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tl
IL^^MBI
MEapiEm.
iLiBflaMjiyr
.N
li
THE
PRINCIPLES AND PRACTICE
OF
OBSTETRICS.
BT
GUNSlIfG S. BEDFOBD, A.M., M.D.,
or OBtnnioi;, thx DitBAnB of womkh Aim oaiLDBXir, akb cukical oBsnraioi, n
uvrmuTT o» jnw tobk ; aittbok of ** cuxical uotuus ox thb vmtMMM of
WOKm AMD OBILDUX."
inustTBlrl} bg Jout CoIortH l,it^ogrKp()(C 9Istn *n^ Ninrta«n{ur CSooH Sngribingg.
Mnltom retrtat adhac operis, mnltnmqaa nstabit, tpc alU nato,
post mille MBoala, pradndetor oocaaio aliqoid adjideuui
Sexkoa, Lib.
THIRD EDITION, CAREFULLY RBVISEO AND
NEW YORK:
WILLIAM WOOD & CO., 61 WAI.KER STREET.
1863.
'■^'
Entered ftoeording to Aet of CongreM^ In tbe jear eighte«n hnndred and slxty-oae, bf
GUNNING 8. BEDFORn,
In the Clerk*! offloe of the District Conrt of the United States for tbe Svatbem District of
New York.
B. ORAIOnaADi
PrbiUr, Stcrrotypcr. eiid Ktcetroiypar,
Carton Vuiniing.
81, S3, Mtd 83 CVnfrv StntL
SiZ
To
THE ALUMNI AND STUDENTS^
WHO HAYB ATTENDED
THE AUTHOR'S LECTUEES OX OBSTETEICS IN THE UNIVERSITT OP NEW lOM,
AMD TO WHOSE UNIFORM COURTESY AND KINDNESS HE IS 80
GREATLT INDEBTED,
Vps 9oIttme is ^Sedtonatelg ^tbicakb.
PREFACE.
In writing a work on the " Principles and Practice of Obstetrics "
I Lave had constantly before me one cardinal object — to be
useful. I have endeavored to present to the Profession a practi-
cal Book, one which will develop the phenomena of parturition
in their various phases as they occur in the Lying-in nx^m. The
anatomy of the Pelvis and Genitalia, and their special bear-
ings on Parturition, have been dwelt upon with a minuteness
to which they have a just claim. Abortion, the subject of
Labor, its Divisions, its Mechanism and Management, its deter-
mining cause, together with the forces engaged in the expulsion
of the child, the treatment of the puerperal woman and her
new-born infant, Flooding both ante-partum and post-partum,
Placenta Pnevia, Puerperal Fever, Puerperal Mania, Anncsthe-
tics, have all been considered with the fulness their importance
demanded. Nor have I neglected the physiological disquisitions
necessarily involved in the consideration of the numerous ques-
tions connected with Menstruation, Reproduction, Pregnancy,
Foetal Nutrition, Puerperal Convulsions, and other kindred
topics.
Manual, Instrumental, and Premature Artificial Delivery
Lave received their share of attention ; they have been discussed
freely and at length. On the subject of Instruments, I have
spoken without reserve, and have not failed to raise my voice,
in the most emphatic manner, in rebuke of what I believe to
be oftentimes their unnecessary and reckless employment If
what I have said on this point shall exercise an influence in
PREFACE. y
behalf of suffering woman, in the hour of her need, I shall
indeed be happy. Touching the grave questions of Embryo-
tomy and the Csesarean section I have suffered my mind to be
governed by no predilection, but have examined, with the singl<
purpose of reaching the truth, the substantial evidence both for
and against these alternatives; my deductions are the results
of what I believe to be a thorough and impartial analysis of this
evidence.
The arrangement of the work is rigidly systematic* the van-
ous subjects following each other in what I conceive to be the
proper order of their dependence. In one word, I have had in
view the wants of the obstetric student; I have endeavored to
aggregate facts, and dispense as far as possible with theoretical
discussions. Throughout the work I have maintained strictly a
Conservative Midwifery, as I have always done — and shall con-
tinue to do — ^in my oral teachings in the University. It has
also been my endeavor to inculcate upon the accoucheur a
due reverence for the resources of nature, so that he may not
thoughtlessly lapse into that too common error — "Meddlesome
Midwifery." Among other things, it has been my special aim
to bring the work fully up to the existing state of Obstetric
Science in all its varied relations. For this purpose I have dili-
gently consulted the ablest and most recent authors ; at the same
time, I have not been unmindful of the obligations of our
science to the early Fathers. May I presume to hope that the
Book, both in its matter and arrangement, will not be unaccep-
table to the general practitioner, or to the Professor of Obstetrics
himself?
In reference to the Illustrations, I have consulted quality
rather than quantity, and have in every case endeavored to
make them explanatory of some important practical lesson.
"With this view, I have not hesitatc4^ where it could be done
with advantage, to avail myself of the graphic delineations by
Maygrier, Moreau, Montgomery, and others. The engravings,
representing Forceps delivery, are the Daguerreotypes of my
instnictions on this subject in the University, and I trust they
may convey accurate rules for guidance on this impoilant and
interesting part of the Accoucheur's duties.
Vi FBEFACE.
In order to facilitate the object of the reader, and place
promptly within his reach the numerous subjects discussed in
the volume, a Table of Contents, and, in addition, a full and
carefully prepared Alphabetical Index have been provided. I
have also added a list of authors to whom reference has been
made, and this will give some indication of the labor expended
on the work.
The Book itself embodies ample internal evidence of failure
or success in the accomplishment of the objects proposed. If
that evidence, under a fair examination, shall lead to the decision
that the design has not been carried out, it will be to me a
source of the deepest regret. If, on the contrary, it shall be my
good fortune to have my efforts approved by the Profession,
then I shall be abundantly repaid for my labor, and may, with-
out arrogance, exclaim — " Nee EgofmsiraP
In conclusion, I cannot but cherish the hope that if this Volume
should fall into the hands of some of my numerous pupils, residing
in various portions of this and other countries, it may serve to
awaken old associations, and bring back to memory the many
happy hours we have spent together in the lecture-hall; and
may these words be accepted as proof that their preceptor
continues to entertain for them feelings of deep interest and
altection.
Vsw Toms, 66 Firm Amnm,
PREFACE
TO THE SECOND EDITION.
An Author can covet no richer compensation for his labors
than the endorsement of his Peers. It would, therefore, be
aflTectation in nie to attempt to conceal the pleasure I experience
in being thus early called upon for a Preface to the Second
Edition of the ^^Prindplea and Practice of ObstetricsJ*^ But
a little over four months has elapsed since the book was first
issued from the Press. In view of the unhappy and disturbed
condition of the country, and the consequent derangement of
commercial as well as of scientific pursuits, I have, indeed, good
cause for self-congratulation ; and I avail myself of this occasion
to return my cordial thanks to the Profession for the counte-
nance, which they have so promptly extended to my eiForts.
The eulogistic notices of the Medical Press — both home and
foreign — ^have imposed upon me an obligation not soon to be
forgotten — an obligation I can cancel in no other way than by
the pledge, that it shall be my earnest care to endeavor to
render myself still more worthy of its good opinion.
The present edition has undergone a thorough revision ;
numerous verbal and typographical errors, more or less incident
to a first issue, have been corrected. I again submit the work
to the Profession, not without hope that it may continue to
have awarded to it the seal of their approbation.
Miroh, 1862.
PREFACE
TO THE THIRD EDITION.
Again has the grateful duty devolved on me of returning
thanks to the Profession for the continued — and I hope I may
say without egotism — unexampled patronage extended to the
" Principles and Practice of Obstetrics!'^ It is now but thirteen
months since the book was first presented to the world, and my
Publishers admonish me that a Third Edition is called for. To
say that its reception is beyond my most sanguine hopes, and
that I am deeply impressed with a sense of the obligation im-
posed by this prompt recognition of my labors, would be but
the reiteration of a self-evident truth ; and I may add, that both
the pleasure and obligation are greatly enhanced by the fact
that, in the short period which has elapsed since the work was
issued from the Press, it has already been recommended as a
Text-Book in nine of our medical colleges. What greater honor
can an Author claim at the hands of his Peers — what higher
incentive to future effort! These influences, if my life be
spared, shall not be lost upon me. Again, also, I have most
cordially to thank the Medical Press, here and abroad, for their
continued commendatory and flattering notices.
This Edition has been carefully revised and enlarged ; besides
additions to the Text throughout the volume, it will be seen
that a lecture on Phlegmasia Dolens has been incorporated.
New York, 66 Fifth Avenue, Dec. 1862.
CONTENTS.
LECTURE I.
POSITION AND BONES OF THJB PEJiYIS.
Ifidwiferj an Exact Science— The Passage of the Child through the Maternal
Organs is founded on the Principle of Adjustment — The Pelvis ; the Position it
occupies in the Human Skeleton — Importance of its Position in Childbirth — The
Direction of the Pelvis; its Variations — Bones of the Pelvis in the Adult and
Foetus — Sacrum, CoocyZf and the Two Innominata — Auterior Sacral Plexus of
Nerves ; its Influence in the Production of Numerous Pathological Phenomena —
The Os Coccyx; its Importance in Childbirth — Dislocation of the Coccyx —
Fracture of the Coccyx — ^The Spinous Process of the Ischium — How, when mal-
ibrmed, it may interfere with the Process of Delivery i
LECTURE II.
USES, ABTICULATIONS, AXES, AND DIVISIONS OF THE PELVIS.
Uses of the Pelvis — Articulations, or JointA of the Pelvis — Do these Articulations
during Pregnancy become Relaxed ? — Is their separation necessarj', at the time
of Labor, for the passage of the Child ? — Objections to the Theory of Separation
— Pathological Changes in these Articulations— Form o! tlie Pelvis — The Greater
and Lesser Pelvis — Straits ot the Pelvis— The Pelvis is a Crooked Canal ; Proof
— Axes — Varieties of the Human Pelvis— Influence of Sex and Age — Contrast
between the Male and Female Pelvis — Pelvis of the newborn Infant — The Pelvis
in Connidxion with the Soft Parts — Its Measurements. . . - 12
LECTURE III.
DIVISIONS AND PRESENTATIONS OF FCBTAL HEAD.
Foetal Head; its Regions, Diameters, Circumferences, Extremities, Sutures, Fonta-
nelles — Sutures of the Adult and Foetal Head contrasted — Arch and Base of
Foetal Head — The former undergoes Diminution during Childbirth, the latter does
not ; Reasons for — Contrast between Diameters of Foetal Head and those of
Maternal Pelvis — Deductions — Articulations of Fcetal Head — Two Movements,
Extension and Flexion — Rotation. Presentation of Foetal Head; its relative
Frequency — Presentation of Vertex— Circumstances which modify the Frequency
of Head Presentations — Causes of the Frequency of Head Presentations — Differ
epce between Presentation and Position— Six Positions of the Vertex by BaMde-
locqne— BaLiiir^ Frequency oftbeee Foaitioua — NaSgeld's Division. . . • YI
X CONTENTS.
LECTURE IV.
MECHANISM OF LABOR IN VERTEX PRESENTATIONS.
Mechanism of Labor — Its Importance — Mechanism in the first Vertex Position —
Left Occipito-acetabular— Position of the Fcetus— Relations of the Head to the
Pelvis— Necessity for a Change in these Relations— Movements imposed upon the
Head— Flexion, Descent, Rotation, Extension, and External Rotation— Object
and Causes of these Movements — Proof that these Movements occur — Gerdy's
Explanation of External Rotation — Mechanism in the Second Position — Right
Oocipito-acetabular- Mechanism in the Third Position — Right Posterior Occipito-
iliac, the Second in Frequency, according to Naegeld — Conversion of the Poste-
rior Occipital into Anterior Occipital Positions — How this Conversion is accom-
plished— Mechanism in the Fourth Position— Left Posterior Occipito-iliac— Ne-
cessity of an accurate Knowledge of the Principles on which the Mechanism of
Parturition is founded — ^The pracUcal application of this Knowledge at tlie
Bedside 44
LECTURE V.
DEFORMITIES OF THE PELVIS.
Pelvic Deformities, how divided— Evils of Increased Capacity — Case in Illustration
— Dangers of Increased Capacity during Pregnancy and Labor— Diminished
Capacity— Dangers of— Varieties of Pelvic Defonnities — Causes of — Rachitis,
MolUties Ossium— Distortion of Spinal Column does not necessarily cause Distor-
tion of Pelvis. Obstructed Labor from Polypus— Removal of Polypus, and subse-
qu(*nt Delivery of Child by Forceps — Pubic Arcade — Congenital Deformity of—
Craniotomy — The Space through which a Living Child can pass — Experiments
of the Author — Discrepancy of Opinion among Writers— The Space through
which a Child mny be extracted by Embryotomy. How to ascertain that Defor
mities exist — In tlie young Girl — In the married Woman. Measurements of the
Pelvis — Baudelooque's Pelvimeter — How employed — Its reliabilities — Objections
answered. The best Pelvimeter, the Finger of the well educated Accoucheur —
The " Toucher** — How conducted. . • 67
LECTURE VI.
ORGANS OF GENERATION.
Organs of Generation — External Organs — The Mens Veneris, Iiabia Externa, Clitoris,
Labia Interna, Vestibulum, Meatus Urinariua. and Uretlira — Secretory Apparatus
of the External Organs — Sebaceous and Muciparous Follicles — Vulvo- vaginal
Gland — ^Tlie Internal Organs — The Vagina, its Anterior and Posterior Relations
— ^The Urethro-vaginal, Ve^ico-vaginal, and Recto-vaginal Septa — Vesioo-vaginal
and Recto-vaginal Fistula; — How produced — Orifice and Superior Extremity of
Vagina— The Hymen, its Absence no Test of Loss of Virginity — Its Presence no
Evidence that Sexual Congress has not occurred— Retention of Menses mistaken
fi>r Pregnancy — Blood-vessels and Nerves of Vagina — Uterus, Uses and Situation
of— How divided— The Structure of Uterus composite — External and Internal
Coat— Intermediate Tissue is Muscular— Is the Utems an Erectile Organ?—
Bouget*8 BesMTches— Blood-vessels, Nerves, and LymphaUos of Ul«ni0— Recto-
CONTENTS. XI
uterioe Fossa, Importance of— Ligaments of Uterus— The Cervix, its Peculiaritiea
before and after Pubertjr^Os Tines, Cicatrices upon, not alwa/s reliable as evi-
dences of CbildbiPth^The FaUopian Tubes— The Ovaries, the Essential Organs
of Generation — Structure and Uses of the Ovaries. 79
LECTURE VII.
MENSTRUATIOK.
Functions of tne Uterus and its Annexse— Essential to Health, but not to Life-
Forces in the Female Economy two-fold — Proof— Uterine Organs before and after
Puberty — Indications of Puberty — Menstruation — Meaning of the Term— Age at
which First Menstruation occurs— Influences which Promote and Retard it— Girls
in the Country contrasted with those in the. Cily — Influence of Race on the Men-
strual Function — Menstruation in young Children — Tardy Menstruation— Cause
of Menstruation — Conflicting Opinions — The Menstrual Function dependent on
Organic Development — Menstruation does not consist in the Discharge of Bloody
but in the Maturity of the Ovules — Ovular Theory — Dr. John Powers's Claim —
Periodicity of Menstruation — How explained — Is the Menstrual Fluid an Kxuda>
tion, or Secretion? — Is it Blood?— Does it escape by Endosmosis? — The Source
of the Menstrual Discharge, and its true mode of escape — Menstrual Blood in the
Uterus and Vagina — Diflerence between— On what the Diflerenee ia depen-
dent— Duration of each Menstrual Period, and Quantity Lost — Is Menstruation
peculiar to the Human Female? — General Properties of the Menstrual Dis-
charge— Period of Final Cessation— Why called the Critical Period — Aptitude
in the Female for Impregnation — Case of Catherine de' Medici — Early Marriages
in India 92
LECTURE VIIL
REPRODUCriOX.
Reproduction — Its Importance and Necessity — Early Opinions concerning — Meambg
of the term Fecundation ; in what it consists — Reproduction the Joint Act of both
Sexes — The Female furnishes the " Germ-cell" — The Ovisac or Graaffiau Vesicle —
Membrana Granulosa— Discus Proligerus — Zona Pellucida — Germinal Vesicle-
Germinal Spot — Modifications in the Ovisac previous to its Rupture — Corpus
Luteum — "Coagnlum" does not contribute to its Formation — Corpus Lufcnm not a
Permanent Structure — True and False Corpora Lutea — Former connected with
Pregnancy, Latter with Menstruation — Characteristics of each — True Corpus
Luteum an Evidence of Gestation, but not of Childbirth— Can two " Germ-cells" bo
contained in one Ovisac?— The Male Vivifies the " Germ-cell" — Spermatozoon, the
True Fertilizing Element — What are the Spermatozoa ? — Contact between '* Sperm-
cell" and "Germ-oell" necessary for Fecundation— How accomplished — Opinions
oonoeming — Aura Seminalis — Electrical and Magnetic Influence — Doctrine of the
Animalculists — Chemical Hypothesis— Mr. Newport's Experiments on tlie Frog —
Deductions — Where does this Contact take Place ? — Experiments- of Bischoff and
Valentin— Theory of Pouchet— Movements of Spermatozoa— Deductions from
Analc^\— Experiments of Nuck and Haighton— -Fimbriated Kzlremity of Fallo-
(iu Tabe»— Peculiarities oC \^'
3U1 CONTENTS.
LECTURE IX.
DEFINITION AND DIVISIONS OP PREGNANCY.
Pregnancy ; Definition and Divisions of — Is Pregnancy a Pathological Condition f —
The Uterus and Annex» before and after Fecundation— Two Orders of Pheno-
mena following Impregnation ; Physiological and Mechanical — IIow the Uterus
Enlarges — Microscope and its Proofs — Development of the Muscular Tissue of the
Uterus ; how accomplished— Solid Bulk of Uterus at Full Term— Meckel's Esti-
mate— Increase of Blood-vessels, Lymphatics, Nerves, and other Tissues of Uterus
— Nausea and Vomiting ; how produced— Influence of Nausea and Vomiting on
Healthy Gestation ; the Explanation of this Influence — Blood — how Modified by
Pregnancy — Is Plethora characteristic of Gestation 7 — Cause of this Hypothesis —
Treatment of Acute Diseases in Pregnancy — Aphorism of Hippocrates on this
Question — Increase of Fibrin in Inflammation — Deductions — " Buffy Coat" not
always the Product of Inflammatory Action — " Bufiy Coat '* in Chlorosis, Preg-
nancy, etc. — Kiestine ; what its Presence indicates — Blot's Experiments — Sugar
in the Urine of the Puerperal Woman — Deductions — How are we to know that
Pregnancy exists? Importance of the Question; its Medico-legal bearings; Illus-
tration— The Proof of Pregnancy altogether a Question of Evidence ; how this
Evidence sliould be examined. 131
LECTURE X.
SIGNS OP PREGNANCY.
Ekridences of Gestation ; how divided ; their Relative and Positive Value — Suppres-
sion of the Catamenia — Can a Pregnant Woman Menstruate? — Nausea and
Vomiting material to a Healthy Gestation — Depraved Longings — Salivation of
Pregnancy; how distinguished from Mercurial Salivation — Salivary Glands in
Connexion witli the Mammjc in the Female, and the Testes in the Male — Sym-
pathy between ; Illustration — Parotitis — Mammary Changes— Secretion of Milk
not always dependent upon Pregnancy — Milk in the Breast of the Virgin, and in
the Male— Mammary Metastasis — Illustration — The Areola; its Value — Color
not its Rsj*ontial Attribute— Depo?it of Black Pigment and Excitement of the
Sexual Organs — Connexion between — ^Tho True Areola; its Value — Areola
around tlio Umbilicus — Discoloration of Integument between Umbilicus and
Pubes — Dr. Montgomery's View of Areola — Can Pregnancy exist without the
Areola? — Changes in Uterus and Abdomen — First two Months of Gestation,
Uterus descends into Pelvic Excavation — Consequences — ^Vesical Irritation —
Pain and Depression of Umbilicus ; how Explained — Impregnated Uterus at end
of third Month— Gradual Ascent of the Organ — Right Lateral Obliquity — Pain
in Right Side; how Explaired- Uterus at end of eighth Month — Cough and
Oppressed Breathing; Reasons for— Projection of Umbilicus; its Value as a
Sign of Pregnancy— Uterus at end of ninth Month — Contrast with eighth Month
— ^Ascent of Organ in Primipara and Multipara ; Difference Explained— Bladder
«Dd Urethra ; Change in Position — Thrombus of Vagina and Vulva — (Edema of
TiOwer Extremities ; how accounted for. 143
LECTURE XI.
SIGNS OF PREGNANCY, CONnNUKD.
ErlAenees of Pregnancy continned— -The Bffect of Fecundatk>n on Development of
UteniB — Order of Development — ^Fundus enlarges first three Months— Body torn
CONTENTS. Xlll
third to sixth Month — Wisdom of this Arrangement — Shape of Impregnated
Uterus— Modifications of Cervix in Pregnancy — Error of certain Authors-
Uterine and Vaginal Extremities of Cervix — Cervical Canal — Relaxation ol
Tissues of Cervix — Cervix does not Lengthen — Error of Madame Boivin — Promi-
nence of Oa Tincae— Softening and Moisture — Mucous Follicles— Development of
— Increased Mucous Secretion not a Pathological State— Uses of this Secretion —
Cervix begins to shorten at its Uterine, and not at the Vaginal Extremity —
Proof — Opinions of Stoltz and Cazeaux — Placenta Pnevia and Shortening of Cer-
vix— Mod ideations of Cervix in Primipara and Multipara — Increased Development
or Uterine Appendages in Pregnancy — How does the Cavity of the Uterus
enlarge? — Ancient Theory — Increased Nutrition the true Caus&— Thickness of
Utenne Wails: Opmions respectmg — Os Uteri at Time of Labor — Discoloration
of Vagina as a sign of Pregnancy — Is ttiis Discoloration peculiar to Preg-
nancy? 163
LECTURE XII.
QUICKENING, BALLOTTEMENT, AND PLACENTAL SOUFFLE.
Evidences of Pregnancy continued — Quickening — Ancient Theory — Law of England
in regard to Quickening — What is Quickening? — Opinions of Authors — Nervous
and Muscular Development — Muscular Contractions of the FcBtus — Sensible and
Insensible Muscular Contractions — Quickening not a Psychical Act, but the result
of Excito-motory Influence — Spinal System — Its Physiological Importance —
When does Quickening take Place ? — Does not always Occur — Delusive Quickening
— Illustration — Contraction of Abdominal Walls mistaken for — Final Cessation of
Menses and Supposed Quickening — Attempted Imposition — Queen Mary of Eng-
land— Manipulations to Detect Quickening — Influence of Cold on Movements of
Foetus — Illustration — ^Ballottement or Passive Movement of Foetus — Rules for
Detecting — Positions of Foetus and Ballottement — Pulsations of Foetal Heart —
Auscultation — Mayor of Geneva — Average Beats of Foetal Heart— Not Synchro-
nous with Maternal Pulse — Auscultation, how Applied — Auscultation and Position
of Foetus — Twin and Extra-uterine Pregnancies— How ascertained — Placental
Souffle — Uterine Murmur — Kergaradec — Conflict of Opinions — Souffle not always
Dependent upon Pregnancy — Uterine and Abdominal Tumors ; Cause of— Souffle
no Evidence of Life of Foetus — Pulsations of Umbilical Cord — Dr. Evory Ken-
nedj. 176
LECTURE XIII
EXAMINATION OF THE FEMALE.
Examination of the Female to Ascertain the Existence of Pregnancy — ^The Thre&
Senses, Feeling, Seeing, and Hearing, to be employed — The "Toucher;" what is
it T — External Abdominal Examination ; its Objects ; how to be conducted — Va-
rious Causes of Uterine Enlargement; how to be distinguished — Examination per
Yaginam ; Rules for — The Vagina ; its Position and Relations — Position of the
Female— Relation of the Vagina to the Cervix Uteri— Examination per Anum ;
when indk»ted— Retro- Version of Uterus — Prolapsion of Ovary into Triangu^ai
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<jr 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§io 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
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•• A« an Axnf
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ith BO mu
tn an r-x\
fliei
-JLlMklUJt,^ 9W1VL'< LU VUO JJ^iltftJC^X
St lib
'.:i
live lexilio^kou
we tliink,
1 volumee for
-" li work nf
. . V
-t
lid b«
Ciireljei*
rt»Uuw, or uudvr poor iuj$Uu^'Vu>u. '^ — VifiCinnaU Mfdicai and iiurgicai NtUMU
'*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.
d
•f ractical knowledge of « fsoputar Oiwtctnisiau;^— i«*n^
<{ Joyrn^
r.3? 1
puTutWKn, Wtiili
rnlfSK of Dr.
impariMXtooti tht
Sat
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
A CONSPECTUS^^OF T " * TnT^MAOOrn-T \'
Of THE LONDON, Em?fBt!RGH. A^ ES OF V\\
PRACTICAL COMPENDIUM
AKB
MATERIA MEDICA AND PHARMACT.
By AJ^THONY TODD THOMr!=?n>r. MB,, ia.S.,
Mlour of the Hoyiil College of I' ilea nod Tm^-I
peutics in Univ I _ ^
Seventh American £difion^ much enUtrfjed and improved.
Edited by CHARl'Bfi JL LfeR, M.D.,
.Fiift»^ dr Ovarii F&Uialog^ and MateriA Medial b Q«nfvi ICidl^ ^41^ ^T
r* ^^ ' ^ ^^ Price ^125/ free of pofiUge. * 'i^ l H X
Cinul lubsun.
tncMli^K of oi>>'
, .—the whole ai ^ ...
m^AOB of «<U|j I !
_ JE, t^fnixenmont, I
tha mclh- ' "f !'■ ;■
of pr**ecmitioi,
lo 1>|I4«« of VA'i -
fwUonA «ti*l r
dl««aft«t» of tn'
Iir(|i«rfttli>nA,
ihn ilck— * 1-
n.l ♦>!£»<»■
42UAntt(|' tff apium f'3 . TMifntloni^
« Uble fur MovrljUnl 1i of irtntak—
tjii.:. • nf w.ii.*. .M , vspoetallj of
'tsurv vf leuiMmur* of
of HoUlft— of ib« lii«r»-
riltom^ of ftll thftt
lo of cTorT prmctl-
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THK
ACTITIONER'S PHARMACOPOEIA;
0
JmNIVERSAL 3?^OTRMia[ELAlB»L f> 1
COOTAININa TWO THOl LAS3iPIED PRkScRIPTIOXS,
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Aod much othtjr uBtfi !
iL*t!t?midi* and Student,
Rt*port of Pro|owi>r Valf'niliie iTI^II-s fiur|plc4Ai C IJiiiqtaei
lu tilt! Utiivertlty of If(!vv Vt^ik. S« i^^ioii of IS51^01>.
BySAMUEl
Illufitralod wiU> a SUiel Portrait of De. Mott.
PHc« 90 pfeiittL
^^CattHo^
OF NxVWTRE Am") ART
IS„:THE' CTTRE OF DISEASE.,
By SIR laaarPOMM, MB. tOXOH I, P.B,8u.
H^ ■■j'Jf.f.S ■* tlOC
Qua rvrf HMt Um-
■*& iV«VnMD«9tr f/a|ii} Fl>r^«» Mii^i to
•ttber l>j h.
Aft ii.r<THiV| ,
f.-r fli»' prof
DIt* HOOPER'S
PHYSICIANS' VADE-IECUM
PRmCIPLKS
a* OF TUE
VOTICB OF PHTSia
rLTKE OF GENERAL . .. . uOLdGY AND TUmmTTICS.
By WM. A. GUY, lt»., etc.,
SECOND JEDITION.
Q^H i^.p £ E 3 y 1J N, M /A S K E D ;
OB, A. COKSIDKKATlOa Or THB MOST
FBnaniEinr expiiigai sdiisies if the nsiBXT the.
TTrrit A9 ftirriiUUTftuf of
SOMJC OF THE CAUSES WHICH COlTrKlBUTE TO THEIR SUPPORT*
ByDASKHro, KD.
HOW TO TORSE SICK CHILDEEN:
OONTAININQ PTRErnON'.^ THAT ^^ A Y BR ForN^n OF J5KRT:CK to AtL
Is one 19n)o« Tulunir,
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* "EhotUd ^ In t^t bttfidA f>f ^rtrr otM 1ilw> f I ' Urn oyi n^to tfciltr ill n,*
Wo99* Jr<M«Mii €ata1ogU£
WOmtftVMVBKTt,
. A.
HANDBOOK
H 0 S f^ IT k I "p R A C'l* r C E V .•
AN INTRODUCTION
TO VftB
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By ROBERT D. LTONES, M.D., K.O.C.^ &c., &c., <fec.
Iq one handy. X2xno» volume of 233 pages, bound in muslin.
Price $1 10.
THE ^lAC^EHTA,
THE ORGANIC NEByOU^ SYiSTEM, -
THE BLOOD, THE OXYOEW, AND THE A^JJlMAt NERVOCS SYSTEM, PHYSIOLO-
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By JOHN O'RBULy, M.D», .
One OoUto roinme, bound in mttsliD,
Price $2 00.
/ . • . . . .
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Ibwtk American from the Seventh London Edition.
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FIEST UNES
THEOEY AND PRACTICE
INCLUpiNG. THE PEINCIPAL OPERATIONS.
By SAMUEL COOPER, M.D.,.
Senior Surgeon to the ITnlvertlty CoDege Ho^ital, and PlDfeasor of Surgery
, in the aame CoUege, etc..
With
NOTES AN0 ADDITIONS,
ByWILLABD PARKER, M.IX,
Professor of Surgery w the Golkge of PhymciaoB and Surgeons, etc
I'
In two Oet«vo Tolamee. Illustrated, boimd in leather.
Prioe $6 00.
A TREATISE OIT
FRACTUfiES IN THE VICINITY OF JOPOS^
AWD OK ClItTAtt
FORMS OF ACCIDENTAL ^SH WNr.ENITAL DlSLnCATIOyS,
B/ ROBERT iVlLLT
^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 ,