3&~
 

 
 
 
ON THE
THEORY   AND   PRACTICE
                           OF
             MIDWIFEKY.
                    -'    BY

   FLEETWOOD £JIURCHILL,  M. D., M. R. I. A.,

FELLOW OF, AND PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN IN, THE KING AND
  QUEEN'S COLLEGE OF PHYSICIANS IN IRELAND; EXAMINER IN MIDWIFERY IN THE QUEEN'S UNIVERSITY
    IN IRELAND; ONE OF THE PRESIDENTS OF THE OBSTETRICAL SOCIETY; ASSOCIATE MEMBER
           OF THE COLLEGE OF PHYSICIANS, PHILADELPHIA, U. S., ETC. ETC.
WITH  ADDITIONS
                      BY

      D. FRANCIS CONDIE, M.D.,

  FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; AUTHOR OF " A PRACTICAL
          TREATISE ON THE DISEASES OF CHILDREN," ETC. ETC.


WITH ONE  HUNDRED AND NINETY-FOUR ILLUSTRATIONS.
A NEW AMERICAN,

      FROM THE
FOURTH CORRECTED AND ENLARGED ENGLISH EDITION.
        PHILADELPHIA:
BLANC HARD  AND   LEA.
                1860. 
Cbiol&n,
  8G0
53  5  1
              Entered, according to Act of Congress, in the year I860, by

                     BLANCHARD AND LEA,

in the Clerk's Office cf the District Court of the United States for the Eastern District of Pennsylvania. 
\
      CHARLES  JOHNSON, Esq., M. D.;







                      THIS VOLUME












                          ASA





TOKEN OF RESPECT FOR HIS HIGH PROFESSIONAL ATTAINMENTS,





                         AND OF





             GRATITUDE EOR HIS  PERSONAL KINDNESS. 
"Thine is a high and holy office; see that thou exercise  it purely; not
  for thine own advancement, not for  thine own honour, but for the  glory
  of God and the good of thy neighbour.  Hereafter thou wilt have to give
  an account of it."—Hufeland. 
EDITOR'S  PREFACE.
  The scope, arrangement, and  general  character of the Treatise of
Dr. Churchill, are confessedly such as to adapt it, in an eminent degree,
for the use of both the student and practitioner of midwifery.   Each
successive edition  has been carefully revised by the  author, and made
to embrace  every improvement that had been developed in respect to
the theory and practice of obstetrics subsequent to the appearance of its
predecessor, rendering, thus, the  latest edition of the work, just issued
in Dublin, and of which  the present is a faithful reprint, a full, clear,
and accurate exponent of the existing state of every department of Mid-
wifery, whether considered as a Science or an Art.
  The American Editor, in presuming  to add anything to a treatise so
complete and excellent as that of Dr. Churchill, may, perhaps, be con-
sidered as having performed an uncalled for labor.  He, nevertheless,
believes  that  the  additions  he has made will  not be  condemned as
superfluous, but will be found, on the contrary, adapted  to augment, in
some degree, the value of the work.
  A number of illustrations, in addition  to those of the  author, have
been inserted where it was believed they would aid the reader in  obtain-
ing a clearer conception of the descriptions and practical directions of
the text.  All these additions are indicated by enclosure in brackets [ ].
  There has been appended, also, with the approbation of Dr. Churchill,
an extract from his " Manual for Midwives and Monthly Nurses."  In this
extract the exposition of the duties  and  the directions for the conduct
                                                          (v) 
V'i           EXTRACT FROM  THE  AUTHOR'S  PREFACE.
of the nurse,  before, during,  and subsequent to labor, are presented
more in detail than in the body of the Treatise.
  These additions, together with the fact that the work has  had the
benefit of two revisions by the author since  the publication of the last
American edition, have caused a notable augmentation in the size of
the volume, which at present contains fully one-half more matter than
when  last reprinted.   This  has rendered necessary the adoption of a
smaller type,  notwithstanding  which the number of pages has been
increased by nearly two hundred.
  Philadelphia, August, 1860.
   EXTRACT FROM THE AUTHOR'S PREFACE TO A FORMER AMERICAN
                             EDITION.
  " I owe a large debt of gratitude to my kind American friends, which
I gladly take this opportunity of acknowledging, and also to the profes-
sion  in America  for the flattering  reception  they  have given to my
volumes.   No reward could be more highly valued by me, nor could
anything  make  me more anxious,  by labor and study, to make my
works as perfect as possible, than the knowledge that their usefulness
may extend to another hemisphere." 
        PREFACE

               TO

THE  THIRD  EDITION.
  The demand for a new Edition of this work affords me an opportunity
of expressing my gratitude to the Profession for their kind reception of
the  former ones,  and of endeavoring to make the present still more
worthy of their acceptance.
  I have more than once carefully examined every paragraph, and have
corrected  or modified every  expression not  in  accordance with the
knowledge acquired by a more lengthened experience.  I  have not
hesitated to acknowledge a change  of opinion, when such appeared more
in accordance with truth, nor have I felt that a doubtful expression is
unwise when our information is insufficient to justify positive conclusions.
It has been well  observed by an eminent  writer,  that " He who does
not in all cases prefer doubt  to the  reception of falsehood, or to  the
admission of any  conclusion on insufficient evidence, is no lover of truth,
nor in the right way to attain it on any point."
  Some portions  of the work have been entirely re-written, several new
sections  added, and  one  new chapter;  by which means,  I hope,  the
practical value of the work has  been  increased.   I trust also the refer-
ences to modern authorities, which I have annexed to this Edition, will
be found useful.  The publishers have liberally augmented the number
of wood-cuts, so as to render the illustrations more complete.
  The Statistical Tables have been much  enlarged in this Edition:  so
that, as  the  conclusions are based upon much larger numbers, we may
regard them as a  nearer approximation to the truth.   No doubt, as I
formerly observed,  an absolute and unguarded reliance upon numerical
                                                         (Yii) 
viii             PREFACE TO  THE THIRD  EDITION.
calculations may lead us into error; for in grouping together a number
of cases to ascertain their positive or relative frequency, their causes,
the ratio of mortality positive and comparative,  etc., it is next to impos-
sible  to obtain  exactly similar cases,  or patients  under exactly  similar
circumstances;  for this we have to make allowance, and also for differ-
ences in habits of life, constitution, or atmospheric influences, modes of
previous treatment, etc.,  so  that we shall find  abundant  reason to use
our statistical deductions  with  caution and allowance; in fact, we can-
not  possibly ascertain the exact  truth, but only a  more or less close
approximation to it.  But even thus far these calculations are of great
value, for,
   1.  They lead to a habit  of definite thought and statement;  so that
instead of  general terms, we use numbers or proportion, and in so far
as accuracy is attained, we  give a fixed and scientific character to our
observations.
   2.  As Dr. Simpson, in his excellent essay on the value  and necessity
of statistics in operative  surgery, has remarked, " Statistics offer a test
by which the impressions of our recorded  and limited experience are
 corrected ;  and they furnish  a mode of investigation capable of resolving
many existing practical problems in surgery."
   3. They afford  us in general the only true and ultimate "measure of
value" of any proposed  alternative operation,  or of any new practice
in surgery  or midwifery.
   For  these and other  reasons I still hold the  opinion that numerical
 calculations, applied to midwifery, are of great value, notwithstanding
 the numerous chances of error, and the impossibility of drawing conclu-
sions from  them with absolute accuracy.
   In preparing this Edition I have been indebted to numerous  friends
for  the correction of errors, for permission to make free use of their
 writings,  to copy  their plates, or to give wood-cuts of their instruments
 and casts.   Among these I  cannot  but  mention Dr. Shekleton and Dr.
 M'Clintock of Dublin, Dr. Simpson and Dr. Zeigler of  Edinburgh, Dr.
 Dyce and  Dr.  Christie  of Aberdeen, Dr. Oldham of London,  etc.,  to
 whom, as well as to other friendly assistants, I beg leave to return my
 best  thanks.
   137, Stephen's Green, Dublin. 
PREFACE
                TO

THE  FOURTH  EDITION.
  I trust the reader will see proofs that this  Edition has undergone a
careful revision.  I  have added what I found wanting,  pruned what
appeared redundant, and corrected what was vaguely or carelessly ex-
pressed.  I earnestly hope that it has been rendered less imperfect and
more useful.
  Since the last Edition, a controversy has been in some degree forced
upon me, on the operation of craniotomy, but, unlike most controversies,
I do believe it has  had  no evil  effects — has left no ill-feeling after it.
Nay, I am free to  confess that it  has done me good, for, by obliging
me to sift the question  thoroughly, it  has  enabled me to define more
precisely the  grounds  of the operation, and to restrict its limits  in a
more definite  manner; and of this  the students of this volume will, I
think, have the benefit.  As the  subject has not been so fully ventilated
in any English work, I have thought it  advisable to append the essay
I published on the question.
   I allude with regret to another controversy both unpleasant and un-
profitable.  Dr. Francis Ramsbotham has accused me of copying many
of  his plates without acknowledgment, implying  that I put them forth
as  my own.   Such  a  thought never entered  into my head.   I copied
from previous  authors as they  had done from their predecessors,  men-
tioning in my preface to the First Edition that I had so availed myself
of  their labors.  I  regret that  I did not. specify with  each wood-cut
whence it was taken.  I must now be satisfied with apologizing to Dr.
Ramsbotham  and all others who think that I have  done them injustice,
assuring them that  nothing could be further from my intention than to
claim a merit not justly my due.   I am too old to wish for quarrels,
and too busy to have time for controversy, so that I trust  that what I
have said will be sufficient to prevent future misunderstanding.
   15, Stephen's Green, April, 18G0. 
 
CONTENTS.
                                                                            PAGE
Preliminary Observations..........33


                                  PART I.

           ANATOMY  OF THE PELVIS  AND ORGANS OF GENERATION.
CHAP.
 1. Of the bones of the pelvis    ..........    35
 2. Of the joints of the pelvis    ..........    39
 3. Of the pelvis collectively      ..........    41
 4. Deformities of the pelvis     ..........    49
 5. Of the external organs of generation    ........    60
 6. Of the internal organs of generation........66


                                 PART  II.

            OF  THE PHYSIOLOGY OF THE ORGANS OF  GENERATION.

 1. Menstruation      ............    77
 2. Disorders of menstruation    ..........    91
 3. Generation — Conception..........102
 4. Utero-gestation    ........••••   HI
 5. Signs of Pregnancy..........    .   155
 6. Duration of pregnancy...........167
 7. Sterility.............I"1
 8. Spurious pregnancy...........174
 9. Super-foetation............177
 10. Extra-uterine pregnancy..........180
 11. Pathology of the foetus...........187
 12. Abortion.............190


                                 PART III.

                  PHYSIOLOGY OF THE  UTERUS — PARTURITION.

  1. Classification—Definitions..........199
  2. Mechanism of parturition..........203
  3. Natural labor.............222
  4. Convalescence after natural labor.........247
  5. Tedious labor.......;.....257
                                                                      (xi) 
xii
CONTENTS.
CHAP.
 6.
 7.
 8.
 9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
29.
30.
Powerless labor
Obstructed labor
Deformed pelvis
Obstetric operations — 1. Induction
Version,  or turning
The vectis, or lever
The forceps
Craniotomy
The Caesarian section
Symphyseotomy
Mal-position  and mal-presentation of the
Plural births—Monsters  .
Prolapse of the funis umbilicalis
Retention of  the placenta
Flooding
Convulsions
Lacerations
Inversion of the uterus
Sudden death
Puerperal fever
Phlegmasia dolens  .
Puerperal mania
Ephemeral fever or weid
Sore nipples   .
Inflammation and  abscess of the breast
of premature labor
child
APPENDIX.
Obstetric Morality.....
Qualifications and duties of Monthly Nurses  .
613
629 
LIST  OF  WOOD   ENGRAVINGS.
 FIG.
 1.
 2.
 3.
 4.
 5.
 6.
 7.
 8.
 9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
Os Innominatum, inner surface
       "        outer surface
Os Sacrum
Concavity of Sacrum .
Skeleton of trunk
Pelvis — front view  .
  "     brim  .
  "     cavity .
  "     lower outlet.
  •'     canal of
  "     equable excess of
  "       "     diminution of
  '•     distortion of brim .
cavity
exostosis
lower outlet
  "     oblique distortion
Calliper for measuring pelvis (Baudelocque
Measurement of pelvis by the fingers
    tt            a           <<
External organs of generation  .
Anatomy of external organs of generation
Section of pelvis
Uterus, tubes and ovaries .
   "   cavity of
   "   double  ....
   "   bicollis  ....
   "   double  ....
   u      <<        ...
Section of ovary, Graafian vesicles.
Ovum of  rabbit ....
  "   of  man   ....
Ovary at  menstrual period .
(xiii) 
XIV
LIST  OF WOOD  ENGRAVINGS.
no.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88. Deformed pelvis
89.
90.
91.
92.
93.
94.
95.
96.
97.
Spermatozoa  ....
Graafian vesicle after impregnation
Ovary after escape of ovum
Corpus luteum ....
   "      "   from Montgomery
Vessels of gravid uterus  .
Nerves of gravid  uterus  .
Cervix uteri at 3d month of gestation
      "      at 6th month.
      "      at 8th month
      "      at 9th month
Decidua vera  .
Decidual cotyledons .
Decidua reflexa, formation  of around ovum

Human ovum of two weeks
      "            '•      laid  open
Placenta and cord  .
    "    section of .
Human ovum at an early period
      "      about 3 weeks

      "            2 months
      a               t<
      "           3 months
Section of a hen's egg
Vitelline membrane, Blastoderma — T. W. Jones
Changes in the ben's egg  during  incubati
Vesicula umbilicalis, from Baer
Diagram of foetus and membranes about the 4th week, from Carus
   "        "           "         "       6th week
Position of foetus in utero
Foetal head diameters
Mode of examination by ballottement
Tubal foetation      ....
Dewees' wire crotchet
Bond's placental forceps  .
External layer of uterine muscular fibres
Internal   "        "       "       "
Planes of  the pelvis
Outlet of the pelvis .
Foetal head, diameters
Mechanism of parturition — 1st position
Vertex presentation — 1 st position  .
   "       "            "        first step in mechanism of labor
Outlet of pelvis with foetal head passing through in the 1st position
First position of vertex, third step in mechanism of labor
Mechanism of parturition — 2d position   .....
Outlet of pelvis — foetal head passing  through in the 2d position 
LIST  OF WOOD  ENGRAVINGS.
XV
 na,
 99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
 121.
122.
 123.
 124.
 125.
 126.
 127.
 128.
 129.
 130.
 131.
 132.
 133.
 134.
 135.
 136.
 137.
 138.
 139.
 140.
 141.
 142.
 143.
 144.
 145.
 146.
 147.
 148.
 149.
 150.
 151.
 152.
 153.

 154.
Mechanism of parturition — 3d position
Outlet of pelvis — foetal head in the 3d position
Mechanism of parturition — 4th position
Outlet of the pelvis and foetal head in the 4th position
Head at lower outlet in the 4th position
Head at the lower outlet
Vaginal examination
Extraction of placenta  .
Obstructed labor — polypus uteri
     "       "     ovarian tumor
     "       '•     vaginal cystocele
Version or turning .
Roonhuysen's vectis
Modern vectis.
Application of vectis
Chamberlen's forceps
Short forceps .
Long forceps .
Dr. Radford's forceps
Churchill's forceps .
Operation with long forceps

   "          short forceps
Axes of pelvis
Dr. Huston's forceps
Dr. Hodge's forceps
Dr. Bond's forceps .
Hayn's perforator .
Smellie's perforator
Crotchet
Churchill's crotchet

Mr. Holmes's perforator

Knife for amputating limbs
Blunt hook
Dr. Davis's bone forceps .
Oldham's instrument
Craniotomy forceps
Dr. Meigs's Embryulcia instruments
Craniotomy forceps
     .<       "
The cephalotribe
Use of the perforator
 a           a
Application of the Crotchet
    a               a
Perforator for cranioclasm
The cranioclast
Sketch of the head of a child delivered by cranioclasm, showing
   form and amount of diminution caused by the operation  .
the change of
381
382 
XVI
LIST  OF  WOOD  ENGRAVINGS.
 FIG.
155.
156.
157.
158.
159.
160.
161.
162.
163.
104.
1G5.
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
181.
182.
183.
184.
185.
186.
187.
188.

189.

190.
191.
192.
193.
194.
Face presentations ....
Face presentation— 1st position
Passage of the head through the external par
Face presentation — 2d position
Forehead under the arch of the pubis
Breech presentation— 1st position .

   "        "        2d position  .
   "        "        extraction of head
Presentation of inferior extremities
Arm presentation-
• 1st position
 2d position
s in face presentation
Compound presentation — hand, foot, and funis
Hydrocephalus
Prolapse of the funis
Hour-glass contraction of the womb
Removal of adherent placenta
Placenta proevia
Duck-billed speculum
The manner in which Sims adjusts and fixes the silver sutures
Bozeman's button as it is being passed along the threads down to the wound
Bozeman's button-suture finally applied ...    ....
Bozeman's suture adjusted   .........
Tubular needle for passing wire threads through the lips of vesico-vaginal fistula
Fork or pulley used in drawing through the wire threads
Blunt hook for directing the point of the needle    ....
The iron wire splint of Simpson finally adjusted    ....
Dr. Coghill's instrument for finally tightening and fixing the wires .
The iron-wire splint finally adjusted and the ends  of the stitches twisted and
    secured across the lower bar of the splint
The tenaculum,  or sharp hook used for catching up the edge of the mucous
    membrane of the vagina around the fistula     .....
Straight knife used for paring  the edges of the fistula   ....
Bent knife used for paring the  edges  of the fistula  .....
Lateral view of the  bent knife  to show the angle at which the blade is bent
Laceration of perineum, Dr. Horner's operation    ..... 
ON
THE  THEORY   AND  PRACTICE

                          0 F

            MIDWIFERY.
           PRELIMINARY  OBSERVATIONS.

  1.  The theory and  practice of Midwifery  embraces  the anatomy  and
physiology of the organs of generation, and also the anatomy of the region
in which they are contained.

  A correct knowledge of the structure, magnitude, and other peculiarities
of the pelvic cavity, is indispensable to a due appreciation of the  mechanism
of parturition :  the anatomy of the organs of generation must of course be
preliminary to  an investigation  into  their functions,  and it  is only  by a
minute and accurate observation of these functions that we are able to detect
and  comprehend the deviations from their  course; in  other words,  their
pathology.

  The four great functions of the uterine system are menstruation, concep-
tion, gestation, and parturition, which are so  intimately connected, that each
is dependent on the other; and for the development of either,  the co-opera-
tion of several  organs is necessary.  A breach of this union, or the absence
of this co-operation, will involve functional irregularity or inefficiency; and
together with the deviations of individual organs from the normal standard,
and  certain organic deficiencies, will constitute the  pathology of the female
generative system.

   2. We have  thus, in a few words, a natural arrangement of subjects laid
down, which I  shall follow in the subsequent parts  of this volume.

   Part I. will  include  the normal and abnormal anatomy of the pelvis, and
 of the external and internal organs of generation.
        3                                                    (33) 
34
PRELIMINARY OBSERVATIONS.
  Part II, the function of menstruation, with its abnormal conditions :  and
of conception, utero-gestation, ovology, etc., with their abnormal deviations,
as sterility, superfcetation, extra-uterine gestation,  foetal  pathology, abor-
tion, etc.

  Part III.,  Midwifery properly so  called,  that is, parturition,  with its
abnormal varieties.

  This arrangement will bring under our notice  all that relates to the theory
and  practice of midwifery.   In addition to  the description  of the various
functions mentioned above, there will  be given full details  for their  manage-
ment, and for the  treatment of their deviations; all of which I shall endea-
vor to state as clearly and concisely as possible. 
PART  I.
THE  ANATOMY OF THE PELVIS  AND  OF  THE ORGANS OF

                         GENERATION.
                          CHAPTER I.

                 OF  THE  BONES  OF  THE PELVIS.

  1. The pelvis is an irregular bony cavity,  situated at the base  of the
spinal column, and above the inferior extremities, with which it is connected
by articulations and muscles, and for which, as well as for the muscles of the
trunk, it constitutes a "point d'appui."
  As it  forms one of the two  mechanical elements of parturition, it is of
great consequence to  understand rightly its component parts, their connec-
tions, relations, coverings, and abnormal varieties.   These we shall  therefore
proceed to investigate at once.
  2. In the adult, the pelvis may be divided  into four-parts or bones, viz.,
two, ossa innoviinata, the os sacrum, and the  os coccygis; but in  early life
they are more minutely divisible.  Let us now examine these bones separately.

                                 Fig. 1.
Os Innominatum, inner surface.
  3. Each Os Innominatum (Fig. 1), at an early period of intra-uterine life,
consists of cartilage onlv, in which, subsequently, numerous spiculae of ossifi-
                                               '             (35) 
V
36                     BONES  OF  THE PELVIS.

cation are seen, and which at birth have coalesced so as to form three bones,
separated by cartilage.
  After birth, the process of ossification continues until these separate bones
meet in the acetabulum, where they are identified with each other, and at the
symphysis pubis, where the opposite ossa pubis are united  by cartilage and
ligaments.   The breadth of each os innominatum, from the anterior-superior
to the posterior-superior spinous process, is six inches, and the height from
the tuber ischii to the highest part of the crest of  the ilium is seven inches.
  The three bones into which each os innominatum is  divided at birth have
received  different names, and require a distinct notice.
  4. The Os Ilium,  hip,  or haunch bone (Fig.  2), is the  larger  of  the
three, of a triangular shape, situated  superiorly, and with its fellow forming
what is called the false pelvis.
  Its external surface (*), or dorsum,  is convex,  irregular, with elevations
and depressions which serve for the attachment of  the  glutsei muscles.   Its
internal  surface,  or venter (10), is concave and smooth, affording a bed for
the iliacus internus  muscle.  The  lower portion, body or base (5), is  the
thickest part of the bone, and forms  more than one-third of the acetabulum.
Above the body, the bone spreads out into its ala or wing, which  rises  ob-
liquely forwards, upwards, outwards, and then backwards, terminating in the
crest  or  crista ilii—a semicircular ridge of some thickness, which, at its
posterior part, curves downwards and forwards.   Its borders serve for the
attachment of the abdominal muscles, and certain  ligaments to be  hereafter
described ; and it terminates anteriorly, in the anterior-superior, and ante-
rior-inferior spinous processes (4,5).   The former afford attachment to Pou-
part's ligament, the tensor vaginae femoris, the sartorius,  and a  portion of
the rectus femoris muscles.  Between  the posterior spinous processes is a
deep arch, — the sciatic notch, — which is divided  by ligaments into the two
sciatic foramina: through the upper of these, which is the larger, pass the
gluteal, sciatic, and pudic arteries, the sciatic and pudic nerves, and the pyri-
form  muscle ; whilst, through the inferior opening, the pudic arteries  and
nerve re-enter the pelvis, and the obturator internus muscle passes out.  The
posterior part of the crest of the ilium terminates in an irregularly oval rough
surface, with numerous prominences, which occupy corresponding  depressions
in the sacrum, and constitute (with a thin layer of cartilage  interposed) the
sacro iliac synchondrosis of each  side.   The body of the bone is divided
from the ala internally by a well-marked ridge (12), running from the junction
of the ilium,  with the sacrum, forward ;  this is part of the linea ilio-pectinea,
and defines the boundary of the true pelvis.
   Thus we find that the ilium is connected posteriorly with the  sacrum,  and
identified anteriorly with the ischium and pubis in the acetabulum.
   5. The Os Ischium, os sedentarium, etc., is the  lower of the three bones
composing the os innominatum, and the next in  size to the os ilium.   Its
base or body (2), which  forms the inferior portion  of the acetabulum, is the
thickest part; below this we find a narrower portion, from which a spinous
process juts  out backwards and inwards, and  affords insertion to  part of the
sacro-sciatic ligament.   This process varies  in length  and direction, and is
occasionally  of some importance  obstetrically.  From the neck, the bone
descends downwards and  forwards, until, enlarging at its lower portion, it
forms the tuber ischii (u), the bony seat, a rough, thick protuberance ;  and
turning upwards, at an obtuse angle, becomes the ascending ramus (15) of
the ischium.   Its internal surface is smooth and even, and forms one of the
inclined planes  of the  pelvic cavity.   Its external surface  is rough,  and
gives attachment to  the sacro-sciatic  ligament, to the semi-membranosus,
semi-tendinosus, the long head of the biceps flexor cruris, and the quadratus
femoris muscles. 
BONES  OF  THE PELVIS.                     3 7
  Thus the ischium is identified with the ilium and pubis in the acetabulum,
with the descending ramus of the pubis, and is connected  by ligament with
the sacrum.
  6. The  Os Pubis, pecten or share-bone, is the smaller and most anterior
of the three bones.  Its base  is  the  thickest part, and forms the anterior
and smaller third of the acetabulum, beyond which the bone  narrows ; and,
proceeding  forwards, constitutes the horizontal  ramus (16)  of the pubis ;
somewhat triangular in shape,  and about half an inch in breadth.   It meets

                                 Fig. 2.
0s Innominatum, outer surface.
its opposite at the symphysis pubis ("), and completes the anterior wall of
the pelvis.   From the inferior part of the symphysis, and at an acute angle
with the horizontal ramus, a thin plate of bone, the descending ramus (*8),
proceeds downwards to  meet the ascending  ramus of the  ischium, and with
it to form one side of the arch of  the pubis.   Upon the angle formed  by
these bones and their opposites will depend the dimensions of  the arch, and
the facility or difficulty  of the transit of the child through the lower outlet.
  The inner and superior edge of the horizontal ramus is a continuation of
the linea ilio-pectinea, which it completes ; and near its pubic  termination is
a small spinous process, to which  is attached the  inner  end  of Poupart's
ligament, and near it the pectineus  muscle, whilst the inner and outer edges
of this portion of the  bone  afford insertions to  the abdominal  muscles.
Although I have stated that the anterior part of the bony pelvis is completed
by the osa pubis and ischium, yet in the centre of  each side a considerable
space is left, called the obturator foramen (*>), which is nearly closed  by the
obturator ligament.   The object  attained by  this  arrangement is lightness
of structure where strength is not needed.   The shape of these foramina is
stated by Meckel, Cruvelhier, Cloquet, etc., to be oval in the  male and tri-
angular in the female.  Other and  opposite  statements have been made, but
from the  observations of Dr.  John Neill1 there can be little doubt that the
former opinion is the  correct one, and this affords  an additional  distinction
between the male  and female  skeleton.  The  os pubis is identified with the

  i Summary of Trans, of  Coll. of Pliys. Philadelphia, vol. iii.   No. 2.  Amer. Med.
Jour., Oct 1850, p. 558. 
38
BONES  OF  THE TELVIS.
ilium  and  ischium  in  the acetabulum,  with  the ascending  ramus  of the
ischium, and is connected with  its fellow opposite by cartilage at the  sym-
physis pubis.
  Of  the three bones, the ilium forms a  part of the  brim and cavity of the
pelvis, but  none of the outlet;  the ischium, part of the outlet  and  cavity,
but none of the brim ;  whilst the ossa pubis enter into the formation of both
brim and outlet.
  1.  The Os  Sacrum, os  basilare,  etc., (Fig. 3^ terminates the vertebral
column, and may be said to consist of  several vertebra? anchylosed.  Its forma-
tion commences by about thirty-five  points  of  ossification, these   shortly
coalesce into fifteen ; at birth the number is reduced to five (the number of ver-
tebrae of which the bone consists), and subsequently they form but one bone.
In the adult it is of a triangular shape, the base of the triangle being above,
and inclining forwards; the apex below, and somewhat backwards. Its length
is from four to four and a half inches, its breadth four inches, and its greatest
thickness two  and a half inches.   M. Baudelocque found that the thickness
of this  bone  scarcely varies  a  line,  even in deformed pelves.  Its  specific
gravity  is small, owing to  its spongy texture, so that for  its size it is pro-
bably the lightest bone  in the body.  Its external  surface  is rough and
convex, exhibiting four or five spinous processes like those of the vertebra?,
but smaller, and diminishing in size  as they descend.   Anterior to these we
find a continuation of the spinal canal,  containing the cauda equina; with
four holes on each side communicating with it, for the transmission of nerves.
Its internal surface (2)  is smooth, and  concave to the amount of half an
inch,1 crossed by four transverse lines,  marking the  former division of its
                 Fig. 3.                               [Fig. 4.]
               Os Sacrum.

bones by cartilage;  here  are  also  four pairs of holes  sloping  outwards,
through  which pass nervous filaments, which afterwards form  part of the
great sciatic nerve.   The upper edge of this bone completes the brim of the
pelvis; the  oval shape of which, however, is broken by the projection of the
central portion,—the promontory of the sacrum (x).  The lateral surfaces (3)
are rough, uneven, and covered with a thin layer of cartilage;  the irregu-

  1 ["The inner face of the sacrum is more or less concave in different subjects.  When the
conformation is natural, its concavity, according to M. Dubois, may be estimated at about
TVhs of an inch (fig. 4).] 
OF  THE JOINTS OF  THE  PELVIS.
39
larities  correspond to similar  ones in the ilium, and  with  them form the
sacro-iliac synchondroses.   This is probably the most important bone in
the pelvis, obstetrically considered, inasmuch as it forms a great portion of
the brim and cavity, and enters  largely into  the various deformities of the
pelvis.
   It  is connected  superiorly with the last  lumbar vertebra, laterally with
the ossa ilia, inferiorly with the os coccygis, and by ligaments with the ossa
ischia.
   8.  The Os Coccygis,  or huckle-bone (4), is the continuation and termina-
tion of the os  sacrum and vertebral column.   It is formed  by four or five
points of ossification in  the foetus, which  do not afterwards unite, but are
tipped with cartilage, and movable by a ginglymoid joint.  The entire bones
form a pyramid, the apex  of which is below.   The external surface is irre-
gular, and the internal smooth, terminating the plane of the  sacrum, and
extending it anteriorly.  The small sciatic ligament and the ischio-coccygeal
muscle are inserted into  it.
   To the accoucheur  this apparently insignificant bone, or  bones, is of im-
portance, as any deviation from its normal direction, or usual mobility, may
influence the progress of parturition.
                         CHAPTER  II.

                OF THE  JOINTS  OF  THE  PELVIS.

  9. Before proceeding to the consideration of the pelvis  collectively, let
us briefly examine the joints by which the separate bones are connected, and
especially as deficient information on this subject has heretofore led to erro-
neous practical conclusions.  I shall notice, l,the sacro-iliac synchondroses;
2, the symphysis pubis ;  and,  3, the sacro-coccygeal joint.
  10. The Sacro-iliac  Synchondrosis, of either side, consists of a rough
irregular surface  on the posterior  part of the ilium and the side of the
sacrum, each of which is covered with a layer of cartilage from one-sixth to
one-eighth of an  inch in thickness; the sacral  layer being the thicker, and
the entire, when the  bones are forcibly separated, adhering to the sacrum.
At  the  point of junction of these two layers, their substance is somewhat
softer, which has  led to the erroneous supposition that it is a joint properly
so called.   This union of the bones  is strengthened by strong ligamentous
bands,  which by some writers are described as  the  superior, inferior, ante-
rior, and  posterior sacro-iliac  ligaments.   They stretch  across  from one
bone to the other  in front  and behind, rendering the joint perfectly immo-
vable, unless great force be used.   Additional strength also is obtained by
the sacro-sciatic ligaments  connecting the lower part of the sacrum with the
ilium.                                                                 .
  11. The mode  in which the sacrum  is inserted between the ossa ilia is
worthy  of notice ;  it resembles  the  position of the  keystone of an arch in-
verted—i. e., its transverse diameter is greater  inside than outside, because
the pressure which  it has to resist is from within.  The interposition of car-
tilage is probably  for the  purpose  of diminishing the effect of shocks, and
so preserving the integrity of the union. 
40
OF  THE JOINTS  OF  THE PELVIS.
   12.  The Symphysis Pubis is situated anteriorly, and formed by the junc-
tion of the two ossa pubis, whose  extremities are covered by cartilage or
fibro-cartilage.  It was formerly supposed that the junction was effected by
the interposition of a single  mass of cartilage ; but  the  researches of Dr.
W. Hunter led him to the  conclusion that the  end of each bone is covered
with cartilage, and that between each so covered, there is a matter resembling
the intervertebral substance.  "With this view M. Baudelocque and Dr. Burns
agree, but M. Tenon thinks that sometimes the one and sometimes the other
mode obtains.
   Occupying two-thirds of the length, and the posterior third of the centre
of this junction, we find a true arthrodial articulation, six lines in length and
two in breadth, in shape like  an almond, lined by synovial membrane, and
containing a small quantity of  synovia.  M.  Gardien  defines  this joint as
" an arthrodial articulation in part, and the remainder a true synevrotic syn-
chondrosis."1
   13.  Though the joint be  weak in itself, it is strongly fortified by ligaments.
The capsule  is strong, and is connected with, or partly formed by, the ante-
rior and posterior  pubic and sub-pubic  ligaments, which consist  of inter-
lacing fibres  stretched  across the joint on all  sides, and  firmly attached to
each os pubis.
   14.  Ambrose Pare, Severin Pineau, and other ancient writers, with  Si-
gault, Chaussier,  Gardien, Matthews Duncan,2 etc.,  among the moderns,
judging from its occurrence in certain animals, have concluded  that the ossa
pubis are separated to a certain extent during labor, and that this joint is a
special provision for increasing the antero-posterior diameter of the brim of
the pelvis; and certain post-mortem examinations of females who died near
the full term of gestation,  have  been adduced  in proof  of the fact.  On the
other hand this separation is denied,  and I believe most justly, by Denman,
Baudelocque, Boyer,  Burns, Dewees, etc.  M. Baudelocque, and others, have
sought for it in vain in cases where no violence has been used; and, from a
fair examination of the observations on record,  we may conclude that it
never takes place as a natural process, but that we occasionally meet it as an
accident.  Dr. Dewees'3 arguments appear to me conclusive :  "1. It is not
stated to be more frequent in  distorted than in well-formed pelves, which
ought to be the case on account of the greater pressure.   2. When it does
occur, it is attended with severe inconveniences, which are not observed after
ordinary labor.   3. That such a separation as has been imagined, would not
materially increase the antero-posterior diameter  of the brim, as  it would
require the two ossa pubis to be separated one inch from each  other to gain
two lines."
   I may add, that this separation can only be effected by the rupture of the
pubic ligaments and sacro-iliac synchondroses,  the structure of which  prove,
beyond doubt,  that they were not intended to expand  ; and that  when this
accident does  occur, it completely incapacitates the patient from moving
about, by depriving the lower extremities of a firm "point d'appui," which,
as  M. Martin has recently shown,4 can only be restored  by a  band passed
firmly around the pelvis, and pressing the sacro-iliac synchondroses strongly
together.
   15.  The Sacro-coccygeal joint is of the kind called ginglymoid, admit-
ting of extensive motion, especially backwards, so as to permit the enlarge-
ment of the lower  outlet, in its antero-posterior diameter, at least  one inch.
The articulating surfaces are covered with cartilage, and between them is a
synovial capsule ; whilst on the outside, and entirely embracing the joint, is
a fibrous capsular ligament.
  1 Traite" des Accouchemens, vol.  i. p. 28.        2 Dublin Journal, vol. xviii. p. 60.
  3 Compendious System of Midwifery, p. 13.      4 Gazette Me"dicale, Nov. 1851. 
OF  THE PELVIS.
41
  16. Abnormal deviations.  Relaxation, of violent disruption of the pubic
joint  and sacro-iliac synchondroses, has been well  described by Dr. Den-
man1 and others.   The most remarkable symptom is the difficulty or impos-
sibility of sitting erect, of assuming  an upright position without help, of
standing or  walking.   There is often pain or uneasiness in  the pelvic region,
which may give rise to a suspicion of uterine disease ; and a sense of weak-
ness and looseness in the bones.  Relief will be immediately afforded  by a
binder, which, by its tightness, shall supply the  degree of  firmness  in which
the pelvis is deficient;  this and absolute rest are our chief remedies, and the
former should be  worn until a natural union takes place.
  But a  further evil may occur, as Dr. Denman  has pointed out.  Inflamma-
tion may take place in the injured joints, and matter be formed on their
loosened surfaces.  "When suppuration," he observes, "has taken place, in
consequence  of the injury  sustained at the junction  of the ossa innominata
with the sacrum, the abscess has in some cases been formed near  the  part
affected,  and been cured by common treatment.  But in others, where matter
has been formed and confined at the symphysis  of the ossa pubis, the symp-
toms  of a hectic fever have been produced, and the  cause has not been dis-
covered till after  the death of the patient.   In  others, the matter has burst
through  the capsular ligament of the symphysis at the inferior edge, or per-
haps  made its way into the  bladder;  and in  others, it has insinuated itself
under the periosteum, continuing its course till  it arrived at the acetabulum.
The mischief being thus extended, all the symptoms were  aggravated ; and
the matter making its  way to the surface, a large abscess has been formed
on the inner  and  fore  part  of the thigh, or near the hip, and the patients
being exhausted by the free and proper  discharge, have at length yielded to
their  fate."1   In  all such cases, where it is possible,, the abscess should  be
opened, and the matter evacuated.
  It. The sacro-coccygeal joint may become  anchylosed,  and so offer a
decided impediment  to the  dilatation of the lower outlet during labor, as
we  shall  see by and bye.
                        CHAPTER  III.

                 OF  THE  PELVIS  COLLECTIVELY.

   18. Having thus examined each bone of the  pelvis separately,  and the
joints by which they are united, our next object is the consideration of the
pelvis as a  whole, in relation to the rest of the body, its magnitude, axes, etc.
   It is connected with the trunk by the articulation of the sacrum with the
last  lumbar vertebra, effected in the  same  manner  as the junction of the
vertebra? with each other: with  the  lower extremities, it is connected by
means of the hip-joints.
   But the position of the pelvis in situ is very different from what we might
suppose from  examining it separately.   The brim  of the pelvis is neither
horizontal  nor perpendicular,  but  oblique.   When the body is erect, the
upper part of the sacrum and the acetabula are nearly in the same descend-
ing line.  The obliquity has been variously estimated ; that of the brim from

     1 Introduction to Midwifery, p. 17.  7th Ed.                   2 Ibid. 
42
OF  THE PELVIS.
35° to 60°,  and that of the  outlet from  5^° to 18°.  Naegele states  the
obliquity of the brim to be from 50° to  60°, and that of the outlet from
10° to 11°; the point of the coccyx being seven or eight lines above  the
summit of the arch of the pubis, and the sacro-vertebral angle three inches
nine lines higher than the pubis.
  19.  The  advantages of this obliquity  are obvious.  As Dr. F. Rams-
botham has truly  observed : " Were the axes of the  trunk  and pelvic  en-
trance in the same line, owing to the upright position  of the human female,
the womb,  towards  the  close of gestation, would  gravitate  low  into  the
pelvis, and  produce most injurious pressure on the contained viscera; while
Skeleton of Trunk.
in the early months not only would  the  same distressful inconvenience be
occasioned,  but there  would be great danger of its protruding externally,
and  appearing as a tumor between  the  thighs, covered by  the  inverted
vagina."1  We  may add, that, when not pregnant,  the patient would be
obnoxious to  prolapse  of the uterus and the other pelvic viscera,  upon
making very slight expulsive efforts.
  20. Now let us examine the  Pelvis itself.   It is divided by the linea ilio-
pectinea into the false and true, or upper and lower pelvis.   The Upper or
False Pelvis is formed by the lateral divergence of the alas of the ossa  inno-
1 Obstetric Med. and Surgery, p; 12.  2d Ed. 
OF  THE PELVIS.
43
Front view of Pelvis.
minata.   It is not of much importance obstetrically, except for the general
relation which its normal size bears to that of the true pelvis, and the infer-
ence to be drawn therefrom as to the normal or abnormal  condition of the
latter.  Dr. Burns  gives the following measurements, which I believe are
correct: — " From the symphysis  pubis  to  the commencement of the iliac
wing at the inferior spinous  process, is nearly  four  inches.    From the
inferior spinous process to the posterior ridge of  the ilium, a line subtend-
ing the hollow of the costa, measures five inches.   The distance from the
superior spine is the same.   From the top of the crest of the ilium to the
brim of the pelvis, a direct line measures three inches and a half.  The dis-
tance between the  two  superior anterior spinous  processes of the ilium,  is
fully ten inches.   A line drawn from the top of the crest of the ilium to the
opposite side, measures  rather more than eleven  inches, and touches in its
course the intervertebral substance  between  the  fourth and  fifth lumbar
vertebras.  A line drawn from the centre of the third lumbar vertebra, count-
ing from the  sacrum to the upper spine of the ilium, measures six inches and
three quarters.  A  line  drawn from the same vertebra to the top of the
symphysis, measures seven inches and three quarters : and  when the subject
is erect, this  line is exactly perpendicular."1
  21. The Lower or True Pelvis is the part involved in  parturition, and
which therefore ought to be  known with great accuracy.   For the purpose
of description, it is divided into the brim, cavity, and outlet.
  22. The Brim op  the Pelvis is defined by the linea ilio-pectinea :  it  is
of an oval form, except  posteriorly,  where the oval is  broken by the  pro-
montory of the sacrum.   Its influence upon labor  will be understood, when
we recollect that it is the first  solid  resistance with which  the  head of the
foetus meets :  that any diminution in its size is more hazardous and less reme-
diable  than in any other part  of the  passages ; and lastly, that deviations
from the normal proportions of the brim most frequently entail similar ones
in the cavity.
  The three principal diameters are, the antero-posterior (Fig.  71) from the
prominence of the sacrum  to the  inner  and upper edge of the  symphysis
pubis; the transverse (2) across the widest part of the brim, at right angles
to the  antero-posterior;  and the oblique diameter (3) from the  sacro-iliac
i Principles of Midwifery, p. 23.  9th Ed. 
44                        OF THE  PELVIS.

                                 Fig. 7.
Brim of Pelvis.
synchondrosis of one side, to the opposite side of the brim, just above  the
acetabulum.
  Vrolick states that, to exhibit accurately the relations  between the head
of the foetus and the brim of the pelvis, their diameters should be so drawn
as to intersect each other in the central  point  of the brim ; and to  do so,
the anterior extremity of the oblique diameter and the transverse diameter
must be rather more forward than they are usually placed.1
  23. The measurements of these diameters are not  exactly the  same in
different  women, though the  variation  is  but  slight.   I  shall place  the
measurements given by some of the chief authorities before the reader.
Antero-post. diameter...	Denman.	Burns.	Ramsbo-tham.	Rigty.	Baude-locque.	Velpeau.	Moreau.
	4 in. & a fraction.	4 in.	4 in.	4-3 in.	4 in.	4 in.	4 in.
Transverse..	5	5	H	5-4	5	5	5
		H.	5	48	H	4*	H
  If we take the smallest of these estimates, there will still be space enough
to admit the head of the child ; and if we allow half an inch for variations,
this will give us a pretty correct idea of the diameters of the brim.
  The circumference varies from thirteen to fourteen and a half inches.
  Dr. Burns has given us some other measurements : " From the sacro-iliac
symphysis to the crest of the pubis on the  same side  is four inches  and a
half;  from the top of the sacrum to that part of the brim which is directly
above the foramen thyroideum, is three inches and  a half; the  line, if drawn
to the acetabulum in place of the foramen, is a quarter of an inch shorter;
a line drawn across the fore part  of the brim, from one acetabulum to the
other, is nearly four inches and a quarter." 2
  24. The Cavity of the Pelvis, whose fixed boundaries  are the sacrum,
the  ischium, and  the pubis, is  of unequal  depth.   Posteriorly it  measures
five inches, or six if the  coccyx be  extended ; from the brim  to the tuber
ischii, three inches and three-quarters ; and the depth of the symphysis pubis
is from two to two and a half inches.

    1 Edin. Monthly Journal, Sept. 1852.         2 Principles of Midwifery, p. 20. 
OF  THE PELVIS.
45
  25. The antero-posterior diameter from the hollow of the  sacrum to the
symphysis  pubis, is about four inches and a half; the transverse, at right
angles with the former, is about  four inches and three-quarters; and the

                                  Fig. 8.
Cavity of I'elvis.
oblique about five  inches :  a variation of a quarter of an inch either way
being allowed.
  There are other measurements of considerable importance, inasmuch as
the child's head  passes obliquely through the cavity of the  pelvis.   Thus,
from the sacro-iliac synchondrosis of one side to the tuber ischii of the other,
is six inches ;  and to the  ramus of the ischium, five inches :  from the ante-
rior margin of the sacro-sciatic  notch, to the opposite side, is six inches, or
six and a quarter;  from the anterior margin of the descending ramus of the
ischium, to  the opposite  side, at the  same level, is four inches and three-
quarters.
Lower Outlet of Pelvis.
  26. The bones which constitute the pelvic cavity are smooth on  their
inner surface, and present a series of inclined planes, calculated to influ-
ence the direction of the foetal head in its descent.  They tend at first down-
wards and slightly backwards, then downwards and forwards.
  27. The Outlet of the Pelvis is of an oval  shape, but irregular.  Its 
46
OF  THE PELVIS.
     lateral boundaries are immovable ;  but its antero-posterior diameter may be
     extended, owing to  the  mobility of the coccyx.   The  arch  of the pubis,
     according to Osiander, forms an angle varying between 90° and 100°, and
     will permit the passage of  a circular body whose diameter is  an inch and a
     quarter.
        28.  The antero-posterior diameter  of the  outlet, from the  arch of the
     pubis to the point of the coccyx, is from four to five inches; the transverse,
     from  one tuber ischii to the other, is about four  inches ;  and  the oblique,
     four inches and three-quarters, allowing for a variation of half  an inch.
        29.  Now, if we compare the diameters of the brim with those of the out-
     let, we find  that the proportions are completely changed ; that which was
     the shortest at the  brim being  the  longest at the  outlet, and  the  longest
     diameter of the brim being the shortest at the  outlet.   This remarkable
     change is, however, effected gradually ; for in the  cavity we observe merely
     an approximation in the diameters.   The effects of these changes upon the
     mechanism of parturition are very important, as we  shall see by and bye.
        30.  The axes of the upper and lower outlet of the pelvis form an obtuse
     angle with each other;  the former being described by a line  running  from
<9    the coccyx  upward to a little above the umbilicus, and the latter by a line
 ►    drawn from the second bone of the sacrum through the centre of the pubic
     arch.
        If we combine these together with the inclination of the pelvis, we  shall
     obtain a tolerably accurate  notion of the direction of the canal of the pelvis.
     This is marked out by the central line in the accompanying figure (Fig. 10),

                                     Fig. 10.
Canal of Pelvis.
which I have copied from  one given by M. Danyau in his translation oi
Naegele's work on Oblique Distortion.
  31. There  is a  considerable difference  between the male  and femah
pelvis, both in shape  and size.  In  the  former, the  brim is more circular
and the cavity deeper.   In the male, the depth of the symphysis pubis  i*
nearly double that  of  the  female ;  the  sacrum is more perpendicular; the
sacro-sciatic notches and foramina smaller;  the obturator foramen oval • the 
OF  THE PELVIS.
47
arch of the pubis is narrower, its angle being about 70° or 80° ;  the tubera
ischii are nearer to each other, and the coccyx less movable.
  From the  greater width  of the  female  pelvis, the acetabula are further
apart than in the  male, although the  thigh  bones approach  each other in
their descent, and the knees (in  the erect position) are nearly in contact,
giving a peculiarity to the movements of the female not observable in  the
other sex.
  32.  So far, we have considered the  skeleton pelvis only ;  but the subject
would be incomplete without a brief notice of the soft parts lining the pelvis,
and  covering it  externally.   The former modify the diameters of the pelvis,
and  the latter must be taken into account in forming a diagnosis in the living:
subject.                                               fo               °
  The iliac fossae are each occupied by the iliacus internus muscle,  internal
to which, and slightly overlapping the edge of the brim, is the psoas  muscle;
these pass over  the anterior part of the brim to their insertions.   Near the
inner margin of the psoas muscle we find the iliac  artery and vein, with the
crural nerves and lymphatics.  In  the cavity we find the obturator internus
and the pyramidalis muscles, with the hsemorrhoidal and sacral vessels,  and
the sacral nerves. The rectum passes down nearly in the  centre of the sacrum,
and the bladder lies behind and above the symphysis pubis.  These parts are
held in situ by cellular membrane,  superficial and  deep  fascia, etc.
  _ The lower outlet is nearly closed by soft parts, which are capable  of great
distension.   On either  side  of the  sacrum and coccyx are situated the sacro-
sciatic ligament, the coccygeus muscle, and layers of fascia and cellular sub-
stance ;  whilst the termination of the rectum, and the  perineum,  consisting
of transverse muscular fibres, fascia and cellular tissue,  close the outlet  pos-
terior to the orifice of the vagina.
   33.  The effect of these additions, in diminishing the internal measurements
of the pelvis, is not very great, except at the lower outlet.   The  transverse
diameter of the brim is diminished about half an  inch,  or rather  more when
the psose muscles are in action, and the conjugate  diameter about a quarter
of an inch.  The diameters of the cavity  are not lessened more than a
quarter of an inch.   The lower outlet may  be said to be almost closed in
the absence of any distending force, the orifice of the vagina being the only
vacancy ; but the elasticity of the perineum, etc., occasions the soft parts to
be little or no permanent diminution of the antero-posterior diameter.
   34.  To the crest of the ilium the abdominal muscles  are attached, and on
the outer surface of  the ossa innominata there  is  a large mass of muscles,
the glutaai, pyriformis, gemellus superior and inferior, obturator internus and
externus, and quadratus  femoris.   These  muscles are separated by fascia,
and are covered by a thick layer of adipose tissue, and  the skin.   The ante-
rior wall of the pelvis  gives  origin to a great number of muscles,  most of
which have been already enumerated.
   35.  The external measurements of the pelvis are of  considerable import-
ance in the diagnosis  of deformity, as  deviations externally appreciable will,
in most cases, though not in all, be found to accompany internal ones.  Un-
fortunately, the  data we possess  are  but  few ; however, the following, I
believe, are correct: —
   The external  antero-posterior diameter of the pelvis is from 7 to 8 inches.
   The  external transverse, between the crista  ilii of  each  side, 13 to 16
     inches.
  From the anterior superior spine of one  side to  the other, 10 to  12 inches.
  From the great trochanter of one side to the sacro-iliac synchondrosis of
     the other, 9 inches.
  The depth of the  pelvis, from the top of the  sacrum to the coccyx, from
     4 to 5 inches. 
48
OF  THE PELVIS.
  In order from these measurements to form a sufficiently-correct estimate
of the internal diameters of the pelvis, we must deduct from them the thick-
ness of the parietes;  i. e., about three inches nntero-posteriorly, and four
inches laterally, according to Baudelocque, Navas, and Yelpeau.   The depth
is easily  ascertained externally;  posteriorly,  by taking the  length  of the
sacrum; laterally, by measuring from the anterior superior spine of the ilium,
and dividing by two ;  and anteriorly, by taking the depth of  the symphysis
pubis.
  It is but fair to add, that doubts have been expressed of the  utility and
accuracy of these  measurements, by Mesdames Boivin  and Laehappelle, on
account of the varying thickness of the parietes  of the pelvis : but, even
allowing  for this,  they appear to  me of some value as an  approximative
estimate.
  36. In this  opinion I. am supported by M. Naegelo, who, in his  recent
work on Oblique Distortion, has pointed out certain external measurementa
as a means of  diagnosis, and has given  a careful estimate of forty-two cases.
His French translator, M. Danyau, has added to these eighty cases mea-
sured by himself, and the average result is as follows :
  1. From the tuber ischii of one side to  the posterior superior spinous
       process of the  opposite side, 6 inches, 6 lines.
  2. From the anterior superior spine of the ilium of one side to the poste-
       rior superior spine of the other side,  7 inches, 10 lines.
  3. From the spinous process of the  last  lumbar vertebra to the anterior
       superior spine of the ilium of either side, 6 inches, 7 or 8 lines.
  4. From the great  trochanter of one side to the posterior superior spine
       of the ilium of the opposite side, 8 inches, 2 lines.
  5. From the centre of the  inferior edge  of the  symphysis pubis  to the
       posterior superior  spine of the  ilium  of either  side, 6 inches, 3 or 4
       lines.1
  These measurements are those of ordinary-sized pelves ; they will of course
vary if the pelvis be unusually large or small; but the utmost variation in
No. 1 was 6 lines ; in No. 2 was 11  lines ; in No. 3 was 7 lines ; in No. 4
was 9  lines;  and in  No. 5 was 9 lines;  and these were almost all single
exceptions.
  37. The next point relates to the practical  application of  these facts, or,
in other words, to the best mode of ascertaining the size of the pelvis in the
living subject.  A certain amount of information may be obtained from the
general and equable contour of the pelvis, the breadth of the hips  as com-
pared with the shoulders, the degree  of  obliquity of the pelvis,  the curve of
the sacrum, etc.;  and in many cases  we may  pronounce, from a  cursory
glance, that the patient is well or ill made.   Should this not  be so appa-
rent, we must have recourse  to external  measurement, which is easily  effected
by means of a pair of curved calipers  and a foot measure.   Care'must be
taken to place the points of the instrument accurately,  as a slight deviation
may produce  different  and  incorrect  results.   The  measurements thus
obtained we can reduce to the internal diameters of the  pelvis by making the
deductions already mentioned, although without any pretensions to absolute
accuracy.
  38. There is greater difficulty in ascertaining the magnitude  of the pelvis
internally.   In Great  Britain we are  almost limited  to  the  information
afforded  by the "toucher;" and  undoubtedly, by this  means alone, a well-
educated finger may obtain a sufficiently-accurate estimate for practical pur-
poses.   When making an  examination  for this purpose, the finger should

  1  Des Principaux  Vices de Conformation du Bassin, par Naegele, translated by M.
Danyau. 
DEFORMITIES.
49
be passed  direct to the promontory of the sacrum, and thence carried for-
ward  slowly to the symphysis pubis :  we may then pass it across the pelvis,
in the direction of the transverse and oblique diameters, and finally follow
the course of the brim, taking  note of any deviation from  the usual  form,
or of any obstacle.  The  state of the sacrum and cavity  generally, and the
mobility of the  coccyx, can readily be ascertained by the finger, as well  as
the dimensions  of the lower  outlet.   Although  deficient in  precision, the
information thus obtained may satisfy us of the possibility of the passage of
the child ; and of course, if the patient be pregnant, and still better if she
be in  labor, there will be more  certainty, as we  shall then  have the child's
head  as a standard of comparison.
   39.  But, in order to arrive  at greater accuracy, certain instruments have
been invented, chiefly by continental obstetricians, for measuring the internal
as well as the external diameters of the pelvis.   Thus we have the "compas
d'f'jMisseur" of Baudelocque, the  "cephalometre" of Stein,  the "mecome-
tre" of  Chaussier, the  pelvimeters of De Creve, Aitken,  Coutouly, Bang,
Traisnel, etc., with various  modifications of modern invention ; but I do not
think it necessary to enter into any minute description of these instruments,
as they are seldom, if ever, used in  these countries.  The  natural delicacy
of the sex precludes their employment in  the cases in which  they would  be
of the greatest  value : I mean,  before marriage,  or conception.
                          CHAPTER  IV.

  ABNORMAL DEVIATIONS  IN  THE  P E L V I S.— D E F 0 RM IT I E S.

  40. Under this title I shall include  not  merely distortions of the pelvis,
but also certain equable  deviations from its normal dimensions, which are
of importance.  The  abnormal deviations of  the pelvis may be either general

                                 Fig. 11.
4
Equable Excess of Pelvis. 
50
DEFORMITIES.
or special.   The general  or eqimble deformity of the  pelvis involves the
whole  of the  true pelvis equally, and may consist either in an  excess or
diminution of its usual dimensions.
  41.  The former of these  (the pelvis crqnahiliter justo major of conti-
nental  writers) is not very unusual,  nor is it advantageous in parturition,
except perhaps in face  presentations, and it may be attended with inconve-
nience.   Giles de la  Tourette has recorded one where the antero-posterior
diameter was five inches and  a  half,  the  transverse  six and  a  half, both
diameters of  the  lower outlet  five  and a half, and the distance between the
crests of the  ilia  twelve and a half inches.   Dr. Burns mentions  his having
a very large  one, but not quite equal to the one just mentioned.   My friend
Dr. Murphy  possesses one  of about the same size.   The relative proportion
of the diameters sometimes  varies, so  that the  brim may assume an oval
shape  antero-posteriorly, or a heart shape,  and  still all  the  diameters be
excessive.
  42.  It is evident that a pelvis preternaturally large may be a disadvantage
to a female  who is  not pregnant,  as it will favor prolapse of  the  pelvic
viscera;  and also  to  one who  is  pregnant, by  more readily permitting
descents, displacements, etc.   Its inconvenience during  parturition consists

                                 Fig. 12.
Equable Diminution of Pelvis.
in the want of that degree of contact with  the head of the child necessary
to impress upon it the usual partial rotations and changes of direction ; and
the facility with which it would admit of prolapse of the womb afterwards.

                                 Fig. 13.
Distortion of Brim of Pelvis. 
DEFORMITIES.
51
  43. It is more rare to find a pelvis whose size is equally diminished (the
pelvis  cequabiliter justo  minor),  without  much  relative disproportion
between  its diameters, although Naegele and Velpeau  think it more com-
mon than writers in general  have supposed;  and in support of this opinion
it may be added, that modern investigations have discovered that in many,
if not  most cases of rickets, even where  there is no  apparent distortion of
the pelvis, there is a certain diminution (one fourth, I believe) in the aggre-
gate diameters.   The obstruction which this  deformity offers to delivery is
sufficiently obvious.
  44.  The special distortions of the pelvis are much more frequent.   They
occur at the brim, in the cavity, or at the lower outlet, but are rarely limited
Distortion of Brim of Pelvis.
to one  of these  situations.  The distortion may also occur in any of the
diameters, though the antero-posterior diameter of the brim, and the trans-
verse of the lower outlet, present them most frequently.
  45. At  the brim we find distortions more common in the antero-posterior
diameter,  as I have said;  next in the  oblique, and lastly in the transverse
diameter.

                                 Fig. 15.
Distortion of Brim of Pelvis. 
52
DEFORMITIES.
  The sacrum may be pushed forward  toward the symphysis, or the  sym-
physis toward the sacrum.
  If the sacrum be more slightly pressed forward, it will make the opening
a heart shape, and may change the  length of the oblique as well as the an-
tero-posterior diameters.
  In some cases the acetabula are  pushed inwards, as well as the sacrum
forwards, diminishing the oblique and  antero-posterior diameters,  and  com-
pletely distorting the brim.   This was  the case with  Isabel Redman, ope-
rated upon by Dr. Hull; and  similar examples are recorded by Weidmann,
Aitken, Mad.  Boivin, etc.
  In other cases, the oval of the brim is transposed, the long diameter being
antero-posterior instead of transverse;  as in the next figure.

                                Fig. 16.
Distortion of Brim of Pelvis.
  46. In the cavity, distortions are in most cases  consequent upon those of
the brim or outlet; though we occasionally meet with instances where  the

                                Fig. 17.
Distortion of Cavity of Pelvis. 
DEFORMITIES.
53
sacrum is too much or too little  curved, when the other parts  of the pelvis
are of normal form.   In some very rare cases the cavity contracts gradually
from the brim to the  outlet, forming what has been called a "funnel-shaped
pelvis."
   The capacity of the cavity may also be  diminished by a fibrous  or bony
growth from the sacrum, as in the annexed figures.   The first (Fig. 18) is

                                  Fig. 18.
Distortion of Cavity (Exostosis).
comparatively small, though sufficient to  interfere  seriously with labor;  the
second (Figs. 19, 20), which is an exostosis, would preclude the  possibility
of delivery "per vias naturales."

                                 Fig. 19.
Exostosis of Cavity of Pelvis.
  The third is a fibrous growth from the periosteum :  the  case  occurred in
the Dublin Lying-in Hospital, and has been described by Dr. Shekelton,1 to
1 Dublin Journal, vol. x. p. '1S7.  New Series. 
54
DEFORMITIES.
whom I am indebted for the cast from which this drawing has been taken.
These morbid growths from the periosteum or bone  involve the same diffi-
culty as distortions, inasmuch as they are incompressible and  immovable ;
but, unlike most  distortions, they increase slowly, so that the  longer they
continue, the greater the obstacle.
   47. The lower outlet is comparatively independent of the brim and cavity.

                                Fig. 20.
Exostosis of Cavity of Pelvis.
It is by no means  uncommon to experience delay, arising from a narrowing
of the brim, with a rapid passage of the  head through  the  outlet; but of
course, in extreme cases of distortion, the outlet participates, as is shown in

                                Fig. 21.
Exostosis of Cavity of Pelvis.
the figures annexed; fig.  22 being the lower outlet of fig. 15, and fig. 23 of
fig. 17.   On the other hand, distortions of the lower outlet  may occur with
a normal shape and size of the brim.   They are most frequent in the trans-
verse diameter, owing  to  the  approximation of the tubera ischii, which at
the same time will diminish the span of the arch of the pubis, and  so effectu- 
DEFORMITIES.                          55


     Fig. 22.
Distortion of Lower Outlet of Pelvis.
ally, though  not apparently,  shorten  the  antero-posterior diameter.   The
other way in which the latter diameter  is lessened, is by  too great a curve
forward of the lower part of the sacrum and coccyx, and by the anchylosis
of the coccygeal joint.   There is a case related  by Dr.  Summer, in  the
American Journal of Medicine, in which the projection of the coccyx,  the
joint being anchylosed, was so great as to cause the death of three infants
successively.   The fourth time Dr. S. endeavored to straighten it, but being
unable, he  broke it, and the child was born alive. The same proceeding was
necessary in  two subsequent  labors.  The spinous process of the  ischium
may offer some obstruction, if it be unusually long, and curved inwards.

                                 Fig. 23.
Distortion of Lower Outlet of Pelvis.
  48. The amount of these distortions varies as much  as  possible : it may
be so slight as merely to retard delivery;  or it may be so great as to pre-
clude it altogether, as in Mr. Bell's case, where the antero-posterior diameter
was about half an inch, or in that recorded by  M.  Naegele, in which it was
even less.
  49. In most cases of pelvic deformity the distortion is somewhat unequal,
one side suflering more  than the other; but there is a class of cases in which 
5 6                          D E F O R M1T I F S.

this distortion is almost entirely confined to  one side.  An allusion to such
will be found in  several authors ;  but it remained for M. Naegele to add to
his high reputation by a careful and accurate description of this oblique dis-
tortion (" das shriig verengte becken," or "pelvis oblique orata").   In
these  cases (fig. 24), the affected side is flattened, and the sacro-iliac  syn-
OWique Distortion of Pelvis.
chondrosis  anchylosed.   Half  the  sacrum is  imperfectly developed ;  and
the other, though at first sight it appears well  formed, is found to be awry :
the promontory of the sacrum and the symphysis pubis are not (as they ought
to be) opposite to  each other, but the former leans to the affected side, and
the latter is pushed over (as it were) to the sounder side, so as to make the
form of the pelvis  oblique.
   50. As we should expect, the planes and axes are altered more or less in
all well-marked cases of distortion.   When the promontory of the sacrum
projects, the axis of the upper outlet is more horizontal; but if the aceta-
bula are pressed inwards, it may become more perpendicular.  The axis  of
the lower outlet may be changed in  the opposite, but more frequently in the
same direction, the two becoming almost parallel: nay, there is a case quoted
by Velpeau, in which they  were reversed : that of the lower outlet look-
ing forward, whilst that of the brim was directed backward.  In the majority
of cases, I believe we may  say that the planes and axes of both outlets
approximate to the plane of  the horizon.
   51. The principal causes of distortion are, 1, rickets in infancy and child-
hood;  and, 2, malacosteon, or molleties ossium, in  adults.   The  effect  of
both diseases  is to deprive  the bony structure of the  earthy matter which
gives it firmness;  in the  absence of which, the bones  become flexible, and
are influenced by muscular motion,  or long-continued pressure.   Thus, if in
such circumstances the patient maintain the sitting  posture  long, the pro-
montory of the sacrum may be pushed forwards, or the symphysis upwards;
the lower part of the sacrum may be too  much curved, and the  os coccygis
rendered horizontal.  If the upright position be continued  long, the aceta-
bula may be pressed inwards, and the promontory of the sacrum forwards.
If the  patient lie much on  her back, the sacrum may be flattened ;  or, if  on
one side, it may be rendered unequal.
   Besides  these special deformities, it has already been mentioned, that, in 
DEFORMITIES.
57
patients  affected with rickets, the aggregate of the diameters  of the pelvis
is lessened one-fourth,  even when the pelvis is apparently unaffected.
  52. Any of these special distortions may occur in the same way in adults
affected with malacosteon, and at any period of their life ;  so that it has  hap-
pened that a female, who had borne children naturally, has at a subsequent
labor exhibited such an extent of  pelvic distortion as required the use of
instruments,  or the Caesarean operation.
  Both diseases appear to be more frequent in manufacturing towns than in
country districts.
  53.  It  is  extremely difficult  to  assign the  cause  of oblique distortion.
Naegele states that he could detect no traces of rickets or mollities  ossium
in any of his cases, nor had any suffered from external violence.  The bones
presented  the  same appearance as  those of healthy young females.   He
believes that it neither  arises  from  external causes, nor from  internal dis-
ease ; but from an original anomaly of development.1   Dr. Rigby, however,
thinks that ulcerative  absorption must have existed at the sacro-iliac junc-
tion,  probably in early life.
   54. I have already mentioned as a cause of deformity, 3, exostosis;  and
may further add, 4, fractures of the pelvis, and 5, inflammation  of the sacro-
coccygeal joint, terminating in anchylosis, to which I  have already referred,
but upon which it is unnecessary that I  should dwell.
   55. The diagnosis  of distortion is easy in proportion to its  amount.  If
the pelvis be much deformed, it may be  detected by an external or internal
examination, and estimated with sufficient accuracy for practical purposes.
But if it be only slightly affected, it will not be so easy to decide upon the
possibility of the passage of the child, unless we have the head of the child,
to  compare with the pelvis.   Without this, we must  chiefly depend upon a
comparison of the external measurements with those of a well-formed pelvis,
and upon  the information  obtained by a careful internal examination.  From
these sources, an experienced practitioner will probably obtain data  for a
satisfactory  though cautious diagnosis.   But if we are not consulted until
the patient be in labor, our task will be comparatively easy, because the head
 will be in apposition with the part (brim, cavity, or outlet) where we suspect
the narrowing to exist.
   Dr. Simpson's  plan is to place  the patient under the influence of chloro-
form, and then introduce the entire hand into the pelvis; the breadth of the
knuckles,  when the hand is closed, affords a definite object of comparison
with the antero-posterior diameter of the brim.
   A very slight degree  of narrowing of the transverse diameter of the lower
outlet may be  detected,  by its rendering the arch of the pubis more acute,
 and,  consequently, preventing the  head  of the child pressing close up under
it.   Whenever we find the head fitting tightly between the tubera ischii, and
yet a space under the arch of the pubis free, we may be  certain that the
tubera ischii are closer together than natural.
   56. Oblique  distortion  may be detected in two ways, according to M.
 Naegele : 1, by dropping a line perpendicularly  from the  spinous process
 of  the last lumbar vertebra, and another from the symphysis  pubis;  when
 the pelvis  is well  formed, these two lines are exactly one behind the other:
 but when  it is obliquely distorted,  they  are parallel, with a  considerable in-
terval :  2, by measuring the pelvis externally in  the way already described
 (§  35, 36), we find that there  is  always a  difference between the two  sides
 of  the pelvis, varying from  one to two  inches.   To  give an example, in a
pelvis affected with oblique distortion of the left side, the measurement No.
 1 (§  36), was :

  1 The reader will find  an excellent translation of Naegele's valuable memoir, by Dr.
Christie, of Aberdeen, in theliritish Record of Obstetric Medicine. 
58
DEFORMITIES.
               6 in. 11 lines on the left side, and 5 in. 8 lines on the right,
      No. 2,   7  "  9   "     "      "         6 " 10  "
      No. 3,   6  "  6   "     "      "         5 "  3  "
      No. 4,   9  "  0   "     "      "         8 "  0  "
      No. 5,   6  " 11   "     "      "         6 "  1  "
  Let the reader  compare these with the measurements of a well-formed
pelvis, as  already given, and he will be convinced that either method, or the
two combined, will afford fair grounds for a diagnosis.
  Anchylosis of the sacro-coccygeal joint will be discovered by its immobility
when pressed by the finger during an external examination.
  The effect of the different kinds and degrees of deformity upon the mechan-
ism of parturition,  and the practical considerations upon which the manage-
ment of such cases must be founded, will be discussed in the Third Part of
this work.
  [In a great  majority  of the  cases  of reduced  or distorted  pelves, the
degree of  deviation from the natural  standard, although perhaps sufficient
to cause great difficulty in delivery, is nevertheless too  small to be  readily
detected by the external measurements  pointed  out by the author.  The
calliper, or " Le compas d'epaisseur de  Baudelocque" (fig. 25), so much

                                 Fig. 25.
                    Calliper for measuring Pelvis (Baudelocque's).

relied on  by some,  is only calculated  for measuring  the  antero-posterior
diameter, and its indications  are not always to be depended on here.   In
experienced hands, it will afford important but  not conclusive testimony as
to the probable distance between the promontory of the  sacrum  and the
symphysis pubis.  The manner of accomplishing this is to place the patient
on her side on the bed, and then, separating the thighs, the extremity of one
branch of the instrument is  applied to the first spinous process of the sacrum
behind, and  the opposite extremity upon the  middle of the symphysis in
front: the intervening space is shown by the scale (d), and ought to be full
seven inches.  By deducting half an inch for the thickness of the pubis, and
two and a  half inches for the  sacrum, four inches  remains  as the probable
antero-posterior diameter of the upper strait,  or  brim.  The  oblique  dia-
meters are also measured by the same instrument.   Placing one of its ends
upon  the external surface of the great trochanter,  and  the other on  the  pro-
jecting portion of the opposite sacro-iliac junction, in  a well-formed pelvis,
we should have about nine  inches of separation.   Allowing  two and three
quarter inches for the trochanter, neck of the  femur,  and  acetabulum, and
one inch and  three quarters for the posterior symphysis, leaves four inches
and  three  quarters as  the  oblique diameter.  But this measurement, for
obvious reasons, is less to be relied  on than the  first;  in fact, two occasions
of error exist, more  or less,  in  both ; viz.,  1, In  fixing the extremities of the
instrument exactly on the right points ; and, 2, the variations that occur in
different  individuals, in the thickness of  the bony walls of the pelvis, and 
DEFORMITIES.
59
e-pecially of the  soft parts covering  them.  In  ordinary or well-formed
pelves these difficulties are not great, it is true ; but when much malformation
exists, thev are  sufficient to destroy  all confidence in the accuracy of the
results.   In figure 23, page 55, for  instance, the  instrument, properly ad-
justed,  would indicate a full-sized  antero-posterior diameter, although in
reality the space which is available for the passage of the child is extremely
small.
   A  careful examination with the hand, applied along the lnmbar column,
the sacrum, and coccyx, and over the arch of the pubis, observing the angle
formed by these parts, one with another,  and, in short,  their general form
and proportions, will convey to one well acquainted with their normal state
a more satisfactory opinion than any instrument that has yet been invented.
   But  there may be exostoses or other tumors within the pelvis, very seri-
ously affecting the space, and totally undiscoverable by external examination,
so that, for all  certainty, internal investigation  alone  can assure  us  of the
true  condition of the parts.   The pelvimeters  of Coutouly, Mad. Boivin,
and others, for internal admeasurement, have been found painful, inconvenient,
and uncertain, and are now, at least in this  country, entirely discarded; the
only instrument here employed for such explorations is the finger ;—as justly
observed by  a  late continental writer, " It is  the  best and surest of all
pelvimeters."
   The manner  of making this  examination is  thus  described by Chailly:
"To appreciate the extent of the  antero-posterior diameter of the superior
strait, the index finger  should  be passed in the  vagina in  the axis of the
inferior strait, towards the  sacro-vertebral angle, the radial side of the finger
being applied immediately under the pubis.  If the end of the finger does
not touch  the sacro-vertebral angle, it is because the diameter is of normal
dimensions ; or, if  it is contracted, that the  degree of contraction  is  so
small that parturition  will not be materially affected  by it.  But, if the
finger readily touches the sacro-vertebral angle, there  is reason to apprehend
more or less difficulty.  To  measure, in this case, the extent of the sacro-pubic
diameter, it is  necessary to mark, with the nail of the  index finger of the
other hand, the finger  introduced, directly below the pubis, the  labiae and
nymphae being carefully separated for the purpose;  on withdrawing the
finger, the  length of the part  introduced may  be readily measured  with  a
graduated  scale.
                Fig. 26.                              Fig. 27.
     Measurement of Pelvis by the Fingers.           Measurement of Pelvis by the Fingers.

  " Some little  allowance is to be made  for the length of the  oblique  line
represented  by the finger, which,  instead of passing directly to the centre
of the pubis, falls under it.
  " With the finger  we can easily discover  whether the concavity of the
sacrum  is  augmented or  diminished,  which will  enable us to  determine
whether the antero-posterior diameter of  the excavation is deranged.
  " The antero-posterior  diameter of the inferior strait may be ascertained
 
60
EXTERNAL  ORGANS OF  GENERATION.
in  the same manner as the corresponding diameter of the upper strait :  the
end of the forefinger being placed on the extremity of the coccyx, the hand
must be raised until the radial edge of the finger touches beneath the pubis ;
being marked at this point, it can be measured as before described.
   " The finger thus introduced enables us at the  same time to judge of the
flexibility or otherwise of the sacro-coceygeal joint.ri  There is indeed very
little difficulty in  ascertaining accurately the diameters of the inferior strait
with the  fingers externally applied.
   During the labor, the internal examination of the pelvis is greatly facili-
tated by the relaxed condition of the internal parts ; and, if necessary, the
hand may be introduced for the purpose.]
                         CHAPTER  Y.

        OF THE EXTERNAL ORGANS OF GENERATION.

  57. We may now proceed to describe the generative organs in the female.
These are ordinarily divided into the external and internal, or, with regard
to their functions, into the copulative and formative.   The external or copu-
lative, consist of the mons veneris, the labia majora, and minora, the clitoris,
the hymen, and the vagina.   The internal or formative, consist of the ovaries,
the fallopian tubes and uterus.   Most English writers place the vagina
among the internal  organs ;  but, as it  belongs to  the  copulative, I have
classed it with them ;  the point is of little  importance.   There is  a striking
analogy between the male and female organs, except as to situation ;  and at
an early period of foetal life, the sex cannot be distinguished.  In the pre-
sent chaDter we shall notice the  external organs.

                                Fig. 28.
                         External Organs of Generation.

  58. The Mons Veneris is the triangular, cushion-like  prominence at the
lower part of the abdomen and upper part of the symphysis pubis.   It con-
sists of a  thick layer of adipose  tissue  underneath the skin, upon  which at

               1 [L'Art des Accoucheniens, par Chailly, 175-189.] 
EXTERNAL  ORGANS  OF  GENERATION.
61
puberty, a quantity of hair makes its appearance.  I have remarked a pecu-
liarity in women with regard to this growth of hair.   It is strictly confined
to the labia and mons veneris, and scarcely ever extends to the thighs in the
neighborhood of the vulva.   In the cellular tissue, is lost the round liga-
ment, and there is sometimes  a  small  pouch  of peritoneum.   The skin is
plentifully supplied with sebaceous glands.
   The ?/..se of this cushion is*e* very evident.
   59. Abnormal deviations.—Occasionally the growth of hair is excessive.
In one case Dr. Davis found it necessary to  destroy  it  on account  of the
itching it caused.  On the other hand, in some  cases it is nearly absent with-
out apparent inconvenience.   This part is also the seat  of cutaneous erup-
tions and abscess.1
   60. The Labia Majora, vel Externa, are  two  folds of skin  externally,
and  mucous membrane internally, continued downwards from the sides of the
mons veneris  to  the fourchette.   Their junction  superiorly constitutes the
anterior commissure of the vulva, and  they enclose  the external organs of
generation.  Their breadth and thickness are  greatest superiorly, gradually
decreasing until they disappear near the fourchette.   Superiorly they are in
contact, but they are  separated posteriorly.   The  external  labia, contain,
between the skin and mucous  membrane, subcutaneous fascia, adipose and
cellular tissue, nerves and blood-vessels, and glands.  M. Huguier,  in a very
elaborate memoire, has described these glands, which  he divides into  three
varieties — " follicules sebaces, piliferes, et organes  mucipares."  The  most
important are, however, those he has termed the vulvo-vaginal glands, which
are situated  one on each side of  the vaginal orifice, and a little behind it,
opening by ducts about half an inch long near the hymen  at the base of the
carunculae.   They are about the size of a small almond,  and  secrete mucus
profusely at certain times.  They are thought to be the analogues of  Cowper's
glands in the  male.2  Externally, the labia are thinly covered  with  hair, and
thickly studded with sebaceous follicles.
   Their use is to protect the sensitive  organs contained between them, and
at the time of labor to facilitate the distension of the external orifice.
   61. Abnormal deviations.—These are chiefly, 1, excessive growth, attended
with mechanical inconveniences ; 2, inflammation and  abscess ; 3, cutaneous
eruptions,  pruritus, etc. ;  and 4, encysted tumors,  hernia, etc.
   62.  The  Labia Minora, or NyMphje, are two  lateral folds of mucous
membrane,  internal to  the labia majora, with which they  are in contact ex-
ternally, and by which they are generally covered in the  adult. They extend
from the anterior superior portion  of the vulva to about  the  middle of the
orifice of the  vagina, and contain between their mucous coats a spongy vas-
cular tissue and nerves.   They enfold the clitoris, the meatus urinarius, and
cover part of the vaginal orifice.  In young persons they are firm and elastic,
but  in old age they become flabby  and loose.
   They doubtless contribute, with the labia majora, to maintain the integrity
and  sensibility of the parts they cover.
   63.  Abnormal deviations.—The nymphse  are obnoxious to inflammation,
follicular ulceration, and hypertrophy, either congenital or the  result of
disease.
   64.  The  Clitoris is the  analogue of the penis in  the male.   It consists
of two  corpora cavernosa, which arise from the rami of the ischia and pubis,
and  unite on the symphysis pubis.   It  possesses two  muscles analogous to

   1 It would be inconsistent with the object of a work like the present to enter  into details
upon the various diseases to which the parts are subject; I must  therefore content my-
self with enumerating them, and  refer the reader to my work on Diseases of Women.
   2 M6m. de l'Acad.  Med. de Paris, vol.  xv. p. 528. 
62
EXTERNAL ORGANS  OF  GENERATION.
the erectores  penis, and terminates in  a gland  covered by a prepuce, but
which is imperforate.  The clitoris projects about the eighth of an inch, and
is  situated just below the  point  of junction of the nymphoe.   It is richly
endowed with nerves, extremely sensitive, capable of erection, and is  said to
be the seat of  sexual gratification.  In  the foetus  it is disproportionately
large, but it does not increase afterwards in proportion  to  the surrounding
parts.
   65. Abnormal  deviations.—The clitoris  may vary in  size from congenital
malformation or disease; but the researches of M.  Parent-Duchatelet1  have
disproved the opinion that it enlarges from frequent sexual indulgence ; and,
according to the  same  high authority, its  excessive development does not
entail extreme sexual desire.
   This  organ may be  attacked  by inflammation, or by malignant disease.
Bartholinus relates the case of a courtezan whose clitoris  was the seat of
calcareous deposition
   66. Below the  clitoris there is a smooth  triangular space,—the Vestibu-
LUM,—at  the lower part of which we find the Orifice of the Urethra, or
the Meatus Urinarius, just at the upper edge of the orifice of the vagina.
The exact situation of this opening is important, because we are frequently
called upon to introduce the catheter, and in ordinary cases it should be  done
without exposure.  The operation is not difficult:  the  patient being placed
on her back, and  the labia  being separated, the point  of the forefinger of
the left hand should be placed just within the orifice of  the vagina, so as to
press  slightly its upper edge :  the catheter should then  be passed along the
inner  surface of the finger, until it reaches the vestibulum, near the edge of
the vaginal opening;  when there, a very slight  movement will cause  it to
enter  the  meatus  urinarius.  Or the patient may be placed on her left  side,
in  the ordinary position for labor, and  the finger carried from behind for-
ward  to the vestibulum ; the catheter should then be passed  along the finger
in  the direction of the axis of the outlet, and on reaching the vestibulum, a
slight movement will detect the orifice.   The operation is more difficult when
the parts  are swollen  or distorted, as  happens occasionally from disease.
during pregnancy or labor, and after delivery; and if we cannot detect the
orifice by  the touch, we  must  of course use a  light; and then, for obvious
reasons, it is better that the patient should be  placed on her side.
   The orifice is round, though its sides are usually in contact^ and its edges
are somewhat thickened.
   67. The Urethra is a membranous canal about an inch  or an inch and a
half in length, dilatable, and directed obliquely from before backwards, and
from below upwards, running under and  behind  the svmphysis pubis,  from
which it is separated by loose  cellular tissue.  Internally it opens into the
bladder.   Its  direction is subject  to  variation.   During pregnancy, the
bladder being carried upwards with the uterus, the urethra  curves under the
pubic arch,  and  then ascends perpendicularly.  The  same change  occurs
when  the  uterus is enlarged from other causes.  In prolapse of the pelvic
viscera its course  is reversed.   These changes should be  borne in mind when
catheterism is required.
   68.  Immediately below the  orifice of the urethra we find a much  larger
opening, of about an inch in diameter,—the Orifice of the Yagina   Its
sides are in contact ordinarily, but it is capable of enormous distension   and
of  again returning to its natural size.  The opening is closed inferiorly in
infants,  by a fold  of mucous membrane of a crescentic  shape, the concavity
looking upwards,  and which is called the Hymen.   This membrane is easily
destroyed, or it may become so relaxed as  scarcely to be perceptible  which
1 De la Prostitution de la Ville de Paris.  1836. 
                EXTERNAL ORGANS  OF GENERATION.             63

will account for its rarity in adults.  It was formerly held to be peculiar to
the human female, but the  researches of MM. Duvernoy, Cuvier, and Steller
have proved  its existence  in many animals.   From  very early times it has
been made the test of virginity,  its absence being considered  conclusive
proof of sexual intercourse having taken place ; nnd the fate of the wives
of Henry VIII. is an extreme instance of the injustice to which this opinion
led.  Modern investigations have proved, not  only that it may be destroyed
by many causes unconnected with sexual indulgence,  but that intercourse
may take place, followed by pregnancy, without its destruction, as  in three
cases which occurred in my own practice.
  It is therefore of no value as a  test of virginity.
  69. Abnormal deviations. — The principal  ones  are the following: 1, it
may be unusually thick and strong, so as to preclude intromission ; 2. instead
of the single opening superiorly, it maybe pierced with several small holes;
3, instead  of the usual form, the  hymen may consist of a single or double
bridle stretching across the orifice of the vagina;  or, 4, it may be imperfo-
rate, and close the vagina completely.   Examples of each kind are recorded
in the different works on midwifery, and in the periodicals.  These abnormal
deviations  are of importance only as they may prevent sexual connexion, or
impede  the natural discharges or delivery;  and once  discovered, they are
easily removed.
  70. The Carunculje Myrtiformes are four or five small tubercles, which
in most females occupy the situation of the hymen,  of  which they are con-
sidered  the remains by most anatomists: others, however, suppose them to
be small duplicatures of the mucous membrane of the vagina.   They may
possibly facilitate the distension of the orifice of the vagina by unfolding.
  Abnormal deviations.—Occasionally they are greatly hypertrophied.
   71. The parts contained within the  vulva  are abundantly supplied with
nerves,  owing to which, and to the extreme delicacy of their texture, they
possess  exquisite sensibility.   This explains the  very severe pain  which
accompanies even trifling diseases of these parts ;  and it is merely a repeti-
tion of the fact observed in other mucous membranes, viz., that they acquire
their highest degree of sensibility  near their junction with the skin.
   72. The Fourchette is the inner edge of the posterior commissure of the
vulva, and the anterior border of the perineum, between which is  a space
called  the fossa navicularis ; it is formed by the union posteriorly of the
labia.   It  consists  of a fold  of mucous  membrane, meeting  externally the
skin of  the perineum, and is  frequently, perhaps generally,  torn slightly in
first labors.
  73. The Perineum is the name given to the space between the posterior
commissure and  the  anus.   It is  of a  somewhat triangular shape, and its
medium length, in women who have not borne children,  is from one to  two
inches.   It is  shorter, of course,  in those who have had children.   In the
centre a prominent line may be observed, running antero-posteriorly,  called
the  "raphe."  The  perineum is  composed of  various  tissues;  externally
there is  the  skin, then adipose and cellular tissue, fascia, a  portion of the
constrictor vaginae, levator  ani, transverse and  sphincter muscles; besides
which, it contains the superficial and transverse arteries, veins, nerves, and
lymphatics.  Very  few hairs grow on this part.
  The use of the perineum is obvious:  it closes  the lower outlet posteriorly,
so as to  prevent the prolapse of the pelvic viscera;  whilst it admits of dis-
tension  when necessary, and  by  its elasticity, speedily  resumes  its former
condition.
  74. Abnormal deviations. — The perineum is sometimes unusually long,
increasing the risk of its laceration during labor;  or it may be very short,
and so afford inadequate support  to the  superimposed viscera.   It may be 
 64             EXTERNAL  ORGANS  OF  GENERATION.

 torn in various ways  during labor, as we shall see hereafter, and  either not
 unite or present the  cicatrices of former lacerations.   It  is sometimes the
 seat of hernia, according to Smellie. Mery, and Curade.
   75.  The Vagina is a musculo-membranous canal, extending1 from its orifice
 in the vulva (§ 68) obliquely through the cavity  of the pelvis to the uterus.
 It posses upwards from the vulva behind and below the urethra and bladder,
 between the ureters, and  anterior to the  rectum, describing nearly the  line
 of the canal of the pelvis  (§30).   Its form is cylindrical, somewhat flattened
 superiorly, but. when quiescent, its parietes are in  contact.  Its dimensions
 vary according to nge,  and other  circumstances ;  for instance, it is propor-
 tionately longer in the foetus than in the child.   In  some individuals  it is
 very long, in others very short.   Dr.  Dewees mentions a case where it was
 only an inch and a half long, and I have met with others nearly as short.
 It is also longer and  narrower in virgins than in those who  hove borne
 children.   Ordinarily it is about six inches in length, by one in  width.
   The proper tissue of the vagina is dense, and  of a grey pearly color, re-
 sembling in some degree fibrous tissue, and about a line and a half in thick-
 ness anteriorly, though less near the womb.   It is well supplied with  vessels,
 which  are multiplied and interlaced so much towards  its anterior  extremity
 as to  constitute a kind of erectile tissue, which  has  received the name of
 plexus retiformis-  Internallv, the vagina is lined by  mucous membrane of
,a pink color, continued from the vulva, and which near the orifice, and there
 only, possesses great  sensibility, except when it  is the seat of inflamma-
 tion, and then the whole canal is very tender.   The mucous coat is disposed
 in the form of transverse rugae, anteriorly and posteriorly,  which, by unfold-
 ing,  permit the distension of the vagina.
   From the "cut de sar," at the inner extremity  of the vagina,  the mucous
 membrane is reflected  down upon the projecting  cervix uteri, and exhibits
 peculiarities of which I shall  speak presently.   In addition  to its  proper
 tissue and mucous coat, the vagina has some muscular fibres surrounding its
 orifice,  which have received the name of constrictor vagina?, and  which serve
 to contract the orifice, and to draw  down the clitoris. The vagina, in com* ion
 with the vulva, is abundantly supplied with blood-vessels  from the intei lal
 iliac arteries, and wiih nervous filaments from the pudic nerves.   The  lym-
 phatics, which are very numerous,  are derived from the hypogastric  plexus.
 The use  of the vagina is twofold; first,  for copulation, and, secondly, for
 the transmission of the foetus;  and, to facilitate the latter  process, the inn?r
 membrane, which in its ordinary state secretes just enough mucus to lubri-
 cate its surface, during labor, secretes it most profusely.
   It has been established by the observations  of Whitehead, Tyler Smith,
 and others, that the vaginal mucus is acid, thus differing  from  that  of the
 uterus,  which is alkaline.
   76.  Abnormal deviations.—The vagina varies  much in length, as  already
 stated: its width differs equally in different subjects;   it may be so  narrow
 as to render intercourse difficult and painful; its  exit  may be closed by the
 hymen, or by a membrane higher up ; its sides may be adherent, or the* seat
 of cicatrices or callosities;  or it may be altogether wanting.
   Of course, occlusion  or absence oif this canal will prevent the  escape of
 the menses, and render copulation  impossible, constituting  one cause of  ste-
 rility;  but, though a partial closure  may impede intromission,  it does  not
 render impregnation impossible.  I may add, that the narrowness or width
 of the canal is no proof of virginity, or the contrary;  for M. Parent-Ducha-
 telet states, that in many of the younger prostitutes of  Paris it was wide and
 dilated ; whilst in others,  who  had followed  their degrading  pursuits  for
 twenty  years, it might have been  mistaken for the vagina of virgins.    Dr.
 Montgomery has pointed  out, what most practitioners must have  observed,
 how very quickly,  after delivery, the vagina recovers its usual size  and lone. 
EXTERNAL  ORGANS  OF  GENERATION.
65
   The vagina is also very obnoxious to  attacks of acute and chronic inflam-
mation, and  their consequences;  to lesions of nutrition, and to specific  and
malignant diseases.
   [The annexed two cuts will assist in presenting to the mind of the student
a clear idea  of the anatomy of the  external organs  of generation.]
  Front view of the erectile structures of the external organs of generation in the female. — a. Bulbus
vestibuli.  6. Sphincter vagina? muscle,  e, e. Venous plexus, or pars intermedia.  /. Glands of the cli-
toris,  g. Connecting veins,  h. Dorsal vein of the clitoris,  k. Veins going beneath pubes.  1. The obtu-
rator vein.
                                      [Fig. 30.]
  A view of the muscles of the perineum in the female. — 1. Tuber ischii. . 2. Sphincter vaginas muscle.
3. its origin from the base of the clitoris.   4. Vaginal ring of the same muscle, which receives a part
of the fibres of the levator ani.  5. Intercrossing of the sphincter ani and sphincter vaginas muscles at
the perineal centre.  6. Erector clitoridis muscle. V. The clitoris covered by its prepuce.  8. Transversus
perincj muscle of the female.  9. Sphincter ani. 10.  Levator ani.  11. The gracilis.  12. Adductor mag-
nus.  13.  Posterior part of the gluteus magnus.
      5 
66
INTERNAL ORGANS  OF  GENERATION.
                         C HA PTER  VI.

         OF THE INTERNAL ORGANS  OF  GENERATION.

  77. According to the arrangement I have proposed, our  next subject  is
the formative, or internal organs of  generation.  But before we proceed  to
take them in detail, it will not be unprofitable to direct the attention  of the
student to the relative situation of the pelvic viscera, as shown  in the next
engraving.
                                 Fig. 81.
Section of Pelvis.
  Proceeding from before, backwards, we  find the urethra running in an
oblique direction, antero-posteriorly, and from below, upwards,  under the
arch of the pubis, and then merging in the  bladder, which, when distended,
rises about half its height above the symphysis pubis.  Below the urethra,
but with an interval between them, is the vagina,  running  its oblique course
to the  os uteri, which is a little above the level of the pubes.  The position
of the  uterus is  not vertical, but inclining  a little forward, with  its fundus
above the level of the bladder.  The peritoneum is reflected from the abdo-
minal parietes, on the fundus and posterior  wall of the bladder down  to the
commencement of the cervix uteri;  from whence it passes  over the anterior
surface, fundus, and posterior surface of the uterus, and on to the posterior
wall of the vagina, down to  about an inch below the  level of the os uteri,
from whence  it is reflected upon the rectum.  The latter organ lies between
the uterus and the sacrum, and a little to the left side of  the  uterus.   I do
not of  course mean that this exact position  of the  parts never varies, but
the sketch I have given is sufficiently accurate  for practical purposes ;  and
it is very important for the practitioner to be acquainted  with the position
and elevation of the pelvic viscera.
  We  may now pass on to the description of the uterus, fallopian tubes and
ovaries.1
  1  I beg to refer the reader for more minute details than I have space for, to Dr. Farre's
able article in Dr. Todd's Cyclopaedia of Anatomy and Physiology, Parts  49, 50. 
INTERNAL ORGANS OF GENERATION.
67
  78.  The Uterus is the receptacle provided for the nutrition, maturation,
and, ultimately, for  the  expulsion  of  the  foetus.  It is the largest of the
generative  organs, and is peculiar to the human female, though there is  an
approach to  such an organ  in the mammalia.   It is a hollow symmetrical
viscus, in shape somewhat triangular  or pyramidal, resembling  a flattened
pear, but rounder posteriorly than anteriorly ; situated, as we have just seen,
in the  centre of the  pelvis, behind the bladder, above the vagina, below the
small intestines, and  in front of the rectum.   For the convenience of descrip-
tion, anatomists ordinarily divide it into the fundus, or that part above a
line drawn  from the orifice of one  fallopian tube to the other;  the cervix,
or the narrow and inferior part; and the body, or that  part between the
fundus and cervix.  Dewees maintains that the cervix  differs essentially, in
structure and function, from the rest  of the uterus.   The  microscopic re-
searches of Dr. Tyler Smith have shown certain peculiarities of arrangement,
and differences of structure, in  its internal and external mucous membrane;
its  general structure is more dense, less vascular, and  the menses are not
excreted by this part.   In the  unimpregnated  state it projects  into  the
vagina about half or three-quarters  of an inch, the anterior lip being the
lower.
  79.  The uterus gradually assumes  its  normal form' during foetal  and
infantile life.   Dr. Rigby remarks, that it is at first divided into two cornua,
and usually continues so until the end  of the third month,  or even later; the
younger  the  embryo, the  longer are  the cornua, and  the  more acute the
angle which they form ; but even after this angle has disappeared, the cornua
continue for some time  longer.  The uterus  is  at first of an equal width
throughout;  it is perfectly smooth, and not distinguished from the vagina,
either  internally or  externally, by any prominence whatever.  This  change
is first observed when the cornua  disappear, and leave the uterus with a
Uterus, Tubes, and Ovaries.
simple cavity.   The upper portion is proportionally smaller,  the  younger
the embryo is.  The body of the uterus gradually increases,  until, at the
period of puberty, it is no longer cylindrical, but pyriform.   Even in the
full-grown  foetus the length of the body is  not more than a fourth part of
the whole uterus ;  from the seventh to the fourteenth year it is only a third ;
nor does it reach half until puberty has been fully attained.  The os tincse,
or os uteri externum,  first appears as scarcely a  perceptible  prominence,
projecting  into the vagina.   The  parietes ofthe uterus are thin in propor-
tion to the age of the embryo.   They are of equal thickness throughout, at
first;  at the fifth  month, the  cervix becomes  thicker than the upper parts; 
68
INTERNAL  ORGANS  OF GENERATION.
between five and six years of age, the uterine parietes are nearly of an equal
thickness, and remain so until the period of puberty, when the body becomes
somewhat thicker than the cervix.1
  SO. The adult healthy uterus  may vary a little in size, but the following
measurements, given by Dr. Burns,2 are sufficiently accurate.   " The length
of the uterus, from the margin  of the  lip to the fundus, is two inches  and
three-quarters ;  breadth between the insertion of the fallopian tubes, from
two  inches and  three-eighths to two inches and five-eighths ;  the middle of
the fundus rises  a quarter of an  inch  above a line drawn from the insertion
of one tube to that of the other;  the commencement of the body is an inch
and a quarter broad,  its thickness is an inch ;  the whole of the wall is half
an inch, but at the fundus it is seven-eighths, or  one-eighth of an inch less.
The  thickness of that part of the cervix which projects into  the vagina,
including  the coat of that canal which is reflected  over it, is an inch and one-
eighth ; its breadth an inch and  a quarter.  The  breadth of the termination
or lips of the os uteri, an  inch  and  one-eighth ; thickness, including both
lips,  three-quarters  of an inch.   The length of the  transverse chink, or os
uteri, from three-eighths to half an inch ;  each lip is three-eights of an inch
thick, though the posterior is said to be the thinnest."   "From the margin
of the lip to the top of the  cervix is  an inch,  but sometimes only  three-
quarters, or even less.   From the top of the triangular cavity of the fundus
to the end of the narrow cylindrical cavity of  the body is an inch  and one-
eighth ; the extreme  breadth of the  top of the  cavity stretching from  the
entrance  of one  tube to that of the other  is nearly an inch and a half."

                                 Fig. 33.
Cavity of the Uterus.
  According to the calculations of Levret, its superficies may be  reckoned
at sixteen  inches, and its  cavity at eleven-twelfths, or about three-quarters
of a cubic inch.
1 Library of Practical Medicine, vol. vi. — Midwifery; p.
2 Principles of Midwifery, p. 50.
16. 
INTERNAL ORGANS  OF  GENERATION.
69
  The weight of  a  virgin uterus,  according to  Meckel, is from seven to
eight drachms ;  but  after child-bearing it amounts to an ounce and a half.
  81. The Os Uteri, or Os  Tincce, is situated  at  the lower part  of the
cervix, varying  in form  in different individuals ; in many it is a transverse
chink or slit, in  others a circular  opening, and in some triangular, resem-
bling a leech-bite, especially  in those who have borne  many children.   It is
generally about  the  size  of a goose-quill, or rather smaller.
  The Canal of the Cervix  is from half to three-quarters of an  inch long,
leading from the os  uteri; it first widens and then contracts again where it
enters the cavity of the uterus,  marking the os uteri internum, as it has
been called.  Between the os uteri externum  and internum the mucous mem-
brane is curiously disposed in rugae, branching out from a central line ; this
has been called  the arbor vitas.   The internal surface of this canal is thickly
studded  with mucous  follicles, called glandulce Nabothi, and which,  after
impregnation, secrete a thick mucus which blocks up the canal.
   The cavity of the  uterus is of a triangular shape, the base being upwards ;
its dimensions have  already been given.
   82.  Much difference of opinion  has  existed, and many  discussions  have
taken place, as  to the structures which compose the uterus ; though of late
years the opinions of authors are more harmonious.   It possesses three dis-
tinct tunics:  I.  We have already seen  (§ 77) that  it is covered anteriorly
and posteriorly by peritoneum, which is reflected laterally to the sides  of
the  pelvis, near the sacro-iliac synchondroses, forming  the broad ligaments
of the uterus, or the alee vespertilionis, on each side, containing the fallopian
tubes, ovaries, and  round ligaments.  From  their attachment to the pelvis
they may, perhaps, serve  as supports to the uterus, at least before conception.
This serous covering is identical with the lining of the abdomen.
   83. II.  The Middle Coat of the  Uterus is by some asserted, and by others
denied, to be muscular;  but  this really appears to me little  more than a dis-
pute about the  name, for those who  deny its muscularity admit  that it per-
forms the  functions of a muscle.  Mr.  Rainey has  examined very minutely
with the microscope the middle coat of  the uterus, and  finds that it is made"
up of "fusiform nucleated fibres, contained in a matrix of exceedingly cohe-
rent  granular matter.   The  average breadth of one of these fibres, at  its
dilated or nucleated part, is  about  To^th of an inch.   Their length cannot
be  ascertained with certainty, as it is impossible to estimate the degree  of
curtailment which they suffer in being separated from  the granular matrix
in which they lie embedded."1  The fibres belong to the class of non-striated
or  involuntary  muscles.    This middle  coat  differs in color from ordinary
muscle,  being yellowish, with  a faint tinge of red, like  the middle  coat  of
arteries, and it  is much  more dense than muscular tissue.   It  consists  of
fibrous structure, though it  is not easy to trace the course of the fibres in
the  unimpregnated  womb;  however, when the  uterus is enlarged from im-
pregnation or other causes,  it can readily be done, and  they may be  divided
into  several  sets.   The  superficial set are very irregular,  interlacing with
each other in  every direction, though  with a general tendency from the
fundus  towards  the  cervix;   but  some regularity is observable in the deeper
sets; for instance, there is a circular arrangement around the orifice  of each
fallopian tube, and at the os uteri; a layer diverging from the middle line
anteriorly and  posteriorly, and perpendicular bauds  descending to the  os
uteri.   Among  these  more regular layers there are  irregular fibres inter-
spersed.  From the middle coat  fibres are sent off to the fallopian tubes and
round ligaments.
   84.  111. The Mucous Coat.—A considerable number  of distinguished
1 Philosophical Trans.: 1850.  Part ii., p. 519. 
70
INTERNAL ORGANS  OF  GENERATION.
foreign writers, among whom we  find Morgagni,  Assoguidi, Chaussier, and
Morcau, have  denied the existence of any lining  membrane in the uterus,
from the difficulty of separating and demonstrating it.  I cannot understand
this ; for it has always appeared to me very evident, even in a state of health
and quiescence, but still more when the  seat of disease or pregnancy.
  Others, as Dewees, Boivin and Duges, etc., do not question  the  presence
of a lining membrane, but contend that it is  not mucous ;  and apparently
for the sole reason that one of its functions (menstruation) is not a function
of mucous membranes.   This objection, however,  is  refuted by the fact that
other mucous  membranes do occasionally secrete  a fluid apparently identical
with the menses (vicarious menstruation); and we  may add,  that the uterine
membrane presents the anatomical and histological characteristics of mucous
membrane ; that it secretes mucus, undistinguishable from that of the vagina.
Its pathology  also is that of mucous membranes.
  For these reasons I have no doubt that the uterus is lined by mucous
membrane,  continued from the  mucous membrane  of the  vagina  after it
covers the cervix uteri.  Dr. Tyler Smith has recently published some very
interesting and original microscopic researches on the structure of the mucous
membrane covering  the cervix  and lining its  canal,  of which I shall give a
brief abstract, especially on account of their bearing upon disease.   The
external   mucous membrane consists of  epithelium, basement membrane,
fibrous tissue,  bloodvessels, and nerves, like other mucous membranes.   The
special peculiarities  are as follows :  The  epithelial  layer is tessellated or
squamous, and so arranged as to form a membrane of considerable thick-
ness.  Immediately beneath, the basement membrane covers the villi;  each
villus contains a looped bloodvessel,  passing  to  the end of the villus, and
returning to its base, where it inosculates with the bloodvessels  of the neigh-
boring villi.  The  villi  are everywhere covered  by  pavement epithelium,
which renders  the external surface smooth.  The points of the villi are nipple-
shaped, with  a depression in the centre.   From Dr. Smith's researches, it
appears doubtful if the external surface possesses any mucous  or  glandular
follicles.   Just within the os uteri a small extent of smooth surface is found,
with villi  covered by cylinder epithelium, like those of the intestines ;  these
villi being three or  four times larger than those of the external surface, and
containing one or two looped vessels.   Underneath the villi  of  this part,
and  externally, a dense fibrous and  vascular tissue is  found, mixed with
involuntary muscular fibres and nerve fibres.   Higher up, we find the pecu-
liar  structure  of the  cervical canal.   It exhibits  four columns of oblique,
curved, or transverse  rugae, with four longitudinal  grooves or ridges.  Under
the microscope, these rugae, and the fosse between, are found to be divided
and  subdivided many times, and these rugae, and even the  secondary septa,
are covered with mucous follicles so  numerously,  that Dr.  Smith  calculates
that in a well-developed virgin  cervix  uteri there must  be 10,000 mucous
follicles.    The villi of this portion of the canal are  numerous, and covered
with cylinder  epithelium.   Thus we have a provision made  for a very large
extent of glandular secreting surface; in fact, Dr. Smith calls the cervix "an
open gland,"  and he regards this as the principal seat of leucorrhoea.   The
normal mucus secreted by this portion is very viscid, and almost transparent.
It adheres to  the crypts and rugae, and fills the canal of the cervix.   It has
an alkaline reaction, whilst that from the cervix externally is acid.  It con-
sists of minute corpuscles, caudate corpuscles,  minute oil globules,  and occa-
sionally dentated epithelium, in a thick, tenacious plasma ;  and its use, Dr.
Smith thinks, is to close the canal of the cervix, and probably to afford a
suitable medium for the passage of the spermatozoa  into the uterine cavity.1

                     1 Med.-Chir. Trans., vol. xxxv., p. -ill. 
INTERNAL  ORGANS OF GENERATION.
71
  85. The Arteries of the uterus are four in number, furnished by the aorta,
the hypogastric, and emulgent arteries.  The two superior — the spermatic
— arise from the aorta or emulgent arteries, and descend along the sides of
the womb in a serpentine course; they are distributed to the upper part of
the uterus, to the fallopian tubes  and ovaries.   The two inferior — the ute-
rine arteries — given off  by the hypogastric arteries, run along the sides of
the uterus, to within  a short distance of  the  lips, then divide, and supply
the cervix and upper part of the vagina.   The spermatic and uterine arte-
ries anastomose freely with each other.
   86. The Veins are more numerous than the arteries, are capable of greater
distension, and lie superior to their corresponding  arterial branches.   They
possess no valves, and, like the arteries, are of small size  so long as the
genital system  is  quiescent, but increase very  greatly during  pregnancy,
when they form what have been called the uterine  sinuses.
   87.  Some uncertainty has existed as to the Nerves  of the  uterus; but
the researches of Drs. R. Lee, Robin, Snow Beck,  and Hirschfeld,  added to
those of their predecessors, have rendered our information more complete.
They arise from the  aortic plexus, and from the  hypogastric  nerves and
plexus, being a mixture of  spinal  and sympathetic nerves.  I shall take
the liberty of quoting Dr. Lee's account of a dissection of these nerves  in
the unimpregnated uterus : " The aortic plexus, the hypogastric nerves and
plexuses,  were all much  smaller than in any of  the  gravid uteri I had pre-
viously seen.  From the fore and middle part  of the left hypogastric plexus
a small branch passed down on the inside  of the ureter, to the trunk of the
uterine artery and veins, which was  surrounded  by a plexus of nerves,
as  in  the gravid  uteri  before examined.  From  this, branches passed
upwards to  the  fundus  uteri, and a communication between  these and the
spermatic nerves  was quite evident.   From the  left hypogastric plexus,
numerous branches passed also directly into the uterus, without entering the
ganglia at the cervix, which ramified on the peritoneum  behind, and on the
muscular  coat.  Branches from the posterior part of the hypogastric plexus
communicated with some branches of the sacral  nerves behind the ganglion.
The trunk of the left hypogastric nerve was easily traced through the plexus
to the upper part of the  ganglion, which was remarkably large and distinct,
and consisted of white  and  grey matter.   Into the posterior part of the
ganglion the third sacral nerve sent numerous  branches.   From the anterior
margin of the ganglion a broad band of white and  grey nerves passed round
the  outer surface  of the ureter, and, after uniting with a similar  band on
the inside, sent  branches to the plexus  surrounding the uterine artery and
vein, and  also  branches  to the anterior surface of the uterus.   Large flat
nerves were  seen passing off from  the  anterior border  of the ganglion,  to
the bladder  and vagina,  and from its inferior and posterior borders to the
vagina and rectum.  A great number of nerves likewise passed off from the
inner surface of the ganglion into the cervix uteri.   The nerves sent off from
the ganglion were both larger and more numerous  than those which entered
it.   A great web of nerves was seen under the peritoneum, both on the
anterior and  posterior surface of the uterus, intimately connected with the
nerves sent off  by  the ganglion and hypogastric plexus."1
   88. The Lymphatics are very numerous, though very small, in the  unim-
pregnated uterus.   The  most numerous set of these vessels  runs from the
upper part of the  body and cervix  of the womb along with the spermatic
vessels,  and  with those from  the  ovary, in front of the  psoas muscles, and
terminates in the glands, in front of the aorta, vena cava, and lumbar vertebras.
Another set accompanies the uterine artery, and issues with the round liga-

     1 The  Anatomy of the Nerves of the Uterus, by Robert Lee, M. D, etc., p. 7. 
7 2              INTERNAL  ORGANS OF  GENERATION.

ment through  the  inguinal ring.   A  third set joins the lymphatics of the
vagina, and enters the hypogastric plexus.
  89. The lower portion of the uterus is within the reach  of a vaginal ex-
amination, so that we can estimate its  size, temperature, integrity, mobility,
sensibility, etc. ;  and by the use of the speculum we are able to ascertain its
color, the state  of its surface, and, if necessarjr, to apply local  remedies.
Further information as to its condition may be  obtained  in many cases by
abdominal manipulation ;  and, in the  case  of enlargements, by the applica-
tion of the stethoscope.   An examination "per rectum" is of value in cer-
tain diseases of the uterus, and especially of  the ovaries.
  90. Abnormal deviations. — 1. The uterus maybe  altogether wanting;
several such cases are on record.1  2.  The  canal of  the cervix may be ex-
tremely narrow throughout, or it  may be the  seat of stricture.   3. It may
be closed, either by the union of its sides, or by the mucous membrane being
continued over the os uteri.   4. The  uterus  may be malformed ;  and it  is
remarkable that these malformations,  which are owing  to  an  arrest of de-
velopment, appear to reproduce the  analogous  organs  of lower  classes of
animals ;   for instance, the double uterus, (fig. 34) resembles in some degree
the tubular oviduct of birds, it opens by two  ora uteri into the vagina; or
both the  uteri and vagina may be distinct.2
Fig. 34.                                 Fig. 35.
                                                    Uterus Bicollis.

  The uterus bicollis (fig. 35) exhibits#two bodies with but one os uteri, and
resembles the organ of some rodentia and carnivora.
  Again, the junction of the cornua may take place higher up, constituting
the uterus bicorporeus ; here the lowest part of the body of the uterus is
single, and the  upper double.
  In the uterus biangularis the body of the womb is tolerably well  formed,
and terminating in cornua, as in the monkey tribes.   Several intermediate
stages of this progress, from the lowest to the highest form of a single uterus,
have been noticed, but I shall only add two more illustrations; one when the
uterus is double, opening by two  orifices into two separate vaginae (fig. 36),
and another when  the uterus was separated into  two cavities by a  septum,
but having only a common opening inferiorly (fig.  37.)
  These congenital malformations are by no  means very rare ;  Dr. Cassan
collected forty-one examples, and many others have since been recorded.

  1 Kussmaul has published a volume devoted to these and analogous deviations- see also
cases by Dubois, Lancet, Dec. 8, 1855.
  2 Amer. Journ.  of Med. Science, p. 331.  Oct. 1852. 
INTERNAL ORGANS  OF GENERATION.              73
  The effect of the three first abnormal deviations will be either the absence
of menstruation, and consequent sterility, or inefficient or painful menstrua-
tion.   The deviations from arrest of development may exert no injurious

               Fig. 36.                               Fig. 37.
Double Uterus.                          Double Uterus.
influence upon menstruation or conception, but they have been adduced to
explain the phenomenon of  superfcetation, as it  is pretty certain that a
double conception may take place ; and, when  it is single, the vacant cavity
is lined by decidua.   In addition, the uterus is the seat of many forms of
disease.
   [A singular instance  of  malformation of the uterus is recorded by  M.
Lecluyse.  The subject of it "was a  small female,  who had previously been
twice confined with an arm  presentation.  The  occurrence of the same acci-
dent for the third time caused the accoucheur to make a minute examination,
in order, if possible,  to  find an explanation of so  unusual a circumstance.
The result of the  investigation  was, the womb, instead of being of  the
natural pyriform shape, had its greatest diameter in a transverse direction;
so that  the long axis  of the elliptic form which the foetus occupies in utero
was horizontal.   This anomaly was  thought by M.  Lecluv»e to account for
the three consecutive  arm presentations."1]
   91. The Fallopian Tubes  are two cylindrical  canals, about four inches
long,  proceeding from the upper angles of the  uterus.  They are  contained
in the superior and lateral  folds  of the  broad   ligaments.  Internally, they
open obliquely into the uterus,  at which point the canal is narrow ; it after-
wards expands, and then again contracts towards its external termination,
where it is open to the abdomen.  Externally,  the tubes are of equal thick-
ness for about three inches  and a half, when they expand, and terminate in
a fringed process, called the fimbriae, or  morsus diaboli, which is applied to
the qvary during impregnation.   The tubes are covered externally by peri-
toneum,  beneath which is their proper tissue, with some circular and longi-
tudinal fibres, derived from  the middle coat of  the  uterus.  Internally, they
are lined  by mucous  membrane, disposed in longitudinal folds, the villi of
which are  highly developed after impregnation.   The tubes share in  the
vessels and nerves  by  which  the ovaries are  supplied.
   Their function is the transmission of spermatozoa to the ovary in the first
instance, and afterwards of  the impregnated ovum  to the uterus ; in fact,
they are the excretory ducts of the ovary.
   92.  Abnormal deviations. —The  tubes, one or both, may be impervious,
from disease, or as a congenital malformation.  The closure of both of course
entails sterility.  They are also  subject to inflammation and its consequences,
and to malignant diseases.
  1 [Llmiking's Abstract, p. 240, American edition, from Journal de Chirurgie, Mars, 1845.] 
74
internal  organs  of generation.
  93. I have already stated that the round ligaments are formed by fibres,
derived from the middle coat of the uterus.   ]\Ir. (1. Rainey asserts, that
they are composed of striated fibres,  and are of the nature of voluntary
muscular fibre, and that their function is in  some way connected with the
act of  coition.1  M. Rau has  also  published  an  interesting  paper on this
subject.2   He conceives that for two-thirds of  their course, these fibres are
a continuation  of  the  muscular  fibres, both superficial and  middle, of the
uterus.  He admits the correctness of  Rosenberger's description of the
courses of the three bundles of muscular  fibres that form part of the  liga-
ment while in the inguinal canal.   Some  of the fibres proceed to the hori-
zontal  ramus and symphysis pubis.
  M. Rau  thinks that the round ligaments exercise no function during the
unimpregnated  state of the womb ;  but, that towards  the end of pregnancy,
they contribute to give a forward tendency to the fundus uteri,  and especially
during the early part of labor.
  94.  The Ovaries are the essential organs  of generation in the female;
they are the " analogues" of the testes in the male, and up to the time of
Steno, were called "lesfes mulieris."  They are situated on each side of the
uterus, to which they are attached by the posterior duplicature of the broad
ligaments, hence called the  ligamentum ovarii.
  They are  small oval flattened bodies, broader at the end distant from the
womb ; about an inch and a quarter or an inch and a half long, from half to
five-eighths of  an inch at their greatest  breadth,  and a  quarter of an  inch
thick.   They hang  loosely  in the pelvis, beneath  and somewhat behind the
fimbriated extremity of the fallopian tubes.   Smooth externally in virgins,
they become wrinkled in old age.
  Their external covering  is the serous  membrane, constituting the broad
ligament, in which  they are completely enveloped, except at the  part where
the vessels enter.
  Underneath the peritoneum  they  possess a  proper fibrous  coat  of dense
structure, called the Tunica Albuginea.
  95.  When laid open,  we  find their internal structure to consist of cellular
tissue,  permeated by numerous  blood-vessels  derived from  the  spermatic

                                Fig. 38.
                       Section of Ovary, Graafian Vesicles.

arteries, running tortuously across the  ovaries in nearly parallel lines; and
by nerves.   Embedded in the cellular parenchyma of the organ, in the adult,
a number (from 10 to 20) of small vesicles may be observed, which, though
noticed by Fallopius and Vesalius, were more particularly described by De
Graaf, and called after him, Graafian Vesicles.
  They vary somewhat in number ; and in size, from that of the  head of a
small pin to that of a small pea.
  96.  There is some difference of opinion  as to the age at which these  vesi-
cles are developed : some say,  about  the period of puberty ; others, among
whom  is Dr. Rigby, state that  they make their appearance about the seventh

              1 Philosophical Transactions.  1850.   Part II. p. 515.
              - Zeitschrift fur Geburtslmlfe.  July, 1851. 
internal  organs of  generation.
75
year; but according to  M. Negrier, in his "Becherches sur les Ovairesv
they are  to  be found much earlier.  He states that at birth the texture of
the ovarian parenchyma is homogeneous, but that  in the course of a year,
an uncertain number of miliary granulations may be observed; after a  short
time, these granulations  are  surrounded by an opaque zone, and a  small
vesicular globule,  whose walls are formed  by this  zone, is  annexed to the
granule.   This  globule  contains a vesicle (the Graafian)  formed  by two
membranes, concentric  and in contact.   At the  age often or twelve, certain
of the vesicles increase in size, and cease to be  transparent, because of the
interposition between the two membranes of a  grey pulpy matter.  At the
same time, the vesicles go on increasing more rapidly than the cavity in the
ovarian tissue in which they are  lodged, which gives  to them a compressed
and slightly corrugated appearance.  The grey  pulp of the vesicle is gradu-
ally changed to a yellow color, marking the epoch of puberty.   The vesicles
are connected to the part in which they are embedded by cellular filaments,
which become weaker in  proportion to  the age  of the child.  During early
life the vesicles  occupy  the deeper parts  of the ovary,  but gradually ap-
proach the circumference ;  and,  at the time when the pulp becomes yellow,
some of them are  in contact with the  envelope of the ovary.   I have con-
densed this  account from  M. Negrier, but am  not able  to decide upon its
correctness.
   97- So much  for  the  development  of the Graafian  vesicles: upon their
intimate  structure very great light has been thrown of late years by the
labors of Baer, Rathke, Purkinje, Valentin, Wagner, etc., in Germany ;  of
Prevost, Dumas, Coste, etc., in France ; and of Allan Thompson, Wharton
Jones, and Martin Barry, etc., in England.   From  their writings the follow-
ing description has been gathered, which I believe to be correct, with the
exception of a few minor points  not yet settled.
   The Graafian  vesicle consists of an external and an  internal  membrane :
the former (tunic  of the ovisac, Barry) is extremely vascular;  the latter
(ovisac, Barry) is smooth and velvety, deriving its vessels from the former.
The cavity  enclosed by  these membranes  is far from being filled by the
ovum ; it contains, besides, a whitish  or yellowish albuminous  mass which
consists chiefly of  granules, from ^00th to  30oth part of  a line  in diameter,
connected together by a  tenacious fluid, and forming the tunica granulosa
of Bischoff,  Wagner, and Barry.   Its density is  unequal; towards some part
of the periphery of the vesicle these granules are accumulated in a disk-like
form, making a slight prominence in which is a depression.
   The disk and prominence are termed by Baer the discus proligerus and
cumulus.  Dr. Barry has also observed certain granular cords, resembling
the chalazae in the egg in appearance and function, and which he  has called
the retinacula. In the depression in the cumulus is lodged the ovum (ovulum,
Baer), the discovery of  which by Professor v.  Baer explained satisfactorily
the small size  of the ova observed in the fallopian tube by De Graaf, Cruik-
shank, and Haighton, compared  with the Graafian vesicle in the  ovary.  The
ovum is surrounded by a thick white ring, which has been called zona pellu-
cida, but which  Valentin and Wagner  conceive to  be a membrane;  internal
to which we find a granular layer, the vitellus, the  larger granules  of which
are superficial and compact,  whilst internally it is a clear albuminous fluid,
almost devoid of granules.
   Embedded in  this vitellus, but nearer to its  circumference than centre is
the germinal  vesicle, or  vesicle  of Purkinje, a very important  part of the
ovum.   It was first discovered  in  eggs by Purkinje, but in mammalia by
Wharton Jones, Coste, Valentin, and  Bernhardt.  It  appears  like a clear
ring of very small size, measuring in man and  mammalia at most g^th part
of a line in  diameter.  Upon the surface of the germinal vesicle a dark spot 
76
internal organs  of  generation.
was discovered by Wagner, and called by him macula germinatira.   " It is
almost always seen as a simple rounded body from 3Jjotn to 3<j0th  part of a
Fig. 39.
Fig. 40.
 Ovum of Man, from Bernhardt.—1. Ger-
minal vesicle.   2. Vitellus.  3. Chorion.
(Zona pellucida ?) 4. Tunica granulosa.
   Ovum of Rabbit.—aa. Discus proligerus.  66. Pale
 oil globules,  c. Zona pellucida. d. Vitelline mem-
 brane,  e. Vitellus.  f. Germinal vesicle,  g. Ger-
 minal spot.

line in diameter;  it is very rarely observed double or as an aggregate of
granules, which, however, is sometimes the case in immature ova."
  It may serve to render this minute description more intelligible  to the stu-
dent, if I give the summary of Valentin  and  Barry of the contents of a
Graafian vesicle :
             Valentin.
1.  An external membrane (yolk-bag).
2.  Fluid contents (yolk).
3.  Layer  of  granules which  form the
    disk (blastoderma).
   Ovum or ovulum, in which is to be
    distinguished —
   An outer  membrane.
   A  granular layer, internal to it.
   A  transparent half-fluid content.
   The germinal vesicle
                                                  Barry.
                                      1. Tunic of the ovisac.
                                      2. Ovisac.
                                      3. Membrana  granulosa,  in  which
                                           are found —
                                      4. Tunica granulosa  and retinacula
                                           (disk and cumulus of  Baer).
                                      5. Zona pellucida.
                                      6. Membrana vitelli.
                                      7. The yolk.
                                      8. Germ vesicle, with Wagner's ger-
                                           minal spot.
  Dr. Barry states that the tunic of the ovisac is not  always present; but
that, when it is, it is  furnished by the ovary.   The order  of time in which
the parts are formed is thus given by him :—1, the germinal  vesicle with its
contents;  2, an envelope consisting  of peculiar granules and oil-like glo-
bules ; 3,  the ovisac ; 4, the yolk ; 5, the membrana vitelli; 6, the  zona pel-
lucida ;  and  7, the  tunic  of the ovisac, tunica granulosa,  retinacula, and
membrana granulosa.
  98. Abnormal deviations. — One or both  ovaries may be absent, or atro-
phied.   There  may be few or no Graafian vesicles,  or they may be morbidly
changed.   The ovaries  may also be  the  seat  of inflammation, dropsy  ma-
lignant diseases, etc.
  The absence  or disorganization of both  ovaries, or of all the Graafian
vesicles, entails sterility ; but conception  is not impossible so Ion"-  as  a por-
tion remains healthy.
  Having thus minutely investigated the  anatomy of the sexual system  in
the female, we  may now proceed to consider its functions. 
PART  II.
PHYSIOLOGY OF  THE ORGANS OF GENERATION.
                          C HA P TE R  I.

physiology of the  uterus and OVARIES.—1. menstruation.

  99. The generative organs of the female  are in a state of activity only
during the prime of life,  embracing a period of about 'thirty years,  and
during this time, the most remarkable  characteristic of their functions is
their periodicity.
  It is impossible to separate the functions of the uterus  from those of the
ovary,  because in each we may discern  their combined  influence.  Those
offices which are peculiarly uterine may thus be enumerated : — 1, the secre-
tion of mucus;  2,  secretion  of the  menses ;   3, formation of decidua; 4,
reception  and nutrition of the  foetus ;  and 5, the expulsion  of the foetus.
From the ovary, on  the other hand, is derived, 1, the effective stimulus to
menstruation, and 2, the  fecundated germ ; so that we see that the effective
co-operation of both the organs is necessary for the  fulfilment of either of
the three great functions of the uterine system, viz., Menstruation,  Concep-
tion, and Parturition.  We shall consider these functions in order.
  100. Menstruation. — In healthy women  at the period  of puberty a
certain amount of sanguineous  fluid is eliminated by the uterus, and escapes
from the vagina, every month ;  this is termed  the catamenia or menses,  and
the function itself, menstruation.
  That it is excreted by the uterus, has been ascertained in cases of prolapse
and inversion  of the organ ;  and that it  is really a  secretion by its lining
membrane, and not blood  mechanically filtered through it, is, I believe, now
generally admitted.
  [It has been  shown by the researches of modern physiologists, that  the
catamenial fluid is ordinary blood mixed with  the  mucus of the vagina  and
epithelial  cells.  Menstruation,  therefore,  is,  strictly  speaking, a  periodical
hemorrhage from the uterus.  The doctrine of the  secretion  of the menses
is altogether untenable, and has been given up by nearly all the authoritative
writers of a late date on  the functions of the female sexual  organs.   Dr.
Dalton, who has examined the  subject with great care, remarks that "the
menstrual blood is discharged by a kind  of capillary hemorrhage, similar to
that which takes place from the lungs  in cases of haemoptysis, only  less
sudden and violent.   The  blood does not form any visible coagulum, owing
to its being gradually exuded from many minute points, and mingled with a
large  quantity  of mucus.  . .  .  The  hemorrhage  which  supplies  it comes
                                                           (77) 
78
MENSTRUATION.
from the whole extent of the mucous membrane of the body of the uterus,
and is, at the same time, the consequence and the natural termination of the
periodical congestion of the parts."1  Madame Boivin expresses a similar
opinion.   Dr. W.  Tyler Smith, in his Manual of Obstetrics (page 57),  pro-
nounces the catamenial fluid to be essentially different from the  product of
any secretory  process.   The same view is expressed by Professor Meigs,
Professor H. Miller, of Louisville, and others of equal eminence.]
  A female in whom this discharge recurs at the usual periods, in the usual
quantity, and of the usual quality, is said to be "regular;" and various
conventional phrases are in use to avoid a more direct reference, as "being
regular,"  "unwell,"  etc.
  101.  The occurrence of menstruation  defines the period of puberty, at
which the girl becomes a woman and capable of conception  ; as its cessation
terminates the prolific period of female life.  In Great Britain this generally
happens between  the ages of thirteen  and sixteen, although we meet with
cases of earlier and later puberty, dependent, probably, upon  peculiarity of
constitution, habits of life, pursuits, etc.  A case  is  recorded by Dr. Wall,
in the second volume of the Med.-Chir.  Trans., of a child who menstruated
at nine  months  old, and continued to do so regularly afterwards.  There is
another instance in  the  American Journ. of Med.  Science, for Nov.  1832,
by Dr.  Le Beau, of New Orleans, of a child born with the marks  of puberty,
in whom the catamenia appeared at three years of age, and recurred regu-
larly.   I  find also a case by Mr. Enabling,* of menstruation at less  than
three years old ; one by Dr. Diffenbach3 at  nineteen months  old; one  by
Dr.  Calais* at six years old; one by Dr.  Carus5 at two years old  ; one  by
Mr.  Whitmore6 of a child who menstruated from a few days after birth, till
it died  at  four years of age; one by Dr. Lenz7 at  eighteen months;  and
one by  31. Gruere8  at one year old.  In  all these  cases menstruation not
only commenced at that age, but continued to return at the regular periods.
Additional examples  may be  found in the writings  of Lobstein, Meyer,
Plocquet,  etc., etc.
  Mr. Roberton, of Manchester, has stated  the age at which it commenced
in 450 cases.9

           10 menstruated  for the first time  at 11  years of age.
19		a.		a	a	12
53		"		n	"	13
85		11		a	(i	14
97		"		n	K	15
76		(1		n	a	16
57		a			"	17
26		u		a	k	18
23		a		n	n	19
4		it		n	"	20
Which gives	the	mean	age	15204	years.	
  Mr.  Whitehead, in  his work  On  Abortion,  gives the following table,
showing  the  age at which puberty was  established in 4000  individuals in
Manchester:—

  1 [Human Physiology, Philadelphia, 1859, page 477.]
  * Lancet, Jan. 29th, 1848.                 3 Meckel's Archiv fur Anat, p. 367.
  * Journal de Mel. et de Chir., vol. ii., p. 37.  5 Ed. Monthly Journal, 1842, p. 1050.
  c Northern Journal of Med., July, 1845.     i Caspar's Wochenschrift., Oct. 3 1840.
  8 Journ. de M6d. et de Chir. Pratique, May, 1842.
  9 Physiology and Diseases of Women, and Midwifery, p. 29. 
MENSTRUATION.
79
10 years 9 first	
11 "	26
12 "	136
13 "	332
14 "	638
15 "	761
16 "	967
17 "	499
18 "	393
19 "	148
20 "	71
21 "	9
22 "	6
23 "	2
24 "	1
25 "	1
26 "	1
  These  tables seem to bear  out the  inference of Mr. Roberton, that the
"natural period of puberty, instead of being the fourteenth or fifteenth year,
occurs in a more  extended  range of ages, and is more equally distributed
throughout that range than  authors have  alleged."   It is influenced, how-
ever, by many causes; for example, it is earlier in towns than in the country,
for M. Brierre de Boismont found the mean  age of  first menstruation to be
fourteen  years six months in Paris, and fourteen years ten  months  in the
country,  and fourteen years nine months in small towns.
  [ilf. Brierre de Boismont, in  his work,  "De la Menstruation consideree
dans ses Bapports Physiologiques et Pathologiques,v among a mass  of inte-
resting facts, gives the following  curious table of ages at which menstruation
commences.  It is the most  extensive table yet published, and  includes the
results of 2352 cases: —
	Paris,	Paris, 85	Lyons,	Marseilles, 68	Manchester,	Gottingen,
Age.	1200 cases by	cases by Marc	432 cases by	cases by Marc	450 cases by	137 cases by
	Meniers.	D'Espine.	Petrequin.	D'Espine.	Roberton.	Osiander.
5	1	0	0		0	0
7	1	0	0	0	0	0
8	2	0	0	0	0	0
9	10	1	0	0	0	0
10	29	0	5	0	0	0
11	93	3	14	6	10	3
12	105	14	26	10	19	1
13	132	6	47	13	53	0
14	194	18	50	9	85	20
15	190	14	70	16	97	32
16	141	7	79	8	76	24
17	127	6	58	4	57	11
18	90	5	38	2	26	18
19	35	8	21	0	23	10
20	30	3	9	0	4	8
21	8	0	5	0	0	1
22	8	0	1	0	0	0
23	4	0	0	0	0	1
24	0	0	3	0	0	0
At  the  age of
    a

    (<
    a
    a
    tt 
80
MENSTRUATION.
  This table demonstrates  that  by far the greater number of women begin
to menstruate during their 14th or 15th year, and that the proportion dimin-
ishes both above and under that age.1
  A very interesting  case  by Dr. Carus, of  Dresden, is mentioned in the
recent medical journals, of a child born in the mountains of Saxony,  in
whom menstruation began  at two years of age.
  " She  was scarcely a year  old, when she began to grow rapidly.  At the
end of her second twelvemonth, the catamenia appeared,  and have  continued
ever  since to flow regularly  once a month.  The Academy of Medicine  of
Dresden sent for both her and  her mother, and, in  order to examine  more
particularly into the case, kept them under their observation during several
weeks.   The infant was 37 inches 3 lines long.   The  mammae were  firm,
like those of a strong girl  of  16.  Her  body was stoutly made, and the
genital  organs were covered with dark brown hair.   Her physiognomy and
tone  of  voice were childish, which contrasted singularly with the strength
of  her  body.  Her intellectual functions were equal to those  of a  child
three years  old, and  her head was  covered with  beautiful dark  brown
hair."2]
   Again, the rank of life  and degree  of civilization exert  an influence, for
the same writer states that he found the mean age in 171 of the poor to  be
fourteen years ten months; in 135 of the comfortable working-classes to  be
fourteen years five months ; and in 53 daughters of the rich and noble, thir-
teen  years eight months.
   By most writers, a very great effect is attributed to climate.   Menstrua-
tion, it  is said, commences much earlier than the  period I have named  in
 hot climates, and much later in cold ones.  Women are stated to  be mothers
 very  commonly at ten or twelve years old  in the East, and to cease bearing
 at  twenty-five  or thirty; and  that in Lapland, and other northern  climes,
 they do not begin to  menstruate till about twenty or twenty-four, and con-
 tinue until sixty years of age.   Now,  without denying the occurrence  of
 such cases, I do not believe that either extreme is very common, and although
 there is a difference according to climate, that difference is far less than has
 been supposed.
   Thus iMr. Roberton, in  his valuable researches,  gives  it as the result, that
 in  Labrador and Northern Europe, the  period of first menstruation is very
 nearly the  same as in this country, nor does the discharge continue later;3
 whilst in India, although the average  age, in his return, is earlier, it is pro-
 bable that puberty does not actually appear earlier there than here.*
    Dr. Tilt, who has published a valuable table on this subject, finds the mean
 age for the first menstruation in hot climates, out of 629 cases, to  be thirteen
 years and  sixteen days;  out of 5775 cases,  in temperate climates, fourteen
 years, four months, and four days; out of 4018 cases, in  cold climates, fifteen
 years, ten months, and five days.5
    102.  In these countries the discharge continues until the age of forty-five
 or fifty; in some cases it ceases earlier,  in others it continues longer;  gene-
 rally according to the age at which it commenced.  From Mr. Roberton's
  work I extract the periods at which it ceased in 77 individuals :6

   1 [Edinb. Med. and Surg. Journ., Jan. 1843.]
   2 [American Journ. Med. Sciences, April, 1843, from Allgemeine Zeit. fur Chirurgie.l
   » Physiology and Diseases of Women, etc., p. 56.              * Ibid, p. 127.
   5 Edinburgh Monthly Journal of Med. Science, Oct., 1850, p. 294.
    6 Phys. and Dis. of Women, and Mid., p.  185. 
MENSTRUATION.
81
26	at the a	ige	of 50
2	it		51
7	u		52
2	ii		53
2	t<		54
1	u		57
2	ii		60
1	i<		70
         In  1 at the age of 35         In
            4       "       40
            1       "       42
            1       "       43
            3       "       44
            4       "       45
            3       "       47
           10       "       48
            1       "       49

  The period of its  cessation  is called by women the "time, or turn of
life;" and  is preceded by irregularity and occasional  interruption.  It is
looked upon as a  critical period,  from the supposed  liability to serious
attacks and the greater mortality; but the researches of MM. Benoiston de
Chateauneuf, Bellefroid, etc., have shown that the mortality at this period
of female life is not greater than amongst males at the same age.
  103. As the name (menses, catamenia) implies, the discharge recurs every
month; that is,  deducting four or six  days for the time of its flow, every
twenty-seven or twenty-eight days.   Mr. Roberton found that, out of  100
women, 61 menstruated every month, 28 every three weeks, 10 at uncertain
intervals, and one, a healthy woman,  aet. twenty-three, every fortnight.   The
shortening of the interval of twenty-six or twenty-eight days is a deviation
from functional integrity, owing, most likely, to habits of life, impaired con-
stitution, etc.  Dr.  Gall made some very curious observations, from a journal
which  he kept  of  the  periods of menstruation  in  different  women:  " It
resulted" (I quote from Elliotson's Physiology, not  having the original at
hand)  "that women are divided into two great classes, each  having a dif-
ferent  period.  The women of the same class all menstruate within eight
days :  after this time an interval of ten or twelve days follows, during which
very few women menstruate.   At the end of the ten or twelve days begins
the period of the second great class, all the individuals  of which  also men-
struate within eight days."  Admitting exceptions to the rule, Dr. Gall says
that it applies generally to all parts of Europe.
  104. The duration of each menstrual period varies from three to six days,
or even  longer.   The quantity which escapes  each time  is  from  four to
eight ounces, varying according to the temperament  or constitution of the
individual.  It is not discharged at once, but slowly and gradually.   As to
the character of the secretion, it greatly resembles venous  blood, being of a
dark-red color, thin, and either without odor, or with a very faint one.   It
consists  at first  of pure blood, but  in  its  passage through the vagina its
fibrine is probably dissolved by the acid secretions of that part.  It is found
to redden litmus paper, and to contain phosphoric and  lactic acids,  with
some phosphate  of  lime.
  105. The symptoms which precede and accompany the  first menstruation
are very slight  in  some cases, well-marked in others.   There is generally a
degree of languor and lassitude, fatigue after exertion, inequality of spirits,
dark shade  under the eyes, headache, sometimes pain in the thyroid gland,
pain in the back, weight and aching in the pelvis and down the thighs, etc.:
occasionally there is a smart attack of fever.
  If the  discharge  takes place, most of these  symptoms disappear,  and the
female merely complains of weakness, and exhibits pallor of countenance.
  Or the menstrual secretion may make  its appearance quite suddenly, with-
out any previous suffering or any symptom likely to attract  attention, and
in such cases it is a cause of considerable alarm, and it may be that steps
are taken to suppress it  by the girl herself, which may be very injurious.
  Or the symptoms enumerated may occur, and pass  off once  or twice with-
       6 
82
MENSTRUATION.
out the appearance of the menses, or with  a white discharge only.   This
may generally be remedied by an  improvement in diet and  tonics at the
approach of the next  menstrual period.
  Sometimes the color of the discharge is light at first, growing deeper each
period.   During its flow, the skin exhales  a peculiar  odor, the appetite  is
diminished, and  often  capricious, and occasionally sympathetic pains are felt
in the breasts.   There is a case1 related of a woman whose  breasts secreted
milk after each  menstrual period,  and  I have myself seen a similar  case.
The amount of suffering differs, as  I have said, in different women, according
to some peculiarity of constitution, and according to the degree of  care and
good management bestowed upon them during the earlier periods.   In some
it is never attended  by pain or distress, beyond  a slight  indisposition to
exertion ; in others,  more or less  pain and uneasiness  attend each period,
whilst  in  some  women  it always amounts  to dysmenorrhcea,  and is accom-
panied with great suffering,  debility, or  feverishness.  I may add  that the
first menstruation is not necessarily a type  of the subsequent periods.   The
more perfectly the function is performed the less is the distress.
   106.  The effects of the development  of  this function upon the body and
mind of a  young  girl  are  very  striking.   The  figure enlarges,  becomes
rounder and more fully formed, the pelvis expands, the mammas enlarge, and
the general bearing becomes  graceful and dignified.  The mental change is as
remarkable :  the  pursuits of girlhood are  exchanged  for more  womanly
interests ;  and  a  more exquisite  perception of her  position and  relations
results  in higher  enjoyment, veiled  by  a more  delicate  modesty.  These
changes are rapid, and, occurring at this  peculiar period, doubtless fit the
individual for the more perfect fulfilment of the duties about to devolve upon
her.
   107. From the importance of  this function, a few brief directions as to
 the management of  young girls  at its  commencement  will not be out  of
 place.  And  first,  I would  protest  against the demand  not unfrequently
 made  upon us, that  at  the usual  age we should endeavor to  bring on men-
 struation in cases  in which  it has not appeared.   The  intimate dependence
 of this function on  the general development of the  body ensures  its estab-
 lishment  at  the proper time in the majority of cases, and in  those where  it
 is  tardy it most frequently arises  from causes over which we  have  no imme-
 diate  control,  and to attempt to interfere will probably end in mischief.
 The cases suitable for our medical interference we shall enumerate by-and-
 bye.
    I do not think that girls should  be  instructed  beforehand as to the oc-
 currence of this discharge,  or certainly, if it be done,  it should  be in the
 most general manner; but I think we may safely leave  this to the watchful
 care of the  mother.
    Warm clothing and rest are  very necessary.   The custom of wearing
 drawers, which is  becoming general, will, I have no doubt, contribute  to
 the more  perfect performance  of this function, and to  the health of  young
 women generally.
    During menstrual periods, especially the earlier ones, the girl  should  be
  much  restricted in  her exenfise,  and  be  prevented from  violent or  rapid
  movements.  And especially she  should guard against cold.   Exposure  to
  cold air, too liberal use of  cold water in washing, bathing the feet in  cold
  water if it be summer, may  inflict permanent injury.
    During the intervals, the  girl may resume her ordinary habits;  and what-
  ever is calculated to strengthen the constitution, and to improve the general
  health, such  as fresh air,  exercise, bathing, and good diet, will also tend to
  render complete and permanent the healthy performance of this function.
                   1 British and Foreign Med. Review, Oct. 1840. 
MENSTRUATION.
83
  This  is scarcely the place to indicate  the  moral management of young
girls, but I may just mention that, as this is the most susceptible age for re-
ceiving  impressions, it is desirable  that they should be  of a healthy kind ;
that as  all such as enervate, all those which appeal  to  the imagination —
novels and poetry, which make life  a dream of  idle fancy or of affection un-
connected with duty.— should be controlled, if  not avoided.   As the girl is
becoming a woman she should be treated  as such,  and true views of life and
duty, as well  as  of  pleasure, be laid before her.   Late hours, excitement,
balls, exhibitions, etc., should be made the exception, not the rule, remem-
bering always, that while softness,  and affection, and grace, are the natural
attributes of woman, it is the province of a wise educator to instil principles,
and strength,  and practical wisdom.
  108.  The next very important  question  is the condition  of the organs
during  menstruation.  By a great number of writers the attention  has been
limited  to the uterus, which,  being the seat, was regarded as the chief, if not
the sole organ involved.  Upon careful investigation, we find that the uterus
is congested during  menstruation ;  its vessels are distended with blood, its
substance more flaccid than usual, of a  more decided pink color, and its
lining  membrane of a deep red, studded  with bloody points,  and  covered
with menstrual fluid.   The  cervix,  however, participates but slightly in the
increased  vascularity, and its lining membrane is scarcely altered in color, so
that the os uteri  internum is marked by the abrupt termination of the dark
color  of the lining membrane  of the body.  On  making a vaginal exami-
nation,  we find the cervix  softer, more puffy, and slightly swollen,  and the
os uteri more  open, than  at other times.  The fallopian tubes are also some-
what more vascular than usual.
  A very careful examination  was made by Dr.  Janser of the  organs of
generation of a girl who was murdered four days after menstruation, and he
thus describes the state  of  the  uterine mucous membrane : " It was much
swollen between the body and neck.  In the uterus itself it formed a velvety
membrane, glossy and brilliant, easily detached with the handle of the scalpel,
and presenting a fine network of vessels.   This mucous  membrane  was evi-
dently thickened : it was composed of the uterine glands, ranged  perpen-
dicularly alongside each other, and fitted with cylinder epithelium not ciliated.
The structure between the  uterine glands was composed of a network of
delicate fibres, of some nucleated cellular fibres, and  of  amorphous tissues.
The surface of the uterus was covered with a thin layer of mucus, and lined
with cylindrical  epithelium, without cilia.   The  orifices of  the  fallopian
tubes were  open.   The vaginal mucous  membrane was  pale, but was only
covered with a thin layer of  mucus, containing epithelial  cells."   The writer
adds, " It results from this  observation that the mucous membrane of the
uterus  presents, during menstruation, characters  analogous to those which
exist during gestation, such as the hypertrophy of the uterine  follicles, and
the disappearance of vibratile cilia."1
   M. Pouchet conceives that not only  does  this peculiar change in the
mucous membrane take place, but that a deciduous membrane is formed and
discharged each  month.   Dr. Lee believes it  to  be a frequent occurrence
with unmarried females;  Dr. J. C. Dalton  thinks its  periodical occurrence
very probable.   Professor  Bischoff's examinations  did not  confirm  this
opinion.  Dr. Tyler Smith and others believe that the mucous  membrane  is
exfoliated every month.
  These changes rapidly subside when the function  ceases, and the parts
return to their ordinary state.
  109.  A still more essential question, however, is the state of the ovaries,

        1 Med.  Annals, vol. xiii. part iv.  Lond. Journal of Med., April, 1850. 
S4
MENSTRUATION.
and the influence they exert upon menstruation.  From time to time it has
been suggested that these organs were of greater importance  to  this func-
tion than was generally admitted, or even of equal importance to the uterus
itself.  A reference of this  kind is made by Dr. Friend, in his "Emmeno-
logia;" and Dr. Power goes further,  and attributes menstruation entirely to
the action of the ovaries : Dr. Vaughan  also regarded the  menses as a se-
cretion dependent upon the ovaries ; and other authorities might be adduced.
Indeed, there are certain facts which cannot but lead to an  admission of a
certain influence exerted over menstruation by these  organs : for instance,
it is well known that they participate in the congestion which is observed in
the uterus at the monthly periods ; again, when the ovaries  have  both been
atrophied or diseased, as noticed  by Morgagni and  Frank ; or when one
was congenitally absent and the other disorganized, as in a case related to
me by my friend  Dr. Montgomery, the secretion of the  menses has been
prevented  altogether, or it  has  ceased prematurely.   Moreover, when  the
uterus is absent but the ovaries present, the menstrual molimen  and other
sexual peculiarities are observed.  Lastly,  when the  ovaries have been re-
moved, as in the case mentioned by Mr. Pott, menstruation ceased entirely.
   These considerations  alone  would, I  think, be sufficient to  justify  the
opinion that, although the uterus be  the seat, and its  lining  membrane  the
secreting agent in  the process, yet that the impulse or stimulus upon which
the function depends is in some way  or other derived from the ovaries.
   Nor is this inference weakened by the  changes which are observed in the
ovaries during menstruation, which  may throw some  light also as to  the
nature of the stimulus.   For almost  all the accurate information  we possess,
we are indebted to the recent  researches  of Drs. Girdwood, Lee, Ritchie,
Knox, Renaud, Dalton,  etc.,  in this country  and  America, and Pouchet,
Negrier, Gendrin, Bishoff,  Raciborski,  Chereau,1 etc.,  on the   Continent,
although the main fact established by their labors was curiously noticed by
Mr. Cruikshank so long as 1797 : "I  have  also," he says, "in my possession
the uterus and  ovaria of a young woman, who died with the menses upon
her.   The external membranes of  the ovary were burst  at  one  place, from
Fig. 41.                               Fig. 42.
Ovary at Menstrual Period.
whence I suspect an ovum escaped, descended through the tube to the uterus,
and was washed off by the menstrual blood."  Several similar observations
have been  published  by Dr. Lee  in the Cyclop, of Pract.  Medicine, and

               1 See Mailer's Physiology:  Supplement, p. 45, et seq. 
MENSTRUATION.
85
since in the Med.-Chir.  Transactions;  Mr. Girdwood and M. Gendrin have
each added five cases, and M. Negrier  five more, of the same kind.  All the
observations agree that, in females dying during or soon after menstruation,
a small irregular rupture or cicatrix was found in  the coats of the ovarium
(fig. 41), and that this communicated with the remains of one of the Graafian
vesicles; from which Dr. Lee concludes that it is "extremely probable that
all  the phenomena  of  menstruation depend upon, or are  connected with,
some peculiar changes in  the Graafian vesicles, in consequence of which an
opening is formed in the  peritoneal and proper coats.  Whether an entire
vesicle, or only the  fluid it contains, escapes through this opening at the
period of menstruation, further observations may hereafter determine."
   The  changes which  take place in the vesicle are thus stated by M.  Ne-
grier :  an afflux of  transparent  fluid occurs in  the vesicles, distending  and
ultimately causing its rupture at the least resisting part, which corresponds
to the surface of the ovary.   This opening is cicatrised, at least externally,
in about eight or ten days, so as to prevent the escape of the blood which
proceeds  from the  lacerated  vessels of the vesicle, and, in consequence, a
clot is frequently formed in the capsule of the vesicle (fig. 42).   Sometimes
it contains a serous  fluid,  colorless, or  tinged with blood.
   A  very valuable  prize  essay on the subject has lately been published by
Dr. J.  C. Dalton,1 in which he  records eleven cases in which he observed
these menstrual corpora  lutea, and gives very minutely the changes which
take  place in them.   He  thinks the exact period of the menstrual flow, at
which  the vesicles rupture, variable :  sometimes during  the flow, in other
cases — as stated by Bischoff, Pouchet, and  Raciborski— at the termination.
 The appearance of the corpus luteum will depend upon the extent  of the
rupture, and the amount of haemorrhage into the cavity.   " As to the seat
 of the peculiar growth which characterizes these bodies," he considers  it to
 be the proper membrane of the vesicle hypertrophied, and that the proliger-
 ous disc, and a considerable portion of the membrana granulosa are expelled
 with the ovum.   " The  new growth or deposit of yellow matter, when
 examined under the microscope, is seen to consist of an abundance of pecu-
 liar,  irregular-shaped  granular cells, varying in size, and sometimes enclos-
 ing minute, opaline, yellowish globules, like  oil.   The contour  of the  cell
 wall can  in most instances be completely traced throughout; but in some
 instances it is indistinct in certain  parts of the circumference.  There are
 also to be seen  in the  field  of the  microscope a  few  oil  globules similar to
 those in the  interior  of  the cells, but for the most  part  of larger size."
 Recent researches seem to show that the development of fatty matter is an
 early step in the death and removal of tissues ; and it is possible that a simi-
 lar step may thus be  observed in these menstrual corpora lutea, for we find
 them  attain their maximum in the course of three weeks, then rapidly retro-
 grade  until the yellow matter diminishes  in  size,  becomes softer and more
 friable, and at length  merely exhibits  a cicatrix, with a  small, faint  yellow
 spot.   Dr.  Dalton  agrees  with  those already  mentioned, who regard the
 discharge of ova as an essential part of menstruation.
   I may add here the  examination of the  ovary in the case related by Dr.
 Jauser, to which I  have already referred.   " The surface of the left ovary
 presented a deep red spot, surrounded by finely injected vessels.   This  spot
 was  formed by a small globular mass, embedded in the ovary, and of an in-
 tense red through its whole thickness.   The mass in question was separated
from the  tissue  of the  ovary by a thin yellow envelope, and was composed
of fibres like those of areolar tissue, arranged in superimposed layers.   The

   1 On the Corpus Luteum of Menstruation and Pregnancy, p. 45.  [See also Treatise on
Human Physiology, by the same author, pp. 478, et seq.] 
S6
MENSTRUATION.
yellow envelope was formed by the same kind  of fibres, among which there
was a pretty considerable quantity of fat, not contained in cells.   Near this
body, there was  seen  a small yellow, spherical, nodulated  mass, composed
of areolar tissue  and fat.   The right ovary contained two  yellow bodies."1
No ovule was found ;  but  the examination was four or five days after men-
struation.
   M. Bischoff has published  the minute examination  of thirteen  cases, in
which the clot was found in the  place  of  the discharged ovum, the rent in
the coats, cicatrices,  and marks  of former ova, congestion of the uterine
mucous membrane, but neither decidua nor ovule.    There  are but two  or
three cases (by Hyrtl  and  Letheby) in  which the ovum has been found.
   If the reader  will  carefully compare the cases  here quoted, and  those
recorded by the  authors mentioned,  but which  it would  be  out of place  to
detail more fully here, he will agree with me,  I think, that they justify the
following conclusions  : —
   1.  That ovarian influence is necessary to menstruation :  a. because when
the ovaries are congenitally absent, or have been removed, or have become
disorganized, menstruation is absent or ceases,  b.  Because when the uterus
is absent  or  has been removed, the ovaries being  present,  the  menstrual
molimen may still recur periodically,   c. Because coincident with the com-
mencement and  cessation  of  menstruation we  find  corresponding  organic
changes in the ovaries.
   2.  We find that the ovaries do not contain a definite and limited number
of Graafian vesicles,  as Haller and others have thought, but a vast assem-
blage, according to the researches of Dr. Martin Barry, and the number of
which vesicles may be increased, according to  Dr.  Ritchie.
   3.  In the ovaries of women who menstruate  regularly, there may be ob-
served  a number of the Graafian vesicles, in different degrees of develop-
ment, from the size of a millet seed to  that of  a cherry stone.
   4.  There are  cases on record of women who died just before  menstru-
ating, in one of whose ovaries a vesicle was observed  in  a state of great
maturity, enlarged and prominent, with its  outer  coverings much thinned,
semi-transparent, and in one point apparently  about to burst.
   5.  In a considerable number of cases of death  during menstruation, one
ovary presented  a cavity recently emptied, or partially filled by a clot, from
which a duct-like canal passed through the coats  of the ovary.  That this
cavity contained a Graafian vesicle cannot reasonably be doubted.
   6.  On examining the ovaries, a number of cicatrices may be observed,
some more, some  less recent; and in  several  cases  these  have been ascer-
tained  to correspond  exactly with the number of  the menstrual  periods.
According to  Mr. Girdwood's researches,  this  is always the case.
   7.  These cicatrices, when cut  open, exhibit the yellow spots, which result
from an hypertrophied condition of the proper membrane of the Graafian
vesicle.  These menstrual  corpora lutea  have given rise  to  much contro-
versy as to their difference  from, or relation to, the corpora lutea  of preg-
nancy, of which I shall have  more to say  presently.
   8.  Cases are  on record in which  (according to Dr.Tlitchie) menstruation
has taken place  without the escape  of a vesicle, and others, also, in which
there was evidence of the escape of a vesicle previous to menstruation.  This
latter case has occurred more frequently  than  the former  (and answers to
those  cases in which  conception has  preceded menstruation, or occurred
during lactation), but both are  so  rare as scarcely, if at  all, to  affect the
question.
   9.  This view is further supported by the analogy of other mammalia as
Loudon Journal of Med., April, 1850. 
MENSTRUATION.
87
both Bischoff and Raciborski have shown in the case of the bitch ; so ruuch
so that the former accurate observer lays down the law as equally applicable,
that "the ova formed in the ovaries of females of  the human species and of
mammiferous animals, undergo a periodical maturation quite independent of
the influence of the male seminal fluid."1
   The conclusions which have been so ably put forth by M. Pouchet are as
follows :  " 1. That in all classes of mammalia ova are produced spontane-
ously in the  ovaries.   2.  That they are expelled  spontaneously at regular
intervals,  independently of coition.   3.  That in the  human female they are
so expelled  at each menstrual  period, this  period  corresponding to the rut-
ting season  of animals.  4. That the ova are, and can be, fecundated only
after their expulsion from the ovary;  the various solid  membranes by which
they are protected previous to this expulsion  opposing a complete obstacle
to  the access of the spermatic corpuscles, the actual contact of which is
indispensable to the  impregnation  of  the ovum.   5.  That in all probability
the part where fecundation usually takes place, is the  cavity of the  uterus,
or the lower part of the fallopian tube."2  With these  views Bischoff, Raci-
borski, and  others agree ; but although there is a great body of evidence in
support of  this view, it  may be doubted whether  it is  as  yet sufficient to
warrant such positive deductions.
   Professor Midler's opinion, which is more cautiously expressed, is perhaps
more strictly in accordance with the present state of our knowledge.   He
observes that " the number of facts at present collected are insufficient to
establish it as a law, that an ovum is discharged from the ovary of the human
female at  every normally developed period of menstruation.   Yet it must
be  observed, that although the diseases  causing death must, in the majority
of instances, disturb the function of the ovaries,-.and prevent the  extrusion
of the ovum, yet to  each of those inquirers who have been on the watch for
such cases,  several instances of ruptured follicles in menstruating  women
have occurred within a short space of time.   And the fact that the ovaries
of the human female become turgid and vascular  at the menstrual periods,
as those  of  animals  do at the time of heat, strongly favors the opinion that
the generative system of the human female is subject to the almost universal
law of the periodical discharge of ova."3
   110. The final cause of menstruation is said to be, 1, To get rid of the
surplus blood employed during gestation in the  nutrition of  the foetus,  but
which in the unimpregnated state might be injurious ;  and, 2, To prepare
the uterus for impregnation and conception.   The first is a mere hypothesis
grounded on an  assumption, for  it is not proved  that there is any surplus
blood when  the female  is not pregnant;  I need, therefore, say no more
about it.
  As to the second theory, it is based upon the observation, that conception
seldom or never takes place before the  period  of  the first menstruation, or.
puberty ;  that it does not  occur in those who do not menstruate, or after
the cessation of  menstruation ; and that calculations  show  that it takes
place more readily soon  after a menstrual period.  This  latter is a very old
observation, and is held by most modern  obstetricians.  Naegele, for instance,
calculates the duration of pregnancy at  nine months and eight days from
the last menstrual period, and in normal cases he says he  has never been
wrong.   The popular mode of calculation is pretty much the  same.
  [As regards the  coincidence of menstruation and  conception we have
conflicting testimony.   The late Dr. Dewees, whose experience was very
extensive, wrote  as follows: " The final cause  of the menses is perhaps  en-

  1 Muller's Physiology: Supplement, p. 45.     2 Theorie Positive de la Fe"condation.
  3 Physiology: Supplement, p. 50. 
88
MENSTRUATION.
veloped in some obscurity ;  but of this we know at least one incontrovertible
fact, namely, that the  healthy performance of this  function is  in some way
or other connected with the capacity for impregnation ; as no well-attested
instance is upon record, where this has taken place in a female who never
had had this discharge, or even when it was not of a healthy character, and
with a greater or less  degree of regularity."  In these  remarks  we must
understand Dr. Dewees as  merely asserting  his own  experience, for the ex-
perience of numerous equally competent observers is in direct opposition.
The regular and healthy  performance of the menstrual function is  certainly
indicative of a  natural condition of the  female genital organs, and  of the
consequent aptitude of the  individual for impregnation ; yet it is not always
so ;  every healthy menstruating female  is not fruitful;  and I have known
many instances where women bore children regularly, although the men-
strual  office was neither regularly nor  healthfully  performed.   Professor
Dunglison well observes: "As a general rule, the appearance of the menses
denotes the capability of being impregnated, and their cessation the loss of
such capability.  Yet, females have become mothers  without  ever having
menstruated.   Fodere attended a woman who had menstruated but once —
in her seventeenth year, although thirty-five years  of age, healthy, and the
mother  of five  children.  Morgagni instances a mother and daughter,  both
of whom were  mothers before  they menstruated.  Sir E. Home  mentions
the case of a young woman, who was married before  she was seventeen, and
having never menstruated, became pregnant; four months after her delivery,
she became pregnant again ;  and four months after the second delivery, she
was a third time pregnant,  but  miscarried.   After  this she menstruated for
the first time, and continued to do  so  for several  periods, when she again
became pregnant;  and  Mr. Harrison, at  a meeting of the Westminster
Medical Society, remarked, that he knew an instance in which the mother
of a large  family had never menstruated.1   Such instances prove  that ova
are maturated without the ordinary recurrence of a sanguineous exhalation
from the lining membrane of the womb."
   " The menstrual flow," remarks Dr. Dalton,2 "is, in fact, only the external
sign and accompaniment of a more important process taking place within.
It is habitually scanty in some  individuals, and abundant in  others.   Such
variations depend upon the condition of vascular activity of  the system at
large, or of the uterine organs in  particular; and though the  bloody dis-
charge is usually an index of the general aptitude  of these organs for suc-
cessful impregnation, it is not an absolute or necessary requisite.  Provided
a mature egg be discharged from the ovary at the appointed period, men-
struation, properly speaking, exists, and pregnancy is possible."
   The modern ovular doctrine of menstruation is unquestionably encompassed
with some difficulties : these have caused it by a few  to be considered rather
as " a plausible and ingenious hypothesis, than as a well-established theory."
Mr. Kester3 thinks that "the actual state of our knowledge  of the  nature
of menstruation may be expressed  in the following propositions : —
   " 1 Menstruation is a periodical function  of the  uterus.
   " 2.  Ovulation is the constant function of the ovaries.
   " 3.  Ova are matured in  the  ovaries at all ages,  but more rapidly during
menstrual life.
   " 4.  Ova are discharged  at  all periods of female  life, in the intervals of,
as well  as at the time of, menstruation.
   •' 5.  Ovulation and menstruation being often concurrent, indicate  that they

  1 [Human Physiology, 4th edition, vol. ii. p. 357.    2 Human Physiology  p  476 1
  3 [London Medical Gazette, Nov. 1849.]                                   J 
MENSTRUATION.
89
are both the result of the attainment of a certain point in the development
of the female economy.
   " 6.  The law of periodicity in the one not obtaining in the other, leaves still
wanting the inseparable link in the chain of causation whereby menstruation
can be shown  to be the effect of ovulation.
   " 7.  At the menstrual period, the ovaries  experience an extension  of the
uterine congestion, and become, equally with  the uterus, the seat of increased
functional activity.
   " 8.  The  menstrual  flow is a  true haemorrhage, as shown by chemical
analysis, and by the phenomena of disease."]
   M. Bischoff thus expresses himself: "At certain periods, known as those
of'heat' or 'the rut' in animals, and 'menstruation' in the  human female,
the  ova which have become  mature disengage  themselves from the ovary,
and  are extruded.   Sexual desire manifests  itself in the human female with
greater intensity at these periods, and in the females of mammiferous animals
at no other time.  If the union of the sexes takes place, the ovum is fecun-
dated by the direct action of the semen upon it.  If no union of the sexes
occur, the ovum is  nevertheless extruded from the ovary, and  enters the
fallopian tubes, but there perishes."
   I  may here remark, 1, That if this  view  be strictly correct, conception
could scarcely occur previous to the appearance of the menses, or without
their reappearance ; and yet  both cases do occur, and the latter not very
rarely.   2, That the discharge of the ovum must necessarily be about the
termination of menstruation,  or it would escape with that excretion.   3,
That conception  must take place within a few days of that period,  or the
ovum would escape, and only during  that short space, because  afterwards
there would be no vesicle to be fecundated.   How long this period may be
it is difficult to say; but it would be difficult to reconcile this view with the
cases which occur, of impregnation taking place ten, twelve, or twenty days
after the cessation of  the menstrual  period,1 which  are not uncommon.
Jewish females are required to abstain from intercourse for five days before
and  seven days  after menstruation,  and yet they are very fruitful; and
Hirscher mentions a case of conception, where he  ascertained that impreg-
nation occurred twenty-two days after healthy menstruation.  If we calculate
the  period of pregnancy according to  Naegele, or allow a few days more
(reckoning from the mid-period, in the popular mode), my own experience,
and  that of others,  would show that  more women  overrun than anticipate
the nine months.  I cannot think that the period for conception is so limited
as these opinions, if correct, would require ;  neither am I sure that there is
an increase of sexual desire at the menstrual period.
   111.  Dr. F. H. Ramsbotham has  lately put forth his views of the final
cause of menstruation, which I think it right to lay before the reader.  He
conceives that the  function of menstrution is " identical with  the nutrition
of the young ovum, and that the menstrual discharge  indeed is nothing less
than the rudiments of the deciduous membrane itself; or rather that it would
have become the deciduous membrane, provided conception had occurred :"
and  he explains the process more fully thus,—"An ovule  ripe for impregna-
tion  pans from the  nest in which it had been elaborated, being conveyed by
the grasp of the fallopian fimbriae. At the same time  Nature establishes an
action tor the purpose of preserving it, provided an opportunity of becoming
impregnated by contact with the  male semen  is afforded  it.   Should that
contact take place, and conception follow, the fluid formed is retained within
the uterus,  and is gradually converted into the deciduous membrane, which
becomes the  first medium of  communication  between the newly animated
i Oldham: Med. Gaz., July 13th, 1849. 
»
90                         MENSTRUATION.

ovum and  the  maternal vessels.   If. on the contrary, conception does not
happen, the ovule perishes, and the fluid secreted for its advantage not being
required, is allowed to exude  externally, as  a  superabundant  and  useless
excretion."1
  The first difficulty involved  by this view is the  limitation  of the  period
of impregnation, which hardly corresponds  with the latitude allowed, so far
as we can infer from the  period  of delivery.    This,  Dr. R. thinks, may be
explained by the impregnation taking place either  in the ovary or fallopian
tube, and the additional time required for the descent of the ovum.
  In a subsequent communication, Dr. Ramsbotham widens  his theory  a
little, by supposing that the ovum may "part from its previous connections
some days before the  menstrual fluid  is secreted," and so be liable  to im-
pregnation ;  and, on the  other hand, that  the  ovum  may be retained after
the escape of the catamenia ;  and that if within a certain  period it be im-
pregnated, the  uterus may then take on new action, and  form a fresh secre-
tion, which is converted into decidua.
  This extension of the period of conception, to a  certain extent removes  a
second objection, viz., that  we can hardly  suppose impregnation to occur
after the commencement of the menstrual secretion, because of the  impedi-
ment that would be to the ascent of the spermatozoa, and because separation
of the sexes is almost universal during these periods, unless we suppose also
that the  menses are retained  in utero after secretion, of which we have no
evidence.
  I  must add,  as a third objection, that I  cannot  think that we have any
adequate proof that the menstrual  secretions  can be  converted into  the
decidua, considering the  difference in their elementary  constituents.  That
the  same  condition of the  organ  may, under  a different  stimulus,  secrete
either the  one or the other, according to the  peculiar stimulus, I can easily
understand, but that does not seem to be Dr.  Ramsbotham's view.
  Lastly, this theory seems hardly consistent with the laws of menstruation,
when  the  fallopian tubes are impervious, or  with  cases  of extra-uterine
fcetation in which a deciduous membrane is  found.
  Having noticed these  different theories,  I  think it will be the wiser plan
to put forward no theory of  my  own.  Our  knowledge is at present very
deficient, but the inquiries recently set on foot may perhaps result in a more
perfect acquaintance with these important processes and their various relations.

  1 Med. Times and Gazette, Jan. 17th, 1852, p. 57.   Some  interesting correspondence
upon this subject will be  found  in  the same journal for Jan. 24th, p. 92; Jan. 31st,  p.
 115; March 20th, p. 229; March  27th, p. 325, of the same year. 
*
DISORDERS  OF  MENSTRUATION.                 91
                         CHAPTER  II.

                 DISORDERS  OF MENSTRUATION.

  112. These  functional derangements  are  divided into three classes: 1.
Amenorrhcea ;  2.  Dysmenorrhcea, or difficult menstruation ;  and 3. Menor-
rhagia, or  excessive menstruation.  Each will require a separate, though
brief notice.1
  113. I.  Amenorrhcea maybe  divided into  two classes:  emansio men-
sium, when the  menses  have never appeared ; and  suppressio mensium,
when, having been  regular, they are obstructed.  In considering absent
menstruation as a disease, the reader will bear in mind the difference of age
at which the catamenia appear,  as it is  not  intended  to  include late  men-
struation as such,  in the present class.
  114. Emansio  Mensium.— Menstruation may be absent from congenital
malformation.   The ovaries  may be wanting, or, if present,  they may be
atrophied or diseased ; the vesicles may be diseased or absent.  But, although
the ovaries be well developed, other organic  irregularities may prohibit the
periodic evacuation ; for example, the uterus  may be absent, or incompletely
developed  ; the canal of the cervix may be closed, the os uteri impervious :
the vagina absent, its sides  adherent, or its orifice closed by adhesion, false
membrane, or an  imperforate hymen.
  When the defect is ovarian, we find no effort at menstruation at all; the
body is generally pretty well  developed, and its functions (except the one)
tolerably  correct, but  the sexual characteristics  are  wanting.  When the
uterus is absent or defective, on the contrary, these sexual peculiarities are
observed, and there is an effort at menstruation every month, but of course
no  discharge.  There is a considerable  difference, however,  when  the  pas-
sage merely is  obstructed ;  then  the menses may be  secreted,  and retained
in the cavity of the uterus or vagina, until, from over-distension, the parietes
give way.
   115.  The diagnosis will depend upon these peculiarities, and  the treatment
must be adapted   accordingly.  Nothing effectual can be done if the uterus
or ovaries be  absent;  but, in occlusion of the  os uteri or vagina, an  effort
must be made to  remove the obstacle.   The  os uteri,  or canal of the cervix,
may be pierced by a pointed probe, a trocar, or an instrument like that used
by  Mr. Stafford  for strictures of  the urethra.   An artificial vaginal  canal
may be formed by the knife, or by forcibly separating  the parietes.  Occlu-
sion of the vaginal  orifice may be remedied by the knife or trocar.  Great
care will be required  after any of these operations :  leeches,  cold lotions,
fomentations, or  poultices may be necessary.   A  piece  of lint, spread with
simple cerate, should be introduced into the opening to prevent the formation
of new adhesions.
   116.  Sim])le Amenorrhcea is  the name given  to  those cases where the
sexual system  is  developed, the signs of puberty  present, but where no dis-
charge at  all escapes from the vagina.   The subjects of this disease may be
of robust  habit  of body, or weak,  pale, and delicate.  In  the  former, the
constitutional suffering is more severe, with some  febrile action, flushed face,
headache, full pulse, etc.  In the latter, the sympathies of distant organs are

  1 For fuller details concerning these disorders, I beg to refer my readers to my volume
on Diseases  of Women. 
92
disorders of menstruation.
manifested more  slowly, and  there is little, if  any, febrile action.^  They
appear, in fact, something like the acute and chronic statres of other diseases.
In either, an attempt at menstruation may be made every  month, accom-
panied by rigors,  pain in the back and loins, weight at the lower part of the
abdomen, aching along the thighs, general lassitude and uneasiness, etc.,
etc., without any discharge.  But, though these symptoms pass away, ano-
ther series arises : the  patient complains of frequent headache, sometimes
with intolerance of light and sound, throbbing, and a sense of  fulness in the
head, pain in the  side or back ; the stomach and bowels become irregular,
the countenance pale, and  the strength  reduced.   Paroxysms of  dyspnoea
and hysteria may also occur,  and the patient acquires the appearance of
confirmed ill-health.   Of course these symptoms will differ in  different con-
stitutions ;  and cases  occur occasionally in which a long  continuance of
amenorrhcea has but slightly disturbed the general health.
   A vaginal examination with the finger or bougie affords no information
in these  cases.
   The causes of  this variety, says Dr. Locock,  " are  generally to be  found
in the previous habits of the patient; for it is most frequently met with in
those who have led sedentary and indolent lives,  who have indulged in luxu-
rious and gross diet, and been accustomed to hot rooms, soft  beds, and too
much sleep."
   The proximate cause is probably some peculiar condition of the ovary in
the majority of cases. •
   The diagnosis must  be formed upon the fact of there being, a menstrual
effort or not;  and, if  there  be, upon the existence  or non-existence of
obstructions.   If  the  menstrual molimen  occur,  and  there  be neither
obstruction nor discharge, we  may conclude the case to be  one  of simple
amenorrhcea.
   117.  The treatment  must depend  upon the constitution of the patient.
 and will vary, as it is  administered  during an  interval, or at a menstrual
period.   In patients of a full habit, venesection will often afford relief.   This
must be followed during an interval  by  a diminution in  the quantity  of the
food, absence of  stimulants, exercise,  and occasional purgatives.  When the
 patient  is of a weak, nervous, or leuco-phlegmatic constitution, the  system
 should be strengthened by generous diet and the moderate use of wine, with
 gentle exercise.  Preparations of iron  will be  found very useful.  By the
 older writers a long list of emmenagogues is given ; but modern experience
 has reduced the number.   Iodine, strychnine, electricity, and  iron, certainly
 seem to  have a  direct power over the uterus,  and  may be used  advan-
 tageously.   Stimulating injections  into the  vagina or uterus have been
 recommended,  but  they are very questionable.   M. Carron du Yillard has
 succeeded with the cyanuret of gold,  Dr. Loudon by leeches  to the breasts,
 Sir J. Murray by cupping-glasses to  these organs, Rostan by  leeches to the
 os tincae, Soult  with aconite,  Hannay  with  the ammoniated  tincture of
 guaiacum, and Schonlein by enemata  of aloes.   Stimulating the neighboring
 organs (the rectum and bladder) is often beneficial.
    [The  author has shown less than his wonted  clearness  on this subject.
 He has  fallen into the common error  of regarding amenorrhcea as a disease;
 whereas it is only an occasional symptom — merely the  non-performance of
 a function, the exercise  of  which is  not always necessary for the health of
 the female, during  the  period of her life when  it usually occurs.   It has
 been shown (page 90) that women  may even  bear  children without men-
 struating.  I know a maiden lady, now  nearly fifty years old,  who has gene-
 rally enjoyed very  good health, although she never menstruated more than
 twice a  year, and sometimes only once in twelve or fifteen months.   Amen-
 orrhcea,  therefore, is not properly a disease, but a  consequence of  either 
AMENORRHCEA.
93
individual  organization, disorder of the uterus or ovaries, or of some other
organ  or  organs, of sufficient importance for the disturbance of their func-
tions to affect materially the  patient's  constitution.   When it is the conse-
quence of peculiar organization, of course all attempts to excite or produce
the discharge will  be vain,  and most likely pernicious;  when it depends
upon disorder of any one or more organs,  it is obvious that the pathological
condition  of these must be sought out and removed before we can  hope that
the menstrual flow can be restored.  In  such cases, all the  means adapted
to restore health to the system,  medicinal  or  hygienic, may be regarded as
emmenagogue ; but that we possess any article having the direct power of
causing or restoring the regular monthly discharge of blood from the  uterus,
apart from its property of overcoming  some morbid condition of the uterus
or ovaries, or of some other  organ  by which the general health of the indi-
vidual is  impaired,  has not  yet been proved, nor is  it probable that  any
such exists.   Nothing can be more opposite and heterogeneous than the
articles commonly  prescribed as emmenagogues;  and it  is  therefore  with
 justice that they are  classed by Dr. Ferguson as "nostrums."   The little
confidence reposed in such agents has induced some practitioners to attempt
the restoration or establishment of  the  discharge by means of a more direct
nature.   In some instances  of  mere torpor, electricity has  been useful in
exciting the capillaries to greater activity by its direct impression  on  the
nerves of the uterus ;  but it is a means which is  adapted  to a very  limited
class  of cases.   " Stimulating injections into the vagina and uterus," are
indeed questionable — into the latter organ, imminently dangerous.   This is
the declaration of Bretonneau, Ricord, and several other respectable autho-
rities.   " M. Hourmann  relates  a  case where violent abdominal pain, fol-
lowed  by metro-peritonitis, was  caused by the injection of  a decoction of
walnut leaves into the uterus, for the cure of an obstinate  leucorrhceal dis-
charge, which had been traced to the cavity of that organ.  Wishing to
ascertain  whether these dangerous  symptoms  could be produced from a por-
tion of the fluid having passed through  the  fallopian tubes into  the cavity
of the abdomen, he found, on injecting fluid into the uterus after death, that
such was actually the case."  If  the opinion now generally admitted by
physiologists shall be fully established, that menstruation is intimately con-
nected with, or dependent on, the maturation and shedding of Graafian vesi-
cles, it is  manifest that little good can be  expected from articles that are not
calculated to impress favorably the ovaries.]
   118. Amenorrhcea, with vicarious Uterine  Leucorrhcea, differs essentially
from the  preceding varieties,  inasmuch as uterine secretion exists, whereas
in them the uterus was quiescent.   The product is a white or colorless fluid,
and so far, not the  menses;  but the symptoms of menstruation occur,  and
the patient does not require medicine acting directly upon  the uterus.  I
have  already alluded  (§ 105) to the  leucorrhcea which occurs at the com-
mencement of menstruation, and which is generally superseded by the  menses
after one or two periods.  It is only when this change does  not take place
that we need interfere.   The white discharge may continue  periodically to
usurp  the place of the catamenia; but, in addition, it  often continues during
the interval.
   119. Treatment.—When the white discharge is persistent, the case is one
of uterine leucorrhcea, and requires the appropriate treatment;  but when it
occurs only at intervals, as vicarious of the menses, our object should be to
strengthen  the  constitution  by generous  diet,  exercise, bathing, etc.,  and
tonic medicines.   I have found great benefit in such cases from the carbonate
of iron.
   120. Svppressio Mensium.—A suppression of the menstrual discharge 
94
DISORDERS  OF  MENSTRUATION.
may occur suddenly, or more gradually;  in other words,  it may be  acute or
chronic.
  121. Among the  causes of Acute Suppression of the Menses maybe men-
tioned cold caught  during their flow, by wet feet, etc. ; sudden mental emo-
tion, or a bodily shock, fear, disease, etc.
  The amount of disturbance consequent upon the sudden arrest, varies a
good  deal.   Most  frequently a  degree of fever results,  with  headache, hot
skin,  thirst, quick  pulse,  etc.;  or the patient may be  attacked  by local
inflammation of  the brain, lungs,  intestinal  canal,  or of the uterus itself.
Sometimes, instead of inflammation, we  see  attacks of  hysteria  simulating
inflammation, or of neuralgia of  different  parts.    Occasionally  derange-
ments of the senses, aphonia, imperfect vision, etc., or  paralysis and apo-
plexy, follow.
   The sudden suppression, from a definite cause, will distinguish this form
of  amenorrhcea from all others.
   122.  Treatment.—The  first object  is  to recall the discharge, if  possible.
For this purpose the patient should take hip-baths or pediluvia, and swallow
some warm drinks.  Mild diaphoretics and  gentle  purgatives will also be
useful.   Should  all our attempts  fail,  we may content  ourselves with miti-
gating the severer symptoms, until the approach of the next menstrual period,
when the diligent use  of the ordinary remedies will  probably be followed by
the proper secretion or by a colorless discharge.  If neither take place, then
we must have recourse to some  of those  remedies, already mentioned, which
act directly upon the uterus.
   123. Chronic  Suppression of the Menses may be the  issue of  an  acute
attack, or it may arise from the gradual supervention of delicate health, or
from  disease of the ovaries, uterus, etc. ; or it may occur as the termination
 of menstruation.  The quantity  of the discharge  may diminish, and the
periods  become irregular, until  at length the function ceases.   But very
 often the menses are  superseded  by leucorrhcea, at first periodic,  but ulti-
mately persistent.
   The symptoms which develope  themselves are headache, loss  of  appetite,
 pain  in the side and back, debility, and general deterioration  of health.
   The most important point for diagnosis is to distinguish this form of sup-
 pression from pregnancy, and which will mainly depend upon  the absence of
 the usual signs of  pregnancy, at a period when they ought to be present.
    124. Treatment.—When the  suppression has been the result of disease,
 upon its removal the catamenia will return; and, if it have  been caused by
 leucorrhcea, the  proper treatment of  that disease will generally end in  the
 restoration of the menstrual discharge.  When the  suppression is uncompli-
 cated, the remedies for simple  amenorrhcea may be tried ; but caution will
 be necessary, and a careful estimate of the general  condition  of the patient,
 together with a vaginal  examination, in order to  make sure that there is
 neither organic disease, nor obstruction of the womb, and that  the case be
 not one of premature  but normal cessation of  the menses.
    125.  Vicarious  Menstruation. — This is  a very  curious  deviation from
 normal menstruation,  and seems a provision for, in  some degree, mitigating
 the constitutional effects of suppressed menstruation, by substituting a simi-
 lar discharge from some other part. It is recorded to have taken place from
 the nostrils, eyes, ears, gums, lungs, stomach, anus,  bladder, nipples, the ends
 of the fingers and  toes, from different joints,  from the axilla, from the stump
 of an amputated limb, from ulcers, from varicose tumors, and from the sur-
 face  of the skin generally.  The more extensive  mucous membranes are,
 however, most frequently the seat of the discharge.   It  appears to be some-
 times blood ; in others it has the  characters  of catamenial fluid, beino- dark-
 colored, thin,  and not coagulable.  The repetition of this  discharge may 
DYSMENORRHEA.
95
occur at the regular period, or it may intermit; and it does not appear that
any serious result follows, even when  delicate organs  are  the seat  of it.
Sooner or later the uterus resumes its functions, and the attack  ceases.
  [The cases of the so-called "vicarious  menstruation," are nothing more
nor less than cases of simple capillary hemorrhage, resulting from the general
disturbance of the circulation which occurs during amenorrhcea.  The hemor-
rhage may take  place  at nearly the natural periods of menstruation, but
generally it appears  at irregular  periods.   Although  in every case it is
dependent on an  arrest  of the  menstrual  discharge from the uterus, yet it
cannot properly be said to take or supply the place of the latter.]
   126. Treatment.—After this discharge has once occurred, it will be proper
to take measures to relieve the  system in a less questionable manner, by vene-
section, cupping, or leeches ; and a careful watch will be necessary.   If the
evacuation take place from the lungs or stomach, opium combined with lead
or bismuth, and the mineral acids, will be found beneficial.   During an in-
terval, the patient may  be treated much in the same way as for amenorrhcea,
 and occasionally we may try some of the direct remedies.
   127. II. Dysmenorrhea, difficult or painful menstruation.—This form
 of  abnormal menstruation consists of  severe pain in the secretion or emis-
 sion  of the discharge,  which may be scanty, profuse,  or  about the usual
 amount.   The attack is occasionally confined to one or two  periods, but
 more frequently lasts for a longer time, and sometimes for  many  years.
 From the different  character  of the pain  and  constitutional  symptoms, I
 have divided the disorder into  three species,—neuralgic, inflammatory, and
 mechanical dysmenorrhcea.
   128. Neuralgic Dysmenorrhcea.—This variety may occur at any age, but
 is more frequent after the thirtieth year than before ; in unmarried than in
 married women,  and, if married, in  those who have not borne children.   It
 is almost confined to those of a nervous temperament, and of a thin delicate
 habit.  The monthly paroxysms present all the characteristics of neuralgia;
 and  I am very much inclined to agree with Dr. Tyler Smith, that the chief
 seat is in the ovaries.   For a short  time previously,  there is a  sense  of
 general  uneasiness, a deep-seated  feeling of cold,  and headache, sometimes
 alternating with pain in the back.   The latter commences in the region of
 the sacrum, and extends round to the lower part of the abdomen, and down
 the thighs.  The amount of suffering varies; but it is sometimes very great.
 After a longer or shorter period, the catamenia  appear, sometimes  slowly
 and  scantily, in  others, in  slight  gushes.   The quantity differs in  different
 persons,  and in the same person at  different times.  The quality of the dis-
 charge may be unchanged,  but we frequently find  it paler, and occasionally
 mixed with small clots.
   In some cases,  there is a  membrane,  composed  of plastic lymph, dis-
 charged  either in shreds, or in the form of the uterine cavity  which  it has
 lined.  It seldom occurs regularly,  contrary to the opinion  of  Dr. Denman.
 It was first, I believe, described by Morgagni; and since by Denman, Burns,
 and  other obstetric writers.  Dr. Simpson has recently expressed an opinion
 that these productions " are not the results, as is generally  supposed, of
 fibrinous or plastic exudations upon the free surface of the uterus,  but that
 they consist of exfoliations  of that membrane itself."   At present I confess
 I am not  prepared to agree with the able and learned Professor.   Denman
 states that he never knew  a woman conceive by  whom this membrane was
 secreted ;  but this conclusion appears to be too general. Conception is rare
 under such circumstances;  but I have known it occasionally take place.
   The symptoms enumerated  are not always mitigated on the appearance
 of the menses; the pulse is  scarcely quickened, nor is there any feverishness.
 The  duration of a period is variable.  In some cases there  is comparatively 
06
DISORDERS  OF MENSTRUATION.
little constitutional injury  sustained, but  in  others the  patient's  health is
much deteriorated.
  The  cervix uteri undergoes the change usually observed during menstrua-
tion, but nothing else is detected by an internal examination.
  From an attentive examination of these  cases, I have been led to the con-
clusion that the disease is generally of a simple neuralgic character.   Pro-
bably in  those cases where the membrane is discharged there  may be, as
Dr. Locock thinks, a degree of inflammation  of the mucous membrane, of a
peculiar kind.
  The  causes are cold, sudden shocks, mental emotions, etc.,  acting upon
an irritable condition  of the womb.
  129.  Treatment.—The  indications are twofold ;  first, to reduce the pain
during  an  attack; and, secondly, to prevent its  return, by appropriate
remedies during  an interval.   The  first  indication  is  best  answered  by
sedatives;  opium or some  of its preparations;  hyoscyamus,  conium, etc.,
which  may be given alone or in combination with camphor.   Should the
stomach be irritable, they may be exhibited in an enema.  I have remarked
that the discharge increases when the pain is  relieved.  Other remedies have
been tried with success ; as, the  acetate of ammonia by Massuyer, Cloquet,
and Patin ;  ergot of rye by Dewees and Gooch, etc. etc.
  [In  a few instances,  I have derived advantage from the administration of
ten grains of ergot, morning, noon,  and  night, commencing three or four
days before the expected attack, and continuing it daily until the period
arrived.  As soon as the attack commences, I  have always found it  advisable
to moderate its violence by sending the patient to bed,  applying warmth to
the feet  and to  the vulva,  and administering some  of the preparations  of
opium.  Three grains of opium as a suppository, or sixty drops of laudanum,
suspended  in a  tablespoonful  of  mucilage, as an enema, is a prescription
that has always afforded great relief at the  time, and,  apparently, lessened
the disposition to a return at the next period.   In severe cases, it may be
proper to repeat the anodyne every day until  the pain ceases.]
  During the intervals, every effort should be  made to strengthen the patient,
and to diminish general and local irritability.  The diet should be nourish-
ing,  and plenty of exercise in the open air should be taken by the patient.
Chalybeate waters or some preparation of iron may be  given.   Dr. Locock
speaks highly of a mixture of equal parts of vinum ferri and the spirit.
cether. sulph. co., of which from half a drachm to a drachm may be taken two
or three  times a day.   Dr.  Dewees has tried the tinct.  cantharid., and Dr.
Chapman the senega root, with success.  A blister to the sacrum, or a caustic
issue, is  often of great use ; and  I have seen much benefit derived from the
daily use of vaginal injections of tepid or cold water, during the interval.
On the approach of the next period, warm water should be substituted, and
the patient  should use a hip-bath or pediluvium for two or three  nights in
succession, antecedent  to the eruption of  the menses.   I have succeeded in
curing a case in which the false membrane  in sheds was  discharged every
month, by repeated  applications of the strong tincture of iodine to the cervix
uteri.   This is by far the most obstinate variety of  the  disorder.
  [Dr. Dewees  found  advantage  from the administration  of  the volatile
tincture of guiacum during  the intervals of menstruation.  When the patient
was  of a robust habit, with a firm and bounding pulse, he directed the use
of the remedy to be preceded by bleeding, smart purging, and a  low diet.
To obtain benefit  from the guiacum,  perseverance in  its use for  several
months is often necessary.  The dose directed  by Dr. Dewees was a teaspoon-
ful  three times a day, in a glass of sweetened milk,  or, when not counter-
indicated, in a glass of some light wine.  The tincture used by the Doctor
was  made of four ounces gum guiacum, one drachm and a half of carbonate 
DYSMENORRHCEA.
97
of soda, and an  ounce of allspice ;  these were digested in  a pint of proof-
spirits for a few  days, when the volatile spirits of ammonia was added in the
proportion of  one or two drachms to every four  ounces of the tincture.]
  130. Inflammatory Dysmenorrhcea. — The  subjects of  this form differ
as widely from those of the former as its symptoms.  It occurs in females of
a full habit and  of a sanguine temperament, in the married as well as in the
unmarried, and  in those who  have  borne children.  Few precursory symp-
toms announce the attack ; a  degree of restlessness and feverishness, rigors,
flushing, and headache, generally precede the severer symptoms.  For some
time before and  after the catamenia appear, the  suffering is  very great;  the
patient complains of pain across the back, aching of the limbs, weariness,
and intolerance of light  and  sound ; the face is  flushed, the skin hot,  and
the  pulse  full,  quick,  and  bounding.  Delirium  occasionally  supervenes.
Most frequently the  symptoms are mitigated when menstruation takes place,
and by degrees  subside.  The discharge is generally sufficient, and in some
cases is accompanied by the  secretion  of the plastic  membrane spoken of
above.
   During the intervals, the health of  the  patient is little affected ;  she may
be subject to  headaches, and pain in the side, but these are generally trans-
sient, and  do not interrupt the functions of the different organs.  Uterine
leucorrhcea is not unfrequently present  during  the interval.  An internal
examination  during the attack affords evidence of some  congestion of the
uterus ; the cervix  is swollen, and the heat of the  parts  increased.   Dr.
Dewees- has noticed  pain and swelling of the breasts as an  occasional accom-
paniment of  this form of dysmenorrhcea.
   [In a recent very interesting treatise on the Diseases of Menstruation, etc.,
 Dr. E. J. Tilt has endeavored to show: That dysmenorrhcea is often pro-
duced by subacute ovaritis ; and sometimes of the uterine engorgement which
it determines.  That  it is often the  result, also, of morbid ovulation,  and
frequently a  symptom of ovarian  peritonitis.   That  subacute  ovaritis, by
determining the inflammatory  swelling of the neck  of the womb, is a common
 mediate cause of dysmenorrhcea;  the painful  symptoms  being, in  many
instances, produced  by the partial closure of the neck  of the womb, and the
consequent effusion  of menstrual secretion into the peritoneum ]
   A  severe attack of  either variety has the effect  of precluding conception;
 but I have repeatedly known  conception to take  place in spite of, and with
benefit to slighter cases.
   [Dr. Ryan relates two cases in which the dysmenorrhcea was aggravated
by marriage;  we  have seen many such.   According to Dr.  Dewees, concep-
 tion very rarely,  if ever, occurs, when  there has been discharged during
 menstruation  a membranaform substance.  Dr. Ashwell  (Diseases of Females)
 states, " that  when pregnancy occurs during the continuance of dysmenor-
 rhcea, the female is exposed to the risk of abortion.]
   131. Treatment. — The success of remedies in this variety of dysmenor-
 rhcea  affords a confirmation  of its  character.    Yenesection, cupping the
 loins, leeches, or scarifications to the cervix  uteri, afford the quickest relief.
 They should be followed by saline purgatives, with febrifuge medicines, and
 cooling drinks.    When by these means  the  inflammatory symptoms are
 subdued,  a dose of calomel and opium at bed-time is often very useful.
   During the interval great benefit may be derived from judicious manage-
 ment.  The  patient should take active  exercise, and be as much as possible
 (if the weather be fine) in the open air.  Walking is preferable to riding or
 driving.  Brisk purgatives, and the aloetic are the best, should be regularly
 administered  ; and on the approach of the next monthly  period, if much
 excitement arise,  it  may be  well to  abstract blood by cupping before the
 regular attack comes on.
        7 
98
DISORDERS  OF  MENSTRUATION.
  132. Mechanical Dysmenorrhcea. —I have applied this title to a difficulty
in  the emission of the menses, caused by a narrowing or  stricture in some
part of the canal of the cervix.   What may be the cause of this diminution
of calibre, whether it be congenital or the result of inflammation, is not easy
to determine;  but  there  can  be  no  doubt  of its  existence.   Capuron
enumerates it among the causes of dysmenorrhcea ;  and the late Dr.  Micin-
tosh, of Edinburgh, states that he repeatedly detected  it.   Professor Simp-
son  considers it a verv frequent cause.  I found it remarkably evident in a
case  I attended with Dr. Charles O'Reilly, of this city.   It  may occur at
any  part of the  canal, and the  degree of obstruction  may vary up to com-
plete closure.  I apprehend that there can be little doubt that dysmenorrhcea
may result from.tip's cause, though I am far from thinking it  so common as
was  supposed by Dr. Macintosh ; neither  do I believe that, even where it
exists, it  is always the cause of the difficulty and pain.   In  several  cases,
although  I have cured the stricture, the dysmenorrhcea has continued.  Nor,
even in Dr. Macintosh's case, is there sufficient evidence to prove his point;
for he does not show that there  was any retention of the menses, but merely,
that  at subsequent periods  menstruation was easier and  more  abundant:
this might have  arisen from the  direct stimulus to the uterus afforded by the
introduction  of bougies.
   133. Treatment.—The fact that such a stricture of the canal of the cervix
has  been  observed, should lead us to make an examination with a small-sized
bougie, in all cases of very obstinate dysmenorrhcea,   Such an examination
is neither difficult,  painful,  nor injurious,  if proper  caution  be  observed.
Should stricture be detected, the remedy is the repeated introduction of
bougies about every second  or third day, and increasing  in  size, until the
obstacle be overcome.   No force must be used ;  and, if any irritation  mani-
fest itself, it  must be allowed to subside before the operation be repeated.
   Dr. Simpson has invented an  instrument for the division of the cervix in
these cases ; but I rather think the object  can  be more  safely attained by
dilatation, and quite as satisfactorily.
   134. III.  Menorrhagia. — I shall follow Dr. Locock's  example, and
apply this term  to  an  increase in the  monthly evacuations, whether accom-
panied by blood or not.  Excessive menstruation may occur in various  ways :
the  menses may return too frequently, or too copiously, or at unusual  inter-
vals, as during gestation and suckling.   Some allowance also must be made
for  differences of constitution, and  perhaps of climate.
   I have  observed three  distinct forms of the disease.  In the first, the dis-
charge is of the natural quality, but the quantity or frequency of recurrence
is greatly increased.  In the second, the discharge is large, and occasionally
mixed with blood ; but no change  in  the condition of the body or neck of
 the womb can be  detected by an internal  examination.  In the third, there
 is a considerable loss of blood,  with a marked change in the size and posi-
 tion of the uterus.  Let us examine each of these varieties in detail.
   135. The first variety of Menorrhagia occasionally commences with  a
 sudden and violent gush from the vagina, after which it stops for some  hours,
 and then recurs;  and this alternation may continue during the usual  period
 of menstruation.   Sometimes,  on  the  other  hand, the discharge  goes  on
 regularly, but lasts for ten days or a fortnight, or even three weeks ; or, the
 quantity  each time not  being excessive, it may return every two  or three
 weeks ; and, although this latter case is most frequently met with in women
 who have borne  many children, I  have seen it occasionally in unmarried
 females.   It is also, more than  the  others,  connected  with that state  of the
 lining membrane which gives rise to uterine leucorrhcea.
   The symptoms are exactly those we might anticipate from the long con-
 tinuance  of a debilitating discharge.  Exhaustion, languor, indisposition to 
MENORRHAGIA.
99
exertion, weakness  across the loins  and hips, pallor of countenance, head-
ache, throbbing of  the temples, tinnitus aurium, and giddiness, occur more
or less in  these cases.  If relief  be  not obtained, and especially if uterine
leucorrhcea  be present, all  these symptoms  will be aggravated.   The ex-
haustion and languor increase, the face becomes sallow, an aching  pain is
felt across the loins and round the lower part of the  abdomen, pain in the
left side, repeated and severe  headaches, derangements of the stomach  and
bowels follow, and,  in short, all the secondary symptoms and disturbance of
the general  health which result from anaemia, no matter how produced.   In
some extreme, but rare cases, we have diarrhoea and anasarca, with nervous
symptoms,  melancholy,  and  even  epilepsy, resulting  from the  disease.
Nothing is discovered by a vaginal  examination :  there is neither  swelling
nor  increase of heat about the uterus ; the os uteri is  slightly open,  as usual
during menstruation, but there is no tenderness.
   Among the causes we may  enumerate repeated  child-bearing, over-suck-
ling, excessive coition, cold, mental emotion,  etc.
   136.  Treatment.—The first indication is to remove the  cause : if it pro-
ceed from over-suckling, the child should be  weaned, and the patient should
live "absque marito."
   In persons  of a full habit of bodj', when the  attack is recent, it may be
necessary to take blood from the  arm, cup the loins, or apply leeches to the
anus.   The discharge may be moderated  by a  combination of the acetate
of lead with opium.  When this  has failed, I have generally succeeded with
ergot of rye, in five-grain doses, three times a day.   Dr. Locock recommends
cold to the  vulva, hips, and abdomen, with vaginal injections of cold water;
and Dr. Dewees has used a vaginal injection  of sugar  of lead and laudanum,
with rest on a hard bed, twenty drops of elixir of  vitriol, and  gentle purga-
tives, with success.   I should  altogether deprecate injections into the womb,
recently advised by French writers, as a very hazardous practice, and which
even their own experience does not justify. A far safer, and as I have found
it, a very effectual  practice, is to  employ enemata  of cold water.  Plugging
the  vagina  has also  been  recommended, and as a "dernier ressort" may be
tried, though it is not a  very  scientific  remedy.   Dr. Macintosh speaks
highly of an enema containing a scruple of  the acetate of lead.  The tinc-
ture of Indian hemp has a powerful effect upon  this form of the disease.  It
was  first  tried by my friend, Dr.  Maguire of Chapelizod, and on his recom-
mendation,  by Dr.  Hunt and  myself, with extraordinary success, both in the
number relieved and the rapidity of cure.  From five to  ten drops three
times a day in some suitable menstruum will  be found sufficient.
   During the intervals, a blister  may be applied to the  sacrum,  and either
kept open or  repeated.  Yaginal injections,  at first of tepid and afterwards
of cold water,  daily, will be found very useful.   Benefit will also be derived
from sponging the  loins and lower part of the abdomen with cold salt-water.
Tonics may be given, comfortable  warmth preserved, and  a  generous, but
not  too stimulating, diet allowed.
   137.  The second variety of Menorrhagia differs from  the first, in the
discharge of blood which accompanies the secretion.  It seldom occurs in
unmarried or young females,  and generally  in  those of  a leuco-phlegmatic
constitution, who have  been debilitated by disease or  frequent child-bearing.
The progress of the disorder is gradual; one or two small clots  appearing
at first, then an intermission, and a more copious recurrence.   After some
time, the  discharge of blood may be  considerable, so as  in  some  cases to
produce fainting.   It is of  course impossible to ascertain whether the cata-
menia themselves are altered in  quantity or quality.   A vaginal examina-
tion throws no light upon the nature of the  disease, the uterus  being in its
usual state during  menstruation.  The constitutional effects  are similar to 
100
DISORDERS  OF  MENSTRUATION.
those noticed under the first form (§ 135), but more  severe, and produced
more rapidly.
  138.  Treatment.—The remedies recommended for the former variety are
equally available  here.   Opium, alone or  in  combination with lead, and
ergot,  or  Indian  hemp,  during the attack  ; with counter-irritation  to  the
sacrum, the douche to the loins, or  cold sponging, vaginal  injections or ene-
niata, during the  interval, are our chief resources.
  [The juice of the common lesser  nettle  (Urtica urens) is strongly recom-
mended by M. Ginestet,  in doses of fifteen to thirty drachms.   In preparing
the juice, a quantity of  the  green  herb is  bruised,  with the addition of a
little water, and the fluid portion then  strained off by pressing the mass in
a linen bag.  One  dose is  said   to be  generally sufficient  to check  the
discharge.1]
  139. The  third variety  of Menorrhagia differs considerably from  the
other two ;  the discharge is more profuse, and its effects more severe ; it is
accompanied by  marked alterations  in the condition  and relations  of the
uterus, occurs at a later period of life, and is more difficult to cure.   The
attack  is not confined to any one  kind of constitution or temperament; it
occurs in the plethoric and in the  debilitated, in the melancholic as well as
in the  sanguine.   I have never seen it in  a patient under forty years of age,
nor  after the cessation of the catamenia.
   The attack is preceded for some time by irregularity of the menses, both
as to time, quantity, and the duration  of each period, with occasional ute-
rine leucorrhcea during the  intervals.  It is not until the menses have flowed
naturally for about twenty-four hours, that the sanguineous discharge appears.
Large  clots are  then  expelled, in  addition to a  great increase in the fluid
discharge.  At first, the  attack lasts seven  or ten days only, but in cases of
longer standing  I have  occasionally known it to continue throughout the
interval, and terminate  after the next period either gradually or suddenly.
The quantity lost varies, of course :  it is sometimes very large ; it was suf-
ficient in one case to excite fears of a fatal  result.
   The recumbent posture appears to have no effect upon the discharge, there
being  as much observed during the night as the day.  Any exertion or long
standing never fails to increase the amount.
   During  the  attack,  the patient  complains  of excessive  exhaustion, of a
sense  of weight in the pelvis, of a dull pain there occasionally, and of weak-
ness in the loins.   In all the cases I  have seen there was considerable dysuria,
especially  after  long standing : several,  indeed, were obliged to  lie down
before they were able to evacuate the contents of the  bladder completely.
   The general health, of course, suffers  considerably ; the appetite dimin-
ishes,  the  tongue is clean, though  pale, the bowels become constipated, the
surface blanched,  and the strength  much reduced.
   The pulse is  occasionally quickened, but more generally quiet, and en-
feebled in proportion to the loss of blood.
   An  internal examination will detect the os uteri somewhat lower in the
pelvis, and directed more towards the sacrum  than usual.    It is rather more
patulous  than ordinary, and the cervix  is more or less swollen, especially
anteriorly where it expands into the  body.   It appears to be tilted forward
by its increased  weight, so  as to press upon  the bladder, thus affording a
satisfactory explanation of the dysuria which I have  noticed  in every well-
marked case.  No increase of heat  is observed in the vaginal canal, or about
the  cervix.  The cervix  and lower part of  the body of the uterus are gene-
rally,  but  not always, slightly tender on  pressure.  Of course, the amount
of  these alterations will vary in different cases.

    [' Ranking's Half-Yearly Abst. from Encyclop. MeU de M. Lartigue, Oct. 1844.] 
MENORRHAGIA.
101
  The disease must be regarded as congestion of the uterus occurring at
the menstrual period, and  giving rise, by its  excess, to a rupture of some
small vessels.   AA7hether it has  anything to say to  the  production  of the
organic diseases of the time of  life at which it occurs, may not be easy to
decide : I think it not improbable.
   The diagnosis will  not be difficult, if we bear in mind the  mode of inva-
sion, the character of  the  discharge, the local characteristics, and the sub-
sidence of the attack.
   140.  Treatment.— Although the complaint appear simple, it is neither
easy nor possible in all cases to restrain the hemorrhage by means applied
during the  attack.  I  have found opium  alone, and in  combination with
large doses  of the acetate  of lead, ineffectual,   Cold to the vulva and ene-
mata of cold water were equally powerless.   Plugging the vagina arrested
the discharge for a time, but the irritation  it excited seemed to aggravate
the other symptoms.   Leeches to the vulva had  no  effect upon it, and the
preparations of iron did little or no good. The only  remedy,  in short, which
seems to have the power of controlling  the discharge during  the menstrual
period, is the ergot of rye or Indian hemp.   The former may be given in
doses of five or ten grains twice or thrice a day.  I have never seen it pro-
duce any ill effects in this disease, although I have  certainly known  it fail
altogether.
   During an attack  the patient should be kept in  a state of perfect rest:
she  should  lie on a hard mattress, covered  rather lightly with bed-clothes,
but  with warmth applied  to the feet.   All her drinks  should be cool and
devoid of stimulants, unless she become faint, and then a little wine may be
 allowed.
   At this  period, ergot of rye, or any astringent medicine, may be  given.
 If the discharge be not arrested, and show a disposition to continue through-
 out the interval, it may perhaps be justifiable to inject the vagina with cold
 water  or an astringent lotion.   I have never  tried this, but have  found
 enemata of cold water answer the purpose  very well.
   So long  as the discharge continues, the  employment  of the remedies for
 the cure of the disease must be suspended ;  but, when once it has entirely
 ceased, not a moment should be lost.    A blister should  be  applied  to the
 sacrum, and either kept open or repeated.   I have always found good result
 from this;  the  pain  in the back  generally becoming less severe, and the
 whites diminishing in quantity.   But  by far  the most  powerful means we
 possess are vaginal injections of cold water, of a solution of  acetate of lead,
 or other astringents, two or three times a day.   The patient should lie on
 her back in bed, and the fluid should be thrown  up   gradually.   An  almost
 immediate  improvement is the result, followed by the subsidence  of  all the
 prominent  symptoms, even in those cases which relapse subsequently.  The
 swelling of the uterus will be found upon examination to have disappeared,
 there is probably scarcely any whites, no pain in the back or weight in the
 pelvis, and the patient is  able to walk about without inconvenience.
   When the improvement is so marked as  this, there is  but  little fear (with
 due caution) that the patient will  relapse at the next monthly period ; but
 where the  relief, though decided, is not complete— where  the disease still
 lingers, then in all probability the next menstruation will be accompanied
 with the old symptoms, to be met again, and perhaps more successfully, by
 the same remedies. 
102
GENERATION.—CONCEPTION.
                       C HAP TE R  III.

                  GENERATION. —CONCEPTION.

  141. Immediately after the effective  intercourse of the male with the
female, a series of changes commences, which ultimately issue in the forma-
tion of a new being, possessed of individual or independent life.  The first
step in this process is called Generation, Fecundation. Conception, etc.  The
period of  fecundity in the human female lasts about thirty years, ?'. e., from
the fifteenth to  the forty-fifth year, or thereabouts ;  in other words, it is con-
temporaneous with menstruation.
  142. From the hidden nature of the process  and the stupendous  results,
the subject has always possessed the  deepest  interest for physiologists, and
at the same time given rise to  a multitude of  theories, most of them, to say
the least,  mere  hypotheses.   Dr.  Allen  Thompson, in his  valuable  paper,1
thus  classifies them : " The greater number of the  older theories of  genera-
tion  may be brought under one or other of these divisions ; viz., the theory
of the ovists,  of the spermatists, or  of that of combination, evolution,  or
epigenesis.  According to the first-mentioned of these  hypotheses, or that
of the ovists, the female parent is held to afford all the materials necessary
for the formation of the  offspring, the male doing  no more than awakening
the formative powers, possessed by and lying dormant in the female product.
This was the theory of Pythagoras, adopted in a modified form by Aristotle;
and we shall afterwards see  that it  resembles  most closely the prevailing
opinion of more modern times.  The  terms, however, in which some  of the
older authors  expressed this theory are very vague ;  as, for example,  in the
notion that the embryo or new product is formed from  the menstrual blood
of the female,  assisted by a sort of moisture descending from the brain during
sexual union.
   "According to  the second theory, or that  of  the spermatists, among the
earlier supporters of which  Galen may  be reckoned, it  was supposed that
the male  semen  alone furnished  all  the vital parts  of  the new animal, the
female organs merely affording the offspring a fit place and suitable materials
for its nourishment.  Immediately upon the discovery of the seminal animal-
cules, these minute moving particles were regarded by some as the rudiments
of the new animal.  They were said to be miniature'representations of men,
and  were styled homunculi; one author going  so far as to delineate in the
seminal animalcule the body, limbs, features,  and all the parts of the  grown
human body.   The  microscopic  animalcules  were  held  by others to  be  of
different sexes, to copulate, and thus to engender male and  female offspring:
 and the celebrated Lieuwenhoek, who was among the first to observe these
 animalcules, described minutely the manner in which they gained the interior
 of the egg, and held that after their entrance they were retained by a valvular
 apparatus.
   'The theory of syngenesis or combination seems to  have been applied
 principally  to the explanation of the  reproduction of quadrupeds and man,
 the existence and nature of the ova of which were involved in doubt.  This
 hypothesis consists in the supposition, that  male  and female parents both
 furnish simultaneously some semen or product; that these products, after

            1 Cyclopaedia of Anatomy and  Physiology.  Art. — Generation. 
GENERATION.—CONCEPTION.
103
sexual union, combine with one another in the uterus, and thus  give rise to
the egg or structure from which the foetus is formed.  In connection with this
theory, we may also mention that of metamorphosis, according to which, a
formative substance is held to exist, but is allowed to change  its form in
order to be converted into the new being ; as also the notion of Buffon, that
organic molecules universally pervade plants and animals, that these are all
endowed with productive powers, that a certain number are employed in the
construction  of the textures of organized bodies, and that in the process of
generation,  the superabundant quantity of them proceeds to the sexual
organs, and there constitutes the rudiments of  the offspring."
   It would be mere waste  of  time to enumerate the  modifications  of  these
theories, which have been promulgated in profusion  from time to time; of
which  "groundless  hypotheses"  Drelincourt  reckoned  two hundred and
sixty-two, and  in addition to which, as  Blumenbach  remarks, "nothing is
more certain than that Drelincourt's own theory formed  the two  hundred
and sixty-third."
   143.  The best plan will be to state briefly such facts as we possess, which
hear upon the  conditions of generation  and  the changes  produced by it.
We have already ascertained that the ovaries contain curtain vesicles, and
we have reason to believe  that these undergo certain changes before and
after a successful coitus, and that their contents, or that  of one, constitutes
the  contribution of the female  towards the  production of  a new being.
Again,  we know that the testes of the male secrete a peculiar fluid called
semen, which in the  act  of intercourse  is projected  into  the vagina, and
arrives  by  a process we cannot as yet explain in the  uterus of the  female,
and is  supposed  to exert a peculiar  influence upon  the  Graafian vesicles;
but the difficulty has been to explain how that influence is communicated or
carried  to the ovary, or whether impregnation  takes place in the ovary, fal-
lopian tubes, or uterus.  Yarious  theories  have been propounded (that of
an aura seminalis, for example), but none were  consistent with the  obser-
vations made upon other orders of  animals ;  from which it appeared  that
contact of  the semen with the ova was necessary.  This obstacle seemed to
be removed  by the observations  of Dr. Bischoff of Heidelberg,  Dr. M.
Barry, and  Professor Wagner of Berlin, who  believed themselves to have
detected spermatozoa in the fallopian tubes, especially at their ovarian ex-
tremity.  It appears doubtful whether spermatozoa have really been detected
in the  ovary or at the upper extremity of the  fallopian tubes, but Bischoff
still holds the opinion that impregnation takes place generally in the upper
part of the  fallopian tubes :  Prevost, Dumas,  and Barry, that spermatozoa
enter bodily into  the ovum.   The latter view is not  supported  by recent
researches, and  Pouchet opposes both that and Bischoff's, maintaining that
fecundation takes place only  in the  lower part  of the fallopian tubes or
uterus.   A very strong argument in  favor of ovarian or tubal impregnation
is the occurrence of extra-uterine — ovarian or feetal — gestation.  In  such
cases the spermatozoa must have reached both  tube  and ovary.   What I
think clear enough is, that the contact of the spermatozoa with the liberated
ovum is necessary to fecundation ;  and this is  confirmed both by the obser-
vations  of  comparative  anatomy and by the experiments of Cruikshank,
Haighton, and  Blundell, who found that if the  fallopian tubes were rendered
impermeable, impregnation was prevented ; but this does not prove where
impregnation is effected ; whether in the tubes or in the  uterus, or, as may
be probable, sometimes in one  and sometimes in the other.  The experiments
of Spallanzani  and  others have proved that a very small  quantity of semen
is sufficient for fecundation.
   [The  semen as it is discharged from the urethra, is  an  exceedingly mixed
fluid, consisting of spermatozoa derived  from  the testicles, with the secre- 
104
GENERATION.--CONCEPTION.
tions of the epididymus and vas deferens,  the  prostate or Cowper's glands,
and the mucous follicles  of the  urethra.   It  is now almost universally ad-
mitted that it is the spermatozoa alone which contribute  the essential or
fecundating portion of the seminal fluid.  These bodies are  developed within
certain cells found  in the secretion of the testes before this leaves the gland.
Within  the cells the spermatozoa are in the form of filaments arranged in
bundles, but in the passage  of the semen  through  the  efferent vessels, the
cells rupture and set free the spermatozoa.   Each spermatozoon consists of
an oval and  flattened body, and a filamentous  portion  or tail.   The width
of the body is about the  one six-thousandth part  of an inch, and the entire
length of  the  spermatozoon is from the fourth to the sixth-hundredth part
of an inch.  These bodies  present no evidences of  organization, consisting
apparently of a homogeneous, tolerably firm, albumenoid substance.  They
have an almost constant  vibratory or wriggling motion,  precisely similar to
that of  a  ciliated epithelium cell, which at  one  time  caused them  to be con-
sidered as distinct animalcules.   They are, strictly speaking, " organic forms
which are  produced  in the  testicles, and constitute a part of their tissue  ;
just as the eggs, which are  produced in the  ovaries, naturally form a part
of those organs, .  .  . and  like the egg, also, the spermatozoon  is  destined
to be discharged from the organ where  it  grew, and to retain, for a certain
length of  time afterward, its vital properties."1

                                  Fig. 43.






  •                 \  A)i   ['/







   Spermatozoa from man, and their development.  (Wagner). — a. Spermatozoa from the  semen of the
  vas deferens. 1 to 4. Show their variety of character.  5. Seminal granules.—B. Contents of the semen
  of the testis. 1. Large round corpuscle or  cell. 2. A cell containing three roundish granular bodies,
  from which the spermatozoa are developed. 3. A fasciculus of spermatozoa, as they are seen grouped
  together in the testis.

   The question as  to  how  the  sperm arrives  at  the ovarium, has  not yet
been settled.    Professor Wagner,  who is high  authority,  considers  that the
sperm reaches the ovary partly by the  ciliary motions,  which begin in the
cervix uteri, partly by the contractions of the tubes, and  partly by the  mo-
tility  of  the spermatozoa.'2   Dr.  Carpenter,  however, seems to think the
latter is the sole means !   " That the spermatozoa make their way towards
the ovarium,  and fecundate the ovum either before it entirely quits the
ovisac, or very shortly afterwards, appears  to be the general  rule in regard
to mammalia;  and the question  naturally arises, — by what  means do they
arrive there ?   It has been supposed that the  action of the cilia, which line
the fallopian tubes, might account for their transit;  but the direction of this
is from the ovaria towards the uterus, and  would therefore be opposed to it.
A peristaltic  action of the fallopian  tubes themselves  may generally be
                1 [Dalton's Human Physiology, p. 460.]
                2 [Dunglison's Human Physiology, vol. ii.  p. 372.]
 
GENERATION.—CONCEPTION.
105
noticed in animals killed soon after sexual intercourse ;  and in those which
have a two-horned  membranous uterus, such as is evidently but a dilatation
of the  fallopian  tube, this  partakes of the same movement, as may be well
seen in the rabbit; in  animals, however, which  have a single  uterus  with
thicker walls  (as in the human  female), it must evidently be unavailable.
Among the tribes whose ova are fertilized out of the body, the power of
movement inherent in the spermatozoa is obviously the means by which they
are brought into contact with the ova;  and it does not seem unreasonable
to suppose that  the same is the  case  in  regard  to the higher classes; and
that the transit  of these curious particles from the vagina  to the ovaries, is
effected by the  same kind of action  as  that which causes them to traverse
the field of the microscope."1]
   144. Thus, then, we  may enumerate as the conditions of generation, the
actual contact of the male  semen or its spermatozoa with a healthy Graafian
vesicle or an ovule.   The  immediate effect  of this contact or of  successful
intercourse, is the  production of great excitement and vascular turgescence
of the uterus, ovaries, and fallopian  tubes, which lasts  for some  time, and
during which  an alteration takes place in the relations of the different parts.
The fimbriated  extremity  of one  of  the fallopian tubes is turned towards
the  ovary of  that side, and embraces it closely, over the  vesicle which has
been, or is to  be, impregnated.   This delicate operation  has been attributed
partly to the vascular  turgescence,  and partly, as  in  certain animals, to
muscular  action.   How soon it takes place  after impregnation is  not yet
determined ;  it  must occur at each menstrual  period,  if the ovular theory of
menstruation  be true.
   145. With  regard to the ovum itself,  one or more of the vesicles enlarges
and becomes  vascular,  the vessels converging towards the point, at which
the  rupture of  its  coats is to occur.   " The  fluid," says Dr. Allan Thomp-
son, in the essay already quoted, " contained in the vesicles which  are about
to burst,  previously  transparent  and nearly  colorless, now becomes more
 viscid and tenacious, somewhat turbid, and of a reddish  color; and  in some
animals, it is  possible  in such  ripe vesicles  to perceive with the unassisted
eye, in a favorable light, a whitish opaque spot on the most prominent part,
indicating the layer of granules, or proligerous disc,  in the centre of which
the  ovum is situated.  After a  certain time, a small opening is formed at the
 most prominent part of the coverings of the vesicle ;  the vesicle bursts, and
its contents escape through the opening: they are received into the  infundi-
bulum, which is now applied firmly against the ovary;  and the  ovum enter-
ing  the fallopian tube is conveyed along  it, probably by its slow  and  gradual
vermicular contractions, until it  at last  arrives at the uterus."   Recent ob-
servations would lead us to attribute some influence  in this transmission, to
 the  ciliary motions of the villi  of the mucous membrane lining the tube.
   146. It is  scarcely possible to obtain an  opportunity  of examining the
minute changes which take place in the Graafian vesicle in the human female ;
we must therefore avail ourselves of the  information afforded by comparative
physiology, and the more readily, as  the process  does not differ essentially.
The following description is extracted from Dr. M. Barry's beautiful paper:2
—"Among the changes occurring  in the  ovum (of the  rabbit) before it
leaves the  ovary, are  the  following: viz., the germinal spot previously at
the  inner surface, passes to the centre of the germinal vesicle ; the germinal
vesicle, previously  at the  surface, passes to the centre of the yelk;  and the
membrane, investing the yelk, previously extremely thin,  suddenly thickens."
The tunica granulosa and retinacula are discharged  with  the ovum.
   " Among the  changes usually taking place in the ovum during its passage

   » [Human Physiol.,  p. 595.]          i Philosophical Trans.,  1839, part ii.  p. 350. 
106
GEN ERAT10N. —CONCEPTION.
through  the  fallopian tube, are the following: viz., 1. An outer membrane,
the chorion,  becomes visible.   2. The membrane  originally investing  the
yelk,  which had suddenly thickened,  disappears by liquefaction ; so that the

                                  Fig. -14.
  Graafian Vesicle after
Impregnation.—1. Tunica
granulosa.  2.  Chorion.
3. Zona pellucida. 4. Thick
transparent  membrane
5. Yelk ball. 6. Germinal
vesicle. 7. Germinal spot.
yelk is  now immediately surrounded by  the thick  transparent  membrane
(zona pellucida)  of the ovarian ovum.   3.  In the centre of the yelk there
arise several very large and exceedingly transparent vesicles.  These disap-
pear,  and are succeeded by a smaller and  more numerous set.   Several sets
thus successively  come into  view, the vesicles of each succeeding  set being
more  numerous and smaller than the last, until a mulberry-like structure has
been produced, which occupies the centre of the ovum.   Each of these vesi-
cles contains a colorless and  pellucid nucleus, and  each nucleus presents a
nucleolus.
  " In the uterus, a  layer of  vesicles, of the same kind as those of  the last
and smallest here mentioned, makes its appearance on the whole of the inner
surface of the membrane which now invests the  yelk.   The  mulberry-like
structure then passes from the centre of the yelk to a  certain part  of that
layer  (the vesicle of the latter coalescing with those of the former, where the
two  sets are in contact, to form a membrane, the future amnion), and the
interior of the mulberry-like structure is now seen to be occupied by a large
vesicle,  containing a fluid and dark granules.  In the centre of the  fluid of
this vesicle  is a spherical  body, composed  of a  substance  having  a finely
granulous appearance,  and containing a cavity filled with  a  colorless  and
pellucid fluid.   This hollow and spherical  body seems to be the true germ.
The vesicle  containing  it disappears, and in its  place  is seen an elliptical
depression,  filled  with  a pellucid fluid   In  the centre of this depression is
the germ, still presenting the  appearance of a hollow sphere."
  It is unnecessary to  apologize for this minute  account of the changes in
the vesicle ; the interest of the question, and the light thrown upon it by the
able and careful  researches of the distinguished  physiologist from  whom I
have  quoted, are  more than  sufficient  reason for laying the  results before
my readers.
  147.  Let us now retrace  our steps  a little;  during the increase of the
vesicle in the ovary, " the inner coat becomes intensely vascular, and on its
external surface, a soft gelatinous substance, of a yellowish-red color, con-
sisting apparently in part of blood and in  part of lymph, is poured out be-
tween the two coats of the vesicle, in considerable quantity all round, except
at the point where it is pressed towards the external surface of the  ovary."
Such is Dr.  Montgomery's description of the formation of the corpus luteum,
which he conceives  aids in the expulsion  of the ovum, after having served
'•' as a sort  of little temporary uterus" to the contained germ, "lined with a
serous membrane, covered externally by another, and having interposed be-
 
GENERATION.—CONCEPTION.
107
tween them the fleshy or granular structure of the  corpus luteum,  through
which blood-vessels ramify, and exhale through the lining membrane a serous
fluid for the support of the early ovum, which as yet lives only by imbibition."
Professor von Baer thought that the corpus luteum was the lining membrane
of the vesicle in a  state of hypertrophy, and Dr. R. Lee believes it to be a
deposit external to the lining.  Drs.  Paterson and Renard agree with Dr.
Montgomery ; but Knox,  Pouchet, Midler, and Dalton, regard  it as  a hyper-
trophy of the outer membrane, and formed after the escape of the ovum.
   148.  Shortly  after the evolution of  the ovum, the size of the  ovary is
found to be increased,  especially at a certain  part which is prominent, and
about  the  size of a nut.   At an early period after  conception, this  small
tumor is of a bluish-red or purple  color, owing probably to the  effusion of
blood  attendant on the rupture  of its  coats, and having numerous vessels
filled with  the  florid blood ramifying on its surface.   In some part of this
colored surface of the tumor,  a cicatrix, depression, or aperture  may be dis-
covered, being the  point at which the ovum escaped from the ovary into the
fallopian tube.
   149.  These external appearances,  however, are inadequate to prove the
presence of a true  corpus luteum ; they require confirmation by  the results
of an internal examination.   " Upon  slitting open the ovarium at this part,"
says Dr. W. Hunter, " the corpus luteum appears a round body, of a very dis-
tinct nature from the rest of the  ovarium.  Sometimes  it is oblong or oval,
but more generally round.  Its centre is white, with some degree of trans-
parency, the  rest  of its  substance has a  yellowish  cast, is  very vascular,
tender, and  friable, like  glandular flesh.   Its  larger  vessels cling round its
circumference,  and then send  their smaller branches inward through its sub-
stance ;" which substance, according to Dr. Allen Thompson, "has  a lobular
structure, the lobules  radiating in a somewhat irregular  manner from the
centre to the circumference.   The central part of the  corpus luteum fre-
quently remains hollow for some time  after its production, opening exteriorly
by a narrow passage from the part where the rupture of the vesicle  origi-
nally took place ;  at other times,  this  passage  is closed more early, and there
remains nothing but an indication of its  place, in  a depression in the centre
Ovary after escape of Ovum.           Corpus Luteum, from Dr. Montgomery.
of the most projecting part of the corpus luteum.  The lobules of the cor-
pus luteum, examined with the microscope, exhibit  merely a granular struc-
ture, and are not formed of acini, as some have described them, so that there
is no reason to consider them bodies of a glandular nature." 
108
GENERATION.—CONCEPTION,
   150.  The following  measurements  of the ovaries  and corpus luteum,  at
the third month of pregnancy, are given by Dr. Montgomery :
      The unimpregnated ovary.             Ovary containing a corpus luteum.
Length   ...    1 inch 5 lines.      Length   ...    1 inch  3 lines.
Breadth  ...       "   7£  "       Breadth  ...      "    9   "
Thickness   .   .       "   5£  "       Thickness   .   .      "7^ "
   Dr. Knox has drawn up the following table of measurements of the corpus
luteum at different periods of pregnancy.
No. of days after Impreg-nation.	Name of Reporter.	Long diameter, in lines.	Short diameter, in lines.	Thickness of the glaudu-lar part.	Diameter of the Central Cavity.
5 8 46 62 62 70 93 108 108 155 186 186 186 201 280 280 280 285	Ditto................ Ditto................	9 9 ft 6 9£ 7 9 7 8J 6 6 -1 (i" 7 6 6 4	6 6 7* 3* 8 6 {■>} 7 6 7 5 5 4 5 5 •>i -z	l.V n r i 3 2* 2 3 3 1 1	1 3 4V and 2* 4.! and 1J 2 o 4 3 1*
	W. Hunter.........				
					
					
					
	W. Hunter.........				
					
   151.  For a short time after the escape of the ovum, the corpus luteum is
said to  increase in size, then to remain stationary, and afterwards to diminish
slowly.   After the third or fourth month the central  cavity contracts, and
its sides coming  in contact, gives it the appearance  of  an irregular white
line, somewhat radiated.   After delivery, the corpus luteum shrinks, absorp-
tion takes place, and it disappears, though at what time is not quite certain.
Dr.  Montgomery has observed it five months after delivery ;  but Dr. Pater-
son's investigations would lead to the conclusion, that  it  seldom remains so
long.
                                    [Fig. 47.]
                 e            /             g            h
  Successive stages of the formation of the Corpus Luteum, in the Graafian follicle of the Sow as seen
in vertical section;—at a is shown the state of the follicle immediately after the expulsion of the ovum,
its cavity being filled with  blood, and no ostensible increase of its epithelial lining  having yet taken
place; at b, a thickening of this lining has become apparent; at c, it begins to present folds which are
deepened at d, and the clot of blood is absorbed pari passu, and at the same time decolorized • a con-
tinuance of the same process as shown at e,f, g, h, forms the Corpus Luteum, with its stellate cicatrix. 
GENERATION.—CONCEPTION.
109
   Dr. Dalton gives it as the result of his observation, that the corpora lutea
 of menstruation and pregnancy follow the same course of development in
 the first period.  " Together with the rupture  of the vesicle, the same effu-
 sion of blood takes place in either  case, followed by a gradual absorption
 of the coloring matter  of the clot, and hypertrophy and folding up  of the
 membrane of the vesicle.  When, however, the ovum becomes impregnated,
 and  continues its growth in the uterus, the corpus luteum,  instead of  reach-
 ing its maximum of development at the  end  of three weeks, and afterwards
 undergoing  a  rapid process of atrophy, continues  to  develop  itself for a
 considerable period, and does not, in fact, become very decidedly retrograde
 until after the termination of pregnancy."  "The difference in the progress
 of the  corpus luteum, however, relates not only to its  size, but also  to  its
 general characters and  aspect.   The external wall becomes much  thicker in
 proportion to the central coagulum, and  at the same time  acquires a  firmer
 and more highly organized structure.  Moreover, the color both of the con-
 voluted wall and of the central  coagulum constitutes an important  means
 of distinction.  It  has  been shown  that the corpus  luteum  of menstruation
 retains the bright color of its walls till  the  whole  body has become much
 reduced in size, and that the coagulum in its interior also  remains more or
 less  stained with  red till a late  period.   On the other hand, if pregnancy
 occur, the circumstances are  reversed.   The  color,  both  of the wall and
 the coagulum, fades rapidly after the first two  months, while the  substance
 of the yellow body continues to increase ;  consequently, during  the greater
 part of gestation, the corpus luteum of pregnancy will be distinguished from
 that of menstruation by the  dull  hue of its  convoluted  wall,  and by the
 absence of color in the  central coagulum."1
   The number of corpora lutea corresponds exactly to  the  number of chil-
 dren ;  as  Dr. W. Hunter remarked,  " Where there is  only one  child, there
 is only one corpus luteum,  and two  in the case  of twins."  Meckel examined
 two hundred females of the class mammalia,and found this correspondence exact.
   [Dr.  Carpenter denies that there is a correspondence between  the number
 of corpora lutea found  in the ovaries of  a woman, or of cicatrices on  their
 surface, and  the number of children she  may have borne.   The  number  of
 corpora lutea must  always be less, he remarks,  when there have been many
 conceptions ;  but the number of cicatrices  may be  greater;  for several
 causes,  such  as the  escape  of unimpregnated ova, or the bursting of little
 abscesses, may give rise to such appearances.2]
   152.  Two very important questions here demand notice :  1. Are corpora
 lutea the result of pregnancy only, and does their presence indicate previous
 impregnation ?  And,  2. If  not the  result  solely of  pregnancy, can the
 corpora lutea of pregnancy be distinguished accurately from those of men-
 struation ?
   Various opposite opinions have been held upon the first  of these points.
   Haller,  Meckel, Haighton,  Arelpeau,  Montgomery,  Midler, etc., believe
 that corpora lutea are  the result of impregnation  only ;  others,  as Cruik-
 shank,  Gross, Seymour, Gooch,  Blundell, Renaud, etc., believe that whilst,
 as a general rule, corpora lutea result  from conception, yet that they are
 occasionally  met with in virgins, the one  being  true, the other false corpora
lutea.
  [" The true corpus luteum," says Carpenter, "is distinguished by its  capa-
bility of being injected from the vessels of the ovary ; which is not the case
with tubercular deposits, or other substances  which  may simulate it."3]

  1 Prize Essay, p. 71.   [See also Human Physiology, by J. C. Dalton, jr., M.D., p. 478,
et seq]
  'l [Principles  of Human Physiology, 2d Am. Ed., p. 597.]
  3 [Human Physiology, Am. Ed., p. 596.] 
110
GEN K RATION. —CONCEPTION.
  A third class  of  writers,  who  believe that ova  are  discharged  during
menstruation, and have observed the peculiar change in the part of the ovary
from which thev have escaped, regard  them as equally true  corpora lutea.
and denv that there is any essential difference  between the corpora lutea of
menstruation  and pregnancv.   This opinion was  put forward by  Sir E.
Home, and  is adopted by  Dewees,  Bischoff,  Napier,  Pouchet, Raciborski.
Chereau, etc.   M. Pouchet states as his opinion, that " since the fact of
spontaneous ovulation has been demonstrated,  it must now be superfluous to
point out  the futility of the distinction between true and false corpora lutea ;
thev are all  produced by  the same  processes;  they have  all discharged  ova
before presenting themselves under the aspect  which they assume after that
occurrence.   And whether the ovule which they have expelled does or does
not become  fecundated, whether or not it undergoes  the transformation into
an embryo,  all have nevertheless the same form and the same structure."1
   153.  Now,  the  cases and dissections  I  have heretofore quoted, even if
they be considered inadequate to  warrant  the deduction of  a general rule,
do at least prove both that an ovum is frequently, if not always, discharged
at a menstrual period, quite independent of sexual congress, and that certain
changes take  place  in the membrane from which  it escaped, which are in
some degree analogous to the corpus luteum ;  that these changes constitute
what may be  called  the  corpus luteum  of menstruation-  So far  I must
agree with the two latter classes of authorities; but, on the other hand, we
find  the corpus luteum of pregnancy to differ  from this in many particulars,
and  so much so, as to justify the opinion of the first class of authorities —
that the true  corpus luteum  (taking that  found  in the  ovaries of women
during gestation as the standard) was the result and evidence of conception,
and  of nothing else.
   This is  the conclusion to which Dr. Dalton has  arrived, by an extensive
and  minute  investigation in the human subject and in animals, and  I think
the evidence we possess quite  sufficient to satisfy any impartial inquirer.
   It becomes, then, of  great  importance  to  state explicitly the points of
difference between the  two classes  of corpora lutea, and the more so, as
certain medico-legal inquiries  are considerably influenced by their presence
or absence.
   Dr.  Dalton thus states the result of his investigations :—" 1. The corpus
luteum of pregnancy arrives  more slowly at its maximum of development,
and  afterwards remains  for a long time as a very noticeable  tumor, instead
of undergoing a process  of rapid atrophy.   2. It retains a globular, or only
slightly flattened form, and gives to  the touch a sense of considerable resist-
ance and  solidity.  3.  Internally it has an  appearance  of advanced organi-
zation, which  is wanting  in the corpus luteum  of menstruation.  4. Its con-
voluted wall, particularly, attains a greater development, this portion mea-
suring sometimes  so much as  three-sixteenths to  one-fourth  of an  inch  in
thickness;  while in the corpus luteum of menstruation it never exceeds  one-
eighth, and is almost always less than that. This difference in the thickness
of the convoluted wall is one  of the most important  points  of distinction.
It will be  much  more  striking when viewed relatively to the size  of the
coagulum.   5.  The color is  not  by any means so decided a yellow, but a
more  dusky and  indefinite hue.   6.  If  the period  of  pregnancy be at all
advanced, it is not found, like  the corpus  luteum of menstruation, in company
with unruptured vesicles in active process of development."-
   [Dr. Dalton, in  his Human Physiology, page 486, thus sums  up the general
 differential  characteristics  of  the corpus lutea of  menstruation and of preg-
 nancy: "The corpus luteum of menstruation  differs from that of pregnancy

   1 ThSorie Positive de l'Ovulation Spontanea, etc. p. 18-3.       2 Prize Essay, p.  73. 
                          UTERO-GESTATION.                      ] 1 1

in the extent of its development and the duration of its existence.   While the
former passes through all the important phases of its growth and decline in
the period of two months, the  latter lasts for from nine to ten months, and
presents, during a great portion of the time, a larger size and a more solid
organization.   It will  be  observed  that,  even  with  the corpus  luteum  of
pregnancy, the bright yellow color, which is so important a characteristic, is
only temporary in its duration, not making its appearance till about the end
of the fourth week, and disappearing after the sixth month."]
  Thus, if due care be taken, the corpus luteum of pregnancy can be distin-
guished from the  changes  which follow  ordinary ovulation, by whatever
name they are called, and therefore the presence of such a corpus luteum is
as sure an evidence of  pregnancy as it has ever been considered.
                          CHAPTER  IY.

                        UTERO-GESTATION.'

  154. Before  proceeding to investigate the farther development  of  the
ovum, let us examine the changes which impregnation occasions in the
uteres, and which prepare it for the reception and nutrition of the foetus.

                                 Fig. 48.
Vessels of Gravid Uterus.
  It has already been stated, that conception is accompanied or immediately
followed by congestion of the  uterus;  its vessels are filled with blood, and
enlarge gradually, until  they become of  great size.   Many which did not
carry red blood before, and therefore were invisible,  are  now evident, and
the whole form an intricate net-work on the surface and in the substance  of
the organ.   Not only are the arteries (fig. 48)  distended, but to meet this

  1 For a minute  account of the changes which  take place, I would refer the reader to
Dr. Farre's admirable article in Todd's Cyclopaedia, parts 49 and 50. 
112
UTERO-GESTATION.
increased  labor imposed upon them, their coats are actually increased in
thickness,  so  much  so as to preclude their return to their former condition
after the  object of  their temporary enlargement is fulfilled.   This explains
why we always find them more or less enlarged and tortuous in women who
have borne children.
  The coats of the veins are much thinner, and admit of still greater disten-
sion ; this is so marked in that part of the uterus to which the placenta is
attached,  that they  have received the  name of uterine sinuses.
  The lymphatics undergo a  proportionate development, and, in the latter
months of pregnancy, may easily be traced.   Mr. Cruikshank, I believe, has
the credit of  first demonstrating them.

                                 Fig. 49.
Nerves of Gravid Uterus.
  155. The nerves of the uterus (fig. 49), which are very small in its unim-
pregnated state, increase in size, until at the full term they form large cords,
which  send  off numerous branches to accompany the uterine vessels,  and
which, anastomosing freely with each other, exhibit an appearance of  net-
work, similar to that observed in the vessels.   It is now acertained  that
the real  increase is not in  the nerve-substance, but  in the nerve termina,
and  so enlarged they do not recover their pristine size after delivery.   We
are much indebted to the labors of Hunter, Tiedemann, and recently of Dr.
Lee, for  the  additions  they have made to our knowledge of the nerves of
the uterus.
  156. Great as these  changes are, they are equalled, if  not surpassed, by
those which take place in the  proper tissue of the uterus.  In proportion
as space is required for the fcetus, on account of its growth, the fibres are
loosened, and separate  from  each other, leaving between  them large inter-
spaces, which afford space  for, and are occupied by, the enlarging blood-
vessels and nerves.  The amount of  distensibility  is very great,  and fully
equal to the  accommodation of the fcetus, during the term of intra-uterine 
UTERO-GESTATION.
113
life.   Nor is this distension accompanied by much thinning of the parietes :
according to Meckel, they increase in thickness during the first three months,
and  afterwards  diminish  to the  end  of gestation ; but  even then they are
from one to two-thirds of an inch thick,  and even more about the insertion
of the placenta.   To explain this, it has been assumed that new matter is
superadded  during gestation, and removed after delivery;  and  this opinion
is confirmed by the difference in weight between a virgin uterus and one at
the full term, emptied of its contents ; the former weighing one ounce, the
latter about twenty-four.   Even when deprived of its extra quantity of blood
by  firm contraction  after delivery, it  is many  times  larger  than before
conception.
  Mr. Barney's researches seem to show that this is in  the first instance
simply  from the  increase .in the volume of the  fuciform  nucleated fibres;
this being, he thinks,  "quite sufficient to account for the amount of augmen-
tation of the entire organ, without supposing that organic muscular fibres,
not present in the inactive state of  the uterus, are  absolutely formed durin°-
the various  stages of  its enlargement."   " The unimpregnated uterus being,
according  to  this notion, little more  than  an  assemblage of  embryonic
nucleated fibres, wholly inactive until after the reception  of the  ovum, when,
being roused by an appropriate stimulus, they are called into active opera-
tion, and become  developed  simultaneously and proportionally to the deve-
lopment of  the fcetus  contained within it; so that, when one has arrived at
a state requiring to be expelled, the other has acquired the utmost degree
of fitness necessary to effect its expulsion.   Now, after the expulsion of the
fcetus, since according to the laws  of development, it is as impossible  that
these fibres  of the impregnated uterus can return again to their primitive or
embryonic  condition,  as that a full-formed foetus could relapse into the state
of an ovum, they must necessarily become absorbed, and therefore a new set
of embryonic fibres would require to be formed for the expulsion of the next
ovum : so that each fcetus will  have, according to this  conclusion, its  own
peculiar expulsory fibres."1
  The process of absorption has been shown by Professor Retzius of Stock-
holm,  Dr. Heschl,2 and others, to  be marked by a species of fatty degene-
ration,3 which Mr. Barlow and others  regard as  a  step towards organic
death.
  157.  The increase  in  the  size of the womb is  said to  commence at  the
fundus, immediately after the descent  of  the ovum, and  as this is developed,
the body enlarges; last  of all, and not  before the fifth month, the cervix.
But an ingenious American writer, Dr. Read,4 has proposed the  following
substitute for this view, and has adduced  some weighty arguments  in its
favor: — "The  attachment of the placenta  to any  portion of the uterus
causes a development at that place,  which proceeds pari passu, till the limits
of growth in the placenta having been reached, the  enlargement is continued
and kept up by the pressure constantly exerted on the uterine  walls by the
growing contents till the time of parturition."
  During the  first four months the  entire organ is contained in the cavity of
the pelvis ;  soon  after which time  the  fundus may be felt, in thin females,
above the symphysis pubis ; about the fifth month it reaches midway between
the  pubes and umbilicus, and gives  a roundness and fulness to the lower part
of the abdomen ; at the end of the sixth month, it is as high as the umbilicus,
which it protrudes ; during the  seventh  month, it  ascends midway between

  i Philosophical Trans.,  1850, part ii. p. 519.
  2 Researches on the Conduct of the Human Uterus after Delivery, translated by Dr. R.
M'Donnell.
  3 Edin. Monthly Journal, Aug., 1852, p. 127, note.
  * American  Journal of  Med. Science, April, 1858.
       8 
1 14
UTERO-GESTATION.
the umbilicus and the ensiform cartilage ;  at the  end of the eighth month,
it reaches the ensiform cartilage and fills the abdomen, having the intestines
above and behind it.
  During the ninth month, although it somewhat increases in size, yet, from
the yielding of the abdominal parietes, it does  not ascend,  but on  the con-
trary is  somewhat  lower than  previously.   Its  capacity is immensely in-
creased :  according to the  calculations  of Levret, its  superficies  may  be
estimated at 339 inches, and its  cavity will  contain 408 inches; its length
being from 12 to 14 inches;  its breadth from 9 to 10, and its depth, antero-
posterior!}', from 8  to 9 inches.
   158. A considerable change takes place  in the cervix uteri ;  it  becomes
somewhat swollen, but soft,  elastic, and cushion-like ;  the  os uteri  loses in
some degree its defined form, and is dilatable ; the canal through the cervix,
during the early months, is closed by the glutinous secretion of the follicles,
and these glands are themselves enlarged, so as occasionally  to be felt rolling
under the finger.
   During the first three months, the os uteri  is lower than usual in the pelvis,
owing to the increased weight of the uterus,  and  directed a  little more for-
Fig. 50.                                  Fig. 51.
Cervix Uteri at three months.                    Cervix Uteri at six months.
wards ;  as the uterus rises above the brim of the pelvis, it is directed back-
wards, and after the fifth  month, the cervix is said to be drawn  out by the
expanding uterus, and shortened.   At the sixth month it is said to lose  one-
fourth of its length  (fig. 51);  at the seventh  it is  only  half its  original
length ; at the eighth it loses another quarter (fig. 52);  and at the ninth the
neck is obliterated (fig. 53) :  so that upon making an examination, we find
Fig. 52.                                Fig. 53.
Cervix Uteri at eight months.                   Cervix Uteri at nine months.
the vagina closed superiorly by the rounded lower end of the uterus, but no
•protruding cervix.   It would  appear, however, that this shortening of the
cervix is  more  apparent than real.   Examined  by the finger, it certainly
protrudes less into the vagina, and its length is  really somewhat less;  but 
ITERO- GESTATION.
115
this, according to the researches of Stolz, Cazeaux,1 and Matthews Duncan,
is not by distension of its cavity, but by approximation of its two extremities.
The latter author2 has given sectional outlines of the cervix uteri at different
periods, made from  dissection, and which appear to justify his conclusions.
At  the same time he states that the capacity of the canal becomes greater
as pregnancy  advances by an  increase  of breadth ; that the length  of the
vaginal projection of the cervix diminishes as the uterus rises, as represented
in the plates, and that the substance of the cervix becomes  more soft and
bulky.   In these views Dr. Farre  seems to coincide.
  159.  The figure of the uterus  at the  full term  is oviform  (fig. 48), the
larger end  being uppermost, and rounder in proportion than the lower end.
Some variations in  shape are observed from the pressure of neighboring
parts, the  position of the patient  or of the fcetus.   Occasionally the  uterus
stretches unequally, so as to constitute true obliquity, one side being more
developed  than  the other.  Such  cases are  not common, nor do we  know
much of their effect upon labor.
  The axis of the uterus, at the end of gestation, is commonly more perpen-
dicular  than that of the  brim  of the pelvis ;  but this want of agreement  is
rectified at the time of labor by the uterine contractions which tilt the fundus
forwards.
   160.  The lining membrane of the uterus participates in the general con-
gestion of the uterus at the  time of conception.   It becomes turgid with
blood;  its villi, according to Von Baer,  elongate, and  over  and between
them is spread  a thin layer  of pulpy,  semi-fluid  matter, secreted  by the
mucous membrane :  this  is the decidua (fig. 54).  It was noticed by Burton,
but described particularly by  W.  Hunter, and called after him the decidua
of  Hunter.   The  pulpy matter,  after a short time,  acquires consistence,
and, in its appearance and connection with the  subjacent membrane,  resem-
bles the coagulable lymph thrown off by mucous  membranes in a state of
disease.  It lines the entire  cavity of  the uterus, closes  it  inferiorly, and,
according  to John Hunter and Breschet, sends off  a short process into the
fallopian tube, through which, they conceive, the ovum descends.
   Dr. Sharpey, of  London,  whose  microscopical  researches are so well
known, on investigating the membrana decidua  of a bitch, came to the con-
clusion that  it was  not  a secretion from the lining  membrane of the uterus,
but that membrane  itself altered and modified.3   It appears that W. Hunter
regarded the decidua as the  mucous membrane modified, and this view has
also been put forth by Bischoff.   Having had the opportunity of examining
the uterus of a woman supposed to have been impregnated about three weeks
before  death, he was enabled to demonstrate  quite satisfactorily that the
membrana decidua in the human female,  as in the  bitch, is merely the ordi-
nary mucous  membrane  of the uterus considerably developed, and  that it
consists essentially of enlarged uterine follicles and  their blood-vessels, toge-
ther with an unusually large quantity of secretion which these follicles have
poured out.  The internal surface of the uterus presented  an appearance
quite different from its ordinary one, being finely villous ; and this was espe-
cially evident on  placing it in water, or examining perpendicular sections
of  it.   The surface itself, when looked upon from above, appeared as if per-
forated by a  number of  small apertures, or covered  with numerous  white
points, and  these, when examined by  the  microscope, were found  to be
openings of cylindrical  glandules.  These glandules or follicles were from
H  to 2 Paris lines  in length,  were held together by a transparent material,
and terminated  each by a blind extremity wdiich rested on the fibrous tissue

    ' Midwifery, p. 108, Amer. Trans.          2 Edin. Med. Journ.,  March, 1859.
    3 Muller's Physiology, try Baly, part iv. p. 1578. 
116
UTERO-GESTATION.
of the uterus.  They ran a somewhat wavy course, but  never  branched or
anastomosed.  Previous to impregnation it seems to be exceedingly difficult
to discover these glands in the mucous membrane of the uterus.   Probably
thev then exist in  a very undeveloped state, but immediately on the  occur-
rence of conception increase rapidly, and exude an abundant secretion.   Of
these glands and their secretions (together with blood-vessels) the membrana
decidua and, later on, the placenta essentially consist.   The statement that
a membrana decidua exists in the fallopian tube as well  as  in the uterus, in
cases of fallopian  impregnation, Bischolf combats by observing that so far
as has vet been seen,  the lining membrane of the fallopian tube contains no
glands by which the formation of  a structure corresponding to an ordinary
membrana decidua could be effected.
Fig. 55.
Decidual Cotyledons.
  A similar view to the above, with regard to the membrana decidua, was
advocated  also by  M. Coste1 some years  ago,  and since by M.  Cazeaux,
and  recently repeated before  the Academie des Sciences, Paris ;  and it  is
held, with  some modifications, by those who, with  Cruveilhier, Fergusson,-
T. Smith, believe that, after delivery, the muscular structure of the uterus is
denuded  of mucous membrane.  It has always appeared to  me that this
point is  far from being  proved,  and I see,  by Dr. J.  Matthews  Duncan's
paper,3 that his investigations have led him to the conclusion that the mucous
membrane  is not thrown off,  except at the  part  to which the placenta  is
attached.
  The decidua is rough externally at an early period, and smooth internally;
and  so far resembles serous membranes, that  it is a shut sac, and contains a
small quantity of fluid.   Its color is reddish or whitish  grey.   Its thickness
varies in different places;  it is thicker near the placenta, and thinner near
the cervix uteri; it  also becomes thinner after the third month, in proportion
as pregnancy advances.  It adheres but loosely to the mucous membrane  at
an early period, but firmly during the  latter months, so much so that Yon
Baer states that it cannot be separated  without  bringing away  the lining
membrane  also ;  this, however, is  not always  the case.   The medium  of  its
connection with the uterus is  chiefly the small vessels which  are supplied  to

  i Archives Gen. d'Anatomie G6n. et de Physiologic, Sept. 1846.  London  Med Gaz ,
Nov.  1850.
  2 On Puerperal Fever, p. 76. et seq.
  3 British and Foreign Med.-Chir. Review, Oct.  1853, p. 506.
Fig. 54.
Decidua Vera. 
UTERO-GESTATION.
117
it by that organ, and which are arranged in loops round  its villi; they are
very numerous near the placenta, but more scanty at the cervix.
  161. A very important observation on  the structure of the decidua vera
has been  made by Dr. Montgomery, in  his valuable work On the Signs of
Pregnancy.   " Repeated examinations," he remarks,  "have shown me that
there are on the  external  surface of the decidua vera  (fig.  55) a great
number of small cup-like elevations, having  the  appearance of little bags,
the bottoms of which are attached to, or imbedded  in, its substance; they
then expand or belly out a little, and again grow  smaller towards their outer
or uterine end, which in by far the greater number of them is an  open mouth
when separated from the uterus;  how it may be while  they are adherent I
cannot  at present say.   Some of them,  which  I have found more deeply
imbedded in  the decidua, were completely closed sacs.  Their  form  is cir-
cular, or nearly so ; they vary in diameter, from  the twelfth to the sixth of
an inch,  and  project about the twelfth of an inch from the surface of the
decidua."  In a note, Dr. Montgomery suggests  that these  "decidual coty-
ledons" serve "as reservoirs  for nutrient fluids separated from the maternal
blood, to be thence  absorbed, for the  support and  development of the
ovum."
   162.  Those who  hold the  membrana  decidua  to  be a distinct  secretion,
suppose  that when the ovum arrives at the uterine extremity of the fallopian
tube, it must either push  the membrana decidua before it, or  pierce  it, in
order to enter the  cavity of the uterus.   Opinions have been much divided
as to which of these two operations takes place: Dr. W. Hunter,  Dr. R. Lee,
and M. Breschet say that the  ovum passes into the sack of the decidua; but
Lobstein, Burdach,  Yelpeau, and  others,  conceive  that the  sac remains
entire, but that the  ovum  passes behind it  to the  situation where it fixes
itself,  and that its free surface (that part I mean which is not in contact
with the uterus) is  covered by the displaced decidua, to which the name of
decidua reflexa has been  given, to distinguish  it from the decidua vera,
and which was first observed  by Dr. W. Hunter.    As the  ovum  expands, so
does  the decidua reflexa, until at  the end of gestation its inner surface is in
contact  with the  inner surface of the decidua vera, just like (if I may be
pardoned a very homely simile) the layers of a  double night-cap when put
on  the head.   That space of the uterine parieties  from which the decidua
was detached by the  ovum,  increases with  the  enlargement  of the uterus,
and is occupied subsequently by the placenta; but  between this organ and
the uterus anew layer of membrane — the decidua serolina — is  deposited,
resembling the  decidua vera, to which it is  united at the circumference of
the placenta.
   A third view is  held by those who, like Dr. Sharpey, MM. Bischoff and
Coste, regard the membrana  decidua as nothing but the hypertrophied mu-
cous membrane of the uterus.  They consider that the fallopian tubes open
freely into the uterine cavity, and that the  ovum, on entering the uterus,
becomes buried in  the mucous membrane by which it is covered.  As the
ovum increases, the hypertrophied  membrane is distended, and forms what is
termed the decidua reflexa.  As  far as  I understand, they seem to say that
the ovum divides the mucous membrane into two layers — an outer and an
inner—answering to the decidua reflexa and the  placenta decidua,  whilst the
remainder answers to the decidua  vera,
   The decidua reflexa becomes thinner  as pregnancy advances, and is ulti-
mately expelled, more or less entire, with the foetal membranes,  whilst the
decidua vera may remain for some time, and be then discharged in shreds
with the lochia,
   163. We know that the decidua exists  before the descent of the ovum, and
is therefore  independent of it; and it is stated  by most authorities, that in 
US
UTERO-GESTATION.
cases of double  uterus,  both  contain decidua, and in extra-uterine fcetation
the uterus is lined by decidua.   There  are, however, exceptions to the lat-
ter ;  for in the cases published by Dr. 11. Lee' the decidua surrounded the
ovum in the tube, and was not present in the uterus.
   [We shall endeavor to render the formation of the decidua reflexa, accord-
ing to the views entertained by modern  physiologists, somewhat clearer than
does the description given of it by the author.
   When the impregnated ovum is  about to descend into the cavity  of the
uterus, the mucous membrane of the entire  body of  the latter takes on an
increased activity of growth and a special development.   It becomes tume-
fied and more vascular; and as it increases in thickness, its surface is formed
into rounded, projecting eminences or convolutions.  When the fecundated
ovum passes through the  lower orifice of the fallopian tube, it insinuates
itself between the opposed surfaces of  the  lining membrane of the uterus,
and soon  afterwards becomes lodged in  one of  the  furrows or depressions
between the above-described projecting convolutions of the internal thick,
rich, soft,  vascular, velvety lining of the uterus, which is the decidua vera.
It is at this situation that an adhesion is subsequently to take place between
the external membranes  of  the ovum on  the  one hand, and  the  uterine
mucous  surface, or decidua, on  the  other.   At the point wdiere the ovum
becomes  thus arrested  and entangled,  a still  more rapid development than
before  takes place in the uterine mucous membrane.   Its projecting folds
begin to grow up around the ovum in such a manner as  partially to enclose
it in a kind of circumvallation of the uterine membrane, and to shut it off,
more or less completely, from the general cavity of the uterus.   It is thus
Fig. 56.                                 Fig. 57.
 First sta^e of the formation of the Decidua          More advanced stage of Decidua reflexa.
reflexa around the Ovum.
soon contained in a special cavity of its own, which still communicates for
a time  with  the  general  cavity of the  uterus, by a small opening, situated
over its most prominent portion.   As the growth  of the mucous membrane
around  the  ovum  goes on, this opening becomes  gradually  smaller, until,
finally, the projecting folds of mucous membrane touch each other and unite,
forming a kind of  cicatrix, which remains  for a certain time to  mark the
situation of  the  original opening.  The ovum has now become completely
enclosed in  a distinct  cavity of its own, being  everywhere covered with a
decidual layer —an outgrowth  of the altered mucous  membrane of the ute-
rus, and by  which  it is  concealed  from view when  the  uterine cavity is laid
open.   This newly-formed layer  of  decidua, enveloping, as just described,
the projecting portion  of the ovum, is called the decidua reflexa, because it
is reflected over  the  ovum by a continuous  growth from the general surface
of the  uterine mucous  membrane. It gradually  grows larger  and larger,  as
1 Med. Gazette, June 5th. 1840. 
UTERO-GESTATION.
119
the ovum becomes developed in size, until, finally, it comes in contact at its
external surface with the entire mucous coat lining the cavity of the uterus.
  The decidua vera, agreeably to the views  here set forth, is the  original
mucous membrane lining the surface of the uterus ; while the decidua reflexa
is a new formation, which has grown up around the ovum and enclosed it in
a distinct cavity.   For a full exposition of this  subject, we  would refer the
reader to Dalton's Human Physiology, page  516 et seq.]
   104. Abnormal deviations.—The decidua occasionally exhibits the effects
of inflammation ;  it may be hypertrophied or increased in thickness by layers
of adventitious membrane, and pus  has been found on  its  surface.  In its
substance calcareous depositions and  spiculae of bone  may  sometimes be
detected.   It may adhere  firmly to the  lining membrane of the uterus, and
persisting after delivery, may constitute the nucleus of a mole, etc.
   165. We have  seen that, on  leaving  the  ovary, the ovum  is received into
the  fallopian tube ;  that  its  further transmission is effected by muscular
motion and  the  ciliary movements of the villi  of the  mucous  membrane;
and that there is reason to believe (judging  from the  ovum  of the rabbit)
that in its passage through the tube, an additional covering is developed.
   It is difficult to determine the  period (even if it be regular) at which the
ovum arrives in the uterus.   One thing appears certain ; that several days
elapse from  the  moment  of  impregnation.   One of the earliest ova  on
record is that described by M. Yelpeau (fig. 58, natural size ; fig. 59, opened
and magnified),  which could  not have been  more than fourteen days old,
unless the midwife who gave it to him, and  who was herself  the subject of
the  miscarriage, deceived him ;  and she appears to have had no reason for
so doing.1

               Fig. 58.                              Fig. 59.

W.
"ter
        Human Ovum of two weeks.           Human Ovum of two weeks, laid open.

  166. When the ovum arrives at the uterus, it consists of two membranes,
the chorion and amnion; in the interspace between which is contained the
vesicula alba or umbilicalis, and a gelatinous substance — the tunica media
of Bischoff.  Internal to the amnion, we  find the  liquor amnii,  and the
embryo.   Each of these parts we shall now examine in detail.
  167. The Chorion  is the outer envelope proper to the  ovum, and cor-
responds to the membrane lining the egg in oviparous  animals.   It is found
covering the ovum at the earliest period at which this has been seen in the
uterus, surround'ng it loosely, and forming a shut sac.   It is smooth on its
inner surface, but externally it  is  covered  over with short cylindrical villi.
As  the ovum advances  in  age,  these villi diminish in  number, assume a
vesicular appearance,  and terminate  in delicate  rounded extremities.  The
interspaces are larger and more smooth.  About the  beginning of the second
month the villi divide into branches, which  arise  from  short thin stems, and
terminate either in thin filiform  or vesicular enlargements.   The process of

  1 Dr. Allen Thompson has given an excellent notice of early ova, observed by himself
nnd others, in the Edin. Med. and Surg. Journal, vol. lii.  p. 119, to which I beg to refer
the reader. 
120
UTERO-GESTATION.
obliteration thus commenced, continues until no villi remain, except  at that
part of the chorion which is in contact with the uterus ; the other part pre-
senting the appearance of a thin, colorless, transparent membrane.
  The umbilical cord is inserted into some part  of the inner surface of the
chorion, and the part  of  the outer surface which  corresponds to this inser-
tion, is always that which comes in contact with the uterine parietes, and
upon which the placenta is formed.
  The chorion may be divided into two lamina?,  especially where it covers
the placenta;  the outer is called the exochorion, the inner the endochorion,
by Burdach, who  believed the latter to be  the vascular layer of the allan-
tois.  From the endochorion, according to Bischoff, are derived the vessels
which run to the villi.   The chorion  itself  appears to be destitute  of ves-
sels, unless, as Dr. W.  Hunter suggested, we regard  as such the white fila-
ments observed near the edge of the placenta.  The intimate  structure of
the membrane is cellular, and in many places bears a strong resemblance to
that of vegetables, each cell containing a distinct  nucleus ;  the villi  partici-
pate in the same texture,  but their cells are  filled with a granular matter.
  The strength of the membrane is greatest in early ova ;  at the termina-
tion of pregnancy it is considerably weaker than  the amnion : at an early
period it  is equally strong  in all parts, but afterwards it is stronger near
the placenta.  It is covered externally by the decidua reflexa, and internally
it is separated from the amnion  by a layer of  gelatinous  matter, which is
afterwards condensed into a thin membrane, called  tunica media by Bischoff,
who first described it.
  168. Abnormal  deviations.—Inflammation  may attack  the membrane,
giving rise  to vascularity, opacity, thickening,1  or the  effusion of fluid be-
tween it, and the amnion.   Occasionally false membranes are deposited upon
it, and the villi may be the seat of hydatids.  Dr. Montgomery  has a prepa-
ration in  his  museum, in which the cord is inserted  into the part of the
chorion covered by the decidua reflexa, instead of into that attached to the
uterus.   The  fcetus, of course,  perished for want of nourishment.   Hemor-
rhage sometimes occurs into the space between the chorion  and amnion.
  169. I have already mentioned that during the  first months of gestation,
an albuminous or  gelatinous mass  of varying consistency is found between
the chorion and  amnion.   It is  often  mixed with flocculi, or  threads, and
occasionally presents a reticulated appearance.    " When put into spirits,"
Wagner observes, " this mass assumes the appearance of  the cellular tissue
that is found between the muscles, and seems, in fact, to bear the same rela-
tion to the amnion and the chorion as  the  intermuscular cellular membrane
does  to the fasciculi between which  it lies."  The space it occupies is, in
early ova, considerable, but it  gradually diminishes as the  two membranes
approximate,  and  in proportion the interposed  matter is  condensed  into an
extremely  delicate membrane,  like the arachnoid, termed  by Bischoff and
Wagner the tunica media.  By Yelpeau it is called the "  corps rcticulare,"
and  he considers it to  be the allantois;  but this opinion is rejected by other
physiologists.
  170. The Yesicula Alba, or umbilical vesicle (fig. 63), is also contained
in the interspace  between the amnion and chorion.  According to  modern
investigations, it  is  constantly present  as a normal formation in  the earlier
months of gestation, and is connected with the intestinal canal of the foetus.
It is, in fact,  the vitellus, surrounded  by the  blastoderma, upon  which the
embryo is fust formed, and  it bears  a perfect analogy to  the yelk of the
egg, except that  it is not  ultimately enclosed within "the abdomen of the
fcetus.  In very early ova, it is large in proportion, of a rounded  or oval

              1 Dr. Montgomery, Dub. Hosp. Gaz., March 15, 1857. 
UTERO-GESTATION.
121
 form, and lying upon the intestine, with which it communicates.   In  a short
 time, however, the inner end  becomes narrow, and forms a pervious canal,
 or duct, through  which its contents may be transmitted.  M. Yelpeau found
 it pervious in almost every ovum of six weeks old  that he  examined ;  and
 he states  that he not only saw vitellary matter in the intestine, but  that he
 could push  the  fluid from  the vesicle through the duct into the intestine.
 The length of the duct varies in different ova, and  its calibre diminishes as
 gestation advances,  until, in the second month, it is impervious and  thread-
 like, but  may still be traced to the loop of intestine contained in the sheath
 of the umbilical cord.   The vesicle contains a yellowish-white or yelk-colored
 fluid, in which numerous  globules  are  suspended.   Its parietes consist of
 two laminae, an  external  vascular,  and  an internal mucous layer.   It pos-
 sesses two  vessels,  the omphalo-mesenteric  artery and vein,  which ramify
 upon  its  surface  and on the  duct.  As  gestation advances, the vesicle is
 emptied,  shrinks, and remains flat  and  collapsed to the  termination  of
 pregnancy.
   Its  use is evidently to contain nutriment for the fcetus, before the develop-
 ment of the placenta.
   171. The Amnion (fig. 63). — In  the  quotation from Dr.  Barry's paper
 (§  146) descriptive of the changes which take place in the ovum after im-
 pregnation, it will be remembered that the  amnion was stated to be formed
 by the coalescing of the  layer of  small vesicles formed on the inner surface
 of the  membrane which invests the yelk, with the  "mulberry-like structure
 formed in the centre of the yelk, but passing to its circumference."  M. Coste
 calls the  amnion a  "true epidermis of the blastoderma," and states that it
 is detached from the external surface  of the  embryonic spot.  The membrane
 thus formed envelopes the embryo very  closely  at an early period, and is
 continuous  with the common integument of the fcetus, at the open abdominal
 parietes.   At a  later period, it is distended with fluid,  and so  separated
 from the  fcetus ;  and after  being  reflected upon the funis, of which it forms
 the  outer coat, it terminates at the umbilicus.  In the progress of gestation,
 the  amnion approaches the chorion, until, at last, it is in contact with it or
 rather  with the  tunica media.   It is thin  and transparent, but  of  a  firm
 texture,  resisting laceration  much more  than the other membranes.  Its
 external  surface  is  somewhat flocculent,  but internally it is quite smooth,
 like serous membrane, and like it, secretes a bland fluid.   Neither vessels
 nor nerves can be demonstrated in the amnion in a state of health,  though
(it may  be presumed to possess them.
   172. Abnormal deviations. — The researches  of M. Mercier have estab-
 lished the fact  that this membrane  may be  the seat of inflammation, and
 that in such  cases  it  becomes vascular, and secretes a  disproportionate
 quantity  of fluid.   It is  not quite certain  whether its quality is changed
 from diseased action.  The  membrane may also  become thickened  and
 opaque.
   173.  The Placenta. — Let us  now consider  the  chorion  at a more ad-
 vanced period of gestation, and we  shall find that a new organ has been
 developed on that  part of it which  is in  contact with the  uterus.  This
 organ  was first  called the placenta, I believe, by Fallopius ;  it is a  spongy
 vascular mass, existing in some form  in all mammalia, as an appendage of
 the  chorion.  It is  of considerable size at  the termination of utero-gesta-
 tion, its diameter being six or eight inches, its  circumference  eighteen or
 twenty-four, and  its  thickness from one  inch to one and a half.   In  general
 it is of a rounded  or oval  form.   Internally, its surface is smooth  and
 shining, from its being covered by the chorion and amnion, beneath which
 the  radiations of the umbilical vessels may  be  discovered.   The chorion,
 which  covers its inner surface  immediately, is firmly attached to it, and sends 
122
UTERO-GESTATION.
processes  between  its lobes and  lobules, whilst the amnion, lying over the
chorion, is  but loosely attached.   The  outer or  uterine  surface, if the
placenta be  "in situ" or removed carefully, is uniform  and  level, though
not  exactly  smooth, being covered by  the decidua  serotina ;  if this  be
peeled off, the  lobes  and lobules into which  the  placenta  is divided, are
evident, and  we find processes of the  decidua serotina,  entering  these di-
visions.  The vessels of one lobe have  very rarely any  direct communication
with those of another.
                                  Fig.  60.
                               Placenta and Cord.

  174.  As to the formation of the  placenta, we  observed that the villi of
the chorion diminish gradually in number, and finally disappear from every
part of its surface, except where it  is in contact with the uterus, at which
part they become, as  it were, concentrated, and grow with great luxuriance,
in consequence of the development within them of vessels derived from the
inner layer of the chorion  (the endochorion), or from between the two layers.
These vessels  go on enlarging and multiplying, interlacing and anastomosing
with  each other, until  they, with their  connecting (or separating) sheaths
of villi or decidua serotina, form the  mass of the placenta.   The vessels are
divided into  arterial  and  venous branches.   The two umbilical arteries, at
their insertion into the internal surface of the placenta, divide and subdivide
into radiating branches, which, plunging into  its substance,  are minutely
divided and  distributed to the  different lobes.   It is generally stated that
the ultimate radicles  of the arteries  terminate directly in the radicles  of the
umbilical vein, without the intervention of capillaries ; but there is room for
doubt upon  this point    The radicles of the umbilical vein coalesce, until
the  large vessels formed  by  them unite  in forming the umbilical vein, which
is enclosed  in the  sheath of the funis umbilicalis with the arteries.  The
arteries  are  extremely tortuous, and the veins are without valves.   It may
be  doubted whether  the placenta is supplied with nerves, but it is  pretty
certain that it possesses lymphatics.
   ["The formation  of the  placenta commences by the penetration  of the
ramified villi, or filamentous processes of the chorion, into  the tubuli of the
decidua; the villi  thus serve as roots,  which suck  up and convev  to the
embryo the nourishment secreted for it by the maternal structures.'"]

  1 [Carpenter's Human Physiology, p. 603.   For a very clear account of the formation
of the placenta, we would refer the student to Dr. Dalton's " Treatise on Human Physi-
ology," p. 523, et  seq.] 
UTERO-GESTATION.

       [Fig. 61.]
123
   Section of a portion of a fully-formed Placenta, with the part of the Uterus to which it is attached:—
 a, umbilical cord; 6, 6, section of uterus, showing the venous sinuses; c, c, c, branches of the umbilical
 vessels; d, d, curling arteries of the uterus.

   175.  The  situation of  the placenta  may  be  ascertained  with tolerable
accuracy, by the  use of the stethoscope before delivery, and the examination
of the  perforation in the  membranes afterwards.   By some writers it  is
stated to be at the fundus, or a little  on one side of it; by others  at the
posterior or anterior  surface :  it  would  seem, from  the  researches  of M.
Naegele, jun., to be most frequently on the left side;  next, on the right side
of the uterus.   He  states that the stethoscope indicated the placenta to be
attached to the left side, in two hundred and thirty-eight cases  out of six
hundred ; and to the right side of the uterus, in  one  hundred and forty-one
cases.   In twenty no  sound was  perceptible ; in  one hundred and  sixty it
was  weak, or diffused so  as to be  uncertain ;  in seven  the placenta, was
attached to the fundus;  in thirteen to the anterior wall; and  in eleven cases
there was placental presentation.
   176.  A  much-controverted  question now demands our attention : viz.,
Whether there be direct vascular communication between the placenta and
uterus ? and if not,  how is the  aeration of the fcetal blood effected ?  I am
afraid we cannot as  yet decide the point in dispute.    It was for a long time
believed  that the blood-vessels of the uterus and  placenta communicated
with each other, and  that  an  interchange of blood took place, so that the
fcetus obtained fresh blood from  the  mother for its own nutrition.  This
opinion was supported by Cowper, Noortwyk, Haller, Senac, and in  modern
times by Flourens.
   177.  The researches of the Monros, Hunters, Wrisberg, and others, how-
ever,  very satisfactorily disproved  the  existence  of this vascular continuity.
The labors of the Hunters, in particular, threw great light upon  the  anato-
mical relations between  the blood-vessels of the mother and  fcetus.   " They
satisfied  themselves,"  says  Dr. J.  Reid,  in  his paper,1 "that the umbilical
arteries terminate in the  umbilical veins, and not in the vessels  of the uterus ^'
1 Edin. Med. and Surg. Journal, No. 146. 
124
U T E R 0 - G K S T A T I 0 N .
and  that  the  blood in the umbilical arteries "passes from  them into the
veins, as in other parts of the  body, and so'back  again into  the child."
They further  observed, that  numerous  small curling  arteries,  the largest
being about the size of a crow-quill, passed from  the  inner  surface of the
uterus, that they penetrated  the decidua, and  opened into  the interstices
between  the  fcetal  blood-vessels  of the  placenta.  Prolongations from the
uterine  sinuses were also traced through the decidua, and were  observed to
terminate in the placenta in the same manner as  the curling arteries, so that
"in the umbilical portion of the  placenta, the arteries  terminate in veins by
a continuity of canal;  whereas in the uterine portion, there are intermediate
cells, in which  the  arteries  terminate, and from  which  the veins  begin.  It
was therefore concluded, that the  blood of the  mother was  poured by the
curling  arteries into a  kind of cellular tissue, filling up the intervals between
the ramifications of the fcetal placental vessels,  from which  it  returned to
the uterine sinuses of the mother through their placental prolongations, after
having  acted  upon  the  blood of the foetus  through the thin walls of the
umbilical  placental  vessels."
   178.  Lauth,  Yelpeau,  Seiler,  Coste,  Radford, Ramsbotham,  Millard,
Xoble,  etc.,  agree with the  former opinion  of  Dr. R.  Lee, doubting the
existence  of these utero-placental vessels, and assume that the placenta is to
be considered exclusively as the fcetal organ.  Dr.  11. Lee now believes that
there is a direct communication between the uterine vessels and the cavernous
structure  of the placenta.1  Dutrochet's theory of  endosmose and exosmose
has been adduced to explain the nature  and process  of the  interchange  of
blood, but I do not believe that it is considered satisfactory by many persons.
   179.  The  investigations  of Weber,  Eschricht, Owen, and  Iteid,  seem
rather to carry us  back to  a  modification of the opinions promulgated  by
the Hunters.   According to Weber, the  large vessels which leave the uterus
to pass  into  the decidua are  deprived of  all  except  their innermost tunics,
which are as  soft and tender as coagulated lymph.  The veins form a net-
work, and have this peculiarity, that they become wider the more deeply
they penetrate between the lobules.   Thus  the  veins  themselves  form cells
or sinuses, into which the fcetal villi project.  The delicate and yielding coat
of the vein is borne inwards  by  each villus  pressing upon its exterior, and
so is itself the covering  of all the villi which  compose the fcetal lobules,
and which seem to project into its  exterior.   Eschricht supposes  that the
utero-placental vessels divide  and subdivide in the  placenta like  the arteries
and veins in the other  parts of the body.  Wagner, in his Physiology, agrees
pretty nearly with Weber, and describes the  utero-placental vessels as wind-
ing like a network around the tufts of the chorion containing the vessels of
the embryo.
   The last author to whom I  shall refer is the late Dr. J. Reid, from whose
essay I  have  already quoted,  and whose  industry and  acumen obtained  for
him  a distinguished place among the physiologists of the present day.2  In
August, 1840,  he carefully examined the uterus  of a woman who had died
in the seventh month of pregnancy.  "On separating  the adhering surfaces
of the uterus  slowly and cautiously under water, I satisfied myself, but not
without considerable difficulty, of the existence  of the utero-placental ves-
sels  described  by the  Hunters.  After a portion of  the  placenta had been
detached  in this manner, my  attention was attracted towards a number of
rounded bands passing between the uterine surface of the placenta and the
inner surface of the uterus.  These bands were generally observed to become

  1 Lectures on the Theory and Practice of Midwifery, p. 136.
  2 May  I be excused, going so far out of my way as to recommend most cordially to my
brethren the admirably-written life of this eminent physiologist, by Dr. George Wilson. 
UTERO-GESTATION.
125
elongated, thinner,  and of a cellular appearance,  when put upon the stretch,
and were easily torn across ;  while at other times, though much more rarely,
they could be drawn out in the form of tufts from the mouths of the uterine
sinuses.  On slitting up some of the uterine sinuses  with the scissors, these
tufts could  be seen  ramifying in  their interior,  and were more or less elon-
gated ;  many of them appearing only to dip into  the  open  mouths of the
sinuses, while others proceeded from a quarter of  an inch  to an inch from
the open mouths of the sinuses by which they had entered, and in some cases
they extended themselves into one of the neighboring sinuses."   The parts
were  then  injected, as well  as was possible, and when  the  branches of the
tufts contained in the  uterine sinuses were filled  with injection, "their con-
tinuity with the umbilical placental vessels was clearly ascertained ;" and an
examination  with  the  microscope proved their identity with the umbilical
vessels in the placenta.   As  to  their anatomical relations to the  sinuses :
" these tufts  were found to protrude into the open  mouths of certain of the
uterine sinuses  only; and it need scarcely be added, that they were observed
only in those sinuses placed  next the inner surface  of the uterus, and not in
any of the  deeper sinuses.   These tufts were surrounded externally by a  soft
tube, similar to the soft wall of the utero-placental vessels, which passed
between the margin of the open mouths  of the uterine sinuses and the edges
of the orifices in the decidua, through which the tufts protruded themselves
into the sinuses.   The size  of  these tufts varied considerably.   Some of
them appeared  to fill up completely the open mouths  of the  sinuses by which
they entered, while  others filled them only partially.   On  examining these
tufts as they lay in the sinuses, it was evident  that, though they were so far
loose, and could be floated about, yet they were bound down firmly at various
points by reflections of the  inner coat of the venous system  of the  mother
upon their outer surface."  "In this uterus we ascertained that while some
of the utero-placental  veins contained no prolongation of the fcetal-placental
vessels, in others these passed along their interior,  and  projected  into the
uterine sinuses.   On tracing those utero-placental veins which contained no
fcetal vessels, as far as the placental surface of the decidua,  the inner coat
of the venous system was seen to be prolonged  upon some of  the  tufts of
fcetal-placental vessels in their  immediate neighborhood.  On tracing  one
of the larger of the curling  arteries through  the decidua, it was  also  ob-
served, that  when  it reached the placental surface  of that  membrane, the
inner coat  of the arterial system of the  mother  was prolonged  upon some
of the tufts of  the  fcetal-placental vessels which projected into their orifices.
Those numerous branches of the  fcetal-placental vessels  which reach the
placental surface of the decidua, and  do not  pass into the  uterine sinuses
nor into the orifices of the utero-placental vessels, are  attached  by their
apices to the placental surface of  that  membrane."  After an elaborate de-
scription of the structure of  the tufts and vessels of  the placenta, Dr. Reid
observes, "the  interior of the placenta is thus composed of numerous trunks
and branches (each including an  artery and an accompanying vein), every-
one of which, we believe, is closely ensheathed in prolongations of the inner
coat of the vascular system of the mother, or at  least with, a membrane con-
tinuous with it.  If we adopt this view of the  structure of the placenta, the
inner coat of the vascular system of the mother is prolonged over  each  in-
dividual tuft, so that when the blood of the mother flows into the placenta
through the curling arteries of the  uterus, it passes  into a large sac formed
by the inner coat of the vascular system of the mother, which is intersected
in many thousands of  different directions, by the placental tufts  projecting
into it like  fringes, and pushing its thin wall  before them in the  form of
sheaths,  which  closely envelop both the  trunk and each individual branch
composing these tufts.   From this sac the maternal blood is returned by the 
126
UTERO-GESTATION.
utero-placental veins, without having been  extravasated, or without  having
left her own system  of vessels."   "The blood  of the  mother contained in
this placental sac,  and the blood of the foetus contained in the umbilical ves-
sels, can easily act and react upon  each other through the spongy and cel-
lular walls of the placental vessels and  the thin  sac ensheathing them, in the
same manner  as the  blood  in  the branchial vessels  of aquatic  animals is
acted upon by the water in which they float."  These ample quotations will,
I believe, give the reader a just view of Dr. Reid's observations and opinions,
and  I may add, that  on visiting Edinburgh, Dr. Reid  had the kindness to
show me one of the  portions of uterus  and placenta on which his investiga-
tions were made, and there was no  difficulty in demonstrating the  tufts dip-
ping into the uterine sinuses.   Xo  doubt further observations are  necessary
for the perfect  elucidation of the subject; but I certainly think that, as far
as our knowledge extends, it is in favor of the opinion adopted by Dr. Reid
and  the later physiologists.
   180.  Abnormal  deviations. — The placenta is liable to malformations and
displacements,  and to a series of diseases, some of which have  been ably
described by my friend Professor Simpson of Edinburgh,1 Mr. Bremner,2 and
Dr.  Elkington, and others.3
   1.  It may be the seat of sudden  or gradual congestion, ending  in resolu-
tion or in effusion of blood " into the substance of the organ, upon its ute-
rine or foetal surfaces, or between the membranes."  Dr. Simpson  suggests,
that perhaps  the  so-called tumors, tubercles,  or white spots, etc., of the
placenta, of various  authors, may in  fact  be coagula of blood  in  various
stages of transformation.   The symptoms to which placental congestion and
apoplexy give  rise,  depend for their clear manifestation upon the  extent of
the  hemorrhage.  In moderate cases,  there is  a degree of uneasiness and
weight in the  region of the  uterus, and sometimes a fixed  or intermittent
pain, which may extend down the thighs.  When the hemorrhage  is  severe,
it will  be attended  by the usual  symptoms  of  loss of blood.   The result
to the  fcetus  in many cases  is death,  and  thus the congestion  may cause
abortion.
   2.  Inflammation may attack the placenta, either in its  parenchyma or
membranes, or all  together, and it may  either affect one  lobe only, or several
at the same time.   It may issue in  the  effusion of lymph, either into its sub-
stance or upon its fcetal or uterine surfaces.   In the former case we have
the yellow induration of the placenta ;  in the latter, adhesions  between the
uterus and  placenta ; and, when the fcetal  surface is the seat, there  may be
increase of  the  liquor amnii, lymph on its surface, or,  possibly, adhesion to
some part of  the  foetus.  Another termination of  placentitis is in the pro-
duction  of purulent  matter, in the substance  or upon the surfaces of the
placenta.  The most constant symptom of  placentitis is pain in the uterine
or lumbar regions, and, in  some cases, violent vomiting; in others, rigors,
succeeded by  febrile symptoms.   Inflammation of  the  placenta  may cause
the  death or  malformation of the embryo, and place the mother in  some
danger.   For more minute details, I beg to refer the reader to Dr. Simpson's
learned essay.
   3.  The placenta may be hypertrophied  or atrophied in part or the whole
of its substance.
   4.  From  the researches of Kilian Barnes,4 Hassall,5 Barlow,6 Cowan, and
Druitt,7 it appears that the vessels  of the placenta may undergo fatty degen-

  1 Edin. Med. and Surg. Journal, vol xlv. p. 265.          «Ibid., vol. lxxii. p. 56.
  3 Piov. Med. and Surg. Journal, May 30th, 1849.
  * Ou Fatty Degeneration of the Placenta, etc., Med.-Chir. Trans., vols, xxxiv. and xxxvi.
  5 Microscopical Anatomy.        « \ie(j Times and Gazette, Oct. 30th, 1852, p. 432.
  7 Med.-Chir. Trans., vol. xxxvi. p. 99. 
UTERO-GESTATION.
127
eration, just as the small vessels of the lungs  or other parts.   Dr. Hassall
observes that "in the placenta affected with fatty degeneration, certain of
the lobes, in place of presenting the red  spongy texture of healthy tissue,
exhibit  a fatty appearance, and are of a yellow color, glistening, firm, and
exsanguine, while the remaining lobes  present their ordinary characters, at
least to the unaided eye."   The  minute alterations which he  has detected
are as follows : " 1.  We observe that the villi are thickly studded with innu-
merable  spherules of oil.  2. The chorion is  much altered,  it is  thickened
and destitute of nuclasi.  3. The walls of the vessel no longer contain nuclasi;
these having, in  all probability, become degenerated  into spherules of  oil.
4. The spherules of oil are contained, some in the chorion, some in the walls
of the  blood-vessels, and  many in  the intervals  or spaces  between them.
5. The cavities of the vessels are almost  invariably free from fatty deposi-
tion.   6. The vessels  are destitute of blood."  No doubt that so far as it
extends, this change is destructive to the functions of the organ; but it does
not follow that the remaining healthy  portion may not be adequate to the
complete nutrition of the fcetus.  Mr. Barlow remarks very justly, that pla-
cental apoplexy may be owing to this fatty degeneration of the vessels.   Dr.
Druitt and others regard  this change  as a natural  rather than a morbid
process; that it  is in fact the mode of death of a temporary  organ, whose
functions are about to terminate.
   5. It  may be the seat of cartilaginous  or calcareous  degeneration, or of
other morbid products.
   6. It may give rise to hydatids.
   181.  The Umbilical  Cord, funis or navel-string, is  the  connecting link
between the foetus  and placenta (fig. 60),  terminating with the functions of
the latter  at birth.   It is visible  at the earliest  period of  pregnancy.   It
arises from the centre of the  placenta most frequently, but occasionally from
its edge (battledore placenta), and is formed by the umbilical arteries and
vein, embedded in (the Whartonian) gelatine, and enclosed  within a sheath
of the  chorion internally, and of the amnion externally.  Besides the vessels,
it contains the duct of the umbilical vesicle  and the urachus,  the omphalo-
mesenteric vessels, and, at  an early period, the foetal intestines at its fcetal
extremity.  At first,  the cord is  thin and cylindrical, the vessels  running a
straight course through  it; from the third to the  ninth  week,  it appears to
be divided by two or three vesicular swellings, which ultimately disappear.
After  this  time, the  vessels  run  in a spiral form, the  arteries around  the
vein, from left to right, and form in their course a number of small loops or
knots.   The vein has no valves,  and its calibre is equal to that of both the
arteries.   The cord is also supplied  with lymphatics, as  has been  proved by
the injections of Fohmann and Montgomery.   It is probable, though not as
yet demonstrated, that it may possess nerves also.
   The length  of the  cord varies  much ;  it is very rarely  less than eight
inches, though such cases are on record, and it is sometimes  five or six  feet
long.   Out of 500 cases, selected from  the writings of Osiander, Adelmann,
and Henne, with some additional measurements of my own,  I find the most
common length to be  eighteen inches;  none were  under twelve, nor above
fifty-four inches.   Dr. Storer has  found the  most common length  to be two
feet;  next, twenty-six inches ; next, twenty-three inches ; the shortest was
four and a half inches, and the longest forty-three.   Dr. G. Thompson, of
Boston,1 mentions one of five feet nine  inches ;  Mr. Rouse  one of fifty-one
and a  half inches, which was coiled  six times round the neck;2 and  Dr.
Tyler Smith, one of fifty-nine and a half inches.

           1 Boston Med. and Surg. Journal, vol. xlii., No. xxii. p. 451.
           1 The Lancet, Sept.  1, 1855. 
128
UTERO-GESTATION.
  [Abnormal shortness of the umbilical cord is by no means of such frequent
occurrence as excessive  length.   As stated above, among  500 cases Dr.
Churchill  found it in no instance shorter than 12 inches.  Mr. .1. B. Thomp-
son, however, relates a case  in which the  funis was only seven and  a half
inches  long.1  Mr.  Stone has met with  a case,  in which the funis was still
shorter, being only  six inches • and Mr. Win. Collyns,- another, in which the
funis was scarcely that length.]
  By most writers,  the pulsation of the arteries of the cord is considered to
be dependent upon  the heart; but  Osiander contends that they are to a cer-
tain degree independent,  and some  facts  which  he  adduces appear to afford
confirmation to his  opinion.
  After the birth of the child, the pulsation  ceases in about fifteen or twenty
minutes, and that portion of the cord which remains attached to the umbili-
cus, dies and gradually withers, until it falls off, in the majority of  cases, on
the fifth or sixth day.
  In ordinary cases the funis lies free and loose in the cavity of the amnion,
above the head of the child ; but  occasionally,  owing to the movements of
the child at an early period, it may be coiled round its neck, tied  in knots,
or escape below  the  head,  so  as  to  prolapse  during labor.'  The coiling
round the neck happens about once in nine or  ten cases ; or  according to
the examples I have collected, 204 times in 1920 cases.  Dr. Weidemann
states that in 28,430 deliveries there were 3230 cases  of coiling  round the
neck, and 149 around other parts  of  the body.   Pie attributes it to  a long
funis, abundant liquor amnii, and a  small child.3  It, is commonly enumerated
among the causes of delay  in labor,4 on account  of the  shortening  of the
cord which it occasions, and sundry other evil  effects  are attributed  to it,
which I believe to be altogether imaginary, for  the coiling  does not  occur
except when the cord is longer than usual, so as to leave  enough of it free.
For more minute  details  I take the liberty to refer the reader to an essay on
the subject in  my Researches on Operative Midwifery, etc.
  182. Abnormal deviations.—1. The  vessels of the cord may divide at
some distance from the  placenta :   2,  instead of two arteries  and one vein,
there have been found two veins and one artery, one vein and one  artery, or
three arteries : 3, two cords have been attached  to  one placenta with  a
single child: 4, the cord may be tied in double  or single knots :  5, the ves-
sels are sometimes partially or wholly closed : 6, cases are on record  of the
absence  of funis and  umbilicus:   7,  in  an  acephalous  fcetus born  in the
Western Lying-in Hospital, we found the  cord inserted  into the  neck, near
the angle  of the jaw, from whence  the vessels passed down behind the clavi-
cle and sternum, through the chest  into  the  abdomen, where they were lost:
8, when  the  umbilical ring is imperfectly  closed, the sheath of  the cord
sometimes  contains a portion of the intestines :  9, in cases  of twins, the
placenta and  cords are generally distinct,  and  without communication, but
occasionally a cross branch  passes  from  one to  the  other : 10, the cord may
be inserted into a part of the chorion, covered by the decidua reflexa, instead
of that part upon which  the placenta is  to be developed : 11, the cord may
be so much twisted (at an  early period) as  to  diminish  the calibre  of the
vessels, and to impair the nutrition of the embryo :  12, the  vessels may be-
come varicose, or the sheath of the cord may contain hydatids : 13, the coats
of the vessels  may  give way, and hemorrhage ensue:  14, the  cord maybe
torn across, by the mother's falling or receiving a violent concussion.
  183. The Allantois "arises on the fore part of the posterior extremity

  1 [London Lancet, June 4,  1842.      * Provincial Medical Journal, Aug. 6, 1852.1
  3 Med. Times and  Gazette,  July 18.  1857.
  4 Lee's Lectures on Midwifery, p. 121. 
UTERO-GESTATION.
129
of the mucous layer which is closing  to  form the  intestine, as a growth of
the intestine, which proceeds very rapidly.  It passes out where the ventral
laminae are still unclosed, in the  region  of the umbilicus, and in birds and
mammalia reaches  either mediately or immediately the inner surface of the
exochorion.  By the constriction  of the navel it is separated into two por-
tions, which communicate ; that within the body of the embryo is the saccu-
lated urinary bladder,  with  the  urachus or  tube of  communication.  It
receives its vessels from the hypogastric, which are spread out as a vascular
layer, especially upon that portion of its  surface which faces the exochorion.
According to Burdach  (as we have  seen) the vessels form a distinct layer,
the endochorion."  I have preferred quoting this concise description from an
article in  the Brit, and For. Med. Review, as giving  a good account of the
opinions held by most recent physiologists, to embarrassing the reader by
a  detail  of the  different hypotheses  which have  been  broached upon the
subject.
   184.  The Liquor Amnii is the name given to the fluid secreted by the
amnion, and contained in its cavity.  At first, it  is small in quantity, clear
and transparent;  but  afterwards it increases in quantity, and  becomes
slightly opaline.   Dr. G. 0. Rees has published in No. 6 of Guy's Hospital
Reports,  an  analysis of some amniotic  fluid which he  obtained in a case
where premature labor was induced.  He found its specific gravity 1008-6,
and in 1000 parts it contained
       Of water.........983-4
       Of albumen, with traces of fatty matter   .    .     .     5'9
       Albuminate of soda, chloride of sodium   .    .     .     6-1
       Animal extractive, soluble in water and alcohol, urea,
         chloride of sodium      .    .     .     .    ...     4-6
       With traces of alkaline sulphate.
Towards the end of gestation the albumen diminishes.
   Professor  Scherer has published an  analysis of liquor  amnii  at the fifth
month of gestation, and at the full time as follows : —
                          At five months.                 At nine months.
       Water    .    .     .   97584   ....   99L474
       Solids    .    .     .    24-16   ....    8'526
97584
24-16
7-67
7-24
9-25
       Albumen .     .     .     7 67    .     .     .    .     0-82
       Extractive     .     .     7-24         .     .     .     0-60
       Salts     .     .     .     9-25    .     .     .     .     7- 061
  The amount at the full time varies from half a pint to several quarts; but
the average quantity is about  a pound.   The fluid is usually stated, and I
believe  truly, to be  a secretion from the inner surface of the amnion : but
Meckel attributes it  to the maternal vessels, especially in the earlier months.
  The uses of the liquor amnii are very intelligible and important: 1, it is
probable that it serves for nutriment to the fcetus, at least during the early
months : 2, it  preserves an  equable  temperature for it, during  its intra-
uterine life ; 3, it diminishes the impression from sudden movements, shocks,
etc., and thereby prevents injury :  4, during labor it protrudes the mem-
branes, and is the primary  agent in dilating the os uteri.
  185.  Abnormal deviations—It  maybe very scanty, or, in the  opposite
extreme, excessive.   The  latter deviation from its natural state is probably
the result  of inflammation, and occasions  some mechanical inconveniences
to the mother, and risk to  the child during gestation,  whilst at the time of
labor it seems to enfeeble the uterus during the first stage.  The quality of
     1 Medical Times. Aug. 7th, 1351, from Schmidt's Jahrbucher, vol. lxvii. p. 7.
       9 
130                     UTERO-GESTATION.
the fluid may be changed, though it rarely decomposes.  Its color is some^
times yellow or brown.
   186*  The Embryo.1 — If the  reader will take the trouble to turn  back to
§ 146. he will  find that, in the quotation from  Dr. Barry,  the  last change
there described as occurring  after impregnation, was the disappearance of
the germ vesicle.  When the vesicle  bursts in the  hen's egg, the formation
of the germ-membrane, or blastoderma  commences, according to Purkinje,
and it is completed by the fifth day, according to Yon Baer.   In mammalia,
however, it appears  to exist previous to the  bursting or disappearance of
the vesicle ; at least it is visible immediately the vitellus becomes  transpa-
rent after that occurrence.   Between this  membrane and the chorion there
is a thin layer of albumen, and at some point we find  an  aggregation of
granules, forming  the  cumulus of the blastoderma.   It  is at this part that
the embryo is developed, lying as it were  upon the membrane.   The  form of
the germinal membrane gradually changes, becoming more oval.  It  consists
of  three superimposed laminae  or layers, at  least at the central point or
cumulus ;  and  upon this  separation into layers rests the modern theory of
development,  as  first  proposed by Dollinger and  Pander,  and afterwards
illustrated by Yon Baer, Rathke, Burdach, etc. etc.   'Above, and most ex-
tended." says the author of the very able article in the Brit, and For. .Med.
Review, from whom  I have already quoted, "is the  serous layer ; below and
least extended  is the mucous: between the two, and later in its appearance,
is the vascular layer.  In one or other of  these, as distinct  primitive forms,
there lies concealed that which is essential, in the different organs  and tis-
sues  of which  the body is composed, and in virtue of which they admit of
being referred  to distinct original groups.  On the serous layer, arise the
organs  of  animal life — the brain and  spinal  cord, organs  of sense, skin,
muscle, tendons, ligaments, cartilage, bone;  on the mucous, the organs of
vegetative  life, the intestinal canal, lungs,  liver, spleen, pancreas, and other
glands.  The heart  and vascular system  arise from the vascular layer, if this
is to be considered  as a separate one.   To  which division  the generative
system  is to be primarily referred, is  still undetermined."  This is the view
generally accredited, but Dr. Barry seems to think  it doubtful.  He has not
observed this  "splitting of the  germinal membrane," nor does he conceive
that  the membranous layers originate the embryo, but the reverse : that the
" previously-existing germ, by means  of a hollow process, originates  a struc-
ture having the appearance of a membrane."
   In the centre of the  blastoderma, where it is supposed to divide  into the
serous and mucous layers, there is observed a clear  space, the area proligera
or pellucida, in the centre of which and in the transverse axis of the  vitellus,
there is a mass of globules, loosely connected together, forming the primi-
tive streak or trace of Yon Baer, and  around this the area  vasculosa is
developed.   I  may  mention that  these  changes have been  observed in the
ova of  different mammalia, as well as in the egg ; and there is every pro-
bability that the human ovum undergoes identical mutations.
   The  appearance  of the primitive  trace is observed in.eggs at about the
fourteenth hour  of  incubation,  and in  the human  ovum may  probably be
referred to the second or third week.
   To proceed with the next changes: " The globules of the primitive streak
seem next  to be resolved, and then there is a change of appearances.  On
the sides of the streak are two lumince dorsales, which bound a median fur-
row ; and  below this furrow is the chorda dorsalis, which is the axis of the

   1 For  a more minute account of the modern researches on the subject of embryonic
development than I have been able  to give, I must  refer  my readers  to Drs. Baly and
Kirke's Supplement to Miiller's Physiology. 
UTERO-GESTATION.                      131
future embryo, and the origin of the spinal column.   That portion of fluid
which separates the chorda dorsalis  from  the  lamina dorsalis is the future
cord and brain.   The chorda dorsalis thickens  at the fore part, to form the
first appearance  of skull, and the fluid between the dorsal lamina? is in larger
quantity, in correspondence with it; so that the central parts of the nervous
system and their coverings are laid down at the same time, and grow simul-
taneously.   The  separation between  the spinal cord and brain  is a very
early one, and is coincident with a bending  downwards towards the yelk,
of the anterior part  of  the laminae dorsales, which define the limit between
the skull and column, brain and cord."
   Next follows  the  closing of the lamina? dorsales  over the fluid which is
the rudiment of  brain and cord.   The brain, therefore, as Yalentin  remarks,
ought not to be  considered as growing from one end  of the cord.  "At first
there is  only a  single cerebral vesicle ; for in  the  brain, as well as in the
cord, granules accumulate first on the periphery, the central part continuing
to  be fluid.  The single vesicle is then elongated, and  next appears con-
stricted in certain regions, so as to  form  three cells, which  communicate.
The anterior cell corresponds to the cerebrum, the middle cell to the corpora
quadrigemina and neighboring  parts, and the posterior cell to the medulla
oblongata and neighboring parts."   " The deposit of granular matter which
accompanies the further development of the brain and cord, is seen on that
side of both which corresponds  to  the  viscera, sooner than on that which
corresponds to the spine."
   " Two  other  laminae  (lamina? ventrales of Yon  Baer) are in the mean-
time proceeding from the axis of the embryo, one  on  each side    They grow-
out laterally, and tend  to converge  in the  median line, as did the dorsal
laminae ;  but they form a larger curve, and follow a different direction ; that
is, they converge to meet below the axis, and they do so meet, except in the
umbilicus."
   187. After the  rudiments of organic life  have been commenced in  the
central portion  of the serous layer, a fold  of its  peripheral portion arches
over the dorsal  surface of the embryo, "so as to represent a sac  whose open-
ing is at the edge of  the fold."   The opening gradually decreases  until the
opposing folds of membrane are  in  contact,  and  then vanishes, leaving the
fcetus surrounded by two membranes.  The one next to the fcetus is  the
amnion;  the  other is gradually separated  from the amnion, and joins  the
serous lamina of the blastoderma; this is  the "false amnion" of Pander, or
the "serous covering" of Yon Baer.   This mode of formation of the amnion
has been observed by Yon  Baer in the dog, sheep, and pig; and  his obser-
vation has been  verified by Dr. Allen  Thompson.
   The membrane which surrounds the vitellus or yelk is very  vascular; it
becomes  oval in shape, and more  pointed where it is in contact with the
embryo, until  at length  it contracts  into a  narrow duct, thus  forming the
vesicxda alba, and duct.
   The allantois, as already mentioned, arises from the lower end of the in-
testinal canal on a little vesicle, and  increasing in size, encircles the embryo
along with the umbilical vesicle.
   188. The heart of the embryo, which is the product of  the vascular layer
of  the blastoderma,  is formed  at an early period ;  at first it appears as a
twisted canal ;  at the under side  it receives  two  omphalo-mesenteric veins,
and in the situation  of  the future bulbus aorta; it divides into four vascular
arches, which first uniting into  the aorta, again divide, run down near the
vertebral column, and give off the omphalo-mesenteric arteries, which ramify
on the blastoderma and umbilical vesicle.
   189. Thus, then, we have seen  the embryo developed in the layers of the
blastoderma, and formed by a gradual closing in of the  laminae towards the 
132
UTERO-GESTATION.
median line ; the brain and spinal marrow, which are its earliest rudiments,
are covered  in, and in like manner  the  parts  anterior to  the spine, as  the
thorax, abdomen, etc., are formed.  We are indebted to comparative anatomy

              [Fig. 62.]
  Diagram of an early Human Ovum, showing the
Amnion in process of formation, and the Allantnis be-
ginning to appear:—a, chorion ; b. vitelline mass sur-
rounded by the blastodermic vesicle ; c, embryo; d, e,
and/, external and internal folds of the serous layer,
forming the amnion; g, incipient allantois.

0. . rjLt-r i. - • ^
for opportunities of observation ; but there is no doubt that the same pro-
cess  takes place in the human ovum.   Professor Wagner has given a de-
scription of a human ovum  of about three weeks old, part of which I shall
take the liberty  of  quoting : " Such ova, still surrounded by decidua, mea-
sure  about seven  lines in length ;  in  the  naked chorion, they are  about
five  lines  long.   The chorion  at  this  time is  beset externally with small
cylindrical hollow villi.  The embryo itself is two lines long.   It is plainly
surrounded by an amnion,  which lies loosely, but still pretty closely about it,
and obviously proceeds from the abdominal laminae.   The embryo is curved,
and presents anterior cerebral  vesicles or hemispheres, pretty well developed
(figured rather large  in figs.  63, 64J, and considerable corpora quadrigemina
Fie. 63.
Fug. 64.
                        Human Ovum of about three weeks.

immediately behind them ;  there is the distinct appearance of an eye, and a
rounded offset from the  medulla oblongata indicates the  acoustic vesicle;
several branchial arteries and  fissures are also conspicuous, the last of them,
however, not  completely formed.   The oral aperture is just above the upper
branchial fissure.   The anterior  and posterior extremities  are curved  leaf-
like processes, still of very small dimensions.''  The abdomen is vet an open
cleft, in which, but projecting beyond it, is  the heart, " of very large relative
dimensions, and consisting  of a  simple atrium, or  auricle, "and  ventricle;
behind the  heart is the  liver, and  under the liver the intestine, which is
attached by means of  a  distinct  mesentery."  Where the large  and  small
intestines meet, the canal makes a sweep in the umbilical vesicle.   On either
side of the mesenteric  lamina, we  find the  primordial kidney,  composed of
short caeca.   The  allantois  is  seen  extending from the low'er part of the
intestine.
!^,h
(s^-x\.ItA.\. 
UTERO-GESTATION.
133
  190. During the second month, we find the extremities  larger and more
projecting;  the body curved, the  head  disproportionately large, and  bent
downwards,  indications of the  nostrils,  and a gaping  oral aperture.   The
abdomen is  closed  about the fifth week, except at the  umbilical aperture,
through which a loop of intestine  still escapes.   The os coccygis resembles
a tail, bent forward, and of considerable size.

              Fig. 65.                                 Fig. 66.
Human Ovum of about two months.
   The forehead is more vaulted, because of the development of the  hemi-
spheres of the brain ; the spinal cord is cylindrical, of nearly uniform  thick-
ness, and terminating in a blunt extremity; posteriorly it is open.   " The
medulla  oblongata makes a bend  forwards at the top of the neck, and then
ascends  perpendicularly into the capacious  cranium,  where the  corpora
quadrigemina present themselves, as two large semi-globular masses, having
behind them a  pair of narrow lateral  laminae,  the  rudiments of the  cere-
bellum.   The medullary stem, or crus cerebri,  passes under the  corpora
quadrigemina, and again bending downwards,  the corpora striata and optic
thalami are evolved upon it."
   The first points of ossification appear about the seventh  week, in the cla-
vicle and lower jaw ; the vertebral arches are not yet closed in, and the ribs
appear like little streaks.  The only trace of muscular fibre is  in  the dia-
phragm.    The heart at this  time begins to change  its  form, and the inter-
ventricular septum to  form.   The liver is very large and granular.   The
stomach  is assuming somewhat of its normal  form;  the urinary bladder is
enclosed, but the anus is imperforate.
   After this period, the different parts are developed with tolerable rapidity:
the separate  portions  of the brain  are  evolved, and the  organs of sense
acquire  their external  characters ;  the  eyelids,  nose, and ears are  formed.
About the seventh  month,  the membrana  pupillaris is ruptured,  and the
pupil becomes visible.   The cranium continues cartilaginous for some time,
then points of ossification are seen, which radiate until each bone is nearly
complete.
   The upper and lower extremities increase, the hands and feet are deve-
loped ;  the fingers and  toes  separate, and the nails become distinct  about
the sixth or seventh month.
   In front of the coccyx we find the anus, which  at first is imperforate; and 
134
UTERO-GESTATION.
anterior to it, the organs of generation, in form at first of a conicle tubercle,
which is subsequently developed  into the penis or clitoris,  while the skin at

                                 Fig. 67.
                       Human Ovum of about three months.

the sides is prolonged into the scrotum or labia.   The testes are originally
placed on each  side of the vertebral column, but afterwards descend  along
the iliac vessels to the inguinal ring, through which they pass, carrying with
them  a portion  of the peritoneum to form their tunica vaginalis.
   The liver and kidneys are completed before the termination of pregnancy,
and soon commence the performance of their functions; for the meconium is
found to be colored by the bile even in premature children, and urine is fre-
quently voided  during delivery.
   [The formation of the ovum,  and the development of the  embryo, are
among the  most incomprehensible  subjects  to a student;  at the risk, there-
fore, of some repetition of what is  said  upon these  points by the author, I
here jntroduce the following quotation, with the accompanying illustrations,
from  Dr.  Rigby's work on Midwifery, in which the subjects are very clearly
and concisely treated :
   "Embryo. — There is, perhaps, no department of physiology which has
been  so remarkably enriched by recent discoveries, as that which relates.to
the primitive development of the ovum  and its embryo.   The researches of
Baer, Rathke, Purkinje, Yalentin, etc., in Germany;  of Dutrochet, Prevost,
Dumas, and Coste, etc., in France ; and  of Owen, Sharpey, Allen Thompson,
Jones, and Martin Barry, in England, but more especially those of the cele-
brated  Baer, have greatly advanced our  knowdedge of these subjects, and
led us deeply into those mysterious processes of nature which  relate to our
first origin and  formation.
   "These researches have all tended to establish  one great law, connected
with  the early development of the human  embryo, and that of other mammi-
ferous animals, viz.,  that it at first possesses a structure and  arrangement
analogous to that of animals in a much lower scale of formation ;  this obser-
vation also applies of course to the ovum itself, since a  variety of changes
take  place  in it after impregnation, before a  trace  of the embryo can be
detected.
   "At the earliest periods, the human ovum bears a perfect analogy to the
egg<  of fishes,   amphibia, and birds : and it is only by carefully examining 
                          UTERO-GESTATION.                      135

the changes produced by impregnation in the ova of these lower classes of
animals, that we have  been enabled to discover them in the mammalia  and
human subject.
   "As the bird's  egg, from its size, best affords us the  means of investi-
gating these changes, and as in all essential  respects they are the same in the
human ovum,  it will be necessary for us to lay before  our readers a short
account of its structure  and contents, and  also of the changes which they
undergo,  after impregnation.  In doing this we shall merely confine our-
selves to the description  of what is applicable to the human  ovum.
   " The egg is known to  consist of two distinct  parts, the vitellus or yelk
surrounded by its albumen or white;  to the  former of these we  now more
Fig. 68.                              Fig. 69.
  Section of a Hen's Egg within the Ovary.—
a. The granulary membrane forming the peri-
phery of the yelk. 6. Vesicle of Purkinje em-
bedded in the cumulus,  c. Vitellary membrane.
d. Inner and outer layers of the capsule of ovum.
e. Indusium of the ovary.
 particularly refer.  The yelk is a granular albuminous fluid, contained in a
 granular membranous sac (the blastodermic membrane), which is covered by
 an investing  membrane called the vitelline  membrane  or yelk-bag.  The
 impregnated vitellus  is retained in its capsule in the ovary precisely as the
 ovum of the mammifera is in the Graafian vesicle.   The whole ovary in this
 case has a clustered appearance, like a bunch of grapes, each capsule being
 suspended by a short pedicle of indusium.
   " In those ova which are considerably developed before impregnation, the
 granular blastodermic membrane is observed to be thicker, and the granules
 more aggregated at that part which  corresponds to the  pedicle,  forming a
 slight  elevation with  a depression  in its centre, like the cumulus in the pro-
 ligerous disc of a Graafian  vesicle.   This little disc is the blastoderma, ger-
 minal membrane, or cicatricula ; in the central depression just mentioned is
 an exceedingly minute vesicle, first noticed by Professor Purkinje of Breslau,
 and named after  him  : in more correct language it is the germinal vesicle.
   "According to Wagner,  the germinal  vesicle is not surrounded by a disc
 before impregnation ; and  it is only  after this process that the above-men-
 tioned disc of granules is formed.   By the time the ovum  is about  to quit
 the ovary the vesicle itself has disappeared, so that  an ovum has never been
 found in the oviduct containing a germinal vesicle,  nothing  remaining  of it
 beyond the little  depression in the cumulus of the cicatricula.
   " The rupture  of the Purkinjean or germinal  vesicle has been supposed
by  Mr.  T.  W. Jones  to take place before impregnation; but the observa-
tions of Professor Yalentin seem to lead to the  inference that it  is a result
of that process, and must be therefore looked upon as one of the  earliest 
13G
UTERO-GESTATION.
changes  wdiich  take place  in the  ovum or  yclk-bag upon quitting the
ovary.1
  " During its passing through  the oviduct (what in mammalia is called the
fallopian tube), the  ovum receives a thick covering of albumen, and as it
descends still farther along the canal the  membrane of  the shell is formed.
  " On examining the appearance of the  ovum in mammiferous animals, and
especially  the  human ovum, it  will be found that it  presents a form and
structure' very analogous  to the ova just  described, more especially  tho.-e of
birds.   It  is'a  minute spherical sac, filled with  an albuminous fluid, lined
with its blastodermic or germinal membrane, in which is seated the germinal
vesicle or vesicle of  Purkinje.   When the ovum has quitted the ovary the
germinal vesicle disappears,  and on its entering the fallopian tube it becomes
covered with a gelatinous, or rather albuminous covering.  This was inferred
by Yalentin, who  considered that 'the enormous  swelling of the ova, and
their passage through the fallopian tubes,' tended to prove the circumstance.J
It has since been demonstrated  by Mr. T. W. Jones in a rabbit seven days
after impregnation.   The vitellary membrane  seems,  at this time, to give
way, leaving the vitellus of the  ovum  merely covered by its spherical blasto-
derma, and encased  by the layer of albuminous matter which surrounds it.
   "  From what we have now stated, a close analogy will appear between the
ova  of the  mammalia and those of the lower classes, more especially  birds,
which from their size affords us the  best  opportunities of investigating this
difficult subject.
   "In birds, the covering  of the  vitellus is  called y elk-bag;  whereas,  in
mammalia  and man it receives the  name  of vesicula umbilical is.   Its albu-
minous covering, which corresponds to the white  and membrane of the shell
in birds, is called chorion: by the  time that the  ovum  has reached  the
uterus, this outer membrane has undergone a considerable change ;  it  be-
comes covered with a complete  down  of little  absorbing  fibrillae, which
rapidly increase in size as development advances, until  it presents that tufted
vascular appearance, which  we have already mentioned when describing this
membrane.
   " The first or primitive trace of  the embryo is  in the  cicatricula  or ger-
minal membrane, which contained the germinal vesicle before its disappear-

                Fig.  70.
 Changes in the lien's Egg during
Incubation. — a. Transparent  area.
b. Primitive trace.
ance.  In the  centre  of this, upon its  upper surface, may be  discovered a
small dark line :3 ' this line or primitive trace is swollen at one extremity, and
is placed in the direction of the transverse  axis of the egg.'

  1 [We said, " one of the earliest changes."   Mr. Jones considers that  "the breaking
up of the surface of the yelk into  crystalline forms," is the first change which he has
observed]
  2 [Edin. Med.  and Surg. Journ., April, 1836.]
  3 [Allen Thompson on the Development of the Vascular System in the  Fcetus of Ver-
tebrated Animals.  (Edin. New Philosoph. Journ., Oct. 18:id.)]
 
UTERO-GESTATION.                       13?
  "As development advances, the cicatricula expands.   'We are  indebted
to Pander,'1 says Dr. Allen Thompson in his admirable essay above quoted,
'for the important discovery, that towards the twelfth  or  fourteenth  hour,
in the hen's egg the germinal membrane becomes divided into two layers of
granules, the serous  and mucous layers of the cicatricula ; and that the rudi-
mentary trace  of the  embryo, which  has  at this time  become  evident, is
placed in  the subtance  of the uppermost or serous layer.'   'According  to
this observer, and according to Baer,  the part of this layer which surrounds
the primitive trace soon becomes thicker;  and on examining this part with
care, towards the eighteenth hour, we  observe that a furrow has been formed
in it, in  the bottom of which  the  primitive  trace  is  situated ;  about the
twentieth hour this  furrow is converted into a canal open  at both ends, by
the junction of its  margins (the plicce primitivce of  Pander, the laminae
dorsales of Baer) : the canal soon becomes closed at the cephalic or swollen
extremity of the primitive trace,  at which part it  is  of a pyriform shape,
being wider here than at any other  part.   According to Baer  and Serres,

                                 Fig. 71.
   Changes in the Hen's Egg during Incubation.—a. Transparent area. 6. Laminae dorsales.  c. Cephalic
  end. d. Kuiliments of dorsal vertebra?, e. Serous layer. /. Lateral portion of the primitive trace.
  g. Mucous layer,  h. Vascular layer,  k. Laminae dorsales united to form the spinal canal.

 some time after the canal begins to close, a semi-fluid matter is deposited  in
.it, which on its acquiring greater consistence, becomes the rudiment of the
 spinal cord ; the pyriform extremity or head is soon  after this seen  to be
 partially subdivided into three vesicles, which  being also filled with a semi-
 fluid matter, gives rise to the rudimentary state  of the encephalon.'   'As
 the formation of the spinal  canal proceeds, the parts  of the  serous layer
 which surrounds it, especially towards the head, become thicker and more
 solid, and  before the twenty-fourth hour we  observe on  each side of  this
 canal four or five small round opaque bodies ;  these bodies indicate the  first
 formation  of the dorsal vertebra?.
   "'About the same time, or from the twentieth to the twenty-fourth hour,
 the inner layer of the germinal membrane undergoes  a farther division,  and
 by a peculiar change is converted  into the vascular mucous layers.'2 It will

  1  [Pander, Beitriige zur  Entwickelungs-geschichte des Hiinchens im Eie.  Wurzburg,
 1817.]
  2  [A. Thompson, op. cit ] 
138
UTERO-GE STATION.
thus be seen, that the germinal membrane is that part of the ovum in  which
the first changes produced by impregnation are observed.   The rudiments
of the osseous and nervous systems are formed by the outer or serous layers ;
the outer covering of the fcetus .or integuments, including the  amnios, are
also furnished by it.   ' The layer next in order has  been called vascular,

                 Fig. 72.
because in it the development of the principal parts  of the vascular system
appears to  take  place.  The third, called the mucous  layer, situated  next
the substance of the yelk, is generally in intimate connection with the vascu-
lar layer, and it is to the changes which these combined layers undergo, that
the intestinal, the respiratory, and probably also  the glandular systems, owe
their origin.'1
   " The embryo is therefore formed in the layers of the germinal membrane,
and becomes,  as  it were, spread out  upon  the  surface of the  ovum; the
changes which the ovum of mammalia undergoes appear, from actual obser-
vation, to be precisely analogous to those in  the  inferior animals.   (Baer,
Prevost, and Dumas.)  From the primitive trace,  which was at first merely
a line crossing the cicatricula, and which now begins rapidly to  exhibit the
characters  of the spinal column, the parietes  of the  head and trunk gradually
approach farther and farther towards the anterior surface  of  the abdomen
and head until they unite ;  in this way the  sides  of the jaws  close in the
median line of the face, occasionally leaving the union incomplete, and thus
appearing  to produce in some cases the  congenital  defects  of hair-lip  and
cleft palate.  In  some way the ribs meet  at the sternum ; and it maybe sup-
posed that sometimes this bone is left deficient, and thus may become one of
the causes  of  those  rare cases of malformation, where  the child has been
born with the heart external to the parietes of the thorax.   In like manner
the parietes of the abdomen and pelvis close in the linea alba and symphysis
pubis,  occasionally leaving the  integuments  of the navel deficient,  or, in
other words, producing congenital  umbilical hernia, or at the pubes a non-
union of its symphysis with a species  of inversion of the bladder, the  ante-
rior wall of that viscus  being nearly or entirely  wanting.
   " The cavity of the abdomen is  therefore  at first open to the vesicula um-
bilicalis or yelk, but this changes as the abdominal parietes begin  to  close
in ;  in  man and the mammalia merely  a part  of it,  as above mentioned,
forms the intestinal canal,  whereas, in oviparous animals, the whole of the
yelk-bag enters the abdominal cavity, and serves for an early nutriment to
the young  animal.   Another change connected with  the serous or  outer
layer of the germinal membrane  is the formation of the amnion.   The  fcetal
rudiment, which  from its  shape has  been called  carina, now begins  to be
enveloped  by a membrane  of exceeding  tenuity, forming a double covering
upon it; the one which immediately invests  the  fcetus is considered to form
1 [A. Thompson, op. cit., 2'.>8.] 
UTERO-GESTATION.
139
the future epidermis;  the other, or outer fold, forms a loose sac around  it,
containing the liquor amnii.   Wrhilst these changes are taking place in the
serous layer of the germinal membrane, and whilst the intestinal canal, etc.,
are forming on the anterior surface of  the  embryo, which is turned  towards
the ovum,  by means of the inner or mucous layer, equally important changes
are now observed in the middle or vascular layer.   'In forming this fold,'
says Dr. A. Thompson, 'the  mucous layer is reflected farthest inwards; the
serous layer advances least, and the  space between them, occupied by the
vascular layer, is  filled up by a dilated part of this layer, the rudiment  of
the heart.'1

                                                          Fig. 7.3.
                                                         a.

  Vesicula Umbilicalis, from Baer.—b. Is a portion of the convexity of the
amnion, upon which at a, is the fundus of the diminutive human allantois.
  c. The duct of the vesicula umbilicalis, dividing into two intestinal portions;
and besides this duct are two vessels which  are distributed upon the vesicula
umbilicalis, and form a reticular anastomosis with each other.
   " Whilst this rudimentary trace of the vascular system  is making its  ap-
pearance, minute vessels are seen ramifying over  the  vesicula umbilicalis,
forming, according to  Baer's  observations, a reticular  anastomosis, which
unites into two vessels the vasa omphalo-meseraica.2  These may be demon-
strated  with great ease in the chick : the cicatricula increases in extent; it
becomes vascular, and  at length  forms a heart-shaped  network  of delicate
vessels, which unite into two trunks, terminating  one on  each side  of the
abdomen.
   "The umbilical vesicle now  begins to separate itself more and more from
the abdomen of the fcetus,  merely a duct of communication passing to  that
portion of it which forms the intestinal  canal.  The first rudiment of the cord
will be  found at this separation ; its fcetal extremity remains for a long  time
funnel-shaped, containing,  besides a  portion of intestine, the  duct  of the
vesicula umbilicalis, the vasa omphalo-meseraica (the future vena porta?), the
umbilical vein  from  the  collected venous radicles  of the chorion, and  the
early  trace of the umbilical arteries.   These last-named vessels ramify  on a
delicate membranous sac of  an  elongated form, which rises from the inferior
or caudal extremity of the embryo, viz., the allantois; whether this is formed
by a portion of the mucous layer of the  germinal  vesicle, in common  with
the other abdominal viscera, appears to be still uncertain ; in birds this may
be very easily demonstrated as a vascular vesicle arising from the extremity
of the  intestinal  canal ; and in mammalia, connected with the bladder  by
means of a canal called urachus; from its sausage-like shape, it has received
the name of allantois.
   "The existence of an allantois in the  human embryo  has been long in-
ferred from the presence of a ligamentous cord  extending from  the  fundus
of the bladder to the umbilicus, like the urachus in  animals.   But from  the
extreme delicacy of the  allantois, and  from its  function  ceasing  at  a  very
early  period, it had defied  all research,  until lately,  when  it has been satis-
factorily demonstrated in the human embryo by Baer and Rathke.   It oc-
cupies the space  between the chorion and amnion, and  gives  rise occasion-
ally to  a collection of fluid  between these membranes,  familiarly known by
the name of the liquor amnii spurius, which, strictly speaking,  is the liquor
allantoidis.

        1 [Op. cit., p. 301.          2 British and Foreign Med. Rev..No. 1.]
 
140
UTERO-GESTATION.
  "The function of  the allantois is still in a great measure  unknown.   In
animals it evidently acts as a species of receptaculum urinoe during the latter
periods of gestation ;  but it is very doubtful if this be  its use during the
earlier periods.   It  does not seem directly connected with the process of
nutrition,  which at this time  is proceeding so rapidly, first by means of the
albuminous contents  of the vitellus, or vesicula umbilicalis, and  afterwards
by the absorbing radicles of  the chorion ;  but, from analogy  with the struc-
ture of the  lower classes  of animals, it would appear that it is  intended to
produce  certain  changes  in  the  rudimentary  circulation of  the embryo,
similar to those which, at a later period of pregnancy, are effected by means
of the  placenta, and  after birth, by the lungs, constituting the great functions
of respiration.
  " In many of the lower classes  of  animals,  respiration (or at least the
functions  analogous  to it) is  performed by organs  situated at the inferior or
caudal extremity of the  animal:  thus,  for instance, certain insect tribes, as
in hymenoptera, or  insects with a sting, as wasps, bees, etc. ;  in  diptera, or
insects with two wings, as the  common fly;  and also the spider-tribe, have
their respiratory organs  situated  in  the  lower part of the abdomen.  In
some of the Crustacea, as, for instance, the shrimp, the organs of respiration
lie  under  the tail, between the fins, and floating loosely in the water.  Again,
some of the mollusca,  viz., the  cuttle-fish, have  the respiratory organs in the
abdomen.   We also know that many animals, during  the first  periods of
their lives, respire by a different set of  organs  to  what they  do in the adult
state ; the most familiar illustration of this is the frog, which, during its tad-
pole state, lives entirely in the  water.
  "As the growth of  the embryo advances, other organs, whose function is
as temporary as that of the allantois, make their appearance : these also cor-
respond to the respiratory organs of a lower class of animals, although higher
than those to  which  we have just alluded, — we mean branchial processes or
gills.  It is to Professor  Rathke1 that we  are  indebted for pointing out the
interesting fact, that  several transverse slit-like  apertures may be detected
on  each side of the neck of the embryo, at a very early stage of development.
In  the chick, in which he first observed it, it  takes place about the fourth
day of incubation: at this period the  neck is remarkably thick, and contains
a cavity  wdiich communicates  inferiorly with the  oesophagus and stomach,
and opens  externally  ou  each  side by means of the above-mentioned  aper-
tures,  precisely as is observed in fishes, more especially the shark tribe; these
apertures  are  separated  from each other  by lobular  septa, of exceedingly
soft and  delicate structure.   Rathke observed  the  same structure in  the
embryo of the pig  and  other mammalia;  and  Baer  has  since shown it
distinctly in the human  embryo.   It is  curious  to see how the vascular
system corresponds to the grade of development then present: the heart is
single, consisting of one  auricle  and  one ventricle ;  the  aorta gives off four
delicate, but  perfectly simple  branches, two of which  go  to  the right, and
two to the left side ; each of these little arteries passes to one of the lobules
 or  septa at the side of the neck, which  correspond to  gills, and  having
 again united with three  others, close to what  is  the  first rudiment of the
 vertebral  column, they form a  single trunk, which afterwards becomes the
 abdominal aorta.   In a  short time these  slit-like openings  begin to close;
 the branchial processes  or septa become obliterated, and indistinguishable
 from the adjacent parts ; the heart loses the form of a single heart;  a cres-
 centic fold begins  to mark the future division  into  two  ventricles,  and
 gradually extends until the  septum between them is completed.   It  is also
 continued along the bulb of the aorta, dividing it into two trunks, the aorta
1 [Acta Naturje Curios., vol. xiv.] 
UTERO-GESTATION.
141
proper and  pulmonary artery;  at the upper part the division is left incom-
plete, so that there is an opening from  one vessel to the other, which forms
the ductus arteriosus.1   A similar process takes place in  the auricles,  the
foramen ovale  being apparently formed in the same manner as the ductus
arteriosus ;  these changes  commence in the human embryo about the fourth
week, and are completed about the seventh.

                                  Fig. 74.
 Vesicula Umbilicalis, from
Baer. — a. Branchial proces-
ses. 6. Vesicula umbilicalis.
c. Vitellus.  d. Allantois.  e.
Amnion.
  "At first the body of the embryo has a more elongated form than after-
wards, and the part which is first developed is the trunk, at the upper extre-
mity of which a  small  prominence, less  thick than  the  middle part,  and
separated from the  rest of the body by an indentation, distinguishes the
head.  There are as yet no traces  whatever  of extremities, or of any other
prominent parts ;  it  is straight, or  nearly so, the posterior surface slightly
convex,.the  anterior slightly concave, and rests with its inferior extremity
directly upon the membranes, or by  means of an extremely short umbilical
cord.
  "The  head now increases considerably in proportion to the rest of the
body; so much  so,  that at the beginning of the  second month, it  equals
nearly half the size of the whole body: previous to, and after this period, it
is usually smaller.   The body of the embryo becomes  considerably curved,
both  at  its  upper as well  as  its lower extremity, although the trunk itself
still  continues straight.   The head joins the body at a right  angle, so that
the  part  of it which corresponds to  the chin is fixed directly upon the upper
part of the breast; nor can any  traces of neck be discerned, until nearly the
end of the second month.
  "The  inferior  extremity of the vertical  column, which  at first resembles
the  rudiment of  a tail, becomes shorter towards the  middle of the third
month, and takes a curvature forwards under the rectum.   In the fifth week
the  extremities become visible, the upper usually somewhat sooner than the
lower, in the  form of small blunt prominences, — the  upper close under the
head, the lower near the caudal extremity of the vertebral column.  Both
are  turned somewhat outwards, on account of the size of the abdomen ; the
upper are usually directed  somewhat downwards, the lower ones somewhat
upwards.
  " The  vesicula  umbilicalis may still be distinguished in the  second  month
as a small vesicle, not larger than a pea,  near the insertion of the cord,  at
the  navel, and external to the  amnion.   From the  trunk, which is  almost
entirely occupied  by the abdominal cavity, arises a  short, thick  umbilical
cord, in which some  of the convolutions of the intestines may still be traced.

  1 [In making these observations upon the formation of the ductus arteriosus, we mu-t
request our readers to consider this as still an unsettled question.]
 
142
UTERO-GESTATION.
Besides  these,  it usually  contains,  as  already observed, the  two  umbilical
arteries  and  the umbilical vein, the urachus,  the  vasa  omphalo-meseraica,
or vein  and  artery  of the  vesicula  umbilicalis, and perhaps, even  at  this

     Fig. 75.

                       Diagram of the fcetus and membranes about the fourth week.  From Carus.
                     — a. Vesicula umbilicalis. already passing into the ventricular and rectum
                     intestine at g.  b. Vena and arteria omphalo-meseraica. c. Allantois springing
                     from the pelvis with the umbilical arteries,  d. Embryo, e. Amnion. /. Cho
                     rion.
period, the duct of communication between the intestinal canal and vesicula
umbilicalis, the  fcetal extremity of  which, according to  Professor  Oken's
views, forms the processus vermiformis.
   " The  hands  seemed  to be fixed to the shoulders  without arms and the
   Diagram of the Fcetus and Membranes about the sixth week. From Carus.—a. Chorion. 6. The larger
  absorbent extremities, the site of the placenta, c. Allantois.  d. Amnion,  e. Urachus.  e. Bladder f. Ve-
  sicula umbilicalis. g. Communicating canal between the vesicula umbilicalis and intestine.  A.Vena
  umbilicalis.  i, i. Arteriae umbilicalis. I. Vena omphalo-meseraica. k. Arteria omphalo-meseraica.
  n. Heart,  o. Rudiment of superior extremity, p. Rudiment of lower extremity.

feet to adhere to  the  ossa ilii; the  liver seems to fill  the whole  abdomen;
the ossa innominata, the ribs, and scapulae, are  cartilaginous.
   "In a short  time the  little  stump-like  prominences of  the extremities
become  longer,  and are now divided into two  parts, the  superior into the
hand and  the fore-arm, the inferior  into the foot and leg ; in one  or  two
weeks later, the arms and thighs are visible.  These parts of the extremities
which are formed  later than the others, are at  first smaller, but as they are
gradually developed they become larger.  When the limbs begin to separate
into an upper and  lower part,  their extremities become rounder and broader,
and  divided into the fingers  and toes, which at first  are  disproportionately
thick, and until the  end of the third  month are  connected  by a membranous
substance   analogous  to the  webbed feet  of water-birds ;" this  membrane
 
UTERO-GESTATION.
143
gradually disappears, beginning at the extremities of the  fingers and toes,
and continuing the division up to their insertion.   The external parts of
generation, the nose, ears, and mouth, appear after  the development of the
extremities.   The insertion of the umbilical cord changes  its situation to a
certain degree ; instead of being nearly at the extremity of the fcetus, as at
first, it is now situated higher up, on the anterior surface  of the abdomen.
The comparative distance  between  the umbilicus  and pubis  continues to
increase, not only to the full period of gestation, when it occupies the middle
point of the  length of the child's body, as pointed out by Chaussier, but
even to  the age  of puberty,  from the  relative size  of the  liver becoming
smaller.
   " Though the  head appears large at first, and for a long  time continues
so, yet its contents are tardy in their development, and until the sixth month
the parietes of the skull  are in great measure membranous or cartilaginous.
Ossification commences in the base of the cranium, and the bones under the
scalp are those in which  this process is  last  completed.
   " The contents of the skull are at first gelatinous, and  no distinct traces
of the natural structure  of  the brain can be identified until the close of the
second  month ;  even then  it requires  to have been  some time previously
immersed in alcohol to harden its texture.  There are many parts of it not
properly developed until the seventh  month.   In  the medulla spinalis no
fibres can be distinguished  until the fourth month.   The thalami nervorum
opticorum, the corpora striata, and  tubercula quadrigemina, are seen in the
second  month ;   in the  third, the  lateral  and longitudinal  sinuses  can be
traced,  and contain blood.   In  the  fifth we can distinguish the corpus cal-
losum ;  but the  cerebral mass has yet acquired very little  solidity, for  until
the sixth month it is  almost semi-fluid.1
   "About the end of the third, during  the  fourth, and the  beginning of the
fifth months,  the mother  begins  to be sensible of the movements  of the
fcetus.   These motions are  felt sooner or later, according to  the bulk of the
child, the size and  shape  of  the pelvis, and the quantity of  fluid contained
in the amnion ; the waters being in larger proportionate quantity the younger
the fcetus.
   " The secretion of bile, like that of  the  fat, seems to begin  towards the
middle  of pregnancy, and  tinges  the meconium, a mucous secretion of the
intestinal tube, which had hitherto been colorless, of a yellow color.   Shortly
after this the hair begins to grow, and the nails are formed about the sixth
or  seventh month.  A very delicate membrane  (membrana pupillaris), by
which the pupil  has been  hitherto closed, now ruptures,  and the  pupil
becomes visible.   The kidneys, which  at first were composed of numerous
glandular lobules (seventeen or eighteen in number), now  unite, and form a
separate viscus on each side of the spine  ; sometimes they unite into one
large mass, an intermediate portion extending across the spine, forming the
horse-shoe kidney7.
   " Lastly, the testes, which at first were placed on  each side of the lumbar
vertebrae, near the origin of the spermatic vessels,  now descend along the
iliac vessels towards  the inguinal rings, directed by a cellular cord, which
Hunter has called Gubernaculum testis: they then  pass through the open-
ings, carrying before them that  portion of  the peritoneum which is  to  form
their tunica vaginalis.
   " The length of a full-grown fcetus is generally about eighteen or nineteen
inches;  its weight between  six and  seven pounds.   The different parts are
well developed and rounded ;  the  body is generally covered with the vernix
caseosa ; the nails  are  horny, and  project beyond  the tips of the  fingers,
1 [Campbell's System of Midwifery.] 
144
UTERO-GESTATION.
which is not the case with the toes;  the  head has attained its proper size
and hardness; the ears have the firmness of cartilage; the scrotum is rugous,
not peculiarly red, and usually containing the testes.   In  female children,
the nymphae are generally covered entirely by the labia,  the breasts project,
and in both sexes  frequently contain  a milky fluid.  As  soon as  a child is
born, which has been carried  the full time, it usually cries loudly, opens its
eyes, and moves its arms  and legs briskly; it soon passes urine  and fmces,
and greedily takes the nipple.1
   "Thus  then, in  the space of forty weeks, or ten lunar months, from an
inappreciable point, the fcetus attains a medium length of about eighteen or
nineteen inches, and a medium weight of between six and seven pounds."]
   191. It was formerly "asserted that the position of the child in utero during
the early  months  was sedentary, facing anteriorly ;  and that towards the
end of gestation, owing to the greater weight of the head, and to its volun-
tary efforts, it made a revolution, so as to present with the head.  This,

                                 Fig. 77.
Position of Foetus in Utero.
however, is not the case.  With some  exceptions, the position of the child
is unaltered from  an  early period of pregnancy to its termination, whether
the head be upwards  or downwards.  The arms  are  generally folded  over
the chest, the knees drawn up  to  the abdomen, the back curved, and the
head bent upon the chest so as to  occupy as little space as possible.  In
ordinary cases, the face  and anterior  surface of the child neither look for-
ward, as was formerly supposed, nor in the direction of  the  transverse dia-
meter of the pelvis, as is sometimes stated, but obliquely; so that in the first
and second position the back of the foetus is turned  partly forwards ; and
the chest^ in the third and fourth.   This point having been established by
observation, we  are enabled in  many cases to ascertain  the  position of the
infant before labor has commenced, by means of the  stethoscope, according
[Naegele's Hebammenbuch.] 
UTERO-GESTATION.
145
as the pulsation is heard at one side or other of the  abdomen,  and more or
less clearly.
   192. Yarious causes of the position of the fcetus in utero have been  men-
tioned, such as gravitation, voluntary movements, etc.
   Although the supposition that the greater weight of the head is  the cause
has the high authority of Dr. Hunter,1 I do not think it can be maintained,
any more than Ambrose Fare's notion, that it was owing  to  its  efforts to
escape2 from the uterus;  or M. Dubois'view, that it  is the  result  of an
instinctive and voluntary determination on the part of the foetus.3
   Drs. M'Clintock and Hardy4  have furnished data, in addition to those we
already possess, for the subversion of the first of these opinions, and the
latter appears to me to require proof rather than an  answer.   M. Cazeaux
regards the  shape and mode of enlargement of the uterus as  the chief, if
not the ordy cause of the position of the fcetus—that it is not an "instinctive
but a mechanical" arrangement.5
   But the entire question has been investigated by my friend  Dr.  Simpson,
with elaborate care and great acuteness, and I confess that his conclusions
appear to me more comprehensive and  more  correct than any preceding
authority.  They are as follows :•—" 1.  The usual position of the fcetus, with
the head  lowest and presenting over the  os  uteri, is not assumed  till about
the sixth month of intra-uterine life, and becomes  more frequent  and  more
certain from that time onwards to the full term of utero-gestation.  2.  Both
the assumption and maintenance of this  position are vital and  not physical
acts, for  they  are  found dependent on the existence and continuance of
vitality in the  child ;  concurring with  its life, but being  lost  by  its death.
3. In human physiology we do not know or recognize any vital  power or
action, except muscular action, capable of producing motions calculated to
alter or  regulate the  position,  either  of the  whole body  or  of any  of its
parts ;  and further, the motory muscular actions of the fcetus  are  not  spon-
taneous or voluntary,  but reflex or excito-motory in  their nature, causation,
and effects.  4. The position of the fcetus, with the head placed over the os
uteri, is that position  in which the  physical shape of the normal and  fully-
developed fcetus is best adapted to the  physical shape of the normal and
fully-developed cavity of the uterus.  5. This adaptive position of the con-
tained  body to the containing cavity  is the aggregate result of reflex or
excito-motory movements  on the part of the  fcetus, by which it keeps its
cutaneous surface withdrawn as far as  possible from the causes of irritation
that may act upon it as excitants,  or that happen to restrain its freedom of
position or of  motion."6   And the mal-positions and mal-presentations he
attributes to: — "1. Prematurity of the labor, parturition  occurring before
the natural  position of the fcetus  is established.   2. Death of the child in
utero, or, in other words, the loss of the adaptive vital  reflex actions of the
fcetus.  3. Causes altering the normal shape of the fcetus or contained  body,
or causes altering the normal  shape of the uterus  or containing  body, and
thus forcing the fcetus to  assume, in its reflex movements,  an  unusual  posi-
tion, in order to adapt itself to the unusual circumstances in which it hap-
pens to be placed.   4. Preternatural presentations are occasionally the  result
of causes physically displacing either the whole fcetus or its presenting part,
during the  latter periods  of utero-gestation  or at the commencement of
labor."
              1 Description of the Gravid Uterus, p. 66.
              2 Works, Trans., p. 889.
              5 Mem de l'Acaclemie de Medecine, vol. ii. p. 280.
              * On Midwifery and the Puerperal State, p. 4.
              5 Traite du Aecouchemens, p  148.  Brussels Ed.
              6 Ed. Monthly Journal of Med. Science, vol. ix. p. 867.
10 
146
UTERO-GESTATION.
  193. The length of a full-grown fcetus is from 18 to 22 or 24 inches
The longitudinal diameter of its head (x 2) is from 4 in. to 4^ in.
The transverse     ....
The occipito-mental or oblique (3 *)
The cervico-bregmatic (5 6)
The trachelo-bregmatic .
The inter-auricular
The fronto-mental (7 8)  .
The transverse diameter of the shoulders
 "       "       "        "  hips

                                 Fig. 73.
. 3*	to 4
	5
. 4	to 4^
. . si	to 4~
	3
	31
■ 4|	to 51
to 5
                            Fcetal Head Diameters.

In general, it may be observed, that all the measurements are less in female
than in male children.
  [Dr. Meigs1 makes the  occipito-frontal  diameter four inches and ten-
twelfths of an inch in width.  " I  speak," he remarks, " with  great  confi-
dence as to the above estimate, for I have correctly measured and recorded
the size of three hundred crania of  mature children  that  I  received in the
course of  my obstetric practice."
  The bi-parietal diameter,  being the  mean derived from the measurement
of one hundred and fifty crania, he makes three inches and eleven-twelfths
of an inch.
  The occipito-mental diameter, being the mean derived from the measure-
ment of  one hundred and  twenty-six crania, he makes  five inches  and  a
half]
  The weight of  a full-grown child at birth varies in the same  and  in dif-
ferent sexes.   Rcederer found  the weight in Germany to be from seven to
eight pounds.  Dr. Joseph  Clarke, in  the Lying-in Hospital, Dublin, ascer-
tained the weight of the majority to be about  seven pounds, but that  it
varied from four to eleven pounds.   In France, the average weight is less;
according  to Camus, it is six pounds and a quarter, and observations at La
Maternite have confirmed this  estimate.   In  Bru sels it is six pounds and a
half; but in Moscow, nine  pounds  and one-fifteenth.   Dr. Beck  states  that
the average weight in America exceeds seven pounds.
   Dr. Elsbaesser, of Wurtemburg,  has published some extensive researches
on  this subject: he found in 1000 children at birth, that 13 weighed from 4
to 5 pounds; 58 from 5 to 6 ;  1" from 6 to  7 ;  318 from  7 to 8 ; 83 from S
to  9;  and 11  from 9  to  10 pounds,  giving an average of 4  pounds 14
ounces.   (The Wurtemburg pound is rather more, and the inch  rather less,
than the English.)
                 1 [Obstetrics: the Science and the Art, p. 63.] 
UTERO-GESTATION.
147
    The maximum length of males in 1000 children was 19 in. 17 lines.
                            females    "      "        19  "    1   "
    The minimum length of males     "      "        14  "15   "
                            females    "      "        14  "    9   "*
  Dr. Storer, of Boston, found that in 222  males the average weight was
7^ pounds, and in 184 females the average weight was 7-g pounds.2
  [The variations in the weight of new-born  infants are very considerable
in all countries  : but  it is  highly probable that the average in this respect,
if it could be correctly ascertained, would not be found to vary much in dif-
ferent  countries.   In the United States, it is by no means customary in pri-
vate practice either to measure  or weigh the infant  at the time  of birth,
except  when the size is strikingly above or  below the usual standard :
hence all general statements as to the medium weight of new-born infants in
this country are derived chiefly from births in alms-houses and hospitals, and
can hardly be  considered to represent fairly what obtains among the mass
of  the people.]
   194.  The umbilicus changes its relative position as the  development of
the fcetus proceeds,  until at birth it is near the middle of  the  entire length
of  the  child.   According to Chaussier, Bigeschi,  and others, this  relative
position of the umbilicus is a test of its maturity, being distant from the
central point in proportion to its immaturity.  But it seems doubtful whether
its position is  so exactly central  in mature children as these authors state;
for M.  Moreau has recently measured  500 children, born at  the full term in
La Maternite,  Paris, and of this  number  he  found only four  in whom the
umbilicus was  exactly central.   In the  remainder, the  point  of  insertion
of the funis fell on an average from eight to ten lines below the middle.   In
a few children born about  the sixth  or eighth month, the umbilicus  was
central.
   Dr. Elsbsesser examined 200 children, and found that the length of the
supra-umbilical portion was—
     In the males      .    .     .    .     .     .    9 in. 2^ lines.
     In the females     .    .     .    .     .     .    9  "  "  "
 The infra-umbilical  portion was —
     In the males.......7 in. 9 lines.
     In the females......7  "  7  "
  So that the difference in the length was —
     In the males      .    .     .    .     .     .    1 in. 3-40 lines.
     In the females......1 "  3-57   "
    Dr. Storer found the average length of males was eighteen, and of  females
 twenty inches.
    195.  The characteristics of the maturity and  perfection of a  child at
 birth, according to Fodere and  Capuron, are, its  ability to cry as soon as
 it  reaches  the atmospheric air, or shortly after; to move its limbs with
 facility and more or less strength, its  body being  of  a clear red color; the
 mouth, nostrils, eyelids, and ears, perfectly open;  the bones of the cranium
 possessing some solidity, and the edges of the fontanelles not far apart; the
 hair,  evebrows,  and nails, perfectly developed ;  the  free  discharge of the
 meconium a few hours after birth, and finally,  the  power of swallowing and
 digesting, indicated by its  seizing the nipple or  finger  placed within  its
 mouth.
    The child may be considered immature when its length  and volume are

    1 Edin. Monthly Journal of Med. Science, vol.  iv. p. 803.
    2 Report of  the Boston Lying-in Hospital, Amer. Journal  of Med., Oct., 1850. 
148
UTERO-GESTATION.
much less than those of an infant at the full term; when it does not move
its limbs, or makes any feeble motions;  when it seems  unable  to suck, and
has to be  fed artificially ; when the skin  is of an intensely red color, and
traversed by numerous bluish vessels;  when the head is covered  with down,
and the nails are not formed ;  when the bones  of the head are soft, and the
fontanelles widely separated; the eyelids, mouth, and nostrils closed ;  when
it sleeps continually,  and an artificial heat is necessary to preserve it; and
when it discharges its urine and meconium imperfectly.
  There are cases on record of children prematurely born at  the  fifth and
sixth month of gestation attaining maturity ; but ordinarily we do not con-
sider a child "viable" until about the seventh  month of utero-gestation.
   196. The proportion of the sexes in Europe, according to  the learned
M.  Quetelet, is about 106 males to  100 females, nor does it  appear that  in
this part of the world  climate has much influence.   At the Cape  of  Good
Hope female births predominate among the free inhabitants,  and male births
among the slaves.   A country life seems to favor the production of male
progeny ; and the relative  ages of husband  and  wife exert  a  decided in-
fluence;  for  in proportion as the  husband is younger than the wife, girls
predominate, and within certain limits, a  disproportion  the  other way has
the opposite effects ;  or, as Mr. Sadler has expressed it,  upon a mean num-
ber  of births, the  sex of  the  child is  that of the  parent whose age is  in
excess.
  The season of the year seems to influence to some degree both  the num-
ber of births and the greater proportion of female children.  In  Philadel-
phia the  greatest number  of conceptions occur in the spring months, and
the greatest excess of male conceptions in the winter season.1
  [Dr.  G. Emerson, of Philadelphia, has carefully investigated the in-
fluences operating  to change the number of births,  and  also the relative pro-
portion of the sexes at birth ; he includes them under two heads :  —
  1st. The Seasons.—The following general  results relative to this  point
were obtained from  estimates based  upon  65,542 births in  Philadelphia.
The greatest number of conceptions occurred  during the winter and spring
months; the maximum being  17,645 in the spring months.   The smallest
number occurred in  the autumn  and  summer months, the minimum  being
15,200 in the summer quarter.
  The greatest excess of male  conceptions is shown  to be  in the winter
season, when, the total being 17,184, the males were 9,007, and  the females
8,177.  The excess of male conceptions for the other three quarters or sea-
sons, varies but little from the minimum excess, which occurs in spring.
   2d  The plenty  or deficiency of food, purity or impurity of  the  air, over-
working, and whatever tends to exalt or to impair  the  vital  energies  of the
people.  In many parts of Europe, where the general population is over-
worked and under-fed, the excess of male  births is very  small;  being
throughout France and Prussia under 6  per  cent., and in  England  about
5 per cent.   In Philadelphia, where the general condition of the population
is very favorable, the male births exceed the  female about  7 per cent.   In
the rural districts of the United States, and especially in the newest settle-
ments, the preponderance  of boys at birth is believed to be not less than  10
per cent.   An opposite result is found when fatal epidemics alarm and de-
press the  public mind.   Thus, among the children  born in  Philadelphia,
whose conception occurred during the prevalence  of the cholera in  1832,
there was a preponderance of  females.   The same result was shown  in the
births which took place in Paris, nine  months after the cholera  prevailed
there in 1832.  The births, at a somewhat later period  after  the  visitation
1 Tran«. of American Med. Association, vol. iii. p. 93. 
UTERO-GESTATION.
149
of the epidemic, exhibit an increase in the amount of males, in consequence,
it is presumed, of the parents being  endowed with vital energies above the
average, as is shown by their exemption or recovery from the disease.1]
  The number of twin cases at La Maternite was 444 in 37,441  cases, or  1
in 84; in the Dublin Lying-in  Hospital 2101 cases in 134,908.  or about 1
in 64 ; in the same  number  29 triplet cases occurred, or 1 in 4652; and  one
case of quadruplets.
  The mean  proportion of still-born children in the cities of Europe is about
1 in 22 births ;  the  extreme variation is from 1 in 11 at Strasburg,  to  1 in
36 at Stockholm.
  In the Lying-in Hospital in  this  city, from its establishment in 1757 to
1836, there occurred 8021 still-born children in 134,908 cases, or about  1 in
17.   [In Xew York, from 1854 to 1857, there were 48,323 births, and 5931
still-births, at the full time and prematurely ;  that is  to say, 1 to every  8*1.
In Philadelphia, the premature  and  still-births were, in 1858, as 1 to every
148 births.]
  The number of still-born  males is greater  than that of females : in West
Flanders and at Berlin in the proportion of  14 to 10.   [The excess of still-
born females is in Philadelphia even  greater.]
  197-  The  Physiology of Fcetal  Life is simply that  of organic nutri-
tion ;  at  first by superficial imbibition, afterwards  probably by absorption
by the villi of the chorion,  and ultimately by the changes made  in or addi-
tions  to the fcetal blood in the placenta.
  The sources of nutriment during  the earliest periods of embryonic life
are the vitellus, or  the fluid in  the umbilical vesicle, and  possibly the gela-
tinous matter (tunica media) between the amnion  and chorion.   After the
formation of  the amnion, its fluid may possibly contribute to this end.   Dr.
Montgomery, as we have seen,  suggests that  the  milky  fluid contained in
the decidual  cotyledons may also be available for this  purpose.
  There is no doubt of the  functions  of the placenta: there  the blood of
the fcetus is  renovated  from that  of the mother, in the same way as the
blood  of  fishes is aerated by the water passing through the gills.
  Whether, in the earlier  months,  absorption  is carried on by  the  surface
alone, or whether, as Yelpeau suggests,  a portion of the liquor  amnii finds
its  way into  the stomach,  may be  difficult to decide, but that a  certain
amount of digestion is carried  on, is impossible to doubt.
  [A distinguished physiologist observes  on this subject that, " The most
plausible opinion he can form on  this intricate subject is, that  the  mother
secretes the substances, which are  placed in contact with the  fcetus, in a con-
dition best adapted for its nutrition;  that in  this  state  they are received
into the system, by  absorption, as the chyle or the lymph is received into the
adult,  undergoing modifications in their  passage through the foetal placenta,
as well as in  every part of the system where the elements of the  blood must
escape for the formation of  the various tissues.
  " With regard to the precise nutritive functions  executed in the fcetal
state, and first, as  concerns digestion, it is  obvious  that this cannot take
place to any extent,  otherwise excrementitious matter would have been  thrown
out, which by entering the  liquor amnii, would be  fatal to  its important
functions, and probably to the very existence of the fcetus.   Yet, that some
digestion is effected, is manifest from the presence of meconium in  the in-
testines, which is probably the excrementitious matter arising from the diges-
tion of the mucous  secretions of the alimentary canal."2
  The sources from which the nutrition  of the fcetus is derived  during  the
first four months of intra-uterine life, are involved in no little obscurity. Sub-

         1 [Transactions of the American Med. Association, vol. iii.  p. 93.]
         2 [Dunglison's Human Physiology, 4th edition, vol. ii. p. 497.] 
150
UTERO-GESTATION.
      sequently to the fourth month, it would  seem now to be very generally ad-
      mitted that the fcetus derives  its nourishment solely through the placenta.
      The abundant nutritious materials of  the blood in the maternal sinuses of
      that organ, passing through the intervening  membrane by endosmosis, and
      entering the blood  of the  fcetus.   This, however, cannot be the case pre-
      viously to the  formation of the placenta.   Nor  can the fcetus be nourished
      then by the digestion of any substance introduced into its stomach, from the
      fact that no gastric juice is formed previously to birth.  It  is supposed, as
      we have just shown,  by Dr. Dunglison, that the  presence of meconium in
      the intestines,  is a proof that digestion takes place during fcetal life, the me-
      conium being in fact the  excrementatory matter resulting from such cause.
      But this is disproved by an examination of the composition  of the meco-
      nium,  and from it being more  than probable  that this substance is itself an
      excretion from the internal mucous membrane.
        The meconium contains a large quantity  of fat, as well as various inso-
      luble  substances, probably  the residue of epithelial and mucous accumula-
      tions.   It does not  contain the slightest trace of biliary matter.
        " It is a  singular  fact," remarks Dr. Dalton,1  " that the  amniotic fluid,
      during the latter half of fcetal life, finds its way, in  greater or less abund-
      ance,  into the  stomach, and through that into  the intestinal canal.   Small
      cheesy-looking masses  may sometimes be found  at birth  in the  fluid con-
      tained iu the stomach, which  are  seen on microscopic examination to be no
      other  than portions of the vernix caseosa, exfoliated from the skin into the
      amniotic cavity, and afterwards swallowed into the stomach.   According to
      Kolliker,2 the  soft downy hairs  of the fcetus, exfoliated from the skin, are
      often  swallowed in the same way, and may be found in the meconium."
        The manner in which the fcetus during the earlier months  of its existence
      is nourished, must  be considered  as  still an open  question.    The doctrine
      that it is by the absorption and appropriation  of the nutritive matter con-
      tained in the liquor amnii, or of a plastic fluid secreted by the uterine  parie-
      tes, seems scarcely tenable.
        It may be proper to remark that in very young foetuses of the pig, both
      the allantoic and amniotic fluids have been found to be saccharine.]
        198.  Before describing the  circulation in  the fcetus, there  are certain ana-
      tomical peculiarities which demand our notice :— 1.  There  is a supplemen-
      tary vein, situated at the thick edge of the  liver, and leading from the um-
      bilical vein to the vena cava aooondono, called the  ductus venosus: 2. The
      septum between the auricles is imperfect, having in its centre a valvular oval
      aperture called the foramen ovale: 3. The pulmonary artery, soon  after
      its origin, gives off a branch,  the  ductus arteriosus, which  enters the aorta
     i just below its  arch.  The  general effect of these peculiarities is to render
      the heart virtually  a  single one, to provide  for the quiescent state of the
      lungs, and to modify  the distribution  of  fresh blood.
        Different opinions  have  been given as to  the course of the blood in the
      fcetus : I shall mention first, Sabatier's and Winslow's.   Sabatier's figure-of-8
      circulation is  thus  described  by Dr.  Flood : — "The blood of the fcetus is
      conveyed from  the placenta by the  umbilical  veins to the liver,  through
      which it circulates,  and then passes into the  inferior cava.   A portion of it,
      however, is transmitted, in a comparatively pure state," through the ductus
      venosus. " which opens into the left hepatic vein, and  then  into the inferior
      cava.   From the inferior cava the blood ascends into the right auricle, then
      by the foramen ovale into the left auricle,  left ventricle, and arch of the
      aorta.  A portion of the blood thus  carried into the aorta descends into its
      thoracic part; the rest, after  circulating through the head and upper ex-

        [' Human Physiology,  p. 550.        * Physiological Chemistry, Histology, p. 97.]


■'">'■ J ■ A^ -  .****-«£<. 'Wvt«.**0 cOst4ic^i*x vi (^>i^ky^f tCu*  f«-tF  r<  .-.4,  ^
s^UZ, t*.><rt+yl  t,~ir.i4 tU7  tL, h'-&£ <-*W Auu ^ >,,,/ ^  J  kjJ 
UTERO-GESTATION.
151
trcmities, returns by the superior cava to the right auricle, and passes thence
into the right ventricle and pulmonary  artery.   A small part of this blood
goes to the lungs by right and left branches;  but the rest, conveyed by the
ductus arteriosus, joins the blood that we left descending through the thoracic
and abdominal  aorta, and all that is not employed in the  nutrition of the
body and lower  extremities, is  returned by the hypogastric arteries to the
placenta."   The object  of this theory is to show that the head and superior
extremities receive a supply of purer  blood, which they  are supposed to
need for their development; but there  are great  objections in the way: —
1. Even supposing the  pure blood were conveyed in the manner stated, it
is too small in quantity to  answer the  purpose, being only one-fifth of the
whole : 2.  Supposing it to be  sufficient, the  presumed effects are not pro-
duced, the intestines, ribs, etc., being just as perfectly formed at birth as the
brain ;  and  3.  No such  transmission of pure  blood across the  auricle,
through the foramen ovale, can take place, because of the effects  of gravity,
the descending current from the superior cava, and above all, because of the
active  contraction  of the right auricle.   In Winslow's  explanation, it  is
assumed that the heart is virtually single and the blood mixed.   According
to him, "The blood of  the system generally passes from the superior and
inferior cava  into the right auricle.   One part of this is transmitted through
the right  ventricle and pulmonary artery, and thence (except a supply for
the nourishment of the  lungs) through the  ductus arteriosus into  the de-
scending aorta ;  a second and larger part passes through the foramen  ovale
into the left  auricle, then into the left  ventricle and arch of the aorta, the
branches of which supply the head  and upper extremities.   The continued
stream passes into the descending aorta, mixing with that already  described ;
and all of it  that is not employed in  the nutrition of the  body and lower
extremities, is reconveyed by the umbilical arteries to the placenta."
   Dr.  Carpenter, the most recent, as he is certainly one of the ablest, of
our physiologists, thus describes the circulation :—" The fluid brought from
the placenta by  the umbilical  vein is partly conveyed at once to the ascend-
ing cava by means of the ductus venosus. and partly flows through the vena
portae into the  liver, whence it reaches the ascending cava by the  hepatic
vein.   Having  been  thus  transmitted through  the two great depurating
organs, the placenta  and the fcetal  liver, it is in  the condition  of  arterial
blood ; but being  mixed in the vessels with that which has been returned
from the trunk and lower extremities,  it loses this character in some degree
by the time it arrives at the heart.  In the right auricle which it then enters,
it would be  also mixed with  the venous blood  brought thither  by the de-
scending cava, were it not that a very curious provision  exists to  prevent
(in a great degree, if not entirely) any such  further dilution.  The Eusta-
chian valve has  been found, by the experiments of  Dr. John Reid,1 to  serve
the purpose of  directing the  arterial blood  which  flows  upward from the
ascending cava, through the  foramen  ovale, into  the left auricle, whence it
passes into the left ventricle ;  whilst it also directs the venous blood, that
has been returned by the descending cava, into the right ventricle.  When
the ventricles contract, the arterial blood which the left contains is propelled
into the ascending aorta, and supplies the branches that proceed to the head
and upper extremities before it undergoes any admixture : whilst  the venous
blood contained  in the right ventricle is forced through the pulmonary artery
and ductus arteriosus into the descending  aorta, mingling with the  arterial
current which that vessel previously conveyed, and passing thus to the trunk
and lower extremities."2
1 Anal. Phys. and Path. Researches, chapter ix.
1 Principles of Human Physiology, p. 1035. 
152
UTERO-GESTATION.
  [" It will be  found,"  remarks Dr. Dalton,1 whose account of the fcetal
circulation is particularly  clear  and  accurate,  "it wdll  be found  upon
examination, that  the  two venae cavae, superior and  inferior, do not open
into the auricular  sac on the same plane or in  the  same direction, for while
the superior vena cava is situated  anteriorly, and is directed downward  and
forward, the inferior is situated quite posteriorly, and passes into the auricle
in a direction from  right to left, and nearly transverse  to  the  axis of the
heart.   A nearly vertical curtain or valve at the same time hangs downward
behind the orifice  of the  superior vena cava and in front of the orifice of the
inferior.  This  curtain is formed by the  lower edge of the septum of the
auricles, which,  as we have before  stated, is incomplete at this age,  and
which  terminates  inferiorly, and toward  the  right in a crescentic border,
leaving at that  part an oval opening, the foramen  ovale.  The stream of
blood, coming from the superior vena cava, falls accordingly in front of this
curtain,  and passes directly  downward,  through the  auriculo-ventricular
orifice, into the  right ventricle.   But the  inferior vena cava, being  situated
further back and  directed transversely,  opens, properly  speaking, not  into
the right auricle,  but  into the  left;  for its stream of blood, falling behind
the  curtain  above-mentioned,  passes  across through   the  foramen ovale
directly  into the  cavity of  the  left  auricle.   This direction of  the  current
of blood coming from  the inferior vena cava, is further secured by a peculiar
membranous valve, which exists at this period, termed the Eustachian valve.
This valve, which is very thin and transparent, is attached to the  anterior
border of the orifice  of the inferior vena cava,  and terminates by a cres-
centic edge, directed toward the left, the valve, in this way, standing as an
incomplete membranous partition between the  cavity of the inferior vena
cava and that of  the  right auricle.   A  bougie, accordingly, placed in the
inferior  vena cava, lies naturally quite behind  the  Eustachian  valve,  and
passes directly through  the foramen ovale into  the  left auricle.  The  two
streams of blood, therefore,  coming  from the superior and  inferior venae
cavae,  cross  each other upon  entering  the  heart.   This  crossing of the
streams does not take place, however, as it  is sometimes  described, in the
cavity of the right auricle, but,  owing to the  peculiar position and direction
of  the two veins at this  period, with  regard  to  the  septum of the  auricles,
the stream coming from  the  superior vena  cava enters  the right auricle
exclusively, while that from the inferior passes almost directly into  the left
auricle.
   "It will also be seen, by  examining the positions of the aorta, pulmonary
artery and ductus  arteriosus,  at this time,   that  the  arteria  innominata,
together  with the left carotid,  and left subclavian,  are  given off from the
arch  of the aorta,  before its junction with the ductus  arteriosus, and this
arrangement causes the blood of the  two venae cavae, not  only  to enter the
heart  in  different directions, but also to  be distributed, after  leaving the
ventricles, to different parts of the  body.  For the  blood of the  superior
vena cava passes  through the right  auricle downward  into the right  ven-
tricle, thence, through the pulmonary artery  and ductus arteriosus, into the
thoracic aorta, while the blood  of the inferior cava, entering the left auricle,
passes into the left ventricle, thence  into the arch of the aorta, and is dis-
tributed to the  head and upper extremities, before reaching the  situation  of
the arterial duct.   The two streams, therefore, in passing through the heart,
cross  each other  both behind  and  in  front.   The venous  blood, returning
from  the  head and upper  extremities  by the superior vena  cava, passes
through the abdominal aorta and the umbilical arteries to the lower part of
the body,  and to  the placenta;  while that returning from  the  placenta,  by
1 [Human Physiology, p. 581.] 
UTERO-GESTATION.
153
the inferior vena cava, is distributed to the head and  upper extremities,
through the vessels given off from the arch of the aorta."]
   199. The circulation of the fcetus  is independent of that of the mother,
though it may be sympathetically affected.   By applying the stethoscope to
the abdomen of the mother, we can hear the fcetal heart, which beats from
120 to 140 times in a minute ; sometimes, but rarely, it is 150 or 160.   The
sounds audible, however,  are double  this amount, inasmuch  as the  beat  is
double ; the first sound is short, feeble, and obscure, the second comparatively
loud and distinct; the  first is inaudible a little distance from the fcetal heart;
the second  is audible over a great part of the abdomen,  and it is the second
which  is generally counted ; in fact, it is  impossible to count both, from
their  extreme  rapidity.   The  rhythm  of these  sounds in  utero  is  quite
different from what it is in the adult; i. e.,  the first is quick and the second
prolonged, and then an interval nearly equal to  the  two sounds.   Shortly
after birth  a remarkable  change in rhythm  takes place ; the first sound be-
comes  longer and is about equal in strength and loudness to the second, and
the two divide the period of pulsation equally : e. g., if in utero, we divide
this period into 1 . 2—3. 4 parts; the first and second sound occupy 1. and
2, leaving 3 and  4 for  the interval.   After birth, the two sounds occur as
1  2 3 4.   As the child  advances in  age, the rhythm is again changed to
that of the  adult.1  Dr.  M'Clintock  has proved, by extensive  observations,
that the frequency of the heart's action  diminishes after birth until it attains
the usual standard of  infancy.
   200.  After birth remarkable changes take place.   From the painful im-
pressions  on the  surface and senses, efforts are  made by the child, which
cause inspiration and end in crying, by which means the lungs are more or
less inflated, and space   is afforded  for the pulmonary circulation, which
supersedes the use of the foramen ovale  and ductus  arteriosus : the blood
from the lower extremities cannot pass through the umbilical arteries, and
does pass through the ascending cava into the  right auricle and ventricle,
and thence  into the lungs, where it undergoes analogous but  more perfect
changes to those effected in  the placenta, and is distributed to  the body
generally.   By degrees,  the foramen  ovale closes,  and the ductus arteriosus,
ductus venosus, and umbilical arteries are obliterated ;  the adult circulation
is then established.
   Digestion takes place  on the reception  of food, the liver becomes more
active, and  the usual excretions of the kidneys and intestinal canal occur.
   Before birth, the only sense in exercise was that of touch, but immediately
afterwards those of sight and hearing are called into  activity, and  at a later
period those of taste  and smell.  A considerable time elapses before the
sensuous impressions are correctly appreciated, yet every day adds its quota
of instruction,  and hourly experience at length produces accuracy.
   The brain, which was perfectly quiescent during gestation, is now the
focus for the impressions  produced upon the senses, and the seat of such in-
tellectual operations as can take place at so early a period ; and the nervous
system generally is the centre to which  all organic operations are referrible.
   201. In conclusion, I shall briefly notice the so-called laws of development.
   The first  of these is the law of  unity of  organization, in virtue of which
"the  progressive  phases  of the  embryo correspond  to the  abiding forms,
which are preserved in the total organism  of animated nature as typical of
its gradative evolution ; and that as  the  embryo of each higher animal
passes rapidly through the forms of the animals inferior  to it, in order to
attain its maturity and specific rank of being, that of man is transitively the
1 Dublin Quarterly Journal, May, 1855. 
154
UTERO-GESTATION.
compendium  of all; not, indeed, without a difference, since in each instance
the changing form of the  embryo bears the impress  of  the transitional and
incomplete character, while it ever preserves the  promise  and  prophecy of
the being into which it is to be  finally evolved."   This law of transitive de-
velopment, so eloquently  described by  Mr. Green  in  the extract I have
quoted  trom  his  Hunterian oration, has been  established by the researches
of Wolff, Otto, Meckel, and other German physiologists;  but it is only just
to state that  the idea was  familiar  to  our  great  natural  philosopher, John
Hunter,  who  remarks:  "If we were capable of  following  the progress of
increase  of the number of  the parts of the most  perfect animal, as they are
formed  in succession, from  the very first, to  its state of  full  perfection, we
should probably be able to compare it with some one of the incomplete animals
themselves, of every order  of animals  in  the  creation, being at  no stage
different from some of those inferior orders ; or,  in other words, if we were
to take a series of animals from  the more imperfect to the perfect, we should
probably find an  imperfect animal corresponding with some  stage of the
more perfect."
   In accordance with this law, we find the fcetal nervous  system at the earliest
period resembling that of the annelides, then  that of the invertebrata, and
afterwards that of fishes, reptiles, birds,  etc.   The same may be said of
other organs, and we have already given  an example in the case of the
uterus (§90).
   More  striking illustrations may be derived from certain abnormal devia-
tions, of which Mr. Green remarks, " and it did not  escape  Hunter, as  a
consequence  of the same law, that congenital defects, hitherto comprehended
under the vague  designation of monstrosity,  are to  be  explained by the
development of the embryo being interrupted at some  early stage of its
regular  evolution, and  that the  defective form  which is the result,  is analo-
gous to the form  and structure of an inferior class."
   Thus  we have the law exhibited in the successive transitions of the fcetus
until its arrival at its  perfect state ; and, if possible, more strikingly illus-
trated by those exceptions where it fails to attain this perfection.
   202.  The  other law I shall notice has also received  its most impressive
elucidation from certain exceptions : it is called the law of symmetry, con-
jugation, or  affinity, founded upon the general observation that all formations
proceed from the circumference  to the centre.  According to M. Serres, the
body generally, and each  organ, whether single or double at birth, is origi-
nally divisible into two parts, that each half grows  towards the mesial line,
where it meets its opposite and  is joined to it, as we  saw in the case of the
dorsal and ventral laminae.  If  the law of progression  be  equally observed
by both halves, the organ  resulting from their union will  be perfect; if the
growth  be unequal, deficient, or excessive, the result  will be deformity by
defect or excess.   Again,  connected with this law of symmetry, and perhaps
causing its deviations, is the fact, that development of each part of the body
is to a certain extent dependent upon its vascular supply ;  if this be deficient
or in excess, so most probably will be the other.
   203.  We are now able to classify to  a certain extent the deviations from
the normal formation  of  the fcetus, viz., into those whose deformity results
from an arrest of the transitive  development, those arising from irregularity
of symmetrical growth, and those dependent upon  vascular irregularities.
 Others still remain, however, the larger class probably depending upon dis-
eased action  in the organs or structures'of the fcetus  or of its dependencies,
and some of which it is very difficult to explain at present.
   [One of the most remarkable of these  congenital defects is the "sponta-
neous amputation of  the foetal limbs  in  utero," so well described by Dr.
 Montgomery of Dublin.   Since the publication of  his  paper in the year 
SIGNS OF PREGNANCY.
155
1832,1  the  subject  has attracted a good deal  of attention in Europe, and
also in this country, and several very interesting cases  have been detailed:
in some,  it seems to lmve been  caused by the umbilical  cord encircling the
limbs and acting as a ligature; in other cases the origin of the ligature has
been ascribed by Dr. Montgomery to organized lymph.   Professor  Gurlt,
of the  Royal School of Medicine at  Berlin,  in a paper published by him in
1833, regards "  these threads as  prolongations  of the egg membrane from
which  the  fcetus grows, wdiether this skin (or membrane) be taken  as the
navel bladder or the amnion," and  "objects to their being  considered as
formed by organized lymph," as supposed, by Dr. Montgomery.   "The pro-
longations of the membrane," Gurlt thinks, "are afterwards, by the con-
stant motions of the fcetus, twisted  into slight  but  firm cords,  or threads,
which may involve  different portions of the fcetal limbs, (as we sometimes
find the umbilical cord  several  times  round  the neck, or other parts  of the
child's body,) so as to  stricture them, and  cause their separation :  in this
way he explains the presence  of the  ligatures concerned in the  production
of spontaneous  amputation."2]
                         CHAPTER  Y.

                      SIGNS OF PREGNANCY.

  204,  Having now minutely described the  process of utero-gestation, let
us examine the signs and symptoms to which it gives  rise, and by which it
may be  detected.   I need say but little as to  the importance of such an in-
quiry, or of the responsibility which  is incurred by a physician, when his
opinion is demanded.  The honor, and therefore the happiness of a female,
may depend upon his decision ; the peace of  families may rest upon it; and
the inheritance of property be controlled by it.   The limits  of  this work
oblige me to  treat the question rather as a  physiological than  a medico-
legal one ; but although much  is omitted which  might be available in the
latter point of view, all that is  adduced applies equally to both.   In all
such cases, the reader is to remember that he may not merely be requested
to investigate  a case of doubtful pregnancy, where no shame is involved, but
that he  may be consulted in cases where pregnancy is  concealed  by unmar-
ried women, or by married women  under certain  circumstances, to  avoid
disgrace ; and on  the other hand, where it is pretended, in order to secure
an  inheritance, to  extort money, or to delay punishment.  In considering
each " sign," I shall  endeavor to state its value  as evidence, as well as to
describe its characters as a symptom.
  205.  The signs of pregnancy have been variously classified, and no doubt
in a formal treatise  a scientific  classification is necessary;  but  in a brief
summary like  the  present, it  appears  to  me that it will be more useful to
take them rather in the order  of time in which they are developed; by which
means the student  will find  grouped together the early evidences of preg-
nancy,  and again, those indicative of more advanced gestation.

  1  [Dublin Journal of Medical Science, vol. i., p. 140.]
  2  [For further information on this  curious subject the reader is referred to Dr. Mont-
gomery's essay,  contained in his invaluable work  on  the "Signs and Symptoms of
Pregnancy."] 
156
SIGNS OF PREGNANCY.
  206. The general condition of a pregnant woman is plethoric, the pulse
is quicker and fuller, the quantity of circulating fluid is said to be augmented,
and its quality altered by the increase of fibrine, judging from the prevalence
of the butty coat in blood taken under such circumstances.
  Well-marked sympathies are excited in distant organs, which often amount
to distressing irritation, and the nervous system may suffer both primarily
and secondarily.  Variations in temper and disposition are of frequent occur-
rence, as well as caprices  of taste.  The chylopoietic viscera are often de-
ranged, and  the secretion  from the kidneys altered.   The skin may change
its color,  and become sallow or discolored in patches,  though in  some cases
it becomes more florid, with occasional eruptions on the face.  Some women
become fat during pregnancy, others lose flesh.
   But in  some  particulars, the deviations from the ordinary state are more
remarkable, and constitute  the special signs upon which our diagnosis must
be grounded; these we shall now notice, premising  that the  diagnosis of
early pregnancy  is no  easy task,  but  one which requires great care  and
discrimination.
   207.  Cessation of menstruation.—One of the first circumstances which
leads a female to suspect that she is pregnant, is the non-appearance of the
catamenia at the proper  time, and if at the  second period they are  still
absent, it is deemed conclusive, or nearly so.
   Ko doubt  this is one of the most unvarying, as it is one of  the earliest,
results of pregnancy.   But, strictly speaking, it is not conclusive, inasmuch
as the discharge may  recur for  some  months  after conception, or even
monthly during the whole period of utero-gestation.    Such cases have been
recorded  by  Mauriceau,  Puzos,  Desormeaux,  Johnson,  Frank,  Dewees,
Kennedy, Montgomery, etc., and  several such have occurred to myself.1
   [Dr. Meurer has recorded a remarkable instance of menstruation during
pregnancy in a  woman,  aetat.  27,  who was pregnant for  the  fourth time
when  he  wrote.   She always  had had  her menses regularly during preg-
nancy, and  only during that time.   They came on without any illness;  and
she had always borne healthy children, at the full  period.  While unmarried,
and  except  during pregnancy, she never menstruated, but she was never un-
well  from it.  Her general  appearance was  rather  masculine.2  In very
many  of  the cases of  supposed menstruation during pregnancy, there  is
nothing more takes place than a hemorrhage from about the cervix uteri,
in consequence of inflammatory ulceration or abrasion of the epithelial cover-
ing of this part.   Sometimes these conditions  precede  pregnancy, but are
aggravated by the afflux of blood  and  augmented vascular activity of the
gravid uterus, while  in other instances  they  originate during  pregnancy.
The  hemorrhage is often very considerable, and in  accordance with a law
which, to a certain extent, governs all the capillary hemorrhages of females,
it is most liable to  occur at or about the catamenial periods.]
   Again, conception may take place  previous  to menstruation, or immedi-
ately after ceasing to give suck, before it has had time to occur.  Nay, some
cases are on record where women menstruated only during gestation.
   Lastly, the catamenia may be arrested by disease of various kinds, and it
is even possible for pregnancy to occur in such cases.
   If, then, menstruation may be suspended by other causes on the one hand,
 and may continue, notwithstanding pregnancy, on the other hand, it is evi-
dent, that by itself, the cessation of menstruation is not a proof of concep-
tion, although it is of considerable value (inversely as to the frequency of the
exceptions)  as evidence,  especially combined  with other signs.   I may add,

   1 For an explanation  of this occurrence, the reader may consult a paper by Dr. J.
Matthews Duncan in the Ed. Monthly Journal, April, 1853.
   'l [London  Medical Gazette, Nov. 1840, from Med. Correspondenzblatt, Bd. 9, No. 31.] 
SIGNS OF PREGNANCY.
157
that in cases of concealed pregnancy the woman sometimes stains her linen
with blood, in order to simulate this discharge.
  208. Morning sickness.—The intimate sympathy between the uterus and
stomach, is shown  by the  irritability of the latter soon  after conception.
Most women  suffer more or less from  nausea and vomiting,  especially on
rising in  the morning; hence it  is  termed  "the morning sickness."  The
irritability  may  commence  immediately after  conception,  as in two cases
mentioned by  Dr. Montgomery ; but more generally it sets in about the fifth
or sixth  week, and  ceases  soon after the third month.   The  daily attack
lasts but  a short time, from ten minutes  to  an hour, after which the patient
completely  recovers, and is able to take food.
  As an evidence  of pregnancy, its occurrence at the regular time and in
the usual manner, is of  great value when combined with  other symptoms,
but the exceptions and  irregularities are sufficiently frequent to render it
more doubtful if taken alone ; for it may be altogether absent, and yet the
patient be  pregnant, or  if present, it may occur at unusual times, or with
extraordinary violence ;  with  some women it occurs during the night only,
with others  it lasts  during  the entire day, and may continue throughout the
period of gestation.  On the other  hand, it may be present as morning sick-
ness, from various causes, and yet the patient not be pregnant.
   Dr. Ramsbotham remarks, that when vomiting " is entirely absent, utero-
gestation does not proceed with its usual regularity and activity;"  and  so
far my experience agrees with his, that irregularities in this particular are
frequently followed by deviations in the other symptoms of pregnancy.
   [" This remark does not  entirely correspond with my experience," remarks
Dr.  Huston, in a note to a former edition.   "I have  known  many  women
proceed  regularly through  their  pregnancy, afld be  safely  delivered  of
healthy children,  without experiencing the least degree  of morning sickness.
But where a woman laboring under  this disturbance  is suddenly relieved,
before the  usual time for  its cessation, there is reason to apprehend some
mischief to the  ovum, the  more  especially if  she  has  been exposed to any
mental or other cause capable of strongly impressing the nervous or vascular
system."
   " There is little doubt," says Dr. Montgomery,1 " that, in general, vomiting
is a useful  concomitant in pregnancy, and that its sudden cessation is very
often indicative of  an  unfavorable change in the contents of the womb, and
of approaching abortion, but I have seen so  many instances in which females
have been altogether exempt from this affection in several successive preg-
nancies,  through which they have passed most favorably, and  gave birth to
strong and  healthy children, that I must decidedly dissent from the opinion
of Dr. Ramsbotham, above quoted, as a general rule, although entertaining
the highest respect for its author."]
   209.  Salivation. — The irritation caused by  pregnancy may affect the
salivary  glands, and induce  salivation,  although it  is  not of  very frequent
occurrence.   It is enumerated by Hippocrates and the earlier writers as one
of  the signs of  pregnancy;  but  recent authorities consider it of  less value.
Cases, however, are mentioned by Dewees, Montgomery, and others.  Several
such have occurred to myself, in which  it commenced at an early period, was
very profuse, but unaccompanied by swelling of the glands or tenderness,
and ceased spontaneously, in one  case, about the fourth month,  in another
about the  fifth, and in a third about the eighth.  As  Dr. Montgomery has
observed, it is " easily distinguished from the pytalism induced by mercury,
by the absence of sponginess and soreness of the gums, and of the peculiar
fcetor, and by the presence of pregnancy."

              1 [Signs  of Pregnancy, Philadelphia Edition, page 90.] 
158
signs of  pregnancy.
  210. Mammary Sympathies.—About two  months after conception, the
attention of the female is attracted to the state  of the breasts.   She feels an
uneasy sensation of fulness, with throbbing and tingling pain in their sub-
stance and at the nipples.  They increase in size and firmness, and  have a
peculiar knotty, glandular feel; the areola darkens,  and after some time, a
milky fluid is secreted.
  But it must be recollected that the breasts may enlarge from other causes ;
this  happens with  some women at  each  menstrual  period : when the cata-
menia are  suspended, or  after they cease ;  and at  such time a milky fluid
may be secreted.   Distension of the uterus from hydatids or other causes, is
accompanied by a change in the breasts.   On  the other hand, Gardien  and
Mahon have remarked, that when menstruation takes place during the early
months of gestation,  the  swelling and pain of  the  breasts are absent;  and
Dr. Montgomery mentions a case in which no alteration  took place until
after delivery, in consequence of the delicate state of the patient's health.
  In the  virgin state the color of the nipple and areola differs comparatively
little from that of the  surrounding skin.  It is generally a few shades darker,
but sometimes scarcely that.
  But after conception a great change is observed in most women, though
less marked in those of very light complexions.   The first alteration percep-
ceptible is " a soft and moist state of the integument, which appears raised
and  in a  state of turgescence, giving one the idea,  that if touched by the
point of the finger, it would  be found emphysematous; this state appears,
however,  to be caused by infiltration of the subjacent cellular tissue, which,
together with  its altered  color, gives us the idea of  a part in which there  is
going  forward a greater  degree of vital action than is in operation around
it, and we  not unfrequently find that the little glandular follicles, or tubercles,
as they are called by Morgagni, are bedewed  with a secretion sufficient to
damp and  color the woman's inner  dress."  The above is an extract from
Dr. Montgomery's work,  to which, and to  the plates accompanying it, I  beg
to refer the reader.   This first change in  the areola takes  place at an early
period ; Dr. Montgomery states that he has recognized it at the end of the
second month.   Dr Houghton of Dudley has mentioned to me the particu-
lars of a  case in which he observed it as early as the  fourteenth or fifteenth
day, and the circumstances leave no doubt that  the lady could not have been
more advanced  in  pregnancy.  "During  the  progress of  the  next  two
months, the changes  in  the areola are in general  perfected, or nearly  so;
and  then  it presents  the following characters  : a circle round the nipple,
whose color varies in intensity according to the  particular complexion of the
individual, being usually much darker in persons with black  hair,  dark eyes,
and sallow skin, than  in  those  of fair hair, light-colored eyes, and delicate
complexion.   The extent of the circle varies in diameter from an  inch to an
inch and  a half, and  increases in most persons as  pregnancy advances, as
does also the depth of color."  In the centre of the colored circle, the nipple
is observed partaking of the altered color  of the part, and appearing turgid
and  prominent,  while the surface of the  areola, especially that  part of it
which lies  more immediately around the base of the nipple, is studded over
and  rendered  unequal by the prominence of the glandular follicles, which,
varying in number from twelve to twenty, project from the sixteenth to the
eighth of an  inch ; and  lastly, the integument covering the part appears
turgescent, softer and more moist, than that which surrounds it, while on
both  there  are to be observed at this period,  especially in women of dark
hair and eyes, numerous  round spots or small  mottled patches of a whitish
color, scattered  over the outer part of the areola, and  for about an inch or
more all around, presenting an appearance as if the  color  had been dis-
charged by a shower of drops falling on the part.  Dr. Montgomery fixes the 
SIGNS OF PREGNANCY.
159
time of this peculiar appearance at about the fifth month, at which time the
breasts have become full and firm, with large veins ramifying on their surface.
After  the sixth month,  a number of silvery streaks like  cracks may be
observed, the result of over-distension.
  To these  well-marked  changes in the  areola  and nipple there  are  many
exceptions ; the color, which  is in general the most prominent alteration,
may not deepen so decidedly ; and many  cases of women of light complexion
occur, in whom it  scarcely differs  from  the surrounding skin.  Besides, as
Dr. Ingleby has well remarked, " when the color of the  integument around
the nipple has  been once modified by pregnancy and nursing, it is no longer,
I think,  a conclusive criterion."  Again, in other cases the sebaceous glands
are but slightly developed ; but I have almost invariably observed  the puffy
state of the areola in first  pregnancies.    If the fcetus die,  the changes are
arrested, and gradually decline.
   On the other hand, something resembling the deepened color of the areola,
as well as enlargement of the mammary gland, is  said to be present, when
the  uterus  is  distended  from other causes ; and I  have  repeatedly seen the
follicles  developed in patients neither  pregnant  nor nursing.  Upon the
whole, however, the changes  in the breasts  and nipples  are certainly the
most unequivocal of all  the early  signs of pregnancy.
   211. Milk in the breasts, although a popular evidence much relied  upon,
can  scarcely be considered of any value  at all.   It is true, we do often find
it at an early period, and generally at a later; yet it occurs so  frequently
without pregnancy, that no certain conclusions can be drawn from it.    For
instance, Baudelocque mentions the case of a girl of eight years old, who
milked her  breasts  in  presence  of  the Royal Academy of  Surgery, October
16th, 1783, and Belloc  another;  in  both, the secretion  w^s. apparently the
result of the application of a child to the breasts.   A similar case, but in a
woman, is  related  by Mr.  Semple.1  Milk is also  occasionally  secreted at
each  return of the catamenia, and may remain  very long  after weaning.
Fodere mentions that he has frequently known  it secreted at the final  cessa-
tion  of menstruation.2
   212.  From  what has preceded, the student will have gathered that the
diagnosis of pregnancy  in the early months must  be more or less doubtful.
No  single  sign can be relied  on as conclusive ;  it is only when two or three
are  present, and occur in proper sequence, that we  can feel  pretty certain.
For example : if a patient miss one or  two periods,  we may have grounds
for  suspicion,  and  these will  be strengthened if morning sickness occur in
the second  month; but if to these be added enlargement of the breasts and
darkening  of the areola, the case  will  be  pretty certain.   In many cases,
too,  we may derive assistance from the character and circumstances of our
patient.  In  doubtful cases,  it is  much  better to avoid  giving a positive
diagnosis until time  shall have developed more characteristic signs.   It  is
 not,  however, until  the  latter half of gestation that we obtain positive evi-
dence, which  can  neither be simulated nor evaded.  This we  shall  now
consider.
   213. Enlargement of the  Abdomen.— The gradual distension  of the
uterus has  already been described (§ 157) as tolerably equable, enabling us
to estimate the period of pregnancy by the height to which it has attained
in the abdomen.   During the  early months, although it be not perceptible
above the pubis, yet the abdomen increases  by degrees, owing to the intes-
tines being  pushed up from the pelvis.   This enlargement, however, is varia-

   1 North of  England Med.  and Surg. Journal, vol. i. p. 230.
   2 [For an account of several cases of mammary secretion, in both the male and unim-
pregnated female, the reader is referred to Dunglison's Human  Physiology, and Mont-
gomery on the '• Signs and Symptoms of Pregnancy," Philad. ed., p. 110, et seq.] 
100
SIGNS OF PREGNANCY.
ble, owing to the distention of the intestines by gas  or faecal accumulation.
In some cases, the abdomen even becomes flatter at first, from the sinking
of the uterus in the pelvis ;  but it soon increases  again, and by the end of
the third month it  is visibly but equally enlarged.   During the fourth month
the womb ascends  above the symphysis pubis, and may be felt as a rounded
tumor, which goes  on  augmenting till it occupies the whole abdomen.  When
it reaches the umbilicus, it pushes it forward, so that in the sixth and seventh
months it is about  level with the surrounding skin, and afterwards it projects
beyond it in most  women.
  The feel of  the  abdomen distended by the uterus is  very different  from
the impression it  gives when  the distension is  caused by fluid,  flatus, etc.
The uterine tumor is firm, hard, elastic, and defined, preserving its form in
all  positions of the body, though more remarkably when the patient is up-
right; whereas  in  ascites the defined tumor is wanting, the fluid obeys the
law of gravitation, and the abdomen has not the  same firm, elastic feel.   The
best mode of examining the uterine tumor, is to  make the patient first stand
up, and then lie down ;  this will demonstrate the form of the womb better
than  keeping in one  position ; and  after lying for some time,  the  uterine
parietes become relaxed and less firm.  Percussion  will distinguish between
pregnancy and tympanites.
   Nevertheless, cases do occur which are very embarrassing;  for the uterus
itself may be distended by air, fluid, or hydatids, and then  the form of the
uterus and  abdomen  will be the same as in pregnancy.  In such cases, our
guide  must be  the history of the case,  and further investigations into the
contents of  the uterus.   I have  already described the changes which  take
place in the cervix (§  158).
   214. Quickening. — This term is popularly applied to the mother's per-
ception of the first movements  of the foetus, under the erroneous  belief that
it was its first movement, as it then became alive  or quick.   We know that
the foetus is  alive  from the moment of conception, and have little doubt but
that movements take  place at a much earlier period.   By modern writers,
then, the  term  is applied to  the first perception of movement on the part of
the  mother,  which generally occurs  about four  or four  and a half months
after conception, though  some feel it earlier, and others  not till  afterwards.
Dr. Montgomery  observes: "Experience  has shown that it happens from
the  tenth to the  twenty-fifth  week;  but according to  my experience, the
greatest number of instances will be found to occur between the end of the
twelfth and sixteenth week after conception ; or, adopting  another mode of
calculation, between the fourteenth and  eighteenth  week after the last men-
struation."   Out of one hundred cases, Roederer found that eighty quickened
at the fourth  month,  and, of the remaining twenty, some at  the third and
some at the fifth.
 - The sensation is at first like a feeble pulsation ;  and, though so slight, is
often accompanied by sickness  of stomach and faintishness, or even complete
syncope.   By degrees it becomes stronger and  more  frequent, until the
movements  of the different extremities  are distinguishable.  Authors are
 not agreed as to the explanation of quickening, or  why  the movements are
felt at the fourth month  or thereabouts, and not earlier.   I think, upon the
whole, that the most probable explanation  is the  one  which the late Dr.
 Fletcher, of Edinburgh, used  to give in his lectures.  "  The movements of
the fcetus while the uterus  is in the cavity of the pelvis are not perceived,
because the  uterus is not supplied with  nerves of  sensation, and it is sur-
rounded  by  parts  similarly deficient; but when it emerges from  the pelvis,
it comes  in contact anteriorly  with the abdominal parietes, which are libe-
rally supplied with sensitive nerves, and  which, by  contiguity of substance, 
SIGNS of  pregnancy.
161
feel the movements, and thus the woman becomes conscious of them."  This
view is strengthened by the fact,  of which I have  repeatedly been assured,
that the movements, unless when violent, are felt in front only.
  Its value  as  a sign  of pregnancy is  somewhat  impaired by the interval
which  frequently intervenes between the first faint sensations and their repe-
tition ; by the late period at  which  they are felt in  some  cases; and, in  a
medico-legal point of  view, by our being dependent upon  the  evidence of
the patient herself; or  the patient maybe deceived by flatus in the intestines.
On the other  hand,  cases occur where no  sensation  is  perceived  by the
mother.   " Of this fact," says Dr. Montgomery, "the writer can speak with
certainty, having  now in  several instances, by applying  his hand  to  the
abdomen, distinctly felt the motions of the fcetus in  utero,  while the mother
had no perception of them."   In a case lately under  my care the movements
of  the child were exactly  similar, and scarcely more felt by the  patient at
the termination of  pregnancy  than at quickening,  and yet  both mother and
child were strong and  healthy.
   215. The movements  of the fcetus may be felt  by the practitioner some
little time after quickening, by placing the hand, especially if it be  cold, upon
the abdomen; and the  impression will of course be  in proportion to the vigor
of  the motions.   At an advanced period  it would not be easy to mistake
them ; but we may be  deceived at an earlier period.  Dr. Blundell relates a
case of a woman who  possessed  the power of simulating these movements
by the action of the abdominal muscles.
   [Dr. Simpson stated, at a meeting of the Edinburgh Obstetrical Society,
a variety of observations  and experiments,  showing that, contrary to  the
commonly-received opinion, the mere  application of cold (as a coid  hand,
etc.) to the surface of  the abdomen of a pregnant woman, had not the effect
of  exciting  motions in the fcetus.   The application of portions of ice even,
of  the size of the hand, had no such effect.1]
   Dr. Tyler Smith describes two abdominal movements in the latter month
of  pregnancy;  one traversing  irregularly over the abdomen, giving a feeling
of ridges  or  prominences to the hand, and  the other like a shock or impulse;
the former he regards  as due to the peristaltic movements of the uterus, and
the latter only to the fcetus, and I must confess I think there is great weight
in  his arguments.   I am happy to express my obligations to his work, which
I regard as one of the most important and ingenious that has appeared for
many years, both  as  expressing more clearly the "idea" of uterine and
 ovarian  physiology, and also  as  giving it for the first  time the  unity of a
system.
   216. Ballottement.—A vaginal examination will enable us to ascertain
not merely the state of the cervix, but also to decide upon  the presence of a
fcetus, by repercussion, or ballottement, as  it is termed by the French.  The
 patient should be in the upright position ; or  if she be in bed, her shoulders
 should be raised; the  operator must then introduce his forefinger, and place
it upon the cervix uteri, whilst the other hand is employed to keep the ute-
rine tumor steady,  then  suddenly but slightly jerking upwards the point of
his finger, he will feel  a sensation of something  having  receded from it, and
 which he will  perceive  to fall again on the point of his finger in a moment
 or two.   The jerk of the finger upon the head of the fcetus causes it to float
upwards a little in the liquor amnii, and  its own  weight makes  it descend.
 Dr. Montgomery justly remarks that "should  this be distinctly felt, it  is
proof positive  of a fcetus in utero, there being no  other condition or  disease
of  the organ in which a solid body can be felt in this way floating in  the

                1 [Monthly Journal of Med. Science, July, 1830.]
       11 
162
SIGNS OF PREGNANCY.
cavity."  Of course it proves nothing as to the life of the child.  The period
when this test is most available is during the fifth and sixth months.

                         [Fig. 79.]
  217. Auscultation. — M. Mayor, of Geneva, first applied, in 1818, aus-
cultation to the diagnosis of pregnancy; he was followed, in 1821, by M.
Lejumeau de  Kergaradec, and, since his time, the  investigation has been
pursued with zeal  and intelligence  by Haus, Hohl, Kennedy, Montgomery,
Naegele, jun., Depaul, etc.1   M. Mayor  observed  only the sounds  of the
fcetal heart, but M. Kergaradec detected not only  this double  sound, but
another single, whirring sound, which he called "bruit placentaire," because
he believed  it to be situated in the placenta.   To these two sounds Dr. E.
Kennedy has added a third, which is heard only occasionally—the pulsation
in the funis.   Each of these deserves a separate investigation.
   As to the mode of making the examination, it may be  effected with the
naked ear applied to the abdomen, or by  the stethoscope ;  the latter is pre-
ferable, as it enables us to define and limit the sound, and in most  instances
it is  more convenient.  The patient, if possible, should be placed  on her
back in bed, with the head raised, and  the  abdomen covered only by the
night-dress.   If  there be any doubt,  it  will  be necessary to remove the
night-dress  and apply the stethoscope immediately to the abdomen.   I have
repeatedly  succeeded  in  detecting  the fcetal  heart  thus,  when  the sounds
were too faint to be heard  through  any covering.   In  this  way we can
obtain access to all parts of the uterine  tumor,  except posteriorly, and by
turning the patient to one side or the other, we can easily examine the lateral
portions    The auscultator should  place  himself in  the easiest  posture pos-
sible, especially avoiding a dependent position  of the  head, in which case
 he would be apt to mistake  the throbbing of his own arteries for sounds
 communicated from the patient.  The stethoscope  should be placed lightly
 upon the abdomen, and the pressure be varied, in order to ascertain whether
 the sounds  are in any degree modified  by it.
   218. The Uterine Souffle, or bruit placentaire, is a single intermitting
 whirring sound, heard over a certain extent of the uterine surface.   It has
 been  compared to the sound of a pair of bellows,  to  that  made  by gently
 blowing over the mouth of a bottle, and to that heard when  a shell is applied
 to the ear,  etc.  Perhaps the best comparison is with the "bruit de soufflet^
 of the heart, which is doubtless sufficiently familiar to all.   Dr. E.  Kennedy
 remarks, that it  assumes all the variations  of the  latter sound—viz., the
 rasping or  sawing sound, the musical or  hissing sound, a  sound  resembling

   1 By far the most complete account of obstetric auscultation will be found in the work
 of M. Depaul, Traite" Theorique et Pratique de  1'Auscultation Obstetricale.  Paris, 1847. 
signs of  pregnancy.
163
the cooing of a dove, and a drone resembling that of a bagpipe, accompa-
nying the sound, yet without interfering with it.
   It is stated by  Hohl and others to be limited to  the  situation of the pla-
centa (§  175), and so it is generally; but in many cases it extends to some
distance, and in others, according to Naegele, it may be heard in  almost any
part of the uterus : he further states, that it may constantly be heard at the
lower part of the  uterus, by applying the stethoscope  near Poupart's liga-
ment.  I cannot say that I have been able to verify the latter statement, but
I have found it very possible to produce a souffle in that situation by a little
extra pressure of the stethoscope.
   219. The period when it first becomes  audible is about the fourth month,
according to Montgomery, Hohl, and Naegele ; Dr. E. Kennedy states that
he has succeeded in detecting it  as early as  the  tenth week;  and, on the
other hand, it cannot be heard in some cases until the fifth month.   It may,
however, always be distinguished before the pulsations of the fcetal heart;
and even when the fcetus perishes, it continues for some time afterwards.   It
is feeble  when first heard, but increases in intensity and strength;  the inten-
sity,  however,  is  subject to  some  variation.  It  is synchronous  with  the
mother's pulse, and  subject to its  varieties, but without impulse.  During
labor  its intensity varies ; in the upper  part  of the uterus  it is frequently
inaudible during  a pain ; after delivery it ceases entirely, though not always
instantly.
   220. M. Kergaradec,  as I have already said, placed the seat of this sound
in the placenta;  more  recent investigations,  however, have  decided that it
is situated in the uterus.  M. Ulsamer and Dr. E. Kennedy conceive it to
result from the difference between  the calibre of the arteries  supplying the
uterus and the uterine sinuses : that the expanding current of blood rushing
from an  artery into a larger sinus gives rise to the sound, just as the passage
of blood through a constricted valve of the heart or aorta does to the bruit
de soufflet.  M.  Depaul  and M. Caseaux also place its seat in the uterus,
and  the latter  authority considers that it is in part, at least,  owing to a
 "serous  polyhaemia," as advocated by M. Beau.1   Other explanations have
been given, but all are agreed now that  its seat is in the uterus, and not in
the placenta; and most, I believe, that it indicates the position of the latter
organ.
   221.  As a test of pregnancy, its positive value (that is, its being audible)
is very great, though not quite conclusive,  as it is  heard sometimes in cases
 of disease, of which  I had a remarkable instance  under my own  care, and
 may occasionally be produced by too great pressure of the stethoscope upon
 an artery.  Neither does it prove that the fcetus is alive, in cases of preg-
 nancy, as it is observed to  persist for a  short time after the death of the
 child ; it is heard also in some cases of blighted ova which have degenerated
 into moles, and in cases of hydatids.
   On the other hand, its negative  evidence (our not being able to detect it)
 is of much less value, as we  may not be able to hear the sound although the
 patient be pregnant,  probably from the placenta being attached posteriorly.
   In 212 cases, M. Jacquemier found it  present in 80 cases, and  absent in
 132.  In 600 cases M. Naegele heard it  238  times on  the left, 141 times on
 the right side, and in 20 cases it was absent.
   222. Pulsation of the Fcetal Heart.—Yery different from the uterine
 souffle is the sound which attracted the attention  of M. Mayor, the pulsa-
 tion of the fcetal heart.   It  consists of a rapid succession of  short, regular,
 double pulsations, differing from those of the adult heart in rhythm and fre-
 quency.   The sound is  like the muffled  ticking of a watch,  or, as Naegele
1 Archiv. G6n. de Med., 1850. 
164
SIGNS OF PREGNANCY.
remarks, like the pulsations of the heart of a new-born  child.  Their fre-
quency is about double those of the adult, or from 120 to 140 pulsations in
a minute—i. e., 240 to 286 audible sounds ; but in counting,  we reckon  the
second sound  only, as it would be impossible to count both, and the second
is  the  loudest.  I  have  already described  (§ 199)  the  peculiarities of the
double  sound in  the fcetal  heart, with the change  of rhythm which takes
place at birth,  and  which I need  not here repeat.   M. Naegele, jun., found
that, in 600 cases, the average frequency was 130 (i.e., 200 sounds)  strokes
in a minute.
   The variations in strength and rhythm of the pulsations of the fcetal heart
are very nnmerous, and not easily explained ; no doubt many are caused  by
changes in  the condition of the fcetus itself, and others by impressions re-
ceived from the  mother; for although the fcetal circulation  is independent
of that of the parent, yet there is so intimate a sympathy, that disturbances
in the maternal system are communicated to that of the foetus, some (in case
of sudden shocks) immediately, and others (in case of disease) more tardily.
   The situation in  which the fcetal  heart  is heard  most distinctly, is about
the middle, or inferior abdominal  region, more  frequently on the left than
on the right side.   "The extent of surface," says M. Naegele, jun.,1 "over
which the beating of the heart is  heard, cannot be  accurately defined in
inches and lines, but it is certainly audible through a larger space than most
observers have represented.   Its sounds  reached beyond the linea alba to-
wards the other side, in  one hundred and eighty-five of three hundred and
seventy cases, in  which the position  of the foetus with its back to  the left
side of the mother was  distinctly  ascertained by the ear, and afterwards
verified by the result of the  labor ; in forty-six, they  were  audible over nearly
the whole abdomen ;  while in one hundred and thirty-seven, they were con-
fined to the left side,  and did not reach the mesial line.   The heart's sounds
were  audible beyond the  mesial line, only in  forty-five of one hundred and
eighty-five  instances, in  which the back  of the  fcetus was directed to  the
right side ;  one hundred  and fourteen times they were distinguishable on the
right side only; but in twenty-six they extended  over the whole abdomen.
In all these instances in which the  heart's sounds were not limited to one
lateral half of the abdomen, their greater intensity at one part indicated the
situation of the back, and consequently the position  of the fcetus."
   So far as the second sound of the fcetal  heart is concerned, my experience
agrees with that of  M. Naegele, but I have found that the first sound becomes
inaudible at a  very moderate distance from the situation  of the fcetal heart.
   The earliest period at which the pulsations can ordinarily be detected, is
the middle of the fourth  month, or the beginning of the fifth.   Dr. E. Ken-
nedy has heard them in a few instances before the expiration  of the fourth
month.  Dr. Montgomery names the end  of  the fifth month.   The  earliest
period mentioned  by Naegele, is the eighteenth week, in  thirty out  of fifty
patients who were examined before the middle of pregnancy.  In some cases
they did not become audible  before the fifth month.  It is easy to conceive
that various circumstances  may impede the transmisdon  of the sound, and
so alter the time  at which it would otherwise be first heard, as, for example,
excess of liquor amnii, thickness of the abdominal parietes, or feebleuess of
the fcetus.
   223.  When the pulsation  of the  fcetal heart is heard,  it is proof positive
of pregnancy,  equally remote from imitation or evasion.   The only circum-
stances at  all likely to  embarrass us for a moment, are the sounds of the
maternal heart, which may sometimes be heard ;  the  sound of the contrac-
tion of the  abdominal muscles; or of the uterine arteries;  but the  greater
On Auscultation, translated by Dr. West, p. 41. 
SIGNS OF PREGNANCY.
165
rapidity, the  rhythm, and the clearer, though feebler, sound  of  the fcetal
pulsations will distinguish them  with facility.
  On the other hand, the pulsations being inaudible is not conclusive proof
that the patient is not pregnant, as the child may have died, or, as in some
rare cases, they may be inaudible for a time, though the fcetus  be living.  I
know this to  be the fact, though I cannot  explain it.   M. Depaul mentions
that in 906 cases it was only absent in eight cases.
  In some rare cases of pregnancy the pulsations of the aorta  are heard, or
rather felt, even beyond the fifth month ;  but why they are thus transmitted
I cannot say.  As a general rule, if they are  distinctly heard, it is good
evidence that the  patient is  either not pregnant, or that the uterus has not
risen up out of the pelvis.
  224.  Pulsation of the Umbilical Cord, or funic souffle.—If the posi-
tion of the funis  be  favorable,  as, for instance, if it be  twisted round the
neck, body, or limbs of the fcetus, or  in any way placed between the fcetus
and the anterior or lateral parietes of  the  uterus, it is quite possible,  as Dr.
E.  Kennedy has  shown, to hear the pulsation of its arteries corresponding
to  the  fcetal heart's  action.   Both Haus and  Hohl have denied this, but
without just  reason, in my opinion;  for  Dr. E. Kennedy states that "in
some cases where the parietes  of the uterus and abdomen were  extremely
thin, he  has  been able to distinguish the funis by the touch externally, and
has felt it rolling under his  finger, and then applying  the stethoscope, its
pulsations has  been discoverable, remarkably strong."   Professor Naegele,
jun., agrees  with  Dr. E. Kennedy as to the seat of the pulsation,  and attri-
butes it to the tortuosity of the arteries, and to  the  dilatations observed in
them.   Occasionally the sound is rather a souffle than a pulsation, but fainter
than the uterine  souffle, and  distinguished from  it by its being synchronous
with the pulsations of the fcetal, and not the maternal heart.   Dr. E. Ken-
nedy found that he could produce  the souffle by pressing slightly upon the
cord with the edge of the  stethoscope.
   225.  We have  now examined the principal signs developed during the
latter half of pregnancy—to wit, enlargement of the abdomen, quickening,
the motions of the child, ballottement, and the results of auscultation ; and
we find that whilst all are valuable, there is a degree of uncertainty attached
to the first three which calls for a very careful estimate on our part:  that
the positive  evidence of the latter modes of investigation is conclusive, but
that the negative evidence, or absence of the usual results, is not proof that
the patient is not pregnant.   So that,  as was before observed,  we ought
rather to depend upon the coincidence of  two or more of the signs of preg-
nancy, than  attempt a diagnosis from  any one alone : the only sign  indeed
which can be regarded as proving that the woman is pregnant of a living
child, is the pulsation of the fcetal heart.
   226.  Kiesteine. — There  are two  other  signs which I have deferred
noticing until now, because they require more research to entitle them to a
place among the recognized evidences  of gestation, and it seemed better
that the student's attention  should  rather be directed to those considered
valid, than embarrassed by doubtful  ones.  The first of these tests is  derived
from  the urine.   M. Nauche was the first who accurately described the
change  which takes place in the urine  of pregnant women.   He found  that
" by allowing the  urine  to stand for  some  time, in  thirty or  forty hours a
deposit takes place of white, flaky, pulverulent,  grumous matter, being the
caseum, or peculiar principle of the milk formed in the breasts  during gesta-
tion."  This deposit  has lately  received the name of Kiesteine.   M. Egui-
sier has published the result of his researches on the subject.1   He states
1 Lancette Francaise, Feb., 1839, p. 36. 
106
SIGNS OF PREti NANCY.
that "the urine of a pregnant woman, examined in the morning, is generally
of a pale yellow color, and  slightly milky ;  it first reddens, and  then turns
blue the  'papier tourncsol,"1 as ordinary urine.   Exp6sed to the  contact of
air, a cloudiness is observed from the first day, resembling fine wool;  from
the first day, also,  a white matter  is deposited.   These phenomena are  not,
however, constant.  From the second to the sixth day, small opaque bodies
are seen rising from the bottom to the  surface of  the fluid, and  then collect-
ing together until they form a layer, covering the whole surface : this is kies-
teine.  It is sufficiently  consistent to be raised  from off  the  fluid.   It is
whitish, opaline, slightly granular, and resembles much  the layer of fat which
swims on the surface of fat broth when cool.  Examined by the microscope,
it appears a gelatinous mass of indeterminate form.  When  it is old, cubical
crystals are  sometimes detected."  "It persists thus for three or  four days;
the urine then  becomes troubled; small portions are detached  from its  sur-
face, and sink to the bottom, until the layer is entirely broken up.   Kiesteine
appears to exist in the urine from the first month until the period of de-
livery."  Dr. Montgomery seems  to think  this appearance  constant, when
the deep color and  turbid condition of the urine permit of observation.
  Dr. Golding Bird has published a series of experiments  on this subject,1
which confirms the value of this test.   The pellicle formed in  the urine of
twenty-seven out of thirty pregnant women, and it was found only in  two
instances out of a number, in the urine of  unmarried women.  I shall quote
his conclusions: —" 1.  That certain organic matters,  closely resembling, if
not  identical with, caseous   matter, mixed with  abundance of  the earthy
phosphates  in  a crystallized state,  are eliminated from the blood during
pregnancy ;  and if  not  otherwise removed,  or taken  up, are finally thrown
out of the system by the kidneys.  2.  That certain accidental circumstances,
especially connected with those morbid actions in which the kidney is called
upon to perform a compensating function for  the skin, as  indicated by the
abundance of azotized matter, in the form  of amorphous lithate of ammonia,
in the urine, interfere temporarily  with the  development of  caseous matter,
as they do in checking the cutaneous and  other secretions.   3.  That, taken
in connection with  other symptoms, as the formation of a dark areola round
the nipple, and cessation of menstruation and abdominal  enlargement, the
formation of a caseous pellicle in the urine affords a very valuable corrobo-
rative indication of the existence of pregnancy."
  This subject has been  investigated by the late Dr. E. K. Kane, in the
Philadelphia Hospital, and  he  has arrived at  the following conclusions: —
1. That kiesteine is not peculiar to pregnancy, but may  occur whenever the
lacteal elements are secreted wdthout  a free discharge at the mammae.   2.
That though sometimes obscurely developed, and occasionally  simulated by
pellicles, it is generally distinguishable from all others.   3.  That when preg-
nancy is  possible, the exhibition of a clearly defined kiesteine pellicle is one
of the least  equivocal proofs of that condition :  and, 4. That when this  pel-
licle is not  found  in the more advanced stages of supposed  pregnancy, the
probabilities, if the female be  otherwise  healthy, are as 20 to 1 (80 to 4)
that the prognosis is incorrect.2
  227. Jacquemier's Test. — This consists in a violet color of the mucous
membrane of the vagina and vulva, dependent probably upon pressure above.
M.  Parent-Duchatelet confirms  the result of M.  Jacquemier's observations,
which he states were made upon  a large number of pregnant women,  and
that the change of  color was never absent.  I had lately an opportunity of
minutely examining a well-marked case, and found that the violet color was
caused by a great number of minute veins in a varicose condition.

               1 Guy's Hosp. Reports, No. 10.
               2 American Journal of Med. Science, July, 1843. 
DURATION  of  pregnancy.
167
  This, however, is denied by Dr.  Wistrand, as he has not found  the  livid
color  following  the course of the veins, but extending uniformly over the
entire mucous membrane.   He regards  it as owing  to  the hyperaamic con-
gestion, produced by compression  of the utero-pelvic veins, and that it may
be perceived  towards the close of the second month,  becoming more evident
during the third and fourth.1  Malvani, Heiberg, Sperind, regard this as a
never-failing  sign of  pregnancy, and  Dr. Wistrand  agrees with them.
Huguier states that it is not found in any other state than pregnancy ; but,
on the other hand, Lange thinks that it does not occur in so marked a degree
in all  pregnant women, that it can certainly be  distinguished from  similar
changes of color from other causes.
  228.  Twin Pregnancy. — The inadequacy of  the signs which  are  com-
monly stated to  indicate  plural pregnancy, must have been  felt  by every
accoucheur.   Those upon which the greatest reliance is placed are, the dis-
proportionate size of the abdomen compared with the period  of gestation;
the flattened  state of the  abdomen in  front, with the appearance of being
divided into  halves ;  the inequality of its  surface ; the tumultuous move-
ments of the  foetus ; the inordinate weight and distension ; and the excessive
oedema of the  lower  extremities.   No doubt many of  these  circumstances
may be observed in twin  pregnancy, yet none of them are sufficiently dis-
tinctive, while several may arise from other causes.   An additional difficulty
may arise from one of  the foetuses dying, and yet being retained along with
the living one until the full time.
  M.  Hohl  has  remarked that in twin cases the  uterine  soufle is heard
" over a larger surface, with greater intensity and more varied tone ;" but in
ten twin cases observed by Naegele, jun., no variation in this sound was ob-
served sufficient to excite  suspicion of twins.
  The only sign upon  which reliance  can be placed, is, as Dr. E. Kennedy
has pointed out, the hearing the pulsation of two fcetal hearts, equally dis-
tinct, and at a  distance from each  other, especially if the  number  of pulsa-
tions should  be different in the two situations.
   "Usually," says Naegele, "the  beating of one heart is heard in the left
or right inferior abdominal region, while that of  the other is  audible in the
superior abdominal region of the  opposite side.   But it never happens, be
the position  of the  children what it may, that the beating  of the two hearts
is heard on the same horizontal plane.   It  is the more important to  bear in
mind the different situations of the two hearts, because  their action is  often
synchronous.
                        C HAP TER  YI.

                    DURATION OF  PREGNANCY.

  229. What is the ordinary term of gestation, and what may be the devia-
tions from it ?  Such are the questions to be briefly discussed in the present
chapter, rather in  a physiological than  a medico-legal point of view; for
full particulars, I refer the reader to Beck's and Taylor's Jurisprudence, and
Montgomery's Essay on the subject.

             1 Dublin Quarterly Journal, vol.  xiv. p. 449.  New Series. 
168                  DURATION  OF  PREGNANCY.

  The first point to be settled is the ordinary term of utero-gestation; and
we are met at the outset by the difficulty of obtaining accurate data.  The
common mode of calculation is from a fortnight after the last menstruation;
and the period  so fixed is corrected by the time at which quickening occurs.
In many instances  this proves pretty correct; in the majority,  I think, it is
rather overrun ; and,  at any rate, the uncertainty as to the period of con-
ception, and  the variation in  the time of quickening, are sufficient to render
the computation no more than an approximative estimate.
  Cases, however,  occasionally occur,  where conception  follows  a single
coitus, and if they were sufficiently numerous,  they would settle the ques-
tion ; but they are rare.  Dr. Montgomery relates the case of a lady who
went to the sea-side in June,  1831, leaving her husband in town.  He visited
her for the first time  November 10th, and  returned to town the next day.
She quickened  on the  29th of January,  1832, and was delivered August 17th,
exactly two hundred and eighty days from the time of conception.
  The deductions from such cases, and from general calculation, have led to
fixing the term of gestation  at ten lunar months, or nine calendar months
and one week,  or forty weeks, or two hundred and eighty days, allowing for
some variation  either  way.  In an able and interesting paper,1 Dr. Matthew
Duncan disputes the accuracy of this calculation, and maintains the truth of
Harvey's statement that 275  days is the  normal period of pregnancy, and
that  the patient will be confined after ten lunar months, on the day the cata-
menia would have  appeared,  had she not  been pregnant.  If  we  take the
average of cases when the period  of  fruitful  coitus can be ascertained, it
will certainly fall short of 280 days.
  230. But then, allowing for the uncertainty of the ordinary data, or sup-
posing the "point de depart" unquestionable, are we to  conclude  that the
actual duration of pregnancy is determinate and invariable ?  We know that
it may be accidentally abbreviated without destroying the child, from various
causes, but then this   is not  the natural  course.   In  some  cases, also, the
natural duration may be within the limits here laid down;  for example — in
Dr.  Girdwood's case, the period  was 274 days.2  Dr.  Rigby gives three
cases of 260, 264, and 276.   Dr.  Lockwood,  four cases, of 270, 272, 276,
284  days.3  There  is  a case in the American  Journal of 272 days.4  Dr.
Reid5 mentions cases at 276;  three  of  274, one 275,  273, 271, 278, 263,
280, 264,  274,  276, 280 ;  two of 266,  265, 272, 275, and 271 days;  and in
all these there appear sufficient grounds for believing in their accuracy, most
of them being  the result of a single coitus. On the other hand, May it also
be prolonged?   So much diversity of opinion has obtained on  this point,
that it is very difficult to come to a satisfactory conclusion.  In the celebrated
Gardiner  peerage  case, the  most eminent  accoucheurs in  the country were
arranged  on opposite sides.    Drs. Gooch, R, Blegborough, Davis, Sir C.
M. Clark, and  Mr. Pennington, discrediting protracted gestation ;  and Drs.
Granville, Conquest,  Blundell, Merriman, Power, Hopkins, etc.,  advocating
its possibility.
   Dr. Dewees remarks : ■" I have had every evidence, on this side  of absolute
proof, that it has  been prolonged to ten calendar months, as an habitual
arrangement, in at least four females ;  that is,  each went one month longer
than the calculations  made, from an allowance of ten  or twelve days after
the cessation of the last menstrual  period; and from the quickening, which
was  fixed at  four months."  Professor Desormeaux relates a case of a lady
whose pregnancy lasted nine  months and  a fortnight.   The late Professor
1 Edin. Med. Journal, Nov. 1856.
8 Amer. Journal of Med. Science, Dec. 1847.
* Lancet, July 20th, 1850.
2 Lancet, Dec. 1844.
* Ibid., April, 1842. 
DURATION  OF  PREGNANCY.
169
Hamilton, of Edinburgh, declares his " solemn conviction, that he has met
with at least twelve cases, in the course  of practice, where  there could not
be the shadow of doubt of  the protraction  of  human pregnancy beyond the
ordinary period."   M. Yelpeau has recorded nine cases of the kind.
  To these authorities  may be  added the  names  of Harvey, Smellie, Zac-
chias, La Motte, Le Roi, Le Bas Fodere Capuron, Gardien, Murat, etc.
  Dr. Montgomery relates  two cases in his work, one of which came  under
my observation ; in the first the gestation continued two hundred and ninety-
one days, and in the second forty-one weeks and two or three days  at least.
I have referred to some of the cases on record, because,  the question  being
chiefly one of authority, positive evidence must infinitely outweigh  mere
negation.
   In the case of Anderson v.  Whittaker,  gestation1 had lasted 283 days
from  the only coitus, and  in Dr. Lee's case 287 days;2  Dr. Beatty's3 case
was 291  days ;  Mr. Skey's 293 ; Dr. Ashwell's, 300 days; Dr. MTlvain's,
293 ; Dr. James Reid's, 287 and 293.
   [It is very certain that  there are well-authenticated instances on record
in  which the period of gestation has  been  extended beyond the usual term.
In the  cases  of single intercourse, 293 days form the  longest period, or
eighteen days beyond what is deemed to  be  the usual average duration of
pregnancy in the  human female.  Now it is a coincidence with the results
of Lord Spencer's tables, that of the 764 cows whose data were so accurately
noted, the greatest excess beyond the  average  term  of gestation in them
(2*5 days) was  also eighteen days.   In a  case related  by Dr.  Ashwell, of
a prolongation  of gestation to  the 300th day, the exact  date of impregna-
tion is not given ; it is stated that the husband left a few days after the cata-
menial  period ;  now as this is the only case of pregnancy extending to 300
days, some, perhaps, may doubt the exactness of the husband's statement as
to  time.
    With a view  to ascertain the experience of those who  were most  likely to
 have paid particular attention to this subject, upwards of forty  of the most
 eminent  obstetric practitioners  in London,  Dublin, and Edinburgh, were
 applied to by Dr. Reid.   The large majority  of these  expressed a firm con-
 viction as to the occasional extension of the usual period of pregnancy by a
 few days beyond 280.   Several had met with  one or two cases of protracted
 gestation, out of many hundred, on the exact data of which they could rely;
 others, who  had not kept notes of their cases, could not  positively speak to
 facts, but had no moral doubt as to the  period  being  extended in  some in-
 stances.  Some, who  have had extensive experience in private and hospital
 practice, stated that they had  never  met  wdth  an undoubted case of pro-
 tracted gestation ; whilst two  affirm it  as  their strong  conviction, that no
 case ever exceeds the  280th day from conception, and one, that it is never
 carried beyond  the ninth calendar month.
    In order to show that no other data than the calculation from a single
 coitus is to be depended upon to fix  the commencement  of pregnancy, Dr.
 Reid presents the following table, the result of 500 cases, in which the exact
 number of days intervening between the last  day of menstruation and that
 of parturition is shown.  With  the exception  of about 50, they were private
 cases, in which  the data  were  most  correctly kept;  and the others were
 selected from upwards of 1000 hospital and dispensary cases, presenting an
 equal certainty  as to date,  in females superior to the usual class of hospital
 patients.

         i Lancet, July 20th, 1850.               2  Med. Gazette, 1831.
        3 Dublin Med. Journal, vol. viii. 
170
DURATION OF PREGNANCY.
         '252
           53
           54

37th week.-j  ^rg
           257
           258
         [259

         [260
         I  261
         |  262
38th week. -{  263
         I  204
         |  265
         [266

         [267
           268
         |  269
39th week.\  270
           271
[274
40th week, -j 277
          I 278
          | 279
          [280
          [281
           282
          I 283
41st week.{ 2S4
          I 285
          | 286
          [287
41
1
3
1
2
4
4
4

61
r lo cases.
 9 }-48 cases.
10
 5
10-

 91
13 I
 5 I
13 [-81 cases.
12
13 |
16j

211
20
16
16
22
21
15
          Days.
         f 288
         I 28'.)
         I 290
42d week. \ 291
          292
          293
          294
         f295
          296

43d week. ^ 298
          299
          300
          301
131 cases.
181
25
14
15
14
15
-112 cases.
           302
           303
           304
44th week.\ 305
           306
           307
          [308
         f 309
           310

45th week. -J  g, .
           315
           316
in
 8
 9
14 \&Z cases.
 6
 3
 6J
V
8
6 ^-28 cases.
1
1  [ 8 cases.
0
1
2
6 cases.
°1

il
1J
Total,  500 cases.
  In the case which occurred 314 days after the cessation of the catamenia,
it is noted that quickening did not happen until the 6th month, proving, in
Dr. Reid's opinion, that conception  had taken  place  later than had  been
thought.  Had minute investigation been made, at an early period, into the
remaining five cases which went beyond the 44th week, it is most likely that
similar facts might have been observed.
  It will be  seen that the above table  agrees with that  of Dr. Merriman
(114 cases), in showing that the greatest proportion of women complete the
period of gestation in the 40th week after  the  cessation of the catamenia,
and a very considerable number in the 41st week.
  In Dr. Murphy's table  of 182 cases, the numbers born in the 39th and
40th weeks were  about equal, being 24 and 25 ;  whilst the greater propor-
tion (thirty-two)  were in  the  41st week, and 25 in the 42d week — equal to
those in the 40th.
  In Dr. Reid's  table the 282d day was  that  on which the largest actual
proportion of the patients were delivered ; but the number from the 274th
to the  282d day ran so near to each other that we must rather take that as
the average  period.   If we allow a range of from two  to  six days  after
menstruation, as elapsing probably before conception takes  place, it will
then appear that about the 39th week after impregnation  is most probably
the ordinary duration  of pregnancy ; and this will  coincide with the result
of the table taken from cases of single coitus. 
STERILITY.
171
  In a note to a former edition of this work, Dr. Huston states that he has
known at least two instances in which he had the strongest reasons for be-
lieving that gestation  extended, in one case two  weeks, and  in  the  other
three  weeks, beyond the usual period, or nine calendar months.]
  231. An additional  argument  has been deduced from the irregularity of
the period  of gestation among  cattle.  According to the researches of M.
Tessier:  out of 160 cows, 14  calved  from 8 months to 8  months and 26
days;  3 at 270 days ;  50 from  270 to  280 days; 68  from 280  to 290 days;
20 at 300, and 5 at 308 days ; the extremes being  thus 67 days apart.  Of
102 mares, 3 foaled on the 311th day  ; 1 on the 314th ;  1 on 325th ;  1 on
the 326 ; 1 on the 330th ; 47 from  340 to 350 days ; 25 from  350 to  360 ;
21 from 370 to 377, and one on the 394th day ; the extremes being 83 days.
With sows, the extremes were 15 days ; and with rabbits (out  of 139 cases)
7 days.
   [Recently, Earl Spencer has  communicated the results of his observations
for a  number of years on cows, to  the English Agricultural Society.1  Of
764 cases, 314 calved  before the 284th day, 310 after the  285th, and only
16 after  the 295th ; so  that the probable  period of gestation, he thinks,
ought to be considered 284 or 285 days.]
   232. In  conclusion, there  is  no doubt that the usual period of gestation
may be anticipated by at  least two months, without necessary injury or
death to the infant;  and it appears to me that the evidence we possess, as
well as the weight of authority, is in favor of occasional protracted gesta-
tion ; and  that, to use the words of Dr.  Montgomery,  I "cannot  imagine
why gestation should be the  only process, connected with reproduction, for
which a total exemption from any variation in its period, should be claimed."
   But on the other hand, it must be confessed that many of  the cases ad-
duced are valueless, because  founded on data which are necessarily uncer-
tain ; and I should be  unwilling to admit any as conclusive,  occurring in
persons exposed to frequent intercourse,  and calculated in  the  ordinary
manner.
   Dr. Clay, of Manchester,  has  recently published  some facts tending to
show that  the duration  of gestation  depends  much upon  the age of the
parents; that the younger the  parents, the shorter the pregnancy, and vice
versa, and this he conceives will  explain  the variations  that  have  been
observed.  In this calculation he takes the mean age of both parents, allow-
ing something either way for the earlier maturity of the mother.
                       CHAPTER  VII.

                             STERILITY.

  233. Haying thus completed the history of conception  and utero-gesta-
tion, we shall now consider certain  abnormal  deviations from the ordinary
course of  these functions;  and the first in order is sterility,  or inability to
conceive.
  The causes of this defect have been divided into functional and organic,

              1 [Journal of the Agricultural Society, part ii. 1839.] 
17 2
STERILITY.
into curable and incurable ;  into those  which cause sterility, properly so
called, and those which merely occasion impotence.   Without adopting any
special classification, I shall enumerate the organic and incurable cases first,
and then the curable,  whether  functional or organic;  and  adding other
causes, not included in either class.
   234.  The absence of the ovaries  will render the person  incurably sterile,
as will also  the absence of  one and  disease of the other,  or the disorganiza-
tion of  both.   Cases of this  kind are not infrequent.  Disease of the sub-
stance of the ovary may be extended to the  Graafian vesicles, or they may
be congenitally deficient, and so conception be prevented.   " The most fre-
quent variety of ovarian disease," says Dr. Davis, in  his Obstetric Medicine,
"which we  may suppose calculated  to produce this  effect,  is that of an ob-
viously  morbid enlargement of the  vesiculae  Graafianae, accompanied by a
degenerated structural condition of  their parietes."
   235.  The fallopian tubes  may be  congenitally deficient or imperforate,
though such  cases are  extremely  rare.  Their  canal  may be  obliterated
from acute  or chronic inflammation, or their fimbriated  extremities may
become  adherent to the ovaries.   Even  though  not imperforate, yet the
canal may be filled with adventitious matter.1  In all these cases, sterility is
the consequence, because the contact of the spermatozoa with the  ova is pre-
vented : and notwithstanding the daring proposal of Dr. Tyler Smith, I fear
it must still be classed among the incurable causes.   Dr. Tilt considers sub-
acute inflammation of the ovaries and fallopian tubes as a curable cause of
sterility.2
   [According to Dr. Tilt, the manner in which subacute ovaritis  becomes a
cause of sterility is by the production —
   1. Of morbid lesions of the stroma, or of the vesicles of  the ovula therein
contained.
   2. Of a false membranous deposit  lining the ovaries, so as to preclude
the exit of the ovula.
   3. Of lesions in the tubes destined to convey the  ovula to  their uterine
abode.   He likewise stated that sterility was sometimes  produced by the
uterine extremities of these tubes being blocked  up by a glutinous deposit.
   Dr. Tilt has  given the history of three cases in which the diagnosis of the
disease  was  fully confirmed,  by  an  accurate examination of the patient
through  the rectum, and  the treatment recommended  caused  a cessation
of the sterility after it had lasted five, six, and seven years.   The remedial
measures  prescribed were, leeches, to  diminish the chronic ovarian conges-
tion ; blisters, to break the  chain of  morbid nervous action, fostered by long
habits of suffering; mercurial ointment, combined with narcotic extracts and
camphor, to reduce pain and vascular action ; medicated enemata were also
administered with the same intention.3]
   236.  The uterus may be absent, of which numerous cases are recorded;
or it may be undeveloped,  which  Dr. Yanoni  considers a cause of sterility.
If present, its cavity may be partially or wholly  obliterated, as was noticed
by Morgagni, Baillie, and Mott;  these cases are of  course incurable.  The
canal of the cervix may be  impervious, or its mouth covered by membrane,
as in many cases  on record ; but though sterility results so long as it con-
tinues, it is within reach of  treatment, and may be cured by puncturing.
   Diseases  of  the uterus, such as  carcinoma, polypus, prolapsus, etc., are
enumerated  among the causes of sterility, but erroneously, I think.  Madame

  i Lancet. May 19th, 1849.
  2 London Journal of Medicine, vol. i. p.  1166.
  3 [The views of Dr.  Tilt on this  subject  are fully developed, and illustrated by an ex-
tended series of observations, in his treatise on "Diseases of  Menstruation,  and Ovarian
Inflammation, in connection with Sterility, Pelvic Tumors, and Affections of the Womb."] 
STERILITY.
173
Lachapelle, Dr. Davis, Dr. Oldham, and  others, have related cases of con-
ception and delivery,  notwithstanding the  existence of  scirrhus and  even
open cancer.
  M.  Chopart  mentions a case of complete  prolapse, which proved no bar
either  to  intercourse  or conception.   Many cases of polypus discovered
during labor, or causing abortion, have been met with; several have occurred
to myself.
  Inversion of course involves sterility; and  the same may be said when the
cavity  of the uterus is occupied by fluid or solid  matters, and the os  uteri
closed, as in physometra, hydrometra, moles, etc.,  but  these belong to the
curable causes.   I have seen a case in which the uterus was  bound down to
the left side of  the pelvis in consequence  of  a pelvic abscess which followed
her first confinement.   She has since been  sterile, and I think that is the
cause.
  237.  The  vagina  may be absent, imperforate, or partially  adherent,
Some of these cases are curable by careful incision  and  separation, as in Dr.
Physic's and M. Amussat's cases.1  Again, it may  be the seat of callosities,
cicatrices, tumors, etc., and by them be partially  closed, offering an obstruc-
tion to copulation ; but they, also, may generally be relieved by an opera-
tion.   Extreme narrowness of the canal  is  seldom the cause of impotence,
as it is generally overcome ; but extreme shortness is  considered  as  occa-
sionally an incurable  cause, though I rather think  without sufficient reason,
as,  though short, it may not be sexually  disproportionate.   Closure of the
orifice of the vagina  by membrane is  an effectual impediment  to  coition,
and, until removed, to conception ; but partial closure may admit of concep-
tion.   I have attended three ladies in their confinement, in whom the hymen
was perfect, the perforation barely admitting the tip of my  finger, and the
membrane was  strong enough to  resist the  pressure of the  head for a con-
siderable time.
  238.  Functional derangements do not necessarily produce more than  tem-
porary sterility.  I have  seen patients conceive  with very scanty menstrua-
tion, and I have  known them conceive when both  sexual desire and grati-
fication were wanting ; but as yet I have never  known patients other than
sterile in  whom sexual  desire is  absent  and menstruation deficient.   The
variety of dysmenorrhcea in which lymph is secreted, is considered by Denman
and others to preclude conception; this, however, is not universally the  case,
and the disease in many cases is curable.
   Congestion, erosion or ulceration of the cervix uteri, uterine leucorrhcea
when  excessive, and   perhaps vaginal  leucorrhcea, may also  be  included
among the curable causes of  sterility.  The same result obtains tempora-
rily, in  cases of irritable uterus,  and some  diseases of other organs.   Mr.
Whitehead has lately suggested that the uterine  mucus, instead  of being
alkaline, as  in  its healthy state, may be rendered acid  by certain affections
of the  uterus; and as the researches of M. Donne  have shown that sperma-
tozoa lose their vitality sooner in  acid mucus, it  may be a frequent cause of
sterility.2
   Unsuitable  marriages,  whether as to  disparity of  age or constitution,
often  prove unfruitful:  cases are on  record of  parties who together  were
sterile, being both fruitful with other individuals.  Excessive sexual indul-
gence often defeats its object.
  239.  I have  thus cursorily noticed most, if not all, the appreciable causes
of impotence and sterility in the female.
  There is, however,  a considerable class of unfruitful marriages of which

     1  Gream: Lancet, 1849. vol.  i. pp. 91-204. Churchill's Diseases of Women.
     2 On Abortion and Sterility, p. 406. 
174
PSEU DO- PREGNANCY.
no explanation can be given ; we can only conjecture that the ovaries or
fallopian tubes are defective, or that some sexual incompatibility exists.
  The uterus and vagina are within reach of an examination, and their con-
dition can be  minutely ascertained by means  of the finger, the  speculum,
and bougies.
                       CHAPTER VIII.

        SPURIOUS  PREGNANCY — PSEUDO-PREGNANCY.

  240. It may not be unprofitable hereto say a few words upon that curious
and obscure disease which  has received the  above  names, and which Dr.
Simpson has proposed to call " pseudo-cyesis."
  Isolated cases of the disease have probably occurred to  most men in ex-
tensive practice, and numbers of them have  been recorded by  ancient and
modern writers, but the  most, if not the only, complete  monograph on the
subject is a lecture by Professor Simpson,1 and I think  he  will  forgive the
ample use I must make of it in this chapter.
  241. The phenomena of the disease  have  essentially an hysterical cha-
racter ;  there is almost always some derangement of the menstrual function,
with certain reflex irritations, and a swollen state of the abdomen.
  242. Cases of this  kind occur in females of  all ages.   Dr. O'Ferrall has
recorded one in a girl set. thirteen.  I have seen one in another aet. seventeen.
Dr. Simpson thinks the complaint  as  frequent  during  the first year after
marriage as at any other time.   I have seen it in a woman who had borne
several children, and Dr. Montgomery thinks it most frequent at the climac-
teric period.   From the undoubted  fact  of unmarried females  being liable
to the disease, it is clear that its recognition is important, not merely for the
purpose of cure, but to  avoid the injurious suspicions to which the patient
would otherwise be exposed.
  243. Symptoms.—I have already mentioned that the  abdomen is swollen
in various degrees, but rarely, I think, to a very extreme degree.  It feels
firm and  elastic, and  as a general rule yields a clear resonance on percus-
sion.   This is  not  always the  case, however;  for in one case 1 saw, the
upper part of the tumor was  rather dull, whilst the lower was quite clear,
without our being able to explain the difference.   The abdomen  is generally
equably swollen, but protruding more anteriorly.  In women who  have not
borne  children the  lumbar  region  bulges, and  is resonant,  but when the
patient has been pregnant, the tumefaction may  assume the exact form of
the pregnant uterus, as in a case I saw, where it  filled the mould, as it were,
left by former pregnancies.
  The catamenia. are  generally deranged, scanty, irregular, or,  perhaps, al-
together suppressed, and as  the breasts very  commonly  sympathize and en-
large, and the stomach exhibits some reflex  disorder, we can easily excuse
in an ordinary person the suspicion  of the existence of pregnancy.
  244. Now, if the person be unmarried, and of a questionable character,
it is more than probable that in the estimation of her friends, her character
will soon cease to be questionable.  If she be married, pregnancy will pro-

              1 Med. Times and Gazette, Sept. 3, 10,  and 17, 1859. 
PSEU DO-PREGNANCY.
175
bably be taken for granted, and the mistake only detected when labor ought
to occur, or when, curious to say, some sort of abortive imitation of labor
does take place.   The mistake is even more likely to occur in women " of a
certain age," as  they seem rather easily persuaded of an event so  creditable
to their virility,  and of this nature are probably all the stories current of
ladies deceiving  themselves  and their friends.   The difficulty is  somewhat
increased at this period of life by a not unusual increase of fat giving to the
enlargement a more resisting feel and a duller resonance.   Having decided
in favor of pregnancy, from the  assemblage of the foregoing phenomena,
the patient finds confirmation  strong in  certain sensations which  she  sup-
poses to be fcetal  movements, but which, when  questioned, she admits are
not exactly the same as in former pregnancies.   And the difficulty of diag-
nosis is much increased,  as  Dr.  Simpson  has  remarked, by a repetition of
individual peculiarities which occurred in  former pregnancies ; as, for ex-
ample, peculiar  discolorations  of the skin, or eruptions, or  neuralgias,  or
changes of temper.
   Nevertheless it should  be remembered  that  there is  generally some irre-
gularity or defect in the  sequence, or grouping,  or character of these symp-
toms which distinguishes spurious from  true  pregnancy when minutely in-
vestigated, and it is upon this mainly that our diagnosis will depend.
   245.  As to the  course of the  disease, it will  vary.   The symptoms may
disappear after a few weeks or months, or they may continue for  about the
usual term of pregnancy, and then  disappear.  Or in some  few cases the
enlargement and its train  of symptoms  may  go on for twelve or eighteen
months, or for some years.
   246.  Diagnosis.—Dr.  Simpson has truly observed that  "however closely
all the  ordinary symptoms of real pregnancy may be represented  and simu-
lated in the  spurious  affection, and however  minutely even the  individual
idiosyncracies sometimes seen in the  former may be imitated  in the latter,
there is usually some deviation from  the ordinary course of events and some
difference in the  order  and correspondence  of the ordinary  phenomena,
which may serve to put you on your guard, and lead to the discovery of the
true state of affairs."  The symptoms of early pregnancy may be  simulated,
but all those of  a later period cannot.  Suppression of menstruation, sick-
ness of stomach, and  increase of the breasts and abdomen, may be present,
but they may not  have the  usual  completeness or sequence.  Enlargement
of the uterus, diminution of its neck, the placental  bruit and  the  sounds of
the fcetal heart will not, and their absence at a (supposed) period  when they
ought to be present, will  in competent hands be conclusive.
   247.  If the abdomen be pressed between the two hands placed at its sides,
we can at once detect that there is no such solid body as the  gravid  uterus
present; and if to this we add careful percussion, we shall be satisfied that
the distension is neither by solid nor fluid.  An examination per vaginam
will reveal to us  the cervix, and  as far as we can reach it, the body, of its
normal size when unimpregnated ; with the usual mobility and with an entire
absence of direct shock when the abdomen is lightly struck.
   The only difficulty in coming to a conclusion will be when the  uterus  is
coincidently retroverted or enlarged by fibroid or other growths, or in case
of an ovarian tumor.
   248. Auscultation affords only negative evidence,  of course ;  but in prac-
tised hands even this is of great value at a (supposed) advanced period.  I
need hardly say that on this point we should not trust to one or even two
examinations.
   249. But perhaps the best aid we  have in our diagnosis is in  the effects
of anaesthetics.   Bring the patient fully under the influence of chloroform ;
carefully and cautiously at first, but completely at last, and Ave may observe 
176
PSEUDO-PREGNANCY.
the abdomen relax in its tension, flatten, and finally subside ;  thus giving us
an opportunity to  ascertain the exact condition of the  abdominal organs.
Wait a little, and as the effect of the chloroform goes off, the abdomen will
rise gradually until it attains its previous size.
   Taken altogether, the evidence thus obtained will hardly fail to be con-
clusive.
   250. Pathology. —There may or may not be any uterine or ovarian dis-
ease.   Some degree of congestion or erosion is not uncommon ; with ante-
version or retroversion it may be, but it is clear that these do  not  form an
essential part of the disease.  Dr. Simpson thinks that "the aggregate of
symptoms wdiich we class tinder the designation of  'spurious pregnancy' in
women, is in some way or other dependent upon the changes which occur in
the ovaries and in  the  uterus at the period  of menstruation."   I think  this
very likely, but as  yet  it is  only a brilliant suggestion to be tested by minute
investigation.
   251. But what is the  enlargement ?   Is  it  simply a gaseous distension ?
Apparently not, for in some  cases Dr. Simpson introduced a tube  into the
rectum, and placed the free end in water, whilst the  abdomen subsided under
the influence of chloroform, but not a bubble  of air escaped.  He believes
that "the phenomenon most probably depends  on some affection of the dia-
phragm, which is thrown into a state of  contraction, and pushes the bowels
downwards into the abdominal cavity."   Although  I have no  better expla-
nation to give, I confess myself far from satisfied with this.
   252. Treatment.—There are three things to be borne in mind in the treat-
ment of this affection : 1st,  that the  general health is more or less disturbed ;
2d, that  the menstrual function is  incomplete  ; and 3d, that  there may be
some special local disease.   Whatever the  latter be, it  is of  course to be
specially treated, and removed if possible, concurrently with which an effort
should be made to improve the general health.   I have no doubt that if we
succeed  in  restoring the  regularity of the  catamenia, we shall find that a
great step will be gained;  but it may be a question whether we should im-
mediately have recourse to emmenagogues.   It may be first  desirable, as
Dr.  Simpson  advises,  to endeavor to allay the irritable condition of the
uterus and ovaries; and for this purpose he recommends the  bromide and
iodide of potassium.   Five or six grains of the former may be  given three
times a day, either alone or with  from two  to three grains of the iodide of
potassium.  Or it may be applied locally in  the form of a pessary.   Further,
carbonic acid gas,  with or without  chloroform, may be thrown  into the
vagina.  Such soothing remedies Dr. Simpson has found very beneficial.
   For the nausea and  vomiting we may have recourse to  any of the  remedies
usually recommended.   Opium, acetate of lead, prussic  acid, carbonic acid,
ice, creosote, or perchloride of iron or  oxalate of j3eriuin, as recommended
by Dr. Simpson.
   As far as the distension  may be due to flatulence, we  may seek  relief by
assafoetida, ox gall, turpentine, the  valerianates, powdered charcoal, etc.
   The bowels should be kept free by effective  but  mild purgatives, and the
diet bland and nourishing. 
SUPERFCETATION.
177
                        CHAPTER  IX.


                          SUPERFCETATION.


  253. The term Superfcetation has been applied to those cases of abnormal
conception in which a female  already pregnant  has  been  supposed to con-
ceive a second time before the termination of the first gestation.  The belief
in the possibility of such an occurrence is universal among the older writers,
and cases are adduced in  support of this view, but modern writers have been
more  divided  in  opinion ;  it is denied by  Hebenstreit, Ludwig, Nutger,
Schmidtmiiller, Blumenbach,  Beck, etc.  ; but admitted by  Haller, Hervey,
Ploucquet, Barzelotti, Velpeau, Cuming, etc.
  254. The cases alluded to are such as the  following: — 1.  It is not un-
common for women  to be delivered  of a full-grown  child and a blighted
ovum at the same  time, and from the disparity between  them it  has been
assumed that the  period of conception was different for each.
  2. Again, a woman may be delivered of two living children at one birth,
or within a few hours of  each other, one of which may be  fully developed,
while the other appears immature.
  3. Further, the same woman  has given birth to twins, of different color,
as in the case related by Buffon, and quoted by Fodere and all recent writers
on  the  subject, of a  woman  at Charleston, South  Carolina,  who was de-
livered in 1714  of twins, within a very short  time  of each other, the one
being black, the other white.   On examination, the woman confessed that
on a certain day, immediately after her husband had left her, a  negro en-
tered her room, and by threatening to murder her in  case of refusal, obtained
connection with her.
  Dr. Moseley mentions  a similar case : — "A negro woman  brought forth
two children at a birth, both  of a size, one of which was a negro, the other
a mulatto.   On  being interrogated upon the  cause of their  dissimilitude,
she said she perfectly well knew the cause  of it, which was, that a white
man belonging to the estate came  to her hut one  morning before she was
up, and she  suffered his  embraces almost  instantly after her black husband
had quitted her."1  Cases of the same kind have been published  by M. de
Bouillon, Drs. Dewees, Trotti, Guerarde, Delmas, Dunglison,  etc.
  4. Lastly, cases have  occurred where the birth  of a mature  child was
succeeded, after the lapse of some months, by the birth of another.  Seve-
ral such cases  might be cited.   In  the Recueil  de la  Societe d'Emulation,
there is one  of  M. A. Bigaud, of Strasburg,  aged thirtyT-seven,  who was
delivered of a lively child on the 30th of April.   The lochia and  milk were
soon suppressed.   On the 17th of September of the same year (i. e., about
four and a half months after the first delivery)  she  brought forth a second
apparently  mature and  healthy child.  On the  death  of  the woman the
uterus was found  to be single.
  In the case related by Desgranges, of Lyons, the woman was  delivered
on the 20th of January, 1780, of a  seven months child ; and on  July 6th,
1780, five months and sixteen days after the  former birth, she  gave birth to
a second, which had apparently reached its full time.
  The late  Dr. Matou published a similar case in vol iv. of  the Trans, of
1 On Tropical Diseases, p. 111. 
178
SUPERFCETATION.
the College of Physicians, London.   Mrs.  T., an Italian lady, but  married
to an Englishman,'was delivered of a male child at Palermo, November 12,
1807.  On the 2d of February,  1808, not quite three calendar months after
the preceding accouchement,  she was delivered of a second male infant.
Dr. Maton assured  Dr.  Paris  that "both the children were born perfect;
the first,  therefore, could not have been a six-months child."  Other cases
may be found quoted by Beck, Yelpeau, and Cuming, and collected in  the
elaborate essay of Dr. Alexander Henry.1
   255. Upon the strength  of  these  cases,  it is  assumed that a second  im-
pregnation may  be  effected, although the uterus be  occupied by the results
of a previous conception.  Our  first object is, therefore, to ascertain  how
far the cases, considered in themselves, warrant such a conclusion, and then
whether, if the cases are not otherwise explicable, we are bound  to adopt
this theory as the true explanation.   First, then, I would observe that  the
first and  second  class of cases can  be easily  explained without having re-
course to the doctrine of superfcetation at  all.   When twins are conceived
from  the one intercourse, it  not unfrequently  happens that one  ovum is
blighted, and sometimes rejected, sometimes retained, and  occasionally the
appearance of the ovum, when subsequently expelled, will  be found to cor-
respond  to the period of pregnancy at which  symptoms  of uterine disturb-
ance  and threatened abortion appeared.   Again, nothing is more  common
in twin pregnancy than to find  one more  fully grown  than the other,  and
nothing  more easily explained.   So that neither of these cases are any sup-
port  to  the  doctrine, because  they  are susceptible of another and more
simple explanation.
   The third class, where children of different colors are  brought forth, is
equally unavailable ;  for, at the utmost,  they only prove that a double con-
ception may occur from connection with  two individuals, if  such intercourse
take  place with  a very short interval.   If  such  cases occurred with an in-
terval of four or five months between the birth  of the children, the case
would be altered ; but I am not aware of any such on record.
   It must be confessed  that the  fourth class  of  cases is very difficult of ex-
planation, and they are the only ones of any force in support of the theory.
It has been supposed, that in such cases both children were begotten at the
same moment, but that the tardy birth of the latter was owing to  its slower
development:  but this explanation requires  previous  proof that a  slow
growth of the fcetus involves a protracted  gestation.
   Another explanation has been proposed, based  on the fact, that when
pregnancy has  occurred with a double uterus, one cornu only is  occupied by
the child.  It may in such cases be possible (so it is argued) for the woman
to conceive a second time,  and the child to  occupy the vacant cornu, although
the woman were previously pregnant;  and in support of  this view, a case
 is adduced which occurred to Mad.  Boivin, and which is related in M.  Cas-
 san's thesis, On Double Uterus and Superfcetation : " On the 15th  of March,
 1810, a  woman, aged forty, gave birth  to a female infant, weighing about
 four  pounds.  As the abdomen  still remained bulky, Madame Boivin intro-
 duced her hand, but could find nothing in  the uterus.  But the examination
 led her to suspect that there was another fcetus, either extra-uterine, or  con-
 tained in a second  cavity in the womb.  At length  on  the 12th of May, a
 second female infant was born, weighing not more than about three pounds,
 feeble, and scarcely able to respire.  The mother assured Madame Boivin
that she had no connection with her husband (from whom she had been some
time separated), except thrice in two months, viz., on the 15th  and 20th of
 July, 1809, and on the 16th of September following."  In this case there
1 London Med. Journal, 1849, p. 1087. 
SUPERFCETATION.
179
can be little doubt of the existence of a double uterus, and it would be diffi-
cult to disprove that the second child was not the fruit of the last concep-
tion, and, if so,  a clear case of superfcetation ; but, even granting so much,
it only proves the possibility of such an event when  the  uterus is double,
and it would not only be very bad logic  to assume that the uterus was double
in all  cases when two  children are  born  at considerable intervals;  but it
would be inconsistent with facts, for it is expressly stated that  in the case
of M. A.  Bigaud,  already quoted, the uterus was found, after her death, to
be single.
   256.  Thus, whilst we  need not deny that a double uterus may afford an
opportunity for  a  double conception, at  distant periods, we  cannot admit
one such case as explaining all the cases of that kind on record ; and with
respect to such, we  have made no advance towards  an explanation.  Ad-
mitting this, are we necessarily to  adopt the hypothesis of superfcetation ?
I think not, because the real difficulties  of such a theory appear  insurmount-
able ; and if so, our ignorance of the true explanation is no argument for
the adoption of a false one.   The  physical  difficulties are those which
depend on the changes induced by impregnation.   The reader will find that
it was  stated (§ 160)  that,  shortly after conception,  the uterus is lined by
the deciduous membrane, a  shut sac, closely adherent to the lining mem-
brane of the uterus throughout,  and covering the orifices of the  os uteri  and
of the fallopian tubes; that the canal  of the cervix  uteri is, during preg-
nancy, plugged  with tenacious mucus secreted  by the glands.   Now if this
be the case, and if it be an essential condition of generation (§ 143) that the
spermatozoa pass into the uterus, if not  through the fallopian  tubes to  the
ovaries, it is evident that the theory of superfcetation involves so much appa-
rent  physical impossibility,  that it must be rejected,  unless it can be shown
how  the spermatozoa can obtain access to the ovaries when the  uterus is (as
it were) hermetically closed.
   Another view has been latterly put forth by Dr. J. M. Duncan, which, if
true, would  help  us  to  a  solution of the difficulty.  He states that  the
decidua reflexa  is not in contact with the decidua vera till after the third
month, and  that up to that  time there may be free communication between
 the ovary and vagina, and consequent  liability to  a  second impregnation.1
 Additional evidence, however, would be necessary to establish this opinion,
and until we possess it, I must honestly confess that I have no better expla-
nation to offer of  such cases as  Dr.  Maton's ; but surely it is more philoso-
phical to  acknowledge  our ignorance, and patiently to wait for additional
information, than,  in  our impatience in a  state of uncertainty, to adopt a
theory  involving such  difficulties.
   257.  In conclusion,  I  would say, 1.  That the theory of superfcetation is
unnecessary to explain the birth of a mature foetus and blighted ovum ;  of
 a mature and immature fcetus, born together  or  within a month  of each
other ;  or of fcetuses of different colors, as they may reasonably  be supposed
to be the  product of one act of generation, or of two, nearly contempora-
neous.   2.  That in cases of double uterus, it is possible  for a second con-
ception to take  place,  and (judging from the subsequent birth of the second
child, in  the only  case on record) at a  later period than the first.   3. That
in the remaining cases, where one mature child succeeded the birth of another
after a considerable  interval, we have no proof of a double uterus  in  any,
and positive proof that in one case it was single, and  that to the explanation
of these cases, no theory as  yet advanced is adequate  ; that of superfcetation
being opposed  by physical difficulties, which, are  insurmountable in  the
present state of our knowledge.
1 Edin. Monthly Journal, April, 1853. 
180
EXTRA-UTERINE  PREGNANCY.
  [Notwithstanding this  positive assertion of  Dr. Churchill, we have  on
record well-authenticated cases of superfcetation, in which it has been shown
that the uterus  possessed  but a single  cavity.    Simpson, Duncan,  Tyler
Smith, and others deny that there is anything to prevent fecundation  in the
condition of the pregnant uterus, during the  early  period  of gestation.
The mucous  plug has been shown by Dr. Tyler Smith to be in no respect
different, except in quantity, from the mucus wdiich always occupies the cer-
vical canal of the uterus in the unimpregnated state, and through which the
spermatozoa make their way  in  ordinary fecundation.   The  cervical  plug
therefore presents no insurmountable impediment to the occurrence of super-
fcetation.   Neither does any obstacle occur to the passage of a second ovum
into the cavity of the uterus  when already occupied by one ;  inasmuch as
neither of the layers  of the decidua  in  the first month of pregnancy pass
over the orifices of the fallopian tubes nor the uterine orifice of the cervical
canal.   Until the end of the  third month the  ovum  with  its envelopes is
attached to  a small portion only of one of the parietes of the uterus, leaving
every other portion of the decidua vera  perfectly free for the  reception and
development of a second ovum.   " The infrequency of superfcetation," as
well remarked  by Dr. Tyler Smith, " probably depends  more upon the
absence  of  perfect ovulation  during  pregnancy than upon  any  positive
mechanical impediment to the ascent of  the spermatozoa, or the incapacity
of the decidua vera to receive a second ovum."]
                          C HAPTE R  X.

                  EXTRA-UTERINE  PREGNANCY.
                                          •

   258.  From certain causes, with which we are but partially acquainted, it
sometimes  happens that the ovum, instead of passing into the fimbriated
extremity of the fallopian tube on the bursting of the Graafian vesicle, and
being thence  transferred into  the uterine  cavity,  in the gradual manner
already described, is arrested in some part of its progress, where an effort is
made to supply  the place of the uterus, and afford space and  nutrition for
the fcetus.   This, however, can only be  partially successful, and the fcetus
ultimately  perishes for want of nourishment.   To  this misplaced gestation
various names have  been given — " Extra-uterine pregnancy," " Conceptio
vitiosa," "  Grossesse contre nature," " Exfoetation," etc., etc.   ''
   This  abnormal  deviation from  ordinary  gestation was known,  but not
minutely, to  the ancients.   Albucasis relates a  case of fcetal bones being
extracted from an abscess, which had formed near the umbilicus, and similar
examples were recorded  by  Cornac, F. Plater, Cordaeus, Horstius, Primrose,
Hildanus,  Riolan, jun.,  etc.   In  more  modern  times very  numerous  and
well-authenticated cases  have been published, and  have been carefully col-
lected and  referred to by Dr. Campbell in his learned essay on this subject,
to which I  have been principally indebted for this  chapter;  and if I need
any excuse for the freedom  with which I  have availed myself of his labors,
it  must be found  in  the fact that his assiduity  in collecting, jtnd care in
referring to the numerous cases on record, as well as the  accuracy of his 
EXTRA-UTERINE  PREGNANCY.
181
reasoning and  the  excellence of his practical recommendations,  have left
little or nothing for me to do but to follow in his steps.
  259. All  the varieties of extra-uterine pregnancy may be  reduced to
three : —
  1. Ovarian fcetation, when the ovum is detained in the ovary;  2. Tubular
fcetation,  when the fallopian tube is the seat of the  arrest;  and, 3. Inter-
stitial fcetation, when the ovum enters the  parietes of the uterus, but is de-
tained in an interspace of the fibres before it arrives in the uterine cavity.
  Dr. Campbell has added another variety, which he calls  the ovario-tubal,
a compound of the two first, when  the sac containing the  fcetus is  formed
by the ovary and fallopian  tube jointly.   A fifth species, ventral fcetation,
is enumerated by most authors, where the  ovum is found in the  abdominal
cavity ;  but I think Dr.  Campbell is right  in supposing  such  cases to have
originally belonged to one  or  other variety previously mentioned, and for
which a separate section is scarcely necessary.
  A brief notice of each variety, with the details of a case or two, will be
necessary before considering the symptoms and termination, etc.  For refer-
ence to cases, I beg to refer the reader to Dr. Campbell's book.
  260. 1. Ovarian Fcetation. — By some writers  the existence  of this
species  of extra-uterine gestation  is considered  as rather  doubtful,  on
account of the facility afforded  for the escape of the ovum  after the rupture
of the Graafian vesicle, but the  evidence of facts is too strong to be resisted.
  The earliest example on record is to be found in the Philos.  Trans., vol.
ii.,  p. 650, communicated by the Abbe de la  Roque.  It occurred in 1682:
the right ovary was enlarged  to the size of a hen's egg,  and  lacerated
through its whole length.  The fcetus was found in the abdominal cavity, in
the midst  of a large quantity of blood.
  The following instance  I quote  from  Dr. Campbell; it occurred in the
practice  of  Dr. Granville,  and, from his high character, no  doubt  can be
entertained of its accuracy.  " The subject  of the case was  a lady,  aged
thirty-nine, the mother of seven children.   Until Dec. 1818, when she con-
ceived, the catamenia  were regular;  and from this period  till June  9th,
1829, the time of her decease, she experienced various and  severe sufferings,
ar.d there were occasional  discharges of  a colorless fluid 'per vaginam.'
After death a considerable tumor, soft and movable, was  perceived imme-
diately above  the pubes, and rather  to the left of the linea alba.   On re-
flecting  the abdominal parietes, blood  to the amount of several  pounds was
observed to  fill every space which  the viscera did not occupy.   The tumor
alluded to was  about four times  the size of a hen's egg, and displayed the
same general black-reddish hue of all the ambient parts.  A bloodvessel, the
size of a large crow-quill, which penetrated the dense portion  of the tumor,
was traced upwards  to the descending aorta, and was  ascertained to be a
branch of the left spermatic.   A.  smaller and much  shorter vessel  arising
from the tumor, was  also found to  communicate  with  the spermatic  vein,
thus establishing a complete circulation to and from the parts.   The  inferior
and left  half  of the tumor  presented a surface, consisting  at  two or three
points of  diaphanous  membranes,  through  which a  fcetus of about four
months'  growth was  readily discovered.  The left ovarium was  the  seat of
the  tumor, which, as it gradually enlarged, distended the tunics of that organ
in the same progressive manner, in a ratio with its own size.  As the fcetus,
however, increased further,  the ovarium burst in three places;  and thus the
membranous sac forming the tumor partially protruded  into the abdominal
cavity.   During this destructive process, that part of the parietes of the
ovarium to which the placenta was attached was also lacerated, so as to tear
the  adhesion of the mass, thereby producing  sudden  and fatal hemorrhage
The right  ovary was sound." 
182
E X T R A - U T E R1 N E  PREGNANCY.
  261. 2. Tubal Fcetation.—When the  arrest of the progress of the
embryo takes place at the fimbriated extremity of the fallopian tube, we fre-
quently find that  the ovary forms part of the walls of the cyst in which the
fcetus is contained, though it is not always easy to point out the exact locality

                                 Fig. 80.
Tubal Foetation.
of the arrest.  "In some instances," says Dr. Campbell,  "it maybe pre-
sumed that in the incipient stages of gestation, the ovulum is connected with
only one of these appendages, either  the  ovary or the tube ;  and that the
second organ, whether ovary or tube, becomes involved merely in consequence
of its state of activity, its progressive enlargement, and the pressure exerted
by the ovum,  together with the consequent morbid excitement."  Such cases
constitute the " ovaria-tubal gestation" of this author, and to this class  he
conceives to belong those which have been  recorded as  examples of " ven-
tral-fcetation."
  262.  But of all the varieties of extra-uterine gestation, that where the
embryo is contained in the tube itself is  the most frequent.  Riolan pub-
lished the first well-attested example, and he was followed by Littre, Sancto-
rinus, Poteau, etc.,  etc.  The following example is taken from the Transac-
tions of a Society for the Improvement of Medical and Surgical Knowledge,
vol.  i. p. 216  : "A married woman  in her  second pregnancy, in consequence
of a bilious complaint to which she had  formerly been  subject, used some
remedies she had been wont to employ,  and also a warm bath.  She had
been obstructed but one period, and paid  so little attention to this circum-
stance, that she did  not make  it  known, either to  her husband or to the
ordinary medical  attendant.  On May 13th, 1791, the morning  subsequent
to her having used the bath, she was suddenly seized, without any previous
exertion, wdth a violent pain in the  lower  part of the abdomen, followed  by
syncope, from which she soon recovered.  A moderate bleeding and an opiate
diminished, but did not  entirely subdue, the pain, which now attacked the
loins as well as the  abdomen, and recurred in violent paroxysms, accompa-
nied by vomiting, yawning, and fainting.   On  the 16th  she was somewhat
easier;  but towards evening there was  an aggravation of her sufferings,
accompanied  by cold  sweats, coldness  of  the lower  extremities,  interrupted
articulation, great restlessness, with want  of pulsation at the wrist, and she
expired.  Autopsy. — Nearly a gallon  of  blood was  found effused into the
abdominal cavity;  a laceration  of  an  inch  and a half in length about the
middle of the right fallopian tube ;  an embryo of the sixth or seventh week
in the blood; the uterus lined  with  decidua, and its cavity filled  up with
gelatinous matter."
  I  cannot but  notice in this  place  two cases published by Dr. R.  Lee,1
1 Med. Gazette, vol. xsvi. p. 436. 
EXTRA-UTERINE  PREGNANCY.
183
because of the peculiarity of the situation of the membrana decidua :—"A
lady died suddenly, in 1829, from internal hemorrhage, produced by rupture
of the right fallopian tube, which contained an ovum.  On opening the tube,
and  examining the different parts of the ovum, I found a deciduous mem-
brane everywhere surrounding the  chorion, and closely adhering to the inner
surface of the tube, as the decidua usually does  to the lining membrane  of
the uterus in ordinary gestation.   Within the decidua the chorion, placenta,
amnion, and  embryo were distinctly seen."   Again, "on the 18th of July,
1836, Mrs. K----, after suffering some time with symptoms of inflammation
and  retroversion  of the uterus, was seized  with great faintness, and  soon
expired. A large quantity of fluid blood  was found in the abdominal cavity,
and  the right fallopian tube was extensively lacerated  near  its  fimbriated
extremity.   On removing the uterus and its appendages  from the body, and
carefully examining the  ovum  contained  in the right fallopian tube, it was
evident that a deciduous membrane everywhere surrounded the chorion, and
adhered to the inner surface of the tube.  The uterus  was considerably en-
larged,  and its inner surface was coated with a very thick layer of yellowish-
white soft  substance, like common adipose matter,  and bearing no resem-
blance to the deciduous membrane.  There  was  no trace of any arterial or
venous canal in this coating."
   263.  3. Interstitial Fcetation.—This form is the rarest of the three or
five ; but the following case leaves not a  doubt of its existence.  It occurred
in the practice of the late Mr. Hey, of Leeds, and by him was communicated
to Dr. W.  Hunter.  " The patient, aged thirty-five, of  a healthy constitu-
tion, was seized, when two months advanced in  her second gestation, with
pains resembling colic, which were subdued by appropriate remedies; but in
the  sixth month  they returned with much  greater violence, and were  more
diffused than formerly."  They  were repeatedly alleviated, but as frequently
returned.  When the term  of gestation  was completed, the movements  of
the child ceased.   Pains came on, but with  little effect, and vomiting, which
produced great emaciation, and ultimately  proved fatal.  "Dissection ex-
hibited adhesions between the omentum,  intestines, peritoneum, and  a large
peculiar sac, which occupied nearly the whole abdominal cavity.  Besides a
well-formed fcetus, free from any mark of decomposition,  the cyst, which was
a line and a  half in  thickness, contained a quantity  of chocolate-colored
fluid, and some purulent-looking matter.  The  umbilical cord passed  from
the fcetus through a narrow aperture into a  cavity whose walls were  an inch
and a half  in thickness, but of much smaller dimensions than that which
contained the fcetus.  This smaller cyst,  which must have been the uterus,
contained a placenta of a size so unusual that it filled three-fourths of the
cavity of the organ ;  both together weighed two  pounds and a half avoir-
dupois.  No  trace of  cicatrix could be detected in  the uterine parietes.
The membrane of the ovum, after lining  the uterine  cavity,  was  reflected to
form the inner lining of the cyst which lodged the foetus."
   264.  Causes.—After the instances I have quoted in illustration  of each
variety, we may now proceed to  inquire  as to  the  causes  of extra-uterine
gestation, which,  however, are by no means easy of discovery.   It is pos-
sible that either congenital malformation  or  pathological changes may retain
the fecundated germ in the  ovary, or prevent its entrance into the fallopian
tube, or arrest its  progress  after its entrance.   Narrowness or  obliteration
of the tube may effect this.
   [Velpeau  seems to  think that  occasionally too  great density, or preter-
natural thickness  of the covering of the ovule, or envelope of the ovary,
may detain the ovum and prevent  its entering the fallopian tube at the proper
time, and thus become  the  cause  of extra-uterine pregnancy; and likewise
various pathological conditions of the tube, as paralysis, spasm, excision, or 
1S4
EXTRA-UTERINE  PREGNANCY.
insufficient length, engorgement, contraction, or inflammation and ulceration
of its mucous membrane, etc.   Astruc believed that unmarried women were
more liable to this accident than others, and it is supposed to be caused by
fear or other strong mental emotions.  Two striking instances are mentioned
by  MM. Lallemand and Baudelocque, in  which it seemed to be  caused by
fright.    Dr.  Rigby very properly observes on  this subject, that "it  must
always remain a matter of great obscurity as to the immediate causes of
extra-uterine pregnancy, more especially of the ovarian and ventral species;
and the more so as we are still  ignorant of the mechanism by which the fim-
briated  extremity of the fallopian tube grasps the  ovary immediately over
the  impregnated vesicle of De Graef at the moment of  conception.  In
many cases we are inclined to believe that this function of the fallopian tube
is destroyed  by adhesion between it and  the  ovary, a circumstance  of not
uncommon occurrence ; but from the alteration in  the shape and size of
these parts, as also from extensive adhesions which  are usually found  after
death  in such cases,  it wall ever  be difficult,  and perhaps  impossible to
prove it,"]
  In addition, interstitial  fcetation has been attributed to narrowness of the
uterine  orifice of the  fallopian tube, or an unusually large  interspace be-
tween the fibres, or to a partially cornuated uterus.
  But these  causes, it is evident, are mainly conjectures.
  265.  Symptoms.—The symptoms vary a good deal.  So long as the part
in which the embryo is lodged  can  accommodate it, there may be but little
disturbance,  and nothing to afford grounds for a correct diagnosis. In other
cases, the local symptoms resemble those in disease  of the uterus or ovaries.
In  the greater number of cases, there is much  suffering from an early  period.
Certain of the signs of pregnancy may be present, but a degree of  irregu-
larity in their intensity will frequently be observed.   Thus, the  catamenia
may be present or absent, and,  if present, either scanty or profuse ; and not
seldom there is hemorrhage, or a discharge of clots, which have been mis-
taken for portions of the placenta.   The  mammary sympathies are excited
in most cases, and the changes in the areola take  place.  The patient may
or may  not suffer from nausea  or vomiting, and  in  some cases at an early
period the fcetal movements have been felt by  the  patient.   The increase
of the  abdomen generally differs from that in  ordinary pregnancy, being
more to  one  side, and the  pain or uneasiness may be limited to the spot
where  the tumor is felt.  M. Chaussier lays  great  stress upon a sense of
weight and uneasiness, deeply seated in the pelvis, and occasionally extend-
ing to the kidneys.
  An examination per vaginam reveals a great  deviation from the state of
the organs in ordinary gestation.  The os uteri may be high or depressed,
but it is  very seldom drawn out or dilated;  in fact, it is generally as it was
before impregnation, or nearly  so.
  266.  When the cyst in  wdiich the ovum is contained  bursts, however, a
series of new and alarming symptoms are superadded.   The patient  com-
plains of great uneasiness or pain suddenly occurring, languor, debility, and
exhaustion to an  extreme degree ;  there is  sometimes a sanguineous  dis-
charge from  the vagina, with dysuria, tenesmus, irritable stomach, etc. ; in
short, the patient exhibits the symptoms of collapse from loss of  blood.
  In tubal fcetation,  these symptoms generally come on more suddenly than
in the other varieties, so as at once to excite suspicion of a rupture of  some
internal organ having taken place.
  In interstitial foetation, the symptoms are a modification of those  in the
other varieties.  In some there are abdominal pains and sanguineous  dis-
charges,  in others these are absent; but in all the cases on record the tunie- 
EXTRA-UTERINE  PREGNANCY,
185
faction and fcetal movement were confined to one side  of the abdomen.  It
is also remarkable, that in all, the child appears to have lived to the term
of utero-gestation.
  267. I have already stated that matters may go on more or less quietly
for some time, not  without injury to the health of the mother, but without
danger to her life.   However, the crisis must come sooner or later,  when
the cyst gives way, and symptoms of collapse set in,  followed by those of
inflammation.   This crisis  may be hastened by various circumstances, such
as violent action  of the abdominal  muscles, and the  consequent pressure
upon  the tumor,  sudden shocks, or blows upon the  abdomen, coughing,
vomiting, etc.   The rupture  of the  cyst may be followed  shortly by fatal
results, owing to the shock to the system, the hemorrhage, subsequent in-
flammation,  or from one or more of these consequences combined.
   268.  But there  are many exceptions to such prompt terminations.   The
patient may survive the shock, hemorrhage, and subsequent inflammation,
and the parts may  accommodate themselves to the presence  of  the fcetus, so
that the patient shall recover a  certain amount of health, and suffer but
little local inconvenience ; nay, she may even again conceive and bear child-
ren ;  "nine  women conceived once during the retention of the  extra-uterine
fcetus; two  twice;  one three  times; one four times; one  six times; and
one seven times."
   The period during  which the fcetus  may be retained before the mother's
death or its own expulsion  varies  much.  Dr. Campbell gives the following
account  of  seventy-five cases; it was  retained  "three months in two in-
stances ;  four months in one ;  five months in one ; nine months in two ;  fif-
teen months in three ; sixteen months in two;  seventeen months  in  two ;
eighteen months in seven ;  one year in  five ;  two years in eight; three  years
in seven ; four years  in four; five years in  one;  six  years  in  two;  seven
years in three ; nine years  in one ; ten years in three ; eleven years in  two ;
thirteen years in one ;  fourteen years in two ; sixteen years in one ; twenty-
one years in one ; twenty-two years in one ; twenty-six  years in two ; twenty-
eight years in one  ; thirty-one years in  one; thirty-two years in one ; thirty-
three years in one ; thirty-five years in two ;  forty-eight years in one ;  fifty
years in one; fifty-two years in one ; fifty-five in one ;  and fifty-six years in
one case."
   Professor Dyce,  of Aberdeen, has favored me with a  case  in which the
fcetus was retained in the abdomen eight years : the patient was twice  preg-
nant afterwards, and delivered of living children, but sunk some months after
with hectic symptoms.
   These cases afford a striking instance of the power of the human frame
to adapt  itself to  new and  apparently adverse circumstances.  In  many
cases,  after some time, an effort is made to get rid of the  foreign body by
artificial openings ; thus the fcetus  maybe  passed piecemeal  through the
abdominal parietes, the colon, rectum, or vagina.   In  some  rare cases, the
fcetal  bones have made their way into the bladder.
   269. Experience alone could have convinced us of  the possibility of the
fcetus  living  in these  misplaced  gestations ; yet it may continue  to  draw
nourishment and exist for any period within the full term of gestation.   "In
ninety-eight cases," says Dr. Campbell, "in  which we can decide, or nearly
so, on  the stage of pregnancy, the fcetus in seventy-nine patients died at the
close of nine months, or soon thereafter ; one in the eighth ;  seven about the
seventh ;  one in the sixth ;  two in the fifth ;  two in the fourth ; five in the
third, and one at the end of the first month."
  The development during the life of the fcetus  appears to proceed at the
ordinary ratio, and subject to the law^s of normal  gestation ; the placenta, 
1S6
E X T R A - L T E R I N E  PREGNANCY.
cord,  and membranes  are obvious  before decomposition takes place ; but
the placenta is generally thinner than usual.   Authors have  differed  as to
whether the ovum  receives an additional covering or not, analogous to the
decidua; but the evidence adduced by Dr. Campbell and Dr. R. Lee's recent
researches  seem conclusive in the affirmative ; and  it is probable that this
membrane,  which closely resembles the decidua, may perform an office similar
in the  nutrition of the foetus.  The part to which the placenta is  attached
receives an increased vascular supply for the occasion.
   Almost all writers have described the uterus in these cases  as lined with
(so-called)  deciduous membrane, though in some cases much hypertrophied;
but in one of Dr.  Lee's  cases it was  absent, and he doubts  whether, when
present, it  possesses " an organized  vascular structure, similar to that of the
true decidua."
   270. Treatment. — If we are  satisfied of  the nature of the case, the first
indication  is to prevent or postpone the laceration of the cyst in  which the
ovum is contained, and which so often proves fatal.   With  this view, undue
exertion of every kind is to be avoided, and all circumstances likely to excite
uterine irritation.   No pressure should be made upon the tumor, and any
uneasiness  in  it should be allayed  as promptly as possible by venesection,
leeches, or  opium.
   When  the rupture  takes place,  marked by the sudden giving way, col-
lapse, and  exhaustion, etc., the second indication is to moderate the effusion
and support the strength ;  for which  purpose the patient should be  placed
on a hard bed, with her head low, and the abdomen  firmly compressed by a
binder, over which cold should be  applied,  by means of pounded ice in a
bladder.
   Acetate  of lead  may be of  service,  with suitable stimulants and broths.
   Should we succeed in relieving the state of collapse, we must next combat
the inflammation which will set in, by the abstraction of blood, calomel and
opium, blisters, etc.
   As the child dies soon  after the rupture of the cyst in most  cases, we must
next endeavor, by quietness and the  absence of excitement  and  irritation,
to aid  the natural  powers in  accommodating themselves to the new circum-
stances of  the case.   The bowels must be kept free by gentle laxatives, and
any renewal of the pain must be met by the application of  a  few leeches or
an anodyne.
   If we find after a time that any effort is made to remove  the fcetus  by the
formation of an abscess  or fistulous communication  and discharge of fcetal
bones, it may in some cases be advisable to assist the process by enlarging
the opening in the abdominal, vaginal, or rectal parietes; but this should be
done with great judgment and care, as  serious hemorrhage may ensue, and
we are never to forget that nature is generally  competent to complete the
process she commences.
   Any subsequent inflammation must  of course be treated in  the  usual
manner. 
PATHOLOGY-  OF  THE FCETUS.
187
                         CHAPTER XI.

       PATHOLOGY OF THE FCETUS. —SIGNS OF  ITS DEATH.

  271. When describing the  contents of the gravid uterus, a short notice
of the principal  pathological changes  to  which  they are  exposed  was
appended, so that I need not recapitulate them here.  They, however, with
the diseases to which the fcetus is obnoxious,  constitute an important devia-
tion from normal gestation.  The latter remain for notice at present,
  Abundant  observation has  proved that the fcetus is liable to almost all
the forms of disease which attack the child; that many of them  are quite
independent of the maternal state ; but that, in addition, it may be affected
secondarily through  the mother.  Amongst the examples of the latter, must
be classed those cases of premature births which occur during epidemics, and
where the fcetus appears to have participated in  the disease of the mother,
as in the observations of Roederer, Wa'gler, Schrnurrer, and  Russell.  I have
observed a considerable quickening of the action of the fcetal  heart some
days after pregnant women have been attacked by fever.
  According to Duettel, Schweig, Zurmeyer, etc., children born of mothers
suffering under intermittent fever, have  exhibited the same disease imme-
diately after birth.
  Many cases have been recorded by Hildanus, Bartholinus, Mollenbroccius,
and, in later times,  by Van Swieten, Mead, Baker, Lynn, Jenner,  Simpson,
etc., of children born with  small-pox.   3Ieasles have also  been observed in
new-born  infants  by Osiander, Stark, Girtanner,  Ortila, etc.   Nor  are they
exempt from other  diseases of the skin,  as  erythema, strophilus, pemphi-
gus, etc.
   272. There is scarcely any internal organ which has not  been observed to
be the seat  of inflammation.    The presence  of hydrocephalus is the  result
of inflammation (acute or  chronic)  of  the arachnoid.  Hogween, Veron,
and Cruveilhier, have recorded cases of pleurisy.  Mende and Koelpin have
observed abscesses of the lungs; Zierhold, oedema; and Wrisberg, scirrhous
induration ;   Husson, Chaussier,  and Billard,  have  discovered tubercles;
Cruveilhier, lobular pneumonia; and  Lobstein, calcareous deposition in
these organs.  Brachet, Chaussier, Duges,  Billard, Carus, Simpson, etc.,
have observed cases  of peritonitis ; Chaussier, of enteritis, etc.
   Of the  cause of such attacks we know little or nothing.
   273. Chronic diseases are even more numerous : the fcetus may suffer from
a general  hypertrophy, or atroplu/;  may  be  attacked with various forms of
syphilitic disease; may labor  under worms, calculus, dropsy, jaundice, or
hernia: and the pancreas, liver, or kidneys may exhibit organic pathological
changes.
  The bones and joints are not unfrequently diseased ; thus, for instance,
children are  born with rickets, as related  by Osiander, Carus, Otto,  and
others ; with caries,  as observed by Carus and Joerg ;  or necrosis, as in M.
Billard's  case.  Numerous cases of fractures and dislocations of  different
bones are  on record.
  274. This brief and imperfect sketch will suffice to prove the truth of the
statement made at its commencement, that the fcetus  does not enjoy an ex-
emption from disease whilst "in utero ;" unfortunately we possess neither the
means of detecting nor of curing these affections.  The subject is,  neverthe-
less,  one of  great interest: to enable  any  of  my  readers to pursue  the
investigation further, I shall subjoin the  names of some  of the authors 
188
PATHOLOGY  OF  THE  FCETUS.
who  have written  expressly upon  it:  Murat,1 Osiander,2 Joerg, Citrus,3
Mende,* C. W. Hufeland,5 Meissner,6  Hardegg,7 Billard,8 Bergk,9 Zurmeyer,10
J. Grcetzer,11 Prof. Simpson.12  M. Groetzer's work is an excellent  summary
of the labors of his predecessors, and Prof. Simpson's Essays are equally
admirable for their research, careful observation, and logical deductions.1*
  275.  Death of the Fcetus.—But although we may not be able  to detect
disease in the fcetus, it is often of great importance to ascertain whether it be
dead  or alive, and  is therefore  desirable, if possible, to determine  what  are
the signs of its  death.  The question may be of consequence to the medical
jurist, and is always to the obstetrician, as influencing our decision  as to  the
best time for operations.
  The diagnosis of a dead fcetus is confessedly very difficult i  since the time
of Mauriceau the  subject has been investigated  by many writers,  and still,
notwithstanding the powerful aid afforded  by the stethoscope, many cases
are exceedingly doubtful;  and for obvious reasons, since most of the symp-
toms  upon which we must rely depend upon  the sensations of the  mother,
and sensations are  notoriously delusive.
  276.  The signs  which  are  given as evidence of the child being dead are:
the cessation of  its movements ;  the subsidence or flaccidity of the abdomen ;
the recession of the umbilicus ;  the loose feel of the uterine  tumor, and its
rolling about in the abdomen ;  a  sensation  of dead weight and coldness in
the abdomen ; the breasts suddenly become flaccid, and their secretion sup-
pressed ; the health being deteriorated ; the  appetite bad ;  the countenance
sunk ; a dark areola rouud the eyes ;  foetid  breath ;  repeated rigors, etc.
  277. Taken separately, none of these signs are certain : the movements
of the fcetus may be suspended for some  days without its  being dead ; the
degree of tension  of the abdomen varies much in the course  of pregnancy,
especially in women who  have had several  children ;  the uterine  tumor is
occasionally felt as a weight  (as it were a foreign body) by women who  bring
forth  the child alive ; the coldness is  a mere  sensation, and therefore of little
value, a dead fcetus not being really colder than a living one ; and the health
may be deteriorated, and a dark shade  appear under  the eyes, from  many
causes beside the death of the foetus.   The breasts, however, seldom become
flaccid, after having been tense, from  any cause but the death of the child.
  Besides, it is a matter  of  common  experience, that women retain a dead
fcetus "in utero"  for weeks  or months, and exhibit few  or  none  of these
symptoms.  In  such cases women have even fancied that they felt  the foetal
movements  up to  the time  of  labor, without any change in the abdomen,
breasts, or general health.
  278. But although taken  singly, none of these signs  are conclusive,  yet
cases occur in which the concurrence  of several is nearly so.   Suppose,  for
example, that in the sixth  month of pregnancy a patient  should   find  the
motions of  the child, which  up to that period had been  lively, cease ; and
soon  after observe that the abdomen and uterine tumor had lost their tense
and rounded form, at  the same time feeling the latter weighty and rolling
loosely in the lower belly, and finding the  breasts, which  had been  tense,

  1 Diet, des Sciences Med.   Art.: Fcetus.     2 Handbuch der Entbindungskunst.
  3 Zur Lehre von Schwangerschaft, etc.
  4 Au*fiihrliches Handbuch der gerichtliche Medizin.
  5 Die Krankheiten der Ungebornen, 1827.
  6 Kinderkrankheiten, 1829.                 t De Morbis Foetus Humani.
  8 Mai des Enfans nouveaux-n^s.            9 De Morbis Fcetus Humani.
  10 De Morbis Foetus.                      " Die Krankheiten de8 Foetus, 1837.
  12 Ed. Med. and Surg. Journal, vol. 1. p.  39; vol. lii. p. 17.  Ed. Monthly Journal of
Med.,  April, 1849.
  13 [An excellent monograph on the  subject of  fcetal pathology is contained  in  the
"American  Journal  of Medical Sciences," for August, 1840, and  October,  1841; by
William Roberts, M. D., of New York.] 
PATHOLOGY  OF  THE FCETUS.
189
firm, and glandular, subside and become flaccid, we should undoubtedly have
almost proof of the death of the child.
  The value of these  signs in  short consists in their  concurrence, and  in
their contrast to the patient's previous condition and sensations.
  279. We  have found the value of auscultation in detecting pregnancy by
proving the life of the fcetus, and it may very naturally be asked, what evi-
dence does it afford of its death ? in other words, as the hearing the pulsa-
tions of the fcetal heart proves the child to be alive, does their being inaudible
prove that it is dead ?  I  have already stated that in some cases, although
the child  be alive,  yet the sound of its heart is inaudible,  or temporarily
suspended, and such cases of course prevent a directly affirmative answer to
the question.   Again, much depends upon  the  tact  and  experience of  the
auscultator ; one person may detect a pulsation that is inaudible to another ;
to pronounce, therefore, that a fcetus is dead  because we do  not at any one
visit hear the heart, would be too hasty a conclusion.
   But if after  hearing the heart pulsating distinctly,  we find  it gradually or
suddenly become inaudible, and continue so, the evidence will be very strong;
and if, in  addition, the principal  symptoms above enumerated be present,
there can  be little  doubt of the death of the fcetus.  Dr. Simpson attaches
importance to the sudden increased frequency of the fcetal heart as indicative
of  impending  danger,  and my own experience would lead  me to  concur
with him, although it may certainly  be only temporary.
   280.  Thus far we have  considered the  signs  of the death of the fcetus,
during utero-gestation previous to  labor;  when this  process  commences.
other and more distinctive  evidence  is accessible.
   On the rupture of the membrane when the fcetus has been some time dead,
the liquor amnii is frequently changed, being of a dark color,  and of thicker
consistence  than usual; but if the death be recent, no such alteration will be
found.
   ["The  liquor" has been repeatedly seen, not  only "thicker than usual,"
but actually foetid, although the child was alive and healthy.   In such cases,
it arises probably from decomposition of a portion of blood which is extrava-
sated by a partial  separation of the placenta,— or, perhaps, of a small frag-
ment of the placenta itself]
   Great stress is laid upon the state of the scalp and bones of the cranium,
and, I believe, justly.   After the fcetus has been dead  some time, if the finger
be pressed upon the scalp, it is  felt to be  emphysematous, crepitating under
the touch,  and a  portion  of the cuticle  will peel off.  The  bones of the
skull also overlap more, and feel loose within the scalp.
   When present, these signs  are, I believe, conclusive, but  the latter only
will be found if the death be recent.  It is  stated by  Dr. Parr and others,
that no tumor is formed upon  the head of dead children; this, however, is
only true when the child  has been  some time dead.   I have seen distinct,
well-formed tumors on the  head of children who  had  been  dead twenty-four
hours   The absence of pulsation at the greater fontanelle, and its diminu-
tion from the collapse of the bones, is admitted  to be an important sign.
   281. In face presentations, when the  child is dead, the lips are flabby,
the tongue'flaccid  and motionless, and  the  presenting part slightly swelled.
In breech presentations, the  sphincter of a living child resists or contracts
upon the finger, but when dead it is relaxed.   The discharge of meconium
is of no value in breech presentations, and of very little  in any other.  When
the arm protrudes, it  shortly becomes  livid and cold, and the  pulse at the
wrist often imperceptible, but  this does not prove  the child  to be dead.
The peeling of the epidermis is conclusive.   In prolapse of the funis, the
pressure to which it  i* exposed very soon destroys the child, and  in most
cases the  presence or absence of pulsation in it  is a  satisfactory test of the
life or death of the child.   Dr. E. Kennedy, however, records a very instruc- 
190
ABORTION.—PREMATURE LABOR.
tive exception to this rule ; the cord  had been prolapsed for an  hour, and
during a pain no  pulsation was  perceptible; when the pain  subsided,  he
"drew the funis backward  towards the sacro-iliac symphysis, and  then was
able to detect a very indistinct and irregular pulsation, which corresponded
to a slight fcetal  pulsation over  the  pubis."  The  forceps were in conse-
quence applied, and the child was saved.
  282. Dr. Collins and Dr. E. Kennedy regard the evidence afforded by the
stethoscope during labor of the child's life or death  as conclusive, or nearly
so; certainly the  information  thus obtained  of the changes which occur in
the fcetal circulation is extremely valuable, and  the  gradual diminution  in
frequency and force of the heart's action, and  its  ultimate cessation, will
justify our belief in the death of  the  child.   It must be remembered that it
is not simply the absence of pulsation that is to  determine our opinion, but
its cessation after having been heard.
                       CHAPTER  XII.

                 ABORTION. —PREMATURE LABOR.

  283. The expulsive action of the uterus may be exerted at any period of
gestation, though it appears more easily excited at or previous to the third
month, on account of the frailty of the connection between the ovum and
uterus.   It is also more liable to occur at  the time of each month, corre-
sponding  to  a  menstrual period, than  during the interval, in accordance
with the periodicity peculiar to the female generative system.
  If it occur before the sixth month, it is called an abortion, subsequent to
this  period, premature  labor.  It is  always an untoward event, and  may
exert an  unfavorable influence upon the health of the female, but it  cannot
be considered as dangerous, unless it be accompanied by great hemorrhage,
and even in such cases it is rarely fatal.
  284. Frequency. —Dr.  Collins met with at least 393 premature cases in
16,414;  Dr.  Beatty  met with 21 premature  cases in  1200.   In my  own
report, 65 cases of abortion are recorded in 1705 deliveries; Madame La-
chapelle records 116 cases  in  21,960 cases of  pregnancy ;  M.  Deubel 35 in
420 ; making in all 530 premature cases in 41,699 deliveries, or 1 in  78i
  Mr. Whitehead has recently published some statistics  of abortion from
which I shall give an  extract.  " Two thousand  married  women  in  a state
of pregnancy, admitted for treatment at the Manchester Lying-in Hospital,
were interrogated in rotation  respecting their existing condition  and  pre-
vious history.  Their average age at the time of inquiry was  a small frac-
tion below 30 years.   The sum of their pregnancies, already terminated,
was  8681, or 4'38 for each ; of which rather less than 1 in 7 had terminated
abortively.  But as abortion seems somewhat more frequent during the latter
than in the first half of the child-bearing period, the real  average will, con-
sequently, be rather  more than 1 in 7."  Of  747, all had aborted once at
least, some oftener.   "Their  average age was 3208 years.   The sum of
their pregnancies was 4775, or 6-37 ; that  of their abortions  1222,  or 163
for each  person."  From the preceding statements it appears that more than
37 out of every 100 mothers experience abortion before they reach the age
of 30 years.   As to  the  pregnancy  most  likely to be prematurely termi-
nated, Mr. Whitehead  states that "of 22G women  pregnant for the second 
ABORTION.--PREMATURE  LABOR.
191
time, 20 or 8'8 per cent,  had aborted of the first, and of 230 pregnant  for
the third time, 58 or 25-20 had previously aborted.   Of 602 cases,"abortion
occurred at the following periods :  in  35 at 2 months, in 275  at 3 months,
in 147  at 4 months, in 30 at 5 months, in 32 at 6 months, in 55  at 7 months,
and in  28 at 8 months.1
   285. Causes.—The causes of abortion may be either maternal or ovuline.
   1. The maternal causes may arise from the  condition of the mother, or
they may be accidental.   That certain states  of the  constitution,  or of the
general health, render the patient obnoxious to this accident, there  can be
no doubt;  and Denman  is  probably correct in attributing many cases to
this rather  than to the  specific  cause  assigned ; for as he observes, " that
about which the patient was employed,  when the first symptom appeared, is
fixed upon  as  the particular cause, though probably she was before in such
a state that abortion was inevitable."   The  habits  of life have also a con-
siderable influence, for we find abortion most frequent in the  extremes of
society.
   On  the  other hand, it is  wonderful with what tenacity the  ovum is  re-
tained by persons of delicate constitution,  and under very trying  circum-
stances ; thus women far gone in consumption  conceive, complete  the term
of utero-gestation, and are delivered of healthy children.  And Mauriceau
mentions a case2 of  a woman who fell from a window in the third story of a
house, in the seventh month of pregnancy, and  broke one of the  bones of
her fore-arm, dislocated  her wrist, and  bruised  herself very much;  yet she
fulfilled the period of pregnancy, and was delivered  of a living child.   Dr.
Davis  also  relates  the case of a lady wdio was thrown  from her horse,  when
three or four months pregnant, and much bruised, yet without interruption
to gestation.   So that we cannot pronounce a priori, that  delicate women
will abort,  although it is undoubtedly a cause far from uncommon.
   When this  constitutional  or local susceptibility is extreme,  a very slight
shock indeed will be sufficient t'» cause the accident; thus one lady will mis-
carry after having a tooth drawn, another from making a false step going
down stairs, etc. ;  and in one case I attended, it seemed to be brought on
by the lady's reading an account of a railroad catastrophe, and in  another
by a hearty laugh.
   286.  Certain local disorders  are  said to cause abortion, as leucorrhcea,
uterine irritation, a  patulous  state  of the os  uteri,  diseases of the  rectum,
bladder, etc.
   Mr.  Whitehead  mentions that of 747 women, the  sum of whose  abortions
amounted to 122, the assigned causes were as follows : —
   "Inward weakness," impaired health, and acute disease     .    . 911
   Accident, mental perturbation, etc.    ...... 222
   No assignable cause  .........  90
   This "inward weakness" to which so many attribute  their  miscarriages,
is, in  fact,  leucorrhcea, arising  from disease  of the lower  portion of  the
uterus.  Out of 378 cases an examination showed that 275 were  thus  affected
with inflammation  and  superficial erosion of the cervix, varicose ulceration,
oedema, fissured ulceration, induration  of the cervix, endo-uteritis, follicular
ulceration,  syphilitic disease, etc., thus confirming the statement of  M. Boys
de Loury and Dr. Bennet  as to ulceration being a common cause of abortion.
   The same consequence  may follow febrile complaints ; thus a patient will
often miscarry during the course of typhus fever, small-pox,  scarlatina, mea-
sles, etc., but it is possible that the miscarriage in these cases may result from
the death of the fcetus, and not directly from the disease.  In this way pro-
bably it is that syphilis gives rise to abortion or premature labor.
1 On Abortion and Sterility, pp. 245-6.
2 Observation 242. 
192
ABORTION.—PREMATURE LABOR.
     287. Among the accidental causes of abortion may be enumerated blows,
   falls, violent concussions, excessive or  sudden exertions, straining, severe
   coughing, etc., which in most cases act by separating partially the ovum from
   the  uterus.
     Mental emotions, anger, joy, sorrow, good or bad news suddenly told, may
•  excite the uterus to action,  and effect the expulsion  of its contents.
     Lastly, a female may acquire a habit of aborting.   Each occurrence pre-
   disposes to a repetition of the  accident at about the same period ; and after
   it has happened several  times, it  is extremely difficult  to carry her safely
   over that period.   Thus  Dr. Young, of Edinburgh, had a patient who mis-
   carried thirteen times in succession, and Dr. Schultze one to whom the same
   accident happened twenty-two times at or about the same period of gesta-
   tion.  I was  myself consulted by a lady who stated that in less than three
   years she had miscarried ten  or twelve times  during the second month of
   gestation.  It is  remarkable, that these patients seem to have as great an
   aptitude for conceiving as for miscarrying.
     Dr. Tyler Smith1 has divided the causes of abortion into excentric, centric,
   and  special, so far  as the  mother is  concerned.   The  former includes the
   causes already mentioned, which act by irritation of the mammary, trifacial,
   vesical and uterine nerves; the second, those which  act through the  medium
   of the blood, as scrofula, syphilis,  the exanthemata, etc. ; and the third in-
   cludes cases of disease.
     288. 2. The ovuline causes of miscarriage may be stated generally to be
   anything which compromises the  life  of the child, whether  the ovum be
   thereby  detached or not.   Thus certain pathological conditions of the
   amnion, chorion, decidua, the  erroneous insertion of the funis,  diseases of
   the placenta,  especially fatty degeneration,2  separation  of  the  ovum, etc.,
   must necessarily interfere with the perfect  nutrition of  the  fcetus, and per-
   haps cause its death and subsequent expulsion.   Or the fcetus  may die of
   some of the diseases mentioned in  the last chapter.   As a rule, it may be
   stated that the death of the foetus will be followed by its expulsion, but the
   period of this occurrence varies very much ; a few days only may elapse, or
   it may be months, or, in a few rare cases, years.  I think,  also, that the
   evidence we possess shows the much greater frequency of the ovuline than
   the maternal  causes  of abortion ; and  if so, we must conclude, that as it is
   better that a  blighted fcetus should be  thrown off,  so abortion in many, if
   uot most instances, is a salutary effort when not complicated.
     The occurrence of hemorrhage from internal or external causes is not an
   unfrequent cause of  abortion, partly from the injury done to the fcetus, and
   partly from the distention and irritation of the uterus.   The blood may be
   effused between the uterus and decidua, between the decidua and  chorion,
   between  the chorion and  amnion, into the substance of the placenta, or into
   the cavity of the amnion.   It has also been  poured into the peritoneal cavity,
   probably through the fallopian tube, as  noticed  by  Botal,  Ruysch, and
   Smellie.
     [It is well ascertained that those females who are subject to membranous
   dysmenorrhcea are also prone to suffer abortion during  the early months of
   pregnancy.   Now Dr. Simpson has shown that the  membrane discharged
   in membranous dysmenorrhcea is, in  the same manner as the decidua, the
   mucous  membrane  of the uterus itself hypertrophied,  and exfoliated, or
   thrown  off at  a  catamenial period.   As regards  the  decidua  Dr. Tyler
   Smith supposes that there is no great difference between an abortion a few
   weeks after conception and membranous dysmenorrhcea,  except that  in abor-

     1  On Parturition, etc., p. 127.
     2  Dr. Barnes on Fatty Degeneration of the  Placenta,  Med. Times and  Gaz., March
   19th. 1853. 
                 ABORTION.—PREMATURE  LABOR.              193

tion the decidua is loaded with the fruit of the womb, and may be discharged
more or less in a state of disintegration.  According to him  every abortion
really consists in the throwing off of the mucous membrane of  the uterus
and the ovum  which has  been developed  upon its surface.   Dr.  Smith be-
lieves that, in  many cases of abortion, as in menstruation both  of healthy
and of  morbid  type, the disintegration and  exfoliation  of  the  developed
mucous membrane,  or decidua, is the first step in the process, and the direct
cause of the loss of the ovum.  From this point of view then, we must con-
sider the  show in  cases  of abortion, and the continuous sanguineous  dis-
charge,  as similar to the discharge in menstruation.  In many cases it hap-
pens that  abortion is threatened, and there is  a  colored discharge for many
days without the loss or injury of the ovum.   Abortion does  not  take place
in such  cases,  probably because the  disintegration of  the decidua does not
occur at the part at which the ovum or the placenta  is implanted  upon it,
or not to a sufficient extent to injure it.
   In all cases of abortion, Dr. Smith maintains that  the developed condi-
tion of the mucous membrane, common to the menstrual period and to preg-
nancy, plays an important  part, and is the  chief cause of the hemorrhage
which then takes place, and in many cases it is  also, in all probability, the
actual cause of  abortion.   The tendency of abortion  to  occur at the cata-
menial periods has  long been a matter of observation.  In  explanation of
this tendency  the periodical influence of the ovaria, as well as of the uterine
mucous membrane must be taken into consideration.1]
   289.  Symptoms.—When threatened with  a miscarriage, the patient gene-
rally experiences a sense  of  uneasiness, languor and weariness, with aching
or pain in the back; after these preliminary symptoms have lasted for some
time, those of labor supervene, and  in most cases they do not differ much
from those of  labor at the full term ;  the pain may even be as great.
   A slight discharge of mucus or  blood from the vagina is observed, pains
are felt in the  back, extending round the loins  to the abdomen, and down
the thighs, recurring at  regular intervals, and  increasing in strength  and
frequency*.  The stomach  frequently becomes irritable, and  discharges  its
contents. '  The pulse is quickened, the  skin hot, voluntary efforts are made
in aid of the uterus, and ultimately the contents  of the womb, or a portion
of them^jire expelled.
   290.  Brit although these symptoms are generally present, yet the progress
of different cases is so dissimilar, that we must enter a little more into detail.
1. Occasionally  cases occur where  the ovum slips out of the uterus  (so to
speak) with scarcely any pain, little  or no  hemorrhage, and  followed by a
speedy recovery.   We see this chiefly  in persons who have acquired the
habit of aborting.   2. Other patients present  the ordinary symptoms  of
labor, as  enumerated above,  but  which  subside after a  time, without the
expulsion, of anything from the uterus, until the  expiration of the full term
of utero-gestation,  when the birth of  a full-grown child is accompanied by
the expulsion  of a  blighted fcetus, the case being one of twin conception.
3. Again, the pains of labor may come on with more or less flooding, and
after some time the fcetus  alone be expelled, the shell of the ovum being re-
tained.  The latter is generally detached after a time, or it may be dissolved,
and discharged along with the lochia.   So long  as it remains, hemorrhage
is to be feared ;  and in some  cases  where it dissolves by putrefaction, irrita-
tive fever  or uterine phlebitis is excited ;  such cases, therefore, excite great
anxiety, and require careful treatment; although in other  cases the shell of
the ovum dissolves, and is discharged unconsciously, with  no unpleasant
symptom whatever.  4. Very alarming hemorrhage may precede or accora-

  1 [See Manual of Obstetrics, by Tyler Smith, M. D., London, 1858, p. 142, et seq.]
       13 
194
ABORTION.—PREMATURE LABOR.
pany abortion.   I cannot say that I ever met with a case in which it  proved
fatal, though I have seen life reduced to the lowest ebb.   It is also import-
ant to remember that flooding scarcely ever continues after the expulsion of
the ovum.   5. There are two very remarkable cases on  record by  Dr.  A.
Wood and Dr. Malcolm, in which tetanus supervened upon early abortion,
on  the  eighth  and sixteenth day respectively.  Both patients died;1  and
other examples have been collected by Dr. Simpson in his essay.2
  291.  The flooding may be  caused by external  accidental circumstances,
such as blows, falls, etc., or it may result from some condition of the ovum
or  its vessels beyond  our cognizance; it may be  internal for a time,  and
afterwards escape, or it may be discharged per vaginam from the beginning.
  There is of course  no difficulty in the diagnosis in the latter case; but it
is not always easy to detect internal  hemorrhage.   In general, the  patient
becomes pale, exhausted,  and faint, with a dark  shade under  the eyes,  and
a quick, weak pulse.  She  complains of headache, lassitude, slight shiver-
ing, occasional dull pains in the pelvis, weight about the rectum, perhaps a
difficulty in voiding  urine, tightness  of the epigastrium, etc., with  reaction
at intervals.
   The uterine tumor, if  above the pelvis, will be found unusually tense,  and
larger than the supposed period of pregnancy would warrant.  After a time,
the distension of the uterus excites contraction, then the membranes give
way, and the blood  escapes.  The fcetus is  of course  lost.   The intensity
of  the symptoms,  and the injury to the  mother are in proportion to  the
amount of the flooding,  which, in fact, constitutes the primary danger of an
abortion.   Generally speaking,  the flooding is less the nearer the gestation
is to its completion.
   292.  Treatment.—The first question that occurs to us when called in to a
case of threatened miscarriage  is, whether it can  be  averted.  If we pos-
sessed any means  of  ascertaining the state  of  the ovum and  fcetus, the
question will probably be, whether it ought to  be averted ; for certainly when
the fcetus is dead or seriously injured, it is much better that it  should be  cast
off. But we do not possess this knowledge, and must therefore content our-
selves with the conviction, that  if the vital relation between the ovum  and
uterus be  compromised, it will  be expelled, and in the  meantime  use the
most suitable means to  arrest,  if possible, the progress  of the case, or to
avert danger from the mother.
   If the hemorrhage  be very slight, and the pains very trifling, our efforts
may be successful; but if the pains  have continued for some time,  and are
accompanied with bearing down, and especially if there be much flooding,
there is little hope of  success.   In some cases, if the patient  be robust  and
plethoric,  it may be advisable to take away blood from the  arm ;  and she
should  repose on a hard bed, lightly covered with clothes, in a cool room,
and be kept in perfect quiet, mental  and bodily.   All causes of irritation,
excitement,  or  distress,  must  be removed,  and  stimulants   of every kind
 avoided.   We may then attempt to suspend the uterine action, by means of
opium, or some of its preparations, in full doses.
   The  hemorrhage may be successfully treated,  at this stage, as I have
repeatedly found, by means of the tincture of Indian hemp (Dublin Phann.),
in  doses of five or six drops every two, four,  or six hours. Or we may have
recourse to the acid mixture, which should be strongly acid, but in which  I
have not much faith ; and applications of cold water to the vulva, or enemata
of cold water.
   If our attempt thus to arrest miscarriage fail, we must then act according
to  the circumstances of the case.  The most  important point is the hemor-
rhage ;  for though it  may not risk life directly, it may seriously impede

        1 Edin. Monthly Journal, March, 1850.          2 Ibid., Feb. 1854. 
ABORTION. —PREMATURE  LABOR.
195
recovery, and leave the health much injured.   If there be little hemorrhage
and the pains increase and expel the ovum, little treatment will be necessary.
  293.  If the fcetus alone be expelled, we may wait awhile (if no  flooding
occurs) to see if the uterine efforts will detach the  secundines;  if not, per-
haps we may be able to reach the lower portion of them with the finger, and
gradually withdraw them ;  if this  fail, we  may frequently succeed with the
ergot of rye.
  [The use of the  ergot of rye under  these  circumstances is  not always
without inconvenience ;  for  although it  be true  that " flooding constitutes
the primary danger of abortion," intense pain and nervous  excitement are
not unfrequent attendants, and ergot never fails to  aggravate the sufferings
of the patient in these respects.   Time,  rest, and opium,  are  the grand
remedies in abortion, for which there are  no substitutes.  Where the strength
of the patient and condition of the circulation allow of it, bleeding, in the
early stage, if it do not prevent  abortion, will rarely fail to mitigate the
violence of its attendant circumstances.]
   But there are many cases in  which none of  these plans will succeed.  Are
we then to leave the case to nature ?   In many cases we may, but in others
we know that after a time  the shell of the ovum will putrefy, dissolve, and
be discharged ;  and experience proves that this process sometimes involves
considerable danger: danger of hemorrhage first, and afterwards of uterine
 phlebitis.  I shall speak of the treatment in cases of flooding presently; and
 with regard to the danger of uterine phlebitis from absorption  of a putrid
 ovum, it may be sufficiently imminent to warrant interference.   The French
 recommend a pair of long thin forceps, with which the ovum is  to be seized
 and removed ; but against such an instrument  there lies the serious objection,
 that we cannot be certain of not injuring the uterus, unless we introduce the
 finger also.  I have contrived  an instrument which I  think may be useful
 when the end of the ovum protrudes from the os.  It consists of a steel rod,
 divided into three claws at one extremity, which  expand widely when free.
 It is enclosed in a small flexible catheter, and when this is pushed towards
 the termination, it closes the claws ; when retracted, the  claws  open.   The
 ovum may thus be seized without  danger of injuring the uterus, and we can
 use it where it would be difficult or very painful to introduce the hand into
 the vagina.
   The late Mr. Wainwright, of Liverpool, published a short paper in one
 of the journals, in which he recommended extraction of the ovum  by intro-
 ducing the hand into the vagina, and one, or at  most two, fingers into  the
 uterus.  That this is practicable, and in certain  cases advisable, I know  by
 experience, having  repeatedly practised it; but it  must be remembered that
 it is not free from danger,  and before we have recourse to  it we should be
 satisfied that the natural powers will  not act, even under the  influence  of
 ergot.  Further, if done at  all,  it should be before the  secundings have
 putrefied,  or irritative fever set in.
   [Dr. Rigby advises the mode recommended by Levret as preferable to the
 employment of the fingers, viz., to throw up "a powerful stream of warm
 water by means of a syringe."   Dr. Dewees employed a wire  crotchet  for
 the removal of the secundines  when they were not thrown off spontaneously,

                                  Fig. 81.
                            De-wees' Wire Crotchet.

or by the use of ergot,   This instrument "consists of a piece  of steel  of
the thickness of a small quill at its handle and  gradually tapered off to  its 
196
ABORTION.—PREMATURE LABOR.
other extremity, which is bent to a hook of small  size."  In the accompa-
nying drawing (fig. 81), the instrument is represented of one-third the proper
size.  Various  other contrivances to effect  the  same object have been pro-
posed at different times; the best, because  the safest and  most efficient, in
my estimation,  is the "placental forceps" of Dr. Henry Bond  of this city.

                                 Fig. 82.
Boud's Placental Forceps.
This instrument is well represented  in the  accompanying drawing (fig. 82).
" It is about  ten  inches long, curved laterally on a radius  of about twelve
inches, and the  blades are about one inch and a half longer than the handles.
The blades terminate in an  oval  expansion nearly half an inch wdde.  The
handles  and blades, including the edges of the oval expansion, are rounded
or bevelled off, so  as  to preclude  all probability of wounding or pinching
any of the surrounding soft  parts.  The inner part of the oval expansion is
made concave  and rough, so as  to maintain a  secure  grip upon the body
embraced.  The curvature is intended to be such, that when introduced with
the finger as  a director, in cases where the perineum is rigid, there shall be
no unnecessary or  inconvenient  pressure  on this part, or  on the urethra.
The  outside  of the  oval part of the blades is  made  slightly convex  and
smooth, without a fenestra,  so that in passing them through the os uteri,
and expanding them so as to embrace the  placenta, there  shall be the least
danger of abrading or lacerating  that part."1]
  294.  Thus far I have spoken  of the treatment of the  simpler forms of
abortion ;  let us now proceed to consider those cases which are complicated
with flooding.  When it is considerable, there is little or no chance  of pre-
venting miscarriage,  and  as the  danger from hemorrhage ceases with the
expulsion of  the ovum, our  endeavors must be directed  to moderate the dis-
charge,  until that event take place.  The most direct means of restraint we
possess  is the plug ; but this must never be used,  if internal hemorrhage can
take place to such an  extent as to destroy life :  in  other  words, not if the
uterus be empty,  and the patient  far advanced in pregnancy.  If the  uterus
be filled with its natural contents, or be  only slightly distensible, even though
empty, we  can restrict the amount of loss by filling the vagina, and stopping
the external  outlet.  For this purpose Dewees recommends a sponge, others
a silk handkerchief, or tow; but I  have found cotton  wool by far the best,
and most easily introduced through a speculum.   The vagina must be filled
completely, and after six or eight hours the plug should be withdrawn, and,
if necessary,  a fresh one introduced.
   [It should be kept  constantly  in mind that, whenever there is the least
prospect of saving the fcetus, the plug is inadmissible ;  for the blood being
prevented  by it from flowing  out of the uterus, will be liable to penetrate
between the  internal surface of the latter  and the ovum,  and thus increase
its detachment.  At the same time, the tendency of the uterus  to contract
and  expel its  contents, is  increased by the presence of the plug, and the
coagulum of blood within its cavity.]
   Cold  should be applied to the  vulva,  by means of a  cloth dipped in cold
water and suddenly applied  : it may be removed after the shock is produced,
1 [Amer. Journ. of the Med. Sci.. April, 1814.] 
ABORTION.--PREMATURE LABOR.
197
and reapplied at intervals.   I have  also seen  great  benefit from enemata
of cold water.   Opium in small doses is very useful, nor does it suspend the
uterine contractions ; and  the tincture of Indian hemp,  as before recom-
mended.   Drs. Dewees and Conquest recommend the  acetate  of  lead; and
others, large  doses of dilute  sulphuric  acid in infusion of  roses, Gallic acid,
tannin, or Ruspini's styptic ; but I cannot  say that I have obtained  much
benefit from them.
   295. When the plug is removed, we should carefully examine the os uteri,
so as to ascertain if the  ovum  is descending ;  if we  are  able to reach the
lower end of it,  it is often  possible, by a little  dexterity,  to hook it down.
If it be beyond our  reach, we may replace the plug, and give ergot to  excite
the uterus to action.  Borax is highly esteemed in Germany, and has been
recommended by Dr.  Copland, for its influence  in exciting uterine contrac-
tion ; it may either be given  alone or combined with  the  ergot.  After the
ovum is removed, it will be well  to  have the vagina syringed twdce  a-day
with tepid water.   It soothes the parts, and removes any putrefying  blood
or irritating discharge.   But supposing  that although by these  means the
hemorrhage be arrested, yet that the ovum is retained without any evidence
of irritative  fever,  are we  to interfere for its removal ?   I think not.  In
such cases, I give half drachm doses of ergot occasionally, watch the patient
carefully,  plug when  necessary and wait.   After the  lapse of days  or per-
haps weeks, the  ovum may be expelled in one or several masses, or a change
in the amount and character of the discharge will warrant us in  concluding
that the ovum is dissolving and coming away.   Longer experience has made
me less fearful of leaving these cases to nature, and more  unwilling to inter-
fere hastily.
   296.  In the majority of cases, the  natural efforts,  or the means just  re-
 commended,  will succeed in expelling the ovum ; but in some they fail, and
 the  patient may be reduced to the verge of death by the  flooding, which is
 kept up by the presence of the  ovum.   In  such cases a  more direct  inter-
 ference has been recommended.   M. Levret advises warm-water injections
 into the vagina  and uterus;  Dr. Dewees, the use of a wdre crotchet;1 and
 some French writers  (as already mentioned), the use  of  a  delicate pair of
 forceps.   The use of any instruments of this  kind will require great care,
 and can only be  safe so far  as  their  application can be regulated  by  the
 finger.  In many cases, where the parts  are dilatable, two or more fingers
 may be easily introduced, and the ovum extracted, or the hand  may be  in-
 troduced  into the  vagina, and the ovum  swept out of the uterus  by one
 finger.   I have  several  times had occasion to perform this  operation in  ex-
 treme cases,  and I  have  been able to do so with perfect success, as  far as
 the extraction of the ovum  is concerned, and  without any unpleasant con-
 sequences.
   But let rne be quite understood by my junior readers ;  such  an operation
 at an early period  of gestation is not  without danger, and requires delicacy,
 gentleness, and  tact: to have recourse to it in any but extreme cases would
 be unpardonable rashness ; but I should deem it just as wrong  to allow a
 patient to die of hemorrhage without having had recourse to it.
   297.  The after-treatment of patients who have  miscarried requires great
 care.  The popular belief is. that abortion is  more  dangerous than labor,
 and I am not sure  that it  is far  wrong.   No  doubt  exists that  women  are
 as liable to puerperal disease after abortion or premature labor  as after de-
 livery at the full time, and they require a more careful management than  is
 generally adopted by them.
   The patient should rest in bed the  usual time, and then return gradually
   1 [Dr. Dewees, it is believed, never employed the "wire crotchet "for the removal of
 the ovum, but solely to bring away the secundines after the rupture of the ovum, and the
 escape of the fcetus ] 
193
ABORTION.—PREMATURE  LABOR.
 to her usual occupations.  Attention should be paid to the lochia, that they
 be not checked, and to the bowels.  The dietfor some days should be bland
 and nnstimulating.
   29S.  The prophylactic treatment of abortion or premature labor requires,
 in the first place, the removal or avoidance of all possible causes ; and se-
 condly, the adoption of all means calculated to strengthen the constitution.
   The state of the stomach and bowels must be carefully regulated, the diet
 be light and nutritious, and exercise taken in the open  air, but not so as to
 occasion fatigue.   If the patient be robust, the  pulse full and quick, and
 some threatening symptoms present, a small  bleeding may  sometimes be
 useful; but if she be weak and cachectic, we must have recourse to tonics.
   If the patient have  previously miscarried, as she  approaches again  the
 same period, she  must take  absolute rest, lying on a  sofa or bed, lightly
 covered, the greater part of the day, until the period be passed.  Rest, more
 or less absolute, is one  of the most powerful prophylactic means we possess,
 and in all such cases sexual intercourse should be prohibited from the  period
 pregnancy is suspected, until after quickening.
   Cold  sponging,  the use of the "bidet," or cold bathing as recommended
 by Mr. White, of Manchester, is highly beneficial, provided we  guard against
 too  great a shock.   In some cases I have seen a beneficial effect produced
 by daily syringing  of the vagina with cold or nearly cold water, at the time
 of using the bidet or hip-bath.
   [" In the management of cases of threatened abortion," says Dr. Lever,1
 "it is my rule, if possible, to get a thorough knowledge of the immediate or
 exciting cause of the hemorrhage or pain, or both ; secondly, before using
 opium, to ascertain the  state of the os uteri, and especially whether the ante-
 rior part of the  neck has lost its plumpness and firmness, and has become
 soft and baggy.   If with the discharge we  have  a patent state of the os
 uteri, and if the neck be soft and loose, the exhibition of opium  will do harm,
 by retarding the  emptying of  the  uterus, which must  sooner  or later take
 place.  But while I do not advocate the use of this drug under the circum-
 stances related,  I  can  speak loudly in its  praise after the  abortion has
 occurred, especially if such have been attended with a large loss of blood;
 it will then  allay  excitement, tranquillize the circulation, and procure sleep.
 These remarks, however, do  not altogether apply to  those  cases  which
 menace from accident, or from mental causes, or those which may be said to
 be due  to  habit.   In these, with the application of cold,  perfect quietude,
 and  unstimulating diet,  I have known  the exhibition of opium by the mouth,
 or, what I prefer, a cold starch injection with opium, thrown into the bowels,
 and  repeated every night, or more often according  to existing circumstances,
 followed by the best results."]
  When the habit of miscarrying has been acquired, one of the most effective
 means of breaking it, is to give  the  uterus  a  long rest, by separating the
 woman  and her husband for several months.
  [This habit is  sometimes so firmly fixed as  to  be very difficult  to over-
 come.   Dr. Huston states, in a note to a former edition, that he has suc-
 ceeded  in some very obstinate  cases by confining the  patient  to a sofa,
 commencing some time before the usual period of miscarriage and  continuing
 several  weeks  after the time  had gone by — carefully avoiding the  erect
 position and all unnecessary muscular exertion, and using  at the same time
injections daily of opium, in sufficient doses to  prevent uterine  action —the
quantity varying  from two to five grains in the state of powder, suspended
in mucilage.  By these means a condition of tolerance on the part of the
uterus may be acquired, which will allow gestation  to go to the full period.]
1 [Lond. Med. Gaz., 1849.] 
                    PART  III.

PHYSIOLOGY OF  THE  UTERUS.  PARTURITION.
                         C HAPTER  I.

              CLASSIFICATION. —DEFINITIONS, ETC.

  299. We have now arrived at the last great function of the uterine system—
that of Parturition, with its abnormal variations.
  It consists in the expulsion of the fcetus and its appendages from the cavity
of the uterus, and ends in the separation of the child and the mother.
  It occurs, as we have seen already, at the end of nine calender months and
a week —ten lunar months — forty weeks — or 280 days, a  few days being
allowed  either way.
  300. The magnitude and importance of the event, and the regularity with
which it takes place, have induced physiologists of all ages to assign causes
for it, but as yet without success.
  Thus it has been supposed  that the uterine action is excited by the strug-
gles of the fcetus for want of adequate nourishment, or  from the constraint
of its position, or from the endeavor to breathe; by others it has been attri-
buted to the acrid nature of the liquor amnii.  Buffon has likened the pro-
cess to the dropping of  ripe fruit.   Hervey, Burdach, and  others  attribute
it to the uterus having attained its maximum of irritability at the exact time
that the fcetal development is complete.  It would be easy to fill pages with
similar explanations, but these  may suffice : they  are all either  more elabo-
rate expressions of  the fact, or mere hypotheses.
   301. But though  all search has hitherto failed in  discovering the exciting
cause of labor, it has established the fact, that the periodicity which we found
to characterize the other uterine functions prevails here also.  For example,
abortion or premature  labor, when  not the result of  external accidental
causes, occurs very  generally at a monthly — or  what, but  for conception,
would have been a menstrual period.
   A sain,  as remarked by Stark and others, the  normal  period for partu-
rition corresponds to a menstrual period : on this principle Kluge calculates
the duration of pregnancy in every case at 280 days, and so much more or
less, as impregnation took place immediately before or after menstruation.
Speaking generally, labor may be looked for at about the tenth period after
the last appearance of the catamenia.
   Lastly,  in extra-uterine gestation, an  attempt at  labor  occurs very gene-
rally at the same period.
   So that, taking the monthly  discharge as the type of utero-ovanan pen- 
200           CLASSIFICATION.—DEFINITIONS,  ETC.

odicity, we may observe that it continues, though at times less demonstrably,
throughout the whole period of the functional activity of  the sexual system.
  After a most ingenious and elaborate  investigation, Dr. Tyler Smith con-
siders that he has proved that " ovarian excitement is the law of parturition
in all its forms of ova expulsion."  "When the ovarium is severed from the
rest of the sexual apparatus, as in the mammalia  and human  female, the
ovarium is connected  with the rest of the  parturient canal by a series of
reflex arcs.  By means of the spinal excitor nerves  of the ovaria, that por-
tion of the spinal centre which presides over the actions  of the uterus is, at
the end of utero-gestation, thrown  into a  state of  excitability or polarity,
somewhat resembling the general spinal excitability of tetanus.   It is  curi-
ous that at this time, besides the ovarian excitement of the catamenial period
which ushers in  parturition,  there is upon the  surface of the ovarium the
cicatrix (corpus luteum)  left  by the ovarian phenomena  of conception, but
which speedily disappears after delivery.   The  uterine nervi-motor system
being thrown  into such  a  state of persistent  excitability, that the uterus
firmly contracts equably upon its contents, the fcetus  itself, hitherto defended
by  the  liquor amnii, becomes  an ordinary excitor, and  the  reflex actions of
labor  are  gradually  established.   The  equable contraction  of the  uterus
preceding  labor is, in effect, just as though  the  membranes had been punc-
tured in the operation of inducing  premature delivery, and the head of the
foetus brought to exert pressure upon the os and cervix uteri."
  Admitting that ovarian excitement  thus  excites uterine  action, I  do not
think that Dr. Smith has satisfactorily explained the cause of that  excite-
ment occurring regularly  at the  tenth menstrual period rather than at any
other.
  302.  Classification of Parturition. — The basis of all classification
must be the  definition of natural labor,  inasmuch as the other classes and
orders are but deviations from or complications of it; but upon this  defi-
nition writers are much at variance.   Some make the efficiency of the ex-
pulsive force the  sole question, and  include under natural labor, all such as
are terminated by the  natural powers.  Thus Hippocrates, Smellie, Baude-
locque, Rigby, etc., etc.,  include face, breech, and foot presentations in this
class.   Others conceive that the  presentation  ought to  be taken into con-
sideration, and therefore  Denman, Blundell, Davis, Ashwell, Ramsbotham,
etc., etc., limit natural labors  to head presentations.
  I  prefer the latter  arrangement,  because I deem it better that what we
take  as natural labor, should present as nearly as  possible a perfect type.
Now the elements of  labor are three : — 1, the expulsive  force ; 2, the child
or body to be expelled ; and 3, the passages through which  it is to be expelled.
If these be equably adapted to each other, the  natural objects  of the labor
will be attained — viz., the  delivery of a living child  with  safety to the
mother; and  the  labor may well be termed natural.  But this  result  does
not obtain except with head  presentations,  or at least not in anything like
the same  proportions ; for  in breech cases 1 in 3± are lost,  and 1 in 2£ in
foot presentations, which is far more  than  when the  head presents.   This
alone would, I conceive, be a valid reason for limiting natural labor to head
presentations ; not that the   natural  powers  alone  may not terminate the
labor with  other presentations,  but that  the  average  mortality is much
higher.
  Again,  I think that the preponderating  frequency of head presentations
ought to have much weight in determining  the most natural form of  labor;
and I find  that in 327,802 cases the head presented  321,503 times, whereas
breech presentations occur only once in 52^ and footling cases once  in  90}
cases. 
               CLASSIFICATION.—DEFINITIONS,  ETC.           201

  303. For these reasons, therefore, we shall include only head presentations
under the term natural labor, and this  will constitute the first great class of
labors ;  the second will include deviations from it, in  consequence of ine-
quality or inefficiency in any one of the elementary conditions of parturition,
such as  inefficient force, defective passages, or abnormal presentations ; each
of these will constitute a sub-division  into orders.
  Besides these abnormal deviations from natural labor, there exist many
which do not fall under any natural classification, but which may be grouped
together as a series of complications, without any necessary relation to  the
character of the labor.   So far then our arrangement will stand thus :

           Class I.   Natural labor.

           Class II.   Unnatural labor.
                a.  From abnormal condition of the expulsive force.
              Order 1,  Tedious labor.
                    2.  Powerless labor.
                b.  From abnormal condition of the passages.
                    3.  Obstructed labor.
                    4.  Distortion of  Pelvis.
                c.  From abnormal condition of the child.
                    5.  Malposition and malpresentations.
                    6.  Plural births.   Monsters.

           Class III.  Complex  labor.
              Order 1.  Prolapse of funis.
                    2.  Retention of the placenta.
                    3.  Flooding.
                    4.  Convulsions.
                    5.  Lacerations.
                    6.  Inversion of the uterus.
                    7.  Sudden death.

   This arrangement is nearly the same as that given by Dr. Merriman in
 his valuable Synopsis of  Difficult Parturition ;  and I think  it will be found
 to include  all  the important deviations from natural labor.  I have not made
 any distinction dependent upon the kind of assistance required in certain
 difficult labors  (as, for instance, the  "manual  or  instrumental  labors"  of
 some authors), but I shall interpolate the necessary chapters  on operative
 midwifery, after treating of pelvic distortions; and add a chapter or two, in
 conclusion, on some of the more formidable diseases of child-bed.
   304.  Presentations.—We understand  by the presentation, that  part
 which presents itself at the brim of the pelvis.  Some writers,  especially the
 French, enumerate a great variety of presentations, all of which, I think,
 may be advantageously included under four heads.
      1.  Presentations of the head.
      2.       "        " breech, including the hips and loins,
      3.       "        " inferior extremities, including the knees and feet.
      4.       "        " superior  extremities, including the shoulder, elbow,
                          and hand.
   Others,  such as the back, belly, sides, etc., are so extremely rare, if they
 occur at all at the full term, that  it would be  superfluous to treat of them
 separately.  Their practical management "would be the same as for presen-
 tations of  the shoulder or arm.
   The  following table will be sufficient to give some notion of their relative
 frequency  in the practice of the same individuals. 
202           CLASSIFICATION.—DEFINITIONS, ETC.
Inferior	Superior
extremities.	extremities.
238	80
255	68
184	48
40	19
3	1
8	4
21	4
7	4
187	40
15	4
29	12
22	9
61	26
181	60
  305.  The  diagnosis  of different presentations  may  be thus generally
stated.  The head may be known by its hardness,  by the  sutures and fon-
tanelles.
  The breech, by its softness, by the cleft between the buttocks, the amis, os
coccygis, scrotum or vulva.
  The knee,  by its rounded form, by the condyles of the femur.
  The foot, by its long form, its being at right angles with the leg, the nearly
equal length  of the toes, the  narrow heel, etc.
  The elbow, by the olecranon process rendering the joint  sharper than the
knee.
  The hand, by its shortness, the unequal length of the fingers, and the
divarication of the  thumb.
  306.  Positions. — The position  is the relation which some part of the
presentation  bears to a given part of the pelvis ; thus the positions of the
head are determined by the relation of the fontanelles to the foramen ovale
and sacro-iliac synchondroses;  or, in  more general terms,  the position may
be said to be the relation of  the  extreme points of certain diameters of the
child to the extreme points of the pelvic diameters.  These  we shall examine
in detail in the next chapter.
  307.  Stages of Labor.—For the convenience of description, it has been
the practice to divide the process of labor into so many parts or stages, some
making three, others four, five, or six: I shall  content  myself with three;
the first extending from the commencement of labor to  the passage of the
head through the os uteri, the second terminated by the birth  of the child,
and  the third occupied by the expulsion of  the  placenta.
Author.	Total No.	Head pre-	Breech
	of Cases.	sentations.	presentations.
Mad. Boivin. . . .	20,517	9,810	372
Mad. Lachapelle. .	15,652	14,677	349
Dr. Jos. Clarke . .	10,387	9,748	61
Dr. Merriman . . .	2,947	2,735	78
Dr. Granville . . .	640	619	2
Edin. Hospital. . .	2,452	2,225	17
Dr. Maunsell . . .	839	786	. .
Mr. Gregory ....	691	645	14
Dr. Collins.....	16,414	15,912	212
Dr. Beatty.....	1,182	1,105	28
	4,666	4,266	59
Dr. Churchill. . . .	1,640	1,119	35
Drs. M'Clintock) and Hardy.... /	6,634	5,815	140
Drs. Sinclair and ) and Johnston. J	13,748	11,874	309
 
MECHANISM OF PARTURITION.
203
                        C HAP TER  II.

                 MECHANISM  OF PARTURITION.

  308. Before describing the phenomena of natural labor, it will be better
to investigate the mechanism by which the expulsion of the child is effected,
and with this view we shall first examine the elementary agents of parturi-
tion, separately, and afterwards their joint action.   These  primary condi-
tions, or agents,  are, 1, the  expulsive force; 2, the passages;  and 3, the
child.
  309.  1. The Expulsive Force.—The  uterus is  in all  cases the main
agent in the expulsion of the fcetus, and in  some, the sole  power employed;
as, for instance, when  the  death of the mother precedes  the birth of the
child; or when the mother  is delivered  in  a state  of syncope or asphyxia,
as related by Haller and Henke ;  or in  cases  of prolapsus uteri, as men-
tioned by Wimmer, Chopart, etc.
  We have heretofore seen that the uterus, if not muscular, possesses  at
least the character of muscularity, that it is  composed of regular and irregu-
lar layers of fibres ; at the time of labor these fibres contract, become shorter
and  thicker, and by their joint action diminish the size of the uterine cavity.
The contractions are periodical, with distinct  intervals, and  each one is
called "apain."  They were so named, no doubt, from  the suffering they
occasion, but, in  obstetric  language, the term " pains" refers to the uterine
action, and not to the suffering.
   [The annexed cuts will exhibit the arrangement of the muscular fibres  of
the uterus according to Madame Boivin, M. Doville and other authorities.]

                [Fig. 83.]                           [Fig. 84.]
External Layer of Uteriue Muscular Fibres.     Internal Layer of Uterine Muscular Fibres.
  The contractions commence in the cervix, according to Midler, Michaelis,
and Wigand, and there  is reason  to  believe, some time previous to the be-
ginning^ real labor, and without suffering; for in most cases,  at the com-
mencement of labor, we find  a slight degree of dilatation of the os uteri,
without  any complaint on the part of the  patient.   After this unconscious 
204
MECHANISM  OF  PARTURITION.
uterine action has continued for a time, it is attended with pain, which marks
the commencement of labor.   The  suffering  increases with the increase of
the pains.   They are seated at first  in the loins, and gradually extend round
to the abdomen and down the thighs.   From their acute, stinging character,
these pains, which are  limited to  the  first  stage,  are  called "cutting or
grinding pains :" during the second  stage, the suffering is less acute, though
not less, severe, and the uterine contractions being aided by voluntary efforts,
the pains are called "forcing or bearing-down pains."  The former occasion
the patient to cry  out, but the outcries  are  suppressed  during the second
stage, from the necessity of  holding the breath, to fix the chest as a "point
d'appui."   The cause of the suffering is, first, the forcible distension of the
cervix, next, the pressure  of the fibres during contraction upon the nervous
filaments, and, lastly, the dilatation  of the passages.   The amount of suffer-
ing depends a good deal  upon the temperament  of the patient, and upon
her habits of life ; among  savages  it  appears slight, but it is excessive in
civilized life.
   310.  Each uterine  contraction has a peculiar character ; slight at first, it
gradually increases until it arrives at its maximum of force, remains station-
ary for  a short time,  and  then  quickly subsides :  and this is characteristic
of the entire labor ; for the pains which  are slight at first, go on increasing
in frequency and force, until,  having  arrived at  the maximum degree of
power, all obstacles yield before them, and delivery is accomplished.
   Another remarkable peculiarity is their periodicity ; each pain is followed
by a distinct interval of rest and ease, diminishing as the  labor advances, but
in a regular manner.   M. Saccombe has given an exact record of  the fre-
quency and duration  of the pains, in one case, which I shall extract.1  Be-
tween 10 and 11 o'clock, a. m., the  patient had seven  pains,  and  from 11
a. m.  to mid-day eleven pains, as follows : —
                                             Minutes.           Seconds.
    From the 1st pain to the 2d the interval was 15 and its duration 21
2	it	3
3	a	4
4	n	5
5	a	6
6	n	7
7	u	8
8	a	9
9	a	10
10	it	11
11	it	12
12	it	13
13	a	14
14	a	15
15	a	16
16	ii	17
17	u	18
18	a	19
14	a		27
10	u		27
8	a		29
7	it		32
6	n		35
6	a		36
6	ii		40
6	ii		42
5	u		45
6	n		45
5	a		47
5	n		49
5	u		55
4	<(	1	' 2
4	K	1	'10
4	n	1	'27
4	it	1	'33
  At this period the waters escaped, and the head was soon expelled.   M.
Saccombe remarks that, "it  results from this  observation: — 1. That the
interval between the pains is in inverse ratio to  their duration.  2.  That the
duration of  each pain  is in direct ratio to  its intensity; that is  to  say, in
proportion  as the  interval between the pains gradually diminishes, so does
their  duration  increase, and  in  proportion as  their duration increases, so

                1 E16mens de la Science des Accouchemens, p. 202. 
MECHANISM  OF  PARTURITION.
205
does their intensity."  The same  conclusions equally apply to  the  severer
pains of the second stage.
  311. The pains, as  I  have already said,  commence in the  cervix, and
gradually involve both the body and fundus ; their first  effect, as Wigand
has observed, being  to elevate, as it were, the  presenting part, and  after-
wards to force  it down.   During  a pain, the uterus becomes hard, round,
and prominent,  with  the fundus tilted forwards ;  when  the pain subsides, it
softens, but does not quite recover its former flaccidity.
  It is  impossible to  estimate exactly the amount of force exerted by the
uterus;  it is  always  in proportion to the resistance, although the mode in
which it is  exerted varies;  in some cases, it overcomes the obstacles by  rapid
and  energetic pains, in other cases, the same end is attained  by a longer
and slower process.
  The first stage of labor is  completed by the uterine action alone,  but
during the  second stage it is  aided by the voluntary muscles, especially those
of the abdomen, which press  directly upon the uterus, and by the depression
of the diaphragm, which diminishes the cavity of the abdomen.  The addi-
tional effort made during the second stage is owing to the increased amount
of resistance to be overcome.
   Towards the termination  of  labor, expulsive efforts are made by  the
vagina,  and these are still more evident in the extrusion of the placenta.
   312.  Uterine action is not directly subject to the  control of the will,
although mental emotions  exert a considerable influence  upon it.  For in-
stance, labor may be brought on  by mental  excitement; and, on the other
hand, anger,  fear, surprise, etc., may suspend  the pains.  Betschler relates
a case where the labor was  arrested by the  fright occasioned  by a violent
storm, and many of my readers are familiar with the case related by Baude-
locque, in which  the pains ceased each time that the pupils who were to
witness the case came in sight of the patient.   A temporary suspension of
labor on the  arrival of the accoucheur (especially if sudden and unexpected),
is a very common occurrence.
   I have spoken of the voluntary exertions made during the second  stage
of labor: these, it is true,  are at first under the command of the will, but at
a more advanced period it is  scarcely possible for the patient to withhold the
co-operation  of these muscles.
   Dr. Tyler  Smith thus sums up the motor  actions of the uterus: "Yoli-
tion may be said to affect the process only indirectly.  Emotion has  a  direct
influence, but it is accessory rather than essential to its performance. Reflex
 action is the  great physiological power, which being absent,  the function of
parturition could not be  properly performed.   Peristaltic,  or immediate
 action, is the basis or radical element upon which the other causes of motor
 action operate."1
   313.  2.  The Passages.—Let me recall in a few words  to  the reader's
recollection the diameters of the pelvis: those of  the  brim being — the
antero-posterior, 4 to  i\ inches, the transverse,  b\  inches, and the oblique,
 4| to 5 inches ; the  relative  proportion of these gradually  changes in the
 cavity, until  at the  lower outlet  the  transverse  is 4 inches, and the antero-
posterior 5 ;  in other words,  that  which  was  the longer at the upper outlet,
is the shorter at the  lower.   From these diameters, a deduction  of a quarter
 of an inch in the antero-posterior, and half an inch in the transverse diame-
ters, must be made,  on account of the soft tissues clothing the pelvis.
   I also remarked before, the great changes in the axes of the pelvis,  which
form an obtuse angle with each other, that of the brim looking upwards and
forwards, and that of the outlet downwards and forwards. Lastly, I pointed
1 Parturition and Obstetrics, p. 48. 
206
MECHANISM  OF  PARTURITION.
out, as an important mechanical agency, the  inclined planes of the cavity
of the pelvis, the direction of which is downwards and forwards.
  [As no correct idea of the mechanism  of  labor can be acquired unless
attention is paid to the several planes of the pelvis, and the variations  pro-
duced in the direction  of these planes by changes in the position of the body,
and by disease, we have taken the liberty to introduce here an extract from
Dr. Meigs' " Obstetrics—the Science and the  Art," which, with the accom-
panying illustrations, places this subject in a very clear light.
  "Plane of the Superior Strait.—The plane  of  the strait is an imagi-
nary superficies, the anterior margin of which is at the symphysis pubis, its
posterior margin  at the promontory, while the rest of its margin touches the
inner  lips of the linea iliopectinea.
  " When the woman  stands erect, or lies  at  length  on the back, the plane
of this strait dips at an angle of 50° to  the axis of her body.
  " Inclination  of the Plane.—It must clearly appear that the  plane of
the superior strait dips at a variable angle in various  positions of the trunk
of the body ;  for if the subject be standing, it dips as above at 50°, but if
the trunk be inclined forwards, the dip will be lessened ; or if the  trunk be
inclined far backwards, it may be increased.  Now this is an important item
of obstetric knowledge, since upon  it is founded advice as to  the  decubitus
of the patient, whom we may direct to  extend her trunk or to flex it more
or less,  as we may desire to bring the plane of the superior strait into a posi-
tion that may favor both the entrance of the presenting part into the strait,
and its passage through it.
  " The figure is designed to  show that  the plane  of the strait may give
different angles with the spine, according as the spine is brought more  for-

                                 Fig. 85.
Planes of the Pelvis.
ward, or carried further backwards over the opening.   Thus e e e is a circle
of which the diameter  bf represents the inclination of the plane of the
upper strait, equal to an angle of 135° fa, which is  the ordinary altitude
of the spinal column  or axis of the trunk.  If the patient  lying upon her
back should have her shoulders raised, so  as to carry the spine forward to c,
equal to 22-30°, the angle would be reduced to 112-30°.  But if the shoul-
ders should be still  more elevated to  d, the axis of the trunk would be at
right angles to the  plane of the strait bf.
  " The same effect as to the inclination of the plane  of the strait is pro-
duced in the patient,  lying on her  side, whenever she bends her head and
trunk forwards; and, indeed, in labors, we see women constantly prompted 
MECHANISM  OF  PARTURITION.
207
by an instinctive sense of the utility of it, bending the trunk quite over the
abdominal strait, to which, moreover, the old nurses and experienced crones
urgently exhort them.   A child's head, that in one inclination of the  plane
should be driven against the symphysis pubis, would with a lesser inclination
of it plunge at once to  the bottom of the pelvis.
  "Justus Heinrich  Wigand, the lamented author of the celebrated volume
entitled Die Oeburt des Menschen, was deeply impressed with the import-
ance of a careful attention to the inclination  of the  plane in labors.  He
often  made use of his knowledge of it as a foundation of his prognosis.   I
have copied these outline  figures from  the  second edition of his work, by
Froriep.  They represent the female torso in profile.  Each figure has marked
upon  it six lines, of which the two horizontal ones extend parallel to each
other, from the promontory of the sacrum  and the symphysis  pubis re-
spectively.
   " In a well-formed pregnant female, the profile will resemble the outline
figure, provided the  child be not very large, nor the liquor of the amnios
excessive in quantity.   As in fig.  86, the back bone will not be excessively
Fig. 86.
Fig. 87.
Planes of the Pelvis.
curved.  A line drawn horizontally forwards from the top of the sacrum will
pass out at the navel, and equal  angles will be formed by a line drawn from
the top of the sacrum to the symphysis pubis, which indicates the inclination
of the superior strait, and one drawn from the same point to the scrobiculus
cordis.  A line from the scrobiculus cordis to  the symphysis pubis, will be
perpendicular to  the one first mentioned.
   " Inspection of such a figure might well serve to  establish a favorable
prognosis ; since, casteris paribus, any untoward circumstances  would be very
little to be expected with so perfect a form, proportion, and arrangement of
parts.
   " Figure  87 is a copy of Wigand's figure 3d, in which he proposed to
represent the profile of a pregnant woman  of apparently perfect form,  but
the inclination of whose superior strait is excessive, as  may be seen by  ob-
serving the line drawn from the top of the sacrum to the top of the symphysis 
208
MECHANISM  OF  PARTURITION.
pubis.  In such a patient the plane of the strait looks almost backwards, and
the indication  of Conduct would  be to cause her to bend her body strongly
forwards, flexing her  thighs very much  upon  the pelvis.   Such a direction
alone might suffice to  correct the excessive inclination of the plane, whereas,
if she should lie  on the back with the shoulders low, and the limbs extended,
the presenting part could hardly fail to be driven upon  the  top  of the ossa
pubis.   In this figure the back is much more curved than in the former one.
The horizontal line, from the base  of the sacrum to the symphysis, rises far
above the navel, and the upper triangle or that of the scrobicle is much
smaller than that of the pubis.  The line falling from  the scrobicle to the
pubis retires, whereas in the former figure it is perpendicular.  In this figure
the perpendicular line from the base of the sacrum is far in advance of the
upper dorsal vertebra?.
   " The contemplation of these ingenious profiles of the admirable German
cannot fail to increase the tact and knowledge of the  student, to whom the
study of them is warmly recommended.
   " Here is Wigand's fig. 4 (fig. 88), in which is the profile of a woman with a
pelvis so deformed as  to imply a necessity for the  operation of perforation, ou
Fig. 88.                              Fig. 89.
                              Deformed Pelrix.

account of its vitiated conjugate diameter.   The angle formed by the back
part of the sacrum and spinal column is much too small.  The bend is quite
different from the gentle curve seen in the first profile.  The scrobicle pro-
jects very much over the symphysis pubis, as by the line  uniting them may
be seen.   The horizontal line from the base of the sacrum comes out just
above the navel.  The line from the scrobicle to the base of the sacrum, and
that from  the sacrum to the pubis are not equal —as in the first and more
perfect figure.  The chord line from the promontory to the coccyx retires,
and the whole of it is in rear of the upper part of the spinal column.
  "Wigand's 5th figure (fig. 89)  represents a pregnant woman, the conju-
gate diameter of  whose superior strait does not exceed one inch  or one inch
and a half; and which,  according to most of the German accoucheurs, indi-
cates a resort to the Caesarian operation.
  " The belly is quite pendulous over the pudenda.   The plane of the strait 
MECHANISM  OF  PARTURITION.
209
makes  a very sharp angle with the horizontal line which  comes out  high
above the umbilicus.  The back is extremely hollow, in  consequence of the
sinking of the sacral promontory  down towards the pubis, and the line from
the scrobiculus cordis to the ossa pubis retreats  strongly in  a backward
direction,  leaving the  breast to hang far over the pudenda in  front.  The
curve of the sacrum is sharp, and the compensating curvature of the upper
part of the vertebral column is highly characteristic of this malformed pelvis,
and is an  evil omen to the unfortunate woman.
   " Such are some  of Wigand's  outline  figures.  I  believe that the study
of them will be very useful to the student.  It takes many years of practice,
and  a great  clinical  experience  and close  observation like Wigand's, to
enable one to become possessed, at a glance, of the peculiarities of the case.
He,  however, was a Master in our art, a man who devoted his  time to its
improvement,  and  spent the last moments  of his  truly missionary life in
laboring to complete the beautiful volume  from which I have taken  his
drawings.  It is a privilege and an honor to evoke  such a man from his too
early grave, in order that  he, though dead, may yet speak in  this distant
land.
   " Plane of  the Inferior Strait. — The plane of  the inferior strait is
usually regarded  as bounded by the inner lips of  the two tuberosities of the
ischial bones, the rami of the ischia and pubis, the ischio-sacral ligaments,
and the point  of the  coccyx.  In this way we speak  of the plane  of the
inferior strait as one plane only ;  whereas, there are, in fact, two  such planes,
an anterior and a posterior.
   " This figure exhibits the  contour of the  outlet.   The line c  d represents
the transverse diameter.  The letters ce ae d show the anterior semi-circum-

                                 Fig. 90.
Outlet of the Pelvis.
ference, while cfbfd show the posterior semi-circumference of the outlet.
Now from c d to a is an inclined plane, and from c d to b is another inclined
plane.   These planes intersect each other at an angle of 140°, and they
ought  to be  distinguished as the  anterior and  as  the  posterior inclined
planes  of the  perineal strait.
  " In  midwifery it will be found  that as  the child  descends, in order to
escape  from the womb, it first impinges  upon the posterior inclined  plane,
which it depresses first, and then begins  to depress the posterior edge of the
anterior inclined plane.   When it has succeeded in depressing the edges of
the  two planes,  it escapes betwixt them, whereupon they resume their place
like two valves,  whose  floating  margins had  been first violently separated,
and then allowed to close again."]
       14
/4-o° 
210
MECHANISM OF  PARTURITION.
  314.  Xow what mechanical  effects  are  these  peculiarities  calculated to
produce upon the passage of the fcetal head ?   1.  It is evident that as cer-
tain diameters only of the child's head correspond to certain  others of the
pelvis, the gradual change in these must be followed by a similar change in
the position, of the head ; because  the expulsive force  presses the head for-
wards, and it can only advance by  making this adaptation.  2. The change
in the direction of the axes, and  the effect  of the inclined planes, more espe-
cially of the curve  of the  sacrum, must necessarily efi'ect a change in the
direction in which the fcetal head moves ;  in fact, they alter it from that of
the axis of the brim to that of the outlet.
  But in order that  this adjustment of position and  alteration of diameter
may be effected, two things are necessary—first,  that the pains should con-
tinue (with intervals), and, secondly, that the foetal head should correspond
to the size of the pelvis ; for if it be too small, it will  want the due resist-
ance, and may be  driven through  the pelvis irregularly ;  and if it be too
large, it will not pass at all.
   315.  Our estimate of the passages, however,  would be incomplete, if we
did not regard the uterine cavity as forming one extremity of them.  The
long axis  of the child's body is almost always in accordance with the  long
axis of the uterus ;  but previous to labor  the latter  is  not in  accordance
with the axis of the brim, but  rather  more perpendicular :  the uterine con-
tractions,  however, remedy this by  tilting the fundus uteri forwards, and so
place the child in the right line of  direction for entering the pelvis.
   316.  Having said thus much of the passages generally, let us endeavor to
estimate the  obstacles which the  head meets in  its progress : the first of
these is the cervix uteri.  The resistance  it offers appears to be the effect
partly of  muscular action  and partly of its elastic cellular tissue ;  but, as
Dr. Murphy has  observed,  more generally of the latter than the former,
unless there be much irritation.  The dilatation is evidently in the first in-
stance  purely mechanical, and  effected by repeated efforts, rather  than by
great force at one time, but afterwards the dilatation is  aided by muscular
action.  This will be rendered clear by considering the process more in detail.
During the last few  weeks of gestation, the cervix  becomes slightly softened
and dilated, and the result  of  the  first  pains which  retract or elevate the
child, is to press down  a pouch of  membranes filled with liquor amnii ("the
bag  of the waters").   This  forms a  firm, equable wedge,  adapted to  any
size or  form  of os uteri, and which, as the  uterine fibres of the  body and
fundus  are stronger  than those of the cervix, must be forced down into  and
through the os uteri with each  pain, dilating it to the size of the wedge thus
formed, and continuing the  process until the membranes give way.   So far,
all is mere mechanical dilatation, but  if a prolonged and careful  examina-
tion  be made, when  the child's  head  is substituted for the wedge of mem-
branes, it will be found that the  contractions of the fibres  of the cervix
which at first narrow the os uteri, do at length retract it  over the head more
and more  each time, until, at length, the combined retraction  of the cervix
and propulsion of the head, force the latter altogether  through the os uteri.
This  is particularly ascertainable in certain  cases, when  the anterior lip is
unusually  long in dilating.  Besides the effective way in which this arrange-
ment attains its object, it has other advantages ; the os  uteri is dilated by
the bag of the waters with far  less pain than by the fcetal head.
  The  second obstacle  is the bony circle of the brim  of the pelvis, into
which the head can  only pass by the adaptation  of certain  of its diameters
to those of the pelvis, and even the apposition is so exact that it requires a
degree  of compression, or " moulding" of the head, to facilitate its entrance.
This is further aided by the head being placed  obliquely in every way, and
it is  at length effected by repeated  pains.  When this moulding is completed, 
MECHANISM  OF  PARTURITION.
211
and the due position  attained, the head  is  gradually  propelled  into and
through the cavity, receding somewhat after each pain, and again advancing
in a somewhat spiral direction, until it arrives at the third obstacle, or lower
outlet, closed in by ligaments,  muscles, cellular tissue, etc., and external  to
these  the perineum.   These tissues resist  long,  and their dilatation  is very
painful; they are first softened by mucous  discharge, and then relaxed (how
I know not), long before  there is direct pressure upon  them : afterwards,
they  are subject to alternate  pressure  by the  head,  and relaxation, until,
being fully distended, they yield, and the head, directed forward by  the curve
of the sacrum, is applied  directly to the vaginal  orifice, and  gradually, very
gradually,  forced through it.
  With first children the  mucous membrane of the orifice of the vagina  is
more or less everted, and frequently torn posteriorly, without the injury ex-
tending to the perineum.
   The amount  of  resistance varies in different subjects;  it is greatest wTith
first  children, and in  women  of advanced age ; it is also  greater  in the
second than in the first stage, but more rapidly overcome, owing to the
greater force  employed.   The facility  with  which the head traverses the
pelvis depends  partly upon the force, partly upon the resistance, and partly
upon the amount of compression which  the head will  bear:  this is very con-
siderable, though it is less practicable if the sutures be ossified.
   317. These obstacles constitute  the natural division of labor into stages,
the first terminating when the  os uteri ceases to  impede the  descent of the
head, and  the second with the  passage of the child through the lower outlet,
 as already mentioned.
   The length  of  each stage is of course in proportion to  the resistance,
 and inversely to the power employed ; but in natural labors it is as about 2
 or 3 to 1 (at least in first  labors), i. e., if the whole labor bel2 hours, the first
 stage will  probably be 8 or 9 hours;  but, of  course, this will vary much,
 and within certain limits  without injury.
   When, however, the entire labor is indefinitely prolonged, the relative pro-
 portion of  the  two stages is altogether  destroyed, and either may be  many
 times as long  as  the  other.   We shall speak of this  by and by.  Of the
 third stage (expulsion of the placenta) I shall treat under Natiwal Labor

                                  Fig. 91.
Foetal Head Diameters.
  318. 3.  The Child. —I have  not much  to add  of the mechanical in-
fluence of  the child in the process of labor, inasmuch as it is altogether pas-
sive.   The measurements of the child's head  are as follows : — 
212
MECHANISM  OF  PARTURITION.
       1. The longitudinal diameter from  .     .    4  to 4^ inches.
       2. The transverse   .     .     .     .     .    3i  " 4
       3. The occipito-mental or oblique  .               5
       4. The cervico-bregmatic     .              4   " 4h
       5. 'Ihe trachelo-bregmatic     .     .     .    3J   " 4
       6. The inter-auricular    ....          3
       7. The fronto-mental    ....          3^
  The first of these diameters corresponds to the oblique diameter of the
brim and antero-posterior of the  lower outlet;  the second to the antero-
posterior diameter of the brim and  transverse  of the lower outlet  in  ordi-
nary cases;  the third  to  the antero-posterior diameter  of the  lower outlet
in face presentations :  the others to certain diameters of the pelvis, to which
the head is only transitorily applied.
  The transverse diameter of the shoulders is from 4f to 5^ inches.
                             '•   hips        "      4  "  5
  These diameters being at right  angles with the long diameter of the head,
it follows that when the  latter corresponds to the longer (or antero-poste-
rior) diameter of the outlet, they will be exactly in  apposition with  the long
diameter of the brim.
  319.  The diameters are pretty regular in well-developed infants,  and cor-
respond very closely to those of the clothed pelvis.  Yet certain adaptations
facilitate the transit of the child—viz., the compressibility of the  head and
body  of the child, which it is calculated will permit it to be forced through a
pelvis whose  antero-posterior diameter at the  brim is only three inches.
And further, the head enters and  passes through the pelvis obliquely, both
as  to its longitudinal and transverse axes, i. e., one fontanelle and the  ante-
rior part of  the presentation are lower than their opposites, thus diminish-
ing the longitudinal transverse diameters from a quarter to half an inch.
   This appears to be  the proper  place  to notice some very interesting re-
searches, published by Prof.  Simpson, of Edinburgh,1 on  the different size
of  the head in male and female children, and the consequences which result
to  the mother and child.
   He states that  the head of the male  at birth  is larger than that of the
female, in its circumference, by |ths of an  inch, in its transverse diameter by
^th, and in  the inter-aural diameter by gths of  an inch.
   Now it  appears from the following table,  that the proportion of males is
greater than that of females in some very  important deviations from natural
labor.
	Total Cases.	51 al.-s.	Females.	Proportion.
Tedious labor.......	119	65	54	148 to 101
	28	17	11	153 " "
	88	54	34	161 " "
	34	23	11	207 " "
	44	31	13	240 " "
	24	16	8	200 " "
I	74	50	24	200 " "
  From a large collection of facts bearing upon and  illustrating the sub-
ject, the author has drawn  the following conclusions of the dangers conse-
quent upon this slight excess of size in male children.
1 £d. Med. and Surg. Journal, Oct., 1844. 
MECHANISM  OF  TARTURITION.
213
  1.  Of the mothers  that  die  under parturition and its immediate conse-
quences a much  greater  portion  have given birth to male than female chil-
dren.
  2.  Among labors presenting morbid complications and  difficulties, the
child is much oftener male  than female.
  3. Among the children of the  mothers that die from labor  or  its conse-
quences,  a larger  proportion  of those that are  still-born are male  than
female ; and on  the contrary, of those that are born alive, a larger propor-
tion are female than male.
  4. Of still-born  children, a larger proportion are male than female.
  5. Of the children that die during the actual progress of parturition, the
number of males is much greater than the number of females.
  6. Of those children  born  alive, more  males than females are seen to
suffer from the morbid states and injuries resulting from parturition.
  7. More male than female children die in the earliest periods of infancy,
and  the disproportion between  the  mortality of the two  sexes gradually
diminishes from  birth onwards  until some time subsequently.
  8. Of the children that die in utero and before the commencement of
labor,  as large a proportion are female as male.
  9. In laborious  labor with the head presenting, in proportion as the order
of  labor  rises in  difficulty, the  amount of  male births  in them  rises in
number.
   10.  Of the  morbid accidents that are liable to happen in connection with
the third (second) stage of labor,  as  many take place with female as with
male births.
   11.  More dangers and deaths occurs both to mothers and children in first
 than in subsequent labor.
   12.  The  average duration of labor  is longer with  male than with female
children.
   The long axis of the child in general corresponds to the  long axis of the
 uterus, though occasionally it  is  somewdiat oblique :  this, according to De-
 sormeaux, occurs  once in  249  cases, according to Meckel once in 287, and
 to Osiander once in 300  cases.
   320. Having  now considered  these elementary powers  or  conditions of
 labor  separately,  we are  prepared to  examine them in action ; in  other
 words, to ascertain the Mechanism of Parturition.   Nothing can be more
 simple, but certainly  nothing  more erroneous, than  the views held by the
 older  writers  on midwifery.  They concluded that the head passed through
 the pelvis, in  the  same position as that in which it emerges from it — that
 is,  with its long diameter antero-posteriorly.   The first writer  who corrected
 this opinion was Sir Fielding Ould, of this city, who wrote in  1742, and who
 stated that in the  first part of  its progress the face is turned  to one side or
 other  of the pelvis, " so as to have the chin directly on one of the shoulders."
 Dr. Smellie in 1752 corrected  the error of Ould with regard  to the contor-
 tion  of the child's neck, but  in other respects  agreed with Sir F. Ould.
 Similar opinions  were  promulgated in  1770 by Deleurye in France, and
 subsequently  by Schmitt and Mampe in Germany.
   The next step  in  advance was  made (without inter-communication) by
 Saxtorph of  Copenhagen, and Solayres de Renhac of Montpellier, who  in
 1771 published  two essays, which agreed in this fact, that the long diameter
 of the head of  the child, in  natural labor, entered the pelvis in a direction
 neither  parallel to the  conjugate, nor to the transverse diameters  of the
 brim,  but parallel to  one of  its oblique diameters; that is,  with the sagittal
 suture running in  a line  directed  at one extremity to the sacro-iliac synchon-
 drosis behind, and to the  foramen ovale anteriorly.   They further showed
 that of the two oblique  diameters,  the long axis  of the head, in a very large 
214
MKCHANISM of  tarturition.
proportion, occupied the left, or that running between the  right sacro-iliac
synchondrosis and left foramen ovale.   M. Baudelocque adopted the opin-
ions^oThis-master, Solayres de  Renhac, as the basis  of  his arrangement,
and through  his great  influence the doctrine of  the  oblique positiou of the
head has been generally diffused  and received.
  There were, however, many points which needed revision and correction;
and for the full demonstration of that which was true, and the correction of
that which was erroneous, with the  addition of many new observations, we
are indebted  to the labors of Xaegele of Heidelberg, who in 1818 published
his essay On the Mechanism of Parturition, which was translated  into  our
language by  Dr.  Rigby in 1827.   The  more closely his opinions have been
tested  by experience and careful  observation, the more clear does their cor-
rectness appear.
   Having so high an estimate  of the labors of  M. Naegele, the reader will
not be surprised  at my adoption of his descriptions in the present volume;
and it  would give me great pleasure if,  on my recommendation,  all my read-
ers would peruse his excellent essay.
   321.  We have already stated that the position  of  the head is the relation
which  its diameters bear to those of  the brim of the  pelvis ; or,  in other
words, the situation of the  extreme points of the  longitudinal  diameter of
the head compared with the extreme points of  the oblique diameter of the
brim.   Now the  former are sufficiently well indicated  by the anterior and
posterior fontanelles,  and the latter by the foramen ovale, right and left,
and the sacro-iliac  synchondrosis, right and left.
   Naegele states that the child usually presents with the  head in either of
two positions corresponding to the two  oblique diameters, but with the supe-
rior fontanelle at either extremity ;  thus those I have called 1st and 3d will
belong to the left oblique, and the  2d and 4th to the right oblique; but it
is more convenient, wdth the majority of German and English modern writers,
to make four, which therefore I have  adopted.   In the first, the posterior
fontanelle corresponds to the left foramen ovale ;  in the second, to the right
foramen ovale;  in the third,  to the right  sacro-iliac synchondrosis;  and
in the  fourth to the left sacro-iliac  synchondrosis;  the  anterior fontanelle
of course corresponding to the opposite extreme of the oblique diameter.
   These numbers do not correspond wdth  those affixed to the  presentations
of other writers  ; but in order that  no confusion may arise, I shall give  a
table of the  corresponding numerals of different authors:
Numbers affixed to Presentation by              Description of Presentation.
5	c||	.p	Anterior part of Cranium pointing to
a	o so 1	* 3	
1			Right sacro-iliac synchondrosis.
2	2	4	Left do. do.
3	4	6	Left foramen ovale.
4	5	5	Right do.
	3	/	Promontory of sacrum.
	6 7	8 1	Symphysis pubis. Right os ilium.
6	8	2	Left do.
 
                   MECHANISM OF PARTURITION.               215

  322. Now let us trace the progress of the head in the different positions.
  In the first  position (fig. 92), it is, as I have stated, placed obliquely,
corresponding to the right oblique diameter of the brim, the posterior fon-
tanelle being towards the left foramen o_yale or acetabulum, and the anterior
towards the right sacro-iliac synchondrosis, the two fontanelles being at first
on a  level; consequently the sagittal  suture  will run nearly in the left j
oblique diameter of the  brim, but  rather nearer to  the sacrum than the j
Mechanism of Parturition — First position.
pubis, because the anterior half of the presentation is  almost always lower
than the posterior.   If  the finger be at this time introduced into the centre
of the  os  uteri,  at the  very commencement  of labor, it will  impinge upon
the right tuber parietale, above which and on the upper edge of the parietal
bone, the primary tumor is formed.

            " [Fig. 93.]                             [Fig. 94.]
Vertex Presentation : first position.                  mechanism of labor.
  By the action of the uterus the head is forced downwards into the cavity,
preserving in some cases merely the obliquity it possessed at the brim ; but
in other cases it assumes  an oblique position  as regards  its longitudinal
axis; one fontanelle—generally the posterior—being lower than the other:
this is more remarkable as the head advances.  In other respects, the  posi-
tion of the head and the presenting part is unaltered in the cavity, the pos- 
216
MECHANISM  OF  PARTURITION.
terior fontanelle still  corresponding to the foramen ovale, and  not, as fre
quently stated, to the arch of the pubis.
  When the  head arrives at the  lower outlet, Naegele observes, " by con-
tinued pressure of the uterine contractions the posterior fontanelle gradually
moves itself by slight degrees, repeated at equal intervals, in a direction from
left to right (frequently more or less from above downwards), and the occipi-
tal bone advances from the side of the pelvis under the arch  of the pubis.
It is not, however, the centre of the occiput  that advances under the puba!
arch, but the  head approaches the os externum with the posterior and supe-
rior  part of the right parietal bone  and remains  in this position until it has
Outlet of the pelvis, with the foetal head passing through in the   First Position of Vertex: third step
  fir>t position.  The asterisk marks the presenting portion.         in mechanism of labor.
passed through  the outlet of the pelvis with the greatest circumference which
it opposes to  it, when it then turns itself with  the  face  completely towards
the right thigh  of the mother."  That the head really passes thus obliquely
through even  the external parts maybe proved by tracing the sagittal suture,
which will be  found running obliquely from  left to right, and  by examining
the tumor of the scalp, which, after delivery,  occupies the posterior and supe-
rior quarter of  the right parietal bone, and  a portion  of the occipital bone,
if there has been sufficient delay at the vaginal orifice.

                                  Fi-. 97.
Mechanism of Parturition — Second position. 
                   MECHANISM  OF  PARTURITION.                 217

  323.   When the head is in the second position, (fig. 97), its longitudinal
diameter corresponds to the  right  oblique  diameter of  the pelvis,  and it is
placed obliquely as in the former case, acquiring the  second obliquity as it
descends ;  and it passes through the pelvis and lower  outlet precisely in the
same mode as in the first position, only that the slight rotation is from right
to left, and that when  expelled it completes the  quarter-turn, bringing the
neck under the arch of the pubis.

                                 [Fig. 98.]
Outlet of the pelvis and the foetal head passing through it in the second position.
             The asterisk marks the presenting position.
  324. In the third position (fig.  99), the anterior fontanelle corresponds
to the left acetabulum, and the posterior to the right sacro-iliac synchon-
drosis, at nearly the same level, until the pressure occasions one or other
(generally the posterior) to  descend.  The sagittal  suture  divides  the os

                                 Fig. 99.
Mechanism of Parturition — Third position.
uteri obliquely and unequally, and the tumor of the scalp is found upon the
upper edge  of the left parietal  bone, nearly at  an equal distance from its
angles, and the finger, passed in  the central line,  impinges upon it.
  " As soon  as the head is engaged  in  the cavity of the pelvis,"  Naegele
observes, "the great fontanelle turns  towards the descending ramus of the
left os ischium, and both can  be  felt  at an equal height as to each other.
As soon as the head experiences  the  resistance which  the inferior part of 
21S
MECHANISM  OF  PARTURITION.
the pelvic cavity opposes to it, or, in other words, the oblique surface which
is formed by the lower end of the os sacrum by the os coccygis, the ischia-
tic ligaments, etc., by which it is compelled to move  from its position back-
wards, in a direction forwards, it turns by degrees with  its great  diameter
into the~feft oblique diameter of the pelvic cavity ;  i. e., the posterior fon-
tanelle is directed to the right foramen ovale,  and as the head approaches
nearer and  nearer  to the inferior aperture, it is the posterior and superioi
quarter of the left parietal bone, which is felt in the cavity of the pelvis,

                                 [Fig. 100.]
Outlet of the pelvis, and the foetal head in the third position.
       The asterisk marks the presenting portion.
opposite to the pubal arch ; so that when the  point of the finger is intro-
duced under and almost  perpendicular to the  symphysis pubis, it touches
nearly the middle of the  superior and  posterior quarter of the left parietal
bone ;  and  this is  precisely the part,  as  the head  advances further, which
first distends the labia, with which the  head first enters the external passage,
and the  spot upon  which  the  swelling  of  the  integument forms itself."
Thus, the head is changed from the third position into the  second, and so
passes out, the  face, according to  Naegele, generally turning towards the
left thigh of the  mother.
                                 Fig. 101.
Mechanism of Parturition — Fourth portion.
  325. In the fourth position (fig.  101), the posterior fontanelle corresponds
to the left sacro-iliac synchondrosis, and the anterior  fontanelle to the right 
MECHANISM  OF  PARTURITION.
219
foramen ovale ; and as the head is pressed through the cavity of the pelvis,
changes analogous to those just described, take place, but in  the  opposite
direction—that is, the head is turned (from left to right, so as  to  bring the
posterior fontanelle towards the left foramen ovale ; in other words, that as
the head is changed from the third to the second position, so from the fourth
it changes into the  first.   It  then passes out,  exactly as it did when pre-
senting in^the first position.  The primary tumor will be at the upper edge
of the right parietal bone; but the pressure of the lower outlet will extend
it over the tuber, to the upper and back part of this bone.

                                 [Fig. 102.]
Outlet of the pelvis and toetal head in the fourth positicn.
     The asterisk marks the presenting portion.
  326. When the head presents in the third or fourth position, if the pelvis
be unusually large, or the fcetal head unusually small, or even w<ith a pelvis
and head of ordinary proportions, if the pains come on very violently when
the head is at the upper outlet, the changes into the second  and first posi-
tions may not take place, owing to  the absence of sufficient resistance  or
adequate time, but the head be driven through the pelvic cavity and lower
outlet in the position (or nearly so)  in which  it presented at the brim, the
upper and anterior part of the  left (third position) or right (fourth position)
parietal bone, and a portion of the superior part of the frontal of the same
side corresponding to the arch  of the  pubis, and the posterior part  of the
right  or left parietal bone, and part of  the occipital, sweeping over the
perineum.   As the head passes out, the forehead looks upwards,  under the
arch of the pubis.   Naegele states :  '' Of ninety-six cases of the third vertex
position, which I observed with particular  care, and  described in my note-
book, I remarked the head three times to come through the  external  pas-
sages  with the head upwards or forwards."
  This occasions more suffering, and some delay, as the longitudinal diame-
ter of the head is presented to  the lower outlet without adaptation or modi-
fication.
  [" The mechanical form of the  pelvis,"  says  Dr. Meigs, "is  so miracu-
lously adapted to the wants of the  economy in  labor, that it  has power,  in
a major part of these fourth  positions, to  rotate the vertex from the  right
sacro-iliac junction to the right acetabulum, and thence  to the pubal arch ;
and that without any assistance given by the accoucheur.
  " It is true that this favorable rotation sometimes requires the  aid of the
hand,  or even of an instrument.  It  also occasionally happens, that neither
the  hand alone, nor any instrument, can enable the surgeon to  bring the 
220
MECHANISM OF  PARTURITION.
vertex round to the  front.   In such  case, it slides  into  the  hollow of the
sacrum, and the  labor is  thenceforward rendered more painful  and more
difficult.
  "When, in fourth positions, the vertex can rotate first to the acetabulum,
and then to the arch, the labor is not seriously  retarded ;  but when the pos-
terior fontanelle gets into the hollow of the sacrum, and will not suffer ro-
tation, then the flexion becomes greater and greater as the fontanelle slides
down along the point of the sacrum, along the  face of the coccyx, and down
the mesial line  of the perineum, until having pushed  off the perineum 4.10,
the occipito-frontal diameter, the vertex slips  over  the  fourchette, and im-
mediately turns over backwards, in strong extension, which allows the fore-
head, eyes, nose, mouth and chin successively to emerge from underneath
the crown of the pubal arch, to complete the birth  of the  head.   The  an-
nexed figure of a head in an  occipito-posterior position, show these truths
clearly enough.
                                Fig. 10.3.
                    ncad at the Lower Outlet in the fourth position.

   " This is the mechanism in all cases of birth in occipito-posterior positions,
without rotation to the front;  and the  student will clearly understand that
it must be so, since the  length of the line from  forehead  to vertex is too
great to permit  it to be otherwise."1]
   327. Until very recently, the passage  of the head with the. forehead under
the arch of the  pubis was believed to be the ordinary termination of pre-
sentations in the third or fourth position ; but since the publication of Nae-
gele's  work has directed  more careful  attention to this  point, abundant
proof has been obtained " that what has been considered as a regular phe-
nomenon  is a deviation, and exactly that which has been esteemed a devia-
tion from  the usual course and rule is perfectly regular."  Solayres de Renhac
and W. I. Schmitt noticed the change from the third into the second posi-
tion ; but for the minute explanation we are indebted to M. Naegele.
   328. As to the comparative frequency of the four positions,  there is no
doubt  of  the greater  predominance  of the first;  it occurred to  Naegele  in
the proportion of 69 per cent, of all his head presentations ;  to  Madame
Lachapelle in 77 per  cent. ;  to Madame Boivin  in 80 per cent., and to M.
Halmagrand in  the ratio of 74 per cent.
   The fourth position is also confessedly the least frequent, occurring to M.
Naegele in the ratio of -03 per cent.  ; to Lachapelle and Halmagrand in '04
per cent. ; and to Madame Boivin in -05 per cent.
1 [Obstetric?.—the Science and the Art.] 
MECHANISM  OF  PARTURITION.
221
  There is a great  difference  of  statement, however, as to the comparative
frequency  of the second and third positions ;  thus Naegele, in 1290 cases,
only met with  the second position in one instance, or in the proportion of
•07  per cent.   M. Halmagrand describes  it as  occurring  in 5  per cent. ;
Madame Boivin in  19 per  cent. ;  and Madame  Lachapelle in 21 per cent.
On  the other hand,  Naegele found  359 cases of the third position in 1210
cases, or 29 per cent. ;  while Madame Lachapelle  gives only -077 per cent.
of such cases,  and Madame Boivin only  -05.  Dr.  Simpson  observed accu-
rately the positions  in 335  cases  of cranial  presentation, and found the first
position in 256 cases, the second in 1, the  third in 76, and the  fourth in 2
cases.
  Dr. Swayne, of Bristol, found that in 286 cases, the first position occurred
in 247 ; the second in 28 ; the third in 3 ;  and the fourth in 8 cases.1   Dr.
Miller, of Louisville, found the fourth position more frequent than the third,
and both less frequent than the second.
  It is extremely difficult to explain these  discrepancies satisfactorily.   M.
Naegele conceives that the examination was not made until after  the change
from the third into the  second position had been effected ; and he  thinks that
this opinion is confirmed by the fact that the frequency of the second posi-
tion of  authors agrees with the  frequency with wdiich  he has observed the
head to present in the third position.  The researches of Dr. Breen, Pro-
fessor Simpson, etc., have  led them to coincide with Naegele, and correctly
so,  in my opinion.
  329.  Diagnosis.  ^The diagnosis of the positions of the head is a matter
of  some difficulty, and requires delicacy of  tact and  experience ;  of course,
the difficulty is greater before the os uteri is fully dilated.  Naegele has  laid
some stress upon the fact, that the movements  of the child are felt more on
one side than the other; so that when this happens on the right side, as is
most frequent, we may presume  the  head  to be in  the first position,  and
when on the left side, in the second.   That this  observation is correct, my
experience leads me to believe ; but it affords no means of distinguishing be-
tween the first and fourth,  nor between the second and  third positions.
   The stethoscope has also been  called in to our aid, and in many instances
the information it  affords is  conclusive.   We  cannot always distinguish a
head from a breech presentation by it ; but if by other means we can ascer-
tain that the head  presents, it is possible  by this  means to detect the posi-
tion earlier than by any other.  "Thus," M.  Naegele, jun., observes,  "if,
in a case  of vertex  presentation, the  pulsations  of the fcetal heart are  dis-
tinctly heard in the  left inferior abdominal region, diminishing in intensity
as the ear leaves this part, but extending  upwards and forwards, and con-
tinuing audible as far as the linea  alba, or even  beyond  it, it may be pre-
sumed that the head occupies the first position.  We are warranted in sup-
posing  that the head is situated in  the second  position if the heart's pulsa-
tions are most distinctly heard in the right side of  the  abdomen."2
  Careful observation of the movements of the child, and of the stethoscopic
phenomena, have also  led to the  conclusion,  that in  some cases the child
takes up its position at an early period, and does not change it till birth ;
whilst in  other cases the  changes are frequent, but diminish towards the
eighth  month.  The foetal heart will always  be found to correspond with
the  motions of the  child as felt by the mother.
  330.  We possess an  unfailing test of the  correctness of our diagnosis in
the  tumor of the scalp, or "caput  succedaneura," as it has been called.    It
is formed by the pressure of the head against the openings through which

        1 Prov. Med.  Surg. Journal.
        2 A Treatise on Obstetric Auscultation, translated by Dr. West, p  71. 
9-2 9
NATURAL LABOR.
it has to pass — i. e., first  against  the circle  of the os uteri, and secondly
against the circumference of the vaginal orifice, and it always forms on the
lowest or presenting  part, so that the primary tumor indicates the part of
the head which presented at the os  uteri, and  the  primary and second to-
gether, that which  occupied the  lower orifice.  The  tumor itself consists
most frequently of serum, sometimes with  blood mixed, and in a  few cases
of blood alone.1
  We have already seen, that, in the first position, the primary tumor occu-
pies the right tuber  parietale, and  the secondary, in addition, the posterior
and superior angle of the  parietal bone, with a part of the occipital bone:
in the second position, it occupies the left tuber parietale primarily, and the
posterior angle secondarily : in the  third,  the  primary tumor  is  somewhat
anterifir to the left tuber parietale  ; but by the change to the  second posi-
tion the tuber and posterior  part of the bone becomes the seat of the second-
ary tumor : and  in  the  fourth, the primary tumor is anterior  to  the right
tuber parietale, but  the  secondary tumor includes it and the posterior part
of the bone.
CHAPTER  III.
            PARTURITION. —CLASS  I.  NATURAL  LABOR.

  331. Definition.—The term "natural labor" is applied to those cases in
which the head presents, and descends  regularly into the pelvis;  where the
process is  uncomplicated,  and concluded by  the natural powers within
twenty-four hours (each stage being of due proportion), with safety to the
mother and child, and in which the placenta is expelled in due time.
  Slight differences will be found in the  definitions given by different authors;
for instance, Dr. Power limits the  time  to six  hours ; Dr. Cooper to twelve;
whilst  Dr.  Breen extends it to thirty hours.   Dr. Burns also includes the
fcetus  having  arrived at the full term ;  but these variations are of compara-
tively little importance.   Within the limits I have  laid down there will be
found  room for  great diversity in the  peculiar  features of each case, and
experience teaches  us that scarcely any two labors are  exactly alike.   First
labors  are in general more tedious than subsequent ones, at least  when the
resistance is chiefly from the soft parts.
  332. The following table will show the proportional duration of  labors:—
Dr. Merriman
Dr. Collins
Dr. Maunsell
Dr. Beatty
Dr. Churchill
Dr. Granville
Drs. M'Clintock and Hardy
Total No.	Terminated	In 12	In 18	In 24	Above 24
of Cases.	in 6 hours.	hours.	hours.	hours.	hours.
500	206	398	442	450	
15,850	13,012	15,084	15,346	15,586	264
839	347	647	734	793	36
1182	577	958		1114	69
1285	366	760		1119	166
640		515	above 1	2 hours	104
6634	3882	5280	5706	5852	269
1 Churchill on Diseases of Children, p. 66. 
NATURAL LABOR.                      223
  In addition to these specific details, I may mention that Dr. Smellie cal-
culated that 990 in 1000 are  natural labors : Dr. Leake 900 in 1000 ;  Dr.
Bland found 1792 cases of natural labor  in  1897 cases; Dr. Jos. Clarke
9748 in  10,199; Dr.  Merriman 2607 in 2735;  Dr. Lever 4266 in 4666;  and
Professor Assalini, out of 269 cases, reports 205 as "quick and easy."
  333. It will be observed that I have inserted a parenthesis in  the defini-
tion, to the effect that each stage  should be in due proportion to the other
(i. e., the first to the second  as 2 or 3 to 1), and this I have done to guard
against the error of making time (or the entire duration of the labor) our
sole standard, instead of symptoms;  for a labor may be natural  as to time
(i. e., completed within  twenty-four hours), and  yet if the first stage be very
short (say one or two hours), and the second prolonged (say twenty hours),
the character of the  labor may be altogether changed, and the formidable
symptoms of powerless  labor be developed.
  334. Precursory  Symptoms.—Before describing the ordinary course of
labor, it is necessary to point out  certain  symptoms  which indicate its
approach.   These  vary in  intensity in different women : in  some they are
but slight, and may  perhaps pass unnoticed ;  in others they are very  well
marked.   The most important are, — 1, the subsidence of the abdomen ;  2,
frequent micturition ; 3, griping and  tenesmus; 4,  painless uterine contrac-
tions ; and 5, mucous discharge from the vagina.   Let us examine each of
them briefly.
  335.  1. Subsidence of the abdomen. — We have heretofore seen (§ 157),
that at the commencement of the ninth month the fundus uteri reaches to
the ensiform cartilage ;  but that during  the last month it subsides : this  is
especially remarkable during the  last fortnight, and is sufficiently marked
to attract the attention  of the patient.   The uterine  tumor becomes appa-
rently less, and sinks forward.  It  may probably  be owing partly to the
absorption of the liquor amnii, partly to the lower end of the uterus sinking
into the pelvis,  and partly to some relaxation of the uterine tissue  permitting
a greater amount of  lateral expansion, and a consequent diminution in its
height.   The  tilting forward is  owing to a relaxation of  the  abdominal
parietes, and increases in successive pregnancies: sometimes, though rarely,
it is so excessive as to require the support of a bandage, and even to retard
the first stage of labor by deranging the axis of the uterus.
   336.  2. Frequent  micturition.—In proportion to the enlargement of the
uterus, is the pressure exercised by it upon the neighboring viscera.   During
the last  month, when it  sinks down into the  pelvis,  and falls  forward, the
pressure upon the bladder is considerable, and  its capacity is so much dimi-
nished as to render a  frequent evacuation of  its  contents  necessary.   In
addition, there  is a certain  reflex influence from the  uterus to the bladder,
and an  increase of irritability in the latter, on  account of which it is  less
tolerant  of the  presence of urine  than  under ordinary circumstances.  Its
value as a sign  of approaching labor, however, is lessened by the fact that it
occurs from the same causes, just before the uterus rises out of  the pelvis,
and that it may be present during several  weeks in  the  latter part of
gestation.
  337. ^. Griping, tenesmus, or diarrhoea. — Similar mechanical and reflex
effects of advanced gestation to those just noticed, may be produced in the
rectum and large intestines, and the result will be  an irritable  state of the
bowels,  occasional griping  pains, and a desire to go to stool when but little
is passed.   It  must  ever be  remembered  that this  frequent passing of a
small quantity  of fluid  faeces is quite compatible with a great accumulation
of faecal matter above the seat of  the irritation, and may often be relieved
by a free evacuation.  It is an uncertain sign  of the approach of labor.
  338. 4. Painless uterine contractions.—During the last month of gesta- 
224
NATURAL LABOR.
tion, and especially towards  its termination,  patients frequently  notice n
squeezing sensation in the abdomen, which lasts for a little  time, then sub-
sides, and is not attended with pain.  As was remarked  by Leroux, if the
hand be  placed upon  the abdomen, the uterus will be felt tolerably hard, well
defined, and tilted forwards.   This partial contraction appears in some cases
to be excited by the movements of the child.   I  have never observed it till
towards the termination of pregnancy, except in cases of threatened abortion
or premature delivery.   Velpeau  states that the cervix  uteri  may also be
felt alternately  relaxed and contracted.
   It appears extremely probable that by this painless  mechanism is effected
that change in  the  cervix and os uteri which have been observed to take
place previous  to actual  labor.
   339. 5. Mucous discharge of the vagina.—This is called "the shows" by
nurses :  it is generally observed about twenty-four hours  previous to the
commencement of actual labor, and evidently prepares the passages for the
transit of the fcetus.   The quantity and quality vary : sometimes the fluid is
thin, in other cases  thick and viscid  (which Wigand  says is more favorable),
becoming thinner at the time of labor ; some women  have it profusely, others
scantily.   It is generally colorless  until  labor has  set in ; but  during the
dilatation of the os uteri, striae of blood are mixed with it, arising  from the
rupture of some of  the small vessels of the cervix uteri.
   340. Of these precursory symptoms, it will be remarked, that the first and
third only indicate an advanced period  of gestation ; the fourth, according
to my experience, that labor is  not far off; but the fifth is the  only one
which  shows that it is close at hand.
   In addition to these more marked symptoms,  many minor ones might he
enumerated ; such,  for instance, as swelling of the labia and lower extremi-
ties, cramps in  the thighs  and legs, the improvement of the appetite and
spirits, diminution of the dyspnoea, a sense of greater lightness and facility
of walking, etc. ; but these  being unequal and  uncertain, are therefore of
less value.
   341. Symptoms of Labor. —I shall now proceed  to  the description of
labor in each stage ;  first detailing the phenomena, and afterwards prescrib-
ing the requisite  management.  Before I proceed, I should wish to impress
upon my junior readers  the extreme importance of carefully and  minutely
studying the subject of natural labor, not merely in books,  which must neces-
sarily be  imperfect, but  at  the bedside of the  patient.   No case of labor,
however  simple, can be attended without  some addition to our knowledge,
if we are vigilant:  almost all  recent improvements in practice have arisen,
and  I believe all future ones will arise,  from a more perfect knowledge of
the natural process, and  a more correct appreciation of the natural powers.
   As I have already  treated of the mechanical and  vital agencies employed
in effecting delivery, I shall now confine myself to a practical consideration
of the results.
   342. The commencement of labor is dated by the  patient from the mo-
ment that the  uterine contractions become painful, and correctly so, pro-
vided  the entire  uterus  be engaged, if they recur  regularly and  continue
without suspension.   But this is not always the case;  the  uterus not unfre-
quently at first  acts partially, irregularly,  and inefficiently:  such efforts are
called  "false or spurious pains."   They arise from various causes, such as
over-fatigue, indigestion,  constipation, cold, etc., and  are occasionally excited
by the motions of the child.   A little careful observation will enable us to
distinguish them  from true  pains,  as  they commence about  the fundus,
and are of limited extent, recur at  regular intervals, are  not attended with
the mucous discharge from  the vagina (§ 339), and do  not dilate the  os
uteri, or  protrude the "bag of the waters;" on the other hand, true pains 
NATURAL LABOR.
225
generally commence in the lower part  of the uterus, and are first felt in the
back, extending gradually to the front, recurring with regularity though in-
creasing in frequency, dilating the os uteri, and protruding the membranes.
  As these false pains may occur at any period of gestation, and sometimes
bring on  labor prematurely, or when at the full term occasion distress and
loss  of rest, it is always desirable to  relieve  them :  this may generally be
done by rest, if the patient have  been fatigued, or by aromatic purgatives,
followed by an opiate, if the stomach and bowels are deranged.
  343. The true pains  recur  at  regular intervals, gradually increasing  in
frequency and power; and each  pain  from its commencement augments in
intensity, until, having arrived at its  maximum, it remains stationary for a
short time, and then subsides: thus presenting, as  it were, a type  of the
entire course of the pains.
  The pains exhibit, however, different characteristics according to the stage
of labor, and have therefore been divided into two kinds, "cutting or grind-
ing pains," and " bearing down or forcing pains."  The  cutting or grind-
ing pains " are indicative of, and confined to, the first stage of labor, during
the dilatation of the os uteri.   They are short, severe,  and not very fre-
quent, obliging the patient to suspend her occupation, and partially arresting
respiration, but not inducing  any voluntary efforts.   They are  generally
(but not always) seated in the back, gradually extending round the loins  to
the abdomen and thighs.  The suffering they occasion is very considerable,
and  although (except in some irritable subjects) it  is less than that which
accompanies  the stronger pains  of the second  stage, yet it appears more
difficult to  bear, and the  patient gives utterance to groans and loud outcries.
The outcry which attends upon the cutting pains,  is an excellent diagnotic
mark of the first stage of labor, and in some cases we are obliged to depend
upon it alone.
   344. During the first stage we generally find  the  patient more irritable
and restless  than subsequently,  moving  from one place  to another, and
changing both occupation and position frequently: she is low spirited and
fearful,  weeping  from dread  rather than  suffering,  anticipating  evil, and
scarcely to be comforted.  This distressing state disappears, however, as the
labor advances.  In  some cases the despondency  which  has darkened the
last  few months of pregnancy is exchanged  for cheerfulness and courage the
moment  labor sets in.   In general I  have remarked, that, whatever the
mental condition may have been  during pregnancy, and even the first stage
of labor, the violent pains, severe suffering, and hard  work of the second
stage, occupy the  mind as well  as  body,  to the  exclusion of desponding
anticipations,  and,  as it were,  rouse up all the patient's energy and courage
to meet the exigencies of the  case.  A singular  deviation from mental  in-
tegrity, apparently from extreme suffering, has been the subject  of a valuable
essay by  my friend, Dr. Montgomery;  I allude to the partial and  tempo-
rary delirium which occurs occasionally, just as the head is passing through
the os uteri or os externum.   It  seldom lasts more than a few minutes, and
in one case I attended the patient was conscious of talking incoherently, but
felt quite unable to arrest herself.
   345. During the first  stage of labor, and especially at  the time the head
passes through the os uteri, severe rigors  occur;  not from cold, as they are
observed equally when the patient  is warm, but as  the prelude to a pain.
The surface is generally of the usual temperature, and free from perspiration,
at least till near the end of the stage.  The pulse is  seldom  permanently
quickened until the second stage : although, as Hohl has remarked, if it be
carefully examined, it will be found to become  more  frequent during the
first  part of a pain, then to remain stationary for a moment, and afterwards
to subside.
      15 
226                      NATURAL  LABOR.

  During this  stage also, the stomach is  apt  to  become irritable, and dis-
charge its contents, probably from  sympathy with  the  uterus, rather than
from  mechanical pressure,  as  the abdominal  muscles are  as yet inactive.
This  is always beneficial, as it not only removes indigestible matters which
may be in tfie stomach, but certainly relaxes the cervix uteri.
  346. If the hand be placed upon the abdomen when the pains come on,
the uterine tumor will  be observed to  contract, become  hard, and tilt itself
forward,  so as ultimately  to bring  the axis  of  its  cavity  into complete
accordance wdth that of the brim ; and  after remaining in this state for a
longer or shorter time, it relaxes, but does not quite return to its pristine
flaccidity.
  The results of auscultation are very interesting: M. Hohl1 thus describes
them  : " If we direct our attention to the changes of tone which the uterine
pulsations present,  we  shall find them  generally stronger, more distinct, and
varied in tone during labor, and this is especially the case just before a pain
comes on.   Even if the patient wished to conceal her pains, this phenome-
non, and more especially the rapidity of the beats, would enable us to ascer-
tain the  truth.   The moment  a pain begins,  and even before  the patient
herself is aware of it, we hear a sudden short rushing  sound,  which appears
to proceed from the liquor amnii,  and to be partly  produced by the move-
ments of the child,  which seems to anticipate the coming on of  the contrac-
tion ; nearly at  the same moment all the  tones  of the arterial pulsations
become stronger; other tones, which have not been heard before, and which
are of a  piping resonant character, now become audible, and seem to vibrate
through  the stethoscope, like the sound of a string  which has been struck,
and drawn tighter while in the  act of vibrating.  The whole tone of the ute-
rine circulation rises in point of pitch.  Shortly after this, viz. :  as the pain
becomes stronger and  more general, the uterine sound seems, as it were, to
become  more  and  more distant, until, at  length, it becomes very dull, or
altogether inaudible.   But as soon as the pain has reached its  height, and
gradually declines,  the  sound is again heard as full as at the beginning of
the pain, and  resumes its former  tone, which,  in  the  intervals between the
pains, is as it was during pregnancy, but somewhat  louder."
   347.  An internal or vaginal examination reveals  to us the condition of
the passages, the state of the os uteri,  and the rate of progress.  At an early
period, the  vagina  will be found cool,  moist or dry,  and  undilated, of nearly
the calibre  it  was before labor commenced ; as it advances, however, even
during the  first  stage, the entire canal becomes more flaccid, and if not
dilated,  at least relaxable and  dilatable.   The os  uteri is high up, but not
always in the  same situation : in first labors it is  nearer to the promontory
of the sacrum than the symphysis pubis; in subsequent confinements this is
often reversed.   The  lips of the  orifice are sometimes soft  and thick ; in
other cases hard and  thin ;  the former dilate  more readily,  and the  latter
generally become softer and thicker, before dilatation takes place.  At the
commencement of labor the orifice will readily admit  the point of the fore-
finger, and  by the repeated pains  it is gradually widened, so as to allow the
child to  pass.   The rate of dilatation is slowest at the beginning ; it is said,
and I believe truly, to take as much, or more time  to dilate the os uteri to
the size  of  half-a-crown, than to complete the  process;  and  for a very evi-
dent  reason — viz., the want of a  mechanical dilating  force (§ 303), the bag
of the waters not being protruded until some progress has been made.
   If  the finger be maintained in the orifice during a pain, we feel the circle
tighten and become hard, until the head is  pressing through the cervix ; after
which time the lips are retracted by  each  contraction.   We ascertain  the

               1 Die geburtshiilfliche Exploration, part  i., sect. 105. 
NATURAL LABOR.                      227
progress  of the labor by carefully  estimating the advance  made  by each
pain.
  348. Towards the end of  the first stage, or at the time when the os uteri
is pretty  well dilated, we remark an increase of the sanguineous striae in the
vaginal discharge, and the accession of voluntary efforts, slight at first, but
gradually increasing.   About this time generally, the membranes give way,
the liquor amnii escapes, and by the next pain the head is forced  through
the os uteri, and enters upon the  second stage.
  The phenomena are now somewhat changed, especially in  their intensity.
The pains are more frequent and longer, the intervals shorter, and the suffer-
ing greater in general: but owing to the necessity of fixing  the  chest as a
fulcrum for muscular  exertion, the  breath  is  suspended during a pain, and
the outcry suppressed, except at its termination.  The character of the outcry
is therefore as good a test of the second stage as of the first.   At the acces-
sion of each pain the patient holds  her breath, and seizing  hold of some-
thing with her hands, brings the muscles of the extremities, of the back and
abdomen, to aid the expulsive efforts of the uterus.   These  are the " bear-
ing-down pains" of the second stage.
   It is not easy to explain the change in the character of  the  pains, nor
why straining should occur  only in the second stage.  Wigand attributes it
to sympathy between the os uteri and  vagina, and between  the  abdominal
and other muscles.   It certainly cannot be merely owing to the presence of
the foetal head in the vagina.   No doubt the increased resistance, and the
necessity for more power to  overcome it, is the final cause, though we cannot   ?
thus explain the immediate change, which I believe to be a reflex action, due
to pressure upon  the  lips of the  os  uteri, and soft parts of  the  cavity and
 outlet, as the same effect may often be produced by pressure with the finger,
 just as we may double the strength of the pains by pressure upon the edge
 of the perineum, at a later  period.
   Further, the arrest of the circulation, from the suspension of respiration,
 distends the cutaneous vessels, the surface becomes florid, the face almost
 purple, the veins of the forehead, temples, and neck are distended,  and the
 eyes are bright and prominent;  the heat of the skin  is greatly increased,
 and a profuse perspiration ensues.   The pulse, which was quiet during the
 first stage, or at most quickened during a pain, is now increased in frequency
 during an  interval, and  the changes noticed  by Hohl, are very remarkable
 during the pains; i.  e., it becomes more frequent at the setting  in  of each
 pain,  until it  attains its maximum rapidity, at which it remains  for a short
 time stationary, and then subsides.   At the termination of the second stage
 it will generally be  found  to  range between ninety and one hundred and
 twenty beats in a minute.
   The effects of this arrest of respiration and forcible bearing down are
 sometimes very injurious.   Dr. Blundell mentions having seen  a case of
 general  emphysema during  labor, which he thinks is owing to a  rupture of
 the larger air tubes.  A similar case is reported by Dr.  Abbot, in which the
 whole face, neck,  and chest, were  emphysematous.   It subsided,  eight  or
 nine days after labor, wdthout any unpleasant consequences.
   349. Vomiting also frequently occurs; but in the second stage  it is  as
 much the result of pressure as of reflex irritation, and  it is generally favor-
 able, as  it seems  to  relax  the  soft  parts.   However, as it is  a symptom
 developed  also in  unfavorable cases, it may be well to observe, that it may
 reasonably excite  uneasiness when it comes  on with  symptoms of collapse
 (during  this stage),  after  the sudden cessation  of uterine  action ;  when
 symptoms of fever, such as rapid pulse, furred tongue, heat of skin, etc., are
 present ; when it is accompanied  by abdominal tenderness;  and especially
 if the fluid be sanguineous  or dark colored. 
228
NATURAL LABOR.
  If the second stage be prolonged, the patient often feels heavy and sleepy,
and may doze between the pains, — the result, of the fatigue, combined with
the congestion about the face and head. Under ordinary circumstances this
need excite no uneasiness, as the patient is refreshed by it; but if it be ex-
cessive, and accompanied with headache, especially in  primapara, we must
be watchful, and on  our guard against an attack of  convulsions.
  As the head advances through the pelvis, it presses more  or less upon the
nerves which pass through  that cavity to  the lower extremities,  and gives
rise to spasms and cramps, which add to the suffering of the patient. They
may be partially relieved by friction.
  The pressure of the head also evacuates the contents of the rectum, but
effectually prevents the emptying of the bladder.
  350. If an internal examination be  made at the beginning  of the second
stage, we shall find the vagina dilatable, and as though it had been dilated,
its walls rugous and flabby, and prepared  to yield  to  the  pressure of the
head.  The head  itself will be perceived  at the upper part  of the pelvis,
filling it more or  less completely, descending with each pain, and receding
at its conclusion ; the advance exceeding the recession, and the excess mark-
ing the rate of progress  of the labor.   At a later period the  head will  be
felt on the floor of the pelvis, where it meets with  considerable resistance,
but wdiich  is  overcome by  the mechanism already described  (§  303): we
observe here  the same repeated advance and recession,  the  head each time
propelled a little further than before, and often with a kind of spiral move-
ment, until, after  a time  proportioned to  the difference between  the force
employed and the resistance, the obstacles  yield, and the head presses upon
the perineum, which undergoes the same process of  dilatation.
  351. At this period of the  labor, when  the head is  distending the peri-
neum and dilating the external orifice,  both the suffering and  the exertion

                                 Fig. 104.
Head at the Lower Outlet.
reach their maximum point; and yet it is beautiful to observe how cautiously
(so to speak) and how securely the process is effected.   Adequate expulsive
force is called into action ; and  if it were continuous nothing could save the 
NATURAL LABOR.
229
patient from injury;  but each pain is just  long enough to gain upon the
advance made by its  predecessor ; and the head, detained for a few moments
at its furthest point of advance, then  recedes ;  and this is repeated until the
perineum is completely softened, and  the os  externum dilated.   Nor is this
all;  the resistance offered by the perineum carries the head forward, so that
its lowest point (the  tumor) shall press against  the os, and by the time the
perineum yields, the  orifice is sufficiently wide to secure the proper direction
of the head in its transit.
   At the latter part  of the second stage, the pains are often what is called
"double;" i. e., they succeed each other so quickly, that a new one com-
mences before the former has quite terminated.   At length the force con-
quers all resistance,  and  with a throe of agony the head is  expelled ; after
which there is a short rest, equal  to two or three pains, then  the uterine
power is again exerted to expel the body of the child.
   The second stage  is now completed ; the  suffering,  which was intense, is
exchanged for perfect ease, and  the sense  of  relief is inexpressibly great.
If the  hand be placed on the  abdomen, it will  be found flabby, the  uterus
large, and  moderately contracted.
   352.  The third stage of labor includes the detachment and expulsion of
the  placenta.   In some cases, the  contractions  which expel the child,  expel
the  after-birth.   In  almost  all cases, however, it is partially or wholly de-
tached, remaining in the uterus or vagina, from whence it  may be  expelled
by the natural powers alone, or aided by general traction.
   The interval  which elapses after the expulsion of the  child, before the
uterus again  actively contracts to  expel  the placenta, varies somewhat  in
different cases, apparently according to the  fatigue that organ has under-
gone.   Dr. Clarke found the average interval  to  be  twenty minutes.   Out
of 654 cases which I have accurately noted in  my own private practice, I
 find that in 468 the  placenta was expelled in (within)  five  minutes ;  in 119
cases,  within ten minutes; in 35, within  fifteen minutes ;  in 16,  within
twenty minutes ; and in  18 within half an hour.
   Where due attention has not been  paid, the  interval will  be longer; but
from the above data we  may conclude that  in natural labor the  placenta  is
 more or less  detached by the concluding pains  of the second stage  of labor,
 and that it ought to be expelled within an  hour or an hour and a half, and
 that when  the interval exceeds this, the case fairly comes  under the  order
 of " retained placenta,"  of which I shall treat hereafter.
   When this interval, whatever it be, has  elapsed, the uterus again con-
 tracts, but much less forcibly, and by one or two pains, the connection be-
 tween  the  placenta  and uterus is  completely severed, the now useless ap-
 pendage is extruded into the vagina, and by the contraction of this  canal
 is expelled, with a gush  of  blood or  clots (dolores cruenti).   The bag of
 the  membranes is generally turned inside  out, especially if the after-birth
 have been  extracted  by pulling the cord, and the situation of the perforation
 in the  membranes through which the  child passed will enable us to estimate
 the  distance  of the placenta from the os uteri;  the distance of the perfora-
 tion from the placenta being exactly  the same as the  distance of the  latter
 from the os uteri.
   353.  Management of Natural Labor.  —Let us now turn from the de-
 scription of the phenomena of natural labor to  a consideration of the duties
 of the  attending accoucheur,  and the mode of  managing  such  cases.  I
 have already stated  that most of the modern improvements in midwifery
 have resulted from a more correct  appreciation  of the natural powers ;  so
in the management  of natural labor  the  great improvement has been the
 absence of interference.  There is, in  truth, but  very little for the accoucheur
to do, if the  case be natural and the circumstances favorable, and very little 
230
natural labor.
that he needs, except patience and gentleness;  and  therefore the old prac-
tice of carrying certain instruments  and certain medicines about with  him
is strongly to be deprecated, as to say the least, a  needless exposure of him-
self to temptation.   All the surgical appliances needed are,  an  elastic-gum
catheter  (male) and a  lancet; and, if in the country, a  small  quantity of
laudanum, ergot, and tartar emetic.   He ought also to be provided with a
few strong pins, and  some  ligatures of twine  or tape ;  and if there be a
prospect of much delay, he will not be the worse of a book  in  his  pocket.
But to return ;  although there is little to do in a natural labor, we cannot
of course assume that any case to which we  may be called is of this class,
without inquiry;  our first object, then, when summoned  to a patient, is to
ascertain her present state, whether she be in labor  or not, etc.  ; if she be,
the presentation and position of the child, the rate  of progress and probable
termination of the labor.
  354. As to the present state of the patient,  a careful examination of the
bodily functions generally,  and  of the pulse,  tongue, skin,  etc., will show
whether the patient is in ordinary health, or  whether we  may have  to con-
tend with any complication, as  fever or organic disease;  and the  informa-
tion may enable us to  anticipate, and perhaps prevent  some attacks.   A
more minute investigation must be instituted into the state  of the uterine
system, as to the presence  of true pains ;  their frequency, force, and regu-
larity ; the character  of  the outcry,  the  amount of voluntary effort,  the
quantity  and quality of vaginal discharge,  etc.  By these  symptoms, we
shall be able to form an opinion as to  the existence  of labor, the stage  and
rate of progress, and  the preparedness of the passages, etc., and also as to
the propriety of seeking for more special information, by means of a vagi-

                                Fig. 105.
Vaginal Examination.
nal examination.   This will add to the information previously acquired,  a
knowledge of the presentation and position.
  255. It is not possible to fix a definite time for this examination;  for in
many cases it will  depend upon the patient.   It  may, however, be stated
generally, that it is satisfactory to  make it as  early as* convenient, and that 
natural labor.                      231
certainly no time should be lost after the escape of the waters, lest we miss
the best opportunity for  rectifying a mal-presentation.  Further, the at-
tendant should never leave his patient for more than a few minutes, unless
he has ascertained  that all is right.  The frequency with which the exami-
nation should be repeated must  depend  chiefly upon the rate  of progress.
During the first stage (judging by  the outcry and cool skin) it is  scarcely
necessary, if once  we have  ascertained  that all  is  right;  but during the
second stage, it may be repeated  according to  the rapidity of the  advance,
every four, six, eight, or ten pains;  and when  once  the head  distends the
perineum, the accoucheur  should  keep his finger upon the head during each
pain,  so as to regulate the support  necessary for the  perineum.   To the
junior student only can any directions as to the mode of making an exami-
nation be necessary, and they may be brief.  The patient should  lie upon
her left side, with the hips near to the edge of the bed, and the knees drawn
up towards the abdomen.   The forefinger of the right hand  (or two fingers,
and in some cases those of yie left  hand) having  been  well oiled or soaped,
should be passed along the perineum, and into the vaginal orifice ;  it is then
to be  directed upwards   and  backwards,  towards the  promontory of the
sacrum, until the os uteri  or the  presenting part be found.   Having  done
this, we shall be able to estimate the calibre, heat, and moisture of the vagina,
the dilatability of the os  uteri, the resiliency and general condition of the
cervix, as well as the actual dilatation by the bag of the waters, or the fcetal
head, during a pain%  If  the  membranes be  entire, an  experienced finger
will in most cases detect the presentation ; if they have given way this will
be much more easy and certain ;  and if  it be the head, by  finding the fon-
tanelles and comparing their situation with certain parts  of the pelvis, the
position may be determined.
   It is generally recommended to introduce the finger during a pain, as less
unpleasant to the  patient; but  the  examination must occupy both a pain
and an interval, if we hope to obtain full information.  A comparison of the
knowledge thus obtained, with  the frequency and  force of the pains, will
enable us to estimate the  rate of progress of the labor;  and these results,
combined with the  local  and  general condition  of  the  patient, will afford
adequate grounds  for our prognosis.   In  conclusion, I would  earnestly
recommend to my junior  readers  to take every opportunity of passing the
catheter and making vaginal examinations in the  dead subject as well as the
living.
   356. We will now suppose that the conclusion from  these  investigations
is favorable, that  the patient is in  good  health, is really in labor,  that the
head  presents, and  that  she is  making  a sufficiently rapid progress, with
every prospect of a safe termination.
   It is not necessary during the  first stage, that the accoucheur should stay
in the room with the patient, nor even in the house, if the  progress be slow ;
before leaving her,  however, he must be  certain that all is right, that every-
thing is in readiness ; and he must give some general directions to the nurse.
The patient is better  out of bed during the early part of the labor, if it
happen in the daytime, as she will  be less fatigued, and probably less impa-
tient than if she lay in bed the whole time ; she may rest on the sofa when
tired, and occasionally walk about, or pursue  any slight  occupation if she
be able.
   It is very desirable to keep her tranquil and cheerful, for which  purpose
she should be told  of all that is favorable in her case, and all subjects calcu-
lated to depress her spirits should be  avoided.  In this matter much depends
on the nurse, who  should receive proper cautions.  I am satisfied that in
most, if  not in all  cases, it is  better  to  deal frankly with our patient, and
not to make false promises in hopes of encouraging  her  to  bear the pains. 
232
NATURAL LABOR.
Let her be told that all is favorable, and that, as far as we can judge, the
labor will terminate  safely for herself and  her child, and  she will bear to be
told  that she has yet some time to suffer.   Moreover, as it is impossible to
calculate with accuracy upon the duration of a labor, an  assurance  that it
will be over in a certain time  will, in all probability, issue in disappointment:
and if so, in  distrust either of our truth  or skill.   I have dwelt  upon  this
the more, because nothing is more common  than for the  patient to beg of
the attendant to say how long she will have to endure the pains.
   During  this first stage the  patient may be allowed her usual diet, but
without stimulants, as it is rather advantageous to have  the stomach occu-
pied.  The bowels  should be freed  by medicine or enemata, if  necessary,
and the urine regularly evacuated ; and it may be as well to put my junior
readers on their guard against a  frequent error of nurses, in confounding the
dribbling of the liquor amnii,  after the  rupture  of  the membranes,  with
"passing water."   I  need  not  say that this  may take  place,  and yet the
patient suffer from retention  of urine.
   357.  The patient  should be cautioned against making any voluntary effort
during the first stage ;  at least,  until obliged by the increasing  violence of
the pains, as no effort can at this time hasten the labor.  "Women," says
Dr.  Denman, "may be assured that  the best state of mind they can be in
at the time of labor is that of submission to the necessities of  their  situ-
ation ; that those who are most patient actually suffer the least; that if they
are resigned  to their pains, it is impossible for them ^>  do wrong, and that
attention is far more frequently required to prevent hurry than to forward a
labor."
   Neither is it necessary, as was formerly taught, for the  accoucheur to en-
deavor to hasten the labor by manual dilatation of the os uteri or passages;
such an "abominable custom," as Denman justly calls it, would rather  have
the  effect  of retarding the  labor by the irritation it  would occasion, and
might, as in a case I witnessed, give rise to  inflammation, and sloughing
afterwards.
   358.  Among the  matters  which should be in readiness are two or three
short pieces of tape or twine, for tying the navel-string, a pair of  scissors,
some strong  pins, and a binder.  The latter should be made of a double of
diaper, nearly half a yard wide, and long enough to go round the hips, and
to allow for pinning over.  These things ought to be provided by the nurse;
but  as labor sometimes occurs unexpectedly, or the nurse may be forgetful,
it is well for the  attendant to have a supply of twine and pins, with a pair
of scissors, in his pocket-case.   Towards the end of the first stage it is cus-
tomary for the nurse to "make the bed," which is done by placing a skin of
leather or a square of oiled silk over the blanket and mattress, to protect it,
at that part  of the  bed which will be occupied by the  patient's hips;  over
this is placed the sheet, and  upon this two or three sheets folded  square, on
which the patient is to be placed.  These folded sheets  will absorb most of
the  discharges,  and can  afterwards  be  removed  without disturbing the
patient, leaving dry bed-linen underneath.  The skin or oiled silk is allowed
to remain for some time longer.
   359. Soon after the second stage of labor has  set in, the patient (espe-
cially if she have borne children before) should undress, and go to bed.   The
position for  delivery has varied in different times, and still varies in  different
countries.   In the earliest times the  sitting posture was preferred : and in
Ambrose Pare, Deventer, and other old  writers, we have a description and
plates  of labor-chairs, one  of which the  late Professor  Hamilton used to
exhibit to his class.    In China and Cornwall the patient is delivered  upon
her knees, or leaning  over something.  In Darfour a pole is fixed across the
room, which the patient holds with both her hands, and is delivered standing. 
NATURAL LABOR.
233
In France, and some parts of Germany, the woman is placed upon her back,
with the  knees drawn  up ; but  serious objections exist to either of these
plans;  by far the best  and  most natural position is the  one now adopted
almost  universally in Great Britain and in  many parts of the Continent —
viz., on the left side, the hips being close to  the  edge of the bed, and the
knees drawn up towards the abdomen.  It is usual to place a pillow between
the knees to keep them separate, but I cannot say that I think it of any ser-
vice.   The patient's night-dress sh<3uld be  drawn up underneath her, above
the hips, to escape soiling ;  and she may be  allowed to grasp a sheet fastened
to the bed-post, or, what is much better, the hand of an attendant.
  But  although I have advised that the patient should  lie down soon  after
the commencement of the second stage, it is  not  necessary that she  should
remain in the one position the whole  time, provided that  the proper one be
assumed before the head  presses upon the perineum.
   [The position upon the left side, with the knees drawn  up, is that almost
universally directed  by American accoucheurs, and  it is  certainly the one
which is the most convenient to the practitioner, and productive of the  least
possible exposure  of the female's person.   It is only, however, when the
labor is proceeding rapidly that  it is  necessary for the female to retain, un-
interruptedly,  the  position described.   Change of position, or even rising
from the  bed and sitting in  an easy chair, in  cases where  the  labor  is  pro-
ceeding slowly, will conduce to the comfort  of the  patient,  wdiile, at the  same
time, it will often prevent injurious consequences from the heat, pressure,
and constraint liable to result from long continuance in one position.]
   360. In most cases the liquor amnii escapes about the  beginning  of the
second stage,  but  occasionally, when the  membranes  are unusually tough,
they remain entire  until the head has cleared the os uteri,  or even, but more
rarely,  until it is  passing through the os  externum.  When we are quite
satisfied that the head has passed through the os uteri, we may rupture the
membranes  by pressing  the  finger against  them during  a  pain, as  their
integrity is an impediment to the advance  of the  child after this time ;  but
it should not be done hastily, nor until we  are certain  that their usefulness
is at an end.  When the patient  becomes hot, the  bed-clothes should be
lightened, and  the room  at  all times be  kept pleasantly cool and fresh.
Food cannot be taken at an advanced period of the labor, but warm drink,
such as whey, gruel, or tea, may be allowed.
   361. When the head is on the floor of the  pelvis, the accoucheur  should
take his place by the bed-side, and examine gently during each pain  for the
purpose  of deciding when  it is necessary to support  the perineum.   The
object  in  supporting the perineum is twofold ;  first, to  afford a moderate
counterpoise externally to the pressure exerted from within, so as to prevent
the structures yielding  under sudden or severe pains ;  and secondly,  to pro-
long (as  it were) the curve of the sacrum, and so make certain of the  head
being carried forward to the  orifice of the vagina, instead of being forced
through the perineum for want of such a direction forwards.   Now to  fulfil
these two objects, it is  clear that we  need not interfere at all until the  peri-
neum is distended  and protruding; but when we find  this to be the  case,
then we should cover the left hand with a soft napkin, and apply the  back
of it along or across the perineum, commencing at the coccyx and reaching
to the  anterior edge.   The  amount  of pressure  needed  is but little ;  no
attempt must be made  to retard the  progress of the head ;  but whilst the
perineum  near  the coccyx is  firmly supported, the  more  anterior  portion
should  be left free  to yield before the pressure of  the head.  Neither is the
skin to be retracted when the head  presses through the  orifice, but rather
carried forward, so as to lessen the chance of laceration. 
234
NATURAL LABOR.
  Either hand  may of course be used;  I  prefer the left, because it leaves
the right at liberty to examine, and to receive the head of the child.
  Let me repeat, that to make our assistance useful, and not injurious, the
support should be moderate, equable, and rather firmer near the coccyx (but
yielding as that bone yields), than towards the anterior edge;  that it need
not be afforded until the perineum protrudes ;  that then it should be afforded
during each pain,  and until  the  pain  has entirely ceased.   I really believe
that it would be better not to touch  the' perineum than to make injudicious
pressure ; it has been my lot to witness more than one  case where rupture
was  owing to excessive and  injudicious support.
  362. As the  head passes through  the vaginal orifice,  the accoucheur
should receive it into his right hand, allowing it to make the usual rotation,
and  carrying it forwards as the pains expel the shoulders and body  of the
child.  The left hand must be employed in supporting the perineum  as the
shoulders press forward.   When  the head  is  expelled, the nurse  should be
directed to make gentle steady pressure upon the uterus, and to follow it
down, keeping her hand firmly upon it until  the  binder  is applied ; by so
doing we shall rarely have any trouble or delay with the after-birth.  In the
large majority of cases in which  I have taken care that this practice was
adopted, the placenta was expelled within  ten minutes, as  I  have recently
shown.
  When the child is born,  its mouth  should be  examined, and  any mucus
that may  have accumulated  in it  removed.
   It not  unfrequently happens that the funis is coiled around the  child's
neck, and fears  have been expressed of its  retarding the expulsion  of the
body, or causing  the rupture of the cord, or the  inversion of the uterus.
These fears I believe to  be  unfounded, for extensive researches  show that
the funis is never twisted round  the  neck,  unless it be beyond the ordinary
length, and yet the ordinary length is sufficient to permit the birth  of the
child, after deducting the amount lost in the coiling.  A very few cases are
on record of cords so short (six or eight inches) as to require division before
the child could be delivered ;  but in ordinary cases, if we find, on examina-
tion with the finger when the head has  escaped,  that the cord  is twisted
round the neck, all we need do is to draw down more of the cord, and slip
the loop over the head or shoulders.   If we cannot do this, we must loosen
the cord as much as we can,  so as to prevent the strangulation of its vessels,
and then wait for the uterus to expel the child.
   363.  There is generally a short interval after the head is born  before the
pain expels the  body, and it occasionally, though seldom, happens, that this
interval is prolonged, to the manifest risk of the child,  whose face and head
become livid and swollen, and it endeavors  in vain to breathe.   If it be
allowed to remain thus, it wall die of apoplexy ; but, on the other hand, if
we extract it hastily, without uterine action, there is danger of hemorrhage.
Under these circumstances, we have the choice of two evils, and must  choose
the  least : the nurse should be directed to use friction over the uterus, and,
if this fail in exciting it to action, she must make firm pressure on that organ,
whilst the accoucheur takes hold  of the child's head, and inserts a finger into
the  axilla, and gently extracts the body.   The hemorrhage may be prevented
by pressure, but nothing can save the child but removal.  I have repeatedly
acted thus, and without any ill consequences.
   364. If the child be healthy, and have not suffered from pressure,  etc., it
will cry as soon as it is born, and when  respiration is established, it may be
separated from' its mother, rolled in flannel, and removed.  This having been
done, the hand  should be placed  upon the abdomen to ascertain (from the
size of the uterus) whether there be twins ; if not, we may proceed to apply
the  binder, which should embrace the hips inferiorly and the whole abdomen. 
NATURAL LABOR.
235
It should be pinned firmly, but not  too tight, and  be kept  on during the
whole time the patient is in bed.   I  do  not  know that we can  consider the
binder absolutely necessary.   Dr. Davis states that he has not  used one for
fifteen or twenty years, except in cases  of flooding ; and Mr. Kesteven has
written  an elaborate  paper to disprove its necessity and to show that its
supposed advantages  have  been exaggerated.1   I  cannot agree with these
gentlemen, however, for I am  satisfied that it is very useful, at first in main-
taining a certain degree of contraction of the uterus, and giving support to
the abdomen, and afterwards in promoting a return  to the  natural condition
of the uterine and abdominal parietes ; for which reason I  think it deserving
of rather more attention than  is usually paid  to it, at least  after  the first day
or two.   1  believe that, if it be duly applied during the time the patient
keeps her bed, she will avoid that loose state of the integuments, which gives
rise to what is called "pendulous belly."
   [It is not the general  custom  in this country to apply the binder until
after the delivery of the  placenta, nor until  then do we think  it necessary.
When, however, the labor is completed, the application of a proper bandage
adapted to embrace the entire abdomen  from the pubes to the cartilages of
the ribs, and  to gently and  moderately compress  the uterus,  is a measure
from which the best effects are always derived.   It gives an agreeable sense
of support—prevents the faintness which is liable to follow the  expulsion of
the fcetus and secundines, especially in cases of rapid labor occurring in deli-
cate subjects—assists the  contraction of the uterus, and  in  this manner is
an additional guard  against  hemorrhage.   The bandage should be so ap-
plied as to make the most  pressure at the hypogastrium and the least at the
upper portion of the abdomen.  In  many cases  it may be desirable to aug-
ment the compression  directly over the uterus  by the application  at this
 point of a napkin,  once or twice folded, beneath the binder.]
   365.  When the  binder  is applied the hand should  be placed firmly  upon
 the fundus uteri,2 and the patient may be allowed to rest awhile, if there be
 no flooding; after which,  when the  uterus contracts, gentle traction should
 be made by the  funis, to ascertain if the placenta  be detached ;  if so, and
 especially if it be the vagina, it may be removed by continuing the traction
 steadily in the axis of the upper outlet at first, at the same  time making
 pressure upon the  uterus ;  if the cord  do  not  yield,  the after-birth is not
 detached as yet, and no force must be  used.  A little  patience, with  occa-
 sional frictions to the uterus,  will be all  that is necessary.
   [In our  attempt  to extract the placenta by careful and judiciously directed
 traction on the cord,  the latter is to be  taken  hold of,  with  one hand, near
 its cut extremity, and entwined about the two first fingers to render the hold
 more secure, while the first two  fingers of the other hand are passed, along
 the course  of the cord, into the vagina, as well  to  note the progress of ex-
 traction, as to facilitate this by gently depressing  the  cord and by serving,
 at the same time, as a pulley to  give a proper direction to the tractive force
 exerted upon the cord.  Traction is  to be  made  in  the  first  instance in a
 direction downwards  and  backwards, until  the placenta has reached the
 vagina, when the direction of the traction is to  be  changed to  upwards and
 forwards, in the direction  of the axis  of the vagina.   The  position of the
 hand is very well illustrated by  fig.  106.]
   After the placenta has  been expelled  or withdrawn, the  binder may be
 tightened  if necessary, and a warm napkin applied to the  external parts.
 The soiled  sheets  underneath the  patient  may  be  removed, and the night-
 dress drawn down ; but no further  change should be  made for two or three

   1 Med. Gazette.  Sept. 12th,  1851.  The binder is the subject of a paper in the Lancet,
 July 7. 1855, by Dr. Gilmour,  of Liverpool.
   2 Robertson's Phys. and Diseases of Women and  Midwifery, p. 354. 
236
NATURAL LABOR.
hours, as it is most important for the patient to avoid all exertion at this
time.   In some places and with some practitioners it is customary to give
stimulants on the completion of labor ; but as they  are unnecessary in ordi-
nary cases, they must be  used very moderately.  Rest and  quiet are the

                                [Fig. 106.]
                     Extraction of the Placenta and Membranes.

best and only necessary restoratives.  A still stronger objection exists in
my mind against the practice of giving a dose of laudanum, unless specially
called for, as it  may suspend uterine  action, and give rise to hemorrhage.
We may depend upon it that  nature  is  fully equal  to the emergency, and
that the less we interfere the better for our patient; in the words of an emi-
nent writer, "Meddlesome midwifery is bad."
   Although our duties are now ended as  far as the mother is concerned, we
should allow an hour to  elapse before leaving the house, and before we go
we should carefully examine the surface, pulse, uterine tumor, etc., and ascer-
tain from the nurse  the  amount  of  discharge, so that we may be satisfied
that all is right, or if wrong, that we  may remedy it promptly.  We ought
also to visit the patient after six  or  eight hours,  to see that the progress of
the convalescence  (to be presently described) is favorable.
   366.  Now let us  return to  the child : after waiting until respiration is
fully established, or until the pulsation in the cord cease, a ligature is to be
placed upon  the funis about two inches from the navel, and a second a few
inches further on ;  and the cord divided between the two  by the scissors.
Some  foreign writers object to the  ligature  as unnecessary, and the case of
animals has been  brought forward  as a  proof;  but Dr. Hunter has shown
that their mode of dividing the funis prevents hemorrhage by the "torsion"
exercised upon  the vessels, and most practitioners  of any standing must
have met with cases where hemorrhage  occurred in spite of a ligature; so
that in these countries the propriety of the  practice  is generally admitted.
In former times,  as we find from the writings  of Johnson,  Aikin, Whyte,
and others, but one ligature was used  ; but on the authority of Denman, the
second ligature was added to prevent mischief, if there  should be a second
child with a vascular communication  (as sometimes happens)  between  the
two placentae.   Dr. Dewees objects to  this, on  the ground  that the loss of
blood hastens the extrusion of the placenta  ; and Dr. Wood's1 experiments
so far confirm Dr. Dewees' opinion.   The end of the funis should always be
examined  before  the child is  dressed, and  if any oozing have occurred, an
additional ligature must be applied nearer to the umbilicus.   This fragment
1 Edinburgh Monthly Journal, June, 1849, p. 853. 
NATURAL LABOR.
237
of the funis gradually dries up, withers, and falls off on the fifth or sixth
day generally, though the  time may vary from  the second to the fifteenth
day; and the surface contracts and cicatrices.  In some cases, however, the
centre remains red, prominent,  and moist, like a large granulation, with or
without bleeding.  I have  found it cured easily  by alum or nitrate of silver.
In one  case Dr. Simpson  mentions1 that the granulation increased to the
size of a cherry, and was  not relieved  by caustics;  he applied a ligature
around its base, and it dropped off in  a few  days.
   367.  Thus far I have described the ordinary management of ordinary
cases, both as  regards mother  and child ; but  there are not unfrequently
slight deviations from this simple course, and some of them  as regards the
child must now be noticed.   For instance, when  born it  may be in a  state
of defective vitality, asphyxia, or apoplexy.
   1.  It may be in a state of anaemia,  syncope, or asphyxia, from uterine
hemorrhage, too early detachment of the placenta,  or defective nutrition.
In these cases  very feeble,  if any, efforts at  inspiration  take  place, there is
no pulsation in the cord, and the action of the  heart is very weak.  There
is consequently no object in preserving the utero-fcetal connection ;  the  funis
should be tied and divided, and the child plunged into a warm bath : if this
fail, cold effusion must be  tried : but that which I have seen  most effectual,
is light and  rapid friction of the  body and extremities with warm flannel,
 with  or without stimulants.  Tickling  the  nose  or  fauces with a feather,
 electricity, and stimulating enemata, have been recommended ; but I am not
 aware that they have been very successful.   Inflation may be  tried by means
 of a  proper  tube  introduced into  the  larynx, or a flexible catheter passed
through the  nose, and with greater prospect of success  than most of the
 other means.   Great care  must be taken to introduce the instrument cau-
 tiously and correctly, and to inflate slowly and  gently.  The " Marshall
 Hall" method  has recently been successfully  employed in these cases, and in
 all it ought  to be tried, but  I  have found  friction the most effective.  In
 some cases, the infant, apparently healthy, is born dead, without anything in
 the nature of the labor to account for death ; and in such  cases, I have been
 led to believe,  it may be owing to intra-uterine  pressure upon the cord, per-
 haps from its  being coiled round the body or limbs.
   2.  In other cases, the child may be in a state of oppression or asphyxia
 from prolonged labor, or from some deviation from the normal presentation,
 etc. ; but in such instances  the  pulsations  of  the funis, though weak, are
 perceptible, the color of the surface is natural,  and the  shape of the head is
 unaltered.  Here it would  evidently be wrong to divide  the cord until respi-
 ration has been established; therefore, placing  the infant in such a position
 that  there shall be no impediment to the circulation through the cord, we
 must adopt some  of the plans already mentioned for its restoration.   Fric-
 tion with hot  flannel, warm baths, aspersion wdth cold water, stimulants to
 the surface, or inflation may be in  turn tried, until the child makes an  effort
 to breathe.   When it has fully recovered, the cord may be tied and divided.
 If these means fail, we may try the effect of  loss of blood by cutting across
 the cord and allowing a dessert or table-spoonful of  blood to escape before
 applying the ligature.  Should this not succeed, the case is hopeless.
   3.  There is a third  class of cases  when  the child is threatened with or
 attacked by apoplexy, from prolonged labor, the pressure of a narrow pelvis,
 or (as already noticed) from an interval elapsing between the birth of the
 head and body.  In such, the heart's  action is  labored, the pulsation in the
cord  feeble and oppressed, the surface blue, the  face livid, and in some  cases
 the form of the head is changed.   The treatment is exactly the  opposite of
i Edinburgh Monthly Journal, July, 1847. 
23S
NATURAL LABOR.
            that for the first class of cases ;  unless the circulation be relieved, the child
            will die  of cerebral congestion or apoplexy; therefore the first thing to be
            done is  to divide  the cord, and  allow from half an ounce to an  ounce of
            blood to escape ;  after wdiich we  generally find the surface paler,  the pulse
            quicker  and firmer, and  an effort made to respire ; the cord may then be
            tied.   If respiration do not take place, cold sprinkling, warm baths, friction
            or inflation may be tried.
               Dr. Ogier Ward read an interesting paper before the Royal Medico-Clii-
            rurgical Society, upon the immediate and more remote effects of compression
            of the head during parturition.   To this he attributes symptoms of imperfect
            cerebral development and  its consequences, epilepsy and paralysis.   The
            remedy he considers to consist in establishing full respiration as soon as pos-
            sible, during which the depressed  portion of the skull may be observed to
            expand  and assume its natural shape.1
               I have  only to  add, that in all these cases  we should not  be  easily dis-
            couraged, but continue  our efforts for  a considerable time, as  we  often
            succeed after a longer time than we should  have believed possible.
               [The assertion has been made by authorities of great weight, that in every
            case of  simply suspended animation in the new-born infant—that is to say,
            in every case  where there is no  defect of development  in  any important
             organ, and where  no vital part has received serious injury either  before or
             during birth—it is possible, by proper management on the part of the medi-
             cal attendant,  to induce respiration, and by so doing secure life and viability
             to the still-born fcetus.   This assertion is entirely  confirmed by our  own
             experience.
               In  a very  able lecture on suspended  fcetal  animation, its causes and
             management, published by Dr. J. Gaillard Thomas, of New York, in the early
             part of 1860,  the  cases of still-birth are arranged into four classes.  In the
             first, the non-occurrence of respiration is referred  to non-oxygenation of
             the blood of the foetus during the latter portion of its intra-uterine exist-
             ence, in consequence of compression of the cord, of severe and  protracted
             compression of the placenta, from a spasmodic or unintermittent contraction
 ..,_.,_•■■.  of the uterus, as takes place especially under the influence of ergot, to he-
      '■'- '•'-■ ^ morrhage from  partial  or complete separation  of the  placenta,  previously
^- ■  • -  •-. v • * to birth, and finally to maternal loxaeniia^   In  this form of still-birth, there
 f«hr-i"- <  is duskiness of the infant's face, purple and pouting  lips, glassy eye, non-
 tt^ \AtrrJ~ -  flaccid,  unyielding limbs, a very feeble intermittent, or  no pulsation of the
             heart, and  entire  absence of respiration.   The  treatment of this form of
             asphyxia neonatorum is to excite, if possible,  respiration, by removing any
             mucus that may be accumulated about the fauces of the infant, by slapping
             it smartly upon the buttocks  and chest;  by blowing suddenly and forcibly
             in its face and mouth, and  dashing cold water upon it with the hand. These
             failing,  we should expose the infant to a draught of cold air, and  while thus
             exposed, put at once in  practice Marshall  Hall's plan of postural respira-
             tion.   The action of the lungs being thus induced, the circulation is to be
             promoted by upward friction  of the  limbs with  the hand, without intermis-
             sion of  the respiratory efforts, and when the stagnation of blood in the lungs
             is disappearing, but not before, by the use of the warm bath.
               A second form of still-birth  is produced, according to Dr. Thomas, by
             the fcetus being subjected during birth to causes which  produce a sudden
             cessation  of  the  heart's action,  as  compression of the  fcetal brain,  from
             overlapping of the bones of the skull at the sutures in its passage through
             the pelvis,  loss of blood, from rupture of the cord, or an arrest of the supply
             of blood to the fcetus by the compression  of the flaccid coats of  the veins,
1 Lancet, March 15th, 1851. 
NATURAL  LABOR.
239
while the more unyielding coats of the arteries allow a flow of blood from
it towards the placenta.  The child still-born from these causes is pallid, its
limbs are flaccid, and its face sunken  and cadaverous.  In these cases, the
first endeavor should be to establish respiration and circulation by the same
means as have been just detailed.   The cord should not be divided or tied,
until respiration is fully established ; it should be  gently stripped by the fin-
gers in such a manner as to press all the blood it contains slowly and steadily
into the infant's body.
  The third form of still-birth is from cerebral congestion.  It is caused by
obstruction of the circulation through the vessels of the neck, in cases of
face  presentation,  by the constriction  of  these vessels  by  the  cord, and by
the compression of the chest in -cases of tardy delivery  of the shoulders.
The infant presents a dark  purple congested condition of the face, puffed and
violet-colored lips, protruding eyes, and general intumescence of the head.
The treatment in such cases  is  embodied, according to Dr. Thomas, in the
following three directions :  1st.  Let blood flow freely from the severed cord,
to the extent of an ounce or more, as  the symptoms may demand;  2d.  Es-
tablish artificial respiration;  and 3d, Avoid  the warm bath.
   The fourth form of still-birth is from hemorrhage of the brain, the result
of intense or persistent congestion  of  the encephalic vessels, or of injury of
the fcetal head by its being forced, by  violent uterine  efforts,  against some
prominence  of a  deformed pelvis, or by the unskilful  use of instruments.
 Cerebral hemorrhage may be  suspected in the still-born infant when, in addi-
tion to the symptoms of congestion, there is a stupid, listless condition con-
tinuing after the establishment of respiration, or when  an  attack of convul-
sions supervenes, followed, in both instances, within a short period by death.
 In  the very few cases in which  the infant  survives, it may continue  hemi-
plegic for many months, and  ultimately recover.   The treatment is the same
as in still-births from cerebral congestions.]
   368.  The tumor of the scalp, already noticed, subsides in a very short
time, without requiring any application in most instances; other cases, how-
 ever, are not so tractable.  The more simple tumors consist of serum effused
 underneath the scalp ; others, of serum mixed with blood :  again, in more
rare cases, we find blood effused under the pericranium ; and lastly,  in addi-
 tion to the blood effused, the pericranium appears to secrete a  ridge of bony
 substance limiting the effusion.   These  cephalcematomata, which are very
 rare, are about the size of an almond, apparently not painful, and may be
 distinguished  by their persisting for several days, and by the semicircular
 ridge or boundary, which can  be felt by the finger.1  No doubt they are fre-
 quently the  result of pressure, but not always, as I have seen them form
 twenty-four hours  after birth; and they do not disappear as  do  the other
 forms of tumor.   Spirit or stimulating lotions may be used, and in some
 eases they will be successful;  in others it will  be  necessary to lay open the
tumor and apply simple dressings.   The reader may consult upon this sub-
 ject, essays  by Wagstaffe,  Gedding, Naegele, etc., and the works of Osian-
der, Michaelis, Grcetzer and Valleix.
   369.  The only  remaining  deviation from  the  normal  condition  of  the
infant which I shall notice, is umbilical hemorrhage, either before, or much
more frequently after, the  separation  of the remains  of  the navel-string,
and which is always very difficult to manage, and often fatal to the infant.
   It is not of very frequent occurrence, which may be the  reason why it has
been omitted from most systematic works, or  treated very slightly.   How-
ever, increasing attention has  been shown to it latterly, and we possess valu-

                   1 Churchill's Diseases of  Children,  p. 66. 
240
NATURAL LABOR.
able papers on the  subject by Radford,1 Homans,2 Ray,3 Bowditch,* Pout,
Manley,5 Bailey,6 Minot,7 Willing,8 and Smith.9
  It is remarkable that the majority of the cases on  record were male  in-
fants, and also that in some cases there  appeared something  like an here-
ditary predisposition, two or three children of the same family having been
attacked.   Mr. Ray's case was the third  male  child (of the same mother)
who had died of umbilical  hemorrhage, and he  mentions having been  in-
formed of a family in which four male children died from the same cause. Out
of thirty-two cases collected by Dr.  Minot, twenty-two were males and ten
females.   He  mentions one case, communicated by  Dr. A.  Hooker, of a
woman who lost four children, and another who lost two, in this way.
  370. The causes of this hemorrhage are.somewhat obscure ; in some cases
it seems to be owing to a defective ligature of the cord ;  but in others, and
these are  the more numerous, to causes more  deeply seated.  I think  the
cases, as far as our knowledge extends, may be classified as follows :
  1. If violence be  used  to the  remnant  of the funis at any period before
its decadence,  it may give rise to hemorrhage, as in  the  case  recorded  by
Dr. Hill.10
  2. If, when the remains of the funis fall off, the vessels have not undergone
the process of closure and healing, a very alarming hemorrhage may result,
and one it may be impossible  to  arrest.   Of this kind were Dr. Radford's
and Mr. Willing's cases.
  3. In a case which occurred in my own practice, about a fortnight after
the child's birth, the navel became  inflamed, a small collection of matter
formed, and its spontaneous discharge  was accompanied by a good deal  of
blood.  When the abscess was  empty, I succeeded fortunately in stopping
the bleeding, by pressure and astringents.
  4.  Some of these  cases seem  to  depend upon  an  unclosed state of the
umbilical  vessels, or defective hepatic ducts ; although  this  does not in-
variably cause  bleeding.  An American  physician, Dr. Anderson, of New
York, has favored me with an example, in which the ductus communis cho-
ledochus was imperforate, giving rise to jaundice, and umbilical hemorrhage.
Dr. Minot mentions  that in one case the gall ducts were wholly absent;  in
another the ductus communis terminated  in a "cul-de-sac ;" and in a third,
it was closed by a plug of inspissated bile.
  5. In a large proportion of  cases, the hemorrhage is accompanied  by
jaundice,  whether dependent upon  malformation or not,  and certainly not
always connected with  organic  disease of the liver;  although Dr. Minot
mentions that  in  three or four out of seven cases it  presented deviations
from the ordinary healthy appearance.   It has been suggested by Dr. West,11
and  maintained by Drs. Bowditch,  Homans, Bailey,  Manley, and  Minot,
that the disposition to hemorrhage from the navel may, and probably does,
depend upon some morbid condition of the blood,12 as shown by the dispo-
sition to hemorrhage in other parts,  analogous  to what we see in  adults.
As  Dr. Minot remarks,  "the facts which I have collected lead me to think
that idiopathic hemorrhage from  the umbilicus in young infants is only one
of the various manifestations of  the hemorrhagic diathesis, which in other

  1 Edin. Med. and Surg. Journal, July, 1832, p. 520.
  2 Boston Med. and Surg. Journ., July 11. 1849.      3 Med. Gazette, March, 1849.
  * Amer. Journ., of Med. Science, Jan. 1850, p.  63.    "> Med. Gazette, May 3d, 1850.
  6 Amer. Journ., of Med. Science, April 1852, p. 432.    * Ibid., October, 1852, p. 318.
  « Med.  Times and Gazette, March 25th, 1854.        9 Ibid., Nov. 3, 1855.
  10 London Med. Gazette, vol. lii. p. 556.
  11 On Diseases of Infancy and Childhood.
  12 Campbell on Icterus Infantum.   Northern Journal of Med., Aug. 1844.  Adams,
Ainer. Journ. of Med. Science, April, 1851, p. 364. 
NATURAL LABOR.
241
cases is exhibited in  bleeding from  the  gums, mouth, stomach, intestines,
etc., and in the appearance of purpuric spots beneath the skin in various
parts of the body.  In proof of this we see the occurrence of these pheno-
mena with umbilical hemorrhage.   Thus  nothing is  more common in the
latter disease than a purpuric eruption.   In three cases, there were bloody
dejections; and in one, bleeding from the gums.   Another argument is the
thin and watery condition of the blood,  and its deficiency in fibrine, whereby
mechanical means become almost wholly inefficacious  to arrest its flow.1
   6. Finally, we  have the  cases which exhibit  an  hereditary  tendency to
hemorrhage, as I  have already mentioned, whether the proximate causes of
the diathesis be malformation, organic disease, or an  abnormal condition of
the blood.  It does not appear that the character or duration of the labor
has any influence in the  production of this accident.  The labor was easy
and natural in most cases.
   371. Symptoms. — The  period at which the  hemorrhage occurs  varies
from the third to  the  eighteenth day.   In eleven cases, Dr. Bowditch found
the average was  seven days and three quarters ; in Mr. Ray's case it came
on the tenth day  ; in  Mr. Bailey's, on the ninth and twelfth days.  Of forty-
one cases, Dr. Minot  states that the  average  was the eighth day: in four
cases it began before the separation of the cord ; in three immediately after ;
in others at periods varying from one to thirteen days.
   It is remarkable that most of the children seem  to be healthy at birth,
 some few only appearing feeble.  In some cases (nine out of thirty-nine,
 according  to Dr. Minot) the hemorrhage appeared without any previous
symptoms; but in a large majority it was preceded by other symptoms, and
 principally by jaundice, with constipation and clay-colored stools.   In some
 rare cases, the child has appeared to be  in pain, and in a few, cerebral symp-
 toms have  occurred.  Upon the whole,  however, there  are  but two promi-
 nent symptoms  which are  generally present — viz., the  bleeding and the
 jaundice, and the latter, as I have stated, not  always.  Unless  when the
 portion of the navel-string is removed  by violence,  or some violence is ap-
 plied to the umbilicus afterwards, the hemorrhage is neither rapid nor pro-
 jected in jets from any visible vessel, but rather a continuous weeping.  Dr.
 Bowditch observes that "the funis  drops  off, and  usually nothing abnormal
 is observed, or at most, only a delicate  sponginess of the umbilicus.  After
 three or four days an oozing commences, which  either increases with every
 application, or perhaps is slightly checked by astringents, etc.; but it  almost
 always proves fatal, and the patients before death become perfectly blanched.
 In these cases it  is very  common to observe an alteration in the structure
 and functions of the liver ;  the dejections  being non-bilious, and at the post-
 mortem examination,  disease of the hepatic structure, or of the ducts, being
 observed."2
   The character of the  blood is ordinarily described as thin,  and of unu-
 sually light color, and in  general  it does not coagulate, so  that we  may
 conclude that it contains less fibrine than in health.
   The most frequent termination is in  death ; in fact, almost all the cases
 terminate unfavorably ; it may be at any period from the first day of hemor-
 rhage  to the seventh  or eighth,  according to the rapidity or continuousuess
 of the bleeding.
   I have already alluded to the principal post-mortem revelations.   One  or
 more of  the  hepatic vessels may be defective  or impervious, the duct of the
 gall-bladder  may be  impervious or obstructed, the liver may be congested,

             1 Amer.  Journ. of  Med., Oct.  1852.
             2 Amer.  Journ. of  Med. Science, Jan. 30th, 1852, p. 64.
       16 
242
NATURAL LABOR.
softened, or flaccid, and the blood  thin, pale,  and not coagulable.  Or, in
some few cases, we may detect none of these changes.
  372. The diagnosis is of course  quite easy,  and the simultaneous occur-
rence of petechia?,  or ecchymosis,  or  hemorrhage from  the  mucous mem-
branes, will mark the case as belonging to the fifth class.   From what I have
said, the reader will gather that the prognosis is very unfavorable.   In spite
of all our efforts, a very large proportion die, especially in the fourth, fifth,
and sixth  classes.   Out of forty-six cases, Dr. Minot states that thirty-nine
died at periods varying  from six hours to six weeks from the commencement
of the hemorrhage.
  373.  Treatment. — In  all  cases, styptics or astringent remedies may be
applied, and generally with some temporary relief.  The best are a solution
of alum, sulphate of zinc or copper, infusion of matico, gallic acid, Ruspini's
styptic, collodion,  etc.
  In the first and  second  classes, pressure has  been frequently tried, and as
frequently failed,  from  the softness and yielding of the abdomen. As a
modification of pressure,  I suggested filling the navel with plaster of Paris,
in a fluid  state, which, becoming  instantly solid,  and being held in situ by
the inner  folds of  the umbilicus, would be likely  to  make firm pressure.  I
have  never tried it myself, but I find that it has succeeded in at least one
case.   When compression fails, Dr. Radford proposes to cut down upon the
umbilical  vessels, and tie them ;  and it is a reasonable experiment,  although
it has failed.  The ligature en masse  is preferred by M. Paul Dubois, and
he thus performs it:—A cushion is placed under the infant's loins, to render
the abdomen prominent.  The operator introduces horizontally from left to
right a hare-lip  pin, which pierces  the  integument at the base of the navel.
By means of a loop of  thread passed under this pin, he raises the integu-
ments, and a second pin is  introduced, perpendicularly to the first,  and
beneath it: the thread  is then  twisted several  turns in a  figure-of-eight
shape, round each pin,  and to complete the ligature the base of the umbi-
licus is encircled with waxed thread.  The pins may be removed towards the
fourth or  fifth day, but nothing must be done to hasten the separation of the
eschar,  which must be left  entirely to itself.   In  two cases in  which M.
Dubois adopted this plan, the bleeding was  arrested, and did not return, but
the children died.   In  Drs. Bowditch  and  Bailey's  cases it was tried, and
failed, the hemorrhage  returning,   Dr. Brown is opposed to this plan, as
likely to excite  peritoneal inflammation, and so hasten death.  Dr. Manley
prefers it to cutting down upon and tying the vessels.
   In the  fourth, fifth, and sixth classes the same  remedies may be tried, hut
there is less hope  of  success,  as the hemorrhage is not local, but dependent
upon causes over  which we have little or no control.  Dr. Minot suggests
the internal use of tonics and astringents, and I  think with reason, treating
the patient as we  should  a case of purpura, or  hemorrhage from the mucous
membranes.
   Mr. Ray and Dr. Bowditch suggest  the employment of the  actual cautery
in these cases, nor do I see any objection to trying it in such  hopeless cases,
if other means fail.  We must do all we can  to keep up  the strength by
means of nourishment — milk, broth,  wine and water, etc.
   Thus it appears that our  list  of remedies comprises strong astringents,
pressure,  caustics, the actual cautery,  and the ligature.  Dr. Minot remarks,
that  of his cases, those  in which  the bleeding was  permanently arrested,
were by the following means : compression in three cases ; ligature in three;
collodion in one ;  plaster of Paris  in one ;  scrapings of shoe leather in one,
and nitrate of  silver  in  one case.   But  although the bleeding was arrested,
yet in several of these cases the infant died from exhaustion produced by it.
   As prophylactic treatment, Mr. Ray suggests attention to the  mother's 
NATURAL LABOR.
243
health during gestation ;  abundance of healthy natural nourishment for the
child after birth ;  and that in families where this accident has occurred, the
accoucheur should daily superintend the dressing  of the  navel  until it  has
quite  healed, using collodion styptics  or compression.   Dr. M. S. Perry
suggests the use of  mineral acids during  pregnancy, by women whose  pre-
vious  children have  suffered from umbilical hemorrhage.

   374.  This is probably the best place for me to introduce some  notice  of
the employment of  Anaesthetics in Midwifery, whether in natural labor, or
in cases requiring operation.
   The two sole agents in use now for the  purpose of producing insensibility
to pain, are ether and chloroform ;  but the latter has so far superseded the
former, that I may  confine my remarks to the use of chloroform.
   To my friend, Professor Simpson, belongs the credit of having been the
first to  administer ether  during labor,  and also of having discovered the
value of chloroform as an  anaesthetic, and of introducing it into practice.
It is  composed of  two atoms of carbon, one of hydrogen, and three of
chlorine;  or one  of formyle and three of  chlorine, sp.  gr. 1-480; it rapidly
 evaporates, and possesses an  aromatic, pungent taste, and a fragrant smell.
   When inhaled, it  gives rise to exceedingly pleasant sensations, and a rapid
 flow of thoughts and images,  resembling a pleasing  dream, until, as  the dose
 is increased, these become  confused and incoherent, previous to deep sleep
 being induced.   The first stage is one  of excitement,  then follows  calm
 sleep, and  at length stupor;  but the excitement is said to be less  than when
 ether is used.
   The  beneficial effect is the  alleviation of pain, in consequence of, and in
 proportion to, the amount of insensibility, so that we possess the power of
 graduating its effects as we may deem advisable.
   That injurious effects  are occasionally produced,  is no  more  than  we
 should expect  from so powerful an  agent: that they have occurred in so
 very  small a proportion may well excite  our wonder.   Almost all the un-
 pleasant symptoms  are referrible to  the nervous  system, such as spasms,
 twitchings, hysterics, convulsive  movements, incoherent talking,  etc. Several
 fatal cases of collapse have been recorded, and although some doubts have
 been entertained  as to whether  the death was caused by the chloroform, I
 fear the evidence is too clear.   So far as I can judge, the mode of death is
 twofold ;  either a fatal syncope, or a fatal  asphyxia being induced.   It is
 remarkable that in  most of these cases,  I  believe, the chloroform was admin-
 istered, not to relieve pain, but  in  anticipation of  it,  as  for tooth-drawing,
 etc.   It is of importance to remember that the pulse and respiration afford
 very accurate indications  of the propriety of continuing the  inhalation ; we
 should stop instantly if we find the  former becoming weak  and the latter
 irregular.   In Edinburgh, most reliance  is placed upon the  state  of the
 respiration ;  any hesitation or failure demands the  instant stoppage  of the
 inhalation.
   375. So much for the  general use  of chloroform ; now let us  see what
 has been the result of its employment in  midwifery.  It has  been now  used
 extensively in Great Britain, in America,  and on the Continent, and we have
 an account of many thousand cases in which it has been  employed.  From
 this it  appears,
   1.  That in midwifery practice no  death has occurred which can be fairly
 and directly attributed to the chloroform when administered by medical men.
 In the  cases brought forward by Mr. Gream and Dr.  Ramsbotham, there is
 no evidence to prove that the deaths did  not result from the circumstances
 of the labor, and no ground  to  attribute the accident to this agent.
   2.  That some  unpleasant  symptoms  have occurred in  hysterical  and ner- 
244
NATURAL LABOR.
vous women during the stage of excitement, but no instance of the alarming
or even fatal collapse which has occurred  in cases unconnected with  preg-
nancy or parturition.   These  symptoms disappear in a few moments  if the
chloroform be discontinued, or, as is said,  if the dose be increased.
  3. In a small proportion of  cases, the uterine contractions are weakened,
rendered less frequent, or even  suspended, so long as  inhalation is continued,
but that they return if the use  of chloroform be discontinued.
  4. In the great majority of cases it does not interfere with the labor  pains,
except  by  suspending  all voluntary exertions, if the insensibility be com-
plete.   Where the  dose given  is milder, although great relief  be afforded,
the patient will not become insensible, and will be able to exert  considerable
force.
  5. That chloroform, in full doses,  is capable of entirely removing the pain
of obstetrical operations, and thereby increasing the facility of their perform-
ance.   Moreover, that the dose can be so  graduated  as to afford degrees of
relief, so that, in natural labor, a certain amount of suffering may be spared
without producing insensibility, or incurring the risk, whatever that may be,
of a full dose.
  6. It neither prevents nor  weakens the subsequent  contractions of the
uterus, and consequently does not render the patient more  liable  to flooding.
  7. That certain women seem more obnoxious to its injurious effects than
others, and  in  some these effects are said to continue some time.  Giving
full  force  to  these  cases, they appear to  form a  small  part  of  a  large
number whose recovery was not retarded,  and whose subsequent health was
uninjured.
  These inferences, I  think, are fairly deducible from  the published cnses:
whether, as has been asserted,  many fatal or bad cases have occurred  which
have not been recorded, I cannot say;  but until  we know the particulars, it
is clear that we can allow no  weight to such a supposition.   It is much to be
regretted that so much personal and party feeling has entered into the pub-
lications on the subject, instead of a simple desire  to discover in what cases
this new agent is admissible,  and  in what it ought to be rejected, with the
reasons for such decision.
   376. It is right, however, to notice respectfully some  of the objections
which  have been made by most experienced  and  conscientious practitioners.
   1. The first objection I shall notice is,  that as  "in  sorrow  shalt thou
bring forth children " was part of the original curse pronounced  upon the sin
of  man, therefore any attempt to  mitigate the suffering is a direct and un-
warrantable interference with an ordinance of God.  Now it will be remem-
bered that labor ("in  the sweat of the brow"), pain, and death  were equally
the result of the same  sin, and inflicted by the same Hand, and yet we never
hear of the wickedness of lightening labor, of relieving pain, or of postponing
death, each of which must be  wrong,  if relieving the suffering of childbirth
be  wrong.   It is monstrous that one set should claim the  privilege of relief,
and object to its being extended to the other.  If further  argument  be
needed, the  reader  may refer to  Dr. Simpson's critical remarks upon the
Hebrew word translated "labor."
   2. It has been stated that, in operations, the loss of sensibility deprives
the operator of a valuable indication as to whether he is inflicting injury or
not.   I do not see  much force in this objection,  I confess.   If  the operator
be  skilful,  and habituated to the use of instruments,  he will not  do mischief
because the patient does not  cry  out; and if he be not  skilful, her crying
out will not prevent him.  I am sure that the patient  being spared the shock-
ing pain of most operations, and  the operator the distress of witnessing it,
is a blessing beyond price, and more  than anything calculated  to  secure a
safe and skilful performance, and in all probability a favorable convalescence. 
NATURAL LABOR.
245
  3.  Our ignorance of the bad consequences of chloroform, and of the cases
improper for its exhibition, and the consequent probability of our compli-
cating the labor by some serious accident voluntarily incurred, has been, and
is yet, I think, an  objection deserving of careful  consideration.   No doubt
the increased and  increasing number of facts recorded affords a ground for
sound conclusions, in  proportion to their extent;  but it is still to be desired
that  there should  be a careful classification and minute investigation of those
cases in which any unpleasant symptoms have occurred, with the object of
discovering the circumstances, whatever they  may be, which counter-indi-
cate  the employment  of anaesthetic agents.   Interruption of uterine action,
diminution of uterine  force, and affections of the nervous system,  seem to be
the chief evil effects to be feared in parturient women.
   4. The probability  of uterine hemorrhage after labor was formerly much
insisted upon, but  I think experience  has shown that this fear is groundless.
It has not occurred  more frequently in patients who have used chloroform
than in others.1
   377. Thus far I have given the inferences which appear to me to be fairly
deducible from the cases on record, irrespective of the opinions of the various
writers who have  engaged in the controversy.   The following practical  con-
clusions  may be regarded  as  my  own opinions, formed after  much thought
and  reading, and after some slight personal experience.   I would not  wish
to put them  forth dogmatically, for  I do  believe that we are not yet  in  a
condition to define accurately, or to speak  positively on the subject.   I  con-
fess  that  I can  neither agree w ith those who think that chloroform can do
no evil, and  therefore ought to be used in every case, nor yet  with those
who regard it as in all cases injurious, and therefore to be reprobated.
   1. In  most obstetric operations, anaesthesia appears to me  to be of great
use,  not so much  because it is supposed to relax the soft parts, or to mode-
rate uterine action, as because it enables the patient to bear  the additional
pain we inflict without outcry or movement.  It surely must be a great
advantage in performing a dangerous operation that the  patient should lie
still, and not by her  struggles increase our difficulty, and the risk of injury
to herself.   If the tissues be relaxed, which is doubtful in many  cases,  it is
of course an  additional advantage ;  and if it happened in a case of turning
that the  uterine action were suspended, of course the operation would be all
the more easily completed ; but these are rather accidental advantages  than
essential consequences.   In operative midwifery, therefore,  chloroform  may
be given until anaesthesia is  produced before commencing,  and its effects
may be kept up during the  operation, provided that there be no counter-
indication to its use,  and that no unpleasant symptoms arise ; in  either case
it should be given up altogether.  In  the last edition of this work I excepted
from the use of chloroform two classes of cases, viz., convulsions and hemor-
rhage, more from a fear of its being injurious than from any evidence we had
of its being  so.   Since then, the experience of  Drs.  Channing, Turner,
Keith, Norris, Shekleton, etc., has shown that, so far from being mischievous
in convulsions, it  is most  useful as  a remedy.2  And  as to  hemorrhage  I
must add, that the fear I feel is one of anticipation, and  not founded on
experience.  Dr. Simpson and others  have administered it in placenta praevia,
when there has been great loss, without any evil  effects.
   2.  It may be administered with  great advantage in certain cases, in which
a thorough examination, with  the  hand introduced into the vagina, is neces-
sary  for determining upon the proper line of treatment; as in distortion, for
instance,  to enable us to  determine  whether the diameter  of the brim is
sufficient to enable a living or  mutilated  child to pass, or whether we must

           1 British and Foreign Med. Chir. Review, April, 1855, p. 359.
           2 See the Chapter on Convulsions. 
246
NATURAL LABOR.
have recourse to the crotchet  or Csesarean section.  Under the influence of
chloroform,  we may compare the breadth  of  our hand across the knuckles
with the brim of the pelvis,  and arrive at a very accurate measurement,
without pain to the patient.   This Dr. Simpson tells  me he has found very
satisfactory.
  3. As to  its exhibition in natural labor, as I do not believe that in  the
large majority of cases convalescence is at all impeded by the suffering,  I
cannot see the necessity, or even the propriety,  of urging  the  employment
of anaesthesia in every case ; and I do feel that even  greater caution ought
to be used than in operative  midwifery.  We may be justified in  running
some risk where an important point is  to  be gained,  such  as perfect quiet-
ness during  an operation, which we  should not be  justified  in incurring
merely to relieve  pain.   Thus  in hysterical  or  nervous patients, in  those
laboring under nervous affections, or organic  disease of the lungs or heart,
etc., I do not think we ought to employ it.
  But on the other hand, as pain is undoubtedly an evil in  itself, if there be
no  counter-indication, and if  the suffering be either  great or prolonged,  I
cannot see that we are prohibited from the employment of anaesthetics, more
especially as it is not necessary in such cases to produce insensibility.  It is
quite possible to afford immense relief, to "render the pains quite bearable,"
as a patient of mine observed, by a dose which  does not produce sleep or
impair the  mental  condition  of  the patient, and which all our experience
would show is absolutely free from danger.
  In  my own practice I have  never urged a patient  to  use  chloroform in
natural labor, and,  on the other hand,  I have not felt  justified in refusing a
moderate dose of it when the patient  urgently desired it, and  none of  the
conditions were present which seemed to me to counter-indicate it.
  378.  The period at which it has been  administered varies with different
practitioners;  some commence before  the  os  uteri is  dilated, others about
the time the head escapes through it.   There can seldom be  any necessity
for  its use, I think, before the  os uteri is fully dilatable, and it is more likely
to interfere with the uterine action at an earlier than a later period. At  the
commencement of the second  stage would, I should think, be soon enough,
and this seems to be Dr. Simpson's practice.
  379.  There is a difference of  opinion as to the extent to  which the anaes-
thesia should  be carried.   Prof. Simpson prefers inducing complete insensi-
bility at first,  and then keeping up  just so much  of the effect as he deems
advisable.   Dr. Rigby prefers  commencing with smaller doses in natural
labor, and increasing them if  necessary ; and the Obstetric Committee of
the American Med. Association, in their Report, agree with this view.  Of
course, if we are to operate, the patient should be placed thoroughly under
the influence of the chloroform before  we  commence, and its effects kept up
by occasional inhalation.   But  in ordinary cases, as  I have said, I prefer
beginning with a moderate dose and watching its effects, and, if necessary,
increasing the anaesthesia.
  The dose  should be  administered at the  beginning of each pain, and  in-
creased when  the head is passing over the perineum.   The  anaesthetic state
may he kept up for hours without mischief, especially when complete insensi-
bility is not  required.
  I have  tried various  modes of administration, instruments specially con-
trived for the purpose, sponge, lint, etc., and I believe that by far the best
is the  one originally proposed  by Dr.  Simpson, viz.,  a clean white pocket-
handkerchief,  folded funnel-shape ; into which  half a drachm or a drachm of
the  chloroform is to be poured, and which may then be first placed near the
mouth of the patient, and after a few  respirations, over both  mouth and
nose.   It is a good plan to allow the patient to hold the handkerchief her- 
             CONVALESCENCE  AFTER NATURAL  LABOR.         247

self, unless we wish to produce deep anaesthesia, as it will fall from her hand
when sleep commences.
  [The employment  of anaesthesia in all cases of labor, as a matter of rou-
tine, merely for the purpose of securing to the parturient female freedom
from pain, has, it is believed, at present few advocates, while the number of
those who are in favor of the  practice in certain forms of difficult, tedious,
and instrumental labor, is evidently augmenting.
  It must be admitted, that, in a very large  number of cases of natural labor,
anaesthesia has  been  induced  without, apparently,  any  evil consequences
accruing to either mother or child — whether, however, all the instances in
which injury has resulted from the practice have been made public we have
no  means of judging.  That  so few should have been heard of is really a
matter of surprise, considering the powerful influence the  several anaesthetic
agents necessarily exert upon the nervous  system, and the extensive  and
careless manner in which they  have too  often been resorted to.
   It is true that, in the  practice of midwifery, anaesthesia has seldom been
carried to the extent of producing entire  unconsciousness, and even when
inordinate doses of  ether  or  of chloroform  have been  administered, the
patient has been probably saved from any bad effects in consequence  of the
accoucheur's rashness, by the careless manner in which  the  agent has been
used, causing the greater portion of  it to escape into the  air of the chamber
instead of passing into her lungs.
   The time is near at hand wdien, from a full and honest comparison of facts,
the question as to the propriety of employing anaesthesia in obstetric prac-
tice will be definitely settled, and  the cases  and the period of labor, and the
 extent in which it may be safely  and beneficially resorted to, become fixed
 upon certain and well-established data.   Already the  ultraism of the early
 partisans of the practice is rapidly  abating, while  many of those who at
 first objected to it, as under all circumstances dangerous, if not  positively
s injurious, are willing to avail themselves of its aid in certain forms  of labor.]
                        CHAPTER  IV.

           CONVALESCENCE  AFTER NATURAL LABOR.

  380. The history of natural labor would be incomplete  did we not  say
something  of the state of the  patient after delivery, both  as to the effects
produced, the gradual restoration of the parts  engaged, and  the requisite
treatment.
  If we examine the  condition of a patient a few hours after delivery, we
find a considerable change, both locally and generally, and  which cannot be
attributed to mere  fatigue.   The nervous system  is more  or less affected ;
the  secretions are altered, and new ones established ; the  condition of  the
uterine system itself, and  in  its relations, is completely changed, the circu-
lation disturbed, etc. etc.
  Let us briefly examine these  peculiarities separately.
  381. 1. The  nervous shock.—The sudden alteration of the eye, the dimi-
nished or increased sensibility of the brain, the  disturbance of the respiratory 
248         CONVALESCENCE  AFTER NATURAL  LABOR.

and circulating systems, the modified secretions, the  great exhaustion, etc.,
are all evidences of a shock to the nervous system, the effects of which are
thus extensively felt.   After easy labors the shock  is not very remarkable,
and the patient soon  recovers  from it;  but it is too  manifest to be doubted
after  those of a more serious character.  I cannot agree with those who
attribute the state of the  patient to fatigue, and I am happy to have in this
opinion the support of the late Professor Hamilton, of Edinburgh, who, in
his practical observations, distinctly recognizes this nervous shock  as an
effect of labor.  When it is moderate, it gradually subsides if  the patient
be kept  free from  all excitement and  disturbance, and obtain a few  hours'
sleep.   In proportion to the  rapidity and completeness  of its  subsidence,
will be the return of comfort and health to the patient.
   382.  2.  The state of the circulation  and respiration. — The changes in-
duced in  these systems appear to be  the combined result of the nervous
shock and muscular exertion.  From extensive investigations I have obtained
the following results.   During  the second stage of labor the pulse (as already
noted) always increases in frequency, though the amount varies in different
persons.  Shortly after delivery it falls, nearly, but not quite, in proportion
to its previous frequency ; i. e., it descends nearly as much  below the  ordi-
nary standard as it was above  it.   After the  lapse of a few hours a reaction
takes place,  the amount of which is nearly,  but not quite, in proportion to
the original increase and  subsequent collapse.  Again, after twelve or four-
teen hours, it subsides, to be again increased on the secretion of the  milk;
after  which, if the  patient go  on well,  it gradually returns to the  ordinary
standard.  To illustrate my  meaning, let us suppose that during the second
stage the pulse mounts up  to 120 ; then, during the  collapse, it will fall
perhaps to 60 ; and, on reaction taking place, it will rise  to  100 or 110.   I
do not intend to  give this  illustration  as  the  accurate  standard of these
changes,  but merely  as  illustrative of the  alterations  I have  generally
observed ;  nor do  I say that they occur in every case, but only that I have
noticed them in a very large majority.   I have never been  able to discover
any proportion between frequency of pulse induced by the secretion of milk
and its previous state.  The importance of these successive alternations will
be seen more strikingly when we come to consider the variations from normal
convalescence ; it may suffice to  say. that I  have seldom  seen  them absent
(the pulse having  increased during the  second stage) without serious cause.
   The frequency of respiration after natural  labor is  in accordance with that
of the pulse, when the  nervous shock  has been moderate.   During the in-
crease of the circulation the number of respirations per minute is increased,
and again diminished during the collapse.
   383.  3.  State of the uterus, vagina, etc.— Immediately after  delivery the
uterus contracts more or less firmly, so  as to reduce its size to about that of
an infant's head.   This contraction is beneficial in several ways : it prevents
hemorrhage, it empties the uterine cavity, and diminishes the calibre of the
uterine vessels and sinuses.  After a short period of contraction an interval
of relaxation ensues,  followed in  its turn by renewed contractions.  The
repeated contractions and concurrent absorption reduce the size of the uterus
gradually, until, about the eighth or tenth day, it is small  enough to descend
into the pelvis.  Previous to this, it can be  examined through  the relaxed
abdominal parietes, and a tolerably accurate knowledge obtained of its con-
dition ; but  subsequently we  can only reach the fundus at the  brim of the
pelvis; and  after another week it disappears altogether.   Some, as Murat
and Ramsbotham,  attribute  this rapid  diminution in size to uterine contrac-
tion  alone ;  others conceive, with Dr.  Hamilton,  that absorption goes on
rapidly at the same time, and  recent investigations show  that Dr. Hamilton 
             CONVALESCENCE AFTER  NATURAL LABOR.         249

is right.   Dr. Heschl has described the process minutely as a fatty degene-
ration, and his views confirm those of Dr. Retzius, of Stockholm.
  It may be interesting to my readers to have  a brief sketch of the changes
which take place  after delivery, according to  the most recent researches,
although there are several points which require  confirmation and elucidation.
According to Dr. Heschl, the fibres of the  uterus undergo an entire fatty
transformation, commencing  between the fourth  and eighth day after deli-
very, and at all points pretty evenly.  With the advance of the fatty trans-
formation, the uterus becomes friable, and the  tissue surrounding the fibres
becomes absorbed, the  structure  loses its reddish color, and becomes  of a
dirty yellow.   About the fourth week, the uterus  having resumed its normal
volume, the commencement of a new uterine tissue may be observed ; in the
body of the organ, and in its  outer layer, nuclaei, cells, and finally cells drawn
out into fibres, make their appearance, and  ultimately become the new ute-
rine substance.   As these increase,  the old tissue is  absorbed, and the  pro-
cess is complete  at the end of the second month.  During this process going
on in the cervix uteri, hemorrhage often occurs, which gives to this  portion
the ecchymosed appearance mistakenly attributed  to the effects of labor.
The veins and capillaries undergo a similar  transformation.1
  384.  The condition of the cavity of the uterus is of great interest.   When
examined a day or two  after delivery, the  lining membrane  appears loose
and corrugated,  somewhat softened, and covered  more or less by  patches of
the decidua.  The part  to which the placenta  was attached is raised above
the level of the surrounding parts ;  its surface  is  unequal, resembling in this
respect a granulating ulcer; its size is  wonderfully reduced.   The whole
internal surface  is of a  dark ash color,  while  the discharge upon it may be
greenish or brownish, giving the appearance of  a morbid condition  of the
parts—indeed, I have known it pronounced to  be gangrene.   The structure
of the uterus, if cut into, is found to be less dense  than natural, and the fibres
more distinct;  the sinuses are still  very evident, and at the placental inser-
tion they are filled with clots of blood.   The os and  cervix uteri are covered
with ecchymoses, as though they had been severely bruised ; and sometimes
small lacerations may be observed in the margin.   The orifice remains open
for some days, but gradually closes.   According to Dr. Heschl, the placental
spot undergoes a  fatty transformation similar  to the other parts, and a for-
mation  of a new uterine substance.
  According to  Cruveilhier, Fergusson, and others, the mucous membrane
is thrown off at delivery, and the muscular  fibres left bare; and Dr. Heschl
describes its re-formation, but he admits that the matter is not very clear to
himself.   A few days after delivery the internal surface of the uterus appears
covered with a red-colored soft, pap-like, flaky  substance, consisting of pave-
ment and cylindrical epithelium, and young  cellular substance, in which
vessels  become evident the third week, and  the glands afterwards.   Now, I
would just observe,  that if the mucous membrane  is thus exfoliated after
labor, it is the only example  in the  human body of a mucous membrane un-
dergoing the process  physiologically, and, from the  very few observations I
have been able to  make, I feel inclined to agree  with Dr.  M. Duncan,2 that
no  such exfoliation  takes place, except, perhaps,  at the insertion  of the
placenta, and of this  I do not feel quite sure.  Dr.  Duncan examined seve-
ral  cases most carefully, and in none  was the uterus denuded of mucous mem-
brane.  Of one where death had taken place on the fourth day after delivery,
he  thus speaks:  " The whole  inner surface of  the organ  was manifestly

  1 Remarks on the  Conduct of  the Human Uterus  after Delivery, translated by Dr.
R. MDonnel, of Dublin.
  2 Dr. J. M. Duncan on the Internal Surface of the  Human Uterus after Delivery. —
British and Foreign Med.-Chir. Review, Oct. 1855, p. 506. 
250         CONVALESCENCE AFTER NATURAL LABOR.

covered by a mucous membrane ; lacerated at the site of the placental inser-
tion, a surface between three and four inches in diameter, a number of clots
were entangled in the venous  openings.   Elsewhere the  mucous membrane
was  distinct.  It  was covered  by the lochial  secretion.   On scraping the
surface, the  lochia and epithelium  were easily removed, laying bare the
fibrous structures  of the mucous membrane beneath," thus confirming Vir-
chow's observation that the site of the placenta was the only part denuded
of mucous membrane.   Dr. Chisholm has published two cases analogous to
those of Dr. M. Duncan.
  The vagina is speedily reduced in size after its great distension :  at first
there is considerable heat and soreness ; but this shortly subsides, unless the
head of the child have remained long in the pelvis, or the lochia be acrid.
The  lower outlet,  too, resumes  its natural  capacity in  a shorter time than
would have been believed possible.
  The abdominal integuments  are longer  in  resuming their natural state;
they remain flaccid and loose  for a considerable time ; but  if care  be taken
in "the bandaging, but little  evidence, beyond the presence  of the white
streaks, is afforded, after a month or two, of their previous distension.
  385. 4. After-pains. — The contractions of the uterus,  subsequent to
delivery, of which we have spoken, are generally unaccompanied by pain in
primipara;  but in subsequent labors  they cause more or less suffering, and
are called " after-pains."  [As  a general rule, it is true that females do not.
suffer from after-pains subsequent to a first  confinement.  Exceptions, how-
ever,  occasionally  occur.   We have known primiparous  women to experi-
ence  as severe after-pains as those  who had  previously borne children.]
They vary a good deal in their frequency, their severity, and their duration.
The first is generally felt within half an hour after delivery,  and they ordi-
narily cease in thirty or forty hours, though they may continue longer. They
are not generally accompanied  by bearing-down efforts,  nor by increased
frequency of the pulse.   During their presence the discharge from the uterus
increases,  and coagula are frequently expelled.   From this latter  circum-
stance they have been attributed to the presence of coagulated blood in the
uterus, but,  at most, this  is only an occasional exciting cause.   Their opera-
tion is, within  certain limits, undoubtedly salutary ;  they prevent hemor-
rhage, diminish the size of the uterus, and expel its contents.   The applica-
tion  of the child to the breast often brings on or aggravates the after-pains.
  386.  5.  The lochia.—The discharge of blood which accompanies delivery
continues for some time afterwards, doubtless  from  the  mouths of the ves-
sels exposed by the separation of the placenta ; but after a while the cha-
racter of the discharge changes, and it can no  longer be considered  a mere
escape of blood,  but exhibits  all the characters of a secretion.   This state
of the lining membrane of the uterus  would lead us to expect such an oc-
currence.   The  discharge is  called the  "lochia;"  or, in  popular language,
"the  cleansings."   For three, four, or five days, it continues of a red color,
but much thinner, and more watery than blood, and not coagulable;  it then
sometimes becomes yellowish, like puriform  matter;  but  more frequently
maintaining its serous consistence, it changes its color successively to green-
ish, yellowish, and lastly to that of soiled water.
  It has a very peculiar  odor, which  can neither be mistaken nor forgotten,
but which it  is impossible to describe.   The duration of the lochia varies a
good deal;  in some patients  it ceases naturally and without bad effects, a
few days after delivery, and I have repeatedly observed  this with those de-
livered of still-born or putrid infants.   Generally  speaking, in these coun-
tries it does not cease till about the  end of three weeks, or a month ; but
much depends upon the constitution of the person.  As to the quantity, it
is impossible to fix any limits ; it depends partly upon the extent of secreting 
             CONVALESCENCE  AFTER  NATURAL LABOR.          251

surface,  and partly upon the duration of the discharge.   As the secretion is
necessary for uterine health, the  sudden interruption of it is  generally at-
tended with evil consequences.
  387. 6.  The secretions and excretions.—From the exertions of the second
stage of labor the secretion of the skin is increased, so that the  surface is
bathed  in perspiration.   After delivery, this active state of the secretion
diminishes somewhat, but still continues above  the ordinary standard ;  and
very often the  perspiration has a faint sickly odor.  The skin is soft  and
flabby, with a  slightly greasy feel.  As  convalescence  progresses, the  sur-
face returns to  its natural state.
  The kidneys  may retain their usual  activity, or, which  is more frequent,
have it somewhat increased  after  delivery,  notwithstanding  the unusual
amount of perspiration ; but this may be owing to the  diet consisting prin-
cipally of fluid matter.
  The state of the bowels varies ;  sometimes it is unaltered ; in others it
is the reverse  of  what it was  during gestation, patients  who were consti-
pated having now no  need of medicine ;  and  those who were  annoyed by
diarrhoea  having  solid motions.   The latter change is by  no means uncom-
mon, and  may  probably be owing to the increased secretion from the  skin
and kidneys.
  7.  The milk.—The enlargement of the breasts during gestation is gene-
rally accompanied with the  secretion of a serous fluid, differing  from  true
milk, though in some cases (seldom with first children)  true milk is secreted
during labor, and  the woman can give suck immediately afterward.
  In ordinary cases, however, the breasts remain quiescent for about twenty-
four hours, but soon after that begin to enlarge,  with  stings  of pain.   At
the end of the  second or beginning of the third  day, they are perceptibly
larger,  heavier, and  more tense ;  the patient may suffer from rigors, heat of
skin, pain and  soreness of the breasts, and the pulse is quickened.  At this
time the secretion commences, at first slowly and with difficulty, but after-
wards more freely, and in proportion to the freedom is the diminution of
the pain and fever, until, after a few clays, it takes  place without distress or
disturbance.   The milk (colostrum), during the first five or six days, differs
from that secreted afterwards, and often acts as a  purgative to the child.
  388.  Management of Women in Childbed. —I cannot do better  than
follow the order in which  I have  noted the phenomena of childbed.
  In ordinary cases  the shock to  the nervous system does not require any
active treatment.   The patient should be kept in a state of  perfect quiet,
the room  slightly darkened, and very few persons except the nurse admitted.
Little talking should be allowed,  and no whispering.  Everything calculated
to excite mental emotion should be avoided,  and the patient be kept  calm
and cheerful.   The horizontal posture should be strictly preserved,  and the
patient  allowed to sleep, after which the nervous system will have recovered
its  tone, and the patient  will be free from danger on this account.
  389.  As the  state of the  pulse is merely symptomatic, it will be best re-
medied  by our  successful management of the patient in other  respects.  It
should be narrowly watched, and accurately  estimated,  as its deviations will
often be the first  evidence of mischief going on.
  390.  Immediately after the  expulsion of the after-birth, a warm napkin
should be applied  to the vulva, and changed at short intervals during the
day.  This will afford relief from the smarting pain consequent upon the
passage of the  child.  After some hours, when the patient is recovered, the
external parts  should be washed with tepid  milk and water,  containing a
small portion of  spirit.  This  must be repeated  twice a day, not only for
the  sake of cleanliness, but  to  aid in restoring the parts to their  natural
state. 
252         CONVALESCENCE  AFTER NATURAL LABOR.

  A horizontal posture is peculiarly favorable to the general condition of
the patient, and especially to the uterine  system, in the  relaxed  state in
which it is after delivery;  the patient cannot assume  an  upright  position
without a  certain amount of displacement, and  a  risk  of hemorrhage, or
possibly of sudden death.   By keeping the  patient on  her back,  we may
even remedy  old displacements.   A lady had prolapsus uteri after her second
confinement,  which lasted  till she became  again pregnant;  this was men-
tioned to me when I was called to her in her third  labor.   I kept  her  un-
usually long in  bed, and subsequently on a sofa,  and the parts completely
recovered their natural state, so that she suffered no more from the displace-
ment.   In  ordinary cases, the after-pains require no treatment; but if they
should deprive the patient of sleep, we  may give an aromatic purgative or
a dose of  laudanum.
   The only attention which  the  lochia  require, is, that the napkins should
be changed sufficiently often, and applied warm, as  any sudden impression
of  cold to the external  parts  may  be followed by  suppression  of that
discharge.
   391.  Directions should be given for  the patient  to  void urine within six
or eight hours after delivery, or sooner; and this should be done as nearly
in the horizontal posture as possible.   Owing to the distensible state of the
abdominal parietes, the patient will often wait much  longer, if not reminded;
and the consequences may be very troublesome, if not serious.  The bladder
may become  paralyzed, or inflammation may spread from it to the perito-
neum.  If there should be any difficulty in evacuating the bladder, as some-
times happens, a cloth  wrung out in warm  water, and  applied to the vulva,
will probably remove it;  or, if not, we  must have recourse to catheterism.
   392.  The state of the bowels after delivery is  of great importance; it is,
perhaps, better that they should continue  quiet for twenty-four or forty-
eight hours after  delivery ;  but after  that time has elapsed, we should pro-
cure  a  discharge  by medicine, if there  should be none  spontaneously.  A
dose  of castor  oil,  senna,  or rhubarb, may  be given,  and, if  necessary,
repeated.   The frequency of repetition must be regulated by the state of the
bowels previous to labor.   If we suspect  any accumulation, we should  not
be satisfied until  the intestines are well cleared  out; and if  the patient do
not suckle her child, purgatives will be the  more necessary, for the relief of
the breasts.   In the latter case, the saline purgatives will be found the more
useful.
   393.  The state  of the surface will point out the propriety of not exposing
the patient to a draught of cold air.   She should be allowed to cool gradu-
ally, and then the bed and bed-clothes so arranged as to afford a comfortable
degree of warmth.   The  chamber should  be  kept cool  and fresh.  The
smaller the fire  (if there be one) the better.
   394.  When the breasts begin to enlarge and become painful, relief may be
obtained by friction with warm oil or fomentations,  at  the same time giving
a dose of aperient medicine.  But the best remedy is the application of the
child ; and the sooner this is done the  better, as the  secretion and escape
of the milk will be  facilitated, the  feverishness  diminished, if not  avoided,
and a good nipple more easily formed than when the breasts are distended.
   It is better to do this, even if it should not be the intention of the patient
to suckle  her infant, as it will afford  relief; and by not  suffering the child
to  do more, we insure the  ultimate  subsidence  of the  secretion, which is
always  in  proportion  to  the demand upon it: if this  be very slight, it  will
soon cease altogether.
   395.  The  importance of  preserving  the  horizontal posture has already
been  stated ;  I shall  therefore  merely  add, that the patient should never
leave her  bed,  even to have it  made, before the eighth or ninth day; far 
         VARIATIONS  FROM  ORDINARY CONVALESCENCE.      253

more mischief results from premature exertion than from all the  errors in
diet added together.
  396.  The regulation of the diet is, nevertheless, of considerable import-
ance, as  excess, by  inducing feverishness,  may retard the  convalescence.
The patient should  be confined to slops— gruel, panada, arrow-root, milk,
whey, weak tea, etc.—wdth bread or toast and  butter, or biscuit, for five or
six days.   When the excitement produced  by the secretion of milk has sub-
sided, if there be no counter-indication, she may take some  broth, and on
the seventh or eighth day some chicken, or a mutton chop, with some wine
and water.
  In all that concerns the diet, or the assumption of the upright position,
or making exertion, it cannot be too strongly impressed upon all, that an
excess  of caution is  an error on the safe side.
  397.  On  certain  Variations  from  ordinary  Convalescence. —
Although the following observations are a deviation from the plan I pro-
posed,  yet  I should  not feel  justified in their omission, and  I do not  know
that a  better opportunity will offer for them than the present, as they may
be usefully compared with the preceding description of ordinary convales-
cence.   These deviations may depend upon the constitution, or the character
of the  labor, or upon pressure exercised locally.  Even without reference to
the influence  of the labor, there are certain irregularities which  occasion
anxiety both to the patient  and to  her physician.   Some  of these issue in
serious disease ; others, more numerous, are mere temporary deviations from
the normal course, but requiring familiarity and  tact to  distinguish them
from the more important attacks.  Of the  more serious affections — such as
fatal syncope, puerperal fever, etc. — I shall enter fully in the latter part of
this volume.
   398.  1.  The nervous shock  may be very  severe.  In these  cases the
patient complains of great exhaustion ; the senses are either unnaturally
dull, or morbidly acute,  the breathing is  hurried  and  panting, and the
accordance between  the respiration and circulation is broken.  The aspect
of the patient is that of a person in a state of collapse.   The countenance
is expressive of suffering, anxiety, and oppression.   The pulse may be either
very slow and labored, or unusually rapid,  very small, and fluttering.  There
are many cases, however, where the shock, though far from  being so severe
 as in the case I have supposed,  is quite sufficiently so to excite the fears of
the medical attendant.   Reaction  is long before it occurs, or  it  may take
place imperfectly or excessively,  and the  patient  remain for some time in  a
very weak  condition.
   Under proper treatment, the patient will gradually recover from this state
of exhaustion or collapse, unless the shock be  extreme, and then death may
supervene in a few hours.  I have seen  several cases of this kind ;  in one
case the labor was  tedious,  but  terminated  naturally; two  others were in-
strumental deliveries; but in none, where a post-mortem examination was
obtained, was there  either injury or disease discovered.  A due estimate of
the nervous shock is of great importance in severe cases ; for in almost every
instance the progress of the convalescence is  in  inverse proportion to the
amount of  this disturbance.
   The best remedy in these cases is opium, either in a large dose, or in small
and repeated ones ;  if not only gives the patient a chance of sleep, the best
restorative of all, but even if it  fail in this, the system will  be  quieted, the
respiration rendered more equable, the pulse slower and more natural, and
the relation between these two systems restored.
  The  exhibition  of stimulants (wine or  brandy, and water) in  moderate
quantities is necessary ; but we  must be careful not to exceed,  or they will
do mischief instead of good.  The  amount  of stimulants given in cases of 
254      VARIATIONS FROM  ORDINARY  CONVALESCENCE.

collapse should  have some reference to the probable reaction, as well as to
the present state of the patient.   Ammonia or musk are the best medicinal
stimulants, and  they may  be  combined  wdth  the opium.   The  diet of the
patient, when the effects of the shock have subsided, must be nutritious.   It
may be necessary to  postpone the application  of the child to the breast for
some days, or even to give up sucking altogether in some cases.
   All that has been said already upon the necessity of perfect quiet, applies
with tenfold force to these cases of extreme nervous shock.
   [These remarks of the author are deserving of the serious attention of the
young practitioner.   "I have seen more than one instance," says  Dr. Hus-
ton, in a note to a former  edition, "in which there was reason to believe the
life of the  patient was sacrificed from ignorance of the true character of the
condition here referred to.   If the  attention of the practioner be at the time
particularly directed to puerperal fever,  he is liable to confound  the exhaus-
tion in which he finds the  patient, with the early stages of that disease.  The
cold extremities constitute the chill, while the haggard countenance, hurried,
respiration, and frequent  pulse,  are  regarded as  conclusive evidence of a
rapid peritonitis.   Bleeding  from  the  arm or by leeches, is the instant re-
sort, and a few short  hours  confirm the worst anticipations,  by  the  fatal
termination,  a result which the efforts of the attendants have but too success-
fully aided in producing.
   " The author speaks vaguely in  recommending ' Opium, either in a large
dose, or in small and repeated ones.'   Where  much  pain and jactitation
occur, the dose  should be large, say a grain and a half, or two, or even three
grains ;  but  when the object is  to  soothe the  nervous system,  and sustain
the circulation,  small doses, as half a grain or ten or fifteen drops  of lauda-
num, repeated every hour  or two, with  or without carbonate  of  ammonia,
wine whey, or other mild stimulants, are  appropriate remedies.   When reac-
tion ensues, of  course these are to be laid aside.]
   399. 2. The  state of the pulse.—One variation from the usual  alternations
of the pulse has just been  noted, in cases of great nervous shock,  when it
either sinks below its due  proportion, or more frequently remains very quick,
weak, and fluttering, during the period  of collapse.
   In almost all the cases of flooding after labor, when I have had an oppor-
tunity of examining the pulse up to the time of the occurrence, I have found
it remain quick, and  perhaps full, instead of sinking after delivery.  This
has been so  marked  in several  cases, that I now never leave  a patient so
long as this peculiarity remains;  and in more than  one instance I believe
the patient has owed  her  safety to this precaution.   Three cases occurred
 within a very short time of each other,  in which I noted this undue quick-
ness of the pulse without any other untoward symptom ; at that time there
 was  no excessive discharge, and  the  uterus was well contracted.  In  all
 these, alarming hemorrhage occurred within an hour, and was with difficulty
 arrested.  I have also remarked an undue frequency of pulse when  the after-
 pains are extremely violent; and as the uterus is in such cases rather tender
 on pressure, it  requires  care  to  distinguish between this state and the com-
 mencement of inflammation.  This observation will also  apply to the quick-
 ening of the  circulation, which takes place when lactation commences, and
 which, in addition, is accompanied by rigors.  A careful examination, how-
 ever, will generally  lead  us  to  a correct conclusion,  and  the subsequent
diminution of the frequency of the pulse will remove all doubt.   Again, the
pulse is quickened  when a large  coagulum is contained in the uterus, or if
the patient suffer from diarrhoea, or gastric disturbance.   In some of these
cases the diagnosis  may be  obscure, and it may be necessary to suit our
 treatment rather to the anticipated attack  than to the present symptoms; 
         VARIATIONS  FROM  ORDINARY CONVALESCENCE.       255

thus, we may give  small  doses of blue pill or calomel in combination with
opium, along with  medicines suited to  the peculiar symptoms present.
  All the observations I have been able to make confirm Dr. John Clarke's
remark, that no patient can  be considered safe whose pulse exceeds one
hundred.
  400. 3.  The state of the uterine system.—Instead of a gradual decrease
in the size  of the womb, I  have occasionally found on  the fifth or six day
that its bulk has  increased, and that it has felt less firm than previously :
this, combined with increased  frequency  of the pulse, has apparently  threat-
ened an attack of hysteritis ;  nor was  this anticipation lessened, by the un-
comfortable sensations  of the patient, nor  by the  sudden increase  of the
lochia.  However, in most of  these cases, I found upon applying hot  fomen-
tations to the abdomen, that more  or  less coagula were discharged,  afford-
ing instant relief to  the patient, and indicating the source of the symptoms.
Purgative enemata also favor the expulsion  of the clots ;  and in such cases
may be given with great benefit.
  Dr. Simpson has  published some interesting observations on the  morbid
deficiency and morbid excess  in the involution of the uterus  after delivery,
and he has given several cases in which  the uterus continued for a consider-
able time as large  as after delivery.  It is not  the result of any deposit, and
the histological characters are those of the pregnant uterus.   These cases
are not common, but the opposite extreme is still more rare.   In one case
related  by Dr. Simpson,  the  patient  after  her  confinement  suffered  from
amenorrhoea, anaemia, and diarrhoea, under which she  finally sank;  and  on
examination  the uterus was diminished one-third below the natural standard.1
Similar conditions of the uterus had been pointed out by Dr. Montgomery.2
  It has been already mentioned that  the uterus is not free from tenderness
in cases where the after-pains are severe ; and if it be rudely pressed, the
outcry of the patient may lead us to suspect the presence of serious disease.
It will be  observed, however, that this  tenderness  is greatest during each
uterine contraction,  and that as these contractions  subside,  the  soreness
diminishes.
  Fomentations to the abdomen will generally mitigate this sensibility; but
if the after-pains be severe, and the tenderness considerable, a full dose of
laudanum,  followed by an aromatic purgative, will probably relieve both.
  The vagina may be attacked  with inflammation, which sometimes  proves
extremely distressing; this will  form the subject of  a separate notice.
  In cases where  the lochia  are acrid, the orifice  of the vagina, with the
labia and  external parts, are apt to be excoriated.   The patient may suffer
extremely either from a smarting pain, or from itching ;  and it is difficult to
say which is  the more distressing.   Extreme  cleanliness, frequent bathing,
lead lotions,  black wash, or vaginal injections of warm water, may be tried,
and will ordinarily  afford  relief: if not, the disease will  generally subside
with the cessation of the lochia.
  401.  4.  The after-pains. — Instead of the  after-pains  coming on about
half an hour or an hour after the  labor, in  moderate degree, and ceasing
after a short time, they occasionally commence immediately after the extru-
sion of the placenta, with great severity, and long continuance.   In these
cases the tenderness of the uterus is marked, but when t\\e pain is relieved
by remedies,  the tenderness  disappears also.   The pulse, also,  is quickened
for  the time.   This deviation does not  depend upon the presence of coagula,
as in the worst cases I have seen none were  expelled, but it seems rather a
spasmodic contraction of the uterine fibres.   The best remedy  is a full dose

              1 Edin. Monthly Journal, Aug. 1852, p. 127.
              2 Dublin Journal,  Nov. 1835.  Ibid., vol. xxiii. p. 161. 
256      VARIATIONS  FROM  ORDINARY  CONVALESCENCE.

of opium, which should be repeated if necessary.   At  the  same time  hot
flannels may be applied to the abdomen and vulva.
   The after-pains sometimes continue  at  intervals unusually long, and  are
very severe  whenever the child is applied to the breast.   They occasion dis-
tress and exhaustion by preventing  sleep,  and should therefore  be relieved
if possible,  by cordials, aromatic purgatives, or a dose of opium.
   402.  5.  The lochia.—Variations  in  the quantity, quality, or odor of  the
lochia, not unnaturally  excite great  alarm in the mind of the patient, who
regards any deviation in this secretion  as  a proof of serious disease.   Yet
very remarkable differences do  occur, without  any morbid affection  of  the
uterus or vagina.
   The  discharge may cease a few hours  after delivery,  especially after  the
birth of still-born or putrid children, without  any unpleasant symptoms.
   The discharge may continue the  usual  time, but in very  small quantity;
and this is commonly the case when  flooding occurs during or after delivery.
   On the other hand, it may be excessive, though not prolonged  beyond the
usual time ; or without being excessive, it may continue  unusually long.  In
these cases it may be necessary to  allow the patient a  better diet, and to
give tonics,  such as bark, preparations of iron,  etc.
   In some cases, the lochia, after decreasing in quantity for some time, are
suddenly discharged  in  double quantity,  and of a red  color, but without
coagula.  This generally happens when the patient is permitted to  sit  up
too soon.  Or it may happen at a later period, in consequence  of walking
about too much.  A  little extra rest will, however, suffice  to restore the
patient to her former state.
   Again, the os uteri is sometimes obstructed by a clot,  and the lochia are
greatly diminished, or perhaps altogether restrained, until the expulsion of
the clot affords an exit  to the accumulation.
   Instead of the usual  changes,  from red to yellow, or greenish, the red
discharge may persist;  or  after these changes have taken place, the red
discharge may return.   In these cases it  is necessary to be on  our guard,
as the change may be the precursor  of secondary hemorrhage. The patient
should be confined to the horizontal position, and clothed very lightly.
   The lochia, after going through their ordinary changes, may terminate in
uterine leucorrhcea, which may become  permanent.   This will be  best re-
medied by counter-irritation to  the  sacrum, and the internal exhibition  of
copaiba, iron, or ergot of rye.
   Again, the  unusual color of the lochia may excite alarm.    Instead  of the
transition from red to a pale red, yellowdsh, or greenish color, they are some-
times a dark brown, and perhaps more tenacious than usual,  or acrid, so as
to excoriate the vulva.
   Lastly, examples occasionally occur where the lochia have a very offensive
foetid odor, occasioning  great  annoyance both  to the patient and her
friends.  The discharge is  generally of a dark color, and  often acrid.  It
may arise from the decomposition of a small portion of the placenta or mem-
branes which were left in the uterus or vagina, or from  the  putrefaction  of
coagula.  In such cases the vagina  should be  syringed  two or three times
a day with warm milk and water, or a very weak solution of chloride of lime.
   403.  6. The bladder.—"After severe labor," says Dr. Burns, "the neck
of the bladder and urethra are sometimes extremely sensible, and the whole
of the vulva is tender, and of a deep red color.  This is  productive of very
distressing  stranguary, which  is occasionally accompanied with  a conside-
rable  degree of fever.   It  is long in being removed, but yields at last to a
course of gentle laxatives, opiates, and fomentations.   Anodyne clysters are
of service.   An inability to void the urine requires the regular and speedy
use of the catheter." 
TEDIOUS LABOR.
257
  Retention of urine is  not  very unfrequent after a prolonged  first labor.
It is distressing, but  not dangerous, and I have generally found the bladder
resume its  functions after  seven or eight days;  during which catheterism
will be necessary once or twice a day.  I have no  doubt that it results from
a slight degree of inflammation, caused by pressure, or from a  spasmodic
action of the sphincter.
  404. 7.  The breasts.—Variations in  the period  at  which the milk  is
secreted are common, but of  no moment.    If the vascular action be exces-
sive, it must be moderated  by antiphlogistic remedies, such as tartar emetic,
purgatives, fomentations, etc., and by the frequent application of the infant.
  If, as in some  rare cases,  no secretion  should  take place, the child will
require a wet nurse,  but the mother will not suffer.
  When the nipples are deficient or mal-formed, we must endeavor to draw
them out  by the breast pump ;  but if this do not succeed, we must obviate
the ill effects  of the secretion  of milk, by tartar  emetic, saline purgatives,
fomentations, etc.
                         CHAPTER  V.

PARTURITION. —CLASS  II.  UNNATURAL OR ABNORMAL  LABOR.
                    ORDER  1.  TEDIOUS LABOR.

  405.  Definition. — The head of the child presents, and the labor is ter-
minated without manual or instrumental assistance, but it is prolonged beyond
twenty-four hours, from causes which occasion  delay in the first stage.  The
placenta is expelled naturally.
  406.  Very slight experience is sufficient  to  show that delay in labor may
occur in  either the first or second stage, and  a more extended  observation
will prove,  1, that when the delay is excessive, the relative duration of the
two stages  is destroyed, so  that  they bear no steady proportion  to  each
other;  thus, for instance,  in a labor of sixty hours, the first  stage  may oc-
cupy fifty-nine, and the second only one, or vice versa; 2, that the  effect of
a prolonged labor  upon the constitution of the  patient, depends upon the
stage in which the delay occurs :  and 3, that delay in the first stage  involves
per se  very little if any danger, no matter how tedious it may be,  but that
delay in the second stage, beyond  a comparatively short  time, is always of
serious import;  therefore, the only injury done by a prolonged first stage,
is the influence it  may have upon the patient during the second stage, by
rendering her less tolerant of the constitutional suffering.  Although these
deductions are not distinctly enunciated  by writers on midwifery, yet they
appear to be involved  in their practical remarks, inasmuch as  they distin-
guish the causes of delay in the first stage from those in the second,  as being
much less dangerous.   The  above conclusions, drawn from  numerical esti-
mates, and supported practically by high authority, are sufficient, I think, to
justify  our making the distinction  between  "tedious"  and  "powerless"
labors to  depend upon  the stage at which the  delay occurs.
  407.  Statistics. — Unfortunately our best  statistical reports only give
the entire lenjrth of the labor, wdthout distinguishing the  stages, so  that the
first Table I shall give  will merely  show the frequency of those labors whose
duration exceeds twenty-four hours.
      17 
258                       TEDIOUS  LABOR.
	Total Number of	Abovo twenty-
	Labors.	four hours.
Dr. Jos. Clarke .....	10,387	134
Dr. Merriman ... ...	2,947	128
Edinburgh Lying-in Hospital .	2,452	48
Dr. Maunsell ... ...	839	46
Dr. Thomas Beatty.....	1,182	69
Mr. Lever ......	4,666	62
Dr. Churchill......	1,285	166
  Thus in 23,758 cases of labor, we  have 653 prolonged beyond twenty-
four hours, or nearly 1 in  36.
  I may add, that delay is most common among first cases.
  408. The following Table is intended to exhibit the relative duration of
each stage in  labors of twenty-four hours and upwards, in which the delay
occurred in the first stage,  and the results to the mother and child.  The
registers of the Western  Lying-in Hospital have furnished the data, and as
the cases are therein entered  under the inspection of Mr. Speedy and myself,
I believe they may be depended upon.
Number	Duration	Lenptth of	Length of	Results		Results to Child.	
of Cases.	of Labor.	First Stage.	Second Stage.	to Mother.			
	hours.	hours.	hours.				
5	24	23}	J	favorable.		favorable.	
13	24	23	1			12 '	' 1 putrid.
2	24	22	2			1 <	' 1 still-born.
3	25	22 to 24	1 to 3				
1	25	19	6				
2	25	17	8				
2	25	16	9			1 '	' 1 still-born.
1	26	253	}				
7	26	25	1			6 «	' 1 still-born.
2	26	23	3				
3	27	26}	i				
2	27	26	1				
1	28	27*	i				
3	28	27	l				
2	28	26	2				\
1	28	25	3				
1	28	22	6				
1	29	28}	}				i
2	29	28	1				.
2	29	27	2				.
1	30	29}	}				t
2	30	29	1				t
1	30	28	2				
1	30	26	4				
1	30	23	7				
1	30	19	11				
2	31	30	1				1
2	31	29	2				
1	31	27}	3}				
1	31	27	4				
1	32	31}	}				
4	32	31	1				t
1	32	24	8			unfavorable.	
1	33	32}	}			favorable.	
1	33	32	1			a	
						J	
 
TEDIOUS LABOR.
259
Number of Cases.	Duration of Labor.	Length of First Stage.	Length of Second Stage.	Results to Mother.	Results to Child.
	hours.	hours.	hours.		
	33	31	2	favorable.	favorable.
	34	33	1	a	
	34	30	4	tt	"
	34	29	. 5	a	a
	35	34}	\	"	"
	35	33	2	((	>.
	36 36	35} 35	i	,,	'•
	36	33	3	"	"
	36	31	5	"	"
	37 37	36} 32	i 5	tl	"
2	38	37	1	it	«
	38	34	4	it	"
	39 39	38} 35	4	u	a a
	40	39|	i 4	tl	1 " 1 dead.
	41	39	2	"	dead.
	41	33	8	it	favorable.
	42 43	41| 41	2	it	a
	44	26	18	it	"
	45	44	1	a	«
	45	44}	}	"	a
	46	36	10	a	"
	47	43	4	a	"
	48	47	1	tt	"
	. 48	44	4	a	a
	48	34	14	tt	"
	49 49	38} 46	3	a	a
	49	41	8	it	dead.
	50	49}	}	"	favorable.
	50	49	1	"	"
	51	50	1	'<	(t
	51	48	3	'<	"
	52	48	4	"	"
	53 53	52* 52	4 1	a	a n
	53	46	7	<<	"
	54 54	53} 53	i l	it tt	a
	54	33	21	a	a
	55 57 57	54} 56} 56	i l	"	t(
	57	53	4	•'	'■
	58	57	1	"	"
	59	57	2	"	dead.
	59	55	4	•'	favorable
	60 66	59} 62	\ 4	"	i<
	69	63	6	"	"
	74	72	2	"	"
	74 76	73| 71	* 5	<< a	a
	78	72	6	"	"
	96	66	30	"	dead.
	100	84	.16	"	favorable.
	103	74	29	"	a
1	177	176	1	"	a
 
260
TEDIOUS LABOR.
  409. Some  apology may be due for the  length of this Table, and I trust
it will be found in the fact that, at least as far as I know, it is the only one
of the kind on record.   The reader will understand that from this list I have
excluded all presentations but the head, all operative cases, all cases which
were prolonged in the second stage, and all such as were of doubtful accu-
racy, but that beyond this  I have in  no  degree  selected  the cases.  The
entire number amounts to one hundred and forty-three.  Of these not one
of the mothers died, although in  some cases the first stage  was enormously
prolonged,  and but  ten  of the children, one  of which was putrid.  If the
relative length of the  stages be  examined, it will be  found that it  did not
follow, because the first was very  long, that the second should be long also;
and in many cases (not included  in the Table) when the second stage was
delayed, the first  was extremely short.  Thus  I think that,  so far as it goes,
this Table  proves the  propositions with which I  started ;  viz., that "when
the delay is excessive, the relative duration of the  two stages is destroyed,
so that they bear no steady proportion to each other," and that "delay in
the first  stage involves  very little if  any danger, no matter how tedious it
may be."
  The only apparent exceptions to this rule, of which I am  aware, are those
cases in which some  mechanical impediment exists, and which belong to an
order to be hereafter considered.   In these cases mischief  arises, not  from
the prolonged first stage so much as from the  impediment to the completion
of the second ; and  2, certain cases in which, from some peculiar irritability
of constitution, prolonged suffering in the first stage disposes the patient to
"powerless labor" in the second.  In such, the uterine power becomes ex-
hausted, and the  pains, instead of increasing  when the obstacle is removed,
gradually diminish in  force,  and without  any mechanical  cause, the labor
may be  indefinitely prolonged, and constitutional symptoms set in.   Such
cases  are, however, comparatively rare.  Moreover,  a prolonged  first stage
is a bad preparation for undue prolongation,  or for any accidental compli-
cation of the second.
  These conclusions I  think are fairly deducible from the premises, but there
are others  which  I would guard against, and these are, first, that  because no
evil happened in these  cases, therefore nothing is to be done in any case
where the  delay is in the first stage ;  and  secondly, that the  delay was the
result of bad management, whereas  in most  cases the patients were not
brought under our care until the greater part of the time  had elapsed.   I
do think that when we find no evil resulting from the delay, we are not war-
ranted in too active interference ; but I am equally convinced that when we
can remove the cause of it,  we are bound to do so.
   I may add, in confirmation of my own conclusions, the statement of  Den-
man,  "that neither mother nor child  is ever in any danger (except in hemor-
rhage  or convulsions) on account  of the  labor, before the  membranes are
broken," i. e., in  the first stage.
   410.  Symptoms.—I conclude,  then, that these cases of labors prolonged
in the first stage, present nothing formidable as regards  the mother, and
very little  as regards the child ;  but yet we find that the continued suffering
produces  a great degree of fatigue,  and in  nervous women especially, the
loss of sleep is very much felt;  the  spirits are depressed,  and the  patient
expresses a great dread of the result.   Notwithstanding this, however, the
condition of the  patient is favorable.    The skin is cool, the  pulse quiet, the
tongue clean and moist;  there is rarely any headache ; the stomach may be
more or less disturbed, but the  other bodily functions are  performed in  a
healthy manner.   The  pains  recur regularly,  though their extent  is  often
limited, and their power inefficient,  their duration and frequency  varying
occasionally.  Still, a perceptible though  slow progress is made. 
TEDIOUS LABOR.
261
  The strength is seldom impaired, and the patient often  gets  some quiet
sleep, which tranquillizes the mind, and restores the bodily powers; there is
neither fever nor inflammation, the vagina is cool and moist, and both urine
and faeces are evacuated easily and spontaneously.
  The tranquil pulse, cool skin, and loud outcry, are all indicative of the first
stage of labor, and on  examination, the head  is found  not to  have passed
through the os uteri, whether or not the  membranes be  broken.
  The nervous shock is never in proportion to the length of the first stage
of labor, but of the second.
  411.  Causes and Treatment. —The causes which occasion delay in the
first stage of labor are various, and not  always peculiar or confined to it,
and the treatment  must be adapted to each.   No doubt can be entertained
of the propriety of removing them, when this can be done, even though the
delay they  occasion may be  innoxious.   Let us examine the principal causes
and their treatment separately.
   412.  1.  Inefficient action of the uterus is a very common cause of delay,
and occurs most commonly in delicate women  confined for the first time.   It
may arise from constitutional weakness,  a deranged  state of the digestive
organs, mental depression, uterine plethora, or irritation of the os and cervix
uteri, etc.
   [It not unfrequently occurs in women  who present no striking indications
of  delicacy, but rather the reverse, and who are  not known to labor under
any constitutional  weakness.  The inefficient  uterine action in these  cases
results, apparently, from some constitutional peculiarity—and often descends
from mother to daughter.   The females of some  families are, on the other
hand, remarkable  for the ease with which they give birth  to their children,
independently  of   any physical   peculiarity  discoverable on  the closest
 scrutiny.]
   I have also found that when from any cause (diarrhoea,  for example,)  the
labor is precipitated a few days before the time, the first  stage is a tedious
 one, and also with the  first child in cases of twins.  It may also  happen that
 when the  patient  is attacked by false pains  (producing no effect upon  the
 os  uteri) these may run on into  real  pains with a prolonged first stage in
 consequence.
   We  find the pains feeble,  of short duration,  limited in extent, often seated
 iu  front, and producing little effect upon the  bag of membranes  or cervix
 uteri.   When  the  intestinal canal is  deranged,  they  are  mixed  up with
 griping pains in the abdomen, which in many  cases modify or supersede  the
 real pains.
   It should also be stated that bodily weakness or even the presence of fatal
 disease does not  always involve  feeble  uterine effort;  patients in the last
 stage of consumption  are often delivered with great facility.
   413.  Treatment.—The first element in the  management of these cases is
 time.  We must exercise patience ourselves, and  encourage our patient to
 do so.  All that is calculated to cheer her should be communicated, and  she
 should be  occupied, if possible, and amused.   If it be  day-time, she should
 not lie down,  but may rest on a sofa, and walk about occasionally, taking
 the pains  sitting  or standing.   The bowels must  be  freed by medicine, if
 necessary,  and for this purpose enemata of a stimulating character may be
 used, as they very often also quicken  the  uterine action.   The diet should
 be bland and nourishing, but not stimulating.
   These palliative measures will  be sufficient  in many cases,  in others they
 are of no use, and the patient  may be exhausted from the prolonged suffer-
 ing and want of sleep ; and the best thing we can then do (if  there be no
 counter-indication) is to give a full dose of opium, so as to  snspend the pains
for  a time  and procure sleep.   If it  succeed,  the  patient  will wake  up 
262
TEDIOUS  LABOR.
refreshed and strengthened, and the pains most probably return with increased
strength.   In some cases the  inefficient  uterine action seems due to some
excess of  uterine irritability, and in such cases I have  found the opium of
great use  ; and the pains, instead of being suspended, increased in force and
efficiency.   Perhaps this may explain the success which  Dr. Soma states that
he obtained from the exhibition of belladonna, without attributing to that
drug any special power of increasing the uterine action.  A purgative enema,
administered when the patient awakes, is often of great service.
  When the inefficiency of  the  pains  depends  on intestinal disturbance, it
will be right to evacuate the bowels freely before the opiate  be given,  if one
be necessary.   Should there be indigestible matter in the stomach, it is pro-
bable that it will be evacuated spontaneously.
  In cases  of plethora of the uterus, or irritation of the cervix, we shall
often derive benefit from the abstraction  of  blood, after which the  pains
generally  become stronger; if  they do not, we may have  recourse to the
opium for temporary relief.
  414.  So far the remedies mentioned tend merely to the  removal of ob-
structions to uterine action;  but as it does not follow that in  all cases this
relief is followed by vigorous action, we have next to  seek  for some agents
which  shall act directly upon the uterus.   The one upon which most reliance
is placed  is the ergot  of rye.   This vegetable substance appears to have
been known for a long period in Germany, under the name of Rockenmutter,
Mutterkorn, etc.,  and to have entered into the composition  of various nos-
trums  for hastening labor.  It is mentioned by Camerarius in the Actes des
Curieux de la Nature for 1668 ;  and in 1777 Desgranges published his first
researches upon it, in the Gazette  de Sante.   Its introduction into British
practice was,  I believe, owing to Drs.  Stearn and Chapman, of  New  York,
whose favorable  experience of its effects  has been tested by  many prac-
titioners,  and  apparently  with different results.  [The  attention of the pro-
fession was first called to this article by Dr. Stearns of  the State  of New
York,  in a letter addressed to  Dr. Ackerly, in the year 1807 ;  and in the
year 1813, attention was  further directed  to it by Dr. Prescott, in a letter
which  he  read before the  Massachusetts  Medical Society.  Subsequently the
high authority of Dr. Dewees has served to bring  it extensively into prac-
tice—too  much so it is to be feared for the credit of the  profession  and the
interests of humanity.]  Desormeaux, Lachapelle, Beclard,  Capuron,  Jack-
son,  Hall, etc., deny that  it  has  any effect at all; on the other hand, we have
the  authority of  Bordot, Chevreuil,  Gendrin, Bigeschi, Luroth,  Davies,
Blundell,  Jewel, Smith, and many  others, in stating that it is effective and
beneficial.  From repeated  trials, I can  bear witness to  its  efficacy, though
it is somewhat irregularly exerted ; but  I must add that  I  have  seen  it do
mischief.
  The substance  itself, according  to Decandolle, "is a peculiar species of
fungus which  attacks  the ovary of grasses, and protrudes  from them in a
lengthened form,  especially from  rye;" hence  the  popular  term, "spurred
rye."
  [Recently,  Mr.  Smith,1  and  Mr. Quekett,2 have maintained  that the
ergot is not, properly speaking, itself a fungus, but rather  a diseased state
of the grain occasioned  by the presence of a fungus; to  this  fungus Mr.
Quekett gives the name Ergotcetia abortans.  By the  microscope, sporules,
sporidia,  or jointed bodies, are  discovered, which  appear to be the repro-
ductive particles  of the fungus 3]
  It is an oblong, slightly curved  grain, about as  thick, and twice as long

  1 [Transactions of the Linnean Society of London, part xviii. p. 449, London, 1840.]
  2 [London Lancet, June 22, 1839.]
  s [Dunglison's New Remedies, 3d edition, p. 431.] 
TEDIOUS  LABOR.
263
as a grain of wheat, of  a dark-brown color externally, but lighter, and with
a shade of pink, internally.   It has been analyzed by Yauquelin and Wright.
The latter chemist states its component parts as follows :
    A thick white oil
    Ozmazone
    Mucilage ....
    Gluten   ....
    Fungin  ....
     Coloring matter
     Fecula   ....
     Salts     ....
     Loss     ....
3100	grains
5-50	a
9-00	u
7-00	a
11-40	u
3-50	ii
26-00	(<
310	ii
3-50	ii
100-
  The chemical analysis of ergot has  thrown out little light upon its active
principle  as yet, for none  of its component principles  produce the same
effect as the substance administered entire.
  It may be exhibited  in various ways;  that which I have found most cer-
tain, is to  mix the bruised or powdered grain with a little water or milk,
and simmer it for a few minutes over  the fire, then give  the  grounds along
with the fluid.   Both vinous and acetous tinctures have been prepared, but
I have not found them  as effectual  as the powder.  Mr. Battley has also a
"liquor secalis cornuti," which seems more certain than the tinctures ;  and
I have also tried  an  extract which  succeeded pretty well.   From fifteen
grains to a scruple of the powder, half a drachm  to a drachm of the tinc-
ture, and from five to ten grains of the extract, may be given every twenty
minutes, until the effect be produced, or until  we are satisfied  that it will
not act.   I would not  give more than a drachm, or at the utmost a drachm
and a half of the powder  (or its equivalent in  tincture or extract) ; for if
that do no good, more will be useless and may  be injurious.   If  it succeed,
we find in five or ten minutes  after its  exhibition that the pains are stronger,
longer, and more frequent; their  increased frequency, indeed, is often re-
markable, even when their force is but little augmented.   I have noticed,
that shortly after an effective dose has been taken, the  pulse becomes slower
until after the pain is over, but that ultimately  it remains quicker.  Besides
this power of strengthening  feeble pains, the  researches of Dr. F. Rams-
botham and others have proved it capable  of originating uterine action.
  415. So far we have spoken of its  beneficial  effects ; and  although in by
far the majority of cases no injury is  produced  by it, yet in five or six cases
I have witnessed cerebral disturbance  in  different degrees, from a severe
headache  up to delirium, coma, and insensibility, follow its use.   By others,
it is said to disorder the stomach, and if given  in large doses, to  cause gan-
grene ; but such cases  must be very rare.   I think I have seen retention of
the placenta, from irregular uterine contraction after the birth of the child,
fairly attributable to it.
  By Girardin, Burns,  Moreau, and others, the child is  stated to be more
frequently still-born after  the use of ergot, either  from some  poisonous in-
fluence indirectly exerted upon it, or  by the greater pressure of  the uterus
upon the cord.   I have seen  some cases confirmatory of this statement, and
of the latter mode of explanation, as the uterine action was almost inces-
sant.   Dr. F. H. Ramsbotham's cases rather support this view, for he states
that when the ergot did not  bring  on uterine  contractions,  no  bad effects
were produced  upon the fcetus.  Dr. Beatty has published a very interesting
paper, showing that in certain cases the ergot  does exert a poisonous effect 
264
TEDIOUS LABOR.
upon the fcetus,  and he concludes that the child is  not safe unless the labor
be concluded within two hours from the administration of the ergot.  More
recent observations seem to confirm this view.
  416.  From what has been said, we may conclude that  ergot of rye may
be tried, 1, when the pains are feeble and inefficient, without especial cause;
2, if the os uteri be soft and dilatable ; 3, if there be no obstacle to a natu-
ral delivery; 4,  if the head or breech present,  and  be sufficiently advanced;
and  5, if there  be  no  threatening  head symptoms, nor  excessive general
irritability.
  But on the other hand, it  should not be given :  1, if the os uteri be hard
and  rigid; 2, if  the  presentation be beyond  reach ;  3,  if there  be a mal-
presentation ;  4, if the pelvis be  deformed; 5, if there  be any serious ob-
stacle  to delivery in the soft parts ;  and, 6, if  there be  head  symptoms, or
much general irritation.
  Though in  some cases, when timely administered, it  may anticipate the
use of the forceps at a later period, it is not likely, as some have supposed,
ever to supersede the use of that  instrument, and it is not suited in those
cases in which the crotchet is required.
  [Of the power of ergot to excite uterine contractions there  can be no
doubt; but that it often fails to do so under circumstances apparently favor-
able for its action,  will be admitted  by all wdio have had much  experience
wdth it.  Why this is so, we know not.  Yery generally it will be found to
act with decided energy in cases where the parturient action of  the womb
has  already commenced increasing  this  action  in force, and rendering  it
more continuous.  In this country its too extensive employment has left no
doubt on this point.   The only questions which remain to be settled are as
to the circumstances under which it is proper to be used, the dose, and mode
of administration.   The experience  of Dr. Huston, as he states in a note
to a former edition, confirms the observations  of Drs. Patterson and Rams-
botham, as to its power of  bringing on premature labor, and its fatal in-
fluence on the child when employed for that purpose,  although he "cannot
admit  that this  occurs  in consequence  of the  child being poisoned by the
ergot through the  system of the mother."  Consequently, it should never
be administered previously to the setting in of  labor, and even then only
with the greatest caution, at the  proper period, and under the most favor-
able circumstances  for its use.
  The incessant action of the uterus, under the influence of ergot, is very
unlike the intermittent contractions which  occur in  natural labor.  This
state of permanent contraction  of the organ either detaches the  placenta,
or so compresses it as to destroy its functions  before the  child is in a situa-
tion to respire.   The appearance of the children born under these circum-
stances confirms this statement.
  The intelligent practitioners of this city  use the ergot chiefly in the ad-
vanced stage of labor,  or after the birth of the  child, to  overcome uterine
inertia.  They always  avoid its  administration where  any  obstruction or
great disproportion between the size of the  child and the passages of the
mother exists.   It  is a rule with them also  to  abstain from its employment
until the os uteri is not only dilatable, but fully dilated, and the other soft
parts in a favorable state of relaxation.   Even when thus  cautiously had
recourse to, the child will not unfrequently be  dead-born.
  The dose given is from one to two scruples  of the powder,  or an amount
of the  article equal  to that, whatever may be the preparation employed.
Some  prefer smaller doses, as ten or fifteen grains, repeated every  fifteen or
twenty minutes until the desired effect is produced.
  Some practitioners always administer the powder in the  form of electuary,
or diffused in water.  The  best mode  of giving the ergot is, perhaps, re- 
TEDIOUS LABOR.
265
cently powdered, in hot water, in doses  of a scruple  every twenty minutes,
until a drachm is taken, unless the proper effect occurs sooner :  more than
that quantity is never required, if the  article be good, and the case  one
adapted to its use.
  Experience has shown that  ergot, especially when  powdered, rapidly de-
teriorates;— to avoid this and at the same time furnish an article in a con-
venient form  for immediate use, the Pharmacopoeia of the U. S. prescribes
a urine made  by macerating two ounces of the ergot  (bruised) in a pint of
wine, of  which one  or  two drachms  are  given at a  time, and repeated if
necessary.
  The oil, tincture, and extract,  are rarely used.]
  417. Borax is said by German writers to have the power of quickening
uterine action, though it is seldom used in  this country.  Dr. Rigby says,
"We have combined these two medicines (ergot and borax) with the best
effects, and generally give them  in the following manner;  R Secalis Cor-
nuti 9i—ij ;  Sodse subbarat. gr.  x; Aq. Cinnamomi giss.   M. fiat haustus.
Cinnamon, which is a remedy of considerable antiquity, has also a similar
action upon the uterus,  although to a less degree."
  418. At a meeting  of the  Edinburgh Obstetrical Society,  Dr. Simpson
mentioned that he had tried the Indian hemp, and found that uterine action
seemed to be markedly  and directly increased by it, but that his experi-
ments were too few to be decisive.1  I have never given it for this purpose,
but it seems worthy of a further trial.   Dr. Grigor, of Nairn, has since tried
it in sixteen cases ; in  nine  there was no perceptible increase of uterine
action, but in  seven it  succeeded very well,  without  any anaesthetic or
unpleasant effects.2   Dr. A. Christison tried it in seven cases3 successfully.
  419. Dr. Maguire mentioned to me  that he had  tried a drop of Croton
oil  as an oxytoxic. and  that it succeeded admirably, whether it acted upon  °cuSy
the bowels or not;  it did so in the only case in which I have had an oppor- ~r L ,cTct.
tunity of trying it,  but  it left a very unpleasant sensation  of heat  in the
throat.
  Dr. Harris, of Alabama, has recently stated that  a strong  decoction of
the Uva Ursi has produced the same effect in  five cases, without any unplea-
sant symptoms.*
  420. Dr. Radford, of Manchester,  has lately proposed the application of
galvanism in tedious labor from want of power in the uterus, in accidental
hemorrhage,  irregular contraction,  and  to bring on premature labor, and he
relates a  case  of hemorrhage in which  he  employed it  successfully,  and
another in which the pains had ceased.   Professor Simpson tried it in eight
eases of protracted labor, and thus sums up the results:—"In one instance,
the pains were  more frequent  in  their occurrence, but shorter in their dura-
tion, during the application of the galvanism.  In five other cases, the em-
ployment of  the galvanism neither increased the average frequency of the
pains, nor their average duration.   In one, the pains ceased while the gal-
vanism was applied, and returned upon its removal.   In  another the uterine
action ceased while the  galvanism was applied, and did  not return for
twenty-four hours afterwards."   In Mr. Houghton's excellent paper, I find
it stated  that Mr. Dorrington used it successfully in five cases ; Mr. Clarke
in  two;5  Mr.  Cleveland in  one; and Mr.  Dempsey in ten  cases.  Mr.
Houghton himself succeeded admirably in five cases.6   Thus the effects have
been decided in twenty-five cases, equivocal  in one, negative in seven, out
of  thirty-three cases, which is, I think, amply sufficient  to justify a further
trial.

  1  Ed. Monthly Journal, July, 1850, p. 91.             2 Ibid., Aug. 1852, p. 124.
  3  Ibid., Aug.  1851.             * Philadelphia Med. Examiner, Nov. 1853, p. 727.
  5  Dublin Hosp. Gazette, March 1st, 1845.     6 Dublin Quarterly Journ., Feb. 1852. 
266
TEDIOUS LABOR.
  421.  M. Kiwisch states that he has found the water douche of great use
in stimulating  the  uterus to  action.   M. Paul Dubois relates one case in
which he tried it;  and with  sufficient benefit, I think, to justify our repeating
the trial.1
  Dr. Washington  relates  that  he  has found dry cupping  to  the  sacrum
effective in augmenting uterine action.  The first class should first be applied
to the  lowest  point  of the sacrum, and after about  ten  minutes, another
higher  up.2  I have had  no opportunity  of  testing this, but it does not
appear  to me unlikely that  such  an effect might be produced.
  I  have already alluded to  the beneficial effects of stimulating purgative
enemata; and  I may add that  some writers have recommended stimulants
externally, such as  mustard poultices, or friction with stimulating liniments.
I have never found them of any  use.
   [Labor  is occasionally rendered tedious, during its first stage,  by the
occurrence of irregular and spasmodic pains.  " They are recognized," says
Dr. Lever,3 "by their acuteness,  by the want of consentaneous action in the
uterine  fibres — some portion of  the uterus, during their continuance, being
hard and  contracted, while  the other portion is soft and  yielding; there is
also no  distinct or regular interval of time between the paroxysms of  pain.
If untreated or unrelieved, the  strength  of the patient is  exhausted before
the establishment of true labor pain ;  or,  the child, which at the commence-
ment presented normally with the head, may even  have its position changed
to that  of the shoulder, in consequence of the uterus contracting on one side
only, and  thus forcing its  contents over  to the  uncontracting  or yielding
side.  In such cases, the utility  and  value of opium are most  marked.  It
maybe  exhibited by the mouth or per anum.  It will calm the spasm, subdue
irregular  action, alleviate pain, procure sleep ;  and after this, true and regu-
lar uterine action will be established.  Manifold are the instances  of its value
I have  witnessed under such circumstances."]
   422.  2. Undilatable os uteri. — In order to put the reader in full  posses-
sion of  all that concerns rigidity of the cervix uteri, I shall have to trans-
gress the strict limits of this chapter, and  include a class of cases which in
their effects more  properly belong to the chapter  on Obstructed  Labors.
The large majority of cases of right cervix offer resistance in the first stage
only ; i. e., they yield before any symptoms " of powerless labor " set in, but
a small number resist  permanently.   Anatomically  speaking, the labor is
still in  the first stage, for the  head is within the os uteri; but virtually,
taking  the symptoms as a standard, they run on  into the  second stage, of
which they exhibit all the characteristics.
   Trusting that the advantage  of having  the whole subject under view at
once may compensate for the irregularity, I shall first speak of the ordinary
class of cases.   With the first child the cervix uteri is more unyielding than
subsequently, and also in women of advanced  age.   It may give way, how-
ever, within a  reasonable time ;  but in some cases it does not,  and on ex-
amination we  find the lips thin, hard,  and rigid,  or soft,  semi-pulpy, or
oedematous, and that little  progress in dilatation  is made during each pain.
The pains themselves may  be frequent, and very severe, notwithstanding the
slight effects they appear to produce.  The thick  pulp or oedematous cervix
uteri is carefully to be distinguished from the  soft  and flabby condition,
which is a kind of transition  state in the ordinary process of dilatation, and
into which the thin and rigid cervix must pass  before it will dilate.  The
pulpy oedematous cervix is as undilatable as the thin and hard.   The  latter
is more frequent in primipara ;  the former occurs indifferently, and appears

      1  Moniteur des Hopitaux, 12th Feb. 1853.
      2  Association Journal, May 27th, 1853, p. 469.               8 [Op. cit.J 
TEDIOUS LABOR.
267
to be the result of irritation, caused in some cases, doubtless, by too frequent
examination.
   423. Treatment. — Several remedies have undoubted power in most cases
of this   nd, and a suitable selection of them should be  tried before we
conclude that further interference will be necessary.   In fact, the failure of
these is in many cases the  only test we have whether the rigidity be such as
will yield or will resist.
   The first, and  perhaps the most effectual, when the  patient can bear it, is
loss of blood.  Some  caution is necessary, not to  carry it to too great an
extent; but, within reasonable limits, we need not  fear any ill effect upon
the patient or the progress of the labor.  Dr. Dewees recommends it even
with delicate women ;  in one case he took away two quarts of blood, and
the patient did well.   Dr.  Davis has taken between  thirty and forty ounces;
but it will not in  general be necessary to abstract so much.   Neither ought
we in any case to bleed in anticipation of the difficulty, as has been advised.
   In most cases of rigidity, fourteen  or sixteen ounces  rapidly taken from an
ample orifice in the  arm will be sufficient, and if it make the patient feel faint,
so much the better;  after which, if she  be much  fatigued, rest may be pro-
cured by means of an opiate; and  this  will  generally be  succeeded by a
softened, yielding condition of the parts.
   424.  Should the venesection only  partially succeed,  however,  or in case it
be not desirable to have recourse  to it,  we may  then  try the tartar emetic,
which I believe was first used in these cases by Dr.  Every Kennedy, of this
city.  It is an exceedingly  valuable remedy, perfectly safe, and very success-
ful.  It should be given in small doses,  so as to  excite and keep up a state
of nausea, and it may be advantageously combined wdth a purgative, — take
for instance  the  following formula:  R. Magnes.  Sulph. gj ;  Infus. Sennas
sviiss;  Antim. Tart. gr. iij ;  Syr. Zinzib. gss.   M. capiat cochlearia duo
omni semihora,  vel omni hora.   Dr.  Hall, of Montreal,1 recommends larger
doses, a grain every half hour;  but this I have never found necessary, and I
can conceive cases in which much depression and prolonged vomiting might
be very injurious.
   Emetics were recommended  by Lowder, and  by  many others since his
time, founded on the observation, that the spontaneous vomiting in labor is
almost always followed by relaxation of the os uteri; but as the same bene-
fit results from exciting nausea, it  is much better  to avoid  the shock of
vomiting.
   Opium has been  used to suspend  uterine action ;  but it is far more effec-
tive when given after bleeding.   Tobacco enemata have been proposed and
tried; but their effects are  so uncertain and occasionally so formidable, that
their use is hazardous, and  to be deprecated.   Dr. Dewees says that they do
not succeed.in softening the cervix.
   425. Belladonna was recommended by Chaussier, from its effects  in re-
laxing sphincters : but  there are very serious objections  against its use.  Dr.
Rigby states, "for our  own part we must confess,  that although  we have
seen  this application  tried repeatedly, it has never produced  the desired
effects; but has invariably brought on very troublesome and distressing symp-
toms, such as sickness,  faintness, headache, vertigo," etc.
  French practitioners  are in the habit of using mucilaginous injections,
after the recommendation  of Gardien, nor is  there  any objection to them,
although I cannot say I have seen much good from them.   The hip-bath
was tried by Dr.  Dewees,  but  without  adequate benefit; it weakens the
patient, and may possibly give rise to hemorrhage.
  ["In practice," remarks Dr.  Lever,2 "we find women, who have  suffered

   1 British American Journal, Dec. 1850.       2 [Lond. Med. Gaz., Nov. 1849.] 
268
TEDIOUS LABOR.
in early or unmarried life from one or other of the forms of dysmenorrhcea,
when pregnant and in labor, with the os uteri thin, sharp, knife-life, so that
its edge is scarcely to be felt—in fact, is often overlooked by the unpractised
finger?  The sufferings of the  patient are intense;  the dilating stage of
labor is protracted ; and, if untreated or unrelieved, by the time the  os uteri
is dilated  nature  is exhausted, uterine efforts fail, and such a case is fre-
quently terminated either by the forceps  or by craniotomy.   In most cases,
these evils may be averted by the timely employment of opium, and the best
mode of securing  its good office is in the form of enema.
   " We  occasionally find the first stages of labor  rendered tedious by a
hardened,  undilatable condition of the os uteri, in women  who have  suffered
from  chronic inflammation of the neck of the  uterus, or those wdio have worn
mechanical contrivances for the  purpose of supporting  the viscus, and in
those who, from  disease, imaginary or real, have been submitted to the in-
fluence of some escharotic, at the present day by  far too commonly practised.
This condition of the os uteri needs no description ;  the sufferings of the
patient are excessive and protracted, and, if unrelieved, may be followed by
results serious to  mother, and  fatal to child.   In addition to blood-letting,
applicable to some cases, to the warm bath, of immense value, to the exhi-
bition of  antimony, and this is of the greatest  service, we find, when the
latter has  been exhibited, and  has produced its desired results, relaxation
of the os uteri, and  increase of discharge, that  opium, given in a full dose,
will render these permanent, and thus prove  a most valuable agent in com-
pleting a safe delivery.
   " Opium has been recommended most strongly in cases where the os uteri
is callous  ; but if the callosity depends upon previous injury, or is the result
of disease, its value, in my opinion, depends upon its power to curb uterine
action until  vaginal interference removes the obstruction to the passage of
the fcetus.   But  there is another condition  of  the os uteri in  which opium
acts, and like a charm : —in women who have suffered from irritable uterus,
where the vagina is generally dry and hot, although not over-sensitive; but
the moment  the   examining finger touches the os uteri, the patient shrieks
 out, shrinks  from the  attendant, and by her cries and  motions evinces the
 sufferings she  endures.   In addition to subsidiary  measures,  as the warm
bath, the  injection  of linseed  tea  into the vagina, great benefit is to be de-
 rived from the use of opium, either by the mouth or by the rectum ; the latter
 mode of  employment being the one I prefer."]
   426. I  believe  we shall rarely fail in softening the more simple  cases of
 rigidity by some  one or other  of these means ;  and  it may be a great ques-
 tion how  far any  manual or digital interference  for the  purpose of dilating
 the os uteri  is admissible.  Dr. Smellie both recommended and practised it;
 Drs. Hamilton  and  Burns advocate it, and  also the present able Professor
 of Midwifery in  Edinburgh.
   On the other hand, Dr. Murphy, and almost  all the English authorities,
 Dr. Collins and all the Irish, object to any mechanical interference whatever.
 I think some confusion has arisen from the uncertainty of the amount ot force
 or dilating  power to be  employed.  If this be much, we have  evidence
 enough that it may do injury ; if it be little, will it suffice ?  That a certain
 amount of dilatation may be effected without injury by passing the finger
 along the borders of the os uteri, with a very moderate degree of pressure,
 I know, because  in  some of the  more  obstinate cases  of  simple rigidity I
 have tried it;  and I know  also that the pulp of the forefinger,  placed firmly
 at the edge of the cervix during a pain, without any attempt to dilate, seems
 to favor  dilatation  by giving a point of resistance in those cases, especially
 where the pelvis is large.   More than this I would not venture to recom- 
TEDIOUS  LABOR.
269
mend, although it has been  practised with benefit;1  but this much is safe,
and may be very serviceable.
  427. But  now  let us speak of those more obstinate cases  of rigidity in
which all these remedies have failed after a fair trial, and the failure of  which
points out that they belong to a separate class, and that other means must
be employed.
  The rigidity in  some  of these cases appears to be owing to a natural
density of structure ;  in  another and larger class, to be the result of inflam-
mation following  previous labor, or disease  or violence.  There  is  also a
small class in which it results from organic disease of  the cervix.
  In these cases the pains may continue  strong and frequent, increasing in
force, and assuming  the characters  of second-stage  pains, with voluntary
efforts superadded.   After a while the pulse becomes permanently quick, the
skin hot and sweating, the face  flushed, and meantime no progress is made
in the dilatation  of the  os  uteri, the cervix feels hard  and tight, and the
head, covered  by the cervix, is forced down into the pelvis, if it be sufficiently
spacious.
   The remedies which act so beneficially in the simpler cases  seem to have
no effect here,  and if  relief be not afforded, the case  gradually assumes the
character of powerless labor, with or without complication.
   Now, what is the result if  the case be trusted to nature ?   It may  termi-
nate in various ways,  all  of them very serious.
   1. The  patient  may become utterly exhausted,  and die, as in powerless
labor, or be  carried off by a convulsion before delivery.  This happened with
one of Smellie's2 cases.
   2. In cases where  the pains  are  vigorous,  the cervix uteri, in  part, or
entire, has been torn off.  Such cases are recorded by Mr. Scott,3 M. Steidele,
Dr. E. Kennedy,4  Mr. Power,5  Dr.  Lever,6  Dr. Davis,  Dr.  Reardon, Dr.
Johnston,7 and I have seen two myself.  These cases, though involving some
danger, do not generally prove fatal.
   3. Rupture  of the  cervix may occur spontaneously, and  if confined to
the cervix, and the pains be  good, and the patient not too much exhausted,
may terminate  successfully;  but  if the labor have been  much prolonged,
assistance may be required, and the patient may sink.   Dr. F.  Ramsbotham
relates two fatal cases of this kind.8
   4. Rupture of  the  body of the uterus is by no means unfrequent, and of
course proves  fatal.   Several examples of this have been recorded, and are
collected in Dr. Trask's paper. In addition to the fearful mortality as regards
the mother, I may mention that nearly all the infants are lost.
  5. Let me add  that,  if delivery have  been  effected by craniotomy, the
patient may have  sunk so much by the  previous  long labor, that  she may
survive but a short time.    One of Smellie's cases died in twenty-four hours
after delivery.9
  428. With these results before our eyes, I need not say that the prognosis
is very serious.  With the best assistance we can render, the results are very
doubtful, but left to  nature  beyond  a  certain  period, the majority  of the
cases end fatally.
  Unless the previous history, or a careful examination, inform us of previous
or present disease, our diagnosis wdll depend  upon the fact that time and
pains, with the  usual remedies, have failed, and that the cervix is as rigid as
ever.

  1 Dr. Rawson, Lancet, July 23d, 1853, p.  96.      2 Cases, vol. iii. p. 205.
  3 Merriman's Synopsis.                       4 Dublin Journal, vol. xvi.
  5 Ibid.                                     6 Guy's Hosp. Reports, Oct. 1845.
  7 American Med. Journal, April, 1851, p.  342.
  B Obstetric Med. and Surg., p. 242.              9 Cases, vol. iii. p. 64. 
270
TEDIOUS  LABOR.
  429.  Treatment. —When this is the  case—i. e., when we find that, not-
withstanding sufficient time has been allowed, that the pains have been good,
and the usual remedies have been  tried in vain, and  that the symptoms of
powerless labor are setting in,—it is clear that we cannot be justified in leaving
our patient to the efforts of nature so long as any resource remains.
  In such cases it has been found that  incision of the  cervix, by liberating
the head, affords both mother and child a much better chance than any other
method.   In Mr. Tweedie's case  both mother and  child  were saved.1  In
Mr. Butler's  case the cervix was incised in two labors :  one child was saved.'
In Dr.  Buckminster's case both mother and child were saved.3   In Dr.
Gardner's case the mother was saved, but the infant was  putrid.4  In two
cases by Dr. Pagan,  both mothers were saved.5  Many other such cases are
on record, but these will suffice to show that, by this  proceeding, the mother
and frequently the child, may  be  saved, provided it be not deferred until the
patient becomes exhausted ; otherwise,  as in  Smellie's case,6  the patient may
die after delivery.
  The two points, then, which require very great care  and caution to deter-
mine  are, 1.  Whether the case is one which  may be  terminated naturally or
by a milder method, and 2, if  not, what is the proper time for operating.  I
have already stated that the setting in of the bad constitutional symptoms
after the failure of the natural efforts aided by the  usual remedies, will, in
my opinion, indicate  that more decisive  help must be  given if  we  hope to
save the patient;  and I should say that the  moment  we arrive  at this con-
clusion is the proper time for  putting it into execution.
   The  mode of doing so is  not difficult;  the points of a pair of probe-
pointed scissors should be introduced between  the head of the child and the
cervix, and an incision made, about an inch long, on either side : if necessary,
two more at right angles may be added ; and I think there is less danger of
a  mischievous  extension  of the  rent with four than  with  two.  There is
generally but little hemorrhage, and no pain.  Great care should be paid to
the state of the parts during convalescence.
   Let me add  that, contrary to what we might expect, it does not appear
that an extension of the  laceration to the body  of  the uterus  is very liable
to occur.7
   430.  I am aware,  of course, that great names maybe quoted against such
a proceeding, but,  with great respect, I would say that facts such as I have
quoted are of higher authority than  great names;  and of  late years some
practitioners of ample experience have  concurred in  the  propriety of the
operation.   M. Baudelocque  advises  it, after  waiting  a sufficient time, and
trying ordinary means ;  Dr. Dewees is in favor of it in such cases;  Profes-
sor Murphy  prefers it to waiting for the child's death, and then craniotomy;
Dr.  F. H. Ramsbotham  admits  that in some  cases it may be necessary;
MM. Chailly and  Cazeaux are  in favor of it.   Dr.  Lever concludes that
artificial dilatation is unjustifiable, but that  incision  is the proper remedy in
insuperable rigidity for the purpose of preventing a  laceration  of the cervix
such  as he has recorded,  and, a fortiori, for an alternative of rupture of the
body of the  uterus.8
   431.  3.  Excess of liquor amnii.—It occasionally happens that the secre-
tion of liquor amnii  is in excess, most probably in consequence  of some in-
flammatory state of the  amnion ; at  least the researches of  M. Mercier and

  1 Guy's Hosp. Reports, vol. iv. p. 119.        2 London Med. Gaz., vol. xx. p. 589.
  3 Amer. Journal of Med., Oct. 1847.         *  Ibid, July, 1852, p. 127.
  5 Edin. Monthly Journ., Aug. 1854,  p. 172.    6  Cases, vol. iii. p. 211.
  7 For more minute details, see the chapter on Occlusion  of the Os Uteri, in Churchill's
Diseases of Women.
  8 Dub. Hosp. Gaz., March 16, 1847. 
TEDIOUS LABOR.
271
others  seem to favor this opinion.  In  other  cases a considerable quantity
of fluid is found between the amnion and chorion, thus  adding to the bulk
of the  contents  of  the uterus.   The state of over-distension involves no
danger to the mother, though it  certainly impairs the force of the  uterus,
and so prolongs  the first stage.  I may  add that the child is often still-born
or diseased.
   432.  Treatment.—We must be cautious in  assuming this to be the cause
of delay, and temporize until experience has proved that the uterine action
is deficient.  If necessary, rest may be procured by opium, and  if, after that,
there is no improvement, and the uterus be unusually large, the membranes
may be ruptured ;  after which the pains  become stronger and more frequent.
Before we do this, however, we must be sure that the os uteri is dilatable,
and the presentation natural.
   433.  4.  Toughness  of the membranes. — Generally speaking, the mem-
branes yield to the  pressure from above about the time when the os  uteri is
fully dilated ; but this is not always the case.  They sometimes  remain entire
 until protruded through the  external orifice,  but in these cases  without
 causing delay ;  in other cases their adhesion to the uterus is more firm, and
 they neither break nor protrude, but of course  occasion a prolonged first
 stage, because  the  liquor amnii which is retained  prevents the  more  forcible
 contraction of the uterus. A very remarkable case has been recorded by the
 late Dr. Montgomery,  in which extraordinary  strength  of the  membranes
 resisted  powerful uterine efforts for several hours.
   434. Treatment.—The delay should never, on slight grounds, be attributed
 to this cause, and not  unless the pains  are  active, and the os uteri perfectly
 dilatable* when no doubt remains, the  remedy is  obvious — viz., to rupture
 the membranes.
   435. 5. Absence of the "bag of the waters.''''—Occasionally the  head is
 placed in such close apposition  to the lower segment of  the uterus,  that,
 being kept there by the pains, it covers the os uteri, prevents  the formation
 of the bag of the waters, and deprives the patient of the  wedge power in
 dilating the os uteri.   In  such cases the dilatation is effected by the head
 alone, as when the liquor amnii has escaped too early, and  the effect is very
 similar.   I have  repeatedly seen the first stage of labor  prolonged many
 hours from this cause  in women who  have  had  several children, and whose
 former labors had been very short.
    [It is very certain that the dilatation of the os uteri in labor is liable to
 be very greatly impeded by the rupture of the membrane and the escape of
 the liquor amnii during or before the setting  in of the first stage, not, how-
  ever, from the bag of waters as a  wedge forcibly dilating the  os uteri.   The
  true cause of the retardation of labor  from the  early rupture of the mem-
  branes, is because the  pouch formed by the waters inclosed in the membranes,
  by adapting itself to the shape  and inequalities of the cervix, makes more
  equable pressure on its fibres, and consequently subdues their resistance more
  equably th;in can  any part of the child  that may present  without its inter-
  vention.   The head being brought too  early in contact with the cervix uteri
  by acting unequally upon its muscular fibres, while it  overcomes the resist-
  ance of some,  increases that of others, and thus  delays the dilatation of the
  os  uteri and increases the sufferings  of the female by irritating  it to an
  irregular and somewhat spastic  action.  Something similar, though not to
  the same extent, occurs when the head of the child, simply  covered  with the
  membranes, is brought early in labor in contact with the cervix uteri.]
    436.  Treatment.—Yery little interference  is necessary.   In  some  cases we
  may be  able to push up the head (very gently) during an  interval  between
  the pains, and so allow the liquor  amnii  to descend.   If we cannot do so,
  we must allow time, and wait patiently, as the  delay is  seldom inordinate. 
272
TEDIOUS LABOR.
If, however, the patient should suffer from this  cause, I should be  inclined
to rupture the membranes, provided it be not a first labor.
   437.  6. Premature escape of the liquor amnii. —This may occur  from
weakness of the membrane, from violence, accidents, or careless examina-
tions, and as the early dilatation of the os uteri is effected mechanically by
the "bag of the waters" acting as a wedge, its absence will delay the opera-
tion by making the head of the child the dilating power, for which  it is by
no means so well suited.
   438.  Treatment. — If the pains be active, and  the os uteri  not rigid, all
that is necessary is a little patience, and it is merely  a question of time, in-
volving, it is true, longer suffering to the mother, but no danger  to her or
her child.  In all such cases, an early examination should be made,  in order
that no time may be lost, if the presentation be abnormal.
   If the os uteri be undilatable,  and with first children it is  not unusual
under  the circumstances, the remedies already recommended (§ 423) for such
a state of the parts must be employed.
   439. Obliquity of the uterus.—The uterus may acquire an inclination one
way or the other during pregnancy, from different causes, so as to affect the
progress  of the  first stage, by destroying the  unity of axis  of the uterine
cavity and pelvic brim, so that the head of the child is not applied in a right
direction to the brim.
   Thus the position in which the patient lies during pregnancy  may give the
uterus an inclination to the right or left, and the relaxation of the abdominal
parietes may cause "pendulous belly."   I  have no doubt that obliquity may
cause  delay;  but it is far less frequently the  case  than was  supposed by
Deventer, who first pointed it out  to his disciples.  Dr. Denman, who objects
to Deventer's  opinion, remarks, nevertheless, that  "it  must,  however, be
allowed that some labors are procrastinated by the mere  oblique position of
the os uteri."  Dr. Wm. Hunter very truly remarks,  "As far as I have been
able to observe,  the mere obliquity of the uterus never occasions so difficult
a labor as to require any artificial arrangement to bring the  os uteri into a
proper situation.   In such cases, as in  many others, art can do little good,
and patience will never fail,"
   The mal-position of the os uteri will be detected  on making an examina-
tion ;  it will be  found at one extreme of the transverse diameter of the brim,
 or close to the sacrum ;  and when our attention is thus excited, ;ui exami-
nation of the uterine tumor will decide  upon the existence of the obliquity.
 The mere deviation of the os uteri  from its  ordinary situation is not suffi-
cient,  because that will soon be altered by the pressure of the  pains, if the
 axis of the uterine cavity be in accordance with that of the brim.
   440.  Treatment.—Although I do not believe that the completion of the
 first stage may be delayed by lateral inclination of the uterus,  I cannot but
 agree with  Dr.  Hunter that little is necessary except patience  ; the uterine
 contractions tend,  as we have seen, to bring the axes into accordance, and
 this may be aided by placing the patient on  the side opposite to the incli-
 nation.  I do not think that interference with the os uteri is necessary.
   Few practitioners, I fancy, will  doubt that, in an aggravated case of an-
 terior obliquity, or " pendulous belly," the deviation from the proper direc-
 tion must be a serious difficulty, and one that patience alone is not likely to
 remedy.  In these cases it is customary, and very useful, to place the patient
 on  her back,  at least till towards  the end of labor;  but  in some cases this
 alone  is not  sufficient.   "We  have found," says Dr. Dewees, "more than
 once,  in cases of extreme anterior obliquity, that it is not sufficient for the
 restoration of the  fundus, that the woman  be placed simply on her back:
 but we are obliged also to lift up and support, by a  properly adjusted  towel
 or  napkin, the pendulous belly,  until  the  head shall occupy the  inferior 
TEDIOUS LABOR.
273
strait."   I believe that this will be sufficient in all cases;  but a very high
authority—M. Baudelocque—practised further manipulation.   In a case of
the kind  he  attended, after placing the  patient  on her back, he says, " I
raised the abdomen with one hand to diminish the obliquity of the uterus ;
while with two fingers of the  other, after having pushed back the child's
head very little, I was able  to  hook the  anterior edge of the orifice of the
uterus, to bring it towards the  centre  of  the  pelvis, where I kept it during
a few pains;  and then permitting the  woman to bear down with the  little
strength she had left, she was delivered in the space of a quarter of an hour."
   441. There is a certain condition of the os uteri, the result, probably, of
some obliquity, although it is not externally perceptible, which causes con-
siderable delay in the first stage.  I allude to those cases where, in the pro-
gress of the dilatation of the os uteri, its anterior  lip is caught between the
head and the  symphysis pubis, and  its retraction prevented.   It may also
result from the unequal dilatation of the  anterior  and posterior half of the
cervix, as in some cases I have  found on examination  during a pain, that
although the posterior lip was dilated  and retracted, the anterior was drawn
still more tightly over the crown of the head.   However produced, the effect
is a delay of some hours in  the  first  stage.   Dr. Hamilton was the first, I
believe, to call the attention of the profession to this peculiarity.
   442. The remedy is simple :  during an interval between the pains, the os
uteri is soft and dilatable, and  it is very  easy with one finger to push the
anterior lip over  the crown of the head ;  and  having done this with  great
gentleness, it should be maintained there  by steady pressure during the next
two or three pains.   It will soon be  felt retracting whilst contracting, and
then it will slip over the head altogether.   After  this difficulty is removed,
the labor will proceed more rapidly to its termination.
   When the  head  fills the  pelvis very tightly, it is not easy, nor in  some
cases possible, to raise  the  anterior lip, on account of the want  of space;
and as no force should be used, we are compelled in such cases to  trust to
the gradual predominance of the expulsive force over the resistance.   And
when the lip of the os uteri becomes oedematous  from the pressure, or in-
flamed, as is  not very uncommon, it will  require  great gentleness; in fact,
if not easily raised, it had better be let alone.
   443. The  causes already  enumerated  may  be  considered  natural   ones,
which, in general, can neither be foreseen nor prevented ; but we  are not to
forget that delay in the first stage is  frequently the result  of mismanage-
ment.  Thus  the use of cordials on  the plea of supporting the strength,
keeping the room hot and close, putting  the  patient  to  bed too soon, en-
couraging her to  make efforts  prematurely, injudicious attempts at assist-
ance, omitting to evacuate the  urine, etc., will all act  upon the  labor, and
retard its progress.   A well-instructed nurse  will avoid these mistakes; but
we may be called in  after the effect  has been produced, and  then a little
common  sense will be our best  guide.
   444. These causes will act  upon  the first stage of labor, and although
they offer a certain amount of  obstruction, and make the labor other than a
natural one, none are of such a kind as to prevent its  being completed by
the natural agents.
   Again, we have seen that the delay in  itself is  attended with little,  if any
ill-effects to the mother, or to  the child ;  that at most it occasions a degree
of fatigue, weariness, and  exhaustion (which is soon  repaired);  conse-
quently, whilst this is a  sufficient warrant for endeavoring  to remove the
cause, it  does not justify our attempting to hasten  the labor, merely because
the first stage is tedious.
       18 
274
POWERLESS LABOR.
                        CHAPTER  VI.

         PARTURITION. —CLASS  II.  UNNATURAL LABOR.
                   ORDER 2.  POWERLESS LABOR.

  445. Definition. — The labor is prolonged in the second stage, by causes
which act on the uterine power primarily or secondarily, rendering the pains
feeble and inefficient,  or  totally suppressing them.  In consequence of the
stao-e at which the delay takes place, certain symptoms arise which render
spe°dy delivery imperative.   The pelvis is sufficiently roomy.
  446. We  have just seen that the delay in the  first stage of labor is unat-
tended with serious results to the mother, and very rarely to the child, and
we remarked, that although feeble, the pains recur regularly ; that the labor
advances, though slowly ; that the strength is not seriously impaired, though
temporary fatigue  may be induced ; that there is no fever or local inflamma-
tion  ; that the vagina is cool and moist; the evacuation of  urine and fasces
easy; that  there  is no  abdominal  tenderness;  and  lastly,  that  even if
unaided, the labor will be completed by the natural powers.
  447.  Symptoms. —We have now to investigate the effects of delay in the
second stage ; and we shall find them very different.  For a  time the second
stage may continue without any bad symptoms, even though unusually long,
nor  can we  fix a definite  time after which they are developed ; I have known
them occur  after six hours, or not until twenty or thirty hours have elapsed;
but  in general there are symptoms of constitutional suffering  after the second
stage has exceeded twelve or fourteen hours.
   The pains which had  been regular and  powerful, are observed after this
period  to become irregular, both as to recurrence and force ;  for  a while
they may be more rapid, and then return less frequently, and evidently with
far less effect.  They may continue to grow weaker until the characteristic
bearing-down effort ceases altogether;  and with equal suffering we  have the
loud outcry and slight force of the first stage, just as though the labor had
retrograded.  In  some cases the character only  of the pains is changed, and
not  their frequency;  in others they return at lengthened intervals.
   448. Other symptoms accompany or shortly follow  this break-down of the
uterine action; the shivering which  was mentioned as a symptom in natural
labor, often becomes extremely severe, so as to resemble a slight convulsion;
the  vomiting becomes more frequent and distressing, and green or bilious
 matters are ejected ;  the patient is  restless, throwing her arms about, and
 repeatedly  changing her position;  the skin  is  hot, whether moist or dry;
 the  pulse rises and continues from one hundred  to  one hundred and forty:
 the  tongue  is dry, loaded, and furred, with sordes about the  teeth ; the mind
 is disturbed, fearful, and despondent;  the vagina is hot, and, as well as the
 os uteri, tender to the touch ;  the bland mucous discharge  is changed to a
 yellow or brownish color, and  is  sometimes, though  rarely, acrid or foetid;
 and the pressure of the child's head prohibits the evacuation of the bladder.
   449.  These symptoms succeed each other much in the order in which they
 are  enumerated, if the patient be not relieved ; of course they vary in degree,
 and in  many cases some are absent; but sufficient will be present  in every
 case when  the second stage is  excessively prolonged,  to  characterize the
 labor.   Should the patient be so unfortunate as to obtain no assistance, the
 case goes on from bad to worse ;  all the symptoms are aggravated, and new
 and most formidable ones are added.  The vomiting becomes more frequent, 
POWERLESS  LABOR.
275
and the matters ejected are dark-colored :  the abdomen becomes tender, the
jactitation  and restlessness  ungovernable, the pulse  rapid  and feeble, the
skin covered wdth cold clammy sweat, the tongue brown and dry ;  the patient
falls into a  state of half-stupor, with low muttering delirium, and ultimately
death closes the melancholy scene.  In  all such cases the child  is in great
jeopardy, and unless the woman be timely relieved, it will be lost.
  That these symptoms do really arise when the second stage of labor is pro-
tracted, from whatever cause, will not be questioned by those whose expe-
rience among the mismanaged poor has been extensive ; and there can be
no doubt that they would arise in similar cases among the higher ranks,
were  not the assistance of art enabled to anticipate them.
   450.  Causes. —I do not profess to be able to explain why this series of
alarming or fatal symptoms should result from delay in the second, rather
than in the first stage of labor ; it may be that the first stage is a more local,
the second  a  more constitutional process ;  that in the latter the  different
systems of  the body (vascular, nervous, muscular, etc.) are more deeply in-
volved, and that a return  to their natural  state, without the removal of that
which occasioned their implication, is impossible ;  or we may say, if we pre-
fer, with the Arabian writers, that it arises, "ex lege naturae,"  that the
process must be fulfilled, or the lives of the  mother and child be sacrificed.
Whatever form of expression we use, the  fact remains the same ; the symp-
toms which  arise from delayed second stage differ from those in the first, and
the case will terminate fatally if unaided.
   I have stated that these symptoms arise because of the delay in the second
 stage, and that they are the same, no matter  what be  the cause of the delay.
 It may be  occasioned by some peculiar  condition of the  uterus  itself, by
 obstruction in the  soft parts, by deformity of the  pelvis; but still we find
 the  same series of symptoms.   As the treatment differs according to the
 cause, I shall in this chapter refer only to those which affect the uterus itself,
 taking the  phenomena which result as the general type.
   451. Inefficient or powerless condition of the uterus in the second stage,
 as in the first, may be the result of various circumstances, such as weak con-
 stitution, mental emotion, disease, etc.  Women  of a weak constitution,
 especially in their first confinement, not unfrequently find the uterine powers
 fail, after some  hours of endurance, and that without our being able to re-
 store them.   These are the cases, and these only, in which there is anything
 to fear from a prolonged  first stage; for the  exhaustion produced by it, and
 which in healthy women is of no consequence, maybe the cause of inefficient
 uterine action in the second stage.
   In women of an irritable nervous temperament, there is also occasionally
 a failure of uterine powers in the second stage.
   Mental emotion,  though it has  less influence in the second stage than in
 the  first, may nevertheless suspend the power of the uterus; and although
 in most cases it returns after an interval of freedom from pain, yet in others
 it does not, and bad symptoms set in.
   Disease  of the uterus,  even when offering  no physical impediment to de-
 livery, may yet so interfere with the joint action of the muscular fibres, as  to
 render the  pains of little avail.  Whilst this  is confined to the first  stage, it
 is of little import;  but the uterus may complete that stage, and yet be seri-
 ously affected by the continuance of the same cause in the second ;  then the
 consequences  become serious.   Thus rheumatism  of the  uterus, which  so
 often simulates the false pains and aggravates the suffering of the real ones,
may at length interfere with  the  forcing  pains, so  much  as to detract from
their efficiency, or to  render them almost nugatory.
   -Again, tumors in the uterus offer a  mechanical impediment  to  the con-
traction  of the organ, besides their interference with the conjoint action of 
276
POWERLESS  LABOR.
the fibres, and in some very rare cases they have been known to render the
labor powerless.  I  saw a case rendered powerless by a tumor or tumefac-
tion of the posterior part of the cervix.  The crotchet was used, and after
delivery I detected this condition of the neck.
   Other uterine affections, acting upon a certain condition of the constitu-
tion, may render the organ unfit or unable to complete  the process of de-
livery, and the delay being in the second  stage, the symptoms already de-
scribed will be developed, though the time at which they appear varies very
much.
   I need not say that  mismanagement will  greatly aggravate this tendency
in all cases ; and in some, good and judicious care  may possibly avert it.
   452. Treatment.—The cause of the bad symptoms of powerless labor is,
as we have said, the delay in the second stage ;  but the reason of our inter-
ference is not the  delay, but  the  urgency of the  symptoms, so  that if the
labor should be prolonged, and no ill consequences arise, we should not be
justified in interfering further than to remove the cause.
   Of course a case  of powerless  labor, presenting the formidable array of
symptoms I have described, will very rarely occur in the  hands of a judicious
practitioner, as he would previously decide upon  the propriety of interfer-
ing ; but we may be called to  consult upon such cases.   Our duty then will
be to examine the condition of the patient carefully and minutely: the pulse,
tongue, head, abdomen, and  above all, the genital  system, so as to appreci-
ate correctly the present state of the patient; and  not this only, but we
must calculate, as accurately as possible, from the  history of the symptoms,
duration of the labor, etc., the rate at which the  patient is running down.
 These investigations are for the  purpose of solving  three important ques-
tions.—1. Whether  interference be necessary: 2. What mode of interference
is preferable :  and 3. The best time for interference.
    453. 1. The necessity for terminating the labor is grounded chiefly upon
the condition  of the mother.   If  we find the pulse permanently quickened
 (say 100 or upwards),  a  degree of fever present,  the head  not  advancing,
from the  pains having lost their force, with more or less  of the other symp-
 toms I have  described, we  may be  pretty certain either that thg natural
 efforts will not terminate the labor, or, supposing  that  possible, tne condi-
 tion of the patient  will be so much  deteriorated in the time required, as to
 render the delivery  by the natural powers more dangerous than the employ-
 ment of  art.   In forming a conclusion upon this point, the estimate of the
 "rate of progress"  of  the labor wdll  be of  great value.
    454. 2. The time at which we ought to interfere will depend chiefly upon
 the rapidity of the accession and increase of the unfavorable symptoms, and
 partly also upon the condition of the child.  For example, if the patient he
 getting rapidly worse, and the bad symptoms increasing formidably, the only
 object then will be to determine upon the  quickest mode of delivery :  but,
 on the other hand, if  her state be less threatening, demanding less prompti-
 tude, then we  may  take into consideration the  condition of the child, nnd
 acccording as we believe  it to  be alive or dead, we  may venture upon a short
 delay, or deliver immediately.
    I have already enumerated in detail the signs of the life or death of the
 child : the most important of which are, the results of repeated auscultation,
 the movements of the child felt  by  the  mother, and  the elastic  feel of the
 integuments of  the head.   The  positive evidence of the first two is quite
 conclusive ; i. e., when the fcetal heart is heard, or the  movements felt, there
 can be no doubt that the child is alive, but their negative evidence is not  so
 conclusive.   We may conclude that  the child has died durinir labor, if, after
 having heard the pulsations of the fcetal heart distinctly, we have found them
 gradually become weaker, and at length permanently inaudible ; if the move- 
POWERLESS  LABOR.
277
ments, at first lively and distinct, have ceased ;  and if the tumor of the scalp
has acquired a  flabby emphysematous feel.   The  peeling  of the cuticle is
valuable, but rather as  a  proof of the child having been  dead some time.
Now, what  is the practical  use to be made of a  knowledge of the child's
being living or dead ?   1.  If the child be dead, there need be no delay;  the
moment we  are  satisfied either that the natural powers will not be able to
terminate the labor, or that the condition of the mother demands assistance,
we may instantly interfere,  and we are  free to consider the mother's interests
only as to the mode of  doing so.   2. If the  child  be  living, and the symp-
toms not very urgent, a short delay may be  allowed, so as to give fair play
to the natural powers ;  or  if immediate* relief  be desirable, we  should give
the child a chance, if possible,  by employing means which do not necessarily
involve  its destruction.   But I would repeat, that the saving of the mother's
life being our first object and attainable, if the circumstances of the case de-
mand it, we  must  discard  all consideration of the  child, even  if it be alive,
unless compatible  with  the mother's safety.
   455.  3. The modes of delivery at our command are, 1, the vectis;  2, the
forceps ; 3, the crotchet. We may lay it down  as an axiom that that method
of delivery is best by which  labor  can be  terminated  most easily, and with
the greatest safety to the  mother  and child.   If there be space enough be-
tween the fcetal  head and  the pelvis, the  vectis may be tried as a tractor;
but  the forceps is  a much better instrument, for if it can be applied without
force (and in no other case should  it ever be attempted), we hold the power
of delivery in our own  hands, and unless  the  pelvis be found too small, or
the operator deficient in dexterity,  but little time will be lost, and no  injury
be done to mother or child.   Even taking the statistics amongst the poor
and worst-managed part of  the community, the mortality to the mother  is
one in  twenty-one,  and to  the child one in  five, which  is  less than that
attendant upon other operations.
   I have therefore no  scruple whatever in recommending  a trial wdth  the
forceps  before using the crotchet, in every case where there is sufficient space,
except in those cases where the child is dead.
   If the state of the  mother preclude all consideration for the child, or if it
be dead, then the perforator  and crotchet may be  used, the great advantage
of this operation being the facility of  delivery when the bulk of the head is
reduced, and its disadvantage, the  damage done to the child.   I shall speak
more in detail about these  operations by and by.
   456.  If the case be  from the  beginning  under our  own  care, and  our
interference be well-timed  and ably executed, in all probability the patient
will recover well;  but if she have been neglected and allowed  to run down
before assistance is rendered,  unpleasant  consequences may follow, as, for
instance, the nervous shock  may be severe, or  even fatal;  the patient sink-
ing, twelve or twenty-four  hours after delivery, without ever rallying after
the operation.   Again, from the long-continued pressure of the head of the
child upon the soft tissues  of the pelvis, inflammation  may arise, and unless
subdued, may terminate in  pelvic abscess, or abscess between the vagina and
rectum ;  in  sloughing  of  the  vagina,  with  or without perforation of the
bladder or rectum ; or  the contusion  of the parts may be so severe as to
cause the patient to  sink  ;  or lastly,  peritonitis or hysteritis may be deve-
loped somewhat later.
   Such  serious consequences, which are unfortunately but too frequent, indi-
cate the necessity not merely  of  terminating the labor by judicious and
timely aid,  but  also of attending  minutely  to the local  condition  of the
patient for some time after delivery.  Especial directions should be  given
to the nurse to syringe  the vagina two or three times  a day with tepid milk
and  water,  to bathe the external parts with a weak mixture  of spirit and 
27 8
OBSTRUCTED  LABOR.
water, and to place between  the  labia a strip of lint smeared with  simple
cerate, and if necessary we should  satisfy ourselves by a careful  examination
as to the state of the parts.  If much inflammation  arise, a large soft poul-
tice of linseed meal, or "stirabout," may be applied  over the external parts,
and black wash to the vulva.
   I must  beg of the reader to reperuse the chapter on Abnormal Conva-
lescence, in  connection with  this  and some  of the  subsequent  chapters, as
the deviations therein described occur most frequently after the more dan-
gerous labors.
   457.  Before concluding  this chapter,  I would wish  to  allude  more dis-
tinctly than  I have  as  yet been able to  do, to an  interesting, though not
numerous class  of  cases, exhibiting the symptoms,  more or less intense, of
powerless labor, with the  exception of the  inefficiency of the pains.  The
pulse is rapid, the  patient very feverish, the head  may be affected, or the
abdomen tender, etc.; yet the labor,  though sufficiently tedious to give rise
to these symptoms, does  actually  advance,  and may be completed by the
natural efforts, but at a serious expense to the mother, and great risk to the
child.   I was called to such a case some time ago  : the patient had been
allowed to deliver herself, and  she died of the shock in a few hours.  The
local  injury already described is also  more frequent after  these  cases than
even after those where  assistance has been given.  I know not any cases in
which the physician has more need of all the tact and judgment  which expe-
rience only can give, nor any more difficult to describe in a book so clearly
as to guide the junior practitioner, than such as these.   The natural powers
are not inadequate to the delivery, yet bad symptoms are present, the danger
imminent, and greatly increased by delay.   On the one hand,  we have  to
guard against unnecessary interference, and  on the  other,  against the evils
of hesitation when  assistance is required.   As it is clear that the possibility
of the labor being finished  l>y the natural powers alone is not in  itself a pro-
hibition of all interference, I can only repeat that  the necessity for our aid,
and the time when  it ought to be given, must be deduced from  a careful
estimate of  the  present symptoms, and  the  rate at which they have  been
developed ; and if we find that the  probable time required for the completion
of the labor will be so great as to  add to  the patient's  risk, then  ought we
undoubtedly to put  in requisition all our resources for her liberation.
                         CHAPTER  VII.

         PARTURITION. —CLASS II. UNNATURAL LABOR.
                  ORDER 3.  OBSTRUCTED LABOR.

  458. Definition. — The progress  of the  labor is impeded by some me-
chanical obstruction  in  the passages  connected with the soft parts, which,
by causing delay in the second stage, leads  to the development of the symp-
toms of powerless labor.
  459. Symptoms. —In the last chapter  I stated that delay in the second
stage of labor gives rise to  a certain  series  of formidable symptoms, no
matter what may be the cause of delay ; and we there considered  such causes
as act upon the uterus, impeding its action or diminishing its force.  In the 
OBSTRUCTED  LABOR.
279
present chapter we shall investigate other causes of delay, such as are found
in the soft parts of the passages.
   The symptoms in the two orders will be the same, if the amount of delay
be equal;  but there is this difference  from the  commencement, that in  ob-
structed labors the uterine action is intact, nay, perhaps more vigorous than
usual, but ineffective in proportion to  the magnitude  of the obstacles.   If
they be not very great, the augmented force brought to bear upon them may
be successful; if they be  considerable, delivery may be impossible without
assistance ; and lastly, in some extreme cases, delivery "pervias naturales "
may be impossible.
   Making allowance  for  different constitutions,  the  symptoms  developed
during the progress of labor will be in proportion to  the prolongation  of
the second stage,  as laid down  in the  last chapter.   It  will be  remarked,
however, that  some of the  causes I am about to enumerate act upon  the
first stage.   They certainly  do prevent its completion,  and by rendering the
progress of the labor  mechanically impossible, do  really give rise  to the un-
favorable symptoms, and so far may be taken as an exception to the con-
clusion, that no evil arises  from a prolongation of the first  stage.   How-
ever, I believe that in such  cases  the  first stage virtually  terminates before
the bad symptoms set  in,  for I have repeatedly found  that where the physi-
cal impediment exists  at  the brim, whether it be a tumor  or distortion,  the
 os uteri is fully dilatable, the membranes broken, the  character  and  force
of the pains changed  as usual, etc. ; in short, a transition is observed from
the local and general  condition of  the  first stage to that of the second.
   460. Causes.   1.  Minute or imperforate os uteri.—There are cases  on
record in which before labor, or  even for some time after its commencement,
no os uteri could  be  detected.  Mazzoni mentions having observed  such,
and Dr. Campbell relates two examples :  "Both were  first pregnancies;  in
the first, uterine action continued  about  twelve hours before the os uteri
could be distinguished,  when it felt  like a  minute cicatrix.  The second
woman had regular pains for two nights and a day before the os tincae could
be perceived, and she suffered so severely as to  require  three persons  to
keep her in bed.   Both patients  were largely bled,  gave birth to living child-
ren, and had a good recovery."  I was myself called to a case in  which the
os uteri was not discoverable  until after  forty hours of labor, and then it
felt  about the size  of a  small  crow-quill; notwithstanding the  delay and
obstruction, however,  the patient was delivered naturally of a living child.
   As the effect of disease, the os uteri may be contracted, and its opposite
edges become adherent, so  as  to close it partially or completely.  Again,
the os uteri may be diminished and the cervix rendered undilatable, by cica-
trices, the result of former injuries.
   Lastly, cases are on record of total  absence of the  os uteri, without our
being able to trace out the cause; some  probably are  congenital.  Under
one or other of these  classes, observations will be found recorded by Smel-
lie,1 Wright,2 Cuffe,3 Tompkins,4 Hatin,5 Tweedie,6 Waller,7  Naegele,8 Gooch,a
Lauverjat,10 Gautier,11  Morlanne,12  Bedford,13 etc.
   The  amount of delay will depend upon the  resistance, and this chiefly
upon the completeness  of the  closure of the os uteri.   When  there  is  a

  1 Works,  vol. iii. p. 55.                2 London Med. Gazette, 1846, p.  688.
  3 Ryan's Journal, vol. vi. p. 87.         * Lancet,  1831-2, vol. i. p. 749.
  5 L'Exp^rience, May, 1839.             6 Guy's Hospital Reports, vol. ii. p. 258.
  7 Ibid., vol. iv.  p. 120.                8 Ibid., vol. iv., p. 137, from Naegele's Thesis.
  9 Lectures on Midwifery, by Skinner.   10 Diet, des Sciences  MeM., vol. xxiii. p. 301.
 11 Ibid.                            i2 Ibid.
 13 Now York Journal of  Med., March,  1843, and American Journal of Med. Science,
April, 1848.
  If the reader will consult my work on  Diseases of Women, he  will find the cases given,
and fuller details upon the subject. 
280
OBSTRUCTED  LABOR.
small opening, there is hope  that time, pains, and the remedies mentioned
for rigidity of the os uteri, may succeed.   If  these fail, then the remarks I
made on that subject apply to these cases.   The natural result of such cases,
and, a fortiori,  of those of complete  closures of the os uteri, are, 1, ex-
haustion and collapse ;  2, separation of a part or the whole of the cervix;
3, rupture of the uterus.
  In cases of so  serious a character, a correct diagnosis is of the last import-
ance, and should be  made with the utmost care and caution.  "We may
suspect," says Dr. Rigby, " that the protraction of labor arises from agglu-
tinated os uteri,  when at an  early period of it  we can  discover no vestige of
the opening  in  the  globular mass formed by the inferior segment of the
uterus, which is  forced down deeply into the pelvis, or at any rate when  we
can only detect a small fold or fossa, or  merely a concavity, at the  bottom
of which is a slight indentation, and which is usually a considerable distance
from the median line of the pelvis.  The pains come on regularly and power-
fully, the lower segment of the uterus is pushed deeper into the cavity of the
pelvis, even to its outlet, and becomes so tense as to threaten rupture ;  at
the same time it becomes so thin, that a practitioner who  sees such a ease
for  the first time  would be induced to  suppose the  head  was presenting,
merely covered by the membranes.  After a time, by  the increasing severity
of the pains, the os uteri at length opens, or it becomes necessary that this
should  be effected by art;  when once this is  attained, the os uteri goes  on
to dilate, and  the labor  proceeds naturally, unless  the  patient  is  too much
exhausted by the severity of the labor."
  461.  Treatment. — Our first object will be to see what the natural powers
will be able to effect;  for which purpose the patient  must be managed as in
natural labor, and allowed to continue her efforts for  some time; there is  no
danger in so doing, as  it will be a considerable time before any unpleasant
symptoms will arise.
  If the continued pressure discover the os uteri, but the cervix resist still,
then we may  try any of the remedies advised for " undilatable os uteri,"
such as venesection, tartar emetic, etc., and in most cases they will be found
useful.
  In  some cases, when the os uteri is more or less closed by agglutination,
although, as Dr. Rigby observes, " the obstacle  is capable of resisting the
most powerful efforts of the uterus, a moderate degree of pressure  against
it, whilst in a state of strong distension, either by the tip of the finger or a
female catheter,  is quite sufficient to overcome it; little or no pain is pro-
duced, and the appearance of a slight discharge of blood will show that the
stricture has given way."
  If these methods fail, we  must  have recourse to the knife, and  make one
or more incisions as near the situation of the  os uteri as possible.   Mnscati
recommends a number of small incisions around the os uteri, for the purpose
of securing its equable dilatation.
  [The young practitioner should not be too  hasty in  deciding that a case
is one of agglutination or absence of the  os uteri, in which the latter cannot
be reached  by the finger for some hours after labor has set in—and  that an
operation is necessary to obviate the consequent impediment to the birth of
the child.  In first labors, the os uteri is  not unfrequently found high up, in
front of the promontory of the sacrum, and almost out of reach of the finger.
It may remain thus for many hours undiscovered  by  the inexperienced, and
although  it may cause much  delay in the labor, it will in  time be brought
into the axis of  the strait by the force of the pains.   This may be expedited,
after labor has continued some time, by drawing it forward  with the fingers,
as advised by Baudelocque.]
   It  is gratifying to know that this formidable operation  is  not attended 
OBSTRUCTED  LABOR.
281
with so much danger as we might expect.   In five cases, both mothers and
children were saved ; in four, the mothers  were saved, but not the children;
and in two only did death occur  after the operation, and in both great delay
had been permitted.
  462.  2.  Carcinoma or scirrhus of the uterus.—Strange as it may appear,
conception has been known to take place not only when the cervix uteri was
carcinomatous, but when it was  the  seat of open cancer.  Zeppenfeld, Sie-
bold, Lachapelle, Oldham, and  others,  have put such cases  upon record.
Madame Lachapelle records  seven cases,  of whom four recovered from the
delivery.   Of course such a hardened and  undilatable state of the cervix will
offer a very serious obstacle to the descent of the child's head, and  that in
proportion to the extent of the disease.    In a few instances it has yielded
to the pressure, and the child has been born naturally.
  I attended myself a case in which corroding ulcer proved a cause of delay
for some hours, but just as we were  debating the propriety of incising the
cervix, spontaneous rupture took  place under the pressure of a powerful pain,
and the child (still-born)  was expelled.    The mother died afterwards from
the consequences of the rupture, which  had extended into  the body of the
uterus.   And  more recently,  I was consulted in another case of malignant
ulceration, where conception afterwards  took place ; the patient went nearly
to the full time, and had a natural labor, but sank a few hours afterwards.
   463.  Treatment.—Fortunately such  cases are  extremely  rare; but  from
those who have been most conversant with  them, we find, according to Bayle,
Cayol, and Lachapelle, that  some have terminated  without help ; others,
according to Siebold,  have  been  delivered by version :  or,  according  to
Madame Lachapelle, by the  forceps and  by vaginal  hysterotomy.   If the
cervix resist  all the efforts of  the uterus, I suppose we must, as a " dernier
ressort" have recourse to the knife ;  but it is for the sake of the child only,
as the mother's end will only  be  hastened  by it, and therefore, before doing
it, we must be sure that the child is alive.    If it be not, it would be better
to open the head.
   464. 3. Narrow and undilatable vagina.— In  some  women the vagina is
naturally small and contracted ;  but  this  is rarely a serious obstacle to the
natural powers, unless it be the first child, and the patient advanced in life.
   The calibre of the vagina  may also be diminished by callosities or cica-
trices, the consequences of former  inflammation  and sloughing, and which,
consisting of a semi-cartilaginous substance, may form rings or spirals around
the vagina, and offer great resistance to  the descent of the child.   These
obstructions  will be detected at  once, on examination, by their hard gristly
feel, and their form.
  Lastly, more or less perfect occlusion  of the vagina may be present, owing
to the adhesion of its sides, sometimes leaving a portion of  the vagina per-
vious inferiorly, sometimes obliterating nearly its  whole length.1
  The  impediment which a congenital  narrowness of the vagina offers  is
overcome  by patience and pains, aided by  fomentations or injections  before
unfavorable symptoms arise ;  but when it is obstructed  by adhesions or con-
tractions, this may not take place.   The  labor is prolonged beyond a cer-
tain time,  and then the  symptoms of  powerless labor (§ 447) set in, and  on
examination, the cause  of  the delay is sufficiently  clear.
  But this is not  all.   My friend, Dr. Doherty, has very justly observed, in
a paper read before the Obstetrical Society, "It  is very seldom, even when
a single and  prominent band encircles the   canal,  that this is  the only mis-
chief which has been done ; for,  generally speaking, we have  more or less
puckering of the parietes, and not infrequently, as I have already mentioned,
1 Churchill on Diseases of Women. 
282
OBSTRUCTED  LABOR.
communications with  the  adjoining viscera.   The consequence  of  these
changes is, that the canal is less  able to  bear a forcible dilatation ; and  if
the narrowed portion be permitted to delay the  fcetal head too long, a rup-
ture of the vagina above it may occur, even if no breach of surface already
exist.  But if  even a small opening  into an  adjacent cavity  be already
formed, it is very likely to be  converted into  a rent,  which throws both
chambers into  one, constituting one of the greatest  calamities which can
befall a woman.
   Still worse, if possible, is the  result occasionally ;  for abundant testimony
is  on record, as I have elsewhere shown, to prove that this  obstruction of
the vagina,  when left to the natural efforts beyond a certain  time, may give
rise to rupture  of the uterus, and death.
   465. Treatment. —As in the cases last described, we must wait until ex-
perience  has proved how far the natural powers are  capable  of overcoming
the resistance.   In some cases  we find, contrary to our expectations, that
after the  pressure of the child's head has continued for some time, the  stric-
ture yields, and, as it were, unfolds, so as to permit the passage of the  child.
In  other  cases, laceration takes place  (not without danger), and delivery
follows.
   Should the parts continue to resist steadily, then  we must have recourse
to bleeding  and tartar emetic, which will very often preclude the  necessity
of relief  by the knife.   If they fail in producing benefit within a reasonable
time, we  must interfere to prevent worse results — either  the constitutional
symptoms already noticed or local injury.
   To avert such a catastrophe,  we must  have recourse  to the  knife, if the
previous  remedies fail; two, three, or more incisions  should be made, just
through the resisting band, if it be circular;  but  if  the sides of the vagina
be  adherent, they must be carefully and  gradually  divided.   The pressure
of the descending head will dilate the passage.   The  greatest care must be
taken not to wound the neighboring viscera.   The hemorrhage maybe con-
siderable, and occasionally the case terminates fatally.
   Should the uterine action be  exhausted by the' length  of the labor, and
unfavorable symptoms  develop themselves, it may be necessary to terminate
the labor promptly by instruments.   I am  myself satisfied that, in  the  more
aggravated  cases of stricture,  premature labor  or abortion ought  to be in-
duced,  if we are cognizant of  the fact at an early period.
   I need not say that in the after treatment the  most careful attention should
be paid by the  accoucheur himself to the state of  the vagina, and as soon
as the inflammation and tenderness subside, a bougie should  be  introduced
daily, to  guard against the re-formation  of the  stricture.
   466. 4.  Tumors in the pelvis.—Tumors of various pathological charac-
ters may  form in the different parts of the pelvis : thus we  may have fibrous,
adipose,  steatomatous, sarcomatous, and  scirrhous growths, and  they may
be situated either behind the rectum, between the rectum  and vagina,  or in
connection with the proper tissues  of the vagina.   Again, the os uteri may
give origin to a tumor, as polypus.  Dr. Denman met with a case  of cauli-
flower excrescence of the os uteri.
   This is not the place for the description  of these various  diseases, which
I have fully discussed  in another volume.   Our object  at present is to in-
quire what is their effect  upon  labor.   The obstructions  they offer to the
descent of the child's head will depend  upon their  size, their mobility, and
their compressibility.   If small, the delay may  be immaterial, and the diffi-
culty overcome  by extra force ; but if beyond a certain size,  they may  delay
the labor so long as to give rise  to the unfavorable symptoms of a prolonged
second stage, or absolutely prohibit the  passage of the child.   But this  effect
of their size is sometimes  obviated by their mobility, i. e., the tumor may 
OBSTRUCTED  LABOR.
283
be pushed to one side, or drawn up out of the way of the child, as in a case
published  by my friend, Dr. Beatty, in which the  tumor was so large, and
apparently so fixed, that Caesarian section was anticipated ; nevertheless, at
the time of labor it was elevated  sufficiently to allow of the birth  of the
child without any assistance.  In the case of a polypus too, we find that in
some cases the pressure of the child's  head  has detached the tumor, or ex-
pelled it without separation, as related by Dr. F.  Ramsbotham.  Lastly, in
cases where the tumor is too large, and  immovable, it has been found  so
far compressible, that after some delay and  extra compression of the child's
head, the labor has terminated naturally.
   The chances in favor of the  tumor  being elevated or pushed  out  of the
way, are increased in proportion as it is high up in the pelvis ; next to these
the most favorable situation is on one  side of the promontory of the sacrum,
and the least so, in the antero-posterior diameter.   The difficulty occasioned
by the size is augmented by the hindrance  they offer to the adaptations of
the head,  and to its successive changes of position.
Polypus Uteri.
   467. When we have reason to believe  in  the  presence of any of these
tumors, a most particular investigation should be instituted.   The examina-
tion, as Mr. Ingleby observes, "should be  made in the absence of pain, and
(if possible) before  the presentation has  become engaged in the pelvis, lest
the tension wdiich the mass undergoes during  strong labor should obscure
the diagnosis.   If the  presentation be in part only below the brim,  it may
be difficult to determine whether the apparent firmness of the tumor  is not
owing to obstructed circulation.  Whilst  making the usual examination 'p>er
varjinam,'1 it will be  advantageous to pass the forefinger of the left hand into
the rectum, with a view of  ascertaining more  correctly the  contents  of the
tumor."1
  468.  Treatment.—If, owing to the moderate size of the tumor, its mobility
or compressibility, there is  a probability  of the  natural  powers being ade-
quate to the delivery, we have nothing to do but wait patiently;  but if the
delay be so excessive as to  threaten bad  symptoms, or if the obstruction be

  1 Facts and Cases in Ob«tretric Medicine, p. 121. I beg to refer the reader to  this ex-
cellent essay, and to Dr. Merriman's  paper in  the Med.-Chir. Trans , vol. x., for much
valuable detail which I  have been obliged to omit. 
2S4
OBSTRUCTED  LABOR.
insurmountable, we must then afford assistance, and  the  mode will  depend
upon the size, mobility, contents, or mode of attachment of these tumors.
  Thus, if the tumor be movable, and we see the patient sufficiently early,
we should endeavor to raise the tumor above the brim of the pelvis, as was
done by Dr. Merriman, during an interval between the pains, and maintain
it there during the next pains, so as to allow the head to become engaged
in the brim ;  and to  do this the patient should  be placed on her knees and
elbows, so as to have the influence  of gravitation in our favor;  if we  suc-
ceed, the labor will go on regularly;  but if, as is most frequent, we  fail, we
must then try if the  tumor be removable. If it be a cauliflower excrescence
or a polypus, it will  be advisable to pass a ligature around it.  In the case
of polypus this has repeatedly been done wdth impunity.  Other tumors have
been removed, as in  Mr. Drew's case of one between the vagina and rectum,
wdth success;  but this is a much more serious operation,  and should not be
attempted until we  are certain  that  its bulk cannot be reduced in another
way.
  Many of these tumors  are composed of fluid or semi-fluid matter,  and
such may be emptied by passing a trocar and canula, or by a free  opening
with the scalpel; after which the walls of the cyst will subside, and allow
of the passage of the child.   This operation should  always be performed
before we attempt delivery by operating upon the child.
  If a slight operation upon the tumor is likely to be successful, there can-
not be the least doubt that it ought to be preferred, nor do I myself feel that
we should be justified in sacrificing the child where there existed any hope
of being able to extirpate the tumor.
  469.  But suppose  the  tumor  be solid, immovable, and  incompressible;
then it is clear that our only means of delivery is to act upon the child, and
the mode will depend upon  the size  of the tumor.   If it be small,  though
sufficient  to  obstruct a labor attended with  feeble pains, then perhaps the
addition of extracting  force  by means of the forceps may suffice.   These
cases, however, are very rare, and we must take care that the force employed
do not add to the subsequent risks, by inducing the evil results of excessive
pressure upon the soft parts  of the mother.
  If the tumor be too large  to allow of the use  of the forceps, or if they
have been tried unsuccessfully (extirpation  being out of the question), we
have  then no  alternative but the  reduction of  the  bulk  of the child by
craniotomy, and, if necessary, evisceration.   This, however, is so painful an
alternative, that it should never be thought of until we are satisfied  that
nature  is inadequate to  the delivery, that  the  obstacle cannot be pushed
aside, nor lessened by puncture, nor removed, etc., and that interference has
become imperative in order to save the life of the mother.
   Some few cases occur in  which even  craniotomy will not enable us to
effect the delivery;  in which the pelvis is very nearly filled  by a firm incom-
pressible tumor, as in the cases related by Dr. Montgomery, Dr. Shekleton,
and  others.  We have no remedy for such, except by providing an artificial
exit for the  child,  by performing the Caesarian  section; a formidable and
very fatal  operation, it is true, but  which  is infinitely better than  leaving
mother and child to perish.   But before having  recourse to it, we must be
perfectly satisfied that no other means afford a hope of success;  and I need
hardly add, that none of these serious  operations should be undertaken with-
out a consultation, if that be possible.
   470.  5.  Diseased ovary.—The ovary maybe  enlarged from disease origi-
nating  previous to  or during  pregnancy, and not suspended  by it.  The
enlargement  is  sometimes solid, but more  frequently it contains  fluid, or
matter the consistence of honey.  If the disease progress slowly, the uterus
with the ovaries by its side, will have emerged from the pelvic cavity in time 
OBSTRUCTED  LABOR.
285
to remove the obstacle, which will then be in the abdominal cavity.  But in
other cases, either from the situation or rapid increase of the ovarian tumor,
or by adhesions  between it and the neighboring parts, it is retained in the
pelvis,  and  may offer serious obstruction  to  the second stage of  labor.
"There are two  forms of ovarian tumor," says Mr. Ingleby, "which obstruct
the passage  of the child.   In the one a small cyst in connection with a very
bulky cyst, or else a portion of a large cyst, passes  into  the recto-vaginal
septum, and bulges through the posterior part of the  vagina.   In the other,
and that which  occurs by far the most frequently, the whole ovary, moder-
ately enlarged, prolapses within the septum.  The descent is peculiarly liable
to happen at two periods : the first, near the end of  gestation ;  the second,
during labor; the prolapsus being promoted by the relaxation of the soft
parts.   The  changes which the ovary undergoes when long detained in the
 septum, will depend upon the capacity and yielding state  of the parts.   If
 the woman  have not previously  borne  children, it may remain  small, and
 scarcely retard  delivery :  but under contrary circumstances,  it acquires a
 large size, and  nearly fills the vagina.   In rare cases, the bulging is said to
 have appeared at the anterior part of the pelvis.  Again, the ovarium, when
 moderately  enlarged, and confined within the abdomen, may alter the course
 of the  gravid uterus in  its ascent out  of  the pelvis, so that the organ can
 neither preserve its perpendicular direction, nor freely develop  itself on the
 side on which the  tumor is  situated,  and  thus  the lateral obliquity, as de-
 scribed by writers, is  almost necessarily produced.  Although this mal-posi-
 tion of the uterus may fail directly to obstruct the entrance of the presenta-
  tion with the brim, the axis  of the organ  as respects the pelvis is no longer
  maintained,  and labor will probably prove tedious."
    A very remarkable case has been published by Mr. Rankin and Dr. Wil-
  son, in which an ovarian tumor  occupied  the  pelvis in two labors, during

                                 Fig. 108.
Ovarian Tumor.
the latter of which it was pushed above the brim, and the child delivered by
turning.   In the  third labor, there were two tumors above the pelvis, and
the child passed between, rupturing one,  and was delivered naturally.1
                  1 Glasgow Med. Journal, Jan.  1854, p. 414. 
286
OBSTRUCTED  LABOR.
  The observations  made  upon other tumors in the pelvis are in most re-
spects  applicable to enlarged ovaries.   There will  be  delay in the second
stage, or the head will be prevented  altogether from entering upon this stage,
in proportion to the size, immobility, and incompressibility of the tumor;
modified in some degree by its situation.  But  an  ovarian tumor is much
more likely to be moved out of the way of the  child  at the time of labor,
than any other, and also more apt to give way and burst under the pressure
of the head.
  The diagnosis is not  always easy.  If the tumor within the recto-vaginal
septum be movable,  elastic, and communicating to the finger a  sense  of
fluctuation, it is  probably ovarian  :  but it is not  always thus ; it may be
hard, not  fluctuating, and, in fact, to the touch  apparently solid.   In such
cases the  only test we  can apply,  practically, is puncture.   Dr. Litzmann,
who has published a valuable paper on this subject,  states as  the ground of
diagnosis  between ovarian tumors and fibroid cystic growths,  their gradual
direction  from one  sacro-iliac synchondrosis towards  the centre, and the
possibility of pushing them more or less easily above the brim of the pelvis.
Fibrous or  scirrhous  growths  are to  be distinguished by their  place  of
origin.
  471.  Treatment,—We must first allow time to see whether the tumor may
not  be displaced by the efforts of nature, and also to estimate the effects of
pressure upon it, and we shall have time for this before the bad  symptoms
appear.   If  the  obstacle be insurmountable by the natural  powers alone,
and cannot  be  raised above  the brim  of the pelvis by the hand, we must
then puncture the cyst through the vagina, nor are we to be deterred from
this on account of the apparent solidity of the tumor, as many such contain
fluid.  A  long trocar should be used, and plunged quite through the parietes
of the tumor.   If fluid be freely evacuated, we shall have no  further trouble
with the labor : if it be viscid, and do  not  pass freely through the canula,
the  opening  must be enlarged.
   But  suppose the  tumor should  really prove  to  be solid, and cannot he
pushed above the brim ; it is  clear that we cannot attempt to extirpate it in
such a case,  and we must then act  upon the  child.   Version  has  been pro-
posed,  but it appears to me very unsuitable ; it  adds  much to the mother's
risk, without increasing in any degree  the probability of saving the child;
the  tumor would  offer even a greater  obstacle  to  the passage of the head
reversed,  than in its natural position.
   If the  tumor, though solid, be  small, perhaps a little additional power
 might enable the child's head to pass  without  injury to mother  and  child,
 and in such  a case the forceps might be used, but I do not think cases suit-
 able for this instrument are frequent.
   If all  these plans fail, or are unsuitable, there is  no  resource (except  for
 those who prefer Caesarian section) but to evacuate the brain, and, if neces-
 sary, the  contents of the chest and abdomen, and then extract the child.
   Dr. Merriman has collected eighteen cases, and it appears "thattwice the
 labor was effected by the  pains, unassisted by the  art of the accoucheur;
 but one of these women lost  her life, and one of the children  was still-born.
 Five times  the  perforator was used after a longer or  shorter duration of
 labor: three of these women died, another recovered very imperfectly, and
 one got well.   Five times the labor was terminated by turning the child:
 all  the children were  lost, and one only of the mothers recovered.  Three
 times the tumors having  been opened, the labor was  afterwards  trusted to
 nature :  two of these women recovered, but the other  remained  for a long
 time in an ill state of health : two only of the children  were  preserved.  In
 three cases the tumors having been opened, it  was still found necessary to
 have recourse to the  perforator:  one  of these women  died ;  one remained 
OBSTRUCTED  LABOR.
287
in an ill state of health for eighteen months, and then sank under her suffer-
ings ;  the third recovered.
  Thus, in 18 cases, it appears that of the women,

                                9 died,
                                3 recovered imperfectly,
                                6 perfectly,
               Of the children, 15 were still-born,
                                3 were alive.

   "Upon the whole," Dr. Merriman concludes, "the evidence we at present
 possess is more in favor of  opening the tumors, when they contain a fluid,
 than of any  other mode of procedure ; for of the nine women who recovered
 more or less perfectly,  five appear to owe their safety to this operation, and
 of the children born  alive, two were preserved by the same means."
   In  these cases, the mortality to the mothers was very great;  and though
 in all cases there must be risk at  the  time and subsequently, still there is
 reason to hope that a cautious estimate of the value of the  different means
 at our command, and an early and judicious employment of them, will insure
 a more favorable result.   In such cases it must be borne in mind, that whilst
 the obstacle occasions  the necessity for the operation, the time  must be de-
 cided by the constitutional symptoms, or, at least, that assistance  must never
 be delayed after the  symptoms of powerless labor set in.
   Dr. Litzmann has collected from various sources forty-seven cases, involving
 fifty-six labors, in  which the process was impeded by ovarian  tumors.   Of
 the entire, seven  children were  born alive, thirty-five  were  still-born, of
 fifteen  there is no  account;  of  the mothers,  thirty-two  recovered  and
 twenty-four died.  The details are as follows :—In ten cases  natural delivery
 took place, mostly after tedious and severe labor.  One child was born alive,
 of the  others nothing is said ; four of the  mothers died.   In seven cases
 the tumor was  pushed above the brim;  in three of these turning  was per-
 formed ; in one the forceps were  applied;  the rest terminated naturally.
 Two of the children were still-born ; and of the remaining  five, two speed-
 ily died.  One of the mothers died.  In  nine  cases,  puncture  or incision
 of the  tumor was performed :  once through the abdominal parietes, twdce
 through the rectum, in  the  rest through the vagina.   In  three cases the
 labor terminated naturally ;  in three, perforation  and extraction was neces-
 sary  ; in one turning,  and in one the forceps.   One child  was  born alive,
 and five of the mothers died.   The forceps were applied altogether in eleven
 cases, in seven of which  they were the only means employed.  Of these, two
 children were still-born,  and four mothers died.   Turning was performed in
 eight cases.  Embryotomy was performed in seventeen cases ;  in four after
 puncture, and in one in artificial premature labor.   Of the remaining twelve
 cases, five were fatal to  the mothers.  Premature labor was induced in two
 cases.1
   472. With respect to all  tumors of  the pelvis which  have rendered the
 use of the  perforator necessary, I would wish strongly to  recommend the
 induction of premature labor in the next pregnancy, at such a period as
 shall supersede the necessity of an operation, provided that the size, situa-
 tion, and density of  the tumor continue the  same.
   473. 6.  Vaginal  cystocele. — I  have already spoken  of  the necessity of
 keeping the bladder empty, as its distension very often protracts the labor;
 but the effects may be more  serious, if from frequent child-bearing the pos-
 terior and inferior supports of the  bladder have been  weakened, for then it

      1  Association Journal, May 27th, 1853, p. 469, from Deutsche Klinik, 1852. 
288
OBSTRUCTED  LABOR.
may be caught by the head of the child in its descent, and pushed before it
into the cavity.  Fortunately such cases are very rare, for their consequences
may be very serious.   Two very  interesting  cases, however, will be  found
recorded by the late Mr. Crosse of Norwich,1 and one by Dr. Doyle.2
  The patient will complain of fulness, tension, a feeling  of pressing down
and dragging, with a desire to evacuate urine frequently, and of inability to
do so.   On examination we detect a tumor in front  of the pelvis, partially
covering the head, and containing fluid.   The finger passes  easily posterior
to the  tumor, but  not anteriorly, and the  catheter cannot be passed in the
usual direction, indicating clearly its nature.  With care, there is not much
danger of an incorrect diagnosis, but  if not on our guard we may mistake
it.   Dr. Merriman relates a case wdiere the bladder was perforated on the
supposition that it was a hydrocephalic head,  and Dr. Hamilton  used to
mention one in his lectures, where it was mistaken for the bag of waters, and
punctured.
  No  doubt, a bladder sufficiently distended and prolapsed  must occasion
difficulty and delay in the second  stage, but the danger to the mother from
the rupture of that organ is at least equal to the risk of mischief from the
delay.
  474.  Treatment.—This double danger renders it necessary that when we
are assured of the nature of the impediment, we should be prompt in  our
endeavors to remedy it.   A male elastic  catheter must  be introduced, with
the point directed downwards and backwards, and if the head have  not de-
scended too low, we shall probably  be successful in emptying  the bladder.
Fig. 109.
Vaginal Cystocele.
The head may also be raised a little with  the finger during  an interval, to
facilitate the introduction.  Even if we succeed, it will be necessary to watch
carefully against  the effects  of the  previous pressure; but  if we fail, and
either the labor be arrested by the obstacle", or the pressure threaten a rup-
ture, our only resource, I believe, is  to tap the bladder with a very fine
trocar, through  the vagina.   Let  me,  however, impress upon  my junior
readers the necessity of being quite  certain of  the nature of the case, and

  i Cases in Midwifery, p. 62.          * Dublin Med. Press, No. 95, Lect. 28, 1840. 
OBSTRUCTED  LABOR.                      289
of the prolapsed bladder being really an impediment, or in danger of rup-
ture, before attempting so serious an operation.
  Should the quantity of urine be moderate, and the pressure not excessive,
and especially if the head of the child be small, the case may perhaps be left
to nature ;  but  then, after the labor is over, we must  immediately evacuate
the  bladder, and watch the patient  carefully.
  475. 7. Calculus  in  the bladder. — It is very rare  that urinary calculus
has been found an obstacle to labor; but such cases are on record.   Guille-
meau was the first to relate  one :  the result was contusion, sloughing, and
vesico-vaginal fistula.  La Gonache performed  the operation of lithotomy
under similar circumstances, and extracted  a calculus  several inches in cir-
cumference.  Smellie relates a case which occurred in the practice  of Mr.
Archdeacon, in which the calculus was expelled  by the pressure of the head,
after a long and  tedious labor: the  patient suffered  from incontinence of
urine afterwards.  M. Dubois detected a  calculus in the bladder pressed
down by the head of the child ; and M. Phillippe,  of Rheims, extracted one
in the fifth month of pregnancy.   M. Monod has published a case  of this
kind, in which he removed a calculus, weighing nearly three ounces, by vagi-
nal lithotomy.  It had  proved  an  insurmountable obstacle to the progress
of labor, filling the  entrance of the vagina.   The labor was completed by
the  forceps, but the child was  still-born.   The  patient recovered well, the
urine passing by the urethra the followdng  day.1  Mr. Erichson  also relates
 a similar case  which rendered perforation necessary, and afterwards the
 removal of the stone by  vesico-vaginal section.2
   So long as the bladder and calculus remain above the brim of the pelvis,
 no  mischief will result;  but if  it project backwards,  and be caught by the
 head, and pushed down  before it, the bladder will be  seriously bruised, and
 the labor impeded in proportion to the size of the calculus.
   A careful examination will  show  that the tumor is covered by the bladder,
 and its hardness will indicate its nature.
   476.  Treatment.—If  the calculus be discovered during the first stage of
 labor, it may be impossible to raise it  above the  brim, and  to  maintain  it
 there until the  head  is engaged, after which there will be no danger;  but if
 we cannot do this, I fear our only resource is vaginal lithotomy ; as it is much
 better to have to deal afterwards with an incised wound than a laceration.
   477.  8.  Vaginal hernia.  —It is very possible for a loop of intestine to
 slip down behind the uterus into the " cut de sac " between the vagina and
 rectum, and if  it be empty, it will be  no impediment; but if it contain a
 mass of scybalaa, that wdll form an  obstacle to the descent of the head, but
 one that is seldom attended with danger, except from  the pressure to which
 the intestine  is exposed.
   478.  Treatment.—If  the hernia  can be reduced, it  must be done as early
 as  possible ;  but if  not,  we  may  be  able  to deliver with the  forceps.  I
 never heard of its being necessary  on this account to lessen the child's head.
   479.  9.  Collection of fceces  in the rectum. — This is  not a very uncom-
 mon cause of delay  towards the end of labor, nor is such an accumulation
 inconsistent  with  frequent  and fluid, but  small, evacuations daily.   It  is
 easily detected  ; the tumor is felt  in the  situation  of the rectum, and its
 irregular form  and want of elasticity would almost be sufficient to indicate
 its  nature.   It is possible, however, to press it  downwards, and then the
 escape of faeces will  put  the question beyond doubt.
   480.  Treatment.—If proper  care have been taken during pregnancy, and
the  first stage of  labor, we shall never be troubled by this obstacle ;  but if

  1  Med. Gazette, March 20th,  1850, from L'Union Me"dicale. Also Crosse's Cases in
Midwifery, p. 64.
  2 The Lancet, Dec. 8th, 1855.
       19 
290
OBSTRUCTED  LABOR.
not, we must remedy the neglect by enemata of warm water whenever we
detect the state of the intestine;  and if, as in some  rare cases, this be not
sufficient, the faeces must be removed by a spatula or scoop.
  481.  10.  Swelling of the soft parts.—The late Professor Hamilton was,
I believe, the first to  notice this state as  an  obstacle to the delivery of the
head.   Dr. Campbell observes, " The capacity of the  pelvis  may be dimi-
nished by general tumefaction of its linings, consequent on interrupted cir-
culation, from a detention of the child's head, or from frequent examination.
This  cause  of protraction is  one of no  ordinary nature, since,  unless the
case be promptly and energetically atttended to, the result may be  calamitous
from lesion of structure.  "Unless a practitioner have had  the management
of the patient from the commencement of labor, he is apt to view this variety
of diminished capacity as arising from  original defect  in  the development
of the bones themselves."
  482.  Treatment.—Great relief is  afforded by venesection ;  and, if neces-
sary,  small doses  of tartar  emetic should be  administered.   Dr. Campbell
advises the application of the forceps, if there be room;  but if the pains
be adequate, I would rather leave the labor to the  natural efforts, because
of the risk of injuring the passages.   If the  pains  be feeble, we must, of
course,  expedite the delivery.
  483.  11.  Perfect hymen.—Impregnation is quite  possible without injury
to the hymen : cases have been recorded repeatedly  of  women in whom the
hymen was found perfect at the time of labor.   I myself attended one some
time ago.   In most cases the membrane yields  to the pressure of the head
at once; but it  may (as in the  cases I attended)  offer along resistance;
though  I am not  aware of its having ever been the cause of powerless labor.
  484.  Treatment.—The remedy is  very simple ; if the hymen do not yield
to the pressure of the  head  after a reasonable time,  it must be divided by
the  scalpel.  A very slight incision will suffice, and great care must be taken
so to  support the perineum, as to prevent the laceration extending beyond
the fourchette.
  485.  12. Bigidity of the perineum. —I mention  this among  the causes
of delay, especially in women of mature  age, although I believe it never
causes such delay as to give rise  to  unfavorable  symptoms, except when a
tough cicatrix has formed after a former laceration.
  In ordinary cases of excessive resistance, much benefit will be derived from
venesection  and  tartar emetic, followed  by fomentations, or gentle friction
with hog's lard.   If it be clear from any cause (though such  cases must he
extremely rare) that the perineum cannot dilate, an  incision must be made
through the obstacle.
  13. Sanguineous tumor of the labium.—When this accident occurs before
the  head is passing through the vaginal orifice, it may speedily assume such
a size as will offer a  decided  obstacle, yet delivery  is of course  necessary.
The  question to be decided will be whether to deliver with the forceps first,
and then evacuate the  tumor, or to open the tumor first and then  deliver. I
should say that we must be  guided by the size of the tumor:  if it be possi-
ble to deliver without danger of laceration, I should  prefer that, and then to
allow some time to elapse before incising the tumor.   But if it be  very large,
it will be better to have to deal with  an incised wound than a laceration, and
we must make sufficient pressure at the time and afterwards, to guard against
serious hemorrhage.
  486.  Other causes have been enumerated as protracting  the second stage,
as shortness of the funis, prolapse of the uterus, etc.;  but though, to a cer-
tain extent,  they may have such an effect, yet  not so far as to give rise to
the  symptoms of  powerless  labor.  Prolapse of the  uterus at the  time  of
labor can only be partial, and must  arise from  excessive  amplitude of the 
OBSTRUCTED  LABOR.
291
pelvis : careful pressure around the external orifice will retain it within the
vagina, and the child will be expelled naturally.  Brevity of the umbilical
cord, or its coiling,  has also been said to delay the descent of the child, but,
I believe, without any reason.   Those  who  supposed this, remedied it  by
dividing the cord, which  I believe to be very rarely necessary.
  487. Symptoms.—It is unnecessary that I should do  more than allude to
the symptoms which arise, when, in consequence of any of these causes, the
labor is delayed in the second stage ;  as 1 have fully described them under
the head of Powerless Labor, from  which they differ in nothing, except that
we do not so frequently find  the character of the pains  changed.   It is evi-
dent that the fault is not in the want or inefficiency  of pains, but in the
obstacles opposed to them.  The symptoms then will be  in proportion to the
delay, making due allowance for difference of constitution and temperament,
 and the delay will be in proportion to the extent of the obstruction, assuming
that no interference has been attempted.
   For some time  (from twelve to twenty hours) after the first stage has been
virtually or really completed, the labor will go on apparently favorably ; but
after this, the pains producing no effect, we  find that the patient  becomes
 feverish, restless,  and  thirsty ;  the  pulse rises, the skin is  hot, the tongue
 dry and furred, and the gums and teeth coated with  sordes.  In some cases,
 but not always, the character of the pain is changed ; the outcry and suffer-
 ing increased, but the force diminished and the voluntary  efforts suspended.
   If the patient be neglected, the unfavorable symptoms increase : the abdo-
 men becomes tender, and sometimes tympanitic;  vomiting is frequent; the
 urine is  retained ;  the vagina  is hot  and tender; the discharge  becomes
 yellow or brown, and perhaps offensive ;  violent rigors occur, and the patient
 is irritable and despondent, and ultimately sinks into a delirious or comatose
 state.
   488.  Prognosis.—In any case to which we are called, our prognosis must
 depend upon the  actual state of the patient, and the possibility of removing
 the cause, or the facility  with which labor may be terminated by instruments.
 If called early, before bad symptoms  are developed,  and the cause  of delay
 be one we can remove, the prognosis will be favorable, as far as delivery is
 concerned, with a reservation as to the results of the operation necessary for
 the removal of the  cause.  If the  obstacle cannot be removed, and we are
 obliged to operate upon  the child, there  will be, in addition to the usual risk
 of the operation, something  additional in proportion to the difficulty of ex-
 traction.  If we  be not called until serious symptoms appear, the shock of
 any operation will add  much  to  the patient's  danger, and our prognosis
 should be very guarded.   In these cases it should be distinctly stated that,
 although there is danger to the patient if the operation be attempted, there
 is much  greater danger, or perhaps the certainty of death to  mother and
 child, if nothing  be done.
   489.  Treatment.—For each cause  of delay I have mentioned the special
 treatment necessary.  I shall, therefore, now merely recapitulate a few general
 principles.  1.  In no case need we interfere when the obstacle can be over-
 come by the natural powers within  a reasonable time.   2.  That the less
 serious the mode of interference  the  better;  so  that, if the natural efforts
 are insufficient, we should endeavor to push the obstacle out of the wray; to
 puncture it;  or  to remove it.   3.  That if the  uterine efforts be vigorous,
 the mere removal of the  obstacle will enable them to complete the labor.  4.
 That in some cases, besides removing the cause of delay, it is necessary to
 employ extracting force ; and, in such  cases, the  less violent the operation
 the better;  thus the vectis (if effectual)  would be  preferable to the forceps ;
 the forceps to the crotchet;  and the crotchet to the Cassarean section.   5.
 But in our estimate of the risk of these operations, we must not  omit the 
292
DEFORMED  TELV1S.
time they occupy, with reference to the condition of the patient;  thus  the
time gained by the forceps may render it more  useful than the vectis.   6.
When the forceps cannot be used, no false humanity should make us hesitate
to destroy the child (I assume, of course, the necessity for an  operation) in
time to save the mother ; because its life cannot be  saved : and both it and
the mother  will be lost if we do not terminate the labor.
                       CHAPTER  VI II.

        PARTURITION. —CLASS II.  UNNATURAL LABOR.
                  ORDER 4.  DEFORMED PELVIS.

  490. Definition.—The progress of the  labor is impeded by abnormal
deviations in the form  of the pelvis, giving rise to delay in the second stage,
or rendering the descent of the child impossible  without  assistance, or alto-
gether impracticable.  The symptoms are those  of powerless labor.
  491. If the reader will have the kindness  to turn back to the chapter on
Abnormal Deviations  in the Pelvis, he will  find  that I there described the
following variations from  the  ordinary standard:  1,  the equably  enlarged
pelvis  (pelvis  cequabiliter justo major) :  2, the equably diminished pelvis
(pelvis cequabiliter justo minor) : 3, special distortions of the  brim :  4, of
the cavity :  5, of the lower outlet:  and 6, oblique distortion.  As in that
chapter these deviations were described, and the  means of diagnosis pointed
out, it only remains for us now to  consider their effect upon the  labor, which
I shall do in a few words.
  492. 1. The  "pelvis asquabiliter justo  major"  can scarcely be included in
the practical consideration of the  effect of distortion ; but as it does modify
the labor, a few words may not be amiss.  As the adaptation of the child's
head to the  pelvis,  and the changes observed in its  descent, depend upon
the combined effect of  the propelling force and the resistance, it is clear that
if the pelvis be so large as to afford  little  or no resistance, these changes will
not take place ;  nor is that of  much consequence.  Further, the absence of
resistance will render the labor so rapid as to preclude due preparation on the
part of the  mother, as in the cases related by Drs.  Montgomery and Rigby.
In  one, a patient of Dr. Douglass, the child was born in the night without
waking the  mother. Nor are  these rapid labors  from deficient  resistance
without  inconveniences :  the uterus may be depressed to  the  edge  of the
vaginal  orifice, and even somewhat beyond it, and there is  certainly more
danger of subsequent hemorrhage.  The only danger to the child arises from
the chance of its falling  on the ground, when expelled without warning.
   Little can be done in such cases,  even if we happen to be in  time, except
to  support the external parts, so as  to prevent partial  prolapse of the uterus,
and by pressure over the uterine  tumor to guard against flooding.  During
convalescence,  the  patient should be kept  a  longer time than usual in the
horizontal position.
   2.  The opposite  extreme, the " pelvis aequabiliter justo minor," may offer
very serious resistance to the progress of  labor.   In general, however, it
renders  the labor difficult and tedious, but not impracticable by the natural 
DEFORMED  PELVIS.
293
powers.   The moulding and adaptation of the fcetal head occupies a longer
time, the  compression is greater, the pains more violent, and the second
stage more prolonged, but the amount of delay varies, and its effects also
upon the constitution of the patient.
  492.  3.  The special distortions of the brim are very important, and it may
generally be remarked, that a small  special  deformity will  prove a greater
obstacle than the same  amount  of equable diminution  of size.  When the
oval of the brim is transposed so that the antero-posterior diameter is the
longer, the position of the child's head will of necessity be changed,  so as
to bring its long diameter into  accordance wdth that of the  pelvis.  The
heart-shaped brim may  have no influence upon the head unless the promon-
tory of the sacrum be much projected ; then we shall find a corresponding
indentation upon the skull of the child, and perhaps  a fracture of one of the
bones, as remarked by Dr. Michaelis, of Kiel.   And not only this, but the
head, if prevented from freely  entering the pelvis, and if the pains be very
violent, and the patient have had several children, maybe driven to one side,
and the cervix,  being unable to resist the  pressure, may give way.  If the
distortion be excessive, it may preclude the entrance of the head altogether.
   4. Distortions in the  cavity may be  merely a continuance of deviations
in the brim, or they may be limited to the cavity ; in the latter case we may
find the head enter the pelvis with tolerable facility, and descend in the  usual
manner, until it arrives  at the impediment.  If the sacrum be too straight,
there will be danger of the head being driven through the perineum for want
of the forward direction which is ordinarily communicated to it by the  curve
of the sacrum :  on the other hand,  too great curvature of the sacrum may be
a serious difficulty, even insurmountable without assistance, or if  overcome
it may exert injurious pressure upon the skull of the child.  Exostosis of the
sacrum, or fibrous  tumors growing from the  periosteum, will prove an ob-
stacle in proportion to the size :  if small, it may be overcome by the uterine
efforts alone, or with  assistance :  if large,  it may be incompatible with the
delivery of a living child, or even a mutilated one.  And it should be always
remembered that these tumors increase really though slowly, and  that the
impediment they offer to the passage  of the child in one labor is a deficient
measure of the  obstruction they  will give in a subsequent one.
   5. Distortions of the lower  outlet may  depend upon those in  the upper
part of the passages,'or,, which is rare, they may occur  alone.  The  latter
consist generally in^b^approximation of  the tuber  ischii, or narrowing of
the pubic arch,  or ijatjpuichylosis of the coccyx.   If  the  pubic arch be nar-
rowed, the antero-p'sflj^rior diameter of the lower outlet is virtually lessened,
because the head carttot fill the arch, but  is thrown backwards upon the os
coccygis.   If the coccygeal joint be anchylosed, that will also diminish the
antero-posterior.diameter of the outlet; and if it  be not broken by the ex-
pulsive force, it may be  indent or fracture the bones of the cranium. When
the pelvis is funnel-shaped, the resistance will not be felt until the head is at
the lower  outlet, and it may then require assistance.
   6. Oblique distortions of the pelvis offer great obstruction to the passage
of the child, and although, if slight, a modification of the usual adaptations
of position may allow its descent,  yet in many cases it is requisite to inter-
fere and terminate the labor artificially.
  494.  So far I have merely sketched  the kind of influence which the various
deformities are calculated to  exert upon the labor ;  but another  most im-
portant consideration remains, viz., the amount of the difficulty.  A due appre-
ciation  of the limitation caused by the distortion is absolutely necessary to
the practical management of such  cases, and in forming  our judgment we
must take  into account the relative as well as the positive size of the  aper-
tures or cavity;  for although they should be much reduced, yet if  the  fcetal 
294
DEFORMED  PELVIS.
head be very small, there may be comparatively little difficulty ;  and, on the
other hand, if the head be large and the sutures ossified, a very  slight dimi-
nution in the usual capacity of the pelvis will offer great obstruction.  In n
practical point of view, we  may make  three  degrees  of  distortion :  first,
where the pelvis is sufficiently reduced in size as to offer an amount  of diffi-
culty which in some few cases may be overcome by forcible pains, if time be
allowed, but which generally require extracting force  in addition, there being
space enough to allow the use of the forceps.  Secondly, where the head is
unable to enter the pelvis, or having entered, is tightly wedged in the cavity
or impacted, as it is called.   In these cases there  is not space enough to
admit the forceps, nor if they could be introduced, would the head bear the
compression  necessary to enable us to extract the child alive ;  there is no
resource but to evacuate the contents of the cranium.  Thirdly, there are
very rare  cases of extreme distortion, where  the  canal of the pelvis is  so
reduced that it would be impossible to extract even  a mutilated child.
  495. It  is not easy to  name the  actual diameters answering to  each of
these classes, because, as  I  have already observed, the  size of the pelvis
must always be considered relatively to the child's head.  But this much
may be stated, that a living child cannot pass through a pelvis whose small
diameter is less than three inches.   M. Le Roi fixes upon 3£ inches, Drs.
Osborn and  Aitkin 3 inches, Dr Jos. Clarke 3*,  Dr. Burns 3£, Dr. Ritgen
2, Dr. Busch 2^ to 3 inches, as the smallest diameter.  It is clear, then, that
unless there  be a space of full three inches, it would  be  useless, probably
injurious, to  use the forceps.    In such cases  Dr.  Simpson proposes to turn
the child ;  and  if we are certain of the exact diameter, it may be applicable
occasionally, but as a general rule its  propriety is not as yet established.  In
the majority  of cases, if it be under  this, the case will belong to the second
class, in which the perforator and crotchet must be used, provided that there
be space enough for the extraction of the child after mutilation.   Dr. Os-
born  states that one  inch and a half diameter will be space enough  for this
purpose.   M. Baudelocque conceives that craniotomy is inadmissible when
the diameter  is only an inch and two-thirds ; Dr. Dewees when it is less than
two  inches ;  Drs.  Hull  and  Burns think that it may succeed when it is an
inch and three-quarters;  Drs. Gardien and Hamilton when it is an inch and
a half;  and Dr. Davis when  it is one inch.   We must not forget the safety
of the mother in our measurements.    It may be possible to extract a muti-
lated child through  the smaller of these diameters,-but? it would be at the
expense of the  mother's life;  and I  feel satisfied  thai if it be much below
two  inches, the  case will come under the third class,  anfl tour only remedy be
the Caesarian section.
  496. If  deformity be suspected, an external as  well as an internal exami-
nation should be carefully made ; if we can reach  the promontory of the
sacrum and the presentation, we can  then  estimate the relative size of the
head and  the brim ; if the presentation  be beyond reach, we may still  be
able to ascertain the distance between the sacrum and  pubis with tolerable
accuracy.   In addition there is a peculiarity about the first stage of labor.
"Besides the general appearance of  the patient,"  says Dr. Rigby, "we fre-
quently find that the uterine  contractions are very irregular; that they have
but little  effect  in dilating the os uteri; the head does not descend against
it, but remains high up ; it shows no disposition to enter the pelvic cavity,
and rests upon  the symphysis pubis, against which it  presses very forcibly,
being pushed forwards by the promontory of the sacrum."  There is less
difficulty in detecting the disproportion in the cavity or lower outlet, as it is
within reach, and on examination during a pain, we find that no progress is
made, and  during an interval  we can  perceive that the  head is larger than
the passage it has yet to traverse. 
DEFORMED  PELVIS.
295
  497.  Symptoms. — If the  labor be allowed to continue beyond a certain
time, we shall  have all the constitutional symptoms of powerless labor (ex-
cept perhaps the change in the pains), because the delay is in the second
stage, really or virtually.  It is true the head may not be able to clear the
os uteri, on account of the obstructions at the brim, but the os uteri becomes
softer and dilatable, the pains forcing, and the cry suppressed ; all marking
the transition from the first to the second stage, and it is never until after
this change that bad symptoms set in.
  But  besides these constitutional symptoms, which I need not recapitulate,
other effects  not  unfrequently result, even where  we are successful in de-
livering the patient.   The  long and  forcible  pressure  of the head of the
child against the soft parts at the brim and in the cavity may be followed
by  inflammation and sloughing.   Thus the lower part of the uterus and the
vagina may be seriously injured, and if the slough be deep, the bladder or
rectum may be perforated.   I have already pointed  out the possibility of
rupture of the uterus.
   The child, too, may suffer  considerably: if the head enter the  brim and
be  much compressed, its life  may be sacrificed ;  or partial pressure on any
part may  fracture  one of the bones  of the cranium, or give rise to inflam-
mation or sloughing of  the scalp.
   If the os coccygis be anchylosed, so as to offer a decided obstacle to the
passage of the head, it may be broken by forcing it  backward, as in Dr.
Summer's case,1 rather than risk the loss of the child.
   498.  Treatment.—If the distortion be slight, it is  possible that the  extra
force which will be exerted may be sufficient after a longer time for the ex-
pulsion of the child, and  a  fair trial should be given.   But if the dispro-
portion be so marked that it is  evident that the  child cann6*t pass without
assistance, or if unfavorable symptoms are present, we ought to lose no time
in  determining by the degree of deformity to which  of the  classes (§ 494)
the case belongs, and acting accordingly.   If it come  under the  first, and
there be space enough, we may try the  forceps ;  if under the second, ver-
sion or craniotomy,  and,  if necessary, evisceration, will be our only  re-
source ;  if under  the third,  the Caesarian section.   I would  caution my
junior friends against coming to a conclusion and acting upon it without a
consultation.
   The greatest  care will  be necessary after delivery to guard against the
consequences I have mentioned.  Vaginal injections of warm water should
be  used twice  a day, and externally fomentations and poultices, if necessary.
I have found great benefit from the  exhibition  of small doses  of calomel
and opium at moderate  intervals, or of a full dose of opium at bed-time  in
these cases.
   I shall  now proceed to consider in  detail  the  operations to which I have
as yet  only slightly referred.

           1 Ed. Monthly Journal for Oct. 1850, from American Journal. 
296
INDUCTION of  premature labor.
                        C HA P TE R  IX.

OBSTETRIC OPERATIONS.—1.  INDUCTION OF PREMATURE  LABOR.

  499. Very little need be  said as to  the  importance of obstetric opera-
tions :  the danger to the mother and child,  the circumstances under which
they have to be performed, and the little time which is allowed for reflection,
or consultation, all point out the absolute necessity of our being prepared
beforehand for any case which may occur.  If any further inducement were
required, I might  add, the influence which a successful or unsuccessful ope-
ration  has upon the reputation of a practitioner, or refer to the fact which
the periodicals attest, that  a surgeon may be  indicted for the results  of his
operations.  But I prefer supposing that a conscientious feeling of our respon-
sibility in undertaking the  charge of a case, will  be  the strongest induce-
ment to the acquisition  of  that knowledge which is the safeguard of those
who confide in us.  It is, I believe, an  axiom, in  which I fully concur, that
no operation should be  attempted  wdthout a consultation, if it be possible
to obtain one.
   In estimating the dangers of any operation, we must always take into
consideration the prevalence  of  any epidemic.   If, for example, puerperal
fever or erysipelas be epidemic, the danger of any operation is increased in-
calculably.
   Obstetric  operations may be divided into three classes : 1, those which
are not intended  to injure the mother or child, as the induction of prema-
ture labor, version, the use of the vectis, and the forceps; 2, those which
involve the destruction  of the  child, but which are not intended  to injure
the  mother,  as craniotomy,  and the cephalotribe ;  and 3, those  in which
danger is involved to both mother and child, as the Caesarian section.
   I  have said, "not intended  to injure," because I would not mislead my
junior readers, by leading  them  to  suppose that any operation is without
danger to both mother and child.   They are all dangerous, but in different
degrees,  as we shall see by and bye, and it should be our earnest endeavor in
all cases to  limit  ourselves to the safest practicable operation.
   Now let us examine each in detail.
   500. 1.  The Induction of Premature Labor for the purpose of  saving
the  life  of  the infant, of its  mother, or of both, though of  comparatively
modern origin, is an operation of great value in certain cases, and it is one
of the few  instances of an  improved  science augmenting the  number of
operations.
   There would appear to  be, in  the minds of all men, a repugnance to in-
terfere with the natural progress of those great phenomena which ordinarily
run  a definite and uniform  course ;  and  in the present case this objection is
increased, because the proposed  interference  is to remedy one irregularity
by another.  Accordingly, the first consideration has  always  been, not the
usefulness, but the morality of the operation.  Dr. Denman states1  that
Dr. Kelly informed him "that about the year 1756 there was a consultation
of the most eminent men at  that time  in London, to consider the  moral
rectitude of, and  the advantages which  might be expected from, this prac-
  1 Introduction to Midwifery,  p. 318, 7th ed.   For more minute  details and references
about these operations, I beg to refer the reader to my  Researches on Operative Mid-
wifery. 
INDUCTION  OF  PREMATURE  LABOR.
297
tice, which met with their general approbation."  The conclave decided in
favor of the morality  of  such  interference, and shortly afterwards the ope-
ration was  successfully performed  by Dr. Macaulay.  Subsequently, Dr.
Kelly " practised it, and  among other instances, he  mentioned that he had
performed this operation three times upon the same  woman, and that  twice
the children had been born living."  So  numerous, and, upon the whole, so
successful, have been the  instances in which it has been tried since Denman's
time, that it has taken its place among the regular  obstetric operations in
the various systems of British writers and teachers.
   Dr. Denman's remarks upon the propriety of the operation, as to morals,
are so conclusive,  that I may be excused if I quote them : " With regard
to the morality of  the practice, the principle being commendable — that of
making  an effort to preserve the life of a child, which must otherwise be lost,
and nothing being done  in the operation which could be  injurious or dan-
gerous to the mother, but on  the  contrary, a  probability of lessening both
her danger and suffering—I apprehend, if there be a reasonable prospect of
success, no argument  can be  adduced against it which will not apply with
equal force against any kind of assistance at the time of parturition ; against
inoculation, or medicine  in  general;  and, in fact, against  the  interposition
 of human reason and faculties in  all the affairs of life."
   501.  In  France, however, the proposed  operation was by  no  means so
 frankly  received nor so readily adopted.   Certain doctrines of the national
 Church, or at least the  interpretation of them by the Doctors of the Sor-
 bonne, touching the importance of foetal life, seem to have aggravated the
 risk of  the operation, and to have  deterred professional men from making
 the attempt.   The great name and extended influence of Baudelocque were
 opposed to wdiat he considered (in the case  supposed) a crime ; and a cele-
 brated teacher recently deceased, Capuron, has stigmatized it as "un attentat
 commis envers les lots divines et humaines."  Even so late as 1827,  on the
 occasion of a  memoir presented  by M. Coste, demanding if it  would be
 allowable to bring on  labor prematurely in females laboring under aneurism
 of the  heart, the Academie Royale de Medecine pronounced  the question
 "inconvenient et presque immorale."  It is said, however, by M. Sue, that
 M. Petit ranged himself on  the side of the advocates of the operation, and
 since then it has  been recommended and practised  by Stolz,  Ferniot, Paul
 Dubois, Dezeimeris,  Burckhardt,  Yelpeau,  Figueira, Coste, etc.   I  am
 happy to see, also, that in a report recently made to  the Academie de Mede-
 cine, by M. Cazeaux, in the name of a commission, it is declared that the
 operation is not immoral, but justifiable, as being less fatal to the mother,
 and offering a mode of delivery in contraction of the pelvis, certain hemor-
 rhages, and tumors which are irreducible and  irremovable.1
   The  objections of the French authors may be thus summed up: —
   1. It is immoral.   2.  It is  almost impossible to determine the exact rela-
 tions between the head of the child and the pelvis.   3.  The manoeuvres
 necessary for  exciting labor are  highly dangerous.   4. The uncertainty of
 all women  as  to  the  period of their pregnancy.   5. The  difficulty of dila-
 tation of the os uteri at the seventh month.   6.  The danger of subsequent
 disease.  Each of these objections will  be answered as we proceed.   It is
 quite evident,  as M.  Marinus observes, that these  writers had in  view  the
 "accouchement force" performed at the seventh or eighth month—a different
 operation,  and one perfectly unjustifiable at so early a period.
   502.  It has been recommended and practised in Germany by Weidmann,
 Mai, Siebold (four times), Schilling  (once),  D'Outrepont (twice), Riecke
 (twice), Haase  (twice),  Falco (three times), Vezin (three times),  Mende

             i Journal des Connoiss. Mcd.-Chir., 29 Fev. 1832, p. 136. 
298
INDUCTION  OF  PREMATURE LABOR.
(four times), Betschlcr,  Froriep, Wenzel, Spiering,  Ritgen  (thirty time.O,
Carus (twice),  Kluge  (twenty times),  Reisinger,  Busch, NaegeK' (once),
Seulen (once), Neumann (once), Spoendli (once), Ilayn (once), Mampe(five
times),  Rosshirt,  Kilian  (three  times), etc.  etc. ;  but opposed by Stein,
Osiander, sen.,  Bernstein, Ebermaier, Gumprecht, Piringer, Joerg, etc.
  In Italy it seems to have  met with less  opposition ;  or, at any rate, less
aversion has been expressed.  Successful cases have been published by MM,
Ferrario, Billi, Lovati, Bongoianni, etc. etc.
  Paul  Scheel in Denmark, Solomon de  Leyden  and Professor Yrolik  in
Holland, and M. Marinus in  Belgium, have each advocated the practice.
  503.  So much for the history  of  this operation, and  the  difficulties
attendant upon its introduction into practice.
  As to the origin of it, all writers are agreed in  attributing it to the fol-
lowing circumstances :—It has not unfrequently happened that the life of a
seven or eight months' child has been preserved  by accidental  premature
labor, in cases where the birth of a child at the full term had been previously
found impossible from pelvic distortion.   From the complete success of such
cases, as regards both mother and child, it was inferred that premature labor,
artificially induced, might, in certain cases of pelvic deformity, be employed
to supersede an operation (craniotomy) which involved not only the destruc-
tion of  the child,  but  considerable risk to the mother.  The proposal was
not, it must be remembered,  to deliver  the fcetus  artificially, but merely,  as
was stated by Ritgen, "to  communicate a slight  but certain impulse," by
virtue of which the process of parturition may be carried on  and completed
by  the natural  powers.
  504.  The reasoning of Dr. Denman  appears to me conclusive, as to the
" moral  rectitude" of  the operation ; the next question, therefore, is as  to
its  safety to the child  and the  mother, confining  ourselves for a moment  to
the  consideration of the cases  originally proposed to be benefited  by the
operation.
   It is  perfectly  established that a fcetus is " viable" at  the  completion  of
seven months of  utero-gestation, and many instances  are on record of chil-
dren born at that period living to a good old age. M. Chaussier (of Dijon)
and his wife were both seven months' children ; his Majesty George III. was
also a seven months' child ;  and M. Fodere relates the case  of the wife  of
a judge, whose pregnancies always terminated  at the seventh  month.   Ex-
amples  of  "viable" infants  born at an  earlier period are likewise to  be
found ;  but I beg to refer to the able work of my friend Dr. Montgomery
for further details ; concluding, from all the evidence  we possess of the via-
bility of  seven months'  children, that premature labor, accidentally or arti-
ficially  induced, at the completion  of the  seventh month, does  not involve
danger to the child from the immaturity of its  growth merely.
   As to the actual risk of labor to the fcetus, as  ascertained by an estimate
 of  facts, I  may adduce the following testimony : —
   Of twelve cases mentioned by Denman, the majority of the children were
 saved.   Mr. Barlow reports seventeen cases — six  children were still-born,
 five died  a few  hours after birth, and six lived.  Of Dr. Merriman's ten
 cases, four  children  were saved.   Dr. Merriman, jun.,  mentions forty-six
cases—sixteen children lived, and all the mothers' recovered.   Dr. Conquest
 says, that out of nearly one hundred  cases, about  half the children  were
 born alive.  In Mr. Gregory's case, the child was born alive, but died sub-
 sequently.   In Dr. Collins's case, the child lived.  In Mr. Corry's and Dr.
 Paterson's cases,  the  infants were saved.   Dr. Hamilton states'that "pre-
 vious to the 26th of January,  1836, the author brought on premature labor
 in  twenty-one  individuals, on  account of defective apertures, viz., in  four-
 teen, once ; in one, twice ;  in three, thrice ; in two, four times;  and in one, 
                INDUCTION  OF  PREMATURE  LABOR.             299

ten times.  Of the forty-five infants thus prematurely brought into the world,
forty-one were born alive.   The death  of the four still-born can be readily
accounted for."  In the practice of Mr. Moir, and Dr. John Moir, premature
labor was  induced twelve times on six women.   .Nine of the infants were
born alive, and the cause of the death  of the  three still-born  infants could
not be  attributed to the operation."  Of Dr.  F.  Ramsbotham's ninety-two
eases, forty-nine children were born alive.   Dr. Lee saved twelve children in
thirty-one cases ; in several  of  which the crotchet was necessary after labor
had been induced.  The child lived in Mr.  Hearne's and M. Spoendl's cases.
M.  Ferrario saved five children out of six; M. Kluge, nine out of twelve ;
M.  Solomon, thirty-four out of sixty-seven ;  M. Burckhardt, thirty-five  out
of fifty-two ;  M. Siebold, two  out of three ;  M. Mampe, four out of five,
the fifth being a shoulder presentation.
   Dr.  Shippan,  in his Inaugural Thesis, presented  to the  Medical Faculty
at Wurtzburg, in 1831, has given  a summary of ninety cases ; seventy-three
children were born alive, but eighteen of them died subsequently.   Accord-
ing to  MM. Yelpeau and Kilian, one hundred and fifteen children were saved
out of  one hundred and sixty-one cases.   M. Figueira has collected  two
hundred and eighty cases from  different sources, in  which  one hundred and
sixty-six children were saved.
   We  may conclude from these different data, that more than  half the chil-
dren were saved notwithstanding a cause of failure to which I have not yet
referred.  I allude to the greater frequency of mal-presentations in  prema-
ture labor, than  in labor at the full time.   In Dr.  S. Merriman's cases, for
example, there were eighteen mal-presentations out of the forty-six, only
one of which was saved.  In ninety-two cases of Dr. F. H. Ramsbotham's,
thirteen presented with the breech or lower extremities, and six transverse,
making nineteen mal-presentations.  In two hundred  and forty-three prema-
ture cases related  by Dr. Arneth, there was  one mal-presentation in  five,
thus confirming the observations of Merriman, Dubois, Cazeaux, M'Clintock,
and Hardy, etc.   If we could subtract  all  the cases of mal-presentation, we
should find, I doubt not, that the proportion of children lost to those saved
by  the operation was very much smaller.
   505. There is unquestionably some risk  incurred by the mother, but  not
 more than by an  accidental premature labor.   After  much consideration,
Denman concludes that "it is perfectly safe to the person on whom it is per-
formed."  We have already seen  that Dr. Kelly performed it three  times
successfully on one person.   Dr. S.  Merriman seems to think  that its safety
was rather overrated, but he adds, "at all events, the method in question, if
carefully conducted, cannot be  more hazardous  to the mother, perhaps is
much less so, than the operation for lessening the head of the fcetus in utero,
and it is  incomparably less perilous than the Caesarean operation, or  the
division of the symphysis pubis."  Out  of his forty-six cases, not one proved
fatal.  Dr. Hamilton observes,  " The late Dr. Merriman first called in ques-
tion the safety of the operation ; but the cases on  which he formed his doubts
on  this point were evidently cases  of accidental  coincidence, for the safety
of the practice is now fully established."   Dr. Blundell concludes his obser-
vations by saying, that  " with all its faults about it, the practice is of great
value,  and there are now living in  society individuals whose heads  have in
this manner  been preserved from the  perforator."  Dr.  Moir and his  son
operated above twenty times, and all the mothers recovered l In Mr. Corry's
case, the  woman  recovered rapidly.   Dr. Gregory  and Dr.  Collins each
operated  once, with safety  to  the mothers.  Dr.  F. H.  Ramsbotham  has
had recourse to this operation sixty-two times, and it does not appear  that
1 Ed. Monthly Journal, July, 1851. 
300            INDUCTION  OF PREMATURE  LABOR.

the mother suffered in any of them.   Dr. R. Lee lost three mothers  out of
thirty-one cases.   Mr. Hearne  saved the mother.  In the numerous cases in
which Dr. Simpson has performed the operation, the mothers always recovered.
Drs. Sinclair and Johnson have recorded six cases in four patients ; two for
deformity of the pelvis, and two for  dropsy : the  two  former recovered, the
two latter died from disease ; five children were born alive.1
   The statistical details given by Yelpeau and  Figueir would justify, I think,
a much more unqualified commendation.   Velpeau  states that it has been
performed

       In Great Britain.......72 times
       In Germany.......79  "
       In Italy........7  "
       In Holland........3  "

Making  a total of 161 cases,  of which number 8 mothers  died, 5 of them,
however, from causes unconnected wdth parturition.
   M. Figueira has collected 280 cases, of  which  only 6 mothers died.   M.
Solomon operated 67 times, M. Kluge 12, and M. Ferrario 6 times success-
fully.  M. Reisinger lost  1  patient  in 14.  All M. Mampe's patients re-
covered.   MM. Spoendli and Seidell's patients recovered well.   Of the 90
cases collected by Dr. Shippan,  7  mothers  died.   In three of these the
operation was performed once; in 2, twice ;  and in 1, three times.
   Dr. Hoffman has collected 524 cases, which he has published in a valu-
able essay;2 of these 271  cases were German, 192 English,  17 French, and
3  American.  The following abstract contains some  valuable facts;  of 147
cases, the youngest was aged  seventeen, the eldest  forty-four; more than
one-half  had reached or passed their thirtieth  year.   Of 258 cases, only 49
were first pregnancies.  In 34  cases the operation was repeated three, four,
or more times on the same woman.  Ergot of rye was given in 45 cases, in
38 of which 23 children were born alive, 15 dead, and 12 died within thirty-
six hours.  Prepared sponge  was used  in  70 cases, and 42, at least, were
born alive.   Puncturing the membranes was resorted to in  180 cases, and
of 178 children, 103 were born alive, 12 still-born, and 63 born dead.  Out
of 120, there were 45 cephalic, and  75 non-cephalic presentations ; of these
75, there were  19  cross-births.   In  84  cases, labor had to be completed by
the forceps in 36, by turning in 18, and by perforation in  11 cases.  Of
373 cases, 250 children were born alive, and 123 dead ;  but in 77 of these
latter,  the death  of the child could  have had no reference to the operation.
Of 192 of the children born living, 127 continued to live, and 65 had died; 28
in the course of six hours, 6 in twenty-four hours, and the rest at intervals
from a day to a year or more.
   We  may therefore agree with M.  Marinus, that "if these  facts be true, it
is established that females undergoing this operation incur no immediate
danger;  and if we push our research still  further, we shall find that these
same females were not attacked by  pure  lesions of the uterus, as has been
advanced ;  several of  them underwent the operation two  or three times,
with as much safety as if they  had been delivered at the full term of utero-
gestation."
   Thus the  first,  third, fifth, and  sixth  objections made by the French are
answered satisfactorily.
   506. We have  now only to inquire as  to  the utility of  the operation,
before considering the cases to which it is applicable.
   The positive utility of the operation has already appeared in the numeri-

       1 Practical Midwifery, etc.,  p. 502.
      2 Neue Zeitschrift fur Geburtskunde, vol. xxiii., pp. 161, 222, 371, 436. 
INDUCTION OF PREMATURE  LABOR.
301
cal results taken from different authors, showing that more than  one-half of
the children (all of whom must otherwise have been lost) have  been saved,
and that but a small proportion of the mothers has been lost.
  507. The comparative utility is equally in favor of the operation.
  It is peculiar to  midwifery  operations, that they form an ascending
series, increasing in gravity from the simplest to the most severe — no two
being equal;  and  therefore, in. considering the suitability or practicability
of any one, we do so with the knowledge that if the one we prefer do not
succeed, we must  have  recourse to another more severe and more danger-
ous.  An example will  make my meaning clear.   If, in any given case, we
attempt to deliver with  the forceps,  but  are  not able  to succeed, we must
subsequently  have recourse to the perforator ;  there is no other method, of
only equal severity with the forceps, which we can try.   Or again, if crani-
otomy and evisceration will not  render the transit of the child  possible, we
have  no recourse but symphyseotomy or Caesarian section.
  Thus, the alternative of any operation in midwifery is not one of less, or
even  of equal  danger, but necessarily one of a more  serious  nature, and
consequently  we cannot estimate the utility of  any obstetric operation fairly
if we consider it by itself; a just appreciation involves a due estimate of its
alternatives.
  It is to the alternatives of the induction of premature labor that I would
 wish  to  call  attention, as demonstrating  very strikingly the comparative
 utility of  the practice.
  In  the cases  which have been supposed to demand this operation, there is
 always a considerable diminution in the calibre of the pelvis from bony dis-
 tortion, so that it would be quite useless, at the full term of the  utero-gesta-
 tion,  to attempt  the delivery by the forceps ; the only alternatives, there-
 fore,  if we allow pregnancy to be completed,  are, the perforator, symphyse-
 otomy, and the Caesarian section.
   Now let us compare the mortality attendant upon each of these operations
 with  the  results of artificial premature labor.
   1.  By the  use of  the  perforator not only  are all  the children destroyed,
 but extensive statistics have shown that about one  in  five of the mothers
 perish, either from the direct effects of the operation, or from the length of
 the previous  labor.
   2.  Caesarian section is the "dernier ressort" of midwifery, involving the
 utmost danger  to  the mother and child, and justifiable only when  no other
 chance for either remains.  I have collected  450 cases ; 230 mothers were
 saved, and 210 lost,  or about 1 in 2^.   Of 315 children,  211 were saved, and
 104 lost,  or about 1 in  3^.
   3.  Symphyseotomy is attended with worse  results  than Caesarian section.
 One-third of the mothers have been lost, and  many of those who recovered,
 suffered  severely from the consequences of the operation.  One-half of the
 children  were lost.
   If, then, to the absolute advantages of the  operation  proposed,  be added
 the comparative gain from avoiding these terrible alternative operations, we
 may form a  tolerably correct estimate of the  utility of the "induction" of
 premature labor.
   508.  Having, as  I trust, established from  facts and  testimony the three
 leading principles of the morality, safety, and utility of this operation, I shall
 now proceed to inquire as to the cases in which it is available.
   1.  The class of cases for which it  was first proposed, and in  which it has
 been  most frequently employed, is that in which the diameters of the upper
 outlet of the  pelvis are too much reduced by distortion to permit the passage
 of a fcetus at  the full term, and yet not so much diminished as to prohibit the 
302
INDUCTION OF  PREMATURE LABOR.
passage of a foetus at an earlier but still "viable" age.   In the words of
Denman: "It is under circumstances and in situations preventing the suc-
cessful use of the vectis or forceps, and just compelling us to the fatal mea-
sure of lessening the head of the child, that it may be a duty to propose, on
a future occasion, the bringing on of premature labor."
  The first step is to endeavor to ascertain the size of the fcetal head at  dif-
ferent periods of utero-gestation, after the seventh month ; in order that, by
adapting the diameters of the deformed pelvis to the approximate diameters
of the fcetal cranium, we may be enabled to fix upon the moment when they
are in correspondence for the induction of premature labor.  It is of course
impossible to do this in any individual  case, but an approximation may be
attempted, by taking the measurements  in a considerable number of cases
at the same periods.
  The following table has been thus constructed by M. Figueira: —
Age of Foetus.	Bi-parietal Diameter.	Occipito- frontal Diameter.	Occipito-hrcgmatic Diameter.
7th Month. 7* -8th " 8} " 9th "	2 in. 9 lines. 3 " 3 " 1 " 3 " 2 " 3 " 4 "	3 in. 8 lines. 3 " 9 " 3 " 10 " 4 " 4 "	2 in. 10 lines. 3 " 3 " 1 " 3 " 2 " 3 '• 4 "
  509. To this kind of calculation it has been objected, that we cannot be
quite  sure of the exact age of the foetuses measured ;  and to the practical
use of it, that the female cannot be quite sure of the exact period of preg-
nancy.  That this objection has a certain weight, must be admitted ; but that
it  is sufficient to prohibit the operation  I cannot believe, for it may always
be obviated in practice by assuming the longest possible period of pregnancy.
If, for example,  a patient imagine that she is six months pregnant, but that
she may be  six and a half, by calculating for the six and a half  months, we
shall have assumed the largest size to which the fcetal  head can have attained;
and if labor be not brought on till seven months and a half, we shall also have
secured a fcetus of the "viable " age.
   Ritgen has made another series of calculations which have led to the fol-
lowing practical adaptations:
   He says labor may be induced at the
29th week, when the antero-posterior diameter of the pelvis is
30th           "            "            "            «
31st           "            "
35th           "            "            "            «
36th           "            "            "
37th           "            "            "            "
In.	Lines
2	7
2	8
2	9
2	10
2	11
3	0
  There is a very slight difference between the tables of Figueira and Rit-
gen, which may be  allowed for in practice.  The compression of  the foetal
head  will also  render  its diameter less  than the subsequent measurement
would lead us to suppose.
  It will be at once observed that there are two measurements of the pelvis
which limit the operation ;  if the pelvis exceed the greater measurement, the
operation is uncalled for ;  and if less  than the  least, it will not succeed  in
saving the child.   The smallest of these diameters appears to be about two 
INDUCTION OF PREMATURE  LABOR.
303
and a half inches, and the greater three and a quarter.  If the pelvis, in its
sacro-pubic diameter, be less than the former,  a "viable" child  will not
pass; and it is  generally admitted  that  a living  child may be propelled
through a pelvis whose antero-posterior diameter is three and a half inches.
The opinions of  different authors accord  pretty accurately with this calcu-
lation.
  510.  Another  difficulty still remains, what has been put forward as a very
serious objection by the opponents of this  operation ;  and that is, the un-
certainty of  ascertaining the exact diameter of the pelvis in the living sub-
ject.   Various mechanical contrivances have been proposed  by  Aitken,
Coutouly, Baudelocque, Asdrubali, Chaussier, and  others (of which I have
spoken in a former part of this work) ; but in this country they could rarely,
if ever, be employed.   Nor do I think  them necessary; a well-practised
finger  is, after all, the best pelvimeter, and  will yield sufficiently  accurate
information.  But we may go  further; for  by the aid of chloroform the
entire  hand  may be  passed into the pelvis,  and a direct measurement ob-
tained  by comparing the breadth  of the hand across the knuckles  with the
antero-posterior diameter of the brim.  But giving the utmost force to this
objection, to  what does  it amount ?   As Yelpeau justly observes :  " If the
pelvis be wider than  we thought, premature delivery (at or after the seventh
month) is accomplished  without risk.   If, on the contrary, the narrowing be
more considerable, the fcetus will certainly perish ;  but then, had no opera-
tion been attempted until the full  term, the fcetus would equally have been
lost, and the mother would have run greater risk."  Besides, much information
may be derived from the history of the previous  labors of the patient;  for
it is rarely, if ever, for the first child that the induction of premature labor
is proposed.   Dr. Merriman remarks, "that  the  use  of the  perforator in a
former labor  is not alone to be  considered as a justification of this opera-
tion."   This is  undoubtedly true  in the  present uncertain state of opinion
concerning the use  of the forceps  and crotchet, inasmuch as the latter  in-
strument is frequently used where there  is  no  distortion.  But if we are con-
vinced  that the perforator was used  from the impossibility of otherwise
delivering the patient, it might  then  be an adequate reason ; and if it further
appeared that her labor had  been thus terminated more than once, and  for
the same reason, the  operation would then  seem to be imperatively required,
and I  think  that we  should be perfectly justified  in refusing to undertake
the case unless the patient consented.
   I have now answered all the six objections put forward by  the French,
as fairly and  completely as our  facts permit.
   511.  2. A narrowing of the transverse diameter of the lower outlet, as
it offers a fixed impediment to parturition, may be an equally valid ground,
for the induction of premature  labor.
   512.  3. Exostosis,  or fibrous tumors of the pelvis, if they offer an im-
pediment to the  delivery of a child at  term,  or  at  the  earliest viable  age;
as they are solid, and cannot be removed by any operation, will  evidently
justify the induction  of premature labor,  or  abortion, for the  purpose  of
avoiding the  Caesarian section.   Some  of the cases related by Dr. Merri-
man would appear to  confirm this conclusion,  and the authority of Dr. Ash-
well and his practice are in favor of it.   Mr. Ingleby concludes that " pre-
mature  labor may with  great  propriety be proposed  on pregnancy recur-
ring, assuming the delivery of a living child at term to  have already proved
impracticable, the tumor to remain unchanged, and its excision  not deemed
expedient."
  513.  4. When the uterus is the seat of fibrous tumors, and impregnation
takes place, certain morbid changes occur, involving danger to the mother. 
304            INDUCTION OF PREMATURE LABOR.

" The tumors soften during the latter months ; the increased vascular supply
leads to inflammation ;  unhealthy and imperfect suppuration is established
in them, and death occurs soon after parturition."  This being the expe-
rience of Dr. Ashwell, he has proposed "the induction of premature labor
before that period when the tumors shall be subjected to pressure and con-
tusion from the firm,  large, and unyielding gravid uterus."   Before  we
act upon this suggestion, however, we must be pretty certain that such pres-
sure is likely to take place, and that the case  really demands  so  serious a
remedy.   Mr. Ingleby has some valuable observations on this subject.
   514. 5.  In the cases I have supposed, the safety of the child is the great
object of the operation ;  and they are limited,  therefore, to those  patients
in whom the pelvis, though  deformed, is still  large  enough to permit the
passage of a "viable" child.   But there are cases where the  distortion is
so great as to render the passage of  a seven months1 child impossible, and
others still worse,  where no reduction of a viable  child's bulk mill enable
it to pass.
   I do not see why abortion  should  not  be induced  at  an early period in
such cases.   This question was answered affirmatively by Dr. W. Hunter in
1768,  and a  similar approval  has been expressed  on  the  Continent  by
Fodere, Marc, Velpeau, Stolz, Jacquemier, Chailly, Cazeaux,1 and Spiegel-
berg and Scanzoni.   The life of the  child must inevitably be sacrificed, and
the  safety of the mother alone regarded ;  and  surely, after the calculations
I have adduced, it cannot be  pretended that Caesarian section, the alterna-
tive in these cases, offers such  a chance to the mother and child as would jus-
tify our preferring  it.   "When the pelvis is known to be distorted," says
Dr. Aitken, " so as to render  the birth of a living  child impossible, is it not
lawful and proper, to prevent the dangers  of  embryotomy, to induce early
abortion ?"
   An objection to this  extension  of  the  operation has  been made by Dr.
Merriman and  others, on the  score that it would be  " opening a wide door
to the dreadful abuse of the operation."  That, in short, by multiplying the
examples of inducing premature labor or abortion, we should  run  the risk
of its being performed unnecessarily or for wicked purposes.   But so may the
fact of its being performed at all, and so may the practice  of using ergot
of rye for the purpose of exciting uterine contractions.   I do not, in truth,
see any force in this objection, for such cases are extremely rare; nor do I
anticipate any  such prostitution of their power  on  the part of the members
of our profession ;  and  beyond the  profession, the operation  is not likely
to be much known.  It will,  of  course, be necessary that the case be tho-
roughly investigated by more than one person, and the time appropriately
chosen.
   Mr.  Radford, of Manchester, has suggested that by combining craniotomy
with the  induction of premature labor, in those cases where we are called
too  late  for  the fcetus  to pass even  at an  early period, we may avoid the
Caesarian operation.
   515. 6. In certain cases of rupture of the uterus  the cause is almost en-
tirely mechanical.   There is  some narrowing of the upper outlet, perhaps a
projection  of the promontory of the sacrum,  offering  an obstacle to the
ready descent of the fcetal head, which is driven  forward with great force
by the uterine  contractions.   Under such circumstances, the head  may be
pushed to  one side, and if the tissues be  not very firm, it will be  driven
through them into  the  cavity of the peritoneum.  Recovery from such an
accident  is very rare, but nevertheless it has occurred;  and if the woman
1 Midwifery, p. 846. 
INDUCTION OF  PREMATURE LABOR.
305
become pregnant  subsequently, a premature delivery may save both mother
and child.   As the best argument I  can employ in favor of this operation
in such cases, I may mention that it was adopted successfully by Dr. Collins,
when Master of the Great  Britain Street Lying-in Hospital.   The patient
had recovered from rupture of the uterus, and became  again  pregnant.   She
was admitted into the hospital in the seventh  month of pregnancy, and the
membranes were ruptured  on  the 4th of March, 1832.   Labor came on on
the 7th, and was completed in  ten hours.   The patient was delivered of a
living child, and recovered.   The child, however, lived but  two days.  The
case is perfectly illustrative of  the advantages which may be derived from
the operation in  this class of cases.  The mother was saved, and the child
at birth appeared likely to live; its death does  not seem to have  resulted
either from its early age or from the labor.1
   7. In certain cases of cicatrized vagina, when the obstacle is extreme and
very rigid, and when it is not discovered until pregnancy has occurred, the
operation  is  quite admissible  at any period,  inasmuch as it would be very
doubtful whether the operation for occluded vagina ought to be undertaken
whilst the patient is in that condition ; and the risk of rupture of the uterus,
if we leave  the case to  nature, is very great.   Dr. Oldham  has recorded a
successful case of this kind, and others have related many cases in which the
patient was lost from neglect of this operation.
   8. Dr. Denman observes : " There  is another situation in which  I have
proposed and tried with success the method  of bringing on premature labor.
 Some women who readily conceive proceed  regularly in their pregnancy till
 they approach their full  period,  when, without any apparently adequate
 cause,  they have  been repeatedly seized with rigors,  and the child has
 instantly died, though it may not have been expelled for some weeks after-
 wards.  In two cases of this kind I have  proposed to bring on  premature
 labor when I was certain the  child was living,  and have succeeded in pre-
 serving the children without hazard to the mothers.   There is always some-
 thing  of doubt in these cases,  whether the child might  not  have been
 preserved  without the operation ; but as such cases often come  under con-
 sideration,  and as I am  disclosing all  that my experience has taught me, it
 seemed necessary to mention this  circumstance."   Mr. Barlow  thinks  the
 "doubt" expressed  in the  above extract a sufficient ground for  negativing
 the operation ; but I cannot agree with him.
   9. The question has  been mooted, whether it would be  right to  induce
 premature labor on account of the presence of certain diseases caused by or
 connected  with  pregnancy.  Denman remarks:  " The  propriety  of this
 practice has also been  considered  when women  have, during  pregnancy,
 suffered more than common degrees of irritation,  and especially when  the
 stomach is  in such a state that it cannot bear  nourishment of any kind or in
 any quantity, and the patients are thereby reduced to a stage of dangerous
 weakness.   Presuming  that these symptoms  are purely in  consequence of
 pregnancy, it may, perhaps, be justifiable to bring on premature labor."
   Dr.  Merriman  relates a case occurring in the practice of a  "provincial
 surgeon of considerable eminence."  " The patient was teased with  a very
 severe cough, and her stomach was so irritable as to retain  no food whatso-
 ever, nor even opium in a solid  form.  She had taken absorbents, stomachics,
 bitters, aromatics, and  opiates, without experiencing any relief: liniments,
 fomentations,  and blisters had been extensively  applied without benefit, and
 she was thought to be  sinking into her grave, when it was proposed, as a
 last resource, to bring on premature  labor, six weeks before the full time,
   1 The patient was afterwards delivered naturally at the full time.   The details of the
 case will be found in Dr. Collins's Practical Midwifery, p. 255.
       20 
306
INDUCTION OF PREMATURE LABOR.
and the patient was delivered of a living child, and  ultimately recovered."
A case of fatal vomiting during pregnancy  is related by Dr. Johnson in the
Lancet, March 3d,  1838, p. 825.   "A lady, thirty years of age, soon after
marriage ceased to  menstruate, and became  affected with  morning  sickness,
which symptoms were naturally enough attributed to pregnancy.   The sick-
ness, however, gradually became worse, and at last nothing of any kind could
be retained on the stomach.  Pregnancy was  not detected,  but the disorder
attributed to some disease of the pylorus.   The sickness  and  extreme ema-
ciation were the only symptoms present.  After death no  morbid appear-
ances were  observable  in  any part  of the body.   The uterus contained a
fcetus about four months old.  This  patient was literally  starved to death."
" The treatment pursued consisted in the use of various salines, anti-emetics,
counter-irritation, leeches, acetate of  morphia sprinkled over a  blistered
surface," etc.   Surely the induction of premature labor in  this case would
have been justifiable, as affording the mother  a chance of recovery.
   Other similar cases are on record, both of fatal vomiting, and of success
by means of premature labor;  and a case occurred to myself, in consulta-
tion with Dr. Maguire,  of  Castleknock.  The patient was  a young woman,
pregnant of her third child, and at about four months was attacked with in-
cessant vomiting, until  her life was rendered intolerable, and her strength
utterly exhausted.  I never saw such agony in any case.  We tried all the
usual remedies, with occasional relief, but the vomiting returned, and finding
that she could obtain no nourishment whatever, that her bodily powers were
worn  out, that her  pulse was steadily 120, I determined, at  the sixth month,
to induce premature labor, which  I  effected by puncturing the membranes
and giving ergot  of rye.   She was delivered of a  dead foetus,  recovered
rapidly, and has since  borne a child at the full time.1   In another  case I
followed the same practice, and with success so far that after the foetus was
expelled, the vomiting entirely ceased, but she had been so  much exhausted
that an attack  of diarrhoea carried her off.
   It sometimes happens that the serous effusion which is  usually confined
to the lower extremities of pregnant females, is extended to the cavities of
the pleura and peritoneum, and as it thus gives rise to  a train of severe and
perhaps dangerous symptoms, the  induction  of  premature  labor may  be
advisable in some cases, and has been practised by Siebold and Carus. Two
such cases  are related by Sinclair and Johnson.2
   Puzos induced premature labor in a case  of strangulated  hernia, to facili-
tate the operation,  and  afford a better chance to the child.   He saved the
child, but the mother died afterwards.
   On this part of the question I confess it appears to me almost impossible
to lay down definite and general rules ; the decision must rest with the judg-
ment of the medical attendants in each individual case.
   516.  10.  The only exception made by Baudelocque to his condemnation
of artificial premature labor, is in those cases  of great uterine hemorrhage
before the  completion of the term of utero-gestation, when the child is pro-
bably destroyed, and the safety of the. mother compromised.
   These are all the circumstances which have ever been considered to justify
our interference in  the  manner proposed.
   Mode of operating.—Eight methods of exciting uterine contractions have
been adopted and recommended by different practitioners.
   1.  Abdominal frictions and  manipulation, with  warm baths,  etc., have
been advised, but they very rarely succeed, their supposed  advantage being
the absence of unnecessary irritation.
          1 Churchill on Diseases of Women, Book II., Sect, ii., Chapter ii.
          2 Practical Midwifery, pp. 504, 508 
INDUCTION  OF  PREMATURE LABOR.
307
  2.  Separating the membranes for two or three inches around the os uteri
will frequently bring on labor, and as  this is  a close  imitation of natural
labor, it has been preferred by many.  Dr. Hamilton remarks, " that he is
now convinced,  from the experience of  the last ten years, that if there be a
sufficient portion of the decidua separated from the cervix uteri,  there is  no
occasion for the introduction of the open male catheter," i. e., for puncturing
the membranes.  Dr.  Conquest considers it as effectual  as the other methods,
and much safer  for the infant, as saving it from pressure during the  pains.
If it fail, we can still have recourse to  the third plan.  Professor Braun, of
Yienna, has carried this separation  a  good deal further.   He introduces a
well-oiled catgut bougie high up into the  uterus behind the membranes, and
leaves it there.  He says that it always excites pains in from six to  twenty
hours, and  may be removed when  the waters escape.1
   3. The membranes may be  ruptured either directly or obliquely.   For
this purpose Wenzel, Ritgen, Kluge, and  others, have  invented appropriate
instruments;  but a female catheter  may  be used, or a piece of wire, or a
canula having concealed within it a spring trocar.   Care must be  taken to
wound neither the mother nor child.    This  plan was adopted in  Mampe's
and  Spoendli's cases, and, from its  greater certainty, it has been  preferred
by most practitioners.  Dr. F. H. Ramsbotham induced premature  labor this
way in thirty-six cases : sixteen children were  born alive, and twenty dead,
but two were delivered by craniotomy, and one by  version.  Dr. Moir, of
Edinburgh, states that he had  pierced the  membranes obliquely at  some dis-
tance from  the os, when separation of the membranes  had failed.  ' He  and
his father had thus operated above twenty times.2
   4. MM.  Brunninghausen and Kluge have  proposed and practised, with
great success, the dilatation of the os uteri by means of  a piece of sponge
placed within it, and maintained there by a plug in the vagina.   Yelpeau's
experience  of the  value of these different plans is  thus expressed:  "The
two  latter  methods are chiefly practised.   By the third, the effect  is not
always produced ;  it  required  three  operations  in the case related by M.
Riecke.  The separation of the membranes (the second method) is not suffi-
cient to bring on uterine contractions ;  as  the  distension of the cervix is not
permanent, the  first attempt is rarely successful.   Distension, by means of a
piece of sponge, as proposed by  M. Kluge,  is much more certain.  The
irritation which results  is permanent, progressive, regular, and sustained by
the plug which is maintained in the vagina.  Under the influence of such an
excitement, uterine action  is soon brought on, and it rarely fails to acquire
sufficient energy."  It is advocated by Stoltz, P. Dubois, Chailly, and others ;
and Hayn,  of Konigsberg, to whose  case I have referred, adopted  this plan
with success: but some authors do  not agree with Velpeau in  thinking it
more certain than rupturing the membranes.   Dr.  Simpson has been in the
habit of adopting  this plan  for many years without  a  single failure, and
without irritation.   He prefers beginning with a  tolerably large  tent, and
introducing a larger one every six  or eight hours.   Labor generally comes
on within a short period, and the first stage is  shortened by the sponge.  It
has,  also, the advantage of not rupturing the  membranes.  Dr. Simpson
usually orders tepid water to  be thrown  up  the vagina  every hour for the
purpose of  enlarging the sponge.
   5. M. Kiwisch, of  Prague, has proposed a plan which  seems to me very
admirable.   He directs a continuous  stream  of warm water upon  the  os
uteri by means of a long tube suspended  from a height  of  about  ten feet,
and introduced  into the vagina.   The  pressure  pushes up the membranes,

               1 Med. Times and Gazette, June 11, 1859,  p. 606.
               2 Ed. Monthly Journal,  July,  1851. 
308
INDUCTION  OF PREMATURE  LABOR.
and probably separates them from the uterus, and the combination of this
and the warmth rarely fails  to bring on  labor after eight  or ten applica-
tions.   It may be applied once or twice a day for ten minutes or a quarter
of an hour.   Dr. Arneth1 mentions that it has been tried in six cases in the
Vienna Lying-in Hospital, and that it  succeeded perfectly in all  but  one.
It has been used several times  in the Dublin Lying-in  Hospital,  and  suc-
ceeded  perfectly.   M. Paul  Dubois  has tried  it successfully in  two cases.
In one, labor came on after three applications, and in the other after eleven.
Both were  cases of  contracted pelvis,  and about  the seventh  month, and
both  women recovered well.2  Dr. Tyler Smith has published a case in
which he induced premature  labor by a stream  of warm and  cold water al-
ternately in  four days;3 and there is  another, by Mr.  Lacy,4 of distorted
pelvis, in which the douche was successful  after using it six times, three each
day.   Dr.  Simpson's  plan, of substituting Higginson's  syringe, appears to
me advantageous, as  we can  regulate the amount  and force  of the water,
and the apparatus is  less formidable.  He informs  me that he  has tried it
in several cases with  great success.   The  stream of  water  should be  kept
up for five or ten minutes  each time,  care being taken  to limit the escape
of water from the vagina.  Labor in one case came on the same day, in
others it required four or five repetitions of the injection.   Dr.  Sinclair, of
this  city, has contrived a double syringe for this purpose, which the opera-
tor can work by each hand alternately,  and  so keep up a continued stream.
Dr. Cohen,5 Dr. Leopold Harting,6 and  Dr. Stultz,7 introduced a small tube
through the os uteri, and directed the steam of water between the walls of
the uterus  and the  membranes : twenty-three cases have been recorded by
them.   Professor Scanzoni has been equally successful with carbonic acid,8
and Dr. Simpson wdth ordinary air.
   The profession is now in possession of sufficient experience to pronounce
favorably of this plan, and it will probably supersede the other methods, as
avoiding all their inconveniences and  possessing all  their advantages.  It
preserves the membranes  entire, and  occasions neither  local nor constitu-
tional irritation, and seems peculiarly suited for cases  of distorted pelvis,
where it is difficult to reach the os uteri.
   6.  Ergot  of  rye is now generally believed  to have the power of origi-
nating uterine contraction, and where it succeeds, it is a very effectual and
safe  mode  of inducing premature labor,  because we can preserve to  the
child  the safeguard of the liquor amnii,  which is of the greatest importance.
Dr. F. H.  Ramsbotham has published cases in which it  was  tried for this
purpose.   Labor was brought on  by its use alone in fifty-five  cases, without
interfering  with the membranes of the os  uteri.   All the mothers  but  one
recovered ;  thirty-three of the  children were  born alive, and  twenty-two
still-born.   Of the thirty-three born alive, five  died soon after birth.9   Dr.
Patersen,  of Glasgow,  and Mr. Heane,  of Gloucester,  succeeded by this
means.   We have also seen that Dr. Hoffman found forty-five cases in which
it succeeded in bringing on premature labor.   Although  the  medicine  ap-
pears successful as regards the induction of  labor and the consequences to
the mother, yet the proportion of children lost is greater than by the other
methods;  and this  must be a serious  objection  to  its use when  the pelvis
will admit the passage of a viable child.

  1 Die Geburtshiilfliche, Praxis, etc., zu Wien, p. 234.
  2 Moniteur des Hopitaux, 10 and 12 Feb. 1853.
  s Med. Times and Gnzette.                * Lnncet, Dec. 4, 1852, p. 517.
  5 X  Zeitschrift fiir Geburt., 1846. vol. xxi.  « Monntschrift fur Geburts., 1853, vol. i,
  f Deutsche Klinik, 1834, Jan. 14th, et seq.  8 Med. Times and Gazette, Oct. 11, 1856.
  a Ibid., Jan.  7th and 14th, 1854. 
VERSION,  OR TURNING.
309
  7.  Prof. Scanzoni  has tried, and in two cases successfully, to bring  on
premature labor by applying  an india-rubber apparatus, like  a sucking-
pump, over the nipples for about two hours.  In  one, seven, and in the
other, three  applications  were  sufficient.1  The chief objection  seems to
be the chance  of irritating the  breasts, and of failure in exciting  uterine
action.
  8.  Dr. Radford  has proposed galvanism as a mode of inducing labor in
1844, and Dr. Simpson wrote in favor of it about  the same  time.  The
former practitioner has used it four times  successfully to induce premature
labor in  cases of contracted pelvis; in a fifth case it failed.  Dr. Barnes and
others have also successfully employed it.
  It has been suggested, that the application  of the  extract of belladonna
might aid in the dilatation of the os uteri;  but independent of the fact being
rather doubtful,  the practice  would  be dangerous,  in consequence of the
active absorption  and  the  development  of the  poisonous effects of the
medicine.
  517.  An interval, varying from twenty-four to ninety-six hours, generally
elapses  after the operation, before uterine action commences, which it does
sometimes by shivering and feverishness.  " Great disturbance in  the nervous
system," says Dr. Gooch, " is produced by it; severe rigors, rapid pulse, and
delirium are  the occasional consequences ;  but  these  symptoms, proceeding
from nervous irritation, do not continue long enough to produce any serious
consequences." In many cases these  symptoms are altogether absent.  The
patient will require the same management  as after ordinary labor.  It will
be advisable to have  a nurse in readiness, to supply the infant with its natural
nourishment, until the mother  shall have milk for it.
C HAP TER  X..
    OBSTETRIC  OPERATIONS. —2. VERSION,  OR TURNING.


  518.  The term version or turning, is applied by midwifery teachers gene-
rally to that manual operation by which  one presentation is  substituted for
another less favorable ; and, in a more limited sense, to  the rectification of
certain  mal-positions.
  For the furthering of one or other  of these purposes, it has been known
to the profession for a considerable period ; but the full benefit of the opera-
tion, and  the class of cases in which it is useful, are of much later discovery.
It is recommended by Hippocrates, Celsus, P. JSginetus, Rbodion, etc. ; by
the early  English authors, as Raynalde, Pechey, etc. ;  among  the French by
Ambrose  Pare, Guillemeau, Portal, etc.

               » Med. Times and Gazette, Oct. 1st, 1853, p. 359. 
310               version,  or turning.



  519. Statistics : —
			° i	o m	
Date.	Author.	Hospital, etc	C5 D	— «	References.
1781	Dr. Bland,	Westminster Dis-pensary,	9	1,897	Merriman's Synopsis.
	Dr. Jos. Clarke,	Dublin-Lying-in Hospital,	48	10,387	Trans, of Assoc, vol. i.
	Dr. Merriman,	London Private Practice,	14	2,947	Synopsis, 4th edit., p. 335.
1816	Dr. Granville,	Westminster Dis-pensary,	8	640	Report of, p. 25.
1826	)				
to	[ Dr. Collins,	Dublin Lying-in	33	16,414	Prac. Treat, on Mid., p.
1833	j	Hospital,			73.
1828	Dr. Cusack,	Wellesley Dispen-sary,	5	313	Dublin Hosp. Rep., vol. v. p. 495.
1832	Dr. Maunsell,	a	2	442	Edin. Journal, No. 117.
1833	tt	"	0	416	Dublin Jour. vol. v. p. 307.
1828	Mr. Gregory,	Coombe Hospital,	3	691	Dublin Hospital Report,
1834	1				vol. v.
to	r Dr. T. Beatty,	Cumberland-street	6	1,182	Dublin Jour., vol. viii. p.
1837	J	Hospital,			66; vol. xii. p. 273.
	Dr. Reid,		28	5,691	Ranking, vol. iv.
1836	)				
1837	I Dr. Churchill,	Western Lying-in	11	1,640	See Reports.
1838	i	Hospital,			
	Mr. Mantell,		8	2,510	Amer. Med. Jour., vol. iv. p. 245.
	Dr. Adams,		9	628	Ranking, vol. iv.
1842 to 1845	} Drs. M'Clintock	Dublin Lying-in	23	6,634	Pract, Obs., p. 181.
	j and Hardy,	Hospital,			
1847 to 1854	1 Drs. Sinclair and	Dublin Lying-in	47	13,748	Pract. Med., p. 514.
	| Johnston,	Hospital,			
1842	)				
to	Y Dr. Hall Davis,	Royal Maternity	35	7,302	On Diff. Labor, p. 271.
1857	J	Charity.			
	Mad. Lachapelle,	Maison d'Accouch.	155	15,652	Practique des Accouch.,
Dec.	~				p. 198.
1799					
to	- Mad. Boivin,	Maternity,	218	20,517	Memorial de l'Art, etc.,
July	j				p. 354.
1811					
1808	M. Ramboux,	Clin, de Liege,	1	216	Bull de la Faculty etc., vol. ii. p. 73.
1825 1826	I Dr. Merrem,	Cologne,	3	157	Ibid., vol. xvii. p. 283.
I 1828	M. Papavoine,	St. Louis Paris,	1	240	Jour, du Progres de Me"d. vol. xiv.
1829		Hotel Dieu, Paris,	2	280	Velpeau, l'Art d'Acc. p. 50.
1830 1831 |	| M. Ciniselli,	Clin, de Pavia,	2	94	Gaz. MeU de Paris, 1835.
183:]	M. Mazzoni,		18	481	Prospetto Ragionato, etc.
 
version,  or  turning.               311
		«		6 m	
Date.	Author.	Hospital, etc.		«0 O V.	References.
1834	)				
to	[ Dr. de Belli,	Milan,	51	2,739	Ranking, vol. iv.
1843	i				
1789	1				
to					
1792	|				
and	^•M. Boer,	Vienna,	151	29,961	Die Natlirliche Geburt-
1801	1				shiilfe, etc., vol. i. pp.
to	I				72, 148, 237; vol. iii.
1806	J				pp. 62, 130, 245.
	M. Naegele,	Heidelberg,	22	1,411	Velpeau's Tab. View.
1801	) G. M. Ritcher,	Moscow,	25	2,571	5 Synop. Prac. Med. Ob-( stetric, p. 416.
to 1807	1 "	Private Practice,	27	624	
1812	)				
and	y E. Von Siebold,	WurzburgHospital,	6	310	Siebold's Jour. fiir. die
1813.	i				Geburtshiilfe, etc., vol. i. pp. 114, 576.
from	1 r				
1818 to		Berlin Hospital,	60	2,055	Ibid., vol. iii. to x.
1829	j				
1819 1820	{ M. Ritgen,	Giessen,	1	180	Ibid., vol. vi. pp. 34, 262.
1814	1				
to	]■ M. C. G. Carus,	Dresden,	29	2,133	Ibid., vol. vi.
1824	J				
	M. Kilian,	Clin, de Prague,	63	2,350	Bull, de la Faculty, etc. vol. xxv. p. 352.
	M. Klein,		216	35,417	Arneth, p. 135.
	M. Bartsch,		40	4,425	Ibid.
1824	1				
to	[ M. Kluge,	La Charity, Berlin,	19	1,254	Siebold's Journal, vols.
1827	j				vi. vii.
1825	Prof. Andre"e,	Breslau,	5	181	Ibid., vol. vi. p. 154.
1825	)				
to	1 Dr. Brunatti,	Dantzic,	3	380	Ibid., vols. vii. ix.
1828	J				
1825 1826	JDr. Theys,	Trier,	1	49	Ibid., vols. vii. viii.
1826	Dr. Henne,	Konigsberg,	2	156	Ibid., vol. viii. p. 121.
1826	Dr. Voigtel,	Magdeberg,	1	29	Ibid., vol. viii. p. 831.
1827	Dr. Kiistner,	Breslau,	6	176	Ibid., vol. ix. p. 92.
1829	)				
to	y Dr. Adelmann,	Fulda,	1	166	Ibid., vols. xi. xiv.
1832	J				
1830	1				
to 18:12 1833	VVr. Siebold,	Marburg,	8	321	Ibid., vols. xi. xii. xiii.
	J 1				
1835 and	1 " J	Gottingen,	7	504	Ibid., vols. xv. xvi.
1836					
	Prof. Schwerer,		183	21,804	Ranking, vol. v.
	Dr. Arneth,	Vienna,	44	6,608	Die Geburtsh. Praxis, etc. p. 71.
1821	]				
to	>■ Dr. Ricker,	Nassau,	2473	304,150	Med. Times and Gazette,
1842	J				Oct. 11, 1851.
 
312
VERSION, OR TURNING.
  Thus we see that the records of English  practice yield  71,483 cases, and
247 cases of version,  or about 1 in 247 ; French practice,  40,376 cases, aud
451 cases of version, or about 1 in 89^ ; and German practice, 393,823 cases,
and 3393 cases  of version, or 1  in  116.   The  whole number of cases  is
505,691, and of version 4133, or about 1 in 122J.
  520.  It is not so easy to make  out a satisfactory table showing the danger
of the operation to the mother and child, from  the want of details.  Many
writers do not mention whether any of the mothers died, and  some omit the
result as regards the child.
  In the following table, I have taken all the numbers upon which I could
depend,  and  though  the list is  not extensive, I believe  that the average
mortality will be found pretty correct.
Authors.	Number of ATersion Cases.	Mother lost.	Children lost. 1
Mad. Lachapelle ....	155	Not stated.	! 45
	218	Not stated.	48
Dr. Clarke.....	48	6	35
Dr. Collins.....	33	3	13
	5	0	2
	3	0	0
	6	1	6
Dr. Churchill.....	11	0	8
Drs. M'Clintock and Hardy .	23	1	6
Professor Andr<je ....	5	0	3
	7	1	3
	6	0	2
	1	0	0
Dr. Boer......	26	0	10
	18	0	7
	44	3	14
	183	14	93
	2473	176	1431
  Thus, in 2939 cases, where the result to the mother is specially mentioned,
212 mothers died, or nearly 1 in 14.
  I do not give this result as the exact mortality of the operation, because
it is evident that the deaths in many cases must have been owing to the cause
which demanded the operation,  as in placenta praevia ; but as we find that
even in several of these cases the fatal termination was evidently more owing
to the operation than to the hemorrhage, I am  inclined to think the calcu-
lation not very far from the truth.  However, any erroneous inference  from
these statistics will be guarded against by the recollection of the various and
serious accidents which require the  operation.
  In 3347 cases, where the result to the  child  is detailed,  1472 children
were lost, or rather more than 1 in  3.
  To a certain extent the same  observations apply to this calculation of the
mortality amongst the infants, and  similar allowance must be  made.
  521. The object of the operation is threefold :—
  1.  To  place the head in a more favorable relation to the pelvis, or to sub-
stitute the head for some other presentation.
  2.  To  substitute the inferior extremities for some other  less favorable
presentation.
  3.  To  hasten the termination of labor, in consequence of  complications,
as convulsions, flooding, prolapse of the funis, etc.
  It has been proposed to turn and deliver instantly, in case of the sudden 
VERSION, OR TURNING.
313
death of the mother, instead of having recourse to the Caesarian  section:
but the mortality amongst children so delivered  would preclude this  appli-
cation of the operation.
  There is so  much difference in the means by  which the first and second
objects are attained, that it is necessary to say a few words upon each.
  522. 1.  Version by the head, or cephalic version, as it is termed, consists
(a) in clearing the upper outlet of any part which may hinder the descent of
the head; (b)  in seizing the  head, and  bringing it down to the brim of the
pelvis; (c) or  in rectifying the  mal-position of the head.
  As the majority of children enter the  world head foremost, this mode was
decided to  be the standard of natural  presentation  at a very early period,
and attempts  were made to correct any deviations.  Rhodion, Raynalde,
etc., endeavored to change footling  into head presentations, but not by in-j
texnaj. manoeuvre.   After the discovery by  Arab. Pare, Guillemeau, and
others, of the  ease with which  labor could'be terminated by bringing  down
the  feet, cephalic  version went  very much  out of fashion.  By the  great
bulk of recent writers  (especially in our own country) it is either not men-
tioned at all, or with reprobation.   Still there  are  cases in which  its suita-
bility could  not be overlooked, and in  consequence we find  an admission
here and there of its utility.  Smellie recommends it in certain  mal-positions
 of  the head;  Mauriceau advises it if the neck present;  and De la Motte,
 Melli, and Roux speak of success obtained in this manner.  Le Roi  preferred
 it generally to version  by the feet.
   These, however, were only exceptions to the  rule : it remained for  Flam-
 mant, professor at Strasburg, to recall the attention of the profession  to the
 operation, in such a way as to  procure its  readmission (at least on  the Con-
 tinent) into the number of valuable obstetric  operations.   His example has
 been followed by several German  and French  writers.    Labbe, Eckhardt,
 and  Wigand, published  successful  cases in 1803;  Schnaubert in  1815;
 D'Outrepont  and Regnaud in 1825.   Busch gave an account, in 1826, of
 fifteen cases, in which fourteen infants were  born living.  In 1827  Ritgen
 collected forty-five successful cases.   Riecke has had  sixteen  cases.   It has
 been eulogized by MM. Yallee, De Roche, Ubersaal,  Stoltz, and Toussaint.
 Joerg and some others advise the head to be seized  and placed in position
 when nearest the cervix, and  Gardien seems inclined  to  recommend  it
 strongly, " if  practitioners were  only as well versed in the use  of the forceps
 as the professor of Strasburg/'
    One of the few British writers  who  speak well of it, is the late  distin-
 guished professor at Glasgow, Dr. Burns, who says : " For instance, if the
 patient be known usually to  have a short labor, if the pains be brisk, the  os
 uteri dilated,  or in a relaxed and easily dilatable state,  the liquor amnii re-
 tained, and the head movable, then the head may, without any difficulty  or
 much irritation, be placed in the proper position, with a fair and reasonable
 chance of success."   I may also  cite  the  testimony of Dr. Dewees, who
 acknowledges that "should nothing  but the  position  of the head,  with a
 slightly diminished capacity in  the antero-posterior diameter, affect the labor,
 we may sometimes enable the  woman to deliver herself, provided the  waters
 have discharged themselves, by the aid  of two or three fingers within the
 vagina, and  applied to the  side of the head, so  as to  carry  the vertex to-
 wards one  of the acetabula;" — "when  thus  placed, we may commit the
 termination to the natural efforts, provided no other circumstance complicates
 the labor."
    523  It is stated as an objection  to the employment of this  kind of mani-
 pulation, that it is more difficult to catch firm hold of the head and to bring
 it to the upper outlet; that if we succeed in bringing it to the brim  we can
 do no more, but  must then leave it to nature, or use the forceps.  To these 
314
VERSION,  OR  TURNING.
and similar objections, Yelpeau has returned  the  following answer: " 1st,
It is not always very difficult to seize  the  head, and to exert considerable
force upon it;  2dly, if the waters have not been long  discharged, one may
often  without difficulty seize the vertex, and bring  it  to the  centre of the
brim,  however far  it may  have been  distant;  3dly,  that in general it is
better to force the head to descend, by pushing up the  presenting part, than
by bringing down the head ;  4thly, that delivering by the breech is far from
being a simple and  safe operation ; as regards the child, it is less so than
cephalic version,  even if the forceps should afterwards be applied."
  No one  can for a moment deny that there is  considerable weight in the
objections I have named;  but a more detailed  investigation will  show that
they are valid only against an indiscriminate employment of the  operation,
and not against its use in the cases to which it ought to be confined. These
cases may be divided into two classes :  1, where  the  pelvis is of sufficient
size, and nothing but the  mal-position of the child's  head calls for inter-
ference  ; 2, in  certain mal-presentations, such as the neck or shoulder, and
perhaps in a few arm cases, if the uterus  be not strongly contracted, and
especially if the waters have not escaped.   It is evidently not  calculated for
any case where prompt delivery is necessary.
  Its advantages are found  to be, — first, a greater facility in reaching the
head, for it is not proposed to be used in cases where the feet are near the
os uteri;  and secondly, a vast saving of infantile life.    This operation will
be no more fatal  to  the child than natural labor, if performed early, whereas
in footling cases and in version by  the feet, more than  one in three are lost.
   [In a prize essay on " Difficult Labors and their Treatment," Professor M.
B. Wright, of Cincinnati, states that he has succeeded in effecting cephalic
version in cases  of shoulder presentation, etc.,  even where turning by the
feet  was impracticable.   He attributes his success mainly to his manner
of proceeding, which is certainly one of the best that  has been yet suggested.
It consists in returning the  arm of the child, should  it be prolapsed,  and
placing it as nearly as possible in its original  position across the breast,
when the operator is to apply his  fingers to the top  of the shoulder, with
the thumb in the axilla or on such part  as will  give him  command of the
chest and  enable him to apply a degree of lateral  force.   Whilst the left
hand is applied to the abdomen of the  mother over the breech of the fcetus,
with the right, lateral pressure is  to be  made upon the shoulder in such a
way as  to give to the body of the  fcetus a curvilinear  movement.   The left
hand at the  same time makes pressure with  the  view of dislodging, as it
were, the breech, and moving  it  towards  the centre of the  uterine cavity.
The body is thus made to assume its original bent position, the points of
contact with the  uterus are loosened, and perhaps diminished, and the force
of adhesion is in  a great degree overcome.   Without any direct action upon
the head, it gradually approaches the superior strait, falls into the opening,
and will, in all probability, adjust  itself in a favorable vertex presentation.
If not,  the head  may be acted on as in deviated positions of  the vertex, or
it may be grasped, brought into the strait, and placed in correspondence with
one of  the oblique diameters.]
   524.  2.  Turning  by the feet, or podalic version. —This was known to
the ancients, but confined  by most of them to the case of dead children.
To Ambrose Pare,  we  are indebted for demonstrating its facility and com-
parative safety, and for inculcating in practice.   His distinguished pupil,
Gillemeau, followed  in his  footsteps, to be himself succeeded  by others of
brilliant talent and  profound research, who cleared up the difficulties, and
settled  the limits, and laid down the rules for the  operation.
   The peculiar advantages of version by the feet are :  —
   1. That it gives to the operator the entire control over the  whole process 
VERSION,  OR  TURNING.
315
of the labor, so that he can regulate its duration, either acting with, or inde-
pendent of, the pains.
  2.  That though inferior  in its results to labor wdth head presentation, it
is about equal to any other, and superior to some.
  3.  That in some cases it is the only chance of saving the child's life, or of
avoiding evisceration.
  4.  That in certain cases it affords a probability of saving the mother's life,
when other means are hopeless.
  On the  other hand, its disadvantages are not to be overlooked ; for —
  1.  From the distance the hand has to traverse, and the difficulty of seizing
the feet and of  turning the child in  utero, there must ever be a fearful risk
of injury to the mother.
  2.   The  mortality amongst the infants thus brought into the world is very
great; as far as our statistics extend, they yield 1472 out of 3347 delivered,
or more than 1  in 3.
  525.  From all  that I have said, it will not be difficult to specify the cases
to which the operation is applicable.
  1.  It may be used in all cases of mal-presentation, whether of the supe-
rior  extremities or trunk.
  2.  If, upon the introduction of the hand for  cephalic version, it be found
impossible to rectify the mal-position of the head, we are advised to  seek for
the feet, and bring them down.
   3.  In all cases of placenta prcevia, many cases of ruptured utei'us, convul-
 sions, prolapsed funis, etc., the operation is available, and has been used
 with great success.
   4.  Dr.  Simpson has  revived  the recommendation  of Exton, Pugh, Ould,
 and  Burton, to substitute turning, in certain cases of distortion of the pelvis,
 for craniotomy, on the grounds that the base  of the skull being narrower
 than the inter-parietal diameter, and the head more compressible under trac-
 tile  than  expulsive efforts, the child might be delivered, and perhaps saved
 by a less  severe operation.  And further, that as turning might be attempted
 at an earlier period  than is usual for craniotomy in such cases, we might
 thereby afford the mother greater security of a favorable result to  herself.
 And he has supported his views by statistics taken from Dr. Collins's work,
 but  without sufficient care and caution, as it appears to me.
   Now let  us examine into the practical application of his proposal.   The
 bi-mastoid diameter in the six cases of measurement he gives, varied from
 2£  in. to  3| in.; and  a living child can pass through a pelvis  of 3|- in.
 antero-posterior diameter with  or without the forceps.  With a pelvis of this
 size the operation is then  unnecessary, and if the antero-posterior diameter
 of the  pelvis  be  less than 2| in. the  operation  would  be  impracticable.
 Then these are the limits of the operation : for  us to attempt to drag a child
 through a smaller space would be unjustifiable.   For the success of the  ope-
 ration, then, we  must be  able to ascertain  that the pelvis is wdthin  these
 limits, and perhaps in some few cases, with whose former labors we are  accu-
 rately acquainted, we may do this, but  in an immense majority of cases it
 will be, I think, impossible ; and it happens, as Dr.  Collins has showm, that
 the  greater number of cases of difficult labor he met wdth were first  cases, in
 which,  of course, no such  precise judgment could be  attained.   It is  only
 fair, however, to state that, by putting the patient under the influence of
 chloroform, and  introducing the hand  into  the vagina, Dr. Simpson has an
 opportunity of estimating the diameter of the brim more accurately than by
 any of the ordinary modes of measurement.
   Again, the  life of the child  is not secured  and  its chance but  little in-
 creased, even if our estimate of the pelvic diameters be accurate ;  for if in
 turning with an  ordinary-sized  pelvis, rather  more than one-third of the 
316
VERSION, OR TURNING.
children are lost, the mortality will be surely much increased if its diameter
be reduced more than one-fourth.
  Moreover, if we should miscalculate the size of the pelvis, or if the head
should be  a trifle larger than usual, so  far from  the safety of the mother
being increased, it would  be very seriously diminished ; for we  must then
craniotomize the child after  incurriiig the hazard of turning, and in a most
unfavorable position.
  Lastly, even if we succeed in  selecting a suitable  case and in  extracting
the child, it has yet  to be proved that the mother would not incur consider-
able danger from contusion or  laceration  in  forcibly dragging the child
through  a narrow pelvis;  for I  must remind my  readers  that we  have no
statistics of the proposed operation to compare with those of the old  method,
the few cases adduced by Dr. Simpson being of no value for  this purpose.
  I must therefore object to  the general adoption of Dr. Simpson's plan, for
the reasons above stated : the difficulty of ascertaining the exact diameters
of the pelvis, the very little benefit to the child, the great risk to the mother
of doubling the operation.   At the same time I do not mean to deny that
there are  some  cases  in which it may be worth trying, as every successful
case is a rescue  of a life from destruction.   So far as it is applicable, it is
one mode of limiting the operation of craniotomy, an object we must all have
at heart.   In these  conclusions I am very glad to adduce  the concurrence
of Dr. Radford, whose  papers are no  doubt familiar to my readers in the
pages of the Provincial Medical and Surgical Journal.
   526.  The next point for our investigation is the  period most suitable for
making the attempt; so as  not  to interfere rashly on the  one hand, nor to
delay too long on the other,  " neque temere  nee tiniide----."  Of the two
errors, it is hardly too much  to say, that excessive delay is the more serious.
   1. If the case be  one requiring cephalic version for the  rectification of a
mal-position, it is clear  that the operation can only be safely, if at  all per-
formed, before the uterine efforts have wedged the head into  the upper strait;
the attempt should be made  so soon as it is evident that the natural powers
will not rectify the mal-position.  It will be an additional motive for prompt
assistance, if we find the pains violent, and that the patient have had many
children, lest the head, not being able to enter the brim, should be turned
aside, and forced through the uterine or vaginal parietes.
   2. (a) If we are called to  an arm presentation, or  any demanding podalic
version, before the escape of the. liquor amnii, and we find  the os uteri hard
and undilatable, it will be advisable to wait until some change takes place,
before we introduce the hand ; neither is there  any risk worth mentioning,
provided  we remain with the patient, to operate instantly when the waters
break.
   (6)  If  we see the patient  before the  rupture of the membranes  and find
the os uteri soft and dilated  or dilatable, there is no reason for deferring the
attempt, if the case  require this kind  of interference,  and great advantage in
operating while the  uterus is distended.   If we act as soon  as the os uteri
will admit the hand, it is the better time, because we  then  turn the child as
if in a bag of water; and this gives  us  so clear an advantage that it needs
no explanation.
   (c)  If  the os uteri be dilatable, the sooner the attempt is  made after the
escape of the waters the better.   Gardien says that the most favorable mo-
ment is just when the waters break.
   (d) After the escape  of the waters, we sometimes find the os uteri neither
rigid nor much dilated, and the pains  moderate.   In  such  cases, no time
should be lost;  the hand should be  introduced into the vagina, and gentle,
yet firm and persevering, efforts  made to pass it into the uterus.   Dr. Blun-
dell says: " In  ordinary cases, if the mouth of the womb  be as  broad as a 
VERSION,  OR  TURNING.
317
crown piece, and if the softer parts be relaxed  thoroughly, the introduction
of the hand is not exposed to greater risks than usual, there  seems to be no
circumstances preclusive of the  operation, and the sooner you commence the
better."
   (e) So far, although these cases are each more serious than the other, yet
in none of them has any very great difficulty, either of decision or of execu-
tion, been experienced.  We are, however, often called to a class of cases
where our utmost judgment, patience,  and skill will be  needed.  I refer  to
those cases  of arm presentation, where, in the  language of Foster,  "the
membranes have been a long time ruptured, the waters totally evacuated, and
the womb closely contracted around the fcetus, which is then thrust  con-
siderably into the pelvis, the parts of the woman being  dry, hot, tender, and
often in a state  of inflammation  and tumefaction, especially when unskilful
endeavors have been used to  extract or turn the fcetus, or to dilate the
parts."
   In such a case, to force the hand through the os uteri would be to rupture
that organ, and cause the death of the woman.  It is admitted by all authors,
 I believe, that the  operation must be  postponed for a time, and means  tried
 to soften the uterus and suspend  its contractions.   For this  purpose all are
 agreed in the propriety of taking sixteen or eighteen ounces of  blood  from
 the arm, and following up this with a large  dose (gtt. lxxx. to gtt. c.) of
 laudanum.   Dr. Collins has proposed another  remedy of great  value.   He
 says:  " In  such a situation, where  the  individual is strong and plethoric,
 twelve or fourteen ounces of blood  should  be taken  from  the arm, and a
 tablespoonful of the following  mixture given every half hour, which I have
 found exceedingly useful, both in  quieting uterine action, and  in inducing
 relaxation :—
                      R  Aquae  fontis,  gvj.
                         Antim.  tartar, gr.  iv.
                         Aceti opii,  gtt. xxx. M."

   By these  means, after the lapse of  a short time, we  shall find the uterus
 relax, and the os uteri soften,  so that with a little patience, gentleness, and
 time, we may attain our object.  It is very probable, though I cannot speak
 from personal experience, that the full exhibition  of chloroform wdll render
 the introduction of the hand under such circumstances much more easy, as
 it surely renders the operation  painless.
   3. When the case is one of placenta prcevia or even of accidental hemor-
 rhage (if it demand delivery),  it  is a general rule to  operate as soon as pos-
 sible.  The  os uteri seldom offers any resistance, when the loss of blood has
 been great; and as this loss is necessarily increased  by the natural efforts in
 unavoidable flooding, it is evident that  the earlier we  deliver, the better for
 the patient.
   If we decide upon trying this  operation in convulsions, prolapsed funis,
 or ruptured uterus, it will be  wise to attempt it as soon  as  the state of the
 os uteri  will permit.
    527. Method of operating.—This  operation is usually divided  into  three
 stages:  the introduction, the  turning,  and  the extraction.   I shall shortly
 describe these, in each kind of version.
    1. Cephalic  Version. — The rectum and bladder having  been previously
 emptied, the patient is to be placed in the posture  most  convenient to the
 operator ; some recommend that she  should lie on her back, others that she
 should kneel, or lie on her left side, as  in ordinary labor.   The latter posi-
 tion is generally adopted  in this country.  Whichever hand we choose to
 operate  with is to be well oiled or soaped, and then insinuated  through the
 os externum edgeways.   Mr. Roberton recommends that the vagina should 
318                   VERSION, OR TURNING.
be filled with lard previously,  and that  the  left hand should be used.1   As
most men are right-handed, I think  the greater facility in using  that hand
will counterbalance any supposed inconveniences.   (Jrent gentleness will be
necessary, and, contrary to the advice of some, it would  seem better to do
this during an interval of pain.   When the  greater part of the head is in
the vagina, it will be necessary to change its direction from that of  the axis
of the lower outlet to that of the upper outlet.  This  wdll  avoid all injury
to the vagina, and will bring the points of the fingers to about the situation
of the os uteri.   Through the os uteri (and membranes if entire), the hand
is to be insinuated very gradually, in a conical form, and during the interval
of the pains; holding still, but not losing ground, when the pain comes on.
When the hand is in the womb, if our  object  be  to rectify the position of
the head, it should be seized,  and placed in one of the  oblique diameters of
the brim, with the posterior fontanelle  corresponding  to one  of the aceta-
bula—i. e., in the first or second position.    If our object be to change the
presentation—for example, to substitute the head for  a shoulder—we must
gently push  up the  shoulder, and then seizing the head, bring it down to
the brim, and place it in the most favorable relation to the pelvis ; and it
might facilitate the  operation if the patient were  placed on her hands  and
knees.
   Having now done all that we can by the hand alone, it may  be withdrawn,
 and the further progress of the  labor  left to  the efforts of nature; should
these  be found inadequate, recourse must be had to the forceps.
   528. This is the ordinary method of placing the head in position for de-
 scending ; but Wigand has stated that it is  possible, before the waters have
 escaped, to change  the position  of the head, or even the presentation, by
 external  abdominal manipulations.  Yelpeau confirms  this from his own ex-
 perience, and something similar is stated by Sennert and  Martins.   Riecke
 has also  related several such cases, and Meissner four quite recently.   Dr.
 Burns, in a note to his ninth edition, states that: " Mr. Buchanan,  of Hull,
 informs me that he succeeded in one instance  lately,  'where the left side of
 the breast of the fcetus lay diagonally over the  pelvis, with  the head  for-
 ward,' in bringing the head right, by making the patient kneel  and  raise
 the breech, whilst  the  shoulders  were brought  as  low as possible.   The
 water had not been  discharged.   The  situation  of the head, when it came
 down, was  made more favorable by the finger.  The child was alive."
   A very interesting memoir has been published by  Professor  Martin, of
 Jena, on turning by external  manipulation  alone,  founded  on  thirty-four
 cases, seven of which occurred to himself.   The conditions which render the
 operation eligible  are — 1.  The non-necessity for immediate delivery; 2.
 Mobility of the  child, which generally ceases after  the  discharge of the
 waters;  3.  Absence of great sensibility of the womb  or abdomen; 4.  Suf-
 ficient capacity of pelvis, but a moderate  contraction  is no counter-indica-
 tion ;  5. A normal  activity of pains ;  6.  The child being alive is a subor-
 dinate condition.   The mode of operating is as follows : — As long as the
 os is  undilated and  the pains irregular, the patient is kept  upon the  side
 upon which the part desired to be forced into the pelvis is placed.  When
 the os is dilated, and the waters are  expected to escape, the  bladder and
 rectum having been emptied, she is laid on her back,  the lower part of the
 body being somewhat  raised.   With one hand (warm),  continuous  and
 moderate pressure, downwards,  is made on that part of  the fcetus which lies
 nearest the os, whilst the rest of the body is  pressed upwards.   This simul-
 taneous  pressure is begun  during the interval of a pain,  and continued
 during its  commencement, while during  the height  of this the  uterus is
1 Phys. and Dis. of Women and Midwifery, p. 328. 
VERSION,  OR  TURNING.
319
firmly supported on every side.  After  a short  pause the manipulation is
again commenced ; and if the operator's hands  become  tired, an  assistant
may support the belly on each side while he rests.   If the  pains  are  long
absent the patient may be placed on her side, the projecting part being sup-
ported by a band or cushion,  and this position should be maintained when
the head has entered the  pelvis.  When the manipulations have succeeded,
and the  head or breech is within the os uteri, the membranes should be rup-
tured, to secure from further change.  The pressure may be sometimes dif-
fused, sometimes special,  by the points of the fingers ; and it should always
be double and simultaneous :  downwards of the  part we wish to engage in
the pelvis, and upwards towards the  fundus of the rest;  and for  this pur-
pose an accurate recognition of the parts of the child is  indispensable.1  It
appears that this operation has the support of  M. Ritgen's authority, and
Dr. Spingler has recorded a case in which he succeeded.2
   529.  2. Podalic Version.—I shall not repeat what I have said as "to the
mode of introducing the  hand through the os externum  and os uteri.  The
hand and arm  of the infant will be our guide ;  for it is better not to attempt
to put it back, much less to separate it, " after the manner of the ancients."

                                Fig. 110.
Version, or Turning.
Denman remarks :  " In no case is it necessary, or in anywise serviceable, to
separate the arm of the  child previous to the introduction of the hand of
the operator.   In some cases to which I have been called, in which the arm
had been separated at  the  shoulder, I have found greater  inconvenience,
there being much difficulty in distinguishing  between the lacerated skin of
the child and the parts appertaining to the  mother.   The presenting  arm
is never  an impediment  of any consequence in the operation, and therefore,
in my opinion,  ought not to be regarded,  or  on any account removed."
  Arrived at this point, an examination should be made as to the position
of the child's body.  Having ascertained all  about it, the hand is to be
          1 Ranking's Abstract, vol. xii. p. 278, from Froriep's Notizen.
          2 Ibid., vol.  x  p. 329. 
320
VERSION,  OR  TURNING.
passed over the front (chest and belly) of the child, as it is in front that we
meet with the feet.   It is often a matter of  difficulty to reach them, as well
from the distance to be  traversed  as  from the  contraction of the uterus.
This part of the operation should  be  slowly and gently performed, resting

                                Fig. ill.
Version, or Turning.
occasionally, and keeping the hand quite still and flat upon the body of the
child during a pain, so as to avoid both injury to the  mother and great pain
to ourselves from the violence of the uterine contractions.
   Having found one or both inferior extremities, before we begin to extract
we must examine the limbs we hold, and be  assured that we have not mis-
taken a hand for a foot.   The feet being held firmly in the hand, must then
be brought with  a waving motion slowdy into the  pelvis.  While we are
withdrawing the hand, the waters of the amnion flow away, and the uterus
being somewhat emptied by the evacuation of these, and the extraction of
the inferior extremities, we must wait till it contracts, and  on the accession
of a pain the  feet must  be  brought  lower,  till they  are at  length cleared
through the os externum.
   The turning of  the child is accomplished during an interval of pain, the
feet being brought over the front of the child, and not over the back, which
would risk dislocation of the spine ;  and as  the feet are  drawn down, the
head will ascend.
   The extraction of the child is to be accomplished gradually during a pain,
and in drawing downwards we should be careful not to place the foetus in a
wrong position as  to the  pelvis.  Some advise us to leave the labor to nature,
after turning the child, but to this Dewees rightly objects.   He says: "The
whole act of turning  should  be considered as one of necessity rather  than
of choice ; therefore, where it is proper to commence with it, it is, we believe,
always proper to finish with it, and not trust the delivery  to the powers of
nature, after having brought the feet  into the vaerina, as  recommended  by
some."   The case is after this to be managed precisely as  a footling case. 
VERSION, OR  TURNING.
321
  530. Throughout the operation I have spoken of bringing down the feet;
it is now right that I should mention some modifications of this plan.
  Peu, Burton, and  Win.  Hunter recommended that the hips  should be
seized and brought to the brim of the pelvis.  The latter, in his MS. lectures,
says, speaking of arm presentations :  " In this case you are to introduce the
hand into the uterus, and gently put up the arm, and turn  the  child  to a
breech presentation.   Reduce it if possible to a perfect breech case, that it
may come more gradually,  on account  of the head and the navel-string, lest
you strangle the child.  If, however, you find  this impracticable,  let it come
footling,  but sustain the child at the  hips  as long as you can, they being,
next the head, the largest and most unyielding part." In Germany this  plan
has been advocated  by Schweighauser, Schmidt, and Betschler;  it is, how-
ever, seldom  or never tried.  The breech would  be more difficult to seize *
and bring down than the head, and we should (as in cephalic version) lose
all control over it,  after placing it in position.
   531. Again, it has been strongly advised  to hook down the knees instead
 of seizing the feet, by Burton, Delpech, and Breen.  In  this recommenda-
 tion, Dr. Burns seems to  coincide.  I shall quote Dr. Breen's own statement
 of its advantages.   " By this proceeding (hooking the finger in  the flexure
 of the knee) the child would be made  to revolve on the  lesser axis  of the
 trunk, and the foot would be brought into the vagina within  the  reach  of a
 noose.  By adopting a different procedure, and endeavoring to lay hold of a
 foot according to  the usual directions, it is  obvious that the hand of the
 operator must traverse a greater space of the uterus—a matter of very con-
 siderable difficulty, either when the action of that viscus  is strong, or when
 it is closely  contracted on the body of  the  child.   This difficulty being sur-
 mounted, when the foot is laid hold of, it is  very apt to slip, and recede  from
 the grasp, as well from the violence of uterine action, as from the  hand being
 cramped  and nearly powerless by reason  of the previous exertion.   By
 adhering to the  direction of booking the knee, the hand  of  the  operator is
 in a great measure protected during the pains, and he is enabled deliberately
 to proportion the force requisite to change  the position, to the resistance he
 encounters.   Besides, as the knees  must have been nearly in contact with
 the superior part of the  abdomen, from the earliest development of the ex-
 tremities of the embryo, should what may be called accidental circumstances
 have removed them  from this natural and usual position, but little force will
 be requisite to restore them to  it."1   Of course, should a foot be nearer the
 os uteri than a knee, Dr. Breen would advise its being seized.
    These reasons certainly appear of sufficient weight to justify the admission
  of Dr. Breen's suggestions,  as an improvement upon the  previous mode of
 turning.
    532. Lastly.  As it is not  always  easy to seize both feet, we are  told  by
  many writers not to be solicitous about the second, but  to  extract  by one
  alone.  The reason  given is simply to  avoid pain to the mother,  and to save
  the difficulty and trouble of seeking for a second.  A similar recommenda-
  tion has been given  by Dr.  Radford, of Manchester; but for very different,
  and, as far as my experience goes, for  very  valid reasons :—"The results of
  practice," he says, "prove what might be inferred by reasoning, that the
  child's life  is much more frequently preserved in those cases  in which it
  presents the breech, than where the feet come down first." " Is  there,  then,
  no practice which would  enable us to bring down  a part, approximating in
  its measurements to those of the breech presentation, which we have already
  stated to be so safe  to the child, but  which  cannot be  affected   in turning

               1 Edinburgh  Med. and Surg. Journal, vol. xiv. p. 29.
       21 
322
VERSION, OR TURNING.
operations ?  There is,—and this practice consists in nevkr bringing down
more than one  foot in the manual operation of turning a child."
  The following measurements were obtained from children born at the full
period of utero-gestation ; —
The circumference  of that portion of the head which
  presents in labor, is from.....12 to 13| inches.
Do.  of the breech, with the thighs flexed upon the abdo-
  men, as in breech presentations, from     .    .     .   12 to 13^  "
Do.  of the breech,  with one thigh turned upwards to-
  wards the abdomen, the other extended,  from   .     .   11 to 12j  "
Do.  of the hips,  the  legs extended  as in feet presenta-
  tions, from    ........10 to 11^  "
  It is evident  from these measurements, that it will  be safer for the child to
bring down  only one  foot, for inasmuch as the breech with the thigh turned
up is more bulky than the hip with  the  legs extended, by so much will the
passage be better prepared to admit the quick transit of the  child's  head,
upon which the safety of the infant depends.
  Dr. Simpson  recommends seizing one knee, and that the opposite to the
upper extremity which presents, i. e., if the right arm present, the left knee
is to be brought down.
  533.  From what  has been stated, it will appear that the difficulties of the
operation are almost entirely owing to the uterus being in action.  When
it is quiescent,  or nearly so, the  operation is easy; but when the contrac-
tions are violent, it is often tedious, difficult, and very painful, both for the
patient and  operator.  These contractions  equally impede the introduction
of the hand, the finding  of the feet, and the turning of the child.   Once so
much is accomplished, they become of valuable assistance in completing the
delivery.
  534. The danger  to the mother may arise — 1.   From the operator not
changing the direction of his hand, in accordance with the pelvic axes, and
consequently pushing his fingers through the vagina.
  2. The hand may be forced through the walls  of  the uterus, if too much
force be used in searching for the feet.
  3. The uterus may bruise itself against  the hand, or the  limbs of the
fcetus,  during the turning.
  4. Rupture of the cervix uteri may occur, either  during the introduction
of the hand or the extraction of the child, especially if the operation be
hurried or too  much force be used.
  5. Without  any evident injury, the irritation of the operation may give
rise  to subsequent inflammation.
  6. The nervous shock may be serious, or even fatal.
  The simple  enumeration of these dangers ought,  one would think,  to go
far  towards obviating most of them.
  535.  The danger to the child consists—1. In compression of the funis,
which commences about  the time the buttocks appear at the os externum.
After this time, if there  be much delay, the child will perish from the  inter-
rupted circulation, unless by chance the funis should have lodged in the angle
at the junction  of the os sacrum with the os ilium.   To obviate this danger,
it was proposed  by Pugh to introduce  a  pipe into the child's mouth, and
excite respiration, while  the head was yet in the vagina.  Bigelow and Bau-
delocque are said to have employed this in practice.
  2. If much extracting force be used, the spine may be dislocated ; the hips
also; and the leg has been pulled off.
  3. Compression of the head is enumerated by Dewees as one of the dan-
gers to which the fcetus  is exposed. 
THE VECTIS,  OR LEVER.
323
  536.  It only remains for me now to say a word as to the after treatment.
The patient will probably need an  anodyne after the operation, and it is
good practice to join  a  few grains of calomel with  the opium or Dover's
powder;  or a mixture containing sixty drops of landanum, two drachms of
sal volatile  in six ounces of camphor mixture, may be  ordered, of which a
table-spoonful may be taken every two or three hours.   It wdll be necessary
to exercise great watchfulness to detect the first inroads of inflammatory
action, which must  be met by antiphlogistics, according to the strength of
the patient, and the violence of the attack.
  Careful inquiry should  be made as to the character of the lochial discharge
each day, and if necessary the vagina be syringed with warm water.
  The most absolute quiet and rest are desirable.  If the infant  be alive,
the mother should not be teased with it for some hours.
                        C HAPTER XI.

      OBSTETRIC OPERATIONS. —3. THE  VECTIS, OR LEVER.

  537. So many claims have been put forth to the invention of this simple
instrument, that it  is not very easy  to trace it to its author.   It  has  been
ascribed to Celsus, to  Mauriceau,  to Schitling,  and to  Palfyn; but the
credit, as far as I can judge, belongs to  Henry Roonhuysen, from whom it
is extremely probable that Dr. Chamberlen obtained a knowledge of the
invention.  To others it was also communicated, but "for a consideration;"
and the matter was kept secret, until, in 1753, two Dutch practitioners, MM.
Jacobus de Yisscher and Hugo van der Poll, whose names  deserve  most
honorable mention, and more especially  as they did not practise midwifery,
conceived the  object of making public a  discovery which promised  such
valuable results.  They bought the secret for a large  sum of money (Baude-
locque says 5000 livres de France) of Gertrude de Bruyn, daughter of Jean
de Bruyn, and wife of Herman  van  der Heiden, and immediately published
an account of it in the Dutch language,  thus  terminating the secret history
of the vectis.
  I have not been able to ascertain that the Chamberlens imparted a know-
ledge of the vectis  to any practitioner in this  country, although at the time
of the publication  of Yisscher and Yan der Poll  the forceps was ordinarily
used in London.   Since then it  has  obtained more  or less  notice  in works
on midwifery, though it has been to a great extent superseded in practice
by the forceps.
  538.  In France, Mauriceau  invented  an instrument something  like the
vectis, for the purpose of extracting  the head when separated from  the body.
In 1715, Isaac de Bruas, and  in 1738, M. Rigaudeaux, constructed each  a
vectis, to meet the  difficulty of certain cases to which they were called.   In
1753, Warroquier,  of Lisle, used one blade of Smellie's forceps as a lever.
After the publication of  Yisscher and Yan der Poll, the instrument occu-
pied the attention of the profession,  who  were  much divided in opinion  as to
its merits.   At present it  is but slightly esteemed.
  539.  As it was  amongst the Dutch  the vectis originated,  so  do  they 
324
THE VECTIS,  OR  LEVER.
appear to have estimated it most highly, and cultivated it most successfully.
In addition  to  the  names of Henry and Robert Roonhuysen, I may men-
tion those of ^uysch, Boekelmann, De Bruyn, Plattmann, Boom, Rooy, De
Moor, Yisscher, and Yan der Poll;  of Titsing,  Palfyn, Berkmann, Yan de
Haar,  Stylcke, Jans, De Bree, De Bruas, Yan  Genns, Rathlaw, etc.   Yan
Swieten, in his Commentaries upon the Aphorisms of Boerhaave, published
in 1754, refers to the discovery of this instrument as a benefit conferred on
the human race.   He remarks :  " Quamvis autem egregii  viri, qui varios
forcipes invenerunt, aut perfecerunt,  omnem laudem mereantur, et ob indus-
triam  et  ob candorem, quo  sua inventa publico communicaverunt, tamen
videtur vectis ille  Roonhuysianus reliquis esse prseferendus."  The  cele-
brated Camper published a paper in 1774,  in which  he  advocated  the use
of the lever, and spoke highly of its advantages.   In  1794, Johannes Mulder
published a very learned and valuable history of the forceps and vectis.

             Fig. 112.                                   Fig. 113.
/

 r
■ tuiJl.-jUlll.
V
             I I  l(


          Roonhuysen's Vectis.                              Modern Vectis.

  540. The Yectis  of Roonhuysen is thus described by M. Preville, from
the memoir of Yisscher and Yan der Poll: " L'instrument de Roonhuisen
est un morceau long et quarre de fer bien forge, de lOf pouces de long et
large d'un pouce : son epaisseur sans etre garni est de £ d'un pouce, etetant
garni, de | d'un pouce.   Ce fer  est droit au milieu de la longueur de 4
pouces,  et se  conrbe insensiblement vers les extremites.   Ces courbures
sont a peu pres semblables, et etant mesurecs dans leur concavites elles ont
3 pouces £ de courbure  et  environ f de pouce de fond.  Ce  levier  de  fer
doit etre soigneusement  arrondi de tous cotees, et principalement aux  quatre
coins, afin qu'il ne puisse pas faire du mal lorsqu'on l'appuie.   C'est pour-
quoi les extremites des courbures, quoique bien arrondies, doivent etre gar-
 
THE VECTIS,  OR LEVER.                   325
nies d'un emplatre de diapalme edendu sur du gros linge de la longueur d'un
pouce en dedans ; le morceau droit du milieu situe entre les deux courbures,
et par lequel se fait la plus forte pression contre les os pubis, doit etre tout
a fait garni de  cet emplatre, et un peu plus fort au milieu.   II faut surtout
avoir attention que ces emplatres soient appliques fort egalement  sur  le fer,
sans le moindre pli.  Apres avoir garni le fer  de ces  emplatres, on le gar-
nit tout entier de peau de chien  mince et fort douce, et  il faut observer que
cette peau doit etre appliquee fort unie, et que les coutures de la peau  soient
dehors,  c'est a dire, du cote convexe de l'instrument."    It is added, "Nous
avous trouve une petite corde entortillee  autour d'un  des bouts de l'instru-
ment, dans l'endroit ou. la courbure est plus grande, comme on le voit meme
dans la figure; ce que nous croyons ne servir a autre chose, si non pour
marquer qu'on doit se  servir de ce cote plutot  que l'autre, ou pour mesurer
l'approche de  l'instrument."
  541.  Many  changes have been made in the  form of the  instrument and
in the  materials of which  it  is  formed.  Titsing padded  it wdth  wool;
Morand and Herbiniaux made it of ivory ; others of  wood, bone, or  silver.
"When the vectis was first known in this country," says Dr. Denman, "that
described  by Heister was preferred to those recommended by the surgeons of
Amsterdam.   The  vectis  used  by Dr. Cole was like  one blade of the for-
ceps, somewhat lengthened and enlarged.   That of Dr. Griffith was  of the
same kind, with a hinge between the handle and the blade ;  and that  of Dr.
Wathem was not unlike Palfyn's, but with  a flat handle and a hook  at the
extremity of the handle, which prevents  its slipping through the hand, and
might be occasionally used as a crotchet.  Many other changes have been
made in the  construction of  the instrument, but the vectis now generally
used is  of the  following dimensions : The whole length  of the instrument
before it is curved is 12^ inches.   The length of the blade before it is curved
is 7£ inches.   The length  of the blade when  curved is 6^ inches.   The
widest part of the blade is If inch.  The weight of the vectis is 6^ ounces.
The handle is  fixed in  wood.
  The one in  ordinary use is that described by Dr. Lowder, and improved
by Mr. Gaitskell, who says : " The vectis  should be thirteen inches in length,
one half to form the  handle, the  other  the curve.   The handle should be
made of hard  wood, rendered rough for  the purpose  of obtaining a  firmer
hold, and  made to screw on and off.   When the instrument is made  with a
hinge handle,  it is very difficult to introduce ;  therefore this construction of
the instrument should never be adopted."
  Mr. Ogden  has  given the description of an instrument which he  calls the
"tractor-vectis," and which is to  be  used  solely as an extractor.  It does
not differ  very much from the  lever in  the plate, except that the curve is
sharper, and the fenestrum so shaped as to secure a firm hold on the. chin or
occiput.  The  oblong diameter of the fenestrum is  lfths of an inch, and the
transverse l§4;h of an  inch.  The rim encircling this is of uniform thickness,
and |ths  of an inch wide.  It  is introduced posteriorly, and its  position
changed to the right or left, as may be desirable.1
  542.  The nature of the aid afforded by the vectis is threefold :—
  1.  To correct mal-positions, or aid the natural  rotations of the  head at
the brim, or in the cavity of the pelvis;  and to this the majority  of French
practitioners limit its employment.
  2.  As a lever of  the first or second kind, i. e., making a fulcrum  of the
pelvis, or of the left hand of the  operator external to the pelvis.  Its em-
ployment in the first  way is extremely  hazardous,  from the certainty of
crushing the soft structures lining the pelvis, and the probability of injuring
i Obstetric Record, Feb. 1st, 1849. 
326                  THE  VECTIS,  OR LEVER.
the urethra or the child's head.   Many authorities who employ and recom-
mend the lever, would altogether reject it, and I think justly, rather than so
use it.  This objection does not hold against the second mode, which is the
proper one, if it be employed as a lever at all.  The discoverers  and  first
possessors of the secret made the arch  of the pubis the fulcrum.   In order
to avoid the urethra, Boom, Boekelmann, and Titsing rested it upon the
ramus of the ischium.
  3.  As a tractor.—Dr. Burns  says: " It is unfortunately named, for it ought
not to be employed to wrench,  but to hook or draw down the head ; and its
proper  application would  be less  apt to be  mistaken were it called the
tractor."   This can only be done with the curved  vectis ; with the one used
by Roonhuysen no tractile power could be exerted.  When the force thus
employed is sufficient, it is by far the  safest  application of the instrument,
but I confess that I have not been successful in my trials with it.
  543. The cases suitable for the employment of the vectis appear to be the
following :
  1.  Before the head has  fully entered the upper outlet, when, either from
slight mal-position, or from very slight  narrowing, the uterine efforts are
ineffectual in advancing the labor.   Froriep advises it in cases of face  pre-
sentation, and after version, when the head is difficult to extract.
  2.  It was recommended  by its  early patrons in  cases where the  head has
become impacted in the pelvis : in  fact, it was considered as superseding in
a great measure the use of the  crotchet.  After the description I have given,
I need hardly say that it  is not merely powerless in  such cases, but very
likely to be injurious. Levret, and some other French writers, have admitted
its employment in some cases where the head  was rather tight in the passage
—to use their own words—on the point of being  " enclavee," but not when
impacted.
  I have hitherto deferred stating the  two principal conditions of its  em-
ployment, even  in  these cases, viz., the presence of labor pains, without
which there could not be a chance  of success ; and the dilatation of the os
uteri.
  3.  The case which appears to be most suitable for the use of this instru-
ment, and in which the probability of success is greatest, is  that  in which
the head, having descended into the pelvic cavity, is arrested in its progress,
not by any mechanical  impediment, but by the inefficiency (not absence) of
labor pains, and when the  patient is beginning to  show symptoms of consti-
tutional  or local disturbance.   This condition does not take place until the
second stage of  labor  has lasted some time, and as, after these symptoms
have  shown themselves, there is danger to the patient in further delay,  it is
importaint to obtain aid.  "In this most favorable presentation," says Dr.
Breen, "the uterine  action is- occasionally for hours  exerted  in vain, from
causes which we are frequently  unable to  account for.  Much  delay  may
excite, fears for the safety of the child, and lay the foundation of a tendency
to inflammation in some of the soft structures  of the  mother, indicated by
some one,  or several of the following symptoms; increased frequency or
fulness of the pulse ; tongue loaded in its centre ; secretion of urine dimin-
ished, and  becoming higher in color, sometimes  requiring to be drawn off
by the catheter;  countenance assuming an anxious aspect; stomach irrita-
ble ;  general increase of restlessness."
  Xow as there is supposed to be space enough, and pains, though feeble, a
slight additional force wdll  often succeed in  bringing  the infant into the
world at once.   As there is nothing in the nature of the operation to add
to the danger, and especially as the tractile force will probably be sufficient,
it seems  peculiarly  suitable to tip's case ; and I may add, that all the testi-
mony I can collect is in favor of its application. 
THE  VECTIS,  OR LEVER.
327
  4.  In cases of convulsions, or other accidents  occurring during parturi-
tion,  provided only that the pains  continue, the assistance of the lever may
be sufficient to terminate the labor.
  544. As to  the  time when the  instrument may be most advantageously
used, I  may adopt the words of Mr. Dease :  " It requires a certain degree
of cool  discernment, which I believe is  only acquired by long practice, to
know when a woman is still capable of assisting her labor, or when the head
is sufficiently low in the pelvis to use the extractor."  If the  object desired
be to aid the head  in passing  through the upper outlet  or  to rectify its
position there, it will be well to operate as soon as  the os uteri is dilated or
dilatable.
  When the  head is in the pelvis, it  is desirable  to have it as low down as
may be, as the operation is then much easier.  " Under these circumstances,"
says  31 r. Dease, "I think it best  to  examine the woman as she lies on her
side  : if the surgeon finds that  the head is sunk deep in the pelvis towards
the  sacrum, at least one  half, he  may apply the extractor: he should not
form his judgment of the descent of the head from examining  towards the
pubis;  for here, from the  shallowness of the pelvis, and the swelling  of the
scalp, he will be very apt to be deceived, and  imagine the head to be much
lower than it really is."
   In coining to a conclusion on this point, however, regard must be had to
the constitutional symptoms ; if these be urgent,  it would be unwise to  lose
time after the period at which the vectis may be  easily applied.
   The occurrence  of any of the accidental complications will  in each case
determine the period for  operating, according to the urgency of the symp-
toms.
   545.  I  regret much not  having any statistical results to submit,  but in
this, as in too many other cases, practitioners  seem to have concluded, that
as the instrument  is said to be  quite safe, it was  therefore useless to  record
the faets.
   De Bruyn is said to  have used it successfully  800  times in forty-two years.
MM. Titsing and  Berkmann used it 262  times  in twenty-four years,  and
saved eighty or ninety children in the hundred.
   Dr. Copeman has published twenty-four cases occurring  in his  private
practice.1  All the  mothers recovered well, and  twenty-four children were
saved.
   546.  As to the comparative results:  the alternative of the vectis  is the
forceps, and  their respective merits  have been  the subject of controversy
with most writers  who have treated of  them.   Upon  reading over the dif-
ferent sides of the question, it would seem that each writer has taken  up the
subject too  much  as a partisan.   To compare  their utility in certain cases,
 is little more than a waste of words ; as, for example,  where the pains have
ceased, or where compression is required to extricate the head of the child.
In such cases the vectis is of no use, and it would be highly reprehensible to
employ it.   But where there is room, and when the pains persist, there the
vectis, being sufficiently powerful, has  this signal  advantage,  that there is
but the one blade  to be introduced, and but the thickness of that one blade
added to the child's head.   It is possible that  the  single blade may be able
to act where the  bulk of two would render extraction  impossible.   These
appear  to me to  be the peculiar  advantages  of  the vectis, and therefore I
shall not detail the controversy more  fully, but refer to the works of Osborn,
Bland,  Denman, Camper,  Herbiniaux, Levret, Burns, Conquest, etc., etc.
   One point, however, I must notice, which has  been  urged in favor of the

          1 Records of Obstetric Consultation Practice, etc., p. 63, et seq. 
328
THE  VECTIS,  OR LEVER.
vectis — viz., the secrecy with which it may be used.   Now this I consider
a decided disadvantage.  I most fully agree with  the opinion of Dr. Osborn,
and shall make no apology for transcribing it at length, as  it applies forci-
bly to all midwifery operations: "In the first place I am  persuaded, that
if concealment in the use of the means intended for relief in laborious or dif-
ficult  labors be not permitted, but that the absolute necessity of such means
be  first established, and that every  practitioner be  obliged openly  and
avowedly to use  them,  we should never  again hear or read of one person
having  used the vectis  in 800 and another in 1200 cases (Yan  Swieten,
Camper, and Herbiniaux).   Nor shall we  again  hear of the great number
of women which  some practitioners are constantly boasting of having de-
livered ; for no man can attend a great number of women  in  labor, in the
manner he ought, in the way nature demands, or a conscientious  discharge
of his duty requires.  Nor do real difficulties occur so  often as to render it
possible to believe that  any man's life could afford such numbers of difficult
cases as are  stated in  the  printed accounts from  abroad.   As I  feel
thoroughly  convinced of the  propriety and  necessity of a  fair and candid
avowal  of the use of instruments, in every case of midwifery where they are
to be employed, so I must insist that their concealment cannot be justified
by any proper motive.   Such an open  avowal implies  a conviction in the
practitioner's mind of that irresistible necessity for their use that supersedes
every other consideration : it implies a consciousness of the rectitude of his
conduct, and  it implies a voluntary acceptance of the  consequences of the
operation, which ought  to make part of his professional duty : and it clearly
demonstrates  to  the satisfaction of the  patient  and her friends, that no
motive of convenience to himself could  urge him to an  operation which may
prove ruinous to his  own reputation  and interest.   Besides,  not to insist
upon that  responsibility from the operator, is to  deprive the patient of the
best and surest security against a precipitate performance of the operation.
If once the practitioner can rest assured that, let the  event of the case be
ever so unsuccessful, the injurious effects  of his operation will  be  buried in
eternal oblivion,  by blending the mischief arising  from  the indiscreet use of
instruments with the  natural consequences of labor,  he will certainly have
nothing to weigh against  the tempting  advantages of convenience or emolu-
ment to himself;  but while he is shortening the duration of the  most irksome
part of his  professional duty, the waiting upon a slow  and lingering labor,
he will  flatter himself that, by delivering, he is doing an acceptable service
to his patient, in shortening the duration of her sufferings."1
   547.  Method of operating.—Premising then that the case is one adapted
for the vectis, that there is space enough, that the os uteri is fully dilatable,
if not dilated, that there are pains,  and that the patient and her friends have
been  made acquainted with our intention, it next remains for us to consider
the method of using the instrument: —
   lstly.  As a lever, and,
   2dly. As a tractor.
   1.  As a lever. — The first point to be  decided  is, over what part the in-
strument is  to be applied; and here we have latitude enough.
   " Some," says Dr. Gooch, " apply it over the occiput; others behind the
ear, by which it has a bearing against  the prominence  of the  mastoid  pro-
cess,  and others against the chin.   The two first  are  perhaps the  best when
the head is high, as considerable force is required to  move it, which  may
be employed with more safety against  either the occiput or mastoid process
than  against the chin.   But when the head is low down, resting on the peri-
1 Essays on Midwifery, p. 144. 
THE VECTIS,  OR LEVER.
329
neum, less  force  will be necessary, and  the  vectis may  then  be applied
against the chin ;  but the instrument requires to be used with  great cau-
tion, lest the jaw should be injured."  De Bruyn applied it  over the mastoid
process;  Camper over the lower jaw;  Lowder on the forehead,  etc.,  etc.
  I have already pointed out the temptation to make the soft parts  of  the
mother the fulcrum, and the mischiefs which result.   As far as my judgment
extends, it would  seem that the vectis ought never to be  used as a lever of
the first class; even as one of the  second  class, much caution wdll be  neces-
sary.   "When an instrument  of this sort is used, it is proper to make  the
hand the fulcrum  on which it acts:  now if the  force required is  but  small,
this may certainly do  well enough, but where  great force is required,  this is
a very bad support;  besides, the bony parts of the pelvis lie so  convenient,
that we may rest  our instrument on any part  of it.   Yet we should  recol-
lect, that whatever part we  convert into a fulcrum, we injure more or less,
according to circumstances.   If we apply it over the symphysis pubis, we
press  upon the urethra;  or if in other situations, we shall  injure  the clitoris
 or vagina."1
   "The  injuries  inflicted, indeed," Dr. Ramsbotham observes, "must have
 been frequent and great — and this led Peu, in 1772, to  suggest the  possi-
 bility of delivering by the vectis, without making a fulcrum of the mother's
 structures.  He proposed a practice, which is  now sometimes adopted, of
 grasping the shank of the instrument with the left hand—the outer edge of
 the little  finger being applied towards the vulva — making that hand  the
 fulcrum, and  pressing the  extremity of the blade on the child's head, by
 raising the handle firmly on the right."2

                                 Fig.  114.
Application of Vectis.
  Having determined on what part  of  the  infant the lever is to be applied,
the instrument is to be well  warmed,  greased, or soaped, and the patient

 1 London Practice of Midwifery, p. 208.
 2 Lectures in Medical Gazette, 31st May, 1834, p.  307.  See also Baudelocque, vol.
ii. p. 47. 
330
THE  VECTIS, OR LEVER.
placed in the usual position  for delivery, on her left  side ;  the  operator is
to introduce one or two fingers of his left hand to serve as a director for the
vectis, which is to be carefully and gently passed over the convexity of the
child's head, until it has  reached the point to which  the force  is to be
applied.
   This attained,  the  handle  should now be held firmly with the right hand,
while the  index and  middle  finger of the left, fixed about two inches from
the screw part, wdthin the vagina, become  a fulcrum.   On this  fulcrum, or
point.of support, the instrument is  made to move from the sacro-iliac sym-
physis towrards the hollow of the ilium, by the action of the right hand on
the handle.   In this way it describes the section of a circle, and glides on
to the occiput.  Should the occiput point to the right ilium, the left hand
must  be employed ; if to the left ilium, the right hand must be used.  When
a pain takes  place, the accoucheur should gently aid it by drawing down in
the axis of the pelvis.  In this  way the occiput is depressed, while the chin
approaches  the child's breast, and the head is reduced to the smallest com-
pass,  and is thus  enabled to pass through the cavity of the pelvis.  As  soon
as the occiput is brought so low as to press on the perineum, the instrument
should be withdrawn, and reintroduced with the  usual precautions.   The
object now in view is to place  the instrument over the face of the child.  To
effect this, the hand must be passed up, as at first  directed, to the right or
left sacro-iliac symphysis, according to the situation of the  face.  When the
instrument gets above the brim of the pelvis, a finger or two  must be in-
serted by the side of the  instrument, and  pressed on till it passes over the
forehead on to the face, so as to  embrace  the chin.  The  practitioner has
now nothing to do but to draw down during the time of pain, increasing the
power according  to the degree of resistance.1
   Or if we  prefer it, the right hand, grasping the handle, may be made the
fulcrum, and the  force applied by the left hand at the junction of the blade
and handle, directing it downwards and backwards until the descent of the
head is accomplished.  If  the instrument should slip, a fresh purchase must
be obtained.   As the head passes over the perineum, the efforts may be re-
laxed ; and if the  pains appear sufficient, it may be withdrawn altogether,
and the termination left to nature.
   2.  As a tractor. —The preliminary steps, introduction, etc., are the same
as when it is used as a lever; but  instead of making use of one hand as a
fulcrum, both hands are  employed in  the  one  office of maintaining a firm
purchase, and drawing downwards and a little backwards during the pains.
The  effort is to be relaxed during an interval; and this alternation of trac-
tion and rest is to be continued until the head has descended to  the inferior
outlet.  As before, it  may be  allowed to pass  over the perineum without
assistance, if the pains be  adequate to  its expulsion.
   548. There  is, I believe, no  danger to the  mother or child when the
vectis is in skilful hands, but in those of the ignorant or inexperienced great
mischief may be  done.
   1.  It may be introduced before the os uteri is dilatable; of this error, con-
tusion, laceration, and death may be the consequences.
   2.  By an  incautious mode of passing the instrument, the parietes of the
uterus may be ruptured.
   3.  By employing the extracting power, without bearing in mind the differ-
ent axes of the pelvis, and the position of the foetal head in relation to those
 axes, the lever will be inefficient, and the mother injured.
   4.  By  passing the instrument outside of the uterus instead of  within its
cavity, a fatal wound may be inflicted.

          1  Gaitskell, London Medical Repository, November, 1823, p. 380. 
THE  FORCEPS.                        331
  5.  By exerting  the power without regard to the pains, the operation will
be in vain.
  6.  By making a fulcrum of the soft parts of the mother, much injury may
result.
  7.  By exerting  too much force as the head passes over the perineum, or
neglecting to support it, you may tear the perineum,  so as to lay the genital
fissure open  to the anus.
  8.  By making too much pressure wdth the point of the instrument upon the
part  of the child to which it is applied, a wound may be inflicted.
  549.  The  subsequent treatment varies very little from that required after
ordinary labor; there is very little shock, and no injury,  if the operation be
skilfully performed.  The  parts  should, however,  be carefully  examined,
and,  if necessary, a spirit lotion  applied.  The same treatment  should be
applied to the  head of the child, if  the instrument have  bruised the integu-
ments.
                       CHAPTER  XII.

         OBSTETRIC  OPERATIONS. —4. THE  FORCEPS.

  550.  It will be at once admitted, I believe, that the greatest triumph of
surgery is to diminish  the frequency of  operations, and to substitute those
of minor severity and danger for others involving more serious risk.   If this
be true, then it must be granted that the invention of the forceps, and their
employment  in practice, is one of the greatest improvements recorded  in
the annals of operative midwifery.   Before the introduction of this instru-
ment, the only extracting force at command was obtained by the insertion
of a  hook into the head of the child; such as is now used in the operation
of craniotomy.
  This proceeding must of course have been fatal to the child in an immense
majority of cases,  and the very few  who were  born  alive,  must have been
subsequently endangered by the mutilating process employed in the delivery.
But  this  was not all;  every man  possessing  common feelings of humanity
must have shrunk from the painful necessity of such a proceeding, and have
deferred  the operation as long as  possible,  by  which the danger to the
mother was  greatly increased.   Now, from  this double  risk and fearful
mortality we have been relieved by the invention of the forceps ; for although
we are still obliged to destroy the child occasionally, to secure the safety of
the mother, yet this class of cases is incomparably smaller than that in which,
by the timely application  of  the forceps, both the child and mother escape
injury.
  For these reasons, I conceive that I am justified  in stating that the in-
vention and employment of this instrument is one of the greatest improve-
ments that has ever occurred in  midwifery, even though I  may not go the
length of certain of its advocates, in asserting that  it is  entirely  without
danger to the mother  or her infant.
  551.  It cannot be said that the  ancients were altogether ignorant of this 
332
THE FORCEPS.
method of extracting the infant, although  it does not appear to have been
generally  known.  Mulder, in his valuable  work, gives the following extract
from a translation of the works of Avicenna : " Oportet ut inveniat obste-
trix possibilitatem hujusmodi fcetus, quare  subtilietur in  cxtractione ejus
paulatim;  tunc si valet illud in eo, bene est; et si  non liget eum cum mar-
gine panni et trahat cum subtilitur valde  cum quibusdam  attractionibus.
Quod si illud non confert administrentur  forcipes, et attrahatur cum  eis;
si vero uon confert illud extrahatur cum incisione, secundum quod facile fit,
et regatur regimine fcetus mortui."   This  very distinct allusion to the for-
ceps seems to have made  no impression, for we find  no similar attempt to
extract the child until the middle of the sixteenth  century ; at which time
(1554)  Rueff recommended an instrument  resembling a pair of lithotomy
forceps, for the purpose of extracting dead children, or of supplying a de-
ficiency of manual force.  It does not appear, however, that he appreciated
the value  of  the forceps as  subsequently employed, nor did  his contempo-
raries carry out his suggestion, for it was not until a century later that the
instrument was brought into  practice.  Before  the time of the  Chamber-
lens, it was unknown in England, and even at the time that Dr. Hugh Cham-
berien published his  translation of Mauriceau, in 1672, it was still a secret.
No allusion to such an  instrument is to be found in Raynalde's work (1634),
norin the translations of Portal (1705), Deventer (1716), or La Motte (1745).
  552.  In his preface to the translation of Mauriceau, to which I have re-
ferred, Dr. Hugh Chamberien, after mentioning the  method  of extracting
the child by hooks, observed : " But I can neither approve of that practice,
nor of those delays,  beyond  twenty-four hours, because my father, brother,
and myself (though  none else in Europe, as I know) have, by God's bless-
ing, and our industry,  attained to,  and long practised a  way to  deliver
women in this case without any prejudice to them or their infants ; though all
others (being obliged, for want  of such an expedient, to use the common
way)  do and must endanger, if not  destroy, one or both, with hooks.  By
this manual  operation, a labor may be despatched (in  the  least  difficulty)
with fewer pains  and sooner, to the great  advantage and without danger,
both of woman and child ;  if, therefore, the use of hooks by physicians and
chirurgeons be condemned (without thereto necessitated through some mon-
strous birth), we can much less approve of  a midwife using them, as  some
here in  England  boast  they  do, which rash  presumption in France  would
call them in question for their lives."
  This  extract,  however, does not  fix the date of the invention by Dr.
Chamberien,  nor  have we any very accurate data  for doing so.  Through
the kindness  of a friend, I possess a pamphlet (A Yoice in Rharaa) by Dr. j
Peter Chamberien, published  in 1647, in  which  he speaks of his father's
(Dr.  Paul Chamberien) discovery  for the saving of infantile  life.   This 4
would fix the date of the  discovery some time  before 1647.   Of the  sons,
Drs. Peter and Hugh Chamberien  are the only ones whose names are fami- -,$
liar to us.
  From some vagueness of expression in  the extract I have quoted from
Dr. Hugh  Chamberlen's preface, it was even doubted whether the instra-M
ment alluded to was  the forceps, but that doubt has been set at rest by Mr.
Cansardine, who  has published  an account  of the discovery of  Chamber-
len's  own  instruments.  " The  estate of Woodman  Mortimer Hall, near
Maldou, in Essex, was purchased by Dr. Peter Chamberien, some time pre-
vious  to 1683, and continued in his family till about 1715, when it was sold
by Hope Chamberien to William  Alexander, wine-merchant, etc."   In an
old chest,  found in one  of the chambers of this  house, certain obstetric in-
struments were discovered,  along  with "old coins, trinkets,  gloves, fagj|

                                                                    ■3m 
THE  FORCEPS.
333
Bpectacles," etc., and were presented to Mr. Cansardine, who thus describes
them: "First, we have  a simple vectis, with an  open fenestrum; then we
have the idea of uniting two of these instruments by a joint, which  makes
each blade seem as a fulcrum to the other, instead of making a fulcrum of
the soft parts of the mother ;  and which also unites a power of drawing
the head forward.  This idea  is at first by a pivot, which being riveted,
makes the  instrument totally incapable of application.   Then he goes  to
work again, and having made a notch  in each vectis for the joint, he fixes
a pivot in one only, which projecting, is to be received into a corresponding
hole in the  other blade, after they have been applied separately.   It may
be observed, that although there is a worm to a projecting part of the  pivot,
yet there is no corresponding female screw in the hole which is to receive
it.   Every  practical accoucheur will  know, that  it  is not easy, or always
possible, to lock the joint of the forceps with such accuracy as to bring this
pivot and  hole  into  opposite contact.  This Chamberien soon discovered,
and next produced a more light and manageable  instrument, which instead
of  uniting by a pivot, he passes a tape through the two holes, and winds it
round the joint, which  method  combines sufficient accuracy of contact, se-
curity, and mobility."1
   There can now be no doubt of the credit  of the invention being due  to
Dr. Paul Chamberien, and I have proved that it took place before the year
 1647.  The secret was, however, carefully preserved, nor had it been  com-
municated in  the year 1716, for in Dr.  Hugh Chamberlen's third edition  of
Mauriceau, published in that year, the passage I have quoted is continued
in the preface.
   ["The accompanying cut is taken from a drawing of the most perfect  of
 Chamberlen's instruments.  No. 1 is the forceps  locked : a, the blades;  b,
the handles;  c, the hole in the joint, through which is passed the string  to
connect the blades.
   " No. 2, the front view of a single blade : a, the fenestra; b, the groove
in the shanks forming  the lock, by which the  two blades, perfectly similar
in form, are adapted to each other; c, the handle.

                                Fig. 115.
                          Chamberlen's Forceps.

"The following are the dimensions:  extreme length, eleven inches and a
 "  length of blades, seven inches and a quarter;  of  handle, four inches

       1 Mr. Cansardine's paper, in Med. Chir. Trans., vol. ix. p. 183. 
334
THE  FORCEPS.
and a quarter; greatest width between the blades, three inches and three-
eighths ; width between the blades at the points, three-fourths  of an iuch;
greatest breadth of the blade, one inch and a half."1]
  About this time,  or  soon after, the secret appears  to  have been commu-
nicated to  one or two, for Dr. R. W. Johnson, when speaking of the for-
ceps, says :  "Besides these, I have a pair  of forceps, wdiich  did belong to
the late Mr. Drinkwater (late Surgeon and Manmidwife  at Brentford), who
began practice in 1668, and died in 1728.  The size and form  of this  pair
agree with those of Chapman and  Giffard, save only that the hooks of the
handle are turned outwards."
  And  Mr. Chapman, in 1733, published a description  and a  plate of the
instrument,  which  he had used from 1726, stating it to be  the instrument
used by the Chamberlens ; but without stating whence he procured it.  I
have not succeeded in discovering from whom  he received it, though from
his not claiming the merit of the invention, it is evident that  it was com-
municated to him.  He has,  however, the great credit of being the  first in
these countries who  published an  account  of it for  the benefit  of the
profession.
Fig. 116.                           Fig. 117.
                                                Long Forceps.

  After this period, the forceps is  described and recommended for various
cases by almost all  British writers.

  1 [Appendix to Dr. Ramsbotham's Principles and Practice of Obstet. Med. and Surg.] 
THE  FORCEPS.
335
  553.  The credit of first introducing this instrument into French practice
is due to Palfyn or Gilles le Doux of Ypres.   One of the first persons who
used it was M. Duse, whose  example was  followed  by Mesnard, Gregoire,
Levret, Coutouly, etc.
  The earliest German practitioner who made use  of the forceps appears
to have been Cornelius Yan Solingen in 1673 ;  he was followed  by Slevogt,
Yelsen, Schlichting, etc.
  554. The original instrument has been variously  modified  according  to
the fancy of different practitioners.
  The chief peculiarities may be pointed out in a few words.
  1. The most striking variation observable, is in the length of the instru-
ment— some  being sixteen  or  eighteen inches long (fig. 117), and others
only eleven (fig.  116).   The object of the greater length is evidently to
enable us to act before the head has descended into the pelvis.  The shorter
forceps can only be used  when  the head is in the cavity.   The longer  in-
strument possesses greater lever power,  and requires greater skill  and care
in its management.
   2. There is a considerable difference  in  the  distance between the blades
of different forceps when closed —some being nearly wide enough to admit
an ordinary sized head, whilst others  approximate very closely.   These  in-
struments must  necessarily possess a very different  degree of force ;  with
the latter, the  head may be powerfully grasped  and compressed,  and a great
extracting force exerted,  whereas the former can do  little more than extract
with moderate force, when the resistance is not great.  The latter  are the
more useful in skilful hands, but the  former  are perhaps safer  for  ordi-
nary use.
   3.  To some of the instruments a second curve is added, the convexity of
which is intended to correspond to the hollowr of the sacrum, and  the con-
cavity to the symphysis pubis, in  order that the instrument may be applied
in the axis of the cavity  and upper outlet.   The second curve ("  curvatura
nova," as Mulder calls it) had  been added both to  the long and short for-
ceps.  I do not believe that it  is advantageous in either kind ; in  the latter
it is often very inconvenient.   It is far better to have both these instruments
perfectly straight, the diversity of curves  recommended by different writers
answering no useful purpose.
   4. The fenestrum varies in length and  breadth in  different  forceps; in
some it is altogether absent,  and in others it is very wdde.   The  object of
the latter modification is to avoid as much as possible adding to the bulk
of  the child's head, and to diminish the risk of injury  to  mother and child.
 I doubt whether the object be attained  by this arrangement,  and  when the
forceps are introduced antero-posteriorly, the additional breadth  of the blade
 which is underneath the  arch of the  pubis, may prove very mischievous to
 the sides of the outlet.
   5. In other forceps the breadth of the  blade is continued  to the handle,
for the purpose  of containing  an opening, through which the  other blade
 (which is slightly narrower) is  passed, so as to insure their apposition.
   6. Certain contrivances have been  added to  the handles  of the instru-
ment, to prevent their being pressed too closely together; and in  some for-
ceps the blades do not cross, in order to avoid compressing the child's head.
   7.  The blades have  been wrapped  with  leather, to prevent injury to  the
scalp of the child.   This plan is now very properly  abandoned, as it could
not be of any use, and rather added to  the difficulty of introduction.   The
blades have also been covered with  gutta percha; and Dr. Shekleton in-
forms me that it facilitates the  introduction, and he thinks it in several ways
an improvement. 
336
THE  FORCEPS.
  8. Mr. Radford has altered the long forceps, and, as he states, with great
advantage.  The blade, which is to  be  applied over the  occiput, is much
shorter than the other, so that when  it touches  the neck, the other (owing
to the  oblique  position in which the head descends) will embrace a great
extent of the anterior part  of the  head.   He has  also lessened the com-
pressing power of the instrument, by  placing the joint nearer the outer end
of the forceps.
  9. Dr. Davis, of  University College, London, has  shown much ingenuity
in varying the forceps, so as to meet the different circumstances in which they
are  required.
  10.  Dr. Bond has proposed an arrangement of the joint of the forceps,
by which they  are  permitted a rocking motion upon  each other without
diminishing the power of the  instrument.  The handles are Siebold's, and
the  blades Dr. Davis's, but the  lock is Dr. Bond's invention.1  I cannot
speak of  the value  of the invention,  but I do not  admire the form  of the
blades.
  In London, a modification of Levret's forceps is used for the higher ope-
ration, and Smellie's for the cavity of the  pelvis.  In Edinburgh, both the

            Fig. 118.                                   Fig. 119.
           Radford's Forceps.                            Churchill's Forceps.

long and short forceps are employed, with the single  or double  curve.  In
Dublin, the long forceps is rarely used, and the short one resembles Smellie's,
without the second curvature.   In  France, Levret's forceps,  or  a modifica-
tion of it, is in general  use.   In  Germany, the forceps  of Boer, Levret,

             1 American Journal of Med. Science, July, 1850, p. 70.
 
THE  FORCEPS.
337
Schmidt,  Stark, Siebold, Brtinninghausen, Naegele, Osiander,  etc. ; and  in
Italy, the forceps of Levret or Assilini are employed.
  Since the first edition  of this  work, I  have taken some pains to modify
the shape and proportions of the short forceps,  and from the  testimony of
many practitioners,  I think I may say that I have  succeeded in improving
the  instrument, although the alterations are but slight (fig. 119).   I still
prefer the single curved forceps.   The length should be 12 inches, of which
the handles occupy  4.  The interval between the points of the blades when
closed should be 1 inch, and at the widest part of the  curve  3 inches.   The
breadth of each blade at the widest part should be  1 inch, the  fenestrum 2^
or 3  inches long,  having the lower  part of the blade solid steel, to give
greater firmness.  The  curve  of the instrument should not commence for
fully 3| inches above  the handle, and will  consequently be much increased
towards the point.  Lastly, the edges of the blades and  fenestra must be
nicely bevelled off.  The advantages I have found  from these changes are
an increase of tractile power, without the necessity of  grasping the  handles
so tightly, and compressing the head ; the  exact fitting of the head into the
hollow formed by the curves, so as to avoid  distending the  perineum by a
part  of the instrument not actually of use,  and the  prevention  of springing
and slipping by the  solidity of the lower part of the blades.
  The hand that is  to use the instrument  is, however,  of more importance
than the  instrument  itself, of which it maybe observed with truth, that "that
which is best administered is best."
  555. The object of the operation with the  forceps is,
  1.  To  facilitate delivery, when its progress  is  arrested by certain mal-
positions of the head, at the brim, or in  the cavity  of the pelvis.
  2.  To  supply the  want of uterine  action, or to render it effective  for the
expulsion of the child.
  3.  To  save the mother from the  evil  consequences  of a  labor too pro-
longed, and from the necessity of a severer operation.
  4.  To save the  life of the child, or at  least afford it a chance of escape
from certain destruction.
  That these objects are  attainable will,  I trust, appear from the nature of
the aid afforded by the forceps, and that  they have  been in  many instances
attained,  the statistics of the operation  will  prove.  It was not for some
time  after the invention of the instrument that its  powers, and the  limita-
tions of those powers, were understood.   The story of Chamberlen's Paris
adventure is a good  illustration.   He visited Paris, and offered to  deliver
any patient the faculty chose, with his instrument; they gave him a case of
distorted  pelvis ; he tried, and  of  course  failed, and  left the city in disgrace.
Had  he carefully studied  the cases to which the  instrument was applicable,
he would have been  spared the annoyance.
  It  is evident that  the forceps possesses  a  twofold power.
  1.  That of grasping and compressing the head of the child.
  2.  That of acting as a lever of the first kind,  and as an extractor.
  The compression  exercised by it must  be limited fVithin the  degree the
head  can  bear without injury, and may be limited by the form of the instru-
ment.  The extracting force will  be  in  proportion  to  the firmness of the
grasp, and limited by the resistance, and the danger  of injury to the  mother.
Xow it is ascertained, that if there be space sufficient,  such a grasp may be
obtained of the child's head, without injury to it, as  will enable us to extract
it, and that the extracting force thus  exercised is not sufficient to injure the
mother; thus the  forces  may supply the want of uterine pains.
  Many cases occur  in which the transverse diameter of the child's  head is
slightly greater than  the  antero-posterior  diameter of the brim, or the trans-
      22 
338
THE  FORCFTS.
verse diameter of the lower outlet;  but where a slight additional compres-
sion would  enable it to pass :  now, if this  do not exceed the amount of
compression which the head will  safely bear, and  if the force required for
extraction be not sufficient to injure the mother, such compression and ex-
tracting power may be afforded by the forceps, which will  thus render the
uterine  action effective.  No doubt it requires great tact and long expe-
rience to decide upon the probability of success, but we have high authority
for the propriety of the attempt in  such cases.  To those who lack expe-
rience, the failure of a very cautious effort will be a sufficient evidence of
its impracticability, and with ordinary care no  mischief will be done.
  Lastly, in  most cases where the head is not impacted, a sufficient grasp
may almost  always be obtained,  either at the upper outlet  or in the cavity,
to enable us to change the position of the child.
  556.  Statistics. — I trust I have made it appear, from the nature of the
aid afforded, that  the  first and  second objects of the operation are attain-
able; how far this is the case with the third and fourth must be  shown by
statistics.  But before I give the results of the operation to the mother and
child, it may be well to ascertain the  average frequency of its occurrence.
For these purposes, I have searched all the records  within my reach, and
the result is the following Tables : —
FREQUENCY  OF  THE  OPERATION.

     a.  Among  British Practitioners.
Date.	Authors.		Total No. of Cases.	No. of Forceps Cases.	References.
1781 1787 to 1793 1818 1825 to 1833 1828 1829 1826 to 1833 1834 to 1837 1838 1840 1836 to 1840 1849 { 1820 to 1827 1842 to 1844	Dr. Bland Dr. Jos. Clarke Dr. Merriman Dr. Granville Ed. Lying-in Hospital Dr. S. Cusack a Dr. Collins Dr. Beatty Mr. Lever Mr. Warrington a Mr. Mantell . Dr. Churchill . Drs. M'Clintock andl Hardy . . j Dr. Ramsbotham . Dr. Murphy Dr. Stoker Dr. Reid Mr. Earle Dr. Toogood . Dr. Adams Dr. Pagan Mr. J. Thompson, Kil- •» marnock . . j Drs. Johnson and Sin-1 clair ... j Dr. Hall Davis		1897 10,387 2947 640 2452 398 303 16,414 1182 4666 88 110 2410 1640 6634 68,435 467 451 5691 4320 1135 628 8684 3300 13,748 7302	12 14 21 5 15 1 3 24 9 9 1 3 6 3 18 112 4 8 31 32 15 14 82 46 200 6	Merrinnm's. Trans, of Assoc, vol. 1. Synopsis. Report of West Disp. Reports. Dublin Hosp. Rep., vol. 5. Ibid. Prac. Treat, on Midwif. Dublin Jour., vols. 8, 12. Guy's Hospital Reports. Amer. Med. Journal. Ibid. Ibid. I Researches, etc. Pract. Obs., p. 95. Obst. Med., p. 720 Rept. of Univ. Col. Hos. Amer. Jour., Oct. 1851. Ranking, vol. 4. Prov. Jour., June, 1846. Ibid., vol. 8, p. 103. Ranking, vol. 4. Glasgow Jour. July, 1853. Glas. M. Jour.,July, 1855. Pract. Mid., p. 163. DiflFt. Parturition, p. 271.
 
             THE  FORCEPS.


b.  Among French and Italian Practitioners.
339
Date.		Authors.	Total No. of Cases.	No. of ?orceps Cases.	References.
1	1797 to 1809	Mad. Boivin .	20,517	96	Memorial, p. 337.
1803 to 1811		Mad. Lachapelle .	22,243	174	Pract. des Accouch.
	1808	M. Ramboux .	216	2	Velpeau.
	1815 to 1828	M. Pigeotte de Troyes	1,362	2	"
	1819	M. Papavoine .	24	1	"
	1829	Hotel Dieu, Paris .	280-	1	"
	1830, 1831	Sig. Ciniselli .	94	1	"
	1834 to 1843	Dr. de Belli	2,739	62	Ranking, vol. 4, p. 184.
	c. Among German Practitioners.				
	Date.	Authors.	Total No. of Cases.	No. of Forceps Cases.	References.
	1801 to 1807	M. Ritcher, Moscow	3,195	49	Velpeau.
	1811 to 1827	f Moschner and Kursak, \ Prague	1 12,329	120	Siebold's Jour., vol. 9.
		M. Boer, Vienna	. 29,961	119	Arneth, p. 134.
		M. Klein .	. 35,417	730	Ibid., p. 135.
		M. Bartsch	4,425	61	Ibid.
		Prof. Schwerer	. 21,804	194	Ranking, vol. 5.
	1812 to 1813	C. v. Siebold, Wurtzbur	g. 318	26	Siebold's Jl., vol. 1 to 3.
	1817 to 1826	" Berlin	1,634	212	Ibid., vols. 3 to 8.
	1827 to 1829	E. v. Siebold, Berlin	491	77	Ibid., vols. 9 to 11.
	1829 to 1833	" Marburg	344	34	Ibid., vols. 10 to 13.
	1834 to 1837	" Gb'ttingen	507	37	Ibid., vols. 15 and 16.
	1825 to 1827	Dr. Kilian, Prague .	2,350	120	Velpeau.
	1808 to 1814	Dr. Henne, Copenhager	i . 555	1	Siebold's Journal, vol. 2.
	1826	a it	130	4	Ibid., vol. 8.
	1821 to 1825	Dr. Riecke	. 219,303	344	Velpeau.
	1819,1820	Dr. Ritgen, Giesen .	180	20	Siebold's Journal, vol. 6.
	1825	Dr. Merrem, Cologne	142	5	Ibid., vol. 7.
	1814 to 1827	Dr. Carus, Dresden .	2,908	184	Ibid., vol. 9.
		Dr. Naegele, Heidelbei	g. 1,411	22	Velpeau.
	1825, 26, 27,	Dr. Kluge, Berlin .	809	55	Siebold's Jour.vols. 7,8,9.
	1825, 1826	Prof. Andr6e, Breslau	351	8	Ibid., vols. 7, 8.
	1825. 26, 27,	Dr. Brunatti, Dantzic	284	22	Ibid., vols. 7, 9.
	1825, 1826	Dr. Theys, Trier	49	3	Ibid., vols 7,8.
	1826	Dr. Voigtel, Magdeber	g.. 29	3	Ibid., vol. 8.
	1827,1828	Dr. Kiistner, Breslau	370	8	Ibid., vols. 9,10.
	1830, 31, 32,	Dr. Adelmann, Fulda	170	7	Ibid., vol. 14.
	1797 to 1837	Dr. Jansen, Ghent .	. 13,365	341	Med. Gazette, March 6, 1840. Schmidt's Jahr-biicher.
	1847 to 1849	Dr. Arneth, Vienna .	6,608	45	Die Geburtsh. Praxis, p. 92. Med. Times and Gazette,
	1821 to 1842	Dr. Ricker, Nassau .	. 304,150	4223	
					Oct. 11, 1856.
  Thus among British practitioners we  find 594 forceps cases  in  147,645
cases of labor, or about 1 in 249.
  Among the French, we have 339  forceps cases in 47,475 labor cases, or
about 1 in 140.
  And among the Germans, 7074 forceps cases in 755,593 labor cases, or
about 1 in 106^. 
340
THE  FORCEPS.
  If we add the whole together, we find 8007 forceps cases in 850,713 cases
of labor,  or about 1 in 106^.

          RESULTS OF THE OPERATION TO  MOTHER AND CHILD.
Authors.
Dr. Smellie
Mr. Perfect
Dr. Jos. Clarke .
Dr. Merriman   .
Dr. Granville
Dr. Ramsbotham
Edinburgh Lying-in Hospital
Dr. Maunsell
Dr. Beatty, sen .
Dr. Gooch  ....
Dr. Ashwell
Mr. Warrington .
Dr. R. Lee .
Dr. Collins ....
Dr. Thos. Beatty
Dr. Churchill   .
Drs.  Hardy and M'Clintock
Dr. F. Ramsbotham .
Dr. Murphy
Dr. Pagan  ....
Dr. Roberton
Dr. Storer  ....
Mr. J. Thompson
Drs.  Johnston  and Sinclair
Mad. Boivin
Mad. Lachapelle
Dr. Boer   ....
Dr. Siebold....
Dr. Ritgen ....
Dr. Andre'e ....
Dr. Brunatti
Dr. Voigtel ....
Dr. Kiistner
Dr. Adelmann  .
Prof. Schwerer .
Dr. Arneth ....
Dr. Ricker ....
 Number of
Forceps Cases.
  52
  18
  14
  21
   5
 140
  15
   4
 111
   6
   6
   1
  42
  24
   8
   9
  18
  73
   4
  82
  43
   8
  46
 200
  96
  79
  19
 312
  20
   8
  23
   3
   8
   7
 194
  45
4223
Mother lost.
     0
     1
     4
Not stated.
     0
     0
     1
Not stated.
     0
     3
     4
     0
     0
     5
     3
     0
     9
     0
     0
     0
     11
Not stated.
     14
     2
     11
     3
     1
     1
     0
     2
     1
     7
     7
     93
Children lost.
     9
     4
Not stated.
     6
Not stated.

     5
     1
     0
     0
     3
     0
     31
     8
     5
     0
     8
     17
     1
     19
 29
 20
 23
  5
 47
  4
  4
  6
  0
  1
  1
 48
 14
684
  Now if we add together the number of forceps cases where the result to
the mothers is stated, we shall  find, that of those detailed  by British prac-
titioners, of  812 forceps cases,  38 mothers were lost, or 1 in 21£.
  Amongst the French and Germans, in 4941 cases, 142 mothers were lost,
or about 1 in 34.
  Whilst of  the children, the British statistics give 142 lost in 694 cases, or
about  1 in 5 ;  and foreign statistics 858 in 5037 cases, or about 1 in 5£.
  The total  result is, that in 5753 forceps cases, ISO  mothers were lost, or
about  1 in 32;  and in 5731 cases,  998 children were born dead, or about 1
in 5.
  To those who, like myself, regard the wider employment of the forceps as
the best mode of diminishing the frequency of the employment of  crani-
otomy, it is a  matter of rejoicing  to  find this instrument increasingly em-
ployed, and that with each  enlargement of our statistics, the death-rate for
mother and child has diminished. 
THE  FORCEPS.
341
  I am unable to explain the greater proportional frequency of operations
in  some of the German reports, except by supposing  that  their hospitals,
being on a small scale,  are reserved for the worst cases met with in extern
practice among the poor.  Were I quite sure of this being  the case, how-
ever, I  should have omitted  them from Table I., as they would then  mani-
festly be an unfair record of  the  proportional frequency of the operation.
  It would be unjust to compare the frequency of  forceps cases  among the
Germans and British,  without  recollecting the  minor  degree of  mortality
amongst  the  children  in  the  practice  of  the former,  and the very much
smaller number of crotchet cases.   It would seem, that although the Ger-
mans use the forceps much more frequently than we do, they often thereby
avoid a much more fatal operation.
   The  rate of mortality exhibited by the last Table is undoubtedly an over-
estimate, as many of the deaths included in it  were unconnected wdth the
operation ;  but as  this is not stated, except by a few  authorities, though
probably equally true of all, I have preferred quoting the  numbers  given,
and appending this note.
   If it were possible to  collect a sufficient  number of cases from  private
practice, I have no doubt that our estimate of the value of the forceps would
be at once truer and much more  favorable.  For  example, Dr. Beatty's cases
in the foregoing table  occurred  chiefly in private  or consultation practice,
and we find that in 111 cases he lost neither  mother nor child.
   Mr.  Crosse used  the forceps  in 23 cases; the mothers all recovered : 7
children were still-born, and 3 died soon  after birth.
   I can add to these 65  operations either in consultation or in my private
practice ; out of these 2 mothers died subsequently of puerperal fever, which
was epidemic at the time; in both  the  operation was  extremely easy and
quick.   All the children were saved but six :  of these  one  was  putrid, one
had the funis prolapsed, one occurred in a case of  convulsions, two breathed
but soon sank, and one was dead-born.
   It is greatly to be regretted, that the statistics of the result of the opera-
tion to the mother and child are so limited.   Many writers  who have care-
fully recorded the number of operations,  have very carefully omitted to state
whether the mother  recovered,  or the child was saved, leaving us to make
the inference that both were saved.   But we know that such an  inference
would be incorrect.   Can any one believe, that whilst  British practitioners
lose one woman in twenty-one,  Mad. Boivin and M. Baudelocque lost none
at all ?  I have, therefore, omitted or marked in the latter Table, all those
who have neglected to  state the  results.
   [In a very elaborate paper on " the  more frequent use of  the Forceps  as
a means of lessening both maternal and fcetal mortality, by Mr. Philip H.
Harper, read before the Obstetrical Society of London, June 1st, 1859, the
author has  endeavored to show, and we think  that he has succeeded in  so
doing,  that there is no  especial  maternal risk which necessarily attaches  to
the use of the forceps, and that the various injuries and other ill effects which
are usually attributed  to them,  are not the result of their use, but of their
abuse.   That when maternal death occurs after their use, it is generally the
result of the length  of time  the labor has lasted  before their application.
That so long as they are  applied as the last resort in tedious labors, so long
will the maternal mortality after  their  use  appear to be very high.   The
author of the paper shows from the only statistics which furnish the neces-
sary data, that one mother in twenty-two, and one  child in five died in cases
of unassisted tedious labor, whilst  one  mother in  fifty-six and one child  in
8.4 died where the  forceps  were used, and  one  mother in ten  died after
craniotomy.   Showing that the maternal  risk is  less after the use of the
forceps than after craniotomy or even unassisted tedious labor. 
342
THE  FORCEPS.
  The author endeavors also to prove that we may safely avail ourselves of
the power of these instruments as compressors within certain limits, if they
are used early and properly applied.   That  there are  a  large  number of
tedious labors, from abnormal  or diseased action of the uterus itself, where
they are most valuable, and where they ought to be most freely used, and
that the period for their use is early in labor, as soon indeed as the os per-
mits, and long before the maternal system has begun to suffer, either locally
or generally.1]
   557.  If  we  fail in  our endeavors  to extract  the infant with the forceps,
we have no resource but to employ the perforator and crotchet; and, there-
fore, in estimating the utility of the forceps,  we  must  also compare it with
its alternative operation, inasmuch as every successful case of the former
may be considered as so much  gained from the latter.
   Now, in craniotomy all the children are destroyed, and one in five  of the
mothers is lost; whereas  we have seen, that by the forceps we save four out
of five of the children, and twenty out of twenty-one of the mothers.   If we
had more  minute reports, the  success  would  undoubtedly  appear  much
greater.
   558.  The special advantages of the forceps are said to be :
   1.  That they are easily applied.
   2. That  their powers  are calculated to attain the object for which they
are used.
   3. That they do this by imitating the natural  powers.
   4. That they aid the expulsive efforts of the uterus better than any other
instrument, and supply their place, which  no  other instrument can.
   5. That they are less liable  to slip than the vectis.
   6. That they are attended with less fatal consequences than the perforator
and crotchet.
   On the other hand, those writers who have defended the use of the vectis,
as compared with the forceps, have enumerated several disadvantages  of the
latter — such as,
   559. 1.  The  difficulty  of their application  in  all cases, and in some, the
impossibility  of using them, owing to the position  of  the head or want of
space.
   That the introduction  of two  blades  may be  more difficult than that of
one, in certain cases, is very evident, but that there is much greater difficulty
in  introducing  the forceps than the vectis, in the majority of cases proper
for its use,  I do not believe.   The latter  part of the  objection  is of no force,
because those cases where the  introduction of the instrument is impractica-
ble are not cases in which its employment is contemplated, and, undoubtedly,
if the impaction were so great  as to prevent the  application of the forceps, it
would more surely render the vectis impotent.
   2. The risk of  bruising the  os uteri in the  application of the forceps.
   I do not think  that there  is much  risk, if the operator be a competent
person.   Dilatation or dilatability of the os uteri being an essential  condi-
tion of the operation, the supposition would  involve great want of skill and
care in the operator.
   3. That  when the forceps are applied,  they are apt to  slip and lose their
hold.
   This may sometimes happen, but it is  much more likely to occur with the
 vectis.
    4. That the pressure upon the child's  head may destroy life.
   No doubt; but as the pressure is regulated by the resistance, this ought
never to happen, except in cases  in which the  crochet must otherwise  be
used, and in which the vectis would be powerless.

     1 [See Transactions of the Obstetrical Society of London, vol. i., 1860, p. 142.] 
THE  FORCEPS.
343
  5. That by adding to the volume of the head, they are apt to lacerate the
perineum.
  That the compression exercised upon the head of the child is amply suffi-
cient to compensate for the additional bulk  of the blades, there can be no
doubt, even in those cases where the extraction is most easy ; but we have
an additional safeguard in the removal of one of the blades just before the
head passes over the perineum.
  6. That as they can never be used secretly, they have a tendency to alarm
and intimidate the patient, and in this respect are inferior to the vectis.
  When speaking of the vectis, I mention its secret employment among its
disadvantages ; and I now quote this objection, for the purpose of entering
once more my earnest protest  against the employment of any instrument
secretly.
  [The  forceps  and vectis are calculated for different cases.  Under some
circumstances one, and under some the other is to be preferred.   When the
object is merely to change the position of the head, to facilitate its rotation,
or to apply a very moderate  degree of extractive force, the vectis answers
very well; but whenever much traction is necessary, or the head is high up
in the pelvis, it is nearly useless.]
   560. Having now given  the  history of the operation, stated  its objects,
and shown that they are attainable, from the nature  of the aid afforded, and
from numerical calculation ;  and, having  enumerated the positive and com-
parative advantages of the operation, with the objections that have at differ-
ent times  been made to the  use  of the instrument,  I shall next proceed  to
mention the cases to which the forceps has been considered applicable.   I
would wish, however, that it should be remembered, that as I am not writ-
ing the history of my own  experience  only, but that of others, so I am not
to be considered as necessarily the advocate of the forceps in all these cases.
 I have selected them from authors of the highest authority, and their evi-
dence is altogether  independent of support from me.
   I must  also  premise, that in  no cases is the forceps (or, indeed, any in-
strument) to be applied, until  we are perfectly satisfied that the obstacle
cannot be overcome by the natural powers, with safety to the mother and
child.   This limits the operation in one direction :  the other limit is deter-
mined by the impossibility  of extracting the child without laceration  or
serious contusion of the soft parts in the pelvis, as this would involve great
injury and peril  to the mother without saving the child, as the compression
 involved would almost certainly destroy it.   As  a general rule,  if  the child
 be dead, craniotomy is preferable to the forceps.
   1. When the  head is unable to enter the brim of the pelvis from  mal-
 position (suppose wdth its long diameter corresponding to the antero-posterior
 diameter of the  upper outlet), which is not  rectified by the pains, the long
 forceps may be applied to change the position, provided the os uteri be fully
 dilatable,  and  that the change cannot be made  by the hand alone.
   2. When the head is in the upper outlet, fitting closely,  but not impacted,
 and the pains are inadequate to overcome the resistance, a little help with
 the forceps, applied laterally or obliquely, will often overcome the difficulty.
   3. When the  head, presenting at the brim, is somewhat too large for the
 antero-posterior diameter of the pelvis, if the excess be not more than may
 be remedied by the allowable degree of compression, the  operation may be
 successful.  It will require some experience  to ascertain this, before a  trial,
 and great skill and  care in making the trial, but as the alternative is turning
 or the crotchet, it is surely worth while to make a cautious attempt with the
 forceps, from which  no harm need result in case of  failure.
   In all these cases it will  be necessary to use the  long forceps ;  in the fol-
lowing the shorter are sufficient, but, of course, either may be employed. 
344
THE  FORCEPS.
  4. When the head is in the cavity of the pelvis, and is there detained by
want of space, if the compression required for its extraction be not greater
than the head of the child will bear with safety, and the violence  to the soft
parts of the mother in extraction be not  such as necessayily to injure her,
the forceps may  be  safely used, either laterally, obliquely, or antero-poste-
riorly.   Siebold is said to have been able to reduce the transverse diameter
of the head of the child six lines  with Levret's forceps ; Osiander, nearly an
inch ; Baudelocque, four and a half lines ;  Thouret and Yelpeau,  five or six
lines ; and Flamant, five and a half lines.  Of course the amount will be in
inverse proportion to the degree  of ossification.
  5. In face  presentations, the  longest diameters of the  child's head are
brought to bear upon the pelvis,  adding greatly to the difficulty of its transit
through the lower outlet, even when the pelvis is large, and  still  more if it
be under the average dimensions.   In such cases, aid may often be given by
the forceps, so as to save the child's life,  and to mitigate  the suffering and
its  consequences  to  the mother.   It is not, however, to  be  assumed,  that
because the child descends faceling, assistance will be necessary;  the majo-
rity are delivered by the natural efforts.
  6. The  same observations apply to certain,  though more rare cases,  when
the forehead is turned  towards the symphysis  pubis.
  7. But  the utility of the forceps is seen more  clearly in those cases in
which the  pains, at  first very strong, have gradually declined  so  as to be
nearly or altogether powerless,  but not from the resistance occasioned by a
narrow  pelvis.  There may be sufficient space,  the os uteri and external  parts
well dilated, and  yet the labor does not advance.   In  such  a case, the second
stage cannot be  very  much  prolonged without certain  symptoms arising,
indicative of danger to the  mother; and here we are able  to relieve her
without difficulty or risk, and to save the  child (if it  be alive) by the timely
use of the forceps.   In such cases (and every  one must have met with them)
I think  I may say, that the operation adds absolutely nothing to the danger
either to mother  or child.
  8. When the hand or arm descends with the head, the additional bulk will
require  more expulsive force, and occasionally, aid must be afforded by the
forceps.
  9. In some cases of  convulsions, hemorrhage, and rupture of the uterus,
where the  head is wdthin reach,  the  forceps  are found extremely useful in
expediting the delivery.
   10. In certain  cases of breech presentation, it is very  difficult  to extract
the head after the body is expelled, either from mal-position,  or  from the
incompressibility  of the base of the skull; in these cases the difficulty may
be removed or overcome by the forceps.
  11. The forceps may be used after vaginal hysterotomy or symphyseotomy.
  12. In prolapse of the  funis, when it is an  object to hasten the labor, in
order to save the child.  The pulsation of the cord will  show whether the
operation affords a chance.
  561.  These are, I believe, all the  cases in  which the forceps have been
used or recommended  by high authority ; to  complete the subject, I  may
mention certain cases in which they ought not to be employed.
  1. In distortion of the  pelvis,  or when  its calibre is diminished  from any
cause, such  as tumors,  exostosis,  etc., if the narrowing of the pelvis be too
great to admit of the passage of the child's head,  when  moderately com-
pressed  ; these cases can only be terminated  by the perforator,  or hyste-
rotomy.
  2. When the os uteri is rigid and undilatable, or when the passages are
much inflamed and swollen, the forceps ought not to  be used.
  3. In some cases, where the  patient has been mismanaged, and allowed 
THE  FORCEPS.
345
to remain too long, the system is in such a state that we are obliged to have
recourse to the most expeditious mode of delivery.   In these cases, if there
be a strong doubt of success with the forceps, it may be wiser to  have re-
course to the  perforator, more especially as, in  such cases, the child is gene-
rally dead.  But such cases could  scarcely happen under the care of a well-
educated practitioner, nor are they at all frequent.
  4. If the child be dead, we are  advised to prefer craniotomy.  If  we are
quite certain that the child is dead, the  principal objection against crani-
otomy is removed, and the operation  is easier  and  safer than  the  forceps;
but this is not always easy to determine.   The stethoscope is a most valu-
able source of information;  but it must be remembered, that while  its posi-
tive evidence  is unquestionable, the negative evidence (i. e., no  sign being
audible) is not equally conclusive.   Dr. Collins, whose experience has been
very extensive, remarks : "I  know of no case where the advantage derived
from the use of the stethoscope is more fully demonstrated than in the infor-
mation it enables us to arrive at, with regard to  the life or death of the
fetus, in the  progress of tedious and difficult labors."
   562.  We next come to consider the period for operating.   "It is  one of
the nicest points  in practice, correctly to decide,  whether any given case of
protracted labor may be trusted with safety to the further exertions of the
natural agents, or whether the means of art ought to be  promptly brought
to their assistance.   In determining  this important  question, the whole of
the symptoms are to be collectively and severally considered, and their differ-
ent tendencies accurately examined, that we may equally escape the impu-
tation  of haste and  indiscretion  on the one hand, and  of delay and inde-
cision on  the other; yet, let us ever bear in mind, that  more  injury may
 possibly accrue from too long delay, than arise from premature assistance."1
   The decision of this point must, in a great  measure, be left to the judg-
 ment and experience of the practitioner.   No very definite rule can  be laid
 down :  we find both individuals and nations differing upon the subject;  the
 Germans operate more frequently, and at  an earlier period than the British,
 but on the other hand, they have fewer crotchet cases.  And  I think it must
 be admitted that until lately we have been too much  afraid of the forceps,
 and have allowed cases to become the subjects of craniotomy, which, at an
 earlier period, might have been safely delivered by the forceps.
   In forming our decision, there are  several points for consideration  :
   1. The local circumstances of the  case, such as the position of the head,
 space  in the pelvis, complications,  etc.;  these  constitute  the principal
 grounds of necessity for the  operation, and have been enumerated.
   2. The general condition of the patient, and the presence or absence of
 the symptoms  of a prolonged second  stage;  if  present,  their  amount,
 urgency, rapidity of development, etc.
   Our great  object in the use of the forceps is  to anticipate these formidable
 symptoms, and to rescue the patient from  the danger.  I think, then, that
 as regards the mother we may conclude :
   1. That as these  formidable symptoms are not consequent  upon a pro-
 longed first  stage,  therefore, before  the completion  of the first stage of a
 labor,  that is, before the os uteri is perfectly dilated, and the  membranes
 broken,  the  use  of  the forceps cannot properly come into  contemplation.
 But I would remark, that when the obstacle is at the upper outlet, the
 second stage virtually commences when the os uteri is fully dilatable, as the
 head cannot  pass through it, and  the usual symptoms may arise if  the labor
 be sufficiently prolonged.
   2. That when  the second stage has lasted so long as to  prove the inade-

         1 Ramsbotham's Practical Observations on Midwifery, vol. i. p. 256. 
346
THE  FORCEPS.
quacy of the natural powers, or at all events, so soon as the symptoms of a
prolonged  second stage make their appearance  (quick pulse, dry tongue,
fever, etc.), then we ought promptly to interfere.   "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 their
application before the forceps  are applied, though the pains should have
altogether  ceased during that  time."   The symptoms, however, are a surer
guide than the duration  of the labor merely; some patients will show more
signs of suffering after six hours, than others  after twelve or  sixteen.  Dr.
Collins  observes : " Let  it be carefully recollected, at the same time, that so
long as the head advances ever  so slowly, the patient's pulse continues good,
the abdomen free from pain on pressure, and no obstruction to the removal
of the urine, interference should not be attempted, unless the child be dead."
With great respect, I think this rule defective : to a certain extent it is true,
but it is not the whole truth, for there  are many cases which continue exactly
in this state until powerless labor sets in,  and  in which, from  the character
of the labor,  it may be  certainly foreseen that these  symptoms will arise,
and that the woman will not previously deliver  herself.   In  all such cases I
would maintain that the  forceps should be  used so  soon as we feel justified
in coming  to that conclusion.
   3. The life  of the child is a very important element for our consideration.
After the second stage  has lasted a certain  time, there is considerable risk
to the child, and it  may  even die before the symptoms on the part of the
mother  become very formidable, though this is  not generally the case.  This
condition may sometimes be detected  by the stethoscope, the  action of the
heart becoming feeble and irregular.  In such a case, if no counter-indication
existed, it  would  be our  bounden duty to interfere for the purpose  of saving
the child's  life, provided  the operation were practicable.
                                 Fig. 120.
Operation with Long Forceps.
  563. Method of operating.—WThen  once we have determined upon the
propriety of operating, the operation itself is not very difficult; it requires
B.:/A 
THE  forceps.
347
a thorough tactile knowledge  of  the pelvis, some manual dexterity, and
steadiness.   I shall first describe the  application of the long forceps at the
brim, and then (the long or short forceps) in the cavity of the pelvis.
  I.  The long forceps. — These  may be applied  either in the transverse,
oblique, or antero-posterior diameter of the pelvis.  If our object be com-
pression or a change  of the position, the antero-posterior diameter (fig.
120) will be the best; but  if necessary they may  be applied  in the trans-
verse, or still better in  the oblique, diameter (fig. 121) of the brim.   In this
position, as there is more space, their application is more easy; but it must
be remembered, that in proportion to the grasp  we take of the head in its
longitudinal  diameter, we  diminish  that diameter, but increase the trans-
verse, and so may  add  to the difficulty of the descent of the head.   There-
fore, only sufficient force should be used to enable us to extract.   "When
about to apply the long forceps, it is to  be remembered that the  difficulty
exists at the brim  of the pelvis, that  the antero-posterior diameter, or that
from the symphysis pubis to the promontory  of  the sacrum, is diminished;
iu the application  of the instruments, therefore, care  should be taken that
they be placed over the head, in such a situation that  they may occupy the
most  roomy part  of the pelvis, which will be  its lateral  diameter.   In a
 natural presentation and situation, one blade of the instrument wdll conse-
 quently be  placed over  the forehead, the  other over the occiput."1   Dr.
 Simpson considers the oblique diameter as the best, and  indeed  the only
 proper situation in which to apply the long forceps, at the brim,2 as in the
 accompanying plate.   (Fig. 121.)
Fig. 121.
                          Operation with Long Forceps.

  The patient is to be placed on her left side (or on her back), close to the
edge of the  bed; the forceps, warmed and oiled, are to  be  within reach,

       1 Waller's edition of Denman, p. 279, note.
       2 Proceedings of Edinburgh Obstetric Society, Seventh Session, p. 17. 
348
THE  FORCEPS.
and the operator should introduce two or three fingers  of his left hand, or
his whole hand, during  an interval  of pain, along the head of the child
within the os uteri, for the purpose of protecting it, and guiding  the  blade
of the forceps.   The upper or anterior blade is then to be passed along the
inside of the fingers or hand, in the axis  of the upper outlet, until it glides
over the part of the head to which we wish to  apply  it.   It  is then to be
retained in  situ by an  assistant, and the hand or fingers withdrawn ; the
right hand (or two fingers) is next to  be introduced  on the  opposite side,
and the second blade passed carefully up, and applied to the  head.   If the
blades have been  properly placed, they will  lock ;  but if  not, one must be
withdrawn, and reintroduced.  When locked, the handles may be  tied toge-
ther or grasped  firmly,  and the extracting  force  applied, of which 1 shall
speak presently.
   The most  important  points to remember  in  the application of the long
forceps are:—
   1. To guard the os uteri with one hand.
   2. To introduce the upper or anterior blade first.
   3. To pass the blades in the axis of the upper outlet.
   4. To regulate the force of the grasp, according to the  circumstances of
the case.
   564.  II.  The short forceps.—These may be passed  in accordance with
the transverse, oblique, or  antero-posterior diameters of the pelvis.  In
many cases it is impossible to introduce them laterally, but it  is always pos-
sible, and  in my opinion by far the best way, to  introduce the first blade
under the arch of the pubis, and then give it an oblique  position ; introducing
the second or posterior blade opposite to it, which is  not difficult.   Thus

                                 Fig. 122.
Operation with Short Forceps.
applied we shall be quite  as able to extract, but we must  bear in mind the
observation made when speaking of the long forceps, that pressure in the
long diameter of the child's head increases its lateral or transverse diameter,
and so far augments the difficulty of its extraction.
  The bladder and rectum should be evacuated before the attempt is made,
and  the  forceps warmed  and oiled, as already mentioned.   The  patient  is
then to be placed near the edge of  the bed, and after a careful examination, 
THE  FORCEPS.
349
our decision formed as to the part to which the instrument is to be applied.
One or two fingers  are  then to be introduced into the vagina, during an
interval of pain, to guide the forceps and protect the soft parts.
  We  must always be careful that "the point  of the instrument be con-
stantly kept in  contact with the  head;  to effect which, it wdll be necessary
to remember that the child's head  is in every part convex, and, therefore,
as the instrument  advances, the  handle  must be raised, or otherwise in its
progress  it may pass on, instead of going under, the os uteri, if any part
should remain in contact with the child's head."1
   The forceps must be introduced at first in the axis of the lower outlet, but
this direction must  be almost immediately changed into  that of the upper
outlet, or there  will be danger of wounding the posterior wall of the vagina.
The upper  or anterior blade should be introduced first, and then the lower
or posterior one.   When both are applied, they ought to be opposite, and
if so,  will easily lock ; but if, on endeavoring to  lock  the forceps, it  should
be found that they  do not  readily come  together, they have not  been pro-
perly introduced : no force or violence should be used to bring them toge-
ther,  but the  second blade  should be  withdrawn, and introduced  afresh.
Great care  must also be taken that the soft parts, or hair, are not included
in the lock, as  this  wdll give great pain.   The lower part of the handles
may be tied together by a ligature, so as  to determine the force of the  grasp,
which has this advantage, that it  fixes the degree of compression, and leaves
the operator at liberty to occupy himself with the extraction only.  If, how-
ever,  the head fit tightly,' and more compression than merely that which is
sufficient for extraction  be  necessary, it  will be useless; the operator must
then regulate the compression with his hand, and extract at the same time.
" When the forceps are first  locked, they are placed far backward, with  the
lock close to, or just within, the internal surface of the perineum ; and they
can have no support  backwards  except  the very little which is afforded by
the soft  parts.   The first  action with them should therefore be made by
bringing the handles, grasped firmly in one or both hands, to prevent  the
instrument  from playing upon the head of the child, slowly towards  the
pubes, till they come to a  full rest.   Having waited  a short interval with
them in this situation, the  handles  must be carried back in the same slow
but  steady manner to the  perineum,  exerting, as they are carried  in  the
different directions,  a certain degree of extracting  force ; and after waiting
another interval, they are again to be raised towards the  pubes, aceording
to the situation of the handles."2  We must remember "that the force em-
ployed in extracting the head be always and  steadily from  blade to blade,
but with intervals resembling the labor pains, and constantly in the direction
of the axis of the pelvis, till the occiput begins  to emerge from  under  the
arch of the pubis, when the handles are to be  raised over the  symphysis
pubis with  the right hand,  while the left is applied to strengthen and  pre-
serve the perineum."3   I believe  that the facility of extraction  depends very
much in drawing the  head  well down in  the axis of the lower outlet, in  the
first instance, and then carrying it well forward under the pubic arch, and
this, whether the forceps be applied laterally or obliquely.  The whole power
or force wdiich  the  instrument enables us to use  ought not to  be exerted in
the first  instance, but such  a degree as any individual  case may require,
which  can  only  be  known  by first  trying a moderate degree of force,
increasing it slowly and deliberately, according to the exigence of each case.
   When we thus employ the power we possess  gradually, steadily, at inter-
vals, and in the direction of the axes of the pelvis,  we must not forget  the
danger (in some cases at least)  from pressure  or contusion.   Our guide  in
   1 Osborn, Essays on Parturition, p. 99.        2 Denman's Introduction, p. 281.
   3 Osborn, Essays on Parturition, p. 100. 
350                        THE  FORCEPS.
this matter is the pulse, which  rapidly rises if injury be inflicted.  " If the
pulse be 120 or  130  before you commence  operations, it is clear that you
cannot, from counting the beats, take  an intimation whether the soft  parts
have or have not sustained injury ; but if, before the forceps be applied, the
pulse is under 100 in the minute, then should contusion be produced by your
efforts with  the  instrument, the rise of the pulse will  indicate it.    Alter
every effort wdth the  forceps, therefore, count, waiting  two or three minutes,
so as to allow the beats to subside after muscular exertion, and  count com-
pletely round the circle.  If you find it below 100, no serious injury has
been inflicted ; if the frequency is increasing, although it  does  not  neces-
sarily follow that serious injury has been inflicted,  yet  the existence of con-
tusion becomes probable, and further  efforts must not be made without much
consideration."1
   When our efforts have been  so  far successful, that the occiput emerges
from the lower outlet, if there be pains, it is better to remove one blade (the
posterior one, when they are  applied antero-posteriorly) of the  forceps, to
lessen the risk of laceration, and the  perineum should be carefully supported
by an assistant, whilst the operator uses the other blade as  a tractor, if ne-
cessary.   If the  head be high up in the pelvis, we must  take care that the
usual half-turn be made as it descends,  so as to bring the face into the hollow
of the sacrum.
   In breech  cases, when the head is detained, the  operation is not very dif-
ferent ; the blades are to be passed up antero-posteriorly, or laterally, and
locked across the chin, or back of the head, and the extracting force applied,
gently, firmly, and at intervals, not  forgetting the natural turns, so as to
bring the face into the hollow of the sacrum, if possible.
   565.  Difficulties. — " The  difficulty of applying the forceps," says Dr.
Denman, "is most frequently occasioned by attempting to  apply them too
soon:  or passing them in a wrong direction ; or by entangling the soft
parts of the mother between the instrument and the head of the child, against
all which accidents we are to be on our guard."
   1. The first difficulty we meet with  is in the introduction of the blades.
There  may not be space enough, and if  we  find this to be the case, after a
fair  and careful trial,  we are not to persist at the risk of injury to the mother,
but  craniotomy must be performed.
   When the  head is pressed down  against  the tuberosities of the ischia,
there will often be difficulty in passing the blades between them;  and if the
head cannot be raised up during an interval  of pain, the forceps had  better
be applied  antero-posteriorly, or both  blades being introduced posteriorly,
we may gradually slip them to either side.  I do not  speak of the difficulty
of applying  the  forceps when  the  os uteri is rigid, because it should never
be attempted.
   2. As I  have already mentioned, there may be  some difficulty in locking
the blades, and then one of them must be withdrawn  and reintroduced.  It
is quite possible to deliver the child without locking the blades, but there is
more chance of injury,  and the instrument is more apt to slip.
   3. The extraction  may be difficult, or even impossible.  The great value
of experience in  such cases is, that it teaches us how far we may carry our
efforts without injury.   Perhaps a little more compression, or a  little  more
force, may  crown our efforts with success, provided that it  did  not  exceed
safe limits.   But great care and caution will be necessary, and if we find
our efforts fruitless after a fair trial, we shall  then  be justified in having re-
course to the  perforator, nor will the patient be  the worse  for the  failure
with the forceps,  if the attempt have been judiciously made.
1 Blundell's Principles and Practice of Obstetricy, p. 505. 
THE  FORCEPS.
351
  566.  The principal dangers to the mother are :
  1.  In the introduction of the blades, if it be not  effected in the axis of
the upper  outlet, the vaginal  parietes may be lacerated, and if the cervix
uteri be not guarded by the hand, the blade may be pushed  through it, or
it may be included between the end of the blade and the child's head.  Cases
of mal-practice illustrative of these dangers might easily be quoted, but it
is sufficient for my purpose to allude to them as a caution.
  2.  The soft parts in the pelvis may be bruised or lacerated in the extraction;
  3.  The perineum  may be lacerated.
  The  dangers to the child arise :
  1.  From want of care in introducing the blades, by which the scalp may
be bruised or torn, or an ear cut off.
  2.  From excessive compression, by  which the skull  may be indented, the
bones fractured, or death from pressure induced.
  Dr. Blundell  has  given a distressing picture of the  accidents which may
result from an  incautious  or maladroit use of the forceps.
  " The grand  error you  are  apt to commit in using the long forceps, is
force.  In violent hands, the long forceps is a tremendous instrument; force
kills the child, force bruises the softer parts, force  occasions mortification,
force breaks open the neck of the bladder, force crushes the nerves ; beware
of force, therefore, arte non vi.   Other errors, too, there are, against which
I beseech you to guard..  You may use the forceps without heed ;  you may
try to use it  when the parts are rigid,  and the os uteri not fully expanded;
you may attempt to apply it without knowing the position of the head ; you
may oscillate  the instrument too extensively from side to side ;  you may
draw without intermission, instead of imitating the pains ; you may close
the handles too forcibly by the  hand or ligature ; you may hurry the head
through the  outlet;  you may neglect to throw the face towards  the sacrum ;
you may forget the  perineum ;  you may fail  to conduct the head, when it
emerges, towards the abdomen and mons, by drawing it too much upon the
perineum."
  567. After-treatment. —The first symptom which will require our  atten-
tion, is the shock caused  by the operation.  If it be  great,  a  combination
of opium with ammonia wdll be found the best remedy, with wine and water
in moderate  quantity.  If it  be not severe, perfect  quiet will be sufficient,
and the subsequent management is the same as after ordinary delivery, with
increased caution, however, and  daily attention to the state of the vagina.
If there be any soreness  or inflammation, warm water injections should  be
used twice a day.
  568. It is  right here  to notice some instruments which have been proposed
as substitutes for the forceps.   1. Dr. Conquest many years  ago proposed
one,  consisting  of a loop  of thin whalebone, fastened into  a wooden handle.
The  loop is easily introduced, and placed over  the occiput or chin, and he
supposes that sufficient  extracting force may then be exerted.  When placed
over the chin, it may, perhaps;  but on trial, I found that  over the occiput
it had no purchase, but slipped immediately.
  2.  Dr. Simpson has  invented  a "sucker-tractor,"  consisting  of  a cup of
vulcanized India-rubber, which is to be applied  over the child's head, or a
portion of it, and to which is attached a  syringe, for exhausting  the air.
He has succeeded several times, without  injury to the child, but as yet he
does not consider the instrument complete.  No doubt enormous force may
be exerted by it, and if it do not injure  the  child, it is certainly very safe
for the mother.
  3.  Dr. Evans, of  Chicago, U. S., has contrived an instrument consisting
of a band, wdth network and strings, which is to surround the forehead, and 
352
THE  FORCEPS.
embrace the head firmly, so as to allow of tractile  force being exerted.   It
is applied by two steel rods (something in the way that the ligature  is car-
ried around  a polypus  by Gooch's  canula),  which are afterwards joined
together.1
  It is  an ingenious instrument, but whether likely to supersede the forceps
in any case, I cannot tell.
  [Although  Dr.  Churchill avows  his preference for "the  long or short
forceps  wdth the single  curve," etc., he appears in reality not  to be at all
tenacious  on  the  subject  of  its  construction.   " The hand," he remarks,
"that is to use the instrument is  of more importance than the instrument
itself, of which it may be observed with  truth, that 'that  which is best ad-
ministered is  best.'"  In  this expression, we believe  that he  inculcates a
serious error.
  A prudent  and well-qualified operator, it is true, may not  do harm with
a bad instrument, but, on  the other hand, he may be  unable  to  accomplish
any good with it," in  cases where, with a better constructed  one, he would
succeed without difficulty.
  "I have  repeatedly," says Dr. Huston,  in a note to a former edition,
"seen gentlemen of large experience in the art, completely  foiled in attempt-
ing to  grasp  the head  at  the upper strait, wdth a forceps having only the
single curve, although when an instrument differently constructed was placed
in their hands  they accomplished it very readily ; and I have myself delivered,
successfully for both mother and child, under the same circumstances, with a
long double-curved  forceps, after others had failed with  one  without the
second curve,  or of insufficient length."
  If the use of the forceps is to be confined to cases in which the head has
descended  into the cavity of the pelvis, resting on the perineum or protru-
ding at the os externum vaginae, then, indeed, "the hand  that is to use the
instrument is of more importance than the instrument itself;" nor is it  of
much importance  what  hand it  is,  if guided by  the  common  feelings  of
humanity, so simple and  easy is the operation.   But when  it is important to
hasten the delivery while the head remains above the upper strait, or is still
engaged in it, as in convulsions, hemorrhage,  some cases of prolapse of the
funis, aneurism, inability of the female, from  feebleness, to sustain  longer
the natural parturient efforts, or when it is required to overcome contrac-
tion of  the brim to a degree not so  great as to demand the perforator—in
such cases the kind of instrument  we employ is of  the greatest  importance.
The blades should be adapted to the head of  the child, the shape  should
correspond wdth the  axes of the pelvis, and the  handles should be long
enough to allow the operator to  obtain a secure hold outside  and free of
the vulva, or success is not to be expected  at the hands of the most dexterous
obstetrician.   British  practitioners, we  are aware, seldom employ the forceps
under the circumstances we have mentioned.  In this we think they are
wrong,—they  differ,  certainly, from the practitioners  of this country and of
Continental Europe.
  According to the rule for the application of the forceps, which, according
to Dr. Robert Lee,2  is  adopted by  the majority of English practitioners,
every case in which the  unaided powers of the woman shall fail to make the
head "descend so  low into the pelvis that an ear can be felt," will call for
the perforator!   The fruits of this practice may be learned from the fol-
lowing table, furnished by  the same  author:

              1 Ranking's Abstract, vol. ii. p.  275.
              2 [Clinical Midwifery, by Robert Lee, M. D., etc., p. 1.] 
THE  FORCEPS.                         353
A Comparative View of the Frequency of Forceps and Craniotomy Cases
                     in eleven Lying-in Hospitals.
Hospitals.	No. of Labors.	Forceps Cases.	Proportions.	Cranioto-my Cases.	Proportions.
Dublin, Clarke	10,199	14	1 in 728	49	1 in 248
" Collins	16,654	27	1 in 617	118	1 in 141
Paris, Baudelocque	17,388	31	1 in 561	6	1 in 2898
" Lachapelle .	22,243	76	1 in 293	12	1 in 1854
" Boivin	20,517	96	1 in 214	16	1 in 1282
Vienna, Boer .	9,589	35	1 in 274	13	1 in 737
Heidelberg, Naegele	1,711	55	1 in 31	1	1 in 1711
Berlin, Kluge .	1,111	68	1 in 16	6	1 in 185
Dresden, Carus	2,549	184	1 in 14	9	1 in 283
Berlin, Siebold	2,093	300	1 in 7	1	1 in 2093
  From this table it will be seen that those who relied most on the forceps,
had the fewest occasions to resort to craniotomy, and vice versa.   Of the
extreme cases on each side, it will be observed that Dr. Collins, whilst he
employed the forceps but once in 617 cases, resorted to craniotomy once in
141 cases ;  or nearly four and a half times as often as he did to the forceps.
Dr. Siebold, of  Berlin, had recourse to the forceps once  in every 7 cases,
and to craniotomy but once in 2093 cases !  It is  not difficult to imagine on
which side was the greatest mortality.   Whence arises this prodigious dif-
ference ?   Unquestionably from the different  principles by which the prac-
titioners of these countries are  guided.   As properly observed by Dr. Lee,
"if we compare the reports  of  the  principal Lying-in Hospitals  of Great
Britain, France, and  Germany,  and examine the  doctrines inculcated by
the best systematic writers of these countries, it is impossible to avoid being
struck with the  want of uniformity which  prevails in  all that relates to the
operations  of midwifery.   Although the cases of difficult  parturition must
be nearly the same in every part of  Europe, cases  of  instrumental delivery
are far more numerous in some countries and institutions than in others, and
the method of operating is widely different."
   To the practitioners of this country, the reports of the English Lying-in
Hospitals are of a most surprising character, especially when it is considered
that these Institutions are under the  supervision of men of the highest stand-
ing in  the  profession.   The frequency with which many of the  Germans
employ the  forceps is in strong contrast with British practice, and is perhaps
scarcely more rational.
   The  frequent occasion which  English practitioners find for  a  resort to
craniotomy appears to proceed  from the rules by wdiich they are  governed
in regard  to the  use  of  the forceps, and which  limit its  application to a
comparatively small number of cases.  Whether these rules  are  deduced
from a  consideration of the mechanical properties  of the  instruments they
employ, or  whether the instruments  are constructed in reference to the ob-
jects contemplated by the rules, they certainly concur in restricting the use
of this means of relief within much narrower limits than either Continental
or American practitioners deem necessary or proper.
   The sufficiency of the English or almost any other forceps for the manage-
ment of cases where the head of the child has passed through the upper
strait, is admitted ; but are they equally capable of useful application before
matters have advanced thus far ?   The application of the various short for-
ceps, when  the head of the child has  not passed through the upper strait, is
certainlv out of the question.  The distance which it is necessary to pass
      23 
354
THE  FORCEPS.
the instrument within the pelvis, and the almost impossibility of  obtaining
by it a secure hold of the head, renders it valueless.  The only exception,
if it really be one, is the forceps of Dr. Davis.   A very serious  objection,
however, to this instrument is one that is common to  all of its class,— the
blades are so short that, when introduced sufficiently far to embrace the head
in the upper strait, the  lock is  brought within  the vulva.  This, beside the
danger of injury to the soft parts of the mother, leaves to the operator a very
insufficient hold of the handles for efficient action.   The great width of the
blades, too, is an objection, perceived by Dr. Davis himself;  he has endea-
vored to  obviate the difficulty by the occasional use  of one blade formed
very narrow.
  These objections are made, however, with great deference, as well from
the high character for skill of the inventor, as from the fact that it is the
instrument preferred by the Professor of Midwifery in  Jefferson College, Dr.
Charles  D. Meigs.
  Dr. Churchill  prefers "the long or short forceps, with the single curve."
There is certainly no advantage in the second curve to the short forceps; it
being only applicable in cases where the head has descended into the cavity
of the pelvis ; as there is in such cases but one strait to  pass, an instrument
which corresponds  in form with the axis of that one strait, is all that  is re-
quired.   But it is widely different when the head is to be delivered from the
upper strait.  It must be borne in mind that the axes of the two straits run
in very different directions — that of the upper strait  being downward and
backward, and of the lower,  downward  and forward.   Now in order to
embrace the head in the upper strait, the instrument must pass through the
outlet in the axis  of the lower strait, or nearly  so ; and, consequently, it
must  have a form corresponding, in a considerable degree, with the curved
line running through the axes of both straits, otherwise there will be excessive
pressure made upon the perineum by  the instrument,  and extreme difficulty
in adjusting it properly on the head of the child.
Fig. 123.
Axes of Pelvis.
  A glance at the accompanying cut will exhibit this better than any verbal
description.   A.  The sacrum.   B. The coccyx.  C.  The pubis.  D. The
perineum.  Dotted line a, plane of the upper strait;  dotted line  6, plane of
the lower strait;  c, imaginary line passing  from the umbilicus to the upper
part of the coccyx, and through the centre of the upper strait or its axis ;
d, a similar  line, extending from the -middle bf the sacrum through the os
externum vagina?, and marking the axis of the lower strait.  The curved 
THE  FORCEPS.
355
dotted line between these straight lines, shows the course the head of the
child must take in passing  through the pelvis, and which  must necessarily
be traversed by the forceps when applied at the superior strait.
  If we are never to  apply the  forceps but when an  ear  can be felt, and
"the head is resting on the perineum," there  is indeed little occasion for a
long instrument;  but  what is to  become of patients laboring under organic
affections  of the heart,  hemorrhage, convulsions, certain  tumors  of the
pelvis,  slight contractions  of the  brim,  great debility,  aneurism,  hernia,
arrest of the head from want of proper rotation, etc. ?   ISo practitioner
should feel himself at  liberty to stand by in such cases and see his  patient
sink into the grave without  attempting delivery until  the  head rests  upon
the perineum, or an ear can be felt;  nor should he dare to plunge the per-
forator into the foetal  head, without first endeavoring  to save its life by the
use of the forceps.
   As to  the ear as a  guide, Dr.  Rigby is perfectly right in saying that the
position of the head should  always " be determined by the direction  of the
fontanelles and sutures, not by feeling for the  ear."  " The ear can seldom
be reached  without a good deal  of  pain, even under the most favorable
circumstances."1
   The average of the results  of British practice, as  shown by their statis-
tics, is certainly creditable :  this is owing, no  doubt, in a great measure, to
 the prudent avoidance of all unnecessary interference.   But in shunning one
 error, we not unfrequently fall into the opposite  extreme ; and this would
 appear to be the  case with  our  brethren  of England and  Ireland.    If we
 confine our examination to instrumental cases, the comparison between their
 success and that of their neighbors is less flattering to them.
   The extreme  difficulty, not to say failures, which  Dr. Huston, of Phila-
 delphia,  experienced  in  operating with  the short forceps  and those with a
 single curve, under the circumstances we have just considered, induced him
 many years ago  to attempt to supply what seemed to him a great deficiency
 in the various forceps in common use.  The forceps of Professor Siebold he
 found to possess  many advantages over any  others that he had met with,
 and he believed  that  with  some  little alterations it  would accomplish the
 objects he had  in view.   The annexed engraving (fig. 124) represents the
 instrument and its several parts, as made by Wiegand and  Snowden, pretty
 accurately.
    Width of the blade at a, one  inch and five-eighths; of the fenestra, one
 inch;  separation  of  blades at the widest part when properly locked, two
 inches and a half (but this is increased nearly a quarter of an inch by the
 maimer in which the  blades are  ground, being  concave  on their inner face,
 and convex externally :  by this  arrangement  the liability of the instrument
 to slip off the head is  lessened ; length of the blades to lock at b, nine inches ;
 length of the handles from joint at b, five inches.  The lock, which is exactly
 like that of the German instrument, is formed by a thumb-screw, c, which
 is fastened into the male branch  at d, and is received into a mortise  in the
 female branch at e.   This  mortise is countersunk, so  that when the screw or
 pivot is  screwed  down completely, the blades  cannot  be separated.
    The instrument of  Dr. Huston  is  the same length  as that  of Siebold's;
 the blades of the former are,  however, longer than those  of the latter, and
 the handles, from the pivot, correspondingly shorter.   This brings the lock
 more completely free from  the vulva when operating at or above the upper
 strait;  at the same time, the shaft, or narrow part of the  blade beyond the
 pivot, constitutes in fact part of the handle equally effective with the handle
 proper.   The fenestra  of the blade is nearly double the width of that  of
1 [Rigby's System of Midwifery.] 
356
THE  FORCEPS.
the German instrument, and the sweep of the second curve  an inch  and n
quarter greater.  The instrument is also  four ounces lighter than the for-
ceps of Siebold.
                                Fig. 124.
Dr. Huston's Forceps.
  According to Dr. Huston, the objects gained by these modifications are:
  1. The blades being longer, the soft parts  of  the woman cannot be en-
tangled with the lock.
  2. The increased width of the fenestra? avoids the thickness of the instru-
ment being added to that of the head,  renders it  less liable to slip off, and
lessens its weight.
  3. But the most important modification is in  the  increase  of the second
or pelvic curve, by which the blades correspond better with  the form of the
pelvis, so that when their extremities  are  in  the axis of the upper  strait,
their shafts pass directly through the axis of the outlet.  By this arrange-
ment, the instrument is more readily applied when the head is high up, and
all undue pressure on the perineum  is avoided.   This form  of the instru-
ment also enables the operator to apply it when  the  patient is on her back
on a mattrass, without bringing her down so low as  to  have her limbs off
the bed, which adds much to the comfort of the patient and the decency of
the operation.
  From this description of the instrument it will be understood that it is
calculated, in  every case, to be passed along the  sides of the pelvis.
  The following figures represents the forceps employed by Dr. Hodge, of
the University of Pennsylvania.  It is calculated, in a considerable degree,
to accomplish the same objects as the one  employed by Dr. Huston.   The
eclectic forceps, as Dr. Hodge calls his instrument, weighs  one pound and
one ounce ; being nine ounces lighter than the  French forceps, as usually
manufactured by  Mr. Rorer of this city, and eleven  ounces lighter than a
specimen of Dubois' forceps, made in  Paris. 
THE  FORCEPS.
357
  The whole length  of the  instrument in a direct line from b to c is 16
inches.   From the joint a to extremity b, the  length of the  handles is 6*8.
From atocc, extremities of the blades is 9-5, in a direct line.   From a to

                                Fig. 125.
Dr. Hodge's Forceps.
,   d, length of parallel shanks is 3-5.   From d  to c, the proper  blades, in a
   direct line, is 6 inches.  From  c c,  the  extremities, to e f, the greatest
   breadth, 3"7 inches.
     The separation between the points c c, when the handles are in contact,
   is -5 of an inch.   From e to /, the greatest breadth when the handles touch,
   is 2-5; when the separation at e f is 35, the points c c are separated to 2
   inches.
     The breadth of the blade is 1-8, slightly tapering to 1'7 near c c, the ex-
   tremities.   The breadth of the fenestra is  1-1; the thickness of the blade is
   "2 of an inch.
     The perpendicular elevation of the points c  c, when the instrument is on
   a horizontal surface, is 3-4  inches, which indicates the degree of curvature
   of the blades.
     The elevation of  the  handles  near the joint, above the same horizontal
   line, is 13 (including the thickness of the blades), which indicates the extent
   of the angular bend in the handles.
     An important modification of the forceps was a few years since announced
   by the late Dr.  Henry Bond, of Philadelphia.1
     At  an early period  of his professional life it occurred to him that cases
   are sometimes met  with, though not very frequently, where, owing  to  the
   position or the form of  the  fcetal head, and its relation  to the pelvis, it is
1 [American Journ. of the Med. Sciences, Oct. 1850.] 
358
THE  FORCEPS.
found impracticable to  adapt the  clams to  the  head  so as to lock the
branches, or to do so without violent injury to the mother or child.
  Dr. Blundell very justly observes :  " Unless the blades be elastic, absolute
adaptation can (I conceive)  never be obtained ; for while the form of the
instrument remains unchanged, that of the head itself varies."  " The lock
should be loose, so as to admit of a junction of the  blades, although they
may not be brought into exact apposition with each other;  for, in applying
them to  the head, this  adaptation cannot always  be obtained."  For this
reason,  he says that Smellie's lock (made loose) is decidedly the best.
  According to Dr. Meigs, if we fail to adjust the  branches accurately in
apposition, we either cannot make  them lock, or we lock them  in  such a
way that the edge of the instrument contuses, or even cuts  the part of the
scalp or cheek on which it  rests, leaving a  scar, or actually breaking the
tender bones of the cranium, while the other edge cuts the womb or vagina
by its free projecting edge.   In fact the forceps is designed for the sides of
the head; and if, under the  stress of circumstances, we  are  compelled to  (ix
them in any other position (an incident not very unfrequent), we shall always
feel  reluctant to  do so, and  look forward with painful anxiety to the birth,
in order to learn whether we have done the  mischief we feared, but which
we could not avoid.1
  Dr. Bond remarks, that the difficulty and  the danger in such cases evi-
dently arise, to a great extent, from the  want of an accommodating, rocking
motion  of the branches of the forceps upon each other, such as will allow
the depressed  ("cutting and  contusing") edge to rise, and the elevated edge
to sink  and come in contact  and apposition with the head ;  that is, that the
blades may be adapted to the head by varying from their usual relation to
each other.
  In the instrument,2 designated in figs.  126, 127,  128,  Dr.  Bond has at-
tempted  to supply the desideratum just  referred to,  that is,  to give the
branches of the forceps an accommodating rocking motion upon each other,
the extent of which can be regulated at will, and which shall in no respect
lessen the power of the instrument.   The mechanism devised to obtain this
motion is very simple, not liable to derangement, and it  may be adopted in
the construction of forceps of other  forms  than that here presented; pro-
vided that the  pelvic curvature of the branches does not take such a wide
sweep, as to throw the  pivot far out of the direct line  between the handle
and  the centre of the fenestrae.
  The instrument of Dr. Bond does  not differ, as a whole, from  those now
iu use;  nothing connected with it except the lock, has any claim to novelty.
Its whole length is about fifteen inches,  and its weight about fifteen ounces.
The length of the  handle is  six  inches, and  that of the blade nine inches.
It might be made somewhat  shorter and lighter without  impairing its power.
  In fig.  126 the pivot is seen of full size, the screw is  of about double the
diameter and  nearly double  the length of those in other instruments.  This
additional strength is necessary,  because the bearing point of the  pivot is
not  immediately above the  blade in which it is inserted (as in other instru-
ments), especially when this  bearing point  is elevated  so as to give tbe
blades a free rocking motion.  The additional length is required to give the
screw a  firm lodgment, when it is partly withdrawn from  the blade.  The
thumb-piece is made to fit so close upon the  female  blade, without resting
upon it,  and is so thick and  rounded, that there can be no  risk of injury

  1 [See "Obstetrics; the Science and the Art," chap, xv., for much information and ex-
cellent lessons on the use of the forceps.  We commend attention to the author's emphatic
inculcation of the idea, that "the forceps is the child's instrument."]
  2 [The  instrument,  from  the manufactory of  Messrs.  John Rorer & Sons, of Phila-
delphia, is made of German steel, and spring-tempered.] 
THE  FORCEPS.
359
should it ever happen to  be brought  into contact with the patient.   The
screw, when well made,  will turn so  easily  that the thumb-piece  may  be
made much less prominent than it is here represented.  When the forceps is
used, the thumb-piece should be placed parallel with the blades ; otherwise
it may interfere with the rocking motion.  Between the  thumb-piece and the

        Fig-126.                Fig. 127.                   Fig. 128.
Dr. Bond's Forceps.             Dr. Bond's Forceps.
screw, the pivot is of the form of two frusta of cones of equal dimensions,
united  together  at  their  smaller  diameters, forming an  obtuse angle  or
groove at their junction.  The base of that cone joined to the screw projects
a little, forming a shoulder, intended to limit the  motion of the screw into
the blade.
  The notch in the female blade, made to receive the pivot, is so deep  that
the latter, in relation to the  edges of the branch, is nearly in  the middle;
yet the width of  this branch,  opposite to it, is swelled out, so as to  give it
adequate firmness.   The width and the form  of the  sides  of the notch  are
accurately adapted to those of the pivot, and the bottom of the notch termi-
nates in an edge, like the knife-edge of a balance, which is intended to rest
in, and bear upon, the angle or groove in the pivot.   On  the under side of
the male blade is seen a protuberance, finished so as to  present no salient
points.   It is a shield for the extra length of the screw.  When the pivot
is screwed entirely down, the branches have no  more lateral  or rocking 
360
THE  FORCEPS.
motion than those of any other forceps, and in this condition, they will very
generally be used.  But by turning the screw, so  as to elevate the bearing
point, more or less freedom is given to  the rocking motion, according to its
elevation ;  and this motion is  effectually restricted within any desired limits.
When, by means of this free motion, the operator has been enabled to grasp
the head,  he  may sometimes change its position, so that the clams may be
then adapted to the head, without the obliquity at first necessarily allowed
to them by the elevation of the pivot;  and then, if desirable, the pivot may
be screwed down, and  the  blades will  become as  fixed  as  those  of other
forceps."
   The blades of Dr. Bond's  forceps (figs.  127  and 128) resemble nearly
those of Dr. Davis.   The shanks  are  considerably longer; the clams are
not quite  so long ; the radius  of their pelvic curvature a little less, especially
that of the outer limbs, so that it will be less liable to  be obstructed by the
promontory of the  sacrum, in passing  the  instrument above  the superior
strait.   The fenestra? are wider in their  middle and  posterior  part than those
in most other forceps.   When the pivot is elevated, so as  to allow the blades
their rocking motion, this width becomes  especially requisite  in  order to
secure a firm hold on the head, and to avoid the risk of their slipping side-
ways.   The space between  the blades  is  such, that, when  applied to the
head, the  handles shall not be at a  distance from each  other, awkward and
inconvenient to the operator.   From the pivot, the upper line of the shank
continues  forward, without any elevation or depression, to the beginning of
the pelvic curvature ;  and the form and the relation  of the shank to the
clam are intended to be such as to  interfere the least wdth the perineum.
   The pivot  it wdll be seen (fig. 127) in these  forceps,  is in a direct line be-
tween the handles and the centre of the fenestra?.   This  is a point  of im-
portance  in those cases where the rocking  motion  of the blade may be re-
quired,  as it  will cause each limb of the clams to  press with nearly equal
force, thus avoiding undue pressure upon any one part of the head, and the
liability to slipping or displacement.
   "I am  aware," remarks Dr. Bond, "that the first impression of some per-
sons, upon looking at the illustrations, will be, that the instrument is too
straight, that the pelvic curvature ought to be continued into  the shanks.
If the whole operation, or the most difficult and important part of it, con-
sisted in passing the blades above the superior strait, narrow blades, with a
curve of  a wider sweep, like  those of  Professor Siebold, slipping in pro-
bably with rather more facility,  would be preferable.   But as those here re-
presented can be passed above the superior strait with facility, it  seems to
me that what I have already said  upon the importance, in many  cases, of
having the pivot in nearly a direct line between the handles and the fenestra,
furnishes a valid reason for adopting a  model not differing essentially from
that here  presented."
   The remarks of Dr. Churchill on the "period of operating" with the for-
ceps, are highly judicious, and  deserving of the especial attention of the junior
practitioner.   They are the more satisfactory because they inculcate sounder
doctrines, according to our view of  the subject, than are  to be  found in the
writings of some of our late as well as  older British  authors, at least.
   When the  difficulty  exists "at the brim  of the pelvis, it will  be better in
all cases to apply the forceps  in the transverse diameter."  If there be want
of space,  it will be almost always in the antero-posterior diameter, and on
that account there will be difficulty  in passing the blades of the forceps be-
tween the head of the child and the pelvis ;  not only so, but it is nearly im-
possible to pass the posterior blade far  enough, in consequence of the projec-
tion of the sacrum—if the instrument be straight, that is,  without the second
curve, the extremity will be arrested by the upper portion of the sacrum, or the 
CRANIOTOMY.
361
shank of the blade will press very seriously against the perineum ; in fact,
it cannot pass thus without pushing this part back with  great violence, as
any one may see by looking at the vertical view of the pelvis represented in
fig.  123, page 354.
  In attempting to apply the instrument antero-posteriorly, there is always
danger of  injuring the bladder and rectum, which  alone is  a sufficient reason
for rejecting this mode of operating, if  any other will answer.
  The only valid reason that can be discovered for applying the forceps an-
tero-posteriorly is, that the pressure made by the instrument in that case is
upon the part of the head corresponding with the  least diameter of the brim.
But if the blades be made without pretty wide fenestra?, their thickness will
be added  to that  of the head, and will be quite equal to all that will be
gained by the compression, if this be confined within the  limits compatible
with a proper regard for the safety of the child; and if it is required the head
should be  reduced more than this, the perforator should  be employed.   It
must be admitted by all who have had experience in these matters,  that  the
soft parts  of the mother will bear as much compression as the brain  of  the
child: if this be so, where the life of the latter is to be preserved,  there is,
certainly,  no reason why the necessary compression or moulding of its head
may not be left to the influence of the resisting parts.  When this moulding
operation  is left to the maternal parts, the compression is made exactly at
the points where it is needed, which can hardly be  expected from  the arbi-
trary influence of the instrument.  We very much doubt the propriety of
employing the  forceps as a means  of compressing the head of the fcetus,
unless, perhaps,  when the perforator is required.   It should  be resorted  to
only as a lever to alter the position of the head,  or as a tractor to  aid in its
expulsion.   That  the  forceps should never be  used as a compressor,  but
solely as a tractor, is strongly insisted upon by Professor  Meigs.]
                       CHAPTER XIII.

          OBSTETRIC OPERATIONS.—5.  CRANIOTOMY.

  569.  The next  obstetric operation we have  to consider belongs to the
second  class, that is, where one life is  terminated to save the other; the
mother's safety being secured  by the destruction of her child, in cases where
both would be lost if no interference were  attempted.   This is not an ope-
ration of election in any sense, but of stern and sad necessity; neither have
we any choice which life we will save ;  the  child cannot be  saved by any
means compatible with the mother's safety, and therefore it  is destroyed.
As to the arguments for and  against the morality of the operation, I must
refer my readers to the Appendix to this edition, where I have endeavored
to investigate the question fairly and fully.   I have seen  too many difficult
cases to agree with Dr. Tyler Smith that craniotomy  can  be abolished, but
it has always been my object that it should be restricted within the narrowest
limits.   Professor Scanzoni, no mean authority, observes :  " From all we
have said, we conclude, that as yet,  we know of no means which will render
craniotomy useless.   It is  an  operation which, undertaken on good grounds 
362
CRANIOTOMY.
and  performed with address and good instruments, will  save many lives,
which otherwdse would be sacrificed."
  The instruments (or part of them) employed in this operation are of great
antiquity ;  and although they were originally proposed for  the extraction of
dead children only, yet this scruple had not  the  effect  of  saving the life of
the child, but merely postponed the interference until after its  death.  This
conscientious  quibble  (refusing to  destroy a child, but allowing it to die)
was soon detected, and then the hook was used with living children, provided
that delivery were otherwise impossible.
  The class  of cases to which  it was  applied, doubtless, included  a vast
number which  were  subsequently  relieved  by the forceps; but there were
still left a great many in which it  was indispensable.
   Several  of the  ancients recommend this operation.   Hippocrates advises
the breaking up of the cranium, and  extraction by the  hook.   Moschion
advises embryulcia in those cases where the fcetus cannot be extracted by
the hands, and if embryulcia be insufficient,  the  exsection of  the limbs and
body of the child.  Albucasis,  the Arabian physician, describes instruments
for compressing and breaking up  the child's  head, and  others for extracting
it.   Of certain cases of difficult labor, when the child is presumed to be dead,
Celsus remarks,  " Si caput proximum  est, demitti debet uncus qui vel oculo
vel auri vel ori interdum etiam fronti recte injicitur."
   In the Birth of Mankinde,  written  by Eucharius  Roslin, translated into
Latin about the year 1535, and into English by Thomas Raynalde, in 1634,
I find the  hook recommended to bring  away dead children.  " If so be," he
says, " that it lie the head forward, then fasten  a hook either upon one of
the eyes of it, or the roof of the  mouth, or under the chin, or on one of the
shoulders—which of those parts shall seem most commodious and handsome
to take it  out by, and  the hook  fastened to draw it  out very tenderly, for
hurting of the woman."   If the  head  be too large, it is  to be opened with
a sharp penknife, or broken in pieces.   He  also recommends excision of the
 extremities,  if they present (the child being  dead), or evisceration, to facili-
 tate the delivery.
   Ambrose  Pare's work  is dated 1579, and it was translated into English
 in 1634.   In it are given plates of different hooks for drawing out the child,
 and a knife for the excision of  the limbs.
   From this time we find the operation recommended by every author, but
 the instruments underwent considerable modification, and the  class  of cases
 in which they were used considerably decreased.  Of course this latter change
 was one of the consequences of the invention of the vectis and forceps.
   570. The following are the principal modifications  of the instruments for
 craniotomy : —
   1. Albucasis  describes a species of forceps wdth teeth, which he terms a
 " misdach, or almisdach," for the  purpose of crushing the head, and  enabling
 it to pass.
   2. He also gives a plate  of  a  single and double hook, for extracting the
 child, and of  a knife for cutting off the head.
   3. Ambrose Pare contrived  two kinds of blunt hooks, and a double one
 with sharp points, for the extraction of the  foetus, and a knife for excision.
   4. Mauriceau invented an instrument which he called  a "tire tete," con-
 sisting of a circular plate of steel, fixed upon a rod.    The circular plate was
 to be introduced into the head (previously  opened by a  scalpel), and being
 placed across the  opening, traction was to be made.   This instrument was
 never  much  used, owdng to the difficulty of introduction,  and its feeble
 power when introduced.
    5.  Sir  F.  Ould's "terebra occulta" consisted  of a  sharp-pointed rod in-
  closed in  a canula or sheath, and retained  by a spiral spring at the lower 
CRANIOTOMY.
363
end.   When  the handle was pressed upwards, and the resistance of the
spring overcome, the point of the instrument protruded  a certain distance,
but was retracted when the pressure upon the handle was removed.  Its
application to the head was easy and safe ;  but it must have been nearly use-
less, from the small  opening it made.
  6.  Dr. Simpson, of St. Andrew's, invented an instrument, which he called
a "ring scalpel," for  opening the  skull.   It consists of a loop  of  steel,
through which the finger is to be  passed, and from which protrudes a sharp-
pointed blade about an inch long, by which the cranium  was pierced.
  7.  M. Mesnard described a crotchet which could be used either double or
single, and which was  the original of the one in present use.   He also  gives
a plate  of a "perce-crane," and a pair of  "tenettes a conducteur," that is,
craniotomy forceps.
  8.  Dr. Burton copied  Mesnard's double crotchet  and perce-crane" with
some slight modification.
  9.  M. Levret  gives a plate of a single crotchet, which  was arranged to fit
into a socket  on  the top of another blade for the purpose of protecting the
mother, and rendering the purchase more secure.
  10. Dr. Smellie recommended Mesnard's crotchet (single or double); but,
instead  of the "perce-crane," he used a pair of strong scissors, with stops at
the shoulders to  prevent the blades entering too far.   Denman abolished the
Fig. 129.                  Fig. 130.                    Fig. 131.
Hayn's Perforator.               Smellie's Perforator.                Crotchet.
cutting edge altogether, and added strength to the blades.   A  spoon was
also used to evacuate the brain, but it is now very properly discarded.
  11.  Dr. Wallace Johnson published  an account of  his instruments  for 
364
CRANIOTOMY.
opening the head and  extracting the child.  I do not know that  they have
ever been used by any other person.
  12. Dr. Aitken proposed a flexible  or living crotchet,  which could be
adapted to the convexity of the child's head.
  13. M. Baudelocque recommended a very simple extractor, consisting of
a small piece of wood, to the centre of which a ribbon was attached.  An
incision having been made with a bistoury or "perce-crane," the bar of wood
was to be introduced and placed crosswise, and then extraction made by the
ribbon.
  14. M. Osiander has given a plate of an instrument for piercing the skull,
and  another for  extracting.   The latter  is the same as Smellie's  double
crotchet.
  15. Professors de Hayn, Yanhueval, Joerg,1  and other German  practi-
tioners,  use a  species of trephine for perforating the  head.  It has the
Fig. 132.                  Fig. 133.               Fig. 134.
Churchill's Crotchet.                     Holmes's Perforator.
advantage of occasioning no splinters, and of perforating the face as easily
as the skull.  The accompanying plate is copied from M. Cazeaux's Atlas,
and represents M. de  Hayn's instrument.   (Fig. 129.)
1 Presse MeU Beige, Dec. 31, 1848. 
CRANIOTOMY.
365
  16.  Dr. Davis has invented several species of crotchet, both single and
double, as well  as a pair of forceps for breaking up the  skull.   These are
well exhibited in the fourth edition of  his work.
  These are a few of the principal instruments which  have been employed
in the operation of craniotomy.   I have not given  a detailed description,
because most of them are discarded;  the instruments in  general use being
a pair of scissors  with shoulder-stops,  as recommended by  Smellie, but
having a sharp  edge on the outside (fig. 130), and  a  modification of Mes-
nard's simple crotchet (fig. 131).   I have found it an advantage to  shorten
the points of the scissors above the stops, and also the  hook of the crotchet;
the latter of which should be slightly cleft (figs. 132, 133).  Mr.  Holmes
and others have modified the latter, so that in closing the handles we open
the blades (figs. 134, 135).  Further, I have copied  plates of a knife for
Fig. 135.                     Fig. 136.              Fig. 137.
Holmes's Perforator.          Knife for Amputating Limbs.        Blunt Hook.
cutting off the head or limbs if necessary (fig. 136), a blunt hook (fig. 137),
and Dr. Davis's bone forceps for breaking up the skull (fig.  138).
  Dr. Oldham of London has recently proposed an instrument (fig. 139),
which I think likely to be useful.   It consists of a straight steel stem, fixed
into a wooden handle, and bent at an  acute  angle at  the other extremity,
the whole being fourteen inches long.   It can be inserted  through the fora-
men magnum into the spinal canal, and thus  obtain a purchase when the
vault of the cranium has been  broken up.  Or it will serve to steady the
head when it has been severed from the body, whilst the crotchet is applied.1
  From the inconveniences sometimes experienced with the crotchet, and to
1 Lancet, May 14th, 1853, p. 447. 
366
CRANIOTOMY.
avoid the risk of injuring  the mother, craniotomy forceps have been  em-
ployed by different individuals.
  Among the moderns,  M Mesnard has  the  credit of first inventing  and
using this instrument, and since his time it has undergone various modifications.
  Dr. Haighton  used a pair resembling  the  lithotomy forceps : and since
his  time Drs.  Conquest  and Davis, Mr. Holmes, and others, have invented
Fig. 138.             Fig. 139.                Fig. 140.
Dr. Davis's Bone Forceps.   Oldham's Instrument.           Craniotomy Forceps.
and described varieties of the instrument (fig. 140).   The object of each is
the same, viz., to avoid the risk of tearing the soft parts of the mother; and
the principle of seizing the skull between two  blades, furnished with teeth,
is also alike.
  Dr. Zeigler of Edinburgh has invented an extracting forceps  (fig. 144),
which  must possess great power from the  grooved condition of its inner
surfaces, and from its figure is adapted to cases of contracted  pelvis, when
the head has been  previously perforated.   Both blades are  applied outside
the cranium, as other forceps;  but by substituting for one  of these blades
another with teeth (fig. 145), a craniotomy forceps of the ordinary kind is
produced.1
  I am free to confess that I do not like the craniotomy forceps, although
I have tried them repeatedly.   They are  by no  means so manageable as the
crotchet; and the interposition of the hand of the operator will always pro-
tect the mother from injury by the latter.
lEd Monthly Journal, May, 1849, p. 770. 
CRANIOTOMY.
367
  There is one case, however, in which these forceps may be more useful,
and that is, when the bones of the head  are extremely hard, so that it is
almost impossible to fix the point of the crotchet.
  17. M.  Baudelocque, Jr., has invented an instrument, which he calls a
"cephalotribe," for the purpose of crushing the  head (fig. 146).   It con-
sists of a very strong pair of  forceps,  about two feet in length, the handles
of which are connected by a screw which pierces them, and which is turned
by a handle until the blades are so closed as to effect their object.   Yelpeau
states that instruments somewhat similar have been  formerly used by Assa-
lina, Osiander, Delpech, Colombe, etc.   M.  Baudelocque  is said to have
used it three times  successfully (and safely as regards  the  mother) in  the
year 1832, and once again in  1834.   It is also said that M. Champion  has
tried it with success.   M. Cazeaux speaks favorably of it in certain cases,
and with certain modifications j1 but its appearance is so formidable, that I
doubt if it could be used in this country.  I  am not aware that the attempt
has been made.
[Fig. 141.]             [Fig. 142.]        [Fig. 143.]
Dr. Meigs's Embryulcia Instruments.
  [Professor  Meigs  uses  the  forceps  and perforators  represented  in figs.
141, 142, 143.  These forceps  possess advantages over  the ordinary instru-
ments for extraction after perforation  of the  head, and are certainly safer
in unpractised hands than the crotchet.
  They are eleven inches in length ;  the gripe is serrated and the sides  of
the  mandibles  are  rounded, in  order that they may not pinch any tissues
                 1 Traite' des Accouchemens, p. 585 Ed. Beige. 
368
CRANIOTOMY.
except those intended to be included in the bite, which, on account  of the
seme, is very sure and strong.1]
  571.  The object of the operation of craniotomy is to terminate the labor
with safety to the mother, in cases where, from the disproportion between
the size of the fcetal  head and the pelvis, a living child can neither  be ex-
pelled by the  natural powers, nor extracted by the  forceps.   Such a case,
if left to nature (as it is called) will terminate fatally for both mother and
child ; consequently, although the child is destroyed to facilitate the delivery,
and to save the mother, it cannot be said to  be sacrificed, inasmuch as no
efforts of  ours could  have insured its safety.
Fig. 144.                            Fig. 145.
Craniotomy Forceps.
  The case presupposes, on the one hand, actual disproportion sufficient to
prohibit the passage of the fcetal head, even when compressed; and on the
other, that the distortion is not so great as to prevent the extraction of the
child when mutilated.
  Dr. Osborn states that when "the bones approach much  nearer  to  each
other than three inches, it is utterly impossible  for a living child at full ma-
turity by any means to pass."2   He fixes upon 2f inches as the diameter
rendering craniotomy  necessary.  M. Alphonse Le  Roi says that 3^, Dr.
Aitken 3, Dr. Jos. Clarke 3£, Dr. Burns 3£, Dr. Ritgen 2, and Dr. Busch 1\
to 3 inches, is the smallest antero-posterior diameter through which a living
child can pass.
  As to the other  limit of  the  operation, that is,  the smallest  diameter
through which a child can  be extracted  after  craniotomy,  Dr. Osborn re-
marks :—"Whenever there is a space from pubis to sacrum, or from the fore
to the hind part  of  the upper aperture  of the  pelvis, equal to an inch and
a half, I am convinced it will be always practicable to extract a child by the
crotchet, after the head has been some time opened, and the texture of the
child's body is  softened by  putrefaction (as recommended above),  and the

             1 [See Obstetrics — The Science and the Art, 2d edition.]
             2 Essays on Midwifery, p.  194. 
CRANIOTOMY.
369
whole of the  parietal and  frontal bones  are picked away."   Baudelocque
Bays that the crotchet is  inadmissible when the diameter is only If of an
inch;  Dr.  Dewees when it  is  less than 2; Dr. Hull and Dr. Burns believe

                                Fig. 146.
The Cephalotribe.
that it may succeed when the  diameter is If; MM. Gardien and  Hamilton
when it is 1^; and Dr. Davis when it is 1 inch.   We must not omit, how-
ever, another condition, viz., the safety  of the  mother.  It may be  quite
possible to extract the child as far as mere  mechanical extraction  is con-
cerned through an aperture  extremely  small, but what is  the  result to the
mother?   In the case related by Dr. Shekelton  where the antero-posterior
space  was little more than an inch, the child was lessened and extracted, and
the mother died "in ten minutes after the operation."1   In another case
under  the present  Master, Dr. M'Clintock, wdiere the space was greater, the
woman died  within twenty-four hours.  Now I  quite agree with  Professor
Murphy,2 that, where the space is so much reduced, that the mother incurs
such peril, in addition to the loss of the child, it  would be far better to have
recourse to the Caesarian section.   I would not venture  to  have recourse to
craniotomy unless  the antero-posterior diameter was fully two  inches.  M.
Cazeaux agrees with this opinion, but decidedly  prefers it  to  the  Caesarian
section when the diameter is above this.
  572.  The nature of the operation is  simple, but the aid afforded  may vary
in degree.
  1. In the case of dead children, the older practitioners used the crotchet
alone as an extracting force, without opening the head.
  2. In some cases where the sutures  are very loose, the evacuation of the
brain wdll be  sufficient, as the bones of the  cranium collapse so much under
the influence  of the pressure downwards, that the child may be expelled by

   1 Dublin Journal  of Med. Science, vol. x. p. 287.          2 Ibid., Feb. 1859.
      24 
370
CRANIOTOMY.
the natural powers.   But in this case, it is assumed that the pains are suffici-
ently strong and frequent.
  3.  When  (as  is  frequently the case) the pains are inefficient, or when the
state of the patient demands prompt relief, then we must not only evacuate the
brain, but add extracting force, by means of the crochet or craniotomy forceps.
  4.  In some cases the distortion  of the pelvis is too considerable to admit
the passage of the head, even  when emptied of its contents ;  or the ohMruc-
tion may result from the ossification of the bones of the  skull; in either case,
an extension of  the  operation is necessary to  complete the delivery.  This
may be effected by  breaking  up the cranium with a small  pair of forceps,
resembling Dr. Davis's ; or according to M.  Baudelocque, jun., by the use
of the cephalotribe.   It would  require unusual hardihood to venture upon
the latter instrument in private  practice in this country.
  5.  In these cases  of distortion, after the  head  has been extracted piece-
meal, we may find it impossible  to bring away the body of the infant.  We
must then use the  perforator,  for the purpose  of evacuating the contents of
the chest and abdomen, and afterwards apply the crochet to extract the child.
  One or more  of these modifications of the operation will be successful in
all cases which come within the  limits already described.
  573.  Statistics.—The positive advantage we obtain from embryotomy is
the safety of  a  large proportion  of the mothers, wdio, in addition to the
children, must have  perished  had no aid been afforded.   The children, of
course,  are all lost.
  What the proportion of success  is,  I shall now endeavor to show; but
previous to this I shall adduce whatever evidence we possess to ascertain
the comparative frequency  of  the operation.
FREQUENCY  OF  THE OPERATION.
     a.  Among  British Practitioners.
Date.	Authors.			Total No. of Cases.	No. of Crotchet Cases.	References.
1781	Dr. Bland			1,897	8	Merriman's Synop. p. 333.
1787 to 1793	Dr. Jos. Clarke			10,387	49	Trans, of Assoc, vol. 1.
	Dr. Merriman			2,946	9	Synopsis.
1818	Dr. Granville			640	3	Report, p. 25.
1828, 1829	Dr. S. Cusack			701	5	Dub. Hosp. Reports.
1832, 1833	Dr. Maunsell .			839	5	Ed. and Dub. Jour.
1829	Mr. Gregory .			691	2	Dublin Hosp. Rep., vol. 5.
1826 to 1833	Dr. Collins			16,414	79	Practical Treatise.
1834	Dr. Thos. Beatty			1,182	3	Dublin Jour., vols. 8, 12.
	Mr. Lever			4,666	25	Guy's Hospital Reports.
	Dr. Beid			5.691	22	Ranking, vol. 4.
1835,37,38,39	Dr. Churchill .			1,640	11	Reports to June, 1840.
1838	Mr. Warrington			88	1	American Journal.
1829	Mr. Mantell .			2,510	3	Ibid.
1848 {	Drs. M'Clintock a Hardy	nd\		6,634	52	Pract. Obs., p. 95.
1820 to 1827	Dr. Ramsbotham			68,435	85	Obst. Med. & Surg. p. ,20.
1842 to 1844	Dr. Murphy .			467	2	Rept. of Univ. Col. Hosp.
	Dr. Storer			451	2	Amer. Jour., Oct. 1851.
	Dr. Adams			628	4	Ranking, vol. 4.
	Dr. Toogood .			1,135	6	Prov. Jour., vol. 8, p. 103.
	Dr. Copeland .			1,290	2	Crosse's Med., p. 12.
	Dr. Pagan			8,684	15	Glasgow Jour. July, 1852.
1847 to 1854	Drs. Sinclair and John- "1 son . . j Dr. Hall Davis			13,748	130	Pract. Mid., p. 224.
				7,302	9	On Difft.Parturition,p.271.
 
CRANIOTOMY.                        371
b.  Among French Practitioners.
Date.	Authors.	Total No. of Cases.	No. of Crotchet Cases.	References.
1797 to 1809 1803 to 1811 1834 to 1843	Mad. Boivin . Mad. Lachapelle . Dr. de Belli . .• .	20,517 15,654 2,739	16 14 39	Memorial, p. 337. Pract. d'Accouch., p. 500. Ranking, vol. 4.
c.  Among German Practitioners.
Date.	Authors.	Total No. of Cases.	No. of Crotchet Cases.	References.
1801 to 1807 1811 to 1827 1812 1818 to 1829 1832 1814 to 1827 1819 1825 to 1827 1794 to 1804 1821 to 1825 1825, 26, 57 1825 1827 1829 1797 to 1837 1847 to 1849 1821 to 1842	M. Richter, Moscow f Moschner and Kursak,"» \ Prague . . / Dr. Siebold, Wurtzburg . " Berlin " Marburg . Dr. Carus, Dresden. Dr. Ritgen, Giesen . Dr. Kilian, Copenhagen . Dr. Henne, Prague . Dr. Naegele, Heidelberg. M. Boer, Vienna Dr. Riecke Dr. Kluge, Berlin . Prof. Andr6e, Breslau Dr. Kustner, Breslau Dr. Adelmann, Fulda Dr. Jansen, Ghent . Dr. Arneth, Vienna. M. Klein .... M. Bartsch Dr. Bicker	2,571 13,329 170 97 155 2,908 103 2,350 500 1,411 39,390 219,303 809 351 176 57 13,365 6,608 35417 4,425 304,150	3 4 1 1 1 9 1 4 1 5 84 51 8 2 o i 5 4 53 3 143	Velpeau. Siebold's Jour., vol. 9. Ibid., vol. 1. Ibid.. vol. 10. Ibid., vol. 13. Ibid., vol. 9. Ibid., vol. 6. Velpeau. Siebold's Journal, vol. 2. Velpeau. Die Geburtsh. Praxis. Velpeau. Siebold's Jour. vols. 7, 9. Ibid., vols. 7, 8. Ibid., vol. 9. Ibid., vol. 11. Med. Gazette, March 6, 1840. Die Geburtsh. Praxis, etc. p. 99. Ibid. Ibid. Med. Times and Gazette, Oct. 11, 1856.
  Thus among British practitioners, we  have 517 crotchet cases in 150,381
cases of labor— or about 1 in 291.
  Amonc: the French and Italians, 69  crotchet cases in 38,908 — or 1  in
563f.
  And among the Germans, 386 crotchet cases in 646,645 labors — or 1 in
1675.
  Added  together, we have 835,934 cases, and 746  in which the crotchet
was used — or 1 in 1120^. 
37 2                        CRANIOTOMY.
RESULTS OF  THE OPERATION TO  THE MOTHERS.
Authors.	No. of Crotchet Cases.	Mothers died.	Authors.		No of Crotchet Cases.	Mothers | died.
Dr. Smellie .	44	4	Drs. Sinclair and John-"1		130	26
Mr. Perfect .	3	0	ston			
Dr. Jos. Clarke	49	16	Dr. Storer		2	1
P. P . .	12	8	Dr. Beatty .		3	0
Dr. Granville	3	3	Dr. Churchill		11	1
Dr. Ramsbotham .	34	5	" P. P		20	0
Dr. Maunsell.	5	2	Mr. Warrington .		1	0
Mr. Gregory .	2	1	Dr. Pagan		15	>>
Dr. Collins .	79	15	Dr. Siebold .		3	1
Dr. Lee, P. P	80	4	Dr. Ritgen		1	0
Drs. M'Clintock and 1 Hardy . . /	52	8	Dr. Klug'fe		8	3
			Dr. Andr<5e .		2	1
Dr. M'Clintock, P. P .	5	0	Dr. Kiistner .		2	0
Dr. F. Ramsbotham	60	6	Dr. Adelmann		1	0
Dr. Murphy	2	0	Dr. Arneth .		4	2
Mr. Cross, P. P .	7	0	Dr. Ricker		123	35
  This table gives the mortality of 134 in 747 — or about 1 in 5£.
  At first sight one would expect  the mortality among the  mothers to be
less after the use of the crotchet than the forceps;  although the result of
these investigations shows the  reverse to be the case, and Dr. M'Clintock,
in a very interesting paper,  brought forward evidence to show this to be
really the case.   The only  explanation  I  can  give, is founded upon the
natural unwillingness of every humane practitioner to destroy life—the con-
sequence of which feeling, is  the delay of the operation so long as there is a
hope of evading it.    This delay, however, is unfavorable to the mother, and
when at length the  operation is performed, although it may have been less
severe than delivery by the forceps, yet her condition has rendered her much
more susceptible of injury from it.   If we  separate the cases in the  table
which occurred in  private  or consultation practice, we find the mortality
very much less.   In consultation I have had recourse to craniotomy twenty
times, and all  the  patients recovered ; in four  other cases I was called in
when the mother was past hope ; these I therefore  omit.  Dr. Robert Lee
has  recorded eighty cases of craniotomy from disproportion, without com-
plication, and  although  he was  not  called to  some until  much time had
elapsed, only four died.
   Dr. Joseph  Clarke operated twelve times, and all the women recovered.
Mr. Cross  operated seven  times, and all recovered.   Dr. M'Clintock, five
times, and all recovered.
   This gives a result of  117 cases, and 4 deaths, or 1 in 29.
   574. The comparative advantages of the operation are very decided.  In
the cases we have  supposed, the forceps is useless,  and the  natural powers
inefficient;  if, therefore, embryotomy were  rejected  as  inadequate, the only
alternative would be the Ctesarian section, the  mortality of which  is much
greater, for 1 in 2^ of the mothers are lost; and 1 in 3^ of the children.
   It would, however, be a serious omission if I did not notice another alter-
native operation, which, although not available after labor has commenced,
may supersede the necessity for embryotomy  in subsequent pregnancies.  I
allude to the induction of premature labour.   In all cases where pelvic dis-
tortion renders craniotomy  necessary at  the  full time, it becomes our duty
to recommend the  induction of premature  labor in  subsequent pregnancies,
 at such a period as shall, if possible,  afford a  chance of life  to the child, or 
CRANIOTOMY.
373
at least save the mother from a severer operation, and not merely to recom-
mend, but to insist upon it.  No woman has a right to require us to destroy
successive children,  when  an operation  like this can supersede craniotomy.
The  mortality among the mothers is very small,  and  more than half the
children are saved.
  575. So much for the positive and comparative advantages of the opera-
tion.  I  am not aware that there can be any just objections against it,  in
suitable cases;  but undoubtedly there are most weighty objections against
employing  it without  careful consideration  and consultation.   In fact,  it
ought to be deeply impressed upon every practitioner, that he who destroys
the child, without due evidence that it cannot be saved, and that this is his
only resource for saving the mother, is guilty of murder.
  But it may be asked,  when the  responsibility is so serious, what evidence
will be sufficient to  satisfy a conscientious  practitioner  that  he may not  be
committing a crime in  his  anxious endeavor to afford relief?  To this it
may be answered :
   1.  That the continuance of strong labor pain for a certain time, without
any advance of the head of the child, is so far evidence of a fixed obstacle to
the passage of the child.
   2.  The failure  of a cautious  attempt to introduce the forceps  will, to a
certain extent,  demonstrate the amount of the disproportion between the
head and the pelvis ; and the failure of a careful yet firm attempt at extrac-
tion by the forceps  (when the application has been  effected), will prove that
 the disproportion cannot be remedied by compression.
   3.  A well-educated finger will enable us in most cases to ascertain whether
the diameters of the pelvis are such as will allow of the passage of a living
child.   And  even though this mode be uncertain,  we have a means of cor-
recting  our estimate, by  comparison with the  child's  head,  in  opposition
with  the pelvis.  If the natural efforts  after several hours, or the forceps
with a proper and  safe amount of compression and force, cannot bring the
widest part of the head of the child through the narrow part of the pelvis,
we may fairly conclude  that the only resource is craniotomy.
   4.  The general condition of the  mother will also  aid our decision.  If she
be much  exhausted, if fever be present, the uterus powerless, the life of the
child doubtful, and  the  success  of  the forceps dubious, we may shrink from
inflicting the  double shock of an unsuccessful application of the forceps, and
subsequent delivery by  the crotchet.  But these cases  are very rare ;  they
only happen when the patient has  been mismanaged, and it requires experi-
ence  and judgment to  decide upon the propriety of terminating  them  by
embryotomy.
   A careful consideration of these circumstances will, I think, enable us  to
arrive at a correct conclusion  in an individual case ; and as the  responsi-
bility incurred in the destruction of the infant may lead to timidity, it should
also be remembered that hesitation to act when the case is clear, involves a
more fearful responsibility, by compromising  the life of  the mother.
  576. The cases in  which the operation is demanded are those in which
the child is  dead, or in which  the character  of the labor will involve  its
death, or in  which it  cannot be  delivered alive by any means compatible
with  the safety of the mother.   The limits of the operation are rightly
restricted on the one hand by the extended use of the forceps, the induction
of premature  labor, and in certain  cases by version ; and on the other hand,
by the employment  of the Caesarian section.  Within these limits, the cases
suitable occur.
  1. When the child is dead and the labor tedious.  But we must be quite
sure that the  child be dead, before this is made the ground of interference.
If the head be putrid, and there is space  in the pelvis,  it is much  better  to 
374
CRANIOTOMY.
use the forceps, as the bones and integuments of the skull give way so easily
under the crotchet, that it is sometimes very difficult to extract the child.
I have seen  the operation prolonged two hours from this cause alone.
  2. In some cases of convulsions, rupture of  the uterus, etc., where imme-
diate delivery is necessary, and where the forceps cannot be applied, crani-
otomy must be  performed.
  3. In  flooding cases, before the head has passed through the  os uteri, if
the cervix be dilatable, the  child may be thus delivered ;  and this is pecu-
liarly desirable  when  the  flooding  is large and the child  premature.   Of
course it cannot be  attempted  when  the  placenta  covers  the os uteri, nor
must we have  recourse to  it unless  the woman is endangered  by the he-
morrhage.  In these  two  latter classes of cases, the child dies in  most cases
before we could possibly deliver it by any other means.
  4. In distortion of the  pelvis, when  the antero-posterior diameter of the
brim is less  than three inches, we have  no  chance of delivery by  the natural
efforts or by the forceps;  so that to save the mother we must destroy the
child.
  5. When  the transverse diameter of the lower outlet is diminished to the
same extent by the approximation of the tubera ischii, if the forceps applied
antero-posteriorly are insufficient to move the  head, we must have recourse
to craniotomy.
  6. When  the calibre of the pelvis is diminished  to a certain degree by a
fixed  obstacle — as, for example, a fibrous tumor,  or an exostosis growing
from the  bone  or periosteum, it may not  be  possible for the natural efforts
alone, or aided by the forceps, to expel the  child.   In such cases it will be
necessary to lessen the head and apply the crotchet.   In these three latter
class  of cases, the passage through the pelvis may be so  much diminished
as to render it necessary to break up the skull, or to eviscerate the child.
  7. In some cases of ovarian disease, where  the tumor has formed adhesions
within the  pelvis, so  as to prevent its being  pushed above the brim, it has
been found  necessary to lessen the head, before the child could be extracted.
We are not, however, to decide upon  this measure until the natural powers
have  had a fair trial, as it sometimes happens, that in the  progress of labor
the tumor is so  much displaced as to allow  of the passage of the child.
Further, before sacrificing the  infant, we ought to ascertain whether the
contents of  the tumor may not be drawn off, by passing a long trochar into
it.  If a  small quantity of fluid escape, it may allow of the application of
the forceps, and  so enable  us  to  save the  child.   If, however, the tumor
prove to be solid and  immovable, we must, as  a "dernier  ressort" have re-
course to the perforator and crotchet.
   8.  When the  child is  hydrocephalic to such an extent  as to  prevent its
entering or passing  through the pelvis, whether distorted  or of  the  natural
size, there can be no  question of the propriety of opening  the head.
   9. If an  arm  descend  along with  the head, the  diameters of  which cor-
respond closely to those of the pelvis (whether the  latter be of the usual size
or not),  it may be necessary to terminate the labor by opening the head.
   10.  I have already  alluded to  a class of cases, where, from mismanagement,
the patient  has been  allowed to continue too long without help,  and in con-
sequence is  greatly  exhausted, with fever,  quick  pulse, delirium, etc.  In
such cases the patient will  soon die  if she  be not  assisted ; and from the
unfavorable state in which she is, she cannot bear a prolonged  or  very
painful operation.   Xow  if there  be sufficient space  for the forceps, they
ought to be preferred, and it would  be very wrong  to use  the  perforator;
but if this  be  doubtful, and the probabilities against our succeeding with
that instrument, then  the  consideration of the patient's inability to bear a
severe operation may in  some  cases  decide  us in favor of embryotomy. 
CRANIOTOMY.
375
These cases, however, are but few, and they must be well marked, to justify
our adopting at once such extreme measures.
  11. In footling  or breech  cases, when  the  head (separated or not from
the body) cannot be extracted, we must evacuate its contents.
  577.' The next question to  be decided is the period of labor at which the
operation should be performed.
  1. In all cases where the diminution of the pelvic diameters is so great as
to render it impossible that a living child can be born naturally or extracted,
there can be no hesitation in  recommending that the head should be opened
at an early period  of the labor, say as soon as the os uteri is dilated or fully
dilatable.   By this means we shall afford a chance of the completion of the
labor by the natural powers, as  there can be no objection to waiting a few
hours before extracting  the child.
   2. When the distortion is  less, we cannot be sure  as to the result of the
natural efforts, and we must wait until it is evident that they are inadequate ;
then an endeavor should be  made to use  the  forceps, and if this fail, there
should be no delay in the performance of  embryotomy.
   3. These observations will apply equally to the case of morbid  growths,
 ovarian disease, etc., obstructing the passages.
   4. In cases  of convulsions, ruptured uterus, etc., the time  for the opera-
 tion is determined by circumstances connected with those accidents, and
 which  will  be found laid down in the chapters  on the subject.
   5. In cases where the child is dead, there need be no delay in performing
 craniotomy as soon as the delay  in the labor renders it desirable.
   [In  the  first volume  of the Transactions of the Obstetrical  Society of
 London, published 1860, there is a  very elaborate and highly  interesting
 paper by Dr. W.  Tyler  Smith, " On the Abolition of Craniotomy from Ob-
 stetric Practice in  all Cases where the Fcetus is Living and Viable."
   It is upon the  extension  and development of three  great conservative
 measures — the  use of  the forceps, turning,  and induced labor—that  Dr.
 Smith insists the diminution and abolition  of craniotomy must mainly depend.
    "Although," he remarks, " I would contend for the abolition of craniotomy
 in the case of living children, as a rule of practice, believing firmly that it may
 always be  avoided if we properly develop the whole of  the resources at our
 command,  I am not so Utopian as to expect that cases will not occasionally be
 met with in practice, in which perforation of the living  child will not only be
 necessary,  but a positive duty.   Cases will occur of deformity overlooked, of
 impaction from delay, and swelling of the  soft parts, of malpositions and mal-
 presentations unrectified, and other forms of dystocia, in which such a point
 of difficulty has been reached, that  either the  mother or the  child  must be
 sacrificed.   Under such circumstances, it would be the  bounden  duty of the
 accoucheur to craniotomize rather than allow the mother to perish.
    "But I  believe that such deplorable contingencies need never occur,  and
 that cases of this  kind,  when they do happen, ought to be considered as de-
 pending on some  error or neglect, and to  be held only as exceptions to right
 practice.   Nothing will tend so much to diminish or prevent such cases, as
 the establishment of the non-necessity of craniotomy as the rule  of practice.
 Considering the various means at our disposal in the way of preventing the
 necessity for craniotomy,  I do not hesitate to express  my strong conviction
 that, as the rule, craniotomy in the case of the living and viable child should
 be abolished, and  that if all the resources of obstetrics, in the way of preven-
 tion,  management,  and alternative  treatment, were properly wielded, the
 necessity for  the  operation would never occur.   There is no  department
 of medicine in  which, looking to what has been already done, there is more
 reason to  be proud and hopeful  for the future, than obstetrics."
    After referring to the fact that, in London, previously to the year 1670, 
376
CRANIOTOMY.
the deaths from child-birth, was 1 in 39, whereas it is now rather less than
1 in 200,—showing that two centuries ago, more than five women were lost
in child-bed where  but one now perishes,  Dr. Smith remarks, that, " look-
ing to the  results  obtained by the most successful  practitioners, there are
good  grounds for expecting that the deaths from child-birth may ultimately
be reduced to less than 1 in 1000.  No class of cases  admits of improved
management to a greater extent  than  instrumental labors, and  of these
craniotomy cases are by far the most fatal."   If the facts and  arguments
adduced by him are of any value, Dr. Smith believes  that they show that
" the  diminution or abolition of craniotomy must greatly diminish  the  loss
of maternal, as well as of foetal life.  Rightly considered, the interests of the
mother and child rarely if ever come into collision.  With the  one exception
of high  pelvic deformity, it may be laid down as  a moral axiom in obstetrics,
that the treatment which most certainly assures the safety of the  child, is
also the safest for the mother."]
   578.  Mode of operating.—It is not absolutely necessary for  the opera-
tion that the os uteri should be fully dilated, though it is a great  advantage,
and greater care will be required when this dilatation has not taken place.

                                 Fig. 147.
Use of the Perforator.
  The rectum and bladder are first to be evacuated ; the patient is then to
be placed on her left side, with the  hips  over the  edge of the bed, and an
assistant beside her, to fix and steady the abdomen.
  One or two fingers  of  the  left hand are then to  be  introduced  into the
vagina, and their extremities fixed upon that part  of the head of the child
which  is to be perforated.   Contrary to ancient practice, this should never 
CRANIOTOMY.
377
be the sutures, because after the opening is made in that situation, the bones
collapse and close it.  Having determined upon the situation, the perforator
is to be passed along close to the palm  of the hand  and  the  inside of the
fingers, so as to avoid injury to the soft parts of the mother.
  Having arrived at the point of insertion into the skull, guided and guarded
by the fingers of the operator, the perforator is to be pressed firmly forwards
with a semi-rotatory motion, until it pierce the bone  (fig. 147) ;  it is then
to be passed  in up to the shoulders, and the handles are to be separated by
an  assistant  as widely as possible (fig. 148).   The  cutting  edges of the
scissors are then to be  placed at right angles with the  first incision,  and
again separated, so as to make a  crucial incision.  This being effected, the
perforator is  to be passed into the  skull, the brain thoroughly  broken up,
and the medulla oblongata  cut across.  The scissors are then  to be with-
drawn, and the first part  of the operation is complete.
Fig. 148.
Use of the Perforator.
  The left hand is  again to be  introduced, as a guide  and guard  to the
crotchet, which should be passed  into  the  cranium for the purpose of com-
pletely breaking up the brain.  When  this object  is attained, if we-wish to
terminate the operation at once, the crotchet may be fixed on the outside or
inside of the head ;  the former was adopted by the older practitioners, but
the latter is recommended generally at  present (fig. 149).  In some cases it
is useful to employ two crotches — one internally and the other externally.
The scalp should be carefully folded over  the edges of the  bones, in order 
378
CRANIOTOMY.
to prevent injury to the passages, and then extracting force must be gradu-
ally and steadily applied during the pains, or at intervals, in imitation of
them, in the axis of the outlet through which the head is passing : the left
Fig. 149.
Application of the Crotchet.
hand  remaining in the vagina, and two fingers, being placed on the head,
opposite to the insertion of the crotchet, both for the purpose of steadying
it and of preventing mischief, if the instrument should slip.   If the part of
the skull in which the crochet is  fixed give way, we must  obtain another
purchase.  The amount of force, and its continuance, will depend of course
upon  the resistance to the passage  of the child ;  but if, after a certain time,
no progress be made, in order to  avoid contusion of the soft parts  of the
mother, it will be well  to break  up the skull with the forceps adapted for
that purpose  (fig. 138).  The perineum must  be carefully guarded, and  care
must  be taken that no injury be inflicted by the spiculse of bone.
   After the head is extracted, the body generally follows without much  diffi-
culty  ; but should this not be the case, we must have recourse to eviscera-
tion.   The scissors must be plunged into the  chest, and the contents broken
up: the. crotchet hooked upon the ribs, and traction exerted.  The contents
of the abdominal cavity may be evacuated in a similar way, and after this
we shall generally be  able to extricate the child.
   If  the craniotomy forceps  be  used, one  blade must be  passed into the
skull,  and the other on the outside, and  sufficiently far to secure  a firm  hold
(fig. 150); the blades then being closed, the operator must draw down firmly,
yet gently, and at intervals.
   In  the plate I  have placed  the instrument  on  the forehead of the child,
in order to show its application ; as a general rule, hovever, we would  seize 
CRANIOTOMY.
379
the occiput with them, unless there be special reasons for  preferring some
other part.
  579.  The principal difficulties of the operation are as follows :
  1.  If the bones of the  skull be very firm, it is not easy to perforate, and
the point of the scissors is very apt to slip.  This  can only be avoided by
great care and steadiness.
  2.  A similar state of the bones will offer a serious  obstacle to the insertion
of the  point  of the  crotchet;  but a little  perseverance will in most cases
Fig. 150.
Application of the Crotchet.
overcome it.   The fingers of the left hand placed on the outside of the skull,
will render it still more easy.
  3.  The  extraction may be difficult.  If the narrowing be not too great,
the difficulty may be overcome by steady force ;  but if such a degree as may
be exerted with impunity do not move the head, we must then break up the
skull, as already stated.
  580.  The dangers to which the patient may be exposed in this operation
are more serious than when the forceps is used.
  1.  The perforator may slip, and the vagina or uterus be wounded.
  2.  The  hook may slip, or the bone in which it is fixed may suddenly give
way; and if the hand of the operator be not interposed, a severe, or even
fatal  rent may be inflicted.
  3.  The perineum may be lacerated by the injudicious exertion of extract-
ing force.
  4.  From the condition of  the patient, she generally suffers more from the
shock to the nervous system, than in the  operations previously described.
  5.  There is also greater danger of subsequent inflammation of the womb
or vagina, with  perforation  of the bladder,  especially  if much force  have
been  necessary.
  After-treatment.—The nervous  shock will be best  remedied by  quiet,
small doses of opium, and moderate stimulation. 
380
CRANIOTOMY.
  The state of the vagina  and uterus should be  carefully  watched,  and
vaginal injections of warm water used occasionally.
  If any  symptoms of inflammation arise, they must be met  promptly by
the appropriate remedies,—venesection, leeching, calomel, and opium, etc.
  In other respects, if the  patient  go on well, she must be treated as after
natural labor.
  [Cranioclasm.—Dr. Simpson, of Edinburgh, has proposed, in cases where
labor can  be accomplished only by a reduction of the size of the child's head,
an  operation which  he denominates cranioclasm.   He believes  it to be an
easier, safer, simpler, and shorter operation than the ordinary one of crani-
otomy, and  one  which, inasmuch as it  is adapted  to dislocate and break up
the bones composing the basis of the cranium, diminishes to a much  greater
extent the size of  the child's head,  facilitating  thus, its passage through a
very contracted  pelvis, in which case alone is the  breaking up of the head
justifiable.
  In the performance of cranioclasm the instruments required are, 1, a per-
forator, to  open  the  head (fig. 151), and 2, a  cranioclast, to break down
the skull,  and extract the head through the pelvis  (fig. 152).

              Fig. 151.                           Fig. 152.
I
             The Perforator.                       The Cranioclast.

  The perforation of the head is effected in the  same manner and according
to the same rules, precisely, as in the operation of craniotomy.
  The perforator  used by Dr. Simpson is  so constructed that the blades
can be separated by the simple approximation of the handles.  As this can
be done with  one hand, the other is left free to guide and guard the point of
the instrument, rendering the assistance of another practitioner or a nurse
unnecessary.   The ends of the  handles are kept apart, during the passage
of the point through the skull, by means of a hinged bar, which allows of the
ready approximation of the handles, and consequent separation of the blades,
without it being necessary for the  operator to stop, after the instrument has
pierced the skull, to  remove  the straight solid bar which, in Naegele's per-
forator, is used to keep the  extremities of the handles asunder.   Dr. Simp-
son has, also, usually had the instrument made with an  angled indentation
at the base of each of its cutting edges or sides.   These lateral indentations
 
CRANIOTOMY.
381
prevent the point and edges from readily slipping out of the skull when the
instrument is opened, an  accident which has sometimes happened under the
use of the common form of the perforator or perforating scissors.
  The cranioclast is  of the usual length  and weight  of  the guarded crani-
otomy forceps employed in  British practice—being about 13 inches long,—
5^ inches from the tip to the middle of the button joint; its outer blade, at
its broadest point, one inch, and its inner blade, of course, somewhat narrower:
and the exterior of the length of the fenestra of the outer blade,  about three
inches.   It is a kind  of forceps with a movable button joint, so as to allow
the instrument to be  introduced either in  a fixed  form with the blades con-
 joined, or each blade separately, like  the common midwifery forceps.   The
inner or smaller blade is solid and convex, and serrated on the side by which
 it fits into the  concavity of the other larger fenestrated blade.   Both  have a
 slight curve to enable them to be adapted to the curved form  of the bones
 of  the cranial  vault.   The concave surface of the outer fenestrated blade,
 and the convex surface  of the inner  solid blade, are serrated with relative
 transverse ridges and grooves, so as to make the  hold of the  instrument as
 perfect as possible without the fear of lacerating  the included tissues.
   In using the instrument, the smaller solid blade is first introduced, through
 the opening made by the perforator in the vault of the skull, very deeply into
 the interior,  and then the other, or fenestrated blade, being passed over the
 occiput outside the  scalp, the two are made to  lock, after they have been
 pushed in this position as far down over the occiput as they can be made to

                                 Fig.  153.
 Sketch of the head of a child delivered by means of cranioclasm.  The size of the normal bend is
shown in outline in order that the dezree of diminution, which is effected during the operation, and
the change of form produced by it, may at once be more easily seen and understood. 
382
CRANIOTOMY.
go.  Then, by a slightly twisting movement, first on  the one side and then
on the other, the bone is at once and easily broken across, or dislocated be-
hind the foramen magnum.   This may sometimes be all that is required.   In
other cases it  will be necessary to pass  round  the blades  of  the instrument
over the parietal bones,  so as to loosen and comminute in the same way the
temporal bones,  or  it may be  found  advisable to  break away the frontal
bones from their base, or from connection with the sphenoid.
  An  idea of the extent to which  the base of the skull may be  and has
been reduced by means of the cranioclast, may be obtained by merely looking
at the annexed sketches (figs. 153, 154), which shows at  once the great

                                 Fig. 154.
IP:,--S
   Sketch of cast of the crushed head of an infant delivered by means of cranioclasm, and of the same
                 head in a renlistended state.  (Half the natural size.)

change in shape and size which the head has undergone during the pro-
cess of cranioclasm.
  The artificial  extraction of the child is not necessary in all cases of crani-
oclasm.   Occasionally, after the head has been reduced in size, the normal
uterine contractions are sufficient to expel the fcetus.  In the vast number
of cases, however,  the immediate artificial extraction of the child will  be
called for, especially if the operation of cranioclasm,  as will generally be the
case, has been deferred until the patient's constitution shows, more or less
markedly, signs  of  distress and suffering.
  Extraction may be effected by the cranioclast, in some instances, without
even shifting  it  from its  position  over the  occipital  bone, where, in most
cases, it is first to be applied.   In experimenting with the instrument as  an
extractor, Dr. Simpson has rarely or never seen it slip when a sufficient hold
was taken, and the previous comminuted condition  of the cranial walls is
not such as to prevent them from serving as  a sufficient and safe medium  of
prehension and  traction.  In some  cases the sides of the skull may afford a
better  and more secure hold than the  occipital region.  The following are
the advantages,  which,  according  to Dr. Simpson, cranioclasm has over 
THE CAESARIAN SECTION.
383
craniotomy.   1. It is, particularly in cases of any considerable deformity
and difficulty, far speedier and simpler in its performance than craniotomy.
2.  It saves the maternal passages from the  danger of  injury and laceration,
caused by the  successive withdrawal of portion after portion of the broken
and separated  cranial bases, as is generally requisite in craniotomy.   3.  It
diminishes the size of the fcetal head much more effectually than can be accom-
plished by craniotomy.  4. By craniotomy we cannot fracture and reduce the
size of the hard bases of the fcetal skull, as we can by cranioclasm.  5.  Hence
we have  ultimately the head in cranioclasm so much reduced that we can
extract it both much more easily for ourselves,  and, consequently, also more
safely for the mother.1]
                       C HA P TE R  XIV.

 OBSTETRIC OPERATIONS. —6. THE  C^ISARIAN  SECTION, OR  HYS-
                             TEROTOMY.

  581. So far, I think, our investigations have fully borne  out an observa-
tion  made in a former  chapter, viz., that obstetric  operations formed an
ascending series—each one exceeding the other in importance and danger;
and that whilst no  two could be compared in terms of equality, the value of
each was shown by its alternative, which is always one of greater danger.
Thus the  mortality  of  premature  labor is  less than  its alternative, the
crotchet; that of the forceps less than the crotchet; and we shall now see
that  inasmuch as when  it is employed early,  the  safety of the mother  is
nearly secured, the danger of embryotomy to her is far less than that  of the
Caesarian section.   This  operation is indeed the dernier ressort of midwifery.
Preferable as it is to  the certain death of both parties, it is far more  serious
in its consequences than any other operation.   It comes under the class of
operations already  noticed, in which  the life of mother  and child are  neces-
sarily more or less compromised.
  It  is  of very ancient date, being  known  to  the  Greeks, and  called
iatiaotofiotoxt.ri, or iixj3pioi%xrj•  but  I believe  by them only employed after the
death of the mother.  From the circumstances of several remarkable per-
sonages having entered the world in  this  way, it was deemed fortunate to be
so born—a royal road,  in  short, to distinction.   Pliny has recorded  that
Scipio Africanus was thus extracted.  He says, " Auspic'atius enecta  matre
nascuntur, sicut Scipio Africanus prior natus."  He is not correct, however,
in stating that Scipio was the first thus  brought into this world ;  Claudius
Cajsar, who  distinguished himself in the  war with  the Samnites,  having
preceded him.  From being thus "cut out" of their mother's womb, these
individuals were first termed  "Caesones," afterwards  "Coesares,"  on the
authority of Pliny, Festus,  Pompeius,  Solinus,  etc.    " Quia  caeso  matris
utero in lucem prodiscunt."  Caeso Fabius, who was three times consul, was
thus  extracted.  Julius Caesar is also stated to have  been brought into the
world by means of this  operation, although it is an error to state  that the
uame Caesar was given to him on this account, inasmuch as he inherited  it
  1 [Clinical Lectures on the Diseases of Women, by J. Y. Simpson, M. D., London Med.
Times and Gazette, May  8, June 9, 1S60.] 
384                  THE CJESARIAN  SECTION,
from his father.   Among  the  ancients, persons thus born were considered
sacred to Apollo, to which Virgil alludes in the lines—

               " Unde Lycham ferit exsectum jam matre premta,
                 Et tibi, Phoebe, sacrum."—JEneid, x. 315.

  Thus iEsculapius was  called the son of Apollo, because (it is said) he
was  brought into the world by hysterotomy.  For this reason, also, those
things in  Rome which were sacred to Apollo were preserved by the family
of the Caesars.
  Some modern  historians have  included  Edward VI., King of  England,
among those who benefited by this operation, and this statement is repeated
in some works  on midwifery.   I have taken  some trouble in tracing this
story, and  I find no reason to believe it to be true.  Sir John 11 ay ward, in
his Life and Reign of Edward VI., was  the first to put it upon record.  He
says,  " All reports do constantly run that he was not by natural passage
delivered into the world, but that his  mother's  body was opened for his
birth, and that  she died of the incision the  fourth day following."  That the
latter statement is inaccurate, is proved  by an examination of a ^\IS. of the
ceremonies of  her  funeral.   Queen Jane  Seymour died Oct. 24th,  1537,
twelve days after King  Edward's birth.   With regard to the mode  of the
king's entrance into life, I  shall quote the  words of the compiler of these
memoirs.   In the note he observes, that Sir John Hayward was the first to
record the fact, " for none of our historians that wrote before Hayward give
any countenance  to this, but only mention  her departure soon after,  except
it be Sanders, (whose pen was  not directed  so  much by truth as malice,) who
frames a story,  that when the Queen was in extreme labor, they asked  the
King whom he  would have spared — the Queen or his son ?  He answered,
his son, because he could easily find out other wives.  But yet even  he has
not a word of cutting the young infant out of his mother's belly."  This
story is manifestly fabulous, inasmuch as the fact  of the  infant being a son
could not be known before its birth, and otherwise the point intended by it
would be  without force, because  the king  had already  a daughter.   The
commentator adds, "that Dr. Burnet, now Bishop of Salisbury,  mentions
original letters in the Cotton  Library, that show how the Queen was well
delivered.    These letters are  exemplified  in  Fuller's  Church  History, the
one from the Queen herself and the other from her physicians, both written
to the Privy Council."  This evidence, I conclude, sets the question at  rest,
and I ought perhaps to apologize to my readers for occupying so much time
with it; but it  appeared to me to be well to ascertain the truth about it.
  There is also a tradition that Robert  II., King of Scotland, was born by
the Caesarian section,  an accident having happened to his mother.
  To return to the regular history of the operation.
  Rousset, about 1581, published a  treatise  on  the Caesarian section, in
which he quotes ten successful cases.  On one of the patients the operation
was performed six times;  she became pregnant a seventh time, and no one
being willing to  operate, she died  undelivered.   His essay was translated
into  Latin by Bauhin, 1661, and may be  found in Stach's collection.   To
this work of Rousset's, Bauhin added an appendix of cases ; he states that
he saw the operation performed seven times.
  There is no doubt that in many of these  cases the operation was unneces-
sary ; and  one cannot feel quite sure of the trustworthiness of the reports
of the cases.  Mauriceau even asserts that " that which Rousset reports of
the  Caesarian section is  nothing but the ravings, capriciousness, and impos-
ture  of their authors."
  There is no mention of the operation in Raynalde's work on the Byrthof 
OR HYSTEROTOMY.
385
Mankynde (1634), nor in the Childbearer's Cabinet, so that we are indebted
to the French and Germans for our earliest information on the subject.
  Ambrose Pare, whose work was translated in  1634 (having been written
in 1570), was opposed to the performance of the  operation  on the living
woman, on account  of .the danger of  hemorrhage, but recommends it for the
purpose of saving the child when the mother has died suudenly.
  In the translation of Guillemeau's work, 1635, there is a chapter on the
Caesarian section, which is recommended  immediately after the death of the
woman, "that thereby the child may be saved, and  receive  baptism."  "In
some  women,"  the  author observes, " I  have made  this practice very for-
tunately, and among the  rest,  in  Mad. le Mabre,  M. Philippes, my uncle,
being joined  with me ;  and likewise in  Mad. Pasquier, presently after she
was dead, Mons. Paraeus and the Curate  of St. Andrew being present." As
to performing it on  living women in  difficult labors, he says, "which for my
owne parte I will  not counsell any one  to, having twice made  tryall  of it
myselfe, in the presence of Mons. Params, and likewise seene  it done by
MM. Viart, Brunet, and Charbonnet, all  excellent  chirurgions,  and men of
great experience and  practice, who omitted nothing to do it artificially and
methodically.   Nevertheless, of five women in whom this hath  been prac-
tised, not one hath  escaped.  I know that it may be alledged that there be
some that  have been saved  thereby;  but though it should happen so, yet
ought we rather to  admire it, than either practise or imitate it".....
"After Mons. Paraeus had caused us to make trial of it, and seene that the
success was very lamentable and unfortunate, he left and  disallowed this
kind of practice, together  with the whole colledge of Chirurgions of Paris."
   In Chamberlen's  translation of Mauriceau  (1672), we find a  strong pro-
test against performing the  operation on living women, and great doubts
 expressed as to its having ever been successful.  He  admits its utility  when
 the mother is dead.
   Dionis, whose work was translated in 1719, has a chapter on the Caesarian
 section, which he recommends when the woman is  dead, but deprecates it
 during her life.  He describes the operation minutely.
   Sir. F. Ould, 1742, is the first British  author I  possess who  notices the
 operation,  which he says may  be performed " either while the mother is
 living, or after her death,  according to the nature  of the circumstances."
 Nevertheless, he observes that the " Caasarian  operation  is most certainly
 mortal, as we  shall  endeavor to prove presently from reason and the nature
 of the thing;  and I hope it will never be in the power of any one to prove
 it by experience."
   La Motte's work was translated in 1746.  He neither discredits the  cases
 related by previous authors, nor doubts the possibility of  success;  but  he
 observes, "the  os sacrum, ischium, and pubis, being from their  first confor-
 mation so close to one another, that the surgeon can hardly  introduce a few
 fingers between them, it being consequently impossible for the  child to  come
 through, is the only case where this operation is to  be put in practice."
   Burton, in 1751,  entered into a more minute detail than any of his prede-
 cessors, and gives  references to cases.   He concludes, that " seeing, there-
 fore, both reason and repeated experience confirm the possibility of  success
 in this operation, nothing should deter a  skilful operator from  performing
 it when it is absolutely necessary."1
   Smellie,  1751, takes, as usual, a sound  common-sense view of this matter:
 "When a woman,"  he observes, "cannot be delivered by any of the methods
 hitherto prescribed  and recommended in  laborious and preternatural labors,
 on account of the  narrowness  or distortion of the  pelvis, into which it is

                    i A New System of Midwifery, p. -12.
       25 
386
THE  CJESARIAN SECTION,
sometimes impossible to introduce the hand ;  or from  large excrescences or
glandular swellings,  that fill up the vagina and cannot be removed ;  or from
large cicatrices in that part and at the os uteri, which cannot be separated;
in such emergencies, if the woman is  strong and of a  good habit of body,
the Caesarian  operation  is certainly advisable, and ought to be performed ;
because the mother and child have  no other chance to be saved, and it is
better  to have recourse to an operation which has sometimes succeeded,
than leave them both to inevitable death."1
   The operation  is described  by  almost all authors, both English and Con-
tinental,  but with considerable difference of opinion, both as to its useful-
ness and the cases to which it is  applicable.   I shall not, however, occupy
the reader with further detail, but again refer him to my researches on Ope-
rative Midwifery for  those minute  particulars which  would be misplaced here.
   582. After  this short sketch, we may proceed  to consider the operation
itself, its object, and the means for attaining it.
   The objects  of this very formidable  operation are of extreme importance.
   1. To afford a chance of escape to  the mother, and of life to her offspring,
in cases where the child cannot  be extracted through the natural passages
by any means at our command,  or in cases  when the  extraction,  if com-
pleted,  would  be  almost  certainly fatal  to the  mother.   As to using
it as an ordinary substitute  for craniotomy, the proposal is simply absurd.
If the reader will turn to the appendix, he will find the question investigated
at length.
   2. To extract  the child  so promptly, as to  afford it a chance of life, when
the death of the  mother has taken place suddenly.
   3. To relieve the mother from the risk  of fatal inflammation, owing to
the presence of the fcetus in the abdominal cavity acting as a foreign body.
   583.  The nature  of the operation by which these objects are to be effected
is simple, viz., that  of cutting through  the abdominal and uterine parietes,
so as to come at  the child, and  then removing the  entire contents of the
uterus, and closing the external incision by  sutures and sticking-plaster.
   But though so simple, it is most dangerous.   Wounds of the peritoneum
of the simplest kind, though not necessarily and  invariably fatal, are  very
frequently  so.   In  most  cases, inflammation of the serous membrane  has
followed, and  in very many it has terminated in death.  There is  another
source of danger.   If the wound in  the uterus  should not  be completely
closed by its  contraction,  hemorrhage to a fatal  amount, from the uterine
sinuses,  may  occur, though  it is not  so frequent as was supposed by the
earlier writers.   This appears to  have been the cause  of death in the cases
related by Dr. Cooper and Mr. Thompson.
   The formidable nature of  the operation,  however, only makes it the more
necessary to ascertain clearly the grounds  upon wdiich  it is justifiable.  It
is  sufficiently evident,  from what has  been  already stated, that the older
practitioners  performed it unnecessarily;  this is  proved, I say, by the fact
that the same woman bore children afterwards without assistance.   Now, it
is an established axiom in midwifery, that the mother's life is not to be  com-
promised in  order  to save  the  child.  A  certain amount  of risk may be
fairly incurred, but beyond this,  the safety of the mother is  to be  secured,
 because that  is in our power, and if necessary, the child  sacrificed, because
it  cannot  certainly be  saved without sacrificing  the  mother.   In no  cases
 where the  mother's security can be  so purchased,  can we  be justified in
 having recourse  to the  Caesarian section ;  but there  are cases on record,
 where the pelvic outlets are so narrowed by distortion, that a mutilated child
 could  not be  dragged through.   In Mr. Thompson's case, the antero-pos-
 terior diameter of the upper outlet was only fths of an inch.  In Dr. Cooper's
1  Midwifery, vol. i. p. 239, Gth ed. 
OR  HYSTEROTOMY.
387
second case it was 1£, and the transverse  diameter of the lower outlet only
1 an inch.   In Dr. Young's case, the antero-posterior diameter of the upper
outlet was  1| inch.   In a skeleton in Dr. Hamilton's possession it was only
fths of an inch.   In  one  of Dr. Hull's cases (Ann  Lee) the  conjugate
diameter, taken from the symphysis  pubis to the projection of the sacrum
was  If inch, and  from the acetabula to the projection of the sacrum, l^ths
inch on each side.  In the  other case  (Isabel  Redman), the passage was
narrower, though the deformity was different.   " Out of 80 cases, the opera-
tion  was necessitated by  narrowness of the antero-posterior diameter of the
pelvis in 62.
                 Thus it was        1  inch in  1 case.
                                    H   "  in  8 cases.
                             H to 2    "  in 23   "
                             2" to 2i   "  in 25   "
                             2^ to 2§   "  in  5   <(1

  It is quite plain  that  a fcetus, ever so much mutilated,  could  not pass
through some of  these pelves, nor through any wdthout great efforts.
  Dr. Osborn, who was extremely cautious, and had a great horror of this
operation, has fixed  H inch antero-posterior diameter, by  3 transverse, as
the smallest space through which a child, after evacuation  of the contents
of the cavities, and the breaking up of the  cranium, could  be extracted by
the crotchet; but others  have deemed this impossible.  Certainly great risk
of injury to the soft parts  of the mother would  be incurred by the  force
necessary to drag the fcetus through so small a space, not  quite, perhaps,
but nearly equal to that resulting from the Caesarian operation.  Moreover,
there are cases on record by Drs. Shekelton and M'Clintock, in which a child
was extracted through  a  pelvis whose diameter was  about that  fixed  upon
by Dr. Osborn, and the mothers  died, one  immediately, and the other within
twenty-four hours.   In such cases, I agree with Dr. Murphy, that the risk
of the Caesarian section would be less for the mother, and we should give
the child a  chance.
  I  should, therefore,  conclude  that  when, from any cause,  the antero-
posterior diameter of the upper outlet, or  the  transverse diameter of the
lower, is not fully 1\ inches, there is no  possibility of delivery  "per vias
naturales,"  with safety to the mother,  but that we must have recourse to the
Caesarian section.
  [Dr. Meigs believes that the operation may be demanded  in different dia-
meters in different cases, and that it is impossible to fix a minimum diameter
through which a  female  may be delivered.  In  diameters of an inch or an
inch and a  half the  Caesarian section is of course inevitable.   Dr.  Meigs,
however, would not  hesitate to  recommend it in  a  pelvis the diameter of
which ranged from two to two and a half inches, where the patient is in im-
minent danger of  sinking, while in another and less pressing case—wdth the
same pelvic dimensions — where  the  patient had  sufficient  strength left to
bear the operation of craniotomy, he would as certainly advise the latter in
preference  to the Caesarian section.  Dr.  Meigs  relates  a  case where the
diameter of the pelvis was not beyond two inches, in which  he delivered by
embryotomy on two  occasions, and in which  the  Caesarian  operation  was
subsequently performed twice, successfully as to  both mother and child—no
change in the condition of the pelvis having taken place in the  meantime.]
  584.  Statistics.—But it  may  fairly be asked, what chance does so serious
an operation afford to either mother or child ?  The only mode of answering
this  question is by adducing the  evidence on record.   The following tables
contain a list of  British  and American  operations,  successful and  unsuc-
cessful.
                    1 Yelpeau, Traits des Accouch., p.  4! 7. 
Date.
Operator or Authority.
1	1737	Mr. K. Smith, Edinburgh
o	1773	Professor Young
3		Dr. White, Manchester
4		Mr. Wood, Edinburgh
5	1709	Mr. Thompson, London
G	1773	Professor Young
7	1774	Dr. Cooper, London .
8	1774	Mr. Chalmers, Edinburgh
9	1774	Mr. John Hunter
10	1775	Mr. Whyte. Glasgow
11	1777	Mr. Atkinson, Leicester
12		Mr. Clarke, Wellinguorouj
13	1794	Dr. Hull, Manchester
11	1798	"...
15	1795	Dr. Hamilton, Edinburgh
1(5	1798	Mr. Kay, Forfar
17	1799	Mr. Wood, Manchester
18	1800	Mr. John Bell. Edinburgh
10		Mr. Dunlop, Rochdale
•JO		Mr. Wood
lii		Dr. Kellie, Leith
• )•)		Mr. Kinder Wood
23	1813	Dr. Wallis
24	1817	Barlow and Cort
25	1821	Barlow and Dugdale.
2(5		Dr. Henderson, Perth
•2~	1820	Dr. Radford, Manchester .
28	1821	" . . .
29		
I. UNSUCCESSFUL CASES.
	Hours		Results	Results	
Patient's Name.	in	Cause.	to	to	References.
	Labor.		Mother.	Child.	
Patcrson	7 days		died	dead alive dead	Smellie's Mid., vol. iii. p. 423. MS. Lectures. Hull's first letter. Ibid.
Martha Rhodes	24 hours			alive	Med. Obs. and Enq., vol. iv. p. 261. MS. Lectures.
Eliz. Foster.	2 days	moll, ossium		"	Ibid., vol. v. p. 218.
Eliz. Clarke.	12 days			a a dead	Hamilton's Outlines, p. 339. Med. Obs., vol. v. Hull.
El. Hutchinson	8 days	moll, ossium		alive	Hull, p. 67.
	3 days			dead	Mem. Med. Soc, vol. v.
Isabel Redman	12 hours	moll, ossium		saved	First Letter, p. 162.
Ann Lee	10 days			dead	Ibid., p. 172.
Jean Douglass	2 days 3 days	malacosteon		alive	Outlines. Hull's letter.
El. Thompson		distortion		saved	Mem. Med. Soc., vol. v. Med. Cliir. Trans., vol. iv. p. 347.
Susan Holt .				alive	Hull's Baudeloc, p. 134.
H.Rlieubotliam	24 hours			dead	Med. and Phys. Journal, vol. vi. p. 340. Ed. Jour., vol. viii., p. 11. Med. Chir. Trans., vol. vii. p. 204.
	48 hours	tumor		saved	Med. Times aud Gazette, March 12, 1853.
Ann Hacking				alive	Barlow's Essays.
Mrs. Ridgedale				"	Merriman. p. 317.
Mrs. Lowe .	18 hours	distortion		a	Ibid.
Mary Ashwell	34 hours	"		dead	Ed. Journal, No. 140.
Mary Nixon	19 hours	a		lost	Ibid. Pamphlet, 1849.
 
II. UNSUCCESSFUL CASE.S —CONTINUED.
30
31
33
34
38
39
40
41
42
43
44
45
40
47
48
49
50
51
52
53
54
1848
1851
1843
1853

1854
1850
1850
1858
1858

1826
1829

1834
1841
1843
1845
1847
1849
1850
1848
1848

I860
Operator, or Authority.
Dr. Merriman  ....
Dr. Shipman  ....
Drs. Cyrus Falconer and Goodman

Dr. Radford   .

Dr. Waller

Dr. Simpson
Mr.  Humphrey
Dr. Clay  .    .
Dr. Murphy
Dr. R. Greenhalgh  .
Drs. Douglass  and Vanvalsah
Dr. Crichton
Dr. M'Kibbin, Belfast
Mr. Ward
Dr. Montgomery, Dublin .
Mr. Ross, Invergordon
Dr. Elliott, Waterford
Mr. Whitehead,  Manchester
Mr. Braid
Messrs. Bailey and Hardy
Mr. Lyon,  Glasgow .
Mr. Skey,  London  .
Mr. Campbell, Disburn
Mr. Nimmo, Dundee
Dr. Shipman,  U. S. .
Dr. Sannerman
Dr. West, London
Dr. Oldham, London
Patient's Name.
Betty Wilcock
Will
Hours
 in
Labor.
17 hours
48 hours
12 hours
14 hours
17 hours
0 hours	distortion
	fib. tumor
	moll, ossium
	tumor
	distortion
6 days	exostosis
	fib. tumor
5 days	tumor distortion
  tumor
distortion
 tumor
distortion
Results
  to
 Child.
 saved
 dead
 saved
twins "1
saved j
 saved

 dead
saved
dead
saved
dead
alive
dead
alive
dead

saved
dead
saved

dead

saved
dead
Amer.  Jour., vol. xviii. p. 122.
Amer.  Jour. N. S., vol. vi. p. 204.

Assoc.  Jour., Jan. 19, 1856.
Med. Times and  Gazette, vol. xxvii. p.
  206.
Brit. Med.  Jour., 1854, p. 1066.
Ibid., 1856, p. 779.

Dub. Jour., No.  0, 1859.
Med. Times and  Gaz., May,  1858.
Amer.  Med. Journal.
Ed. Jour., July,  1828, p  53.
Ibid., Nov.  1831,  p. 352.
Lancet, Mar. 28,  1840.
Dub. Jour., vol. vi. p. 418.
Ed. Monthly Jour., 1842.
Letter  to the Author.
Ranking, vol. vii. p. 330.
Ed. Monthly Jour., Dec. 1845.
Hanking, vol. v. p. 293.
Ibid., vol. x. p. 330.
Ed. Monthly Jour., Sept. 1850.
Amer. Med. Jour  , July, 1849.
Lancet. July 13, 1850.
Med. Times, Feb.  22, 1851.
Ibid. 
II. SUCCESSFUL CASES.
Operator, or Authori	ty.			Patient's Name.	Hours in Labor.	Cause.
Mary Dunally, Midwife Mr. Barlow Mr. Cellen, New York Dr. Richmond, Ohio, Ame Mr. Knowles, Manchester Mr. Greaves, Rockingham Mr. Gibson, New York, A Dr. Fox . Mr. Goodman, Manchestei Dr. Henderson, U. S. Dr. Radford . Dr. Thornton, Dewsbury Mr. James Hawkins Dr. Oldham Dr. P.rodie Heron Dr. W. 11. Merriman				Alice O'Neal Jane Foster Mrs. Sankey Mrs. Haigh Anne X— . Mat. Tanner same patient	12 days 5 days 5 days 5 days 3 days 2 days	distortion distortion exostosis dis. of sacrun distortion scirrhus
Results
  to
Mother.
Results	
to	References.
Child.	
dead	Ed. Medical Essays, vol. v. part 1, p.
	439.
n	Med. Rec. and Res., p. 154.
saved	New York Journal, March, 1823.
cc	Western Medical Journal, November,
	1827.
	Trans, of Prov. Ass., vol. iv.
saved	Lancet, 1833-4, p. 148.
"	American Journal of Medical Science,
	May, 1835.
a	Lancet, March 28, 1840.
tt	Ibid., 1833-4, p. 148.
tt	Ranking, vol. vii. p. 239.
putrid	Ibid., vol. v. p. 293.
saved	Prov. Medical and Surgical Journal,
	August 22, 1849.
a	Ranking, vol. x. p. 212.
a	N. Orleans Medical and Surgical Jour-
	nal. November, 1850.
a	Med. Exam., September, 1850.
dead	Southern Medical and Surgical Journal,
	March, 1851.
<«	Lancet. March 28, 1857.
saved	Medical Times and Gazette, May 8th,
	1858.
«	Lancet, vol. ii. p. 220, 1851.
dead	Amer. Jour. N. S., vol. xii. p. 386.
	Ibid., vol. xxxi. p. 507.
	Ibid.
 
OR  HYSTEROTOMY.
391
  Thus in British and American  practice, out of 79  cases, 23 mothers were
saved and 56 lost, or more than two-thirds.
  Out of 77 cases where the result to the child is mentioned, 44 were saved
and 33 lost, or nearly one-half.
  In  addition, I have collected  from  foreign authorities 371 cases, out of
which 217 mothers recovered and 154 died,  or about 1 in 2|.x   Out of 189
of these cases  where the result to the child is given, 139 were  saved and 50
lost, or nearly one-fourth.   Taking the entire number, which amounts to  450,
we  find that  230 mothers were  saved and  210 lost, or about 1 in 2 ;  and
that out of 315 children, 211 were saved and 104 lost, or about 1 in 3^.   M.
Figuiera collected 790 cases, of which 424, or nearly one-half, were fatal to
the mothers.
  In  Nassau, Dr. Ricker says,  that in  311,409 cases, there were 12 cases
of Ca_'sarian section, 2 mothers and 7 children were saved.
  As to the value  of each  case, that  must depend  upon the reporter.   I
have  not felt it my duty to exclude  any which are related upon definite
authority—my endeavor throughout has loeen to ascertain that authority as
far as possible, and to  avoid repetitions.  For so much  I am  responsible,
and I trust I  shall be found  correct.   It may, however, be objected to this
catalogue of operations, that many of the cases occurred in the " dark ages"
of  midwifery and may perhaps have been exaggerated or invented.  Sup-
pose  that  we admit  this, and only take those  which  have occurred since
 1750, this calculation  gives 321  operations, from  which 149  mothers re-
covered, or more than one-half, and by which 130 children were saved, and
 57  lost, in 182 cases where the result is mentioned.
   Dr. West has collected 409 cases, of which 251 (considerably more  than
 one-half) proved fatal to the mothers, 237 children were saved.
   Dr. Arneth mentions that Kayser  has collected  and analyzed 338 cases,
 of  which number 210, more than half,  proved fatal to the mother;  86 of the
 children were either dead born or perished soon after birth.
   585.  Further: *«& a good number  of these  patients  the  operation  has
 been performed more than  once ; on  some, three and four times.   And if
 we credit the older writers we find five, six,  and seven times with success.
   This is shown in  the following table :—

  1 I do not mean that  so many mothers were saved from  death by the operation, but
 that they were saved from the  effects of the  operation.  No doubt, many were really
 saved from death, which could not have been otherwise  avoided; but we have proof that
 many could have  been  delivered by other  means, inasmuch as  they afterwards bore
 children naturally.
  In 11 cases recorded in foreign journals since my tables were constructed,  I find that
 six mothers were saved and five lost;  eight children were saved and three lost. 
392		THK C JF.S A RIA X S Er T 1 0 N			■	
1				No. of	No. of	
No. 1	Date.	Operator or Au-thority.	Patient or Place.	Opera-tions.	Children saved.	Result to Motliers.
		—Guillet		6 times	6	saved.
2	)	Le Noir aud Le-		3 times	3	recovered.
		brun				
3	.	M. Jobert		twice	1	"
4		M. Peyronnie		"		"
5		M. Sommius	his own wife	7 times		"
6	: '}	A Surgeon at) Paris /	his own wife	5 times		'•
7				3 times		"
8			At Aucois 0 times			"
9		Count Nessan		7 times		"
10	1775-9	M. Lambron		twice		"
1 11 12 13	17971 1801 I 1805 j	Mangold and "1 L. Mautz /		3 times	: :*	recovered twice— died after 3d.
14	1797 | 1806/	M. Bacqtia	—Gabery	twice		recovered.
15	1796-1 1810 r	Rhode and"I Sommer /				
16						
17 18	1802 \ 1805/	Lorinzer	Groger	•'		a
19	/18051 17-14/	M.le Maistre 1 d'Aix /	—Fauve	3 times		do. died after 3d.
20	1313,'15	Dr. Charmeil		twice		recovered.
21	M817) \1819 /	M. Locher		<•		recovered once— died 2d time.
22	1821,'20	M. Merrin	—Viandes			recovered.
23	1823	M. Bosch		"		j
24	1823,'25	M. Schenck		"		"
25	1805, '07 f 1826, )	M. Dariste	Martinique	•'		"
26	\ 30,32 [ I 39 J	M. Michaelis	—Adawetz	4 times		"
27		Dr. Zwancke				
28 29 30		Weidemann, ~1 Michaelis /		4 times		recovered.
		Dr. Boowin		twice		recovered.
31	.	M. Gardey		"		.'
32	f 1825) \1826/	Dr. Schmidt		"	■ -\	recovered once— died 2d time.
33	/ 1824 \ \1826 f	Dr. Engletrum	Amsterdam	::{	2 \ saved (	recovered once— died 2d time.
34	1833.''35	Dr. Bouvin				recovered.
35	1832, '38	Dr. Kilian		n		a
36	/ 1837 \ 1843	a		»		a
37	f 1840 \1844	Dr. Mesten-1 hausen /				
				('		it
38	J1846	Drs. Bach ) and Stolz /		-		ii
39	•	Dr. Wieckel		thrice		'< 1
  M. Stolz has also published a case in which he performed the operation
twice with success.1
  [Professor Stolz, of Strasburg, has reported not merelv one, but six cases,
in which he  has performed the Csesarean section.   In four of these cases
i Med. Circular, Aug. 22, 1855, p. 89; Ed. Med. Journal, Aug. 1855, p. 179. 
OR  HYSTEROTOMY.
393
both mother and child were  saved by the operation, but in the other two
the child only.]
  Dr. Simpson mentions that, when he visited Bonn, he saw a  woman upon
whom  Kilian had operated three times successfully, and who  was looking
forward to a fourth operation,1 which my friend, Professor Retzius, of Stock-
holm, informs me has since been successfully performed.
  [Professor Gibson, formerly of Philadelphia, operated twice on the same
patient, and both times successfully for mother and child.2]
  Dr. Decoene has recently performed  hysterotomy in  a case of ruptured
uterus, for the purpose of removing the children (there were twins) from a
woman on whom  he had  formerly performed Caesarian section.  She  re-
covered the  more recent as well as the former operation.3
  586.  After a careful examination of the cases on record, it  appears that
a certain amount of success has  attended the operation, and  that modern
improvements have rather  increased  the number  of recoveries; so that I
think we may fairly conclude,  that as  so  many women  have recovered from
the operation, it does afford a chance to both mother  and child, and that
therefore we may be justified in  having recourse to  it;  but that, as  the
danger is much,  greater than  from any other operation, we should not be
warranted in performing it, if there  were a prospect  of success  by other
means.
  This, then, constitutes the sole  advantage  of the  operation,  that in cases
where ice cannot deliver the  patient  with safety by any other means, and
when,  consequently, both mother  and child  would inevitably  die, we may
afford each  a chance by performing the Ccesarian section.
  It has no  comparative advantages,  being itself the ultimate standard by
which the other operations  are to be  estimated,  and which are  valuable, in-
asmuch as they afford a means of escape from this more formidable one.  In
this point of view I must not omit noticing one which, although  not avail-
able in any case  to which we are  called  at the time of  labor,  may prevent
the necessity of a second operation.  I allude to the artificial  induction of
premature labor, or of abortion.   Whenever the  diameters of the  pelvis
are so  reduced as to render the extraction of a mutilated fcetus impossible,
or even hazardous, I conceive that it would be grievous neglect of duty not
to propose  this  alternative ;  nay, more, I really think we have a right to
insist upon  it; for surely,  it  can  hardly be  expected  that  a conscientious
medical man will consent to destroy child after child, or to  subject mother
and child to the fearful risk of the Caesarian section, when a  means of avoid-
ing it is in his power.   It is true that by this operation the child may be
lost, but the  mother will, in all probability, be saved; and the  bare chance
of saving the child by Caesarian  section, can never compensate for the ad-
ditionnl risk  to the mother.
  [It is very certain that nothing can justify a resort to the Cassarian sec-
tion in  any case  in which there is a fair  prospect of the labor  being termi-
nated with safety to the mother, either by the unaided powers of the uterus,
or by instrumental assistance.   Formidable as the operation  must be viewed
under all circumstances, modern statistics have shown us, nevertheless, that
when it is resorted to early in labor, it is attended with less  danger than
was formerly ascribed to it, and  that it affords a chance in a  considerable
number  of cases, for the escape of  both mother and child from the almost
certain  death which must happen to both if it were  omitted.]
  587.  The  disadvantages  of the operation will  be easily gathered  from
what has been said ; they are  mainly,  the great  risk of  hemorrhage  or  of

  'Edin. Monthly Journ., Julv, 1850.    2 [Amer. Journ. Med. Sciences, May, 1838.]
  3 Med. Times and Gaz.,  May 21st, 1853, p. 630. 
394
THE  CAESARIAN SECTION,
fatal peritonitis to the mother, and the small chance afforded to the child ;
these constitute the objections to the operation.
  That these  are very serious  objections  cannot be denied, nor that they
would  be insurmountable, had  we  any  other mode  of delivery.   Put when
we consider that the only choice is between this operation, which does afford
some chance,  and certain death to both  mother  and child, we cannot, I
think, hesitate about running the risk.   Doubtless, however, the dangers of
the operation should make us pause, and carefully examine the  facts of the
case, with the aid of the  experience of others, before we decide upon this
proceeding.  In the present day it would be an indelible disgrace to an ac-
coucheur, that  his  patient, after recovering from  the Caesarian operation,
should bear children without assistance.
  [We are informed by M. Castel,  that in  a  case which occurred  in one of
the French  hospitals, the Ca?sarian section being determined on, some delay
took place in accommodating with seats the  crowd of students  who had as-
sembled to witness the operation :  during the time  thus occupied the female
was  delivered  naturally.   M. Gomelle states  that at the  hospital of M.
Dubois, a small woman, who had five times submitted to the Cassarian sec-
tion, was delivered naturally the sixth time.]
  588.  The cases suitable for the operation  are not very numerous.
  1. When the pelvis is  so distorted  from  any  cause that the  diameter of
the upper or lower outlet is reduced to  an  inch  and a half  or two inches, it
may be considered  impossible to extract a mutilated fcetus;  or, if possible,
it must be  with so much force as to entail the death  of the mother.  The
operation is equally necessary under these circumstances, whether the child
be alive or dead, and it may also  be required  (in  consequence  of mollities
ossium) after several children have been born naturally.
   2. Morbid growths from the  periosteum,  which  offer a fixed and perma-
nent and increasing obstacle, may so much reduce the calibre of the passage
as to render this operation necessary.   This was the case with the  patients
of Dr. Montgomery and Dr. Shekleton.   But before we decide upon the ne-
cessity for this mode of delivery, we must be  quite sure that  the  obstacle
can neither be displaced  nor reduced in volume ;  and this can  seldom be
determined until labor commences.  On the other  hand,  we must remember
that all tumors increase, however slowly, and  that, therefore,  the patient
having been delivered "per vias naturales" in one labor, is no proof that
she may be in the next.
   3. In some cases of  ruptured uterus, when delivery is imperative, but im-
possible "per vias naturales,"  Cassarian section  has been recommended.   It
appears to me that the additional risk  from  the  operation renders  its pro-
priety very questionable.
   4. The operation has been performed successfully in cases of extra-uterine
fcetatiou,  where the continued presence of  the fcetus in the abdominal cavity
threatened the mother's life.
   5. In case of the sudden death of the mother, the Cassarian section may be
performed for the  purpose of saving the infant.   Successful cases are  on
record ; and one recently  by  Mr. Harlay,  in Edinburgh.1  Of course  the
operation  will be useless, unless the woman have arrived at that period  of
pregnancy when the child is "viable."  It will also be in vain if much time
have elapsed after the death  of  the  mother.   Dr. Jackson,  however, re-
covered an infant half  an hour after the death of the mother.
   6.  If, towards the end of pregnancy, the uterus be wounded extensively,
Dr. Hull considers the Caesarian section necessary.
   7.  Authors have mentioned other cases to which the operation was appli-
1 Edin. Monthly Journal, July, 1850. 
OR  HYSTEROTOMY.
395
cable, as  in  occlusion to the vagina, scirrhus uteri, etc.   But these hardly
appear to be adequate grounds for so serious an  operation.
  589. The best period for the  performance of the operation appears to
be at the commencement  of the  labor, provided there be no doubt of its
necessity.  The strength of the woman is then unimpaired, and she can not
only support the operation better, but has greater prospect of escaping sub-
sequent inflammation.   It is supposed, and  I think not without foundation,
that the ill success which has attended the operation in this country is partly
owing to the late period at which it has been undertaken.
  In  Mr. Thompson's  case, it was performed 24 hours after the commence-
ment of labor ;  in Dr. Cooper's,  12 hours ;  in Mr. Chambers' case the labor
had lasted 12 days;  in Dr. Hamilton's, more than 2  clays;  in  Mr. King's,
more than 3 days; in  Mr. Atkinson's, nearly 3 clays; in one of Dr. Hull's
(Isabel Redman), 12 hours; in  the  other (Ann  Lee), 10 days;  in the case
of Mary Donally,  12 days;  in Mr. Barlow's case, 5 days.  Dr. Hull pro-
poses to operate as soon as the os uteri is dilated, and  before the membranes
burst.   De  Graafe advises the  operation  to be performed just  after  the
rupture of the membranes, and the commencement of the expulsive  pain.
   590.  Method of  Operating.—Having  determined upon the necessity,
 and the  proper period for the operation, the next subject for consideration
 is the best mode of performing it.   Very little alteration has taken place in
 this respect  since the earlier writers.
   The bowels  and bladder are to be evacuated, and the patient placed on
 her back, upon  a table covered  by a mattress.   Her fortitude must decide
 upon the necessity for restraint, and  its amount,  if chloroform  be not used.
   Before commencing the  operation  it will  be proper to ascertain (by the
 stethoscope) the situation of  the placenta, or,  at least, that it be not in
 front.  The incision through  the integuments must  then be  made, either
 vertically, through the linea  alba — obliquely, on the outside  of the rectus
 muscle — between that muscle and the spine — or horizontally, beneath the
 umbilicus.   The latter is the best if the patient be deformed.   It should be
 about eight  or ten inches in length, and when vertical, it may be commenced
 a little above the umbilicus, and terminate near the  pubes.   This incision
 should divide the parietes of the abdomen down  to the peritoneum, which is
 then to be cautiously punctured, and a director, or the finger, inserted into
 the wound, so as to avoid injuring the intestines, and the peritoneum divided.
 The  uterus  will now be exposed, and an incision must  be made  into, but
 not through its parietes, of the  same length as  that through the abdominal
 parietes.  This incision must be cautiously deepened, until the membranes
 are exposed.   A slight opening must then be made in  them,  and some of
 the liquor amnii removed, by small pieces of sponge.   It has occurred to me
 that this might most  readily be effected by a syringe.   The object in view
 is to prevent effusion into the abdominal cavity.  By Lauverjat and others
 we are recommended to rupture the membranes previously.  The opening
 is  then to be  enlarged, and the infant withdrawn, the funis  tied, and the
 placenta and membranes removed.
    The remaining liquor  amnii,  with any blood  which  may have  escaped,
 must be removed from the cavity of the  uterus, and the operator should
 make sure that the os uteri is pervious for the  escape  of the  lochia.   No
 sutures  are required in  the uterus :  as it contracts,  the wound will be
 reduced to about \\ to 2  inches in length, and the. lips will come into appo-
 sition, if it  be  healthy.   It is only in  cases where they do not do so, that
 there is anything to fear from   hemorrhage.  When  the uterus is diseased,
 the wound does not close perfectly,  and of course, union cannot take place.
    The abdominal cavity is next to be lightly sponged, to remove any blood
 which may have  escaped,  and  then, the intestines being  retained " in situ " 
396
THE  CAESARIAN  SECTION.
by an assistant, the lips of the external wound are to be closed by so many
sutures  of silver or iron  wire as may be necessary.   Dr. Monro, of Edin-
burgh, advised "that  in  performing the  Caesarian operation, we should be
careful  that the  viscera be exposed as little as possible ;  and that the sides
of the wound should be  kept contiguous by a greater number of stitches
than are  commonly employed in  wounds, in order to  exclude the air from
the cavity of the abdomen."   In addition to the sutures, straps of adhesive
plaster  may be applied, and over all I would suggest Dr. Macartney's water
dressing.   The patient must then be placed in bed, and  the  utmost  quiet
observed.  Stimulants  will  probably be necessary  during and  after the
operation ; and when the patient is settled  in bed, an opiate may be given.
  As a variation from this mode of operating, I  may mention Dr. Aitken's
suggestion of performing it " while the parts are immersed in tepid water,
so as to exclude  the air," and so, perhaps,  diminish its fatal  effects.   I do
not know that this plan has ever been tried.
  M. Roubaix, in an elaborate essay on this subject, lays down the following
objects  at which we  are to aim in performing the opsration :  1, to prevent
the entrance of air into the peritoneal cavity and  uterine sinuses; 2, to pre-
vent the effusion of blood  and liquor amnii;  3, to  make the incisions in such
a manner that union by first  intention  may be encouraged as far as possible;
4, to take  precaution  against inflammation of neighboring  tissues;  5, to
perform the operation  at a favorable time.1
  591.  The difficulties of the operation are not great.  With a little care,
we  may avoid that part of the uterus to which the placenta is attached, and
which is the most vascular, as the stethoscope, previously applied, will indi-
cate whether it is  situated  anteriorly  or  not.    Caution will  also avoid
wounding the child when  dividing the uterus.
  In approximating the lips of the external wound, the intestines are some-
times troublesome, and it is of importance not to include any of them, as that
would add the dangers of strangulated hernia to the unavoidable risk of the
operation.
  The principal dangers  of the operation are—
  1. Hemorrhage,  from the incomplete closure of the wound in the uterus.
  2. Strangulation  of a  loop of the intestines, either in the wound of the
uterus,  or  in  the external wound, although due  attention will avoid  this
danger  altogether.
  3. Subsequent inflammation of the  uterus and peritoneum.
  The patient may die of the shock within  a few hours, or her  strength  may
be exhausted by hemorrhage into the  abdominal cavity;  but if she survive
for a day or two, her death will then probably be  owing to inflammation.
  592.  Subsequent treatment.—The most incessant care  and  attention will
be  required.   The  water-dressing should be continued,  and  it may be as
well to  administer small doses  of calomel  and opium.   On the first appear-
ance of inflammation at the  edges of  the wound,  leeches should be applied
along it, and if there be tenderness, a considerable  number should be applied
over the abdomen,  and repeated if necessary, and the doses of calomel and
opium increased.

  1 Prov. Med. and Surg. Journ., Oct. 30th,  1850, from Encyclographie for June, 1850. 
SYMPHYSEOTOMY.
397
                       CHAPTER  XV.

         OBSTETRIC OPERATIONS. —7. SYMPHYSEOTOMY.

  593.  But  one more operation remains for consideration, and I  should
have omitted it altogether, had I not felt it as much a duty to point  out its
inapplicability, as the  suitability of the others to the cases for which  they
were intended.   I do not for a moment wish to undervalue the humanity
which desired to  substitute a minor operation for one so formidable  as the
Caesarian section.  But when the results of experience support the opinion
of the wisest and best midwifery authors, it would be a criminal neglect did
I not adduce the objections to this operation in their strongest form.
  First, however, it may be interesting to give a sketch of  its history.
  M. Sigault, while yet a student, being impressed with the fatal results of
the Caesarian section, conceived that it might be altogether avoided by an
artificial  separation of the ossa pubis.   This notion was  based upon the
assumed  fact, that this joint spontaneously separates in difficult labors.
This had been asserted over  and over again by the  older writers, and upon
this assumption  Sigault based his experiments upon the dead body.   In the
year 1768, he presented a memoir to the Faculte de Medecine on the subject,
proposing that the operation should be tried at first upon animals, and  then
upon condemned criminals.   The  memoir was referred to  M. Ruffel,  who
reported  unfavorably, and the subject was dropped.   However, M. Sigault
was  not  discouraged :  he  again proposed it in his Thesis,  on  taking his
degree  at Angers, and in Paris, on seeking for his license ;  and as the  pro-
posal was communicated to others, and favorably received, it excited a good
deal of interest.
  In M. Alphonse Le Roi, Sigault met with an able second, and  they deter-
mined to give the operation a fair trial the first opportunity.  This occurred
on the  1st October,  1777, in  the case of ----Souchel, who  had  previously
been delivered by craniotomy.  She was  safely delivered by the new  opera-
tion, and a report was immediately made to the Faculte de Medecine, who
were requested  to appoint a commission to superintend the patient's reco-
very.   MM. Grandclas and Descemet were appointed to this office, and not-
withstanding that the bladder was injured, and  the mother barely escaped
with life, such was the enthusiasm excited  in the  Faculte de Medecine by
their report,  that  they lost  sight of  the calm investigation becoming  a
learned body, and on the strength of  one case — and that  not a very satis-
factory one — voted medals  to  MM. Sigault  and Le Roi, and procured  a
pension for the former and for his patient.
  The inscription upon the medal was :—

                A. 1768.  Sectionem Symphyseos Ossium
                      Pubis.  Invenit. Proposuit.
                               A. 1777.
                            Fecit feliciter
                         M. Sigault, D.M.P.
                 Juvat M  Alphonsus Le Roi,  D.M.P.

  Persons were  not wanting to applaud the  inventor  and  his operation,
which was characterized as "the result of inspiration," and several  practi-
tioners  in France and Germany  followed his example. 
398
SYMPHYSEOTOMY.
  M.  Sigault himself operated on four other women, one of whom died, and
several of the children.   He seems, indeed, to have become less confident in
its safety and efficacy; for he refused to perform it unless there was a space
of 2\  inches in the short diameter ; and before his death, in such a case,  lie
recommended the Caesarian section.  " It was soon found, however, not to
merit  the high encomiums bestowed upon it.   Every operation was found
to have  its victim, although it was several times performed upon  women,
whose pelves were either not at all, or very slightly  deformed, and  who,
either before or after the operation,  were delivered without any extraordinary
assistance—a convincing  proof that the operation  had been, in these cases
at least, unnecessarily resorted to."1
  In  1778, he published  a " Discours sur les Avantages de  la  Section du
Svmphyse  du Pubis," in  which he  examines the usual means  of assisting
difficult labors,  and concludes  by  stating his reasons for preferring Symphy-
seotomy to the  Caesarian  section.
  The first  persons, I believe, who investigated  the propriety and efficacy
of the new operation in this country, were Dr. W. Hunter, Mr. Hunter, and
Dr. Denman.   The former published the result of his inquiries in the Lon-
don Med. Obs.  and Enquiries.   " The  women of  Great Britain," says Dr.
Osborn, " are therefore under considerable obligations to the late Dr. Win.
Hunter, who, from an accurate mensuration of those pelves where the Caesarian
operation had  actually been performed in this country, and  of others still
smaller, preserved  in  his museum, has demonstrated the  futility of the sec-
tion  of the symphysis  as a succedaneum for that operation,  or  as a certain
means of  preserving  both the mother and child."   He  suggested a combi-
nation of the Sigaultian operation with craniotomy, as affording the  mother
a better chance than  the Caesarian section.   But, as Dr. Osborn remarks,
"Prof. Guerard's case is exactly in point, and confirms  by experiment  what
was to be expected & priori.   The child's  head in that case was  opened,
after  the division of the symphysis  had  been performed; but  the professor
was, notwithstanding, foiled in every attempt to deliver,  both by the  forceps
and the crotchet;  and the event in the end  proved fatal to the mother."2
   The  next writer who  notices  the operation is  Dr.  Leake, who, in his
work  on the Diseases of Women,  1781, has a few pages upon  this opera-
tion,  of which he is inclined to judge favorably, though with  caution.   He
answers  some of the  objections urged against it, but admits that more ex-
perience was required.
  The operation was performed in  the year 1782, for the first and last time
in this  kingdom, by  Mr. Welchman, of Kington,  in  Warwickshire.   The
child  was putrid, and the mother died ; but Mr.  Welchman thinks that her
death was not caused by the operation.3
   Dr. Osborn,  in  his Essays  on Midwifery, 1783, gives a good historical
sketch of the operation, and after a very careful examination into the merits
of it,  he arrives at the conclusion that "no circumstances whatever,  real or
imaginary,  can ever render it a warrantable operation."
   Mr. Dease, in his Observations  in Midwifery,  1783,  disapproves of the
operation.   He says,  it was "of  worse consequence than the Caesarian ;  as
it subjected the woman to all the  dangers  of  the latter, without the  same
advantages  of saving  the  child."
  Dr. Hamilton, Sr.,  in his Outlines of the Theory and Practice  of  Mid-
wifery, 1784, doubts the efficacy of the operation, and points out its hazard.
   Dr. Aitken, Elements of Midwifery, 1784, says that the operation maybe
useful " when about half  an inch of addition  to  the short diameter  (of the
pelvis) is sufficient to allow delivery."
    1 Hull's Second Letter, p  04.          2 Essays on Midwifery, pp. 282, 323.
    3 London  Med. Journal, 1790.   Hull's First Letter, p. 138. 
SYMPHYSEOTOMY.
399
  Dr. Hull, in his First  Letter, 1790, points out the inadequacy of the
operation ;  and in his Second Letter enters more fully into the  history of
it, and shows that the combination of symphyseotomy with craniotomy (first
proposed by Dr. Hunter, and repeated by Mr.  Simmons) is worse than the
Caesarian section.
  Dr. Denman, in  his Introduction  to Midwifery, objects  to the  operation,
except, perhaps, in a case  where the life of the child (it being  alive) was of
such immense importance to the nation,  that  the  mother might fairly run
the risk.
  By every modern British writer the operation is denounced, and is not
likely ever to be again attempted in  this country.
  The contagion of enthusiasm  spread  rapidly among the French, though
some more  cautious and  philosophical writers held aloof, and  others de-
cidedly  disapproved of the  new operation.  It  has  not, however, even in
more modern times, been  so  completely discouraged as we might have ex-
pected from the results  of the cases in which  it  has  been employed.  The
last case performed in France was by M. Masleur, at Lagemont; the space
gained admitted one finger between the divided  symphysis;  and the neces-
sity for the  operation may be judged by the fact that, after recovery, the
patient bore a living child naturally !
   The operation has been performed in Italy.   It has also been  modified
by  Prof. Catolica, after the suggestion of Desgranges and Champion.  In-
stead of  dividing the symphysis, the ossa pubis were cut through, nearer
their junction with the ossa ilia, and by this means a positive increase in the
antero-posterior diameter was gained.  M. Galbiati performed this opera-
tion in 1819, and it proved fatal.
   In Germany, it was at first highly extolled ;  but the general opinion  after-
 wards was  unfavorable  to its utility.   Indeed, it would  be astonishing to
 find any  candid man who could resist the evidence afforded by the  cases in
 which it  has been tried.
   594.  Statistics.—49  cases  have been recorded :  of  these 16  mothers
 died, or about 1 in 3 out of 40 cases;  the child  was born alive  in  11, and
 dead in  19, or 1 in 2.
   I shall not give these cases in detail, but a slight analysis may  show more
 fully the slight ground the advocates of the operation had for exultation.
   1.  It was performed unnecessarily in four cases, as was proved by a sub-
 sequent natural delivery.
   2.  Without any cause in one case, the patient having borne children natu-
 rally, and there being no deformity  ; and  in another, where there was suffi-
cient space.
   3.  Without the possibility of  benefit from it in one case, where the an-
tero-posterior diameter was only If inch.
   4.  Although 33 mothers recovered, 10 children were lost, 14 saved, and  1
much injured.  Of 7 nothing is stated.   Of the 16 mothers who were lost,
5 of their children only were saved ; 9 were dead, 1 much injured,  and of  1
nothing is stated.   So that,
   5.  In the latter case,  16 mothers  were sacrificed to save 5 children.
   0.  Again, although  33 mothers  recovered, yet to save 14  children they
paid very dearly — for 1 had the bladder and urethra injured ;  2 had incon-
tinence of urine ; 3 had prolapsus  uteri.   In one, the bones of the pelvis
exfoliated, the cervix uteri and posterior part  of bladder were gangrenous;
and several were endangered by the operation, whilst of a great number no
details are given.
  We shall now examine the merits  of the operation a little more minutely.
  595. The object of the operation is to increase the  short diameter of the
pelvis, by the enlargement of the arch formed by the ossa ilia and pubis, so 
400
SYMPHYSEOTOMY.
as to allow of the passage of the child in cases where it must otherwise have
been extracted through  an artificial  opening ; and by this means afford a
greater chance of life both to the mother and child.
   596.  The yxature of the aid afforded is easily comprehended, though  the
amount is altogether  overrated  by the early advocates of the operation.
The cartilage  of the symphysis pubis being divided, the  pressure of  the
head, or the assistance of the operator, may separate the ossa pubis, at  the
expense of some of the sacro-iliac ligaments;  for the separation of the ossa
pubis will be exactly in  2^'oportion to the yielding of the  sacro-iliac syn-
chondrosis; so that, if  the latter were anchylosed, the operation would  fail
altogether.
   Again,  it must be remembered, that owing to the  posterior situation of
the sacro-iliac synchondrosis, the space gained will be mainly in the oblique
diameter of the  pelvis; next to this  in the transverse, and least of all in
the antero-posterior diameter.   But it is from the last-mentioned diameter
being  too  short  that the difficulty exists, and therefore upon the amount
gained in it, depends the successful issue of the operation.
   The entire question turns upon this point.   If by the separation of  the
ossa pubis so much space be gained as will make up the difference between
the sacro-piubic diameter in a deformed pelvis,  and the same diameter in
an ordinary one, then the operation  is, at  least mechanically, adapted to
the object in view.
   Hence it is  very important to ascertain  as nearly as we can, how much
may thus be added to the antero-posterior diameter.   We know from Sigault
and Le Roi's case, that the ossa pubis may be separated four inches: how
much will this  increase  the short diameter ?   Dr. Bentley, in  his  Disserta-
tion, quotes the  experiments  of Ripping of  Paris, and Lobstein  of Stras-
bourg, in support of the conclusion that the utmost  gain by the operation
is four lines in the short diameter,  and Dr. Aitkin says half an inch.
   I feel satisfied  myself  that  half  an inch is the very utmost that can be
gained, except by such violence as  would be utterly unjustifiable.   But then
Dr. Leake  observes that the head will press into the opening, and " it will
therefore follow that as much of the occiput, or hind head, as is intruded into
an aperture at  the pubis of two inches and a half, so much  precisely will be
the space  gained by this operation, and superadded to the short axis of the
pelvis from sacrum to pubis, which will be  equal to the enlargement from
side to side — the circumstances here  contended for."  This is undoubtedly
ingenious, but not quite correct, inasmuch as the long diameter of the head
at the  upper  outlet corresponds with  one of the oblique, and not with  the
sacro-pubic diameter; so that the  occiput would correspond  pretty nearly
with the acetabulum, and the tuber parietale with the interval between the
ossa pubis.  In this situation, no part of the head could pass through the
opening unless the operator changed its position.  Further, Dr. Osborn has
justly remarked,  that this pressing into the opening would be at the expense
of so much injury to the bladder and soft parts  as would render the opera-
tion unjustifiable.
   597.  The advantages of the operation, as enumerated by its  supporters,
are :
   1. That it substitutes  an operation of less  danger for the Caesarian sec-
tion ;  but this,  we have seen, is not true, for  although one in three of the
mothers only are lost by it (rather less than by the  Caesarian section),  yet
those  who  recover are  liable to  accidents  which fully counterbalance this
slight advantage.
   2. That it affords a better chance of saving the child ; but  we have seen
that only one-half of the  children were saved, whilst by the Caesarian section,
more than two-thirds were preserved. 
SYMPHYSEOTOMY.
401
  3.  That it is a less painful operation.   This is true as regards the period
of operating, but if the  period  of convalescence be included, with the se-
quela? which occasionally occur with each, I should  doubt the  fact.
  4.  The  section of the pubis which  allows  the child to be  born by the
natural passage, carries not with it those ideas of cruelty which the Csesarian
operation does, where the patient is, as it were, embowelled alive.   This is
very  plausible but very false humanity.
  598. The objections  against the  operation are to my mind  unanswerable,
although some that have been  put forward as such have been refuted by
experience.  It must be remembered that the  operation is contemplated for
those cases in which the Caesarian section would otherwise be  necessary.
  1.  For these cases the operation is inadequate.   In a former chapter, we
have  seen that  the Caesarian operation ought not to be performed in any
case  where the antero-posterior diameter is more than two inches, inasmuch
as the delivery can be accomplished  by a less hazardous method.   Xow, as
the Sigaultian operation adds but half an inch (at the utmost), this would
increase the antero-posterior diameter to 2^ inches.  But it has been ascer-
tained that a living child cannot pass through a pelvis whose short diameter
is less than 3 inches; consequently, the Sigaultian  section cannot  avail in
these cases, unless craniotomy be superadded.   But the  mortality of the two
would be greater than that of the Caesarian section,  for 1 in 3 of the mothers
would be  lost, and all  the children, by the combined  operations;  whereas
by the latter, although  1 in 2£ of the mothers are lost, more than two-thirds
of the children are  saved.
  2.  Even  if the space gained would  secure the delivery, the mortality of
mothers and children would not justify its preference to the Caesarian section
—especially if we take  into account the sequelae.  These objections appear
to me quite conclusive against the operation ;  but as others  have  been
adduced, it may be as well to enumerate them.
  3.  The cartilage of the symphysis may be ossified ; which will render the
operation impracticable, even after it has been commenced.
  L^ Great injury may be inflicted by the knife on the bladder or soft parts
within the pelvis.
  5.  Equal injury  may happen from  the  violence used in separating the
ossa pubis.
  6.  The  soft parts may be  injured by pressure against the  edges of the
divided ossa pubis.
  7.  The sacro-iliac synchondrosis may be ruptured past remedy.
  8.  The divided cartilages may not unite.   Experience, however, has shown
the groundlessness  of this objection.
  9.  The admission of  external air may excite inflammation.
 _ These latter objections have, of course, a certain  weight, but hardly suffi-
cient to prohibit the operation, if it were adapted to the cases for  which it
has been proposed.
  But there is another class  of cases for which it would seem  at first sight
more  suitable,  and which, indeed, appear to have been contemplated  by
those  who  recommend its performance, where the antero-posterior diameter
of the upper outlet is three inches.   I mean those cases where the difficulty
is too great for  the forceps, and in which,  as we have seen, craniotomy is
necessary.   Here the gain  of half an  inch  might enable a living  child to
pass.   But the operation is  objectionable in these cases, because of  the
results;  for independent  of  the  ill  consequences to those who recover, we
find that one in three of the  mothers die, and only half  of the children  are
saved ; whilst, although all the children are sacrificed by craniotomy, only
one in five  of the mothers die.  And it must  also  be  borne in mind, that
      26 
402
SYMPHYSEOTOMY.
these results of craniotomy have occurred under  more unfavorable circum-
stances than those of the Sigaultian operation.
  599. From  these considerations, I  trust that my readers will agree with
me in the following conclusions :
  1. That the Sigaultian operation is undeserving of the encomiums passed
upon it, inasmuch as it offers no increased chance of safety to the mother or
child—the statistics of the  cases in which it  has been tried having shown
that one  in three of the former, and one-half of the latter  are lost; besides
that in those of the mothers who recover, much inconvenience is experienced
from the consequences of the operation.
  2. That it  is  perfectly  inadmissible as  a  substitute for the  Caesarian
section,  because the utmost  space  gained by it would not  permit  the child
to be born alive in any case in which the Caesarian operation ought to  be
contemplated ;  and if the child must,  in addition, be destroyed, the combined
mortality of the mothers and children would then be far  greater than from
the Caesarian operation.
  3. That it is equally inadmissible  as a substitute  for craniotomy alone,
in cases where the forceps are inadequate, because  the consequences to the
mother are more serious from it than  from craniotomy.
  600. If, as I believe,  these conclusions are correct, I need only add an
account of the mode of  performing the operation, not as a model, but  to
complete  its  history.   Perhaps the best  mode  of doing this is to give the
account of one of  M.  Sigault's cases,  abridged  by Dr. Osborn.  '' Mons.
Sigault,  with  a common bistoury,  cut  through the integuments and linea
alba, beginning the operation at the upper and central part of the symphy-
sis pubis ; then introducing  his forefinger as a director, he cut through the
ligaments and  cartilage  ; immediately  upon the completion of which, the
two  ossa  pubis, with a peculiar noise,  spontaneously separated  two inches
and a half;  this was demonstratable,  for  M.  Le Roi laid  his four fingers
into  the  opening.   M.  Sigault immediately introduced  his hand into the
uterus, broke the  membranes, and brought  down the  feet.   M. Le Roi
accomplished the delivery.   The whole  operation, both section and delivery,
was  finished  in five minutes.  The child was born  alive.   A ligature was
passed round the body of the mother, to keep the pelvis  firm.   The patient
having no bad symptoms, was left till  the next day, when  every circumstance
continued favorable ; she had passed  her  urine voluntarily twice, there had
been no hemorrhage, and she had suffered little pain."
  Having entered thus fully upon the operations proposed for the  relief of
the previous classes of unnatural labor, we may now resume the considera-
tion  of the remaining deviations from  natural  labor. 
MAL-POSITION AND  MAL-PRESENTATION  OF THE CHILD.   403
                      C HAP TE R  XVI.

       PARTURITION.   CLASS  II.   UNNATURAL LABOR.
 ORDER  5.  MAL-POSITION AND  MAL-PRESENTATION  OF CHILD.


  601.  We have already investigated those cases of unnatural labor which
arise from defective  uterine power, and from an abnormal condition of the
passages.  The only class  of deviations  which remains, is that  which is
caused by some peculiarity on the part of  the child.   In these cases we as-
sume that the uterine power is  intact, and that there is no impediment in
the passages.  The difficulty is  a purely  mechanical one; but if  it be not
removed, after a certain  time the constitution is involved and the character-
istics which we noticed in powerless  labor present  themselves.  Thus,  as in
the case  of  defective  passages,  that which at  first was purely local  and
mechanical, involves at length the vital  powers  and the constitution of the
patient.
   We shall  first notice certain  mal-positions.  1. Face presentations, as
they are  called ;  and  2, those cases  in which the  forehead emerges under
 the arch of the pubis.
                                Fig. 155.
Face Presentation —First position.
  502.  Mal-positions.   1. Face Presentations.   At  first sight it may
seem strange to call a "face presentation" a mal-position ;  but a moments
thought will show that when the face is planted  across the upper outlet, it
is merely because, from some cause, the head  which presented  has deviated
from its usual  mode of descent.   Dr.  F.  Ramsbotham remarks, "I am in-
clined to think  that most of the face presentations we meet with in practice,
were originally brow presentations, and have been  changed by the action 
%
404          MAL-POSITION  AND MAL-PRESENTATION

of the uterus  in the way I have  already specified."  In  face presentations
the head is bent backwards, so  as to place  the  face nearly flat across  the
brim of the pelvis in its oblique diameter.
   603.  Mechanism.—The face may present in two positions, according as
the forehead  is toward one or other os  ilium.  In  the  first position,  the
forehead is  towards the left  ilium,  or rather the left acetabulum, and  the
chin towards  the right  ilium,  or right sacro-iliac synchondrosis, the  bridge
of the nose representing the line described by the sagittal suture in the first
cranial  position (fig. 155).   The right side of the face is anterior, and beinir
anterior is more depressed than the other upon entering the brim, so that,
on making an examination, the finger touches  the right eye or the zygoma,
and upon this part the primary tumor forms.   M.  Naegele remarks that
there forms "  a swelling, first  upon the upper  part of the right half of  the
face, which  in this species of face presentation  (first position)  is  always
situated lowest."  If the progress of the head  through the external pas-
sages be unusually rapid, this is the only tumefaction observed ;  " but if it
advance slowly, and the head  remain a long  time in the cavity of the pelvis
before it actually enters the vagina,  the inferior half of the right side of  the
face, viz., part of the right cheek, will be remarked after birth as being  the
principal seat of the swelling."
   The head, as we have said, enters the  brim  obliquely  as  to its diameter
and plane, and thus descends  into the cavity ;  when  there, the chin  makes
a turn from  right to left, and so emerges obliquely under the  arch  of  the
pubis (figs. 156,  157),  whilst the vault  of  the  cranium sweeps over  the
perineum.
   This first position is by far the most frequent.

                                 Fig. 156.
Face Presentation — First position.
  The second position is  the  reverse of the first:  the forehead is  turned
towards the right acetabulum, and the chin to the left sacro-iliac synchon-
drosis (fig. 158).   The primary tumor forms  on  the upper part of the left
cheek, and the secondary (if there be two) on  its lower part: the face enters
the cavity obliquely, and so emerges from the outlet; but  the chin makes a 
OF  THE  CHILD.
405
quarter turn from left to right  anteriorly, and when expelled is under the
arch of the pubis, whilst the head sweeps over the pelvis.

                                 [Fig. 157.]
            Passage of the Head through the external parts in Face Presentation.

  The older writers  describe the head as emerging from the lower outlet in
face presentations, with the  chin towards the perineum ;  and Dr. Smellie
has given a plate in  illustration of this.   A moment's examination will show
that this is mechanically impossible, and the careful observation of Naegele
and others has been  unable to detect any such case.

                                  Fig. 158.
Face Presentation — Second position. 
406          MAL-POSITION  AND  M AL- P U ESENT ATION
604. Statistics.—Frequency.
a. British Practice.			b. French Practice.		i
	Total No.	Face		Total No.	Kil.T
Authors.	of Cases.	present.	Authors.	of Cases.	preseut.
Dr. Jos. Clarke	10,387	44	Mad. Boivin .	20,517	74
P.P.	3,847	7	Mad. Lachapelle	15,652	65
Dr. Merriman	2,947	10	M. Ramboux .	491	3
Dr. Granville .	640	1	M. Dubois	10,742	30
Dr. S. Cusack	701	3	Dr. de Belli .	2,739	17
Dr. Maunsell . Mr. Gregory .	839 691	7 2			
					
Dr. Thos. Beatty .	1,184	4	c. German Practice.		
Dr. Collins . Dr. Lever	16,414 4,666	33 24			
					
Dr. Reid	5,691	25	MM. Moschner \ and Kursak j	12,329	1°2
Drs. M'Clintock and	I 6,634	14			
Hardy			Dr. Carus	2,557	24
Dr. F. Ramsbotham	48,996	162	Dr. A. E. v. Siebold	1,003	10
Dr. E. Murphy	467	7	Dr. E. C. v. Siebold	494	4
Dr. Metcalf .	300	1	Dr. Kilian	9,392	122
Mr. Crosse	1,394	5	Dr. Merrem .	157	1
Mr. Earle	4,320	4	Dr. Naegele .	115	4
Birmingham H.	650	13	Dr. Kluge	799	6
Mr. Rose	600	1	Dr. Brunatti .	100	2
Mr. Bailey	2,819	15	Dr. Adelmann	57	1
Mr. Watson .	800	14	Dr. Jansen	13,365	15
Dr. Copeland .	1,290	7	Dr. Arneth	6,608	40
Dr. Bliss	771	8	Prof. Schwerer	21,804	50
Dr. Pagan	8,684	6	1 Wurtzburg Hospital	637	10
Mr. R. U. West	2,106	10			
Mr. J. Thompson .	3,300	6			
Drs. Sinclair and "> Johnston /	13,748	40			
Dr. Hall Davis	7,233	110			
  Thus in British practice, out of 141,259 cases, there were 567 face presen-
tations, or  1 in 249;  among the French, 50,141  cases, and 189 face presen-
tations, or about 1 in 265^;  and among the Germans, 69,417 cases, and 411
face presentations, or about 1 in 169^ ;  the whole giving 1167 face presen-
tations in 260,817 cases, or about 1 in 223^ cases.
  As to the mode of delivery, and results to mothers and children, I cannot
make out a regular table, but must content myself with such scattered notices
as I have been able to obtain.   Mr. Giffard relates 4 cases ;  1  was delivered
naturally, and 3 with the forceps ; neither mother nor children  were lost.
Dr.  Smellie gives 19 cases ; 3  delivered naturally,  5 by version, 4 by the
forceps, and  5 by craniotomy;  3 mothers and  11 children were  lost.  Mr.
Perfect relates 8  cases :  1 delivered naturally,  2 by version, 4 by forceps,
and 1 by craniotomy  ; none of the mothers, but 2 of the children were lost.
Dr.  Jos. Clarke performed  craniotomy twice in his 44 cases ; all the rest
were delivered naturally.  Dr.  Ramsbotham has recorded  3  cases :  2 de-
livered  by  the forceps, and 1 by craniotomy; all'the children were lost, hut
none of the mothers.   Dr. Granville's single case was delivered by version.
Dr.  Cusack's 3 cases  were delivered naturally ; neither mother nor child was
lost.   Dr. Collins' 33 cases were all delivered naturally ;  the  mothers were
saved, and but 4 of the children lost, 1 of which was an  acephalous  foetus.
All  Dr. Pagan's 6 cases  were delivered naturally ; all the mothers recovered,
and 5 of the infants were  saved.   All Mr.  Thompson's  cases, mother and 
OF  THE  CHILD.
407
child, recovered.1  Drs. Johnston and Sinclair lost 6 children, and 1 mother
died  of peritonitis.2  Dr. Hall Davis lost 8 children.3
  Of Madame  Boivin's  74 cases, we are informed that  41 were delivered
naturally, 14 by version, and  2 by craniotomy, but  nothing is said of the
mortality.   Of Madame Lachapelle's 65 cases, 41 were delivered naturally,
20 by version, and 4 by the crotchet; 7 children are stated to have been lost.
  Of 80 cases under  the  care  of Dr. Boer, of  Yienna,  all but one  were
delivered without assistance ;  in that one case the forceps were used.  None
of the mothers suffered,  and 3 or 4  of  the children only were lost.   Of Dr.
A. E. v. Siebold's 10 cases, 6 were delivered by the forceps.   Of the  40 cases
related  by Dr. Arneth, all were  delivered by  the natural  powers ; 3 boys
and  2 girls were lost.4
   Thus, so  far  as our data go, out of 384  cases, 248 were delivered natu-
rally, and 77 required  artificial assistance (i.e. 42  versions, 20 forceps, and 15
craniotomy).   In  190 cases where the  result  to the mothers is given, 3 died,
or 1 in 60 ;  and of 256 children, 19 were lost, and 15 destroyed, or about
 1 in 7.
   It is worthy of remark, that  the  mortality among both mothers and chil-
 dren is greatest when  assistance was given ;  for of Dr. Collins' 33, M. Boer's
 80,  and Dr. Arneth's  40 cases,  delivered naturally, none of the mothers, and
 but  12 of the children  were lost.   These notices show  also the change of
 opinion as to the necessity for assistance.
   ["I  have treated,"  says Dr. Huston, in a note to a former edition, "seven
 cases of face presentation ;  four were delivered with the forceps, one with the
 vectis,  and  the others without assistance, the  children  being small.   The
 mothers all recovered, but two  of  the  children were still-born."   We have
 seen nine cases of face  presentation ; four of them were delivered without
 assistance.   In these cases the mother had a favorable recovery, and the
 children were born alive and did well;  three were delivered with the vectis ;
 the  mothers all did  well, one  of the  children was still-born, but recovered
 under the use of appropriate means, in the remaining two cases the applica-
 tion of the forceps was found to be necessary to accomplish delivery.  In both
 the  children were still-born; one was subsequently resuscitated, but the other
 perished.]
   605. Causes.—It  is  very difficult  to  assign  correct causes for this mal-
 position.  It may be  owing to  some shock — coughing, for instance, or sud-
 den uterine action, just before the head  takes up its permanent position at
 the  brim.
   Dr.  Simpson attributes  mal-position  and  mal-presentations generally  to
 the  following causes : —
   1. Prematurity  of  the  labor: parturition occurring  before  the natural
 position of the fcetus  is established.
   2. Death of the child in utero ; or,  in other words, the loss of the adaptive
 vital reflex actions of the  fcetus.
   3. Causes altering the normal shape  of  the  fcetus or contained body, or
 causes altering the normal shape of the uterus or containing body,  and thus
 forcinc: the fcetus to  assume,  in its  reflex movements, an  unusual position in
  order to adapt itself to the unusual  circumstances in which it happens to be
 placed.                                                                .
   4. Preternatural presentations are occasionally the result of causes physi-
 cally  displacing either  the whole  fcetus or  its  presenting  part, during the
 latter periods  of gestation or at the commencement of labor.
   606.  Diagnosis.—" The presentation of the face," says  Dr. Denman, "is
   '  Glasffow Med. Journal, July, 1855, p. 130.          2 Practical Midwifery, p. 75.
   3  On Diff.  Parturition, p. 274.
   *  Die GeburtsshUlfliche Praxis, etc., zu Wien. Von Dr. F. H. Arneth.  1851, p. 4j. 
408          mal-position and  mal-presentation

discovered by the general inequalities of the presenting part,  or by the dis-
tinction of the particular parts, as the eyes, nose, mouth, or chin.   There is
no very great difficulty in making out this  presentation  before  tumefaction
takes place : but afterwards it may be  mistaken for  the breech,  unless we
are very careful.   The bridge of the nose will be the best  guide, as being
prominent, firm, and unlike any part of the breech.  The eves  or mouth may
be confounded with the anus, and the malar bone with the tuber ischii.
  607.  Symptoms.—The only effect which a face  presentation  has upon
labor is to retard the second stage, but not to such an  extent,  or very rarely,
as to give rise to unfavorable  symptoms.   The resistance to be  overcome is
greater,  because the bones of the face and base of the cranium which pass
the first  through the brim, cavity, and "outlet are incompressible,  and because
there is not the  same power of adaptation ;  but the  impediment only calls
forth more energetic action on the  part of the uterus, and we perceive that
the progress of the labor, if slow, is still evident.  The suffering, of course,
is more severe, as well as more prolonged.   The  child when born is a fright-
ful  object in  most cases;  one eye closed, and the half or the entire of one
cheek swollen, red, and contused  ; but these injuries speedily pass away, and
in a day or two the  face assumes its ordinary aspect.  I  should mention,
that if a rough and careless examination of the  presenting part be made in
these cases,  the  eye  may be seriously damaged, or  even destroyed.  The
mortality amongst  the children  is rather  more  than in head presentations,
but less  than in  any other mal-presentation.
   If, as  is very rarely the case, the delay should  be excessive, the  symptoms
of powerless labor will be developed, and will call for  prompt relief.
   608.  Treatment.—Formerly,  when this mal-position was regarded as an
unnatural  presentation,  it was held  necessary  or advisable  to deliver  the
patient by art without loss of time, as appears from the statistical results of
the operation.  M. Portal  appears to have  been the first to  suspect that
nature  might be adequate to the delivery, and Deleurye concurred in  this
opinion.   M. Boer, in 1793, objected to any interference ; and of late years
it has been  established  as  a rule, that  assistance is unnecessary merely on
account  of the mal-position.   If  there should be any disproportion between
the size  of the head and  the pelvis, or the pains should become inefficient, or
accidental complications occur, then of course we must have recourse to  the
mildest  form of assistance.   If  within reach, the forceps  will  probably be
the best instrument.
   In ordinary cases we  must keep up the courage of  the patient, and exer-
cise all our own patience and kindness until the  delivery be effected.
   If there be a difficulty in  establishing  respiration, after the birth of  the
child, as  from  the cerebral congestion there  may be,  the  cord must be
divided, and an ounce  or two of blood  allowed to  escape, previously to
applying the ligature.    The child's face may be fomented with a decoction
of  chamomile flowers or  poppy heads, and  afterwards bathed frequently with
a spirit  lotion.
   609.  2.  The  forehead  towards  the  arch  op the  pubis.—When
describing the mechanism of parturition, it  was stated, when the head pre-
sents in the third or fourth position, it ordinarily changes into the second or
first in its passage  through the  pelvis, but that occasionally this change of
position does not take place,  and that  the head then passes down through
the lower outlet, with the forehead turned obliquely  under the arch of the
 pubis.   When there, the head may be forced  equally down, if  there be room,
 presenting the  longitudinal diameter (a  little modified) to the antero-pos-
terior diameter of the lower outlet, or the forehead may remain  stationary
 at  the pubis whilst the posterior part of the head sweeps over the perineum.
    610.  Statistics.—Frequency. 
OF  THE CHILD.                        4Q9
Authors.					Total No. of Cases.	Forehead to Pubis.
Dr. Bland......					1,897	5
Dr. Merriman					2,947	44
Dr. Granville .					640	2
Dr. Cusack					303	o
Dr. Maunsell .					849	7
Dr. Collins .					16,414	12
Dr. Storer					440	1
Mr. Crosse					1,394	26
Dr. Toogood					1,135	8
Dr. Metcalf					300	1
Dr. Pagan					8,684	31
Mr. R. U. We	st .				2,106	59
Mr. J. Thompson .					3,300	28
Drs. Johnston and Sinclair					13.748	20
  Thus, in 43,367 cases, the face was turned to the pubis 156 times, or about
1 in 278.
  As to the result to the child ; of 50 cases where the result is specified,  9
were lost.
  611. Causes. — It is not  easy to explain why the  ordinary chanee  does
not take place.   I have observed  that it may be prevented if the  pelvis be
somewhat narrower than usual, and especially if it be funnel-shaped :  also,
if the  pelvis be  disproportionately large,  as  due resistance will then be
wanting; and  lastly, if very violent pains come on suddenly just after the
head has entered the brim.   It is probable  that  other causes may produce
similar effects,  but they are not so easily detected.
  612.  Diagnosis.—The mal-position will be  detected by the flatter shape
of the forehead, which does  not fill up the  arch of the pubis so well as the
posterior part of the  head ;  and  especially by the situation of the fonta-
nelles, the larger one being anterior, and the smaller one posterior.
  613.  Symptoms.—The effects of this mal-position upon labor in its second
stage  are  by no  means serious;  in ordinary cases it causes some delay at
the latter  part of it, and calls for more  expulsive force ; but the effort  is
successful, and the  child is expelled.   If, however, the pelvis be  narrower
than usual, it  may offer a  considerable impediment, as a larger diameter  is
presented to the lower outlet than in the usual position.  I have seen a few
eases in which the  impediment,  though so slight,  was sufficient to  cause
mischievous delay even in women who had borne children before, and whose
pelvis was perfectly well formed.
  The effect upon the child is generally  of no  moment, unless the  pelvis be
so deficient as  to require an operation.
  614.  Treatment.—If the pelvis be not smaller than usual, assistance will
rarely be necessary ; and,  if we suspect a  narrowing, still  sufficient  time
must be allowed to prove whether the relative disproportion be such as the
natural agents can  overcome.  If it be not,  then, after a due and careful
Estimate of the obstacle, we must determine whether  there is room for the
application of the  forceps, or whether the  only alternative  is craniotomy.
In some few cases the forceps may be necessary from a failure of the uterine
power.  The  time for operating must be determined  by the  amount of the
obstacle, and the symptoms present.
  615.  Mal-preskntations. — Having  taken the presentation of the  head
as a type of natural labor,  we must include the presentation of any other
part of the body  under the class of mal-presentations.   If we were to follow
implicitlv Baudelocque, and  other foreign authorities, there  is scarcely any
part of the body which may not  present;  but Denman,  Lachapelle,  and 
410          mal-position  and mal-presentation

Naegele consider that such regions as the back, loins, belly, neck, etc., never
con.-titute the presenting part.

                                 Fi-. 159.
Forehead under the Arch of the Pubis.
   Taking the presentations in the order of frequency, we shall now inquire
into
   1. Breech presentations, 1 in 59^.
   2. Presentation of the inferior extremities, 1 in 105.
   3.        "     of the superior extremities, 1  in 231f.
   4. Compound presentations, where two or more parts present at the brim.
   616.  1. Presentation of the  Breech. — The breech may present itself
at the brim in different positions : but as it enters it will be found to arrange
itself so that either,  1, the back of the  child shall  be turned anteriorly to-
wards the belly of the mother ; or, 2, the back of the child shall look poste-
riorly towards the back  of the mother.  Not that the  back of the child is
directly anterior or  posterior,  but oblique,  the transverse diameter  of the
child's hips  corresponding to one  or other of the oblique diameters  of the
brim.
   "In every case," observed  M. Naegele, "whether the nates have at first
a  completely transverse  or oblique direction, they will always be found, on
pressing lower into  the superior  aperture of the pelvis, to  have  taken an
oblique position, and  that ischium which is  directed anteriorly to stand the
lowest.   They pass through the entrance, cavity, and outlet  of the pelvis in
this position,  which  is oblique both as to its transverse diameter as well as
to its axis."
   Thus, in the first and  most frequent position (fig. 159), the left ischium
corresponds to the left acetabulum, and, being anterior,  it is depressed, and
presents at the os uteri,  so that the finger impinges upon it  if it be  passed
into the centre of the os  uteri.   In this oblique position the breech descends
into the cavity, and this part first passes through  the vaginal orifice, and
appears between the labia; whilst the other ischium sweeps over the peri-
neum, and the belly  of the child is towards  the inner surface of the right
thigh of the mother.   "The rest of the trunk," according to the admirable
description  of the author just quoted,  "follows  in this position ; and as the
breast approaches  the inferior aperture of the pelvis, the  shoulders  pass 
OF  THE CHILD.
411
through its superior  aperture  in  the  left oblique diameter;  and during its
passage (viz., the breast) through the  pelvic outlet, the arms  and elbows,
which were pressed  against it, are born at the same moment."   It is not
always the case that  the arms  are pressed close to the side of the child, one
or both may be stretched  out above  the head, and then, as labor advances,
first one will be  pressed  through the orifice (generally the right),  and then
the other  or it  may be  necessary to draw them down (fig. 160).   " But

                                Fig. 160.
Breech Presentation — First position.
whilst the shoulders are descending in the above-mentioned oblique position,
the head, which during the whole progress  of  the  labor  rests with its chin
upon its breast, presses into  the  superior aperture  in the direction of the
right oblique diameter (viz., with the forehead corresponding to the right
sacro-iliac synchondrosis), and  then into the  cavity of  the  pelvis in the
same direction, or one more  approaching  the conjugate diameter.  After
this, it presses through the external passage and the labia in such a manner,
that while the occiput rests against the os pubis, the point of the chin, fol-
lowed by the rest of the face, sweeps over the perineum as the head turns
on its lateral axis from  below  upwards."   (Fig.  161.)   This brings the
occipito-frontal diameter of the head in correspondence with the long diame-
ter of the outlet.
  In the second position, the right ischium, corresponding to  the right ace-
tabulum, is turned forward  and  depressed,  passing obliquely through the
cavity and outlet  in  the  former case, but with the  direction  of its surface
reversed ;  its anterior surface being directed  towards the left side of the
pelvis and left thigh of the mother, whilst the head  enters in the left oblique
diameter.
  The tumor (marked by a red  or livid spot) will  be found  on the left or
right ischium, according as it  was the first or second position.
  617.  M. Naegele has noticed two deviations  from the ordinary mechanism
of breech cases, which I shall give in his own words.   First: " It sometimes
happens that the body, which, directed with its anterior surface forwards and
to the right, or forwards and to the left, is born  as far as  the shoulders, 
412          MAL-POSITION AND MAL-PRESENTATION

turns itself then (and frequently during  the course of a single pain, by which
it is fully expelled) from the side completely forwards, and then to the oppo-
site side, so that the anterior surface of the child, which for instance in the

                                 Fig. 161.
Breech Presentation — First position.
first case, was, before the pain came on, still  directed forwards and to the
right, will be afterwards instantly, in the twinkling of an eye, situated back-
wards and to the left."  Dr.  Collins has  noticed  this change as rendering
the interference recommended by  some authors unnecessary.

                                 Fig. 162.
Breech Presentation — Second position.
  618.  The second deviation is thus described by Naegele.   "It sometimes
happens, in presentations of the nates, that the head does not rest with the
chin upon  the breast;  but the occiput, as in  those of the face, is pressed
against the nape of the neck ;  in this case the passage of the breech through
the pelvis, according to which species of nates presentation it may be, fol-
lows in the manner  already described, as  far as the  head ; this, with the
occiput depressed on the nape of the neck, enters the superior aperture with 
OF  THE CHILD.
413
the vertex corresponding to one or other ilium of the mother, and in pass-
ing  through it, and pressing lower into the  cavity of the pelvis, the vertex
gradually turns more and more backwards, so that  when the trunk is born,
the arch of the cranium is directed to  the hollow of the sacrum, and the in-
ferior surface of the under  jaw to the internal one of the symphysis pubis.
The passage through the inferior aperture takes place in the following way,
viz.,  whilst the  under jaw  presses with its  inferior surface against the  os
pubis, the point of the occiput, with  the vertex, followed by the forehead,
sweeps first over the perineum."  Thus bringing the occipito-mental diameter
of the head into  a  position  with the antero-posterior diameter of the outlet.
  619. Thus, as I  observed in speaking of the passage of the head, whether
we  consider the  ordinary or extraordinary adaptation of the diameters in
breech presentations, we see at  once the  admirable  way in which  the ar-
rangements are calculated  to provide for the passage of the child  with the
least possible waste of space ;  aud it may  convince us that in far more  cases
than we should d priori  suppose, nature is adapted to the fulfilment of the
functions of parturition ; and  interference, when injudicious, is more likely
to impede than to  further her efforts.
   620.—Statistics.—Frequency.
a. British Practice.			b. French Practice.		
Authors.	Total No. of Cases.	Breech present.	Authors.	Total No. of Cases.	Breech present.
Dr. Bland	1,897	36	Mad. Boivin .	20,517	373
Dr. Jos. Clarke	10,387	61	Mad. Lachapelle	15,652	349
Dr. Merriman	2,947	78	M. Ramboux .	491	4
Dr. Granville .	640	2	M. Dubois	10,742	391
Edin. Lying-in- 1	2,452	17	Hotel Dieu, Paris .	280	3
Hospital j			M. Mazzoni .	452	5
Dr. Cusack	701	14?	Dr. de Belli .	2,739	44
Dr. Maunsell . Mr. Gregory .	416 691	6 14			
					
Dr. Collins .	16,414	212	c. Germa'	% Practice.	
Dr. Beatty . Dr. Lever	1,182 4,666	28 59			
					
Dr. Reid	3,250	79	M. Richter	2,571	48
Mr. Warrington Mr. French	110 89	4 2	Moschner and "1 Kursak /	12,329	125
Dr. Churchill .	1,525	35	A. E. v. Siebold .	1,944	44
Drs. M-Clintock 1 and Hardy J '	6,634	101	E. C. v. Siebold . M. Kilian	1,165 2,350	18 125
Dr. Storer	440	5	M. Naegele .	1,411	76
Mr. Crosse	1,394	25	Dr. Merrem .	299	14
Mr. Earle	4,320	41	Dr. Henne	555	6
Mr. Rose	600	9	Dr. Kluge	1,074	27
Mr. Bailey	2.819	14	Dr. Carus	2,908	43
Dr. Bliss	771	15	Dr. Brunatti .	295	6
Birmingham Hosp. .	650	17	Wurtzburg Hospital	637	18
Dr. Metcalf .	300	3	Dr. Theys	28	1
Dr. Toogood .	1,135	11	Dr. Adelmann	53	2
Dr. J. Lee .	850	5	Dr. Arneth	6,608	113
Mr. K. Watson	800	11	Prof. Schwerer	21,804	97
Dr. Copeland .	1,290	13			
Dr. Pagan	8,684	131			
Mr. R. U. West .	2,106	27			
Mr. J. Thompson .	3,300	18			
Drs. Johnston "1 and Sinclair J	13,748	309			
Dr. Hall Davis	7,233	93			
 
414          MAL-POSITION  AND  MAL-PRESENTATION

  Thus in British practice, breech  presentation  occurred 1363 times in
91,651 cases, or about  1 in 67^; in  French practice 1169 times in 50,873
cases, or about 1 in 42J ; and in German practice 793 times in 54.794 cases, or
about  1 in 66i; the  entire number of breech presentations being 3325 in
197,318 cases,  or about  1 in 59.j.
  The following  table exhibits the result to the child in as many cases as I
could collect:
Authors.					No. of Breech Presentations.	Children lost.
Mr. Giffard.......					13	4
Dr. Smellie					27	16
Mr. Perfect					9	2
Dr. Jos. Clarke					61	21
Dr. Ramsbotham					14	7
Dr. Merriman .					79	9
Edinburgh Hospital					17	5
Mr. Gregory .					14	4
Dr. Collins					242	73
Dr. Beatty					28	12
Mr. Lever					59	30
Dr. Churchill .					35	14
Drs. M'Clintock and Hardy					80	34
Dr. Metcalf .					3	0
Dr. Storer					5	0
Dr. Arneth .					113	19
Mr. J. Thompson .					18	5
Drs. Johnston and Sinclair1					258	84
Dr. Hall Davis					93	18
  Thus, in  1148 cases of breech presentations, 337  children were lost, or
about 1 in 3^.
  621. Diagnosis.—The breech of the child is distinguished by its round-
ness and  softness, by the cleft  between the buttocks, by the anus and  by
the organs of generation ;  and it would seem unlikely that it should be mis-
taken for anything else.  Yet it may be confounded with a face  presenta-
tion which has advanced  slowly, and  where there is much swelling ;  to the
touch there is really a great similarity, but in the latter we have the bridge
of the nose obliquely across the os uteri, and in the former the more or less
movable coccyx may be felt close to the anus, and joining the broader and
firm sacrum.   This  will also distinguish  it from  a shoulder presentation,
which might be mistaken for one of the tubera ischii.
  The discharge of meconium  is of very little value, as it  occurs in  head
presentations, although in  the  latter case Dr. Collins  remarks, "it comes
away in a more fluid state, and has not its natural  appearance, being mixed
with the discharges from the uterus and vagina;" nor is it found on the end
of the finger after examination.
  622. Symptoms.—The duration  of  the labor varies a good deal; in  some
cases, it is concluded  as  quickly as  if the head descended, in others  it is
more tedious ;  there is more delay when the arms  are  stretched upwards
than when they are down by the side.   There is also  delay in the  expulsion
of the head, owing to the incompressibility of the base of the skull, which is
the first to enter, and its being less able to adapt itself to the  brim.   It is

  1  Fifty-six in addition were  putrid, and one in addition to Dr. Davis's cases; but in
estimating the mortalitv resulting from  the presentation, these clearly ought not to be
included. 
OF  THE CHILD.
415
very seldom that any bad symptoms arise on the part of the mother, as as-
sistance  is generally afforded ;  but there is danger that mischief may  be
done if the interference be not judiciously timed, and gently executed.   If
there be any narrowing of the brim, there will be proportionate delay ; and
if the  patient  be not delivered, the  symptoms  of powerless labor may be
developed.
  That there is danger to the child, the statistics I have  given  prove, more
than one in four being lost, and this is owing to  the delay in the transmis-
sion of the head.  The  body does  not dilate the passages  so well as the
head,  as the head is wider than any part of the  body, or at least  the body
may be  compressed  into a smaller  space than  the  head.   This  of course
occasions the head to pass slowly;  but besides,  a little time is required to
allow  of the adaptation  of the head to the brim, cavity and outlet, and for
such compression as can be made ; and as, during this time, the cord is ex-
posed to pressure, it is not surprising that asphyxia or pulmonary apoplexy
should result, of which the child generally dies.   Even where the life of the
child  is saved,  the pressure to which  the  organs of generation  have  been
exposed may be followed by inflammation  and sloughing, according  to
Denman.
  623. Treatment.—A very minute and thorough examination is necessary
in these cases,  to assure  ourselves of the accuracy of our diagnosis;  but
this once done,  the less frequently the examinations are renewed the better,
lest the parts should be  irritated.  As to the actual  management, I must
repeat what I have said before, that the less interference  the better for the
patient.  Dr. Collins remarks most soundly, that "the  most common and
dangerous error committed by the  medical attendant  arises from officious
and injudicious  attempts to hasten or  assist during the early stages of labor,
than which he  could not well adopt a more  hazardous course.   No inter-
ference whatever is required until the breech shall have been expelled through
the external parts, unless the  uterine  action be inadequate to  effect this;
otherwise the child must often be forfeited, owing to the difficulty experienced
in consequence  of the soft parts being badly prepared to admit the passage
of the head.  This being the most critical part of the delivery, should much
delay  take place, the continued pressure  on the  funis speedily deprives the
child of life.  To guard against this, therefore,  the breech  should be per-
mitted to pass slowly and unassisted, so as gradually and perfectly to dilate
the soft parts, thereby gradually facilitating the completion of the labor."
  At  the same  time,  as the breech  passes, the perineum  must be carefully
guarded with the left hand, whilst  the right is employed  in  supporting the
child as it is expelled, and carrying it forwards and downwards towards the
legs of the mother, allowing it perfect  liberty  to  change its  position,  or
make  such turns as the mechanism may impress  upon it.   It will rarely, if
ever, be necessary for us to attempt to adapt  the child to the passages, as
we have seen that even when  the head is in an apparently unfavorable posi-
tion at the brim, it rectifies itself in the cavity.   What  we must do, is  to
offer no impediment to these changes.
  When the umbilicus appears at the  external orifice, the danger from pres-
sure on the funis commences ; the cord should be drawn down a little, and
removed as much as possible out of the way of pressure.   The strength  of
the pulsations is an  important guide  as  to the  necessity for assistance:  if
they be strong,  we can allow a little time for the  natural powers  to act;  if,
on the contrary, they be very weak, we must expedite the delivery as much
as possible, consistent with the safety  of the mother, by drawing down  the
body of the child during  a pain.
  When the chest is through  the external parts, the arms may offer a diffi-
culty ;  if they be close to the side  of the child, we shall have no trouble, but 
416          MAL-TOSITION AND  mal-presentation

if above the side of the head  they must be brought down by passing one or
two fingers over the shoulder as near  as possible  to  the  elbow,  and then
drawing the arm across the face and chest until the elbow arrives at the ex-
ternal orifice : having extracted one, the other is easily liberated,  and it is
generally easier to  begin with the one nearest the perineum.   (Jrent care
must be taken not to draw directly downwards, or we  may break  the arm,
but across the front of the child, and  neither violently nor suddenly, or much
mischief may be done to the soft passages.
  When the arms are free, the shoulders will pass out, and the head of the
child will take up its position at the brim in the manner described ;  but here
there is a considerable delay.   If there be  no demand  for  prompt  delivery,
and the cord pulsate strongly, it is  better not  to interfere, and when the
head is in the cavity, two fingers of the left  hand may be introduced  and
placed  in the mouth, or. what is better, on  the upper jaw, which, for many
reasons, is more  suitable than the lower, as usually recommended,  and pres-
sure made so as  to  depress the chin upon the breast; thus presenting a
shorter diameter of the head  to the lower outlet, and facilitating the expul-
sion of the  head.  The  body of the  child  should  be carried forward quite
to the  thighs of the mother, and extracting force, varying in amount ac-
cording to the exigency of the case, applied  to the shoulders, in the direc-
tion of the  axis of the lower outlet.   " In some few cases," Dr. Collins says,
" advantage is derived from pushing  up the head a little so as to  alter its

                                 Fig. 163.
Breech Presentation — Extraction of Head;
position."   This manoeuvre, when dexterously executed, will generally ex-
tricate the head with ease and promptitude, if the patient have had children.
In these cases it is peculiarly necessary that pressure should be applied over
the uterus  from the  time that the chest is expelled, in order to secure the
regular expulsion of the after-birth.
  624.  But if the uterine power should fail (as in powerless labor), or any
circumstances demand speedy delivery before the breech is expelled, one or
two  fingers  should  be  passed  into  the  groin,  and assistance gently and
steadily afforded  during  a pain.   The blunt hook is frequently used for this
purpose, but it has serious disadvantages, and if used incautiously, the thigh 
OP  THE CHILD.
417
of the child may be fractured.   After the breech is born, we may extract by
grasping the body of the  child, covered with a napkin ;  and let me impress
upon my junior readers, that extracting force,  to  be successful (not to say
safe) must always be made in the axis of the  brim or outlet, at whichever
part the resistance may be.
  In  some cases, however, the head is not  so easily extracted, and I per-
fectly agree with  Dr.  Collins, that "should  there be  any considerable ob-
struction to the  getting away of the  head, we  are by no means justified in

                                 Fig. 164.
Presentation of Inferior Extremities.
using violence; the soft parts of the mother will be sure to suffer from such
a mode of proceeding, and on the child's part, nothing is to be gained, as it
is destroyed by pressure on  the funis, continued during the time the ordi-
nary efforts  have been  diligently but  unsuccessfully  employed for  its de-
livery."   If the pulsation in  the cord have ceased, " the only safe plan under
these circumstances will be to lessen the head by means of an opening made
behind one or both ears."   If the pulsation be  good, it will be right to try
the forceps, provided they can be introduced without difficulty; but we must
remember that we  cannot in these  cases  gain  much space by compression,
because we grasp the base of the skull.
  625. 2. Presentation of the Inferior Extremities.—Under this head
I include presentations of one or both of the knees  or feet, as the former
are always converted into footling  cases  as the labor advances.  In point
of frequency they stand next to breech presentations.
  62G. Mechanism.—Adopting Naegele's arrangement, we shall  make but
two  divisions of this mal-presentation.    1. When the toes  are directed
backwards, and 2,  when the  toes are directed  forwards.   The former is the
more frequent, and both correspond to the two classes of breech presentations.
  As we should expect, the  feet, meeting with no resistance to  fix them,
are liable to change their position during their descent, until the hips enter
the brim, which they do precisely as was described  in breech cases (§ 617).
In fact, in its further progress the  case  is  identical with breech cases, and
the  description already given will serve as well for footling cases,  on which
account I need not repeat it.
  The expulsion of the body of the child may be more rapid, owing to the
absence of the additional bulk of the thigh when doubled up on the abdomen,
but  it is just so much the less safe for the child.
      27 
418            MAL-POSITION AND MAL-PRESENTATION
Fig. 165.
Presentation of Inferior Extremities.
627.  Statistics.—Frequency.
a. British and American Practice. <			i b. French and Italian Practice.		
Authors.	Total No. of Cases.	Pres. of Infr. Ex.	Authors.	Total No. of Cases.	Pres. of Infr. Ex. 242 247 3 32
Dr. Bland Dr. Jos. Clarke Dr. Granville . Dr. Merriman Ed. Lying-in Hosp.. Mr. Gregory . Dr. Maunsell . Dr. Beatty Dr. Collins . Dr. Lever Mr. French . Dr. Churchill. Drs. M'Clintock and Hardy Dr. Murphy . Dr. Storer Mr. Crosse Mr. Earle Birmingham Hosp. . Dr. Bliss Dr. Metcalf . Mr. Rose Mr. Bailey Dr. Toogood . Dr. J. Lee. . Dr. Copeland . Dr. Pagan Mr. R. U. West . Mr. J. Thompson . Drs. Johnston and "I Sinclair j Dr. Hall Davis	1,897 10,387 640 2,947 ' 2,452 691 839 1,182 16,414 4,666 89 1,525 | 6,634 467 440 1,394 4,320 650 771 360 600 2,819 1,135 850 1,290 8,684 2,106 3,300 13,748 7,302	18 184 3 40 8 7 21 15 187 29 1 22 38 6 2 6 40 2 8 4 7 29 3 13 10 113 29 8 181 44	Mad. Boivin . Mad. Lachapelle M. Ramboux . Dr. de Belli .	20,517 15,652 501 2,739	
			c. German Practice.		
			Moschner and "I Kursak / M. Richter . A. E. v. Siebold . E. C. v. Siebold . Dr. Kilian Dr. Carus Dr. Kluge Dr. Brunatti . Dr. Theys Dr. Adelmann Dr. Arneth Prof. Schwerer	12,329 2,571 2,059 947 2,350 2.908 1,074 295 21 53 6,608 21,804	82 30 25 11 8 23 17 3 2 2 59 119
 
                            OF THE CHILD.                         419

  Thus in  British practice, we have 93,749 cases, and 935 presentations of
the inferior extremities, or about 1 in 100^.
  In French practice, 45,409 cases, and 524 presentations of the inferior ex-
tremities, or about I in 86f.
  In German  practice, 53,019 cases, and  372  presentations of the inferior
extre  ities, or about 1 in 142^.
  Alto ether 192,174 cases,  and 1831 foot or  knee presentations, or about
1 in 105.
  The following table shows the mortality among the children :—
Authors.	Footling Cases.	Children lost.	Authors.	Footling Cases.	Children lost.
Mr. Giffard .	23	13	Mr. Gregory .	7	3
Dr. Smellie	9	3	Dr. Beatty	15	10
Mr. Perfect .	11	6	Dr. Collins .	187	73
Dr. Jos. Clarke	184	62	Dr. Lever	29	16
Ur. Ramsbotham .	2	1	Dr. Churchill .	22	10
Dr. Merriman	40	6	Drs. M'Clintock \ and Hardy J	25	5
Edin. Hospital	8	2			
Dr. Arneth	59	11	Mr. J. Thompson .	8	0
Dr. Metcalf .	4	2	Drs. Johnston "1 and Sinclair J	127	59
Dr. Murphy .	6	1			
Dr. Storer	2	2	Dr. Hall Davis	44	18
  This gives a very large mortality, 303 children being lost out  of 812, or
about 1 in 2^.
  628. Symptoms.—The first  circumstance in  the  labor  which excites our
suspicions of its being unnatural, is very often the early rupture of the mem-
branes, and the large quantity  of liquor amnii which escapes, and  on making
an examination, we discover the absence of the head  blocking up the brim,
although we may not be able to make out the presentation.   As the labor ad-
vances'one or both of the feet or the knees descend through the os uteri, some-
times with the toes pointing downwards, but more frequently bent up towards
the tibia.   An examination at this period will enable us to form a diagnosis.
The labor  proceeds gradually, and  the  hips descend  into  the pelvis; then
the chest, shoulders,  and the head,  precisely as described in breech pre-
sentations,  and with the same  evolutions and adaptations.
  Danger'to the mother can only arise from a prolongation  of  the second
stage, or injury to the passages, and  there is  little risk of either so long as
vio?ent efforts be not made to extricate the child, and  if the  pelvis be well
formed.
  The danger to the child is  greater than  in  breech  presentations, one in
two and a half being  lost, and from  precisely the  same cause which made
the latter more  dangerous  than head  presentations—viz., the  inadequate
dilatation of the passages.  The child passes through as a wedge, and each
succeeding part being wider  than  the preceding, has to effect  dilatation
sufficient for itself, and that at a stage when time is of  great value from  the
pressure  to which  the child  is exposed.    The  breech, with the legs turned
up, is certainly less bulky than the head, and  therefore prepares badly lor
the quick transit of the latter ; but if the size of the breech be diminished by
the thio-hs being extended, it is clear that much greater resistance and delay
of the  head will result: and in this greater delay and consequent prolonga-
tion of the pressure  upon  the  funis  is the explanation of the increased
mortalitv.                                    ,    ,. .      .   .,     , .
   629.  Diagnosis.—Footling presentations, when high  up in  the pelvis, 
420
MAL-PRESENTATION  OP  THE CHILD.
may be confounded with presentations of the hand ;  and if one foot only be
down, the heel may be  mistaken  for  an  elbow.   However, a little care will
enable us to distinguish them.  For instance, the foot is longer and the sole
flatter than the hand ;  the toes are shorter, and more equal in length than
the fingers, and the great toe does not separate from the others, as the thumb
does from  the  fingers.  The presence of the heel, with the ankle-bone on
each side, is quite different from the hand and wrist.   Tracing from the heel
along the sole  of  the foot to the toes,  will, of course, distinguish the heel
from the  elbow.  In an  examination, the  knee maybe distinguished from the
elbow, for which it may in some  degree be mistaken,  Naegele remarks, in
that it is thicker,  that  it has two prominences, and a depression  between
them ;  while on the other hand, the elbow,  which is thinner, presents to the
feel between the two prominences a projection in which it seems to end.
   630. Treatment. —  In every particular, the treatment of breech presen-
tations applies to footling cases, except that I think there is rather  more
temptation to pull down the child at an early period, because  of the greater
facility for so doing; but, from what  I have said, it must be evident that it
is more necessary that the labor  should  be let  alone.   There  can be no oc-
casion  to interfere until the pressure upon  the funis is felt, i. e., until the
umbilicus is visible, and then the  risk  to the child must decide  upon whether
assistance is to be  given or not.   The same method must be adopted for ex-
tricating the arms, and for facilitating the expulsion of the head :  and  in the
more difficult cases we have the same  remedies at command.
  631. 3. Presentation of the superior extremities.—In almost all  cases
of this kind, it  is the shoulder which  primarily  presents, and afterwards the
arm prolapses ; occasionally however we find the hand at the beginning of
the labor at the os uteri, and more rarely the elbow.
  In all cases the back  of the child either looks forward towards the abdo-

                                Fig. 166.
Arm Presentation — First position.
men of the mother (fig. 166), or backward towards her spine (fig. 167) ; the
former being twice as frequent as the latter.
  In the majority of cases, with such a position of  the child, labor may be
considered as impracticable, unless assisted  by art;  and yet even with such
an untoward position, the natural powers have occasionally succeeded in ex- 
SUPERIOR  extremities.
421
pelling the child.   Dr. Denman, in 1772, first noticed the fact, and he sup-
posed that, during an  interval of uterine relaxation, the  shoulder and arm
receded,  and the breech came down into the pelvis; hence  the name  he
gave to it, "spontaneous evolution of the fcetus."

                                 Fig. 167.
Arm Presentation — Second position.
  This explanation of the process, which I hastily attributed  to a mistake
on Denman's part in a former edition,  has, however, been  confirmed by
Fig. 168.                                Fig. 169.
                              Arm Presentation.

other observers—for  example, M. Boer, Dr. Mitchell,1 Dr. Dyce,2 and Mr.
Crosse.3
  1 Charleston Med. Journ., May, 1850.     2 Edin. Monthly Journal, May, 1850, p. 437.
  5 Cases in Midwifery, p. 105.
       36 
422            mal-presentation  of  THE CHILD.

  That there  is another  and more  common mode in which  the evolution
takes place is  certain, for I have seen it from beginning to end, and for the
true explanation of which we are indebted to the accurate observation  and
ingenuity of my friend, the late Dr. Douglas, a distinguished practitioner of
this  city, in an essay published  in  1811, from which  the  following short
description is  extracted.   Before its expulsion, the  situation  of the fcetus
"resembles the larger segment of a circle;  the head rests  on the pubis
internally, the  clavicle presses  against the pubis externally, with the acro-
mion stretching towards  the mons veneris (fig.  168) :  the  arm  and shoul-
der are entirely protruded, with one side of  the thorax not only appearing
at the  os  externum, but partly  without it:  the lower  part  of the same
side of the trunk  presses on the perineum, with the breech  either in the
hollow of the  sacrum or at the brim of the pelvis, ready to descend into it
(fig. 169) ; and by a few further  uterine efforts the remainder of the trunk,
with the lower extremities, is expelled (fig. 170).  And to be more minutely
explanatory of this ultimate stage of the process, I  have to  state that the
breech is not expelled exactly sideways,  as the upper part of the trunk had
previously been ;  for, during the progress of that pain by which the  evo-
lution in completed, there is  a twist made, about the  centre  of  the curve, at
the lumbar vertebras, when both buttocks, instead of the side of one of them,
are thrown against the perineum, distending it very much  ; and immediately
after the breech, with the lower extremities, issues  forth ; the  upper and
back part of  it appearing first, as if the back  of the child had originally
formed  the convex, and its front the concave side of the curve."
Fig. 170.                                Fig. 171.
                             Arm Presentation.

  Thus the head and the shoulder depressed in the pelvis are fixed, and the
remainder of the body doubled up, is, inch by inch, forced into the pelvis,
and through the external parts, until all below the  arm is expelled, leaving
the case to be terminated as a breech or foot  presentation (fig. 171).  At 
SUPERIOR
EXTREMITIES.
423
no part of the process is the arm at all retracted ; but if moved at all, it is
Btill further protruded : the name of " spontaneous expulsion," given by Dr.
Douglas, is therefore more suitable than  that of "spontaneous  evolution."
An essential condition of this  extraordinary  effort of nature, is  the relative
disproportion of the fcetus and pelvis ; either the fcetus must be smaller, or
the pelvis larger than usual, to permit it.  The accuracy of Dr. Douglas's
explanation has been proved by the observations of Dr. Gooch  and others.
I can also add my testimony, having some years ago had an opportunity of
witnessing the entire process.
   It sometimes happens in arm presentations, when  the  child is small  and
the pelvis large, and especially with premature births, that  the  child is ex-
pelled double.  Dr. Dyce describes a  case  in which  the  shoulder and but-
tocks were  brought down nearly together, the arch formed by the body look-
ing downwards.1
   I have seen the reverse more than once, and I think it is the more common,
i. e.,  where the body doubled  is  protruded, the extremities, back, and head
being above.
   632.—Statistics.—Frequency.
a. British Practice.			a. British Practice.		
Authors.	Total No. of Cases.	Pres. of Sup. Ex.	Authors.	Total No. of Cases.	Pres. of Sup. Ex.
Dr. Bland	1,897	8	Mr. Earle	4,320	34
Dr. Jos. Clarke	10,387	48	Mr. Rose	600	3
Dr. Merriman	2,947	19	Mr. Bailey	2,819	7
Dr. Granville .	640	1	Dr. Toocood .	1,135	3
Ed. Lying-in-Hosp.	2,152	4	Dr. J. Lee	850	3
Dr. Collins .	16,414	40	Mr. K. Watson	800	11
Mr. Gregory .	694	4	Mr. J. Thompson .	3,300	5
Dr. Cusack	701	5	Drs. Johnston \ and Sinclair J	13 748	60
Dr. Maunsell .	839	4			
Dr. Beatty . Dr. Lever	1,182 4,666	4 12	Dr. Hall Davis	7,302	25
					
Mr. Mantell . Dr. Churchill .	2,510 1,525	4 9	b. Frenci	i Practice.	
Drs. MClintockl and Hardy J	6,634	26 29 4			
			Mad. Boivin .	20,517	80
Dr. Reid	5,691		Mad. Lachapelle	15,652	68
Birmingham Hosp. .	650		M. Ramboux .	491	4
Dr. Murphy .	467	-	1 Dr. de Belli .	2,739	37
Dr. Copeland . Mr. Crosse	1,290 1,394	4 3	, Wurtzburg Hospital	637	3
  Thus in British practice it  occurred 382 times in 96,454 cases, or  about
1 in 252^;  and in French practice,  192 times in 40,036 cases, or about? 1 in
2081   Altogether 574 times in 136,490 cases,  or about 1 in 208^.

                  ' Ed. Monthly Journal, May, 1850, p. 433. 
424
MAL-PRESENTATION OF THE  CHILD.
Authors.
Mr. Giffard
Dr. Smellie
Mr. Perfect
Dr. Jos. Clarke
Dr. Ramsbotham
Dr. Merriman
Edin. Hospital
Dr.  Collins
Mr. Gregory
Dr. Cusack
Dr. Maunsell
Dr. Beatty
Mr. Lever
Dr.  Churchill
Drs. Hardy and M'Clintock
Dr.  Murphy
Mr. J. Thompson
Drs. Johnson and Sinclair
Dr.  Hall Davis .
Presentation
of Superior
Extremities.
24
34
 6
48
27
19
 4
40
 4
 5
 4
 4
12
 9
26
 2
 5
42
25
Mothers	Children
lost.	lost.
0	15
3	19
1	2
6	21
6	18
	2
4	20
	3
0	2
	4
1	4
3	8
0	5
 5
28
15
Delivered l.y
Version. Crotcht.
21
28
 6
 4
 o
 4

 9
19


25
20
11
  The second of the preceding tables is intended to show the mortality to
both mother and child, so far as it is mentioned by the author : where it has
not been recorded,  I have left the space blank ; but if either died, I have so
specified.  I have thought it worth while, also, to add some columns show-
ing the different modes of delivery practised.
  From this record we find, that out  of 314 cases of presentation  of the
superior extremities, 175  children were  lost, or rather more than one-half.
Out of 282 cases, 30 mothers were lost,  or nearly 1 in 9.
  633.  Symptoms. — Labor with  this  mal-presentation is, as the statistics
show, extremely dangerous  to  the mother  and child, and  especially as the
remedy involves a very serious  operation.   Dr. Rigby has  given a graphic
picture of a case of this kind when unassisted : " After the membranes have
burst, and discharged more  liquor amnii than in  general when the head or
nates presents, the  uterus contracts tighter around the child,  and the shoulder
is gradually pressed deeper  in the pelvis, while the pains increase consider-
ably in violence from the child being unable, from its faulty position, to yield
to the expulsive efforts of nature.   Drained of its liquor amnii, the uterus
remains in its state  of contraction even during the intervals  of the pains;
the consequence of this general and continued pressure is,  that the child is
destroyed from  the circulation  in the placenta being interrupted, the mother
becomes exhausted, and  inflammation or rupture of the uterus and vagina
are the almost unavoidable results."
  Ou  the part of the  mother, so long as the labor is virtually in the first
stage, the symptoms are perfectly natural and favorable; but after the second
stage  (marked  by voluntary effort  and change of cry) has lasted for some
time, then we have in detail the symptoms  of powerless labor, exactly as I
have described them ;  but  with a  difference in  the results, owing  to the
mechanical  obstructions offered by the mal-position  of the  child ; and I re-
gard these cases as the  most striking illustration of the fact I have repeatedly
pressed upon the reader's attention — viz.,  that the development of unfavor-
able symptoms  is owing to the stage at which the delay occurs, and not to
the kind of impediment; for here we find that the same symptoms arise from
a purely mechanical impediment on the part of the child, the uterine  system 
SUPERIOR  EXTREMITIES.
425
being in perfect integrity, as we found to result from inefficient pains, from
tumors in the soft passages, or from deformity of the pelvis.
  634.  Diagnosis. —Our first suspicion will probably arise from finding, on
examination, that we are not able to reach the presentation ; this,  of course,
proves nothing ;  but it ought to induce a very careful investigation, and we
may find the  os  uteri very little dilated,  and suffering comparatively little
pressure  during  each pain, or the  hand may be  felt protruding through  the
undilated  os  uteri.   The high situation  of the presentation  (if it be  the
shoulder) renders it difficult to ascertain the part which is descending.   We
may derive confirmation of our suspicions from  finding the bag of the mem-
branes protruding, of a  conical or elongated form, and evidently  not cover-
ing the head.
   When the shoulder has descended a little, we  may be able to reach the
 axilla, and we shall  find  that the shoulder is  rounder than the elbow,  and
 has not the condyles of the humerus, so that this will decide the point for us.
   The hand may be mistaken for the foot; but its shortness,  the length of
 the fingers, and  the divarication of the thumb, will enable  us to distinguish
 it.  The situation of the thumb, and the aspect  of the palm of  the hand, will
 mark whether it is the right hand or the left.
   635. Causes. — This mal-presentation has  been  attributed to irregular
 early contractions of the uterus, to irregular distention, to obliquity, etc. etc.
 They may possibly have some such effect; but  I  think all the explanations
 as yet offered are insufficient.   Dr. Rigby concludes :—" We may, therefore,
 state that the causes of arm or shoulder presentations are of two  kinds, viz.,
 when the uterus has been distended  by an unusual quantity of  liquor amnii,
 or when, from  a faulty condition  of the early  pains of labor, its form has
 been altered, and with it the position of the child."
    636. Treatment.—As (with very few exceptions) the labor is impracti-
 cable, we have nothing to expect  from the natural efforts except an increase
 of difficulty, it becomes our duty to interfere promptly in every case.  Should
 the mal-presentation have been detected before the rupture of the membranes,
 and before the  os uteri is fully dilated,  we may wait for a time to allow of
 as complete dilatation as possible  ; nor is there  any risk so long as the mem-
 branes are entire.   But if they have given way, we ought not, and if the
 os uteri be fully dilated (whether the membranes be entire  or  not) we must
 not wait a moment, but proceed to deliver by turning.  When the liquor
 amnii has not escaped, there is seldom  any difficulty, but after that event,
 we generally find the uterus more or less strongly contracted upon the child,
 and in proportion to this contraction is the difficulty.  If the  uterine action
 be very intense, the operation may be impossible without  risk of rupturing
 the uterus ;  and in such cases, instead of proceeding at once to turn, a  dose
  of tartar emetic or opium, or a combination of both, may be given, so as to
  moderate  or suspend  uterine action, and admit of the introduction of the
  hand.   If the  pulse  be quick and strong, venesection may  be beneficial.
  I have already  given the details of the operation of turning.
    [Dr. Churchill, in his recommendation of bleeding in the cases  referred to,
  does  not  exhibit that decision which the importance and efficiency of the
  measure would  seem to demand.   When, in cases where turning is demanded,
  the waters are evacuated, and the uterine contractions so strong as to render
  the operation difficult and dangerous, there is no remedy equal to free blood-
  letting, pushed even ad deliquium, a full dose of laudanum beinggiven, at
  the same  time,  to prevent any undue reaction.  If the practitioner is prompt
  and  skilful, he  may effect the turning before the relaxation produced by the
  bleeding shall have passed off.   It is unnecessary in these cases to lose time
  bv searching for both feet, as delivery can be  accomplished equally well by
  bringing down only one, while the risk to the child is less.  If, however, the 
426
MAL-PRESENTATION OF  THE  CHILD.
child  be dead, or there is much hemorrhage, it will be proper to seize and
bring down both  feet, with the view  of accomplishing the delivery more
rapidly,  provided  always both  can be gained  without much delay or dif-
ficulty.]
   Should these measures  fail, and version be impracticable, we must open
the chest of the child, and eviscerate ;  after which it may be extracted by
the crotchet.  " Several writers," says Dr Collins, "recommend, in difficult
cases of this nature, the separation of the child's head, so as to bring the body
away by the presenting arm, and afterwards deliver the head by the crotchet;
this we  would condemn, unless we  failed in our efforts, by breaking down
the thorax, which is very  unlikely, if the operation be  properly performed,
and the pelvis  not extremely  under size.   We  once saw a delivery effected
as  above described, and the  greatest  difficulty was experienced in the ex-
traction of the  head ; it was necessary to introduce  the hand  to  bring it
into the vagina, and then it had to be lessened before it could be removed."
   637.  But, it  will at once  be asked, what  practical application can be
made of our knowledge of the occurrence of spontaneous expulsion  ?  I am
afraid not much.  I am satisfied that we  ought not to wait for it in  any case
in which turning  can easily  be  accomplished,  because, if it did not occur
(and, according to Dr. Douglas,  it does not occur above once in ten thou-
sand  labors), the operation will be  rendered tenfold more difficult, from the
greater depression of the child, and more energetic action of the uterus; it
would,  in fact, be  exchanging a comparatively easy and not very dangerous
operation for a very difficult one, in which the  risk to the mother would be
great, and the death of the child certain, provided this rare phenomenon did
not occur.  I think, however, that  in  such  a case  as Dr. Douglas has de-
scribed, we may venture upon a  little delay, to  afford a chance of sponta-
neous expulsion.  " If the arm  of the fcetus," says Dr. Douglas, "should be
almost  entirely protruded,  with the  shoulder pressing on the perineum; if a
considerable portion of its thorax be in the hollow of the sacrum, with the axilla
low in the pelvis ;  if, with this disposition, the uterine efforts be still powerful,
and if  the thorax be forced sensibly lower during the pressure of each suc-
cessive pain, the evolution may with great confidence be expected."
   [Dr.  M.  B. Wright of Cincinnati, in an essay which appeared a few years
since, and to which  a gold medal was awarded by the Medical Society of
the State of Ohio, has  presented a strong plea in favor of cephalic version
in cases of arm or shoulder presentation.   He  maintains that it may be per-
formed whenever  turning  by  the  feet is practicable, even, indeed, when this
 cannot  be  effected, and with greater  safety to  mother and  child.  There
cannot, we think, be any doubt as to the  possibility in certain favorable cases
 of arm or shoulder presentation — when the head of the foetus is small and
 the pelvis large — of cephalic version, particularly in the  manner practised
 by Dr.  Wright, being effected ; and whenever such is  the  case there is un-
 questionably a greater probability of the child being saved than when podalic
 version is resorted to.  In complex and complicated cases of  shoulder pre-
 sentation, however, though not absolutely impracticable, cephalic version is
 always attended with great difficulty,  and is as replete with danger to both
. mother and child as turning by the feet.  To  such  cases it  is altogether
 unadapted.    Even  under the  most  favorable  circumstances,  we are  to
 recollect that  after  the  mal-position of the head  has been  rectified  by
 cephalic version,  notwithstanding the  pain  and risk to which the female has
 been subjected, the delivery is still  to be effected by the regular contractions
 of the  uterus — by a "labor" that may, for all we know,  be sufficiently
 tedious and painful to produce an amount of exhaustion as shall require,  to
 insure  the safety of the patient, a resort  to instrumental delivery ;—hence, it
 is evident that, under all  such circumstances  as indicate the necessity for a 
SUPERIOR  EXTREMITIES.
427
speedy termination  of the labor, podalic is invariably to be  preferred to
cephalic version.]
  As  the minute details of management are the same in natural  and un-
natural labors, I have not  thought it necessary to repeat them,  but refer the
reader to the  chapter on that subject.
  638. 4.  Compound presentations.—From an untoward position of the
body or extremities of the child,  one or more parts may come together to
the  os uteri;  in some cases  merely adding to the bulk to be transmitted
through the passages without altogether preventing it, in others rendering
interference necessary for the delivery.   For instance :—
  1.  The hand or arm may present with the head, of course adding to its
size, and perhaps, if the pelvis be small, prohibiting its entrance into the
passage.   As a general rule, the hand or  arm  is  stretched out or placed
along the side of the head, descending with it or before it;  but Dr. Simpson
has met with  a case in which the fore-arm was placed across the back of the
head and fteck, at once increasing the bulk  and opposing  a projecting ob-

                                Fig. 172.
                             H
                  Compound Presentations — Hand, Foot, and Funis.

struction which caught upon the brim of the pelvis.   He brought the hand
downwards and forwards : but the pains proving insufficient, and the child
getting weak, he delivered by podalic version.1  Nor is this compound pre-
sentation without danger if the uterine action be violent.   Dr. James Gray
has related a case in which the hand, presenting with the  head,  was forced
through the walls  of the  vagina and  rectum.2  Such cases, however,  are
very rare.   Compound  presentations, as Dr. Merriman has observed, rarely
occur except when the pelvis is large.  In  the cases recorded, by Drs. Jos.
Clarke, Collins, and  Jansen, no example  is mentioned:   and in  those of
Mesdanips  Lachapelle and Boivin only  three,  i.e.,  three  cases  in  75,903
deliveries.   For which  reason, if it be discovered early, a cautious attempt
should be made to replace  the  arm above the  head, so as to  allow it to
descend ; but, above  all things, we must be cautious neither to draw down

  1 Ranking's Abstract, vol. ii, p. 263.     2 Edinburgh Monthly Journal, Jan., 1851. 
428
compound  presentations.
the hand nor to displace the head, as either may convert a simple manageable
case into an arm presentation.
   If the arm cannot be replaced, the case must then be treated  as  one of
relative disproportion ;  perhaps a little time and extra uterine action (which
is  generally exerted, as we have said, in proportion to  the demand for it)
may suffice :  if not,  and the delay should excite  unfavorable  symptoms, we
must first see if the forceps are applicable, or version, and, as a last resource,
if  all others fail, we  must  lessen the  head.   I prefer the forceps to version,
because of its inferior mortality  as regards both mother  and child; and
version (when possible) to the crotchet, for the same reason.
   2. The feet and hands may present,  or one of each, and  in these cases
it  not unfrequently happens that the cord prolapses (fig. 172) from the upper
outlet not being filled by the presenting part.
   In such cases, it is evident that one or other extremity must descend and
give the character to the labor, making it an  arm or  footling case.
   Now it is exactly for the determination of  this question that w*e ought to
interfere.   There can be no doubt of the propriety of drawing down the foot
or feet into the pelvis so as to preclude the possibility of the arm descending,
and when this is done, the case is one of footling  presentation, and to be
managed accordingly.   But I must repeat my caution, that the greatest care
is  necessary,  first, not  to  mistake  a hand for a  foot,  and, secondly, not to
favor the descent of the hand and arm by the mode of examining.
   Prolapse of the cord increases the danger to the child, and may (according
to  the rules  laid down) require us to hasten  the labor, if the pulsations be
weak and the  woman have previously had children.
                        CHA PTER  XYII.

          PARTURITION. —CLASS II.  UNNATURAL LABOR.
               ORDER 6.  PLURAL BIRTHS. —MONSTERS.

   639.  1.  Plural Births. — I have already stated the signs by which twin
 pregnancy is  to be recognized,  and also that in the majority of cases they
 are very dubious.   Each child possesses its special envelopes and a separate
 placenta, though they are sometimes  so pressed together as to appear but
 one, and occasionally a vascular  communication passes from one  to the other.
 The labor is often  premature, and  the children are generally  smaller than
 usual.
   The mode of transmission  of each child may be perfectly natural, or either
 or both may come under some of  the orders of  unnatural  labor already de-
 scribed, requiring the management suitable  for such cases : so far, a separate
 notice of plural births is unnecessary : but on the other hand, there are some
 important  points of practice, and some details as to the presentation and
 mortality in  such cases,  which require to be investigated.   In  this chapter,
 therefore, I shall chiefly remark upon the circumstances peculiar  to  plural
 births, and, to  avoid repetitions, refer to the previous sections for the or-
 dinary treatment.
  A woman may conceive  of two, three, four, or five children, but I am not
 aware of more than four  children having been born alive at one  birth.
  The statistics I have been  able to collect are not very extensive, but there
are some interesting points which I  have endeavored to  investigate as fully
as the means permit. 
                PLURAL  births. — MONSTERS.




640.  Statistics.—1. Frequency.
429
a. British Practice.								
Authors.			Total No. of Cases.	Twins.	Triplets.	Quadru plets.		
Dr. Jos. Clarke ....			10,307	184	3	1		
Dr. Merriman .			2,947	39	1			
Dr. Granville .			640	9				
Edinburgh Hospital			2,452	31	2			
Dublin Hospital			129,172	2,062	29		1	
Dr. Maunsell .			839	13				
Mr. Gregory .			691	12				
Dr. Beatty			1,182	18				
Dr. Lever			4,666	33				
Dr. Reid .			580	9				
Mr. Warrington			110	3				
Dr. Churchill .			1,640	25	1			
Drs. M'Clintock and Hardy			6,634	95	1			
Dr. F. Ramsbotham			48,996	536	3			
Dr. Murphy			467	3				
Dr. Storer			451	5				
Mr. Crosse			1,394	17				
Mr. Earle			4,320	53				
Mr. Rose			600	10				
Mr. Bailey			2,819	41				
Mr. Waddington			2,159	19	1			
Dr. Toogood .			1,135	12				
Dr. J. Lee			850	9				
Mr. K. Watson			800	18				
Dr. Copeland .			1,290	9				
Dr. Adams			628	10	1			
Dr. Pagan			8,587	95	1			
Mr. R. U. West			2,106	23				
Mr. J. Thompson			3,300	25				
Drs. Johnston and Sinclair			13,748	233	1			
Dr. Hall Davis			7,302	69				
b. French Practice.								
Mad. Boivin.....			20.357	154	3			
Mad. Lachapelle			15,481	165	3			
Hotel Dieu, Paris			280	4				
M. Mazzoni			452	9				
Dr. de Belli .			2,739	34				
c. German Practice.								
Dr. Henne.....			1,214	1				
Dr. Richter			2,571	52				
Moschner and Kursak			12,329	165				
A. E. v. Siebold			1,409	20				
Dr. Riecke			219,303	2545	34		2	
Dr. Kluge			809	15				
Prof. AndrfS			176	5				
Dr. Theys			55	4				
Dr. Brunatti .			99	2				
Dr. Adelmann .			56	1				
Dr. Jansen			13,365	157	1			
Dr. Hoffman .			6,139	98	. i			
Dr. Klein			35,084	325				
Dr. Bartsch			4,383	42				
Prof. Schwerer			21,804	250	1			
Dr. Arneth ....			6,527	81				
Gebarklinik			39,121	445	' 3			
Wurtzburg Hospital			637	31	• I			
 
430
PLURAL  BIRTHS.
  So far as these numbers go, we find among British practitioners, in 257,935
cases, 3431 cases of twins,  or about  1 in 75 ; and 43 cases of triplets, or 1
in 5561^.  Among the French practitioners, in 39,409 cases, 336 cases of
twins, or about 1 in 108 ;  and 6 of triplets, or 1 in 6568.   Among German
practitioners, in 369,080 cases, 4239  cases  of twins,  or about  1 in 87 ; and
38 of triplets, or about 1 in 9765.  Taking the whole,  we have 666,424 cases,
and  8006 of twins, or 1 in 83 ; and 87 cases of triplets, or 1 in 7443.
  I have formerly quoted the comparative frequency in  different countries
stated by M. Quetelet.
  [Dr. E. Yon  Siebold gives1  an account  of  the twin  births which have
occurred at the  Gottingen  Midwifery Institution since its establishment.
These amount to 89  in number, occurring in 7139 births, which had taken
place between the years  1792 and  1859 — making 1 twin case in every 80
births.   According to Yeit's statistics, the proportion in Prussia is 1 in 89;
in Wirtemberg,  1 in 86 ; and  in Saxony, 1 in 78.   The proportion has been
found to vary greatly in  different towns.  Kiirschner in  his Thesis  sets it
down as  1 in 158 at Naples, 1 in 126 at Palermo, 1 in 118 in Lunenburg, 1
in 110 at Marburg, 1 in 96 at Hamburg, 1 in 88  at Berlin, 1 in 86 at Leipzic,
1 in  85 at London, 1  in 84  at Paris,  1 in 74 at  Vienna and Wurzburg, 1 in
68 at Dresden, 1 in  62 at Heidelberg, 1 in 72  at Prague, 1 in 75 at  Phila-
delphia, 1 in 57  at Dublin.]
  2.  Mortality.
Authors.			Twin Cases.	Children lost.	Triplet Cases.		Children lost.
Mr. Giffard Dr. Smellie Mr. Perfect Dr. Jos. Clarke . Dr. Ramsbotham Dr. Granville Dr. Collins . Mr. Gregory Dr. Beatty Dr. Lever . Dr. Jansen Drs. M'Clintock and Hardy Dr. Arneth. Dr. Hoffman Mr. J. Thompson Drs. Johnston and Sinclair Dr. Hall Davis .	•		14 8 7 184 15 9 240 12 18 33 157 95 81 98 25 233 69	9 2 7 282 9 4 58 16 8 6 16 19 8 38 85' 9	1 2 3 2 4		4 ' 4
  Thus, out of 1298 cases of twins (i. e., 2596 children), 636 were lost, or
about 1 in 4 ; and out of 12 cases of triplets (i. e., 36 children), 11 were lost,
or 1 in 3.
  This  mortality, however, which is very large, must be qualified by allow-
ing for the great  number of children whose death could not be attributed to
the labor.  Dr. Jos. Clarke had 43  still-born ; Dr. Collins had 54 premature
labors among the twin  cases, and  12 cases  of the birth of a putrid fetus.
Drs. Johnston and Sinclair record  27 cases of putrid fcetus.
  The mortality to the  mother in twin cases has been computed as 1 in 20:
in Dr. Collins' cases it was 1 in 34  : in Drs. Johnston and Sinclair's it was
1 in 23.   I regret that, from the imperfection of  the records, I cannot give
ample statistics on this  point.
[Monatsschrift f. Gebiirtskunde, Bd. xiii.] 
PLURAL  BIRTHS.                        431
As to the sexes in twin cases, the following cases are recorded :__
Authors.	No. of Twin Cases.	Both Males.	Both Females.	One Male and one Female.
Dr. Jos. Clarke .....	184	47	68	71
Dr. Collins.....	240	73	67	97
Dr. Lever ......	33	11	11	11
Dr. F. Ramsbotham ....	536	171	183	182
Drs. M'Clintock and Hardy	95	38	09	35
Drs. Johnston and Sinclair .	233	76 416	58 409	99
	1,321			495
  Thus we find that twin children are most frequently of opposite sexes, and
that twin males are more common  than twin females.  From Dr. Collins'
record, I may state, that  of his  twin male cases 23 were  dead (1 putrid),
and that of these 23,13 were the first-born children ; of the female twins, 11
were dead (4 putrid) ; and of the twins of opposite  sexes, 22 were lost (7
putrid),  of which  15 were boys  and 7 girls.   Drs. M'Clintock  and Hardy
state that "of the 190 children, 171 were born alive ;  viz., 85 first-born, and
86 second-born.  Of the entire number of children, 111 were boys, of whom
58 were  first-born, and 53 second-born ;  79 were girls, of whom 37 were first-
born, and 42 second-born ; 101 boys were born alive, viz., 52 first-born, and
49 second-born ;  70 girls  were born alive ;  viz., 33 first-born, and 37 second-
born;  10 boys were dead  born, viz., 6 first-born, and 4 second-born ; 9 girls
were dead born, viz., 4 first-born, and  5 second-born ; 5  of these females
were putrid."1   Of Drs. Johnston and Sinclair's  233 cases in 466 children,
in 76 cases both were boys; 133  were born alive, 14 still-born, and 5 putrid ;
in 58 cases, both were females, 106 were born living,  6 dead, and 4 putrid.
In 99  cases they were of opposite sex;  58 of the male children were alive,
9 dead, and 5 putrid ;  89 of the girls were alive, 6 dead, and 4 putrid.2  This
is important, since from it we  learn that there is more danger to  the boys
than the girls, and  particularly when there are twin cases of opposite sexes.
  From  the reports of the same authors, the presentations, placed in order
of births, were as follows : —
Authors.	Both Head.	Head and Breech.	Head and Foot.	Both Breech.	Breech and Head.	Breech and Foot.	Both Foot-ling.
Dr. J. Clarke .... Dr. Collins .... Dr. Lever .... Drs. Johnston and Sinclair	16 103 15 125	7 44	25 25 5	2 8 2 19	6 25 26'	1 9 1	3 5
----------------- Authors.	Foot and Head.	Breech and Elbow.	Head and Arm or Shoulder.	Face and Head.	Head and Face.	Foot and Hand.	Foot and Breech.
Dr. J. Clarke . Dr. Collins .... Dr. Lever .... Drs. Johnston and Sinclair	10 19	1 ' 9*	5 2 10	1	1	1	1
1 On Midwifery and Puerperal Diseases, p. 239.    2 Practical Midwifery, pp. 273-4. 
432
PLURAL  BIRTHS.
   Dr.  Collins thus states the mortality of  his different  presentations: when
both were head  presentations, he  lost 24 (4 putrid), when the head and
breech (i. e., the first child with  the  head, and the second with the breech)
presented, 2 of the former and 5 of the latter were lost; when the head and
feet, 2  of the former and 3 of the latter ;  when  the feet and head, 4 of  the
former and 2 of the latter; when the breech and the head,  1 of the former
and  6  of the latter;  when both were footling cases, 2 were lost;  when  the
breech and feet, 3 of the  former and  2 of the latter were lost.
   This confirms what I have elsewhere stated, that the less the passages are
dilated by the presenting part, the greater the mortality amongst the children,
because of the delay in the transit of the remaining parts of the body of the
child.
   [According to Yon Siebold,1 in a series of 35 cases  of twins attended by
Osiander between  the  years  1792 and 1822, the head  presented in both
children  19 times, the head and  breech 6  times, the  head and feet 4 times,
the breech and feet, twice.  In one case the feet presented in both children,
and in  another case, the breech.   In  one case, one child presented the head
and  the  other the shoulder, and  in one case the position was not accurately
ascertained.
   In the 35 cases — 70 children, 28 were delivered without interference, the
remaining 42 being removed by the forceps, turning, or extraction by the feet.
   In a series of  54 cases of twins attended by Yon Siebold himself, in con-
junction  with Mende, between the years 1823 and 1859, the  head presented
in both children  22 times, the  head and breech 11 times, the head and feet
10 times, the head and shoulders  5  times, breech of  both  children twice,
breech and feet twice, the feet once, the breech  and shoulder once.
   Of the 108 children born in these  54 cases, 83 were  delivered without  in-
terference, and 25 by  the forceps, turning,  or extraction by the feet.
   In 87  of the entire  number of cases, 2 boys were born in 28, 2 girls in 17,
and a boy and girl in 42;  there being 99 boys and 77 girls in 178 children.]
   Dr.  Simpson has investigated the subject of the alleged  infecundity of the
female  in twin births  of males and females.   He concludes " 1. That in the
human subject, females  born co-twin with males are, when  married, as likely
to have children  as any other females belonging to the general community.
2. That when they are married and become mothers, they  are, in  respect to
the number of their children, as  productive as  other females.   3.  That the
same law of fecundity of the female in opposite-sexed twins seems to hold
good among all  our uniparous domestic animals, with the exception of the
cow alone."2
   641. Symptoms. — The first, second, or third child may present naturally
or unnaturally, and in that respect the course  of the labor will resemble that
of similar cases with  single children.   But it is  generally remarkable that
the progress  of the first child is slower than we  should  have expected ; for,
on examination,  there  appears no want  of space, and the  pains may be
strong.   This I  suppose  arises from  the pressure of the  entire uterus not
bearing directly upon the child which is  to pass first, but at least as much
and primarily upon the  second child.   The pressure  upon the second child
causes  it  to press down  the first child ; but  in this transmission of force much
power  is  necessarily lost, and thus  it is that  we find very  gradual progress
in these cases, notwithstanding that the pains are good  and the space ample.
When  the first child is born, whatever suspicions  may have been previously
entertained are changed into certainty, unless in the case of a small blighted
fcetus ; for, upon  placing  the  hand  upon  the  abdomen, the uterus is felt
nearly  as large as at first, and the child may be detected  through its parietes.
   After the birth of the first child,  there is an interval of rest, varying from
1 [Opera citat.]
2 Edinburgh Med. and Surg. Journal, No. 158. 
PLURAL  BIRTHS.
433
ten minutes to some hours ;  nay, instances are on record of days and weeks
intervening before the birth  of the second child.  Of 212 cases related by
Dr. Collins, in which the interval is accurately marked, in 38 it was 5 minutes •
in 29, 10 minutes ; in 45, 15 minutes ; in 23, 20 minutes ; in 30, half an hour;
in 5,  three quarters  of an hour ; in 16, 1 hour; in 8, 2 hours ; in 3, 3 hours ;
in 5,  4 hours ; in 1,  4| hours ; in 3, 5 hours ; in 2, 6 hours ; in 1, 7 hours ;
in 1,  8 hours; in 1, 10 hours; and in 1, 20 hours.  Thus in by far the larger
number the uterine action was resumed within half an hour.   Dr. Merriman
refers to three remarkable cases:  in one the second child was  retained four-
teen  days after the  first; in  the second, it was  retained  six weeks; in the
third case, the woman was delivered of twins, and  two days  afterwards of
two more boys.   Drs. M'Clintock and Hardy have noted that in 3 cases the
interval  was  5  minutes; in  9, 10 minutes; in 10,  15;  in 11, 20;  in  2,
25; in 13, 30 ; in 1, 40 minutes; in 4, 1 hour;  in 3, 1^; in 1, 2; and in 1,
2£ hours.  Drs. Johnston and Sinclair found that the "average duration of
labor when both  twins were  males was 10^ hours, and for primiparae 14|
hours ; when both were  female, 9| hours, in primiparse,  14  hours ; when
male and female, a little more than 12 hours, with primiparae, nearly 23^ hours.
  After  this interval, whatever it may be, the pains return; and if there be
nothing  unusual  on  the part of the child, the labor is completed in less time
than  with the first child, because of the previous dilatation of the passages.
For the  same reason, when the second child presents with the breech or foot,
the mortality is less  than usual.  Dr. Denman remarks, " the most fortunate
presentation of the  second child in a  twin case  is certainly with the inferior
extremities, because it may in this position be  extracted without injury or
difficulty, and if assistance  be required, this may be given with safety and
convenience."
  There is one important point to be  borne in mind—viz., that the  more
quickly the two  labors succeed each  other, and the  more rapidly they are
terminated, the more probability there is of collapse afterwards, whether
there be hemorrhage or not.   I have seen a lady placed in very great peril
from this cause, without any unusual loss.   I rather think, also, that there
is more danger of hemorrhage, but of that I am not quite certain.  On this
account  the  medical attendant should not leave the patient  for some time
after all  is over.
  642. Treatment.—Whether the first child present with the head  or any
other part, it is to be treated exactly according  to the rules heretofore laid
down, just as if it were a single birth ; and so,  as far as  the  labor is con-
cerned, must the second  child ; thus, if the first  be a natural labor and the
second a mal-presentation, we need not interfere with the first, but assistance
may be necessary with the last child ;  or the first may be a mal-presentation
requiring assistance, and the second a natural labor needing none.   For the
reason already stated, viz.,  the diminution of direct uterine force, it occa-
sionally happens that the first child has to be delivered by the forceps.   The
rules laid down for the employment of that instrument apply equally to these
cases, but it is even  more necessary that no undue delay should take place.
  So far we  must act according to the nature  of the case.  But suppose
that the  uterus do not resume its action  after the ordinary interval, are we
still to leave all to nature ?   It is clear that, if  the passages be allowed to
recover from the former distension, there will  be  more  trouble with the
second child, especially if it be a mal-presentation ; and that there must be
a risk of hemorrhage so long as the uterus remains uncontracted ;  and it
would seem  that delay  involves  danger  to the second child. ^  For these
among other reasons, opinions have varied  as to the necessity of interference,
and as usual,  the  practice has ranged from one  extreme to  the other ; some
having advised instant delivery to obviate these  dangers, and others, finding
that in many cases left to nature no evil has followed, recommending that 
434
PLURAL  births.
we should abstain from all interference.  Dr. Denman advises ns to wait for
four hours, "if there be no  cause  for delivery sooner."  Dr. Ramsbotham
two or three hours, Dr. Burns about an hour.  Dr. F. Ramsbotham  agrees
with Denman.   Dr. Campbell  suggests  that ergot should  be given  before
we attempt to extract the child.  The rules laid down by Dr.  Collins appear
to me extremely judicious; he  advises a middle course, " as soon as the first
child is born, a binder should be applied so as to make gentle pressure upon
the abdomen;  we should not leave  the  house until the second child is deliv-
ered.   If we find, after the lapse of half an hour, that the membranes of the
second child still remain  unbroken, they may be punctured with advantage,
with the view  of exciting uterine action,  as the soft parts having been so
well dilated by the  passage of the  first, no  bad result can ensue.   This
expedient in some instances will be found not to succeed ; and in such cases,
when we do not observe any progress made in  the course of two hours  after
rupturing the  membranes, the best mode of proceeding will  be  to pass the
hand cautiously into the uterus, and  bring  down  the  feet.  There will be
but little difficulty  experienced  in this operation,  the  parts being in so
relaxed a state.  When the head  has made any considerable descent into
the pelvis, the forceps will be the best means of  affording assistance.   It is
very rarely, however, that we are called upon to effect delivery by either of
the latter methods ; yet experience has shown  that the  second child  is very
likely to be still-born if left longer  than two  or three hours unassisted."
   There are  circumstances, as Dr.  Merriman has  justly observed, which
would negative any delay in the delivery of the second child : as, for ex-
ample,  1, when artificial aid  has  been required with the first child;  2, when
the second child presents preternaturally ;  and 3, when  the labor is compli-
cated with convulsions, hemorrhage, etc.
   Any deviation from normal  labor with  the  second child is to be treated
according to the rules laid down, without  regard to its being a twin case.
   643.  With  regard to the placenta of the first child ;  unless it  come away
quite easily, I believe that in all cases it is  better to leave it until after the
birth of the second child, as  its removal might excite uncontrollable flooding.
After the birth of  the second (or third) child, the binder is to be tightened,
and pressure  or friction made upon the uterus, and when we find it disposed
to contract, then we may draw down  (in  the axis of the upper outlet) first
one cord, and if that do  not yield, the other, or both together,  so as to aid
in the  expulsion.   But it must be remembered that, after the delivery of
plural children, the uterus is less disposed to renew its  exertions, and there-
fore a longer  interval must be allowed : and that by the detachment of the
placenta a much larger surface of bleeding  vessels will  be exposed, and
therefore,  that we  should  avoid their forcible  separation by traction, and
 should be particularly careful to secure the due  and permanent contraction
 of the uterus  afterwards.  It will probably be  safer and wiser in these  cases
to give a moderate dose (^ss.) of  the ergot of rye immediately after the
 birth  of the  last child.  " In twin cases," Dr.  Collins observes, " when it
becomes necessary to  remove  the placenta, we should be  careful  not to
 withdraw our hand from the  uterus, until  both be separated,  at the same
 time waiting  for uterine action, so as to induce  as perfect a contraction of
 this organ as practicable:  a point of most vital importance."   The shock
 to the nervous system is generally greater  than after natural labor, and in
 some  cases it is very severe, amounting to  collapse, as  in the case  I  have
 mentioned : this will justify the exhibition  of stimulants and opium, and it
 demands extreme quiet and care.
   The management of twin cases  applies equally to triplet  and quadruplet
 cases ; especially the care recommended as to the placenta.
   Dr.  Denman states that "it is a constant rule to keep patients, who have
 borne one child, ignorant of there being  another, as long  as it can possibly 
MONSTERS.
435
be done.".  There is certainly no occasion to frighten  the patient by an
abrupt communication ; but, on the other hand, I  do believe  that conceal-
ments are bad, and that in midwifery, as  everywhere else, " honesty is the
best policy;" besides, the patient is almost certain  to suspect the state of the
case, and to inquire concerning it.   I think, with Dr. F. Ramsbotham, that
in all cases  " it is better neither to inform her abruptly of the nature of the
case, npr to naake any mystery about it;  but  certainly to tell  her that she will
soon give birth to a second;  and this may be coupled with a congratulation
on the fortunate progress of the labor so far ; and an assurance that she will
have but little more  pain  to bear, and that the case presents no  features
calling for anxiety."
  644. I have hitherto spoken of twin  cases in which one of the children
only presented ; but it has  occasionally happened that both bags of mem-
branes have ruptured, and  an  extremity of different  children descended, at
the same time.   Thus, the late Dr. Fergusson, of  this city, has published  a
case in which the head of one  child and the foot  of another  presented to-
gether.   The midwife drew down the  leg, and so jammed the  head and
breech in the pelvis together.   However, the pains being powerful, expelled
the natural  presentation first, and the  other afterwards.   A similar case is
recorded by Mr. Alexander,1 and  Mr. Allen relates one2 in which the two
heads occupied the pelvis together ; and both were naturally expelled.   Dr.
Murphy3 mentions a case in which the heads of twins were jammed in the
pelvis  together; and my friend, Dr. Christie, of  Aberdeen, has related to
me a similar case, in  which the feet of the first child presented, but the  head
of the second  descended into the pelvis in advance of the head of the  first.
He succeeded, by pushing up the head of  the  first child, in liberating and
pushing  back the head  of the second, after which the labor -was speedily
terminated.   Dr. F.  Ramsbotham mentions having  been called  to a  case
when a right and a left foot  belonging to different children  presented ; he
pushed up one and extracted by the  other, and  both children were  born
living.
   Such cases are no doubt very puzzling at first,  and may excite  some
anxiety as to the result;  but it may be remarked, that the descent of a foot
with the head proves that the pelvis is unusually large, and in all the cases
it appears that the pains were very powerful.   It would, therefore, be right,
if we could not push up one of the presenting parts, to give fair play to the
natural powers, and  only upon conviction of their inefficiency to lessen the
bulk of  one child.   If the  head  of the footling case were within reach, it
would be better to operate upon it, as the child's life will have already  been
compromised  by the  pressure upon the cord,  whilst the other child has in-
curred little or no danger.   In such a case as Dr. F. Ramsbotham's, we  must
of course adopt a similar line  of  practice, pushing up one  leg and drawing
down the other, until the breech be engaged in  the upper outlet.

   645.  II. Monsters. — All that is obstetrically important relating to this
subject may be comprised in a  few words.   As  far as we are concerned, we
may divide all these deviations from normal formation into monstrosities by
defect and excess, those from disease, and  the cases where  two children are
conjoined.   The only practical point involved is their relation in size to the
pelvis ; consequently  with those by defect we have nothing to do, as there is
no  difficulty in their  transit through the pelvis.   Monsters from excessive
development of different parts likewise come under the class of which we are
treating, just so far as their bulk is rendered disproportionate to the pelvis.
  646. The principal diseases which  render the  child disproportionate to
the passages are hydrocephalus and ascites.  Neither are  very uncommon,
    1 Edin. Med. and Surg. Journal, 1822.           2 Med.-Chir. Trans., vol. xii.
    s Lectures on Parturition, etc., p. 274. 
436
MONSTERS.
and most practitioners must have met with cases of them.   When a child
affected with hydrocephalus presents at the brim, the entrance may be effected
with difficulty,"or it may be  quite impossible:  the head being nearly incom-
pressible.  On examination,  therefore, we  find that, notwithstanding  good

                                 Fig. 173.
Hydrocephalus.
pains,  in  well-marked cases, the head does not even  dip into  the pelvis;
that no advance whatever is made by the uterine pressure (fig.  173).  The
head  feels full and tense during a pain, but during  an interval the fluid
gives way under the point of the finger.   The bones of the head are uncon-
nected, and give  the impression of being loose in  the scalp.  If the labor
were left to nature, we should, after due time, have  all the bad symptoms of
a prolonged second stage.  The diagnosis is obscure : if we ascertain the pel-
vis to be of the usual size, and still find that the great bulk of the head is
above the brim, and cannot descend, the  case is clearly one of great dispro-
portion, and it is equally plain that the excess is on the part of the  child;
in such circumstances, if  the bones are loose and  the head flaccid during an
interval, it will be fair to suppose the case one of hydrocephalus, especially
if we find the pulsations  of the fcetal heart have ceased.
   I  need not say that the diagnosis will be much more difficult if the feet
present, although the same principles of treatment apply equally, first having
established the impractibility of delivery, from relative disproportion.
   647.  In ascites, there is much less obscurity, the head having been expelled, it
is easy to see that the difficulty arises  from the distention  of the abdomen of
the child, and a careful examination will, in  most cases, distinguish between
ascites and tympanites.   In the latter case, the air is seldom limited  to  the
abdomen, but the face and chest will be found more or less puffed.1
   M. Depaul has published a  memoir upon distention of the fcetal bladder,
as an impediment which he seems to think more common than simple ascites.
He recommends  puncture of the bladder through the abdominal parietes as
the only remedy, and after  birth  an attempt  to  remedy  the original defect
which  occasioned the retention.2   A  case  of  difficult  labor  from enormous
enlargement of the kidneys is on record,3 but as far as I know, it is the only one.
             1 Ed. Med. and Surg. Journal, vol. xvii. p. 561.
             2 Ranking's Abstract vol. ii.,  266, from L'Union  Me" licale.
             3 British and Foreign Med. Chir. Review, Oct. 1856, p. 557. 
MONSTERS.
437
  648.  Double monsters are very rare, and may create great difficulty in the de-
livery, although there are cases on record of the children having been born
alive.   Dr. Burns quotes several such : " In the seventh volume of the Nouv.
Journ.  p. 164," he says, "is a case where two children were born at the full
time, united by the inferior part of the belly, from the centre of which came the
cord.  The vertebral columns almost touched at the lower part.  The two chil-
dren, who were of different sexes, lived, we are told, twelve  days, but nothing is
said of the labor.   In the Bulletin  for  1818, p. 2, two  children, who were
joined by the back of the sacrum, are stated to have been born, and lived till
the ninth  day.   The first child presented  the head,  but the  midwife  could
not well tell how the second got out.   There is another case,  at page 32, of
a woman who, after many days of labor, bore a monster  double  in its upper
parts.   The  spinal column  was united from the sacrum to the top of  the
dorsal  vertebrae, then the cervical vertebrae divided to  form two necks.   The
midwife finding the head to present along with the cord and a hand, tried to
turn, but  could discover nothing  but superior extremities.   She therefore
let her alone.  The head w7as afterwards expelled, but  neither nature nor
art could deliver the body.   M.  Ratel  finding the head and two arms almost
separated from  the body, cut  these parts off, then introducing his  hand, he
found another head, turned the child, and brought away  the whole mass.
   There is  a skeleton in  the Royal College of Surgeons of Ireland of  a
double monster, the children being joined  by the lower  part of the sacrum,
and I  believe they were also bom  alive.   The  Siamese twins  are another
instance of the kind ; and two similarly joined were in the possession of the
late Dr. Montgomery.
   649.  Treatment. — I have already stated the general principle  by which
 we are to be governed in all these cases.   Whenever the  monstrosity adds so
 much to the bulk of the child as to-render the delivery impracticable by the
 natural powers alone, or assisted  by the forceps, we must lessen the bulk.
   In cases of hydrocephalus there need be no hesitation, if the head be not
 too large to pass  ; no interference is required whether the child be alive or
 dead;  but if it be so large that  it cannot pass,  we  have no choice but to
 perforate.   In the majority of cases the child  is dead before the operation.
 The ground of the operation  is the  mechanical impediment to delivery,  and
 the death  of the child  will justify an  early interference.  The  operation is
 very easy ;  but should  the operator not have suspected hydrocephalus, but
 disproportion from another cause, the sudden rush of water may alarm  him
 lest he should have perforated the bladder.  In footling  cases the head must
 be perforated behind the ears.
   When the body cannot be extracted,  owing to the distention by  air or
 water, relief may be afforded  by plunging the perforator into  the body.
 '  As to the double monstrosity, Dr. Burns remarks very truly : " The gene-
 ral principle of conduct must be, that, when the impediment is very great,
 and does  not yield to such force as can be safely exerted  by pulling that part
 which is protruded, a separation must  be  made, generally of that part which
 is  protruded, and  the  child  afterwards  turned, if necessary.   Unless the
 pelvis be greatly deformed, it will be practicable to deliver even a double
 child by means of perforation of the cavities, or such separation as may be
 expedient, and the use  of the hand, forceps, or crotchet, according to cir-
 cumstances.  A  great  degree of deformity may render the Caesarian opera-
 tion necessary."
   I may add, as  a caution to my junior  readers,  that the  destruction of a
 monster after birth (no matter how great the deformity)  is punishable as
 infanticide. 
438
PROLAPSE  OF  THE FUNIS.
                     C HAP TE R  XY III.

          PARTURITION. —CLASS  III.  COMPLEX  LABOR.
      ORDER  1.  PROLAPSE OF THE FUNIS  UMBILICALIS.

  650. Having fully considered natural labor where the agents or elements
of parturition are equally  balanced ;  and unnatural labor, where the abnor-
mal deviation is dependent upon some deficiency or irregularity in the power,
the passages, or the child, we shall now pass  on to the third class, or com-
plex labor, of which, as I observed before, the characteristic  peculiarity is
not anything in the mechanism  of labor, but consists in some accidental com-
plication.   The labor itself may be natural or unnatural, but  more fre-
quently the former than the latter: however, with the consideration of the
labor (except as connected with the complication) we have nothing to do.
  Prolapse  of the Funis Umbilicalis. — The first complication  I shall
describe is prolapse of the funis, either alone or along with the presenting
part; and occurring either at  the commencement  or during the course of
the labor.
  This accident has no influence whatever upon the progress of the labor;
but a very serious one upon the life of the child, and  any interference which
may be advised is for the purpose  of rescuing it from peril.
  651. Statistics.—We may  form  some idea of  the  frequency of its oc-
currence, and of the result to the child, from  the following table: —
  1. Frequency.
British Practice.			French Practice.		
Authors.	Total No. of Cases.	ProlapRe of .Funis.	Authors.	Total No. of Cases.	Prolapse of Funis.
Dr. Bland	1,897	1	Mad. Boivin .	20,357	39
Dr. Jos. Clarke	10,387	66	Mad. Lachapelle	15,652	41
Dr. Merriman	2,947	8	M. Mazzoni .	452	18
Dr. Granville . Ed. Lying-in-Hosp.	640 2,452	1 3			
					
Dr. Collins .	16,414	97	German Practice.		
Dr. Cusack	398	5			
Dr. Maunsell .	839	2			
Mr. Gregory .	691	7	M. Richter	624	4
Dr. Beatty . . .	1,182	6	A. E. v. Siebold .	492	2
Dr. Lever	4,666	6	Dr. Voigtel .	29	1
Dr. Reid	3,250	16	Dr. Jansen	13,369	86
Mr. French .	89	1	M. Bartsch .	4,425	16
Dr. Churchill.	1,525	7	M. Klein	5,490	55
Drs. MClintockl and Hardy J	6,634	37	Dr. Arneth .	6,608	33
Dr. Bliss	771	1			
Dr. Metcalf .	300	2			
Mr. Rose	600	2			
Mr. Bailey	2,819	9			
Dr. J. Lee	850	2			
Dr. Copeland .	1,290	5			
Mr. J. Thompson .	3,300	3			
Drs. Johnston and "1 Sinclair J	13,748	98			
Dr. Hall Davis	7,302	19	1		
 
PROLAPSE OF  THE  FUNIS.
439
  Thus, in British practice it occurred 404 times in 84,991 cases, or about
1 in 210^;  in French practice, 98 times in 36,546 cases, or about 1 in 373 ;
and in German practice, 197 times  in  31,037 cases, or about  1  in  162|.
Taking the whole together,  we have 152,574 cases, and  699 examples of
prolapsed funis, or about 1 in 218.
  The risk  to the child may  be estimated from the following table : —
  2.  Mortality.
		Cases	Chil- (	ord		Delivered by				
< Authors.		of	dren							
		Prolapse.	lost. re	placed		Nat.	Version.	Forceps.		
Mr. Giffard ....		21	17	2			15	5		
Dr. Smellie		6	2				5			
Mr. Perfect		4	3				4			
Dr. Jos. Clarke		66	49							
Dr. Merriman .		8	4							
Dr. Ramsbotham		1	1				l'			
Dr. Collins		97	73							
Dr. Cusack		5	5							
Mr. Gregory		7	4							
Dr. Beatty		6	4							
Mr. Lever		6	2							
Dr. Churchill .		7	5							
Mr. J. Thompson		3	2							
Drs. Johnson and Sinclair		98	42			*6l'	'l6	9		
Dr. Hall Davis .		19	9				4			
Mad. Boivin		39	9				26	13'		
Mad. Lachapelle		41	7	14		1	12	13		
Dr. Voitgel		1					1			
Dr. Jansen		86	38'				46	6*		
Drs. M'Clintock and Hard	y	37	25	5		' 6*				
Mr. Roberton .		22	15							
Dr. Metcalf		2	2							
Dr. Bartsch		16	4	' 5			' 2	' 3*		
Dr. Klein .		55	20	27		. .		2		
Dr. Arneth		33	11	11		. . | . .		9		
  Here we find that out of 722 cases of prolapse, 375 children were lost, or
more than one-half;  a larger mortality than we find in any other order of
practicable labor.
  It must always be remembered, when speaking of the results of this acci-
dent to the child, that in lying-in hospitals many of the cases do  not  seek
admission till some time after the occurrence, when the chance  of a safe de-
livery  is diminished;  and  some not  until the cord has ceased  to pulsate.
Twentv-two such cases occurred out  of the  seventy-three  unfavorable  ones
Dr. Collins has recorded ;  in eleven  of Drs. M'Clintock and Hardy's, and
twenty-one in Drs. Johnston and Sinclair's report.
  652. Causes.—Many circumstances have  been assigned  as likely to cause
or to favor the occurrence of this complication.
  1. 'Mal-position of the child. —Smellie, in his plate of this accident, has
represented the child lying across the uterus, with the umbilicus at the upper
outlet, and the cord hanging down in the cavity of  the pelvis ; and Froriep
regards this as an exact  explanation.  After a careful  examination of the
cases I have  seen, and a tolerably extensive investigation into those recorded
by authors, I can find few, if any, facts in support of this view, and must,
therefore, attribute the explanation rather to Smellie's ingenuity than to his
observation.
  2. It would appear that a small child  with a large quantity of the liquor 
440
PROLAPSE OF  THE  FUNIS.
amnii, by allowing the head of the fcetus to move away from the brim of
the pelvis during the latter months, will favor the escape of a loop of the
funis.
  3. The sudden rupture  of the membranes, and the forcible  rush  of a
large quantity of the liquor amnii, may have a similar effect, and especially
when aided by an untoward position in the mother, as occurred to a patient
of mine who was standing up when the membranes suddenly ruptured.

                                . Fig. 174.
Prolapse of the Funis.
  4. It will be favored by a presentation of the feet or knees, as they do not
fill up the upper outlet;  and even where the cord does  not descend at the
commencement »of labor, it may before the breech enters the pelvis.   In
short, if the presenting part do  not block up the os uteri, the cord, being
specifically heavier than  the liquor  amnii, will be apt to prolapse, as Mr.
Roberton has  observed.1   M. Naegele is  not correct, however, in stating
that it occurs most frequently in footling cases.
  5. M.  Naegele  adds irregular shape, or irregular action of the uterus,
as an occasional cause.
  6. Excessive length of cord forms  undoubtedly an important element; but
it requires other conditions also,  since in the cases of cords of from thirty-six
to fifty four inches long, which I  have noticed, no prolapse occurred.
  7. I may state, from my own  observation,  that I have found, in several
cases of prolapse, that the placenta  was situated low down near the cervix
uteri, and, in some few others, that  the funis was inserted into the lower
edge of the placenta.
  There are cases,  however, which are  not  attributable to  any  of these
causes.
  I have already mentioned a case in which prolapse  was prevented by the
coiling of the cord round the neck of the child.
  653. In  all  cases of prolapsed funis, the child is in  the  utmost danger
from the moment the upper strait of the pelvis is filled by the part of the
child descending, in consequence of  the pressure  upon the cord, just as in
footling cases.   The effects of this  pressure are in proportion to the time it
is continued, if the cord be not partially shielded from it by its situation.
1 Phys. and Dis. of Women and Mid., p. 339. 
PROLAPSE OF THE  FUNIS.
441
  There are but few cases in which the child escapes safely when  the  labor
is left to the  natural  powers.  In those in which  I have  seen this  happy
result, the  pelvis was very large, the child of a moderate size, and the pains
very violent, so that the second stage  of labor  occupied  but a very short
space of time.   The same result will obtain  in those cases where the cord is
shielded from  pressure by being lodged in the angle at the junction of the
sacrum and ilium.  The chances will be still greater, if the  patient have
previously borne five or six children.
  654. Treatment. — The means to be adopted will depend entirely upon
the state of the  prolapsed cord.   Should it exhibit marks of putrefaction,
or be without  pulsation, it will be useless to  interfere,  because hopeless as
regards the life  of  the infant, and the  labor  may  be allowed  to  terminate
naturally,  or  be  terminated  by craniotomy if there be any undue  delay.
Capuron advises us not to interfere  at  once, even  though the cord should
pulsate, but rather to wait until the pulsations become  feeble.  It will cer-
tainly be desirable  that the  os uteri  should  be as much dilated as possible ;
and if we discover the prolapsed cord before the  rupture of the membranes,
it will be well to postpone their rupture until  that object be effected.
  Various modes of management have been proposed.
  1. We  are  advised  to  push the cord upwards,  beyond the brim  of the
pelvis, and there to retain it with one or two  fingers, until the upper outlet
be  filled by the descending head.   This would seem easy and certain, but in
practice it is not so;  for the pains which force down the head, force down
the cord also ; and besides, there is some risk of  displacing the head.   This
re-position is  still more difficult, if any other part than the head present.
On the whole, I believe  I  may say that it  rarely succeeds.   Dr. Arneth
states, that in  the Yienna  Hospital, the funis was generally carried over  and
beyond the head of the child, and lodged in  the hollow of the neck ;  and
that of forty cases in  his own practice and  that of Klein and Bartsch in
which this plan was adopted, thirty-eight of the  children were born alive.1
  2. It has been proposed to return the cord, and to hook it over the limbs
of the child.   This may also succeed,  but it is a very difficult and a some-
what dangerous  operation ;  and I am inclined to  agree  with Dr. Burns, that
"if the  hand  is to be introduced so far, it is better at once  to turn  the
child."2 It is but right to add, that Sir R. Croft succeeded twice in this way.3
  3. Yarious mechanical expedients have been contrived for retaining  the
cord when replaced.  Thus, enclosing the cord in a leathern bag,  and  push-
ing it beyond the  head of  the child,  was recommended by  Mackenzie;4
attaching the cord to the extremity of a canula, by Ducamp ;  or  of a cath-
eter, by Dudan ;5 the reductor, by Aitken ;  a thin  elastic  flat rod of steel,
by Dr. D. Davis;6 and a modification of some  of these contrivances  was
suggested by Champion, Favereau, and Guillon.7 Dr. Harris, of Philadelphia,
returned the cord above the  knees in a breech presentation, and  the child
was saved.
  4. Osiander, Busch, Hogben,  and  Hopkins, propose to retain the cord by
introducing a piece of sponge after its replacement.
  5; Dr. S. Merriman has twice succeeded in saving the infant, not by re-
turning  the cord, but by placing it in the angle  formed by the junction of
the  sacrum and ilium, where  it is in a great  measure shielded from pressure.
  ["Many various methods  of repositing the cord, or  putting it  back into
the  womb, above  the fcetal  head,"  remarks  Dr. Meigs,8 "have  been  pro-

  1 Die Geburtshiilfliche Praxis, etc., p. 138.    2 Principles of Midwifery,  p. 4S3.
  8 Meniman's Synopsis, p. 99.               * Merriman, p. 99.
  5 Revue Med.,  1828. vol. iii. p. 502.
  6 Elements of Operative Midwifery, 1825. p. 170.
  ' Velpeau, Traits des Accouchemens, p. 342. Ed. Brux.
  6 [Obstetrics;  the Science and the Art, 2d ed.j 
442
PROLAPSE  OF  THE FUNIS.
posed;  they have mostly been  found ineffectual, the  cord being apt to fall
down again, even after it had been put into the proper place.   I have never
yet had an opportunity to try a method which I beg leave to propose to my
readers, and which is as follows :  Take a piece of riband  or tape, a quarter
of an inch wide aud four or five inches long.   Half an  inch from the end,
fold the tape back, and sew the edges so as to  make  a small pocket.  Then
fold the other end in the  opposite direction, and sew that also, to make a
pocket of it.  Now  if the  cord be taken in the tape, and held as in a sling,
a catheter may be pushed into one of the pockets, and that one thrust into
the other, so that we shall  have the cord  held as in a sling, which is itself
supported on the end of the catheter or womb-sound.  Let the catheter be
now pushed up into the  womb,  beyond the fcetal head  ; it  will carry the
secured portion of cord with it, and the catheter being withdrawn, the tape
is left in the uterine cavity, where no harm can be occasioned by its presence.
If required, several  such tapes could be secured round the cord, and all of
them fixed on the end of the same catheter, and pushed at the same moment
far up within the cavity of the womb."]
   If we determine to try the preceding plans,  or if the advance of  the head
preclude any attempt at re-position, or, lastly, if the cord  come down during
labor, we may increase the chances of safety  by applying  the forceps  and
hastening delivery, as soon as the head is within reach.
   6.  Dr.  Gaillard Thomas,  of New York, has proposed a modification in
the re-position of the funis, so simple and so in  accordance  with common
sense, that one only wonders that none of us ever thought of it before.1  He
recommends that the woman should be placed  on  her hands  and  knees, so
as to reverse the inclined plane formed by the cavity of the uterus and pelvis;
and to have in our favor the influence  of  gravitation.   In this position, if
the membranes be not broken, it  is possible that the loop  of  the cord may
slip above the head  spontaneously.   If the cord have descended,  the hand
is to be introduced  into the vagina, and the  cord passed  above the head,
and the same position to  be maintained  for a few pains.   In two cases in
which he tried it, no part returned prolapsed, and the head coming forward,
he had no further trouble  with the cord.
   7.  If the patient have had children before, and if the pelvis be roomy,
and the soft parts well dilated, perhaps the best chance  for the child is in
turning,  particularly  if there  should be  a mal-presentation.   But as this
 operation is not without hazard to the mother, we should accurately esti-
 mate  the favorable or unfavorable probabilities as regards the child, before
 we attempt it.  Dr.  M'Clintock  has recently  showed that  while more chil-
 dren are  saved  by this than by any other  method, the risk to the  mother is
 not so great as has  been supposed.
    Madame Boivin turned  the child in 25 cases, and  used the  forceps in 13
 out of the  38 cases  she has recorded, and  saved 29 children.   Madame La-
 chapelle, in 23 cases, used the forceps 13 times, and version 10 ;  17 children
 were saved.  In one case, Dr. Collins saved the child by returning the cord,
 and retaining it by  the hand in  the vagina ;  in another, by enclosing it in
 a linen bag, returning it, and retaining  it there by introducing a piece of
 sponge.
    Should the delivery have been  completed  within a short  time after the
 cord has ceased to  pulsate,  it will  be our duty to  employ for  some time the
 usual means for resuscitating the child ;  so long as the  heart beats ever so
 faintly, there is hope.

       1 Transactions of the New York Academy of Medicine, vol. ii. part 2, p. 21. 
RETENTION  OF  THE  PLACENTA.
443
                        CHAPTER  XIX.

         PARTURITION. —CLASS  III. COMPLEX LABOR.
            ORDER 2.  RETENTION OF THE  PLACENTA.

  655.  In the definition of natural labor I included the expulsion of the
placenta "in due time;" and when speaking of the third stage I mentioned
that Dr. Clarke found the average interval between  the birth of the child
and expulsion of the after-birth was  twenty minutes ;  and that out of  654
cases observed by myself, in 622 it was  expelled within a  quarter of an hour ;
from these data I remarked,  "we may conclude with  the highest authorities,
that in natural labor the placenta ought to be expelled within an hour or an
hour and a  half, and that when  the  interval exceeds this, the  case  fairly
comes under the order of 'retained placenta.' "
  There is, however, an exception to the  stringent application of this rule,
and that  is when, from the length of the labor or its abnormal character,
the uterus has been over fatigued, so  that it does not  so  soon  resume  its
contractions.   There is no  reason  to suppose  the  uterus  exempted  from
fatigue in proportion to its  exertions,  any more than  any  muscle of the
body;  and when it has been so fatigued, we do not find that it requires and
takes a longer interval of rest than usual, and that after this has elapsed, it
contracts again, and expels the remaining  contents.    In estimating the
interval which ought to  elapse before  we  interfere, we must, therefore, take
into consideration the peculiar kind of labor and probable amount of fatigue,
and allow a certain variation accordingly.
  Some writers have recommended that the placenta should never be ex-
tracted except in  case  of hemorrhage;   but  it was found,  that if left to
nature, it was  occasionally  retained  until it putrefied  and excited uterine
inflammation; for this  reason, others recommended its immediate extrac-
tion ; but the truth appears  to lie between the two  extremes.  We do not
interfere when the uterus is  adequate to the expulsion, but when we are
convinced that its efforts are suspended or inadequate, we extract it to avoid
the risk of hemorrhage or inflamation  of the uterus.
  [Much,—almost all the difficulty which occurs in respect to the  delivery
of the placenta in  cases of natural labor, originates, we  are persuaded, from
mismanagement — either the improper administration of ergot with the view
to accelerate labor, hurrying the birth of the  shoulder and trunk, by manual
interference, after the expulsion of the head, or the neglecting to secure the
prompt and regular contraction of the uterus, and the early removal of the
placenta lying loose  in its cavity,  subsequent  to the birth of the child.  The
common direction to wait, after the child is born, from an hour to an  hour
and a half, for the spontaneous expulsion  of the placenta, before any attempt
is made to remove it, has been productive of no little mischief.   With Dr.
Meigs, we believe that there cannot and ought not to be adopted any fixed
rule in respect to the period that should  elapse before proper measures are
taken to secure the extrusion of the  placenta  from  the womb.   The only
thing to be kept in mind is that the placenta must be got rid of at as early
a period as practicable,  there being no security for the  patient while  it re-
mains.  There is no good  reason why,  after the  child  is born,  the practi-
tioner should wait  patiently for a renewal of labor pains in order that the
expulsion of the placenta may be effected.   His chief care should be to have 
444
RETENTION  OF THE  PLACENTA.
the uterus rid of the latter as early as this can be effected with a due regard
to the safety of the  mother, in order that prompt, regular, and  permanent
contraction  of the organ  may  take place.   If within a reasonable  time,
under the diligent employment of abdominal frictions and gentle pressure,
the placenta is not expelled from the uterus, the practitioner has then  good
reason for concluding that its retention is caused by something unusual, and
should  at  once proceed to  ascertain its  exact nature,  in  order  that the
proper means may be employed  to overcome it.]
   656?  Definition.—I would, therefore, define cases of retained  placenta
to be those  in which the uterus does not, after a due interval of rest, detach
or  expel the placenta,  and which,  consequently, require to be extracted.
This  interval may be fixed at an hour or thereabouts, for ordinary cases;
but, on  the one  hand, more time  may be  required  if the  fatigue  have
been  excessive,  and, on the other,  prompt interference will  be necessary
if hemorrhage supervene.
   657.  Statistics. — The following table  will enable  us  to estimate its
frequency, causes, and, in some measure, its consequences.
Authors.	Total No. of Cases.	Retained Placenta.	Inertia.	Irregular Contrac-tions.	Morbid Adhesion.	Mothers lost.
Mr. Giffard		24	3	7	11	3
Mr. Perfect		19	2	14	3	A
Dr. Jos. Clarke	10,387	21	,	5		5
Dr. Ramsbotham	,	27	2	1	24	10
Dr. Granville .	640	7				
Edin. Hospital.	2,452	6		.		6
Dr. Cusack	701	22		5		1
Dr. Maunsell .	416	2				
Dr. Collins	16,414	66	37	19	10	0
Dr. Reid .	3,250	32				
Dr. Beatty	783	1	1			1
Dr. Lever	4,666	37	22		15	
Dr. F. H. Rams- \ botham J '	68,435	403	1			
Dr. Toogood	1,135	24				
Dr. Lee .	850	5			. 5	
M. Riecke	219,303					
A. E. v. Siebold	238	188				
Drs. Johnston ") and Sinclair J	13,748	57	21	9	27	4
  From this it appears, that in 343,670 cases, it occurred 881 times, or about
1 in 390.   In 243 cases, when the result to the mother is given, 40 died,or
about 1 in 6 ; but much allowance must be made for this excessive mortality,
owing to  mismanagement  on the part of midwives before an accoucheur is
called in.   The immediate  cause of death is generally hemorrhage.
  658. Causes and Treatment. — The principal causes of retention of the
placenta are : 1. Inertia of the uterus ; 2. Irregular contraction of the uterus;
and 3.  Morbid adhesion between  the uterus and placenta.   These we shall
consider separately, with their treatment.
  1. Inertia of the  uterus.—I  have already stated that the contractions
which expel the child generally detach the placenta, and often partially expel
it, but it may be unaffected  by  them; in this state  it will, of course, remain
until the occurrence  of uterine  action.  But cases not unfrequently occur in 
RETENTION  OF THE  PLACENTA.
445
which the uterus  remains quiescent  after expelling the child, owing some-
times to the length and severity of the labor, and sometimes, apparently, to
a peculiarity of uterine constitution ; in other words, to a cause unknown.
Now, if in such cases the  placenta be entirely adherent, no evil consequences
will result for some time ; there is, of course, the risk of a partial separation
occurring, and a secondary risk from decomposition if it remain long enough :
but there is no immediate danger.  On the other hand, if it  be  partially or
wholly detached, and lying in the uterus, the separation will have  exposed
many large vessels, and  the absence  of uterine contraction permits th*e un-
controlled escape of blood, so that,  in these cases, there is  generally more
or less flooding — it may be, even  to a fatal  extent: therefore,  in  addition
to the more  distant  danger, which  these cases share in common with the
former, there is immediate danger from hemorrhage, of the most urgent kind.
If the hand be placed upon the abdomen,  the uterus is felt large and flabby,
without any of the  firmness which is its  characteristic in a  state  of active
contraction.
   659. Treatment.—The  promptitude of our interference  depends en-
tirely upon the presence  or absence  of flooding.   If there be great hemor-
rhage, the placenta  must  be instantly removed, either by traction by the
cord, or  by the introduction of the  hand.   There is  one exception to this
rule, however,  and that  is when hemorrhage has  occurred to such an extent
that the patient  has fainted, and  is almost  moribund :  in this case a very
little additional  loss may be fatal, even  so little as may occur on  removing
the placenta ;  but as for  the present it is arrested by the syncope, we may
postpone the operation  until the patient  rallies a little, taking  care not  to
wait  until the hemorrhage return.   " If there have  already been  hemor-
rhage so profuse  as to occasion danger," says Denman,  "and the common
 consequences of loss of blood, as fainting and the like, have already followed,
the placenta ought  not then to be extracted, nor the patient disturbed, nor
 any change made, till she is somewhat recovered from  her extreme debility;
 as the danger would  be thereby increased, and the patient die, during,  or
immediately after the operation,  as  I  have seen  and  known  in  several
instances."
   There may,  however,  be no flooding :  and in some cases it might be pos-
 sible to remove the placenta by a steady pull at the cord,  but to  say nothing
 of the risk of breaking it, we should be only exposing the patient to a risk
 of hemorrhage by withdrawing the  placenta whilst  the uterus was relaxed.
 The best plan is first to try and excite the uterus to contract by friction and
 pressure upon the abdomen, and then  to   draw by the  cord  steadily and
 firmly.   If the uterus still remain  inert, we are recommended by M. Mojon,
 and some continental practitioners, to inject the umbilical  vein  with cold
 water, so as to stimulate the uterus by the impression of cold.  I have men-
 tioned this, but I should fear that there would  be risk of exciting inflammation
 by it.   I have, however, repeatedly given the ergot of rye in such cases, and
 with the best effects ; when successful, it brings on uterine contractions, and
 causes the spontaneous expulsion of  the after-birth, at the same time that it
 effectually guards against hemorrhage.  If it fail, we have  no resource but
 to extract the placenta by the hand,  an operation never to be lightly under-
 taken, as it is one of the most dangerous, in consequence of the frequency
 with which it is followed by inflammation.  It should be performed very gently
 and deliberately.   The  fingers, formed into  a cone,  are to be introduced in-
 to the vagina  and os  uteri, in the axis of the outlet  and brim, guided   by
the funis, and  so  gradually up to the placenta, which may be grasped  by  its
inner  surface, as  Hamilton and  Burns  recommend, or  the finger  may  be
gently insinuated between it and the uterus, so as to peel  it off very carefully 
446
RETENTION  OF  THE PLACENTA.
and  gently.  Great care must be taken, on  the one hand, not to injure the
surface of the uterus, and, on the other, to remove the whole of the placenta;
and having done this, the detached mass should be grasped, and the uterus,
which by the operation will  be excited to action, allowed  to expel both it
and  the  hand.   By so  doing, we shall secure its  contraciion,  and  guard
against hemorrhage, and meanwhile external pressure should be exerted by
the other hand, and maintained by compresses and the binder.  This opera-
tion should  never be performed without clear conviction of its necessity.  I
perfectly agree with Dr. Denman,  who observes, that although " it is often
mentioned as a slight thing, yet I  am persuaded  that every person who at-
tends to the consequences of the practice will think it of importance, and
that, if possible, it always ought to be avoided.
   After the  operation,  we must remain some time with the patient, to be
sure that the uterus does not again relax, and  hemorrhage ensue, giving
ergot of  rye if there be  the least threatening,  and for some time  watch
carefully lest inflammation should set in.
   660.  2.  Irregular contraction.—After the  delivery of the child  in ordi-
nary cases, the uterus closes equably over the after-birth, pressing  it on all
sides and forming a globular tumor in the abdomen.  There are occasional,
though rare exceptions,  however, to this  equal  contraction, in  which  the
uterus contracts  unequally,  and yet forcibly, and so far from effecting  the
expulsion of the placenta,  which is the principal object of its contraction, it
is thereby effectually retained.   This irregular contraction sometimes follows
natural labor, but more  frequently labor with mal-presentation or instru-
mental  delivery,  and it  is attributed  (not without justice, I think,  in some
cases) to the action of the ergot of rye.1
   There are three kinds  of irregular contraction which  may be briefly no-
ticed : 1. The  first is seldom noticed in  books,  and yet  it is of  frequent
occurrence.   It  appears  to consist  in a contraction of the fibres of  the
cervix uteri  to a greater degree than  of those of the body and fundus.  If
the hand be placed upon the  abdomen, the uterus is to  a certain degree,
but not firmly, contracted, whilst, if the finger be passed into  the  os uteri,
the cervix is found  to be hard and contracted, and the  cord when  pulled
does not give.   The placenta is sometimes adherent, but more  frequently
partially or wholly detached, and a portion  of it  may often be felt in  the os
uteri.   In common with the  other varieties of irregular contraction there
is sometimes hemorrhage, but frequently none at all, and  the necessity for
interference  chiefly arises from the indisposition of the  uterus to rectify the
irregularity  and  expel the  after-birth.   The globular tumor,  moderately
contracted, the  narrowed os uteri, and the  firm retention of the placenta,
even when partially or wholly detached, will distinguish these cases from all
others.
   2. The second irregular contraction is that which has received the name
of "hour-glass contraction."   The fibres around the body of the uterus are
thrown into a state of permanent contraction, the remaining portion being
only in a state of moderate action, giving  to the  uterus something  of the
figure of an hour-glass, and dividing its cavity into  two unequal chambers,
 an upper and  a lower, in the former of  which  the placenta is mainly or
 entirely contained.  It may  be entirely adherent, or partially or  wholly
detached, though seldom the latter.   Occasionally there is  hemorrhage.
 This variety of irregular contraction  has been attributed  to the too rapid
 passage or extraction of the child ;  to a lingering labor with women of an
 irritable constitution,  and  to the partial  action  of ergot.  Dr.  Douglas

             1 Hasbrouck, New York Journal of Med., Nov. 1853, p. 334. 
RETENTION  OF  THE PLACENTA.               447
thinks that hour-glass contraction  rarely or never occurs without morbid
adhesion of the placenta.   Drs.  Campbell and F. Ramsbotham  deem it a
very rare occurrence.   It is very seldom  that we can discover any irregu-
larity  of form in the uterus by placing the hand on the abdomen, and, in
consequence,  the diagnosis is very obscure, until the hand be introduced for
the purpose of extraction.
  3. The third irregularity is a preponderating contraction of the circular
fibres  of the  uterus, throwing the organ into the  shape of  a long  cylinder,
so that it feels narrower than usual;  and instead of a globular  tumor just
above the pubis, it  is often felt reaching  up above the umbilicus, and in-
ternally it may be difficult to reach to the fundus.  As in  hour-glass con-
traction, there is not always flooding, and the causes are probably the  same.
The diagnosis is  aided, however, by the shape of the uterus, although it is
often  sufficiently obscure.
   661. Treatment.—The first variety of irregular contraction can  generally
be remedied without the introduction of the hand.  Steady and firm traction
should be made  by the  cord  in  the  axis of the  brim,  and maintained for
some  time without  relaxation, at  the  same time  that very firm  pressure is
made over the uterus, and towards the  pelvic cavity; this in  many cases
overcomes  the spasmodic action,  and  the placenta  is rather suddenly  re-
leased.   If it fail, one or two fingers introduced within the os uteri may be
 sufficient, as  they may be able to seize a portion  of the after-birth, and so
 aid in the traction.  . I have seldom found it necessary to do more than this ;
but of course if it do not succeed,  the  placenta must be extracted by intro-
ducing the hand  carefully and gently,  as before described.
[Fig. 175.]                          [Fig. 176.]
Hour-glass Contraction of the Womb.          Removal of adherent Placenta.
  In the second and third form of irregular contraction, traction by the cord
is quite ineffectual, so firmly is the placenta grasped.  We can only wait, there-
fore, until we are satisfied that it will not be separated and expelled naturally,
and cannot be withdrawn by the cord, and then at once proceed to  extract
it.  The  introduction of the hand is to be effected in the way already de-
scribed, until we arrive at the contraction, which is to be overcome by gentle
but steady pressure of the points of  the fingers gathered  into a cone ;  and
when we reach the placenta, we must remember to detach the whole, and to
allow the hand to be expelled by the  uterus.   In the hour-glass contraction, 
448
RETENTION of the  placenta.
the lower chamber is so complete, and the contraction so close, that persons
have suspected that the aperture through which the cord was traced was, in
fact, a laceration :  a little patience and  perseverance,  however, will  show
the true state of the case,  and besides, although  the  child often escapes
through a laceration  into the abdomen, it is very rare for the placenta to
do so.
  [When hour-glass contraction is ascertained to be present, no reasonable
hope  can be entertained of a  spontaneous expulsion of the placenta ; to wait,
therefore, for such an occurrence is a mere loss of time.  The proper course
is for the accoucheur to proceed at once to overcome the contraction of the
uterine fibres, and deliver the placenta by manual interference.]
  Opium  and venesection have both been recommended  for the relief of ir-
regular contraction ;  but  I quite agree with  Dr. Ramsbotham that both are
objectionable.
  Let me again impress upon my readers  the necessity  of great care to se-
cure the  regular, equal, and permanent contraction  of the uterus afterwards.
  662.  3.  Morbid adhesion  of  the placenta to the  uterus. — Many of the
diseases of the placenta to which I have heretofore referred, may occasion
adhesion between its  outer surface and the inner surface of the uterus.   Thus
inflammation may end in  the effusion of lymph connecting  the two, or in in-
duration.   Again, the adhesion  has apparently been affected by calcareous
or scirrhous deposition.   The space occupied by the adhesion  is generally
limited.
  This, accident is manifestly the  result  of  disease during  pregnancy, and
has no relation to the kind of labor.  It  is much more dangerous than
irregular contraction, because the uterine action generally  detaches more or
less of the placenta;  but the adhesion retaining the mass in the uterus, prevents
its contraction and the closure of the bleeding orifices of the uterine vessels.
We find, therefore, more or less flooding, sometimes to an enormous extent.
Almost the  only exceptions are the few cases where the  adhesion is very
extensive,  and the detached part small.
   The diagnosis is  in  almost  all  cases impossible, until  the extraction is
attempted : a strong suspicion  will be excited, however, by the occurrence of
uterine contraction,  without  extrusion of the after-birth.  The previous his-
tory of the patient may in some degree confirm these suspicions; if she have
suffered  much pain  in  some fixed  parts of the uterus during pregnancy, it
may  have resulted from inflammatory action.  Whenever  we see  a patient
suffering thus, we should always ascertain by the stethoscope whether it is
in the situation of the after-birth,  so that we may be prepared for the con-
sequences  at the time of  labor.
   663. Treatment.  —As we cannot be sure that the retention arises from
adhesion, we must only have recourse to  the usual preliminary means, and,
finding them ineffectual, to extraction.   The hand  is to  be introduced  in the
usual manner, and on trying to separate the placenta, we shall discover that
 some part of it is closely adherent, as it were amalgamated with the uterus.
 It would be extremely wrong to use violence in endeavoring to detach it;
 if, therefore, we cannot  easily effect this, it is better to peel off the placenta
 all round  up to the adhesion, and then to separate the loose part from  the
 adherent  portion close round  the  adhesion, leaving the latter in the  uterus
 to soften and  come  away with  the lochia.   In a  case of  Dr. Smellie's, in
 which  he removed  the indurated and adherent portion, the patient died of
 hemorrhage ;  and several similar cases are on record.
   It cannot be denied that danger may arise from the decomposition of what
 remains;  but we have no means of  avoiding it, except by care afterwards.
 If the discharge be very  offensive, vaginal injections of tepid milk  and water 
FLOODING.
449
should be used  twice a-day, and  any symptoms of inflammation promptly
treated.
  664.  The  extraction of the placenta  may be  rendered necessary by the
rupture of the cord, inasmuch as we can afford no assistance ;  but it  is by
no means so easy, as we lose the guide it affords us into the os uteri and to
the situation of the placenta.  In such a case, of course, we must first try
fairly what  the  natural powers, stimulated by friction and ergot, will effect,
and if they fail, the hand must be introduced with greater caution,  and the
placenta very gently sought for,  and detached  in  the usual manner.   Once
more let  me repeat the necessity of removing all the placenta, for  a  small
portion left behind may render all our exertions fruitless as to the result.
   I  have deferred the  consideration  of  the treatment of the hemorrhage
until the next chapter, as  I preferred limiting this  chapter  strictly to the
management of retained placenta;  the two chapters  should, therefore, be
taken together.
                       C HAPTER  XX.

         PARTURITION. —CLASS III.  COMPLEX LABOR.
                       ORDER 3.   FLOODING.


  665.  There is no  deviation  from the ordinary course of  labor so trying
to the medical attendant as flooding; not only on account of the imminent
danger; but from the sudden and rapid progress of the attack, and the im-
possibility of waiting for assistance.  Nothing can preserve our calmness
and presence of mind under such circumstances, but understanding the sub-
ject  clearly  beforehand,  and being perfectly prepared  for meeting  each
variety of the accident with its appropriate treatment.
  I have already spoken  of the hemorrhage accompanying  abortion, and it
remains now for us to consider those forms  of flooding which occur just pre-
vious to or during labor and afterwards.   During the  last month of gesta-
tion and at the commencement of labor, patients are exposed to two forms
of hemorrhage, differing  in their causes, but depending upon the situation
of the  placenta.   The  first has been called " accidental hemorrhage," be-
cause it arises from a partial and accidental separation of the placenta, which
occupies its usual situation ;  and  the second is justly termed " unavoidable
hemorrhage," because the placenta, being placed partially or wholly over
the os uteri,  the dilatation of this will  unavoidably separate the after-birth,
and  give rise  to  hemorrhage :  as Naegele has observed, " the very action
which  nature uses to bring the child  into the world  is that by which she
destroys both it and its mother."  After delivery, flooding may occur to any
extent, and from various causes.
   Each of the varieties of hemorrhage will require  a separate and careful
consideration.   But  first let us ascertain  their frequency and mortality, as
far as possible.
       29 
450
FLOODING.
666. Statistics:—
		O oa	fcC	§	o	"a -"	o		o	* ^ 1 ** = i O j	
Authors.		55 « 03 Q O in	Jo	o 53	0 ■a O	3 o I s |,<2	1	•■2fl O *-> o sJ3		j J j J	
Mr. Giffard			35	6	1-	[ 1		19		1 5	1
Dr. Smellie			34	13	1(	) 6	3 24		8	3	2
Mr. Perfect		.	18	6	"	8	1	! || 6	3	2	1
Dr. Bland .		1,897	9	3	i						
Dr. Jos. Clarke .		10,387	24	5	1(	) 10	4 ii		1	, 10	
Dr. Merriman .		2,947	32	1	V	[ 21		4	1	5	
Dr. Granville		640	•>			1		2			
Dr. F. Ramsbotham		49,996	350	'. '. 13c		> 159		83		10K	,
Edinburgh Hospital		-',452	31	3		1	1	1 ~	i	28	1
Dr. Collins		16,414	131	12	1"	' 13	1	11	2	107	8
Dr. Cusack		701	15	• •		6		• •		5	
Dr. Maunsell		839	110	1				5	i	6	i
Dr. Beatty		1,182	6	1				! 4	o	2	l
Dr. Lever .		4,666	51	4	/	• 16		:' 13	2	35	>»
Mr. French		89	5					i			
Dr. R. Lee			47	10		24	4	oo	6		
Dr. Reid .		3,250	52			22		3		-i	
Mr. Warrington		110	4		]			1 2		2	
Dr. Churchill .		1,640	25	' 6	(	) ' 3	(	1 1	6	21	
Drs. M'Clintock and Hardy		6,634	93			29	4	8	3	56	
Birmingham Hospital		650						4	1		
Mr. Earle ....		4,320						22			
Mr. Rose ....		600	20			18		o			
Mr. Bailey		2,819	61			56		5			
Dr. Toogood		1,135	21					1			
Dr. J. Lee.		850	11					4		7	
Mr. Watson		800	27						o		
Dr. Copeland		1,290				5		2			
Mr. J. Thompson		3,300	13	' 3	I			5	2		
Drs. Johnston and Sinclair		13,740	105	10	^	, 81	4	[ 24	6	33	
Dr. Hall Davis .		7,300	234	2	u	} 23	C	) 11	2	39	
Dr. Richter		624	5					5			
A. E. v. Siebold		730	9	2	i	. .		3	.)	6	
Dr. Voigtel		29	1	0	]	. .		1	0		
Dr. Jansen		13,365	11			4		7			
Dr. Bartsch		4,383						11	6	'.	
Dr. Klein ....		11,410						15	>>		
Dr. Arneth		6,527						9	1		
  From this table we find that in 163,738 cases, hemorrhage occurred 1338
times, or about 1 in 122 ; out of 782 cases of hemorrhage, 126 mothers were
lost, or about 1 in 6; out of 944  cases, 288 children were lost, or about
1 in 3.
  Further, out of 218 cases of accidental hemorrhage, 32 proved fatal, or 1
in 6 ;  out of 261 cases of unavoidable hemorrhage, 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.
  667. 1. Accidental Hemorrhage.—In these cases, as I have said, the
placenta  is in its ordinary situation ; it may be at  any part of the uterine
parietes except the cervix,  as then the case would come  under the class of
unavoidable hemorrhage.    The immediate cause  of  the flooding  is the
separation of some portion of the  placenta from the womb and the lacera-
tion of its vessels;  as these cannot be closed by the uterine contraction, 
FLOODING.
451
because the uterus is full, of course the blood is poured  out  freely.   The
amount of the loss is said to  be in proportion to the extent of the surface
exposed, and, perhaps, in many cases this  may be true, but there  are strik-
ing exceptions :  fatal hemorrhage  may take place from a space  not more
than an inch square.   In some rare cases, a portion of the centre of the
placenta is detached, and a cavity formed  which  is filled with blood, but as
it is surrounded with adherent after-birth, of course none escapes externally.
Or  it may extend beyond the placenta, and be retained by the  adhesion
of the  membranes or other causes.   "In  such cases," Dr. Burns  remarks,
"the effusion  is accompanied with  dull internal pain at the spot where it
takes place.   This pain  is something like  colic, or like the  pain  attending
the approach of  the menses.   The  part of the womb where the extravasa-
tion takes place,  swells gradually, and in  a  short  time the  uterus  feels
larger.   If the quantity be  considerable,  the  size increases, the uterus is
felt to be firmer and tenser, as well as larger, the strength diminishes, and
some faintings may come on.   In course of time, weak, slow pains are  felt;
but if the injury be great, these  decline as  the weakness  increases.   They
may or may  not be attended  with the  discharge  of coagula from  the  os
uteri."   The hemorrhage, in fact, is at first internal, and  generally, though
not always, becomes  external.  Dr.  Burns  suggests that in some  cases the
bleeding may be  the result of the separation of the decidua, and a laceration
of the  vessels running to that membrane from the inner coat of the uterus,
and not from a separation of the  placenta.
  668.  Causes.—Violent shocks, such  as blows, falls, etc., may have  the
effect of detaching a portion  of the  placenta, and  in some  cases, a  very
slight shock will  be sufficient; I was called to a case in which it was effected
by  a hearty  fit  of laughter.   Besides  these causes,  fatigue, over-exertion,
violent  straining at stool, lifting  heavy weights,  excessive  action  of the
utero-placental vessels, disease  of the placenta, general plethora, spasmodic
action  of that portion of the womb to which the  placenta  is attached,  may
be equally effective.  Dr. Burns observes,  "we  sometimes  find that extra-
vasation is produced by an increased action of the uterine vessels themselves,
existing as a  local disease.   In this case, the patient for some  time  before
the attack feels a weight and uneasy sensation about the hypogastric region,
with slight darting pains about the  belly  or back."   It may also occur in
the course of labor, the placenta being partially detached  by the uterine
action, and may even prove fatal.
  669.  Symptoms.—The  exciting  cause may be instantly  followed  by the
discharge, or preceded  by general and local uneasiness, dull pain and aching
in the belly and back ;  and if the  hemorrhage be retained, by rigors, tension,
and weight in the abdomen, and by  faintness. When the flooding is internal
during labor, none may escape  until after the expulsion of the child or pla-
centa, as occurred  with a patient  of mine ;  and the characteristic symptoms
are gradual diminution  or cessation of the pains, with  fainting, which  may
possibly  be mistaken  for symptoms of laceration, but differing from  this
latter accident in the gradual cessation of  the pains, and the absence of re-
cession  of the head.   At length,  with or  without  a pain, the dischage
commences, varving in amount from a few  ounces to a quantity sufficient to
compromise the patient's safety.
  If it be profuse,  the patient faints, of course, and for a time the discharge
is arrested ;  but after she  has  rallied, it again  recurs, and the syncope is
repeated.  The surface is blanched and covered with cold  sweat, the coun-
tenance sunk, with dark  circles around  the  eyes, the  pulse  becomes weak,
quick, and fluttering.   If the flooding be not arrested, all these symptoms
increase ;  the  sight becomes dim, there is a ringing  in the ears, frequent
sighings, intolerable restlessness, uneasiness, jactitation, and death;  preceded 
452
FLOODING.
by fainting or convulsions.   The fatal result is not always in  proportion to
the amount of hemorrhage ;  in certain constitutions or in certain conditions,
a comparatively small loss will end fatally, whereas in others a  much larger
loss will be borne with impunity.
  Labor pains may come on at  some period of the discharge,  or they may
be entirely absent;  a good deal will depend on the period of pregnancy at
which the complication occurs.   If they do, it will be observed that during
a pain the hemorrhage is  arrested, but that  it returns on  the  cessation of
the pain.
   If an  internal examination be made, the os uteri will  seldom be found
dilated, unless there have been  pains for some time, but the cervix is gene-
rally softened and relaxed by the hemorrhage ; and what is of great import-
ance, in  most cases we can pass the finger  within the os uteri sufficiently to
ascertain the presence of the  membranes, and that no  part of  the placenta
is within reach.
   As regards the child, this complication is most dangerous ; if the hemor-
rhage be excessive  it is almost always still-born.
   670.  Diagnosis.—The diagnosis of  accidental from unavoidable hemor-
rhage  is of extreme  importance, inasmuch  as the treatment  of the two is
essentially different.  There are four points in which the two varieties differ
remarkably,  and which will enable us to distinguish  them.    In  the first
place, we can generally make  out some  definite external cause for accidental
hemorrhage,  and its occurrence  is accidental and irregular, whereas in una-
voidable hemorrhage the only exciting  cause is the expansion of the cervix,
and the time of its  first occurrence has  a  certain degree  of regularity.
Secondly, in  accidental hemorrhage  the discharge takes place freely, during
an interval, but is at once arrested by a pain during its continuance ;  but in
unavoidable  hemorrhage the discharge which  continues  also during the
intervals, is greatly increased during the pains.   Thirdly, in  cases of acci-
dental hemorrhage, the os uteri  is free,  closed  by membranes  only, and the
cervix is of equal thickness all  round ;  whereas  in placenta praevia the os
uteri is more or less covered by the after-birth, or if it only reach to the
edge of the cervix, the latter is  felt to be considerably thickened at that part.
   Lastly, in  many cases we  may ascertain  the situation of the placenta by
the stethoscope, and  its presence in the body or fundus of the uterus will
decide the case to be one of accidental hemorrhage.
   I have already stated that weakening or cessation of pains, fainting, sense of
distension, are the  characters of internal hemorrhage, with the absence of
any other cause calculated to  produce these symptoms.
   671.  Treatment.—The  indications  of management must be drawn from
the period of pregnancy, the state of the os uteri, and amount of discharge.
   Lit us suppose that the patient has  not  arrived at her full time, that she
has no  pains, that the os uteri has not begun to dilate, and that the discharge
is not profuse.  In such a case  the patient  is not in immediate  danger; and
as  prompt delivery would be difficult,  it may be well to temporize, and see
how far we can arrest the discharge.  For which purpose the  patient should
be placed in bed on a hard mattress, and very lightly covered with bed-clothes;
the temperature of the room should be reduced very low, and nothing but
cold drinks  allowed.   Enemata of cold water exert a very powerful control
in such cases.  The plug maybe used (according to the restrictipns formerly
laid down), inasmuch as the uterus being full, there is little danger of  inter-
nal hemorrhage to any extent.   The best  plug  is cotton wool, which  may
be most easily introduced through a cylindrical  speculum ; but we may use
common tow, or one  or two silk handkerchiefs ;  and the  object will not be
attained unless the vagina be quite filled.
   Internally  we may give the acid mixture,  with  a large proportion of acid; 
FLOODING.
453
for instance, half an ounce of dilute sulphuric acid to six ounces of infusion
of roses, an ounce to be taken every hour.   To  tell  the  truth, I  think it is
more highly estimated than it deserves.   Lead, in large doses fgr. x. Acet.
Plumb. 2dis horis), has been  recommended :  Dr. Conquest speaks favorably
of it.   It may be combined with opium, or either may be given separately.
I have no doubt of the beneficial effects  of  opium, either in large doses (gr.
ij.) or (gtt. Ix.  Tree. Opii), or  repeated  small ones.  I have  also seen the
Tinct. Cannabis Indicae exert very beneficial influence.
   Large drinks of cold water alone, or  with the addition  of  the nitrate of
potash, seem beneficial.  Of  course the  patient cannot be allowed to sit up,
or to leave her bed, and it is an advantage to  free the bowels by  enemata
of cold water, as involving less effort in the evacuation.
   672. There are many cases in which, under this treatment,  the discharge
is diminished, and the patient carried to her full time in safety ; but in others
it will fail,  either on account  of the increase of the discharge or because the
pains of labor are brought  on.  In  these  cases, as well  as in those where
the amount of discharge is great from the beginning, another line of treat-
ment is practised which would  be very doubtful  in the former  case.   I have
said that the discharge is observed to cease during a pain, and the reason is
simple.  During a pain, the placenta is pressed by the contents of the uterus
on the one hand, and against the bleeding vessels on the other, and by its
pressure as a tourniquet, the  flow of blood is arrested.  An observation of
this fact led to the inference, that if the liquor amnii were evacuated, the
pains would be quickened, the pressure increased and rendered more perma-
nent, besides that the labor would be sooner terminated.   As  Dr. F. Rams-
botham has remarked,  " the  vessels  of  the  uterus are diminished in size by
the contractions of the uterine  parietes : the open  orifices are in a degree
plugged by the parietes being brought into  closer and stronger contact with
that portion of the placental mass disunited from the  uterine surface ; and the
pains are usually increased in frequency and power by the augmented stimu-
lus impressed upon the os uteri."  Moreover, in cases of large flooding,  we
need not anticipate the usual delay in the dilatation  of the os uteri; for,  as
I have mentioned, the  hemorrhage softens  the cervix uteri, and prepares it
to yield easily to  the pressure of the head.   In  these cases, therefore,  when
the flooding is profuse,  and the danger imminent, the membranes should be
ruptured by the finger  or a female catheter.  Soon  afterwards, we find the
pains increase, the flooding diminish,  and the labor advance.
   For the clear understanding  of the  principles  of this  practice, and the
cases  to which it is suited, we are mainly indebted to the late  Dr. Rigby of
Norwich, who published his valuable essay on Uterine Hemorrhage in  1775,
although  the  plan was first  recommended  by Julian Clement and Puzos.
That  it is  very successful we have the testimony of many authors, as Den-
man, Baudelocque, ylerriman, Ramsbotham, Blundell, etc.  Dr. Rigby suc-
ceeded by  it in 64 cases, without  having  occasion to turn the child.   Dr.
Merriman in 30 cases.   Dr. F.  Ramsbotham in  23 out of 25 cases.
   Some writers, as Hamilton, Burns,  Stewart, etc., have opposed the evacua-
tion of the  liquor amnii on the following grounds : 1, that  by  it gestation is
suspended : 2, that it is not certain to bring on labor in time to avoid danger :
and, 3, that it may not arrest the hemorrhage, and if not, we  must turn and
deliver under more disadvantageous circumstances.   The  first objection  is
true, but of no value, unless the others be true also ;  for if the operation suc-
ceed, and save the woman's life, which is in danger, the shortening of gesta-
tion is of no consequence.   The second objection,  though contrary to the
general opinion, is better founded ; for although, where there are pretty good
pains, they increase after rupture of the membranes, especially if ergot be given,
yet if there be little or no uterine effect before the membranes are ruptured, 
454
FLOODING.
pains may not come on  and the hemorrhage  may prove  fatal.   I saw one
example of this, and on post-mortem examination, the head of the child was
found filling the brim,  and the uterus filled with blood.   The third objection
I think hardly holds good, if the pains have been good before rupturing the
membranes ; for most likely the  pains  will increase ; and if not, there will be
but little more difficulty  in turning.
  673.  I should  say, then, that if  there  be decided pains and dilatation, or
good pressure upon the os uteri, that we may safely give an ample dose of
ergot,  and before the loss has been  excessive, rupture the membranes for the
purpose at once of arresting the hemorrhage and hastening the labor.   But
if there  be no  uterine effort, or very  slight pains, it would  be dangerous
practice to rupture the membranes.  If you remember that the uterus  is so
filled that external  hemorrhage cannot take place  to a  very great extent,
you  will see that by plugging  the  vagina thoroughly, all external hemor-
rhage can be stopped.    If so, is it not better to do that, and gain time  until
an  effort be  made  to excite uterine action ?   Besides, we often  find  that
when we succeed in thus arresting the hemorrhage for a time, on the remo-
val of the plug (which  ought to  be done every day) it does not return.  After
filling  the vagina thoroughly, therefore, I would advise that half-a-drachm
of powdered ergot should be given every three  or  four  hours for a time,
until uterine action is  fully excited, and then, if the hemorrhage return, we
shall be justified in rupturing the membranes.   If this fail, or in place of it,
we ought to try the effect of galvanism, by which Dr. Radford  succeeded in
cases in which there was no uterine action and a rigid and undilated os uteri.
Drs. Haeniger  and Jacoby, Mr. Cleveland, Mr. Dorrington,1 Mr. Wilson,2
and  Mr. Clarke,3 have  also found a favorable result from its  employment.
If this fail, or be counter-indicated, then  we must  adopt the  plan recom-
mended (without any definite notion of the nature of the case) by Ambrose
Pare, Guillemeau, etc.  etc, viz.,  introduce the hand and bring down the feet,
thus terminating the labor.   The operation will  be facilitated by the relaxa-
tion produced by flooding, and  though more dangerous for the child, if the
mother's safety demand it, must be done.
   The child may be premature,  however, the os uteri not sufficiently dilated,
or there may be  other reasons why this operation is objectionable, although
immediate delivery is called for ;  and in such cases, as the os uteri is generally
soft and dilatable to a certain  extent, and the  child dead, I have found it
the best plan to perforate the head and  extract with the crotchet.   The opera-
tion is not difficult, nor is there any risk, if  the operator  be  careful to pro-
tect the point of the perforator, and afterwards to extract slowly, cautiously,
and at intervals.
   In  the case of internal hemorrhage occurring during the progress of the
labor, the treatment will depend upon  the stage of the labor, and the amount
lost, judging by its effects.   If  the patient be in danger of sinking, and the
os uteri dilatable, but the head  within  the uterus, there can be no doubt that
we must deliver by turning ; but if  the loss be moderate, we  may perhaps
 afford to wait until the  head descends into the cavity of  the pelvis; and in
 all cases where it is within reach of the forceps, they ought to be used for
immediate delivery, if the case be mechanically suitable.  But  little  hesitation
need be felt on account  of the child in deciding upon  the mode of delivery,
 as it is lost in almost every case of excessive hemorrhage.
   674. By a  judicious application of the suggestions I have made, we shall
be able to temporize beneficially in  cases where no  pains exist, or perhaps
 to carry on the patient  to her full  time ; or if  there be pains, or we succeed

       •Prov. Med. and Surg. Journal, March 11th, 1846, p. 105.
       2 Ibid. April 29th,  1816.         3 Dublin Hosp. Gazette, March 1st, 1848. 
UNAVOIDABLE  HEMORRHAGE.
455
in  exciting them, then, by one  or  other  of these methods, we may almost
always succeed in terminating the labor without incurring an additional loss
of blood, and if that have not been excessive previously, the mother may be
saved.  As we have seen, nearly one in three are lost.   There is danger to
the child in proportion to the hemorrhage, and additional danger if we are
obliged to turn.
  There are cases, however, to which we  are called  after alarming flooding
has continued  for  some time,  and although we succeed  in delivering the
woman, she may die afterwards from  loss  of blood.  In  such extreme cases,
and such  only, transfusion, as recommended by Dr. Blundell, seems to be the
only resource.   It has succeeded in fourteen cases on record ; but it has also
failed many times.  It is performed by  means  of  a  syringe  and tube ;  a
small tube is inserted into the median or other vein of the woman's arm, and
blood from a healthy person is taken up by the syringe, previously warmed,
and after expelling all the air from  the  instrument, its  pipe is passed into
the small tube, and the blood very slowly forced in.  If the lips or eyelids
of the patient quiver, or the respiration become more difficult, we must stop,
or death may result.   If her countenance and pulse improve, we may con-
tinue.  In  this manner blood to the amount  of sixteen or eighteen ounces
may be gradually injected, if necessary ; although a much less  quantity may
save the patient.   Great care must be taken  that the instrument  be clean,
and  of a proper temperature, and that the blood be  healthy and fluid.
   Two  additional successful cases  have been recently published  by  Mr.
Wheatcroft.1
   675. In all these cases, a liberal but judicious allowance of stimulants is
necessary;  but in regulating the amount,  we must not forget that the subse-
quent reaction will be somewhat in proportion.
   As to  the  placenta, it is very often expelled immediately after the child,
and  if it be not, it will be much better to extract it, and secure a firm con-
traction of the uterus, than to allow the hemorrhage to  continue.
   After the delivery is completed,  the  stimulants  must  be continued, if
necessary, or chicken  broth may be substituted for them.  Notwithstanding
the danger of suspending uterine action,  I have seen  so much benefit from
small doses of laudanum combined with ammonia, that I have no hesitation
in recommending its  exhibition.
   The utmost  watchfulness  will be  needed to suppress any return of the
hemorrhage, and to enable us to guard against  any subsequent attack; for
it should always be borne in  mind that hemorrhage is by no means a guaran-
tee against inflammation afterwards.

   676. 2. Unavoidable Hemorrhage.   Placenta prcevia, placental pre-
sentation, etc.—In this variety, the flooding is the necessary consequence of
the dilatation  of the os uteri, by which the connection between the placenta
and  the uterus is separated, and the more the labor  advances, until the head
passes through the os uteri, the greater the disruption, and the more exces-
sive the hemorrhage.   From this very circumstance it follows that the danger
is much  greater than in the former cases, and also that what in them was
the natural mode of relief, is here an aggravation of the evil, and cannot be
employed as a remedy.
   In these cases the placenta may be situated partially or entirely over the
os uteri  (fig.  177), or it  may come down only to  the  edge of the cervix
uteri; and there is some difference in the management accordingly.
   That  the placenta was occasionally found at the os uteri was known as
early as the time of Guillemeau,  Mauriceau, De venter, Pugh,  etc., but they

                i British Medical Journal, April 10, 1858, p. 290. 
456
FLOODING.
believed  that  it had  originally been situated differently, but had been de-
tached and fallen down.   Paul Portal first spoke of it, as adhering to this
part, in consequence  of which he was obliged  to deliver by art.   Giffard,

                                 Fig. 177.
Placenta Praevia.
 Levret, Roederer, and  Smellie were also cognizant of this  fact,  and they
 seem to have been aware of the mode in which the hemorrhage was pro-
 duced, and of its inevitable occurrence.  But it is undoubtedly to Dr. Rigby,
 of Norwich, that the  profession is indebted for the full and clear elucidation
 of the subject.   Time, which is  the great test of merit, has  only confirmed
 the truth of his observations, and illustrated the value of  his essay.
    677.  The  cause of  the  hemorrhage is evidently  the  separation of the
 placenta from the cervix uteri, and the exposure of the mouths of the torn
 vessels ;  and this separation is effected and increased by the uterine contrac-
' tions dilating the os uteri.
    Dr. Simpson  considers that the source  of the hemorrhage is, mainly at
 least, from the placenta, and that it is venous in character; in this I cannot
 agree with him.   I am sure I have as frequently, at least, noticed the blood
 to be arterial as venous,  and this observation  has been recently confirmed
 by Dr. Mackenzie, of London, whose experiments  appear to me  to prove
 satisfactorily that, though some  blood may escape from the  separated por-
 tion of the placenta,  by far the principal portion is from the  uterine vessel.1
 Dr. Barnes also considers the uterus to be the source  of the blood.
    678.  Symptoms.—The first discharge is usually about three weeks before
 labor commences, coincident with  the commencement of the  process  of
 dilatation already noticed.   The amount of the discharge varies, but in
 general it is not excessive in the first instance, nor is it accompanied with
 pain.  After its cessation, the patient rallies ; but in a week or two it  re-
 turns, perhaps in greater quantity, and again ceases, thus continuing (if not
 interfered with, or if  premature  labor do not come on) until the full term.
1 Association Journal, Dec. 23d, 1853, p. 1127. 
UNAVOIDABLE  HEMORRHAGE.
457
With the first sensible contraction of the uterus, the flooding comes on more
profusely, and is observed to increase during each  pain.  Thus it would go
on until death supervened before delivery in most cases, if no assistance were
afforded.   I  say in most instances, because there are some cases  on record
in which the  placenta was forced through  the os uteri before or along with
the child, decidedly the happiest natural termination.   The  first case on
record,  I believe, is that by F. Lossius, in his Observ. Medicinal., 1672, p.
380, obs. 24, in the following words : " tandem secundiam  ante partum  ex-
cluserat, non  tantum foetu sed et matre salva."   I am indebted to my friend,
Dr. Aquilla Smith, for this early example.  Besides  this, Smellie and Lee
have  recorded three ;  Ramsbotham five ;  Hamilton  two; F. Ramsbotham
two; Baudelocque, Perfect,  Chapman, Merriman,  Barlow,  Collins,  and
Maunsell, one; etc., etc.
   Thus far the symptoms are alike (supposing the head to present), whether
the placenta be situated  entirely or partially over the os uteri or only down
to its margin ; but the difference is detected on making an internal exami-
nation.   In the former case, the os uteri is felt to be closed by a thick, soft,
spongy  mass, firmer than a clot, and  not breaking down under the  finger,
through which the presentation cannot  be felt;  in the second, this  spongy
mass stretches over a portion only of the os uteri ;  its edge can be distinctly
felt,  and also the  membranes covering the remaining portion of the os
uteri, through which we  may be able to detect the presentation ;  whilst in
the third case the  os uteri is closed by  the membranes only ; but some por-
tion  of  the cervix is found to be much  thickened,  whilst the rest is of  the
usual thickness; in the  latter case,  after delivery, the perforation  in  the
membranes is found close to the os uteri.
   I should mention that in  some cases where  the placenta covers the os
at the beginning, it is  found to  extend only partially over the orifice when
dilated.
   If the feet present, with only a partial  implantation  of  the placenta, or
with it coming to the  margin  of the  os uteri only, they may pass through
the os uteri;  and although  the  detachment of the  placenta will increase
with the dilatation, yet the flooding will be arrested  by the pressure of  the
body of the child upon the placenta.   This may be considered as the most
favorable presentation in " placenta praevia," because it saves the introduc-
tion  of the hand to turn the child.
   The effects of  the hemorrhage  upon  the mother, are  precisely  as  before
described, but produced more rapidly, and  more speedily fatal.
   679.  Diagnosis.—The sudden  and apparently causeless occurrence of the
first  hemorrhage, the increased discharge during a pain, and the  detection
of the placenta, partially or wholly covering the os uteri, or descending to
its margin, are" the distinctive characteristics of  placenta praBvia;  in acci-
dental hemorrhage, as before observed, there is generally some assignable
cause, the discharge is arrested during  a pain,  the  os uteri is closed by the
membranes, and  the placental murmur can generally be heard away from
the os uteri.
  There may  occasionally be some  doubt as  to whether the os uteri  be
closed by a  clot or by the placenta ; but the former is less firm, and is easily
broken up by the finger,  and  we may often feel the  adhesion of the placenta
to the cervix  within the os uteri.
  680. Treatment.—If we are called on the occasion of the first or second
hemorrhages,  and  find that the discharge has not been  great, and that the
term  of  pregnancy not being  complete,  the uterus is not in  action, we may
try palliative  treatment,  as previously recommended  (§ 671), perfect quiet,
rest on  a hard bed, a cool room, and light clothing, with  cold  and acid
drinks, enemata of cold water, small doses of opium, and the plug if neces- 
458
FLOODING.
sary.   The bowels must be gently freed.   It is hardly necessary to say that
in no form of uterine hemorrhage is venesection admissible.
   But the hemorrhage may be so profuse as  to demand  interference, or if
not  so  at first, it  will become so immediately on the commencement of
labor; and, from the nature  of the case, there is no hope of a natural ter-
mination,  unless the pains be so violent as to force away the placenta before
the child; and as we need not wait for it, nor for the occurrence of uterine
action, the only question is whether the os uteri is  in such a condition as to
admit the passage of the  hand without risk of laceration.   If not, which
will  probably  be the case if gestation  be not completed, we  must wait, and
fortunately, in the plug well applied, we possess a means of control over the
discharge, for  in this variety there is  absolutely no danger of internal  he-
morrhage.  When  we have thoroughly plugged  the vagina, we may give
any  hemostatic remedies we  please, and  on removing the plug,  we must
ascertain  whether the os uteri is  more yielding, and either replace the plug,
or turn, according  as we find, just as was  advised by  M. Leroux, in  1776.
Very often,  as in a case I  saw lately, the flooding does not return, and if
the placenta only partially cover the os uteri, labor may  come  on and ter-
minate naturally.
   But if,  on examination,  we find the os  soft, yielding, or dilated, there is
no occasion to delay,  and the best plan is to  terminate the labor before  the
woman's constitution  has suffered greater damage.
   The hand is to be passed in the usual  way into the vagina, in the axis of
the lower outlet, and its direction immediately changed into that of the brim,
which will bring the points of the fingers near to  the os uteri, into which
they are to  be gently yet firmly  insinuated,  and then passed between  the
placenta and  cervix,  on that  side on which we believe the  placenta to be
narrowest, until it arrive at the membranes, which must be pierced, and  the
feet found and brought down.  Some writers, Smellie and Mohrenheim, for
instance, have  proposed to perforate  the  placenta, instead  of  passing  the
hand between  it and  the uterus; this is  by no means  easy, and appears to
me extremely objectionable.  When the  body of the child is in the  pelvis,
it will act as  a tourniquet, and the flooding will cease ;  nevertheless, it is
well not to  delay the delivery, as internal  hemorrhage might occur.   The
mode of completing it I have  already described : it is  rarely that a child is
saved.
   In placental presentation, even more than in accidental hemorrhage, it is
desirable  to extract the placenta if it do not follow the child  immediately,
and  the same care and watchfulness will be necessary to secure a good per-
manent contraction, and to guard against subsequent hemorrhage.   Pressure
above and over the uterus  should be made with compresses  and the binder,
and if there be much  draining, cold must be applied to the vulva, and ergot
or cold enemata administered.
   681.  It is an advantage if the  foot present, even  when the placenta covers
the os uteri, because the operation of turning is rendered  easier; but when
the os uteri is only partially  covered, this  is still  greater, because by rup-
turing the membranes we facilitate the descent of the feet, and have only to
seize them in the vagina and extract the child.
   When the placenta reaches  only to the margin of the  os uteri, the case
is truly one of unavoidable hemorrhage;  but yet it  admits  of the same
treatment as  accidental hemorrhage, no  matter what  be  the presentation,
temporizing, if that be necessary, but if there be pains, after rupturing  the
membranes, the pressure of the head whilst dilating  the os  uteri will close
the  mouths of the bleeding vessels with the placenta,  and so arrest  the
flording until the child is  expelled.  This I  have  found  by repeated expe-
rience, and therefore, when we are certain of the case, and  pains are present, 
UNAVOIDABLE  HEMORRHAGE.
459
our duty is limited in the first  instance to  evacuating the liquor amnii ■  but
if this fail, we must turn and deliver the child.
  682. Such has been hitherto the  mode of proceeding recommended  by
practitioners of the highest authority; it  remained for my learned and  in-
genious friends, Dr. Radford and Prof. Simpson, to propose another, which
at first sight is remarkable mainly for its boldness, but  which  Prof. Simpson
has supported with his usual research, and which is  at present  the  subject
of controversy.
  I have  already stated (§ 678) that the  placenta is sometimes expelled be-
fore the child, and that the  mother is  not always  lost in these cases.   Now,
it  appears that these  instances are  not  so rare as  was  supposed.   Dr.
Simpson  has collected 56 published  cases, and he has been  furnished with
74 unpublished  ones (130 in all), in which  the placenta was either expelled
or extracted first,  and he finds that in all,  10 women died, or about 1 in  13:
and of 110 cases the infant was born  dead in 73, or 69 per cent., and alive
in 33, or  31  per cent., i. e.,  nearly every third child was saved.   In placenta
prsevia, under ordinary management,  1 in  3, or thereabouts, of the mothers
are lost, and more than half of the children.
   Taking this as the basis of his proposal,  Dr. Simpson advises us in cer-
tain cases to substitute extraction of the placenta for turning the child.   In
 justice to the Professor, it must be remembered that he does not intend that
this plan  should in every case supersede either the rupture of the membranes
or turning the child.
  Dr.  Lee, of London, who has entered into controversy with Dr. Simpson,
has objected to the proposed  plan :—1.  That the mortality,  under the  or-
dinary treatment,  as stated  by  Dr. Simpson and me, is exaggerated ;  but he
is far from having proved this.  2. That it was never practised by the older
accoucheurs ; but this would be equally an  objection  to any  improvement.
3. That the child must inevitably be sacrificed ; this would  be a  very serious
objection, if the mortality among the  children in the ordinary  mode of treat-
ment were small, but  it is  so  great  that  it is an insufficient argument  on
which to  reject the operation.
  The probability  of hemorrhage after the  extraction of the placenta would
most likely occur to any one as an objection ; but Dr.  Simpson states that
"in 19 out of 20 cases in which it has happened,  the attendant hemorrhage
has either been  at once arrested, or it has become so much   diminished as
not to be afterwards  alarming."   This Dr. Simpson  attempts to explain by
the supposition that the bleeding  proceeds almost entirely from the placenta,
and not  from the uterus.   But Dr.  Lee  contends,  and I think correctly,
that it escapes from the uterine sinuses laid bare by the detachment of the
placenta.   Dr. Ashwell advocates  this  view,  and,  with  others of high
authority, decitledly oppose Dr. Simpson's  plan of extraction.
  683. Let us next see i-n what cases  it is  proposed to  have recourse to this
novel operation, and then we shall be  in a  condition to  investigate its merits
better.  Professor Simpson thus states the circumstances in which he would
recommend it:—"When  the  hemorrhage  is so  great as to show the neces-
sity of interference, and is not  restrainable  or restrained by milder measures
(such  as the evacuation of  the liquor  amnii), but  at the  same time turning
or any other mode  of immediate or forcible delivery of the child is especially
hazardous or impracticable, in consequence of the undilated or undeveloped
state of the os uteri, the contraction of the  pelvic  passages,  etc.   Or, again,
the death, prematurity, or non-viability of the infant may not require us to
adopt modes of delivery for its  sake, that are accompanied (as  turning  is)
with much peril to the mother, provided we have a simpler and safer means,
such as the  detachment of the placenta, for at  once commanding and re-
straining the hemorrhage and  guarding the  life  of the parent  against  the 
460
FLOODING.
dangers of its  continuance.   Hence, as I have elsewhere stated, I believe
that the  suppression  of the  flooding, by the total  detachment of the pla-
centa, will be found the proper line of practice in severe cases of unavoidable
hemorrhage, complicated with an os uteri so insufficiently  dilated  and un-
dilatable as not to allow of version  being performed with perfect safety to
the mother ;—therefore, in most primiparae, in many cases in which placental
presentations  are (as very often happens) connected with  premature labor
and imperfect  development  of the  cervix and  os  uteri; in labors super-
vening earlier  than the seventh month ;  when the  uterus is too contracted
to allow  of  turning;  when the pelvis or passages of the  mother are organi-
cally contracted ;  wdien the  child is dead ;  when it is premature  and not
viable, and where the mother is in  such  an extreme state of exhaustion as
to be unable, without immediate peril of life, to  be submitted to the  shock
and dangers of turning  or forcible delivery of the infant.   This enumeration
is far from comprehending all the forms of placental presentations that are
met with in practice ; but it certainly includes a considerable proportion of
the  cases of this  obstetric complication ;  and  among them, all, or almost
all,  of  the  most  dangerous  and most  difficult  varieties  of unavoidable
hemorrhage.   In adopting  the practice, one error, which I would  strongly
protest against, has been committed in some instances.   Besides completely
detaching  and  withdrawing the placenta, the child has been  subsequently
extracted by  direct operative interference.   If the hemorrhage ceases, as
it usually does, upon the placenta being completely separated, the expulsion
of the child  should be  subsequently left to nature,  unless it present preter-
naturally, or the labor  afterwards  show any kind of complication which of
itself would  require operative interference  under  any other circumstances.
Both to detach a placenta and extract a  child would be hazarding a double,
instead of a single operation."
   Dr. Radford states that the placenta  ought never to be  detached in such
cases, unless, " 1.  The  danger to  the woman is so great  from exhaustion as
to render the  ordinary plan  of delivery, by turning the child, hazardous.
2.  When there exists some obstacle to the extraction of the child, either from
distortion in the bones of the pelvis, or  tumors connected with it, or  in its
cavity, but connected  with  the soft parts.   3. When  the child is dead."
Subsequently,  he protests against the operation until the cervix and os uteri
will allow the  introduction  of the hand,  as  that "is the only instrument by
which the placenta should be detached ;  indeed, I  hesitate  not to say, that
it cannot be safely and  effectually separated  by any other means."
   Dr. Edwards thus sums up the cases in which this practice seems admis-
sible.  1. When the patient is of so weakly and delicate a constitution, that
loss of blood to any great extent would be attended with present danger and
subsequent  injurious effects.   2.  When the child is well ascertained  to be
dead.   3.  In cases in which the powers of life have been excessively lowered
by the hemorrhage, and  the  os uteri  remains firm and  unyielding.   4. In
cases in which, although the os uteri is dilatable, the powers of life would be
unequal to the shock of turning.   5.  In primiparae, when the soft parts are
so contracted that they would be  liable to  be bruised or  torn in turning.
6.  In contracted pelvis.
   684.  We shall now examine in detail the practical value of this operation in
the cases proposed, so far as our facts  will permit, and assuming the correct-
ness of Dr.  Simpson's  statistics.   The rates of mortality,  by the  ordinary
treatment, I believe to be about one in three of the mothers, and sixty-five
per cent, of the children, according to a statement of  Dr.  Lee's, quoted by
Dr. Simpson,  i. e.,  of  course, taking large numbers.   According to Dr.
Simpson, when the  placenta has  been first  expelled or  detached, the mor-
tality is one in  fourteen of the mothers, and sixty-nine per cent, of the ehil- 
UNAVOIDABLE  HEMORRHAGE.
461
dreu.   So far  there appears to be an  important advantage gained by the
new method, but  it will be found, on further inquiry, that there are great
difficulties, if not insurmountable objections to it.
  1.  There appears to me great practical difference  between the placenta
being expelled first, and extracted first, although Dr.  Simpson  makes none,
but includes both equally in his  statistical table.   The former is the result
of vigorous uterine action : the latter mayor may not be accompanied by it;
and I think there is much force in the doubt expressed by Dr. Barnes, as to
whether  the results would be as favorable in cases of detached as of  ex-
pelled placenta.   The 17  cases quoted  from Dr. West by Dr. Simpson,  are
much too few  for proof.   Dr. Radford  has given two tables, the first of 41
cases, and the second of 14 cases, in which the placenta was separated and
detached by the hand, and of these  5  mothers  were  lost, or 1 in 11, and 7
children  saved, or 1 in 8.   Of 20  no  information is  given.  We must  re-
 member  that  in the one  case there  is  no irritation, no force applied to  the
 cervix and os  uteri, in the other there must be.
   2.  This  distinction between  detached  and expelled placenta alters  the
 ratio of  mortality among the children fearfully.   Dr.  Simpson  has recorded
 in his tables,  but one case  of the child being born alive, when the interval
 after the expulsion or extraction  of the placenta was more than 10 minutes ;
 and 16 of the 17 children, in the cases  quoted from Dr. West were lost.  If
 any attempt be made to  save the child by artificial delivery, this will  be to
 "incur the hazard of a double operation," and will defeat  the object of  Dr.
 Simpson's proposal.
   3. In  Dr. Simpson's first  table, of 47 cases, with an interval after the  ex-
 pulsion or extraction of the placenta of from ten minutes to ten hours before
 the birth of the child, I find that delivery was completed by art in  18 cases,
 in 14 of them by turning.   In the second table,  of 21  cases, where the inter-
 val was  less than ten minutes,  in 7 cases by turning, and in one by eviscera-
 tion.  In the third table, of 27 cases, where the child came with the placenta,
 or followed immediately,  there are 5 cases of turning,  and  1  of extraction
 recorded.   In the fourth table, of 27 cases, where the interval is unknown,
 delivery was  effected by turning in  15 cases, by the forceps in 2, aud by
 decapitation in one.
   From this it appears that in a very large proportion of cases (46 cases in
  119), artificial delivery was necessary, in  many, no doubt, from mal-presenta-
 tion ; but still, in these cases, detachment of the placenta alone would have
 been useless,  in many injurious;  nor, if the operation were performed before
 the dilatation of the os uteri, could the  mal-presentation have always been
  ascertained.  Again, we  find that delivery by art was more  frequent, accord-
 ing as the interval after the separation  of the placenta was prolonged,  and
  I should suppose, although Dr. S. does  not  mention it  in  his tables, that
  the interval would be much greater in  cases where the placenta is extracted
  than where it is expelled, and, consequently, that the  probability of a second
  operation being necessary would be  greater in such cases, which would con-
  stitute another important difference between these two classes  of  cases, or,
  as Dr. Simpson admits,  would double  the hazard.
    Of 41 cases given by Dr. Radford,  " in 18 turning was performed, in 6  it
  is presumed to have  been so, in  1 the child was  drawn by the presenting leg,
  16 were terminated by the natural efforts, 1 by the vectis,  1  by the perforator
  and crotchet."  In  table 2d, of 14  cases, 2 were terminated by the natural
  efforts,  10 by turning, 2 by  the forceps.
    4.  The first class of cases in which  Dr. Simpson thinks  this new method
  advisable, is  where the hemorrhage is  excessive, and the os uteri undilated
  and undilatable.   Now, although it  is evident that so long as this state
 continues  (fortunately it is rather the  exception  than the rule), turning  is 
4 62
FLOODING.
impracticable, I confess I do not see how the placenta can be easily or safely
detached.  I put out of the question using any instrument but the finger for
this purpose, for  I quite agree with Dr. Radford that any other would  be
extremely hazardous to the mother under such circumstances.   And I concur
with him that " in those cases of unavoidable hemorrhage which occur before
the expansion of the cervix uteri, it would  be quite impossible  to force the
finger along the  cervical  canal, and reach the  edge of the placenta, so as
entirely to detach it;  and in those cases which  occur at  the latter part  of
pregnancy, or  beginning of labor, with a rigid os uteri, it appears to me to
be out of the power of the operator, with the finger alone, to reach so far
as the  edge of the placenta."  It must  also  be borne  in  mind that Dr.
Simpson's favorable rate  of mortality does not  apply to this class, as there
are no statistics of such cases.
   5.  "In premature labors, with an undeveloped os uteri," there will be the
same difficulty in detatching the  placenta, whether the  child  be viable  or
not, and we  are in the  same ignorance of what would be  the result to the
mother.
   6.  In a great number of the cases in Dr. Simpson's tables (23 in 91), as
we have seen,  the presentation  was abnormal,  of the  shoulder,  arm, or hand
and head, and in  such cases artificial  delivery must take place, and it may
be a question  whether, if  we first merely removed the placenta, on account
of the exhaustion of the mother, we should not thereby increase the difficulty
of turning at a subsequent period.
   7. In the cases mentioned  by Drs. Simpson, Radford, and Edwards, of
distortion of the pelvis, or tumors  in the soft parts offering an obstacle to
the  extraction of the  child, the  new  operation would  not be exactly  an
alternative, but a substitute, as version would  be out of the question in most
instances, and the doubt remains whether it could be effected if the obstacle
were great.    If it could, it might facilitate the use of  the perforator and
 crotchet.
   8. In cases of  extreme exhaustion,  where the mother is  unable to bear
the  shock of turning or any additional loss of blood, if the os uteri be dilated
 or dilatable, and  the  circumference of the placenta within reach—as the
 hemorrhage is said to cease after the removal of the placenta—the opera-
tion  may be  admissible  for the  purpose  of gaining time, even with the
 chance of artificial delivery afterwards.
   9. In cases where the  flooding is considerable, the presentation natural,
 and the pains strong (the cases in  which the  placenta is sometimes expelled
 before  the child), there seems to be no objection to  arrest the hemorrhage
 by the removal of the placenta, leaving the conclusion of labor to the natural
 powers, either alone or stimulated by galvanism, as Dr. Radford has pro-
 posed.   To those two classes the results of Dr. Simpson's  statistics almost
 exclusively apply.
   I have thus examined with care this very difficult subject,  and although I
 would  be far from pronouncing dogmatically upon  it, I  feel bound in duty
 to state, that  except in the cases I have mentioned,  I could not consent to
 substitute the  new method of treatment for the  old, and even in those cases
 I would recommend the very utmost caution.
   685.  Dr.  Robert Barnes has proposed  another mode  of treatment based
 upon some very ingenious views.1   He has divided the  uterus into  three
 zones ;  the  lower one, the cervical, being the  only portion of the uterus
 narrower than the child, is the only part dilated by the process of labor, and
 therefore  the  only part from which the placenta will be detached by that
 process.   So  much of the placenta as may be within this zone will and may
   1  The Physiology and Treatment of Placenta Praevia, being the Lettsomian Lectures
 on Midwifery for the year 1857. 
UNAVOIDABLE  HEMORRHAGE.
463
be detached, but any portion beyond it will not be so necessarily.   So far,
I think, he is right.  Again, we know,  as I have already mentioned, that if
the hemorrhage be arrested, it does not always return, from which Dr. Barnes
infers that a renewed hemorrhage is always the result of a new detachment
of a portion of the placenta.   Carrying this view into practice, Dr. Barnes
proposes that the cervical portion of the placenta should be detached, with
the hope that the hemorrhage will cease  and not return.   He does not ad-
vise this plan for  all  cases, and  the cases  in which  he  has tried it are but
few.  I must refer my readers  to his  able  work for fuller detail;  all I will
say at present is, that I rather  doubt the fact of an old detachment giving
rise to no renewed bleeding, and  fearing that the artificial detachment of the
adherent after-birth might give rise  to a severe additional flooding, I should
be afraid to run the risk, especially as by the plug, and,  when suitable, turn-
 ing, we have a mode  of prompt delivery by which  any great increase  of
 hemorrhage may be avoided.  Without denying that it may be suitable in
 some cases, I should hesitate  in recommending it until further experience
 shall have tested its merits.
   ["Messrs. Simpson,  Radford, and  the  other gentlemen  who  advocate
 the  new  method  in  placenta  praevia,"  remarks Dr. Meigs,1  "very earn-
 estly recommend the prompt separation of the whole of the placenta ;  and
 they are persons whose  opinions are justly to  be esteemed of the greatest
 weight; but notwithstanding the profound  respect with  which I receive any
 statement of theirs, I cannot but think that in any case  in  which it is possi-
 ble to detach the whole  of the placenta, it  would be  also possible to intro-
 duce the whole  of the hand, and thus  commence at once  the operation of
 turning, which  ought to  be esteemed as the essential indication of treatment
 in placenta praevia, and which the  earlier  it  is  done, so much the greater
 chance does it  give both of rescuing  the child and saving the woman from
 fatal losses of blood."
   Before the Obstetrical Society of London Dr. Robert Barnes read a paper,
 April 6th, 1859, giving the history of fourteen cases illustrative of the physi-
 ology and treatment of placenta  praevia.   The following series of therapeu-
 tical deductions he believes to  be sustained by the result of these cases.
   " 1.  That inflammation of the uterine structures, particularly of the cervix,
 is especially likely to supervene upon delivery attended by placental presenta-
 tion ; and that the danger of this complication is increased by the forcible
 dilatation and contusion of  the  vascular cervix, caused  by the introduction
 of the hand, or by the extraction of the  child.
   " 2.  That the greatest  amount of flooding generally takes place  at the
 commencement of labor, when the os is beginning to expand.  That the os
 is alwavs,  from its being near  the seat of the placental attachment,  highly
 vascular, and is frequently,  at this  stage, very rigid.   That any attempt to
 force the hand through this structure, at  this stage, either for the purpose
 of wholly detaching the placenta, or of turning the child, must be made at
 the risk of injuring the womb; and that  the dragging the child through the
 os when in this condition—even  when  it has not been necessary to pass the
• hand into the uterus—is a proceeding  affording slender chance of life to the
 child, and dangerous to the mother.
   "3.  That the entire detachment of the placenta is not necessary to ensure
 the arrest of the hemorrhage ;  and that, therefore, it is not necessary either to
 wholly detach the placenta before the birth of the child, or, in cases uncom-
 plicated with cross-presentation, to proceed  to forced  delivery with  a view
 to wholly  detach the placenta  after the birth of the child.
   " 4.  That, since the dilatation of the cervical portion of the womb must
> [Op. cit.] 
464
HEMORRHAGE AFTER  DELIVERY.
take place in order to give passage to the child, and since, during the earlier
stages of this necessary dilatation, hemorrhage is liable to occur, it is desir-
able to expedite this stage of labor as much as possible.
  " 5. That in cases where labor appears imminent, with considerable flood-
ing,  whilst  the os internum uteri  is still closed, the arrest  of the  flooding
and  the  expansion of the os may be favored by plugging  the vagina, and
especially the cervix; by the use  of ergot;  by the stimulus of galvanism
to the uterine muscles, or by the method, recommended by Professor Braun,
for bringing  on labor in puerperal convulsions.
   " 6. That, since a cross-presentation,  or other unfavorable position of the
child at the os internum uteri is apt to impede  or destroy the regular con-
tractions of  the  uterus, which are necessary  to  the arrest of flooding, it is
mostly desirable in cases complicated with unfavorable positions of the child,
to deliver as soon as the condition of the os uteri will  permit.
   " 7. That, in some  cases, the simple  use of means  to excite  contraction
of the uterus, such as  ergot, rupturing the  membranes, the administration
of a  purgative, or the  employment of galvanism, will  suffice to arrest the
hemorrhage.
   " 8. That, in some cases where it is observed that the os uteri has moder-
ately expanded—namely, to the size of a crown-piece,  or less,—the  placenta
being felt to  be detached from the cervical zone,  and the hemorrhage having
ceased, it is  not  necessary to interfere with the course  of the labor, now
become normal.
   " 9. That, at the critical period, when the total detachment of the placenta,
or forcible  delivery are dangerous or impracticable operations, the introduc-
tion of the index finger through the os,  and the  artificial separation of that
portion of  the placenta which lies within the lower or cervical zone  of the
uterus, is a safe and feasible operation.
   " 10. That the  artificial detachment  of  all that  portion  of the  placenta
which adheres within the cervical zone of the uterus will at once liberate the
os internum uteri  from those adhesions which impede its equable dilatation ;
and by facilitating the regular contraction of this segment of the uterus,
favor the arrest  of hemorrhage, and  convert a labor complicated  with pla-
cental presentation into a natural labor."1
   For a very full report of the statistics of placenta praevia, so arranged as
to present  as far as  possible  their true  bearing  upon  the several questions
involved in a consideration  of  the proper treatment  of the accident, with
direct reference to the safety  of the mother and  child,  the reader is referred
to the Prize Essay of Dr. I. D.  Trask,  contained in the 8th vol.  of the
Transactions of the  American Medical Association, page 593.]
   The necessary  stimulants  and support  must be afforded, as in accidental
hemorrhage, and if the  patient be  extremely sunk and exhausted, we may
have recourse to transfusion.

   686.  3.  Hemorrhage after delivery. —A certain amount of blood is
always lost after delivery, nor is this injurious ;  and it is only when it is so
great as to produce an impression upon the  constitution and the pulse that
it is to be considered as flooding.   Of course, in  all cases it  escapes from the
mouths  of the vessels, exposed by the  partial  or  entire separation  of the
placenta, not being closed by firm uterine contraction.
   It sometimes, but rarely, takes place when  an interval elapses between the
expulsion  of the head and body of the child, but much more frequently after
its birth, before or after the expulsion of the placenta.  The presence of a
clot  or a polypus in the uterus may also give rise to it.

       1 [Transactions of the Obstetrical Society of London, vol. i., 1860, p. 83.] 
SECONDARY  HEMORRHAGE.
465
  The hemorrhage after the expulsion of the placenta may be the result of
want of contraction of the uterus ; but there are severe and even fatal cases
which are caused by a limited rupture of  the cervix.
  Dr. F. H. Ramsbotham has recently published a series of very interesting
cases, in which hemorrhage co-existed with severe  after-pains, owing, appar-
ently, to the presence of a firm coagulum in the uterus, which it failed to expel.
The remedy consists in introducing the hand and removing  the coagula.
  I have, in the last chapter, spoken fully of retained placenta and its treat-
ment, which I shall not now repeat, but shall confine myself to the treatment
of the hemorrhage, whose effects are similar to those already noticed.
  687. Treatment.—Let us suppose, therefore, that the placenta has been
extracted or expelled, but that the flooding is not arrested.  The first object
is to produce a  firm  and  persistent contraction ; and  to effect  this, whilst
with one hand we  firmly grasp the uterus, with the other cold is to be sud-
denly applied to the genitals by means of cloths dipped in cold water.  The
advantage of grasping the uterus is, that we thereby secure  an artificial con-
traction, as it were,  until the means employed effect a real  one.
  Ergot may be given at the same time, and in no case is it more beneficial.
 Cold enemata and cold drinks are also valuable  auxiliaries.   If these fail,
 we  may pour cold water from  a height upon  the abdomen,  and the shock
 will generally succeed in rousing the uterus into  action.   Dr. Tyler Smith
 succeeded,  as a last resource, by injecting iced water into the uterus,1 in two
 cases; and Mr. Chavasse, of Birmingham, speaks  highly both of the success
 and safety of the practice.2  Compression of the aorta is said to  be  effectual
 in some cases.   It was  introduced by Saxtorph,  and has since been recom-
 mended by  MM. Lentin, Chailly, and others.    Dr.  Radford recommends
 galvanism.  When all  has  failed, Dr. Gooch recommends the introduction
 of the hand into the uterus,  for the purpose of exciting it to contract by the
 irritation.  I have no doubt of its success, but it is more hazardous than the
 other means I have mentioned.
   The internal  remedies advised  in  the other forms of hemorrhage  (as lead
 and opium) are  equally suitable to this, whether primary or secondary. The
 restorative treatment is likewise the same.
   In all cases where, after a previous labor, the  patient has  suffered from
 hemorrhage, I am in the habit of giving half a drachm of the ergot of rye,
 immediately after the birth  of the  child,  and repeating it if necessary.  By
 this means I have  rarely failed to protect the  patient  against a repetition
 of the accident.   It is right to mention that so far from flooding affording
 the patient any immunity from subsequent inflammation, I should say that it
 is not very rarely followed by such an attack.

   688.  4. Secondary Hemorrhage.3 —By this  term  I understand a loss
 of  blood occurring  after the discharge which  accompanies  a delivery has
 moderated  into  the ordinary amount of the lochia.   It may occur after six,
 eight, or ten hours, or at any period within the month.
   Of 43 cases  recorded by Dr. Collins, the  discharge occurred within  12
 hours in 40, on  the 4th day in  1, on  the 5th in 1, and in  1  on  the 10th day.
 In 25 cases recorded by Drs. M'Clintock and Hardy, only 1 occurred so late
 as the 7th day.  In 5 cases given by Drs. Johnston and  Sinclair, the bleed-
 ing occurred  on the 4th day in 2, on the 8th  in  1, on the 9th in 1, and on
 the 21st day in 1 case.  Dr. Stevenson  met with  1 case on the  10th day  ;4

  1  Lancet, July 7th, 1849, vol.  ii. pp. 6, 693.            2 Ibid., Dec. 29th. 1849.
  *l have been much indebted to a valuable and learned essay on this  subject by my friend
 Dr. M'Clintock, in the Dublin Quarterly Journal for May, 1851, to which I beg to refer
 such of my readers as mav be anxious for further details than I have given.
  *Xew York Annalist, Oct, 1st, 1848.
        30 
466
SECONDARY  hemorrhage.
Dr. Fergusson 1  on the 13th.1  Dr. Roberton has  given  14 cases;  in 1 it
occurred on  the  7th, in 2 on  the 9th, in 2 on the 10th, in  1  on the 11th, in
1 on the 12th, in  2 on the 14th,  in 2 on  the 16th, in 1 on  the  19th, in 1 on
the 22d, and in 1  on the 27th day after delivery.  In 5 of the cases there was
but a single attack;  in the remainder the hemorrhage recurred.2  In  Mr.
Campbell's case it was on the  14th day.3
   68(.h  Causes.—The causes are various.  The  retention of  a portion of
an adherent placenta, after an operation  for its removal;  the  formation of
a firm coagulum, which  the  after pains are  not sufficient  to expel;  the
relaxation of the uterine contraction within a limited period ;  local or general
disturbance of the circulation  ; constipation, according to Moreau;  disorder
of the liver,  according to Dr. Ayre ; inflammatory  ulceration of  the  cer-
vix, according  to Dr. Bennet; polypus uteri, inversion, disease of the body
of the  uterus,  a minor degree of laceration, and thrombus of the  cervix
uteri.
   Any  of these causes  may give rise to very serious hemorrhage at an un-
certain period after delivery, and  the most important point for the attendant,
when summoned, is to ascertain to which of these causes it  is attributable.
The size of the uterus will assist us in deciding the question of the retention
of the placenta or a clot,  and  in most cases some light will be  thrown upon
the matter by a careful internal examination, added to the  previous history.
After all, in  many cases it  is  only by the " method  of exclusion " that  we
can arrive at a conclusion as  to the nature of the case.
   It does not  appear that the attack is frequently fatal, except when it is
complicated with organic  disease.  Of Dr. Collins' cases, four  died, one  of
rupture  of the uterus, one of sloughing of the  vagina, and two from the
effects of the hemorrhage.*  Of  Dr. M'Clintock's cases, two died, one from
the effects of the hemorrhage, and one of uterine phlebitis.5  None of Dr.
Roberton's cases  proved  fatal; but  he  relates two from the practice of his
colleagues, Mr. Windsor  and  Mr. Clough,  and  quotes  one from Madame
Boivin, which ended unfortunately.6
   690.  Treatment. — Having decided  upon the nature  of the  case, the
treatment is  not  difficult.   The  application of cold externally, or enemata
of cold  water, and ergot, are. perhaps, the most valuable means, and the
latter will facilitate the expulsion of any  portion of the placenta, if loose, or
of a clot.
   [" Iced-water may be injected  into the bowels,  a quart at once, which is a
favorite remedy  of my highly esteemed  and judicious colleague, Professor
B. R. Palmer, who informs me that it has never failed in his hands to excite
uterine contraction and arrest the bleeding."7]
   Dr.  M'Clintock speaks highly of the plug, but  it  must be combined with
pressure over the uteres, to guard against internal hemorrhage.
   ["To attempt," remarks Professor Miller, of Louisville, Ky., "to control
hemorrhage  from an empty  and flaccid uterus, by plugging the vagina, is
highly hazardous.  We may, it  is true, prevent  the issue  of blood by this
expedient, but we can have no assurance that it will not  continue to pour
from the vessels,  and collect in the uterine cavity, until life is exhausted.  It
is better to  contend with an open than a lurking  enemy — let the blood,
therefore, have an unobstructed channel;  we can,  then,  the  more clearly
discern our patient's  danger — which it  is folly to hide from  our eyes — and
shall be incited to more earnest efforts to save her from impending death."8]
  !New York Jour, of Med., Sept.  1850.    2Phys. and Dis. of Women and Med., p. 365.
  s Med. Gaz., Oct.  26th, 1849, p.  732.     *Prac. Treatise on Midwifery, etc., p. 158.
  5 Prac. Obs.  in Midwifery, etc., p. 236.    6Dis. of Women and Midwifery, p. 365.
  '[Henry Miller, M. D., of Louisville, Ky.  Principles and Prac. of Obstetrics.]
  B [Principles and Practice of Obstetrics.] 
CONVULSIONS.
467
  Tincture of the Indian hemp, the oxide of silver, spirits of turpentine, and
a blister to the sacrum, are all valuable remedies.
  In cases of disease, ulceration, polypus, etc., a selection of these remedies
may be used for  the purpose of arresting the hemorrhage ; but other treat-
ment will be necessary for those cases, which I have detailed in the volume
on Diseases of Women, and need not repeat here.
  Inversion of the uterus, and its treatment, will also be found in the same
volume.
  Mr.  Slyman proposes an elastic bag introduced into the uterus,  and filled
with cold water  or air, so as to make pressure.1
C HAP TE R  XXI,
          PARTURITION. —CLASS III.  COMPLEX  LABOR.
                     ORDER  4.  CONVULSIONS.

  691.  The next complication I shall notice is that affection of the nervous
system termed convulsions —i. e., a convulsive seizure of the entire body and
extremities,  omitting  those partial  attacks which  we  see  occasionally,
although  they may be of a convulsive or spasmodic nature.  The complica-
tion is a very frightful  and a  very  dangerous one, and  may occur  either
during gestation, immediately before, during, or after parturition.
  The variety of opinions and  methods  of treatment which have been put
forth seems mainly to have arisen from confounding the different species  of
convulsion :  and in order to avoid this,  I shall describe  three varieties—the
hysteric,  the epileptic, and the  apoplectic convulsion.

  692  1  Hysteric Convulsions.—This variety is confined to the period
of "-estation, and is more frequent  during the  early  months than  subse-
quently.   Females  of a nervous  or hysterical constitution are  the most
obnoxious to the attacks.                              .                 .
  Causes.—Want of sleep, or excessive fatigue, may give rise to hysteric
convulsions  or they may be caused by disordered digestion.
  693  Symptoms —The attack is generally preceded by a tightness about
the throat, by sobbing,  or repeated  attempts at swallowing.   The patient
then becomes still and motionless, or may roll about from  side to side. Ihe
hands  are frequently pressed  upon  the breast, or carried to the  neck,  as
though to remove  some  obstruction.   The face is generally,  though not
always, pale, and not distorted;  no froth issues from the mouth nor  are
there the convulsive motions  of  the lower jaw,  by which in epilepsy  the
tongue  is sometimes severely  bitten.    In  many  cases the muscles  of  the
back  are violently contracted,  which Dr. Dewees thinks a pathognomonic
symptom   The  patient is not insensible, though she cannot  express  her
feelings or wishes.   After this state  has continued  for a longer or shorter
time,  the sobbing becomes more violent, or the patient screams and sheds
tears, and the fit thus terminates.  A great quantity of limpid  urine is also
discharged.
                       i Lancet, Jan.  13th, 1849,  p. 37. 
468
convulsions.
  The paroxysm may be a single occurrence, or return after a time, with
the same phenomena.
  It does not generally influence  the  progress of gestation, though I have
seen premature labor take place during the paroxysm.  The mother's-health
may be rendered rather more delicate, but it is not  seriously compromised
by the disorder.
  694.  Diagnosis.  1.  From epileptic convulsions.—The body is but slightly
contorted; there is no complete insensibility; there is no frothing at the
mouth, nor biting the  tongue, nor stertorous breathing ;  and  after the fit is
over, the patient recovers her usual state—the reverse of all which symptoms
occur in epileptic convulsions.
  2. From apoplectic convulsions.—In these the patient loses conscious-
ness and voluntary motion at first, and ultimately all motion  ceases; this is
not the case in hysteric convulsions;  besides which, in the latter the breath-
ing is not stertorous, and the patient soon recovers.
   695.  Treatment.—If the pulse be quick (which is not ordinarily the case),
or the head ache, venesection may be practised, or a few leeches be applied
to the forehead ; but this is rarely necessary.   In most cases, antispasmodics
combined with diffusible stimuli (valerian or assafoetida, with  ammonia), will
relieve the patient.   Volatile alkali, held to the nostrils, is useful; or cold
water dashed upon the face.
   When the paroxysm is over, a moderate  dose of opium may be given;
and, after a sound sleep, the patient will find herself nearly restored.   The
stomach must be attended to.   Tonics  may be given if necessary, and ape-
rient medicine.

   696.  2.  Epileptic  Convulsions.—This  variety is by far  more frequent
than either of the others.
697.  Statistics.—Frequency.
Authors.					Total Number of Cases.	Convulsions.
Dr. Bland.......					1,897	o
Dr. Jos. Clarke					10,387	19
Dr. Merriman .					2,947	5
Dr. Granville .					640	1
Dr. Cusack					398	6
Dr. Maunsell .					848	4
Dr. Collins					16,654	30
Dr. Beatty					399	1
Dr. Ashwell					1,206	3
Dr. Mantell .					2,510	6
Dr. Churchill .					600	0
Drs. Hardy and M'Clintock					6,634	13
Dr. F. H. Ramsbotham .					68,435	67
Mr. Earle					4,320	8
Mr. Rose					600	2
Mr. Bailey					2,819	11
Dr. Toogood .					1,135	1
Dr. J. Lee					850	2
Mr. K. Watson					800	4
Dr. Copeland .					1,290	3
Dr. Arneth					6,527	13
Mad. Boivin .					20.357	19
Mad. Lachapelle					38,000	61
Mr. J. Thompson					3,300	6
Drs. Johnston and Sinclair					13,748	63
Dr. Hall Davis i					7,302	5
 
convulsions.
469
  Thus we have  347 cases of convulsion  in  214,663 cases of labor  or 1 in
about618f.
  On the whole,  the  mortality is considerable, though  probably much less
so than formerly.   Jacob states that in his time scarcely any survived.  Dr.
Parr, in his Med. Dictionary, that six or seven out often die.   Dr.  Hunter,
that the greater proportion were lost.
Authors.						Cases of Convulsions.	Mothers lost.
Mr. Giffard.......						4	o
Dr. Smellie						8	2
Mr. Perfect	,					14	5
Dr. Bland						2	0
Dr. Jos. Clarke	.					19	6
Dr. Newman .						36	8
Dr. Ramsbotham						26	10
Dr. Maunsell .						4	2
Dr. Collins						30	5
Dr. Beatty						1	0
Dr. Churchill .						2	0
Dr. Mantell .						6	2
Drs. Hardy and M'Clintock						13	3
Dr. F. H. Ramsbotham .						43	3
Dr. Arneth						13	4
Dr. Meigs						20	3
Dr. Huston						13	2
Mr. J. Thompson						6	0
Drs. Johnston and Sinclair						63	13
Dr. Hall Davis.						5	0
  Thus, out of 328 cases, 70 mothers were lost, or about 1 in 4^.
  Women of all temperaments may be attacked, but it is more common, as
Dr. Collins has remarked, "in  strong plethoric young women with their first
children; more especially in such as are of a coarse make, with short thick
necks."1  Dr. Ramsbotham has stated that "women with large families are
equally or perhaps more liable to be assailed."   This, however, is not borne
out by numerical investigation, for of thirty-six cases related by Dr. Merri-
man, twenty-eight were with  first  children.   Of Dr.   Ramsbotham's  own
cases, more than two-thirds  were with first children ;  of Dr. Collins' 30 cases,
29 were with first children ; and of Dr. Johnston and Sinclair's 63 cases,  49
were primiparae.
  698. Causes.—Various and very obscure  have been  the explanations  of
the  causes  of puerperal convulsions.   Dr. Locock  thus enumerates them :
"The immediate  causes of puerperal convulsions are  often very obscure.
They appear sometimes to depend  upon  a loaded  state of the brain ;  at
other times the brain appears to be  influenced by distant irritation, either in
the  uterus or digestive organs; and, again in some cases, puerperal convul-
sions are induced apparently by a peculiar irritability of the nervous system.
It has been remarked, that  there has been a greater disposition to puerperal
convulsions in those patients who have been in early life subject to convulsive
attacks,  particularly of an  epileptic  character;  and  also in those who have
suffered  similarly in former  labors, and have omitted  those measures usually
employed as precautions.    That the uterine organs are in some way particu-
larly implicated, is evident from the convulsions being of a character which
may be said to be peculiar  to the state of either pregnancy or parturition."
1  Prac. Treatise on Midwifery, p. 199. 
470
CONVULSIONS.
"The  immediate attack may  be brought  on by a loaded  or disordered
stomach, or by  food,  however small in quantity, of an indigestible kind.
Some substances (shell-fish for  instance) have been found very frequently to
induce convulsions in the puerperal condition, when at other times they may
have  been  taken by the same individual with perfect impunity.  A  sudden
fright, afflicting intelligence, or  any unexpected or depressing mental emotion,
may excite the paroxysm ;  hence it has been long remarked, that unmarried
women are more particularly  likely to be  sufferers  from  convulsions, from
the shame  and distress under  which  their children are  usually born.  The
violent straining caused by labor  pains, from the disturbance of the frame
by the earlier uterine contractions, causing a temporary rush of blood to the
head, will sometimes bring on convulsions."1
  The application of Dr. Marshall Hall's theory, however, by Drs. Thomp-
son, Murphy,  and  Tyler Smith, has thrown much light  upon the  matter.
The former gentleman  insists  that no  injury to  the cerebrum or cerebellum
can cause convulsions, so long as the true  spinal system is not involved, in
which Dr.  T.  Smith agrees  with  him.   He then states that the proximate
cause  of puerperal  convulsion consists in  a morbid irritation of the true
spinal system, and more especially of the medulla  oblongata, propagated to
it from the mucous surfaces,  through the incident nerves of the excito-motor
system.2
   Dr. Murphy3 enumerates, among the proximate causes, morbid irritation
of the  uterus from  hyperaamia or anaemia,  and morbid irritation of other
organs, and regards the whole  as a beautiful illustration of the reflex nervous
function ;  the peripheral nerves that supply the affected organ rapidly com-
municating their irritation to  the spinal system, which, as an excito-motor
centre, radiates the irritation  over the whole of the voluntary muscles, and
the muscles of respiration.    Even the involuntary muscles,  as the uterus and
heart, do not  escape.
   Dr. Tyler Smith, in  his  admirable work,  has entered  into  a most elabo-
rate investigation of the causes of convulsions :  after which he observes:—
"In conclusion, to give a summary of the whole subject, the true  puerperal
convulsion can only occur  when the central  organ of this system, the spinal
marrow, has been  acted on  by an excited  condition of an important class
of  its incident nerves, namely, those passing from the uterine organs to the
spinal centre, such excitement depending on pregnancy, labor, or the puer-
peral state.   While the spinal marrow remains,  under the influence of either
of  these stimuli, convulsions  may occur from two  series  of causes ; those
acting primarily in the spinal marrow, or centric causes ;  and secondly,
those affecting the extremities of its incident nerves ; causes of eccentric or
peripheral origin.

   " I.  Causes acting immediately on the central organ :—
   1.  Pressure  exerted  on the medulla oblongata by congestion, coagula,
 nervous effusion within the cranium.
   2.  Loss of blood.
   3.  Morbid  elements  in the blood.
   4.  The  influence of emotion.

   " II. Causes acting  on the  extremities of excitor nerves :—
   1.  Irritation of the incident spinal  nerves  of the uterus  and uterine
 passages.
   2.  Irritation of excitor nerves  within the cranium.

   1 Cycl. of Pract. Med.   .Art. :  Puerperal Convulsions.
   2 Essay on the Epileptic form of  Puerperal Convulsions.   Ranking, vol. viii. p. 313.
   3 Lectures in Med. Gazette, Jan.  1849. 
CONVULSIONS.
471
  3.  Irritation of the incident spinal nerves of the rectum.
  4.  Irritation of the ovarian nerves.
  5.  Irritation of the gastric and intestinal  branches of the  pneumogastric
nerves.
  6.  Irritation of the incident spinal nerves  of the bladder.
  7.  As probable causes may be enumerated, irritation of the cutaneous nerves
of the mamma?, and of the hepatic and renal branches of the pneumogastric.
  "Though the subject distinctly admits of this division, several causes may
act together, and centric and  eccentric causes may be in operation at the
same time.   I have made no  attempt at a division into  predisposing  and
exciting, proximate and remote  causes, as other authors have usually done,
because it is evident that a cause which, in one case, is the  exciting or proxi-
mate, may, in another, be the predisposing or remote cause."1  Subsequently,
Dr. Tyler Smith  endeavors to explain the  operation  of the causes, and to
trace  the gradual progress from the slight commencement up  to  the com-
pletion of the convulsive paroxysm: but the investigation, though able, and
full of interest, is too long for quotation, and I must refer my readers to his
work, with an assurance that the perusal of the whole will abundantly repay
them.
   Among the most common  exciting causes are usually enumerated intem-
perance  in  eating  and drinking ;  mental emotion ;  fright,  as in  the  case
related  by Denman, of a  lady who was  going on a party of pleasure, and
whose carriage broke down ; she was near the time other lying-in, and was
very  much  frightened, though  she received  no  apparent injury.   When
she fell  into labor, this was preceded  by  convulsions,  in which  she  died
undelivered.2
   Mr. Robbs has related a  case3  in which  the  convulsions seem to have
been  owing to the irritation  of  worms ; at  least, they ceased on the expul-
sion of two  large lumbrici.
   Atmospheric influence, according  to  M. Duges,4 appears to have some
peculiar effect in producing the disease, so that it assumes the character of
an epidemic.  This is  confirmed by the observation  of  Dr. Ramsbotham,
who  observes:—"I have  repeatedly  remarked,  among the numerous  pa-
tients of the Royal Maternity Charity, as well as among  others to whom  I
have been  accidentally called, that several  cases  have occurred soon after
each  other.   Whether this fact ought to be  attributed to mere  chance, or to
the agency  of some general principle upon  the female system,  I must leave
to others to determine in  future ;  but I am inclined to suspect that it may
be ascribed to the latter principle.   And here I may be allowed to observe,
that I have witnessed the occurrence of several cases during  warm weather;
at a time when the clouds have been charged with electric fluid ;  when at-
mospheric  appearances have threatened a thunderstorm, and when, perhaps,
they have ended in one."5  And most practitioners will probably have had
occasion to remark the occurrence  of several  cases about the same time, as
if they depended upon some general cause.
   699.  In considering  the exciting causes  of the disease, we  cannot over-
look  the condition  in the urine.   Hamilton6 and Demanet7 first stated that
puerperal  convulsions  were  liable  to be preceded by anasarca,  and their
observations were confirmed by the highest authority.  Dr.  Simpson  and
Dr.  Li'ver8 were the first to connect this dropsy with that condition of the
kidney which gives rise to the  secretion of albumen, and since their time,

  1 Parturition and Obstetrics, p. 306.    2 Introi to Midwifery, p. 429.
  3 Med. Gazette, Sept. 21st, 1849.       * Diet, de M£d. etde Chir. Prat., vol vi. p. 541.
  5 Pract Obs. in Mid., vol. i. p. 250.    6 Duncan's Annals of Med., vol. v. p. 313.
  7 Recueil lV'-iodique de la Society de Me"d., vol. ix. p. 110.
  8 Guy's Hospital Reports, 1843. 
472
CONVULSIONS.
the researches  of Cahir and Bouchut, Raver, Depaul, Cazeaux, etc., have
confirmed and extended their observations.  That in a large proportion  of
cases of convulsions  there  is albuminuria, with or without anasarca, there
can  be  no doubt;  but, on  the  other hand, albuminuria may occur without
convulsions, and convulsions without albuminuria.   For example, Dr. Blot1
found albumen in the urine of 41 pregnant women out of 20'), and chiefly
in primiparae ;  and Dr. Litzman2  examined  the  urine of 131 females,  79
during  pregnancy,  80 during  labor, and 80  after delivery;  albumen was
present in 37, and  absent in 95 ; of the 37, 26 were primiparaa.  What is
the exact relation between  the  two is difficult to  say precisely.  I believe,
with Dr. Simpson,  that they both stand in the relation  of effects of another
cause, viz., "a  pathological state of the blood, to  the occurrence of which
pregnancy may some way  dispose ; 3 or  it may be that the excretion  of
albumen so discomposes the equilibrium of the  component parts  of the blood,
that in their disproportion they give rise  to  these  peculiar- morbid effects.
This seems to be the  opinion of Dr. Braun,4 who terms the  disease " Ursemic
Eclampsia,"  from " Ui'semic intoxication  of the blood," and he  considers it
analogous to the first stage of  Bright's disease.  Frerichs has  pointed out
the altered condition of the blood in pregnant women, viz.,  the increase  of
water and of fibrin, diminished quantity  of albumen, diminution of  the red
and increase of the white corpuscles, as a subordinate cause.
   Dr. Cormack has published an excellent paper on the connection  between
renal congestion and puerperal convulsions.5   He considers that in many
cases the latter  are  the toxicological results  of non-elimination of the ex-
cretions of the blood, and that in  the greater  majority of cases this non-
elimination depends  upon  renal congestion,  caused by the pressure of the
gravid  uterus.
   Many authors have assumed  the  previous  occurrence of epileptic, as a
predisposing cause  of puerperal convulsions, as I did myself in  the previous
editions of this work, but I am induced to think this very doubtful.  In the
work from which I  have  quoted, Dr. Tyler  Smith  observes that "the sus-
pected affinities between epilepsy and puerperal convulsions deserve attention.
It would seem a priori, that epileptics, or persons who  have been subject to
convulsions during  infancy, would be far  more liable  than  others to attacks
of convulsion during  the puerperal state.    It would also seem probable that
patients suffering from  puerperal convulsion should  become  subsequently
liable  to epileptic attacks.  But  experience does not positively support
either of these probabilities."6   In a more recent publication he mentions,
that in  fifty-one pregnancies occurring in fifteen  epileptic subjects, only two
had puerperal convulsions,7 and the experience  of Drs. Hardy and M'Clintock
confirms this view.
   Of those cases of severe epilepsy before marriage which  have come under
my care, in one only  was there  any attack during gestation or parturition ;
whilst in the numerous cases of puerperal convulsions I have seen, I have
not known one in which the convulsions returned in the absence of pregnane v.
   There is a curious  instance on record of periodical convulsions during  the
time of gestation only.  " The wife of a citizen of Ferrara, twenty years of
age, of a bilious  constitution, and the mother of three children,  was  attacked
with periodical epilepsy whenever she conceived, and sustained a paroxysm
of that malady once  a fortnight during the whole  of her gestation ;  but as

  * L'Union MSdicale, 10 Oct.  1852.        2 Deutsche Klinik, May, June, July, 1850.
  3 Ed. Monthly Journal, Oct. 1852, p. 369.
  4 The  Uraemic  Convulsions of Pregnancy, Parturition, and Childbed.   Translated by
Dr. Matthews  Duncan.  A most valuable little work,  to which I beg to refer my readers.
  5 Lancet, April 13th, 1850.                  6 Parturition and Obsterics, p. 323.
  7 Med. Gazette, 1849,  vol. ix., p. 1074. 
CONVULSIONS.
473
soon as she was delivered, the  disease left her.  Its occurrence, therefore,
was always to her a sign that she had become pregnant."1
  I have seen  a case something like this.  A lady was attacked by convul-
sions of an  epileptic  character the  first time she conceived, and they were
repeated at the moment of quickening.   She escaped an attack during her
second pregnancy, but was seized  at the  moment of conception  the third
time.   She passed through her labor without the least threatening of con-
vulsion.
  700.  Symptoms.—The symptoms of epileptic convulsions  resemble very
closely, if they are not  identical with, those of ordinary epilepsy.   In the
majority of cases there  are  certain premonitory symptoms.   The patient,
for some time  previous,  suffers  from pain in the head,  giddiness, confusion,
ringing noise in the ears,  obscure vision, temporary loss of sensation,  rigors,
nausea, or even vomiting.  The face is flushed, and  the  eyes injected.  Dr.
Hamilton, senior, mentions as peculiar, an intense pain in the forehead ; and
Dr. Denman,  a  severe  pain  in the stomach, and these, he  thinks, are the
worse kind of cases.  Osiander has noticed a tumid state of  the hands and
face preceding the attack.  Most practitioners  are familiar with a dropsical
swelling of the face  alone, or face  and  upper  extremities, which is not un-
commonly followed by convulsions, and which  we may regard undoubtedly
as a precursory symptom, if  the urine be at the same time albuminous.  In
some few cases,  however, there are no precursory symptoms ; the patient
has no warning until the moment before she becomes insensible.  The " aura
 epileptica" is  seldom felt.
   As the attack approaches, these symptoms are  aggravated ; the  pupils
 become dilated, the face more injected,  the eyes fixed, and the patient loses
 consciousness.
   During the attack, the  face is swollen, of a dark  red or violet color, and
 distorted by spasmodic contractions ; the eyes are agitated, the tongue pro-
 truded, and the under jaw repeatedly closed with  force, so as to wound the
 tongue.   A quantity of froth  is ejected from the mouth, which is  generally
 drawn  more to  one side of  the face than the other.   The  muscles  of the
 body are thrown  into violent and irregular action;  the  limbs are jerked in
 all directions, and with  such  force that it  is sometimes difficult to keep the
 patient  in bed.   The  respiration  is at first  irregular, and being  forced
 through the closed teeth and the foam  at  the  mouth, has a peculiar  hissing
 sound ;  it subsequently becomes nearly  suspended.   The pulse is quick, and,
 at the beginning, full and hard, but afterwards small and almost impercep-
 tible.   The body participates  in the purple color  of the face.  The urine
 and faeces are often passed involuntarily.   This terrible paroxysm,  however,
 is not of very long duration.    After a  period varying  from  five minutes to
 half an hour, the convulsive  movements become less violent, and gradually
 subside;  the countenance is  less distorted, and assumes  a  more natural and
 placid appearance ;  the eyelids close, the respiration becomes more regular,
 though still sibilant, and the  circulation is  restored,  the pulse becoming more
 perceptible, though  still very quick ; the patient rests  quietly in  bed, and
 the paroxysm has terminated for the time.
   During the interval, the  patient's condition is very variable.   She may
 partially recover consciousness, so as to recognize  persons around her, and
 to be aware of something extraordinary having happened, without knowing
 what,  and without being able to express herself clearly.  In  other  cases, the
 return  of intelligence (but without  recollection) may be complete  until the
 approach of the next fit, accompanied with great  weakness, headache, and
 coufusion.  These are  the more favorable cases.   Others, again,  remain in
i Comm. by Lanzoni, Ephem. Germ., dec. ii. an. 10, p, 160. 
474                         CONVULSIONS.
a state of total insensibility, almost  approaching to coma or asphyxia, with
sibilant or stertorous  breathing, and  without muscular motion, or  with a
restless throwing about of the body and extremities.  This calm is,  however,
of no very long duration ; it may be half an hour, or two hours, but sooner
or later  the  paroxysms return, to  be succeeded by an interval which in its
turn gives place to a paroxysm.  I  have known as many as eighteen  parox-
ysms occur in twenty-four hours.
   701. The urine,  as  I have already mentioned, is in the large majority of
women, albuminous.  Dr. Lever remarks, "I have carefully examined the
urine in every case  of puerperal convulsions that has since come under my
notice, both in the  Lying-in Charity of Guy's Hospital and in private prac-
tice, and in every case but one, the urine has been found albuminous at the
time of the convulsions."  And this has been confirmed by Simpson,  Sabatier,
Legroux, Richelot, Blot, Mascarrot, Braun,  and others.  More recent re-
searches have thrown a good deal of light upon the occurrence of this renal
affection.   De Yilliers and Regnault1 observed it as early as the sixth month;
Litzmann not till the eighth.   The  most characteristic  symptom is  dropsy
of the hands, arms,  and face; but dropsy  does not necessarily  co-exist.
" The quantity of albumen is usually very conspicuous, and increases as the
time of delivery approaches.  In proportion to the intensity and duration
of the morbid process in the  kidneys, are found casts of the uriniferous tubes
in greater or less quantity,  the  epithelium lining  them being sometimes
normal, sometimes in  a state of fatty degeneration.   In  the milder cases,
the tube casts are  often found just  at delivery, or soon after.  Careful ex-
amination will probably, in all cases, detect a not inconsiderable diminution
of the urine."2   Dr. Cormack and  Dr. Litzmann  attribute the  albumen to
mechanical  pressure  upon the  kidney,  by the  enlarged  uterus producing
congestion of that  organ, and they adduce  as an argument  the greater fre-
quency of albuminuria  in primiparae.  Neither regard it as the consequence
of granular  degeneration ;  and certainly,  the temporary character of the
phenomenon is not consistent with structural disease.  Dr. Seyfert attributes
it to the disturbance of respiration  and circulation.   According to  most
observers, the  albumen disappears  within  a short time ;  often forty-eight
hours after delivery.
   The termination of  the attack varies in different patients; some remain
in a state of  half-stupor and great exhaustion for hours or days, and gradu-
ally recover.   Other patients become  maniacal, and  may even remain so for
a long time, and ultimately  recover.  I had a  patient who  remained in a
state of mental derangement for several  months before she was restored to
health.  In a few cases the patient continues comatose, and gradually passes
into a state resembling apoplexy, and dies.
   It is not always, however, that the  recovery is complete.   Sometimes the
patient lies apoplectic, or in a state analogous ;  or she  is deaf, or blind, or
incapable of speaking,  or both ; or  the  limbs  are paralyzed.  In  fine, it
seems as if the sensorium had received  some permanent injury, the corres-
ponding  parts of the body suffering in consequence.3   Cases of partial or
complete paralysis  are  recorded by  Lever,  Simpson, and others, as a termi-
nation of convulsions.4
   702. I have already mentioned that convulsions  may attack the  patients
either during pregnancy, at the time  of parturition, or after delivery.
   It will  be  necessary to say a few words  upon  its occurrence  at each of
these periods.
   703. Pregnant  women  are  more  especially  obnoxious to this  disease

  1 Arch. Ge'n. de Me'd. 1848. Recherches sur les  Hydropisies chez les femmes enceintes.
  2 Association Journal. Jan. 21st, 1853. p.  64.        3 Blundell's Obstetricy, p. 638.
  * Churchill's Dis. of Women.  Chap. Paralysis in Childbed. 
CONVULSIONS.
475
during the latter two months of gestation, though it may occur at an earlier
period, and at irregular  intervals.  The nearer the patient is to her con-
finement, the greater the  risk of an attack, on  account of the  extreme dis-
tention of the uterus, and its increased irritability.
  Although the beginning of labor may not be detected,  either by an
internal or external examination at the  outset  of these attacks, yet during
its continuance labour may commence and run  a natural course.  In such a
case, the fits will be found synchronous with uterine  contractions, though not
recurring with each.
  In many  cases, however, the  uterus remains  perfectly quiescent, and  ges-
tation may  be carried on  for a time longer.   In almost all cases the child is
still-born, often putrid ;  but whether its death  preceded the convulsions, or
resulted from them, is not easily determined.   When  the former is the case,
may we not attribute the convulsions to the  dead child acting in some  sort
as a foreign body?  Dr. Ramsbotham  observes, "When the result proves
thus satisfactory, the convulsions seldom return ; but the woman rarely com-
pletes her full period of gestation.   The process  of labor commonly com-
mences within the space of a few days ; sometimes within that of twenty-four
hours.  Its progress is as regular and natural as if no previous derangement
had taken place ; but the child is too frequently still-born, and occasionally
shows marks of approaching putrefaction."1
   [Instances occur of convulsions  happening at each  succeeding pregnancy,
and persisting until abortion takes place.  This is one of the greatest afflic-
tions that  can  befall the  married  female.   "I have witnessed," says Dr.
 Huston, in a note  to a former edition, "the attack twice  in  the same lady,
 with only an interval of  three months, both times terminating, as remarked,
in abortion.  She  was a remarkably  delicate woman, of great nervous im-
 pressibility.  During the attacks she had  no frothing  at the mouth, nor
 stertorous  breathing, but  after recovery, was unconscious of all that had
 passed.  She was  bled freely at the  commencement of the first attack, be-
 cause of pain in  the head,  and had a tedious recovery; the  next time,
 she was put under the  use of excitants,— sinapisms, wine whey, camphor,
 morphia, etc.,—and recovered  rapidly.   The symptoms were very similar in
 both attacks : as the more prominent of the convulsive phenomena subsided,
 those of a  hysterical character, such as  crying, laughing, etc., became more
 prominent."]
   The labor runs  a natural course generally, and in a fair proportion of
 cases the mother recovers tolerably well, though there  are startling excep-
 tions, as in the following instance : " A lady,  in the  end  of her pregnancy,
 was seized with convulsions;  her attendant was sent for,  and decided that
 there was  no indication of labor, and  that a stay was unnecessary.   The
 midwife left  the  house,  and  returning early the following morning,  the
 patient was found  dead ; the child, too, the birth of  which no one seems to
 have suspected,  lay lifeless beneath the clothes."2
   When convulsions occur at the  commencement of labor, it might naturally
 be attributed, in some cases at least,  to  mal-presentation of the child ; but
 this is not  the case.  Mal-presentation is  observed very rarely in  cases of
convulsions.
   704.  During labor, the return  of the paroxysm takes  place at  the com-
mencement  of  a labor  pain, although not with  every pain.   There is  a
greater expression of suffering from  the uterine contraction than  from the
convulsion.   The  symptoms  I have  described appear to be  more intense
when the attack comes on  during labor  than during gestation.   The uterine
contractions do not appear to  be  impeded  by the  fits ; the  labor generally
             i Ramsbotham, Pract. Obs. in Midwifery, p. 641, note.
             2 Blundell's  Obstetricy, p. 641, note. 
476
CONVULSIONS.
runs a natural course in the usual time, if not terminated by art;  neither is
it necessarily fatal to the infant, although there is great danger.
  It is remarkable, and not easily explicable, that after the convulsions have
ceased, and the labor is over, there is a great  tendency to abdominal in-
flammation, adding  fearfully to the mother's risk.   Denman, I believe, was
the first to point out this fact, which Dr. Collins and others have confirmed;
and  which should be remembered in the treatment.
  705.  When  the  patient  is attacked by convulsions after delivery,  they
generally occur  from two to four hours  after the birth of the child, some-
times  later.   There  can be little hesitation  in  attributing them to some
injury received  by the  brain  or nervous system during labor, though we
may not be able to specify the particular mischief.   It  does not, however,
depend upon the length or difficulty of the labor; they  occur as  frequently
after natural labor.
  The loss of blood at the time  of delivery does  not necessarily  prevent
the  occurrence  of  the  fit, though  it adds to the danger by the  debility it
occasions.
  Duges  considers cases of convulsions after delivery to be more tractable
than any others, whilst Dr. Ramsbotham  states exactly the contrary.  I
should say that the cases where  the  convulsions occur during labor, and
continue  afterwards, are the least manageable;  next to these  the attack
during labor only ; then, those after delivery ;  and lastly,  the  most favor-
able are those which occur during gestation.
  After recovery from the consequences of the  attack, the patient  may
enjoy her usual health, and her subsequent pregnancies do not appear to
be very liable to similar attacks.
   706. Morbid  Anatomy.—In the majority of cases,  a post-mortem ex-
amination affords  but little information.   In many  instances there is no
deviation whatever from the healthy state of the  brain,1 in others, according
to Braun, we  find anemia, oedema, and diminished consistence.   Sometimes
the vessels of the brain are turgid with blood ;  and in other cases there is
a quantity of serum effused  on the surface and base of the brain, or into the
ventricles.  The heart  is generally flaccid  and  empty, and  the  lungs  of a
pale color.   Some fluid is occasionally found in  the pleura,  or pericardium.
Traces of inflammation have also  been discovered in the peritoneum.   In a
few cases the  spleen is unusually large  and the kidneys congested.   Dr.
Braun states  that  they may exhibit one  or other stage  of the three forms
of  Bright's disease.   He has given  a very minute account of the appear-
ance to be observed, but it is too long for insertion, and 1 must refer the
reader to his work.
   707. Diagnosis. —1. From hysteric convulsions.—In the attack I  have
just described, there is  a total loss of consciousness,  great muscular action,
frothing  at the  mouth,  frequent recurrence of  paroxysms,  and  incomplete
restoration or total insensibility during the intervals.  In  hysteric convul-
sions, on the contrary, the patient scarcely loses  consciousness, exhibits only
moderate spasmodic action, has no frothing at the mouth, does not  suffer from
a frequent recurrence of the fits, and recovers shortly  after each.   The sob-
bing,  sighing, weeping, and screaming of the hysteric convulsions  are  also
peculiar to it.
  2.  From apoplectic  convulsions. — In epileptic convulsions,  the whole
body is thrown into violent spasms, which are  repeated, with  intervals of
quiescence, and often of partial return  of  sense.  The  breathing is rather
sibilant than stertorous, and the muscles preserve their tone  even  during the

  1  Bouteilleux, Thesis, Paris, 1816.  La Chapelle, Traite" des Accouch., vol. iii. p. 23.
Cruveilhier, Distribution des Prix a  la Maternity, Paris, 1hJ8,  p. 31.   Baudelocque,
Thesis, p. 65.  Ciniselli, Ann. Univ. di Med., vol. lxix. p. 472. 
CONVULSIONS.
477
intervals ;  whereas in apopletic convulsions, the spasmodic movements occur
at the commencement, and are not repeated ;  sense and sensibility are totally
lost,  the breathing is stertorous, and the muscles lose all power, so that the
arm when  raised, and allowed to fall, does so like that of a person recently
dead.
  708. Prognosis.—On  the whole, the  mortality is  considerable, though
probably much less so than formerly.  Jacob states that in his time scarcely
any survived.   Dr. Parr, in his Medical Dictionary, that six or seven out of
ten die.  Dr. Hunter, that the  greater proportion were lost.   And we have
found that about one in four  and a half are lost.
   709. Treatment.—The division of convulsions into sthenic and asthenic
is of great value as regards the treatment.  When the  patient is pale, exsan-
guined, and weak, it is clear  that much caution must be used in  abstracting
blood.  Of  course it may be advisable, but our main reliance must be upon
counter-irritation to the head and neck, cold  in moderation, calomel, opium,
and, I believe, upon anaesthetics.   In the sthenic form,  when the head is hot,
the face flushed, and the pulse full, firm,  and frequent, as soon  as possible
after the convulsion, the  first thing to  be done is to take away blood from
the arm or temporal artery, largely, and in a  full stream.   If the paroxysms
continue, this may be repeated.   Denman took  forty ounces and  Blundell
seventy ounces  of blood from a patient under these circumstances.  We are
not to be  deterred from a free use of the lancet by the  absence of immediate
relief—the benefit is rather in the  ultimate and early recovery of the patient,
than  in the  immediate arrest of the  paroxysms.   " The  quantity likely to
suffice for the relief of a case of only threatened convulsions might amount
to between twenty and thirty ounces; but if the convulsions  are supposed to
have been long established, or to have taken place very suddenly, the prac-
titioner would have to take away perhaps thirty or forty ounces of blood, or
even fifty, in cases of great intensity of the symptoms.  The rule should be,
that the pulse must be  reduced into a state  of mellowness and softness be-
fore  the arm is  allowed to be tied up.  In a few extreme cases, in which the
author has from time to time been consulted, he has considered it necessary
to order a second bleeding, after the lapse of two or three hours subsequently
to the former one.  But  he has never, that  he recollects, recommended for
the second bleeding the abstraction of more  than fifteen ounces  of blood."1
Another good  effect  from venesection  is the prevention  of the  abdominal
inflammation, to which we have seen that the patient is exposed subsequently.
If there be  any objection  to repeating the venesection, leeches may be ap-
plied ; or  if the patient  be sufficiently quiet, the nape of the neck may be
cupped.   Dr. Braun is strongly opposed  to  bleeding  in  anaemic eclampsia,
as not only having no good effect, but as  producing  irreparable injury.
   [There  can  be no doubt that, under the  circumstances described by Dr.
Churchill, the employment of blood-letting to an extent sufficient to produce
a decided  effect upon the pulse, is strongly indicated in the  commencement
of the attack of puerperal convulsions.   It acts beneficially  by relieving the
surcharged condition of the cerebral vessels,  moderating the severity  of the
pressure to which they are subjected during the convulsive  paroxysm, and
thus diminishing the danger of rupture  and  effusion; it, also, removes the
counter pressure from the medulla oblongata.   While, however, blood-letting
is often a  sufficient remedy for simple convulsions depending upon a  turgid
condition  of the blood vessels  of  the brain  and  of the medulla oblongata
and  spinalis, no little judgment  and discrimination are  required,  not only
to keep it within safe bounds  in  the cases  in which  it is indicated,  but to
detect those circumstances under which  it will be more likely  to prove  injuri-

                  1 Davis's Obstetric Medicine, vol. ii. p.  1027. 
478
CONVULSIONS.
ous than beneficial.   In cases of puerperal convulsions occurring in delicate
anaemic females, no matter what may be  the character of the symptoms by
which they are attended, blood-letting—even one copious bleeding, but espe-
cially repeated bleedings—would tend to  rather augment than to relieve the
frequency and violence of the paroxysms.   With the great majority of prac-
titioners, in the management of puerperal convulsions, as has been properly
remarked by  Dr.  C.  A.  Lindsley,1 to bleed is  the rule, absolute  and im-
perative — no  matter what is  the condition of the patient.   No  effort ia
directed to  discover  any existing cause  of spinal  irritation and to resort
to the appropriate means for its removal — whether indigestible food in the
stomach, unaccumulation of hardened fieces in the bowels, or of urine in the
bladder.  The condition  of  the uterus and  the state of the vascular system
and its  contents are alike overlooked.   The rule is absolute—to bleed boldly
and fearlessly.   Such rank and rash empiricism is altogether inexcusable —
under its  influence it is very certain that blood-letting  has been practised
under circumstances where  it  should  have been entirely avoided, and  that,
in cases where within proper limits it was called for, it  has been carried to a
most injurious excess.
   "It   would  appear," Dr.  Lindsley remarks,2 "that  after  the  circula-
tion is reduced,  either by  proper  depletion, or  from any other cause,
to somewhat below par, blood-letting acts no longer as a sedative, but be-
comes itself a most certain irritant of the  spinal marrow.  The continuance
of convulsions, therefore, is not a reliable  indication for further bleeding; but
the state of the circulation in the interval of the fits, is the only proper crite-
rion, regard being had to the different effects of an engorged and an empty
state of the spinal vessels."]
   A strong purgative (calomel and jalap, for example) should  next be ad-
ministered, as from the free evacuation of the bowels great benefit is gene-
rally derived;  and it  may also excite  uterine contractions, and hasten the
delivery.
   [Numerous observations, as is well remarked by  Dr. Lindsley,3 attest the
fact that large accumulations in the stomach or intestines, whether of food,
of faeces, or the presence of worms or of  foreign bodies,  may excite convul-
sions in the puerperal female in  consequence of the irritation  they induce
being transmitted to the central organ by reflex action.  Whenever, there-
fore, such offending matters are found to exist, their prompt  removal is obvi-
ously demanded.   But the manner in which this is done is important.  There
can be but little difference between irritating drugs and irritating faeces, and yet
the most drastic purgatives are often administered, with the effect too often of
only thus changing one cause of irritation for another.  It is but fair to pre-
sume that copious injections of water simply, would be quite  as effectual, and
vastly  safer, inasmuch as they are  more rapid  in their effect, and leave
nothing to  irritate the intestine  after their mission is accomplished.   If
necessary, their action may be assisted by the addition of castor oil or tur-
pentine.  If an overloaded stomach  or undigested food is  suspected to be
the cause of the convulsive paroxysms, an emetic of sulphate of zinc should
be administered.  If the patient, however, is plethoric, venesection should
always  precede the  emetic, to  guard against any injury from the increased
distension of the cerebral vessels during the  act of vomiting.
   Mr. Vines mentions  an instance of  puerperal convulsions in which, after
resisting for two days all the  usual remedies, including the delivery of the
child, the paroxysms ceased immediately upon withdrawing from the bladder
five and a half pints  of turbid and highly  ammoniacal urine.  This case

    1 [Proceedings Connecticut Medical Society, A. D. 1858.1        2 [Loc. citat.]
    » [Op. citat.] 
CONVULSIONS.
479
shows the necessity of attention to that condition  of the urinary bladder in
all cases of eclampsia.]
  The head may then be shaved, and cold lotion or ice applied.   Denman1
speaks highly of cold affusion.   He says,  "On a patient in convulsions who
had been bled, and for whom many other  means had been fruitlessly used, I
determined to try the effect of cold water.   I sat down  by the bed-side, with
a large basin before me, and  a bunch of  feathers.   She had a writhing of
the body, and other indications  of pain, evidently occasioned by the action
of the uterus before the convulsions;  and when these came on, I dashed the
cold water in her face repeatedly, and prevented the convulsions.   The effect
was astonishing to the  bystanders, and indeed to myself.  On the return of
the indications of  pain, I renewed the use of the cold water with equal suc-
cess ;  and proceeded in  this manner until the patient  was delivered, which
she was without any more convulsions, except once when  the water  was
neglected.
   [Dr. Lindsley,2  also, suggests the  application of cold water to the head.
Applied in a continued stream, it is adapted to lessen the distended state of
the cerebral blood vessels, and  thus  relieve the counter pressure upon the
medulla oblongata.  In the form of douche it would tend to excite an inspira-
tion, and thus dilate the glottis.  When the cold water is applied along the
spine it should be  continuous — the intermittent application  excites instead
of allaying irritation.]
   A warm bath has been recommended,  but besides that its value is doubt-
ful, it would in most cases be  very difficult to administer it.
   After the lapse of some time, the head and nape of the neck may be covered
with blistering plaster, as counter-irritation will materially further the restora-
tion of the patient.
   When, after copious bleeding and purging, the attack is somewhat  subsi-
ding, it has been  recommended to give an opiate.   Considerable difference
of opinion  has existed upon this point, owing, I think, to the different parties
not specifying with sufficient accuracy the time at which it  should be admin-
istered, and the cases suitable for it.   Under the circumstances I have men-
tioned, it  seems to be the opinion of the highest authorities that it may be
 of service.  Dr. Collins remarks, " Many of our best writers  have actually
condemned the use of opium in convulsions, stating it to be most injurious —
some even  destructive.   Ample experience has convinced  me that it  is not
 only harmless, but  highly beneficial  in those cases  where  the fits continue
after delivery.  And  I should hope the cases adduced will  prove  satisfac-
torily that it is also useful under many  other circumstances, when proper
steps had  been previously taken.   Its  combination with tartar  emetic, and
 and occasionally with calomel, is most advantageous."  Calomel, given so as
to affect the constitution, has  been  found beneficial.   Dr.  Collins speaks
very highly of tartar emetic with opium, in doses sufficient to produce nausea,
but not vomiting.  " In every severe case of convulsions,  after having car-
ried into  effect the ordinary mode of  treatment, as bleeding freely,  acting
briskly on the bowels with calomel and jalap, and at the same time adopting
the means  usually had  recourse to for protecting the  patient  during  a pa-
roxysm I  endeavored  to bring her under the influence of tartar emetic, so
as to nauseate effectually, without vomiting.  With this view, a tablespoon-
ful of the following mixture was given every half-hour  :—
                         Aquas Pulegii, gviij.
                         Tartar Emetici, gr. viij.
                         Tinct. Opii.  gtt. xxx.
                         Syr.  Simpl. 3ij.
                                              M.
           i Midwifery, p. 435.                        2 [Op. citat.] 
480
CONVULSIONS.
  " In some cases  the quantity of tartar emetic used was  only four graina
to an eight-ounce mixture ; and in others, the quantity of opium  was some-
what increased."
  It will be necessary to insert a  wedge  of leather  or wood  between the
teeth, to prevent injury to the tongue, and also to remove everything out of
the way, by striking against which the patient might hurt  herself.  [A roll
of linen or muslin answers as well as leather, and is much better than wood ;
besides, it is always to be  obtained at the moment  when  wanted.]   This
treatment applies equally to  convulsions  occurring before, during, or  after
labor — except that in the latter case venesection must depend on the state
of the patient.
  710.  Very recently  it has been  proposed to administer anassthetics, so as
to produce insensibility, in  hopes,  at the same time, of  calming the convul-
sions ; and certainly so far as we can  fairly judge  from  the  cases on record,
it appears  a most  valuable  and successful remedy.  Dr. W.  Channing, of
Boston, U.  S., has  used ether in ten cases ;  six mothers recovered and three
children, a larger proportion than when ether was not  used.1   Mr. Turner,
of Mansfield, administered chloroform in a case of convulsion after delivery,
with perfect  success.   When given on the approach of  a fit, it arrested it at
once.  The patient recovered.2  Dr. Keith gave it in convulsions occurring
during pregnancy.   It quieted the fits, and when labor came on, the patient
was  placed completely under its influence, and kept so until delivery.   She
recovered well, and with no recurrence of the attacks.3  In  a case related by
Mr.  Morris it was equally beneficial.4   In a case which  occurred at Gosport,
the inhalation was  continued for three hours, after the patient had had thirty-
three fits, and the success was complete.5  Dr. Shekleton, the late master  of the
Dublin  Lying-in Hospital, has tried it in  nine cases ; in five the convulsions
were completely  arrested, and in four they were  lessened  in  intensity  and
frequency.6   Mr. Bolton  had  recourse  to it after  bleeding and opium  had
failed, and with great success.7  I have tried it in several  cases with  great
benefit.   Dr. Braun tried it  in  sixteen cases, all  of which recovered  com-
pletely.
  711.  The next important  question  is,  whether we are to interfere with
the progress of gestation or parturition.
  I  believe it is the general opinion,  that, until labor sets in naturally, inter-
ference  would be injurious ; so that in convulsions during gestation, we have
nothing to do  with the uterus, but must  confine ourselves  to the treatment
of the convulsive disease, and it is more especially useful if we have to de-
liver artificially.
  If the attack take place at the  commencement  of the  labor, some practi-
tioners have been anxious to hasten the operations of nature by manual dila-
tation ;  but this has been abandoned, and very properly, as likely to increase
the convulsions, without  advancing the progress  of  delivery.8  Belladonna
has  been applied  to  the cervix uteri, for the purpose of  dilatation, but I
should doubt its utility, and dread  its poisonous effects.9  The older writers,
with some moderns, have proposed incision of the cervix, but the  risk  would
outbalance any benefit to be derived  from so " heroic "  a remedy..   But sup-
posing  the  os uteri to be dilated or dilatable, are  we then to proceed  to de-
liver by art ?  This question has been much debated, and opposite opinions
have been advocated.   Some advise  instant interference,  and others no  in-
terference at all.10  The true plan seems to be to avoid  both extremes.   We

  1 On Etherization in Midwifery, pp.307, 330.  2 Lancet, Jan. 12th,  1850, p. 53.
  3 Ed. Monthly Journal, Aug. 1850.         *Ibid., May 1849, p. 767.
  5 Med. Times, March 23d, 1850, p. 229.      6 Dublin Jour, of Med., Aug. 1852, p. 100.
  i Lancet, Jan. 29th,  1852, p. 108.          8Denman's  Introd. to Midwifery, p. 430.
  9BluudeH's Obstetricy, p. 950, note.        10 Denman's Introduction, p. 425. 
CONVULSIONS.
481
are not necessarily to interfere at this  stage of the labor, beyond rupturing
the membranes, which sometimes hastens the progress of the labor.  Version,
or turning, has been often recommended, but, from all the cases I have seen or
collected, it  would  appear a  most hazardous measure.  Dr. Ramsbotham
advises it, and yet the three cases he relates in which he practised it, proved
fatal.   Five  patients out of seven are generally lost. Dr.  Collins is strongly
opposed  to  it.   We may therefore conclude  that version is not to be at-
tempted,  unless it should be proved that chloroform will secure the patient
from a recurrence of the convulsions on the introduction of the hand.
  But when the head has descended into the pelvis, so  as to  be within reach
of the forceps, and  there is sufficient  space,  it will be proper to  apply that
instrument, inasmuch as delivery, when it can be  accomplished, is essential.
The attempt must be made during an  interval between the  paroxysms, and
under chloroform, but should the introduction  of the blades bring on a violent
fit,  it  will be necessary to withdraw them, lest they should be forced through
the vaginal  or uterine  parietes during  the struggles of the patient.
   Dr. Braun considers that  craniotomy is never to be practised in convul-
 sions  without there be  disproportion.   In this I cannot agree with him.   If
 the os uteri be dilatable, the  pains feeble, and  the convulsions very severe,
 we cannot hope that the mother will escape after many hours of such suffer-
 ing, whereas we know that her best chance is delivery.   We dare not  turn,
 but we can  craniotomize the  child, and deliver, and if the  child should be
 dead, it will be our duty to do so.  Even if it be not, as forty-five per cent.
 are lost,  it will be a question  whether  in  neglecting to deliver  for the sake
 of  affording the child  this bare chance  of life, we do not thereby sacrifice
 the mother.  In the worst case of convulsions  I ever saw, to which I was
 called some time ago,  I had no hesitation.   The fits  occurred with the first
 pains, were often repeated, the  patient was comatose  and insensible, the os
 uteri dilated to the size of a crown  piece in twelve hours.  I felt that the
 patient would probably die before the completion of  labor  naturally, and I
 therefore perforated and  extracted the child (under  chloroform), and  the
 patient recovered, after an insensibility  lasting  nearly three  days.   More-
 over, if the child be dead at any period of labor at which we may be called,
 craniotomy affords the most  speedy  means  of delivery.  And  lastly, when
 the head is in  the pelvis, if the space is too small for the  forceps to be
 applied, as  the child  cannot be saved, we ought to have  recourse to this
 operation, as soon as we are satisfied  of the state of the case.
   After the convulsions have  ceased, Dr.  Collins remarks:  " Should  the
 patient  become  maniacal, as is occasionally the result when the fits have
 been  severe, and have  continued  for any length of time after delivery, all
 local  distress, as pain  in the head,  or  any symptom that would indicate
 abdominal  complication, should be diligently looked after,  and  treated ac-
 cordingly :  as by so doing, keeping  her fully under the influence of tartar
 emetic" at  the  same time acting  well on the  bowels, and excluding light
 from her room, as also  all other external irritants, the  best results may be
 expected.    It is a great satisfaction to the friends  of the patient in such a
 situation to be  assured that there is little liability to a return of this derange-
  ment of mind, as is the case in most other forms of mania."
    712.  Prophylactic Treatment.—When we  are consulted by a patient
 during  pregnancy  who presents any of the threatening  symptoms before
 noticed, such as headache, giddiness,  occasional  blindness or double vision,
 and  especially  if  these be combined with  anasarca  of the face and other
 extremities, and with albuminuria, there can be no doubt that active meas-
 ures are required.  Brisk purgatives, with venesection, or cupping the loins,
 if suitable and the patient can bear it, should be  adopted, with  smaU doses
 of tartar emetic or diaphoretics, moderate exercise, and  a regulated diet
        31 
482
CONVULSIONS.
  All pressure should be removed, the lungs be allowed full play, and, if we
believe, with Dr.  Cormack, that the pressure of the gravid uterus upon the
kidneys causes  the albuminuria, then  the  patient should  avoid  the supine
position as much  as possible.
  On the  other hand, these symptoms may accompany an impoverished state
of the blood, and the patient will require a good diet, with tonics.  Cold or
counter-irritation to the head  may, at the same time, be  necessary.   Both
Frerichs and Litzmann state that they have found benefit  from benzoic and
acetic acid.   If the renal disease have  existed  for some time, our treatment
must be less active :  cold and counter-irritation, with gentle  purgatives and
acids.   Diuretics are to be  avoided, but  counter-irritants to the  loins, by
means of mustard poultices, will be useful.
  When convulsions  occur before labor sets in, we are advised by Chailly,
Pietra Santa, Sabatier, Braun, and Daniel, to bring on  premature labor,
and M. Bouchacourt, of Lyons, succeeded  once in this way.   MM. Legroux
and Richelot doubt the propriety of this,  and I agree with them; inasmuch
as labor, when it comes on, is  not necessarily accompanied by a recurrence
of convulsions, especially if some time  has  elapsed since the attack.

  713.  3. Apoplectic  Convulsions.—This variety seldom or never occurs,
except towards the termination or after the conclusion of labor.  Dr, Burns,1
indeed, mentions  its occurrence at the commencement of labor, and  MM.
Morithon2 and Menard3 at the sixth month of pregnancy.
  Causes.—It is evidently caused by the stress upon the cerebral vessels
during the labor  pains.
  It is very probable that anxiety of mind  may predispose  to the  attack; at
least in one case  I saw this appeared to be the case.
  714.  Symptoms.—In many cases the patient suffers from pain  and throb-
bing in the head for some days  previously ;  but in  others  there are no pre-
monitory  symptoms.
  Generally speaking, during the labor the patient complains of  headache;
and during the second stage the face may  be observed to  be much  flushed,
and the eyes injected.
  Strictly speaking, there is but little  convulsion ; the body and  extremities
are agitated or thrown about for a short time,  and then the patient lies in a
comatose  state.   There is little or no distortion of the face, and no frothing
at the mouth.  The muscles  become flaccid and  powerless;  the  respiration
is stertorous ; there is no return of intelligence, and rarely any repetition of
the paroxysm, though such cases have  been recorded.  The pulse is full and
slow, and the pupils in some  cases dilated, in others contracted, but in all
insensible to light.
  In almost all  cases the condition of the patient remains unaltered until
death; but there are  a few cases, answering, I presume, to the congestive
apoplexy  of Abercrombie and Lallemand, where our  timely aid is successful,
aud the patient recovers sense  and motion  ; and, if proper care be taken, is
speedily well.
  I do not  know that I can give a better illustration of this disease than by
relating the two  following cases.  For the first I was indebted to my friend,
the late Dr. Aston ; it appears to be  a simple case  of apoplexy from con-
gestion :  the second occurred in the practice of a dispensary to which  I was
attached.    I quote  them from a report I published some years ago in the
Medical Gazette  : " Catherine Costello, aged eighteen years and nine months,
of low stature and corpulent figure, complained first of severe headache on
Wednesday, January 2d,  1833.  The pain was more violent than any of

  1 Midwifery, p. 527.     " Trans. MeU, vol. v. p. 162.     » Ibid., vol.  iv. p.  241. 
convulsions.
483
the kind she had ever experienced.  Sickness of the stomach set in nearly
at the same time, and she continued throwing up green bilious matter during
the entire day;  the bowels were confined for four days ;  the face and  ex-
tremities were  much swelled, which commenced two  days before, and con-
tinued  gradually to increase as the headache  became more intense.   She
wanted about seven weeks to complete the usual term of utero-gestation.   I
[Dr. Aston] was sent for in the evening; she was walking about the  room,
but suffered most acutely;  the face was  swelled to such a degree as almost
to hide the eyes, and her speech was somewhat thick.   The motion of  the
child had  not been felt all  day.   As  she had an objection to bleeding, I
omitted it for the present, and directed some opening  medicine to relieve
the bowels;  and having given  the requisite  directions, I left her; but in a
few hours  her husband came for me in all haste, requesting my immediate
attendance,  as  she had had a  fit, and appeared to be  in a dying  state.
Upon further inquiry, I was told that the pain in the head got much worse,
when suddenly the eyes  became fixed, the face distorted, convulsive  motions
ensued, and ended  with  stertor,  which must have been of short continuance,
as no  such symptoms existed when I visited her a short time  afterwards,
although she was unconscious of anything that  happened until  after vene-
section, which I immediately performed to the extent of eighteen or nineteen
ounces, from which she  experienced almost instantaneous relief.   The heat
of skin was much  greater than natural;  thirst  extremely  urgent;  pulse
pretty frequent, but  inclined  to  hardness;  after  venesection  it became
quicker; shortly after,  slower and softer, until  it gradually came down to
the natural standard.   From this  time  all the symptoms subsided, and she
was delivered January 5th, and recovered well."
   " Mary----, set. 30,  was attended in her  first confinement by a pupil of
the Wellesley Dispensary,  on Monday,  November 20th,  1832.   The  labor
was natural, and terminated within the usual period.   She complained  of
 severe headache during  her labor,  and seemed sleepy towards the conclusion.
 After  asking some question of the attendants, she  settled  to sleep; some
irregular motions of the limbs were noticed by those in the room,  but nothing
further, until her breathiug became loud and  heavy, when, as they could not
 rouse her, I was sent for.   I found her perfectly insensible ; pupils fixed  and
 contracted ; breathing stertorous ;  heat of head but little increased ;  abdo-
 men distended  with flatus  ; muscles perfectly flaccid ; pulse firm, and  tol-
 erably full.  The usual  remedies were tried, but unsuccessfully, and she died
 during the night.   A post-mortem examination was permitted, and we found
 great  effusion of blood, filling  both ventricles.   A  quantity of serum also
was found at the base of the skull.  On further inquiry,  I learned that she
had been the victim of  seduction and desertion, and that she had suffered
from depression of spirits  and  severe headaches for  some weeks before her
 confinement."
   715. Pathology.—The brain may be found  greatly congested, but with-
 out  any effusion ;  but this  I believe to be rare.
   There may be great  effusion  of serum, which by  its pressure will  cause
 symptoms of apoplexy.
   More frequently, blood is poured out  into the ventricles, into the substance
 of the  brain, or at its base.
   Cases of this kind have been noticed by Denman, Targioni, Marchais,
 Lachapelle, Leloutre, Schedel,  Yelpeau, etc.
   716. Diagnosis.—The entire and persistent  insensibility, the absence of
repeated paroxysms with their accompanying symptoms, will at  once enable
us to distinguish apoplectic from epileptic or hysteric convulsions.
   It is not easv to distinguish  that form which  arises from congestion from 
484
lacerations of the
that caused by effusion, the chief  difference  being in the  intensity of the
symptoms.
  717.  Treatment. — The most active antiphlogistic measures should be
instantly put into requisition ;  a large quantity of blood should be taken
from  the  arm, jugular vein, or temporal  artery, and repeated if necessary.
This is  the more  requisite, as it is from the effect of bloodletting that we are
mainly to look  for the distinction between  apoplexy from congestion, and
apoplexy  from  effusion.   If no relief whatever be afforded, the case may be
regarded  as nearly hopeless ;  but if the patient be at all benefited, the head
should then be shaved, and ice applied.
  After.a short time a large blister may be applied to the head or neck, and
a brisk  purgative given.
  These remedies will generally afford relief in those cases which are susceptible
of it, and they may be modified or repeated  as circumstances  may require.
  Should this variety occur during labor, and the uterine action be suspended,
it will be desirable to deliver the patient as  speedily as possible, so as to
save the child ; and for this  purpose, if the head be within reach, the long
or short forceps should be applied.
                      CHAPTER XXII.

           PARTURITION. —CLASS III. COMPLEX  LABOR.
                      ORDER 5. LACERATIONS.

  7IS. Dnder this head  I propose to treat  of rupture of the uterus and va-
gina, vesico-vaginal and  recto-vaginal fistula, and laceration of the perineum.

  1.  Rupture of the uterus. — This  formidable  and very fatal accident
has long been known to  practitioners in  midwifery.1
  It is not,  however, confined to the  time of parturition  but, may occur
during gestation, or at a more advauced period of life.
  719. Statistics. —The following table  will  indicate the frequency of its
occurrence.
Authors.					Total No. of Cases.	Cases of Rupture.
Dr. Jos. Clarke......					10,387	8
Dr. Merriman .					2,947	1
Dr. M'Keever .					8,600	20
Dr. Collins					10.654	34
M. Pacaud					4.180	2
Dr. F. H. Ramsbotham .					68.435	13
Dr. Toogood					1,135	4
Mr. K. Watson					800	3
Drs. M'Clintock and Hardy					6,634	9
Drs. Johnston and Sinclair					13,748	17
  XI would recommend to the attentive perusal of the reader, a most valuable monograph
on this subject by Dr. J. D. Trask, Amer. Journ. of Med. Sciences, Jan. and April, 1848. 
UTERUS  and  vagina.
485
Making a total of 111 cases in 133,520 patients, or about 1 in 1203.
Dr. Burns says that it occurs about  once in 940 cases.
It rarely occurs with first children.
Of Dr. Jos. Clarke's cases —
       1 was the 2d pregnancy.
       1  "      3rd
	2 "	4th
	1 "	7th
	1 "	8th
	1 "	9th
Of Dr.	M'Keever's	cases —
	4 had 2	children.
	5 " 3	"
	4 " 6	"
	2 " 7	"
	2 " 8	"
	1 " 9	a
Of Dr.	Ramsbotham's cases—	
	2 were 2d pregnancies. 1 " 4th	
	3 " 7	th "
Of Dr.	Collins' 34	cases —
	7 were 1 6 " 2	*t pregnancies. nd
OfDi
Collin	s 34 cases —
6 were 3d pregnancies	
2	" 4th
2	' 5th "
5	" 6th
1	' 8th
1	" 9th
2	" 10th
2	" 11th
  Dr. Cathrall's case was a 1st pregnancy.1
  Dr. Simms' patient had had several chil-
dren.1
  Dr. Hooper's case was the 4th pregnancy.3
  Mr. Kite's,4    "    "   2d     "
  Dr. Frizells,5  "    "   7th     "
  Mr. Powell's,6 "    "   1st     "
  Mr. Birch's  cases were the 3d  and  4th
pregnancies.'
  Mr. Partridge's case was  the 7th preg-
nancy.8
  Thus, of 75 cases, 9 occurred in the first pregnancy;  14 in the 2d ;  13 in
the 3d ;  and  37  in the 4th or subsequent pregnancies.
  In Dr. Trask's collection  24 cases  occurred in the 1st pregnancy;  18 in
the 2d ;  17 in the 3d ;  21  in the 4th ;  18 in the 5th ;  16 in the 6th ;  9 in
the 7th ; 5 in the  8th ; 5 in the  9th ; 9 in the 10th ;  8 in the 11th ; 3  in
the 12th ;  2 in the  13th ; and several in the 17th.
  720. Causes.—Various causes may give rise to it, and it may happen at
different periods —
  1. During gestation. — That form of extra-uterine  pregnancy  which is
called interstitial fcetation may give rise to it.  The ovum, instead of passing
direct from the  fallopian tube into the uterine cavity, is retained in an in-
terstice  of  the uterine  fibres, where it grows up to a certain point.   As it
increases, the outer portion of the  uterine parietes becomes gradually thinner
by absorption (as in the case of  abscess), and at length  gives way,  and the
foetus is  precipitated into the abdomen, converting  the case into  one of
ventral foetation ;9 it  may also be  the  consequence of disease, as in Mr. Else's
and Dr. Spark's10 cases; from softening, and from  abscess in the  walls,  as
related by  Duparcque.11  Any violent accident, such  as  a fall or a blow,  or
great fatigue, may give rise  to it.   It sometimes occurs without any assign-
able cause; the patient, perhaps, is  awakened  from  sleep by it, as in the
cases related  by  Mr. Scott of Bromley,12 and Mr. Glen of Brompton.13  It has
been attributed to irregular  action of the uterine fibres.
  721. 2.  During  labor.—a. If the uterus have been attacked by inflamma-
tion  during pregnancy, its tissue  may have been so  much weakened or dis-
organized,  that the violent  contractions  which take place during labor may
rupture  it,  from the  want of consentaneous  action in the  part affected,  or
from the pressure  of some  part of the child against it.  Steidele  relates a
 'Mod Facts and Obs., vol. viii. p. 140.
 3 Mem. of  Med. Society, vol. ii. p. 118.
 5 Trans, of Association, vol. ii. p. 15.
 7 Ibid., vol. xiii. p. 357.
 9 Med. Gazette, vol. ii. p.  400.
11 Ruptures de l'Ute>us, pp. 15, 16.
13 Merriman's Synopsis —Appendix.
 L Ibid., p. 150.
 <Ihid., vol. iv. p. 253.
 6 Med.-Chir. Trans., vol. xii. p. 537.
 8 Ibid., vol. xix. p. 72.
10 Ibid., vol. ii. p. 218.
12 Med.  Repository, vol. vii. 
486
LACERATIONS  OF  TnE
case where rupture occurred in consequence of gangrene.1  My friend, Dr.
Murphy,2 has  published an excellent paper illustrative of this cause of rup-
ture,  with  cases  where the uterus was  atrophied, thinned, or softened  in
texture.  Duparcque quotes cases of thinning of the uterine walls, softening,
scirrhus, aud gangrene.  Dr. Trask states that of 49 cases in his collection,
where the condition of the  uterus was given, in 10 it was healthy ;  in 14 it
was thinned; in  14 softened; in 1 both thinned and softened; in 2 both
softened and thickened ;  in 1 thickened ; in 3 diseased.   In some cases the
seat of  the laceration corresponds exactly with the situation of the previous
pain.  Dr. Tyler Smith believes that in  many cases violent uterine action is
in itself the cause of rupture; the immediate cause being either emotion  or
volition, or a reflex or peristaltic action.
   The period of  labor at which  the rupture may occur from this cause will
vary ; it may be at the beginning, before the  rupture of the  membranes;
during the passage of the  head through the pelvis, or after the delivery.
   b.  A certain amount of narrowing of the upper outlet may give rise to  it.
This  is  a purely mechanical cause.  The head of the child is forced down-
wards by violent labor pains, but is  unable to enter the pelvis, from the con-
traction of the upper strait; now if the pains continue with great power, the
head is  turned to one side  or the other,  or posteriorly ;  and the only obsta-
cle here being the uterine or vaginal parietes, the head is driven through them
at the weakest part. They offer the less resistance, probably, from the woman
having  generally borne several children.  In one of Dr. Clark's cases, the
antero-posterior diameter of the upper outlet measured but 3 inches ; in two
others,  3^.   In case 18 of Dr. Douglas,  the pelvis measured but two inches
antero-posteriorly; and in another case  (20) there was a bony  ridge on the
top of the  symphysis  pubis, to which the rent corresponded.  In one of Dr.
Ramsbotham's cases the antero-posterior diameter was only  2  inches;  in
another 3  inches ;  and a  third  had always had  difficult labors previously.
In one  of Dr. Collins' cases, the same diameter measured 2^ inches; and in
several  it  appeared narrower  than usual.   Dr. F. Ramsbotham has never
known  a case in which there was not  some  contraction.3  Dr. Roberton
collected 37  cases  from various sources, in  which there was diminution  of
the pelvic diameters.*
   Various explanations have been given of the modus operandi of this
contra'ction,  Dewees attributing the rupture to inflammation  and gangrene,
Denman to the effect of pressure and attrition, Dr. Burns to pressure of the
cervix between the head and the pelvis, and Dr. Ramsbotham to thinning
from pressure and inflammation.   However this cause may act, it doubtless
gives rise more  frequently to rupture  of the cervix than of any other part.
I  quite  agree with the  opinion of Drs. M'Clintock and  Hardy, that the
effect is  more likely to be produced when the amount is slight  than when it
is excessive.
   The sex of the child will contribute to the increase of this disproportion
—male  children having the larger heads.  Now,  of the 20 cases mentioned
by Dr.  M'Keever, 15  children were males, and 5 females; and of Dr. Col-
lins' 34 cases, 23 were males.   This result of  an unusual size of the child's
head is  still more  remarkable when the head is dropsical, as  in the cases
related  by Campbell,  Collins, Lord, Ramsbotham, Chance, etc.5
   It  occurs at all ages;  but the proportional frequency is greater above 30
years of age than previously.

  1 Diss, de  Rup. in Partu, dolor. Utero.    2 Dublin Journal of Med. vol. vii. p. 198.
  3 Obstetric Med. and Surgery.
  * Pbys. and Diseases of Women,  and on Midwifery, p. 292.
  5 Trask's Essay, Amer.  Journ. of Med., Jan., 1848. 
UTERUS  AND  VAGINA.
487
Dr. Collins found
  1 patient of the age of 16 years.
  1
  1
  3
  2    a    a     a
  1
  3
  1
21	"	2
24	<<	1
25	(C	1
26	a	3
27	it	5
28	"	1
29	ii	1
Dr. Collins found
  7  patients of the age of 30 years.
                       32
                       33
                       34
                       35
       <      «    "    36
             «    "    37
                  "    40
  c.  The oblique position of the uterus, or of the child's head at the brim,
has been assigned as a cause, from its directing the force of the child's head
against the side of the cervix uteri and vagina.
  d.  Some one  of the tissues  of the uterus  may give way previous  to  or
during labor ; perhaps from previous disease ;  perhaps from some peculiarity
of structure ;  and in  some cases, without any appreciable cause.  Sir Charles
M. Clarke  published a case, in which the peritoneal  covering of the uterus
alone was torn ; and similar cases have  been since  recorded  by Mr. Par-
tridge, Mr. White, Dr.  Ramsbotham,  Mr. Chatto,  and Dr. Davis.   Dr.
Collins has  also met with  a case of this  kind, and  others are  on record.
Dr. Radford  published two cases in which the muscular coat was  torn, the
serous membrane remaining uninjured.  Dr.  Ramsbotham met with a case
nearly similar; and Dr.  Collins  met with  nine such cases.  Duparcque  re-
lates one, and Velpeau two.   Many years  ago, I assisted at the post-mortem
examination of  a  patient who  was attacked  with symptoms  of  ruptured
uterus, sudden  pain in  the  abdomen,  vomiting,  collapse, etc. ;  and who
died in  a few hours.   We found no  rupture in any part, but extensive
effusion  of blood beneath the  peritoneum, covering  the uterus, and lining
the iliac  fossae ;  the result, probably, of a  ruptured  bloodvessel.  There
were also twelve or  fourteen ounces  of sero-sanguineous fluid in  the peri-
toneal cavity.   Though the  extent of mischief is less in these cases, yet they
are equally fatal.
  e.  Violence in turning the child may rupture the uterus, and  it may ac-
company this operation, in certain states of the cervix,  without any fault  of
the operator.
  /.  Rigidity of the os  uteri,  or imperforation,  may  occasion laceration.1
There are several cases on record where the cervix uteri has been torn com-
pletely off during labor.  Steidele, Mr. Scott  of Norwich,  Dr. E. Kennedy,
Dr. Power, and  Dr.  Lever, have each recorded such  cases,  and I have seen
one myself.   It appears to  be the result  of pressure at the  brim  of the
pelvis, rendering the texture of the cervix soft and easily torn.2
  g.  Occlusion,  partial  or  complete, of the vagina has in many cases oc-
casioned  rupture of the  cervix and body of the uterus, as I have  shown
elsewhere.3
  h.  It  may be caused  or  aided by  the  peculiar presentation;  but this
cannot be very often the case, as, out of 303  cases collected by  Dr.  Trask,
there  were  only  16 presentations of the shoulder, arm, or side,  and two  of
the breech ;  the  remainder  were head presentations.
  The duration of the labor has been  supposed to influence the  occurrence
of rupture ; but Dr. Trask has  shown that this is not the case.  In   89
cases, 48  were not  more than 12 hours in  labor ;  and the average  duration
of the whole was rather more  than 21 hours.  In 38 cases the pains were
moderate,  in 63  they were  severe ;  and in the majority of Dr. Roberton's
cases the  labor was under 13 hours.
1 Ante, p. 268, on Rigidity of Cervix Uteri.
2 Diseases of Women.  Chapter on Occlusion of Os Uteri.
3 Ibid., Occlusion of Vagina. 
488
LACERATIONS  OF  THE
  Among the direct causes are enumerated blows, falls, anger, convulsions,
excessive  movements of  the child, over-distension, etc.   In one case,  M.
Malgaigne attributed  it to  the  raal-administration of  ergot of rye.  Dr.
Trask gives four such cases.
  722. 3. At  an advanced period of life. — The structure of  the cervix
uteri is much changed in  old age  ; it  becomes close  and dense,  resembling
cartilage, and the canal through it is always reduced  in size, and sometimes
obliterated.   When the outlet  for the  escape of  the uterine mucus is thus
closed, it accumulates ;  and if the quantity be sufficient to distend the cavity,
a process of thinning or absorption commences in  some part of the walls of
the uterus, and  proceeds  until an opening  is  made into the peritoneal sac.
The same process will take place with any other fluid thus deprived of exit.
Duparcque quotes  two cases of the kind.   In some few cases a similar pro-
cess has occurred during middle life, as  in  the case related by Dr. Gozzo of
Naples, whose patient was only set. 38.J
  723. Pathology. —If the laceration be the result  of disease, it may take
place at any  part  of the organ,  the  body,  fundus,  or cervix ;  and it will
generally be found  to correspond to the situation of the pain felt by the pa-
tient previously.  The edges of the rent exhibit marks of disease, the tissue
is thinned, softened and pulpy, breaking down easily  under the finger.  The
color may be changed  to  a deep  red or brown color, and occasionally the
odor is offensive.
  When the laceration is the result of mechanical causes, it generally takes
place near the cervix,  and involves both the uterus and vagina.   It may run
along  the anterior  or  posterior  surface of  the uterus, or at  one  side.  In 6
of Dr. Jos. Clarke's cases, it was on the anterior surface, and in 1  posteriorly.
In  Dr. Simms'  and Hooper's cases, it was anteriorly; in Mr. Birch's, pos-
teriorly;  and in Mr. Cathrall's case, on the right  side.  In 3 of Dr. Rams-
botham's cases,  it was posteriorly  ; in 1, along  the right side ;  and in an-
other,  along the left.   Of 23 cases, Dr. Collins found 1 on the right, and 1
on  the left side — 11 posteriorly, and  10 anteriorly.   In Dr. Trask's exten-
sive collection of cases, we find  that  of those which  occurred during gesta-
tion, in 7 the laceration was of the fundus,  in  1 of the posterior part, in 2 of
the anterior part, in 2 of the right side, in  1 of the left side, in 3 of the cer-
vix and vagina, in 1 from cervix to fundus, in 1 of cervix, body, and bladder, in 2
of the posterior  and inferior parts, in 1 the lower segment of the womb was torn
off. Of those which occurred during parturition, 11 were of the fundus, 13 of
the posterior part, 14 of the anterior part, 8 of the  right side, 7 of  the leftside,
2 of the vagina, 15 from cervix to fundus, 2 involving the bladder,  47 at the
cervix and involving the vagina and separation  from the vagina,  2 of the
body,  7 transverse.   Thus, of the total occurring  during gestation, 13 were
of  the fundus and body, and 8  of  the cervix : of  the total  occurring during
parturition, 63  were of the body and fundus,  and 64 of the cervix, involving,
more or less, the body of the uterus  and  the vagina.2   In one of  Dr. Ro-
berton's cases, the  cervix was separated from the  vagina, except a shred, in
8 the laceration was anterior, in 11 posterior, in 5 lateral, in 3 anterolateral,
and in 3 postero-lateral.3
   The direction of the rent may be nearly  perpendicular, or inclining to one
or  other  side, or running transversely.  In  these cases the structure of the
uterus is scarcely altered ; its  texture is  firm, and its color natural, except
where blood is  ecchymosed.   The edges of the rent are jagged and uneven.
Occasionally, but very rarely, the  bladder has also been torn.4

    iBrit. and For. Med.-Chir. Review, Oct.  1848.
    2 American Journal of Med. Science, April, 1848,  p. 393.
    3 Phys. and Dis. of Women and Midwifery, p. 312.
    1 Archives Gen. de M6d., vol. xviii.p. 10*9.  Laennec Picquet, These, Paris, 1822. 
UTERUS  AND  VAGINA.
489
  When  the  serous  membrane  alone  is  injured, we  find numerous small
incisions, resembling scarifications, from a  quarter to half an inch in  length,
and one or two lines  in  depth, or a smaller number of larger lacerations.
They are almost always  curved, with the convex part  towards the  fundus,
and may  be situated on the anterior or  posterior wall of the organ.   In all
the cases hitherto mentioned, more or less  blood is found effused in the peri-
toneal sac, and  in many, the usual products of peritonitis.
  When  the  muscular structure  alone  is injured,  it may  present either a
simple solution  of continuity, or evidences of disease.   Blood  may be found
in the cavity of the uterus, and the serous membrane may be inflamed, with
the usual results.
   The cervix uteri, when  separated, has generally  a bruised  appearance, is
swollen, and of a red color.   The edges are ragged  and uneven.  The canal
of the  vagina is  rendered continuous with that of  the uterus, but the con-
nection between them is not compromised.
   When  the uterus of an old person is ruptured, from the cause assigned,
we shall discover a perforation in  some part of it, with a considerable thin-
ning of the walls around  it.
   In all these cases, with the exception  of those in which the os uteri is torn
off, or the muscular structure alone injured, we find  marks of extensive peri-
tonitis, unless the patient die of  the shock.
   754. Symptoms. —These  vary very slightly, whether the uterus be torn
completely through, or whether  the peritonal or muscular tissues alone be
injured,  or whether the vagina be alone damaged.
   Certain authors have pointed  out what  they deem premonitory symptoms ;
but these are exceedingly ambiguous.   The circumstances which  may justly
excite our fears are, previous difficult labors, the occurrence of partial hys-
teritis during gestation ;  and during labor, the  coincidence of violent  labor
pains with a narrow pelvis.
   Rupture of  the uterus and  vagina  is  marked by a sudden, acute, and
intolerable pain, like  a cramp;  a sense of some part bursting, giving way,
or tearing, with an audible noise, according to the testimony of some pa-
tients ;  the suspension of the labor pains ; recession of the head generally ;
hemorrhage from  the  vagina;  and a  rapidly succeeding  state of collapse.
Of these symptoms,  the excruciating  pain and  the  collapse are the most
constant; as in some cases  the  bursting or tearing  is not felt; and when
only one tissue suffers, the labor may continue, and there may be no hemor-
rhage.   The pain continues, with little or no  intermission.   The stomach
is disturbed, and vomiting ensues, at first of the contents of the stomach,
then of a greenish, and  ultimately of a black  matter — the "coffee-ground
vomit."  The countenance is pale  and ghastly, with an expression of intense
suffering and  anxiety; the surface is cold and  clammy.  The  pulse is very
rapid, small, feeble,  and fluttering, the  respiration  hurried  and difficult;
and  the  patient requires to be raised in bed.   There is  almost always  a
discharge of blood from the vagina ; sometimes slight, and at others so con-
siderable as to  cause death.
   We know, also, from post-mortem examination, that in most cases, hemor-
rhage takes place into the abdominal cavity ; and  some authors have attri-
buted the state of collapse to this cause ; but though it may  aggravate the
collapse, we know that this is present when there is no internal hemorrhage.
When the rupture is complete,  the expulsive efforts cease,  because the child
escapes, partially or wholly, from the cavity of the uterus into the abdominal
cavity, where  it may  be  felt  by the hand through  the abdominal parietes.
The  presentation, which was probably within reach before  the accident,
cannot now be ascertained by the  finger.
   When the rupture is complete, a loop of intestine may escape  through it, 
490
LACERATIONS OF  THE
and  give rise to the symptoms  of strangulated hernia.  Dupar^que quotes
three cases of this kind from Remigius, Percy, and Beauregard.   Dr. Trask
collected sixteen cases in which  this occurred.  A case is related by Dr.
M'Keever,  where a yard and  a  half of intestine  became strangulated, and
sloughed off.
  The state of collapse may  continue for some time, if it do not prove im-
mediately fatal; but  at length  a certain  amount of reaction takes place ;
inflammation sets in, and the patient exhibits all the  symptoms of peritonitis
—acute pain, exquisite tenderness of the abdomen on  pressure,  tympanites,
decubitus on the back, with  the  knees drawn  up, quick, small, hard pulse,
hurried respiration, etc., etc.
  When the vagina alone is  seriously ruptured, the sudden  pain is absent,
but the collapse  is more or less  complete, and although the regular labor
pains become feeble or cease, the uterine action is not paralyzed, as in rup-
ture of the uterine substance ; but if we aid in the delivery we shall find the
uterus assist in expelling the  child and placenta.   There will, of course, be
no recession, but there will be hemorrhage, external or internal.  In a case
which came under my observation, the  collapse was  not complete, but  suffi-
cient to indicate some grievous  organic injury ; the  patient was then de-
livered by the  forceps, during which operation the uterus acted  firmly, and
afterwards expelled the placenta without assistance.   The external  hemor-
rhage was  very  moderate,  but  the  collapse,  pallor, quick weak  pulse,
continued for four or five days,  and  then  suddenly increased, and ended in
death.  On examination post-mortem,  we  found  that  the vagina had  been
ruptured at its junction with the  uterus, that a large  sac filled with  blood
had thus  been formed, covered at  its  upper part only by peritoneum,  and
that this covering had  given way,  probably at the  time when the  collapse
became complete, and that a  large  quantity of blood had then been effused
into the peritoneum, but that inflammation  had  not set in, evidently for want
of time.   M. Danyau has published1 a case of rupture of the vagina only,
which he saw, and which was characterized by  cessation of  pains, recession
of the head, abdominal tenderness, collapse, etc., but the  child had escaped
into the abdomen through the rent.  He  refers to  seventeen cases of  this
kind, four of which, those of  Ross, Douglas, Smith, and his  own, recovered.
In none was gastrotomy performed.
  725.  Terminations.—The patient may die  of the  shock a few minutes
or hours after the accident, or after delivery; or she may survive the shock,
and  die of the peritonitis; or,  lastly,  she  may be carried off by secondary
diseases, as sub-peritoneal, or lumbar abscess, etc.2

  Of Dr. Jos. Clarke's patients—              Of Dr. Collins' cases—
         1 died undelivered.              2 women died in 14 hours after delivery.
         1  "  in  4 hours.
         1  "    20   "
         2  «    24   "
         1  "    30   "
  Of Dr. Ramsbotham's—
      3 died shortly after delivery.
      2 in   1 hour     "
      1 "  3 days      "
  Of Dr. Collins'  cases—
4 women died immediately after delivery.
1        "  in  2 hours     "
3              4  "       «
1        "    10  "

  In a case under my care, the patient died in five minutes undelivered.

  1 Brit, and Foreign Med. Review, April, 1852, from M<jm de la Soc. de Chirurg., vol. ii.
  2 Burns' Midwifery, pp. 528, 531.  Denman's Introduction, p. 261.
1	"	17 "
1	"	24 "
1	"	25 "
1	"	30 "
4	" on th	e 2d day
1	"	3d "
4	a	4th "
1	it	5th "
2	"	8th "
1	i<	9th "
1	it	11th "
1	a	14th "
1	a	24th "
 
UTERUS  and  vagina.
491
In by far the greater number of cases, the accident proves fatal.
Of Dr.	Smellie's	3 cases,	2 died.	Of Dr. Collins' 34 cases, 32 died
Dr.	Jos. Clarke's'	8 "	7 "	Dr. Beatty's 1 " 1 "
Dr.	Merriman's	1 "	1 "	Drs. M'Clintock and
Dr.	M'Kecver's	11 "	9 "	Hardy's 9 " 9 "
Dr.	Ramsbotham's	13 <<	10 «	
  726.  Some cases,  however, are on record where the patient  recovered.
Heister  relates a case mentioned to  him by  Rungius ; and  Spiering, one
cured  by Forquosa.    M.  Peu,1 Dr.  Hamilton,2 Dr. James Hamilton,3 Dr.
Jos. Clarke,* Dr.  Douglas,5 Dr. Labatt,6 Dr. Frizell,7 Mr. Ross,8 Mr. Kite,9
Mr. Powell,10 Mr. Birch,11 Mr. Smith,12 Mr. Maclntyre," Dr. Hendrie,1* Mr.
Brook,15 Dr. Davis,16 Mr. Church,17 M. Stobo,18 have each recorded one case
of cure.   Dr.  M'Keever and Dr. Collins have  each related  two, and Dr.
Ramsbotham  three  cases.   Duparcque  has  collected four  from  French
authorities.  Osiander states that he has known several cases of recovery.
Velpeau quotes several cases.
  There are a very few instances on record where the patient has recovered,
although the foetus remained in the peritoneal  cavity.
  In cases  of interstitial fcetation, also, the patient has sometimes survived
both shock and inflammation.
  727.  Diagnosis. — The  sudden  acute pain,  the  cessation  of labor, the
collapse, and the recession  of the child, will  render if easy to  recognize the
case.'
  But when the rupture is partial, it may be more difficult, and we must
rely mainly upon the sudden pain and the collapse for  our diagnosis.  The
occurrence  of peritonitis subsequently, will serve to clear up the difficulty.
  In a very able  paper in  the Dublin Journal, Dr. McClintock has  shown
that the life or death of the child  is  a most valuable diagnostic  sign.  In
cases of laceration the  child dies almost immediately.
  The sudden  occurrence of Peritonitis in old women may excite a suspicion
of its origin, but it will not be easy to arrive at certainty.
  Prognosis.—From the details already given, it is  almost unnecessary to
state that the prognosis is  always grave.   So  very few are saved that there
is but a faint hope of the recovery of the  patient.
  728.  Treatment.—The  first question  which  presents itself, when a rup-
ture of the uterus is  recognized, is, " shall the patient be delivered at once,
or left to nature ?"  When  the os  uteri is  undilated instant delivery may
be impossible : but in all  cases where it is possible, the testimony  of ex-
perience is  in favor of immediate delivery.
  Dr. W. Hunter and  Dr.  Garthshore advised that the case should be left
to nature ;  and subsequent to  the  publication  of his Introduction to Mid-
wifery, Dr.  Denman came to the  same conclusion.   The evidence of  facts,
however, must be  allowed  to counterbalance  even such illustrious names;
and that evidence is unquestionably in favor  of delivery.
  Dr. Trask's  researches confirm the  propriety of immediate  delivery; for
of those who recovered, the average time that elapsed between the  occur-
 1 Pratique des Accouchmens, p. 341.
 ' Select Cases in Midwifery, p. 138.
 5 Essay on Rupture of the Uterus, p. 7.
 7 Trans, of Association, vol. ii. p. 15.
 9 Mem. of Med. Soc, vol. iv. p. 253.
11 Ibid., vol. xiii. p. 357.
13 Med. Gazette, vol. vii. p. 9.
15 Med. Gazette. Jan. 17, 1829.
17 Lancet, May 19th,  1849.
 2 Outlines of Midwifery.
 * Trans, of Association, vol. i.
 6 Dublin Med. Essays, p. 343.
 8 Annals of Medicine, vol. iii. p. 377.
i" Med.-Chir. Trans., vol. xii. p. 537.
12 Ibid., vol.  xiii. p  373.
14 Amer. Journ. of Med. Science, vol. vi. p. 351.
i6 Obstetric Medicine, vol. ii. p.  1070.
'8 Med. Times, Anril 6th, ]850. 
492
LACERATIONS of  the
rence of rupture and delivery was under five hours, whilst in those that died
it was over five hours.   Of Dr. Trask's cases, 154 were delivered by arti-
ficial  means, 97 died, 57 survived ;  of 89 abandoned undelivered, G5 died,
24 survived; of 31 delivered by natural efforts, 20 died, and 11 survived;
of 6 in whom artificial  delivery was tried and failed, all  died undelivered.
Thus, a comparison of those delivered by art with those  abandoned unde-
livered, gives 37 of the former saved to 27 of the latter in the hundred.  But
this is not all, for we  find that the average continuance of  life after rupture
in those delivered is  twenty-two hours, and in those undelivered, only nine
hours.
   729.  The mode of  delivery will depend altogether upon the circumstances
of the case.
   1.  If the  head  have not receded, and be within reach,  or be already in
the pelvis, it will be well to deliver with the forceps, if possible;  but if not,
we must  have recourse  to the perforator, and with the less hesitation, as
Drs.  M'Clintock and Hardy have shown that the death of the foetus almost
instantly follows the  occurrence of rupture.
   2.  If the  child have  escaped into the cavity of the abdomen, or if the
brim of the pelvis be much contracted, the hand must be introduced into the
vagina, and, if practicable, passed through the laceration, and the feet seized
and brought down, so  that the child may be extracted  through the rent.
Care must be taken to avoid  dragging down  or injuring the intestine, in
case  it should have  prolapsed.  The placenta is  then to  be removed, the
vagina cleansed, etc.   In all these cases the child is born dead.
   3.  If the uterus have  contracted very firmly, it may be impossible to pass
the hand through the rent; or the pelvis  may be too narrow to admit of
the child being extracted footling, or even  of  the passage  of the hand.   In
such cases we are advised to perform the Caesarian section, and extract the
child and secundines through the abdominal parietes.   Successful cases are
related by Thibault  des  Bois,  Lassus, Haden, Baudelocque,  Latouche  and
Jopel,  Lambron, Glodat, etc.   To these may be added cases related by the
following :—MM.  Coquin,1 Sommer,2 Ceconi,3 Ruth,* Rust,5 Gais, Xaegele,
Weinhardt,6 Heim,7 Busch, Demay,8 Lechaptois et Lair,9 Yelpeau.10
   4. This will be the only mode  of delivery, in ruptures  occurring during
gestation, before labor has commenced.
   " In regard to the point of duty in the management of such cases (of rup-
tured uterus), I have to remark," says Dr. Meigs,11 "that, upon  discovering
 even the  smallest  commencement  of a laceration of the vagina or cervix
 uteri, the earliest practicable precautions should be taken to ensure  delivery
 per vias naturales, and  the prevention of the escape of the child into the
 peritoneal sac.   This should be done, where it is practicable and convenient,
 by seizing the head, if it be the head, in the grasp of the obstetrical forceps;
 by bringing down the feet, if it be a breech ;  by turning and delivering, if it
 be a shoulder case ;  or by turning to deliver, if it be a case of face presenta-
 tion, or departure of the chin, or any condition indeed in which the operation
 of version would be most likely to rescue the woman from the  dangers by
 which  she is surrounded.
   " Should  the laceration have  permitted  the child to escape at once into
 the  peritoneal  sac, let  the attendant lose  no time, but  bare his arm,  and
 resolutely, with his hand passed through the rent, explore the abdomen in
 search of the feet, which he should immediately withdraw through the open-
 i Bulletin de la Faculte, 1812, p. 86.
 3 Bulletin de Ferussac, vol. v. p. 47.
 5 Luroth, Ibid, vol. xix., p 85.
 8 Journal G6n., vol. v. p. 58.
10 Traite" d'Accouch., p. 355.
 2 Ibid.
 * Ibid., vol. vi. p. 280.
 6 ibid.              7 Ibid.
 » Ibid., vol. i. p. 187.
" [Op. cit.] 
UTERUS  AND VAGINA.
493
ing of laceration.   But if this be  not done;  if some hours  should  have
elapsed subsequent to the occurrence of the  accident;  if the woman be
already much exhausted by hemorrhage, by constitutional shock and irrita-
tion, the question will arise as to the properest  manner of fulfilling the indi-
cation, which must ever be to extract the child.   The hemorrhage will now
have been stayed :  were it not so, the woman would be already dead: to
pass the hand through the  rent, should it be in the vagina, would be to set
the hemorrhage  again on  foot.  It will be always impossible to pass the
hand through the rent in  the uterus, because the uterus, being now con-
tracted, will have reduced the size of the rent in proportion to the conden-
sation of the organ.   The child can  never be returned through a contracted
rent, having passed through it while  the uterus  was  yet undiminished in size.
I say, then, the question arises as to  the mode in which the indication is to
be carried out.
   " I am firmly convinced, that, should I be called this day to the conduct
of such a case, I  should feel bound by my conscience to recommend a delivery
by a gastrotomy  operation.  I cannot think that a clean incised wound along
the linea alba, sufficient in  length to permit the extraction of the child from
the peretoneal sac, however exceptionable in itself merely considered, can be
held  in the least degree  objectionable, when compared with  the delay, the
fatigue, the contusion and  the renewal of the  suspended hemorrhage, that
would inevitably attend an attempt to extract per vias  naturales."
   730.  During the stage of collapse, it may be necessary to give stimulants,
ammonia, camphor, musk, wine, etc. ; but this should  be done with  great
judgment, so as  just to attain our  object, and no more ; bearing in mind
that whilst we may  be  relieving  the collapse,  we may be aggravating  the
reaction, and increasing the danger at that period.   A  large dose of opium
may be given after the delivery.
   When inflammation sets in, of course the treatment must be actively anti-
phlogistic.  Three or four dozen leeches should be applied over the abdomen,
 and repeated, if  necessary.  Large bran poultices  are  useful, and hip-baths
 are recommended.   Calomel  and opium, or opium alone, is the most valuable
remedy we possess.  It should be  given  in large  doses, or in smaller ones
 more frequently, so as to influence the system rapidly.
   If the rupture have  arisen from  narrowness of  the  upper  outlet of the
 pelvis, and the patient recover, and again  become pregnant, premature labor
 should be induced,  at such a  period  of gestation as will allow the fcetus to
pass without difficulty.   It is of course desirable that the operation should,
if possible, be deferred until the fcetus is "viable ;"  but I do not think this
 a sine qua non, when the child cannot be saved we ought to save the mother.
 Dr. Collins relates a successful case of this kind,  in which the patient was
delivered  the first  time after the rupture by artificial premature labor, and
 afterwards naturally.   In  Dr. Douglas' case, the patient was delivered by
turning, the first pregnancy after the accident, and naturally the second.   It
would, however, be much wiser for the patient  to avoid the risk of a subse-
quent delivery.

   731. II.  Yesico-vaginal  Fistula.—Perforation of the  coats of  the
vagina, anteriorly or posteriorly, with the subjacent organs, the bladder or
rectum, is not very rare, and is one  of the most distressing and intolerable
accidents to which  females are subject; and the more so, as a cure  is but
seldom effected.   Indeed, vesico-vaginal fistula has long been considered as
one of the opprobria of surgery;  and, until recently, of late  years the cure
has been given up as hopeless.
   Yesico-vaginal fistulae are  more frequent than perforations of the rectum ;
they are generally found separately, but in some cases co-exist.  A case was 
494
VESICO-VAGINAL FISTULA.
received into the Meath Hospital some  years ago, in which the bladder and
rectum  were both perforated, the perineum lacerated, the canal of the vagina
distorted by cicatrices,  and closed at its upper part by adhesions.
   Strictly speaking, we can  hardly consider this form of laceration a com-
plication of labor, it is  rather one of its sequelae, except in those unfortunate
cases where injury is inflicted during extraction  of the child, or the urine is
allowed  so  to accumulate  as to  expose  the  bladder  to rupture from the
pressure of the child's head.
   732.  Causes.—Yarious causes may give rise  to this accident:
   1. Either wall of the vagina may be wounded, accidentally, or on purpose,
by cutting instruments.   Such has been the  result of criminal  attempts to
procure abortion.  In  these cases, however, a cure often takes place spon-
taneously.
   2. The long retention of  a pessary in the vagina may give rise to inflam-
mation  and  ulceration of the vaginal tunics, and  ultimately to perforation of
the bladder or rectum.   This, however,  but seldom occurs, and then only in
aged females,  for whom little can be done in the way of cure.1
   3. In powerless  or difficult labors, where the head  of the child is long
retained in  the pelvis,  or where, by its  size, it makes great pressure, the
vagina  may be the seat of inflammation, ulceration, and perforation, involv-
ing  either of  the subjacent  organs, but  much  more frequently the bladder.
In these cases, the vagina is frequently narrowed, or deformed by irregular,
circular, or spiral cicatrices,  rendering the detection of the fistula somewhat
difficult.
   4. A maladroit use  of instruments may occasion  this injury.   Cases of
both kinds of fistula could easily be adduced  from  authors, as the result of
carelessness or incompetence in the operator.
   5. Retention of  urine  during labor will generally involve more  or  less
pressure upon the bladder;  if within certain  limits, perforation will be the
result of subsequent inflammation ;  if the distension be  excessive, and the
bladder protrude into the pelvis, so as to be pushed before it by the descend-
ing  head of the infant, then, most  probably,  rupture of the bladder  and
vagina  will  take place.
   6. The bladder is occasionally lacerated in rupture of the uterus, though
there may not necessarily be a perforation of the vagina.2
   7. In corroding ulcer and cancer  of the uterus, the ulceration may involve
either or both walls  of  the uterus, and perforate the bladder, or rectum, or
both.   For these cases, however, nothing curative can be attempted.
   8. A pelvic abscess may open into the bladder, uterus, or rectum, or into
more than one of these  cavities, and the opening may remain fistulous, as in
the cases published by Dr. Simpson.3
   733.  The situation of the perforation  is of great importance in the cure
of vesico-vaginal fistulas.   It may be at  the junction of the urethra with the
bladder — in the neck  of the bladder—or in some part of its body.  The
opening may  be  more  or less circular in  form, or it may be a rent running
longitudinally from  before  backwards, or transversely.   The curability of
the fistula will depend,  in  a great degree, upon the amount of the loss of
substance.
   734.  Symptoms. —These depend primarily upon the cause  of the fistula,
and will vary according to it;  and secondarily,  upon the escape of the con-
tents of the wounded organ.  Whichever organ be wounded, the  result is
inexpressible distress to the  patient.   The escape of urine is attended with
so marked and irrepressible an odor, that the  patient is placed "horsde
societe."  Obliged to confine herself to her own room, she finds herself an
    1 Cooper's Surgical Diet., p.  1090.           " Blundell, Dis. of Women, p. 69.
    3 Ed. Monthly Journal, Dec.  1852.  Obstetric Works, p. 232. 
VESICO-VAGINAL  FISTULA.
495
object of disgust to  her dearest friends, and even to  her attendants.   She
lives the life of a recluse, without the comforts of it,  or even the consolation
of its being voluntary.  It  is scarcely possible  to conceive an object more
loudly calling  for  our pity,  and strenuous exertions to  mitigate, if not re-
move, the evils of her melancholy condition.   In addition  to the offensive
smell, the escape of the urine gives rise to excoriation of the vagina, external
parts, and thighs.  The flow of urine is constant when the neck of the blad-
der is the seat of the injury, and at intervals when  the  wound is small and
situated more posteriorly.
  In all cases a careful examination should be  made,  by passing a catheter
into the bladder, and a  finger into  the vagina ; then placing the points of
both in apposition,  the whole posterior  surface of the bladder should be
passed over, and carefully examined.   At some one  point the  finger and
catheter will come in contact;  the catheter may then be  passed  into the
vagina, and the extent of the damage ascertained.  In many cases the specu-
lum will afford us an accurate view  of the opening, and  enable us to ascer-
tain not merely the extent of it, but the condition of its edges.  When the
vagina is not  cicatrized, it  is not  generally difficult to obtain the informa-
tion we desire: but  when deformed by cicatrices, it will require  both  care
and patience.  By far the most satisfactory mode of  making this examina-
tion, as shown by Dr. Marion Sims, is to place the patient on her face with
the hips raised, or on her hands and knees, and then  raising the perineum
with a Sims dilator,  the air will distend the vagina, and exhibit the entire
canal perfectly.
   In the majority of  cases, little is to be hoped for from the efforts of nature ;
the borders  of the wound become  thickened  and callous,  and the case re-
mains stationary during the  patient's life.   In some  few  cases, however, the
result is more favorable ; as, for instance,  when the wound has been inflicted
by a sharp instrument.   In two cases under my care, where the wound was
precisely at the insertion of the  urethra into the bladder, and was followed
at first by absolute incontinence of urine, a cure was obtained naturally.  The
wound slightly contracted, without healing, and the muscular fibres  of the
bladder assumed the  office  of a  sphincter muscle, and closed  the  orifice, so
that the patient could retain urine almost as long as previous to the accident,
and could evacuate it at pleasure.
   735. Treatment.—We  cannot  wonder that many  methods should have
been tried to remedy so offensive an accident,  nor that so  few should have
succeeded, when we recollect the obstacle  presented by the constant passage
of urine.  The probability of relief depends partly upon the  situation, and
partly upon the character of the fistula.  When it is far back in the poste-
rior wall of the bladder, and when there has been much loss of substance, a
cure is seldom obtained ; but when near the neck, we may sometimes succeed.
   I shall now notice  the principal plans which have been proposed.
   1. DesauWs method,1 as  it has  been called,  consisted in maintaining a
catheter constantly in the urethra, so as to afford an outlet for  the urine, and
at the same time preventing its escape, by plugging the vagina.  J. Cloquet
has added a kind of syphon  to the catheter.   Chopart succeeded in curing a
case by this means, where the wound was  in the neck; but he failed in one
where it was in the body of the viscus.   Peu,2  S. Cooper, and Blundell, each
relate a case of cure.
  There is no doubt  that much relief may occasionally be derived from this
plan.   I  had a case  in  which the patient was ultimately enabled to retain
her urine for two hours, without dribbling, though the wound did not entirely
close; but in  some  of  the cases on  record the wound completely healed.

    i OZuvres Chirurgicales, vol. iii. p. 299.       2Prat. des Accouchmens, p. 384. 
496
VESICO-VAGINAL FISTULA.
There  is this objection  to the plan, however, that in  many instances the
patients cannot bear the catheter above an hour at a time.1   I saw two ex-
amples where this circumstance proved  a serious obstacle to the cure.
  736. 2.  Cauterization. —This is obtained by the repeated application of
the nitrate of silver or the strong acids.   Dupuytren, who I think first pro-
posed the plan, used the "nitrate acide de mercure," or  the nitrate of silver.
Relief has  occasionally been afforded by this means, but a cure is very rarely,
if ever, effected.    Where there is much loss of substance, it affords no chance.
I have seen  it fail repeatedly.  However,  Dupuytren,  and  Delpech,  and
Baravero, are said to have thus cured several cases.
  The best mode of applying the caustic is by means of a fenestrated specu-
lum, which will leave the upper  surface of the  vaginal canal exposed, or by
Lalleman's " porte caustique."  The  caustic  should be lightly applied, as
the object is  not to produce a  slough, but  merely a contraction.
  737. 3.  Actual Cautery. — If the loss  of  substance  be slight,  and the
wound small, there is no doubt that a cure may be obtained by this means.'
Dupuytren, who  first proposed  it, cured several,3 Dr. M'Dowel, one;4  Dr.
Kennedy, two ;5  Mr. Liston,  four  or five  ;6 and  others have been equally
successful.   Dr. Colics has tried it successfully where the orifice was not too
large, but  without benefit where the  fistula was extensive.   I witnessed a
successful case treated by Dr. O'Ferrall, of St. Yincent's Hospital.   I also
tried  it in one case under my own care, but it failed, as I  anticipated, on
account of the large  size of the opening,  and equally in another very small
one.
  The facility with which  the  operation is performed will depend upon the
situation  of  the  fistula being  more or less anterior.  The patient may be
placed upon  her back, as for lithotomy, or upon her  knees and elbows.   Dr.
Kennedy adopted the former; but I  have found the latter far more con-
venient, and  I think less offensive to the  patient's feelings.   The light can
reach  the part more readily, and the position of the operator is more con-
venient.   The patient must be placed  before a window, or a candle must be
used.  The next point  is  to dilate the vagina, so as to insure access  to the
wound, without contact with the vagina.   This may be done by three brazen
spatulas, sufficiently long to reach beyond the rent, and broad enough to pro-
tect the vagina — or by a double-bladed-speculum.   I  have also used, with
great  facility and  safety, a metal cylinder, closed  at its  extremity,  but with
an  opening in the side, a little distance from the end, and corresponding to
the fistula.   A catheter should be  passed  into  the bladder,  and  through  the
fistula, to  guide  the operator, and to  keep the  mucous membrane of  the
bladder from protruding.
   Having these preliminaries adjusted, the cauterizing iron, at a white heat,
should be lightly applied around the edges of the  wound, and withdrawn.
The dilators, or  speculum, may  then be removed, and the patient placed in
bed.   If it do not occasion  irritation,  it  will be advantageous  to allow the
catheter to remain in the bladder.  The  patient should be kept quiet, and
the bowels freed  by  medicine.   A certain amount of local irritation gene-
rally succeeds, which subsides in the course of a few days ;  after which  the
operation  may be repeated as  often as  necessary.  The  operation should not
produce a slough, or the patient will  not be benefited, but  merely a corru-
gation or  shrivelling of the edges.   If we thus reduce the wound, so as to
bring the edges  in contact, adhesion may then take place, and the patient
be cured.   But it must  in candor be confessed, that whilst it is not difficult

  1 Davis's Obsteteric Med., vol. i. p. 127.      2 Jeanselme, 1'ExpeVence, Jan. 1838.
  » Sanson, Path. Me"d.-Chir., vol. v.  p.  294.     * London Med. and Phys.  Jour., 1831.
  5 Dublin Jour, of Med. Science, vol. ii. p. 241.  « Lancet, June 23d, 1838. 
VESICO-VAGINAL FISTULA.
497
or uncommon to benefit the patient to a great extent, a complete closure of
the fistula is very rare.
  738. 4. The  Suture.—This method  is  said  to  have been  invented by
Roonhuysen ; at all events,  it has been  long known and  practised by the
profession, with varying results.
  It has  been performed with success by Dieffenbach, Blandin, Chanam, and
Jobert;1  by Sanson, who failed ;  by Deyber, who nearly, if not quite cured
his patient; by Malagodi of Bologna, who has published his successful case ;
by MM.  Lallemand, Duges  and  Roux, who failed;  and  by M.  Naegele.
Mr.  Earle cured three cases by this means.   Mr. Hobart, of Cork, formerly
published a successful case,2 and since states that he has perfectly cured at
least ten  by the suture.   He  says : " In reply to your letter, I  have  only to
say,  that many  cases of vesico-vaginal fistula came before me within the last
fifteen years, many of whom were  cured, some relieved, and  others not at all
benefited.  I think  there were  from ten to fifteen perfectly cured, and all
by the same means."  A successful case is related in the American Medical
Recorder.3  Dr. Evory Kennedy has  succeeded in diminishing the  orifice
several times;  and  in one case in which the twisted  suture was used, the
cure was complete.   Mr. Hayward,  of Boston, U.  S., has  published a very
 interesting case, which was perfectly  successful.*
   On the other hand, the late Dr. Colles, of Dublin (whose name alone is a
 sufficient guarantee  for all that science, and skill, and care could do),  allowed
 me to state that he  has repeatedly tried the common interrupted suture, but
 though he has by these  means lessened the orifice, he has  never succeeded
 in closing it entirely : and this was  the result under very favorable  circum-
 stances.   He has also seen very unpleasant  consequences result from the
 operation ;  hemorrhage (the edges  of the fistula having  been removed by
 the knife) to a great amount; fever, hectic, etc.
   M. Naegele  has  described an instrument, consisting of two  small  plates,
  joined at the back like the pages of a book, and fixed in a  handle of steel.
 The anterior  edges are  brought together by a screw fixed in the handle,
 and the  edges  of the wound  being included, are retained in apposition, and

                                 [Fig. 178.]
Duck-billed speculum of Sims, slightly modified by Bozeman, (one quarter size.)
the  lower part of the handle removed.5   M. Lallemand has also invented
one, which he calls a " sondeerigne," by which a similar  effect is produced,6
but, not having seen the instrument, I am unable to give a description of it,

  'Lancet. May 12th. 1838.           "London Med. and Pins. Journal, vol. v.
  8 April, 18211, p. 410.               * Amer. Journal of Med. Sciences, Aug.  1839.
  5 Erfuhrungen  und Abhandlungen, etc., p. 389.
  6 Velpeau, M6d. Ope'ratoire, vol. iii.
      32 
498
VESICO-VAGINAL  FISTULA.
He has cured one case with it, partially cured  another, but failed  twice.
MM. Langier and Lewziski have also contrived similar instruments.
  Yerv recently, however, the improvements in  the mode of operating and
materials used, have given good hopes  of success to a greater  extent than
we had ventured to hope.   Many cures  have been effected under the care of
Drs. Marion Sims, Bozeraan, Simpson, Baker Brown, Spenser Wells, Collis,
Sawyer, M'Clintock, and others.   I shall briefly mention the more important
methods.
  The first great improvement was the use of  silver wire for the sutures by
Dr. Marion Sims.1   At first he used " clamps"  to retain the wire, but latterly
he has discarded them, and simply twists the ends of each suture together.

                                [Fig. 179.]
The manner in which Sims adjusts and fixes the silver sutures.  (After Sims.)
The advantage of the silver wire (and the same may be said of annealed iron
wire)  is that it does not cut  out, nor excite suppuration,  nor rust.  The
patient is  placed  in  a  prone posture,  with the hips raised, the duck-billed

          1 Silver Sutures in Surgery.   Anniversary Discourse, etc., 1858. 
VESICO-VAGINAL  FISTULA.                  499
speculum is introduced at the perineum, and, being raised, the whole  canal
is  exposed.    The  edges  of the  fistula  having  been pared,  a sufficient
number of sutures, about  y3^ of an  inch  apart, are inserted, and the ends
being twisted, the edges  of the wound are brought together, so that no urine
can escape.   He does not remove the wires before the eighth day ; and he
allows his patient a  more  liberal diet than usual.   Dr. Sims deserves the
credit of the  silver wire sutures, the duck-billed speculum, and the S-shaped
metallic catheter to be left in the bladder.
   The next great step is also due to our American brethren.   Dr. Bozeman,
of Alabama,1 acknowledging the claims of Dr. Marion  Sims, and adopting
after  him the silver wire, speculum,  and  curved catheter, yet found a want
of success in  keeping  the edges of  the wound in steady apposition, and pre-
venting the irritation  of the wound by urine  discharge, etc.   To  supply  this
want, he invented the " button shield," an oval  plate of silver  or lead  not
much thicker than cardboard, and  of a size and shape to suit the fistulous
opening.  It is perforated along the centre with a row of holes to admit the
sutures, the two ends  going through one hole.   When all have been inserted,
the button shield is pressed down to  the fistula,  and the wires are drawn as
tight as we wish, and retained either by split  shot or perforated "saddles"
squeezed flat by a strong pair of forceps.   He has  also, with great ingenuity,
invented a variety of  subsidiary instruments to  facilitate  the operation, for
example, crooked forceps, bent knives, ligature adjusters, etc.   The  result
in little more than two years has been  that of twenty-four operations in
which the button suture  has been employed, only two failures occurred.

              [Fig. 180.]                            [Fig. 1SL]
 Fig. 180. Bozeman's " button" as it is being passed along the threads down to the wound.  (From Bozeman.)
 Fig. 181. Bozeman's " button-suture" finally applied and fixed with perforated shot. (From Bozeman.)

  Dr. Maurice Collis  proposed, as a modification of  the  older operation,
that, instead of the edges being  pared,  they should  be split with  the knife,
and the vaginal half alone included in the  ligature ;  but in this suggestion
he had been anticipated  by Dr.  Hayward, of Boston.2  He used  iron wire
ligatures and portions  of india  rubber for quills.  This  operation was per-
formed by himself twice,  Dr. Sawyer, Dr. Thorpe, and  two  other  surgeons.
Two cases were completely cured, two were greatly improved, and two failed
altogether.  Dr. Collis has since used Bozeman's button shield.
  Mr. Baker Brown3 has published the history of nine successful cases treated
on Dr. Bozeman's plan.
  Professor Simpson, of Edinburgh,4 whose zeal leads him  to try every sug-
gestion for the relief of suffering, has  succeeded by Bozeman's operation in
curing five cases.   But not satisfied with our present means, he has endeav-
ored to  improve  them.   Instead of the solid button shield, he uses an oval
ring of twisted wire, through the interstices of which the ligatures are passed,
and being  brought together over  the  intervening space are  twisted by an

  1 Remarks on Vesico-Vaginal Fistula, etc., 1856.  On Vesico-Vaginal Fistula, 1858.
  2 Surgical Reports, etc. p.  222.            s On Vesico-Vaginal Fistula, 1858, p. 6.
  4 Med. Times and Gazette, 1859, Jan. 1st and 8th. 
500                      VESICO-VAGINAL  FISTL'LA.
admirable little instrument he has invented.   By  this means you  can see the
adaptation  of the lips of the wound, and  he believes  that  all movement of
                               [Fig. 183.]             /
  Fig. 1S2. Bozeman's suture-adjuster.  The long figure gives a face -view of the instrument, the short
figure gives a lateral view of its extremity (half-size).
  Fig. 183. Tubular needle for passing wire threads through the  lips of vesico-vaginal fistulae.  A wire
is represented as passing through the  tube.  The figure is of full size—the extremity of the  needle,
looking thicker and larger than it really is.  Only the commencement of the handle is represented in the
woodcut.
  Fig. ls4. Fork or pulley used in drawing through the wires to prevent them from  cutting the vaginal
raucous membrane above the wound (half-size).
Fig. 185. Blunt hook ior directing the point of the needle (half-sire). 
VESICO-VAGINA  FISTULA.
501
one upon the  other will  be prevented.   I confess from all  I have seen I
prefer the button shield.   He  has also  invented an improved needle, which
acts very nicely.  It consists of  a  hollow tube  terminating in a fine needle
point, and  bent or  curved about an inch  from the end.   Through this the
wire (he uses iron wire, as being cheaper and quite as good) can be passed
before  or after the opposite sides of the fistula have  been pierced by it, and
when protruded through  the  open  end, it can  be seized and  held  with the
forceps, and the needle withdrawn.
[Fig. 186.]
[Fig. 187.]
  Fig. 186. The iron-wire splint finally adjusted as it is being
 passed along the threads down to the pared wound.
  Fig. 187. [Dr. Coghill's instrument for finally tightening and
 fixing the suture.  In using it, one end of a wire  having been
 brought through one of the small tubes which are on the sides of
 the instrument near its lower extremity, and the other through
 the opposite of these tubes, the instrument is pushed down close
 to the lower bar of the splint, both ends of the wire suture being
 now drawn  quite tight, so as to make the splint compress and
 consolidate the parts, a turn of the instrument suffices to fix
 them there.  To make sure of this, however, a turn  or two more
 may be given, when the wires are to be clipped off with a pair of
 stout sharp  scissors, close to the point of the instrument.]

  With his usual research he has discovered that a Mr. Gossett, of London,
in  1834 used  ligatures  of gilt wire  in  cases of vesico-vaginal  fistula, and
though this  was prior to Dr. M. Sims' adoption of them, to my mind it does
not diminish one whit the credit due to him.
  Lately  Dr   M'Clintock  has  performed Bozeman's operation once  with
perfect success, and once with such an amount of success as gives hopes that
another operation will complete the cure.         _
  Dr Beatty has also performed the same operation with complete success,
with  the slight modification  that  instead of  one row of holes in the button
shield two rows were made, and the  opposite wires twisted_over the  inter-
vening  space    This  is much  more  easy than fixing the wires by split or
perforated shot or saddles, and answers quite as well
  Now  as to  the time and method  of operating.   The best time will be
about a week  after a menstrual period,  and  it should  be done  on a bright 
502
VESICO-VAGINAL  FISTULA.
day in as  good a light as possible.   The patient's  bowels should be freed
previous to the operation.   The instruments required are, the duck-billed
speculum, knives  straight and curved, toothed forceps, three or four needles
of different kinds, iron or silver wire, the little fork, the ligature and suture

                                 [Fig. 188.]
  Shows the iron-wire splint finally adjusted and the ends of the stitches twisted and secured across the
                            lower bar of the splint.

adjuster, the twister, long scissors, forceps of different kinds, and a strong
and long  pair of pliers,  and small sponges  on rods.    The button  shield
(which I prefer to Dr.  Simpson's wire oval) each one  should make for him-
self of thin lead to suit the direction  and size of  the  fistula, and pierce it
with just  so many holes as he  intends to apply sutures.  If two rows  of
holes  are made, neither saddles nor shot will  be necessary ;  but if only one,
little saddles may be made of bits of lead perforated.
  The patient may be placed on a table in a prone  position with the hips
raised, or  she may kneel on the table or stand, with the shoulders  lower than
the hips.   These latter positions are generally best, I think ; but if we wish
to give chloroform, she must lie on  her back  in the position for lithotomy,
and in some cases this is  the most convenient position.  A trial should  be
made of each, and the best position  chosen.  Then  raising the perineum
with  the  speculum,  and  separating the  labia widely  with a long-toothed
forceps and a knife, a slice should  be taken  from  the entire circumference
of the fistula, or the edge split  entirely round.   "Very great care must  be
taken that we have a raw surface with no  portion of the old surface remain-
ing,  and  as the bleeding obscures  our  view, we may derive  assistance  by
applying  tincture  or decoction  of  matico  from time to time so  as to arrest
it for a moment.   When we  are  satisfied with this part of the operation, at
once the most difficult and the most important, the patient may be allowed
to rest awhile by changing  her position,  whilst the operator sees that  he
has all ready for the remaining  part of the operation.   Placing  the  patient
once more in position  and exposing the parts by the speculum  and  fingers
of assistants, or retractors, the  ligatures are to be passed in at some dis-
tance from  the edge  of the wound, and  not  through  into  the bladder, but
emerging at one edge to  be passed through the other  edge and  out  beyond
it.  With the small hook  or forceps they are to be removed from the  needle,
and drawn  further through.  This is to be repeated as often as necessary.
It is better to have too many than  too few, and unless we use Dr. Simpson's
needle (which we can  scarcely do when  the fistula  is vertical), it is  well to
have as many needles  threaded  as  we intend  to have sutures.   Having  in-
serted the sutures, the next thing is to  assort them  in pairs  by  a little
instrument  Dr. Bozeman  contrived, and then running the suture adjuster
down each pair of ligatures, the lips of the wound will  be drawn together 
VESICO-VAGINAL  FISTULA.
503
and we  can see whether they are nicely adapted.   If we are satisfied, the
ligatures are next to be passed through the holes in the  button  shield, and
secured either  by shot,  saddles, or by  twisting  with Dr. Simpson's  instru-
ment ;  we  must  be careful that the  shield  sits firmly and  closely  on the
wound,  and that  the sutures are tight enough, but not too tight.   The wire
may then be cut  close to the shield, and  the  ends bent down  and the opera-
tion is completed, having generally occupied from  an  hour  to an hour and
a half or two hours.   The patient should be carried to bed, and a catheter
passed and so fixed that it will not slip out.   Dr. M. Sims' crooked catheter
remains in  very well if the patient lie on her side ; it should be removed and
cleansed every day ;  and if it  escape, it  must  be  instantly re-introduced.
[Fig. 189.]     [Fig. 190.]     [Fig.  191.]      [Fig. 192.]
   Fig. 189. The tenaculum, or sharp hook used for catching up the edge of the mucous membrane of
 the vagina around the fistula (half size).
   Fig. 190. Straight knife used for paring the edges of the fistula (half size).
   Fig. 191. Bent knife used for paring edges of the fistula (half size.)
   Fig. 1!12. Lateral view of the same (bent) knife to show the angle  at which it, the blade, is bent
 (half size).

Two grains of opium should be given immediately, and a grain three times
a day for two or three days; the object being  to lock up the bowels, but I
agree with Dr. Simpson  that  it  is probable that the  beneficial  effects  are
not limited to producing constipation.   Moderate diet may be allowed,  but 
50 1
VESICO-VAGINAL  FISTULA.
the patient  must remain  in bed.   The  bowels need not  be  disturbed  for
seven or eight days;  but I think  it better to have  them  evacuated before
we  remove  the shield.   As neither the shield  nor ligatures occasion any
irritation, we need not be in a hurry to remove them, and it is clearly better
to leave them  unnecessarily long  than take them  away  too  soon.   The
eighth or tenth day is  quite soon  enough.  All  that is  necessary is to clip
across the wires close  to the  shield with the  scissors, and with the  forceps
remove the shield.  In  some  cases it will be  advantageous to leave the
wires a few  days longer, and then very quietly withdraw  them.   The vagina
should  be syringed with  cold water every day from the beginning, but  no
attempt should be made to see whether any orifice remains until a few days
after the removal of the  shield.  If no urine  escapes  per  vaginam we may
rest satisfied,  and in  a  week or so carefully examine the cicatrix with a
blunt instrument, keeping a silver catheter in the bladder meanwhile.  If
no  unhealed spot be discovered, we may still further test  its  soundness  by
injecting the bladder full of cold water ;  if none escape by the cicatrix (and
we  can see  if  it do), we  may be  satisfied that the cure is complete.  But
there is a  source  of confusion and doubt which  I  may mention.  After a
catheter has remained  so long in the bladder, the sphincter and  urethra lose
their  power to a certain extent, and  urine may dribble along  outside the
catheter, leading  us to fear it  is escaping through the fistula.   Or, as in a
patient of Dr. M'Clintock's, the power of these parts may be lost more com-
pletely, so that when she is allowed to get up, she can retain urine only for
a short time, and, without examination, we should conclude that the opera-
tion had failed.   Inspecting the bladder, and  observing  whether any escape
through the fistula, is the true test  in these cases.  The urethra by degrees
recovers its  retentive power.
  739.  5. Dr. Blundell saw a fistula in the  neck of the bladder, near the
urethra, cured by laying  open  the  urethra to the rent,  and then healing it
up, as is done in ordinary fistula.    Dr.  Porter, of the  Meath Hospital, per-
formed a similar operation, which terminated successfully.
  740.  6.  '' Elythro-plastie."—This name is given  to the  operation  by
which a portion of  integument  is taken  from  a  neighboring part, and
applied to the vesico-vaginal fistula, and retained by sutures ;  the old con-
nection being  maintained until  union has taken place.   It is exactly similar
to the  rhino-plastic operation  for repairing  noses.   It was  suggested  by
Velpeau, but first practised by  Jobert.   Of his four operations, one patient
was cured  at  once, one  by a second operation, one died, and  with  one it
failed.  M.  Roux did not succeed with  it.   I  am not aware that any  other
surgeon has tried it.
  741.  7. Closure of the Vagina.—When using the caustic for the cure of
vesico-vaginal fistula, in the year  1833,  M. Aridal de  Cassis chanced to  touch
the vaginal  mucous membrane with it;  this  caused considerable inflamma-
tion, and on making an examination subsequently, he found the sides of the
vagina  adherent.   The patient also observed that the dribbling  of urine had
entirely ceased.   Unfortunately, a careless examination was afterwards made,
and the^e adhesions were destroyed.   But the  hint was not thrown away;
for on the next occasion, in the same year, M. Vidal de  Cassis attempted to
relieve  the fistula in this way, and was  perfectly successful, until the clumsi-
ness of an assistant destroyed these adhesions also.  There is no doubt that
in many cases this would  be found a valuable means of relief.  Caustic  of
any kind will answer the purpose of exciting inflammation, though  adhesion
may not always take place.  I have seen a circle of the mucous membrane
removed, and  the parts brought together by suture, for the purpose of clos-
ing the orifice of the vagina, but union did not take place.
   When we have  recourse  to  this method, care should be taken to leave a 
VESICO-VAGINAL FISTULA.
505
very minute opening for the escape of the menstrual fluid, if menstruation
have not ceased.
  742. 8.  The Plug.—If none of the  means hitherto described  afford a
probaljility of  cure, or fail upon trial, it is at least a  comfort to know that
we can still remove a portion  of the  distress caused  by this frightful com-
plaint, provided the irritability of the vagina be not too great to bear a
plug.1   Various cases of relief by this means are on record.  Dr. Gooch, in
1814, suggested to Mr. Barnes, of Exeter, the employment of an india rubber
bottle, of sufficient size to fill the vagina, and having  upon  one  side of it a
small piece of  sponge, to be applied to the fistulous  opening.   Mr. Barnes
used  this  with great  benefit  to his  patient.2  M. Duges  has  proposed a
similar plan, but the pessary was made  of different materials.3   Dr. Evory
Kennedy has succeeded in taking  casts (with wax) of the vagina,  with the
fistula, in several cases ; and from them he made moulds, and had caoutchouc
bottles cast in  the moulds.   These were large enough  to fill the  vagina, and
to close both the fistula and the outer opening, so as  entirely to prevent the
escape of  urine. ' I have attained  the same  object by means of a  piece of
sponge covered with  thin bladder.   It should be  large enough to fill  the
vagina, and  of a suitable shape.  A narrow neck,  of  the dimensions of the
vaginal orifice, is to  be formed, by wrapping it with twine, which  is to be
covered with lint.  The whole has much the shape of an egg-cup.   It should
be dipped in oil previous to being used, and then it can be easily introduced,
and the stalk filling up the external orifice, no urine can escape.    It can be
removed and replaced by the patient herself.
   Various other suggestions have been made, but either of these plans will
relieve the patient from the  constant  dribbling and offensive odor, and will
allow the excoriations to heal.
   If the patient  cannot pass water with the plug in situ, she should learn
to withdraw it and re-introduce it herself.  Dr. Burns states that " Dr. Bal-
manoo showed me a patient  who derived  much comfort from having a hollow
tin globe,  like  a pessary, inserted into the vagina.   It was perforated at the
upper part, like a pepper-box, and from  the under  a catheter  descended,
which entered into a  flat flask, suspended between the thighs.  Little or no
urine escaped by the vagina."4

   743.  III.   Vesico-utf.rine and  Vesico-utero-vaginal Fistulje.—M.
Jobert, in his recent work,5  has entered very fully into some variations from
the ordinary vesico-vaginal fistula, to which it is right that  I  should briefly
allude.   The  first  of these is the  vesico-uterine—when  the  opening is
directly from the bladder through the uterine parietes, without injury to the
septum between the bladder and vagina; and the second—the vesicoutero-
vaginal—in  which there is  a fistulous communication between the bladder,
uterus, and vagina.   Dr. Bozeman doubts the existence of the former, but I
have proof that he is  mistaken.
   The extent  of destruction in either case varies very much : there may be
a small perforation with  smooth edges, a ragged wound, or very  extensive
destruction of  the parts involved.
  744.  Causes.—In  the  majority of cases, so far as we know,  the method
of production  is  mechanical in the first instance.   A large fcetal head, a
tight  pelvis, or a prolonged second stage  of  labor, may give rise to inflam-
mation  and  sloughing from pressure, and if the cervix  uteri  have been
brought down  before  the head into  the pelvis, pressure on this part  may
determine  the complication of the uterus with what would otherwise be a
  1 Davis's Obstetric Med., vol. i. p. 128.        2 Med.-Chir.  Tivans., vol. vi.  p. 58G.
  8 Duparcque, Ruptures de I'Uterus, p. 339.     4 Midwifery,  p. 93. note.
  5 Traite des Fistules Vesico-Ute'rines, etc.  Paris, 18-52. 
506
VESICO-VAGINAL  FISTULA.
simple vesico-vaginal fistula,   Xo doubt the awkward or violent use of the
forceps may also inflict this injury.
  Dr.  Simpson has  shown, however,  that  vesico-uterine,  vesico-rectal, and
utero-intestinal fistulae, may be the result of a very different cause—viz., of
pelvic abscess opening into the bladder and uterus, the bladder and rectum,
or the uterus and  some  part  of the intestinal canal.  The cases he relates
are very  interesting, and  that  of vesico-uterine fistula the more so, from a
cure having apparently  taken place from  spontaneous contraction  of the
openings.1
  Perhaps a post-mortem examination alone could have made us, in the first
instance, acquainted with the exact nature of vesico-uterine  fistula;  but
now that it has  been ascertained, there is no real difficulty in making out
the case.  There is incontinence of urine  ; a careful examination with the
finger in the  vagina and a catheter in  the bladder will show  that in this
canal  there  is no  breach  of surface :  an  examination with the speculum
allows us to see the urine welling up through the os uteri, and  finally if we
pass the  catheter through the fistulous opening in the bladder, we can touch
it with a metallic  sound passed into  the  cervix  uteri.   In a  case  which
came under my care there was no difficulty in coming to a positive conclusion
by these  means.
  Vesico-utero-vaginal fistulse present the  same symptoms as the more sim-
ple  vesico-vaginal  fistulas, only that,  on  examination, we find a greater
extent of destruction, the anterior  lip  of the  os  uteri being more  or less
destroyed.   The  urine escapes in  every position, and the  catamenia are
discharged mixed with urine.
  The prognosis is  more serious, inasmuch as  the  uterus has participated in
the injury ; it is possible  in either variety, but  especially in  the first, that the
sloughing may extend so  far as to compromise the life of the patient.
  745. Treatment.—1.  Prophylactic.   It is as  yet  an unsettled question
how far  we may be  able to prevent so melancholy a consequence of  labor.
When we recollect that the cause is, first, pressure of the cervix between
the  head of the  child and the symphysis pubis, and secondly, general pres-
sure of the vaginal  parietes from the head  being  too long detained in the
pelvic cavity, we cannot  doubt that, in some  cases at least, we have the
remedy in  our own hands.   If, when the  os  uteri is dilatable, the  anterior
lip  be gently pushed up above the  head during an interval, and maintained
there during a pain, it will escape injurious pressure, and this is not difficult
to accomplish.  Again, a labor prolonged in  its  second  stage, so much as
to  occasion inflammation  and sloughing, will  generally be found  to have
exceeded the period when assistance becomes necessary;  and if the forceps
be admissible, they  will  be safer in careful hands than  the delay.   When the
forceps cannot be used, the alternative is either further delay or craniotomy;
the former of which may incur the risk of this  injury, which should therefore
always be taken into consideration in our decision.
  746.   2.  Curative:  a.— Vesico-uterine  fistula.  An attempt has been
made, by plugging  the canal of the  cervix uteri, and keeping a catheter
constantly  in the bladder, to  prevent  the passage  of the  urine through the
wound, and so afford it an opportunity to heal.  Again, it has been advised
to  apply the  nitrate of silver to the fistula, but, to say nothing of the diffi-
culty, neither of these plans  appears to have  been successful.   One of M.
Jobert's  plans is as follows :  he dissects off the  reflected vagina from the
anterior  lip until  he arrives  at the fistula, the borders of which are to be
refreshed with the bistoury, and sutures applied in the situation most suit-
able to the direction of the wound.  A second  method consists in an attempt
to close  the communication between the uterus  and  vagina, leaving open
1 Ed. Monthly Journal, Dec. 1852, p. 532. 
RECTO-VAGINAL FISTULA.
507
that with the bladder, by first dividing  the- cervix laterally, then  dissecting
the vagina  from the anterior lip, and uniting it by section to the posterior
lip.   He gives a case of complete success by this latter process.
  In thecase which came under my care I adopted a simpler plan ; I pared
out the  inner surface of the cervix uteri, and put in four silver sutures with
Bozeman's button  shield, which I removed on the fourteenth day.   I found
the orifice much less,  but not entirely closed.   I  intended to repeat the
operation, but as the patient found she could  retain urine  for three hours
without any escape she felt  her condition  so much  improved  that she de-
clined any further attempt.   Since then I  see that a  German physician, Dr.
Simon, has succeeded in completely curing a  case in this manner.
  b. Vesico-utero-vaginal fistula.—In this complication M. Jobert proposes
three different operations.   The  first consists  in dissecting off the vagina
from the  remains of the cervix, then  paring the borders  of  the fistulous
opening, and lastly in uniting  by suture the remains  of the cervix with the
edges of the vesico-vaginal opening ;  the second, in dissecting off the vagina
from the cervix, in dividing this latter at each side,  and after refreshing the
edges of the fistula, in  uniting by suture the  posterior lip of the os uteri to
the edges of the fistula.  The third differs only in a depression being made
in the anterior lip to  fit more accurately the  edges of the vesical  fistula.1
 If necessary, incisions may be made laterally in the vagina, or semicircularly
 at its orifice, to relieve  the strain upon the ligatures.  M. Jobert gives the
 details of four cases, three of which he states were cured.

   747.  IV.  Recto-vaginal Fistula.—There can be no doubt that recto-
 vaginal  fistulas  are less frequent, and more easily cured, than  those  fistula?
 which involve the bladder.   There are a few  cases, but very  few,  on record,
 where this defect was congenital;  most commonly it arises from causes con-
 nected with labor, as in the  case of vesico-vaginal fistulas, that is, from .too
 prolonged pressure of the  child's head  giving  rise  to  inflammation  and
 sloughing, or from the  awkward use  of instruments;  and in addition it may
 occur as a laceration, or from disease of the rectum, or from a pelvic abscess.
 This injury may exist  alone, or it may be combined with a vesico-vaginal
 fistula.
   The  extent, situation, and direction  of the wound may vary to  any ex-
 tent, but in  almost every case the sphincter ani is  uninjured.   When we
 examine the parts, the mucous membrane of the vagina and rectum is red
 and congested, the mucous follicles unusually developed,  and the septum
 thickened when the injury is  recent, but  when of long standing,  the edges
 are hard and cicatrized.
   748.  Symptoms.—The edges of the wound, at least when recent, secrete
 a certain quantity of  matter, which is discharged  by one  or  other outlet.
 When very recent, the vagina may be  found inflamed to a greater or less
 extent, and  giving  rise to  a purulent discharge.    But the characteristic
 symptom is the escape of air or fasces through the vagina, which, however,
 may be  modified  by various circumstances.   When  the fistula is small  or
 oblique, air may escape,  but the fasces will be retained unless they are very
 fluid.  Unless  the opening  be  direct and large, solid matters  are rarely
 passed, but their presence at the orifice is a continual irritation.   When the
 opening is of sufficient size,  fascal matter and gas escape involuntarily, and
 the condition of the patient is most  pitiable.   Even if the bodily injury did
 not affect her health, her distress of  mind in addition is generally sufficient
 to do so ;  she is cut off from society, and in the solitude of her own suffer-
 ings, her spirits and health are apt to deteriorate.
1 Traite" des Fistules, etc., p. 70. 
508
recto-vaginal  fistula.
  In some cases, however, matters do  not  become  so  desperate, although
such instances  are  not common.   For example, when the injury is small in
extent, and  the result of laceration rather than sloughing, it may heal with
quiet and care ;  or, if small, it may be closed  by granulations or by the
formation of something like a flap  or valve.  I had  a patient who had a
small recto-vaginal fistula  for several years, through which nothing passed
unless  she took physic or had a diarrhoea, and from which she suffered very
little annoyance.
  749. Treatment.—The methods  of cure do not differ much from those
I have enumerated for  vesico-vaginal  fistula;  they  are, however,  more
easily  applied.   These  are,  1, cauterization ;  2,  compression ; and 3, the
suture.   Whichever we  try, we  must  remember  that  the entire  fistulous
opening must be included.
  When the fistula is small, cauterizing by the  acid  nitrate of mercury,
nitric acid,  nitrate of silver, or  the actual  cautery, has  succeeded in the
hands  of  Dupuytren, Amusat, and others ;  and if it fail, we may pare the
edges of the wound from the rectum to the vagina, and apply sutures, with
absolute quiet  and  rest.   Cases of cure  by these means have been recorded
by Xoel, Saucerotte, Fielding, Portal, Mott, etc.,  etc.
  M. Cullerier, Sr., proposed compression, and invented an instrument for
the purpose, which he said succeeded ;  but it seems to  have failed in other
hands.
  The insertion of a seton has been tried by Dr. Barton, of Philadelphia,
in the  case of a recto-vaginal fistula following an  abscess, and with success,
but it can only be suitable in very rare cases.
  As M. Jobert observes, although some or all of these methods may suc-
ceed when the  opening is moderate,  there remains a class of cases in which
they must fail,  because  of the  extent  of the  mischief.   For such cases  he
has  proposed a plan, which  he terms  "autoplastic par glissement," which
consists in renewing the edges of the  fistula, in the insertion of the inter-
rupted suture,  in  relaxing  the  surrounding tissues by incisions, in appro-
priate  regimen.   The patient being placed  on her back, with  the thighs
drawn upwards, the superior wall of the vagina is  to be raised by a univalve
speculum, and  the lower depressed  so  as  to bring  the fistula  into view.
Its borders  are to  be removed by the  knife, and  three or four sutures, ac-
cording  to  the extent of the  opening  from the rectum to the vagina,
inserted through the parietes of both vagina and rectum, guided and guarded
by the finger in the latter canal.  When all the sutures are  inserted, the
parts are to be cleansed,  and the  sutures tied.  Then there are to be made
incisions through  the  vaginal  parietes,  for  the purpose of taking off the
strain from the sutures, and  these may be longitudinal, transverse, or semi-
circular according as either is likely  to afford most relief.  After the opera-
tion, the patient must be kept quiet, and the bowels constipated  by diet or
medicine,  until  the  sutures are removed on the sixth day.  Every day the
vagina must be syringed  with  emollient fluids, and when the union  is com-
plete, the bowels may be freed by enemata.1  M. Jobert gives  three very
interesting cases  in which the operation was successful.  The  chances  of
cure will be greatly increased, nay, I almost think rendered certainties, by
the employment of wire sutures near together and Bozeman's button shield.
After the edges have  been well  pared in the whole of their thickness, the
sutures should  be inserted  at  a  sufficient distance  from the margins, and
should embrace the walls of the rectum as  well as the vagina.   Then they
may be passed through the  double row  of holes  in the shield, and twisted
tight enough, but not too tight.   The  shield may be  left on a  fortnight,
1 Traite" des Fistules, p. 340. 
LACERATION  of  the perineum.
509
and the  bowels (which must be constipated by opium) should be freed by
an enema the day before we remove the shield.

  750.  V.  Laceration of the Perineum. — When this accident is of slight
extent, it may not  interfere  with  the comfort of the patient;  but when ex-
tensive, it will be a cause of constant distress ;  and in either case the proper
cure of the  wound is  important; as, if callosities form, or irregular cicatrices,
much impediment  may be offered in  subsequent labors.  It  is  an accident
much more  common with first labors than afterwards.
  It will be recollected that when the head  of the child descends so as to fill
the cavity of the pelvis, it necessarily makes pressure upon the lower part of
the rectum  and the sphincter ani ; that it then receives  a direction forwards
and downwards, and successively distends the central space of the perineum
and its anterior border.  When the perineum  offers much resistance, as with
first children, the  mucous  membrane  of the posterior  wall of  the vagina,
owing to its laxity of connection with the subjacent tissue, is partially everted
and tonus a kind of artificial perineum.  This  is almost  always torn, but the
refit may extend no farther;  and if we examine the day after delivery, we
shall find this mucous membrane retracted, and  the true perineum untouched.
This is  not to  be confounded with the laceration of the true perineum, of
which we are about to treat.
   751. The situation and extent of the rupture vary according to the cause
and the circumstances of the  case.
   1. It may commence at the anterior border, and extend to the sphincter ani,
and this is  the most frequent extent.
   2. The  rent  may  involve the entire  perineum, and  extend through the
sphincter ani, laying the cavities of the rectum and vagina  into one.
   3. The central space of the perineum is  sometimes ruptured, leaving the
anterior edge (the fourchette; and the sphincter ani  untouched.  Cases are
related  by Hernu,  Coutouly,  Lachapelle,1 Meckel,2  Lebrun,3  Thiebaut,1
Frank, Martin,5 Moschner,6 Jungmann, Marter de Konigsberg,7 Trinchinetti,8
Merriman,9 Waller,10 Douglas,11 Jobert,12 Ellis,13 and Thatcher.14  And  a case
occurred in this city.   Dr.  Simpson has related the case of a perineal fistula,
the consequence and proof  of this occurrence, continuing  till the patient's
death, a year afterwards.15
   The rent may run  along  the central raphe of the perineum —on one side
— diagonally — or in the form of the letter  V or Y.   In most of the above
cases, the child actually passed through the central opening ; but in  some
cases, by careful management, it was transmitted through the natural orifice,
without rupture of the fourchette.16
  4. The recto-vaginal septum, sphincter ani,  and part of the perineum may
be torn, so  as to permit the transit of the child, leaving the anterior portion
of the perineum entire.
  752.  Causes. — The accident may arise from a deviation from the ordinary
mechanism  of parturition ;  from mal-conformation of the  passages or soft
parts ;  from mal-presentation ;  or from  mismanagement.

  'Duparcque, Ruptures ou De'chirures, etc., p 368.
  2Neue Jour, fur die Chir., vol. iv., 1811.   3 Annals de MeU Phys., July, 1825.
  4 Jour, de la Soc. de Me"d., vol. xxxiv. p. 178.
  5 Arch. Gen. de  Med. vol. xxxiv.          6 Bull, de Ferrusac.
  'Siebold's Journal,  vol. xi. p.  726.        8 Obs. sur l'Accouch. diff., Milan, 1819.
  9 Synopsis of difficult Parturition, p. 263, 4th ed.
  10 Waller's Note in Denman's Introduction, p. 36.
  11 Dublin Hospital Reports, vol. iii.        12 Bull, de la Soc. Med. d'Emulation, 1822.
  13 Amer. Jour, of Med., Jan. 1849, p. 260.  "Edin. Monthly Jour.,Jan. 1851.
  15 Edin. Monthly Journal, No. i. July, 1855.
  16 Denman's Introduction to Midwifery, p. 36. 
510
LACERATION  OF  THE PERINEUM.
  1. If the sacrum be too perpendicular, the head of the child, instead of
receiving its direction anteriorly, in the direction  of the  axis  of the lower
outlet, will be forced downwards upon the posterior portion of the perineum.
  2. If the arch of the pubis be too  acute, so as  to prevent the presenting
portion filling its upper part, extraordinary dilatation of the orifice  of the
vagina will  be necessary, and the head will be pressed with unusual force
upon the anterior part of the perineum.
  3. A similar effect is said to be  caused  by a thickened state of the urethra
and circumjacent parts, in the arch of the pubis.
  4. The too rapid passage of the head may be attended  with this  accident.
This may depend upon the extraordinary  violence of the  pains, or  upon the
small size of the head, which prevents its receiving the successive changes of
direction from the plane surfaces of the pelvis, and  the changes in the axes
of the cavity and lower outlet.
  5. Exostosis in any part of the  pelvic  cavity may so act upon the direc-
tion in which the fcetal bead is propelled, that rupture of the perineum may
result.
  6. Excessive breadth  of  the perineum,  by receiving the force  of the
descending head in  its centre, may be  a  cause of laceration, because  the head
rests in the centre, and distends it, instead of gliding forwards to  the ante-
rior edge.
  7. Bigidity of the perineum, or an  old  cicatrix  may  resist the dilating
power of the  head,  and ultimately  give  way  under the employment of
greater force.
  8. The tissue  of the perineum  may  be weakened by  disease, or  by too
much pressure, so as to offer little  or  no resistance.
  9.  Occlusion of the lower  outlet by  the hymen.  As this  membrane,
though much thinner than the perineum, is far less  distensible, if it do not
give way, the perineum may.   I attended  a  case in which  the hymen resisted
the pressure of the head (with strong  pains) for two  hours after the  perineum
was perfectly distensible,  and in which  there was  every probability that the
perineum would have been lacerated,  had not the hymen ruptured.  Lacera-
tion of the hymen may also be extended into  the perineum.
   10.  Mal-position of the child's head,  by presenting a longer diameter than
usual to the lower outlet, may give rise to this accident.
  11.  Mal-pjresenlations.—Face  presentations, involving the passage of the
head in its longest diameter  over  the perineum ; breech, or footling cases,
which do not receive a  proper direction so readily as the head,  may also
lacerate the perineum.  Dupuis relates  a  case, where one foot came through
the vagina, and one was forced through the perineum.
   12.  The accident may  arise from the woman being awkwardly placed for
delivery, or from her starting awai/ from the attendant;  or from her exert-
ing too much voluntary force at the time  the  head passes through the lower
outlet,
   13.  The perineum may be torn, in  consequence of want of care  when in-
struments are used.   They ought generally to be removed just as  the head
passes through the vaginal orifice.
   From this detail of the causes which  may produce or predispose to  lacera-
tion of the perineum, it will be seen that it may not always  be in our power
to  prevent its occurrence.
   753.—Symptoms.—If  the laceration be very slight, no ill consequences
will ensue ; the parts  will either  heal  or contract, so that an examination
would scarcely reveal the fact; if it extend to the sphincter, the patient may
feel a want of support at the lower outlet, and a sense of  " falling through ;"
but even in such cases,  such is  the  wonderful reparative power of  nature,
the mischief is often remedied.   I have  seen many cases  in which  at first 
LACERATION  OF  THE PERINEUM.
511
there seemed no prospect of relief but in an operation, recover and suffer no
inconvenience.   On examining such cases after recovery, I found the vaginal
orifice not  much larger than natural,  but  more posterior, with its borders
thickened and  contracted as if in  process of and to facilitate contraction, the
vulva had been somewhat drawn  backward.   I am now so satisfied of this
as a not unusual  process, that unless I had the opportunity of inserting
sutures within thirty  hours after delivery, I should postpone  all operative
interference for  six months  or more.    It  is said to influence  subsequent
cohabitation, and though I doubt it, may favor procidentia of the uterus.
   If the recto-vaginal septum be torn, the condition  of the patient will be
very pitiable.  The fasces (for some time at least) pass through  the vagina
involuntarily,  and  the utmost attention to cleanliness  will  not suffice to pre-
vent the offensive smell, which  renders the patient an  object  of disgust to
herself and her friends.  The lochial discharge passing over the  wound will
 for a time  prevent any natural efforts  at cure ;  and  the  edges may become
 callous, or degenerate into ulceration.
   754.  Treatment.—1.  Preventive  management.—A few words may not
 be misapplied in pointing out the best mode of preventing this occurrence.
   1.  Defects  in  the  passages,  which render the  mechanism of expulsion
 inefficient, may often  be remedied by the application  of the hand in such a
 manner as to  give a direction forward  to the head.
   2. Direct support  should be given to the perineum when distended  ; but
 this is frequently carried to excess, and  produces the accident it is intended
 to prevent; it should be moderate  and gentle, just  so much  as to support
 the parts,  but no more.   I must altogether object to any attempt to retard
 the passage of the child, as erroneous  in theory, and mischievous  in practice.
    3. When the perineum is rigid  and undilatable,  benefit may be derived
 from fomentations with hot water, the use of warm oil, lard, or pomatum.
    4. Under  no  circumstances is it justifiable to dilate the external orifice
 with the  hand, as formerly recommended; on the contrary, instead of draw-
 ing back the  perineum, it ought to  be carried forward.
    5. If laceration be  threatened in  consequence of the persistence of the
 hymen, it may be incised with a blunt-pointed bistoury.
    6. The patient should always cease forcing, and cry out or  remain per-
 ftctlv quiet during the exit of the child.
    755.  2. Curative treatment.—Slight cases, as I have said, will generally
 heal without  assistance.   Even  when  the  rent is more extensive, a cure may
 be effected without further  interference than great  cleanliness,  keeping the
 patient in one position, so as to preserve  the edges of the wound in contact,
  and constipating the bowels  after free purgation.   If this do  not succeed,
  we are advised  to use a degree of  compression, passing a binder around the
  hips, and a pad on either side  of the perineum, so  as to secure the apposi-
  tion'of the  lips  of  the  laceration.  Strips of  adhesive plaster have been
  applied, but  they do not answer.   In many cases either of these  plans has
  succeeded, but  in many cases  also they have both failed, especially when the
  recto-vaginal septum is involved.  However, we have still another resource-
    In the suture,  which was first proposed by Ambrose Pare, and practised
  by Guillemeau  La Motte, Saucerotte, Trainel, Xoel, Dieffenbach, Roux, etc.
  Before this can be attempted, however, the primary inflammation must have
  subsided • nor  is it forbidden, even though a considerable time  should have
  elapsed  ' M. Montain cured  a case  on  which  he  operated thirty-six days
  after deliverv and others have succeeded at a more distant period.
    Three different kinds of suture  have been adopted—the interrupted, the
  twisted and  the quilled suture.  Osiander, Dieffenbach,  etc.  succeeded with
  the first  but according  to  Duparcque,  the success and  failure have beeu 
512
LACERATION  OF  THE PERINEUM.
nearly equal.  Mr. Alcock cured  one,1 and Mr.  Raver  two patients in this
way.  Dr.  Mettauer,2 of Virginia  i,U.  S.), succeeded with metallic sutures;
they were  introduced, and  the parts approximated,  by twisting  the ends
together.   They were removed in six weeks, and union found to have taken
place.   The great objection to the interrupted suture is, that the lips of  the
wound are not  closely applied in the whole  extent, and the union is often
partial.3
   The same observation may be applied to the  twisted suture,  although it
has succeeded with Morlanne, Saucerotte, Xoel,4 Dieffenbach,5 etc.  M. Lan-
genbeck's method of operating consisted, 1, in separating for some  little dis-
tance the anterior wall of the rectum from the posterior wall of the vagina;
after removing the surface of the  laceration, in applying sutures, beginning
at the rectum ; 3, in  including the angles of the  torn vagina  in the last
suture, at the fourchette, by which  means the canal  of the vagina is com-
pleted, and any discharges carried off; 4, in  tightening all the sutures after
all have  been  inserted ;  5, in taking off the strain upon them, by making an
incision through the skin on  each side of them.6
   M. Jobert has used a new kind of suture ;  " after paring the edges of the
wound, he  threads a broad lace lengthwise through them, and  then drawing
the  lace, he pinches  all the edges to a point''7 precisely as the  mouth  of a
bag is closed by drawing the string.   One case of cure is quoted.
   M. Reybaud  passes a row of pins through  the pared edges of the  fissure,
with the points to the  vagina, which are to be guarded by slips of gutta
percha ;  the edges of the fistula are to be  brought together by  tying  the
corresponding pins' heads with waxed thread.8
   The quilled  suture is evidently better adapted  for the purpose, as  the
entire surfaces of the  laceration  may  be brought into contact.   Dupuytren
succeeded  once, Roux  and Dieffenbach  several times, M. Dubois failed,
but Mr. Davidson  succeeded completely.  He thus relates the case :9 "On
the 6th of X^ovember,  1838, in company  with  Dr.  Henry Davis, I performed
the  operation in  the following manner :  I passed deeply  a strong  double
ligature, by means of a common curved needle, close by the edge of the rec-
tum, and another, rather more than  half an inch from the  first, towards  the
vagina;  after which I pared the edges of the wound, which I had  not pre-
viously done, that  I might not be annoyed by the oozing of blood, so as to
be enabled  to  place the ligatures more accurately.  The ligatures being intro-
duced, I employed, as cylinders, two pieces of elastic gum catheter,  about an
inch and a half  in  length, one  of which  was  placed in the loops which  the
double ligature  formed on one side, and the  other between  their  separate
ends, tying them firmly upon the cylinder. Baron Roux found, in  his cases,
that the  use of  the quilled  suture caused an eversion of the edges of  the
wound ;  to remedy this,  he had recourse to several small sutures, at different
points between the different ligatures.  To effect the  same  object,  and  also
with a view of keeping the divided parts more closely and firmly in contact,
I adopted  the following  plan, the materials for which I had prepared  pre-
viously to the operation  : I armed a curved  needle with a piece of  narrow
tape, four inches long, having a knot at one end ;  this was passed down each
end  of both cylinders about  half an inch, and brought outwards, the end of
the tape being prevented slipping through by the knot; the tapes were then
placed in such a situation as to be intermediate to the ligatures; this being
done, I turned the cylinders gently towards the edge of the wound, and tied
the corresponding tapes  over it, which, I think, rendered it much more solid
  1 Merriman's Synopsis, p.  110.      2 Ed. Med. and Surg. Journal, vol. xix. p. 552.
  3 Cooper's  Surgical Diet. p. 1209.    * Capuron, Mai. des Femmes, p. 4*'.>
  5 Lancet. March 3d, 1838.         6 Gazette des  Hopitaux, 22 Jan., 1853,  p. 33.
  ' llanking's Abst., vol. xxi. p. 200.   8 Ibid.,  p. 201.   9 Lancet, May 4th, 1839. 
LACERATION  OF  THE  PERINEUM.
513
than any number of small ligatures could  have done."   The bowels were
constipated by opium, the urine drawn off night and  morning, and the diet
consisted of small quantities of  gruel and hard biscuit.  The ligatures were
removed  on  the  seventh day,  and union  was found to  have taken  place
throughout.  Of course we should  now use iron or silver wire sutures.  The
urine was evacuated naturally after nine or ten days, the bowels relieved 013
the seventeenth, and after six or seven weeks she was  able to go about as
usual.   Dr. Codes has rarely succeeded in curing, though  he has diminished
the rent.   If there  should be  loss of substance, or contraction  of the two
sides of the perineum, so that they will  not readily meet or remain in con-
tact, Dieffenbach  makes  an incision through the skin,  on each side.  Dr.
Horner has suggested that the sphincter ani should be divided on each side,
in order  to allow the parts to remain in contact.  In  one case he also con-
structed  a flap for the upper and  lower  half, from opposite sides, so as to
supply the  loss of substance.   His plan  of dividing the sphincter has been
also recommended by Messrs. Copeland, Bransby Cooper, and Baker Brown.1
The latter  gentleman,  who  has  published several  successful  cases,  also
advises constipation for some time after the operation.  He takes a large
superficial portion from each side, and passes three ligatures deeply through
the parts, and three superficial ones, so as to secure the exact apposition of
the edges of the wound.   The bowels should be freed well before the opera-
tion, and opiates given, so as to constipate them ;  when  union  is attained,
this may be remedied by an  enema.  The catheter must be  passed  morning
and evening for some time.
   [In  Dr.  Horner's case the  rupture occurred  in  a young married lady
during her first accouchment;  but  it was only after the birth of her second

              [Fig.  193.]                          [Fig. 194.]
 Lacerated Perineum. —1, 1. Vulva.  2. Anus.      Lacerated Perineum. —1. 1. Vulva.  2. Anus.
3,4. Lacerated perineum. 5. Ki-jbt flap. 6. Left    3. Upper or left flap.  4. Lower or right  flap.
flap.  7. Clitoris.                          5. Clitoris.
child that the case came under his notice.   The  laceration extended  from
vulva to anus ;  the open parts were cicatrized  to about an inch in depth,
presenting  a  fissure  extending from near the  os coccygis to the clitoris.
           i On the Rupture of the Perineum and its Treatment.  1852.
      33 
514
LACERATION  OF  THE PERINEUM.
The patient, of rather a full habit, and well organized in other respects, was
rendered miserable and helpless by a want of control over the natural evacua-
tions, and by a constant tendency to diarrhoea, only to  be restrained by the
continued use of opiates.  Much of the fceeal  matter passed forward through
the rima vulvae, which added to the distress of her situation.
   An operation was performed in the usual way, by paring off  the cicatrix
of each margin of the perineum, and  then  fastening it  carefully with inter-
rupted  stitches  along the  rectal and  vaginal  edges  of the rupture, the
sphincter ani  muscle being divided on  each side  the  anus ;  a procedure
which  Dr. H.  considers proper in all  old cases of the kind.  Unfortunately,
the menstrual  flux came on  prematurely, and everything like adhesion gave
way.
   Xearly fifteen  months  subsequently a second  operation  was performed.
Additional difficulties had now to be contended against.  The portion pared
off from the perineum had reduced its extent; the slit from the  vagina into
the rectum  had  been elongated  or deepened.   If the  attempt  to produce
permanent lateral adhesion  had failed before, its success was still less pro-
bable  now.   Under these considerations Dr. II.  determined  so to modify
the operation, that  if unsuccessful the condition  of the patient should, at
least, not be rendered worse by it.  The patient being  under the influence
of a mixture of chloroform  and ether, two flaps were made from the  peri-
neum and adjoining parts of the vulva, the  one on the right and the other
on the left.
   By placing  the base of the right flap below, and the base of  the left flap
above, the crossing of the two flaps formed a partition between the rectum
and vulva ;  the  free side  of the  right  flap  forming the upper  part of the
rectum, and the  free side of the  left the lower part of the vagina.  The
approximation of the  flaps and  the  contiguity of their raw surfaces  were
secured by interrupted  stitches along the rectum  and vagina.   In forming
the left flap, owing  to a sudden  contraction, its transverse  part being first
made,  was not as desired,  but fell short of Dr. H.'s intentions.   For the
first ten days or so there was a strong indication of success.  A large firm
stool  now occurred, and  on examination immediately  afterwards the  flaps
were  found not to be adherent.   They were, however, in situ,  so that the
partition formed  by them between  the rectum and vagina was still kept up.
In a month after the operation  the  left flap had become  shrivelled away
almost entirely, and  the right flap had lost one-half its  original size ; it still
remained, however,  as a barrier between the two canals ; and by the intro-
duction of a linen compress into the  vagina, upon the flap,  so as to keep it
in its  place, the discharge of feces was to  a great extent regulated.  The
patient felt the call  for defecation, could make  timely  provision for it, and
was much improved  in respect to comfort.   An examination of the patient
six months after the operation showed that the  indications of an operation
having been performed  had subsided.   Upon a superficial examination there
appeared to be a regular division  between the anus and vulva—an  actual
reproduction of the perineum.  There was in fact, however, only the claus-
trum made  by the operation—its edge was  still loose,  but it had the  effect
of directing the  discharges from the rectum backwards, and those from the
vagina forwards.  The recto-vaginal fissure had diminished much in depth,
and the condition of the patient had  been much improved.  She could par-
ticipate in her house-work—had a  much better control of flatulent and fceeal
discharges than formerly, and was apprized  of their approach.   "It yet re-
mains to try," says Dr. PL, "whether by a protracted application of the
milder escharotics to the  free edge of the new claustrum, a  perfect adhesion
of it may not be  obtained."
   In performing  the  operation described  above, Dr.  Horner  recommends 
INVERSION OF THE  UTERUS.
515
that the vertical incisions for the flaps be first made, as the  relaxation of
the tension of the parts  affects much the state of the flap when the trans-
verse cut is first made, and thus interferes with the plan of the operation.1]
  The diet should be spare : a little gruel and biscuit will answer very well.
Of course, absolute rest is necessary.
  "If the radical cure fail," Dr.  Bums  observes, "the patient  must use a
compress, with a spring  bandage, if the  stools cannot-be retained.   But it
sometimes happens that  the torn  extremity of the rectum, or the anterior
parts, containing  a fragment of the sphincter, or a portion of the internal
sphincter, as it has been called, forms a kind of flat valve, which rests on the
posterior surface of the coccyx, so that the orifice now resembles a slit, and
the feces, unless very liquid, remain in the hollow of the sacrum, and  do not
pass  through  the vulvular orifice till an effort be made to expel.   Sometimes
the perineum  unites, but  the septum does not, and the inner  surface  of the
rectum protrudes  into the vagina.  In these cases the edges of the septum
must be made raw, and stitches used."
  In a case which I had  the opportunity of-seeing through the kindness of
Dr. Beatty, not only had the sphincter been torn through, but the  lacera-
tion  extended nearly two inches  up the recto-vaginal septum.  Dr.  Beatty
first  pared the edges of this  laceration down to the sphincter, and inserting
four  wire sutures, fixed them with the  button shield, which was removed on
the eighth day, and the union found to be  complete.  After  an  interval of
six weeks the edges of the torn  sphincter were removed, and three  or four
wire  sutures  inserted and tightened  by twisting.   A  rectum bougie was
kept constantly in the orifice, and the bowels were constipated for  a week
each time.   After eight clays  the ligatures were  removed,  and  the cure
found to  be  perfect.   The  patient  has now perfect command  over the
sphincters.
                     CHAPTER XXIII.

          PARTURITION.—CLASS  III.  COMPLEX LABOR.
             ORDER 6.  INVERSION OF THE  UTERUS.

  156.  This  is a very rare complication, but  a very distressing and  dan-
gerous one.   It is neither more nor less than a turning of the uterus inside
out.  The fundus descends through the os uteri, forming a cavity lined by
the peritoneum, open towards the abdomen, and containing the ovaries and
fallopian tubes, whilst that which was formerly the lining membrane of the
uterine cavity, has become the external covering of the tumor.
  The deo-ree of inversion  may vary : it may be partial  or complete.   Mr.
Newnham5 who has published a  valuable  monograph  on this  subject, has
spoken of  three  degrees — depression, partial,  and  complete  inversion.
With regard  to  the  first, he observes:  "The  fundus of the uterus is de-
pressed within its cavity,  but does not  form a tumor in the vagina. _  the
actual existence of this  stage of  the disease can  only be known by mtro-
i [Amer. Journ. of the Med. Sciences, Oct. 1850.] 
516
INVERSION OF  THE  UTERUS.
 ducing the finger into the  uterus, and  by ascertaining  the  state  of that
 organ by pressure upon the abdomen.   By the  former process, the fundus
 of the womb will be found to have approached  the os internum, and by the
 latter a corresponding  depression will  be observed, instead of that regular
 contraction which is so familiar to every prudent practitioner.   This  state
 is generally accompanied with an  effort to bear down, by which  it is often
 converted into partial or even complete inversion."   Of  course, so slight a
 change in the uterus is only perceptible through the parietes of the abdomen
 when the patient has been recently delivered.  In the unimpregnated uterus,
 such an examination would yield  no information.   "When the inversion is
 partial," continues  Mr.  Xrewnham,  "the fundus  of the  uterus is  brought
 down into the vagina, forming a  tumor of considerable  size,  presenting  a
 semi-spherical form, and closely invested  by the os uteri.   In this  case the
 depression of the fundus, observed through the parietes of  the abdomen,
 will be considerably greater than in the former, "and the  edge of the cavity
 thus formed will alone be felt.   In the complete  inversion, the uterus will
 be found  not only filling the vagina,  but protruding beyond  it, resembling
 in its form  that of the uterus after recent delivery, only that its mouth is
 turned towards the  abdomen.   The os uteri may be felt at the superior ex-
 tremity of the tumor, forming a kind of circular thickening at its apex, and
 the uterus is wholly wanting in the hypogastric  region.   This state is usually
 accompanied with inversion of the vagina."1
   757.  Inversion may occur under very different circumstances;  as for ex-
 ample :  1.  Immediately after delivery, as the result of a peculiar Condition
 of the uterine fibres, of too quick delivery,2 etc.  Dr. Skae has recorded one
 which occurred after an abortion at four months,  and which was reduced
 twelve hours afterwards.3   2.  A few days after parturition, though Xewn-
 ham conceives that in these cases depression of the  fundus existed  from the
 first.  3.  Or very gradually, in consequence of a polypus attached to the
 fundus,  the uterus  not being pregnant.   Astruc, Capuron, and Xewnham
 doubt the existence of such cases ;  but several are on record,4 and I witnessed
 one myself, of the nature of which  no doubt could be entertained.5   We may
 be deceived, however, and suppose an inversion to have occurred gradually,
 because it has  remained long  undiscovered.   Levret mentions a  case oc-
 curring after delivery,  which was not detected for five years.
   By almost all authors, inversion has been divided into acute  and chronic;
 not,  however, confining the term  chronic to cases  where the production of
 the inversion has  been slow, but including all those where it has  existed for
 some time.  The division appears to me to be  useful and practical, though
 perhaps not conveying as much  information as the terms " reducible" and
."irreducible," which  Dr. Radford,  of  Manchester, has proposed as the
 substitute.
   758.  Causes.—Various causes are enumerated by authors,  some of which
 are real, and some only fanciful.   Most of them, however, are such  as would
 act merely mechanically.  It has  been observed to follow very quick labors,
 especially if the  patient  be delivered  standing, or if she make  too violent
 efforts.   It may occur spontaneously,6 after the labor  has been completed
 quite naturally, and in these cases it has been  attributed  by Dr. Radford to
 atony of the uterus, or to active contraction of one part, with  an atonic con-
 dition of another.   Dr. Tyler Smith regards inversion as depending upon an
 irregularly active condition of the uterus, by which the  fundus  is first de-

   1 An Essay on the Symptoms, Causes, and Treatment of Inversio Uteri, p. 2.
   2 Williams, Lancet, July 27th, 1880.    3 Edin. Monthly Journal, May, 1849, p. 773.
   •* Jourdan, Diet, de M6d., vol. xxiii. p. 289.
   5 Dublin Journal of Med. Sciences, Sept., Nov., 1837.
   6 Waller's Ed. of Denman, p. 241, note. 
INVERSION OF THE  UTERUS.
517
pressed, then  carried  downward by  the annular contraction  of the  uterus,
and, finally, completely everted.  Xauche considers the inactive state of the
uterus, and some effort made by the patient, or by an attendant pulling the
cord, as the principal causes.1   Capuron enumerates, as predisposing causes,
the development of the womb, the dilatation  of its orifice, and the atony or
flaccidity of its walls.   The exciting causes may be  the weight of the  fundus,
violent expulsive efforts, tractions by the funis, and  the dragging downwards
by a  polypus.2  Henkel  attributes  this accident to  violent  after-pains;
Meissner to a bodily predisposition, owing to a  laxity of fibre.  Siebold
savs, that atony of the uterus, with a large pelvis, and the too rapid abstrac-
tion  of the contents  of  the uterus, may expose the patient to  inversion.3
Boivin  and Duges enumerate, among  the principal  causes of inversion, a
flaccid, distensible  state of the uterine parietes ; inertia  of the uterus, espe-
cially if, at the same time, an  effort  be made for the extraction of the
placenta; irregular uterine  contraction, too prominent  sacral  promontory,
dragging at the  cord, and uterine polypus.*
  It is very credible, that violence in extracting the placenta may be followed
by inversion ;5  or, as Denman observes, "there is reason to believe that the
uterus has been inverted, when, on account of a hemorrhage, or some other
urgent  symptom,  the hand  has been  introduced  within the cavity of the
uterus while in a  collapsed or wholly uncontracted state, and the placenta
beino" withdrawn before it was perfectly loosened,  the fundus of the uterus
has unexpectedly followed, and  a complete inversion has been occasioned.6
Forcibly pulling the funis, for the purpose of detaching the  placenta, may,
perhaps, under certain circumstances, give rise to this accident, but it is not
a frequent cause.  Shortness of the funis, or the shortening of it by coiling
 around the neck of the fcetus, has also  been  alleged, but, I believe,  without
 any foundation.   Cords  of  ten  inches  long will permit,  and have permitted,
 the exit of the fcetus without displacing the womb, and it is very rare indeed
 to find the funis  so  short.    As to the shortening  of the cord  when it is
 twisted around the neck, this can never be  the cause of inversion, since it
 rarely occurs but  when the cord is longer than usual,  and  it very seldom
 reduces the length of the cord below twelve inches.
   But inversion may occur  quite unconnected with parturition, as I have
 already stated.  If a tumor form at the upper part of the fundus  uteri, it
 will  first distend  the uterus  mechanically, and then, by its  weight, it  may
 descend through the os  uteri, dragging the fundus after it, and  so produce
 complete inversion.   Such a case I saw in Jervis-street  Hospital, under  the
 care of Surgeon Lynch.   Cases of this  kind  are also  related by Dr. Browne,7
 M. Leblanc,8 Dr. Oldham,  and one, more  recently, by Dr.  Higgins,  who
 successfully removed  both the uterus and  the tumor with the knife, having
 previously" tied  a  tape around the  upper portion as a precaution  against
 hemorrhage.   The patient bore the operation well, and  recovered perfectly.9
   759. Symptoms. — We shall first examine the symptoms  which  arise in
 acute inversion, i.  e.,when it occurs soon  after delivery, and when  the dis-
 placement is  nearlv or quite complete.   These are always serious and alarm-
inn;,  indicating the' important nature of the  accident.   The  most universal
symptom is a  sudden exhaustion or sinking, which comes on  immediately
after the inversion.  It does not depend upon flooding, for it  occurs in  many
cases where there  is no hemorrhage.   The countenance becomes deadly pale,
the voice weak,  the pulse rapid, small,  and fluttering, nausea and vomitings

  » Mai. Prop,  aux Femmes, vol. i. p. 131.    2 Mai. des.^Femmes, p. 49-3.
  3 Handbuch der Frauenzimmerkrankheiten, vol. iii., p. 3Go.
  * Diseases of the Uterus, p. 137.           5 Manning on Female Disease?, p. 28.j.
  •Midwiferv  P  421.                     7 Dublin Med.  Journal, vol. vi. p. 33.
  "Mem de l'\cad. de Chir., vol. iii. p. 379.   9Ed. Monthly  Jour. July, 1849, p. 889. 
518
INVERSION OF  THE  UTERUS.
occur, etc., so that the patient is suddenly threatened with the extinction of
life.1  Several authors speak of more decidedly nervous symptoms, and even
of convulsions,2 but by some, at least, the restlessness and agitation preceding
dissolution,  appear  to  have  been mistaken for convulsions.  When the
inversion is slighter  in degree, these phenomena  will generally be found less
strikingly marked.   Hemorrhage, even to a very large amount,  not  unfre-
quently occurs,  aggravating, though not changing, the  symptoms already
enumerated, and materially enhancing the danger of the patient.   Mr. Newn-
ham observes, "When the  uterus has become inverted, immediate hemorrhage
takes place, which is quickiy  followed by faintness and a sense of fulness  in
the vagina, and in the greater number  of instances,  almost by immediate
dissolution."3
   Our suspicions of inversion will  be excited when  this persists longer than
usual, and an examination  should instantly be made to ascertain  the  cause,
if possible.   In many cases, however, there is no hemorrhage at  all, or not
in  proportion to the  inversion, but  merely the  nervous  symptoms and
exhaustion;  nor does the difficulty of rallying the patient seem to be less in
these cases than in those accompanied by flooding.
   There is  generally a very violent uterine contraction immediately pre-
ceding or accompanying the  inversion, leading  the patient to anticipate a
second child ; this supposition  is further confirmed by the pressure of the
inverted uterus as it passes  through the pelvis.  Even  on an examination
per vaginam we may be deceived, by mistaking the uterus for the breech of
a second child.  The patient  complains of great pain,  with a sense of drag-
ging from the loins,  and occasional retention of urine.  If pressure be made
on the abdomen, we shall  not be able to feel the contracted uterus, and this
being at a time  when it is large, constitutes a marked and valuable symptom.4
When the inversion is  incomplete, we may sometimes  feel  the uterus  above
the brim of the pelvis, but  having a cup-like depression superiorly.
   If we examine per vaginam,  we shall find a tumor either in the cavity of
the pelvis or  hanging through  the vulva.  This tumor is globular, sensible,
elastic,  with  a rough and bleeding  surface, wider below than  above, where it
is tightly encircled by the cervix uteri.  If the displacement be not reducible,
it sometimes happens that the  tumor is attacked  by inflammation, running
on into sloughing and  gangrene, owing  to the strangulation caused by the
contraction  of the cervix,  and  ending  in the death of the patient.   If the
placenta have not been previously expelled, it  will be  found adherent  to
some part of the tumor, adding greatly to its bulk.  A considerable  differ-
ence in the size of the tumor will be observed according as the inversion is
complete  or incomplete, recent or of old standing.   If quite complete, we
may acquire further  information from  a visual examination.   The tumor is
of a red color when the inversion is recent, but  gradually becomes of a dull
brown.5   If  incomplete, we shall  still be able  to  detect it in the vagina,
though, if there be depression merely, we may not be able to  reach it.
   760.  The  foregoing are  the most prominent symptoms of acute inversion ;
those which  characterize the chronic stage of the disease, whether that stage
be the issue of an acute attack  or the result of a gradual displacement, are,
of course, much less  formidable.  The patient is subject to occasional hemor-
rhages, and to a constant and profuse mucous discharge during the intervals.'
Every month the surface is  observed to be covered with  red drops, which
are in fact the menses.7   The patient complains of pain, a sensation of weight
in the pelvis, and dragging from the loins.   If the  uterus protrude through

   i Duncan's Annals of Med., 1800, p. 390.      2 Burns"s Midwifery, p. 518.
   3 Essay on Inversion,  p. 86.                * Denman's Midwifery, p. 420.
   5 Boivin and Duge=, Dis.  of Uterus, etc., p. 114.
   6 Gardien, Traite" des Ace, vol. iii. p. 325.    7 Clarke, Dis. of Females, vol. i. p. VA. 
INVERSION OF THE  UTERUS.
519
the external parts, its sensibility will gradually diminish, in consequence of
the formation of a kind of epithelium upon its surface ;  and if it be exposed
to rude contact,  or  if acrid secretions be allowed  to  accumulate upon it,
circumscribed inflammation may occur, followed by ulcerations,  either super-
ficial or profound, and involving some danger to the patient, if not remedied.
  The constitution of the patient sympathizes deeply with so extraordinary
an accident.  After recovery from the state of exhaustion or nervous depres-
sion into which she  was first thrown, the repeated hemorrhages and constant
leucorrhcea will  render  her countenance  pale and exsanguined, and subject
her to various secondary symptoms, such as syncope, dropsical effusions,
hectic, etc.
  161.  Terminations.—The  patient  may  die from  exhaustion or  from
hemorrhage soon after the accident, according to Heister,1 Peu,2 Levret,
Giffard, Windsor, Clarke, Denman,3 Boivin, and Duges ; or from the more
distant consequences of the repeated hemorrhages, as related by Mauriceau,4
Haighton, Cooper,  Windsor.   Fatal cases are also related by  Peu,  Portal,5
Vanderweid, and Millot, Chapman,6 Saviard,7 Heister,8  Smellie,9 and Mauri-
ceau.  Boivin and  Duges  add, that "death  following  a very few days after
the inversion, may have been occasioned by pains, convulsions, and syncope,
caused even by the violence which the uterus  has undergone."
   Distension and inflammation of the bladder may occur, involving con-
 siderable danger.10  The inverted uterus  may be strangulated, and be sepa-
 rated by sloughing or gangrene with great  danger, although  cases  are on
 record where this termination issued favorably.11 Or, if the  patient do not
 sink from the primary shock, and if no destructive  process take place in the
 tumour, it will, after a while, shrink very much in size,  and the patient may
 suffer comparatively very little annoyance.   Denman mentions the case of a
 patient who consulted him for an inverted  uterus twenty years before her
 death; and Lamotte another, " in which the inversion was  complete thirty
 years  before."  Very rarely the  detruded organ  has   become the seat of
 malignant disorganization, either cancer or corroding ulcer.
   762. Diagnosis.—The  facility of the diagnosis will depend very much
 upon the  extent  of the inversion ; when incomplete, it is very difficult, and
 even when complete it will often require great care.  It is less obscure if the
 examination be  made soon after the accident.
   1.  If incomplete, it may be mistaken for polypus uteri, but  it will be dis-
 tinguished by its bleeding and  rough surface,  by its insensibility, and by the
 "cul de sac" within the os uteri.   In a case published by Dr. M'Clintock,12
 the  diagnosis was by no means so easy.  The tumour was not large, nor
 peculiarly sensible, nor had it a rough surface ; moreover, there was some-
 thing  like a neck to it, and  a well-marked  os uteri surrounding it.   The
 finger alone could  not have distinguished it  from  polypus, but at no  part
 could a bougie be passed into  the uterine cavity, and  when the tumour was
 drawn down, all appearance of cervix and os  uteri  was  obliterated.
   2.  If complete, it will resemble prolapse  of the  uterus, but may be dis-
 tinguished by the period of its occurrence,  by the flooding, by the absence
 of the smooth vaginal covering of the bladder anteriorly, and of the os uteri
 inferiorly.
   3.  It may be  distinguished from prolapse of the vagina  by its hardness,
 its rough, flocculent, and bleeding  surface, and by its unvarying size.

    ! Surgery, vol. ii. p. 559.            2 Prat, des Accouch., p. 585._
    3 Midwifery p. 422.                * Traite" des Accouch., vol. ii. p. 294.
    5 Obs.  76.                        6 Midwifery, Case 29.
    7 Obs.  15, 36.                      8 Obs., Case 369.
    9 Midwifery, Case iii., p. 444.         10 Burns's Midwifery, p. 519.
   11 R van's Journal,  March 12th, 1836.   12 Dublin Quarterly Journal, Feb. 1859. 
520
INVERSION OF  THE  UTERUS.
  The value of some  of these characteristics, such as the  hemorrhage, the
state of the cervix, and the size  of the  tumor,  is  limited to a short period
after the accident, and to those cases which occur after delivery.
  763.  Treatment.—1.  Of acute inversion.  Our first object is unquestion-
ably to  reduce the displaced  organ ;  and if we are  on  the  spot when the
accident occurs, it is in  general not very difficult.   It  is of  the last  import-
ance that the reduction be attempted instantly.   Every hour increases the
difficulty, and the lapse of four or five, according to Denman,1 may render it
impossible.   The  period  when the inversion becomes irreducible,  will be
found to vary somewhat in different cases, and  according to the  experience
of different practitioners.  There is also a great difference,  according as the
inversion is complete  or incomplete.   It has  been  stated to have been
reduced spontaneously, when the fundus  uteri  was merely depressed,2 and
even when the displacement was complete.
  But no anticipation  of such an occurrence will justify our losing a  moment
in attempting to re-invert the  uterus    The  protruded organ should be
grasped firmly and passed  in through the vaginal orifice, followed by the
hand (previously  well  oiled,) which, when in the vagina,  should be closed
and formed into a cone, and made  to press mainly upon the fundus uteri.
X"o effect will be produced  upon the inversion  until  the vagina shall have
been put upon the stretch ; but  then,  after some  time, it will be found to
recede, and on being still further pressed, it suddenly starts from the hand
(like a bottle of  india-rubber when  turned  inside out), and the organ is
restored to its natural condition.   The hand, now  in the cavity of the uterus,
is not to be withdrawn, but rather allowed to be expelled by the uterine con-
traction.   This will insure  the patient  against a repetition of the accident.
We should also assure ourselves,  before the removal of  the  hand, that the
restoration has been complete.   I  need  not say  that (unless counter-indi-
cated)  the operation will be more easily performed under chloroform.
  Mr.  Xewnham advises  that we should endeavor to "return first that por-
tion of the uterus which was  last  expelled from the os uteri."   It will be
found very difficult to  attend to this minutely, when the hand with the uterus
is in the cavity of the  pelvis, for want of room ;  and whilst the tumor is
external, the re-inversion does not take place ; it is expressly stated  by seve-
ral authorities, that they did not feel the reduction properly commence until
the  vagina was stretched to its full  extent.
   7G4.  In many cases  the  placenta remains attached to the womb at the
period  of inversion, and different opinions have  been held as to the propriety
 of  removing  it before reducing the displacement.    Baudelocque, Gardien,
 Capuron,  Boivin  and  Duges, Radford,  and others,  recommend its prior
 removal;  but Denman, Clarke,  Burns, Carus,  X'ewnham,  Blundell, Gooch,
 etc., as decidedly oppose it.  Mr.  Newnham remarks, "It has been recom-
 mended by several respectable authorities to remove first the placenta, in
 order to diminish the  bulk of the inverted  fundus, and thus facilitate the
 reduction.   But it is surely impossible that this proceeding can be  attended
 with any beneficial consequences, whilst the irritation of  the uterus would
 necessarily tend to bring on those bearing-down efforts which would  pre-
 sent a  material obstacle to its reduction, and  would increase the hemorrhage
 at  a period when every ounce of blood is  of infinite importance."  "Besides,
 returning  the placenta while it remains attached to the uterus, and its subse-
 quent judicious treatment as a simply retained  placenta,  will have a good
 effect in bringing on that regular  and natural  uterine contraction  which is
 the hope  of the  practitioner and  the  safety of the  patient."   It  may be
 doubted, I think, whether  the removal of the placenta is attended with so
i Midwifery, p. 420.
2 Capuron, Mai. des Femmes, pp. 504, 509. 
INVERSION OF THE  UTERUS.
521
much danger ;  for in many instances it has been found  impossible to reduce
the uterus in consequence of the great addition to its bulk which the adhe-
sion of the placenta occasions ; and in such cases there is no hesitation about
the propriety of removing the placenta, nor have I met with any evil effects
recorded as the  result of so doing.   I  have no  doubt, therefore, that as
removing the  placenta would facilitate the  reduction  of the inversion  by
lessening its volume,  that  the proper  method in general would be to peel it
off before attempting to restore the organ.
   765.  When  the  tumor is in danger  of strangulation  from the circular
band of the fibres  of the cervix uteri, or in case such band should seriously
impede the reduction, it has  been recommended to divide it with a bistoury.
 Of course  the bladder and rectum  should  be  emptied previous to returning
 the uterus, unless we  are present at the moment the accident occurs ;  at that
 time, the operation occupies  so short a time, that catheterism may be defer-
 red until afterwards,  and  constipation  for twenty-four  hours  will rather be
 an advantage.   If the inverted  uterus and the neighboring parts should be
 much swollen, or if the patient be feverish, it may be necessary to take away
 some blood and foment the parts before attempting the reduction.
    766.  But should  the disease  be of some  days' standing, are we to look
 upon the reduction as hopeless ?  Certainly not.   There are cases on record
 of the attempt having been successful  after days and weeks have elapsed, and
 the condition  of  the  patient is so distressing  that no means, however appa-
■ rently unlikely, should be left untried.  In  Loffler's case, 6 or 7 hours had
 elapsed ; 17 in Mr. White's case ; 24 in Mr. Winter's ;  28 in Mr. Dickenson's ;
 3 days in Mr. Cawley's ; 7 in Dr. Radford's Tease 6) ; 8 in MM. Chopart's and
 Ane's; 8  in Mr. Ingleby's ;  10 or 12 in M.  Lauverjat's ;  13  in  M. Hoin's ;
 and 12 weeks in  Dr. Belcombe's.   Recently  Mr.  Canney1 reduced one of 5
 months'standing;  and M. Barrier,2 one of 15 months, both  under chloro-
 form ;  and I  have no doubt that this agent will be found of great value in
 facilitating the operation.  Plenck advises dilatation  of the os uteri before
 attempting the reduction, and  perhaps in some cases this may  be possible.
    If we succeed in  restoring the womb to its natural state  and  situation,
 great care will be requisite to avoid a recurrence of the accident, or, what is
 more likely, a prolapse of the uterus.  The  patient should remain  longer
 than usual in the horizontal  position,  with the head low, the pelvis elevated,
 and the knees bent.  A dose of opium will be  found very useful,  and, if there
 be much exhaustion, it must be repeated, and stimulants in proper  quantity
 be given.   A pessary has been  advised, in  order  to maintain the uterus in
 its place, but this will very rarely be necessary.  When the lochial discharge
 has entirely ceased, it may be beneficial to use  some astringent injections into
 the vagina once  or twice a day, especially if leucorrhcea be present.
    767.  If the inversion be irreducible, we  must then consider how far it
 may be advisable to  content  ourselves  with palliative  remedies, such as
 returning the  tumor into the vagina  to protect it from injury, and support-
 ing it either by a bandage and compress, as recommended by Dr.  Hamilton
 for prolapsus uteri, or by a pessary.
    Should this plan  not be practicable, or fail of success, it may then be a
 question as to the propriety of extirpation.    There is  abundant evidence to
 prove that life may be preserved after the loss of the womb.  Rousset relates
 a case where the uterus was destroyed  by gangrene, and  the patient recovered ;
 and Rousset, Primrose, Radford, and Cooke, have given cases in which the
 uterus  appears to have sloughed off, without compromising the patient's life.
 This being the case, there is every encouragement, within certain limits, to
 'effect that removal  by art which  nature thus so  beneficially accomplished.
           i Med. Times and Gazette,  Sept. 18th,  1852. p. 286.
           2 Ibid., Sept. 4th, 1852, p.  231, from Archives Gen., Mai, 1852. 
522
INVERSION OF TnE  UTERUS.
In this opinion Sir C. Clarke fully coincides:  he observes,  " In those cases
of inversion of the uterus where the woman has passed the menslru ding age,
when her comfort is destroyed  by the disease, and when the profuseness of
the discharge threatens her with death, from the debility which it produces,
it may be advisable  to  recommend the performance of an operation which
has  been attended  with  success, viz., the removal  of the  inverted  uterus
itself."   " How far  it may be right  to  resort to this operation during the
menstruating part of a woman's life,  the author has no means of judging."1
The operation, however, has been performed during the "menstruating part
of a woman's life," with complete success.   We may therefore conclude that
the operation is perfectly justifiable, provided 1st, that the patient is in a fit
state of health for  an  operation ; and 2dly, that the uterus be not affected
with scirrhus or cancer.
   The operation has been successfully performed by Ambrose Pare, Petit,
Carpi, Sclevogt, Vater, Laumonier, Bouchet, Boudol,  Dessault, Hunter of
Dumbarton,  Chevalier,  Johnson, Hamilton, Clarke  of  Dublin, Xewnham,
Windsor,2 Davis, Hull, Blundell,3 Moss,4 Lassere,5 Williams,6 Higgins,7 Ged-
dings, Teale, M'Clintock, etc.   Other cases less fortunate are on record.
   The operation  consists in applying a ligature  of silk, whipcord, fishing
line, or  silver wire, around the tumor  at  its highest part, and gradually
tightening it, as the  patient may be able to bear it, until the tumor is entirely
separated.    Or  a double ligature may be passed  through the centre  of the
neck of the  tumor,  and each  half included in  a separate ligature.   Or, as
was successfully done by Dr. Geddings,8 and Mr.  Teale,9 we may prefer, after
tightening the ligature to a certain degree, to remove the tumor immediately
by cutting below the ligature, or what  is simpler,  and  I  think  safer, the
tumor being drawn  down may be removed by the ecraseur,  as was done by
Dr. M'Clintock.   We must take care to include only the uterus and  not to
wound the peritoneum.   Before doing this, it will be necessary to satisfy our-
selves of the  adequacy of the ligature to restrain any hemorrhage.
   The symptoms which  arise after the  application of the ligature are just
such as we might expect from  the strangulation of so important a viscus.
The patient  suffers  from  nausea,  vomiting and pain, which greatly diminish
in the more favorable cases, but which are the prelude to peritonitis in the fatal
ones.  When these symptoms are violent, it will  be  necessary to  loosen the
ligature, and wait some hours before again tightening it.   A full dose of opium
should also be given,  and the bowels kept free by enemata.   The strength of the
patient should be maintained by a nutritious,  though  not stimulating diet.
   [Extirpation of the uterus, when it is the seat of no malignant disease, is
a terrible operation, and, even under the circumstances mentioned in the text,
of doubtful propriety.   Not only have some women lived  many years afflicted
with inversion, but  in several  instances without any great pain or suffering
in their general health.   In some cases, too, the uterus  has returned spon-
taneously, after  the  lapse of considerable time, to its natural condition, and
the individuals have conceived and borne children.   Several very instructive
cases of the kind are related by  Professor Meigs, in his edition of  Colombat,
two of which occurred under his own  notice.]
   If the inversion  be caused  by or complicated  with polypus, it may be
necessary to  remove both,  and  the polypus should be excised  before apply-
ing the ligature to the uterus.

  1 Diseases of  Females, vol. i.  p. 149.           2 Med.-Chir.  Trans., vol. x. p. 358.
  3 Diseases of Women, p. 144.     4Brit. and Foreign Med. Rev., April, 1837, p. 561.
  5Encyclograph. des Sciences M6d., vol. xxxvi. p.  179.
  6 Lancet, July 27th, 1839.                    7 Ed. Monthly Journal, July, 1849.
  8Charleston Med. Journal.  Ranking, vol. xx. p. 201.
  9 Med. Times and Gazette, Sept. 1,  1855. 
SUDDEN  DEATH.
523
                      C HAP TE R  XXIV.

                          SUDDEN DEATH.

  768. I do not know whether, strictly speaking, I ought to include among
complex labors that appalling occurrence  which many, perhaps most men of
much experience, have witnessed at least once  in  their lives, of  a patient
whose delivery has been natural, and whose condition such as to excite no
alarm, suddenly, and without apparent cause, dying.  A more fearful accident
can hardly be conceived, aggravated as it is  by the contrast of a few hours
before, and by the wholly unexpected nature of the event.
  But though  such cases do occur, and are now and  then registered in the
journals, comparatively little attention has been bestowed upon the subject
until of late.   Dr. Ramsbotham, sen., published a paper on the subject, which
was afterwards incorporated in his Practical Observations;x and the subject
is noticed by Mr. Travers,2 and Dr. Meigs.3   Very lately, Dr. Cormack* has
written upon the subject ; and  more recently it has occupied the attention
of the French Acadamy of Medicine.  But by far the most complete investi-
gation is an essay by my friend Dr.  M'Clintock,5 who has very kindly given
me permission to  make free use of the cases he has collected and published
therein.
  At present it is quite impossible to give  a complete and satisfactory history
of the subject;  probably the best plan I can adopt is to lay the cases before
the reader, classifying them so far as I am able, with such practical deduc-
tions  and  suggestions  as they may warrant.   In this, I do but follow Dr.
M'Clintock's arrangement, adding  a few cases from my own experience, and
some from various sources which may have escaped him.
  769. I.  Syncope.—It appears beyond question  that many of these cases
are examples of fatal syncope, though we are not able to trace its cause in
each case.   For example, Dr. Merriman  relates the  following instance:—
"An  accoucheur was once attending a young woman in labor of her  first
child.  Soon after it commenced, and during  his  absence, she fainted, with-
out any obvious cause.    On his return the circumstance was mentioned, but
as by this time  she appeared perfectly recovered, no further notice was taken
of it,  and she was safely delivered without any unusual symptoms.  On the
third day after the delivery she took a dose of aperient medicine, and while
in the act of relieving herself, fell back and immediately expired."
  One of the three cases mentioned  by Dr. Denman  certainly comes  under
this head.   He relates  it as follows :  " Another raised herself in bed to take
nourishment about half an hour after delivery.   She fell  back and  died im-
mediately.   She was opened by the celebrated Dr. Jenner.  There was no
effusion of blood in the brain or in any other part; but the heart was found
flaccid, perhaps somewhat enlarged, and not a drop of blood in either  auri-
cles or ventricles."6  The second case was that of "a woman in  labor who
was put to bed, and  made  an  effort to  change her situation ; she  died in-
stantly in the act of  moving, but she had previously complained of a pierc-
ing pain in  her head  and  loss of sight."  Another was in such a situation,
that the child was expected to be born the next pain ;  she threw herself back

  'Page 116, 2d Ed.                2Inquiry into Constitutional Irritation, p. 48.
  3 Woman and her Diseases, p. 557.    i London Journal of Medicine, vol. ii. p.  941.
  5 Med. Tress, Dublin. March 10th and May 5th, 1852.
  6 Introduction to Midwifery, p. 427. 
524
SUDDEN DKATH.
and died instantly.  The two  last cases are the only ones I have found in
which death took place before delivery.   I do not think  they died of apop-
lexy, but whether of fainting or asphyxia I cannot decide.
  The account given by the Rev.  Dr. Buchanan  of the death of his wife, is
a very graphic picture of fatal  syncope  occurring  about  the fourteenth day,
and is  the more interesting as the description of a non-medical person.1  Dr.
Simpson mentioned a case  to the  Edinburgh   Obstetrical  Society, which
appears to me to come under this  division.   " A  patient attended by one of
the pupils of the hospital, rose  up  and stood for the first time, about a week-
after  delivery.  She immediately fainted and expired."2   The Nashville
Journal of .Medicine and Surgery3 gives two cases of collapse after  parturi-
tion, which proved fatal, related  by C.  R. Winston, M.D., of Nashville,
Tennessee.
  Of a similar kind appear the cases  related by  MM.  Robert, Danyau, etc.
In M.  Robert's case, the  patient,  aged twenty-five,  who was much  excited
by political occurrences, was delivered of her third child.  All went on well
until the ninth day, when being assisted from her  bed, she  suddenly sank
down and expired.*  M. Robert has met with two  other cases :  one was a
primipara, the other had borne several  children, and both  died on the six-
teenth day.   A post-mortem examination threw no light  upon either  of these
three cases.   M. Danyau mentioned that MM. Dubois, Moreau, Baudelocque,
and himself, had each seen  similar cases.   In his case  the labor was easy
and the recovery excellent; he visited her on the twentieth day, and found
her agitated  and perplexed ;  in a short time afterwards she passed into an
adjoining chamber, and  there  died.  At the autopsy no  air was found in
the veins or heart; the only pathological change worthy of note was a vas-
cularity of the pericardium, and slight effusion into its cavity.
  Dr.  Chisholm has related a case of arm  presentation, in which he turned
and delivered with no more difficulty or  hemorrhage than usual, on Jan. 12th,
1S54.   She went on well until  the 19th, when he was suddenly sent for, and
found  her dead.  " The account given by her friends was, that while sitting
up in bed,  after having taken her  breakfast  as usual, she was seized with a
pain in her  back  which made  her scream out:  shortly  afterwards,  she  fell
back fainting ;  and having made a very  imperfect rally from this, soon
fainted again and  expired."   A post-mortem examination  threw no light
upon the cause of death.   There were no signs of asphyxia in the lungs, and
no traces of  disease anywhere  ; but the heart was rather softer and paler
than usual, and uncontracted, with clots in all its cavities.5
  Early in the year 1852, I was requested  by a  medical friend to see with
him a patient who had  miscarried a few hours before, with very little pain
and no hemorrhage.  On visiting her half an hour previously he had found
her fainting, without any ascertainable cause.  Although we were  not five
minutes  on  our way,  she was  dead before we  arrived.  X'o post-mortem
examination could be obtained, and  yet I think  that we cannot hesitate to
regard this as another example of fatal  syncope, and not death from organic
disease, for up to the previous day she had been in perfect health.   Some
time ago, I attended a  lady in a  miscarriage, who  had not  more than  the
usual  amount  of loss, after which she  felt very  faint, but recovered.  She-
went on quite well for several days, when suddenly one evening I was sent
for, as she thought herself dying.   I found that  she had become very faint,
without any  apparent cause, and notwithstanding every means that we could
try she gradually sank, and died in a few hours, with no  other symptom than
faintncss.  She had suffered a  good deal from morning  sickness, but other-
1 Memoirs of Rev. Dr. Buchanan, p. 378.
3 L'Union Medicate, 10 Jan., 1852.
5 Edin. Monthly Journal, Sept., 1854, p. 348.
2 Ed. Monthly Journal, 1849, p. 707.
*Feb., 1851. 
SUDDEN  DEATH.                       525
wise  had been a  stout healthy woman.  I was refused permission to make
an examination.   Although the death  in this case was less sudden, I can
only  suppose it to have occurred from syncope.
  But what is  the condition which gives rise to this  fatal syncope?   We
know little or nothing.   It  does not  depend upon  hemorrhage,  nor the
shock of labor, nor fear;  for the distance of time from the labor, in many
cases, shows that from such  effects, if  they existed, the patient must have
recovered.  They appear, in fact,  to be cases  of cardiac paralysis.   Unfor-
tunately, in most of the cases  the unexpected suddenness  of the event de-
prives us of the  opportunity of  treatment;  but knowing the possibility of
such an accident,  may put us on our guard,  and lead  us to be very cautious
in permitting the patient to sit up or to make exertion if  she be unusually
delicate, or if anything in the labor or convalescence excite our fears.
   770. II. Another cause of  sudden death  is what has been called, "idio-
pathic asphyxia," which,  Dr.  Christison observes,  "causes  death almost
instantaneously, or in a few minutes, or sometimes not for an  hour and a
half.   The symptoms are those of fainting merely, and the only appearance
in the dead body is flaccidity of the heart, with an unusual or total want of
blood in its cavities."
   M. Chevallier, who was, I  believe, the  first to  describe this  form of
sudden death,  gives us an  example of  it : the case of a woman who  died
shortly after having been  delivered of twins.   After the birth of the second
child she appeared a good deal exhausted, and as the discharge of blood
was very moderate, the accoucheur thought  it best to defer the extraction
of the placenta.   She recovered  a little, but about  two  hours afterwards
grew suddenly faint, breathed  short, and died  in about half an hour."  "All
the viscera were free from  disease.   The uterus contained the placenta, with
 a small quantity of blood ; but all the cavities of the  heart were in a state
 of relaxation, and completely destitute of blood.   There  was no blood  in
the vena cava near the heart, and the emptiness of its ascending branch ex-
tended  as low as the iliac veins."1   He  quotes also a similar case from
 Morgagni,2 in which the patient died before  the  expulsion  of the placenta,
 aud the heart was flaccid and  nearly empty.   Without attempting to ex-
 plain the production of such a disease, and  attributing it to some loss of
power,  first in the minute vessels, and afterwards in  the larger  ones, and
 the heart, M.  Chevallier contents  himself with recommending the horizontal
position, the employment of stimulants, brisk friction, warmth, in some cases
 a hot bath, stimulating enemata, etc.
   I am  at a  loss whether to place Dr. Ramsbotham's cases (43, 44,  45) 3
under this head or the former.   The  fatal  attack took place  soon  after de-
livery, without hemorrhage or any apparent cause, but the death was not  so
sudden as in the former class—in  one case  about two  hours after  delivery,
 in another about three, and in a third two days after.   That eminent author
thus graphically  describes the  symptoms,*  " Shortly  after the birth of the
child, and the removal of the  placenta, when  the woman has previously ap-
peared to be doing well,  she complains  of unusual  faintness ; says she is
extremely ill; at the same time she is unable to describe what is the matter
with her.  If inquiry be  made  into the state of the  uterus, that viscus is
found  to be tolerably well contracted; if inquiry  be  also made  as to the
quantity  of blood  escaping externally, that is not  unusually  large.   The
 woman complains of no pain about the belly ; there is  no mark of derange-
ment; notwithstanding,  she presently gets worse ;  the pulse begins to flag;
the countenance assumes a pallid, cadaverous aspect;  she becomes extremely
restless,  and ceases to express  her feelings except by a moan.   By  and bye

    1 Medico-Chir. Trans., vol. i. p. 160.               2 Epistola xlvii. Art., 44.
    3 Pract. Observations, 2d Ed., p. 118.              « Ibid., p. 117. 
526
SUDDEN  DEATH.
she is  seized with a violent  pain, or rather stricture, across the chest, and
soon ceases to breathe, to the astonishment and grief of all around her."
  Dr.  M'Clintock mentions two cases related to him by Mr. Barker, of this
city.   " In each of these  cases, death took place quite suddenly and unex-
pectedly, not many days  after delivery."  " As may be supposed, Mr. B.
submitted the bodies of these women to a very extensive and close scrutiny;
but he failed in discovering anything to account for death, except an  unusual
flaccidity of the heart, with complete absence of blood in its cavities.   We
may fairly  conclude with  him, therefore, that dissolution  was the result of
idiopathic  asphyxia,  or of some cognate syncopal affection."1  Professor
Beatty has recorded a case of a healthy woman, ast. 40, in the  ninth month
of pregnancy, who complained of weakness and  sick stomach, and imme-
diately afterwards fell back dead.   He examined the  body most carefully,
and the appearance led to the conclusion that  the cause  of death was idio-
pathic asphyxia.
  But what relation does this  idiopathic asphyxia bear to the former cause
of death—I mean fatal syncope ?   Are they essentially different, or merely
varieties of the same condition ?  Dr. Samuel Wright seems to  regard them
as pretty much the same,  both consisting of a sudden paralysis of the heart.1
The post-mortem appearances mentioned by M. Chevallier are nearly iden-
tical with those given by others of  mortal syncope, and the symptoms only
differ in the rapidity of their  course.  It is possible that in the  one case the
paralysis may commence in, or be limited to, the  heart, and in  the other to
the lungs, but  it  is very  difficult to speak decidedly on the subject.3   And
certainly,  as Dr.  M'Clintock  observes, "if we look upon the  idiopathic
asphyxia  of M. Chevallier as  nothing  more than a variety or form of syn-
cope, the  liability of its invading a woman in  childbed  becomes still  more
apparent, from the state  in which her constitution is left by the act of par-
turition ;  a  state of which  the prominent characteristics  are, an  unusual
proclivity  to diseased  action, an  excited  condition of the vascular, and  a
morbid sensibility of the nervous, system.   The shock of labor is not re-
covered from for many days, and during  this  period (the  length of which
necessarily varies  under different circumstances) the vis vitce is minus;
hence any impression of a severe kind, whether affecting mind or  body, is
not met by the same vital resistance as at other times."
   But the difference in degree, the more gradual progress towards death, is
an advantage so far, that it gives time  for the  employment of remedies, and
Dr.  Ramsbotham observes,  that when  the patient has been kept  up, and
after-pains have recurred, she has recovered.   The  ocurrence  of the  after-
pains, I take it, are rather an effect than a cause of the improvement.
   Prompt administration of  stimulants,  aspersion with cold water, a current
of air, warmth to the feet, perhaps  galvanism, and especial attention to the
uterus, so  as to prevent any loss of  blood, are  the chief means  at our  com-
mand, and which ought to be continued in as long as there is the least hope.
   771. III. The shock to the nervous system of a prolonged and severe
labor  may sometimes prove  fatal,  without hemorrhage  or organic injury,
and this especially when the  mind has been anxious or depressed previously.
Mr. Travers observes, that "pain,  when amounting  to  a certain degree of
intensity and duration, is of itself destructive.   Difficult and protracted par-
turition is every now and then fatal from this cause ; and even in cases  in
which neither extraordinary difficulty nor protraction was experienced, a fatal
prostration has sometimes supervened, which  has admitted of  no other ex-
planation.  The delivery has been complete, without any degree of physical

     1 Med. Press,  March 10th,  1852, p. 146.
     2 Path. Researches on Death from Suffocation and from Syncope, etc., p.  14.
     3 Med. Press,  March 10th, 1852, p.  146. 
SUDDEN  DEATH.
527
injury, and  not more  than an  ordinary quantity of blood has escaped from
the vessels of the uterus ;  yet  the woman, in spite of the encourgement de-
rived from  the consciousness of safety to herself and infant, and of comfort
from the conclusion  that  her  sufferings were at an end, has never rallied,
either in strength or spirits, but after an interval not exceeding a few hours,
passed in a low and sinking state, has unexpectedly, and with little percep-
tible alteration, expired."1  He  relates two instances of this  kind, one of
which is as  follows: "A young lady, happily married, impressed, probably,
by some unexpectedly fatal occurrence in the circle of her friends, entertained,
from the commencement of her pregnancy, a morbid fear of  death in child-
birth, which, although unwarranted by any indication,  became,  from its con-
tinuance and increasing strength, a source of  anxiety to one of her imme-
diate and  confidential relatives.   She was  attended by a skilful and expe-
rienced  accoucheur, who was  also her relation.   He  assured  me that the
labor was  in all respects  easy and safe, and that not a single unfavorable
circumstance attended it.   The  child was  still-born and  imperfect.  The
mother  died  suddenly, six hours after delivery.   Every region of the body
was examined with care by an  eminent anatomist, and presented the appear-
ance of health."
  One  or two remarks appear to me to be called for in qualification of the
above statement.  1.  That the pain of a severe  and  protracted labor will
occasionally produce such serious results I firmly believe, for I have  known
it, but I also believe it must be the pain of the second stage, either unusually
severe, unusually prolonged, or unusually effective,  owing to some peculiarity
of constitution of the patient.  I do not believe that such a termination
occurs  from a prolonged first stage, when the second stage is short.   2. We
must not  attach  too  much importance to the fear of  dying in childbed, al-
though  it is calculated to  be injurious, as a  depressing cause ;  for we every
day meet with patients who do well, notwithstanding the most decided con-
viction that they shall die.  It probably requires, in addition, some peculiar
bodily  condition for  it to produce  its mischievous effects.   3.  I think it
might  be  suggested,  with  some show of probability, that the case quoted
from Mr. Travers belongs rather to one of the former  classes.
   Dr. M'Clintock quotes  a case in which there was certainly some hemor-
rhage,  but  in which the death appears to have been more owing to the ex-
haustion and shock of the labor.   It occurred  in  the  practice of Dr. Cup-
paidge  of  Castlerea,  who  states, " In the beginning  of last month, I was
sent for one morning, at ten  a.m., to see Mrs. C, a farmer's wife, who was
the mother of five children, and of rather  delicate constitution.  Her last
labor had been very  tedious, and was terminated  by instrumental assistance
 (the forceps,  I  believe).   On my arrival, I learned that  she  had been  in
strong  labor for three days and nights.   She seemed much exhausted, and
was perspiring freely, with  a  feeble, rapid pulse.   The pains were frequent
and violent, and the fcetal head was pretty low in  the pelvis.  After waiting
some time, and seeing the child  made  no  advance, I applied the forceps,
and extracted  it with ease, but not in time to save its life.   The  placenta
came away in a very few minutes, and I put on the binder tightly. In about
n quarter of an hour, observing her to yawn and appear restless, I examined
if there was any discharge, and put  my hand over the uterus.  It felt rather
relaxed, and on  making  pressure it contracted, expelling a small quantity
of blood.   Bv this she seemed  improved, but in about twenty minutes began
again to sigh and yawn, and toss her arras about,  which made  me grasp the
uterus  more  forcibly, whereby a few coagula were dislodged.   Symptoms of
prostration, with extreme restlessness, dejection of countenance, and rapid
1 Inquiry, p. 48. 
528
SUDDEN  DEATH.
intermitting pulse, now began to develop themselves, and though I gave her
abundance of burnt whiskey, the  only stimulant procurable, she continued
to sink, and expired an hour and a half from the time of delivery."1  There
can be no question here, I think, but that the  fatal result was attributable
to the exhaustion  aud shock of labor,  although, under such circumstances,
very slight loss of blood has a powerful effect.
   I remember a case which occurred at  the Western Lying-in Hospital, and
which  taught me  a lesson.   A patient had been  long in  labor, and  was
showing signs of constitutional  suffering, but as the pains were good, and
the head was descending, though slowly, it was  determined, in consultation,
to wait for two hours.   Within  that time the woman  delivered  herself, but
the shock  and exhaustion were so great, that she never rallied, but sank in
a few hours without another symptom.   Perhaps I may be allowed to men-
tion another case,  which occurred in my own  practice, as an illustration
of the violent shock sustained,  though the case does not  fairly belong to
this  chapter, as the patient did  not die.   The wife  of an  officer was de-
livered very rapidly of twins,  and immediately after, the double placenta
was expelled without hemorrhage, and all seemed well.  But within  half an
hour she complained of being  weak, her pulse  became quicker and feeble,
and she exhibited all the symptoms of collapse.   The uterus relaxed, and
on pressure a clot was expelled, but the entire loss  was not much more than
in an ordinary labor.  I had the  advantage of Dr. Johnson's valuable as-
sistance, but it was two hours before the collapse yielded to our efforts, and
she then rallied.   No doubt, in this case,  the loss  had some  effect, but that
was owing to the  depressing effects of the shock  of  sudden delivery upon
a  delicate nervous woman, without-which  I am  sure it would have been
harmless.
   There can be little difficulty in distinguishing this class of cases from the
others of  which I have spoken : the history, the length and difficulty of the
second stage of labor, the operation, etc., will  generally be sufficient, even
were the symptoms more alike ;  but there is no sudden fainting, nor is the
aspect of  the patient that  of one fainting, but rather that of one  sinking
gradually,  but more or less  rapidly, and with a  severe  shock to the nervous
system.
   The treatment which  seems to have the best effect is  the union of an
anodyne with stimulants.   Wine  and  brandy  must  be  given  liberally at
first, until some degree  of reaction is obtained, and then the quantity may
be diminished, and chicken  broth  gradually substituted.  Meantime a mix-
ture should be added,  consisting of camphor  mixture  ovj., carbonate of
ammonia ^ij., and laudanum gtt. Ix., of which the patient may take a table-
spoonful every one, two, or three hours.   The most perfect quiet should be
observed,  the room should be darkened, and the patient allowed to sleep as
long as she can.
   772.  IY. The  absorption of air by the  uterine sinuses, was suggested
by the younger Legallois in 1829, and by Ollivier in 1833,2 as being possibly
the cause  of some, at least,  of the sudden deaths after delivery.   The elder
Legallois  had found in some of his experiments, that sudden death resulted
from air penetrating to the  vena cava from the uterine veins.  Of the possi-
bility of this occurrence one cannot doubt, and the researches of Dr. Rose
Cormack3 have very much elucidated  this subject;  his experiments  and
subsequent  observations, justify,  I think,  the  conclusions given  by Dr.
M'Clintock, viz.,  that the admission of air into the current of the blood is
capable of destroying life suddenly ;  that it is highly probable that air may
find an entrance into the vascular system through the uterine vessels ;  and

     1 Med. Press, March 10th,  1852. p. 147.          2 Diet, de Mid.  Art. Air,
     3 London Journal of Me"d., vol. ii. p. 941. 
SUDDEN  DEATH.
529
that in certain  cases  of  sudden death after delivery, the only cause which
could  be detected  was the presence of air bubbles  in the heart and vena
cava.   Dr. Rose Cormack has collected seven cases in support of this view;
in six, the presence of air in the veins was demonstrated, and none exhibited
any other morbid lesion sufficient to account for death.   He observes, " If
a large quantity of air have  entered the circulation, unequivocal evidence
of this  will be found by listening to the heart, when the churning sound will
be heard.   If death does not almost at once close the scene, the phenomena
of asphyxia will set  in, their rapidity and violence depending upon the
quantity  of air which  has  entered, on its  passing  up to the heart in one
large volume, or in divided quantities,  on the presence or absence of hemor-
rhage,  and on the  strength of the patient."1
  There is a case related by Dr. Ramsbotham which resembles death from
this cause, but  unfortunately the veins and heart were not examined.  The
woman had been delivered of a dead child, which was followed by the ex-
pulsion of a quantity  of  offensive gas.  The placenta had to be withdrawn,
and then the uterus contracted, and the woman  appeared well  between two
and three o'clock.   Between  five and six she died quite suddenly.  Nothing
appeared, on post-mortem  examination, to account for her death."2
  Another case has been recorded by Mr. Berry, more recently.3  A woman,
aged twenty-two, was delivered of her first child,  after  a natural labor, at
seven p.m., June 17th, 1850.   The placenta came  away in twenty minutes,
unattended by  any immoderate loss of blood.   At half-past eight she ex-
pressed herself as comfortable, and at  eleven  took some gruel.  At one
o'clock in the same night, her husband, who lay in  the same room with her,
became alarmed by the patient's difficult breathing and feeling of faintness,
and immediately sent for her medical attendant, but before his arrival at
two o'clock, she was dead.  On examination, the abdominal organs, including
the uterus, were healthy, with the exception of  a granular condition  of the
kidneys.   The  mouths of the uterine vessels were patulous ; the lungs were
congested, and  contained tubercles; the heart was  enlarged and distended,
and, upon  making an incision into it, a gush  of air escaped, and it became
flaccid.  Xo blood was found  in its cavities.   About an ounce of serum was
found in the pericardium.   The brain was quite  healthy, and there were no
signs of decomposition in any part of the body.
  Mr.  G.  May, jun., has  published three  cases.  In the first, death occurred
on the  rupture  of  the  membranes  before  delivery.   After  death there was
nothing to account for it  but distension of the heart by air.   The second
died six  hours  after delivery, and the third on the eighth day.  Nothing
adequate to account for death was  discovered except air in  the heart and
large vessels.*
  "The mechanism,"  says  Dr. M'Clintock, "by which the introduction of
air into the veins can be effected, admits of being explained in a few words.
The veins of the gravid womb present  four remarkable characteristics—viz.,
their extraordinarily  large size, their freedom of  inosculation, the total
absence of valves, and their termination on the internal surface of the uterus,
at the site of the placenta, by large open orifices.  If the uterus be examined
soon after delivery at the full  term, the majority  of these  apertures will
readily admit a goose quill,  and some will even  allow the little finger to
penetrate  without  laceration.  During contraction of the uterus all the
openings are hermetically closed, but when it is relaxed, they again become
proportionally  more  or less  patulous.   From this  it is manifest that the
same condition  of the organ  which causes flooding is exactly that which is
 » London Journ. of MeU, vol. ii. p. 950.        2 Pract. Obs. in Midwifery, p. 122.
 3 Prov. Med. and Surg.  Journal, Nov. 27th, 1850.
 1 British Med. Journal,  June 6th, 1857.
       34 
530
SUDDEN  DEATH.
indispensable for the ingress of air;  so  that the latter, when it does take
place, is almost of necessity preceded or accompanied by hemorrhage.1
  But the question then arises, How comes air into the uterine cavity ?  It
may penetrate, doubtless, during  the  process  of  expulsion of the child, or
during  the interval before  the  expulsion of the  placenta, or it may be the
result of decomposition, as in Dr.  Ramsbotham's case.   That air is expelled
from  the uterus  occasionally, during, or  immediately after labor,  we  know.
Dr. Meigs has noticed it a great many times;  Dr. Rose Cormack has also
observed it;  Dr. M'Clintock witnessed  it in  four different  cases; I  have
repeatedly noticed  it;  and  it is  mentioned by other  writers.  So that we
may conclude, with Dr. Cormack, "I have not  only no difficulty in believing,
but am constrained to admit, that should any impediment be offered in such
cases to the free  exit of air  by the os uteri, it must be  forced into the uterine
veins,  were their mouths not protected  by coagula ;  and thence it  would
rapidly pass, by the current of  the  circulation, up the vena  cava, into the
right auricle."2
   The intensity of the  symptoms probably depends partly on the quantity
of air and partly on the condition  of the patient.  Death may occur sud-
denly, or, life being prolonged,  the  patient may die of asphyxia at a later
period.  The character of  the symptoms in the  severer cases being similar
to those in the cases of fatal syncope or  of idiopathic asphyxia, renders the
diagnosis between the three during life almost, if not quite, impossible; it is
only by the detection of the presence of air in the  heart or great vessels after
death, that we can positively assure ourselves of that  having been the cause
of death.
   As to the treatment  of these cases,  Dr. Rose Cormack  observes, " In the
most rapid class  of cases in which death is suddenly threatened from paraly-
sis of the heart from over-distension, we must first strive to relieve the heart
from that condition ;   when the phenomena are  chiefly those  of asphyxia
from more gradually increasing  obstruction in the lungs,  the various means
for treating  asphyxia must be resorted to, and among these, in  many cases,
I believe the alternate  use of hot and cold douches will  be found to be very
valuable, especially if combined with stimulants, judiciously varied, and skil-
fully administered, externally and  internally.   In many instances repose,
dashing cold water in the face,  keeping the surface warm, and time, may be
the only means which ought to be used.''3
   773. Y.  The formation of a fibrinous coagulum in the heart was first
pointed out by Dr. Meigs  as a possible cause of death.  He  says,  " It is
well known that  the coagulability of the  blood is greater in proportion as
any hemorrhage progresses ; therefore a woman who has lost during her
labor  forty or eighty ounces of blood, has the  rest of it more coagulable
than it was before the flooding commenced.   Again, fainting consists  in the
too little intensity  of the presence of  blood in  the brain ; and a  woman just
gone through a flooding, experiences a sensation  of faintness from lessened
vascular distension of  the  encephalon.  If she  suddenly assume an  erect
position, the tension becomes instantly lessened in consequence of the  gravi-
tation of the blood.  But (and this is the danger) if she faint  badly while
her blood  is  become  thin and  highly  coagulable from hemorrhage, the
scarcely moving  current partially stops in the heart, and when she comes out
of the deliquium, if ever, she does so with a coagulum  in the auricle and ven-
tricle ;  she has got a false polypus in the  cavities, and will surely die."*  In
another place he observes,  "I beg  you to consider briefly the effects to be
produced by a mass of fibrinous remainder of  a clot suddenly found within,
    1 Medical Press, March 10th, 1852, p. 147.
    2 London Journal of Medicine, vol. ii. p. 941.            3 Ibid., vol. ii. p. 938.
    * Obstetrics; the Science and the Art, p. 308. 
SUDDEN DEATH.
531
and moulded by the cavity or cavities of the heart.  Inasmuch as the venous
blood can only get back to the arterial side bypassing through the pulmonic
heart, such  a clot, if of large size, must either wholly or very greatly hinder
the return  of the  venous blood.  In  fact, it would be equal to a partial
ligation of the cava  superior  or  inferior.   Death  is  likely to  follow  the
occurrence, either immediately or within a few hours.  I have observed it to
occur within eighteen  hours, in thirty-six hours, in eighteen days."1  In  one
case he mentions, the  symptoms were sudden sinking, mental anxiety, rapid
pulse, and effusion into the pleurae.   A post-mortem justified his  diagnosis.
   A case in which the cause of  death was considered to have been a clot in
the heart, is related by Dr. Keith.    He attended the patient of twins, Nov.
1850 ;  the labor was tedious, and she was  kept under the influence of chloro-
form for thirteen hours.   The first child was delivered by the  forceps ;  the
second came footling.   When  the placentae were expelled,  there was a great
rush of hemorrhage,  which was arrested by the contraction of the uterus.
The patient  fainted ;  but  gradually  recovered; slept;  and  on awaking,
showed no unusual symptom.   From this time to the  fifth day she went on
pretty well, considering the previous history.   The lochia were natural,  and
there was some milk in the breasts.   " During this whole  period, however,
there was an unusual  degree of  restlessness, and an undefined feeling of  dis-
 comfort, for which, though frequently asked, she could give no definite cause.
 The pulse  was  also faster than usual, and very small."  "On the morning
 of the fifth day, the nurse told me that she had spent a good night; and her
 own principal request was, that she  might have a partridge for dinner.  On
 feeling the pulse, however, it was  much  more  rapid  than on the preceding
 day, and very feeble."  "I left at ten o'clock, and at twelve an urgent mes-
 sage was sent to  my house.  As I was out at the moment, Dr. Duncan  was
 sent for, and at half-past  twelve he found her pulseless, and evidently sink-
 ing.   I saw her half  an hour later; she  seemed  then to  have very slightly
 revived, after taking a large quantity of champagne  and brandy.   The pulse
 was, however, quite gone at the wrist, the heart's action extremely rapid and
 feeble, the breathing very laborious."  She  died at three o'clock.   On ex-
 amination, an effusion of serum and a thin layer of lymph were found in the
 peritoneal cavity ;  the uterus was healthy;  the  right  side of  the heart was
 unusually distended ;  " and on  opening the  right auricle it was  found quite
 filled with  a large mass of fibrine, quite colorless,  and  especially at one part,
 where it adhered to the wall of the  auricle,  of a firm  and leathery consist-
 ency."2   It is a little difficult in  this case  to disentangle the effects  of the
 latent peritonitis from those of the clot in the heart.  I have seen more than
 one case of fatal  peritonitis of which there were no characteristic symptoms
 during life, the main  anxiety being  caused by the quick  pulse ;  but I think
 iii the present case there appear to have been symptoms resembling asphyxia,
 which can hardly be said to be  referrible  to the peritonitis.
   The only practical inference from such cases is, the care  necessary not
 merely to  arrest  hemorrhage,  but to guard  the  patient  against its conse-
 quences.   The horizontal  position, with the head as  low, if not lower than
 the body ; the  use of stimulants and nutriment, judiciously administered ; the
 equable warmth  of the body after the hemorrhage  has ceased; and  above
 all, great caution, for several days,  about sitting  up in bed, or removing to
 the sofa, and  making any exertion, are all  available  means for the preven-
 tion of this accident, which ought never  to be neglected.
   774. YI.  Disease of the heart.  — For more than  one reason, we might
 naturally fear for the result of delivery when there exists organic disease of
 the heart   The  disturbance of the circulation, and the impediment to the
i Woman, and her Diseases, p. 577.         2 Ed. Monthly Journal, Jan. 
532
SUDDEN  DEATH.
free  course  of  the blood which vavular disease  offers, even in moments of
tranquillity, must be many  times increased during the turmoil of labor, with
its repeated arrests of respiration and recurring congestion.   If under ordi-
nary circumstances  the impediment gives rise to effusion,  much more may
such a result be expected during the labor ; and an effusion into the cavity
of tne arachnoid, pleura, or peritoneum may be very serious.   Again, after
delivery, the volume  of blood previously required for the fcetal nutrition, and
circulating in the uterus, will be thrown into the general circulation, adding
to the existing embarrassment of injured  valves, or a diseased heart, unless,
indeed, there be considerable discharge — which in turn, however, if exces-
sive, may equally, though for an opposite reason, be a source of trouble.
   At a meeting of the Edinburgh Obstetrical Society,1 " Dr. M'Cowan stated
that on the 16th  of June, 1846, he was requested to visit Anne Barker, aged
twenty-one, said  to be in labor of her first  child.   On  his  arrival,  he found
her  suffering from spurious pains,  and  complaining  much of difficulty of
breathing,  and pain in the left sub-mammary region.  The face  was very
cedematous, as also the lower extremities.  Under the  usual  treatment, the
pains subsided.  During the two following days, she complained occasionally.
On the 19th, she had much pain in the side;  respiration  laborious; pulse,
which had hitherto been about 70 or 80,  rose to 120, but feeble.   Venesec-
tion to ten  ounces produced faintness without alleviating the pain.   She was
then cupped to four ounces with immediate relief.  About three a.  m. of the
20th, labor commenced, and proceeded naturally and speedily till nine a. m.,
when she was delivered of a still-born male child, and instantly expired.
   "Post-mortem.—The body presented a generally oedematous appearance.
On  opening the thorax, the pericardium was found distended with a dark
fluid.   The heart was much enlarged, extending about two inches to the
right of the sternum ; right ventricle very thin and dilated.   The aortic open-
ing could with difficulty admit  the  point of the little finger; its valve was
hard and cartilaginous.  The whole  heart was filled with coagulated blood.
The surfaces of the  pleurae were strongly adherent; the greater part of the
left lung was hepatized.  The uterus and other organs seemed healthy."
   At  the  same meeting, Dr. Simpson mentioned that he had seen  a similar
case of sudden death some years before,  and which, from the history of the
patient, he  attributed to disease of the heart.
   Dr. M'Clintock mentions, that  on two occasions he has seen a patient
die almost under his hands, immediately after delivery, from this cause; and
he  mentions another lady who  died suddenly on the tenth or twelfth day,
and  who was known to labor under organic disease of the heart.  He relates
also another case, furnished to him  by Dr. Fitzpatrick, in which death took
place on the fifth day, and which seems, at least in a great measure, attribu-
table to the same cause.        *
   A case of sudden death,  on the day after delivery, has been  related by Mr.
Young,2 in which no abnormal appearance was detected, except hypertrophy
of the  heart and disease  of the aortic valves.  Mr. Young attributes her
death  to this and  to  the distended  state of the stomach, and large size of
the liver arresting the functions  of  the heart.
   Now there is no difficulty in such cases in detecting organic disease ; and
if the accoucheur do ascertain the fact, is he justified in remaining  passive ?
I think not.   If, as  these cases show,  the original embarrassment of the
circulation may be increased to a fatal degree by continued labor, why allow
it to go on ?   We cannot  prevent labor,  but surely we  can  shorten  it; and
if ever there is a case in which the  use  of the forceps is justifiable merely to
shorten labor,  this is certainly one.   I ain happy to have  the authority of

  1 Ed. Monthly Journal, May 1849, p. 766.     2 Association Journal, Nov. 19th, 1853. 
SUDDEN  DEATH.
533
Dr. Simpson to confirm this  opinion ;  and still more happy to be able to
quote a successful case so treated.  In the summer of 1851, my friend, Dr.
Stokes,  asked me to take  charge of a patient who had  been admitted into
the Meath  Hospital, with extensive valvular disease of the heart, disturbed
circulation, dyspnoea and  oedema.  She was in  the eighth month of preg-
nancy at that time ; and before the end of the ninth month, under Dr. Stokes's
judicious treatment, the oedema had  subsided, the circulation become tran-
quillized, and the respiration easy, unless she  were agitated or exerted her-
self.  Fearing the effect of labor upon her diseased heart, I determined to
shorten it as much as possible.  I arrived at the hospital about half an hour
after the commencement of labor, fortunately the os uteri had rapidly yielded,
and I found the head in the pelvis.  I immediately applied the forceps, and
delivered her in about five minutes  of  a  living child.  The placenta was
expelled immediately.   When I applied the forceps,  she  was beginning to
show signs  of distress in respiration, and more than usual  congestion ; but
after delivery this instantly subsided, and she recovered speedily and well from
the labor.
   775.  VII. Obstruction and rupture of the pulmonary arteries.—We are
indebted to the researches of Mr. Paget for a knowledge  of the effects of
obstruction in these vessels ; and in his second paper he suggests that many
of  the cases of sudden  death  for which  no apparent cause has been found,
may have been  owing to clots obstructing  the pulmonary  arteries, and that
the cause of this coagulation is some change in the composition of the blood.
   The first case  of the kind  recorded,  I  believe,  is the following, by Mr.
Havers.1   A delicate lady, aged  thirty-four, was delivered of her second
child, after a natural and  easy labor.  The removal of  the after-birth was
attended with some little difficulty, and was followed by  a  gush of blood so
sudden  and violent as to place her life in imminent danger.   This took place
on the 18th of August,  and she progressed  favorably till the morning of the
23d, when  her  attendant "found  her  restless, her countenance sallow, her
eye unusually bright and wandering, and her manner catching and irritable.
She said she had passed  a bad  night, which  she referred to the fulness of
her breasts producing a feeling of palpitation and distress at the pit of the
stomach.   Her tongue  was slightly coated, and her pulse as usual, quick
and weak."   These symptoms subsided  under  an  alterative  dose,  and
matters went on well until the  morning of the 30th.  " She had been on the
sofa and easy chair each day, was  in good spirits, and  apparently in good
health.   On that day she was better than usual;  she made her lunch  at an
early hour, and  told her  nurse  that  she was  so well  that she would  dress
herself without assistance ;  while in the  act of dressing she fell on the bed ;
the nurse observed some frothing  at  the mouth, and  slight convulsions of
the face.   She  spoke feebly once, then  laid herself back  and died."   Mr.
Paget was present at the post-mortem examination.  " With the exception of
the cicatrix of an old abscess in  the apex of the right lung, and paleness of
the heart, to be just now referred to, the organs were generally healthy.   The
muscular structure of the heart was pale and thin, especially that of the right
ventricle, which contained some dark blood.  Each of the pulmonary arteries
contained a clot of blood nearly  filling the calibre  of the  vessels.  The chief
clots were about an inch and  a  quarter in length, mottled  and firm, and in
some instances slightly adherent to the  sides of the vessel.  In tracing the
divisions of the artery," numerous  other clots were  found, of the same character
as the larger ones, and  extended even into the  smaller ramifications  of the
arteries."   Mr. Paget was  of opinion that these clots existed two days before
the death of the patient.
i Med. Times and Gazette, Feb. 14th, 1852. 
534
SUDDEN  DEATH.
  Since the publication of the  foregoing  case  an additional example has
been afforded in an illustrious exile.  The  Duchesse de Nemours recovered
very well after  her confinement,  and on the 14th day, whilst her maid was
dressing her hair, she  suddenly  exclaimed, "I feel ill," and  died.  A post-
mortem examination showed that death was owing to a clot in the pulmo-
nary artery.
  Aud  still more recently Dr. Mackinder has related two cases.  " In the
first, the patient was  32 years of age, and had been delivered of her second
child after a natural and  easy labor.   Seventeen days afterwards, while ap-
parently in  good health, she rose up convulsively, said she was choking, and
died.  On subsequently examining the body, a large, branching, fibrinous
plug was found completely stopping up the right  pulmonary artery, and its
immediate ramifications, while the entrance to the left pulmonary artery gave
lodgment to a large and tolerably firm concretion.   The heart was  rather
thin, and the lungs slightly congested, but there was no  further trace of
disease  about the body.   " In the second case, the patient had an easy labor,
and for a few days afterwards all appeared to progress favorably, when she
imprudently left her bed-room, and exposed herself to cold.   Shortly after-
wards she was seized with difficulty of breathing,  gasping, and cold clammy
sweats,  from which death  relieved her in twenty minutes."1  Unfortunately a
post-mortem examination could not be obtained.    How far these obstructions
may be the result of simple coagulation, or in part, at least, owing to what
Yirchow has termed "embolism," is difficult to  say until our information is
more complete.
   A very interesting case of rupture of the right pulmonary artery  during
labor, followed by instant death, has been published by Dr. Crooke.2  The
labor was  going on slowly, but well, and on the  occurrence  of a powerful
expulsive pain, the patient's face became livid, and she complained that "her
heart was leaying  her," and died  in a few minutes.   On pod-mortem ex-
amination  all the viscera were healthy;  there was fluid blood  and coagula
in the cavity of the chest, which was found to have escaped from a rupture
of the right pulmonary artery.
   Of course, it will require more observations before we can arrive  at any
very positive conclusions ; it does  not seem improbable, however, that such
clots, which would more readily form after hemorrhage, might  occasion as-
phyxia  and death.  In the present state of oqr knowledge of the subject, I
fear we can deduce no further  practical  instruction than  the  necessity of
arresting hemorrhage as  speedily as possible, and keeping the patient in an
horizontal position until  the blood has so  far recovered as to lose its dispo-
sition to coagulation.
   776.  VIII.  General dropsy.—When  ascites  and anasarca occur  to a
considerable extent during pregnancy, the  patient may die immediately after
delivery, without any very obvious cause, but apparently from  asphyxia, as
the following case will show :  Mrs. ----, aged thirty-eight, was in the sixth
month of her fourth pregnancy when she  suddenly  became dropsical: the
hands, arms, body, and lower extremities were swollen ; there was much fluid
in  the  peritoneal cavity, for she was larger than if at the full term.  The
pulse was  120, and the respiration sometimes  difficult, and always hurried.
Labor came on unexpectedly in  the country, and  I did not see her  until it
was over.   The  child  was dead;  the placenta had to  be  extracted, and
though there had been some hemorrhage, she had not the aspect of a person
sinking from  that  cause.   When  I  saw her  her  lips were blue,  her aspect
pale but not pallid, the surface  warm, the  respiration  hurried, and the pulse
100, and  weak.  She  had spoken  after delivery,  but  could  not answer my

                 1 Med. Times and Gazette, July 23, 1859, p. 96.
                 2 Medical Press,  Sept  17th, 1853, p. 193. 
SUDDEN  DEATH.
535
questions, though she seemed to understand me.   She had  no convulsions,
nor any head symptoms.   She gradually sank in spite of our utmost efforts,
and died about three hours after delivery.   No post-mortem was permitted.
What was the immediate cause of death ?  Not hemorrhage, nor an affection
of the head — not fainting, certainly.  There may, for aught I  can tell, have
been  a clot in the heart, but I came to the conclusion that it was asphyxia,
from  effusion into the lungs.
  777. IX.  Minute perforation of the intestine. — I saw a case of this kind
a short time  ai^o, which  might have been  mistaken for one belonging to
some of the former classes, had there not  been a post-mortem- examination.
Mrs. C----, aged thirty, was confined of her first child after a natural  labor,
and  recovered well up to the sixth day, except  that  she had no milk.  On
the sixth day she had an attack of weid, without abdominal pain, from  which
she recovered as usual after twenty-four hours.   On the tenth day she  had a
ri""or, with diarrhoea, and some griping pain, from which she was  soon relieved.
On the twelfth day the rigor returned, with abdominal uneasiness and  slight
tenderness, a pulse of 110, no thirst, some diarrhoea, the lochia natural.  At
this time I saw  her;  and leeches  having  been applied, calomel and  opium
given, I  merely  suggested a full opiate  at bedtime.   The next day she  was
much better ; pulse 84, neither pain nor tenderness of the abdomen, no rigor,
and the bowels quiet.   The day after I did  not see her, as she told her medical
 attendant in  the morning that she felt quite well.   On  his visit the next
morning  (the  fifteenth day after delivery), he  found her in a state  of the
most complete collapse, pulseless, voiceless, and bathed in a cold clammy
 sweat.  She  rallied a little under the  use of stimulants, but died  in the
 evening.   At the post-mortem examination we found no peritonitis, and the
 uterus was perfectly  healthy ; but the termination  of  the  ileum and com-
 mencement of the colon were much inflamed, and on raising this part  of the
 intestine a quantity of fluid fceeal matter escaped from a minute  perforation,
 and  we found more of it  in the pelvis.  In this case the cause of death was
 evident__collapse after  perforation;  but the  extreme  minuteness  of the
 perforation, and the  rapidity with which  death took place,  were  very re-
 markable.
   778.  Scarlatina.—The  first of the following cases  may fairly  be con-
 sidered one of  sudden death, and I believe it is  the only one  of  the kind
 recorded.   I have added the second as illustrative, although the patient
 recovered.
   Case I.—December 14, 1858, sent for to Mrs. S., and received the fol-
 lowing  history:—A delicate  lady, suffering a good deal during pregnancy,
 taken in  labor  of her fifth  child December 13, and was delivered early in
 the  morning, after  an easy labor of a few hours.   Placenta came away
 naturally; no hemorrhage ;  pulse quiet and good.
   During the day she went on quite well ;  lochia natural.
   In the evening Dr.  Smith  found the pulse alarmingly quick and  very
 weak, without  anything  to  account for  it.  No pain ;  no local  distress;
 no excessive discharge.
   Dr. Jacob, of Maryborough, was sent for, but nothing  local or general
 could be ascertained  with any certainty to account for it, unless  it might
 be the commencement of  a latent form of uterine phlebitis.  Some calomel
 had been  given on  this supposition,  but was  suspended on  account  of
 diarrhoea.  ^Nourishment and wine were liberally given, with  benefit to  the
 pulse and strength.   The next day, December 14, I was sent for, and arrived
 at 10 P.M., the  report at  that time being  that the patient was rather  better.
 I found that there had been no rigor; there was neither enlargement of the
 uterus nor tenderness of  it or any part of abdomen; no swelling ; no tym-
 panitis •  lochia  plentiful, but rather pale, and not offensive ;  urine copious, 
536
SUDDEN DEATH.
and  passed  naturally;  pulse 140, very weak and  wavy.   Upon minute
questioning, she told me that she had neither  pain nor distress of any
kind.   Countenance pale, but calm and easy;  neither hurry  nor distress in
breathing, alee nasi quiet;  no headache.  I examined the chest very care-
fully ; on  percussion it was resonant  everywhere; respiratory murmur full
and  equable;  not  an abnormal  sound throughout.   Upon examining the
heart, there was no enlargement, but the rhythm of the sounds was de-
stroyed  by the disappearance of the first sound ;  there was no impulse, but
the second sound was natural.
  This, then,  was  the only  deviation from  the  healthy condition that I
could detect, after  a most careful  examination  of every organ of  the body.
And what explanation  did  it afford  of the  perilous condition of the pa-
tient ?   I confessed that explanation I had none to give ; all I ventured to
say was, that the uterine  system was  not in fault, but that the disease was
in the heart or circulating fluid.
  I lay down about 2 o'clock, and at 5 a.m., they came  to me to say that
the pulse had begun to sink again.   I found  her in precisely  the same con-
dition as  before, with that  exception."  The pulse  was 150  or  160;  the
respiration rapid, but not difficult; and, in spite  of strong stimulants, her
state  went from bad to  worse,  until she lost the  power of swallowing,
became  insensible,  and  finally died about  11 a.m., without pain,  struggle,
or convulsion.
  I returned to town, I may frankly confess, very much puzzled, and by no
means comfortable; but the  mystery  was cleared  up when I heard, two or
three days afterwards, that the nurse and the lady's  husband  were laid  up
with a very  severe  form  of scarlatina.   I have no  doubt that the  scarlatina
poison,  acting on a system weakened and rendered unusually  susceptible by
delivery, had caused death before the ordinary symptoms of  that disease
had time to  develop themselves.
  Case II.—On February 23d, Surgeon Morgan  asked me to visit Mrs. B.
with him.   She had  been confined, February 21, of her  thirteenth child,
after a  natural  labor, and was doing well until  the morning of the 23d,
when she awoke with palpitation and a weak pulse  of 140,  but without
pain.
  I found the pulse 130,  and very weak.  There  was a nervous tremulous-
ness about her,  and  a frightened look.   She complained of nothing but
excessive  weakness;  no  pain, no distress.   The uterus felt ra'her larger
than usual, but not tender ;  lochia quite natural,  and without odor.  Some
milk in  the breasts.  On  examination  the lungs appeared perfectly healthy,
and  there was no  abnormal sound in the heart, but the first sound was
weaker  or less loud than  the second.
  In short, we could  find no satisfactory local cause for the  patient's con-
dition, and,  in fact, no deviation from organic health, except in the rhythm
of the heart.   Remembering the former case, I asked if any of the family
had  recently had  scarlatina  or  measles, but  was told that  they  had  not.
Under such absence of grounds for correct diagnosis, it was clear that  our
duty was  to treat  the prominent symptom (exhaustion) actively, whilst we
took some precautions as  to certain possibilities.
  This  we did by the exhibition of stimulants  and nutriment, and by poul-
tices to the abdomen.  Without troubling the reader with the daily report,
I may briefly state  that the  patient became weaker on  the 24th and 25th;
at noon of  which  day Dr. Morgan thought she was dying.   Xo  local  de-
rangement could be detected at any time, and she took freely, and retained,
both food, spirits,  and medicine.   Her  nights were rather restless, and  her
sleep not refreshing.  On the evening of the  25th we determined to try the 
PUERPERAL  FEVER.
537
full  exhibition of quinine, and accordingly gave her six grains at bedtime,
and three grains every three hours when awake.
  The next day there was a perceptible  improvement;  she had slept better,
and felt more comfortable.  The pulse was only 120, though weak.  The
quinine, claret, and Hoffman's liquor were continued.
  February 27.  A more decided improvement.  Pulse 116, fuller and firmer ;
feels stronger, and had  no weakness  at noon, as previously.  As she com-
plained  of headache  and  singing in the ears, the quinine was omitted, but
food- and wine continued.
  On the  28th  I found  her so  much better that I ceased my attendance.
She had slept very well;  pulse 104, and fuller ;  no local distress ;  no feeling
of excessive weakness.   From this time  Dr. Morgan informs me that conva-
lescence progressed favorably.
   Up to this point we were at sea as  to the nature of the attack, although
we had the benefit of Dr. Corrigan's  assistance;  but on the evening of the
 28th I think  the solution  of the problem was afforded by the fact of one of
 the servants showing unmistakeable evidence of scarlatina.
   I fear it may  be thought that I  have extended this  chapter to a dispro-
 portionate length ; but the subject is new in a  systematic treatise, and so
 inadequately understood,  that I  felt that the main value would consist in a
 detailed account of  the  principal facts which have been recorded.  When
 the subject is better  known, we shall be able to condense.
                      CHAPTER  XX Y.

                        PUERPERAL FEVER.

  Having now terminated the series  of abnormal deviations  from natural
labor, and the various accidental  complications of that process, I shall add
a chapter or  two upon some  of the  more formidable diseases of childbed,
referring  the reader for fuller details and references to my work on Diseases
of Women.

  779. Puerperal Fever is probably the  most fatal disease to  which women
in childbed are liable, and  it is  by no means of rare occurrence.  Its phe-
nomena varv very much, and it has  consequently been  differently described,
and under various names, such as  Puerperal Fever, Childbed Fever, Peri-
toneal  Fever,  Low  Fever of Childbed, etc.  Another source of  apparent
contrariety has been the prevalence  of the disease epidemically, and the
varying characteristics of these  epidemics.   Unfortunately, the uniformity
of the disease was assumed until comparatively recent times; and, as Dr.
John  Clarke observes, each author erected his own experience into a stand-
ard  by which to judge of the descriptions and practice of others.
  According to Dr. Hulme's researches, the older writers were not ignorant
of this disease.   It is  described  by Hippocrates  and Avicenna.  Plater
(1602) makes it to consist in inflammation of the uterus.  Sennert  (1656)
describes it, and  recommends bleeding.   Riverius  (ln'74)  attributes it  to
suppression'of the lochia, and Sylvius (1674) to deficiency  of  the  lochia.
Willis (1682) takes the same view of its nature as Plater.   It  is  mentioned 
538
puerperal  fever.
by Reynalde, Pechey, Strother (by whom it was first called Puerperal Fever),
and other early English writers ; by Viardel, Peu, Mesnard, and other ancient
French authors, and by the Germans.
  From  careful investigation it has been proved that the disease prevails
epidemically, and that it is  more  virulent in hospitals.   It  is everywhere
more frequent among the lower classes than the higher.   In  Dublin  this is
even more remarkably the case than in London.
  780. For the purpose  of giving a more distinct view of  the prevalence of
puerperal fever, I have made out (as accurately as possible) a chronological
list of the  different epidemics, with  the  names  of the authors  by  whom
they are noticed  or described, and  the  pathological  characteristics  when
ascertained.
Date of Kpidemic.	Plaoe.	Author.	Characteristics.
1664	Paris,	Peu, (Lee).	
1746	Paris,	Malouin,	Peritonitis, Hysteritis, etc.
		Jussieu,	Disease of Ovaries.
1750	Lyons,	Doulcet,	Peritonitis, U. Phlebitis.
175')	Paris,	Pouteau,	Hysteritis, Erysipelatous.
1760	London,	Leake,	Inflam. of Omentum, etc.
1760-61	Aberdeen,	Gordon.	
1761	London,	White,	Peritonitis.
1767	Dublin,	Jos. Clarke.	
1769	London,		
1770	London,	Leake,	Peritonitis (partial).
1771	London,	White.	
1773	Edinburgh,	Young.	
1774 to 81 |	Paris, London,	Tenon, Doulcet,	
	Vienna,	etc.	
1774-87, 88	Dublin,	Jos. Clarke,	Peritonitis.
1782	Paris,	Doulcet,	Peritonitis, Hysteritis.
1783	London,	Osborn,	Peritonitis.
1795	Vienna,	Jaeger,	Peritonitis, Phlebitis.
1786	Paris,	Tenon.	
1787	Gottingen,	Osiander.	
1788	London,	Jos. Clarke,	Hysteritis, Peritonitis, etc.
1787-8	London,	Do.	Peritonitis, .Hysteritis, etc.
1789-90, 91, 92,	Aberdeen,	Gordon,	Peritonitis.
1803-10. 12, 13,	Dublin,	Collins, Douglass,	Peritonitis.
1808	Barnsley, Yorksh.	Hey,	Peritonitis.
1812-13	Leeds, Yorkshire, Sunderland, coun-	Hey,	Peritonitis.
1813 -j	ties of Durham, and Northum-berland, Dublin,	y Armstrong,	Peritonitis.
1811	Heidelburg,	j Naegele. \ BayrhoflFer. Dun,	
1812	Holloway, London,		Peritonitis.
1814-15	Edinburgh,	Hamilton.	
1816	Paris,	Tenon,	U. Phlebitis, Hyster. Perit.
1817-18	Pennsylvania, U.S.	Dewees,	Peritonitis.
1818-19, 20-23	Dublin,	Collins,	Peritonitis.
1819	Vienna,	Boer.	
! 1819	Glasgow,	Burns.	
1821-22	Edinburgh,	Campbell,	Peritonitis.
1821-22	Glasgow, Stirling,	Campbell,	Peritonitis.
1827-28	London,	Gooch,	Peritonitis.
1827-28. 29,	London,	Ferguson,	Peritonitis, Hysteritis.
1835-36-38	London,	Do.	Phlebitis, etc.
2825-27, 28, 291	Dublin (Lying-in Hospital,)	Collins.	
 
PUERPERAL  FEVER.                     539
Date of Epidemic.		Place.	Authors.	Characteristics.
			f	Inflam. of Peritoneum, Ute-
1829		Paris, (Maternity),	Tonnelle, 1	rus and appendages, and Uterine Phlebitis.
1829-40, oc-casionally,	{	London, Birming-ham,Dublin (Ly-ing-in-Hospital.)	>E. Kennedy.	
1831	{	Birmingham, ") Aylesbury, j	Ceeley.	
1836-34		Vienna,	Bartsch,	Uterine Phlebitis.
1836-7	{	Dublin, (New) Lying-in-Hos. J	Beatty,	Peritonitis, Pleuritis, etc.
1838		Paris, London.		
1842		Rennes, London.		
1843		Rouen.		
1844		Rouen, Rennes.		
1845	{	Rouen, Paris, Giatz.		
1846	{	Rouen, Dublin, Scotland.		
1852	{	Brakel, West- \ phalia, J	Disse,	Typhoid fever.
1854-5		Dublin,	M'Clintock,	Do.
  781. From a review of the history of the epidemics of puerperal fever, it
appears that there is some remarkable connection between them and lying-in
hospitals.   I  do not mean to assert that the epidemics always originate in
and are kept up by these institutions, but I refer to the fact that we have no
record of any epidemic independent of them in earlier times.   The  first in
Prance, England, and Ireland occurred in the Hotel Dieu of the former, and
in the lying-in  hospitals of the latter countries; and although our earlier
writers allude to inflammation of the womb, etc.,  occurring in childbed, they
make  no mention of its prevailing extensively or as an epidemic.  No doubt
it has since been observed in private practice, in London, Edinburgh, Dublin,
Leeds, etc.; but its extent  in these cases is, after all, comparatively limited.
In Dublin the higher ranks have been singularly free from attacks of the dis-
ease.   Dr.  Joseph Clarke  practised for forty-four years in this city, during
which time  he attended 3847 cases of midwifery,  and  yet in that number he
met with only three cases of peritonitis, and three others where the disease
is doubtful, but which may have been uterine phlebitis, although, during that
time, puerperal  fever was more  than  once epidemic  in the hospital.   It  has,
however, certainly been more frequent of late years.
  Y82. Perhaps the most general fact connected with puerperal fever is the
presence of local disease.   In  almost all  cases  of the  epidemic, when an
opportunity of post-mortem examination has been permitted, local lesions of
some kind  or other have been detected, and even where this opportunity was
denied, little doubt was felt by the medical  attendants that  such existed.   It
seems very  probable, also, that in many cases where the local disease seemed
but slight, there would now be recognized very important changes,  for we
know  that  a patient may die of inflammation of the  uterine veins or lym-
phatics, with very obscure  symptoms, and without either enlargement or
obvious tenderness  of the  uterus, and that these morbid lesions may easily
be overlooked if the  examination be hasty or superficial.   It is  only fair,
however, to state that Dr. Copland, in an excellent article on puerperal fever,
differs from this view.  He  states that his experience has "convinced him
that a most rapidly fatal and a most malignant form of puerperal fever is 
5 40
PUERPERAL  FEVER.
occasionally developed  in  lying-in hospitals, which is certainly not charac-
terized  by uterine phlebitis  nor by purulent collections in the uterus or its
appendages, nor even in some cases by peritonitis, the chief lesions often
being merely a remarkable alteration of the blood, general lacerability of the
tissues,  or loss of their vital cohesion soon after death,  with a dirty, muddy,
offensive, and  sometimes a scanty effusion into the serous cavities."1  lie
adds, however, that  such cases are rare.
   The  local  affections in  puerperal fever embrace all the usual results of
inflammation,  and involve  all the tissues  of the organs of gestation, either
separately or  together.  The most frequent appears to be  peritonitis, ori-
ginating very  probably in  the outer covering of the uterus, but spreading to
the entire serous cavity.   We  find also inflammation  of the  muscular tissue
of  the  uterus with  its consequences,  abscess,  softening, and  gangrene;
inflammation  of the  lining membrane, softening, and  gangrene ;  inflamma-
tion of  the veins and lymphatics, with the secondary affections thence arising,
inflammation  and purulent deposits in different organs, muscles and joints;
and inflammation of  the ovaries, with its consequences.
   T83.  I  must repeat my conviction that  there are not many cases of puer-
peral fever without some local disease of the organs employed in parturition,
or  of the neighboring tissues ;  but  are we thence necessarily to conclude
that puerperal fever is always simply a local affection, the local disease being
primary and the fever secondary ?  Must we adopt Dr. Robert Lee's opinion,
that his " observations are subversive of the general opinion now prevalent,
that there is a specific, essential, or idiopathic fever, which  attacks puerperal
women, and which may arise independently of any local affection in the uterine
organs, and even prove fatal without any change in the organization of their
different textures ?   As the constitutional  symptoms thus appear to derive
their origin from a local cause, it would certainly be more  philosophical and
more consistent with the principles of nosological arrangement to banish
entirely from  medical nomenclature the  terms puerperal or childbed fever,
and substitute that of urine inflammation, or inflammation  of the uterus and
its appendages, in puerperal women."2
   In the former  editions of this  work I adopted Dr. R. Lee's views, and
employed  his  arrangement; but whilst I  confess  my obligations to his able
researches, and agree with him as to the presence of local lesions generally,
I  am bound  to  state honestly and  frankly that more extended experience
has led me to doubt the accuracy of these views, and to believe that malig-
nant puerperal fever is something  more than a local  affection, and that the
constitutional disease is often  rather primary than secondary.   At the same
time  I  have no doubt that Dr. Lee's views are  applicable to many cases.
   What,  then, is the essential nature of  the malignant epidemic, puerperal
fever ?   This is a question not easy  of solution, and one which has led to the
expression of very different opinions.  It  has been regarded as

                         Inflammation of the Uterus, by
   Hippocrates,           F. Plater,          La Motte,            Villars,
   Galen,               Sennert,           Sydenham,           Astruc,
   Celsus,               Riverius,           Boerhaave,           Pouteau,
   iEtius,               Sylvius,            Van Swieten,         Denman.
   Paulus Avicenna,      Strother,           Hoffmann,
   Raynalde,            Mauriceau,         Jussieu,

                  Inflammation of the Omentum and Intestines, by
   Hulme,                          Leake,                        La Roche.
1 Dictionary of Pract. Med.  Part xiii. p. 500.
2 Researches on the more Important Diseases of Women, p. 3. 
PUERPERAL FEVER.
541
Peritonitis, by
Waller,
Johnson,
Forster,
Cruikshank,
Bichat.
Pinel,
Gardien,
Capuron,
Gordon,
Hey,
Armstrong,
Clarke,
Campbell,
Collins.
Peritonitis connected with Erysipelas, or of an erysipelatous character, by
Pouteau,
Home.
Lowder,
Willis,
Puzos,
     Young,
     Abercrombie,
     Gordon,


Fever of a peculiar nature, by

        Levret,
        Doublet,
Armstrong,
Hey,
Campbell, etc.
Hamilton.
Peu,
Petit,
Selle,
Finch,
   Disorder of a putrid character, by

Tissot,              Le Roi,

   Disease of a complicated nature, by
Kirkland,
Walsh,
Tenon,
Tonnelle,
Fever with Biliary disorder, by

       Stoll,
White.
Lee,
Ferguson.
Doulcet.
  If we regard  the  peculiar characteristics of different epidemics, we find
them extremely varied.   In one, the lochia are suppressed ; in another, they
are  profuse ;  and in a  third, unaltered.   Diarrhoea is common in  one epi-
demic, constipation in another; typhoid symptoms in one ; inflammatory in
another.   And as to the  effects  of  remedies, we find as great a diversity;
one high authority recommends saline  purgatives, which fail in the hands
of other practitioners ;  another loses all his patients until he bleeds largely
at the commencement, whislt others lose all who are so bled.   Calomel  is the
universal remedy in  one epidemic, opium in  another, purgatives in a  third,
inunctions in  a fourth, turpentine in a fifth, etc.
  Now, from these variations, the inference is obvious, that the type of the
disease varies in different epidemics, and that the treatment must necessarily
differ.   But I think  we may go a step further ; and if any one will carefully
compare a case of simple inflammation of the womb or peritoneum in  child-
bed with a case of  malignant epidemic  puerperal fever, their  symptoms,
general and local characteristics,  course,  and the effects of remedies,  he
will be obliged to come  to  the  conclusion that,  although the latter may
exhibit local disease, it  is not exclusively nor  primarily a local affection.
  784. I should wish to speak very cautiously and guardedly on so difficult
a subject, but after a careful comparison of the experience of others with my
own, I am inclined to believe that the essential difference  between  epidemic
puerperal fever and  simple inflammation  consists in a morbid deterioration
of the  blood in the former case, which is rarely present in the latter, or not
till an  advanced stage ;  whether  this deprivation result from some general
noxious influence or from some malign peculiarity of the constitution.   The
following  considerations  seem to support this  view:   1. Puerperal fever
prevails most during the winter and spring months, in moist and cold weather,
or durino- alternations of cold and warm moist weather, as the following table
shows:— 
542
PUERPERAL FEVER.
Table  I.  (Dr. Gordon's.)
October .
November
December
January .
February
March
1821, March
  "  April
  "  May
  "  June
  "  July
  "  August
  "   September
  "   October
  "   November
  "   December
Cases of Puerperal. . 13 . 8 . 12			April May June	Cases of Puerperal . 6 . 6
	8 6		July August September	'. 5 . 5
Table		II. (Dr. Campbell's.)		
Case	s of Puerperal. 1 7 2		1822, January . " February. " March	Cases of Puerperal . 7 . 6 . 5
	2 3		" April " May	. 4 . 4
	1		" June	. 3
	. 1 . 7 . 13 . 11		" July " August " September " October .	o '. 1 . 3 . 2
Table  III.  (Dr. Ferguson's.)
January . February1 March April'. . May . . June . . July . . August . September October . November December	1827	1828	1829	1830	1831 ' 4* 1 ' 2' 2 9 2	1832 2 ' l" ' 1 2 2	1833	1834	1835	1836	1837	1838	p
	1 3 4 ' 2	2 2 ' 4* 3 3 3 8 4 8	3 7 3 1 1 6 3	3 2 1 1			1 2 2 2 1 1	' 3* 4 2	2 2 ' 2 5 6 5 2 2	4 6 6 6 2 4 3	3 ' 3* 2 1	9 ' 8* 9	34 17 2'' 34 20 '! 4 12 11 21
Attacked. Died . .	10 1	37 7	24 6	7 2		8 5	9 3	9 5	26 10	31 9	9 2	26 20	■l()r> 08
Table  IV.   (M. Duges'.)
1819, January
  "  February
  "  March
  "  April .
  "  May  .
  "  June .
Cases.
 81
 82
 65
 47
 67
 35
1819, July   .
  "  August
  "  September
  "  October
  "  November
  "  December
Cases.
 40
 40
 53
 69
 74
 63
Table  V.   (M. Delaroche's, Geneva.)
January
February
March  .
April   .
May
June
Cases.
 77
 43
 76
 55
 35
 40
July   .
August .
September
October
November
December
Capes.
 37
 36
 51
 51
 66
 61
» Hospital closed Feb. 1838.
2 Closed from April to Nov. 1838. 
PUERPERAL FEVER.
543
  Thus, the most injurious  months in Aberdeen were October, December,
November;  in  Edinburgh,  November, December, January;  in London,
January, March, February, December,  May;  in  Paris, November, October,
February ; in Geneva, January, March, February : and during these months
we find other diseases prevail most whose characteristic is depravation of the
blood.
  2. The  two epidemic diseases which most commonly prevail at the same
time, and under somewhat similar circumstances, are erysipelas and typhus
fever, especially the former,  whose presence in surgical hospitals is always
indicative of impending puerperal fever.   Some have  gone further, and
expressed their opinion of these  diseases  being so far identical, as that in-
fection  from either erysipelas  or typhus fever may give rise  to  puerperal
fever.   Mr. Nunnelly, in his work On Erysipelas, considers the two  diseases
to be identical, prevailing during the  same atmospheric conditions,  exhibit-
in"* the same general symptoms, and each capable of reproducing the other.
Dr. Hutchinson and others have seen  both puerperal fever  and  erysipelas in
the same patient  at the same  time, and I have noticed that the infants of
women attacked  by puerperal fever are very liable to erysipelas or diffuse
inflammation.   It is  also beyond  question,  that infection carried from  a
patient suffering from erysipelas to a lying-in woman, may in  her  give rise
 to puerperal fever.   I am not, however,  about to contend for the identity
 of  these two diseases, but merely to point out the great probability that the
 essential feature of  erysipelas is a morbid alteration of the blood, or, in the
 words of Mr. Nunnelly, that " it is highly probable, if not certain, that  there
 is some change produced  in the  state of  the blood,  which change may de-
 pend upon alterations we  are  unable  at present to appreciate, but which is
 likely to occur in many tissues, and may thus affect the mass of the blood,
 more or less quickly,  and  to a greater  or less extent, according to the  influ-
 ence they have upon, and  the connection they have with, the blood in a state
 of health."1
   As to typhus fever, there  is  evidence on  record that women in childbed,
 exposed to the contagion  of  typhus, have  exhibited all  the  symptoms of
 puerperal  fever.   The late  Dr. Labatt mentioned to  me that he had known
 a patient laboring under typhus fever,  and brought into the lying-in hospital,
 originate puerperal fever in patients in  the same ward, who had recently
 been  confined.   And Dr. Collins  mentions  a similar instance.  No doubt
 exists  at present,  I  believe, that in  typhus fever the state of the blood is
 much deteriorated, and that this constitutes  a most important, if not essen-
 tial, character of the  disease.   As bearing upon the present question, I may
 quote the following passage  from Dr. Ormerod :2 "Besides the sudden in-
 crease, under such  circumstances, of  the  number of  patients suffering from
 fever, there is observed  in all epidemics, from the plague of Athens down-
 wards, a tendency of all  diseases to  assume, as  far as may be, the epidemic
 type. ' Much, probably, of this is explicable on the supposition of the exist-
 ence of the same atmospheric  condition affecting all  who cannot resist it, in
 the same way ; but however this may be, as far as general impressions  in the
 absence of notes will justify the assertion, simultaneous with the occurrence
 of fever in the  medical  wards,  phlebitis  and  troublesome sores  are more
 commonly met with in the surgical wards of this hospital, and erysipelas of
 the head and face  in both."   Much more evidence of a similar kind  might
 be adduced, but this is sufficient for my purpose.
    3.  Dr Simpson3 has adduced the analogy between certain  forms of puer-
 peral fever and the secondary fever which occurs after great surgical opera-
 tions, and which there can be  little doubt is owing to  the absorption of mor-
       i On Erysipelas, p. 72.                  ' On Continued  Fever, p.  168.
       s Med. Times and Gazette, April 23, 1859, et seq. 
514
PUERPERAL FEVER.
 bid matter.   This very closely agrees with the conclusions expressed by Dr.
 Ferguson, as follows : " 1, the phenomena of puerperal fever originate in a
 vitiation of the fluids ; 2, the causes which are capable of vitiating the fluids
 are particularly rife after  childbirth ; and 3, the various forms of puerperal
 fever depend upon this  one cause, and may readily be deduced from it;"1
 and he quotes in confirmation  the analogy drawn by Cruveilhier between
 the surface of the uterus and an amputated stump.2
   785. Thus  then we  find that the  same  seasons give rise to erysipelas,
 typhus fever,  and puerperal fever; that they  prevail epidemically at  the
 same time ; and as an epidemic take on the same type, and appear capable,
 the one of giving rise to  the  other, or of co-existing in the same patient.
 Further, that the symptoms of certain forms at least of puerperal fever are
 similar to those  which occur  after great surgical operations, and  that the
 secondary lesions are similar.   Now,  in  erysipelas,  typhus fever,  and  the
 secondary fever after operations, there can  be little doubt  of the  depraved
 condition  of the blood, and it is  highly probable that  their low typhoid
 character  is owing to this blood-poisoning.   I think,  therefore, that  the
 conclusion, that the peculiar character and  malignancy of certain epidemics
 of puerperal fever also depend upon a morbid condition of the blood, how-
 ever produced, in addition to the local disease, is inevitable."3
   Unfortunately we have but little direct evidence of  the state of the blood
 in puerperal fever.  Dr. Arnott's researches have disproved John Hunter's
 opinion, that phlebitis destroyed life by an extension of the inflammation to
 the heart; and with other investigations  have  shown that  it is owing pro-
 bably to deterioration of  the blood.   M. Bouillaud,  in 1825, attributed  the
 typhoid symptoms in phlebitis to a mixture of pus with the blood ; and  he
 adduces the  experiments of Baglivi, Magendie, and Gaspard, as confirming
 his opinion, they  having produced similar results by the injection of putrid
 matter into  the system.   We know from  the observations  of Dance, Ton-
 nelle, Duplay,  Lee, and  many others, as well as from our own observations,
 that pus is found  in the uterine veins in considerable quantity in some forms
 of puerperal fever, and we  find that the symptoms described  as characteristic
 of irritative phlebitis closely resemble those  of puerperal fever.
   Mr. Moore states that he " has seen a black precipitate in the blood of a
 person laboring under the  adynamic  form of the disease.   Such a deposit
 is often found  in  typhus and  in  the last stage of infectious erysipelas and
 phlebitis.    Another  similarity  between the blood in this affection and  in
 other diseases of a typhoid and malignant character, is the peculiarly offen-
 sive odor  occasionally arising from it."*
   In  the  epidemic which  occurred in 1845, in Paris, and which  presented
 the symptoms of low typhus, MM. Bidault and Arnold state that the blood
 was dark  and semi-coagulated, as  in low typhus fever.5  And  in the epi-
 demic  which  occurred at  Griitz in the same  year, Dr. Schoeller mentions
 that the blood  was very fluid, and exhaled a peculiar bat-like odor ; in other
 respects it resembled  the blood of persons poisoned by Prussic acid.6
  Dr. Scanzoni has recently maintained that the  special causes of puerperal
 fever originate in the  altered condition of the blood,  and consist mainly in
the presence of pus.7
  1 On Puerperal Fever, p. 53.                    2 Anat. Path., Liv. 13.
  3 For further details, I refer the reader to a review in the  Brit, and For. Med.-Chir
Review for October. 1855, to Dr. Murphy's paper in the Dublin Quarterly Journal, Aug
 1857, Dr. Fordyce Barker's able paper, read before the New York Academy of Medicine,
and to Dr. Simpson's valuable  lectures in the Med. Times and Gazette, beginning April
23, 1859.
  * On Puerperal Fever, p. 183.                    5 Gazette Me'dicale, Aug. 1845.
  6 Med. Jahrbuch. der K. K. Oester. Staats, Oct. 1845.
  7 Ranking's Abstract, vol. vii. p. 335. 
PUERPERAL FEVER.
545
  In a case of puerperal peritonitis,  on the evening  of the second day, Dr.
Simon  found  that the  blood formed  a tolerably firm  clot, and was covered
with a buffy coat of an inch and  a half thick;  the  chemical  analysis fur-
nished similar results to those obtained by MM. Andral and Gavarret.
  In cases of metro-peritonitis,  quoted  by Dr. Day, from the analysis of
Scherer, Haller, Becquerel,  and Rodier, the blood presented  an increase of
fibrin, and a great diminution of blood corpuscles.
  Dr. Copland  states  that  he is  not  acquainted with  any analysis of the
blood in the most malignant form  of  puerperal  fever,  except that which Dr.
Day quotes from Haller, who states that the blood was of a very dark-brown
color.  The clot was  dark, of a loose consistence, and covered by a buffy
coat, over which was a delicate membrane,  which presented under the
microscope a firmly granulated appearance and fat vesicles.   The serum was
turbid, but after standing for some time  it became clear ;  its  reaction was
alkaline; its  specific gravity 1025.   The fibrin was  5'16 ; the blood cor-
puscles 7 V "5 2.   According to Becquerel and  Rodier,  the cholesterin and
phosphates are increased.
  Although the evidence I have now  adduced may not be sufficient to prove
that purulent  depravation  of  the  blood is the sole  or essential cause of
malignant puerperal fever,  I think it affords  ground  for believing that the
general element which constitutes the difference between this form of  puer-
peral fever  and  simple inflammation  of the uterus  and peritoneum, may
consist in some  form of deterioration of the  blood,  depending either upon
atmospheric malaria  from without or absorption of some noxious matter
generated within the  body.  At  all  events,  I  cannot  but agree with Mr.
Moore, that "in puerperal  fever,  typhus, cholera, and  other  epidemic and
contagious diseases belonging to the  class  neuroses, there  is, besides in-
flammatory action, another element  unknown,  but which  has an essential
influence  upon the intercurrent phlegmasia? arising in their course, and which
may yield at one point only to appear at another."1
  786. Various causes have been assigned for the production of this disease :
it has been attributed  to difficult labor,2 to uterine inflammation,3 to an accu-
mulation  of noxious humors,4 to  violent mental emotions, stimulants, and
obstructed  perspiration;5   to  miasmata; to  admission of cold air to the
body and into  the uterus;   to hurried circulation ;   to suppression of the
milk ; to diarrhoea ;6 to putrid contagion from alteration in the fluids during
pregnancy ;7  to hasty separation  of  the placenta ; to too tight application
of the binder ;8  to  sedentary employment ;  to stimulating  or spare  diet;
to fashionable dissipation;  to retained portions of  placenta;  to floodings
from non-contraction,  according to Mr.  Skey;  from  violence  but not from
want of contraction, according to Dr. Armstrong ; to  inflammation  of the
intestines and  omentum, from the pressure of the gravid uterus;9  to at-
mospheric  derangement; to erysipelas, metritis or  phlebitis, and to con-
tagion  of a specific kind.
  A word or two upon some of these supposed  causes may not be  out of
place.  I do not think we can  fairly regard difficult labor as a direct cause,10

  1 On Puerperal Fever, p. 126.
  2Of 1116 cases in the Dublin  Lying-in Hospital in 1819-20, 68 were  first labors;  but
they were not remarkably tedious.                                      .
  3 F. Plater, Prax. Med., 1686, vol ii. chap. xii.  Hoffman, 1734, vol.  iv. part l. Bur-
ton, 1751, Essay on Midwifery, part iv.   Smellie, Tissot, Kirkland, Denman, etc.
  * Sennert, Opera, vol. ii. part  ii. :  Ulcers, b. ii. ch v.
  5 F. Cooper, 1766, Comp. of Med., part iii. sect. iii.  Leake,  vol. ii. part xxxm.
  6 R. W. Johnson, 1769, New System of Midwifery, part iv. chap. vii.
  7 J. Miller, 1770, Obs. of Prevailing Diseases, part iii. ch. ii.
  8 Manning on Female Diseases, ch. xx.     9 Dr. Hulme on Puerperal Fever, p. 14*.
  10 Armstrong on Puerperal Fever,  p. 2.
      35 
546
PUERPERAL  FEVER.
although the condition in which  the  woman is left may render her more
obnoxious to the epidemic.   Primiparae certainly seem somewhat more liable
to be attacked,1  and also patients who at the  time of labor are in a weak,
reduced state.2
  [We have had repeated opportunities of studying epidemic puerperal fever.
To  each visitation of the  disease in Philadelphia and its  suburbs, witnessed
by  us, the same remarks are  applicable as were  made  in  the  account we
rendered to the  College of Physicians, of the very fatal  and extensive epi-
demic which prevailed in Philadelphia during the spring of 1840.   Namely :
that the disease occurred alike in the young and middle aged, the robust and
delicate, in those surrounded by every comfort and afforded every attention
demanded by their  situation, as in the poor  and destitute ; as well in those
confined for the first time, as in those who had  already borne a number of
children;  and as well  after the most  rapid  and easy labors, as after those
that were protracted and  difficult.3]
  Mental emotion may undoubtedly be considered  an  effective predisposing
cause.   Under its influence females are peculiarly exposed to puerperal fever,
and less able to bear it;  thus it has been remarked, that unmarried women
are often victims.4  Several of the worst cases  I have seen were mainly at-
tributable to this cause.   Cold may fairly be admitted into the list of causes.
Portions of placenta remaining in the  uterus, and putrefying, may, I believe,
give rise to puerperal phlebitis, although this is by no means invariably the case.
  Gastro-enteric irritation may certainly be propagated  to the neighboring
tissues;  and cases  which appeared simple at first may thus  assume the
character of puerperal fever, especially during an epidemic.
  That hemorrhage during or after labor does not prevent  puerperal fever,
we  have abundant proof; but that it renders  a patient more liable to it,
except so far as it reduces her strength, may be doubted.
  To a considerable  extent, as we have  seen,  the state of the atmosphere
influences the disease; in damp, moist weather, it  is much more prevalent,
and less so in warm, dry weather.
  Whatever that which we call epidemic influence  may be, there can be no
doubt that to it  the majority of cases are attributable, especially the worst
and most fatal.
  787.  Another very important question yet remains for our investigation,
viz., that of the infectious or contagious  nature of puerperal fever, particu-
larly when it is epidemic.   Of the  simple  cases of peritonitis or phlebitis after
labor,  occurring  sporadically, I do  not know that any one considers them
contagious;  but of the low  malignant fever, opinions have varied consider-
ably.  Drs.  Hulme,  Hay, Armstrong, Dewees, Davis,  Baudelocque, Ton-
nelle, Jacquemier, Kiwisch, Dewees, Meigs, etc., deny the contagion; Drs.
Gordon, Young, Clarke,  Denman, Burns, Hamilton, Blundell, Gooch, Mr.
Ceely, Drs.  Ramsbotham,  Rigby, Lee,  Copland, Channing, Holmes, etc.,
affirm it.
  In all cases where a disease is epidemic, it is, and ever must be, a difficult
matter to decide as  to the  extent of  its infectiousness, because, in order to
be  exposed to either the contagion or  infection, a  person must also necessa-
rily be placed in circumstances favorable to  the exertion of its influence as
an  epidemic.   But after  a  close  and  careful examination of the history of
epidemics, of the cases recorded, and of the  opinions of men of the greatest
experience, I believe that the weight  of evidence is  in  favor  of puerperal
fever being infectious and contagious, i. e., that  it may be communicated

        i Collins' Pract. Treatise, p. 384.
        2 Dr. Jos. Clarke's Essay, Med. Comment,  1791, p. 311
        3 [Trans. College of Physicians, Philadelphia,  old  series, vol i. p. 51].
       4 Home, Chir. Exp., p. 83. 
PUERPERAL  FEVER.
547
from a patient laboring under it to another who is in contact or close neigh-
borhood with the affected party.
  788. Leaving the  general  question of contagion from one patient to
another, let us for a short space examine into the evidence in  favor of the
communicability of the disease by a  third party from  a patient laboring
under it to another during or after her delivery, as this has a direct practical
bearing upon the duties of medical men.   The exact value of  the facts on
record will be better estimated by a little classification.
  1. It seems impossible to doubt that contagious matter capable of exciting
puerperal  fever may possibly be conveyed  by a third party unaffected by it;
for  example, in the cases on record of  puerperal fever following the services
of medical men and nurses who were in attendance upon erysipelas immedi-
ately before.   The instances are too remarkable and too numerous to be
regarded as coincidences,  nor would even  the prevalence of an epidemic of
puerperal  fever  at the  time invalidate our conclusions;  it might certainly
render the cause more influential.
  2. It is the recorded  opinion of Rokitansky, Semelweiss, and others, that
morbid matter acquired in the dissection of subjects not dying of childbed
fever may be conveyed by the dissector, and  excite the  disease in a patient
delivered by him; and to this,  among  other causes, has  been attributed the
presence of puerperal fever  in the wards of the Vienna Lying-in Hospital.
A celebrated foreign  practitioner attributed two  outbreaks  of this  disease
among his private  patients to  his  having  handled  morbid  specimens just
before attending a patient in her accouchement.
  3. We  should, therefore, have less difficulty in believing that similar effects
may be produced by those passing from the dissection of puerperal patients
to the  delivery of healthy ones, especially if the most rigid precautions were
not observed.  For instance, in the autumn of 1821,  Dr. Campbell, of Edin-
burgh, attended the dissection of a married woman who died of the disease,
after  an abortion of  the  early months ;  he removed  the pelvic viscera and
external parts, and carried  the whole  in his coat pocket to the class room.
The next  morning, dressed  in the  same  clothes, he  assisted, with some of
his  pupils, at an instrumental delivery  at Bridewell.  This woman was seized
with the  same affection, and  died.  The same night he  accompanied Dr.
Orr to the delivery of a woman residing in the north back of the Canongate ;
she was equally unfortunate ;  and three other poor women shared the  same
fate in quick succession.   In a subsequent year, 1823, he assisted at the dis-
section of a childbed  fever case, but could not wash  his hands with the care
he  desired ;  thence he went to attend two  other women  in labor, both of
whom died of puerperal fever.
  At a meeting of the College of Physicians, Philadelphia, U.S.,  Dr.  War-
rington stated that, after assisting at an autopsy  of puerperal peritonitis, he
was called upon to deliver three women in rapid succession.  All  these
women were attacked with different forms of what is commonly called  puer-
peral fever.
  " Mr. Davies states that in the autumn of 1822 he met with  twelve cases,
while his medical friends in  the neighborhood did not meet with any,  or, at
least,  with very few.   He could  attribute this to no other  cause than his
having been  present  at the  examination  of  two  cases, and his having con-
veyed the  infection to his patients, notwithstanding every precaution."
  ""A  young  surgeon, shortly after examining the body of a sporadic case
that had died, delivered three women,  who all died of puerperal fever." _
  "Mr. Ingleby states that  two gentlemen, after the post-mortem^ examina-
tion of a case  of this  disease, went in the  same dress, each respectively, to a
case of midwifery.   The  one case was attacked in thirty  hours afterwards,
the  other  in three days.   One of the same  surgeons attended, in  the  same 
548
PUERPERAL  FEVER.
clothes, another female, and she was  attacked  on the evening of the fifth
day, and afterwards died."1 .
  Now with regard to cases  attended immediately after  the post-mortem
dissection, there seems little room for doubt as  to the exciting cause of the
fever.   It may have been  conveyed in the clothes or on the hands of the
accoucheur, but it is, at any rate, adequate  to the effect, and the sequence
is too  simple and too close to be rejected.
  4. Can we venture to say the same of the following case: Dr. Merriman
mentions in the Lancet for May 2, 1840, that  he was present at the exami-
nation of a case of puerperal fever at two p.m.  He took care not to touch
the body.   At nine o'clock the same evening he attended a woman in labor;
she was so nearly delivered that he had scarcely anything to do.   The next
morning she had rigors, and died in forty-eight hours.
  We do  not  know whether  puerperal fever was epidemic at the time, but
the cause suggested  seems so inadequate that we should be inclined to look
for some other explanation.
   5.  So far, then, we have seen medical men engaged in handling morbid
matter, their dress and persons exposed to  the effluvium from dead bodies,
and passing directly to attendance upon lying-in-women ; here we have a
distinct, appreciable exciting cause adequate to the production of disease in
healthy persons, and which may have been,  and probably was, conveyed to
the patients who were first attended, and  in whom puerperal fever appeared.
 But in several instances the  disease was not  confined  to the first women
 attended,  but  appeared in others  delivered successively.   How are we to
 explain this, and  how can we explain the pertinacity with which puerperal
 fever  seems occasionally to track the footsteps of one  or two practitioners,
 whether at first lighted up by morbid matter derived from dissection or not?
 Take  the following  examples.   Dr. Gooch mentions that "A general prac-
 titioner, in large midwifery practice, lost so many cases  from puerperal fever,
 that he determined to  deliver no more for some time, but that his partner
 should attend  in  his  place.  This plan was pursued for one month,  during
 which not a case of the disease occurred in their practice.  The elder prac-
 titioner being then sufficiently recovered, returned  to  his practice, but the
 first patient he attended was attacked by the disease, and died."  This latter
 fact see!ms to us to prove  that the disease was  epidemic at the time.  Similar
 instances have come to our own knowledge  more recently.
    Dr. West, of Philadelphia, states that seven females delivered by  Dr. S.
 Jackson, in rapid succession, were all attacked with puerperal fever, and five
 of them died.   These  were the only cases that occurred in that district, for
 the women became alarmed, and sent for other assistance.
    A physician in Boston, U.S., had the  following consecutive cases: — On
 March 24th, April  7th, 10th,  11th, 27th, and 28th, and May 8th, seven  in
 all, of which five died.   He then left town.
    Another physician writes to Dr. Holmes as  follows:—" The first case was
 in  February, 1830,  during a very cold time.  She was confined on the 4th,
 and died on the 12th.  Between the 10th and  28th of this month I attended
 six women in  labor, all of whom did well  except the last, as also two who
 were  confined  March 1st and  5th.  Mrs.  E., confined February 28th, sickened
 and died March 8th.   The next day, March 9th, I inspected the body, and
 the night after attended a lady, Mrs. G.,  who sickened and died on  the  16th.
 The 10th I attended another,  Mrs. B., who sickened but recovered.  March
  16th  I went from Mrs. B.'s  room to  attend  a Mrs. H.,  who sickened and
 died  on  the  21st.   The  17th I inspected  Mrs. G.   On the 19th I went di-
 rectly from Mrs. H.'s room to attend another lady, Mrs. G., who  also sick-
Copland's Dictionary.  Art. Puerperal Fever. 
PUERPERAL  FEVER.
549
ened, and died  on the 22d.  While Mrs. B. was sick  on the 15th, I went
directly from her  room, a few rods, and attended another woman who was
not sick.   Up to the 20th of the month I wore the same clothes.  I now
refused to attend any labor, and did not until  April  21st,  when,  having
thoroughly cleansed myself, I resumed my practice, and had no more puer-
peral fever.   The cases were not confined  to a narrow space.   The  two
nearest were half a mile from  each other, and half that distance from my
residence.   The others were from two to three miles apart.   There were no
other cases in their immediate vicinity."
   Dr. Ramsbotham has known the disease  to spread  through a particular
district, or to be confined to the practice of a particular  person, almost every
patient being  attacked  by it;  whilst  other  practitioners had not a single
case;  and he considers the distemper as being capable of conveyance not
only in common  modes, but through  the dress of the  attenclauts on the
patients.
   In Sunderland, 40 out of 53 cases occurred in the practice of one surgeon
and his assistant.
   Dr. Roberton,  of Manchester, states,  that between the 3d of December,
1830, and January 4th, 1831, a midwife attended  30  patients of a  public
charity, 16  of whom had puerperal fever, and  all died.   Other midwives of
the same institution attended 380  women during  the  same time, and none
suffered from  it.  He also mentions the case  of a practitioner, who intro-
duced the catheter for a poor woman in puerperal fever, late one evening,
and attended  a lady  in  her confinement  during the same night, who was
attacked with  puerperal fever on the second  day.
   Analogous cases have been recorded by Dr. Pierson, of Salem, U. S., Dr.
Peddie, and Mr. Becroft; and such examples  are, doubtless, very startling,
and require a careful examination, to ascertain their exact  value as bearing
on the question at issue ; but we shall first hear what Dr. Meigs says on the
other side.  His first argument is from personal experience :—" I have prac-
tised midwifery for many long years.  I have  attended some  thousands of
women in labor, and passed  through repeated epidemics of childbed fever,
both in town  and hospital.  After all this experience,  however, I do not
upon careful reflection and self-examination,  find the least reason to suppose
that I  have ever conveyed  the  disease  from place to place  in any single in-
stance.   Yet for  many years I carefully considered whether such  a transfer
by a third person might be possible, and carefully read  the  statements of
various authors to that effect.   In the course of my professional life,  I have
made many necroscopic researches of childbed fever, but never did suspend
my ministry as accoucheur on that account.   Still I certainly never was the
medium of  its transmission.  I  have, in numerous instances, gone from the
bedside of women dying  of childbed fever, whether sporadic, or the most
malignant degree epidemic, without making my  patients sick.  I have also
endeavored to assist my brethren, when they had  such cases and I  had none.
In a series  of labors,  468 in number, and beginning with No. 1, I find that
Nos.  18 and 19  were  affected,  and that  No.  18 died  with childbed fever;
No. 31 was sick, but recovered ; Nos. 195 and  259 were sick, but recovered;
but 291  died, as did  also 293.  Nos.  332, 339, 435, 444,  and  445 were
attacked, and  recovered.   The  above cases—viz., 18, 19, 31, 195, 259, 291,
293, 332, 339,  435, 444, 445,  455, are, in all,  13 cases in 468 labors, of which
3  died and 10 recovered.   Now, if I was the  medium  of contagion for any
one of that series of  468 confinements, why did I poison them in the ratio
and order above  set forth ; and why did I  not communicate the disease in
more than 13  out of  468  cases ?   What  became of my nebula from 31  to
195 ;  to  259,  and between  291 and 445, and so  to the  end, or 468 ?  Such
a table is far'more easily explained by regarding the falling-out of the cases 
550
PUERPERAL  FEVER.
as coincidences and accidents, than as material causations, through a private
pestilence.''
   Again, as regards the singular limitation of the disease to the practice of
one person,  Dr.  Meigs observes :  "At page 631 of my work On Obstetrics,
second edition, I have related the circumstances attending the practice of a
physician at Philadelphia, who, in one  of our epidemic seasons, lost a con-
siderable number of women in childbed.  His patients were scattered over
a great superficies of the city and districts, some  of  them being more than
two  miles from  the others.  At  that  time many women were attacked, in
various parts of Philadelphia, as well as in the State  of Pennsylvania ; yet,
so far as has come to my knowledge, no  other medical gentleman happened
to encounter such a great number of childbed fevers as he did.  I visited, in
consultation with him, some of the  very worst of the cases, and touched the
patients, and was as liable to imbibe or to be clothed with the effluvia from
their bodies as he was ; nevertheless, I  did  not carry poison or other cause
of disease to any patient of mine ; and if not I, then how should he become
capable of doing so?  He is a gentleman who is scrupulously careful of his
personal appearance,  of  great experience  as  a  practitioner,  and  well in-
formed  as to  modern opinions on  the  contagion of childbed fever.   Still
those of you who are contagionists will say that he carried the poison from
house to house,  and if so, then you ought to give some rationale of the fact.
Did he carry it  on his hands ?  But a  gentleman's hands are clean.  Did
he carry a nebula or halo about him ?  Then why not I also  ?  If the nebula
adhered to his clothing, it might as well  as  have adhered to mine.   What
will  you say, young gentlemen, of the experience of my friend, Dr. D. Rutter,
formerly of Philadelphia, but now of the city of Chicago, who passed through
terrible scenes here, in an epidemic  of childbed fever,  some years ago, when
he had  a most extensive  midwifery  practice in town and country ?  During
that sad time, I saw several fatal cases with him in consultation ; and though
he seemed to be tracked  by the cause of the disease, to judge by the numer-
ous  attacks  of it in his lying-in  patients, I was not tracked by it.   I took
no precaution, except such as every decent man should be supposed always
to take ; yet I never did carry the disease from his cases to any houses where
I  visited lying-in women.  But he was charged with being a carrier of con-
tagion.  How could he carry the cause ?  What was the cause ?   Was it
some ozone that stuck to  his hands or coat:  Was it a nebula, a halo, or a
miasm that  mixed with the hairs of his head or the woollen or cotton fibres
of his dress ? or an  exhalation from his skin, or a halitus from his lungs, like
the  fiery breath of Cacus ?   And  can you say of him,  as Virgil  sings —

                   " 'Faucibus ingentem primum, mirabile dictu
                     Exomit.—jEneid, lib. viii. p. 252.

Come now,  was not such  poison more sticky than  birdlime,  seeing that Dr.
Rutter, worn  out with fatigue, and wounded  in spirit by his cares  for the
unfortunate victims of an epidemic disease, left the city for the purpose of
gaining some  strength, and to escape  from the repetition of  such disheart-
ening  labors,  and that even a quarantine could not  liberate  him  from this
poisoned cloud ?  One might hope it would have been blown away by the
wind, or that  it would have  evaporated  or become too dilute to  kill, after
a  ride of seventy miles, and an absence of ten days.   But it happened, after
this rustication  of ten days at a distance  of thirty-five  miles from the city,
that your birdlime or cloud still  adhered to  him,  as  your contagionists
would say.  And more than that, he could not even  wash it away or shave
it off;  for upon coming back to the city, and to his professional toil,  before
he engaged in practice again, he caused  his head to  be  closely shaved ;  he
entered a warm bath and washed himself clean; he procured a new wig, 
PUERPERAL  FEVER.
551
new clothes, new hat, new  gloves and new boots.  He did not touch any-
thing he  had worn, and took  the  precaution to leave  his pencil at home,
and his watch.   Well, what do you think happened next ?   He went out to
attend a lady in labor, who had a  favorable parturition, yet was next day
assailed by a horrible childbed fever, of which  she  died in  spite of all his
efforts, and mine  to  help him  ; for  he  called me in in  consultation imme-
diately after being summoned himself to her chamber.   I know that that
lady died with peritonitis.   I  was  a great deal with  her in her illness, but
she did  not poison  me or my clothes;   for although  I went  on with my
practice,  I poisoned nobody,  and made nobody have  even so  much  as  a
finger-ache.  Dr. Rutter repeated this attempt at personal disinfection at a
subsequent period, which was  two years later, and with  the same ill-success.
The  gentleman was  much  and disparagingly spoken of on account of the
above mentioned  events in  his practice, which I cannot but regard as  both
cruel and  unjust,  particularly as  his  success  in the  treatment was  most
brilliant;  for during the epidemic he had charge of seventy cases, of which
he lost only eighteen, and I know not the man who can boast of a higher
triumph of his art of healing in this malady."1
   789.  Let us now  look  a little closer into this matter.   The broad  fact
apparently established by the foregoing observations is,  that puerperal fever
does sometimes  prevail chiefly, or is altogether limited, to  the  patients of
certain practitioners, and the  question arises, To what is this owing ?  The
question is not, whether contagion is the only, or the chief, or the ordinary
means by  which the disease is  propagated ; for it is admitted  on all hands
to prevail  epidemically.   Nor is it the question, whether, under favoring
circumstances, contagion may not  be  conveyed  to  the patient by  the ac-
coucheur,  for we  have related  cases in which it seems impossible  to doubt
that this took place.   We  must therefore eliminate from the foregoing ex-
amples the case of the physician who wrote to  Dr. Holmes, because, having
made post-mortem examinations, his  experience may rather be  referred to
section 3.   In most  of the instances, we are not told  whether the practi-
tioners examined the bodies after death ;  if they did, we cannot deny that
there was a possibility that they might have carried the infection.
   Again,  if, as Dr. Rigby  remarks, "the discharges from a patient in puer-
peral fever are highly contagious," it is at least possible that the case of the
midwife mentioned by Dr. Roberton may be thus explained, inasmuch as
her duties about her patients would necessitate more  or less contact with
the excretions.
   Excluding these classes of Cites, evidence enough remains to show that
the fever does sometimes follow in the track of particular accoucheurs;  and
the real question before us is,  whether it does so by contagion conveyed by
him from  other patients, in spite of the  ordinary precautions, or in certain
cases, notwithstanding the extraordinary  precautions  of baths, change of
air, change of clothes, etc., or whether in  such  cases the prevalence of an
epidemic  of puerperal fever is a sufficient explanation,  admitting  it to ex-
hibit caprices similar to other epidemics.   It is impossible  to bring the
matter to  a demonstration  either way, difficulties meet  us upon either sup-
position,  and  perhaps the  best plan to adopt will be for us to weigh these
difficulties separately.
  Against the explanation  which attributes, with Dr. Meigs, all to epidemic
influence,  is the fact  of its  greater prevalence in the practice of  certain me-
dical men, and its being in some cases apparently limited to them.   That
one man  should  see  more  cases than another  of any epidemic disorder  is
common  enough, and would be  no difficulty in the present case; but that
i On Childbed Fever, p. 102. 
552
PUERPERAL  FEVER.
one should see all, and others none, does seem rather startling.   But is the
proof of the latter  sufficiently conclusive and  sufficiently extensive ?  Dr.
Gooch does not tell us whether the disease was epidemic  or not, nor does
Dr. West.   [The cases referred to by Dr. West occurred in  the practice of
Dr. S. Jackson, at Northumberland, Pa., and they formed the entire extent
of the disease in  that  neighborhood, at the period of their occurrence, and
for several years  before and  subsequently.]   The gentleman who  wrote to
Dr. Holmes states that no other cases occurred in the vicinity, but we have
rejected his example as being one of possible contagion  on  the ground of
his post-mortem examinations.  In  Sunderland  there were at least thirteen
cases which occurred in  the  practice of others,  besides the surgeon and his
assistants.   The  two examples related by Dr. Meigs  occurred during epi-
demics.  So that it must be confessed that the evidence we possess to show
the insufficiency of epidemic influence as an explanation, and  the  necessity
of finding  some other  cause for its greater prevalence in a particular direc-
tion, is neither extensive nor positive.
   The explanation  which  attributes this peculiarity to contagion, has the
merit of being simple and  apparently adequate, but the difficulties  on ex-
amination  are  more numerous and  fully as great.  Assuming for a moment
that the disease can be only communicated during labor, let us recall to our
readers what  takes  place during an ordinary visit to a patient in puerperal
fever, during which time the  infection is  to be taken.   The visit may occupy
five or ten minutes, the physician stands by the bed, feels the pulse, examines
the abdomen, but does not come in contact  with the discharges.   Having
made his investigations, he washes his hands carefully, and  then pays more
visits, passing  through the air, until evening, or until he is called to a labor.
If many hours elapse, he must have washed  his hands several times.   Yet,
in spite of all  this, we are  to suppose that he carries morbid matter on his
hands or  clothes, acquired  from the fever  patient, enough to  poison the
lying-in woman.   And not only this, but  the explanation is supposed to be
equally valid even  though he change his clothes, thus limiting the infection
to the hands,  and even though he use chloride of lime or potash.
   If the  morbid matter be  conveyed on  the hands, the infection, we sup-
pose— and such seems to  be the general opinion — must be  imparted during
labor ;  but if on the  person or clothes, the effect might of course be pro-
duced subsequently, and  hence  another difficulty.  During  the  visit, the
consulting physician is  as close  to the  fever patient, examines her, handles
her quite  as  much at the visit as her ordinary attendant, and, it  may be
 assumed, adopts afterwards much  the  same precautions.   Yet  we do not
 hear of his conveying the  fever to his own patients in any case, and we
 have Dr. Meigs's positive statement that such an occurrence never took place
 in his practice.  The  advocates of contagion should explain this.
   Again,  in all contagious diseases the intensity of the contagion imparted
 to, and  conveyed by, a  healthy  person (as in scarlatina, for example) must
 surely be in proportion to the shortness of the time which  elapses between
 his visit to the sick person and to the party to whom he conveys it; in other
 words, that his chance of  so conveying it would  diminish with  the lapse  of
 time.   For example, an accoucheur visits a  patient in  puerperal  fever, sup-
 pose, and acquires this  contagious property ;  if this rule be true, the first
 patient  he attends will be more liable to take  the disease than the second,
 and the second than the third.   How then explain the fact, on the principle
 of contagion, that no such sequence of attacks is observed ?  the cases affected
 observe no such order, as  the reader will see by turning back to Dr.  Meigs's
 registry.
    Moreover, in two of the most striking cases we have quoted, Dr. Gooch's
 and  Dr. Rutter's  there is a circumstance which is  not reconcilable with,  or 
PUERPERAL  FEVER.
553
explicable by, the doctrine of contagion, as we understand  it.   In the one
case a month, and  in  the  other ten days, of absence elapsed, and the latter
was accompanied by a complete renewal of clothing, and yet  the first case
attended  by both was  attacked by puerperal fever.  Are we  to  attribute this
to remaining contagion, and, if not, does it not point directly to some other
influence which may have  operated previously as well ?
  Thus, a belief in the contagiousness of puerperal fever under ordinary cir-
cumstances, and excluding the cases in sections 1, 2, and 3, must involve, on
the one hand, the conclusion that  it is  of all contagious disorders the most
virulently contagious,  inasmuch as it assumes that it can be conveyed by a
healthy person exposed for a few moments  only to its  influence, to  a third
party hitherto in health,  and  this notwithstanding that the hands, the only
part in contact with the sick person, have been carefully washed, the  clothes
changed, and the entire person exposed to the air, it may be for hours ; and
yet on the other hand, that  this contagious property  limits  itself  to  the
ordinary attendant, and does not affect the consulting physician.  Admitting
that we can not fully  and satisfactorily explain  the limitation of the  disease
on the supposition of epidemic influence only, I ask the reader whether the
difficulties attendant  upon the  explanation by contagion are  not more
insuperable ?
  In conclusion, therefore, whilst I feel  compelled by the evidence on record
to admit the possibility of  puerperal fever being conveyed and communicated
or excited by those who attend  midwifery  cases after being employed in
dissection or post-mortem examinations, and also by those who are much in
contact with the  fever patient or the discharges,  especially  if strict pre-
cautions are not adopted  as to cleanliness and change of dress ;  I do not feel
that in other cases, where no such conditions exist, that the evidence at all
 justifies  our attributing the spread of the disease to contagion, and  I think
fewer difficulties and contradictions are  incurred  by attributing its extension
to epidemic influence, and its  limitation  to conditions or  circumstances  of
which we are at present ignorant.
   Convinced ourselves from personal observation, that contagion or infec-
tion is one, at least, of the means to which the propagation of puerperal fever
is to be referred, we nevertheless admit that there are a number of  facts—
chiefly however of  a negative character—which  it is very difficult to recon-
cile with the contagiousness of either of the forms of the  disease.   One of
the strongest evidences in favor of its contagious or infectious character, as
 Dr.  Tyler Smith very correctly remarks, is that the only successful efforts to
reduce the mortality from puerperal  fever, have  been those directed to the
removal of infection and  contagion.  In the course of a few years the mor-
tality in the great hospital at  Vienna, from this affection, was  reduced from
 1 in 10,  to 1  in 74 of the women  delivered, by the enforcement of measures
to prevent the inoculation and injection of the  puerperal patients.
   790.  Now,  what are the  precautions which ought to  be taken by  persons
who practise this branch  of the profession ?  We have seen that in all proba-
bility the contagion  if at  all conveyed, is so either  by the clothes  or the
hands of the  practitioner, from a patient laboring under the disease,  or from
the dead body.   I would suggest the following :—1. That when engaged in
close attendance upon a patient laboring under puerperal fever,  the  medical
attendant should, if possible, procure  a substitute to  attend  any new case
 of labor;  but if  he  cannot,  then,  2.  He should, before such  attendance,
change  every  portion of his dress,  and wash his  hands in  a  solution of
chlorate of lime, as well  as in soap and water.   3. Dr.  Semelweiss'  sugges-
tion  of  paring the nails close, is worth adopting, as  particles of morbid
matter  may  easily be concealed underneath, and  applied to the  mucous
membrane of the vagina.    4. At the termination of each visit to a patient 
554                     PUERPERAL  FEVER.
in puerperal fever (or in any infectious disease), the hands  should  be care-
fully washed with soap  and water before  leaving the  room, and his clothes
repeatedly changed and well aired.   5. That if a medical  man have patients
in childbed, one of whom  should  be attacked by puerperal fever,  his daily
visit should be first paid to the other patients and afterwards to the puerpe-
ral case,  if the distance permit of  his so doing.   6.  It will  be wiser for any
one engaged in midwifery  practice to procure  an  assistant to make post-
mortem examinations for him ; and if he  be present, he ought  not to wear
the same dress in  attending obstetric cases  until  it  have  been well aired.
If the autopsy be  made by  himself,  extraordinary precautions should be
taken as to repeated ablution, with solution of chlorate of lime, etc ; and a
complete change of dress;  or perhaps, as Dr. Copland suggests, he ought
to allow some days to  elapse before  attending obstetric cases.  7.  These
remarks  apply to all autopsies, no matter of  what  disease the subject died,
although they are more stringent in cases  of death from puerperal;  and also
to attendance  upon and  dressing cases of erysipelas, diffuse inflammation, etc.
   791. In treating of puerperal fever, various arrangements  or classifications
have been adopted  to include the different forms of the disease.  Thus Dr.
Douglas describes three forms :—

   1. The inflammatory.
   2. The gastro-bilious.
   3. The epidemic or contagious  (typhoid).
M. Tonnelle :—
   1. The inflammatory.
   2. The adynamic.
   3. The ataxic (irregular or nervous).
M. Martens:—
   1. The inflammatory (where one organ only is affected).
   2. The nervous (beginning with delirium).
   3. The putrid.
M. Vigarous :—
   1. Gastro-bilious.
   2. Putrid bilious.
   3. Pituitous (vomiting of pituitous matter).
   4. Hysteritis (phlogistic).
   5. Sporadic (arising from cold).
M. Gardien :—
   1. Angiotemic fever, strictly inflammatory.
   2. Adeno-meningic ; slow, insidious fever,  slimy tongue.
   3. Meningo-gastric ;  bilious derangement, yellow skin,  etc.
   4. Adynamic.
   5. Ataxic,  or nervous.
   6. Fever, with local  phlegmasiae.
Dr. Gooch :—
   1. Inflammatory.
   2. Typhoid.
Dr. Blundell:—
   1. The mild epidemic, with little peritonitic tendency.
   2. Malignant epidemic,  with great pain.
   3. Sporadic ; peritonitis, limited.

Dr. John Clarke :—
   1. Inflammation of the uterus and ovaria. 
PUERPERAL  FEVER.
555
  2. Inflammation of the peritoneum.
  3. Inflammation of the uterus, fallopian tubes, or peritoneum, connected
      with inflammatory affection of the system.
  4. Low fever, connected with affection of the abdomen, which is sometimes
      epidemic.
Dr. Robert Lee:—
  1. Inflammation of the uterus, peritoneum, and peritoneal sac.
  2. Inflammation of the uterine appendages, ovaria, fallopian tubes, and
      broad ligaments.
  3. Inflammation of the mucous and muscular,  or proper tissues of the
      uterus.
  4. Inflammation and suppuration of the  absorbents  and veins of the
      uterine organs.
 Or, in other words—
   1. Inflammatory puerperal fever, dependent on peritonitis.
   2. Congestive,  dependent on inflammation of the uterine muscular tissue.
   3. Typhoid, arising from venous inflammation.

 Dr. Ferguson : —
   1. The peritoneal  form.
   2. The gastro-enteric.
   3. The nervous.
   4. The complicated.

 Dr. Copland, in the very valuable article in his Dictionary, treats —
   1. Of the inflammatory states  of  the puerperal fever, or inflammation —
       a, of the uterus; b, of the ovaria and tubes;  c, of the peritoneum ;
       d, of any two, or all of them.
   2. Synochoid puerperal fever,  complicated  with inflammation — a,  of the
       peritoneum ; b, of the uterine veins ;  c, of the uterus and appendages.
   3. Adynamic or malignant  puerperal fever;  a,  simple;  b,  complicated
       with predominant alteration (a) of the  blood and (6) of the fluids and
       peritoneum;  (c) of the fluids,  serous  surfaces, and soft solids gene-
       rally ; (d) of the uterus, or of the uterus and appendages ; (e) of the
       internal surface of the uterine vessels,  substance of the uterus, etc.

   792.  No doubt each  of these arrangements has its advantages and disad-
 vantages, nor is  it very easy to  propose  one free from objection.  I shall
 take as  a basis for the one I adopt, the fact, as I believe, that in nearly all
 cases there exists  local disease, and also that malignant  puerperal fever is
 more than a mere local affection ; in fact, an essential fever.   We shall first,
 then, treat of the local forms of puerperal fever, such as we see it when it
 occurs sporadically,  or in certain epidemics; and then of the malignant form,
 which may have for  its local complications  any of the  preceding diseases.
 And  lastly, I shall  interpolate  a section on a gastro-enteric  affection of
 childbed, which in some of its characteristics resembles an  attack of puer-
 peral fever.

   The classification  will then stand  thus : —
     1.  Puerperal peritonitis.
     2.      "     hysteritis.
     3.  Inflammation of the ovaries and the  uterine appendages.
     4.  Uterine phlebitis.
     5.  Inflammation of the absorbents.
     6.  Gastro-enteric fever.
     7.  Malignant puerperal fever. 
556
PUERPERAL PERITONITIS.
  Or in another aspect, we may say —
    1. Inflammatory fever.
    2. Gastric fever.
    3. Malignant fever.

  I am very far from thinking this arrangement perfect;  one very obvious
defect, but which I   see no way of remedying, is that several of the local
affections which are here separated do  in practice occur  together.  Thus,
hysteritis, or ovaritis is often accompanied by peritonitis,  and uterine phle-
bitis may occur with hysteritis,  or inflammation of the absorbents.   Still,
however, there is a broad line of distinction in many epidemics ; and I must
only guard against the defect of such arrangement  by stating strongly at the
commencement, that I  do not intend to describe the varieties as essentially
and widely distinct  as  to symptoms, causes, and course  in  every epidemic;
and in the course of the description  endeavor to  point out the coincidence
and the limitations of  the local affections.
  It may give an idea  of the comparative frequency of the local affections
if I quote the experience of MM. Tonnelle and Duges.

  In 222 cases,  M. Tonnelle found —
    Peritonitis in 193.
    Alterations of uterus and appendages in 197.
    Combined lesions  of uterus and peritoneum in 165.
    Peritoneum alone  affected in 28.
    Uterus alone in 29.
  In 266 cases, according to M. Duges —
    The uterus was  affected in three-fourths ;
    The ovaria in one-seventh of the cases.
    There was perforation of the stomach —10 cases in 266.
    Inflammation of the stomach and intestines — 4  " 266.
    Pleuritis, single or double     .     .      .  40  " 266.
    Pericarditis   ....              6  " 266.
    Arachnitis......1  " 266.
    Purulent deposit  in muscles   .     .     .   8  " 266.

  I shall now proceed to consider the special forms of the disease.

  793.  I.  Inflammation of the Peritoneum.—This variety of the disease
was the one chiefly  observed  in  the epidemics in London,  Aberdeen,  Leeds,
Edinburgh, and formerly in Dublin ; and it has occurred in other epidemics.
It appears to affect the peritoneum  covering the uterus  primarily,  and  to
extend from thence to  the remaining portion of the serous membrane, involv-
ing not unfrequently the uterine appendages.
  The attack may commence even before delivery, of which I had  an exam-
ple ; but more generally from twenty hours to  three days  afterwards.  Dr.
Joseph Clarke mentions that two of his patients were ill during labor ; three
were  attacked on the second  day, one on the  fourth, and one on  the ninth
day.   In the epidemic of 1788, one was attacked four days before delivery,
one on the day of delivery, eight on the second day, and three on the third.1
  794.  Symptoms.—The first  symptom is  either sudden rigors, pain,  or
some variation in the pulse.  Dr. Campbell  has remarked that in some who
were attacked early,  the sinking  of the pulse which  takes place after delivery
in ordinary cases, was  absent, and its frequency rather increased.  Generally
speaking, the  rigors are first noticed ; to these succeed heat of skin, thirst,

                 1 Essays in Med. Comment., 1791, pp.  311-315. 
PUERPERAL  PERITONITIS.                  557
flushed face, quickened  pulse, and hurried respiration.  The heat of skin,
however,  soon subsides, and  during  the course of  the  disease it may not
exceed the natural standard.   To these symptoms succeed nausea, vomiting,
pain in the head, and increased sensibility of the uterus.  In some cases the
uterine tenderness  (not amounting to pain) is contemporary with the rigors,
or immediately succeeds them.   Pain in the abdomen soon attracts notice.
It generally commences in the  hypogastrium, or in one of the iliac regions,
gradually radiating over the abdomen.   The pain may be slight or severe,
continuous, or in paroxysms — the intermissions being more remarkable  as
the disease advances.   After the remission, the pain shortly returns with
increased violence.   We are not, however, to  consider the pain as pathog-
nomonic  of the disease, for we sometimes see abdominal pain resembling that
in puerperal  peritonitis, which  afterwards disappears altogether.  And  in
certain cases  of undoubted puerperal peritonitis there is  no pain, or pain  of
slight duration.  I have seen five or six cases of intense puerperal peritonitis
(as shown by dissection) in which there was neither pain nor tenderness.
   Dr. Ferguson  has carefully estimated the frequency of this symptom, and
he has found that

                                 who had no pain was .  .  19
                                  who had pain for 1 day  was 51
                                                2   "   48
                                           »     3   "   22
                                           «     4    "   18
                                           »     5    "    6
                                                7    "    5
                                                8    "    4

   The pain from the first is accompanied with  more or less sensibility of the
 hypogastrium ; this tenderness becomes  exquisite as the inflammation ex-
 tends, until at  length  the patient cannot bear the  slightest pressure ; even
 the weight of the bed-clothes is intolerable,  and the tension and pressure of
 the parietes are avoided, by lying  on the  back,  with the knees drawn  up.
 The enlarged uterus can frequently be felt through the integuments, above
 the brim of the  pelvis,  at an early stage of  the disease.1   Shortly after the
 disease is  established, the abdomen becomes  tumid and tympanitic, and in
 some cases,  at a  more advanced stage, the presence of  effusion may be de-
 tected.  The air which gives rise to the tympanites may be contained either
 in the intestines or the  peritoneal sac.
   The effect of the disease upon the lochial discharge varies; in the ma-
 jority of cases  it continues to flow as  usual; in some, the  quantity is  di-
 minished; and in  others  it is suppressed.2  The secretion of  milk is much
 more uniformly influenced by the attack.   If  it have commenced before  the
 incursion of the disease, it 'is suspended, and the mammas become flaccid ;
 if the disease precede,  the secretion is generally prevented.  It is remarka-
 ble, that a great number of the patients lose all interest in  their infants, and
 even  refuse to give them suck.
   The pulse is uniformly high throughout the disease, varying from  110 to
 140 in a minute, and towards the termination to 160 and upwards.   It is
 generally small and wiry,  but is liable to modifications, from treatment, and
 from the peculiar character of the epidemic.3
   The tono-ue is generally coated with a whitish film in the centre,  but  red
 around  the° edges.  In some  few cases, it is  dry and brown  in the centre,
 with  a  yellowish or white fur at the edges.  The thirst is considerable  at

       i Campbell on Puerperal Fever, p. 33.  Lee on Puerperal Fever, p. 21.
       2 Hey on Puerperal Fever, p. 23.  Armstrong on Puerperal Fever, p. 4.
       s Hulrae on Puerperal Fever, p. 6.  Campbell on Puerperal Fever, p. 35.
The number of his patients 
558
PUERPERAL  PERITONITIS.
the beginning and towards the termination of the disease, but much less
during its height.   The stomach is disturbed at a very early period, and the
nausea and vomiting continue at intervals throughout the attack.   At first,
the matter voided is merely the contents of the stomach, mixed with mucus;
afterwards bilious matter  is ejected ;  and lastly,  green, brown, and  black
fluids, constituting what is  called  the "coffee-ground vomit."  Mr.  Murray
found this to consist chiefly of resin, together with mucus,  gelatine,  phos-
phate of  lime, and muriate of soda in small proportions.1  In many cases
the irritation extends throughout the  intestinal canal,  and diarrhoea  is the
result.  This, by some, has been  held to be a favorable symptom, but br-
others as  an  aggravation of the disease ; and certainly my own observations
would rather incline me to the latter opinion.  The dejections vary in char-
acter and consistence, becoming very dark  and foetid towards the termina-
tion in bad cases.
   The urine is  generally turbid or high  colored,  and somewhat diminished
in quantity; and the patient has frequently some difficulty in voiding it.
Dr. Hulme observes that " The patient at first  often complains of some diffi-
culty in making  water, and discharges it in small quantities ; but this usually
goes  off after having a stool or  two.   The urine, after standing for some
time to settle, generally appears  of  a brown  color, and  deposits a  crude
sediment, half-floating, at the bottom of the glass."2
   Throughout the course of the disease, the skin is much about the natural
heat, and dry, but as a  fatal termination  approaches, it becomes cold and
clammy.
   The intellectual faculties are  rarely affected.  Dr. Gordon,  indeed, men-
tions that delirium was occasionally, but rarely, observed in the epidemic he
describes  ; but in general  the patient retains her consciousness and senses
until very near the end.   The countenance is very much changed ; the fea-
tures are  all  drawn upwards, and expressive of great anxiety and  suffering.
A patch  of crimson, like  a  hectic flush, is sometimes observed on one or both
cheeks, and is an unfavorable symptom.
   Such are  the  characteristic symptoms as laid  down by those  who have
had most experience in the disease.  Its duration will vary according to the
virulence  of  the epidemic;  some cases  have terminated fatally on the first,
second, or third day of the attack ; others from the fifth to the tenth.  Dr.
Denman  fixes the general termination on the eleventh day;  Mr. Forster,
from  the  fourth  to the  sixth day ;  Dr. Leake, the tenth or eleventh day;
Dr. Hulme, the seventh or eighth day;  Dr.  Hamilton, the fifth or sixth
day ; Dr. Gordon, on the fifth day ; Mr. Skey, within a week ; and M. Bang,
on the  sixth day.   Dr. Campbell  states that the greater number of his
patients died on the fifth day ; one died on the first; three on the second:
three on  the third ;  four  on the  fourth;  seven on the fifth; one on th«
sixth ; two on the seventh  ; and one on the eighth day ;3 Dr. Blundell says
that it may  destroy  the patient within twenty-four hours from  the  com-
mencement of the disease, or that " three or  four days, not to say five or
six, may  be the average duration of the affection."4  Dr. Collins  thus gives
the result of  his  experience :  " In fifty-six deaths in the hospital, it proved
fatal  at  the following periods  from the date of  the  seizure,  viz., two  in
twenty-four hours ;  one in twenty-seven;  one in thirty-six;  nine on the
second day;  fifteen on the  third ;  thirteen on the fourth ; four on the fifth ;
five on the sixth ;  three on the seventh; two on the eighth ;  and one on th'
eleventh day."5
   795. Morbid Anatomy.—The  peritoneum may, in some few  cases, ex-
hibit no signs of  inflammation ; but generally it is found more or less vas-
  1 Campbell on Puerperal Fever, p. 181.          2 On Puerperal Fever, p. 9.
  3 Ibid., p. 50.       4Obstetricy, p. 74.        5 Pract. Treatise on Mid., p.  374. 
PUERPERAL  PERITONITIS.
559
cular, especially that portion of it covering the uterus.  Dr. R. Lee has given
it as his experience,  that  "puerperal peritonitis commences  in  the  peri-
toneal covering of the uterus, and extends from thence with greater or less
rapidity, according  to the severity of the attack, to the whole  peritoneum.
In some cases the inflammation is confined to the uterus, and it is  generally
most severe in this  situation, or in the parts immediately surrounding that
organ ;  even when it  has extended to the  other viscera, and affected  them
most severely, the  peritoneum of the uterus invariably  exhibits signs  of
recent  inflammation.   The lymph is, for the  most  part, thrown  out in
thicker masses upon the uterus than in any other situation ;  and this viscus
seems always to suffer in the greatest degree.  In  the cellular membrane,
under the  peritoneum, serum and pus are also  not  unfrequently found de-
posited.  The cellular tissue  also, which  surrounds the vessels of the uterus
where they enter and  quit the organ, not unfrequently contains  some serous
or purulent fluid, and  the same appearance has been  observed in the cellular
membrane connecting together the muscular fibres."1
  Dr. Collins states, that " in thirty-seven  of the fifty-six women who  died,
the following post-mortem appearances were  discovered :—the  abdomen
being  ostensibly  the seat of the  disease, the morbid  appearances  were
chiefly found there ;  however  in seven  we observed fluid effused into the
thoracic cavities, similar in appearance  to that met with in the abdomen.
Effusion of fluid, though differing in character and quantity,  was invariably
found to have taken  place.  In  twelve  it seemed to  be serum of a straw
color ; in  eighteen, it was sero-purulent, something of the  consistence  of
thick cream ; and in seven it appeared bloody-serum, with quite a glutinous
feel when  rubbed  between the finger and thumb.   In these  latter cases,
which rapidly proved fatal, there was no lymph whatever found; whereas,
in the other varieties, it was usually found  deposited in large  quantities,
particularly in the vicinity of the uterus, but often  over the entire  surface
of the intestines and  abdominal  serous  membrane.   In almost every body
examined, the peritoneum exhibited great increase of vascularity ; nor could
we discover in any instance that the inflammation seemed to penetrate deeper
than this membrane.   The uterus, in  a  great majority of cases, was  quite
natural  in  appearance ; in some, it was  soft and flabby; and in a few, un-
healthy matter was  found in its sinuses.   The ovaries, in numerous instances,
had suffered much in structure from the effects of inflammation ; being gene-
rally much  enlarged, and so softened in texture as to be broken in pieces by
the least pressure."2
  Thus we find vascularity of the peritoneum and thickening somewhat in
proportion  to the  duration of the  disease, a layer  of lymph covering the
intestines and omentum, and agglutinating them together, effusion of serum,
etc., to be the most general effects of this disease.    These appearances may
be limited to  the uterus and  pelvic viscera, or they may embrace the entire
abdomen ;  in some rare cases they appear almost confined to the omentum.
  The  quantity  of serum with flocculi of  lymph floating in it varies con-
siderably, and I think  somewhat in proportion to the  duration of the disease.
In those cases which rapidly prove fatal,  we more frequently find the organs
covered with  a layer of semi-fluid lymph ;  but in more prolonged cases, in
addition, we find more or less effusion.  It does not vary in chemical com-
position from that in  ordinary peritonitis.   It may be  clear or turbid, of a
yellowish white color, with shreds of lymph in it, resembling very much the
whey produced in making cheese.   In some rare cases blood is found in the
peritoneal sac, either  alone or mixed with the serosity.   Puriform matter is
also frequently found, especially in the pelvis, around and behind the uterus,

  1 More Important Diseases of Women, p. 24.       2 Pract. Treatise on Mid., p. 398. 
560
PUERPERAL PERITONITIS.
where the inflammation has apparently been most intense.   It is sometimes
contained in a cyst, which is apparently a concretion of the outer surface
of the pus.
   But the effusion  of serum or pus may not be confined to the free surface
of the serous membrane merely, but may occur beneath it.   In  an epidemic
which prevailed in Dublin,  Dr. Sam.  Cusack states that "Two kinds of
effusion were met  with  in  the  cells of  those  tissues (sub-serous and pelvic
cellular  tissue), one a reddish serum,  occasionally so copious as to pervade
not only the cellular tissue about the uterus, the pelvic cavity, and the  iliac
regions, but even sometimes to distend the cells of the delicate cellular tissue
which connects together the two layers of the mesentery.   The  other species
of effusion is  not of so fluid  a nature, resembling jelly in  appearance and
consistence.   This also occupies the cellular tissue,  and is most  conspicuous
where the looseness of the peritoneum admits of free effusion.   Thus the lax
nature of the cellular tissue connecting the layers of the peritoneum, which
form the broad ligaments of  the  uterus, admits of its being poured out in
considerable quantities  in that situation."1
   796.  Diagnosis.—1.  From after-pains, or hysteralgia.—These affections
occur soon after delivery, and  diminish or disappear by the third or fourth
day—about the period when  puerperal fever  commences.   After-pains are
accompanied by a perceptible  contraction  of the uterus, which is absent in
puerperal fever.   The  pulse is sometimes  accelerated by after-pains, but is
seldom  steady in its frequency ; in puerperal peritonitis it never falls below
its frequency at first, but  generally increases.   The hypogastric tenderness
in after-pains is not great, except during a pain, and it goes on decreasing;
whilst in puerperal peritonitis it rapidly increases.   The  constitutional dis-
turbance is incomparably  greater  in puerperal peritonitis, and  it augments
every day ;  whilst in hysteralgia it diminishes.   The sedative, which gener-
ally relieves after-pains, has little or no influence upon the pain  in puerperal
fever.   Notwithstanding  these  distinctions, there  are  undoubtedly  many
cases in which the diagnosis is by no  means easy at first; and our treat-
ment should be arranged so as to  err (if we be in error)  on the safe  side.
   2. From intestinal irritation.—This affection frequently assumes many of
the characteristics of puerperal fever.   There  are, however, several points
of difference.   It is generally  accompanied  by marked evidences of gastric
and intestinal  disorder.   The tongue  is loaded, there is flatulence, nausea,
and vomiting, constipation, or  diarrhoea.   The abdominal  pain is diffused,
and does not radiate from the uterus, as in puerperal  peritonitis ; neither is
the uterus enlarged, nor tender.  The  abdomen may be enlarged and tense,
if there be much secretion of air ;  but percussion will  at once  distinguish it
from  enlargement by the effusion of serum :  it  is rarely  very tender on
pressure, and  gentle friction  affords relief.   It may occur at any period
after delivery, and at first may occasion some anxiety from  the  resemblance
of the  symptoms  to  those of puerperal fever; but twenty-four hours will
generally clear  up the difficulty ;  the  pulse falls,  the milk is  secreted, the
lochia are not unhealthy, and the pain and distress are relieved by medicines.
A little inquiry will generally  elicit the fact that the bowels had been neg-
lected previous to delivery.2
   3.  From ephemeral fever, or weid.—The commencement of ephemeral
fever may excite some alarm, from its  resemblance  to puerperal fever; but
its duration is shorter,  its  decline rapid, and its constitutional symptoms less
severe.   There is also far less abdominal irritation, and the breasts continue
distended.3
   4.  From hysteritis.—The main  distinction is the  character and situation
   1 Edinb. Med. and Surg. Journal, No. 98.       2 Lee on Diseases of Women, p. 22.
   3 Armstrong on Puerperal Fever, p. 22. 
PUERPERAL  PERITONITIS.
561
of the tenderness:  in puerperal  peritonitis, the  slightest  touch  on the
abdominal parietes causes acute torture ;  whereas,  in hysteritis, the  patient
can bear pressure very well,  until we  can feel the enlarged uterus.  Any
increase of  pressure, after the  abdominal parietes  are  in contact with the
uterus, gives acute pain.1   The  symptoms  of hysteritis are also more  local.
   797. Prognosis.—The general prognosis is unfavorable, even in sporadic
cases, but still more  so when the disease is epidemic.
   Dr. Hulme declares it to be as bad as the plague.

                     Dr.  Leake lost, 13  cases out of   19
                     Dr.  W. Hunter 31      «       32
                     Dr.  Clarke     21      "       28
                     Dr.  Gordon    28      "       77
                     Dr.  Campbell  22      "       79
                     Dr.  Armstrong  4      "       44
                     Dr.  Lee       40      "     100
                     Dr.  Collins     56      "       88
                     Dr.  Ferguson  68      "     205

   In  the  epidemic in Paris  (1746), in Edinburgh (1773),  and in Vienna
 (1795), none recovered.
   Mr. Hey observes, " For some time after the commencement of this fatal
 malady, it proved fatal in every case that  came within  my knowledge; and
 though a few patients  recovered under the treatment which my father and I
 had formerly found successful with puerperal  fever,  yet the success was very
 small till the method hereafter described was fully adopted."2
   Dr. Ferguson states, " If we take the results of treatment adopted in vari-
 ous puerperal  epidemics, by various  practitioners,  we  shall find that on a
 large scale one in every three will die, with all the resources which medicine
 at present offers.  To save  two out  of three, then, may be termed good
 practice in an epidemic season."3
   If the epidemic be  as  severe as some which have occurred in Dublin, it
 would be very successful practice to save one  out of three.
   798. Treatment. — It must  be borne  in  mind,  that when any peculiar
 mode of treatment is advised, the character of the epidemic is the test of its
 propriety.   Forgetfulness of this rule has  been the  source of much contro-
 versy, and no slight  acrimony.   As Dr. John  Clarke remarks,  each  author
 takes the epidemic he has witnessed as the type of all, and remorselessly con-
 demns all treatment  which does  not agree with that  which  he has found suc-
cessful.   There is no question that the employment of antiphlogistic remedies,
by Gordon,  Hey, Armstrong,  etc.,  was  a  great improvement upon  the old
methods, in the epidemics which they witnessed ; but  it is not to be taken
for granted  that it would  have answered equally well in the previous ones.
For many years past it has been found either inadmissible or injurious in the
cases we have had in Dublin.    The type of the disease  and the state of the
patient have not  only prohibited the use of the lancet,  but  have indicated
very clearly the  necessity  of a line of  treatment very different,  if not the
opposite.   Thus, in  all cases,  we must carefully appreciate the general con-
stitution of disease and the special  character of the  epidemic, as well as the
state of the  patient, in order to decide upon the most suitable treatment, with
reasonable probability of success.   Moreover, in cases where  bleeding is ad-
missible, it has appeared to me that the time for its beneficial use is very limited.
After the disease  has  lasted more than from twelve to twenty-four hours, I
have seen but little benefit from  bleeding ;  and the same observation  I have

   1 Armstrong on Puerperal Fever,  p. 20.          2 On Puerperal Fever, p. 10.
   •Ibid., p. 112.
      36 
562
PUERPERAL  PERITONITIS.
heard from Dr. Charles Johnson, of this city, whose opinion is most deservedly
of the highest authority.
   Having premised thus much, I shall  describe the treatment which  has
ordinarily been found the most efficacious.
   If the pulse be firm, a large quantity of blood is advised to be taken from
the arm.  Dr. Gordon recommends from 20 to 24 ounces, at the beginning,
and, if necessary, this may be repeated.   The blood  generally exhibits the
buffy coat.   Dr. Ashwell considers  Dr.  M. Hall's  method of placing  the
patient upright  and bleeding to incipient syncope, of  great value in puer-
peral peritonitis.1   Should any circumstances forbid a repetition of the vene-
section, a number of leeches  (from 60 to 100,  Campbell) may be applied to
the abdomen, and when  they fall off, the abdomen should be  fomented, or
covered with a  light bran poultice.   The fomentation, or poultice, may be
repeated at  intervals, as it has a very soothing effect.
   This practice  boasts the support of very great names—Denman, Leake,
Gordon,  Armstrong,  Hey, Campbell, Mackintosh, Jos.  Clarke, MM. Duges
and Tonnelle, Blundell, Conquest, Gooch, Dewees,  Lee, Meigs, etc. ;  but it
was recommended with limitations by Kirkland, Hull, Gardien, Douglas, etc.;
and in some epidemics, as I have said, it is either inadmissible or injurious.
Dr. Collins  remarks, that " In fifteen only of  the eighty-eight did we deem
it advisable  to bleed generally:  seven  of the fifteen recovered."   "I am
satisfied, however, that in hospital,the immediate application of three or four
dozen leeches, followed by the warm bath, in which the patient should re-
main as long as her strength will bear it, will be found in the great majority
the most judicious means of  removing blood."2
   After  full depletion, the next powerful remedy is mercury, alone or in
combination with opium.  Without explaining its modus operandi, it is
sufficient to state the fact, that it has been found to exercise a remarkable
influence over inflammation of serous membranes.   It may be given in large
doses (gr. x. every three  or four hours),  or in smaller ones, more frequently
repeated (gr. ij. every hour); and it should be continued until an impression
is made upon the disease, or until the mouth is affected, unless purging be
induced.  The mouth will be affected much more rapidly, and with smaller
doses, if to  each be added a  very minute quantity of tartar emetic, say y'gth
 of a  grain ; but this will not do if there  be  nausea or vomiting.   1 am in-
debted to Dr. A. Smith for this suggestion.   After  a  decided effect is pro-
duced, the dose may be  diminished,  and the intervals lengthened.   For the
purpose of preventing intestinal  irritation,  it is  usual to combine it with
 Dover's powder of  opium.   Perhaps  it  is not too much to  say, that the
 befnefit of the opium in this  combination is not confined to the prevention
 of intestinal disturbance, but that it exerts a positive and beneficial influ-
 ence upon the inflammation.   When the calomel acts on the bowels, it may
 be omitted,  and the opium alone continued; and I  have seen as much benefit
 from it alone, as from the calomel.  Some years ago I saw a case of puer-
 peral peritonitis, in consultation with a friend, and we  administered large
 doses of opium  (gr. j.  every hour) with  the  greatest benefit.  Since then,
 several similar cases have occurred to me.   Dr.  Stokes was the first to point
 out the value of opium in bad cases  of peritonitis, where bleeding was inad-
 missible ; and I have repeatedly verified his observations.
    Mercurial frictions are a  valuable mode of affecting  the system, and for
 this  purpose I would strongly recommend the Linimentum Hydrargyri of the
 London Pharmacopoeia.   But I  may say of mercury as I said of  bleeding,
 that though very efficacious in  many cases, there are others in which its
 effects are injurious, or in which it is inefficacious.

     1 On Parturition, p. 481.        2 Pract. Treatise on Midwifery, pp. 391, 393. 
PUERPERAL  PERITONITIS.
563
  Tartar emetic was recommended by Hulme, and used by several since his
time, with apparent benefit.   The state  of the stomach, in many cases, how-
ever, will prevent its exhibition.
  Purgatives have been warmly recommended by Hulme, Denman, Gordon,
Hey, Armstrong,  Chaussier,  Stoll; and  as  strongly  reprobated by Baglivi'
John Clarke, Cederskiol, Thomas, Campbell.  " My own experience," says
Dr. Ferguson,  " with  regard to aperients is, that whenever  they  create
tormina, there is the greatest risk of an attack of metro-peritonitis succeed-
ing.   This so constantly occurs, that  I invariably mix some anodyne —
usually Dover's powder, or hioscyamus,  or hop, with the  purgative."   If the
bowels be constipated, an enema, of turpentine and castor oil will be useful.
The spontaneous  diarrhoea is not always beneficial, but will often need to be
restrained by astringents, or opiates.
  Emetics were employed before 1782 by English practitioners, and in 1782
they were recommended  by Doulcet,  of Paris, who relied upon them  exclu-
sively, and derived  from them extraordinary success.   Other  practitioners
have also used  them  successfully ; but  they have failed so often, as to have
gone out of use, especially in these  countries, perhaps in  consequence  of our
mistaking the proper  cases.   M. Tonnelle states  that  M. Desormeaux tried
them  with  great  success in  1828, but that  in the next  year they generally
failed.  In September, 1829, they succeeded, but in  October and November
they failed.   They did not, however,  appear to produce  any aggravation of
the symptoms.   Dr. Ferguson remarks, that " The practical question, then,
is, what are the cases in  which the remedy  is applicable ? The clue has been
already given, I imagine, by Doulcet himself; it  is  when the violence of the
malady has fallen on the liver especially, and when there is early nausea and
spontaneous vomiting."1
   In  the  year 1814,  Dr. Brennan, of Dublin, proposed  the internal  use of
turpentine, which he regarded  as a specific,  and which  in many cases was
very successful.   He gave it in doses of a tablespoonful at a time, in a little
water, sweetened.   Drs.  Douglas,2 J. A. Johnson, Dewees, Payne,3 Kinneir,
Blundell, and Waller, have  found it more or less useful.   Drs. Jos. Clarke,
and other practitioners, tried it, but without success.   Dr. Clarke  observes,
"In addition to  the  usual  routine  of  practice, numerous trials were made
with  the  rectified oil of turpentine, in doses from six  to  eight drachms;
sometimes  in plain water, sometimes combined  with  an  equal quantity of
castor oil.   The first  few doses were generally agreeable to the patient, and
seemed to alleviate the  pain.   By  a few  repetitions  it  became extremely
nauseous, and  several patients  declared that they would  rather die than
repeat the dose.   In more  than  twenty  trials  of this  kind,  not a  single
patient recovered."4  It is certainly beneficial when the  intestines are tym-
panitic, especially in the form  of enema,  and as a counter-irritant  to the
abdomen ;  but  I  have never seen it exert any remarkable influence upon the
disease.
   At an advanced state  of  the  disease, blisters are very useful.  They may
be  applied to  any part, or the whole  of  the abdomen, and  dressed with
mercurial ointment.
   Recolin, Dance, and Tonnelle have recommended injections of warm water
into the vagina and uterus, three or  four times a  day.  Drs. Lee and Camp-
bell have tried  them in a few cases  with  decided advantage.   I  have fre-
quentlv svrin"-ed the vagina with  warm water  with  benefit; but I never
threw the injections into the uterus.
   Hip  baths have been found useful by Desormeaux  and   Collins;  but

  1 On Puerperal Fever, p. 204.                  2 Dublin  Hosp. Reports, vol. iii.
  8 Ed. Med. and Surg. Journal, vol. xxii., p. 53.    * Letter to Dr.  Armstrong. 
564
PUERPERAL  HYSTERITIS.
the pain of moving the  patient is  an insurmountable obstacle to their fre-
quent use.
  Loeffler, as Ceeley of Aylesbury, have seen good effects result from the
application of cold  to the abdomen.
  The irritation  of the  stomach may be allayed by effervescing  draughts,
containing a few  drops of laudanum, or by a few grains of the subcarbonate
of potash, dissolved in aq. menth. virid.
  A selection of these  remedies will afford a tolerably good chance to the
patient, if we are called early ;  but in many instances we shall fail, either in
cutting short the disease, or in curing it ultimately.   It is of the greatest
importance, however, that all the means at our command should be tried
perseveringly, and  that  our forebodings should not be allowed to diminish
our exertions.

   799.  II.   Puerperal Hysteritis.—Inflammation affecting  the proper
tissue  of the  uterus  has been  frequently described.  It  is mentioned  by
Astruc, Vigarous, and Primrose.   Pouteau observed it in the epidemic of
1750.   Ricker and Boer have  described it under the term Putrescirung or
Putrescenz der Qebarmutter,  and cases of it have been recorded by Smith,
Danyau,1 and Tonnelle.2  In certain epidemics it is tolerably frequent, occur-
ring either  alone or as  one among other local  affections.   Thus, Tonnelle,
in 222 fatal cases of puerperal fever, found 79 cases  of simple metritis,  29 of
superficial softening, and 20 of deep softening.   M.  Duges found the uterus
affected in 3 cases out of 4 ; and  Dr. R. Lee states, that in 45 dissections,
the muscular coat of the womb was softened in 10 cases.
   This form of the  disease may be the only affection  in certain cases of puer-
peral fever, or it may be the most  prominent, though not the sole affection,
or it may only be one of several forms of local disease.
   800. Symptoms.  —These will vary somewhat, according to the character
of the epidemic, and a great deal according to the severity of the attack.  In
the milder form, where  the disease does not proceed so far as to disorganize
the uterine tissue, I have generally found it commence, on the third or fourth
day, with rigors, followed by heat of skin, thirst, and headache.   The pulse
rises to 100 or 110 ; the tongue is dry and  furred ;  the countenance expres-
sive of suffering, but without the anxious, pinched, drawn-up character we
find in puerperal peritonitis. The patient complains of uneasiness, pain and
tenderness in the uterine region,  and upon examination we find the uterus
more or less enlarged, hard, and tender.  The abdomen, at first, is soft and
without any tenderness,  which is  first felt when we  perceive that we are
making  pressure upon the enlarged uterus.  As the disease advances, the
abdomen often becomes  tympanitic, and in  some cases the inflammation ex-
tends to the peritoneum.
   The  state of the lochia  is by no means uniform ; in many cases they are
diminished  or  suppressed;  in  others, their  character is changed, and they
become  offensive ;  in other cases,  again,  they  are  quite  unaltered.  The
secretion of  milk  is  generally arrested.   There   is  occasionally  another
symptom, which I think is more marked  in hysteritis  than in  any other
variety of puerperal fever,  viz., dysuria, which causes  much distress, and
which may amount to  retention,  and  this  especially, as Dr. Dewees has
remarked, in cases  which have required instrumental aid.
   The severer form of  hysteritis, as described by Dr. R.  Lee and M. Ton-
nelle, is ushered in by rigors, followed by increase of heat and  headache.
There is occasionally delirium, and other  evidences  of cerebral disturbance.
The countenance is pallid, anxious,  and disturbed ;  the skin, at first hot and
                    1 Repertoire Ge'n. d'Anatomie, vol. v. p. 1.
                    2 Essai sur la M6trite Gangreneuse, 1829. 
PUERPERAL  HYSTERITIS.
565
dry, becomes cold, with sometimes  a blue or yellowish tinge.   The respira-
tion is hurried, the pulse rapid and feeble, with great prostration of strength.
The tongue  soon  becomes foul, and the lips and teeth covered with sordes.
More or less of nausea, vomiting, and diarrhoea are generally present.  The
patient complains of pain at the hypogastrium, where the enlarged  uterus
may be felt, and which is very tender on  pressure. The lochia are diminished,
or altogether suppressed,  and frequently they become foetid or acrid.
   This  form presents a very different aspect to the former.  It is quite
evident, that in addition  to the local affection common to both, the  consti-
tution  is  deeply involved,  either in consequence of its  previously impaired
condition, or owing to some peculiarity of the epidemic, or  in  consequence
of the local disease having produced a  more rapid and profound impression
on the general system.
   801.  Hysteritis may terminate—1. In resolution ; as is the case with the
mild variety which, I have  described, and in which there is a gradual subsi-
dence of the symptoms.
   2. In  abscess;  which may open into the  uterine  cavity,  or into the peri-
toneal sac.   I had an opportunity of  seeing a case  of the latter kind, some
time ago, in a patient, whose case has been published by my friend, Dr. Beatty.
   3. In  softening. This termination was observed 49 times  by M. Tonnelle,
 and 10 times by Dr. R. Lee.   "Among the 222  fatal cases of puerperal fever
 observed by M. Tonnelle,  in the Maternite, at Paris, in  1829, there were 49
 in which the muscular tissue was found softened.  M.  Tonnelle states, that
 softening of the uterus, after showing itself frequently in the first half of the
 year 1829,  and  particularly about January, disappeared  entirely in  the
 months of July and  August, which were characterized in a remarkable man-
 ner by the frequency of inflammation of the  veins.   Afterwards, it began to
 ra"-e anew with great violence in September and October, and again disap-
 peared in the last two months,  during  which time the mortality was incon-
 siderable."1
   4. In gangrene.   This has been described  by M. Boer, in his valuable
 work,2 and by Ricker,3 and  noticed by Siebold, Busch, Boivin and  Duges,
 Danyau, etc.
   802. Morbid Anatomy.. — The peritoneal coat of the uterus very often
 exhibits marks of inflammation.  It may be vascular, and coated with lymph,
 or softened. The size of the womb is  manifestly increased, and its substance
 soft and flabby.   Small collections of  purulent matter are sometimes found
 in its parietes, which in these spots exhibit various degrees of absorption.
 Boivin and Duges  observe that " Pus is sometimes found even in the sub-
 stance, and generally nearer to the exterior surface than the interior; thus
 pus collects into distinct abscesses, from one to  five inches in diameter, some-
 times  into a simple or multilocular deposit, with a greenish or viscous ap-
 pearance ;  at other times it is  infiltrated into the fleshy fibres, imparting to
 them a yellow reddish color, perceptible through the peritoneum.   In this
 latter case tumors form, which  are sometimes hard  and projecting, upon the
 fundus uteri;  at other times flattened, soft, and broad; these latter come
 further  down  towards the  lateral parts, and often form a continuation, to-
 gether with purulent infiltrations, between the lamina? of the broad liga-
 ments  with the cellular tissue of the  pelvis and the substance of the liga-
 ment  of the ovarian vessels, frequently giving rise to those large abscesses
 of which we have already spoken."4   The substance of the uterus may be,
 in patches  reduced to a mere pulp, of a dark purple, yellowish, or greyish
 color, and occasionally of a bad color.   This softening generally commences
   i Lee on more important Diseases of Women, p. 38.
   2 Naturliche Geburtshulfe, etc.. vol. i. p. 202.    » fold's Journal, vol. n. p. 62.
   * Boivin and Duges, Diseases of the Uterus, etc., trans., p. 32G. 
566
PUERPERAL  HYSTERITIS.
at the inner  membrane, and penetrates more or less through the substance
of the uterus.  According to Dr. Ferguson's experience, 'The point of in-
sertion of the placenta is the most ordinary seat of all uterine lesion, whether
of abscess, softening, or phlebitis ; the  next point, the large and congested,
lead-colored cervix uteri."  False membranes of coagulable lymph are found
on the lining membrane of the cavity, mixed with blood and lochia.
  M. Tonnelle states that the disease in Paris exhibited  two distinct forms,
"the softening of the uterus, properly so called, and the putrescence.  In
the first form, the softening affected only the internal membrane of the uterus,
and it presented itself under the appearance of irregular superficial patches
of a red or brown color, which occupied almost all the points of this surface;
its  limits  were not determined, the diseased tissue passing by irregular gra-
dations or shades into the healthy tissue.   In the second species the soften-
ing extended deep into the  substance of the uterus.  The tissue of this organ
was so softened  that the fingers could  not  seize it without passing through
it in all parts.   The superficial  softening was combined  almost always with
some alteration of structure — peritonitis, metritis, or  uterine phlebitis; and
it did not appear to M. Tonnelle that the existence of these had a very sen-
sible influence  on the progress of the symptoms.  The  softening  in the second
degree was also  sometimes combined with  other disorders ; but it formed
usually the principal alteration, often the only one, and invariably impressed
upon the  disease the most  decided typhoid character."1   MM. Boivin and
Duges,2 and  M. Duplay, have noticed similar changes, and the  latter author
especially has  accurately described the circumscribed  mortification found on
the internal surface of the uterus.  The cause of this  peculiar  softening has
been much debated, some attributing it to a specific action of the parts or to
alteration of the  blood, and others to inflammation ; in some cases it appears
to be the result of inflammation,  but  in others there is no evidence of pre-
vious or concurrent inflammatory action.
   803.  Diagnosis.—When complicated with peritonitis, the diagnosis is
very difficult;  but when the uterus is alone affected, it is easier to distin-
guish it :  —
   1.  From after-pains, weid,  etc., it differs  very widely  in its persistence,
and in the gravity of the  accompanying constitutional symptoms.
   2.  From puerperal peritonitis.   The  most  marked  distinction between
them is the tenderness on pressure, which, when the peritoneal sac is inflamed,
is  general  and  superficial, rendering the  slightest pressure intolerable;
whereas, in hysteritis, the  abdomen  will bear pressure  very  well  all  over,
until we  ourselves feel that we are pressing the  enlarged and  hardened
uterus.   The only exception to this rule  I  have met with are those cases of
peritonitis where there is no abdominal tenderness.   The pulse in  hysteritis
is weaker, and the patient sinks  more rapidly than in peritonitis, the lochia
are  more frequently foetid,  and the entire  symptoms have a  more marked
typhoid character in the severer form.
   804.  Prognosis.—In the milder form  many cases recover;  the uterus
remains hard and tender for some time, but the pain and tenderness diminish,
the  pulse  becomes quieter, the  tongue clean, the bowels regular, and the
appetite returns.   The  preservation or  reappearance of  the  natural cha-
racter and smell in the lochia is a valuable sign,  and a still better is the con-
tinuance of a good secretion of milk.
   In the  severer form, especially when it prevails epidemically, the  prognosis
is very unfavorable,  almost every well-marked case proving fatal, and the
patient dying with symptoms of a bad typhoid character.
   8U5.  Treatment.—The reader will  bear in mind  the observations I

  JLee on  Diseases of Women, p. 38.    2 Diseases of the Uterus, etc., trans., p. 325. 
INFLAMMATION  OF  THE  UTEEINE APPENDAGES.      567
have already made as to the modification of treatment required by the gene-
ral constitution of disease at any given period, the peculiar type of the pre-
vailing epidemic, and the state of the patient.  As a general rule, I think
patients bear bloodletting better in the mild form of hysteritis than in some
of the other varieties, but even here I have not been able to use the lancet
of late years.   Venesection, however, may be  necessary and  proper,  and
the earlier  in the disease we have recourse to it the better.  If inadmissible
from any cause, we  shall, I think, always derive advantage from  leeches
applied over the uterus, followed by constant poultices and fomentations.
   Calomel and opium are  of great value when  they act  kindly.  I have
rarely seen a  patient die who  was fairly under their influence, but it fre-
quently happens that diarrhoea is induced, and then we must omit the calomel,
and apply  mercurial frictions, with opium given internally.
   When the  acute  stage is  over, very great benefit will be derived from
repeated blisters to the abdomen, and by covering it with a layer of prepared
 wool.   The  bowels  must be  kept free,  but by the gentlest  means, active
 purging seeming to aggravate the symptoms; and at all events it is an obstacle
 to the use  of mercury.
   No  remedy that has been tried seems to have much power over the severer
 form when it prevails epidemically.   If antiphlogistics are admissible at all,
 which I very much doubt, it must be in the earliest stage, but I  should have
 more faith in counter-irritation and the liberal exhibition of tonics, such as
 bark, with wine, and, if  necessary, opium, just as they are  given in typhus
 fever.

    806. III. Inflammation of the Uterine Appendages.—Under this head
 is included inflammation of the serous membrane, and proper tissue of the
 ovaries, fallopian tubes, and broad ligaments.   It  is not always  possible
 to separate these affections from inflammation of the peritoneal cavity, with
 which they are so often  conjoined;  but there  are  cases in which they exist
 alone, or  predominate in a striking manner, or where the  consequences of
 the disease continue longer in these parts.   Puzos has described such cases
 by the term, "Depots  laiteux dans Vhypogastre," and Levret, as "Engorge-
 mens laiteux dans le  bassin."   The  observations  of  MM. Husson  and
 Dance likewise prove that this is a frequent, and often fatal, termination of
 inflammation of the peritoneal coat of the uterus and its appendages.   M.
 Tonnelle  found  fifty-eight  cases of  inflammation  of the ovary and four of
 abscess, out of one  hundred and ninety cases of puerperal fever.
    807.  Symptoms.—As inflammation of the uterine appendages is generally
 combined with more or  less inflammation of the peritoneal  cavity, the symp-
 toms  will  present many of the characters of peritonitis, but  probably in a
 moderate  degree ;  and  as they subside,  or  as the  local affection  becomes
 more developed, we shall detect  mischief in the  situation  of these append-
 ages.   The pain is less acute and less universal than in general peritonitis :
 it°is seated in one of  the iliac fossae or the lateral portion  of the hypogas-
 trium  from whence it may radiate to the groin and down the thigh.   A
 careful examination will detect a degree of hardness in the part, compared
 with the rest of the abdomen,  perhaps a definite swelling with great tender-
 ness on pressure.   Percussion, which probably yields a clear sound over the
 abdomen  generally, gives a very  dull sound over this portion.
    An internal examination will often throw light upon the seat of the dis-
 ease • the vagina will be found hot and painful at  its upper part, and the
 tumefaction may be detected through its lateral parietes.
    The  disease  o-enerally  commences  with rigors,  thirst,  headache,  quick
 Dulse  etc  presenting an  array  of constitutional symptoms very similar to
 those in peritonitis, which, therefore, I need not repeat.  If the disease be 
568
inflammation  of  the
extensive, there is generally observed  much  exhaustion  following the first
stage, and the attack may prove quickly fatal.
  Should the disease not prove fatal, the attack may terminate —
  80\ 1. In resolution, without the organs  being seriously injured ;  or in
some  cases adhesions may be formed  between continuous portions of  the
serous membrane, which, though for the present innocuous, may be injurious
subsequently.   Boivin and Duges relate a case in  which anteversion was
caused by these adhesions.   If the fallopian tubes have been involved,  the
cavity of one or both may be obliterated, or they may become adherent to
some  neighboring part,  so as to  prevent altogether their ordinary functions.
  2.  In suppuration.   Matter may form in either  ovary or broad ligament,
or a more extensive pelvic  abscess may be  formed, including these organs
and the neighboring tissue.   The matter may escape into the  peritoneum,
and excite fatal inflammation ; but this is comparatively rare, or the abscess
may open into the  bladder, vagina, or rectum, or  make its way to the sur-
face of the abdominal parietes.  Many examples of each are on record, and
I have myself seen most of them, but in my experience the opening has most
frequently been into the rectum.      '
  809. Morbid Anatomy. — In some cases  we find, on dissection, that the
disease has been confined to the serous membrane, presenting similar phe-
nomena to those already noticed—thickening, effusion  of lymph or serum,
etc.   The broad ligaments, fallopian tubes, and ovaria, are red and vascular.
The morsus diaboli  is of a vivid red color, and  sometimes softened, and in
its cavity, or under the peritoneum, deposits  of pus may be discovered.   Dr.
John Clarke states  that " Inflammation is often observed running along the
fallopian tubes, which, when cut open,  will be seen loaded with  blood.   The
ovaria, too,  are often affected in the same way.    Pus is often found in the
cavity of the fallopian tubes, and also in the substance of the ovaria, which
are in some cases distended by inflammation and matter, so as to equal in
bulk a pigeon's egg."1   Effusion  of serum  or purulent matter may also be
found between  the folds of the broad ligaments.
  The ovaria  may  be  imbedded in lymph, the product of inflammation of
their  serous  coat.  Sometimes  they are swollen,  red, and  pulpy.   One or
both  of  these  organs may be affected.2  Dr. Gordon mentions that in his
cases of puerperal, the right ovary was always diseased, and the left healthy.
Upon laying open the ovaries, their structure will be found more or less dis-
eased.  There  is a great increase  of vascularity, and frequently a softening
of their proper tissue.   In a few cases it  is  utterly disorganized.   Blood is
sometimes effused into the Graafian vesicles, so as to destroy their texture.
Pus may be  found in small masses throughout the  ovary,  or that organ may
be reduced  to  a sac full of purulent matter, which  may escape in different
ways, as  already noticed.3
  810. Diagnosis. — The situation of the pain and tenderness, the  dulness
on percussion,  the slight increase of hardness, and  the results of an internal
examination, are the only grounds of diagnosis during the earlier acute stage.
If, however, the disease  continue, and do not terminate  in resolution,  these
symptoms become more marked, and we cannot easily make a mistake as to
its nature and seat.
  811. Treatment.—In  some cases venesection may  be  necessary,  but
more  commonly leeches to  the  part will  be sufficient;   they  should  be in
sufficient numbers, and may  be repeated if necessary.  After the leeches fall
off,  a poultice, hot, soft, and  sloppy, should be  constantly applied,  not
merely to encourage the  bleeding, but for its soothing  effect upon  the
inflamed  parts.

    1 Essays, p. 63.                     2 Ferguson on Puerperal Fever, p. 38.
   s Lee on Diseases of Women, p. 26. 
UTERINE  APPENDAGES.
569
  Calomel and opium may be given to a moderate extent, if the bowels are
not irritable during the acute stage.   Vaginal injections of warm water, two
or three times a day, and hip-baths occasionally, will be found very soothing
and grateful.
  If the disease persist  and matter form, it must be  treated in  the way I
shall presently describe.

  812. The foregoing  description applies to those  cases which occur as a
variety of puerperal fever, in connection, it may be, with other local affec-
tions, and during  an epidemic :  but inflammation and abscess may occur
after delivery, independent of an epidemic, and with  no other complication :
nay,  it may happen to  married women who have had no children, and even
to virgins.   I hope  the  reader will pardon the irregularity, if, in order to
complete the subject, I introduce here a brief summary of the  peculiarities
of the disease in its more isolated and chronic form.
   As I  have just observed, this species of inflammation  of the  uterine
appendages may  occur,  though  rarely,  independently  of pregnancy  and
labor,  but  far more frequently after labor,  and at  varying intervals ; the
first  intimations being  perceived in some cases from  three to ten days after
delivery, and in others not until the lapse of some weeks.
   813.  Causes. — It is  very difficult  to  assign  any special cause for this
attack.   It  may follow blows, falls, or  a fright; but it  is  more  frequently
the result of cold or of excessive sexual intercourse.   From the  coincident
suppression of the milk or lochia, it has been frequently attributed to either
accident, but, as I  believe, without sufficient  grounds.   That it  may occur
in consequence of the long-continued pressure of the child's head in lingering
labor, I do not doubt; but it is evident that  this is not a frequent cause, as
most of the cases  I have seen occurred after natural labor.  Lastly,  it may
be the termination of a more general acute inflammation.
   814.  Invasion.—The  mode of invasion varies a good deal:—
   1. In certain cases there are few, if  any, preliminary symptoms :  uneasi-
ness, perhaps, but  not amounting to pain, in  one or other iliac region, and
upon placing the hand on the spot, a tumor is detected.
   2. Or, after a favorable convalescence for some  days, just as the usual
term of our attendance  expires,  the  patient experiences  a slight  febrile
attack,  with some  shooting  pains in  the abdomen, which subside  after a
time, though the fever continues without apparent cause, until, in the  course
of time, the local disease develops itself.
   3. Again, in other cases, the attack is purely local,  and its nature  pretty
evident; from the beginning there is pain in one or other iliac region, ten-
derness, and shortly after, tumefaction, with fever.
   4. Lastly, the  affection may at first  assume the character of a more
general affection  of the  peritoneum, the pain extending over the abdomen,
occurring mainly  in paroxysms, with  tenderness on  pressure,  and  fever;
but  by and  by* the  general tenderness and extended  pain subside,  and
become, as it were, localized, by which the character of the attack is made
evident.
  815. Symptoms.__Having thus briefly alluded to the  various modes in
which the disease  commences, I prefer taking the symptoms separately, in
order of their importance and  prevalence,  rather than  in that  of their
succession.
  1.  The presence of  tumefaction or of a distinct tumor, is invariable ;  it
occurs in all cases, and  characterizes the disease.   It may be found com-
pletelv above Poupart's  ligament, and the  linea  ilio-pectinea,  sometimes
occupying one iliac fossa entirely, and  even  extending upwards  as high as
the umbilicus, and forwards  to the linea  alba;  or it may be situated more 
570
inflammation  of  the
deeply in the pelvis, just  reaching  to Poupart's  ligament, protruding the
groin, and from its fixedness giving the impression  of being firmly connected
with these parts.   In the  former case, the tumor is  larger, more  defined,
and  far more  movable :  in the latter, it is rather undefined, immovable and
more painful.   In both it  is equally hard; in fact, as hard as a stone  until
suppuration commences;  and  equally  tender on  pressure.   If a vaginal
examination  be  made in the former case, we do  not always discover any
change; the  vagina may  be cool,  no tumefaction may be detected, and
movement of the uterus  may occasion little pain.   But in the latter cases,
and  also in the former when the inflammation  is much  diffused, the vagina
is hot, somewhat tender,  and  at one of its  sides, or at its  upper part in the
" cul de sac," on one side  of the cervix uteri, a hard, painful swelling  may
be detected, which is evidently connected with  the tumor in the groin, and
in these cases the uterus  cannot be moved without acute pain.
  2. Although the period at which  it may be  developed  varies, yet sooner
or later pain is an accompaniment of the disease.   It maintains, as it were,
its seat in the tumor, from  whence stings  of pain  radiate in all directions.
When the tumor is  high,  that  is,  above the brim  of the pelvis, the  pain is
more limited to the tumor; when situated in the pelvis and groin, it extends
across that cavity, down  to the anus, to the back,  and down the thigh.  In
these cases it  is  almost always difficult, in some cases  quite  impossible, to
straighten the thigh,  so as  to stand upright.   Walking, too, is both difficult
and  painful.
  3. In these latter  cases,  also, when the  tumor occupies a  portion of the
pelvic cavity, we often find the patient distressed  by tenesmus, and a desire
to make water, the consequence, probably, of  an extension of the  irritation
to the bladder and rectum.  Occasionally, when the tumor is large, it offers
a mechanical impediment to  the  functions of these viscera, and the patient
may suffer from  dysuria,  or be unable to evacuate the intestinal canal.
  4. The amount of fever, as well as the time of its setting in, varies. In
some cases it precedes or accompanies the first local  symptoms; in others,
it supervenes after the tumor has been detected some time.   In a few  cases
it is almost confined to the evening, and during the process of suppuration
there are, in almost all cases, evening exacerbations.   The pulse ranges from
90 to 110; the  tongue is  loaded, the skin hot, the thirst considerable, and
the urine high colored.   The appetite is always bad.   These  symptoms are
somewhat mitigated, or at least the patient suffers less, in cases not connected
with parturition.
  816.  Terminations.—After being fully developed, and running on  even
for a considerable time, the disease may terminate :
   1. In resolution.—This most frequently occurs with cases in  which the
tumor is  above  the brim,  and  limited in  extent;  and  in such, we  find the
pain diminishing and ultimately ceasing, the tumor first becomes less tender,
then less in  size, until at  length  it disappears.   This  process will occupy
from one to three months.
   2. In abscess. — When suppuration takes place we can  generally feel  a
degree  of softening,  with an obscure sense of fluctuation in the tumor, either
externally or internally;  the  patient  complains  of  more  throbbing, and
occasionally of rigors, and by degrees (if  not  anticipated) the coverings are
thinned, and the matter may escape—
   a. Externally, through the abdominal parietes covering the tumor.
   b.  Into the vagina, through which the matter escapes.
  c. Into the intestinal  canal, and  especially the rectum, with the  evacua-
tion of matter per stool.
   d. Into the bladder. 
UTERINE  appendages.
571
  e.  Into the peritoneum, where it gives rise to peritonitis, always alarming,
but not always fatal.
  /.  Into the surrounding  cellular tissue, where it may burrow until it finds
an outlet.
  The matter may be evacuated by any of these "routes;" and if the open-
ing be sufficiently large, the sac may be emptied, and the abscess fill up and
heal.  But if  the opening be small, the discharge may continue for an
indefinite length of time, the opening remaining fistulous, and the cure being
proportionably difficult.  I have repeatedly seen the matter evacuated by
the first three ways, and I think equally frequently.   I have also seen it pass
into  the bladder, but very rarely.  I have never yet seen it evacuated into
the peritoneal  cavity, and I cannot but think it very rare.
   3.  The extent of the disease, or the secondary affections caused by it, may
prove fatal after an indefinite length  of time.
   817. Diagnosis.—A good deal of light will  be thrown upon the diagnosis,
when the disease occurs within a  reasonable time after parturition, and espe-
cially when the patient has  suffered  from abdominal  pain : in such cases, if
we discover a  tumor in one of the iliac fossae, with  tenderness and pain, we
shall have adequate grounds for diagnosticating this affection.
   If, however, the attack occur  independently  of child-bearing, or at a con-
siderable interval afterwards, there may be difficulty in distinguishing between
it and some of the chronic organic diseases  of the ovary, especially when the
tumor  is above the pelvic brim : our safest  guide, probably,  will be the
amount of  pain and constitutional disturbance, which is much greater in the
disease I have been describing.
   An ileo-ccecal abscess when situated rather lower than usual may easily be
confounded with an  ordinary pelvic abscess, which  is the more  undesirable,
 as if we attempt to open  it we may penetrate  into the intestine.  I  have
 seen one such case,  and the only grounds  of  differential diagnosis I  could
 make out  was  an  unusual resonance of the tumor  on percussion, which I
 believe never exists with pelvic abscess.
   I  have known this affection mistaken for sciatica;  and when the tumefac-
 tion is mainly confined to the pelvis, and pressure  is made upon the nerves
 issuing from that cavity, the pain may be limited to the"track of the nerves,
 so as to deceive  any but a careful observer.   However, a minute investiga-
 tion will probably enable us to trace  the pain into the pelvis, and then an
 external, and especially an internal, examination will at once reveal the cause
 of the pain.   The flexion of the  thigh, which  alone might also mislead, will
 of itself lead  to an examination  of the groin,  and so to the detection  of the
 tumor.
   818.  Treatment.—The indications of cure are, 1, to procure resolution
 of the tumefaction; or, 2, to promote suppuration and  evacuation  of the
 matter.
   1. If we are  called in at an early period of  the attack, it is often possible
 to arrest its  progress, as  has  been well remarked  by Dr. Doherty; nay,
 even where the disease has  lasted some  time, as in  the cases mentioned by
 Puzos, it is in  some cases  quite possible to  procure  resolution.   For this
 purpose Mauriceau and the author just named, advise  repeated venesection,
 with purgatives, alteratives, absorbents, etc.   I believe that the repeated
 application of leeches will be found more effectual at less expense of strength.
 A dozen should be applied  over the tumor, followed by bran poultices, and
 repeated  if necessary, i. e., if the pain and throbbing be not relieved.  If
we  succeed in  arresting  the progress of the  inflammation, a succession of
 small blisters will be of great use.    Fomentations,  and an occasional  hip-
 bath, also  afford great relief to the patient;  but still more comfort is derived
from' vaginal injections of warm  water, twice a-day. 
57 2          inflammation  of  the veins of  the

  Internally, we may exhibit mercury in small doses, perhaps even so far as
to affect the gums, though this is not generally necessary, and an occasional
purgative ;  but my experience has led  me to the conclusion that brisk
purgation is not beneficial;  it appears to augment the  local irritation, and
certaiuly increases the  pain.   If the  pain prevent sleep, an  opiate may be
given.   When the disease shows signs  of retrocession,  I have  seen  benefit
derived from an  application  of the emplastrum hydrargyri.   The diet should
be nutritious, but bland and unstimulating.
  2. If, however, notwithstanding the prompt and  sedulous  use of the means
I have indicated, the disease should not yield, we may be sure that suppura-
tion will take place,  and our object will then be to  promote  this by poultices
and fomentations, constantly applied.
  The formation of matter  will  sometimes be indicated by rigors,  but in
many cases  it is by the touch only that we can recognize  this occurrence.
I cannot too strongly impress upon my readers the advantage of making an
opening into the abscess when  it is  posssible, and so  deciding the  course
which the matter is  to take, instead of leaving it to burrow and  make an
opening in some dangerous  situation.   The  best  situation  for our incision,
if the case admit of it, is through the abdominal parietes ; the next, through
the wall of the vagina.   If,  from the high situation of the tumor, we fear
that, when opened,  the matter  may escape  into  the peritoneal cavity, we
might adopt the method so  successfully practised in abscess of the liver by
the late Dr. Graves, and cut down to, but not through,  the peritoneum, and
then apply poultices, with little doubt but that the matter  will  ultimately
make its appearance through the wound.   Should the abscess open sponta-
neously, we  must counteract, as well as we can, any unpleasant consequences
which  may result;  but, whether  opened spontaneously or  by the  knife, we
must endeavor to empty the sac, and to secure a free exit for the matter as
it is secreted, by which means we shall avoid the prolongation of the disease,
and all the distress  of a fistulous opening.  When the  abscess points into
the vagina,  it is sometimes  difficult to tell whether it  has opened  or not,
from the small size of the orifice, and in such cases the microscope may be
of great use.  Very lately I was  able to decide that an  abscess had broken
and commenced  discharge, by the presence of pus corpuscles in the vaginal
discharge.  When  the matter has been fairly evacuated, the diet must be
generous,  and a  full share of wine or porter allowed.

  819. IV.  Inflammation  of  the Veins of the Uterus, or  Uterine
Phlebitis.—This  form of the disease has been  frequently noticed  by the
more modern authors;  amongst others, by Dr. John Clarke, Waller, Meckel,
Louis, Dance, Tonnelle, Lee, Boivin, and Duges,  Ferguson, etc.,  and  in a
series of  papers on Metro-peritonite, by M. Nonat.1   Nor is it very rare:
for M. Tonnelle  found pus in the veins in 93 cases; and in the thoracic duct
in 3 cases out of 134 ;  and Dr. Robert Lee, in 45 cases, had 24 of uterine
phlebitis.
  820. Causes.—Dr. Robert Lee considers that it may be the result of
mechanical  injury to the uterus,  either during the labor, or by the force
used to extract the placenta.   "Uterine  phlebitis,''he says, "appears to
result from  the  mechanical  injury inflicted upon  the uterus by protracted
labor; from the force required for the extraction  of the placenta in uterine
hemorrhage ; from retained  portions of the placenta undergoing decomposi-
tion in the uterus ;  the application of cold, and, perhaps, of contagion ; or
from any  of the causes which produce the other varieties of uterine  inflam-
mation.   M. Dance  considers deranged states of the lochia to be a frequent

                    1 Revue Med. Franc, et Etrang., 1837.
       34 
UTERUS,  OR  UTERINE  PHLEBITIS.
573
cause of the disease ; but these are consequences  and not causes  of uterine
phlebitis.1   It may follow after hemorrhage,  or arise  from cold, or  the
decomposition of retained  portions of the placenta.   It may be excited  by
any of the causes of the other varieties of puerperal fever.   Dr. Bartsch
observes, y As to the causes  under which uterine phlebitis was developed,
we found it occurring most frequently—1.  In women who approached  the
critical period  of life, especially if  they were primiparous.  2. In women
affected with varicose tumors of the thigh,  and external genital organs.
3. In females, who, during  pregnancy,  were submitted to the  influence  of
depressing passions—fear  of  exposure, jealousy, sorrow, etc.  4. In indi-
viduals who, from the symptoms  they  presented, had frequently employed
abortive remedies.  5. From  mechanical injury of the uterus during  preg-
nancy, especially  if it were followed by abortion.   6. In females subject to
chronic disease, as cough, difficult menstruation, hemorrhoids, fluor albus,
chronic diarrhoea, and constitutional syphilis.   7. After flooding, during or
after  delivery,  especially from placenta praevia,  after difficult  labors, after
obstetrical operations,  especially  those requiring the introduction  of  the
hand into the uterus.   8.  Finally, the  greater number of cases occurred in
the months of  February, March, April, and May, in females  who, the  year
before, had been attacked by 'la grippe.'"2
  821. Symptoms. — In women  of  previous  good health, the  attack com-
mences generally  in twenty-four or thirty-six hours after delivery.  The pa-
tient complains of pain  in the uterus, more or  less acute, preceded, accom-
panied, or followed by rigors.  The uterus is tender on pressure, and  the
lochia and milk are both suppressed.   There is headache, and  slight inco-
herence ;  a sense  of general uneasiness,  and sometimes nausea and vomiting,
with acceleration  of the pulse.   After a time, these symptoms are succeeded
by increased heat of surface, tremors of the  muscles of the face and extremi-
ties, rigors, great thirst,  dry brown tongue,  frequent vomiting of green fluid,
rapid full  pulse, hurried respiration, etc.  The head becomes more involved,
and we find the patient in a state of drowsy insensibility,  or violent delirium
and  agitation, followed  by extreme  exhaustion.   The surface of the body
assumes a deep sallow  or yellow  color;  and occasionally petechial or vesi-
cular eruptions have been  observed on different parts of the  body.   The
pain may or  may not increase, but'the uterine tenderness is certainly aug-
mented, and  the  abdomen  is often swollen and tympanitic.  In some very
rare cases, there is little  or no local distress, and the existence of the disease
could not  be discovered  except for the secondary affections.  Such was the
case with a patient under my care.   She had no uterine pain or  disturbance,
no tenderness on  pressure;  and  yet, on the seventh day after delivery, a
smart febrile attack preceded the formation of a large abcess near the left
elbow-joint:  after which, a second followed, on the top of the shoulder, and
a third in  the right arm,  above the elbow.
  822. The patient  may die  during  the  acute  stage, but the majority live
longer, and exhibit the  most interesting  phenomena., connected with this
variety of puerperal fever, and distinguishing it from all others.   I allude to
the secondary diseases of other organs.
  The brain, though often functionally disturbed (135 in 304, Lee and Fer-
guson), is not frequently the seat of organic disease.   Its vessels are some-
times  congested, and  lymph diffused in the pia mater, or  serum in the ven-
tricles.  According to  M.  Duges, there  is  arachnitis once  in 266 cases.
Portions of the brain are occasionally softened and  disorganized ;  or there
is purulent infiltration into the cerebral  substance.
  In the chest, we find evidences of inflammation of  the pleurae, effusion  of

   i Diseases of Women, p.  54.             2 Report in Lancet, April 16th, 183C. 
57 4
INFLAMMATION  OF  THE  VEINS OF THE
in	10 cases
in	4 "
in	8 "
in	3 "
in	2 "
serum of the same character as that in the peritoneal sac, and occasionally
efl'usion of blood.

       M. Tonnelle found pleurisy       .     .     .     in 29 cases.
                         effusion of serum   .     .     in  8  "
                         effusion of blood    .     .     in  6  "

  The lungs are often greatly condensed, of a dark red color, with infiltra-
tion of purulent matter ;  or they may be in a state of "complete dissolution,
having all the characteristics of gangrene, except in many cases its peculiar
fcetor."

       M. Tonnelle found pneumonia
                         tubercles
                         abscess
                         gangrene
                         pulmonary apoplexy

   The symptoms of the secondary affection in these cases (cough, dyspnoea,
etc.) are but slight, and are completely masked  by the more serious primary
disease.   Dr. Robert Lee observes,1 " In four cases which have fallen under
my  observation, where there  had been  only obscure pain during  life,  with
slight  cough and dyspnoea,  copious effusion of lymph and serum was found
within the cavities of the thorax ; the pleura was covered with false mem-
branes, and portions of the lungs had fallen  into a  state of complete  gan-
grene.   In  one individual, the pleura had given way  by sloughing; and the
right side of the chest was found distended with air.  Gangrene, also, some-
times takes place rapidly in those parts of the body on which the  patient
rests ;  and the same process is established in other soft parts, where no pres-
sure has been made.   In a case related by Cruveilhier, which did not prove
fatal, the nose became black and gangrenous."
   The  heart is often enlarged, softened, and friable;  its  inner membrane
deeply stained ; lymph and serum  are also  occasionally found in  the  peri-
cardium.   There are white  patches on  the  outer  covering of the heart.   I
have never  remarked any  peculiar disorganization  of the great  arteries;
they are often  intensely stained.
   The intestinal canal is not  frequently the  seat of organic change.  The
mucous  membrane  of the stomach  is  sometimes inflamed,  softened,  and
occasionally its coats  are perforated, giving rise to peritonitis.  Duges has
remarked, that the brown viscid matter exuding from the perforated  portion
of the stomach, seems to act on the neighboring organs like caustic — adding
as a proof of this surmise, the fact of his finding a continuous series  of per-
forations of the diaphragm, mediastinum, oesophagus,  and lungs,  all in the
immediate vicinity of  a perforation of the large extremity of the stomach."2
Between  the mucous and muscular tissues, there is an effusion of clear red-
dish serum, when the vomiting has been excessive.  The raucous membranes
of the intestines, also, may be softened, and the walls of the canal perforated.
M. Tonnelle found gastro-enteritis	. in 1 case.
enteritis	. in 4 cases
entero-colitis .	. in 1 case.
the stomach softened	. in 8 cases.
the stomach ulcerated	. in 5 "
the stomach perforated .	. in 5 "
The liver is occasionally diseased :  its substance may be congested, soft-

 1 Diseases of Women, p. 49.            2 Ferguson on Puerperal Fever, p. 36. 
UTERUS, OR UTERINE PHLEBITIS.
575
ened, or contain abscesses,   M. Tonnelle  met three cases of abscess in the
liver.
  The structure of the spleen may be softened and disorganized.  M. Ton-
nelle relates two cases of abscess.
  The kidneys present inflammation of their peritoneal coat, depositions of
pus, and flakes  of lymph,  alterations in  their veins,  softening, and great
engorgement; both  kidneys  are  rarely attacked  at once.  The ureters and
bladder are more often the seat of pain and  congestion, than of disorganized
structure.
  The eyes are also affected.  The conjunctiva becomes inflamed, the eye-
lids swollen, lymph is  effused into the anterior  chamber, and  the sight is
destroyed.   Cases of this kind are related by Dr. M. Hall and Mr. Higgin-
bottom, although not by them attributed  to uterine phlebitis.1   Dr. R. Lee
 states, that " In two cases which came under his care, the conjunctivas of
 both eyes, without much pain, suddenly became intensely red ; the cornea?
 opaque, and the eyelids much swollen, and under their lining membrane  a
 large serous deposition took  place ; lymph and  pus  were  also effused into
 the anterior chamber, and  in one the cornea ultimately burst."2   A case of
 the secondary affection of the eyes is related by Drs. Hardy and M'Clintock.3
    The joints are attacked  by inflammation, and  sometimes the cartilages by
 ulceration ; and the various  products  of  inflammation are  found within the
 capsular ligaments.*  M. Duges  has thus placed the  joints in the order of
 frequency of disease : 1, the  hip ; 2,  the elbow  ; 3, the knee  ; 4, the foot;
 5,  the metacarpus; 6, the shoulder.   Dr.  Ferguson has found  the elbow and
 knee more frequently affected than the hip.   M. Tonnelle met six cases of
 abscess of the knee ; two  of the  elbow ;  and two of the symphysis pubis.
 Drs. M'Clintock  and Hardy relate one  case of puerperal arthritis of the
 shoulder, and another of the little finger.5  Upon the  whole, they agree with
 Dr. Ferguson as to the joints most frequently affected.
    Sero-sanguineous fluid  may be effused into the muscles or cellular sub-
 stance of the limbs, giving to them  the appearance of erysipelas. ^ M. Ton-
 nelle mentions three such  cases.   As to the extent of this infiltration, it may
 be circumscribed  within a few inches,  or  it may  extend between two joints,
 rarely  occupying  the whole limb.
    An abscess may be formed in the muscles or cellular membrane of a limb;
  or a succession of abscesses may occur, as  in the case I have mentioned ;  or
  the pus may be diffused through the various soft structures.   The quantity
  is sometimes enormous; the patient suffers much pain, and may be seriously
  injured, if the discharge continue long.   The symptoms in the latter case are
  those met with ordinarily  in abscess, except that at the beginning they some-
  times resemble a  rheumatic  attack.
    823. Morbid Anatomy.—The primary  morbid change is evidently in the
  veins  of the uterine  region ; their coats  are thickened, and sometimes  so
  much  contracted as to render the canal impervious.   The  lining membrane
  is generally paler,  and coated with lymph or pus, which may extend to a
  considerable distance.6   Acccording to Boivin and Duges,7 "it is in the
  lateral veins, at  the point where they are collected together to leave the
  uterus, and merge into the  plexus of the ovarian veins, that the pus is most
  commonly found ;  in some rare  instances,  all the sinuses are  filled and even
  distended with it; sometimes there are  albuminous  concretions mixed with

    1 Med -Chir Trans., vol. xiii.    2 Diseases of Women, p. 50.   3 Midwifery  p. 139.
    * Lee on Diseases of Women, p. 50.  Beatty, Dublin Journal, vol. xvi. p. 340.

    « Ferguson on" Puerperal Fever, p. 39.  J.  G.  Sasse, de  Vasorum Sanguif.  Inflam.
  Halle, 1797.
    1 Diseases of the Uterus, trans., p. 327. 
57 6     INFLAMMATION OF THE  VEINS  OF THE  UTERUS.

the fluid ; even the veins are occasionally obliterated by a yellow concrete
matter.   When the substance is entirely fluid, the interior of the vessels is
of a light rose color, whitish, and smooth, and often even pale and yellowish.
We have observed, though only twelve or fifteen times, that this inner sur-
face was uneven and adherent to the albuminous flakes."
   The  disease may be confined to  the veins of the uterus, or may involve
those of  neighboring parts.    The spermatic  vein  is  the   one more fre-
quently affected, then the hypogastric ; but it  may involve  the renal veins,
as far as the kidneys, or even  the vena cava.  It is remarkable, that it is
generally the veins of one  side  only that are  affected, and that side is the
one to  which  the  placenta was  attached.   AVhen the disease affects veins
distant  from the  uterus, the surrounding  cellular  tissue  is  hardened, and
contains puriform matter.
   Dr.  Ferguson observes that,  "In a certain number of cases, no lesion can
be discovered  in the vein, but the presence of some unnatural  fluid.  It is dis-
puted whether it is absorbed, or the product  of venous inflammation.  It is
of little moment which of the two opinions be adopted ; the  disease depends
not upon how the matter is produced,  but whether  it enters the circulation.
Whether this be by absorption  or by  inflammation, puerperal fever is the
result."
   824.  Diagnosis.—It  may in many cases  be extremely  difficult to distin-
guish this from the other varieties, at least in the early stage.
   Generally speaking, the pain  and tenderness are more local and  limited
than in peritonitis, and at an advanced period the presence of the secondary
disease will at once indicate its true character.
   825.  Treatment.—Severe cases of  this species of puerperal fever appear
to  defy all  our  resources.  When it is the prevailing  characteristic of an
epidemic, the  vast majority will die.
   " The two indications," says  Dr.  Ferguson, "are, 1.  to attend to the local
lesions  ; 2.  never to  forget that these are  not the disease, but merely the
effects  of a more diffusive, though concealed cause, to act  on which our
remedies should be directed.  The rationale, of the treatment, therefore, con-
sists in the  exhibition of such remedies as will act on this cause, and  such as
will alleviate or remove the local affections ; taking care that in our attempt
to effect the latter end, we do not so act on  the constitution as to give addi-
tional energy to the more deadly power of the concealed cause."
   This rule should direct our employment  of leeches, blisters, calomel, and
opium, etc., in the early stage,  and stimulants and tonics in  the latter.   Dr.
R.  Lee says  that " The French physicians,  however,  are of  a contrary
opinion, and are  satisfied that we  possess  a powerful remedy, even in the
worst  cases, in  mercury, employed so as to excite salivation.  In  several
cases of uterine phlebitis, I have  employed this remedy  to  a  great  extent,
externally, and speedily brought the system under its influence : yet the pro-
gress of the symptoms was not arrested ;  and the patient died as others had
done, when the  mercury had not been administered.   In other cases  I have
employed mercury to a great extent, internally, without the slightest benefit;
and it may  justly be doubted, from the results of M. Desormeaux's practice,
whether or not it  possesses the influence M. Tonnelle supposes ;  for of forty-
three cases where mercury was used by him as the chief remedy,  only four-
teen recovered."1
   Dr. Copland  speaks in a more hopeful tone as to the results of treatment.
 " Hunter's  treatment of phlebitis," he says, " was powerfully tonic, stimulant,
and restorative ; and he directed it with  the view, correct  both in pathology
and therapeutics,  of enabling  the  vessels of the diseased  part to throw  out
lymph  capable of coagulation,  and of  assisting  the powers  of life by these
1 Diseases of Women, p. 113. 
         inflammation of  the  uterine lymphatics.      577

and other means to resist the progress and retrieve the consequences of the
disease."  Dr. Copland advises a small venesection, or leeches if necessary,
and afterwards turpentine fomentations, a full dose of calomel, camphor,  and
opium, followed  by turpentine, by the  mouth  and in  form of enema.   " In
most instances the intention is not so much to  evacuate the bowels (for they
are often sufficiently open), as it is to  exhibit  a remedy which is calculated,
by its passage into the circulation, at least partially to resist the changes
taking place  in  the  blood and  vascular system  generally, and at the same
time to  procure the discharge, both from the bowels and from the uterus, of
such morbid matters  as would be inevitably most injurious if retained  even
for a short  period."   Dr.  Copland seems to have obtained more  favorable
results from the use of turpentine than  most other practitioners.  In Dublin,
although it is occasionally beneficial, I do not know that much confidence is
placed in it.
   I feel very  much inclined to agree with  Dr. Copland, that probably  "no
other plan  of cure will be found more beneficial for it than now advised ;
that no other than powerfully restorative, tonic,  and soothing means will be
found beneficial  in this form of phlebitis, or indeed in any other."1

   826.  V. Inflammation of the Uterine  Lymphatics.—This variety of
puerperal affection was first noticed in France by M.  Dance;  and since by
Boivin and Duges,2 Tonnelle,  Duplay,  Cruveilhier, and  Nonat:3 the former
found pus in  the lymphatics in thirty-two cases,  and in  the thoracic duct in
three.
   In this country, it  was first recorded by Dr. R. Lee, in the following case,
published in the Medico-Chirurgical Transactions.4 " A woman, aged thirty,
in an advanced state of pregnancy, was admitted into St. George's Hospital,
 July 1st, 1829, under the care of Mr. Caesar Hawkins, in consequence of
 sloughing of the skin covering a diseased bursa of the patella. The removal
 of the bursa was followed by great constitutional disturbance, and on the
 14th  labor came  on.   Two  days after,  symptoms of uterine inflammation
 made their appearance, and on the eighteenth day death  took place.  Though
 the pain was  relieved by bleeding, she never rallied after the attack.  On
 examining  the body, some puriform  lymph  was found in the  pelvis, but
 there was no increase of vascularity in the peritoneum.   In the broad liga-
 ments some fluid was also effused, and on each side numerous large absorbent
 vessels were observed passing up with  the spermatic vessels to the receptacu-
 lum chyli,  which was unusually distended.  All these vessels, and  the reser-
 voir itself,  were  filled with pus, but that in  the receptacle was mixed  with
 lymph,  so as  to be more solid ; the vessels themselves were firmer and thicker
 than usual.   The  thoracic  duct was healthy.   The uterus was scarcely  con-
 tracted, and the internal surface of the lower half was soft and shreddy, and
 in a state of  slough.    The upper part, where no pus was found externally,
 was also healthy,  or nearly so, on its inner surface."
   Boivin and Duges state that the lymphatics "from half a line to_ a linein
diameter, may be  seen, in  consequence of their  injection with fluid, which
distends them in the whole length of the ligaments which contain the ovarian
veins :  we  have  observed the lumbar glands in some cases lengthened by the
pus injected  into  the vessels;  and it  has  been  found even in the thoracic
duct."5
   The local symptoms are exceedingly obscure, and the constitutional  ones
quite as severe as in uterine phlebitis,  and  in  the present state of our know-

      i Dictionarv of Practical Med., part xiii., p. 535.
      * Diseases of the  Uterus, p. 329.         3 Revue Med., 1837.
      4 v0i. xv. p. 64.                   .   5 Diseases of the Uterus, p. 339.
       37" 
578                  gastro-enteric fever.

ledge not to be distinguished  from them.  The secondary lesions also re-
semble those in phlebitis.
  As to the treatment, we  are  quite at a loss; as yet, we know of none
capable of controlling the disease.

  827.  VI. Gastro-enteric Fever.—I am not quite satisfied t<> include
this puerperal affection under the head  of puerperal fever,  because it rarely
involves the uterine system ; and because, on the whole, its course and ter-
mination are favorably contrasted with  the  other forms of childbed fever.
Yet as it  is not unfrequent, and I  have known it prevail epidemically, and
as I have no other place for it, I have ventured to place it  here.
  The affection prevailed epidemically  in Dublin in 1851, and less exten-
sively in 1852.   I saw twelve or fourteen cases of the disease.  Ii resembled
" weid" in some degree, but with a  considerable difference,  and differing yet
more widely from the ordinary forms of  puerperal fever.  Dr.  Ferguson has
described one form  of puerperal fever, which  seems to have a close resem-
blance to this  affection; yet his "second form," with gastro-enteric irrita-
tion,1 seems to be a  much more serious attack  than  the  one which 1  am
about to describe.
  I shall venture to describe the disease  from my own experience, first re-
lating one  or  two cases, the better to enable my readers to form their  own
judgment.

  Case I.—Mrs. ----was confined of her tenth child in July, 1851.   The
labor was  natural, the lochia and milk  secreted  amply, and she progressed
favorably until the  eleventh day.   On  the morning of that day, on which
she was to leave her bed for  the first time, before attempting to rise or dress,
and without the slightest apparent cause, she was  attacked  with a rigor,
followed by heat and sweating.   The pulse  became quick, and remained at
about 100.  The tongue became furred  and  white; the bowels flatulent and
constipated.   The  milk, which had been  abundant, almost entirely disap-
peared.  The uterus was neither enlarged nor painful, nor  was there any
tenderness on pressure.  The lochia continued  natural in character, though
diminished in quantity.   A day or two afterwards, the bowels, which had
been freed by medicine,  became too much relaxed, accompanied by a most
distressing amount of flatulence and frequent griping pain.   The pulse very
slowly diminished in frequency, and the  milk gradually returned.  Through-
out, the uterus and  its secretions were apparently  unaffected.   On  the
morning of the eighteenth  day the patient  appeared  much  better, nearly
convalescent; but,  in the course of the day,  she had another rigor, followed
bv fever, which  subsided, after twenty-four  hours, like an  attack of weid.
From  this time her convalescence  was  uninterrupted,  though slow, and the
milk was ultimately restored to its usual abundance.

   Case  II.—Mrs. M----was  confined of her second  child,  January 14th,
1852, after a favorable labor.   The placenta was expelled  in a few minutes,
and everything went on well until  the afternoon of the 16th, when a rigor
occurred  after taking some  castor oil.  Soon  afterwards, most violent pain
in the bowels came on and continued, but increasing in paroxysms.  There
was considerable tenderness on pressure, but not over the uterus especially.
To the rigor, of course,  succeeded  fever.  The skin became hot;  the pulse
rose to 130, with little or no thirst, but with a  total loss of appetite.  There
was neither nausea nor vomiting, and the bowels were freely moved by the
oil.   Neither the milk nor the lochia  were arrested, except for a few hours.
1 On Puerperal Fever, p. 22. 
GASTRO-ENTERIC  FEVER.
579
Forty drops of laudanum were  given, and thirty more after an hour's inter-
val.  A linseed-meal poultice was applied over the entire abdomen.  These
measures were successful, to a  great  extent, in the relief of pain, and  she
obtained some sleep.  January 11th.  I found that the patient had suffered
a good  deal  of pain  occasionally, but the  general tenderness had greatly
subsided.   There  was a spot, however, in  the left iliac region, which was
very painful on pressure.  The uterine tumor was free from tenderness.  The
lochia were natural in quantity and  appearance, but  had  a heavy smell.
The pulse were 120; the  skin  hot, but moist; some thirst; bowels moved
twice.   Twelve leeches were applied  to  the tender spot in the iliac region,
and the  poultices continued.   Vaginal injections of warm  milk and water
twice a-day.   Twenty drops of  laudanum were given immediately, and a pill
of calomel, gr. j., pulv. ipecac,  comp. gr.  iij., pulv. Jacob, gr. ij., was or-
dered to be  taken  thrice  a day.  18th. Much relieved after the  leeching.
Pulse 110.   Tongue white, but not loaded.   Very little pain or tenderness,
except in the left  iliac region.   Has slept better.   Milk abundant.   Lochia
natural, and free from smell.  Ts much  troubled with  flatulence.   The pills
and poultices were continued.   Towards evening, notwithstanding the opium
she had taken, she had an  attack of diarrhoea, accompanied  with most dis-
tressing  tenesmus  and burning pain  in the rectum, which was not relieved
until she had had  two enemata  with thirty drops of laudanum in each.  19th.
Some uneasiness  in the rectum, but no purging.  The iliac tenderness has
entirely disappeared.  The milk and lochia natural.  Pulse 100 in the morn-
ing, but  it  sank to 84 in the evening.  From this time my patient gained
strength, and was no more troubled with pain.  The bowels acted naturally,
and the  appetite  was increasing, when, on  the seventh day from  the first
attack, she had a  rigor of long  duration, followed  by heat and sweating,  and
lasting  twenty-four hours, just  as in the former case.   After this, she reco-
vered very  rapidly, and has been well  ever since.

   Case  III.—Mrs. M----was confined  about the same time  as the  last
case, under the care of Mr.  Morgan.  Her labor, which was natural,  was
followed by smart hemorrhage. About, the third day  she  was seized with
violent pains in the abdomen, increasing in  paroxysms to an intense degree.
There  was no  rigor ; the  pulse rose to 120, and the skin became hot, but
there was no thirst.   The breasts were full and the lochia natural.   Although
the abdomen generally was tender  on  pressure, there was no  peculiar tender-
ness over the uterus.  A full dose  of laudanum relieved the pain to a certain
extent,  and  the  bowels  were  freed  by medicine.  We then applied  the
mercurial ointment, on lint, over the abdomen, and  a poultice over it, and
gave small doses of calomel,  Dover's powder, and James's powder, three
times a-day.   The next day she  was much  better.   Pulse 110.   Tongue
coated ;  the  skin cooler;  some pain  and  flatulence,  with uneasiness on
pressure.   Milk and  lochia natural.  The  day after she was attacked with
violent  diarrhoea  and severe pain in the bowels, accompanied with great
exhaustion, so that we were obliged to give wine, and had some difficulty in
controlling the bowels by  means of opiates, astringents, anodynes, enemata,
etc.  After we had  succeeded  in  quieting  the bowels  by these means, and
relieved the pain, the pulse still continued  for some days above the  natural
standard.  In other respects the convalescence proceeded quite satisfactorily.
   Although the foregoing brief cases can scarcely give an adequate idea of
the attack  being so alarming as it really was, yet those engaged in midwifery
practice will feel  that, coming on so soon  after delivery, and commencing
with such  formidable symptoms, I might  be excused for fearing that the
issue would  be more serious than it proved.  The commencement of the
attack in many cases closely resembled that  of puerperal fever, and it was 
580
GASTRO-ENTERIC  FEVER.
not until after twenty-four hours that I could feel sure that  the  patient had
escaped the more formidable disease.
  828.  I shall now shortly lay before the  reader a summary of my observa-
tions  of this  affection of childbed, as it appeared during the epidemic, and
as I have observed it in isolated cases.
  1.  The attack, in almost every case, occurred within a week after delivery :
in some cases on the second day ;  in others on the third, fourth,  or fifth day.
In one case only have I known it  to commence on the eleventh day, and it
is remarkable that this patient had, for other reasons, been kept in  bed up
to that  time.   In no case have I been able to trace this attack to any special
cause, exposure, imprudence, or errors  of diet ;  but  there was  evidence in
some  of the cases that the bowels had not been sufficiently attended to during
pregnancy.   For the benefit of my junior readers, I may observe that it not
unfrequently happens that the bowels may be moved daily during pregnancy,
and yet that there may be an accumulation of fascal matter to  a  considerable
extent.   I remember  a  case  in which  I could trace the  colon across the
abdomen by enormous faecal accumulation, although the lady had complained
of diarrhoea during pregnancy.  In all  cases, therefore,  it  is  necessary  that
we should be sure that the bowels  are amply freed, and not merely moved.
   2.  In comparatively few  cases  the attack commences with a rigor, not
very severe, but sufficiently well marked.  In two cases I observed the rigor
to  be repeated  at the exact interval of a week, the  second  attack lasting
twenty-four hours, and resembling weid very closely.   The sweating stage
was more profuse than usual.
   3.  The most striking symptoms  in all the  cases I have seen were the pain
and diarrhoea.   The  former  came  on rapidly,  increasing in paroxysms, and
continuing until relieved by  medicine.  It was general  over the whole
abdomen, whilst severe, but as it declined it was felt  more  in one part than
another ;  I think most frequently in the left iliac region.   After the  first
severe attack was relieved, all the  patients complained of frequent flatulent
pains, with great  discharges of flatus.   Along  with,  and in proportion to,
the amount of pain was the  degree of tenderness ; but it was remarked that,
after  the first impression  of  pain, the pressure, if equal  and firm, was rather
a relief;  also, that the uterine region was less tender  than any other part of
the abdomen.   It is worth noting, that in no single case did nausea or vom-
iting  occur, but in all there was diarrhoea, even  in those  in which the bowels
were  confined at the commencement of the attack, or in which large doses
of opium  had been given for the relief of the pain.   The amount varied ; in
some the  discharges were few, but  large and unhealthy ;  in others they were
very numerous, and followed by great exhaustion.
   4.  The pulse  was invariably quick at first, generally 120, sometimes  140,
and gradually subsiding  as the distress diminished.    In  a few cases it con-
tinued  epiick for many days,  and  excited much uneasiness.   Its  frequency
was accompanied by heat of surface at first, which, however, soon diminished.
In  most cases there was a  good  deal of perspiration, and in one or two it
was excessive.  The absence of thirst was rather  remarkable  in all cases,
except  just after the exhibition of opium.  The tongue  was  coated with
white fur, but neither loaded nor dry.
   5.  In every case but one the secretion of  milk was unaffected, the breasts
remaining or becoming  full and hard.   In the exceptional case, the milk,
which had been abundant,  was completely suppressed for a  time, but ulti-
mately  restored.
   6.  The lochia were generally diminished or suppressed for a few hours at
first,  but  they speedily returned, and occasionally had a heavy smell for a
day or two, after which they became natural and healthy. 
MALIGNANT  PUERPERAL  FEVER.
581
  7.  I have already mentioned that, in two of the cases, there  occurred a
repetition of the rigor, followed by heat and sweating, like an attack of weid.
  8.  As a general rule, the attack  lasted about  a week; few were conva-
lescent earlier, and one or two were protracted a  few days longer.
  9.  I need not say that the diagnosis was a  matter of extreme anxiety to
me, beginning,  as the  attack  did, with so much  resemblance to puerperal
fever, and presenting such formidable symptoms.   However, one thing was
cleari that, whatever else I might have to treat, I had undoubtedly to  deal
with a severe attack of intestinal irritation, as was shown by the pain, its
fluctuations in seat, and its paroxysmal character, and  which  was confirmed
by the occurrence of diarrhoea,  So far was clear; but then arose the ques-
tion as to whether there  might not exist enteritis or peritonitis;  and some
support to  this view was afforded  by the rigor, the  quick pulse,  and the
tenderness; but then the pain was  shifting  and paroxysmal, which is not
generally the case  in these diseases, and the tenderness was superficial, and
not increased by prolonged pressure.   Add to this, that the decided improve-
ment in the course of twenty-four hours negatived  such  a supposition. There
then  only remained the question of how far the uterine system was involved;
 and as I found no particular tenderness over the  uterus and no enlargement
 of that organ ; that the  lochia, if modified for a  few hours, shortly resumed
 their natural character;  and lastly, that the secretion of milk was  abundant
 and unchecked, I came  to  the  conclusion that the uterine system was un-
 affected, that  no inflammation existed in the peritoneal serous membrane or
 in the intestines generally, but that the  attack was one  of severe irritation
 of the gastro-intestinal mucous membrane, accompanied with high fever, from
 some unexplained cause.
   10. In the epidemics I have described I saw no fatal case, nor do I  think
 such a result will occur unless  the uterine system become involved, which
 would place the case in  a different category.  Such complications, however,
 do occur, and  I  have seen several such cases in consultation which termi-
 nated less fortunately.   The indications of such  an extension of the disease
 will  be found in the  increase  and  permanency of the fever, perhaps  in its
 change of type,  in the suppression of the milk  and lochia, and in the local
 tenderness on  pressure.
   11 The treatment was  simple  enough, and  very  successful.   Ine nrst
 object was to  relieve the pain by large, and, if necessary,  repeated  doses
 of opium  by the mouth, or by enemata  of laudanum and starch, and exter-
 nally by poultices of  linseed-meal, alone  or mixed with flour  of mustard.
 When relief was obtained, if the bowels had not been sufficiently moved, I
 gave a dose of castor oil, but  had  I known that diarrhoea would follow the
 pain, as it generally did, I need not have done this.  I then as  a safeguard,
 gave small doses of  calomel  or grey  powder,  with Dover's and James s
 powders three or four times  a day, and  in  two or three cases applied the
 uno- hydrarg. to the abdomen underneath the  poultices.   After I became
 more familiar  with the  attack, I either omitted  the  mercury altogether, or
 left  off the moment I was satisfied that the uterus was unaffected  but 1 con-
 tinued the James's and Dover's powders and the poultices, until all pain and
 uneasiness ceased.                                           .         . ,
    The flatulence was  most effectually relieved  by camphor mixture, with
 aromatic spirit of ammonia, compound spirit of ether and tincture of orange-
 peel   I kept the patients on  low diet at  first, of course and  I found it
 necessary to  be very cautious for some time, in increasing the nourishment,
 as a meal was very apt to  be followed by pain and flatulence.

    goo  VII   Malignant  Puerperal  Fever.—This form is comparatively
 rare"'except  when the disease prevails  epidemically.   It  may  attack the 
582
MALIGNANT  PUERPERAL  FEVER.
patient  before delivery, immediately after, or after some days, and perhaps
the most frequent time is at the end  of  the second or the  beginning of the
third day.   " In the case of a female attacked before delivery," Dr.  Cop-
land observes, "to which I was called by Mr.  Barnwell, the symptoms were
the same as those observed by me in other cases.  This patient was seized
early on the 12th of February with  acute pain throughout  the abdomen,
with enormous distension, and  exquisite tenderness;  with very rapid, full
and soft pulse, varying from  130  to 136,  and with  frequent vomiting.   I
saw her in the afternoon of the same day.  The vomiting  and  state of the
pulse were as here stated.   She complained of headache and  of thirst, and
was very despondent.  Her tongue was broad, flabby, slimy, and tremulous;
her countenance pale, anxious, and covered by perspiration,  and her gene-
ral surface warm, moist, and clammy.  Labor pains came on that evening,
but were even inefficient, the action of the uterus  having  ceased.  Mr.
Barnwell administered secale cornutum, which ultimately induced uterine
action,  and she was  delivered after a  labor of about twenty hours.   On the
following day (the  16th),  the  distension  and  tenderness  of  the abdomen
were diminished ; but the sickness  and vomitings, with borborygmi and flatu-
lent eructations,  continued.   Apathetic  depression of spirits,  anxious ex-
pression of countenance, flabby  and slimy state of tongue,  a  very  rapid,
fluent,  and weak pulse, clammy state of the skin, scanty  amd  almost sup-
pressed urine, quick and  oppressed breathing, a feeling of pressure of the
diaphragm, requiring the head and shoulders to be elevated,  were  soon fol-
lowed by the symptoms ushering in dissolution.1
   830.  The same author has given  a  graphic picture of the attack when
it  occurs almost immediately after delivery.   He says  that "the earliest
indication of the impending mischief, is the great rapidity, softness, and
weakness of the  pulse, often  attended  by pain  and tenderness at the epi-
gastrium, by sickness and vomiting, followed by general distension and pains
darting through the abdomen.   But in the majority of cases there are neither
chills nor rigors : in a few a feeling of coldness  only ; and  in still fewer,
slight rigors.  In this state of the  disease the patient  soon becomes  de-
spondent, predicts her dissolution, is  afterwards  apathetic, and  makes little
or no inquiry for her infant.  The milk  and lochia are either  little  or not at
all diminished, or are more than  usually abundant.   The abdominal pain
and distension are sudden and quick in their accession;  but  the pain soon
ceases,  the distension remaining,  and afterwards changing its  character if
the disease  continues above  two or three days.  The  tongue,  from  the
commencement, is  flabby, broad,  and  slimy, or covered  by a mucous  or
creamy coating;  the pulse is usually  from 120 to  140,  or  even  upwards,
fluent,  soft, or broad ; and the general surface presents a lurid, or  dusky, or
 dirty hue, and is covered by a clammy or offensive perspiration.  The coun-
tenance is  pale and inexpressive, unless where  the pain  is  acute, when it
becomes  anxious  and covered  with perspiration.  The  mind  is  but little
 disturbed, beyond  a state  of complete  apathy.   As  the  disease  proceeds,
respiration is short, suspirous, or difficult;  the pulse, small, soft,  or irregular;
the bowels frequently relaxed,  and the  stools  offensive  or passed without
control.   Distressing feelings of sinking, leipothymia, or restlessness super-
 vene, and are soon followed by symptoms of impending dissolution."
    I think it will be found that in the majority of cases the milk is not secreted
 at all, or very slightly, and that the lochia, which  may appear natural for a
day or  two, become  scanty, and with an offensive odor.   I have  also seen
the abdomen remain  in its natural  state,  neither painful, tender, nor  dis-
tended  ; but these are rather exceptions.
1 Diet, of Pract. Med., part xiii. p. 519. 
MALIGNANT  PUERPERAL  FEVER.
583
  831. The most  common  period, I have  said, for the  incursion  of the
disease, is on the second, third, or fourth day ;  but it may occur even later.
Its  commencement may  be marked by  a  rigor, or more  frequently  by a
creeping, chilly feeling, a  sort  of imperfect rigor.   Dr.  John  Clarke ob-
serves, "It has hardly occurred to me to  see  a case  in which  the  disease
began with a shivering fit, which is common in the commencement of many
other fevers, and in the cases where the constitution sympathizes with the
local inflammations which have  been  already treated of.   If there was any
degree of rigor, it  has been so slight as to have escaped the attention of the
patient, and the observations of her attendants.   Indeed, so great a diminu-
tion of the sensibility accompanies the whole complaint, that even if a slight
rigor should  take  place, the patient might not observe it,  or being sensible
of it at the time, might not afterwards remember it."1   Coincident with this
symptom, or preceding it, or independent  of it, we always find the  pulse
unusually quick ;  instead of being from 80  to 90, it is generally from 120 to
130, and often higher, confirming  the accuracy of Dr. John Clarke's obser-
vation, than no woman can be considered safe whose pulse is not under 100.
But not only is it rapid, but it is generally small, weak, and  easily com-
pressed,  not at all a pulse which would justify blood-letting.
  At an early stage in the disease, many patients complain of pain in the
stomach, bowels, or region of the uterus, accompanied by more  or less ten-
derness, and followed by distension.  This, however, is by no means always
the  case.   In a patient I saw some time ago,  who died on the third day of
the  disease, there  was neither  pain, distension,  nor  tenderness in  any  part
of  the abdomen.  In others, we find distension with but little pain  and no
tenderness.   Sickness of stomach, vomiting, and diarrhoea, may occur at
the  very outset of the  disease, or on the  second or third  day, or  not till
towards the termination  of  the disease ;  in  some cases it does not occur at
all.   Dr. John Clarke  says that the purging commences  on  the third or
fourth day, or even later.
  But however the disease  may commence, and however slight and  few the
local symptoms may appear, to the experienced eye they are  always most
formidable, and generally run a rapid course.   The fever has a low, typhoid
character ; the patient is nervous, depressed, and  fearful;  the  pulse is soft,
small, and increasing in rapidity; the respiration quick, hurried, high, and
often panting ; the abdomen in many cases swollen, tympanitic, and painful;
sometimes generally tender, sometimes only in a particular part; the lochia
are sometimes altogether arrested, sometimes merely diminished in quantity,
but more commonly, at least after a day or two, changed in quality, with a
foetid odor;  in some rare cases they continue quite unaltered To the  last.
The secretion of milk, however, I have  found  invariably suppressed  in the
worst cases ; in others, arrested after it  had occurred.  The urine appears
generally diminished in quantity.   The  mental functions are but little dis-
turbed till towards the termination, when it is not  uncommon for the patient
to  be partially or temporarily delirious, but never violent.   In many cases
there is a peculiar nervous hurry, an excitement of  manner, with tremulous
movement of the features and hands.  In most cases she is greatly depressed
and fearful, anticipating  an unfavorable  result; in some  few others I have
known the hope of life vivid to the end.  A patient I saw lately prognos-
ticated  her speedy removal to the  drawing-room  an hour before her death.
It is veiv remarkable, that in most cases the natural affections  of a mother
seem perfectly quiescent, the  patient rarely asking after, or manifesting any
interest in, her child after the disease has fairly  set in.
  In the epidemic described by Dr. Joseph Clarke, he says, that " It always
  1  On Pregnancy and Labor, etc.,  volume on Diseases  of Women, published by the
Sydenham Society, p. 419. 
584
MALIGNANT  PUERPERAL  FEVER.
began with a distinct chillness or shivering.   The  pain in the cavity of the
abdomen was not  more frequent in one part than in another, nor  was the
tenderness  so  great as  to  be much affected by such  trifling causes as the
pressure  of the  bed-clothes.   Little or  no  vomiting  appeared in any stage
of the disease, no  delirium, and no unequivocal marks  of putrescency in any
part of the system.  The pulse in general beat from 120 to  140 strokes in a
minute.   The lochial discharge and secretion of milk were not subject to any
general law.   Sometimes they continued regular for a  short time, and some-
times they  were  suppressed from the beginning."1
   Dr. Douglas has thus sketched this form of puerperal fever as it appeared
in the Dublin Lying-in  Hospital  in 1812 :—" The sensorium here is seldom
in any degree  disturbed, whereas in the other varieties  it is so  frequently,
and even sometimes is excited to high delirium.   The  pulse  here  is usually
from the moment of attack soft, weak, and  yielding, and in  quickness often
exceeds  160 ; whereas  in the first species  it is  full, bounding, and incom-
pressible ;  and in  the  second, small, hard, and incompressible, and  in both
moderately quick.   The eye, instead of being suffused with a  reddish or
yellow tint, as in  the others, is  here  generally pellucid, with dilated pupil.
The countenance,  instead of  being flushed, as in the others, is here pale and
shrunk, with an  indescribable expression of anxiety, an expression altogether
so  peculiar that the disease could  on  many  occasions be  pronounced or
inferred from the countenance alone.   The  surface of the body, instead of
being, as in the  others,  dry, and of a high pyrexial heat, is  here usually soft
and clammy, and of a heat not above the natural temperature ; and not only
is the skin  cool,  with clammy exudation, but the  muscles, to the impression
of the finger, feel  soft  and flaccid, as if deprived of the  vis  insita by the
influence of the contagion.  Indeed, there  is  such prostration of strength
and depression of the vital principle from the very outset of the 'attack, that
I must suppose  the contagion to act upon the human frame probably through
the influence of  the nervous system," etc.2
   Dr. Gooch  found that  " the cases which  were so numerous in these  un-
healthy seasons  had the common symptoms and  course  of  puerperal  fever.
They began a few days after delivery ;  the leading symptoms were, diffused
pain and  tenderness, with  some swelling of the  abdomen, a quick  pulse,
which was  generally at  first full  and vibrating.  Sometimes it was small, but
still it was hard and incompressible ; the skin was hot, though not so hot as
in other  fevers ; the tongue was white and moist;  the milk was suppressed.
As  the disease  advanced, the belly became  less painful, but more  swelled,
and the  breathing  short;  towards the  end, the pulse  was very frequent and
tremulous, and the skin covered with a clammy sweat; even  in this state the
tongue continued  moist and  the  mind clear, and death took place generally
about the fifth day."3
   In the epidemic which appeared in Paris, in 1838, M. Voillemier describes
the typhoid form  as beginning with a  long  and severe rigor, often  a  few
hours only after delivery ;  pain very intense over the whole abdomen, which
rapidly became  swollen;  pulse  feeble,  compressible,  and undulating, often
150 ; respiration hurried, anxiety extreme, severe frontal headache ; counte-
nance sunk, pale,  and  covered with a  clammy sweat; constant vomiting of
green matters ;  purging, stools foetid.   The patients rapidly sank at the end
of a few days, or even hours.  There was no regularity in  the condition of
either the  lochia or milk.*
   Dr.  Copland  thus sums up the characteristics of the attack: "-Whatever

              1 On Puerperal Fever.  Sydenham Soc, p. 355.
             2 Dublin Hospital Reports, vol. iii.  p. 154.
             3 On the More Important Diseases of Women, p. 40.
             * Journ. des Connoiss., M6d.-Chir., Dec. 1839, Jan. 1840. 
MALIGNANT  PUERPERAL  FEVER.
585
may be the period or mode of its accession, this variety of the disease always
pursues a rapid course,  and unless early arrested by energetic means,  it
almost always tends to general contamination of the fluids and  structures,
and to death.   At the commencement, the nervous system  of organic life
and the blood appear to be suddenly and seriously affected, as shown by the
general loss of vascular tone and of sthenic action, by the  disturbance of all
the vital functions, and relaxation  of contractile parts.  The earliest symp-
tom is often the remarkable rapidity of the pulse, which is also  broad, open,
soft, or fluent; or small,  thready  or irregular,  but always very quick  and
compressible.   Rigors and chills are generally absent; or if they have been
present, they  are either slight  or  of short  duration.   In  the  most rapidly
fatal cases, or such as arise in crowded or close lying-in  wards,  they rarely
occur ; and in these the disease  may  be  complicated, or  present no promi-
nent  lesion  or  affection; the  whole frame  participating in  the  malady,
through the medium of the organic, nervous, or vascular systems; or if any
 prominent lesion appears, the peritoneum  or  other shut cavities must fre-
 quently experience it, and present  the appearances hereafter to be noticed."1
   I have  quoted  thus largely from different authors, to show,  in the first
 place, that we are not to  expect any absolute regularity of symptoms, which
 will vary, not merely according to  individual peculiarities, but also accord-
 ing to the peculiar character of the epidemic, which may differ each year,
 and which certainly does differ in different cities : and secondly,  as illustrat-
 ing the broad fact that the disease has a constitutional rather than a  local
 ongin.   The most invariable symptoms are, the typhoid  character,  the vital
 depression, the quick weak  pulse, suppressed milk, and  disordered lochia;
 and I have seen more than one patient die without a single other symptom ;
 neither pain, nor tenderness, nor  swelling of the abdomen  or its  contents.
 Of course, in most cases other symptoms are added, such as I have already
 enumerated ; but I feel it important to impress upon  my junior readers that
 the disease is to be judged by the character of the symptoms present, and
 not by their number nor  by the amount of  suffering.
    The disease advances with varying rapidity, and in its  progress the symp-
 toms increase and assume a more fatal character.   The  heat  of skin is not
 augmented  but the surface is  pallid, clammy, and assumes a dirty color, with
 dark circles about the eyes.   The pulse becomes quicker, smaller, and weaker,
 and towards the end, irregular and intermitting.   The respiration is rapid,
 irregular and often sobbing ;  the tongue moist, sometimes clean, but gene-
 rally loaded  with a  whitish  or yellowish  fur, indented  by the teeth, and
 tremulous.   Occasionally, though rarely, it  is dry and brown,  as in typhus
 fever    The nausea  and vomiting  may  increase or diminish, and  there
  are frequent eructations, of bad  flavor.   The abdomen becomes very tense,
  with constant, or more commonly irregular, stings  of  pain, with  heat,  or
  general tenderness.  The patient may either suffer from  intense restlessness,
  anxiety or lie in a  semi-torpid state.   The mind gradually becomes apathe-
  tic and indifferent, and  the patient may either gradually  and quietly though
  rapidly,  sink,  or dissolution may  be preceded  by  restlessness, dyspnoea,
  lividity of countenance,  etc.                                       •.
    Dr John Clarke mentions two symptoms worthy of notice,  but which 1
  think'are by no means common : — " In some  instances  aphthae will appear
  over the  whole internal surface  of the mouth and tongue  the hard and soft
  palate the  uvula, tonsils, and pharynx, so that they will  all become perfectly
  white and ^welled   The irritation  from this cause produces a  constant dis-
  nosition to^cou-h,  which is also partly occasioned by the secretion  of a thick
  mucus about the pharvnx,  which chokes  up the trachea, keeping  up  a per-
  petual difficulty of breathing.  In some instances similar aphthous appear-

                  i Diet, of Practical Medicine, part xiii., p. 520. 
586
MALIGNANT PUERPERAL  FEVKR.
ances will be found about the anus."   "In some instances purple spots have
appeared before death, as in petechial fevers, probably depending either on
great weakness of the vessels, which allows the fluids to escape into the cellu-
lar membrane, or upon some alteration in the state of the fluids themselves,
by reason of which they are not so easily retained, or partly on  the one, and
partly on the other."
  832.  The local  symptoms will vary very much,  according  to the part
principally affected ;  for  I  believe  that any of the  forms of local disease,
already described, may be found complicating this low childbed fever.
  1.  In some  cases,  there are absolutely no symptoms indicating  abdominal
disease.  Neither  pain, tenderness, nor distension is present.  In a ease I
saw, to which  I have referred, although the symptoms were  of the worst
kind, the only local symptom up to death was inflammation of a  small branch
of varicose veins of  one leg, which was soon much relieved.
  2.  Peritonitis appears to  be the most frequent local affection, judging from
the descriptions of the different epidemics ; but  the practitioner would be
greatly deceived who expected it to present the acute and well-marked symp-
toms usual in the ordinary cases of that disease.  All the local characteristics
are, if I may be allowed the  phrase, muffled. There may be pain, even severe
pain, but it rarely amounts to the agony we wituess in idiopathic peritonitis;
very often it is but slight,  and in paroxysms, diminishing as the disease ad-
vances ;  and in two or three cases, in which  I found after death universal
peritonitis, there had been neither pain nor tenderness.
  3.  If the inflammation chiefly or solely occupy the womb or its appendages,
there may  be a good deal of pain, tenderness,  and enlargement;  or it may
be slight and obscure, and only to be detected  by a careful and minute ex-
amination.  In the  latter cases, I have  most commonly detected a tender
spot on the one side or other of the body  of the uterus, and sometimes even
when  there has been no  perceptible  enlargement, and no tenderness  when
the uterus  was generally pressed.
  4.  In some  of the worst  cases I have seen,  presenting the most  marked
typhoid character, with apparent freedom from  local disease and running the
most rapid course, the only  local lesion was uterine phlebitis, sometimes ac-
companied with tenderness on pressure at  the  sides of the uterus, but very
often without  pain or tenderness.   But in such cases the disease is too quick
in its course for the secondary characteristic lesions to show themselves, and
therefore during life we can only assume  the  probability of venous or lym-
phatic inflammation.
  In general,  subject to the modifications I have  mentioned, the local  affec-
tions  will  present the symptoms and characters  I  have already described
under the  several heads ; and I repeat that, in the low malignant childbed
fever, we may find any of these local  affections, or  even  two or  more com-
bined.
   833. The duration of  the disease  varies much.  In  certain  epidemics,
cases  have ended fatally in twenty, twenty-four, or thirty hours  from their
commencement;  generally speaking,  however,  the final termination  is most
frequent from the third to the fifth day.   Dr. Collins thus enumerates the
periods of the commencement and termination of the cases he has recorded :
— "Of eighty-eight cases that occurred  during  ray residence,  one  had the
disease well-marked before  delivery ;  one was attacked in six hours ; one in
nine ; one in ten ; three in  twelve ;  one in  thirteen ; one in fifteen ; two in
seventeen ; one in  eighteen ; one in twenty ;  one in twenty-one ;  and two
in thirty hours from delivery.   Thirty-two were  attacked on  the first day;
twenty-nine on the second ; eight on the third  ; two on the fourth, and one
on the eighth day.   The  disease seems to run its  course with great rapidity
in most instances.   In fifty-six deaths in the hospital,  it proved fatal at the 
MALIGNANT PUERPERAL FEVER.
587
following periods after the date of the seizure : viz., two in twenty-four hours ;
one in twenty-seven;  one in thirty-six; nine on the second day; fifteen on
the third ; thirteen on the fourth ;  four on the fifth ;  five  on  the sixth ;  three
on the seventh;  two on the eighth, and one on the eleventh."1
  834.  Pathology. — Morbid Anatomy. —I must refer my readers to the
foregoing  sections  of this  chapter for a description of the  peculiar morbid
appearances observed in the different  species of local affection, peritonitis,
hysteritis, phlebitis, etc.; but in this malignant  form there is  in addition,  as
Dr. Copland has observed, an impaired cohesion of the tissues generally, and
more or less of a turbid serous effusion into the serous cavities. He mentions
also that in several cases in which bloodletting had been practised, " on every
occasion I was  struck by the peculiar faint odor and very dark hue of the
blood ;  by the very soft  state of the clot when  the blood did separate into
crassamentum and serum ;  by the appearance which occasionally presented
itself, of a mass exactly  resembling in color and consistence a common jelly,
the coloring matter covering the bottom of the  vessel in the  form of a pre-
cipitate ;  and  by,  in  some instances, a slight separation only of serum, the
large,  loose, gelatinous  crassamentum,  consisting   chiefly  of this jelly-like
matter, the lowest stratum of which  contained the black or dark-brown pre-
cipitate of coloring matter.   These appearances of the blood  were presented
in several cases in the hospital, in 1823 and three or four  subsequent years,
in which cases blood  had been taken before I saw the patients.  It may here
be remarked that I have seen many cases of this  form of the disease, in which
leeches had  been applied to the abdomen ; but  in nearly all,  and especially
in  those which  occurred in  the hospital, the blood which flowed from the
bites did not coagulate ; and great difficulty, almost amounting to an im-
possibility,  of  arresting the  bleeding  from  them,  was  generally  observed,
 owing both to  the state  of this  fluid, and to the impaired vital cohesion of
the tissues  characterizing the advanced stage of the malignant form of this
 domestic  pestilence."2
   In a former  section of this chapter,  I have adduced  other evidence of an
 altered state of the  blood,  and judging from all the evidence we possess, I
 am inclined to believe  that  the  pathology of  this malignant form  of the
 disease consists in a depravation of the circulating fluid, either from absorp-
 tion of noxious matters, or  from inflammation of the veins, or from both
 combined, and  accompanied by a diminished cohesion of  the tissues generally.
   835. Causes. — I have  already  enumerated every imaginable  cause, I
 think,  to  which puerperal fever has  been attributed, and I need not now re-
 capitulate them.  I shall merely observe, that a natural and  easy labor does
 not necessarily preclude an attack, nor does a considerable loss  of blood
 confer any immunity; on  the contrary, when the disease  prevails, whatever
 depresses the system seems to favor its production.  It is chiefly when  the
 disease is epidemic  that we see  this  low and malignant form, and a know-
 ledge  of this fact, and of the coincident prevalence  of erysipelas, should put
 practitioners on their guard, and induce tenfold more care and watchfulness
 than usual.   Nor although  the  more numerous cases  occur in hospital  or
 dispensary  practice,  are we  to anticipate an immunity in private practice.
 During the epidemics in this city, there have been several cases among  the
 richer classes, which proved fatal.   And in the more recent  epidemic, the
 prevalence  of the disease  among the  better classes has been still more re-
 markable.  In  addition, I have  remarked that during  an  epidemic, even if
 the disease do not  appear in  private, lying-in women do  not recover as
 frankly as usual.
   I have already said enough about contagion,  and earnestly cautioned those

                 1 A  Practical Treatise on Midwifery, etc., p.  382.
                  2 Diet, of Pract. Med., part xiii. p. 523. 
588
MALIGNANT  PUERPERAL  FEVER.
engaged  in  practice to adopt every possible precaution to avoid being the
agents in spreading it.  It would  surely be a life-long sorrow to feel that a
patient had  been sacrificed to our carelessness.
  836. Diagnosis.—There can be no difficulty in distinguishing this disease
from every other ;  its occurrence soon after delivery, the alarming nature of
the symptoms, and their rapid progress, are unlike any other affection.
  1. Weid will sometimes commence very severely, and excite  our anxiety;
but in general it is later in its commencement, more acute than low childbed
fever in its symptoms, and comparatively evanescent.
  2. The ordinary sporadic puerperal fever  is more acute, and with more
prominent local symptoms ; there is nothing like the low typhoid character
of malignant puerperal, except in uterine  phlebitis;  and  if the latter be
rapid in its  progress, the two forms of the disease are similar in  symptoms,
and run a nearly identical course.
  837.  Prognosis.—It is scarcely possible to conceive a disease in which
the prognosis is more unfavorable than in a severe  case  of low malignant
epidemic  puerperal fever.   Dr. John  Clarke states,  that according to  his
experience,  about  three-fourths die, and I do  not believe  this to be above
the average.   Of  course, some  epidemics  are  milder  than  others, and a
larger proportion recover; in others, almost all fall victims.  "The danger,"
says Dr. John Clarke, "seems to be greater in proportion as the accession
is sooner after labor.   Those who have had the disease  at a  later period
have not been attacked with the same violence ; the  depression of strength
has been less considerable, the tumefaction  of  the  abdomen less extensive,
and their chance  of  recovery  has been, consequently, better.   It  has not
occurred in  my sphere of observation to see  any recover in whom the  swelling
of  the belly has been in  any great degree.   Indeed, it is hardly possible,
when we  consider the  great injury which all the contents of  it must  suffer
from  the  effusion  of extraneous matter poured  into the cavity, as  will be
hereafter  described."
  The  unfavorable  symptoms are, a pulse of increasing  quickness and
diminished  strength, suppressed secretion of milk and lochia, foetid lochia,
nervous agitation, rapid, high breathing, swollen abdomen, diarrhoea, sunken
countenance, clammy skin, exhaustion, etc.
  On the other hand, a slower pulse, quiet  bowels, diminished distension of
the abdomen,  natural  respiration,  and a  warm, moist skin,  with  natural
evacuations, and a continued supply of milk, are very favorable symptoms ;
but no improvement in  any symptoms  can  be considered satisfactory unless
the pulse  becomes decidedly slower, fuller,  and more steady.
  838.  Treatment.—If,  by the treatment of low puerperal fever, we  are
supposed  to mean such remedies as afford a reasonable hope  of cure in the
majority of  cases, I  must frankly avow that I know of no such remedies.
As Dr.  John Clarke observes, "This disease is less obedient to  the power
of medicine than almost any which I know.  Its attack  is so very insidious,
and often entirely unperceived, and its fatal termination is often so  sudden,
that the time when  medicine  could be useful has often elapsed before  it has
been even known  that  the  disease existed at  all."   I am satisfied that if
active  treatment be at all efficacious, or even  justifiable, it must be within
the first twelve hours—and how rarely do we  see a patient so  early ? nay,
in many cases I should doubt if very active  treatment  is ever justifiable.
Thus, if bleeding  be ever allowable,  it must  certainly be within the first
twelve hours ;  but in the majority of cases I have seen, it was not admissible.
Drs. Gordon, Armstrong, and others, no doubt, have  spoken highly of the
effects  of early and large  bleedinirs ;  but, so far as I  can judge, the disease
was of an acute  inflammatory character.  Dr.  John Clarke gives the result
of his  experience  in  these words: " In the first place, then, let me  caution 
MALIGNANT puerperal  fever.
589
(especially younger) practitioners not to be misled by the tumefaction of
the abdomen, so as to employ the lancet with  the  expectation of curing a
supposed inflammation.  Bleeding from the system has been always attended
with manifest disadvantage, although it has been tried in  patients who have
been apparently strong and plethoric before.  It has in some instances, for a
short time diminished the pain, and the buffy appearance  on the blood taken
away has been  supposed to justify the  operation ;  but it generally lowers
the patient  extremely, and in some cases I have known  it evidently hasten
death.   Bleeding from  the skin of the belly by leeches, though it do  not
produce  the same degree  of debility, yet has in no  instance,  within  my
knowledge,  contributed in any  degree  to the cure of the patient."   He
equally objects to blistering the abdomen; but from the  cases I have seen,
I am inclined to think it useful, and it affords an  opportunity of  applying
mercurial ointment to a highly  absorbent surface.
   Mr.  Norris has lately tried the application of the tincture  of  iodine over
the abdomen, both in the sthenic  and asthenic forms of puerperal fever,
 and from his testimony to its success I should be  anxious to give it a fair
trial.1
   M. Doulcet's plan of emetics  seems to have failed in producing the bene-
 ficial results he expected.  Dr.  Copland tried it, but it did not succeed, and
 in Dr. John Clarke's hands it was disadvantageous.
   Calomel, in  small or large doses, with or without opium, seems to be our
 sheet anchor, especially if we see the patient early.   I have seldom found  it
 possible to give it  in  large doses, in  consequence either of the  existing
 intestinal irritation,  or  of' the  irritation produced  by it;  so that I  have
 generally given it in doses of one or two grains of calomel,  with  one-third
 of a grain of opium, or two or three of Dover's powder,  every two, three, or
 four hours.  At the same time I must candidly confess that, latterly espe-
 cially I have not found mercury to exert so decidedly beneficial an  influence
 upon'the  disease, and it has frequently  aggravated the suffering  by occa-
 sioning diarrhoea.  Can it be  owing to the  changed type  of  the disease,
  just as we find  blood-letting, formerly  so  useful,  now  impracticable or
 injurious?   Dr. Copland derived more benefit from the larger doses of
 calomel and  opium, every five  or six hours, with  a dose of  turpentine and
 castor oil.  He  also tried "the effects  of camphor in large doses, m con-
  junction with  calomel and opium, or with quinine  and capsicum, omitting
 the calomel,  aided  by the turpentine, and  preceding them  by an emetic,
 when its use was indicated by the symptoms."  If the diarrhoea be trouble-
 some, the calomel must be omitted, but mercurial inunction may be substi-
 tuted, and  I have found the  linim hydrargyri of the London Pharmacopoeia

 ^Dr" John Clarke's  plan was  to give bark, in powder  and  decoction, with
 opium,  wine,  fomentations to  the abdomen, etc.  Jn some cases a gentle
 emetic was given, and emollient or anodyne clysters if diarrhoea were present.
    The spirits  of turpentine seems to be  of use in some cases but certainly
 not to the  extent supposed by Dr. Brennan    It forms an admirable  fomen-
 tation to the abdomen when blisters are not used, and if the bo jel^e con-
 fined, is a  useful  addition to castor oil, as a purgative  giver, ei her^ by the
 mouth or as an enema.  It  may be given in doses of from two drachms^ o
 half an ounce, once or twice a day, but it is  so disagreeable to the  stomach,
 that after a few doses patients frequently refuse to take  any more
    Manv remedies which have  been found beneficial m  the  other and  more
 locd  forms of puerperal fever, seem to be of little or no use in this variety,
 so that our means of treatment seem  reduced to  leeches,  at  a very  early

                     i Med. Times and Gaz., Dec. 11th, 1852. 
590
PHLEGMASIA DOLEN'S.
period;  fomentations or  blisters  to the abdomen ;  calomel and  opium,
camphor and turpentine, wine, and other stimulants.
  From  the  asthenic or typhoid character  of this disease, and the atmos-
pheric constitution during  which it prevails,  I feel myself  inclined to antici-
pate  more favorable results  from  a treatment  resembling  that of other
typhoid affections.   It is true, that bark, given in the  Dublin  Lying-in-Hos-
pital, did not succeed, but  yet I should be inclined to try it in  such cases as
I have described, and we have the testimony of Dr. John  Clarke, and Low-
der,  and  others in its favor.
  I have no doubt whatever of  the  propriety of keeping up the strength by
the timely administration  of nourishment,  and  of the exhibition of wine
much earlier and to a more liberal extent than has been usual.  In truth, the
type  of  disease  generally  and  equally  of puerperal  diseases has so much
changed   of late  years,  that instead  of  the antiphlogistic treatment,  which
was  undoubtedly succeseful,  we must  substitute  a different, and in  some
respects  an opposite, treatment, to be equally  successful at present.  Atten-
tion to this  change of type  will explain the success  ol  different remedial
measures, and is absolutely necessary to the  scientific practice of our  pro-
fession.                               -
  When  the disease occurs in hospitals, the patient should be  separated
from all others,  with  separate  attendants,  and  the  greatest  cleanliness
observed.  Before the  ward  is  again used, it should be well scoured and
ventilated, the bedstead scoured, the bedclothes washed, and the bed washed,
or burned, which is better.
                      C HAP  TER  XXVI.

           PHLEGMASIA  DOLEXS. —CRURAL PHLEBITIS.

  839. This disease, under various  appellations,—anasarca serosa, buckne-
mia sparganosa,  phlegmasia  lactea,  oedema  lactium, milk  leg, white  leg,
swelled leg,  etc.  etc.,—has been long known  to  the profession,  although
there has been, and still is, much  difference of opinion  as to its exact nature.
It was described  by Roderick a  Castro, in 1603, and  subsequently by Mau-
riceau, Puzos, Levret, Petit, Leake, White, Hull, Trye, etc.   It consists in
a colorless swelling  of one  or  both  legs (simultaneously  or successively)
shortly after delivery, with pain, tenderness, and  fever,  lasting a  certain
time, and  running a  pretty definite course.   The  left leg is  far more fre-
quently affected than the right, although it is not easy to account for it.
  It may occur with first  children,  but it is more frequent after subsequent
deliveries.  Women  of a delicate  constitution  or lymphatic temperament are
said to be the most liable to its attacks, and especially those who suffer from
any uterine irritation after delivery.  It not unfrequently follows  extraction
of the placenta, as in Mr. Chatto's case.1  Women who have suffered from
it once are very apt  to have a slight return of it after the next confinement,
without any repetition of the cause.   I  have a patient  in whom this occurred
several times, each time in a slighter degree.
Med. Gazette, Sept. 14tb, 1839. 
PHLEGMASIA DOLENS.
591
  It may commence at any period after delivery, and the time makes a con-
siderable difference in  our judgment  of the case,  according  as it begins
before or after the  sixth day.   Of twenty-two cases observed by Dr.  R. Lee,
seven were attacked between the fourth and twelfth  day, and fourteen after
the second week.   Levret mentions its occurrence on  weaning the child;
and Dr. Blundell,1  that in  "some rare instances it makes its appearance even
months after delivery."
  But it is not necessarily or exclusively a "post-partum" disease, and as it
has an  important bearing  upon the correct pathology of the affection, I may
be excused for entering into a little detail upon this subject.  The  earliest
writer who mentions its occurrence unconnected with parturition is, I believe,
Puzos, who relates two cases of pregnant women, one of four, and the other
of seven  months, in whom it occurred.  Dr. Meigs says that he has met with
many examples of phlegmasia dolens in pregnancy.   Denman, Burns, De-
wees,  M'Clintock, etc., mention its  occurrence after  abortion, especially
when a portion of  the  ovum has been  left behind.   Drs. Willan and  R. Lee,
Mr. Lawrence, Drs. Copland and Dewees, have recorded cases which occurred
in patients laboring under malignant ulceration of the cervix uteri.  Dr.
Blundell has  met  with the disease in connection  with malignant  fungous
growth from the same  organ.   Dr.  Copland  relates a case consequent upon
hysteritis, in a lady who had  not been pregnant for  some years.  The attack
has also followed suppression  of the menses by cold, as in the cases related
by Tommasini and Boulogne, Dr. R. Lee,  and Mr. M'Clintock.   Again,
there may be  no disease or disorder of the womb or its functions, as in the
cases of phlegmasia dolens accompanying dysentery related by Dr.  3!ayne ;
 and  lastly, it  may occur  in the upper extremity,2 or in a well-marked form
 in the male sex.
   840  Symptoms. — As  we  have  generally to do with the disease as  it
 occurs in women who  have suffered from  irritation or inflammation of the
 womb, it is not  surprising that the ordinary premonitory symptoms should
 commence with pain  or uneasiness in the lower part of the  abdomen, ex-
 tending  along the brim  of  the  pelvis.   I have seen this  pain extremely
 severe, like an exaggerated after-pain, and lasting for some hours.   In some
 cases  there is a well-marked or imperfect rigor, in  others nothing of the
 kind.   The patient is  irritable, depressed, and  complains of great weakness,
 headache, and thirst.  Dr. Denman remarks that,  "Before the appearance
 of any swelling or sense  of  pain in the limb  about  to be  affected, women
 become  very  irritable, with  a sense of great weakness, and grievously op-
 pressed in their spirits, without any apparently sufficient reason ; complaining
 only of transient  pains in the region of the uterus,  and  from these the
 approach of  the  disease  has frequently been foretold.   After a short time
 they are seized with an extremely acute  pain in the calf of the leg, extending
 to the inside  of the heel,  and then, observing the course of the lymphatics,
 stretching up to the ham, along the internal  part of the thigh, to the groin,
 occasioning a slight soreness  on the lower part of the abdomen."3
   Sometimes, however, there are no precursory symptoms, the patient being
 suddenly seized with pain in the calf of the ieg;  or it may commence like
 rheumatism,  affecting  the back and hip-joint;  as Dr. Burns has remarked,
 " Sometimes  there is no uneasiness  in the belly, and the first  symptom  is
 sudden pain in the calf of the leg.  Within twenty-four hours after the pain
 is felt, the limb swells, and becomes tense  ; it is hot, but not red—it  is rather
 pale, and somewhat shining.  The swelling sometimes  proceeds from the
 "•roi'n downwards ; but in most cases it is first perceptible about the calf  of
 the  leg, and   proceeds upwards.   It is generally followed by an  abatement,
         i Obstetricy, p. 785.        2 Dr. Winn, Med. Times, Aug. 14th, 1852.
         3 Introduction, p. 506. 
592
PHLEGMASIA  DOLENS.
but not a cessation of  the  pain.   Sometimes the disease begins  like rheu-
matism, affecting the back and hip-joint.  Then the upper part of the thigh
becomes painful and swelled, and next the calf of the leg suffers;  sometimes
the limb at first feels colder than the other."1
   When the disease begins in the pelvis, the  pain speedily extends  below
Poupart's ligament down the thigh, to the ham, calf of the leg, and foot.  It
is  constant, but occasionally remitting, and not much relieved by posture,
though a depending position materially increases it.   Shortly after the com-
mencement, the inguinal region is tumefied and tense, and in a day or two
the thigh becomes swollen, tense, white, and shining.   This swelling may be
confined to the  thigh, or extend to the heel, and it will vary much in amount;
occasionally, the  leg  is enormously increased in size.   When  the  pain
originates in the back  and  hips, the nates and vulva become swollen, glassy,
and tense.   When the  disease commences in the calf of the leg, the swelling
is  first observed there or at the ankles, gradually extending itself  up the leg
and thigh.   The temperature of the limb is generally increased,  though in
rare cases  it is below the natural standard.   At the commencement and
decline of the disease,  the limb pits upon pressure ; but when the distention
is  very great, it does not.   Just as Dr. R. Lee  has described: — "In several
well-marked cases, however, of crural phlebitis at the invasion of the disease,
the impression  of the  finger has remained  in different parts of the limb —
more particularly along the tibia; but as the  intumescence has increased,
the pitting upon pressure has disappeared until the acute stage has  passed
away.   At the  onset of the disease I have also observed in several cases a
diffuse erythematous redness of the integuments along the inner part of the
thigh and leg."
   In most cases the femoral vein  may be traced from the groin down the
thigh,  feeling hard, and rolling under  the finger  like a cord.   Of course,
this is  not the case when the attack is limited to the leg.   There is a degree
of tenderness over the entire limb,  but it is very marked along the course
of the inflamed vessel; generally there is neither redness nor discoloration,
but  in  some few cases a faint red streak may  be perceived.   The inguinal
glands share in the irritation,  and may be  swollen and hard ;  in some rare
cases they suppurate ;  and according to Dr. Burns, mortification has taken
place, and  amputation been  necessary.2  Abscesses  may also  form in the
cellular  membrane.  Either  leg may be affected;  but,  as I have already
observed, the left is more frequently attacked ;  and it not uncommonly hap-
pens that the sound leg participates in  the  disease before the  other is per-
fectly well, and then the disease  runs a similar course a  second time.  Mr.
Sankey observes, " Most of my patients have had both legs affected, though
not at the same time ;  but after going  through the process Dr.  Wynn has
described in on,e, the other becomes  affected ;  and unless prevented by the
application  of blisters, goes through the same stages, and  takes the  same
time as the  first."3  In the cases of double attack which I have seen, the
second  limb was certainly  more slightly attacked  than the first; although
this does not accord with  the  great experience of Dr. Denman,  who found
the second as severe as the first.4  I have already stated  that patients who
have suffered from phlegmasia dolens after one  labor,  are very liable to have
slighter returns, without apparent cause, after the next labor.  When once
the swelling takes  place, the  limb becomes useless;  the  patient can neither
bend it nor place it on the ground.
   The constitution, as might  be  expected, suffers considerably during the
attack : the pulse becomes quick (from  100 to 140) though weak,  the tongue
white and coated,  the thirst considerable, the countenance pale, the appetite
  1 Burns, Midwifery, p. 609.                  2 Midwifery, p.  609.
  3 Ed. Med.  and Surg. Journal, vol. x. p. 102.   * Introduction to Midwifery, p. 507. 
PHLEGMASIA DOLENS.
593
lost, the bowels deranged, and the urine turbid.  The patient is restless, and
generally sleepless.1  In very severe cases  there is more  or less tenderness
above Poupart's ligament and  at the side  of the uterus, the lochia may be
diminished or deranged, and the internal genitals are tender.
  With this account of symptoms, commencing perhaps with a rigor or chill,
followed by pain in the abdomen, pain and  swelling in the thigh and leg,
quick pulse, etc., the acute stage may continue, for one, two, or three weeks,
when the more formidable  symptoms having subsided, the patient is more
comfortable, and the disease takes  on a more local character.   Dr. Stokes
has remarked that the greater the swelling, the  less formidable and more
local the disease.
   841.  Terminations.—1.  The disease  may, and most  frequently does,
terminate in resolution ; the general symptoms  gradually subsiding, the dis-
 ease becomes local; and after five or six weeks the swelling diminishes, the
 tenderness  disappears, the  general  health is restored, and  by slow degrees
 the patient  recovers the use  of her limbs.   It is long, however, before the
 affected leg entirely loses its wooden feel, and attains its natural power of
 motion and sensation.
   2.  The subsidence may be still more  gradual, the limb continuing swollen,
 with an occasional increase of the tumefaction for months, the patient having
 imperfect sensation in it, and  imperfect command over it.   In such cases I
 have noticed a dense, thickened feel of the skin,  or subcutaneous cellular
 tissue • and in one or two cases the patient had an attack  of cutaneous in-
 flammation, resembling large hives (Uticaria), which  lasted for  a few days,
 and  was somewhat  painful,  but then  disappeared.   The  veins  sometimes
 remain varicose,2 but I  should hardly think that this is  the  effect of  the
 disease  ■ It is more likely to have been the effect of the previous pregnancy.
   3  Suppuration may take  place, even to such  an extent as  to supersede
  and change the character of the original disease, and even to threaten  death
  from exhaustion.                                                . .
    4  Death may occur,  either suddenly, perhaps  on the  patient raising her-
  self  in bed • or more gradually,  from exhaustion,  from paralysis,3 or  from
  some of the 'secondary diseases consequent on phlebitis.   Dr. Burns observes,
  " This is not generally  a fatal disease, but it is tedious, and often  accompa-
  nied with hectic symptoms.  Death, however, may be caused by suppuration
  or gangrene; or by exhaustion, proceeding from  the violence of the consti-
  tutional disease ; or by exertion made  by the patient, which has sometimes
  suddenly proved fatal; or, after the leg  appears to be  getting better  daily
  shivering with vomiting, pain in other parts, and rapid pulse, with delnium,

  ^842^ Morbid Anatomy.—1.  On opening the limb it is found to be dis-
  tended with serum, effused into the cellular membrane
    2  The vein is found to be obliterated in some part of  its course by clots
  of blood firmly adherent to its parietes, which are thickened ; its inner mem-
  brane is of a deep red  color,  the result either of staining or of inflammation
  -mos  probably the latter.   A layer  of coagulable lymph is sometimes found
  lin^ the different vessels, and they have been observed to contain purulent
  matter   The veins which have been  found to part cipate in  these changes
  are the  femoral the external, internal, and common iliacs  of either side ; the
  £i^*™£™*te. circumflexa ilii,  the uterine, vaginal, and saphena veins,

  a1.thEvIdeenaceCsa^inflammation of the absorbents have been found in a con-

            ,,-j  •<•    ^ ror                 2 Lee on Diseases of Women, p. 119.
    1 Burns, Midwifery, p. bU».
    3 Todd, Cyclop, of Pract. Med. Art. Paralysis.
    * Midwifery, p. 609.
          38 
594
PHLEGMASIA DOLENS.
siderable number of cases, and in some, purulent matter  has  been detected,
according to M. Bouillaud.1
  4. M. Duges  has  shown that  inflammation of the nerves  occurs, at least
occasionally, as a complication of this disease.2
  5. Proofs of the occurrence of the  secondary effects  of phlebitis may be
found in different parts, especially in the serous cavities, and in  the forma-
tion of abscesses of the limb,  and even  of more distant parts.
  843.  Pathology — We are now in a condition to inquire into the pathology
of this affection, which has given rise to so much dispute, and to such varie-
ties of opinion.   The older notions on the subject are  mere speculations.
For instance, Mauriceau  considers it to  be owing to a reflux upon the lower
extremities  of certain  matters, which ought to  have been evacuated in the
lochia.3  Puzos4aud Levret5attribute  it to deposits of milk in  the affected
parts (depots du lait) ; and  the  same opinion has extensively prevailed in
these countries, as one of the popular names for the disease (^milk leg) testi-
fies.  With some practitioners it  was customary to keep  the child constantly
to the breast, to prevent the metastasis when  threatened, or to remove  it
when it had occurred.
  In the year 1784, Mr. White of Manchester, published  an inquiry "Into
the nature and cause of that swelling of one or both of the lower extremities
which sometimes happens to lying-in women ;" and he suggested or adopted
the opinion that the disease  depends on obstruction, or  on some  other mor-
bid condition of the lymphatic vessels and glands of the affected parts.   Mr.
Tyre, of Gloucester, in  an  essay  on  this subject in  1792, attributed the
swelling to a rupture of the lymphatic  vessels, as they cross the brim of the
pelvis, under Poupart's ligament.  Soon after this, Dr.  Ferriar maintained
that there is a general inflammatory state of the absorbents  in this disease.
Dr.  Hull (1800) considered the  proximate  cause  of this disease to  be an
inflammatory affection, producing suddenly a considerable  effusion of serum
and coagulable  lymph  into  the  cellular  membrane of  the  limb.  All the
textures — muscles, cellular membrane, lymphatics,  nerves, glands, and blood
vessels — he supposed to become  affected.
  So far the  opinions were  a mixture of theory and observation, without
any attempt to base them upon pathological research.   The first light thrown
upon the subject by a post-mortem examination, was by Dr. Davis, Professor
of  Midwifery in University  College,  London,  who in  1817 examined the
conditions of the veins in a  patient who had died with the disease, and found
that they were the seat of extensive inflammation.   The  dissection is as fol-
lows : — " March 6th, 1817. —The left lower extremity presented  an uniform
oedematous enlargement,  without  any discoloration, from  the hip to the foot.
This was found, on further examination, to proceed  from the ordinary ana-
sarcous effusion into  the cellular substance.  The inguinal  glands  were a
little enlarged, as they usually are in a dropsical limb,  but pale colored, and
free from the slightest sign of inflammation.   The  femoral  vein, from the
ham upwards, the external iliac  and the common iliac  veins as far as the
junction of  the latter with  the corresponding trunk of the right side, were
distended and firmly plugged with  what appeared  externally a coagulum of
blood.   The femoral portion  of the vein, slightly thickened in its coats, and
of a deep red color, was filled with  a firm bloody coagulum, adhering to the
sides of the tube, so that it could not  be drawn out.   As  the red color of
the  vein  might have been caused  by the red clot everywhere in close contact
with it, it cannot be deemed a proof  of inflammation.  The trunk of the
profunda was distended in the same way as that  of the femoral vein; but

    1 Diet, de Med. et de Chir. Prat.   Art. Phlegmasia dolens.            2 Ibid.
    3 Mai. des femmes grosses, vol. i. p. 446.         * Traite des Accouch., p. 360.
    5 L'Art. des Accouch., p.  932. 
PHLEGMASIA DOLENS.
595
the saphena and its branches were empty and healthy.  The substance filling
the external iliac and common  iliac portions of the vein, was like the lami-
nated coagulum  of an aneurismal sac, at least with a very  slight mixture of
red  particles ;  the tube was completely obstructed  by this matter,  more
intimately connected  to its surface  than in the femoral vein ;  adhering,
indeed, as firmly as the coagulum does to any part of an old aneurismal sac ;
but in its centre there was a cavity containing about a teaspoonful  of a thick
fluid of the consistence of pus,  of a lightish brown tint, and poultaceous ap-
pearance.   The uterus, which had contracted to  the usual  degree  at  such  a
distance of time from the delivery, its appendages and blood-vessels, and the
vagina, were in a perfectly natural state.   There was  not  the least appear-
ance of vascular congestion about the organ, nor the slightest distension of
any  of its vessels.   Its whole substance was, on the contrary, pale, and the
vessels everywhere contracted and empty.   The state of the abdominal cavity
and  its contents was  perfectly natural.   That the substance occupying the
upper part of the venous trunk, and the fluid in  its central cavity, had been
deposited there during life, from  inflammation of the vessel, does  not  admit
of doubt.  I am also decidedly of opinion, in consequence  of its firmness,
and  close adhesion  to the vein, that the red coagulum in  the femoral vein
was  the result of a similar affection extending along the tube ; and that the
passage of the blood through it, in the whole tract submitted to examination,
must have been completely obstructed before death."1   He then taught that
phlegmasia dolens resulted  from this cause, and in  May,  1823, published  a
paper with cases and  dissections.2
   In January, 1823, M. Bouillaud  related  several cases and dissections in
which the crural veins  were obliterated in women  who had suffered from
oedema of the lower extremities after delivery;  and M. Bouillaud distinctly
stated that he considered obstruction  of the crural veins to be the cause not
only of the  oedema of lying-in women,  but of many partial dropsies.3  The
date of this paper, although earlier than  Dr. Davis's paper, in  no way in-
terferes with the claim of the latter to be the first who discovered and taught
that phlegmasia dolens is essentially crural phlebitis.  In  1824, M. Velpeau
published some  researches, from which  he  concludes  that  not only the veins
are involved in the inflammation in some cases, but that inflammation  of the
lymphatics is at least as frequent a cause of phlegmasia dolens.4
   In 1826,  Mr. Guthrie hinted that probably the inflammation of the veins
of the  lev: might  be merely an extension  from  the  uterine veins, and Dr.
Robert Lee believed  that he demonstrated this in 1829, by tracing the dis-
eased veins  back into the uterus, and finding there  the disease equally well
marked :  " The left hypogastric or external iliac vein," he  says, "  was in the
same condition, but in some cases reduced to a cord-like substance, and its
cavity throughout completely obliterated.  The branches of this vein, taking
their origin in the uterus, and usually termed the uterine plexus, were found
completely plugged up with firm red coagula."5   More recently Dr. R. Lee
has laid before the Medico-Chir. Society the results of his experience in the
following summary:  the paper contained  the record of forty-three cases of
phlegmasia  dolens.   The first nine cases were accompanied by post-mortem
descriptions and preparations illustrating  the disease ; and  the author was
led  from  the whole of the facts thus adduced, to  the conclusions he had for-
merly expressed " That the inflammation of the iliac and femoral veins gave
rise  to all the phenomena of phlegmasia dolens,  and that  the inflammation
commenced in the uterine branches of the hypogastric veins, and from thence
extended  to the femoral trunks of the affected side."  The next series com-

    i Letter from W  Lawrence, Esq., in Davis's Obstetric Medicine,  vol. ii. p. 1204.
    2 Medico.-Chir. Trans, vol. xii.          » Lee on Diseases of Women p 149.
    ♦Arch Gen de MeU, Oct. 1824.        5 On Diseases of V* omen, p. 131. 
596
PHLEGMASIA  DOLENS.
prised the history of twenty cases, which the author thought furnished addi-
tional evidence in favor of this conclusion, though, in  consequence of the
recovery of the  greater  number  of the patients,  an opportunity was  not
afforded of determining by dissection the actual condition of the crural veins.
Nine  cases  followed,  which demonstrated  that  phlegmasia  dolens  might
occur wholly unconnected with pregnancy and  parturition, and that in such
cases the inflammation likewise commenced in the uterine branches of the
hypogastric veins,  and followed a course similar to what occurred in puer-
peral  cases.  In some of these the inflammation  of the uterine veins  was
produced by cancerous disease of the os and  cervix uteri; in  others there
was no organic disease of any kind previously existing.  The concluding
cases were five, in  which  crural phlebitis had  followed  inflammation of the
saphena veins and of the deep veins of the  lower  extremities, from fracture
of the tibia and fibula, and pressure of encephaloid tumors on the thoracic
viscera.1
  MM. Petit, Gardien, and Capuron regard the disease as inflammation of
the lymphatic vessels and glands.2
  Dr. Burns adds  another tissue as entering into the disease, for he remarks,
"I consider that the nerves are  implicated as much as the veins, and that
whilst  both may contribute, we shall find, in  different  cases,  one or other
predominate."3  I am not aware whether  this opinion was  the result of
post-mortem investigation  or not,  but  it has  since been confirmed by the
researches of M. Duges.   Dr. Dewees agrees with Dr. Hull,  and the able
paper by M. Bouillaud so far confirms  his view, as that, in  his opinion, in-
flammation  of the  symphyses, veins, lymphatics, and nerves, is the proximate
cause of the disease.
  So  far, then, it appears established, 1, that in phlegmasia dolens  there is
inflammation of the veins of the thigh and leg ;  2,  that marks of inflam-
mation are found at the commencement of these veins in the uterus ; 8, that
at least in some cases the lymphatics and nerves are  involved in the inflam-
mation, although probably not in the first instance, nor as a primary  cause.
  844. But still two very important questions  remain : 1, Does the inflam-
mation originate in the crural vein itself, or does it originate  in the uterus,
and extend down  the vein ?   2.  May not the  inflammation of the vein be
owing to some  special condition to which it  is secondary,  as, for instance,
some morbid condition of the blood ?
  In support of the latter view, Dr. Mackenzie read a paper at the Medico-
Chirurgical Society (1853), founded  upon  a series of experiments on  ani-
mals, in which he  tried, 1, the application of ligatures to the iliac veins;  2,
chemical and  mechanical irritation of their lining membrane ; and 3,  sus-
tained compression of the femoral veins by metal plates.  Without  entering
more  fully into  these experiments, I may give the conclusions  which  the
author  drew from them : " 1, that inflammation of neither  the iliac nor
femoral veins would account for,  or give rise to phlegmasia dolens ;  2,  that
the extensive obstruction of the veins met with in  this disease is not produ-
cible by merely local causes, such as injury or  inflammation of these vessels;
3, that irritation  of the  lining  membrane  of veins, independently of such
local injury or inflammation, will only give rise to obstruction of these vessels
to an extent commensurate with that of the irritation which may have been
excited within them ; 4,  that extensive  irritation of the lining membrane of
veins, giving rise to obstruction and all the  phenomena of phlebitis, may be
excited by the presence of various unhealthy matters in the blood circulating
with this fluid, and determined  upon particular portions of the  venous
system ;  5,  that the origin of the disease is therefore to be sought for  rather

  1 Lancet, May 21st, 1853, p. 580.   2 Mai. des femmes, p. 551.   3 Midwifery, p. 611. 
PHLEGMASIA DOLENS.
597
in a vitiation of the circulating  fluid than in any local injury, inflammation,
or disease of the veins."1
  Notwithstanding the ingenuity of the author of this paper, we cannot-but
feel that experiments  of  this kind  are  but imperfect illustrations of  the
effects of disease ;  and  secondly, that in this disease, as  the two conditions
exist in most cases—viz.,  inflammation of  the veins  and  a source of possible
vitiation of the blood, it may be impossible to decide the exact limits of each.
  After careful consideration and  some experience, but without wishing to
express myself dogmatically, the conclusions to which I have  myself arrived
are the following: — 1, that in phlegmasia dolens  of puerperal women the
most  striking and  general pathological  condition is inflammation and ob-
struction of the veins;  2, that in most cases this  state of the  veins extends
to the veins  of the  uterus,  where the disease in  all probability originated;
3, various considerations, however, lead us to conclude that the disease of
the crural veins is  not a retrograde propagation  of the disease from the
crural veins, but that the first morbid process is a vitiation of the blood, and
that the effects upon the limb are produced in  the  course of circulation, so
 that,  although the uterine and crural phlebitis be continuous anatomically,
 they  are pathologically separate and distant;  and 4, that a vitiation of the
 circulating  fluid, primary or secondary, may be a more important element of
 this disease in most, if not all, cases, than has hitherto been supposed.2
   These conclusions will embrace all cases  of phlegmasia dolens, either of
 the upper or  lower extremities, both  of the  puerperal and non-puerperal
 state, and also those which occur in men, and I think they afford  an expla-
 nation (so far as we can expect one) of many of the vital phenomena of the
 disease, as  well as being consistent with the results  of post-mortem investi-
 gations.  At  the  same time, it cannot  be denied that there is  room for
 further research into the state of the blood circulating in the  affected parts,
 and other minute points  of chemical or microscopical interest.
    845.  Causes. —The exciting cause seems generally  to be the impression
 of cold or previous uterine  disturbance.   Almost all the cases I  have seen
 have occurred after leaving bed at too early a period after labor.
    846.  Prognosis.—Though we cannot say that the disease is without danger
 altogether, when  severe, yet the proportion of deaths  is  so  small, that in
 the great majority of even severe cases, our prognosis  may be favorable;
 still  more decidedly when  the  attack is  slight.  The danger, I think, may
 generally be estimated by the amount  of uterine disease.  I have also re-
 marked that the  severity of the constitutional  symptoms is  often inversely
 as the swelling of the limb.
    847.  Diagnosis. —The characteristic marks of the  disease are, the time
 of its occurrence—after delivery ;  the uterine symptoms preceding, the pain
 down the thigh and leg, the swelling;  but especially the painful, hard, cord-
 like, femoral vein.   When the greater part of these symptoms are present,
 there can be no doubt of the nature of the disease.
    848.  Treatment.—The  condition of the patient after confinement will
 of necessity somewhat modify the activity of the treatment.
    Generally speaking, the venesection will not be required ; but if the patient
 be of a pletoric habit, if she have in some degree recovered her confinement,
 and  if the  disease set in with great violence, it may be  advisable.   Leeches,
 in numbers  proportioned  to the  severity of  the  attack, should be applied
 along the course  of the femoral vein, to the groins, or to the calf  of the leg,
 and  a poultice applied when they fall off.3  If decided relief be not obtained,
 they may be repeated in smaller numbers, once, twice,  or thrice.

          i Lancet, March 19th, 1853, p. 276.
           2 British and For. Med. Rev., July 1854, p. 71.
           s Bateman's Report: Ed. Med. and Surg. Journ., vol. iii. p. 128. 
598
PHLEGMASIA DOLENS.
  As the bowels are almost always in some degree disordered, appropriate
remedies must be  tried.   If diarrhoea  be  not present, purgatives may be
given, and  we are  advised to prefer the saline.1   I have seen much benefit
result from small doses of tartar emetic given along with the cathartic, during
the acute stage.    Some effervescing draughts may also be given.
   Different statements have been made  as to the  effect of blisters ; some re-
garding  them as  specifics.   Mr. Sankey observes :2  "What I  consider a
specific is a blister applied to the calf  of the leg, immediately on discover-
ing the complaint.   The first I apply to the  calf of the leg, as the pain is
generally most severe in that part, and there is less fear of its  not healing
than if applied lower.   If required, I repeat them every two or three days,
not  at the same place, but  higher  or  lower, according to the  seat of the
pain."  Others,  as Dewees, etc., altogether rejecting them  as mischievous.
My own experience is decidedly in favor of their utility, although in  many
cases turpentine fomentations will answer equally well.
   In the more acute and severe cases, and especially if there be evidence
that there is irritation  or inflammation  of the uterus, it will be advisable to
give small  and repeated doses of calomel and opium until either the symp-
toms give  way or  the constitution is brought  slightly under mercurial influ-
ence.  In milder cases an  occasional mercurial  purgative is beneficial, but
it will rarely be  necessary to continue its administration steadily.
   When the pain is severe,  or the patient  irritable,  restless, or sleepless,
opiates  will be found very useful, and  with  them, as Denman  has recom-
mended, we may combine diaphoretics  or diuretics.3
   When, by these means, the acute stage has been terminated, and the con-
stitutional  symptoms  relieved,  the  local and general treatment must be
changed.   Gentle support may be afforded  to the limb by a tight  flannel
bandage, and  slightly stimulating frictions employed.  In this  stage, espe-
cially, the frequent application of small blisters has been recommended. Dr.
Denman thus expresses himself: — " Then, also,  but not sooner, it is neces-
sary and proper to  support the swelled limb by a slight  flannel bandage,
drawn gradually tighter, and to use different applications,  such  as the vola-
tile liniment,  or one composed of three  parts liniment, saponis, and one part
of tinct. cantharid.,  and sometimes small quantities of the ung. hydrargyri.
The frequent application of small blisters to different parts of the  limb has
been  also then strongly advised, and in  many cases with evident advantage.
Electricity has been  tried ;  but of its real benefits I am not competent to
judge.   Certainly, many patients have been  much relieved by persevering
in the use  of warm sea-bathing; and  they are to be encouraged, but with
some caution, to use exercise."
   Tonics  may also  be given — decoction  of bark or  quinine,   with  dilute
sulphuric acid, will be found the most serviceable.  With these  means must
be combined  an improvement in the diet, gradual, yet decided—meat broths,
and a fair allowance  of wine or malt liquor.
   If at any period of the disease the lochia should become  offensive, vaginal
injections of tepid milk and water should be used once or twice  a day.

  1 Dewees. Diseases of Females, p. 492.
  2 Ed. Med. and Surg.  Journ., vol. x. p. 402.    8 Introduction to Midwifery, p. 509. 
PUERPERAL  MANIA.
599
CHAPTER  XXYII

    PUERPERAL MANIA.
  849.  Females may suffer from  an attack of mania during  gestation,
during  labor, or after parturition.  The two latter cases  will occupy our
attention in this chapter.   The temporary delirium, or mania, which occurs
during  labor, was, I believe, first recorded by the late Dr. Montgomery.  It
appears at two particular periods of the labor — first, as  the  head passes
through the os uteri, and  again, at its exit through  the os  externum. _ It
would  appear to be owing to the extreme suffering at these times, acting
upon an irritable and nervous temperament.  It is very temporary, generally
lasting but  a few minutes, and then  subsiding.  The most curious point
about it is, that the patient is  generally conscious of  her incoherence.  As
Dr. Montgomery observes, " It comes  on  suddenly during  perfectly natural
labor,  and most frequently at that particular  stage of the process which I
have pointed  out (dilatation  of the os uteri).  It is not accompanied nor
followed by anv other unpleasant or suspicious symptom ; it occurs,  perhaps,
immediately after the patient has been talking cheerfully, and having lasted
a few  minutes, disappears, leaving  her perfectly clear and collected, and
returns no more, even though the subsequent part of the  labor should be
slower and more painful.   In  every instance which came under my  observa-
tion, the patients were conscious that they had been  wandering, and occa-
sionally apologized for anything wrong they might have said, although they
were  not aware of what the exact nature of their observations might have
been."1   I  have  seen several cases of this  kind, and, without  exception,
they corresponded very accurately with this description of Dr.  Montgomery's.
 In one case the delirium, which occurred  first during the  dilatation  of the
 os uteri, returned as the  head was  passing through the os externum ; and
 this patient informed me that she  was conscious of talking nonsense, and
 had in  vain  endeavored to resist  it.  Dr. Montgomery  attributes this
 momentary incoherence to the suffering attendant upon the forcible distension
 and dilatation of the cervix, and there can be no doubt,  I  think,  that this
 is the  true explanation.
   850  I shall now proceed  to  the  consideration of puerperal mama,  or
 that form of insanity which occurs in childbed soon after delivery,  or at the
 commencement of suckling.   It is  a  very distressing  malady in itself, but
 doubly so from  occurring at a  moment ordinarily  so joyful: and yet we
 cannot be surprised at the susceptibility manifested  at this particular time,
 when  we remember that  "the sexual system in women is a set of  organs
 which are in action only  during half the natural life  of the  individual, and
 even  durino- this half they are  in action only at intervals.    During these
 intervals of"action they diffuse an unusual excitement  throughout  the nervous
 system • witness the hysteric affections of puberty, the nervous susceptibility
 which occurs during  every menstrual period, the nervous affections ot breed-
 ing, and the nervous susceptibility of  lying-in women." 2     _
    Attacks  of puerperal  insanity are not infrequent.   Esquirol  states, that
 of 600 women in La Salpetriere,  52 were of this kind; and  of 1119 cases
 admitted in four years, 92 were cases of puerperal mania.  He found it even

           l Dublin Journal, vol. v. p. 61. Old Series
           2 Gooch on the More Important Diseases of Women, etc, p. lit - 
600
PUERPERAL  MANIA.
more frequent in proportion among the higher ranks, for  out of 144 cases
of mental derangement in  females of  opulent  families, the  attack came on
during childbed or lactation in 21.  Dr. Haslam states, that  of 1644 females
in Bethlem Hospital, 84 were cases of  this kind ; and Dr. Rush mentions  5
cases out of 70 at the  Philadelphia Lunatic Asylum.
   The attack may, in  some  few  cases, be a continuance or a  further de-
velopment of the nervous affections of  pregnancy; the nearer the approach
to mental derangement during this period, the greater the probability of an
attack after delivery.
   851.  There are two periods, however, at which patients  seem especially
obnoxious  to it— 1st, immediately after delivery, to which  the  term jiaro-
phrosyne puerperarum has  been given ; and 2dly, about the fourth or fifth
day, when  the  full secretion of milk  is established, and then  it has been
termed mania  lactea.  Dr. Burrowes adds  a third  period—about the
fourteenth  or fifteenth day, and he then attributes it to the  effect of cold in
checking  the secretion of the milk.   I  find  that of Esquirol's cases, 16
became delirious from the first to the  fourth day; 21 from the first to the
fifteenth day ; 17 from the  sixteenth to the  sixtieth day ;  19  from the sixtieth
day to the twelfth month ; and  19 after forced or voluntary weaning.  Of
Dr. Burrowes' cases, in 33 the access was before the fourteenth day; in 11,
after the fourteenth and before the twenty-eighth day.
   852. Symptoms.  The premonitory  symptoms vary a good deal.   In one
sense,  hereditary predisposition, or the nervous affections of gestation, are
premonitory, but in most  cases  we shall  generally find, previously to an
attack, a degree of exhaustion, conjoined with great excitability, headache,
and want of sleep ;  or the attack may accompany or follow convulsions, as
I have  seen  in more than  one  case.  Dr. Ilaslara remarks: " The first
symptoms of the approach of this disease  after delivery are, want  of sleep,
the countenance becomes  flushed, a constrictive pain is often felt  in the
head, the eye assumes a morbid lustre, and wildly glances at objects in rapid
succession ;  the milk  is afterwards  secreted in less quantity, and when the
mind becomes more violently disordered it is totally suppressed."
   Writers speak of various species of  puerperal insanity, principally of two,
 however,—those  cases in which the  form  is melancholia, or mania, and
those  in which  phrenitis, or inflammation of the membranes  of the  brain,
 exist;  the  former is  the true puerperal mania, and may  be  distinguished
 into two varieties — those where  fever is present, and  those in which it is
 absent.   "Mania," says Dr. William Hunter, "is not an uncommon appear-
 ance in the course of the month, but of that species from which they  generally
 recover.    When out  of  their  senses, attended with fever,  like, phara-
 phenitis, they will, in all probability, die; but when without fever, it is
 not fatal,  though it (i.e., the fever) generally takes place before they get
 well.   I have had several  private patients, and have been called in where a
 great number of stimulating medicines and blisters have been administered;
 but they have gone  on at another time talking nonsense  until the  disease
 has gone  off, and they have become  sensible.   It is  a species of madness
 they generally recover from, but I know of nothing of any singular service
 in it."   "Putting together," says Dr.  Gooch, "This statement  of Dr.
 Hunter with my own experience, I extract from it the following meaning:
 that there are two forms of  puerperal  mania,  the one attended by fever, or
 at least — the most important part of  it — a rapid pulse ;  the other accom-
 panied  by a very moderate  disturbance of the circulation; that the latter
 cases,  which are very far  the most  numerous, recover;  that  the  former
 generally  die.  This  agrees closely with  my  own experience."   Dr. Bur-
 rowes  states that he has not seen any case  attended  with fever, "except
 when coincident with the  first secretion of milk, or where  inflammation  of 
PUERPERAL  MANIA.                      601
the breasts or other parts has occurred, or upon forced weaning where there
has been  abundance  of  milk."   But this is far from being  generally true.
I have seen several cases in which mania occurred before the secretion of
milk, and  yet the pulse was very  quick, and the skin hot,  with thirst, loaded
tongue, etc.
 ^ In  the  one variety we find  the  attack preceded by wakefulness, excita-
bility, headache, and  after a while the mind is evidently astray ; the patient
may be joyous or melancholy, singing and talking incessantly, or obstinately
silent, suspicious of every one, fancying injuries and offences on the part of
her husband  or  friends,  and forgetful of her child.  The heat of the body
may be slightly increased ;  that  of the head is generally so, with a partial
pain  and  sense  of pressure  or  tightness,  throbbing  in  the  temples,  and
noises  in  the ears.   The  skin  is generally relaxed  and moist,  but  dis-
colored ; the face pale, the tongue whitish and loaded ;  the abdomen  soft,
and usually free from  tenderness; the pulse weak and quiet ;  there is little,
if any, sleep, and but  little thirst; the bowels are torpid,  and the stools un-
healthy, often offensive.
   In other cases we find  the skin hotter,  the pulse quick  and small, the face
often  pale, sometimes flushed, the eyes red  and  vivid, and a delirium  more
resembling that of fever, with a  brownish dry tongue, and sordes about the
teeth.
   Dr. Burrowes has described  an attack  of puerperal mania, somewhat
different from  the above.  " In  every instance,  this  variety  has come on
before the fourteenth  day from delivery ;  it is preceded by pervigilium, the
ideas  are  at first rapid and confused, images like  those  of dreams  appear,
and the delirium  is soon confirmed  by these  illusions being  considered as
realities, and the speech  and action  corresponding with  these  impressions.
The muscular powers are rarely violently exerted, though the patient fre-
quently attempts getting out of  bed without  any fixed object:  on the
contrary,  she generally lies supine; the countenance is  rather vacant; the
eyes are  half closed, or fixed on  vacuity,  and,  when roused, follow  some
imaginary object; the tunica conjunctiva is often highly injected, and the
pupils very  little sensible  to light;  the head  is hot;  the skin  soft and
relaxed, and partial  sweating about  the throat and neck.  She continually
mutters incoherently ; loses consciousness, except when suddenly or strongly
urged ; if spoken to, answers shortly,  and perhaps rationally, but lapses
directly into  the former state of indifference ; the pulse is quick and uncer-
tain ;  bowels generally easily moved ;  lochia and secretion of milk suspended.
About the fourth or  fifth day the debility is greater;  there is more coma;
the pulse  is  quicker, smaller and  more unequal, with slight subsultus;   pick-
ing at surrounding objects, or the bedclothes; averse  from food or drink;
insensible  of evacuations ; the tongue throughout presents nearly a natural
appearance,  though  sometimes  tremulous  when  protruded.   It is usually
fatal  by the seventh  or eighth  day;  and if the patient survive, chronic
insanity commonly supervenes, and melancholia oftener than  mania."1
  That active inflammation of the brain or its membranes may occur during
childbed is  beyond question, but as it  is very rare, and does not strictly
belong to  the question of puerperal mania, I shall not at  present enter  upon
its consideration.
  Thus, then, we may have an attack of mania supervening  upon delivery,
or occuring  from the'fourth to the fourteenth day,  with or  without precursory
symptoms • in two varieties the  main distinction  appears to be in the  pulse
__in  one  it,  is quick, in  the other natural; the third variety resembles low
fever.
                     i Commentaries on Insanity, p. 371. 
602
PUERPERAL  MANIA.
  The state of the uterus is apt to be overlooked, because there are but few
symptoms, if any, referrible to it, and partly also because the patient is not
always, able  to answer questions rationally.   As far as my own experience
goes,  I should say that, 1,  in certain patients no uterine complication occurs
at all; 2, that in others, the  uterus  becomes involved in the course of the
maniacal affection ;  and 3, that in some we may trace distinct marks of uterine
disorder from the commencement, such as suppressed milk, offensive lochia,
and  tenderness  in  some part of the uterus.   I suspect, moreover, that a
division  of  these classes  into  two  will correspond  very  closely  with Dr.
Gooch's classification by the  pulse ;  the  first class, and  part of the second,
presenting almost always a quiet pulse ;  the severer cases of the second, and
all the third, having the pulse rapid, with high fever.
  In  all  the varieties the stomach  and bowels  are much disordered.   The
character of the mania is not in any  way peculiar to childbed.
   853. The progress, duration, and termination of the attack vary a good
deal  in  different patients.   Dr.  Burrowes  observes,  that  sometimes the
slighter attacks  which occur immediately after delivery will disappear under
the operation of a smart purgative, and an  opiate.   Of the  92 cases  given
by Esquirol, 55  recovered  : 4 recovered in the  first month, 7 in the second,
6 in the third, 7 in  the fourth, 5 in the fifth, 9 in the sixth,  15 between the
sixth and twenty-fourth, 2 after two years.  Of these, 38 recovered in the first
six months.   Of 37 cases given by Dr. Burrowes, 35 recovered  : 9 recovered
in the first month, 5 recovered in the second,  5  in the third,  3  in the fourth,
2 in the  fifth,  4  in the sixth,  1 in the seventh,  2  in the eighth, 1 in the ninth,
1 in the twelfth, 1 in the fourteenth, and 1 in the twenty-fourth month.   That
is, 28 recovered in the first  six  months.  Of 80 cases by Dr. Haslam, 50
recovered.
   But it may continue much longer,  Of the  cases described by Esquirol, 6
died; 1  six months after delivery, 1 in a year, 2 after eighteen months, 1 in
three years, and 1 in five years.   In Dr. Burrowes' table, it is stated  that 1
recovered after  two years,  1  after three years, 2 after four years, 1 after six
years, and  1  after seven  years ; but he says that he never met with one
permanently fatuous from  puerperal insanity.   Of Esquirol's  92 cases, six
died, or  1 in 15.  Of Dr. Burrowes' 57 cases,  10 died, or 1 in 6 ; 7  within
twelve days of the  access of delirium, 2 within  seven  days, and 1 after four
months.   Two  of them had active  uterine disease, and two others died  of
relapses  after they  had recovered from puerperal mania.   Thus we find that
the  number of  cases that recover is very  considerable ;  out of 229, 146
recovered,  or more than one-half.  Of  90 of  those who recovered, 66 were
cured within six months, and the remainder at irregular intervals up to two
years.  Some we find continued insane  much longer, remaining so for four,
five, six, and seven years.   But, on the other hand,  a large  proportion  of
deaths has sometimes occurred : 1 in 15 at La Salpetriere, and 1 in 6  among
Dr. Burrowes' cases.
   [In simple uncomplicated  cases of puerperal  mania, although the disease
may frequently  be protracted, the diagnosis, according to our experience, is
for the most part favorable.   Distressing as the symptoms  always are, and
alarming as they often become to the friends of the patient and to the inex-
perienced practitioner, the uncomplicated forms of puerperal  mania will be
found almost invariably to recover under judicious treatment.  It has been
pertinently  remarked, that "the question is not  so much whether the patient
will get  well,  as when she  will get well."]
   I do not  think, however, that any statistics from a  lunatic asylum can be
taken as a correct  standard of the mortality in  puerperal mania, for patients
are not sent there  until the  disease is  more  or less  chronic : now, a great
number of those who recover, do so within a short time after confinement, 
PUERPERAL  MANIA.
603
as in two cases I witnessed lately, both of which recovered from the delirium
within ten days.  Among the better classes, a patient would not be placed
in an asylum  until she had  recovered  from her confinement, and until the
ordinary treatment had failed.  On the  other hand, death  occurs in many
cases within the month after childbed.  " Mania," says Dr. Gooch, "soon
after delivery, is more dangerous  to life than melancholia  beginning several
months afterwards."  He states,  also, that none of his  patients with a slow
or moderately excited pulse died, whereas, in the fatal  cases, the  pulse was
very rapid, though some with a rapid pulse  recovered.  In  the  two cases I
have referred  to, the pulse was  very rapid, yet both recovered.  "Nights
passed in sleep, a pulse  slower  and firmer, even though the mind continue
disordered, promise safety to life.  On the contrary, incessant sleeplessness,
a quick, weak, fluttering pulse, and all the  symptoms of increasing exhaus-
tion, portend a fatal termination, even though the condition of mind may be
apparently improved.  In the cases which I have seen terminate fatally, the
patient has died with symptoms  of exhaustion, not with those  of  oppressed
brain, excepting only one case."1
   I should myself lay great stress, in forming a prognosis, upon the presence
or  absence of uterine complication, as well as  upon the frequency of the
pulse.   Any complication, indeed, must diminish the chance of recovery.
   854.  Causes.—I shall now consider the causes of this distressing malady.
There seems little doubt that in  many cases (Dr. Burrowes says in half the
number, or  possibly more, and  Dr.  Gooch  bears the same  testimony) the
predisposition  is hereditary, and of course mental deviations during gesta-
tion render  an attack of puerperal  mania  extremely probable.   Sleepless-
ness, which  so fearfully increases nervous  irritability, seems a very general
predisposing cause.
   Among the  exciting causes we find cold, irritation, irregularities of  diet,
distress of mind, sudden mental shocks, frights, disordered bowels, excessive
secretion  of  milk, and  constitutional  irritation  thence arising,  etc. ; or the
 attack may form  a part of  or follow convulsions, as in a case which came
under my care not long since.
   Great stress is laid upon moral causes by the  French writers.  Esquirol,
 as  I have before  mentioned, states their frequency, compared with the  phy-
 sical, as four to one : and Georget mentions that out of seventeen cases, there
 were but two not proceeding from a direct moral cause.   During the inva-
 sion of France, in 1814-15, eleven out of  fourteen cases were from terror.
 British writers do not attribute so large an  influence to this cause.
   855. As to the proximate cause or pathology, it is not very easy to speak
 positively.   I may allude to four different views on the subject: 1. From its
 occurring in  many cases immediately after delivery, some have  attributed it
 to  disease of the  uterine system.  Fabret  mentions a case of cancer which
 excited mania.  Dr.  Briere  has related  a case  of mania  from  inflammation
 of the womb.   Dr. Cooke discovered disease of the womb in two cases of
 puerperal mania.   Dr.  Burrows  mentions  having seen abortion and mania,
the result of inflammation of the womb, in two cases in which he was con-
sulted ; one died, and the  other recovered;  and  in two of the deaths in his
table there was disease of the  uterus, but whether it preceded the mania or
not does not appear.  In  one  of the  species of puerperal mania described
by Dr. Burns,  he says, "the delirium is connected  with the state  of the
uterus, particularly of the veins which are inflamed."2  At a meeting of the
Obstetrical Society of Dublin, Dr. Montgomery mentioned a case of puer-
peral mania in which the uterus and ovaries were  found in a state of in-
flammation •  and Dr. Hardy another, in which peritonitis existed,  but was

      i Gooch on Diseases  of Women, p. 124.             * Midwifery, p. 619. 
604
PUERPERAL  MANIA.
not suspected till  after death.   I  have certainly seen uterine inflammation
follow  puerperal mania, but that  it existed previously I  cannot say :  the
usual symptoms were absent.   Still these  cases, which are all I have been
able to make out, form so very small a proportion to the cases in which
there has been no disease  of the womb, that without  denying that the con-
dition of the uterine  system is in some way connected  with  puerperal mania,
it is clear we cannot attribute  it solely to organic disease of that organ.
  2. Other writers regard the disease  as  inflammation of the brain or its
membranes.  Now it is granted, of course, that such cases  do occur,  but
they are rare ;  and it  is contended that in ordinary  cases puerperal mania
does not arise from inflammation, and the results of post-mortem examina-
tions are in favor of  the latter opinion.   Bums, Campbell, Davis, Lee,  and
others,  speak of it  as a modification  of  phrenitis;  Burrowes,  Pritchard,
Gooch, etc., as not being inflammatory.  The latter distinguished observer
thus gives  the result of his experience: "In No. 1, the disease occurred  in a
pale lady, without any heat of skin or much quickness of pulse, and was not
relieved by loss of blood.   In No. 3, it occurred in one whese constitution
was drained and  enfeebled by nursing.   In  No. 4,  it occurred in  a  pale
woman,  habitually hysterical, subject to bear  dead children,  from want of
power to afford them life for nine months.  In No. 5, it occurred in one in
whom, for  urgent reasons, the circulation had  been reduced  to  the lowest
ebb consistent with  life.   In  No. 7, in one who had  been living very  low
for a week, with such  marked  symptoms  of the irritation of debility,  that
at first sight I thought it was the  close  of  some disease that had been over-
looked.  It was speedily relieved, not by cupping  and purging, but by the
tranquillizing and sustaining  power of opium.  In No.  8, the disease  was
treated, though with  all possible prudence and moderation, as an inflammatory
state of the brain, by leeches, cupping, purging, and low diet, yet the patient
died, not with symptoms of oppressed brain, but with those of exhaustion ; and
on  examining the body, the whole venous  system was found extraordinarily
empty of blood.   In No. 10, the patient fell as if shot, under the stroke of the
lancet; and on examining the head, there  was found no effusion, and empty
bloodvessels.   In No. 11,  the disease came on after puerperal convulsions
(a  disease  generally, but not always, depending on  cerebral congestion), and
after one of those enormous bleedings commonly practised in these cases, and
no  morbid appearances were  discovered  after death,  in  the  brain.   These
cases,  if fair specimens of puerperal insanity, lead straight to  the conclusion
that the disease is not one of congestion or inflammation, but one of excite-
ment without power."1  Add to this, that Esquirol found  no  traces of cere-
bral inflammation upon most careful examination.
   3. Dr. Marshall  Hall believes  that  the disease  "results, in general,  from
all the circumstances following parturition combined, but chiefly from the
united  influences  of intestinal irritation and  loss  of blood."   "I am  per-
suaded," he adds, "that real puerperal  phrenitis is comparatively a rare dis-
ease, that  puerperal mania is  seldom of an inflammatory character, and that
it is especially to be treated by those measures which are suited to the mixed
case of intestinal irritation and  exhaustion."2  That many  cases occur in
patients exhausted  from some  cause, the  extract I have given from Dr.
 Gooch will prove, and that the stomach and bowels are  disordered  in  most
cases is recorded by almost all writers, so that we  cannot deny that Dr. M.
 Hall's  view has  much to support it.   Nevertheless, it  does  not  seem to
 express the whole truth, nor is the want easily supplied with any degree of
 precision.
   4. The  explanation of Dr.  Gooch, which I  have already quoted, as to the
1 Diseases of Women, p. 144.
3 Diseases of Females, p. 251. 
PUERPERAL  MANIA.
605
peculiar nervous susceptibility induced by the organic changes consequent on
impregnation and child-bearing, although I believe it to be correct, is neces-
sarily vague ;  nor is the view of Dr.  Ferriar more accurate.   He  says:  "I
am  inclined to consider puerperal  mania as a case of conversion.   During
gestation and after delivery, when the milk begins to flow, the balance of the
circulation is so greatly disturbed as to  be liable to much disorder from the
application of any exciting cause.  If, therefore, cold affecting the head, violent
noises, want of sleep, or uneasy thoughts, distress a puerperal patient before
the determination of blood to the breasts is regularly made, the impetus may
be converted to the head, and produce either hysteria or insanity, according
to its force or the exciting cause."
  Perhaps it is best simply to enumerate the elements which  may concur to
produce the attack.   We have the nervous shock  varying  in degree, but
always increasing  the  nervous irritability ; the great vascular change; the
disturbance of respiration and  circulation ;  the exhaustion  ; and in  many
cases the loss  of blood ;  this combination must necessarily leave the nervous
system in  a favorable state for the operation of the  exciting causes  I have
enumerated, and the result is mania.
   856. Treatment.—The treatment of puerperal mania is very simple as
regards the materials, yet requiring  calmness  and judgment in their appli-
cation.
   1.  Those who regard it as any modification of phrenitis, of course recom-
mend bloodletting, with more or less liberality.  Now, from  what  I  have
said as to the nature of the disease, it will be  clear that in  most  cases it is
inadmissible, or, if ever used, it must be with  extraordinary caution, and by
means of leeches, in cases where there is strength  and quickness of  pulse,
and flushing of the head and face.  I have, however, never found it advisable;
aud Esquirol, Haslam, Gooch, Burrowes, and Pritchard, are all opposed to
it.   The  last-named  author remarks :  " If we consider that the greatest
danger to be apprehended for patients laboring under  puerperal madness
arises from a state of extreme exhaustion, that many women die  from this
cause within a short interval from the commencement of the disease, and that,
if they survive this period, the healthy state of the mind is in most instances
restored,  it will be evident that our chief endeavors must be directed to the
present support of life."  "Bloodletting, as a general  remedy for  puerperal
madness,  is condemned by all  practical  writers on whose judgment  much
reliance ought to be placed."1
   2.  When the  stomach is overloaded, when indigestible  food  has been
taken, or even for the purpose of lowering the pulse by the shock  of vomit-
ing, emetics have been found useful.  They must, however, be used with cau-
tion when the face is pale, the skin cold, and the pulse quick  and weak. Dr.
 Gooch prefers ipecacuanha to antimonials.  Dr. Burrowes recommends nau-
seating doses  of tartar emetic, with the  saline  mixture  and digitalis, for the
purpose  of reducing the violence and fury of the patient;  and Dr. Beatty
informs me that he has derived great advantage from tartar emetic.
   3. From the almost universally disordered state of the bowels, great relief
is afforded by one or two brisk purgatives of calomel, followed by castor oil
or Gregory's powder.   The  stools are dark-colored,  and highly  offensive;
 and in addition to the advantage of clearing out the bowels, purgatives act
admirably as derivatives from the head.
   4.  After the bowels have  been freed, the greatest benefit will be derived
from narcotics.   Denman prefers small and repeated doses of opiates, but
Gooch  Burrowes, and  Pritchard recommend full doses, and  with this  I con-
cur • ten grains of Dover's powder, twelve drops  of black drop, or an equi-
1 On Insanity, p. 313. 
606
EPHEMERAL FEVER, OR WEID.
valent of the other preparations of opium.   If opium disagrees, hvoscyamus
must  be  given; and should  sleep be induced, repeated small doses may be
administered ;  when the head is very hot, and face flushed,  we should  post-
pone  the exhibition of opium ;  and we must guard against constipation.
  In  more than one case  recently under my care, in which opiates had no
effect in quieting the patient  or  procuring sleep, we tried the inhalation of
chloroform,  and with great benefit: she became quiet, ceased talking, and
occasionally was put to sleep for an hour or two at a time.  Mr. Waters, of
Liverpool, has published three cases of this disease in which the exhibition
of chloroform was most beneficial: all recovered speedily.1
  5.  The bead  may be  shaved, and a cold lotion  applied ; if the delirium
continue,  a blister may be applied, but it is not generally necessary.
  6.  In protracted cases, or when the  patient is exhausted,  nourishing diet,
broths, etc., and even  tonics,  must be allowed;  ammonia,  with  cinchona;
oil of turpentine, wine, etc.
  7.  As  uterine inflammation  not uncommonly arises in the course of or
follows puerperal  mania, a  close watch should be kept  for the  earliest
symptoms, and if they appear,  calomel in small and repeated doses,  or mer-
curial inunction, should be added to the other remedies, with  such other local
applications as may be deemed advisable.
  8.  It will be necessary to keep the most careful watch upon the patient;
the  nurse, who ought, if possible, to  be one familiar with such  attacks,
should never leave the room ;  friends ought to be absolutely refused admis-
sion ;  the apartment kept slightly darkened, and the entire  house perfectly
quiet.
  9. When the mania disappears, and the patient is convalescent, a change
of air and scene is most advisable.
                    CHAPTER  XXVIII.

                   EPHEMERAL  FEVER,  OR  WEID.

  857. This is a short attack of fever, to which females are especially liable
during the early part of their convalescence, though it  may occur at a later
period.   Women of sensitive constitutions are the most obnoxious to it.
  858. Causes.—The most frequent  cause  is the impression of cold, per-
haps on rising from bed, or changing the room, etc.   Indigestion, or irre-
gularity of the bowels, may also give rise to it.   Fatigue, mental agitation,
and want  of rest are also enumerated among the exciting  causes.
  859. Symptoms. — The  attack commences by general  uneasiness, palpi-
tation, and shivering, with headache, pain in the back and  limbs, soreness
of the breasts, thirst,  rapid, and sometimes irregular  pulse, etc.   " On or
before the approach of the disease," says Dr. Campbell,  "the patient is
observed  to yawn and  stretch herself greatly, and to appear very languid.
To this succeeds a sensation of cold, first between the shoulders,  and there-
after along the spine, and at last it becomes general over the whole body,

           1 Journal of Pscychological Med.,  No. 5., Jan. 1857, p. 123. 
EPHEMERAL FEVER,  OR  WEID.
607
attended with  pain in the head and large joints.  Sometimes a  sense of
soreness is felt in the uterine region, and if the lochial discharge be present,
both it and the milk are diminished in quality."1   To this succeeds  a well-
marked  hot stage, with flushed face, throbbing temples, pain over the eyes,
rapid full pulse, pain  of the breasts, soreness of the abdomen, etc., and it
terminates in a profuse sweat, which removes the fever, and relieves the other
symptoms.   The tongue is coated, the stomach is often  disturbed, and the
bowels confined.   During the paroxysm, the fever often runs very high, and
the distress is proportionally great.   Occasionally the mind is confused and
distressed, and in some  cases  the patient is delirious.   For  the  time, the
secretion of milk is diminished or suspended,  and the lochia also ;  but they
return after the paroxysm.
   The fit is generally completed in twenty-four hours, always in forty-eight,
and, if  properly treated,  it seldom returns;  if neglected,  however,  it may
assume  the  form of  an intermitting, or continued fever.   " It consists of a
cold, hot, and a sweating stage; but if care be not taken, the paroxysm is
apt to return, and we have either a distinct intermitting fever established, or
sometimes from the  co-operation of additional causes, a continued and very
troublesome fever is produced."2   Unless  it  assume this  character,  it is of
very little consequence, and very easily managed.
   860.  Diagnosis. — From  the violence with which  it commences, it may
 easily be mistaken for puerperal fever;  but the cessation of the paroxysm
 after some  hours, and the absence of  marked  abdominal tenderness,  will
 generally enable  us  to distinguish it.   Indeed,  the peculiar  violence with
 which it commences is itself more characteristic of weid  than of puerperal
 fever.  " The suddenness of the attack, the great irregularity of the pulse, the
 absence of all local  pain except that of the head, the  intensity and  irregu-
 larity of the  succession of the different stages,  will  distinguish this  from
 every other puerperal affection."3
   861.  Treatment.—During the cold stage, hot bottles and warm bed-
 clothes may be applied, so  as  to relieve the distress.   Warm  drinks and
 cordials may also be given.
   During the hot stage a comfortable quantity of clothing must be continued,
 and diaphoretics given, so as to favor perspiration ; and during the sweating
 stage, we must guard against cold, and diminish the clothing very gradually.
   As for purgative  medicines, which are necessary, I have found the com-
 bination of salts, senna, and tartar emetic the  most useful;  but any other
 purgative may answer the purpose.  If the tongue be foul, and the stomach
 loaded, an emetic may be advisable.
   Yery rarely will it be  necessary to take away blood, and then only if there
 be much local pain.   A few leeches to the head, or to the breasts, if they be
 painful, may be of use;  but in  the majority of cases  they are unnecessary.
   We should carefully examine the state of the uterine system, as irritation
 may otherwise go on unsuspected, and  be  the  cause of  much subsequent
 distress.
   The  diet may be  nutritious after the paroxysm  is over, and  mild tonics
 mav be "-iven, if necessary.   Dr. Campbell recommends five-grain doses of
 camphor* four or  five times  a day, for some days, to allay nervous irrtiability.
   Great'care must be taken,  after the fever has  terminated, to avoid all
 occasion of cold, or any cause which may reproduce the attack.

        i Midwifery, p. 341.                   2 Burns's Midwifery, p. 572.
        3 Campbell's Midwifery, p.  541. 
608
SORE NIPPLES.
                      CHAPTER  XXIX.

                           SORE NIPPLES.

  862. This  is a very frequent  and troublesome occurrence, and far more
painful than  would be  supposed.   It is  more frequent with first children,
but some women  suffer  from it  after each confinement.  It comes on gene-
rally after two or three days' suckling, and continues for an uncertain time,
after which it generally subsides.
  863. Causes. —In the majority of cases, it is simply the  reiterated appli-
cation of the  child which causes  it, by removing the sebaceous secretion —
so that  the skin, when dry, contracts, slightly hardens, and cracks.  This
process is aggravated by a slight degree of inflammation.  But sore nipples
may be owing to the  state of  the child's  mouth, as is frequently seen when
the child suffers from aphthae  ;  and on the other hand, the discharge from
the nipples may inflame and excoriate the child's mouth.
  864. Symptoms. — At first  the  nipple and areola are observed to be dry,
rough, and harsh ; then a great number of  minute cracks  may be seen ; or
the surface becomes excoriated,  and pours out a serous discharge, which in
some cases is acrid, and  spreads  the excoriation  to the surrounding skin.
Or the nipple may exhibit deeper fissures, dividing  it into two or three por-
tions.  Lastly,  in some cases the nipple becomes ulcerated, and part, or
nearly the whole, destroyed.   Each  attempt at suckling makes the nipples
worse for some time, and occasions them  to bleed.   The torture to the
patient is very  great,  and it requires all her fortitude to persist  in  nursing
at the cost of so much suffering.
  But this is not all;  for if the  inflammation be great, it is propagated
along the lymphatics to the mammary gland, and then  gives rise to inflam-
mation and abscess ; and, indeed, I  believe  this to  be one of the most fre-
quent causes  of abscess.
  865. Treatment. — To prevent this disorder the nipples should be washed
with soap and water, and dried, and afterwards  bathed with spirit and water,
night and morning, during the last month  of pregnancy.  In many cases this
will  be successful.  A combination  of  white wax and  butter is  a popular
remedy, and  is  often useful.   Stimulating ointment, such as ung. hyd. nit.,
diluted with axunge, is sometimes  of service;  or the parts  may be touched
with burnt alum, nitrate of silver, or dusted  with some mild  dry powder.
  When  excoriation or "chapping" has occurred, spirit lotions may be ap-
plied, or  one formed  of sulphate  of alum, zinc, or copper, acetate of lead,
etc., is dissolved in rose water;  but the one I have found most effectual is a
weak solution of nitrate of silver,  to be applied after each time of suckling
— care being taken to  wash the nipple previous to the next application of
the child.   Mr. Druitt recommends  a solution  of five grains of pure tannin
in an ounce of  distilled water.1  Dr. Johnson thinks highly of the following
lotion and ointment, which may  be applied alternately,  or either alone:2

            Subborat. sodae, ^ij.
            Cretae praecip., 3j.
            Spt. vini,
            Aqua? rosae, a a ^iij.   M. Ft. lotio.

  1 Braithwaite's Retrospect, vol. x.      "M'Clintock and Hardy's Midwifery, p. 14. 
         INFLAMMATION AND  ABSCESS  OF  THE BREAST.      609

         R Ceras albas, givss.
           01. amygdal. dulc. gj.
           Mel. despumat., §ss., dissolve ope caloris, dein adde gradatim
  Bals. Peruvian, giiss.
          Ft. ting.

  Drs. M'Clintock and Hardy speak  highly  of tincture of catechu in simple
excoriated nipples.
  In two cases of  ulcerated or fissured nipples, Prof.  Simpson  drew the
edges together, and  covered them over  with  a pretty strong layer of the
solution of gun-cotton.  This maintained the edges so firmly together, that
suckling  did  not reopen them, and consequently they soon healed.  I have
tried it, but with a less successful result.   M. Bourdell has recommended the
application of lint  soaked in tinct. of benzoin, and repeated frequently, so
as to form a coating over the sore.   It is painful at first, but not afterwards.1
  Various  mechanical means  have  been contrived  to  cure the  disease.
Nipple shields, of wood, ivory, or silver,  may be procured, which intervening
between  the  child's  mouth and  the nipple, will often relieve the irritation
altogether.   But in many cases the child  cannot draw the milk through
them, and then we may have recourse to "calves' teats," properly prepared,
or to a piece of chamoise leather, shaped and protruded in  the form of  a
nipple, and  pierced with  many  holes.  If any of  these plans succeed, the
nipple will heal in  a few days, and the child may be again applied to it.
  Feeding the child two or three times in the day, or giving it to  another
person to nurse, will facilitate the cure,  provided we do  not allow the milk
to accumulate too  much, in which case inflammation may be excited, and
terminate in abscess.
  In very few cases is it necessary to give up suckling. Even if our remedies
fail,  the irritation will  generally subside in a fortnight or three weeks.
                       C HAPTER  XXX.

          INFLAMMATION AND  ABSCESS OF  THE BREAST.

  866. Females are obnoxious to inflammation of the breast during preg-
nancy, after delivery, and at  any period  of suckling;  but more  especially
with first children, and during the first three months of nursing.
  867. Causes. —The irritation aud congestion  which take place from the
secretion  of milk vary in amount.   If these  be  within  certain limits, the
secretion  takes place with slight feverishness  for a day or two ;  if beyond
these limits, the breast becomes hot, tense  and  painful,  and unless the usual
means reduce this external irritation, it will run on into inflammation and
abscess.   This excessive  congestion  may  be regarded  as one of the most
frequent  causes of mammary  abscess,  soon after delivery, and  with  first
children.   Dr. Burns observes, " Some have  the breasts prodigiously dis-
tended when the  milk  first comes, and the hardness  extends even  to  the

                           iL'Union Med., 1858.
       39 
610     INFLAMMATION AND  ABSCESS OF THE  BREAST.

axillae.  If, in these cases, the nipples be flat, or the milk do not run freely,
the fascia, particularly in some habits, rapidly  inflames.  Others  are  more
prone  to have the dense substance in which the acini and ducts are em-
bedded, or  the  acini  themselves,  inflamed."1   Exposure to cold,  mental
emotion, moving the  arms  too much at the  time  the  breasts are so much
enlarged, are  all said to give rise to it.  Inflammation very frequently ex-
tends itself from the nipples, along the  lymphatics, to  the deeper tissues, as
already mentioned.
   868.  Symptoms.—The severity of the symptoms will depend  upon the
depth  and extent of the inflammation.  When the subcutaneous cellular
tissue and  the skin alone  are involved, there will  be  some local pain and
soreness, with a circumscribed hardness and  tension, and a blush of inflam-
mation upon the skin.  But when the fascia or gland is involved, the pain
is very severe, extending to the axilla ; the swelling considerable, the tension
great,  and the constitution  suffers proportionably.  The pulse is quick and
full, the skin  hot, there are headache, thirst, sleeplessness, etc.   The  skin
covering the inflamed part may be of a uniform red, or red in patches.  If
the  gland  be inflamed, the breast has a nodulated feel, as if it consisted of
several large tumors.  The secretion  of milk is, at least  for a while, sus-
pended ; but it will take place after the acute stage has somewhat subsided.
   After the inflammation  has continued for some  time, suppuration  takes
place,  and  the matter makes  its way to the surface.   This occurrence  is
marked by shivering, followed  by  heat and perspiration, and a sense of
fluctuation in the tumor, which is prominent and smooth.   The  pointing is
frequently  in the neighborhood of the nipple.   By degrees the intervening
substance is  absorbed, and the  cuticle  giving way, the matter is evacuated.
The matter of superficial abscesses is simple, or, as it is called, " laudable"
pus; but when the abscess is more extensive, sloughs  of cellular tissue and
fascia  are discharged.  In  a healthy person,  when the matter has been com-
pletely evacuated, the abscess soon  heals up, leaving only a degree of hard-
ness for some time.
   Such is the general course  of the disease ;  but there are some  important
variations.   " It sometimes happens,"  says Dr. Burns, "if the constitution
be scrofulous, the mind much harrassed, or the treatment at first not vigilant,
that a very protracted and even fatal disease may result.   The patient has
repeated and almost daily  shivering fits, followed by heat and  perspiration,
and accompanied with induration or sinuses in the breasts.  She loses her
appetite, or is constantly sick.   Suppuration slowly forms,  and  perhaps the
abscess bursts ;  after which the  symptoms abate, but are soon  renewed, and
resist all internal and general remedies.   On inspecting the breast, at some
point  distant from the  original opening, a degree of oedema  may be dis-
covered—a never-failing sign  of deep-seated matter there ;  and by pressure,
fluctuation may be ascertained.   This may become distinct very rapidly, and
therefore  the breast should  be carefully examined  at  least  once a  day.
Poultices bring  forward the  abscess, but too  slowly  to  save  the strength,
and therefore the new abscess, and every sinus which  may have already
formed or  existed, must be  at one and  the same time  freely and completely
laid open ;  and so soon as a new part suppurates, the  same operation is to
be performed.   If this be neglected,  numerous sinuses  form, slowly dis-
charging foetid matter, and both breasts are often thus affected.   There are
daily shiverings, sick fits, and vomiting of bile, or absolute loathing at food;
diarrhoea, and either perspiration, or a dry, scaly, or leprous  state  of the
skin ;  aud sometimes the internal glands seem to  participate in the disease,
as those of the mesentery ;  or the uterus is affected, and matter is discharged
i Midwifery, p. 623. 
INFLAMMATION  AND  ABSCESS OF THE  BREAST.      611
from the vagina.   The pulse is frequent, and becomes gradually feebler —
till after a protracted suffering of some months, the patient sinks."1
  869.  Treatment.—The first indication is to subdue the inflammation, and
to prevent the formation  of  an abscess.   For this purpose, the patient  may
be bled if the fever run high ; or a number of leeches  may be applied, and
repeated if  necessary, followed  by a large  soft poultice, or fomentations.
When the bleeding has  ceased, the  poultice  or fomentations may be  con-
tinued ;  or  an evaporating cold  lotion  substituted.   " A convenient and
simple mode of applying  warmth is to immerse a wooden bowl in hot water,
and having  wrapped  some flannel around the breast, place  it in  the bowl.
By this means an effectual and equable warmth may be kept up for a con-
siderable length of time."2
   The bowels should be  briskly purged by saline medicines,  and  their effect
is much increased if  tartar  emetic, in moderate doses, be joined with them.
"I have been in  the habit of combating this affection in a way first com-
municated to me  by my friend the late  Mr. Gregory, who employed it with
great success in  the Coombe Lying-in  Hospital.   The  remedy to which I
allude is tartar emetic, whose power of controlling inflammatory affections
of the breast would lead  one to imagine  that it excited a specific  actipn  on
the  mammary gland.  On  the accession of inflammatory symptoms in the
 breast, after purging the patient, I administer this medicine in doses of one-
 sixteenth of a grain,  repeated every hour, so as to induce slight nausea.  It
 is never my object to cause free vomiting; and  if this  should occur, I omit
 the  medicine for  an hour or two, and  then recommence  its use  at longer
 intervals.   In  ordinary  cases, I usually find, after twenty-four hours,  that
 the pain and fever are mitigated, and the breasts are smaller and softer."3
 Indeed, this medicine has a more powerful effect in abating inflammation of
 the breast than anv I have  ever tried.   The diet should be bland, and chiefly
 fluid.   The milk  should be gently drawn away at intervals, and the breast
 supported by a sling.
   When we find  that our efforts are unavailing to prevent the formation of
 matter,  the  second  indication must  be fulfilled.   We must facilitate  it as
 much as possible, and by no means can it be  done more effectually than by
 constant  poulticing—changing the  poultice  three  or  four times  a  day.
 Opium alone, or in combination with salines, should  be given, to lessen the
 pain and induce sleep.                                            •   n.
   There is some difference of opinion  as  to  the propriety of opening the
 abscess when the matter is detected.   My own  experience coincides with
 Cooper's rule : " Perhaps,  as a general rule, the surgeon should never wait
 for an abscess of  the breast to approach the surface, but make an opening
 as soon as the slightest  degree  of fluctuation is perceptible; for  if this be
 not done, and the-abscess is not very superficial, the matter  will spread and
 form  sinuses in   different directions/   Sir A. Cooper  remarks:   If  the
 abscess be quick in its progress ; if it be placed on the anterior surface of the
 breast • and if the sufferings which it occasions are not excessively severe, it
 is best'to leave it to its  natural course.   But if, on the contrary  the abscess
 in its commencement is  very deeply placed-if its progress be tedious- f the
 local sufferings be excessively severe-if there be a high degree o  iintati e
 fever  and  the patient  suffer from profuse perspiration,  and v>ant  of  est,
 much rime  is saved, and pain avoided, by discharging the matter with a

 lawieli quite  superficial,  a longer  delay may be allowed ; but I am quite

   ,,,.,  .,      ro-              2 Earle, London Medical Gazette, vol. x. p. 153.
   ! RS Dublin Journal, vol. iv. p.  840  « Cooper', Surgical Dictionary, p. 946.
   5 Sir A. Cooper on Disease of the Breast, p. 10. 
612     INFLAMMATION AND  ABSCESS OF THE  BREAST.

satisfied  that it is better to open  them than to allow them to open spon-
taneously.
  After the matter is discharged, the diet may be improved ; and if a con-
siderable discharge continue, tonics may be  necessary.   The  opiate at night
may be continued for a short time,  and then omitted.  If the abscess be
small, the child may suck the affected breast;  but if large, it had better be
artificially  drawn, and  the infant confined to the  other breast.  In some
cases the child  must be removed altogether, as the suckling may lead to
abscess in  the  sound breast.   When all inflammation  has ceased,  but the
abscess still continues to discharge, especially in large ones, the cure will be
hastened by strapping the  breast with adhesive plaster, as recommended by
Mr.  Phillips, and by Drs. M'Clintock and Hardy.1
  When sinuses  form,  the only remedy is  to lay them  all open.   It will
require care to prevent the patient sinking.   Wine,  bark, and good diet will
be necessary.
                        1 Pract. Observations, p. 16. 
APPENDIX.
                    "OBSTETRIC  MORALITY."


   [I  have  added the following essay as an Appendix because of the im-
 portance of  the subject, and because I know of no English author who has
 entered as fully into  the subject.   I should  be very sorry to be regarded as
 the advocate of craniotomy, but I may well contend for its employment in
 certain cases, inasmuch as I have always labored  to restrict their'number,
 and to substitute the forceps when possible.   The  essay is  reprinted nearly
 verbatim from the " Dublin Quarterly Journal," and I have thought it better
 not to alter  its form.]
   My attention  having been called to an  article  in the Number of " The
 Dublin  Review" for April, 1858, p.  100, on "Obstetric  Morality," I have
 thought the subject of sufficient importance  to bring it before the Obstetrical
 Society.   The article is written  to show the immorality of the operation of
 craniotomy under any circumstances, if the child be alive ;  and although the
 question has been repeatedly debated in  former times, yet as it is compara-
 tively new to the present generation,  it  appears to me very  desirable  that
 those who are now practising midwifery, and those who are preparing to
 practise it, should know the precise reasons for  admitting or rejecting the
 operation.
   I have read the review over very carefully several times, as dispassionately
 as I  could,  and I am free  to confess that I am satisfied neither with the
 theological nor obstetrical  reasoning of the author; I strongly suspect, in-
 deed, that the writer is not a medical man.
   If any apology be needed for my taking up the subject, I trust it will be
 found in the fact that  one  of my works (conjointly with  Dr.  Maunsell's) is
 taken as the  exponent of this "Obstetric  Morality."   Of the tone of the
 review towards myself, though somewhat uncharitable  in its  imputation of
 motives, I make no complaint; but I should have preferred the third edition
 of my work being taken as the  expression of my  present views, instead of
 the first edition,  published sixteen years ago.
   In the observations which follow I shall discard  all personal feelings, and
 simply confine myself to the question in debate,  and I shall endeavor so to
 treat the subject as to give no offence to those who may differ from me.  lu
 a mixed question like  the  present, it is perhaps  improbable that  all should
 agree, but in  differing, it is surely possible that each  may give  the other
 credit for the highest motives, and respect him for his conscientious adherence
 to what he thinks right.
  The question  at issue, the morality  or immorality of destroying a living
child by craniotomy—has always been regarded in a threefold  aspect, moral,
theoloo-ical,  and  obstetrical, the  latter  resting on  and inseparably connected
with the former,  at least in the opinion of one party; so that, although this
is not the place for a moral  or theological dissertation, nor I the most com-
                                                            (613) 
01 1
OU.STETRIC  MORALITY.
   petent person to undertake it, yet it is impossible to avoid the subject entirely.
   I shall, however, confine myself to a  short statement and examination of the
   arguments: with this  advantage, that  the reviewer, having  based his theo-
   logical reasons upon Holy Scripture, an authority to which I implicitly bow,
   we have, so far, common ground.
      I.  In the first place, the reviewer  objects to  the destruction of an unborn
   babe  on the grounds that it is a breach of the  sixth commandment, " Thou
   shalt  do no  murder ; " and also that  it is contrary to the  denunciation in
   Genesis ix. 6 — "Whoso sheddeth man's  blood,  by man shall his blood be
   shed,  for in the image  of God made He man."  If the latter text be more
   than  authorization of  capital punishment  for murder, which I do not deny,
   it is  clear that it must be subject to limitation, otherwise it would prohibit
   killing in  self-defence, or in defence of another, which is considered lawful
'  by the Roman Catholic Church, and it would render war unlawful.  If, then,
   it be  thus modified, there is  no reason why the limitation  may not be  ex-
   tended so as to include the operation in question, provided I can show, that
   it cannot justly be considered a  breach  of the sixth commandment.
      What, then, constitutes murder, and in what does it essentially differ from
   killing or homicide?  For our present  purpose we  shall  derive the best
   assistance  from the law of the land, which is the highest practical exponent
   of the law of morals.   I am indebted to  a distinguished legal friend for the
   following definitions : — " Murder is the killing any  person under the king's
   peace with malice prepense, or aforethought, either express or implied by
   law :" so  say Lord Coke, Sir Matthew Hale, Sergeant Hawkins, etc.  " Of
   this description, the malice prepense,  malitia precogitata, is the chief char-
   acteristic,  the  grand criterion by which murder is  distinguished  from  any
   other species of homicide."1  It should, however,  be  observed, that when
   the law makes use  of  the term  malice aforethought as a description of the
   crime of murder, it is not to be understood merely in the sense of a principle
   of malevolence to particulars, but  as  meaning that the  fact has  been
   attended with such circumstances as are the ordinary symptoms of a wicked,
   depraved, and malignant  spirit, a heart regardless  of social duty,  and
   deliberate*/ bent upon mischief."2
      This malice may be either express or implied by law.  Express malice is
   when one person  kills another  with a sedate, deliberate mind and  formed
   design : such formed design being evidenced by  external circumstances, dis-
   covering the inward intentions,  as, lying in wait,  antecedent menaces, former
   grudges, and concerted schemes to do the party  harm.3
      Malice  is implied  by law  from any deliberate and  cruel act, committed
   by one person against another,  however sudden, thus, when a man kills an-
   other suddenly, without any,  or an  inconsiderable provocation, the law im-
   plies  malice, for no person, unless of  an  abandoned heart, would  be guilty
   of such an act upon a slight or no apparent cause.4
      I think  it will be at once admitted  that  killing a child in utero, which I
   shall  prove  can be by no  means born alive,  and which must die in a few
   hours, but the  prolongation  of whose life,  even for those few hours, will
   most seriously, if not  irreparably, endanger  that of the mother, cannot be
   brought under the definition of murder; there  is  no malice aforethought
   expressed or implied ;  it is done from necessity, and without any evidence
   of a  "wicked, depraved, or malignant spirit:"  it is not, therefore,  in any
   true  sense murder.   Had there  been the slightest reason for thinking it so, I

      1 Blackstone's Commentary, vol. iv. p. 198; Gustinean's case, 1 Leach, p. 457.
      2 Justice Foster's Crown Law, pp. 256, 202.
      3 1  Hale,  451 ; 4 Blackstone's Commentary, p. 199.
      4 East's  Pleas,  of the Crown, cap. v. sect. 2, p.  215; Blackstone's Commentarv, vol.
   iv. p.  200. 
OBSTETRIC  MORALITY.
615
have no doubt that there would have been a provision made by law, just as
there has been against criminal abortion : so far from this, " an  infant in its
mother's womb, not being in rerum nature, is not considered by law as a
person  who can be killed within the description of murder."1
  Killing or Homicide is by law divided  into three kinds : it is either justi-
fiable, excusable, or felonious.   It is justifiable where the killing arises from
imperious  duty prescribed by law, as the lawful execution of a criminal; or
is owing to some  unavoidable necessity, as in the case of an attack on life,
property, or chastity, where the death occurs in self-defence.  This is admitted
by the  Roman Catholic  authorities, for I find in a little work, with the im-
primatur of the Most Rev. Dr. Cullen, the following : — "It is not a sin to
defend your own life or another's life, chastity, or property of great value,
when  unjustly attacked, even though it cannot be defended without taking
away the life of him who attacks it."2
  It is excusable — 1.  In case  of death  by  accident, without  any culpable
neglect or default, and whilst engaged  in lawful occupation or amusement.
2. When  death  occurs in protecting one's self from an assault, or the like,
in the  course  of a sudden affray, where the  slayer had no  other probable
means  of escaping from his assailant.
  It is felonious  in the case  of murder or manslaughter.
  Now I shall be able to show that craniotomy, under proper circumstances,
is "an unavoidable necessity," and if, therefore, it be legally justifiable to
take one life for the protection of another, we  have precisely the conditions
applicable to  our case, with this additional justification, that the life we take
is forfeited, i.  e., it will inevitably cease, as the child cannot be born alive.
  It is the more important to be satisfied on this point, for it is clear that,
so far as craniotomy is concerned, it must be decided on moral grounds, in-
asmuch as, whether the child dies in utero or is  killed, baptism is equally
out of the question.
  There is an argument frequently used by the reviewer,—" that we are not
to do  evil that  good may follow," about which  a  few words  may not be
amiss.   It is perfectly true, as  an  aphorism, but, used as  the reviewer uses
it, it is a petitio principii, for the "evil" is the very point in dispute.  Again,
what is meant by " evil ?"  Pain is an evil, yet we  inflict pain to save life,
—" doing evil that good may come."  That, therefore, cannot be the mean-
ing.   It  must be moral  evil,  something involving  guilt, which  would be
unlawful.
  Moreover, in the way in which it is applied by the reviewer, it is an accu-
sation  by implication, "we may not do evil," etc., which  is what you pro-
pose to do.   It may  "be slanderously reported, and some may affirm that
we say, Let us do evil that good may come;" but in the  true sense  of the
word "evil," we repudiate the principle  as  strongly as the  reviewer or the
Roman Catholic  Church.
  II.  But the second and graver objection, and one that seems to underlie
the former, is, that in destroying the  fcetus  in utero we destroy both  soul
and body, because it  cannot be previously baptized.  It is only fair to give
the reviewer's own words on this subject : — "It is no less certain that this
soul, which has been created by God, and infused into  the body at the first
moment of existence, has, in the language of holy David, been conceived in
iniquities, that is, that it has inherited the stain inflicted on all his posterity
by the prevarication of Adam.  Nothing defiled can enter into heaven, and
the defilement of this soul can  only be washed out in the waters of baptism.
To it,  in common with  all mankind, have been addressed the words of the
Saviour,  ' Unless a man be born again of water and the Holy Spirit, he can-

  1 1 Hale  P. C. p. 433-    2 " What Every Christian must Know and Do." p. 23, note. 
616
OBSTETRIC  MORALITY.
 not enter the kingdom of heaven.'  It is strange that those who profess to
 be guided exclusively by Scripture should deny that the external rite of bap-
 tism is necessary to salvation, for it is plainly and  repeatedly inculcated in
 the Word of God.  That the second birth by water and the  Holy (J host,
 spoken of in John iii., means the external rite of baptism may be inferred
 from  the fact that our Lord's disciples  soon after began to baptize, as we
 learn from the beginning of the following chapter.   The word 'to  baptize,'
 signifies 'to wash:' and  on the very last occasion  on which our Lord ad-
 dressed His Apostles after His resurrection, He told them : "All  power is
 given to me in heaven and in earth.  Going, therefore, teach ye all nations,
 baptizing them in the name of the Father,  and of the Son, and of the Holy
 Ghost.'  When the people  were  melted to compunction  of  heart by St.
 Peter's first sermon, they asked what they should do ?   ' But Peter said to
 them, Do penance and be  baptized, every  one of you, in the name  of Jesus
 Christ,  for  the  remission  of your  sins.   They therefore that received his
 word were baptized.'  That this baptism was by water is manifest by what
 occurred when Philip preached Jesus to the eunuch ;  for ' as they went on
 their way, they came  to  a certain water, and the eunuch said,  See, here is
 water, what doth hinder  me to be baptized  ?   And they went down into the
 water, both  Philip and the eunuch,  and he baptized him.'  Ananias told St.
 Paul, when  sent to him by God, ' Rise up,  and be baptized, and wash away
 thy sins.'  So also, when St. Peter saw the Holy Ghost falling on the Gen-
 tiles, he  exclaimed, 'Can any man  forbid  water, that these should not be
 baptized ?'   This idea is strongly conveyed in various places by St. Paul.
 ' Christ loved the Church,' he says,  ' and delivered himself up for it, that he
 might sanctify it, cleansing  it by the laver  of water in the word of life.'
 Again,  he calls the ' laver  of water,' the 'laver of regeneration, and renova-
 tion of the Holy Ghost,'  alluding manifestly to our Lord's words (John iii.),
 and thus clearly establishing that  the regeneration,  without which no  one
 can enter into the kingdom  of God, is baptism by water.   ' Not,' he says,
 ' by works of justice which we have done,  but according to His mercy he
 saved  us, by the laver of regeneration, and the renovation of the Holy
 Ghost.'" —p. 125.
   Now, putting aside the  question  of when the soul is  first joined to  the
 body, on which  subject  Holy  Scripture is  silent, I  am  quite prepared to
 admit simply and implicitly the authority  of the texts quoted.  I do  not
 deny that baptism was by water, nor that baptism is one of the sacraments
 " generally necessary  to  salvation;" but all  these texts  involve one condi-
 tion, viz., the possibility  of baptism.  This,  I think, must  be  admitted prima
 facie, and I object to apply such texts to cases for which  we  have no shadow
 of proof that they were intended.   It appears to me that the blessings of
 baptism, and the penalties for its neglect, can be  and were intended only to
 apply to those children  whose baptism  was possible.   The duty  and  the
 power must  be correlatives.   Now of children dying in utero nothing what-
 ever is said in Holy Scripture, yet my reviewer deduces, from the texts above
 quoted, the  doctrine  that the souls of such  children are lost.  As I have
 said, I cannot give him textual authority for the contrary, but I can adduce
 an example which proves my point completely.  When the thief on the cross
 said, " Lord, remember me  when thou comest into Thy kingdom," the answer
 was,  "This  day shalt thou  be with Me  in paradise."  Of his salvation,
 therefore, there cannot be the slightest doubt, and vet—he was not baptized.
   Of course, if the reviewer had stated that the operation of craniotomy
 had been prohibited by the Roman  Catholic Church, there would have been
no necessity for argument.1  The members of that Church would feel bound
  1 1 do not pretend to determine the exact authority of the following extract, although
it is not improbable that it may have been the " exciting cause" of the review: — " Sedu- 
OBSTETRIC  MORALITY.
617
by its decision, and it would have been  no business of mine to contest  the
point; but as he has made it depend upon reasoning from Holy Scripture,
I have felt quite at liberty to question the accuracy of his conclusions.
  The teaching  of the Church  of England  and Ireland  on the subject of
baptism is to be  found in  her Book of Common Prayer, and is so accessible,
and  indeed so well known, that any detail is quite  unnecessary here.   She
recognizes baptism as one of the  sacraments " generally necessary to salva-
tion," and declares that "it is certain by God's Word, that  children which
are baptized,  dying before  they  commit actual sin, are undoubtedly saved."
But in accordance with her declaration that " Holy Scripture containeth all
things necessary to salvation :  so that whatsoever is not  read  therein,  nor
may be proved  thereby, is not to be required of any man that it should be
believed  as an  article of the faith,  or be thought requisite or necessary to
salvation  :" not  having found any expression as to the result to those dying
unbaptized, when baptism  is impossible, she is silent, content to leave their
future lot to the loving-kindness and tender pity of Him who died for all.
   Morally  and  theologically, then, the  case stands thus : — My  reviewer
contends  that destroying  the child in utero is murder.   I have  proved, on
the  highest legal authority, that this stigma  is unjust, and that it does  not
come under any true definition of murder, inasmuch as it involves no malice ;
that it is  even something less than justifiable killing, inasmuch as the child's
death is inevitable without our interference ;  we do but hasten it.
   Again, he maintains that baptism being a sacrament  essential to salva-
tion, all children dying or destroyed in utero are lost.   I say, on the contrary,
that his  authority from  Scripture fails, inasmuch,  as in  the cases  quoted
baptism was  possible ; whereas  in these it is not whether the  operation be
performed or not: and I have  given one undoubted instance  of  salvation
without baptism, where  its  administration was  impossible.  For my  own
part, whilst I  feel the tenderest  regard for the lives of these innocents,  and
 would do my best to preserve  them, if that fail,  I have  no fears  for their
 souls for  whom  Christ died, but look  forward with sure and certain hope to
their resurrection to  eternal life.
   III.  Now  let us turn  to the  obstetrical  side of the  question : and  our
first endeavor must be to recognize,  and in recognizing to define, the limits

lam  operam dent sacerdotes, ut quantum poterunt, impediant nefandum illud scelus quo,
 adhibitis chirurgicis instrumentis, infans in utero interficitur.   Omnis foetus quocunque
 tempore gestationis editus, baptizetur, vel absolute, si constet de vita; vel sub conditione,
nisi  evidenter patent eum vita carere."—Deereta Synodi plenarice Episcoporum Mbernice,
 apud Thurles habitoe anno 1850.   Article "De Baptismo," p. 20.
   On the other hand, authorities are  not wanting to justify the limited use  of the opera-
 tion  For example in the learned work of Migne, "  Theologise cursus completus," (Paris,
 1839) at page 483 of vol. xiv., in a note we read as  follows concerning remedies likely to
 cause the  death of  the foetus: — "  Dicebit administrate remedii, ....  si  nulla  spes
 affuleeat prolem baptizandi,  nam salus matris ad minus tanti est quam sains temporalis
 et momentanea prolis, imo magis preponderat;  illicitum erit, si spes probabilis affulgeat
baptizandi prolem."                             .        .            .    oro,
   Lain if we turn to the works of St. Thomas Aquinas (Pans, 1839, vol vi.  p. 2oo)_we
 find this'sentence • — " Si certum esset, non adhibito remedio, foetum cum matre pentu-
 rum et^e contra certum aut probabile, adhibito remedio, matrem salvavivi, multi existi-
mant quod tunc liceret adhibere remedium, quia in his circumstantns vix in aestimationem
venit salus prolis  certo  peritune, indeque jus  habet mater sibi consukndi.   It is only
 fair  to say that St. Thomas is himself doubtful on the point, but it is quite enough for my
nnrnnsp that '-multi existimant.
P Las ly  St. Alphonsus Liguori, in bis " Homo Apostolicus," 1837, p. 186, says:-«Puto
 omnino tenendum    . . pnebere medicinam matri cum penculo fcetus animati hcere  in eo
sok"casu  quo  nulla spes appareat rationabilis de  prolis vita,  ut  possit baptizan, post
matris mortem.'^   ^    ^ certain, either that I  do not deserve  the hard epithets the
Reviewernhns bestowed upon me with so liberal a hand ; or that they apply with equal
justice to  these authorities. 
613
OBSTETRIC  MORALITY.
of the responsibility devolving upon the accoucheur, both as regards the
child and the mother.
  No man possessed  of common human feelings, particularly if he  have
children of  his own,  can fail to  feel the utmost tenderness  towards the
feeble being  he is to  usher into the  world.   Even if  we leave  the soul out
of consideration,  the  fact of a human life being  involved will  be sufficient
to insure  the utmost efforts  of  skill and attention.   The accoucheur is
responsible that no hygienic arrangement shall be neglected, no errors  of
management committed, and no assistance withheld, either during the labor
or afterwards, which may tend to secure  life  and  health to the  child.  The
records of modern practice show  how steadily this  object has been  kept in
view.   The improved management of the first stage of labor has shortened
the duration  of the second, by the prolongation of which the life of the  child
is threatened.  The action  of the second stage, when too tedious, is  often
quickened by the  ergot of rye, and we are saved the necessity of a recourse
to instrumental assistance.   And  when we are obliged to assist in this way,
I am  certain that in every case where there is a posssibility of success, those
instruments  are preferred which involve no necessary injury to the child.  A
comparison  between the relative  frequency of operations with  the  forceps
and crotchet at present and  in former times, both in the Rotundo and other
hospitals,  will bear out the  truth  of this remark.   And in all  the modern
text-books,  this rule  is emphatically laid  down.   For myself  I can  truly
assert that I have always taught this in my lectures and  in  my writings,
and in practice I have  rigidly followed  the  same  principle, that the  child
is to  be saved, if  possible.   I therefore  demur to the reviewer's sweeping
assertion that we  evince great indifference  to infantile life.   The saddest
consummation  of  an  anxious attendance is the necessity of hastening the
death of  an unborn  babe,  in order that the mother's death  may  not  be
thrown upon ns also.
  But although the reviewer says little about it, we must not forget that we
are equally  responsible  for  another life,  the mother's,  and  that  of im-
measurably  present value to  her  family and to  society ;  and  special pre-
cautions are  accordingly taken.   Much of the care to which I  have  alluded
is equally for the  benefit of the mother, and if some risk  be  occasionally
incurred to secure a living child,  extraordinary care is taken to render that
risk as  small as  possible.   The responsibility does not terminate with de-
livery, but extends until  complete recover}'-.   For one moment just look at
the interests  involved in this recovery.   The husband, whose  happiness is
bound up in  the  life  of his  wife,  and who has intrusted that to us  ; other
children, it may be, whose well-being is dependent upon their mother ;  to
say nothing of a  circle of friends and dependents who look to  her for com-
fort and guidance ; and all these interests now hanging in the balance, form
very onerous items in  our calculations of responsibility.
   Such responsibility we incur every day, in every case, but it is only felt
as a heavy burden in difficult or impracticable  cases.  Then we feel that
there must be some limitation to  it, inasmuch as our power is restricted:
we  do not hold  life  and death  in our  hands—we do  not determine the
character of the  labor.   What,  then, are those limits beyond which our
responsibility does not extend ?   It  appears  to me, that our responsibility
is exactly in proportion to our command of the essential conditions  of
success.   Not that we are responsible for success, for that depends  upon a
Higher Power; but that, as far as we are concerned, all the means  of suc-
cess within our control shall be  applied  in  a manner and  at a time  most
likely to insure it.  Now the  first and most essential condition, both for the
mother and the child, is  timely delivery, and if we have the power, we are
responsible for its exercise in such a manner as will benefit both.   Suppose, 
OBSTETRIC MORALITY.
619
for example,  a case of powerless labor, suitable for the forceps ;  if we care-
lessly allow the  labor to  continue so long  as to  involve  the  death of the
child, we are as much responsible for its death as  if we had had recourse to
destructive instruments, instead of deliverinp: it by the forceps.
  But if it be physically impossible that the  child  can be born  alive, then
I hold that the  accoucheur's responsibility for its life ceases  entirely,—no
blame can  rest upon him  for its death.  Nor do  I  believe that he  can be
held responsible in the ordinary meaning of the term, although,  in the case
supposed, he has to hasten the child's death to secure another life, for which,
so far as delivery is concerned, he is unquestionably, and in the fullest sense
of the word,  directly responsible.
  For I would beg you to consider seriously the different position in which
we  stand  as  regards  delivery, towards the child  and towards the mother.
Delivery is essential to the safety of both ;  it may be incompatible with the
life of the child,  but  it can  always be accomplished  before the life  of the
mother  is  seriously compromised.  Having, therefore, the command  of the
essential condition of success,  the  full responsibility rests upon us, that so
far, the mother's life  shall be insured ; and as all responsibility for the child
has ceased, we say that the mother becomes our sole object.
   It  is the due appreciation of these relative responsibilities in difficult cases
that distinguishes the wise and experienced accoucheur:  he preserves a just
equipoise between them so long as it  is possible to fulfil both, and recognizes
the proper moment when one ceases.   One, I say, not either:  for I protest,
as  strongly as my reviewer,  against the notion  which he  attributes  to us,1
that  we choose  which of the  two  lives we shall save, a notion as false in
theory as it is in practice.   No  man  dare make such a choice, for we have
neither the necessary  knowledge, nor the right,  nor the authority, to decide
which is the  more important life, and best  worth preserving.
   And  no one ever does make such a choice.   Perhaps the least suspicious
evidence I can adduce is to  refer to the  cases to which, in my own book, the
 operation  of craniotomy  is said to be applicable.   You will  find that, in all,
the child is either presumably dead, or the labor is mechanically impracticable
 with  safety to the child.   So that, without hesitation  or  limitation, I would
lay it down as a canon,  that craniotomy is never to be contemplated when a
 living child  can,  by any  means compatible with, the safety of the mother, be
 delivered  "per vias naturales," and upon this  rule I invariably act.
   This rule  happily limits the number of such  painful cases;  yet, although
 not numerous, instances do occur in which I believe craniotomy to be not
 only necessary and justifiable, but  imperatively demanded, even though the
 child be  alive,  if we would not voluntarily  incur  the  responsibility of the
 mother's  peril,  and  perhaps  death ;  and  upon  this class of cases  I  shall
 trouble the Society with some  observations in  answer to my reviewer.   He
 especially  refers to cases of mechanical disproportion from narrowness of the
 pelvis, and from a hydrocephalic head.  Both these classes, and some others,
 involve  merely  questions  of  mechanical  disproportion,  and may,  for our
 present purpose,  be treated  together ; but I shall add a few words separately
 on hydrocephalic children.
   1 The reviewer states that "this seems to have been the opinion  of the French doctors
 who attended  the Empress Maria Louisa during her accouchement,  for they consulted the
 first Napoleon as to whether they should spare the mother or child in case they found it
 necessary to  kill one of them."   I believe  that this is about as true  as the phrase
 attributed to  General Cambronne,—" Les  guides meurent mais ne se rendent pas ;"  or
 Wellington's " Up, Guards, and at  them," both  of which were denied  by the  supposed
 authors  In  truth, M. Dubois was too  experienced a  man to make such a speech ;  if
 anvthin" like  it was made, it was, probably, a request to know whether the  mother was
 to be alloyed to die  because the child could not be born alive.  And let me just remind the
 reviewer in anv case, that the parties were of his own Church. 
620
OBSTETRIC  MORALITY.
  Now in order to meet the question fairly, I shall assume that we have to
deal with the case of a pelvis so narrowed  at  either brim or outlet that a
living child, even aided by the  forceps,  cannot pass, but through which a
mutilated child  can be extracted, without undue risk of injury to the mother;
and it matters little to the argument whether the difficulty be from deformity
of the bony tissue, from a fixed irreducible tumor, or from excess of bulk on
the part of the child.   I say I must assume, for the sake of the argument,
such a case, although I am  met  at the outset by the objection on the part
of the reviewer, that in practice we cannot be  sure of such cases, for that
there is little  certainty, and no uniformity, in  the  measurements given  by
authors ; that,  in fact, they are  not agreed  about the size  of the aperture
through which a living child cannot pass.  This is certainly true, though the
difference is not great, and it is  a difficulty which would  be  seriously felt in
many cases if we had to give an opinion h priori, or before the commence-
ment of labor.   But after labor has commenced, the  position  of the ac-
coucheur is quite changed, and he has acquired new and decisive means of
forming a correct judgment.   He can compare  the size of the aperture with
the size of the  child's head, for they are in close apposition : he  has the evi-
dence of what hours  of strong pains can do towards forcing  the  head down-
wards ;  nay, more, he can test the applicability of the forceps, whether they can
be introduced, and whether, when introduced, he can draw down the head.
With these advantages I undertake to say that no man will find any difficulty
in deciding whether a patient can be delivered without craniotomy or not.
   Let me now remind you  of the course of a labor of this kind when left to
nature.   During  the first stage no bad symptoms appear, nor  for some time
after the commencement of the second, nor is the child in present peril; but
after a time somewhat varying  and uncertain,  indications of  constitutional
suffering are developed,—the symptoms of  powerless labor, in  short,—and
from that moment the mother may be said  to  be in danger,  which is fear-
fully increased by every hour's delay  and  suffering.   In process of time
the symptoms become still more formidable, and involve so  much general
derangement that the evil effects continue after delivery:  and if this  be not
effected, the patient  will ultimately die in a state of coma or convulsion, or,
perhaps, before this  final stage,  the walls of the uterus may  give way whilst
we are waiting,  and death result  from  the laceration.   If the  woman be
delivered within  a  reasonable  time  after  the setting  in  of  unfavorable
symptoms, they  shortly disappear, and her recovery  will,  in  almost all
cases, be complete.   If the labor be  allowed to  continue, and  exactly in
proportion to the delay, the recovery will be less favorable, and the danger
after delivery greater, until we  arrive at that  point of  time  when delivery
itself cannot save the mother.  At what period of the  labor the death of
the  child, which  is inevitable, will occur, it is  impossible to  state with any
accuracy.   It does, doubtless,  sometimes take place comparatively early,
perhaps before any very bad symptoms have set in ; but I  feel little doubt
that, as a general rule, it is not until a much later  period, in fact not until
the  mother is in imminent peril, in  many cases  not until the last stage.
   Now, what is the right and proper thing  to be done in such cases ?  The
child we shall assume to be living, but it is physically impossible to extract
it alive through  the passages.  The  mother is in  great danger, which in-
creases rapidly, and  they will inevitably both die if left alone.   We may (at
least for  the present) dismiss the question of baptism, as that is impossible,
whether we craniotomise or  not, and  there are two courses open to us— 1.
To  wait  until  we may reasonably suppose the child to  be dead, and  then
perforate and  deliver, regardless of the consequences to the mother ; or 2.
To perforate as soon as the bad symptoms  set in, after having assured our-
selves of the impossibility  of using the forceps, and  so secure  the life of the 
OBSTETRIC  MORALITY.
621
mother.  The reviewer indicates a third method, the Caesarean section, which
I shall examine presently.   In our choice  of these last two  methods the
reviewer  and I  are at issue ;  the conclusions at which we arrive are diame-
trically opposite.  He chooses the  first, and rejects craniotomy so long  as
the child is alive.  " But it will be  said," he observes," must the accoucheur
fold his arm and allow both mother and child to perish, when he might pro-
bably save one  of them ?  To  this we answer, once  more, that  he cannot
commit murder ;  that he must not do evil in the hope that good may follow;
and that the medical man, like  every other member of  society, must be pre-
pared to encounter in  this dim world a great many calamities which he can
neither remedy or alleviate."  Now I have shown that we  do not commit
murder.   I agree fully in the rule that we are not to do evil that  good may
 follow, but the review'er's use of it in  this place  is plainly a " petitio prin-
 cipal for I deny that we do evil, that is,  morally, or involving guilt; and
 that "doctors  have  to encounter many calamities in  this dim world  which
 they can neither remedy or alleviate," is undoubtedly true, but is this  a case
 in which the doctor can shelter  himself under the comfortable conclusion that
 " he can neither remedy or  alleviate it ? "   Is it  not  quite evident that  his
 voluntarily refusing  to deliver makes him an active, willing  and  responsible
 accomplice in the death of the mother ?
    I  have  no  hesitation in  stating my deliberate opinion,  that the second
 plan which has received the sanction of the best and most distinguished men
 in the profession, is  the right  and the  wise course to adopt, and the one
 which best adjusts and  preserves the balance of our responsibility. For, in
 the first place  I have proved that  the  destruction of a child under such cir-
 cumstances  is  not  murder, but justifiable in law.  Nay,  if you think a
 moment one cannot say that the blame  of the child's death rests upon  the
 accoucheur at all, for that is inevitable if he do  nothing.   All  he is justly
 answerable for is of depriving it  of life a few hours  before it would other-
 wise cease to live.  And for what?   The  mother is  in imminent danger,
 and will die if  assistance be withheld, but  she can be saved now.   I say,
 therefore  if this assistance be not  given, the  accusation of  murder  (by
 omission) would come with  greater force against the party who  voluntarily
 allows  the mother's  life to be imperilled.   Take  lower ground  if you like,
 than the abstract question of right.   Granted, if you please,  that hastening
 the child's death is  an evil: so is the death of the mother :  which of the  two
 is the lesser evil, considering that you cannot prevent the first, and can pre-
 vent the latter ?                       ,.,,,•         "UT t-^f^rxA.
    No good man will  forget that for all his deeds he is responsible to God
 but for our profesional actions  we  have the additional tribunal of professional
  and public opinion.   Narrow the  circle still further, and it  is  clear that each
  of us is specially answerable to the party who has intrusted us with the lives
  most dear to him.   The latter has the most direct and deepest interest in
  both the  objects of our care, and  it appears to  me that it is impossible to
  io-nore  his right to be a party  to whatever decision we come to.
   ° Suppose it to be our painful duty  to announce to  the  husband that the
  labor is such that the child cannot be born  alive, but that it mus be destroyed
  if we hope to save  the mother; nay, that if we  wait until it die,  the mother
  wi       be  so  much the  worse.   Are  there  many husbands  that would
  he  tate ?   Would  not natural feeling and common sense lead him to decide
  that   he  child's  safety being impossible, the  mother s   safety should be
  secured?   If this  be  the case, the accoucheur  who  refuses  to  act must be
  prepared to meet the responsibility he thus incurs towards society   Admit-
  SnT ally that a man's conscience must be his  guide, I do  not think  in a
  case like the  present he can always be  at liberty to ignore  the  consciences
  of others. 
622
OBSTETRIC  MORALITY.
  I have thus endeavored,  I hope not unsuccessfully, to define the position
iu which we stand as regards the mother, in cases where the child cannot be
saved.   I have shown the responsibility which has ceased for the life of the
child, has thereby, as it were, doubled in behalf of the  mother; that quies-
cence on  our part cannot be considered as a submission to necessity, or to
the decrees of Providence ; but that, whether we  interfere or not, we are
equally voluntary, intentional, and active  agents.   That in hastening the
death of the child, we in no sense incur the guilt of murder,  nor are we fully
responsible for its death, which, with  or without our interference, must have
ensued ;  but that if we, by waiting for its death, imperil the mother, we are
in the fullest sense responsible for that result.
  But at this point I am met by the reviewer with a quotation from my own
statistics  to  show, that the gain to the mother is not so great after all; for
that 1  in  5 die after craniotomy.  No doubt this  is a very large mortality;
but if  the reviewer had been a medical man, or if he had taken the trouble
to read the next  sentence in my book, he would have found it explained as
in many cases the  result  of  the doctrine he is  upholding, viz., the waiting
until the child is dead, and the consequent increase  of peril to the mother.
In many cases, doubtless, the delay is voluntary;  in others it  arises from
ignorance on the part of the poor,  so that,  when assistance is procured, the
patient is too far gone for  ultimate safety.   I should be very glad to furnish
a table of cases without complication, in which the operation was performed
before the patient was  too far  reduced ; but  I fear that I shall not be able
to adduce many.  In Dr. Collins' Life of Dr. Joseph  Clarke are given the
records of his private practice, and I find that  he performed the operation
twelve times from mechanical disproportion (including one case  of hydroce-
phalus), and all the mothers recovered favorably;  yet the reviewer specially
mentions that, of the same  operation performed in hospital under Dr. Joseph
Clarke, 1 in  3 of the mothers died ; an ample confirmation of the explanation
I have given.
   In Dr. Robert Lee's  "Cases in Midwifery" there  are  eighty cases of
craniotomy recorded, under similar  conditions  to those I have indicated, viz.,
mechanical disproportion without  complication, although  Dr. Lee was not
called in  many of them until too long a time had elapsed ; but, even so, only
4 died, or 1  in 20.  Dr. Lee's character is a sufficient guarantee that the
operation was the patient's only chance, and he expressly regrets that some
of them were not delivered earlier ; had they been, probably none would have
died.
   In the record of Mr. Cross' practice, there are t  cases in which craniotomy
wras performed, and all the women  recovered.
   Dr.  M'Clintock has met 5  cases in private practice in which the operation
was required from disproportion, and all the mothers recovered.
   In looking over my own case-book I find that I have never performed the
operation in consequence  of mechanical disproportion, in  my own private
practice ;  the only cases being two of excessive hemorrhage, in which, there
being  no doubt  of the child being  dead, this  operation  was preferred  to
turning ; and one case of  convulsions, in which the child was already dead.
But in  consultation I have  had  recourse to craniotomy  in twenty  cases,
shortly after  it became evident, either that the child was  dead, or that it
could  not be born alive ;  of these,  all the mothers recovered well.   In four
other  cases  I was called in after the labor  had  been so protracted that  the
mother's case was hopeless,  and the  operation did  not save them ;  these,
therefore, I exclude.
   From  these cases, though their number is more limited than one could
wish, I think we may fairly conclude  that if the operation be performed as
soon as it is imperatively demanded,  and before the  mother is run down, it 
OBSTETRIC  MORALITY.
623
is not attended with greater danger than  must always be anticipated from
any great operation, for it appears that out of 124 cases, some of which were
unduly prolonged, only four women died, or 1 in 31, i.e., 3 per cent.   Nay,
more, Dr.  M'Clintock showed, at a recent  meeting of this Society, that of
the two modes of delivery, by the  forceps, and by  craniotomy, the latter,
cceteris paribus, is the safer for the mother.
   With regard to M. Debreyne's experience, quoted by the reviewer, that
" it is almost always fatal to the mother," if it be more than one of the loose
expressions  occasionally used  by writers,  I can  only say that  it  speaks
volumes against M. Debreyne's practice and that advocated by the reviewer,
for I have shown that the excessive mortality results from unreasonable delay.
   Now let me say one word upon children  with hydrocephalus. These cases
come under the same law as those  of which I have been speaking, i.e., the
law of disproportion or  of relative bulk.   The reviewer declaims strongly
 against perforating them, because, as he says, such children have been born
 alive.  No doubt this is  true, but the cases are few ; in the greater number
 the child is dead, or has been necessarily destroyed.   But their life or death
 does  not determine  the use of the perforator; if the head be not too large
 to pass through the pelvis, we should no more think of  destroying the  child
 than if it  were deformed in any other way: if,  on  the other hand, it cannot
 pass, it must be opened for the same reasons as we perform  craniotomy in
 distorted  pelvis.   Probably the  reviewer  was  not aware  that such cases,
 when let  alone, involve  serious danger to the mother: yet of seventy  cases
 collected  by Dr. Keith, in sixteen there was rupture of the uterus  and death.
 The  same result followed in five cases related by Dr. R. Lee.
    So far, I have assumed  that we  have only a choice  between the two
 methods  of  dealing with these cases :  that there is no alternative but de-
 stroying  the child,  or allowing  it to die; but the reviewer maintains that
 there is, and, if I understand him, that it ought in all cases to be the substi-
 tute  for craniotomy.  He says that " when it has been proved by  experience
 and  to an  absolute demonstration, that a full-sized child cannot be born
 alive, the induction of premature  labor ought undoubtedly to be adopted.
 The only lawful  alternative is the Caesarean section, and this itself is so for-
 midable and dangerous, that, when it can be foreseen,  and its necessity
 avoided by any lawful and less dangerous  means, it is an undoubted duty to
 have recourse to them."   That is, for every present  impracticable labor we
 are to have  recourse to the Caesarean section ;  but for any future  ones in the
 same woman to the induction of premature labor.  I perfectly agree with
 the reviewer, that for all cases of obstruction for which  I have recommended
 craniotomy, and he the Caesarean  section, premature labor ought to be ad-
 vised in subsequent pregnancies, and this  doctrine he found in my book, if
 he read it.   At  the same time, I cannot but congratulate the profession on
 finding the Dublin Review an advocate for the  induction of premature labor:
 it is  a sitrn  of progress very encouraging to us, for the reviewer must be
 aware that this conservative operation was first proposed by  those Pro-
 testants,  upon whose  alleged disregard of infantile life he is so severe ; and
 also that for vears it was  opposed in France, Italy, and  Germany, by the
 Roman Catholic clergy. Even so  late as  1827, M. Capuron, a distinguished
 and devout practitioner, characterized it as " Un attentat commis envers les
 lois  divines et humaines."
    Now let us consider the Caesarean section as a  substitute for craniotomy.
    The reviewer bases his conclusions upon the statistics  given in my book.
 The entire  number stated is 423, of  which  231 mothers were  saved  and
 192  lost  or about  1  in  2^; of  238  children,  HIT were saved, and  U lost.
 Let me observe that, although I have collected this number, I  am far from
 Dledo-injr myself to the trustworthiness of the persons by whom they were 
624
OBSTETRIC  MORALITY.
recorded.   The incomplete account of the children also is a great drawback,
as our statistics might be altered if we knew what became of the remainder.
  If we inquire a little further, we find that M. Figueira has collected 790
cases, of which 424 were fatal to the mother, or considerably more than one-
half, but say 50 per cent.
  Again,  Dr. Arneth mentions that M. Kayser collected and analyzed 338
cases, of which 210  proved fatal  to the  mothers, or nearly 2 out of  3, but
say 60 per cent.
  Moreover, if we take the cases  which have occurred in Great Britain and
America  alone, I find, out of  63 cases,  18 mothers were saved, and 45 lost,
or nearly  three-fourths,  say 70 per cent.  In 60  cases, where  the result to
the child  is mentioned, 34 were saved, and 26 lost, or, 1 in 2.}.
  Thus we cannot in fairness take the more favorable statistics as a ground
of our proceedings:  we must  either strike an average, or, where that is im-
possible, base  our calculations upon the lowest.  Now, according to Figueira,
we shall  lose  more  than  one-half; according  to  Kayser,  two-thirds;  and
according to British and American experience,  nearly three-fourths ;  whilst
of the children we may, under similar circumstances, possibly save one-half,
— I say possibly, because, as  the  result to many of the children was not
noted, it may  as well be less as more.
   Let us  go a step further.   It is well  known  that, of late years, the cases
have been more carefully selected in these countries, and in many ways have
been managed by previous preparation both of the patient herself  and of
suitable means and appliances, which require time and foreknowledge.  To
show this, take the cases that  occurred in Great Britain and America  before
1830: 35 such cases will be  found in  the Table I have given, of whom 30
died  and  only five recovered, or 1 in 7 ;  i. e.,  -Jjths, or  86 per cent,  of the
mothers were lost;  more than one-half  the children were saved.
   So far, then, we  find that  a more minute analysis has not improved the
mortality  after this grave  operation :  we  see that it varies from one-half to
two-thirds, three-fourths, and  six-sevenths of the  mothers, and about one-
half of the children : whilst we found that a careful examination of crani-
otomy reduced the mortality to 1  in 31.   That is, you lose 1  mother in 31
after craniotomy, and all the children ; but in the same number by the Caesa-
rean section, you would lose  about 16, 20, 22, or 27 mothers, and save 16
children.   Or, taking the lowest of these figures, and admitting for a moment
the  lives  to be'of equal  value, out of 31 cases, or 62 lives, you save 30,
which is exactly the number of lives that would be saved by craniotomy, if
my calculations  are  right.  If we take the  higher numbers,  the saving of
life will be reduced  respectively to 27,  25, and 20, in 62.  And, moreover,
we should not forget that, whereas craniotomy is an operation of necessity,
not  election, we  shall  have voluntarily  chosen this  operation, and have
knowingly incurred this fearful destruction of mothers.  To any person thus
acting, the reviewer's words will  cease  to be ironically severe, and become
simply descriptive.   "And  if  we  may sacrifice one life  to save the  other,"
he says, "if we may sacrifice the  less important to save the more precious,
we may,  of course, occasionally kill the mother to  save the  child, because
there are  many circumstances in which the life of the latter is much more
precious than  that of the  former."
   After what  I have said, I think, we shall hardly be prepared to agree with
the  verdict of the reviewer, that if all the circumstances of both operations
were compared  impartially, "the  advantages would remain on the side of
the  Cassarean section, which is much the easier and simpler of the two."
Let us examine  a little  closer into this, as bearing upon practice.   One
cause of  a high rate of  mortality after the Ca'sarian section is, that  the
patients have often been  allowed to remain in labor too long before  the 
OBSTETRIC  MORALITY.
625
operation.   One advantage has been—and it is essential to success—that the
operator has known some time previously that  he would have  to  operate,
and has had time in some degree to prepare his patient, to secure suitable
assistants, and  to  get  ready various matters which are sure to be required.
The danger arises, first, from the shock of the operation ; second, from hemor-
rhage ;  third, and  chiefly, from  subsequent peritonitis, and this latter risk
will be much increased by bad food, bad air, and bad nursing generally, but
especially by the prevalence, at  the time, of any epidemic.
   Now, in substituting this  operation for craniotomy, consider the  circum-
stances in which we must almost necessarily be placed, and see whether they
are favorable  to success or not.  They appear  to me to combine every dis-
advantage of the cases of hysterotomy on record, with none of the advantage
possessed by the operator in them.
   In the first place, so formidable an operation  will naturally be postponed
to the latest possible moment, on account of its known danger, which will
materially diminish the chances of both  mother and child.  Then, as it is
quite impossible, in such cases as we have been considering, that the  operator
could  anticipate its necessity, he will necessarily be unprovided with things
requisite, and with assistants ; nay, it may be night before he makes up his
mind,  and he  may possibly be  in the country, remote  from  all  qualified
assistance.  Moreover these cases are very much more frequent among  the
poor than those in comfortable  circumstances, and here we  have  combined
the drawbacks of bad  air, bad food, and injudicious management, with pos-
sibly a prevalent epidemic.
   Under these circumstances, what will be the probable mortality ?  You
 may unhesitatingly dismiss the  hope of saving  one-third, or one-fourth, or
 even one-seventh of  the  mothers, and  half  the  children ; but can you, with
 any reasonable certainty, calculate in saving one-twentieth of the  mothers,
 and one-fourth of the children ? and if not, look at the unfortunate  position
 of the  accoucheur,—he  has  sacrificed so  many of the mothers to  save  so
 small a proportion of  the children.   May we not fairly characterize this as
 doing evil that good, and very little good, may arise, which we  reprobate
 as strongly  as the reviewer.
   But allow me to add that, if  we are to be guided solely by the desire of
 delivering a living child, at whatever expense  to the mother,  I do not see
 how  we can  limit the  operation  to  the cases we  have  supposed —viz.,
 mechanical  disproportion.   There are  others in which we fail in saving the
 child by ordinary  means, where it might indubitably be born alive by  means
 of the Caesarian  section.    Take, for example, a case of  prolapse  of the
 funis, which you fail in  replacing, and where turning is impracticable,  and
 the  application  of  the  forceps impossible;  the labor being  natural, the
 mother will be delivered without risk, but the child will be  dead.   Now in
 this case Caesarian  section would undoubtedly save the child, but dare any
 one propose  its adoption ?  Yet the principle is the same, only  pushed a
 little further.                                    ,   .,    .          .  .
   The reviewer lays much mistaken stress upon the Caesarian section being
 "simpler and easier," which he would not have done had his medical  know-
 ledge kept pace with his theological.   In craniotomy, in the cases we have
 been considering, no wound or injury is  inflicted upon the mother;  a mu-
 tilated child is forcibly drawn  through the passages, and that is  all.   In
 the  Caesarian  section, on the other hand, the  largest serous cavity  m the
 body  and that by far the more sensitive to morbid action, is fully laid open,
 the uterus is  divided, and  there will be  more  or less hemorrhage  into the
 peritoneum.   After the operation is  over, there  is every probability of an
 TtHck of peritonitis from the exposure  and rough contact with the  serpus
 membrane; and this disease is one of the most fatal we ever met in  practice.
        40 
6 26
OBSTETRIC  MORALITY.
It must be either ignorance or folly to compare the danger of the operative
proceedings of craniotomy with those  of the  Ciesarian section, as regards
the mother.   And medical men are aware of and admit this.   I know a
little  of foreign  obstetric literature, but I cannot call to  mind a  single
Roman Catholic  writer of eminence who has recommended this substitution.
I should at this  moment be perfectly willing to abide by the decision of a
jury of French or Austrian obstetricians of authority on  this subject; and,
however decided, I can assure the reviewer that he will find  no  one  in this
country  to  take  his  advice about  the  Ciesarian  section.1   Any one who
should venture to do  so would, I have  little  doubt, find  himself  put upon
his defence before the  tribunals of his  country, and in the hands  of  a jury
who have wives,  and value  them.
   Allow me to add a  confirmation  of the  opinion I have  expressed, in the
words of Dr. West, no mean authority, it will  be admitted :—" If, then," he
says,  "such and  so many dangers beset this operation, while the  causes of
that mortality are, for the  most part, beyond the power either of surgical
dexterity or medical  skill to  obviate, and  some of them  inseparable from
those  processes  which needs  must follow delivery, we may,  I  think, feel
satisfied that the general rule  in British midwifery which  prohibits the per-
formance of the  Ciesarian section,  except  where delivery would  otherwise
be  altogether impossible, rests on  a far sounder  foundation than that of
mere prejudice,  or blind obedience to  the dicta  of  men  eminent in their
profession."
   I have now gone  pretty fully into  these important questions;  I have
shown that hastening the death of a child  that cannot be born alive is not
murder,  as the reviewer has been  pleased  to  term it; but, according to the
law of morals and the law of the  land, justifiable and right.  I have ex-
pressed my own faith in  the safety of the child's soul when baptism is  impos-
sible, whether it die ' in utero' or is destroyed.   I  have endeavored to prove
that the responsibility of the accoucheur for the child  ceases when his power
over  it fails ; but that, in the one essential particular, his responsibility for
the mother  does  not cease, but rather augments,  because that condition is
within his own control.   We  have seen that craniotomy is not recommended
in any case  in which the child  can be delivered alive, and  that, although the
mortality to the mothers is very high where assistance is  deferred until the
death of the child has taken place, it is comparatively small when afforded
in reasonable  time.
   As to the alternative of  the Caesarian section, I hope  I have  convinced
you that, whatever may be its  mortality, when deliberately planned and ar-
ranged beforehand, with assistants  and all the various appliances necessary,
yet that, hurriedly performed, with the  patient exhausted with  prolonged
sufferings, and the operator deprived of  the advantages of due preparation,
the mortality  must inevitably  be so  fearfully high, whilst the number of chil-
dren  saved  would be so small, that were we prepared, as  the reviewer is, to
sacrifice so many mothers in our endeavor to save the children, the sum total
of  lives saved would,  at  the best, not be more, but might very probably  be
much less than by the operation of  craniotomy.
   There are  two or  three points  of  secondary importance upon which I
should like  to say a few words, if I  have  not exhausted your patience.  The

  1 Since this remark was published I have seen the question put to the test.  In a case
of pelvic distortion  where the forceps failed, the priest refused permission to  perform
craniotomy, and brought an accoucheur of his own choosing, who, he said, would deliver
the woman without injuring the child.   He tried  the forceps and failed, and  then  the
original attendant offered to give up the  patient to him for the Ciesarian section if he
would take the responsibility.  This he declined, and they sent the woman to the Rotunda
Hospital, where she was delivered by craniotomy. 
OBSTETRIC  MORALITY.
627
reviewer states that I mention, as one of the objects of the Caesarian section,
" the extraction of the child so promptly as to give it a chance of life, when
the death of the mother has taken  place suddenly ; and he adds, in a tone
of blame,— "But he  never again reverts to  the subject, so  far as we have
been able to discover :  and, indeed, the  teaching of professors of midwifery
in these countries has led to the horrible practice of leaving  the living child
iu the womb of its dead mother.  A great many cases have fallen within our
own observation, in which the woman has reached the end of her pregnancy,
where the death was  sudden, and it was morally certain that the child was
alive, and  yet  it was left in the dead mother's womb,  and  buried remorse-
lessly along with her."
   The quotation from my work proves, on his own showing, that the allega-
tion against the teachers of midwifery does not apply to all; and, from what
 I know of my fellow-professors, I  do not think  that  it is true of any.   I
 believe  most firmly  that far less than being "morally certain that the child
 was alive" would induce every teacher and practitioner to give the child the
 chance  of life : and I regret to see in the pages of the Dublin Review what
 I cannot but believe to be an unfounded slander.
   But  the reviewer has seen "a great  many "such  cases of sudden death,
 etc.  Now as  he has had free use of my statistics, I call upon  him to give
 me the benefit of  his, and to say how  many he  has seen,  and under what
 circumstances.  I am  unwilling to say  an uncourteous word  of any one, but
 I must frankly confess  that I do not believe this assertion.    Sudden deaths
 at the  end of pregnancy, or in the last  two months,  are very rare ;  the  ma-
 jority  result from accidents,  hemorrhage, rupture  of the  uterus,  cerebral
 affections, or acute disease  affecting other organs.  Dr. M'Clintock informs
 me that in the seven years he has been Assistant and Master in this Hospital,
 he has seen but two cases of death during pregnancy.
    I myself have seen two or three women  (in  consultation or  dispensary
  practice)  die  undelivered from hemorrhage, and  two from  rupture of the
  uterus, but no others, in twenty-six years' practice.  Now, in the two latter
  classes of cases, the  operation would be useless, for hemorrhage sufficient  to
  kill the mother would undoubtedly destroy the child ; and Dr. M'Clintock
  has established the fact that the child dies almost instantly  after rupture has
  occurred.  I  never  saw a  woman die of couvulsions or apoplexy before de-
  livery  ; but we know that in such cases, when the life  of the mother is  pre-
  served'the child is often born dead, and I think it very unlikely that it would
  survive the mother's  death.   At any rate, the  stethoscope  would test  this,
  as well as in death  from acute diseases; and if the fcetal heart were heard,
  I think it would be  the duty  of the medical man to propose the  operation ;
  it is clear that the decision does not rest with him.  In case of accidental
  death  from violence, I believe everyone is prepared to  try and save the child,
  and the probabilities are much  more in its  favor than in any of the  other
  cases;  yet the reviewer ought to know, that of all the cases of this kind  on
  record 'in a large  majority the child has been found dead.
    I cannot help remarking here that, not only in what relates to this ques-
  tion but to  all  those he touches upon, the reviewer altogether ignores the
  husband  and father, as necessary to be consulted, or having a voice in the
  decision   Whether the child is to be destroyed, or whether we are to wait
  until  it dies to the  peril  of the mother, or  whether she is to be  opened the
  moment she  is dead,  is to be decided  by the  clergyman or the  doctor, but
  apparently without  reference to the person most deeply  interested!   And
  yet he has not only the natural right of his relationship, but legal power ;
  for Dr  Lever recently mentioned  that he  had consulted Dr. Alfred Taylor
  to know "whether he would be justified in performing  this operation  with-
  out the consent of the father, as it appeared unjustifiable  homicide to  allow 
628
OBSTETRIC  MORALITY.
the infant to die ?   Dr. Alfred Taylor gave his  opinion  that, in law, the
infant belonged to the father, — the infant, " with the life thereof; " and that
if  Dr. Lever touched it, even to rescue it from death,  an  action  would  lie
against him.  The  father in two cases had  refused Dr. Lever permission ;
and  in this  country although there is a strong feeling  against burying the
child in  the womb  of its mother (a distortion probably of the true view),
yet I have known permission to extract it refused until it was altogether too
late.   I  confess  that, although wrong, one can make  much  allowance  for
the  feeling which objects to the  mutilation (as it would appear) of a wife,
instantly after  death,  and in  fact before the husband had  been  able to
realize his loss.
   The "moral certainty" of the reviewer seems to me  very easily acquired,
if he believe all the stories he quotes from M. Debreyne of  children delivered
alive by the Caesarian  section,  after five, twenty-four, forty-eight hours, and
three days,  or even after the interment of the mother.   It would take us too
long to examine  into the evidence  of  such miraculous cases, and  I, for one,
object to take them on  31. Debreyne's authority.   The reviewer does not tell
us the date  of his book, and  I confess  I have not met with  it.   The  position
he holds seems equally  indefinite ; he is " Professeur particulier de Medicine
pratique, Pretre, etc.," whatever that may  mean;  but it would require  a
very weighty " Professeur particulier" to justify the demands he makes upon
our credulity.
   Again, the reviewer  "reprobates in the strongest terms the language of
Dr. Churchill, who confounds the induction  of  premature  labor with  the
procuring of abortion."  Begging the critic's pardon, I do no such thing;
I couple the two  together,  certainly, but they were obviously intended  to
apply  to different  cases.  If,  when the reviewer was  so  shocked with the
paragraph in the chapter on Caesarian section which he quotes, he had turned
to the chapter on induction of premature labor, where  the details are given,
he would have read thus : — "In the cases I have  supposed, the safety of the
child is the great object of the operation  : and they are limited, therefore, to
those patients in whom the  pelvis, though deformed, is still large enough to
permit the  passage of  a viable child.  But there  are cases where the distor-
tion is so great as to render the passage of a seven months'' child impossible;
 and others  still worse,  where no reduction of  the child's bulk will  enable it
to pass.   I do not  see why abortion should not be induced at  an early period
 in such cases.   The life of  the  child must inevitably  be  sacrificed, and the
 safety of the mother alone regarded ;  and surely, after the calculations I have
 adduced, it cannot be pretended that the Caesarian section,  the alternative
 in these cases, offers such a chance to mother and child as would justify our
 preferring  it."   I  am  sorry that the reviewer should  have wasted so much
 virtuous indignation, but it is  his own fault.  I did not, and do not, propose
 the induction  of abortion as a substitute for  premature labor, but in  cases
 in which premature labor, when  the child is viable, would  be  of  no  use.   In
 those  very  rare cases of extreme distortion, or after the patient has recovered
 from the Caesarian section,  performed for extreme distortion;  I do say that,
 to  save the mother from the excessive  risk  of  the latter operation by one
 from which she  runs no risk, would be more justifiable and  better practice
 than to  allow her to  go  to the full term.    The reasons I have already so
 fully given apply equally to these cases, so that  I need not enter into them
 again.  I do not believe that  we endanger the soul of the  child ;  and I have
 no  doubt that the mother's safety will  be  more fully insured than by any
 other mode of treatment.
    Let me add that of which the reviewer seems ignorant,  that the operation
 was proposed in such cases  by Dr. W. Hunter in  1768, and that on the Con-
 tinent it has been  sanctioned  by such men as Fodere,  Marc,  Velpeau, Solz,
 Jacquemier, Chailly, Cazeaux, Spiegelberg, Scanzoni,  etc. 
QUALIFICATIONS  AND   DUTIES

                       OP THE

          MONTHLY  NURSE.
  [The following pages are extracted, with the sanction of the author, from
a little  " Manual for Midwives and Nurses," recently issued by Dr. Churchill.
The subjects discussed have already been treated in chapters 3 and 4 of Part
III., but  the additional details  and  minutiae  so clearly  presented in the
" Manual" can hardly fail to prove of value to the young practitioner, when
called upon for the first time  to  take  charge  of the lying-in room, and to
assume the responsibility of giving all  the requisite instructions to the nurse.
  Having found it  desirable  to  arrange our extracts in somewhat different
order from that  in which they occur in the " Manual," a few verbal altera-
tions have been rendered necessary to  preserve  their due connection.  With
these exceptions, however, no  change  whatever has been attempted.]
  Qualifications of a Monthly Nurse.—1. A good nurse ought not only
to be a woman of irreproachable moral character, but she ought to have a
deep sense  of religion.  This will lead her to  regard her office as  a high
vocation, the duties of which  are to  be conscientiously performed for His
sake, who entrusted them to her ; it  will support her under fatigue, and in
the  midst of scenes of difficulty, distress, and  sorrow, will lead her to the
only source  of  strength,  and  comfort,  and  wisdom.  An irreligious nurse
will generally be more or less  inefficient.
  2. She ought to  possess a tender  sympathy for the sufferings of others;
and, so far from interfering with her usefulness, this will  render her efforts
more diligent and untiring, at the same time that the  gentleness and feeling
she manifests will soothe the patient and acquire her confidence.
  3. A habit of quick  yet careful observation is essential, lest she should
overlook  some important symptom, or undervalue some unusual occurrence,
and  so lose the earliest  opportunity of affording  relief, or of sending for
advice and assistance.
  4. She should possess a certain amount of education.   A nurse who can-
not read, cannot be trusted with the administration  of medicines without
great risk ; but a degree of cultivation ensures greater intelligence, and, as
they have abundant leisure, they have time  for improvement.   I can also
say,  from experience, that a nurse who can read  pleasantly has it in her
power  to beguile many a weary hour  for her patient.
  5. Neatness  and  cleanliness  should  characterize not only her person and
dress, but the entire sphere  of  her duties.   The arrangements of the sick
chamber, of the bed, of the patient, and of the infant, should all be marked
by order, cleanliness, and neatness.   A slatternly  nurse  is generally some-
thing worse.   She  should have  " a place for everything,  and everything in 
630
QUALIFICATIONS AND  DUTIES
  6. As tidiness should be the character of her department, so  quietness
and gentleness should mark her movements  and actions.   There should be
no hurry, no bustle, no  fuss.   As  everything should have its proper place,
so every duty should  have its proper time and order, that the patient may
neither be flurried nor discomposed.
  7. A scrupulous attention to the directions of the obstetrician in attend-
ance should be  regarded as  the nurse's first duty, on  no account to be
neglected from carelessness, or evaded  at the request of  the patient or her
friends.   As she is responsible to him for the  faithful execution of his orders,
she is so far answerable for the safety and life of the patient.   To  practice
any improper concealment towards the  attending  obstetrician is a gross in-
justice to both parties,  which,  may cost the patient  her life, and bring irre-
trievable disgrace upon  the nurse.
  8. A nurse should cultivate habits of perfect accuracy  and truth towards
the patient, her friends, and the medical attendant:  it is quite possible, and
often necessary, to refrain from telling the whole truth to the patient, with-
out telling what is untrue.  For the sake of her own health, as well as for
the efficient discharge of  her duties,  she should be temperate in eating;  of
early, active habits, and of constant watchfulness, so long as she is in attend-
ance upon a patient.
  Natural  Labor. —The beginning  of labor is dated by the patient from
the time that the uterine contractions become painful; and this is quite cor-
rect, provided that the  entire  uterus be engaged, and that the pains recur
regularly.   There is  a  kind  of irregular contractions, however, which are
called  "spurious or false pains," from  their teasing the patient without
advancing the labor.  They arise from various  causes, as  over fatigue, im-
proper  food,  constipation, cold,  etc.,  and you will know them  by their
irregularity, by their  commencing at the fundus,  or top  of the womb, and
being of limited extent,  by their not being accompanied by mucous discharge
or "shews," nor pushing  forward the " bag of the waters," nor dilating the
mouth of the  womb.  Whenever you find the pains to possess these charac-
ters, you may be  sure that they are  spurious pains,  especially if, as is often
the case, the patient have not arrived at the  full time ;  and you had better
recommend rest, bland  food, and attention to  the bowels.   If this be not
sufficient, the family physician should, without delay, be consulted.
  The true pains, on the other hand,  recur  at regular intervals,  but these
intervals gradually become shorter; in other words, the pains become quicker,
and also stronger.  And  although they begin  in  the back, generally, they
spread  round to  the front, until the  entire womb is contracted and becomes
hard.   The result of  this contraction is, that the " bag of the waters," as it
is called, is pushed  by degrees to the  mouth  of  the womb, and gradually
dilates it: at the  same time, there is a  pretty abundant discharge of mucus
from the vagina.   These  peculiarities  may almost always be observed, even
at the beginning  of labor, and when you find  them, you may be satisfied that
the  female is really in labor.
  As the pains change  their character  as labor goes on, a convenient dis-
tinction has  been made into  "cutting  or grinding  pains:" and  "forcing
or bearing down pains ; the former are confined to the first stage of labor,
and  are short, piercing, and  not very  frequent at  first;   neither does the
patient  bear down with them, unless, very improperly, she be told to do so.
As  the labor goes on they increase, and sometimes occasion as much suffer-
ing  as  the pains of the  second stage.   They cause  the patient to cry out,
and, perhaps, it is better that  she should do so, to  a  certain extent;  but she
should  be  encouraged to control  the  expression of pain  and restlessness
within  reasonable bounds.  A refractory, noisy, restless  patient, certainly
suffers  more than a quiet submissive one. 
OP  THE MONTHLY  NURSE.
631
  The  "forcing or bearing down pains " are very different, and are very well
described by their  name.  The patient is obliged to bear down, she catches
hold of something, stiffens her body, holds her breath, and does most effectu-
ally aid the uterine contractions in expelling the child.   And whereas, with
the grinding pains, the skin was cool  and the pulse quiet,  but  the patient
restless and crying out, during  the bearing down pain  she  cannot cry out,
because she is obliged  to hold  her breath ; she lies  quiet in order to force ;
her skin  becomes  hot  and bathed in  perspiration, and  her  pulse is quick.
Thus, by the state of the skin and the cry alone, you will generally know in
what stage the labor is.
   You will remember the division I have made of labor into three stages;  as
a general rule, the  waters come away about the  termination of the first stage,
and so  may serve you as a sort of landmark.  Now let us mention the principal
symptoms which you meet with in each stage.   I  have just described  the
pains of the first  stage — they are cutting, increasingly frequent, gradually
becoming stronger,  rendering  the patient restless  and irritable,  often low
spirited, and requiring soothing and encouraging  treatment.   During this
stage,  also,  the  stomach  often becomes irritable, and  the  patient may be
troubled  with retching or vomiting,  which rather does  good than harm, as
it relaxes the parts and diminishes the resistance.
   During the first stage, shivering  is apt to occur, and especially towards
its termination, just as  the head is pressing through the  os uteri.  The  pulse
and skin  are but little affected, at least not until near its completion.
   If, during  this stage, you place your hand on the abdomen, you will  feel
the womb very hard during a pain, and somewhat softer, though still harder
than before labor, during an interval.   It is also tilted  forward in order to
place the child's head in a favorable position for entering the pelvis.   Fur-
ther information will be obtained by an  internal examination ;  but  I  had
better  first tell you  how this is to be  made.   The patient should be placed
on her left  side, with  the hips close to the edge of the bed :  then, having
oiled your  right forefinger, you pass it (under  the clothes) from behind  for-
ward,  until  you arrive at the  external orifice,  into which you  introduce it,
and direct it rather backwards and upwards until you arrive at  the os uteri,
which  will  feel  like a  small ring, and within which  you will find the  mem-
branes protruding.  You must be very careful  not  to press too roughly, or
you will  rupture them  ; but when they are relaxed, you  can  feel the present-
ing part through them.   Thus you may ascertain if the labor be natural,
and how far  it  has advanced, judging by the size  of  the  os uteri,  and  its
softness or hardness.  If you keep your finger at the os uteri during a pain,
so as to estimate its force,  and the effect it produces, you may give a shrewd
guess  whether the labor is likely to be long  or short.   Of course you  will
also notice the state of the vagina, whether it is cool or hot, moist or dry,
or whether  there  be any unusual obstruction,  etc., and  on withdrawing your
finger, you will  observe  the  character and amount of  the  discharge.    Re-
member, this examination  is  to be with gentleness and delicacy, without  ex-
posure or pain, and if all be right, it  will not be necessary to repeat it during
the first stage.
   During the second stage the pains become longer, stronger, and more  fre-
auent, and are seconded by the efforts of the patient: the pulse  is quick, the
skin hot, and the face  flushed.   Vomiting sometimes occurs,  but if the labor
have not been unusually prolonged, it is  neither a bad sign nor injurious.
The patient also feels  a degree of heaviness or drowsiness, so that it is  not
uncommon  for  her to doze  between the pains; and this should always be
permitted.   As  the head passes  downward  through  the  lower outlet, it
presses  upon some of the nerves which supply the lower limbs, and causes 
632
QUALIFICATIONS AND  DUTIES
severe cramps in the thighs or calves of the legs, which may be somewhat
relieved by friction.
  If an internal examination  be made  during this  stage, you will  neither
feel the bag of the waters nor the os uteri, as a general rule, for the former
has been  ruptured, and the latter has been  drawn upward over the child's
head; but you will touch  the  head (or whatever part presents) directly, and
find  it filling some  portion  of the  vagina.   During a pain you will feel it
descend a little, and go  back when the  pain ceases ; but by the frequent
repetition of this process, you will observe the head gradually come down,
until it  fill the pelvis and press upon the perineum.   At this time the pro-
gress becomes slower, a great many pains seem to cause little  advance, and
this  for two reasons :  first, the head has  to  be adapted  to the lower outlet
by a change of position and  by compression,  or moulding, as it is termed;
and  secondly (especially in first  labor), because it  takes  time to dilate the
soft parts.
  After the pressure upon the perineum has  gone on some time, it begins
to yield,  and you  find it bulge  out with each pain,  and by degrees the
head  begins to  appear at  the orifice of the  vagina, pressing forward, then
receding,  but steadily gaining ground, until with a stronger pain than usual
or a double  one, it  passes into the'wrorld, generally with the back of the
head directed forwards towards the pubis,  and the face of the perineum;
but  this  position almost  instantly changes, and the face is turned upwards
(most frequently)  or downwards.  The  next pain  after  the head is born,
effects this ; and  presses the shoulders  on  the perineum, over which they
pass with  much less difficulty and delay than the  head ;  and are followed
immediately by the body of the child, when  the second  stage is completed.
It is important for you to remember this second pressure upon the perineum,
for if proper attention be not  paid,  the perineum, that escaped injury from
the head, may be torn by the  shoulder.
   After the birth  of  the child,  a short time of rest occurs, and then the
womb again contracts, and pain is felt, but not so severe as formerly.  This
is for the expulsion of the afterbirth, which  is generally separated from the
womb by the pains, which expel the child, and only  needs  a further contrac-
tion to  be removed entirely from the uterine  cavity.   After the birth of the
child, there  is  always more  or less discharge of blood, which continues till
the placenta conies away, and then generally, though not always, diminishes.
If the interval between the expulsion of the  child and placenta be long, the
latter will be accompanied by its clots.
   If the  patient have had children, the pains return in an hour or two, and
continue  at intervals  for a day or more, but they are seldom very bad, and
after suckling  has been fairly established, they subside.   These are called
 " afterpains," and, though unpleasant, are of great use in expelling any clots
which may be in the womb, and in preventing hemorrhage.  After  its con-
tents have been expelled, the womb contracts, and may  be felt as a hard
tumor at the lower part of the belly, about as large  as the infant's head.
   Dutiks of Nurse  during Pregnancy.—You are not to  regard  preg-
nancy as a diseased state, requiring medical treatment necessarily; on the con-
trary, it is a natural condition, and  needs little more than common sense, in
the  majority of instances, to  conduct it to a happy  termination.   A certain
 amount—rather less, perhaps, than  at another time—of exercise  should  be
taken ; as  the  stomach is irritable, or at least more easily disturbed  than
 usual, some care should be taken to  avoid those articles of diet likely to dis-
 agree ;  longings, as they are called, may be, to a certain extent, gratified,
 provided they are not forbidden by  common sense;  and the dress should be
 comfortable, according to the season of the  year and the weather.  I  need
 not say  that the  personal vanity,  which seeks gratification in well-fitting 
OP  THE MONTHLY  NURSE.
633
clothes, must give way to the necessity for freedom, looseness, and  ease in
dress.   The stays, for example, should be  altered entirely :  the front bone
or steel should  either be removed or exchanged for one much slighter;  a
gore of elastic should be inserted on each side, so as to allow of expansion;
and  the  breasts  should  be freed  from all  possibility of pressure.   If the
patient intend to suckle her  child, she should, every morning and evening,
for about two months before  her  confinement, wash the nipples with soap
and  water, dry them, and then bathe them with equal parts of brandy and
water,  or  brandy and  strong green tea:  this  will harden the  skin, and
diminish the  probability of sore nipples.   The bowels should  be  carefully
regulated,  if necessary,  not  by large doses of medicine, but  by moderate
ones repeated.  Take care and do not mistake : an irritable condition of the
bowels, with small, frequent motions for a proper freedom, is  quite consistent
with large accumulations, and  requires medical advice.  Powerful  purga-
tives must never be given to a pregnant  woman, for  fear of bringing on
labor.  Small doses of castor oil, or Gregory's powder,  or Epsom salts, will
 answer in  many cases.   The spirits of a pregnant woman are very variable :
 it will, of course, be your duty to promote cheerfulness, by suggesting to her
 the  many happy considerations connected with her condition,  and by abstain-
 ing  from all unpleasant histories, etc.   Quiet and cheerfulness, fresh  air and
 exercise, by promoting the healthy performance of the bodily functions gene-
 rally,  will naturally favor the successful  completion  of pregnancy.  But
 some  deviations from the natural course  may occur, some  symptoms may
 arise,  which may indicate  that  all  is not quite right;  and I  wish to  caution
 you against the attempt to treat such yourself.  By so doing you will lose
 time  at least,  which, in  some cases, may result  in  serious consequences.
 Whenever, therefore,  any unusual or threatening symptom occurs, be the
 first to advise that a medical man  be consulted : by so  doing,  you will pro-
 mote  your own  interest, as well as that of the patient.
   Preparations for Confinement.—At the time you are engaged as nurse,
 you will  be also consulted as to  certain  preparations  for confinement.  If
 possible, you should secure a large airy bed-chamber, a bed with a comfort-
 able hair  mattress, with ample means for order and tidiness  : let the patient
 have  castor oil  in the house, and a sufficient supply of bed linen, napkins, etc.
 A dressed sheepskin, or a large square, waterproof cloth, should be provided,
 with diaper forbinders, strong  pins, etc.   See that the infant's clothes are
 correct__with strings, instead of pins; and  prefer rather  an abundance of
 inner clothing to external finery.
   Preliminary Duties  of  Nurse.—In  most cases you will be summoned
 before the attendance of the accoucheur is  considered necessary, and your
 object should be,  on the  one hand, to avoid  calling  on him  unnecessarily
 early, and, on the other,  to  make sure that he is summoned  in time.  In
 order to decide upon this, you  must take into consideration the distance at
 which he  lives,  the character of the patient's former labors, the rate of pro-
 gress of  the present labor, and the presentation.   If, for  instance, it be a
 first labor and  the presentation natural, you may wait until the waters break,
 or the pains  change their character, provided the distance be not consider-
 able.   If the former labors  were rapid, you must send so much the sooner;
 and if you discover any  other presentation  than the head, you must send
 instantly, no matter how little progress may  have been  made.   To  ascertain
 tlii*  of course  you  must make an examination in the way I have described,
 but' havino- done so, it will scarcely be  necessary to repeat it, as the change
 of pains and of outcry will inform  you when the second  stage begins, and the
 doctor should then be in  attendance.                      _
    On your arrival at the patient's house, yon will  ascertain  her present
 state, and not  put her to  bed, unless for examination, during the first stage. 
634
qualifications and  duties
If labor be only beginning,  and it the day time, she  had better not remain
in her bedroom, but leave that to be aired and settled.   Or, if she remain in
her room, it should be kept fresh, and every thing in it arranged in a clean
and orderly manner.   The various  things that are likely to be  wanted, such
as sheets, napkins, hot and cold water, baby's clothes, etc.,  should be placed
within reach, and aired, if necessary.  The binder, pins, ligatures, and scis-
sors should all be ready, and the bed properly made up.   All this  may be
done neatly and quietly, without hurry or parade.   Hurry and fuss  will agi-
tate and  disturb the patient, and your object should be to cheer, comfort, and
encourage her.  She will, no doubt, be very glad to  talk to you, and if it be
her first  time, to find  out  from you something  about what she has to go
through.   If all be right, you have an opportunity of encouraging her, but
I would advise you rather to avoid details.   Above  all, neither tell her the
histories  of other patients,  nor make promises as to the period of her being
well;  as  if she once find out that you have been mistaken, or have been
deceiving her, it will depress her, and she will put  no  further trust in any
thing  you tell her.   And  further, let me add a caution against gossiping,
either with the patient's friends or servants,  about any thing you may have
seen or heard in other families ; it will certainly be repeated,  and  vou will
inevitably get into disgrace.   A nurse is necessarily a confidential person,
above a servant, and trusted with many things as a friend ; and  she should
conscientiously regard as sacred all the  information she may obtain when
professionally employed.   I  have known several  excellent women much
injured by a  neglect of this rule.  A cheerful, kind,  and  genial manner,
marked by respect for others, and therefore  for yourself, with orderly, neat
habits, and confidential trustworthiness and  truth, are  principal recommen-
dations in a nurse-tender.
   But to return :  on your arrival, you should ascertain that the bowels have
been  recently moved,  or if not, give  medicine or a plain  enema  of warm
water or thin  gruel,  and throughout  the labor take care  that the patient
pass water at intervals.  On  the  arrival of  the  medical man,  of course the
patient is in his hands, and  you receive your orders from him.  Your chief
duty  will be to have everything at hand which  he may want, so that there
may be neither delay nor hurry.
   Management  of  Labor.—Duringthe first stage  of labor there is not
much to  be done.  You  will probably^be called at the beginning, before the
patient is very bad ;  and it is not necessary, especially if it be  in  the day
time,  that she should  go to bed immediately, as you will probably  find the
pains  stronger and more frequent while  she  is sitting  up.  She may walk
about the room a little, and occupy herself, so as to relieve the weariness
of waiting.  You need  not interfere at this period with her ordinary diet,
but she  is better without stimulants, and you  should make sure  that the
bowels are freed, if necessary, by a dose  of castor oil or an injection. Quiet
and cheerful  conversation,  a cool room, mild diet, slight occupation, and  a
hopeful view of the case, will be all that is necessary until the second stage
sets in.   She should never be encouraged to bear down, or "assist herself,"
as it is termed, until the second stage begins, and the pains force her to do
so ; nor  is her crying aloud  objectionable, unless it be excessive, and she lose
all control of herself.
   Preparation  of  the Bed.—When the waters break,  unless this occur
prematurely,  the  patient should, generally, go  to  bed  at once ; but,  pre-
viously, the bed must be made so as to protect it from moisture, and to admit
of the soiled linen being removed at once, and without disturbing the patient,
and this is the way you should do  it: — Under or over the lower sheet (for
it does not signify which), you should have placed a tanned sheepskin, or a
yard  and a half square of oiled silk, or water-proof cloth, at; the right side 
OF  THE MONTHLY  NURSE.
635
of the bed, where  the  hips are to be, and hanging  a little over the side ;
upon this, the end of a sheet  folded twice lengthwise, and upon this again,
a sheet folded four times  square, so that, after a labor is  over, this upper
sheet can be easily removed, and if the under one be  soiled, it can be drawn
out so as to bring  a dry part under the patient,  whilst the  soiled portion is
rolled up and pinned.   When the  discharge  has moderated,  say in six or
eight hours, this sheet  and the leather may be removed, and the under sheet
and bedding will be found perfectly dry, and may easily be kept so by the
free use of napkins.
   When the  patient is placed on  the bed thus made, with  her hips close to
its edge, the under portion of her nightdress should  be turned up above the
hips, and a folded napkin or two so placed  as to secure that  the waters or
discharges do not flood the  bed, and make the patient uncomfortable, or
render a change of dress necessary.   Thus arranged, you will find the patient
not only protected  from discomfort at the time, but afterwards she can be
made quite comfortable, without fatigue, exposure, or exertion.
   Position and  Duties  of  Nurse During  Labor.—During the second
stage of labor your place is on the side of the  bed opposite to the physician.
You can give the patient your hand to pull until the head is  born, when it
is your duty to make steady and firm pressure  upon the uterus as it contracts
 and descends;  and this you  should  do, not by pressing it directly towards
the spine, but by enclosing the fundus of the  womb in your right hand, and
 pressing it downwards towards the pelvis.  Then you will follow down the
 uterus until  the child is born, and you will keep up this pressure  until the
 binder is applied, and afterwards  you can resume it if the doctor wish.  You
 should always have  a vessel ready to receive the afterbirth.  The most con-
 venient thing for this purpose is a small basin.
   During  the labor,  but especially during  the  second stage, the patient
 suffers more or less  from  thirst, and the most suitable drink will  be whey,
 milk and  water, or weak tea,  or a moderate quantity of cold water.  From
 a mistaken notion of keeping up the strength, wine  and water is sometimes
 given ; but  I believe  this to be unnecessary, and I think it  will rather be
 found to  increase the heat, and sometimes to interfere with the labor pains.
 During the early part of the  labor,  the patient should be allowed, or rather
 encouraged, to take her usual meals; as the pains increase, she will lose all
 inclination  for eating, but it is of consequence  that she should take some-
 thing  occasionally, if  the  labor be  prolonged, in order to  give the stomach
 something to do, otherwise, she will, probably, suffer from  flatulence.  It is,
 especially,  the nurse's province, as I have already remarked, to see that
 attention  be paid to  the natural  evacuations ;  that the  bowels  are freed
 during the  early part of the labor, and that  throughout, afterwards, the
 urineis discharged.   Neglect of  this  latter precaution may lead to very
 unpleasant consequences.
   She should keep the room  quiet and cool, and give the  patient some cool
 drink  occasionally,  a  little thin  gruel, milk and water, whey, or  weak tea,
 whichever she prefer;  see that the bladder is emptied at intervals ; should
 not mistake the escape of "the waters"  for this ; and if the bowels have not
 been moved previously, she  should  give an injection of warm water or thin
 gruel.   She will encourage the patient more  to bear her labor courageously,
 by a frank, simple statement that all is  right and going on favorably, than
 by fallacious promises of speedy delivery, which the nurse knows, and the
 patient will  soon find  out, not to be true.
   As  the  pains increase in strength, they compel the patient to " bear down,"
 and o-enerallv she does not need  to  be told to do this, for she cannot help it;
 but it will be well to direct her only to do this so long as the pain is severe ;
 as it declines, it will be of no use,  and only occasion fatigue.   It is usual to 
636
qualifications  and  duties
fasten a sheet round the bedpost  for the patient to pull, and sometimes to
place a box at her feet for her to  push against.   The latter is objectionable
on many accounts :  it tends to disturb the position  of the hips, which should
be  maintained, and  it may remove the perineum from  the hand of the
obstetrician at the moment when support is most essential; and I think that
the voluntary rigidity of the thighs and hips, thus occasioned, rather hinders
the escape  of the child's head.   There is no objection to the  sheet, if care is
taken that  the patient do not draw herself beyond  the protected  portion of
the bed.   I think, however, that the hand  of a  person  sitting opposite to
her is still better, as  she can pull as much as she  wishes without changing
her position.  Unless under peculiar circumstances, it is wrong to have any
one  sitting  on the bed, or leaning over the patient, as it adds much to her
heat and discomfort.  As  the labor advances, the patient becomes very hot,
and  some of the upper bed-clothes may be removed for a time.
   The Binder.—When labor is found to be progressing regularly, the nurse
should see that half a dozen strong pins, a pair of scissors,  some ligatures
of threads  or tape or twine, and the  binder, are in readiness.   The  latter
should, generally, be about half a yard wide,  and from a yard and a half to
two  yards  long;  but it is  best to make the  binder according to measure,
taking for its length what will go round the woman's hips, with two or three
fingers breadth additional, to allow for overlapping;  and for its  breadth,
taking from just  beneath  the breast to the level  of the  hip joint.   It is
usual to make  the binder of  strong diaper or twilled  calico, doubled and
stitched  at  the edges.  If the lady is to be confined in the winter,  a very
good binder may be made of thin "lining flannel," and one fold of  diaper
or twilled  calico.   A strip of calico  stitched  to the  binder behind and
passed between the legs, below a napkin, and then pinned in front, is useful
in keeping  the binder straight.   Of whatever material it is  made, it  should
be well washed and dried  before it is  required for use.  There are  other
binders ingeniously contrived  with buckles and straps, and  cut to  fit the
shape, but  I have not found  them as easily put on or removed, nor do I
think that they make as firm pressure as the simple binder above described.
   Duties of Nurse after the Birth of the Child.—When the child is
born, and the placenta expelled, the nurse should remove the soiled linen
from the patient,  and apply warm napkins, so as to make her comfortable
for the time, without exposure or exertion on  her part; and having replaced
the bed clothes, which were lightened  during the  heat of the second stage,
the nurse is at liberty to turn her attention to the infant.
   Application of Binder.—The first thing  to be done after the birth of
the child is to apply the binder.  To do this  properly, the nurse  should roll
up about the half of it, and pass it underneath  the patient to  an assistant,
who will unroll it, and pass over  the end of it to you.   Take care that it is
fairly  and  smoothly under the hips; then, drawing it tight over the  lower
part of the abdomen and hips, pin it there first; and drawing it equally and
firmly over the  upper portion,  fasten it by two or three other pins, so that a
pleasant and comfortable,  yet  firm, pressure may be made.
   I  may as well mention  here the mode of making additional pressure, by
pads or compresses.   If this  should  be necessary, fold a napkin in a roll
first, and place that  across the  abdomen,  above the  uterus;  then fold  as
many more as may be necessary, in squares, and place them over the uterus:
the former will prevent the womb from ascending  in the abdomen, and  the
latter, from,enlarging anteriorly.  The binder  is then to  be drawn  tightly
over the whole.   You will find that in this way you can make any amount
of pressure you please.   There  is  one point I wish  to impress upon you
very strongly, and that is, that this, and almost every other operation with
which you are concerned, may,  and ought  to  be done, with little or no 
OF  THE MONTHLY  NURSE.
637
exposure, or uncovering of the patient.  The neglect of this precaution is
not only an offence  against delicacy, but it causes the patient to run great
risk of catching cold, and cold in childbirth is a very serious thing, indeed.
  Subsequent Treatment.—When the doctor leaves the house, the nurse's
first duty is to see that his directions are implicitly obeyed.  Remembering
all  the patient has gone  through, it is evident to  common sense, that the
quieter she is kept the better: not more than one or two persons should be
allowed to enter the room, and no running in and out should be permitted.
There should be very little conversation, and that neither in a loud tone, nor
in whispers, for the latter tease  the patient by exciting but not gratifying
her curiosity, and the former will give a headache.   The room should be
shaded, but not kept too dark, the temperature should be carefully regulated,
and sufficient ventilation secured.
   There are two questions the patient is almost sure to ask, and which you
should be prepared to answer: first, whether she may change her position,
by turning on  her  back,  or on the other side ?  There can be no objection
to this in ordinary cases ;  but if there be any disposition to flooding she had
better remain as "she is, that  being  the  most convenient position ;  or if she
be in a great mess from discharges, she  had better wait until this is removed
and she is made more comfortable.
   The second question is, whether she may go to sleep ?  Against this there
is a prejudice  amongst nurses, I believe, because in flooding cases the patient
feels sleepy, and if allowed to sleep without being disturbed by examinations,
 and the flooding continue, she  may faint without its being discovered, and
 perhaps  die without assistance.   But if the nurse watch over the uterus and
 the discharge, so as to ascertain, from time to time, that there is no flooding,
 there is  no reason why the  patient should not sleep, and certainly there  is
 nothing  which will refresh her so much.
   Having  now mentioned what  you are to  do, let me conclude by a few
 cautions as to  what you are not to do.
   1.  You are  not to amuse your patients by accounts of the wonderful and
 dangerous cases you have attended, even though the relation may be to
 your own credit.
   2.  You are  not to relate anything which may tend to depress your patient,
 or render her anxious and uneasy.
   3.  You are  not to tell  lies, or make  promises, as to her labor being soon
 over, even for  the purpose of cheering  her;  as she will surely find  you out,
 and will not afterwards believe you, even when you tell the truth.
   4.  You  are not to put her to bed  during the first stage, nor encourage
 her to make  bearing  down  efforts at an early period, because they will do
 no good and will fatigue  her.
   5.  You are  not to  give hot or stimulating diet or drinks, under the belief
 that they will  quicken the labor.
   6  You are not to allow too many visitors in the room —one or two are
 quite  enough • hot rooms, hot  drinks, many visiters, and  useless efforts are
 most pernicious, and may easily convert a natural labor into  a tedious one,
 if  not something worse.                  ,-,.-,        j ,
    7  You are not to keep the patient too hot during the second stage.
    8  You are not to mistake  the  dribbling of "the  waters" for  passing
 urine  but make sure that the bladder is emptied at intervals.
    9  You are to apply  the  binder, remove the soiled linen, and make  the
 patient comfortable, without exposing  her to cold.
    Care of the New Born  Infant. —When the child has been  separated
 from the mother, it is usually rolled in flannel, and placed at the foot of the
 bed  or  on a sofa, where  it  exercises its lungs  by crying freely; nor is this
 injurious for it is not by the first efforts, nor by gentle efforts, that respira- 
638
qualifications and  dutii s
tion is fully established.  Before  laying it down, however, tne nurse should
gently and carefully wipe the eyelids, to remove  any discharge which may
prove irritating, and see that there is no bleeding from the cord.
  Washing the Infant.—As soon as the nurse is at liberty, her attention
is required by the child, and the first procedure is washing.  This should be
done in warm water—soap is not necessary—in a gentle and handy  manner.
It is not advisable to be so particular as to make  the process very long, for
the second washing will be  far  more effectual.   The  cheesy  matter with
which  the child may be covered, will readily wash off if it  be first  smeared
with butter, lard, or sweet oil, but if not entirely removed by the  first wash-
ing, it will be found dry and falling off in flakes or dust, the  next  time the
child  is  undressed.  It  is a very common practice to apply whiskey or
brandy to the infant's head, but this appears a very useless custom,  and one
which  may lead to mischief, if a drop of the fluid should splash into the eye.
  Dressing the Infant. —When the washing is finished, the  child should
be gently and thoroughly dried with  warm, soft napkins, before the  fire, and
all its clothes  having  been warmed it should be dressed as speedily as pos-
sible, and made warm  and comfortable.   Do not forget, before you put on
the flannel binder,  to  make sure that there is no bleeding  from  the navel-
string. .  A little soft rag should be folded around the remains of the funis,
and  turned up  upon the belly ;  over this the  flannel binder is placed.   All
the articles of dress that  come in contact with the  skin should be soft, and
all handling performed gently, as is obviously  necessary, if you consider the
extremely delicate state of a new  born infant.  Strings should be substituted
for pins, wherever it is possible,  and all complicated contrivances avoided ;
it is  desirable a baby should be dressed, or undressed, as easily as possible.
You must be very  cautious with  the  few pins which are deemed necessary,
not to allow the points  to come in contact with the  child ; and with the
strings and bandages, that they be not too tight.   You will be expected, no
doubt, to give  an  opinion upon the important subject of  caps, and will,
naturally, ask me for mine.   Doubtless, "much may be said on both sides,"
but I confess  that I can  see  no advantage in dispensing with them, but  a
saving of expense.  It  is not more natural to have the head uncovered, than
it would be to have the legs so ;  I am sure that the absence of caps never
prevented " water in the head," and certainly the infant has one more chance
of taking cold, to say nothing  of their looking very  ugly, withoui caps.
However, I generally let  my patients take their  own  way,  as  I  know that
they will do  as they like, whatever I  may think ; this  only  I stipulate, that
the head shall, at  all  events, be  lightly covered with  a flannel shawl for  a
week.
  Now,  remember,  that  as regards dress, the  infant requires softness, loose-
ness, and warmth ;  and as regards handling, gentleness and  dexterity.
  Physic  for the Infant. —After washing  and dressing,  comes the ques-
tion  of physic and  food.   No doubt, if the mother have plenty  of milk,  it
will act  as a  purgative, and render medicine unnecessary ; perhaps, even
without it, the child's bowels might be moved spontaneously :  nevertheless,
as few women have milk the first day, and as the retention of the meconium
is apt to  gripe the child, and  make it uneasy, it  is generally advisable to
give a small teaspoonful of castor  oil: at any rate, if the  bowels arc not
moved in the course of twelve hours.  Sugar and water, or butter  and sugar,
are sometimes given to the new born infants, but if any purgative be required,
castor oil is far better than such mixtures.
  Food  of Infant.—By far the best food  for an infant  until  its mother
can supply its wants, or to make up for her shortcomings for a week or two,
is equal  parts  of cow's milk and water,  sweetened ; or three parts of ass's
milk, and one part of water.  But how often should an infant be fed ? When- 
OF  the monthly  nurse.
639
ever it  is hungry,  of course ;  but not, necessarily, whenever you think it
hungry, because  it cries.  A new born baby will", probably, require some-
thing about  every two  hours, and surprising as it may seem, it is quite
possible, at this early period, to  lay the foundation of orderly habits, and
quite impossible to overrate their value.   Give the baby its food everv two
hours, or thereabouts, unless it be  asleep : either its natural  food, or milk
and  water, with a spoon, or from a cup or feeding bottle ; the latter is the
best, provided you wash it each time after using it, and remove and  cleanse
the teat on the nipple.   A little  experience will show you the proper quan-
tity to give each  time ; and, fortunately, any little excess is remedied by the
stomach rejecting the  surplus.   When " possitting," as it is called,  occurs,
or if the stomach be unusually delicate, it is better to give the child less at
a time, and rather oftener.   If the  mother have not milk enough, or if full
nursing be too much  for her strength, you  must supply her deficiency by
feeding; and I think it will be better to feed the baby at  night,  so that she-
may get a good  sleep,  and let her nurse it during the day; after  a time,
when she is quite strong, she may reverse this, and feed the child during the
day, if she cannot nurse it altogether, as the most natural, and most conveni-
ent,  and  most comfortable sleeping place for the baby  at night is in  its
mother's arms, at least for some time.   As the child grows  older, a  change
of food will be required, for the same food, if continued long, almost  always
disagrees with the child.   During the first month, and  I am only at present
concerned with this period, the changes need be very few ; but  for infants
somewhat older,  I  may mention,  as varieties in  addition  to milk—barley-
water, prepared barley or groats, arrowroot, panada, rusks, and  bread jelly.
The latter is  made by  pouring boiling water on the  crumb  of bread and
squeezing it out again four or five times, and then simmering it gently with
a little water in a saucepan until it is thick enough to set, which it will do on
cooling.  A spoonful of this jelly, with water or milk, and sugar, makes a
very nice food.  Whatever food you give, take care that it is very thin.  No
doubt a child is " more satisfied" by thick  food, just as you are after a heavy
meal, but it is not the more healthy way of feeding for either.
   Subsequent Treatment of Infant. — Having said so much  about food,
we must retrace our steps a little.  Very little physic will  be necessary after
the first dose ;  and the less the better.   Until the dark green stools  (meco-
nium) have passed off, and the discharges become yellow, the child is apt to
be griped and  uneasy, but  this will only last a day or two ; the mother's
milk will  then be  coming, and that, at first,  acts as a gentle purgative, so
that the bowels  will generally be  moved three or four times a-day, which
will  be sufficient.   You  are not  to think it your duty, however,  to give the
child medicine if it do not come up to this standard ; nor are you to remedy
too great frequency by a dose of castor oil: in such a case you should ask
the  medical attendant  for  a prescription.    Remember,  that to a  young
infant a purging  is  much more serious than a slight costiveness.  In addi-
tion to  castor oil, the only medicine of which a nurse should have command
(unless  ordered by the  doctor) is fennel water, which  may be given mixed
with water, or with the food, if the child suffer from flatulence ; and these
medicines should be kept apart from all others.   Avoid all quack medicine,
and  all tampering with  stronger medicines than  those I have mentioned, or
you  may incur a  life-long reproach.  I knew a nurse who, either from care-
lessness, or a wish to relieve the child, gave it a small dose of laudanum, and
it was with difficulty saved from death.   No doubt, young  infants  suffer from
flatulent pains, and  make their sorrows heard, but you are not  at once to
conclude  that'they need physic; a little fennel water, warming the feet, a
warm flannel to  the stomach,  or a warm bath, will  almost  always afford
relief.  When a child cries violently, without apparent reason, it is not a bad 
640
qualifications  and duties
plan to see if the point of a pin be not the cause.  And if simple means do
not afford  relief in a reasonable time, you  ought to send  for the medical
attendant without  delay; you may lose valuable time, and what will affect
you  sensibly, credit, by trying to cure the case yourself, when it is beyond a
nurse's skill.
   Sleep of  Infant.—Next, and nearly equal in importance to the infant's
food, is  its sleep.   Without sleep an infant cannot thrive ;   and a nurse
should make  it a rule never to disturb an infant, not even to show it to the
dearest friends.  You can easily give it a habit  of sleeping at  an earlv age,
and  hunger will generally  wake it:  the  more it sleeps the better.   When
convenient, after the first few days, the best  place  for  it to sleep  is the
mother's bed, as it will be sure to be warm there ;  but if you lay it down in
a  cot you should  ascertain that its feet are warm, and  that  it is  warmly
covered,  and secured  against draughts.  As it gets  older, it will remain
longer awake, of course, but you should, as  far as possible, keep to regular
times for sleep, and the midday sleep should be continued  until it is three or
four years old.
   Cleanliness  of  Infant.—Another matter  of great  importance to an
infant is  cleanliness.   I do not  mean  that "rough and tumble" cleanliness
which consists in putting on a clean  frock over  soiled  petticoats, or a clean
pinafore  over a dirty frock ; but  that minute cleanliness of  a child's person,
and of its inner as well  as its outer garments, which ought to be the aim of
all good  nurses.   An infant should be washed  most carefully, after being
fed,  every morning, and  in a slighter  degree in the evening, and its dress
entirely changed each  time.  The water should  be  pleasantly warm,  and
soap will rarely be necessary.   A soft  fine sponge or flannel should be used,
and the  operation  performed with  gentleness  and  quickness.  Take care
that all the creases and folds of the  skin are cleansed, and every part of the
body which comes in contact with  another  part, as neglect here will surely
lead to scalding and chafing.  After this it must be thoroughly dried  with a
warm  soft napkin,  and all the creases well  powdered.  For this purpose,
fine  starch or hair powder is generally used  ; they answer the  purpose very
well generally, but there is a much better powder,  called " Lycopodium," or
puff-ball  powder, which may be obtained  from  the chemists.   If a part be
dusted with  this powder, water will pass over  it without dissolving it, or
washing  it off, or wetting the skin.   I  have found  this most useful with soft
children, who are  scalded, but especially when  the buttocks or groins  are
affected.
   Washing and dressing are distressing enough ; and when all is finished,
the child is generally ready for a sleep, in which it should always be indulged.
A very careful watch should be kept upon the natural evacuations, so as not
to allow  them to remain in contact with the  child longer than you can help :
half the cases of chafing and scalding we meet, arise from the nurse's neglect
in this particular, although they are  ingenious enough in  finding  out other
causes.   No napkin  that  has  been soiled  by   the bowels should ever be
applied again until  it has been washed; and at first, or  with children of
tender skins, no napkin that has ever been wet should be  used more than
once.  More than twice they should never be used, even with older children,
and  before applying them,  you should  see that they are thoroughly dry, and
soft, and warm.   After each movement  of the  bowels, the  infant should be
sponged, dried, and dusted, and the latter always after passing water.   In
these operations also, it is curious how early regular habits may be acquired ;
after a month or two, a baby will quite understand what it  is " held out" for ;
and  such habits promote health as well as cleanliness.
   Chafing and its  Treatment.—But suppose, in spite  of all your care, a
child should chafe, and become sore: you must  bathe the parts very  gently
with milk and water, and dry them carefully, two or three  times a-day, and 
OF  THE  MONTHLY  NURSE.                  641
dust them with the lycopodium powder; if they do  not improve, you may
try  a lotion of the sugar of lead (20 grains to an ounce of water), or of the
sulphate of zinc (white vitriol), four grains to an ounce of distilled water;
applying either, after washing or drying the part.   If you employ the sugar
of lead lotion, remember that it is poisonous, and be careful where it is kept,
and also  that  it is  properly  labelled for fear of mistakes.   If, under  this
treatment, it  do not  heal  in  a  few days, the family  doctor ought  to be
consulted.
  Convalescence after Delivery.—Let us now  return to  the patient,
whom  we left  settled after delivery, and allowed  to sleep;  and  trace the
progress  of her recovery, and the symptoms which  characterize her conva-
lescence.   I shall treat  the subject under different  heads, and describe the
symptoms as they occur  naturally, or as they deviate from their natural and
healthy condition ; and under each head I shall speak of your duties.
   1. A very slight  observation will show you that the condition  of the
 patient is much changed  after labor.   She is much more exhausted than you
 would expect,  from  the  exertion  she  has made ;  she is  pale, wearied,  and,
 as  you say, "worn out;" yet, on the other hand, her senses  are  too  acute,
 and she is painfully affected by light and  noise, which  she would not have
 minded previously.    Her appetite is gone, and the various secretions are a
 good deal altered.
    Nervous Shock.—This all arises from the shock to the nervous system,
 and is independent  of both the exertion and the amount  of blood lost.
    Nay, this shock  is sometimes  so  severe, especially after an  operation, as
 to protract the recovery for many weeks, or even, in rare cases, to prove fatal.
    In ordinary cases no medical treatment is required  on account of this state
 of things ; but you must be careful  to allow the patient to rest until she
 recovers from it.  Keep the room quiet, cool, and shaded ; forbid visitors, and
 allow no whispering, and little talking,  and every day will show an improve-
 ment.
    Even more  care,  caution, and  stillness will be  necessary after operations,
 or when  the shock is more severe than usual, and will have to be continued
 longer.  You will also have to carry out the directions of the medical attend-
 ant as to medicine  and diet, and this you must  always do with scrupulous
 punctuality.   When  directions have once been given, you are  not at liberty
 to deviate'from them, either to gratify the patient or  her friends, or in accord-
 ance with any notion of your own.
    2.  The respiration and circulation remain somewhat hurried after delivery,
 but by degrees this  hurry subsides ; and  when this is the case,  your only
 duty, in  reference to it, will be  to  keep the patient cool, comfortable, and
 tranquil.   Should  either the breathing or circulation become  quicker or
 labored,  you must instantly inform the medical attendant.
    3.  Immediately after the expulsion of the  placenta, I have told you that
 the uterus contracts, and if all  goes on well, this contraction continues per-
 manent,  but increased now and then by afterpains.   It may be  felt as a hard
 tumor in the lower part of the  abdomen,  about the size of an  infant's head,
 and each day it diminishes, until at length it sinks into  the pelvis, and can-
 not be felt.                                                           .
    The vagina has been, of course, very much stretched by the passage ot
 the child Ibut it is  so elastic that it speedily recovers its natural state.  The
 inner ed^-e of the perineum is often  slightly torn  in  first labors ;  but  if it be
 not more than this, you will hardly be able to discover it the next day, and
  it is of no consequence.
    Every day and  more  than once  each day, for the first few days, you will
  mike  a  point  of ascertaining that the  uterus is properly contracted ;  for as
  Ion" as  it is so, there is little fear  of  flooding.  But it may be  larger than
        41 
642
qualifications and  duties
it ought to be from various causes; and if you find it so, especially if it be
tender on pressure, you must mention  it to the doctor, and ask directions
from him.
  A fresh binder  should  be  applied every morning, and tightened so as to
afford firm support without being painful : it becomes  displaced very soon,
however, and will  require rearrangement three or four times a-day.  You
should always  pay special attention to this matter, as it is a great vexation
for a lady to find her figure spoiled when she is able to dress and go down
stairs.   The abdomen is so loose  for some time, that,  unless artificial pres-
sure be made, it is almost sure to distend from flatulence, and once distended,
you will find it almost impossible to remedy it until the next confinement.
  The external parts should  be  carefully washed with warm water  ten or
twelve hours after confinement, and this should be  repeated daily with every
precaution against cold.   A soiled sheet folded should be placed under the
hips, and the patient be kept covered.  If you discover more than the slight
laceration I have mentioned, or if there be any unusual inflammation or sore-
ness about the vulva, you should call the attention  of the doctor  to it on his
next visit.
  4. After-Pains.—Connected with the condition of the womb are the after-
pains which result from  its contractions.   You  rarely observe them after
the first confinement, and as rarely are they absent  after  subsequent ones.
They commence generally in the  course of an hour or two  after delivery,
last for  a minute or two, and then subside, to  be renewed at intervals.
During, or immediately after each, there is often a  slight increase of the dis-
charge, or some clots expelled,  although the pains are themselves a security
against flooding.   They continue  for two or three days, increased for a time
by suckling, but gradually becoming less frequent  and less severe until they
disappear.
  This is the ordinary form of afterpains, and so  far from  regretting their
occurrence, medical men consider  them as beneficial when not  too severe.
In some  instances, however, this is the case ;  they are as painful as labor
pains,  coming  on very frequently, lasting some   time, and  depriving the
patient of rest.   Or, after apparently subsiding, they may recur on the third
or fourth day, and at the same time you may observe the uterus  larger than
it ought  to be : after a time you will generally find a clot expelled, and then
the afterpains cease.
  Little  treatment is required if the afterpains are natural and not exces-
sive ; a warm napkin, or piece of flannel over the uterus, will afford tempo-
rary relief.  In the more severe cases, you had better obtain a prescription
from the medical attendant; or, if you are acting alone as midwife, you may
give a draught containing from twenty to twenty-five drops of laudanum.
  5. The  Lochia.—The discharge of blood which occurs  after delivery,
diminishes in  quantity, but continues  for  some time:  this is  called "the
lochia,"  or "lochial discharge," or "cleansings."  At first, it is red like
blood, but after a few days it  gradually becomes  paler, then yellowish or
greenish,  and is  called by nurses the "green waters."  Occasionally the
blood coagulates in the vagina, and forms  a large clot, which may require
pains to  expel it,  or  it  may  even render passing water difficult.  When
expelled, it occasions the  patient some alarm and  uneasiness ; but this you
may relieve, as it  is of no consequence, and merely indicates that the dis-
charge has been more than usual.   The quantity varies very much, and so
does the  duration  of the discharge; sometimes it is very scanty, especially
when the child dies before birth ; and sometimes it ceases in  a fortnight,
especially when there is an abundant secretion  of milk.   It ought to be over
in about  a month at all events.
  Ou the other hand, there may be too much at  first; or it may come on
more flush some days after delivery, or on sitting up ; or it may return after 
OF  the monthly  nurse.
643
having changed its  character;  and in all  these variations there maybe
nothing seriously astray ; but  it will only be right that you should acquaint
the doctor with  the  occurrence,  that he may decide whether any treatment
be necessary.
   It will be your especial  care  that neither by cold nor exposure shall the
discharge be checked.   Napkins, well dried and warm, should be constantly
applied, and changed often enough to prevent their becoming wet applica-
tions ;  and the binder should be  kept tight so long as the discharge is exces-
sive.   Nor  should the patient be allowed  to make any exertion until the
quantity has moderated  and the color changed, or  else it  may so  increase
as to amount to flooding.
   6. State  of Bowels and Bladder.—Owing partly to the quiet lying in
bed, and partly to the relaxed state of the abdomen, the bowels are seldom
moved after delivery until medicine is given  ; and the patient will sometimes
allow the urine to accumulate  in the bladder.  Occasionally, indeed, when
the second stage of labor has  been tedious  and  difficult, the patient is not
able to pass water at all for some days subsequently.
   Now it is very desirable that the urine  should  be passed at moderate
intervals, and you should induce her to try  and do  so some time, say six or
eight hours, after delivery.  The application  of  a warm cloth to the vulva
will facilitate this,  and, applied afterwards,  it will remove any  smarting.
If the patient  turn  on her face and  knees, she  will  sometimes succeed in
voiding urine, when  she cannot do  so in any other position.   If after one
or two moderate efforts (and you must never allow  much forcing)  she  is
unsuccessful, you must obtain  assistance and have the water drawn off.
   However desirable it may be  that the bowels should be moved, I  do not
think it wise to  effect this  by medicine for  twenty-four  or thirty-six hours
after delivery.   This rest will allow the patient to  recover a little, and  the
organs to return more or less to their natural state; nor have I ever  known
any mischief to arise from waiting so long.   After this time, if they are not
moved  naturally, a  dose of castor oil, Gregory's powder, or the common
 "black bottle " (senna,salts and ginger), (moderate in  amount, may be given
very early in the morning.   As a general rule, I think that pills do not act
satisfactorily when the patient is confined to bed.   If  the first dose of medi-
cine produce no effect, it  may be repeated, or, what is perhaps  better, an
enema of a pint of warm water, or thin gruel, with a tablespoonful of  castor-
oil, or table-salt may be given.   In administering this, you will have to be
very gentle  : remember that all  the parts are  very tender : direct the point
of the pipe back towards the spine, use very little force, and stop and  change
the direction if  the patient complain of pain.   Should she  suffer from piles,
you had better not try the  enema.   And when the medicine operates, or the
patient passes water, do not let her sit up :  she must use the bed-pan, and, at
the most, have  her  shoulders  slightly raised.  To prevent the patient re-
ceiving any cold impression from the pan, it should be warmed at  the fire
before°using it,  or, what is better, should be cased in flannel.
   Piles. —As  I have referred to piles, I  may as  well say a word  or two
about them   They  are very common during pregnancy ; and  in some cases
where they  did not exist during pregnancy,  they  come on after delivery, and
add much to the patient's sufferings.   Sometimes they grow from the orifice
of the anus and are called external piles ;  in other cases  they form within
the bowel  and  are  forced  down when the  bowels  are  moved, and  remain
outside • these are the most painful, as, when down, they are grasped by the
anus for orifice of the bowel) and strangulated.   Now when your  patient
complains of piles it is your duty by an examination to ascertain whether
thev are external or internal; if the latter they must  be returned within the
bowel which  you can do by oiling the points of your fingers, and pressing
the piles gently yet firmly, upwards, until  they  pass into the bowel;  and 
644
QUALIFICATIONS AND  DUTIES
this you must repeat whenever they come  down.  If they be external and
very tender,  you should foment  them twice a-day, and  apply a nice soft
poultice of linseed-meal afterwards :  if  this afford but little relief, two or
three leeches  may be applied to them.  When the tenderness has diminished,
a little ointment of galls, smeared over them two or  three times a-day, will
generally reduce their size, and hasten their disappearance.
  7. Condition of Breasts. —During the latter part of  pregnancy, as you
know, the  breasts are enlarged, and  even  before labor often secrete a thin
kind of milk ; but you do not  generally find true milk  formed  until after
labor.   About the end  of  the second, or during the third day (sometimes
earlier), the  breasts  enlarge and become  hard,  and, if  not relieved,  very
painful, particularly in first confinements.
  This  change may be preceded by a rigor, or fit of  shivering, and accom-
panied by a degree of fever, with quick pulse, hot skin, headache, and thirst:
these symptoms  need not alarm you, if you are satisfied that they arise from
the milk.   Let me remark  here,  that the  occurrence of a rigor in childbed is
a circumstance that always demands particular attention,  as it is often the
first symptom of inflammation of the womb, or of some  form  of that most
dangerous complaint, puerperal  fever.  If it be caused by the coming of the
milk, it need  occasion no alarm, but ascertain  positively,  and without delay,
that this is really the  cause of the rigor.   You may come to this conclusion
if you  find that the breasts are becoming kind and  tender — if the lochia
continue in proper quantity, and if  there be no pain or tenderness  of the
uterus.   Whenever you are in doubt whether this shivering be dependent
or not upon the state of the breasts, your safest plan is to call in the assist-
ance of the accoucheur, for the loss of a very few hours  in puerperal fever
may place the  woman  beyond  the  power of  medicine.   Whenever  your
patient takes a  shivering, therefore, no matter from  what  cause, attend to
her instantly, as it is most desirable to check  it.  Put a hot jar or hot
blanket to her feet; lay an additional blanket over her shoulders,  and give
her a warm drink of whey, tea, milk and  water, or  oatmeal tea.  To this
drink,  a few grains (8 or 10) of nitre, or half a teaspoonful of sweet spirits
of nitre, or a  dessert spoonful of mindererus spirit may be added, if at hand.
   The  true remedy for  the enlargement of the breasts  is, of course, the
application of the child ;  but in some cases the increase is so rapid, that the
child can make  no impression, especially with first children, or if the nipples
be defective ;  and the breasts go on increasing, until, by the  excessive dis-
tension, inflammation is excited, and an abscess, or "bieling" of the breast,
may be the result.  In  other cases,  when the infant is put too often to the
breast before the milk is come, or where  the skin of the nipples is very ten-
der, it becomes  irritated and inflamed, and either cracks or ulcerates, giving
rise to  great  suffering and disappointment.  Nay more, unless you  are very
careful, and even sometimes, in spite of all your care, the inflammation may
extend  from the nipple into the gland of the breast, and an abscess form.   I
believe this, and cold from exposure, to be the  two most frequent causes of
this painful and troublesome affection.
   Putting the Child to the Breast.—How soon after delivery ought the
child to be put  to the breast ?   If the patient have had children before, and
the breasts contain milk, I should say the sooner the better, after she is rested
from the fatigue of labor, say in six or eight hours.  If it be her first child,
and the breasts  be enlarged, I generally  have the child applied once within
twenty-four hours, and  twice or thrice the next day, if it  get any milk; but
not more, lest the nipples should be irritated.   But if the breasts are flaccid
and flat, you  had better wait until the second or third day.  If the draught
be free, the  child strong, and  you are able to apply it  early enough, and
sufficiently frequently, you will  almost certainly avoid milk fever, and the
excessive and painful enlargement of the  breasts; but the condition of the 
OF  THE MONTHLY  NURSE.
645
nipple may, possibly, interfere with the frequent application of the child.
As the breasts increase, the child may make more ample use of them during
the day time, until on the fourth or fifth day its entire nourishment is derived
from the mother.
  If, however, the breasts become hard and knotty and painful, in  spite of
the efforts of the child, you may afford great relief, and facilitate the flow of
milk, by rubbing them gently with a little warm oil —rubbing  them gently,
I say, not as if you were polishing a mahogany table.  In performing this
simple operation,  the patient should lie on her back, and rather toward  the
side  opposite to the  breast that is to be rubbed,  and you  should  make  the
friction with  your hand  around the base  of the breast first, and  gradually
approach the nipple.  Do not move your hand in a direction from the nipple
towards the base  of the gland, but just the reverse.  A small bit of camphor
dissolved in the oil is a pleasant addition.
  In  this state of the breasts, a "cire cloth" is  often applied to  them, and
with much benefit.   This is nothing more than a piece of soft old linen,  the
size  of the breast, and having a hole  cut in the centre for the nipple.   On
one side it is spread  with olive oil and bee's wax melted together, and this
side is applied to the breast.  Although rather a dirty application, it is often
found to be productive  of ease to  the  patient, and may be kept on for two
or three days.
   But I should wish here to point out to you a distinction too  often for-
gotten.  When the  breasts are enlarged  and knotty from over distension,
rubbing affords great relief;  but if they are  running on into inflammation,
rubbing will make them  worse, and destroy the only chance  of escape from
an abscess.   I have seen  this mistake and its results over and over again.
The chief distinction for your guidance is,  that in over distension  the  hard-
ness is equal over the whole breast, there is little or no tenderness,  and  the
skin is pale ; whereas in inflammation,  one part of the breast is particularly
tender, and there is a peculiar hardness there;  the breast  is very painful
when moved,  and there is a blush  on the  skin  of some portion  of it.  In
these latter cases the soothing treatment — fomentations, poultices, etc., — is
the only one likely to be successful.
   Attention to the Nipples.—As  regards the nipples, I have  already
mentioned  that the  skin should be hardened  during the  latter months of
pregnancy, by the application  of spirits and water,  after washing with soap
and water, and drying.   It is a good plan  to  sponge the  nipples with cold
water each time  after  suckling, and then  to apply brandy and water.   If
you find the nipples  becoming tender and raw, or cracked  and painful, great
relief may be obtained by the application  of a small soft poultice, for a short
time after suckling,  and then from the use of a lotion of alum and water, or
equal parts of tincture of catechu and water, or strong green tea.   In some
cases, it is  advisable to apply a weak solution of lunar caustic, but this you
had better leave to the doctor.
  Inflammation and Abscess of the Breasts.—If, notwithstanding the early  ;<. t. :>,
and careful application of the child, and attention to the nipples, the breasts
should inflame, either fromfcold, over secretion,} or extension of inflammation
from the sore nipple, what are you to  do ?  Not to rub them, but to foment
and poultice them until you can get advice; but if  you should not be able
to obtain this, six  or eight leeches may be applied, followed by constant
poulticing, until  either the inflammation  subsides, or  suppuration  takes
place, supporting the  breast  by a  sling, so that it cannot hang down;
taking care, at the same time, to keep the bowels free.   During this pro-
cess it is better to confine the patient to a  simple, moderate  diet; allowing
broths  if there be not  much fever, but no wine until the abscess is evacu-
ated •  and remember that it is better to have the abscess opened than  to let
it break • it will  be  more  completely emptied, will heal sooner, and it may 
646
QUALIFICATIONS AND  DUTIE8
happen, that by avoiding the neighborhood of the nipple, the future use of
the breast may be secured.
   Care  of Breasts in such as do not Suckle. — But suppose the infant
to be dead, or the patient  unable  or determined  not  to  suckle  her child,
what are you to do ?  You cannot prevent the secretion of milk, and  I do
not think that the methods of checking  secretion, by cold applications,  etc.,
are safe or advisable. But if you remember that the amount of milk secreted
depends  partly upon the food taken  into the system,  and partly upon the
amount of milk drawn from the breasts, you will  see that you have a safer,
though slower, method of putting an end to it.  Diminish the diet, especially
the fluid  portion of it, and take away a  little milk occasionally, by the child
or by a breast-pump, just enough to relieve the sense of distention, and you
will soon find  that less  is  secreted, and  if you gradually diminish the
amount you take  away, in the course  of a week or two, the  patient  will not
require this assistance.   And, at the same  time, you may have recourse  to
gentle frictions, fomentations, and^the cire cloth.
   Incontinence of Milk. — When the milk runs freely on the application
of the child, scarcely any assistance or interference on  your part will be ne-
cessary ;  but, on  the other  hand, I have  met with a few instances in which
the  milk  all  ran  away, so  that with  an ample supply  the child was nearly
starved.   In one  case, both breasts kept continually leaking without cause;
in other  cases, when the rush or draught was excited in one breast, from the
application  of the child or any other cause, it not only was felt as usual  in
the other, but the milk ran from  it as  freely  as it was drawn from  the one in
use.  This may be called "incontinence  of milk," and seems to depend upon
some local weakness.   In such cases,  I think that astringents applied to the
nipple, and the use  of nipple glasses, are of  the greatest benefit.
   Changes in the Milk. — At a more advanced period  of nursing, when
the mother is exposed to various external influences, you will find the  milk
liable to  be affected both as to quantity and quality.   Thus the exciting  or
depressing passions will  equally affect the quantity of milk ; but they may
do more, they may change  its quality, and so injure the child seriously.   I
know an instance of this in two ladies  who, when nursing, were plunged in
grief by the death of a third sister, and both lost their children shortly after.
Great grief is, therefore, a  strong  argument for weaning the  child, or for
substituting feeding for  nursing, for a time.   But those  emotions which
merely check the secretion, are of less  consequence ;   and, in general, when
they cease, the milk returns.  I need hardly tell you,  that the " milk pow-
ders," sometimes  given to increase the milk, are a delusion, except so far as
they act upon the imagination of the  patient and relieve her fears.
   Summary of chief  points in respect to Management of Convales-
cence after Delivery. — I have now gone over the  chief peculiarities  of
childbed, their variations,  and the management  necessary :  there  remain
still a few points of management, upon which it  is desirable that I should
say a few words.
   1. Cleanliness.—You cannot be impressed too deeply with the necessity of
cleanliness and tidiness, not only personal,  but general, as regards the sick
room.  The patient should be carefully  washed, her  hair settled,  and her
night  dress and  cap, after  the second  day, changed  morning  and evening,
the napkins changed twice a-day or oftener, and  the parts carefully washed
with warm  water,  and dried  once, a-day.   The bed-clones  should  be
straightened when tossed, the room dusted and made orderly every morning,
all unnecessary matters removed, and everything  kept in its proper place.
Trifling  as  such  things may seem, they exert  a positive influence upon the
patient,  and may thus favor or hinder her convalescence.
   2. Diet. — The  diet of the patient is  of great importance,  though  I  am
not disposed to attribute to it as great  an influence as some have done, nor 
OF  THE MONTHLY  NURSE.
647
have I seen as much mischief arise from deviations from the ordinary rules
as from other causes;  still it  is evident that errors in diet, whether as to
quantity or quality, ought to be sedulously avoided.  In general, the patient
should be kept on bland, sloppy diet for five or six days; perhaps your best
guide will be the state of the milk : when the secretion has been reduced to
the ordinary quantity required by the child, or in other word, when the child
is able to take all its mother has for it, the diet may be safely increased, if
in other respects she is going on well.   Whey, milk and water, or weak tea
for ordinary drink; gruel,  panada,  sago,  tapioca, or bread  and  milk for
lunch and dinner; with tea, not too strong, in the evening, will afford suf-
ficient variety ; bread and butter, of course,  she may have.   When the first
rush of milk has subsided, about the fifth or sixth  day, chicken broth, with
or without bread or toast, as  she pleases, or beef tea, may be allowed for
dinner; then chicken  panada,  chicken roast or boiled, a chop, etc., with a
glass of wine, until she gradually resumes  her ordinary diet.   I think wine
agrees best with the  patient for the first few days, but afterwards she may
have malt liquor if she prefer it.
   3.  Rest.—Of even  greater importance than the diet, is the keeping the
patient in bed sufficiently long, and for some days in  the  supine  position;
almost all the more serious attacks of illness I have seen, have resulted from
sitting up or getting up too soon.  The labor first, and then  the  lying in
bed, render the system  so sensitive, that a very slight  exposure is sufficient
to give cold.  For three or four days the patient should absolutely be con-
fined  to the horizontal position, and not be allowed to  sit up in bed.  Cases
of sudden death  have repeatedly occurred from patients sitting  up too soon
after delivery.   Then she may be propped up with pillows  or a bed-chair
during meals, and occasionally through the day, avoiding  fatigue,  and  not
even permitting  this liberty  if there have been flooding.
   I turn a deaf  ear to all requests to leave her bed, even to have  it made,
before the eighth day,  and I have found  the  benefit of so  doing.   The  bed
can be shaken up very effectually, if the patient be placed near one edge,
and then near the other, while  the bed is making;  and this prolonged rest
allows the  organs which have been so much  disturbed, to  return gradually
to their natural  condition, and by the eighth day the  general sensibility is
so much diminished that the patient is less susceptible of cold.    On the
eighth day, then, she may sit up for an hour, not dressed, for that would
fatigue her too  much, but warmly wrapped  up  in petticoats,  shawls, and
dressing  gown.   The  next  day she may sit up longer, and be more fully
dressed, and afterwards she will gradually resume her usual habits in this
respect.
   4.  Occupation.—Another point of minor importance, but bearing upon
the patient's comfort,  is her occupation  during the period of confinement
after labor.   Of course, for two or three days she is too weak to think about
anything but her safety and  her child, and too much occupied with these to
need any other.   But as she gets  stronger, the day passes  heavily, and the
ordinary sick-room gossip is hardly sufficient  to satisfy any but very ignorant
or very common minds.  If you are able to read nicely, as you ought to be,
you may thus be a great comfort to her.   A chapter of The Book, to which
all turn in sorrow and in suffering, read in the morning, after washing and
dressing will calm and compose her mind: and  occasionally through  the
day, a few pages of an interesting  but  not exciting  work, will make  the
time pass  very pleasantly.   For some few days  the patient ought not to
read herself but as she gets  stronger, she  will  become  uncomfortable if
unoccupied, and provided the bed be placed sideways to the light, there can
be no objection to her reading a little.  When she sits up, she will, of course,
be able to find employment that will not fatigue her. 
648   qualifications  and  duties of monthly  ni rse.

  Symptoms  adapted  to Create Alarm. — Having thus treated  pretty
fully of the phenomena of childbed, with certain deviations from the commou
course, and the necessary treatment of each, I trust you will find no difficulty
in the ordinary management of lying-in women ; but as you know that very
dangerous  attacks occur at this period, especially  when  puerperal fever is
epidemic, which it is of the highest importance to have  checked  at the very
commencement; and as some of the symptoms I have noticed, have a strong
resemblance to the beginnings of disease, it may be  well to  draw  your
attention to some circumstances  which ought to  excite your  alarm, and
induce you to call in assistance as soon as possible.
  1. The  occurrence of rigors, particularly on the second  or third day, if
the breasts are not full  and hard, and especially if there be any pain in the
belly.  I have already spoken of the urgency of this symptom, and told you
how to distinguish between shivering from the milk and from inflammation.
If you cannot fairly attribute it to the milk, you will not lose a moment in
sending for the doctor;  if you delay but a few hours, the  patient may be
past help.  Meantime,  however, you may apply a fomentation to the belly,
but take care how you  do it.   Place a blanket folded lengthways under the
patient, and next to her body;  then wring out flannels  in hot water, and
apply them, but not too wet; then fold the ends of the blanket over all, and
repeat this in ten  minutes.   Not a drop of water should  be allowed to fall
on  the bed or night-clothes, and when you finish  the fomentation, dry the
patient thoroughly, and  place a  warm, dry flannel all over the abdomen.
Or, instead of  the fomentation, you  may apply a  poultice  of scalded  bran
(in  a flannel bag), or of linseed meal: the latter should  be made thin and
sloppy, or it will become hard, and applied as  hot as the patient  can bear it.
  2. The  occurrence of weakness or fainting, without special cause, or after
having been raised in bed, is most alarming.   In such a case, lay the patient
quite flat in bed, and give a little wine, but summon the doctor instantly.
  3. The  same treatment will  be necessary,  in case of  any oppression or
unusual difficulty of breathing.
  4. Severe pain  in the uterus, extending down the thighs, even if it be only
an exaggerated after-pain, demands relief; and as it may be more than this,
viz., the commencement of  inflammation, you  had better obtain assistance,
especially if it be  preceded  or accompanied by shivering.
  5. The  sudden  stoppage of the lochia—especially  if the milk be not
abundant,  or, on the other hand, an unusually  profuse  discharge—is too
serious a matter to be neglected.  Until you obtain assistance, you may, in
the former case, safely apply a poultice to the lower part of the abdomen;
and in the latter,  if the discharge amount to  flooding, after tightening the
binder, you may dip a napkin  in cold water  and apply it for a  moment to
the external parts.   Do  not make a slop about the patient, and do not let
the wet napkin remain in contact with her, as it does no good after the first
impression of cold.
  6. An attack of vomiting or diarrhoea may  occur without apparent cause,
or as the  consequence  of repeated doses  of medicine, and  it is  never to be
overlooked.  If it continue beyond a very short time, you had better call in
a doctor.
   7. If, after repeated and moderate attempts, aided by the means already
recommended, your patient cannot pass water within ten or twelve  hours,
professional assistance will be  necessary.   Such cases rarely occur, except
with first  children, or where the second stage has been unusually prolonged ;
but when it does  happen, you must  neither rely upon  your own  remedies,
nor allow time to be lost. 
INDEX.
Page 159
609,
Abdomen, enlargement of
Abdominal labor   .   .  .
Abortion......
   "     causes.   .   .  .
   "     ovuline causes .
   "     treatment
   "     prophylaxis  .
   "     induction of.
Abscess of breast   .   .  .
Accidental hemorrhage.....
Adhesion of the placenta .... 250-
After-pains........255,
Air in the veins a cause of sudden death.
Alarm, symptoms to create ....
Albuminuria in convulsions ....
Allantois..........
Amenorrhoea........
Amnii, liquor........
Amnion, the.........
Amputation of foetal limbs in utero   .
      "    knife  for......
Anatomy of the pelvis......
Anaemia of new-born infant  ....
Anaesthetics in convulsions  ....
      "     in midwifery    ....
Apoplectic convulsions.....
Apoplexy of child at birth  ....
Appendages, uterine,  inflammation of.
Areola, mammary, in pregnancy  .  .
Arm presentations.......
          "        statistics  ....
         "        treatment.   .  .  .
Arteries of uterus.......
Ascites of foetus........
Asphyxia of new-born infant   .  .  .
Auscultation in pregnancy  ....
Axes of pelvis.......205
190
191
192
194
198
308
645
450
■448
642
528
648
471
128
  91
129
121
154
365
  35
237
480
243
482
237
567
158
420
423
425
  71
435
Ballottement.......
Baudelocque's callipers   .  .   .
     "        cephalotribe .   .
Barnes,  on placenta prsevia .   .
   "    on vesico-vaginal fistula
Bearing down pains of labor
Beatty on vesico-vaginal fistula
Bed, preparation of   ...   •
Binder,  the.......
Bladder, state of,  after delivery
Bleeding in puerperal peritonitis
   a           "     mania
Blisters  in      "     fever .   .
Bloodletting in puerperal convulsio
 162
-354

 161
  58
 369
 462
 505
  .   501
  .   634
234, 636
256, 643
561, 563
  .   605
  .   588
is.   477
Blood, transfusion of ...   .  Page 455
Blundell, on vesico-vaginal fistula .  .  504
Blunt Hook.........365
Bond's placental forceps.....196
   "   forceps........359
Bones of the pelvis.......35
Borax as an oxytoxic......265
Boillaud, on phlegmasia dolens.  .  .  595
Bowels, state of........643
Bozeman, on vesico-vaginal fistula. 497-499
Breasts, care of the, in such as do not ~t  fi .„
           suckle......j
   "   condition of......644
   "   putting child to.....644
   "   inflammation and abscess of. 609-645
   "   state of, after delivery  .  .  .  257
Breech presentations......410
         "         statistics   .  .   .  413
         "         treatment  of  .   .  415
Brennan, on turpentine  .... 563, 589
Brim of the pelvis.......43
     "      "     distortions ....    51
Bruit placentaire.......162
Button shield, Bozeman's.....499
Burns on cephalic version  .   .  .   .  313
   "   on prolapse of funis ....  441
   "   on laceration of perineum  .   .  515
   "   on phlegmasia dolens .   .   591, 596
   "   on mammary abscess ....  609
Burrowes on puerperal mania   .  . 600, 601

Caesarian section.....       383
           "     statistics  ....  387
     "     "     method of operating .  395
Calculus in the bladder, a cause of ob- ) ogq
     structed labor....../
Callipers..........58
Calomel In puerperal fever ....  589
     "         "    mania ....  605
Campbell, on puerperal peritonitis   .  558
    "     on ephemeral fever   .  .   .  606
Canal of the cervix uteri.....69
Cannabis indica in tedious labor  .   .  265
Carunculfe myrtiformes.....63
Catamenia.........77
Carcinoma uteri, a cause of obstructed ) C)„.
     labor........./
Cauterization in vesico-vaginal fistula.  496
Cavity of the pelvis......44
     "     "        distortions of .   .    52
Cephalsematomata.......239
Cephalic version   ....  313, 317-426
                             (649) 
650
INDEX.
Cephalotribe.........369 ! Dalton, on corpus luteum
Cervix uteri.........69
Cervix uteri, canal of......69
  "     "  during pregnancy  .   .   .   114
Chamberlen's forceps......333
Chafing of infant.......640
85,  109
 .   152
 .   118
 .   336
 .   366
 .   594
Child, position of, in utero  ....   144
Child, at birth, measurements .   .   .   146
  "       "    weight.....146
  "       "    signs of maturity .   .   147
  "       "    management  of   .   .   234
  "       "    still born  ....   237
Child-bed, management of women in .   251
     "     fever........537
Chloroform.........243
     "      in convulsions  ....   480
     "      in puerperal mania .  .   .   606
Circulation in fcetus......150
     "      state of, after delivery .   .   248
Chorion..........119
Churchill's forceps.......336
Clarke, John, on inflammation of ute- ")  rfi„
     rine appendages.....j
Clarke, on malignant puerpe- "1 rgo   ggg  cog
     ral fever  ....  J   '    '
Clarke, Joseph, on do......583
Clarke, on extirpation  of uterus  .   .   522
Cleanliness of infant......640
     "       "      after delivery.
Coagula of blood in heart a  cause of)
     sudden death......J
Clitoris..........
Coccyx...........
Coghill's  instrument for vesico-vagi- "1
     nal-fistula.......j
Cold to abdomen in puerperal perito- "I
     nitis.........J
Colles, on vesico-vaginal fistula
Collins, on puerperal peritonitis
Collis, on vesico-vaginal fistula .
Complex labor........438
Compound presentations.....427
Conception.........102
Confinement, preparation for  .  .  .  633
Contagion of puerperal fever  .  .  .  546
Convalescence, abnormal.....253
       "       after natural  labor,  247, 641
 Convulsions.........467
     "     hysteric......467
     "     epileptic......468
     "     apoplectic......482
 Copland, on uterine phlebitis  .   .  .  577
     "    on  puerperal fever.  545, 582, 584
 Corpus luteum of menstruation ...    85
     "    '•    of pregnancy .  .   107-109
 Cranioclasm.........380
 Craniotomy.........361
     "    forceps.......366
     "    obstetric arguments for   .  617
 Crotchet..........364
 Croton oil in tedious labor  ....  265
 Crural phlebitis........590
 Cullerier, on recto-vaginal fistula  .  .  508
 Cupping, dry, in tedious labor .  .  .  266
 Cusack, on puerperal  peritonitis  .  .  560
 Cutting pains of labor......225
 Cystocele,  vaginal, a cause of ob-)  237
     structed labor......J
        on foetal circulation .   .
   "    on formation of decidua
Davis, forceps......
  "   bone forceps   ....
  "   on phlegmasia dolens
Death of foetus, signs of.....188
  "   sudden........523
Decidual cotyledons......116
Decidua..........115
Deformities of pelvis......49
Denman, on phlegmasia dolens .  .   .  591
Dessault, on vesico-vaginal fistula .   .  405
Development, laws of......153
Dewees' wire crotchet......195
Diameters of fcetal head.....146
Diet after delivery.......646
     "    of pelvis......45, 46
Distortions of pelvis......49
     "       •'     effects of, on labor.  292
Double  monsters.......436
Douglass, on puerperal fever  .  .     584
Dressing infant........638
646
530
 61
 39
501

554
497
559
499
566
167
 95
Dry cupping in tedious labor  .   .   .  266
Duges, on puerperal convulsions  .   .  471
  "          "     hysteritis .   .   .  565
  "    on  inflammation  of uterine 1 K-_
           lymphatics
Duplay, on puerperal hysteritis
Duration of pregnancy
Dysmenorrhoea.....
       "      neuralgic.....95
       "      inflammatory  ...    97
       "      mechanical   ....    98

Earle, on vesico-vaginal fistula .  .   .  497
Edwards, on placenta praevia  .  .   .  460
Elythroplastie........504
Emansio mensium.......93
Embryo, the development of.  .  .134,153
Embryulcia.........361
Emetics in puerperal peritonitis   .   .  563
    "         "      mania.  .  .   .  605
Enteric gastro fever......578
Ephemeral fever........606
Epileptic convulsions......468
Ergot of rye........262
     "     to cause premature labor .  308
Erysipelas and puerperal fever .  .  .  543
External organs of generation ...   60
Extirpation of the inverted  uterus .  .  521
Extra-uterine pregnancy.....180
Extremities,  inferior, presentation   .  417
      "      superior      "     .  .  420

Face presentations.......403
     "     "       statistics ....  406
     "     "        treatment   .   .  .  408
Fallopian tubes........73
False pains.........630
Feet, turning by  the......314
 Ferguson,  on puerperal peritonitis      561
     "           "     hysteritis.   .  566
     "     on uterine phlebitis .   .   .  576
 Ferriar, on phlegmasia dolens .   .   .  594
     "   on puerperal mania   .   .   .  605
 Fever, puerperal.......5:;7
   "    gastro-enteric......678 
INDEX.
651
Fever, ephemeral.......
First position of child......
  "  stage of labor......
Fistula, vesico-vaginal.....
   "    recto-vaginal......
Flooding.........449,
Foetal life, physiology of.....
Foetal circulation.......
    "       heart, sounds of  .   .   .
    "       head, diameters of   . 146,
Foetus,  changes in, after birth .   .   .
   "    amputation  of  limbs  of, in 1
           utero......j
   "    development of.....
   "    measurements of.....
   "    movements of......
   "    nutrition of......
   "    pathology of......
   "    position of, in utero ....
   "    signs of death of.....
   "    viability of.......
   "    weight of, at birth  ....
 Foot presentations.......
 Force expulsive, uterine.....
 Forceps, placental.......
   "    the.........
   "       statistics.....338,
   <<       suitable cases for  .  .  .
   "       mode of operating .  .  .
   "       after treatment  ....
 Forehead towards the pubis ....
       "       statistics.....
       "       treatment.....
 Fourchette, the........
 Fourth position of child.....
 Funic pulsation and souffle  ....
 Funis umbilicalis.......
   "  presentation of......
   "  prolapse of.......
   "      "    statistics.....
   "      "    treatment.....

 Galvanism in tedious labor  ....
     "     to cause premature labor  .
 Gastro-enteric  fever......
     "     "      treatment   .  .
 Generation.........
     "     external organs of  .  .   .
     "     internal organs of   .  .   •
 Gestation..........
     "     term of.......
 Glandule nabothi.......
 Gooch, on puerperal fever           •
    a          "    mania .  .  • 60U
 Gordon, on puerperal peritonitis  .   .
    "     on inflammation  of  uterine)
              appendages   ...   J
 Graafian  vesicles.......
 Grinding pains of labor.....
 Guthrie,  on phlegmasia dolens .  .   .
606
215
225
493
507
464
149
150
163
211
153

154
153
146
161
 49
187
144
188
147
146
417
203
196
331
353
343
346
351
408
409
409
  63
218
165
127
438
438
438
441
Hemorrhage, treatment.....465
     "       secondary.....465
Hemorrhage umbilical.....239
Hall, M., on convulsions.....470
     "   on puerperal mania  .  .  .   604
Haunch bone........36
Hayn's perforator.......363
Hayward, on vesico-vaginal fistula   .   497
Head, version by.......313
Hernia, vaginal........289
Hey, on puerperal peritonitis  .   .  .   561
Hip-bone..........36
Hobart, on vesico-vaginal fistula  .  .   497
Hodge's forceps........357
Holmes's perforator......364
   "    on puerperal fever ....   548
Horner, on lacerated perineum.   .  .   594
Hour-glass contraction.....446
Hunter, W., on puerperal mania   .  .   600
Huckle bone.........39
Hull, on phlegmasia dolens .  .   .  .  513
Hulme, on puerperal peritonitis   .  .  558
Huston's forceps.......356
Hydrocephalus of foetus.....435
Hymen..........62
   "   imperforate.......290
Hysteric convulsions......467
Hystetritis puerperal......564
      "    treatment......566
Hysterotomy........383
Hemorrhage
265
309
578
581
102
  60
  66
154
167
  69
584
-603
558
568
  74
225
595

449
1. acci
dental.....450
treatment
452
.       i                 454
internal.....*J_Z
unavoidable .  .  •   •
treatment .
after delivery   .  •
457
464
Ilium,  os..........
Imperforate os uteri......
Incontinence  of milk......
Indian hemp as an oxitoxic ....
Induction of premature labor   .  .  .
    "     mode of operating   .   .   .
    "     of abortion......
Inertia of uterus.......
Infant, care of, new born.....
  "    physic for.......
  "    food for........
Inflammation of lymphatics ....
       "     of peritoneum ....
       "     of uterine appendages  .
       "     of breasts  .... 609,
       "     of uterine veins  .   .   .
Innominatum, os.......
Internal hemorrhage  .   .     .   •   ■
Internal organs of generation
Interstitial foetation  .   .  .
Instrumental labor ....
Introductory observations
Inversion of the uterus   .  .
     "      terminations  ....
     "      treatment.....
Ischium, os.........

Jacquemier's test of pregnancy.   .   .   166
Jobert, on vesico-vaginal fistula   .   .   508
   "    on laceration of perineum.   .   512
Joints of pelvis.......39-41

Kane,  on kiesteine.......165
Keith, on sudden death.....531
Kennedy,  E., on  vesico-vaginal i  497_505
     fistula.......S
Kiesteine..........l6o
18S
 36
279
646
265
296
306
308
261
637
638
638
577
556
567
645
572
 35
454
 66
485
331
 33
515
519
520
 36 
652
INDEX.
Labia majora........61
  "   minora........61
Labium, sanguineous tumor of .   .   .  290
Labor, abnormal.......191
  "    natural.......222. 630
  "    tedious........257
  "    unnatural.......257
  "    powerless.......274
  "    management of, natural   . 229, 634
  "    obstructed.......278
  '•    premature.......190
       stages of......202, 631
  "    symptoms of.....223, 224
  "    with convulsions.....467
  "      "  distortion.....292
  "      "  flooding......449
  "      "  inversion of uterus   .   .  515
  "      "  lacerations.....484
  "      "  malposition.....403
  "      "  malpresentation   .   .   .  403
  "      "  prolapse of funis  .   .   .  438
  "      <'  retained placenta .   .   .  443
Laceration of the perineum ....  509
Lacerations.........484
Lallemand,  on vesico-vaginal fistula  .  497
Lee, R., on  puerperal peritonitis  .   .  559
   "         hysteritis......564
   "         inflammation  of uterine "I  r~n
             lymphatics ....  J
   "         uterine phlebitis   .   .   .  574
   "         phlegmasia dolens .   .   .  592
Lee, on placenta prasvia.....459
Lever, the.........323
Ligaments,  the round......74
Liquor amnii........129
     "      excess of......270
     "      premature escape of .   .  271
Lochia, the......250, 256, 642
Low fever of childbed......537
Lymphatics of uterus......71
     "      uterine inflammation of  .   577
M'Clintock, on vesico-vaginal fistula
    "     on sudden death.   .   .
Machinery of parturition.
    "        expulsive force
    "        passage of pelvis, etc.
             child......
Mackenzie, on phlegmasia dolens  .
    "      on prolapse of funis
Malignant puerperal fever  .  .   .
Mal-position of child.....
Mal-presentation......
Mammary abscess......
    "     sj^mpathies in pregnancy
Mania, puerperal......
   "   lactea.......
Maturity of child......
Meatus urinarius......
Mechanism of parturition   .  .   .
    "     of head in 1st position  .
    "        2d position ....
    "        3d position ....
    "        4th position    .  .   .
Meigs, on hysterotomy   ....
   "   on placenta praevia
   "   prolapse  of funis  ....
M.igs, on sudden death  ....
198
Meigs, on puerperal fever   ....  550
Meigs's embryulcia instruments  .     367
Membrana decidua.......115
Membranes, toughness of   ....  271
Menorrhagia.........98
Menstruation........77
     "      commencement of .   .   7S. 82
     "      cessation of.....81
     "      condition of uterine or-)
              gans during .   .   .   /
     "      excessive......98
     "      final cause of  ...   .   S7
     "      difficult  and painful   .   .   95
     "      non-appearance of.   .   .   91
     "      suppressed.....93
     "      vicarious......94
     "      arrest of, in pregnancy  .  156
Mercury in  puerperal peritonitis  .   .  562
Milk in breasts of pregnant female   .  159
  "  the..........251
Mons Veneris........60
Monsters..........43,5
Monthly nurses, duties of  ...   .  629
Morality, obstetric.......613
Morning sickness.......157
Mucous membrane of uterus   ...   69
Murphy, on convulsions.....470
Murray, on puerperal peritonitis
Muscular structure of uterus  .

Naegele, on breech presentation
    "   on vesico-vaginal fistula
Narcotics in puerperal mania
Natural labor......
    "       precursory symptoms
501
529
203
203
205
211
596
441
581
403
403
609
158
599
600
147
  62
203
215
216
217
218
387
463
441
530
                                     558
                                  .   203

                                 411,412
                                  .   497
                                  .   605
                                     222
                                  '.   223
            stages of......225
    "       symptoms  of   ....   224
    "       internal examinations. 226-230
    "       management of           229
Navel string.........127
Nervous shock.....247-253, 641
Newnham, on inversio uteri....   520
Nipples, sore.........608
   "   management of  .   .  633, 634, 645
Nunnelly, on puerperal fever   .   .  .   543
Nurses, monthly duties of   ...  .   629
   "     "       during pregnancy  .   632
   "     "       labor......63,4
   "     "      after birth of the child 634
Nutrition of foetus.......149
Nymphae..........61

Obliquity of uterus.......272
Observations, preliminary  ....   33
Obstetric morality.......613
     "   operations......296
Obstructed labor.......278
Oldham's vertebral hook.....366
Operations,  obstetrical.....296
Opiates in puerperal convulsions  .  .  479
     "      "       mania ....  605
Organs of generation.....35-77
Osborn,  on craniotomy.....368
Os tincse
Os uteri
on hysterotomy
on symphyseotomy
minute or imperforate
387
398
 69
 69
279 
INDEX.
653
Os uteri, rigid........266
Outlet of the pelvis......45, 209
Ovaries, the........74-77
     "    disease of. a cause of ob-\  „„.
            structed labor  .   .  .   /  z°
     "    physiology of.....77
     "    during menstruation...    84
            "    pregnancy   .  .   .   108
Ovarian fcetation.......181
Ovum, the..........129
Oxytoxics..........262

Paget, on sudden death.....533
Pains, spurious.......224, 630
    "  cutting........225
    "  gi'inding........225
Parophrosyne puerperarum ....   600
Parturient female,  management of,
     after delivery......
Parturition.........199
251
200
203
187
 35
 43
 42
535
    "     classification of  .
    "     mechanism of  .
Pathology of foetus.....
Pelvis.........
  "  the true......
  "  the false......
  "  joints of.......39-41
  "  axes of the.......205
  "  brim of the.......43
  "  canal of the.......205
  "  diameters......43, 45, 46
  "  difference between male and female. 46
  "  deformities of.....49, 292
  "  abnormally large.....50
  "       "     small.....51
  "  cavity of........44
  "  outlet of........45
  "  external measurement of .   .   .    47
  "  internal       "         ...    48
  "  passages of.......205
  "  planes of........206
Perforations of intestines, a cause of
    sudden death  ......
Perineum, the........63
    "     rigidity of......290
Peritoneum, inflammation of           556
Peritoneal fever........537
Peritonitis, puerperal......556
    "      morbid anatomy ....  559
    ;'      treatment......561
Phlebitis, uterine.......572
    "     crural.......590
Phlegmasia dolens.......590
       "       pathology.....593
       "       treatment.....597
Physiology of the uterus  and ovaries. 77-199
    "      of generation.....77
           of foetal life.....149
Piles...........648
Placenta, the........l-°_
    "     extraction of.....235
    "     retention of......443
    "     praevia.......44o
Placental souffle........162
    "     forceps.......196
Plug, the, in hemorrhage.....452
   P"     in vesico-vaginal fistula.  .  505
Plural births.........4-8
Podalic version.......314
Polypus uteri........
Positions..........
Powerless labor........
      :'      treatment.....
Pregnancy, signs of......
    "      duration  of.....
    "      extra-uterine.....
    "      spurious......
    "      twin.......
Pregnant women, general condition  .
Preliminary observations.....
Premature labor........
    "     "     induction of
Presentation of face......
     "       of breech.....
    "       of inferior  extremities
    "       of superior extremities  .
    "       of hand or arm with head
    "       of feet and hands  .
Presentations........
Prolapse of funis.......
Pseudo-pregnancy.......
Pubis, os..........
Puerperal fever........
       "       contagion ....
       "       1. peritonitis
       "       2. hysteritis ....
       "       3. inflammation of ap-"I
                    pondages  .   .  J
       "       4. uterine phlebitis
       "       5. inflammation of
                    uterine  lym-
                    phatics .
                 gastro-enteric fever
                 malignant fever
                 hysterics .
-319
 283
 202
 274
 276
 155
 167
 180
 174
 167
 156
Puerperal mania
Pulsations of foetal heart .
       "          funis .
Pulse,  state of, after birth
Purgatives in puerperal peritonitis
190
296
403
412
417
420
427
428
201
438
174
 37
537
546
556
564
567
578
581
564
599
163
165
254
563
Quickening.........160
Radford, on galvanism in tedious labor.
    "    on placenta praevia
Radford's forceps.......
Ramsbotham, on face presentations   .
       "     on puerperal fever  .
Recto-vaginal fistula......
       "    "      treatment .
Respiration, condition of, after delivery.
Retention of the placenta   ....
       "      statistics.....
       "      treatment.....
Rigby, on uterine hemorrhage .   .   .
   "   on puerperal fever   ....
Rigidity of cervix uteri.....
   "     treatment.
Roberton, on puerperal fever   .   .   .
Roonhuysen, on the lever   ....
Round ligaments, the......
Rupture of uterus.......
       "      statistics.....
Sncro-coccygeal joint  .
Sacro-iliac synchondrosis
265
460
336
403
549
507
508
248
443
444
445
453
551
266
267
549
324
 74
484
484

 40
 39 
65 4
INDEX.
Sacrum, os.........38
Salivation of pregnancy.....157
Sanguineous tumor of labium  .   .   .   290
Scalp tumor of........239
Scanzoni,  on puerperal fever   .   .   .   544
Scarlatina, a cause of sudden death  .   535
Scirrhus uteri, a cause of obstructed")   no,
     labor.........j
Secondary hemorrhage.....465
Second stage of labor......227
Second position  of child.....216
Sexes, relative proportion of   .   .   .   148
Share bone.........37
Shock to nervous system, a cause of)   c-0(,
     sudden death....../
Sickness,  morning.......157
Sigault, on  symphyseotomy ....   397
Signs of pregnancy......155
Simpson, on turning......315
     "   on puerperal fever.  .  .   .   543
     "   on cranioclasm.....380
     "   on puerperal convulsions   .   471
     "   on placenta prsevia   .  .   .   459
     "   on vesico-vaginal fistula .   .   499
Sims,  on vesico-vaginal fistula .  .   .   497
  "    on sleep of infant.....640
Smellie's forceps.......336
     "   perforator.....361-363
Smith, Tyler,  on abolition  of cranio- "l  „_A
                tomy...../  6,b
              on puerperal fever  .  .   553
     "        on convulsions   .  .  .   470
Sore nipples.........608
Spermatozoa.........-103
Spontaneous evolution......421
Spurious pregnancy......174
Stages of labor.......202, 225
Sterility..........171
Still born child........237
Stolz,  on Caesarian section  ....   392
Sudden death........523
       "    1.  from syncope   .  .  .   523
       "    2.  idiopathic asphyxia .   525
       "    3.  shock......626
       "    4.  air in the veins.  .  .   528
       "    5.  coagulum in the  heart.  530
       "    6.  disease of the heart .   531
       "    7.  obstruction or rup- ~)
                  ture of pulmonary j-  533
                  arteries   ...  J
       "    8.  general dropsy .  .  .   534
       "    9.  perforation of intestine.  535
       "    10.  scarlatina  ....   535
Superfcetation........j 77
Suppressed  menstruation.....93
Suture, in vesico-vaginal fistula   .   .   497
Symphyseotomy.......397
Symphysis pubis.......40
Syncope of newborn infant ....   237
   "   a cause of sudden death .   .   523

Tartar emetic in  puerperal peritonitis .   563
   "    "   in  iuflamed breasts  .   .   611
Tedious labor........257
     "       causes and treatment.   .   261 j
     "       statistics......257 '
Third position of child.....215
Third stage  of labor......229
Thomas, on re-poi.ition of the funis   .  44'2
Tonnelle, on puerperal hysteritis  .   .  56)
    "    on uterine phlebitis  .   .   .  574
Toughness of membranes, a cause of) o--,
    tedious  labor......j
Tractor vectis of Ogden.....325
Transfusion.........455
Trask,  on placenta prcevia  ....  464
Tubal fcetation........182
Tubes,  fallopian........73
Tumor of scalp........239
Tumors in the pelvis......282
Turning..........309
         statistics.......310
   "     object of the operation   .   .  312
   "  1.  cephalic version  .  .   .313,317
   "  2.  podalic version.....3,14
   "     by external manipulation   .  318
Turpentine in puerperal peritonitis    563
                       fever ...  589
Twin births.........428
  "  pregnancy......167, 428
Tyre, on phlegmasia dolens  ....  594
Umbilical cord........
       "     pulsation of the .
       "     hemorrhage of the  .
       "     vesicle......
Unavoidable hemorrhage.....
Unnatural labor.......257,
Undilatable os uteri......
      "    vagina.......
Urethra..........
   "    orifice of.......
Urine, in convulsions......
Utero-gestation.......m
Uterine appendages, inflammation of .
    "   phlebitis.......
    "   lymphatics,  inflammation of .
    "   phlebitis.......
    "   contractions......
    "   souffle  ........
Utero-gestation........
Uterus.........
   "   arteries of the.....
   "   muscular coat......
   "   mucous lining......
   "   vessels and nerves of.  .   .
   "   changes  induced by gestation  .
   "   double........
   "   inertia of.......
   "   inflammation of.....
   "   obliquity of.......
   "   physiology of.....77.
   "   rupture of.......
   "    after delivery......
   "    inversion of.......
Uva ursi in tedious labor    .  .
127
165
239
120
455
403
266
281
 62
 62
471
154
567
572
577
572
203
162
111
 67
 71
 69
 69
 71
114
 72
261
564
Vagina, orifice of  ...
    "   structure of.....
    "   narrow or undilatable  .   .
    "   state of, after delivery  .
Vagina, closure of vesico-vaginal fistula
Vaginal examination  .   .   . 226, 230
    "   cystocele.....
   "   hernia......
Vectis, the.......
-199
 484
 248
 515
 265

  62
  64
 281
 248
 504
 631
 287
2m;) 
INDEX.
655
Vectis, the,  cases suitable   ....  326
   "        mode of operation  .  .   .  328
Veins, uterine, inflammation of.  .   .  572
Venesection in puerperal peritonitis  .  561
Version..........309
   "   in convulsions......480
Vesicles, Graafian, the.....74
Vesico-uterine fistula......506
Vesico-utero vaginal fistula ....  507
Vesico-vaginal fistula......493
       "       treatment.....495
Vesicula alba........120
Vestibulum.........62
Vicarious menstruation.....94
Vidal de Casis on vesico-vaginal fistula. 504
Vines, on puerperal convulsions   .   .  478
Voillemier, on puerperal fever .  .   .  584
Vomiting in puerperal mania  .  .   .  605

Washing infant........638
Water-douche in tedious labor .  .   .  266
Weight of child........146
Weid...........606
White, on phlegmasia dolens  .  .   .  594
Wire crotchet........195
Wright,  M.  B., on cephalic version   .  314
THE END. 
 
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  As tne Medical News and Library is in no case sent  without advance payment, its sub*o k.
 will always receive it free of  postage.                                               -criners
  Remittances of subscriptions can be mailed at our risk, when a certificate is taken from the P
 master that the money is duly inclosed and forwarded.                                   *ost-
                                  Address      BLANCHARD & LEA, Philadel^hu 
AND  SCIENTIFIC  PUBLICATIONS.
3
                                   ASHTON (T.  J.),
                          Surgeon to the Blenheim Dispensary, &c.

ON  THE  DISEASES,  INJURIES,  AND MALFORMATIONS  OF  THE
  RECTUM AND ANUS; with remarks on Habitual Constipation.  From the third and enlarged
  London edition. With handsome illustrations.  In one very beautifully printed octavo volume,
  of about 300 pages.  (Now Ready.)  $2 00.
Introduction.  Chapter I. Irritation and Itching of the Anus.  II.  Inflammation and Excoria-
  tion of the Anus.   HI. Excrescences of the  Anal Region.  IV. Contraction of the Anus.  V.
  Fissure of the Anus and lower part of the Rectum.   VI. Neuralgia of the Anus and extremity
  of the Rectum. VII. Inflammation of the Rectum.  VHI.  Ulceration of the Rectum.  IX. He-
  morrhoidal Affections. X. Enlargement of Hemorrhoidal Veins.  XI. Prolapsus of the Rectum.
  XII. Abscess near  the Rectum.  XIII. Fistula in Ano.  XIV. Polvpiof the Rectum.  XV. Stric-
  ture of the Rectum.  XVI. Malignant Diseases of the Rectum.  XVII. Injuries of the Rectum
  XVIII.  Foreign Bodies  in the Rectum.  XIX. Malformations of the Rectum.  XX. Habitual
  Constipation.
  The most complete one we possess on the subject.
Medico-Chirurgical Review.
  Its merits as a practical instructor, well arranged,
abundantly furnished with illustrative cases, and
clearly and comprehensively, albeit too diffusely,
written, are incontestable.  They have been  suffi-
ciently endorsed by the verdict of his countrymen
in the  rapid exhaustion of the first edition, and thev
would certainly meet with a similar reward in the
United States were the volume placed within the
reach of American practitioners.  We are satisfied
after a  careful examination of the volume, ana a
comparison of its contents with those of its leading
predecessors and contemporaries, that the best way
for the reader to avail himself of the excellent ad-
vice given in the concluding paragraph above, would
be to provide himself with a copy of tne book from
which it has been taken, and diligently to con its
instructive pages. They may secure to him many
a triumph and fervent blessing.— Am. Journal Med.
Sciences, April, 165S.
                             ALLEN (J.  M.), M. D.,
                 Professor of Anatomy in the Pennsylvania Medical College, &c.

THE  PRACTICAL ANATOMIST;  or, The Student's  Guide in the Dissecting-
  ROOM.  With 266 illustrations.  In one handsome royal 12mo. volume, of over 600 pages, lea-
  ther.  $2 25.
  However  valuable may be  the  " Dissector's
Guides" which we, of late, have had occasion to
notice, we feel confident that the work of Dr. Allen
is superior to any of them.  We believe with the
author, that none is so fully illustrated as this, and
the arrangement of the work is such as to facilitate
the labors of the student in acquiring a thorough
practical knowledge of Anatomy. We most cordi-
ally recommend it to their attention.—Western Lan-
ce .
  We believe it to be one of the most useful works
upon the subject ever written.  It is  handsomely
illustrated, well printed, and will be found of con-
venient size for use in the dissecting-room.—Med.
Examiner.
                             ANATOMICAL ATLAS.
By Professors  H.  H.  Smith and W.  E. Horner,, of the  University of  Pennsyl-
  vania.  1 vol. 8vo., extra cloth, with nearly 650 illustrations.  J3?° See Smith, p. 27.
               ABEL (F.  A.),  F. C.S*  AND  C. L.  BLOXAM.
HANDBOOK OF  CHEMISTRY,  Theoretical,  Practical, and Technical; with  a
  Recommendatory Preface by Dr. Hofmann.  In one large octavo volume, extra cloth, of 662
  pages,  with illustrations.  $3 25.

                         ASHWELL  (SAMUEL), M. D.,
                   Obstetric Physician and Lecturer to Guy's Hospital, London.

A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN.
  Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third
  and revised London edition.  In one octavo volume,  extra cloth, of 528 pages.  $3  00.
  The most useful practical work on the subject in j  The  most able, and certainly the most standard
the English  language. — Boston Med. and Surg,  and practical, work on female diseases that we have
Journal.                                     I yet seen.—Medico-Chirurgital Review.

                            ARNOTT (NEILL),  M. D.
ELEMENTS  OF  PHYSICS;   or  Natural  Philosophy,  General  and  Medical.
  Written for universal use, in plain or non-technical language.  A new edition, by Isaac Hays,
  M. D.  Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra-
  tions.  $2 50._________________

                      BIRD (GOLDING), A. M.,  M. D., See.
URINARY   DEPOSITS:   THEIR  DIAGNOSIS,   PATHOLOGY,  AND
  THERAPEUTICAL INDICATIONS.   Edited by Edmund Lloyd Birkett, M. D. A new
American, from the fifth and enlarged London edition. With eighty illustrations on wood.   In one
handsome octavo volume, of about 400 pages, extra cloth.  $2 00.   (Just Issued.)
  The death of Dr. Bird has rendered it necessary to entrust the revision of the present edition to
other hands, and in his performance of the duty thus devolving on him, Dr.  Birkett has sedulously
endeavored to carry out the author's plan by introducing such new matter  and modifications o'f
the text as the progress of science has called for.  Notwithstanding the utmost care to keep the
work within a reasonable compass, these additions have resulted in a considerable enlargement.
It is, therefore, hoped that it will be found fully up to the present condition of the subject, and that
the reputation of the volume as a clear, complete, and compendious manual, will be fully maintained. 
4
BLANCHARD  &  LEA'S  MEDICAL
                       BUDD (GEORGE),  M. D., F. R. S.,
                     Professor of Medicine in King's College, London.
ON DISEASES OF THE LIVER.    Third  American, from the third  and
  enlarged London edition.  In one very handsome octavo  volume, extra cloth, with four beauti-
  fully colored plates, and numerous wood-cuts.  pp. 500.   $3 00.
  Has fairly established for itself a place among the
classical medical literature  of England.—British
and Foreign Medico-Ckir. Review, July, 1857.
  Dr. Biidd's Treatise on  Diseases of the  Liver is
now a standard work in Medical literature, and dur-
ing the intervals which have elapsed between the
successive editions, the author has incorporated into
the text the most striking novelties which have cha-
racterized the recent progress of hepatic physiology
is not perceptibly changed, the history of liver dis-
eases is made more complete, and is kept upon a level
with the progress of modern science. It is the beat
work on Diseases of the Liver in any language.—
London Med. Times and Gazette, June 27, 1857.
 This work, now the standard book of reference on
the diseases of which it  treats, has been carefully
revised, and many new illustrations of the views of
the learned author added  in the present edition.—
and pathology; so thatalthough the size of the book I Dublin Quarterly Journal, Aug. 1657.
BY THE SAME AUTHOR.
ON  THE  ORGANIC  DISEASES  AND FUNCTIONAL  DISORDERS  OF
  THE STOMACH.  In one neat octavo volume, extra cloth.  $1 50.
                           BUCKNILL  (J. C),  M. D.,
               Medical Superintendent of the Devon County Lunatic Asylum; and
                           DANIEL  H.  TUKE,  M. D.,
                        Visiting Medical Officer to the York Retreat.

A MANUAL OF  PSYCHOLOGICAL  MEDICINE;  containing  the History,
  Nosology, Description, Statistics, Diagnosis, Pathology, and  Treatment of INSANITY.  With
  a Plate.  In one handsome octavo volume, of 536 pages.   $3 00.
  The increase of mental disease in its various forms, and the difficult  questions to which it  i«
constantly giving rise, render the subject one  of daily enhanced interest,  requiring  on the part  of
the physician a constantly greater familiarity with this, the most perplexing branch of his profes-
sion.  At the same time there  has been for some years no work accessible in this country, present-
ing the results of recent investigations in the Diagnosis and Prognosis of Insanity, and the greatly
improved methods of treatment which have done so much in alleviating the condition or restoring
the health of the insane.  To  fill this vacancy  the publishers present this volume, assured that
the distinguished reputation  and experience of the authors will entitle it at once to  the confidence
of both student and practitioner.   Its scope may be gathered from the declaration  of the authors
that "their aim has been to  supply a text-book which may serve as a guide in the acquisition  of
such knowledge, sufficiently elementary to be adapted to the wants  of the student, and sufficiently
modern in its views and explicit in its teaching to suffice for the demands of the practitioner."
               BENNETT  (J.  HUGHES),  M.D.,  F. R. S. E.,
               Professor of Clinical Medicine in the University of Edinburgh, &c.

THE  PATHOLOGY AND TREATMENT  OF  PULMONARY TUBERCU-
  LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken
  for or associated with, Phthisis.  One vol. 8vq,extra cloth, with wood-cuts.  pp. 130.  $1 25.
                          BENNETT (HENRY), M. D.
A PRACTICAL  TREATISE  ON  INFLAMMATION OF  THE UTERUS,
  ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease.   To which
  is added, a Review of the present state of Uterine Pathology.  Fifth American, from the third
  English edition.  In one octavo volume, of about 500 pages, extra cloth. $2 00.  (Now Ready.)
  The ill health of the author having prevented  the promised revision of this work, the present
edition is a reprint of the last, without alteration.  As the volume  has been for some time out of
print, gentlemen desiring copies can now procure them.
                          BOWMAN  (JOHN  E.), M.D.
PRACTICAL HANDBOOK  OF  MEDICAL   CHEMISTRY.   Second Ante-
  rican, from the third and revised English Edition.  In one neat volume, royal 12mo., extra cloth
  with numerous illustrations,  pp. 288.  $1 25.

                                 BY THE SAME AUTHOR.

INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING  ANA-
  LYSIS.  Second American, from the second and revised  London edition.  With numerous illus-
  trations.  In one neat vol., royal 12mo., extra cloth,  pp.350.  $125.
BEALE ON THE LAWS OF HEALTH IN RE-
  LATION TO MIND AND BODY. A Series of
  Letters from an old Practitioner to a Patient.  In
  one volume, royal  12mo., extra cloth,  pp. 296.
  80 cents.

BUSHNAN'S PHYSIOLOGY OF ANIMAL AND
  VEGETAB LE LIFE; a Popular Treatise on the
  Functions and Phenomena of Organic Life.  In
  one handsome royal 12mo. volume, extra cloth,
  with over 100 illustrations,  pp. 234. 80 cents.
BUCKLER ON THE ETIOLOGY, PATHOT nrv
  AND TREATMENT OF FIBRO-BRONCH I'
  TIS AND RHEUMATIC PNEUMONIA   in
  one 8vo. volume, extra cloth,  pp.150  SI 25
BLOOD AND  URINE (MANUALS OV1  rv
  JOHN  WILLIAM  GRIFFITH  c   f iv2i
  REESE, AND ALFRED  MARKWICK   o
  thick volume, royal 12mo.,  extra clnth . .?
  plates,  pp. 460.  «1 25.    '       Cl0th> WlUl
BRODIE'S  CLINICAL  LECTURES ON «sitd
  GERY. lvol.8vo. cloth. 350 pp.  8125. 
AND SCIENTIFIC  PUBLICATIONS,
5
                              BARCLAY (A. W.), M. D.,
                        Assistant Physician to St. George's Hospital, &c.

A MANUAL OF MEDICAL  DIAGNOSIS;  being an Analysis of the Signs
  and Symptoms of Disease.  In one neat octavo volume, extra cloth, of 424 pages. $2 00. (Lately
  issued.)
  Of works exclusively devoted to this important i  The task  of composing such a work is neither an
branch, our profession has at command, compara-  easy nor a light one; but Dr. Barclay has performed
tively, but few, and, therefore, in the publication of j  it in a manner which meets our most  unqualified
the present work, Messrs. Blanchard &  Lea have |  approbation.  He is no mere theorist; he knows his
conferred a great favor upon us. Dr. Barclay, from
having occupied, for a long period, the position of
Medical Registrar at St. George's Hospital, pos-
sessed advantages for correct observation and reli-
able conclusions, as to the significance of symptoms,
which have fallen to  the lot of but few, either in
his own  or any other country.  He has carefully
systematized the results of his observation of over
twelve thousand patients, and by his diligence and
judicious  classification, the  profession  has been
presented with  the most convenient and reliable
work on  the subject of Diagnosis that it has been
our good  fortune ever to examine; we can, there-
fore, say  of Dr.  Barclay's work, that, from his sys-
tematic manner of arrangement, his work is one of
the best works " for reference" in the daily emer-
gencies of the practitioner, with which we are ac-
quainted j but, at the same  time, we would recom-
mend our readers, especially the younger ones, to
read thoroughly and study diligently the whole work,
and the "emergencies" will not occur so often.—
Southern Med. and Surg. Journ., March, 1858.
work thoroughly, and in attempting to perform it,
has not exceeded his powers.—British Med. Journal,
Dec. 5, 1857.
  We venture to predict that the work will be de-
servedly popular, and soon become, like Watson^s
Practice, an indispensable necessity to the practi-
tioner.—N. A. Med. Journal, April, 1858.
  An inestimable work of reference for the young
practitioner and student.—Nashville Med. Journal,
May, 1858.
  We hope the volume will have an extensive cir-
culation, not among students of medicine only, but
practitioners also.   They will never regret a faith-
ful study of its pages.—CincinnatiLancet,MaT. '58.
  An important acquisition to  medical literature.
It is a work of high merit, both from the vast im-
porcance of the subject upon which it  treats, and
also from the real  ability displayed in its elabora-
tion.  In conclusion, let us bespeak for this volume
that attention of every student of  our art which it
so richly  deserves—that place in every medical
  To give this information, to supply this admitted  library which it can so well adorn.—Peninsular
deficiency, is the object of Dr. Barclay's Manual. |  Medical Journal, Sept. 1858.
                          BARLOW  (GEORGE H.),  M. D.
                           Physician to Guy's Hospital, London, &c.

A MANUAL OF THE PRACTICE  OF MEDICINE.   With  Additions by D.
  F. Condie, M.D., author of "A Practical Treatise on Diseases of Children," &c.  In one hand-
  some octavo volume, leather, of over 600 pages.  $2 75.
                                               will be found hardly less useful to the experienced
                                               physician.  The American editor has added to the
                                               work three chapters—on Cholera Infantum, Yellow
                                               Fever, and Cerebro-spinal Meningitis.  These addi-
                                               tions, the two first of which are indispensable to a
                                               work on practice destined for the profession  in this
                                               country, are executed with great judgment  and fi-
                                               delity, by Dr. Condie, who has also succeeded  hap-
                                               pily in imitating  the conciseness and clearness of
                                               style which are such agreeable characteristics of
                                               the original book.—Boston Med. and Surg. Journal.
  We recommendDr. Barlow's Manual in the warm-
est manner as a most valuable vade-mecum.  We
have had frequent occasion to consult it, and have
found it clear, concise, practical, and sound.  It is
eminently  a practical work, containing all that is
essential, and avoiding  useless theoretical discus-
sion.  The work supplies what has been for some
time wanting, a manual of practice based upon mo-
dern discoveries in pathology and rational views of
treatment of disease. It is especially intended for
the use of students  and junior practitioners, but it
                            BARTLETT (ELISHA), M. D.
THE  HISTORY,  DIAGNOSIS, AND  TREATMENT  OF  THE  FEVERS
  OF THE UNITED STATES.  A new and revised edition.  By Alonzo Clark, M. D., Prof.
  of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c.  In
  one octavo volume, of six hundred pages, extra cloth. Price $3 00.
  It is the best work on fevers which has emanated
from the American press, and the present editor has
carefully availed himself of all information exist-
ing upon  the subject in the Old and New World, so
that the doctrines advanced are brought down to the
latest date  in the progress of this  department of
Medical Science.—London Med. Times and Gazette,
May 2, 1857.
  This excellent monograph on febrile disease, has
stood deservedly high since its first publication.  It
will be seen that it has now reached its fourth edi-
tion under the supervision of Prof. A. Clark, a gen-
tleman who, from the nature of his studies and pur-
suits, is well calculated to appreciate and discuss
the many intricate and difficult questions in patho-
logy.  His annotations add much to the interest of
the work, and have brought it well up to the condi-
tion of the seience as it exists at the present day
in regard to this class of diseases.—Southern Med.
and Surg. Journal, Mar. 1857.
  It is a work of great practical value and interest,
containing much that is new relative to the  several
diseases of which it treats, and, with the additions
of the editor, is fully up to the times.  The distinct-
ive features of the different forms of fever are plainly
and forcibly portrayed, and the lines of demarcation
carefully and accurately drawn, and to the  Ameri-
can practitioner is a more valuable and safe guide
than any work on fever extant.—Ohio Med. and
Surg. Journal, May, 1857.
                             BROWN  (ISAAC  BAKER),
                         Surgeon-Accoucheur to St. Mary's Hospital, &c.

ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT-
  MENT.  With handsome illustrations.   One vol. 8vo., extra cloth, pp. 276.  $1 60.
  Mr. Brown has earned for himself a high reputa- I and merit the careful attention of every surgeoa-
tion in the operative treatment of sundry diseases j accoucheur.—Association Journal.
and injuries to which females are peculiarly subject.
We can truly say of his work that it is an important
addition to obstetrical literature.  Theoperative
suggestions and contrivances which Mr. Brown de-
scribes, exhibit much practical sagacity  and skill,
  We have no hesitation in recommending this book
to t:ie careful attention of all surgeons who makfl
female compiaints a part of their study and practice.
—Dublin Quarterly Journal. 
c
BLANCHARD & LEA'S  MEDICAL
              CARPENTER  (WILLIAM  B.),  M. D., F. R. S., &.c,
           Examiner in Physiology and Comparative Anatomy in the University of London.

 PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief applications  to
   Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from
   the last and revised London edition. With nearly three hundred illustrations.  Edited, with addi-
   tion-, by Francis Gurney Smith,  M. D., Professor of the Institutes of Medicine in the  Pennsyl-
   vania Medical College, &c.  In one very large and beautiful octavo volume, of about nine hundred
   large pages, handsomely printed  and strongly bound in leather, with raised bands.  $4 25.

   In the preparation of this new edition, the author has spared no labor to render it, as heretofore,
 a  complete and lucid  exposition of the  most  advanced condition  of its  important subject.  The
 amount of the additions required to effect this object thoroughly, joined to the former large  size of
 the volume, presenting objections arising from  the unwieldy bulk of the work, he  has omitted all
 those portions not  bearing  directly upon Human Physiology, designing to incorporate, them in
 his forthcoming Treatise on General Physiology.  As a full and accurate text-book on  the Phy-
 siology of Man, the work in  its present condition therefore presents even greater claims upon
 the student and physician than  those  which have heretofore won for it the very wide and distin-
 guished favor which it has so long enjoyed.   The additions  of Prof. Smith will be found to supply
 whatever may have been wanting  to the  American student, while  the introduction of many new
illustrations, and the most careful mechanical  execution, render the volume one  of the  most at-
tractive as yet issued.
   For upwards of thirteen years  Dr.  Carpenter's
 work has been considered by the profession gene-
 rally, both in this country and England, as the most
 valuable compendium on the subject of physiology
 in our language.  This distinction it owes to the high
 attainments  and  unwearied industry of its accom-
 plished author.  The present edition (which, like the
 last American one, was prepared by the author him-
 self), is the result of such extensive revision, that it
 may almost  be considered a new work.  We need
 hardly say, in concluding this brief notice, that while
 the work is indispensable to every student of medi-
 sine in this country, it will amply repay the practi-
 tioner for its perusal by the interest and value of its
 contents.—Boston Med. and Surg. Journal.

  This is a standard work—the text-book used by all
 medical students who read the English language.
 It has  passed through several editions  in order to
 keep pace with the rapidly growing science of Phy-
 siology.  Nothing need be Baid in its praise, for its
 merits are universally known ; we have nothing to
 say of its defects, for they only appear where the
 science of which it treats  is incomplete.—Western
 Lancet.
  The most complete exposition of physiology which
any language can  at present give.—Brit, and For.
 Med.-Chirurg. Review.

  The greatest, the most reliable, and the best book
on the subject which we know of in  the English
language.—Stethoscopt.
   To eulogize this great work would be superfluous.
 We should observe, however, that in this edition
 the author has  remodelled a large portion  of the
 former, and the editor has added much matter of in-
 terest, especially in the form of illustrations.  We
 may confidently recommend it as the most complete
 work on  Human  Physiology  in  our  language.—
 Southern Med. and Surg. Journal.
   The most complete work on the science  in our
 language.—Am. Med. Journal.
   The most complete work now extant in our lan-
 guage.—N. O. Med. Register.
   The best text-book in the language on this ex-
 tensive subject.—London Med. Times.
   A complete cyclopaedia of this branch of science.
 —If. Y. Med. Times.
   The profession of this country, and  perhaps also
 of Europe, have anxiously and for some time awaited
 the announcement of this new edition of Carpenter's
 Human Physiology.  His former editions have for
 many years been almost the only text-book on Phy-
 siology in all our medical schools, and its circula-
 tion among the profession has been unsurpassed by
 any work in any department of medical science.
  It is quite unnecessary for us to speak of this
 work as its merits would justify. The mere an-
 nouncement of its appearance will afford the highest
 pleasure to every student of Physiology, while its
perusal  will be of  infinite service in advancing
physiological science.—Ohio Med. and Surg. Journ.
BY THE SAME AUTHOR.
PRINCIPLES OF COMPARATIVE  PHYSIOLOGY.   New American, from
  the Fourth and Revised London edition.   In one large and handsome octavo volume, with over
  three hundred beautiful illustrations,  pp. 752.  Extra cloth, $4 80; leather, raised bands, $5 25.

  The delay which has existed in the appearance of this work has been caused by the verv thorough
revision and remodelling which it has undergone at the  hands of the author, and the large number
of new illustrations which  have been prepared  for it.  It will, therefore,  be found almost a new
work, and fully up to the day in every department of the  subject, rendering it a reliable text-book
for all students engaged in this branch of science.  Every effort has been made to render its typo-
graphical  finish and mechanical execution worthy of its exalted  reputation, and creditable to the
mechanical arts of this country.
  This book should not only be read but thoroughly
 studied by every member of the profession.  None
 are too wise or old, to be benefited thereby.  But
 especially to the younger class would we cordially
 commend it as best fitted of any work in the English
 language to qualify them for the reception and coin-
 prehension of those truths which are daily being de-
 veloped in physiology.—Medical Counsellor.
  Without pretending to it, it is an encyclopedia of
 the subject, accurate and complete in all respects—
 a truthful reflection of the advanced state at which
 the science  has now arrived.—Dublin Quarterly
 Journal of Medical Science.
  A truly magnificent work—in itself a perfect phy-
 siological study.—Ranking'! Abstract.
  This work stands without its fellow.  It is one
few men in Europe could have undertaken j it is one
no man, we believe, could have brought to so suc-
cessful an  issue as Dr. Carpenter.  It required for
its production a physiologist at once deeply read in
the labors  of others, capable of taking a general
critical, and unprejudiced view of those labors and
of combining the varied, heterogeneous materials at
his disposal, so as to form  an harmonious whole
We feel that this abstract can give the reader a verv
imperfect idea of the fulness of  this work  and nn
idea of its unity, of the admirable manner in which
material has been brought,  from  the most v<Trin,,.
sources, to conduce to its completeness  of the Ii  h
ity of the reasoning it contains, or of the cle-
of language in which the whole is clothed  \'«»?fi?*
profession only, but the  scientific world bm
must feel  deeply indebted to Dr. CarDent** e  r?e)
great work.  It  must, indeed, add largely l°JJ V"
his high reputation.—Medico/ Times.    y  en to 
AND  SCIENTIFIC PUBLICATIONS
7
                CARPENTER (WILLIAM B.), M. D., F. R. S.,
          Examiner in Physiology and Comparative Anatomy in the University of London.

THE  MICROSCOPE AND ITS REVELATIONS.   With  an Appendix  con-
  taining the Applications of the Microscope to Clinical Medicine, &c.  By F. G. Smith, M. D.
  Illustrated by four hundred and thirty-four beautiful engravings on wood.  In one large and very
  handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50.

  Ur. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher,
eminently qualify him to produce what has  long been wanted—a good  text-book  on the practical
use of  the microscope.  In the present volume his object has been, as stated  in  his Preface, " to
combine, within a moderate compass, that information with regard to the use of his ' tools,' which
is most essential to  the working microscopist, with such an account of the objects best fitted for
his study, as might  qualify him to comprehend what he observes, and  might thus prepare  him to
benefit science, whilst expanding and refreshing his own mind "   That he has succeeded in  accom-
plishing this, no one acquainted with his previous labors can doubt.
  The  great importance of the microscope  as a means of diagnosis, and the number of microsco-
pists who are also physicians,.have induced the American publishers, with the author's approval, to
add an Appendix, carefully prepared by Professor Smith, on the applications of the  instrument to
clinical medicine, together with an  account of American Microscopes, their modifications and
accessories.  This  portion of the work is illustrated with nearly one hundred  wood-cuts, and, it is
hoped, will adapt the volume more particularly to the use of the American student.
  Every care has been taken in the mechanical execution of the work, which is confidently pre-
sented as in no respect inferior to the choicest productions of the London press.
   The mode in which the author has executed his  intentions may be gathered from the following
condensed  synopsis of the

                                      CONTENTS.

[ntroduction—History of the  Microscope.   Chap. I. Optical  Principles  of the Microscope.
   Chap. II.  Construction of the Microscope.   Chap. III.  Accessory Apparatus.  Chap.  IV.
   Management of the Microscope   Chap. v. Preparation, Mounting, and Collection of  Objects.
   Chap. VI. Microscopic Forms of Vegetable Life—Protophytes.  Chap. VII. Higher Cryptoga-
   mia.  Chap. VIII. Phanerogamic Plants.  Chap. IX. Microscopic Forms of Animal Life—Pro-
   tozoa—Animalcules. Chap. X. Foraminifera, Polycystina, and Sponges.  Chap. XI. Zoophytes.
   Chap. XII. Echinodermata.  Chap.  XIII. Polyzoa  and Compound Tunicata.  Chap.  XIV.
   Molluscous Animals Generally.  Chap. XV. Annulosa.  Chap. XVI. Crustacea.  Chap. XVII.
   Insects and Arachnida.  Chap. XVIII. Vertebrated Animals.  Chap. XIX. Applications  of the
   Microscope to Geology. Chap. XX. Inorganic or Mineral Kingdom—Polarization. Appendix.
   Microscope as a  means of Diagnosis—Injections—Microscopes of American Manufacture.
  Those who are acquainted with Dr. Carpenter's
previous writings on Animal and Vegetable Physio-
fogy, will fully understand how vast a store of know-
ledge he is able to bring to bear upon so comprehen-
sive a subject as the revelations of the microscope j
and even those who have no previous acquaintance
with the construction or uses of this instrument,
will find abundance of information conveyed in clear
and simple  language.—Med.  Times  and Gazette.
  Although  originally  not intended  as  a  strictly
medical work, the additions by Prof. Smith give it
a positive claim upon the profession, for which we
doubt not he will receive their sincere thanks.  In-
deed, we know not where the student of medicine
will find such acomplete and satisfactory collection
of microscopic facts bearing  upon physiology and
practical medicine as is contained in Prof. Smith's
appendix; and this of itself, it seems to us, is fully
worth the cost of the volume.—Louisville Medical
Review, Nov. 1856.
                                BY THE SAME AUTHOR.

ELEMENTS (OR MANUAL) OF  PHYSIOLOGY,  INCLUDING  PHYSIO-
  LOGICAL ANATOMY.  Second American, from  a new and revised London edition.  With
  one hundred and ninety illustrations.  In one very handsome octavo volume, leather,  pp. 566.
  $3 00.
  In publishing the first edition of this work, its title was altered from that of the London volume,
by the substitution of the word " Elements" for that of " Manual," and with the author's sanction
the title of "Elements" is still retained as being more expressive of  the scope of the treatise.
  To say that it is the best manual of Physiology
now before the public, would not do sufficient justice
to the author.—Buffalo Medical Journal.
  In his former works it would seem that he had
exhausted the subject of Physiology. In the present,
uegiveB theessence, as it were, of the whole.—iV. Y.
Journal of Medicine.
  Those who have occasion for an elementary trea-
tise on Physiology, cannot do better than to possess
themselves of the manual of Dr. Carpenter.—Medical
Examiner.
  The best and most complete expose- of modern
Physiology, in one volume, extant in the English
language.—St. Louis Medical Journal.
                           BY the same author.  (Preparing.)

PRINCIPLES OF  GENERAL  PHYSIOLOGY,  INCLUDING  ORGANIC
  CHEMISTRY AND HISTOLOGY.  With a General Sketch of the Vegetable and  Animal
  Kingdom.  In one large and very handsome octavo volume, with several hundred illustrations.
  The subject of general physiology having been omitted in the last editions ot the author's << Com-
parative Physiology"  and "Human Physiology," he has undertaken to prepare a volume which
shall present it more thoroughly and fully than has yet been attempted, and which may be regarded
as an introduction to his other works.
                                 BY THE SAME AUTHOR.

A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS  IN HEALTH
  AND DISEASE.  New edition, with a Preface by D. F. Condie, M. D., and explanations of
  scientific words.  In one neat 12mo. volume, extra cloth, pp. 178.  50 cents. 
BLANCHARD  &  LEA'S  MEDICAL
                           CONDIE (D.  F.),  M.  D., See
A PRACTICAL  TREATISE ON THE DISEASES OF CHILDREN.   Fifth
  edition, revised and augmented.  In one large volume, 8vo., leather, of over 750 pages. $3 25.
  (Just Issued, 1859.)
  In presenting a new and revised edition of this  favorite work, the publishers have only to state
that the author has endeavored to render it in every respect "a complete and faithful exp isition oj
the pathology and therapeutics of the maladies  incident to the earlier stages  of existence—a full
and exact account of the diseases of infancy and childhood."  To accomplish this he has subjected
the whole work to a careful and thorough revision, rewriting a considerable portion, and adding
several new chapters. In this manner it is hoped that any deficiencies which may have previously
existed have been supplied, that the  recent labors of practitioners and observers have  been tho-
roughly incorporated, and that in every point the work will be found to maintain the high reputation
it has enjoyed as a complete and thoroughly practical book of reference in infantile affections.
  A few notices of previous editions  are subjoined.
  Dr. Condie's scholarship, acumen, industry, and
practical sense are manifested in this, as in all his
numerous contributions to science.—Dr. Holmes's
Report to the American Medical Association.
  Taken as a whole, in our judgment, Dr. Condie's
Treatise  is the one from the perusal of which the
practitioner in this country will rise with the great-
est satisfaction.—Western Journal of Medicine and
Surgery.
  One of the best works upon the Diseases of Chil-
dren in  the English language.—Western Lancet.
  We feel assured from actual experience that no
physician's library can be complete without a copy
of this work.—N. Y. Journal of Medicine.
  A veritable pediatric encyclopaedia, and an honor
to American medical literature.—Ohio Medical and
Surgical Journal.
  We feel persuaded that the American medical pro-
fession will soon regard  it not only as a very good,
but as the vert best " Practical Treatise on the
Diseases of Children."—American Medical Journal.
  In the department of infantile therapeutics, the I fore the profession of the United States; indeed, we
work of Dr. Condie is considered one of the best may Bay in the English language. It is vastly supe-
which has been published in the English language, rior to mostof its predecessors.—Transylvania Med.
—The Stethoscope.                            \Journal.
  We pronounced  the first edition to be the best
work on the diseases of children in the English
language, and, notwithstanding all that has been
published, we still regard it in that light.—Medical
Examiner.
  The value of works by native authors on the dis-
eases which the physician is called upon to combat,
will be appreciated by all;  and the work of Dr. Con-
die has gained for itself the character of a safe guide
for students, and a useful work for consultation by
those engaged  in practice.—N. Y. Med.  Times.
  This is the fourth edition of this deservedly popu-
lar treatise. During the interval since the last edi-
tion, it has been subjected to a thorough revision
by the author;  and all new observations in  the
pathology and therapeutics of children  have been
included in the present volume.  As we said before,
we do not know of a better book on diseases of chil-
dren, and to a large part of its recommendations we
yield an unhesitating concurrence.—Buffalo Med.
Journal.
  Perhaps the most full and complete work now be-
            CHRISTISON (ROBERT),  M.  DM V. P. R. S. E., «tc.
A DISPENSATORY;  or, Commentary  on the  Pharmacopoeias of Great Britain
  and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac-
  tions, Uses, and Doses of the  Articles of the  Materia Medica.   Second edition, revised and im-
  proved, with a Supplement containing the most important New Remedies.  With copious Addi-
  tions, and two hundred and thirteen large wood-engravings.  By R. Eglesfeld Griffith, M. D.
  In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50.

                       COOPER  (BRANSBY BJ, F.  R. S.
LECTURES ON  THE PRINCIPLES  AND  PRACTICE  OF  SURGERY.
  in one very large octavo volume, extra cloth,  of 750 pages. $3  00.
COOPER  ON DISLOCATIONS  AND FRAC-
  TURES OF THE JOINTS—Edited by Bransbt
  B. Cooper, F. R. S., &c.  With  additional Ob-
  servations by Prof. J. C. Warren. A new Ame-
  rican edition.  In one handsome octavo volume,
  extra cloth, of about 500 pages, with numerous
  illustrations on wood. $3 25.
COOPER ON THE ANATOMY AND DISEASES
  OF THE BREAST, with twenty-five Miscellane-
  ous and Surgical Papers.  One large volume, im-
  perial 8vo., extra cloth, with 252 figures, on 36
  plates.  $2 50.
COOPER  ON  THE  STRUCTURE AND DIS-
  EASES  OF  THE TESTIS, AND  ON  THE
  THYMUS GLAND.  One vol. imperial 8vo., ex-
  tra cloth, with 177 figures on 29 plates. $2 00.
COPLAND ON THE CAUSES, NATURE, AND
  TREATMENT OF PALSY AND APOPLEXY.
  In one volume, royal 12mo., extra cloth, pp. 326.
  80 cents.

CLYMER ON FEVERS;  THEIR DIAGNOSIS,
  PATHOLOGY, AND  TREATMENT  In one
  octavo volume, leather, of 600 pages.  $1 50.

COLOMBAT DE L'ISERE ON THE DISEASES
  OF FEMALES,  and on  the special  Hygiene of
  their Sex. Translated, with many Notes and Ad-
  ditions, by C. D. Meigs, M. D.  Second edition,
  revised and improved.  In one large volume, oc-
  tavo, leather, with numerous wood-cuts. dd. 720.
  83 50.                              vv
                           CARSON (JOSEPH), M. D.,
           Professor of Materia Medica and Pharmacy in the University of Pennsylvania

SYNOPSIS  OF  THE  COURSE OF LECTURES ON MATERIA MEDICA
  AND  PHARMACY, delivered in the University of Pennsylvania.  Second  and revised edi-
  tion.  In one very neat octavo volume, extra cloth, of 208 pages.   $1  50.

                          CURLING  (T.  B.),  F. R.S.,
             Surgeon to the London Hospital, President of  the Hunterian Society, ice

A PRACTICAL  TREATISE ON DISEASES OF  THE  TESTIS, SPERM/
  TIC CORD, AND SCROTUM.  Second American, from the second and enlarged English eii""
  tion.  In one handsome octavo volume, extra cloth, with numerous illu.-irations. pp. 4^0. $2 oo" 
AND  SCIENTIFIC  PUBLICATIONS.
               CHURCHILL (FLEETWOOD),  M. D., M.  R. I. A.
ON THE THEORY AND PRACTICE  OF  MIDWIFERY.   A new American
  from the fourth revised and enlarged London edition.  With Notes and Additions, by D. Francis
  Condie, M.  D., author of a  "Practical Treatise on the Diseases of Children," &c.  With 194
  illustrations.  In one verv handsome octavo volume, leather, of nearly 700 large pages.  $3 50.
  (Now Ready, October, 1860.)
  This work has been so long an established favorite, both as a text-book for the learner and as a
reliable aid in  consultation for  the practitioner, that in presenting a new edition it is only necessary
to call attention to the very extended improvements which  it has received.  Having had the benefit
of two revisions by the author since the last American reprint, it has been materially enlarged, and
Dr. Churchill's well-known conscientious industry is a guarantee  that every portion has been tho-
roughly brought up with the latest results of European investigation in all departments of the sci-
ence and art of obstetrics.  The recent date of the last Dublin edition has not left much of novelty
for the American editor to introduce, but he has endeavored to insert whatever has since appeared,
together with  such matters as  his experience has shown him would be desirable for the American
student, including a large number of illustrations.  With the sanction of the author he has added
in the form of an appendix, some chapters  from a little "Manual for Midwives and Nurses," re-
cently issued by Dr. Churchill, believing ihat the details there presented  can  hardly fail to prove of
advantage to the junior practitioner.   The result of all these additions is that the work now con-
tains  fully one-half more matter than the last American edition, with nearly one-half more  illus-
trations, so ihat notwithstanding the use of a smaller type, the volume contains almost two hundred
pages more than before.
  No effort has been spared to secure an improvement in the mechanical execution of the work
equal to that which  the text has received,  and the volume is confidently presented as one of the
handsomest that has thus far  been laid before the American profession; while  the very low price
at which it is offered should secure for it a place in every lecture-room and on every office table.
  A better book in which to learn these important
points we have not met than Dr. Churchill's. Every
page of it is full of instruction; the opinion of all
writers of authority is given on questions of diffi-
culty, as well as  the directions and advice of the
learned author himself, to which he adds the result
of statistical inquiry, putting statistics in their pro
per place and giving them their due weight, and no
more.  We have never read a book more free from
professional jealousy than Dr. Churchill's.  It ap-
pears to be written with the true design of a book on
medicine, viz:  to give all that is known on the sub-
ject of which he treats, both theoretically and prac-
tically, and to advance such opinions of his own as
he believes will benefit medical science, and insure
the safety of the patient.  We have said enough to
convey to the profession that this book of Dr. Chur-
chill's  is admirably suited for a book of reference
for the practitioner, as well as a text-book for the
student, and we  hope it  may be extensively pur-
chased amongst  our  readers.   To them we most
strongly recommend it. — Dublin Medical  Press,
June 20, 1860.

  To bestow praise on a book that has received such
marked approbation would be superfluous. We need
only  say,  therefore, that if the first edition was
thought worthy  of a favorable reception by the
medical public, we can confidently affirm that this
will be found much  more so.  The  lecturer, the
practitioner, and  the student, may all have recourse
to its pages, and derive from their perusal much in-
terest and instruction in everything relating to theo-
retical and practical midwifery.—Dublin Quarterly
Journal of Medical Science.

  A work of very great merit, and such as we can
confidently recommend to the study of every obste-
tric practitioner.—London Medical Gazette.

  This is certainly the most perfect system extant.
It is the best adapted for the purposes of a text-
book, and that which he  whose necessities confine
him to one book, should select in preference to all
others.—Southern Medical and Surgical Journal.
                         BY  the same AUTHOR.  (Lately Published.)
ON THE DISEASES OF INFANTS AND  CHILDREN.   Second  American
  Edition, revised and enlarged by the author.  Edited, with Notes, by W. V. Keating, M. D.  In
  one large and handsome volume, extra cloth,  of over 700 pages.  $3 00, or in leather, $3 25.
  In preparing this work a second  time for the American profession, the author  has spared no
labor in giving it a very thorough revision, introducing several new chapters, and rewriting others,
while every portion of the volume  has  been subjected to a severe scrutiny.  The efforts of the
American editor have been directed  to supplying such information relative to matters peculiar
to this country  as might have  escaped the attention of the author,  and the whole may, there-
fore be safely pronounced one of the most complete works on the subject accessible to  the Ame-
rican Profession.  By an alteration in the  size of the page, these very extensive  additions  have
been accommodated without unduly increasing  the size of the work.
                                   by the same author.

ESSAYS ON THE  PUERPERAL FEVER, AND  OTHER  DISEASES  PE-
  CULIAR TO WOMEN.   Selected from the writings of  British Authors previous to the close of
   the Eighteenth Century.  In one neat octavo volume, extra cloth, of about 450 pages.   $2 50.
  The most popular work on midwifery ever issued
from the American press.—Charleston Med. Journal.
  Were we reduced to the necessity of having but
tne work  on midwifery, and permitted to  choose,
we would unhesitatingly take Churchill.—Western
Med. and Surg. Journal.
  It is impossible to conceive a more useful  and
jlegant manual  than Dr. Churchill's  Practice of
Midwifery.—Provincial Medical Journal.
  Certainly, in our opinion, the very best work on
he subject  which exists.—N. Y. Annalist.
  No work holds a higher position, or is more de-
serving of being placed in the hands of the tyro,
the advanced student, or the practitioner.—Medical
Examiners
  Previous editions, under the editorial supervision
of Prof R. M.  Huston, have been received with
marked favor, and they deserved it; but this, re-
printed from a very  late Dublin edition, carefully
revised and brought up by the author to the present
time, does  present an unusually accurate and able
exposition of every important particular embraced
in the department of midwifery. * * The clearness,
directness, and precision of its teachings, togetner
with the great amount of statistical research which
its text exhibits, have served to place it already in
the foremost rank of works in this department of re-
medial science.—N. O. Med. and Surg. Journal.
  In our opinion, it  forms one of the best if not the
very best text-book and epitome of obstetric science
which we at present possess in the English lan-
guage.—Monthly Journal of Medical Science.
  The clearness  and precision of style in which it is
written, and the  greatamountof statistical research
which it contains, have served to place it in the first
rank of works in this departmentof medical science.
—N. Y. Journal  of Medicine.
  Few treatises will be found better adapted as a
text-book for the student, or as a manual  for the
frequent consultation of the  young practitioner.—
American Medical Journal. 
10
BLANCHARD  & LEA'S  MEDICAL
           CHURCHILL  (FLEETWOOD),  M.  D., M.  R. I. A.,  ice.
ON THE DISEASES  OF  WOMEN;  including those of Pregnancy and Child-
  bed. A new American edition, revised by the Author. With Notes and Additions, by D. Fran-
  cis Condie,  M. D., author of " A Practical Treatise on the Diseases of Children." With nume-
  rous illustrations.  In one large and handsome octavo volume, leather, of 768 pages.  $3 00.
  This edition of Dr.  Churchill's very popular treatise may almost be  termed a  new  work, so
thoroughly has he revised it in every portion.  It will be found greatly enlarged, and  completely
brought up to  the most recent condition of  the subject,  while the very handsome series of illustra-
tions introduced, representing such pathological conditions as can be accurately portrayed, present
a novel feature, and afford valuable  assistance to  the  young practitioner.  Such additions as ap-
peared desirable for the American  student have  been made by the editor, Dr. Condie, while a
marked improvement in the mechanical execution keeps pace with the advance in all other respects
which the volume has undergone, while the price has been kept at the former very moderate rate.
  It comprises, unquestionably, one of the most ex-  extent that Dr. Churchill does.  His, indeed, is the
act and comprehensive expositions of the present  only  thorough treatise we know of on the subject;
state of medical knowledge in respect to the diseases  and it may be commended to practitioners and stu-
of women that  has yet been published.—Am. Journ.  dents as a masterpiece in its particular department.
Med. Sciences, July, 1857.                        — Thi Western Journal of Medicine and Surgery.
  This work is the most reliable which we possess    As a comprehensive manual for students, or a
on this subject; and is deservedly popular with the  work of reference for practitioners, it surpasses any
profession.—Charleston Med. Journal, July, 1857.   other that has ever issued on the same subject from
  We know of  no author who deserves that appro- I the British press.—Dublin Quart. Journal.
bation, on " the diseases of females," to the same I

                              DICKSON (S.   H.),  M. D.,
           Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia.

ELEMENTS OF  MEDICINE;  a Compendious View  of Pathology and Thera-
   peutics, or the History and Treatment of Diseases.   Second edition, revised.   In one  large and
   handsome octavo volume, of 750  pages, leather.   $3 75.   {Just Issued.)
   The steady  demand which has so soon exhausted the first edition of this work, sufficiently shows
 that the author was not mistaken in  supposing that a volume of this character was needed—an
 elementary manual of practice, which should present the leading principles of medicine with the
 practical results, in a condensed and perspicuous manner.  Disencumbered of unnecessary  detail
 and fruitless speculations, it embodies what is most requisite for the student to learn, and at the
 same time what the active practitioner wants when obliged, in the daily calls  of his profession, to
 refresh his memory on special points.  The  clear and attractive style of the author renders the
 whole easy of comprehension, while his long experience gives to his teachings an authority every-
 where acknowledged.  Few physicians, indeed, have  had wider opportunities for observation and
 experience, and few, perhaps, have used them to better purpose.  As the result  of a long life de-
 voted to study and practice, the present edition, revised and brought up to the date of publication,
 will doubtless maintain the reputation already acquired as a condensed and convenient  American
 text-book on the Practice of Medicine.
                     DRUITT (ROBERT),  M.R. C.S.,  &c.
THE PRINCIPLES  AND PRACTICE  OF  MODERN  SURGERY.    A new
  and revi>ed American from the eighth enlarged and improved London edition.  Illustrated with
  four hundred and thirty-two wood-engravings.  In one very handsomely printed octavo volume,
  leather, of nearly 700 large pages.  $3 50.  (Now Ready, October, 1S60.)
  A work which like Druitt's Surgery has for so many years maintained the position of a lead-
ing favorite with all classes of the profession, needs no special recommendation to attract attention
to a revised edition.  It is only necessary to state  that the author has spared no pains to keep the
work up to its well earned reputation of presenting in a small and  convenient compass the latest
condition of every department of surgery, considered both as a science  and as an art; and that the
services of a competent American editor have been employed to introduce whatever novelties may
have escaped the  author's attention, or may prove of service to the American practitioner.  As
several editions have appeared in London since the issue of the  last American reprint, the volume
has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and
improvement.  The extent of these additions  may be estimated from the fact  that it now contains
about one-third more matter than the  previous American edition,  and that  notwithstanding the
adoption of a smaller type, the pages have been increased by about one  hundred, while nearly two
hundred and fifty wood-cuts have been added to the former list of illustrations.
  A marked improvement will also be perceived  in the mechanical and artislical execution of the
work, which, printed  in the best style, on new type, and fine  paper, leaves  little  to  be desired as
regards external finish; while  at the very low price affixed it will  be  found one of the cheapest
volumes accessible to the profession.
  This popular volume, now a most comprehensive
work en surgery, has undergone many corrections,
improvements, and additions, and the principles and
the practice of the art have been brought down to
the latest record and observation. Of the operations
in surgery it is impossible to speak too highly. The
descriptions are so clear and concise, and the illus-
trations so accurate and numerous, that the student
can have no difficulty, with instrument in hand, and
book by his side, over the dead body, in obtaining
a proper knowledge and sufficient tact in this much
neglected department of medical education.—British
and Foreign Medico-Chirurg. Review, Jan. 1S60.
nothing of real practical importance has been omit-
ted ;  it presents a faithful epitome of everything re-
lating t) surgery up to the present hour. It is de-
servedly a popular manual, both with the student
and practitioner.—London Lancet, Nov. 19, 1859.

  In closing this brief notice, we recommend as cor-
dially as ever this most useful and comprehensive
hand-book.   It must prove a vast assibtance, not
only  to the student of surgery, but also to the busy
practitioner who may not have the leisure to devote
himself to the study of more lengthy  volumes —
London Med. Times and Gazette, Oct 22 1859
  In the present edition the author has entirely re-    In a word, this eighth edition of Dr  Druitt'a
written many of the chapters, and has incorporatsd  Manual of Surgery is all that the surgical student
the various improvements and additions in modern ' or practitioner  could desire__Dublin Quarterly
surgery.  On carefully going over it, we find that , Journal of Med. Sciences, Nov. 1859.            * 
AND  SCIENTIFIC  PUBLICATIONS.
11
                            DALTON,  JR. (J.  C),  M.  D.
                 Professor of Physiology in the College of Physicians, New York.
A  TREATISE ON  HUMAN PHYSIOLOGY, designed for the  use of Students
  and Practitioners of Medicine.  With two hundred and fifty-four illustrations on wood.   In one
  very beautiful octavo volume, of over 600 pages, extra cloth, $4 00; leather, raised bands, $4 25.
  (Just Issued.)
  This  system of Physiology, both from the ex-
 cellence of the  arrangement studiously  observed
 throughout every page, and the clear, lucid, and in-
 structive manner in which each subject is treated,
 promises to form one of the most generally received
 class-books in the English language. It is,in fact,
 a most admirable epitome of ail the really important
 discoveries that have always been received as incon-
 testable truths, as well as of those which have been
 recently added to our stock of knowledge on this sub-
 ject.  We  will, however, proceed to give a few ex-
 tracts from the book itself, as a specimen of its style
 and composition, and this, we conceive, will be quite
 sufficient to awaken a general interest in a work
 which is immeasurably superior in its details to the
 majority of those of the same class tn which it be-
 longs.  In  its purity of style and elegance of com-
 position it  imy safely take its place with the very
 best of  our English classics;  while in accuracy of
 description it is impossible that it could be surpass
 ed.  In every line is beautifully shadowed forth the
 emanations of the polished scholar, whose reflec-
 tions are clothed in a garb as interesting as they are
 impressive; with the one predominant  feeling ap-
 pearing to  pervade the whole—an anxious desire to
 please and at the same  time  to instruct.—Dublin
 Quarterly Journ. of Med. Sciences, Nov. 1859.

  The work before us, however, in our humble judg-
 ment, is precisely what it  purports to be, and will
 answer admirably the purpose for  which it  is in-
 tended.  It is par excellence, a. text-book; and the
 best text-book in this department that we have ever
 seen.  We have carefully read the book, and  speak
 of its merits from  a more than cursory perusal.
 Looking back upon the work we have just finished,
 we must say a word concerning the excellence of its
 illustrations.  No department is so dependenfupon
 good illustrations, and those which keep pace with
 our knowledg e of the subject, as that of physiology.
 The wood-cuts in the work before  us are the best
 we have ever seen, and, being  original, serve to
illustrate precisely what is desired.—Buffalo Med.
Journal, March, 1859.
  A book of genuine merit like this deserves hearty
praise before subjecting it to any minute criticism.
We are not prepared to find any fault with its design
until we have had more time to appreciate its merits
as a  manual for  daily consultation, and to weigh
its statements and conclusions more deliberately.
Its excellences we are sure of; its defects we have
yet to discover.  It is a work highly honorable to
its author;  to his talents, his industry, his training;
to the institution with which  he is connected, and
to American science.— Boston Med. and Surgical
Journal, Feb. 24, 1859.

  A new book and a first rate one; an original book,
and one  which cannot be too highly appreciated,
and which we are proud to see emanating from our
country's press. It is  by an  author who, though
young, is considerably famous for physiological re-
search, and who. in this work  has erected for him-
self an enduring monument, a token at once of his
labor and his success.—Nashville Medical Journal,
March, 1859.
  Throughout  the entire work, the definitions are
clear and precise, the arrangement admirable, the
argument briefly and well stated, and the style
nervous, simple, and concise.  Section third, treat-
ing of  Reproduction,  is a monograph of unap-
proached excellence, upon this subject, in the Eng-
lish tongue.  For precision, elegance and  force of
style, exhaustive method and  extent of treatment,
fulness of illustration and weight of personal re-
search,  we know of  no American  contribution to
medical science which surpasses it, and the day is
far distant when its claims to  the respectful atten-
tion of even the best informed  scholars will not be
cheerfully conceded by all acquainted with its range
ana depth.—Charleston Med. Journal, May, 1859.
  A new elementary work  on Human Physiology
lifting up its voice in the presence of late and sturdy
editions of Kirke's, Carpenttr's, Todd  and Bow-
man's, to say nothing of Durglison's and Draper's,
should have something superior in the matter or the
manner  of its utterance in  order to win for itself
deserved attention and a name. That matter and
that manner, after a candid perusal, we think dis-
tinguish this work, and we are proud to welcome it
not merely for its nativity's sake, but for its own
intrinsic excellence.   Its language we  find to be
plain, direct, unambitious, and falling with a just
conciseness on hypothetical or unsettled  questions,
and yet with sufficient fulness on those living topics
already understood, or the  path to whose solution
is definitely marked out.  It does not speak exhaust-
i /ely upon every subject that it notices, but it does
speak suggestively, experimentally, and to their
main utilities.   Into the subject of Reproduction
our author plunges with a kind of loving  spirit.
Throughout this interesting and obscure department
he is a clear and admirable teacher, sometimes a
brilliant leader.—Am. Med. Monthly, May, 1859.
           DUNGLISON,  FORBES,  TWEEDIE,  AND  CONOLLY.
THE  CYCLOPEDIA  OF  PRACTICAL MEDICINE: comprising Treatises on
  the Nature and Treatment of Diseases, Materia Medica, and Therapeutics,  Diseases of Women
  and Children, Medical Jurisprudence, &c. &c.   In four large super-royal octavo volumes, of
  3254 double-columned pages, strongly and handsomely bound, with raised bands.  $12 00.
  *#* This work contains no less than four hundred and eighteen distinct treatises, contributed by
Bixty-eight distinguished physicians, rendering it a complete library of reference for the country
practitioner.
  The most complete work on Practical Medicine
 extant;  or, at least,  in  our language.—Buffalo
 Medical and Surgical Journal.
  For reference, it is above all price to every prac-
 titioner.—Western Lancet.
  One of the most valuable medical publications of
 the day—as a work of reference  it is invaluable.—
 Western Journal of  Medicine and Surgery.
  It has been to us, both as learner and teacher, a
 work for ready and frequent reference, one in which
 modern English medicine is exhibited in the most
advantageous light.—Medical Examiner.

  We rejoice that this work is to be placed within
the  reach of the profession in this country, it being
unquestionably one of very great value to the prac-
titioner.  This estimate of it has not been formed
from a hasty examination, but after an intimate ac-
quaintance derived from frequent consultation of it
during the past nine or ten years.   The editors are
practitioners of established reputation, and the list
of contributors embraces many of the most eminent
professors and teachers of London, Edinburgh, Dub-
lin, and Glasgow.  It is, indeed, the great merit of
this work that the principal articles have been fur-
nished by practitioners who have not only devoted
especial attention to the diseases  about which  they
have written, but have also enjoyed opportunities
for an extensive practical acquaintance with them
and whose reputation carries the assurance of ..heir
competency  justly to  appreciate  the opinions of
others, while it  stamps their  own  doctrines with
high and just authority.—American Medical Journ
DEWEES'S COMPREHENSIVE  SYSTEM OF
  MIDWIFERY.  Illustrated by occasional cases
  and many engravings.  Twelfth edition, with the
  author's  last improvements and  corrections.  In
  one octavo volume, extra cloth, of 600 pages. $320.
DEWEES'S TREATISE ON  THE  PHYSICAL
  r£v MEDICAL  TREATMENT OF CHILD-
    .    , Tu eifoSt edltlon-  In one volume, octavo,
  extra cloth, 548 pages.  $2 80          '  l"'av">
DEWEES'S TREATISE  ON  THE DISEACFS
  OF FEMALES.   Tenth edition.  In one votme
  octavo  extra cloth, 532 pages, with plates. S3 00 
13
BLANCHARD &  LEA'S  MEDICAL
                         DUNGLISON  (ROBLEY),  M.D.,
          ProfessOT of Institutes of Medicine in the Jefferson .Medical College, Philadelphia.

                        NEW AND ENLARGED EDITION.

MEDICAL  LEXICON;  a  Dictionary  of Medical Science, containing  a concise
  Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene,
  Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry,
  &c.   Notices'of Climate and of Mineral Waters; Formulae for Officinal,  Empirical, and Dietetic
  Preparations, &c.   With French and other Synonymes.   Revised  and very greatly enlarged.
  in one very large and handsome octavo  volume, of 992 double-columned pages, in small type;
  strongly bound in leather, with raised bands.  Price $4 00.

  Especial care has been devoted in the  preparation of this edition to render it in every respect
worthy a continuance of the very remarkable  favor which it has hitherto enjoyed.  The rapid
sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by
the profession as the standard authority.  Stimulated by this fact, the author has endeavored in the
present revision to introduce whatever might be necessary " to make it a satisfactory  and  desira-
ble—if not indispensable—lexicon, in which the student  may search  without disappointment for
every term that has  been legitimated in the nomenclature of the science."  To accomplish this,
large additions have been found requisite, and the extent of the author's labors may be estimated
from the fact that about Six Thousand subjects and terms have been introduced throughout, ren-
dering the whole number of definitions about Sixty Thousand, to accommodate which, the num-
ber of  pages has been increased by nearly a hundred, notwithstanding an enlargement in the size
of the pase.   The medical press, both in this country and  in England, has pronounced the work in-
dispensable to all medical students and practitioners, and the present improved edition will not lose
that enviable reputation.
  The publishers have endeavored to render the mechanical execution worthy of a volume of such
universal use in daily reference.  The greatest care hns been exercised  to obtain the typographical
accuracy so necessary in a work of the kind.  By the small but exceedingly clear type  employed,
an  immense amount of  matter is condensed in its thousand ample pages, while the binding will be
found strong and durable.  With all these improvements and enlargements, the price has been kept
at the former very moderate rate, placing it within the reach of all.
   This work, the appearance of the fifteenth edition
 of which, it has become our duty and pleasure to
 announce, is perhaps the most stupendous monument
 of labor and erudition  in medical literature.  One
 would hardly suppose after constant use of the pre-
 ceding editions, where we have never failed to find
 a sufficiently full explanation of every medical term,
 that in this edition "about six thousand subjects
 and terms have been added," with a careful revision
 and correction of the entire work.  It is only neces-
 sary to announce the advent of  this edition to make
 it occupy the place of the preceding one on the table
 of every medical man, as it is without doubt the best
 and most comprehensive work of the kind which has
 ever appeared.—Buffalo Med. Journ., Jan. 1858.

   The work is a monument of patient  research,
 skilful judgment, and vast physical labor, that will
 perpetuate the name of  the author more effectually
 than any possible device of stone or metal.  Dr.
 Dunglison deserves the  thanks not only of the Ame-
 rican profession, but of the whole medical world.—
 North  Am. Medico-Chir. Review, Jan. 1858.
   A Medical Dictionary better adapted for the wants
 of the  profession than any other with which we are
 acquainted, and of a character  which places it far
 above  comparison  and  competition__Am.  Journ.
 Med. Sciences, Jan. 1858.
  We need only say, that the addition of 6,000 new
 terms,  with their accompanying definitions, may be
 said to constitute a new work, by itself.   We have
 examined the Dictionary attentively, and are most
 happy to pronounce it unrivalled of its kind.  The
 erudition displayed, and the extraordinary industry
 which  must have been demanded, in its preparation
 and perfection, redound  to the lasting credit of its
 author, and have furnished us with a volume indis-
 pensable  at the present  day, to all who would find
 themselves au niveau with the highest standards of
 medical information.—Boston Medical and Surgical
Journal,  Dec. 31, 1857.
  Good lexicons and encyclopedic works generally
are the most labor-saving  contrivances which  lite- !
rary men enjoy ; and the labor which is required  to j
produce them in the perfect manner of this example
is something appalling to contemplate. The author
 tells us in his preface that he has added about six
 thousand terms and subjects to this edition, which,
 before, was considered universally as the best work
 of the kind in any language.—Silliman's Journal,
 March, 1858.                                   '
  He has razed his gigantic structure to the founda-
 tions, and remodelled and reconstructed the entire
 pile.  No less than six thousand additional subjects
 and terms are illustrated and analyzed in this new
 edition, swelling the grand  aggregate  to beyond
 sixty thousand ! Thus is placed before the profes-
 sion a complete and thorough exponent of medical
 terminology, without rival or possibility of rivalry.
 —Nashville Journ. of Med. and Surg., Jan. 1858.
  It is universally acknowledged, we believe, that
 this work is incomparably the best and most com-
 plete Medical  Lexicon  in  the  English  language.
 The amount of labor which the distinguished author
 has bestowed upon it is  truly wonderful, and the
 learning and  research displayed  in  its preparation
 are equally remarkable.   Comment and commenda-
 tion are unnecessary, as no one  at the present day
 thinks of purchasing any other Medical Dictionary
 than this.—St. Louts Med.  and Surg. Journ., Jan.

  It is the foundation stone of a good medical libra-
 ry, and should always be included in the first list of
 books purchased by the medical student.—Am. Med
 Monthly, Jan. 1858.

  A very perfect work of the kind, undoubtedly the
 most  perfect  in the English language.—Med. and
 Surg. Reporter, Jan.  1858.
  It is now emphatically the Medical Dictionary of
 the English language, and for it  there is  no substi-
 tute.— N. H. Med. Journ., Jan. 1858.
  It is scarcely necessary to remark that  any medi-
 cal library wanting a copy of Dunsylison's Lexicon
 must be imperfect.—Cin. Lancet, Jan. 1858.
  We have ever considered it the best authority pub-
lished, and the present edition we  may safely say hat
no equal in the world— Peninsular Med. Journal,
Jan.1858.                                     '

  The most complete authority on the subject to bt
found in any language.— Va. Med. Journal,Feb. '58.
BY THE SAME AUTHOR.
THE PRACTICE  OF  MEDICINE.   A Treatise on Special Pathology and Th«.
  rapeutics.  Third Edition.   In two large octavo volumes, leather, of 1,500 pages.   $6 25. 
AND SCIENTIFIC  PUBLICATIONS.
13
                         DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

HUMAN   PHYSIOLOGY.   Eighth  edition.   Thoroughly revised  and  exten-
  sively modified and enlarged, with five hundred and thirty-two illustrations.  In two large and
  handsomely printed octavo volumes, leather, of about 1500 pages.  $7 00.
  In revising this work for its eighth appearance, the author has spared no labor to render it worthy
a continuance of the very great favor which has been extended to it by the profession.  The whole
contents have been rearranged, and to a great extent remodelled ; the investigations which of late
years have been so  numerous  and so important, have been carefully examined and incorporated,
and the work in every respect has been brought up to a level with the present state of the subject.
The object of the author has been to render it a concise but comprehensive treatise, containing the
whole body of physiological science, to which the student and man of science can at all times refer
with the certainty of finding whatever they are in search of, fully presented in  all its aspects; and
on no former edition has the author  bestowed more labor to secure this result.
  We believe that it can truly be said, no more com-
plete repertory of facts upon  the  subject treated,
can anywhere be found.  The author has, moreover,
that  enviable  tact at description and  that facility
and ease of expression which render him peculiarly
acceptable to the  casual,  or the studious reader.
This faculty, so requisite in setting forth  many
graver and less attractive subjects, lends additional
charms to one always fascinating.—Boston Med.
and Surg. Journal.

  The most  complete and satisfactory  system of
Physiology in the English language.—Amer. Med.
Journal.
  The best  work of the kind in the English lan-
guage.—Silliman's Journal.
  The present edition the author has made a perfect
mirror of the science as it is at the present  hour.
As a work upon physiology proper, the science of
the functions performed by the body, the student will
find it  all he wishes.—Nashville Journ. of Med.
  That he has succeeded, most admirably succeeded
in his purpose, is apparent from the appearance of
an eighth edition. It is now the great encyclopaedia
on the subject, and worthy of a place in every phy-
sician's library.—Western Lancet.
                         BY THE  same author.  (A new edition.)

GENERAL  THERAPEUTICS  AND  MATERIA MEDICA;  adapted  for a
  Medical Text-book.  With Indexes of Remedies and of Diseases and their Remedies.   Sixth
  EniTiON, revised and improved.  With one hundred and ninety-three illustrations.  In two large
  and handsomely printed octavo vols., leather, of about 1100 pages.   $6 00.

                                                The work will, we have little doubt, be bought
                                              and read  by the majority of  medical students; its
                                              size, arrangement, and reliability recommend it to
                                              all; no one, we venture to predict, will study it
                                              without profit, and there are  few to whom  it  will
                                              not be in some measure useful as a work of refer-
                                              ence.  The young practitioner, more especially, will
                                              find the copious indexes appended to this edkion of
                                              great assistance in the selection and preparation of
                                              suitable formula.—Charleston Med. Journ. and Re-
                                              view,  Jan.1858.
  In announcing a new edition of Dr. Dunglison's
General Therapeutics and Materia Medica, we have
no words of commendation to bestow upon a work
whose merits have been heretofore so often and so
justly extolled.  It must not be supposed, however,
that the present is a mere reprint of the previous
edition; the character of the author for laborious
research, judicious analysis, and clearness of ex-
pression, is fully sustained by the numerous addi-
tions he has made to  the work, and the careful re-
vision to which he has subjected the whole.—N. A.
Medico-Chir. Review, Jan. 1858.

                        by the  same author.  (A new Edition.)

NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND
  ADMINISTRATION.  Seventh edition, with extensive  Additions.  In one very large octavo
  volume, leather, of 770 pages.  $3 75.
  Another edition of the " New Remedies" having been called for, the author has endeavored to
add everything of moment that has appeared since the publication of the last edition.
  The articles treated of in the former editions will be found to have undergone considerable ex-
pansion in this, in order  that the  author might  be enabled to introduce, as far as practicable, the
results of the subsequent experience of others, as well as of his  own observation and  reflection;
and to make the work still more  deserving of the extended  circulation with which the preceding
editions have been favored by the profession.  By an enlargement of the page, the numerous  addi-
tions have been incorporated without greatly increasing the bulk of the volume.—Preface.
  One of the most useful of the author's works.—
Southern Medical and Surgical Journal.
  This elaborate  and  useful  volume  should be
found in every medical library, for as a book of re-
ference, for physicians, it is  unsurpassed  by any
other work in existence, and  the double index for
diseases and for remedies, will be found greatly to
enhance its value.—New York Med.  Gazette.
  The great learning of the author, and his remark-
able industry in pushing his researches into every
source whence information is derivable,have enabled
him to throw together an  extensive mass of facts
and statements, accompanied by full reference to
authorities; which  last  feature renders the work
practically valuable to investigators who desire te>
examine the original papers.—The American Journal
of Pharmacy.
                            ELLIS  (BENJAMIN), M.D.

THE  MEDICAL  FORMULARY:  being a Collection  of Prescriptions,  derived
  from the writings and practice of many of the most eminent physicians of America and Europe.
  Together with The usual Dietetic Preparations and Antidotes for Poisons.   To which  is added
  an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform.   The
  whole accompanied with a few brief Pharmaceutic and Medical Observations.  Tenth edition,
  revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the
  Philadelphia College of Pharmacy.  In one neat octavo volume, extra cloth, of 296 pages. $1 75. 
14
BLANCHARD  &  LEA'S  MEDICAL
                                 ERICHSEN (JOHN),
                     Professor of Surgery in University College, London, &c.

THE SCIENCE  AND  ART  OF SURGERY;  being a Treatise on Surgical
  Injuries, Diseases, and Operations. New and improved American, from the second enlarged
  and carefiilly'revised  London edition.  Illustrated with over four hundred engravings on wood.
  In one  large  and handsome octavo volume, of one  thousand closely  printed pages, leather,
  raised bands.  S4 50.  (Just Issued.)
  The very distinguished favor with which this work  has been received on both sides of the Atlan-
tic has sn'mulatedthe author to render it even more worthy of the position which it has so rapidly
attained as a standard authority.   Every portion has been carefully  revised, numerous additions
have been made, and the most watchful care has been exercised  to render it a complete exponenl
of the most advanced condition of surgical science.  In this manner the work has been enlarged by
about a hundred pages, while the  series of engravings has been increased by more than  a hundred,
rendering it one  of'the most thoroughly illustrated volumes before the profession.  The additions of
the author having rendered unnecessary most of the notes of the former American editor, but little
has been added in this country; some few notes and occasional illustrations have,  however, been
introduced to elucidate American  modes of practice.
  It is, in our humble judgment, decidedly the best
book of the kind in the English language. .Strange
that just such books are notoftener produced by pub-
lic teachers of surgery in this country and Great
Britain  Indeed, it i» a matterof great astonishment,
but no less true than astonishing, that of the many
works on surgery republished in this country within
the last fifteen or twenty years a? text-books  for
medical students, this is the only one that even ap-
proximates to  the fulfilment of the peculiar wants of
youngmen justenlenngupon the study of thisbranch
of the profession.— Western Jour .of Med. and Surgery.

  fls value is  greatly enhanced by  a very copious
well-arransed index.  We regard this as one of the
most valuable  contributions to modern surgery. To
one entering his novitiate of practice, we regard it
ihemosi serviceable umdew bich he can consult. He
will find a fulness of detail leadinghim through every
step of the operation, and not deserting him until the
final issue of the ease is decided.—Sethoscope.
  Embracing, as will be perceived, the whole surgi-
cal domain, and each division of itself almost com-
plete and perfect, each chapter full and explicit, each
subject faithfully exhibited, we can only express oui
estimate of it in the aggregate.  We consider it an
excellent contribution  to surgery, as probably the
best single volume now extant on the subject, and
with great pleasure we add  it  to our text-books.—
Nashville. Journal of Medicine and Surgery.
  Prof. Erichsen's work, for its size, has not been
surpassed; his nine hundred and eight pages,  pro-
fusely illustrated, are rich in physiological, patholo-
gical, and  operative suggestions, doctrines, details,
and processes; and will  prove  a reliable resource
for information, both to physician and surgeon, in the
hour of peril.—JV. 0. Med. and Surg. Journal.
                             FLINT (AUSTIN), M.  D.,
        Professor of the Theory and Practice of Medicine in the University of Louisville, &c.

PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES  AFFECT-
  ING THE RESPIRATORY ORGANS.   In one large and handsome octavo volume, extra
  cloth, 636 pages.  S3  00.
  We regard it, in point both of arrangement and of
the marked ability of its treatment of the subjects,
as destined  to take the first rank in works of  this
class.  So far as our information extends, it has at
present no equal.  To  the practitioner, as well as
the student, it will be invaluable in clearing up the
diagnosis of doubtful cases, and in shedding light
upon difficult phenomena.—Buffalo Med. Journal,
  A work of original observation of the highest merit.
We recommend the treatise to every one who wishee
to become a correct auscultator.  Based to a very
large extent upon cases  numerically  examined, it
carries the evidence of careful study and discrimina-
tion upon every pasje.  It does credit to the authOT,
and, through him, to the profession in this country.
It is, what we cannot call every book  upon auscul-
tation, a readable book.—Am. Jour. Med. Sciences.
                           by the same author.   (Now Ready.)

A PRACTICAL  TREATISE  ON THE DIAGNOSIS,  PATHOLOGY,  AND
  TREATMENT OF DISEASES OF THE HEART.   In one neat octavo volume,  of aboul
  500 pages, extra cloth.   $2 75.
                                              diseases of the chest.   We have adopted his work
                                              upon the heart as a text-book, believing it to be
                                              more valuable for that purpose than any work of the
                                              kind that has yet appeared.—Nashville Med. Journ..
                                              Dec. 1859.
                                                With more than pleasure do we hail the advent of
                                              this work, for it  fills a wide gap on the list cf text-
                                              books for our schools, and is, tor the practitioner,
                                              the most valuable practical work of its kind.—JV. O
                                              Med. News, Nov. 1859.
  We do no* know that Dr. Flint has written any-
 thing which is not. first rate; but this, his latest con-
 tribution to medical literature, in our opinion, sur-
 passes all the others.  The work is most comprehen-
 sive in its scope, and most sound in the views it enun-
 ciatis.  The descriptions are clear and methodical;
 the statements are substantiated by facts, ai.d are
 made with  such simplicity and sincerity, that with-
 out them they would carry conviction.  The style
 is admirably  clear, direct, and free from dryness
 With Dr. Walsbe's excellent treatise  before us, we
 have no hesitation in saying that Dr. Flint's book is
 the best work on the heart in the English language.
 —Boston Med. and Surg. Journal, Dec. 15,  1859.
  We have thus endeavored to present our readers
 with a fair  analysis of this remarkable work. Pre-
 ferring to employ the very words of thedistinguished
 author, wherever it was possible, we  have essayed
 tn condense into the briefest spacea general viewof
 his observations and suggestions, and  to direct the
 attention of our brethren to the abounding stores of
 valuable matter here collected and arranged for their
 use and instruction.  No medical library will here-
 after be considered complete without  this volume ;
 and we trust it will promptly find its way into the
 hands of  every Ameiican student and physician.__
 N. Am. Med. Chir. Review, Jan I860.
  This last work of Prof. Flint will  add much to
his previous well-earned celebrity, as a writer of
great force and beauty, and, with his previous work,
places him  at the head of American writers upoa
  In regard to the  merits of the work, we have no
hesitation in pronouncing it full, accurate, and ju-
dicious.  Considering the  present state of science,
such a work was much needed.  It should be in the
hands of every practitioner .—Chicago Med. Journal,
April, 1860.
  But these are very trivial spots, and in nowise
prevent us from declaring  our most hearty approval
of the author's ability, industry, and conscientious-
ness.— Dublin Quarterly Journal of Med. Sciences,
Feb. 18G0.                                    '

  He has labored on wi'h the same industry and care,
and his place among the first authors of our country
is becoming fully established. To this end, the work
whose title is given above, contributes in no small
degree.  Our spa :e will not admit of an extended
analysis,  and we  will close this  brief no'iee  by
commending it without reserve  to  every class of
readers in the profession.—Peninsular Med. Journ.,
Feb. 18G0. 
AND SCIENTIFIC  PUBLICATIONS.                   15
                        FOWNES (GEORGE),  PH. D.,  «tc.
A  MANUAL OF ELEMENTARY CHEMISTRY;  Theoretical and Practical.
  From the seventh revised and corrected London edition.   With  one  hundred and ninety-seven
  illustrations.   Edited by Robert Bridges, M. D.  In one large royal 12mo volume,  of 600
  pages.  In leather, $1  65; extra cloth, $1 50.  (Just Issued.)
  The death of the author having placed the editorial care of this work in  the practised hands of
Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience
could suggest to keep it  on a level with  the  rapid advance  of chemical science.  The additions
requisite to thi* purpose  have necesMtated an enlargement of the page, notwithstanding which the
work has been  increased by about fifty pages.  At  the same lime every care has been used to
maintain its distinctive character as a condensed manual for the student, divested of all unnecessary
detail or mere theoretical speculation.  The additions have, of course, been mainly in the depart-
ment of Organic Chemistry, which has made such  rapid progress within  the last few years, but
yet equal attention has been bestowed on  the other branches of the subject—Chemical Physics and
Inorganic Chemistry—to present all investigations and discoveries  of importance, and to keep up
the reputation of the volume as  a complete manual of the whole science, admirably adapted for the
learner.  By the use of a small but exceedingly clear type the matter of a large octavo is compressed
within the  convenient and portable limits  of a moderate sized dtiodfcimo, and at the very low price
affixed, it is offered as one of the cheapest volumes before the profession.
  Dr. Fownes' excellent work has been universally
recognized everywhere in his own and this country,
as the best elementary treatise on chemistry in the
English tongue, and is very generally adopted, we
believe, as the standard text book in all c ur colleges,
both literary and scientific.—Charleston Med Journ.
and Review, Sept. 1859.
  A standard manual, which has long  enjoyed the
reputation of embodying much knowledge in a small
space.  The author hasachieved the difficult taskof
condensation with masterly tact. His book is con-
cise without being dry, and brief without being too
dogmatical or general.—Virginia Med. and Surgical
Journal.
  The work of Dr. Fownes has long been before
the public, and its merits have been fully appreci-
ated  as  the best  text-book on chemistry now in
existence.  We do not, of course, place it in a rank
superior to the works of Brande, Graham, Turner,
Gregory, or Grnelin, but we say that, as a work
for students, it is  preferable to any of them.—Lon-
don Journal of Medicine.
  A work well adapted to the wants of the student
It is an excellent exposition of the chief doctrines
and facts of modern chemistry. .The size of the work.
and still more the condensed yet perspicuous style
in which it is written,  absolve it from the charges
very  properly urged against most manuals termed
popular.—Edinburgh Journal of Medical Science.
FISKE  FUND PRIZE ESSAYS —THE  EF-
  FECTS  OF  CLIMATE ON  TUBERCULOUS
  DISEASE. By Edwin Lee.M.R.CS .London,
  and THE INFLUENCE OF PREGNANCY ON
  THE DEVELOPMENT OF TUBERCLES  By |
  Edward Warren, M.D , of Edenton,N. C.  To-
  gether in one neat 8vo volume, extra cloth. $1 00.
FRICK ON RENAL AFFECTIONS;  their Diag-
  nosis and  Pathology.  With illustrations.   One
  volume, royal l2mo., extra cloth.  75 cents
                       FERGUSSON (WILLIAM),  F. R. S.,
                     Professor  of Surgery in  King's College, London, &c.              ,
A  SYSTEM  OF  PRACTICAL  SURGERY.   Fourth American,  from the third
  and enlarged London edition.  In one large and beautifully printed octavo volume, of about 700
  pages, with 393 handsome illustrations, leather.  $3 00.

                          GRAHAM  (THOMAS),  F. R. S.
THE ELEMENTS  OF INORGANIC  CHEMISTRY,  including the Applica-
  tions of the Science in the Arts. New  and much enlarged edition, by Henry Watts and Robert
  Bridges, M. D.   Complete in  one large and handsome octavo volume, of over 800 very large
  pages, with two hundred and thirty-two wood-cuts, extra cloth.  $4 00.
  #*# Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be
had separate, cloth backs and paper sides.  Price $2 50.
                                              afford to be without this edition of Prof. Graham's
                                              Elements.—Silliman's Journal, March, 1858.
                                                From Prnf. Wolcott Gibbs, N. Y. Free Academy.
                                                The work is an admirable one in all respects,and
                                              its republication here cannot fail to exert a positive
                                              influence upon the progress of science in this country.
  From Prof. E. N. Horsford, Harvard College.
  It has, in its earlier and less perfect editions, been
familiar to me, and the excellence of its plan and
the clearness and completeness of its discussions,
have long been my admiration.

  No reader of English works on this science can
                      GRIFFITH  (ROBERT E.),  M. D.,  &c.
A  UNIVERSAL FORMULARY, containing the methods of Preparing and Ad-
  ministering OlHcinal and other Medicines.   The whole adapted to Physicians and Pharmaceu-
  tists.  Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas,
  M. D., Profe.-sor of Materia Medica in the Philadelphia College of Pharmacy.   In one large and
  handsome octavo volume, extra cloth, of 650 pages, double columns.  $3 00; or in sheep, $3 25.
                                               This is a work of six hundred and fifty-one pages.
                                              embracing all on the subject of preparing and admi-
                                              nistering medicines that can be desired by the physi-
                                              cian and pharmaceutist.— Western Lancet.
                                               The amountof useful, every-day matter.for a prac-
                                              ticing physician, is really immense.—Boston Med.
                                              and Surg. Journal.
                                               This edition has been greatly improved by the re-
                                              vision and ample additions of Dr  Thomas, and is
                                              now,  we believe, one of the mosl complete works
                                              of  its kind in any language.  The additions amount
                                              to about seventy pages, and no effort has been spared
                                              to include in them all the recent improvements.  A
                                              work of this kind appears to us indispensable to the
                                              physician, and there is  none we can more cordially
                                              recommend.—N. Y. Journal of Medicine.
  It was a work requiring much perseverance, and
when published was looked upon as by far the  best
work of its kind that had issued from the American
press.  Prof Thomas has certainly "improved," as
well as added >o this Formulary, and has rendered it
additionally deserving of the confidence of pharma-
ceutists and physicians.—Am. Journal of Pharmacy.
  We are happy to announce a new and improved
edition of this, one of the most valuable and useful
works that have emanated from an American  pen.
[t would do credit to any country, and will be found
of daily usefulness to practitioners of medicine; it is
better adapted to their purposes than the dispensato-
ries.— Southern Med. and Surg. Journal.
  It is one of the most useful books  a country practi-
tioner can possibly have.—Medical Chronicle. 
BLANCHARD <fc  LEA'S  MEDICAL
                           GROSS (SAMUEL D.),  M. D.,
             Professor of Surgery in the Jefferson Medical College of Philadelphia, &c.
                                        Just Issued.

A  SYSTEM  OF  SURGERY:  Pathological, Diagnostic, Therapeutic, and Opera-
  five.  Illustrated by Nine Hundred and Thirtv-six Engravinos.  In two large and beautifully
  printed octavo volumes, of nearly twenty-four hundred pages; strongly bound  in leather, with
  raised bands.  Price gl2.
                               From the Author's Preface.

  " The object of this work is to furnish a systematic and comprehensive treatise on the science and
practice of surgery,  considered  in the broadest sense; one that shall serve the  practitioner as a
faithful and available guide in his daily  routine of duty.   It has been too much the  custom of mod-
ern writers on this department of the healing art to  omit  certain topics altogether, and to speak ol
others at undue length, evidently assuming that their readers  could  readily supply the  deficiencies
from other sources, or that what has been thus slighted is of no particular practical value.  My aim
has been to embrace the whole domain  of surgery, and to allot to every subject its legitimate claim
to notice in the great family of external diseases and accident*.  How far this object has been accom-
plished, it is not for me to  determine.   It  may  safely be affirmed, however, that there is no topic,
properly appertaining  to surgery, that will not be found to be discussed, to a greater or  less extent,
in these volumes.  If a larger space than is  customary has been devoted  to the consideration of
inflammation and  its  results, or  the great principles of surgery, it is because of the  conviction,
grounded  upon long  and close observation, that  there are  no subjects so little understood by the
general practitioner.   Special attention has also been beslowed upon the discrimination of diseases;
and an elaborate chapter has been introduced on general diagnosis."
  That these intentions have been carried out in the fullest and most elaborate manner is sufficiently
shown by  the great extent of the work,  and the  length of time during which the author has  been
concentrating on the task his studies and his experience, guided by the knowledge which twenty
years of lecturing on surgical topics have given him of the  wants o'f the profession.
  Of Dr. Gross's treatise on Surgery we can  say
no more than that it is the most elaborate  and com-
 Elete work on this branch of the healing art which
 as ever been  published in  any country. A sys-
tematic work,  it admits of no analytical review;
but, did our space permit, we should gladly give
some extracts from it, to enable our readers to judge
of the classical style of the author, and the exhaust-
ing way in which each  subject is treated.—Dublin
Quarterly Journal of Med. Science, Nov.  1859.
  The work  is so superior to its  predecessors in
matter and extent, as well as in illustrations and
style of publication, that we can honestly recom-
mend  it  as the best work of the kind  to be taken
home by the young practitioner.—Am. Med. Journ.,
Jan.I860.
  The treatise of Prof. Gross is not, therefore, a
mere text-book for undergraduates, but a systema-
tic record of  more than  thirty years' experience,
reading, and reflection by a  man of observation,
sound judgment, and rare practical tact, and as such
deserves,  to take rank with the renowned produc-
tions of a similar character, by Vidal and  Boyer, of
France, or those of Chelius, Blasius, and Langen-
becK, of Germany.  Hence, we do not hesitate to
express the opinion that it will speedily take  the
same elevated position in regard to surgery that has
been given by common consent to the masterly work
of Pereira in Materia Medica, or to Todd and Bow-
man in Physiology.—JV. O. Med. and Surg. Journal,
Jan. 1SG0.                                   '
  At present, however, our object is not to review
the work  (this  we purpose doing hereafter), but
simply to announce  its appearance, that  in the
meantime  our readers may procure and examine it
for themselves.  But even this much we cannot do
without expressing the opinion that, in putting forth
these two volumes, Dr.  Gross has reared for him-
self a lasting monument to his skill as a surgeon,
and to his  industry and learning as an author.—St.
Louis Med. and Surg. Journal, Nov. 1859.

  With pleasure we record the comp'etion of this
long-anticipated work.  The  reputation which the
author has for manv years sustained, both as a sur-
geon and as a writer,  had  prepared us to expect a
treatise of great excellence and originality; but we
confess we were by no means prepared tor the work
which is before us—the most complete treatise upon
surgery ever published, either in  this or any other
country, and we  might, perhaps, safely say, the
most original.  There is no subject belonging  pro-
perly to  surgery which has not received from the
author a due share of attention. Dr. Grots has sup-
plied a want in surgical literature which has long
been felt by practitioners;  he has furnished us with
a complete practical treatise upon surgery in all its
departments   As Americans, we are proud  of the
achievement; as surgeons, we are most sincerely
thankful to him for his extraord nary labors in our
behalf.—N. Y. Monthly  Review and Buffalo Med
Journal, Oct. 1850.
                                    BY THE SAME AUTHOR.

 ELEMENTS OF PATHOLOGICAL ANATOMY.   Third  edition, thoroughly
   reviseo and greatly improved  In one large and very handsome octavo volume, with about three
   hundred and  fify beautiful illustrations, of which a large number  are from  oSal drawing
   Price in extra cloth, U 75; leather, raised bands, $5 25.  (Lately Published)       drawmSs"
   The very rapid advances in the Science of Pathological Anatomy during the last few years have
 rendered essential a thorough modification  of this work,  with a view of making- it a correct exno
 nent oi the present stale of the subject.  The  very careful manner in which?h s task  has b?en

 «ZTLml  v^'hanT1 °1 f™'™ "^ lt has ""^one, have enabled t^heautho7tosay^ha,
   with the many changes and improvements now introduced, the work may be re-arded almos  B«
 a new treatise » while the efforts of the author have  been seconded as regar^the rneXnca
 execution of the volume, rendering it one of the handsomest productions of fheimericTn press
   ^l™,!!?1 S,nCerely C0,Wulate the author on the    We have been favorably impressed with the gene-
                                               ral manner in which Dr. Gross has executed his task
                                               of affording a comprehensive digest of the present
                                               state of the literature of Pathological Anatomy, and
                                               have much pleasure  in recommending his work to
                                               our readers, as we believe one well  deserving of
                                               diluent perusal and careful study.—Montreal Med.
                                               Chron., Sept. 1857.

                                   BY THE SAME AUTHOR.

A«fr?^C?CAL  TREATISE ON FOREIGN  BODIES IN THE AIR-PAS-
  .At^b. In one handsome octavo volume, extra cloth, with illustrations,  pp.468.  $2 75.
successful manner in which he has accomplished his
proposed object.  His book is most admirably cal-
culated to fill up a blank which has long been felt to
exist in this department of medical literature, and
as such must become very widely circulated amongst
all classes of the profession. — Dublin Quarterly
Journ. of Med. Science, Nov. 1857. 
AND  SCIENTIFIC PUBLICATIONS.
17
                           GROSS (SAMUEL D.),  M. D.,
             Professor of Surgery in the Jefferson Medical College of Philadelphia, &c.
A  PRACTICAL  TREATISE  ON  THE  DISEASES,   INJURIES,  AND
  MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND
  THE URETHRA.  Second Edition, revised and  much enlarged, with one hundred and eighty-
  four illustrations.   In one large and very handsome octavo volume, of over nine hundred pages.
  In leather, raised bands, $5 25; extra cloth, $4 75.
  Philosophical in its design, methodical in its ar-
rangement, ample and sound in its practical details,
it may in truth be said to leave scarcely anything to
be desired on so important a subject.—Boston Med.
and Surg Journal.
  Whoever will peruse  the vast amount of valuable
practical information it contains, will, we think,
agree with us, that there is no work in the English
language which can make any just pretensions to
be its equal.—N. Y. Journal of Medicine.
  A volume replete with truths and principles of the
utmost value in the investigation of these diseases. -
American Medical Journal.
                              GRAY (HENRY),  F. R. S.,
                    Lecturer on Anatomy at St. George's Hospital, London, &c.

ANATOMY,  DESCRIPTIVE AND  SURGICAL.    The Drawings by H.  V.
  Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly
  by the Author and Dr. Carter.  In one magnificent imperial octavo volume, of nearly  800
  pages, with 363 large and elaborate engravings on wood.  Price  in extra cloth, $6 25; leather
  raised bands, $7 00.  (Just Issued.)
  The author has endeavored  in this  work to  cover a more extended range of subjects than is
customary in the ordinary text-books, by giving not only the details necessary for the student, but
also the application of those  details in the practice of medicine and  surgery, thus rendering it both
a guide for the learner, and an admirable work of reference for the active practitioner.   The
engravings form a special  feature in  the work, many of them being the size of nature, nearly all
original, and having the names of the various parts printed on the body of the cut, in place of figures
of reference  with descriptions at the  foot.  They thus form a complete and splendid series, which
will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh
the memory of those who may find in the exigencies of practice the necessity of recalling the details
of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with a thorough
treatise on systematic, descriptive, and applied  Anatomy, the work will  be found of essential use
to all physicians who receive students  in their offices, relieving both preceptor and pupil of much
labor in laying the groundwork of a thorough medical education.
  The work before us is one entitled to the highest
praise, and we accordingly welcome it as a valu-
able addition to  medical literature. Intermediate
in fulness of detail between the treatises  of Siar
pey and of Wilson, its characteristic merit lies in
the number and  excellence of the engravings it
contains.   Most  of  these are original, of much
larger than ordinary size, and admirably executed.
The various parts are also lettered after the plan
adopted in Holden's Osteology. It would be diffi-
cult to over-estimate the advantages offered by this
mode of pictorial illustration.   Bones, ligaments,
muscles, bloodvessels, and nerves are each  in turn
figured, and marked with their appropriate names;
thus enabl ing the student to comprehend, at a glance,
what would otherwise often be ignored, or at any
rate,  acquired only by prolonged and irksome ap-
plication.   In conclusion, we heartily commend the
work of Mr. Gray to the attention of the medical
profession, feeling certain that it should be regarded
as one of the most valuable contributions ever made
to educational literature.—N. Y. Monthly Review.
Dec. 1859.
  In this view, we regard the work of Mr. Gray as
far better  adapted to the wants of the profession,
and especially of the student, than any treatise on
anatomy yet published in this country.  It is destined.
we believe, to supersede ill others, both as a manual
of dissections, and a standard  of  reference to the
student  of general or  relative  anatomy. — N. Y.
Journal of Medicine, Nov. 1859.
  This is by all comparison the most excellent work
on Anatomy extant.   It is just the thing that has
been long desired by the profession.   With such a
guide as this,  the student of anatomy, the practi-
tioner of medicine, and the surgical devotee have
all a newer, clearer, and more radiant light thrown
upon the intricacies and mysteries of this wonder-
ful rcience, and are thus enabled to accomplish  re-
sults which hitherto  seemed possible only to the
specialist.  The plates, which are copied from  re-
cent dissections, are so well executed, that the most
superficial observer cannot fail to perceive the posi-
tions, relations, and distinctive features of the vari-
ous parts, and to take in more of anatomy at a glance,
than by many long hours of diligent study over the
most erudite treatise, or, perhaps, at the dissecting
table itself.—Med. Journ. of N. Carolina, Oct. 1859.
  For this truly admirable work the profession is
indebted to the distinguished author of " Gray on
the Spleen."  The vacancy it fills has been long felt
to exist in this country.  Mr. Gray writes through-
out with both branches of his subject in view.  His
description of each particular part is followed by a
notice of its relations to the parts with which it is
connected, and this, too, sufficiently ample for all
the purposes of the operative surgeon.  After de-
scribing the bones  and muscles, he gives a concise
statement of the fractures to which the bones of
the extremities are most liable, together  with the
amount and direction of the displacement to which
the  fragments are  subjected by muscular action.
The  section on arteries is remarkably full and ac-
curate.  Not only is the surgical anatomy given to
every important vessel, with directions for its liga-
tion, but at the end  of the description of each arte-
rial trunk we have a useful summary of the irregu-
larities which may occur in its origin, course, and
termination.—N. A. Med. Chir. Review, Mar. 1859.

  Mr. Gray's book, in excellency of arrangement
and completeness of execution; exceeds any work
on anatomy hitherto published in the English lan-
guage, affording a complete view of the structure of
the human body, with especial reference to practical
surgery.  Thus the volume constitutes a perfect book
of reference for the practitioner, demanding a place
in even the most limited library of the  physician or
surgeon, and a work of necessity for the student to
fix in his mind what he has learned by the dissecting
knife from the book of nature.—The Dublin Quar-
terly Journal of Med. Sciences, Nov. 1858.
  In  our judgment,  the mode of illustration adopted
in the present volume cannot but present many ad-
vantages to the student of anatomy. To the zealous
disciple of Vesalius, earnestly desirous of real im-
provement, the book will certainly be of immense
value; but, at the same time, we must also confess
that  to those simply desirous of "cramming" it
will be an undoubted godsend.   The peculiar value
of Mr. Gray's mode of illustration is nowhere more
markedly evident than in the chapter on osteology,
and. especially in those portions which treat of the
bones of the head and  of thsir  development.  The
study of these parts is thus made one of comparative
eiise, if not of positive pleasure; and those bugbears
of the student, the temporal and sphenoid bones, are
shorn of half their terrors.  It is, in our estimation,
an admirable and complete text-book for the student,
and a useful work of reference for the practitioner;
its pictorial character forming a novel element, to
which we have already sufficiently alluded.—Am
Journ. Med. Sci., July, 1859. 
BLANCHARD  &  LEA'S  MEDICAL
GIBSON'S INSTITUTES AND PRACTICE OF
  SURGERY. Eighth edition, improved and al-
  tered. With thirty-four plates. In two handsome
  octavo  volumes,  containing about 1,000 pages,
  leather, raised bandt.  $6 50.
GARDNER'S MEDICAL CHEMISTRY, for the
  use of Students and the Profession. In one royal
  12mo. vol., cloth, pp. 396, with woodcuts.  81.
GLUGES ATLAS OF  PATHOLOGICAL  HIS-
  TOLOGY.  Translated, with Notes and Addi-
  tions, by Joseph  I.kidy, M. D.  In one volume,
  very large imperial quarto, extra cloth, wi»-l 320
  copper-plate tigureB, plain and colored,  $5 00.

HUGHES' INTRODUCTION TO THE PRAC-
  TICE  OF AUSCULTATION  AMi  OTHER
  MODES OF PHYSICAL DIAGNOSIS  IN DIS-
  EASES OF THE LUNGS AND HEART.  Se-
  cond edition   1 vol. royal l'imo., ss. cloth, pp.
  304. $1 00.
                        HAMILTON (FRANK  H.),  M. D.,
                      Professor of Surgery in the University of Buffalo, &c.
A PRACTICAL TREATISE  ON FRACTURES AND  DISLOCATIONS.   In
  one large and handsome octavo volume, of over 750 pages, with 289 illustrations.  $4 25.  (Now
  Ready, January, 1S60.)
  This is a valuable contribution to the surgery of
most important affections, and is the more welcome,
inasmuch as at the prestnt time we do not possess
a single complete treatise on Fractures and Dislo-
cations in the English language. It has remained for
our American brother to produce a complete treatise
upon the subject, and bring together in a convenient
form those alterations and improvements that have
been made from time to time in the treatment of these
affections. One great and valuable feature in  the
work before us is the fact that it comprises all the
improvements introduced into the practice of both
English and American surgery, and though far from
omitting mention of our continental neighbors, the
author by no means encourages the notion—but too
prevalent in  some quarters—that nothing is good
unless imported from France or Germany.  The
latter half of the work  is devoted to the considera
illustrated, which will be a desideratum for those
practitioners who cannot conveniently see the  mo-
dels applied.—New York Med. Press, Feb. 4, 1860.
  We regard this work as an honor not only to its
author, but to the profession of our country.  Were
we to review it. thoroughly, we could not convey to
the mind of  the  reader more forcibly  our honest
opinion expressed in the few words—we think it the
best book of its kind extant.  Every man interested
in surgery will soon have this work  on his desk.
He who does not, will be the loser.—New Orleans
Medical News, March, 1800.
  Now that it is before us, we feel bound to say that
much as was expected from it, and onerous as  was
the undertaking, it has surpassed expectation, and
achieved more than was pledged in its  behalf; for
its title does not express in full the richness of its
contents.  On the whole, we  are prouder of this
tion of the various dislocations and their appropri- I «imenw.  xju mt>  w'.o.e  we u.c ,,,«Uc, x,  ,..,«
ate treatment, and its merit is fully equal to that of ' work than of any which has for years emanated
the preceding portion.-TAe London Lancet,U*y 5, j from th« American medical press;  its sale will cer-
ffiU       5J    "   •*""              '   '  '  tainly be very large in this country, and we antici-
1SG0
  It is emphatically the book upon the subjects of
which  it treats, and we cannot doubt  that it will
continue so to be for an indefinite period of time.
When we say, however, that we believe it will at
once take its place as the best book for consultation
by the practitioner; and that it will form the most
complete, available, and reliable guide in emergen-
cies of every nature connected with its subjects; and
also that the student of surgery may make it his text-
book wi'h entire confidence, and with pleasure also,
from its agreeable and easy style—we think our own
opinion may be  gathered as to its value.—Boston
Medical and Surgical Journal, March 1, 1860.
  The work is concise, judicious, and accurate, and
adapted to the wants of the student, practitioner,
and investigator, honorable to the author and to the
profession.—Chicago Med. Journal, March, 1860.

  We venture to say that this is not alone the  only
complete treatise on the subject in the language,
but the best and most practical we have ever read'.
The arrangement is  simple and  systematic, the dic-
tion clear and graplrc, and  the illustrations nume-
rous and remarkable for accuracy of delineation
pate its eliciting much attention in Europe.—Nash-
ville Medical Record, Mar. 1860.
  Every surgeon,  young and  old,  should  possess
himself of it, and give it a careful perusal, in doing
which he will be richly repaid.—St. Louis Med.
and Surg. Journal, March, 1860.
  Dr. Hamilton is fortunate in having succeeded in
filling the void, so  long felt, with what  cannot fail
to be a t once accepted as a model monograph in some
respects, and a work of classical authority.  We
sincerely congratulate the profession of the United
States on the appearance of such a publication from
one of their number.  We have reason to be proud
of it as an original work, both in a literary and sci-
entific point of view, and to esteem  it as a valuable
guide in a most difficult and important  branch of
study and practice.  On every  account, therefore,
we  hope that it may soon be widely known  abroad
as an evidence of genuine  progress on this side of
the  Atlantic, and further, that it may be  still more
widely known at home as an authoritative  teacher
from which every one may profitably learn, and as
affording an  example of honest, well-directed, and
untiring industry in authorship which every surgeon
The various mechanical appliances are faithfully  may emulate.- Am. Med. Journal, April, 1860
                         HOBLYN (RICHARD D.),  M. D.
A DICTIONARY  OF  THE  TERMS  USED  IN MEDICINE  AND  THE
  COLLATERAL SCIENCES.   A new American edition.  Revised, with numerous Additions,
  by Isaac Hays, M. D., editor of the " American Journal  of the Medical Sciences."  In one large
  royal 12mo. volume, leather, of over 500 double columned pages.  $1  50.
  To both practitioner and student, we recommend use ; embracing every department of medical science
this dictionary as being convenient in size, accurate
in definition, and sufficiently full and complete for
ordinary consultation.—Charleston Med. Journ.
  We know of no dictionary better arranged and
adapted. It is not encumbered with the obsolete terms
of a bygone age, but it contains all that are now in
down to the very latest date.—Western Lancet.
  Hoblyn's Dictionary has long been a favorite with
us.   It is the best book of definitions we have, and
ought always  to  be  upon the  student's table.—
Southern Med. and Surg. Journal.
HOLLAND'S  MEDICAL NOTES AND  RE- I
  FLECTIONS.  From the third London edition.
  In ore handsome octavo volume, extra cloth. S3. |
HORNER'S SPECIAL  ANATOMY AND  HIS-
TOLOGY.  Eighth edition.  Extensively revised
and modified.  In two large  octavo volumes, ex-
tra cloth, of more than 1000 pages, with over 300
illustrations.  $6 00.
                            HABERSHON (S.  O.), M. D.,
   Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guv's Hospital &C
PATHOLOGICAL  AND  PRACTICAL  OBSERVATIONS  ON  DISEASES
  OF THE ALIMENTARY  CANAL, OESOPHAGUS,  STOMACH,  CAECUM,  AND INTES-
  TINES.   With  illustrations on wood.   In one handsome octavo volume of 312 page*, extra
  cloth  SI 75.  (Now Ready.)                                                       ' 
AND SCIENTIFIC  PUBLICATIONS.
19
                            HODGE (HUGH L.),  M. D.,
Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, &c.

ON  DISEASES  PECULIAR  TO  WOMEN, including  Displacements  of the
  Uterus.  With original illustrations.  In one beautifully printed  octavo volume,  of nearly 500
  pages.  (Now Ready.)

  The profession will look with much interest on a volume embodying the long and extensive ex-
perience of Professor Hodge on an important branch of practice in which  his opportunities for
investigation  have been so extensive.  A short summary of the contents will show the scope  of
the Work, and the manner in which the  subject is presented.   It will be  seen that, with the excep-
tion of Displacements of the Uterus, he divides the Diseases peculiar to Women into two great
constitutional classes—those arising from irritation, and those arising from sedation.

                                   CONTENTS.
PART I. Diseases of Irritation.—Chapter I. Nervous Irritation, and its Consequences —II.
  Irritable Uterus.—III. Local Symptoms  of Irritable  Uterus: Menorrhagia and Haemorrhugia;
  Leucorrhcea;  Dysmenorrhcea—IV. Local  Symptoms of Irritable Uterus; Complications.—V.
  General Symptoms of Irritable Uterus :  Cerebro-spinal  Irritations.—VI. General Symptoms  of
  Irritable Uterus.—VII. Progress and  Results of Irritable Uterus.—VIII. Causes and Pathology
  of Irritable  Diseases —IX. Treatment of Irritable Uterus;  Removal or Palliation  of the Cause.
  —X. Treatment of Irritable  Uterus: To  Diminish  or Destroy  the  Morbid  Irritability—XL
  Treatment  of the Complications of Irritable Uterus.—XII,  Treatment of the Complications  of
  Irritable Uterus.
PART II. Displacements of the Uterus.—Chapter I. Natural Position and Supports of the
  Uterus.—II.  Varieties of Displacements of the Uterus, and their Causes.—III.  Symptoms  of
  Displacements of the  Uterus.—IV. Treatment of Displacements of  the Uterus.—V. Treatment
  of Displacements;  Internal Supports.—VI. Treatment of Displacements ; Lever Pessaries.—
  VH. Treatment of the Varieties of Displacements.—VIII. Treatment of Complications of Dis-
  placements of the Uterus.—IX. Treatment of Enlargements and Displacements of the Ovaries, &c.
PART III. Diseases of Sedation.—Chapter  I. Sedation  and its Consequences: Organic and
  Nervous Sedation; Passive Congestion; Reaction; Treatment—II. Sedation of the  Uterus;
  Amenorrhcea: Sedation of the Uterus from  Moral Causes; Sedation of the Uterus from Physical
  Causes.—III.  Diagnosis and Treatment of Sedation of the Uterus.
  The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size.
                        JONES  (T.  WHARTON), F. R. S.,
          Professor of Ophthalmic Medicine and Surgery in University College, London, &c.

THE  PRINCIPLES  AND  PRACTICE  OF  OPHTHALMIC   MEDICINE
  AND SURGERY.  With one hundred and ten illustrations.  Second American from the second
  and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills'
  Hospital, &c.  In one large, handsome royal 12mo. volume, extra cloth, of  500 pages. $1 50.
JONES (C.  HANDHELD), F.  R. S., & EDWARD H. SIEVEKING, M.D.,
                Assistant Physicians and Lecturers in St. Mary's Hospital, London.

A MANUAL OF  PATHOLOGICAL  ANATOMY.   First American  Edition,
  Revised.  With three hundred and ninety-seven handsome wood engravings.  In one large and
  beautiful octavo volume of nearly 750 pages, leather.  $3 75.
  Asa concise text-book, containing, in a condensed
form, a complete outline of what is known in the
domain of Pathological Anatomy, it is perhaps the
best work in the English language.  Its great merit
consists in its completeness and brevity, and in this
respect it supplies a great desideratum in our lite-
rature.  Heretofore  the student of pathology was
  This is a new and very much improved edition of
Dr. Kirkes' well-known Handbook of Physiology.
It combines conciseness with completeness, and is,
therefore, admirably adapted for consultation by the
busy practitioner.—Dublin Quarterly Journal.
  Its excellence is in its compactness, its clearness,
and its carefully cited authorities.  It is the most
convenient of text-books. These gentlemen, Messrs.
Kirkes and Paget, have really an immense talent for
silence, whichls not so common or so cheap as prat-
ing people fancy.   They have the gift of telling us
what we want to know, without thinking it neces-
sary  to tell us all they know.—Boston Med  and
Surg. Journal.
obliged to glean fromagreat numbeT of monographs,
and the field was so extensive that but few cultivated
it with any degree of success.  As a simple work
of reference, therefore, it is of great value to the
student of pathological anatomy, and  should be in
every physician's library.—Western Lancet.
  One of the very best handbooks of Physiology we
possess—presenting just such an outline of the sci-
ence as the student requires during  his attendance
upon a course of lectures, or for reference whilst
preparing for examination.—Am. Medical Journal.
  For the student beginning this study, and the
practitioner who has but leisure to refresh his
memory, this book is invaluable, as it contains all
that it is important to know, without special details,
which are read  with interest only by those who
would make a specialty, or desire to possess a criti-
cal  knowledge of the  subject.—Charleston Med.
Journal.
                   KIRKES (WILLIAM SENHOUSE),  M.D.,
               Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c.

A  MANUAL  OF  PHYSIOLOGY.    A new  American, from the third and
  improved London edition.  With two hundred illustrations.  In one large and handsome royal
  12mo. volume, leather,  pp. 586.  $2 00.  (Lately Published.) 
20
BLANCHARD <fc LEA'S  MEDICAL
KNAPP'S TECHNOLOGY; or,Chemistry applied
  to the Arts and to Manufactures.  Kdited by Dr.
  Ronalds, Dr. Richardson, and  Prof. W.  R.
  Johnson. In two handsome 8vo. vols., with about
  500 wood-engravings.  $6 00.
LAYCOCKS  LKCTURKS  ON THE  PIIINCI-
  l'i.KS AND METHODS  OF  MEDICAL OB-
  SERVATION AND RESEARCH,  lor the Use
  of Advanced Students and Junior Practitioners.
  In one royal l'2mo. volume, extra cloth.  Price SI.
                         LALLEMAND AND WILSON.
A  PRACTICAL   TREATISE  ON  THE  CAUSES,   SYMPTOMS,  AND
  TREATMENT OF SPERMATORRHOEA.  By M. Lallemand.   Translated and  edited by
  Henry J McDougall.  Third American edition.  To which is added-----ON DISEASES
  OF THE VESICUL^E SEMINALES; and their associated organs.  With special refer-
  ence to the Morbid Secretions of the Prostatic and  Urethral Mucous Membrane.  By Marris
  Wilson, M. D.  In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.)
                          LA  ROCHE  (R.), M. D., &.c.
YELLOW  FEVER,  considered  in its Historical,  Pathological,  Etiological, and
  Therapeutical Relations.  Including a Sketch of the Disease as it has occurred in  Philadelphia
  from 1699 to 1854, with an examination of the connections between it and the fevers known under
  the same name in other  parts of temperate as  well as in tropical regions.   In  two large  and
  handsome octavo volumes of nearly 1500 pages, extra cloth.  $7 00.
nant and unmanageable disease of modern times,
lias for several years been prevailing in our country
to a greater extent than ever before;  that it. is no
longer confined to either large or small cities, but
penetrates  country villages, plantations, and farm-
houses; that it is treated with scarcely better suc-
cess now than  thirty or forty years ago; that there
is vast mischief done by ignorant pretenders to know-
ledge in regard to the disease, and in view of the pro-
bability that a  majority of southern physicians will
be called upon to  treat the disease, we trust that this
able and comprehensive treatise will  be  very gene-
rally read in the south.—Memphis Med. Recorder.
 From Professor S. H. Dickson, Charleston, S. C,
             September 18, 1855.
  A monument of intelligent and well applied re-
search, almost without example.   It is, indeed, in
itself, a large library, and is destined to constitute
the special resort as a book of reference, in the
subject of which it treats, to all future time.
  We have not time at present,  engaged as we are,
by da# and by night, in the work of combating this
very disease, now prevailing in  our city, to do more
than  give this cursory notice of what we consider
as undoubtedly the most able and  erudite  medical
publication our country has yet produced. But in
view of the startling fact, that this, the most malig-

                                  BY THE SAME AUTHOR.

PNEUMONIA ; its Supposed Connection, Pathological and Etiological, with Au-
  tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria.  In one
  handsome octavo volume, extra cloth, of 500 pages.  $3 00.

                             LUDLOW (J. L.),  M. D.
A MANUAL  OF  EXAMINATIONS  upon Anatomy,  Physiology,  Surgery,
  Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics.  To
  which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended
  and enlarged.  With  370 illustrations.  In one  handsome royal 12mo. volume, leather, of 816
  large pages.   $2  50.
  The great popularity of this volume, and the numerous demands for it during the two years in which
it has been out of print, have  induced the author in its  revision to spare no pains to render it a
correct and accurate digest of the most recent condition of all the branches of medical science.  In
many respects it may, therefore, be regarded rather as a new  book  than a new edition, an entire
section on Physiology having  been  added, as also one on Organic Chemistry, and many portions
having been rewritten.  A very complete series of illustrations has been introduced, and every
care  has been taken in the mechanical execution to render it a convenient and satisfactory book for
study or reference.  The arrangement of the volume in the form of question and answer renders it
especially  suited for the office examination of students and for those preparing for graduation.
  We know of no better companion for the student I crammed into his  head by the various professors to
during the hours spent in the lecture room, or to re- whom  he is compelled to  listen.— Western Lancet,
fresh, at a glance, his memory of the various topics | May, 1857.

                               LEHMANN  (C.  G.l

PHYSIOLOGICAL  CHEMISTRY.   Translated  from the  second  edition by
  George E. Day, M. D., F. R.  S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry
  in  the Medical Department of the University of Pennsylvania,  with illustrations selected from
  Funke's Atlas of  Physiological Chemistry, and an Appendix of plates.  Complete  in two large
  and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus-
  trations.  $6 00.
  The work of Lehmann stands unrivalled as the
most comprehensive book of reference and informa-
tion extant on every branch of the Bubject on which
it treats.—Edinburgh Journal of Medical Science.
  The most important contribution as yet made to
Physiological Chemistry—Am. Journal Med. Sci-
tnces, Jan. 1856.
                        by the same author.   (Lately Published.)

MANUAL OF CHEMICAL  PHYSIOLOGY.    Translated from  the German,
  with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital
  t orce, by Professor Samuel Jackson, M. D., of the University of Pennsylvania.  With illus-
  trations on wood.   In one very handsome octavo volume, extra cloth, of 336 pages.  $2 25.
                         From Prof. Jac&son's Introductory Essay.
  In adopting the  handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the
students of the University, and in recommending his original  work of Physiological Chemistry
for their more mature studies, the high value of his researches, and the great weigbt of his autho-
rity in that important department of medical science are fully recognized. 
AND SCIENTIFIC  PUBLICATIONS.
21
                         LAWRENCE (W.),  F. R. S.,  Sec.
A TREATISE  ON  DISEASES  OF  THE  EYE.  A  new edition,  edited,
  with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi-
  tal, &c.  In one very large and handsome octavo volume, of 950 pages, strongly bound in leather
  with raised bands.  $5 00.

                           MEIGS (CHARLES D.)f M.  D.,
              Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia.
OBSTETRICS:  THE  SCIENCE  AND  THE  ART.   Third edition,  revised
  and improved.  With one hundred and twenty-nine illustrations. In one beautifully printed octavo
  volume, leather, of seven hundred and fifty-two large pages.   $3 75.
  The rapid  demand for  another edition of this work is a sufficient expression of the favorable
verdict of the profession.  In thus preparing it a third time for  the press, the author has endeavored
to render it in every respect worthy of the favor which it has received.  To accomplish this he
has thoroughly revised it in every part.  Some portions have been rewritten, others added, new
illustrations have been in many instances substituted for such as were not deemed satisfactory,
while, by an alteration in the typographical arrangement, the size of the work has not been increased,
and the price remains unaltered.   In its present improved form, it is, therefore, hoped that the work
will continue to meet  the wants of the American profession as a  sound, practical, and extended
System  of Midwifery.
  Though the work has received only five pages of
enlargement, its chapters throughout wear the im-
press of careful revision. Expunging and rewriting,
remodelling its sentences, with occasional new ma-
terial, all evince a lively desire that it shall deserve
to be regarded as improved in manner as well as
matter.  In the matter, every stroke of the pen has
increased the value of the book, both  in expungings
and additions —Western Lancet, Jan. 1857.
                                                The best American work on Midwifery that is
                                              accessible  to the student and  practitioner—N. W.
                                              Med. and Surg. Journal, Jan. 1857.
                                                This is a standard work by a great American Ob-
                                              stetrician.  It is the third and last edition, and, in
                                              the language of the preface, the author has "brought
                                              the subject up to the latest dates of real improve-
                                              ment in our art and Science."—Nashville Journ. of
                                              Med. and Surg., May, 1857.
                            BY THE SAME author.  (Just Issued.)
WOMAN:  HER DISEASES AND THEIR  REMEDIES.   A Series of Lee-
  tures to his Class.  Fourth and Improved edition.  In one large and beautifully printed octavo
  volume, leather, of over 700 pages.  $3 60.
  In other respects, in our estimation, too much can-
not be said in praise of this work.  It abounds with
beautiful passages, and for conciseness, for origin-
ality, and for all that is commendable in a work on
the diseases of females, it is not excelled, and pro-
bably not equalled in the English language.   On the
whole, we know of no work on the diseases of wo-
men which we can  so  cordially  commend to the
student and practitioner as the one before us.—Ohio
Med. and Surg. Journal.
  The body of the book is worthy of attentive con-
sideration,  and  is evidently the production of a
clever, thoughtful, and  sagacious physician.  Dr.
Meigs's letters on the diseases of the external or-
gans, contain many interesting and rare cases, and
many instructive observations.  We take our leave
of Dr. Meigs, with a high opinion of his talents and
originality.—The British and Foreign Medico-Chi-
rurgical Review.
  Every chapter is replete with practical  instruc-
tion, and bears the impress of being the composition
of an acute and experienced mind.  There is a terse-
ness, and at the same  time an accuracy in his de-
scription of symptoms, and in the rules for diagnosis,
which cannot fail to recommend the volume to the
attention of the reader.—Ranking's Abstract.
  It contains a vast amount of practical knowledge,
by one who has accurately observed  and  retained
the  experience of many years.—Dublin Quarterly
Journal.
                                                Full of important matter, conveyed in a ready and
                                              agreeable manner.—St.Louis Med. and Surg. Jour.

                                                There is an off-hand fervor, a glow, and a warm-
                                              heartedness infecting the effjrt of Dr. Meigs, which
                                              is entirely captivating, and which absolutely  hur-
                                              ries the  reader through from beginning to end.  Be-
                                              sides, the  book  teems with solid instruction, and
                                              it shows the very highest evidence of ability, viz.,
                                              the clearness with  which the information is  pre-
                                              sented.  We know of no better test of one's under-
                                              standing a subject than the evidence of the power
                                              of lucidly explaining it.  The most elementary, as
                                              well as  the obscurest subjects, under the pencil of
                                              Prof.  Meigs, are isolated and made to stand out in
                                              such bold relief, as to produce distinct impressions
                                              upon  the mind  and memory of the reader. — Th*
                                              Charleston Med. Journal.
                                                Professor Meigs  has enlarged and amended this
                                              great work, for  such it unquestionably is, having
                                              passed the ordeal of criticism at home and abroad,
                                              but been improved thereby ; for in this new edition
                                              the author has introduced real improvements, and
                                              increased the value and  utility of  the book im-
                                              measurably.  It presents so many novel, bright,
                                              and sparkling thoughts; such an exuberance of new
                                              ideas  on almost every page, that we confess  our-
                                              selves to have  become enamored with the book
                                              and its author; and cannot withhold our congratu-
                                              lations from our Philadelphia confreres, that such ■
                                              teacher  is in their service.—N. Y. Med. Gazette.
                                   BY THE SAME  AUTHOR.

ON  THE   NATURE,   SIGNS,   AND  TREATMENT   OF  CHILDBED
  FEVER.  In  a Series of Letters  addressed  to  the  Students of his Class.  In one handsome
  octavo volume, extra cloth, of 365 pages.   $2 50.
  The instructive and interesting author  of  this
work, whose previous labors have placed his coun-
trymen under deep and abiding obligations, again
challenges their admiration in the fresh and vigor-
ous, attractive and racy pages before us. It is a de-
lectable book.  * * * This treatise upon child-
bed fevers will have an extensive sale, being des-
tined, as it deserves, to find a place in the library
of every practitioner who scorns tolagin the rear.__
Nashville Journal of Medicine and Surgery.
                       BY THE SAME AUTHOR J  WITH COLORED PLATES.
A TREATISE  ON ACUTE  AND CHRONIC DISEASES  OF  THE  NECK
  OF THE UTERUS.  With numerous plates, drawn and colored from nature in the highest
  Btyle of art.   In one handsome octavo volume, extra cloth.  $4 50.
MAVNE'S DISPENSATORY  AND   THERA-
  PEUTICAL REMEMBRANCER.  With every
  Practical Formula contained in the three British
  Pharmacopoeias.  Edited, with the addition of the
  Fermulse of the U. S.  Pharmacopoeia, by R. E.
  Griffith,M.D.  112mo. vol. ex. cl.,300pp. 75 c.
MALGAIGNE'S OPERATIVE SURGERY, based
  on Normal and Pathological Anatomy.   Trans-
  lated from the French by Frederick Brittan,
  A.B.,M.D. Withnumerousillustrationsonwood.
  In one handsome octavo volume, extra cloth, of
  nearly six hundred pages. $2 25. 
22
BLANCHARD  <fc  LEA'S  MEDICAL
                        MACLISE  (JOSEPH),  SURGEON.
SURGICAL  ANATOMY.   Forming  one volume, very  large  imperial  quarto.
  With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored.  Con-
  taining one hundred and ninety Figures, many of them the size of life.  Together with copious
  and explanatory letter-press.  Strongly  and handsomely bound  in extra cloth, being one of the
  cheapest and best executed Surgical works as yet issued in this country.  SI 1 00.
  *„* The >ize of this work prevents its transmission through the post-office as a whole, but those
who desire to have  copies forwarded by  mail, can receive  them in five parts, done  up in stout
wrappers.  Price $^ 00.
  One of the greatest artistic triumphs of the age
in Surgical Anatomy.—British American  Medical
Journal.
  No practitioner whose means will admit should
fail to possess it.—Banking's Abstract.
  Too much cannot be said in its praise; indeed,
we have not language to do it justice.—Ohio Medi-
cal and Surgical Journal.

  The most accurately engraved  and  beautifully
colored plates we have ever seen  in an American
book—one of the best and cheapest surgical works
ever published.—Buffalo Medical Journal.

  It is very rare that so  elegantly printed, so well
illustrated, and  so useful  a work,  is offered at  so
moderate a price.—Charleston Medical Journal.

  Its plates can boast a superiority which places
them almost beyond the reach of competition.—Medi-
cal Examiner.
  Country practitioners will find these plates of im-
mense value.—N. Y. Medical Gazette.
  A work which has no pnrallel in point of accu-
racy and cheapness in the English language.—N. Y.
Journal of Medicine.

  We are extremely  gratified to announce to the
profession the completion of this truly magnificent
work, which, as a whole,  certainly  stands unri-
valled, both for  accuracy of  drawing, beauty of
coloring,  and all the  requisite explanations of the
subject in hand.—Th*  New Orleans  Medical  and
Surgical Journal.

  This is by far the ablest work on Surgical Ana-
tomy  that has come  under our observation.  We
know of no other work that would justify a stu-
dent, in any degree,  for neglect of actual dissec-
tion.  In  those  sudden  emergencies that so often
arise, and which require the instantaneous command
of minute anatomical knowledge,' a work of this kind
keeps the details of the dissecting-room perpetually
fresh in the memory .—The Western Journal of Medi-
cine and Surgery.
                             MILLER (HENRY), M. D.,
     Professor of Obstetrics and Diseases of Women and Children in the University of Louisville.
PRINCIPLES AND PRACTICE OF OBSTETRICS, &c.; including the Treat-
  ment of Chronic Inflammation of the  Cervix and Body of the  Uterus considered  as a frequent
  cause of Abortion.  With about one hundred illustrations on wood.  In one very handsome oc-
  tavo volume, of over 600 pages.  (Lately Published.)  $3 75.
  The reputation of Dr. Miller as an obstetrician is  too widely spread to require the attention of
the profession to be specially called to a volume containing I he experience of his long and extensive
practice.  The very favorable reception accorded to his " Treatise on Human Parturition," issued
some years since, is an earnest that the present work will fulfil the author's intention of providing
within a moderate compass  a complete  and trustworthy text-book for the student, and book of re-
ference for the practitioner.                                                                 ,
  We congratulate the author that the task is done.
We congratulate him that he has given to the medi-
cal public a work which will secure for him a high
and permanent position among the standard  autho-
rities on the principles and  practice of obstetrics.
Congratulations are not less due to the medical pro-
fession of this country, on the acquisition of a trea-
tise embodying the results of the studies, reflections,
and experience of Prof. Miller. Few men, if any,
in this country, are more competent than he to write
on this department of medicine.  Engaged for thirty-
five years in an extended practice of obstetrics, for
many years a teacher of this branch of instruction
in one of the largest of our  institutions, a diligent
student as well as a careful observer, an original and
independent  thinker, wedded to no hobbies, ever
ready to consider without prejudice new views, and
to adopt innovations if they are really improvements,
and withal a clear, agreeable writer, a  practical
treatise from his pen could not fail to possess great
value.—Buffalo Med Journal, Mar. 1858.
  In fact, this volume must take its place among the
standard systematic treatises on obstetrics;  a posi-
tion to which its merits justly entitle it.  The style
is such that the descriptions are clear, and each sub-
ject is discussed and elucidated with  due regard to
its practical bearings, which cannot fail  to make it
acceptable and valuable to both  students and prac-
titioners.   We cannot, however, close this  brief
notice without congratulating the author and the
profession on the production of such an excellent
treatise.  The author is a western man of whom we
feel proud, and we cannot but think that his book
will find many readers and warm admirers wherever
obstetrics is taught and studied as a science  and an
art.—The Cincinnati Lancetand Observer, Feb. 1858.
  A most respectable and valuable addition to our
home  medical literature, and one reflecting credit
alike on the author and the  institution to which he
is attached.  The student will find in this work a
most useful guide to his studies; the country prac-
titioner, rusty in his reading, can obtain from its
pages a fair resume of  the modern literature of the
science; and we hope to see this American produc-
tion  generally consulted by the profession.— Va.
Med.  Journal, Feb. 1858.
                             MACKENZIE  (W.),  M.D.,
                 Surgeon Oculist in Scotland in ordinary to Her Majesty, &,c. kc
A  PRACTICAL  TREATISE  ON  DISEASES   AND INJURIES  OF  THE
  EYE.  To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of
  the Human Eyeball, by Thomas  Wharton Jones, F. R. S.  From the Fourth Revised and En-
  larged London Edition.  With Notes and Additions by Addinell Hewson, M. D., Surgeon to
  Wills Hospital, &c. &c.  In one very large and handsome octavo volume, leather, raised bands, with
  plates and numerous wood-cuts.  $5 25.
  The treatise of Dr. Mackenzie indisputably holds
the first place, and forms, in respect of learning and
research, an Encyclopaedia unequalled in extent by
any other work of the kind, either English or foreign.
—Dixon on Diseases of the Eye.
  Few modern books on any department of medicine
or surgery have met with such extended circulation,
or have procured for their authors a like amount of
European celebrity.  The  immense research which
it displayed, the thorough acquaintance with  the
■abject, practically as well as *u—-fi"nlly,ajid the
able manner in which the author's stores of learning
and experience were rendered  available for general
use, at once procured for the first edition, as well on
the continent as in this country, that high position
as a standard work which each successive edition
has more firmly established.  We consider it the
duty of every one who has the love of hiB profession
and the welfare of his patient at heart, to make him-
self familiar with this the most complete work in
the English language upon the diseases of the eye.
—Med. Times and Gazette. 
AND SCIENTIFIC PUBLICATIONS.                    2d
                           MILLER (JAMES),  F. R.  S. E.,
                     Professor of Surgery in the University of Edinburgh, &c.
PRINCIPLES  OF  SURGERY.   Fourth American, from the third and revised
  Edinburgh edition. In  one large  and very beautiful volume, leather, of 700 pages, with two
  hundred and forty illustrations on wood.  $3 75.
  The work of Mr. Miller is too well and too favor-
ably known among us, as one of our best text-books,
to render any further notice of it necessary than the
announcement  of a new edition, the fourth in our
country, a proof of its extensive circulation among
us.  As a concise and reliable exposition of the sci-
ence of modern surgery, it stands deservedly high—
we  know not its superior—Boston Med. and Surg.
Journal.
                                                 The work takes Tank with Watson's Practice of
                                               Physic; it certainly does not fall behind that great
                                               work in soundness of principle or depth of reason-
                                               ing and research.  No physiffian who values his re-
                                               putation, or seeks the interests of his clients,  can
                                               acquit himself before his God and the world without
                                               making himself familiar with the sound  and philo-
                                               sophical views developed in the foregoing book.—
                                               New Orleans Med. and Surg. Journal.
                            BY the same  author. (Just Issued.)

THE  PRACTICE  OF  SURGERY.    Fourth  American from  the  last Edin-
  burgh  edition.   Revised by the American editor.  Illustrated by three hundred and  sixty-four
  engravings on wood.  In one large octavo volume, leather, of nearly 700 pages.   $3 75.
  No encomium of ours could add to the popularity
of Miller's Surgery.  Its reputation in this country
is unsurpassed by that of any other work, and, when
taken in connection with the author's Principles of
Surgery, constitutes a  whole, without reference to
to which no conscientious surgeon would be willing
practice his art.—Southern Med. and Surg. Journal.
  it is seldom that two volumes have ever made so
profound an impression in so short a time as the
" Principles" and the " Practice" of  Surgery  by
Mr. Miller—or so richly merited the reputation they
have acquired.  The author is an eminently sensi-
ble, practical, and well-informed man, who knows
exactly what he is talking about and exactly how to
talk it.—Kentucky Medical Recorder.
  By the almost unanimous voice of the profession,
his works, both on the  principles and practice of
surgery have been assigned the highest rank.  If we
were limited to but one work on surgery, that one
should be Miller's, as we regard it as superior to all
others.—St. Louis Med.  and Surg. Journal.

  The author has in this and his " Principles," pre-
sented to the profession one of the most completeand
reliable  systems of Surgery extant.  His style of
writing is original, impressive, and engaging, ener-
getic, concise, and lucid. Few have the faculty of
condensing so much in small space, and at the same
time so persistently holding the attention. Whether
as a text-book for  students or  a book of reference
for practitioners, it cannot be  too strongly recom-
mended.—Southern Journal of Med. and. Physical
Sciences.
                            MORLAND  (W. W.),  M. D.,
                        Fellow of the Massachusetts Medical Society, &c.

DISEASES OF THE  URINARY ORGANS; a Compendium of their Diagnosis,
  Pathology, and Treatment.  With illustrations.   In one large and handsome octavo volume, of
  about 600 pages, extra cloth.   (Just Issued.)  $3 50.
  Taken as a whole, we can  recommend Dr. Mor-
land's compendium as a very desirable  addition  to
the library  of every medical or surgical  practi-
tioner.—Brit, and For. Med.-Chir. Rev., April, 1859.
  Every medical practitioner whose attention has
been to any extent attracted  towards the class  of
diseases to which this treatise relates, must have
often and sorely experienced the want of some full,
yet concise recent compendium to which he  could
refer. This desideratum has  been supplied by Dr.
Morland, and it has been ably  done.  He has placed
before us  a  full, judicious,  and reliable  digest.
Each  subject  is treated with  sufficient minuteness,
yet in a succinct, narrational style, such as to render
the work one of great interest, and one which will
prove in the highest degree useful to the general
practitioner. To the members of the profession in the
country it will be peculiarly valuable, on account
of the  characteristics which  we  have mentioned,
and the one broad aim of practical utility which is
kept in view, and which shines out upon every page,
together with the skill which is evinced in the com-
bination of this grand requisite  with the  utmost
brevity which a just treatment of the subjects would
admit.—N. Y. Journ. of Medicine, Nov. 1858.
               MONTGOMERY (W.  F.),  M. D., M. R. I. A., fee,
        Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c.

AN  EXPOSITION OF THE SIGNS  AND SYMPTOMS  OF  PREGNANCY.
  With some other Papers on Subjects connected with Midwifery.  From th«*second and enlarged
  English edition.  With two  exquisite colored  plates,  and numerous wood-cuts.  In one very
  handsome octavo volume, extra cloth, of nearly 600 pages.  (Lately Published.)   $3 75.
  A book unusually rich in practical suggestions.—
Am. Journal Med. Sciences, Jan..1857.
  These several subjects so interesting in them-
selves, and so important, every one of them, to the
most delicate and precious of social relations, con-
trolling often the honor and domestic peace of a
family, the legitimacy of offspring, or the life of its
parent, are all treated with an elegance  of diction,
fulness of illustrations, acuteness and justice of rea-
soning, unparalleled in obstetrics, and unsurpassed in
medicine.   The reader's interest can never flag, so
fresh, and vigorous, and classical is our author's
Btyle;  and one forgets, in the renewed charm of
every page, that it, and every line, and every word
has been weighed and reweighed through years of
preparation; that this is of all others the book of
Obstetric Law, on each of its several topics; on all
points connected with pregnancy, to be everywhere
received as a manual of special  jurisprudence, at
once announcing fact, affording argument, establish-
ing precedent, and governing alike the juryman, ad-
vocate, and judge.  It is not merely in its legal re-
lations that we find this work so interesting.  Hardly
a page but that has  its hints or facts important to
the general practitioner; and not a chapter without
especial matter for  the anatomist, physiologist, or
pathologist. — N. A. Med.-Chir. Review,  March,
1857.                                 '        '
      MOHR (FRANCIS), PH.  D., AND  REDWOOD (TH EOPHI LUS).

PRACTICAL   PHARMACY.   Comprising  the Arrangements,  Apparatus, and
  Manipulations of the  Pharmaceutical Shop and Laboratory.  Edited, with extensive Additions
  by  Prof. William Procter, of the Philadelphia College  of Pharmacy.  In one handsomely
  printed octavo volume, extra cloth, of 570  pages, with over 500 engravings on wood.  &2 75, 
BLANCHARD  &  LEA'S MEDICAL
                               NEILL (JOHN), M. D.,
                         Surgeon to the Pennsylvania Hospital, &c; and

                      FRANCIS GURNEY  SMITH,  M.D.,
              Professor of Institutes of Medicine in the Pennsylvania" Medical College.

AN  ANALYTICAL COMPENDIUM  OF  THE   VARIOUS  BRANCHES
  OF MEDICAL SCIENCE ;  for the Use and Examination of Students.   A new edition, revised
  and improved.  In one very large and handsomely printed royal 12mo. volume, of about one
  thousand pages, with 374 wood-cuts.  Strongly bound in leather, with raised bands.  $3 00.
  The very flattering reception which has been accorded to this work, and the high estimate placed
upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex-
hausted two large editions, have stimulated the authors to render the volume in its present revision
more worthy of the  success which has attended it.  It has accordingly been thoroughly examined,
and such errors as had on former occasions escaped observation have been corrected, and whatever
additions were  necessary to maintain it on a level with the advance of science have been introduced.
The extended series of illustrations has been still further increased and much improved, while, by
a slight enlargement of the page, these various additions have been incorporated without increasing
the bulk of the volume.
  The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto
been received.   As a book for daily reference by the student requiring a guide to his more elaborate
text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate
examination, or as a source from which the practitioners of older date may easily and cheaply acquire
a knowledge of the changes and improvement in professional science, its reputation is permanently
established.
  The best work of the kind with which we are
acquainted.—Med. Examiner.
  Having made free use of this volume in our ex-
aminations of  pupils, we can speak from experi-
ence in recommending it as an admirable compend
for students, and as especially useful to preceptors
who examine their pupils.  It will save the teacher
much labor by enabling  him readily to recall all of
the  points upon which his pupils should  be ex-
amined. A work of this sort should be in the hands
of every one who takes  pupils into his office with a
view of examining them; and this is unquestionably
the best of its class.—Transylvania Med. Journal.

  In the rapid course of lectures, where work for
the students is heavy, and  review necessary for an
examination, a compend is not only valuable, but
it is almost a sine qua non.  The one before us is,
in most of the divisions, the most unexceptionable
of all books of the kind that we know of.   The
newest and soundest doctrines and  the latest im-
provements and discoveries are explicitly, though
concisely, laid before the student. There is a class
to whom we very sincerely commend this cheap book
as worth its weight in silver—that class is the gradu-
ates in medicine of more than ten years' standing.
who  have not studied medicine since.  They will
perhaps find out from it that the science is not exactly
now what it was when they left it off.—The Stetho-
scope.
                NELIGAN (J.  MOORE), M. D.,  M. R. I. A., &c.
                             (A splendid work.  Just Issued.)

ATLAS  OF  CUTANEOUS DISEASES.   In  one beautiful quarto volume, extra
  cloth, with splendid colored plates, presenting nearly one hundred elaborate representations  of
  disease.  $4 50.
  This beautiful volume is intended as a complete and accurate representation of all the varieties
of Diseases of the Skin.  While it can be consulted in conjunction with any work on Practice, it has
especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the
profession some years since.  The publishers feel justified in saying that few more beautifully exe-
cuted plates have ever been presented to the profession of this country.
  Neligan's Atlas of Cutaneous Diseases supplies a  give,  at a coup d'ctil, the remarkable peculiarities
long existent desideratum much felt by the largest  of each individual variety.  And while thus the dis-
class of our profession. It presents, in quarto size,  ease is rendered more definable, there is yet no loss
16 plates, each containing from 3 to 6 figures, and  of proportion incurred by the necessary concentra-
forming in all a total of 90 distinct representations  tion.  Each figure is highly colored, and so truthful
of the different species of skin affections, grouped  has the artist been that the most fastidous observer
together in genera or families.  The  illustrations  could  not justly take exception to the correctness of
have been taken from nature, and have been copied  the execution of the pictures under his scrutiny —
with such fidelity that they present a striking picture  Montreal Med. Chronicle.
of life; in which the reduced scale aptly serves to

                                  BY THE SAME AUTHOR.

A   PRACTICAL  TREATISE   ON  DISEASES  OF  THE  SKIN.   Third
  American edition.  In one neat royal 12mo. volume, extra cloth, of 334 pages.  $1 00.

   M®~ The two volumes will be sent by mail on receipt of Five Dollars.


OWEN  ON  THE DIFFERENT FORMS  OF I  One vol. royal 12mo  extra cloth m,th .,™,r„„,
  THE SKELETON,  AND OF THE  TEETH. |  illustrations.  81 25'           with numerous


                         PIRRIE (WILLIAM),  F. R. S. E.,
                       Professor of Surgery in the University of Aberdeen

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.   Edited  by John
  Neill, M D., Prote-or of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania
  Hospital, &c. In one very handsome octavo volume, leather, of 780pages, with 316 illustrations

  We know of no other surgical work of a reason- 1 rately discussed the nrir,o,vi»„ „<■
able size, wherein there is so much theory and prac- ! safe andI effectual  rf?  11.'^' &?d a


  Prof. Pirrie, in the work before ub, has elabo- ! Nashinlle Journal of Medicine and Surgery. 
AND SCIENTIFIC  PUBLICATIONS.
25
                               PARRISH  (EDWARD),
  Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c.

AN INTRODUCTION  TO  PRACTICAL PHARMACY.   Designed as a Text-
  Book for the Student, and as a Guide for  the Physician  and Pharmaceutist.  With many For-
  mulae and Prescriptions.   Second edition, greatly enlarged and improved.  In one handsome
  octavo volume of 720 pages, with several hundred Illustrations, extra cloth.  $3 50.   (Now
  Ready.)

  During the short time in which this work ha3 been before the profession, it has been  received
with very great favor, and in assuming the position of a standard authority, it has  filled a vacancy
which  had been severely felt.  Stimulated by this encouragement, the author, in availing himself
of the opportunity of revision, has spared no pains to render it more worthy  of the confidence  be-
stowed upon it, and his assiduous labors have made it rather a new book than a new edition, many
portions having been rewritten, and much new and important matter added.  These alterations and
improvements  have been rendered necessary by the rapid progress made by pharmaceutical science
during  the last few  years, and by the additional experience obtained in the practical use of  the
volume as a text-book and work of  reference.  To accommodate these improvements, the size of
the page has been materially enlarged, and the number of pages considerably increased, presenting
in all nearly one-half more matter than the last edition.  The work is therefore now presented as a
complete exponent of the subject in its most advanced condition.  From the most ordinary matters
in the dispensing office, to the most complicated details of the vegetable  alkaloids,  it is hoped that
everything requisite to  the practising physician, and to  the apothecary, will be found fully and
clearly set forth, and that the new matter alone will be worth more than the very moderate cost of
the work to those who have been consulting the previous edition.
  That Edward Parrish, in writing a book upon
practical Pharmacy some few years ago—one emi-
nently  original and  unique—did the  medical and
pharmaceutical professions a great and valuable ser-
vice, no one, we think, who has had access to its
pages will deny; doubly welcome, then, is this new
edition, containing the added results  of his  recent
and rich experience as an observer,  teacher, and
practicil operator in the pharmaceutical laboratory.
The excellent plan of the first is more thoroughly,
and in detail, carried out in this edition.—Peninsular
Med. Journal, Jan. I860.
  We know of no work on the subject which would
be more indispensable to  the physician or student
desiring information on the subject of which it treats.
With Griffith's " Medical Formulary" and this, the
practising physician would be supplied with nearly
or quite all the most useful infomation on the sub-
ject.—Charleston Med. Journal and  Review, Jan.
I860.
  This edition, now much enlarged, is one of the
most useful works of  the past year.—N. O. Med.
and Surg. Journal, Jan. 1860.
  The whole treatise  is eminently practical; and
there is no production of the kind in the English
language so well adapted to the wants of the phar-
maceutist and druggist. To physicians, also, it can-
not fail to be highly valuable, especially to those
who are obliged to prepare and compound many of
their own medicines.—N. Am. Med. Chir. Review,
Jan. 1860.

  Of course, all apothecaries who have not already
a copy of the first edition will procure one of this;
it is, therefore, to physicians residing in the country
and in small towns, who cannot avail themselves of
the skill of  an educated pharmaceutist, that we
would especially commend this work.  In  it they
will find all  that  they desire to  know, and should
know, but very little of which they do really Know
in reference to this important collateral  branch of
their profession;  for it is a well established fact,
that, in the education of physicians, while the sci-
ence of medicine is generally well  taught, very
little attention is paid to the art  of preparing them
for use, and we know not how this defect can be so
well remedied as  by procuring and consulting Dr.
PaTrish's excellent work.—St. Louis Med. Journal.
Jan.1860.
                              PEASLEE (E.  R.),  M. D.,
         Professor of Physiology and General Pathology in the New York Medical College.
HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology;
  for the use of Medical Students.  With four hundred and thirty-four illustrations.  In one hand-
  some octavo volume, of over 600 pages.   (Lately Published.)  $3  75.
  It embraces a library upon the topics discussed
within itself, and is just what the teacher and learner
need.  Another advantage, by no means to be over-
looked, everything of real value in the wide range
which it embraces, is with great skill compressed
into an octavo volume of but little more than six
hundred pages.  We have not only the whole sub-
ject of Histology, interesting in itself, ably and fully
discussed, but what is of  infinitely greater  interest
to the student, because of greater practical value,
are its relations to Anatomy, Physiology, and Pa-
thology, which are here fully and satisfactorily set
forth.— Nashville Journ. of Med. and Surgery, Dec.
1857.
  We would recommend it to the medical student
and practitioner, as containing a summary of all that
is known of the important subjects which it treats;
of all that is contained in the great works of Simon
and Lehmann, and the organic chemists in general.
Master this one volume, we would say to the medical
student and  practitioner—master this book and you
know all that is known of the great fundamental
principles of medicine, and  we have bo hesitation
in saying that it is an honor to the American medi-
cal profession that one of its members should have
produced it.—St. Louis  Med. and Surg. Journal,
March, 1858.
             PEREIRA (JONATHAN), M. D., F. R. S.f  AND L. S.
THE  ELEMENTS  OF  MATERIA  MEDICA  AND   THERAPEUTICS.
  Third American edition, enlarged and improved by the author; including Notices of most of the
  Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia
  Medica.  Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and
  Pharmacy in the University of Pennsylvania.  In two very large octavo volumes of 2100 pages,
  on small type, with about  500 illustrations on stone and wood, strongly bound in leather, with
  raised bands.  $9 00.
  %*# Vol. II. will no longer be sold separate.

                              PARKER  (LANGSTON),
                         Surgeon to the Queen's Hospital, Birmingham.

THE MODERN  TREATMENT  OF  SYPHILITIC  DISEASES, BOTH PRI-
  MARY AND  SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi-
  lis by a safe and successful  method.  With numerous Cases, Formulae, and Clinical Observa-
         From the Third and entirely rewritten  London  edition. In one neat octavo volume
tions.  ---.....- -
«rtra cloth,  of 316 pages
$1 75. 
26
BLANCHARD  &  LEA'S  MEDICAL
                     RAMSBOTHAM (FRANCIS H.),  M.D.
THE  PRINCIPLES AND  PRACTICE OF OBSTETRIC MEDICINE AND
  SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly
  revised by the Author.  With Additions by W. V. Keating, M. D.  In one large and handsome
  imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty-
  four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred
  large and beautiful figures. $5 00.
                          From Prof. Hodge, of the University of Pa.
  To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being
the best au'horized exponent of British Midwifery.  Its circulation will, I trust, be extensive throughout
our country.
  It is unnecessary to say anything in regard to the
utility of this work.  It is already appreciated in our
country for the value of the matter, the clearness of
its style, and the fulness of its illustrations. To the
physician's library it is indispensable,  while to the
student as a text-book, from which to extract the
material for laying the foundation of an education on
obstetrical science, it has no superior.—Ohio Med
and Surg. Journal.
  The publishers  have secured its success by the
truly elegant style in which they have brought it
out, excelling themselves in its production, espe-
cially in its plates.  It is dedicated to Prof. Meigs,
and has the emphatic endorsement of Prof. Hodge,
as the  best exponent of British Midwifery.  We
know of no text-book which deserves in all respects
to be more highly recommended to students, and we
could wish to see it in the handsof every practitioner,
for they will find it invaluable for reference.—Med.
Gazette.
                                RICORD (P.), M. D.
A TREATISE ON THE VENEREAL DISEASE.   By John Hunter, F. R. 8.
  With copious Additions, by Ph. Ricord, M. D.  Translated and Edited, with Notes, by Freeman
  J. Bumstead. M.D , Lecturer on Venereal at the College of Physicians and Surgeons, New York.
  Second edition, revised, containing a resume  of Ricord's Recent Lectures on Chancre. In
  one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $3 25. (Just Issued.)
  In revising this work, the editor has endeavored to introduce whatever matter of inlerest the re-
cent investigations of syphilographers have added to our knowledge of the subject.  The principal
source from which this has been derived is the volume of "Lectures on Chancre," published a few
months since by M. Ricord, which affords a large amount of new and instructive material on many
controverted points.   In the  previous edition, M.  Ricord's additions amounted to nearly one-lhird
of the whole, and with the matter now introduced, the work may be considered to present his views
and experience more thoroughly and completely than any other.
                                             secretaries, sometimes accredited and sometimes not.
  Every one will recognize the attractiveness and
value which this work derives from thus presenting
the opinions of these two masters side by side.  Bui,
it must be admitted, what has made the fortune of
the book, is the fact that it contains the " most com-
plete embodiment of the veritable doctrines of the
Hopital du Midi," which  has ever been made public.
The doctrinal ideas of M. Ricord, ideas which, if not
universally adopted,are inconiesiably dominant, have
heretofore only been interpreted by more or less skilful
                                              In the notes to Hunter, the master substitutes lum-
                                             selfforhis interpreters, and gives hisoriginal thoughts
                                             to the world in a lucid and perfectly intelligible man-
                                             ner.  In conclusion we can say that this  is  incon-
                                             lestably the best treatise on syphilis with which wc
                                             are acquainted, and, as we do not often employ the
                                             phrase, we may be excused for  expressing tlie hope
                                             that it may find a place in the library of every phy-
                                             sician.— Virginia Med. and Surg. Journal.
                                 BY THE SAME AUTHOR.
RICORD'S LETTERS ON SYPHILIS.  Translated by W. P. Lattimore, M. D.
  In one neat octavo volume, of 270 pages, extra  cloth.  $2 00.


ROYLE'S  MATERIA  MEDICA   AND  THERAPEUTICS;  including  the
  Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States.
  With many new medicines.   Edited by Joseph Carson, M. D.   With ninety-eight illustration*.
  In one large octavo volume, extra cloth, of about 700 pages.  $3 00.

                         ROKITANSKY (CARL),  M.D.,
     Curator of the Imperial Pathological Museum, and Professor at the University of Vienna  &c

A  MANUAL  OF  PATHOLOGICAL  ANATOMY.   Four  volumes,' octavo,
  bound in two, extra cloth, of about 1200 pages.  Translated by W. E. Swaine,  Edward Sieve'
  king, C. H. Moore, and G. E. Day.   $ j  50
  The profession is too well acquainted with the re-
putation of Rokitansky's work to need our assur-
ance that this is one of the most profound, thorough,
and valuable books  ever issued  from the medical
press.  It is sui generis, and has no standard of com-
parison. It is only necessary to announce that it is
issued in a  form as cheap as  is compatible with its
size and preservation, and  its sale follows as a
matter of course. No library can be called com-
plete without it.—Buffalo Med. Journal.
  An attempt to give our readers any adequate idea
of the vast amount of instruction accumulated in
these volumes, would be feeble and hopeless. The
effort of the  distinguished  author to concentrate
in a small space his great fund of knowledge, has
so charged his text with valuable truths, that any
attempt of a reviewer to epitomize is at once para-
lyzed, and must end in a failure.—Western Lancet.
  As this is the highest Bource of knowledge upon
the important subject of which it treats, no real
student can afford to be without it. The American
publishers have entitled themselves to the thanks of
the profession of their country, for this timeousantl
beautiful edition.—Nashville Journal of Medicint.
  As a book of reference, therefore, this work must
prove of inestimable value, and we cannot too highly
recommend it  to the profession.—Charleston Med.
Journal and Review.

  This  book is a necessity to every practitioner.—
Am. Med. Monthly.
                            RIGBY (EDWARD),  M. D.,
                    Senior Physician to the General Lying-in Hospital Ac
A  SYSTEM   OF  MIDWIFERY.   With  No?es and Additional Illustrations.
  Second American Edition.   One volume octavo, extra cloth, 422 pages.  $2 50.
                        by the same author.  (Lately Published.)
ON  THE  CONSTITUTIONAL  TREATMENT OF FEMALE DISEASES
  In one neat royal 12mo. volume, extra cloth, of about 250 pages.  $1 00. 
AND SCIENTIFIC  PUBLICATIONS.
27
                             STILLE (ALFRED),  M.  D.
THERAPEUTICS AND  MATERIA MEDICA; a Systematic  Treatise on the
Action, and Uses of Medicinal Agents, including their Description and History.  In two large and
  handsome octavo volumes, of  1789 pages.  (Now Ready, 1860.)  $8 00.
  This work is designed especially for the student and practitioner of medicine, and treats the various
articles of the Materia Medica from the point of view of the bedside, and not of the shop or of the
lecture-room.   While thus endeavoring to give all practical information likely to be useful with
respect to the employment of special remedies in special affections, and the results to be anticipated
from their administration, a copious Index of Diseases and their Remedies renders the work emi-
nently fitted for reference by showing at a  glance the different means which  have been employed,
and enabling the practitioner to extend his resources in difficult ca-es with all that  the experience
of the profession has suggested.   At the same time particular care has been given to the subject
of General Therapeutics, and at the commencement of each class of medicines there is a chapter
devoted to the consideration of their common influence  upon morbid  conditions.  The action of
remedial agents upon the healthy economy and on animals has likewise received particular notice,
from the conviction that their physiological effects will afford frequent explanations of their patho-
logical influence, and in many ca^es lead to new and important suggestions as to their practical u>e
in disease.  Within the scope thus designed by the author, no labor has been spared to accumulate
all the facts which have accrued  from the experience of the profusion in all ages and all counfries ;
and the vast amount of recent researches recorded  in the periodical literature of both hemispheres
has been  zealously laid under contribution, resulting in a mass of practical information  scarcely
attempted hitherto in any similar work in  the language.
  Our expectations of the value of this work were
based on the well-known reputation and character
of the author as a man of scholarly attainments, an
 elegant writer, a candid  inquirer after truth, and a
 philosophical thinker;  we knew that the task would
 be conscientiously performed, and that few, if any,
 among: the distinguished medical teachers in this
 country are better qualified than he to prepare a
 systematic treatise on therapeutics in accordance
 with the present requirements of medical science.
 Our preliminary examination of the work has satis-
 fied us that we were not mistaken in our anticipa-
 tions.  In congratulating the author on the comple-
 tion of the great labor which such a work involves,
 we are happy in expressing the conviction  that its
 merits will receive that reward which is above all
 price- the grateful appreciation of his medical bre-
 thren.—New Orleans Medical News, March, 1960.

  We think this work will do much to obviate the
 reluctance to a thorough investigation of this branch
 of scientific study, for in the wide range of medical
 literature treasured in the English tongue, we shall
 hardly find a work written in a style more clear and
 simple, cun veying forcibly the facts taught,  and yet
 free from turgidity and redundancy.  There is a fas-
cination in its pages that will insure to it a wide
popularity and attentive perusal, and a degree of
usefulness not often attained through the influence
of a single work. The author has much enhanced
 the practical utility of his book by passing briefly
 over the physical, botanbal, and commercial history
 of medicines, and directing attention chiefly to their
 physiological action, and their application for  the
 amelioration or cure of disease.  He ignores hypothe-
 sis and theory which are so alluring to many medical
 writers, and so liable to lead them astray, and con-
 fines himielf to such facts as have been tried in the
 crucible of experience.—Chicago Medical Journal,
 March, I860.
  The plan pursued by the author in these very ela-
 borate volumes is not strictly one of scientific unity
 and precision; he has rather subordinated  these to
 practical utility. Dr. Stille has  produced a work
 which will be valuable equally to the student of
 medicine and the busy practitioner.— London Lan-
 cet, March 10, 1860.

  With Pereira,Dunglison, Mitchell, and Wood  be-
fore us, we may well ask if there was a necessity
for a new book on the subject. After examining this
work with some care, we can answer affirmatively.
Dr. Wood's book is well adapted for students, while
Dr. Stillfe's will be more satisfactory to the practi-
tioner, who desires to study the action of medicines.
The author needs no encomiums from  us, for he is
well known as a ripe scholar and a man of the most
extensive reading in his profession. This work bears
evidence  of  this fact on every page.—Cincinnati
Lancet, April, I860.
                            SMITH  (HENRY  H.),  M.D.
MINOR  SURGERY;  or,  Hints on the Every-day Duties of the Surgeon.   With
  247 illustrations.  Third edition.  1 vol. royal 12mo., pp. 456.  In leather, $2 25; cloth, $2 00.
                                BY THE SAME AUTHOR, AND
                         HORNER (WILLIAM E.), M.D.,
                   Late Professor of Anatomy in the University of Pennsylvania.

AN ANATOMICAL  ATLAS,  illustrative of the Structure of the Human Body.
  In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful
  figures.  $3 00.
  These figures are well selected, and  present a
complete and  accurate representation of  that won-
derful fabric, the human body.  The plan of  this
Atlas, which  renders it  so peculiarly convenient
for the student, and its superb artistical execution,
have been already pointed out.  We must  congratu-
late the student upon the completion of this Atlas,
as it is the most convenient work of the kind that
has yet appeared ; and we must add, the very beau-
tiful manner in which it is "got up" is so creditable
to the country as to be flattering to our national
pride.—American Medical Journal.
       SHARPEY (WILLIAM), M.  D.,  JONES  QUAIN, M.  D., AND
                         RICHARD  QUAIN,  F. R. S., &.c.
HUMAN ANATOMY.   Revised, with Notes and Additions, by Joseph Leidy,
  M. D., Professor of Anatomy in the University of Pennsylvania.  Complete in two large octavo
  volumes, leather, of about thirteen hundred pages.  Beautifully illustrated with over five hundred
  engravings on wood.   $6 00.

                              SIMPSON (J.  Y.',  M. D.,
                 Professor of Midwifery, &c, in the University of Edinburgh, &c.

CLINICAL  LECTURES ON THE DISEASES OF FEMALES.   With numc-
  rous illustrations.
  This  valuable s-eries  of practical  Lectures is  now appearing in  the  "Medical  News and
Library" for I860, and  can thus be had without cost by subscribers to the "American Journal
of the Medical Sciences."  See p. 2. 
2S
BLANCHARD  &  LEA'S MEDICAL
                           SARGENT (F. W.), M. D.
ON  BANDAGING  AND  OTHER OPERATIONS OF  MINOR  SURGERY.
  Second edition, enlarged.  One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood-
  cuts.  Extra cloth, $1 40; leather, $1 50.
  Sargent's Minor Surgery has always been popular,
and deservedly so. It furnishes that knowledge of the
most frequently requisite performances of surgical
art which cannot be entirely understood by attend-
ing clinical lectures.  The art of bandaging, which
is regularly taught in Europe, is very frequently
overlooked by teachers in this country; the student
and junior practitioner, therefore, may often require
that knowledge which this little volume so tersely
and happily supplies.—Charleston Med. Journ. and
Review, March, ls56.
  A work that has been bo long and favorably known
to the profession as Dr. Sargent's Minor Surgery,
needs no commendation from us. We -would remark,
however, in this connection, that minor surgery sel-
dom gets that attention in our schools that  its im-
portance deserves.  Our larger works are also very
defective in their teaching on these small practical
points.  This little book will supply the void which
all must feel who have not smdied its pages.—West-
ern Lancet, March, 1856.
                         SMITH  (W. TYLER), M. D.,
                      Physician Accoucheur to St. Mary's Hospital, Ac.
ON  PARTURITION,  AND  THE PRINCIPLES  AND  PRACTICE  OF
  OBSTETRICS.  In one royal 12mo. volume, extra cloth, of 400 pages.  $125.
                                BY THE SAME AUTHOR.
A PRACTICAL  TREATISE  ON THE PATHOLOGY AND TREATMENT
  OF LEUCORRHCEA.  With numerous illustrations.  In one very handsome octavo volume,
  extra cloth, of about 250 pages.  $1 50.
SOLLY ON THE HUMAN BRAIN; its Structure,
  Physiology, and Diseases.  From the Second and
  much enlarged  London edition.  In  one  octavo
  volume, extra cloth, of 500 pages, with 120 wood-
  cuts.  $2 00.
SKEY'S OPERATIVE SURGERY.  In one very
  handsome octavo volume, extra cloth, of over 650
  pages, with about one hundred wood-cuts. 83 25.
SIMON'!* GENERAL PATHOLOGY, as conduc-
  ive to the  Establishment of Rational Principles
  for the  prevention ano Cure of Disease.  In one
  octavo  volume, extra cloth, of 212 pages.  $1 25.
                     TODD (R.  B.),  M. D.,  F. R. S.,  &c.
CLINICAL LECTURES  ON CERTAIN DISEASES  OF THE  URINARY
  ORGANS AND ON DROPSIES.  In one octavo volume, 284 pages.  $1 50.
                         BY THE SAME author.  (Nov) Ready.)
CLINICAL LECTURES  ON CERTAIN ACUTE  DISEASES.    In one neat
  octavo volume,  of 320 pages, extra cloth.  $1 75.
  The subjects treated in this volume are—Rheumatic Fever, Continued Fever, Erysipelas,
Acute Internal Inflammation, Pyemia, Pneumonia, and the Therapeutical Action of Alco-
hol.  The importance of these matters in the daily practice of every physician, and the sound
practical nature of Dr. Todd's writings, can hardly fail to attract to this work the general attention
that it merits.
                           TANNER (T.  H.), M. D.,
                         Physician to the Hospital for Women, &c.

A MANUAL  OF CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS.
  To  which is added The Code of Ethics of  the American Medical Association.  Second
  American Edition.  In one neat volume, small 12mo., extra cloth, 87$ cents.

                   TAYLOR (ALFRED  S.),  M. D., F.  R. S.,
              Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital.

MEDICAL JURISPRUDENCE.   Fourth American Edition.   With Notes and
  References to American Decisions, by Edward Hartshorne,M. D.  In one large octavo volume,
  leather, of over seven hundred pages.  $3 00.
  No work upon the subject can  be put into the
hands of students either of law or  medicine which
will engage them more closely or  profitably; and
none could be offered to  the busy practitioner of
either  calling, for the purpose of casual or haBty
reference, that would be more likely to afford the aid
desired. We therefore recommend it as  the best and
safest manual for daily use.—American Journal of
Medical Sciences.
                                            It is not excess of praise to say that the volume
                                          before us is the very best treatise extant on Medical
                                          Jurisprudence.  In saying this, we do not wish to
                                          be understood as detracting from  the merits  of the
                                          excellent works of Beck, Ryan, Traill, Guy, and
                                          others; but in interest and value we think it must
                                          be conceded that Taylor is superior to anything that
                                          has preceded it.—N. W. Medical and Surg. Journal.

                  by the same author.  (New Edition, just issued.)

ON  POISONS, IN RELATION TO  MEDICAL JURISPRUDENCE AND
  MEDICINE.  Second American, from a second and revised London  edition.  In one  larsre
  octavo volume, of 755 pages, leather.  $3 50.
  Since the first appearance of this work,  the rapid advance of Chemistry has introduced into
use many  new substances which may  become fatal through accident or design —while  at the
same time it has likewise designated new and more exact modes of counteracting or detecting those
previously treated of.   Mr. Taylor's position as the leading medical jurist  of England, has during
this period conferred on him extraordinary advantages in acquiring experience  on these subjects,
nearly all cases of moment being referred to him for examination, as an expert whose testimony
is generally accepted  as final.  The results of his labors, therefore, as gathered together in this
volume, carefully weighed and sifted, and presented in the clear and intelligible style for which
he is noted, may be received as an acknowledged authority, and as a guide to be followed with
implicit confidence. 
AND  SCIENTIFIC  PUBLICATIONS.
29
                 TODD (ROBERT BENTLEY), M. D.,  F. R. S.,
                    Professor of Physiology in King's College, London; and
                         WILLIAM  BOWMAN, F. R. S.,
                      Demonstrator of Anatomy in King's College, London.

THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN.  With
  about three hundred large and beautiful  illustrations on wood.  Complete in one large octavo
  volume, of 950 pages, leather.  Price $4 50.
  E5F* Gentlemen who have received portions of this work, as published in the " Medical News
and Library," can now complete their copies, if immediate application be made.  It will be fur-
nished as follows, free by mail, in paper covers, with cloth backs.
  Parts I., II., III. (pp. 25 to 552), $2 50.
  Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00.
  Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25.
  A magnificent contribution to British medicine,
and the American physician who shall fail to peruse
it, will have failed to Tead one of the most instruc-
tive books of the nineteenth century.—N. O. Med.
and Surg. Journal, Sept. 1857.
  11 is more concise than Carpenter's Principles, and
more  modern than the accessible edition of Mailer's
Elements; its details are brief, but sufficient; its
descriptions vivid; its illustrations exact and copi-
ous ; and its  language terse and  perspicuous.—
Charleston Med. Journal, July, 1857.
  We know of no work on the subject of physiology
so well adapted to the wants of the medical student.
Its completion has been thus  long delayed, that the
authors might secure accuracy by personal observa-
tion.—St. Louis Med. and Surg. Journal, Sept. '57.
  Our notice, though it conveys but a very feeble
and imperfect idea of the magnitude and importance
of the work now under consideration, already tran-
scends our limits ; and, with the indulgence of our
readers, and the hope that they will peruse the book
for themselves, as we feel we can with confidence
recommend it, we leave it in their hands. — The
Northwestern Med. and Surg. Journal.
                         TOYNBEE (JOSEPH), F. R. S.,
               Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital.
A PRACTICAL TREATISE ON  DISEASES  OF  THE  EAR;  their Diag-
  nosis, Pathology, and Treatment.  Illustrated with one hundred engravings on wood.  In one
  very handsome octavo volume, extra cloth, $3 00.  (Now Ready.)
  Mr. Toynbee's name is too widely known as the highest authority on all matters connected with
Aural Surgery and Medicine, to require special attention to be called to  anything which he may
comniuiiicate to the profession on the subject.   Twenty years' labor devoted to the present work
has embodied in it ihe results of an amount of experience and observation which perhaps no other
living practitioner has enjoyed.  It therefore cannot fail to prove a complete and trustworthy guide
on all matters connected with this obscure and little known class of diseases, which so frequently
embarrass the general practitioner.
  The volume will be found thoroughly illustrated with a large number of original wood-engrav-
ings, elucidating the pathology of the organs of hearing, instruments, operations, &c, and in every
respect it is one of the handsomest specimens of mechanical execution issued from the American
press.
  The following condensed synopsis of  the contents will show the plan adopted by the author, and
the completeness with which all departments of the subject are brought under consideration.
CHAPTER I.  Introduction—Mode cf Investigation—Dissection.  It. The External Ear—Ana-
  tomy—Pathology—Malformations — Diseases.   III.  The External Meatus — Its Exploration.
  IV. The External Meatus—Foreign Bodies and Accumulations of Cerumen.  V. The External
  Meatus—The Dermis and its Diseases.  VI. The External Meatus—Polypi.  VII. The External
  Meatus—Tumors.   VIII. The Membrana Tympani—Structure and Functions.  IX. The Mem-
  brana Tympani—Diseases.  X.  The Membrana  Tympani—Diseases.  XI. The Eustachian
  Tube—Obstructions.  XII.  The Cavity of the Tympanum—Anatomy—Pathology—Diseases.
  XIII. The Cavity of the  Tympanum—Diseases.  XIV.  The  Mastoid Cells—Diseases.  XV.
  The Diseases of the  Nervous Apparatus of the Ear, producing what is commonly called " Nerv-
  ous Deafness."  XVI. The Diseases of the Nervous Apparatus, continued.  XVII. Malignant
  Disease of the Ear.   XVIII. On the Deaf and Dumb.  XIX. Ear-Trumpets and their uses.
  Appendix.

                    WILLIAMS  (C. J.  B.),  M.D.,  F. R. S.,
                 Professor of Clinical Medicine in University College, London, &c.

PRINCIPLES  OF  MEDICINE.   An  Elementaiy  View  of the  Causes, Nature,
  Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre-
  servation ofhealth.  A new American, from thethird and revised London edition, inoneoctavo
  volume, leather, of about 500 pages.  $2 50.  (Just Issued.)
  We find that the deeply-interesting matter and
style of this book have so far fascinated us, that we
have unconsciously hung upon its pages, not too
long, indeed, for our own profit, but longer than re-
viewers can be permitted to indulge.  We leave the
further analysis to the student and practitioner.  Our
judgment of the work has already been sufficiently
  pressed.  It is a judgment of almost unqualified
praise.—London Lancet.
  A text-book to which no other in our language is
comparable.—Charleston Medical Journal.

  No work has ever achieved or maintained a more
deserved reputation.— Va. Med. and Surg. Journal.
                               WHAT TO  OBSERVE
AT  THE  BEDSIDE  AND  AFTER  DEATH,  IN  MEDICAL  CASES.
  Published under the authority of the London Society for Medical Observation.  A new American,
  from the second and revised Londou edition.  In one very handsome volume, royal 12mo., extra
  cloth.  §1 00.
  To the observer who prefers accuracy to blunders I   One of the finest aids to a young practitioner we
and precision to carelessness, this little book is :n-  have ever seen.—Peninsular Journal of Medici**.
valuable.__iV. H. Journal of Medicin*.            I 
50
BLANCHARD &  LEA'S  MEDICAL
                  New and much enlarged edition—(Just Issued.)
                       WATSON  (THOMAS),  M.D., tc,
                        Late Physician  to the Middlesex Hospital, Ice.

LECTURES   ON   THE   PRINCIPLES   AND  PRACTICE  OF  PHYSIC.
  Delivered at King's  College, London.  A new American, from the  last revised and enlarged
  English edition, with Additions, by D. Francis Condie, M. D., authoAof " A Practical Treatise
  on the Diseases of Children," &c.  With one hundred and eighty.five illustrations on wood.  In
  one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in
  small type;  the whole strongly bound in leather, with raised bands.  Price $4 25.
  That the high reputation of this work might be fully maintained, the author has subjected it fo a
thorough revision; every  portion has been  examined with the  aid of the  most recent researches
in pathology,  and the  results of  modern investigations in both theoretical and practical subjects
have been carefully weighed  and  embodied throughout its pages.  The watchful scrutiny of the
editor has likewise introduced whatever possesses immediate importance to  the American physician
in relation to diseases  incident to our climate which are little known in England, as well as those
points in which experience here has led to different modes of practice ; and he has also added  largely
to the series of illustrations, believing that in this manner valuable assistance may be conveyed to
the student in  elucidating the text.  The work  will, therefore, be found thoroughly on a level with
the most advanced state of medical science on both sides of the Atlantic.
  The additions which the work has  received are shown by the fact that notwithstanding  an en-
largement in the size of the page, more than two hundred additional pages have been necessary
to accommodate the two large volumes of the London edition (which sells at ten dollars), within
the compass  of a single volume, and in  its present form  it contains the matter of at  least three
ordinary octavos.  Believing it to be a work which should lie on the table  of every physician, and
be in the hands of every student, the publishers have put it at a price within  the reach of all, making
it one of the cheapest books as yet presented to the American profession, while at the same lime
the beauty of  its mechanical execution renders it an exceedingly attractive  volume.
  The fourth edition now appears, so carefully re-
vised, as to add considerably to the value of a book
already acknowledged, wherever the English  lan-
guage is read, to be beyond all  comparison the  best
systematic work on the Principles and Practice of
Physic in  the whole range of medical literature.
Every lecture contains proof of the extreme anxiety
of the author to keep pace with ihe advancing know-
ledge of the day»  and" to bring  the results of  the
labors, not only of physicians, but of chemists and
histologists, before his readers, wherever they can
be turned to useful account. And this is done with
Buch a cordial appreciation of the merit due to  the
industrious observer, such a generous desire to  en-
courage younger and rising men, and such a candid
acknowledgment of his  own obligations  to them,
that one scarcely knows whether to admire most the
pure, simple, forcible English—the vast amount of
useful practical  information  condensed  into  the
Lectures—or the manly, kind-hearted, unassuming
character of the lecturer shining through his work.
—London Med. Times and Gazette, Oct. 31, 1857.
  Thus these admirable volumes come before  the
profession in their fourth edition, abounding in those
distinguished attributes  of moderation, judgment,
erudite cultivation, clearness, and eloquence, with
which they were from the first invested,  but  yet
richer than before in the results of more prolonged
observation,  and  in the able  appreciation of  the
latest advances in pathology and medicine by one
of the most profound medical thinkers of the day.—
London Lancet, Nov. 14, 1657.
  The lecturer's skill, his wisdom, his learning, are
equalled by the ease of his graceful diction, his elo-
quence, and the far higher qualities of candor, of
courtesy; of modesty, and of generous appreciation
of merit in others. May he long remain to instruct
us, and to enjoy, in the glorious sunset of his de-
clining years, the honors, the confidence and love
gained  during  his useful life.—N. A. Med -Chir.
Review, July, 1858.

  Watson's  unrivalled, perhaps  unapproachable
work on Practice—the copious additions  made to
which (the fourth edition) have given it all the no-
velty and much of the  interest of a  new book.—
Charleston Med. Journal, July, 1858.

  Lecturers, practitioners, and students of medicine
will equally hail the reappearance of the work of
Dr. Watson in the form of a  new—a fourth—edition.
We merely do justice to our own feelings, and, we
are sure, of the whole profession, if we thank  him
for having, in the trouble and turmoil  of a large
practice, made leisure to supply the hiatus caused
by the exhaustion of the publisher's stock of the
third edition, which  has been severely  felt for the
last three years.  For Dr. Watson  has  not merely
caused the lectures to be reprinted, but scattered
through the whole work we find additions or altera-
tions which prove that the author has in every way
sought to bring up his teaching to the level of the
most recent acquisitions in science.—Brit, and For.
Medico-Chir. Review, Jan.  1858.
                             WALSHE (W. H.),  M. D.,
       Professor of the Principles and Practice of Medicine in University College, London, &c.

A  PRACTICAL  TREATISE ON  DISEASES  OF  THE  LUNGS; including
  the Principles of Physical Diagnosis.  A new American, from the third revised and much en-
  larged London edition.  In one vol. octavo, of 468 pages.  (Just Issued, June, 1860.)  $2 25.
  The present edition has been carefully revised and much enlarged, and may be said  in the main
to be rewritten.  Descriptions of several  diseases, previously omitted, are  now  introduced; the
causes and mode of production of the more important affections, so far as they possess direct prac-
tical significance, are succinctly inquired into;  an effort has been made to bring the  description  of
anatomical characters to the level of the wants of the practical physician ; and the diagnosis and
prognosis of each complaint are more completely considered.  The seciions on  Treataiknt and
the Appendix (concerning the influence of climate on pulmonary disorders), have, especially been
largely extended.—Authors Preface.                                                    '
  **# To be followed by a similar volume on  Diseases of the Heart and Aorta.

                          WILSON  (ERASMUS), F. R. S.,
                                Lecturer on Anatomy, London.

THE  DISSECTOR'S MANUAL;  or,  Practical and  Surgical  Anatomy    Third
  American, from the  last revised and enlarged English edition.  Modified  and rearranged,  bv
  William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania   In one
  large and handsome royal 12mo. volume, leather, of 5S2 paa-es, with 154 illustrations   $2 00 
AND SCIENTIFIC PUBLICATIONS
31
                  New and much enlarged edition—(Just Issued.)
                         WILSON  (ERASMUS),  F. R. S.
A SYSTEM  OF  HUMAN  ANATOMY, General  and Special.   A new and  re-
  vised American, from the last and enlarged English Edition.  Edited by W. H.Gobrecht, M. D.,
  Professor of Anatomy in the Pennsylvania Medical College, &c.  Illustrated with three hundred
  and ninety-seven engravings on wood.  In one large and exquisitely printed octavo volume, of
  over 600 large pages; leather.   $3 25.
  The publishers trust that the well earned reputation so long enjoyed by this work will be more
than maintained by the present edition.  Besides a very thorough revision by the author, it has been
most carefully examined by the editor, and the efforts of both  have  been directed to  introducing
everything which increased experience in its use has suggested as desirable to render it a complete
text-book for those seeking to obtain  or to renew an acquaintance with  Human Anatomy.  The
amount of additions which it has thus received may be estimated from the fact that  the present
edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged
page requisite  to keep the volume within a convenient size. The author has not only thus added
largely to the work, but he has also made alterations throughout, wherever there appeared the
opportunity of improving the arrangement or style, so as to present every fact in its most appro-
priate manner,  and to render  the whole as  clear and  intelligible as possible.  The editor  has
exercised the utmost caution to  obtain entire accuracy in  the text, and has largely increased the
number of illustrations, of which there are about one hundred and fifty more in this edition than
in the last, thus bringing distinctly before the eye of the student everything of interest or importance.
   It may be recommended to the student as no less beautyof its mechanicalexecution, and the clear-
distinguished by its accuracy and clearness of de-
scription than by its typographical elegance.  The
wood-cuts are exquisite.—Brit, and For. Medical
Review.
  An elegant edition of one of the most useful and
accurate systems of anatomical science which has
been issued from the press  The illustrations are
really beautiful.  In its style the work is extremely
concise and intelligible. No one can possibly take
up this volume without being struck with the great
ness of the descriptions which it contains is equally
evident.  Let students, by all means examine tne
claims of this work on their notice, before they pur-
chase a text-book of the vitally important science
which this volume  so fully and easily unfolds.—
Lancet.
  We regard it as the best system now extant for
students.—Western Lancet.
  It therefore receives our highest commendation.—
Southern Med. and Surg. Journal.
                        by  the same author.  (Just Issued.)
ON DISEASES  OF THE SKIN.   Fourth and enlarged American, from the last
  and improved London edition.  In one large octavo volume, of 650 pages, extra cloth, $2 75
  The writings of Wilson, upondiseases of the skin,
are by  far the most scientific and practical  that
have ever  been presented to the medical world on
this subject.  The presentedition isa great improve-
ment on all its predecessors.  To dwell upon all the
great merits and high claims of the work before us,
seriatim, would indeed be an agreeable service;  it
would  be a mental  homage which we could freely
offer, but we should thus occupy an undue amount
of space in this Journal.  We will, however, look
at some of the more salient points with which it
abounds, and which make it incoinpuraoiy superior in
excellence to all other treatises on the subject of der-
matology.  No mere speculative views are allowed
aplacein this volume, which, without a doubt, will,
for a very long period, be acknowledged as the chief
standard work on dermatology.  The principles of
an enlightened and rational therapeia are introduced
on every appropriate occasion.—Am. Jour.  Med.
Science, Oct. 1857.
                                      ALSO, NOW READY,

  A  SERIES  OF PLATES  ILLUSTRATING WILSON  ON DISEASES  OF
    THE CK1N • consisting of nineteen beautifully executed plates, of which twelve are exquisitely
    colored' presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re-
    presentations of about one hundred varieties of disease, most of them the size of nature.   Price
    in cloth $4 25.
    In beauty of drawing and accuracy and finish  of coloring these plates will be found equal to
    lything of the kind as yet issued in this country
 a^T.ue plates by which  this edition is accompanied
■reave nothing to be desired, so far as excellence of
  delineation ami perfect accuracy of illustration are
  concerned.—Medico-Chirurgical Review.
    Of theso plates it is impossible to speak too highly
  The representations of  the various forms of cutane-
  ous disease are singularly accurate, and the  color-
  ing exceeds almost anything we have  met with in
  point of delioacy and finish—British and Foreign
  idedical Review.
                                     BY THE SAME AUTHOR.

  ON   CONSTITUTIONAL  AND   HEREDITARY   SYPHILIS,  AND  ON
    «vt>i-ti i ITTO  PR ITPTIONS   In one small octavo volume, extra cloth, beautifully printed, with
    Sexqui^colored plates, presenting  more than thirty varieties of syphilitic eruptions.  $2  25.

                                     BY THE SAME AUTHOR.

   HEALTHY  SKIN- A Popular  Treatise on the  Skin and  Hair, their Preserva-
    tion and Management.  Second American, from the fourth London edition  One neat volume,
    r0yaU2mo.5 eltra cloth, of about 300  pages, with numerous illustrations.  $1 00 ; paper cover,

    75 cents.
  We have already expressed our high appreciation
of Mr. Wilson's treatise on Diseases of the Skin.
The  plates  are comprised in a separate volume,
which we counsel all those who possess the text to
purchase.  It is a beautiful specimen of color print-
ing, and the representations of the various forms of
skin disease are as faithful as is possible in plates
of the size.—Boston Med. and Surg. Journal, April
8, 1858.
WHITEH K \D ON THE CAUSES AND TREAT-
  MENT OF ABORTION  AND  STERILITY.
Second American Edition.  In one volume, octa-
vo extra cloth, pp. 308.  «1  75. 
32         BLANCHARD &  LEAS  MEDICAL PUBLICATIONS.
                 WINSLOW  (FORBES),  M.D.,  D. C.  L., &.c.
ON OBSCURE  DISEASES OF THE BRAIN AND DISORDERS OF THE
  MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis.   In  one
  handsome octavo volume, of nearly 600 pages.  (Just Issued, June, IsOO.)  §'i 00.
  The momentous questions discussed in this volume have  perhaps not hitherto been so ably and
elaborately treated.  Dr. Winslow's distinguished reputation and long experience in everything re-
lating to insanity invest his teachings with  the highest  authority, and in this carefully considered
volume he has drawn upon  the accumulated  resources of a life of observation.  His deductions
are founded on a vast number of cases, the peculiarities of which  are related in detail, rendering
the work not only one of sound instruction, but of lively interest; the  author's main object being
to point out the connection between organic disease and insanity, tracing the latter through all its
stage.- from mere eccentricity to mania, and urging the necessity of early measures of prophylaxis
and appropriate treatment.   A subject of greater importance to society  at large could s-careely be
named; while to the physician who may at any moment be called upon for interference in the most
delicate relations of life, or for an opinion in a  court of justice, a work like the present may be con-
sidered indispensable.
  The treatment of the subject may be gathered from  the following summary of the  contents :—
Chapter I. Introduction.—II.  Morbid Phenomena of Intelligence.  III. Premonitory Symptoms
  of Insanity.—IV. Confessions of Patients after Recovery.—V.  State of the Mind during  Re-
  covery.—VI. Anomalous and Masked Affections of the Mind.—VII. The Stage of Consciousness.
  —VIII.  Stage of Exaltation.—IX. Stage of Mental Depression.—X.  Stage of Aberration.—XI.
  Impairment of Mind.—XU-  Morbid Phenomena of  Attention.—XIII. Morbid Phenomena of
  Memory.—XIV. Acute Disorders  of  Memory.—XV. Chronic  Affections of Memory.—XVI.
  Perversion and Exaltation of Memory.—XVII. Psychology and Pathology of Memory.—XVIII.
  Morbid Phenomena of Motion.—XIX. Morbid Phenomena of Speech.—XX. Morbid Phenomena
  of Sensation.—XXI. Morbid Phenomena of Ihe  Special Senses.—XXII. Morbid Phenomena of
  Vi-ion, Hearing, Taste, Touch, and Smell.—XXIII.  Morbid Phenomena of Sleep and Dreaming.
  —XXIV. Morbid Phenomena of Organic and Nutritive Life.—XXV. General Principles of  Pa-
  thology, Diagnosis, Treatment, and Prophylaxis.
                           WEST  (CHARLES),  M.  D.,
Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hostital for
                                    Sick Children, &.C.
LECTURES ON THE DISEASES OF WOMEN.   Now complete in one hand-
  some octavo volume, extra cloth, of about 500 pages; price $2 50.
Also, for sale separate, Part II, being pp. 309 to end, with  Index, Title matter,
  &c, 8vo., cloth, price $1.
and children is not to be found in any coi ntry__
Southern Med. and Surg. Journal, January 1858.
  We gladly recommend his Lectures as in t ie high-
est degree instructive to all who are interested'in
obstetric practice.—London Lancet.
  We have to say of it, brieilviand decidedly, ttiht
it is the best work on the suuje
and that it stamps Dr. West as
:t in any langu ,
the facile princ
of British obstetric authors.—idinb. Med. Journ)
  We mustnow conclude this hastily written sketch
 with the confident assurance to our readers that the
 work will well repay perusal.  The conscientious,
 painstaking, practical physician isapparent on every
 page.—N. Y. Journal of Medicine, March, 1858.
  We know of no treatise of the kind so  complete
 and yet so compact.—Chicago Med. Journal, Janu-
 ary, 1858.
  A fairer, more honest, more earnest, and more re-
 liable investigator of the many diseases of women
                          BY THE same  author.  (Now Ready.)
 LECTURES  ON  THE  DISEASES  OF INFAflCJK  AND  C.HILDHOOD.
  Third American, from the fourth enlarged and improved London edition. Tin one handsonle
  octavo volume, extra cloth, of about six hundred and fifty pages.  $2 75.
  The continued favor with which this work has been received has stimulated he author to r«\
 der it in every respect more complete  and more worthy the  confidence of the profession;  Gial
 taining nearly two hundred pages more than the last American edition, with several addition!
 Lectures and a careful revision and enlargement of those formerly comprised  iii it, it canh*irdK
 fail to  maintain its reputation as a clepr and judicious text-book for the student, and a sf'ie an J
reliable guide for the practitioner.  The fact stated by the author that these Lectures " now embod r
the results  of 900  observations and 288  post-mortem examinations made among  nearly 30,0C )
 children, who, during the past twenty-years, have come under my care," is sufficient to >-how the: r
high practical value as the result of an amount of experience which few physicians er»J<-yi
  The three former editions of the work now before diseases it omit^to notice altogether-  Bit thos
us have placed the author in tne foremost rank of
those physicians who have devoted special attention
to the diseases of early life  We attempt no ana-
lysis of this edition, but may refer the reader to some
of the chapters to which the largest additions have
been made—those on Diphtheria, Disorders of the
Mind, and Idiocy, for instance—as a proot that the
work is really a new edition; not a  mere roprint.
hi its preient shape it will be found of the greatest
possible service in the every-day practice of nine-
tenths of the profession.—Med. Times and Gazette,
London, Dec. 10, 1859.
  All things considired, this book of Dr. West  is
by far the best treatise in our language upon such
modifications of morbid  action and disease as are
witnessed when we have to deal with infancy and
childhood. It is true that it confines itself to such
 who know anything  of.tfie present condition o '
 paediatrics will readily admit th^t it would be nex
 to impossible to effect niore, or effee it bittfer, thai
 the accoucheur of St. Bartholomew's haf done in si
 single volume.  The lecture (XVI.) upon Disorder!
 of the Mind in chilorei} is an admirable specimen of
 the value of the later Information convi>ed in the]
 Lectures of  Dr. Cha/les West.—London Lancet}
 Oct. 22, 1859.        |               «         1
  Since the appearanfce of th*  first edition, about!
 eleven years ago, the/experience of the!author has|
 doubled ; so that, whereas the lectures at first were
 founded on six hundred observations, and one nun-'
 dred and eighty dissections made among nearly four^#
 teen thousand children, they now embody the results
 of nine hundred observations, and'two hundred and
eighty-eightpost-mortem examinations made among
nearly  thirty thousand children,  vvlio, daring the '
disorders as come within the province of the phy-
sician, and even with respect to these it is unequal past twenty years, have been udder his oure.
as regards minuteness of consideration, and some | British Med. Journal, Oct. 1, 18591
BY THE SAME AUTHOR.
iKm^
AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER-
  ATION OF THE OS UTERI.  In one neat octavo volume, extra cloth.   $1 60. 
I
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