  committed  to  nature. 


606 


THE  PBINCIPLES  AND  FRACTICK  Or  OBSTETRICS. 


cised  ill  arder  that  be  may  determine  npon  the  coarse  to  bo  jmr* 

Bue»l. 

Wfiat  ho  is  to  do  is  this— the  forcqis  being  adjusted  oil  the  hc^, 
the  atxjoucheiir  should  seixe  the  handles,  and  i*ndcavor  to  change 
the  pohiiion  to  a  diagonal  one  by  bnnging  the  occiput  toward  tho 
lefl  acetabuhira  ;  but  much  di*xtcrily  will  be  needed.  If  ho  attempt 
by  mere  force  to  push  tho  head  upward,  lie  may  inflict  immesuuir* 
able  injury;  or  to  endeavor  by  powerful  tractions  to  cause  the  head 
to  descend  into  tho  pelvi?^  before  it  has  undergone  the  ri^uired 
change  of  pofsition,  would  be  equally  dangerous  and  nugjitory,  !!# 
should,  on  the  contrary,  attempt  in  the  first  place,  if  I  may  *a  term 
it,  to  unlock  or  loosen  the  head  by  a  ruulious  and  continued  Uteral 
movement  fVom  nght  to  lelL  This  onee  accompUiihe<l,  the  ocdpet 
is  to  be  placed  in  apposition  with  the  left  acvtabuJumf  mnd  ibt 
extraction  tenmnated  a:s  alroady  indicated.  If  the  ibrehvad  be  al 
the  pubes,  and  tlie  occij>ut  toward  the  sacrum,  tho  ^^me  rtiict 
obtain  botli  for  the  introduction  of  the  inUrumcnt,  and  the  deliveiy 
of  the  child;  except  tl»at,  instead  of  the  occiput^  tho  forcbt'id 
should^  in  converting  the  <1irect  position  into  a  diagonal  one,  bo 
brought  to  the  lofl  acetabulum.* 

In  the  event  of  the  head  being  locked  when  resting  either  ta  tbe 
dSagonaJ  or  transverse  position,  tlie  rules  for  the  introduction  of 
the  instrument  are  the  ttame  as  when  the  head  occupies  cither  of 
these  positions,  and  h  not  locked.  These  rule;*  have  already  been 
given ;  yet  it  is  well  to  remenjber  that,  in  both  instances,  tbe  for- 
ceps should  be  so  introduced  as  to  seize  the  head  on  its  lateml  ftur* 
faces,  and  not  place  one  blade  on  the  occiput^  and  the  other  on  tho 
face,  as  is  recommended  by  some  authors,  when  the  head  occupiei 
a  transverse  |K»sition. 

*  It  maj  happeo  that,  either  in  nn  occipltopubic  at  ocoipito-ttcnil  potitloki^  il 
wUl  bo  CMier  to  turn  the  occiput  or  forchciid  to  the  rii<ht  tostMid  of  tht  IfH  Mtl^ 
bulum.    In  socli  oaae  it  should  be  dvn^  without  fa«8tt«tioo. 


LECTURE    XL. 

Forceps  Delivery  continued — Use  of  the  Instrument  when  the  Head  is  retained 
after  the  Kxpulsion  of  the  Body — Circumstances  justifying  the  Forceps  in  these 
Cases — Application  of  the  Instrument,  the  Head  at  the  Inferior  Strait,  wit!i  the 
Occiput  at  the  Symphysis  Pubis,  the  Face  in  the  Concavity  of  the  Sacrum — 
Application  in  a  reverse  Position — When  the  Occiput  is  at  the  Left  and  Front  of 
the  Pelvis — The  Occiput  at  the  Right  and  Front  of  the  Pelvis — Use  of  the  Instru- 
ment, the  Head  resting  at  the  Superior  Strait— Tiie  Forceps  in  Face  Presenta- 
tions—Under what  Circumstances  indicated — Practice  of  the  Old  Sciioolmen  ia 
Face  Presentations — Objections  to — When  Version  is  to  be  Preferred  to  Forceps 
Delivery  in  Face  Presentiitions — The  Manner  in  which  the  Face  usually  presents 
St  the  Superior  Strait — Right  Mento-iliac  Position — Left  Mento-iliac  Position — 
Mode  of  Descent  in  these  Positions — Manner  and  Difficulty  of  applying  the  For- 
ceps in  Face  Presentations  at  the  Superior  Strait — Use  of  the  Instrument  when 
the  Face  is  at  the  Inferior  Strait — Mento-anterior  Position — Mento-posterior  Posi- 
tion— Comparative  Rarity  of  the  latter  Position— Tlie  Oblique  Positions  of  the  Face 
at  the  Inferior  Strait — How  managed — Face  Presentation  and  Convulsions — Case 
in  Illustration. 

Gentlemex — We  have  now  to  speak  of  the  use  of  the  forceps  after 
the  body  of  the  child  has  made  its  exit  through  the  maternal  organs. 
Although,  when  discussing  the  natural  presentations  of  the  foetus 
in  utero,  I  told  you  the  presentation  of  either  of  the  obstetric 
extremities  of  the  ovoid  is  in  perfect  keeping  with  the  resources  of 
nature,  yet,  at  the  same  time,  you  were  admonished  that  the  child 
encounters  more  hazard  when  either  of  the  pelvic  extremities  is 
found  at  the  superior  strait,  than  in  an  ordinary  vertex  presenta- 
tion ;  and  for  the  double  reason  that,  in  the  first  place,  the  umbili- 
cal cord  is  much  more  liable,  especially  in  footling  cases,  to  undue 
and  dangerous  pressure ;  and,  secondly,  there  is  the  possibility  of 
more  or  less  difficulty  in  delivering  the  head  after  the  body  has 
made  its  escape.  The  mode  of  overcoming  this  difficulty  by  sim- 
ple manipulation  has  been  fully  explained  in  a  previous  lecture.  It 
may,  however,  sometimes  be  found  impracticable  to  bring  the  head 
into  the  world  by  any  manual  effort,  and,  under  these  circum- 
stances, it  will  become  necessary  to  resort  to  the  forceps. 

I  am  inclined  to  believe  that  a  dexterous  accoucheur,  one  who 
not  only  knows  what  to  do,  but  how  the  object  is  to  be  accom- 
plished, will  almost  always  succeed  in  delivering  the  head  by  a 
manual  operation,  unless  the  obstacle  be  in  consequence  of  more  or 
leflfl  disproportion  between  the  head  and  pelvis,  the  latter  being 


608 


THB  PRIKCIPLES  AND   PRACTICE  OF  OBSfTBTBIOB* 


alight ly  contracted,  or  ihc  farmer  sliglitljr  enlarged*  In  thc$*»  Ullef 
iuslaiices,  it  U,  I  Uiink,  that  ihe  use  of  the  force|>s  will  be  more  frf 
qnetitly  indicated  alter  the  trunk  has  been  expelled.  Wiib«  per- 
haps, more  than  my  share  of  pelvic  presentalion?i,  cither  in  toy  own 
tnimcdiate  practice  or  ihrungh  consultation,  I  have  met  with  bnl 
two  caiies  in  wIul'Ii  I  conld  not  overcome  difficulty  in  the  deliroty 
of  Hie  head  by  simple  nianipubtiou.  Id  tlie  two  ca^tej  itltudt^  t<i, 
the  an-est  in  the  cxpuUion  of  the  head  waa  o<xafeian€Kl^  in  one 
inHtance,  by  a  contraction  of  about  one  quarter  of  an  mch  in  tbi 
anten>po8ierior  dbuneter  of  the  upper  slrail;  in  iho  other,  the 
bea<I  was  unusual ly  large.  In  botli  cu^es  I  wu.4  obliged  to  hate 
recour»u  to  the  forceps,  and  was  fortunate  in  deUvermg  the  ehQdrcn 
alive, 

Souw  appalling  renuUs  occasionally  ensue  from  the  rude  and 
unskiltiit  atteni])!.^  to  extract  the  hi*ad  by  manipuiation.  Slid),  for 
exampkv  as  the  detruneation  of  the  foi'tua,  rupture  of  the  ittefii% 
breaking  the  neck  of  the  child,  or,  what  i«  just  as  fearful,  dbilcicm,^ 
lion  ;  seriouii  hicerationH  of  the  (*ott  parts*  of  the  nuUher,  inviiitiag 
the  vaginri,  rectum,  or  bladder.  Many  a  talc  of  woe  could  be  loU, 
If  the  truth  were  upoken,  in  reference  to  this  point.  There  b  no 
ueces*Uy  for  the.^»  sad  consequences  once  in  ten  thouicatul  times; 
and  they  accumulate  merely  because  brute  force  is  too  often  ailh. 
glituted  for  judgment  and  &kill.  These  melancholy  uccurrenc^sa  In 
the  lying-in  chamber  attract,  unhappily,  no  special  attention;  snr- 
rounding  friends  are  sati^sfied  becaut^e  they  have  had  rung  into  ibdr 
eara,  and  they  have  faith  enough  to  believe  it,  that  sitLTi^otvpfd 
phrase — ^*' All  wa;*  done  that  could  be  done!*'     How  f«  t'of 

some  njen  that  they  practise  among  a  credulou!*  pul»h  ,  .  ijiat 
their  acta  are  sub|ef*ted  to  no  truth-revealing  «K.*rtttiQyl  But  if 
there  a  corresftonding  bonctit  to  the  public? — h  that  pabUe  its  any 
way  retpiited  for  its  measure  of  faith  Y     I  thiTik  nr*t. 

Luiicationn  for  J*^orcej>9  Ddivery  after  (he  i^atpuUion  of  th$ 
7hmA\ — It  may  become  neces.'^a ry  to  resort  to  the  foroepa  for  iba 
purpose  of  delivering  the  head  after  the  passage  of  the  tnaak 
through  the  nniternal  organs,  under  the  following  cir<  ks; 

I,  In   version,  the  entire  operation  l>eing  completed,  tj»i 

extraction  of  the  head,  thi^a  latter  being  arre^ited  in  oonsequeoot 
of  some  disproportion,  etc;  2.  In  an  original  pelvic  present«tio8i| 
In  which  the  natural  effort  has  been  adequate  to  expel  the  uniikf 
but  not  the  head ;  3,  The  occurrence  of  c^^nvulslona,  exbanslMNi, 
or  atiy  other  aeriouA  complication,  alter  the  exit  of  the  truok  liai 
been  completeti.  When,  in  any  event,  it  becomes  ut^goil  to  sppif 
the  iuMirutncTit,  the  huatl  may  be  arrested  cither  at  thii  iuperior  or 
inferior  i^trait,  in  the  direct,  diagonal,  or  tranjiverse  positionJL  W* 
aball  Hr^t  deneribe  the  manner  of  using  the  foroepSi  the  boad  bating 
reached  the  inferior  str^dt : 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETKICS. 


609 


Application  of  the  Fbrceps  after  the  Escape  of  the  Tnmh\  the 
Occiput  rcfiarding  the  Symphysis  Pvbis^  the  Fave  toward  the  Sa- 
cnan,— If  the  h^^d  should  have  desceniled  to  the  inferior  strait,  the 
first  thing  to  do,  as  preiiiiiinary  to  the  introduction  of  tho  instru- 
iit?iit»  id  gently  to  elevate  the  trunk  and  arms  of  the  fcBtus  tou-ard 
^he  abdomen  of  the  mother  (Fig.  95),     Thua  elevated,  they  are  to 


'^- 


be  maintained  in  this  position  by  an  assistant,  while  the  applieatior* 
of  the  forceps  is  to  be  conducted  as  follows :  Thu  male  l/rnnch^ 
held  by  the  left  hand,  is  glided  along  the  fingers  of  the  other  hand 
on  the  fiide  of  the  pelvb  and  head,  precisely  as  has  been  indicated 
in  tlic  corresponding  poniliou  of  the  vertex,  witli  the  occiput  toward 
the  pubes  and  the  face  in  the  concavity  of  the  sacrnnu  This  branch 
adjnstctl,  it  is  entrusted  to  an  aiJ,  and  the  fciuale  branch  is^  thei» 
seized  by  the  right  band,  and  carried  on  the  other  side  of  the  pel- 
vis. The  instniment  is  locked,  and  the  extractive  and  lateral 
forces  conducted  upon  the  same  |irincif>les  as  previously  described  ; 
the  extremity  of  the  handle  of  the  force]>8  should  he  gra<bially 
raised  toward  the  pubcs  until  the  forehead  bas  pasned  the  vulva, 
and  care  should  be  taken  to  give  proper  sujjport  to  the  perineum, 
in  order  that  biceration  may  be  prevented. 

Appiiradon  of  the  Forceps  after  the  Fscape  of  the  Trunks  the 
Occiput  at  the  Sacrum^  (he  Face  toward  (he  Palms. — Here  the 
trunk  and  arms  of  the  fu&tus,  instead  of  being  elevated,  should  be 
directed  backward  in  the  direction  of  the  perineum,  and  being  held 
by  nn  assi^staut,  the  accoucheur  proceeds  to  introduce  the  forceps 
on  the  sides  of  the  pelvis  and  head  in  the  same  manner  as  if  it  were 
a  vertex  presentation,  with  the  occiput  toward  the  sacrnni,  and  the 
face  at  the  pnbes ;  the  extractive  and  lateral  forces,  together  with 
the  delivery,  are  also  to  be  governed  by  the  aajne  rules  as  in  this 
latter  position  of  the  bead. 

Application  of  the  Forceps  after  the  Fgcape  of  the  IVtmk^  the 
Occiput  toward  the  left  and  front  of  the  Pelvis,  the  Face  at  tJts 
opposite  SacrO'iliac  Symphysis. — Here,  you  perceive,  the  bead 
rests  in  a  diagonal  position,  and  the  body  of  the  child  should  bd 

39 


TH%  raUiCtPLfiS  AXD  FSACmCE  OF  Ol 


Iplored  In  a  corresponilini^  dircxtton.    THo  irank  sod  m 
tore^  should  he  tometl  loirard  the  left  thigh  of  the  m 
cumtuled  to  an  assistant.    The  toalntiiicint  ia  th«Q  Ui  be  isitRidii6t4 
.  Eli  if  the  verteic  prei«ented  with  the  <  o  |l>e  laUf«l  portmi  of 

^ti^ie  pi^lvi^  and  the  face  regarding  '  ,  >^ltepoiDt  af  llie  pfltvio 
cnnaL  Th^  occiput  in  this  case  being  to  the  leh  aad  fromi  of  tht 
f)chi^  the  female  branch  of  the  Instrument  ii  intfoddced  flr%t; 
in  held  by  the  right  hand.,  and  glided  on  tbe  fbtgfitw  of  the 
•  alortg  the  right  side  of  the  pelvia  until  it  reai^liet  the  chin; 
lahould  1>e  continued  in  the  same  direction  m  high  aa  ibe  foreh 
from  which  point  it  should  be  made  to  pa»A,  by  the  j^entlc  propa 
of  the  fingers,  within  the  pelvis,  onder  the  mid^lT  face 

upon  the  \vt\  temple,  in  order  that  it  may  be  S  nuh^r  tl 

pnbe«;   at  the  same  tune  the  extremity  of  the  handle  sbfuiki 
ftiightly  depreisded,  and  turned  loa^ard  the  lefl  thigh,  with  the  \\ct 
of  adjusting  the  blade  properly  to  the  length  of  the  head* 
.branch  is  now  entruftted  to  the  aid;  the  accoucheur  tlien  hold;* 
dale  branch  with  hi?*  M\  hand,  and  introduces  it  along  the  tlngefi 
o(  the  other  hand  in  front  of  the  siicrum^  in  order  to  gm^p 
other  side  of  the  head.    The  forceps  is  then   locked^  *Dd  befur 
reporting  tfi  any  extractive  force,  a  rotary  movtnncnt  from  left  i 
ight  should  be  imparted  to  the  in*«trumcnt,  for  the  pur|N)^e 
^placing  the  occiput  at  the  pubes,  and  the  face  in  ihc  ccmcaihy  < 
Uie  Ka«*rum*    The  combination  of  the  latei-al  and  ejctractife  fgiroct 
h  next  to  be  employed,  and  the  delivery  completed  as  if  tt 
an  original  vertex  presentation  witli  the  occiput  toward  the  i 
phynis  pubis. 

Ap/Mcafion  of  the  Foretpa  after  tfui  Europe  of  the  Thmkf  Cik  ■ 
Occiput  to  the  right  and  front  of  the  Pthns^  the  Face  at  the  i 
iitc  Sacro-ilinc  Si/mpht/niii. — Here,  again,  the  poHttion  of  the  bd 
ia  didgonai  in  the  pelvif^,  and  tbe  same  rules  are  to  be  ob^^'rvMl  j 
the  introduction   of  the  forceps  as  in   the  preceding  ejuusfil^ 
except  that  the  male  branch  h  to  be  introduced  first,  becatiaa 
occiput,  instead  of  being  to  the  leiY,  h  to  the  right.     It  ii  In  bf| 
brought    uniler  the   pubes,    while   the   female    brancli   sbootd 
directed  along  the  front  of  the  sacrum,  in  order  that  tbe  new  oumrel 
of  the  iniitrument  may  correspond  with  the  occiput,  or  anttriof 
IM)rtion  of  the  pelvis.     The  two  branches  being  locked, 
fkiom  right  to  ]el\  U  first  accoraplished  for  the  purpose  of  ohanf?Tftj5 
tbe  direction  of  the  head  from  the  dittgonal  or  oblitpie  to  t 
puHiiion,  by  placing  the  occiput  in  corre^ipoudcncc  with  i 
physii*  ptibi.H,  and  the  face  toward  the  snerum,    Tlie  delivery  intbenl 
completed  in  accordance  with  the  principles  already  indicaterL* 

*  If,  Hd^T  Ui«  «Riip«  or  lUit  trunk,  it  he  found  that  the  Umd  oecopic*  a  i^^>^^^ 
Oftl  |io«itiuu^  ttio  tcTvrm  of  thc^io  we  ImTO  juat  deficdb^d,  r'u,  tli«  ooelp«t  ftl  i 
of  %h9  ncro-tUMC  ffymphyveiy  urul  Ibe  dee  to  tb#  U(«nftl  R&|»lcpr  ■oilbeti  U  tli*  fM^ 


THE   PBIKGIPLES  AND  PRACTICS  OF  OBSTETRICS.         611 

Application  of  the  Ibrceps^  the  Head  at  the  Superior  Strait.— 
Having  pointed  out  the  rules  to  be  adopted  in  the  use  of  the 
forceps,  the  head  being  at  the  inferior  strait  ailer  the  exit  of  the 
trunk,  it  remains  for  ns  to  make  one  or  two  observations  in  refer- 
ence to  the  application  of  the  instrument  when  the  head,  from  what- 
ever cause,  becomes  arrested  at  the  brim.  You  have  been  reminded 
that,  in  a  vertex  presentation,  and  the  body  of  the  child  yet  within 
the  uterus,  the  adjustment  of  the  forceps,  the  head  being  at  the 
upper  strait,  is  one  of  the  most  difficult  operations  in  obstetric  sur- 
gery ;  for  this  reason  you  will  remember,  when  artificial  delivery  is 
indicated,  and  you  have  the  alternative  of  choice,  I  recommend 
version  in  preference  to  instrumental  delivery.  But,  however  em- 
barrassing and  perilous  the  application  of  the  forceps  in  an  ordmary 
vertex  presentation  at  the  superior  strait,  the  difficulties  and  dangers 
are  enhanced  afler  the  trunk  has  made  its  escape  and  the  head 
remains  at  the  brim ;  for  here,  you  will  perceive,  is  the  increased 
difficulty  of  conducting  the  forceps  to  the  strait,  in  consequence  of 
the  vagina  being  more  or  less  obstructed  by  the  upper  portion  of 
the  child's  body,  and  this,  too,  in  proportion  to  the  elevation  of  the 
head  in  the  pelvis.  If,  however,  you  should  have  a  case  in  which 
forceps  delivery  is  indicated,  the  head  remaining  at  the  superior 
strait  after  the  escape  of  the  trunk,  the  same  rules  are  to  govern  in 
the  use  of  the  instrument  as  if  it  wAe  originally  a  vertex  presenta- 
tion, and  the  head  arrested  at  the  brim,  the  only  important  difference 
being  that  proper  provision  is  to  be  made  for  supporting  the  body 
of  the  child,  as  was  pointed  out  when  speaking  of  the  application 
of  the  instrument,  the  head  being  either  in  the  excavation  or  at  the 
inferior  strait. 

Application  of  the  Forceps  in  Face  Presentation, — ^When  treat- 
ing of  face  presentations,*  you  were  told  that,  all  things  being 
equal,  they  are  entitled  to  be  regarded  as  natural,  and,  therefore, 
within  the  resources  of  nature.  But  here,  as  in  the  case  of  an  ordi- 
nary vertex  presentation,  something  untoward  may  occur  render, 
ingit  essential  that  artificial  delivery  should  be  resorted  to.  It  is 
proper,  therefore,  that  the  rules  for  the  use  of  the  forceps  in  these 
cases  should  be  indicated.  It  may,  however,  be  premised  that,  in 
face  presentations,  if  the  face  be  at  the  superior  strait,  vei-sion 
should  be  preferred  to  instrumental  delivery  for  the  same  reasons 
that  this  preference  should  obtain,  imder  similar  circumstances, 
when  the  vertex  presents  and  artificial  aid  becomes  necessary.     It 

the  accoucheur  should  attempt,  if  possible,  to  turn  the  face  toward  the  sacrum.  In 
tills,  however,  ho  would  most  likely  be  foiled;  the  alternative,  under  these  cir- 
camstances,  would  bo  to  apply  the  forceps,  remembering  that  the  new  curve  of 
the  instrument  must  correspond  with  the  facet  After  the  instrument  is  adjusted,  the 
boe  18  brought  to  the  pubes.  and  the  labor  terminated  as  if  it  were  an  original  vertex 
position,  with  the  face  in  front  and  the  occiput  behind. 
^  See  Lecture  xxiv. 


612 


THE  PRINCIPLES  AXD  PKACTICB  OF  OBSTSTBICa. 


was  the  general  practice  among  aocoiicheurn,  before  llie  mc 
of  a  face  [jreHentalion  was  understood,  to  have  recourse  to 
expedients  for  the  purpose  of  overcomini?  what  they  supposedlo  lieii 
insuruiouulable  *lifli cully,  when  the  visage  came  first.    For  exain|ili 
ono  would  reeonimend  to  pu»li  the  fiice  upward  and  reduce  the  ppfcl 
Aenlatlutj  to  thai  of  the  veiiex  ;  another,  to  gmsfj  the  occiput  nhh 
the  lingers  or  lever,  and  draw  it  toward  the  centre  of  the  pelviA^ 

Independently  of  the  undeniable  fact  that  these  mutations  of  tki 
head  are  not  only  extremely  diffitult  toaceompliiiih,  and  the  aitcmpil 
to  eflcct  them  oftentiuies  accompanied  by  more  or  less  danger  to  thAl 
child  and  mother,  it  is  now  well  demonstrated  that  tltey  arv  ilto^] 
gethrr  unnece*!»ary  for  the  reason  that  nature,  when  the  prop 
proportion  exists  between  the   head  and  maternal  organs,  b  < 
petent  to  cause  by  Iier  own  effort**  the  descent  and  expulsion  of  tlia| 
child.     Again  :  it  was  the  custom  of  some  praclitionenft|  jiji  iko^vn  as 
it  was  ascertained  that  the  face  presented,  to  resort  at  once  rilher 
to  version  or  the  forci*ps.     These  abstract  modes  -   luro  hadj 

jio  juMtifieatiort,  and  were  all  fuuudml  on  the  supiH>  utit  a  far# 

presentation  was  abnormal,  and,  therefore,  beyomi  tha  ability  of 
nature  to  remedy.     But  experience  has  proved  the  contrarj*  ut  all; 
this,  and,  in  our  day, '^v hen  either  version  or  tlie  iitKtrumcnt  i*  < 
ployed,  it  is  not  becaune  the  fare  pre:?ient»,  but  because  of  sooiec 
Jiijgeiicy  or  complicaiiou,  which  renders  the  interpotiitioD  of  i 

bHi>fnt**Iy  necessary, 

Ym  t  have  been  tohl  that,  as  a  general  rule,  the  face  is  femid 
the  superior  strait  in  oue  of  two  positions,  although  oo&Aomlif^ 
there  will   be  variations;  the  poiiitions  to  which  I  allude^  are:  1, 
The  forehead  of  the  foBtus  is  toward  the  M\  iliac  bonv,  whilv  i1i« 
chin  regards  the  op[)Osite  side.    This  Is  reco^fiii^ed  as  iberi^i 
fnentomac position  ;  nm]  hi^Y€^  the  fronto-nt  >  r  oS  tim^ 

face  is  in  appcisition  or  correspondence  witli  ti  i*  or  lili* 

iliac  diameter  of  the  brim,  wldle,  on  the  contrary,  the  transTcrae 
diameter  of  the  fmx»  is  parallel  to  the  sacro-pubic  diaineter  of  iW^ 
pelvis.  2.  Tho  forehead  is  towaid  the  right  iliac  bon^,  aiid  tl 
chin  to  the  opposite  point.  This,  it  will  be  perceive^l,  is  the  reverae 
of  the  first  position,  and  is  known  as  the  It^X  ma^to-iliac.  In  eklkm 
of  these  positions,  the  head,  in  its  descent,  undergoes  two  mot^ 
menlii — ilingonal  and  direct.  Thus,  as  the  labor  advances  in  iha 
fi»^t  |K>sition,  it  ehanges  from  the  trans^verse  to  the  oblJc|(je  dirt^ 
tion»  so  that  the  fronio-ntenfal  diameter  of  the  face  accords  with 
the  right  oblique  diatneierof  the  pelvis,  tho  chin  being  opfKk^iw  to 
the  right  foramen  ovale;  then  the  chin,  through  the  direct  moir<s 
mtMil,  is  brought  behind  the  pubes,  and  the  '  riod  ittUli 

the  hollow  of  the  sacrum.     In  the  second  po^  -d 

of  descent  is  precl»ely  the  same,  except  that  the  rotaiy  tnoif 

\  firom  lett  to  right  instead  of  from  right  to  leil. 


THE  FKINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         613 

My  object  in  recalling  to  your  recollection  the  peculiar  direction 
of  the  &ce  in  these  two  most  frequent  presentations  at  the  superior 
strait,  is  to  show  you  the  almost  impossibility  of  applying  the  for- 
ceps, until  the  bead  has  begun  to  assume,  in  the  course  of  its 
descent,  the  oblique  or  diagonal  position ;  for,  until  this  is  done, 
the  &ce  occupies  the  strait  transvei*sely,  either  exhibiting  the  ri^ht 
merUO'iUac  or  left  mento-iliac  position.  Therefore,  if,  before  the 
change  from  the  transverse  to  the  oblique  direction,  there  should 
be  imminent  urgency  for  artificial  delivery,  I  advise  you  by  all 
means  to  abandon  any  attempt  with  the  forceps,  and  proceed  to 
terminate  the  labor  by  version.  It  may,  however,  happen  that  the 
face  will  so  present  at  the  brim  as  that  the  chin  shall  correspond 
with  the  pubes,  and  this  would  be  more  likely,  perhaps,  to  occur  if 
there  were  a  slight  contraction  or  narrowing  of  the  transverse  dia- 
meter ;  or,  instead  of  the  chin  being  at  the  pubes,  it  may  corre- 
spond with  one  or  other  of  the  acetabula  constituting  an  example 
of  the  diagonal  or  oblique  presentation  of  the  face. 

In  such  an  event,  although  I  should  again  as  a  general  principle 
prefer  version  to  the  instrument,  yet  it  is  very  evident,  with  a 
moment's  reflection,  that  the  forceps  could  be  applied  with  about 
the  same  facility  as  if  the  vertex  were  at  the  superior  strait.  To 
illnstrate,  suppose  the  chin  were  toward  the  pubes.  In  this  case, 
the  face  would  exhibit  a  direct  position,  its  ment(hfrontal  diameter 
corresponding  with  the  sacro-pubic  diameter  of  the  brim.  The 
forceps,  under  these  circumstances,  should  be  introduced  along  the 
aides  of  the  pelvis,  and  would  consequently  grasp  the  head  in  the 
proper  or  lateral  direction.  If,  on  the  contrary,  the  chin  regard 
one  or  other  of  the  acetabula,*  the  niento-frontcU  diameter  would 
be  in  api>osition  with  one  or  other  of  the  oblique  diameters  of  the 

*  It  will  sometimes  occur,  that  the  chin,  in  fuce  pFesentationa,  will  occupy  a 
posterior  position,  oorrespondinf^^  with  one  or  other  of  the  sacro-iliac  symphyses, 
and,  under  such  circumstances,  the  natural  powers  may  suffice,  during  the  progress 
of  the  head,  to  bring  the  chin  and  anterior  surface  of  the  child's  body  in  front,  and 
thus  the  labor  will  be  terminated  without  the  assistance  of  Ihe  accoucheur.  But  we 
will  suppose  an  example,  in  which  this  change  in  the  position,  from  behind  forwardi 
cannot  be  accomplished  by  the  natural  effort.  In  this  contingency  what  is  to  be 
done?  In  the  first  place,  it  may  be  remarked  that  the  mere  adjustment  of  the 
forceps  to  the  head  would  not  of  itself  be  so  difficult :  but  it  is  to  be  remembered 
that,  afler  the  adjustment,  the  difficult  thing  to  accomplish  is  to  bring  the  chin  to  the 
front  of  ihe  pelvis,  a  fundamental  requisite  in  all  cases  of  face  presentation  in  order 
that  the  head  may  make  its  exit ;  and  this  will  be  found,  I  may  safely  say,  impossi- 
ble to  do,  unless  the  pelvis  be  unusually  capacious  or  the  head  under  size.  Tiiere- 
fbre,  if  nature  prove  incompetent  to  direct  the  chin  toward  the  anterior  half  of  the 
peivia,  and  this  should  be  ascertained  opportunely,  the  resort  should  be  version.  I( 
however,  from  rigidity  or  other  opposing  conditions  of  the  uterus,  the  hand  cannot 
be  introducHl,  and  these  antagonizing  influences  do  not  yield  to  the  appropriate 
remedies  already  pointed  out,  then  there  is  no  alternative  but  craniotomy  if  the  child 
be  dead ;  if  alive,  the  question  may  arise,  craniotomy  or  the  Cssarean  seotioii— 
which  topics  will  be  fully  discussed  in  a  future  lecture. 


614 


TUE   TEINCIFLES   AND   TRACnCE  OF  OBSTETBICS. 


qpper  strait.  In  such  an  aspect  of  things,  tlie  forceps  cotild  al^  \m 
applied,  the  same  rules  precisely  being  observed  as  if  it  were  a  vertex 
presentation  with  the  ocdput  iu  the  pnbea,  or  to  the  left  or  ngbt. 

So  much  for  the  management  of  face  pre«entatiouii,  through  tilt 
aid  of  instrumental  delivery,  the  head  being  at  tlie  i&uperior  atnuL 
Let  UB  now  examine  the  modtis  in  quo  of  procedure  aJier  the  head 
hjis  paAfieil  into  the  pelvic  excavation.  Under  theie  latter  drcum* 
8tanc4*8,  the  chin  will  be  either  in  front  or  po«leriorly,  eoostitatin^ 
the  m€nf<hanterior  or  mento^ogterior  positions. 

The  Merit  oHtnterior  Posit  ion. — In  this  position,  the  head  may 
re«t  in  the  pelvic  cavity  either  directly  or  obliquely,  depending  itpcm 
whether  the  clan  ha^  coni|*k*teiy  tuitied  toward  the  piibe%  or 
^vhether  its  aspect  is  to  one  or  other  of  the  latemi  points  of  th* 
excavation.  In  the  former  case,  tlie  head  occupying  the  tttr^l 
position,  with  the  chin  at  the  pnbea  and  the  forehead  toward  the 
hacr urn,  the  forceps  must  be  introduced  in  the  same  tnanner  ai  if 
the  occiput  were  at  the  pube§  and  the  face  reirarding  the  aacmiii. 
The  blades*  being  adJuHted  to  tlie  head  and  f»rop>ciiy  loclied,  lli« 
firsit  tractions  .should  be  directed  downward  in  order  that  the  diitt 
may  be  brouglit  from  under  the  pubic  arcade ;  an  !*m»n  aa  Una  ia 
accomplished,  not  forgetting  to  protect  the  perinaitm  by  jiidtcioili  i 
supjujrt,  the  liandle  of  the  itistrumeut  is  to  be  gradufdly  elevated 
toward  the  abdomen  for  the  [lurpu^o  of  completing  the  extrai^ioa 
of  the  face. 

In  the  oblique  or  diagtmal  position,  with  the  chin  at  eiUier  tbelrft 
or  right  of  the  aiitcrior  surface  of  the  pi'lvi»,  the  fame  raJeaare  to 
be  observed  in  the  intn)ducti<»u  of  the  infttrumeut  as  if  the  occipat 
regardctl  one  of  these  point*;  when  the  head  ha§  been  properfy 
grasped,  the  firnt  tidng  to  be  done  ie»  to  produce  a  rotary  moTeineot 
from  left  to  right,  or  fr(m»  right  to  left,  as  the  cAse  may  be,  vritlim 
view  of  ihanging  the  position  from  the  oblique  to  the  direct*  Tka 
delivery  w  then  to  be  proceeded  with  as  already  des^crib^. 

The  Mefito-poMrrior  Fonition. — \l  18  most  fortunate  that  thii 
position  of  the  face  i^  comparatively  of  rare  ocourrenre.     Yon  hava  i 
been  told  that,  in  face  presentations,  the  per»iMrnt  tendency  of  tba 
natural  effort  is,  tlj rough  a  special  mechanism,  to  bring  the  chin  ibr- 
w^ard  either  to  the  pubes  or  to  one  or  other  of  the  lateral  {lointa  o4 
the  anterior  port  ion  of  the  pelvis.     Nature,  however,  im  accaaiottally 
contravened  in  this  effort,  and  then  she  relies  entirely  on  tbe  dit^\ 
erect  inter|iosition  of  the  accoucheur.     Suppose  you  had  an  exampla  i 
of  m:ntO'}H}nti:riut  poitition^  what  course  would  you  pursue?     Ill 
the  first  place,  you  are  to  recollect  that  in  no  caaCi  imleaa  aa  I 
exct'ption,  if  I  may  be  j*ermitted  to  s^ay  so,  to  an  almi  >  rmX 

rule,  can  the  head  be  tnade  to  accomplinh  its  exit  i  tha 

nuitermd  organ^s  the  chin  continuing  to  remain  in  a  poaterior  poii*  \ 
tion* 


THE  PRINCIPLES  AND  PRACTICB  OF  OBSTETRICS.     •    615 

When  speaking  of  this  position  a  few  moments  since,  the  faoe 
being  at  the  superior  strait,  you  were  admonished  of  the  difliculties 
attending  it ;  these  difficulties  are  in  no  way  diminished  after  the 
fiwe  has  descended  into  the  pelvic  cavity.  When,  therefore,  you 
have  become  satisfied  that  nature  is  incompetent  to  bring  the  chin 
toward  the  anterior  portion  of  the  pelvis,  and  further  delay  would 
be  perilous  to  the  child,  and  not  altogether  without  serious  conse- 
quences to  the  mother,  three  indications  will  present  themselves  to 
the  mind  of  the  experienced  accoucheur :  1.  To  endeavor  by  means 
of  the  forceps  to  bring  down  the  vertex,  by  making  an  extreme 
downward  and  backward  traction,  and  thus  substituting  a  vertex 
for  a  lace  presentation ;  2.  To  endeavor,  by  an  adroit  rotary  move- 
ment with  the  mstrument,  to  detach  the  chin  from  one  of  the  pos- 
terior to  one  of  the  anterior  points  of  the  pelvis ;  3.  If  the  head 
should  not  have  passed  beyond  the  mouth  of  the  uterus,  and  this 
latter  be  in  a  condition  to  justify  the  operation,  version  may  be 
attempted. 

These,  then,  are  the  three  alternatives,  the  two  first  most  difficult 
to  accompliiih,  and,  indeed,  I  may  say  the  chances  of  failure  greatly 
preponderating.  Version,  however,  if  the  conditions  premised  bo 
present,  is  much  more  feasible,  and,  in  dexterous  hands,  may  suc- 
ceed. Ilypothecnthig  that  these  three  alteniatives  should  fail,  is 
there  any  other  resort  lell,  or  is  the  mother  to  be  permitted  to  die 
undelivered?  This  is  a  grave  question — but  yet  it  must  be 
answered.  The  last  resort,  perfectly  justifiable  under  the  circum- 
stances, provided  the  child  be  dead,  is  craniotomy ;  should,  on  the 
contrary,  there  be  satisfactory  evidence  that  the  child  is  alive,  there 
may  arise  the  momentous  question — shall  the  child  be  sacrificed,  or 
the  chances  of  life  between  it  and  its  parent  equalized  by  subjecting 
the  latter  to  the  hazards  of  the  Caesarean  section  ? 

Before  closing  my  remarks  on  the  subject  of  face  presentations,  I 
may,  I  hope  without  the  imputation  of  improper  motives,  be  per- 
mitted briefly  to  narrate  the  two  following  instances  in  which  I 
applied  the  forceps  with  safety  to  both  mother  and  child ;  I  am 
induced  to  refer  to  these  cases,  because  they  have,  in  my  judgment^ 
a  useful  practical  bearing,  and  may,  under  similar  circumstances^ 
serve  to  remind  you  of  your  duty : 

Dr.  Oatman  requested  me  to  visit  in  consultation  with  him  a  lady^ 
aged  twenty-seven  years,  the  mother  of  one  child,  three  years  old.. 
She  had  been  in  active  labor  twenty-four  hours  before  I  saw  her ; 
the  pains  from  the  commencement  had  been  strong,,  and  she  suffered 
greatly  from  their  more  or  less  constant  recurrence,  the  slight  inter- 
mission between  them  constituting  a  remarkable- feature  in  the  labor.. 
The  membranous  sac  had  become  ruptured  three  hours  after  the? 
commencement  of  the  parturition*,  but  the  mouth  of  the  uterus  waa 
previously  well  dilated.    Dr.  Oatman,  on  makiag^  a  vaginal  exarni^ 


616         TtlE  PRINCIPLES  AND   PRACTICE  OF  OBaTETmiCB. 


nation,  a»c«?ilained  that  the  face  presented;  the  head  was  -  ji  ^ 
responsive  to  the  vigorous  uoiitnictioris,  but  its  ik*iH'cnt  int.  tK- 
pelvic  cavity  extremely  slow  ;  after  the  face  had  fully  reacheil  the 
ercjivation,  it  became  arrested,  and  notwithstanding  the  contincird 
powerful  eflbrU  of  tlie  uteru;^,  it  made  no  fiinher  progrew.  The 
mother's  strength  was  yielding  under  ihe  influence  of  theme  rrp«*aird 
but  fruilleB8  contractions,  and  the  child's  safety  in  great  |>eril  from 
the  pressure  to  which  it  was  exposed.  It  was  at  thiii  period  of  tho 
labor  that  a  messenger  reached  me  requesting  that  I  wuuld  promptly 
meet  Dr.  Outman,  I  immediately  obeyed  the  ^ummonR,  and  on  my 
arrival  fount!  the  condition  of  things  as  descriljed  above.  The  fuee 
exhibited  an  example  of  7//r/4^<;-<^n/mar  presentation,  the  chin  IVmg 
at  the  left  of  the  piibe«,  with  the  forelicad  regarding  the  opposite 
Bflero-ilinc  (symphysis  ;  in  other  woriL%  the  fuce  rested  in  the  left 
diagonal  position*  I  »M>oti  became  Kati^fied  that  nature  had  Mtn^ 
gled  long  enough,  but  vainly,  to  produce  on  the  heaii  the  rotary 
movement,  which  would  have  resulted  in  placing  the  chin  in  appo- 
iition  with  the  jMibe^  :ind  tfie  forehead  toward  the  fiaerum. 

Tlie  bn^iii  for  this  opinion  wan  the  evident  exhaaation  of  tht 
mother,  together  with  the  unusual  tumefaction  of  the  child's  faoi| 
and  thu  increased  heat  in  the  vagina ;  tht*S4»  phenomenav  remetnlMsr, 
accotnpanied  by  powerful  but  unavailing  contraetiong  of  tb«  mama. 
Tliere  could  be  no  doubt  as  to  tlie  course  to  be  pursued  utid4.'r  Um 
circumstances;  irtaction  on  the  |»art  of  the  ae^*ouchcur,  founded 
upoti  an  abiding  faith  in  tlie  ability  of  nature  to  acH*ompltjdt  %hm 
delivery,  would,  without  a  doubt,  have  resulted  most  disaiArou:^y« 
for  the  evidence  was  abundant  and  unerjui vocal  that,  if  tbw  c</Ddi- 
tion  of  things  had  been  permitted  to  continue,  the  forces  of  tbe 
mother  would  have  given  way,  and  the  life  of  the  child  aacntlcad* 
Wliut,  therefore,  was  the  indication  ?  Why,  evidently,  to  eonamtte 
no  time  ill  idle  exiicctatiou,  but  to  proceed  at  once  and  rcmdrr  the 
needed  ussij-tance,  ^o  that,  by  opportune  interference,  the  live?i  of 
both  mother  and  child  might  be  n^cueil  from  the  dangers  wbieh 
ihreatetied  them.  Dr.  Oatman  concurred  entirely  in  tbia  vkw  of 
the  viise^  and  at  his  reqtto^t  I  applied  the  forceps  in  accordance  with 
the  rules  aiready  indii'ati*d.  As  st>ou  m  the  iuHiruniiut  had  Ueen 
adjUHted  on  the  heail,  I  brought,  by  a  rotary  incTination,  the  cbinto 
the  ptd>efs  thus  ehnnging  the  ]}Obttion  (Votn  the  diagonal  to  thm 
direct ;  this  being  accomplished  through  proper  tractiona  aa  pf^ 
viously  described,  I  ha«l  no  difticuUy  in  bunging  the  h-  ■'  '  tins 
M'orhl,     The  child,  a  little  daughter,  was  alive,  and  th*   <  uad 

A  favorable  convalescence,     Ilesitai  ion,  or,  perhaps,  an  hour's  delay, 
woulci  have  rendered  these  agreeable  results  impos.«at»1e. 

On  another  occasion,  1  received  a  note  from  Dr,  Judson  to  meal 
Idm  under  the  following  circumstances  :  lie  was  in  attendance  on  m 
lady  in  labor  with  her  first  child*     She  was  twenty-one  ye^ir*  of  age| 


THE  PRIKCIPLES  AlO)  PRACTICS  OF  OBSTETRICS.         617 

andy  with  the  exception  of  a  delicate  nervons  organization,  enjoyed 
good  health.  Her  parturition  commenced  at  six  o'clock  A.M. 
Dr.  J.  saw  her  at  eight ;  the  pains  were  slight,  bat  the  labor  had 
fiurly  began.  After  remaining  for  an  hoar  with  her,  he  left  with 
the  request  that  he  might  be  notified  as  soon  as  his  services  were 
needed.  At  four  o'clock  p.m.,  just  ten  hours  from  the  fir:5t  indi- 
cation of  the  parturient  effort,  he  was  again  sent  for.  At  this  time, 
some  progress  had  been  made,  the  os  uteri  dilated  to  the  size  of  a 
dollar  piece,  with  increasing  and  recurrent  pains.  Things  continued 
to  progress ;  at  seven  o'clock  the  membranes  ruptured,  and  there 
escaped  an  unusual  quantity  of  liquor  amnii.  Soon  after  the  rup- 
ture of  the  sac,  the  Dr.  discovered  the  presentation  to  be  that  of  the 
fiioe.  The  pains  increased  in  power,  ansuming  an  expulsive  cha- 
racter ;  the  head  began  to  descend  into  the  pelvic  cavity ;  at  ten 
o'clock  it  had  passed  to  the  lower  strait,  with  the  chin  to  the  pubes 
aod  the  forehead  to  the  sacrum.  The  pains  now  assumed  a  strong 
expulsive  force,  and  during  one  of  them,  the  patient  was  suddenly 
attacked  with  convulsions,  without  any  premonition  whatever.  In 
fifteen  minutes  there  was  a  second  convulsion,  the  pains  becoming 
more  marked  and  vigorous. 

At  this  time,  eleven  o'clock  p.m.,  I  was  requested  to  meet  Dr. 
Jadson.  At  half  after  eleven,  when  I  arrived,  I  found  the  uterus 
contracting  with  full  force,  and  nature  doing  all  she  could  to  ter- 
minate the  delivery.  The  features  of  the  face  were  excessively 
tumefied,  and,  notwithstanding  the  vigor  of  the  pains,  the  head 
did  not  advance  in  a  corresponding  ratio.  Twenty  minutes  after 
ray  arrival,  the  third  convulsion  occurred.  These  were  all  the  facts 
of  the  case,  and  now  the  question  to  be  determined  was  this — 
What,  under  the  circumstances,  was  the  most  rational  course  to  be 
pursue  d  ?  My  own  opinion,  frankly  expressed  to  my  friend,  the 
doctor,  was — that  the  convulsions  were  of  eccentric  origin,  due  alto- 
gether to  the  irritation  of  the  incident  excitor  nerves  of  the  vagina; 
and  this  opinion  was  grounded  upon  the  important  fact  that  the 
convulsive  movement  did  not  occur  until  this  extreme  pressure  had 
begun  to  exert  itself  on  the  walls  of  the  vagina ;  there  had  been  no 
previous  indication  of  any  such  nervous  derangement ;  there  was 
an  entire  absence  of  any  hydropic  condition,  etc.,  indicating  the 
presence  of  albuminuria.  Supposing  this  view  of  the  case  to  be 
sound,  what  was  the  necessary  practical  deduction  as  to  our  line  of 
conduct  ?  It  was  to  remove,  at  the  earliest  possible  moment,  the 
cause  of  the  irritation,  and  this  could  only  be  done  by  prompt 
artificial  delivery.  Therefore,  as  every  instant  of  time  was  pre- 
cious, at  the  doctor's  request  I  applied  the  forceps,  having  first 
placed  the  patient  under  the  full  influence  of  ether.  I  was  fortu- 
nate in  extracting  a  living  child.  The  mother  had  no  recurrence 
of  the  convulsion,  and  was  soon  in  the  enjoyment  of  her  usual  health* 


LECTURE   XLI. 


CuttiDfT  iDfltnjmentaN-Whut  Ihey  Invdre— Importaiioe  of  Um  QoMtioD— WTuit  k 
tbo  SmallcHt  Pelvic  CoTHieity  tbrouirh  ^liieli  n  lArtng  CtiUd  OM  b*  auMb  Co  p««i» 
and  what  ihe  Capacily  tlirouKH  which  a  Child  nuijbo  extmoCed  pi«oeiiiMl7— Pb* 

crepiincy  of  Opioion  on  these  QuejttionK — Symplty**<iionty,  in  whul  It  c^wtinei— > 
Siian»uU  ita  Originator— The  true  cinlnw  of*ll»e  Opemtion  — The  Qiiiiitbn  «»• 
roin^j — OompBriRon  itistituti'd  between  Symphy^^eotom}' »nd  th«  Omirvttti  SecHoi 
— Statbticn  oreach^De^luction — Tim  Cfcsiirwiii  .Sectwrn— Tli«  OpinUini  in  Gfrnt 
Brit^tin  ai»d  on  the  Coiitinetii  of  Europe  ju  to  the  MfhtA  ot  Ute  Of>cnitmn^R<««iii 
for  the  marked  Difleffnce  of  Opuiioii — Anntymii  oti\w  XWwn  of  Aatlioni  turichinf 
the  Ciwwrean  Section— StntUtics  of  the  Opemtion — How  ilM  Fntnliijr  trur  bt 
Modifl^l — Opinion  of  l)ie  Author  an  to  the  AdvntitMg^i*  (»f  the  C!»i^uirr<io  ^cctadQ 
over  Crunlotomy — ^M'hat  are  the  Dangere  of  ilio  OfirnilK>n  f — ^Tli©  B«tiHlfa  cl 
Lnipjithcfiia  in  eontroliing  the  Shock  to  the  Kervou*  Sjatem — Pnnt'incirtcm  Cfmr* 
iti  8i'ciion,  when  reaorl<Ml  to — The  Cusc  of  llie  Friiioesi  uf  Schwa rt24'nbeiY — "nit 
Hoiiion  Law  oil  the  Sutiject  of  the  Potil-iriortumOpcTiiiion— Mcihml  tjf  P<ctiutmiu^ 
the  Cjirsiirean  Section;  the  Verticnl  Incijiion  throtig^h  the  LincA  Alba  prWrrrcU— 
Why? — Should  the  Operation  be  Performed  Ix-fore  or  aflt'r  the  F!  '  tl» 

MeitihraDoua  SacT^ — How  ts  the  Child  to  l>e  Kxtnitried  thrtnijifti  tf  .  Wi 

betJtenifl? — Rulea  for  Reniovinjj  the  Placenta — Drcmiji^  the  Win.  i  j  .  mt^ 
qaeiit  Tpaatroeiit— The  Operation  of  Klytroiotn/.  aa  a  Subaitiluto  lur  5  s.  i  i  ^  inUa 
into  the  tjtenia,  propoaed  by  Jorg  and  otherv — Merita  of  tho  Opmtiita — Dc 
(!hn.4toforia  »tid  the  Heacciio-aubperioeiiia  of  Uie  F*ubic  Boaea^ReaeardiM  ai4 
Statistics  of  IL  PbUaD^Dufeilky 

GE^TLE^rex — Having  descrFbeei  to  von  the  lilntit  instfrnmeut*  mid 
in  midwifery,  tbeir  abjf»ct,  ami  mode  of  employment*  tbe  next  tofiM 
for  our  eonsideratton  will  be  the  ctitting  instrnmcnts  which,  wbcn 
resorted  to,  munt  of  neee««ity  either  destroy  tbe  child,  if  ali*'e,  or 
subject  the  mother  to  the  JiaEards  of  n  perUoiis  openition*  Yciti  mt^ 
therefore,  in  the  discussion  of  thin  question,  wo  approach  ft  pointy 
the  most  important,  perhaps,  m  far  as  a  just  deciwon  in  concermMl, 
In  the  wliole  rnn^e  of  ohsttetric  eeience — a  point  which  not  oftly 
involve«  human  life,  but  irnposoa  upon  the  medind  man  the  higlicsl 
and  mtist  saered  oblij^rnttcui^.  In  the  examination  of  ihia  lopiiSi  I 
shall,  I  truMt,  have  my  mind  emnneipafed  trom  the  lhr.ddom  of  b'jM 
or  pree<iruvivtHl  ojnttion,  an»l  lilmll  endeavor  to  reach  Uie  Irtuli 
thrc^uijh  a  proper  sitting  nft'% idenw ;  for,  nfler  all,  the  etin>loynic«ii 
of  etitiiu^'  iriHtrumenls  wfiether  npon  the  child  or  mother,  in  t-impljr 
aqurMiifiri  trf  testimony  to  be  developed  by  mtrrotmding  iriniiltil* 
etufieen,  and  dt'termin«d  by  the  honest  judtniieut  of  the  acodneboor 
and  hi>i  ftvj<nciatt^  in  enim?^1. 
I*renqitisit€^  for  the  V^  qf  Cutting  Instrumatis. — li  aboald  \m 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         619 

remembered  that  the  fundamental  prerequisite  for  a  resort  to  these 
instruments  is  such  a  disproportion  between  the  maternal  organs 
and  foBtus  as  to  render  it  physically  impossible  that  the  latter  can 
be  made  to  pass,  either  through  the  natural  effort,  version,  or  by 
the  aid  of  the  forceps,  per  vias  naturales  ;  and  this  disproportion 
may  arise  from  a  contracted  pelvis,  the  presence  of  osseous  or  sar- 
comatous tumors,  a  narrowing  of  the  soil  parts,  an  abnormally  large 
child,  or  from  malposition  of  the  fcotus  itself.  In  either  event,  how- 
ever, the  grave  question  presents  itself,  shall  the  cutting  instrument 
be  applied  to  the  child,  or  to  the  mother  ?  In  the  former  case — 
assuming,  of  course,  that  the  child  is  alive — it  will  inevitably  be 
destroyed ;  in  the  latter,  on  the  contrary,  although  the  safety  of  the 
mother  is  in  more  or  less  peril,  yet  it  is  not  necessarily  compro- 
mised, and  the  chances  of  life  are  equalized  between  her  and  the 
child  she  carries  within  her.  The  decision  of  this  question  is,  I 
repeat,  of  momentous  import,  and  cannot  be  regarded  lightly  by 
the  medical  man  who  is  governed  by  a  high  morality,  and  feels  that 
there  is  nothing  incompatible  betw^een  the  scientific  physician  and 
conscientious  Christian. 

Amount  of  Pelvic  Contraction  consistent  with  the  Birth  of  a 
Living  Child, — As  to  what  really  constitutes  a  contracted  pelvis, 
such  as  will  not  permit  the  transit  of  a  living  child  at  full  term, 
there  exists  a  remarkable  discrepancy  of  opinion  ;  and  this  very 
circumstance,  no  doubt,  will  explain,  in  part  at  least,  the  conflicting 
views  of  authors  regarding  the  justification  for  the  employment  of 
cutting  instruments.  For  example,  Busch,  of  Berlin,  says,  for  a 
living  child  to  pass,  the  antero-posterior  diameter  must  measure 
from  2^  to  3  inches ;  Burns  3^ ;  Dr.  Joseph  Clarke  3^.  Dr.  Os- 
born*  places  it  a  fraction  below  3  inches,  while  Dr.  Ritgen  is  of 
opinion  that  a  contraction  of  2  inches  is  not  inconsistent  with  the 
passage  of  a  living  foetus  at  maturity !  My  own  opinion,  arrived  at 
not  without  full  consideration,  and  some  share  of  experience,  is  that 
a  diameter  of  Z\  inches  antero-posteriorly  is  the  smallest  [>ossible 
space,  except  under  very  rare  exceptional  circumstances,  through 
which  a  living  feet  us  at  the  end  of  gestation  can  make  its  exit,f  and 

•  "  Whenever  a  woman  falls  into  labor,  the  small  diameter  .of  whose  pelvis  mea- 
sures only  2 J  inches,  one  or  other  of  the  following  circumslWnces  must  take  place: 
1.  Tlie  child's  head  must  bo  opened ;  2.  For  the  certain  preservation  of  the  cliild's 
life,  the  mother  must  be  doomed  to  inevitable  destruction  by  the  Caesarean  opera- 
tion ;  3.  As  a  mean  between  the  two  extremes,  the  mother  must  submit  to  the 
division  of  the  symphysis  pubis  (symphyseotomy),  an  operation  less  dangerous  to  the 
patient  than  the  Cesarean  section,  but  less  safe  for  tiie  child ;  or,  if  none  of  these 
means  will  be  permitted,  the  wretched  mother,  abandoned  by  art  to  the  excnv>ialing 
and  unavailing  anguish  of  labor,  will  probably  expire  undelivered."  [Essays  on  the 
Practice  of  Midwifery  in  Natural  and  Difficult  Labor.  By  Wm.  Osbom,  M.D.  1792. 
p.  194] 

t  See  Lecture  Fillb. 


620 


THK  PRINCIPLES   JLND  PRACTICE  OF  OB8TRRI09. 


even  with  such  capacity,  more  or  lesa  Iwis^ard  aiid  a  protraded 
delivery  will  bo  the  ahno^t  ncceft.sary  result,* 

Amount  of  Peitne  XMfoimity  through  ichtch  a  J^attus  may  be 
ExtracUd  Fi^nefneal. — ^The  same  want  of  coneiirTeoce  is  noiioed 

*  An  ^xeeptlou^  p<?Hti»])fli,  to  ih'ta  rule  may  he  niado  in  corUIn  m9t>m  &t  by^mMst* 
plialu!!,  in  which  the  boneu  of  the  hond  bpeome  so  cxecwrivdy  yidUhig  am  lo  QCi4n^ 
iiti  extmordinnry  pnMiftiire  without  dL*>stmyhij7  tbo  Hfv  or  th«  child.  I  mw  m  cmm  of 
tfiU  kittd  tuanie  j^ttn  since,  which  occurrtnl  iu  the  practice  of  Dr.  HIblmni  of  tliii 
dty  He  requeatod  me  to  meet  him  in  coasultation  under  Uio  foilnwing  drouiii- 
ftt«ncc«  :  The  Lady,  aged  twetily-nine  years,  wiia  tiiken  in  lubur  with  httr  Unit  chilX 
ut  C  ocltfck  A,u.  Thti  doctor  mw  hi^r  at  8  o'clock  ;  the  [m'mn,  l>t*ft»rc  he  arrrvtd, 
hud  commoiiced  with  an  unusual  degree  of  forco;  he  fnund*  on  exariiinatKtn,  thuoi 
uteri  rullj  dilnte^l,  the  tnembninous  tac  mpturrd,  and  the  head  be^tmiog  to  i1c^fiiD4 
mtn  the  [telvic  cavity.  The  piiiris  toHt  nolhinjyi:  of  their  e:xpulj(i%v  chnmcUT,  but  oon* 
tinued  with  regularity  and  vi^rir.  There  was,  however,  at  4  o'clock  r.n.,  hnt  m 
llight  ndvanee  in  the  position  of'tim  hend  ;  u  ttiii  lime  I  ftuw  the  paUeoi,  being  Juit 
eleven  hours  from  tlie  cornmencemenl  of  the  hiWir.  After  giving  a  histury  of  tba 
caae  na  nltovo  detailed,  Dr,  Ulbburd  requested  me  to  examine  the  patkmt  TKi 
hend  rr>st4Hl  diiigonjiily  in  the  pelvic,  und  had  evidently  c»>titinued  to  make  pp^fiii 
under  tl^e  fttrung  contructions  or  Ihc  ntenjK,  Mhiioiiglt  tin*  iidvanoc*  had  b«ti  «JC» 
tremely  filow.  During  nn  interval  of  patn,  1  again  hiiroduecMl  my  tlngier  inlu  Ilia 
vagina,  when  I  ver>'  dii^tinctly  recognised  a  peculiar  condition  of  the  head ,  ii  vm 
fluocid  U»  Uie  touch,  und  the  iKioeti  were  movable,  the  one  u^Ntn  the  olhrr.  Wli«| 
oould  thia  be?  Waa  tt  beonuae  of  the  de44th  of  ttie  child  and  its  putrffar>timi  *  Tllil 
hypothcila  was  Boon   removed,  been  use   nuitcnlrntinn  Pt*veflled   the  b-  "-im 

ftvtal  heiirl,  und  the  ntothcr,  loo,  was  conocioua  that  her  child  wua  ahv<  ,  cfj 

dbtfnctly  felt  ltd  movementj^ 

Here^  then,  wma  an  iniereisting  atato  of  things  and  there  wad  much  need  u(  tamd 
Judgment,  fv^me  wriiera  phiee  greut  coidtdeuee  in  tliu  tluci-idity  and  tiVfrUipptO^ 
of  the  bonen  of  the  head  na  an  cvidanee  of  the  death  of  the  fcetua ;  and,  thvrcCv^  Itt 
the  cufle  now  under  conaideralton,  If  tfda  evidence  hrul  iM^eti  accepted  aa  wortlij  of 
guidance,  it  might  [H^oaibty  have  huppened  that,  under  I  ho  eonvieii()«i  thnt  th**  rhild 
had  cea^  to  live,  a  reaort  may  have  been  hud  to  the  perroralor  and  1 1  'Am 

purpode  of  bringing  the  deiid  foetus  into  the  wtirld,  and  tliuii  termiiwi      .  .M* 

very  In  these  days  of  fimdneaa  Ibi'  inHtniinents,  such  an  alteru;itiv«  i*  in  nol 
among  the  ver>'  improbnble  things  of  the  lying-in  mom.  From  all  die  vii\-uu^-uu(m 
of  the  ca^e,  I  hud  no  doubt  of  the  true  cauae  uf  the  ttaccidity  and  overluppuig  dthB 
bones,  it  was  manifeittly  an  example  of  hydrooephahis ;  in  tltbi  opinkyn,  I  iraa  K^ffX 
to  find  Dr  Hibbard  fully  concurred.  Witli  thu  diugnoaia.  the  quci«ttao  arow  Wbat« 
QHder  the  cireumst/inceH,  wna  the  counp«t  to  be  pursued 7  It  woa  oi-^  '  *'  •  \^ 
labor  shcniUt  W  curiUdei]  Ut  miture,  artd  for  thew*  oi^vtous  reaNrms  :   t   1  'is 

alive  ;  2.  The  strength  ajid  genera)  condition  of  the  mother  were  gooii.  lu*  ptum 
continued  with  tiieir  wonted  force,  and  at  half*past  three  oVk*ck  A.M..  twwitf*tWo 
houm  fhim  the  ccjiiitnencemcnt  of  the  pdrturition,  we  had  the  «attRfacti<in  of  witMis* 
log  the  propriety  of  the  counx)  adopted  in  the  birth  of  a  !i7ing  child  |  altliotig^  wllit% 
its  head  exhibited  a  mo^t  uncomely  appearance,  in  convcquenoe  uf  tlie  vxirmm 
elongation  It  had  undergone,  the  occipi to-mental  ditimeter  mensuring  nine  tnd*^ 
II  soon,  however,  recovered  from  IhU  tenifiorary  malformation,  an  i  i  its  Ua%k 

four  months  and  one  week.     The  mother  had  an  ordlimry  cstm  1  wtm 

anxiouM  to  ascertain  the  true  c*>ndition  of  the  pelvis  in  this  case,  tHa 

finger  to  the  upper  strjiiL,  It  was  quite  evident  tlnit  there  was  an  n  .  j^ 

hi  tiio  antero-iiosterior  dbunetcr,  whldi  ooutd  not  bavo  presf&it4  a  D^iMM»  wwm 


THE  PBINCIFIiES  AlO)  PRACTICE  OF  OBSTETRIGS.         621 

among  authors  as  to  the  extent  of  deformity  through  which  it  is 
possible  to  extract  a  child  at  full  term,  fragment  by  fragment,  in 
the  operation  of  embryotomy.  Burns,  for  instance,  justifies  the 
operation,  when  there  is  a  space  of  If  inches;  Hamilton  1|; 
Osbom  1 J  ;  Davis  1  inch  !  Dr.  Dewees,  on  the  contrary,  thinks  if 
the  contraction  be  less  than  2  inches,  embryotomy  should  not  be 
resorted  to.  I  have  endeavored  to  show  (Lecture  V.)  that  if  the 
direct  or  antero-posterior  diameter  fail  to  measure  from  2  to  2j^ 
inches,  embryotomy  cannot  be  accomplished  without  the  almost 
certain  hazard  of  laceration  of  the  maternal  organs,  which  may 
more  or  less  involve  life,  or  entail  upon  the  parent  sufferings  to 
which  death  itself  would  oftentimes  be  preferable  ;  and,  therefore, 
I  emphatically  urge  that  the  operation  should  not  be  attempted 
with  a  less  space  than  2^  inches,  with  tlie  single  exception  that  the 
child  be  dead.  Whether  with  this  space,  or  even  a  greater  one,  it 
will  ever  be  justifiable  to  resort  to  the  perforator  and  crotchet,  if 
the  child  be  living,  it  will  be  our  purpose  to  discuss  as  we  proceed. 

JDeductiotis, — Taking,  therefore,  the  two  extremes,  which,  in  my 
judgment,  will  be  found  correct,  viz.  a  space  of  3  J  inches  for  the 
passage  of  a  living  child,*  and  2  J  inches  to  justify  embryotomy,  the 
question  naturally  arises — what  is  the  rule  of  conduct,  when  the 
pelvis  shall  present  a  contraction  between  these  measurements^  or 
below  2  J  inches,  if  it  should  be  ascertained  that  the  child  is  olivet 
and  t/ie  woman  at  the  full  period  of  her  gestation?  In  the  exami- 
nation of  this  question,  it  must  be  constantly  borne  in  mind  that  the 
alternative  of  choice  is  to  rest  altogether  upon  the  simple  but 
impoitant  issue — shall  the  child,  known  to  be  alive,  be  sacrificed,  in 
order  that  the  mother  may  be  saved  ?  or  shall  the  mother  be  sub- 
jected to  an  operation,  which,  while  it  will  involve  her  in  serious 
peril,  will  afford  a  reasonable,  or,  if  I  may  be  permitted  to  say  so, 
more  than  a  reasonable,  hope  for  the  life  of  the  child,  thus,  as  it 
were,  equalizing  the  chances  between  parent  and  offspring.  If  the 
latter  course  should  be  decided  upon,  the  choice  of  operations  to  be 
performed  on  the  mother,  will  be  between  what  is  known  as  sym- 
physeotomy and  the  Cmsarean  section  ;  if,  on  the  contrary,  it  be 
determined  to  destroy  the  child,  then  resort  is  to  be  had  to  cranio- 
tomy^  cephalotripsy^  or  embryotomy^  as  circumstances  may  indi- 
cate. 

I  now  propose  to  review  in  succession  these  various  alternatives, 
yielding  to  each,  as  far  as  I  can  do  so,  its  proper  place  in  the  scales 

♦  I  am  aware  that  authors  of  integrity  have  recorded  examples  of  living  children 
being  bom,  through  the  natural  effort,  when  the  abridgement  was  less  than  3^ 
inches ;  for  example,  Smellie  and  Baudelocque  both  cite  cases  of  this  Icind,  in  which 
the  head,  natural  and  healthy,  had  undergone  extraordinary  pressure,  and  was 
expelled  without  compromising  the  safety  of  the  child.  But  these  are  to  be  regarded 
as  exceptional  instances,  and,  therefore,  cannot  form  the  basis  of  a  principle. 


622 


THB  PRINCIPLES  AND  PBACTICE  OF 


of  right,  and  dediiL-iDg  from  statistical  data  and  ott  ^n  i\m 

buHis  of  condui?t  by  which  tire  conHcietiLioos  nctMiii  to  be 

giiidod,  whejij/rom  dispropartion  between  the  maferftai  orryans  ami 
foetmy  the  latter  canmdpaMn  ^t  ftdl  ttrm^pervHU  w*' '"*■>>■  -  -  -  -^/U 
through  the  intervention  of  eutting  ifistrumenis^ 

1,  tSf/fttp/it/.scQ(om}/, — Tliis  consists  in  a  section  of  Ux 
pubb,  with  tht*  viuw  of  ^iviii^  such  an  utcrease  of  c.H['ii 
allow  the  I'xlt  of  the  child.  The  projector  of  thin  operation  u  ait  a 
French  medical  student,  named  Siganlt,  who  made  it  the  topic  of  a 
nannoir,  which  was  presented  to  the  Anidinny  o(  Surgery  in  I7fi8; 
it  was,  however,  not  well  received  by  the  Academy.  Jiut  Sigault, 
Btill  tirm  in  his  conviction  that  he  would  be  able  to  ilenion^tratc  tlie 
great  fact  that  gymphyseotomy  was  destined  to  become  a  mh^ 
stitutc  for  tlic  Oesarean  sertion,  and  entirely  do  away  with  tht 
nece.H8ity  of  the  latter  operation,  selected  the  same  question  as  |Im> 
subject  of  his  thesis  in  the  school  of  An^jerH  in  1773.*  It  is  due  lo 
thiH  enthusiastic  surgeon  to  state  that,  at  tii'St,  ho  t*irnply  prop«i0ed 
to  experiment  on  living  animals,  and  then  on  condemned  cnminali; 
his  essays  on  the  dead  subject  having  satisfied  him  of  t  .'C* 

ness  of  his  opinion  as  to  the  feaHibiliiy  and  advantage  oi  -a* 

tion  on  the  living  woman  in  certain  canes  of  pelvic  deforuiity*  Aa 
on  most  questions  of  science,  the  )>ersevoring  demandai  of  Sigmill 
for  an  oplniim  soon  gave  rise  lo  two  jiarties  the  one  in  favor,  and 
the  uthcr  adverse  to  the  suffgealion.  Among  the  former,  may  bo 
mentioned  the  learned  Ilullutid  jihyt^tcian,  the  well-kuowti  Dr. 
Camper,  who,  in  1 774,  wrote  a  fetter  on  the  subject  to  Van  Giamelitr, 
entitled,  De  JCmolunu^ntiB S^ionia  JSt/nchondroseoM  03$ium  IhAU 
fVi  Partu  difficilt. 

Nothing,  however,  of  a  positively  decided  character  developed 
Itself  in  the  minds  of  the  profession,  if  we  except  the  mer<T  expfca* 
slon  of  opinion  us  to  the  anticipated  benefits  or  evils  of  tbe  |ifo* 
j>o?*ed  operation,  until  1777,  when  Si^auli,  jtHsl'sted  by  bin  fricml,  A, 
Lc  Hoy,  lcste<l  the  feasibility  of  his  theory,  by  resorting  to  arm* 
physeuiorny  on  a  marritHl  woman,  named  Soucbot,  which  rc*uH«d 
bi  mfety  to  both  mother  and  child.  This  woman,  it  appears,  bad 
previously  borne  four  dead  children.  The  succea*  of  tht>  operjitina 
was  like  the  electric  current,  for  it  winged  it*  Hight  almo>*t  with  ibe 
ra]»rdity  of  lightning  ;  fur  the  lime  being,  all  doubts  were  at  an  end, 
and  Siguult  \V9A  the  idol  of  Continental  Europe.  His  name  bectt&it 
one  of  honor ;  ihe  pior  student,  who  was  ridiculed  at  tiDit,  wa»  now 
the  very  eentrc  of  attniciion  ;  he  was  the  originator  of  a  new  epftcli 
in  obstetric  science  ;  he  had  caused  to  be  expunged  from  pra^-tm 
the  '* barbarous  and  deadly*-  CiPSiirean  section,  and  8ubstituti'4  in 
its  atead  the  *'  rational  and  conservative "  operation  of  Mmphjr- 

*  "Hif?  (billowing  la  ttic  title  ot  the  tlieii«:  An  in  rurtti  ctiotni  Nsttimni  Stclii 
8ynii»I»jrHw«  Qasium  Put>iff  Section©  Caaar&a  proropti>w  d  tutior. 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         628 

feotomy.  I  am  only  quoting  the  words  which  were  on  every  one's 
tongue  at  the  period  of  which  I  speak.  Ilis  fame  was  not  limited 
to  the  adulations  of  the  body  of  the  profession,  but  he  became  the 
recipient  of  the  highest  honors  of  learned  academies — the  very 
academies  which  had  originally  nearly  crushed  his  spirit  by  the 
un&vorable  manner  in  which  his  "  rational  and  conservative  "  pro- 
position had  been  received  !  The  Academy  of  Medicine  of  Paris 
voted  him  a  medal,  bearing  the  following  inscription  :  "  Anno  1768, 
Sectionem  ISymphyseoa  Ossium  Pubis  invenit,  Proposuit :  Anno 
11*1 7^  fecit /eliciter  M,  SigaiUt^  D,  M,  Ipsiqtte^  centum  calculos  iUos 
esse  offerendos,  Juvit  M.  Alph,  Le  Itoy^  J),M,P,  Cui  quinquor 
ginta  offerentur  calculi  illi  argenteiy 

In  addition  to  this  medal,  making  such  honorable  mention  of 
Sigault,  and  his  assistant,  Alph.  Le  Roy,  a  royal  pension  was 
granted  to  the  illustrious  benefoctor  of  the  age.  But  this  was  not 
all ;  many  an  eloquent  pen  was  busy  with  oblations  of  praise,  and 
Sigault  was  lauded  as  the  man,  of  all  others,  who  had  contributed 
a  precious  flower  to  the  garden  of  science,  and  had  conferred  on 
womankind  a  blessing  which  would  not  fail  to  be  appreciated  in  all 
time.  Indeed,  there  was  a  perfect  furor  in  public  opinion,  and 
Sigault  was  its  subject.  Panegyric  after  panegyric  was  issued  from 
the  press,  and  he  must  have  grown  giddy  with  the  eulogiums  of  his 
admiiing  friends,  one  of  the  most  enthusiastic  of  whom,  Roussel  de 
Vausesme,*  supposed  that  nothing  short  of  inspiration  could  have 
led  the  mind  of  Sigault  to  such  a  magnificent  conception :  "  At 
tandem  Sigault,  D.M.P.  haic  alta  mente  diu  revolvens  solus  divino 
quasi  afflatus  numine  quam  monstrarat  natura  viam  ingi*editur.'» 
Again :  under  the  influence  of  the  same  unbounded  enthusiasm,  this 
writer  predicts  that  posterity  will  not  fail  to  regard  symphyseotomy 
as  among  the  most  useful  of  operations :  '*Non  longam  post  elapsam 
annorum  seriem,  inter  operationes  maxime  salutiferas  annumeretur." 

I  have  thus  presented  this  brief  and  running  sketch  of  the  origin 
of  symphyseotomy,  and  of  the  acclamation  by  which  its  first  success 
was  received,  in  order  that  you  may  understand  how  oftentimes  it 
happens  that  human  judgment,  even  in  grave  matters  of  science,  is 
premature  in  its  decisions  because  of  the  crudeness  with  which 
investigation  is  carried  out.  Here  we  find  upon  simple  assumption, 
founded  in  the  first  instance  on  the  success  of  a  solitary  case,  the 
professional  mind,  as  it  were,  becomes  startled  at  what  it  deems  a 
great  fact — learned  bodies  are  impelled  by  the  enthusiasm  of  the 
moment,  and  their  imprimatur  is  aflSxed  to  what  the  future  proves 
to  be  the  veriest  phantom  !  There  is  a  moral  in  all  this  too  palpable 
to  need  comment. 

Let  us  for  a  moment  consider  the  objects  of  symphyseotomy, 

*  De  Sectione  Symphyseos  Ossium  Pubis  Admittanda.    Paris,  1*778. 


THE  PRLNCrPLES  AND   PRACTICE   OF  OBSTETRIC8w 


together  with  tlie  resiilUi  af  the  operation^  and  t)i€*n  d^flcraiBt 
whether^  in  any  event,  it  can  become  the  smbstitiite  for  ihii  Cittt* 
rean  deetioi>;  or  whether^  under  any  eircumstaneeit,  it  should  coo^ 
tintiL^  to  receive?  tfie  sanelion  nf  the  profession  ass  btUDftoe  or  jctfl^ 
fiable  n'mn  in  t\w  lying-in  chamber. 

Its  OhjerU, — Thi?  most  anient  a<]  vociite*  of  ayniphyw^olotny  biiad 
the  motive  for  its  perfurnmnce  upon  the  ejcdusive  fiieU^-that  ll 
wonhl  8o  far  increase  the  eapneity  of  a  deformed  pelviin  as  to  pcrrmil 
a  livlnt>;  child  to  pann,  and  that  it  is  a  les8  daiiLr  '-^u  lliaii 

the  CieHiirean  section.  Ample  experiment  liaa  wi ;  )  sboini 

that  it  IB  not  pos^ibie^  by  the  aeparaiion  of  the  syniphyaia  ptibia» 
to  obtain  in  the  direction  of  the  antero-po»terior  diameter,  at  \hm 
Qtmoist^  an  inrreitae  bey  mid  half  an  i«cA,  and  in  accomplbibing  llik 
there  will  be  the  serious  hazard  of  lacerating  the  ^acro^iltac  vph 
ehandroses.  If  this  be  true — and  tlie  fact  Is,  I  tbink^  univt^mllj 
conceded — it  follows  that  no  good  result  can  be  expected  to  tb# 
child  if  the  contraction  of  the  antero*posterior  «pace  fcbutdd  be  a 
fniction  under  2^  inrhes,  for  we  hold  that  »  living  child  can  not  b« 
ma<ie  to  pa;*3  if  thii*  diameter  bo  h*m  than  3 J  inches;  and  cvi-ii  wttk 
that  jillotment  the  difficulty  will  bo  very  great.  As  the  chief  motirt 
for  etymphy^eotomy  is  to  aave  the  ehtlil,  that  object  would  tnoit 
certainly  be  defeated,  if  the  space  were  much  short  of  2}  iiiehiaiL 
Anoilier  very  important  circumstance  to  be  taken  into  account— 
and  about  which  there  is  a  generfd  aauent  anuuig  authors — ia  iliat 
in  eonse(}uencc  of  the  posterior  relationn  to  the  pelviit  of  the  aacro- 
iliac  synchondroses^  it  ensues,  as  a  necessary  physical  fkct^  that  tlie 
greatest  space  obtained  by  this  nperatioTi  will  be  :  K  Tri  the  otiUqiM 
diameter  of  the  pelvis;  2*  In  the  transverse ;  an<l,  n.  In  the  anltrf^. 
posterior. 

Now,  if  it  be  remembered  that  it  is  the  abridgnuu;  oi  lor 
posterior  diameter,  which  in  the  first  place  constitntcs  the  <  ' 
to  the  delivery,  and,  secondly*  ilie  motive  for  a  resort  to  th' 
tion,  it  would  seem  to  follow,  not  only  as  a«  irresistible  .   ^...„ 
eequitur^  but  as  an  esserjtial  praptical  deduction,  tliat  uulesa  mil- 
physeotoniy  will  alford  an  additional  ^pace  between  the  pitbos and 
sacrum^  such  as  beyonJ  all  ]>era<iventure  will  permit  the  paaaago  of 
a  living  child,  it  failn  to  secure  the  object  for  wldch  its  advocalaa 
have  contended ;  an<l,  under  the  eircumataocea,  in  additioo  ia  tlw 
risks  of  the  operation  itself,  it  would  bfooBiA  necaiBary  to  iuperadd 
the  dangers  to  the  mother  of  embryotomy,  not  to  tpeak  of  tlia 
consequent  sacrifice  of  the  child. 

But  let  us  suppose  that  the  antero-posterior  diameter  nhall  tiseasore 
25  or  even  3  inches — U  symphyseotomy,  with  this  ?;r  -  "  ^ieaicdt 
Its  friends — If  there  be  any  now  left — ^wonhl  perha;  die^lat 

such  an  interrogatory.  I  have  no  hesitation,  however,  in  sayings 
that  in  any  cu.hc  iti  which  the  divi.Hion  of  tlie  p<dvIo  boucs  ban  beoi 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS. 

recommended,  I  should  myself,  as  an  alternative,  prefer  the  Caesa- 
rean  section,  for  the  obvious  reason  that  I  believe  'its  dangers  to 
both  mother  and  child  to  be  less  than  those  involved  in  the  opera 
tion  of  symphyseotomy.  It  has,  I  think,  been  shown  that  the  first 
argument  of  the  symphyseotomists — the  acquisition  of  an  increased 
space — when  the  contraction  is  less  than  2J  inches,  is  worthless  in 
practice ;  and  their  second  argument — that  the  operation  is  more 
conservative  to  parent  and  child — will  be  proved  to  be  equally 
&]Iaciou!s  as  we  shall  see  by  a  glance  at  the  statistics  of  the  two 
operations. 

Statistics, — It  would  appear  that,  in  symphyseotomy,  one  mother 
is  lost  in  every  three,  and  one  child  in  every  two.  These,  it  must 
be  remembered,  are  simply  the  aggregate  results  of  the  operation  ; 
there  is  no  account  taken  of  the  serious  and  not  unfrequently 
remote  fatal  issues  to  the  mother  in  consequence  of  the  injury 
inflicted  on  the  soft  parts,  more  particularly  the  bladder  and  uterus, 
to  say  nothing  of  the  permanently  crippled  condition  of  the  unhappy 
parent,  which  has  occurred  in  more  than  one  instance.  If  we  now 
compare  this  table  with  that  of  the  Caasarean  section,  we  shall  find 
that  in  the  latter  one  mother  is  lost  in  2j,  while  more  than  two 
thirds  of  the  children  are  saved.  Here,  it  is  true,  more  mothers 
die,  but  the  safety  to  the  child  is  greatly  increased.  When,  how- 
ever, a  woman  recovers  from  the  Cesarean  section,  she  has  not 
entailed  on  her  the  accidents  which  so  commonly  result  from  sym- 
physeotomy, but  she  enjoys  good  health,  and  is  not  disqualified  from 
attending  to  her  ordinary  duties,  as  is  proved  by  the  fact — which 
has  repeatedly  occurred — of  the  same  woman  having  been  subjected 
to  the  operation  several  times,  and  with  success  to  her  and  her 
child. 

Again :  the  results  to  the  mother  from  the  Caesarean  operation 
just  given,  are  not,  in  my  opinion,  to  be  regarded  as  fair  exponents 
of  its  positive  fatality,  for  they  are  taken  from  mixed  cases,  the 
great  majority  of  which  wero  no  doubt  operated  on  in  extremis^ 
when  the  vital  forces,  from  previous  effort,  had  been  so  dilapidated 
as  greatly  to  tend  against  recovery ;  and,  as  we  proceed  in  the 
investigation  of  this  question,  I  shall  endeavor  to  demonstrate  that 
the  Ccesarean  section  would  be  far  more  favorable  to  the  safety  of 
the  mother  if  as  a  general  principle^  it  were  resorted  to  earlier^  and 
not  Uft^  as  has  been  too  often  the  case^  until  the  last  spark  of  life 
is  near  extinction,  I  can  comprehend  no  difference,  in  this  essential 
particular,  between  the  Csesarean  section  and  any  other  capital  sur- 
gical operation.  In  the  latter,  is  not  the  great  element  of  success 
an  opportune  and  timely  resort  to  the  knife,  when  the  system  is 
best  prepared  to  resist  the  shock,  and  in  condition  to  lead  to  reco- 
very ?  The  truth  of  this  no  one  will  doubt,  and  yet,  so  far  as  the 
CaBsarean  operation  ia  concerned,  this  great  oonservative  principle 

40 


626 


TOE   PRINCIPLES  AND   PRACTICB  OF  OBOTmaCS^ 


has  but'D  nadly  neglected.  Therefore,  for  ihe  reasons  KtAtrd,  mf\ 
advice  to  you  is  to  rcpudmrc,  as  altogether  tinjuifiUliable,  becatMl 
without  an  equivalent  for  the  hazard  it  uji^oIveB,!!  rec<juriic  10  &fm^\ 
physeotoniy. 

2.  T/ie  Cmsarean  Section. — ^Thift  operation  cotisiistts  in  an  inrisioii  * 
through  tht?  ahdominnl  walls  and  nteru*  of  the  mother,  for  iht*  piuv 
pose  of  extractiug  the  I'hild ;  thin,  at  leant,  is  the  gcnemlly  accepli^ 
definition,  The  deiinition,  however,  is  too  circurnncribed,  for,  in 
strict  courttruetion,  it  is  atill  the  Civsarcuri  section,  wliethcr  iht 
child  he  extracted  by  an  opening  through  the  abduniinal  pariet^ 
or  vagina ;  hence  it  has  been,  I  ihink^  properly  divided  into  oMck 
minal  htjgferotomy  and  vaffimtl  hyHerolQmy^  depending  opoQ 
whether  the  incimon  into  the  utents  bo  through  the  abdoiiMni  or 
vngina,  I  do  not  deem  it  necessary  to  enter  into  any  sp-etjil  dl^ 
eusMon  touching  tlie  early  history  of  this  operation  ;  I  prefer  rilltcr 
to  direct  your  attention  to  the  important  quest  ion — tTnder  wKai  w- 
cwmHtancrg  is  the  Ct^sarran  gr.efion  jn&tiJhtltUy  nufi  %rhaf^  fH  0  cm 
gerrafiife  resource^  are  its  (rue  reiation»  to  craniolumyf 

Few  subjoct^s,  perhaps,  in  midwifery  have  given  ri«e  to  more  tei 
oils  discussion,  and  called  forth  more  decided  c»piuion,  both  for  md  ' 
against,  than  the  very  question  which  wc  are  now  to  comdfl 
ITrre^  we  find  tht*  controversy  not  limited  to  mere  iudi^iduab^liat 
it  has  in  the  full  sense  of  the  tenn,  become  what  may  be  Imlf 
call  oil  national.    In  Great  Britain,  for  example,  the  almci«t  imtiftf^ 
sal  voice  of  the  profession  is  in  favor  of  craniotomy  in  preferent 
to  the  C:esarean  section  ;  the  wnten*  and  [inictitionerw  uf  that  cod 
mon wealth,  as  a  very  general  principle,  avow  thjit  there  is  no  tsm 
parison  to  be  instituted  between  the  value  of  the  life  of  the  mother  j 
and  that  of  the  child;   and,  therefore,  in  cases  requiriii^  nsitiiiyj 
irmtromcnts,  the  perforator  and  crotchet  are  resortwl  to,  vrWtli«r^ 
the  chihi  be  living  or  dead.     On  tl»e  Continent,  on  the  contranr*  ibe 
reverse  of  this  obtains  ;  and  craniotomy  is,  comparatively,  ttiudi  l»i  ] 
frequently  practised  than  the  Caesarean  section.     It  tioe^  rcallr  mtm 
to  me  that,  amid  the  conflict  of  i*entiment,  which  has  and  wuX\  oa 
tinues  to  exist  on  this  vexed  topic,  iiicts  have  had  too  frcqoeillljrUll 
yield  to  an  infleitible  delennination  not  to  surrender  preooiit*eired 
opinion ;  in  this  way,  and  under  the  influence  of  a  false  prindiilii* 
the  humaij  mind  is  oftentimes  fettered  in  its  judgment,  and,  m  % 
consequence,  much  harm  \&  entaileil  both  u[>on  scienco  And  btnna- 
•oity. 

Discrepant  qf  Opinion   touching  the   C€t§an9am  Aseftak—4 
wish  you  distinctly  to  bear  in  memory  that  the  eoiitroTeri]r«  irklt 
regard  to  the  benefit  or  evil  of  the  Cjesurean  operaticm,  0C«iiiS  la 
rest  on  the  contrast  which  authors  have,  in  their  own  inlfMlSf  iiiiSli-  j 
tuted  between  it  and  craniotomy,  and  also  on  the  respertivq  vahit  j 
M'hich  they  affix  to  the  life  of  the  mother  and  child.     It  U  worthy 


THE  FRIKCIPLES  AND  PRACTICE  OP  OBSTETRICS.         627 

»f  recollection,  too,  that  the  deductions  of  both  parties  are  some- 
times from  very  false  premises,  as  I  hope  to  demonstrate  before 
dosing  this  lecture.  It  may  not  be  without  profit  to  array  before 
you  the  opinions  of  some  of  the  leading  authors  on  this  subject, 
and  you  will  appreciate,  in  perusing  their  conflicting  notions,  the 
maxim — Quot  homines  tot  senteniicB^  which  may  be  liberally  trans- 
lated: As  men? 8  features  differ  so  do  their  opinions. 

Dr.  Osborn*  says,  "  The  valuable  life  of  the  mother  should  never 
be  exposed  to  absolute  destruction  by  the  Cesarean  operation  for 
the  certain  safety  of  the  child.  The  perforator  should  be  had 
recourse  to  without  reference  to  the  life  of  the  child." 

Mauriceauf  writes,  "  The  Ciesarean  section  should  never  be  per- 
formed on  the  living  woman  ;  it  is  an  inhuman,  cruel,  and  barbai^ 
008  operation." 

Baudelocque|  holds,  "2b  mutilate  a  living  child^  in  order  to  avoid 
the  Ccesarean  section^  is  the  offspring  of  ignorance  and  inhuma- 
nity ;  nothing  can  excuse  the  practitioner  who  will  have  recourse  to 
the  perforator  or  crotchet  without  frst  being  certain  that  the  child 
is  dead.'*'* 

Gardien§  says,  "  It  is  with  good  reason  that  prudent  accoucheun^ 
in  view  of  t/ie  fatal  residts  of  embryotomy^  prefer  tlie  Ccesarean 
operation."*^ 

Dr.  WeidemannJ  "  recommends  the  Caesarean  section  in  every 
pelvic  deformity  in  which  a  living  child  cannot  be  delivered  by  other 
means  /"  and  he  is  most  emphatic  in  his  denunciation  of  the  crotchet 
and  pei*forator,  for  the  following  is  his  decided  language,  charao- 
terizing  the  destructix>n  of  a  living  child  by  these  means  a  monstrous 
crime :  "  In  fcetum  vivum,  wicas  et  perforaXoria  adigere^  nefcok' 
dam  f acinus  est:'* 

Sme'lie,1"  England^s  great  obstetric  light,  speaks  thus  :  "  When 
a  woman  cannot  be  delivered  by  any  of  the  methods  recommended 
in  preternatural  labors,  on  cuxount  of  the  narrowness  or  distortion 
of  t/ie  pelvis^  etc. ;  in  such  emergencies^  if  t/ie  woman  is  strong  and 
of  good  habit  of  body ^  the  Ccesarean  operation  is  certainly  advisee- 
bUy  and  ought  to  be  performed;  because  the  mother  and  child  /lave 
no  other  chance  to  be  saved^  and  it  is  better  to  have  recourse  to  an 
operation  which  hath  sometimes  succeeded^  than  leave  them  both  to 
inevitable  deathJ*^ 

Sir  F.  Ould  says,  "The  Csesarean  operation  is  most  certainly 

*  Easays  on  the  Practice  of  Midwifery,  p.  225. 
f  Traits  dea  Maladies  dos  Femmes  Grosses,  vol.  I,  p.  352. 
J  KArt  d'AocouchemGnt,  vol  ii.,  p  220. 
§  Traitrt  complct  d' Accouchement,  p.  103. 

I  Comparatio  inter  sect  Caesar,  et  diasectionem  cartilag.  et  ligament  pelr.  In  pttto 
ob.  pelv.  august  impossib. 
^  Midwifeiy,  vol  i.,  p.  239. 


28 


THE  PRINCIPLES  AND   PBACTICE  OF  OBffTETRICa 


inortfii,  and  I  hope  it  will  never  be  in  the  power  of  any  on«  Ur] 
prove  It  by  experience." 

Mcrriman^  npeaks  thus;  "It  cannot  be  matter  of  much  gnrprteJ 
tliat>  with  90  liitk  success  a^  hru  attended  the  Ccfsarean  ftpfratwm] 
t>i  Enfjland^  the  BiiiL^h  accoueheiirs  tshould  be  «o  reluctatii  to  pi 
form  or  adopt  it ;  and,  therefore,  recourse  is  nevtr  hari  io  it^  rmpf 
in  such  dtfphmbk  cases  only  as  preduds  the  possibiiiiy  of  dlaArMPy 
^y  (f^^y  ^ther  meuns^* 

Bhmdt-'llf  8av*S  *^^'  ***  ^'*  axiom  in  British  midtci/ery^  that  wt 
arc  never  to  deliver  by  t/ie  Ccesarean  o^terationy  provided  tee  eaii,  in 
afty  teay^  deliver  by  the  vatural  passages,  1  feel  pentuiidt^  thai 
women  miglit  sornetirites  be  more  safely  and  more  ca^  ered  i 

hy  the  Cesarean  sectio?)^  than  by  the  pas8.ige«  of  lb    ^  ,  bat ' 

if,  actinj^  on  thij*  purj^ua^ion,  we  were  once  to  establish  the  priild- 1 
pK%  that  the  Casarean  delirery  may  be  used  as  a  suf^iiuit  foti 
delivery  by  the  perforator^  there  would,  I  fear,  be  too  many  cos 
in  which  it  would  l»e  needlessly  ndoptcrd  ;  and  men  woald  noir  m 
tilery  not  to  m,y  frtquently^  pei-furrn  thit)  operation  iii  cimivn«fanf«i i 
t;^  ithich  it  ought  fiever  to  have  been  dreamed  of  IFAcrv  tfmAri 
tomic  delivery  is  fn-wticahle^  let  it  be  preferred."*^ 

J>v,  MaunsellJ  observers  ''The  truth  is  that  in  Great  Britatii  tlii 
CiEsarean  operation  uever  did,  and  never  will,  flonrir*!*.*' 

Dr*  Murphy§  advise^  **  In  order  to  deei<le  upon  the  Cwmttan 
let  ion,  yon  should  \veigh  carefully  the  probable  remtlt  to  the  mother^ 
"I/*  the  operation  be  not  ptfformed ;  and  if  it  np|>ear  tu  you  itiil 
perforatiou  is  iui practicable,  or  #o  difficult  to  f)erf</rm  that  (h^  dai^ 
ffer  setms  to  be  nearly  so  great  to  the  pattcpU  as  opening  the  uUnUf 
you  are  then  authorized  to  tindertake  the  operation,  became.  If 
there  be  a  probability  ihtxi  perforation  wiU  not  ensure  saf€ty  to  fM 
mothrr^  you  are  certainly  bound  to  consider  i/t€  ehOd^  aod  give  it  a 
reasonable  chance  for  its  lifej^ 

Sui)]cient,  I  ap|irehend,  has  been  dene  in  the  way  of  qnotii»g 
•uthorities  to  demonstrate  the  extraordinary  dij-crepancy  of  opinicm 
'4m  the  question  we  are  now  eon^dering ;  and  it  will  be  weU  to  ' 
remhid  you  that  the  writers  I  have  cited  are  of  no  mediorre  po«»> ' 
tion  ;  on  the  contiiiry,  they  are  men  of  eminent  name.     IIov  ii 
this  difference  of  sentiment  to  be  reconciled  ?  on  what  pritidplo  of 
reasoning  can  it  be  sntisfactorily  exphiined?     One  would  tmai^iiii  , 
that,  according  to  every  priueiplo  of  logic,  legitimate  deductioot ' 
are  the  necessary  results  of  a  legitimate  construction  of  wcli-fouiMlid 
data.     Im  it,  therefore,  not  true  that  many  of  these  authom  hart 
given  less  consideration  to  this  character  of  data  than  Xhey  have  U» 

*  SjnopaiB  of  Dtfflcult  Parturition*  p.  1$6. 

t  Principles  and  Practice  of  Obstetric  Medtcrot^  p,  371. 

t  Dublm  Pnacliee  of  Miilwtrery,  p  139. 

g  lioctures  oq  Prtridpk*^  and  Pmcttcv  of  Midwifery^  p.  ftHl. 


THS  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         629 

their  own  prejudices  or  preconceived  notions?  I  think  so,  and  it 
is  in  this  way  only  that  I  can  account  for  the  remarkable  want  of 
concurrence  on  a  topic,  involving  so  grave  and  sacred  an  interest  aa 
that  of  human  life.  When  I  speak  of  data,  in  connexion  with  this 
subject,  I  allude  to  certain  statistical  testimony,  which,  if  properly 
discriminated,  will  oflentimes  constitute,  in  questions  such  as  we 
are  now  discussing,  a  very  essential  element  for  opinion;  but  do 
not  forget  that,  for  this  testimony  to  become  a  recognised  and  safe 
substratum,  it  should  be  duly  eliminated  with  the  sole  view  of  sus- 
taining a  fundamental  truth,  and  not  for  the  purpose  of  affording 
apparent  strength  to  individual  sentiment.  In  one  word,  individual 
opinion  should  always  yield  to  well-established  facts,  instead  of 
attempting  to  accommodate  facts  to  opinion. 

In  order  to  illustrate  what  I  desire  most  earnestly  to  urge,  let  us 
suppose  that  a  certain  number  of  you  had  decided  in  your  own 
minds  that,  in  consequence  of  the  far  greater  value  which  you  attach 
to  the  life  of  the  mother  than  to  that  of  the  child,  you  would,  under 
no  circumstances,  hesitate  between  the  Csesarean  section  and 
embryotomy,  but  that,  in  all  cases  calling  for  cutting  instruments, 
your  choice  would  be  a  resort  to  the  latter  expedient.  Such  a 
deci:^ion,  I  think  you  will  agree  with  me,  is  legitimately  entitled  to 
be  considered  the  offspring  of  preconceived  opinion,  and,  as  such, 
it  would,  of  couj-se,  ignore  the  testimony  of  well-attested  facts. 
Decisions  like  these,  are,  I  maintain,  unworthy  of  science ;  they 
ai*e  one-sided,  and,  therefore,  cannot  be  truthful.  This  brings 
me  to  the  reiteration  of  what  I  have  already  stated  in  a  pre- 
vious part  of  this  lecture — that  the  choice  between  the  Csesa- 
rean section  and  other  modes  of  extracting  the  child,  must  be 
determined  by  a  just  balancing  of  evidence;  and,  with  this  con- 
viction, I  shall  now  proceed  to  lay  before  you,  as  briefly  as  may 
be  consistent  with  the  import  of  the  question,  the  particular  kind 
of  evidence  by  which,  according  to  my  judgment,  we  are  to  be 
guided. 

Contrast  between  the  Ccesarean  Section  and  Craniotomy  StOr 
tistics, — You  have  already  seen  that  the  Csesarean  operation  meets 
with  but  little  favor  in  Great  Britain,  while,  on  the  other  hand, 
craniotomy  has  for  a  long  time  been,  and  still  continues  to  be, 
honored  by  the  general  endorsement  of  the  profession  of  that 
enlightened  nation.  In  order  that  you  may  at  once  appreciate  the 
relative  frequency  of  this  alternative  in  Great  Britain  and  on  the 
continent  of  Europe,  I  will  present  you  with  the  following  tables, 
which  I  derive  from  Dr.  Churchill;  Among  British  practitioners, 
617  crotchet  cases  in  150,381  deliveries,  or  about  1  in  291 ;  among 
the  French  and  Italiansi,  69  crotchet  cases  in  38,908,  or  1  in  6633; 
and  among  the  Germans,  386  crotchet  cases  in  646,646  deliveries, 
or  1  in  1,676 ;  altogether,  836,934  labors  in  which  the  crotchet  was 


630        THS  PRIKCIPLC3  AND  PBACHICE  OF  0B0rCRIC0L 


used,  or  1  in  l,l20l .♦  The  mortality  for  the  motlierB  i»  1  in  einerf 
6 ;  and,  of  course,  the  very  nature  of  the  ojiemttun  tlcrmoniitrstai 
tliat  all  the  children  are  sacriSced.  But,  gentlemen,  it  h  emeniiil 
you  f^hotild  note  the  important  fact  that  thi'se  tahlois  grive  ut  oislj 
the  immtdiaU  death**,  in  the  jtroportion  of  I  to  5  of  the  wotaea 
who  hai'c  been  snbjeeted  to  the  liaxarda  of  crnniotomy;  not  out 
word  is  said  of  the  tlreadful  lacerations  and  destruction  uf  the  aoft 
parts,  fiometirnca  tenninating  finally,  invoKing  too  frequently  the 
unhappy  sufferer  in  distretsii  and  anguii»b,  which  would  cau9«  W  to 
invoke  death  ti^  a  blcssirrg ! 

Dr.  Maunsellf  nayn,  **  I>r,  Joseph  Chnrke  found  It  neeeA^ary  b  tbo 
Dublin  Lying*in  llojipital,  to  u:^e  the  perlbrator  in  1  in  208  cafK!«w  In 
the  Welletiley  Female  Institution,  it  was  employed  dining  iho  year 
1812,  1  in  211^  cases;  and  during  the  year  1833,  1  in  KI7  caseft*** 
This  record  would  seem  to  show  a  striking  average  difference  in  the 
frequency  of  the  operation,  as  exhibited  by  the  f»tati*tics  of  Dr, 
Churchill ;  and  what,  it  (*eera??  to  me,  must  be  apparent  to  ©very 
reflecthig  mind  is,  that  these  tables  of  Dr.  MannselL  presenting  the 
number  of  craniotomy  operations  in  well-conducted  ho!*pitAl«,  miper^ 
vis^d  by  men  of  eminent  skill,  must  fnll  grenily  *fioit  of  the  tmt 
average  frequency  of  this  altertialive  among  the  proft^s^ioii  in  o<i|i^ 
door  or  private  practice,  where  oftentimes  "  hot-haste^ and dispillcli 
arc  aubHtituted  for  piitiencc  and  sober  judgment ! 

Again:  Dr.  JuHCfih  Clarke  nientions  that  in  the  49  cm n totality 
operations  periormed  by  him  in  the  Dublin  Lying4n  IlosprUl,  10 
women  out  of  the  49  died,  or  about  1  in  3 ;  not  I  in  5,  according  to 
the  statistics  of  Dr.  Chnnhill  Thus,  the  sad  rcsfiult — 16  of  tli« 
motherB  !oi4t,  mid  all  the  children  destroyed  in  4!)  ca^ed ;  and  VH  it 
is  but  fair  to  presume  tlint  in  the  h:mds  of  Dr.  Clarke^  a  gentleiMn 
of  acknowledged  hkill  and  experionce,  assisted  as  he  no  doubt  wai^ 
in  counsel,  by  other  eminent  practitioners,  this  rnortnliiy  is  mach  Xmm 
than  wheti  the  operatiotj  is  performed  indiscriminately  in  priratc 
|>ractice,  and,  alas!  in  instances  in  which  there  is  too  often  a  want, 
not  only  of  proper  deliberation  aa  to  the  necessity  of  the  altematirei 
but  of  orJimiry  dexlenty  in  the  execution  of  the  deed. 

It  is  proper  now,  in  the  way  of  contrast,  to  turn  tolho  reaultaof 
the  Caesarean  section.  It  would  seenv  thnt  the  mortality  to  tb# 
mothers  in  this  operation  is  1  iu  24,  and  to  the  children  1  in  3|, 
Tlie  deaths,  therefore,  among  the  mothers  are  much  greater  tba«  ia  i 
craniotomy,  for,  according  to  Dr.  Churcbill'd  tablci^,  in  ibis  latter, 
the  fatality  is  only  1  in  5.  Yet,  on  the  other  hand,  in  4SI  caset  of 
craniotomy  occurring  in  the  Dublin  Lying-in  Hospital,  under  Dr» 
Joseph  Cliirke,  IC  mothers  were  sacirifieed,  or  I  in  3  !  This  cer- 
lalrdy  reveals  a  melancholy  picture,  and  it  needs  no  argument  to 

•  Theory  and  Praciice  of  MuhvifiTy.     LoDdoo,  1860:  p^  37 L 
f  Dttblm  Prucnce  ofMidwUcr^s  p.  138. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         681 

Bbow,  according  to  this  latter  table,  how  much  more  destructive  to 
human  life,  if  we  embrace  the  fatality  to  both  mothers  and  children, 
k  craniotomy  than  the  Caesarean  section  ;  foi*,  in  the  practice  of 
Dr.  Clarke,  a  practitioner  of  sound  judgment  and  ripe  experience,  in 
49  cases  there  was  the  dreadful  sacrifice  of  65  lives,  supposing  the 
children  to  have  been  alive  at  the  time  of  the  operation  I  Nor  does 
history  record  the  condition  of  the  33  mothers  who  survived,  whe- 
ther they  were  with  or  without  lacerations. 

Thus,  if  we  adopt  Dr.  Maunsell's  record,  as  a  proximate  basis  for 
opinion  in  reference  to  the  relative  mortality  of  the  two  operations, 
the  Caesarean  section  and  craniotomy,  the  evidence  will  be  greatly 
in  favor  of  the  former  expedient ;  for  while  in  craniotomy  1  in  3  of 
every  mother  is  sacrificed,  to  sa}  nothing  of  the  contingent  injuries, 
which,  if  tliey  do  not  ultimately  lead  to  death,  will  of\entime8 
impose  upon  the  surviving  mother  a  life  of  more  or  less  suffering, 
every  child  is  necessarily  sacrificed.  In  the  Caesarenn  operation,  on 
the  contrary,  one  child  only  is  lost  in  every  3J,  and  one  mother  in 
every  2^,  If,  then,  we  suppose  the  Cajsarean  operation  to  be  per- 
formed in  49  instances,  we  shall  have,  in  contrast  with  65  deaths, 
as  in  craniotomy,  a  very  diflferent  result;  1  death  in  2 J  of  the 
mothers,  and  1  in  3  J  of  the  children. 

But,  gentlemen,  I  wish  to  direct  your  attention  very  emphatically 
to  another  point  in  connexion  with  the  statistics  of  the  Caesarean 
section  as  furnished  by  Dr.  Churchill;  and  in  doing  so,  I  shall 
.  endeavor  to  prove  to  you  that  they  are  not  substantial  data  for  a 
just  comparison  between  the  relative  fatality  of  the  two  operations. 
In  the  fii-st  place,  the  number  of  Caesarean  operations  cited  by  him 
are  what  may  be  termed  mixed  cases,  including  those  of  Gr^^at  Bri- 
tain, the  continent  of  Europe,  and  some  in  our  own  country..  It  is- 
very  well  known  that,  more  especially  in  Great  Britain,  in  conse- 
quence of  the  very  decided  prejudice  against  the  Caesarean  operation, 
it  has  not  been  resorted  to,  in  the  great  majority  of  instances,  imtil 
the  life  of  the  mother  was  nearly  extinct  from  previous  eflfort,  and 
her  forces  so  prostrate  as  to  depnve  her  of  the  elements  essential 
to  recuperation.  .  Again :  I  think  this  objection  is  true,  also,  but 
not  to  the  same  extent,  as  regards  the  cases  derived  from  the  conti- 
nents of  Europe  and  America,  for  it  cannot  be  denied  that,  what- 
ever may  be  the  individual  preference  for  the  Caesarean  operation 
over  craniotomy,  there  is  more  or  less  repugnance  to  commence  it, 
and  hence  the  general  delay.  If,  in  addition,  we  consider  the  effect 
on  the  mind  of  the  patient  when  told  that,  in  the  bqst  judgment  of 
"her  medical  advisers,  the  altemative  for  her  life  and  that  of  her 
offspring  is — to  cut  the  child  out  of  her  wonib  throvgh  an  incision 
of  her  abdomen^  it  is  not  difficult  to  appreciate  why,  under  the 
combination  of  protracted  delay,  and  prostration,  through  fright, 
of  the  nervous  force,  one  mother  in  every  two  and  one  third  should. 


THE   PRINCIPLES   AND  PRACTICE  OF  OBSTCTRICS. 


he  saoriHc'GiL  I  am  free  to  confesJi  I  am  not  n  littte  BUrpiiied  tlm 
iKe  mortality  is  not  far  greater  in  view  of  the  circumitancc*  just 
alliided  to. 

It  Ih  a  fact  hitfhly  commendatory  to  their  wiguciry,  auil  u  Iji*  li,  ji 
the  same  time  exbiUiis^  I  think,  ample  evith*ricc  of  i^oufi^i  thnu-.ii, 
that,  as  early  as  the  sixteenth  century,  s*ome  of  the  writer*  un  tbe 
question  now  before  iw  gave  very  Bif^nitirantcounael,  all  other  tbbg* 
being  equal,  as  to  the  particulai'  tirfu:  during  the  labor  of  peHurtmn^ 
the  Ca»«:MVan  operation  ;  and  I  am  stronrrly  imprcAseil  with  the 
convielimi  lliat,  had  llieir  counsel  been  hearki'ned  to,  great  would 
have  been  the  gain  to  the  parturient  woman.  Houi«8et  and  Kuleftil 
(the  former  wrote  in  1581,  the  hitter  in  1704)  recommcndofl  in  the 
most  decided  mauner  that  "  the  C<Bsarean  operation  sAovl/J  be  pit- 
formrtl  hfj'ure  the  rfule  matt i/miaf ion »  ofthr.  accoucheur  ha€linjm%d 
and  more  or  kss  ejthausted  (he  womajn.^^  Lev  ret,*  ibe  great 
obstetne  anthority  of  his  times  in  Fran<,»e  (1750),  aayn,  **  As  toon  at 
the  labor  has  lairly  commenced  it  is  jiroper  to  proeeed  %iilli  tilt 
operation,  in  onler  ilml  the  most  tavorable  time  may  lie  felvcici 
for  the  ofieration  itself,  a*i  well  as  fur  ita  eonstetpienee*/*  Witb  tW 
sound  advance  which  tjurgery  has  made  iu  the  present  cfminry,  it  li 
gtrange  that  more  attention  has  not  been  given  luactitmUy  to  iImas 
fnufbimental  precept?*,  for  no  really  experienced  jeiur^eun,  I  appro- 
hend,  wilt  altcmpl  either  to  controvert  their  ui^dotn,  or  the  indii- 
enee  they  mu»t  necessarily  exerci«e  on  the  final  isBue  of  the  C»tti 
rt»an  sf?etton. 

Therefore,  I  am  quite  confident,  if  the  alternative  were  mirQ 
Qpixu'tnnehf  resotted  to;  if,  in  a  word,  the  i^anie  principle  of  pai- 
dnnee  t«hould  obtain  in  referenee  tu  it,  which  we  iind  to  c  onsititttte 
the  rule  of  action  in  all  capital  opei  utiona,  the  result  would  he  xullXj 
different;  and  I  have  no  hesitation  in  saying  that,  under  then 
favorable  circum.st:meeft,  tlte  C{e?(ar<'an  operation  would  tM#l  mAf 
prove  to  he  iufinilefy  less  deHtruetive  !*•  hunnm  life  than  eraaicytoiiif^ 
but  that  it  would  ^oon  take  its  rightful  )ilace  a^  n  juft  cspedieiil  ill 
the  lying-iu  ehamher.  The  evidence  in  d(  munsiration  of  th«  wmiMi- 
nes^i  of  tliis  ripiidou  seems  to  mo  to  he  entirely  nali  .in 

additifMi  !o  other  [uoof**,  wc  have  the  f^lrong  enn  -aW 

mony  furni>hed  by  thoj^e  ex;»mi»[es  in  which  theCieAarean  aperatioii 
baa  been  jierfornuHl  several  tinu\s  on  the  wime  woman,  with  ^ucceii 
to  both  mother  and  chifd ;  and  iu  which  vixsi.^  it  is  fairly  to  be  pr»> 
eumed  thai,  at  least,  if  not  the  Hr^^t  operation,  the  subs(c*<pient  i^ea 
were  imdertaken  o/jfiortUNei*/  before  the  stren*:th  of  the  moibet* 
had  become  exhau»te<l  by  antecedent  and  protrai-ted  effort.  Ab% 
mntter  of  Mati^ticnl  inforniation,  it  h  proper  that  I  ^houtd  relbrto 
the  IblhHving  d:itji  furni>hed  by  Keywer  of  t^'upenhaj^cn,  akhoegh 

*  fjFvrct,  Suite  dea  ObicmittotM  sur  Ion  Cnuacs  dei  AceoocbfiBiati  LaboHac^ 
9.344 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  688 

they  are  somewhat  adverse  to  the  position  I  have  just  assumed.  I 
cannot  but  think  there  is  some  error  in  the  details  of  the  cases  he 
cites.  Keyser,  taking  the  time  of  the  operation  from  the  com- 
mencement of  labor,  reports  as  follows :  first  24  hours,  mortality  to 
mothers  0.67,  infants  0.28 ;  between  25  and  72  hours,  0.55  to 
mothers,  infants  0.33  ;  more  than  72  hours  after  labor  commenced, 
mortality  to  mothers  0.72,  to  infants  0.60 ;  so  that  between  25  and 
72  hours  it  was  most  successful  to  mothers.* 

M.  Simonf  (1749)  presented  to  the  Academy  of  Surgery  a  col- 
lection of  sixty-four  cases  of  the  Caesarcan  section,  in  more  than  one 
half  of  which  the  operation  occurred  in  thirteen  women,  some  of 
these  having  been  operated  on  two,  three,  five,  six,  and  even  seven 
times,  and  all  were  successful ;  singular  enough,  most  of  these  ope- 
rations Avere  without  good  cause,  for,  of  the  sixty-four  women, 
thirteen  had  borne  children  naturally  either  before  or  subsequent  to 
the  section.  Stoltz,  of  Strasbourg,  mentions  fourteen  undoubted 
cases  in  which  the  Caesarcan  section  was  resorted  to  with  complete 
success  twice  on  the  same  patient.  Michaelis  reports  a  case  of  a 
female,  named  Adawetz,  bom  in  1795  ;  she  was  four  feet  high, 
affected  with  rickets,  and  the  antero-posterior  diameter  at  the  upper 
strait  measured  two  and  a  fourth  inches.  In  1826,  Dr.  Zwanck 
delivered  her  by  the  Caesarean  section  ;  the  child  had  been  dead  for 
some  time  previously  to  the  operation,  but  the  woman  recovered. 
In  1830,  this  patient  was  again  delivered  through  the  same  means 
by  Prof.  Weidemann,  mother  and  child  both  saved.  In  1832,  the 
Cesarean  section  was  resorted  to  for  the  third  time,  and  the  result 
was  equally  fortunate  to  parent  and  infant. 

Klein  has  gathered  with  much  care  116  Caesarean  sections,  of 
which  90  were  successful. J  Dr.  John  Hull  gives  an  analysis  of  112 
cases,  of  which  90  were  succe8sful.§ 

Halmagrand,||  the  able  annotator  of  Maygrier,  collected  between 
the  years  1835  and  1839  fifteen  cases  of  Caesarean  operation ;  of 
these,  twelve  of  the  mothers  and  thirteen  of  the  children  survived, 
while  three  of  the  mothers  and  two  of  the  children  were  lost ;  thus 
one  mother  in  five  died,  and  one  child  in  about  seven.  These  facts 
are  well  worthy  of  meditation,  and  in  connexion  with  them  it  may 
be  added  that,  in  each  of  the  fifteen  cases  recorded  by  Halmagrand, 
the  only  cause  for  resorting  to  the  operation  was  a  rachitic  condi- 
tion of  the  woman.  This  author  well  asks,  whether  this  extraor- 
dinary comparative  success  may  not  in  part  be  due  to  the  cir- 
cumstance that  the  operations  were  performed  early,  and  before 

•  London  and  Edinburgh  Medical  Journal,  p.  542. 

f  Premier  volume  des  Memoires  de  I'Academie  de  Ohirurgie. 

J  Loder's  Journal,  vol.  ii.,  p.  759  760. 

§  Observations  on  CieHarean  Operation.     Manchester,  1798.     P.  292. 

I  Nouvelles  Demonstrations  d'  Accouchementa.    Par  Maygrier,  p.  461. 


THB  PRINCIPLES  AND  PRACTICE  OF  OBSTITRtCS. 


the  system  had  become  exhausted  liy  fruitless  eflnrt,  Th^9 
statistics,  it  will  be  perceived,  arc  beyond  all  coiitni!«t  in  f;ivor  of 
the  Cesarean  section  over  craniotomy. 

I  dt-'sire  it  to  be  distinctly  undiT^tood  that  my  prt'fvrence  for  thu 
extraction  of  a  living  child  through  the  al>domcn  of  the  fiar^nt, 
over  its*  mutilation,  is  not  an  opinion  of  very  recent  ilate,  nor  UnM 
it  been  ariived  at,  I  trust,  without  due  consideration.  It  is  the 
opinion  I  have  held  and  inculcated  during  my  profe^«uriA]  Itlv,  tm 
can  be  attested  by  the  numeruti^  pupilsi  and  othersi  who  hnvc 
resorted  to  otjr  UniverNity  for  in*itruciion.  In  my  tnumlaiion  of 
Chail!y*j4  Midwifery*  (1844),  I  emphatically  expreiM^ed  mx  views 
upon  the  question  of  craniotomy  in  the  following  unec|uivoc^il  lam 
gtiage:  **In  truth,  it  need^  some  tierve,  and  for  a  man  of  hi?;h 
moral  fei'linnr  mnch  evidence  aa  to  the  necessity  ^»f  the  oiN>r:itioa, 
before  he  can  bring  himself  to  the  [H-rjietration  of  an  act,  wh^ch 
requires  for  his  own  peace  of  mind  the  fullo**t  jtiHtirtc:»lion.  lie  who 
would  wantonly  thrust  an  instrumLMit  of  dciith  into  the  brain  i*f  a 
living  tcptUH,  would  not  i4crui>le»  under  the  mantle  of  night,  to  iiie 
the  stilftto  of  the  assnjwin  ;  and  yet,  how  frcquenlly  ha*  the  child 
been  recklesMiy  torn  pieci-meal  from  it^i  moiht*r'»  womK  and  tU 
fragments  held  up  to  the  contemplation  of  the  aatocii»lied  md 
ignoratit  Hpfciuitirs  as  testimony  undoabied  of  the  op^nit(fr*« 
skill !  Oh !  i'ould  the  gnivo  speak,  how  el(><|uent,  how  d;imnifig 
to  the  charnrter  of  those  who  HpcutiLile  in  hinn^m  life,  would  be 
iU  revelations!"  Such,  gentlemen,  was  ray  Iruiixuage  t«  ISII; 
and  uow^  in  IBdl,  with  a  more  matured  judjxment  and  a  riper 
e^fpcrietice,  I  am,  if  possible,  the  more  streogtheiied  Iq  my  can- 
viol  in  I L 

Therefore,  in  the  fulness  of  my  faith,  I  have  no  bewtation  in 
saying  that,  */  the  child  he  aiwf^  the  woman  at  the  corr*  *  '  -^  of 
her  prctjnaiy^y^  mul  U  be  made  nianifcat  (hat  the  matrrrj  jm 

<tf0  so  eontraetrd  an  to  rendrr  it  pht/AiraUf/  impoAAihie  i/uit  a  iitia^ 
chad  can  he  extras' ted  per  via^  natnralnH^  I  should  b€iiC6en  ihe  i9i>^ 
r99our^2cs— craniotomy  and  the  Cesarean  section — not  hesitats  le 
d$ciile  in  favor  of  the  latter,  f     I  am  quite  aware  that  tT  "  iIi, 

80  efuphatioally  stated,  is  at  variance  v^  ith  the  general  \  tha 

profession  on  this  sulijeet ;  hut  it  has  ime  ment,  if  no  uthcr,  h  U 
aincea*,  and  founded  upon  vvhai  I  believe  to  bo  an  honest  aiiilyms 
of  all  the  evidence.  In  more  than  one  instance  on  nh'0:*d  it  Itai 
been  whovvn  that  embryotomy  h:is  been  hud  rccouvm*  to,  and  living 
children  mutilalrd,   when  the  women  in  subsi^qufnt  bWrst  weia 

^  A    rmcticiil   Treiittflc  on   Uidwirei7.     By   M.    CliAiUy.    Tnit«tlat«d  ^vm  llM 

f  It  iM  firti|>er  heru  tti  riMtiiirk  lUnl  if  it  be  AMoertiiiiicd  tb«  dilkl  li  a  mont^lm 
(aHIkiUv'!)  iiliv«')L  <«r  thiit  it  i«  HllVvtvil  with  iII^mthhc,  nrtiicli  would  nmatt  m  Ifet  tettU^ 
tioti  6nnn  iilU'f  Udivrrj',  thU  might  con>itUuU«  an  vxcfpiiuri  lu  th«*rula. 


THE  PBIKCIPLES  AND  PRACTICB  OF  OBSTETRICS.         686 

delivered  by  means  of  the  Csesarean  section,  with  safety  both  to 
themselves  and  their  offspring.* 

Dr.  Charles  S.  Mills,  of  Richmond,  Va.,  reports  a  case  of  Caesa- 
rean  operation  of  more  than  ordinary  interest,  in  which  he  saved 
both  mother  and  child.  The  special  interest  of  the  case  consists  in 
the  important  fact  that  efforts  were  first  made,  because  of  the  indis- 
position to  resoit  to  the  Caesarean  section,  to  deliver  by  embryo- 
tomy. His  associates  in  counsel  were  Drs.  Deane,  Bolton,  and 
Drew.  The  following  is  the  language  from  the  record:  "It  was 
now  proposed  that  the  patient  should  be  anaesthetized,  and  an  effort 
made  to  reach  the  abdomen  of  the  child  in  order  to  eviscerate  it,  if, 
after  a  more  thorough  examination,  it  should  appear  that  the  child 
could  then  be  brought  away.  This  was  accordingly  done,  and  Dr. 
Bolton  with  great  difficulty  succeeded  in  passing  two  fingers  through 
the  superior  strait  so  as  to  reach  with  their  extremities  the  abdo- 
men of  the  child,  but  could  make  no  use  of  them  to  conduct  an 

♦  The  following  case  I  take  from  the  North  American  Medical  and  Surgical  Jour- 
nal, No.  XXIV..  October,  18:^1,  p.  485,  reported  by  George  Fox,  M.D.: 

Mrs.  R.,  twenty-six  years  of  age,  was  married  16th  of  May,  1830,  and  on  the  14th 
of  June,  1831,  was  in  labor  with  her  tirst  child.  Dr.  George  Fox  was  called  to  her 
assistance,  and,  finding  that  there  was  deformity  of  the  pelvis,  requested  the  counsel 
of  Profs.  James  and  Meigs,  and  Drs.  Lukeus,  Hewson,  and  J.  R.  Barton.  It  was 
concluded,  after  repeated  examinations,  that  the  antero-poaterior  diameter  did  not 
exceed  two  inches.  "The  question  arose  j\s  to  what  was  to  be  done.  The  Cresa- 
rean  operation  was  thought  to  bo  attended  with  so  much  risk  to  the  mother  as 
almost  to  be  necessarily  fatal,  some  of  the  most  distinguished  surgeons  being  entirely 
opposed  to  its  performance ;  and  Dr.  Physic,  who  was  called  upon  for  his  opiuion  on 
tlie  propriety  of  this  operation,  was  decided  and  positive  in  his  opposition  to  it; 
under  the  weight  of  such  authority,  the  idea  of  the  Cesarean  operation  was  aban- 
doned." It  was  then  determined  to  perform  cephalotomy,  and  Prof.  Meigs  agreed 
to  undertake  it.  Before  he  commenced  the  operation,  however,  Prof.  M.,  conceiving, 
after  further  examination,  that  "cephalotomy  would  be  attended  with  as  much  risk 
to  the  life  of  the  mother  as  the  Ctesarean  operation,  thought  it  better  to  call  another 
consultation  to  reconsider  the  propriety  of  performing  the  C^esarean  operation."  The 
consult-ition  resulted  in  the  opinion  that  the  child  was  dead.  Cephalotomy,  there- 
fore, was  performed.  On  the  22d  of  June,  1833,  this  same  female  was  again  in 
labor  with  her  second  child.  Prof.  Meigs  was  called  in,  and  performed  a  second 
time  the  operation  of  cephalotomy.  But  we  not  told  that  in  this  case  the  child  was 
dead;  therefore,  it  is  to  be  presumed  it  was  alive. 

On  March  25,  1835,  this  heroic  woman  was  taken  in  labor  with  her  third  child. 
Dr.  Joseph  G.  Nancrede  was  her  physician,  and,  after  mature  deliberation,  decided 
that  the  C;esarean  section  was  the  only  appropriate  operation  in  her  case.  Dr. 
Nancrede  requested  the  counsel  of  Prof.  Gibson,  who  concurred  in  opinion  with 
him.  Accordingly,  in  the  presence  of  Dr.  Nancrede,  Prof  Deweea,  Dr.  Dove,  of 
Richmond,  Prof.  Homer,  Dr.  Beattie,  Dr.  William  Coxe,  Dr.  Theodore  Dewees,  and  Dr. 
Charles  Bell  Gibson,  the  distinguished  professor  performed  the  operation  with  entire 
success,  saving  both  mother  and  child. 

November  5.  1837,  Prof.  Gibson  was  summoned  to  this  patient,  who  was  again 
in  labor  with  her  fourth  child  I!  He  again  performed  the  Cesarean  section,  and 
with  the  same  success,  saving  both  mother  and  child.  These  facts  must  carry  with 
them  their  own  comment 


686 


THE  PRINCirLES  AND  PRACTICK  OF  OBSTETRT*^ 


instinimont  with  certainty  ar  safety  to  tbe  motiier,  jin^i  wu»  of 
opiriitm  ihat  it  would  he  impossible  lo  deliver  tlie  child  llifuugh  90 
nari-ow  a  passage  even  ifhecotdd  succeed  in  e  visceral  in  j?  it,  lU'ing 
still  lojith  to  report  to  the  Caesiire^ui  seclion,  until  every  effort  to 
<leUvei'/>cr  vias  tuiturai^^  had  been  tried  and  failed,  the  presenting 
lejx  waa  now  enveloped  in  a  banduge,  and,  the  mother  isliil  Iwing 
under  tlie  influence  of  elilorofoim,  gradual  but  very  powerful  W^c 
tion  wuM  made,  hoping  still  to  foroe  down  the  body  into  ihe  (^dvU, 
Tbe  greatest  force  which  could  be  applied  without  ri^Jcing  the 
laoenition  and  separation  of  the  limb,  ]u*oduced  no  other  elfeetthjui 
to  bring  down  the  thigh  a  litllu  lower.  Upon  consultation,  it  wm 
now  unanimously  thought  thut  the  Cesarean  section  ghotild  be 
maiie  without  further  delay."  Fortunate,  indeed,  was  it  that  tlie 
attempt  at  embryotomy  proved  abortive,  for  it  enabled  Dr*  Mills, 
through  the  exercise  of  his  skill,  to  aave  two  liveft,  one  of  which 
woulil  necessarily  have  been  saertfieed,  aod  the  other  subjected  to 
more  or  les;*  hazard.* 

Dunr/ent  to  t/ie  MotMr  of  the  C<BSwrean  Section, — ^Let  os  noir, 
for  a  moment,  intjuire  in  what  connint  the  dangt»r8  to  the  tnothcr 
in  this  opemtion.  They  are  enumerated  as  follows:  L  Shoc'k  to 
Ujo  nervous  sytem ;  2.  Hemorrhage,  or  an  esc:i|K>  from  the  ntcms 
of  the  Ii<[Uor  amnii  into  the  peritoneal  cavity ;  3,  The  po!i4biijiy 
of  a  portion  of  the  intestines  becojuing  compreikseil  and  stntngv- 
laled,  either  in  the  opening  of  the  abdominal  parietcs  or  ntemi 
itself;  4,  Intlammatioii  involving  the  uteruei,  or  peritoneum. 

In  reference  to  these  several  dangers,  the  most  sttrious  t^  perilo- 
neal  intlammation  together  with  its  complication^^ ;  afid  yet^  rrtini 
the  i!:tati>tu  s  we  have  given,  it  would  npjiear  that  the  peril  from  tUi 
influence  is  not  extravagant.  Indeed,  we  have  numerous  and  ejctra* 
ordinary  instances  of  recovery  after  serious  injury  to  the  peritoocuiB 
and  inieHtine»  frotu  traumaiie  causes  such  as  the  goring  of  an  ox,f 
stabs  in  the  ahdonren,  or  the  ru<le  and  unskilful  cutting  into  the 
gravid  »iterus  by  unprofesniurial  hands4  ("uses  too,  are  reoordad 
and  accepted  as  rctiabUs  in  which   women  have  uodergono  Um» 


*  Mcmtlily  Stotboioopo  snd  Reporter,  Juljr,  1856»  p,  427. 

f  Fritx  records  »  sitiguUr  m»e^  aluo  wiities^  by  N^udut,  of  a  |in.^ftttnl  ««■•* 
liaviijg  iHjeu  gv»red  in  Uie  ntxiiiiuietj  by  the  honi  of  An  nx ;  ou  the  falk)irl<ig  dsf  Ite 
wourtil  WAS  eiilArged  by  meanA  of  a  bbtoury ;  the  fcDtUi  was  «xtmctc<  and  tli« 
mother  rvciWercd!     (S<h>  Vclpcnu's  5hd  ,  p,  6iS  ) 

(  Ttte  CMsareua  opt'mtioti  WiVi  pvrUyruwd  ou  «  foirmlv  hi  Irt^lnnd.  luimMl  Aliov 
O'Ntritl  (tT3.iX  ^y  ^**  ifriHinint  luidwifi.^  Mary  DuitcUy;  lUe  htvmjanrqt  cmplofsil 
was  II  nu&rir;  alie  ImU  iho  Up^  of  the  wouui  together  with  lir:  w^me  onm 

wi?nl  K  milo  «ud  returned  with  silk  und  llie  common  t>cvd!»'-i  u  ;  'im;  wiOl 

Uium  flJiQ  joined  the  lips  in  (lie  m;itir]i*r  uf  tbe  slitch  '  "-  lt>nl|y^ 

aad  drOMvd  tlie  nrouTid  with  w1  till*  uf  eggvu     The  wo;  ■  uly^Hrffoa 

di^rs.  TliiscAAe,  increduloa.^  ua  we  mAj  be  dtipoMd,  is  rtgiuiM  «•  perltetly  inub- 
M— "KdiJibttrgU  Mediuad  Ksiiya^  roK  v. 


THB  PRINCIPL£S  AND  FBACTICB  OF  0BSTBTBIC3.         687 

CaBsarean  operation  after  rupture  of  the  worab,  and  have  survived. 
These  facts,  I  think,  tend  to  demonstrate  that,  if  all  things  be  equal, 
the  positive  danger  from  inflammation  per  se  is  not  as  grave  as  is 
generally  imagined ;  and  this  brings  me  to  the  repetition  of  one  of 
the  major  propositions,  that  the  serious  peril  of  the  CsBsarean  sec- 
tion is,  in  a  great  measure,  due  to — at  all  events,  it  is  greatly  en- 
hanced by — the  unnecessary  delay  of  the  operation,  when  the 
woman's  strength  is  exhausted,  the  womb  and  the  adjacent  organs 
fretted,  and  sometimes  even  inflamed  through  the  jointly  abortive 
effoits  of  nature  and  the  injurious  ofliciousncss  of  the  accoucheur; 
80  that,  oftentimes,  a  broad  foundation  for  fatal  results  b  already 
laid  before  the  first  stroke  of  the  surgeon's  knife. 

As  to  the  other  alleged  dangers,  such  as  the  passage  of  blood  or 
liquor  amnii  from  the  incised  womb  into  the  peritoneal  cavity,  or 
the  strangulation  of  a  fold  of  the  intestines,  why  these,  I  contend, 
are  not  necessarily  incident  to  the  operation ;  they  are  chargeable 
to  the  carelessness  of  the  assistants,  whose  duty  it  is,  by  efficient 
service,  to  see  that  these  various  contingencies  do  not  occur. 

But  the  shock  to  the  nervous  system,  you  may  urge,  is  a  very 
important  complication.  Yes,  gentlemen,  this  argument,  I  admit, 
was  not  without  force,  and  great  force,  too,  before  the  introduction 
into  the  lying-in  room  of  that  sterling  boon  to  suffering  woman — 
ansBsthetics.  It  is  in  operations  like  the  Caesarean  section,  in  which 
the  nervous  system  is  thrown  into  tumult  and  disorder,  and  where 
psychical  causes  have  an  unbridled  sway,  that  the  magic  of  anaes- 
thesia discloses  its  full  triumphs.  Under  its  influence,  the  human 
system,  emancipated  for  the  time  from  the  operation  of  external 
impressions,  is  lulled  into  more  than  the  quietude  of  sweet  and 
unbroken  sleep.  We  have,  therefore,  in  anaesthesia  an  important 
addition  to  our  therapeutic  agents  which,  when  judiciously  em- 
ployed, cannot  but  afford  most  happy  results;  the  subjection  in 
which  it  holds  the  nervous  system,  under  capital  operations,  is  dis- 
played not  only  in  the  unconsciousness  of  pain,  but  in  the  shield  it 
affords  against  the  consequences  of  the  shock  otherwise  so  apt  to 
ensue. 

Indeed,  if  the  importance  of  the  uterus  in  its  various  connexions 
with  other  portions  of  the  economy  be  recollected,  it  cannot  appear 
strange  that  a  lesion  of  this  organ  should  be  followed  by  marked 
pathological  effects  on  the  nervous  system,  and  that  these  results  on 
the  nervous  mass  should,  before  the  introduction  of  anaesthesia, 
have  been  prominent  among  the  causes  of  the  comparatively  great 
fatality  of  the  Cesarean  section.  As  a  general  rule,  it  has  been 
observed  that  when  death  ensues  soon  after  the  operation — say  two 
or  three  days — it  is  in  consequence  of  the  grave  concussion  sus- 
tained by  the  nervous  system,  as  is  evinced  by  the  symptoms, 
which,  under  these  circumstanoes,  so  speedily  develop  themselves, 


638 


THE  FR1J!^CIPLK8  AKD   PRACTICE  OF  OBdTKTRICS. 


sudi,  for  example,  aa  a  general  giiiking  of  the  forces  voniiting  and 
hiccouglu  1q  thej?e  case*?,  I  repeat,  in  which  death  »o  rupidtf 
fallows  the  operutioOi  the  true  cause  of  destruction  b  not  inHiUii* 
mation  of  the  pentoneuTti,  utertui,  etc.,  but  19  to  be  traced  to  the 
profotmd  ii«[>res8ioti  to  which  the  nervous  system  h:i8  been  mb- 
jected. 

PoHt-mortem  Cuesarean  Section, — Before  describin*?  the  nmntier 
in  which — when  inilieated— the  Csesareaii  opi^ration  w  to  be  per* 
formed,  it  is  proper  I  should  remind  you  that  it  !iomelinic-«  h<_*com«* 
nucesHury  to  resort  to  this  expedient  even  after  the  woman  h  tUtid  ^ 
and  the  practice  is  fountlerl  upon  the  well-known  fact  that  the  fa*li»i 
does  not  necessarily  die  fiimultaneously  with  its  mother.  Ifid«*eil« 
the^'e  are  numerous  instances  cited  in  which  l\m  post-mortem  CmnA* 
reun  s.'ctiou  U  alleged  to  have  been  bad  recounse  to  twelve,  twenty, 
and  even  forty-eijj^hl  hours  after  the  demise  of  the  parents,  and  the 
children  extnu^ted  alive;  bat  a  due  degree  of  caution  b  to  Im?  rxtr- 
cii*eil  l»efore  accepting  these  cases  as  proved  ;  in  most  of  thern^  ill* 
quire  firobable  tiiut  a  state  of  syncope  was  mistaken  for  death.  It 
is  important,  tor  the  assured  safety  of  tlie  child,  that  no  lime  l>e 
lost  in  its  exlrantion  after  the  death  of  the  motlicr.  There  ii^ 
among  others,  one  example  recorded  which,  I  believe,  standi  wk 
contsftdieted,  ami  hsis  received  the  \(^ry  i^eneral  assent  of  the  pro- 
fes<iotu  I  allude  to  the  extraordinary  c:L?je  of  the  Prince<«'!i  of 
Schwai-tzenberg,  whose  death  occurred  in  Paris  in  1810  under  lh« 
most  painful  circumstances.  She  was  one  of  the  gay  party  partici 
palinir  Jti  the  pleasures  of  a  ball  pfiven  by  her  brother-in-law^  the 
Austri  m  ambaH:>aclor.  During  that  night  of  festivity  there  wa*i 
appalling  con  Anginal  ion  which,  together  with  other  victim!^  caused 
tlie  death  of  the  piincess,  who  was  far  advanced  in  gestation.  On 
the  day  succeeding  her  death,  a  hving  cluld  was  remo%'ed  by  ibf 
Ciesarean  operalitMi.  This  ea&e,  however,  ahhouixh  well  authtmll'  " 
cated,  while  it  proves  the  possibility  of  the  ftetus  in  utero  %nrtmng\ 
its  mother  for  several  hours,  should  be  regardeil  as  a  very  nire€i&> 
ee|Uiaii  to  the  general  rule ;  for  it  is  conceded  that,  as  a  prinripl^^ 
the  child  dies  either  before,  shortly  after,  orsimultanfO!i»iIy  with  itf  I 
parent.  Yet,  notwithstanding  tins  genei*al  fact,  it  is  abuiidatitlf  j 
shosvn  that  numerous  children  have  been  saved  by  the po^it-morfiml 
Cmsarean  section. 

It  is  an  interesting  circumstance  that  one  of  the  earlteist  Icgiida* 
tive  acts  among  the  liomans  provided  that  no  pregnant  womaai 
should  be  admitted  lo  sepulture  until  her  child  had  been  rcmovcdj 
by  this  operation :  Netfat  hot  regla  nmlterem  qua*  pregnans  mc 
eit^  hnmari  tmUqimm  partus  ei  cxculatur  ;  qui  co.'-         * 
anhtianfis  cum  gravida  pereniiaae  t^tdtftter.     In  >  -  1 

propriety  of  this  ancient  law,  and  with  the  view  of  C4irryirig  it  om 
graclically  10  the  sense  in  which  it  was  no  doubt  originally  intended. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         889 

the  Senate  of  Venice,  in  1608,  proclaimed  tlie  imposition  of  severe 
penalties  upon  every  medical  man,  who  should  attempt  this  opera- 
tion on  a  woman  supposed  to  be  dead,  without  exercising  as  much 
caution  an  if  she  were  alive.*  History  mentions  more  than  one 
instance  in  which  an  incision  had  been  made  into  the  abdomen  for 
the  purpose  of  extracting  a  child  from  its  supposed  dead  parent, 
when  it  was  subsequently  shown  that  she  was  still  living!  Hence, 
in  all  cases  of  post-mortem  Caesarean  operation,  it  is  the  first  duty 
of  the  surgeon  to  be  morally  certain  that  the  life  of  the  mother  is 
extinct ;  and,  in  order  to  avoid  all  error,  to  keep  constantly  in  mind 
the  sensible  and  conservative  enactment  of  the  Venetian  Senate,  to 
which  allusion  has  just  been  made. 

Peu  (1694)  had  the  honesty  to  record  a  thrilling  case,  which 
occurred  to  him,  and  about  which,  therefore,  there  can  exist  no 
doubt.  He  says,  in  the  early  part  of  his  practice  he  was  requested 
to  attend  a  young  pnmipara  in  her  accouchement ;  on  his  arrival  at 
the  house,  the  friends  of  the  patient  informed  him  that  she  had  just 
expired,  and  so  he  thought  himself;  he  proceeded  at  once  to  extract 
the  child  by  the  Cajsarean  section,  but  the  instant  he  commenced 
his  incision  the  woman  gave  a  shxidder^  accom.panied  with  grinding 
of  the  teeth^  and  a  moveinent  of  the  lips — un  tressaillement  accom- 
pagne  de  grincement  des  dents  et  de  remUment  des  Uvres  !\ 

How  the  Operation  should  he  Performed.X — I  have  already  said, 
with  unequivocal  cmpha.sis,  that  one  of  the  essential  elements  of 
success  in  the  Caesarean  section  is  to  commence  the  operation  early ^ 
before  the  patie^it  has  become  exJiausted^  and  her  system  fretted  by 
iU-ad vised  interference  on  the  part  of  Iter  medical  attendant;  and 
I  now  state  without  qualification — that  it  is  the  duty  of  the 
accoucheur  to  ascertain  at  an  early  period  of  the  labor  whether  the 
circumstances  of  the  case  are  such,  in  his  sound  judgment  aided  by 
experienced  counsel,  as  to  justify  a  resort  to  this  expedient.  The 
moment  the  question  is  decided  affirmatively,  further  delay  is  not 
only  unnecessary,  but  fraught  with  danger.  Supposing,  therefore, 
that  this  material  point  has  been  duly  determined,  the  next  question 
arises — Should  the  patient  be  made  acquainted  with  the  nature  of 
the  operation  ?  Here,  again,  I  may  perchance  differ  with  my  pro- 
fessional brethren ;  but  I  am  clearly  of  opinion  that  it  is  infinitely 
better,  so  far  as  the  result  is  concerned,  that  the  mother  should  be 
kept  in  partial  ignorance ;  tell  her,  for  example,  that  it  has  become 
necessary  for  the  safety  of  her  child  and  the  termination  of  the 

*  The  King  of  Sicily  (1749)  passed  the  sentence  of  death  on  the  physician,  who 
fiuled  to  perform  the  Caesarean  section  on  a  female  dying  in  the  latter  months  of 
gestation. 

f  La  Pratique  des  Accouchemens,  p.  334. 

X  Prof.  Fordyce  Barker  reports  an  interesting  case  of  Cssarean  section  in  tbe 
American  Medical  Times,  Jan.  26th,  1861. 


640 


THE   PBINC1PL£S  AND   PRACTHCE  OF  OBSTETBICa 


labor,  lliat  you  should  interpose  and  asftist  nalurr,  '  ^omiJ 

keep  iVom  her  the  fact  that  you  are  about  to  lay  o/>f  'omtn 

and  teomhfar  t/t€  purpose  of  extracting  the  h^ant.  Such  a  n*vdA* 
liou»  euTiimon  sonac  tells  us,  would  be  received  by  the  ftufTtrriiig 
wotnan  wjlli  terror,  acting  injuriously  on  her  nen'uus  syftttiri,  luid 
thuft,  to  an  extent  at  lea^t,  firt^^^enting  a  hanriT  to  recovery,  Bui 
how,  you  may  ask^  can  ihe  operation  be  pei formed  wtthi^tii  Uie 
knowlod*;e  of  tbe  patient  ?  The  answer  to  this  quefiiion  bnngi  nm 
to  a  «io8t  important  |>oint,  and  it  is  tliis — pUic^  her  '  **^ 
ifijtuffirc  of  afiCEsthesiOy  lull  her  into  Uftco/ni\.^(nnotcs9^  -  k4 

fier  Ijlhsful  in  her  itjnorance. 

These  preludes  having  been  decided  upon,  rare  should  be 
to  erufjiy  the  bladder  j  the  patient  should  be  on  her  back,  with  the 
lower  limbs  slightly  flexed;  at  least  two  assintant??  will  be  n^.'ided, 
Well  sujipUed  with  8ofl,  delicate  sponges.  Things  being  thus  pre- 
pared, the  question  presents  itself— In  what  way  is  the  inei^oQ  to 
be  made  ?  One  author  recommends  the  obliipie,  another  the  imi** 
verse,  while  a  third  urges  a  verticid  opening  through  the  lineaiiiUL 
Eachof  ihese^  it  is  contended,  has  its  advantages  and  diAadviuitj^gf^ 
The  vertical  incision  through  the  liriea  alha  is  most  oomtnoiilf 
resorted  to,  ami  this  I  shall  describe.  In  selecting  tbb  paint  tat 
the  opening  into  the  abdominal  eavity,  there  is  no  fear  of  wottitding 
the  epigasirtc  artery,  nor  is  there  any  divij^lon  of  muscular  fibrts,  maA 
there  is  much  less  ha^sard  of  involving  the  intestines,  than  in  either 
the  oblii|ue  or  transverse  ineision.  Again:  the  uterus  u  opetird  iti 
the  central  portion  of  its  lung  axis,  and  in  a  direction  i^arallel  to  iu 
luusenlar  tissue.  On  the  other  hand,  the  section  through  the  Urua 
tUhu  is  ol>jected  to  by  some,  because,  it  is  alleged  there  uiO  be 
danger  of  injuntig  the  bladder;  and,  also,  as  the  tissues  ctnbmood 
in  the  opening  are  exclusively  fibrous,  the  healing  or  cicat rii^illoin 
of  the  abdominal  incision  will  necessimly  be  more  or  \rm  titrdy. 
These  objections  are  not  of  mueh  moment,  for  the  bladder  caa  ba 
amply  protected  by  evacuating  its  eontenus  and  liie  cotnpamli^ 
tardiness  of  the  cicatrization  is  of  very  little  consequence. 

The  surgeon,  placed  on  the  right  of  the  patient,  with  hln  t 
assistauls  on  the  opposite  side,  makes  will»  a  convex  bistoury 
incision  from  six  to  seven  inches  in  leugtli,  corameneing  at  ibd 
umbilicus  and  passing  toward  the  pubes.  This  first  incision  vnVX  bgr 
open  the  abdominal  cavity,  which,  of  course,  will  expose  to  vbw 
the  peritoneal  covering;  this  membrane  shootd  be  eaiitioarijr 
incised  below,  so  that  the  index  finger  nmy  be  introduced;  a  |yrolie> 
pninied  bistoury  is  then  carried  along  the  finger  for  the  purpose  of 
incising  the   peritoneum^  to  an   extent   corresponding  willi  tbs 

*  ]n  ord«r  to  avoid  the  Locifdoo  of  tlie  peritoticuin,  Jorg  ia  160^  wsA  RilffaB  il 
ItSOf  |»rDpoei*tl  tto  operation  whicK  sbould  Ihj  open  tbe  tn^ofti  UiiltB^  of  lti9  mH^ 
licr  plane  of  tho  ut^ru&     More  rcoenily  iUis  suggetUon  Iias  been  curkKt  ou& 


I 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  641 

external  opening ;  great  caution  is  to  be  exercised  by  the  assistants 
as  soon  as  the  abdominal  cavity  is  laid  bare  in  steadying  the  uterus, 
and  preventing  the  protrusion  of  the  intestines ;  if  this  pix)trusion 
should  occur,  the  intestines  are  to  be  gently  compressed  and  re- 
placed by  delicate  warm  sponges.  The  peritoneum  being  divided, 
the  next  stage  is  the  incision  of  the  uterus  itself.  This  must  be  done 
discreetly,  not  by  one  abrupt  stroke  of  the  knife,  but  gradually,  so 
that  when  the  cavity  of  the  organ  is  exposed,  the  membranous  sac, 
if  it  should  have  i)rcserved  its  integrity,  may  not  be  too  suddenly 
opened,  or  the  foetus  involved  in  the  incision.*  It  is  recommended 
to  carry  the  incision  into  the  uterus  as  high  up  as  possible,  so  that 
the  inferior  point  of  the  opening  may  not  be  as  low  down  as  the 
opening  made  into  the  abdomen. 

This  precaution  will,  after  the  organ  has  contracted,  prevent  the 
escape  of  the  lochial  discharge  into  the  abdominal  cavity.  It  may 
possibly  occur  that  the  placenta  will  be  so  situated  as  to  be  included 
in  the  incision  made  into  the  uterine  wall — it  would  be  a  rare  cir- 
cumstance, however,  for  this  mass  is  seldom  found  attached  to  the 
anterior  plane  of  the  organ — if  so,  do  not  become  alarmed,  but  pro- 
ceed at  once  to  extract  the  fcetus,   as  if  the  accident   had  not 

Paris  by  A.  Baudclocquo,  Jr. ;  the  operation  is  called  ehjtrotomy,  and  is  performed 
as  follows:  The  incision  commencing  near  the  spine  of  the  pubes  is  ext'.'nded, 
parallel  with  Poupart's  ligament,  to  the  anterior  superior  spinous  process  of  tlte 
ilium.  Carefully  avoiding  the  epigastric  artery,  the  abdominal  parietes  are  divided; 
the  peritoneum  is  then  not  incised,  but  pushed  away  from  the  iliac  fossa  into  tlie 
excavation ;  the  upper  portion  of  the  vagina  is  thus  exposed,  and  a  free  incision 
being  made  inlo  it,  the  index  finger  is  introduced  into  the  opening  for  the  purpose 
of  bringing  the  os  uteri  fully  in  the  direction  of  the  wound  made  in  the  abdomen; 
ihis  transposition  may  be  faciliUUed  by  pressing  with  tlw  olher  hand  the  fundus  of 
the  organ  backward.  The  os  uteri  being  brought  in  correspobdence  with  the  open* 
log  made  in  the  abdomen,  the  delivery  is  to  be  commiUed  to  nature,  and  the  child 
expelled  by  the  force  of  uterine  contraction.  Plausible  as  this  operation  may  ap- 
pear— to  me  it  is  the  very  reverse — it  failed  completely  in  the  hands  of  Baudelocque, 
and  I  am  not  aware  that  it  has  ever  succeeded. 

♦  There  exists  a  difference  of  opinion  as  to  whether  the  Ciesarean  section  should 
be  performed  before  or  after  the  escape  of  the  hquor  amnii.  If  the  amniotic  fluid 
have  not  escaped,  there  will  certainly  be  less  danger  of  injuring  the  child  with  the 
knife,  for  the  fluid  will,  to  a  certain  extent^  interpose  between  the  surface  of  the 
fcetus  and  the  walls  of  the  utenis :  on  the  contrary,  should  the  membranous  sac  be 
entire,  there  will  be  the  danger,  as  soon  as  it  is  penetrated,  of  the  fluid  escaping  into 
the  peritoneal  cavity.  My  own  opuiion  is,  that  it  is  preferable  to  operate  before  the 
rupture  of  the  sac ;  and  as  soon  as  the  womb  is  laid  open,  I  should  advise,  if  possi- 
ble, the  introduction  of  a  catheter  inlo  the  os  uteri  for  the  purpose  of  rupturing  the 
membranes,  and  thus  affording  an  escape  to  the  fluid  through  this  orifice.  If  this 
cannot  bo  accomplished,  then  it  would  be  good  practice  to  puncture  the  sac  below 
the  incision  made  into  the  uterus,  and  in  this  way  the  fluid  would  find  its  exit 
through  the  mouth  of  the  organ,  which  would  prevent  the  possibility  of  its  passing 
into  the  peritoneal  cavity.  The  assmtants  shouM,  at  all  events,  be  on  the  alert,  and, 
in  the  contingency  of  the  sudden  penetration  of  the  sae-by  the  bistoury,  be  prepared 
vith  sponges  to  prevent  the  flowing  of  the  amniotic  liquor  inta  tbe^  abdomeo^ 

41 


342 


TUB  PRINCIPLES  A? 


occurred — in  the  following  manner :  Shoul J  the  head  be  near  tim 
oprnint.%  nvhc  it  gently  W  placing  llu*  inti^xfingt^ni  lidovir  tli^ 
inferior  maxillnry  boncs^  and  employ  proper  extracytiTc  forer;  If,  an 
tile  ccintrary,  the  breech  be  iherr,  wilhtlraw  il  iir»t ;  if  any  utlnrr 
surface  of  the  ftBtns  pre!*enl  sil  the  openings  introtluce  the  hand 
Yury  gently,  and  seize  the  feet.  Ami  thus  deliver  the  child*  A*  fooo 
an  the  chihl  is  extnicled,  if  it  hi*  alive,  a  ligature  in  to  be*  a|iplied  te 
the  cord,  and  then  tuejuiratcd  from  its  mother. 

Wlial  ftbout  the  [>hicent:i?  It  in  recotnmerMled  liy  some  auiban 
to  proceed  at  ouce,  tlie  moment  the  child  i«  in  the  worhf^  to  remofe 
the  aflcr-birth*  In  I  lie  event  of  comj>lett?  detachment  of  the  plft* 
ceni:j  nr  ht'tnorrli:iii:e  in  con  frequence  of  partial  det:*   '  if  Ihii 

body  and  inertia  of  ihe  uterus,  there  cannot  be  tw»*  i%aiiio 

the  |>ro[>nety  of  the  practice  ;  but  in  the  absence  of  tb«*©  contia- 
g^nctcs,  the  rule  I  hold  to  be  a  bad  one»  and  more  or  less  pertliHis 
to  tlic  mother.  Therefore,  my  advice  to  yon  i«  this — let  uature  do 
the  work  of  i^epanition,  if  nhc*  is  not  too  long  in  p**rforniin^  it;  and 
the  moment  the  delaehnient  hii5  been  accomplished^  which  may  b* 
aaeertained  by  flight  tractions  on  the  cord,  then  the  matfl  h  to  bo 
brought  away,  care  being  obnerved  to  remove  with  it  the  men 
branes,  for  if  they  be  permitted  to  remain  in  the  utem^  their  fw*" 
ticnce  will  result  in  more  or  It*^  irritation  and  ditttro^iato  the  paliviii. 
Be  careful,  al»o,  after  the  will»drawal  of  the  after -birth,  to  retoott 
any  coagnla  of  blood  from  the  uterine  cavity. 

But  suppose  nature  does  not  promptly  d(*tach  the  plaj^enta,  bov 
long  would  it  be  judicious  for  the  accoucheur  to  delay  interference? 
If  in  t\ve  or  ten  minutes  ahw  the  extraction  of  the  child  thia  pkoeola 
should  not  have  become  separated,  it  wouM«  I  think,  bo  iinpnident 
to  wait  longer;  the  ac<'oucheur  nhonld  tlien  introdtiec  hw  hxtid 
through  the  inciRion,  and  cause  the  artificial  detachment  in  the 
manner  described  in  a  firevious  lecture.  If  the  extniction  of  tht 
ifler-hirth  be  followed  by  inertia  of  the  womb — a  circumstance  qniti* 
anlikely  to  occur — a  wmall  piece  of  ice  momentarily  aph*  *  l.c 
lips  of  the  opening  will  generally  sufKce  to  awaken  toju  us 

lion§  of  the  organ. 

DrtJi9%ng  (he  WornuL — One  of  the  advan1agt*it  of  ibo  opention 
hy  the  vertical  incision  is,  that  there  are  no  vef^ek  expoflad,  aad 
lienf^  no  hemorrhage;  however,  in  cutting  into  the  n*  \(, 

eomi*  of  the  uterine  arteries  may  be  involved,  but  the  bi  ^    ^m 

be  readily  stayed  by  the  a5«i^iiitnnt!i  making  pressure  on  the  miSftm 
wnth  the  finger;  soon  after  the  extraction  of  ilie  afferr-birih,  tbe 
Wound  contract -%  the  incision  made  into  lis  wall  i?i  rc*laci}d  to  ane 
or  two  inchei^  and  in  thii*  way  all  hi*morrbage  is  arr^teiL  ¥m 
the  purpose  of  closing  the  w*ound  in  the  abdomen,  the  intermplM 
or  twisted  auture  is  usually  employed  ;  adhesive  atHpii  ^boold  lie 
placed  in  the  intervals  of  the  snturet  and  care  taken  to  hMVtt  tk« 


4 


THE  PRINCIPLES  AND  PRACTICE   OF  OBSTETRICS.  648 

lower  extremity  of  the  wound  open  to  afford  escape  to  matter,  etc. 
Nothing,  of  course,  is  done  with  the  incision  made  into  the  uterus, 
for  it  unites  speedily  through  the  process  of  nature.*  As  soon  as  the 
external  wound  has  been  closed  by  means  of  suture,  the  whole  should 
be  covered  with  a  piece  of  linen  spread  with  simple  cerate ;  over 
this  should  be  placed  a  compress  supported  by  a  circular  bandage. 
[t  would  be  well,  as  a  general  rule,  after  the  dressing  has  been  com- 
pleted, to  administer  a  composing  draught  for  the  purpose  of  quiet- 
ing the  system,  and  inducing  sleep.  The  rest  of  the  treatment  is  to 
be  conducted  on  general  principles,  in  accordance  with  the  develop- 
ment of  circumstances.! 

Since  the  publication  of  the  second  edition  of  this  volume,  I  have 
read  wifh  much  pleasure  an  excellent  essay  on  the  "  Statistics  of 
the  Caesarean  Operation,**  by  M.  Philan-Dufeillay,J  and  it  affords 
me  no  little  satisfaction  to  find  that  his  views  are  entirely 
coincident  with  my  own.§  This  author  remarks,  that  "the  method 
usually  followed  of  simply  comparing  the  deaths  with  the  reco- 
veries after  the  ()i)eration,  must  lead  to  false  deductions.  In  nume- 
rous cases,  the  deaths  cannot  be  ascribed  to  the  operation,  but  to 
antecedent  conditions  of  the  patient;  which,  in  many  instances,  may 
be  controlled."  He  presents  a  table  of  88  cases,  collected  since 
1845,  in  which  the  cesarean  section  has  been  performed  ;  "  of  these, 
60  recovered ;  of  the  remaining  38,  the  causes  of  death  were,  in  six, 
some  antecedent  disease ;  two  died  of  puerperal  fever,  the  operations 
having  been  performed  in  hospitals.  In  the  30  remaining  cases, 
the  deaths  must  be  imputed,  in  part,  at  least,  to  the  unsuccessful 
attempts  made  to  deliver  by  the  natural  passages."  M.  Philan- 
Dufeillay  then  speaks  of  the  influence  of  the  duration  of  labor  over 
the  result:  "In  29  successful  cases,  the  natural  powers  were  pre- 
served in  24 ;  in  20,  the  duration  of  the  labor  was  under  24  hours; 
in  19  fatal  cases,  the  forces  were  failing  or  exhausted  in  18;  and  in 
11  cases,  the  labor  continued  beyond  24  hours.''  He  concludes  that 
the  caesarean  operation,  peribrmed  under  favorable  conditions, 
gives  nearly  75  per  cent,  of  recoveries. 

♦  Although,  as  a  (general  rule,  it  is  true  that  the  lips  of  the  wound  into  the 
uterus  do  become  united  through  the  contractions  of  the  organ,  yet  this  is  not  alwaja 
the  case. 

f  It  may  not  be  out  of  place,  as  connected  with  the  current  literature  of  the 
question,  tx)  observe  that  it  has  recently  been  proposed  by  Dr.  Cristoforis  to  substi- 
tute for  the  Cffiaarean  section  and  symphyseotomy  what  he  terms  the  r&sectio  subpe- 
riosiea  of  the  pubic  bones,  including  the  horizontal  and  descending  ramL  He  sug- 
gests first  to  enucleate  the  bones  from  their  periosteal  covering,  in  the  hope  that  it 
will  subsequently  be  filled  by  osseous  deposits.  He  records  four  experiments  on 
dogs,  in  which  this  deposit  of  bony  matter  followed  the  enucleation.  [Ann.  Univ. 
1858. 

t  Arch.  G6n.  de  Med.,  18«1.  §  See  page  632  of  this  volume. 


LECTURE    XLII. 

f^Qinnnl  CVnarefln  Qpenttion,  or  VsiginAl-IIysterotom^r — IndEcatlcmi  (br  fUi  i 
ii(»ti — TwoCMsea  in  lUustrutioii  by  tho  Author — Hinbryotonix— ^Mttttbi^  oTlIt 
Tcrio— Amount  of  T'clvic  CoiJiniction  Justifying  KruUrjrotoroj — Djingvn  Mul 
Fatality  of  the  Opernliurt — DtflVr^nce  of  Opinion  among  Atatliore  AS  to  iho  Cirem* 
aiaiices  indicatinp  Embryotomy— The  Cnrnt  of  KUwilielh  StiorwooJ,  M  Tf^ori^  hf 
Dr,  Osbom — Tim  Dangerous  Pnectdent  (jrowing  out  of  that  Qmc  —  Kyfettoow  d 
tlic  Cliild'fl  I>eatli  In  Utero— What  are  these  Evidettcesf^Cofifliei  of  tatthHift 
Mmong  Writers  on  this  Question — GreutCnutiOD  neoemrx  in  foniUi^  m  JudgmiDt 
— Anulysia  of  the  Evidence— -Too  Oenerid  U»e  of  tbo  Pefrfor»lor  &o4  Cmibtl— 
Melnncholy  Results  of  thia  Fondneaa  fur  Kmhryotoiny — Cam  iti  lUimtntiuii — Moik 
of  Performing  the?  Operation  of  Kmbryotomy — In  llydrr»ivjihaliu,  whnl  b  to  bt 
done? — Dc*coUiition— When  lo  bo  rei^niH]  to— Evisoomtion — WIicd  I 
C(*phiiJoiripBy — Metiutnif  of  Iho  Term — Whea  to  bo  employed. 


Gkxtlkmbn — Having  disposed  of  the  subject  of  the  aMomin^ 
C(t»arttan  secfioft^  it  ia  now  proper  that  I  should  dtfi»cribe  to  yoa 
the  va^incU  Cmsarenn  opera tion^  sonictime^  called  vaffUuil'hyMi^rO' 
tofny.  This  o|jenitioii  may  be  necessary  without  any  dcfotTiih?  €»f 
the  pelviii,  or  any  disproportion  between  it  and  the  fcptn-  ncd 

by  an  increased  size  of  the  latter.     The  usual  rau^es  iii  tb4i 

iiecesisity  for  the  optiralion  are  traceable  to  »ome  pt«culiar  coudiUoii 
of  the  mouth  of  the  uterus — for  exampli^  otvhidon  of  the  os  Htfsi 
at  the  time  of  labor,  or  a  hard,  unyielding  slate  of  it,  frura  seirHtcos 
devcKipment,  ora  tihro-caritlaginoiisehange.  Aerain :  it  may  f^oai«- 
tiiiicH  hapi)en  that  tht?  cervix  of  ihe  organ  is  skj  completely  msilpci^rd, 
cither  retro-verted  or  ante-verted,  that  it  cannot  be  brooght  to  ita 
normal  Bituation  by  the  best  directed  manipulations  of  the  accuodi-' 
eur.  Under  any  of  these  circnmstam  es,  the  whole  force  of  tine 
parturieiit  effort  is  lo^t ;  there  h  no  rt-Kponne  to  the  contracUonik  of  tb« 
uterus,  and  the  danger  neeesRarily  becomes  complicated,  involvinif 
lhes:ifetyof  the  mother  fiom  rupture  of  the  organ,  the  intervi*ntioo  of 
convulsions,  or  positive  exhaustion  of  her  viud  forces ;  the  dostmciiiMi 
of  the  child  will  aliso  be  hazarded  from  long-continued  juid  iQidM 
pressure.  It  is^  therefore,  when  the  labor  is  obstructed  by  uiM»  or 
<»t])er  of  these  several  conditions,  manifestly  a  question  forihe«uQod 
judf^ment  of  the  accoucheur  as  to  the  time  of  reporting  lo  an  <»p». 
ration  for  the  relief  of  parent  and  child — I  repeat  the  terma  pareol 
and  child,  for  it  will  be  his  duly,  in  cases  like  these,  lo  proceed  to 
artificial  delivery  the  moment  ho  is  assured  that  nature  is  nnjihte  lo 
cv'tn-^ome  the  obstacle,  and  not  tarry  until  the  mother  b  on  lint 


THE  PRINCIPLES  AND  PRACTTICE  OP  OBSTETRICS.  646 

borders  of  death  from  exhaustion,  or  the  child  sacrificed  by  pro- 
tracted compression.  I  here  reiterate  what  I  have  previously 
stated :  interference  shotdd  be  opportune^  so  that  in  its  exercise  the 
maximum  of  good  may  he  accomplis/ied — the  saving  of  the  lives 
of  both  mother  and  child, 

I  have  had  the  good  fortune  to  perform  the  vaginal  CoRsarean 
operation  twice,  and  with  the  most  satisfactory  results.  These  cases 
are  of  more  than  ordinary  interest  in  several  particulars ;  in  the 
hope  that  they  may  prove  instructive,  and  with  a  demand  on  your 
kind  indulgence,  I  shall  present  them  to  you  in  detail  as  originally 
published  :* 

December  19,  1843,  Drs.  Vermeule  and  Holden  requested  me  to 
meet  them  in  consultation,  in  the  case  of  Mrs.  M.,  who  had  been  in 
labor  for  twenty-four  hours.  On  arriving  at  the  house,  I  learned 
the  following  particulars  from  the  medical  gentlemen  :  Mrs.  M.  was 
the  mother  of  two  children,  and  had  been  suffering  severely,  for  the 
last  fourteen  hours,  from  strong  expulsive  pains,  which,  however, 
had  not  caused  the  slightest  progress  in  the  delivery.  She  was  taken 
in  labor  Monday,  December  18,  at  seven  o'clock  p.m.,  and  on  Tues- 
day, at  seven  p.m.,  I  first  saw  her.  Her  pains  were  then  almost 
constant ;  and  such  had  been  the  severity  of  her  suffering,  that  her 
cries  for  relief,  as  her  medical  attendants  informed  me,  had  attracted 
crowds  of  pei*sons  about  the  door.  As  soon  as  I  entered  her  room, 
she  exclaimed,  "  For  God's  sake,  doctor,  cut  me  open,  or  I  shall 
die ;  I  never  can  be  delivered  without  you  cut  me  open."  I  was 
much  struck  with  this  language,  especially  as  I  had  already  been 
informed  that  she  had  previously  borne  two  living  children.  At  the 
request  of  the  medical  gentlemen,  I  proceeded  to  make  an  exami- 
nation per  vaginara,  and  must  confess  that  I  was  startled  at  what  I 
discovered,  expecting  every  instant,  from  the  intensity  of  the  con- 
tractions of  the  uterus,  that  this  organ  would  be  ruptured  in  some 
portion  of  its  extent.  I  could  distinctly  feel  a  solid,  resisting  tumor 
at  the  superior  strait,  through  the  walls  of  the  uterus;  but  I  could 
detect  no  os  tincae.  In  carrying  my  finger  upward  and  backward 
toward  the  cul-de-sac  of  the  vagina,  I  could  trace  two  bridles, 
extending  from  this  portion  of  the  vagina  to  a  point  of  the  uterus, 
which  was  quite  rough  and  slightly  elevated ;  the  roughness  was 
transverse  in  shape,  but  with  all  the  caution  and  nicety  of  manipular 
tion  I  could  bring  to  bear,  I  found  it  impossible  to  detect  any  open- 
ing in  the  womb.  In  passing  my  finger  with  great  care  from  the 
bridles  to  the  rough  surface,  and  exploring  the  condition  of  the 
parts,  with  an  anxious  desire  to  afford  the  distressed  patient  prompt 
and  effectual  relief,  I  distinctly  felt  cicatrices,  of  which  this  rough 
surface  was  one. 

*  New  York  Journal  of  Medicine.    March,  1843. 


CI  cat I 
of  the  womb.  At  this  stage  of  llie  era  mi  tint  ion,  I  kncir  nolhtn 
of  the  previous  histoi^  of  the  patient  more  than  I  hai'e  jilready 
stated,  and  the  first  question  1  ad d revised  to  her  wa«  this:  lUre 
yoa  ever  had  any  diflieulty  in  your  previous  coiitini'iiieritH?  Haive 
yott  ever  been  delivered  %vith  iustrunients  ?  She  distinctly  replied 
th:{t  her  previous  labors  hjid  been  of  shoit  duration,  and  fbal  sJje 
had  nevt-r  been  delivered  witli  instruments,  nor  had  she  sustained 
any  injury  in  consuquence  of  h^^r  contineuienls.  I>r.  Venneulc 
informe^l  me  that  tliis  wa^  literally  true,  for  he  had  attended  her  oa 
those  oecjisions*  Tlii^  infurmatiou  somewhat  puzzled  nie,  for  It  was 
Bot  in  keeping  with  what  any  one  might  have  conjectured,  takiAg 
into  view  hur  actual  condition,  which  was  undoubtedly  th^  r^miU  ^ 
direct  injury  done  to  the  parts, 

I  then  sug^e^ted  to  Drs.  Vorraeule  and  Holdeu  the  propriety  of 
questioning  the  patient  still  more  closely,  with  the  hope  of  elietUtig 
someihing  satisfactory  as  to  tfie  eau?*e  of  her  present    *'"" 
remarking,  at  the  same  time,  that  it  would  be  absolululy  i  ; 

to  have  recourse  to  an  operation  fur  the  ptiri>ose  of  deliveriiig  hur. 
On  assuring  her  that  she  was  in  a  most  perilous  siluation,  and,  nt 
the  same  time,  promising  to  do  all  in  our  power  to  relievo  her,  nht 
vohmtarily  made  the  tuUowing  confession :  About  six  weeks  afi 
becoming  pregnant,  slie  called  on  the  notoiious  Ma<iame  K^^teBil 
who,  learning  her  situatiou,  gave  her  some  powders  with  directions 
for  use  ;  these  powdei^s,  it  a|> pears,  did  not  produce  tli<*  demnrd 
etlect.  She  returned  again  to  this  woman,  and  asked  her  if  there 
were  no  other  way  to  make  her  miscarry.  **  J>V'  ^^y^  Madame 
Restell,  '^Z  can  probe  you;  btU  I  must  have  my  prim  f^Jir  ihU 
(^ieratimij^  "  What  do  you  probe  with  ?**  *'  A  pUfce  of  whaU^ 
honeJ^^  "\YelI,**  observed  the  patient,  **I  ciumot  aftbrd  to  pay 
your  price,  and  I  will  probe  myself.''  She  retumetl  hornc%  and 
used  the  whalebone  several  times;  it  produced  considerable  pain, 
followed  by  tlischarge  of  blood.  The  whole  secret  was  non"  dtii 
closed.  Injuries  inflicted  on  the  mouth  of  the  utenis  by  iljc 
violent  attempts  liad  resulted  in  the  circumstances  detailed  aborft 
It  was  evident,  from  the  nature  of  this  poor  woman's  sulTe rings  and' 
the  espalsive  character  of  her  pains,  that  prompt  nrtittcial  delivery 
was  indicated. 

As  the  resntt  of  the  case  was  doubtful^  it  was  important  to  biive 
the  concurrent  testimony  of  other  medical  gentlemen,  ami  a*  il 
embodied  great  professional  interest,  I  requested  my  fifiencU,  Dr. 
Detmold,  and  the  late  Drs,  Washington  and  Doane^  to  «ee  it* 
They  reached  the  house  without  delay,  and  after  exAiiiiuinii 
minutely  into  all  tlie  facts,  it  was  agreed  that  a  bilateral  section  < 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         647 

the  mouth  of  the  womb  should  be  made.  Accordingly,  without 
loss  of  time,  I  performed  the  operation  in  the  following  manner: 
The  patient  was  brought  to  the  edij:e  of  the  bed,  and  placed  on  her 
back.  The  index  finger  of  my  left  hand  was  introduced  into  the 
vagina  as  far  as  the  roughness,  which  I  supposed  to  be  the  original 
scat  of  the  oa  tincm  ;  then  a  probe-pointed  bistoury,  the  blade  of 
which  had  been  previously  covered  with  a  b.and  of  linen  to  within 
about  four  lines  of  its  extremity,  was  carried  along  my  finger  until 
the  point  reached  the  rough  surface.  I  succeeded  in  introducing 
the  point  of  the  instrument  into  the  centre  of  this  surface,  and  then 
made  an  incision  of  the  left  lateral  portion  of  the  o«,  and,  before 
withdrawing  the  bistoury,  I  made  the  same  kind  of  incision  on  the 
right  side.  I  then  withdrew  the  instrument,  and  in  about  five 
minutes  it  was  evident  that  the  head  of  the  child  made  progress ; 
the  mouth  of  the  womb  dilated  almost  immediately,  and  the  con- 
tractions were  of  the  most  expulsive  character.  There  seemed, 
however,  to  be  some  ground  for  apprehension  that  the  mouth  of 
the  uterus  would  not  yield  with  sufiicient  readiness,  and  I  made  an 
incision  of  the  posterior  lip  through  its  centre,  extending  the  inci- 
sion to  within  a  line  of  the  ])eritoneal  cavity.  In  ten  minutes  from 
this  time,  Mrs.  M.  was  delivered  of  a  strong,  full-grown  child, 
whose  boisterous  cries  were  heard  with  astonishment  by  the  mother, 
and  with  sincere  gratification  by  her  medical  friends.  The  exj)re3- 
sion  of  that  woman's  gratitude,  in  thus  being  ]>reserved  from  what 
she  and  her  friends  supposed  to  be  inevitable  death,  was  an  ample 
oom]iensation  for  the  anxiety  experienced  by  those,  who  were  the 
humble  instruments  of  affording  her  relief.  This  patient  recovered 
rapidly,  and  did  not,  during  the  whole  of  her  convalescence,  present 
one  impleasant  symptom.  It  is  now  ten  weeks  since  the  operation, 
and  she  and  her  infant  are  in  the  enjoyment  of  excellent  health. 

I  omitted  to  mention  that  the  urethra  was  preternaturally  dilated. 
I  introduced  my  finger  as  far  as  the  bladder  without  any  conscious- 
ness on  the  part  of  the  patient,  such  was  the  degree  of  its  enlarge- 
ment. 

About  ten  days  after  the  operation,  the  late  Dr.  Forry  visited 
the  patient  with  me,  and  heard  from  her  own  lips  the  narrative  of  , 
her  case,  so  far  as  her  visit  to  Madame  Restell  is  concerned,  and 
which  I  have  already  stated.  On  Saturday,  January  20,  Dr.  Forry 
again  accompanied  me  on  a  visit,  and  a  vaginal  examination  was 
made.  The  mouth  of  the  womb  was  open,  and  permitted  the  intro- 
duction of  the  end  of  the  forefinger;  the  two  bridles  were  distinctly 
felt,  extending  from  the  upper  and  posterior  ])ortion  of  the  vagina  to 
the  posterior  lip  of  the  os  tincce^  which  they  seemed  firmly  to 
grasp. 

In  a  professional  point  of  view,  this  case  is  not  without  interest. 
It  is  evident  that,  without  the  operation,  the  patient  must  have 


MB 


THE   PRINCIPLES  AND  FBACTICK  Or 


sunk.  SIjc  had  been  in  labor  precisely  twenty-nine  bonn  whi*fi  I 
made  Xha  section  of  her  womb,  and  for  twenty  houra  pre^'iouiJy 
the  contmeliona  were  most  energetic^  pos»eiwing  all  t\w  chumrt^r- 
ifttics  of  true  exputsive  pains.     But  xvU  ^ith  all  thia  iuff*    *  t 

lht»  «li;L?hii'8t  change  had  been   etfocted  in  th*?   part**,     i  , 

theri?!bre,  had  been  ro}np<?tent  to  overcome  the  resist nnce«  «ullii*ii*ni 
thxie  was  iil lowed  for  thin  purpose.  Longer  delay  would  umiciubi* 
edly  have  pi  need  the  lives  of  botli  mother  and  chtlfl  in  eitlremn 
peril ;  i'or^  from  the  reiterated  but  unfivailin«r  c(fort«  of  the  womb, 
there  was  reuKon  to  nntitipute  rupture  of  this  viscus,  whi**b  would 
most  probably  have  compromiMed  ihe  life  of  the  mother  ;  while,  ai 
the  iinnm  liaie,  the  child  wii»  exposed  to  congfsrtiun  from  constanl 
pressure  by  the  contractile  force  of  the  uterus. 

The  second  ease  ii*  as  follows  :*  On  Salanbty,  Novombrr  6,  I&47, 
at  6  A»M.,  Dr»  Alexander  Clinton  was  suramone<i  to  utiui^d  Mr*.  L^ 
aged  thirty-i(ix  years,  in  labor  with  her  6r$<it  child,  Dr.  C*  bad  bem 
for  Fome  lime  the  family  physician  of  Mrf».  L,,  and  bad  attrndiil 
her  in  repeated  arrd  severe  at  tarkji  of  nephritis.  On  arnvinff  at  tho 
bouse  he  found  ]Mrs.  L.  in  lab<»r,  the  pains  being  decided,  and 
oecurrint^  with  regtdarity  at  intervah  of  tifteeii  and  twenty  niiii- 
uten*  In  his  examination  per  voginam*  the  doctor  was  unable  to 
detect  the  os  tincie;  be  very  enntlously  explorctl  the  va  1 

prci^niiu!;  jKirtion  of  the  womb  with  his  finj^er,  and,  aA'  i^ 

fruitless  attempts  to  find  the  mouth  of  the  uterus,  he  came  to  tlKi 
eonclnsiori  that  the  difficulty  of  reaching  the  U!<  wai*  owing  iti  mal- 
position of  the  organ,  probably  retroversion  of  the  cervix.  Aeeord- 
iugly,  he  wailed  until  evening,  when  the  pains  iiicr 
lence,  and  assuming  an  expubive  charncteri  he  examin* 
but  without  better  success.  He  then  profiosed  a  enn»uUaticiiL,  iba 
patient  having  been  in  labor  tourteen  hours.  My  eo  I  league,  Pru 
fes!*<»r  ^lott,  was  sent  for.  On  hearing  the  purticubtrs  of  thi? 
he  made  a  vaginal  exami'iation,  and,  a(\er  re|X'ateil  attempt^  fatli 
in  linding  the  month  of  the  womb.  Pnife-«*»r>r  M.  t^uggesitetl 
ptis^ibly  gome  change  might  occur  during  the  night  in  the  ]io«ll 
of  tin*  parts  whi<'h  would  enable  him  to  reach  the  o*  uteri,  aad  i 
the  house  with  the  promiHe  that  he  would  return  in  the  mor 
I>r.  CTniton  continued  w*ith  his  patient  during  the  nighty  aii^l  lli« 
piyn^t  recurred  regularly  witli  more  or  k»ss  Ibrce,  Ik*  maile  wrtral 
examinations  in  the  night,  but  could  feel  nothing  except  a  globular 
surface. 

In  tlie  morning,  Nov.  7,  at  ten  o'clock,  Professor  Motl  relQmed. 
The  pains  were  then  much  more  violent,  and  the  imttent  ^uifrred 
severely.  lie  again  attempte<l  by  examination  to  reach  tbe  niuuib 
of  the  womb,  and  again  failed.     To  use  his  own  languagi*,  ''*  1  huve 


^  Atncrkoii  Journal  ^f  IMlenl  Sdeo 


1641. 


THE  PRINCIPLES  AND  PKACTICE  OP  OBSTETRICS.  649 

seen  a  great  many  obstetric  cases,  and  have  attended  almost  every 
variety  of  parturition,  but  it  is  the  first  time,  after  thirty-six  hours' 
labor,  that  I  could  not  feel  the  os  tinea."  The  case  was  now  assum- 
ing a  dangerous  phase ;  the  pains  were  frequent  and  expulsive, 
with  an  obliterated  mouth  of  the  uterus.  The  fear,  therefore,  waa 
rupture  of  this  organ,  and  death  of  the  patient,  with  but  little 
chance  for  the  life  of  the  child.  The  husband  and  friends  were 
informed  of  the  precarious  situation  of  the  patient.  Drs.  Mott 
and  Clinton  decided  to  have  additional  consultation,  and  at  the 
request  of  these  gentlemen  I  met  them  at  one  o'clock  on  Sunday, 
the  patient  having  been  in  more  or  less  active  labor  for  forty  hours. 

On  examining  her  I  could  not  feel  the  slightest  trace  of  the  os 
tincsB,  and  I  became  satisfied,  after  a  thorough  exploration,  that  it 
was  entirely  obliterated.  Under  these  circumstances,  the  death  of 
the  mother  being  inevitable  without  an  operation,  it  was  proposed 
to  lay  the  womb  open  through  the  vagina,  and  at  the  request  of 
the  gentlemen,  I  proceeded  to  perform  the  operation  as  follows: 
With  a  probe-poiiitod  bistoury  covered  to  within  a  few  lines  of  its 
extremity  with  linen,  and  taking  my  finger  as  a  guide,  I  made  a 
bilateral  section  of  the  neck  of  the  womb,  extending  the  incision  to 
within  a  line  or  two  of  the  peritoneal  cavity.  The  head  of  the 
child  was  immediately  felt  through  t^he  opening.  The  pains  con- 
tinued with  violence,  but  there  was  no  progress  in  the  delivery ; 
the  neck  of  the  uterus  was  extremely  hard  and  resisting,  and  pre- 
sented to  the  touch,  after  the  incision,  a  cartilaginous  feel.  Dr. 
Mott  and  myself  then  left  the  patient  in  charge  of  Dr.  Clinton,  and 
returned  again  at  six  in  the  evening.  At  this  time,  although  the 
pains  had  been  severe,  the  head  had  not  descended,  nor  had  any 
impression  been  made  on  the  opening.  I  then  made  an  incision 
through  the  posterior  lip;  the  patient  was  not  in  a  condition  to 
sustain  bloodletting,  and  a  weak  solution  of  tartar-emetic  was 
administered  with  a  view,  if  possible,  of  producing  relaxation.  Dr. 
Clinton  remained  with  his  patient,  and  promised,  if  anything 
occurred  during  the  night,  to  inform  us  of  it. 

We  were  both  sent  for  at  two  o'clock.  Dr.  Mott  having  arrived 
before  me,  and  finding  the  patient  suffering  severely  from  violent 
and  expulsive  pains,  all  of  which  produced  little  or  no  change  in  the 
positioti  of  the  child's  head,  enlarged  the  incision  which  I  had  pre- 
viously made  in  the  posterior  lipof  thecer>'ix.  We  remained  until 
seven  o'clock  in  the  morning,  when  we  left.  The  patient  being 
much  fatigued,  a  Dover's  powder  was  ordered,  which  procured  a 
comfortable  sleep,  and  temporary  immunity  from  suffering. 

We  called  again  at  eleven  o'clock.  The  opening  had  somewhat 
dilated,  and  the  head  could  be  more  distinctly  felt,  but  it  had  not 
begun  to  engage  in  the  pelvis.  There  was  much  heat  about  the 
parts,  and  the  scalp  was  corrugated.    The  pains  continued  with 


650 


THE  PBIXCIFLES  AND  PBACTICK  OF  OBSTSTRICa* 


reg'ularity,  losing  nolhinu  in  violfnre,  arul  at  ftijc  o'clock  in  tht*  r^tA^ 
ing  of  3Ionday  the  pnliont'f*  strength,  which  had  been  cautiocigl} 
gu&rilctl^  was  evidently  giving  wny,  nnd  her  pulse  riiae  to  nne  htta< 
dred  and  forty  I  In  a  word,  the  symptoms  were  most  alarmm)^. 
The  <[tieRiiori  now  |«rcRt»ntcd  itself — What  was  to  lio  done?  After 
mature  deliberation,  being  esMentially  conservative  in  the  wholt 
management  of  the  cnLse,  we  determined  to  nuike  an  aitempi  to 
deliver  with  the  forceps,  certntnly  not  an  easy  thing  to  do  with  tbe 
head  of  the  fa?tiiH  at  the  «nperior  fitrail,  n<*l  having  bet»nii  lo 
engage  in  the  pelvis,  and  the  mouth  of  the  wotiili  rigid  and  u»- 
yielding.  Tim  forcep!*^  however,  after  a  full  view  of  all  the  dr. 
cumstanee^,  presented  to  us  the  mont  feasible  meaim  of  efTictlng 
delivery. 

At  the  request  of  Drs.  Motl  and  Clinton,  T  appliird  the  iimtru^ 
ment,  and  was  fortunate  enough,  without  much  low  of  time,  in 
locking  it.  The  head  wjw  situated  diagonally  at  the  up|H*r  fttratt, 
with  flexion  but  partially  made.  At  tirHt,  I  directed  my  tractioii 
downward  and  baekwarrl,  the  handle  of  tlie  foroe(>a  forming  aa 
acute  angle  with  the  axi«  nf  tlte  infcnor  strait   of  \)u*  tail 

when  I  ffucceeded  in  tlexitjg  the  chin  of  the  child  upon  i  'lOi, 

I  then  rotuteil  the  handle  of  the  instrument  for  lh«  pnqio«e  of 
giving  the  demi-spii'al  movement  to  tlio  head.  In  ihifl  way,  af^er 
very  great  effort,  I  succeeded  in  bringiiig  the  head  to  I  he  iiift*iior 
Btrait,  and  with  powerful,  Vml  welhguided  tractiouH,  drvw  it  more 
than  one  half  into  the  world.  At  tliis  ftage  of  th*;  o{)«ra)iony  my 
arms  and  handt«  were  nearly  paralysed*  such  wa«  the  foroi*  iic»iv*nary 
to  overcome  the  difficulty.  1  ix^cpici^ted  Dr.  Mott,  who  waJi  by  my 
side,  to  relieve  me,  and  tiller  n«i  inconsiderable  efibrt  he  ^ncceirded 
in  bringing  the  head  into  the  world;  our  gnitilication  wik»  in  tko 
way  dinani»hed  by  the  fact  that  the  child  was  alive,  aii  t?ve!Dl  cset^ 
iainly  not.  to  Uv  ex[iected. 

Ah  strange  as  it  may  appear,  the  only  incimvenicncc  experi«*ced 
by  the  tnother  alter  delivery  waa  an  inability  lo  pann  her  wai««r; 
thin  continued  tor  about  two  w^eekn,  rendering  it  nece«sarj'  to  intro- 
duce the  catiteli'r  tvvi<'e  daily  for  ihe  purpose  of  emptying  ik^ 
bladtler.  1*he  mother  and  chihl  are  in  the  eujoj-ment  oft  excetksiit 
beahh. 

It  mtiy%  pcrhnpA,  be  thought  by  »ome  that  the  patient  aiiuuldlBiT* 
been  delivered  sooner*  and  that  we  su1>jected  her  to  «eriocia  iDd 
unneces^iry  hazard  in  delaying  delivery  by  forceps.     Thin  n 
might  |K»ssib]y  be  sustained  on  general  principlea;  Imt  I 
will  be  conceded  ilial,  tu  thin  individual  case,  we  were  not  < 
titled  in  the  delay,  but  the  result  proved  the  wisdom  of  ihr  .l„.^ 
we  pur^tu^L     In  my  opinion,  nothing,  under  the  peculiar  dreiiai* 
stanecM  of  the  case,  could  have  warrant eil  an  attempt  al  artifioial 
delivery,  save  an  a/tproach  to  txhmutiuii  on  the  pari  ^f  ihe  m^lhftf  \ 


THE  PRINCIPLES  AKD  PRACTICE  OF  OBSTETRICS.  651 

or  the  occurrence  of  some  accident  placing  life  in  imminent  peril 
The  position  of  the  foetal  head,  and  the  condition  of  the  mouth  of 
the  womb,  were  such  as  to  render  extremely  probable  the  failure 
of  any  attempt  at  delivery.  The  obvious  indication,  therefore,  was 
to  trust  to  nature  as  long  as  she  was  capable  of  acting,  and  for  the 
accoucheur  to  proceed  to  aitificial  delivery  the  moment  the  general 
system  exhibited  unequivocal  evidence  of  prostration. 

It  may  be  asked  whether  this  was  primary  or  secondary  closure 
of  the  OS  tinccB.  That  it  was  secondary  is  manifest  from  two  cir- 
cumstances :  1.  The  patient  always  menstniated  regularly  previous 
to  her  pregnancy ;  and  secondly,  to  suppose  that  she  could  have 
become  impregnated  with  an  imperforate  os  tinccB^  is  to  suppose 
what,  under  the  circumstances,  may  be  called  an  absurdity.  There 
are  cases,  however,  recorded  in  which  sexual  intercourse  was  had 
through  the  female  urethra,  followed  by  impregnation,  but  in  these 
examples  there  was  a  communication  between  the  bladder  and 
uterus.  In  the  present  instance,  there  existed  no  such  communi- 
cation. The  only  rational  explanation  of  the  closure  of  the  womb 
in  this  patient  is,  that  it  was  the  result  of  inflammation  of  the  oa 
uteri.. 

Ernhryotomy, — The  term  embryotomy  means  literally  the  cutting 
up  of  the  child  for  the  purpose  of  diminishing  its  bulk,  so  that  it 
may  be  brought  away  in  fragments.  It  may  be  of  two  kinds: 
1.  Where  it  becomes  necessary  simply  to  lessen  the  volume  of  the 
head,  either  by  affording  an  outlet  to  the  brain  (cephalotomy),  or 
removing  the  bones  of  the  cranium  piecemeal  (craniotomy),  or  by 
means  of  the  cephalotribe — an  instrument  of  which  we  shall  speak 
presently — crushing  the  head ;  2.  Where  it  is  essential  to  extract 
the  entire  child  in  portions,  thus  involving  more  or  less  the  section 
of  the  whole  foptal  mass. 

It  can  scarcely  be  necessary  for  me  to  remind  you  that  the  only 
justification  which  can  be  alleged  for  this  operation,  is  such  a  dis- 
proportion between  the  maternal  organs  and  foetus  as  to  render  it 
physically  impossible  that  the  latter  can  be  made  to  pass,  either 
through  the  natural  effort,  by  the  aid  of  the  forceps,  or  version,  sup- 
posing, of  course,  the  woman  to  have  arrived  at  the  full  period  of 
her  gestation.  I  have  already  remarked  that  it  is  not  safe,  so  far  as 
the  mother  is  concerned,  to  attempt  the  extraction  of  a  child  by 
embryotomy  if  the  antero-posterior  diameter  be  less  than  from  2  to 
2  J  inches,  unless,  perhaps,  in  case  of  the  child  being  dead,  and  more 
or  less  advanced  in  decomposition.  Again :  you  have  been  told, 
that,  as  a  general  principle,  although  there  are  some  exce])tional 
instances,  a  living  child  cannot  bo  delivered  with  a  pelvic  diameter 
under  3  J  inches.  If  this  be  so — and  I  am  quite  confident  that  I  am 
strictly  within  the  record— the  question  arises,  if  the  child  be  alive, 
and  the  diameter  should  even  measure  2^  inches,  or  if  it  should 


662 


TWE   PRINCIPLES  AKD  FRACTTICE  OF  OBSTETRICS- 


l)G  more  thaii  2|  Imt  less  than  d|^,*  wbat  is  the  courae  to  he  pim 


My  own  jtrineiple  of  action,  under  the^e  cireumstaiicesi,  woit!«l  \m  a 
prefereiicti  for  the  Cie«iiican  section  over  the  mutilation  of  tlio  diihl^ 
and  for  therennons  detailed  in  the  (irevious  It'etme;  ami,  mcireorer, 
if  I  he  correct  in  my  firjr'iTn(*iit  in  that  lerture,  an  early  r«  i l^ 

CJI^*iure3ln  SL*elion  with  ihe  aid  of  anaD^the«ia  wouhl  no  fii  ti 

its  dangers  in  contrast  witft  ^mhryotoniy^  as  ahaidatcly  to  render  ]|| 
of  the  two  expedients^  but  little  more  fatal  to  the  mother^  whXi% 
inatead  of  ihe  necessary  desi  ruction  of  all  the  eliildren,  a  very  larfQ 
portion  of  I  hem  woidd  be  savefl ;  lor  you  are  not  to  forget  ilial, 
under  the  most  unfavorable  eireunistanocH,  only  1  tii  every  3|  of  tbt 
children  is  lost  in  the  Cie»arean  operation.  I^  however^  it  lie  aaceiv 
tained  that  the  chiM  U  dead,  then  tlie  circumstances  of  the  ca*ii 
entirely  change ;  for  llie  cardimd  argument,  1  contend,  in  favor  of 
the  Ca!*iarean  operation  is  to  prevent  the  horrid  de-Hiruction  of  fa*ial 
exi«tcnce,  while  at  the  isame  time  the  danger  to  the  mother  is  but 
slightly  itihanced.  So  that  the  child  being  dead,  mih  a  dtaineUf 
even  hss  than  two  inehe?»  I  should  unque?^tionahly  have  recouj-selo 
embryotomy;  for  it  wonld  be  only  under  the  most  d**#»peratf»  cir- 
cumstances, that,  knowintr  the  cldld  to  be  Bacrificed,  the  Ca*snrettn 
operation  could  be  selected  as  an  alternative;  and  yet  I  mwn  coii- 
fess  that  if  the  !mtero*posterior  diameter  did  not  measare  1|  toehflti 
the  Cn?s;irean  section  would  (trcHtMit,  in  my  Judgmetit,  a  btJlter 
chance  to  the  mother  tlian  embryotomy. 

You  see,  therefore^  that  if  the  antero-posterior  diameter  itbould 
not  alford  a  <tpaee  of  one  and  one  halff  inches — even  adauiltng  tbe 

*  It  would  he  propter  ir  lUa  dijimetcr  wcro  tJtrco  nnd  ODe-cJghth  ii»cha^  or«f«i 
alit^lttly  under,  to  attempt  delivery  bj  Ihe  forceps,  Tor  it  in  bnreljr  powblo  i|i*|  m^ 
oem  mi^tjt  attend  the  uJIort.  Shouhl  it,  hawovvr,  tm\^  m  1  »iii  nun*  it  woiM  ti  Ibt 
TWl  niiijofitv  oi*  c'Mi^eft,  pui  the  instrument  u^ide,  nud  huTt?  roeourM  (Ui»  dU\M  lutef 
Alive)  to  tho  Civsunan  section. 

f  The  celebruled  case  of  KliJyibcth  Sherwood*  bo  rvp<?iii*dljr  rffvrrvd  to  by  frn(«i» 
on  tuidwifery*  hiiK,  I  um  e«nirtdent,  L»et'ti  |»ruducli?e  of  l>ifcd  prnriico^  and  I  nm  4i»- 
po««ed  to  think  tlmt,  more  e^pet^ially  in  Grent  Britain,  it  hu  b«»n  rvgnrdol  m  tiipW 
aiithonty  for  &  report  to  tlie  i^erfomtor.  So  impnM<^l  hhi  I  witii  iliitf  cixiriAiaii, 
iMid  iituKions  m  I  nm  llmt  U»i?  irue  fjicta  of  llui  chmo  filiuU  l>e  pmjicfly  Appfvcijil^dt  I 
do  not  ctJn?<id^^  an  apology  necoflsjirj  for  quoting  it  in  eslenao,  u  origtiuUly  pablttlnd 
by  Dr,  VVllliani  Osborn,  in  wlios**  practice  the  case  cxxnimHl: 

"  Kti/ii)H4ili  HierwoiMl  wua  forty-two  inches  in  tieijj^it,  find  no  df'fi^rmi-^  «f  nrmr 
to  he  fthle  to  stacd  erect  for  ono  minute*  without  a  crutcli  ouder  tuidi  \rai.  Jtt  ikm 
:\!.-i'  n(  iwenty-iM^'ven  yrnrs  stie  becfiine  with  child.  Korly  oo  SutiiLiy  llilKBi«g, 
N'  >\  rukhiT  13,  1 T7G,  ihe  conipljiioed  of  having  beeii  in  $iaiu  fJi§  hBoprmwdimg  dbyt  rarf 
'^  I  eXHiiiiricd  her  per  vu^jrinain  Llutt  «Teiitng  wilh  greAt  Attcnttoiu  tin  lb* 
II  iMKiiictiiiii  of  the  (liigi?r,  1  perceived  a  tmnor,  equnl  in  miz^,  und  tioC  very  oslilic  la 
the  (^U  to  ft  child's  hend.  U  wn(«,  however.  InHt^ntiv'  disooirrft'd  timc  ibi0  tonor 
Wilt  formed  by  Uio  tMiBit«  of  Uio  os  >'ticniJti.  ntid  l»j«t  hnnhnr  vi*ri«brm,  wkk^^  pfiijfiiiin, 
tiito  the  cttvity  of  the  pelvlg  at  the  brifn,  bartly  Irft  room/twow  fi»^t»ptuM  litai 
U  ami  tfti  §jfmjthififif  pubis,  90  thai  tfie  tpaet  Jrmn  bom  to  frcnw  «tf  thai  ^rt,  axM  mti 


THE   PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         658 

child  to  be  dead — embryctomy  is  not  to  be  resorted  to,  but  the 
alternative  is  the  Csesarean  operation.  If,  on  the  contrary,  this 
diameter  should  yield  slightly  over  one  and  one  half  inches,  then, 
with  all  the  risk  incurred  by  the  mother  from  the  operation,  with  a 

exceed  three  quarters  of  an  inch.  On  the  left  side  of  the  projection,  quite  to  the  ileum, 
which  was  about  two  inches  and  a  half  in  length,  the  spnce  was  certainly  not  wider, 
and  by  some,  who  examined  her  afterward,  it  was  thought  to  be  narrower.  On  the 
right  side,  the  aperture  was  rather  more  than  two  inches  in  length  from  the  protu- 
berance to  the  ileum,  and  as  it  admitted  the  points  of  three  fingers  (lying  over  each 
other)  in  the  widest  part,  it  might  at  the  utmost  be  about  one  inch  and  three  quarters 
from  the  hind  to  the  fore-part ;  but  it  became  gradually  narrower^  both  toward  the  ileum 
cmd  toward  the  projection, 

**The  membranes  were  not  yet  broken,  but  with  some  diflBculty  I  felt  the  child's 
head  through  them,  situated  very  high  above  the  projection.  The  abdomen  was 
?uard  and  tender;  as  she  seemed  much  fatigued  for  want  of  rest,  fifteen  drops  of  tinct. 
opii  were  given,  by  which  some  sleep  was  procured  between  the  pains.  The  mem- 
bnmee  broke  some  time  after  I  left  her,  and  there  was  the  usual  quantity  of  liquor 
amnil  The  next  morning,  being  hot  and  thirsty,  and  her  pulse  very  quick,  ten 
otmces  of  blood  were  taken  from  her  arm ;  and  the  bandage  accidentally  slipping  off 
soon  after  her  arm  was  tied  up,  she  might  perhaps  lose  as  much  more  before  it  was 
discovered.  No  alteration  whatever  had  taken  place  either  in  the  os  uteri,  which 
was  still  but  little  dilated,  though  soft  and  fiabby,  or  in  the  position  of  the  child's 
head.  In  so  extraordinary  and  singular  a  case,  I  naturally  wished  for  the  advice 
and  assistance  of  my  professional  friends.  I  met  in  consultation  that  evening  Drs. 
Bromfield,  Denraan,  Walker,  and  Mr.  Watson.  Every  gentleman  present  imme- 
diately satisfied  himself  by  examination  per  vaginam,  of  the  dimensions  of  the  pelvis, 
some  thinking  it  rather  narrower,  but  none  wider  than  the  dimensions  stated  above 
We  weighed^  with  grtai  deliberation,  every  circumstance  by  which  our  future  conduct  in 
tki8  case  ought  to  be  regulated;  particularly  we  used  our  best  endeavors  to  determine 
the  state  of  the  child  in  utero ;  and  whether^  if  the  Ccesarean  operation  sliould  be  per- 
formed^ which  we  had  in  contemplation  to  do  for  some  time,  there  would  be  a  certainty 
of  preserving  one  life  at  least.  We  were  rather  disposed  to  believe  thai  the  child  was 
dead.  It  was,  therefore,  agreed  that  an  attempt  at  leasts  ought  to  be  made  to  deliver 
the  poor  creature^  by  opening  the  child s  heudL,  and  extracting  it  wiVi  the  crotchet. 

**I  commenced  the  operation  about  eleven  o'clock  that  niglit.  Even  the  first  pari 
of  the  operation  was  attended  with  consiierable  difficulty  and  some  danger.  The  os  uteri 
was  but  little  dilated^  and  awkwardly  situated  in  the  centre,  and  most  contracted  part 
of  the  brim.  The  child's  head  lay  loose  above  the  brim  and  scarce  within  reach  of  the 
finger.  I  desired  an  assistant  to  compress  the  abdomen  with  sufficient  foi'ce  to  keep 
(he  Jiead  in  contact  with  the  brim  of  the  pelvis,  so  as  to  prevent  it  receding  from  the 
scissors.  I  introduced  them  with  the  utmost  caution  through  the  os  uteri ;  and  after 
repeated  trials,  at  length  succeeded  in  fixing  the  point  into  the  sagittal  suture ;  I  very 
soon,  with  great  facility,  penetrated  the  cavity  of  the  head,  and  with  a  common 
spoon  extracted  a  quantity  of  the  brain ;  breaking  down  the  parietal  bones,  made  an 
opening  sufficient  for  the  free  discharge  of  what  remained.  In  this  state  we  left  her; 
BliXioiigh  fatigued  with  this  part  of  the  operation,  no  opiate  was  given,  as  /wished  to 
have  tftefull  effect  of  the  labor-pains.  In  this  expectation  Twos  disappointed,  for,  not- 
withstanding she  was  prevented  from  sleeping  all  night  by  the  frequency  and  violence 
of  the  paint,  in  the  morning  I  was  not  sensible  of  the  smallest  alteration  in  the  position 
of  the  chikCs  head.  Daring  the  whole  day  the  pains  were  neither  so  strong  nor  ao 
frequent  as  they  had  been ;  her  piulse  was  extremely  quick,  but  tolerably  strong ;  the 
discharge  from  the  vagina  was  very  considerable  in  quantity,  and  most  abo7ninably 
fetid.    Dr&  Bromfield,  Denman,  and  Hanter  saw  her  in  the  course  of  the  day ;  s?u 


854         THE    PHINCnPLES  AND  PRACTICE  OF  OBSTBTRICa 


less  space  than  two  and  one  cif^bth  inches  I  ^houKl  not  hi >t>iuit€  to 
luiJtUate  the  chikl — heiDg  tirst  satistitHl  of  iti*  tleaUi — Ibr  in  lbUi!iii«.% 
tlio  compcn8atini»  ar^^nment.  in  favor  of  the  C^ssirciin  i^cctitm — itiir 
safety  of  the  child — doe»  not  obtaiD. 

Mwr  f:rnfnin"d,  IttftUUs,  by  fnore  Uum  thirty  itudentM  In  171  '     *•  -  ■   T\1tidi  nn^ 
jm'nnKed  at  my  rctfui^i,  fruin  a  reproacutution  af  the  -►/  A<r  0i>f 

ttidity  which  iriig^ht  result  from  ili  Wins;  more  gnv  til  vvu. 

**T«.>WHnJ  tMv  fvening,  lh*«  fnitrm  consiiK'rubly  ii    r,  1- 
Jrom  thefuU  ffftci  o/ihem^  no  opuiUs  «?aj  givm;  nhc,  t:, 
pa^nt  conUntM^d  through  tlu  wfwU  ntgkL     Wboo  I  fir^' 
ftrengtli  iviM  yrtntlff  r<ducfti;^  hiT  |nj|jMs  bwit  nnr  hu 
nlmtJtl^  ttatwtVislandifirj  tvery  infmution  had  ln-cn  ii^r 
tiaUarhj  by  forbidiilng  nil  slruug  liquor*,  niid  by  kt?cpirig  the  Wiird  m^ 
flfT  j>pirit.\  houm'ef,  were  j^wti,  «n/i  h^r  rfAUuttrm  un^ifmUtL     Upou  t'A    ■   1      1      ,   , 
tmait  fktrtirm  of  llii*  heiid  Vt'ttf^  found  mjunttd  initj  Uie  pchu. 

*"Our  m^7»Cw«,  by  denying'  tlm  extract ioTi  of  \h**  child  wjp  /tK4  ihirfp  hnnr^ufkr 
opoiiiuic  ih<?  hend,  WHB  to  allow  the  iKrni^  '«d 

as  niiirh  withiu  I'eiidi  of  Dm  cnitd»eC  mm  tU<  .  r. 

ward  10  Induce  »a  grtsat  a  degree  qJ  putrtfaciwn  u  .  « li«!li 

mciinii  it  \an>uld  be<7<:)mu  ftott  atid  dxnpivesible^  ai<  ^MtUao* 

ia  iU  vxtrHctiun.     J7itM«  tn^  jitii-jtrjstA  n\y[)eiire(l  Ui  niu  tii(i'>i  trrmwfHtitJ^ 

And  ihcro  was  no  advantaq^ /mm  further  dday.     On  tho  c«i«  l» /mrjmi  tbM 

so  lttrg«*  u  miira  of/iuMc^  rrwi{^tt*9  u  gliild  ut  full  ti*nn,  with  pbtcentA^  etc,  nHnaiainf 
in  llie  \it4M-U8  hnyrr0ian  was  attatAuielij  ntctusatiry,  tttight  rJjnttc  bi?r  lo  Ui^J'Mbn  dmt- 
^[rr  ot  n,  [Mttrid  fever,  if  mhe  should  e^ctijie  ai<  mo^ioi  ii^fttry  (Vom  tkiv  lia«vil*Ui 
iricf^»ot  and  cemiit^ttrfi/  d*inger  of  the  ojiertition. 

**  t  dutermbed  to  btgin  to  raoko  iift  a(feTn/?<  to  oxtmrt  lb»  dnW ;  I  cull  il  U 
altempU  f(>r  I  wiw  />r  fpwu  ln-itig  Maltf/ied  in  niy  <>tt»ii  mmrf  nf  it*  |FmcClna&UU|k 
Adwrtittfc  to  tho  very  tnnaU  ft{}Ac«  of  only  If  iucli««  at  Ibo  utmmt^  ftnil  in  the  mdmt 
part,  Aud  tlioi  ofdy  on  me  side  of  the  pmj<*otJng  nacruin^  wUtlo  I  ho  «jiii€b  heUftm  if 
and  CAtf  itffmphywuf  on  th«  other sidti  htirrly  amounted  U>  thrUfttorUr*  of  um  i#cA,  t  tTMl 
1  am  j?«Af^/W  in  my /atUui/M  nnd  rjjiffj^um, 

"  Alj<mt  10  o'doek  o»  \Ve«dnc^*iy  momiUK  {the  patteni  haring  ft«m  •«  Mmr  t^mt 
i/w  preriouj  J'Mdiiy),  I  bcgnn  Ihi?  opTaliori  of  extnctiun.  Tin*  'i-  '•  ''  '^ited  m 
before  dcJicriVK?*!,  Jii  tho  mu»l  t-ontr«rt*H!  fi«rl  iif  Uh>  bfitn,  yrhftr^^  f  i»  «a^ 

pahlf  n/  fjvf  inittinff  the  inUuducrion  of  tho  cunwi  prtin*  of  the  cmitvint,  ir«''»fna  ffwil 
d^tuHi^  nnd  dungvn  1  first  cndeavrmHl  to  drnw  lh»*  m  uteri  with  my  fin|?rr  tnto  tht 
widest  iMrt  of  the  brim,  and  lo  dibtfi  it  m  much  mi  ptwiidjlir.  Hi>tli  lli«at  rvsolla 
wre  at'i.HHiiptx«bed,  I  then  (iitroduccd  tho  crotchet  tlm^ugh  the  perfomtloti  ioiA  llw 
hftad,  iind  by  fYj3<ai«/ fjf5*rte  destroy  tHi  ohi  I  <  '    le  of  thwi- -  "    '      i«l 

boncB;  us  the  bonea  beeanno  lo*»8e  »ifd  deiu  wem  cxtr  iU 

foPDOjiMi^  lo  prevent  <w  I'liti^A  <w pcj^tMc  tho  iactiahtm  0/ tke  vagina^ 

♦•Ti>o  gn?ftt  bulk  of  tito  bead,  formed  by  tlw  bnaa  of  the  ukull  #ttlC  Aoiy-rrr,  n^ 
matned  above  tlio  brim  of  the  pt-lvis,  And  it  WM  impc«i»ibl«  to  mifr  wiilmtA  tttlvr 
dhniutAhittg  tiie  volume,  or  dianyttt//  Oie  p<ttitvm;  iXw  former  wta  tlte  ubfluia 
m^tliod,  for  tt  was  a  ccntinuatwik  of  tfu  wme  pr(K«$$,  and  I  ItubUhI  wo«ild  ht  i'^mII^ 
m^if  in  th©  execution,  1  wiia,  however,  rru^  rgrrgumMy  miMaifm  'i<»rf  fiifn^fj-^nM^ 
Muiat  r^:pfa(0dly  /(tilod  in  ev*jry  endenvor  lo  bneak  the  aolld  boni^       '  ^  *;« 

ermiilum,  th«  ingtrwucut,  tki  llrat,  t'nmriia^y  §kppmg.     At  {9«(,  bosA  nf 

the  jKXjairiQ  of  tho  uifltniment,  1  fixed  the  point  lUUtvr^  into  tb*'  ^4 

by  tbjit  means  beoimc  mnator  of  Uw  nxjsi  pwfer/id  pwrchoM  Uu  f  'ii« 

mm  odmiML     Of  titis  I  nvniled  tnvtidf  to  th«  nimoU  wsknkmK^  ^ 

into,  till  tt  srHveil  to  thnl  Jr'/ftr  vf  viclUHCt  which  fK^lny  OtJ^< 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.  655 

The  question  of  whether  the  child  be  alive  or  dead,  is  one  of  great 
significance,  and  is,  in  my  judgment,  with  the  reservations  jnst 
stated,  the  tuniing  point  on  which  must  rest  the  final  decision — 
Csesarean  section  or  embryotomy.     Therefore,  it  is  right  that  we 

extreme  necessity  of  the  case,  and  the  absolute  inability,  in  repeated  trials,  of  succeed- 
ing by  gentler  means.  But  even  this  force  was  to  no  purpose^  for  I  made  no  impression 
on  that  solid  bone,  nor  had  it  in  the  least  ad  vanced  by  ali  my  exertions. 

^^  I  became  fftarful  of  renewing  the  samt  force  in  the  same  way,  and  abandoned  the 
flnit  idea  of  breaking  the  bones  of  the  cranium,  and  determined  to  try  the  second, 
of  endeavoring  to  cliange  the  position.  I  once  more  examined,  as  accurately  as  the 
mangled  state  of  the  head  would  admit,  how  it  presented.  From  tlie  information 
thus  procured,  the  second  method  appeared  to  me  a  forlorn  hope ;.  however,  there 
was  no  other  resource.  I  therefore  again  introduced  the  crot<;het,  fixed  it  in  tlie 
£preat  foramen,  and  got  possession  of  my  former  purchase,  and  succeeded,  together 
with  the  two  fingers  of  my  left  hand,  in  changing  the  position  of  the  head,  and  thus 
diminishing  its  volume.  Continuing  my  exertions  with  the  crotchet,  I  soon  perceived 
the  head  to  advance  into  the  pelvis. 

"Every  difficulty  was  now  removed^  and,  by  a  perseverance  in  the  same  means /or 
a  short  time^  the  remaining  part  of  the  head  was  brought  out  of  the  os  externum. 
After  waiting  a  few  minutes,  a  napkin  was  put  round  the  neck  of  the  chiltl,  and  given 
to  an  assistant.  I  then  introduced  the  crotchet,  and,  first  opening  the  thorax,  fixed 
it  firmly  in  the  sternum.  By  our  united  force,  strongly  exerted  for  about  a  quarter  of 
an  hour,  the  shoulders  were  brought  down ;  and,  lastly,  after  opening  the  abdomen, 
the  whole  body  was  extracted  in  Vie  most  putrid  and  dissolved  state;  but  it  appeared 
to  be  a  moderately  sized  child  at  full  term.  The  placenta  came  away  witliout  much 
trouble.  Tiie  operation  continued  for  about  three  hours;  and  the  poor  creature^ 
although  in  strong  labor  tliree  days,  and  her  bodily  strength  much  exhausted  by 
violent  and  unavailing  pains,  yet  she  supported  the  toliole  business  with  surprising 
fortitude,  and  suftered  mucli  less  than  might  reasonably  have  been  expected  either 
from  the  length  of  the  labor  or  the  extreme  violence  in  the  delivery.  She  went  to 
sleep  soon  after  the  operation,  passed  a  good  night,  complained  of  very  little  pain, 
etc  ;  she  recovered  sofasty  that  slie  sat  up  the  seventh  day,  acknowledging,  v;ith  great 
gratitude,  that  she  was  then  as  well,  in  all  respects,  as  in  any  former  period  of  her 
life. 

"  As  far  as  I  know,  this  woman's  pelvis  was  the  smallest,  through  which  a  child  cU 
fiiU  time,  and  of  the  ordinary  size,  however  lessened  by  art,  has  ever  been  extracted ; 
and  it  was  in  contemplation  in  this  very  case,  to  perform  the  Coesarean  operation,  if  we 
could  have  been  satitfied  of  the  life  of  the  child,  upon  the  presumption  of  the  impossi- 
bility of  bringing  it,  under  the  circumstances  of  age  and  size,  through  the  natural 
passages.  I  hope  the  event  of  the  case  may  prove  the  means  of  frequently  preventing 
that  fatal  operation  (the  Csesarean  section)  in  future.^''  [Essays  on  the  Practice  of 
Midwiferj'.     By  Wm.  Osborn,  p.  240-257.] 

I  think  T  have  rendered  a  substantial  service  by  the  insertion  of  this  case  here ;  it 
is  no  garbled  statement;  on  the  contrary,  it  is  in  ipsissimis  verbis  of  Dr.  Osborn  him- 
solfj  just  as  it  was  distilled  from  his  own  pen.  The  underlinings  are  my  own,  and  I 
intend  them  as  a  sort  of  commentary  upon  the  details.  Dr.  Osborn,  in  his  day, 
occupied  no  mean  position ;  his  opinion  was  one  of  weiglit  in  all  matters  pertinent 
to  obstetric  science ;  and  hence  the  case  of  Elizabeth  Sherwood,  from  the  circum- 
stance mainly  of  its  having  occurred  in  the  practice  of  so  distinguished  a  man,  has 
not  only  become  a  part  of  history,  but  is  regarded  too  frequently  as  an  authority 
why  embryotomy  should  be  preferred  to  the  Cassarean  section.  But  how  different 
the  influence  of  this  case  on  the  professional  mind,  if  the  unhappy  woman  had  died 


650         THE   PRTXCIPLES  AND   PRACTICK  OF  aB8TRftIG8L 

ahotiUl  examine  the  evidence,  which  may  ennblc  ««  to  detennino  if 
the  child  in  ulero  he  living  or  not.  AuthofH  dtfTiT  ii!i  to  xliu  tmltirft 
and  value  of  this  evidence  ;  »am6  fiU|>}>fiaing  thut  the  qiiestiou  b  ooi 
of  i*my  deeiHioii,  while  otliers*  ajs^miii,  and  ecilainly  with  <:•  '  *an, 
regard  it  a«  a  point,  under  certain  circunifetaDces,  of  n  liar- 

rsflitmcnt. 

£ni€Unee9  of  the  Child^s  Ihath  in  Uttfo. — ^Tho  follawinjj  wtt 
ennrneruted  a8  among  the  ordinary  proofs  that  the  child  has  ceiited 
to  live:  U  The  discharge  of  ineconiuni/><r  vtit/inam  *  2»  A  flftocid 
condition  of  the  cranial  boncR,  overlapping  each  other;  3,  A  irant 
of  elaHtieity  in  the  scalp  under  the  force  of  uterine  coDtmcfioii ; 
4,  Ce8,sruion  of  fcetal  movements;  5,  Failure  lo  detrct  thir  imhm^ 
tionfl  of  the  fa*tal  heart,  or  those  of  the  umbilical  cord ;  0.  Fetid 
discharges  from  the  vagina,  together  with  the  paasai^  of  PQiall 
detached  pieces  of  epidermis  from  the  presenting  pcirtiooA  of  Ibe 
fcetus. 

Let  UH  briefly  consider  the  true  import  of  these  §tgn«.  Evety 
pra<*tiUoner  of  ordinary  observation  know*  that  the  di^ehargQ  of 
the  meconium  through  the  vagina  of  the  mother  it*,  per  st^  no  enh 
dence  at  all  that  the  chihl  is  dead ;  for  tt  may  ocnir  consi^^tinilly 
with  the  life  and  full  herdth  uf  the  fcetufl.  In  breech  preftentatioos, 
for  example,  it  i;*  one  of  the  usual  accompaniments  of  thi*  form  of 
birth;  and  I  have  known  it  to  take  place  in  an  ordinary  \w:h\  vr^ 
nentation,  and  the  child  born  alive. 

The  flaccidity  of  the  cranial  bones,  to^fther  with  thnr  r*\rr- 
lapping,  is  one  of  the  unitbrm  circumjitnnce8  attending  hydrocepb** 
bis;  and  Itydroeephalns  although  a  deplorable  compltcjition,  m  do 
proof  that  the  child  doe»  not  live, 

A  wfint  of  elasticity  itt  the  iscalp,  tinder  the  force  of  utrriac^  rffbfti 
needs  a  word  of  comment.  A«  a  general  rule,  when  the  labor  ii 
developed,  and  the  head  pressed  more  or  less  againnt  the  H'alb  of 
tlie  pelvic,  there  will  l>e  recogniJ^ed  cor re^^poni ling  with  iho  orifiot 
of  the  uterus  an  ehuslic  tumor  formed  by  the  Rcalp  of  lbi>  chU^ 
head,     lliis  tumor  is  the  result  of  the  contractions  of  the  vtcrikf 

imdar  hvt  •ccnroultted  aiiflToHfigsf  J  aow  mik  iHo  mulftr  to  poroio  «Vff7  wm4  «t 
lliii  fUttmcmt  with  unbrokca  «ltentitiD ;  nnd  then  I  auk  lilm  wh^i«r,  tnm  te 
frroifitibk  evid4»nc<?  funibbcd  by  tho  details  of  tlio  tutemeiit,  the  fUct  of  IRtiabilfc 
Sb^rw^xKl  hnvmf  survived  the  opemtioti  ts  not  a  circumstunce  wUteh  wooJd  MOC  be 
UkeljT  to  occur  mice  in  ten  tiunuiarid  times  ;  nnd  whflher  hfr  troDVcrf  Ifl  b«I  MI^ 
•nlitled  to  be  cluMd  Rmoaii  iho  mimeuloua^  luilr-liivflUth  eacAfieii  tn/n  ^m/ik'i 
Ttiarofore.  if  titii  be  to,  it  iliould  be  di»0Brdc4  ttma  the  booki  soil  the  twilffjiw  M 
th«  keture  biilK  m  *  guide  fbr  prtcUot^  Ii  tiaa  «xef^riMd  •  tittgukrij  oubipfif 
inAimmoo  over  tbo  mindt  ofionie  ct«v«r  men ;  find  liat  b««ifi,  wtthout  dua  <k»iiw|0b« 
Uoiu  adoptiHl  aa  an  evidoaco  ot  tbo  cxtromo  dcfonnitj  through  which  m  dtiM  oiA  I* 
brott^)t  'mU>  thn  woHd  by  embryotoitiir,  without  cxumpruniiAitii;  lh«  nftfty  of  iIm 
bother  Tbo  cm\j  fiila<»  of  tli«  tfvidenev  h%  it  ptQxtm  wlm^  wikAl  ii  ytdrvM^f 
idnaiiM — thai  erofj  rule  has  its  sxntplkia. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         657 

together  with  the  resistance  encountered  by  the  head  in  its  descent. 
It  is  of  no  consequence,  for  it  in  no  way  involves  the  safety  of  the 
child.  But  in  another  aspect,  it  is  of  much  interest.  The  tumor 
cannot  form  if  the  child  be  dead  at  the  commencement  of  the  labor, 
and  if,  after  its  formation,  the  foetus  should  die,  the  tumor  becomes 
soft  and  flaccid.  Again :  even  when  the  child  continues  to  live, 
the  tumor  will  occasionally  lose  its  elastic  tension,  in  consequence 
of  an  extravasation  of  blood  under  the  scalp,  constituting  a  species 
of  cepJudhcematoma^  or  bloody  tumor,  and  this  is  apt  to  occur  when 
the  head  of  the  child  encounters  an  exaggerated  pressure,  either  as 
the  result  simply  of  strong  uterine  force,  or  conjointly  with  a  con- 
traction of  the  pelvis.  It  may,  also,  happen  that  the  child  will  be 
horn  alive  and  healthy  without  the  slightest  approach  to  the  forma* 
tion  of  the  tumor. 

As  to  the  cessation  of  the  foetal  movements,  it  is  well  known  that 
some  women  never  feel  the  child  move  during  the  whole  period  oi" 
pregnancy ;  others  again,  after  having  experienced  the  sensation  for 
a  certain  period,  fail  to  do  so  afterward,  and  yet  bring  forth  living^ 
children. 

The  pulsations  of  the  foetal  heart  may  or  may  not  be  detected; 
in  the  former  instance,  there  can  be  no  doubt  that  the  cIiiM  is 
alive ;  while  in  the  latter,  it  does  not  necessarily  follow  that  life  is 
extinct. 

Foetid  discharges  from  the  vagina,  together  with  the  passage  of 
small  detached  fragments  of  epidermis,  indicating  the  decomposi- 
tion of  the  foetus,  constitute  very  strong  evidence  that  the  child  is 
dead ;  and  yet  there  are  cases  recorded  in  which  these  phenomena 
have  been  recognised,  and  the  child  alive.  Such  instances,  how- 
ever, must  be  regarded  as  extremely  rare  exceptions  to  a  very  gene- 
ral rule.  One  of  the  most  remarkable  is  that  mentioned  by 
Baudelocque*  as  having  occurred  in  his  own  practice :  lie  was 
called  to  a  poor  woman  who  had  been  in  labor  two  days ;  there  was 
emitted  from  the  vagina  an  insupportable  foetor,  commingled  with 
fluids  of  the  same  character.  The  head  of  the  child  was  at  the 
upper  strait,  and  the  scalp  soft  and  loose  ;  the  epidermis  and  hair 
fell  off  with  the  mere  pressure  of  the  finger ;  there  had  been  no 
movement  of  the  foetus  for  the  preceding  twenty-four  hours ;  the 
mother's  pulse  was  feeble  and  quick ;  the  tongue,  gums,  and  lips 
were  black,  and  she  exhaled  a  cadaverous  foetor.  These  evidences 
— strong,  indeed — of  the  child's  death  determined  Baudelocque  to 
resort  to  the  crotchet ;  he  held  the  instrument  in  his  hand,  but  as 
he  was  about  to  introduce  it,  suddenly  changed  his  mind,  and 
decided  to  substitute  for  it  the  forceps,  although  convinced  that 
ihe  child  was  dead.    It  was  a  most  hapf>y  substitution,,  as  the 

*  L*Art  det  Aoooadiemeiu^  vol  ii.,  p.  229. 
42 


TUS  PBIKCIPLBS  AND  PRAOTICB  0 

seqael  revealed,  for  he  delivered  the  mot 
The  f<Btld  discharges,  etc,  were  the  resalt  < 
cm  the  summit  of  the  head,  which,  howe 
Ibichness  of  the  integuments. 

So,  you  see,  gentlemen,  all  these  phenoni 
composition  of  the  foatus,  may  ensue,  and 
But  remember,  as  I  have  just  remarked,  su 
regarded  as  altogether  exceptional,  and  out 

The  absence  of  pulsations  in  the  cord 
imply  the  death  of  the  foetus ;  fori  have  aire 
of  Dr.  Ameth,  of  Vienna,*  who  mentions  f 
mediate  notice  in  which  no  pulsations  had  \h 
hour  previous  to  delivery,  and  in  each  insta 
ving. 

Procidentia  of  the  cord,  its  coldness,  an 
together  with  its  incipient  putrefa^ion^  ma; 
the  very  decided  proofs  that  the  child  is  dei 

The  decision  of  this  question  is  one  of  n 
U,  therefore,  is  the  duty  of  the  accoucheur 
sure  of  discretion,  in  order  that  he  mayreac 
all,  let  him  be  cautious  not  to  suffer  himc 
tK>nc]u8ion  from  the  mere  love  of  bringing  ti 
piecemeal.  Whether  it  bo  really  a  love  for 
indifference  to  the  shedding  of  innocent  b]o< 
to  determine ;  but  of  one  fact  I  am  quite  co 
and  crotchet  are  oftentimes  employed  in 
recklessness  altogether  startling  to  those,  w 
ihave  its  share  of  influence  in  the  doings  of  t 

Culpable  Indifference  to  Professional   ( 

Rtnoe  I  was  visited  by  a  young  medical  gen 

in  practice  but  a  short  period.     In  the  com 

subject  of  operative  midwifery  was  introduc 

he  had  enjoyed  the  best  opportunities  of  I 

the  use  of  instruments,  for  his  preceptor  ha 

tion  of  embryotomy  on  an  average  sixteen  tii 

gentlemen,  such  an  announcement  may  app 

I  have  myself  witnessed  in  this  city  scenes 

satisfy  my  mind  that  it  is  not  an  exaggerat 

take  the  liberty  of  citing  one  case  among  se 

in  my  memory,  to  show  you  that  I  do  no 

when  I  protest  against  the  unholy  acts  of  m 

iiidither  by  Heaven  nor  education  to  assume  t 

parturient  room. 

The  particukrs  of  the  following  case  I 

*  See  Lecture  xxxL 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         659 

Translation  of  Chailly's  Midwifery:  "Two  years  since,  I  was  re- 
quested to  visit  a  poor  woman  who  resided  a  few  miles  from  this 
city ;  she  had  previously  borne  two  living  children,  and  her  con- 
finements had  not  been  attended  by  any  unusual  circumstance.  On 
arriving  at  the  house,  there  was  presented  to  my  view  a  scene 
which  I  never  can  efface  from  memory.  It  was  a  spectacle  at  which 
the  heart  sickened ;  it  was  humiliating  to  my  professional  pride,  and 
I  could  not  but  experience  feelings  of  deep  mortification.  The  un- 
fortunate sufferer  had  been  in  labor  26  hours,  wiien  two  medical 
gentlemen,  for  reasons  which  I  trust  were  satisfactory  to  them- 
selves and  their  consciences,  decided  to  resort  to  the  perforator. 
This  instrument  of  death  was  accordingly  thrust  into  the  brain  of 
a  living  child ;  the  labor,  however,  did  not  advance,  and  they  pro- 
ceeded to  remove  the  fcetus  piecemeal.  After  four  hours  of  des- 
perate toil — ^and  I  ask  where  could  have  been  their  feelings  of 
humanity — they  succeeded  in  bringing  away  the  entire  foetus  in  a 
mangled  condition,  with  the  exception  of  the  head  which  was  still 
in  the  m  omb.  The  friends  of  the  poor  creature — for,  destitute  as 
she  was,  she  was  not  without  friends  in  this  her  hour  of  tribulation 
— her  friends,  I  repeat,  became  alarmed — their  confidence  was  lost, 
and  the  serious  apprehensions  entertained  for  her  safety,  induced 
them  to  call  in  additional  aid.  I  was  sent  for,  and  on  hearing  the 
particulars  of  the  case,  so  far  as  the  messenger  could  communicate 
them,  I  hastened  to  the  house,  accompanied  by  my  former  pupils, 
Drs.  Busteed  and  Burtzell. 

**  The  patient  was  pale  and  exhausted— her  countenance  was  that 
of  a  dying  woman — she  was  almost  pulseless,  with  cold  extremi- 
ties, and  the  perspiration  ot*  death  on  her !  In  her  death  agony  she 
supplicated  me  to  save  her,  and  said,  with  a  feeling  which  none  but 
a  mother  can  cherish,  that  she  was  willing  to  undergo  any  additional 
suffering,  if  she  could  only  be  spared  to  her  children.  Poor  creature ! 
her  measure  of  anguish  was  indeed  full ;  and  had  she  known  that 
she  was  about  being  removed  from  her  children  by  the  atrocious 
butchery  of  men  to  whom  she  had  entrusted  her  life,  she  would  not 
have  made  the  appeal  she  did.  In  approaching  tiie  bed  of  the 
dying  woman,  and  on  attempting  to  make  a  vaginal  examination, 
to  ascertain  the  condition  of  the  womb,  the  head  of  tlie  foetus  being 
still  in  its  cavity,  having  been  separated  from  tiie  trunk,  you 
may  well  imagine  my  feelings  on  finding  a  mass  of  small  intestines 
protruding  from  the  vagina,  and  lying  between  the  thighs ! 

"The  operators,  not  content  with  slaughtering  the  infant,  had 
ruptured  the  uterus,  through  which  the  intestines  escaped,  and  thu^ 
abandoned  the  woman!  She  lay  in  this  condition  three  hours  be- 
fore I  saw  her,  the  doctors  having  lefl  the  house,  stating  nothing 
more  could  be  done!  Verily,  death  does  terminate  all  human 
effort.  The  question  may  now  be  asked — Why  was  embryotomy  had 


660 


THE  PRniClPLES  AND   PRACTICE  OF  OBSrETRla*. 


recourse  to  m  this  ciwe  ?  I  never  could  aicertam«  There  moft  hiTi 
been  a  secret  reason  for  it — the  burning  love,  i*crhapS|  which  aoftio 
tn«?n  have  for  the  eclat  of  bloody  deedt*.  There  w:w  no  defpmtitjr 
of  ihe  pelvU;  the  head  of  the  iwtm  was  of  the  n^iial  slie;  »iid,fti 
for  *as  I  coii)d  learn,  it  was  an  ordinary  labor.  The  doeton  judged 
It  Jidviftable  to  do  ciomething;  they  dreided  to  turn  and  deliver  bf 
the  feet.  Tficy  accordingly  proceeded,  and,  mistaking  a  hand  for 
a  foot,  pulled  it  into  the  vagina.  They  were  tfien  foiled,  auid,  in 
order  to  eomplcie  the  delivery,  coninienced  cutting  up  the  fci*titi,aad 
extracting  it  (xiecenieaL  Thus  were  two  lives  wantonly  sacrificed. 
The  patient  died  ia  about  two  hours  afler  I  arrived  ;  half  an  ho«ir 
before  she  expired  t^ho  ohiserved — ^  M*/  poor  chitd  wa9  ctllve^  /t^t  I 
felt  it  tnove  vj/ten  t/m  di^ctor^  were  ttariny  it  ftumi  me  P  Sach 
language,  uttored  under  such  circuniMtancea,  was  Indeed  gmpUo 
and  eloquent  in  condetnnution  of  ttio«e  who  had  b«fOn  ]MU'liei|Hi» 
tora  in  tliis  cruel  tragedy,'* 

The  inelnneholy  ease  wliieh  I  liave  just  cited,  harrowing  aa  Ulii 
unfortunately  is  not  alone;  iU  eounterpartst  have  not  only  bfoa 
witnessed  in  the  lying  in  room,  but  the  archives  of  the  )irc^i5»iaii 
record  niuuy  such.  Giraud*  t^tys,  *'I  liave  on  several  oc<?a^ioQi 
been  present  when  embryotomy  was  petfonned  by  the  nio^t  di»- 
tingni>hcd  praeiitioners,  arid  the  nuithcrs  have  died  Innneillaiely 
after  the  ofKM'ation.  In  two  instances,  I  myself  assinted  in  extmclioK 
the  foetus  by  fragnieni;^,  ^t\d  ilie  mothers  sank  a  few  hours  adrr* 
ward;  in  one,  the  intestini-s  pas?ied  through  a  laceration  of  llie 
uterus,  and  projected  from  the  vagina;  in  the  other,  the 
and  posterior  wall  of  thi^  uterus  were  frightfully  lacerated!** 

Mode  of  Perfortniuff  the  OprrutUm  of  Emh       ' 
b€  kept  in  memory  tliat  this  operniion  may  be  J  ,  if< 

the  accoucheur  under  i*everal  il liferent  circumstance*  ;  tor  exafnple» 
when  there  is  such  au  abridgment  in  the  diameteni  of  tlic  tnatcmal 
organs  as  to  render  it  physically  impossible  for  the  child,  witfaont 
mutilation^  to  pass;  wliere  the  maternal  organs  are  nornta!  in  ihtir 
dimoii^ion.^  but  the  exce^iiiive  size  of  the  child  constitutea  the  dift- 
Qulty,  as  is  illustrated  in  hydroceplialus ;  where  there  ts  no  aciioU 
disproportion  in  the  respective  size  of  the  child  or  orgati^  bnt  urhef« 
the  obstacle  conniisU  in  mnlposilion  of  the  fcDtus,  which  cannot  Im 
rectified  either  by  the  hand  or  through  the  agency  of  an  im^m- 
ment»  and  which,  therefore,  may  call  for  the  di^^membermeut  of  the 
etiild*  Trusting  that  you  will  not  fail  to  keep  in  rienr  the  line  of 
argument  which  1  have  endeavored  to  lay  before  you^  as  to  iHc 
justification  of  embryotomy,  I  shall  now  proceed  to  f»o*ml  out  the 
mode  of  procedure  usually  adopted,  afler  you  hare  decided  ibat 
the  operation  is  a  feasible  and  pnciper  resource. 


«  Joiinial  dc  Mcdldae,     Pat  UU.  Corviaart,  LertHix,  and  Boycr. 


I 


THE  PKIKCIPLES  AKD   PRACTICE   OF  OBSTETKICS. 


661 


The  patient  is  placed  on  lier  b:tck,  jvnti  brotiglit  to  ihe  edge  of 
the  biid,  occupying  precisely  the  same  position,  Jih'eudy  described, 
when  delivery  is  to  be  accomplished  eiilier  by  version  or  the  Ibi^ 
cepd.  The^  bladder  and  rectum  being  previously  evacuated,  two 
fingers  of  one  hitnd  are  to  be  iiitroducL'd  as  far  as  tlie  head  of  the 
child,  to  serve  as  i\  guide  for  the  perforator  or  pierce-crane ;  if 
possible,  the  instrutnent  should  be  made  to  enlor  the  cranium 
through  either  the  aaterior  or  posterior  foritanello ;  or,  if  this  can- 
mi  be  clone,  any  other  portion  may  be  selected,  endeavoring,  how* 
evei*,  to  avoid  putietratiiig  the  sntnre:^.  Asi  soon  as  the  instrument 
has  entered,  tUv  handles  should  be  separated,  so  as  to  hiciliLalc  as 
niu  *li  as  possible  the  complete  breaking  up  of  the  lirain.  If  it  be 
necessary,  a  smaU  spoon  may  be  employed  fur  ihe  purpose  of 
bringing  away  the  cerebral  niass ;  and,  if  you  are  operating  on  a 
liviiif/  child,  allow  me,  in  mercy,  to  beseech  you  to  be  thorough  in 
your  work  of  death,  and  see  that  the  medulla  oblongata  is  de- 
Btroyed,  in  order  that 
you  may  be  spare  !  the 
sad  scene  of  witnessing 
the  sobs  of  the  poor 
infant  after  it  has  been 
brought  into  the  world, 
man^^led  and  mutilated ! 

If,  after  the  discharge 
of  the  brain,  and  the  col- 
lapse of  the  cranial  bones, 
the  head  should  not  ad- 
vance, then  recourse  may 
be  had  to  the  guard-crot- 
chet, which  may  be  in- 
serted into  the  foramen 
mnguum  oecipilale,  the 
socket  of  one  of  the 
eyes,  or  behind  the  mas- 
toid process.  In  aildi- 
tion,  should  it  be  found 
necessary,  the  bone  for- 
ceps may  be  employed 
for  the  purpose  of  remo- 
ving the  bones  of  the 
head  iti  fragnionts.  As  a 
general  rule,  when  thfe 
head  has  pnsse»l,  the 
trunk  wifl  to  I  low  witlmut 
much  difficulty;  if  how- 
ever  there  be  an  obsta-  Fia.  M. 


662 


THE   PBINCIFLES   A>'D  FBACTICl  Or  OBSTrTBICS. 


de  to  its  exit,  the  perforator 
purpose 


abdc 


for  the 


may 


bo  introiinccd  int**  ti 


.T 


or 


tbu 


lii 


eviscomiiotJ, 
general  bulk  of  the  flrtus,  InKtanccM  will  occjwionallT  occur,  in 
wbich,  a(\cr  the  delivery  of  the  trunk  of  the  child  (without  wij 
pelvic  dcroriTrity)  the  head  becomes  arrested  at  the  sajierior  ttrait, 
and  ihu  accoucheur  i^  unable  trotu  malpoHition,  or  aomo  otbt^r  cau^iSy 
to  bring  it  into  tlie  cavity  of  the  pelvis.  Uuder  ibesHJ  dreumiitmieiri 
Uio  perforator  and  crotcliet  may  again  be  indicated. 

In  hydrocephahis^*  provided  there  be  evidence  that  the  child  is 
aJive,  1  should  caution  you  not  hastily  to  decide  on  upetiing  the 
cranium  (Fig.  9*3)  for  the  jjtirpose  of  aflbrding  escape  to  th«  accu- 
Diulated  fluid,  for,  if  the  jjelvis  be  natural,  or  even  nUgbtly  eoa- 
tnicted,  it  U  possible  that  the  effort*  of  tlie  Qterus  may  aiiffiee  to 
a^'coinpfjsb  the  expulsion  of  tho  fcetuft,  and  tbt!%,  too,  catt»il«filly 
witb  its  sufety.  Therefore,  my  advice  is — exercise  a  conMliml  9i§i^ 
hmre  ;  sustain  as  far  €u  ma*/  be,  the.  coura^  €mdku§m 

Pof  your  patient^  and  do  not  have  recourse  to  the  perf^ 
Tatar  until  you  are  satiitjif'd  of  the  inabiUiy  oj  naiwre 
to  terminate  the  lat/or^  and  that  furtiwr  ddajf  koM 
prove  perilous  to  the  mother. 
In  a  shoulder  or  arin  pt^esentatioii,  it  may  hififMii 
that  version  caimnt  be  pciformed ;  in  such  an  r%-«fit, 
it  would  be  of  little  avail  to  attempt  to  ainputAtc  tfat 
arm,  tor  this  would  in  no  way  faeibfate  the  del]%'vry. 
It  would  be  far  better  practice  to  introduce  lh*i  i:tinrod 
instrument,  with  an  internal  cutting  border  (Fig. 
07),  for  the  purpo'^e  of  Feparating  iho  head  from  the 
trunk,   as   was   originally    Auggusted  by  Cekus ;  or,  if 

ttfiis  cannot  bo  done,  a  pair  of  long  nci-^tsors  otay  \m 
carried  up,  as  Dubois  reeoninicnds,  in  the  foUovriog 
manner:  The  linger  to  be  cautioi^ly  introduced  w%%k a 
view  of  ascertaining  tlie  position  of  the  neck;  as  soobm 
ilm  IB  done,  the  linger  should  be  hooked  rouDd  ike 
neck  to  force  it  as  near  n^  possible  to  the  upper  «tnut, 
and  then  the  scissors,  carried  up  along  the  fitig«r,  will 
enable  the  accoucheur  to  complete  the  work  of  deoalb^ 
tjon,  When  this  has  been  ejected,  tractioo  stKicittl  Ul 
made  on  the  *.hoalder  or  arm  which  pre»i*nt»,  and  m  ikb 
FtQ.  97.      way  the  trunk  will  be  brought  down.    The  head,  whkk 


I 


*  It  would  ieem  tint,  in  bjdroc«pha1u«^  mature  of  the  ut»nu  Is  noft  an 
Accompfiti intent.     Dr.  Thomns  Kelt  It  Uma  oollectctl  74pHjic9  of  intfa-uleriiup 
phjilua,  aod  in  H  of  thi»p,  theutcma  become  ruptuitHi  during  Ub<»r.     It  Imi 
Ibre^  bed)  luggMled  iu  hydrocephnltj^  ir^pediilljr  \(  the  l»hor  h»  proSonfvdi 
of  TMortiag  to  the  pefromlor  »tTid  t\)n?<^iticnil/  destroying  tite  fhflii  to 
iiii«fl  trocar  for  the  piirpom  of  evikMLiting  the  fluid,  whiob  doc*  oof  tw  rt  ■enjf 
tavolTte  Ute  safety  of  the  fostua     [Simpsiou'A  Obftl^^ihc  Works,  vol,  L,  p.  6A4] 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  663 

of  course  remains  within  the  uterus,  is  to  be  removed,  as  described 
in  a  previous  lecture.  There  is  still  another  alternative  in  these 
cases  of  arm  or  shoulder  presentation,  in  which  version  is  found 
impracticable;  it  is  this — passing  the  finger  along  the  arm  or 
shoulder,  as  a  guide  to  the  axilla,  the  latter  is  penetrated  by  the 
perforator,  and  the  chest  eviscerated;  this  being  accomplished, 
the  delivery  of  the  child,  by  making  a  lever  of  the  arm,  will  not  be 
difficult. 

Ce])halotripsy, — It  is  proper,  before  concluding  this  lecture,  that 
I  should  direct  attention  to  an  alternative  which,  in  the  jud-^ment 
of  some  distinguished  and  experienced  accoucheurs,  m:iy  with 
great  advantage  to  the  mother,  be  substituted  for  the  crotchet  and 
other  instruments,  employed  for  the  extraction  of  the  foetus,  after 
its  cranium  has  been  opened  by  the  perforator.  I  allude  to  cepha- 
lotripsy,  which  consists  in  crushing  the  child's  head  by  what  is 
called  the  cephalotribe  or  embryotomy  forceps,  and  thus  extracting 
it  through  the  maternal  organs.  It  has  been  well  remarked  that  the 
true  dangers  to  the  mother  in  craniotomy  are  in  no  way  to  be 
referred  to  the  mere  act  of  perforation,  but  arise  altogether  from 
the  subsequent  use  of  the  crotchet,  bone  forceps,  etc.,  which  are 
employed  for  the  purpose  of  completing  the  delivery.  There  is 
much  truth  iu  this  observation,  and  in  order  to  overcome  these 
undeniable  objections  to  the  crotchet,  etc.,  A.  Baudelocque,  Jr., 
gome  years  since  constructed  an  instrument,  known  as  the  embry- 
otomy forceps  or  cephjilotribe.  It  has,  since  its  first  introduction 
to  the  attention  of  the  profession,  undergone  several  modifications 

by  dittVre:it  accoucheurs,  ainong  whom 
may  be  named  Cazeaux  (Fig.  98),  and 
Scana^ni.  The  cephalotribe  of  the  latter 
is  a  good  instrument,  and  will  be  found 
to  answer  very  efficiently  all  the  pur- 
poses for  which  it  is  intended.  It  is  an 
error,  however,  to  suppose  that  the  ce- 
phalotribe can  do  away  with  the  perfora- 
tor ;  on  the  contrary,  the  true  excellence 
of  the  instrument  is  developed  only  after 
the  cranium  has  been  previously  emptied 
of  the  cerebral  mass. 

It  has  been  demonstrated  by  nume- 
rous experiments  made  on  dead  f(Etus- 
es  by  Hershent,  that,  if  the  instrument 
be  applied  to  the  head  previous  to  the 
evacuation  of  its  contents  by  the  i)erfo- 
^»-  w.  rator,  the  diameter  in  accordance  with 

which  it  is  grasped  will  be  diminished,  while  the  other  dimensions 
of  the  head  become  increased.    If,  on  the  other  hand,  the  cranium 


6ftt         THE   PIUXCIPLES  AND  PRACTICE  OF  OBSTETRICS. 

be  perforated  and  freed  of  the  brain,  and  then  crashed  by  ineana 
of  the  cephalotribe  (Fig.  99),  it  is  less  voluminous,  and  the  diame- 
ters much  more  contracted.* 

But  the  advantages  of  the  instrument  are  not  limited  to  the 
head  of  the  child  ;  it  may  be  employed  with  benefit,  if  the  fcetus 
be  dead,  in  difficult  breecli  presentations ;  also,  for  the  purpose  of 
diminishing  the  volume  of  the  thorax,  should  it  be  neoessary  atler 


Fra.  99. 


the  escape  of  the  inferior  extremities ;  and  in  some  mstance^,  in 
transverse  positions  of  the  trunk,  when  version  cannot  be  effected . 
in  consequence  of  the  impossibility  of  introducing  the  hand  into 
the  cavity  of  the  uterus.  One  of  the  essential  prereqni>itos  for  the 
.  use  of  the  cephalotribe  is  a  sufBciont  space  in  the  ]»e!vic  canal  to 
admit  the  passage  of  the  foetus  afliT  it  has  been  cruslicHl.  If,  there- 
fore, there  were  not  a  space  of  at  lea<t  two  inches,  the  instrument 
could  not  be  employed  with  any  hope  of  success. 

*  BoanzoDL 


LECTURE    XLIII. 

rhe  Inductu^n  of  Premature  Artificial  Delivery — Premature  Artificial  Delivery — • 
How  divided — When  is  the  Foetus  viable?— The  Period  of  inducing  Artificial 
Delivery  with  the  hope  of  saving  the  Child — Wiiat  was  it  that  first  suggested  a 
Recourse  to  it? — The  History  of  the  Operation — First  performed  in  Great  Britain 
— Siatistical  Tables  showing  the  Diameters  of  tlie  Foetal  Head  at  Difierent  Periods 
of  Development — Tiie  Opinion  of  Dr  Merriman  and  others,  that  Premature  Deli" 
very  sliould  not  be  attempted  in  ti»e  Primipara — Objections  to — ^The  Causes  of 
Ariificial  Delivery — What  are  they? — Deformity  of  the  Sofk  Parts  sometimes  a 
cause — Case  in  Illustration — Excesiiive  vomiting  in  Pregnancy  and  Artificial  Deli- 
very— Examination  of  the  Question — Statistics  of  Premature  Artificial  Delivery 
contrasted  with  those  of  the  CcBsarean  Section  and  Embryotomy — The  various 
modes  of  inducing  Artificial  Delivery — Perforation  of  tUe  Membranes — Ergot, 
Dilatation  of  Os  Uteri  by  prepared  >ponge,  according  to  the  method  of  Klugeand 
Bruningliausen — Meissner's  mode  of  Rupturing  the  Membranes — The  Methcni  of 
Kiwinch,  or  Water-douche — The  Method  of  Cohen — Injection  of  Carbonic  Acid  into 
the  Vagina  as  proposed  by  Dr.  E  Brown -Sequard ;  its  infiuence  on  contraction 
of  non-striated  muscular  fibres — Induction  of  Abortion — Is  it  ever  justifiable? 

Gentlemen — In  the  two  preceding  lectures  we  have  discussed  the 
question  of  operative  midwifery  under  two  important  aspects:  1. 
Whether  the  mother  shall  be  subjected  to  a  perilous  alternative  for 
the  purpose  of  dividing  the  chances  of  life  between  hersflf  and 
offspring ;  2.  Whether  the  child  shall  be  mutilated,  and  brought 
into  the  world  piecemeal,  thus  sparing  the  mother  the  hazards  of  an 
operation  performed  on  her  own  person.  But  I  desire  you  distinctly 
to  recollect  that  the  discussion  oi  tfiis  question  had  reference  to  the 
female,  who  should  not  only  have  arrived  at  the  completion  of  her 
pregnancy,  but  who  was  actually  in  labor  at  the  time  at  which  your 
opinion  was  to  be  determined  as  to  the  choice  of  one  or  other  of 
these  expedients.  In  the  examination  of  this  subject,  and  in  the 
pursuit  of  truth,  we  were  necessarily  compelled  to  narrate  facts  and 
circumstances  well  calculated  to  sicken  the  heart,  and  draw  largely 
on  your  sympathy.  To-day  we  have  a  more  agreeable  duty  to  per- 
form ;  for  it  is  my  purpose  to  present  to  your  consideration  an  alter- 
native, which  will  oftentimes  not  only  do  away  with  the  necessity  of 
the  Cesarean  section  and  embryotomy,  but  will  prove  the  means  of 
greatly  diminishing  the  destruction  of  human  life.  I  allude  to  the 
induction  of  premature  artificial  delivery — one  of  the  most  precious 
boons  which  science  has  yet  bequeathed  to  suffering  woman. 
Piemature  artificial  delivery  may  be  properly  divided  into  two 


688 


THE   PRINCIPLES  ANJJ   PRACTICE  OF  OBSTETRICS. 


branches:  1.  When  the  f<rtiis  is  viable^  or,  io  other  wordiJy  hi 
attaiued  a  flcpreo  of  intra-nterinc  *levdopnient,  which  will  etsablo 
it  tt>  onj<»y  aa  indepentjeut  or  exterruil  exUtetice  ;  2.  Prevm^dy  %q 
the  ffiahUiti/  of  the  Icelns.  Tl»esc  two  dhij^ions  of  the  sti! Jed  I 
shall  now  proceed  tu  examine,  giving  to  euch,  as  fur  as  I  may  \m 
enahled  to  «lo  so,  it^^  resjieetive  value  and  indications 
.  Premature  Artificial  DeUvery  tthtn  the  J'lttUH  is  VitMt^ — II  it 
now  very  generally  admitted  that  a  fcetug  at  the  end  of  the  fixib 
month  of  gestation  is  capable  of  livinj^  iiidef>endently  of  it*  pan-nl; 
and  there  arc  not  u  few  examples  of  fcelal  viability  at  an  earhcf 
period  than  the  completion  of  the  sixth  month.*  It  In  an  intctv^ 
ing  circa tn.^tance  to  note  that  the  Hrst  mi^^e>«tiQri  of  iha  nlteniiti?« 
of  premature  artitlcinl  delivery  orighiated  in  the  fact  obt«t«ricd  by 
acconchenrs,  that  women,  who  hail  previously  been  f»n'  -• 

iLse  of  cutting  instruments,  in  consequence  of  peh  i  -* 

obstructing  the  passjige  of  a  living  ehikl  nt  ftill  term,  Itad  tn'cn 
delivered  without  a  resort  to  these  iuHtruments,  and  with  nafety  to 
themselvcH  and  oiTspnng,  when  taken  aecidenlally  in  hihor^ilio 
geventti  or  eighth  month  of  gci*:ation*  Th^?  einiest  historicxal  nfC<>fd 
toueliing  thii*  ojieraiion  we  find  in  the  following  langna^*  of  l>r. 
Detmian  ;f  **  A  c^jnsultation  of  the  mo<  eminent  men  In  Lofiduti  at 
that  time  (1756)^  was  held  to  con^dcr  tlu^  moral  rcctitndi^  aiid 
ad  v. un  rages  which  might  be  exjieetcd  from  this  practice,  and  il  tsici 
with  their  general  approbation*'* 

ICugland,  therefore,  m  not  only  entitled  to  the  honor  of  hartng 
decided  the  Uiorabty  and  utility  of  the  expedient,  but  to  on©  of  b«r 
medical  men,  Dn  ^Ia*'auley,  i^  ilue  the  cretlit  of  having  bittii  th« 
iir«t  to  have  recourito  to  it,  and  with  success  to  buth  mother  amtl 
child.  Boon  after  this,  it  became  a  rccogniscil  alternative  in  Gr^l 
Britain.  It  was  also  adopted  in  Germany,  Holland,  ami  oilier 
countrieiEs  but,  strange  to  say,  it  wa»  repudiated  in  Knaiee  am  m 
^^ cruel  nnij  inhuman*^  operation,  and  it  was  not  until  1831  tlut  1& 
WUH  resorted  to  in  that  nation  tor  the  tirst  time  by  Stoltz,  of  Stras- 
bourg, saving  both  mother  and  child.  Since  that  period,  it  liaK  met 
with  general  favor  in  France,  and  has  been  repeatedly  perfortned. 


•  Wien  clL«c"J«sinjf  the  ifili*ro*«tinK^  eiil>joct  of  pTvrn«turi»  iirirt  prtitrsctHl  |p*«tiilioQ. 
tt  wn«  »lA\fyii  thiit  Friinot*  had  cnack^cl  u  luvv  gniiit.ii^  (o  «  ctiiltl  litim  mx  tnutiUif,  <9 
outf  tiUDiln.-'i)  iitnl  ^•ijrhtr  iIhviii  after  m3arrui|rL\  hII  its  »mn\  iidU  legal  ritftitJi;  aM  tlik 
tiiu\  '^'if-ii  tn  itM^If.  thougti  oUrn  subjcx't  to  iii>UKV  ifi  prrdii!iiil(*ii  oa  ibt*  fnrt  that 
t)iilflrt-r»  »iro  fvimetiiiK^fi  uulTjcietitly  developed  nt  \\m  i-arly  pifuid  «f  j  n 

ciiuIjIc*  \\k¥tx\  III  livM.     Hiie  luw  urt^tttited  ill  ll»e  dtnire  U>  jin>tnn  ;lif  « 

(hircrit  and  the  priviK*gi=^  of  ihe  rliild»  irt  ihcj^o  inatiuiees  of  (-r  ,  imt 

it  ciiimMi  be  ri'ifiirdod  u%  »  puldtf  ttj  the  induciiou  of  prcnuitur  tbrtba 

ri'iiJ!Mm    iluU  ihe  viability  uf  tho  fn'tus  nt  tli**  sixth   mntiili  i9  to  Iw  MWi<l<f<  Ml 
9xci'[)(ioiiiii  oif\nun^iii<M*,  wb(«n5ttii|  ftt  tbe  seveuLh  fuuntlt,  it  oflBiifimi  oiori  th*  < 
liot4«r  of  iliff  ruio. 

t  Inlroduotioa  to  PmotioiU  Midwifery,  pi  t^<L 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS. 


667 


In  our  own  country,  it  is  also  in  favor.  In  a  word,  under  justifying 
circumstances  premature  artificial  delivery  now  holds  a  high  place 
among  the  alternatives  of  the  lying-in  room ;  for  it  must  be  remem- 
bered that  the  object  of  the  operation  is  not  merely  to  diminish  the 
dangers  to  the  mother,  but  also  to  save  the  life  of  the  child. 

Let  us  examine  what  it  is  that  gives  facility  to  the  passage  of  a 
living  child  at  the  seventh  and  eighth  months,  which  cannot  possi- 
bly be  brought  into  the  world  alive  at  the  full  period  of  utero-ges- 
tation.  In  order  to  determine  this  question,  and  decide  what  the 
pelvic  capacity  must  be  to  allow  the  expulsion  of  a  viable  foetus,  it 
will  be  proper  to  ascertain  the  diameters  of  the  head  at  the  differ- 
ent periods  of  pregnancy.  When  the  head  begins  to  engage,  it  is 
its  biparietal  or  transverse  diameter  which  traverses  the  antero- 
posterior of  the  pelvis,  and  consequently  it  is  very  important  to 
have  an  accurate  idea  of  the  dimensions  of  the  biparietal  diameter. 

The  following  tables  of  M.  Figueira  and  Ritgen,  which  have 
been  presented  by  Dr.  Churchill,*  are  important,  and  elucidate  fully 
this  question : 


Age  of  FotuB. 

Biparietsl  Diameter. 

Occipito-Frontal 
Diameter. 

Ooclpito-breirmatio 
Diameter. 

7  months. 

8  " 

9  " 

2  inches  9  lines. 

3  inciies. 

8  inches  1  line. 
3  inches  2  lines. 
3  inches  4  hnes. 

3  inches  8  lines. 
3  inches  9  linea 

3  inches  10  lines. 

4  inches. 
4  inches. 

2  inches  10  lines. 

3  inches. 

3  inches  1  line. 
3  inciies  2  lines. 
3  inches  4  lines. 

According  to  Ritgen,  premature  artificial  delivery  may  be  induced 
at  the 

29th  week,  when  the  antero-posterior  diameter  of  pelvis  is  2  inches  "7  lines. 
30th     "  "  "  ••         2     "       8     *' 

3l8t     **  "  **  '*  2     "        9     " 

35lh     "  *«  "  "2     "     10     " 

36th     "  •«  "  "  2     "      11     *« 

37th     "  •*  **  "3     •* 

Allowing  for  the  overlapping  of  the  parietal  bones,  and  the  con- 
sequent diminution  of  the  biparietal  measurement  of  the  foetal 
head,  it  would  appear  that  the  extremes  indicating  the  operation, 
all  other  things  being  equal,  will  be  2j  and  a  fraction  less  than  3J 
inches,  and,  indeed,  it  might  become  a  question,  if  the  antero-pos- 
terior  diameter  measured  even  3  J  inches,  whether  premature  delivery 
would  not  present  a  better  chance  of  life  to  both  mother  and  child ; 
for  you  are  to  remember  that  although  we  have  stated  that,  as  a 
general  rule,  a  contraction  of  3  J  inches  is  the  smallest  space  through 

*  Theory  and  Practice  of  Midwifery,  fourth  London  edition,  I860,  p.  296. 


668 


THE  PRINCIPLES  AND   PRACTTICK  Of  0BS7ETBKB. 


which  ri  living  chiM  onn  be  iiiade  to  pa'w  fit  full  tcmv,  yoi  iu  exit, 
if  at-'cosnj^rwhtitl  uruler  this  cotidition  of  ihitig*,  would  \h:  ittti^iMled 
by  mare  or  less  peril. 

Some  wiiiers*  have  urged,  as  an  objection  to  the  »«|m  rit.ifti  in  a 
prinupitra^  the  difficulty  of  arnvin^  at  t\n  accurate  idi^a  of  the  inic 
sixe  oj"  iht*  pelvi^i;  they  allege  the  iiiJ^ufticieuey  of  the  pi-lv«un*li*r  t3 
reach  thia  fact,  and  maintain  that  the  real  dimensions  ran  only  be 
approximated.  I  munt  confess  I  am  unable  to  appreciate  lite 
itrengih  of  thla  objection  ;  for  it  matterH  not  wbelher  the  accouch- 
eur can  come  wilhiti  one  or  more  lines  of  the  actaal  extent  of  the 
iintero*po?«t prior  diameter ;  what  he  de^^ires  i^  sim'ply  to  ap^/rttxi- 
mate  a  knowledge  of  the  physical  condition  of  the  pdvin,  jhi  ihaii 
with  all  the  accesi-ible  facts  before  Itifii,  he  may,  assisted  hy  olber 
counKel,  (hcUU  whrthrr  or  not  fhe  cohtraciion  is  stir/t  fts  to  rfj»*lrr 
it  moralhj  certain  that  a  Utnng  child  cannot  pasif  iU  the  jitH  ttrm 
of  preffnancy.  This  cardinal  fact  being  a.Hc(*rtained,  then  llici  qne*- 
tion  Icffiiiniately  ])roft»eH — What  is  the  general  character  of  ih* 
deformity?  Is  it  jjuch  a^  to  preclude  the  birth  of  a  visible  child ^ 
If  not,  there  shouhl  exi^t  no  doubt  as  to  the  courw  to  be  pnnfiied. 
If,  however,  the  contraction  bt?  r*o  marked,  as  to  demtmsitr^le  llwi 
impossibility  of  the  exit  of  a  aeven  months*  child,  then  the  utrst 
alternative  pre?ienl8  itself  for  conslderaiioii— the  inducti4*n  of  abor* 
lion,  which  kilter  point  will  be  fully  examined  Ijefore  the  doM  of 
this  lecture. 

While,  for  arcrumentN  *5ake,  I  am  willing  to  accord  a  due  degTt« 
of  force  to  the  olijection,  that  the  pelvimeter  is  oftentimes  tn$uiS- 
eient  to  alloxv  us  to  judpre  of  the  real  dimensions  of  the  pehKyel  I 
believe  the  experienced  aceoticheur  will  be  cnalded»  under  ordinarj 
circuniHiauces,  by  the  introduction  of  the  fin*j:er — the  pdvinietei^ 
in  my  opinion,  jxtr  eri^cfJencr  in  the  exploration  of  the  pelvM  of  s 
married  woman — ^to  aj^certain  whether  the  deformity  is  of  a  charai^ 
ter  to  justify  a  resort  to  tfie  <iperation  now  under  di^eiission*  Be 
it,  however,  as  it  may,  the  objections  urged  in  reference  to  tJie 
primiparu  do  not  exist  in  the  multipara ;  for,  in  the  lattc^r,  we  liave 
a  positive  demonstration,  not  only  of  the  existence,  but  the  actiiit 
amount  of  the  pelvic  deformity.  For  example,  supja^jte  the  cmac 
of  a  female,  whose  pelvis  ia  so  contracted  tliat,  having  gono  to  the 

•  Pr  Memmatt  tins  oo  doubt  exercised  moro  ilian  ordiiiinr  inflncaiOD  in  t^ 
em|»hj«ii<*  Utii|rui«gi9  he  amplovH  j«g»in«t  n^courso  to  ^n?miiiun»  Hrtiflfin)  ddiv^  in  A 
primtpiirA.     With  nil  resprct  tur  Urn  ii:iiiie»ii(i  Ntjtlioritv,  I  *  i.  («•  Is  H||M* 

The  fJinnwtn?^  nrv  hi«  words:  **Tbo  practjct*  sJiould  never  t**  J/  ttjurmmn 

has  (I  're*l  ihut  tU<5  mother  \»  inoopabl««  of  bearifi^f  n  luli-grvwu  frntwn  Alii%* 

[Mrtli  ic'fti  TrMtitiiictiaua  of  Lotulon,  vol.  Ui ,  p.  144  ]     if  thji  ofteliift  %a 

n*Wifn'j«ed  to  liie  letter.  U  must,  of  occeseity,  to  a  greater  or  itsa  extent,  Icmd  l€i  dfi^ 
Mtroufl  rvsiiltA,  It  seenns  U)  m»  cruel  to  uy  iHe  Irnst,  Ltinl  tho  Irriurv  ^««i  ioAMrtf^ 
mhy\y  Bliould  be  the  pr«TlouB  destruction  of  its  little  rebUvA  beloro  tts  UmmU  lali 
the  world. 


THE  PKINCIPLES  AND  PRACTICE  OP  OBSTETRICS.  669 

full  period  of  gestation,  she  has  been  subjected  one  or  more  times 
either  to  the  Caesarean  section  or  to  embryotomy,  for  the  reason 
that  a  living  child  could  not  be  made  to  pass  per  viaa  naturales. 
Here,  then,  is  the  certain  evidence  of  past  experience — a  jjioved 
fact — not  a  question  of  mere  speculative  opinion.  It  is,  in  truth, 
what  is  termed  in  law,  the  strongest  and  most  irrefragable  species 
of  testimony.  In  a  case,  therefore,  like  this,  there  is  no  basi.s  for  a 
conflict  of  thought ;  the  sacred  obligation  is  imposed  on  the 
accoucheur,  if  the  space  be  adequate  to  the  passage  of  a  viable  f<B- 
tus,  to  induce  premature  action  of  the  uterus,  in  order  that  both 
mother  and  child  may  be  liberated  from  the  perils  of  embryotomy 
or  the  Caesarean  section,  should  the  mother  be  permitted  to  go  on 
to  her  full  term. 

But,  gentlemen,  there  are  other  conditions  than  a  deformed  pel- 
vis, in  which  the  operation  of  premature  artificial  delivery  may 
very  legitimately  be  regarded  as  a  justifiable  alternative;  although 
in- reference  to  some  of  them  there  has,and  still  continues  to  exist  a 
marked  difference  of  sentiment.  For  example,  there  are  some 
women  who,  from  disease  of  the  placenta  or  other  influences,  are  in 
the  habit  of  bringing  into  the  world  dead  offspring,  the  physical 
appearances  showing  that  death  occurred  a  short  time  before  the 
completion  of  pregnancy.  In  cnses  like  these,  it  has  been  proposed 
to  have  recourse  to  premature  artificial  delivery,  for  the  purpose  of 
saving  the  children  ;  and  again,  the  same  alternative  has  been  sug- 
gested in  instances  in  which  the  volume  of  the  foetuses,  in  several 
successive  labors,  has  been  such  as  to  render  their  passage  through 
the  maternal  organs,  although  presenting  their  normal  proportions, 
physically  impossible.  Certain  serious  diseases  of  the  gravid  woman 
are  also  enumerated  among  the  causes  justifying  this  expedient — 
such  as  dropsy  of  the  cavities,  placing  in  more  or  less  peril  the  life 
of  the  mother ;  aneurism  and  strangulated  hernia,  procidentia,  or 
retroversio  uteri,  complicating  gestation  ;  the  presence  of  abdomi- 
nal tumors  exercising  an  undue  pressure  on  the  uterus  and  other 
organs;  an  intra-uterine,  or  intra-pelvic  growth,  curtailing  the 
dimensions  of  the  pelvis  to  such  a  degree  as  to  prevent  the  ])assage 
of  a  living  child  at  maturity ;  contractions  of  the  soft  parts  ;*  pro- 

♦  The  following  is  an  interesting  case  of  contraction  of  the  soft  parts  in  which  I 
performed,  on  two  different  occasions,  the  operation  of  premature  artiticiul  delivery 
with  entire  success  to  both  mother  and  children.  The  lady  was  a  native  of  Canada. 
Her  husband,  some  months  after  marriage,  took  her  to  South  America,  where  she 
was  delivered  of  a  child.  He  stated  to  me  that  she  had  been  suffered  to  continue 
in  labor  five  days;  and,  aft^r  experiencing  the  most  agonizing  pains,  she  was  Rpon« 
taneously,  in  the  absence  of  her  physicians,  delivered  of  a  putrid  foetus  of  immecae 
size.  In  two  months  after  her  delivery  she  began  to  walk  about  the  room,  and 
although  weak,  was  otherwise  in  tolerable  health.  The  first  intimation  she  had  of 
anything  wrong,  was  ezcesfuve  pai^  in  any  attempt  at  sexual  intercourse ;  this 
proved  to  be  impossible.    In  the  course  of  a  few  weeks  they  sailed  for  New  York ;  aa 


670        THl  FB1KC1PLB8  AND  PBAOnOB  OF  OBSntBICai. 

fose  uterine  hemorrhage,  whether  accidental  or  nnaroidable,  before 
the  completion  of  pregnancy,  aerioaaly  compromiung  the  safety  of 
the  mother ;  convulsions  and  excessive  vomiting. 

The  various  conditions  I  have  just  cited  are  to  be  weighed  with 
due  attention,  and  can  only  be  considered  as  just  motives  for  the 
operation  after  they  have  received  the  sanction  of  a  calm  and  dia- 

toon  lis  tho7  arriTed,  mj  late  lamented  and  duitingaiflhed  friend,  Dr.  Bnshe,  was 
consulted  in  reference  to  the  case.  At  thia  time  liia  health  waa  ao  infirm  aa  to  dit- 
(lualifj  him  for  profee^onal  duty.  He  sent  a  note  to  me  by  her  husband,  reqncatiiif 
tiiat  I  would  take  thia  lady  under  my  charge.  On  Tisiting  lier,  and  making  an  exa* 
mination,  I  found  tlie  entire  vulva  in  a  state  of  adiieaion.  allowing  only  a  small  open- 
ing for  the  meatus  urinariua.  After  hearing  an  account  of  her  labor,  this  oondUkm 
of  things  was  easily  explained.  From  tlie  protracted  and  aevere  pressure  of  tba 
head  of  the  foetus  against  tlie  walls  of  the  vagina,  Inflammation  ensued,  resulting  ia 
iloughing  and  consequent  adhesion  of  the  vaginal  parietea. 

The  indicatkm  in  thia  case  waa  obvioua — the  vagina  needed  natoratioo.  Aooort* 
ingly,  I  commenced  an  incision  just  below  tlie  meatus  urinariua,  and  extended  it 
about  an  iucli  downward ;  the  knife  soon  came  in  contact  with  cicatrices  so  rcnit- 
ing,  that  it  appeared  almost  as  if  I  was  cutting  on  iroa  Tlie  hiciskm  being  oooi- 
pletedf  I  introduced  a  small  sponge  covered  with  oiled  sQk,  and  retained  it  in  sita 
with  the  T  bandage.  Occasionally  witlidrawing  the  sponge,  and  renewing  iK»  I 
found  the  vagina  yielded  slowly  to  this  sort  of  pressure.  With  the  aid  of  a  smaB- 
sized  rectum  bougie,  carefully  introduced  twice  a  week,  and,  after  being  withdrawn, 
replaced  by  the  sponge,  the  vagina,  in  Uie  course  of  a  month,  permitted  the  intrcK 
ductioii  of  tlie  fluger.  Then  1  had  an  opportunity  of  ascertaining  ita  oonditkm.  It 
was  tilled  with  hard  and  unyielding  cicatrices  in  the  form  of  rings  Having  sue* 
ceeded  in  dilating  the  vagina  to  this  extent,  I  recommended  my  patient  to  oontinoe 
tho  8i><»ngo,  and  occnHionally  to  introduce  a  larger-sized  bougie.  In  ulx>ut  three 
months  allerward  I  wud  visited  by  her  husband,  who  seemed  somewhat  chagrined; 
ho  stated  iliat  it  painiMi  hiiu  to  say  tiiat  his  wife  tliouglit  slie  was  again  pri^ant 
This  I  (ound  really  to  bo  the  case,  though  it  is  manifest  from  what  has  been  said, 
that  sexual  intercourse  must  have  been  attended  with  great  difficulty.  With  this, 
however.  I  had  nothing  to  do;  the  mischief  had  been  done,  and  it  was  my  duty  to 
provide  in  tho  beat  i)Ossible  manner  for  the  patient's  safety.  The  8p<mge  and  bougie^ 
gradually  increasing  tho  sizo  of  both,  wero  continued,  and  the  vagina  seemed  to 
yield  nlijfhtly  to  this  equable  pressure. 

The  ))atient  having  nearly  reached  tho  end  of  the  seventh  month  of  her  gestation^ 
I  deemiMl  it  prudent  to  hold  a  con.<ultation  as  to  the  propriety  of  resorting  to  prvma- 
ture  delivery,  feelin;?  in  my  own  mind  that,  although  contractions  of  the  soft  parts 
do  sometimes  yield  sufficiently  to  the  combined  intluencos  of  pregnancy  and  labor, 
yet,  in  her  situation,  it  would,  to  say  the  least,  bo  hazardous  to  the  child  to  allow 
her  to  proceed  to  the  full  term.  On  proposing  a  consultation  to  the  husband,  he 
was  anxious  that  a  particular  friend  of  his,  Dr.  Richardson,  of  Ilavnnn,  then  on  a 
visit  to  this  city,  should  be  calh^l  iu.  This  was  accordingly  done,  and  after  a  full 
X)n8iderati(m  of  all  the  circumstances,  it  was  deemed  prudent  to  bring  on  premature 
delivery.  This  I  did,  and  delivered  the  lady  of  a  healthy,  living  daughter.  She 
again  became  pregnant,  and  went  to  the  city  of  Baltimore,  where  she  was  delivered 
at  full  term,  with  the  forceps,  of  a  dead  child,  after  a  labor  of  six  days*  duration.  In 
consequeuco  of  the  contraction  of  the  soft  parts,  the  vagina  was  lacerated.  About 
three  years  from  her  last  labor,  I  was  again  consulted.  She  was  pregnant,  and.  at 
the  seventh  month,  I  resorted  to  premature  artificial  delivery,  the  soft  part«  not  being 
in  a  condition  to  justify  delay  until  the  completion  of  gestation.  In  this  in 
too^  the  diUd  was  alive  and  healthy. 


THE   PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS.  671 

pnssionate  judgment.  In  reference  to  convulsions,  as  a  cause  for 
the  adoption  of  artificial  delivery,  it  is  to  be  remarked  that  the 
pregnant  woman  may  be  attacked  with  almost  any  grade  of  con- 
vulrtive  disorder ;  and  if  this  latter,  either  under  the  form  of  cata- 
lepsy, hystei-ia,  chorea,  epilepsy,  or  the  true  puerperal  eclampsia, 
should  prove  rebellious  to  remedies,  and,  more  especially^  if  the 
convulsion  be  traced  to  irritation  of  the  uterus^  and  the  life  of  t/ie 
mother  placed  in  perils  I  should  not  hesitate  to  liberate  the  organ 
from  the  irritation  by  promoting  its  premature  action. 

JExcessive  Vomit inff  a^  a  Motive  for  Premature  Delivery, — ^The 
subject  of  excessive  vomiting  in  pregnancy,  involving  the  life  of 
the  mother,  has  recently  attracted  much  attention.  In  1852  there 
was  a  remarkable  discussion  in  the  French  Academy  of  Medicine, 
embracing  more  particularly  the  question — Is  it  ever  justifiable  to 
induce  abortion 'in  cases  of  excessive  vomiting?  The  discussion 
grew  out  of  a  report  submitted  to  the  Academy  by  M.  Cazeaux, 
and  there  was  much  conflict  of  opinion  on  the  subject,  the  ultimate 
decision  being  one  of  a  mixed  character.  It  is  conceded  that  preg- 
nant women  have  occasionally  died  from  the  effects  of  vomiting  ; 
there  are  some  striking  instances  recorded,  and  I  am  quite  sure  the 
unrecorded  experience  of  practitioners  could  furnish  many  more 
examples.  Without  entering  into  a  prolix  discussion  whether  abor- 
tion is  ever  justifiable  in  these  cases,  it  seems  to  me  to  be  more  a 
question  of  sound  judgment  than  one  of  controversy;  and,  in  this, 
as  in  all  other  instances,  in  which  doubts  may  arise  as  to  the  proper 
course  to  be  pursued  in  the  treatment  of  disease,  it  is  the  para- 
mount  duty  of  the  medical  man  to  fortifyhimself  in  every  possible 
way  by  an  appeal  to  judicious  and  experienced  counsel,  together 
with  a  searching  review  of  all  the  surrounding  circumstances  of 
each  individual  case. 

In  this  way,  with  no  preconceived  opinion  to  sustain,  with  no 
prejudice  to  cloud  his  judgment,  no  false  light  to  lead  him  into 
error,  the  sound  physician  will,  I  think,  be  enabled  in  these  con- 
tingencies to  arrive  at  a  just  decision  ;  and,  at  all  events,  whatever 
he  may  do  under  the  influence  of  such  antecedents,  will  have  been 
done  with  good  and  justifiable  intent,  and  therefore  will  deserve, 
and  must  receive,  the  sanction  of  all  right-thinking  men.  I  can- 
not, for  myself,  recognise  any  difference  between  the  decision  of 
this  question  and  multitudes  of  others  more  or  less  constantly  pre- 
senting themselves  to  the  practitioner  while  engaged  in  his  daily 
rounds  of  duty. 

Where  is  the  physician  who  has  not,  at  times,  been  almost  be- 
wildered in  his  desire  to  decide  the  nice  qnesiion— further  depletion 
or  stimulation,  in  a  case,  for  example,  of  pneumonia,  pleurisy,  or 
typhus,  knowing,  at  the  same  time,  that  on  the  correctness  of  his 
decision  must  depend  the  life  of  the  patient !     In  a  case  like  this, 


fi72 


THE   PRINCIPLES  AND   PRACTICK  OF  OBSnOTEIOgL 


after  Uie  pro|jer  exerrUe  uf  hia  jmlgnienl,  looking  merely  at 
eafcty  of  ihe  inviiHU,  whalcver  thai  jud^mimii  nmy  imlicstr,  ot 
whatovcr  the  issue  may  be,  I  hold  that  the  medical  mail  has  iH^ 
cbnri^od  hia  duly.  So,  genllcnien,  is  it  in  symptomatic  vt»iriitmg^ 
en (Ijin Jarring.!  if  nut  checked,  llie  nafeiy  of  tlio  tuoLbtir.  L<M>k 
BcrupulouBly  at  all  tho  cireiiniAtancus  nud  if*  with  the  nul  of  ripe 
eourii^el^  you  gliould  be  impressed  with  the  eotivicttoii  that  ihr  best 
if  not  the  only  alternative  is  in  prernaturo  delivery — i\Min*  ill  my 
opinidii,  you  would  deserve  rebuke  if  you  withheld  thi-  **f 

relief;  for,  afler  all,  the  qne«tion  to  be  deterniiued  in  i  pi«fl 

but  grave  one — life  or  death — and  the  deeision  has  nothtng  to  rril 
upon  but  human  judj^ment. 

Tlie  two  chief  arguments  employed  by  those^  who  oppo^  tbM 
induction  of  premature  delivery  for  the  caune  under  eoMHidemtiori, 
are:  h  Tfiat,  in  aomo  instances^  pregnant  women,- who  have  bcca 
supposed  to  have  been  almost  in  a  moribund  state  from  Uie  «a^ 
haustion  of  vomitincr,  have  recovered  and  brought  f  '  '  ^nj 
children;  2.  Ttnit  the  physician  h  not  justified  in  the  p  **$ 

of  an  operation,  which  neces^anly  leads  to  the  death  of  the  i!iuld« 
I  du  not  perceive  much  force  in  thi't  reiisonhig  excefit  in  iho  aliidniot ; 
andf  when  taken  in  connexion  with  all  the  ci ream  stances  preieiited 
by  each  case,  it  loses,  in  my  view,  all  strenjrth  as  a  gulrl.j  in  pT»c- 
tice.  To  the  Hrftt  arguniunt,  therefore,  I  reply— that  if  a  wouiaa, 
appnrently  inoribmid  from  long^coniinued  and  exceasive  viKQiting, 
should  recover  and  reach  the  full  period  of  her  gestation,  it  k  a 
rare  exception  to  a  general  rule,  ami,  ^  an  exception,  ntlerij 
worrhless  as  a  precedent.  Again:  it  is  well  known  that  vruuMsa 
have  dicil  iVom  the  eilects  of  this  disturbance,  who  wontd  in  all 
probability  have  survived,  if  premature  delivery  had  been  reioriMl 
to.  The  second  argument,  it  seems  to  me,  is  readily  disponed  oC 
The  chances  of  sjiving  the  life  tif  the  motfier,  in  ihene  cai^eft,  w« 
very  much  enhanced ;  and,  w  ithout  the  operation,  should  the  mother 
die,  the  life  of  the  child  is  also  wicrifieed.  But,  I  repeal,  the  wbol# 
question  resolves  itself  into  one  of  expediency,  the  word  cKpediencj 
in  this  case  meaning — the  intcrpretntion  which  ncienre,  otkrijii'ieoee, 
and  a  high  morality  may  plaee  on  the  neces*iity  for  action* 

In  connexion  with  this  subject,  it  may  not  he  tintntere«1m^  to 
cite  the  following  instance  in  which  it  became  necessary  to  indiice 
preranturc  action  of  the  uterus  in  a  patient  affected  with  hydatldt 
of  that  organ:  I  was  requested  to  vi^^il  a  lady  in  consultatiim  wiili 
Dr.  Whiting,  of  this  city.  Several  medical!  gentlemen  ho*!^  prcvi* 
ously  to  my  visit,  seen  ami  prescribed  for  the  patient  Wbcn  I 
i^iw  her,  in  company  with  Dr.  Whiting,  she  was   i  *        ^r 

dissolution.     Her  prostration  was  extreme;  the  com i  *t 

hippocratio;  and,  indeed,  her  frionda  had  abandoned  ail  hope  of 
recovery.     The  particulars  of  the  case  are  these:    Sho  wiw  ilw 


4 


THE  PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS,  678 

mother  of  one  child,  seventeen  months  old;  about  four  weeks 
previously  to  my  visiting  her,  she  had  occasionally  been  troubled 
with  nausea  and  vomiting,  and  for  the  last  two  weeks  had  vomited 
more  or  less  constantly.  Nothing  could  be  retained  on  her 
stomach,  the  vomiting  having  resisted  every  remedy  which  had 
been  administered.  It  was  under  these  circumstances  that  I  was 
called  to  her.  The  medical  gentlemen,  who  had  previously  visited 
her,  had  ordered  cups,  leeches,  and  blisters,  over  the  region  of  the 
stomach,  with  various  other  remedies ;  but  all  without  the  slightest 
appreciable  effect.  The  vomiting  was  still  unchecked,  and  her  death 
hourly  expected.  In  examining  critically  the  case,  I  came  to  the 
conclusion  that  the  vomiting  was  merely  a  symptom  of  trouble 
elsewhere,  and  that  no  remedy  addressed  to  the  stomach  would  be 
of  the  least  avail  in  rescuing  her  from  the  imminent  peril  in  which 
she  was  placed.  On  applying  my  hand  to  the  abdomen,  I  found 
the  uterus  enlarged,  occupying  the  hypogastric  region.  The  alai*m- 
ing  situation  of  the  patient  precluded  delay;  if  her  life  were  to  be 
saved,  everything  admonished  us  that  it  was  to  be  done  by  instan- 
taneous measui;fjs.  My  opinion  was,  that  the  vomiting  was  alto- 
gether sympathetic,  occasioned  by  irritation  of  the  uterus.  I 
therefore  suggested  the  propriety  of  endeavoring  to  bring  about 
contraction  of  the  organ,  in  order  that  its  contents  might  be  ex- 
pelled. This  view  was  concurred  in  by  Dr.  Whiting.  Accordh^.glyy 
with  the  doctor's  full  approbation,  and  at  his  request,  desperate 
and  almost  hof)eless  as  the  case  was,  I  at  once  introduced!  a  female 
catheter  into  the  uterus ;  in  a  short  time  strong  contractions  ensued, 
and  a  large  mass  of  hydatids  was  thrown  off.  Almost  immediately, 
as  if  by  enchantment,  the  vomiting  ceased.  The  patient,  after  a 
tedious  convalescence  from  her  extreme  prostration,  recovered,  and 
is  now  in  the  enjoyment  of  robust  health.  Let  tWs  case  impress  on 
you  the  importance  of  tracing  effects  to  causes  ;  and  bear  in  recol- 
lection this  cardinal  truth — that  the  practitioner  who  prescribes  for 
mere  symptoms  will  oftentimes  find  himself  surrounded  by  obscurity, 
which  will  necessarily  frustrate  the  successful  treatment  of  disease.* 
Statistics  of  the  Operation. — It  will  be  seen  that  no  comparison 
can  be  instituted  between  the  results,  to»  both  mother  and  child,  of 
premature  artificial  delivery,  and  those  obtained  from  the  Csesarean 
section  and  embryotomy.  The  mortality  of  the  two  latter  alterna- 
tives has  already  been  detailed ;  and  we  shall  now,  in  contrast, 
present  a  brief  schedule  of  the  former*    Prof.  Hamiltonf  had  re- 

♦  Dr.  Cliurcbill  records  an  interesting  example  in  which  he  produced  premature 
delivery  at  the  sixth  month,  in  a  young  woman  pregnant  with  her  third  child,  in 
conBcquence  of  excessive  vomiting;  he  says,  he  "never  saw  such  agony  in  any 
case"  from  the  effects  of  vomiting.  The  mother  *^wa8  delivered  of  a  dead  fcetus, 
recovered  rapidly,  and  has  since  borne  a  child  at  full  term." — Churchill's  System  of 
Jlidwifery,  p.  282. 

f  Practical  Obaervatioxi&     1840.    P.  285. 

43 


C74         THE  PRINCIPLES  AND  PRACTICE  OP  OBSTSTRICB. 

oourse  to  premature  artificial  delivery  forty-six  times,  and  forty-two 
of  the  children  were  born  alive ;  on  one  of  his  patients  he  per- 
formed the  operation  ten  times.  Dr.  Ramsbothara,*  under  some 
very  discouraging  circumstances,  induced  labor  prematurely  sixty- 
two  times,  and  more  than  one  half  of  the  children  were  saved.  Dr. 
Merriman,f  in  his  own  immediate  practice,  and  in  consult  at  it  >n,  has 
met  with  thiity-tbree  cases  in  which  the  operati<m  was  ]>erlbnned, 
and  nearly  a  third  of  the  children  saved.  Dr.  Robert  LeeJ  had 
recourse  to  premature  artificial  delivery  twelve  times  in  one  woman 
with  complete  success.  In  two  hundred  and  eighty  cases  collected 
by  M.  Figueira,  one  hundred  and  sixty-six  children  were  saved,  and 
only  six  mothers  died.  In  the  sixty-two  cases  occurring  in  the 
practice  of  Dr.  Ramsbotham,  more  than  one  half  of  the  children 
were  saved,  and  not  one  mothef  lost.  Kilian,  up  to  1831,  had 
gathered  from  various  sources  one  hundred  and  sixty- one  opera- 
tions, the  results  of  which  were  one  hundred  and  fifteen  living 
children,  and  eight  mothers  lost.  It  is,  however,  stated  that  five 
of  these  eight  died  from  causes  altogether  unconnecte<l  with  the 
delivery.  It  will  be  thus  perceived  that,  in  preiyaturc  artificial 
labor,  considerably  more  than  one  half  of  the  children  are  rescued, 
with  the  insignificant  mortality  of  one  in  fifty  of  the  mothers!  Ad- 
mitting, therefore,  that  this  operation  should  be  had  recourse  to 
under  circumstances  fully  justifying  it,  it  cannot,  I  think,  but  be 
regarded  as  one  of  the  brilliant  substantial  triumphs  of  science, 
opening  to  the  contemplation  of  the  conscientious  accouihcur  a 
gratifying  and  cheerful  vista,  and,  at  the  same  time,  closing  up  an 
avenue,  which  has  j)roved  so  destructive  to  human  li!'e. 

Th*  Yurious  Mode^  of  Opcrathujfor  the  Imhictlon  of  Prema- 
turf  Artificial  Ddlvenj. — These  may  be  enumerated  as  follows:  1. 
The  ])eiibration  of  the  membranes,  for  tlie  purpose  of  affording 
escaj)e  to  the  licpior  anmii ;  2.  The  administration  of  ergot ;  n. 
The  dilatation  of  the  os  uteri  by  means  of  ])repared  sponge,  known 
as  the  method  of  Klnge  and  I>runinghausen ;  4.  The  method  uf 
Kiwis<]i,  consisting  of  vaginal  injections;  5.  The  vaginal  tampon; 
6.  Cohen's  method,  consisting  of  injections  into  the  cavity  of  the 
uterus;  7.  The  injection  of  carbonic  acid  into  the  vagina ;  8.  Gat 

•  l>r.  Ramsbotliam  obst-rvrs,  "It  (Kvurrcil  to  ino  Ix^tu'cen  the  vears  1S2:>  :»mJ 
1834.  to  bt*  co:iip<'ll.-ii  to  linltKv  Inbctr  prcri)atnroly  forty  tiino.«.  Tlii'*  n.iv  «*--^m. 
pf/rlinp?.  a  very  larire  nuinbcr:  ami,  in  cxiilanation.  I  may  5?tato  that  th»>  extvi:>«iv*» 
Charily.  \\\\\A\  has  siii»I)H«m1  tlio  principal  part  of  thcso  oanes.  enihra<x*5  the  di5trii-t 
of  SpilallKKls  and  Tx-thnal  (Jrci-n,  which,  I  hdifvc,  contains  more  femah.s  with  ih- 
forrntMl  pilvcs  than  arc  to  l)o  met  with  ovrr  the  same  quantity  uf  .equir**  ;u"r«^  in 
any  otlior  part  of  the  kinjrdoin.  In  nio.st  of  tlie  patient.**,  al.*o,  the  oi>erali'>M  ha<  Uxti 
repeated.  a!i<l  8onie  liave  untlcrpone  it  five  and  six  times." — Ramsbotham's  Sv>tcm 
of  OU-^tetrics,  Keatinj^'s  edition,  p.  315. 

f  Merrinian  on  Difficult  Parturition,  p.  172. 

}  Medical  Gazette,  Feb.  7,  1851,  p.  245. 


THE  PRINCIPLES  AND   PRACTICE   OP  OBSTETRICS.  676 

vanism  as  suggested  by  Dr.  Radford.     I  now  propose  briefly  to 
examine  each  of  these  propositions. 

Perforation  of  tlie  Membrmies, — ^The  first  suggestion,  that  of 
perforating  the  membranes,  is  undoubtedly  the  most  reliable  so  far 
as  the  mere  production  of  uterine  contraction  is  involved  ;  but  it  has 
cei*tain  counterbalancing  inconveniences.  It  is  known  in  Germany 
as  the  method  of  Scheele,  although  it  is  recorded  that  Macauley  had 
recourse  to  this  very  expedient  in  the  operation,  which  he  was  the 
first  to  perform  in  England  for  the  induction  of  premature  delivery. 
The  true  objections  to  the  perforation  of  the  membranes  are — that 
the  escape  of  the  liquor  amnii*  necessarily  brings  the  walls  of  the 
uterus  more  or  less  in  contact  with  the  surface  of  the  foetus,  thus 
incurring  the  hazard,  through  undue  pressure  on  the  cord,  of 
destroying  the  child  by  an  interruption  of  the  pi acen to-foetal  circu- 
lation ;  again :  the  employment  of  a  sharp  instrument,  with  the  object 
of  perforation,  will  be  likely  to  produce  injury  to  the  uterus;  and 
it  is  also  to  be  remembered  that  the  presentation  of  the  pelvic  and 
other  portions  of  the  foetus  than  the  head,  is  far  more  frequently 
met  with  in  premature  than  in  full  term  births  ;f  and  this  latter  fact 
would  consequently  enhance  the  dangers  to  the  child,J  in  the  event 
of  its  becoming  necessary  to  perform  version  after  the  exit  of  the 
amniotic  fluid.  PaulDuboisg  states  that  in  the  Maternit6  of  Paris, 
during  1829  and  the  three  succeeding  years,  of  one  hundred  and 

♦  In  order  to  obviate  the  objection  that,  in  perforation  of  tlio  membranes,  the 
liquor  amnii  escajies  in  full  quantity.  Meissner,  of  Leipsic,  has  contrived  a  mode  of 
openinjj  tliem  so  iliat  he  can  control  the  amount  of  tluid  discharj^ed.  Tliis  lie  accom- 
plishes by  penetrating  tlio  membranes  at  a  distance  remote  from  the  os  uteri,  by 
means  of  a  long  curved  trocar  embraced  in  its  canula.  He  first  introduces  the 
canula  alone  between  tlio  posterior  surface  of  the  membranes  and  internal  wall  of 
the  uterus,  and  being  assured  that  the  upper  extremity  is  turned  toward  the  sac  of 
waters,  the  trocar  is  then  introduced  through  the  canula,  and 'made  to  penetrate 
the  membranes;  as  soon  as  tliis  is"  done,  the  extremity  of  the  canula  is  carried  nito 
the  opening  made  by  the  trocar,  and  the  latter  is  immediately  withdrawn.  In  this 
way,  Meissner  savs  ho  can  draw  off  sufficient  fluid  to  cause  the  uterus  to  contra^ 
without  endangering  the  life  of  the  child  by  the  loss  of  the  entire  quantity.  It  does 
aeem  to  me,  that  the  idea  has  at  least  plausibility  to  recommend  it ;  but  the  carrying 
it  out  practically — though  no  doubt  feasible  in  the  skilful  hands  of  its  author — would 
prove  a  most  difficult  operation,  and  apt,  also,  to  endanger  the  lives  of  both  mother 
and  child,  in  consequence  of  injuries  inflicted  upon  them  Therefore,  while  men- 
tioning the  operation  of  Meissner  as  a  part  of  obsleiric  history,  it  is  my  duty  to  cau- 
tion the  practitioner  as  to  its  too  hasty  adoption.  At  the  same  time,  it  is  but  just  to 
remark  that  Meissner  has  recorded  fourteen  cases  in  which  this  plan  has  been 
adopted  with  safety  to  both  mother  and  child. 

f  See  Lecture  iii. 

J  This  only  applies  to  those  cases  in  which  the  child  presents  crosswise;  for,  I 
have  very  emphatically  stated  that^  all  things  being  equal,  delivery  can  be  accom- 
plished consistently  with  the  safety  of  parent  and  offspring,  in  either  a  breech,  knee» 
or  foot  presentytiou. 

§  Mem.  de  TAcad^mie  Roy.  de  Med ,  vol  il,  p.  271. 


ere 


THE   PRINCIPLES  AND    PRACTirE   OF   OBSTETRtCS. 


twenty-one  tcetuRcs  bom  befori;  iht-  Louipletioii  ol  b^M 
fitly  one  i>re&en  led  the  pulvU,  and  five  the  ahoulder.      i  f  ♦?- 

ritnce  U  amply  confimied  by  all  good  ob»ervt*r».  In  th©  thirty-three 
ca»e§  in  thi^  practice  of  Di%  Mcrrimiiri,  fdlecn  pri^unted  prvti*ma- 
tnrally,  and  in  the  lony-<jne  quoted  by  Dr.  Ranibbotham^  rourttH-u 
ware  \)VvU^vimlnra\,  It  \nny  be  nurjliotu'd  here,  lliiit  Slolisi  recom- 
mends in  cjises  of  prennilure  artiHeiid  delivery — if  it  be  pr€%»otii«l]r 
asee; tained  the iVrtus  oceiipies an  iiregnlar pomtion — ^biifor**  biilijnitJS 
on  bibor,  that  an  attempt  shouhl  be  made,  through  external  abilc* 
niinal  version^  to  change  the  |ire»entation  to  one  of  the  bead^  To 
tilt?*  tliere  can  bo  no  ol>jection  in  any  cross-preaentjiticin  of  iht 
fcptus ;  but,  as  hai  been  aheady  slated,  it  should  be  limited)  lo  lliis 
latter  presrentation,  and  not  had  recourse  lo  when  ©ither  of  the 
pelvic  exiremitie?*  is  at  the  Hiiperior  strait, 

Adnmiifttradon  of  Erffot, — Tlie  eec-tmil  method — ^the  admioi^ 
tration  of  er^H — in  to  my  mind  extiTmcly  objectionable,  altlioiigli 
in  the  advocju7  of  ir«  use  under  these  rirenuLHtancej*  by  Dr.  Ranift* 
bot[»am  it  certainly  ha.s  the  stinction  of  high  authority.  Thin  author 
first  administers  ergot,  sjiy  four  or  five  doscK,  at  intervalii  oflborto 
eix  hours,  an^i  then  ruptures  the  membranes.  Paul  Dubuin,  abcv 
commendi)  the  employment  of  this  drug  i\\  these  ea«c»,  Tho  fm^ 
miHeuiiUH  adrnini^trntittn  of  erg<»t^  ft»r  the  indueticm  of  ^  p© 

ai'titieial  delivery,  nnjst  ocrasiortaHy  be  attended  ^ilh  •-«  ii. 

Beipieneei4  to  l^oih  mother  and  ehiUL  For,  in  the  first  place,  ilia 
justification  of  the  ofieration  is  founded  partly  on  the  fact  that  th4fT« 
is  such  a  contraction  in  the  bony  or  soft  structtircs  of  the  iiiolber — 
or  sucli  an  excess  of  lievelopment  in  the  taMus — a.s  i^erinttMy  |o 
endanger  her  life  and  that  of  her  child,  if  ^he  be  permitted  lo  paai 
on  to  her  full  term*  Now,  if  one  of  the  olmtelrio  extremiliei  oflht 
icetns  should  not  prefK?nt  at  the  snpH'nor  strait — and  ii  '  tit 

always  be  ascertained  hefore  the  dilatation  of  the  uterine  lo 

adininister  ergot  would  be  to  ensure  the  death  uf  thechi!d,  tind  tnciir 
the  hazard  of  grave  lacerations  to  the  mother.  In  all  caiiea,  tlierefoiTf 
be  it  remembered,  in  which  the  child  may  present  erosBwiM>«  or  Ui 
any  other  position  so  as  to  cause  a  ♦ii»iproporlion  between  it  ami  tb« 
part**  through  whicli  it  has  lo  pass,ergi»t  is  certainly  eontra-indieatrd. 

Dilatation  qf  O9  Uteri  by  Prepared  i^ponge, — ^The  ddatatioo  of 
the  OS  uteri  by  the  prepared  sp<njge,  as  suggested  by  tlruiilnK* 
bau^en  and  Kluge,  is,  likewise,  not  without  its  oVjjeetioiit,  For 
instfuice,  it  may  be  found  extremely  difficult,  in  consequence  t-itlirr 
of  resistance  or  malposition  of  I  he  os,  to  introduce  the  spongi%  and 
the  abortive  efforts  made  to  accomplish  the  object  may  tndnco  morr 
or  less  irritation  of  the  pnrts.  It  must,  however,  be  conceded  tbat 
it  possesf^esa  very  marked  advantage  over  the  process  of  perforatiti^ 
the  membranes^  and  allowing  the  liquor  amnii  to  evapf^^for^  bi  tUf 
oase,  aa  we  have  remarked,  the  safety  of  the  child  is  more  or  loa 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         677 

compromised.  The  manner  of  performing  the  operation  is  as  fol- 
lows :  Take  a  piece  of  prepared  sponge,  about  three  inches  in  length, 
conoidal  in  shape  and  properly  pointed,  with  a  string  attached  to 
the  outer  extremity  so  that  it  may,  when  needed,  be  withdrawn. 
Instead  of  employing  the  speculum  for  the  purpose  of  introducing 
it — an  unnecessary  annoyance  and  exposure  of  the  patient — it  will 
saffice  to  carry  the  index  finger  of  one  hand  as  far  as  the  os  uteris 
and  grasping  the  sponge  with  a  narrow  forceps  it  should  be  made 
to  glide  along  the  finger,  which  will  act  as  a  guide ;  in  this  way,  it 
is  introduced  into  the  mouth  of  the  organ,  care  being  exercised  not 
to  penetrate  too  far,  for  fear  of  rupturing  the  membranes;  and  it  is 
then  to  be  secured  by  the  tampon.  The  sponge  thus  arranged  may 
be  permitted  to  remain  unchanged,  should  the  uterus  not  be  brought 
into  action,  for  ten  or  twenty  hours ;  at  the  end  of  this  time  it 
should  be  withdrawn,  and  for  the  purpose  of  removing  iriitation, 
the  vagina  thoroughly  injected  with  tepid  water.  The  first  sponge 
is  then  to  be  substituted  by  one  slightly  larger,  if  it  be  found  neces- 
sary. If,  however,  after  two  or  three  days'  trial,  the  contractions 
of  the  uterus  be  not  provoked — an  unusual  circumstance — it  must 
be  laid  aside,  and  some  other  expedient  had  recourse  to.  The 
modus  operandi  of  this  method  is  quite  apparent,  the  sponge 
absorbs  the  moisture,  always  in  more  or  less  quantity  about  the  os 
uteri ;  as  a  consequence,  it  enlarges,  acting  as  an  irritant  on  the 
incident  excitor  nerves  of  the  vaginal-cervix,  and  thus,  through 
reflex  movement,  brings  on  the  needed  contractions. 

Method  of  Kiwiach, — ^The  method  of  Kiwisch,  of  Wurtzburg, 
known  as  the  water-douche^  was  introduced  to  the  attention  of  the 
profession  in  1846,  and  is,  perhaps,  under  ordinary  circumstances, 
the  safest  and  most  reliable  of  all  the  plans  yet  proposed  for  the 
induction  of  premature  delivery.  It  consists  in  throwing  a  stream 
of  water  against  the  ob  uteri  continuously  for  ten  or  fifteen  minutes ; 
and,  to  render  the  action  of  the  stream  more  certain,  the  fluid 
should  be  alternately  cold  and  warm.  The  suggestion  of  Kiwisch 
has  met  with  very  general  favor;  its  modus  operandi  is,  also, 
through  reflex  action.  One  of  the  advantages  of  the  method  is  that 
it  does  not  subject  the  patient  to  the  necessity  of  keeping  her  bed, 
nor  is  it  accompanied  by  the  inconveniences  of  the  other  means 
already  alluded  to.  The  injection  of  the  water  may  be  repeated  once 
in  three  or  four  hours  until  contractions  of  the  organ  are  induced. 

Vaginal  Tampon, — The  vaginal  tampon  has  been  suggested  by 
Scheller,  as  a  means  of  inducing  artificial  delivery.  It  is  well 
known*  that  the  pressure  of  the  tampon  against  the  os  uteri  will,  in 
many  cases,  provoke  action  of  the  organ  ;  and  consequently  it  has 
been  proposed  as  a  suitable  agent.  It  is,  however,  apt  to  occasion 
more  or  less  suflering  to  the  patient,  and  is  now  generally  aban- 

*  Bee  Lecture  xxxi 


078 


THE  PRINCIPLES   XSU   PRACTICE   OF  OI 


donei],  for  the  more  stibHtatitial  i^eason  thai  it  h  »0[iersiKl«4  hj  mort 

Jfethod  of  Cohen, — Kext,  thci^  b  thtj  method  of  Cobm,  ■ 
con»wt^,  through  thu  a»;eiicy  of  a  curved  iubt%  iit  throwing  Aiiidl 
iiilo  ihe  cavity  of  the  uterus  itself.  Thin  j»Inn  fiajv  its  mhociKn*  boll 
it  i^ectiis  to  me  in  not  so  efKcient  m  the  pro{Kȣuil  of  Kiwiseh* 

Injection  of  Varhonic  Arid* — I  hhoiihl  not  omit  to  mentioti  thtj 
ttsp  of  earhonic  acid  as  ameaim  of  uuluein<^  prematura  actmn  tiftlitt 
tiiorn?»     Dr,  ISrowti-iSi'qutird  was  the  first  to  direct  nt^  •  i  its  ] 

inthieiice  in  cuimln;^  coutraetioim  of  iion*fttrmted  mn 
HiH  observations  on  this  subject  wilt  l>e  found  in  the  Memoirs  of  tbt 
Society  of  Bioh>i?y,  1840  and  '50,  and  ali*o  in  his  work  etttJtlrd, 
*'  HirjKTlfwnfal  JkC^tarr/uMf  itp/dit:d  to  Physiology  and  PatJwioffy^^  j 
1863,  p.  117.  Seanzoni,  Sinijison,  C»  and  J,  Hraun,  lal  by  the] 
experiments  of  Dr*  Sequard,  have  employed  this  agent  with  caoiplet# 
•ueeess  in  seveml  instnneeiSY  not  only  ilk  a  means  of  provoking  c*arly 
enntractionft  of  the  uterim,  bnt  also  in  ineriia  uf  the  organ.  The  ^at 
is  injected  into  the  vagina,  and  isi  qniekly  folloxved  by  markeil  re^ttltJL 

GalvanUnu — Galvanism  was  aug<rested  by  Dr.  Hadfurd,  of  M&a-j 
ch(»ster,  in  1844,  and  he  employed  it  with  imreeRsi  in  four  attim  of 
contracted  peh  r.s ;  so  also  have  Dr.  Barnes  and  others  been  Ibrttt* 
uate  with  this  agent. 

Ifulticiion  of  Abortion^ — /*  it  ever  Justrfiaide  f — U  now  rematni 
for  UH  to  examhie  the  inif^ortunt  question — m  aboition,  tinder  luty 
ciretmiMtance^i,  a  justifiable  alternative  ?  This  question  lirm  been 
mn<'h  controverted,  and  it  is  one  on  which  the  sentiment  of  Uic 
profession  is  not  concurrent.  In  order  that  the  special  pobts  in 
the  discussion  may  be  fully  nppreciatcd,  they  may  be  iidvafilA> 
^eously  presented  under  the  two  ibilowing  heads:  Ist,  When  the 
maternal  passages  are  so  contracted — no  mutter  from  what  cau?*!.^^ 
fts  to  reuflcr  it  certain  that  a  triable  fcetus  cimnot  be  made  to  pass. 
2,  When  the  maternal  passages  are  normal,  bnt  the  inotbei^s  lifc  it 
involved  in  alanning  peril  by  the  occurrence  of  some  »eriaus  i 
plication,  such  as  convulsions,  hemorrhage^  or  excessive  Tomilif»|;» 
It  IS  manifest  that  the  moral  part  nf  the  question  turns  upon  ibe 
simple  interrogatory — is  the  embryo  in  the  earlier  slates  of  its 
existence  n  living  lacing  ?  All  correct  physiology  dcmonstnH<*s  that 
it  becomes  iu  truth,  at  the  very  moment  of  feci i  ^leil 

with  vitality — the  contact  of  the  sperm  cell  and  j  nsti- 

tuting  the  net  of  the  breathing  of  lift,    Ji\^t<:^  of  Leifmio,  1  beHeve, 
alone  claims  the  doubt fVtl  merit  of  describing  the  bttmao  fcsi«s  m 

*  It  .^  not  of  course  intpaded  li4»re  to  diaouss  lUc  gcncml  quc^Ft'  -  -'^  -    lijMf  «ibap» 
Ufm^  wlueh  Lius  lK>crimo.  both  iit  home  undubrQud,  u  moiistrpui  .-  iit  gnflt 

iriitsare  Ui  the  hixity  wtUi  whirh  tlti*  hme  on  the  HuhjoHjir^dtiion-fU      i  nmj  \ 
ttve  rc'sdor  til  An  ihstriu-tivo  (mpff  «ititLtled  "  Criininat  Abcrthn  ift  JmcHes,**  by  Uim»  j 
tio  R.  StoTiT,  iLD,,  ISUa 


THE   PRINCIPLES   AND   PEACTICE   OF   OBSTETRICS.  679 

"  only  a  higher  species  of  intestinal  u  orni,  not  endowed  with  a  human 
soul,  nor  entitled  to  human  attributes."  With  his  infidel  notions 
on  this  point  he  might  have  added — lior  is  the  shedding  of  its  blood 
of  any  more  moment  than  the  slauffhtering  of  the  calf  I 

Besides  the  proofs  of*  ])hysiology,  we  have  the  testimony  of  the 
early  fathers  of  the  Catholic  church  ;  that  church  has  always  main- 
tained, with  an  unwavering  consistency,  so  characteristic  of  its 
canons,  that  the  destruction  of  the  foetus  in  the  womb  of  its  ])arent, 
at  any  period  from  the  first  moment  of  conception,  is  a  crime  ocjual 
in  turpitiule  to  murder,* 

Assuming,  therefore,  as  an  incontrovertible  fact  that  the  human 
embryo  is  in  reality  a  living  being,  the  suggestion  naturally  arises — 
are  we  justified,  and,  if  so,  under  what  circumstances,  in  depriving 
it  of  its  life  ?  It  is  quite  certain  that  the  only  plea  for  such  an 
alternative  is  the  safety  of  the  mother ;  and  as  to  the  force  of  this 
plea  there  has  always  existed  a  difference  of  opinion.  Here,  then, 
we  have  the  naked  question — a  woman  is  pregnant,  carrying  within 
her  a  living  being — her  pelvis  is  so  abridged  that  it  will  be  ])hy- 
sicaly  imjinssible  to  afford  exit  to  a  viable  foetus,  and,  consecpiently, 
if  she  proceed  to  her  full  term,  the  only  chance  of  rescue  will  be  the 
Caesarean  section  or  embryotomy.  Now,  I  repeat,  what,  under  these 
circumstances,  is  the  duty  of  the  conscientious  accoucheur,  who  is 
not  actuated  by  a  thirst  for  innocent  blood,  but  who  is  most  anx- 
ious to  discharge  with  fidelity  the  sacred  obligations  which  his  pro- 
fession imposes  upon  him  ? 

I  cannot  imdertakc  to  determine  this  question  for  others — i*  is 
one  which  must  be  lefl  to  conscience  and  a  sincere  desire,  as  far  as 
may  be,  to  do  what  is  right.  But,  in  no  event,  should  a  decision  be 
arrived  at  without  first  invoking  the  aid  of  wise  counsels,  and  duly 
considering  all  the  surroundings  of  the  case. 

On  the  other  hand,  suppose  the  instance  of  a  pregnant  woman, 
with  a  perfectly  normal  condition  of  the  maternal  organs,  but  who 
has  not  yet  attained  that  penod  of  gestation  at  which  the  child  is 
viable — and  she  should  suffer  from  some  serious  complication  which 
would  subject  her,  according  to  all  human  evidence,  if  not  deli- 
vered, to  the  loss  of  her  life — what,  in  this  contingency,  is  the 
course  to  be  pursued  ?  Here,  in  my  judgment,  the  morale  of  the 
case  is  greatly  changed ;  for  should  the  mother  sink,  in  consequence 
of  not  being  delivered,  her  child,  also,  must  of  necessity  be  sacri- 
ficed. Therefore,  under  these  circumstances,  if  my  convictions  as 
to  the  danger  to  the  mother  were  beyond  a  peradventure,  I  should 
not  hesitate  to  induce  abortion  upon  the  broad  ground  that,  with- 
out the  operation  two  Hoes  would  certainly  be  sacrificed^  whilcj  with 
ity  it  is  more  than  probable  that  one  would  be  saved, 

*  For  an  elaborate  discussion  of  this  whole  question,  see  the  Dublin  Review  for* 
April  and  Oct.  1858. 


LECTURE    XLIV. 


puerperal  Fever— Synonyms ;  ite  Fatiility  rooBl  Fwirt\il— Whiii  ia  Pucrpoiml  Ke?i<rf 

-^U  it  a  Local  PhlegmaslA? — Objectii>r]ii  lo  the  Hyfiolhcfih— Is  It  tn  its  Nsiuro  m 
Toximna,  or  Bl«x)d  IViaonlng?— i^ro-if*  m  Domoiurtnitioo  tif  Ibis  Opinion  lluieo* 
mi  riitliolt*)^*  — PutTjwnil  Fever  not  cuntirieil  Ui  llie  riinanitnt  Woman;  it  msj 
attMck  Vouiig  Wofuett,  Prt'^mjinl  iind  Noti'l'rtifiiaut  WoiiM-n,  X«*w-boni  Lliiklrffl^ 
tnd  ihe  FaHiis  in  Uttro.     The  true  Menning  of  ilieTcnn  Pw^  ^  — Difi- 

gionsof  PiierpemI  Fpv^r — epidemic  nnd  Sp*imiii«?  —  In  it  Cf»iii  i  ztrpsnC 

Viewi*:  Pro*if«lli»t  It  ts  ii  Zymnltc  Di«MfMe;  (JoriUijruifi  HctaMnjilbihtnl  oulj  lliroitgll 
111  AiiUiiii)  Poiaon^ — Prof.  Arnetli's  Acxsjunk  of  Pucrpcrmi  Fv»Trr  in  ViHiii*  lloif^ 
tHl — ^lt4)  ProfKigittion  tiirou^li  lMi!L^ixnioiij».  Thv  Qut'«timi  oT  TnunaiMiiilkSD^ 
tbrcm^li  Dec«»ihpo)Hfd  Ms* Her  l^iiiwa  yf  PocrpiTKl  Fi-vcf,  Sympiom*— ttov 
Divieied^Their  Value — Anatoinloil  Ix-aions — Xot  Unifonn — Sdnictitnn  tho  only 
flppruciuble  Cli»nj;i?  b  in  tite  BIckmI.  l)in(anioiiiB— Witli  wItJit  Alfi'dloiis  Purfprnl 
Fi*viT  inny  pcxMiiibly  U«  Coiilbufidt^  PitijjriuiMit*^iM  the  Kpldemic  Form  |yp»*nurH)lj 
untiivumblc ;  tlie  u.^u»i  Preludes  lo  a  FuUil  TcrminAiion  irtidily  dt'lPcUHl  liy  the 
oboervunt  Phyaicion.  TrMtmciit — Dividt^l  iuiu  rn>phyliiol)o  mm!  BomvduiV— Pn»> 
pbyhietlc— In  wliut  it  ConsUti.  Dr.  Oilhfi^i'd  Ssnitsty  UfMUNirot  m  Dablui  I^iof* 
in  ll(}»p(t;4 — He»ulla.  Kpidemtc  Puerpeml  Fever  nutslwuya  <«iiiflii^  ta  Lrt»{(>iB 
lioRpitulM;  its  ociiaii«'ti>ii»l  iiHY>ivr<?«  in  iHfgtt  Ctlk^  snd  VUlsgeiL  HeiDMtUI  1>««t» 
n^nii^ — fieplutory  Remedied — When  eniptoyett — SlJmutsDls;  irlico  im<lk<tsA 
Opium  TruoUnent ;  tlie  Verntruui  Viride. 

Gentlemen' — T  pro[>oMo  l«i-day  tr»  offer  «*ome  gencml  rcranrks  ewi  i 
diseii.se,  comjectuiJ  inoro  or  Ios8  directly  wil)i  ehild-birth,  llinii 
which  there  ia,  perh*i|js,  no  mahtdy  to  whicti  the  female  is  UAl>tc  iImI 
has  ctilled  forth  more  di.^ci'e|iiint  upiiiioiis,  vr  ettliHled  lu  itft  dl^nuN 
§iun  aUtT  ni»d  more  accomplished  minds.  Writers  in  the  prufe»- 
iiiau  of  the  very  hli^he^t  order  of  itiiellect  Uuve  beeii  en^^agtHl  tti 
the  etudy  of  thi^  question — nnd  in  defiaiiee  of  the  marked  abjtky 
with  which  it  hatt  been  examined,  tlie  reanlt  »til1  is  iliat  we  mra 
wtthont  ti  united  verdict.  I  nHnde  to  what  h  g^neniUy  ki>oini  «9 
ptterpereii fet'er,  Tfiis  aftW^iion  Ija^t  been  de!*cribed  under  a  vaHeljr 
of  namef«»  such  n^—Hhrh  pucf'peniUn^  fi^hrU  ptt4rrpfrixnin^  p^iiih 
nitii^  morlni^f  paerptntrnfn^  tnetritU  puerperaUs^  uieritu  p^dMUm^ 
chilil  Ud  fever^  etc»  When  it  prevails  in  iti*  eptdennjc  form,  it  k 
fully  entitled  lo  be  detioininattd  the  seourtfe  of  the  lying4ii  rmtttu 
Its  mortality  even  tun\\  with  all  the  a<lvanees  of  nitMletit  ^ifilifio 
inv^i;r*ili(m,  is  a[t| tailing.  a'thou<:h  it  has  under^me  a  cont^iamiire 
dinlSliiition  from  former  perioils  of  it?*  lii-tory.  Indeed,  at  oin*  Uiar, 
M  recovery  from  this  fearful  malady  was  the  exception,  while  tht 


i 
I 
I 


THE   PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS.         681 

rule  was  death  !*  It,  therefore,  is  a  subject  well  worthy  of  inves- 
tigation ;  to  the  accoucheur  it  is  one  of  the  deepest  interest. 

I  shall  not  attempt  a  history  of  this  destructive  affection,  nor 
shall  I  venture  to  impose  upon  you  an  array  of  the  conflicting  tes- 
timony which  has  been  presented  touching  its  nature.  I  prefer 
rather,  as  briefly  as  may  be  consistent  with  the  importance  of  the 
subject,  to  discuss  it  under  the  following  heads:  1st,  What  is puer* 
peral  fever  f  2d,  What  its  divisions  f  3d,  Is  it  contagious  f 
4th,  Its  causes,  oth.  Its  symptoms.  6th,  Its  lesions.  7th,  Its 
diagnpsis.     8th,  Its  prognosis.     9th,  Its  treatment. 

What  is  Puerperal  Fever? — ^The  earlier  w liters  regarded  every 
form  of  fever  occurring  at  the  time  of  child-birth  rs  puerperal^  and 
hence  their  views  were  extremely  vague.  No  less  precise  and  satis- 
factory are  some  of  the  modern  teachings  on  this  vexed  question. 
We  are  told  by  one  school  that  puerperal  fever  is  an  essential  or 
specific  disease — by  another,  that  it  is  simply  a  local  inflammation 
of  a  sthenic  or  active  grade — again  it  is  maintained  that  the  phleg- 
masia is  asthenic,  assuming  at  its  very  inception  a  low  typhoid 
type.  In  the  opinion  of  some,  it  is  in  close  alliance  with  hospital 
gangrene,  while  others  hold  that  it  partakes  more  or  less  of  an  ery- 
sipelatous inflammation.  A  prominent  hypothesis,  sustained  with 
no  little  ability  by  Dr.  Robert  Lee,  would  seem  to  refer  the  true 
source  of  the  malady  to  uterine  phlebitis;  and  so  I  might  proceed 
to  enumerate  other  individual  opinions  as  to  tHe  real  nature  of  the 
disorder  under  discussion,  but  such  an  enumeration  would  be  with- 
out profit,  and,  therefore,  I  omit  it.  It  does  really  appear  to  me 
that,  in  the  multiplied  hypotheses  which  have  been  presented  in  the 
attempted  exposition  of  the  essential  nature  of  puerperal  fever, 
there  has  been  a  sad  confounding  of  terms.  For  example,  simple 
peritonitis,  metritis,  etc.,  purely  accidental,  and,  if  you  choose,  spo- 
radic, totally  unconnected  with  epidemic  or  typhoid  influence,  and 
liable  to  occur  from  cold,  or  the  exercise  of  any  other  ordinary 
agency,  have  too  often  been  regarded  as  the  very  types  of  puei*pe- 
ral  fever;  and  their  inception,  together  with  their  progress  and 
phenomena,  looked  upon  as  the  reliable  exponents  of  the  epidemic 
puerj>eral  dise.'ise,  which  is,  as  we  shall  attempt  to  demonstrate,  an 
entirely  diff\)rent  pathological  derangement.  It  is  to  be  remem- 
bered that  both  the  pregnant,  parturient,  and  non-pregnant  female 
may  be  attacked  with  peritonitis  or  metritis,  precisely  as  the  male 
may  be  invaded  by  pure  inflammation  of  the  peritoneum.     Here, 

•  It  is  recorded  by  M.  Malouin,  in  liia  account  of  the  epidemic  at  Paria,  in  1746, 
that  scarcely  one  woman  recovered.  Prof.  Young,  describing  the  disease  as  it 
occtirred  in  the  Royal  Infirmary,  Edinburgh,  1773.  says;  '•  It  bejran  al>out  the  end 
of  February,  when  almost  every  woman,  as  soon  as  slio  was  delivered,  or  pertMpfl 
twenty-fuur  hours  af^er,  was  seized  with  it,  and  all  of  them  died,  though  every 
method  was  used  to  cure  the  disorder." 


then,  there  is  noihtng  spocific — nothing  c.<^cuU:iL  It  in,  if  I  raajri 
term  it,  an  {nflammfitiifn  under  ordinary  circut^stancfs^  ami  U 
be  treated  tm  ordlmtry  antipldogistic  pritwlplt^^  In  ihia  fonn  of 
peritoneal  intlammatinn,  I  repent^  we  ai*e  not  to  seek  for  any  ^pof^ 
tic  or  mysterious  somutbmg,  wlufh  has  produc^id  the  aftertinn.  But 
it  18  a  vastly  different  tiling  when  true  epidemic  pvier|»cral  fercr 
prevails — a  fever  usually  characterized  liy  depression  of  the  ^iial 
forces,  and  exhibiting  many  of  the  pbenotmmii  of  a  typhoid  afl<!0- 
tiou. 

With  the  distinction  jnst  made,  the  question  now  before  tuv  naked 
and  depi-ivod  of  nil  collateral  and  adventitious  ia^ties,  b —  What  i$ 
PuerpercU  I'^ever  .^  Is  it  in  its  origin  a  loc^l  diswase^ — ^a  ph1e;;id»* 
sia — and  are  the  constitutional  disturlmnccs  simply  effVcts?  Or  is 
its  Btarting-point  in  the  constitution,  and  the  local  Je»iloni  merely 
results?  The  whole  matter  is,  it  suoms  to  me,  narrowed  down  to 
these  two  inquiries;  and  let  u»bnefly  examine  them. 

Those  wbij  miuntniii  that  thu  origin  of  the  disorder  i«  Imccable 
to  a  local  phlegmasia  [jave,  with  some  slight  show  of  reason,  basRsI 
their  opinion  on  the  ciromnstanee  th:it,  in  almost  all  the  fatal  cadef 
of  puerperal  fever,  autopsical  examinriti(>D  ha-^  revealed  the  cri- 
denceji  of  inflammation  of  the  peritoneum,  the  uterus,  it^  vei:ift,  or 
some  nf  its  appendages;  and,  therefore,  tltey  associate  the  relntioti 
of  eiinse  and  effect.  No  one  will  atteiii]»t  to  deny,  with  our  pn*- 
sent  kuowknlge  of  pathology,  that  the  lesions  named  are,  more  or 
le^s,  acieomp.'inimcnts  of  the  puerperal  affection ;  a^id  it  wnll  aUo  bo 
ndmitted,  that  the  lesions  are  by  no  means  confined  to  the^e  itiruc* 
tares.  Some  of  the  ablest  pathologists,  aud  aniong  <Jthers  Uokitao- 
sky,  have  demonstrated  that  the  raucous  lining  of  the  aliiiKfitaiy 
canal  and  of  the  respiratory  organs,  the  p*eura,  and  the  articob- 
tions  themselves,  will  not  nnfrequently  afford  evidence  of  change  of 
structure,  under  the  fo»*m  of  evudations,  congestion,  or  pnrulcni 
secretions.  Bui  admitting  the  h'sions  to  exist — ^and  the  fact  can- 
not  bo  controverted — do  tliey  prove  that  tlie  source  of  puerperal 
fyrtv  in  in  the  primary  inflammation  of  some  one  or  more  of  tiuMi 
Btructnres?  I  think  not;  and  the  hyp«abesis  dev^^lops,  in  my 
judgrnenr,  the  freqtient  fdlacy  of  the/>o.y/  hoc  jn'optar  hoc  dr>etruic 

To  my  mind,  t^ne  of  the  most  p«>werfui — indeed,  it  is  irresiijtiblc^- 
arguments  against  the  local  origin  of  pncrperil  fever,  Isi,  that  ocia* 
Bjonally,  in  certain  marked  and  fatal  case**  of  this  dbease,  the  [mtiio- 
legist  has  ht*en  unable  to  recognise  tfic  slightest  afjprociable  trace 
of  intl.iinmalion  m  any  of  the  viscera  dc-^Htgnatcd  as  the  starttog- 
point  of  the  malaily.  This  fact  has  been  well  pointed  out  la  the 
researches  of  Dr.    Ferguson,  Teiwier,*  Tardien,t   Depaal^J  and 

•  TM«iTer.  Do  In  DihUhW  rtmilenle,  p  318.     1838. 

f  Tiirdiru,  .rcnimul  de^  Corm!iMwi;ic#>ii  Meilii*o-riilfurpieftlc«,  IMl,  ^  SSS, 

X  Bt^Jiiul,  IJuHetia  de  rAotdJmio  du  M.nljfrue,  t.  xxWx ,  p.  35^4. 


THE  PRINCIPLES  AND  PRAOTICE   OF  OBSTETRICS.  683 

Others.  This  being  so,  it  is  difficult  to  conceive  with  what  degree 
of* consistency  the  theory  can  be  sustained,  for  certainly  one  affir- 
mative is  worth  a  thousand  negatives.  Other  arguments  might  be 
adduced,  such  as  the  occurrence  of  peritonitis,  metritis,  etc.,  in  the 
parturient  female,  unaccompanied  by  any  of  the  constitutional  dis- 
turbances ordinarily  characteristic  of  puerperal  fever  ;  but  the  accu- 
mulation of  further  proof  I  do  not  deem  necessary,  and  I  have  no 
hesitation  in  avowing  that,  as  far  as  I  can  understand  it,  the  entire 
weight  of  proof  is  adverse  to  the  hypothesis. 

If,  therefore,  puerperal  fever  be  not  traceable  to  a  local  phleg- 
masia, what  is  its  true  source?  A  number  of  able  observers  have 
referred  the  origin  of  the  affection  to  a  peculiar  altered  condition 
of  the  blood — to  a  poison  introduced  into  this  fluid — ^in  a  word, 
they  maintain  that  it  is  a  veritable  toxiemia,  and  in  this  view  I  fully 
concur.  In  my  opinion,  the  whole  chain  of  evidence  on  this  point 
is  in  demonstration  of  the  sentiment  of  Dr.  Ferguson,  that  "  the 
phenomena  of  puerperal  fever  originate  in  a  vitiation  of  the  fluids, 
and  that  the  various  forms  of  puerperal  fever  depend  on  this  one 
cause  of  vitiated  blood,  and  are  readily  deducible  from  it."*  But 
you  may  very  naturally  ask.  What  is  this  poison,  and  how  does  it 
reach  the  blood  ?  The  real  essence  of  the  contaminating  element 
it  may  not  be  so  easy  to  explain;  it  is  one  of  those  mysterious, 
subtile  somethings  which  is  more  or  less  frequently  met  with,  exhi- 
biting varied  pathological  phenomena,  and  oftentimes  resulting, 
with  remarkable  promptitude,  in  the  extinction  of  life.  You  may 
call  it,  after  some  of  the  older  writers,  vl  ferment  or  a  morbific  mat- 
ter^ but  this  in  no  way  facilitates  the  solution  of  the  inquiry — what 
is  this  poison  ? 

Toxiemia,  or  blood-poisoning,  is  a  generic  term,  and  exhibits  seve- 
ral varieties :  in  one  instance  it  results  in  scarlet  fever,  in  another  in 
small-pox,  in  another  in  measles,  in  another  in  puerperal  fever. 
Here,  by  some  of  the  schools,  I  shall  be  charged  with  advocating 
humoral  pathology,  which  has  too  generally  been  regarded  as  a  doc- 
trine long  since  exploded.  I  have  only  to  say  in  reply,  that  I 
always  endeavor  to  advocate  truth,  and  do  not  believe  in  restrict- 
ing our  science  to  any  exclusive  dogmas — "  Je  prenda  le  bien  oiX  je 
le  trouvey 

Indeed,  if  time  permitted,  it  would  be  an  agreeable  task  to  exa- 
mine somewhat  in  detail  whether  the  doctrine  of  humoral  pathology 
is  altogether  a  phantom,  without  a  shade  of  scientiHc  basis,  as  some 
of  the  schools  maintain.  The  examination  might,  perhaps,  result 
in  the  conviction  that  some  of  the  finest  displays  of  modern  science, 
under  the  ministrations  of  organic  chemistry,  have  not  only  ren- 
dered plausible,  but  have  absolutely  demonstrated,  the  truth  of  the 
doctrine  of  "peccant  humors,"  as  taught  by  the  early  fathers. 

•  Ferguson  on  Puerperal  Fever. 


684 


THE  PRINCIPLES  AND   PUACTICK  OF  0BSTETUIC8. 


Hippocrates  himself  inculfaterl  that  fever  wm  but  the  oifsprin^  i 
Rcc'uniulatod  muibid  matter  in  the  b'oo<l,  which,  atu*^"  u  ui*rt 
iiumbt^r  of  days,  through  a  proce*«  of  fennentatuin,  was  thrt»wn  off 
eithur  by  hemorrhage,  ahine  evacualiom*,  the  persjiirutory  surfaec^ 
or  through  the  development  of  sotue  of  the  exanthemata,  ll  does 
seem  to  nie  that  the  doctrine  of  fermentation  finds  a  clever  stiivih 
eate  in  the  distingnishod  cultivator  of  organie  chetnistry  iu  our  day 
— Liebig.  lib  ex|>hination  of  ihu  morbid  phenoniena  coiisttiiiiefit 
on  blood-poisoning  is  strongly  kindred  lo  the  ancient  tlieory. 

It  is  important  to  note  that,  when  blood-poisuning  exists  it* 
effects  are  not  always  identical ;  there  are  marked  grades  of  8cve* 
rity,  and  this  is  abundantly  exempli  lied  in  scarlet  fever.  Iii  mme 
inftlances  this  latter  affection  assumes  an  extremely  mild  form — the 
scarf ( it hia  simplest — in  other  cases  it  proves  the  terror  of  the  hooftc- 
hohl,  seizing  its  victim  in  the  full  bloom  of  health,  and  lernunnting 
life  in  twa  or  three  hours — the  scarlatina  maligna.  Iti  puerperal 
^Q\ii\\  also,  there  will  be  observed  a  modification  in  the  acti<*n  of 
the  puison,  the  disease  being  at  times  cornimratively  lights  arnl 
again  exhibiting  a  fearftd  virulence.* 

If  we  cannot  explain  the  essence  of  the  poison,  yet  observatic 
proves  that  its  influence  on  the  economy  may  be  very  m:iterial]| 
affected  by  certain  conditions,  such  as  the  state  of  the  atmophere," 
the  locality,  etc. 

The  testimony  is  ample  showing  a  connexion  between  puerj»er*l 
fevQV  and  erysipelas.     The  two  diseases  may  prevail  simultaneoualjj 
in  the  same  neighborhootl  ;  ov  if  erystipolns  alone  prevail,  a  thiri" 
parly  may  comnmnicate,  from  a  fmtient  affetied  with  it,  puerperal 
fever  to  a  woman  recently  delivered.f 

On  the  other  band,  well-authenticated  instances  are  recorded  of 
husbands  ami  nurses,  in  attendance  on  women  dead  of  (men 
fever,  1  laving  bi^eu  attacked  with  erysipelas;  and  Dr.  Rigbyt  ■*' 
thai  in  an  e|*idemic  which  prevailed  in  the  GenernI  Lyitig-in  H<»- 
piial,  Lomlon,  the  child  of  every  female  in  whom  the  dise&sc  proved 
fatal  died  of  erysipelas  in  a  few  hours.J 

^  DiHcascs  produced  bf  blood  poiiioning  hnv^  otio  (SfK?cial  chflmctartstic — ibrf 
are  usually  sudden  iu  their  iDvanion,  «nd  after  runninK  ii  fvarful  c(mr»e  for  i»ri 
finite  ]>eriod,  ^»  ftuddenly  dl&ippour.     Tliia  is  wiiliiu  tlio  exfK'rieoeo  (if  aU  > 
pructitioners.     Wo  recognise  tlie  fact  cinstanily  In  yellow  fi?rer|  cholcf*,  u^tiau 
ftvf^r,  metisles,  sciirlet  fever,  puerperal  fever.  Ac,  nil  of  wltich  »fu  duu  to  Uws  oippfi* 
tJon  of  a  morbid  poison.     In  a  pathototfical  sense,  ihe  Beat  of  lesiou  in  tljt»  v  . 
afleeiions  reaultinj^  frvjm  a  tojcicmic  tnflueneo  ia  not  wttliout  iolerwt      In  Mc:i 
and  moiiales,  for  insUfnoe,  the  development  b  on  the  cutAtusoiui  wurfiie** :  in  Irj^iKml 
fever  llie  glandfi  of  the  sniaU  intestines  are  more  or  le^ig  involved,  whilo  iti  elmlunb  It 
is  tlie  general  gaeiro-intestinul  mucous  aurfMCO.     In  puerperal  fever  Lbo  aeroua  fiir* 
facef^  Mud  more  e*tpeciiilly  the  peritoneum,  «ro  usuitily  uflcctcd 

f  In  fioristitutioual  erysipeliia,  whether  affectin^r  Ih©  tniik*  or  Iho  noti*fNne^ttaJl( 
femiile  n  not  unusual  le>*inn  will  be  inHummHtiou  of  tli«  periionetkio, 

%  Rt^by*8  Mid,  p,  392. 


THE  PBINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         685 

Although,  as  a  general  rule,  puerperal  fever  attacks  the  parturient 
female,*  yet  it  should  be  recollected  that  it  is  not  exclusively 
confined  to  this  class  of  paticuts.  Young  women,  married  and  non- 
pregnant women,  the  new-born  child,f  and  the  foetus  in  utero,  even 
when  the  mother  has  no  symptoms  of  the  disease,  are  all  liable  to 
the  affection ;  instances  are  recorded  of  its  existence  under  these 
circumstances ;  and  what  may  surprise  you  still  more,  it  has  been 
shown  that,  in  some  cases,  the  male,  if  subjected  to  the  peculiar 
poison  known  to  generate  the  disease,  will  become  sick,  and  exhibit 
lesions  more  or  less  in  accordance  with  those  found  in  women 
affected  with  puerperal  fever.  While  it  is  proper  to  mention  these 
exceptional  cases,  the  important  fact  is,  that  in  the  great  m.ijority 
of  instances,  the  disease  attacks  the  parturient  female — and  I  am 
inchned  to  adopt  the  explanation  of  the  circumstance  given  by 
Trousseau,  in  the  recent  discussion  of  this  question  in  the  French 
Academy  of  Medicine — he  says  the  lying-in  female  exhibits  a  pecu- 
liar morbid  opportunity^  and  presents  a  remarkable  pathological 
aptitude  for  the  malady. 

Both  in  sporadic  and  epidemic  puerperal  fever,  the  special  poison 
generating  the  disease  may  originate  in  the  person  of  the  partui-ient 
woman,  and  be  conveyed  into  her  blood  through  the  absorption  of 
putrid  coagula,  portions  of  placenta,  ifcc. ;  but  there  are  other 
modes  by  which  the  poison  may  be  communicated,  to  which  we 
shall  refer  under  the  head  of  contagion. 

What  are  the  Divisions  of  Puerperal  Fever  f — It  has  already 
been  remarked  that  there  are  two  distinct  varieties  of  this  disease — 
one  known  as  the  sporadic^  the  other  assuming  the  epidemic  form. 
The  characteristic  of  the  former  is  that  it  is  an  isolated  affection,  and 
does  not  extend ;  while  the  epidemic  variety  is  not  limited  to  one 
or  two  cases,  but  involves  districts  and  neighborhoods,  oftentimes 
proving  frightfully  destructive.  Some  authors  have  made  other 
distinctions,  which  do  not  appear  to  have  much  practical  impor- 
tance— such  as  tn/femma^ory  puerperal  fe\Qry  bilious  or  mucous 
puerperal  fever ;  typhoid  puerperal  fever,  etc. 

*  Tlie  followinp^  is  the  language  of  Tamier,  and  I  quite  agree  with  him  in 
opinion  :  *'  In  ordinary  medical  phraseology,  tlie  term  piierperal  ataU  is  understood 
to  mean  the  particular  condition  presented  by  the  recently  delivered  woman.  This 
definition  is  entirely  too  limited.  I  adopt  the  division  recently  proposed  by  M. 
Monuerot,  viz.  The  first  period  of  the  puerperal  state  commences  with  conception ; 
the  second  comprehends  the  puerperal  state  of  all  authors,  that  of  the  newly  deli- 
vered female ;  tlie  third  period  includes  the  entire  term  of  lactation.  To  these  three 
divisions  I  shall  add  a  fourth — that  of  menstruation.  In  menstruation,  in  gestation, 
and  in  parturition.  1  can  see  but  a  series  of  inseparable  facts,  which  tend  to  the  same 
object — the  reproduction  of  the  species.*'  [Do  la  Fievre  PuerpiJrale,  observe  a  TIIos- 
pico  tic  la  Mateniile  par  Stephane  Tarnlcr.     Paris.  1858] 

f  Puerperal  fever  in  the  recently  deUverod  female,  the  foetus,  and  the  new-boru 
child.    By  M.  Lorain.    Paris,  1856. 


686         THB  PRIKCIPLKS  AND  PRACTICE  OF  OBSTETRICS. 

Is  Puerperal  Fever  Contagious  f — ^Tbc  views  on  this  point  are 
far  from  being  concurrent ;  and  one  of  the  most  emphatic  advocates 
of  the  non-contagious  character  of  the  affection  is  our  distinguished 
countryman,  Prof.  Meigs  of  Philadelphia ;  he  is  also  sustained  by 
Prof  Hodge,  the  able  Prof  of  Midwifery  in  the  University  of  Pa. 
It  is  somewhat  singular  that  those  two  gentlemen,  ripe  observers, 
and  engaged  as  they  have  been  in  extensive  practiw,  should  so 
positively  maintain  an  opinion  in  opposition,  it  seems,  to  me,  to 
evidence  which,  if  thoroughly  examined,  is  irresistible.*  I  do  not 
deem  it  necessary  to  cite  ])articular  examples  in  which  puerperal 
fever  has  been  conveyed  through  the  principle  of  contagion — they 
are  so  numerous,  and  so  free  from  all  doubt — in  a  word,  they  are 
so  conclusive  that  I  cannot  conceive  how  they  can  be  regarded 
otherwise  than  completely  demonstrative  of  the  jwint  at  issue.  I 
have  already  remarked  that  ])uerperal  fever  may,  under  certain 
circumstances,  originate  with  the  patient  lierself.  She  may,  so  to 
speak,  inoculate  herself  with  the  noxious  element  through  absoq»- 
tion  of  putrid  coagiila,  or  portions  of  the  i»lacenta  remaining  in  the 
uterus ;  or  she  may  derive  the  affection  from  the  passage  of  some 
of  tlie  products  of  inflammation  into  her  blood  ;  or  the  translation 
of  the  disease  may  be  by  contagion  through  the  intervention  of  n 
third  paity  ;  and  again,  the  inoculation  may  be  traceable  to  the 
hand  of  the  accoucheur  carrying  the  poison  into  the  system  during 
his  vaginal  explorations.  The  question  of  the  possibility  of  trans- 
mission of  f»iu'r|)oral  fever  by  the  physician  h.is  rt-iiMvod  fresh 
supjiort  within  a  lew  years  from  some  German  investigalors.f 

*  Pr.  Huliiu'.J,  of  IJoslon,  has  (liscii.«scd  this  quc.^ition  of  cvnitagion  iik>l  i.labi> 
rat(.'l\-,  ami  I  refer  the  ri*a<Ier  to  his  admirable  pnp»'r. 

f  In  ail  inti-reslinjc  pa|M*r  hy  Dr.  Arneth,  of  Vienna,  we  havi'  the  following  yilat'.^- 
meat:  I)r.  S(Muinehv<M>s,  assi.«iiam  to  ilie  IVof.  of  Mi<lvvifery,  wa-*  ^*Inlck  witli  ihe 
dillerciwe  as  to  llio  prevalence  of  ]»iierp<Tal  fi-ver  in  llie  two  elinies  (f  tlie  hv-j-iial; 
in  one  (»f  the.^e  clinie.-*.  the  pui)iN  arc  midwivi's;  In  the  other,  metlieal  ."tuvlenl?.  Tue 
bltiT  were,  almost  witiiout  excM'^ilion,  in  the  cv)n>tant  hahit  of  a«i-finj;  at  aiuojirjcs. 
of  whieh  thrre  were  ei^'lit  or  ten  nearly  evt-rv  (hiy.  Tlie  dissections  wen-  rM»n,.'ti:ia.«. 
made  hy  Die  studv-nls;  or  at  least  liii-y  hamlled  the  pathv»U»>;ie.il  pr»'p:ir;ilini,s  aijJ 
carefully  examined  them.  Moreover,  tin*  as.sistant  vva.*  aecu^lom.  d  to  lo'tr.p'  on  the 
ol)steirie  ojit-rations  wiiieh  wtre  p'Tfornu'd  on  dead  l^Mii^•s.  Afl«r  sueh  invi  ?»:^m- 
tions  on  the  ca«hiver  and  snch  practie**.  it  vvjis  not  rare  f>r  the  student.'*  to  prr^'-t-d 
immediately  to  the  wanl.^  i»f  the  lyiniLr  in  liospital.  and  examine  the  pn -^.-naiil  and 
parturient  women.  Tiie  pupils  of  the  other  ehnie.  boin;;  niidwives,  did  not  i.ike  any 
share  in  liie  oeeupation.s  ju«;t  alluded  to  ;  and  even  the  assiMant  of  ll.-it  elii.io  i..id 
comparatively  but  seldom  to  d«>  wiih  pt»st-mf)rtcm  examinatit'iis  as  it  wjo  n'-t  a  p  .rt 
of  his  duty  to  jnstruot  nnd\viv«.'S  in  patholo^ry  or  in  operative  nndwift  ry,  H.jv;::^ 
convinced  himself  that  the  jrreat  prevalence  of  the  di.'»ease  in  \\\a  ward««  wa^*  i-:r,>i-d 
by  tin.'  inoculation  of  the  ft'inale  j;enital.s.  Hr.  Semmehveis.s  entertaineii  iIk-  ;.-{-e 
of  beiuiT  able  to  diminish  the  fri^ditful  mortality.  He  finally  detiuced  fr-rii  hi* 
re.<earciies  tJiese  conclusion'* — Any  tluid  matter  in  a  state  of  putre!a<*tion.  o<:n- 
irnuiicatod  by  linen,  by  a  catheter,  by  a  pponjjre,  by  small  purticle3  of  the  placonia, 
or  even  by  the  ambient  atniosphere  impregnated  with  the  foul  substanci^,  uiay  pro- 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  687 

It  is  now,  I  believe,  very  generally  admitted  that  the  laws  of 
contaixion  can  only  operate  when  the  disease  thus  communicated  is 
the  product  of  an  animal  poison  ;  and  it  is  also,  in  my  judgment, 
clearly  established,  that  puerperal  fever  is  rightfully  classed  among 
the  zymotic  diseases,  or  those  whose  existence  depends  on  the 
presence  of  a  noxious  animal  material.  Since  the  publication  of 
Dr.  Arneth's  paper,  German  physicians  have  made  experiments  on 
animals,  which  have  given  the  following  results:  1st.  Any  kind  of 
putrefied  animal  matter  introduced  into  the  vagina  of  a  parturient 
female  may  engender  a  malady  bearing  a  strong  resemblance  to 
puerf)eral  fever,  and  frequently  followed  by  death  ;  2d.  A  very 
small  quantity  of  the  fluid  in  the  vagina  of  a  woman  or  of  an  animal, 
attacked  with  puerperal  fever,  being  introduced  into  the  vagina  of 
a  parturient  animal  causes  puerperal  fever,  or  at  least  a  disease  very 
much  like  it. 

With  the  above  results,  it  might  very  consistently  be  asked,  why 
every  woman  after  parturition,  is  not  affected  with  puerperal  fever ; 
it  would,  at  first  view,  seem  that  this  should  be  so,  for  there  is  in 
more  or  less  quantity,  putrefied  animal  matter  in  the  uterus  or 
ragina  of  every  recently  delivered  female.  Let  us,  for  a  moment, 
pause,  and  examine  this  point.     In  the  first  place,  it  seems  quite 

duce  puerperal  fever.  Mere  washing  of  the  hands  with  soap  and  water  is  not  suffi- 
cient and  Dr.  S.  has  found  it  necessary  to  make  use  of  a  solution  of  chloride  of  lime. 
In  the  course  of  the  month  of  May,  1847.  it  was  arranged  that  no  one  should 
examine  any  woman  in  the  clinic  without  previously  having  washed  his  hands  with 
the  solution,  and  made  use  of  a  nail-bru.sh.  Kven  in  June,  it  was  impos.sibIe  not  to 
remark  the  influence  of  this  precaution.  Out  of  more  tlian  three  hundred  women 
confined  in  that  montli,  only  six  died;  in  July,  tliree  out  of  about  tiie  same  num- 
ber; in  August,  three  ;  in  September,  twelve ;  October,  eleven ;  November,  eleven ; 
December,  eiglit;  where.'is  in  April,  fifty-seven,  and  in  May  thirty-six  cases  had 
ended  fatally.  In  the  year  1848,  tlie  mortality  among  the  puerperal  women  deli- 
vered by  male  pupils  was  one  in  eighty-four;  while  hi  the  second  clinic,  among  the 
women  delivered  by  midwives,  it  was  one  in  seventy-six.  Since  the  year  1827,  the 
rate  of  mortality  in  the  hospital  had  never  been  so  diminished.  Analogous  results 
have  been  obtained  by  the  same  means  at  Kiel. 

According  to  the  reports  of  the  lying-in  houses  in  the  whole  Empire  of  Austria,  in 
none  of  those  institutions  in  which  midwives  have  been  the  only  pupils  has  puer- 
peral fever  made  its  appearance  as  an  epidemic;  but  it  prevailed  obstinately  in 
Pavia,  where  they  were  in  the  habit  of  dissectir>g  (in  one  of  the  rooms  of  the  lying- 
in  hospital)  bodies  of  the  children  who  died  in  the  hospital 

While  in  search  of  the  true  cause  of  the  prevalence  of  puerperal  fever,  and  before 
the  necessity  of  washing  the  hands  with  cliloride  of  lime  was  appreciated,  a  pregnant 
woman  was  admitted  mto  the  hospital  affected  with  cancer  of  the  uterus.  As 
sevend  days  elapsed  before  her  confinement,  and  as  the  case  was  highly  interesting, 
all  were  anxious  to  examine  her.  The  consequence  was  most  deplorable.  Fourteen 
mothers  who  had  been  confined  at  the  same  time  with  this  woman,  and  who  had 
been  examined  by  the  same  students,  exhibited  symptoms  of  puerperal  fever,  and 
three  of  them  died,  although  the  disease  had  not  been  prevailing  immediately  before, 
nor  did  any  other  case  occur  except  these  fourteen.  [Braithwaite's  RetroBpect^ 
part  23d,  p.  492.] 


688 


THE   FRINCIPIiES  AKD  PKACTICE   OP  OBSTETRICS* 


irtm^* 


certnin  tbnt  the  mere  coritart  of  putreiicfl  mat*^n.i1  with  th©  walli 
of  the  cavitii'S  ot  the  femn^c  gcnltala  b  not  suflicierit  Tor  the  .ihsorp* 
tion  of  the  dek^erious  principles;  and  secondly,  there  mnst  be  some 
oiyemii£C9  in  the  blood-vcsseln,  through  which  the  mutter  will  p:i3«i 
into  the  blood,  and  tht^nee  be  conveyed  to  the  general  circulatioii. 
Therefore,  even  if  cxi»oseil  to  her  own  decomposed  mutter,  or  mat- 
ter from  dead  bodies,  tlic  consequent  development  of  puerperal 
fever  will  depend  upon  the  condition  thnt  there  are  openings  of  fioae 
of  the  liloud-vossels  through  which  resq^'ption  may  be  aecomplbh 

An  interesting:  question  now  arises — H  a  womnn,  with  the 
ditions  named,  more  HiUle  to  contract  puerperal  fever  from  the  | 
Bage  into  the  blood  of  her  ouii  decayed  matter,  or  of  mntter  tr 
ferred  to  her  from  anotljer  female,  or  from  any  dead  body  ?    The 
solution  of  the  ioqniry  wdl  not  be  difficult  with  the  two  foHowitig 
propositions,  which  1  believe  have  the  sanction  of  t^cicnce:  Int, ' 
matter  found  in  dead  boilies  is  more  putrefied,  and,  therefore,  mor« 
poisonuus,  than  that  contained  in  tlje  iiterun  and  vagina ;  2d*  It  i« 
well  known  that  we  become  aecubtomed  lu  poisons  generated  or 
having  Jong  existed  in  our  own  system,  or  produced  from  deeotiHJ 
posed  snbstances  coming  from  otir  own  body.     In  proof,  we  maf  i 
invoke  what  has  been  eHtab!i?*bed  in  regard  to  syphilixation ;  ire 
may  also  refer  to  vaccine,  and  to  an  inleresting  lact  eounceled  ulUj ' 
the  liin-in  of  the  blood.     As  to  syphilization — 1(  an  Indlvjdual  had^ 
for  «ouie  time  a  venereal   ulcer,  ho  that  the  system   has  become 
impregnated,  the  pus  of  thi«  ulcer  catmol,  under  uioeulaluui,  pro* 
dtice  a  similar  one  in  that  individnal,  but  let  the  pu^  bejnfused  into 
the  system  of  another,  and  the  result  will  be  the  appearance  of  t  J 
ay|dulitic  ulcer.     In  vaccination,  when  the  body  ha«  become  charged 
with  the  virus  of  vaccine,  tlji-*  virus  will  fail  to  produce  its  piimitm 
etiecti*  under  a  .second  inoculation.     In  regard  to  the  fibrin  of  iht 
blood — it  in  [)roved  that  the  blood  of  an  animal  of  one  species  wiD 
generally  act  as  a  poison  on  an  auimrd  of  another  species;  and  thif  i 
is  on  account  of  the  tibrin  of  the  blood,  according  to  Dieffcnbach, 
BiscbofT,  and  Dn  Brown-Sequard,  wlio  have  shown  that  no  poisott* 
ous  element  exists  in  defibrinated  bhiod.     It  would  seem,  ther 
to  follow  that  the  poisonou,s  power  of  fibrin,  or  of  a  sub^taae 
eliminated  witfi  it  during  dcfibrinization,  varies  in  diflerent  animsilsi 
and  that  each  species  is  accustomed  to  the  poi:*on  contained  in  itf 
own  blood,  but  is  intolerant  of  the  action  of  the  poison  in  the  blood 
of  another  species. 

It  may  here  be  remarked  that  it  is  the  duty  of  the  medical  : 
when  in  attendance  on  women  attacked  with  puerperal  fever»  do 
matter  what  Ins  vit'Ws  may  be  as  to  the  contagiousness  of  the 
disease,  to  use  every  precaution  against  the  po^isibility  of  translating  j 
the  affection  through  his  own  person.     In  this  precautiuu  DOtbln^J 
will  be  lost,  and  mucli  may  be  gained. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         689 

Causes. — ^It  is  not  easy  to  assign  any  special  class  of  influences  or 
causes  capable  of  producing  puerperal  fever,  for  in  this  affection,  as 
in  epidemic  diseases  generally,  there  has  always  existed  an  intan- 
gible something,  which  has  not  failed  to  embarrass  scientific  investi- 
gation. There  are,  however,  certain  influences  which  are  generally 
admitted  to  predispose  to  the  disease — and  among  them  may  be 
mentioned  the  following :  mental  emotions  of  a  depressing  nature, 
difficult  and  protracted  labors,  yet  I  have  known  puerperal  fever  to 
follow  very  rapid  deliveries ;  women  with  their  first  children  are 
more  liable  to  the  aff'ection  than  those  who  have  borne  one  or  more ; 
cold  and  humid  seasons  seem  to  favor  the  development  of  the  dis- 
ease, although,  in  some  instances,  very  destructive  epidemics  have 
prevailed  in  the  warm  months  ;*  inadequate  nourishment,  a  neglect 
of  the  laws  of  hvgiene,  an  impure  atmosphere,  etc.,  are  so  many 
causes,  which  may  be  enumerated  as  predisposing  to  the  malady. 
In  one  word,  all  influences  which,  from  their  depressing  tendency^ 
are  calculated  to  lower  the  forces  of  the  economy  may  be  regarded 
as  predisposing  more  or  less  to  the  disease. 

Symptoms, — In  order  that  there  may  be  no  confusion  in  reference 
to  the  usual  symptoms  of  this  affection,  and  as  there  is  some  diflfer- 
ence  in  those  of  the  two  varieties — the  sporadic  and  epidemic — I 
shall  fii-st  direct  attention  to  the  symptoms  indicative  of  the  sporadic 
form  of  the  disease.  Here,  I  would  wish  to  impress  on  you  the 
recollection  of  the  important  fact  that,  as  a  general  rule,  before 
there  is  the  slightest  shade  of  suspicion  that  puerperal  fever  is  at 
band,  the  very  first  abnormal  condition  of  the  patient  will  be  an 
accelerated  i)ulse ;  be  vigilant,  therefore,  when  the  pulse  becomes 
quickened  after  delivery ;  for  although  it  may  not  be  followed  by 
peritonitis,  yet  it  portends  no  good.  The  disease  ordinarily  com- 
mences its  development  from  thirty  to  forty-eight  hours  after  partu- 
rition ;  next  to  the  quickened  pulse,  one  of  the  earliest  phenomena — 
it  is  a  very  rare  exception  for  it  not  to  precede  the  other  symptoms 
— will  be  a  rigor,  of  more  or  less  force,  and  it  may  be  partial  or 
general.  Succeeding  the  rigor,  will  be  exquisite  tenderness  over 
the  abdominal  surface,  involving  a  section,  or  a  large  portion  of  that 
region  ;  following  the  chill,  there  will  be  a  heated  and  dry  skin,  and 
an  increase  in  the  rapidity  of  the  pulse,  ranging  from  120  to  ]G0, 
and  upward.  There  is  nothing  uniform  in  the  appearance  of  the 
tongue ;  sometimes  dry  and  extremely  red  ;  again,  it  is  coated  and 

♦  The  researches  of  M.  Laserre  give  the  annexed  results:  In  27  epidemics  in  the 
Mateniit^  of  Paris,  from  1830  to  1841,  16  occurred  during  llie  montlis  of  Jan.,  Feb., 
March.  Oct.,  Nov.,  and  Dec.  Of  the  whole  number  of  labors  in  the  same  mstitutiou 
within  the  same  period,  from  1830  to  1841,  he  presents  tl\e  following  tables:  In 
18,106  accoucheraenls  during  the  six  cold  months,  there  were  868  deaths,  or  1  in  20 ; 
while  in  15,986  accouchements  during  the  six  warm  months  there  were  465  deaths, 
or  1  in  34.     [Reclierches  Cliuiques  stir  la  fi^Tre  puerperale.] 

44 


690 


THE   PRINCIPLES  AND   PBACTICE  OF  OBSTETRIOI^ 


»Iirny  ;  distressinj?  thirgt  is  onr»  of  the  ordinary  ficd^mpanimeiilti 
IbiH  'Hscii^e ;  the  resjiirution  Is  ntpicl  ntiil  .short.  N.'iii5<%i  uM»d  vomi^ 
log  not  unfrequently  ensue ;  the  lochifil  dischargt*  luiiially  btt<«ttti«4 
»ii])|irtfS8ei1,  as  a].so  the  milk  sctTetioti ;  hut  tlic*«e  in  ttonic  cw^m  will 
gt>  on  without  iiUerruption.  Although  the  »kin  b»geiienilly  dry  and 
hot  ;tt  iir^t^  as  tlie  dts^^ase  .advance.^  it  becomes  moiist'nnd  damnjr* 
There  is  a  nutuble  ch^irtge  in  iho  countctiancc — it  U  i'Xpremivc  of 
great  anguish^  and  sunken^  with  a  circum^cribod  Uviility  around  iImi 
eyt»s.  The  bowels  are  contiiied  at  first,  hut  af\erward?*di:irrh<i!«  not 
unfrequently  mis  in;  the  urinary  secretion  18  high-fui«Jtirt?d  tmi 
defective  in  quanlity.  There  is,  in  the  progreai  of  the  aficetioii«  a 
mai'ked  dij^tenMon  of  the  abdoineu — and  thb*  may  ari*e  from  m 
flatulent  condition  of  the  inlc'stinet*,  or  from  a  sero-purulent  eflkiiaii 
M'hieh  if*  one  of  the  ordinary  attendants  on  the  disease,  more  t!fp»* 
cially  when  it  proves  fataL  Commonly,  when  the  effusioii  tak«s 
place  there  h  a  ee&i^tion  of  pain,  wtuch  ofleniimeai  ddutleai  the 
friemlH  into  fidse  hope ;  for,  nuijer  the  circnnifitHnceB,  tbe  alHcuoe 
of  pain  is  but  one  of  the  preludes  to  death — the  other  fatal  ^jmp 
toms  consisting  in  the  extreme  rapidity  of  the  pulse,  which  beoonoiei 
weaker  and  buttering,  with  cold  extremities ;  the  patient  [■ptagi 
into  uneonsclousnesd ;  there  is  a  low  unintelligible  muttentig,  tog^ 
t))cr  with  Bubsultua  teudinum  ;  the  tongue  h  parched  and  cxliiliitafl 
brownish  color,  with  votuitiiig  of  a  dark  ofleusive  nature.  Tbowr 
arc  the  closing  phenomena,  and  arc  soon  followed  bj  death. 

There  i^  one  striking  peculiarity  as  to  the  position  of  tbe  paUoif 
in  this  affection,  and  I  regard  it  ns  quite  characteristic— tbt*  patirat 
remains  on  her  back,  with  her  knees  drawn  np,  and  -  hm 

poinition  for  the  reason  that  she  seekn,  as  it  were  jj  ,  ut 

relievo  iho  abdomen  from  pressure,  the  slightest  adding  ffreatl/  to 
her  distress.     This  attitude  not  only  i-elaxe*  the  a'   '  t  wM§t 

but  in  a  measure  protects  the  patient  from  the  wot  le  h^ 

<Jothe8*     On  the  other  hand,  a  ^jjonlaneous  change  of  posotacMi  on 
the  aide,  for  instance,  should  be  hailed  as  a  moat  favorable  tadi- 
« cation. 

In  the  epidemic  form  of  the  disorder  the  ftynif  ^owbaft 

inodiHcd  ;  a^  a  general  rule  tliere  is  increased  r^^  p<tlae| 

and  fmra  the  violence  of  the  poison,  a  def)re»sk?d  oonditian  of  llio 
forees  in  noticeable  at  the  %*ery  invasion  of  the  malady  ;  tb^?  disico* 
dion  of  the  abdomen  h  mucli  earlier  develo{H.*d,  and  tlie  dUteait  m 
more  rapidly  fatal,  sometimes  destroying  the  |>atlent  in  twenty- fotir 
ur  thirty  hour*.  In  §ome  instances,  it  is  worthy  of  remark  that 
thcpre  18  an  absence  of  pain  on  pressure,  although  tbe  subucxiiMml 
autopsy  may  disclose  the  existence  of  peritonitis. 

lesions, — There  U  nothing  uniform  in  the  anatomieal  hsiom 
acooutpanying  this  aDection,  although  it  may  be  stated  that  rvi* 
dence  of  peritoneal  inflammation  ix  the  most  coiuitacitly  mel  witlii 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         691 

and  it  is  no  doubt  for  this  reason  that  the  disease  has  received  the 
designation  of  pu^erperal  peritonitis.  When  this  lesion  is  observed 
it  will  be  found  almost  always  that  the  peritonitis  is  general,  and 
not  limited  to  one  portion  of  the  membrane ;  the  sac  will  usually 
contain  more  or  less  sero-purulent  effusion ;  and  in  this  particular 
there  is  a  marked  difference  between  simple  and  puerperal  peri- 
tonitis— ^in  the  former  there  are  adhesions  through  pseudo-mem- 
branous formations,  because  in  simple  peritoneal  inflammation, 
instead  of  a  sero-purulent  affection  there  is  the  presence  of  plastic 
lymph,  the  tendency  of  which  is  to  produce  these  adhesions.  In 
the  uterus  and  its  appendages  there  will  also  be  exhibited  various 
changes ;  uterine  phlebitis  is*  among  the  most  uniform  attendants 
upon  the  disease  ;  the  abdominal  viscera  undergo  morbid  changes, 
exhibiting  more  or  less  abundantly  purulent  collections,  and  these 
collections  will  sometimes  involve  the  various  articulations.  There 
is  one  peculiar  feature  usually  charactenzing  the  pathology  of  puer- 
peral fever — it  is  a  softening  of  the  tissues,  and  this  will  oftentimes 
be  observed  in  the  structures  of  the  uterus,  ovaries,  peritoneal 
covering,  liver,  spleen,  and  other  organs. 

In  some  instances  there  is  no  cognizable  alteration  of  the  peri- 
toneum, and  strange  to  say  M.  Charrier*  records  the  history  of  an 
epidemic  puerperal  fever  in  which  lesions  of  the  pleura  were  sub- 
stituted for  those  of  the  peritoneal  sac. 

It  is  worthy  of  note  that  sometimes  in  its  severest  forms,  and 
when  most  rapidly  fatal,  the  only  apparent  changes  are  those  exhi- 
bited by  the  blood  ;  but  in  what  these  changes  actually  consist  it 
is  not  so  easy  to  determine.  It  is  darker,  and  loses  much  of  its 
coagulable  properties.  According  to  Prof.  yogel,f  it  contains  lactic 
acid,  sometimes  carbonate  of  ammonia,  and  again  hydro-sulphate  of 
ammonia,  its  globules  do  not  redden  on  exposure  to  the  atmosphere, 
and,  therefore,  the  act  of  respiration  is  defective  ;  the  globules  are 
in  part  decomposed,  and  dissolved  in  the  serum. 

Diagnosis. — Where  puerperal  fever  prevails  as  an  epidemic, 
there  can  be  no  embarrassment  in  the  diagnosis ;  the  lines  of  the 
affection  are  so  well  defined  that  the  observant  physician  will  rea- 
dily appreciate  its  existence.  Not  so,  however,  in  the  sporadic 
form  of  the  disorder ;  for  here  it  may  be  mistaken  for  metritis,  but 
this  is  of  no  material  consequence,  as  the  therapeutic  management 
in  cither  case  would  be  the  same.  It  may,  however,  be  stated  that 
in  metritis  the  pain  on  pressure  is  more  circumscribed,  and  the 
volume  of  the  uterus  itself  much  increased,  the  patient  bearing  pres- 
sure well  until  some  portion  of  the  organ  is  touched;  whereas  in 
peritonitis,  the  affected  surface  being  more  diffused,  pressure  on 
almost  any  point  of  the  abdominal  region  would  be  followed  by 

*  De  la  fidvre  puerp^rale,  epid^tnie  en  1864.  f  Yirchow. 


mi 


THE   PRINCIPLES  AKD   PRACTICE  OF 


more  or  le^n  suffering.  You  are  not  to  undenttand  that  fmn  In 
perkointi^  is  dimply  tl»e  oftspring  ot*  pre^^iiris  by  the  Imud;  oo  ibe 
contnir}%  the  piititfiit  withuiit  either  chfingd  of  poaitioti  or  prfsMtiart 
will  experience  much  nt^nny,  which  at  intervfils  will  l»e  iijcretteil  by 
the  p:u!t.s»go  uf  t!atu»  i'nytn  one  (lortion  toiinother  of  th«  intfOtiMu 
There  is  some  tact  required  in  the  manual  exploration — loo  ititiok 
force  sithould  not  he  usefl,  far  this,  without  any  romjHrQsiUJti^  good, 
only  a^gravarcH  the  Ciinilition  of  the  paliont.  I^'t  the  m«dli«aAl  am 
keep  f}is  eyes,  as  he  mutiously  pre.«rii*f^  the  abdomen,  on  tlte  comH 
tuuance  of  the  invalid,  and  Ur  will  Minckly  ♦Irncover  uhetlu^r  or 
he  inflicts  suifi>ring, 

"Wheu  !*peakiiig  oftheatifiJuniH  rtet'iiiMi  i»y  uw  i>  . 
^*onian,  the  ijt^noral  phenomena  of  fi/><^r-/>n*/i/i  were 
PO  that  by  reference  l4>  what  wuh  then  said  it  would  he  an  act  of  ODfiar* 
donahle  earelesi^iicsj*  to  nn»tnke  them  for  perittmiti.^.     It  i<i  bsnrfy 
possible  that  Home  eonfusiou  might  exi^t  in  diseri mutating  betiire«o 
puerperal  inflam niat ion  an<lfym/>fi«  »V#"j  *W€.f ////*///>,  u  Vo- 

^uenlly  foUowi^  chi!d-hirlh,  and  which  ha*  already  t  rd 

as  one  of  the  ordinary  aceomjianimcnts  of  puerpciuj  tcver.  In 
simple  fynifmnitfjt^  however,  the  j»ul!*e  will  be  but  ulightly  Accele- 
rated;  no  sunken,  dejected  condition  uf  tlie  eountenant*!! ;  ma^ 
ffcrtfte  prcitifurr  wlfh  frii'fions  will  dimlniith  tlie  |iain.  T\*mji«iutirft, 
alf*o,  may  be  distinguished  frotn  elTusion  by  peieust^ioD  ;  iIk»  ftfrmer, 
tympanites,  rcvearmg  a  resonant  soimd,  while  the  lAHcr,  cAmqcm, 
would  diseloHe  the  evidences  of  fluctuation. 

I*rof/ttosis, — It  need  scarct^ly  be  retnarkcHl,  afkttr  what  bas  bevil 
said  louchini:  the  nature  of  tfie  di^ea^e,  that  epidemie  puerperal 
fever  is  one  t)f  tlie  mo!»t  fatal  dimirder^  Qi'  the  lying-iu  room  i  our 
prognosis,  therefi)ri%  shouhl  always  h<i  j^uarded,  and  no  false  hupci 
eneoiiracfed.     Even  in  it;*  sporadic  tyfM',  th*  althuagh  oiiacb 

less  futal,  is  full  of  danger.     During  the  pK  ibe  mjihidy*  tbv 

experienced  observer  will  be  enabled  to  ibreK^o  with  proph«tie 
truth  its  fatal  termination  by  the  presence  of  cc^rimn  *  -  *- -yit 
indications,     I  have,  a^  has  already  been  remarked,  an  a!  iik 

in  the  pulne;  if  it  !<hou)d  not  exceed  120  beats  in  the  mifiul«f,  Ulb 
nuiy  be  regarded  as  n)OAt  iavorable;  but  how  different  il*  il  r^aeli, 
and  eontinue  at  that  rate,  from  140  to  160!  A  ceasatian  af  psai, 
without  any  diminution  in  the  throes  of  the  T       ^  U*il 

with  an  anxious  and  drawn  countenance — fttei*  jq^ 

op|»re>iSed  respiration,  showing  imperfect  deeari»oniuiltuci  ut'  lb« 
blood ;  involuntary  inte^itinal  discharges,  the  cadaveric  udor,  Ac, 
may  justly  be  regarded  as  the  pretmi-sors  of  dksolutiotiw 

Tftiifni^Ht, — ^Tho  treatment  of  puerperal  fever  majr  very  ftppro- 
pri^itely  be  divided  mlo prophijltu^tic.  and  nmfttifiL 

Propliyfarfic  Treatment, — In  a  dbejise  so  fearfully  df*«trtii.*ttv«, 
it  can  require  no  argument  to  show  the  vital  importaooe  of  pf^^ 


THE  PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS.  693 

ventive  measures,  if  these  can  be  ])roved  to  arrest  the  develop- 
ment of  the  malady.  Without  referring  to  other  proofs,  I  shall 
content  myself  with  alluding  to  the  remarkable  results  obtained  in 
the  Dublin  Lying-in  Hospital,  under  the  mastership  of  Dr.  Collins. 
For  the  four  years  previous  to  the  adoption  of  his  sanitary  mea- 
sures, the  entire  relative  number  of  deaths  in  the  hospital  during 
the  prevalence  of  puerperal  fever,  was  1  in  52 ;  but  from  1829  to 
1833,  under  the  system  of  purification,  the  disease  almost  entirely 
disappeared,  and  the  mortality  diminished  to  1  in  190,  181,  187, 
178,  the  average  deaths  in  the  aggregate  being  1  in  184  cases.  His 
preventive  measures  were  as  follows :  The  wards  of  the  hospital 
were  closed,  during  the  process  of  purification,  against  the  admis- 
sion of  patients ;  they  were  then  filled,  in  rotation,  with  chlorine 
gas  in  a  very  condensed  form,  for  the  space  of  forty-eight  hours, 
during  which  time  the  windows,  doors,  and  fire-places  were  kept 
shut,  so  as  to  prevent,  as  much  as  possible,  the  escape  of  the  gas. 
The  floors  and  wood-work  were  covered  with  the  chloride  of  lime, 
mixed  with  water  to  the  consistence  of  cream,  which  was  not 
removed  for  forty-eight  hours  or  more.  The  wood-work  was  then 
painted,  and  the  walls  and  ceilings  washed  with  fresh  lime ;  the 
blankets,  &c.  scoured,  and  stoved  in  a  temperature  from  120°  to 
130^.  In  addition,  the  strictest  attention  was  always  paid  to  the 
proper  ventilation  of  the  wards.  The  beds  were  composed  of 
straw,  and  never  used  a  second  time  without  washing  the  covers, 
and  a  renewal  of  the  straw.  Dr.  Collins  states  that  from  the  time 
of  the  adoption  of  this  mode  of  purification  until  the  termination 
of  his  mastership  in  1833,  not  one  patient  died  of  puerperal  fever.* 
The  above  results  are  not  without  interest,  and  they  would  seem 
very  broadly  to  indicate  the  efficacy  of  chlorine  as  an  element  in 
destroying  the  poison  of  the  disease. 

Dr.  Collins  further  remarks  that,  in  every  instance  of  the  death 
of  a  patient,  if  the  most  remote  symptoms  of  fever  had  been  pre- 
sent, besides  scouring  every  article  connected  with  the  bedding,  the 
wood-work  and  floor  was  washed  with  a  solution  of  chloride  of 
lime,  and  the  entire  ward  whitewashed.  This  was  readily  effected^ 
as  the  sick  were  invariably  placed  in  a  small  ward,  apart  from  the 
healthy.  To  this  latter  precaution,  he  observes,  too  much  attention 
cannot  be  paid,  as  the  instant  separation  is  of  vast  importance  to 
both. 

The  suggestion  of  Dr.  Collins  in  reference  to  the  separation  of 
the  sick  from  the  healthy  is,  in  my  opinion,  a  sine  qua  non  to  the 
arrest  of  epidemic  puerperal  fever  as  it  prevails  in  hospital  practice. 
In  the  crowded  wards  of  the  hospital,  the  poison  becomes  concen- 
trated, and  this  circumstance,  I  believe,  is  one  of  the  chief  reasons 

*  Practical  Treatise  on  Midwifery*  p.  888. 


894 


THE  FBINCSPLKS  AND  PRACHCE  OF  OBSTETaiGSL 


of  the  fearful  spread  of  the  affection  in  ]ying4fi  estaUiditii€Bli. 
Here,  thcri^  is  a  subject  svoithy  the  aiteDlion  of  the  |)hilantlirofiiil 
— let  the  lavv»of  hygiene  in  reference  to  the  health  of  tho  mtmcroai 
poor,  who  seek  shelter  in  our  public  indtitutious  at  the  time  of  thvir 
aceouchement,  receive  incntcd  attention — let  the^se  la^'s  be  rtgidly 
arid  humanely  enforeed,  and  the  fearful  outUa  to  hfe,  tbroQgb  9ph 
deniie  |iuer|jeral  levLT,  will  be  measurably  closed.  We  are  flrtn  ha 
our  conviction,  that  if  the  poor  were  atten^led  at  thoir  own  hoBus 
— defective  a»  they  may  be  in  ordinary  conifuris — instead  of  h^ttg 
exposed  to  the  infi?etion  of  crowded  ward^i,  the  bills  oi'  mortaiitjT 
would  be  greatly  diminished*  There  is  a  wonderful  charm  la  pare 
air  in  all  ca^^es  of  disease,  hut  more  c^^pccially  an  rvgiirda  eonv: 
cence  from  the  puerix*ral  state. 

Alihtnigh  puerpend  epi<lemic  fever  usually  exlijl»ij-  ''*  t 
devastating  efl't'cij*  m  lying-iu  hoftpiials^  yet  it  jjhuuld  U.  xu.i  .i 
that  these  disastrous  resulla  are  not  always  confined  to  this  etii<^  oi 
asylums.  lu  1619,  the*  epidemic  prevailed  at  the  aame  time  to 
Vienna,  Prague,  Dresden,  VVurtzbou rg,  Bamberg,  in  several  Htitmll 
citiea  of  Italy,  at  Lyons,  Paris,  Dublin,  GlaHgow,  s  m^  ami 

Peteri^burglu      It  is  also  very  remarkable  that  tin  uc  lun 

extended  even  to  the  females  of  some  of  the  dometitie  nntmnli— 
to  slutt^  for  example,  in  the  disease  observed  in  London  iu  KdT 
and  1788;  and  to  cowa  during  the  epidemic  which  occarmd  M 
sev*  n  of  Scotland  iu  182L* 

J,  /  lycatnicnLj— In  regard  to  the  remedial  maiiageioeiit 

of  the  diseasei  much  difference  of  i»entiment  has  existed,  and  thm 
discrepancy  is  mainly  due  to  the  coiiflicting  opiniona  whiob  bare 
prevailed  touching  the  pathology  uf  the  disorder.  On  ibt  Oilt 
hand,  we  arc  directed  to  depend  on  prompt  and  full  depletory 
mea.su res — ^ while,  agsun,  the  stimulating  method  h  comiidcriHi  ai 
presenting  the  only  hope.  There  is  too  much  gene raliaat ion  in 
this  kind  of  therapeutics,  and  neither  the  one  nor  the  other  plaa  can 
be  resorted  to  w  ithout  a  projier  discrimination.  Let  it  bo  em 
fully  treasured  in  memory,  that  there  ii^  no  «pecitiG  for  thb  dineaigt 
In  my  judgment,  the  treatment  of  puerperal  fever  should  fiol  bt 
restricted  to  the  opinions  of  the  respective  school  men,  but,  aa  m 
other  pathological  conditions  of  the  system,  we  should  be  gov^flMsd 
by  the  special  indic4itions  which  may  exist  at  the  time.  The  huie^ 
and  other  of  the  antiphlogistic  ngenus  ^^^  oflentimes  oeccaaarf  in 
paeumonia^  erysipelas,  Jbc,  but  there  are  nnmeroiia  oaaei  in  vUoli 

•  Dftnyna,  BuUetia  do  rAcndt^iiio  de  M^ocinc,  t  xxiiL  Pjiri*,  1B58. 

f  Th*»rf  h  one  point  in  tl>e  treatment,  not  only  of  pncrpcra]  r<?v<»r,  bnt,  mm  a  foli^ 
of  p"  '    diiie«8i'fk  wbk'li  ^hotild  cloita  in  «  sp^cinl  murn  atb«i  of 

tjiti  u  r,  9u6  \t  \9iu  forbid  the  ptiitenisuckUnf  iter  chiU.  «o  naf a- 

rul  auii  ubitt^niory  under  ordinary  dreumstAtwea,  CAoaot  be  d^Khmtjgmd  willt  iMfia* 
mty  wUib  lu  boring  under  oflfeclioiui  incident  to  the  puerpflnl  tfata. 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         695 

these  mea«ir€S  would  prove  quickly  fatal;  the  same  remark  applies 
to  puerperal  fever,  and  this  imposes  the  importance  of  discussing 
the  question  of  treatment  in  reference  to  the  particular  form  of 
the  diseMse  which  may  present  itself.  We  have,  even  in  its  epi- 
demic garb,  what  may  be  termed  inflammatory  pueq)eral  fever ; 
and,  again,  the  disorder  will  exhibit  itself  with  all  the  phenomena 
of  depression,  simulating,  at  the  very  inception,  the  type  of  a  low 
typhoid  affection.  If  this  be  so^and  its  demonstration  will  be 
clearly  recognised  at  the  bedside — it  follows  as  a  fundamental  prin- 
ciple in  therapeutics  that  the  treatment  of  the  two  grades  of  the 
malady  cannot  be  identical.  In  inflammatory  puerperal  fever — 
the  nature  of  which  will  be  defined  by  the  symptoms — prompt 
depletory  measures  are  certainly  indicated.  But,  in  order  that 
these  measures  may  result  in  benefit,  remember  that  they  are  to  be 
resorted  to  opportunely — the  blow  is  to  be  struck  simultaneously 
with  the  advent  of  the  enemy — no  delay  can  be  tolerated  here,  and 
the  only  hope  of  rescue  is  in  the  sudden  arrest  of  the  disease. 
Therefore,  the  prompt  abstraction  of  blood  is  called  for  ;  take  from 
the  arm  from  twelve  to  thirty  ounces  of  blood,  depending  of  course 
on  the  urgency  of  the  case,  and  in  order  that  there  may  be  nothing 
equivocal  in  the  impression  made  on  the  system,  bleed  from  a  large 
orifice,  let  there  be  a  bold  and  full  stream ;  in  one  word,  make 
your  patient  faint ;  syncope  will  more  readily  be  accomplished  by 
placing  the  patient  in  the  sitting  position  during  the  abstraction  of 
blood.  Is  the  bleeding  to  be  repeated  ?  Yes,  if  the  indications 
justify  it.  But  the  repetition  must  not  be  delayed.  Not  more 
than  three  or  four  hours  should  elapse ;  at  this  time,  one,  two,  or 
more  dozen  leeches  may  be  applied  to  the  abdomen,  resting  with 
the  judgment  of  the  practitioner,  and  the  bleeding  promoted  by 
warm  fomentations. 

The  next  indication  will  be  a  free  action  on  the  bowels  ;  .in  order 
that  there  may  be  no  unnecessary  delay  in  the  effect  of  the  raedi* 
cine,  give  immediately  the  good  old  searching  compound : 

5.     Submur.  Hydrarg.  gr.  x. 
Pulv.  Jalapad  gr.  xv. 

"      Antimonial.  gr.  ij. 
M. 
Let  this  be  followed  in  two  hours  with  the  annexed  draught : 

5-     Sulphat.  Magnesiie     3  ij. 
Infus.  Sennse  f.  3  iv. 

Mannse  3  i. 

Tinct.  JalapsB  f.  3  i. 

M. 
If  free  purgation  be  not  accomplished,  I  should  have  recourse  to 
Croton  oil,  which  is  a  favorite  remedy  with  me  in  these  cases ;  it 


606 


THE  PB1KC1PLE3  AND   PRACTICE  OF  OB8TETBICB« 


acta  promptly  and  thoroughly,  producing  full  ser 
stimulutcs  tho  intestinal  mucou^i  surface^  thus  d 

dmvativeinduence,  whioh  neeettmrily  dmiinlshe^tbo  eiigurgt-tt  coo* 
dltion  of  the  vessels  of  the  inflamed  peritoneum* 

IJ.     OleiTii^lii  gtt.  iv. 

Sftcehar.  AIIj.      3  il 
Mueil,  Aeacite  t  3  ij* 
M. 

A  teaspoonful  every  half  hour  until  free  ciithars«i9  folio w< 

When  the  Viowels  have  been  properly  evacuated,  it  i^ 
to  attend  to  that  inipuriant   etnunetory — the  »ikin  ;  and 
combined  view  of  difiphoretic  action,  and  ctihning  nervoits  irritA- 
bilUy,  one  of  the  folU)vving  powders  msiy  be  administ€rc<l  CfTcry 
two  or  three  hours; 

IJ.    Pulv.  Doveri    gr.  xxW, 
"^^     I|K"eac     pr,  vi, 
Divide  in  chart ulas   xij. 

Tho  diet  should  consist,  until  the  inflainniatory  8tag«  ha«  so 
rigidly  of  diluents ;  a  frea  use  of  tho  nitrato  of  pota^,  eithixr  ia 
gruel  or  Abater,  will  l>e  fonnd  of  advantage — say  gt.  xij,  of  the 
poiHrth  to  a  tumbler  of  the  flni<l,  three  or  four  times  a  day. 

We  have  an  iuiportaut  adjuvant  In  blister?*,  after  the  intrriMty 
of  the  disease  ia  tioinevvhat  broken ;  instead,  however,  of  pladn^ 
them  on  the  abdomen,  1  greatly  prefer  applying  tliem  on  thr  inirr- 
nal  e«urface  of  the  thighn,  imnuHliaiely  over  the  femoral  arteries. 
Order  one  or  two  blister.^  i\»  the  indication  may  be,  i*ach  4  tncbr* 
by  6  ;  keep  up  a  i']n*<i  thscharge  by  means  of  tho  epl'*p5i*tic  otot- 
ment,  antl  of>enlimes  the  bi'st  results  will  ensue. 

I  have  8aid  nothing  of  ih*?  speciHc  itifluence  of  mcreunr  to  lira 
dineaiM?.     Except  Jii*  a  purgative  at  the  eommencemeut,  I  '  it 

little  faith  in  the  remedy,     1  have  seen  repeated  instan'  le 

entire  failure  of  any  benefit  from  ptyalism,  wdietlier  ih<«  tnerenry 
be  adminii«tered  internally  or  through  inunction. 

Much  liaM  been  naid  in  coninicndaiion  nf  the  intemal  iisw  of  litr* 
pentinc.  It  has  been  highly  extolled  by  Dr,  lb  enan,  of  DubSn, 
and  many  able  practitioners  have  endorind  his  views*.  Thfre  can 
be  no  doubt  of  the  cflicaey  of  thi*  mtnlieine  in  relieving  the  tynw 
panites^  which  is  ho  usual  an  acconi|faniment  of  the  alfi'etioii*  Half 
art  ounce  of  the  turpenlinc,  with  the  same  ipiantriy  of  cantor  oil, 
every  six  or  eight  hourn,  w  ill  be  fonnd  olleti  cffcrtive  in  rftHiiving 
the  intcfttinal  Hatui* ;  and  frequently  it  will  ndligale  the  inter^otj 
of  the  paiti  m  a  counter-irritant  to  the  nlKlomen,  I  mt^y  hrm 
reninrk  thut,  in  csi«es  of  sevens  tympanitci*  inte^linali'*,  I  have  ft*ii]id 
much  bcnetil  in   large  eneniata  of  tepid  w  atcr.     It  b  nc^Uc«si  to 


I 


W     ^m 


THE  PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS.  697 

observe  that,  as  soon  as  the  disease  has  yielded  to  the  remedies, 
the  recuperative  powers  of  the  system  are  to  be  aided  by  stimu* 
laiits,  tonics,  and  nutritious  diet. 

In  the  adynamic  form  of  the  disease — that  form  characterized  at 
the  very  commencement  by  a  sinking  of  the  forces,  depletion  is  not 
to  be  attempted.  Here,  the  vital  forces,  as  far  as  may  be,  should 
be  maintained.  Stimulants,  nutriment,  and  pure  air  are  very  une- 
quivocally indicated.  But,  alas !  how  often  are  our  best-directed 
efforts  made  negative  by  the  inexorable  demands  of  the  merciless 
foe.  The  sulphate  of  quinine,  although  by  no  means  a  new  sug- 
gestion, has  recently  found  favor  in  the  hands  of  M.  Beau,  at  the 
Hupital  Cochin,  Paris.  He  administers  it  in  large  doses,  preceding 
its  employment  by  an  evacuation  of  the  bowels.  M.  Beau  states 
that  the  efficacy  of  the  remedy  consists  in  giving  it  to  an  extent  to 
produce  head-troubles,  such  as  vertigo,  deafness^  <fcc.,  and  these 
results  should  be  continued  for  several  days.* 

I  should  not  here  neglect  to  speak  of  the  opium  treatment,  both 
in  the  sthenic  and  ataxic  varieties  of  the  disease,  more  especially 
when  lesion  of  the  peritoneal  covering  exists.  As  far  as  I  know, 
the  administration  of  large  doses  of  opium  in  peritonitis,  altogether 
unconnected  with  child-bearing,  was  first  introduced  to  the  atten- 
tion of  the  profession  by  that  eminently  practical  clinical  teacher. 
Dr.  Graves,  of  Dublin.  The  first  time  he  resorted  to  this  remedy 
in  peritoneal  inflammation  was  in  1 822  ;  it  was  the  case  of  a  woman 
in  whom  the  inflammation  set  in  after  the  operation  of  tapping  for 
dropsy.  Dr.  Graves  says,  *'  the  case  seemed  so  hopeless,  and  the 
agony  the  patient  was  suffering  so  intense,  that  I  was  induced  to 
order  opium  for  her  in  very  large  doses ;  she  also  got  wine ;  to  my 
great  astonishment  she  recovered."!  Dr.  Stokes,  another  of  Dub- 
lin's eminent  practitioners,  subsequently  employed  opium  in  that 
most  perilous  fbrm  of  peritoneal  inflammation  springing  from  per- 
f oration — in  one  case  which  recovered,  he  gave  105  grains  in 
addition  to  what  had  been  administered  by  injection  .J 

Prof.  Alonzo  Clark,  of  the  College  of  Physicians  and  Surgeons  of 
this  city,  has  employed  opium  in  heroic  doses  during  the  prevalence 
of  puerperal  fever  at  the  Bellevue  Hospital,  and  with  good  suo- 
cess.§ 

»  Bulletin  do  rA9^(iemiede  Medicine,  t.  xxi.  p.  81. 

\  For  the  conjoined  experience  of  Drs.  Graves  and  Stokes  on  this  point,  I  refer 
the  reader  to  the  tirth  vohime  of  the  Dublin  Hospital  Reports 

{  Clinical  Lectures  on  the  Practice  of  Medicine.     Vol.  ii.,  p.  244. 

§  Some  interesting  details  furnished  by  Prof.  Keating,  the  able  annotator  of  Dr. 
Kainsbotli/un,  touching  Dr.  Clark's  experience  with  opium  in  puerperal  fever,  will 
be  found  in  Rjunsbothara's  System  of  Obstetrics,  p.  534  I  may  here,  however,  be 
permitted  U)  quote  the  following  as  an  evidence  of  the  extraordinary  extent  to  which 
opium  may  be  administered  without  fatal  results.  Prof.  Clark  says  :  "  Regarding 
the  tolerance  of  opiates  in  some  of  thea^  cases — at  the  risk  of  behig  charged  with 


THE  FBINCIPLES  AND  PRACTICE  OF  OBSTETBICa 

It  18  an  interesting  fact  that  when  opium  is  administered  in  theie 
oases  so  as  to  produce  incipient  narcotism,  the  respiration  be- 
comes sensibly  affected.  Dr.  Clark,  with  the  respiratory  move- 
ment reduced  to  12,  and,  as  a  general  rule,  the  pulse  below  100, 
with  the  concurrence  of  other  favorable  symptoms,  such  as  a  subsi- 
dence of  the  pain  and  tenderness,  with  diminution  of  the  tympanites, 
gradually  lessens  the  quantity  of  the  drug,  and  finally  discontinues  it. 

Prof.  Fordyce  Barker  speaks  highly  of  the  veratrum  viride  as  a 
remedy  in  puerpei-al  fever ;  it  certainly  exercises  a  marked  control 
over  the  frequency  of  the  pulse,  and  he  observes,  ^^  in  no  disease 
have  I  seen  its  value  more  strikingly  exhibited.'**  It  requires 
extreme  caution,  and  should  not  be  employed  except  under  ciroum- 
atances  in  which  the  most  unceasing  vigilanoe  as  to  its  administra- 
tion and  effects  can  be  exercised. 

rashness  and  trifling  with  human  lifo — I  will  make  somo  extracts  from  csife  seTen. 
The  treatment  was  commenced  at  10  a.m,  on  2Gth  of  Dec,  two  grains  of  0|>ium 
hourly.  A  2  p.m.,  no  change  in  the  symptoms,  dose  increased  to  gr.  iv. ;  at  a  err'  it.  ; 
at  4,  gr.  V. ;  at  5,  gr.  v. ;  at  6,  gr.  viii. ;  at  8,  gr.  x. ;  at  9.  gr.  xij. ;  at  1 1,  sol  morph. 
sulpli.  (16  gr.  to  f  Ji)  3iffi. ;  at  12,  3i. ;  at  1^  a.m.  (respiration  C).  0;  at  6  a.m., 
(respiration  12).  opium  gr.  xij.;  at  10,  sol  3  L;  at  12  M.,  opium  gr.  xij  ;  at  11  pm^ 
8oL  3  ij- ;  at  2  J,  3  ij. ;  at  3^  opium,  opium  gr.  xxiv. ;  at  5,  gr  xij  ;  at  6|.,  sol.  3  ijasi ; 
at  7^,  3  ij. ;  at  9,  opium  gr.  xiv. ;  at  10,  gr.  xvj  ;  at  1 1,  gr.  xviij  ;  28th,  at  I  A.M.. 
8oL  3  ijss. ;  at  2,  3  iv. ;  at  3|,  opium  gr.  xx  ;  at  4,  sol.  3  ijss. ;  at  5,  3  iii. ;  at  t, 
3  iijss. :  at  6|,  opium  gr.  x. ;  at  7,  sol.  3  iijss. ;  at  8,  opium  gr.  xxij. ;  at  9}.  aoL 
3iv. ;  at  10,  3  iij. ;  at  lU,  3  iij. ;  at  12,  0.  Thus  this  woman  took,  in  tlio  flr>t 
26  hours  of  iier  tn»atment.  opium  Ixviij.  and  sulph.  morpli.  jn*.  vij. ;  or  c»»iititin;r  one 
grain  of  sulph.  murph.  iis  four  grains  of  opium,  one  hundred  and  six  (10(>)  grains  of 
opium.  lu  ihu  second  21  hours,  sho  took  opium  gr.  cxlviii.,  and  sulph  tnoqih. 
Ixxxj.,  or  opium  four  hundred  and  soventy-iwo  (472)  jrnun.s!  On  the  third  day.  site 
took  230  grains;  on  the  fourth,  120  grains;  on  the  liftli,  54  grains;  on  the  >ixth, 
22  grains;  on  the  seventh,  8  grains;  after  which,  the  treatment  was  wliolly  sus- 
pended Thid  woman  was  not  addicted  to  drinking,  and,  after  her  n.-cov<..-y.  she 
assured  me  repeatedly  that  she  did  not  know  opium  hy  sight,  and  had  never  taken 
it,  or  any  of  its  prei>;irations,  unless  it  had  Ix^cn  prescribeti  by  a  physician.  Tliia  ia, 
perhaps,  *  horrible  dosing.'  and  only  justifiable  as  an  experiment  on  a  des{»ereta 
disease;  yet,  this  woman  is  alive  to  tell  her  own  3i<»ry,  as  are  several  others,  who 
took  surprising  quantities  of  this  drug.  But  later  observations  have  shown  that  th« 
tenth  to  the  thirtieth  part  of  this  maximum  U  .sufficient  in  controlling  the  db 
•  Remarks  on  puerperal  fever,  New  York  Academy  of  Medicine,  Oct  1857. 


LECTURE    XLV. 

Puerperal  Mania ;  its  Pathology— Is  it  a  Phrenitis,  or  is  it  essentially  a  Disease 
of  Exhaustion  and  Irritation  f — Opinions  divided ;  Necroscopical  Researches — At 
wliat  Period  of  the  Puerperal  State  is  Mania  most  apt  to  Occur  f — Esquirors  Sta- 
tistics— Frequency  of  the  Disease— Is  Puerperal  Mania  liable  to  recur  in  a  Subse- 
quent Birth  ? — 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  ?— Diagnosis — 
Puerperal  Mania  and  Phrenitis,  Distinction  between — Prognosis — Records  of 
Hospitals  for  the  Insane ;  Records  of  Private  Practice — Duration  of  Puerperal 
M^iia— Is  Permanent  Aberration  of  Mind  Probable  in  this  Disease? — Treatment 
— Marshall  Hall  and  Bloodletting — Opiates — Their  Importance — Moral  Treat" 
ment. 

Gentlemen — Puerperal  Mania  will  occupy  our  attention  to-day ;  it 
is  one  of  those  affections  incident  to  the  puerperal  woman,  which 
always  to  a  greater  or  less  extent  has  its  melancholy  surroundings. 
Imagine,  for  instance,  a  young  mother,  who  has  a  few  days  since 
given  birth  to  a  child,  to  be  suddenly  deprived  of  her  reason  !  Her 
mind  has  surrendered  to  the  encroachments  of  morbid  action,  she  is 
no  longer  cognizant  of  events  as  they  pass,  and  is  thus  cut  off 
from  the  inexpressible  pleasure  not  only  of  intelligently  gazing  upon, 
but  of  ministering  to,  the  wants  of  her  new-born  infant,  whose  very 
condition  of  dependence  makes  it  an  object  of  additional  interest. 
Indeed,  the  affection  very  naturally  throws  a  gloom  over  the  house- 
hold, and  is  a  subject  well  worthy  the  attention  of  the  medical 
man. 

This  malady  may  manifest  itself  during  gestation,  at  the  time  of 
labor,  or  some  days  subsequently ;  again,  it  may  become  developed 
during  the  progress  of  lactation,  or  it  may  follow  weaning.  Instances 
have  been  recorded  of  its  having  occurred  in  very  sensitive  women 
immediately  after  conception. 

Pathology  of  the  Disease. — ^There  is  no  general  agreement  as  to 
the  pathology  of  this  disease.  By  some  it  is  supposed  to  be  an 
inflammation  of  the  brain  and  its  membranes — a  veritable  phre- 
nitis; while  others  maintain  that  it  is  a  disease  more  or  less  of 
exhaustion  and  intestinal  irritation  consequent  upon  the  puerperal 
period.  Without  attempting  to  deny  that  puerperal  insanity  may, 
under  circumstances,  be  the  result  of  phrenitis,  yet  I  think  accurate 
clinical  observation  abundantly  proves  that,  as  a  general  rule,  it  is 
connected  with  a  dilapidated  condition  of  the  forces.    Some  of  the 


700 


TUE  PRINCIPLES  AND   PUACTICE  OF  OBSTETRICS. 


most  markcti  cases  of  melancholia — one  of  tho  form*  of  mAnU-a 
ha%*e  ever  witnessed,  sprung  from  the  exhaustion  of  undue  lactaliao. 
The  nervous  syiitem  of  the  menstnialing,  the  |iregtiaiit,  partttriiiic^ 
and  nnmnjj;  female  U  liable  to  various  modification 9 — so  many 
coiicussiohH,  if  yoii  please,  the  tendency  of  which  ia  to  impair  to  a 
greater  or  \c9n  extent  its  efjuilihrium,  and  tims  di«fio»e  it  to  nume- 
rous derangements,  one  of  the  phases  of  which  may  lie  mmtita,  or 
melancholia.  I  do  not  mean  to  be  understood  that  mere  exhauatiuii 
will  necessarily  oeeaHion  mania;  but  what  I  d*>  believe  w  thi*,  thai 
there  U  a  peculiar  specitic  seoMtiveiies'*  in  the  Aexual  or^an§  of  tho 
female  during  the  puer}»eral  period,  which,  under  the  tnfluvncr  of 
debilitating  and  other  exeiiing  causes  may  ^o  far  a(ff*ct  the  inicgrilf 
of  the  nervous  economy,  as  to  generate  certain  morbi«l  phenomemi— 
in  one  case  we  may  have  hysleria,  in  another  mebuieholy,  ia 
another  convulsive  movements,  and  in  another  partial  or  c?otn|)lp|o 
loss  of  reason.  It  is  by  no  means  a  rare  circumstance  for  amiie  of 
these  abnormal  developmeutJ*  to  present  theni**elve»  dartitg  ai<*ii- 
Btruation,  in  the  course  of  jxe.slation,  or  at  the  lime  of  lalior,  or  after 
the  completion  of  this  procewi.  In  brief,  I  believe  that,  ftt  • 
^erveral  ruk%  puerj»€ral  mania  U  a  Aui  gaitrta  insanity,  and  U§  {»eoii«> 
liarity  is  traceable  to  certain  ajrcncies  actinsr  on  the  sexual  §y«rm, 
and  the  Rubse^fuoiit  re-arlion  of  this  sy!*tem  on  the  nervn, 

It  is  quite  probable  that  the  discrepancy  of  opinion  ir)  ui 

the  pathology  of  the  disease  may  have  arisen  from  a  waul  cif  proper 
di*>crimiuation  in  the  results  of  necroscopical  researches — for  tn- 
stance,  it  is  well  shown  by  these  researches  that,  in  what  may  b« 
desijrnated  ^i-nernl  iuHanlty,  evidiMtcc**  of  inflammation  of  the  bniii 
and  its  membranes,  may  be  repirded  as  the  rule.  But,  a4*cprdiii|^ 
to  the  best  observers,  among  whom  may  be  mentioDed  Ettqttirott* 
such  \yi  not  tlie  fact  in  the  examination  of  tbose,  who  have  <li<jd  of 
puerfieml  mania. 

At  irhat  Period  of  the  Ptferperftl  State  i»  Mnnia  mmt  api  fo 
Oc/*wr  /^Although  puerperal  mania  will  occasionally  exhibit  itself 
during^  pregnancy,  and  after  weaning,  yet  it  i«i  generaJly  eon* 
eeded  that  it  \^  u»ost  liable  to  become  '^  1   a  few  *1  *  »^r 

delivery,  and  in  the  progress  of  advanrt  on,     Tb«  ^ 

tables  by  Esipiirol  are  not  without  inti*re**t :  In  1811,  1812^,  iSia, 
1814,  there  were  eleven  hundred  and  nineteen  insane  women  adtnlu 
ted  into  the  S;ilpetri6re,  of  whom  ninety -two  were  affected  wtlli 
puerperaUnsanity ;  of  the^e,  10  were  attacked  from  f  e 

fourth   day  after  delivery;  21  from  the  fifth  to  the  i  ;  ; 

17  from  the  sixteenth  to  the  aixtieth  day  ;  I  a  from  thu  sixtietli  ilay 
to  the  twelfth  month  of  lactation;  19  after  weaning* 
Frequency  of  th^  DUta^e. — This  aflection  cannot  be  eofifid^rod 


^  Dec  MAladLes  Mentoles,  1S38. 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         701 

as  of  rare  occurrence.  Among  seventeen  hundred  and  nitfeteen 
cases  of  insane  women  in  the  Salpetri^re,  there  were  52  cases  of 
puerperal  mania,  and  Dr.  Haslam  reports  84  cases  among  1644 
women  admitted  at  Bethlem. 

Is  Puerperal  Mania  Liable  to  Recur  in  a  Subsequent  Birtlu — 
This  is  certainly  an  interesting  inquiry — for  when  a  female  has  once 
suffered  from  this  affection,  nothing  can  be  more  natural  than 
that  the  husband  and  friends  should  be  solicitous  as  to  the  proba- 
bility of  its  recurrence  in  a  future  parturition.  One  of  the  most 
practical  writers  on  the  disease  under  consideration.  Dr.  Gooch,  is 
quite  emphatic  on  this  point.  He  says :  "  I  have  attended  many 
patients,  who  came  to  London  to  be  confined  because  they  had  been 
deranged  after  their  former  lying-in  in  the  country  ;  except  in  one 
instance,  not  one  of  the  patients  had  a  return  of  their  disease  !''* 
Such,  too,  is  the  tendency  of  the  testimony  presented  by  other 
eminent  observers.  I  must  confess  it  is  adverse  to  my  own  personal 
experience.  I  once  attended  the  wife  of  a  clergyman  from  the 
South  in  her  third  labor ;  she  had  previously  borne  two  living  chil- 
dren, and  in  each  of  her  confinements  had  been  attacked  with  puer- 
peral mnnia.  The  labor  in  which  I  attended  her  was  in  all  respects 
favorable,  but  in  defiance  of  every  caution,  on  the  fifth  day  after 
delivery  puerperal  insanity  set  in.f  I  have  a  patient  in  this  city, 
whom  I  have  confined  five  times.  In  the  two  first  confinements 
nothing  remarkable  occurred.  In  the  third,  two  days  after  the 
birth  of  her  child,  her  husband  was  compelled  to  absent  himself  on 
urgent  business;  thirty-six  hours  after  his  departure,  she  lost  her 
reason,  and  had  a  tedious  convalescence  of  ten  months.  Twenty 
months  from  the  period  of  her  recovery  she  was  again  confined ; 
and  mania  was  again  developed.  In  her  fifth  partuntion  she  suf- 
fered no  mental  aberration.  I  could  cite  two  other  cases,  which 
have  occurred  to  me  in  consultation,  one  with  Dr.  White  of  this 
city,  the  otherj  with  Dr.  Brown,  of  Little  Falls,  in  which  both 
patients  became  affected  with  puerperal  mania  in  two  consecutive 
deliveries.  It  may  be  that  these  cases  will  be  regarded  as  coinci- 
dences, and  do  not  bear  the  relation  of  cause  and  effect.  However 
this  may  be,  it  seems  to  me  that  with  the  predisposition  necessarily 
induced  by  a  previous  attack,  together  with  the  constant  dread  of  a 
recurrence  of  the  malady,  the  nervous  system  will  be  so  agitated  as 
to  render  it  not  at  all  improbable  that  mania  having  once  become 
developed  will  be  liable  to  exhibit  itself  at  subsequent  periods. 
Under  the  circumstances,  it  woidd  at  least  be  judicious  to  maintain 

•  Most  Important  Diseases  of  Women^  p.  120. 

f  Hereditary  influence  no  doubt  had  its  sway  in  this  instance,  for  both  the  father 
and  the  paternal  uncle  of  the  lady  died  maniacs. 

%  In  this  case,  too,  there  was  hereditary  predisposition,  for  the  mother  of  the 
patient  had  suffered  fh>m  puerperal  mama  soon  after  the  birth  of  her  only  child. 


702 


THE  PRINCIPLES  A>fD  PRACTICE  Of  OBSTETEfCflL 


SI  )^uafdetl  opinion,  and  nt  the  same  time  to  n  «af©  mem 

of  vigilance  against  the  opemtion  of  all  ex*  j  iiiene«. 

Causes. — I'hese  may  be  divided  into  the  prcdi>iposin|^  ami  extnt- 
in^.  Aniong  the  former,  muy  be  placed  prominently  hereditary  in- 
fluence  ;*  a  delicately  organized  nervous  system  keenly  alive  to  moral 
miii  physical  impressions;  unusual  sensibifity  of  the  j^ctual  org»fi»| 
and,  in  my  opinion,  a  previous  attack  is  entitled  to  bo  ranked  muiong 
the  predisposing  oauises  of  the  nflTection.  The  tfxdling  cnit^iGii  may 
be  ftnddeu  mental  emotions,  whether  of  a  depresmng  or  *  *  i^ 
elmracler  ;  disordered  d I jx^st ion  ;  d i sense  of  the  ntenis,  <  C 

the  fjfenitalia ;  exhauntion  from  undue  lactation,  or  from  ii<!fi>or* 
rhage,  througli  the  c!ianges  produced  in  the  nervon*  ny^tem*  Wean- 
ing U  regarded  by  some  writer*  aa  an  excitant  to  pnerperal  numia, 
but  T  do  not  think  it  entitled  to  much  prominence;  if  it  w-  ne 

di?*ea.He  would  assuredly  be  apt  to  develop  itsijf  frequent!  v  .  ti 

who,  from  want  of  proper  feeling  or  other  ctrcumstafic^^  do  iNii 
suekle  their  ehildrt?n  ;  this,  however,  is  $homi  not  to  lie  the  etuo. 
I  am  diHpoBed  to  think  that  some  of  the  instances  of  m?iniii»  irhteh 
have  hocn  referred  io  weaning,  are  due  to  the  e3rhau*«t  lamt 

upon  protracted  lactation  rendering  the  weanin;::^  a  u^        .     , 

tS}/mptomit, — ^l"'ho  aymptoma  indicative  of  puer|>enil  manb  hxwm 
no  special  identity,  and  are  subject  to  variations.  Indexed,  a  ^efj 
pnicl'ical  division  of  the  disorder  lias  been  made  into  what  t*  d€!ilo* 
minated  mania  and  melatieholia,  each  eharaeterized  mon*  or  le^  bir 
SymjJtoms  difterincf  from  each  other.  Mania  ordinarily  occiira  vooQ 
after  delivery,  while  melancholia  h  more  liable  to  manifeftt  itnelf  m 
the  result  of  the  exhaustion  of  nndne  lactation*     V  ibere 

are  usually  all  the  indieationst  of  agitation  and  exrr  —great 

irritalnlity  of  temper — suspicion  is  a  common  wymptom;  sametlmci 
there  will  be  marked  obstinacy  and  inoroi^enessi ;  the  htDtbatid  aod 
infant  become  objects  not  only  of  indifference,  hut  of  actual  dj^lk#; 
there  njny  or  may  not  be  febrile  excitement;  the  puNe  i«  Aoiti^* 
timcH  imchanged — and  a^ain,  it  is  rapid  with  more  or  lews  fevet. 
llie  patient  will  occasionally  become  extremely  violent  both  in  man- 
ner and  language,  and  much  vigilaneo  required  to  prerenl  bcr 
inflicting  injury  upon  herself  or  child,  A  very  tinifortn  ami  i*arly 
symptom  is  rest!  easiness  soon  a  tier  delivery — an  inability  to  sleep— 
the  patient  is  wakeful,  throwing  herself  about  the  betl,  anil  nocno- 
times  sighing.  This  state  of  watcli fulness,  1  cannot  too  ernphali* 
cally  remark,  should  always  be  regarded  with  ?ii  -ii 

fiir  as  may  be,  means  promptly  employed  to  pr^M  i         iiy 

the  digestive  functions  are  much  disturbed,  as  indicated  by  \hm 
coated,  slimy  tongue,  irregularity  of  the  bowels,  defective  ttrioaiy 


^  0r.  Burrowf  njt  tlmt  if  tlie  truth  cotild  itlMm^rs  be  oaocruiiaed.  mon! 
Iiilf  would  probnUljr  be  Ibuad  to  ow«  ibelr  ori^ta  to  this  oaiuei     [Oommflaiarlia  m 
loittiUtjrd 


I 

i 

4 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.         703 

tecretion ;  the  patient,  although  hungry,  will  sometimes  evince  an 
indisposition  to  eat  merely  from  obstinacy ;  this  latter  fact  I  have 
noticed  on  more  than  one  occasion.  In  the  other  form  of  mania — 
melancholia — the  symptoms  are  somewhat  different.  Here,  in  lieu 
of  excitement  and  violence,  there  is  marked  depression  of  spirits — 
there  is,  if  I  may  so  term  it,  a  deep  melancholy  pervading  every 
look  and  act  of  the  invalid  ;  she  is  silent,  listless,  and  indifferent  to 
everything  passing  around  her ;  the  pulse  is  normal,  with  more  or 
less  deranged  digestion.  In  one  word,  she  is  an  object  painful  to 
contemplate,  and  it  is  one  of  those  pictures  in  real  life  well  calcu- 
lated deeply  to  impress  the  observer,  and  call  forth  his  sympa- 
thies. 

Diagnosis. — From  what  has  begn  said  of  the  symptoms  and 
divisions  of  this  disorder,  the  diagnosis  cannot  be  difficult.  The 
time  and  circumstances  of  its  occurrence  will  also  aid  in  facilitating 
a  just  opinion.  Puerperal  mania  might  possibly  be  misapprehended 
for  phrenilis,  but  proper  attention  would  soon  reveal  the  error.  In 
the  latter  affection,  the  hard  and  quickened  pulse,  the  heate<l  sur- 
face, the  suffused  eye,  the  intolerance  of  light  and  noise  will  very 
soon  tell  the  story  to  the  vigilant  physician. 

Prognosis. — Many  will  be  the  anxious  inquiries  as  to  the  proba- 
ble issue  of  the  disease,  and  these  inquines  will  be  directed  to  two 
points — in  the  first  place,  whether  the  disorder  is  likely  to  termi- 
nate fatally — and  secondly,  if  not,  whether  the  mind  will  be  perma- 
nently affected  ?  I  need  not  dwell  on  the  constancy  with  which  * 
these  appeals  will  be  made,  and  the  pressing  urgency  for  a  response. 
It,  therefore,  is  the  duly  of  the  practitioner,  by  a  proper  apprecia- 
tion of  the  statistics  of  the  affection,  to  be  able  at  least  to  approxi- 
mate a  truthful  decision.  It  has  been  well  remarked  that  the  data 
furnished  by  the  records  of  hospitals  for  the  insane  are  not  proper 
guides  as  to  the  results  of  this  disease  under  other  and  more  favora- 
ble circumstances.*  The  fact,  I  think,  is  well  shown  by  the  following 
reports:  in  ninety-two  cases  recorded  by  Esquirol,  fifty-five  re- 
covered, six  died,  and  thirty-one  incurable,  or  one  in  three ;  Dr. 
Haslam  says,  of  eighty-five  admitted  into  Bethlem,  only  fifly 
recovered,  and  thirty-five  incurable ;  Dr.  Burrows  reports  fifty- 
seven  cases,  of  which  thirty-five  recovered,  and  eleven  incurable ; 
among  the  thirty-five  recoveries,  twenty-eight  occurred  during  the 
first  six  months. 

Private  practice,  I  repeat,  presents  no  such  melancholy  experi- 

*  Dr.  Gooch  very  truly  observes,  that  the  records  of  hospitals  contain  chiefly 
accounts  of  cases,  which  have  been  admitted  because  they  have  been  unusually 
permanent,  having  already  disappointed  the  hope,  which  is  generally  entertained 
and  acted  upon,  of  relief  by  private  cure ;  the  cases  of  short  duration,  which  last  only 
a  few  days  or  weeks,  and  which  prove  a  large  proportion,  are  totally  overlooked  or 
omitted  in  the  inspection  of  hospital  reports. 


704 


THE   PRINCIPLES  AKJ)  PKACTICE  OF  OBSTEnilca. 


cnce.  It  is  pertbolly  safe*  iinclor  ordinary  circuttistriruvs,  la  give  s 
favorsible  opiniuii  us  to  ihe  leriuinaiioii  of  tbe  diAea.^!*,  l»oth  as 
r««gardA  tbe  restoration  of  bofly  and  mind.  1  iiay  under  firdimuy 
circumstnncjes,  lor  t  here  are  ticcasitinally  ci3rtain  roadUiotiii  af  tlii 
disordt-r  which  poriend  a  fatal  result,  and  it  is  proper  thai  liiey 
fihoiiM  not  ehidr  the  att<'ntiun  of  the  practitioner,  Thi-s«  condr 
tioris  are  now  admitted  by  the  ablest  phytiieiajis  a*  of  great  incraMint 
in  forming  an  accurate  diagnosis — ths'f/  nm  the  rapid  pulse^  and 
continued  rmtUsanenit  at  (he  t^ert/  Ifutption  of  the  ttuiladi/,  WhcO 
these  two  j>henoniena  exii^t  conjointly,  they  arc  to  bo  re2:arde4  M 
tokens  of  no  good.  Happily  the  threat  majority  of  eiutcM  artJ  not 
characterised  by  the  <inickened  pulse,  although  watchfidiiefl 
common  attendant*  ^ 

I  may  here  remark  that  the  reason  for  the  app  i  of  daogoF 

from  the  nipiil  aetion  of  the  heart,  and  the  eontn  -  of  ri$*l^  Im 

of  easy  iwjlution— these  two  aymptoms  wiliof  oeceittdty  draw  htrgdj 
on  the  «trengt!i  of  the  patient — there  h  no  rejwiirto  thtj  debiltlut^ 
foreeii,  and  death.  In  these  ea^e^s  may  juKtly  be  attributetl  lu  ifX- 
hau.^tion  of  the  syi^tenu 

iMratlon  of  pHf'rp*rul  Matda, — In  most  inj*tances  pflcrpef»l 
mania  is  of  short  duration^  not  unfrec|uently  yiehiing  to  judjdooi 
treatment  in  a  few  days  or  w^^ek-*.  Sometime^  however,  thu  rr- 
covery  is  protrueletl,  and  the  losa  of  re.ison,  more  or  lea**  c?oaiplrU% 
will  cantiniic  for  many  months*  According  to  the  rnoH  rdiablo 
data  on  the  Mibjeet,  well  HUBtained  by  clinical  obser%Mtion,  it  majr 
be  afUrmed  that  the  average  duration  of  the  malady  U  from  oue  lo 
six  month:^,  while  the  permanent  aberration  of  mind  is  tho  mni 
exception. 

Treatment, — A  ripe  and  experienced  judgment  is  eftsential  to  ibe 
proper  treatment  of  thiH  di^sease.  TJie  thoughilcLss  praotitioii€rt 
governed  in  bin  theru|)eutieii  by  mere  »ymptomH«  will  be  ejilnifiidy 
apt  to  connnit  a  grave  error  in  the  management  oi*  the  tnaZady. 
The  excitement  and  violence  of  the  patient  he  will  {iroliablT 
attribute  to  vascular  fulness,  a  phlogistic  state  o\'  ny^tem — it  may 
be  to  phreuilia.  With  thi.^  view^  t»f  tlie  cane,  he  will  of  eoonitj  nsmxri 
to  depleli^ry  measurers  the  first  of  which  will  be  the  tVee  a»o  of tW 
lancet.  This  in  oftentimes  a  fatal  mistake.  Puerperal  phrenitia,  H 
would  be  well  to  reuiember,  is  among  the  very  rare  occurrrticc*  of 
the  lying-iiJ  room ;  and  it  cannot^  be  too  empliatieally  iMirtta  in 
reeolleerion  that  puerjieral  mania  is,  VA  a  general  rule,  a  disease  of 
exhaiiKtion  atul  irritation.  If  the  priictitioner  will  but  kiti^fi  tbia 
cardinal  fact  before  him,  he  will  have  the  key  to  the  treatmctiL  I 
was  forcibly  struck  gfime  years  ^ince  with  t]»e  remark  of  that  mgjlt^ 
cious  observer,  Dr.  Marshall  Ilall — he  say?*,  **  On  biang  called  to  • 
ca.se  of  puerperal  mania,  I  have  long  been  in  the  habit  of  ai^kltig 
whether  the  patient  has  or  has  not  been  bled ;  on  ibk  greatljr  d^ 


I 

I 


THE  PBINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  705 

pends  the  result  of  the  case ;  if  blood  has  been  freely  taken,  the 
patient  will  probably  die ;  if  otherwise,  most  puerperal  cases  of 
mania  issue  well."  If  this  language  of  the  distinguished  physiolo- 
gist were  incorporated  into  a  maxim,  and  inscnbed  upon  the  tablets 
of  memory,  well,  indeed,  would  it  be  for  the  invalid  attacked  with 
puerperal  insanity. 

If  what  has  been  said  be  true — that  puerperal  mania  is  most 
commonly  a  disease  of  exhaustion  and  irritation,  then  it  would 
follow  as  a  legitimate  consequence  that  the  two  broad  indications  are 
to  repair,  as  promptly  as  may  be,  the  waste  the  system  has  under- 
gone, and,  secondly,  to  allay  the  nervous  irritability.  Let  me  here 
ask — what  is  the  most  efficient,  and,  indeed,  the  only  mode  of  re- 
pairing waste  under  those  circumstances  ?  Is  it  not  through  proper 
nutrition  ?  But  nutrition  is  not  an  exclusive  process — it  is  but  one 
link  in  a  chain  of  processes.  Food  taken  into  the  stomach  will  not 
necessarily  nourish — its  nutrient  properties  will  depend  upon  its 
being  properly  digested;  and  if  you  wish  ingesta  to  be  converted 
into  good  blood,  one  material  prerequisite  is — that  the  chylopoietic 
functions  shall  be  in  good  condition.  I  think  I  may  say,  without 
fear  of  contradiction,  that  a  very  uniform  attendant  upon  puerperal 
mania  is  a  disordered  digestion,  as  is  shown  by  the  coated  tongue, 
fcBtid  breath,  loss  of  appetite,  and  irregularity  of  the  bowels. 
Therefore,  with  such  indications,  the  first  thing  to  do  is  to  admi- 
nister a  cathartic,  say  gr.  vi.  submur.  hydrag.  with  gr.  xii.  pulv. 
rhei ;  let  this  be  followed  in  six  hours  by  castor  oil,  or  the  follow- 
ing draught : 

Sulphat.  Magnesi»  3  i 

Infus.  Seimse        f.  |  iv 

Manuse  3  i 

Tinct.  Jalap»        f.  3  i 

M. 
One  half  this  to  be  taken,  and  if  not  effectual,  the  remaining  half 
in  four  hours. 

In  these  cases  of  coated  tongue  and  foul  breath,  great  benefit 
will  sometimes  be  derived  from  an  emetic  of  ipecacuanha — gr.  x.  to 
gr.  xii.  in  half  a  tea-cup  of  warm  water. 

When  the  bowels  have  been  properly  evacuated,  it  is  most  im- 
portant to  quiet  the  nervous  system  ;  if  the  patient  can  be  early  piit 
into  ^  state  of  repose — if  the  exhausting  and  harassing  watchful- 
ness be  speedily  arrested,  the  best  results  may  be  predicted.  For 
this  purpose,  opiates,  in  some  of  their  various  forms,  must  be  re- 
sorted to  ;  but  it  should  be  recollected  that  it  is  most  desirable  to 
make  a  prompt  impression,  and,  therefore,  a  full  dose  should  be 
admhiistered  at  first,  followed  subsequently  by  a  smaller  quantity 
as  circumstances  may  indicate.    If  there  be  nothing  in  the  idiosyn* 

45 


706 


THE   1»BIXCIPLR8  AND  PRACTICE  CT  Om^TlttGBp 


crany  of  thcf  tnvaliil  to  c*mtra*indicate  8u  a  gmiii  or  morcf  of  mM 
o  pi  urn  may  be  given,  or  thirl  r  or  forty  ilrops  of  the  tincture;  aon 
half  grain  or  mort?  of  mor|>l»iue  will  sometimes  act  ailminiUy ;  10 
gniins  of  Dover's  powder ;  or  the  followipg  iiuiy  bo  preicrib^ : 

It 
Synip.  Papa%',  f  3  vi 
Mueil.  AcadflB  f  3  iii 
SoL  Sulph.  Morphiflo  (M,)  gtt.  xx* 

A  table-«*pootiftiI  every  half-hour  nntil  sleep  is  obtaiaetL  Hyfmeym- 
mus  and  catnphor^  five  grains  of  each,  was  a  favorite  prenrription 
with  I)r,  CJooch^  especially  where  opiates  conld  not  be  to1er«U«l,  II 
can  s<*areely  be  necessary  to  eapiin*  tliat  whichever  of  tbcmarcrae^ 
dies  rnay  be  em|)loycd,  they  should  be  repeated  according  lo  tlie 
emercfency  o(^  the  citse,  and  the  sound  dist^relion  of  the  phy)ii<}t«i( 
nor  should  they  be  resoited  lo  if  there  be  heat  of  system  withnuidi 
thirst,  CooHnj^  but  gentle  aperients,  fojjcther  with  diaplH>nilifl% 
will  srjon  remove  these  latter  symptoms.  The  spirits  of  minden&mii 
a  table-spoonfnl  vxery  two  or  throe  hours,  will  bu  foand  n  noHalib 
diaphoretic  for  the  purpo-ie* 

If  there  be  mtich  heat  about  the  head,  evaporating  l»tirtni  tolhm 
part  will  be  of  service,  together  with  warm  water  t  ioBi  fn 

the  feet ;  and  if  thL»re  be  an  approach --as  aonjetimes  u ..,  :  .  ilie  eaat 
— to  Bttipor^  blisters  behind  the  ears  may  bt^  applied  wilfa  marfctd 
good  results.  The  diot  to  be  of  ea^^  digestion,  and  QutriUom — and 
when  not  roiitraindicated,  animal  food  miiy  be  allo%ved  frculjr.  On 
the  same  |>rineiple,  also,  malt  liquors,  in  proper  quantity,  wUl  aid  in 
accomplishing  the  object  in  view — the  building  up  of  tht?  dilafii* 
4ated  forces.  In  one  word^  the  judicious  physician,  seeing  tlie 
indtcaticms,  and  fully  appreciating  the?  surroundings  of  eaeli  caiieM 
they  may  present  themselves  to  his  observation,  must  be  the  jiad|^ 
M  to  the  special  manner  of  adapting  hi^  therapeulies, 

I  have  said  nothing  of  the  morai  treatment  of  puerpenl  maaiA; 
^od  tmr^ing — by  good  nursing  I  mean  discreet  nur*ing— Ims  BMlcIl 
to  do  with  the  recovery.  What  the  pniient  nerds  is  the  msmdm§ 
of  that  oflenlimes  rare  commodity  in  the  etiik-room— eolDiliOli 
Miise.  Above  all  things,  let  Iter  bo  protected  from  the  ttitnuioci  of 
ln4|U]sittve  and  tiilkativc  friends.  Quietude  is  what  she  snottl  needs 
— great  raulitm  should  be  observed  to  avoid  either  in  eonvefteliofi 
or  acts  all  caus€»s  of  irritation:  tlie  nurse  shouUl  U*  reminded  ihat 
the  fiatient  is  never  lo  be  left  alone,  for  instances  have  oeeurred  in 
which  females,  afiV'cted  with  this  disease,  haro  taken  advaolage  of 
their  solitude,  and  eonimitted  acts  of  per^omil  vii>lence. 

One  of  the  iiYaterial  {>oint9  in  the  moral  treatmetil  of  ihli  ftllbo^ 
tioo  is  to  exercise  a  judieious  restraint,  without  )>ermitUxi|{  Um 
patient  to  beeomo  ^onieious  that  there  is  ihe  s%ble&t  sMryfiHanti 


I 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICa         707 

ovor  her  actions.  This  is  the  perfection  of  good  nursing.  It  is 
important,  as  she  convalesces,  to  have  her  mind  agreeably  occupied 
in  some  way  most  congenial  to  her  tastes — ^pleasant  conversation, 
drives  in  the  country,  music,  painting,  etc.,  are  all  so  many  re- 
sources, which  may  be  advantageously  resorted  to. 

In  those  examples  in  which  the  mind  of  the  patient  continues 
unsettled,  accompanied  by  violence,*  rebellious  to  ordinary  restraint, 
the  question  will  of  course  arise  as  to  the  necessity  of  removing 
her  to  some  Institution  fitted  for  this  special  class  of  cases.  The 
alternative,  however,  I  should  be  indisposed  to  adopt  except  under 
the  most  urgent  necessity. 

*  The  soothing  influence  of  ether  will  oftentimes  exhibit  itself  most  benefloiftlly 
ia  quieting  the  vloleut  agitation^  oogasionally  found  to  aooompany  this  < 


LECTURE    XLVL 


PiiJegnuiitU  Dolofin,  aUtioQf^h  f?enpmnj  mcidetit  to  the  jyiierpenl  ct»te,  It  not  ilwifa 
«o~It  mny  develop  iUelf  in  lUv  Hoti-puerpcml  wonmu,  and  aivu  lu  i\w  oisk  «ex; 
btU  lirtlt^  utirltit^trnMl  by  tho  early  FitUtem — Mauriceau  ibfi  fimi  to  dirvd  0p(i«ial 
ntU'rition  Ut  it — Kia  Views  ofiu  PathoU)^— The  Views  of  Pukm  Mid  LmH— 
Ilistoricol  SkeU*li,c*f  I  he  Diiieftse— -Mr,  Wliitc  of  MDiidjcMcr— Mr  Vrjt^  ofGloiaoH* 
K»f— Or.  KMriier— Mr.  Hull— M.  All^eri — M  But»iJlmul— rmfi»»*srir  Davin  of  Voth 
don — I)r.  Rt>b«i?rt  Lft—U  Ph]t*}rmMai»  Dolens^a  Crunil  Piileblii*? — J>r,  Ma€%f<ft* 
«b,of  Londoit — Ig  Plilegrnw.^m  DoleitauToxfcmia? — Synonyms— d«m»«  of  U»  DU> 
eiiPH*;  Syinptoin.4 — Why  is  OCdeiim  a  Symptom  of  Phk'gmitaiK  DaUma ?<— GliUBei  of 
Dmpf*inil  Kn'uMion;  Uk^  tviiition  between  Uio  a'lJemrt  of  phl^fgmtt^tn  tV*|f»T»^  bh^ 
Otmtriiett'd  Vvnoua  Circular  iitu — Proof — Are  the  Veins  A biKjrt*ntn  T—  '  K  t* 

porimeT)t!4— Tlocrhaavp;  Van  Swirien,  Hoffman,  Mor^oK^I,  Cullen^  ud 

BotiiUititti^TheCKdpmfl  of  Pregn*uiey  —  How  Explri'tncd— VVhidi  oft)  i  :x» 

trt^milii^M  b  »«»{ liable  to  PhU-g^masm  Dolensf— Tbe  Cauieaof  \hr  p  \i 

what  PoritHl  a(U*r  LjitK^rdiM.-!^  this  Dist^a^e  nuM^t  unuaUy  ocTur? — ) 
mufliu  Doleii«— StatUiit^ — Diiigncj^is— Prugnosi» — P^o^rfe»^DllI  i 
tion  of  tin*  Di^^a/iQ— Com  plica  tiouB — Wl>«i  art?  they? — PuruJi'nt  iJ-oUccium^^^*thnr 
Gmaequvnces—  Periloniti8^Mclrf>Pori!onuiB— Trcalmcnl  of  P|jiegii»ik  Dokiu — 
lU  Indiottions— Local  AppHcMliouA  with  the  vitiw  ufdiinlniihiDg  Piiiiu 

Gextlemkx— The  dUease  knoun  as  Phkgnm$ia  DolnnM  U  itmuUljr 

rla,s«cd  nnimip  the  nrtVctiont*  incident  to  the  puorpcml  i*tfitc;  hut, 
at  the  same  liniL',  k  should  be  recollected  that  it  In  nut  exdtijiivcljr 
rentricted  to  this  period,  lor  it  will  oce.'i&ionnjly  develop  itMiir  in 
the  nou-ptie»-peral  woiunn ;  and  exnmplea  of  the  diaeaste  have  ctoq 
been  obiK*rved  in  the  male  sex.  I  have  looked  in  vain  for  a  cle»i;ri|i* 
tion  of  this  interesting  affection  among  the  early  Falh'  "     ;ir 

ocience;  there  is  the  .slightest  possible  idliLsiun  to  it  by  ili,  -; 

and  if.  jierhnp,  we  except  Rodcriciis  a  Castro,*  we  have  n 
hi  u»lditioii  toiKhing  it,  until  the  time  of  Alanriceau,  who  aj  |.    ,.^ 
to  have  been  the  fir^.!  to  have  directed  apeeial  attention  to  tbr  fliA* 
order,     IWa  views,  as  we  fihall  pre!*ently  sec*  of  h*  i  ^e 

not  the  views  reeognistHi  by  M-ience  in  our  day  j  noi  n> 

diate  suecc^sofR,  Pijzi»s,  Lcvret,  and  others,  puccced  in  tlirowiiig 
any  ailclilional  light  on  the  true  nature  of  the  tiialady.  It  niuit^ 
however,  be  conceded,  that  these  observers, alt hongh  their  patbalogy 
was  criule  arj«l  without  a  basis,  exhibited  renuukable  cleveme»  in 
dcHciihing  the  more  pronuiunt  symptoms  of  the  di&eafic,  nor  wero 
thtir  therapeutiea  of  the  affection,  con  ti^idering  the  ilmcft  in  wUcli 
they  lived,  less  worthy  of  note. 

•  1603. 


1 
I 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  709 

JUistorical  Sketch  of  Phlegmasia  Dolens. — Mauriceau  attributed 
the  origin  of  the  affection  to  a  collection  of  humors,  which  should 
have  passed  off  with  the  lochia!  discharge ;  and  he  says  the  legs  and 
thighs  become  oedematous  and  greatly  swollen,  sometimes  extend- 
ing from  the  groin  to  the  foot ;  the  CBdema  and  enlargement  may  in- 
volve one  or  both  extremities.*  Puzos  supposed  the  disease  to  result 
from  a  deposit  of  milk  in  the  part  affected,  this  deposit  commenc- 
ing in  the  groin  and  upper  portion  of  the  thigh ;  the  pain  experi- 
enced by  the  patient  was  usually  in  the  direction  of  the  large  vessels 
coursing  along  the  limb.f  Levret,  who  also  believed  in  the  milky 
metastasis,  tells  us  that  the  swelling  caused  by  this  deposit  ordinarily 
terminates  in  infiltration  of  the  cellular  and  adipose  tissues  of  the 
parts  affected,  and  that  all  these  parts  become  very  Qederoatous.| 

Mr.  White,§  of  Manchester,  in  1784,  maintained  that  the  disease 
was  due  to  an  obstruction  of  the  lymphatic  vessels  of  the  parts,  and 
that  these  vessels  became  obstructed  during  the  process  of  labor. 
Mr.  Frye,  of  Gloucester,  in  an  essay  published  in  1792,  taught  that 
the  lymphatics  at  the  brim  of  the  pelvis,  just  under  Poupart's  liga- 
ment, became  ruptured,  and,  as  a  consequence,  there  was  an  escape 
and  diffusion  of  lymph  into  the  cellular  tissue  of  the  limb.  Dr.  Fer- 
rier,  on  the  contrary,  believed  that  there  was  neither  obstruction 
nor  rupture  of  the  lymphatic  vessels,  but  that  the  pathology  of  the 
disease  consisted  essentially  in  inflammation  of  these  vessels  and 
glands.  In  1800,  Mr.  Hull||  advocated  the  opinion  that  the  proxi- 
mate cause  of  the  disorder  was  an  inflammation  of  all  the  ororans 

o 

*  "  J'ai  vft  pluaieura  femmea  ftpres  6tre  accouchees  assez  heureusement,  avoir  les 
jambes  et  lea  cuisscs  toutes  oedemateuses  et  extraordinaireraent  grosses,  quclque- 
fois  depuis  I'ainc  jusques  a  rextremite  du  pied,  parfois  d'un  seul  c6t6,  etd'autres  fois 
de  tous  Ics  deux.  Oct  accident  survient  souvent  ensuite  d^une  douleur  sciatique 
causee  par  un  reflux,  qui  se  fait  sur  ces  parties,  des  humenrs  qui  devroient  ^tre  eva- 
cuees par  les  vindanges,  dont  le  gros  nerf  de  la  cuisse  s  abreuve  quelquefois  tene- 
ment, qu'il  en  peut  rester  &  la  femmo  une  claudication  dans  la  suite." 

[Traite  des  Maladies  des  femmes  grosses,  et  de  cclles  qui  sont  accouchees.  Tome 
premier,  p.  446.     (1740).] 

f  '•  Les  dep6ts  laiteux  lea  plus  communs,  apr^s  ceux  des  mamelles,  sont  ceux 
qui  se  font  sur  les  extr^roites  inft^rieurs.  Ces  d^pdta  ne  se  forment  gu^res  avant  le 
douziemo  ou  la  quatorziemo  jour  de  la  couche.  C*est  dans  Taine  et  dans  la  partie 
superieur  de  la  cuisse  que  le  depot  .commence  k  donner  des  signes  de  sa  presence  par 
la  douleur  que  Taccouch^'O  y  ressent;  et  la  douleur  suit  ordinairement  lo  trajet  des 
gros  vaisseaux  qui  descendent  le  long  de  la  cuisse."  [Traite  des  Accouchemens, 
p.  350.     (1769).] 

X  "  II  e.st  cependant  encore  plus  ordinaire  de  voir  cet  engorgement  laiteux  8e  ter- 
miner aux  depens  de  Tinflltration  du  tissu  cellulairo  qui  garnit  les  interstices  des 
muscles  de  Textremit^  du  mdme  oi^t^  ensuite  du  ti.ssu  graisseux  qui  est  8ou.s  la 
peau  de  la  cuisse,  de  la  jambe,  et  du  pied.  Toutes  ces  parties  deviennent  alors  fort 
oedemateuses."     [L'Art  des  Accoucliemens,  p.  177.     (1766).] 

§  An  Inquiry  into  the  Nature  and  Cause  of  that  Swelling  in  one  or  both  of  the 
Lower  Kxtremities,  which  sometimes  happens  to  Lying-in  Women. 

I  Au  Kssay  on  Phlegmasia  Dolens,  by  John  Hull,  M.D.,  Manchester^  1800. 


no 


TllK   PRINCIPLKS  AKD  rHACTICK  OF  OBSTTTRICS. 


and  tissues  of  the  aflTeeted  lirab,  resulting  in  n  protu 
ofcottgiilablo  lymph;  and  in  this  way  ha  t?x plained  : 
Bwelling,  two  of  the  prominent  charactci  Uticj*  of  the 
saya  the  nerves  are  primarily  aftected — that  thi*  I'-'^f  .„,_„. ..,^ 

the  disorder  ia  essentially  a  neuralgia,  and  th>  one  of  Hi 

etTeetft**     It  may  here  be  remarked,  that  the  o[  '    mwas, 

to  H  certain  extent,  sustained  by  Dugua,  Sieb<jld,  i  u  xlwf 

did  not  altogether  reject  the  pathological  ehrin<i:es  in  the  otlior  tMRMML 

So  far,  we  have,  I  think,  what  may  be  appropnatelf  t4*nii6d 
mixed  opiniona  ns  to  the  true  nature  of  phlogm:i$ia  doten^,  iritlioiil 
much  a[>]irijaeh  to  a  eoneurrence  of  s^nitimeDt  amang  Uie  aathon 
ciicd.  In  January  1H2:J,  however,  a  new  tlw*ory  was  advanced  hj 
M.  Houillaud,f  who  referred  the  di^iease  to  ati  inflammatioti  and 
obstruction  of  the  crnral  veins,  and  it  is  well  to  remark  thai  tlib 
explanation  is  the  one  now  very  generally  acceptetl  t»y  the  prafiia- 
aion.  It  h  claimed  for  M,  Boutllaud,  that  he  waa  the  tirsl  to  poiol 
out  this  pathological  condition  of  the  disease ;  but  it  aeems  rmj 
satisfactorily  dcmon8ti"ated  that  the  credit  reaUy  UdongM  to  tlw 
late  Professor  Davi;^  of  London.  As  early  us  1817,  ho  prored  by 
dissection  of  a  fatal  case,  which  had  occurred  to  him,  Uiat  phle;^ 
masiu  dolens  involved  an  inrtammation  of  tlio  iliac  and  funioml 
veins ;  the  dissection  was  witnessed  by  Mr.  Lawrence,  In  BIay« 
1823,  Prof  Davis  read  before  the  3ledical  ami  Chirurgical  Soci«*ij4 
an  interesting  j^aper  on  the  disease.  It  will,  therefore,  l>c  Jtcrii, 
that  although  Dr*  Davis's  essay  diti  not  appear  until  four  montlia 
subsequently  to  the  paper  of  M.  Bouillaud,  yet  be  had  atsttmllf 
observetl  in  dissection,  six  years  previously,  th©  patbologkal  hel 
under  consideration. 

Dr.  Uolx^rt  Lee,  of  London,  concurs  in  the  view  that  the  patkcK 
logy  of  the  disease  is  re:vlly  a  crural  phlebitis;  but,  at  the  flaim 
time,  he  maintains  that  the  ii  ill  am  mat  ion  commoncea  in  the  Tofam 
of  the  uterus.g 

It  is  proper  here  to  state  that,  in  1826,  Mr.  Guthrie  had  ang- 
gpsted  the  opinion  that  crural  phlebitis  was  simply  an  tfXtenMii 
of  inflammation  from  the  veins  of  the  uterus ;  and  it  waa  nol  mtfl 
I821>  that  Dr.  Loe  demonstrated  the  coincidence  of  ittertoe  and 
crural  phlebitis.  In  a  more  recent  paper  on  this  subject  be  irrilaa 
thus:)  ^'The  results  of  the  last  twenty -four  years'  experieoee  i»i>- 
lirm  roy  previous  observations,  and  I  am  aatiafied  thai  iiiflantaiaiioii 


•  HuftjUrid's  JoutoaI,  p.  16.  Feb,  1817, 
f  De  rc^blii^n  des  rentes  ei  dt*  ami  iuflucncd  vur  1*  formAt*  dot  hj^ftfk  partial 
Anerlitrm  jEfetJonilca  de  m«^!.»  Jnnvier  ISaa,  p.  1841,  T,  U. 
\  ijcd  Ami  Chinirg.  Tnm«,,  vol,  xil,  J  852.1. 
$$  pHllioIo^ical  R(*^  Mivhi-a  tm  lotjiimmiitioii  of  th«  Tolas  ciT  tlM  UMra^  Hnfto 

I  Cyelojuedia  uf  PrncL  Med,,  18^5.  voL  UL.  Art  P1il«{^naift.  Dok^n^  pw  6M^  «IM^ 


THE  PRINCIPLES  AND  PRACTICE   OP  OBSTETRICS.  711 

of  tlie  iliac  and  femoral  veins  is  the  proximate  cause  of  the  disease, 
and  that,  in  puerperal  women,  the  inflammation  commences  in  the 
uterine  branches  of  the  hypogastric  veins."  There  is  no  doubt 
that  Dr.  Lee  is  correct  in  some  cases,  and  that  the  crural  phlebitis, 
which  results  in  phlegmasia  dolens,  does,  in  certain  instances,  com- 
mence in  the  veins  of  the  uterus ;  but  that  this  is  not  always  so  is 
clearly  sliown  by  two  facts:  Ist.  Phlegmasia  Dolens  has  been  recog- 
nised in  tlie  puerperal  woman  undc*r  circumstances  in  which  the 
uterine  veins  were  in  no  way  involved.  2d.  There  are  examples 
of  the  disease  occurring  in  which  the  veins  of  the  lower  part  of  the 
extremity  were  alone  the  seat  of  inflammation,  without  the  slight- 
est manifestation  of  disturbance  in  the  vessels  of  the  uterus. 

That  clever  pathologist,  Virchow,  believes  that  the  incipient 
morbid  condition  of  the  disease  consists  in  the  presence  of  a  coagu- 
lum  in  the  veins ;  and  that  the  inflammation  of  the  vessels,  the  effu- 
sion of  lymph  and  purulent  secretion,  the  breaking  down  of  the 
coagulum  and  the  presence  of  pus  in  it,  are  purely  incidental  to  the 
occlusion  of  the  veins. 

The  last  special  writer  on  phlegmasia  dolens,  Dr.  T.  W.  Macken- 
zie, of  London,  while  admitting  that  the  phlebitic  theory  of  the 
affection  is  better  sustained  by  facts  than  any  other,  which  had 
preceded  it,  believes  that  he  has  demonstrated  the  following  con- 
clusions at  which  he  has  arrived : 

"  1st.  Crural  Phlebitis,  in  a  pure  and  uncomplicated  form,  cannot 
give  rise  to  all  the  local  and  general  phenomena  of  the  disease,  and, 
therefore,  cannot  be  its  proximate  cause. 

"  2d.  Phlebitis  itself  is,  for  the  most  part,  not  a  primary,  but  a 
secondary  affection ;  and,  in  the  great  majority  of  cases,  is  a  conse- 
quence of  the  circulation  of  impure  or  morbid  blood  in  the  veins. 

"  3d.  The  proximate  cause  of  the  disease  is,  therefore,  presum- 
ably a  morbific  condition  of  the  blood,  which  I  have  experimentally 
shown  to  be  capable  of  producing  not  only  the  lesions  of  the  veins 
met  with  in  the  disease,  but  all  its  other  phenomena.'** 

I  have  read  with  much  interest  the  excellent  monograph  of  Dr. 
Mackenzie,  but  really  I  do  not  see  that  he  has  proved  anything 
which  all  good  observers  are  not  willing  freely  to  admit.  In  the 
first  place,  it  seems  to  me  that  crural  phlebitis,!  like  pneumonia,, 

*  Tho  Pathology  and  Treatment  of  Phlegmasia  Dolens,  etc,  1862. 

f  It  may  be  remarked,  tliat  phltlntis  which  precedes  phlfgmasia  dolens^  difTers^in  no- 
sensible  particular  from  ordinary  phlebitic  inflammation.  In  men.  as  in  women., 
this  latter  has  been  occasioned  by  carcinoma  of  tho  rectum,  the  introduction  of  a 
sound  into  tlie  bladder,  giving  rise  to  inflammation  of  the  veins  of  the  prcntoite,  audi 
thus  involving  the  adjacent  venous  trunks.  An  example  of  this  is  recorded  by 
Cruveilhier.  Valleix  mentions  two  interesting  cases  of  phlebitis  caused  by  the 
pressure  of  an  ovarian  tumor.  It  is  also  well  esiJiblished  that  inflammation  of  the 
iliac  and  femoral  veins  is  not  only  not  peculiar  to  women  recently  delivered;  but  n»ay 
arise  from  suppression  of  tiie  menses,  malignant  disease  of  the  os  and  cervix  uteri^, 
and  from  ci.largement  of  the  organ  from  any  patliological  cause. 


712 


THE  PRI?^C1PLES  AKD  FR-iOTlCE  OF  OBSTCTRICS. 


pleurisy,  or  any  other  inflaramalion,  i^,  if  you  please,  a  product  or 
an  effect  ot'siHue  antc'oc<lcnt ;  it  will  not,  I  iJtink,  be  atu-mpteii  to 
beishtnvn  that  it  lias  ;i  spontancKius  orij^in,  and,  therefore,  it  miigt 
rightfully  classed  jiniorig  the  Becoiidary  atleeiions.  Ag^in,  in  in»; 
taiuitjg  that  a  *'  morbific  condition  of  the  blood*'  U  th©  proiimafp 
cause  of  the  disease,  he  says  what  every  experienecKl  ubstecrician  wil 
rnidily  coneedt^  is*  often,  hut  not  always,  the  case;  or,  in  oth 
words,  that  this  state  of  the  iAood  is  fretpiently  the  startliig  imn 
of  the  malady.  If  we  look  at  tlie  phases  through  which  the  pnrr 
peral  woman  pas?*es,  we  cannot  be  surprined  that  she  nhould^  imder 
certain  eireutnstancei*,  have  her  bloml  contarriiriated,  exhihilui;::  n 
veritable  toxtenda.  At  llie  same  time,  I  do  not  doubt  that  m;tri> 
other  iutiuenees,  sueli  as  cohl,  a  protracted  or  instrumental  ddi- 
very,  iiyury  to  the  parts,  t^c,^  will  cause  crural  phlebitis  which  may  ' 
result  in  the  proihictlotj  of  phlegmasia  dolen^, 

1  can  not  myself  see  jnuch  force  in  the  position  assumed  by  Dr., 
Mackenzie,  that  '*' crural  phlebiLis,  in  a  pure  and  uncomjilieated 
form,  cannot  give  rise  to  all  the  local  and  general  phenomena  of  the 
disease,  and,  therefore,  cannot  be  its  proximate  cause.'^  My  owu 
r)i>iniuti  is^ — and  this  opinion  is  fctunded  on  clinical  experience — that 
jihough  crural  ]>hlehitis  is  undoubtedly  an  es^nential  element  uf 
phlegmasia  dolens,  yet  it  by  no  uieans  follow*  that  this  latter  affec- 
tion will  necesitarily  succeod  every  case  of  phlebitic  inflammation ; 
and,  *ni  the  other  hand,  T  am  quite  confident  ihat  T  have  observe 
examples  of  phlegmasia  doleus  developing  itself  an  the  eonsequeao 
of  a  ^' pui*e  and  uncomplicated  form''  of  crural  (»hlebitis. 

Stjnomjms, — ^Phlegmaaia  Dolens  has  been  described  under  a 
variety  of  names,  dej>cnding  on  the  poculiar  palhologi<%al  vioir 
entertained  by  dilTerent  authors.  The  following  brief  eummar 
will  f iirly  exhibit  its  varied  nomenclature :  iMatirioeaii  calh?*! 
ftweUinff  ctf  the  letj  of  the  pueij>eral  woman;  Puzos  and  Levrvt, 
mtfl'i/  {lf/x>sit^  miUq/ enf/orriement  /  Callisen,  rtrife///<i  puerj^erarum  r 
White,  phhf/maaia  alha  doletis  piter/yeramm ;  GcN>d,  »par*juiU 
ucrjirrfirum ;  Young,  cr/V/r/wja  iViiematicmn  ;  Hubert  T 
ids  vrnralis;  llayer,  ht/drophlefjmasia  of  the  r^Mnlar  ( 

infer it^r  enptremities  ;  Duparcquc,  bjmphatk\ pahtful  ami  true^ 

MffmaMa,  It  has  received,  in  addition,  the  following  de*iim*- 
tions:  a.^tlema  lactimn^  phk(/uia»la  lactea^  atmsarca  serosa,  strtfftd 
le(/y  whHe  /t'y,  nnlk  hff, 

(J*.tui!tts.—Amo\\g  the  causes  oC  p/Ueffmctsta  dolena  may  be  enti* 
meraied — exposure  to  cold  and  dampness,  errors  of  diet,  tt>o  *u(m 
gettitig  up  aller  delivery;  and  there  can  W  no  doubt,  that  rod 
manipulations  on  the  part  of  tlie  accouchenr/n»strument:d  delivc 
a  i>r<*iracte(l  labor  during  wljieii  the  orgtms  have  umlergone  midu 
pressure,  aiid  the  artificial  extraction  of  the  (^laceuta,  may  be  tneo^i 
tione«.l  a3  among  the  predisposing  cjaiwes  of  the  aflectiou. 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.  718 

Symptoms, — ^The  symptoms  which  usually  characterize  this  dig- 
ease  cannot  be  said  to  be  uniform,  while  they  are  ordinarily  coinci- 
dent with  those  of  iliac  and  crural  phlebitis.  In  the  first  place,  the 
first  indication  of  trouble  may  be  a  chill  of  more  or  less  duration. 
Again,  the  first  development  of  the  disease  will  be  a  local  pain  on 
one  or  other  side  of  the  pelvis.  It  may  be  said  that  pain  is  one  of 
the  most  constant  symptoms  of  phlegmasia  dolens,  but  it  will  vary 
in  its  type,  severity,  and  seat;  sometimes  superficial,  extremely 
acute  and  lancinating;  at  other  times  dull  and  deep-seated.  It 
may  be  felt  in  the  entire  limb,  or  be  confined  to  one  portion  only. 
It  will  usually  commence  in  the  groin,  and  extend  downwards  in 
the  direction  of  the  affected  limb.  Again,  the  first  evidence  of  the 
malady  will  be  an  acute  pain  hi  the  calf  of  the  leg ;  when  this 
occurs  it  will  generally  be  observed  that  the  swelling,  a  constant 
element  of  the  disease,  will  commence  at  this  point,  or  at  the  foot, 
and  gradually  travel  up  the  leg  and  thigh.  There  is  one  circum- 
stance  which  may  be  regarded  as  pathognomonic  of  phlegmasia 
dolens  when  it  attacks  the  thigh,  and  it  is  this — Tlie  finger  can  dia- 
tinctly  trace  the  femoral  vein  from  the  groin  as  it  courses  down 
the  thigh  ;  it  imparts  a  sensation  of  hardness^  and  roUsj  as  it  toere, 
under  the  finger  like  a  cord.*  Pressure  upon  this  vein  occasions 
very  intense  suffering,  whilst  pressure  on  other  portions  of  the 
limb  is  ordinarily  accompanied  by  little  or  no  sensibility.  The 
pain  of  phlegmasia  dolens  is  occasioned  by  inffammation  of  the 
venous  trunks,  and  it  is  worthy  of  remark  that  the  pain  follows 
very  exactly  in  the  direction  of  the  inflamed  vessels.  The  exten-. 
sion  of  the  limb  will  increase  the  suffering,  and  hence  the  patient 
of  her  own  accord  usually  places  it  in  a  state  of  semi-flexion,  and 
requests  that  it  may  be  retained  in  this  position  by  means  of  a  pil- 
low. The  pain,  under  ordinary  circumstances,  is  most  acute  dur- 
ing the  first  two  or  three  days.  It  usually  precedes  the  cedema; 
and  yet  there  will  sometimes  be  a  simultaneous  development  of 
the  two  phenomena. 

The  swelling  or  oedema  of  the  limb,  like  the  pain,  is  a  uniform 
accompaniment  of  the  disease.  The  general  rule  is  that  it  appears 
first  at  that  portion  of  the  affected  extremity  at  which  the  pain  is 
originally  experienced;  this,  however,  is  not  always  so,  for  it  will 
occasionally  be  observed  at  some  remote  part  of  the  limb  distant 
from  the  seat  of  suffering,  but  always  between  this  latter  and  the 
ultimate  venous  ramifications.     It  must,  however,  be  remembered 

*  The  fact  of  feelinp:  this  cord  is  conclusive  evidence  of  inflammation  of  tlio  vein, 
and  at  tite  same  tidic  of  tho  coagulation  of  tiie  blood  wiihiu  the  coats  of  tlie  vessel. 
M.  Lu;:()l  mentions,  as  an  exccplional  circumstance  (Journal  des  Projrrfes,  t.  xiv.) 
a  rom.'jrk.ible  fact,  and  cites  an  example  in  illustpation — that  nearly  all  tho  veins  of 
thQ  affected  limb  may  become  bard  and  knotty,  presenting  the  peculiar  feel  of  a 
3ord. 


ri4 


THE   PRINXIPLES  AND   PRACTICE  OF   OBSTETRICSw 


tTiJit  no  matter  where  the  cetiema  first  ui  i  thi 

entire  cxtremily.     It«  progreaa  h  alrao  r  <*i»t 

of  f»:iin  towardj*  the  lower  |Kiriion  of  the  limb.  At  tiinesi  ihu  knell- 
ing b  etiorniou«,  givinij  t«  iho  aQV'cted  extrcmiiy  a  volume  |wic« 
the  nhe  of  the  other;  ai  this  period  the  inleg-iiments  oniU*r^o  t-xtrn* 
ordimiry  leusion ;  ihey  presont  a  more  or  less  :v 

rencp,  and  assume  a  marked  whUo  t-olor.     In  i  -  itf 

extreme  ieunion  of  the  partR,  the  linger  will  not  pit  thum  on  pre«- 
snre;  and  it  is  not  until  the  lapf^e  of  some  days,  whtra  llic  ibvitei 
become  more  retaxcitl,  that  the  impression  of  ihe  finger  becaoMM 
visible.  There  is,  nfi  a  general  rnle,  a  decided  diminultoii  in  tlie 
fiiEe  of  the  limb  after  twelve  or  fitleen  dnyi.  The  engorgeineiit, 
when  exoes.4\'e,  may  be  much  lej«ened  by  Blight  aperuiresi  imid« 
with  the  lancet,  as  in  other  examples  of  <rdemalou«  AwellinipL 
Occasionally  there  will  be  oh?*crved,  on  the  white  and  g^i^lttfuiag 
surface  of  the  oxtremity,  rcddinh  bandi«  or  spots  ninning  along  thm 
course  of  the  inflamed  vesselj*;  Rfjtneliine»,  in  lieu  of  iIm^-iv  fl-.-rH 
will  be  seen  vesicles  of  a  dark  or  blacki^^h  hue. 

Conjoined  to  the  lt»cal  synifitom**,  junt  de«*'til 
tinned  ec»rt«in  con«litntion.il  disturbances  more oj 
affection*     For  example,  the  puhe  will  becotne  acceteraiiHi,  wi 
from  100  to  140  and  njiwanU;  the  tongue  coated,  with  nlW' 
marked  thirst;   countennnce  usually  pale;    the  bowds  *oni. 
torpid,  at  nthcr  times  diurrba*a  will  supervene;   lo»*  nt  rz, 

and  derangement  of  the  urinary  «ccreiion,  the  latter  b^  „  .i- 
iiarily  dark  colored  and  tnrbid.  The  patient  1.4  irritaUl#  ami 
re8tle»tflu  SometimcH  the  nkin  U  dry  and  burning;  agaiti  r  '  '.e 
eo%'cri'd  witlj  perspiration.     Shouhl  the  disease  occur  dm  ^w 

iianey,  as  will  HOTuetiuies  happen,  there  will  be  a  dlurm)>  .^ 

tiou  of  milk,  and  the  brea^Ms  will  become  notably  Irswcu,  .,  ...:*» 
the  mjdsdy  should  l>e  of  short  duration.  The  lochial  diickargi^  b 
neither  60  eon^tantly  dimini^died  or  snppresfted  M  would  tiaiarAlly 
be  inferred  wouhi  be  the  ca^te. 

JV/ti/  18  (iLffrma  a  i*t/mptom  of  PhUfjfnnKin  Dcdeits  /— Tbl*  lA 
Au  interesting  inquiry,  anti  is  readily  explained.  AoaitiirrA,  or 
csdema,  \h  an  infill  ration  of  nerum  or  the  watery  clement  of  lite 
blood  into  the  ecllulnr  tis*iio,  ami  reprenent^,  therefore,  <  1* 

numeroUH  forrnn  of  dro^i^ieal  effu'^ion.     There  are  various  .  f 

anasarcouH  engorgements  «*K-h  nn  discaae  of  the  liver^  ki^io^y, 
he:irt^  etc.,  but  of  the  pathology  of  thede  organn,  and  itM  cooae* 
quentH*H,  it  is  tiot  my  purpose  to  sp^ak  at  pri*?ient.  1  shall  timtt 
fiiy^elf  to  the  solution  of  the  •simple  inquiry —  IP/iy  h  anasarra  Om 
Ufiiform  mmtfft^Mtuim^jit  of  p/ticf/masm  dolcnsf  Tlie  anawef  to 
tht«  inierrogaiiuy  is  in  my  opining  oonclusive  evideuoe  of  what  hsa 
already  been  j*tsilt*d,  vir..  ifmt  tht  imthitioffif  o/p/tf  7  dotens  it 

an  iiiac  or  crural  phUbitis,     Anasarca,  tlicn,  ;:  ^vt  phteg* 


THE  PRINCIPLES  AND  PRACJTICE  OP  OBSTETRICS.  715 

masia  dolens  because  of  venous  obstruction,  the  obstruction  in  this 
special  case  depending  upon  the  blocking  up  or  ooclnsion  of  one 
or  more  of  the  veins  of  the  affected  limb,  as  the  result  of  inflamma- 
tion. Lot  us  examine  this  point  a  little  in  detail.  It  has  been 
8ho\vn,  1  think,  veiy  conclusively,  that  one  of  the  attributes  of  the 
venous  system  is  its  power  of  absorbing  fluids;  and  it  has  been 
demonstrated  that  fluid  substances  may  pass  into  and  out  of  the 
veins,  through  the  process  of  transudation  or  imbibition.  But  this 
physical  act — imbibition  or  transudation — requires  for  its  accom- 
plishment a  certain  condition  of  the  veins;  for  example,  if  these 
latter  be  greatly  distended  with  watery  fluid,  the  further  entrance 
of  this  material  will  be  prevented ;  and  when  the  vessels  reach  a 
maximum  point  of  distension,  the  watery  element  of  the  blood 
will,  through  exosmosis^  pass  out  through  the  coats  of  the  engorged 
veins.  Thus  it  will  be  seen  that  excessive  plenitude  of  the  veins 
will  necessarily  result  in  an  eflusion  of  fluid ;  and  it  must  also  be 
recollected  that  this  fulness  of  the  vessels  is  almost  invariably  in- 
duced by  an  obstacle  to  the  free  passage  of  the  blood  through  the 
veins  to  the  heart.  In  phlegmasia  dolena^  as  has  already  been 
remarked,  the  femoral  and  iliac  veins  becoming  the  seat  of  inflam- 
mation are  occluded,  thus  necessarily  obstructing  the  circulation 
of  the  blood  in  these  vessels ;  and  this,  therefore,  is  the  true  expla- 
nation of  the  relation  which  is  found  to  subsist  between  phlegmasia 
dolens  and  anasarca. 

As  early  as  the  sixteenth  century.  Dr.  Lower*  satisfactorily 
established  by  experiments  on  living  animals  that  an  obstacle  to 
the  circulation  of  the  blood  through  the  veins  would  result  in  the 
effusion  of  serum.  He  placed  a  ligature  around  the  ascending  vena 
cava  of  a  live  dog,  and  then  closed  the  wound ;  the  animal  soon 
became  exhausted,  and  died  in  a  few  hours.  The  post-mortem 
examination  revealed  a  large  accumulation  in  the  abdomen  of  a 
serous  fluid  similar  to  what  would  be  observed  in  ascites.  In 
another  dog,  he  tied  the  jugular  veins ;  after  some  hours,  all  the 
parts  situated  below  the  ligatures  became  very  much  tumefied  ;  in 
two  days  the  animal  died  as  if  from  suffocation.  In  this  case,  also, 
a  collection  of  serum  was  observed  in  the  parts  above  the  liga- 
tures. I  might  likewise  cite  Boerhaiave  and  his  illustrious  commen- 
tator Van  Swieten,t  Hoffman,J  Morgagni,§  Cullen,|  and  others,  in 
confirmation  of  the  same  view. 

Majendie,  it  may  be  here  observed,  was  one  of  the  strongest 
advocates  of  venous  absorption.     His  experiments,  quite  conclusive 

*  De  corde,  item  de  motu  et  calore  sanguinis,  etc.     Cap.  ii.,  p.  123,  etsefiuent 
f  Van  Swieten's  Comraentaries,  t  iv.,  p.  186  et  seq.,  1770. 
X  Med.  Tnit.,  t.  iv,  cap.  xiv,  p.  431. 
g  De  sed.  et  cans,  morb.,  epist.  38,  §  19. 
I  Elements  of  Practice,  t  iu,  p.  556,  1787. 


716 


THE   PRINCIPLES  AND   PRACTICE   OF  OBSTETHICS. 


in  tlieinsolves,  was  the  stnt*tin<i-pomi,  if  I  may  iso  term  it, 
rotiR  lenrned  researchuH  on  tliin  ami  kindred  <iut^8tioQ»«  M,  Ui 
ill  182-1,  wrote  as  Ibllavvs:  *' I  siliiill  now  speak  of  those  dro^mieal 
i'^TusioiiJ*^  reputed  pnsHive,  and  shall  endeavor  lo  prove,  by  foctai 
nnd  oljservation^,  thnl  ihey  all  residt  from  obstruction  of  some  R<»n 
in  tfje  venuus  rirouhititnj ;  and,  in  a  great  luiuibcr  of  inaliUK-c^  thu 
obstruction  consists  in  the  occlasioti  of  the  veins  of  the  part  which 
is  the  Beat  of  the  dropsjt.'*  Andral^f  too*  has  recorded  kb  l«!ati- 
mony  in  very  positive  terms  of  the  relation  between  serous  infiltr;^ 
lion  aiid  vt*rioU'«  obstruction. 

W/tirh  of  (he  IfifWiftr  Extremities  is  tnoH  frequenth/  the  Seaij 
of  Phfe(/masia  Dokns  f — It  is  well  ^hown  by  etatistioi  that  the 
lull  limb  is  more  frequently  attacked  than  the  right  \  at  Uic  tame 
time,  itshouhl  be  stated  that  sometimes  both  limbs  become  invoUed. 
This  lalter  cireumstanee,  however,  is  comparatively  rare.  Varion* 
theories  have  been  suggested  in  explanation  of  the  prefere«ce  exhi- 
bitetl  by  the  affection  fur  ihe  Iel\  extremity — sucli  an  the  greater 
frequency  of  the  position  of  the  occiput  of  the  fcetus  to  the  left ;  the 
greutt'r  frequency  of  the  attachment  of  the  placenta  to  the  tell  wide 
of  the  uterus;];  the  tendency  of  the  female  to  rest  on  lh#  left  side 
rather  than  on  the  right  side.  One  or  other  of  these  circa mstancesi^ 
or  all  of  them  conjoined,  may  or  may  not  be  the  true  cause,  but 
further  observation,  I  think,  is  needed  to  decide  the  que£ttion«  Ad* 
mitting,  however,  that  this  \^  really  tlie  explanation,  I  do  not  too 
that  scienee  can  be  mudi  benetitud  by  it,  for,  with  the  exception 
ot  correcting  the  disposition  to  recline  on  the  leA.  rather  ihao  ontbe 
right  side,  nothing  could  be  done  to  avert  the  more  frequent  oeeitr* 
rence  of  the  disease  in  the  left  extremity*  and,  indeed,  if  this  cottld 
be  accomplished,  I  can  ])erceive  no  possible  advantage  derivable 
from  it ;  for  whether  phlegmasia  doleus  attack  the  right  or  left 
limb,  the  progress  of  the  affection,  its  phenomena,  and  therapeutics 
are  identical. 

At  wh<tt  period  after  labor  does  the  disease  usiuaUy  occxtrf*^ 
From  the  most  accurate  information  on  tliis  Rubjeet,  it  would  »eem 
that  there  is  nothing  positive;  the  affection  may  pre^^ent  itself  from 
the  first  to  the  thirty-fiflh  day ;  but,  as  a  general  rule,  it  will  be 
found  to  appear  not  later  than  three  weeks  from  the  time  f»f  p:\rtu* 
rition,  although  there  ore  exceptional  cases  in  which  it  has  not 
mftnifested  itself  until  the  hipse  of  two  months. 

*  Arclj.  gen,  de  Med.,  t  \\ ,  p,  188  et  aeq. 

f  Prvcis  d'Anat.  Vaxiu,  t  i ,  p  328, 

X  M,  Naet^'le,  Jr.,  lias  pmvod.  from  hisi  rcfleorclies  on  the  swbjt^: '  i%\\ 

cenia  in  »iiuiited  most  eomuionly  ori  the  left  surfiico  of  ih©  uicnjs  at 

of  these  researches,  as  well  ah  Ihcwe  of  Br,  Von   Rtt|;en,  on  i 
pgt*  373  of  this  volume.     It  rnoy  ftl^^n   be  BtAteU   tli»»t  Dr  Ci^i 
records  that  in  sixty *six  eatses  in  wliidi  Ujc  plnccmal  pound  wnfcdciccCi-d*  \\,  w 
on  iLo  left  side  of  the  uterus  in  Ihirty-eiglil,  tirid  oti  Ihu  right  in  iwciitve  l  i         ^ 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.  717 

Frequency  of  Phlegmasia  Dolena, — This  disease  cannot  be  said 
to  be  of  common  occurrence.  The  best  observers  will,  I  think, 
concur  in  the  following  statistics  gathered  by  M.  Raige  Delorme, 
as  presenting  a  fair  approidmation  to  the  facts  touching  this  point.* 
fn  1,897  females  delivered  in  the  Westminster  Dispensary,  White 
observed  the  disease  five  times ;  in  8,000  confinements  in  his  own 
pi*actice,  and  at  the  Manchester  Hospital,  there  were  but  four 
cases  of  the  disease.  Again,  in  900  deliveries,  Wyer  records  five 
cases;  in  1897,  Bland  five  cases;  in  200,  Sankey  one  case;  in  a 
practice  of  26  years,  Siebold  has  met  with  it  five  times  ;  Struve  fifteen 
times  in  18  years;  Robert  Lee  28  times  in  six  years.  With  an 
extended  field  of  observation,  I  find  but  three  cases  of  phlegmasia 
dolens  recorded  in  my  note-book,  and  two  of  these  occurred  in 
consultation,  one  with  Dr.  Philips  of  Harlaem,  the  other  with  Dr. 
Forbes  of  Brooklyn. 

Diagnosis, — ^The  diagnosis  of  phlegmasia  dolens  is  not  diflicult. 
There  are  certain  evidences  of  this  disease,  which  cannot  readily  be 
mistaken — such  as  the  pain  along  the  vessels  of  the  limb,  the  cede- 
ma,  and  especially  the  hard  cord  felt  by  the  finger  as  it  presses  on 
the  vtflamed  vein:  Sometimes,  however,  it  may  be  difficult  to  reach 
the  inflamed  vessel,  and  this  may  arise  from  one  of  two  circum- 
stances— either  because  of  the  excessive  engorgement  of  the  part,  or 
the  profound  position  of  the  affected  vein.  But  even  in  these  events 
there  can  be  no  embarrassment ;  for  the  progress  of  the  symptoms, 
and  the  particular  nature  of  the  oedema,  will  broadly  indicate  the 
affection.  It  may  not  be  altogether  unimportant  to  remark,  that  the 
anasarcous  swelling  of  the  limb  may  possibly  be  mistaken  for  the 
oedema  symptomatic  of  disease  of  the  liver,  heart,  or  kidneys. 
But  an  error  of  this  kind  would  disclose  great  carelessness  on  the 
part  of  the  medical  man.  In  these  latter  cases,  for  example,  there 
would  have  been  previous  indications  of  disease  of  these  organs; 
and,  in  addition,  a  proper  local  examination  would  disclose  derange- 
ment in  them,  either  functional  or  organic. 

Prognosis, — Phlegmasia  Dolens  is  not,  as  a  general  rule,  a 
grave  affection,  and  it  may,  therefore,  be  said  to  terminate  favor- 
ably ;  when  it  destroys  life,  it  does  so  through  some  of  the  more 
serious  complications,  which  occasionally  develop  themselves  in  the 
progress  of  the  disease. 

Progress^  Duration^  and  Termination. — ^The  febrile  excitement, 
together  with  the  pain  and  oedema,  so  characteristic  of  the  disease, 
become  gradually  diminished.  The  pain  subsides  first;  but  the 
swelling  continues  more  or  less  stationary  from  three  to  six  weeks, 
and,  under  some  circumstances,  for  a  much  longer  period.  Occa- 
sionally, however,  when  the  disease  is  slight,  the  swelling  will  dis- 

*  Compend.  de  Medecine  Pratique,  T.  Sixieme,  p.  471. 


718 


TITK   PHTKCIPLRS  AKD  FEAOTIOfi  OF  OMTETRTCS. 


appear  fiurn  tvvt^tity-fotir  to  ft*f  i       *  '     *  meiF 

of  the  limb  begins  sensibly  U»  -^ir,*!* 

mgly  Wa«,  and  the  impression  of  lh«  tinger  on  ibe  surun^c  imuh 
nidie  evident^  It  will  flonietimes  happen  that  tho  two  cxt>*  nvine* 
will  bt'coiiic  sncccjtaively  the  «eat  of  the  dl^eaiit*,  and  prt^risi !  v  ihr 
tiunif  phenomena  will  pre.<M3Ut  themselves  as  fit  the  commcneenient  of 
the  attack.  The  ii8u:il  termination  of /Vi/r^/irw/juVi  €lokf^  in  in  rv!H>* 
hui<»n,  which  commenoca  with  the  cessation  of  pain^  anil  m  dinl* 
nishrd  sue  of  the  limb.  Rut  it  should  be  r<M  "  '  '  '\  r  tii^ 
yiulding  of  tl»e  symptoms  will  hometiineH  be  pr«?  4  bj 

a  retnrn  of  tlie  paiti  and  cpdema,  from  error  uf  diet,  eji|icMmrv  to 
cold,  or  too  early  getting  up.  While  resolution  is  progressaop^,  an 
interesting  change  often  lakes  place  in  the  superficial  vebis  uf  the 
limb ;  they  become  more  or  less  distended  with  blood,  nhowiag 
that  a  uew  eollateral  circulation  is  going  on.  31.  Duplay^  wai^  I 
belies ve,  the  tirst  to  diit^ct  attention  to  this  latter  fact. 

The  disease  will  sometimes  lapse  into  a  chronic  stat^;  the  exHifip 
mily  then  becomes  enormously  enlarged,  the  surface  la  bard  tmd- 
Irregular,  and  lookis  not  unlike  elefihanti.iKis.  Indeed^  in  womm 
females  the  extremity  doos  not  resume  its  mitural  sixe  for  laoaliia, 
and  even  years. 

It  should  also  be  mentioned  that  the  allt^cted  limb  will  ocoi* 
sionaily  become  the  seat  of  abseesaea,  and  these  may  be  tingit  or 
multi|tle;   they  may  develop  themselves  in  the  v  oaa  or  in 

the  ^ub-apoueu^tJtic  cellular  tistaue;  hence  they  wi.  ^H*rlicblor 

dec|Mu*ated.  In  the  latter  cju^e,  the  abscesses  will  frequonUy  protc 
miHchiovous.  Other  complications  may  enaue,  such  as  |H*niittisiti«^ 
metrtk-peritonitisY  ascite^^  etc.  These  latter,  howeirttf,  caimtioi  be 
regar-ded  as  the  veritable  accompaniments  or  seqnelie  oi pAUfmt^ 

TrmtmenL — ^This  will  be  modi^ed  by  two  cireuin^ancea,  whicsh 
should  be  constantly  borne  in  mind — the  activity  of  the  attack,  aod 
the  constitution  of  the  patient.  If  the  pain  and  febrile  exctieinctit 
be  sc\  ere,  and  the  system  plethoric,  a  do/.en  or  more  let*cdi*'*  jn^y 
be  applied,  with  nignal  advantage,  to  the  groin,  and  ovrr  like 
intlained  femora!  vein;  these  should  bo  followed  by  warm  potil- 
tici'S  for  the  jmrpose  of  promoting  the  bleeding.     Th.  '       *  ^y 

be  repented  two  or  three  tirnen,  in  smaller  nnmber,  u 

the  indication  which  may  present.  Cathartics,  tinlens  vhctre  bo 
dian  hojiii,  are  e«[>ccially  proper.     Commence  witb : 

Q  Hjrdnrg.  c  crel4  gr,  xy. 

followe<l  by  two  wine  (flasses  of  the  following  saline  mixture  ev* 
four  or  six  hours,  until  free  purgation  is  accojipllshed  : 


*  Did  ae  Med.,  Ait,  PlOvg;  Doifmn,  3d  <^,  p.  94T. 


THE  PRINCIPLES  AND   PRACTICE  OF  OBSTETRICS.  719 

Se  Sulphat.  magnesise, 
Sup.  tart,  poiasisae,  aa  J  i. 
Aqu«e  dc8tillat«e  Oj. 

Ft.  Sol. 

If  there  be  evidences  of  sluggish  liver  with  dry  skin,  it  will  be 
proper  to  administer  occasional  doses  of  calomel  with  antiiliony  or 
Dover's  powder — say  gr.  ii.  of  calomel  with  gr.  J  of  antimony,  or 
gr.  iv.  of  Dover's  powder.  It  is  very  important  to  relieve  the 
patient  of  pain,  and  procure  her  comfortable  sleep.  For  this  pur- 
pose a  table-spoonful  of  the  following  may  be  given  every  half 
hour  until  the  object  is  attained : 

9  Sjrup.  papav.  f.  §  j. 
Mucil.  acacisB  f.  5  U* 
Sol  sulph.  morphis  (KCajend.)  gtt.  xii.     M. 

When  the  limb  is  much  engprged,  great  care  should  be  observed 
in  promoting  a  free  secretion  of  urine ;  for  this  purpose  let  cremor 
tartar  water  be  freely  taken  as  a  drink ;  or  the  nitrate  of  potash 
given,  gr.  xv.  in  a  tumbler  of  water  or  thin  gruel,  twice  or  thrice 
a  day.  The  diet  to  be  bland,  and  the  most  perfect  rest  enjoined, 
with  the  limb  slightly  raised  from  the  plane  of  the  body ;  the  nurse 
should  be  directed  to  protect  the  part  from  contact  with  the  bed- 
clothes, which  may  be  accomplished  by  means  of  a  cradle.  After 
the  leeching  and  purging,  marked  benefit  >vill  oftentimes  ensue  fi-ora 
the  application  of  small  blisters,  repeated  according  to  circum- 
stances, not  to  the  thigh,  but  to  either  the  internal  or  external 
malleolus.  I  have  great  faith  in  the  derivative  action  of  blistei-s 
thus  applied  in  the  acute  stage  o^  phlegmasia  dolens.  If  the  vital 
forces  become  depressed,  quinine,  together  with  a  nutritious  diet, 
will  be  indicated. 

One  word  with  regard  to  local  applications,  after  the  inflamma- 
tory state  has  passed,  for  the  purpose  of  soothing  pain.  A  warm 
bran  poultice  will  sometimes  give  much  relief— wrapping  the  limb 
in  flannel,  secured  by  oil  silk ;  the  extract  of  belladonna  smeared 
over  the  painful  portion  of  the  extremity ;  gentle  friction  with  lau- 
danum and  sweet  oil,  camphorated  oil,  or  soap  liniment;  and  if  the 
surface  preserve  its  integrity,  a  good  local  application  will  be  equal 
parts  of  chloroform  and  olive  oil. 

It  may  here  be  mentioned  that  when  the  oedema  is  excessive,  relief 
will  be  afforded  by  slight  punctures,  thus,  through  the  escape  of  the 
serum,  diminishing  the  tension,  and  consequently  mitigating  the 
pain.  In  the  event  of  purulent  collections,  either  superficial  or  pro- 
found, they  are  to  be  treated  on  general  principles. 


LECTURE   XLVII. 

KthenzAtion — ItH  Importance;  ADststheaui — mctknmg ot the  Term — Ai 
Midwrill*rj  of  Recent  Discovery— in  Surgtjrj,  of  ArrcioDt  I»Atc;  Tli«i 
AK«?»t^  »^'^*  i"  W8e — Sulplmric  Kther,  ChloTQform,  littd  Amjitnm — 8«ilpltai|e 
KtluT  dmi  cmployetl  as  nu  Aniwlhetic  by  I)r.  Mtirum;  in  rantiritlrin,  ity  Pn£ 
Simpfou;  iu  Hmt  trial  in  Amprica»  in  Labor,  by  Dr.  Keep,  ofBonuJD— Oilonafctw; 
it8  Introdnclion  by  Prof.  Simpson;  Amykne;  Dr  Snow  — Cr*nip*initi**o  Saletf  flf 
Siilplnirie  ElhePT  Clilorofomi,  «n<J  Aiuyleue'^Canluie  SyiK^)pi<*  ftnd  P^ralyBii  flf  Ite 
Ueart  from  CliU»roforni — ludknaUma  Tor  tho  use  of  Aitit^(lic>ti<^  in  I'liftMrition 
Should  tliey  be  employe*!  in  Natural  Loborf — Thdr  v  /  oifDffital  Mkt 

Mninnil  Delivery — Anattii}ieUo»  in  Inr«ncy— Infhicncv  oj  i  t  rm  Ccctfi^ 

titma  or  tho  UU'nia;  on  Muther  and  riiild— Flourr-nw  on  thi^  Nuv*  Id 

Ktb^ri/./\tton — Time  and  5Iotie  of  rcsorunjj  to  Amrflthnttcn  in  Vut  ^1i» 

PuIhc;    how  uO'ircied  by  Ktb«ri2iittciD**Er)jixiiig  Bficda  of  Eiheriya«tii»— i«» 
in  lUmstmliotL 

GENTLEATEX—It  Hiust  bc  unlvcrsjilly  coticctlcd  that  tW  contriUtsihMi 
whicli  »cieiioe  hm  made  lo  Buffeniig  lniiiiaiiity*^itnfe«th<mia,  or 
insensibility  to  pain- — whetlier  under  the  surgeon'i*  kiiifi^  or  dnring 
the  til  roes  of  labor,  ^iioiild  be  regarded  as  among  tb(»  moi$t  Kcrllni^ 
aderings  of  the  human  niind*  The  term  auj^e^thesla,  in  otir  day^  b 
etn[)Ioyed  to  designate  a  purlifJ  or  positive  unc'un$^;iou«ncM  throiigh 
the  adminiKtralion  of  what  arc  known  as  anieMhctica — rmire  espe* 
ciully  ether  and  chloroform.  But  while  employed  in  thi«  90CM\  tl 
is  well  to  recollect  that  the  true  signification  of  tfie  word  j^  m  IcMii 
or  privation  of  feeling.  Although  the  intnMluetton  of  ann^MhetJo 
agents  into  the  lying*in  chamber  for  the  purpose  of  dimin*  *  -  ^  :h^ 
anguish  of  the  parturient  woman,  is  of  recent  origin,  y  tj^ 

and  actual  practice  of  having  recourse  to  certain  agenta  HttU  iW 
view  of  preventing  suiTering  under  surgicid  operation!*  is  *if  very 
andcfit  date.  You  will  read,  for  example,  in  tbo  older  Grc^k  and 
Roman  authors,  minute  directions  for  tlic  adujl  '  n  of  tliclr 

favorite  mandragora  n«  the  great  remedy  for  sc^  in  ;  white, 

again,  among  the  Chinese,  the  Indian  hemp  fseetxied  to  poams 
superior  ana?Hthetic  charms.  I  do  not  propose,  however,  eltlier  lo 
diseu6j»  in  detail,  or  enter  into  the  history  of  the  interesting  f|tie«tion 
of  artfoithetic^*,  I  desire  himply  to  present  some  general  retnarlu 
touching  their  origin,  omplovment,  and  results,  during  the  pro^rtfi 
of  parturition  ;  with  this  view,  I  shall  endeavor  to  indicate  ciiHier 
what  circumstances,  in  my  judgment,  etheriKition  or  nn.'M^himi 
will  be  a  ]uslv&a\Ae  ve^tx.*    1\  U  needless  to  remind  you  that  tlHi 


I 


4 
4 


THE  PKINCIPLE3  AND  PRACTICE  OF  OBSTETRICS.         721 

first  introduction  of  these  agents  into  the  lying-in  room  was  very 
generally  hailed  by  what  may  be  properly  denominated  a  wild 
enthusiasm;  and,  as  too  often  happens  in  the  advent  of  new 
remedies,  there  was  more  zeal  than  judgment  displayed  in  their 
administration.  Hence,  with  some  practitioners,  ansBSthetics  were 
had  recourse  to  in  every  case  of  labor ;  the  one  idea  seemed  to 
prevail — the  accompliahment  of  childMrth  without  pain.  With 
such  an  unrestnctcd  and  indiscriminate  employment  of  these 
agents,  two  consequences  were  inevitable,  viz.  their  abuse,  and  to 
a  degree,  loss  of  confidence  in  their  virtues. 

The  Anceathetics  now  in  Use. — ^The  ansBsthetic  agents  which 
have  received  more  or  less  the  sanction  of  the  profession  are : 
1.  Sulphuric  either;  2.  Chloroform';  3.  Amylene.  It  may  not 
be  out  of  place  very  briefly  to  allude  to  eac&  of  these  substan- 
ces. 

1.  Sulphuric  Ether. — Without  intending  to  take  any  part  m 
the  controversy  as  to  whom  is  due  the  credit  of  suggesting  the 
ansBsthetic  properties  of  sulphuric  ether — whether  it  be  Dr.  Horace 
Wells,  Dr.  W.  T.  G.  Morton,  or  Dr.  Charles  T.  Jackson,*  all 
countrymen  of  ours — it  is,  I  think,  universally  admitted  that  the 
original  adminbtration  of  ether  to  prevent  the  pain  of  an  operation 
was  by  Dr.  Morton  ;  this  occurred  on  the  30th  of  Sept.  1846,  the 
ether  being  administered,  by  inhalation,  to  a  man  from  whom  Dn 
Morton  extracted  a  tooth  without  causing  the  slightest  paio. 
Prof.  Simpson  was  the  first  to  resort  to  this  agent  in  parturition, 
which  he  did  on  the  19th  of  Jan.,  1847,  and  became  satisfied  of  its 
ansesthetic  properties  without  its  interfering  with  the  parturient 
effort.  In  our  own  country,  sulphuric  ether  was  administered  for 
the  first  time  in  labor,  April  7th,  1847,  by  N.  C.  Keepv  M.D.,  f  of 
Boston,  with  most  satisfactory  results.  It  is  an  interesting  fact 
that  sulphuric  ether  was  given,  by  inhalation,  both  in  surgery  and 
midwifery,  for  a  period  of  several  months  in  America  and  in  Eu- 
rope, previously  to  the  introduction  of  chloroform  ;  and,  as  far  as  I 
have  been  enabled  to  ascertain,  not  a  single  fatal  case  had  occurred 
under  its  administration.  It  was,  if  I  may  so  term  it,  not  only  in 
good  repute,  but  had  gained  the  very  general  confidence  of  the 
profession  both  here  and  abroad,  until,  a»  we  shall  presently  see, 
the  force  of  circumstances  caused  it  measurably  to  give  place  to 
another  ansBsthetic — chloroform.. 

2.  Chloroform. — When  sulphuric  ether  had  been  tested,  and 
its  anaesthetic  properties  most  satisfactorily  demonstrated,  anxious 
for  something  still  better,  which  would  be  free  from  certain  sup- 

*  The  reader  maj  be  interested,  in  a  peruaal  of  '*  A  Defence  of  Dr.  Charlea  T 

Jackson*8  claims  to  the  Disooveiy  of  Etherization."    Boston,  1848. 

f  A  report  of  the  case  will  be  found  in  the  Boston  Medical  and  Surgical  Journal, 

April  14th,  1847.  ^^ 

40 


722 


THE   PRINCIPLES   AKD   PRACTICE   OF  OBSTETfUCa 


posed  ol»jc*ctions,  the  iintrring  mind  of  Prof.  Simfisoii,  ulwziy^  in 
pufBiiit  of  truth  and  irnproveiiic?iU,  developed  the  fact  that  elilore^ 
form  possessed  in  a  marked  dfgrer  aiia»j*t}ietJc  virtu e«.  Thi'»  limm^ 
ProfesHir  subjected  hii^  own  person  to  experiments,  with  a  view  of 
testing  the  value  of  the  ne*v  agent;  the  r»^adcr  will  be  m«rr  tlittn 
amtise<l  with  the  graphic  doiicHption  by  Prof  IMiller,  of  ll*e  fceikey 
which  ensoed  m  Dr.  Simpfton'a  dintn^*room,  when  he  and  Im  two 
friends,  Dra.  Duncan  and  Keith^  had  placed  themselves  nnder  lh« 
influence  of  chloroform.*  The  jifrxomd  experiments  with  tht«*ciil»- 
stance  were  most  8;itisfactory  to  the  gentlemen,  who  had  ftubmitted 
themselves  to  its  influence;  and  the  result  was  a  paper  from  VtoC 
Simpson,!  which  although  it  provoked  controversy,  &(m>d  gave 
popularity  to  the  new  agent  in  the  lying-in  chamber,  and,  fai  m 
measure,  cans^ed  its  adoption  as  a  substitute  for  sutphtirie  ellier. 
One  uf  the  very  tinst  to  have  recourse  to  chloroform  after  th©  ptiU 
lieation  of  Prof.  Simpson's  paper,  was  Prof.  >lnrj>hy4  of  th«  Londoo 
Univei'i^ity — it  was  most  snccessful  in  his  handt,  and  he  i*  sinee 
entitled  to  be  ranked  among  its  warmest  advocates, 

3.  Amylene. — We  are  indebted  tor  the  diftt*overy  of  this  imlisUliiep 
to  31.  Balard^§  Prof,  of  Chemistry  in  Paris,  who  brought  tl  to  the 
attention  of  the  profession  iu  1844 ;  and  to  Dr.  John  Sn(iw,|  ts  da« 
the  cre<Ut  of  having  been  the  first  to  employ  amyftne  aa  an  aruMilM^ 
tie,  which  he  did  in  Kings  College  Hcjspital,  in  Nov,  IBM.  He 
made  several  e.^periments  on  animals,  and  inhaled  ittuid]  quaali- 
tics  of  it  himself.  Dr.  Snow,  alYcr  resorting  to  it  in  a  number  of 
operations,  believes  it  to  possess  certain  advantages  ovorrhlnroform 
in  many  crises.     Although  it  hns  not  iisyi»tbccn  geri^  <.d 

either  in  America  or  Great  Britain,  it  has  l>een  ex:.:.  .  .-.  ^^^ 
with  favorable  results,  in  Paris,  Strasburg,  and  other  places  oq 
the  Continent* 

CompftraHve  Sa/tft/  nf  Stdphurio  Etlier^  Chloroform^  amd  Am^ 
iene, — On  this  question,  more  particularly  iu  referiiiec  to  the  two 
former  agents,  the  opinion  of  the  profession  is  flividetl.  The  fiu«t, 
liowever,  is  very  certain,  that  the  statistics  derived  from  the  ikdmi- 
•nisi  rat  ion  of  the  two  substances  preponderate  greatly  in  favor  of 
siUphuric  ether,  as  a  safe  and  reliable  anaesthetic.  When  chlorolbrBi 
destroyg  life,  it  would  appear,  from  an  analysbof  the  rtcordwl  &^ 
cases,  that  it  does  so  through  a  peculiar  influence  exerci**?d  iki  ibe 
hearths  action — a  cardiac  synci>pe,  or  what  ha^n  been  desigikftl<ed  ft 
paralysis  of  the  organ.    On  the  other  hand,  It  iia«  bc<m  attttsHuCo- 


•  Suiigiciil  Expericn<?o  i>f  CIibrofbrm»  by  Prof.  MiJlon  pp.  10,  1 1. 
f  An  Account  of  n  Kew  Aiiaanhoiio  Agi*ol  «a  u  Substilijt*  fbf  Sq 
D  Midwifery  and  Surgvr}%  by  J,  Y.  Siroiison.  M,D.     Killn.  IMT, 
X  Chloroform  in  Chiid-birth,  hy  Kdvrjml  Vim.  Murphy,  M.U,  1864. 
g  Annnlea  do  Chlmie  9i  de  Pbjsiquo,  tom.  xiL,  p.  320. 
I  On  ChJoroform  and  other  Anaesthetics,  by  John  Snow,  M.D.     Lam 


lAHlj 


THE  PRINCIPLES  AND  PRACTICE  OP  OBSTETRICS.  723 

rily  shown  by  experiments  on  animals,  by  Dr.  Snow*  and  others, 
that  sulphuric  ether  is  incapable  of  producing  sudden  death  by 
stoppage  of  the  hearths  action. 

As  for  myself,  I  have  some  time  since  abandoned  the  use  of  chlo- 
roform, and  have  recourse  exclusively  to  sulphuric  ether,  which  I 
have  always  found  safe  and  reliable.  I  have  had  no  experience 
with  amylene,  yet  it  has  received  very  high  commendation  from 
those  who  have  tested  it.  Dr.  Snow  has  employed  it  in  seven  cases 
of  labor  with  the  most  entire  satisfaction  ;  aud  he  says  "  the  great 
ease  with  which  it  can  be  breathed,  owing  to  its  entire  want  of 
pungency,  is  a  decided  advantage  it  possesses  over  both  ether  and 
chloroform."  With  such  testimony  in  its  favor,  it  is  not  unreason- 
able to  believe  that  it  is  destined  to  occupy  an  important  place 
among  the  anaesthetic  agents.f 

Tlve  Indications  for  Anaesthesia  in  Parturition, — In  reference 
to  the  particular  circumstances  justifying  the  use  of  anaesthesia  in 
the  lying-in  room,  there  is  no  concurrence  of  opinion  among  accou- 
cheurs; on  the  contrary,  there  is  much  diversity  of  sentiment. 
With  some  it  is  the  universal  habit  in  every  case  of  labor,  no  matter 
how  natural  and  auspicious  it  may  promise  to  be,  to  resort  at  once 
either  to  sulphuric  ether  or  chloroform.  This,  it  seems  to  me,  is 
really  abusing  a»good  thing.  Labor' is  unquestionably  a  natural 
process — it  is,  indeed,  entitled  to  be  designated  in  strict  physiolo- 
gical language  a  function.  If  this  be  so,  is  it  right  to  interfere  with 
a  function,  properly  so  called,  as  long  as  its  exercise  is  normal,  and 
within  the  true  record  of  nature  ?  I  think  not.  Again,  there  is 
another  argument,  which  has  always  struck  me  with  force,  why 
anaesthesia  should  not  be  employed  in  a  natural  parturition,  and  it  is 
this — the  female,  at  the  most  interesting  period  of  her  life — the 
time  of  labor,  should,  all  other  things  being  equal,  have  her  mind 
unclouded,  her  intellect  undisturbed,  her  judgment  fully  adequate 
to  realize  and  appreciate  the  advent  of  a  new  and  important  era  in 
her  existence — the  birth  of  her  child.  Therefore,  I  shall  advise  you 
not  to  resort  to  anaesthetics  in  natural  and  ordinary  labors,  except  in 

■  Dr.  Snow,  in  his  excellent  work  already  alluded  to.  records  in  tabulated  form 
fifty  deaths  from  chlorofonn,  and  in  all  the  cases  (45)  in  which  the  symptoms  which 
occurred  at  the  time  of  death  are  reported,  there  is,  he  observed,  every  reason  to 
conclude  that  death  took  place  by  csirdiac  syncope,  or  arrest  of  the  action  of  the 
heart.  In  forty  of  the  cases,  the  symptoms  of  danjfer  appeared  to  arise  entirely 
from  cardiac  syncope,  and  were  not  complicated  by  over-action  of  the  chloroform  in 
the  brain.  Again,  he  snys,  I  am  aware  of  only  two  deatl'.s,  which  have  been 
recorded  as  occurring  during  the  administration  of  ether,  and  it  is  not  probable  that 
the  death  in  either  case  was  due  to  the  ether.  I  hold  it,  therefore,  he  continues,  to 
be  almost  impossible  that  a  death  from  this  agent  can  occur  in  the  hands  of  a  medi> 
cal  man,  who  applies  it  with  ordinary  inteUis,^nce  aai  attention.    [Op.  ciiat.  p.  262.] 

\  The  pupil  may  consult  with  advantage,  "  A  Treatise  on  Ktherization  in  Child- 
Birth."    By  ProC  Walter  Channing,  M.D.     Boston,  1848. 


7U 


THE    PRINCIPLES   AND  PRAC7TICE  OP  OBSTETRICa 


the  event  of  certnin  contingencjes  wbicb,  in  the  juilgmcnt  of  the 

accoucbenr,  would  justify  their  admini^itration*  The  employment 
of  thene  ageiitJi  will  be  propir  in  cases  of  operative  midwifery,  whe- 
ther instnirnental  or  manual ;  in  eases  of  unusual  pain  aceompajiyiiig 
the  labor;  in  instances  of  rigidity  or  an  unyielding  condition  of  the 
nioutbofthc  womb,  vai^ina,  or  perineum  ;  in  a  woman  of  exci«»ive 
nervous  irritability;  in  certain  cnscs  of  irregular  contraction  of  the 
uterus^  in  which  the  strength  of  the  mother  is  i>everely  tested  witb* 
out  a  corresponding  progress  in  the  delivery  ;  in  many  ca!*es  of 
puerperal  convulsions,  ]M'ovided  there  is  no  tendency  to  cerebral 
congestion  ;  in  apasraodlc  contraction  of  the  nterua  before  the  birth 
of  the  child,  and  subsequently  to  the  birth»  the  plaeeuta  being 
retaitied  by  the  f^pasm  of  the  organ.  In  some  conditions  of  preg- 
nancy— tor  cxunipl*^  where  there  is  a  degrc*e  of  undue  irritubiljij 
of  system,  or  the  hysteric  manifestation,  or  where  it  becomes  neces- 
sary to  extract  a  tooth  ;  and  I  may  remind  you  that  I  have  on  iieve- 
ral  occa.sions  derived  marked  benefit  from  tlie  administration  of 
snlpliunc  ether  in  cases  of  rebellious  dyHmenorrha'a.  Let  me  here 
add  thiit,  in  the  irritability  and  cnnvubiotis  of  children,*  etheriza- 
tion will  oftentimes  exliibit  tlie  happiest  results. 

T/te  Ittfliicjice  of  Anmsihetic»  on  Uterine  Contraction, — ^One  of 
the  original  and  chief  objections  to  the  employmeht  of  an^ntbeliei 
in  midwifery  was  the  ajiprehcnsiou,  advanced  by  some  authors,  that 
they  80  completely  conlrollfd  the  action  of  the  uterus  a*  necessarily 
to  expose  tlie  patieia  to  all  the  hazards  consequent  upon  inertia 
of  the  organ — sucli  as  hemorrhage,  <fcc. ;  this*,  however,  is  an 
unfounded  ajiprehcnsion.  It  is  a  curious  fact  that,  in  acme  Infltan* 
ce-<,  the  activity  of  the  uterus  will  occasionally  become  increased 
mader  the  influence  of  tbej?e  agents ;  and  in  many  eases,  there  will 
be  no  perceptible  influence  exercised  either  as  to  the  fiirce  or  rvgu- 
larity  of  the  contractions.  It  is,  however,  true  that  when  an^eft- 
tbesia  is  carrietl  to  its  maximum — causing  a  state  of  complete 
tinconsciousness,  there  will  oftentimes  be  a  suspension  of  the  labor, 
the  uterus  resuming  its  wonted  efforts  as  soon  as  the  full  eilt*cU 
begin  to  yield.  Individual  idosyncrasy  has  frequently  a  controlling 
influence  on  the  result  of  the  anaesthetic  ;  in  some  instances  a  very 
slight  degree  of  etherization  will  suffice  to  afford  relief,  and  agniQ 
inscnsibiHty  to  Buffering  Mill  not  ensue  except  under  full  untxiU' 
Bciousness* 

*  t  ]^ave  repeat-edly  had  resort  to  eilierizatton  ia  eluldr«fi,  »fid  always  vkHh  [rood 
efl'euL  Dr.  Suow>  experience  is  atnply  eonlirmatory  of  jti  Rafety  uml  efllctefu-y  in 
tht'se  ctiS4?3,  lleaays  'lie  has  given  ehlonorurm  \n  a  few  in-fvince^  ^s  turlr  lui  tint 
ftge  ofeigJit  »nd  ten  daja,  aod  in  a  considerable  number  before  iht*  nu-w  ol' tw« 
ftiOQthii;  he  has  adnumatered  it  to  180  itifAiita  uuder  a  ycurold;  nor  hu«  Ju'  exj** 
fieuccd  any  i\l  efft^Qia  from  it  either  in  ttie*e  ca^cs,  or  in  those  of  chJldrea  mare 
adirpncod  in  life ;  it  is^  alao,  wortliy  of  remnrk  Ihat  none  of  tlie  accidcnCa  fn^n  vfil«* 
roforra,  wludi  have  been  recorded,  hare  occurred  lo  yotiJis  diUdren,"  {p.  4^4 


THE  PBIKCIPLES  AND  PBACTICE  OF  OBSTETRICS.         725 

The  secondary  forces  in  parturition — ^the  contraction  of  the  dia- 
phragm and  respiratory  muscles — would  necessarily  be  interfered 
with  if,  under  the  operation  of  anaesthesia,  the  sensitive  nerves 
should  become  deprived  of  their  special  function — sensibility  to 
impressions — for  in  this  case  reflex  movement  could  not  be  accom- 
plished. 

The  following  are  the  conclusions  of  M.  Flourens*  touching  the 
influence  of  anaesthetics,  under  gradual  inhalation,  on  the  nervous 
system,  and  they  are  not  without  interest:  "Under  their  action, 
the  nervous  centres  lose  their  powers  in  regular  succession ;  first 
the  cerebral  lobes  lose  theirs,  viz.  the  intellect ;  next  the  cerebellum 
is  deprived  of  its,  viz.  the  controlling  of  locomotion ;  next  the  spinal 
cord  loses  its  function  of  sensitiveness  and  motion ;  the  medulla 
oblongata,  however,  still  retains  its  functions,  and,  therefore,  the 
animal  lives ;  with  the  loss  of  power  in  the  medulla  oblongata,  life 
becomes  extinct." 

The  Influence  of  Ancesthetics  on  the  Safety  of  the  Mother  and 
Child, — Under  judicious  administration,  it  may  be  affirmed  that, 
as  a  general  rule,  these  agents  may  be  employed  during  pailuntion, 
with  safety  to  both  mother  and  child. 

Time  and  Mode  of  Mherization, — As  has  already  been  remarked, 
some  accoucheurs  have  recourse  to  etherization  in  nearly  every  case 
of  natural  labor,  and,  to  be  consistent,  I  suppose,  they  commence  it 
simultaneously  with  the  advent  of  the  pains.  We  will,  however, 
imagine  that  you  will  resort  to  it,  under  ordinary  circumstances, 
only  in  cases  of  exaggerated  suflfering ;  and,  therefore,  as  a  general 
rule,  this  will  manifest  itself  afler  the  os  uteii  is  so  far  dilated  as  to 
bring  into  play  a  positive  tributary  or  nervous  force,  imparting  to 
the  uterine  contractions  a  well-defined  expulsive  character.  If, 
therefore,  etherization  be  judged  advisable,  the  necessity  for  a 
resort  to  it  will  usually  exhibit  itself  at  this  stage  of  the  labor.  As 
a  general  principle,  it  will  not  be  necessary  to  cause  full  etheriza- 
tion, the  object  being  merely  to  lessen  the  amount  of  suffering ; 
therefore,  in  such  cases,  unconsciousness  is  not  called  for ;  all  that 
is  needed  is  to  produce  diminished  sensibility.  It  is  proper, 
whether  sulphuric  ether  or  chloroform  be  used,  to  employ  it  at  the 
time  of  a  pain,  and  suspeiid  it  during  the  interval  of  contraction. 
Many  contrivivnces  have  been  suggested,  under  the  terra  inhalers, 
for  the  purpose  of  accomplishing  the  object  in  view.  But  it  seems 
to  me,  the  plan  originally  proposed  by  Prof.  Simpson  will  answer 
every  purpose.  Take  a  delicate  hollow  sponge,  or  a  handkerchief, 
funnel  shape,  and,  if  chlorof<irm  be  used,  throw  upon  the  sponge  or 
handkerchief,  a  small  quantity  of  the  fluid  (say  fifteen  to  twenty- 
five  minims).    This  should  be  applied  to  the  nose  and  mouth  of  the 

•  Gajoette  des  Hdpitaux,  20  Mara,  184Z  • 


726 


TITE  raiNCTFLES  AXP   PBACTICE  OF  OBSTTrTBICS. 


patitmt,  with  the  ret} no?* I  t1i.it  she  wil!  inhnlc*  it.  In  a  very  »bort 
time  its  efFectfl  will  become  apparent  in  occasioning  partial  io^etini- 
bility.  Tills  may  be  rt- pcated,  if  nece;«sary,  on  the  recurrcmee  of 
each  pain*  In  cases,  however,  in  which  in«trnmental  or  niantud 
delivery  i«  to  be  accorivplished,  the  patient  slioiihl,  previoui*ly  to  Ibo 
introduction  eitfier  of  the  in^trnnient  or  hand,  be  put  into  a  Kttttu 
of  uncotisciousness  ?  When  the  instrument  ha»  been  properly 
applied,  the  ana?sthetic  should,  for  a  time,  be  gtwpendcd,  in  order 
that  the  delivery  tnay  be  bcnelitcd  by  the  e*)iiiracli«>n-«*  oft  I  »  ; 

but,  if  there  be  delay  in  bringing  the  child  into  th<t  w  ^  no 

chloroform  may  again  be  had  reeonrse  to  with  the  view  of  cooirol* 
ling  the  senHbility  to  pain  *  Although  it  i«  proper  to  cointncnca 
with  a  small  quantity  of  the  chloroform,  yet,  in  protracted  laborSi 
it  may  become  neoessriry  to  conHutne  s^everal  ounce*. 

It  is  well  to  mention,  in  connexion  with  the  administration  of 
chloroform,  that  it  h  apt  to  produce  natitiea  and  vontiling»  and, 
therefore,  care  should  be  taken  to  administer  it  before  tuidaoi  iift«r 
a  meal. 

If  sulphuric  ether  bo  employed,  it  can  be  administer<Hl  in  tuticb 
larger  qtmnljiy — a  fluid  ounce  nmy  be  poured  into  the  iiponge  or 
handkcrc.ht<»f,  and  inhaled. 

The  Jftfluenc^  of  AiKvMhetieH  on  the  Puhe. — If  care  b«  ui 

walcli  tire  pulse,  it  will  be  found  that  usually  it  increa^  in 

force  and  fVe<inency  at  the  conimenceinent  of  the  inhalation.  On 
the  contrary,  when  ins«*riHil)ility  is  accomplished,  it  fijencniMj 
resumes  its  normal  standard.  If  the  piiticnt  have  suiFen^d  fram 
loss  of  blood,  and  uIho  \\\  ea^es  of  naunea  or  vomiting,  <v 

will  lose  its  force  and  frequency;  but  with  these  excqi  a 

rare  to  observe  the  latter  chatiges  in  the  throes  of  the  heart  utMi^r 
the  administration  of  anieslhetic  agents. 

Melagthuj  J%ffecti  of  An(E8thetics, — I  have  often  obserrcd  in 
practice  the  influence  of  etherization  in  producing  rcIaxatioOf  rna^ 
this  attribute  U  manifest  in  uther  instances  than  in  parturitson,  I 
had  a  short  time  since  a  striking  ilhistration  of  the  fact :  Dr.  Fran- 
cis Fleet,  of  ibis  city,  re(piested  me  to  visit  in  *  -ion  a 
young  lady,  aged  niuetecn  years,  who  had  never  mt  i  d,  and 
who,  before  placing  herself  under  his  care,  had  been  subjected  to  a 
variety  of  enimenagogucs  with  a  view  of  establishing  the  caunn^ 
oiat  function,  but  all  without  avalL  The  Doctor,  on  making  an 
examination,  discovered  that^  commencing  alniut  an  ineh  from  tba 
vulva,  there  was  an  oceluHiun  of  the  vagina.    The  passa^  wat 


I 
I 


^  U*t  \i  Im  di9ttiu:tlj  und^rstoiMl  timt.  In  ooam  of  n^nktn,  tbs  aai 
the  pnlieot  »)k»u1<1  bt»  maintniiicd  until  Uio  ncoouobeur  hw  soceeMM  io 
^C,  and  briiiipinf^  them  down  tt>  the  nuperior  fitmil,  A\  Wm  »tago  ftf  th*  bbor  tb» 
aamithetic  siiotiM  be  ^udp^tudi'd,  [ut  here  it  ia  uDportatit  to  Imi^c  tli&  adT«iit^s»  of  Otm 
ODotfactlf^af  of  tbo  atorua  fur  the  purpose  of  cjtpoditmg  tho  detivt  17. 


THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.         737 

obstructed  by  a  dense  fibrous  band.  On  introducing  my  finger,  I 
recognised  extraordinary  sensibility  of  the  parts  together  with 
unusual  ligidity.  The  patient  was  placed  under  the  influence  of 
ether,  which  acted  promptly  in  overcoming  both  the  sensitiveness 
and  rigidity.  At  the  Doctor's  request,  I  divided,  with  a  bistoury, 
the  membranous  band,  which  immediately  brought  the  os  uteri 
within  the  feel  of  the  finger.  The  menstrual  blood,  which  had 
been  accumulating  for  some  time,  but  which  had  found  no  exit 
because  of  the  obstruction,  flowed  freely ;  and  the  young  lady  was 
soon  repaid  for  her  fortitude  by  taking  to  her  bosom  her  aiiianced 
lover. 


INDEX. 


ibdomen,  changes  in  the,  during  pregnancy,  156;  contraction  of  the  muscles  ofths^ 
siraulaiing  tioetal  movement^  181 ;  how  to  conduct  the  examination  oC,  to  ascer- 
tain tlie  existence  of  pregnancy,  193;  application  of  the  bandage  to  the,  atler 
childbirth,  404 ;  presentations  of  the,  655. 

Abdominal  parietes,  pain  in  and  relaxation  of  the,  in  preg^nancy,  226 

Abdominal  pregnancy,  205. 

Abdominal  tumors,  196. 

Abortion,  statistics  exhibiting  the  frequency  ofj  266,  267 ;  various  divisions  ot,  207, 
268 ;  period  of  pregnancy  at  which  it  is  most  frequent,  268,  269 ;  causes  o( 
269-273;  symptoms  of,  274 ;  prognosis  and  treatment  of)  275-282;  induction 
of;  is  it  ever  justifiable?  678,  679. 

Abscess,  mammary,  treatment  of,  426,  427. 

Accoucheur,  the,  cardinal  object  of.  11,  648;  his  duties  in  the  lying-in  chamber, 
351  et  seq. ;  case  evidencing  the  culpable  indifference  of  an,  to  professional  obli- 
gation, 658. 

After-birtii.     See  Placenta. 

After-pains,  407,  411. 

AlbuniitioMe,  262. 

Albuminuria,  oflen  the  cause  of  abortion,  272;  causes  of)  505;  change  in  thecom- 
pusitlon  of  the  blood  in,  506;  chang:e  in  the  kidney,  607 ;  pressure  on  the  renal 
veins,  608;  less  frequent  in  multiparsB  than  in  primiparce,  608,  509;  not  neoet^ 
Sfirily  followed  by  ursmia,  510;  summary  of  conclusitms  respecting,  515. 

Amnios,  the,  244;  source  and  uses  of  the  liquor  amnii.  245,  246. 

Amyleue,  use  ot,  as  an  anaesthetic,  722.    See  Aniesthetics. 

Antetnia.  connexion  between  abortion  and,  271. 

Aniesthetics,  advantages  of,  in  the  Cu^sarean  section,  637;  in  midwifery,  a  recent 
discovery,  701 ;  sulphuric  ether,  chloroform,  and  amylene.  721,  722;  compara- 
tive safety  of  the  three  aniesthetics,  722,  723;  indications  for  the  use  ot,  in  par- 
turition, 723  ;  influence  ot,  on  uterine  contraction,  724 ;  time  and  mode  of  usmg; 
7?6  ;  influence  of,  on  the  pulse.  726 ;  relaxing  effects  oC  ib. 

Andral,  M.,  on  the  increase  of  fibrin  in  the  blood  as  a  sign  of  inflammatory  action,  133. 

Animalcula,  question  of  tiieir  presence  in  the  spermatic  fluid,  115. 

Animalculists,  doctrine  of  the,  upon  fecundation,  116. 

Animals,  menstruation  in,  104. 

Ante- version  of  the  uterus,  234. 

Anterior  sacral  plexus,  4. 

Anus,  circumstances  necessitating  internal  examination  of  the  female  by  the,  201 ; 
occlusion  of  the,  in  the  intiant  423,  424. 

Aorta,  abdominal,  compression  of  the,  as  a  means  of  checking  uterine  hemorrhage, 
396. 

Apoplexy,  placental.  273. 

Appetite,  depraved,  an  evidence  of  pregnancy,  147. 

Areola  discoloration  of  the,  as  an  evidence  of  pregnancy,  151 ;  Dr.  Montgomery^! 
remarks  on  its  essential  characters,  161.  152. 

Arm,  protnision  of  the,  in  shoulder  presentations,  669. 

Ameth,  Dr.,  on  the  contagion  of  puerperal  fever,  686. 

Articulations  of  the  pelvis,  the,  1 2 ;  question  as  to  their  relaxatioD  and  separatiofi 
during  gestation  and  parturition,  16 ;  of  the  festal  bead,  32. 


730  INDEX.  JU9&-CAB 

Aflcitefl,  or  peritoneal  dropsy.  197. 
Asphyxia,  treatment  of;  in  the  new-born  inrant,  369. 
Anat'cetida,  advantag:ea  oC  in  cases  of  habitual  abortion,  373. 
"Aunt  Betiy,"  case  of.  simulating  pregnancy,  181. 
Aura  seminalia,  the.  116. 

Auscultation,  mediate  and  immediate,  188  ;  of  the  foetal  heart,  201. 
Axes  of  the  pelvis,  the.  19;  their  inclination,  20;  necessity  of  an  accurate  knoiP* 
ledge  of  their  direction  21. 

B. 

Back,  the,  presentation  ot,  557. 

Ballottemcnt.  or  passive  motion  of  the  fcetus,  186;  rules  for  detecting;  186. 

Barker,  Prof  Fordyce ;  on  the  Cosarean  section,  639 ;  on  the  use  of  vemirum  ririda 
in  puerperal  fever.  698. 

Barnes,  Dr.  Robt..  on  vesicular  mole,  285;  on  fatty  degeneration  of  the  placenta.  820 ; 
on  artificial  detachment  of  the  placenta,  476,  477 ;  on  application  of  the  furcvpi^ 
675. 

Bandelocque,  his  six  different  ponitkms  of  the  Tertez  at  the  soperior  strait,  37 ;  bte 
pelvimeter  an  accurate  instrument,  69;  case  of  spoiitaiieotM  rtrdiicti«in  of 
mverted  uterus,  reported  by.  462 ;  on  the  Oerarpan  aectioiv  627 ;  on  eljtro- 
toniy.  641 ;  remarkable  case  recorded  by.  in  whkrh  tlie  diild  proved  to  be  alive, 
in  spite  of  the  strongest  evidence  of  death  in  utero.  657. 

Belladonna,  its  eflQi-acy  in  arresting  abortion,  277 ;  in  spasm  of  the  as  uteri,  380;  in 
convulsions  during  labor,  498. 

Binder,  the,  application  of,  404. 

Bischoir,  on  spermatozoa,  118. 

Blistitrs,  an  m]|iortant  auxiliary  in  the  treatment  of  pueqieral  ferer,  696. 

Blood,  discharge  oC  from  the  vagina,  lf>8;  disdiarge  of,  in  animals,  at  tlie  period  of 
heat,  313;  constituents  of.  in  a  state  of  healili.  133;  bufly  cviat  nui  al^«ya  an 
index  of  inflammatory  action,  ib. ;  changi*s  of.  in  the  pregnant  wiwiihd, 'l2S- 
134;  circulation  of;  in  the  adult  and  the  foetus.  257-261 ;  elaboTHtion  «/,  in 
the  placenta,  261 ;  change  in  the  circulation  in  the  infant  alter  birth,  264 ;  diange 
in  tlie  cr^ni  posit  ion  of  the.  in  uni'mia,  505. 

Bloodletting^,  in  prc^rnancy,  remari<8  upon,  130,  217.  361  ;  ohjcctions  to.  in  the  treat- 
ment ot'coJivulsionH  during  gestation.  49.1,  494  ;  wiien  indicated  in  ci>nvub*k>nff. 
495 ;  importance  of.  in  intijunmalory  puerperal  fever,  695 ;  caution  aptiust,  in 
puerperal  mania,  704. 

Bloo<l-poisoning.  or  toxtrmia,  411,  504,  683;  characteristic  of  diseases  produced 
by.  (584. 

Blood-veRsels  of  the  placenta,  247,  248. 

Blundell.  Dr ,  on  the  o{M.'ration  of  traiiBfiiMon.  400,  401 ;  on  the  Csmarean  section,  628. 

Boivin.  Madame,  on  vertex  presentations,  37;  on  the  muscularity  of  tlio  utunus,  126. 

Braun,  Carl,  on  uraunia,  515. 

Breasts,  the.  changes  in,  af^er  impregnation,  148. 

Breathing.  oppn*s.sed,  in  pregnancy,  treatment  of.  230. 

Breech  pres«'ntationH,  Ktatistics  of.  344;  diagnosis.  345;  prognosis,  346;  flrst  or  left 
anterior  sjicral  p<iaition.  ib.;  s<»cond  or  right  anterior  sacral  poeiiiiin.  347  ;  third 
or  right  posterior  pacraJ  ponition,  348;  fourth  or  lefl  posterior  sacral  poaiikai, 
ih  ;   manual  deUverj*  in,  647. 

BrigiiiV  disease,  no  necessary  relation  l>etween.  and  uremic  convulsions.  515. 

Brown-StMiuaid  Ins  eonclusioiw  o»»  the  8uV)je<a  of  tnmsfusion.  401,  402;  »  the 
itiHiifiice  of  carbonic  acid  on  non-striated  muKcular  fibres,  678. 

Bruit  placrniaire  the,  18r>. 

Buffy  coul  of  the  blood,  not  always  the  index  of  inflammatory  action,  133L 


Ca'sareaji  j»(»ct:on.  tlie.  620:  controversy  wiih  reg;ird  to  the  benefit  or  evil  of  the, 
r»*J«>  (;2i>:  contrast  hetwe.n  the,  and  cranioiojny  statistics,  with  many  illustra* 
live  cases.  G'jy-H.'J.'i :  ilangern  to  the  mother  from  the,  636,  637;  po4a-nM*rteni 
CVi'^anan  siriion,  638.  (i39  ;  how  the  o[H-ration  should  be  perfonntnd.  639-M2; 
dresei'.i.^r  iiie  wound,  642,  643;  vaginal  Ciesarean  sc^ction,  or  vaginal  hystcm* 
tomy.  044. 

Capuron.  on  i\\e  coTtxprewibiUty  of  the  arch  and  l)a8e  of  the  foetal  bead.  32. 

Carbomc  acid,  'u\iccl\ou  ul^  aft  \i^m^:«KA  vA.\\v\>i^\\\%uxUticiAl  delivery,  67  8w 


CAT-CUM  INDEX.  731 

Catalepsy,  characteristic  peculiarity  of,  502.  . 

Catanienia,  retention  of  the,  mistakoQ  for  pregnanpy,  79;  period  between  puberty 
and  their  tinal  cessation,  93 ;  influence  of  climate  on,  95— of  education  and 
nu>de  of  life.  96 — of  temperament,  constitution,  and  race,  97 ;  precocious  and 
tardy,  98 ;  causes  of,  lb.     See  Menses  a/id  Menstruation. 

Cathartics,  in  pregnancy,  218. 

Catheter,  ilie,  directions  for  the  introduction  of,  233, 357,  412-414 ;  obstacles  to  the 
ingress  of  the,  4!  4. 

Caudle,  caution  against  the  use  of,  405,  406. 

Cazeaux,  on  shortening  of  the  neck  of  the  womb,  168 ;  embryotomy  forceps,  663. 

Centric  causes  of  abortion,  271. 

Cepiialalgia,  treatment  of;  in  exhausting  hemorrhage,  399. 

Ceplialic  version,  640;  mode  of  performing,  641  et  seq. 

Cephalotribe,  the,  663 ;  directions  for  its  use,  663,  664. 

Cephalotripsy,  meaning  of  the  term,  66  i. 

Cervix,  the,  of  the  uterus,  87  .  progressive  changes  in  its  condition  during  the  pro- 
gress of  gestation,  164-1 6U. 

Child.     See  Infant 

Chloroform,  tirst  introduced  by  Prof.  Simpson,  710.     See  Anaesthetics. 

Chorion,  the,  and  its  villi,  uses  of,  243,  244;  in  a  case  of  twin  lal)or,  441. 

Churciiill,  Dr.  his  statistics  on  breech  presentiitions,  344;  statistics  on  multiple  preg^ 
nancy.  43 1,  432 ;  statistics  upon  the  frequency  and  mortality  of  post-partum 
hemorrhage,  3w0;  statistics  ofpodalic  version,  538;  statistics  of  crotciiet  cases 
by,  629,  630— of  Caefiarean  section,  630,  631 ;  tables  by,  showing  the  diameters 
of  the  head  ut  the  different  periods  of  pregnancy,  667  ;  on  a  case  of  premature 
artificial  delivery,  673. 

Circulation,  diflerence  between  the  adult  and  the  foetal,  257-261 ;  change  in  the, 
after  birth,  264. 

Clark,  Prcjf.  Alonzo,  interesting  details  on  the  iise  of  opium  in  puerperal  fever, 
697,  698. 

Clarke,  Dr.  Joseph,  on  the  comparative  size  and  weight  of  the  male  and  female  foetus, 
27 

Clarke.  Dr.  Joseph,  stitistics  of  cases  of  craniotomy  and  Ctesarean  section  by,  630,  631. 

Clay,  Cliai'les,  on  duration  of  pregnancy,  303. 

Cliiori.M,  the,  75 ;  Pareiit-Duchntelet  on  tiie.  ib 

Coaguia,  removal  ofl  after  the  delivery  of  tlie  after-birth,  375. 

Coccyx,  anatomy  of  the,  6;  exercises  an  important  mtlueuce  during  childbirth,  6,  7; 
dislocation  and  fracture  of,  7. 

Cohen,  his  method  of  inducing  artificial  delivery,  678 

Colcliicuni  HUtumnale,  value  of,  in  urwniic  poisoning,  514. 

Cold,  Hppliciition  of,  in  cases  of  threatened  abortion,  278 ;  in  post-partum  hemor- 
riiage,  393-395. 

Collins,  Dr..  his  statistics  on  breech  presentations,  344;  on  the  prophylactic  treat- 
ment of  puerperal  fever,  693. 

Colostrum,  the,  409. 

Colpeurynter,  the,  474. 

Commissure,  the  superior  and  inferior,  73. 

Constipation,  in  pregnancy,  162;  treatment  of,  222:  after  delivery,  416,  422;  in  the 
infant,  423 ;  sometimes  a  cause  of  accidental  flooding,  482. 

Convulsions,  connexion  between,  and  the  presence  of  coaguia,  376;  puerperal,  485; 
treatment  of.  during  pregnancy,  492-497  ;  during  labor,  497-500 ;  after  deli- 
very, 500 ;  centric  causes  of,  504. 

Cord,  umbilical,  composition  of  tlie,  250,  251 ;  ordinary  length  of  the,  251;  knot- 
ted cords,  252;  question  of  nervous  tissue  in  the  cord,  253.     See  l<'uni& 

Coronal  suture,  the,  30. 

Corpus  luteum,  tlieory  concerning  the,  91 ;  of  pregnancy  and  menstruation,  112; 
interesting  question  concerning,  114. 

Cougli,  in  pregnancy,  160,  230. 

Coxal  bone,  tiie.  7. 

Craniotomy,  contrast  between  the  statistics  of,  and  these  of  the  CoRsarean  section, 
629-635;  condemnation  of,  634:  the  Cwsarean  section  to  be  preferred  to,  ib. 

Cristoforis,  Dr.,  his  substitute  for  the  Cwsarean  section  and  symphyseotomy — sectio 
subperiostea,  643. 

Crotchet,  the,  as  modified  by  the  author,  579,  680;  statistics  of  crotchet  casts,  039. 

Ctunmings,  Dr.,  natural  and  artificial  lactation,  419. 


7sa 


INDEX 


X^AL-WtM 


l^alton^  Prt»f  J.  Cm  o^i  tH©  corpus  lutcam  of  |m»ffn»n<y,  118. 

iVcidun  Mtcxn,  miKJeororiffih  ortii«$.  243;  ij  ib.;  dcHduft  incfiibr»ii«,  SI 

Dcfunuily.  f>eUic.  exjuinriMlion  o<  i\m  pnipri^  »  in  caivt  uC  i44-Ji4fi. 

Deli  V*  7      ii  dia^nKw'is  unci   -  ^    -  li.  i»i8;  indwBlkinii  oC&lf^AIti 

1 1  lime  for  U^rmiii  '-<>;  mtxio  <jf  t<Tniii»tlmp  5Ji>-#tig 

da  ,  .  52'i  et  »cq, ;    in   i        -  ^        nliiikmi.  647 ;  in  iniok  cr  liii*uffCflHi 

655  ;  111  hip  and  s»lKJultlMr,  witii  prutnimon  of  the  nrrn.  55*1  el  »pq. ;  in^nimcivliJ 
(avtj  Forcepa  and  IriStrumcrjl"*),  5€5 ;  premflture  iirtilldiU*  G(^5 — the  obj^ciioiti 
lo,  coni»idered,  668-614 ;  utatistics  o^  673 ;  the  vAiiann  roodet  of  apcmUag 
fur  Uie  induction  ot  prtfiiiature  anltlcijil  delivery^  674  et  m(\. 

Dentiiiiru  Dt.«  on  Kponttitieous  evolntiun,  5€S;  on  the  ftp|i1ie»tlon  of  tbf  Ibrorfn*  Ml. 

Dosornieiiux,  inltrtsting  ca»o  recorde<i  by»  beariiig  on  iho  duntUiti  of  | 
300,  301. 

Dcvillc,  on  nm^ukritj  of  ihe  uterus,  126. 

DiArrliu.«a,  of  prc>a»ttncy,  trenlment  of,  3*i3. 

Diet  of  liie  piirturient  wonmn,  3G0, 

DiM^asi',  tmu^inisaiou  o(^  fruin  [uirent  to  of[>pnDg,  263* 

DoUi;hisiit,  I^r,,  on  )')»t:inlHheoUM  i'Vuhitioii,  MX 

l>ri»iM«jr,  cn»t^M  oi;  Hituuhiiini^  pregnnncy.  \19,  183;  orihooriry,  197;  Of  fl»  I 
194;  t»eritonea),  197. 

P«b*jii^  on  Vi.'rti*x  preaentntionR,  3B. 

Dubois  jind  Ptijot,  tiibte  by,  allowing  the  influeoo©  of  diniate  on  i 

Dy8ptia!«,  m  prcgtiftncy,  160. 


Elytroloniy.  dMcriptlon  of  U»©  opcmtion  oi;  641. 

Einbrycinic  nutrilion,  255. 

Kaibryrttoniy,  the  spuce  tiiroufrh  wliioli  it  child  may  be  exinictcd  by«  •<*;    ihm 

ir '   -    '■  651 ;  umoujit  of  pelvic  contmction  jufitlfylnir.  1551.  oa'i;  vmm  vi 

I  liervvcMKl,  as  nurnitetl  by  Dr.  Wiiltiini  Oiborii,  65 a-^**©  ;   r^idvCKVt 

<:  .  J^  death  in  ut«ro,  656-658  ;   meiancholy  retsults  of  the  f^fidt>**«  ^«r 

660 ;  mode  of  periijmiiug  tlie  opemtioo,  660-^63. 

Kmetie«,  in  pregnancy,  2 IB. 

Kncyated  dropsy,  197. 

Ephemeral  fever  or  weed,  430. 

Ergot^  u^  ol^  to  arn>at  uterine  hemorrhage,  280 ;  caution  on  the  us©  oC  1(931 ;  in  ^h^ 
v^iiUx  pnevia,  480;  in  ioertla  of  Uie  uterus,  553;  adaunietratttjo  of,  m  prt«mliif« 
ariilici.il  delivery*  616. 

Kaquirol^  eUftdlics  by,  relating  to  Ui9  period  of  tlie  developiii«iil  of  punryeral 
fever.  7m0. 

KUier,  flulpliuficr  twe  of,  in  convulaloiiB  during  pnep'  -d 

by  Ur.  Morton,  721 ;    tiret  iyM?d  in  portiu-ition  I  « 

prd'errfKl   to  clilorolbrm,   75i2,   123;    miod©  of  umlh^,   U'O,    t-ti.      ?**«   Aum^* 

tli^tiCSL 

KthiAriiuiiiim.     See  AnaatltelScii 

Evulutiuii,  ypniitniii-vus^  obw?rviitioDJ  on,  562,  569. 

Rvrat,  tMiiipciii  s^iggest^^d  by,  Uv  reducing  retro-Tersioa  of  the  ntenii^  SS& 

Exdto-rocjUjry  uetion^  phenomena  of,  184, 

Extra- utenne  prt^uancy,  its  Tan«ii«ft,  W$, 

F. 

Face  preaentationa,  statiitkca  ot,  339,  34€  ;  diagoosia  of,  340;  prognoKls  oC  ^41 ;  kT 
the  tirvt  or  right  mento-iliao  potticion,  34 J,  342,  612  ;    in  tbo  Moood  or  k 
ntenUHiitfic  p<i6Jttoo,  343»  343,  C12 ;  use  of  tiie  forcepa  io,  6ll-<tlt ;  mtwlii  ani 
Tittr  jiiul  tiu  iiU>-pc»flcrior  pi^ttioos,  614. 

F^w^^ii-H  iiipj^MXxnUcn.  Uie.  6D2, 

S  :   I  i|auti  pn-jrnancy,  204, 

I  .11  iiaivn  vlh*'^  tite,  BU;  how  tl)G  iie<3uz>dated  oroJe  finda  Bdmlaaioii  to,  lift.  

t'iktr,  ■  I.  HUftuiuu-y  of  bia  statistics  on  marriage  m  Fmuoa,  dtrifi^  h^m  llw 

t  il.  \'n. 

Fcctiii-i  aiiingof  tlie  term.  110;  tlieoriea  oC  1J6:  9ffM  <*i  on  ih«  dflvdop 

i(,v .  '    if  i;m  n^i^nia,  I6:t ;  cn^*  oC  tUfecKNl  At  A  meni^Qil  poriud,  8U2,  30€L 

Fe<»t,  prL^4.iiuaum  ot  \l\e^  '<V\^^  ^t>^;  Umi  i^k](^v.Vqm^  S4^. 

Fciiiiiie  cllild^^;t^  mottallvy  ot,  cotRV^^^s^  ^\v\k  >\\a5.  <^  i»j6i*,ni^ 


FBV-GAS  INDEX.  733 

Pever,  milk,  422  ;  puerperal  680 ;  nature  and  origin  of,  681-684;  connexion  between,, 
and  erysipelas,  684 ;   the  divisions  of,  685 ;  diversity  of  views  on  the  question 
of  conui^iou,  686-688 ;  causes  and  symptoms  of  689 ;  lesions,  690 ;  diaKnosia, 
091,692;   prognosis.  692 ;    pmphyla'ctic  treatment,  692-694 ;   remedial  treat- 
mentf  694-698  ;  ephemeral  or  weed,  43(1. 

Fibrin,  increase  tyt  in  the  blood,  in  acute  inflammation,  183;  in  pregnancy,  134. 

Pibrous  growths  of  the  uterus,  IDS. 

Fibrous  tumor,  case  of  simulating  pregnancy,  138. 

Figg,  E.  Garland,  startling  views  of.  on  the  subject  of  version.  638,  539. 

Figueira.  M..  tables  from,  showing  the  diameters  of  the  bead  at  the  different  periods 
of  pregnancy,  667. 

Fillet,  the,  circumstances  under  which  ii  may  be  applied,  566. 

Finnell,  on  exira-uterine  pregnancy.  204. 

Fistula,  ureihro- vaginal  or  vesico-vaginal,  diagnosis  of,  78;  sometimes  a  consequence 
of  careless  use  of  the  forceps.  670 

Flatus  in  the  intestinal  canal,  afler  childbirth,  treatment  of,  415. 

Flooding,  in  pregnancy,  168  ;  after  the  birth  of  the  child,  388,  .S90.    See  Hemorrhage. 

Floureiia,  M.,  on  the  influence  of  anjesthetics  on  the  nervous  system,  725. 

Foetal  movements  in  utero — how  can  liie}-  bo  excited?  183;  ballottement,  or  pas- 
sive motion  of  the  foetus,  185 :  pulsations  of  the  foetal  heart,  187. 

Foetation,  extra  uterine,  causes,  progress,  and  phenomena  of,  206;  diagnosis  of,  208. 

Foetus,  bones  of  the,  3 ;  the  fcBtil  heaid.  its  regions,  diameters,  sutures,  foutanelles, 
&c..  27 ;  dirt'erence  between  presentation  and  position  of  the,  35  (and  see  Head 
and  Eiabor);  quickening  of  the,  in  utero,  the  result  of  mu.scular  contraction,  178; 
movements  of,  simulated,  181;  nutriticm  of  the,  265;  does  it  breathe  in  utero? 
264;  viability  of  the — incapable  of  exi.stence  previous  to  the  termination  of 
the  sixtli  montli,  268,  606;  the  annexae,  or  appendages  of  the,  241;  death 
of  the,  a  cause  of  abortion,  272;  is  tlie  deterniining  cause  of  lnlK)r  due  to 
the  action  of  tlie?  310;  conditions  for  labor  on  the  part  of  the,  3:<8 ;  presen- 
tations of,  in  natural  labor.  339;  face  presentation.s.  339-343;  pelvic  presenta- 
tions, 343  ;  breech  presentalicms.  343-346  ;  presentations  of  the  feet  and  knees, 
348-350;  presentations  in  twin  labors,  435;  superfuetation,  442-445;  malposi- 
tion of  the.  468;  spontaneous  evolution  of  the,  562. 

Fontanelles,  the  anterior  and  po.sterior.  30,  31. 

Forceps,  the,  fundamental  principle  to  be  observed  in  delivery  by,  66:  in  instru- 
mental deliver}',  569  ;  principles  on  which  forceps  delivery  should  be  basi»d,  ib. ; 
case  illu.strating  abuse  of  the.  570  ;  stati.sties  of  forceps  dehvery,  574 ;  the  true 
power  of  tiie,  675  ;  dangers  of  forceps  delivery,  576 ; .  the  part  of  the  child  to 
which  the  instrument  should  be  applied,  576 ;  how  the  head  should  be  grasped 
by  the,  677  ;  modifications  of  the.  ib. :  improvements  in,  devised  by  the  author, 
578;  indications  for  the  use  of  the,  580;  time  of  resorting  to  the,  5- 1-584; 
rules  for  the  applicjition  of  the,  585  et  seq. ;  method  of  introduction.  587,  588 ; 
locking,  589 ;  force  employed  in  delivery  by  the,  and  method  of  tntction,  589, 
590 ;  unlocking,  590 ;  mode  of  applying  the.  in  the  various  positions  assumed 
by  the  head  at  the  inferior  strait.  591-596;  mode  of  applying  with  the  head  at 
the  superior  strait,  596-601  ;  application  of  the,  in  locked-head,  601-606:  use 
of  the,  when  the  head  is  retained  alter  expulsion  of  the  body,  607-611 ;  in  face 
presentation,  611-617  ;  cases  illustrating  the  application  of  the,  615-617;  the 
embryotomy  forceps,  663. 

Fossa,  the  triangular  or  recto-uterine,  82. 

Fossa  navicularis,  the,  73. 

Fourchette,  the,  73. 

Fox,  Dr.  George,  interesting  case  reported  by,  illustrative  of  the  advantage  ol  ttie 
Cesarean  section  over  cephalotomy,  635. 

Frerichs,  his  exposition  of  the  true  cause  of  unemic  intoxication,  513. 

Funis,  the.  pulsations  of,  191 ;  method  of  ligating,  3ti7,  368;  directions  for  traction 
on  the,  375,  377;  manner  of  dressing  the,  4o6,  428 ;  umbilical  hemorrhage, 
429 ;  peculiarity  of  the,  in  a  case  of  twin  labor,  440 ;  mortality,  causes,  diagno* 
sis,  and  treatment  of  prolapsion  of  the,  460-466. 

G. 

Galvanism,  a  means  of  artificial  delivery,  678. 

Gardner  peerage  case,  points  in  the,  bearing  on  the  duration  of  pregnancy,  299,  300. 

Gariel,  treatment  suggested  by,  for  retroverted  utcnis.  239. 

Oastrotomy,  danger  of  the  operation  of,  iu  extra-aterioe  pregnancy,  214. 


7:^4  INDEX.  GEK-BIP 

Generation,  the  organs  of,  72 :  external  ib. ;  internal,  77 ;  tlie  ovarie?,  the  essenlMl 
orgHns  of,  90;  ancient  theory  of,  108. 

Geitly,  M  ,  iiis  explanation  of  external  rotation  of  the  liead  of  the  foetuji,  51. 

Germ  cell,  90.  Ill  ;  seat  of  contact  bet>\'een  the  germ  and  sperm  cells,  117. 

Gestation,  evidences  of,  143;  suppression  of  the  catamenia,  144;  is  ovuKition  com> 
patible  with?  146;  nausea  and  vomiting,  with  depraved  app^^tite,  146:  secre- 
tion of  saliva,  148;  changes  in  the  breasts— the  secretion  of  milk — the  areola, 
148-153  ;  chauK-es  in  the  uterus  and  abdomen.  164;  descent  of  the  gravid  ute- 
nis  during  the  first  two  months,  155:  p<»«itions  of  the  gravid  uterus.  15^161  : 
cliaiigo  in  the  direction  of  the  urethra,  161  ;  oedema  of  lower  extremities,  ib. : 
eflect  of.  on  the  development  of  the  uterus.  1G3;  phases  through  which  Ih**  cer- 
vix of  the  titenis  passes  during,  164-169;  enlargement  of  the  utenis  and  dis- 
coloration of  the  vaginal  walls,  170-174;  quickening,  175;  simulated  qui«kt»ii- 
ing,  179;  how  the  movements  of  the  foetus  can  be  excited,  183;  puis;iti<»n  of 
the  fcetal  heart  187:  uterine  munnur,  189;  pulsations  of  the  uuibilic-Hl  cord. 
191  ;  extra-uterine,  causes,  progress,  and  phenomena  of)  206;  premature  and 
])rotracted,  268,  666.     See  Pregnancy. 

Glandular  apparatus,  tlie,  of  the  external  genitals,  77. 

Glans  clitoridis,  the.  75. 

Gooch,  Dr.,  his  testimony  on  the  subject  of  the  recurrence  of  puerperal  mania,  701 . 

Graafian  vesicles,  the,  90.  111.  112. 

Graves,  Dr.,  on  the  use  of  opium  in  puerperal  fever,  697. 

Gubler,  M.,  on  milk  in  the  breasts  of  the  new-bom  infant,  421. 

H. 

Hall,  Dr  Marshall,  his  "ready  method."  370;  on  puerperal  convulsions,  485,  486; 
on  depletion  in  puerperal  ntaiiia,  704. 

Halmagraiid.  statistics  hy.  on  the  (^a'sarean  .«»oction.  G.T.'J. 

Halpin.  treatment  suggested  by,  for  retn>verted  uterus,  238. 

Haunch  hone,  the.  7. 

Head,  the,  of  the  fcetus,  27 ;  description  of  its  regions,  diameters,  suturws  fonta- 
nelles,  etc.,  27;  sutures  of  the  facial  and  adult  head.  31  ;  resi>ective  diitmetens 
of  ilie  f(etjil  head  and  adult  female  pelvis,  32;  articulations  .^nd  movement*  of 
tlie  Hetiil.  11).:  rri'(|U('iiC'y  of  licud  presentations,  lV.i\  cause  cf  the  freqiienrv.  34  : 
tin-  aiillior's  elassilicatioii  of  lieiid  pivseiitations.  4."'>;  rejjttions  of.  tt»  tin-  in-lvis 
45:  inovciuenls  iinposed  upon  tlie.  4G;  llexi(>ii,  ib. :  descent  and  roijitii'D,  4"^; 
(Xt^'Msioi).  41):  praetieal  aiiiilicalion,  54;  [>rtseiilalion  of  tlie,  railing:  l«.r  rn  mu:ii 
delivery.  .*)24  et  seq.  :  jncnle  of  applying'  tlie  forceps  with  llie  lic;el  ;it  the  i:if»^ 
rior  .«trait.  r»lU-.''»!M» — ut.  the  suptTior  strait.  59(>-<;oi  ;  applica:ion  ••["  the  fonvpi* 
in  lockcd-iuad.  ()01-G0r»:  use  of  the  forceps  wiien  the  head  is  retaincil  after 
i'xpulsion  of  tlie  bo<ly,  60T-611  ;  diameters  of  the,  at  the  ditlcrent  |>eric<is  of 
previa iicy.  OCT. 

Headache,  trcatincnt  of.  in  exhausting  hemorrhage.  399. 

Heart.  tl;e  lu-tal,  i)ulsations  of,  lt^7-l>9;  i)aij>ilalion  of  the,  in  pregnariey.  160,  224; 
hypertrophy  of  the,  •J'Jo. 

Heal,  the  period  of.   in  aninials.  313. 

Heinorrh;ig«',  in  pregnancy.  ICS;  a  symptom  of  ahortion,  274,  275:  ditTtrenoe 
between  the,  of  nienstniation  and  niiscairia^'C,  275;  treatment  of.  2*»<>:  true 
explanation  of,  in  ciiihlhirth,  312:  nianaL'cnient  of  the  placenta,  in  cjim^  of. 
3Sf<;  frcipicncy  and  morlahly  (f.  IWH);  divisirms  (tf  poet-paitnni,  :!;m).  391; 
e\t»'rn;il,  and  its  ircadncnt.  .'Uil  ct  scc]  ;  trc.-itment  of  exhaustion  froni.  Hi**'. 
.'Jl»7  ;  tnatnu'iit  of  internal,  ih  ;  sec(»ndary,  KrJ.  403  ;  umbilical,  of  the  n<'W- 
])orn  infant.  4j9:  in  a  cas*-  of  invertt'd  uterus  mistaken  for  the  phuvnt.^.  4'.4. 
syjiiptoms.  (iiairnosis.  and  treatment  ot  as  coimecled  with  placenta  pnevia.  46t>- 
'174;  accident.al.  from  jt.irtial  si'paration  of  the  placcntii,  4SU-4^3  ;  accidental, 
at  the  time  of  lahor.  is  I  ;  ."iemndarv.  402*. 
lemorrhoids,  in  i)revriiancy.  1  «;2.  228 
lercilita-y  transmission  of  disease.  2()3. 

lerniaphroditism,  enlar^'ement  of  tiie  clitoris  mistaken  for.  75. 
leruiM  of  the  i:r;ivi<l  ui<mu'j.  a  rare  afleclion,  240;   in  labor,  400. 
lewiit.  C.raily.  on  hydalilorm  mole.  2S.'). 
lewson.  I>r,  measurements  of  the  f<etal  head  by,  30. 
lip,  the,  presentations  of.  5aS. 

Hipp(KTa\es,  dcKitrme  of  \u  head  presentations,  338;  his  directions  for  version,  640; 
facies  \i\p\>ocraV\ca,  <iS)'i. 


HOI)-LAB  INDEX.  735 

Hodg^.  Prof.,  on  the  Don-contagrion  of  puerperal  fever,  686. 

Hook,  the  blunt,  mode  of  lining  in  instrumental  delivery,  667. 

Hour-glass  contraction  of  the  uterus,  treatment  of,  380^383. 

Humoral  pntholo^ry,  683. 

Hunter,  liis  theory  of  the  membrana  decidua,  242. 

Hunter,  Dr.  Septimus,  case  of  malpractice  in  which  the  inverted  uterus  was  mis- 
taken for  tlie  placenta,  454-456. 

HydHtilorm  moles,  284. 

Hydatids,  can  they  form  in,  and  be  expelled  from  the  uterus?  294,  295;  premature 
delivery  in  a  case  of,  672. 

Ilydnx^ephalus,  rupture  of  the  womb  a  not  unusual  accompaniment  o^  662. 

Hydroraetra,  or  dropsy  of  the  uterus,  194. 

Hymen,  the  presence  of  the,  no  test  of  virginity,  78. 

Hysterotomy,  vaginal  and  abdominal,  626 ;  two  interesting  cases  of  vaginal,  645. 
See  Cfesarean  section. 

I. 

Hium,  the,  anatomy  of)  8. 

Impregnation,  aptitude  for,  107;  two  orders  of  phenomena  following,  124;  eflfected 
at  a  oieusirual  period,  307.  308. 

India-rubber  ball,  advantages  of  the,  as  a  support  to  the  uterus,  58. 

Indigestion,  convulsions  induced  by,  487,  488. 

Inertia  of  the  uterus,  causes  of,  552  ;  treatment  of,  553. 

Infant,  new-born,  management  of  the,  367 ;  treatment  of  asphyxia  in,  369-371 ;  wash 
ingand  dressing  the  new-boru,  406 ;  caution  against  physicking  and  cramming 
the,  409;  when  it  should  be  put  to  the  breast,  ib. ;  feeding  tiie,  418  ;  suppres- 
sion and  retention  of  urine  in  the,  420 ;  milk  in  the  breasts  of  the  new-born, 
421 ;  torpor  of  the  bowels  in  the,  423  ;  occlusion  of  the  anus,  423,  424;  puru- 
lent ophthalmia,  424,  425  ;  umbilical  hemorrhage  of  the  new-bom,  429  ;  morta- 
lity of  the,  in  podalic  version,  639 ;  evidences  of  the  death  of  the,  in  utero,  656- 
658. 

Instrumental  delivery,  565.     See  Forceps  and  Instruments. 

Instruments,  obstetric,  the  author's  case  of,  578 ;  cutting,  prerequisites  for  the  use 
of,  018.     See  Symphyseotomy,  Caesarean  section,  Craniotomy,  Embryotomy. 

Interstitial  pregnancy,  121,  205. 

Intra-uterine  growths,  193. 

Inversio  uteri,  446  et  seq. 

Ischium,  the  tuberosity  of  the,  10 ;  spinous  process  of,  when  malformed,  may  inter- 
fere with  delivery,  11. 


Jacquemin,  on  discoloration  of  the  walls  of  tlie  vagina,  172. 

Jones,  T.  Wharton,  his  experiments  showing  the  effects  of  belladonna  on  the  circu- 
lation, 498. 
Jorg,  on  elytrotomy,  640. 

K. 

Keating,  Prof.,  details  furnished  by,  on  the  use  of  opium  in  puerperal  fever,  697, 

698. 
Keep,  Dr.  N.  C,  the  first  to  use  ether  in  parturition  in  this  country,  721. 
Keiller,  Dr.,  case  of  spurious  pregnancy  and  spurious  parturition,  reported  by,  182. 
Keyscr,  of  Copenhagen,  statistics  by,  on  the  Ctesarean  section,  633. 
Kiestoin,  explanation  of  its  presence  in  the  urine  of  the  pregnant  female,  135. 
Kiwisdi,  his  plan  of  the  water-douche,  for  the  induction  of  premature  delivery,  67T. 
Knees,  presentation  of  the,  349,  55 1 ;  four  positions,  349,  350. 
Krahmcr,  Prof,  statistics  by,  on  tlie  duration  of  gestation  in  the  cow,  302. 


Labia  externa,  or  majora,  73;  interna,  or  minora,  75. 

Labor,  how  affected  by  the  sex  of  the  child,  28 ;  mechanism  of,  44 ;  first  vertex 
position,  ib. ;  flexion,  46 ;  descent  and  rotation.  48 ;  extension,  49 ;  expulsion 
of  the  shoulders  and  body,  62 ;  second  and  third  vertex  positions,  ib. ;  fourth 


7SC 


INDEX. 


LAOKEf 


vertex  pcisitioiv,  53;  nf^eea^jry  <>|  u  pmcticiil  knowkHlge  of  th?  pnit    ,      -     T  :, 
fiiippfHe<i  cft9*J  practle^Uy  illustrutiag  the  inechnniHm   i>f.  ib. ;    uL  , 

fi'Luii  pwlvic  Uetiirniitiee,  61 — from  luorbkd  growvli,%  U"l     •"-""<■  •  ^ 

polyptus^  ib. ;  llie  ntiUii>rH  clasMtieution  of,  irtW  UHiuntl  > ; 

deliiiUiori  of  uuturnl,  207;  order  of  Keqiiencti  of  i\w  pro  ifj- 

iii^  cause  of,  SOi*;  expnWve  forces*,  309,  :ilU;  th*?  ovuriaii  Ujot*r|-  H.  .>iil;  D^ 
Juhtt  Tower  a  ih<.H>ry  of  the  dek^rtiuiiiuf:  vansc  of,  UU-^IG;  (hf*  AuibMrt  txpSm^ 
initiotj  of  tht'  dftoin»niliiK  cause  of,  a  18  ;  »tdt  and  ohjfni  vo  Ibroca 

in,  iril  ;  pHmjtry  and  secondary  forces  of,  823,  824;  p  >  f,  «t5- 

3'i8  ;  l^KBl^llllal  or  cUarucleriHUc  ai^s  of,  3:iS-3Jl ;  the  i  .   uu«  Itbor 

pjuiLH,  :i:ci;  fut.-4e  htbor  pains,  iiU^ ;  caiiatf  of  i lit*  di)aL  cm  tHeH  ii^ 

it).;    ri}if<jra    arid  vomitinjLf  during,  334;    mucosanjruif  >:ir\re  hi,  Jh.; 

fanniitiun  and  rupttire  of  Uio  membrnnous  Hnc;  or  bug  of  M-utc^rs,  ^^  n- 

ditiiMis  for.  ou  iU^  pnrt  of  llie  niotlier  uud  fcetuM,  3U7,  3U^;   pn  -  lq 

rmtuiiil  Idbor,  3;:J9-a50;  detnilfd  direcuou«  for  iho  guidiineo  of  Uit;  uccoiicbcBr 
in  II  CJise  of,  351  et  Heq  ;  stages*  of,  3a7  et  *t*q. ;  iimfuiKt^'in^fJt  of  tin*  pasptfltl 
wonitiii  After  Ihtt  blith  of  her  ehiH  40i-4l8,  4^27^30;  uder-pAins,  40T ; 
matJUj^'eEiient  of  a  twin  IuIkjp,  4^6  ft  seq, ;  superfu/^Uinon,  tl'i-^45  ;  pi eU^riiAtii^^ 
mi,  457  ;  exhsmjttiun  during.  4JD;  uct'identjil  hernorrbn^  J»t  ihe  ilaw  <  f  4A4; 
truiilmetit  of  ctjnvulskms  durinj?,  497-604);  nmfiunl  lubor,  61C;  i;c 

of,  rendf.*rii)j7  mnuual  interfi^rcucM;  tiect^s&ary,  5^0;  detailed  dirici  iiji 

applicjiiiou  of  the  forceps,  591-601  ;  u»e  of  oncrsthetics  in,  708. 

lACtution,  ill  pregnuucy,  and  other  conditions  of  the  eyMtom,  149,  IfiO;  wometkam^ 
oiuse  of  iibortiort,  2TU;  Ibrbiddetj  m  puerpeml  iever^  6S4,  Dr.  CuickaiiDgt  CB 
iialurut  niul  urLiticijd^  41fK 

l.a  Chaps^lle,  Mad,,  on  period  of  abortion,  268, 

Liimbduidid  suture,  the,  30, 

Lii!*errt.\  M,,  on  epidemic*  of  puer^iernl  fever,  689. 

Leo,  Dr.  Robert,  his  hypotlie^tis  with  respect  t«i  puerp^nd  ferer,  fi81. 

Lever,  the,  in  insiruiueut;d  delivery,  568 ;  cciDtrsLMt  betweeo  the  foroepfl  and,  ih. 

Lev  ret,  on  the  Cie^Mreun  opefMtiott,  632. 

Lij;ht,  iut(»terinc!(i  ot,  ttrisuig  froin  eiciiuusting  hetnorrlmge,  '699. 

Liiiert  iJeo-peclinea,  ibe^  IT. 

Liquor  amnii,  nource  and  uses  of  the,  245,  346;  does  It  oonlain  Dutrieot  propcfftifff 
256. 

Lochia!  discharj^,  the,  417,  418. 

Locked  bead,  remarks  on.  001,  GQQ;  de5tiitioTi  ot,  603;  d«ng<eni  of,  to  th«  cfaOd  Mid 
mother,  ib. ;  diagnosifl  of«  604  ;  flppliciition  of  the  forceps  in,  605,  00€. 

LjiDg-in  chamber,  deiaiW  dircciioua  for  the  guidftuec  of  Uid  jouog  itcooiicfcttr  Ift 
tJbe  duties  of  the,  35 1  et  seq. 


Kacautcy,  Dr.^  the  first  to  pfrnctifle  premature  ArtificiAl  deUretj  when  Itw  foeCot  fi 
viable.  G6G. 

Malaco^teon,  a  cause  of  pehic  dfromiitr,  62. 

Male  children,  mortality  of,  oompured  with  that  of  female,  2R. 

Mumnifl^  the,  their  relations  to  the  uteruH,  149;  patus  in  the,  dari&g  pregiuncy^ 
226.     See  Lactation, 

MuQto,  occurrence  ot,  ader  parturition,  503;  puerperal,  its  pathologj,  Cft^;  th^^ 
period  ut  which  it  ia  moat  apt  to  occur,  700 ;  not  of  rare  occurrwioiit  ib. ;  lia 
liability  to  recur,  701;  Csauses  and  symptom^  102:  diagnosis  Atid  progDfliiik 
703;  duration,  704;   tr^ntment,  medicitiid  and  mord^  704-707 

Hanual  dc^Uvery.     Se^  Delivery. 

Hanual  Uibor,  457. 

Marrin^re,  conducive  to  health  aod  longevity,  123. 

Wartio,  Kdw^rd,  \m  monojEH^iph  on  trunsfuflion,  400. 

Matit't.  A,,  on  cephalic  veraion  by  external  muiiipulatioD,  &i2, 

Maufifiell,  Dr.,  statiatica  of  cranio'lomy  openuions  by,  63 L 

Maiiriceuii,  on  moles,  283 ;  on  the  Cassarean  sectioti,  6*27. 

Meatus  urinariua,  the,  76. 

Meconium,  the,  409. 
^Medulla  fiplnalis,  the  reflex  action  of  the,  17& 
If  Jioi^  Pro/:,  nteajjurementa  of  the  lojial  head  by,  30; 
meter  of  puerperal  fever,  6tf6. 


on  thtf  noo-ooQiticloiiA  dw* 


IIEI-OPI  INDEX.  737 

Meissner,  his  plan  for  perforating  the  membranea  in  premature  artificial  delivery, 
675. 

Membrana  decidua.  Hunter's  theory  of  the,  242  ;  its  true  structure,  ib. 

Membrana  granulosa,  the.  111. 

Membranes,  perforation  of  the,  in  premature  artificial  delivery,  675. 

Menstruation.  Menses,  the ;  retention  of,  mistaken  for  pregnancy,  79 ;  period  be- 
tween puberty  and  their  final  cessation,  93 ;  uitiuence  of  climate  on,  95— of 
education  and  mode  of  life,  96 — of  temperament,  constitution,  and  race,  97; 
average  age  at  wliich  they  first  appear,  96 ;  precocious  and  tardy,  98  ;  oauses  of, 
ib  ;  dependent  on  organic  development,  99 ;  do  not  consist  in  the  discharge  of 
blood,  bat  in  the  maturity  of  the  ovules,  100 ;  the  ovular  theory,  101 ;  periodicity, 
ib. ;  source  and  nature  of  the  menstrual  fiuid,  102,  292 ;  duration  and  quantity  lost 
at  each  menstrual  period,  103 ;  is  menstruation  peculiar  to  women  ?  104 ;  does  the 
menstrual  fluid  contain  poisonous  elements?  ib. ;  time  of  final  cessation,  106; 
aptitude  for  impregnation  just  before  the  catamenial  period,  107  ;  suppression 
of,  h.<*  a  sign  of  pregnancy,  144 ;  sometimes  occur  only  during  pregnancy,  146 ; 
retention  of  the,  with  interesting  case,  194,  195;  diflerence  between  the, 
and  the  hemorrhage  of  miscarriage,  275;  case  of  fecundation  efiected  at  a 
menstrual  period,  307,  308. 

Merriman.  Dr.,  on  the  application  of  the  forceps,  581 ;  on  the  Cajsarean  section,  628 ; 
objection  by,  to  premature  artificial  delivery  in  a  primipara,  668. 

Meso-rcctum,  the,  4.  » 

Metrorrhagia,  common  occurrence  of,  at  the  critical  period,  106. 

Metroscope,  the,  description  of,  201. 

Midwifery,  an  exact  science,  1. 

Milk,  secretion  of,  an  evidence  of  pregnancy,  149;  instances  of  its  secretion  in  other 
conditions,  150 ;  in  the  breasts  of  the  new-bom  infant,  421 ;  milk  fever,  422. 

Milk  leg,  712. 

MilLs,  Dr.  Charles  S.,  interesting  case  of  Caesarean  section  reported  by,  635. 

Miscarriage.     See  Abortion. 

Moles,  various  opinions  of  authors  respecting,  283.  284 ;  the  true  moles — vesicolar 
or  hydatiform,  ^84-291 ;  false  moles  — molie  spuriye,  291-294. 

Mollities  ossium,  a  cause  of  pelvic  deformity,  62. 

Monkeys,  menstruation  in,  104. 

Monueret.  on  the  puerperal  state,  685. 

Mons  veneris,  the,  73 

Montgomery,  Dr,  summary  of  his  remarks  on  the  areola  of  pregnancy,  152;  on  the 
temporary  loss  of  mind  during  labor,  365. 

Morton,  Dr.,  the  first  to  administer  ether  to  prevent  the  pain  of  a  surgical  opem* 
tion,  709. 

Mucous  follicles,  increased  secretion  of  the,  as  pregnancy  advances,  166. 

Multipara,  modifications  of  the  cervix  uteri  in  a,  169. 

Murphy,  Dr.,  on  the  C«sarean  scctiou,  628. 

N. 

Naegeld,  on  the  inclinations  of  the  planes  of  the  pelvis,  19;  hia  ^evs  on  the 
mechanism  of  parturition,  38 ;  on  vertex  presentations,  42  ;  on  oblique  distor- 
tion of  the  pelviH,  65 ;  on  the  period  of  pregnancy,  306. 

Nausea,  in  pregnancy,  128,  146;  iinporunce  of;  128,  129;  treatment,  220. 

Neboth.  glands  of,  an  erroneous  appellation,  83. 

Nerves,  sacral  plexus  of,  4. 

Nervous  force  as  a  determining  cause  of  labor.  Dr.  John  Power's  theory  of,  314-318. 

Nipple,  how  to  remedy  a  sunken  or  fiat,  410;  treatment  of  sore,  426. 

Nutrition,  a  fundamental  law  of  life,  254 ;  objects  ofj  ib. ;  embryonic,  255 ;  pl»> 
cental,  256. 

NympluB,  the,  75 ;  enlargement  of,  simulating  breech  presentation,  76. 


Obstetric  case,  the  author's,  578. 

(Edema  of  the  lower  extremities,  during  pregnancy,  161. 
Ophthalmia  neonatorum,  causes,  symptoms,  and  treatment  of,  424,  425. 
Opium,  comments  on  the  use  of,  iu  the  convulsions  of  pregnancy,  494 ;  treatment 
by,  in  puerperal  fever,  697. 


738  INDEX.  OS-PLA 

Os.  coccyx,  anatomj  of  the,  6;  importaDt  influence  during  childbirth,  6^  7;  diiloea- 

tion  and  fracture  of,  7. 

Os  innomiiiatum,  anatomy  of  the,  7. 

Os  iscitiuin,  tlie,  10. 

Os  ptjbis,  the,  10. 

Os  wicnini,  the,  description  of,  3. 

Os  sedeiiijiriuni.  the,  10. 

Os  tincfc  the,  81 ;  cicatrices  upon,  not  alwars  reliable  as  evidences  of  childbirth,  88, 
cundition  of  the,  as  pregimnoy  advances,  1G5  ;  peculiar  moisture  of  the  lip0  o^ 
qii  aecompjmiment  of  prt'jfi'ancy,  ih. ;  extraordinary  thinness  of  the,  at  the 
time  oi'lHbtjr,  172;  cauRe  of  its  dilatation  in  labor,  332 ;  rigidity  of  the,  360 ;  8}»asm 
of  tlie,  tn.'atment  of,  378-380;  mode  of  etfecting  artificial  dilatation  of  the,  5*J0  ; 
dihitatiou  of,  by  prepared  sponge,  in  cases  oJ  premature  artilicial  delivery,  G76. 

Osborn,  Win.,  on  the  amount  of  pelvic  contraction  consistent  witii  the  birth  of  a 
living  child,  619;  on  the  Cesarean  section.  627  ;  his  report  of  the  performance 
of  embryotomy  in  the  celebrated  case  of  Elizabeth  Sherwood,  6d2-65G. 

Ovarian  pregmmcy,  203. 

Ovarian  theory  of  parturition,  312. 

Ovaries,  the,  the  essential  organs  of  generation,  90. 

Ovary,  the,  the  seat  of  conuct  between  the  germ  and  sperm  cells,  119;  eoUrgemenft 
of  the,  1 9G  ;  diagnosis  of  prolapsed,  240. 

Ovisac,  the.  112.  ^ 

Ovulation,  is  it  incompatible  with  gestation?  146. 

Ovule,  the  fecundated,  manner  of  admission  to  the  Fallopian  tube,  119;  the  deei- 
duouH  and  the  vitalized,  176. 

Ovum,  blighted,  interesting  case  of  enlarged  uterus  caused  by,  287-291. 

P. 

Pain,  as  a  sign  of  labor,  329  ;  true  labor  pains,  331 ;  false  labor  pains,  832 

Paralysis,  treatment  of,  after  delivpry,  428. 

Paniplegia,  after  deliver)',  treatment  of,  428. 

Parent,  inHuence  of  the,  upon  progeny,  2G3. 

Parent- Duclmlelet,  on  enlarjreinent  of  the  clitoris,  75. 

Partinition,  primary  forces  of,  323;  seconUury  forces,  324.     See  Labor. 

Pathology,  liuinonii.  GH3. 

Pelvic  axis,  true  meaning  of  the  term,  10. 

Pelvic  cxircuiilics,  presentation  of  ilio,  348. 

Pelvic  ver-sion,  539;  .spontaneous*,  (t{'}'2. 

Pelvimeter,  l!ie,  method  of  usin^^  GU;  the  finger  the  best,  70,  Gr.8. 

Pelvis,  the  iiuman,  its  position  in  the  skeleton,  and  aruilomy  of  the,  2;  bones  o(J  in 
the  adult  and  roDtu.s,  3;  its  uses,  12;  articulations  or  joints,  ib — question  of 
tlieir  relaxation,  15;  the  greater  and  lesser,  IG;  the  straits  of  the,  16,  17;  plane* 
of  the  two  straits,  18;  axes  of  the  pelvis,  li);  remarkable  diflerences  between 
that  of  the  new-born  child  and  that  of  tiie  adult  23;  varieties  of.  deju-ndinir 
upon  the  .sex  and  age  (jf  the  indivi(iual,  22,  2i{;  its  ccmnexions  wilJi  the  s<.>rt 
part.s,  23,  ".'4;  measurements  24-2():  respective  diameters  of  the  lioptal  head 
and  adult  female  pelvi.s,  32  ;  deformities  otj  two  cla.'<ses-- increased  cap;icity  and 
diminished  capacity,  67;  illustrative  case,  58,  59;  varieties  of  pelvic  deformity, 
Gl,  G19.  G20 ;  causes  of.  G2  ;  oblique  di.stortion  of  the,  65;  determination  of 
the  smallest  space  through  which  a  living  child  may  bo  extractcil,  HG;  oxami- 
nation  ot  the  propriety  of  version  in  cases  of  pelvic  deformity,  54-4-.'>46;  amount 
of  pilvic  contraction  consistent  with  the  birth  of  a  living  child,  619 ,  amount 
of  pelvic  deformity  througli  which  a  child  may  be  extracteti  pieci»meal,  62(^ 

Perineum,  directions  for  supporting  the,  ia  labor,  363-365;  paralysis  of  the,  after 
delivery,  417. 

Peritoneal  dropsy,  diagnostic  guides  of,  197. 

Peritonitis,  puerperal,  691. 

Peu,  M.,  tiirilling  case  of  Cajsarean  section  by,  639. 

Phlegmasia  dolens,  708. 

Phlegmasia',  treatment  of,  during  pregnancy,  13 

Physometra  of  the  uterus,  a  rare  aflection,  195. 

Piles,  treatment  of  in  pregnancy,  228,  229. 

Piaoenta.  description  of  the,  246;  fcetal  and  maternal  divisions  of  the,  247-149; 
blood- vesseia  oC  \.\\e,  7.41,  IA**,  ^a\v^  d'^^^ueration  of  the,  260 ;  nutrition  by  tb^ 
256 ;  manner  m  v{Viv\ih  \.V\e  WviiAva  cwwNvi^^  \.xwa,  >^\^\A>i&.^^v&.<Ma^  258^  259; 


PLA-PUB  INDEX.  739 

elaboration  of  the  blood  in  the,  261 ;  connexion  between  abortion  and  disease 
of  the,  272;  placental  apoplexy,  278;  fiitty  degeneration  of,  towards  the  close 
of  gestation,  320;  function  of  the,  when  terminated,  372;  situation  of,  373; 
natural  detachment  of,  ib. ;  removal  of,  after  deiachnjent,  374;  examination  of, 
after  removal,  376;  how  the  expulsion  of,  may  be  aided,  377  ;  artillcial  cxtrac- 
liou  of,  37»,  385;  excessive  volume  of,  378;  morbid  adhesion  of!  to  the  uterus, 
383;  absorption  of  retained,  386;  management  of.  in  cases  of  hemorrhage  or 
flooding,  388 ;  in  multiple  pregnancy,  43*2,  437,  438.  440 ;  case  of  malpractice 
in  which  the  inverted  uterus  was  mistaken  for  the  phicenla,  454-456 ;  artificial 
detachment  of  the,  475-479 ;  accidental  hemorrhage  from  partial  separation  of 
the,  480-483 ;  detachment  of,  in  the  Cesarean  operation,  642. 

Placenta  pnevia,  168;  connexion  between  hemorrhage  and,  467-469;  symptoms, 
diagnosis,  and  treatment  otj  470-476. 

PlaceuUl  souffle,  the,  189. 

Plethora,  its  connexion  with  pregnancy  considered,  130. 

Podalic  version,  531  ;  deliver)'  of  the  lower  extremities  and  trunk,  583  ;  delivery  ol 
the  arms,  535 ;  extraction  of  the  head  ib. ;  statistics  of,  538 ;  case  of,  con- 
nected with  malposition  of  the  uterus,  564. 

Polypiis,  case  of  labor  obstructed  by.  63. 

Position,  of  the  parturient  woman,  359,  360;  of  the  foetus,  difference  between,  and 
presentation,  35. 

Power,  Dr.  John,  his  digest  of  the  ovular  theory  of  menstruation,  101 ;  his  theory 
of  the  determining  cause  of  labor,  314-316. 

Pregnancy,  definition  and  divisions  of,  121;  not  a  pathological  condition,  1*22  ;  occa- 
sionally subject  to  derangements  216;  changes  in  the  uterus  during,  124  (and 
see  Uterus);  connexion  betwi-en,  and  gastric  irritability,  128;  changes  in  the 
blood,  129;  not,  per  se,  a  condition  of  plethora,  131 ;  treatment  of  phlegmasiie 
during,  ib. ;  modifications  in  the  urinary  secretion,  135 ;  how  is  pregnancy 
diagnosed  ?  136  ;  difficulty  of  distinguishing,  137  ;  remarkable  and  touching  case 
of  fibrous  tumor  simulating,  138;  how  the  evidence  of,  should  be  examined, 
142  (and  see  Gestation);  cases  of  simulated,  179-183;  period  of.  at  which  the 
placental  murmur  can  be  first  recognised,  190  ;  method  of  examining  the  female 
to  ascertain  the  existence  of,  192;  ovarian,  203;  tubal  or  fallopian,  204;  abdo- 
minal and  interstitial,  205 ;  causes,  progress,  and  phenomena  of  extra-uterine, 
206;  symptoms  and  diagnosis  of  extra-uterine,  208;  dangers  of  extra-uterine, 
212;  treatment  of  extra-uterine,  213;  bloodletting  in,  when  indicated.  217; 
cathartics  and  emetics  in.  218;  nau.«ea  and  vomiting  in,  treatment  ofj  220; 
salivation  in,  22 1  ;  constipation  in,  222 ;  diarrhoea  m,  223 ;  palpitation  of  the 
heart  in,  224;  syncope  in.  225;  pain  and  relaxation  of  the  abdominal  parietes, 
226 ;  painful  mammffl.  ib. ;  pain  in  the  right  side,  227  ;  pruritus  of  the  vulva, 
ib. :  hemorrhoids,  228;  varicose  veins,  229;  coiigh  and  oppressed  breathing, 
230  ;  complications  of,  from  displacement  of  the  uterus,  232 ;  period  of,  at  which 
abortion  is  most  frequent,  208,  269;  duration  of,  297-303;  peculiar  sensations 
as  a  guide  for  computing  the  period  of,  303,  304 ;  the  period  of  quickening, 
304;  rule  for  calculating  the  duration  of,  from  the  last  menstrual  period,  306; 
multiple,  431  et  seq. ;  superfoeiation.  442-445  ;  treatment  of  convulsions  during, 
492-497 ;  frequent  occurrence  of  albuminuria,  508. 

Preputium  clitoridis,  75. 

Presentation  and  position  of  a  foetus,  difference  between,  35 ;  influence  on  presentation 
exercised  by  the  life  or  deatli  of  the  foetus,  33  ;  vertex  presentations,  33-48, 188. 

Presentations,  of  the  foetus  in  natural  labor,  33,  339 ;  8tati.stics  of  face,  339 ;  dia- 
gnosis, 340 ;  presentation  of  the  pelvic  extremities,  343  ;  of  the  breecli,  344,  547  ; 
diagnosis  and  prognosis  of  breech  presentations,  345,  346;  of  the  feet,  348,  349, 
550;  of  the  knees,  349.  350,  551;  in  twin  pregnancy,  435;  classification  of; 
calling  for  manual  delivery.  522  et  seq  ;  pelvic.  547,  552 ;  trunk  or  transverse, 
555;  of  the  thorax.  556;  of  the  back,  557  ;  of  the  hip  and  shoulder  with  the 
protrusion  of  arm.  558  et  seq. 

Preternatural  labor,  457  ct  seq. 

Primipara,  modifications  of  the  cervix  uteri  in  a,  169. 

Procidentia  uteri,  233. 

Progeny,  as  influenced  by  the  parent,  263. 

Prolapsus  uteri,  three  degrees  of,  232. 

Pruritus  of  the  vulva,  in  pregnancy,  treatment  of,  227,  228. 

Ptyalism,  sometimes  a  result  of  pregnancy,  148;  treatment  ot^  231. 

Puberty,  changes  in  the  physical  oondition  at  the  time  o(  95. 


740  nn>EX.  PUB-BiQ 

Pubic  arcade,  the,  deformity  of.  64. 

Pudendum,  the,  or  exlernal  orgrnns  of  generation,  73. 

Puerperal  convulsioiiJ*,  485;  patholojry  of.  485,  486;  eccentric  causes  oC  487—491 ; 
treatment  of.  491;  symptoms,  diagnosis,  and  prognosis  ofj  501-603;  ceotrie 
causes  ot;  504. 

Puerperal  fever.     See  Fever. 

Puerperal  woman,  management  of  the,  afler  the  birth  of  her  child,  404  et  seq. ;  diel 
of  the,  427  ;  recumbent  position  enjoined,  ib. 

Pulsations  of  the  foetal  heart,  187  ;  directions  for  recognising,  188, 189;  of  the  umbi- 
lical cord.  191. 

Purgatives,  prescriptions  for,  in  puerperal  fever,  695,  696. 


Quickening,  ancient  theory  of,  1 75 ;  English  law  with  regard  to,  1 76 ;  the  trae  import 
of  the  term,  177  ;  not  a  p.«ychical  act.  but  the  result  of  excito-motory  inHueno^ 
177.178;  period  of,  178;  simulated,  179-183;  difference  between,  and  ballotte- 
ment,  185;  the  period  of,  as  a  guide  for  calculating  the  duration  of  preg* 
nancy,  304. 

Quinine,  sulphate  of^  in  puerperal  fever,  69T 


Bachitis,  a  cause  of  pelvic  deformity,  62. 

Ramsbotham.  Dr..  on  premature  artiflciul  delivery,  674. 

"Ready-Method."  the,  of  Marshall  Hall.  370. 

Rectum,  distension  of  the.  by  fieces,  occasioning  symptoms  of  retro-verted  uteroi;  239i. 

Reflex  movement,  explanation  of  269;  sometimes  a  cause  of  abortion,  270. 

Rcid,  Dr  James,  table  by,  exhibiting  the  duration  of  pregnancy  dating  from  m  single 

coitus,  305. 
Reproduction,  its  importance  and  necessity,  109;  early  opinions  coDccrning,  110; 

what  is  the  vitalizing  element?  115. 
Respiration,  oppressed,  in  pregnancy,  treatment  of,  230;  artificial,  370,  371. 
Respiratory  organs,  derangements  in  the,  sometimes  occurring  in  pregnuncy,  160. 
Retro-version  of  the  uterus,  2:15. 
Rigors,  in  Inbor,  334. 
Ritgen.  on  elylrolomy,  G40;  tables  from,  showing  the  diameters  of  the  head  at  the 

different  poricKis  of  pregnancy,  GG7. 
Roberton,  Mr.,  Ptatistics  of  the  iiitJiience  of  climate  on  menstruation,  96. 
Roger,  Dr.,  on  the  ocrlusion  and  ossification  of  the  anterior  fontanelle,  31. 
Rouget,  Dr.  Charles,  hip  lescarches  as  to  whether  the  uterus  is  an  erectile  organ,  84, 


Sacral  plexus  of  nerves,  4. 

Sacro-coccygeal  sympliyaia,  the,  12. 

Sacroiliac  symphyae.s  the,  13. 

Sacro- vertebral  articulation,  the,  1 1. 

Sacrum,  the.  description  of,  3. 

Sagittal  suture,  the,  30. 

Salivary  glands,  sympathy  between  the  sexual  organs  and  the,  148. 

Salivation,  sornetime.s  a  result  of  pregTiancy.  148;  treatment  of.  221. 

Scanzoni,  on  head  presentations.  3  4 :  his  Cfphalotribe,  or  embryotomy  forx^epe,  69S. 

Soheller,  his  method  of  inducing  ariiticial  delivery,  677. 

Scholer,  Dr.,  on  trij«mus  nasceniiuni,  367. 

Sciatic  plexus,  the,  4. 

Schwartzenbertr,  the  Princess  of,  post-mortem  Capsarean  section  performed  on,  638. 

Secalo  cornutnm,  efficacy  of,  in  uterine  hemorrhage,  280;  caution  on  tlieuse  oC,  392 

in  placenta  pra?via,  4S0 
Sewuuary  hemorrhage,  402*. 

Semmelweisa,  Dr.,  observations  of,  on  puerperal  lever,  686,  687. 
Sequard.     See  Brown -.S^'quard. 
Sex  of  the  child,  the,  its  influence  upon  labor.  28. 
Sexual  organs,  sympathy  between  the,  and  the  salivary  glands,  148 
Shoulder,  the,  pTeaeulutious  of,  558. 
Show,  t\ie,  a  ft\gn  ot  \.\\e  t^vv"^^^^^  c>^\5i\)W,^"^V. 
Sigault,  persevemwce  oV,  \\\  \t\\t\>\m^\iv^  >Jl\^!>  ov^t^^Ix^xi  ^^  viT&T^v^tK^nQK^^^ftft^^ti^ 


BDC-URJB  INDEX.  741 

Simon,  statistics  bj,  on  the  Csesarean  section,  633. 

Simpson,  Prof.,  on  labor  as  affected  by  the  sex  of  the  child,  28 ;  on  vertex  presenta- 
tions, 39 ;  siatistics  by,  on  presentations  in  twin  labors,  435 ;  bis  plan  of  artifi* 
cial  detachment  of  the  placenta,  475,  47G ;  on  version  in  pelvic  deformity,  644, 
545,  596 ;  the  first  to  use  ether  in  parturition,  709 ;  introduction  of  chloroform 
by,  ib. 

Smellie,  on  the  Cesarean  section,  627. 

Smitli,  Dr.  Stephen,  on  umbilical  hemorrhage,  429.  • 

Smith,  Dr.  Tyler,  his  theory  of  the  determining  cause  of  parturition,  312. 

Snow,  Dr.,  on  anesthetics  in  parturition,  723,  724. 

Souffle,  the  placental  189;  of  the  funis,  191. 

Spasm  of  the  uterus,  378  et  seq. 

Spermatozoa,  115,  116,  118. 

SpinouH  process  of  the  ischium,  the,  1 1 ;  how,  when  malformed,  it  may  interfere 
with  delivery,  ib. 

Stoltz,  on  shortening  of  the  neck  of  the  womb,  87,  168. 

Strangury,  case  of  nervous  perturbation  occasioned  by,  in  a  pregnant  woman,  489, 
490. 

Sub-pubic  arcade,  the,  1 7. 

Sugar,  pjcesent  in  the  urme  of  pregnant  women,  136. 

Sulphuric  ether.     See  Ether. 

SuperfoBtatiou,  remarks  on,  with  cases,  442-445. 

Sutures,  the.  of  the  fceul  head,  30. 

Symphyseotomy,  history  of  the  operation  ot,  622,  623 ;  the  objects  of,  624 ;  statistics 
of,  625. 

Symphyses  of  the  pelvis,  the,  12;  do  they  become  relaxed  during  gestation,  and 
separate  during  parturition?  16. 

Symphysis  pubis,  the,  13. 

Syncope,  treatment  o^  in  pregnancy,  225. 

T. 

Tampon,  the,  when  to  be  employed  for  the  arrest  of  hemorrhage,  280,  393;  use  o^ 

in  placenta  prsvia,  472,473;  the  vaginal,  as  a  means  of  inducing  artificial 

delivery,  677. 
Tamier,  on  the  puerperal  state,  686. 

Tessier,  observations  by,  on  the  gestation  of  the  lower  animals,  302. 
Testes  muliebrcs,  90. 
Thomas,  Dr.  T.  Gaillard,  his  plan  of  postural  treatment  in  prolapsion  of  the  funis, 

4&1. 
Thompson,  Dr.  Cyrus  M.,  case  of  extra-uterine  gestation,  208. 
Tliorax,  the^  presentations  ot,  556. 
Thrombus  of  the  vulva,  430. 
Toudier,  the,  directions  for  making,  70. 

Toxaemia,  or  blood-poisoning,  605.  683 ;  characteristic  of  diseases  produced  by,  684. 
Transfusion,  observations  on,  400-402  ;  method  of  performmg  the  operation,  402. 
Trask,  Dr.,  abstract  of  his  researches  on  artificial  detachment  of  the  placenta,  477- 

480 ;  interesting  facte  from  his  monograph  on  rupture  of  the  womb,  673. 
Trismus  nascentium.  Dr.  Scholer  on,  367. 
Tubal  pregnanoy,  204. 
Tuberosity  of  the  ischium,  the,  10. 
Tumor,  fibrous,  case  of,  simulating  pregnancy,  188. 
Tumors,  polypous  and  fibroid,  labor  obstructed  by,  63 ;  uterine  and  abdominal,  193, 

196;  piiuntom,  197. 
Turpentine,  internal  use  of,  in  puerperal  fever,  696. 
Twin  pregnancy,  signs  of,  433 ;  twins  not  always  equally  developed,  434 ;  not  inoom* 

patiblo  with  natural  labor.  434,  436 ;  management  of  a  twin  labor,  436 ;  into- 

restiiifir  case  of  twins,  439-442 ;  superfoetation,  442-446. 
Tympanites  of  the  abdomen,  197. 
Tympanites  intestinalis,  692. 

U. 

Umbilical  cord,  pulsations  of  the,  191.    See  Cord  and  FoniiL 
Umbilical  hemorrhage  of  the  new-born  infant,  429. 
Uramic  intoxication,  411. 


742  INDEX.  URJB-VAll 

Ursmia,  505  ;  not  necessarily  a  consequence  of  albuminuria,  610;  definition  of,  ih. ; 
not  necewwrily  produced  by  excess  of  un-a  in  the  blood,  512:  the  true  auiae  o^ 
513  ;  treatment  of,  614;  aniestlietics  in,  ib. ;  auuimary  of  couclusiona  respecting, 
515. 

Urea,  not  a  vinilent  poison,  61 1,  512. 

Urethra,  cliauj^e  in  the  direction  of  tlie,  during  pregnancy,  161. 

Urethro-vaginal  tistula,  diagnosis  of,  78. 

Urinary  secretion,  the,  niodilicaiions  in,  during  pregnancy,  135. 

•  Urine,  the,  constituents  of,  in  pregnant  women.  135;  retention  of  after  childbirth, 
411,  412;  incontinence  of,  415;  suppression  and  retention  of,  in  the  inl'aiit.  420. 

Uterus,  the,  advantages  of  the  India-rubber  ball  as  a  support  of,  58;  displacementa 
to  which  it  is  liable,  59;  its  position  and  relations  to  the  adjaci.nt  organs,  80; 
its  divi.sion8,  ib. ;  the  fundus,  body  and  neck,  surfaces,  anglt-s,  and  bordtrs*,  81 ; 
its  size  variable,  ib. ;  shape  pyramidal,  ib. ;  composite  structure,  ib. ;  external 
coat,  82 ;  anterior  and  posterior  broad  ligaments,  ib. ;  triangular  fossii — rect'v 
uterine  fossa,  ib. ;  internal  or  mucous  lining.  83  ;  intermediate  tissue,  84  ;  is  it 
an  erectile  organ  ?  ib. ;  blood -vesseK  85;  lynjphatic  ve.ssels,  8G  ;  nerves,  ih.; 
cervix,  the,  its  volume  and  form.  87,  88 ;  the  round  ligaments,  88  ;  the  FalU»pian 
tubes,  89 ;  the  ovaries,  90;  reciprocal  relations  of  the  general  and  ut*?rine  sys- 
tems, 93;  mallormations  and  absence  of,  89;  special  functions  or  physiolo^ric^l 
oflBces  of,  92;  commencement  of  menstruation,  94:  changes  in  the.  during 
pregnancy,  124,  154;  development  of  the  impregnated — the  mucous  im  mhrane, 
peritoneal  or  serous  membrane,  and  muscular  structure,  12r»;  c^mi-titutional 
sympathies.  127;  descent  of  the  gravid  uterus  during  the  first  two  iinmth5<, 
155  ;  positions  of  the  gravid,  from  the  earliest  moment  of  c<.>nerption  until  the 
completion  of  gcstition,  155-161;  effect  of  fecundation  on  the  devt* lopment 
of  the,  163;  changes  in  the  cervix.  164-169;  diflerence  of  the  cervix  in  the 
primipara  and  multipara,  169;  development  of  the  annexjc  and  the  ext^-mal 
genitalia,  169;  how  the  gravid,  enlarges,  170;  thickness  (►f  the  walls  «lurinu 
gestation,  171  ;  discoloration  of  the  vaginal  wall.s,  172;  the  utenne  rnurinur. 
189;  dilferent  causes  other  than  gestation,  capable  of  inducing  enl.irgomt-nt  i>t, 
193;  dropsy  of  the,  1 94 ;  phy8t)metra,  195  ;  hyiK-Tirophy  and  scirrhus  of  the, 
196;  extra-uterine  pregnancy,  its  varieties,  2()3 ;  prolapsus  uteri.  232  :  anlv- 
version  of  the,  234;  n-tro- version  of  the.  23.'>-2;>9:  liernia  i.f  tli<'.  240;  l.y|>«  ni- 
mic  or  pletlioric  condition  of.  a  eaiis»>  of  abortion.  27"J  ;  ircairnnit  t>l  l.»?n-rrhage 
from  liie.  2S0  ;  snhstances  expelled  from  the — rnolis,  'J8i;  inU  r»  sliii^' ease  of 
enlarged,  fnnn  a  blighted  ovum,  '2ST-21H  ;  can  irue  hydatids  form  in  and  U* 
expelled  from  the?  294.  205;  the  true  .^eat  of  the  determining  e-au^,'  «..f  |»;irtu:i- 
tion,  311.  318-320;  fatty  <h*generation  and  other  change.s  in  tiie  rewntly 
delivered,  3'iO  ;  dillerenee  in  the  parturi«.'nt  toree  exerei-^eil  l»y  the.  322  ;  var^t.-a** 
exeitors  of  rellex  action  in  the,  ib,  ;  iudepi-ndent  contr»eti»)ns  of  ilie.  i»ri.>r  to 
the  commencement  of  actual  labor.  320;  are  the  c<»ntracii<»iis  of  the.  and  the 
pains  of  labor  iilentical  ?  329;  eause  of  the  <iil.atation  of  the  <v*  uteri  -n  lalrt>r. 
332;  direct  result  of  the  eontraelions  of  ihe.  3T4  ;  reuioval  of  O'ag'.la.  :;7u: 
spasm,  of  the<KS  uteri,  378-3bO  ;  h<»ur-gla.<s  t'ontraetion  of  t!ie,  3.^0-3^.{ ;  morbid 
attachment  of  the  placi-nta  to  the.  383-.'»86;  hemorrhage  prtK-'et-timg  from  iii»T- 
tia  ol  the.  390;  the  loehial  diseharge,  417,  418;  jjaiu  in  the.  wlieu  the  clidd  is 
applied  to  the  bren.>^t,  429;  inversion  of  llie,  446;  car.si  s  of  inversitni.  447; 
diagnosis  of  inversion,  44S,  449  ;  treatm«^nt  of  inversion.  450.  451  ;  sfKiniiUM-oua 
reduction  of  inverte«l.  4.')l.  4r)2  ;  extirjiation  of  the  inverted.  4.'. 2.  4r>3  ;  inalj»ra<.-- 
tice  in  a  eas*'  of  inverted.  4.'>4-456;  nitiuencvs  capable  of  exeiting  e<.»ritracl.f»iis 
in  the.  498;  inertia  of  the.  in  connexion  with  pelvic  pre.«ienlalioiis.  .''>52  ;  ca.sei«f 
jK)dalic  versi(»n,  cimnectid  with  nialpo«iiii>n  of.  564;  results  of  tre.itui'-r.t 
in  rupture  of,  extraeteil  from  I»r.  Trask's  monogram  on  ruj^lure  of  the  v^vnib, 
673;  rupture  of  tins  a  n(»t  unusual  accompaniment  of  liydr<K'»plialus.  002: 
premature  delivery  in  a  ease  of  hydatids  of  the,  67  2  ;  inlluentv  ot  anttsiht-t.c-a 
in  contraction  of  the,  712. 

Vagina,  the.  77;  anterior  and  posterior  relation.^  7s  ;  internal  KUii'u.v  of.  70;  not  an 
erectile  organ,  ib. ;  arteries  and  nerves,  uiiciu-e  derived,  SO;  llie  ui.«-el.arge  of 
blood  from,  168;  disixiloralion  of  the  internal  surlaee  of  the,  noi  a  cvtUiin  sign 
of  pregnancy.  172-174;  anatomical  relations  o(  the.  \W. 

Vaginal  examination,  directions  for  making  the,  70,  107.303;  impropriety  uf  Cro 
quent,  360. 

Vaginal  \iysterotomy.  two  \utere>sting  cases  of,  645  ;  and  see  Cicwirean  section. 

Van  Pelt,  Dr.,  ineaauTviiue\\\&  o^  \.\vvi  viwxwxtWx  v^S.  Wxsi  Wv»N.  V\^iAd  at  ti*nu,  30. 


7AN-WRI  INDEX.  743 

Van  Swicten,  on  the  sensatiooR  connected  with  impregnattoOj  304- 

Vectis,  the,  in  instrumental  dAlivery.  568. 

Veins,  varicose,  treatment  of,  229,  2;J0. 

Veit.  Dr.,  on  the  niortahty  of  male  infants,  28. 

Veratrum  'viride,  a  remedy  ki  puerpera'  lever,  698. 

Vertebne.  the  false  sacral,  3. 

Version,  conditions  under  which  it  is  to  t^e  resorted  to,  in  prolapsion  of  the  funis,  465, 
466;  directions  for,  in  pb)Ci>nta  prtevia,  473,474;  cephalic,  516,  640,  641; 
rules  for,  in  manual  delivery,  520-522;  podalic,  631,  564  ;  mode  of  performing 
540,  541 ;  mode  of  performing  cephalic,  by  external  manipulation,  543,  544;*  in 
pelvic  deformity,  544>546 ;  spontaneous  pelvic,  5G2. 

Vertex,  the.  discrepancy  among  authors  as  to  the  number  of  positions  of,  36 ;  sta- 
tistics of  vertex  presentations,  37  ;  the  author's  classification  of  vertex  presen- 
tations, 43 ;  mechanism  in  tlie  tirst  vertex  position — lefl  occipito-acetabular, 
44 ;  mechanism  in  the  second  and  third  vertex  positions— right  occipito-ace- 
tabulur  and  right  posterior  oc*cipito-ihac,  62 ;  mechanism  in  the  fourth  vertex 
position — left  posterior  occipito-iliac,  53 ;  presentations  ot,  in  cases  calling  for 
manual  delivery,  526  et  seq. 

Vesico-vaginul  tistula,  diagnosis  o(  78. 

Vesicular  moles,  284. 

Vestibulum,  tlie,  76. 

Virchow,  his  theory  of  extra-uterine  foetation,  206. 

Vomiting,  in  pregnancy,  128,  146;  importance  of,  128,  129;  treatment  of,  220 ;  in 
labor,  334;  excessive,  as  a  motive  for  premature  delivery,  671. 

Vulva,  the,  or  external  organs  of  generation,  72 ;  treatment  of  pruritus  of  the,  Id 
pregnancy.  227,  228 ;  thrombus  olj  430.  , 

Vulvo- vaginal  gland,  the,  77 

W. 

Water-douche,  the,  as  proposed  by  Bawisch  for  the  induction  of  premature  deli 

very.  677. 
Waters,  the  bag  ot,  245 ;  formation  and  rupture  of  the,  834r-336,  358. 
Weed  or  ephuiuiTal  lever,  430. 
Weidemann,  on  the  Cesarean  section,  627. 

West.  Dr.,  statistics  by.  on  extirpation  of  the  uterus  for  inversion,  453. 
Whitehead.  Dr.,  his  statistics  of  abortion,  266,  267. 
**  Whites,"  the,  a  vague  and  unmeaning  disease,  166. 
Womb.    See  Uterus. 
Wright,  Dr.,  on  the  mode  of  performing  cephalic  version.  641 


Wood's  Msiiical  Catalogue. 


THIKD  EDITION. 

THE  PiaNCIPLES  AND  PRACTICE  OF  OBSTETRICS, 

BY  GUNNING  8.  BEDFORD,  A.M.,  M.D., 

Pror>>Mor  of  ObntrtrioN  the  DtteaMS  of  T^'omen  and  Children,  aod  Cllnloal  OblUtrlet,  in  tlia 
rnirenitv  of  *4ow  York ;  Author  of  Cllnieal  Iioetarei  on  th«  DiMuai  of  Womoii  and  CUIdran. 

lUustratod  hy  fuur  Colored  Lithographic  Platos  and  niaety-nino  Wood  EngrayiDgs. 

One  mperb  8vo«  rolnme  off  ovcfr  TTO  pages.    Price  $4*50 
by  mall,  free  of  postage. 

TMrd  Edition,  eareftilfy  revised  and  enlarged. 

WIUiIAM  WOOD,  61  WALKER  STREET,  NEW  YORK. 

The  extraordiuary  flalo  of  this  work,  in  theae  troublous  tlirtea,  is  far  beyond  tht 
most  saDgtt'me  hopes  of  the  Publisher,  haviDg  passed  to  a  Third  £dition  in  Uio  brief 
period  of  thirteen  mouths  from  the  day  ofpubiicatioQ.  The  foUowiog  extracta  will 
iudicuto  its  ciitliusiastic  reception  by  the  Medical  Press,  botii  at  home  and  tbrond: 

"No  Treatise  on  Obstoixic  Science  and  art  has  ever  received  such  high  and  uni- 
rersal  oouuuendation  by  tho  Medical  l?resa  of  this  country  and  of  Kurope.  In  matter 
audarrangt*uient,  in  philoeopliic  views,  in  elegance  od  well  art  oloqucuce  of  cxprcsfflon, 
theru  in  no  work  in  Uie  KngUsli  language  on  tlio  SHino  subject  which,  in  oiir  judg- 
meub,  can  comparu  with  it.  It  meuLs,  m  Iho  most  salldfaciory  manner,  avarj  posbible 
exigency,  wluch  may  arise  in  the  Lying-in  room.  The  Cook  oxlubitii-  abundant 
internal  cvidenoe  of  intense  labor,  and  tho  most  oxti-us'ivo  roaearcli.  ATe  hesitato 
not  to.  recommend  it  both  to  student  and  Practitioner,  as  tbo  ublpst,  safoHt,  arul  most 
enli;;luened  work  on  the  art  and  Hcionco  of  Obstetrics,  iiccossiblo  in  the  English  lan- 
guage. Dr.  Bedford's  former  work  on  the  '  Diseases  of  "Women  and  Children.'  which 
has  rece{v64  the  high  honor  of  a  translation  hito  tho  French  and  Gonnan  hmjruages, 
had  already  placed  Iiim  among  the  most  successful  Authors  in  this  department '*-*- 
Jfew  York  ATiterican  Uviical  Times, 

"We  have' read  Dr.  Bedford's  I^ook'fVom  the  flrrt  pni^  to  the  last;  and  truly,  it 
is  an  honor  to  our  country.  The  work,  the  more  wo  .^cndy  it,  leads  us  themoro  to  op- 
prcciato  the  amount  of  research  and  labor  expended  v.^,on  !tf»  production.  Whether  as 
a  representative  of  American  me^licallitoratnro,  and  cxivoncnt  of  American  educational 
tiilent,  or  for  its  intrin.sic  merits  as  a  practical  Treatisfs  on  Obstetrics,  ^^'O  may  proudly 
compare  it  with  any  aimilar  foreicT^  publication.  Tliis  volume  must  become  a 
Text  Book  i&  tlie  colleges  of  the  United  Status.  Our  exeliango  journahi  vie  with 
each  other  in  expressions  of  admiration ;  and  tlie  greatoat  fault  we  can  find  with  the 
work  is,  not  that  any  portion  of  it  is  bad,  but  tliat  some  parts  are  so  superlatively 
excellent  that  even  the  brilliancy  of  othens  is  uuseuretL  Hereafter,  whether  as  Stu- 
dent or  Practitioner,  the  obstetrician  will  need .  no  other  Book  as  instructor,  guide, 
cr  A^Uharity  than  Bed/or^ 9  IWinciplts  ami  I'raeUioc.^''^Ntw  York  American  Medical 
Monihhj, 

"Dr.  Bedford  has  explorod  the  whole  of  his  ground  in  a  thorough,  luminous,  and 
systematic  maimer.  As  a  Text  Book,  we  arc  Inclined  to  think  it  has  a  general 
superiority  over  all  othors  on  this  subject.  We  know  of  no  other  work  that  abounds 
with  greater  evidoiiocs  v<f  r^March,  which  is  moru  exact,  or  more  iiliilosophical  in.  its 
deportment.  We  oomnoiid  it  for  its  uuHurpassod  ability  in  all  Uiat  appertains  to 
scieutilio  and. practical  obfitetrios^.  It  is  a  national  wurk,  and  should,  tberefure, 
become  the  Text  Book  in  the  raodk»l  colleges  of  tlie  United  States.  Tlie  friends 
of  Dr.  Bedford's  volume  are  not  only  of  his  own  household,  but  foreign  nations  have 
adopted  the  products  of  his  muid.  No  one  who  reads  thii  CiKjk  can  be  surprised  at 
the  large  praise  extended  to  it  by  some  of  the  best  foreign  reviews  and  jommals.  Tfato 
Authtirs  style  is  original  andpopuUr.  He  is  curefully  loKicul,  stating  his  premises 
plainly,  and  making  his  inferences  strictly  in  harmony  witli  them.  Hence  his  extra- 
ordinary sucoesa^'—jBMif'M  liedical  and  Surgical  Ji^untal 

*'  This  Book  will  rank  as  the  highest  authority  in  tho  dejArtment  of  Obstetrios,  and 
ewerr  phmcian,  who  would  conform  his  views  and  praetice  to  the  tenchinga  of  cor- 


••  A«  an  Axnf 


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'*W9  rvoeiv«  Ibe  volnnn'  ns  ijii  iiiiditioti  to  our  libmrr  witli  thaiikfulnf-Mt  JinH  lh« 

hope  timt  it  mt^y  lecu  to  which  it  is  ».'  i-% 

&i)qaastioiiobIjr  afliitbi  ^  Prindplea  and  r  it 

qp  ver/  AiDj  to  the  k                                    :  iwiedgo.  .  itdttrnuig®* 

fneot,  d«3tir  nud  axi^                                   ig^"^Arfv  ,  <^  ifftiieal 

*'  Tho  skilful  oVietrioinn  wi^kfe  a  fetdy  pen  on  erenr  p«^    The  Book  U  aoom> 
'      ~  ct  which  It  di»auaie%  and  n  ir«f7  fUA  id  uifitters  whioh 


I  a  I11AI17  of  the  works  on  Obtmxk^'*--'K&fth  Atnerie^ 


•^l«te  Treat  i«« 
I  «r»  but  lightlj  i 

[  *   "This  work  miist  take  (he  hijrheet  pluce  Moonp  cwjf  Text  Boolw  on  Obitclrica.   It 

evidently  emlxHUefl  th  I?  re^v'-    '  "■-  t-*^"--*-  .-*..^. -nctice  In  Ibii  bra&cli  oi 

[HbB  Fn$6miotK  i?%prvi9*sl  ,  so  ae  to  ismiMa  tba 

^  ^raflt  amount  of  loii»rinatk>u  ;  eiidGr/'**i^sa|lie  tMkai 

,  flflcf  Surffkal  Journal 

J    **  A  **sir*>fitl  t-ijiiiiinji(ir>n  of  Dr»  B^Bdrord\««  work  Uiti1in««H  ti»  In  p»*r*ommf«inHlincf   it  /y| 

iha'l                                     ^ — one  in  \.  V* 

nil*'**                                       safely  thru  I                                                        ;  ;         .  -^ 
iSm                                       i. 

*     **1  'trict  y«i  ptibliihed  !n  t1ir»  "Rttplisb  lintrinjf^jj  we  most 

'feflme«tl/  rtoouiifltikd  it  to  our  Ptyaicmns**' — Pft 

**  Dr.  Bodford'8  Book  deaU  with  acctimalat^d  i 
I  tn  which  none  but  the  cleareit  intellect  and  the  i 
Ifecilv'  St  hornf*       h\  fM^npfla  of  detail  ItK'idity 
liv-       '        ~     "     ^      Prlnclplea  i>! 

'nQ  th«  finrt 

'*  Thia  Book  comca  from  roi?.     Prof. 


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•f ractical  knowledge  of  «  fsoputar  Oiwtctnisiau;^— i«*n^ 


<{  Joyrn^ 


r.3?  1 
puTutWKn,     Wtiili 
rnlfSK  of  Dr. 
impariMXtooti  tht 

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in 


•*  W©  think  this  thu  roo«l  vultmbid  work  oo  tbt  Mtjtet 

Wo  hATo  perused  e^njry  jMifm  of  tho  Miok  widi  iaWtfai^  and  • 

tberefor^  from  pex^aoil  knowledgioi." — Ci;[icinnati  Mmi  Ji^sr, 

'*  A  c»«M jicniid  of  Dr.  Btdlbi^'s  bocJc  bM  li9d  iii  to  bAttoVB  t^ 
iOsSlQiM  to  \»  icknmrledg^  «xid  tti4  Autbbr  ncofnJiMl  m  « i 
n«0lliioiierorniedkiiie.    Tha  woHc  i»ortli9iBOirFmicliail  cttinfiUir;  ptwti 
■  sudd  to  teod  tovnod  the  relief  and  trcsktment  of  di««mv  wid  ivteflHoikib 
■howD  in  qoickir  aniriDf  ai  ad  aooumU)  di<gnn«ia>    Toxel  «t  odo»  Io  U>*  1 

^r  —  ^: ^ ' -  '♦  -- •>    •  *^^-  -^^ --■ '3  feMchlqgi,    Wo  c«»rdlMllj  I 

t*  I  «,''^£im«fo«*  lancet 


i««  and  GosttiU, 


uoi  uort  «ich  boois  ia  Ckvftt  BciMft,**— * 


to  be  « toiiod  phjrsiciaii  ami  «ii  oxooUtfai  i 


Tb«  eook  &ert  onl  j  pvonc  Dr. 


oTui  «xft«Q8iv«  acqtumtiy&oo  on  biipift  witli  tli0  litarmkATi  ofjiii  fobj^iot  «B  iMi 
lido  of  the  Aa^MSi^XeJ'-^LmAm  SHiiA  M&dkM  J^mrnoL 

**Aa  exmiOAlloo  of  thl^  voile  «Mifiaoi8  m  ttiit  tii«>  autlinr  e^'iiiPM  ^mi 
MacI  Ibr  oliiprfa^oit  *iid  thftt  hl» OfMooB  cr» «Mifi '  i^w«iA 

tallsiile  laiowted||«oirUi«doctniiaiort4e«ui»  [wd«iift 

The  rifiKir  of  Ijtatroetidii  containftia  io  Itaji  folmii^  thf»  abuiiy  triUi  «? hiUt  U  ia  pi» 
^Dtxsd,  and  the  tmthAil  prndiettl  chameter  of  th&  dortrbei  adrancod,  ftra  to  fel  fmf 


W.  WoQd  di  Co^Mtdkal  flatah^fu^ 


•  Tb©  wt»rkmg  ro«n  in  AiDeKcA  »re  alwuys  on  rtj*?  ir*t>k-out  l^r  the  it^w  ligbtft 
rising  orer  the  old  world,  and  tbej  often  too  b4fltilj  Adopt  a«  the  pure  f.^  aeo^ 
the  cnide  lucubradoDS  which  muAt  3cid  place  with  more  Tala&b!'  tlio 
weekly  mddicftl  press.  But  this  oljeenatioQ  doc«  cot  r?i  "-  ir  Autaor^  who  it 
^editably  known  hj  other  works,  and  In  the  one  befor  hlrmelf  to  be  t 
judidovig  phyaidaD^  aaxioug  alike  for  tbo  good  of  hia  patij:.:  i^  n  itii  >5i  on  a 
wfao  hfta  ftoquired  tlje  ba|}fp^  art  of  teaohii^  hoiMiMpt  at  ^ 

in  th«  chain,"— iZimitin'f  Hoi/-  Teasriy  Abstrad  of  ihe  JM.  Saencta, 

"  Thfi  Bubjocta  hAT©  b«en  dovokped  with  no  or6ixiafj  powora  of  cUnlctU  Infltnat 
tkm."— J/.  E  Jftfd  2Tt»»«#.  !     ^  ^ 

*  We  hATe.been  bolQi  pleased  and  instructed  by  a  pemdal  Of  the  book,  and  ooa 
fldontlv  recommend  it,  tJft«ralbra^  to  the  proliMrioQ,  ai  en  «Mfle£it  repertoriam  of 
diniQAi  medioine.  The  eminently  pracstioal  ideas  of  the  author,  clothed  iu  eimple 
and  pdrspimioaa  hmgruigep  are  denvored  in  qtiite  an  attractive)  aflhble,  and  off-b^d 
mamior.** — PhUade^ia  MedL  Examiner, 

**  A  work  of  e^reat  practfea!  intereitr-Hana  well  ealcnlated  to  ftrterest  and  infltrnol'' 
the  busy  practitioner  \  it  pomta  out  to  bim  Uio  moat  modem  thempoatical  igenta^ 
and  thtar  method  of  adnunietMiltieii;  And,  above  ajlf,  gives  bcftutiftil  aad  mBthaarj 
explaoation^  physiologically,  of  the  symptoms  of  disease.  This  litter  quality  Is  a 
great  merit  of  the  book.  As  a  faJthiUl  representai^n  of  the  daily  labors  imd  duties 
of  a  physician  of  our  day,  and  as  an  accurate  delineation  of  the  diseases  of  women 
aud  chiidran,  it  is  well  deserving  of  our  praise.*'— F^j^ii^  M€±  and  Surg.  Jour. 

**  We  were  aetnally  faaeinatsd  into  reading  thi«  entire  voli   i  ^ '  lone 

DO  most  att«ntiTely;  nor  have  we  ever  read  a  bonk  wUh  and 

profit  There  is  tjot  s  disease  oonoected  with  infiinoy  or  li.^-  .,_ii,.*i«  ^^^tem 
which  it  not  most  ably  dUeussed  in  this  exoellent  work/' — Dublin  Qumttrlff 
Jottrrud  of  Medimd  Sdmo$* 

**  Prof*9sor  Bedford'a  book  ia  a  good  one.  We  like  it,  for  we  can  di^t  a  ofnner 
over  it  without  going  to  sloeo^  and  that  is  more  than  we  con  say  of  most  m^csl 
books.''— JVh^  «ArMy  MeiL  J^artar. 

"Tg  read  thfa  work  is  tobe atrock  with  its  trutbfulneai  and  *Hility ;  we  And  sH 
ttiat  la  uselU  in  practiee,  ably  oommunicated,  and  elegantly  expressed.  Amerloaii 
wurka  are  not  generally  Mad  on  this  side  the  Athwtio,  but  we  rcoommcnd  Br. 
Bedford'a  book  as  worthy  of  the  very  best  attention  of  the  profbeaion.'* — Mdkmu 
Qw^ficrly  JownuU  of  iha  Medical  Scknccs^  Lt/fukflL 

**  Wo  have  aaid,  on  former  occasions,  that  the  man  who  wiU  \iimg  ibrward  cljnicat 
or  practical  instrudtion  to  bear  upon  the  medical  teachings  of  our  ommtry,  will  be 


iTrnaorrii, 

r 


H:..  (!.     'Wii  wnnt  nnictMnA  obaervation* — fiv*di  from  the  bed-side.     Dr,  Bed. 


an  exteodive  cli 
hr  tntich  rcadiL 

rd  hf?arty  lUariV:^  Ibr 
Surgical  JorArjuiL 
uiiuoatly  praoljwil,  atil 
ProC  Bodfonla  6XU 


by  Lim  m  the  Umveralcy 
^rch,  Thij  ia  a  good  bookf 
the  labor  lio  has  bestowed 


d  uid  materially  lo  his  already  extended  reputation,''— ^iftn*l^m  MctjL  <lrtd 

iSfi.  >.  J^junusi^  AugvttOt  Ckorgio. 

**  No  one  can  read  this  book  withorit  bcoomfng  eonvinoed  that  it  ccmtrdn^  ronoh 
viduable  inatniotionf  and  ia  the  reaull  of  a  large  experieuco  ixi  tliia  apeciaity."— 
Keuf  Hampshire  Jour,  of  Med. 

"  Tiie  work  contains  graphic  deecription/fi  of  the  disesies  of  women  and  cliildreii| 
iOx  judidoua  advice  as  to  tr<}atmert/' — B>e<oa  Med,  and  Sarg.  J&ur. 
f*  Price  ^3.95.  t»r  mall,  fri^c  ef  poatase* 


Wco^s  MtHceH  ^at^gm 


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^itidw  of  !?:    '"      *  ^  " 

In  ODC  8va  vulum*,  -»^ 

"nn,i    .^r    nrr    hut     m...t.  I.     f|*f    /VUDllMietln^    f  tlOftR^    *«llr>.    «™    *i.n     hk»«Mil».,i 
1  'iM*   J^Hrmll  ^  |*ft,"  — 
i        "Tk' 

'-J    nrmrti.-A.!    .Ji.        fr*.  *ii' 


.  W9(UP^3adiM\€aUih^ 


A  SUPERB 


ANATOMT. 


•      (Br  ABTOUR  HILL  HASflALL,  M.B.f 

USMBkmim  THXaOTAL'OobiiaS  or  SUBOfiONS  OF  BirC&ANO,  4k%,  *«i'  -.'i 
.auMnUmv  ironi  vpx^aovia  jpiAvuf^i  nrooLqi,  i^iip  ADprao^*  co  nqi  tkxt  avp  njitili 

By  HENBY  VAN  AR6DAL«,  M.D. 

dDgtrated'^  seyenty-bino  accuratelr  d^R^^^  and  exquisitely  colored  lithogrtjpMp 
platcfl,  ooDtaining  several  hundred  tigure*.    FornWfjj^  two  largo  octavo     '  '  , 
volumes,  liandsomcly  and  strongly  bound  in 
'  leather,  raised  baxtdt.    Prioe  $7. 

Tb«  PtailialiWtake  trU«  l4  oflirivf  to  tlw  Medlealt >raf<>»ilon n #o(k  whlehbM .b^^a  ffro- 
ifevncc-d  ^•'inoet  compi^  w  its  4«pMtBMnt  publtkoed.  No  paUa  nor  •xdwom  have  btea 
•pared  in  its  prodaetion,  and  it  is  believsd  UwU  it  excels  snythlng  of  the  kind  heretofore  pab- 


^  Kmy  psfls  «f  it  is  %  bftn^not,  SBfAldioff  th* 
marvels  of  erestire  wtsaoin  and  power.  Boco, 
•xtraordioary  dispUjs  of  the  minate  or| 
tloQ  of  the  internal  zneohaiiisni  otr  '^' 
the  two  conditions  of  healtn  atid'd 
•  stmts  Csefioff  «f  .w«a4cr  aad  aniy^yiMyrt. 
"While  the  work  teaches  how  tp.  uaotf^taiKi 
•ppaoaaees;  it  also  poMUs  oat  tW  pliy^l^Wgical 
f anetious  and  analoatosi  cfUlioas  of  partu  la 
akort,  lb*  wbkf  M94  tb«  wkeidG^r*  in  the  sob- 
>oU  tMmtfd  of  ar*  piaaMitfad  la  a  cUar  lUcht.'''^ 

**  We  express  the  aMviatWa,  iunad  apoa  oa, 
siter  MTaral  jtutf  aonsoltMion  of  .iiaiibr 
works,  while  pursuing  microseopdosl  stadias, 
that  ilMre  la  noM  bdier  arraog«d  aa4  iilfa- 
laatod,  sad  m«s  wkJnk  will  gitiL  so.foneral 
satisfeetioo«w<  (batof  Mr.  .HasMJi,  edited  by 
Dr.  Vaa  AnMkT-^Jf^  Ym*  Jlimma  qfX^ 
dMnt. 

**  It  is  marked  bj  a  simplieltj  of  description, 
and  bj  scientiflo  accuracy  in  argument  With 
these  (the  plates)  we  irs  dettrhted.  The  oolor^ 
tng  is  magoifloentr-QttVM  hfgbtaftbiag  fxtm<t 


raaaat  aboat  Jt,  bq(  ^rotbibL  naat,  ae«irat#, 


afta  ^thftaTlr  representinir  thb  objects  as  we 
sara  seen  them  in  the  nhoioest  specimens  of 
Parisian  mooating^'*— jffif/fU/o  Mtdical  JowT' 


* IX is preicrQiacn^ly  ibs.bcs^  iUustrstad jui- 
GTSseoDio  haman  soatumj  ttiat  li  sQOM«ib)s  to 
as40|(bU  oountry.*"— irsc/i^  iieamjLntr. 

^A  work,  of  sckaowledKSd  abUity  and  lota- 
rasi-'^—  W«&t4mJ9timalo/M6dicku  and  Air- 

**  It  is  not  merely  a  scientific^  bat  it  Is  fbf- 
tlMrmora  a  praclioaf  treatise ;  and  in  both  ona- 
racters  it  equallv  sustains  a  high  cbsnctar* 
Tba  gsttina  ap  of  tbe  (Qnstrstions  is  exouisita;: 
ttaah  one  forms  a  pariMt  pictnTo.*"— -  jto^iflg/ 
ChronicU. 

**Tbe  most  eon^sto  in  this  departmsat.^— 
Xekim^M  Anurtfon  Lamcti. 
.  **lt  is  oMgnli&ouiUy  pobUshtd.  U  is  Hia 
only  complete  wori,  of  tbe  kind  in  tba  XngUsb 
lansfoaffe,  and  reii*>et8  hli^h  cro«tIt  upon  'Its 
learned  and  indefeiiirftble  author.''— xSovMens 
Mm^al  a«M  ^l^trfWol  Journal. 


By  JOL/y  K.  CAllPLUr,  M.D.,  F.L.a 
'''•'■         ''■■      'XlHondEdaum.)  ./        . 

QMWMiitaio.  ToloflM.    Prioo  60  oaotflL 

:-•  'r     .•■■.'I       '.  .     j;.  ■     .        .....  1 

-  ^'^'iiY«V  Ml^<^  AaMff'NMI  MOMbra'  ita<isrtsktKff  lo-lrsai  a  slaa  o€  | 

Mod.  ond Surg.  JaumaL  '"■'"• 


nr 


I      ,