? NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland (Sjfoet^^ jv/f I A A *x V o \*W\ ^ \ THE PRINCIPLES AND PRACTICE OP OBSTETRICS. BY GUNNING S. BEDFORD, A.M., M.D., PEOFESSOE OF OBSTETEICS, THE DISEASES OF WOMEN AND CHILDEEN, AND CLINICAL OBSTETRICS, IB TUB UNIVEES1TY Oh KK\f TORK ; ATTTnOE OF " CLINICAL LECTUEES ON T1IE DISEASES OF WOMEN AND CHILDEEN." EllustraUU fij JT°U* &°IorrtJ litfjoflrapfiic piatca ani Ninrta-nine ©Sooto Ensvabings. Multum restat adhuc operis, multumque restabit, nee ulli nato, post mille saecula, praacludetur occasio aliquid adjiciendi. Seneca, Lib. I., Epist. lxiv. THIRD EDITION, CAREFULLY REVISED AND ENLARGED. NEW YORK: WILLIAM WOOD & CO., 61 WALKER STREET. 1 863. ^ aW ft/mno.//33c/,. rim I Entered according to Act of Congress, In the year eighteen hundred and sixty-one, t»y GUNNING S. BEDFORD, la the Clerk's office of the District Court of the United States for the Southern District ot New York. R. OBAI6READ, Printer, St«reotyper, and Electrotype*, Carton SuifDing, 81, 83, and 85 Centre UtruU. To THE ALUMNI AND STUDENTS, WHO HAYE ATTENDED THE AUTHOR'S LECTURES ON OBSTETRICS IN THE UNIYERSITT OF NEW YORK, AND TO WHOSE UNIFORM COURTESY AND KINDNESS HE IS SO GREATLY INDEBTED, £ljift #flhinu is ^ftcciiorratelg £ltbiea&b. PREFACE. Lsr writing a work on the " Principles and Practice of Obstetrics " I have had constantly before me one cardinal object—to be useful. I have endeavored to present to the Profession a practi- cal Book, one which will develop the phenomena of parturition in their various phases as they occur in the Lying-in room. The anatomy of the Pelvis and Genitalia, and their special bear- ings on Parturition, have been dwelt upon with a minuteness to which they have a just claim. Abortion, the subject of Labor, its Divisions, its Mechanism and Management, its deter- mining cause, together with the forces engaged in the expulsion of the child, the treatment of the puerperal woman and her new-born infant, Flooding both ante-partum and post-partum, Placenta Prsevia, Puerperal Fever, Puerperal Mania, Anaesthe- tics, have all been considered with the fulness their importance demanded. Nor have I neglected the physiological disquisitions necessarily involved in the consideration of the numerous ques- tions connected with Menstruation, Eeproduction, Pregnancy, Foetal Nutrition, Puerperal Convulsions, and other kindred topics. Manual, Instrumental, and Premature Artificial Delivery have received their share of attention ; they have been discussed freely and at length. On the subject of Instruments, I have spoken without reserve, and have not failed to raise my voice, in the most emphatic manner, in rebuke of what I believe to be oftentimes their unnecessary and reckless employment. If what I have said on this point shall exercise an influence in PREFACE. V behalf of suffering woman, in the hour of her need, I shall indeed be happy. Touching the grave questions of Embryo- tomy and the Caesarean section I have suffered my mind to be governed by no predilection, but have examined, with the singh purpose of reaching the truth, the substantial evidence both for and against these alternatives; my deductions are the results of what I believe to be a thorough and impartial analysis of this evidence. The arrangement of the work is rigidly systematic, the vari- ous subjects following each other in what I conceive to be the proper order of their dependence. In one word, I have had in view the wants of the obstetric student; I have endeavored to aggregate facts, and dispense as far as possible with theoretical discussions. Throughout the work I have maintained strictly a Conservative Midwifery, as I have always done—and shall con- tinue to do—in my oral teachings in the University. It has also been my endeavor to inculcate upon the accoucheur a due reverence for the resources of nature, so that he may not thoughtlessly lapse into that too common error—" Meddlesome Midwifery." Among other things, it has been my special aim to bring the work fully up to the existing state of Obstetric Science in all its varied relations. For this purpose I have dili- gently consulted the ablest and most recent authors; at the same time, I have not been unmindful of the obligations of our science to the early Fathers. May I presume to hope that the Book, both in its matter and arrangement, will not be unaccep- table to the general practitioner, or to the Professor of Obstetrics himself? In reference to the Illustrations, I have consulted quality rather than quantity, and have in every case endeavored to make them explanatory of some important practical lesson. With this view, I have not hesitated, where it could be done with advantage, to avail myself of the graphic delineations by Maygrier, Morcau, Montgomery, and others. The engravings, representing Forceps delivery, are the Daguerreotypes of my instructions on this subject in the University, and I trust they may convey accurate rules for guidance on this important and interesting part of the Accoucheur's duties. Vi PREFACE. In order to facilitate the object of the reader, and place promptly within his reach the numerous subjects discussed in the volume, a Table of Contents, and, in addition, a full and carefully prepared Alphabetical Index have been provided. I have also added a list of authors to whom reference has been made, and this will give some indication of the labor expended on the work. The Book itself embodies ample internal evidence of failure or success in the accomplishment of the objects proposed. If that evidence, under a fair examination, shall lead to the decision that the design has not been carried out, it will be to me a source of the deepest regret. If, on the contrary, it shall be my good fortune to have my efforts approved by the Profession, then I shall be abundantly repaid for my labor, and may, with- out arrogance, exclaim—" Nee Ego frustra." In conclusion, I cannot but cherish the hope that if this Volume should fall into the hands of some of my numerous pupils, residing in various portions of this and other countries, it may serve to awaken old associations, and bring back to memory the many happy hours we have spent together in the lecture-hall; and may these words be accepted as proof that their 'preceptor continues to entertain for them feelings of deep interest and affection. New Tohk, C6 Fifth Avenue, Oct. 25,1861. PREFACE TO THE SECOND EDITION. An Author can covet no richer compensation for his labors than the endorsement of his Peers. It would, therefore, be affectation in me to attempt to conceal the pleasure I experience in being thus early called upon for a Preface to the Second Edition of the "Principles and Practice of Obstetrics." But a little over four months has elapsed since the book was first issued from the Press. In view of the unhappy and disturbed condition of the country, and the consequent derangement of commercial as well as of scientific pursuits, I have, indeed, good cause for self-congratulation ; and I avail myself of this occasion to return my cordial thanks to the Profession for the counte- nance, which they have so promptly extended to my efforts. The eulogistic notices of the Medical Press—both home and foreign—have imposed upon me an obligation not soon to be forgotten—an obligation I can cancel in no other way than by the pledge, that it shall be my earnest care to endeavor to render myself still more worthy of its good opinion. The present edition has undergone a thorough revision; numerous verbal and typographical errors, more or less incident to a first issue, have been corrected. I again submit the work to the Profession, not without hope that it may continue to have awarded to it the seal of their approbation. March, 1862. PREFACE TO THE THIRD EDITION. Again has the grateful duty devolved on me of returning thanks to the Profession for the continued—and I hope I may say without egotism—unexampled patronage extended to the " Principles and Practice of Obstetrics." It is now but thirteen months since the book was first presented to the world, and my Publishers admonish me that a Third Edition is called for. To say that its reception is beyond my most sanguine hopes, and that I am deeply impressed with a sense of the obligation im- posed by this prompt recognition of my labors, would be but the reiteration of a self-evident truth; and I may add, that both the pleasure and obligation are greatly enhanced by the fact that, in the short period which has elapsed since the work was issued from the Press, it has already been recommended as a Text-Book in nine of our medical colleges. What greater honor can an Author claim at the hands of his Peers—what higher incentive to future effort! These influences, if my life be spared, shall not be lost upon me. Again, also, I have most cordially to thank the Medical Press, here and abroad, for their continued commendatory and flattering notices. This Edition has been carefully revised and enlarged; besides additions to the Text throughout the volume, it will be seen that a lecture on Phlegmasia Dolens has been incorporated. New York, 66 Fifth Avenue, Dec. 1862. CONTENTS. LECTURE I. POSITION AND BONES OF THE PELVIS. Midwifery an Exact Science—The Passage of the Child through the Maternal Organs is founded on the Principle of Adjustment—The Pelvis; the Position it occupies in the Human Skeleton—Importance of its Position in Childbirth—The Direction of the Pelvis; its Variations—Bones of the Pelvis in the Adult and Foetus—Sacrum, Coccyx, and the Two Innominata—Anterior Sacral Plexus of Nerves; its Influence in the Production of Numerous Pathological Phenomena— The Os Coccyx; its Importance in Childbirth—Dislocation of the Coccyx— Fracture of the Coccyx—The Spinous Process of the Ischium—How, when mal- formed, it may interfere with the Process of Delivery.........1 LECTURE II. USES, ARTICULATIONS, AXES, AXI) DIVISIONS OF THE PELVIS. Uses of the Pelvis—Articulations, or Joints of the Pelvis—Do these Articulations during Pregnancy become Relaxed ?—Is their separation necessary, at the time of Labor, for the passage of the Child ?—Objections to the Theory of Separation —Pathological Changes in these Articulations—Form of the Pelvis—The Greater and Lesser Pelvis—Straits of the Pelvis—The Pelvis is a Crooked Canal; Proof —Axes—Varieties of the Human Pelvis—Influence of Sex and Age—Contrast between the Male and Female Pelvis—Pelvis of the newborn Infant—The Pelvis in Connexion with the Soft Parts—Its Measurements. . .-......12 LECTURE III. DIVISIONS AND PRESENTATIONS OF Ftyment of health, to a ripe old age. The spring-time of life is over, and she now lapses into the cold shades of Avinter. One of her great offices has been completed ; she has fulfilled her destiny in the birth and tender care of her children, and she noAV lives still to guide them by her counsels, and rejoice in their position as useful members of society. Such, then, are the three great eras of woman's exist- ence, each marked by its own striking peculiarities, and each, too, surrounded by more or less peril—the eras to which I allude are those of puberty, child-bearing, and the final cessation of the men- strual function. Aptitude for Impregnation.—There is, in the human female, as in the various species of animal creation, a period in Avhich the aptitude to become impregnated, is much greater than at others; and it will be well for you to recollect the fact, for it may occasion- ally enable you, by judicious advice, to consummate the happiness of the married by blessing them with offspring, after years of patient but unrequited effort on their part. You know that, at the men- strual crisis, there is on the surface of the ovary a matured ovule; this, as I have told you, either becomes deciduous matter, and passes away Avith the menstrual blood, or, if it should have life imparted to it by the seminal fluid of the male, it lives, becomes developed, and constitutes the future being. Indeed, the ovule, at this special period of its maturity, is not unlike the luscious peach, as it hangs in full ripeness and flavor from the parent tree—if there be no hand to pluck it in its tempting richness, it falls to the ground and decays. Woman, then, is most apt to become fecundated at this particular time, Avhen the ovule, in all its development, lies on the surface of the ovary; therefore, the simple suggestion, on your part, to the husband to have intercourse with his wife just before the catamenial crisis, will very likely result in impregnation. I am quite confident that I can refer to more than one instance in which I have suc- ceeded, in this way, in adding to the happiness of parties, who for years had been honestly but vainly toiling for the accomplishment of their hopes. It is a matter of historical record, that Henry II. of France, after protracted disappointment, and almost desperate under baffled hope, consulted the celebrated Fern el as to the modus in quo of impregnating his Queen, Catharine de' Medici; the king was advised to cohabit with her royal highness only at the menstrual 108 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. evolution; this counsel was scrupulously observed, and the result Avas the birth of an heir to the croAvn. In India, young girls are made to marry immediately on their first menstruation, for the reason, that the doctrine is maintained there that, at each catamenial crisis, there is an ovule ready for impregnation, and if it be not fecundated, it becomes destroyed, and, therefore, it is held that the party is guilty of child murder.* It appears that this has been the law for a very long period in India, and, as it is evidently based, in a measure, on the ovular theory of menstruation, it is quite manifest that this theory is not altogether of recent origin. You perceive, gentlemen, that, in discussing the general subject of menstruation, I have said nothing of the numerous pathological conditions to which the function is exposed; these I have treated of fully in my work on the Diseases of Women and Children. * " It was upon an ancient theory respecting generation, very much resembling our own, that early marriages seem to have beeu instituted in India. It was said, that if an unmarried girl has the menstrual secretion in her father's house, he incurs a guilt equal to the destruction of the fcetus; that is, according to the doctrine of Pythagoras, and the theory of the ovarists, all the material of the new ovum, and the ovum itself, is formed by the female; menstruation was, therefore, the loss of the ovum, or loss of the foetus." [Dr. "Webb, Prof, of Military Surgery, in the College of Medicine, Calcutta.] LECTURE VIII. Reproduction—Its Importance and Necessity—Early Opinions concerning—Meaning of the term Fecundation ; in what it consists—Reproduction the Joint Act of both Sexes—The Female furnishes the " Germ-cell"—The Ovisac or Graafian Vesicle— Membrana Granulosa—Discus Proligerus—Zona Pellucida—Germinal Vesicle— Germinal Spot—Modifications in the Ovisac previous to its Rupture—Corpus Luteum—" Coagulum" does not contribute to its Formation—Corpus Luteum not a Permanent Structure—True and False Corpora Lutea—Former connected with Pregnancy, Latter with Menstruation—Characteristics of each—True Corpus Luteum an Evidence of Gestation, but not of Childbirth—Can two " Germ-cells" be contained in one Ovisac?—The Male Vivifies the " Germ-cell"—Spermatozoon, the True Fertilizing Element—What are the Spermatozoa ?—Contact between " Sperm- cell" and "Germ-cell" necessary for Fecundation—How accomplished—Opinions concerning—Aura Seminalis—Electrical and Magnetic Influence—Doctrine of the Animalculists—Chemical Hypothesis—Mr. Newport's Experiments on the Frog— Deductions—Where does this Contact take Place ?—Experiments of Bischoff and Valentin—Theory of Pouchet—Movements of Spermatozoa—Deductions from Analogy—Experiments of Nuck and Haighton—Fimbriated Extremity of Fallo" pian Tubes—Peculiarities of. Gentlemen—The subject next in order for our consideration is one which cannot fail to interest you, for it involves the important question—the origin and reproduction of the human species. To treat, therefore, of our own individual origin, and the mode by Avhich the human family is propagated, is, it cannot be denied, to discuss a topic at once full of interest, and not altogether free from mystery. It would be somewhat out of place in lectures intended, as far as I can make them so, to be essentially practical, to speak of generation except so far as it relates to the production and develop- ment of the human fcetus. It may, however, be observed, that organized beings can be perpetuated only through reproduction. Let the earth be covered, the Avaters filled, and the universal globe crowded with living beings, and yet how soon would life become extinct, and the world a blank, were it not for the constant genera- tion of new beings to take the place of those who have run their race, and yielded to the inexorable demands of time. Look at the bills of mortality; see what myriads of the human family are savc] t from earth every year by disease, and the natural decay of the system—and the same argument applies to all animated creation— and then tell me Avhether this prodigious Avaste does not require a corresponding supply. It is Avith all living things, as it is with the 110 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. existence of governments and nations; both are to be perpetuated through the law of succession. Were it not for this great fact, how rapid and final would be the victory of death ! The subject of reproduction has occupied the attention of man from the very earliest periods of his history; and you Avill find that, in the remotest times of our science, hypothesis followed hypothesis in the earnest attempt to elucidate this profound and vexed problem. If we are sometimes amused at the novel and singular views advanced by the early fathers in their explanation of this funda- mental vital act, it must be remembered that their theories and reasoning Avere the theories and reasoning of those, Avho had nothing to guide them but their own observation; they were lost, as it were, in the darkness of the night; they were without the torch- lights, which the progress of science has furnished to the men of modern times, through the developments of physiology, pathology, and chemistry. "While, therefore, I honor the philosophers of the present and proximate ages, for their rich contributions of science, and bid them God-speed in their profound researches, yet I cannot but look back upon the early apostles of our profession with feel- ings of filial reverence. As pioneers, tbey have accomplished much ; as accurate observers, they have given us many substantial principles. Reproduction—Meaning of the Term.—Reproduction, in its strict physiological meaning, implies the development of a being, so that it may be capable of an external or independent existence ; hence, it consists of a series of processes, which, when completed, constitute the entire reproductive act. The first of these processes, in the human species, is the contact of the two sexes, knowm as copulation. The second process is fecundation, which consists in the exercise of a vitalizing influence, through the male, on the germ furnished by the female. This act of vitalization, or impart- ing life, gives rise to another process, conception. In strict physio- logical truth, it may be said the male fecundates, and the female conceives. Then follows gestation, during which the embryo grows and becomes developed; and when its development has been sufficiently accomplished, labor occurs, the object of which is to expel it from the uterus. As soon as this is effected, the entire relations of the new being are changed. It breathes, and, therefore, has a circulation of its own. It is no longer dependent upon its parent for the elaboration of its blood ; its lungs, which, before birth, were without function, commence at once their round of duty; the first gasp of the infant may be considered its declaration of independence. Its organic existence is now called into action; it receives food, which, through the operation of its digestion, is converted into chyle ; this latter passes through the thoracic duct into the venous THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Ill system, Avhence, by the ascending and descending venae cavae, it is conveyed to the right cavities of the heart, and thence to the lungs, where, through the elaborative action of these organs, it becomes decarbonized, or, if you choose, arterialized; it then is taken to the left cavities, and distributed, through the ramifications of the aorta, to all portions of the system, imparting nutrition and development to every tissue. It is a physiological truth, that reproduction is the joint act of the two sexes, and it noAV remains for me to show you Avhat science has disclosed as to the respective parts assumed, in this wonderful scheme, by the male and female. It would not be profitable to array before you the numerous and conflicting theories, which have been maintained with more or less zeal on this subject; I prefer rather to present to you what I believe, at the present day, to be the accepted and recognised facts touching this interesting topic. The Germ-cell.—The female, in the act of reproduction, furnishes the ovule, or " germ-cell," which, as you have already been informed, is a product of the ovary. This ovule has no inherent power of development beyond its mere growth as an ovule; and, as I have remarked to you, after it has reached its maturity, if it be not vitalized by the male, it perishes and passes off with the menstrual blood. The human ovum, like that in all vertebrated animals, is contained Avithin a sac, which, externally, is in apposition Avith the substance or stroma of the ovary ; this sac, through courtesy to its discoverer is known, in mammals, as the Graaffian vesicle or ovisac. Its internal surface is supplied with a number of nucleated epithe- lial cells, constituting the membrana granulosa; these cells likeAvise furnish a disk-like covering to the ovum—the discus pro- ligerous. The Graaffian vesicle contains a quantity of fluid, and, in its centre, is observed the ovule. This latter, in the human subject, is extremely small, measuring not more than T^oth of an inch in diameter, and sometimes much less; it has an external membrane, Avhich, from its transparent character, is called the zona pellucida, inclosing the yolk or vitellus, the object of which is to furnish nourishment to the germ during the earlier stages of its develop- ment. In the centre of the vitellus is the germinal vesicle, Avhich is regarded as the essential portion of the ovum; the nucleus of the germinal vesicle is denominated the germinal spot. Although the ovum is at first in the centre of the Graaffian vesicle, yet, in proportion as the contents of the vesicle approach maturity, the tendency of the ovum is to move toward the circumference of the ovisac, so that, just prior to its extrusion, it is quite near the surface of the ovary; the advance of the ovum toward the outer portion of the ovary is one of the ordinary processes preparatory to its fecundation, and is supposed by Valentin to be due to the fact that, as the ovule progresses in development, there is effused in the 112 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. lower portion of the ovisac a fluid, which presses the discus proligerus before it against the opposite Avail. The Graaffian Aresicle or ovisac, is said to be composed of tAvo envelopes or layers, and it is proper that you should have a clear appreciation of its structure. In reality, the ovisac presents but a single Aascular tunic formed of laminous cells, and of those so- called cells of the ovisac, irregular and grainy. This tunic is covered by a nucleated epithelium, and is immediately surrounded by the stroma of the ovary. You have been told that the ovule, when it has attained its maturity, escapes through rupture of the ovisac. But, previous to this rupture, it is interesting to note the changes Avhich occur in the ovisac itself; for example, there is a general increase in its vascularity and an appearance of fatty cells, with an increased development of those of the ovisac, exhibiting a yellowish color, intended for the production of the corpus luteum, which is regarded by some physiologists as a mere hypertrophy of the membrana granulosa, or internal coat of the ovisac. When the ovum escapes from the ovisac, the internal surface of the latter pre- sents at first a sort of irregular cavity, from the fact that its epithelial lining is throAvn into folds or wrinkles, the direct result of the contraction of the ovisac; this cavity, however, soon begins to lessen in consequence, in the first place, of the increased develop- ment of the granular cells; and, secondly, from the contraction of the ovisac itself. Ultimately, the cavity is almost entirely obli- terated, and is represented by what has been described as the stellate cicatrix. When the rupture of the ovisac is accomplished, there is an effusion of blood in the remaining cavity, forming, of course, a coagulum; this sometimes becomes deprived of its color- ing matter, and is absorbed, assuming the attributes of a fibrinous clot; at other times, the fibrine is absorbed at once, the red cor- puscles become grainy, and disappear slowly; the clot maintaining its reddish color which is due to the hematoidine. The Corpus Luteum of Pregnancy and of Menstruation.—The corpus luteum Avas at one time supposed, when recognised on the ovary, to be a positive indication of previous gestation, and the number of these bodies represented the precise number of children borne by the parent. This opinion, hoAvever, recent researches have shown to be fallacious. In the first place, the error was no doubt, in part, owing to the circumstance that the corpus luteum was regarded as a permanent structure; and, secondly, that its color Avas looked upon as its exclusive characteristic. It has been very satis- factorily demonstrated that neither of these assumptions is correct, for small yellow spots may exist on the ovary independently of im- pregnation ; while the corpus luteum itself, which is the direct result of gestation, disappears after a certain period, and, therefore, is not permanent. You must also bear in mind, that Avhenever there is a THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 113 rupture of the Graaffian vesicle, no matter from what cause, there will necessarily be, as the product of that rupture, a corpus luteum. You have been reminded that, as a general rule, there is an escape of the ovule at each menstrual crisis; hence, there are tAvo classes of corpora lutea, one the result of menstruation, the other of impregnation ; and, therefore, the division of these bodies into false and true—the former representing the corpus luteum of menstrua- tion, the latter that of gestation. This is an important distinction for the reason that, in more than one instance, the previous exist- ence of pregnancy has been attempted to be proved by the recogni- tion, in a post-mortem examination, of these bodies on the ovary, their mere presence constituting the only basis for such an opinion. It must, therefore, be manifest, how essential it is to have a just idea of the characteristics of the true corpus luteum, and understand in what way it is to be distinguished from the one which is simply the offspring of menstruation. I need not tell you that upon this—as on many other questions of science—there is a difference of sentiment among writers, but I belieA'e there is a sufficient concurrence, as to the general points of distinction, to afford reliable data for opinion.* Prof. J. C. Dalton, in an elaborate paper, gives the following summary as the result of his investigations on this subject: " The corpus luteum of pregnancy arrives more slowly at its maximum development, and afterAvard remains for a long time as a noticeable tumor, instead of undergoing rapid atrophy. It retains a globular or only slightly flattened form, and gives to the touch a sense of resistance and solidity. It has a more advanced organization than the other kind, and its con- voluted wall is much thicker. Its color is not of so decided a yel- low, but of a more dusky hue, and if the period of pregnancy is at all advanced, it is not found, like the other, in company with unruptured vesicles in active process of development."! It is now, I believe, generally conceded that the corpus luteum, unconnected with pregnancy, and simply the product of menstrua- * After a careful review of the subject, the following conclusions have been deduced as being most likely to enable the observer to arrive at a just opinion: " 1. A corpus luteum, in its earliest stage (that is, a large vesicle filled with coagu- lated blood, having a ruptured orifice, and a thin layer of yellow matter in its walls), affords no proof of impregnation having taken place; 2. From the presence of a cor- pus luteum, the opening of which is closed, and the cavity reduced or obliterated, only a stellate cicatrix remaining, also no conclusion as to pregnancy having existed, or fecundation having occurred, can be drawn, if the corpus luteum be of small size, not containing as much yellow substance as would form a mass the size of a small pea; 3. A similar corpus luteum, of larger size than a common pea, would be strong presumptive evidence, not only of impregnation having taken place, but of pregnancy having existed during several weeks at least; and the evidence would approximate more and more to complete proof, in proportion as the size of the corpus luteum was greater." [Baly's Supplement to Mullet's Physiology, page 57.] \ Transactions of the American Med. Association for 1851. 8 Hi THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tion, is seldom of greater volume than a small pea, while, usually, it is even less than this; from six to eight weeks it undergoes such rapid and positive diminution as to represent only a very small point on the surface of the ovary; hence this latter will ordinarily exhibit false corpora lutea, in greater or less number, in women Avho have their menstrual periods with regularity. The corpus luteum of pregnancy is characterized by great vascu- larity, and this, no doubt, is explained by the fact that, at the time of fecundation, the uterine organs become the centre of an extra- ordinary afflux of blood, far greater than during an ordinary men- strual crisis. The size, too, of this corpus luteum is Avorthy of atten- tion, as constituting a broad distinction between it and the one Avhich is merely the result of menstruation. As a general rule, it Avill occupy from one-fourth to one-half the surface of the ovary, depending upon the particular period of gestation at which it may be inspected. It is usually larger during the earlier months, say till the third to the fourth ; its volume, however, will vary, occa- sionally, even at given periods of gestation, in different individuals. As the completion of pregnancy approaches, the corpus luteum begins to decline in size, and undergoes a very marked alteration—its vascularity rapidly diminishes, and its color becomes much lighter ; after parturition, whether at the full term, or as the consequence of premature action of the uterus, this body begins to fall into a state of atrophy, and so completely loses its characteristics as to render its recognition next to impossible. It is admitted that two or three months after delivery it completely disappears from the ovary ; and it is now well agreed that a corpus luteum of a previous conception (provided the gestation arrive at the full term) is never found to coexist with that of a subsequent fecundation. After the disappearance of the corpus luteum, its original site is usually noted by a small cicatrix, or line; and it is important to recollect that these cicatrices, like the corpora lutea themselves, are not perma- nent, but become, in the progress of time, more or less effaced. An exceedingly interesting question now arises in reference to the presence of the true corpus luteum on the ovary, and it is well worthy of a moment's thought. Is this corpus luteum always an evidence of previous childbirth, or is it only an evidence of previous impregnation ? That it is not an invariable proof that the female has borne a child, is demonstrated by the fact that there are well- authenticated instances in which the corpus luteum of gestation has been recognised without previous parturition ; but, on a critical investigation, it has been shown, in all these instances, that abortion had occurred; so that the existence of the corpus luteum, although not an evidence of childbirth, must be regarded as a proof that fecundation had taken place. A multitude of influences may ope- rate to destroy the germ, after it has been fecundated, and cause it THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 115 to undergo such marked degeneration as to prevent its recognition. Therefore, it may be, in such instances, that the presence of the corpus luteum will afford the only evidence of the conception. Again: Is it possible for a woman to bring forth twins, and have only one corpus luteum ? The reply to this question is, that there are recorded examples of two ovules being contained in one ovisac, and, consequently, in such case, there would be but one corpus luteum.* It is quite remarkable that those clever observers, Todd and Bowman, in their late work on physiological anatomy, should hold the following language, which is certainly in direct conflict with well-observed facts: " In cases of twins, two corpora lutea are always present."f As regards the existence of the true corpus luteum, and what it proves, it may, I think, be safely affirmed that the researches of modern science have demonstrated the truth of the aphorism long since put forth by that accurate observer, Haller —" Nullus unquam conceptus est absque corpore luteoP The Sperm-cell.—While, as it has been stated, it is the office of the female to provide the ovule, it is the province of the male to impart to it life, so that it may attain, through successive develop- ment, its fcetal maturity. But what is this vitalizing element ? The testes are, to the male, what the ovaries are to the female. They are glands which constitute the essential organs of generation— they secrete, after the period of puberty, a seminal fluid Avhich, according to the experiments of Prevost and Dumas, consists of elements obtained from three sources: 1. The fluid which comes directly from the testicles; 2. The fluid which is secreted byjlie prostate gland; and, 3. That which is derived from the vesiculae seminales. The two latter elements are, as it were, but mere vehi- cles for the seminal fluid of the testicles. This latter contains sper- matozoa, which constitute the real fecundating element; they are small filamentous bodies, Avhich enjoy the power of spontaneous motion, and hence they are regarded by some clever Avriters as veritable animalcula. It seems, however, to be shown that they are not animalcula, but partake of the character of the reproductive portions of plants, which also possess a spontaneous movement as soon as they have been thrown from the parent mass; and it is like- wise conceded that the ciliated epithelia of mucous membrane Avill continue for some time in movement after their separation from the body. Among those who maintain that the spermatozoa partake of the character of animalcula may be mentioned Monro, Haller, Spallanzani, Valentin, Pouchet, and others; while Coste, Charles Robin, and other observers believe the contrary. In man there are developed within the tubuli of the testicles * An interesting example of this kind is cited by Dr. Montgomery, in the second edition of his work, p. 375. f Page 851. 116 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. what are known as the spermatic cells, within each of Avhich is a vesicle of evolution,* as it has been termed, and in each vesicle there is a spermatozoon. It is quite obvious that the sper- matozoon, the duty of which is so important, cannot boast of much magnitude—in the human being it consists of a small, OA'al- shaped body, measuring, in length, from j^oth to g-^jth of a line; its tail, terminating in a Arery delicate point, is from j\ih to i\ih of a line. Its power of movement, it appears, is chiefly through the undulations of the tail. M. Godardf has recently discovered in man a new species of spermatozoon, Avith a very small head, and the tail is endoAved with much more rapid and durable movements than the tail of the common and well-known spermatozoon. The essential fact to be recollected is, that the spermatozoon represents the true fertilizing element, and possesses the exclusive poAver of imparting life to the ovule of the female. It has been shown by Donne that the spermatozoa are deprived of all power of motion under peculiar conditions of the vaginal and uterine secretions—for instance, when there is a morbid acidity of the vaginal mucus, or an excessive alkaline secretion from the uterus. This inability to move is, of course, tantamount to the destruction of the fecundating attribute noAV so generally ceded to the spermatozoon. Therefore, the practical fact is to be deduced that these morbid secretions of the uteres and vagina may sometimes, through their influence on the spermatozoa, be the cause of sterility. Wagner has not found spermatozoa in the mule ; and it is well knoAvn that most hybrids do.not produce offspring. Indeed, it was formerly supposed that all hybrids failed in the fecundating poAver. It has very lately been shown, however, that there are some exceptions to this rule.J Theories of Fecundation.—It is curious to note the various and discordant theories, which have been advanced from time to time in explanation of the true modus in quo of fecundation. For example, it was once imagined that there passed from the seminal fluid of the male a vapor—an aura seminalis—and that it Avas through the agency of this latter that life was imparted to the ovule; and, again, it was maintained that the fluid, after being deposited in the vagina, was absorbed, and reached the ovule through the circulation. Electrical and magnetic influences have also been invoked to demonstrate the profound problem of vivifica- tion. The animalculists, too, contended that each drop of the male sperm contained myriads of living germs already formed, and that, during coition, they are thrown into the uterus, and all of * While in man there is but one vesicle of evolution in each spermatic cell, in animals there are several. f Etudes sur la Monorchidie, etc. 1857. pp. "73, 74 % Memoire sur l'Hybridite' en general, etc. By Paul Broca. Journal de la Physiologie de l'Homme et des Animaux. p. 433. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 117 them, with the exception of one, die; the one which is fortunate enough to escape destruction passes through the fallopian tubes to the ovary, and penetrates a small vesicle which has been prepared for its reception—it then is brought back through the tube to the uterus, where it remains until its full development has been com- pleted. This doctrine of the animalculists is indeed fearful for the con- templation of the philanthropist—it implies a slaughter of human beings unexampled in the pages of history. There is nothing in the carnage of the battle-fields of ancient or modern warfare, which can approach this melancholy sacrifice of human life. With this hypothesis, the reproduction of one's species is no trifling matter—con science, in my opinion, must become veritably seared before engaging in any such enterprise! On the supposition that the spermatie fluid, like the blood, is chemically so constituted that constant motion is absolutely neces- sary for the maintenance of its fecundating properties, Valentin, Bischoff, and others, have advanced the hypothesis that the only object of the spermatozoa is, through their active moArements, to preserve the chemical composition of the fecundating liquor. Carpenter, and other physiologists, are of opinion that Mr. New- port's* recent observations render it very probable that the contact between the ovule and spermatozoon causes the latter to undergo solution ; and that the essential act of fecundation consists in the passing of the product of this solution into the interior of the ovule, thus blending, as in plants, the contents of the " sperm-cell" with those of the " germ-cell." Indeed, it seems noAV conceded by the very best observers, that it is not simply contact betAveen the "germ-cell" and "sperm-cell," but that actual penetration takes place at the time of fecundation. Among others, in confirmation of this vieAV, I may cite the names of Martin Barry, Meissner, Kohen, and even Bischoff, who for a long time had doubted the fact—all these have absolutely seen the spermatozoa penetrating the ovum. Seat of Contact between the Germ and Sperm Cells.—In what particular portion of the uterine organs does this contact between the " sperm-cell" and " germ-cell" take place ? Is it in the uterus, fallopian tube, or ovary ? There has existed, and there still con- tinues to exist, much difference of opinion upon this subject. The early fathers maintained that the uterus itself was the seat of this * In his experiments testing the mode of impregnation in the frog, Mr. Newport has shown that the spermatozoa become imbedded in the gelatinous envelope of the ovule in a few seconds after contact has been accomplished; thence they penetrate the vitelline membrane, and pass to the interior of the ovule. These experiments of Mr. Newport have been fully confirmed by Bischoff.—[Philos. Transac. 1853 pp. 226, 281.] 118 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. contact—and, no matter how discrepant their theories regarding other points touching the question of reproduction, yet there ajjpears to haA'e been a very general assent to the fact—that the uterus constituted the special seat in which vivification was accom- plished. At the present day, however, some of the cleverest physiologists believe that the " germ-cell" is vivified by the " sperm- cell" very generally in the ovary; and this opinion, it seems to me, is founded upon acceptable, if not irresistible, evidence. Bischoff, Coste, Wagner, Barry, Valentin, and others, have positively recog- nised spermatozoa on the ovary of animals killed soon after copula- tion. The following passage from Bischoff is to the point: " I had frequently observed spermatozoa in motion in the vagina, womb, and fallopian tubes of bitches ; but, on the 22d of June, 1858, it was my good luck to perceive one on the ovary itself of a young bitch in heat for the first time; she was covered on the 21st, at seven o'clock, p.m., and again on the folloAving afternoon at two o'clock; at the expiration of half an hour, that is, twenty hours after the first copulation, I killed her, and found several living spermatozoa, endowed with very active motion, not only in the vagina, uterus, and tubes, but even amid the fringes of the latter, in the peritoneal pouch which surrounds the ovary, and on the surface of the ovary itself." Valentin speaks as follows: "On opening the body of a female mammal, one or more days after it has received the male, semen may be found, not only in the body and horns of the uterus, but also in the oviducts, and on the sur- face of the ovary." Here, then, we have more than mere hypothesis ; we have posi- tive affirmation ; and this same character of testimony could be much increased by other observers, but I do not deem it necessary to make further quotations. If, together with the essential fact that living spermatozoa have been seen, soon after copulation, on the surface of the OA-ary, it be recollected that the existence of ovarian and ventral pregnancy has been satisfactorily demonstrated, it does appear to me that it follows, almost as a necessary consequence, that the seat of contact between the two germs is in the ovary. Xature rarely runs vagrant; while she is abundant in her pro- visions for the wants of the system, yet she always exercises a Avholesome jurisdiction; superfluity is not one of her faults; on the contrary, in all her operations she is characterized by a prudent and conservative economy. Why, then, should living spermatozoa be found on the ovary, soon after coition, if it be not in accordance Avith nature's design ? Will it be said that this is a mere coinci- dence, an exception to the general rule, as Pouchet has endeavored to show ? This latter writer, I think, has signally failed in his theory upon the subject. He advances as an argument why the ovary cannot be the point of contact between the germs, that the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 119 peristaltic movement of the fallopian tube is from within outward, . and that, on this account, it cannot convey the semen of the male from the womb to the ovary. It does not appear to me that there is much force in this reasoning, so far as the question at issue is concerned, for, admitting the truth of the direction of the peri- staltic movement of the tube, it does not, in my judgment, in any way invalidate the opinion that the fertilizing element of the semen reaches the ovary, and there vivifies the "germ-cell." You have been told that the spermatozoa enjoy a power of movement, and it is now ascertained that their progress is equal to one inch in thirteen minutes. I believe, therefore, that they find their way to the ovary in virtue of their own movement; as soon as they are thrown from the male into the vagina they commence their journey. The experiments of Nuck and Haighton are quite conclusive as to the ovary being the seat of contact between the germs. You will remember that, in placing a ligature, soon after copulation, around the fallopian tube, and some time afterward killing the animal, Nuck found that fecundation had occurred, and that the development of the ovum Avas going on in the ovarian extremity of the tube. Haighton, on tying the tube in rabbits, ascertained that fecundation did not take place on that side in which the ligature had been applied. Indeed, the most recent observers seem generally to agree that the ovary is the place of meeting of the tAvo germs. Montgomery says, "After the best consideration I could give to it, it is the conclusion arrived at in my mind." In connexion with this point, it may be stated that Coste has recently started a new theory in explanation of why the OArary must neces- sarily be the place of union between the sperm and germ cells. He says, the ovule, as soon as it passes.from the Graaffian ATesicle, undergoes alterations, which render it totally unfit for fecundation. In conclusion, I think it may be affirmed, Avithout denying the occasional meeting of the germs in the uterus and fallopian tubes, that the union is most generally accomplished in the ovary. How does the Fecundated Ovule find Admission into the Fallo- pian Tube?—This question has generated numerous hypotheses; but none of them are Avithout objection. It has generally been supposed that the fimbriated extremity of the tube is made to grasp the surface of the ovary, through the contraction of its muscular fibres; it is very evident, hoAvever, as Rouget has remarked, that it is the action of the longitudinal fibres only which could in any way affect the position of the free extremity of the tube ; but the immediate result of the contraction of these fibres would be a diminution in the length of the tube ; consequently, instead of approximating its extremity to the ovary, the necessary tendency would be to place it more remote from that body. He, 120 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. therefore, repudiates this explanation, and refers the contact of the fimbriated extremity of the tube Avith the ovary, at the time of ovulation, to the combined contraction of Avhat he terms the ovarian-tubal muscular fasciculi. It is a veritable spasmodic con- traction of this muscular apparatus, which consummates the contact. But the question arises as to the special influence, which origi- nates this muscular contraction, or, in other words, Avhat is it that throAVS these fibres into action ? When the Graaffian vesicle has attained its development, and is matured, the distension of the muscular fibres proper to the stroma of the ovary begets a reflex movement, which is immediately transmitted to the tubo-ovarian muscular system. This latter contracts, and this brings the extremity of the tube in close contact with the ovary. The ovule is detached, and then conveyed through the vermicular movement of the tube itself to the uterus, where it remains sufficiently deve- loped to prepare it for an independent or external existence. Precisely the same thing takes place in menstruation; so that whether the ovule be fecundated or not, it drops, as it were, from the ovary, and is received into the tube to be conveyed in the latter case to the uterus, and pass off as a deciduous body Avith the catamenial discharge. The approximation of the tube to the o.vary, at the menstrual period, is explained upon the same principle as Avhen fecundation occurs.* I have now, gentlemen, given you, very briefly, what may, I think, be considered the accepted facts of science touching this interesting question of reproduction in the human species. In the discussion of the subject, I might have entered into many import- ant details, elucidating propagation in the vegetable and animal kingdoms; but, as I have already remarked, such details would not be in keeping with the practical tendency of these lectures. * In certain cases of local peritonitis, it will sometimes happen that, as the result of the inflammation, there will be an adhesion of the fimbriated extremity of the tube so remote from the ovary as to prevent contact at the time of ovulation. This, of course, would result in sterility, or in extra-uterine foetation. LECTURE IX. Pregnancy; Definition and Divisions of—Is Pregnancy a Pathological Condition?— The Uterus and Annexae before and after Fecundation—Two Orders of Pheno- mena following Impregnation; Physiological and Mechanical—How the Uterus Enlarges—Microscope and its Proofs—Development of the Muscular Tissue of the Uterus; how accomplished—Solid Bulk of Uterus at Full Term—Meckel's Esti- mate—Increase of Blood-vessels, Lymphatics, Nerves, and other Tissues of Uterus —Nausea and Vomiting; how produced—Influence of Nausea and Vomiting on Healthy Gestation; the Explanation of this Influence—Blood—how Modified by Pregnancy—Is Plethora characteristic of Gestation ?—Cause of this Hypothesis— Treatment of Acute Diseases in Pregnancy—Aphorism of Hippocrates on this Question—Increase of Fibrin in Inflammation—Deductions—"Buffy Coat" not always the Product of Inflammatory Action—" Buffy Coat " in Chlorosis, Preg- nancy, etc.—Kiestine; what its Presence indicates—Blot's Experiments—Sugar in the Urine of the Puerperal Woman—Deductions—How are we to know that Pregnancy exists? Importance of the Question; its Medico-legal bearings; Illus- tration—The Proof of Pregnancy altogether a Question of Evidence; how this Evidence should be examined. Gentlemen—We shall speak to-day of the important subject of pregnancy ; in all its bearings it is full of interest, and Avhether in its normal, pathological, or legal relations, claims the profound thought of the practitioner. Pregnancy may be defined to be that condition of the female, which exists from the moment of fecunda- tion until the exit of the child from the maternal organs. It is divided into true, false, uterine, extra-uterine, and interstitial. In true pregnancy, there is really a fcetus; in false, the enlargement is dependent upon something other than a foetus; when the product of conception is situated within the uterus, the gestation is called uterine; when, on the contrary, the foetus is lodged externally to this organ, it is known as extra-uterine, of which there are three vari- eties, viz. abdominal, fallopian or tubal, and ovarian. In the first of these varieties, the embryo, under a rule of exception, does not reach the uterus, and becomes developed in some portion of the abdominal cavity; in the second, in the fallopian tube; and in the third, it receives its growth in the ovary. We shall hereafter have occasion to describe more particularly each of these varieties. There is another form of gestation in which, strictly speaking, the fcetus is developed neither within nor without the uterine cavity; and you may well ask—How is this ? It is called inter- stitial pregnancy, for the reason that the foetus does not rest under 122 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. either the peritoneal or mucous coArerings of the uterus, but is found amid the meshes of muscular fibres of the organ, and hence the propriety of its name—interstitial. There have been many attempted explanations of the manner in which the fecundated ovum finds its way into this intermediate structure, but none of them are satisfactory, for they do not seem to be founded on cor- rect data.* The cardinal fact, however, that interstitial pregnancy does sometimes exist, cannot be denied, for it has been recog- nised by several trustworthy observers. In addition to the varieties already enumerated, pregnancy is divided into simple, compound, and complicated. In the first, there is but one fcetus; in the second, there are two or more; while in the third variety, besides a fcetus, the gestation may be complicated Avith an abnormal growth, such as a polypus, fibrous tumor, or ovarian enlargement. Pregnancy not a Pathological Condition.—There has been a difference of opinion as to the true nature of pregnancy, so far as the general laws of the economy are concerned ; and conflicting vieAvs have been advanced as to Avhether it is or is not a patholo- gical condition. There can be no doubt that the general system, as the direct consequence of impregnation, undergoes numerous modifications ; and it is entitled to consideration whether, as a general rule, these modifications should be regarded as evidences of morbid action, or whether, on the contrary, they should not be accepted as testimony that nature is engaged in the attainment of an object, which she cannot accomplish except through the opera- tion of certain changes, which, although not morbid, will neces- sarily encroach more or less on that integrity of function, or, if you prefer it, equilibrium of forces, which, in the unimpregnated female, is looked upon as the standard of health. It does seem to me that this question has been somewhat misapprehended by certain writers, and they have mistaken natural processes for pathological phenomena; they have regarded the workings of nature, under peculiar circumstances, as the manifestations of morbid influence; and hence, in their judgment, the important and interesting period of gestation is a period of diseased action. Even without iiwok- ing the aids of science, common sense, it seems to me, runs directly counter to such an hypothesis. The destiny of woman would, indeed, be one of bitter anguish, if, in addition to her other sorrows, it were decreed that, while engaged in the great act of the reproduction of her species, she * One author, Breschet, says, that if any obstacle should oppose the ovum in its entrance into the uterus, it might glide into some one of the venous sinuses, which, he maintains, are found to open at the origin of the fallopian tubes. The existence of these sinuses has never been demonstrated, and it is now admitted that this eminent anatomist was in error. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 123 should necessarily be subject to the inconveniences and perils of disease. So far, then, from regarding gestation as a pathological state, we maintain that, as a general principle, it is entitled to be denominated a period of increased health. I am speaking now of the general rule, and not of the exceptions, to which we shall here- after have occasion to direct your attention. Indeed, some of the very best observers have declared—and the fact is well established by statistical data—that the probability of prolonged life is increased as soon as pregnancy occurs. Let us now take the con- verse of this proposition, and you will see, in its results, an addi- tional proof that gestation is not in truth a diseased condition; look, for example, at those females who, either from choice or necessity, lead a life of celibacy, and see how much greater is the record of their mortality. Marriage* and pregnancy, therefore— however true religion and an earnest love for God may fill the cloister by devoted and self-sacrificing ladies—should be regarded as among the covenants of nature, and the demonstration is found in the fact of the better health and greater longevity of those who keep these covenants inviolate. Pregnancy, although not a condition of disease, is one of excite- ment, in Avhich the entire economy more or less participates; and to show you how emphatically and promptly the system responds * It is worthy of remark that marriage is conducive to health and longevity, with certain qualifications. Some interesting facts have recently been presented by Dr. William Farr upon this subject, based upon statistics derived from the population of France; these statistics receive additional importanco from the circumstance that the returns extend over the whole of France, and include all grades of its population- According to the census of 1851, with a view of showing the influence of the conju- gal relation, the population is divided into three classes: 1. The married: 6,986,223 husbands; 6,948,823 wives = 13,935,046 married persons. 2. The celibates, or those who have never married: bachelors, ±fs\±,\§h\ spin- sters, 4,449,944 = 8,464,049. 3. The widowed: widowers, 835,509; widows, 1,687,583 = 2,523,092. It appears that, in France, marriage is legal for males at 18, for females at 15; and it is shown that the mortality among the married women under 20 years was double that among the unmarried; while the mortality among the married men at this youthful age was greatly in excess of that of the unmarried. The rate of deaths in the married women was 14.0 in 1000, and among the maidens it was only 8.0, In the married men it was 29.0 in 1000; in the unmarried 7.0. These facts carry with them their own comment, and should serve to admonish parents against the early marriage of their children, before the physical system is sufficiently developed to sustain the requirements of that state. From the ages of 25 to 30, the mortality of the unmarried is slightly in excess, being 9.2 to 9.0. From 30 to 40 the deaths among the wives were 9.1, and among spinsters, 10.3. After 40 years of age, the rate of mortality is still more in favor of the married in women, being, from 40 to 50, 10.0, while in the unmarried it is 13.8. From 50 to 60, married, 16.3; unmarried, 23.5 ; and above 60, married, 35.4 ; unmarried, 49.8. It would seem, therefore, that, all things being equal, matrimony tends to the pro- motion of health and longevity. 124 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. to the changes induced by impregnation, it may be mentioned that oftentimes, with the quickness of thought, constitutional sympa- thies, more or less marked, supervene on the act of fecundation; it is only necessary to understand why this is so, in order that you may appreciate, and, at the same time, see in these sympathies an evidence, not of a pathological state, but an evidence that a neAV link has been added to the chain of phenomena which nature recognises as rightly belonging to her. It is interesting to note the considerate kindness with Avhich the pregnant female was treated in ancient times. Indeed, she became the object of special attention and regard. Among the Jews she Avas, during the period of her gestation, permitted to partake of whatever meats she desired, no matter, how strongly prohibited by the Mosaic commandments at any other time. It Avas a recognised custom, too, among the Athenians, to absolve from punishment the murderer,, whose hands were yet wet with the blood of his victim, if he sought shelter in the house of a Avoman carrying her child. Changes in the Uterus during Pregnancy.—The uterus and its annexae in the unimpregnated female are, except at the menstrual periods, in a state of quietude, and have but little participation in the affairs of the economy. But as soon as fecundation has been consummated, and even before the vivified ovule reaches the Avomb, this organ is summoned upon active and continued duty, involving changes in its local condition, which immediately awaken constitu- tional excitement, and lead directly to increased vital action.* The uterus now becomes a new centre; from a comparatively inert, passive organ it is suddenly converted into one of the highest grade of activity—new duties now devolve upon it—it is no longer in a state of rest—it is converted into a domicile for the accommo- dation of the embryo; but as this latter requires for its develop- ment something more than a place of temporary sojourn, and as, like all living beings, it can only grow by being nourished, there is an afflux of fluids directed toward the uterus, freighted with ele- ments necessary for the nourishment of the germ. These duties and changes incident to the organ, necessarily impart to it increased structure and volume; and in proportion as these changes take place, two orders of phenomena ensue—1. Physiofbgical; 2. Mecha- nical. The former class appertains to the transmission of influences to the various portions of the economy through the ganglionic system of nerves ; the latter has special reference to the pressure and consequent disturbance exercised by the developing uterus on * Harvey has compared the sudden change occurring in the uterus from impreg- nation to the lip of a child stung by a bee, " nempe ut puerorum labia (dum favos depeculantur, ut mella liguriant) apum, spiculis icta, tument, inflammantur orisquo, hiatum aretant." [Harv. Exercitatio 68, p. 438.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 125 the adjacent organs. We shall, when speaking of the symptoms of pregnancy, call attention in detail to these phenomena, and endeavor to give to each one of them its true value. Development of Impregnated Uterus—Mucous Membrane.—The microscope has revealed some very interesting facts regarding tho manner in which the uterus commences to increase in volume, as a consequence of impregnation. For example, the first change in the structural arrangement of the gravid organ is recognised on its internal or mucous membrane; as early as the second week, it becomes notably thickened in its texture, and assumes a much more lax character ; its color is quite red, the result of increase in the contents of the blood-vessels, and folds or plicae are now per- ceptible, so that it can be distinctly separated from the muscular coat of the organ. All these changes become much more apparent as the period of pregnancy advances, and the result is that the mucous membrane (except that portion lining the cervix) lapses into an hypertrophied condition, and constitutes the decidua vera, to Avhich we shall more particularly allude when treating of the envelopes of the foetus. Peritoneal or Serous Membrane.—It is only necessary to recollect the distribution of the peritoneal covering on the anterior and posterior surfaces of the uterus, together with its firm attachment to portions of these surfaces,* to appreciate the necessity for an increase in its elements so that it may, Avithout undergoing lace- ration, continue the same relations with the gravid uterus, which are shown to exist betAveen it and the unimpregnated organ. It was formerly supposed that the broad ligaments—simply dupli- cations of the peritoneum—were arranged in folds which, under the influence of gestation, expanded, and thus enabled the peritoneal membrane to keep pace, without involving its integrity, with the developing uterus. There is no truth in this hypothesis, and it is now admitted that the peritoneum, in common with the other tissues, really receives, as one of the results of pregnancy, an increase of elements, or, in other words, exhibits an hypertrophied condition. Muscular Structure.—The muscular tissue of the uterus also undergoes important modifications, which result in a general increase in the volume of the organ. It is a well-established fact that this muscular tissue becomes developed in two ways: 1. By an increase in the pre-existing elements; and 2. By a new formation of them. For the first five or six months of gestation there are generated new fibres, and those which previously existed assume an extraordinary growth, their length presenting an addition of from seven to eleven times, and their width from two to five. The connecting tissue, which unites the muscular fibres, also pre- * See Lecture 6th. 126 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sents an increase, so that at the end of pregnancy, distinct fibres can be "recognised.* Such is the gradual development of the uterus from the time of fecundation until the completion of the period of utero-gestation, that its solid bulk has been estimated by Meckel to be, at the end of the ninth month, twenty-four times greater than in the unimpregnated organ. This excess of development is principally due to the enhanced growth of the muscular tissue, and, as obstetricians, it is interesting for you to know that, until the sixth month of pregnancy, the walls of the uterus undergo a successive thickening, while the cavity also becomes increased; but, after this period, the walls diminish in thickness, and the area of the uterine cavity, in order to accommodate the fcetus, is still much augmented. The serous or peritoneal covering, as has just been remarked, also becomes thickened; and there is, in fact, an increase in all the tissues of the organ; the blood-vessels and lym- phatics become larger and more distended, and the nerves, whether partly from the production of new nerve-fibres or not, are enhanced in length and width by the growth of their pre-existing elements. Such, very briefly related, are some of the structural modifica- tions produced in the uterus as the result of pregnancy; and you cannot fail to perceive that all these changes are intended for the accomplishment of two objects, viz. in the first place, for the accommodation of the growing embryo, thus affording it a place of temporary sojourn ; and secondly, for the provision of the elements necessary to its nourishment. There has been much discrepancy of opinion as to the special arrangement or distribution of the muscular tissue of the gravid uterus. Madame Boivin, who gave much attention to the subject, and whose fine delineations of this structure have commended themselves to the highest consideration, recognises in the impreg- nated womb three orders of fibres : 1. On the external surface of the organ, there are planes of fibres, which proceed from the median line obliquely doAvnward and outward, toward the inferior third of the uterus, passing in the direction of the round ligaments, of which they constitute a large portion; some of these fibres pass also to the fallopian tubes and ovaries; 2. On the internal surface, there are observed circular fibres, and their central point is the in- ternal orifice of the tubes; 3. Between the two planes of fibres just described, there is a third layer, which is regarded as inextricable. On the other hand, Deville has quite recently endeavored to show that Madame Boivin was in error in her description. There are, according to this observer, two orders of muscular fibre on the exter nal surface of the organ—one transverse, the other longitudinal. The former are derived from the round ligament, fallopian tube, * Kolliker's Microscopical Anatomy, p. 650. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 127 and ovary, and also from the wing of the corresponding round liga- ment. Near the median line, these transverse fibres are inter- sected perpendicularly by a longitudinal band, describing curves more or less marked. This longitudinal band originates, in front, near the union of the body with the neck of the uterus, and passes from below upward to the fundus, and again proceeds from above downward on the posterior surface, terminating a little below the junction of the neck and body of the organ. There is, he remarks, a positive line of continuity between the transverse and longitudinal fasciculi. The former, as soon as they approach the median line, become curved, some downward and others upAvard, so as to become longitudinal, and in this way do actually constitute the median longitudinal fasciculus. This is observed on both the anterior and posterior surfaces of the organ. On the internal surface, there is the same general description of the muscular fibres as on the external surface. In Figures 37 and 38, taken from Cazeaux, who acknowledged his indebtedness for them to the courtesy of M. Deville, the arrangement of the mus- cular structure, as described by this anatomist, is graphically exhibited. *»«• 8T. Fi0. 88. Constitutional Sympathies.—The changes in the local condition of the uterus are promptly followed by more or less constitutional excitement. One of the very first organs in which this excited action is manifested is the stomach, as is shown by the nausea and vomiting, which, in many instances, so quickly, and, in the great majority of cases, so generally, supervene upon pregnancy. There is very little doubt, I imagine, now entertained as to the manner in which the nausea and vomiting are produced. The uterus, you have seen, becomes, as soon as fecundation is accomplished, a new and active centre. Extraordinary changes of structure ensue; all this necessarily induces more or less irritation from the uterus to 128 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the stomach through a reflex action of the spinal cord; this irri- tation is transmitted to the stomach, and, as a consequence, nausea and vomiting are developed. Now, I can readily understand that you may, at first sight, imagine this to be an argument against the assumption that pregnancy cannot be properly considered a patho- logical or diseased condition. But such an inference has no just basis, for I hold that the nausea and vomiting of pregnancy, under ordinary circumstances, instead of being regarded as pathological, are, in truth, physiological phenomena; and it is, in my judgment, precisely for the want of such distinctions that the error has obtained regarding the true condition of the female, while in gestation. / I do not think there is any fact, as a general fact, better esta- blished than that pregnant females, who escape nausea and vomit- /ing during gestation, are exceedingly apt to miscarry. If this ' really be so—and your future observation will, I am quite sure, abundantly corroborate the statement—there must be some im- portant connexion between this gastric irritability and a normal pregnancy—a connexion which holds the relation of cause and j effect. What are the facts ? As soon as impregnation takes place i the uterus becomes suddenly congested, and this tendency of the blood toward the organ continues in unbroken currents until the completion of gestation. Without some derivative influence, in the earlier periods of pregnancy, to hold in salutary check this determination of blood toAvard the uterus, its nervous structure would become so overwhelmed and irritated that premature action of the organ, and expulsion of its contents, would be the con- sequence. In order, however, to guard against such contingencies, nature has found it necessary, in the plan of her operations, to institute two phenomena—nausea and vomiting—the direct result of which is, for the time, to produce relaxation of the general mus- cular tissue, and increased activity of that essential emunctory— the perspiratory surface. I need not explain to you how relaxation of the muscular system, and increased perspiration, necessarily tend to antagonize local congestions. This law, so well established, constitutes the funda- mental basis for the therapeutic treatment of inflammatory affec- tions. Why are you told in aggravated attacks of inflammation of any of the vital organs—in pneumonia, for example—to bleed to syncope? Is it not because of the absolute necessity, in order that life may not be sacrificed, that an immediate and powerful impression be made on the system—and what so potent in its influence to break up the local congestion as the two immediate results of syncope—relaxation and free perspiration?* There is * I am so well satisfied of the importance, so far as a healthy gestation is con- cerned, of the two phenomena—nausea and vomiting—and so truly do I regard them as necessary links in the chain of processes instituted by nature for the sue- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 129 another argument, I think, to show how necessary this gastric disturbance is to the completion of pregnancy, and it is this—as a general principle, it subsides about the middle period of gestation, the uterus, by this time, having become accustomed to its new condition, and, therefore, from this cause at least, in no danger of premature action. Changes in the Blood.—But, gentlemen, let us look at another modification resulting from pregnancy, and see how far, as many writers claim for it, it is entitled to the denomination—pathological —I allude to the change which the blood undergoes during gesta- tion. Through the researches of that clever observer, Andral, subsequently confirmed by the observations of Becquerel and Rodier, the important fact has been established, that, for the first five months of gestation, the absolute quantity of fibrin in the blood is diminished, and that the red corpuscles are also less in quantity. The amount of fibrin, they allege, after this period, is subject to variation; but it ordinarily becomes increased between the sixth and seventh, and eighth and ninth months. It must be remembered that this condition of the blood is not a mere coin- cidence ascertained to exist in one, two, or three given cases of pregnancy; but the value of the circumstance consists in the broad cessful accomplishment of the work of reproduction, that, when these phenomena are absent, I invariably have recourse to minute doses of ipecacuanha for the pur- pose of inducing an irritable condition of the stomach. In more than one instance, I have succeeded in this way, in carrying ladies to their full term, who had previ- ously miscarried—and in whom, on inquiry, there could be detected no cause for the miscarriage, except that they had experienced neither nausea nor vomiting. In illustration, the following case, among several others, is not without interest: In November, 1851, I was consulted by a lady from the State of Georgia, who imagined she was laboring under some disease of the uterus, which, as she supposed, had prevented her from bearing a living child, having miscarried twice successively at the third month of her gestation. After a very careful examination, I could detect no disease of the uterus, nor could I ascertain, on inquiry, that any of the ordinary special causes had operated in the production of the miscarriages. On questioning her particularly as to the state of her health while pregnant, she laughingly observed: "Why, sir, my health was, in both instances, most remarkable; my appetite was surprisingly good, and I did not know what it was to have a moment's sick stomach." Judging that this was a case of miscarriage from the absence of the usual symptoms—nausea and vomiting—I so expressed myself to the lady, and enjoined upon her, as soon as she again discovered herself to be pregnant, to commence with from a fourth to half a grain of ipecacuanha once, twice, or thrice a day, as circumstances might indicate, for the purpose of producing nausea, thus simulating, as nearly as possible, the course pursued by nature, when not contra- vened bjr influences which she cannot control. This treatment to be continued until about the fourth month of pregnancy, at which time, sometimes earlier, some- times later, the nausea and vomiting, usually attendant upon gestation, as a general rule, cease. My patient returned home, and, in twelve months afterward, I received a letter from her physician, Dr. Raymond, in which he remarked: " Tour remedy has been attended by the happiest result. Two weeks since I delivered Mrs. H. of a fine son." 9 130 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ground that this is the general characteristic of the blood during gestation; hence, a pregnant woman may be said to be chloro- ansemic, simulating, someAAThat, the condition of chlorosis, betAveen the pathology of which and the blood of pregnancy there is a striking analogy. This seems, indeed, to come in direct conflict Avith the very general opinion that pregnancy is usually accompanied by a state of plethora; and hence, under this latter impression, the too common practice is, for any supposed fulness in the head, or pain in the chest or abdomen, the free abstraction of blood by the lancet. This is not only, in my judgment, empirical, but it is oftentimes very pernicious practice. To the abstract practitioner, pain in the head, etc., may indicate plethora, and, consequently, the wisdom of blood-letting. Not so, hoAvever, Avith the Avell-educated physi- cian, Avho rejects the testimony of mere symptoms as utterly Avorthless, unless accompanied by a knowledge of the causes to which they are due. Who, for example, does not knoAV that one of the prominent accompaniments of an anaemic or bloodless con- dition of the system is intense cephalalgia, with intolerance of light —and are not these, also, the two prominent and distressing symp- toms of that most fearful disease, phrenitis, or inflammation of the brain ? Then, gentlemen, in the name of truth, what is the value of symptoms, unless elucidated by their antecedents ? In the two examples which I have just cited, you see precisely the same character of symptoms, but due to precisely opposite causes. In the one, tonic and stimulant treatment is indicated—while, in the other, the only hope of rescue is in the prompt and uucomprising use of the lancet, and other depletory measures. The opinion that pregnancy is accompanied by a plethoric con- dition of system is by no means of recent origin—and it seems to have sprung from the belief generally entertained that, as during gestation there is usually a suppression of the catamenia, the very accumulation of this fluid in the system of the gravid female must necessarily induce a state of plethora. This, however, is false reasoning; for the quantity of blood thus retained can, by no mode of calculation, compensate for the amount provided by the mother for the fcetus and its annexae, during their intra-uterine develop- ment. So generally did the idea of plethora and pregnancy pelade the teachings of many of the early schoolmen, that it was one of their injunctions to bleed the pregnant female at least three times while carrying her child; indeed, the observance of this maxim was regarded as essential to the safety of both mother and offspring. Unfortunately, the error has reached our own times, and, as a mere matter of tradition, has a strong popular support. When engaged in practice you will appreciate the necessity of firmly resisting this delusion, Avhich may almost be considered a popular superstition THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 131 Allow me here to remark that, as a general principle, if the preg- nant female observe strictly the ordinances Avhich nature has incul- cated for her guidance; if, for example, she take her regular exer- cise in the open air, avoid, as far as may be, all causes of mental or physical excitement, employ herself in the ordinary duties of her household, partake of nutritious and digestible food, repudiate luxurious habits, the exciting accompaniments of the dance, late hours, late suppers, etc.; if, I say, she will steadfastly adhere to these common-sense rules, the reward she will receive at the hands of nature will be, general good health during her gestation, and an auspicious delivery, resulting in what will most gladden and amply repay her for her discretion—the birth of a healthy child, which is to constitute both the idol of her heart, and the study of her life. But if, in lieu of these observances, the pregnant woman pursue a life of luxury, " eat, drink, and become merry," neglect to take hei daily exercise, and prefer her lounge—then the case is entirely reversed; she becomes plethoric, and, if not relieved by the employment of the lancet,* and other appropriate remedies, she oftentimes dies, having blotted herself from life by her own folly! You see, therefore, that pregnancy per se is not, in reality, a condition of plethora, but becomes so through the vio- lation of the laws prescribed by nature; and this is equally true with regard to the general health of the female during her gravid state. It must, however, be borne in mind that gestation exercises no talismanic influence, nor can it constitute itself an ./Egis by which to aruard the female acrainst the invasion of diseases incident to human nature. For example, a pregnant Avoman may be attacked with pneumonia, pleurisy, or other of the formidable phlegmasiae; in one word, she is liable to any of the numerous catalogue of human maladies; and this brings me, for a moment, to the consi- deration of the treatment of these affections, Avhen occurring in a state of gestation. Hippocrates propounded the maxim that " an acute disease of any kind, seizing a woman with child, generally proves mortal"—mulierem utero gerentem morte quodam acuto lethali.\ Van Swieten, the illustrious commentator of the no less illustrious Boerhaave, in speaking of this aphorism of Hippocrates, concludes that this unfavorable prognosis of an acute disease in pregnancy was necessarily deduced from wThat he held touching the abstraction of blood in gestation—" a woman Avith child, from open- ing a vein is apt to miscarry "—mulier utero gerens vend sectd abortet. It is very evident that neither of these maxims of the * It is very probable that the plethora, in these cases, is due simply to an increase in the amount of water in the blood; but, still, with this assumption, the advantage of the lancet, as a means of temporary, relief, cannot be questioned. f Aphor. 3 torn., ix., p. 213. 132 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. father of medicine receives confirmation at the bedside, Avhere. after all, their true value is to be tested. In the first place, in certain conditions of plethora, brought on in the manner already indicated, accompanied by a bearing-down sen- sation, febrile excitement, and a bounding pulse, the abstraction of blood from the arm Avill oftentimes act like magic, imparting to the disturbed system quiet and calmness, such as the lulling of the tem- pest, and the falling of the waves produce on the bosom of the ocean. Again: my own experience teaches me that acute diseases, if promptly treated, are as amenable to remedies as under any other circumstances; and, furthermore, their therapeutic management should be characterized by the same degree of activity as if pregnancy did not exist. Diseases of a high inflammatory grade are, I am quite confident, frequently fatal in the pregnant female for the reason that the practitioner is timid, his indecision growing out of fear that positive depletion may destroy the child. It seems to me that this is a A'ery false philanthropy; nor has it anything in science either to sustain or justify it. For instance, in a severe inflammation, the mother will perish Avithout prompt and efficient depletion ; and, should she die, Avhat becomes of the child she carries in her womb—especially if it should not have attained a uterine development which will enable it to enjoy an independent existence, in which event, it is true, there is a remote possibility of saving it by a post-mortem Caesarean section ? But, gentlemen, will the active depletion, material to rescue the patient in cases of serious acute disease, necessarily compromise the safety of the child, by depriving it of the nourishment essential to its development ? This is an exceedingly interesting and important question, and one concerning which there is a diversity of opinion. It appears to me, hoAvever, that it is one of those points not to be determined by the forum, nor by the disputations of the contro- versialist—it is simply a question of facts. The facts which, to my mind, are conclusive on this subject, and which every observant accoucheur Avith a moderate field of practice will, from his own personal experience, be enabled fully to confirm, are as follows : 1. Pregnant women, affected with exhausting diseases, and in the last stage of phthisis pulmonalis, are oftentimes delivered of apparently healthy and well-developed children; 2. In cases of excessive nau- sea and vomiting—continuing nearly the entire period of gestation —thus preventing the female from taking her ordinary nourish- ment, the child exhibits no evidence of impaired nutrition; 3. When pregnant women are over-fed, it often occurs, especially if they increase much in adipose tissue, that they bring forth diminished children, instituting a striking contrast between their condition and the corpulence of the parent; 4. After convalescence from diseases which have needed prompt and bold depletion, during gestation, I THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 133 the child exhibits no Avant of groAVth or development, but, on the contrary, usually bears the evidences of having been adequately nourished; 5. The attempts made, in cases of pelvic and other deformities of the maternal organs, to cause a diminished growth of the foetus by restricting the diet of the mother have completely failed.* There is an interesting circumstance connected with the chloro- anaemic condition of the gravid female, to which it is not unimport- ant for the moment to allude. Andralf has demonstrated that, in all cases of acute inflammation, there is invariably an increase in the quantity of fibrin; and, furthermore, that this increase is always proportionate to the intensity of the phlegmasia. In order that a clear understanding may be had of this practical point, and proper deductions made in other than inflammatory types of the system, the folloAving table is presented as disclosing the ordinary variations in the quantity of the chief constituents of the blood in a state of health: Fibrin, . . . from 2 to 3£ parts per 1000. Red corpuscles, " 110 " 152 " " " Solids of Serum, " 72 " 88 " " " Water, ... " 760 " 815 " " " According to Andral, the increase in the quantity of fibrin is so unequivocal a sign of inflammatory action, that if more than 5 parts of fibrin in 1000 be detected in the progress of any disease, it may positively be affirmed that some local inflammation exists.J It is also shown that, under the influence of inflammation, the maximum increase of fibrin is 13.3, the minimum 5, Avhile the ave- rage is 7 ; and the important fact is proved that, in acute rheuma- tism and pneumonia, the greatest increase is recognised. Some practitioners are in the habit—and unfortunately the doctrine per- vades too many of the books noAV in your hands—of judging of the necessity of further depletion simply by the peculiar appearance of the blood after it is abstracted from the system—known as the " buffy coat." It would be a sad tale if the countless dead could * A prominent writer, M. Depaul, suggested in the Union Medicale, 12th of Janu- ary, 1850, the practice of repeated bleedings, together with restricted diet, during the latter half of pregnancy, with the view of arresting the full development of the foetus. This suggestion, as is evident, was founded upon inaccurate data, and con- sequently proved valueless, so far as concerned the object for which it was intended. f See his admirable Essai d'Hsematologie Pathologique. \ What a precious disclosure for the truly obseryant physician! How often does it happen that, with all the vigilance which can be brought to bear, and all the soundness of human judgment, he is baffled in his diagnosis—especially in what may be formed masked inflammatory action—whether the symptoms are really due to inflammation, or whether the disturbance may not be one of the ever-varying grades of neuralgic pain. In such case, the abstraction of a small quantity of blood will at once develop the mystery by ascertaining the relative proportion of its fibrin. Such, indeed, are the rich fruits groAving out of scientific inquiry. 134 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. return to earth, and tell how this error has led to their premature destruction! The "buffy coat," while it is indicative, under certain circumstances, of inflammation, is also one of the characteristics of anaemia; and it noAV seems to be the accepted doctrine that its presence, under any circumstances, is due to one of tAvo conditions: either a positive increase of the fibrin in the blood, in Avhich case the amount of corpuscles may undergo no change ; or there is merely a relative increase, in which there is a loss or diminution of the cor- puscles. This, you Avill perceive, is a very important distinction; for it is in the latter instance, especially, in Avhich the "buffy coat'' will display itself, not because of the inflammation, but simply because of a, disproportion between the fibrin and corpuscles. Noaa*, such disproportion is found to exist in pregnancy, in chlorosis, etc., and, as a consequence, both of these conditions of system are cha- racterized by the " buffy coat."* You see, therefore, gentlemen, Iioav necessary it is, in the practice of our profession, to take an enlarged view of science—to collect, as it were, all the facts, and not be content Avith an isolated or frag- mentary consideration of a principle; rigid and searching analysis, and legitimate deductions from well-established premises, are the elements which our science greatly needs, and they are the elements, too, Avhich will consecrate her discoveries as so many truths, and give them value and efficiency Avhen applied to the amelioration of human suffering, or to the arrest of disease. How often, in the clinic, have I had occasion to call your attention to the subject of chlorosis, and, in connexion Avith its pathology and management, to remind you that one of the characteristics of this affection, Avhich is essentially a disease of debility, is the " buffy coat." You have been told of the fatal error of depletion in chlorosis—and yet this error is constantly committed by those Avho believe that the "buffy coat" is always the index of inflammatory action. It may surprise you—but still the fact is susceptible of demonstration—that even at this day, amid the rich accessions which research and progress are daily contributing to our professional domain, and amid the lights which science is constantly shedding upon those who worship at her shrine, the general belief, so far as practice is concerned, is that whenever the " buffy coaV is recognised, it is an urgent indication for the necessity of further depletion I * The fibrin increases during pregnancy; its general average quantity in this con- dition is 3.40, but during the last two months it is 4.08. The blood of the pregnant woman also undergoes a change in the proportions of its albumen, water, and iron. The average quantity of albumen contained in blood is 70.5; M. Regnauld has Bhown that the average of this element during gestation is 67.17. In the first seven months ft is 68.84; in the two last, 66.42. The increase in the water of the blood is also shown by the same observer. The average quantity of water is 791.1; while during pregnancy it is 817. Becquerel and Rodier have demonstrated that there is a slight diminution in the quantity of iron. [Dubois and Pajeot, op. cit.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 135 Modifications in the Urinary Secretion.—That the urine of the pregnant female undergoes certain changes, is by no means a dis- covery of our own timeS. The fact is alluded to in the writings of Hippocrates and other of the early fathers.* Within the last tAventy or thirty years, special attention has been directed to an element in the urine—kiestein; this name was, I believe, given to it by Nauche, who, together with numerous others, including our OAvn countryman, Dr. Elisha Kane,f has made some interesting contribu- tions on the subject. Kiestein consists of a whitish pellicle; and, when completely formed, its appearance has been compared to the scum of fat, which is observed on the surface of cold broth. Dr. Kane, in eighty-five cases of pregnancy, recognised a Avell-defined pellicle in sixty-eight; in eleven the pellicle was but partially formed, while in six it was absent. The pellicle will sometimes be detected thirty- six hours after the excretion of the urine, and again not until the eighth day. Kiestein has been observed as early as the fifteenth day after fecundation, and frequently at the second month. From the third to the sixth month, it exhibits its most marked charac- teristics ; from the seventh month, it gradually diminishes. Why should this element, kiestein, be found in the urine of the pregnant and parturient female ? It is absurd to suppose that it is there as a mere coincidence ; and Ave, therefore, are justified in ask- ing some explanation of its presence. Is the kiestein in the urine anything less than a demonstration, that nature is engaged in the elaboration of food necessary for the infant as soon as it is born— and is the passage of this substance from the system, through the kidneys, any less of a demonstration than its accumulation in the blood Avould be productive of injurious consequences? Both of these circumstances seem to receive confirmation from the import. ant fact, that, Avhen the child takes the breast, and the secretion and excretion of milk through the mammary organs are in full operation, there is no longer any kiestein to be detected in the urine ; in addi- tion, among the constituents of kiestein is casein, which, you should remember, is an important element in human milk.J Again : recently Blot has announced to the French Academy of Medicine the interesting fact that sugar exists normally in the urine of all pa?'turient women, of all nursing women, and likewise in the urine of a certain number of pregnant women.% Here, then, are two ele- * In 1560, Savonarola spoke very particularly of the modifications of the urinary secretion consequent on gestation, and his description of these changes would seem to indicate that the substance known as kiestein had actually been recognised by him, although not under that name. [Practica Canonica de febribus, pulsibus, uriuis, &c. By J. M. Savonarola, 1560.] f The American Journal of Medical Sciences. 1842. j Kiestein is not invariably found in the urine of the pregnant female, and may be produced by numerous pathological conditions of the system. g It is proper to state that the announcement of Blot has been regarded as crro- 136 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ments, casein and sugar, both components of human milk, found in the urine, and consequently must exist in the blood of the puerperal woman. In certain cases, the urine of the pregnant female is found to con- tain albumen in greater or less quantity, and it is stated as an interesting fact that the albuminous urine of pregnancy does not produce re-action Avith the liquor of Barriwil, while the same cha- racter of urine assumes a violet color, and produces a dark precipi- tate in cases of Bright's disease. Pregnancy, therefore, is a modified condition of the system, but not a diseased condition ; and the type of the modification is, as a general rule, in exact relation with the demands of nature for the accomplishment of the great and mysterious object in Avhich she is engaged—the reproduction of the species. You are not, how- ever, to understand me to say, that pregnancy is not oftentimes complicated AAnth disturbed action, amounting to disease, Avhich Avill require all your vigilance, and a full measure of skill, to arrest it. The Arery vomiting to which we haAre alluded as, under ordi- nary circumstances, constituting one of the physiological pheno- mena of gestation, sometimes places in such imminent peril the safety of the mother, that it not only requires the interposition of the accoucheur, but at the same time presents for consideration one of the gravest topics in the Avhole practice of midwifery, viz. pre- mature artificial delivery—which question we shall fully discuss under its appropriate head. Is the Female Pregnant ?—With these general observations, we shall now enter upon the discussion of the question—How are you to know that pregnancy exists ? And here, gentlemen, we approach a subject which, in every respect, is entitled to your profound atten- tion. Many of you are, as it were, just on the threshold of life, ignorant of the ways of the world, and, therefore, unable to appre- ciate, on the one hand, the schemes of the depraved, and, on the other, the sad wrongs to which the innocent are oftentimes sub- jected. You will not be engaged in practice long before you will be called upon to appreciate, in all their stirring truth, the solemn obligations to society, which your profession will necessarily impose upon you; nor can you form any adequate idea of the influence which you, as medical men, are destined to exercise in the commu- nities in which you may respectively become resident. Touching this very question of pregnancy, your opinion will be invoked by the judges and the lawyers of the land; it may become your pro- vince to stay the arm of the law in the execution of retributive jus- neous by Leconte, who has seen that the quantity of uric acid is increased in the urine of nursing women, which fact, he thinks, is the cause of the supposed error of Blot. On the other hand, Brucke maintains that sugar does really exist in a nota > ble amount in nursing women. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 137 lice; and, on the accuracy of your decision, may depend not only the Avell-being of society and the happiness of individuals, but human life itself will often be at your mercy. In most Christian countries, in accordance with the legi.slation of the Egyptians on this subject, the law obtains that if a female shall be convicted of a high offence, the penalty of which is death, the sentence shall be suspended, if it be proved that she is pregnant.* Who, in a plea of this kind put forth by the unhappy creature, in the hope that the day of her ignominy may be postponed, will be called upon to decide the truth or falsity of that plea? It is a question not within the jurisdiction of the learned courts— their province is to sift evidence as presented by witnesses on the stand, and, through the proper poising of the scales of justice, to protect innocence, and award to crime the decrees of the common- wealth. The plea, gentlemen, will be submitted to the decision of the medical man, and upon his testimony Avill the issue be deter- mined. Again: imagine the case of a woman, Avho, in the desire for gain, or urged on, perhaps, by some more malignant motive, charges the father of a family with having violated her person ; and thus, Avith a vieAV to a successful issue of her scheme, feigns preg- nancy. In this case, too, the testimony of the medical man must decide the question. A woman who has strayed from the path of virtue, and Avhose abandonment results in impregnation, stu- diously endeavors, if not lost to all sense of propriety, to conceal her situation; and Avhen she approaches the medical practitioner for counsel, will have recourse to every art and subterfuge bjr which she may hope to delude his judgment, and accomplish the fiendish purpose of throwing a mantle around her own shame, by the destruction of the child she carries Avithin her! When engaged in the practice of your profession, you will fre- quently be consulted by persons of this description, and, if you suffer your judgments to be dazzled, or your feelings to become too deeply interested, the most painful consequences may ensue. To distinguish betAAreen actual pregnancy, and the numerous diseases capable of simulating it, requires on the part of the accoucheur extraordinary circumspection ; and as he is, from the very nature of his profession, the only earthly tribunal to which the final appeal is made in cases inA*olving the dearest interests of society, and the * It is marvellous that so enlightened a country as England should be guilty of the strange inconsistency of recognising the plea of pregnancy as a motive for a stay of execution, and yet be so indifferent, in her legislation, as to the manner in which that plea shall be tested. In the decision of a question, involving such grave cousequences to both the guilty parent and her innocent child, instead of submitting the arbitration to well-educated and experienced medical men, the law calls for a jury of twelve ignorant women, and the issue depends, not upon whether pregnancy actually exists, but upon whether or not the woman has quickened. This is, indeed, singular legislation! 138 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sacred rights of individuals, it folloAvs that the responsibility imposed upon him is most fearful. A case occurred some years since in this city, which is Avell calculated not only to arrest attention, but to fix on the mind the necessity of positive knoAvledge in obstetric medicine, and the value of accurate diagnosis in disease. A female applied for professional advice; she had for some time previously labored under general derangement of health, and wTas most solicitous for relief. The practitioner Avhom she consulted, being much embarrassed by the history of the case, requested the opinion of several medical friends. The consultation resulted in the unanimous decision that the patient was affected Avith dropsy, and it was proposed that the operation of paracentesis, or tapping, should be performed. The medical gentlemen assembled, according to appointment, and the trocar was thrust into the abdomen of the confiding woman; no fluid, however, escaping; it was, indeed, literally Avhat has been denomi- nated a " dry tap," and you may Avell imagine the astonishment of the spectators. A few days subsequently, the patent died from the effects of inflammation, and the autopsy revealed the interest- ing but astounding fact, that the instrument, instead of passing into what was supposed to be an accumulation of fluid, was thrust into the very heart of a living fcetus! What greater misfortune could befall any one of you than an error like this—to survive it, would require almost a lifetime, so far as your professional repu- tation is concerned, to say nothing of the stinging rebukes of conscience. But, gentlemen, it will sometimes become your duty to shield innocence against the suspicions of an unjust world, and vindicate purity against the assaults of the base and heartless ; and it is in instances like these in which the question of pregnancy, as a mere point of diagnosis, becomes invested Avith its highest degree of inte- rest. Can you imagine anything more melancholy than the Avanton destruction of character through mere suspicion, unless, indeed, it be the destruction of character through the cabals of the depraved? You Avill, I am sure, pardon me, for mentioning the following touch- ing case, Avhich occurred in my practice some years since; and which carries with it its own sad moral; it is worthy of meditation, and is a proper exponent of scenes, which you may be called upon to encounter in your professional career. May it impress you Avith the fulness of your responsibilities as medical men, and cause you to appreciate the sacred offices of your proiession : / I was requested to visit a lady, who was residing in the State of New Jersey, about thirty miles distant from New York. I imme- diately repaired to her residence, and, on my arrival, was received by her father, a venerable and accomplished gentleman. He seemed broken in spirit, and it was evident that grief had taken a THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 139 deep hold of his frame. On being introduced into his daughter's room, my sympathies Avere at once awakened on beholding the wreck of beauty which Avas presented to my view. She Avas evidently laboring under that bane of human existence, consump- tion, and it was quite manifest from her wasted frame, that death had claimed his victim. My presence did not seem to occasion tha slightest disturbance, and with the smile of an angel playing on her countenance, she greeted me Avith these words: " Well, doctor, I am glad to see you on my beloved father's account, for he will not believe that I cannot yet be restored to health. Life, however, has lost all its charms for me, and I impatiently long foi the repose of the grave." These words were spoken Avith extra- ordinary gentleness, but yet, with an emphasis, which, at once, gave me an insight into the character of this lovely woman. Her father was a clergyman of high standing in the English church, and had a pastoral charge in England, in Avhich he con- tinued until circumstances rendered it necessary for him to leave that country, and seek a residence in America. At a very early age, this young lady had lost her mother, and had been almost entirely educated by her father, whose talents, attainments, and moral excellence admirably fitted him for this important duty. When she had attained her eighteenth year, an attachment was formed between her and a young barrister of great promise and respectability. This attachment soon resulted in a matrimonial engagement. Shortly after the engagement she began unaccount- ably to decline in health ; there Avas a manifest change in her habits ; she was no longer fond of society ; its pleasures ceased to allure and prove attractive ; the friends Avhom before she had caressed Avith all the warmth of a sister's loAre, now became objects of indifference; in a word, she was a changed being—her personal appearance exhibited alterations evident to the most superficial observer; her abdomen enlarged, the breasts fuller than usual, the face pale and care-worn, and the appetite capricious, with much gastric derangement. Many were the efforts made to account for this change in the conduct and appearance of the young lady in question. Speculation was at work, and numerous were the sur- mises of her friends. The rumor soon spread that she was the victim of seduction, and her altered appearance the result of pregnancy. The barrister to whom she was affianced heard of these reports, and instead of being the first to stand forth as her protector, and draw nearer to his heart this lovely and injured girl, thus measur- ably assuaging the intensity of grief with which she was over- whelmed, addressed a lttter to her father requesting to be released from his engagement. This Avas, of course, assented to without hesitation. The daughter, conscious of her own innocence, know* 140 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ing better than any one else, her OAvn immaculate character, and relying on heaven to guide her in this her hour of tribulation, requested that a physician should be sent for, in order that the nature of her case might be clearly ascertained. A medical man accordingly visited her, and, after an investigation of her symp- toms, informed the father that she Avas undoubtedly pregnant, and suggested that means should be instantly taken to keep the unplea- sant matter secret. The father, indignant at this cruel imputation against the honor of his child, spotless as he knew her to be, spurned the proposition, and instantly requested an additional consultation. This resulted in a confirmation of the opinion previ- ously expressed, and the feelings of that parent can be better appreciated than portrayed. Without delay, that good man determined to resign his pastoral living, gather up his little property, and proceed with his daughter to America, where, in a land of strangers, he hoped for that comfort and peace of mind, which had been denied him in his own native home. On her passage to this country, the daughter became extremely ill, and there being a physician on board the vessel, his advice was requested. After seeing the patient—she was affected at the time with excessive vomiting from sea-sickness—he told the father there was danger of premature delivery. Such, therefore, was the general appearance of this lady, that a medical man, taking simply appearances as his guide, at once concluded she was pregnant. This is about the substance of Avhat I learned of this interesting and extraordinary woman, and my opinion was then requested as to the character of her malady. My feelings were very naturally much enlisted in her behalf, and I proceeded with great caution in the investigation of her case. Without entering at this time into details as to the manner in which I conducted the examination, suffice it to say that, after a faithful and critical survey, most minutely made in reference to every point, I stated in broad and unequivocal language—that she was not pregnant. The only reply this gentle creature made on hearing my opinion, was—"Doctor, you are right!" These words were full of meaning, and their import I could not but appreciate. They were uttered neither with an air of triumph, nor Avith any feeling of unkindness toAvard those, Avho had so cruelly abused her. The father was soon made acquainted with the result of my examination, but he indicated not the slightest emotion. His bearinc was quiet and dignified. It Avas evident that he had never for one moment faltered in the belief of his daughter's virtue, nor did he require from me or any other living being the assurance that his child had been shamefully wronged. He asked me with great solicitude whether something could not be done to restore her to health, and I thought the old man's heart would break, when I THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 141 told him, that his daughter Avas in the last stage of consumption. It Avas the misfortune of this young lady, to labor under an affec- tion of the Avomb, Avhich simulated, in several important particulars, the condition of pregnancy, and which the world, in its ignorance and undying thirst for scandal, might have readily supposed did in fact exist: yet, there Avas no excuse for the physician, guided as he should have been by the lights of science, and governed by the principles of a sound morality. When I stated unequivocally, and without reservation, to the lady that she was not pregnant, I gave an opinion which I knew Avould stand; my examination was conducted with the single object to reach the truth, irrespective of any other consideration; my sympathies, it cannot be denied, Avere altogether with this afflicted girl; but they Avere not so irresistible as either to blind my judg- ment, or cause me to surrender what I knew was due both to science, and my own reputation as a medical man. The result of the investigation impressed me with the conviction, beyond any shade of doubt, that the entire train of symptoms, indicating gestation, was due to an enlargement of the uterus, altogether unconnected with pregnancy, produced by the presence of a large fibrous tumor occupying the cavity of this organ. This opinion, I admit, was not arrived at Avithout some degree of caution— caution in every wray justified by the peculiar nature of the issue involved in the decision. I left the father with the pledge that he would inform me of the dissolution of his daughter; and thus afford an opportunity, by a post-mortem examination, of testing the truth of my opinion. About four weeks from this time, I received a note announcing her decease, and asking that I would immediately hasten to the house, for the purpose of making the examination. Dr. Ostrom, now practising in Goshen, at my request, accompanied me, and assisted in the autopsy. It may surprise you, gentlemen, yet it is an interesting fact to communicate, for it exhibits the true and unwavering character of the man, that, during the post-mortem examination, the father stood by and Avitnessed every stage of the operation; his form Avas erect, his face pale and thoughtful, and so crushed was his heart that one "tear, it seemed to me, would have broken the agony of his grief. As he stood before me he was not unlike the stricken oak in the forest, which, though stripped of its branches, was yet upright and majestic. The moment I had removed the tumor from the womb he seized it convulsively, and exclaimed ; " This is my trophy ; I will return with it to England, and it shall confound the traducers of my child !" Here, you perceive, both character and life were sacrificed by error of j udgment on the part of those Avhose counsel had been 142 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. invoked. Without a due appreciation of their responsibility, heed- less, as it Avere, of the distressing consequences which Avould inevitably result from the erroneous decision of a case in which character wTas so deeply involved, the medical gentlemen, unjust to themselves and to the profession of Avhich they should have been in part the conservators, rashly pronounced an opinion which consigned to an early grave a pure and lovely being, and broke the very heart-strings of a devoted and confiding parent. Let me, then, gentlemen, by every sense of duty, by the very love which should animate you to become, in these trying emer- gencies, the firm and uncompromising dispensers of rigid justice; let me, I repeat, by these considerations, urge you to a faithful and devoted study of the means by which alone you will be enabled to arrive at positive conclusions upon this momentous question. The entire investigation is simply one of evidence, and what is most needed, will be to separate true from false testimony; to bring yourselves to the consideration of the subject with but one object in view—the elucidation of truth. With preconceived opinion, or with prejudice, you have nothing to do. Let your minds, in the examination of this question, be " like a sheet of white paper," with no bias for or against; and let it be your inflexible resolution to decide by the testimony, so help you God! It shall be my purpose, in the succeeding lecture, to examine the nature and value of this testimony. LECTURE X. Evidences of Gestation; how divided; their Relative and Positive Value—Suppres- sion of the Catamenia—Can a Pregnant Woman Menstruate ?—Nausea and Vomiting material to a Healthy Gestation—Depraved Longings—Salivation of Pregnancy; how distinguished from Mercurial Salivation—Salivary Glands in Connexion with the Mammae iD the Female, and the Testes in the Male—Sym- pathy between; Illustration—Parotitis—Mammary Changes—Secretion of Milk not always dependent upon Pregnancy—Milk in the Breast of the Virgin, and in the Male—Mammary Metastasis—Illustration—The Areola; its Value—Color not its Essential Attribute—Deposit of Black Pigment and Excitement of the Sexual Organs—Connexion between—The True Areola; its Value—Areola around the Umbilicus—Discoloration of Integument between Umbilicus and Pubes—Dr. Montgomery's View of Areola—Can Pregnancy exist without the Areola ?—Changes in Uterus and Abdomen—First two Months of Gestation, Uterus descends into Pelvic Excavation—Consequences—Vesical Irritation—. Pain and Depression of Umbilicus; how Explained—Impregnated Uterus at end of third Month—Gradual Ascent of the Organ—Right Lateral Obliquity—Pain in Right Side; how Explained—Uterus at end of eighth Month—Cough and Oppressed Breathing; Reasons for—Projection of Umbilicus; its Value as a Sign of Pregnancy—Uterus at end of ninth Month—Contrast with eighth Month —Ascent of Organ in Primipara and Multipara; Difference Explained—Bladder and Urethra; Change in Position—Thrombus of Vagina and Vulva—ffidema of Lower Extremities; how accounted for. Gentlemen—The evidences of gestation may be said to possess different grades, and, therefore, we have, 1. Presumptive evidence; 2. Probable evidence ; 3. Positive or unequivocal evidence. Each of these classes or grades of testimony has its own special source, and is due to certain special influences, which it becomes you as obstetricians thoroughly to comprehend. The presumptive and probable evidences may or may not be the result of gestation, for the important reason that they may be the product of various morbid conditions of the uterus or other organs of the system, with Avhich pregnancy itself has no sort of connexion. But, on the contrary, the positive, unequivocal evidences are alone the offspring of impregnation ; so that, when this latter class of testi- mony is recognised, it is undoubted proof that pregnancy exists; it must be remembered that it is the only proof which will justify the opinion—when any important issue is involved in the decision —that a woman is really with child. You see, therefore, how essentially necessary it is, in the examination of this subject, to draAv a broad distinction betAveen certain and uncertain evidence; 144 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and, on no account, to suffer your minds to become beAA'ildered by false or collateral issues. The point to be determined is simply—■ Does pregnancy exist ? It is precisely like any other case, the decision of which depends upon testimony ; the only difference being that, in courts of justice, the issues are determined by human or oral evidence, Avhile with us, we have oftentimes nothing to guide us in our deliberations but the silent, yet eloquent language which nature employs as the true exponent of the condition of the economy. Presumptive Evidences: 1. The Suppression of the Catamenia.—A very marked belief has obtained that when a female becomes impregnated she ceases to menstruate during the period of her gestation. As a general rule this is undoubtedly true ; but there are so many other con- ditions of the system in which this function becomes temporarily arrested, that, by itself, it is of little or no value as a sign of preg- nancy. It is strange that so good an observer as Denman should have regarded the suppression of the catamenia as an unerring proof of gestation; or, in other Avords, that a pregnant Avoman never menstruates. It can scarcely be necessary to enter into an argument to prove how unsupported this opinion is by facts. You have seen in the clinic more than one case, in which the function • continued with regularity during the Avhole period of pregnancy.* I have attended a lady in this city in four confinements, A\ho has not had her courses suppressed during any of her pregnancies, and who was never positively certain of her condition until the period of quickening. Again : it is not uncommon for young married women to have a slight show for two or three periods after their first impregnation ;f and ignorance of the fact has often led to a false diagnosis.! It should be recollected, too, that the menses will occasionally become arrested soon after marriage, and continue so for one or more months without the existence of gestation, the arrest of the function in these cases being most probably due to the new rela- tions of the individual. It is necessary, alsoy to remind you—so universal is the popular opinion that when a woman becomes preg- * See Diseases of Women and Children, p. 171. \ This circumstance seems to have been well understood by Van Swieten, who says, " However, although naturally the menstrua cease in a woman with child, yet with some it happens that during the first months of pregnancy they shall continue to flow without injury to the fcetus, but for the most part in a smaller quantity." [Commentaries, vol. viii., p. 397.] \ Dr. Elsasser, of the Stuttgart Lying-in Hospital, records fifty cases in which menstruation occurred during pregnancy, as follows: once in 8, twice in 10, three times in 12, four in 5, five in 6, eight in 5, and nine times in 2 instances. It occurred most frequently in early pregnancy; fifteen were primiparse, thirty-five multipara. PLATE I. w v^m^ %, iL^# Thvd montli THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 145 riant she ceases to have " her turns"—that in cases in which a female desires to conceal her situation, she will sometimes mark her linen Avith blood, in the hope of imposing upon the practitioner and others, in reference to her true condition. Is Ovulation incompatible with Gestation ?—It would seem in perfect keeping with the physiology of ovulation that this function, as a general rule, should cease as soon as fecundation has been accomplished, and its suppression continued during the entire period of the gravid state. The relations of the uterus and ovaries, Avhen fecundation has been effected, become, for the time being, changed. The former constitutes a new centre, and there is a constant increase of fluids toward it in order that it may be enabled to accomplish the nutrition and development of the foetus. The ovaries, on the contrary, although they do actually become enlarged during pregnancy, surrender their special function—the periodical ripening of the ovules. This, I repeat, is undoubtedly the rule ; but, like all rules, it has its exceptions. The fact that a menstrual floAV is possible in gestation necessarily involves the admission of ovulation; for the sanguineous discharge Avhich ordinarily cha- racterises the menstrual period is but the product of ovulation. At the same time it must be admitted that the regular catamenial evacuation through the term of pregnancy must be regarded as an extremely rare exceptional circumstance; and when it does con- tinue after the early months, the discharge of blood can only pro- ceed from the cervix or upper portion of the vagina, the connex- ion of the ovum Avith the internal surface of the organ being such, as to prevent any portion of this surface from constituting the source of the discharge. As menstruation, Avhen it takes place during pregnancy, is most apt to occur in the first tAvo or three months, it might possibly be confounded with a threatened miscarriage; the distinction, how- ever, Avould consist in the more or less regularity of its recurrence, and its periodical cessation, together Avith the fact of an absence of any appreciable cause to which the discharge of blood could be ascribed. It should also be recollected that the appearance of the catamenia, in consequence of the congestion accompanying it, would itself, in the earlier period of pregnancy, be likely to provoke miscarriage. Hence, in cases like these, the importance of sound judgment; let the patient, at the time, be kept quiet, and, if ple- thoric, the abstraction of a small quantity of blood, Avith a soluble condition of the bowels, would be indicated. If, on the contrary, she be in an opposite condition—nervous and irritable—then the soothing influence of antispasmodics or anodynes is the resource. There are, however, other conditions of the uterus than a threatened miscarriage, Avhich might possibly be mistaken for the catamenia—such as a polypus, ulcerated carcinoma, or even a 10 146 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. fibrous tumor developed Avithin the uterine cavity, each of Avhich Avould be accompanied Avith more or less sanguineous discharge, and it may also be added that the hemorrhage consequent upon placenta praevia might, under certain circumstances, lead to embar- rassment in diagnosis. Menstruation only during Pregnancy.—The experience of Dewees, Baudelocque, and others, seem fully to establish the circum- stance—and examples are given by these Avriters—that, as exceptional cases, some women menstruate during their gestation and at no other time. Deventer cites a remarkable case in Avhich menstruation occurred during gestation only, in four successive pregnancies. In- stances, Avell authenticated, are also recorded showing the possibility of impregnation before the first menstrual eruption, and also after the final cessation of this function, so far, at least, as the sanguineous discharge is concerned; and, again, you will meet sometimes with examples of pregnancy during the period of lactation before the reappearance of the catamenia; so you see, gentlemen, that the cata- menia, Avhether present or absent, establishes nothing, per se, as to the existence or non-existence of gestation; and I may observe, while you remember the general rule, that pregnancy is followed by suppression of the menses, you are also to bear in mind the nume- rous exceptions. 2. Nausea and Vomiting, with Depraved Appetite.—I have already remarked to you that women, Avhen they become pregnant, are usually affected with sick stomach, and you have also been informed of the importance of this gastric irritability to a healthy gestation. It is an interesting fact that, in some females, nausea manifests itself almost simultaneously with the act of fecundation. I have known ladies who, from this very circumstance, would positively affirm that they were pregnant, and the result proved that they were right.* The nausea and vomiting of gestation are peculiar, and differ from idiopathic or primary vomiting in the important fact that, in the latter, there is an indication of more or less primary disease of the stomach; Avhile, in the former, there is no such indication, nor are there any symptoms of general ill-health ; as soon as the con- tents of the stomach have been ejected, the female is, for the time being, quite comfortable. Ordinarily, the nausea and vomiting of pregnancy cease about the period of quickening, and frequently earlier. Sometimes, hoAvever, they will recur during the last two * There are some curious cases reported in support of this opinion. " I was engaged to attend a lady in her fourth labor, which she told me she expected would take place on the 12th of November, early in the morning of which day I was sent for, and she gave birth to a daughter; she told me that she had always reckoned nine months from the first feeling of nausea, -and had never been mistaken." [Montgomery, p. 90.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 147 or three months of gestation, and this seems to be dependent upon mechanical causes. The uterus in its ascent at this period induces more or less irritation of the stomach through the pressure exer- cised upon it, and hence vomiting, under these circumstances, will be more likely to take place immediately after a meal, in conse- quence of the greater distension of the organ. I say that the irri- tability of the stomach in the latter periods of pregnancy is chiefly mechanical; it is well to distinguish it from the nausea and vomit- ing of the earlier months, which I hold to be altogether physio- logical, and Avhich has been explained, in the preceding lecture, to be due to a reflex action of the spinal cord from the uterus to the stomach.* It must, however, be borne in mind, that mere functional or organic disease of the uterus will oftentimes be followed by this irritability of stomach ; it is, indeed, a very common result of sup- pression of the courses from any of the causes, with which preg- nancy itself has nothing whatever to do. I am not a little surprised that so accomplished an obstetrician,! and so valued an authority as Paul Dubois, should say, that vomit- ing is not necessarily associated with gestation. Indeed, I regard this symptom as among the most constant accompaniments of preg- nancy, and its relation to this state, as a general rule, is based on sound physiology. 3. Depraved Appetite.—A frequent consequence of impregna- tion is a depraved appetite—a longing for unnatural food—so that some of your patients will consume, Avith infinite gusto, chalk, slate- pencils, and other kindred dainties. Some become passionately fond of fruits; I kneAV a case in which the lady exhibited such a passion for oranges, that the quantity she consumed is altogether incredible. On the authority of Tulpius,J salt fish Avill sometimes present irresistible charms. I attach more than ordinary importance, as a sign of pregnancy, to this depraved appetite, and am disposed to regard it, under certain conditions, as quite a significant circumstance. For example, if a married woman, Avhose general health has been uniformly good, should suddenly exhibit this morbid taste, I should be much inclined to look upon it, all things being equal, as a strong presumptive evidence of impregnation. If you ask me to explain why, my answer is, I cannot, except as a matter of observation. But there * It was the opinion of Haller that the vomiting in gestation is occasioned by a putrid element in the seminal fluid of the male, which, becoming mingled with the blood, constitutes a sort of poisonous miasm; this may be classed among the fanciful notions not unfrequently met with in the writers of the past. \ Traite Complet de l'Art des Accouchemens, p. 503. j " I once saw a woman who, being with child, was so exceedingly fond of salted herrings, that before delivery she had eaten fourteen hundred, and this without any offence to her stomach, or prejudice to her health." [Art, Obstetric-compend., p. 68.] 148 THE PRINCIPLES-AND PRACTICE OF OBSTETRICS. are many things, which I firmly believe, and yet cannot compre- hend, except on the principle of faith. Man's belief Avould be sadly curtailed if he rejected everything for Avhich he could not give a satisfactory explanation. You believe in God, and yet who ajmong you can comprehend his infinite existence ? You believe in eternity, and where is the human intellect adequate to the compre- hension of the vast theme ? Salivation.—In connexion Avith this depraved taste, it may be mentioned that some women, during their pregnancy, Avill exhibit full ptyalismor salivation, and secrete enormous quantities of saliva. But the ptyalism of pregnancy differs from that of mercury in the fact that there is no mercurial foetor, no soreness or sponginess of the gums, the irritation being confined to the salivary glands them- selves ; and here allow me to remark, by way of episode, that these distinctions should not be lost sight of, for it may, peradventure, happen, that your reputation may be more or less involved in the 'recollection of them. Let us suppose a case in illustration: Mrs. A. consults one of you during her pregnancy; her bowels are torpid, or, for some other reason, you judge it necessary to order an aperi- ent medicine. Soon after this she becomes salivated. You are at once charged with having administered mercury; you are severely censured, and, in all probability, your exeat Avill be very unceremo- niously furnished you, not with a God-speed invocation, but with all imaginable prejudice against you and your skill as a physician. To a young man just commencing professional life, and without reputation to sustain him, such a contingency would prove a severe trial, unless he could promptly and satisfactorily show that the salivation complained of was one of the occasional phenomena of pregnancy; and his justification would be fully established by the diagnostic evidences of this latter form of ptyalism, to which Ave have already alluded. The question of salivation during pregnancy, in a physiological sense, is interesting, for there can be no doubt of the sympathy existing between the sexual organs, both in the male and female, and the salivary glands. In parotitis, or mumps, in which the parotid gland becomes the seat of inflammation, it is quite usual, after a few days, for the testes in the male, and the mamma? in the female, to become enlarged and painful; as soon as this enlargement takes place, the tumefaction of the parotid disappears. Instances, also, will sometimes occur of malignant disease, developing itself in the submaxillary and parotid glands of women at the period of the final cessation of the menses. 4. Changes in the Breasts—The Secretion of Milk—The Are- ola,—The general rule is that, soon after impregnation has taken place, the breasts become the centre of an afflux of fluids, and con- sequently enlarge; the enlargement is accompanied by more or less */ PLATE II Tifth month. / THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 149 of a pricking or stinging sensation; they are much firmer to the touch, and enjoy a greater degree of mobility. This greater firm- ness and mobility are not usually observed in the mamma1, Avhen their increase of size is merely dependent upon the accumulation of fatty material. The nipple, in consequence of the tumefaction, is more prominent, and oftentimes painful. The veins, coursing along the breasts, become distended, and can be distinctly traced by the naked eye. The particular period after pregnancy at which these changes occur is variable; sometimes they begin to develop themselves in two or three weeks, sometimes not until the lapse of two or three months, and, in women of delicate constitution, there Avill oftentimes be little or no change in the size of the mam- mae until the latter months of gestation. Indeed, I have seen cases in which, even after delivery, there could be detected not the slightest physical alteration, and generally, in such instances, the secretion of milk does not commence for several days after the birth of the child, and occasionally, there is not a drop secreted at any period after delivery, thus depriving the mother, Avhose heart is in the right place, of that most natural and sacred duty—the nursing her infant. The mammae are really annexae of the generative organs in the female, and, according to the general law, have an important office imposed upon them—the elaboration of food adapted to the Avants of the neAV-born child. Charles Robin has pointed out an extremely interesting fact in reference to the true physiological relations of the mamma; to the uterus during the progress of pregnancy. He has shoAvn that there is a correspondence in the development of the tissues of the uterus, and the glandular culs-de-sac of the mammary organs. These glandular culs-de-sac, in a state of partial atrophy Avhen gestation does not exist, become cognisable, and are lined with their epithelium at the time the fibre-cells of the uterus undergo an increase in volume. There are numerous causes, other than pregnancy, capable of giving rise to an increase of volume in the breasts. It is quite common for women to suffer more or less from tension of the mam- mae at the time of the menstrual turns. In fact, this fulness of the breasts is sometimes the very indication by Avhich the female becomes aAvare of the approach of her catamenial period. Again : nothing is more common than enlargement of the breasts following sup- pression of the courses—the same thing occurs, also, in Ararious diseases of the uterus—more especially in cases in which there may be morbid growths, such as polypus, submucous fibrous tumors, hydatids, or other morbid developments. Milk in the Breasts. -The presence of milk in the breasts is regarded by many as a very important evidence of gestation ; but while it is one of the usual accompaniments of pregnancy, it must 150 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. not be forgotten that the secretion of milk may take place in vari- ous conditions of the system in which impregnation has not occur- red. The very mammary sympathies to which we have just alluded, including the secretion of milk, so far from being necessarily due to pregnancy, are, in fact, oftentimes the results of ovarian excite- ment,* no matter from what cause. Hence, milk Avill sometimes be Becreted in disease of the ovary, and in the various menstrual aber- rations. It is a well-established fact, that milk has been recognised in the breasts of young virgins, and also of males. An interesting case is mentioned of a faithful young woman who, in order to quiet the infant of her mistress, was in the habit of applying it to her breast, the consequence of wrhich was a free secretion of milk. Perhaps one of the most extraordinary examples of this kind on record—and which is regarded as perfectly authentic—is that of a little girl, in France, eight years of age, deaf and dumb, Avho, by the repeated application to her breast of a young infant Avhich her mother was suckling, had sufficient milk to nourish the child for a month, during Avhich time the mother was unable to nurse it on account of sore nipples. This little girl Avas exhibited to the Royal Academy of Surgery on the 16th of October, 1783, and had such a quantity of milk that, by simply pressing the breasts, she caused it to floAv out in the presence of the Academy; on the same day, she did the same thing at the house of Baudelocque, before a large class of pupils.f The fact may surprise you, but it is well known that virgins, old Avomen, and even men, are often employed as Avet- nurses in the Cape de Verde Islands. In the loAver animals, milk will occasionally be found in the teats as the mere result of sexual excitement—in some instances, in Avhich coition has taken place without fecundation, and in others, in which the female has become excited Avithout intercourse with the male.J * On the 11th of May, 1857, Mrs. R. came to the clinic for professional advice under the following circumstances: She had been married twenty-three years; was forty-two years of age, and her only child was nineteen years old. With the excep- tion of the period of pregnancy and lactation, her courses had always been regular, until about six months before she applied for advice; but she had within these six months become much alarmed from the occasional swelling of one of her breasts; and, on inquiry, it was ascertained that at the time the courses should have appeared, the tumefaction of the breast invariably occurred, and subsided as soon as the cata- menial flow took place. There was not the slightest indication of tumor or other disease of the mamma; it was simply an example of what, perhaps, might be pro- perly termed mammary metastasis. The patient was directed to have four leeches applied to each groin a few days before the usual time for the return of the menses, with a view of relieving the ovarian irritation. This simple suggestion had the effeot of restoring the function, entirely removing the engorgement of the mamma, I have seen several cases of hypertrophy of the breasts following amenorrhoea, and the hypertrophy has always yielded on the restoration of the menstrual function. f Baudelocque, L'Art des Accouchemens, torn. L, p. 188, in 8v . Paris, 1815. j Harvey, in speaking of bitches which did not conceive after coition, and which, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 151 The Areola.—The next change in the breasts to which I shall allude, as indicative of pregnancy, is the condition of the areola— that peculiar circle which immediately surrounds the nipple. In the virgin, in a normal state, this circle is characterized by a beau- tiful hue, not unlike the tint of the budding rose. But I have seen it, even in the virgin, under certain conditions of morbid action, change this tint for a discoloration more or less marked ; it is essen- tial that you should understand the error, which seems to have been perpetuated by many clever writers respecting the color of the areola. According to them, the color is the principal or character- istic attribute. This, however, is not so, and the sooner the error be corrected and heeded, the better it will be for just opinions. Remember, gentlemen, I am now alluding to what may be denomi- nated the true areola, by which I mean the areola Avhich, when recognised, is, in my opinion, a very solid evidence that gestation exists. There is no doubt that, under ordinary circumstances, when pregnancy occurs, there is a discoloration of the areola; but as there are other conditions of the system in which this change of color takes place, it is quite evident that there must be some characteris- tics more reliable in order that a correct diagnosis may be arrived at; in other words, if the areola be worth anything as a test of pregnancy, it must have some marked and peculiar developments dependent exclusively upon gestation; and this is a question Avhich we shall examine presently. Females Avho are subject to hysteria and the various menstrual aberrations, Avill occasionally have dis- coloration of the areola; and I have observed it as by no means an unusual accompaniment of dysmenorrhcea dependent upon chronic inflammation of the ovaries.* It is worthy of remark that the deposit of coloring matter, both in pregnancy and in undue irritation of the sexual organs, has been observed in other portions of the system than in the areola of the nipple. For example, Blumenbach cites the case of a female peasant, whose abdomen became entirely black during each successive preg- nancy ; and a very remarkable instance is mentioned by Camper of a woman who, at the commencement of her gestation, began to turn brown, and before its completion, became perfectly black; the discoloration, however, gradually disappeared after the birth at the time corresponding with the completion of their gestation, if they had been fecundated, appeared to be in great distress, says: " Some of them have milk in their teats, and are obnoxious to the distempers incident to those which have already pupped." * Besides the change in the color, sometimes observed in dysmenorrhcea and other menstrual aberrations, there are occasionally certain developments characteris- tic of the areola of pregnancy, such as slight turgescence of the integument, and elevation of the follicles—but these developments are transitory, and disappear as boou as the menstrual excitement ceases. 152 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of her child. These and other instances, seem to prove, to a greater or less extent, a very marked relation betAveen this deposit of black pigment, and excitement of the sexual organs. Again: it is not unusual to observe, around the umbilicus of the pregnant woman, a dark areolar surface; and also a dark, sometimes brown, line extending from the pubes to the umbilicus. The areola has been studied with great attention by Dr. Mont- gomery,* of Dublin, and his description of its true characteristics, so far as being the result of pregnancy, is so faithful to nature, that I shall recall to you briefly Avhat he says on the subject. " I cannot," he observes, " say positively Avhat may be the very earli- est period at which the changes may be observed, but I have recognised them at the end of the second month, at Avhich time the alteration in color is by no means the most obvious circum- stance ; but the puffy turgescence (though as yet slight) not alone of the nipple, but of the Avhole of the surrounding disc, and the development of the little glandular follicles, with the developed state of the mammary veins, are the objects to which we should principally direct our attention; the color, at this period being, in general, little more than a deeper shade of rose, or flesh color, slightly tinged occasionally with a yellowish or light brownish hue. During the progress of the next tAvo or three months, the changes in the areola are in general perfected, or nearly so, and then it presents the following characters: a circle around the nipple Avhose color A-aries in intensity, according to the particular complexion of the individual, being usually much darker in persons with black hair, dark eyes, and salloAV skin, than in those of fair hair, light- colored eyes, and delicate complexion. The area of this circle varies, in diameter, from an inch to an inch and a half, and in- creases in most persons as pregnancy advances, as does also the depth of color. " In the centre of the colored circle, the nipple partakes of the altered color of the part, is turgid and prominent, its apex being more or less covered with little branny scales, produced by the drying of a sero-lactescent fluid which oozes from the part; the surface of the areola, especially that portion of it more immedi- ately around the base of the nipple, is rendered unequal by 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 a little raised ; emphysematous, turgescent, softer, and more moist than that which surrounds it; while on both, there are, 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 * Signs and Symptoms of Pregnancy. 2d Edition, p. 97. / PLATE IJI THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 153 of the areola, and for about an inch or more all round, presenting an appearance as if the color had been discharged by a shoAver of drops falling on the part. Dubois, referring to this appearance, applies to it the designation of secondary areola. This appearance is not recognised earlier than the fifth month, but toAvard the end of pregnancy is very remarkable, and constitutes a strikingly dis- tinctive character, exclusively resulting from pregnancy / the breasts themselves are, at the same time, generally full and firm ; and A'enous trunks of considerable size are seen ramifying over their surface, sending branches toAvard the disc of the areola; together Avith these vessels, the breasts not unfrequently exhibit, about the fifth and sixth months, and afterward, a number of shining, Avhitish, almost silvery lines like cracks; these being most perceptible in women who, having had before conception very little mammary development, exhibit a rapid and marked enlarge- ment on becoming pregnant. When once formed, these lines con- tinue permanent, and, therefore, will not serve as diagnostic marks of a subsequent pregnancy, and sometimes they do not form at all."* Such are the essential characters generally belonging to, or con- nected Avith, the true areola, the result of pregnancy ; and I quite agree in opinion with Dr. Montgomery that Avhen these peculiar features are recognised in the areola, they should be regarded as positive proof of pregnancy, no other condition being capable of producing them. The true areola, I repeat, in my judgment, and this opinion is founded on extended observation, is not recognised except as a consequence of gestation. The remarkable case which came under the observation of Hunter, it may be Avell to mention as an instance of his faith in this sign. It Avas chiefly on the presence of the areola that he founded his opinion of the existence of pregnancy in a youngj Avoman, Avho had been examined after death by his pupils, and in Avhom there was an intact hymen; and, therefore, the appearance of virginity. In laying open the uterus, it was found that Hunter was right. Let us for a moment look at the per contra of this question. Can pregnancy exist without the development of the true areola ? In my opinion it can, and upon the principle of an exception to a very general rule.f I have already remarked to you that some * See Plates 1, 2, 3, 4, 5, transcribed from Dr. Montgomery's work, and which are most graphic delineations of the areola in the different stages of pregnancy. f In December, 1856, I received a letter from Dr. H. P. Ferguson, of Western Virginia, who kindly sent me a patient, for advice, who had been under his profes- sional care for some montlis. The lady was twenty-seven years of age, had been married eight years, but had never borne any children, nor had she ever been preg- nant. Her general health had always been good, and her menstrual turns regular, 154 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. women Avill pass through their gestation Avithout the slightest enlargement of their breasts ; and you will occasionally meet with cases in which the changes in the areola do not commence their development until the latter months of gestation. It must also be recollected that nursing women, Avho have recently miscarried, may present the peculiar attributes of the areola; so that it may de- volve on you to show, not only that the true areola is absolutely the product of pregnancy, but that the pregnancy of which it is the product, still exists.* Probable Evidences: Changes in the Uterus and Abdomen.—You have already been told that, when fecundation takes place, immediate and remarkable until the June previous to my seeing her. From that time until December, when she first consulted me, her courses had been suppressed ; she had most of the ordi- nary symptoms of pregnancy, except that there was not the slightest change in the breasts, nor any approach to the formation of the areola. This lady had been much annoyed by nausea and vomiting for four months after the menses became sup- pressed, and her appetite had been remarkably depraved; her abdomen was en- larged corresponding with a six months gestation—and yet the breasts, which had always been small, exhibited not the slightest change in development. The patient observed to me, in reply to my inquiry, that she had not felt any movement in her abdomen; and, although she was most anxious to be a mother, she said she was quite confident she was not pregnant. Dr. Ferguson, in his letter, remarks, " Were it not that the breasts remain unchanged, I should say that Mrs. L. is undoubtedly in gestation; have you over seen a case of pregnancy unaccompanied by the slightest mammary development?" As this lady was most auxious to have her true situation ascertained, and as she had been rendered very unhappy by the apprehension that her enlarged size was occasioned by the presence of a tumor, which would destroy her life, I proceeded to a very thorough investigation of her case. On a vaginal examination, I soon discovered that the abdominal enlarge- ment was caused by the enlargement of the uterus; applying one hand to the abdomen, with a view of gently grasping the uterus, and the index finger of the other hand placed on the posterior portion of the cervix uteri, with an alternate movement of ascent and descent made with the hands thus applied, I very distinctly felt the passive motion of the foetus, known by the French as the ballotemcui, and sometimes described by the English under the term repercussion, to which 1 shall have occasion hereafter more particularly to allude, when.speaking of the vaginal explorations in reference to the diagnosis of pregnancy. So certain and unequivo- cal do I regard the ballotement as proof of gestation, that I at once, without the least qualification, assured the lady she was pregnant This opinion seemed to give her great pleasure; and she very quietly, but pointedly, asked me, "Whether I would stake my reputation on the opinion I had given." I immediately replied that I was quite content to abide by the revelations of the future, and that she would discover the future would fully indorse my opinion. She left New York January 3d for her home in Virginia, bearing with her a letter to Dr. Ferguson, in which I expressed my positive conviction of her pregnancy; all doubt in her mind was dissipated by the birth of a daughter on the 27th of the following March. * It will be observed that I have classed the areola among the presumptive evi- dences of gestation, for the reason that I did not desire to separate it from the consideration of the mammary sympathies. At the same time, I regard the true areola as among the most positive signs of pregnancy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 155 changes begin to exhibit themselves in the uterus; these modifica- tions we now propose to examine, in order that they may receive their true value as evidences of gestation. It is only necessary to remember the important duties Avhich the uterus is called upon to discharge in the brief period of nine months—the accommodation and nutrition of the groAving embryo—to appreciate the urgent necessity there is for marked and rapid alteration both in its structure and functions. Almost simultaneously Avith the act of fecundation, and even before the product reaches the uterus, this organ becomes the centre, so to speak, of an extraordinary fluxion. This concentration of fluids results necessarily in increase of vo- lume, because of the increase of tissues. Descent of the Gravid Uterus during the First Two Months.— Contrary to what might, at first view, be imagined, the tendency of the uterus for the first tAvo months after impregnation is, not to ascend into the abdomen, but to descend into the pelvic cavity; and there are certain phenomena, during the earlier periods of pregnancy, consequent upon this depressed condition of the gravid organ, which it is important to remember : 1. As the direct result of the descent of the uterus, there Avill be more or less frequent desire on the part of the female to pass water, because of the pressure of the organ on the neck of the bladder ;* sometimes, also, there Avill be a species of tenesmus, more particularly if the pressure of the uterus, instead of falling on the neck of the bladder, should, as sometimes Avill be the case, be directed against the rectum. 2. It is only necessary for you to refer to Avhat was said, Avhen describing the relations of the pelvic viscera to each other, to understand why an alteration in the position of the uterus must necessarily affect, more or less, the position of the bladder; so that, as the uterus descends into the pelvis, so measurably must the bladder; the effect of this change of position in the latter organ, Avill be pain at the umbilicus, and a cup-like appearance of the cavity. Sir Charles Clarke claims to have been the first to direct attention to this pain at .the umbilicus as a result of procidentia vesica1, and explains the connexion betAveen cause and effect on very rational grounds. The superior ligament of the bladder, formed by the remains of the two umbilical arteries, extends from the fundus of the organ to the umbilicus ; the bladder being prolapsed, the ligament is put upon the stretch, and hence the pain and increased cup-like fossa.f * This desire for frequent micturition is not exclusively the result of a mechanical cause ; it is in oart due to reflex influence. \ I am disposed to attach more than ordinary importance to the pain and increased excavation of the umbilicus as early indications of pregnancy, especially if there have previously been no displacement of the uterus or bladder from other 156 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Together with these peculiarities, Avhich usually accompany early pregnancy, there is a condition of the abdomen at this period well worthy of attention. One would very naturally suppose that, as soon as the impregnated uterus began to increase in bulk, there would necessarily be a corresponding development and promi- nence of the abdomen. But this is not so ; for the first two months after fecundation, the abdomen, so far from becoming prominent, actually recedes, and presents in the hypogastric region the aspect of flatness. This fact had been well observed by the early Avriters, and hence the ancient aphorism ventre plat, enfant il y a—a flat belly denotes pregnancy. On the contrary, about the third montl there is oftentimes quite a prominence of the hypogastric region, which, in a short time, becomes measurably lessened, and hence, a woman who is really pregnant may suppose that she is not so, for the reason that at the fourth month she will frequently be smaller than at the third. It is important that you should comprehend the cause of this difference. At the third month, just as the gravid uterus begins to leave the pelvic excavation, it is not at all unusual for the small intestines, which rest, as it were, upon the fundus of the organ, to become more or less distended with flatus, and it is owing to this circumstance that the greater volume of the abdomen is due ; as, however, the period of the fourth month approaches, this distended condition of the intestines disappears. What is it that produces the flatulent state of the boAvels at the third month ? May it not be due, in the first place, to the irritation experienced by the gan- glionic nerves of the uterus, and thus transmitted to the chylopoie- tic viscera; and, secondly, to a reflex influence occasioned by the physical changes going on in the uterus itself? I am inclined to think that this is the explanation ; but you may urge the objection, if these causes should occasion the collection of flatus at the third month, why should they not also, d fortiori, occasion it during the entire period of the subsequent pregnancy ? I answer that it is probably because the digestive mechanism becomes in a short time accustomed to these combined influences, and ceases as a conse- quence to suffer any derangement. Be the explanation satisfactory or otherwise, the fact is worthy of recollection. Positions of the Gravid Uterus.—Let us now recall to memory the various positions of the impregnated uterus from the earliest moment of conception until the completion of the full period of gestation. These gradual changes of position it is absolutely necessary for you accurately to comprehend, for they have a very important bearing, not only on the question of whether pregnancy causes; for it must be recollected that, in prolapsion of either of these viscera altogether unconnected with gestation, the umbilicus will usually undergo the same changes as in pregnancy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 157 exists, but also as to the particular period of the gestation itself. For the first three months, the impregnated organ is confined within the limits of the pelvic excavation ; this is the general rule, but there are occasionally exceptions to it. The uterus, while lodged in the pelvic cavity, continues to grow and increase in size, and has a tendency to incline toward the hollow of the sacrum, Avhich will consequently cause the cervix to diverge slightly for- ward from the centre of the excavation; and at the same time, because of the ordinary position of the rectum to the left, the fun- Pio. 89. F». 40. Natural state. Third month of gestation. dus and body of the organ are pushed to the right, which will necessarily induce a deviation of the cervix slightly toward the left of the pelvic excavation. Thus, you perceive, gentlemen, that, for the first three months after impregnation, for the reasons just stated, the direction of the neck of the uterus presents three pecu- liarities, viz. doAvmvard, forward, and slightly to the left. I have repeatedly remarked, especially in a first pregnancy, that the patient would complain, in the earlier periods of gestation, of a sense of numbness and darting pains in the lower extremities; and you see hoAV easy it is to account for these phenomena—the sacral plexus of nerves, situated in the cavity of the sacrum, becomes, from the pressure of the uterus, more or less irritated, and this irri- tation is immediately transmitted to the great ischiatic and its tri- butaries, and hence the feeling of numbness and pain. At the third month (Fig. 40), in consequence of its progressive 158 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. development, the fundus of the uterus emerges from the pelvis, and is recognised above the superior strait, imparting to the touch the sensation of a round resisting tumor, occupying the lower and cen- tral portion of the hypogastric region. It will, however, require some tact and nicety of manipulation to detect the organ at this early period through the abdominal Avails, especially in a primipara, and in women with much adipose or fatty matter. As soon as the gravid Avomb has left the pelvic cavity, and fairly entered the abdo- men, the direction which it then pursues is altogether changed; it now follows a line parallel, or nearly so, to the axis of the superior strait; consequently, its course is upward and forward ; and this alteration in its direction necessarily produces a change in the posi- tion of its cervix, which becomes slightly elevated, and instead of inclining forward, looks backAvard, and frequently a little to the left. You perceive that, as the uterus pursues the axis of the supe- rior strait, it receives a point of support from the abdominal walls, the direct consequence of which is, that the pressure exercised pos- teriorly by the gravid organ on the aorta, ascending vena cava, ureters, and upper portion of the rectum, is much diminished. Right Lateral Obliquity.—It is an interesting fact to note that, in the great majority of cases, the gravid uterus, after leaving the pelvis, becomes slightly oblique to the right in its long axis, consti- tuting what is known as the right lateral obliquity ; and various theories have been suggested to account for the circumstance. Some, Avith Levret, have imagined that it was due to the insertion of the placenta on the right lateral half of the fundus uteri; but in order to make this explanation satisfactory, proof is required that, in all cases of this species of obliquity, the placenta is actually in adhesion at this particular point of the organ ; this proof cannot be furnished, for it is directly adverse to facts, and, therefore, the the- ory is without a basis. Madame Boivin thinks that the obliquity is owing to the shortness, greater muscularity, and strength of the round ligament on the right side. I have, myself, never been able to detect any difference in the length or structure of the two round ligaments, although I have had an opportunity of examining a large number in autopsies. Again : it has been attempted to show that the more frequent use of the right arm, and the greater dis- position to recline on the right side, give rise to this obliquity of the organ. But this is not sustained by facts. Without alluding further to the various opinions of writers, allow me to observe that, although, perhaps, difficult satisfactorily to explain, yet the fact itself is interesting and important to be remembered. At the fourth month, the fundus of the organ is midway between the symphysis pubis and umbilicus. At the fifth, it is on a level Avith the umbilicus; at this time the cervix is still higher in the pelvis, and inclined more backward. It THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 159 is not unusual for the pregnant female to complain at the fifth or sixth month of pain in the right side; this is often occasioned by pressure of the ascending uterus against the liver. I have gene- rally been enabled to palliate the pain with an occasional mercurial pill, followed by a saline draught. It will usually, however, be more or less annoying until the birth of the child. At the sixth month (Fig. 41), the fundus is two fingers' breadth Fio. 41. Fig: 43. Sixth month of gestation. Ninth month of gestation. above the umbilicus; and, at this period, the latter becomes partly inverted with a partial disappearance of its cup-like fossa, and forms a slight prominence. This peculiar appearance of the umbilicus is worthy of recollection; it has, under ordinary circumstances, some value as a sign of pregnancy, although I have seen it as the mere result of abdominal tumors and advanced ascites. At the seventh month, the fundus has reached midway between the umbilicus and the curve of the stomach ; at this time the umbi- lical fossa has completely disappeared, and the umbilicus itself, in consequence of its inversion, forms a marked projection. The cer- vix is still more elevated and inclined posteriorly. At the eighth month, the fundus of the organ is high up in the epigastric region. There is now great prominence of the abdomen, with more or less oppression in breathing, in consequence of the pressure of the ascending uterus against the diaphragm; and it is not unusual for the woman to be troubled more or less Avith a cough 160 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and palpitation of the heart. It is just as well for you to remem- ber in this connexion, that the cough is unaccompanied with fever or an excited pulse; it is not the cough of inflammatory action. It, like the palpitation, is simply the result of the mechanical irrita- tion experienced by the lungs and heart, in consequence of the greater elevation of the diaphragm, thus curtailing the usual capa- city of the chest. I speak of this in order that you may not, through erroneous diagnosis, subject your patient, for this cough and palpitation, Avhich will yield as soon as the pressure is remoAred from the diaphragm, to the absurdity of antiphlogistic treatment.* Toward the close of the ninth month (Fig. 42), the uterus descends into the pelvic excavation, and, as a consequence, there will be more or less vesical irritation, and sometimes a feeling of tenesmus occasioned, in the former instance, by the pressure of the organ against the neck of the bladder, and, in the latter, against the rectum. But this descent of the uterus, at the close of the ninth month, is followed by a circumstance Avhich should not be for- gotten ; I mean a diminished prominence of the abdomen, which will sometimes give rise to the apprehension, on the part of the female, that something is Avrong; that she is not pregnant, or that her fcetus is dead. Again: In consequence of the settling doAvn of the gravid womb, the pressure is removed from the diaphragm, and, hence, the respiration is freer, the cough disappears, and the patient experiences a buoyancy of spirits, forming a striking con- trast with the oppression of the previous few weeks ; this she can- not account for, but which you, knowing the cause of the change, can readily appreciate. Why does the impregnated uterus descend toward the end of the ninth month ? May it not be that, at this period, the organ increases in its transverse diameter, and, at the same time, diminishes in length? But, gentlemen, if you ask me whether'the descent of the organ at this period be necessary, whether there be any special benefit derived, I ask you, in return, to reflect, for a moment, on the important work in which nature is so soon to become engaged, viz. the expulsion of the foetus from the maternal organs. The object, therefore, of this change in the uterus, is directly connected with the birth of the child; it is, as it were, one of the arrange- ments preliminary and essential to the important act of labor. These various changes in the position of the uterus, to which we * Although it is true that these derangements in the respiratory organs, at the latter period of gestation, are usually traceable to the ascent of the diaphragm ; yet it must be recollected that these phenomena will sometimes develop themselves at a less advanced period of pregnancy, and here the dyspnoea, cough, etc., may be due to a nervous, or a congested condition of the lung (possibly to oedema of the organ) i the therapeutic indication will depend upon the special cause; for example, if it be traced to nervousness, hyoscyamus, thirty or forty drops of the tincture; or if to congestion, the judicious intervention of the lancet. PI.ATK JV v AREOLA OF THE BREAST Ninth month THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 161 have thus briefly alluded, are liable to certain modifications. For example, in a multipara—a female who has borne several children ■—the uterus in its ascent usually does not reach as high up in the abdomen in the latter periods of pregnancy as in a primipara; and, at the same time, the abdomen is much more protuberant. These two circumstances arise from the fact, that previous pregnancies having so distended and relaxed the abdominal walls, the gravid womb, encountering but little resistance as it passes upward, has a strong tendency to fall forward, constituting a species of ante- version of the organ; whereas, in the primipara, its direction is more in accordance with the axis of the superior strait of the pelvis. In a first pregnancy, the parietes of the abdomen undergo extraordinary distension, and consequently become thin ; occa- sionally, there is a separation of the two recti muscles; and you will remember an interesting case, in the clinic, of a female, who, having been confined Avith twins, was afterwards much annoyed by the protrusion of the intestines through the space left by the separation of these muscles.* Change in the Direction of the Urethra.—When the gravid uterus leaves the pelvic cavity, and during its progress in the abdomen, very important changes are effected in the position of the bladder and urethra; the ascent of the uterus necessarily occasions the ascent of the bladder, Avhich, of course, draws up the urethra in such a Avay that, instead of occupying an oblique position, as it does under ordinary circumstances, it becomes more and more vertical, so that, in the latter periods of gestation, it will be found almost parallel with the internal surface of the symphysis —a most important fact to be recollected in conrrexion with the introduction of the catheter, ignorance of which Avill oftentimes lead to results mortifying to the practitioner, and disastrous to the patient. The superior portion of the urethra will sometimes be so greatly pressed upon by the gravid uterus, that its lower extremity, in consequence of the impeded circulation, Avill become very much engorged, thus giving rise to an enlargement, which, if not under- stood, might result in erroneous conclusions. This condition of the excretory duct is not unusual, particularly in first pregnancies, and arises simply from mechanical obstruction in the blood-vessels. It is of no special import, except that without this explanation you might possibly, in making a vaginal examination, misapprehend the nature of the enlargement, and suppose it to be a foreign growth. (Edema of Lower Extremities.—The oedema of the lower ex- tremities, as an ordinary accompaniment of gestation, amounting sometimes to a fully developed anasarca, is also explained in the * See Diseases of Women and Children, p. 211. 11 162 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. same way; that is, obstruction, from pressure of the impregnated womb, in the venous circulation,* thus preventing the free passage of blood from the loAver extremities to the ascending cava, and thence to the right cavities of the heart. In the same manner also, do you account in part for the appearance of hemorrhoidal tumors, so common in pregnancy; I say in part, for they are like- wise due to the constipation, Avhich is the usual accompaniment of this condition; the constipation ATery frequently arising from the pressure of the uterus against the upper portion of the rectum. You haA'e seen in the clinic several examples of enlargement of the veins in the vagina, traceable to the presence of various kinds of abdominal tumors; and you have been told that these venous en- gorgements are simply the result of obstructed circulation. In pregnancy, also, you will occasionally meet Avith the same phe- nomena ; and I have known, under these circumstances, thrombus of the vulva, to produce fearful hemorrhage. In the latter con- tingency, the great remedy is well directed pressure by means of pieces of sponge.f * There are other causes than obstruction in the venous circulation, which may occasionally produce oedema, or dropsy of the cellular tissue, during pregnancy; for example, organic disease of the heart, the existence of albuminuria, anaemia, etc. \ For an interesting case of thrombus of the vagina, together with its treatment, Bee Diseases of Women and Children, p. 463. LECTURE XI. Evidences of Pregnancy continued—The Effect of Fecundation on Development of Uterus—Order of Development—Fundus enlarges first three Mouths—Body from third to sixth Month—Wisdom of this Arrangement—Shape of Impregnated Uterus—Modifications of Cervix in Pregnancy—Error of certain Authors— Uterine and Vaginal Extremities of Cervix—Cervical Canal—Relaxation of Tissues of Cervix—Cervix does not Lengthen—Error of Madame Boivin—Promi- nence of Os Tincae—Softening and Moisture—Mucous Follicles—Development of —Increased Mucous Secretion not a Pathological State—Uses of this Secretion— Cervix begins to shorten at its Uterine, and not at the Vaginal Extremity— Proof—Opinions of Stoltz and Cazeaux—Placenta Praevia and Shortening of Cer- vix—Modifications of Cervix in Primipara and Multipara—Increased Development of Uterine Appendages in Pregnancy—How does the Cavity of the Uterus enlarge?—Ancient Theory—Increased Nutrition the true Cause—Thickness of Uterine Walls; Opinions respecting—Os Uteri at Time of Labor—Discoloration of Vagina as a sign of Pregnancy—Is this Discoloration peculiar to Pregnancy ? Gkxtlemen—From the instant of fecundation until the accom- plishment of the full term of utero-gestation, the womb is con- stantly undergoing the process of development; this increase of tissue and capacity is in accordance with the growth of the embryo. In one word, the exclusive and only object of these changes is to provide accommodation and sustenance to the growing germ. But the development of the gravid organ is not without order; in the arrangement, which nature has instituted for the successive in- crease in the volume and structure of the uterus, the obstetrician will find much of interest. The increase in the size of the organ, although successive, is not uniform ; as an evidence of this fact, the groAvth of the uterus for the first three months is principally through the development of its fundus; the body of the organ undergoes striking changes from the third to the sixth month ; while it is not until the three last months of gestation that the cervix or neck contributes its share to the general accommodation of the embryo. You cannot, gentlemen, fail to perceive the wisdom of this order in the successive developments of the impregnated uterus; it is essentially conservative, and for the protection of both mother and child. Suppose, for illustration, the order were reversed; and, instead of the fundus, the cervix should be the first to undergo the physical changes necessary for the requirements of the growing foetus. Do you not perceive, at once, the inevitable results of such 161 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. an arrangement—premature delivery, and the consequent destruc- tion of the germ ? But nature, in this, as in all her other opera- tions, is constantly disclosing to her disciples motive for every act she performs. For the first six months of gestation, in consequence of the increased volume of the uterus being caused chiefly by the enlargement of the fundus and body only, the organ presents a peculiar shape Avhich has not been inaptly compared to that of a gourd or bottle; after this period, as the cervix begins to shorten, the form of the uterus becomes more ovoid. Changes in the Cervix.—You will find, in reading the various works on midwifery, that most writers have alluded to the modifi- cations of the neck of the uterus during pregnancy ; but there is more or less discrepancy of opinion as to two important circum- stances connected with these modifications: 1. The degree of value to be attached to them so far as being guides in the diagnosis of the particular period of gestation ; 2. The manner in which the cervix commences and continues to shorten. I propose briefly to examine these questions, and to give to each of them, as far as I may be able to do so, its true bedside importance; for, after all, gentlemen, these questions, so practical in their bearing, must be decided by the revelations of the clinical room. In order that you may have a comprehensive and accurate idea of the phases through which the cervix of the uterus passes during the entire period of pregnancy, I shall divide it into three portions: 1. The lower or vaginal extremity; 2. The upper or uterine extremity; 3. Its canal, being bounded respectively by these two extremities. Your attention has already been drawn to the important fact that fecundation constitutes the uterus an active centre; this very centralization of forces, if I may so define it, toward the organ, imparts to its physical condition a very rapid and remarkable change, and the most palpable appreciation of the nature and ex- tent of this change will be had by comparing the impregnated organ of a primipara with the uterus of the matured but virgin female. In the latter, the organ presents a dense, resisting, and, to all external appearances, homogeneous structure, it being impossi- ble to discern distinctly with the naked eye any of the elements forming the components of the different tissues. Indeed, it may be said with all truth, that so far as its physical nature is concerned, the characteristic of the virgin womb is compactness ; while, with equal propriety, it may be affirmed, that the characteristic of the impregnated organ is softening or looseness of structure, which is the direct result of the fluxion, of Avhich it becomes so active a centre; so that, in the earlier periods of gestation, the increase in the volume of the uterus is to be attributed, not only to new formations, but to the relaxing and spreading out, through the agency of increased circulation, of its pre-existing elements. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 165 For the first six months of utero-gestation, the modifications in the cervix are more or less confined to a softening, and consequent increase in volume of its two extremities and canal; and it is not until the beginning of the seventh month that there is any percep- tible shortening of the cervical portion of the organ, as we shall presently endeavor more particularly to show. Madame Boivin, a woman of extraordinary cleverness, and whose field for practical observation was vast, put forth the idea that, at the second month of pregnancy, the cervix uteri is so much increased in length that it measures two inches ; this opinion has been more or less adopted by her successors, more, I imagine, from the weight of her autho- rity, than from any conviction founded on actual investigation, that the opinion is correct. I must confess I am somewhat surprised that Madame Boivin should have promulgated such a statement— accurate as she generally is in her deductions—for, as far as I have been enabled to test the point, from no limited observation, it is not in accordance with facts. Can it possibly be that this distin- guished woman may, for the moment, have forgotten that the tendency of the impregnated uterus is, for the first two months, to descend into the pelvic excavation, and thus have confounded this descent of the organ with the supposed elongation of its cervix ? Or is it that she may have mistaken a congenital elongation for what she imagined to be a lengthening, the consequence of early gestation ?* Be it as it may, I am quite certain that the cervix does not increase in length during any period of pregnancy.f One of the very first changes observed by the vigilant accoucheur, as connected with the general softening of its structure, will be a slight tumefaction of the anterior and posterior lips of the os tincae, and at the same time the orifice begins to lose its transverse shape, and becomes more circular; this latter condition is in part owing to the increase in volume of the two lips, and also to the circum- stance that the anterior lip now becomes more protuberant, so that the two lips are equal in size and prominence. But there is another circumstance connected with the condition of the os tincae at this period of gestation, Avhich becomes more marked as pregnancy advances; as far as I know, it has not been mentioned in connexion Avith the modifications of the cervix at the commencement of gestation. I allude to a peculiar moisture of the two lips, which, according to my experience, is a constant accom- * The neck of the uterus will sometimes exhibit an elongation from simple hyper- trophy of the part, giving rise to prolapsus, etc. M. Huguier has recently written an exceedingly interesting memoir on this subject, entitled, " Allongements Hyper- trophiques du col de l'Uterus." [Memoires de TAcademie Imperiale de Medecine, vol. xxiii. p. 279.] \ Dr. Matthews Duncan is also of opinion that there is rather an elongation oF the cervix in the early period of utero'gestation. [Edinburgh Med. Jour., March, 1859.] 166 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. paniment of pregnancy. The moisture is occasioned by the pour- ing out of mucus, Avhich is nothing more than the necessary result of an increase in the size of the mucous follicles, which you are aware are found, in more or less abundance, on the internal surface of the cervix. You are not to mistake this secretion of mucus for a morbid or pathological state of the parts—it is in every way a natural and healthy function, and, during the entire progress of gestation, is intended to subserve a most important purpose. Let us examine this point for a moment. After the full development , of the foetus has been accomplished, and it is sufficiently matured in its physical organization to enable it to live independently of its parent, a new train of phenomena is instituted, the object of which is to secure its safe expulsion from the maternal system. Now, in this expulsion, the sexual organs must of necessity be subjected to extraordinary distension, and the os uteri become amply dilated; the walls of the vagina are called upon to contribute largely, and so are the labia. Nature, with consummate forethought, and a provident arrangement worthy of our profound admiration, has taken good care to prepare these organs for the great work of dis- tension. The mucous follicles, so abundant in the cervix uteri and vagina, are the instruments which she brings to her aid. As pregnancy advances, these follicles become more and more developed, and in proportion to their development will be the secretion of mucus. This Arery mucus serves to moisten and relax the parts, and thus prepares them for the excessive distension' to which they are soon to be subjected. In the latter months of gestation, the mucus is apt to become so abundant as to cause the female to imagine that she has that vague and unmeaning disease the "Avhites."* She sends for her medical man, and begs him to give her something to arrest this discharge. If the practitioner be guided by the declarations of his patient—if he should have no mind of his own—or if, in a word, he should not at once perceive that this mucous secretion, in lieu of constituting a pathological condition, is simply one of the wise provisions intended for the successful accomplishment of cer- tain ends, he would most likely prescribe some astringent injection, the tendency of which would be to arrest the discharge, and thus come in direct conflict Avith the purposes of nature. So you see, gentlemen, how essential it is to distinguish betAveen healthy and morbid phenomena.! Shortening of the Cervix.—At the same time that these changes are going on in the two lips, there is a progressive increase in the * See Diseases of Women and Children, " Leucorrhcea," p. 408. \ While observing the caution suggested, yet it is proper also to recollect that the pregnant woman may, under certain circumstances, be affected with a morbid dig* charge from the vagina, which will need attention. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 167 volume of the cervical canal, the tissues of which not only become softer, but there is also an augmented capacity in the canal itself. I cannot but think that authors have labored under a remarkable error in stating the mode and degrees of shortening, which the neck of the uterus undergoes during the various periods of preg- nancy. It is maintained by many that, at the fifth month, it loses one-third of its length, at the sixth, one-half, two-thirds at the seventh, three-fourths at the eighth, Avith an entire obliteration at the end of the ninth month. I believe this error is partly traceable to the circumstance that sufficient importance has not been attached to the fact that the cervix, as one of the immediate results of ges- tation, becomes increased in volume, and this increase of Aolume is mistaken oftentimes for a diminution of its length. As far as I have been enabled to arrive at a just conclusion upon the subject—and no little attention has been given to the investiga- tion—I do not think there is any actual loss in the length of the cervix until near the end of the sixth month, and this brings us to the consideration of the manner in which the shortening is accom- plished. You have already been informed that the order of deve- lopment of the gravid uterus is first an enlargement of the fundus, then of the body, and lastly of the cervix; and it is not until toward the termination of the sixth month that the cervix begins to contri- bute its share to the general capacity of the uterus. At this time, the uterine portion of the neck commences to Aviden, from Avhich there are tAvo direct results : 1. A shortening of its long axis ; 2. An increase in the uterine cavity. This expansion of the uterine extremity of the cervix noAV pro- ceeds Avith more or less uniformity, producing consequently a gra- dual shortening of the cervix, and at the same time a gradual increase in the capacity of the uterus, so that, at the end of the ninth month, the cervix has so completely surrendered its length, that it presents simply a ring, Avhich is known in obstetric language as its obliteration. If you examine a female in the fifth month of her gestation, on introducing your index finger into the vagina— in the manner we shall hereafter point out—and passing it along the outer surface of the cervix uteri, you will very readily ascer- tain that its length is unchanged ; make this same examination at the seventh month, and, when your finger reaches the uterine por- tion of the neck, you will at once recognise a remarkable alteration in the condition of things, viz. that this portion of the organ is more expanded, giving an increase to its various diameters, and then it is that you will also appreciate the important circum- stance that the ceiwix commences to diminish in length, this dimi- nution, remember, beginning above, and not below—or, to be more explicit at the uterine, and not at the vaginal extremity of the part. 168 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. I am thus emphatic upon this point for the reason that a high authority in midwifery, the learned Stoltz, of Strasburg, main- tains that the cervical portion of the uterus begins to lose its length from below upward, and positively asserts that the uterine extremity undergoes no change until the latter part of the ninth month. This opinion of the distinguished professor is also par- ticipated in by Cazeaux, who, as a writer and observer, occu- pies deservedly a high position.* I cannot account for the opi- nion of these distinguished writers. I am confident it is founded in error, and is altogether adverse to bedside experience. If I did not feel the strongest conviction—a conviction amply con- firmed by repeated investigation—that I am right in regard to this question, it Avould be Avith no little hesitation that I should thus unequivocally, but yet most respectfully, doubt an opinion emanating from such valued authority. There is, in my judgment, a very essential practical fact con- nected Avith the manner of the shortening of the cervix ; and it is strange that attention has not been more specially called to it, for it embodies a lesson of great value to the accoucheur, while it is of the deepest interest to the patient. It is as fol- Ioavs : In the course of your practice you will occasionally be consulted by pregnant women in consequence of more or less dis- charge of blood from the vagina ; this necessarily will produce much disquietude in the mind of the patient, and the loss of blood may result from the various causes capable of promoting a miscarriage; such, for example, as bloAvs, falls, or fright. But the cause of the discharge of blood to which I allude, in connexion Avith the shortening of the cervical portion of the ute- rus, is of a very different kind, and traceable to a peculiar cir- cumstance. In placenta praevia, the placenta being attached over the mouth of the womb, either centre for centre, or in a por- tion only of its circumference, one of the most likely things to occur during the seventh, eighth, and ninth months of gesta- tion will be flooding to a greater or less extent—and Avhy ? Do you not see the almost necessary connexion between hemorrhage at these terms of pregnancy and placenta praevia ? What are the facts ? The after-birth is attached, through vascular and other connexions, to the internal surface of the upper or ute- rine portion of the cervix; you have just seen that, at the end of the sixth month, this portion of the cervix begins to widen, for the purpose of giving increased size to the uterine cavity; ' now this very expansion will be at the expepse of some of the vascular connexions, to which we have just alluded, and hence the flooding. If, therefore, gentlemen, a patient without any assign- * Traite Tbeorique et Pratique de l'Art des Accouchemens. Par P. Cazeaux. Cinquieme Edition, p. 97. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 169 able cause on her part, should, in the latter months of pregnancy, be attacked with a discharge of blood from the A*agina, you may legitimately infer that it is because of the implantation of the after- birth over the os uteri. In such an event, the most judicious treat- ment will be called for; in a future part of the course, when dis- cussing the management of flooding, as connected with placenta prajvia, your attention shall be fully directed to the therapeutics of these cases. The Cervix in the Primipara and Multipara.—We have spoken of the two extremities of the cervix uteri, and you have noted the successive changes Avhich occur in them ; you have also seen in what way the cervical canal commences and continues to shorten, until at the completion of utero-gestation it is reduced to a simple circle or ring. It now remains for me to point out certain differences in these modifications depending upon whether they occur in a primi- para or multipara, and it is important that you should understand the nature of these variations. In a primipara, all the changes to which we have alluded progress much more tardily than in the female Avho has borne one or more children. The softening of the uterine tissues is sloAver, so is the tumefaction of the anterior and posterior lips of the os tincae ; and another essential characteristic of the os tincae in the primipara is, that it maintains more or less a conoidal form, and is not dilated so as to permit the introduction of the finger. Again: the internal surface of the two lips is uni- form, uninterrupted by elevations; and also in the primipara, the shape of the cervical canal is fusiform. In the multipara, there is a more rapid development in the modifications of the gravid organ. The lips of the os tincae are more protuberant, and the finger can be readily introduced, for the reason that they never assume their original shape after childbirth ; so true is this, that you will per- ceive a very striking contrast in the form of the Aaginal extremity of the cervix Avhen compared Avith that in the primipara; in tne latter, it is more or less conoidal, while in the multipara it has been very properly compared to an inverted funnel. In the multipara, also, the internal surface of the lips is irregular; and this irregu- larity is owing to the circumstance that, during the passage of the child through the os uteri, there have been shght lacerations of the mucous membrane; these lacerations heal, and form afterwards so many cicatrices, which are easily recognised by the touch. Development of the Uterine Annexos and External Genitalia.— The general groAvth of the tissues, consequent upon fecundation, is not limited to the uterus; the appendages of the organ participate more or less in the effect of this increased nutrition; the ovaries nearly double in size, Avith an augmented volume of their blood- vessels ; the same fact is observed Avith regard to the fallopian tubes; and there is also a marked development in the muscular 170 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. fibres of the broad and round ligaments ; the vagina and external organs likewise undergo important changes; the former, as preg- nancy advances, becomes Avider and shorter, and there is a very evident increase in its spongy tissue. The vagina assumes another modification in the latter period of gestation, as has recently been pointed out by Rouget. He has shoAvn that distinct muscular planes can be detected with the naked eye ; and this Avill at once explain the contractile power displayed by this canal during the passage of the fcetus through it. The mucous follicles become larger, and pour out more or less mucus. There is an interesting circumstance connected Avith this development of the mucous fol- licles, and it is this—in carrying your finger along the Avails of the vagina, you wrill occasionally have imparted to it a sensation, as if you are touching numerous granulations ; and if you do not recol- lect the reason of this temporary change in structure, you might possibly confound it Avith a very important affection of the vagina —granular vaginitis, first described by Deville. The external organs, especially as the final term of gestation approaches, are more or less engorged, and there is an evident relaxation of their tissues. In a word, gentlemen, you cannot but appreciate, as you contemplate these different modifications in the reproductive apparatus, the simple motive, Avhich has so obviously influenced nature—eArery change, you perceive, has been made tributary to the successful accomplishment of the great act in the reproductive scheme—the birth of the child. How does the Gravid Uterus Enlarge ?—TJiickness of its Walls. You have seen that, as the necessary consequence of gestation, the cavity of the uterus enlarges in order to afford accommodation to the germ ; and the question arises, how is this enlargement of the uterine cavity effected ? The opinion entertained by the old school- men upon this subject was a singular one—they taught that the cause of the increase in the size of the organ was altogether mechanical; that, as the embryo gained in development and size, its pressure against the walls of the uterus occasioned a distension equal to its requirements. They, in fact, compared the gradual enlargement of the organ, and supposed it to be accomplished upon the same principle, to the distension of a bladder when filled by air or water.* But the fallacy of this and kindred hypotheses must be apparent to all of you. The uterus grows and becomes developed through the same influence precisely that imparts to the foetus its growth and development—increased nutrition. Prior to the second * It is well to remember that this question of the manner in which the gravid uterus becomes enlarged was determined, not by human dissection, for this was one of the precious elements of trutnful inquiry from which the ancients were debarred; but from the inspection of the impregnated organ in animals, in some of which, it is conceded, the uterus does enlarge through mechanical distension. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 171 month, the embryo is dependent for its nourishment on other sources, as we shall in the proper place indicate; but after this period it derives its elements of growth from the placenta. The uterus, on the contrary, becomes developed, because of the afflux of fluids and increased circulation setting toward it from the first moment of fecundation until the completion of gestation. So you perceive, gentlemen, that both the uterus and the embryo it con- tains pass respectively through their phases of increase, by the simple agency of a more active nutrition. If any argument be required to demonstrate the utter absurdity of the ancient theory of mechanical distension, you need only recollect the interesting circumstance that, in extra-uterine pregnancies, the cavity of the uterus undergoes more or less dilatation.* Thickness of the Walls of the Gravid Uterus.—There has also been much difference of opinion as to the absolute thickness of the walls of the organ during gestation; some contending that they become extremely attenuated, while others maintain that they increase in bulk only at the disc on which the placenta is inserted; and again it is affirmed that the entire increase in the thickness of the parietes is due exclusively to the engorged state of the blood- vessels ; this latter fact being attempted to be demonstrated by the circumstance that, in women who have died of uterine hemor- rhage, the walls are aLvays less in volume. Now, there is no doubt that the latter statement is true; but admitting its truth, what does it prove ? Absolutely nothing, so far as the solution of the point in controversy is concerned; for, Avhile it cannot be denied that there is a relative increase in the thickness of the uterine walls, in consequence of the more active circulation, yet the cardinal fact for you to remember is, that the principal cause of the increased bulk of the gravid uterus is found in the changes of the muscular tissue of the organ; and, as I have already remarked to you, in a previous lecture, these changes are brought about in two ways: 1. By an enlargement of the pre-existing muscular elements; 2. By a new formation of them. So that, while it may be conceded that, after fatal hemorrhage, there is a diminished thickness in the uterine parietes, it must also be recollected that this loss is relative and not absolute, being proportionate only to the amount of dis- gorgement which the blood-vessels have undergone. As a general principle—although there will be more or less marked variations in different women—it may be affirmed that, during the period of pregnancy, the thickness of the walls of the uterus is about the same as in the unimpregnated organ. It is greatest at the fundus, especially where the placenta is attached, * For further details on this subject, the reader may consult with profit an elabo- rate paper on " The Uterus and its Appendages," by Dr. Arthur Farre (Cyclopaedia of Anatomy and Physiology, p. 645. London, 1858). 172 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and gradually diminishes towards the cervical portion. Taking twelve lines to the inch, it may be said that, at the fundus, the thickness is from four to five lines, slightly less in the body, and from tAvo to three lines in the cervix; another interesting fact is, that, for the first five or six months of gestation, the thickness rather increases, and after this period its tendency is gradually to diminish. Let me here direct your attention to an important circumstance with regard to the os uteri at the time of labor. In making a vagi- nal examination, when labor has fairly commenced, it Avill be ascer- tained that the os is oftentimes characterized by extraordinary thinness; and it is this fact which, no doubt, has originated in the minds of some writers the idea that the entire surface of the uterine Avails participates in this attenuated condition. So much, you see, for determining a principle by a single circumstance. It is bad logic, and has been fruitful in the spread of unsound lessons. The Avhole of the testimony or none, is a fundamental maxim in law, and it is not without its application in our profession. Discoloration of the Vaginal Walls. — Among the changes occurring in the sexual organs consequent upon pregnancy, much importance has recently been attached by certain observers to a discoloration of the internal surface of the vagina; and men of high eminence are disposed to regard it as an evidence of very great value that gestation actually exists. There has been some differ- ence of opinion as to Avhom belongs the merit of having first called attention to this peculiarity in the color of the vaginal walls, but I think the credit is due to Jacquemin, of Paris, whose opportunities for investigating this subject were of no ordinary limits, having been appointed by the police to examine the generative organs of the prostitutes of the French metropolis—certainly a wise regula- tion ; for if it be an admitted principle that, for the protection of the community, prostitution must be countenanced, then, I say, let it be freed, as far as may be, from the dreadful scourge entailed upon those who indulge in it—I mean the syphilitic taint; and how can this be so effectually accomplished as through the vigilant examinations, made under the police regulations, of the genitals of the prostitutes, who are to be found in such fearful numbers in the great city of Paris. It would be well, indeed, if some such municipal law obtained in New York, which is but the younger twin sister of Paris in all that contributes to the formation of the true greatness of a people, and at the same time panders to the lowest and most degrading vices. Jacquemin, in describing the discoloration of the vagina, calls it a violet hue, not unlike the lees of wine; and he broadly affirms that, irrespective of any of the other evidences of gestation, this eign alone would be sufficient for him to pronounce upon the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 173 existence of pregnancy. Kilian, of the University of Bonn, a good observer, and a man of much experience, regards the discoloration as one of the " most constant signs of gestation." This opinion is also sustained by Kluge of Berlin, Ricord, Parent-Duchatelet, and others. There can be no doubt that the color of the vagina, in the great majority of cases, does undergo a remarkable change during pregnancy, presenting a sort of bluish tint, and this is altogether the effect of the vascular congestion of the parts. Many of you, who reside in the rural districts, and who, perhaps, are more or less familiar Avith that primitive but honorable occupa- tion of man, agriculture, and its kindred pursuits, must recollect the practice usually resorted to by breeders with a view of ascertaining whether the female of many of the lower animals be in a state to receive the male—or, in other words, whether she be in heat. The practice to which I allude is to inspect the outer opening and internal surface of the vagina, which, in season of heat, will be found to exhibit a very dark color—and I am quite satisfied that this same character of discoloration takes place at the advent of the catamenia in woman.* I have closely watched this latter circumstance, and in the many vaginal examinations which I haA'e made just before the menstrual eruption, I do not know that I have failed in a single instance, in a normal menstruation, to detect this discoloration of the vagina. It seems to me that the true way to arrive at the real value of this sign, as a diagnostic evidence of pregnancy, is to determine, in the first place, the two following inquiries: 1. Is the discoloration of the vagina a universal accompaniment of gestation; 2. Is it ever present, when pregnancy does not exist ? I have no hesitation in stating, from my OAvn personal observation, that pregnancy will occasionally pass through its various stages without the slightest cognizable change in the ordinary color of the vagina, and this is more likely to occur in women remarkable for pallor of skin, and especially in those whose pallor is traceable solely to an anaemic condition—whether the anaemia be dependent upon an original deficiency of the red corpuscles, or upon a sudden or long-continued drain upon the system. In reply to the second point, whether the discoloration is ever present Avithout pregnancy; or, in other words, whether any other cause can produce it, I am quite confident that there are numerous instances, Avhich will amply support the affirmative of this question; and it is with no little surprise that I find so valued an authority as Huguier positively affirming that " this change of color in the vaginal walls is not found in any other condition of the uterus than * Some interesting facts as to the color of the vagina in domestic animals at the time of heat and during gestation, have been recorded by M. Rainard [Traite complet de la parturition des principales femellfesdomestiques!] 174 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. that of pregnancy." Now, gentlemen, what are the facts ? In the first place, I have told you that the real cause of this bluish aspect of the vagina is vascular congestion, and consequent partial inter- ruption in the ordinary current of the blood. If this be true—and the fact is very generally conceded—it should folloAv that Avhenever this vascular congestion is present, no matter from Avhat cause, you may very naturally look for the effect—discoloration of the vagina. You will, therefore, notice the change of color in the case of intra- uterine tumors, in chronic sanguineous engorgement of the uterus, eto. In a word, it is one of the not unusual accompaniments of congestion of the uterus, whether from gestation, or from some morbid influence, with which pregnancy has no possible connexion. From what has just been said, it is very evident that the value of this sign as a proof of pregnancy, is subject to more or less qualification; and it is also well to mention that delicacy on the part of the female will oftentimes prevent the accoucheur from availing himself of the means of ascertaining whether or not it be present. LECTURE XII. Evidences of Pregnancy continued—Quickening—Ancient Theory—Law of England in regard to Quickening—What is Quickening?—Opinions of Authors—Nervous and Muscular Development—Muscular Contractions of the Foetus—Sensible and Insensible Muscular Contractions—Quickening not a Psychical Act, but the result of Excito-motory Influence—Spinal System—Its Physiological Importance— When does Quickening take Place ?—Does not always Occur—Delusive Quickening —Illustration—Contraction of Abdominal Walls mistaken for—Final Cessation of Menses and Supposed Quickening—Attempted Imposition—Queen Mary of Eng- land—Manipulations to Detect Quickening—Influence of Cold on Movements of Foetus—Illustration—Ballottement or Passive Movement of Foetus—Rules for Detecting—Positions of Foetus and Ballottement—Pulsations of Foetal Heart— Auscultation—Mayor of Geneva—Average Beats of Fcetal Heart—Not Synchro- nous with Maternal Pulse—Auscultation, how Applied—Auscultation and Position of Foetus—Twin and Extra-uterine Pregnancies—How ascertained—Placental Souffle—Uterine Murmur—Kergaradec—Conflict of Opinions—Souffle not always Dependent upon Pregnancy—Uterine and Abdominal Tumors; Cause of—Souffle no Evidence of Life of Foetus—Pulsations of Umbilical Cord—Dr. Evory Ken- nedy. Gentlemen—We shall now proceed to an examination of the evidences of gestation derived from other sources. Thus far we have considered those signs only, Avhich are either so many sympa- thetic phenomena, or the direct result of increased vital action. The order of signs, to Avhich your attention will now be directed, is not only of special interest, but some of them, Avhen recognised, are conclusive as to the existence of pregnancy. They may be enumerated as folloAvs: 1st, Quickening; 2d, The passive move- ment of the fcetus, termed by the French, Ballottement, by the English, Repercussion; 3d, Pulsations of the fcetal heart; 4th, The Bruit placentaire, placental souffle, or uterine murmur; 5th, Pulsations of the umbilical cord. 1st. Quickening.—This term is employed to designate the parti- cular period of gestation at which, through the movements of the foetus, the mother becomes for the first time aAvare that she carries within her a living being. The ancient theory upon this subject was not only singular, but the very essence of absurdity ; it incul- cated the principle that quickening was the simple evidence that, at that very moment, vitality was imparted to the foetus ; and that, therefore, prior to this event, the foetus was an inanimate mass, without individuality. In those days, when physiology Avas not a science, and Avhen crude hypothesis oftentimes was substituted for 176 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. truthful and scientific research, it is not strange that such opinions should have obtained. But that this hypothesis, false, and, in every sense, adverse to facts, should, almost in our own times, have been adopted by one of the most enlightened countries in the world, and made the basis of an important law, is a matter Avhich, were it not for the unerring evidence of the Statute Book, would scarcely fall within the range of credibility. The Ellenborough act, of 1803, holds the following inconsistent and unAVorthy language: " If an individual shall Avilfully or maliciously procure abortion in a woman, not quick with child, the crime shall be declared felony, and the offender may be fined, imprisoned, set in the pillory, publicly whipped, or transported for any term not exceeding fourteen years; but if the offence be committed after quicken- ing, it shall be punishable with deaths Now, gentlemen, allow me to ask—Why this distinction in the award of punishment for a crime which, as physiologists, you know to be nothing short of murder, whether committed before or after the period of quick- ening ?* What is the difference between the ovule secreted by the ovary, which passes from the system Avith the menstrual blood, and the ovule on which is exercised the specific influence of the spermatic fluid of the male? The broad, unequivocal, true physiological difference is, that the former is dead, deciduous matter, and, like all things dead, has no inherent power of development. The latter, on the contrary, is vitalized; the very act of fecundation infuses life into it, and it proceeds on its mission of development until, prepared by successive increase for independent life, it is expelled from the organs of its parent. You see, therefore, physiologically speaking, the embryo is as much alive in the earliest stages of fecundation as at any future period of its intra-uterine existence. The mould of the future being is there, with all the necessary elements, through progressive development, for perfect physical organization. Like the little acorn, which, falling from the parent tree, if it find shelter beneath congenial soil, and be alloAved to pursue uninterrupted its natural phases, will become matured into an oak as majestic and sturdy as the one to which it owes its OAvn exist- ence. Away, then, with the absurdity, and, in the exercise of your prerogative as medical men, whether in the chamber of sickness, or on the witness-stand in courts of justice, remember that he who, * Within a few years, this law has been modified, and stands as follows: " Who. soever, with the intent to procure the miscarriage of any woman, shall unlawfully administer to her, or cause to be taken by her, any poison or other noxious thing, or shall unlawfully use any instrument, or other means whatsoever, .with the like intent, shall be guilty of felony, and being convicted thereof, shall be liable, at the discretion of the Court, to be transported beyond the seas for the term of his or her natural life, or for any term not less than fifteen years, or be imprisoned for any term not exceeding three years." [1 Victoria, c. lxxxv. s. 6.] TnE PRINCIPLES AND PRACTICE OF OBSTETRICS. 177 from sordid motives, or Avith a view to conceal his own crime, shall produce abortion is, in the eye of heaven, equally guilty of murder, whether the act be perpetrated before or after quick- ening. The true Import of the Term Quickening.—Let us now inquire what it is that gives rise to the movement, known as quickening. Is it really the movement of the fcetus, or is it attributable to movement of some other organ ? You will observe, in the course of your reading, various theories upon this subject. Some main- tain that the seat of the sensation of quickening is not to be re- ferred to the fcetus, but will be found to be in the abdominal Avails of the woman* Others, Avith Royston, attribute it to the sudden passage of the uterus from the pelvis into the abdominal cavity; Avhile again, it is said that quickening is nothing more than the "evidence of the contractile tissues of the uterus being so far de- veloped, as to admit of the peristaltic actions of the organ." It really seems to me that much time has been uselessly wasted in the attempted explanations of a circumstance Avhich, in my judgment, is in no way difficult of comprehension. The sensation first imparted to the parent, no matter how slight, Avhich makes her conscious that she is pregnant, and that the pro- duct of conception is alive, is a sensation traceable to nervous and muscular development. As soon as the nervous and muscular tissues of the fcetus have received sufficient groAvth to enable them to enter upon their specific and legitimate functions, it is through the agency of one of these functions—muscular contraction—that the mother becomes sensible of her situation. Quickening, then? is nothing more than the ordinary result of progressive increase— in other Avords, the physical organization of the fcetus has reached a state of development, Avhich imbues it wifh the power of move- ment—a movement dependent upon muscular contraction. This contraction may be divided, for practical purposes, into two kinds —sensible and insensible. In the former instance, it is sufficiently strong to impart the sensation to the mother; in the latter, so feeble that she does not become cognizant of it. So you perceive, gentlemen, that Avhile the sensible muscular contractions of the fcetus may be said to constitute quickening, yet the insensible mus- cular contractions may take place some time previously to the period at which quickening usually occurs. Again, the accoucheur, with skilful manipulation, Avill occasionally be enabled to recognise the active movements of the foetus before they have become ap- parent to the mother. I haAre met with more than one instance of this kind, and it is of importance to remember the circumstance. * Eggert says, the fcetus has nothing whatever to do with the movements known as quickening—they being exclusively confined to the abdominal and uterine nariotes. [Rust's Magazine ; vol. xvii., p. 62.] 12 178 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Dr. Montgomery* states that he has had several similar examples; and the fact is confirmed by other observers. I have just stated that the quickening of the foetus in utero is the result of muscular contraction of the fcetus itself. This is un- doubtedly true, but as intelligent students, Avho should not be content with the simple affirmation of a fact, but Avho, in the true spirit of philosophy, have a right to seek its explanation, it is quite reasonable that you should ask what it is that gives rise to this action of the muscular system. Is it the result of volition, or, in other Avords, is it a psychical act; or does it depend upon some- thing beyond the control of the will ? The muscular movements of the foetus in its mother's Avomb are reflex phenomena, the products of excito-motory influence, an influence not dependent upon the brain, but traceable exclusively to Avhat has been deno- minated the true spinal system. This system is not only the source of muscular movement, but it is the very fountain of life itself. Those of you Avhose attention has not been particularly directed to the subject, might, perhaps, express surprise, if indeed you did not manifest more than ordinary incredulity at the statement that an infant born Avithout cerebrum or cerebellum, or without both, is capable of breathing, crying, taking its parent's breast and per- forming other acts connected with life. But Avhile the researches of the physiologist have established the fact beyond a peradventure —they have gone further, and demonstrated that, without the spinal cord, no matter how perfect may be the cerebral mass, life cannot be maintained, for the reason that the two essential func- tions of the economy, respiration—and, consequently, circulation— on which the various organic functions depend, are the results of reflex action of the medulla spinalis. You cannot, therefore, but appreciate the importance of this nervous centre, not only as the source of those forces constituting life, but also as the source from which emanate, either directly or indirectly, many of the disturbing influences, which derange and impair the human mechanism. I shall have occasion to call your attention to the physiology of the spinal system in connexion with the subject of parturition, and you will plainly see that child-birth is but another of those opera- tions of the physiological law, which are constantly presenting themselves to our observation. Period of Quickening.—A pregnant woman usually quickens about the middle term of pregnancy, say the fourth and a half month. But there is no uniform rule on this subject. I have known quickening to occur as early as the fourth month, sometimes not until the end of the fifth, and you will, in the course of your practice, occasionally meet with cases of gestation in which the » Signs and Symptoms of Pregnancy, p. 119. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 179 mothers have experienced no sensation of life during the entire term of pregnancy, and yet bring forth healthy and fully developed infants. If you ask me to explain this, I must acknowledge that I cannot. It is no doubt due to some idiosyncrasy, either on the part of the parent or child, which I do not comprehend, and which, therefore, it would be useless to attempt to elucidate. It may, peradventure, be that these foetuses are a species of " Lazy Law- rence," too indolent even to be made to move. We have many examples of this indomitable love of repose in both boys and men, who have long since left their mothers' womb. They have no object in life—they simply vegetate and die, and history keeps no record of either their advent or departure. Simulated Quickening.—But, gentlemen, what is especially inte- resting to you as accoucheurs, and more urgently so in reference to the diagnosis of pregnancy, is, that married Avomen, Avho are not in gestation, will sometimes imagine they feel life, and this hallucination will occasionally be so marked that it may possibly convert you to their mode of thought, and lead to serious error of judgment. On the principle that a medical man should be as ready to acknowledge his delinquencies as to proclaim his triumphs, and Avith the sincere hope that the recollection of it may hereafter admonish you of the necessity of caution, I shall cite the following interest- ing case, Avhich occurred to me some years since : A married lady, the mother of eight children, came from British Guiana, for .the pur- pose of placing herself under my professional care—her health had been quite infirm for tAVO years preA'iously to my seeing her. On an examination of her case, I discovered that she Avas • laboring under asthenic dropsy, from chronic disease of the liver. In communicating my opinion to her, she very courteously remarked that it Avas quite possible she was affected with dropsy, but she kneAV very well that she was also pregnant. I asked her why she thought so, and hoAV far advanced she imagined herself to be in gestation, to which she replied that she had, for six weeks pre- viously, Arcry distinctly felt the movements of her child, and that, according to her calculation, which had never failed her in previous pregnancies, she was in her sixth month. Although I had suspected nothing of this kind previous to the positive declaration of the patient, yet such was her inexorable conviction on the point, that I immediately proposed t :> institute an examination, for the pur- pose of satisfying my own mind. This she strenuously refused, saying that " It AArould be nonsense, as she was as fully convinced of her situation as she Avas that she Avas a living woman." Under these circumstances, I was content to submit the question of pregnancy to the future, and proceeded to do all in my power to relieve the formidable disease with which she Avas affected. So 180 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. dilapidated was her general health, and such the character of her malady, that I found my efforts limited to the mere temporary palliation of symptoms. She continued to increase in size, Avhich circumstance she constantly referred to her pregnancy; and every day that I visited her, she declared she felt more and more distinctly the movements of her child. She would often, as she reposed on her couch, take my hand, place it on her abdomen, and exclaim ; "There, Doctor, do you not feel it?" I must confess I never did feel it, but courtesy, contrary to conviction—so positive was this lady of her situation—frequently wrung from me an equivocal, but reluctant assent. There Avas another conviction which had taken a strong hold of the mind of this estimable woman, and it consisted in the full belief that, as soon as she should give birth to her child, she Avould regain her health. Well, gentlemen, things passed on in this way until, according to her OAvn computation, she was, as it were, on the borders of confinement; and, at her urgent request, I engaged for her a monthly nurse, Avho immediately entered upon duty. A singular feature in the case was, that the very day corresponding with the period when she expected her labor, I was sent for in great haste, and on entering the room, my patient observed : " Doctor, you see I am not mistaken." This lady assured me, and the statement was confirmed by the nurse, that for an hour previous to my arrival, labor pains had commenced. On making a vaginal examination, you may readily, imagine my embarrassment on discovering that the uterus was unchanged, and that no pregnancy existed ! Still it occurred to me that it might possibly be a case of extra-uterine foetation. I soon, .hoAvever, after due exploration, decided in my OAvn mind that this was not so. I need scarcely tell you that I stood self- rebuked. I had neglected my duty. I was bound by every prin- ciple of self-respect, by the very reasons I have so repeatedly urged upon you, to have insisted—AArhen this lady first placed herself under my care, and disclosed to me her well-settled conviction that she was pregnant—upon an examination, which would have enabled me to decide the question; or, in the event of my failing to obtain her consent, it was an obligation which I owed both her and myself, to withdraw from the responsibility of the case, for I maintain that the medical man, when denied jurisdiction, should not assume responsibility. I must confess, gentlemen, my conduct on this occasion was not at all in keeping with my usual mode of doinor things, for I usually insist—and succeed too—as it is termed, " in having my own way" in the sick room. But let us return to the patient. For the instant I wTas at a loss what to do. Knowing the ardent hope she entertained of her recovery as soon as she should give birth to her child, and well aware, also, of the extreme infirmity of her health, I was apprehensive that a sudden and THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 181 positive assurance on my part that she Avas not pregnant, would result most disastrously to my suffering patient. Accordingly, under the circumstances, I thought it most judicious to inA-oke counsel, and I requested my distinguished friend, the late Dr. John W. Francis, to visit her with me. He, after an examination, corro- borated my opinion, and the lady was then made acquainted with the conclusion at which we had arrived. Such is the operation of mind upon matter, so sovereign the influence of the mind over the body, that, almost from the moment the disclosure was made to her, she began to sink, and in four days her sufferings Avere at an end. There are various conditions of system in which women will be apt to imagine they feel the motions of the fcetus, and, therefore, it requires more than ordinary caution on the part of the practitioner, in order that error may be avoided. For example, women of extreme nervous susceptibility, hysterical Avomen, Avho are usually more or less annoyed by a flatulent state of the intestinal canal, will sometimes mistake a movement in the abdomen, dependent entirely upon a morbid condition, for the active movement of the child. Married ladies who have not borne children, and who, at the approach of the period of the final cessation of the catamenia, usually enlarge in the abdomen from a deposit of adipose matter, will occasionally suppose themselves pregnant, and they will assure you that they have distinctly "felt life."* Again, women, from avaricious or other motives, will feign pregnancy, and, among their other devices, will attempt to impose upon the judgment of the practitioner, by simulating the move- ments of the foetus, through the contraction of their abdominal muscles. AVhen I held the Professorship of Obstetrics in Charleston, South Carolina, Dr. Bennett, of that city, kindly afforded me an opportunity of presenting to my class a very interesting case, in the person of an old colored woman answering to the name of "Aunt Betty." She Avas Avell-known in Charleston as "the old * Some ludicrous blunders have been made in these cases; females who have been married for many years, and who, notwithstanding every legitimate effort on their part—faithfully aided, no doubt, by their devoted consorts—having failed in the con- summation of their wishes—the production of offspring—are extremely prone to mistake, as the era of the final cessation advances, the phenomena usually accom- panying this important climacteric for so many evidences of gestation. The oessation of the, menses, the increased size of the abdomen, together with the numerous nervous perturbations consequent upon this transition state of the eco- nomy, are readily treasured up as so many indications that "hope deferred" is at last to be gratified; and what is worth recollecting is, that it is generally extremely difficult to persuade these good ladies that what they have regarded as so many evidences of their pregnancy, are but the emphatic, yet sad declarations of nature that the springtime of life has passed, and they are about to lapse into the cold shades of winter. 182 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. woman who had been pregnant for fifteen years,'" and I Avas informed that she had accumulated some money by showing the curious how actively her little child "jumped in the Avomb." She Avas in good health, and quite corpulent. As " Aunt Betty : sat before me, there Avas considerable movement in the abdomen, which I very soon noticed she should cause at pleasure. She avus fifty-five years old, and had not menstruated for ten years. Aftei presenting her to my class, and, under the full conviction that she was not pregnant, I succeeded, Avith much coaxing, in obtaining her consent that I should examine her, Avhich privilege she posi- tively declared she had never previously granted any one. The uterus was not enlarged; she was not pregnant, and the deception, which had been practised on the credulous, Avas quite evident— she had, from long habit, accustomed herself to cause the. abdo- minal muscles to contract, which so closely simulated the move- ments of the foetus that she successfully carried out her scheme. Before I left Charleston, the good old Avoman died, and I was enabled, by a post-mortem examination, at which Drs. Francis Y. Porcher, J. B. Whitridge, and Dr. Bennett, Avere present, to con- firm the accuracy of the diagnosis. There was nothing remarkable revealed by the autopsy except that the omentum was loaded with fatty matter, which accounted in part for the enlargement of the abdomen. Sometimes young, unmarried women Avill apply to you for professional advice, and beg you to give them medicine to make them regular. They will tell you, apparently, a very consistent story. It is not unusual for them to haAre a protuberant abdomen, and if you inquire about it, they will say, "It is only a swelling they got since they caught cold," or something equally satisfactory. Should you place your hand on the abdomen, and recognise the movements of the fcetus—not unlikely to occur in some of these cases—and ask the woman if she has ever noticed this peculiar motion, you will be surprised, gentlemen, at the ready coolness with which she will oftentimes reply, " Oh ! yes, doctor, I am dreadfully troubled with it—it is wind in my stomach !"* You must be on your guard—a woman who has fallen is generally well versed in the Avily tricks * Dr. Keiller reported to the Edinburgh Obstetrical Society, March, 1850, the particulars of a very remarkable case not only of spurious pregnancy but spurious parturition: " He was sent for to what was regarded a very painful and protracted labor in which, according to the opinion of the attending accoucheur, the Caesarean section was imperatively demanded. He was astonished to find that all the symptoms of parturition were spurious, and the uterus was unimpregnated. The friends ridiculed the idea that it was not real labor, as the motions of the child could be not only felt, but seen through the walls of the distended abdomen, and the patient herself insisted that the child's movements were so violent that ^i- feared •' it would leap through her side." The symptoms were referable in a great measure to hysteria." THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 183 of life—and she Avill bring every subterfuge to bear in the hope that she may conceal from the public view the evidences of her own shame! Queen Mary, of England, is a striking example of how far imagination, excited by the earnest desire to have issue, may some- times impose on good sense and moral worth. She Avas so confident that she felt the movements of the child in utero, that public proclamation was made of the interesting circum- stance, and the intelligence sped with the Avings of lightning throughout the courts of Europe. Eager, indeed, Avas expectation, and high the hopes of the Queen—her people rejoiced, and national oblations offered for the coming event, Avhich was to make so many of her subjects happy. But, alas! the future threAv a gloom over this cherished anticipation. The supposed quickening Avas but the result of impaired health and incipient dropsy.* How can Fcetal Movements be Excited?—We now come to a Aery important question—How can the movements of the fcetus in utero be excited ? It is quite obvious that, in many cases of supposed or doubtful pregnancy, the accoucheur will be most anxious to decide the question by ascertaining, through certain manipulations, whether or not the child moves in its mother's womb. This fact being positively settled, places the existence of gestation beyond all contingency—it does more, for while it demonstrates that the Avoman is pregnant, it establishes also that the child is alive. Most authors recommend, in this exploration, that the patient shall be placed in the recumbent posture, with the thighs flexed, and the chest gently elevated for the purpose of relaxing the abdominal walls. In my own judgment, it is much better, for the object will be more readily attained, to alloAv the abdominal muscles to be on the stretch, rather than in a state of relaxation, and therefore—although it may sometimes be incon- venient to the patient—I would prefer conducting the examination either in the standing or sitting position. If, in the latter, the * Hume makes the following allusion to the case: "The Queen's extreme desire to have issue had made her family give credit to any appearance of pregnancy; and when the legate was introduced to her, she fancied she felt the embryo stir in her womb. Her flatterers compared this motion of the infant to that of John the Baptist, who leaped in his mother's belly at the salutation of the Virgin. Dispatches were immediately sent to inform foreign courts of this event; orders were issued to give public thanks; great rejoicings were made; the family of the young Prince was already settled, for the Catholics held themselves assured that the child was to be a male; and Bonner, Bishop of London, made public prayers. He said that heaven would pledge to render him beautiful, vigorous, and witty. But the nation still remained somewhat incredulous, and many were persuaded that the Queen labored under infirmities, which rendered her incapable of having children. Her infant proved only the commencement of a dropsy, which the disordered state of her health had brought upon her." [History oi England, ch. xxxvi.j 184 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. patient should place herself upright in the chair, Avith her head and shoulders inclined slightly backward. Now, gentlemen, let us understand ourselves—what is it you Avish to discover ? Simply whether the child moves in utero. I have told you that the move- ment is an excito-motory act; it is obvious, therefore, that you will be most likely to succeed in your investigations by having recourse to those means best calculated to promote the physiological or excito-motory influence. Excito-motory action, in physiological language, consists of tAVO distinct influences—one of these influences commences at the circumference, and travels to the centre, from Avhich emanates, and as a consequence, an action called reflex. The phenomena are pro- duced exclusively through nervous agency. You knoAV very well that a capital remedy in severe uterine haemorrhage is the cold dash applied to the abdomen—it is capital, because it Avill very generally produce contraction of the womb, and thus arrest the flooding. But, Avhat is the modus in quo of this agent thus applied—on what principle does it cause uterine contraction ? On the principle clearly of reflex or excito-motory influence. For example, the peripheral extremities of the nerves distributed upon the abdominal A\ralls become primarily stimulated by the cold; this impression is instantly conveyed, through these nerves, to the medulla spinalis, Avhich imparts to the motor nerves passing from it to the uterus a neAV impulse; and it is to this impulse, transmitted by these nerves to the muscular tissue of the uterus, that the con- tractions of the organ are to be referred. Upon the same principle precisely, will you sometimes observe the magic effects, in uterine haemorrhage, of a piece of ice placed in the vagina. I have many times had recourse to this simple remedy, efficient only on the ground of a sound physiological principle, and with the happiest results. Noav, then, for the movements of the foetus—they may be excited in various ways. Sometimes, the placing of the hand on the abdomen of the mother, and gently pressing it, will answer the purpose. At other times, place one hand flat on one side of the abdomen, and, with the fingers of the other, percuss the opposite side, as you would in attempting to detect fluctuation. Again, thrust the hand into a vase of ice water, and suddenly apply it to the abdomen. It is necessary here to state, as has been pointed out by Prof. Simpson and Bischoff, that the movements, which occur on the application of the cold hand to the abdomen, are movements in the first place of the uterus itself through a reflex action; but this very movement of the womb causes it to press against the foetus, and thus induces action in the latter.* * It should be remembered that these movements of the uterus may be observed before the fcetus can move, or even after its death; and also in cases of uterine enlargement from the presence of some morbid growth. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 185 Some women will tell you that, on experiencing pain in one point of the abdomen, they will make pressure on the affected part, and immediately feel the movement of the foetus. This pain is often- times produced by the pressure of some portion of the foetus against the abdominal walls, usually one of the extremities, and as the mother, to relieve herself, pushes ,the extremity from the painful part of the abdomen, she excites the movement of the child. If any of you have ever witnessed an arm presentation when the arm has passed from the uterus into the vagina, you, perhaps, have noticed that on touching the protruding hand the child will move. This is an interesting example of reflex or excito-motory action. An old author, whose name I do not now recollect, recommended as a sovereign remedy in arm presentations, to prick the palm of the hand Avith a needle, which, as he alleges, will cause the child to withdraAV its arm into the uterus. No doubt, the recommendation Avas based upon the circumstance I have just stated; but it will prove utterly nugatory so far as the effect mentioned is concerned ; and I may also remark that the author Avho suggested the remedy Avas entirely ignorant—for the physiology of reflex action was then unknown—of the true explanation of the movement following the pricking the palm of the hand. 2d. Ballottement or Passive Motion of the Fcetus.—Ballottement or repercussion means nothing more than the passive movement of the child in utero—and differs, therefore, from epiickening in the essential fact that the latter is the result of muscular contraction, Avhile the ballottement is purely passive, a movement in no Avay connected Avith any inherent action of the fcetus itself. For example, when a pregnant women suddenly turns from one side to the other in the recumbent posture, she may tell you she distinctly feels something fall, as it were, to the side on which she reclines. This is the fcetus which, obedient to the laws of gravity, and floating in a quantity of amniotic fluid, follows the impulse given to it by the change of position assumed by the mother. The ballottement, when recognised, possesses great value as a sign of pregnancy. As a general rule, it does not occur earlier than the fourth month, and, according to my experience, it is most readily detected between the sixth and seventh months. Later than this, OAving to the increased growth of the foetus restricting its playground, it is more or less difficult of recognition. It is worthy of recollection that sometimes it evades the most skilful manipulation, during the Avhole course of pregnancy; and I am inclined to the opinion that, in such cases, one or tAvo circumstances Avill exist to account for the failure—either an unusually small quantity of liquor amnii, or a cross presentation of the foetus. This is not a mere speculation of mine—it is substantiated by accurate and well attested data. I have on several occasions failed in detecting the passive movement 186 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of the fcetus; and, in acquainting myself with the actual history of the cases at the time of parturition, I haA*e found one or other of the above circumstances to be present. The following case,-1 think, is in point: A lady from North Carolina, consulted me in December, 1858, for what she supposed to be a morbid growth in her womb. She had been married eleven years, was 39 years of age, and had never become pregnant. Her menses had always been regular as to time, but not free in quantity, until July previous to seeing her. With a very thorough examination of her case, although I failed com- pletely to detect the ballottement, after repeated and careful trials, I pronounced her pregnant. My opinion Avas based upon unexcep- tionable testimony. 1st. The active movements of the child. 2d. The presence of the true areola. The lady Avould not believe that I was right in my opinion—but being an intelligent Avoman, she accepted the compromise Avhich I proposed to her—if, at the end of a feAv months, she did not prove a mother, that I Avould consent to be denounced, not only as a false prophet, but as unworthy of all confidence. The emphatic and positive manner in which I spoke tended to remove her doubts, and she soon surrendered her previous conviction. She returned to Carolina, and, on the 15th of the follow- ing April, was delivered of a healthy living son, for the safety of which she Avas indebted to the skill of her physician, Dr. Shepperd, who Avas compelled to perform Aersion in consequence of a shoulder presentation. It was this form of presentation, no doubt, which prevented my recognising the ballottement. Mode of Detecting Ballottement.—The rules for detecting this movement are simple. In the first place, the examination may be made either in the erect or recumbent position. The index finger of one hand is to be introduced into the vagina, and carried upAvard and backward to the portion of the uterus at which the neck and body of the organ unite— the other hand is to be applied expanded over the abdomen, for the purpose of grasping the fundus of the womb. You are then gently and suddenly to press with the index finger from below upward, and from behind for weird, against the body of the uterus; this pressure will usually cause a momentary ascent of the fcetus, Avhich immediately again descends, and rebounds, as it were against the finger. This sensation, once experienced, is quite con- firmatory of the condition of the female ;* for you must remember * I was requested by a medical gentleman of this city to visit his wife, in consul- tation with his friend and family physician, Dr. Freeman. The lady had suffered, Dr. Freeman informed me, for more than a year from ovarian disease; for two months previous to my seeing her, she had been voiding quantities of pus per rectum. The patient was much emaciated from this circumstance. On an exami- nation, I found the right ovary much enlarged, and it was evident that it had taken THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 187 that the relation of the embryo to the uterus is peculiar; though lodged Avithin the Avomb, yet it enjoys great capacity for motion, either active or passive, for the reason that it is surrounded by more or less amniotic fluid, which enables it to rebound to any impulse which it may receive. I know of no other condition of the uterus, either healthy or morbid, other than pregnancy, capable of produc- ing this sensation of rebound, and therefore, when the latter is really recognised, it is an indication of pregnancy of very great import. 3d. Pulsations of 'Foetal Heart.—One of the striking evidences of the progress of science, developing, as it proceeds, new facts, calculated, by their proper application, for the benefit of the human family, is exhibited in the discovery published in 1818, by M. Mayor, of Geneva, that, by the aid of auscultation, the heart of the foetus can be distinctly heard to beat in its parent's womb. What a precious discovery, and how inestimable its value in many cases in Avhich the true condition of the female is shrouded in mystery—and hoAV important, too, in instances in which, from pelvic or other defor- mities, the alternative of choice between the Caesarean section or embryotomy may depend upon the solution of the question—Is the child alive or dead ? The pulsations of the foetal heart are not in accordance, or, in other words, synchronous with those of the mater- nal heart. While the maternal heart will average from seventy-five to eighty beats in the minute, the former will vary from one hun- dred and ten, to one hundred and sixty.* This latter Variation in the foetal pulsations, may be ascribed to some occasional disturbance experienced by the mother, in her circulatory and respiratory func- tions, and thus transmitted to the child through the influence of the changes in the maternal blood. After these pulsations haA'e been once detected—and they are usually not recognised until betAveen the fourth and fifth month—they Avill be found gradually to increase in force; but as the period of gestation approaches its close, there will be a marked diminution in their frequency. Cazeaux maintains the contrary of this ; I think he is in error. Tyler Smith describes them on suppurative action, the matter passing out through the rectum, in consequence of ulceration, as will sometimes happen in these cases. In addition to the enlarged ovary, I thought I discovered also, an enlargement of the uterus—and on making a vaginal examination, I very distinctly detected the ballottement. I at once pro- nounced the lady pregnant; her condition had never been suspected—her menstrua- tion had been uniform and regular; and no vaginal examination had been previously made, for the reason that its necessity was not indicated. This lady was placed upon tonic treatment, with a view of meeting the waste from the constant discharge of matter. In four months after I saw her, she was delivered by Dr. Freeman of a healthy little girl, and what is extremely interesting entirely recovered her health. * According to Frankenhauser, in the male foetus the heart beats one hundred and twenty-four, and in the female one hundred and forty-four in a minute on an average. 188 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. as declining in frequency and continuous Avith the diminution which follows after birth.* Auscultation.—The double action of the foetal heart—for in it, as in the adult, there are two distinct sounds, unequal in duration —is ascertained by means of auscultation. This, you are aware, is diA'ided into mediate and immediate. In the former, the stetho- scope is employed ; in the latter, on the contrary, the ear is applied directly to the part at Avhich the sound is sought for. It is quite evident that the foetal pulsations cannot readily be mistaken for any other species of vascular action, for the important reason that, on counting them, it will be found there is no correspondence in fre- quency between them and the throes of the maternal heart. Iti having recourse to auscultation, the patient may assume either the recumbent or standing position. It is not necessary to expose her person; the chemise may intervene—although the ear or stetho- scope, applied directly to the naked abdomen, would be more likely to be followed by a successful investigation. The chemise should be made as smooth as possible, and perfect silence observed in the room; after the seventh month, the ear may be employed, if found desirable; but previous to this period, the stethoscope itself Avill be more advantageous. At Avhat portion of the abdomen will the pulsations of the foetal heart be most frequently found ? To answer this question it will be necessary to revert to what we haA'e said, in a previous lecture, touching the relative frequency of the various presentations of the foetus. The head is, out of all comparison, most commonly found to pre- sent with the occiput either in correspondence with the left or right acetabulum; the former constituting the first, the latter, the second presentation of the vertex.f In these respective presentations, you are to ask yourselves with what portion of the maternal abdo- men is the spine of the fcetus in relation, for it is to be borne in mind that the beats of the heart will be more easily detected by auscultating on the back than any other part of the foetal surface— and for obvious reasons, as suggested by Velpeau ; in the first place, the natural curve of the foetal body is on its anterior plane, thus moving the cardiac region further from the abdomen of the mother while at the same time the upper extremities are usually folded on the chest; and secondly, the anatomical relations between the spine and heart afford another motive for selecting the back of the fcetus in this character of exploration. It, therefore, follows from Avhat has been said of the relative frequency of cranial positions, that the back of the foetus will be found most commonly either on the left * P. 143. f The student should not forget what has already been said in regard to the change of the head, as indicated by Naegele, from the right sacro-iliac symphysis to the right acetabulum. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 189 or right lateral portion of the abdomen, at some point between Poupart's ligament and the umbilicus. Occasionally, however, in oonsequence of change in the attitude of the foetus, the pulsations may be detected in various portions of the abdominal cavity. Of course, in pelvic presentations, the sound will be recognised in the upper portion of the uterus. The facility for recognising the pulsations will be much enhanced by the escape of the liquor amnii; as soon as this passes off, the walls of the uterus coming in close contact with the body of the foetus, there is, if I may so term it, a more positive directness given to the sound, and consequently an increased poAver of perception to the auscultator. In addition to the proof of pregnancy and the life of the child, these pulsations, when recognised, will also indi- cate the position of the foetus in utero. If, in your exploration, you should hear the beatings of the foetal heart in two distinct por- tions of the abdomen, the irresistible conclusion will be that it is a ease of tAvin pregnancy ; and again, after detecting the pulsations, if, on a vaginal examination, you should ascertain that the uterus has undergone but slight enlargement, it is very manifest that it cannot contain a foetus, and, therefore, the gestation is extra-uterine. Sometimes, with the best directed efforts, and with all the skill you can bring to bear, it will be impossible to recognise the action of the heart, and yet the Avoman may be pregnant; and, at the full term, bring forth a well-developed and healthy child. So you see, gentlemen, that Avhile the pulsations of the fcetal heart, once posi- tively heard, constitute an unerring evidence that pregnancy exists, their absence is by no means a proof that the female is not preg- nant. 4th. Bruit Placentaire, Placental Souffle, Uterine Murmur.—In 1823, Kergaradec called attention to what he denominated the Bruit f>lacentaire—the placental souffle—a peculiar sound which he maintained was disclosed during pregnancy through auscultation, and Avhich he attributed to the passage of the blood from the uterus into the placenta—the utero-placental circulation—and hence the name placental souffle. Since that time, however, although the general fact is almost universally conceded that a peculiar sound is emitted, yet authors differ as to its cause and seat. Some agree in opinion Avith Kergaradec, Avhile others maintain that the sound is produced, not by the utero-placental circulation, but through pressure exer- cised upon the adjacent blood-vessels by the gravid uterus. Dubois restricts the cause and seat of the souffle to the circulation going on in the substance of the uterus itself. It is quite evident that the opinion of Kergaradec is not tenable, and, among others, for the following reasons : 1st. This sound is sometimes heard after the birth of the child, and expulsion of the placenta. 2d. It is not confined to any given 190 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. point of the uterus, but will be heard in almost every portion of its surface at different times. 3d. It Avill oftentimes be recognised when pregnancy does not exist, in cases of abdominal or uterine tumors. The uterus, during pregnancy, is in an extremely hyper- aemic condition, the A'essels are turgid Avith blood, and consequently the local circulation will be more or less labored; may not this be the simple explanation of the uterine murmur during gestation—and Avhen it is heard after delivery, may it not be explained upon the hypothesis that the sudden emptying of the Avomb has left the vas- cular and other tissues of the organ in such a relaxed state, that the circulation, for a short period after parturition, continues to be sluggish, or, if you choose, labored, and hence the murmur ? When you detect, through auscultation, the bellows sound in the heart, is it not accounted for on the principle that the circulation, through valvular or other disease, is interrupted in its ordinary round ? But hoAV, you may ask, is this souffle produced Avhen pregnancy does not exist—in cases, for example, of abdominal or uterine tumors ? I have no doubt it is the result of pressure upon some of the surrounding vessels. The hypothesis has obtained that the souffle may be occasioned by the peculiar condition of the blood in pregnancy, producing, as is sometimes the case in chlorosis, certain abnormal sounds. That distinguished physiologist, Dr. Brown- Sequard, supposes that these sounds in chlorosis occasionally ema- nate from a tremor of the muscles peculiar to Aveak and aged per- sons ; and he has shown that there is a sound produced in the gravid uterus, Avhich is generally mistaken for the placental souffle, and which is evidently due to the muscular sound; it co-exists with the local contractions of the uterus. There is much diversity of opinion as to the particular period of pregnancy at which the souffle can be first recognised. Some say they have detected it at the eleventh week, others at the third month. But you will find, gentlemen, that these early periods, admitting there is no error, constitute rare exceptions to a very general rule. It is more, I am sure, in accordance with correct observation, to say that it is not until the expiration of the fourth month that it can be detected. The souffle differs in one important particular from the pulsations of the fcetal heart—it is synchronous with the maternal pulse, and, therefore, is connected with the blood- vessels of the mother. It possesses rather a coquettish propensity —after being once heard, it will sometimes bid defiance to the most accomplished auscultator, and will so completely intermit, that several days will often elapse before it again reveals itself. Occa- sionally, the whole period of pregnancy will pass without its ever being detected. From what has been said, it is manifest that its value as a sign of pregnancy is not of a high order, for it may exist where there is no gestation; and while its presence is no THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 191 indication of the life of the foetus, it may be detected Avhen the latter has ceased to live. 5th. Pulsations of the Umbilical Cord.—Dr. Evory Kennedy, who has written so well on the subject of utero-fcetal auscultation, says that he has been enabled distinctly to feel, through the abdo- minal Avails of the mother, the convolutions of the umbilical cord, and also, by aid of the stethoscope, to hear its pulsations. But it has only been, he states, in cases in which the walls of the abdo- men and uterus were characterized by unusual thinness. I have, after repeated attempts under the circumstances indicated by Dr. Kennedy, never succeeded in attaining either one or other of these objects. If the cord were distinctly felt, or its pulsations heard, it would certainly be unequivocal proof of pregnancy. But it seems to me that if the pulsations alone were detected, it would be diffi- cult to demonstrate that they proceeded from the cord and not the heart, inasmuch as they, like those of the latter, are not in cor- respondence with the maternal pulse. It is true that the beatings of the cord might, from its extent, be heard in different portions of the uterine surface—but this, again, would be apt to give rise to the suspicion of Twin-pregnancy.* * A Funis souffle is sometimes heard. Five instances, in five hundred cases of labor, have been reported by Scanzoni. The source of the souffle does not appear to be clearly established, but its presence is supposed to be indicative of danger to the foetus. LECTURE XIII. Examination of the Female to Ascertain the Existence of Pregnancy—The Three Senses, Feeling, Seeing, and Hearing, to be employed—The "Toucher;" what is it?—External Abdominal Examination ; its Objects; how to be conducted—Va- rious Causes of Uterine Enlargement; how to be distinguished—Examination per Vaginam; Rules for—The Vagina; its Position and Relations—Position of the Female—Relation of the Vagina to the Cervix Uteri—Examination per Anum ; when indicated—Retro-Version of Uterus—Prolapsion of Ovary into Triangular ♦ Fossa—Vaginal Ovariotomy—Auscultation—The Metroscope; its Uses. Gentlemen—The examination of a female, for the purpose of ascer- taining whether or not she is pregnant, requires on the part of the accoucheur, in the first place, a thorough knoAvledge of the various evidences of gestation, together Avith a full appreciation of the mor- bid phenomena knoAvn to simulate this condition; and, secondly, he must bring to the examination a facility of tact, which can only be acquired by a long and well-cultivated experience. To arrive at a just diagnosis on this subject will oftentimes constitute, from the complication of the surrounding circumstances, one of the most difficult duties in the entire curriculum of the physician's practice. But, great as is the embarrassment, it may be overcome by an enlarged knoAvledge and due attention. In our discussion of the numerous signs of pregnancy, you will not have failed to notice that they are of different grades, and pre- sent various shades of value. The great majority of them are, to say the least, only equivocal, and will not, therefore, when any important interest, such as life or character, is involved in the decision, form data sufficiently broad to enable you positively to affirm that gestation exists. I admit that a married woman, espe- cially if she have previously borne a child, will generally be enabled to understand that she is pregnant, from the symptoms which ordinarily accompany this state, such as the suppression of the catamenia, morning, sickness, mammary sympathies, and other phenomena. But these signs, as they may be dependent on other influences than pregnancy, are utterly insufficient in numerous cases in Avhich the counsel and judgment of the physician will be invoked, and upon whose opinion must depend all that is sacred to the individual. The accoucheur, in his analysis of evidence, will have to bring into requisition the three senses, feeling, seeing, and hearing • THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 193 therefore, his means of exploration are divided in obstetric lan- guage into—1. The toucher; 2. The revelations made by the eye; 3. Auscultation. The adroit application of these resources, and a judicious appreciation of their deductions, will rarely fail in enabling the practitioner to evolve an opinion in accordance with the truth. The toucher consists of an external and internal examination—in the former, it is restricted to an exploration of the abdominal walls ; in the latter, the finger is introduced into-the A'agina or rectum, for the purpose of sundry investigations, to which Ave shall presently more particularly allude. The eye is more especially employed in examining the state and peculiarities of the mamma?, Avhile the ear is engaged in testing the various auscultatory phenomena. 1. External Examination.—In this examination, the chief objects are to ascertain Avhether there is any abdominal enlargement, and if so, on Avhat it is dependent; also to recognise, if possible, the movements of the foetus. If from distension of the uterus, the increased volume of the abdomen will usually be more or less in the centre of the hypogastric region, pyramidal in shape, with the base upward and the apex doAvmvard ; and the enlargement will present to the touch uniform hardness, Avhile on the sides there will be an absence of fulness, and the abdominal walls at these points Avill yield more or less to pressure. The upper portion of the pyramid will represent the fundus of the organ. By causing the abdominal muscles to relax, Avhich can readily be done by flexing the thighs on the pelvis, and gently raising the head and shoulders of the Avo- man, the hand is enabled to grasp the fundus; this Avill determine the point of its ascent in the abdominal cavity, and thus enable you to approximate, all things being equalj the period of pregnancy. But, gentlemen, supposing the uterus to be distended, how do you know that it contains a fcetus ? You will probably ansAver me, by means of the ballottement, quickening, or the pulsations of the foetal heart. These phenomena, however, cannot be detected in the earlier months of gestation, and sometimes—although pregnancy may exist—the accoucheur fails altogether in recognising them dur- ing the Avhole period of the gravid state. Your diagnosis, there- fore, must be determined by other circumstances; and this brings us briefly to consider the different causes, other than gestation, capable of inducing enlargement of the uterus. They may be enumerated as follows : A. Infra-uterine growths, including fibrous, polypoid tumors, and hydatids; B. Hydrometra, or dropsy of the uterus; C. Retention of the menses; D. Physometra, or a flatulent distension of the organ; E. Hypertrophy; scirrhus. A. Intro-uterine Groicths.—These, constituting pathological states of the organ, are usually accompanied by phenomena Avhich, to the intelligent observer, Avill unmask their true character. For 13 191 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. example, in cases of an intra-uterine tumor, whether simply fibrous, occupying the entire caA'ity of the organ, or polypoid, and pedicu- lated to a given point, there will almost always be hemorrhage with more or less bearing-doAvn pain—the bleeding and pain gene- rally increasing about the advent of the catamenial evacuation. Again: in these formations, the groAVth of the tumors is ordinarily slower, and in this Avay, too, they may be distinguished from preg- nancy, which you know \s rapid in its development, for the reason that there are but nine months allotted to the accomplishment of that chef cVceuvre of nature—the perfect organization of the em- bryo ! Occasionally, Avhen the uterus is enlarged from an intra- uterine growth, auscultation will reveal a souffle; * this may be mistaken for an evidence of pregnancy; but if this latter condition really exist, in addition Ave should recognise the pulsations of the fcetal heart, together Avith the movements of the foetus itself. Nor, in this connexion, should it be forgotten that these growths will sometimes coexist with pregnancy. Pathologists are not of accord as to the special structure of these tumors; it has been generally said that they are composed of a fibrous tissue ; recently, hoAvever, Lebert and C. Robin seem to have demonstrated that they consist of a simple hypertrophy of the fibro-muscular element of the uterus. YirchoAV is also of this opinion, maintaining that the fibrous or fibroid uterine tumor pos- sesses in eA'ery respect the same structure as the walls of the hypertrophied uterus, consisting not only of fibrous connecting tissue and \essels, but also of muscular fibre cells, f In uterine hydatids there will also be occasional bearing-down pains, and more or less discharge of blood; and, in addition, there is a symptom which I consider pathognomonic of these growths, viz. a periodical discharge of water per vaginam. B. Hydrometra, or Dropsy of the Uterus.—In this affection the constitution is usually more or less involved, it being rarely a local disease ; and, in percussing, distinct fluctuation will be revealed. C. Retention of the Menses.—This is a most important derange- ment of the female, and has more than once resulted in false and cruel opinions, affecting not only the happiness, but leading from a broken heart to the death of the individual. Retention of the menses is that peculiar condition in which the menstrual blood is poured out regularly every month into the uterine cavity; through its accumulation, it gives rise to distension of the organ and certain sympathetic phenomena, which have sometimes been mistaken for pregnancy, and formed the basis of most erroneous decisions. See * The souffle is not at all incompatible with an intra-uterine fibrous growth, for it may result from the fact of the tumor being situated over the aorta or other large vessels ; and sometimes, also, the increased vascularity of the uterus may produce it \ Virchow's Cellular Pathology, p. 443. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 195 how easy a thing it is, by a careful examination, to arrive at the truth on this subject. Why is the catamenial fluid retained in utero ? Simply because there is an obstruction to its free passage ; and this obstruction may consist either of an occluded os tincae or an imperforate hymen. Therefore, if either of these be found to exist, your diagnosis is at once arrived at.* D. Physometra.—This is a rare affection; it consists in the accumulation of flatus within the cavity of the uterus, and I believe is almost always traceable to the extrication of gas from some decomposed substance within the organ—such as a retained pla- centa, mole, or foetus. In physometra, there will be revealed, under percussion, a sound of distinct resonance, and the uterus * Among several cases of retained menses in which I have operated, the follow- ing is not without interest: A respectable woman, the wife of a thrifty mechanic, married about six weeks, requested my professional advice. Her husband, a month after marriage, had begun to treat her cruelly in consequence of suspicions in regard to her fidelity. When I saw her, she had the appearance of being about five months pregnant; she remarked that some of the female relatives of her husband had impressed him with the belief that she was pregnant when he married her; hence his cruel treatment. The poor woman was in deep distress, and supplicated me to satisfy her husband that she had been true to him, assuring me, at the same time, that she would cheerfully submit to any examination I might suggest. She informed me that she was twenty-seven years of age, and had never menstruated; her health had been wretched from early girlhood. On visiting her the following day, I ob- served there was an indistinct and circumscribed fluctuation perceptible at the anterior portion of the abdomen, and extending upward within one inch of the umbilicus. The finger being introduced as far as the cervix, I soon appreciated an entire absence of the os tincm, the lower and central portion of the cervix being quite smooth and uniform on its surface. With the other hand applied to the abdomen, I grasped the fundus of the womb, and thus embraced this organ between the hand externally, and the finger introduced into the vagina. The diagnosis was plain; viz. that the fluctuation was the menstrual blood contained within the uterus; in consequence of there being no outlet, this fluid had accumulated, causing a dis- tension of the womb, and giving rise to the suspicion of pregnancy. I stated my opinion very fully to the husband—told him his wife could be relieved by an opera- tion, at the same time assuring him that his suspicions were without the slightest grounds. Having obtained his consent, assisted by two of my office pupils, Drs. Burtsell and Morris, I introduced a speculum into the vagina, and brought distinctly to view the cervix-uteri. This I penetrated at its lower and central portion. Soon, not less, I am sure, than two quarts of grumous blood were discharged from the uterine cavity. It is as well to mention that the perineal strait of the pelvis was somewhat contracted in its transverse diameter. The operation was attended with very little pain; the uterus assumed its ordinary size, and the patient recovered in a few days. I was much gratified with a visit from both herself and husband, the latter appearing truly contrite, while the former assured me of the happiness she experienced in being restored to his confidence and affection. Nearly thirteen months from the day of the operation, I was called to attend her in her confinement; after a severe labor of twenty-eight hours, I deemed it necessary to apply the forceps, and delivered her of a fine living son, assisted by two of my pupils, Messrs. Meriweather and Whipple, of Alabama. 196 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. will be found characterized by unusual lightness. Its volume, too, will be apt to vary in consequence of the occasional escape of flatus through the os tincae. In addition, the antecedent history of the case Avill aid essentially in a correct diagnosis. E. Hypertrophy and Scirrhits of the Uterus.—Here, too, the history of the case, besides the peculiar hardness of scirrhus imparted to the touch, will enable the practitioner to avoid all doubt. I may also, at this time, mention some of the ordinary causes of abdominal enlargement, which might possibly, through unpardon- able negligence, be mistaken for pregnancy—such as abdominal tumors without the uterus, whether simply fibrous, pediculated to the external surface of the organ, or in the form of a steatomatous mass, encysted dropsy, tympanites, ascites, etc., etc. Abdominal Tumors.—Fibrous groAvths, attached by a pedicle to the outer portion of the uterus, are, according to my experience, by no means uncommon. Usually, there are several of them; their growth is sometimes rapid ; most generally, hoAvever, slow. They are not malignant, and Avhen they destroy life, they do so in con- sequence of their pressure on the digestive apparatus, so as to interfere Avith the healthy and necessary play of the nutritive func- tions. I have seen them from the size of an egg to the Aveight of thirty pounds. In my museum, you have examined seAreral extremely interesting specimens of this character. These tumors are generally characterized by great mobility; and, under ordinary circumstances, they can be made, by judicious manipulation, to revolve slightly upon their axis, which consists of the pedicle by which they are attached to the external surface of the uterus ; and if you gently press the ulnar portion of the hand downward, you will frequently be enabled to pass it between these tumors, showing at once their separate and individual existence, and also proving how entirely they are unconnected with increase of the abdomen, the result of gestation. Enlargement of the Ovary.—An enlarged ovary has oftentimes given rise to the suspicion of pregnancy; and while, with proper attention, it is not difficult to make the necessary distinction, yet it must not be forgotten that occasionally this form of tumor coexists with, and constitutes one of, the complications of gesta- tion.* In these latter cases, more than ordinary vigilance will be needed to elicit the truth. It would be proper to inquire whether a tumor had been observed in the abdomen for some time before the suspected pregnancy. But as a means of diagnosis in these cases, you will find auscultation, perhaps, the most efficient, pro- vided you can succeed in detecting the pulsations of the fcetal * For an interesting example of this kind; see Diseases of Women and Children, p. 258. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 197 heart. In simple ovarian enlargement, you will discover, on inquiry, that the tumor commenced not in the lower and central portion of the abdomen, as is the case in enlargement of the uterus, but in one or other of the iliac regions; and for the very substantial reason that this is the location of the ovaries in their natural and healthy state. As the tumor increases in development, its ascent is more or less oblique ; and, on a vaginal examination, the uterus Avill be found to have increased, if any, but very slightly in volume. Should it be a case of dropsy of the ovary, Avhich is by far the most common form of morbid action assumed by this body— percussion will enable you to ascertain the fact, for fluctuation, more or less distinct, will be recognised. This form of dropsy is called encysted, because the fluid is contained in one or more cysts—in the former case, knoAvn as unilocular ; in the latter, multilocular. Tympanites.—The abdomen Avill not unfrequently become dis- tended from a collection of flatus within the intestinal canal; and this is apt especially to occur in nervous, hysterical women. One of the prominent diagnostic evidences of this character of disten- sion is the alternate increase and diminution of the volume of the abdomen—and this depends upon the quantity of flatus which escapes, either through the oesophagus or rectum. In these cases, too, the uterus will not be enlarged. Ascites.—Ascites, or peritoneal dropsy, cannot well be con- founded Avith pregnancy, if the following diagnostic guides be borne in mind : 1. It is the result of some previous derangement— such, for example, as inflammation, disease of the liver, kidneys, or heart; 2. In well-developed ascites, there is ahvays more or less distinct fluctuation—and the fluctuation in this differs from that in hydrometra and encysted ovarian dropsy, in the important fact that it is not confined to any one portion of the abdomen, but is general; 3. The uterus, unless as a rare complication, will be found unchanged in size. Phantom Tumors—Accumulation of Fcecal Matter.—In hys- terical and anaemic women you Avill sometimes meet Avith what are termed phantom tumors, the pathology of which appears to be an irregular contraction and relaxation of the abdominal walls. A careful vigilance will prevent the possibility of mistaking these enlargements for pregnancy ; so also Avith regard to the occasional distension of the abdomen from accumulated faeces. 2. Internal Examination per Vaginam.—It needs no little tact to conduct this examination in a manner at once acceptable to the patient, and profitable to the accoucheur. Indeed, I know of feAV positions more embarrassing to the young practitioner than to be called upon to institute this kind of exploration, Avithout due knoAvledge and experience. It can scarcely be necessary, gentle- 198 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. men, to remind you that your patient is always entitled to a full measure of delicacy and refinement—it should never be forgotten that it is at a heavy sacrifice that she consents to have you by her side in the hour of her trial—and the richest equivalent, therefore, you can offer her for this sacrifice is the high-toned bearing, which every cultivated gentleman knoAvs so Avell how to exercise toAvard a female under these circumstances. You should accustom yourselves to conduct this examination Avith either hand, and whiche\rer one you employ the index finger only is required. It should be extended fully, the thumb brought into Fig. 43. the palm of the hand, and covered by the other three fingers. (Fig. 43.) If you haA'e a scratch or sore on the finger, never intro duce it into the vagina, for you incur the serious hazard of inocu- lating yourself with the venereal poison, if any exist; or the absorption of acrid leucorrheal matter may prove disastrous. The finger should always be lubricated with some mucilaginous or oily material; what I find to ansAver eArery purpose is a little soap and water. Unless there be some personal or other objection to it, I usually prefer making this examination Avith the patient on her back, and in the recumbent position ; the abdominal walls should be in a state of relaxation, as in the external examination, in order to facilitate the accoucheur in his manipulations—for, if they be tense and resisting, he will be unable to feel the uterus with the hand applied externally. A very proper and necessary precaution is, to precede the examination by causing the bladder and rectum to be evacuated of their contents. A neglect of this precaution will be apt to interfere more or less with the thoroughness of the exploration, and add no little to the discomfort of the patient. Preliminaries to the Examination.—You are to remember that there is not the slightest necessity for, nor will any thing justify, the exposure of your patient. Your coat and shirt sleeve should be turned over at the wrist, and a napkin properly pinned over them, so as to protect you from any mucus or other secretions in the vagina—and besides, it is more in keeping Avith neatness and refinement, two attributes ahvays appreciated in her physician by a delicate and cultivated female. How are you to find the vagina ? This may appear to you a very unnecessary question—but, gentle THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 199 men, it is full of sterling import to you as practitioners. What would be the measure of your mortification if, in attempting an examination of this kind, the patient, after more than Christian forbearance, should exclaim, " Doctor, what are you about; do you not know better than that?" and you should discover that the rebuke Avas prompted by the painful circumstance that, instead of the vagina, you had introduced the finger into the anus! And yet, gentlemen, strange as it may seem to you, this blunder has been committed, for Avant of proper knowledge, much to the chagrin of the practitioner, and the outraged feelings of the patient. It. is Avith a vieAV, therefore, of guarding you against the possibility of such an error, that I shall proceed in a few Avords to point out in Avhat Avay it may be avoided. The hand, arranged as I have already described, is to be placed under the sheet, and, Avithout the consciousness of your patient, you should at once carry the index finger to the central and internal surface of the knee corresponding Avith the side of the bed at Avhich you are sitting; then conduct the finger carefully along the median line on the internal surface of the thigh as far as the vulva ; this will bring your finger to the central portion of either the right or left labium externum, and as soon as it has reached this point, all that is necessary Avill be to push the finger a little to the right or left, depending upon Avhich labium it may be, and it is at once in the vagina. Relations of the Vagina—Deductions.—As the finger passes into the vagina, ahvays have its radial border looking toward the symphysis pubis. Noav, before proceeding further, let us pause for a moment, and make one or tAVO observations with regard to the shape and anatomical relations of the vagina. It is, you knoAv, called the vulvo-uterine canal, because it extends from the vulva to the uterus, receiving, as it Avere, into its upper portion the cervix of the latter organ. The vagina posteriorly, in its three middle fifths, is in relation, through the medium of cellular tissue, with the rectum, giving rise to the recto-vaginal septum ; anteriorly, it forms, through the same sort of intervention, a union AA'ith the urethra and bladder, thus constituting for the accoucheur tAvo important septa, viz. the urethro-vaginal, and vesico-vaginal. In addition to these relations, it must be borne in mind that the vagina is a crooked canal, with its concavity forward, and its con- vexity backward ; so that it corresponds Avith the curves of the pelvis, the upper extremity being parallel to the axis of the superior, while the lower is in relation Avith the axis of the inferior strait; the ordinary position of the uterus is such that its long axis is more or less in correspondence Avith the axis of the upper strait of the pelvis ; and it, therefore, follows, that the junction of the upper portion of the vagina and cervix of the organ will form Avith the outer opening of the vagina an angle of about 45 degrees. The 200 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. object of my directing attention to these important facts is, that they may serve as a guide for the direction of the finger after it has reached the vagina. Without special attention to the subject, the young practitioner—I do not think I exaggerate it—in ninety cases out of one hundred, Avill, as soon as the finger enters the vagina, direct it from before backAvard ! In doing this he -will not succeed in reaching the os uteri, which is one of the important objects of his search, either in exploring for the evidences of preg- nancy or at the time of labor—and hence his examination is with- out profit, he forms no diagnosis, and is stultified by his own ignorance! In carrying the finger from before backward, he reaches, not the os uteri, but the rectum—and if it should chance to be filled with masses of faecal matter, by pushing and poking— as he would be likely to do—it is not impossible that he might mistake the pieces of excrement for some anomalous condition of things—perhaps a presentation of the nates, supposing the movable lumps to represent the testes—and in his confusion, he Avould reveal his diagnosis, and request an immediate consultation ! In order, therefore, to avoid all error on the subject, as soon as the finger has passed about three inches into the vagina, the Avrist is immediately to be depressed, and an opposite direction imparted to the finger—and for the obvious reason that, at first, the direc- tion should be parallel to the axis of the inferior strait. You will sometimes meet with cases in Avhich the cervix uteri is situated so high up that it will be extremely difficult to reach it with the finger. Under these circumstances, you will find it o-ood practice to examine your patient in the standing position; in this Avay, by giving the uterus all the advantage of gravity, the diffi- culty will generally be overcome.* Well, you have reached the neck of the uterus—what next ? You are now to ascertain its exact position; is it normal ? Has it descended lower into the pelvic excavation than usual—is the os tincae tumid and moist—is there any shortening of the cervix__is the body of the organ enlarged—does the enlargement indicate disease, or is it the result of pregnancy ? Can you distinguish the fcetus by the ballottement? These, gentlemen, are so many inquiries which will necessarily present themselves to the atten- tion of the accoucheur in conducting an examination with a view of' ascertaining whether or not pregnancy exists. I should have mentioned that, during this exploration, the other hand is to be applied to the abdomen of the female for the pur- pose of gently grasping the fundus of the womb, and thus judging of its volume and exact position in the abdominal cavity. * In cases, also, in which, from disease or otherwise, the breathing of the patient becomes affected in the recumbent posture, she should be examined in the upright position. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 201 The vaginal examination, if properly conducted, will reveal to the observant practitioner much interesting information, uncon- nected with the mere question of pregnancy. For example, he can ascertain the existence of pelvic deformities; the condition of the soft parts, whether normal or otherwise, and thus decide between a pathological and healthy condition of the parts he traverses with his finger. In one Avord, gentlemen, the examination per A'aginam is a precious resource for the well-educated practitioner; it is a field rich Avith disclosures, which may serve as his guide in an infinity of ways. 3. Internal Examination per Anum.—Under certain circum- stances, it may become necessary to examine the female per anum; for instance, in cases in Avhich there may be exquisite sensibility, or much contraction of the vagina ; Avhere there are tumors developed in the posterior Avail of the canal; or in cases of retroversion of the uterus complicating gestation; or where there has been pro- lapsion of the ovary or small intestines into the triangular fossa, bounded anteriorly by the posterior surface of the uterus, and pos- teriorly by the anterior surface of the rectum—sometimes called the recto-uterine fossa. This is a mode of examination extremely repugnant to the female, but, when indicated, it is fruitful in light to the practitioner. You Avill sometimes be consulted by women, AArho will complain of extreme and painful pressure on the rectum, giving rise not only to great physical suffering, but oftentimes interfering seriously with the act of defecation. This pressure may arise from two very different conditions: either from retroversion of the uterus, or a prolapsion of the ovary into the triangular fossa. In either event, an examination per anum Avill greatly assist in elucidating the true nature of the case. The ovary, too, may be distended, exhibiting an example of encysted dropsy of the organ. Suppose such a case to complicate labor; you see how important it would be to arrive at a proper diagnosis, in order that prompt and effi- cient means might be devised to overcome the obstruction to the passage of the child. In such case, the remedy Avould be to per- forate the ovary through the vagina, with a vieAV of alloAving the fluid to escape, and thus diminish the bulk of the tumor.* 4. Auscultation.—It has already been stated that the pulsations of the fcetal heart and uterine murmur are to be sought through auscultation ; and this is accomplished either by the ear or stetho- scope. It requires much tact, patience, and experience to become an efficient auscultator. Nauch some years ago suggested an instru- ment—the metroscope—Avhich he introduced into the Aagina for * On one occasion I performed.the operation of vaginal ovariotomy in a young girl under extremely distressing circumstances. See Diseases of Women and Chil- dren, p. 297. 202 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the purpose of detecting, as early as the third month, the foetal movement, and he also affirms that he has been able to satisfy him self Avith the metroscope of the important fact that the placenta is attached over the mouth of the womb. The instrument consists of a wooden tube flexed nearly at a right angle ; one extremity is introduced into the vagina, and carried to the cervix uteri, while the other is applied to the ear. It can scarcely be necessary to remark that the metroscope has not met with much favor, and is noAV but little used. LECTURE XIV. Extra-uterine Pregnancy; its Varieties—Ovarian, Fallopian, Abdominal, and Interstitial—Characteristics of each Variety—Causes of Extra-uterine Pregnan- cy—Opinion of Astruc—Objections—Progress and Phenomena of Extra-uterine Pregnancy—Placenta and Membranes; the Germ inclosed in a Cyst—Exponent of the Uterus ; Cyst; how formed—Cyst affords no Outlet for Foetus—Rupture of Cyst from Increased Growth of Foetus—Hemorrhage; how Produced—Enlarge- ment of Uterus—Extra-uterine Foetation rarely extends to the Fifth Month— Exceptional Cases—Secondary Cyst; how Formed—Signs of Extra-uterine Foetation—Areola and Tumefaction of Breasts—Illustration—Active Movement of Foetus; Cardiac Pulsations—Malpositions of Uterus from Position of Cyst— Intermittent Pain in Extra-uterine Gestation—Dangers of this Variety of Gesta- tion—Hemorrhage from Rupture of Cyst—Peritoneal Inflammation—Termina- tions of Extra-uterine Pregnancy; Treatment—Gastrotomy; when Performed— Gastrotomy and Caesarean Section—Fearful Hemorrhage in the Former; why— Section of Vagina—Elimination of Foetus; how aided. Gejsttleaien—When fecundation has been consummated, and the vitalized germ does not reach the uterus, it is because of some derangement, which has contravened nature; the development, therefore, takes place not within the uterine cavity, but at some point external to it ; hence, this form of pregnancy is denominated extra-uterine. Pregnancy out of the uterus is unquestionably of rare occurrence in the human female ; yet, on the other hand, there are well-authenticated cases, which give to the subject an interest Avell worthy the attention of the practitioner.* Authors have made numerous divisions which, it appears to me, are more calculated to perplex than aid the student in his investigation of the subject. In lieu, therefore, of arraying before you this long and varied classification, I shall content myself Avith presenting, for your consideration, four different kinds of extra-uterine gestation, which, for practical purposes, will embrace all that science properly recognises: 1. Ovarian; 2. Tubal, or Fallopian; 3. Abdominal; 4. Interstitial. 1. Ovarian Pregnancy.—When the embryo becomes developed in the ovary, it is called ovarian pregnancy; in reading upon this point, you -will observe much discrepancy of opinion, arising out of the question whether it is possible for fecundation to take place before the rupture of the ovisac ? Those Avho maintain that it can- not, deny the fact of ovarian gestation, for they say that true ovarian pregnane}' is Avhere the embryo becomes developed Avithin * This variety of gestation 1ms also been observed in the rabbit, sheep, and bitch. 204 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the ovary, and this can only occur by the spermatozoon penetrating the ovisac, without disturbing its integrity, and vitalizing the germ. But, as they contend that this mode of fecundation cannot be ac- complished, they reject, as a consequence, the possibility of ovarian gestation. Now, gentlemen, it is very evident that this is a mere play of Avords ; it is a species of transcendental logic, Avhich is not calculated either to advance the true interests of science, or subserve the requirements of the physician who, in questions of this nature, is in Avant of Avell-established facts, unaccompanied by any of the refinements of the sophist, or the theoretical niceties of the dis- putant. What you Avish to understand is simply this—is it possible for the fecundated germ to become developed, so as to constitute, in truth and in substance, an ovarian pregnancy ? The fact is proA'ed beyond all peradventure, for the fcetus has been found, in a state of progressive growth, in intimate relations Avith the organ; so that the question is not Avhether the deA'elopment is within or ivithout the ovisac, but Avhether, not occurring in the uterine cavity, it is pos>ible for it to take place in connexion Avith the ovary. I repeat, science furnishes well-authenticated examples of this species of extra- uterine gestation.* 2. Tubal or Fallopian Pregnancy.—This has usually been re- garded the most frequent form of abnormal pregnancy, and is said to bear to the others the proportion of nine to three. Prof. Hecker has recently shown, from carefully collected tables, that this is not so. f For example : in all the cases of extra-uterine foetation, Avhich he has been enabled to gather from various sources, he has ascer- tained that, AA'hile abdominal pregnancy occurred in one hundred and thirty-tAvo instances, the fallopian variety was obsened only sixty-four times. These sixty-four cases, Avith one exception, ter- minated fatally; the exceptional example has been reported by Prof. YirchoAV. It is also interesting to note that Ilecker's researches haA'e fully confirmed the opinion, which has for a long time pre- vailed, viz. that fallopian pregnancy is more frequent in the left than in the right tube. J According to his record, it occurred thirty- seven times in the former, and only twenty-seven in the latter. It should be remembered that, under the term abdominal, Prof. Hec- ker includes also, ovarian gestation. * An interesting case of ovarian gestation has recently been recorded by J. Hall Davis, M.D., in which the left ovary wa3 developed into a cyst, and contained a de- cayed foetus. [Transactions of the Obstetrical Society of London, 1860, p. 241.] \ Monatsschrift fur Geburtskunde, 7-ef. 1859. \ Dr. Finnell, of New York, reports in the New York Journal of Medicine for March, 1857, an interesting case of fallopian pregnancy on the right side. The same gentleman has recently met with a second example of the same variety of gestation also on the right side. Few medical men in this country have enjoyed more ex- tended opportunities of pursuing autopsical examinations than Dr. Finnell, as hia numerous reports to the New York Pathological Society will show. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 205 3. Abelominal Pregnancy.—In this case, the germ becomes deposited in some portion of the abdominal cavity, and passes through certain stages of development; the surest guide as to the particular part of the abdomen in Avhich the developmentpro- gresses, will be the attachment of the placenta. This has^feen variously found on the broad ligaments, in the recto-uterine fossa, on the mesentery, in the iliac fossae, on the internal surface of the anterior Avail of the abdomen; in a word, more or less on all the abdominal viscera. I might cite well-accredited instances of these different points of attachment of the placenta, but, as they are generally accepted as truths, I scarcely think it necessary to con- sume time in their narration. According to Prof. Hecker, there is a very marked difference in the mortality of this and the tubal species; while in the latter, one in sixty-four smwived, in the former, among one hundred and thirty-two cases, there were only fifty-six deaths, giving a mortality of but forty-two per cent.* 4. Interstitial Pregnancy.—The embryo here is developed neither directly under the peritoneal nor mucous coverings of the uterus, but becomes located in the meshes of the muscular fibres of the organ, and there receives its growth. The question naturally arises, how is it conveyed to that particular portion of the uterus, and become embedded in the midst of its very substance ? Several * hypotheses have been adAranced to explain the circumstance, but they are as yet simple hypotheses, without the support of any reli- able data. It was the opinion of Breschet—AA'ho in 1824 Avas the first to describe this variety under the form graviditas in uteri substantia—that the embryo, as it passed into the uterus, fell into the opening of some of the venous sinuses, which he supposed to exist near the uterine extremity of the fallopian tube, and thus found its way into the substance of the organ. But repeated attempts have failed to discover these sinuses, and, Avithout the proof of their existence, it is in accordance Avith true philosophy to doubt their reputed functions. Only twenty-six cases of this species of extra-uterine foetation have been recorded; it is as fatal as tubal gestation, and, like this latter, it was observed more frequently * A very remarkable example of extra-abdominal pregnancy has been reported by Dr. Geuth. The female, from early childhood, had a small movable tumor at the external abdominal ring. After marriage, she had borne three children Some time after the birth of the third child, the catamenia ceased, and the tumor began to en- large. Sixteen and a half weeks after the menstrual suppression, the tumor equalled the volume of two fists; it extended, by a pedicle, into the inguinal canal. The patient suffered greatly, and became much enfeebled. The tumor was laid open, and contained a foetus and placenta of between four and five months. The patient recovered, and has subsequently become pregnant. Dr. Geuth's opinion is that this was an instance originally of hernia of the ovary and fallopian tube, and that pregnancy occurred without the abdomen. [Verhadl. der Ges. fur Geburtsk. Ber- lin, 1855.] 206 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. on the left than on the right side, in the proportion of seventeen to twenty-four. Causes of Extra-uterine Fetation.—-Yarious theories have been advanced in explanation of extra-uterine gestation. It Avas con- tenffed by Astruc that it is much more frequent in AvidoAvs and unmarried women.* Upon this assumption he proposed the theory, that oftentimes fright, from being detected in the very act, deter- mined the error loci of the germ. But hoAV, with this hypothesis, are we to understand the occurrence of extra-uterine foetation in married women, who have not only a right to be pregnant, but are most anxious to become mothers, and who, therefore, so far from experiencing alarm or mental emotion, enter into the act of inter- course with all the earnestness and pleasure, which an honest con- viction of right can inspire ? Again : how is it consistent Avith the Avell-known fact that some married Avomen become pregnant, and bring forth healthy living children Avithout the slightest approach to anything abnormal, to whom sexual intercourse is most repugnant, and Avhose constant hope is that they may not prove mothers ? Is it not reasonable to suppose, that in these there would be strong mental emotion, bordering on avell-developed fright, at the time of cohabitation ? In my opinion, a more plausible explanation is found in the theory, Avhich, I believe, Avas first proposed by Prof. VirchoAV. He has observed that this form of pregnancy is frequently accompanied by adhesions of the internal genital organs, caused by false mem- branes ; these adhesions are mostly on the left side. He, therefore, attributes to their presence an important influence in the produc- tion of the pregnancy itself, and also explains why it is that extra- uterine gestation is more frequent on the left than on the right side. It may be mentioned, en passant, that adhesions of this kind are sometimes the real, but occult cause of sterility. Progress and Phenomena of Extra-uterine Foetation.—In a practical sense, it is essential for you to understand the progress and phenomena of this species of pregnancy, in order that you may be prepared, when it occurs, to render the necessary assistance to your patient. The development of the fcetus and its appendages proceeds nearly in the same manner as when the germ is located in the uterus, although, as a general rule, the cotyledonous element or lobes of the placenta are more abundant. In closely examining an extra- uterine foetation, you will be able to recognise the chorion and amnios; the uterus is more vascular, its fibres and mucous cover ing are in a hypertrophied state, and the entire organ notably enlarged. It is an interesting fact, and in strong illustration of the harmony * Experience proves that extra-uterine pregnancy, in the majority of cases, occurs in women who have previously borne children. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 207 of principle which characterizes the operations of nature, that very soon after the passage of the fecundated germ to whatever part of the maternal organs is to constitute the seat of its growth, there will be observed in that part an increase in the action of the blood-vessels; this, no doubt, is owing to the vital activity, which is so marked in the ovule as soon as fecundation has been accom- plished. So true is it that the vessels become congested, through an afflux of fluid necessary for the wants of the embryo, that if, from accident or otherwise, these vessels should become ruptured, a fatal hemorrhage may ensue even in the very first feAv weeks of the gestation. The germ is inclosed in a species of cyst, which is composed differently in the different classes of extra-uterine foetation. For example, in ovarian pregnancy, the cyst is made up of the fibrous and serous tissues of the ovary itself; while, in tubal pregnancy, it consists of the muscular tissue of the tube, in conjunction with its peritoneal tunic. In abdominal pregnancy, on the contrary, the cyst is composed almost exclusively of an exudation AA'hich, from its plastic character, forms a bond of union between the ovum and the surface Avith which it may be in contact. The cyst represents the uterus; but, unlike this organ, it has no outlet for the passage of the foetus into the world; and this is even so in fallopian preg- nancy, for, in this case, the tube Avill be found obliterated on each side of the cyst. As the embryo increases in development, one of the dangers to be encountered is the rupture of the cyst, which often results in the death of the mother from hemorrhage, and it is not, I think, improbable that this may sometimes be the real, but concealed cause of death, in cases in which females, in apparently good health, suddenly sink. In extra-uterine pregnancy, the uterus, as said before, undergoes more or less enlargement; and this circumstance occasionally com- plicates the diagnosis. Frequently, in consequence of the increased vitality of the lining membrane of the organ, themembrana decidua will be recognised. It is comparatively rare that this variety of gestation reaches its full term; it seldom passes beyond the fifth month, although sometimes it attains the ordinary period ; and there are instances recorded of its duration continuing many years. In these latter cases, the foetus is found in a degenerated state—it is either exsiccated and shrivelled, or will present a stony hardness, and sometimes a mere mass of adipose or fatty matter. The degeneration into a stony hardness is more apt to occur in cases of abdominal pregnancy, and then, as also Avhen the foetus is dead in utero, and becomes converted into a calcareous mass, it is called lithopwdion. Even when the gestation reaches the full time, it is extremely rare for the foetus to be alive—it almost always dies from want of sufficient' nutrition. 208 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. I have told you that rupture of the cyst, containing the foetus, is usually folloAved by fatal consequences—this, hoAvever, is not always so ; occasionally, after the escape of the embryo through the rupture—if the patient survive the hemorrhage—she may sink from peritoneal inflammation, Avhich is extremely apt to folloAv the egress of the fcetus from the cyst. Should, however, the inflam- mation be subdued by prompt treatment, then there Avill generally be the formation of Avhat is called a secondary cyst, in which the fcetus becomes inclosed, and which is the product of the exudation consequent upon the inflammatory action. The fcetus, thus embraced within its secondary cyst—and the same thing may occur Avhile in its primitive envelope—will, some- times, from its weight, or other circumstances, cause inflammation, which may result not only in its own destruction, but also in that of the cyst, involving the neighboring parts in more or less ulcera- tion, so that there may follow a fistulous communication externally, either through some portion of the abdomen, rectum, bladder, or vagina, and through this opening, the fcetus, in a state of decomposition, may be discharged fragment by fragment. This result is likely to compromise the life of the mother. It is, indeed, stated that portions of the embryo have been ejected by vomiting from the stomach. If, therefore, in the course of your practice, you should be called upon to give an opinion as to the possibility of the passage of foetal fragments, through the channels mentioned, you can, Avithout hesitation, state that such a condition of things may result from an extra-uterine pregnancy in the manner indicated. Symptoms and Diagnosis of Extra-uterine Foetation.—How are Ave to knoAV that extra-uterine pregnancy exists? Here, as in uterine-gestation, Ave have nothing specially to guide us in the com- mencement ; menstruation may or may not become interrupted ; in the only case of extra-uterine gestation, which has fallen under my personal notice, in which I was consulted by Dr. Cyrus M. Thomp- son, of the State of Maine, the same phenomena occurred in the breasts, which are usual in ordinary uterine gestation, and the areola, especially, was fully developed Avith its characteristic attributes. The abdomen was more or less enlarged, but there wras no suppression of the menstrual evacuation.* It is maintained, * This was the case of a lady, who married when she was thirty-three years of p.ge. During her maidenhood she enjoyed excellent health, and continued to do so for a year after marriage; at this period, however, she suffered more or less from derangement of the system; her abdomen enlarged, the breasts became tumid, and there was nausea with occasional vomiting. Her menses were quite regular, both as to time and quantity; she had a cough, with purulent expectoration, and a pulse at 110. It was under these circumstances that she visited the city of New York, bringing with her a letter from her family physician, Dr. Thompson, who requested THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 209 by some writers, that the breasts undergo no change in this form of pregnancy, and that there is no secretion of milk. I cannot understand on what this opinion is founded. The phenomena, con- my opinion as to her case. The doctor had fully made up his mind as to the broad meaning of the cough, purulent expectoration, and accelerated pulse—they were the unmistakable evidences of a serious trouble, which had already marked this lady as a victim to that relentless enemy of our race—consumption. She, however, did not appear at all conscious that the cough indicated any such fatal issue, and her whole attention was concentrated upon the abdominal enlargement. Her own conviction was that she had a tumor, which would destroy her life; she did not believe it possible she was pregnant, for the reason that her menstrual flow was regular. I made a very critical examination of the case, and soon became convinced of two facts: First, that the uterus was enlarged, corresponding with a three months' gestation; second, that commencing in the left iliac fossa, and extending obliquely upwards in the direction of the right hypochondriac region, there was evidently a growth independent 'of the uterus. On inquiry, the lady informed me that, just six months before I saw her, she commenced to experience irritability of the stomach, and there was also an increase in the size of the breasts. Soon after this, she felt a sense of pain in the abdomen, which has continued more or less at intervals, and which, within the last two or three weeks, had occasioned her not only much physical distress, but caused a great deal of mental anxiety, from the apprehension that she labored under some serious affection, which would destroy her life. Here, then, were two conditions, which, on examination, I had distinctly recognised, viz.: In the first place, an enlargement of the uterus; and, secondly, an enlargement of the abdominal cavity altogether independent of the uterine development. What could this latter be ? A very natural presumption was—that it might be an ovarian tumor. During my manipula- tions on the abdomen, I very distinctly felt a movement—at first I was not quite satisfied of its nature. I again recognised it, and so distinctly, that it could not be mistaken—it was evidently the movement of a foetus. I then had recourse to auscultation, and, after some time, the pulsations of the foetal heart were detected ; the sounds were emitted about two inches above the umbilicus, and to the right. There was no mistaking them. My pupil, Mr. F. B. Bates, a relative of the lady, heard them, and also recognised the movements of the foetus. From the point of the abdomen at which the pulsations were detected, I came to the conclusion that the breech presented obliquely downward corresponding with the left iliac fossa. Here, then, was clearly a case of pregnancy. What was its true nature ? It was quite obvious that it was not a case of uterine gestation, for this organ, although enlarged, had not yet left the pelvic excavation. I decided, after a full considera- tion of all the circumstances, that it was unequivocally an example of extra-uterine foetation. I have already observed that the areola was well marked, presenting its true characteristics. In reply to the most anxious inquiry of the patient regarding her condition, I told her she was pregnant, but concealed the fact of the peculiar variety of gestation under which she labored. I was unwilling to add anything to her cup of sorrow, which was already full to overflowing; and more especially as I had good reason to believe that the period of her dissolution was near at hand. She appeared delighted with the opinion, and returned home joyous and happy, little dreaming of the sad future, which was so soon to remove her from earth I In all truth, sha verified those trite but expressive words of the poet: " When ignorance is bliss, 'Tis folly to be wise." I gave my opinion to Dr. Thompson in writing; and I received a letter from him, u 210 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sequent upon ordinary gestation, are entirely sympathetic, result- ing from the changes going on in the uterine organs; and these sympathetic phenomena are the results of that close alliance, Avhich is known to subsist between the breasts, the uterus, and its appen- dages. It does seem to me, that the fire, so to speak, kindled in these appendages and in the uterus itself—for Ave have seen that it also undergoes' increase of volume—is sufficient to evoke corre- sponding excitement in the mammae. As I have already mentioned, the fact of the enlargement of the uterus tends to complicate the diagnosis; but in extra-uterine pregnancy, besides the increased size of the organ, there will be discovered on one or other portion of the abdomen, usually on the side, an enlargement, and the patient will occasionally complain of a sense of pain at that point. Here, again, this may be confounded Avith a tumor of the ovary, or a tumdr of some other descrip- tion. It is obvious that, for the first three or four months of extra- uterine foetation, there is nothing to guide us in the expression of a positive opinion as to its existence; and the only means of arriving at a just decision will be the active or passive movements of the fcetus, and the cardiac pulsations. These, Avell recognised, place all doubt at an end. I should mention that, although the uterus increases in volume, yet it does not exhibit the changes which we have described as characteristic of uterine gestation. For example, the cervix does not undergo any sensible diminution in its length, nor, under ordinary circumstances, does the position of the cervix tend backAvard toward the sacrum, as we know is the case in true gestation, in proportion as the uterus ascends in the abdominal cavity ; and, moreover, by a proper abdominal examination, you will be enabled to recognise whether the tumor is the enlarged uterus; but all doubt upon the subject will be dissipated by placing the finger of one hand on the cervix, and the other hand on the abdominal portion of the tumor, thus completely grasping it two months afterward, announcing the death of his patient, under the following painful circumstances: On her return home, she rallied for the first week or two__ her whole thoughts being occupied with the happy anticipation of soon becoming a mother; she quickly, however, relapsed into her former condition—the cough increasing, the pulse reaching 130, with copious expectoration and great loss of flesh. Just one month from the time she left New York she was attacked with profuse haemoptysis, which was followed by profound prostration: the haemoptysis again recurred in two weeks, and two days afterward she sank from exhaustion. The following is a brief extract from the doctor's letter: " In a post-mortem examination, your diagnosis of this case was fully confirmed, There was an extra-uterine foetus, apparently about seven months developed. It was partly decomposed, having, I have no doubt, succumbed a few days before the mother. There was about a pint of blood in the peritoneal sac, which must have added greatly to the prostration of our unfortunate patient. As far as I could determine, it was a case of ovarian extra-uterine pregnancy." THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 211 between the two hands ; and, in this Avay, you can readily detect, by an alternate movement of the hands, whether it be the uterus or something foreign to it. The particular position of the cyst, inclosing the fcetus, Avill some- times exercise an important influence on the position of the womb; and this should be borne in mind, otherwise it might lead to the embarrassment of mistaking extra-uterine pregnancy for simply a displacement of the uterus. If, for example, the cyst should attach itself posteriorly to the uterus, in the recto-uterine fossa, for instance, it might possibly'be mistaken for retroversion of the organ. But, a moment's thought on the part of the practitioner, together with a vaginal examination, w^ould soon reveal the error. The fundus and body of the uterus, instead of being retroverted, Avould be in directly an opposite condition; they would be pushed forward, constituting Avhat is known as an anteversion ; and the cervix, in place of being forward, as is the case in retroversion, would be turned backward ; this malposition Avould be apt also to produce more or less irritation of the bladder. The presence of the cyst in the recto-uterine cavity might mislead. you in other respects in your diagnosis ; for, Ave have elsewhere remarked, that this fossa is occasionally the seat of a prolapsed ovary, or of a portion of the small intestines. But adequate care in your examination, with a knoAvledge of the antecedent circum- stances, will generally avail in enabling you to arrive at a correct opinion. Moreover, those avIio have recorded examples of this peculiar location of the cyst, say, that on an examination per vaginam or anum, the fcetus can be recognised by the sense of touch. Suppose, hoAvever, the cyst should occupy a reA'erse posi- tion, and be found just in front of the uterus. The result, in this case, Avould most likely be retroversion of the uterus, and more or less vesical irritation ; this latter would be the effect of two forces —in the first place, the presence of the cyst; and, secondly, of the neck of the uterus, Avhich, in retroversion, Avould be found turned toward the lower extremity of the bladder. The female, in extra-uterine pregnancy, Avill, at different periods, experience more or less pain, marked by distinct intermittence. When the cyst is composed of muscular fibres, as is the case in interstitial, fallopian, and ovarian gestation, these pains Avill closely simulate labor pains, and are the result of the contractions of the muscular tissue of the cyst. The uterus itself often participates in these contractions, and adds to the severity of the pain.* * Professor Hohl reports an interesting case of abdominal pregnancy, in which he recognised the contractions of the cyst. The cyst was behind the posterior cul de sac of the vagina, and near the posterior wall of the pelvis. He could distinctly feci it, and during the pains, the contractions of the cyst were quite apparent. After death, there were many organic muscular fibres detected in the coat of the ovum. 212 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. The Dangers of Extra-uterine Feetation.—Let us now, gentle- men, briefly examine in what chiefly consist the true dangers of extra-uterine foetation. It is an important question, and embodies Bome interesting practical bearings. It has already been remarked to you, that this form of gestation may terminate in one of two ways : First, In rupture of the cyst, which is generally the result of the increased development of the foetus, although not ahvays so, for the laceration may be caused by Woavs, falls, etc.; Secondly, In the death of the fcetus, the sac remaining undisturbed. These, I believe, may be said to be the tAvo ordinary modes of termina- tion of this species of gestation ; and there are consequences to the mother growing out of each, which it is essential for the practi- tioner to appreciate. In very rare instances, the mother escapes the usual fatal consequences of rupture of the cyst, because of the formation of what is known as the secondary sac, the nature of Avhich we have already explained to you. But the immediate danger of the rupture is death from hemorrhage; and fatal results ensue in at least two-thirds of the cases in which rupture takes place. The laceration is usually preceded by pain in some point of the abdominal cavity, quickly followed by symptoms of marked prostration—cold extremities, pallor of countenance, clammy per- spiration, vomiting, and flickering pulse. This may occur at any period of the pregnancy, even in the first month. In these cases, a post-mortem examination will reveal more or less effusion of blood in the peritoneal cavity—the effusion being the result of the rup- ture of the blood-vessels immediately concerned in the development of the foetus and its annexae. Should, however, the female escape the ordinary consequences of rupture, she incurs the serious peril of peritoneal inflammation, caused by the irritation of the fcetus on the serous lining after it has left the cyst. So you see, the two immediate dangers of rupture of the sac are: 1. Death from hemorrhage ; 2. Death from inflammation. If, however, the cyst be not ruptured, the foetus may continue to live to the completion of the full term of gestation, which fact will be recognised by its moA'ements and the pulsations of its heart; or it may have perished, and still continue to be inclosed in the sac. In either case, as has already been stated, there will be intermittent pains simulating the throes of labor, but altogether ineffectual so far as the expulsion of the foetus is concerned. It, therefore, results that the fcetus may sojourn in the system of the female, and its presence give rise to the following conditions: 1. It may destroy the life of the mother by inflammation; 2. By the derangement which its presence and pressure may occasion in the digestive and other functions; 3. By its decomposition, and passage from the maternal system, through the vagina, rectum, abdomen, bladder, etc., as have already been indicated; 4. It may degenerate into a THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 213 stony, shrivelled mass, and remain for many years in the system, without resulting in anything serious. Treatment.—With this brief review of the principal circumstances connected with extra-uterine pregnancy, the question has, I have no doubt, suggested itself to your minds—What can be done in these cases? Does science afford us any means of relief? These ques- tions, gentlemen, concern us as medical men deeply ; for the great object of our profession is to arrest, if possible, the shaft of death; and when we fail in this, to do all in our power to soothe the anguish of human suffering, and make as light as may be the pro- gress to the grave. We will suppose that your diagnosis as to the existence of extra-uterine pregnancy is either beyond all peradven- ture, or that it is a matter of great doubt.* In the latter instance, to attempt any plan of treatment would be the sheerest folly, for the substantial reason that there can be no indication as to any special medication, as long as you are ignorant of the true nature of the case. You Avould not, I imagine, deem it wise, because a patient complains of pain in the chest, to take it for granted that the pain is necessarily the result of pneumonia or pleurisy, and, therefore, plunge your lancet into the arm and abstract blood ad deliquium ! But we take the former example—the proof of the pregnancy is positive. ■ In this case, some very nice considerations present them- selves : First, the mother's life is placed in great jeopardy, in the various ways already indicated ; Secondly, The death of the fcetus is reduoed almost to a moral certainty. These, then, are the naked and indisputable dangers of ,an extra-uterine pregnancy, if left to pursue its own course ;f and the important question for the practi- tioner is—Does science possess any alternative by which the danger to the mother may be lessened, or the chances of safety to the child increased ? I assume, as a fact, amply sustained by the experience of the profession, that, as a general rule, the certainty of extra-uterine gestation cannot be arrived at before the period of quickening; * Some grave errors have been committed with regard to the existence of this form of gestation; a case which occurred in Berlin is not without its moral: In August, 1828, Dr.Heim, who, with other eminent gentlemen, had agreed that a patient was the subject of extra-uterine foetation, requested Prof. Dieffenbach. to per- form the Caesarean section. The operation was accordingly performed, but to the amazement of all present, there was no pregnancy of any kind. The woman, how- ever, fortunately recovered. [Dr. Heim's Vermischte Medicinische Schrifiten, p. 402. Leipzig, 1836.] f It has recently been suggested by Dr. Bachetti, of Pisa, to attempt the destruc- tion of the embryo at an early period, so that the mother may be protected from harm, through an arrest of its development. He records a case of this kind in which he succeeded in his object by electro-puncture. He implanted two needles into the tumor, and then directed into the latter an electro-magnetic current. [L'TJnion M6- dicale, p. 168. 1857.] 214 THE PRINCIPLES AND PRACTICE OF OBSTE'JT.ICS. therefore, anterior to this period, the question of treatment will not usually arise. There is a difference of opinion as to the course to be pursued after the life of the child has been fully recognised. Some recommend gastrotomy, Avhich consists in an incision of the abdominal walls for the purpose of extracting the foetus, and thus equalizing the chances of life between it and its parent. Now, this is a mode of procedure Avliich should not be resorted to Avithout deliberate reflection, and its justification based upon the reasonable assurance that, taking all the surrounding circumstances into con- sideration, it presents the greatest chance of safety to both mother and child. There is one special danger in the operation of gastrotomy in extra-uterine pregnancy, which does not apply to the Caesarean section in uterine gestation, and it is this : In gastrotomy, besides the dread of inflammation and shock to the nervous system—com- mon to it and the Caesarean operation—there is the cardinal danger of hemorrhage, and for the following reason : As soon as the cyst is opened, and the integrity of the blood-vessels encroached upon, profuse bleeding ensues—the cyst, especially in abdominal extra- uterine pregnancy, possessing comparatively such slight poAver of contraction, for the reason that its muscular tissue is not abundant; in the Ca'sarean section, on the contrary, the uterus speedily con- tracts, and arrests the flooding.* The records of gastrotomy, the child being alive, are certainly adverse to the operation, for it has almost always proved fatal. If, however, you should haAre decided that the extraction of the foetus is justifiable, it may sometimes happen that it Avill be more advisable to make an incision into the vagina, and remo\Te it through this passage ; and this will be more particularly indicated in cases in which the fcetus can be felt distinctly pressing doAvn upon the vagina. Should the head present, the child may be delivered after the incision, by means of the forceps or version, as occurred in the practice of Dubois. He felt the head of the fcetus through the vagina—made an incision into the vaginal wall, and also into the cyst, with a view of terminating the delivery by means of the forceps. He soon found, however, that there were firm and resist- ing adhesions between the head and sides of the cyst, Avhich caused him to abandon the operation. In the course of a few days an extremely putrid odor was emitted through the opening, and the fcetus, having undergone decomposition, came away in fragments ; the bony structures being aided in their passage by means of small pincers, and repeated tepid injections. The mother Avas convales- cent in two months from the time of the operation. * In the interstitial and fallopian varieties of extra-uterine foetation, the cyst ia supplied with muscular fibres—in the former, from the uterus itself; in the latter, from the muscular coat of the tube. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 215 There is another condition in which the operation of gastrotomy may be resorted to. Suppose, for example, after having carried the foetus beyond the ordinary term of gestation, the mother should manifest much suffering from its presence, and her health exhibit evidences of approaching decline from this cause. Under these circumstances, the question would legitimately arise whether it would not be advisable to extract the foetus for the purpose of increasing the chances of life to the mother. Here, again, gentle- men, it is but a question of expediency, which is to be determined by sound judgment, and Avith but one motive to govern that judg- ment, viz. the greater welfare of the parent. I might here mention that Mr. Adams, of the London Hospital, and Dr. Stutter, of Syden- ham, have recently succeeded, by gastrotomy, in the extraction of dead extra-uterine foetuses, several Aveeks after the completion of the full period of gestation. In both instances, the mothers sur- vived.* Should you discover, at any time, an incipient abscess in the abdomen, vagina, or rectum, etc., occasioned by the death and decomposition of the foetus, I need not tell you that it should be promoted by warm fomentations, and, if necessary, opened, so that a passage may be afforded to the fcetus; and its extraction assisted by the various instruments necessary for the purpose. Dr. Camp- bell, f in an excellent memoir on the subject, presents some inte- resting details. He says it is well proved by experience that, when the suppurative process is established, or a breach is actually formed in the parietes of the abdomen, the integuments may, with safety, be largely incised or the pre-existing aperture freely dilated with success. He records thirty cases in which gastrotomy was performed, or the breach dilated, and of these, twenty-eight recovered. In twelve cases of gastrotomy, resorted to after the suppurative process was Avell advanced, ten Avere successful. In nine cases operated on, when the foetus was still alive, or soon after its death, all Avere fatal. * Medical Times and Gazette, London, July, 1860. f A Memoir on Extra-uterine Gestation. Edinburgh, 1840. LECTURE XV. Pregnancy, although not a Pathological State, is occasionally subject to Derange- ments—These Derangements are both Physiological and Mechanical; Illustration— Dogmatical Doctrines of the Ancients in regard to the Therapeutics of Pregnancy— Bloodletting in Pregnancy; when Indicated—Cathartics and Emetics; are they admissible?—Nausea and Vomiting; how Treated—When Excessive—Ptyalism— Constipation—How Constipation is caused in the Pregnant Female; in part through Morbid Nervous Influence; in part from Mechanical Pressuro—Diarrhoea; ite Dangers—Palpitation of the Heart and Syncope—Larcher's Opinion respecting Hypertrophy of the Heart—Pain in the Abdominal Muscles; how Treated—Pain- ful Mammae—Pain in the Right Hypochondrium—Pruritus of the Vulva; Hemor- rhoids ; how Produced—Varicose Veins—Cough and Oppressed Breathing. Gentlemen—I have remarked, in a previous lecture, that preg- nancy cannot, strictly speaking, be regarded as a pathological or diseased state. But while this fact is conceded, yet, on the other hand, it is not to be forgotten, that many of the sympathetic phenomena characteristic of gestation will sometimes, through exaggerated action, assume a morbid character, calling for the intervention of science. Indeed, the derangements of pregnancy may, with propriety, be divided into physiological and mechanical. Do not misunderstand me; a true and complete physiological action is nothing more than a natural function, and while it keeps within the particular sphere of duty assigned to it in the mecha- nism, it cannot, by any construction, be denominated morbid. It is only when the physiological function ceases to be recognised by nature as a sound link in the chain of forces, which make up the entire workings of the system in health, that it becomes converted into a pathological result. Let us illustrate this point. You know very well, that the im- portant office of the kidneys is to secrete urine, through which effete matter is more or less constantly passing from the system; so long as this secretion is performed normally, it constitutes a necessary and precious element of health. But, suppose that, in lieu of the ordinary action of the kidney, there should be an increased secretion of urine, giving rise to that dangerous, and oftentimes fatal malady—diabetes. In this case, we should clearly have substituted a pathological state for what, under ordinary cir- cumstances, is strictly a physiological function. The same thing occurs frequently in pregnancy. For example, there is scarcely a sympathy evoked in the economy as the consequence of fecundation, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 217 which may not, in the manner just described, become morbid, and thus need the attention of the practitioner. Again: as the result of mere mechanical pressure, there may occur various phenomena, which, from their disturbing influences, are entitled to be termed morbid, and which, therefore, are legitimately objects of medical treatment. The digestive, vascular, and nervous systems may all become more or less disordered, as incidental to gestation, and these de- rangements will assume various types. The nausea and vomiting, ptyalism, depraved appetite, constipation, diarrhoea, etc., are all so many consequences, Avhich, under certain circumstances, may require therapeutic management. Bloodletting in Pregnancy.—I have already alluded to the dog- matical and dangerous lessons, inculcated by the early fathers regarding the management of the pregnant woman; and these les- sons have, I fear, ripened into a maxim which, even at the present day, is too often regarded Avith scrupulous fidelity. The old- school men taught that pregnancy is a peculiar state, calling for periodical medication; and that the only security for a safe and healthy gestation was the strict observance, on the part of the practitioner, of certain prescribed rules of treatment. In fact, so far from regarding pregnancy a natural condition of the system, they described it as an abnormal state, and hence Avere predicated upon this basis their vieAVS of its management. For example, the doctrine very generally obtained, that one of the universal charac- teristics of gestation is plethora ; and hence the maxim that blood should be abstracted from the arm of the pregnant Avoman in the fourth, seventh, and end of the ninth month—these being the respective periods in which the gravid uterus is most disturbed by this vascular fulness of the system. You have seen that plethora is not necessarily an accompaniment of pregnancy, and, therefore, any rules of treatment founded upon such an assumption, cannot be sustained according to the laAvs of rigid analysis; and, more- over, if you were to act in blind obedience to this precept, you could not fail to do a vast deal of harm. It oftentimes happens that many of the phenomena of pregnancy, which are supposed to emanate from plethora, are directly traceable, not to an engorged condition of the vessels, but to an exalted vitality in the uterine organs, and its transmission to the various portions of the economy with Avhich these organs are more or less in close sympathetic alli- ance. Then, gentlemen, so far from teaching these crude generalizations of the ancient school, which all bedside experience proves to be erroneous, I shall enjoin upon you the sound principle, that you are to employ the lancet in pregnancy, not because of the fact that pregnancy exists, but because of the incidental occurrence of some 218 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. circumstance complicating that condition, which broadly indicates the necessity of loss of blood. For instance, in all acute diseases, in cases of actual plethora, as shown by the bounding pulse, flushed countenance, headache, etc.; in threatened abortion, Avith marked weight and uneasiness about the hips, accompanied Avith fulness of the system, blood may be abstracted in quantity, according to the judgment of the practitioner, Avith good effect. Cathartics.—It Avas a favorite maxim of Hippocrates, that cathar- tics should be administered to the pregnant female only from the fourth to the seventh month, and that, in all cases, the administra- tion of the cathartic should be preceded by the abstraction of blood ; and, again, it was maintained by Puzos and others, that purgatives were essentially necessary during the ninth month of gestation, for the reason that they protected the female from many of those r>ost- partum difficulties, which were supposed to be due to a constipated state of the bowels. The only remark I shall make on the subject is, that, unless there should be some special reason, such as the presence of inflammation, the necessity for preceding a cathartic by the use of the lancet is one of the fanciful notions founded upon nothing stable in therapeutics; and as to limiting cathartic medi- cines to the fourth, seventh, ninth, or any other period of gestation, is about as philosophical as to enjoin upon a navigator, starting from New York to Liverpool, the absolute necessity of steering north, east, southeast, or due east, on stated days. Like the skilful navigator, the physician must be governed by circumstances; and Avhen, in his judgment, cathartics are indicated, they must be given, not according to any stereotyped rule, but for the special object which may present itself at the time. Emetics.—You will find, in the course of your future experience, that there is a very general prejudice existing, not only among the profession, but also in the public mind, against the employment of emetics during gestation; and this prejudice is founded upon the apprehension that their direct tendency is to produce contraction of the uterus, and, therefore, premature expulsion of its contents. It might appear, a priori, that this apprehension is not Avithout force ; but it seems to me that, in reality, it is not entitled to much consideration. I have paid some attention to this question, and I am clearly of opinion that the prejudice against the use of emetics in pregnancy is not only unfounded in fact, but has occasionally been productive of bad consequences. I do not know how I can better illustrate the truth of this latter remark, than by the brief narration of an interesting case in point, which came under my observation a few months since : A married lady, aged tAventy-seven years, one year married, was in her seventh month of gestation. Her health had always been good, and particularly so since her marriage. Nothing of any im- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 219 portance occurred during her pregnancy, Avith the exception of the ordinary phenomena incident to this condition, until the night of Dec. 23d, Avhen, being in her seventh month, she Avas suddenly attacked, while in bed, with vertigo, followed by loss of conscious- ness, and stertorous breathing. But a few minutes elapsed before I was by her side. Here, evidently, Avas a case of apoplexy. What Avas to be done? In the hurry of the moment, and his mind fixed upon the two prominent symptoms—the loss of consciousness and stertor—the physician would most likely plunge his lancet into the arm for the purpose of relieving the brain of its pressure! He has read in the books, and heard, ex cathedra, that, in apoplexy, blood- letting is the heroic remedy. This is a case of apoplexy, and, therefore, he bleeds. Noav, gentlemen, this may be a syllogistic argument, and so far as the logic of the schools is concerned, it may have impressed upon it the seal of approbation. But the question is too naked—it is too abstract. In one word, it lacks the necessary collaterals for the medical man in the sick room ; and it is precisely this want of completeness which oftentimes paralyses science in its practical ministrations, and exposes both practitioner and patient to the broadest empiricism. It is very true that, in many instances, prompt and full bleeding is the remedy for apoplexy—but not always. We have, for example, apoplexy from gastric repletion— the stomach is filled with indigestible food, thus causing mechanical obstruction to the circulation. In this case, bleeding would be so much time lost, and the last spark of life might become extinct during its performance. As soon as I approached the bed of my patient, I observed, on a chair, a basin, in Avhich I Avas informed she had several times at- tempted to vomit. I noticed in the basin some small pieces of salad, Avhich had evidently been ejected from the stomach. On inquiry, I learned that she had spent the evening at a friend's house, and had partaken very freely of lobster salad and ice cream. Without de- lay, I mixed twenty grains of ipecacuanha in half a tumbler of Avarm water, and, with some little difficulty, caused her to swallow it. In a feAV moments it took effect, and you Avould have been amazed to see the quantity of undigested food thrown from the stomach. As soon as this offensive material Avas ejected, the patient evinced marked and gratifying evidences of returning reason—the stertor ceased, and her consciousness was shortly in full play. She went on to her full term; and I had the pleasure, in two months from that time, of presenting her with a fine little boy, alive and in good health. One moment's hesitation, on my part, or the too ready adoption of the routine practice of bleeding, would have sacrificed two lives, and throAvn into the deepest grief a devoted husband, whose anxiety on the occasion bordered almost on beAvilderment. To show you that emetics are not incompatible Avith a healthy 220 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. gestation, and do not necessarily provoke premature action of the uterus, I may recall to your recollection a very common practice, among young unmarried Ay omen, Avho, finding themselves pregnant, have recourse to these substances in the hope that they may rid themselves of their burden, and thus, through the destruction of the evidence of their guilt, find shelter against the Avithering storm of public opinion. But their hope most frequently ends in disappoint- ment—the remedy has not the desired effect. Again: how often are pregnant women exposed to that unearthly sensation, sea-sick- ness, and yet to miscarry under the most violent and repeated attacks of vomiting, is but an exception to the general rule. There- fore, I have no hesitation in stating, that emetics, during pregnancy, are to be employed, when indicated, with as little reserve as under any other circumstances. I shall now briefly allude to some of the disorders of pregnancy, which will, occasionally, call for the interposition of science : 1. Nausea and Vomiting.—It is conceded that nausea and vomit- ing are the usual, and, so to speak, the natural sympathetic accom- paniments of gestation, and, therefore, under ordinary circumstan- ces, do not require the attention of the physician ; but sometimes, it may become necessary to resort to remedies for the purpose of keeping them within reasonable limits. A great variety of agents has been suggested for this purpose. Opium, in its various prepara- tions, may be given internally, a quarter or half a grain at a dose; two or three drops of the solution of morphia, in a teaspoonful of cold water; small pieces of ice internally, or a piece of ice laid on the epigastric region, will sometimes have good effect. Dr. Simpson speaks favorably of the inhalation of laudanum from a small ether inhaler, hot water being used to promote evaporation. I have, occasionally, derived much benefit from the application to the epigastrium of a cloth saturated with laudanum; chloroform, em- ployed in the same way, has been found useful. Equal parts of lemon juice and cold water, say a tablespoonful of each, or the same quantity of lime water and milk, two or three times a day; two or three drops of tincture of nux vomica, every two or three hours, is a remedy much extolled by Lobach; but, he observes, that after the arrest of the vomiting, severe cramps are apt to ensue, which, hoAV- ever, readily yield to the tincture of the acetate of copper, one drop each hour, gradually increasing to six drops an hour. The extract of belladonna, in ointment, applied to the cervix uteri, first sug- gested, I believe, by Bretonneau and Cazeaux, is sometimes very efficacious. I have employed it with very striking benefit. Its strength should be 3 j. of belladonna to § i. of adeps; a small por- tion to be smeared on the cervix once or twice a day, as may be indicated. It should be applied with the finger, and not through the speculum, for the reason that this instrument may, especially THE PRINCIPLES AND PRACTICE OF OBSTETRICS.' 221 in sensitive women, induce premature action of the uterus. The following, known as the potion of Riviere, has been in much repute, and may be resorted to oftentimes with advantage: R. Acid Citric.........gr. xxxvj. Syrup. Sacchar........f. 3 viij. Potassse Bicarbonat......gr. xxxvj. Aquae Destillat........f. | iv. The citric acid to be dissolved in one half of the water, and then add the syrup; the bicarbonate of potash to be dissolved in the remaining portion of water, and a tablespoonful of each adminis- tered successively. Should the vomiting be aggravated by a con- stipated condition of the bowels, which is often the case, though it may elude the vigilance of the practitioner, one or two of the fol- lowing pills may be given as occasion may require: R. Pil. Colocynth Comp., ) __ . _. TA r' > . . . aa gr. xxiv. Extract Hyoscyam., ) Pil. Hydrarg........gr. xij. Ft. Massa in pil. xxiv. dividenda. Dr. Simpson commends highly the nitrate of cerium in one or two grain doses in water. If the patient should eject bile or vicious secretions from her stomach, then a slight emetic will be indicated; nothing better, perhaps, than 10 or 15 grains of ipecacuanha. You will occasionally, gentlemen, meet with cases of rebellious vomiting, accompanied by a distressing weight in the vicinity of the uterus, with flushed countenance and an excited pulse. In these cases, you -will find the abstraction of blood from the arm, from ij. to iv. ounces, repeated as may be necessary, a most efficient remedy. Indeed, if it be not had recourse to, miscarriage will be very apt to follow.* 2. Ptyalism.—Salivation cannot be said to be a very common attendant upon pregnancy, yet it does sometimes occur, and will occasionally giA^e rise to annoying consequences from the more or less constant dribbling of saliva, and in quantities so great as to weaken the patient. I have seen but few cases of excessive ptyalism during gestation, and, although there are many remedies recom- mended, I have not found anything so effectual as occasional small doses of Epsom salts—say, a teaspoonful in half a tumbler of water * Dr. Clay, of Manchester, calls attention to increased pain and tenderness of the neck of the womb as an occasional cause of persistent vomiting in pregnancy; the increased pain and tenderness being the result of inflammatory action. The slightest irritation of the part induces violent vomiting, and this is arrested as soon as the irritation is removed. Ho recommends such a position of the patient as shall relieve the cervix from direct pressure by the head; and, if necessary, a resort to leeches, to reduce the inflammation. His treatment was adopted with complete success in three cases. [Midland Quarterly Journal, Oct. 1S57.] 222 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. every alternate morning; or, if necessary, daily. If produces serous discharges from the boAvels, and thus to a certain extent antagonizes the excessive secretion of saliva. 3. Constipation.—I think it may safely be affirmed that regu- larity of the boAvels during gestation is the exception, Avhile a ten- dency to constipation is the general rule ; and if this be so, the true reason of this circumstance is certainly Avorthy of a mbmenfs thought. Not to speak of those examples of constipation, Avhich are to be attributed simply to carelessness on the part of the female, there are numerous others continually occurring during the preg- nant state, Avhich need some other explanation. The uterus, it is admitted, under the influence of gestation aAvakens in the economy various sympathies, and these cannot be evoked without occasion- ally bringing about more or less derangement in the healthy or natural functions of the particular organs Avith Avhich they are con- nected. For example, we have seen that nothing is more common in pregnancy than disturbance of the stomach; so likeAvise do the heart, lungs, liver, kidneys, and the nervous centres, etc., become more or less deranged in their respective functions. These sympa- thetic influences are produced through the ganglionic system of nerves, which, becoming to a certain extent the seat of irritation in the uterus, transmit this irritation, through the ganglia and plexuses, to other organs of the system. I believe that, to a certain degree, the constipation of pregnancy may be explained in the same way—the regular action of the intes- tinal canal being modified in consequence of a want of healthy nervous power from the ganglionic nerves; this, at all events, in my opinion, is the true explanation of the torpor of the bowels in the earlier months of gestation. But, at a later period, there is an additional cause brought into operation, viz. pressure of the uterus against the intestines ; this develops itself more sensibly during the last four months of gestation; for, at this time, the uterus com- presses the large intestine just as it passes from the left iliac fossa to the sacrum, and hence there is more or less obstruction at this point to the descent of the faeces into the rectum. You may Aery naturally ask why, Avhen the impregnated uterus becomes largely developed in the abdominal cavity, the whole intestinal canal does not suffer from compression ? The simple reason is, that the intes- tines above the pelvis enjoy great mobility, and are, therefore, from this cause, enabled to accommodate themselves to the distended uterus. It is very desirable to assist nature, during gestation, in removing the usual torpor of the intestinal canal; for, if it be permitted to continue, headache, fever, and loss of appetite will be apt to ensue. For this purpose, I am in the habit of ordering a simple enema of warm water early in the morning, or what will frequently answer THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 223 an excellent purpose, a tumbler of cold water drunk as soon as the patient leaves the bed. Sometimes it may be necessary to give a little manna dissolved in water, and again one or two of the follow ing pills may be administered according to circumstances: R. Massae Hydrargf., ) _. G • J b ' Ua gr. xij. Saponis, ) Assafoetidae, gr. vj. Ft. Massa in pil. vj. dividenda. You Avill sometimes find that, in the attempt to administer an enema, the fluid is immediately returned. This Avill probably be owing to the circumstance that the rectum is clogged up with lumps of ficcal matter, which will be likely to give rise to various local symptoms, such as more or less bearing doAvn in the back passage and tenesmus, Avhich, if continued, may result .in premature deli- very ; pains throughout the pelvis and lower limbs, with indications of paraplegia from undue pressure on the sacral plexus of nerves. Now, this is a very important condition of things, and a little inattention on the part of the accoucheur may result in serious trouble to the patient. Therefore, in all such cases, I Avould advise you particularly to inquire how long a time has elapsed since the evacu- ation of the bowels; whether the pain and tenesmus have continued for several days; and if you have reason to believe the rectum to be filled Avith faeces Avithout the ability to expel them, it will be your duty to proceed at once to remove the offending masses. This may be done in one of two Avays—either introduce the index finger into the rectum, and thus giving it a hook-like form, bring away, piece after piece, the flecal matter, or, if you prefer it, you may introduce a small spatula, and thus rid the rectum of its contents. 4. Diarrhoea.—Pregnant Avomen are occasionally subject to an opposite condition of the bowels, viz., diarrhoea; and it is Avell to remember that the same causes capable of producing diarrhoea, Avhen pregnancy does not exist, may also display their action during this state, such as improper food, cold, etc.; and again, diarrhoea in pregnancy, as in other conditions of the system, will sometimes be the direct consequence of constipation. Have you never, for example, seen a case of protracted constipation followed by severe diarrhoea ? If you have not, such instances will undoubtedly occur to you in practice. In these cases, the intestinal canal becomes irritated by the presence of faecal matter, and more or less profuse diarrhoea will be the result. One word as to the treatment of this latter form of diarrhoea. Give an astringent, and you will most probably destroy your patient. On the contrary, administer a good cathartic medicine, sweep the whole intestinal canal, remove the offending cause—the accumulated faecal matter—and you Avill not only arrest the diarrhoea, but restore your patient to health. There 224 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. is, hoAvever, gentlemen, Avhat may be called the diarrhoea of preg- nancy—that is to say, it will sometimes supervene upon pregnancy almost simultaneously with the inception of this state, produced by a peculiar condition of the ganglionic nerves ; so that, although far less frequent than constipation, yet diarrhoea may be regarded an occasional accompaniment of gestation, and may, by debilitating the system, give rise to unpleasant results ; but what is most to be apprehended is its tendency in women of great nervous suscepti- bility to produce miscarriage. The diarrhoea must be treated on general principles; should it result from improper food or consti- pation, a purgative will be indicated; if the food be still in the stomach, administer ten or fifteen grains of ipecacuanha; if from nervous irritability, calming enemata, etc. A tablespoonful of the folloAving mixture may be given with good effect tAvo or three times a day: R. Cretae Misturse, f § vj. Tinct. Opii, 1 " Catechu, Vaaf3j. " Kino, ) M. 5. Palpitation of the Heart.—In women of great nervous sus- ceptibility, palpitation of the heart is not an unusual attendant upon pregnancy during the earlier months. It sometimes resolves itself into quite a disturbing symptom, and will need attention. If not controlled it may lead to miscarriage. When it is found to be due simply to nervous irritability, gentle tonics and antispasmodics judiciously employed will be followed by good results. Small doses of quinine with nourishing and digestible food; and, as an antispasmodic, thirty or forty drops of the tincture of hyoscyamus will prove valuable. If the palpitation, as will sometimes be the case, should be occasioned by a plethoric condition of system, the broad indication is the lancet, together with the use of saline cathartics and moderate diet. The quantity of blood to be abstracted must rest with the judgment of the practitioner. In the latter months of gestation the female will oftentimes complain of distressing palpitation, which arises neither from nervous irritability nor plethora, but from the mechanical pressure of the elevated dia- phragm, thus encroaching upon the capacity of the chest and therefore, giving rise to functional disturbance of the heart. The most certain remedy in this case will be patience, for the difficulty will terminate with the delivery. But something may be gained by position ; the patient usually experiences more or less relief in the sitting or demi-recumbent posture. It is highly important that the bowels be kept in a soluble state, for constipation will tend to aggravate this particular form of palpitation. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 225 Larcher* has endeavored to show that, during pregnancy, there is a normal hypertrophy of the heart, which consists in a thicken- ing of the left ventricle, the Avails of which are increased in volume from one-fourth to one-third over their ordinary dimensions; this increase is confined exclusively to the left ventricle, no other por- tions of the organ participating in it. The statement of Larcher is deduced from several hundred post-mortem examinations. The interesting practical fact connected Avith this opinion is, that the hypertrophy of the left ventricle will explain the belloAvs sound so frequently detected in gestation, and Avhich, therefore, is not to be regarded, in this case, as necessarily connected Avith fatal organic lesion of the organ. 6. Syncope.—Young married women, in their first pregnancy, are very apt to be attacked Avith syncope. Indeed, according to my experience, this is much more frequent than is generally admitted by Avriters. I have known it to occur as early as the second Aveek of gestation. It is usually confined to the earlier months, but in some cases it exhibits itself at the time of quicken- ing. It will develop itself in women of good health, as well as in those of delicate constitution. Sometimes, its duration is quite brief and evanescent, while again it will continue for a longer period, producing much disquietude on the part of friends. It may take place at any time, and Avithout the slightest premonition. Syncope cannot, I think, as a general rule, be regarded a dangerous complication for the mother. I have never seen fatal consequences ensue from it, except in one case, where it Avas well ascertained that organic disease of the heart had previously existed.f It is, however, not without danger, under certain circumstances, to the child ; for example, Avhen the syncope is long continued, the inter- ruption of the proper supply of healthy blood to the foetus may result in its destruction. Allow me, here, to call your attention to an important distinction betAveen syncope, strictly speaking, and a sudden loss of consciousness, unaccompanied by suspension or dimi- nution in the heart's action ; this latter seems to have an analogy with epilepsy; and, of course, its treatment must depend, as far as may be ascertained, upon the particular cause producing it. In an ordinary case of fainting, the treatment is simple; the patient should be placed instantly in the recumbent position, her head on a plane with her body, in order to facilitate the passage of blood to the brain; the dress loosened, fresh air admitted, cold Avater dashed in the face, and, if necessary, salts of ammonia applied to the nose. It should also be recollected that simple mechanical excitement of the heart by manual pressure is a valu- * Gazette MSdicale de Paris. 1857. p. 258. f It is proper to mention that there are some few cases recorded of sudden death from syncope during pregnancy, the syncope being the result simply of emotion. 15 226 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. able means of re-establishing its rhythmical movement. It can scarcely be necessary to remark that a proper supervision should be exercised by friends in cases in which the female becomes sub- ject to these fainting turns. 1. Pain in the Abdominal Parietes.—In Avomen wTith their first children, more especially, there will occasionally be experienced exces sive pain in the abdominal Avails from the sixth to the ninth month of gestation. The true cause is, no doubt, the great distension to which these parts are subject, and the firmer resistance which they offer in a primipara. Sometimes, the pain amounts to intense suf- fering, and the practitioner must be careful not to confound it Avith inflammation. The diagnosis is Arery clear—in mere pain of the abdominal muscles from distension, there is no fever; pressure and frictions relieve, instead of aggravating, the distress. In inflam- mation, on the contrary, the slightest pressure increases the pain, and there i3 high fever, with an accelerated and hard pulse. I have found in these cases of severe abdominal [tain much benefit from the application, by means of gentle friction, of equal parts of laudanum and SAveet oil; soap liniment, or camphorated oil is also useful. For the purpose of relaxing and soothing the stretched uiteguments a large slippery-elm poultice, applied warm, will be very servicable. 8. Relaxation of the Abdominal Parietes.—You will, in women «vho have borne several children, oftentimes observe an opposite condition of the abdominal parietes. Instead of being excessively tense from distension, they will present an aspect of relaxation, being absolutely as it were, flabby, and utterly unable to afford the necessary support to the developing uterus. This necessarily exposes the gravid organ to the displacement known as anteversion, which, if not remedied, will, during the pregnancy, occasion much disturbance about the bladder, and at the time of labor present serious obstruction to the delivery of the child, as will be more particularly mentioned when speaking of the causes of obstructed delivery., The remedy for this relaxed condition of the abdominal wallu is proper support; it can be afforded by the employment of a broad elastic belt Avhich, if properly adjusted to the person, will prove quite sufficient in preventing the displacement to which I have referred. Before applying it, the accoucheur, if the uterus be already anteverted, should gently grasp the fundus of the organ, through the abdominal coverings, and direct it upward and back- ward with a view of restoring it to its normal position. 9. Painful Mammae.—The breasts, particularly in the primipara, sometimes become the seat of distressing pain. As pregnancy advances, they enlarge, the lacteal glands and ducts undergoing more or less constant development—the consequence is, occasionally, o-reat local distress, producing at times fever, and other consti- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 227 tutional disturbance. In these cases, you Avill find, especially if the bowels be confined, much benefit from the derivative action of Epsom salts given in small quantities in solution, and as circum- stances may indicate. Benefit will also be derived from local appli- cations; gentle frictions Avith some liniment, camphorated oil, laudanum and sweet oil, or a poultice of crumbs of bread, saturated with a small quantity of tincture of belladonna. If the patient be plethoric, the abstraction of a few ounces of blood will be of advan- tage ; and I have known great good accrue from tolerant doses of tartarized antimony. 10. Pain in the Right Side.—About the sixth month of pregnancy, women are often attacked with pain in the right side, which may possibly, through inadvertence, be mistaken for inflammation. The pain usually arises from the fact that the ascending uterus begins to exercise a pressure on the liver. As a general rule, the pain will continue more or less until after delivery, although it may be miti- gated by the occasional use of a mercurial pill at night, followed in the morning by oil, or Epsom salts. 11. Pruritus of the Vulva.—A most distressing itching of the external organs will sometimes manifest itself during pregnancy, and, in its aggravated form, it Avill constitute one of the most pain- ful affections with which the pregnant female has to contend, caus- ing her literally to lacerate the parts by the constant scratching to Avhich she has recourse in the hope of temporary relief. Ulcerations often result, requiring \'ery nice attention on the part of the prac- titioner. You will meet Avith pruritus of the vulva in other cases than pregnancy, but when it is found to complicate gestation, it calls for more than usual vigilance, for, if not controlled, it may lead to abortion. The female, from motives of delicacy, oftentimes conceals the fact of her suffering, and, on this account, the physi- cian is generally not consulted until the malady has reached one of its most aggravated phases. The characteristic feature of the disease is intense itching; sometimes small vesicles, containing a sero-sanguineous fluid, will be observed on the inner surface of the parts, where, in some cases, deep ulceration will be provoked. I have just stated that other causes than pregnancy will produce pruritus of the vulva; such, for example, as the final cessation of the menses, inattention to personal cleanliness, the presence of Avhat are termed the pediculi pubis, known as the small parasite insects, which occasionally infest these parts, discharges from the vagina, ascarides in the rectum, etc. In some instances the worms will pass from the rectum to the vagina, and two cases have recently been published by Dr. Yollez, in Avhich pruritus pudendi resulted from the presence of ascarides exclusively in the vagina, none hav- ing been found in the rectum. In these instances, mercurial oint- ment -will prove an efficient remedy. 228 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Treatment.—The treatment of pruritus must depend upon the particular condition of the parts, and also upon the cause to Avhich it is traceable. When there are no ulcerations, I have generally found, if there be nothing to contra-indicate it, the abstraction from 3 iv- to 1 vi. of blood from the arm, together with saline cathartics, and a lotion applied freely of 3* i. of the borate of soda to Oj. of water, with 3 i. of Magendie's solution of morphia, to be folioAved by good results. When the parts are ulcerated, I always touch the ulcerated surface with the solid nitrate of silver, and this should be repeated every fourth or fifth day, as may be indicated by the progress of the disease. The parts to be cleansed Avith Castile soap and water, and, as far as possible, rest enjoined on the patient. This malady is apt, especially when suffered to continue for some time, to result in emaciation, and in such case, if you limit your remedies *to local applications, you Avill fail in affording relief. Tonics, together Avith nutritious diet, will be indicated. There will occasionally be developed a form of pruritus of the genital organs, assuming the character of eczema, Avhich is extremely difficult to manage, often proving obstinately rebellious to remedies. In this particular condition of things, the folloAving treatment has been proposed by M. Tournie, and which I have found very efficient for the purpose. He recommends, as topical applications, calomel ointment, and a powder of camphor and starch. Should the parts be covered Avith scabs, emollient poultices are first to be employed ; when the scabs are removed, the ointment is to be applied tAvice a day, 3j. of calomel to ~j. of lard; after each application, a poAvder, consisting of four parts of starch to one of finely poAvdered cam- phor, to be freely used. 12. Hemorrhoids.—Hemorrhoidal tumors, or piles, are not uncommon during pregnancy, and frequently give rise to much distress. When large, they may, by the excessive pain they induce, occasion premature action of the uterus. In the pregnant Avoman, there are two causes in operation which tend directly to the forma- tion of these tumors: in the first place, pressure exerted by the gravid uterus on the venous trunks, thus obstructing the free return of blood to the heart, and secondly constipation, which is so fre- quent an attendant upon gestation. These hemorrhoidal tumors may be either external or internal; in either circumstance, they are exceedingly apt to be accompanied by much pain and irritation. Lf they bleed, which is sometimes the case, the patient, for the time being, is relieved, for their disgorgement is always followed by a diminution in their volume, and consequently a lessening of the irri- tation and pressure. Occasionally, however, the bleeding will be so frequent as seriously to affect the health, resulting in an anaemic condition of the system, and imposing upon the female the various nervous and other derangements consequent upon this bloodless THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 229 state. In such case, too prompt attention cannot be directed toward the arrest of the hemorrhage. One of the first indications to engage the attention of the practi- tioner in hemorrhoids is to overcome the constipation, and keep, if possible, the bowels soluble, for, as long as the torpor continues there will be but little hope of benefit from local applications; the recumbent posture will also be of service in measurably removing the amount of pressure exercised by the uterus. If the tumors be large, and from their tension occasion much suffering, one of the most effectual remedies -will be the application of from tAvo to four leeches, depending upon the judgment of the practitioner. An efficient remedy, also, will be an injection, night and morning, into the rectum, of half a pint of cold Avater, and the introduction, for two or three hours each clay, of the metallic rectum bougie. I regard these latter means of very great value in the treatment of hemorrhoids, especially when they are internal. When it agrees Avith the stomach, sulphur Avill be found an excel- lent medicine to administer internally—a teaspoonful may be mixed Avith honey or molasses, and given once or tAvice a day. It is gen- tle in its operation, and Avill, in many cases, exercise a happy influ- ence in diminishing the volume of the hemorrhoids. Let me here enjoin upon you a most important direction, the neglect of which oftentimes, I am sure, leads to much unnecessary suffering on the part of the patient; the direction to which I allude is this: always, after each evacuation of the bowels, instruct the female to intro- duce the protruding piles within the rectum; this can usually be accomplished Avithout difficulty, except in cases in Avhich the tumors have attained a large size. You perceive at once the advantage of the practice. If the tumors remain external to the anus, the conse- quence is they become subject to the full pressure of the external sphincter muscle, and it is this very pressure which so often aggra- vates the intensity of the suffering. Much vesical irritation will sometimes ensue from the presence of the piles, and, unless your attention be specially directed to the circumstance, you Avill fail in giving relief to the bladder, for the reason that, in lieu of regarding the irritation as simply symptomatic, you will most likely mistake it for, and treat it as, an idiopathic or primary affection. The remedy, of course, is the relief of the piles. 13. Varicose Veins.—Women, during the period of their gesta- tion, are subject to enlargement, or a varicose condition of the veins of the loAver extremities. It is the result of the mechanical pressure exerted by the uterus. This enlargement of the venous trunks is, hoAvever, not always confined to the loAver limbs. It will sometimes be observed in the loAver portion of the abdomen, A'ulva, and vagina. These varicose veins are most likely to develop them- selves during the latter four months of pregnancy, when the pres- 230 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sure is greatest; but they Avill also be observed during the earlier months, particularly in cases in Avhich, as will sometimes happen, there is a predisposition to their formation. The great remedy is a uniform and Avell-directed pressure, in order that due support may be given to the distended trunks. A properly-adjusted lace-stock- ing Avill be found Avell adapted for this purpose, or an ordinary roller bandage, commencing at the toes and continuing up to the knee. In cases of fulness of habit, the occasional abstraction of blood, and saline cathartics will be indicated. It is always advis- able in these cases to alloAV the patient, as much as possible, to avail herself of the advantage of position—hence benefit Avill be derived from the recumbent posture and, even when sitting, she should be directed to place her limbs on a chair, so that they may be on a level, or nearly so, with the plane of the body. 14. Cough and Oppressed Breathing.—Some Avomen, and this is more especially the case in nervous, irritable constitutions, are very apt to be troubled Avith a cough in early pregnancy. This cough is peculiar, and is Avell worthy the attention of the practi- tioner ; it may, in strict truth, be denominated a nervous cough; it is usually dry, unaccompanied by expectoration, except in some instances there will be a slight sero-mucous discharge; it is parox- ysmal, Avithout fever, and, on an exploration of the chest, there Avill be an entire absence of all the physical signs, indicating organic lesion of the pulmonary apparatus. Now, Avhat is this cough, and how is its presence to be explained ? It is, unquestionably, one of those examples of sympathy evoked in distant organs, by irritation of the uterus, to which your attention has been so repeatedly directed. This character of cough will sometimes continue rebel- lious to all medication during the whole period of gestation— at other times, it will spontaneously become arrested at the third or fourth month. In cases in Avhich the irritation of the uterus is very marked—as Avill be evinced by local pain, bearing down, and gene- ral uneasiness about the hips, I have found either the injection of laudanum into the rectum, thirty drops to a Avine-glass of tepid water, or the application of belladonna ointment to the cervix uteri, in the proportion of 3j. of the extract to 3 j. of lard, very efficient in relieving the cough. The internal administration of the tincture of hyoscyamus, thirty or forty drops in half a wine-glass of cold water, as occasion may require, is also a good remedy. But, gentlemen, during the latter period of pregnancy, especially in the two last months, there will frequently be a cough of a differ- ent kind—it arises from the mechanical pressure of the uterus against the diaphragm, thus encroaching upon the capacity of the chest, and resulting in irritation of the lungs, Avhich, of course, occasions more or less cough. Accompanying it, there will, also, be a feeling of oppressed respiration. Patience here is the most THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 231 certain remedy, for these symptoms will cease as soon as delivery is accomplished, and frequently in the last two weeks previous to labor, because of the descent of the gravid uterus into the pelvic excavation, thus removing the mechanical disturbance from the diaphragm. However, both the cough and dyspnoea may be pal- liated by keeping the bowels in a soluble state, and if the patient should be disposed to plethora, occasional abstraction of blood will be serviceable. LECTURE X V i. Complications of Pregnancy from Displacements of the Uterus—Prolapsion, Ante- version and Retro-version of the Organ—Three Varieties of Prolapsion—Evils and Treatment of these Varieties—How Direction of the Urethra is Modified—Rules for Introduction of Catheter—Ante-version, Symptoms and Treatment of—Retro- version more frequent than Ante-version—Complete Retro-version occurs only during earlier Months of Gestation—Occasional Serious Consequences of this Form of Displacement—Premature Labor sometimes the Result of Retro-version—Diag- nosis of Retro-version—How determined—Symptoms—Retention of Urine—Punc- ture of Bladder, first proposed by Sabatier—Treatment of Retro-version—Plan of Evrat, Halpin, and Gariel—Retro-version often mistaken for other Pathological Conditions—Prolapsion of Ovary in Triangular Fossa, and Faeces in the Rectum— How distinguished from Retro-version—Hernia of Gravid Uterus. Gentlemex—In the previous lecture, mention has been made of some of the ordinary disorders of pregnancy, arising more or less from sympathetic and mechanical influences, exercised by the gravid uterus on various organs of the economy. We shall now direct your attention to the consideration of other complications of gesta- tion, the result of displacement of the uterus itself. You are well aware that J*is organ, from its peculiar situation and relations, enjoys a remarkable degree of mobility, and is, therefore, liable, especially in its unimpregnated state, to various displacements ; examples of these you have had repeated opportunity of observing in the Clinic. The uterus is, also, subject to malpositions during the period of pregnancy, and these, although much less frequent than when ges- tation does not exist, are yet attended by more serious consequences. There are three forms of displacement to which the gravid Avomb is exposed, and it is proper that you should understand their par- ticular bearing upon gestation: 1. Prolapsus; 2. Ante-version; 3. Retro-version. 1. Prolapsus Uteri.—There are three degrees of prolapsus in pregnancy, as there are in the unfenpregnated condition ; in the first, the uterus has fallen slightly below its normal position ; in the second, it has passed to a level with the vulva; and, in the third, t is completely out of the vulva, constituting a veritable procidentia. The causes of either of these varieties are numerous—such as relaxa- tion of the vagina, or ligaments of the uterus, the presence of tumors in the abdomen, habitual constipation, falls, or blows. When speaking of the changes produced in the uterus in early pregnancy, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 233 you will remember we noted very particularly the important cir- cumstance that, for the first two months, the tendency of the organ is to descend into the pelvic excavation; and this very descent, Avhich is one of the ordinary phenomena of early gestation, may act as a predisposing cause to either of the varieties Ave have named. As a general rule, the uterus, in the first two varieties, usually, about the fourth month, undergoes spontaneous restoration, by the gradual ascent of the organ into the abdominal cavity. Sometimes, however, this is not the case ; and when the uterus presses on the vulva, serious inconveniences will result. For instance, the rectum becomes irritated, giving rise to constipation, and an annoying tenesmus; the bladder, also, is affected. Sometimes, there -will be, more or less, a constant desire to pass water; at other times, there is complete retention of urine, requiring the introduction of the catheter. In these cases, it is of great importance to attempt the replace- ment of the uterus, for the obvious purpose of removing the pres- sure from both the rectum and bladder. With this vieAv, the practitioner should gently grasp with his fingers, previously lubri- cated with oil or lard, the cenix of the organ, and make uniform pressure, at first a little backward, and then upAvard, in a direction parallel to the axis of the superior strait. The patient should be kept in the recumbent posture, and a sponge-pessary introduced, Avhich may be retained in situ by means of the T bandage. It should not be forgotten to have the sponge removed at least once a day for the purpose of cleansing it. After the fou«|h month, its use may generally be dispensed Avith, for the uterus, having as- cended above the superior strait, will usually remain in the abdomi- nal cavity, Avithout the necessity of support. The tenesmus may be f partially relieved by the use of injections of warm soap suds into the rectum, and, in order to facilitate the admission of the fluid, the practitioner Avill sometimes find advantage in the introduction of the index finger into the intestine for the purpose of gently pressing the uterus forward, so that the pipe of the syringe may meet AAith no obstruction. Introduction of the Catheter.—For the relief of the bladder, suf- fering from retention, resort must be had to the catheter. You will readily understand that, in the second variety of uterine dis- placement—the cervix of the uterus pressing upon the vulva—the natural position of both the bladder and urethra will be modified— the bladder, of course, is prolapsed, sometimes protruding slightly beyond the vulva, and the urethra, instead of being oblique from beloAV upward, Avill be so changed in its direction, that, from the meatus to a little beyond its central portion, it will be horizontal, while its vesical extremity -will be drawn doAvnward. You per- ceive, therefore, that without a recollection of this circumstance, 234 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. the successful introduction of the catheter Avould not be an easy thing to accomplish, to say nothing of the serious consequences which would most likely ensue from a forced attempt to overcome the difficulty. The catheter, under these circumstances, should be introduced at first horizontally, from before backAvard, and then the outer extremity of the instrument elevated, while the internal ex- tremity is correspondingly depressed, for the purpose of following the altered direction of the urethra, and thus entering the cavity of the bladder, which you must remember is downward and forward, and not upward, as it is in its normal position; it must also be remembered that, in this case, the convex border of the instrument should be turned upward, and its concavity downward. When the gravid uterus is in a state of complete procidentia, the complications become much more aggravated. The difficulties about the rectum and bladder are necessarily much increased, and the patient is exposed to additional suffering. There are avcII- authenticated instances of Avomen haA'ing passed the period of gestation Avith the uterus protruding beyond the vulva. You can readily imagine the distress and danger consequent upon such a condition of things. When procidentia of the gravid uterus ex- ists, the first duty of the practitioner is to attempt its reduction, by grasping it gently with the fingers, and making pressure from before backward, parallel to the axis of the inferior, and then upAvard in the direction of the axis of the superior strait. When reduced, it should be retained in place by means of the sponge-pes- sary and T bandage. It may, in cases of procidentia of the impregnated womb, become a question hoAV far it is justifiable to promote premature delivery; and this question will necessarily present itself in instances, in Avhich the local irritation or constitutional disturbance is such as to involve, in more or less hazard, the safety of the patient. The ultimate decision must depend upon the accompanying circumstances of each individual case, and the sound judgment of the practitioner. II. Ante-version*—Ante-version of the uterus is comparatively of rare occurrence in early pregnancy ; although you occasionally meet with it in women who have borne many children, and whose abdominal walls are consequently so much relaxed as to be inade- quate to afford the proper support to the ascending organ, and it therefore, falls forward, giving rise to two conditions: 1st, Ante- version ; 2d, An increased prominence to the abdomen. If ante- * There is a broad difference between ante-version and ante-flexion of the uterus. In the latter, the uterus is, as it were, curved on itself in such way that the two upper thirds of the organ are thrown forward on the bladder, but the cervix is undisturbed in its relations with the pelvic cavity. So, also, in retro-flexion, while the superior portions of the uterus are curved backward, the position of the cervix remains unchanged. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 235 version occur in early gestation, before the uterus has left the pelvic excavation, it can readily be replaced by passing the finger into the vagina, and pressing the anterior surface of the organ backward; sometimes, it may be reduced to its normal position by gently drawing the cervix forward, the tendency of AArhichaaiII be to place the body and fundus in a position parallel to the axis of the superior strait of the pelvis. In a more advanced period of gesta- tion, Avhen the uterus is ante-verted, because of relaxation of the abdominal parietes, the practitioner should, in the first place, restore the organ to its normal position by righting it with the palm of his hand applied to the abdomen, making the pressure from below upward, and from before backAvard; and secondly, an ab- dominal brace, or bandage, is to be applied for the purpose of retaining the uterus in situ. HI. Retro-version.—Retro-version is much more frequent than ante-version, and may occur in the virgin, in the married woman, Avho is not pregnant, and it may also complicate pregnancy itself. It is most common when the uterus is in a state of vacuity. It is quite obvious that this form of displacement must take place during the earlier months of gestation, for, after the fourth and fifth months, the longitudinal diameter of the uterus is so much in excess of the antero-posterior diameter of the superior strait, that it is physically impossible for the organ to become completely retro- verted. Retro-version of the uterus implies a displacement of the organ, by Avhich it rests more or less horizontally in the pelvic excavation, ■the fundus being directed toAvard the sacrum, and the cervix regards the internal surface of the pubes. This displacement, when complete, divides, as it Avere, the cavity of the pelvis into two com- partments, an upper and lower—for the former, it constitutes the floor, and for the latter, the roof or superior boundary. The term retro-version was, I think it is generally conceded, first applied to this character of mal-position by Dr. Wm. Hunter. There are numerous causes capable of producing retro-version; among which may be enumerated an enlarged pelvis, a relaxed con- dition of the ligaments of the organ—the round and broad ; undue pressure Avhether against the anterior surface of the uterus, or upon its fundus; the efforts of vomiting, straining in the attempt at defecation, a distended bladder, and any sudden or violent move- ment may also produce it. Retro-version will, sometimes, be con- genita] ; it is almost always, hoAvever, the result of accident. It is sometimes A'ery gradual in its occurrence, and again it is quite sudden. In the latter case, it is the consequence of some extraneous physical violence experienced by the female, such as a fall, blow, or the lifting of a heavy Aveight. When this displace- ment has taken place, it is accompanied by symptoms, Avhich, to the 236 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. vigilant practitioner, will generally indicate its nature—for example, there Avill be more or less uneasiness experienced about the loins, and oftentimes a dragging sensation, irritation of the bladder and rectum, with difficulty in evacuating either; sometimes, it Avill be almost impossible to evacuate the rectum in consequence of the extreme pressure exercised upon it by the retro-verted organ. vAll these results are very much increased in the gravid uterus, and occasionally fatal consequences ensue from its complete hori- zontal impaction between the sacrum and pubes, giving rise, in the first place, to severe pressure, resulting subsequently in inflamma- tion, ulceration, and its consequences. In this case, also, there may be rupture of the bladder from the continued retention of urine, and the impossibility of draAving it off by means of the catheter.* The rectum, loaded Avith faecal matter, will occasion a tenesmus Avhich, provoking on the part of the female excessive efforts to expel the contents, may result in rupture of the vagina, thus causing the fundus of the Avomb to pass through the opening. A case of this kind, Avhich proved fatal, is mentioned by Dubois, as having been communicated to him by Dr. Mayor. There are examples of this displacement, in which death occurred from the severe local inflam- mation, and consequent constitutional disturbance, resulting from pressure of the retro-verted womb. It will sometimes happen that the uterus, from the serious irritation to Avhich it is exposed, will be thrown into premature action, thus ridding itself of its contents. This, in cases in Avhich it becomes impossible to reduce the mal- posed organ, should be regarded as a most fortunate issue, for it will prove the means of saving the life of the mother, and enable the practitioner to restore the uterus to its normal position. In- deed, when this early evacuation of the uterus is not accomplished by nature, it is, under certain circumstances, the only resort left for the accoucheur. The diagnosis of a retro-verted womb is, ordinarily, not difficult. In addition to the local disturbance, to Avhich allusion has already been made, a vaginal examination will soon dissipate all doubt. The finger will readily recognise a change in the position of the * A woman, aged thirty-five years, had enormous distension of the abdomen, which, on examination, had all the characters of ascites; there was dulness over the greater part of the cavity, extending high up above the umbilicus, and evidently due to the presence of fluid. A medical practitioner had been on the point of per- forming paracentesis so urgent was her distress. Fortunately, this was deferred, and she was taken to the Westminster Hospital. On inquiring into her history it was learned that she was three monms pregnant. A catheter could not be intro- duced, and on examination, a retro-version of the womb was detected which had probably existed three weeks, the duration of the swelling. A few ounces of urine dribbled away daily. The fundus of the womb was pushed up, and immediate relief given, upwards of a gallon of urine flowing away without the aid of the catheter, The woman recovered. [Lond. Lancet, April 30, 1859.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 237 organ, the cervix being in front, and the fundus behind, pressing, more or less, upon the rectum; and, in complete retro-version, the posterior surface of the organ will form the upper boundary of the pelvic excavation, being distinctly felt by the finger, extending horizontally from before backAvard. When pregnancy does not exist, retro-version of the uterus can- not be said to be a dangerous complication, although it is one of much annoyance to the patient, and oftentimes, from the difficulty of retaining the organ in situ, of embarrassment to the accoucheur. Very different, however, is the case during the period of gestation, for here, as you have just seen, the most formidable and, occasion- ally, fatal results ensue. Two of the earliest, most constant, and distressing symptoms of this displacement will be irritation of the bladder and rectum ; and this very irritation is frequently the first indication that there is anything wrong. Having told you in what retro-version consists, and spoken of the consequences of this form of displacement, the next point for con- sideration is, as to the remedies to be employed. One of the most imperious demands will be the evacuation of the bladder and rectum, more especially the former. But this is not always readily accom. plished, for the reason that the distended bladder ascends obliquely upAvard into the abdominal caA'ity, and so changes the position of the urethra as sometimes to render it physically impossible to intro- duce the catheter. This constitutes one of the most serious and painful complications of retro-version; and, under such circumstances, as death Avill be inevitable without relief to the bladder, the very important question arises: What is to be done? We have the authority of Sabatier, in these cases, to perforate the bladder above the pubes; and, if the necessity of the operation be indicated, I should not hesitate to have recourse to it; for the double reason that relief must be had, and, secondly, the operation itself does not necessarily involve any danger. The rectum should be evacuated by means of enemata, or, if required, the faeces may be scooped out with a small spoon or spatula. These two viscera being emptied of their contents, an effort should next be made to restore the uterus to its proper position ; for this purpose, various plans have been suggested. In the event of inflammation having arisen from the severe pressure of the uterus against the adjacent organs, any attempt at reduction should be preceded by means best calculated to remove inflammatory action, such as leeches, hot fomentations, and emollient injections into the vagina. Minute doses of tartarized antimony, given to tolerance, Avill frequently be folloAved by good effects in subduing the local excitement. This being accomplished, efforts may be 238 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. made to reduce the organ to its usual axis. For this purpose, the index finger of one hand should be introduced into the rectum, with the view of pressing the fundus of the womb upAvard and fonvard; at the same time, the finger of the other hand is to be carried through the vagina to the cervix of the organ, and a movement made precisely counter to the other—that is, the cervix should be brought a little downward and backAvard. This simple manipula- tion, adroitly performed, will sometimes result in the restoration of the retro-verted uterus, but not always. Much -will sometimes be gained by the position of the patient; for example, if either on the back, or resting on her left side, you should fail in accomplish- ing the object, it will be found useful to direct your patient to place herself on her knees and elbows—this a\ ill tend to facilitate the attempt at reduction ; but the position is an unpleasant one, and oftentimes there Avill be objection made to it. Evrat suggested the introduction into the rectum of a tampon prepared in the following manner : a small rod about twelve inches in length has fastened to one extremity a sort of mop made of fine old linen, and Avell smeared with oil or fresh lard; this tampon is then gently introduced into the rectum; of course, it is soon brought in contact with the lower surface of the malposed organ, and with a uniform but judicious upward and forward pressure, Evrat and others have succeeded in giving to the uterus its natural position. It is, however, to be recollected that, while pressure is made upward and forward by means of the tampon, the finger of the accoucheur should be introduced into the vagina for the pur- pose of making downward and backward traction on the cervix. If it prove impossible to reduce the organ, then it has been pro- posed to perforate the uterus through its posterior wall with a view of affording escape to the liquor amnii, and wdth the hope of so far diminishing the bulk of the gravid uterus as to facilitate the reduc- tion. This, however, is a dangerous expedient, and should not be resorted to except in those cases in Avhich it is absolutely impossible to rupture the membranes through the cervix, Avhich, although difficult in this form of mal-position, may, Avith due care and perse- verance, be accomplished. It has been suggested by Halpin,* in cases which have resisted the ordinary attempts at reduction, to pass into the vagina an instrument, the object of which shall be the exercise of a uniform pressure simultaneously on the entire lower surface of the uterus. Thus he contends, by means of a bladder, he can completely fill the pelvis, and elevate into the abdominal cavity the different viscera contained within the excavation. For this purpose, he places an empty bladder between the fundus of the womb and rectum; he * Arch. Gen. 1340, p. 88. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 239 then cautiously inflates it, and, as the bladder becomes distended, the retroverted uterus is replaced. A plan very similar to this has been suggested by Gariel. He introduces one of his vulcanized india-rubber pessaries into the rectum; it consists of a dilatable air pessary, with an air reservoir, and a tube, to each of which are attached small taps. The collapsed pessary, having been previously placed in warm water, is introduced by means of a probe into the rectuni, immediately behind the uterus; then the tube of the pes- sary is adjusted to the air reservoir; the taps are opened, and by simple pressure of the hand the air is made to escape from the reservoir into the pessary; in this way the pessary presses upon, and raises the retro-verted uterus from the hollow of the sacrum; thus the natural position of the organ becomes restored. This is an ingenious contrivance, but the proper application of the instru- ment requires much care in order that it may prove efficient. It is not at all uncommon for the inattentive practitioner to sup- pose that retro-version exists, Avhen, in fact, there is no displace- ment Avhatever; and, I think, I shall perform an acceptable service by directing your attention briefly to the causes of error. I have more than once been consulted by medical gentlemen, AA'ho have treated their patients for this supposed mal-position, when, upon examination, I have discovered that the symptoms, Avhich had been mistaken for those of retro-version, were due to circumstances with Avhich dislocation of this viscus had no sort of connexion. Two of the most prominent causes of error will be: 1st. A collection of faecal matter in the rectum ; 2d. A prolapsion of the ovary into the recto-uterine fossa. You Avill perceive that either of these contingencies Avill necessarily, to a greater or less extent, give rise to the same local disturbances, Avhich usually characterize a retro-version of the uterus—such, for example, as pain about the hips, distressing pressure on the rectum, Avith fre- quent desire to defecate, together Avith tenesmus. How, then, is the diagnosis to be determined—and in what way is the true nature of the difficulty to be ascertained? If it be a collection of faecal matter in the rectum, this can readily be appreciated, almost in all instances, by a' vaginal examination. Let the accoucheur, as he passes it into the vagina, run his finger carefully along the track of the rectum, with a vieAv of ascertaining, AA'hether or not it is unusu- ally distended—if the distension be due to faecal matter, he will be enabled to recognise the fact by slightly pressing upon the rectum, AA'hich will enable him to separate the different pieces of hardened fieces, and thus become satisfied that it is their presence, which has caused the symptoms to Avhich we have just alluded. Again, in retro-version, Avhile the fundus is thrown backward into the hollow of the sacrum, the cervix of the uterus inclines toward the pubes ; this will not be the case when the rectum is simply loaded with 240 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. excrement. But, in order to remove all doubt on the subject of the diagnosis, let the rectum be freely evacuated by cnemata; if this cannot be accomplished by these means—as is sometimes the case—then the finger, or a small spatula, should be introduced, and the faeces brought away, as has been previously suggested. The rectum being relieved of its distension, it will follow, as a necessary result, if there be no retro-version, that the patient will, at once, experience an absence of the distressing local disturbances. Hoav are Ave to proceed in our diagnosis of prolapsed ovary ? In this case, if the ovary have not undergone enlargement from disease, it Avill not be difficult to displace it from side to side by means of the finger, indeed, in some instances it may be pushed upward without difficulty, but as soon as the finger is AvithdraAvn, it again prolapses ; the most positive demonstration that it is a prolapsed ovary, will be the introduction of the uterine sound. Let the accoucheur carry the sound into the uterus, which must always be done with great caution; as soon as it is sufficiently introduced, the uterus, should it be retro-verted, will, of course, while the sound is Avithin its cavity, become righted in its position ; if, under these circumstances, the finger of the accoucheur be intro- duced into the vagina, he will not feel anything pressing upon the rectum—but, on the contrary, if, after the introduction of the sound, the tumor be felt, then it is evident that it is occasioned by the presence of the ovary in the recto-uterine fossa. Hernia ofithe Gravid Uterus.—Hernia of the impregnated or- gan is extixmeiy~rare-^still there are some recorded examples of it. Dr. Every Kennedy, in his Avork on obstetric auscultation, cites the instance of an umbilical hernia of the uterus in a female, who had previously borne several children. It appears that Avhile in labor with her second child, she was attacked Avith an ordinary umbilical hernia; this continued gradually to increase, when, in a subsequent pregnancy, the gravid organ passed completely out of the abdominal cavity through the umbilical opening, so that, at the end of the ninth month, it extended to the knees. Madame Boivin has recorded a case of ventral hernia of trie impregnated womb, the organ passing out through an opening above the pubes, which opening was the result of a large abscess. Other varieties of hernia have also been mentioned as having occurred, such as inguinal and crural.* * I find, in the Obstetrical Transactions of London, for 1856, p. 11, the following interesting case of umbilical protrusion of the impregnated organ, having occurred in the practice of Mr. G. C. P. Murray: Mrs. M. A. J., thirty years old, mother of three children, observed some blood issuing from her navel; on examining the abdomen, Mr. Murray observed a large tumor the size of a gravid uterus in the latter months; the head of a fcetus could be distinctly fell, at the right and upper portion of the umbilical tumor, the body of the fcetus extending downward on the left side. There LECTURE XVII. The Annexae of the Foetus; The Decidua—Huntar's Theory of its Formation; The Decidua, an Hypertrophied Condition of the Uterine Mucous Membrane—The Reflexa; how formed—Coste's Views—Uses of the Decidua—The Chorion and its Villi—The Uses of each—Nourishment of the Embryo through the "Villi— Professor Goodsir—The Amnion; its Uses—The Liquor Amnii: Origin of—Is it derived from Mother or Foetus?—Casts of the Uriniferous Tubes found in Liquor Amnii—Uses of Liquor Amnii—Various—Does it contribute to Nourish- ment of Foetus?—The Placenta—Peculiar to the Mammiferous Class—How Divided, and Dimensions of—Two Circulations in Placenta—Distinct and Inde- "■ pendent—Red Corpuscles—Difference in Size of in Foetal and Maternal Blood— When does Placenta begin to Form ?—What is the Connexion between Placenta and Uterus ?—Do the Blood-vessels of the Mother penetrate the Placenta ?— Hunter's Opinion confirmed by Dr. Reid and Professor Goodsir—Professor Dalton, his Injection of the Utero-Placental Vessels by Air—Fatty Degeneration of the Placenta—Is it Normal or Pathological ?—The Umbilical Cord; how Composed- Its Uses—Nomenclature of the Anatomist and Physiologist—Difference between— Variations in Volume and Length of the Cord—Twisting of the Cord around the Foetus—Dr. Weidemann's Statistics of—Does the Cord possess any Trace of Nervous Tissue—Dr. Simpson on Contractility of the Cord—Scanzoni's Opinion— Virchow. Gentleiiex—We shall to-day speak of the annexae, or appen- dages of the foetus. These consist of the membranes, the liquor amnii, placenta, and umbilical cord. Each one of these appendages has its own special duty to perform during the progress of the reproductive evolution ; Avhenthis latter is completed, their presence ceases to be necessary, and they are, therefore, expelled from the uterus at the time of childbirth. The membranes are three in num- ber: 1. The decidua, or caduca; 2. The chorion; 3. The amnion. These three membranes constitute so many concentric layers, and form the coque, or, if you please, the shell of the foetus. The was still excoriation of the skin around the navel, but no division of the linea alba whatever, the continuity of the ring being perfect. The coverings of the hernia were composed of skin, fascia, and peritoneum. The tumor consisted of more than two- thirds of the uterus, the lower part lying within the grasp of the umbilicus. The patient being placed in the most favorable position for reduction, gentle manipulation was exercised, after which, to the astonishment of those present, the whole pro- truding organ was returned, with comparative facility, into the abdomen, the ring yielding equally all round to allow of the return of the hernial mass. No portion of intestine had protruded with the uterus. A bandage was applied to the seat of the hernia, which acted well; the patient went on to the full time, and, after a favor. able labor, gave birth to a healthy female child. 242 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mode of their origin, together with their particular uses, is not unworthy of attention. 1. Membrana Decidua.—Until quite recently, it Avas very gene- rally conceded that the membrana decidua Avas produced in the manner originally explained by Dr. William Hunter. He main- tained that this membrane was a neAv formation, and resulted in the following manner: At the time of fecundation, the internal sur- face of the uterus becomes the seat of increased vital action, which results in the exudation of coagulable lymph ; this coagulable lymph constitutes a closed sac, and is the A'eritable decidua, or, as it is sometimes called, caduca; this membrane Dr. Hunter termed the decidua vera, in contradistinction to another fold, the decidua reflexa. This latter is produced, according to his theory, as fol- Ioavs : the caduca A'era forming a closed sac, and occupying the entire cavity of the uterus, it folioavs that the three openings of the ' uterine cavity are completely occluded ; these three openings being the os tincae, and the two superior and lateral angles, Avhich are continuous with the tAVO fallopian tubes. Under this arrangement, it would become a necessary consequence that nothing could enter the cavity of the uterus, unless it either perforates or pushes before it this closed sac, or membrana vera. Hunter, therefore, attempted to show that, as the fecundated OArule is impelled by the fallopian tube toward one or other of the lateral and superior angles, as soon as it reaches this angle, it secures its entrance into the uterus by pushing before it a fold of the membrana vera, and it is this fold Avhich he has denominated the membrana reflexa. This was the exposition of Hunter ; and, as I have already remarked, until within a very short time, it was the accepted theory. Such, however, is the progress of mind, as is constantly deve- loped in the revelations of scientific research, that what was formerly regarded as the true description of the decidua, is now found to be utterly at variance with facts. It has been satisfactorily demon- strated by Coste, Professors E. H. and Ed. Weber, Sharpey, and others,* that, so far from this membrane being the product of a new formation, it is simply the result of a modified or hypertrophied condition of the mucous lining of the uterus. They have shown that the decidua is not a closed sac, but is continuous with the mucous covering of the fallopian tubes; and still more, that its structure is similar to that of the mucous membrane of the uterus itself, containing the same glands and the same layers; and, there- fore, Hunter's theory of the reflexa is as fallacious as is that of the original formation of the decidua vera itself. A very short time after fecundation, the tubular surface of the mucous membrane of the uterine cavity becomes thickened, and its * Midler's Elements of Physiology, pp. 1574-80. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 243 vascularity much increased. The entire internal surface of the organ is covered with a soft, pulpy tissue, in which may be observed numerous cellular elements. It is in this peculiar tissue that the ovum becomes imbedded; and it is this modified mucous lining, which constitutes the decidua vera. Under the microscope, the mouths of the tubes can be distinctly recognised, as also their white epithelial lining. The follicles become much enlarged, and there is poured out from them into the cavity of the uterus a fluid, which serves, as we shall afterward see, through the absorption of the villi of the chorion, for the nutrition of the embryo during the earlier periods of its existence, previous to the formation of the placenta. Decidua reflexa.—There has been much difference of opinion as to the mode of origin of the decidua reflexa. It is now admitted, as I have told you, that the explanation of Dr. William Hunter is not the correct one; and, perhaps, the views of Coste upon the subject are the most reliable of any that have been advanced within late years. According to him, as soon as the ovum enters the uterus, it becomes partially imbedded in the soft, pulpy mucous membrane, constituting the decidua ; the particular portion of the decidua with which the ovum thus comes in contact is immediately the seat of increased nutrition, which causes it to grow or spring up around the ovum, not unlike the fleshy granulations, which are observed to arise around the pea put into an issue for the purpose of increasing the purulent discharge. This increase of a small part of the decidua vera continues until the ovum is completely enve- loped by it; and this growth is Avhat Coste denominates the reflexa.* These two layers of decidua, the vera and reflexa, approach nearer to each other as the ovum increases in development, so that, at about the end of the third month, there is absolute contact between them, forming but one membrane. At the time of partu- rition, the membrana decidua is expelled from the uterus, and hence its name. The blood-vessels of this membrane gradually cease to be supplied with blood, and, at the period of delivery, the quantity is so exceedingly slight, that no hemorrhage accompanies its expulsion. Uses of the Decidua.—There can be no doubt that the chief uses of the decidua are to proA'ide, as it were, a bed for the ovum in the earlier periods of its development, and, through the nume- rous glands distributed on its surface, to afford the necessary nourishment previous to the organization of the placenta, which, we shall tell you, has no existence at the commencement of gestation. II. The Chorion.—It has just been shown that the membrana decidua is nothing more than a modification in structure of the mucous investment of the uterus, and, therefore, it is, strictly speak- * Comptes Rendus, 1847 244 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ing, furnished by the mother. The chorion, on the contrary, together with the amnion, appertains exclusively to the foetus, and, hence, these membranes are, Avith propriety, denominated its pro- per tunics ; the chorion is the most external membrane of the ovum, and forms one of its constituents from the earliest appreciable moment of fecundation. It is a thin, transparent investment, not unlike a small hydatid ; it passes over the foetal surface of the pla- centa, and also affords an external sheath to the umbilical cord. The chorion is intended to discharge, in the earlier periods of embryonic life, a most important and necessary office, which is the nutrition of the embryo itself; and, hence, for this purpose, one of the first changes it undergoes is the production over its cellular surface of villous prolongations, giving to it the peculiar shaggy appearance, which forms, in the first periods of conception, one of its prominent characteristics. These villi constitute so many absorb- ing radicules, through which the fluids furnished by the parent are conveyed from the decidua vera to the embryo, thus supplying the latter wuth the necessary elements of development; and this mode of nutrition continues, as I have told you, until the formation of the placenta. It has been demonstrated by Professor Goodsir, that each one of these villi or tufts is composed of numerous nucleated cells in differ- ent stages of development, inclosed within a layer of basement membrane. At first, the chorion and villi bear no evidences of vascularity, being entirely composed of cells, covered on their external surface by a delicate structureless membrane; soon, how- ever, vessels, conducted by the allantois, give rise to vascular loops in these villi. On that portion of the chorion, from which ema, nates the placenta, the villi increase very much in number, while on the other portion they preserve their original condi- tion. Each of these placental villi is supplied with a vascular loop, betAveen which andr the umbilical vessels there is a direct continuity; and the blood of the fcetus is forced through the ves- sels in the villi by the agency of the fcetal circulation. in. The Amnios.—This is the most internal membrane of the ovum; it is smooth and trans- parent (Fig. 44), and is in slight adhesion with the chorion, by means of the mucous filaments cover- ing its outer surface. The internal surface of the amnios is separated Fio. 44 The Amnios enclosing the Foetus. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 245 from the foetus through the intervention of a fluid—the liquor amnii—to the origin, and special uses of which Ave shall presently refer. Like the chorion, this membrane passes over the fcetal por- tion of the placenta, and also aids in forming the sheath of the umbi- lical cord. Bag of Waters.—These two membranes, together with the decidua, constitute the envelopes of the foetus during the term of gestation, and, at the time of parturition, they possess an import- ance well worthy the consideration of the accoucheur. For exam- ple, they, in conjunction with the liquor amnii, form what is known as the membranous sac, or, in more popular phraseology, the " bag of waters." This " bag of waters," as we shall have occasion to explain when speaking of the phenomena of natural labor, dis- charges a very important office in the influence it contributes toward inducing a proper degree of dilatation of the mouth of the Avomb. As a general pi'inciple, it is not characterized by much power of resistance, and, consequently, becomes ruptured at the proper time by the simple contractile efforts of the uterus. But it will occasionally happen that, owing to a greater degree of tenacity, it proves rebellious to every effort of the contracting womb, and the accoucheur is called upon to rupture it with his finger during a pain, and sometimes, indeed, it will be necessary to incise it, such being the nature of its resistance. The Liquor Amnii.—The origin of this fluid is a question, Avhich has called forth much difference of opinion. Some observers main- tain that it is the production of the fcetus; others, that it is fur- nished by the mother; and, again, there are some Avho argue that it is the joint production of mother and child. It is admitted that the quantity of liquor amnii is relatively greater in the earlier months than at the latter periods of gestation ; and, in addition, it is well to remember that the general quantity of this fluid at the time of childbirth is subject to remarkable variations. Sometimes) after the rupture of the membranes, the escape of fluid will be so slight that this circumstance gives rise to what the old women denominate a " dry labor;" at other times, there will pass from the uterus several quarts. In these latter cases, it will have been observed that the patient suffered during her gestation from more than ordinary distension of the abdominal walls. This sudden gush of fluid has more than once struck terror into the young practi- tioner, causing him to mistake the discharge of the amniotic liquor for a case of fearful flooding; and, occasionally, under this delusion, inducing him to request a consultation, imagining the patient to be in imminent danger! With a moment's forethought, all embarrass- ment will at once cease, for it is only necessary to make a shght examination of the clothes to ascertain at once that the discharge, in lieu of blood, is colorless. 246 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Source of the Liquor Amnii.—The true source of the liquor amnii appears to be derived from the parent; and it is claimed to be nothing more than an exhalation, or, as Velpeau terms it, a vital imbibition, requiring no special canals for its passage. This fluid is found, at times, mixed Avith meconium, and there is no doubt, that there is an excretion of urine from the foetus comming-lins: Avith the liquor amnii. Under the microscope, besides other materials, clear, transparent, elongated cylindrical bodies—the casts of the urini- ferous tubes of the kidney of the foetus—have been distinctly recog- nised, and the detection of these substances is very conclusive evidence that there is a mixture of the urinary secretion, and the amniotic liquor. Again: there are facts recorded upon perfectly reliable authority, in which the death of the foetus, while in utero, was occasioned by rupture of the bladder from over distension, in consequence of an imperforation of the urethra, thus preventing the escape of the urine. According to Vogt, the liquor amnii contains common salt, lactate of soda, albumen, sulphate and phosphate of lime; and even the presence of urea has been detected in it; Bernard has recently observed glucose in this fluid. Vogt has also shown that the ele- ments vary during the different periods of gestation ; for example, the chloride of sodium is in greater proportion during the first months, being the period Avhen cell-development and growth are more active. Whether the liquor amnii be engaged in affording nourishment to the embryo, we shall examine Avhen speaking of the nutrition of the fcetus. Uses of the Liquor Amnii.—The uses of this fluid are various: 1. During gestation, it serves to protect the fcetus against the effects of any sudden concussion, which may befal the mother; 2. It pre- vents the adhesion of those parts of the fcetus, which are intended to remain separate; 3. It affords facility for the foetal movements in utero ; 4. It protects the umbilical cord from undue pressure, thus ensuring a free circulation of blood from the foetus to the placenta; 5. At the time of labor, the liquor amnii performs the important double office of aiding materially, by its uniform and gentle pres- sure, in the dilatation of the mouth of the womb, and, after the rupture of the " bag of waters," it lubricates the vagina and vulva, thus facilitating the ultimate distension which they are so soon to undergo. Placenta.—The placenta, or after-birth, the latter name being given to it for the reason that, as a general rule, it is expelled from the uterus after the fcetus, is a flat, spongy mass, generally circular in shape, but sometimes assuming the oval form. It is the medium of communication between the mother and child—its special office being to supply nourishment to the foetus, during its intra-uterine existence. The placenta is peculiar to the mammiferous class, but in THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 247 these it presents much variation, both in its form and dimensions. In the ruminating animals, it assumes the appearance of small unequal masses, and is consequently multiple. In the mare, it exhibits a reddish, granular layer, which is found to cover the entire surface of the chorion. We, however, are to examine it as it pre- sents itself in the human subject. The term placenta is derived from its supposed resemblance to a flattened cake—this name hav- ing been applied to it by Fallopius. It usually measures from six to eight inches in diameter, and, at its centre, is from one inch to one inch and a half in thickness, gradually becoming less so toward its border or circumference. But while these may be considered the standard measurements, it must be remembered that there are occasionally exceptions; for example, the after-birth at full term will sometimes greatly exceed these dimensions, while again it will fall short of them. Divisions of the Placenta.—The placenta is divided into two surfaces—the foetal and maternal. The foetal surface (Fig. 45) is sometimes called the membranous, because the chorion and amnios both pass over it; it likeAvise has received the name of arbores- cent, for the reason that the distribution of the two umbilical arte- ries, and one vein, give to it that peculiar appearance resembling the branches of a tre*e. This surface of the placenta is smooth, and, as it were, glistening. The maternal portion, sometimes Fig. 40. Fio. 46. denominated uterine, is in contact with the uterus ; and, while the integrity of the contact is preserved, this surface is also smooth, its lobes or cotyledons being more or less in close juxtaposition. But, if the after-birth be examined, subsequently to its detachment from the uterus, the niaterual surface will exhibit an irregular, broken aspect, and distinct separations recognised among the various lobes composing it. (Fig. 46.) Blood-vessels of the Placenta.—Physiologically speaking, it may 248 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be said that the placenta is divided into tAVO distinct portions; one appertaining to the foetus, and the other to the mother; for, as Ave proceed further in the examination of this subject, it will be shown that there are two distinct, independent circulations in the organ ; one on the foetal surface, composed of the vessels in the umbilical cord; the other, on the maternal surface, composed of the utero- placental vessels. Between these tAvo orders of vessels there exists no continuity of canal, and, therefore, the two circulations are independent of each other. I think there is no fact better esta- blished than this absence of continuity of vascular connexion between the parent and foetus. A contrary opinion has been attempted to be proved by the result of injections thrown into the vessels of the umbilical cord, and which have been alleged to pass directly into the blood-vessels on the maternal surface of the placenta; but on a close analysis of these experiments, it has been most satisfactorily shown that, in every case in which the injection has been recog- nised in the vessels of the mother, it Avas through simple extrava- sation. An additional proof, if one be necessary, is furnished by the fact of the marked difference in the size and relative number of the red corpuscles, and, also, in the amount of fibrin and albu- men, as found in the blood of the parent and foetus. These circumstances, now accepted as Avell-demonstrated facts, surely prove the Avant of continuity between the vessels on the maternal and foetal surfaces of the placenta; and the fact, thus established, involves an important consideration connected with the passage of blood from the system of the mother to the foetus, to which your attention will be directed under the head of the fcetal circulation. Flourens and others, it may here be stated, have recently shown that if madder be given to a pregnant animal, the bones of the foetuses become colored by it as much, if not more, than those of the mother, thus proving the permeability of the maternal and foetal blood-vessels in the placenta. It is not until the second month that the formation of the pla- centa commences. Although the circulations on the fcetal and maternal surfaces of this body are not carried on through continuity of canal, yet it must be borne in mind that these two portions of the ovum are mingled, the one with the other, in close alliance throughout their whole substance ; and, in this respect, the human after-birth differs essentially from the placenta of some of the lower classes of ani- mals, in which the uterine or maternal portion consists of the hypertrophied decidua, while the foetal surface is composed of the vascular tufts of the chorion, which, as it were, are found to dip doAAm into the thickened decidua. So that, in this latter case, there is no difficulty in separating these two portions of the organ. Foiled and Uterine Surfaces of the Placenta.—According to the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 249 most recent observations, the folloAving appears to be the mode of origin of the foetal surface of the placenta: The villous tufts, Avhich spring from the chorion, and to which allusion has already been made Avhen speaking of this latter envelope, are composed, accord- ing to Prof. Goodsir, of numerous nucleated cells. There is observed at the terminal extremity of each of these villi, a sort of bulbous expansion, and, through the development of additional cells, the villi become elongated, and dipping down into the decidua, absorb from it nourishment, which is carried to the germ, this is what occurs in the earlier stages of foetal development, for, at this time, as the villi contain no vessels, the nourishment is derived simply through the process of absorption. But soon the villous tufts are supplied Avith a vascular apparatus; each villus is furnished with one or more capillary loops, which communicate with an artery on one side, and a vein on the other. In this way, through the increase and extension of the vascular villi of the cho- rion, the foetal portion of the placenta is formed; Avhile the maternal or uterine originates from the enlargement of the A-essels in the hy- pertrophied decidua, between Avhich, as has already been remarked, these villi dip down. Prof. Goodsir says, " these vessels assume the character of sinuses; and at last swell out (so to speak) around and between the villi; so that, finally, the villi are completely bound up or covered by the membrane, which constitutes the walls of the vessels, the membrane following the contour of all the A'illi, and even passing, to a certain extent, over the branches and stems of the tufts. Between the membrane or Avail of the large decidual A'essels, and the internal membrane of the villi, there still remains a layer of the cells of the decidua."* This, then, appears to be briefly the mode of origin of the maternal portion of the placenta. But a very natural question now arises—how is the blood con- veyed from the system of the parent to the uterine surface of the after-birth, and Avhat is the particular mode of union between this latter and the uterus itself? It is brought through what are termed the curling arteries of the uterus, and deposited into the placental cavity, and it is afterward returned through the large veins, gene- rally called the sinuses.f * Anatomical and Pathological Observations, p. 60. \ It has been, for a long time, a controverted point, as to the particular mode of connexion which exists between the internal surface of the uterus and the mater- nal portion of the placenta. It is quite evident, however, that the original opinion of Dr. William Hunter has been fully demonstrated by the experiments of Dr. Reed and Prof. Goodsir. Hunter*maiutained that the blood-vessels of the uterus passed into the substance of the placenta, and formed a portion of its mass; but repeated attempts have been made to show that his opinion was erroneous, founded, as it was, upon the injections, which were made to pass from the uterine vessels into the. maternal portion of the placenta—it being alleged that these injections reached the placental mass, not through continuity of vessels, but because of extra- 250 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Thus, gentlemen, you have seen that the placenta not only pre- sents tAvo surfaces—one belonging to the fcetus, and the other to the mother—but you have also observed that these two surfaces pos- sess two circulations, distinct and independent; the one carried on by the two arteries and one vein of the umbilical cord, the other by the maternal arteries and Areins, sometimes designated the utero- placental vessels. Under this arrangement, the fcetus derives from the placenta the elaborated blood necessary for its nourishment and growth in the manner we shall presently explain. Fatty Degeneration of the Placenta.—It is worthy of note that, as pregnancy draAvs toward its close, the placenta becomes more hard, and its capillary vessels undergo a peculiar alteration, Avhich consists in the appearance of numerous oil globules in the coats of the vessels, constituting what is termed fatty degeneration of the foetal tufts. This change in the physical condition of the placenta, has been regarded as an evidence of diseased structure ; but recent observation proves that, in the great majority of cases, this fatty substitution occurs in the placenta as one of the phases through which it finally passes. Dr. Druit and others have called special attention to this subject. Sound pathology has unquestionably demonstrated that fatty degeneration is oftentimes the result of morbid action ; but it must also be recollected, that it constitutes one of the peculiar processes to which tissues are subjected, after their functional activity is at an end, and prior to their absorp- tion. This is Avell illustrated in the case of the muscular fibre-cells of the impregnated uterus, Avhen the organ, having accomplished the purpose for wdrich it underwent increase, is about to return to its original size. Dr. Barnes, of London, has recently given the profession tAvo extremely interesting papers on the subject of fatty degenera- tion of the placenta, in connexion Avith the pathological changes to which this mass is liable ; and he has pointed out very cleverly the relation between this metamorphosis of the placenta and abor- tion.* Umbilical Cord.—The cord is the direct channel of communica- tion between the after-birth and foetus. One of the extremities is attached to the placenta, while the other is in connexion with the umbilicus of the child. It is composed of three vessels, two arte- ries, and one vein—the arteries are branches of the hypogastric or internal iliacs, and bring the impure blood from the fcetus to the placenta ; the vein originates in the fcetal portion of the placenta, vasation. Recently, Prof. Dalton, in an interesting paper read before the New York Academy of Medicine, fully confirms the views of Hunter, by means of air thrown from the divided vessels of the muscular walls of the uterus into the placenta itself. See Anatomy of the Placenta, by Jno. C. Dalton, M.D. * Medico-Chirurgical Transactions, vols. 34-36. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 251 and conveys arterial blood from this organ to the system of the fcetus. The student is sometimes apt to become confused when told that the vein contains arterial blood, and the arteries are the chan- nels through which is conveyed the impure or venous blood. But, it must be remembered that the nomenclature of the anatomist is not the nomenclature of the physiologist. The former designates every vessel an artery, without regard to its office or function, Which proceeds from the heart toward a given point, and applies, in the same way, the term vein to every vessel whose direction is toward the heart. The physiologist, on the contrary, considers an artery a vessel for the transmission of arterial blood; and a vein, the channel through which passes impure or venous blood. As the science of anatomy is much more ancient than that of physiology, and, as its nomenclature consequently enjoys the precedence, it is right that the distinction, to which we have just alluded, should not be forgotten. In addition to its three blood-vessels, the umbilical cord has a sheath composed of reflections from the amnion and chorion, and a pulpy gelatinous material, known as the gelatine of Wharton. As a general rule, the volume of the cord equals in thickness that of the small finger; but, sometimes, it will be much greater, and, again, it will be less than this size. When the volume is increased, it is usually due to an infiltration of fluid, and by no increase of size in the vessels themselves, although this latter circumstance has occasionally been observed. On the contrary, when the cord is very small or slender, it is because of the entire absence of this infiltration. The ordinary length of the umbilical cord is from fifteen to twenty inches, which is about the average length of the foetus at full term. But there are occasional exceptions. For example,, cases are recorded in which it exceeded in length five feet, and again it has measured not more than from four to six inches. In the former instance, although the length of the cord is actually far in excess of the normal or average standard, yet it may become comparatively shorter in con- sequence of being coiled around some portion of the foetus.* In * According to Dr. Weidemann, the funis was found twisted around the child 3379 times in 28,430 deliveries. In these 3379 instances, it was coiled around the neck 3230 times, and 149 times around other portions of the body. In the 3270 cases, 2546 consisted of a simple coil, while in 684 instances, there were several coils. As regards the causes of the coiling of the funis, it is related that in 1788 cases, occurring at the Marburg Midwifery Institution, the cord was, in 80 instances, less than 15 inches in length, and inl83 over 25 inches; in 54 cases, the liquor amnii was small in quantity; in 41 it was copious. In 165 the child weighed less than five pounds, and in 28 it exceeded eight pounds. Therefore, it is deduced, that among the causes tending to the occurrence may be mentioned a long funis, abun- dance of liquor amnii, and a small child. Among 2930 children born at Marburg, 132 were dead, and 251 were still-born. 252 the principles and practice of obstetrics. the latter case, in consequence of the extreme congenital shortness of the umbilical cord, there will be more or less hazard of its sudden rupture during the throes of labor in some portion of its extent, 01 of its being torn from the umbilicus, giving rise to serious, if not fatal, hemorrhage. If neither of these accidents should occur, there would still be danger of suddenly detaching the placenta from the uterus, or, if the adhesion be strong enough to resist the traction, the next evil in the order of sequence would possibly be inversion, or turning inside out of the uterus itself, a contingency full of dan- ger to the mother, as will be explained Avhen treating more par- ticularly of this form of uterine difficulty. You will sometimes recognise knotted cords, that is, there will be observed in the extent of the funis one or several knots, and these are more particularly noticed in cases in which the cord Fig. 47. exceeds its ordinary length. (Fig. 47.) It is supposed that this latter circumstance, together with the movements of the fcetus, predisposes to the formation of these knots. I have several times Of 725 born with coiled funis, 45 were dead, and 72 still-born. Among the 45 dead-born, in the 725 examples of coiling, in 18 only could the death be referred to this latter circumstance alone. From results derived from the Midwifery Institutions at Dresden, Gottingen, "Wurzburg, Berlin, and Marburg, it appears that of 13,720 new-born infants, 902 were born dead; while in 1217 instances of coiling of the funis, 31 children were born dead, whose death could be ascribed to that circumstance, giving a proportion of 1"39 to the codings, and 1*19 to the number born dead. Thus, as the sixteenth child among new-born children, in general, as well aa among those in which the cord is found twisted, is born dead; as the twelfth child among the new-born, in general, and the tenth among those around which the funis is coiled, is still-born; and, as in one chu\ \n forty only can this coiling be regarded as really the cause of death, it follows that this accident is not entitled to prominent consideration. [Monatsschrift fur Geburtskunde.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 253 met Avith them, but in no instance have I knoAvn them to interrupt the circulation between the mother and child. The placental extremity of the funis is usually attached to the central portion of the after-birth, although occasionally it will be found inserted near the edge or border of the organ. Cases are recorded in which it is alleged that the fcetal extremity of the cord, in lieu of entering the umbilicus of the child, was observed attached to the limbs, head, etc. But these instances do not come to us with the seal of good faith, and I should be strongly induced to doubt the statement unless in cases of extraordinary monstrosities. Is there Nervous Tissue in the Cord?—Does the umbilical cord possess any vestige of nervous tissue ? This is an extremely inte- resting question from the fact that it is now well known that both the vein and arteries, composing the cord, are capable of contrac- tion. An interesting paper on this subject, demonstrating that these vessels are really imbued with contractile power, was pub- lished some time since* by Prof. Simpson. In that paper, he does not admit the presence of nerves in the funis, but contents himself Avith the bare hypothesis that elementary nervous tissue may in some form exist in it. Scanzoni f says, " Isolated nerve branches from the plexus hepaticus for the vein, and from the plexus hypo- gastricus for the arteries, are described by Schott and Valentin, and, according to the latter observer, they extend three or four inches from the umbilicus, as is revealed by the microscope." Virchow, however, does not admit these views, because he has never suc- ceeded in detecting nerves in the umbilical cord at any period of its development. * Edinburgh Jour, of Med. Science, May, 1851, p. 494. \ Lehrbuch der Geburtshilfe, p. 104. LECTURE XVIII. Nutrition, a fundamental law of life—Objects of Nutrition ; Growth and Develop- ment—Development physiologically considered—Nutrition of Embryo; various Opinions concerning—Yolk Nutrition—Nutrition through Villous Tufts—Liquor Amnii; has it nutrient properties ?—Does it enter the System of the Foetus by Cutaneous Absorption or Deglutition?—The Placenta and Foetal Circulation— Adult Circulation; how it differs from that of the Fcetus—How is the Impure Blood, returned by the Umbilical Arteries, decarbonized in the Placenta?—Endos- mose Action—Albumen cannot pass by Endosmosis; Opinion of Mialhe—Albu- minose—Influence of Parent upon Progeny—Transmission of Hereditary Disease— Change in the Circulation as soon as Respiration is established—Puer Creruleus— Does the Fcetus Breathe in Utero?—Intra-uterine Respiration not Essential to Development or Life of Fcetus. Gentlemen—Nutrition, whether in the vegetable or animal king- dom, is one of the absolute and fundamental necessities of life ; to pursue the topic of development, through the process of nutrition, in the A'arious conditions and phases of animated nature, Avould prove, if not foreign to the purpose of these lectures, a most interesting inquiry. Such a discussion, however, would divert us from our present object, and we shall speak, therefore, simply of the arrangements instituted by nature for the nourishment of the human embryo, from the earhest moments of fecundation until the final accomplishment of intra-uterine existence. The Objects of Nutrition.—Nutrition has no single purpose; you are not to suppose that it is for the promotion of mere growth. If this were so, the result would be simply an aggregation of the primordial elements, without form or symmetry—the archi- tecture of the system would be defectiAre—that beautiful and perfect mechanism, composed, as it is, of multiplied tissues and organs, Avould fail to exist, and in lieu of all this there Avould be substituted a sort of anomalous mass, without order or arrangement. You see, therefore, that, besides growth, nutrition, in order that the great object of nature may be carried out, must subserve another most important purpose, viz. development. Development, in a physio- logical sense, may be said to be the proper adjustment or distribu- tion of growth matter for the formation of the various tissues and organs of the economy; so that, when growth and development have completed the structure of the various parts of the human system, it may then be said that nutrition has efficiently performed a portion of its work. It, however, has something more to do. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 255 The human system, like all living things, is constantly undergoing change—every hour that we five there is waste of structure—this waste, if not supplied by new matter—which can only be done through nutrition, will lead to disintegration and decay. In a Avord, it may be affirmed, that the object of nutrition is three-fold: 1. Growth; 2. Development; 3. Repair of waste. Beginning with the simple cell, the original nucleus, if I may so term it, of the embryo, we perceive, through the successive stages of growth and development, the transmutation of that compara- tively insignificant cell into a type of the most perfect organization, as is disclosed in the mechanism of man ! The subject of embryonic nutrition has called forth many con- flicting opinions; and even in our own day, with all the lights which science has furnished, there still exists more or less dis- crepancy among observers. There is one fact, however, not only full of interest, but well worthy of observation, and it is this—that, throughout the Avhole life of man, there is no period in which nutrition results in such rapid growth and development as during intra-uterine existence; and this is still more marked in the first half of foetal life. But Avhen nature is unchecked in her operations, this rapid development interferes in no way with the perfection of the work in Avhich she is engaged. In the brief period of nine months, the small cell, through successive increase and develop- ment, is converted into the full-groAvn foetus. What an extraordi- nary achievement, and how demonstrative of the power of Him, to whose infinite wisdom all things earthly are due! Modes of Nutrition.—In order to present the subject of foetal nutrition in the simplest possible form, and to convey to you Avhat I believe to be the accepted opinions, at the present day, on this subject, I shall briefly consider the ovum in three different aspects: 1. From the moment of fecundation until its arriA'al within the uterus ; 2. From its entrance into the uterus, until the formation of the placenta ; 3. From this latter period, until the completion of the ordinary term of utero-gestation. These, then, are three dis- tinct periods of development, each one requiring a supply of elements necessary for the nourishment and growth of the neAV being. From the period that the fecundated ovule becomes detached from the ovarian vesicle, until its entrance into the uterine cavity, it may be said to be dependent upon what is known as yolk nour- ishment. But this particular species of nourishment soon becomes exhausted in the case of the human embryo, so that when the latter is lodged within the caA-ity of the uterus, a fresh source is found necessary, wrhich is promptly provided, through the absorption of juices from the decidua by means of the villous tufts on the exte- rior of the chorion, to which allusion has already been made. This 256 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tuft nutrition is in more or less active exercise until the second month, when a new arrangement is made through the vascular connexions, which subsist between the embryo and utenis, as a consequence of the formation of the placenta and umbilical cord. Does the Liquor Amnii contain Nutrient Properties?—A very ancient doctrine touching the nutrition of the fcetus, and main- tained with much zeal, referred the source of nourishment to the liquor amnii; the adA'ocates of this opinion were divided into tAvo sects, as to the mode in Avhich the amniotic fluid entered the system of the fcetus, with the view of affording it the necessary nourish- ment. One declaring that it was through cutaneous absorption, the other through the act of deglutition. It is not improbable that the liquor amnii does in reality contribute a share, during the earlier periods of embryonic existence, to its nourishment; for it is well ascertained that it contains nutritious elements, such as albu- men, salts, etc. Nor is it beyond possibility that some portion of the amniotic fluid may be swallowed by the foetus. On the other hand, there are well-authenticated instances in which this fluid has been recognised in the stomach and intestines, in cases of acepha- lous children; and also where there existed, from malformation, no communication between the oesophagus and stomach. These latter facts, it has been alleged, strengthen the hypothesis of cutaneous absorption. But it is quite evident that the cutaneous absorption of the liquor amnii cannot be sustained by any such testimony. In the first place, even in acephalous children, the amniotic fluid may reach the stomach through the oesophagus ; and, secondly, in cases in which there is an occlusion of this tube, the liquid found in the stomach cannot be the amniotic, for the important reason that, if it be absorbed by the skin, it will commingle with the blood, and not be taken to the stomach. Whatever influence may be exercised by the liquor amnii in affording nourishment to the embryo, it must be admitted that this influence is confined to the earlier periods of embryonic life; for, as soon as the placenta is formed, all the wants of the foetus, as we shall see, are abundantly provided for through this vascular con- nexion. Nutrition by the Placenta.—The placenta, as you know, is com- posed of a maternal and foetal portion, each of these surfaces having its own particular order of vessels, through which a distinct circu- lation is carried on. The utero-placental vessels are engaged in the distribution of blood on the former, while the circulation on the latter is conducted by the vessels of the cord, viz., the two umbilical arteries and one umbilical vein. The blood is brought from the system of the parent, and circulated through the maternal or uterine surface of the placenta by the utero-placental arteries—it is conveyed back to the system of the mother by the utero-placental THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 257 veins. Prof. Goodsir has shoAvn, as already stated, that the uterine arteries proceed from the Avails of the uterus through the hyper- trophied decidua; and, during their progress through this layer of membrane, they take a sort of tortuous or serpentine direction, and hence they have been denominated the " curling arteries " of the uterus. These arteries convey the blood from the system of the mother into the cavernous structure of the placenta, and the blood is again returned to the general maternal circulation through the large veins, which have received the name of sinuses. Thus, you perceive, nature has abundantly provided the maternal surface of the placenta with blood from the system of the parent; but, as yet, you do not understand, in the absence of all continuity of canal betAveen the two orders of vessels on the fcetal and uterine portions of the after-birth, in what way the foetus is benefited by this supply of blood, or, in other words, how it finds passage to the fcetal system for the purpose of providing it with necessary nourish- ment. This, hoAvever, it will be our purpose to elucidate before Ave complete the present lecture. Aelult and Foetal Circulation.—Allow me noAV to call your attention to the foetal circulation. This circulation is marked by certain characteristic differences, which are not found in the case of the child or adult; and these differences are owing to the im- portant fact, that, in the fcetus, existence is a dependent one—it has no power of elaborating the blood essential for its maintenance— this is done by its parent. On the contrary, in the healthy, Avell- organized child, and in the adult, where life is independent, and the individual elaborates its OAvn blood, there is a peculiar arrangement in the mechanism of the vascular and pulmonary systems adapted to this condition of life. You will, perhaps, have a more accurate idea of Avhat I mean by a brief contrast betAveen the circulatory apparatus as it obtains in the adult and fcetus. In both, there is a great central organ—the heart; and in both, also, there are two orders of vessels, viz. arte- ries and veins. In the adult heart there are four cavities, two on the right side, and tAvo on the left. On the right side there are an auricle and ventricle, Avhich communicate with each other, and Avhich are intended for the reception of venous blood ; and on the left side there are also an auricle and ventricle, communicating with each other, and containing arterial blood. These four cavities com- municate with each other only through the auriculo-ventricular openings. Xow, then, let us turn, for the instant, to the arrangement in the foetal heart. Here, as in the adult, there are four cavities : two on the right and two on the left, communicating, as in the case of the adult, by means of the auriculo-A-entricular openings. But, in addition, in the foetal heart, the right auricle communicates with 17 258 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the left auricle, through a small opening known as the foramen ovale. The only difference, then, in the arrangement of the heart proper, as it presents itself in the adult and foetus is, that, besides the auriculo-ventricular openings, there is in the foetus the foramen ovale, which is the point of communication betAveen the right and left auricle. In the adult, the following is the route of the circulation—the A'eins return from the upper and lower extremities the blood which has been distributed throughout the system for the purpose of nourishment, but Avhich, in its round of circulation, has become less charged Avith oxygen, and contains more carbonic acid, and, therefore, is in need of renovation. The veins, I say, return this blood from the upper extremities to the descending vena cava, and from the lower to the ascending vena cava—these two vessels, the descending and ascending cava?, empty their contents into the right auricle of the heart; thence it passes, through the auriculo-ven- tricular opening, into the right ventricle; from the right ventricle, it is conveyed by the pulmonary artery, Avhich bifurcates into a right and left branch, into the lungs; and here, in consequence of the absorption of oxygen and the exhalation of carbonic acid, the venous blood is converted into arterial, Avhich is conveyed through the pulmonary veins to the left ventricle ; from the latter, it passes into the aorta, through the ramifications of which it is conducted to every portion of the economy, imparting sustenance to each tissue and organ.* As soon as it has completed its circuit, it again requires renovation, and for this purpose is returned to the lungs— and so the work of elaboration continues, in more or less perfection, from the first moment of independent existence until the final close of life. This, gentlemen, is briefly-the circulation in the adult or the child, whose life is independent of its mother. Let us now follow the course of the blood in the system of the foetus. Besides the peculiarities already pointed out in the circula- tory apparatus of the latter, there is the ductus arteriosus, which appears to be nothing more than an extension of the pulmonary artery, and which conveys all the blood, except the small quantity going to the lungs, from the right ventricle to the arch of the aorta. Then, there are the umbilical vein, and two umbilical arteries. The blood is conveyed from the placenta to the fcetus in the fol- lowing manner : The arterial or elaborated blood is carried by the umbilical vein, which enters the system of the foetus at the umbili- * Respiration consists essentially in the absorption of oxygen and the exhalation of carbonic acid; but this latter is not formed, as was once supposed, by the com- bination of carbon and oxygen in the lungs; a small amount of carbonic acid is pro- duced in the lungs by the decomposition of carbonates, but its chief formation takes place in the tissues—the muscles, nerve-centres, etc. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 259 cus. When this vein penetrates the umbilical opening, its course is at first from before backward, then from below upward, and from left to right. As soon as it reaches the inferior portion of the liver, it gives off a branch Avhich distributes blood to the right lobe of this viscus ; this same blood is aftenvards conveyed through the hepatic vein, and deposited in the ascending vena cava. In order that you may not be led into error, and with the view of avoiding all confusion, I beg you to remember that the instant the umbilical vein sends off the branch to the liver, it takes the name of ductus venosus. This latter vessel, then, is nothing more than the original umbilical vein, the name being changed as soon as it has parted with the branch, Avhose duty it is to carry blood to the right lobe of the liver. The ductus venosus throws its contents into the ascending vena cava; and you must bear in mind that the blood thus deposited in the ascending cava comes directly from the pla- centa, and is therefore pure, fitted to the nutrition of the fcetus. I have just mentioned that the hepatic vein also deposits its contents in the ascending cava. Hence, then, there are three columns of blood all commingling with each other: 1. The blood, which is derived through the ductus venosus directly from the placenta, and Avhich is pure ; 2. The blood, which has circulated through the li\Ter, and Avhich is returned to the cava by the hepatic vein ; 3. The blood Avhich is brought from the lower extremities, and ultimately deposited in the ascending cava; the latter column of blood is of course less pure than the other tAvo, for the reason that it has already been distributed to the loAver extremities. Well, this volume of blood, derived as you have just seen from three different sources, is conveyed by the ascending vena caAra into the right auricle of the heart. But the upper portion of the cava, as it enters the auricle, is, through the arrangement of the Eustachian valve, rendered almost continuous with the foramen ovale, so that the blood it conveys into the right auricle, instead of mingling with that brought by the descending cava into the same chamber of the heart, passes almost entirely through the foramen ovale into the left auricle. Thence, through the auriculo- ventruular opening, it is com^eyed to the left ventricle, and from this cavity it passes, through the aorta and its branches, to the head and upper extremities. The branches to Avhich I allude, originate at the arch of the aorta, and are the brachio-cephalic trunk, or arteria innominata, the left primitive carotid, and left subclavian. The blood, after being distributed through these channels to the upper parts of the body, suffers a diminution in its nutritive pro- perties, and, therefore, needs elaboration; hence, it is returned by the jugular and axillary veins to the subclavians, Avhich, together Avith the a/.ygos vein, empty their contents into the descending vena cava—this latter conveys it into the right auricle, from Avhich, 260 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. through the auriculo-ventricular opening, it passes into the right ventricle, and from this latter cavity it enters the pulmonary artery. The pulmonary artery conveys to the lungs, during foetal life, but a very small quantity of blood, only sufficient to supply them Avith nutriment, for the reason that they have no power of elaborating this fluid, as is the case in the lungs of the adult. Some provision, therefore, is needed by which the surplus blood from the right ventricle may be disposed of; for this purpose there is the ductus arteriosus, whose office it is to convey all the blood from the right ventricle, not passing to the lungs, to the arch of the aorta. This latter blood is then transmitted through the descend- ing aorta, and, with the exception of the portion of it which is distributed by the external iliacs and their branches to the lower extremities, is conveyed through the two umbilical arteries to the placenta, for the purpose of undergoing fresh renovation. The two umbilical vessels, you will not forget, are formed by the internal iliac or hypogastric arteries. Before calling your attention to the special arrangement in the placenta for the elaboration of the blood, returned to it by the umbilical arteries, I wish, for the moment, to allude briefly to one or two points connected with the route of the circulation in the foetus. You cannot have failed to notice, in the distribution of blood through the system of the latter, the important fact that, to a certain extent, the head and upper extremities are supplied with purer blood than the lower portions of the body. The head and superior extremities do in reality receive blood almost as pure as that which comes directly from the placenta, and for the reason that their development is required to be in advance of that of the lower portions of the system. For example, a part of the blood which is derived directly from the placenta passes through the ductus venosus into the ascending cava, thence into the right auricle, and through the foramen ovale into the left auricle—from this latter chamber it is sent to the left ventricle; from the left ventricle it is conveyed through the arterial branches given off at the arch of the aorta to the head and superior extremities. But you are to bear in mind that, as the blood passes from the left ventricle into the aorta, a small portion of it must, of necessity, descend and thus commingle with blood emptied into this channel by the ductus arteriosus, and which you will recollect is brought there from the right ventricle, after it has been returned from the upper portions of the body. The blood thus conveyed from the right ventricle, through the ductus arteriosus, to the arch of the aorta, has, through its circuit, lost more or less of its nutrient elements; but yet, you perceive, it receives a small supply of pure blood from the left ventricle in the descending aorta—and therefore, although it is true that the blood which circulates through the head THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 261 and upper extremities is purer, because a portion of it comes directly from the placenta, yet it must be recollected that the lower part of the body is not exclusively dependent for its supply upon the blood from the right ventricle—and which has already partly exhausted itself in its circulation to the head, etc.—but it also receives a column of pure blood from the left ventricle as it passes to the aorta. Elaboration of the Blood in the Placenta.—Next let us examine how it is that the impure blood, which is returned from the system of the foetus to the placenta through the umbilical arteries, receives a fresh supply of nutritious matter; or, in other words, how it is that its decarbonization is accomplished. One of the theories brought forth to elucidate this question Avas based on the supposi- tion, that the blood-vessels on the foetal and maternal surfaces of the placenta Avere continuous with each other ; and, on this assumption, it was maintained that the impure blood Avas conveyed directly from the fcetus to the system of the mother—thence to the mater- nal lungs, from which, after having lost its carbonic acid and receiving oxygen, it Avas returned to the placenta, Avhence, through the umbilical vein, it again made its circuit in the system of the fcetus. The deductions from this theory are utterly fallacious, for the assumption on which it is predicated, as I have already pointed out, is Avithout foundation. The vessels of the foetal and maternal surfaces of the placenta do not communicate Avith each other—they are distinct and independent, and so are their circulations. Hoav, then, you may very legitimately inquire, if the blood from the foetus be not returned to the circulation of the mother, does it become purified ? The answer to this question is quite easy, and it may be regarded as one among the accepted truths of physiology. During intra-uterine existence, the aeration or decarbonization of the blood is accomplished altogether in the placenta; and this organ may, in strict physiological meaning, be denominated the lungs of the foetus.* The following is the process of elaboration. The impure blood, as you are aware, is brought from the system of the foetus to the placenta, through the umbilical arteries; these arteries ramify, and communicate by continuity of canal Avith the radicules of the umbilical vein on the foetal surface of the placenta; although there is no direct communication between the vessels respectively, on the two placental surfaces, yet there is a con- tiguity ; and, in fact, these vessels may be said to be, as it were, in juxtaposition, so that the impure blood in the umbilical arteries becomes liberated of its carbonic acid, and is supplied with oxygen from the blood of the mother by an endosmotic action—that is, the * As regards the functions of the placenta, it must be remembered that this body is. at the same time, the representative of the digestive and respiratory organs of the adult. 262 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. oxygen percolating the walls of the canals, displaces the carbonic acid which passes into the maternal system through the same kind of endosmotic process; thus, you perceive, one of the first results produced upon the blood of the foetus is to afford an escape of its deleterious element, the carbon, which, in the form of carbonic acid, passes into the vessels of the mother, which it can do Avith impunity to her health. The parent, however, is not content with receiving into her OAvn system this element, no longer fitted to sojourn in that of her offspring; she does more—she transmits, through the same process of percolation, from her own blood, an element necessary for the continued sustenance of the fcetus. What is this element ? Some say that it is albumen, Avhich is knoAvn to be essential to foetal nutrition. But Mialhe has shown that pure albumen cannot pass through membranes, and he has deA'eloped the interesting fact, that it is a substance, called albuminose, Avhich has the power of per- colating membranous tissues ; it is this substance Avhich passes from the blood of the mother to the fcetus, and from Avhich the latter derives its nourishment. Robin and Verdeil have demonstrated that Avhat was supposed by Guillot, Le Blanc, and others, to be casein in the blood of pregnant Avomen and nurses, is essentially albuminose, which, after all, is strikingly similar to casein and kiesteine. As soon as these changes have been effected in the blood brought to the placenta by the umbilical arteries, the elaborated fluid is immediately taken up by the radicules of the umbilical vein, and again conveyed to the system of the foetus, and there distributed in the manner already indicated. In this simple but efficient way has nature provided, by the constant escape of deleterious, and the constant addition of nutritious matter, for the growth and develop- ment of the foetus. In addition to the office Avhich the placenta performs toAvard the fcetus, of giving albuminose in exchange for carbonic acid, it is supposed, by some observers—and the hypothesis is not without a degree of probability—that it also discharges, to a certain extent, the duty of an excreting organ, by removing, through the maternal blood, excrementitious material, which, if permitted to remain in the system of the foetus, would prove destructive to its existence.* With this supposition, it is easy to comprehend how the system of the mother may become contami- nated by disease derived from her husband; and how, also, this * Bernard has recently attempted to show, that there exists, in the placenta of the mammiferous class, a peculiar function, which heretofore has been unknown, and which appears to supply the glycogenic action of the liver during the earlier periods of embryonic existence. Indeed, he and Ch. Rouget have demonstrated that a gly- cogenic matter exists not only in the placenta and, amnion, but also in all the new cells in the various tissues of the embryo, especially in the epithelial cells. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 263 disease may be transmitted to offspring begotten by a different father.* Transmission of Disease.—The transmission of disease, from parent to offspring, presents a most interesting subject of inquiry to the practitioner of medicine. That this hereditary transmission is more or less constantly taking place, is a fact, unhappily, too well established, and it constitutes a veritable blight upon the race. Scrofula, syphilis, phthisis, carcinoma, etc., all of which I hold to be constitutional taints, may be transmitted either by the mother or father; and this will, of course, depend upon Avhether the former or latter be affected Avith the malady thus transmitted. For exam- ple, a scrofulous mother will pass the disease to her child, through the ovule which she furnishes—that very ovule being a part of her system—containing either the elements of health or disease, just precisely as the case may be. Again: all the soluble elements in the blood of the mother—salts, fibrin, etc.—pass freely into the blood of the foetus. Suppose, again, the mother be free from all taints of scrofula, syphilis, etc., yet, under these circumstances, either of these affections may be propagated by the father, should he have the misfortune to labor under the affliction of either of them, or of any other constitutional malady capable of transmission ; and it is propagated through the spermatozoa, which he emits during sexual intercourse, and which, as you know, are the true essential fecundating elements of the spermatic fluid, f From Avhat has been said of the placental circulation, it must be evident to you that Avhen the blood of the pregnant female is im- * Attention has lately been directed to a very curious class of phenomena, which show, that where the mother has previously borne offspring, the influence of the father may be impressed on her progeny afterward begotten by a different parent; as in the well-known case of the transmission of quagga marks to a succession of colts, both of whose parents were of the species horse, the mare having been one? impregnated by a quagga male; and in the not unfrequent occifrrence of a similar phenomenon in the human species, as when a widow who marries a second time, bears children strongly resembling her first husband. Some of these cases appear referable to the strong mental impression left by the first male parent upon the female: but there are others, which seem to render it more likely, that the blood of the female has imbibed from that of the foetus, through the placental circulation, some of the attributes which the latter has derived from its male parent; and that the female may communicate these, with those proper to herself, to the subsequent offspring of a different male parentage. This idea is borne out by a great number of important facts; and it serves to explain the circumstance well known to practi. tioners, that secondary syphilis will often appear in a female during gestation or after parturition, who has never had primary symptoms, while the father of the child shows no recent syphilitic disorder. For if he has communicated a syphilitic taint to the foetus, the mother may become inoculated with it through her offspring, in the manner just described. [Carpenter's Human Physiology, p. 781.] f The reader wdl find some interesting facts touching the transmission of disease to ihe foetus, in an able Report on the Influence of Marriage and Consanguinity apju Offspring, by S. M. Bemiss, M.D., 1858. 264 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. pure, either from the accumulation in it of bile, or any other poisonous matter, the foetus, which is nourished by that blood, must necessarily be exposed to more or less danger. There is another interesting feature connected with the condition of the blood during gestation, and it is this : It is not uncommon to find women, attacked with eclampsia or puerperal convulsions, bring forth dead children ; sometimes when the child is not destroyed, it will itself have convulsions immediately after birth. I have seen several remarkable cases of this kind. With the doctrine that conAulsions are oftentimes but the results of irritation upon the spinal cord, either through poisonous blood or some other influence, the explanation of the transmission of the convulsive movement to the fcetus is not difficult. The poisonous elements contained in the mother's blood are communicated to the embryo through the act of percolation, of Avhich I have spoken; and these elements will produce, costeris paribus, morbid effects in the latter, precisely similar to those observed in the system of the mother. Change in the Circulation after Birth.—As soon as the child is born, and after its very first inspiration, the whole current of the circulation, as it previously existed, becomes suddenly changed. The blood no longer passes to the placenta; on the contrary, it is transmitted in large quantities from the right ventri- cle to the lungs, and these organs are then called upon to perform active and uninterrupted duty, viz. the decarbonization of the venous blood ; in this way, it is converted into arterial blood, Avhich, through the pulmonary veins, is conveyed to the left chambers of the heart, and distributed to the entire system, as has already been described. The consequence of this change in the route of the blood is the reduction of the ductus venosus and ductus arteriosus to mere ligamentous matter, while the foramen ovale becomes closed, and ceases to afford an opening for the transmission of blood from the right to the left auricles, as was the case during foetal existence. But, occasionally, it will occur that, through imperfect develop- ment or other circumstances, the foramen ovale does not become obliterated, and the consequence will be more or less imperfection in the circulatory function, giving rise, among other phenomena, to a disease, known as puer caeruleus, or blue disease, so called from the circumstance of the defective passage of the blood. Such a result, however, from imperfect closure of the foramen ovale, is not universal, for it has been shown by Dr. J. W. Ogle, and others, that in many adults the foramen still exists, without occasioning any trouble. Does the Foetus Breathe and Cry in Utero ?—It is quite certain that the child cannot introduce air into its lungs if there be no air to be introduced; nor can it cry without the respiratory move ment. Under ordinary circumstances, the fcetus is deprived of the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 265 access of the atmosphere during its sojourn in utero, and, conse- quently, breathing and crying are out of the question. But there are some exceptional cases recorded on undoubted authority in which these phenomena have really been observed before birth, and they are explained in this way—the membranes having been torn, and the mouth of the child in communication with air, either in the vagina or at the neck of the womb, respiration and crying have ensued. It was the opinion of Geoffrey St. Hilaire that the fcetus absorbs air from the entire surface of its body, but a fundamental prerequisite for this theory is the presence of atmospheric air in utero. LECTURE XIX. Abortion—Its frequency—Loss occasioned by it to the Human Family—Dr. White- head's Statistics—The Various Divisions of Abortion—Viability of the Foetus— The Case of Fortunio Liceti—At what Period of Gestation is a Female most likely to Abort?—The Opinion of Madame La Chapelle—Not sustained by general Facts—Abortion more frequent in the Primipara—Why ?—Reflex Action —Whytt—Reid—Prochaska—Marshall Hall—Concentric and Eccentric Nervous Influence—What does it mean ?—Eccentric Causes of Abortion—Hemorrhoids, Strangury, Tenesmus, Sea-bathing, etc.—How do they Produce Abortion ?—Irrita- tion of the Mammae and Premature Action of the Uterus—Cause and Effect— How explained—Lactation, its influence on early Contractions of the Uterus— Centric Causes of Abortion—Anaemia and Abortion—Exsanguification and Con- vulsions—Experiments of Sir Charles Bell and Marshall Hall—Experiments and Deductions of Dr. E. Brown-Sequard—Mental Emotions, Syphilitic Taint, Death of the Fcetus, all Causes of Abortion—Disease of the Placenta and Abortion— Abortion sometimes the Result of Habit—Phenomena of Expulsion in Abortion —The Pain and Hemorrhage of Abortion—How distinguished—Treatment— How divided—The Application of Cold—Its Mode of Action in Arresting Hemorrhage—Tampon and Ergot—When to be Employed—Two-fold Action of Tampon.—Extracting Placenta in Abortion—Exhaustion from Hemorrhage— How Treated—Laudanum, its Efficacy in Exhaustion. Gentlemen—I shall to-day speak of an interesting affection, one which should claim at your hands special attention, for the double reason that it is, in the first place, frequent; and, secondly, it is apt, under certain circumstances, to involve the female in more or less danger—I mean abortion. There is an additional interest surrounding this subject, and it will be found in the extra- ordinary Avaste of fife it occasions through the destruction of fcetal existence. There can be no doubt that the loss to the human family from premature expulsion of the fecundated ovule is very great, and more particularly, when Ave take into account the numerous instances in which the loss cannot be positively ascer- tained ; such, for example, as in very early pregnancy, when the discharge of blood attending the miscarriage is oftentimes judged to be nothing more than a late return of the menstrual flow. Frequency of Abortion.—Dr. Whitehead,* in his work, gives, as the result of his observation in a certain number of cases, the following statistics: In 2000 married women, in a state of pregnancy, admitted into * Dr. Whitehead on Abortion and Sterility. THE PRINCIPLES AND PRACTICE OF OBSTETRICS*. 267 the Manchester Lying-in Hospital, he found their average age to be a fraction below 30 years. The sum of their pregnancies already terminated, Avas 8681, or 4.38 for each, of which rather less than one in seven had terminated abortively. But, as abortion occurs somewhat more frequently during the latter than in the first half of the child-bearing period, the real average will, conse- quently, be rather more than one in a dozen. Of these 2000 women, 1253 had not at the time of the inquiry suffered abortion. The average age of these was 28.62 years. The number of their pregnancies 3906, or 3.11 for each person. The remaining 747 had already aborted once, at least; some oftener. Their average age was 32.08 years. The sum of their pregnancies was 4775 or 6.37 ; that of their abortions, 1222, or 1.63 for each person. From these statistics, it would appear that more than 37 out of 100 mothers abort before they attain the age of 30 years; but as 30 years may be considered comparatively young for the child- bearing woman, it is estimated that abortion occurs in nearly 90 per cent, of those females, who continue in matrimony until the final cessation of the catamenia. This is sufficient, gentlemen, to show you that abortion is by no means of rare occurrence; and the very circumstance of its frequency should impress upon you the importance, as well as the necessity, of thoroughly compre- hending its nature and management.* Divisions of Abortion.—You will find in the books various divisions of this subject; for example, one Avill tell you if the ovum be expelled from the uterus, prior to the third month, it is a mis- carriage ; if between the third, and end of the sixth month, it is an abortion; and between the seventh, and before the expiration of the ninth month, it is premature labor. Again : a recent author, Guillemot, divides the subject as follows: 1. Before the 20th day, he calls it ovular abortion ; 2. If before the third month, embryo- nic ; 3. From the third to the sixth month, foetal abortion. And so I might pursue the subject, arraying before you the multitude of divisions and subdivisions, not forgetting one of the most ancient of all, viz. if the ovule be expelled before the tenth day, it was denominated simply an effluxion. But we shall leave these refined minutiae for those who like them, and give you what Ave think to be more in accordance with practical observation. We shall, therefore, consider the expulsion of the fecundated ovule from the uterus at any period from conception before the termination of the sixth month—an abortion, and from the seventh month, prior to the expiration of the ninth month, premature labor. This division is- founded upon Avhat I conceive to be a rational basis. * In 41,699 deliveries, there were 530 premature births, or 1 in 78^.(Churchill, 4th London Edition, p. 167.) 268 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. It is now generally admitted that the fcetus is incapable of independent existence—in the event of its being throAvn from the uterus—previous to the termination of the sixth month ; so that the law of France on this subject, and I maintain that it is a just law—although it will, undoubtedly, oftentimes afford a mantle to conceal guilt—is, that a child born 180 days after Avedlock, shall be considered not only viable, but legitimate, and entitled to all its legal and social rights. At the same time, it must be remarked, that, under peculiar circumstances of constitutional development, it is possible for a child born previous to this period to live, but the chance is so slight, that the law—wisely, I think—makes no recog- nition of it. I shall not enumerate the instances recorded by authors of extraordinary precocious viability—they do not carry with them that weight of testimony necessary to substantiate them as accepted truths. One of the most remarkable, however, may be briefly alluded to ; it is the case of Fortunio Liceti, men- tioned by Van Swieten. He was brought into the Avorld before the sixth month in consequence of a fright his mother experienced at sea; when born, he Avas the size of a hand, and he was put into an oven by his father, for the purpose, no doubt, of making him rise. Fortunio, we are told, attained his seventy-ninth year.* The period'of Pregnancy at which Abortion is most frequent. —There seems to be no little difference of opinion among writers as to the particular period of gestation at which the female is most likely to abort. A good observer, and a clever Avoman, Madame La Chapelle, announced, as the result of her experience in the Maternite of Paris, that abortions Avere more frequent at the sixth month than at any other time. Now, it must be recollected that Madame La Chapelle exercised a remarkable influence as a writer. Her statements were regarded with much favor, and, therefore, it can readily be conceived why it was that the opinion advanced by her on this question should have been so generally adopted by her contemporaries, and perpetuated by those who have succeeded her. It is not improbable that Madame La Chapelle was quite right, so far as the experience of the Maternite enabled her to decide * October 10, 1842, I requested two of my pupils, Drs. Arendell and Morris, to attend during her labor Mrs. H., who was one of my clinic patients, and whom I had previously attended in three confinements. A few hours after the gentlemen reached her house, she was delivered of a female infant, which weighed two pounds nine ounces; the surface of its body was of a scarlet hue; and there was every indication of its being premature. It breathed, and in a short time after its birth cried freely. I ordered it to be wrapped in soft cotton well lubricated with warm sweet oil. It was nourished with the mother's milk, by having a few drops at a time put into its mouth. At first it labored under great difficulty in swallowing ; but gradually it succeeded in taking sufficient to nourish it, and it is now a vigorous, wealthy young woman. Independently of the evidence afforded by the physical appearance of this infant, I am satisfied, from other circumstances, that the mothei could not have completed her sixth month of pregnancy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 269 this point. But that experience is not sufficient to establish the general fact, and for the obvious reason that women, in a state of pregnancy, are not, as a general rule, admitted into the Maternite in the earlier months of their gestation ; so that Avhile it may be true the records of that establishment do shoAV that the period at Avhich Avomen most frequently abort is about the sixth month, yet these statistics, admitting their entire accuracy, are very far from proving the major proposition—that pregnant women are more liable to suffer abortion at the sixth month. Indeed, all correct observation is, in my judgment, directly adverse to the fact; and I think the results of practice will very conclusively exhibit that, ceteris paribus, abortion is most frequent during the earlier months, say from the first to the third; and the reason for this is no doubt founded on the important circum- stance that, at this early period, the attachments of the embryo to the uterine surface are comparatively so friable, that they are more liable to be broken up, thus ending in the premature expulsion of the product of conception. I also think that the primipara is more disposed to abortion than the female who has already borne several children. In the former, the uterus, for the first time becoming the seat of those rapid and extraordinary changes consequent upon impregnation, will be more likely to aAvaken, through reflex or other influences, irritation calculated to terminate in abortion ; and this is particularly observed in two classes of patients, presenting tAvo opposite conditions of system, viz., 1. In the excessively nervous; 2. In those characterized by unusual plethora. Causes—Abortion sometimes occasioned by Reflex Movement.— The great fact that irritation of the spinal cord may be induced by the excitor nerves, had undoubtedly been demonstrated by Whytt, Redi, Prochaska, and others; but it must be conceded that, Avith- out the practical application made by Marshall Hall of this impor- tant physiological truth, its benefit to science would have been extremely restricted. To him, therefore, is due the merit of having faithfully and perseveringly insisted not only upon its value, but its indispensable necessity for the accurate diagnosis and treatment of disease. Previously to the discovery of reflex movement, it Avas supposed that all nervous aberrations producing irritation of the spinal cord, Avere centric, or in other words, the result of an influence applied directly to the cord; but now that the action of the incident excitor nerves is understood, Ave have another division of nervous disturbance, viz. eccentric, in which an irritation is produced on the peripheral or terminal extremity of one or more nerves ; the impression thus made is conveyed by the nervous trunks to the spinal cord and the medulla oblongata by which, and without the interference of mind, an impulse is reflected back, 270 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. through the motor nerves, to certain muscles, and hence a move- ment is produced. This is physiologically—reflex movement. I have purposely called your attention, incidentally at the present time, to this subject, in order that you may have a clear understanding of the true modus operandi, through reflex influence, of certain causes in the production of abortion. For example, it is not difficult to comprehend Avhy it is that hemorrhoids, a collec- tion of faecal matter in the rectum, irritation of the vagina, etc., will be likely to proA'oke early action of the uterus. Among the causes of abortion, from excito-motory influence, may also be mentioned excessive sexual intercourse in the neAvly married. A calculus in the bladder, or strangury produced by the absorption of cantharides from a blister, as also the tenesmus of dysentery, may be enumerated among the causes of abortion; all these influ- ences act upon the same principle, by reflex movement, bringing into play the excito-motory system of nerves. I have known a lady miscarry from bathing in the ocean. Is it difficult to explain the relation of cause and effect between the cold bath and abortion? It is but another illustration of reflex influence. It is Avell known, as Marshall Hall observes, that cattle made suddenly to ford a creek, Avill, almost as soon as they feel the impression of the chilled water, evacuate both the bladder and rectum. These, gentlemen, are important facts; and I might proceed to illustrate this great principle of reflex action as one of the causes more or'less constantly at work in the production of abortion. Why is it that a piece of ice put into the vagina will often arrest fearful flooding? Why is it that titillating the mouth of the uterus Avith the finger will frequently arouse this organ from a state of inertia to one of positive contraction ? In the operation of turning, soon after the hand has passed into the uterus, the accoucheur will experience the most painful sensation, this being the result simply of the firm grasp of the cervix uteri around his wrist. You have had cases before you, in the clinic, of women, soon after parturition, experiencing severe pain in the uterus from the application of the infant to the breast. This is nothing more than another example of reflex influence ; and so true is this connexion betAveen the uterus and mammae, that Scanzoni has recommended suction of the breasts for the purpose of bringing on contraction of the uterus in cases in AA'hich, from justifiable motives, it becomes desirable to induce premature delivery. Lactation itself is an active, but, I think, not a sufficiently recog nised cause of abortion; and it is important, therefore, for this as well as for other reasons, to direct a female, engaged in suckling her infant, who may suspect herself to be pregnant, to wean her child. This advice, if followed, will oftentimes insure her the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. '271 completion of her gestation. The well-known sympathy existing betAveen the mammae and uterus will, I think, in part explain why a nursing Avoman is liable to abort; the traction of the child's mouth on the nipple being oftentimes an excitor of uterine action. Dr. Barnes* has written an able paper on this subject, and has shown that in a given number of instances, abortion occurred in 17 per cent, of cases in which the female became fecundated during lacta- tion, and in only 10 per cent, when impregnation occurred at other times. Women will occasionally abort from the extraction of a tooth; in this case, the particular pair of nerves more immediately connected Avith this result is the fifth, or, as it is called, the trifacial. Diseases of the cervix uteri, such as ulceration, hypertrophy, indura- tion, etc., also deserve to be ranked among the influences occasion- ing premature action of the uterus ; and these, too, produce their effect upon the principle of reflex movement. The important deduction I wish you to make from what has just been said in reference to this particular class of causes of abortion is, in all instances, to exercise a due degree of vigilance by endea- voring to ascertain in a given case the particular influence, Avhich may be in operation at the time, and, by successfully removing it, render to your patient a substantial service, as far as may be. Centric Causes of Abortion.—There is, however, another dis- tinct class of causes, capable of inducing premature contraction of the uterus; and they differ from those already named in the impor- tant particular that they are centric, that is, their influence is exercised primarily on the medulla spinalis itself, and not secondarily, as is the case in the operation of the eccentric causes, which you knoAv is through a reflected, and not a direct action. To illustrate: suppose a pregnant Avoman receives a blow on the spine, folloAved by abortion. Here, then, is an example of a centric cause, for the reason, that its primary influence is upon that great nervous centre —the medulla spinalis. A bloodless or anaemic condition of system is not an unusual cause of abortion ; and this should explain to you why it is that women who have suffered excessive depletion, either from the lancet, or as the consequence of a long-continued drain, will be exposed to miscarriage. But you may desire to know what connection there is between abortion and anaemia. It has been shown that when an animal is bled to death its dissolution is pre- ceded by convulsions. Sir Charles Bell and Marshall Hall both maintained that, in such cases, the convulsions are the result of loss of blood sustained by the spinal cord. It remained, however, for that eminent physiologist, Dr. E. Brown-Sequard,f to demon- strate by numerous experiments that the convulsions, in these cases, * London Lancet for 1852. f Experimental Researches applied to Physiology and Pathology. 1853. p. 117. 272 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. are not due to the anaemic condition of the cord, but to the increase of carbonic acid in the blood, Avhich is proportionate to the insufficiency of the respiratory movement—the carbonic acid, under these circumstances, becomes an excitant to the cord, and is the true cause of the convulsions. The same observer has also shown that carbonic acid is an excitor of the muscular system, and, in this way, is to be explained the relation of cause and effect between a bloodless condition of the economy and contractions of the uterus. Albuminuria in pregnant women is often the cause of abortion (Rayer, Martin, Solon, Cahen), of premature parturition (Rayer), or of the death of the child (Cahen). Braun says, in one-fourth of the cases of albuminuria during pregnancy, there is abortion or premature labor. Mental emotions, Avhether fright, anger, depres- sion, sudden and excessive joy, etc., are all so many circumstances capable of giving rise to abortion; and the influence of these may be said to be through centric action. Other Causes of Abortion.—A prominent and quite common cause of premature action of the gravid uterus, is a hyperaemic or plethoric condition. This organ may be congested, as a conse- quence of the general vascular state of the system; or it may be the result of some special local influence. For example : malposi- tions of the uterus, or any other abnormal condition, inducing an obstruction to the free circulation of the blood; the abuse of emmenagogue medicines; inflammation, either of the external genitalia, or of the organ itself. The syphilitic taint and the abuse of mercury are also to be enumerated among the causes of abortion. Syphilis may be transmitted from the mother to the child in utero ; or, it may be derived from the father, through the fecun- dating liquor. In either case, abortion may occur in one of two ways. In the first place, from the death of the embryo; or, secondly, it may be occasioned by disease of the placenta, terminating in its early detachment, and consequent expulsion of the ovum. Small- pox may produce abortion, and in one or other of the modes just explained. Death of the fcetus, no matter how produced, is to be regarded as one of the most certain of all the causes of abortion ; and with a moment's thought you will perceive how fortunate this provision is ; for the continued sojourn of the embryo in utero, after its death, would necessarily involve, through its decomposition, the safety of the mother, and hence the necessity for its early ejection. You can readily understand the connection between abortion and disease of the placenta. This latter organ is called upon to perform a most necessary office; and even its partial separation cannot occur Avithout exposing the embryo to serious hazard. Tho maladies to which the after-birth is liable are various; sometimes, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 273 it Avill become indurated; at other times, it will pass to a state of hypertrophy or atrophy; occasionally, it will become the seat of calcareous formations, hydatid developments, unusual fatty dege- neration, etc. ; it may also be invaded by inflammation, or over- Avhelmed by an afflux of blood, constituting Avhat has been so well described by Cruveilhier as placental apoplexy. \ Habitual Abortion.—It is an interesting fact, that some women abort several times successively, and this is called the abortion of habit. A knowledge of this fact inculcates, in the first place, the necessity of the practitioner enjoining on his patient, in her first preg- nancy, the great necessity of avoiding all those causes which are known to favor a premature expulsion of the ovum; and secondly, in the event of a miscarriage, to exercise more than ordinary vigilance in the subsequent pregnancies; and what I have found an excellent expedient in such cases is—as soon as gestation takes place, to interdict sexual intercourse until after the fifth month, for if the pregnancy pass beyond this period the chances of abor- tion will, I think, be much diminished. These cases of habitual abortion are oftentimes exceedingly difficult to manage, simply for the reason that sufficient care is not exercised in ascertaining the true source of the difficulty. It is a fact, fully indorsed by all sound experience, that abortion is A'ery apt to be followed by chronic affections of the uterine organs, such as displacements, or enlargements, and these are frequently the true cause of the early expulsion of the ovum. In such instances,, the obvious indication is, through appropriate treatment, to remedy the displacement, and subdue the enlargement. If it be apparent, that the source of the trouble is plethora, the remedy Avill be the diminution of that state by judicious depletion, together with saline cathartics, and restricted diet; and here, if there be an absence of nausea—one of the ordinary and important phenomena of gestation—give tolerant doses of ipecacuanha, say from one- sixth to one-fourth of a grain every two or three hours, for the purpose of exciting action of the stomach. The reason for this latter treatment has been explained in a previous lecture. It is essential that the patients avoid all excitement, either mental or physical; and it is a rule with me to enjoin more or less quiet in the recumbent position until the expiration of the fifth month. I need scarcely remark that if the cause of the abortion be traced to excessive nervous irritability, this condition must be allayed by timely recourse to anti-spasmodics and anodynes; at the same time, the general health should be improved by tonics and appropriate diet. Dr. Tanner speaks highly, in these cases, of assafcetida.* * One of the best agents with which I am acquainted in the troublesome cases of repeated miscarriage, occurring in weak and irritable women, in whom there is an absence of vascular congestion and any specific disease, is assafcetida. The dose 18 274 THE PRINCIPLES AND PRACTICE OF OBSTETRICS", Whatever may be the particular cause of the abortion, the phenomena connected Avith the expulsion of the ovum resemble more or less closely those of an ordinary labor. The expulsive force is the same, viz., the contractions of the uterus. As a general rule, unless the membranes should be ruptured by the rude mani- pulations of the accoucheur, previously to the expiration of the third month the ovum is usually expelled entire with its envelopes. Symptoms of Abortion.—They may be embraced in the tAvo terms pain and hemorrhage. When a female is threatened Avith premature expulsion of the embryo, these tAvo phenomena—pain and hemorrhage*—will almost always, to a greater or less extent, be present. Diagnosis.—The diagnosis of a threatened abortion needs some little attention. In the first place, a pregnant Avoman may suppose herself menaced Avith abortion, simply because she has pain. But this is not sufficient —the pain of abortion, like the pain of labor, is peculiar—it is recurrent, paroxysmal, marked by distinct inter- vals, and centring toward the loins and hypogastric region. It is, in a word, nothing more than the contractions of the uterus, either masked or fully developed, and which, you knoAv, are not conti- nuous, but intermittent, when engaged in the expulsion of the ovum, whether at full term or at an earlier period. The pain, Avhich the female may mistake for labor pain, may result from colic, indigestion, or various other circumstances, which have no possible connection with any specific action of the uterus. You see, therefore, it will be for you to determine as to the character of the pain, and Avhether it portend danger to the mother and embryo, or whether it be transitory, and will yield to the adminis- tration of appropriate remedies. So far, then, as either the pain or hemorrhage is concerned, it is incumbent to ascertain, in the first place, whether they really proceed from the uterus; and, secondly, if so, does the uterus contain an ovum, or, in other words, is the woman pregnant ? The blood, although derived from the uterus, may not positively indicate an abortion, and so likeA\ise with the pain, for both of these phenomena may exist without gestation. For example: they may be the result of a polypoid growth, of carcinoma, &c.; the bleeding and pain may be altogether unassociated with the uterus itself, and may proceed which I usually administer is about five grains of the extract every night at bed- time, and I generally take care that the patient shall have had from three to five drachms before arriving at that period of her pregnancy at which she has formerly aborted. [Signs and Diseases of Pregnancy. By Thomas Hawkes Tanner, M.D., F.L.S., p. 257.] * The bleeding in early gestation may arise from several circumstances—such as- rupture of the vessels connecting the ovum to the uterus; or there may be a giving way of the serpentine vessels, which distribute themselves in the uterine walls, and which then pour their contents into the cavity of the organ. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 275 exclusively from some abnormal condition of the vagina. The distinction can be arrived at only by a thorough examination. Again : a pregnant Avoman, especially in the earlier months of her gestation, may have a discharge of blood through the vagina Avithout being at all threatened Avith a miscarriage. This discharge may be nothing more than menstruation, which, you are aAvare, sometimes occurs in pregnancy, several examples of wdiich you have seen in the clinic. As a general principle, you will be enabled to distinguish menstruation from the hemorrhage of miscarriage, as folloAvs: 1. Its occurrence will usually accord with the men- strual periods previous to the pregnancy; 2. It is unconnected with any of the causes of miscarriage; 3. The patient is in good health ; 4. The flow is not profuse, lasting generally but two or three days; 5. The pain in menstruation precedes the flow, and usually ceases as soon as the discharge occurs; 6. In miscarriage, whether before or immediately after its completion, the os uteri is more or less dilated and softened; such is not the case in menstruation. Prognosis.—As a general rule, a favorable opinion may be expressed. The danger from losses of blood is much less in the earlier months, for the reason that the blood-vessels are less deve- loped ; it is rare to observe any serious puerperal complications folloAV an abortion—such as inflammation or fever. Treatment of Abortion.—Let us now consider how a mis- carriage is to be managed—a most important point both for the patient and practitioner. When summoned to a female, who supposes herself menaced Avith an abortion, the first and obvious duty of the accoucheur is to ascertain Avhether she be in fact menaced, or Avhether her fears are Avithout foundation. This, of necessity, will involve a just discrimination of her condition—if she have pain, whether it be the offspring of uterine effort; and, if there be discharge of blood, whether it be the result of premature action of the organ. If it be discovered that the patient is really threatened, his duty will be confined to the attainment of one of two objects—either the prevention of the miscarriage; or, if this cannot be accomplished, he must limit himself to those measures, which Avill the most efficiently enable him to conduct his patient safely through her trouble. With regard to the prevention of a threatened miscarriage, I Avish very emphatically to remark that it can often be accomplished, even when apparently there no longer exists any hope of attaining this desirable object; and you must allow me to impress upon you, not only the necessity, but the high moral obligation imposed on the practitioner, of employing, in the most faithful manner, those means best calculated to arrest the early action of the uterus. It is proper, at this time, to examine in Avhat these means consist. The prevention of a threatened miscarriage is not to be achieved 276 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. • by any act of empiricism—it is, on the contrary, to be accomplished, in the first place, by a rigid appreciation of all the circumstances by Avhich each individual case may be surrounded; and, secondly, by a proper adaptation of remedies to the peculiar condition of the system at the time. We will now imagine you are at the bedside of a pregnant female, who has both pain and a discharge of blood from the vagina, and that you have satisfactorily ascertained, through a care- fully instituted examination, that these tAvo phenomena are posi- tively connected with a threatened miscarriage—what is the first thing to be done? Certainly not, for the mere sake of appearing to do something, to be urged on to precipitate and unprofitable interference ; but the judicious physician Avill take a survey of the condition of his patient, for the purpose of ascertaining some of the following points: Is she laboring under marked plethora? Is she of an extremely nervous temperament ? Has she been exposed to any sudden emotion, such as fright, anger, or depression of spirits ? Has she experienced violence from a blow or fall ? Has she been subject to previous abortions ? These are some of the principal inquiries, which a vigilant practitioner would naturally institute in his own mind. You must remember that, in the management of a miscarriage, no matter wdiat may be the cause which has determined it, absolute rest must be enjoined. This is a sine qud non to the success of the remedies to Avhich you will necessarily be obliged to resort. The patient should be placed in a recumbent position with her hips slightly elevated. Acidulated drinks, such as lemonade, may be given, or a capital compound under these circumstances will be the infusion of roses Avith dilute sulphuric acid, say f. f viij. of the for- mer to f. 3 ij. of the latter—a tablespoonful every half hour. The room should be cool, and the covering light. The acetate of lead and opium may be resorted to, either in solution or pill, and often- times with much benefit, under either of the following formu- laries : Acetat. plumbi, 3ij. Aquae destillat. f. § vj. Tinct. opii, f. 3 ij. Ft. sol. A tablespoonful every third hour. Acetat. plumbi, gr. xxx. Pulv. opii, gr. iij. Divide in pil. xij. One pill every two or three-hours. A most important adjuvant, under these circumstances, will be the application of cold, by means of cloths wrung out of ice-water, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 277 and applied to the sacrum, around the loins, and to the vulva itself. Cold, remember, is the most powerful and efficient agent to pro- duce directly and locally—and indirectly at a distance, by a reflex action—contraction of the blood-vessels. It excites contraction of the blood-vessels of the uterus much more readily than it affects the muscular tissue of that organ ; in this way, it will arrest the hemorrhage, and also cause a diminution of the congestion, which is an excitant to uterine action. Another valuable remedy is bel- ladonna. It is well known that it exercises a marked influence on the blood-vessels of the uterus, as upon those of the iris, intestines, etc., causing them to contract, and consequently relieving them of their congested condition. I have repeatedly had recourse to sup- positories of the extract introduced either into the vagina or rec- tum—the latter is preferable, for the blood will be apt to remove the suppository from the vagina—and I can very confidently com- mend it to your attention, as oftentimes one of the most effectual means of arresting a menaced abortion. Suppose, noAV, that your patient is plethoric, Avith more or less febrile excitement; what in this case should be done, especially if there be a hope of preventing the expulsion of the ovum ? Why, obviously to reduce the plethora, which you Avill find not an uncom- mon predisposing cause of abortion. For this purpose, general blood-letting is the great agent.' I much prefer it, under these circumstances, to local depletion. The quantity to be taken must depend upon the sound judgment of the practitioner. Tavo, four, six, or nine ounces may be abstracted, and repeated as events may suggest. It is well to bear in mind that, in these cases, the draw- ing of blood is not for the purpose of combating an active inflam- mation seated in an important organ, but the object is simply to diminish the momentum, if I may so term it, of fhe circulation, and thus protect the uterus from the afflux setting toward it. In addition to the abstraction of blood, give ten grains of nitrat. potassae in a tumbler of Avater, with vj. gtt. of tinct. digitalis. Let this be repeated every four or six hours, together Avith abste- mious diet. It may, however, be that your patient is not laboring under plethora, but she is of an extremely nervous temperament. What in this case is indicated ? Certainly not the abstraction of blood, for this would only tend to aggravate the nervous irritability; but on the contrary, the employment of such remedies as Avill calm and fortify the system, such as the various antispasmodics, ner- vines, etc. In these instances, I have experienced much benefit from the injection into the rectum of thirty drops of laudanum to a Avine-glass and a half of water; lubricating the os tincae and vagina with the ungt. belladon. (3j. extract belladon. to 3J of adeps), and the introduction of opium suppositories into the 278 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. rectum. Internally, a table-spoonful of the following mixture may be given every half hour, until the object be attained: Syrup, papav. f. 3 iv. Mucil. acac. f. § iij. Sol. sulph. morphiae (Majendie) gtt. xx. Ft. mist. In all cases of threatened abortion, the attention of the practi- tioner should invariably be directed to the condition of the rectum ; for it will not unfrequently happen that a collection of faecal mat- ter in this intestine is the starting point—the original exciting cause of the difficulty. If this should be so, the first thing to be done is to evacuate the boAvels by means of an enema. It may, on the contrary, be that the patient is affected with hemorrhoids. If these be external, they should be carefully introduced within the rectum so that they may be relieved from the constriction of the external sphincter. The removal of the hemorrhoidal tumors, under the circumstances, cannot for a moment be thought of, for the operation itself would almost certainly provoke the contraction of the uterus. As I have mentioned to you, in a preceding lecture, the preg- nant female is to be sedulously guarded against torpor of the boAvels, and this direction, too, is especially applicable in cases of threatened abortion. Epsom salts in small quantity, a seidlitz poAvder, manna, the compound rhubarb pill, are all Avell adapted to this end. . Allow me to make one remark in reference to the impregnated uterus in the case of the primipara. You will find, as a general rule, that Avomen of an excessively nervous temperament, Avho may, in fact, be termed very impressionable, are more apt than others to miscarry in their first gestation, and the circumstance is readily explained. In primipara?, the uterus distends with less facility than in subsequent pregnancies; and in women of great nervous susceptibility, the very difficulty encountered in the dis- tension of the organ, frequently tends to premature action of the uterus, and the expulsion of the ovum. In such cases, even before the slightest manifestation of trouble, I have been in the habit of recommending to foment freely, but without using friction, the hypogastric region with Avarm sweet oil and laudanum. This, I am sure, will often prove an efficient remedy in these instances, and I can speak of it, from no limited success, with much confidence. But let us present to you another view of miscarriage. The treatment which we have thus very summarily suggested, is intended for the prevention of this trouble, when it is merely threatened. I shall now call your attention, for a moment, to those remedies indicated in cases in Avhich it becomes impossible to arrest the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 279 expulsion of the ovum, and in which, therefore, the duty of the practitioner will be limited to saving the life of the mother. The true danger to the mother in abortion is the fearful hemor- rhage, and examples are not few in which she has sunk from loss of blood. When, then, it becomes an ascertained fact that the mis- carriage cannot be controlled, the obvious duty of the practitioner is to promote, by judicious interposition, the termination of the delivery; and you are also to bear in mind, whenever the hemor- rhage is such as to endanger the safety of the mother, all regard for the embryo must be suspended ; no matter what may be the possible or probable chances of arresting the miscarriage, every consideration must yield to the higher claim of the parent. It is an extremely nice point always to determine when the hemorrhage is so profuse as to render it essential to induce the expulsion of the ovum, and, also, when it is certain that the abortion cannot be prevented. In some instances, it is true, this question may be decided Avithout trouble; when, for example, a portion of the ovum—which will sometimes happen—has been thrown off; and, again, if the ovum be distinctly felt protruding through the dilated os, it is unequivocal evidence that its expulsion cannot be controlled. As to the question of the amount of hemorrhage Avhich -will not only justify, but absolutely call for the prompt action of the accoucheur to promote the evacuation of the contents of the uterus—this, I repeat, is a question of judgment to be determined by the evidence Avhich may present itself at the time. Permit me, however, to make a single remark on this point. I have known women to lose immense quantities of blood in a tlrreatened abor- tion, and to be apparently moribund from exsanguification, and yet they have rallied, and gone on to the full term. These latter examples, however, are exceptions to the general rule. Well, when there is no longer any hope of restraining the abor- tion, or when the woman is flooding so profusely as to endanger her life, the mouth of the uterus Avill be in one of two conditions —it will be either sufficiently dilated to enable you to feel the ovum, or it will not be so dilated; and again, the ovum will also be in one of two conditions: it will either have partially extruded through the cervix, or it Avill still be within the cavity of the uterus. Now, let us examine each of these points. 1. Should the uterus be so far dilated as to permit the introduction of the finger, I should recommend you, by all means, gently to increase the dilata- tion—and this is readily accomplished by pressing the finger alter- nately foi'Avard and backAA^ard—this very motion of the finger evokes a strong reflex action, which oftentimes results in the prompt expulsion of the ovum. 2. If the os uteri have not undergone dilatation, and the hemorrhage so profuse as to occasion alarm for the mother, then the remedies to be employed are the follow- 280 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ing: 1. Cold; 2. The tampon; 3. The secale cornutum. Here, you perceive, the object is to bring on, as speedily and effi- ciently as possible, contractions of the uterus, for it is on the effi- cient contractions of this organ that you are to rely for the arrest of the hemorrhage. I have told you that, Avhen a miscarriage is merely threatened, and, therefore, it becomes the duty of the medical man to do all in his power to prevent it, the application of cold by means of cloths to the vulva, sacrum, and loins, is of great benefit, because of the contraction it produces in the blood-vessels of the uterus. There is noAV, however, profuse hemorrhage, plac- ing in more or less peril the safety of the woman ; and here, too, cold, properly resorted to, will prove one of the most positive remedies. If you dash cold water—it would be better if it Avere iced—upon the abdomen, you will oftentimes, in these cases, cause a prompt action of the uterus ; or a small piece of ice introduced into the vagina, will occasionally act like magic. In either instance, the uterus is made to contract in consequence of reflex action. The tampon is a valuable agent in this form of hemorrhage. It should consist of small pieces of fine sponge, or lint, which should be carefully introduced into the vagina, as far as the os uteri, until the passage is completely filled up. The whole is then to be kept in place by a compress and bandage. It may happen that the pressure of the tampon against the urethra, or neck of the bladder, Avill prevent the Aoav of urine; in this case, the catheter must be used. I would advise you not to allow the tampon to remain, at any one time, in the vagina for a longer period than four hours; it should be withdrawn at the end of this time, and replaced, if* found necessary, by another ; this is an important direction, for the long- continued use of the same one will be apt to occasion putrefaction of the fluids which necessarily, to a greater or less extent, saturate it. The tampon acts, if I may so say, in a two-fold capacity. In the first place, it arrests, for the time being, the hemorrhage; and, secondly, the irritation produced by it on the mouth of the uterus provokes contractions of the organ, and thereby facilitates the object in view. Another efficient remedy in these cases is ergot-^the secale cornu- tum / and it is efficient because of its action on both the blood- vessels and muscular tissue of the uterus. It is now admitted that this drug affects the vessels and muscular fibres of the organ on precisely the same principle; it acts upon the smooth fibres of the uterus : it acts also on the smooth fibres of the blood- vessels. It, therefore, is true that ergot arrests uterine hemorrhage in a two-fold manner: 1. By producing contraction of the blood- vessels ; 2. Contraction of the muscular structure of the organ. Ergot is not a stimulant of any portion of the nervous system, and may, therefore, be regarded the antagonist of strychnine. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 281 . I should not hesitate an instant, in any urgent case where the strength of the mother is giving way from the loss of blood, and the mouth of the uterus still undilated, to introduce with my index finger as a guide, a female catheter or bougie—I prefer the former— into the os uteri, and thus hasten the dilatation by promoting efficient contractions. Let us noAV suppose the ovum is partly protruding through the os uteri: in this case the proper practice is to terminate Avithout delay its expulsion, by introducing the finger, and making gentle tractions upon it. If, on the contrary, the ovum be still within the uterine cavity, and it be desirable, on account of the hemorrhage, to hasten its delivery, then the means already mentioned—cold, tampon, and the ergot—will be indicated; and what you will find a capital means in addition, for the purpose of promoting strong uterine effort, will be a drastic cathartic—say for example, a couple of aloetic and myrrh pills—or from one to two ounces of the com- pound tincture of aloes ; or if the case be urgent, requiring prompt contractions of the organ, a drastic enema may be administered. If abortion should occur before the expiration of the first three months of gestation, and the ovum come away piecemeal, the pla- centa -will sometimes be retained, giving rise to much uneasiness on the part of the patient, and causing no little embarrassment to the young practitioner. These are the cases in Avhich various con- trivances have been projected for the purpose of extracting the retained mass—such as the tenaculum, the small slender forceps, hooks, etc. These instruments are, in my judgment, not only unneces- sary but fraught Avith danger. The best extractor is the finger. Let it be carefully introduced within the cavity of the uterus, and by skilful manipulation, with the other hand placed upon the abdomen depressing the fundus of the Avomb, the remaining portion of the ovum can, generally, without difficulty be removed. At a later period the uterus Avill be large enough to admit the introduction of the hand, and in this way the after-birth may be extracted. It is a curious and interesting fact that the retained placenta in cases of abortion does not, as at the full period of gestation, undergo decomposition, and, therefore, if it cannot be readily secured, should cause no disquietude. It will often pass off spontaneously, even after all efforts to remove it have proved unavailing. The patient, after an abortion, should, as in an ordinary labor at term, be kept quiet, and preserve the recumbent position. Her diet should be light, the bowels soluble, and all excitement avoided. In the event of alarming prostration from loss of blood, there is no remedy more efficient in bringing on reaction than tea-spoonful doses of laudanum and brandy in a Avineglass of strong coffee, every ten, tAventy, or thirty minutes, according to the requirements of the case. Be not afraid of this remedy, it is the sheet-anchor 282 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of hope in cases in which the patient is almost sinking from exhaus- tion consequent upon profuse hemorrhage. But, of all things to be remembered, see that the uterus is Avell contracted, and not in a state of inertia, for it Avould be the essence of folly to attempt to control the exhaustion AA'hile the Avaste gate is still open. In abor- tion, as in delivery at full term, flooding is ahvays one of the results of inertia of the uterus. In all cases of abortion, an important direction for you to bear in mind, is to examine carefully any clot or substance which may be thrown off from the uterus; and this rule should be observed from the very commencement of the discharge. The object of the examination is to be assured whether the embryo has been expelled; and this necessarily suggests the discussion of the question of moles, or, if you prefer it, molar pregnancy, to Avhich subject the succeed- ing lecture Avill be devoted. In conclusion, I Avould remind you that you will sometimes meet Avith cases in which there is more or less oozing of blood after the entire expulsion of the ovum; and this will ordinarily occur in Avomen of a leuco-phlegmatic tempera- ment, Avith a flaccid, muscular fibre; the hemorrhage in these instances is almost always of a passive type, constituting what may be termed passive or atonic metrorrhagia. When called upon to treat a case of this kind, you Avill recognise great benefit from the injection, night and morning, into the rectum of a half pint of water, cold from the pump, together with the internal administra- tion three times a day, as may be indicated, off. 3 j. of the tincture of ergot in half a Avineglass of cold water. t LECTURE XX. Moles—Importance of the Subject—Moles variously Classified—Mauriceau's Defini- tion—The Opinion of Fernel—Practical Division of Moles—The True Mole always a Proof of Previous Gestation—Distinction between True and False Mole first made by Cruveilhier—Mettenheimer and Paget on True Mole—Dr. Graily Hewitt —Case in Illustration of a True Mole—Can a Married Woman, if separated from her Husband since the Birth of her Child, or can a Widow, Discharge a True Mole from the Uterus consistently with her Fidelity?—False Moles, what are they?—Substances expelled from the Womb of the Young Virgin—Fibrinous Clots—The Membrane of Congestive Dysmenorrhoea—The Hen lays an Egg without the Tread of the Cock—Does the Membrana Decidua pass off at each Menstrual Period, or is it simply the Epithelial Covering?—The Testimony of Lamsweerde, Ruysch, and Van Swieten as to the False Mole—The True Hyda- tids—Can they be produced in the Virgin Uterus ?—The Case cited by Rokitan- sky—Importance of the Question—How are the True Hydatids to be distin- guished from the Hydatiform Vesicle ? Gentlemen—In the course of your practice you will observe, more or less frequently, examples of anomalous substances thrown from the uterus, and this, too, both in the married and unmarried ; hence you at once perceive hoAV much will necessarily depend upon the sound judgment of the physician in order that character may not be unjustly assailed, or wantonly destroyed. These substances have been differently named and classified ; and there has existed no little discrepancy of opinion as to the particular cause of their origin. In a question so vitally important as is the one now before us, it ippears to me there is great want of accuracy in the arrangement and description, Avhich the older authors have given of the various matters discharged from the womb; and this want of definite arrangement will, I think, account for the marked conflict of opi- nion entertained as to the true source of these expelled masses. One of the great masters of obstetric science is constantly quoted in proof of the alleged fact, that when a female expels from her uterus a substance—knoAvn under the vague name of mole—she could only have done so in consequence of intercourse with the other sex. I allude to the learned Mauriceau, who, in one of his aphorisms,* says, " Les femmes n'engendrent jamais des moles, si elles n'ont use du ci 1 287 » n n << u 2 291 " " a u ii 1 293 ii a u " " 2 296 snn i< ii ii u ii n k 1 1 According to this table, the duration of pregnancy, dating from a single coitus, Avill average about 275 days; and Dr. Reid deduces the fact that, from a single coitus, the time will be 39 Aveeks, Avhile in calculating from the last catamenial turn it will be forty; and he accounts for this difference of time on the supposition that from two to six days will probably elapse after the last catamenial evacuation, before fecundation is consummated. Dr. Montgomery presents an analysis of twenty-five cases of gestation, dating from a single coitus, the average duration of the pregnancy being 274 days. Dr. Ma- thews Duncan, in an interesting paper on the subject, holds the average interval betAveen insemination and parturition, to be 275 * See Lecture XII. x London Lancet, 1S50-3. 20 306 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. days. This average he obtained from the observation of forty- six cases.* IV. From the Last Menstrual Period.—A very common mode of calculation, both among the profession and women themselves, is to take the last catamenial turn as the starting point. Some date from the last day of the menstrual evacuation, others from two weeks subsequently. In either of these modes of comput ation, there will necessarily be more or less Avant of precision. I think the fact is very generally conceded, that the most likely time for a female to become fecundated is immediately after a menstrual crisis; but, it is equally Avell established, that impregnation Avill occasionally occur just before the catamenial period, and sometimes during the menstrual flow, Avhile, on the other hand, it must not be forgotten that conception is possible at any time between the two menstrual turns, f It is very evident, that, this being the case, there will sometimes be a considerable discrepancy in time in the various conclusions attempted to be deduced. I have, for several years, adopted a rule Avhich, I believe, Avas originally suggested by the celebrated Naegele; Avith some exceptions, I have found it gene- rally quite reliable, and far more satisfactory in its results than any plan which has yet been proposed. Imagine, for example, the termination of the last menstrual period to be on the 10th day of January; then count back three months, which Avill correspond with the 10th day of October; now from the 10th of October, add seven days—this will bring you to the 17th day of October—the day on which the labor Avill commence. This, I repeat, has, accord- ing to my observation, proved a most satisfactory test; and I, therefore, commend it to you with much confidence. According to this mode of computation, the short and long months are taken promiscuously together, and the addition of seven days constitutes \he aA'erage difference in the time. Many authors have thought it difficult to compute the period of pregnancy, because, they allege, it is not knoAvn what particular time elapses from the moment of fecundation until the germ reaches the uterine cavity. But I cannot perceive much force in this argument; and, in my opinion, it matters not whether one or ten days are needed for the transmission of the fecundated ovum to the uterus; the true mode of calculation is from the moment of fecundation, and hence the value of Dr. Reid's tables, which show that the ordinary duration of pregnancy, from a single coitus, is * Monthly Journal of Med. Sci., March, 1854. \ M. Raciborski has paid very particular attention to the subject of menstruation as connected with fecundation; and he has shown that the general rule is, that wo- men become impregnated immediately before or after, and even during menstruation, and that the exceptions to this law are not more than six or seven per cent. For some interesting facts bearing on this question, the student may consult with profit, his work, "Sur la Ponte des Mammiferes." THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 307 about two hundred and seventy-five days ; and this, I think, is con- firmatory of what we have endeavored to show in a previous lec- ture, that the particular point at Avhich the ovule of the female and the spermatozoon of the male meet is the ovary itself—so that, you perceive, the entrance of the germ into the uterus is one thing, and the fecundation of the ovule is another. The instant contact be- tween the ovule and spermatozoon occurs, the work of growth and development commences ; and it is not improbable that it is to a forgetfulness of this fact that much of the discrepancy in the calcu- lation of the duration of pregnancy is to be attributed. I have told you that conception will sometimes be accomplished during the catamenial period; and I have now, in my mind, a ludi- crous, yet painful case, in corroboration of this fact. Not a very long time ago, a gentleman called upon me, with the request that I would visit his wife professionally at one of the hotels in this city. The appointment was made, and I was there at the hour named— nine o'clock in the evening. As I Avas approaching the office of the hotel, for the purpose of sending my name to the lady's room, I felt a gentle, but Avhat I thought nervous tap on my shoulder, and looking round at once recognised the countenance of the gentle- man Avho had arranged the appointment Avith me; the expression of that countenance was fit for the study and development of the inimitable Hogarth, and it, indeed, seemed pregnant Avith the details of the future. Pale and haggard, he hurriedly took me by the arm, and in a sort of Avhisper, observed, " This Avay, Doctor." After ascending two flights of steps, which Avas accomplished in a marvellously brief period, impelled on as I Avas by my restive com- panion, he took a key from his pocket, Avith Avhich he unlocked the door, and requested me to enter. I had, perhaps, seen darker nights than that, but, I doubt, Avhether I had ever been thus unce- remoniously thrust into a darker room. The moment we had entered, he locked the door, and though I had not uttered a sylla- ble, he hastily remarked, " Doctor, be quiet!" Well, I thought the whole thing very droll, and really it was assuming something more than a broad farce; and, without a moment's delay, I very emphatically observed: " Sir, instantly do one of two things, either unlock this door or give me a light!" I had scarcely made the demand before my companion in the dark applied a match to a gas-burner. I will not attempt to describe the scene disclosed through the influence of that little loco-foco match! Suffice it to say, that a female, ghastly pale and almost bloodless, lay on the bed. My nervous companion imploringly asked me to do something to save her fife, which Avas fast passing away. I soon ascertained the true cause of the patient's extreme prostration. She was not married, and therefore not the Avife, as had been alleged, of the gentleman who had requested my services. 308 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. The victim of a cruel seduction, she had been brought to New York for the purpose of getting rid of the evidence of her shame; and Avith this vieAV her seducer sought the aid of one of those many Avretches Avith AA'hom our city is unhappily but too abundantly supplied, always ready for the perpetration of crime, no matter how monstrous, provided the Avages of their guilt—the money— can be had. I learned that one of these self-styled " Doctors" had, for the last three days, been at Avork on this unhappy girl, and after inflicting on her great suffering, had left her in her present melan- choly condition. You will scarcely credit it, but the fact is never- theless so, that this poor creature, after enduring extraordinary agony, both moral and physical, AAras abandoned by this trafficker in human life, to die ! He had received the Avages of his sin, and he Avas content! The abortion had been produced, and the fcetus removed from the house, but the after-birth was still within the uterus. Now, under these circumstances, Avhat Avas the course for me to pursue? Could I, with any moral justification, abandon this poor girl in the hour of her need ? Could I alloAV her to sink for the two reasons, first, that she had been seduced, and secondly, because she had been attended by an abortionist ? It Avould be the refinement, not to say the absurdity, of casuistry, to admit any such principle of guidance as this for the physician, who feels that one of the great objects of his profession is to heal the sick and give succor to the distressed. As well might it be argued that the surgeon should refuse to dress the wounds of a man shot in the act of burglary. I imagine that strict ethics exonerate the physician from any of the antecedents of such examples—his duty is to bind up the wounds, and administer to the suffering patient, regardless of all extraneous circumstances. Seeing, therefore, the deplorable condition of this unfortunate young woman, I did not hesitate to proceed at once in the discharge of my duty as a medical man. I gave her the strictest professional attention, and, in a short time, she entirely recovered from her illness. My object in introducing the case to your notice is, for the pur- pose of directing attention to a statement made by the pretended husband. He declared to me most positively that he had never had intercourse with the girl, except during her menstruation ; and he mentioned the fact on the ground that he had ahvays heard that a Avoman could not conceive while she had "her flow upon her." I remarked to him that I thought his personal experience was noAV amply sufficient to demonstrate the error of that theory. With cool effrontery he remarked, " Doctor, I think you knoAV all about it, and if you will only tell me hoAV it is possible to avoid having children, I will make you a substantial present!" " Sir," I remarked, " the only remedy for your case is, that you immediately consent to become an altered man!" He saw the point of the advice, and said nothing more on the subject. LECTURE XXII. Determining Cause of Labor—Meaning of the Term; The Expulsive Forces—pi 1- mary and secondary; Determining Cause referred by some to the Fcetus, by others to the Uterus; Opinion of Buffon with regard to the agency of the Foetus ; Ancient Doctrines; Uterus the true Seat of the Determining Cause of Parturi- tion ; Antagonism between Muscular Fibres of Body and Neck of Uterus; Change in Structure of Decidua and Placenta, as alleged by Prof. Simpson; Haller's Theory of the Decadence of the Placenta; Objections to the Theory; Dr. Brown- Sequard's Theory—Carbonic Acid the Stimulant to Muscular Contraction; The Doctrine of Ovarian Nisus, as propounded by Carus, Mende, and Dr. Tyler Smith; Objections to the Doctrine; Is Menstruation Peculiar to the Human Female? The Theory of Dr. John Power, adopted by Paul Dubois, of Paris; Objections to the Theory; Explanation of the Author as to the Determining Cause of Labor; Modifications in Structure of Uterus at Close of Gestation; Peristaltic Movement of Uterine Muscular Fibre; Inherent Contractions; These Inherent Contractions independent of Nervous Force—Proof; Connexion between Inherent Contractions and Matured Development of Muscular Structure of Uterus; Irritability of Muscular Tissue of Uterus increases as Pregnancy advances— Deductions from this Fact; Modifications in Structure of Uterus after Child-birth; Diminution of Musculo-fibre Cells; Fatty Degeneration, a Natural Change in certain Structures after they have completed their Functional Activity—sometimes a Pathological Result. Gextlejien—Having, in the preceding lecture, called your atten- tion to the period at which labor occurs, we now approach the consideration of a question Avhich has called forth numerous theo- ries for its explanation, both from the older and more modern writers—I allude to the determin ing cause of parturition. Before we proceed further it should be clearly understood what is intended to be conveyed by the determining cause of labor. It means nothing more than this: that peculiar influence which first excites the mus- cular fibres of the uterus to contraction. In order that you may have a precise and comprehensive view of the question, let us sup- pose that the impregnated uterus has passed through its various phases of development, the foetus has attained its maturity, and the time for its transmission into the world has arrived—what principle is it which gives the first impulse to that series of muscular con- tractions Avhich, when completed, accomplish the expulsion of the foetus and its annexae ? This is the simple, yet interesting question before us, and one in every way Avorthy of thought. There can be no doubt that the expulsive forces, Avhich result in the delivery of the child, are tAvo, which obstetricians have divided into, 1st, the 310 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. primary, or efficient; and 2d, the secondary, or auxiliary. The former, the primary, are the contractile efforts of the uterus ; the latter, the secondary, the contractile efforts of the diaphragm and abdominal muscles. But what Ave are noAV in search of is—that peculiar something, which is the original starting-point of these two classes of forces. In one word, Avhat is it that gives the origi- nal impulse to the parturient effort ? Is the Determining Cause in the Ftvtus?—As I have already observed, there is a remarkable discrepancy of opinion on this sub- ject—some referring the determining cause to the action of the foetus, while others maintain that it originates in the uterus itself. It Avas the opinion of the great naturalist, Buffon, that the foetus is the agent of its oavii expulsion; and this idea was no doubt derived from the supposed analogy between the human embryo and chick—the latter, as is well knoAvn, breaking its shell as soon as the period of its incubation has been completed. This hypothe- sis of the distinguished Naturalist Avill not abide the test of exami- nation ; indeed, it is utterly at variance with facts. If the deter- mining cause of labor be due to the action of the foetus, hoAv does it happen that the latter is expelled from the uterus after it has ceased to live for days, and sometimes Aveeks, previously to the termination of pregnancy ? Again, Iioav is the placenta expelled ? The doctrine—that the foetus causes its OAvn exit from the uterine cavity—did not, hoAvever, originate with Buffon ; on the contrary, it is a very ancient notion; and it is amusing to read the various explanations given Avhy the developed embryo is induced to seek and accomplish its entrance into the world. It was alleged, on the one hand, that the fcetus, at the period of its full intra-uterine groAvth, suffered from Avant of adequate nourishment; and hunger, therefore, prompted it to leave its parent. It was maintained, also, that the space in Avhich it was confined Avas too limited—it felt an instinctive longing, I suppose, to extend the area of its liberty; and the opinion likewise prevailed, that the desire to pass its water, and evacuate the intestinal canal, were among the causes which moved it to change its place of abode. It can scarcely be neces- sary for me to point out the fallacy of these views; they may be ranked among the fancies of the good old fathers, having nothing in truth to sustain them* Is the Determining Cause in the Uterus ?—It is very generally * Harvey maintained that " in the birth of living creatures, the chief cause of birth isdn the faetus; I mean as to its effort, not to its weight, as Fabricius says, &c.; the fcetus itself runs its head against the inclosures of the womb, opens them by its own strength, and struggles into daylight." "In vivipararum partu praecipuam nascendi causam foetui deberi. Molimini, inquam, ejus non autem ponderi ut Fabricius voluit, &c.; ipse foetus prono capite uteri claustra aggreditur, eademque propriis viribus recludit; et in lucem* elucta- tur." [De General. Animal., pp. 366-7.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 311 conceded, that the determining cause—whatever it may be—resides in the uterus itself, the foetus being in no Avay concerned in the original impulse to contractile effort; and here, again, we have theory upon theory promulgated in explanation of this peculiar influence, known as the excitant of uterine contraction. It Avould be needless, and totally unprofitable, to enumerate these various hypotheses ; I shall, therefore, content myself with a simple allusion to a i'cw of the more prominent of them. A theory, Avhich has obtained much countenance from the profession, refers the deter- mining cause of labor to a cessation of antagonism between the muscular fibres of the neck and body of the uterus—the evidence that this antagonism no longer exists being furnished by the fact that the length of the cervix has entirely disappeared, and exhibits nothing more than a circle, or, as it is sometimes termed, a ring. This explanation finds no support at the bedside; for how fre- quently does it happen, in cases of abortion, for example, that the uterus is thrown into contraction before the slightest shortening of the cervix can be detected ; and again, the cervix Avill occasion- ally have lost its entire length for several days, and even Aveeks, before the contractile efforts of the uterus manifest themselves. Professor Simpson has recently suggested the idea, that the pri- mary impulse to uterine contraction is due, in the first place, to a change in the structure of the decidua and placenta, and, secondly, to a loosening or separation of these bodies from the internal sur- face of the uterus—the modifications of structure being the result of the maturity of the ovum. This view is kindred to the opinion of Haller and others, Avho likened the placenta to the stem of the fruit, and argued, that as the matured fruit falls from the parent tree, because of the decadence of its stem, so does the placenta, Avhen gestation is completed, detach itself, and thus become the exciting or determining cause of parturition. The idea, if true, would necessarily imply that the primary link, in the chain of phe- nomena constituting labor, is the detachment of the placenta from the uterine surface; but to admit such an assumption would be directly contrary to Avhat really occurs—it would, indeed, be con- founding the cause with the effect. The placenta, except under certain circumstances of disease affecting it, or in cases of sudden concussion, becomes detached from the womb, not through any decadence, but simply through the force of uterine contraction. If this were not so, if the first effort of childbirth resulted from the separation of this body, the necessary consequence Avould be hemorrhage, more or less profuse. How often does it occur that some minutes elapse after the expul- sion of the fcetus, before the afterbirth is separated from the Avomb ? It may be safely said, I think, that, as a general rule, the placenta remains in adhesion Avith the uterus until the child has been thrown C12 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. into the Avorld; or, to speak more properly, as the child is jtassing through the vulva, the work of separation is going on, so that wlien the egress of the fetus has been accomplished, if the uterus should be felt in the hypogastric region, firm and contracted, this affords very substantial evidence that the afterbirth is no longer in connexion with the walls of the organ. What is the true explana- tion of hemorrhage in childbirth ? Is it not, except in cases of placenta proevia, the direct result of inertia of the Avomb after a partial or complete detachment of the placenta ? If this be so— and Avho will doubt it—Avith this theory of the early separation of the afterbirth as the determining cause of labor, how few parturi- ent women would escape the dangers of flooding ? Dr. Brown-Sequard* says, " The uterus, in pregnancy, becomes more and more irritable every day ; and Avhen its irritability has arrived at a very high degree, then the slight excitation produced by the carbonic acid normally contained in the blood, is sufficient to put it in action." Let us next turn to Avhat has been denominated the ovarian theory of parturition. Dr. Tyler Smith, in accordance with the opinion of Carus, Mende, and others, has attempted to shoAV that the determining cause of parturition is but the product of ovarian excitement. He holds that, during the entire term of gestation, the ovary becomes the seat of recurrent excitement, corresponding with the ordinary catamenial periods; and moreover affirms that, in consequence of this local congestion of the ovary, there is more or less tendency to abortion at each of these returns. It will be perceived that this hypothesis clearly refers the entire act of uterine contraction to that important and interesting principle—■ reflex influence ; the ovarian nerves being the excitors, which, con- veying the stimulus of irritation to the medulla spinalis, cause this latter to infuse into the motor nerves of the uterus an impulse, which results in contractions of the organ. The theory of Dr. Smith is not without objection. In the first place, I do not regard it as at all settled that ovulation goes on during pregnancy, and without this, why should the ovary become the seat of a periodical nisus?] Secondly, while it cannot be denied that the duration of pregnancy is usually a multiple of the menstrual interval, yet this is far from being necessarily the case. A very substantial objection to this hypothesis is disclosed by the fact announced by Professor Simpson—he removed the ovaries during the latter period of pregnancy without in any Avay inter- fering with the phenomena of parturition. But it seems to me * Experimental Researches, &c, p. 117. \ Scanzoni is also of opinion that ovulation continues during gestation ; but numerous autopsies by Virchow, Kussmaul, and others, prove that if the function really persist in some women, it must be regarded as a rare exception. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 313 that an irresistible and conclusive argument against the theory is this: Dr. Smith, if he be correct in his opinion, would make the parturient effort essentially dependent upon nervous influence, or, in other Avords, he would refer it to reflex action. Before con- cluding this lecture, we shall endeavor to demonstrate the fallacy of this proposition, and prove that the uterus enjoys two distinct forms of contraction—one, inherent, independent; the other, ex- traneous, dependent, or, more properly speaking, the result of nervous force. I have an abiding faith in the analogies of Nature, and I believe that she is perfectly consistent in them. Indeed, many of the solid principles of our science are derived from the proofs furnished by these A-ery analogies. Noav, it appears to me, that the ovarian theory of parturition, if it be founded in truth, should not only exhibit, under a normal condition of system, a universality in its application so far as the human female is concerned, but it should also disclose a necessity for its influence in determining the partu- rient effort in animals generally. We have just seen that if the ovary, under any circumstances, be capable of evoking uterine contraction at the close of pregnancy, it is not always the starting- point of this phenomenon ; and, on examination, it will be readily understood, that the truth of the theory is not borne out by what is observed in the parturition of animals ; in a word, it has not the support of analogy. But let us, for a moment, examine this theory under another point of view. The doctrine is very generally maintained that menstruation is peculiar to the human female. If, by this, it be intended to convey the idea that the function, as it exhibits itself in Avoman, Avith all its phenomena, its duration, etc., is exclusively recognised in her, then I can see no objection to the doctrine, for it is founded upon undeniable evidence. If, on the contrary, it be argued that during the period of heat, certain animals do not ha\'e any san- guineous discharge, no matter how slight, or for how short a time, then I object to the doctrine, for it is adverse to the evidence furnished us by accurate observation. Examine, for example, the slut at the time she is about to take the dog (her period of heat), and you will find not only congestion of the parts, but also a slight sanguineous emission; the same thing will be observed in the coav, mare, and other animals, which, it is well knoAvn, Avill only receive the male at this time, and at no other; and during the period of heat the same phase occurs, which is so characteristic of the cata- menial crisis in woman, viz. the maturation, and subsequent escape of ovules.* There is much variation in the period of heat among different • See Lecture viL 311 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. animals; in the slut, for instance, it takes place tAvice in the year, and continues about fourteen days each time; in the coav, and other domestic animals, it is more frequent than in Avild animals, but it is not marked by any definite periodical occurrence. The duration of pregnancy in the cow is in correspondence Avith that in woman; and, at the completion of her term, the animal is thrown into labor—but, will it be contended, after what has just been said, that the determining cause of parturition in the coav is a multiple of the menstrual interval? I again repeat my faith in the doctrine of strict analogy, and I believe the uterus of the cow, Avhen her gestation is completed, contracts in obedience to the same influence, which constitutes the primum mobile of parturient effort in the human female. What this influence is Ave may or may not be ena- bled to explain before Ave conclude this lecture. Dr. John PoAver,* some forty years since, suggested a theory in explanation of the determining cause of labor, Avhich, undoubtedly, possesses the merit of plausibility, and Avhich has, of late, had new strength added to it in consequence of its adoption by Prof. Paul Dubois, the eminent Parisian obstetrician.f In order that you may thoroughly understand Dr. PoAver's hypothesis, I shall quote his own language: " All organs which are intended to retain, for a time, and after- wards to expel their peculiar contents, are furnished with sphincters, placed at their evacuating orifices. The most remarkable of these are the rectum, the bladder, and the uterus. "The sphincters of the above organs are possessed of tAvo dis- tinct properties—in the first place, they act as valves to prevent improper evacuation; and secondly, they are endoAved with a pecu- liar sensibility which enables them to regulate the necessity or propriety of discharge ; and for this latter purpose especially, they are supplied with a larger proportion of nerves of sensation than the bodies of the organs to Avhich they belong. " To produce the evacuating action of any of these organs, the exciting stimulus must be applied to the sphincter, Avhen the organ contracts and expels its contents. " The existence of sphincters, as above described, is universally admitted Avith respect to the rectum and bladder; but the claim for such structure, with regard to the uterus, is novel; and, therefore, it will be desirable to illustrate the theory, and advance proofs and arguments in support of it. " In the first place, I shall make some observations respecting the * A Treatise on Midwifery, developing new principles. By John Power, M.D. London. Second edition. 1823. Pp. 23, \ The Theory of Dr. Power has also received the endorsement of Prof. Henry Miller, M.D., the late distinguished Prof, of Midwifery in the University of Louis- ville. [Principles and Practice of Obstetrics, by Henry Miller, M.D., p. 300.1 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 315 analogous action of the rectum and bladder, and then proceed to point out the nature and effects of the sphincter of the uterus, as explanatory of the exciting causes of labor. "The faeces, received from the colon, are protruded fonvard along the rectum until they arrive at the sphincter ani, Avhen, in consequence of the impression made upon that part, the action of the rectum is elicited, and they are expelled. That this irritation of the sphincter is here the cause of expulsion may be inferred from the fact, that if the motion for evacuation be attended to, the first perception of it is always at the sphincter, and rarely felt under the earlier periods of accumulation in the rectum, unless indeed the faeces are in a fluid or acrid state, so as to be more readily admitted into contact with the sphincter, or to produce more stimulating effects upon it. This proves that the expulsive action is the effect of stimulation, and not distension. We have equal or more decided evidence of the same principle operating in the evacuation of the bladder. " I shall now attempt to show that the cervix and mouth of the womb discharge all the functions which have been above assigned to sphincters. The cervix appears anatomically distinct from the body of the uterus. It experiences comparatively little change from conception, until the pregnancy is half completed, the enlarge- ment of the Avomb having, in the earlier months, evidently pro- ceeded from the body exclusively, and, it is most probable, that throughout the Avhole term, it continues to be derived therefrom. " The cervix, until the end of the fifth month, retains its former length; after this time, it begins to experience a gradual diminu- tion, until, at the termination of pregnancy, it has entirely disap- peared. The contents of the uterus, Avhich the intervening cervix had previously kept at a determinate distance, are now admitted into direct contiguity Avith the orifice. " When we take into view the manner in which the orifice is supplied with nerves of sensation, it is fair to infer that it is en- doAved Avith a peculiar function, and a high proportion of sensibility ; and Avere Ave to admit that a stimulus applied to it would, in a manner analogous Avith the above-recited production of faecal and urinary evacuations, have the effect of exciting parturient contractions of the uterus, it must be allowed that a necessity exists, during the period of foetal evolution, for the interposition of a valve betAveen it and the uterine contents, to preA^ent their premature expulsion. This valve, Ave conclude, is found in the cervix, and the beautiful simplicity of the contrivance, as Avell as the undevtating and admir- able manner in Avhich nature gradually resumes it before labor comes on, is a fine illustration of the providence of the Divine' Creator to prevent the generative actions from being rendered abor- tive, and secure, at the due time, their propitious consummation. 316 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. " That the orifice of the uterus is the medium through Avhich the parturient actions are excited, is strongly confirmed by the fact, that contractions of the uterine fibres may be occasioned by an artificial stimulus, applied to the part in question, proving that the cause presumed is adequate to produce the effect assigned to it. "Another proof is, that a defect of orificial irritation will be followed by a deficiency of parturient contraction. Thus the labor goes on slowly, or is suspended, when the presenting parts are prevented from making proper exciting pressure on the orifice, as in cases of malpresentation, malformation of the child or pelvis, or where the head recedes in consequence of rupture of the womb, or where the belly is pendulous, etc. " Labor, however, does not always come on as soon as the cervix is obliterated, and occasionally takes place previous to that event. These circumstances require some explanation. " A given and determinate impression of the orifice, differing in degree according to the constitution of the individual and existing sensibility of the part, is necessary to give rise to the uterine con- tractions. Thus, the mere gravitation of the uterine contents in the direction of the orifice, is not alone sufficient to produce them; the pressure and tension given by the insensible contractions must be superadded. If this is wanting, or weak, labor will still be post- poned. On the contrary, if it happens to be strongly or prema- turely excited, as it may be, by evacuating the liquor amnii, and various other causes, before the cervix has been naturally oblite- rated, it may have the effect of either hastening that event, or of stimulating the cervical parts sufficiently to occasion premature action. " The gravitation of the contents of the uterus, doubtlessly co- operates in producing the insensible contraction, while the latter tends to complete the cervical obliteration; and, it is probable, that they continue in giving rise to the uterine contractions. Thus, as I before observed, they operate as cause and effect to each other." I have given this long extract from Dr. Power's clever work because I was desirous that you should read his own Avords in explanation of his peculiar theory—a theory which, as I have already remarked, has recently been accepted as the truthful expo- sition of the determining cause of labor by one of the highest liv- ing obstetric authorities. It is quite manifest that Dr. Power refers the original movement of parturient action exclusively to nervous force, brought into play through the agency of reflex influence. With him the starting- point is irritation of the excitor nerves of the cervix uteri, result- ing in a reflex impulse, which puts, if I may so term it, the Avheel of muscular contraction of the uterus in motion. I may be in error but it really seems to me that Dr. Power, in his attempt to THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 317 sustain his ingenious theory, has himself furnished conclusive objec- tions to it—they are, in fact, the very objections which, to my mind, are entirely subversive of all his reasoning. You are criti- cally to bear in mind that his main proposition is this—that at the end of gestation the cervix uteri having, through the process of shortening, entirely disappeared, " the contents of the organ, which the intervening cervix had previously kept at a determinate dis- tance, are now admitted into direct contiguity with the orifice? It is this very contiguity, you must remember, Avhich causes the impression upon the excitor nerves of the part. Well, for argu ment's sake, suppose that we admit the truth of this reasoning in cases in which the above phenomena occur, viz. the obliteration of the cervix, and the pressure of the presenting part of the foetus against it. How shall we satisfactorily explain the determining cause of labor in instances in Avhich, notwithstanding the oblitera- tion of the cervix, there is no pressure made upon it ? This is the very objection suggested by our author, but strange to say, instead of regarding it as an objection, he says, " Another proof is, that a defect of orificial irritation will be followed by a deficiency of par- turient contraction. Thus, the labor goes on slowly, or is suspended Avhen the presenting parts are prevented from making proper excit- ing pressure on the orifice, as in cases of malpresentation, malfor- mation of the child or pelvis, or where the head recedes in conse- quence of rupture of the womb, or where the belly is pendulous, etc" Do you not see, gentlemen, that the language which I have just quoted, in lieu of a proof, is a positive upsetting of the whole the- ory ; for, in cross presentations, in which it is physically impossible for the presenting portion of the foetus to make exciting pressure on the orifice, labor comes on, and regular uterine contractions supervene. In these latter instances surely the theory is at fault; for it cannot, under these circumstances, explain the determining cause of parturition. Falsus in uno, falsus in omni, is a sound maxim in laAV, and bears with equal force on the question now before us. Dr. PoAver says, " Labor, however, does not always come on as soon as the cervix is obliterated ; and occasionally takes place pre- viously to that event." Noav the very explanation which he gives of the two facts contained in the last quotation militates in the most positive manner against his theory, for he remarks, "A given and determinate impression of the orifice, is necessary to give rise to the uterine contractions. Thus, the mere gravitation of the ute- rine contents in the direction of the orifice is not alone sufficient to produce the pressure ; and tension given by the insensible contrac- tions must be superadded. If this is wanting or weak, labor to ill still be postponed." The italics here are my oavh, and I have pur- 318 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. posely made them in order that you may see the language thus ita- licized is a surrender of the whole argument. If it have any mean- ing it signifies simply this—that the mere pressure of the presenting portion of the foetus against the uterine orifice is not always ade- quate to evoke the parturient effort, and that sometimes the " insensible contractions''''* are needed for this purpose. This is nearly my OAvn opinion, and so firm am I in this belief that I shall endeavor to show that not only are these contractions sometimes needed, but they universally, in a normal state of things, precede any reflex or nervous force, and are entirely independent of what Dr. Power calls " orificial irritation,'' as I shall now proceed to demonstrate. When the period of gestation has been completed, it will be observed that the muscular fibres of the uterus, as thet very first act in the parturient process, commence a sort of peristaltic movement. This movement or contraction is what may be denominated a per se movement—it is inherent, independent, and is to be referred exclusively to the irritability of the muscular structure of the ute- rus, having no connexion Avhatever with a reflected or nervous force. These contractions are similar to the peristaltic movements of the intestinal canal, which are admitted to be the result of inhe- rent irritability, and totally independent of any influence derived from the nervous system. They are Avhat may be regarded as independent contractions, and their object appears to be the exer- cise of a pressure from aboAre downward on the foetus toAvard the os uteri; these inherent contractions of the uterus will, occasion- ally, begin to develop themselves for several days, and even weeks, prior to the setting in of labor. They may, indeed, be regarded as preliminary to the concentrated effort, which results in the expul- sion of the foetus; and, no doubt, one of their purposes is, as it were, to prepare the uterus for the struggle, Avhich is so close at hand. Lf you ask for the proof of this independent contraction of the organ, I will refer you to two important facts, which establish beyond a peradventure that the uterus possesses a contractility of its OAvn, in no Avay dependent upon nervous supply. The facts are Ijhese: 1. The fcetus has been expelled, in virtue of the inherent contraction of the organ, after the death of the mother, when ner- vous force was out of the question ; and it is also well established that the peristaltic movement will continue for some time after life has become extinct.f 2d. Parturition has been accomplished by * The terms " insensible contractions" are not strictly correct. So far from being insensible, they are not only felt by the mother, but oftentimes give rise to more or less distress. They should rather be called independent or inherent. \ De Graaf has, in dissected rabbits, observed the womb to be agitated by a fluctuating and peristaltic motion, and by its own force to drive out the fcetus. [De Mulier. Organ, p. 325.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 319 the unaided efforts of nature in cases in Avhich the lower portion of the spinal cord has been completely destroyed ; you will see it go on, too, in women affected Avith paraplegia, shoAving that the cord is Avithout function, and cannot, therefore, in these cases, minister to uterine contractions. Dr. BroAvn-Sequard* says he has seen, hundreds of times, the uterus or its cornua, full or empty, contracting to appearance spontaneously, after the death of rab- bits and other animals, at a time when the spinal cord had entirely lost not only its reflex power but also the power of acting on mus- cles when directly excited by galvanism, Avarmth, or mechanically. But, gentlemen, the question still presses us—what is the deter- mining cause of labor, or what is it that first induces these indepen- dent movements in the muscular tissue of the uterus ? I may not be very lucid in the exposition of my notion touching the question —but it does seem to me that there is a necessary connexion between this first spontaneous movement in the muscular walls of the uterus, and, if I may so term it, a matured development of the muscular structure of the organ itself. AVhat I mean by matured develop- ment is this—from the instant of fecundation the uterus becomes an active centre, the effect of which is an increased nutrition, Avhich results in the groAVth and development of the various structures composing it. This increase constitutes one of the processes in the interesting scheme of reproduction—and so essential is it that, Avhen interrupted, failure on the part of nature to consummate the act of generation is the consequence. The gradual and successive development of the muscular tissue of the gravid Avomb has, I think, a marked bearing on the point now under consideration. Here, be it remembered, we have this important character of struc- ture, during the period of gestation, constantly receiving, through increase of nutrition, increase of volume, and consequently aug- mented ability for the manifestation of its peculiar function—con- tractility. If you consider, on the one hand, this fact of increase in development, and, on the other, the interesting circumstance that, as pregnancy approaches its termination, the uterine mus- cular fibre is, as a necessary result, proportionately gaining in maturity of growth and development—if, I say, you consider all these things, does it not seem Avithin the range of probability that, under the constant influence of nutrition, and repose, so far as regards its functional display, the muscular tissue of the gravid uterus becomes, as it Avere, surcharged—in a Avord, so full of contractile poAver that, in perfect consistency Avith the general laAVS regulating the animal economy, it commences its series of acts through which alone the exit of the foetus, after full intra-uterine development, can be accomplished. * Experimental Researches applied to Physiology and Pathology, p. 105. 320 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. If I be correct in my exposition of the determining cause of labor, which I have thus briefly presented, it seems to me it must be admitted that the primum mobile of uterine action, when gesta- tion has been completed, is a physiological necessity. Under any circumstances, Avhether the theory be substantial or otherwise, it will, I think, prove not less satisfactory than the opinion of Avi- cenna—" That at a fixed time, labor takes place by the grace of God." Fatty Degeneration and other Changes in the recently delivered Uterus.—It is conceded that the uterus, as soon as its contents have been expelled, exhibits new changes in its elementary consti- tution—the blood-vessels and nerves which, during gestation, Avere largely developed, now diminish in volume, and soon not a vestige can be detected by the naked eye: the muscular tissue becomes much less considerable, through the diminution, both in size and number, of its elements—the musculo-fibre cells—and passes into a state of fatty degeneration,* so Avell demonstrated by VirchoAV and Kilian. In a Avord, the organ becomes invested again with a rudi- mentary character, Avhich continues until stimulated to new forma- tions, and a more perfect organization by pregnancy. Fatty degeneration, or substitution, is very frequently a morbid or pathological condition—but is it always so ? Evidently not— for it is sometimes a perfectly natural result, as is shoAvn in certain structures prior to absorption, Avhen they have accomplished the term of their functional activity. This is well illustrated in the placenta, as has been pointed out by Dr. Druitt, Dr. Robert Barnes, and other observers. The vessels of this body—the placenta— undergo fatty degeneration toward the close of gestation; the remarkable and interesting fact is, that this metamorphosis of struc- ture commences in the tufts or vessels at the circumference of the organ, at which point its special office or function ceases first. This, then, I hold to be strongly corroborative of the opinion I have advanced. Fatty substitution, both of the placenta and of the muscular tissue of the uterus, takes place as soon as these structures have performed their particular part in the reproductive act; and this change in the tissues is not to be regarded as a patho- logical result, but as one of the natural processes of the economy. * Dr. Priestley says, " He has occasionally seen at the post-mortem examinations of women who had previously borne children, the uterine tissue affected by fatty degeneration, and so soft and friable that a sound passed into the uterine cavity, during life, as a means of diagnosis, might have readily been pushed quite through the uterine walls, unless the greatest care were exercised in its manipulation." [Lectures on the Development of the Gravid Uterus, p. 103.] LECTURE XXIII. Seat and Origin of the Expulsive Forces in Parturition—How these Forces are Modified—Spinal Cord—Its Influence—Parturition in part an Excito-motory Act:— Excitors of Reflex Action in the Uterus—What are they ?—Difference in Uterine Contraction due to Inherent Irritability and Nervous Force—What is it that causes the Diaphragm and Abdominal Muscles to Contract as a Secondary Aid in La- bor ?—The Contraction of these Muscles is not always an Act of Volition ; it is sometimes Reflex—Signs of Labor—Importance of—The Signs of Labor divided into Preliminary and Essential, or Characteristic—What are the Preliminary?— What the Essential Signs?—Labor Pain; how Divided ?—Is Pain the Necessary Accompaniment of Parturition ?—What is the true Explanation of Labor Pain ?— Is it identical with Uterine Contraction, or is it the Result of Contraction ? — Change in the Physical Condition of the Uterine Muscular Fibre under Contrac- tion ; Deduction—True and False Labor Pain; how Discriminated—Dilatation of Os Uteri; how Produced—Rigors and Vomiting during Dilatation; What do they Portend?—The Muco-Sanguineous Discharge during Labor; how Pro- duced—Formation and Rupture of the "Bag of Waters;" how the Formation is Accomplished—Uses of the " Bag of Waters " during Childbirth—Caution against its Premature Rupture—The " Caul or Hood;" What does it mean ? Gentlemen—Having endeavored to explain the determining cause of labor, it is now proper to discuss the seat and origin of the expulsive forces, Avhich result in the delivery of the fcetus and its appendages. These expulsive forces may be divided into two kinds: 1. The primary or efficient; 2. The secondary or auxiliary. You must recollect that the peculiar something which constitutes the inception of uterine action, is a very different thing, as a general principle, from the power through which is accomplished the evacuation of the uterine contents. The fact is generally conceded that the primary or efficient element of this power resides in the organ itself, and consists of the contractile efforts, which manifest themselves at the commencement of parturition, and continue with more or less impulse until the delivery is consummated. There is a striking difference in the grade and measure of force exercised by the contracting uterus upon its contents, and this difference will be fully recognised as the labor progresses. At first, and until the neck of the organ becomes so dilated as to experience the direct pressure of the presenting portion of the foetus, the force is com- paratively moderate, and is the result simply of the inherent mobility of the organ itself—an illustration of that independent per se contraction of Avhich Ave have spoken in the preceding lec- ture. But as the labor advances, and when one of the consequences 21 322 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of this advance—the dilatation of the os uteri—has been effected, then these moderate efforts undergo a marked and decided change—■ they assume an expulsive character, which increases in intensity in proportion as the head or presenting part of the foetus escapes from the uterus, and makes pressure on the walls of the vagina and vulva. Difference in the Parturient Force.—It is not sufficient for you, as intelligent students, to know that there really exists a difference in the kind and amount of force exercised by the uterus during the parturient struggle—you require something more ; you desire the* explanation of this difference. Childbirth is, strictly speaking, a physiological act, and its physiology is of the most striking and positive nature. The spinal cord, that essential nervous centre, plays an important part in the general movement, resulting in the delivery of the foetus and its annexae; and you cannot have your attention too steadfastly directed to this interesting fact. It is per- fectly correct to say, that, as a general rule, labor is in part accom- plished through an excito-motory influence, or, in other words, through reflex action. For the production of a reflex movement, tAvo requisites are needed: 1. The spinal cord, which is the great central organ, and which becomes the recipient of impressions ; 2. The incident excitor nerves, which, first receiving these impressions, convey them to the medulla spinalis, and this latter communicating to the motor nerves an increased vis or impulse, an influence is thus extended to the muscles to Avhich these motor nerves are distributed, which results in a movement known, physiologically, as reflex. Excitors of Reflex Uterine Action—It is a matter of great practical interest to remember that there are various excitors of reflex action, so far as the uterus is concerned; and it is the recollection of this circumstance, Avhich will enable you, oftentimes, not only to control morbid influence, but will be suggestive of important remedial agents in cases involving more or less peril, as in hemorrhage, inertia of the uterus, or excessive uterine contrac- tion. Some of these excitors may be briefly alluded to : When a newly delivered woman applies her infant to the breast, it is not at all unusual for her to complain of more or less pain in the uterus—■ this is an example of reflex action, traceable as its primary cause to irritation of the excitor nerves of the mammae, the irritation beinc: induced by the suction of the child's mouth. You are sometimes told that frictions on the abdominal surface, and more especially the application of cold, will evoke uterine contraction. The fact is undoubtedly so—and its explanation is found in the circum- stance that the cutaneous or terminal excitor nerves of the abdomen become impressed by the friction or cold, and hence the reflex movement resulting in contraction of the organ. How precious to the life of your patient will be the recollection of this fact, in fearful hemorrhage of the uterus after the birth of the child—it is on the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 323 principle just explained that you will, with such prompt and decided effect, use the cold-dash, which consists in throwing, with an impulse, a pitcher of cold water upon the abdomen. When everything looks dreary for the patient, and hope is almost aban- doned from the failure of other remedies in these instances of alarming flooding, the cold-dash will, oftentimes, prove of incalcula- ble service in closing up the flood-gates—the mouths of the utero- placental vessels—which are fast exhausting the strength of your patient, and hurrying her with rapid pace to the grave. But, gentlemen, there are other important excitors of uterine action which are represented by the numerous terminal nerves distributed throughout the uterus and vagina, and these constitute the essential class of excitors in the parturient act, because, as soon as labor commences, they are brought more or less into operation, as will be presently shown. In addition, there are the excitors of the rectum and bladder, and hence you can understand why abor- tion will be apt to ensue in cases of constipation, or from the administration of drastic medicines, which act specially on this portion of the intestinal tube; and, also, from the tenesmus of dysentery. A similar result is equally susceptible of explanation when the neck of the bladder becomes the seat of irritation, either from the presence of a calculus, or from the absorption of cantha- rides after a blister has been applied, occasioning strangury. We have spoken merely of what have been designated the eccentric or indirect influences Avhich operate in the production of uterine contraction. It must, however, not be forgotten that there are certain centric or direct influences equally capable of bringing about the same result—influences Avhich, instead of exercising their primary irritation on the terminal or incident excitor nerves, pass directly to the nervous centre itself—the medulla spinalis. If, as I hope, I have succeeded, so far, in making myself under- stood, there AA'ill be no difficulty Avith the data just presented in comprehending the modus operandi of the two kinds of forces—the primary and secondary—which determine the expulsion of the foetus and its appendages. Primary Forces of Parturition.—The first contractions of the parturient womb are altogether due to the inherent, independent irritability of the organ ; and, as has already been explained to you in the preceding lecture, this inherent action of the uterus will, under certain circumstances, suffice to accomplish the birth of the child—shoAving incontestably that childbirth is not essentially dependent upon nervous agency. These first contractions continue at irregular intervals, and their tendency is to aid in the dilatation of the os uteri. When this is accomplished, and even during the progress of dilatation, the contraction increases in force, and here we have a striking illustration of the conservative care and per- 324 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. fection displayed by nature in the great scheme of delivery. Prior to the full opening of the mouth of the uterus, extraordinary poAver was not needed; but, as soon as this stage of the labor has been completed, an increased force is called for; and it is immediately furnished by making the spinal system of nerves tributary to the wants of the economy. Hence, you will find, at this period of the parturient effort, that the irritation of the incident excitor nerves of the dilated os, caused by the pressure of the presenting portion of the fcetus, is instantly transmitted to the medulla spinalis, from which is derived a responsive impulse to the motor nerves of the uterus, resulting in increased energy of the contraction. In this way, you perceive, is explained the primary or efficient element of labor, AA'hich we haAre already told you is centred in the uterus itself, and which is of a two-fold nature: 1. Inherent, the result of simple muscular irritability ; 2. Nervous, the result of reflex action. Secondary Forces.—Let us now turn to the secondary or auxili- ary forces of childbirth, and see, in the first place, Avhat they are; and secondly, the modus in quo of their production. These auxili- aries consist in the powerful contractions of the diaphragm and abdominal muscles, which undoubtedly, although in a secondary manner, render good service in the work in which nature is engaged. As soon as the head or presenting part of the foetus lias fairly escaped through the mouth of the womb, it necessarily exercises a positive pressure on the distended vagina—it is the pressure on this surface, which chiefly induces irritation of the incident excitor nerves, and hence, through reflex influence, the diaphragm and abdominal muscles are awakened to powerful con- tractions.* When these latter commence, the labor undergoes a marked change—it is then what is denominated expulsive, and every succeeding contraction of the organ is characterized by an increased impulse. The will frequently has no control at this time over the muscular contractions of the diaphragm and abdominal walls—they appear independent of volition, nor can they, under full development, be restrained. They are, under these circum- stances, like deglutition and many other phenomena which are dependent upon a special local irritation, under no subjection to the individual. How do you suppose the act of deglutition is accomplished ? Is it a voluntary movement! You can easily satisfy yourselves that it is not, for you will attempt in vain to swallow by any voluntary act of your own. Deglutition is a phe- * I think it right to say that, although the contraction of the diaphragm and abdominal muscles is sometimes reflex during the parturient effort, yet it is quite certain that it is frequently voluntary. One of the most formidable troubles with which the medical man has to contend is involuntary action of the diaphragm, because it gives rise to spasms, more perilous than any other, inasmuch as their direct tendency is to arrest the respiratory movement. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 325 nomenon due to reflex action ; its source is the medulla oblongata ; and irritation of the excitor nerves of the fauces is an essential prerequisite to its performance. The food, during a repast, is the usual irritant, and under ordinary circumstances the contact of the saliva with the fauces enables you to consummate the act. So you perceive, physiologically speaking, deglutition, so far from being ranked among the voluntary phenomena, is essentially and truly automatic in its nature. From what has been said in explanation of the primary and secondary causes of labor, you cannot have failed to observe one cardinal feature, viz. that the forces, necessary to the expulsion of the foetus, commence at first in moderation, and, as the labor advances, they are characterized by vastly increased impulse and vigor. You not only understand that this is so, but you are also prepared to appreciate its necessity. Of course, gentlemen, you must bear in mind that I am now speaking of parturition under ordinary or normal circumstances, and not of those exceptional cases in which the effort commences with extraordinary violence, and is completed in a very brief period. Signs of Labor.—The next topic for our consideration Avill be the signs of labor, and here, permit me to suggest, we touch upon a most important subject for the student and practitioner of mid- wifery—a subject, which if not Avisely understood, will frequently lead to serious embarrassment, if, indeed, it do not subject the medical man to just and Avithering rebuke. How, for example, are you to know that labor is at hand, or has really commenced, except through a proper appreciation of the signs, which indicate either its approach or presence ? It is a question altogether of testimony, and that testimony is made up of signs or indications. It is for you, therefore, to be careful in your analysis of these signs; see that you do not confound true Avith false evidence. For prac- tical purposes, the signs of labor may be classified under two divisions, and I think they will embrace everything, Avhich it is important for you to know on the subject: 1. The preliminary or precursory; 2. The essential or characteristic. Preliminary Signs.—The preliminary indications of labor consist of certain phenomena, which usually exhibit themselves a feAV days previously to the commencement of the parturient act, and they may, in the true sense of the term, be considered as preparatory. They are as follows: 1. When labor is near at hand, the fact will be broadly indicated by the peculiar condition of the neck of the uterus; it will have lost its length—it will be more or less circular— in a word, the neck of the organ will be obliterated; on an exami- nation per vaginam there will be recognised a simple orifice, Avhich, in Avomen Avho have already borne children, Avill usually be suffi- ciently dilated to permit the introduction of the end of the index 326 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. finger, AA'hile in the primiparee there Avill, as a general rule, be an absence of dilatation. 2. For some days, and occasionally for two or three weeks prior to the commencement of actual labor, the female will complain of a sense of uneasiness about the uterus ; ajid this uneasiness will probably be observed several times during the day and night; if, Avhile the patient complains of this local dis- turbance, you should place your hand over the region of the Avomb, you will distinctly perceive that the organ becomes hard for the time being, and as soon as the uneasy sensation passes aAvay, it again becomes relaxed. These are what are known as the inde- pendent contractions of the uterus, and generally develop them- selves earlier in the primipara. They are not accompanied by a bearing-doAvn so characteristic of true labor contractions; they are, on the contrary, but the result of the muscular irritability of the organ, and are to be regarded as simply preliminary. Be careful, and do not confound this early action of the uterus with labor properly so called. The sense of uneasiness, due to these inde- pendent contractions, Avill sometimes occasion much anxiety in the mind of your patient; she regards it as the harbinger of evil, and looks upon it as an evidence that something is wrong. It will be your duty at once to dispel all apprehension, and assure her, Avhich you can do with entire truth, that the greater this local disturbance previous to the commencement of the parturient effort, the more auspicious Avill be the delivery. This is really so, as a general rule, for these contractions of the gravid uterus are not only preliminary, but, Avhen of a decided character, exercise a very happy influence in preparing the os uteri for its subsequent dilatation. Indeed, I have remarked, as a practical fact worthy to be recollected, that, all things being equal, labor Avill be shortened and more favorable just in proportion to the activity of these contractions. 3. For some days previous to the completion of gestation, there will be a remarkable change in the position of the impregnated uterus; and this change, as you will presently see, Avill result in Avhat may be termed mixed phenomena—some highly favorable to the condition of the female; others, again, entailing upon her for the time being, more or less distress. The change to which I allude in the position of the organ is this—the fundus of the womb, in lieu of pressing high up in the epigastric region, is observed to descend. This is Avhat may be termed the righting of the organ; it is, as it were, the placing itself in readiness for the struggle in Avhich it is so soon to engage. If you ask me A\'hy the gravid uterus descends in the abdominal cavity previous to the commencement of labor, I must acknowledge that I cannot satisfactorily ansAver the interrogatory in any other way than by referring the descent to a combination of influences, Buch as increase in the weight of the organ, and of the fcetus, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 327 liquor amnii, etc., together with a softening of the fibro-articular tissues. Be the explanation as it may, the immediate effects of this descent of the uterus require a word of comment. In the first place, when the organ descends into the abdominal cavity, the pressure of the fundus being removed from the diaphragm, the female feels much lighter and more buoyant; she can breathe free, and is relieved from the sense of oppression which she had previ- ously experienced. Secondly, the abdomen becomes much less protuberant, especially in the epigastric and umbilical regions. Let me here, for a moment, call your attention to some of the tempo- ral}' inconveniences of this alteration in the position of the uterus. Just in proportion as the fundus descends will be the measure of descent of the opposite extremity of the organ into the pelvic excavation ; the os uteri, Avhich before Avas high up, and difficult to be reached, is now much more accessible to the finger ; the neck of the bladder undergoes more or less pressure from the presenting part of the fcetus, giving rise to irritation and frequent desire to micturate, and sometimes occasioning a retention of urine. The rectum may be unduly irritated by the superincumbent weight of the prolapsed organ, and hence distressing tenesmus may be the consequence. The A-agina itself does not escape the effects of this descent of the uterus, and one of the results Avill be, through irri- tation of its walls, a more or less profuse discharge of mucus. In addition to Avhat have just been enumerated as among the precursory signs of labor, may also be named the folloAving: — hemorrhoidal tumors, increased oedema of the lower limbs, with an increase, also, in the venous engorgements, all these being more or less the necessary consequence of the pressure of the gravid womb after its descent into the pelvic cavity. Nor should I omit to men- tion, among the indications preliminary to the advent of labor, various neuralgic pains about the hips and loins; and you will not fail to notice in some cases, especially AA'hen the presenting portion of the foetus has thus early, as it sometimes Avill do, passed low doAAm into the pelvic excavation, that the female will complain of a sense of numbness in her lower limbs, Avith occasional inability to move them with the usual alacrity—threatening, indeed, their entire loss of power, or paraplegia. This condition of things will necessarily give rise to much alarm, and it will be your duty to explain to the patient, not only the cause of these neuralgic pains, and of the menaced paraplegia, but also to assure her that both one and the other Avill be evanescent in their character, and are simply the results of the pressure of the prolapsed uterus and its contents against the sacral and other nerves of the pelvic canal. In some females, you Avill remark the exhibition of great anxiety —accompanied by remarkable depression—a short time before the 328 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. setting in of labor. They will become extremely nervous and irri- table, and it will require, on your part, sound judgment in your appeals to their good sense not to cherish feelings of despondency. I have generally observed that this depression usually manifests itself in women of a naturally morbid irritability, and it is impor- tant to control it, as far as may be, because, beyond certain limits, it may exercise a prejudicial influence on the confinement. Such, gentlemen, are some of the more notable of the indica- tions which precede the commencement of labor, and which, there- fore, have with much propriety been denominated preliminary or precursory. You must not, I repeat, confound the vesical irrita- tion, or the tenesmus, or the increased discharge of mucus from the vagina, which are but the effects of mechanical pressure, Avith morbid conditions of these organs. Suppose, for example, a mar- ried lady should send for you a few days before her confinement, and say to you, "Doctor, I am very much alarmed about myself; I am afraid I have some serious disease of the bladder." " Why do you think so, madam ? " " Because, sir, for the last few days I have had so much irritation in that part; I have a more or less constant desire to pass Avater.'' Now, gentlemen, it would be a very foolish thing, to use a mild expression, to mistake this irrita- tion of the bladder—simply a premonitory symptom of approach- ing labor—for disease of the organ, and hence subject your patient not only to useless, but, very probably, mischievous medication. Nor, if another lady complain of distressing tenesmus, must you hastily conclude that she is afflicted with dysentery, and therefore place Jier on the sick list, and convert her innocent and unoffending stomach into a veritable drug shop, for a malady which exists only in your own imagination. You must pardon me for calling your attention to these matters, but I am most anxious that you should, when you enter on the mission of duty, be able to trace effects to causes, and thus distinguish between the shadow and the substance. In these cases, the irritation of the bladder and rectum, like the neuralgic pains and threatened paraplegia—all results of a common antecedent—will disappear as soon as that antecedent, through the termination of delivery, has been removed; and so you must tell your patient. She will find you a true prophet, and consequently her faith in your skill and judgment will be greatly enhanced. Essential Signs.—The essential or characteristic signs of labor are four in number: 1. Pain; 2. Dilatation of the mouth of the womb; 3. A muco-sanguineous discharge; 4. Formation and rup- ture of the membranous sac, or " bag of waters." These four phenomena constitute the elements of labor; and do, in fact, make up its diagnosis. When they are present, parturition is undoubt- edly in progress, and hence they are properly named its charac- teristic indications. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 329 1. Pain.—Under ordinary circumstances, pain is the inevitable penalty of childbirth. " In sorrow shalt thou bring forth," is the decree of Heaven, and it has always seemed to me that the suffer- ing entailed upon the parturient woman but tends to strengthen and consolidate the undying love she cherishes for her offspring. The progress of science, through the application of anaesthetics, has, it is true, to a great extent, emancipated the lying-in chamber from the anguish incident to it, but it may be a question Avhether this interference with the role of nature has not, oftentimes, been productive of serious consequences. That the employment of anaesthetic agents, notwithstanding their undoubted value under judicious administration, has been sadly abused, will, I think, be conceded by every unprejudiced mind. But this is a subject upon which we shall have something to say in a succeeding lecture. Are the Pains of Labor, and the Contractions of the Uterus Identical ?—Those of you who have ever attended a case of labor, and witnessed the intense agony of the woman, will, perhaps, express more than ordinary surprise that certain authors should have endeavored to show that the process of childbirth is not one of suffering. It is nevertheless true that such demonstrations have been attempted, but to my mind they have failed most signally in their proof. Again : even among those, Avho admit one of the characteristic attributes of the parturient effort to be pain, there is much discrepancy of opinion as to the peculiar manner in which the pain is produced. Some writers, and, indeed, they constitute the great majority, maintain that the contractions of the Avomb, and the pains of labor are identical—but this, I think, is an error, and has, no doubt, led to some of the confusion Avhich exists on this subject. So far from the contractions of the uterus and the pains of labor being one and the same thing, I shall endeavor to prove to you—and I hope I may succeed in the development of the opinion—that labor pains are the direct consequences of the contractions, and that they hold to each other the relation of effect and cause. One of the essential conditions in support of this hypothesis is, that the contractions must precede the pain; and do they not ? Let us, for a moment, examine this question. Suppose you are attending a case of labor, Avhich has fairly com- menced—what do you observe ? Your patient, Avho may have had several severe pains, will, perhaps, be in pleasant conversation with you, Avhen suddenly she will exclaim, " Oh, there, doctor, I am going to have another pain." Properly translated, what is the true import of this language ? Why, it means simply that the patient becomes cognizant of a movement in the uterus, which is nothing but the incipient contraction, and experience has admo- nished her that this movement or contraction of the organ will immediately be followed by the pains of labor. Again: place 330 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. your hand on the abdomen of the patient in Avhom parturition has commenced, and you will, by a few seconds, anticipate the coming on of a pain, because you feel the uterus harden under your hand ; or, with the finger introduced into the vagina, you Avill know that a pain is about commencing the moment you feel the neck of the Avomb stiffening, if I may so term it, in response to the contractile effort. There is no speculation here ; it is a matter of fact, Avhich you can ascertain for yourselves in the very first case of labor which may present itself to your observation—sIioav- ing conclusively that the contraction precedes the pain—the former being the cause, the latter the effect. But, I can readily imagine you to say—well, for argument's sake, sir, we accept the hypothesis that uterine contraction and labor pain are not identical, and are truly cause and effect. This admission, hoAvever, you properly urge, does not explain to us how the contraction produces the pain. Well, gentlemen, I shall now endeavor to satisfy you on this point. In the first place, you must bear in mind that the object of the contraction of the gravid uterus is to afford an exit to the foetus and its appendages; and, in order to accomplish this end, there must of necessity be an opening made by these contractions in some portion of the organ, through Avhich the escape of the fcetus may be effected. It is the dilated os uteri which constitutes this opening, and the dilatation is mainly accom- plished by the contraction of the longitudinal muscular fibres, Avhich pass from above dowmvard parallel to the long axis of the organ, and Avhich, therefore, concentrate their whole force upon a given point,* viz. the mouth of the womb. When these longitudinal fibres contract, as a necessary consequence of that contraction, their previous physical condition undergoes tAvo important changes: 1. They shorten in their long axis ; 2. They increase in volume in their respective diameters. This increase in the diameters is, of course, the necessary result of the diminution in the length of the fibre. What, therefore, I desire especially to direct your attention to is this: When the respective muscular fibres of the gravid womb undergo this augmented volume, they must," as a consequence, exercise, for the time being, an unusual pressure on the nerves dis- tributed throughout this very muscular tissue ; and it is this pres- sure Avhich, I believe, in part, satisfactorily explains the phenomena of labor pain. When the contraction ceases, the pain ceases, for the reason that, in the absence of the contraction, the nerves enjoy * The fundus of the gravid womb undergoes a more marked development than any other portion of the organ; and if, in addition to this fact, it be recollected that the longitudinal muscular fibres exist in greater abundance there, it is easy to imagine the feeble resistance offered by the cervix, which is not only less developed, but more sparingly provided with muscular tissue. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 331 Rn immunity from pressure. While, therefore, I am disposed to thiqk that this, to a certain extent, is the true exposition of labor pain, yet I am inclined to adopt, in connexion with the theory of pressure, the views propounded by Dr. Brown-Sequard on this question. He maintains that the pain is partly due to the galvanic discharge caused by the muscular fibres under con- traction, and when they meet with resistance. It is the irritation of the sensitive nerves of the uterus, under the influence of that discharge, which he regards as a principal cause of the pain.* However, as labor advances, the increase of suffering can be traced to other sources. Such, for example, as the pressure of the foetal head against the os uteri during the process of dilatation; and, when the head has passed the mouth of the organ, its pressure on the walls of the vagina and outlet are additional causes of dis- tress ; add to this the irritation which the various pelvic nerves undergo from compression during the egress of the child, and you Avill at once see that the necessary consequence will be enhanced suffering, the susceptibility to which will depend much on the peculiar temperament of the individual. Division of Labor Pains.—Authors have divided labor pains into true and false ; and this distinction it is important for you, as practitioners, clearly to appreciate. True pain is the offspring of uterine contraction; in other words, it is synonymous Avith the existence of labor. False pain, on the contrary, has no connexion whatever Avith any movement of the uterus, and is the product of some cause entirely foreign to uterine contraction. It may be occa- sioned by flatus in the intestines, indigestion, diarrhoea, constipa- tion, disease of the kidneys, distension of the bladder, rheumatism of the uterus or adjacent muscles. There are few things, gentlemen, more essential for the accou- cheur than a just and prompt discrimination betAveen the true and spurious pains of labor. Without an accurate diagnosis on this point, he will be like the ship without its rudder; his progress Avill not only be uncertain, but will be unsafe, and sometimes, indeed, disastrous. Hoav, for example, Avithout the ability to dis- tinguish between these tAvo grades of pain, can you knoAv, Avhen summoned to the sick-room, whether or not your patient be in labor ? Failure in this particular will lead to much embarrassment, and oftentimes prove perilous, if not destructive, to your reputation. True Labor Pains.—These pains, remember, are always con- nected AA'ith the contraction of the uterus, and are slight and almost imperceptible at the beginning of labor. They are first felt in the back, and usually pass on to the thighs; they are distinctly recur- rent—that is, they are not continuous—but come on at intervals. * London Lancet. 1857. 332 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. They may be divided into two kinds—grinding or cutting pains at first; after the os uteri has advanced in its dilatation, they assume a bearing doAvn or forcing character. When the true pain is present, the entire area of the uterus becomes hard; and this change in its condition can readily be recognised by placing your hand on the abdomen. As soon as the pain subsides, the hardening of the uterus is followed by relaxation; again: if during the pain the finger be introduced into the vagina, and the os uteri dilated, the membranes will be felt slightly protruding, in response to the pain, and they will present to the finger a sense of resistance ; but Avith the discontinuance of the pain they cease to protrude, and become flaccid. Besides these characteristic evidences of true labor pain, the patient, during its presence, will manifest her sufferings by sup- pressed groans, or in some more marked way. As soon, however, as the pain has passed, she will not only be free from distress, but will join in agreeable conversation with you. Spurious, or False Pains.—These, as I have already remarked, are not connected writh any action of the uterus; for during their existence the organ will be in a state of entire tranquillity. They are more or less continuous, depending on the special cause Avhich may produce them, and are, therefore, not recurrent. It can scarcely be necessary for me to observe that these pains can only effectually be removed by tracing them to their proper source. For example, if from constipation or indigestion, aperients will be indicated. Should they be due to spasmodic action, or, as some- times -will be the case, to excessive fatigue, a gentle anodyne, in some form not inconsistent with the idiosyncrasy or peculiarity of your patient, will prove the remedy. These pains will not unfre- quently be the result of superabundance of acid in the primae viae; what better, under the circumstances, than the employment of antacids ? It may also happen that inflammatory action or febrile excitement has evoked this character of pain. General or local bleeding, with a judicious resort to purgatives, diaphoretics, etc., will constitute in these cases the elements of relief. II. Dilatation of the Os Uteri.—The doctrine has prevailed, and indeed it has among its supporters some clever names, that the mouth of the womb is opened by the foetus itself—that this latter, as it were, under the influence of a peculiar instinct, desires to be liberated from its accommodations, and therefore spontaneously, and upon its OAvn responsibility, makes a passage for its escape. It cannot be necessary to demonstrate the fallacy of this proposition —its absurdity must be apparent to all of you. We, consequently, are to seek for some other explanation of the true cause of the dilatation, which is so essential to the completion of labor. You must remember that the cervix of the uterus is well supplied with circular muscular fibres, and, as a general rule, they exercise a THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 333 Bpecies of guardianship over this particular portion of the organ. Were it not for them, constituting as they do, a veritable sphincter, the closure of the os would be imperfectly maintained. But as the object of labor is the expulsion of the fcetus, there is a necessity for an opening of the mouth of the uterus, and consequently a temporary surrender of the rigidity of these circular fibres. When the uterine contractions commence, the longitudinal muscular fibres are thrown into action, the result of which is a concentration of force, directed from above downward, falling on a common point or centre—the os uteri. The only resistance to this force will be the circular fibres. Through successive efforts, however, these yield to the more poAverful impulse of the longitudinal fibres, and the result is dilata- tion. Muscular contraction, therefore, may be regarded as the primary or efficient cause of the dilatation of the os uteri; but there arc also two secondary or auxiliary causes, which exercise their influence. The first of these is the "bag of waters;" the second the foetal head. For example, Avhen the dilatation has fairly commenced, the membranes with the liquor amnii will be forced through the opening, and, thus protruding, will exercise a uniform and gentle pressure against .the orifice. When the " bag of waters," through successive contractions, is ruptured, and the amniotic fluid escapes, then the head itself, by its pressure, forms a kind of wedge, which, acted upon by the contractions of the longitudinal fibres, contributes its part to the required dilatation. If proof be required that this is the process through which the opening of the mouth of the gravid womb is accomplished, you will find very substantial evidence of the fact in cases in which there is a marked want of parallelism between the long axis of the uterus and the axis of the superior strait of the pelvis. For in- stance : if there should be ante-version, retro-version, or a right lateral or left lateral obliquity of the organ, the consequence would be that the os, instead of corresponding more or less with the centre of the pelvic excavation, would present its anterior surface backAvard, forward, or laterally. In such case, the force of the contractile effort of the longitudinal fibres would lose its concen- tration, and consequently the dilatation would be greatly retarded, if, indeed, it were not altogether prevented.* We shall, hoAvever have occasion to allude to these malpositions of the uterus, as con- nected Avith childbirth, in a future lecture. There is one important and material point, in a practical vieAv, which you should not lose sight of, as regards the dilatation of the os uteri, and it is this: in the primipara it is much more tardy than in women who have already borne children ; and again, as a general principle, a longer time is required to effect an opening the size of a four-shilling piece than for the completion of the entire process. 334 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Here, allow me to remind you that, during the progress of dila- tation, the female is not unfrequently attacked Avith rigors or shi- vering fits, as they are sometimes called. These rigors should create no alarm Avhen they are simply the product of uterine contraction; on the contrary, I am disposed rather to regard them as favorable indications. You may, under the circumstances, administer warm tea or gruel, and assure your patient that she need feel no anxiety. But, gentlemen, there is another species of rigor in the lying-in room, which is not so innocent, and which may be the prelude of trouble. I mean those distressing chills, which sometimes occur in very pro- tracted labors, and Avhich are accompanied with furred tongue, excessive thirst, oppressed breathing, and a hard and accelerated pulse. These are usually rigors of danger, and will require all the vigilance of the accoucheur. They point to serious inflammatory action. The same observation applies to the vomiting which occurs during labor. It is not unusual for women to be affected Avith " sick stomach " during the stage of dilatation. This is regarded as a most favorable circumstance; it portends no evil, but, on the con- trary, it renders a material service through the relaxation it pro- duces, thus facilitating, among other things, the opening of the mouth of the womb. There is, however, another kind of vomiting, which will occasionally manifest itself after a long and tedious labor; and unfortunately it is but too often the precursor of death. Such is the vomiting, AA'hich occurs after or before full dilatation of the os uteri, with a suspension or entire cessation of contractions —a feeble and rapid pulse, great pain on the hand pressing the abdomen, a sunken countenance, with extreme pallor, and cold perspiration. This is the vomiting indicative of rupture of the uterus, one of the most alarming, because one of the most fatal of the contingencies of the lying-in chamber. III. A Muco-Sanguineous Discharge.—Another of the ordinarily characteristic signs of labor will be this discharge from the vagina ; but it will sometimes happen that there will be an absence of the discharge during the parturition, and this is known as a " dry labor." The mucous secretion is derived from the numerous little follicles in the cervix and vagina. It is poured out usually in great abundance at the close of gestation, and at the commencement of parturition. It is intended to answer a most important object—the relaxing and lubricating the parts, thus facilitating the approaching distension. Commonly, there is commingled with this secretion of mucus a slight tinge of blood, and it is known as the show. Some women will have this show several days before labor commences. The blood probably comes from rupture of the more minute vessels of the uterine orifice. IV. The Formation and Rupture of the Membranous Sac, or THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 335 Bag of Waters.—When describing the appendages of the foetus, and their relation to the uterus, you will remember I told you that the most internal of the membranes is the amnion, and that this incloses a fluid—the liquor amnii—in Avhich the foetus, as it were, floats. One of the first effects of the contraction of the uterus will fall upon the amniotic fluid; but as, from its very nature, this fluid is incompressible, and consequently its volume cannot be diminished, the impulse it receives from the contracting womb forces it to some point of the organ which presents the least resist- ance to its escape, and this point is the os uteri. As soon, there- fore, as the latter begins to dilate, there would be no obstacle to its exit, were it not that it is inclosed in the membranes. These membranes constitute a sac for the amniotic liquor; and, in pro- portion as the os uteri dilates, the loAver portion of this sac, dis- tended by the liquor amnii, protrudes. Under contraction it becomes hard and resisting; in the interval, on the contrary, it softens, and slightly recedes. This sac, as has already been stated, by its gentle and uniform pressure, assists materially in dilating the mouth of the womb; and you Avill observe in practice, that Avhen the os uteri is sufficiently open to allow the head of the foetus to pass, the sac becomes spontaneously ruptured. It will sometimes, however, occur that, owing to inordinate resistance of the mem- branes, it does not rupture. In such cases, when the os uteri is fully dilated, longer to respect its integrity would only be a useless protraction of the labor; and therefore it Avill be your duty to pro- ceed at once to effect its rupture, Avhich may be done by pressing the point of the index finger against the centre of the sac during a contraction. This, hoAvever, will not always answer, and I have occasionally been obliged to open the bag by grasping a fold of it during the interval of contractions, between the thumb and fore- finger. I have, indeed, met with cases in Avhich it became neces- sary to pierce the sac Avith the point of a bistoury. But this needs caution for feat of injuring the fcetus or adjacent soft parts. The practical fact which I have just mentioned, that there is, generally speaking, a spontaneous giving way of the " bag of wa- ters" as soon as the mouth of the uterus is sufficiently dilated to alloAV the head of the child to pass—is one full of interest, and should admonish you against an officious intrusion on the laAvs of nature. How often, for example, is a labor made protracted, and, as a consequence, the mother's strength exhausted, and the life of the fcetus endangered, through the otficiousness of the accoucheur in prematurely rupturing the sac. In doing so, an escape is afforded to the waters before the necessary dilatation is accomplished, thus entailing upon the female much unnecessary suffering, and involv- ing both her and the child in more or less peril. It should be recol- lected, as a sound maxim in midAvifery, that to rupture the mem 336 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. branes, except in certain cases urliich will be mentioned hereafter, before the os uteri is fully dilated, is bad practice. Let us examine this point for a moment. When the sac is ruptured, of course the amniotic fluid in more or less quantity escapes—therefore, in this premature rupture, and consequent loss of the fluid, nature is deprived, in the first place, of an important auxiliary in accomplish- ing the dilatation of the os; and secondly, as there is little or no fluid left in the womb to interpose betAveen the uterine Avails and fcetus, the latter will be exposed more or less to undue and pro- tracted pressure; in this Avay the umbilical cord is in danger of compression, thus interrupting the fceto-placental circulation, and consequently leading to the destruction of the child. In certain cases, you will meet Avith an exceedingly unyielding os —it will give but slightly, and the membranes Avill protrude in a conoidal form, stretching doAvn in this peculiar shape to the vulva itself. Be careful not to be deceived under these circumstances— do not mistake this abnormal form of the sac for one of the extre- mities of the child, an error Avhich has been committed, and which can only be avoided by a proper degree of caution. Finally, the child will occasionally come into the Avorld Avith a portion of the membranes over its head—this is known as the caul or hood, and is regarded by the ignorant as a circumstance most auspicious to the future of the child, for it is supposed that the caul is a certain pre- cursor of the high destiny of the little stranger. It cannot be necessary to say that such an opinion is but the offspring of super- stition, and, like many other things, has no foundation but in igno- rance and morbid imagination. LECTURE XXIV. Natural Labor: Conditions for—What is required on the part of the Mother; what on the part of the Fcetus—Hippocrates and Head Presentations in Natural Labor; Fallacy of his Opinion—Face Presentations in Natural Labor; Mechanism of— Diagnosis of Face Presentations; may be Confounded with Presentations of the Breech—Face Presentations in Dublin Lying-in Hospital—Error of Writers with regard to Version and Forceps Delivery in Face Presentations—Presentation of the Pelvic Extremities; the Breech, Feet, and Knees—Opinion of Hippocrates; his Direction for bringing down the Head in these Presentations—The Practice of A. Petit, Bounder, and others—Presentation of the Pelvic Extremities and Natu- ral Labor—Dr. Churchill's Statistics—Statistics of Dr. Collins; Deduction—Dr. Hunter on Management of Breech Presentations—Diagnosis of these Presenta- tions ; may be Confounded with those of the Shoulder; Prognosis—Are Breech Presentations necessarily Destructive to the Child ?—Do they in any way Com- promise the Safety of the Mother ?—Mechanism of Breech Presentations—Pre- sentation of the Feet; Diagnosis and Mechanism of—Presentation of the Knees; Diagnosis and Mechanism of. Gentlemen—Labor, to be natural, necessarily presupposes* the existence of certain conditions ; and it is, therefore, proper, that Ave should noAV examine in Avhat these conditions consist. Some of them refer to the mother ; others to the foetus. I. On the part of the Mother.—The pelvis must be well con- formed, exhibiting a capacity sufficient for the exit of the child; the mother possess strength adequate to the wants of the delivery; the gravid uterus parallel, or nearly so, to the axis of the superior strait; the os uteri, vagina, and vulva sufficiently yielding to the forces of expulsion; and these latter should possess the requisite degree of efficiency. It must be quite evident to you that these conditions are essentially material to the accomplishment of deli- very by the unaided efforts of nature. For example, if the pelvis be so diminished in size as to render it physically impossible for the child to pass, the interposition of art will be called for, and there- fore, in such case, the labor ceases to be natural; so it is Avith the other prerequisites. How, for instance, could the expulsion of the fcetus be effected by the resources of nature, if the uterus, instead of being in its long axis parallel, or nearly so, to the axis of the brim, should be in a state of ante-version, retro-version, or exhibit a decided right or left obliquity ? In either of these malpositions of the organ, the cervix, in lieu of regarding the pelvic cavity, would be turned toward the sacrum, s\'mphvsis pubis, or to one or 22 338 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. other of the lateral walls of the pelvis, so that the whole force of the uterine effort would be negative in its influence, because of the resistance of the bony structure of the pelvic canal.* II. On the part of the Fetus.—The foetus, in its parent's womb, is doubled upon itself in such way as to preserve an ovoid form; this ovoid is divided, for practical purposes, into the superior and pelvic extremities—the superior embracing the head—while the pelvic extremities include the breech, knees, and feet. It is, there- fore, necessary, in natural labor, that one of the extremities of the ovoid should be present, viz., either the head, breech, knees or feet. In either of these presentations, all things being equal, or, in other words, in the absence of any complication, the resources of nature will be adequate to accomplish the delivery. I am aware that the presentation of the pelvic extremities is usually regarded as preter- natural, calling for the interference of the accoucheur; and this lat- ter opinion, I am sure, has often led to hasty and unnecessary action, resulting frequently in disaster to the child, and more or less injury to the mother. The idea that, in natural labor, the head must present, is a very ancient one; it originated with Hippocrates himself. The Father of Medicine very aptly illustrated the relation of the foetus to the womb by comparing it to an olive in a long-necked bottle. He Baid, that in order to afford escape to the olive one of its extremities must present. This is perfectly true, and applies Avith equal force to the exit of the fcetus. But, strange to say, with all the truthful- ness of the comparison, he taught that for the child to be expelled by the unaided resources of nature, consistently with the safety of both mother and fcetus, an essential prerequisite is—that its head should present at the superior strait.* The authority of the illustri- ous Father of Medicine on this question has not been without its effect; it has introduced bad practice into the lying-in chamber; it has caused the accoucheur to be officious, Avhen he should trust to nature—it has, in a word, inducted him to a " meddlesome mid- wifery " in all cases of pelvic presentations; for, under the convic- tion that this presentation is contrary to nature, he has, as soon as he ascertained its existence, proceeded by ill-advised efforts to terminate the delivery. * These obliquities of the organ may often be corrected by change of position on the part of the female, or through the Ekiltul manipulation of the accoucheur; and whenever they exist so completely as to embarrass delivery, prompt assistance should be rendered in order to remove them. f Ut enim si quis in lecythum angustffi oris olivse nucleum immittat, hunc trans- versar iumeducere non facile est; sic sane mulieri est gravis affectio, ubi fcetus traus- versarius ruerit; etenim ipsum exire per arduum: grave vero etiam est, si in pedes prodierit et plerumque aut matres aut puellae aut ambo, pereunt. Est autem et haec magna causa cur non facile exeat, si mortuus aut sideratus aut duplicatus me- rit. [De Mulier. Morb. lib. 1, torn, vi] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 339 This, I maintain, is all wrong; nature, under ordinary circum- stances, being quite as adequate to accomplish the labor when the pelvic extremities present, as when the head comes first. At the same time, it must be conceded that, as a general principle, dehvery in head presentations is more advantageous for both mother and child. What I wish to impress upon you is this—do not, simply because the breech, knees, or feet are found at the upper strait, therefore conclude that interference is called for. Besides the conditions for natural labor already mentioned, it is essential that there be no disproportion between the dimensions of the fcetus and the pelvis through which it has to pass. Again : the adhesions of the placenta to the uterus should not be such as to resist the efforts of the latter to detach it; nor should the umbilical cord be relatively or positively too short. Presentations of Foetus in Natural Labor.—So far as regards the presentations of the fcetus in natural labor, they may be enume- rated as follows: 1. The vertex; 2. The face; 3. The breech; 4. The feet; 5. The knees. In either of these presentations, therefore, I wish you to recollect, if there arise nothing to compli- cate the delivery, nature can, by her own resources, accomplish the expulsion of the child ; and it must be borne in mind that any other region of the head, except the vertex and face, is preter- natural ; to this fact, hoAvever, your attention will be more par- ticularly drawn when treating of preternatural labor. We have already described the mechanism by which the head is made to pass through the pelvic canal in a vertex presentation,* and shall now speak of the interesting subject of face presentations. Statistics of Face Presentations.—Instances in which the face is found at the superior strait are comparatively rare; occurring, according to statistics derived by Dr. Churchill, from British, French, and German sources, 1167 times in 260,817 cases, or about one in 223^-. f The majority of writers class this presentation among preternatural labors; but I cannot understand why—for it is a matter of clear observation that nature is perfectly competent to effect the delivery if left alone. Indeed, it is a very significant fact, well worthy of reflection, and amply proved by statistics, that, in face presentations, death, among both mothers and children, is most frequent when science attempts to interpose. This is an important circumstance, and should inspire you with renewed con- fidence in the ability of nature in this species of labor. In the Dublin Lying-in Hospital, under the mastership of Dr. Collins, in I 16,654 births, there were thirty-three presentations of the face; , these cases Avere all submitted to the natural process, and all the children born alive, except four, one of Avhich was acephalous. J In * See Lecture IV. f Churchill, fourth London edition, p. 410. X A Practical Treatise oia Midwifery, by Robert Collins, M.D., p. 32. , )1% 340 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the same well-conducted charity, under the mastership of Dr. Shekleton, as reported by Drs. Johnston and Sinclair, in 13,748 deliveries, the face presented thirty-one times, all the children born alive, except six, and recovery of all the mothers but one, she having died of peritonitis. Of the six children born dead, one Avas an acephalous monster, one sunk from pressure of a loop of the cord, and the death of another was ascribed to a beating to Avhich its mother had been subjected.* f/$ /i-*-^ «■■■■ • l- a <■'.' These statistics I regard most interesting in their practical bear- ings, and, to my mind, are irresistibly conclusive—if proof be needed—as to the propriety of classing face presentations among those of natural labor, f And again, they demonstrate Iioav well nature is prepared to discharge her duty Avhen not encroached upon by unwarrantable officiousness. It is the opinion of some writers that, in all cases in which the face presents, an attempt should be made to bring down the vertex; others recommend in these instances version, while some are more Avedded to the forceps as the only means of terminating the delivery. These various directions, gentlemen, do well enough, perhaps, in the books, but they are utterly out of place at the bedside of the parturient woman. Diagnosis.—It will be difficult, under ordinary circumstances, positively to decide that the face presents, previously to the rupture of the membranous sac; but after this has taken place, an attentive examination per vaginam will soon disclose the true nature of the presentation. The first circumstance which will become obvious, is the marked irregularity of the surface of the part Avith which the finger comes in contact; then the different features will be felt and recognised, such as the eyes, nose, and mouth. Occasionally, how- ever, when severe pressure has been exerted by the uterus, the general character of the face will be so altered by the tumefaction it has undergone, as to render it difficult to decide at once the question of presentation. It is in these cases of compression of the parts, that the eye may be mistaken for the external organs of generation in the female foetus, or the nose for the penis in the male. The face is mere likely to be confounded with the breech than with any other portion of the fcetus; when, for example, the finger reaches the malar bone, this latter may, without due caution, be mistaken for one or other of the tuberosities of the ischium; all doubt, however, will be at an end if the finger should distinctly feel the mouth and gums of the child. Let me here advise you of the importance, as far as may be, of the early recognition of a face * Practical Midwifery. By Drs. Johnson and Sinclair, p. 75. \ In the deliveries under my direction in the Royal Maternity and other charities, the face presentations alone have been 110; of these, 102 were born living, under the natural efforts. Of the eight still-born children, in the above number of face present- ations, one was in a putrid state, and had been dead long before labor set in. [Illus- trations of Difficult Parturition. By John Hall Davis, M.D. London, 1858. Page 7.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 341 presentation; repeated vaginal examinations in these cases will necessarily expose the child to more or less danger. For instance: the eye would incur the risk of injury, if indeed it were not destroyed, by the too frequent introduction of the finger. You might, perhaps, suppose that a positive evidence of a breech presentation would be the discharge of meconium ; this, however, is not so. I have met with instances in which the meconium has passed into the vagina in head presentations, and this may occur in cases in which any extraordinary pressure is exercised on the body of the child by the contracting uterus. Prognosis.—It is, I think, quite consistent with the results of practice to say, that the child is ordinarily born alive in presenta- tions of the face ; and the convalescence of the mother as favorable as in an ordinary vertex delivery. It is not unusual, however, for the child to come into the world with its features extremely dis- torted, owing to the general swelling of the face ; but this in a feAV days will disappear, and in no way compromises the life or health of the infant. Looking at the facts as they exhibit themselves in the lying-in chamber, the face will be found, as a general rule, to present at the superior strait in one of tAvo positions, al- though, occasionally, there will be variations. The me- chanism, however, by which the head makes its transit through the pelvic canal is essentially the same. Presentation of the Face in the First Position.—In this position, the finger being introduced into the vagina, and carried up to the mouth of the uterus, will feel the nose; in passing the finger from the right to the left side of the pelvis, along the dorsum or back of the nose, the coro- nal suture will be recognised; this proves evidently that the fore- head of the fcetus is toward the left iliac bone ; and, consequently, the chin will regard the right ilium (Fig. 48); so that the fronto- mental diameter of the face is in apposition or correspondence with the transverse or bis-iliac diameter of the superior strait; while, on the contrary, the transverse diameter of the face is parallel to the Bacro-pubic diameter of the pelvis, in the first position; and hence Fig. 48. 342 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. it is called the right mento-iliac. According to Naegele, in this position the right side of the face is slightly loAver than the left. In response to the contractile efforts of the Avomb, the head is made to descend into the pelvic cavity; it there undergoes a rotary movement, which so changes its relation that the fronto-mental diameter of the face accords with the right oblique diameter of the pelvis, and the chin is opposite to the right foramen ovale; the chin is next brought behind the symphysis pubis, and the forehead turned into the cavity of the sacrum (Fig. 49). From what has just been said, it is obvious that the forehead is obliged to traverse the anterior surface of the sacrum, Avhile the chin descends only the length of the symphysis pubis, in order to reach the inferior strait. The progress of the face having been thus far accomplished, the chin, under the expulsive influence ol the uterus, is made to pass under the symphysis pubis, while the occiput is pushed downward, and the flexion or disengagement of the head is completed. Here let me caution you to guard with great care the perinaeum during the progress of the dehvery, for the distension which it is called upon to undergo in the descent of the face is much greater than in a vertex presenta- tion ; and, without a due de- gree of vigilance, rupture may take place, always an unpleasant complication of childbirth, and sometimes re- sulting seriously to the mo- ther. When the head has passed the vulva, the face is turned upward. As the deli- very proceeds, the head un- dergoes the movement of external rotation in the same way that this movement oc- curs in the presentation of the vertex, and which has been described in a previous lec- ture. Presentation of the Face in the Second Position.—In this position, which is precisely the reverse of the first, the fore- Fio. 60. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 343 head is tOAvards the right iliac bone, while the chin regards the opposite point of the pelvis (Fig. 50). On a vaginal examination, the finger, if directed along the dorsal surface of the nose to the left, will distinctly feel the nostrils, while the coronal suture will be found to the right; thus showing a reverse position, and consti- tuting the left mento-iliac position of the face. The mechanism of passage in the second position of the face is, in all respects, the same as in the first, excepting that, in consequence of the change in the direction of the face at the superior strait, the movement of rotation is from left to right, instead of from right to left. It is well to remember that, in face presentations, the duration of labor will usually be more or less protracted, for the reason that the bones of the face not undergoing compression, as is the case Avith those of the cranium, do not mould themselves to the form of the pelvis, and consequently a more lengthened duration and greater effort are necessary for the transmission of the parts through the pelvic canal. It is an error, however, to suppose that the safety of the child is necessarily dependent upon the shortness of the labor. You will sometimes have occasion to note the falsity of such an opinion. The error frequently leads to officiousness on the part of the accoucheur, and consequent injury to mother and child. In- deed, I am disposed to say that, all things being equal, slow births are generally safe births. Permit me to enforce this upon you as a maxim in the lying-in chamber; it is, as you must perceive, strictly conservative, and at the same time strictly true. Presentation of the Pelvic Extremities.—I have told you that, when either of the pelvic extremities is found to present at the superior strait, nature will be competent to achieve the deliver}', unless something, other than the mere presentation, should inter- fere, calling for the assistance of the accoucheur. You Avill read in the books some very contradictory opinions upon the subject of these presentations; and you will be not a little surprised at the conflicting rules inculcated for their management. For example, as has already been stated, Hippocrates regarded this character of presentation as contrary to nature ; his direction was, whenever the breech, feet, or knees were discovered at the upper strait, to introduce the hand, and, through the operation of version, to bring doAvn the head ! Again : the doctrine has prevailed, and been sus- tained by Antoine Petit, Bounder, and others, that the most natural presentation is Avhen the feet come first; and, in keeping Avith this opinion, it was suggested that, in cases of head presenta- tion, the accoucheur, should turn and bring down the feet. But, gentlemen, it is not necessary to refer more at length to the Aarious opinions of authors on this question. The substantial point for you to remember, and Avhich will serve you AArhen at the bedside of your patient is, that the presentation of the pelvic extremities is 344 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. undoubtedly entitled, for the reasons already mentioned, to be classi- fied as perfectly consistent with natural labor. I. Presentation of the Breech.—The nates or breech present much more frequently at the superior strait than either the feet or knees. Dr. Churchill, with his usual industry, has furnished some interesting statistics, touching the frequency of breech presenta- tions, taken from the records of British, French, and German practice. In an aggregate of 197,318 cases, the breech presented 3325 times, or about 1 in 59^; and in 1148 cases, all he has been able to collect, 337 children were lost, or about 1 in 3£. At first sight, this would appear to be a great mortality; but it must be recollected that these tables are derived from very mixed sources— that is, in many instances, no doubt, the presentation of the breech being regarded as preternatural, artificial aid was had recourse to, and in this way, it is not at all improbable that the safety of the child was compromised. In order to show the actual as well as the relative fatality to the child, in this form of presentation, it does seem to me that an essential prerequisite for such data would be, to derive our facts from those cases which had been entirely confided to nature, and where, consequently, there had been no in- terruption to the natural process by premature or unjustifiable interference. We should then be better able to approximate a just comparison, all things being equal, between the proportion of children lost in breech and vertex presentations.* The presentation of the breech was formerly regarded as one of great danger, because it Avas supposed that the child thus, as it were, doubled on itself, could not have sufficient space to enable it to be transmitted through the pelvis. This opinion, however, is without foundation, for the parts composing the breech are quite compressible, and will yield to the forces of the uterus. Based upon the apprehension that the breech could not pass, it was a favorite practice among some of the English accoucheurs always to interpose, endeavor to push it upward, and then search for the feet, * Dr. Collins, who recommends that, in the absence of any complication, there should be no interference in breech presentations, reports this presentation to have occurred 242 times in 16,654 deliveries. Of these 242 children, 73 were still-born, of which 42 were putrid. Forty of the 242 were premature births, 28 of which were still-born. Fourteen of the 28 were born at the eighth month ; twelve at the seventh; one at the sixth; and one at the fifth. Twenty-six of the 28 were putrid. / Twelve of the 40 premature children were born alive, viz., two at the sixth month ; seven at the seventh; and three at the eighth month. These statistics are extremely interesting and, as far as they go, are decidedly in favor of the position I have as- sumed. It is but fair, I think, to deduct from the 73 still-born cases, the 28 prema- ture births, which were also still-born, for as 26 of the 28 were putrid, it is strong proof that their death was altogether unconnected with the particular form of presen- tation. Therefore, Dr. Collins' statistics will give us 45 still-born children in 242 breech presentations, or about 1 in 5 1-2, which it will be perceived differ widelj from the results furnished by Dr. ChurchilL THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 345 and deliver the child in this manner. Such practice Avas not only bad practice, for it had no justification Avhatever, but it Avas most destruc- tive to the child, and, at the same time, full of peril to the mother. I can afford you no better admonition upon this subject, than by recording the experience of Dr. Hunter, Avho, in the commencement of his professional career, became so imbued with the prevailing opinion at that time, that he adopted it, but soon found cause for its repudiation. " When," says he, " I first began practice, I fol- lowed the old doctrines in breech presentation, although I did not like them ; but yet dared not broach new ones, till I got myself a little on in life ; at this time I lost the child in almost all the breech cases ; but since I ha\re left these cases to nature I always suc- ceed."* There is much good sense in this observation of Hunter, and it demonstrates the folly of blind obedience to mere opinion. Diagnosis.—It will, in general, be extremely difficult to recog- nise a breech presentation before the rupture of the " bag of waters ;" but after the escape of the amniotic liquor, a careful ex- amination will enable you to detect the nates at the upper strait; the finger will feel a rounded tumor, softer than the head, and im- parting somewhat of an elastic sensation; the cleft between the nates and the organs of generation will also be important guides; there is usually, likewise, in this presentation, a discharge of meconium. In consequence of the great tumefaction of the face, and the necessary alteration of its features, errors have sometimes been committed by confounding it with the breech of the infant. Indeed, under certain circumstances, it will need more than ordinary circumspection to avoid the blunder. HoAvever, as has already been remarked, the recognition of the mouth and gums, together with the nose, will readily dissipate all embarrassment. In Avomen, Avhose abdominal Avails are not loaded with adipose or fatty matter, and Avhich, in consequence of previous births, are in a state of more or less relaxation, it will sometimes be possible to feel quite distinctly, through these walls, the head of the fcetus turned upAvard. This is a very positive indication, in case of a single pregnancy, that one of the pelvic extremities presents, and Avhich it is, must be determined by a vaginal examination. Again: a strong evidence of this kind of presentation is disclosed by the fact of your being able to detect the pulsations of the fcetal heart on a level with, or above the umbilicus. It is an interesting circumstance that, AA'hen the fcetus is dead, the anus is open, so that the apex of the finger maybe introduced; but Avhen alive, it is closed. As the nose is an important guide in face presentations, so the coccyx is Avhen the nates present, not only indicating the character of the presentation, but also the true position of the part. It is possible to confound the breech with * Hunter's Lectures, MS., 1768. 346 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the shoulder, and it is essential that the distinction should be made early, for, as we shall tell you, Avhen speaking of the management of a shoulder presentation, it is very important that a correct diagnosis be arrived at before the labor is far advanced. The acromion pro cess, without a due degree of care, may be mistaken for the tuberosity of the ischium; but the absence of the ribs, Avhich can be easily felt in a shoulder presentation, will remove all doubt upon the subject. Prognosis.—Although it is unquestionably true that, Avhen the pelvic extremities present, nature is competent to accomplish the delivery, yet it must not be forgotten that the mortality to the children is much greater than in vertex presentations; and, I am inclined to refer, with most authors, this increased mortality to the undue pressure exerted on the umbilical cord, thus interrupting the circulation between the foetus and placenta. The death of the child may also be the result of delay in the delivery of the head, after the other portions have passed into the world. Notwith- standing this comparative mortality of the child in pelvic presenta- tions, yet it cannot be denied that the danger is much enhanced, and the fatality, therefore, augmented by the officiousness of the accoucheur, in not submitting these cases to nature. As regards the mother, there is no more danger in a pelvic than in a vertex presentation ; and, contrary to the generally received opinion, when the breech presents, the labor is usually more favor- able and shorter than when the feet are found at the superior strait. It is not difficult to explain this circumstance. As soon as the nates begin to descend into the pelvic excavation, they produce upon the surrounding parts a pressure, which immediately calls into action the tributary influence of the spinal cord, thus adding vigor and efficiency to the contractions of the uterus. This, as is evident, is not the case when the feet pre- sent first, for the reason that the diminished volume of the pre- senting parts is incapable of making the degree of pressure necessary to evoke the reflex action of the cord. The breech, feet, and knees may assume four different posi- tions at the superior strait, and we shall now proceed briefly to describe the mechanism of trans- mission in each of these positions. First Position of the Breech. —The sacrum of the fcetus regards the left acetabulum (Fig. 51), constituting the left anterior sacral position. Here, the nates, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 347 back, and occiput, correspond to the left anterior portion of the uterus and pelvis, while the abdomen, chest, and face regard the right posterior portion. It will thus be seen that the nates present at first diagonally at the superior strait; but as, in response to the contractile efforts of the uterus, they are made to descend, the right is turned toward the sacrum, the con- cavity of which it pursues (Fig. 52), while the left is placed under the pubes, forming, as it were, for the other a point of Fig. 52. Fig. 63. support. During the progress of the delivery, the right hip appears first at the vulva (Fig. 53), and then the trunk is expelled, being slightly curved in the direction of the pubes. As soon as the breech makes pressure on the perineum, great care should be exercised in giving proper support to the latter, in order to prevent rupture; and, as the hips pass out of the vulva, a loop should be made of the cord, by draAving down a small portion of it. If the pulsations be found to grow weak, the delivery should be hastened by tractions on the body of the child, as will be described when speaking of preternatural labor. The arms, because of the resistance offered them by the brim of the pelvis, will occasionally ascend toward the face so as to become extended on the lateral portions of the head ; the shoulders descend diagonally at the superior strait, the right, which is posterior, appearing before the left, which is in front; in the pelvic cavity they undergo the movement of rotation, which, of course, places them in the direct position at the inferior strait, whence their expulsion is soon followed by that of the arms. The head passes from the superior strait into the pelvic excavation in a flexed con- dition, the chin being approximated to the sternum, the occiput turned toAvard the pubes, and the face toAvard the sacrum; thus, with the neck under the arcade of the pubes, and the face resting against the coccyx and perineum, the chin escapes from the vulva, and the delivery is completed. Second Position of the Breech.—The sacrum regards the right acetabulum—the right anterior sacral position. Here, the nates, back, and occiput, are in front, and to the right; the abdomen, 848 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. chest, and face behind, and to the left. The mechanism in this position, is fundamentally the same as in the first. Third Position of the Breech.—The sacrum corresponds with the right sacro-iliac symphysis—the right posterior sacral position —the breech, back, and occiput being behind, and to the right, while the abdomen, chest, and face are in front, and to the left. This position is the reverse of the first, and the same mechanism causes the delivery of the child. The head, however, Avill experi- ence somewhat more difficulty in its egress, from the fact that the face is obliged to glide along the symphysis pubis, while the occi- put is passing the hollow of the sacrum, the coccyx, and perineum.* The head, in its exit from the vulva, becomes extended, so that the chin first,f and successively the mouth, nose, and forehead emerge from under the pubes.J Fourth Position of the Breech.—The sacrum corresponds with the left sacro-iliac symphysis, and is the reverse of the second—the left posterior sacral position—the breech, back, and occiput are behind, and to the left; the abdomen, chest, and visage in front, and to the right. Here again, the mechanism is precisely the same as in the preceding position. It is worthy of remark that, in the various breech presentations, the inferior extremities almost always remain flexed lengthwise upon the trunk, and usually pass out of the vulva simultaneously with the head. Presentation of the Feet.§—When the feet present, it is possible * In addition, in these posterior sacral positions, the head of the child will be very apt to be obstructed by the chin catching, as it were, upon the ramus of the pubes, giving rise necessarily to a protracted delay, and involving, in more or less peril, the safety of the infant. In order to prevent this difficulty, as soon as the hips are being delivered—if nature have not spontaneously changed the position, which she sometimes, though rarely, does—the hips should be gently grasped by the two hands, and the body of the child rotated upon its long axis, for the purpose of converting the posterior sacral into one or other of the anterior sacral positions; the third being changed into the second, and the fourth into the first. f Dr. Ramsbotham says, " I believe that in no instance, if the case were left entirely to nature, provided the child and pelvis were of common size and form, would the face be expelled under the arch of the pubes." This is adverse to my observation on the subject, and is certainly not consistent with the evidence fur- nished by the lying-in room. [Ramsbotham's System of Obstetrios. Keating'a edition, p. 327.] { It will sometimes happen, as an exceptional circumstance, that the face, under the influence of a strong contraction of the uterus, will be turned from the symphy- sis pubis into the hollow of the sacrum, and the body of the child will also partici- pate in this semicircular movement. It was Naegele who first directed attention to this fact, and observed it to occur only when the foetus was small, and not at full time. Scanzoni, however, records two instances of this conversion, in which it took place when the foetuses were large, and had completed their intra-uterine life. § In 192,174 cases, there were observed 1831 foot or knee presentations, or about 1 in 105. The mortality to the children 1 in 2J.—[Churchill's Midwifery, 4th Lon- don Edition, p. 427.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 349 to confound them with the hand of the foetus; and this, you may readily imagine, would result in a serious complication of the labor. For example, suppose the accoucheur, always in the habit of inter- fering in these cases, because he believes them preternatural, should seize the hand at the superior strait, and, mistaking it for the foot, make traction, and bring it down into the vagina. It Avould then be too late to repair his error, for he would find it not so easy a thing to replace the hand. Diagnosis.—The diagnosis of a foot presentation is not difficult; it only needs thought and judgment to make the proper distinction. In the first place, the foot is thicker and larger than the hand ; the toes are shorter than the fingers, the great toe being near its fel- lows, Avhile the thumb is separated from the fingers; the foot is narrow, the hand is broad and flat; the foot is at a right angle with the leg; the hand, on the contrary, is, as it were, but an extension of the forearm. First Position of the Feet.—The heels regard the left acetabu- lum, and the toes the right sacro-iliac symphysis—the left anterior- calcaneo position. The breech, back, and occiput are toAvard the left anterior portion of the uterus and pelvis; the abdomen, chest, and face toward the right posterior portion. As in the case of breech presentation, the feet cannot be readily recognised until after the rupture of the membranous sac. Second Position of the Feet.—The heels regard the right aceta- bulum, the toes the left sacro-iliac symphysis—the right anterior- calcaneo position. The breech, back, and occiput in front, and to the right; the abdomen, chest, and face behind, and to the left. Third Position of the Feet.—The heels regard the right sacro- iliac symphysis ; and the toes the left acetabulum, being the reverse of the first position—the right posterior-calcaneo position. The breech, back, and occiput behind, and to the right; the abdomen, chest, and face, in front, and to the left. Fourth. Position of the Feet.—In this position, the reverse of the second, the heels are turned toward the left sacro-iliac symphy- sis, and the toes toAvard the right acetabulum; the left posterior- calcaneo position. The breech, back, and occiput, behind, and to the left; the abdomen, chest, and face in front, and to the right. In the various positions of the feet, the mechanism, after the escape of these latter, is precisely the same as in the breech pre- sentations; and, therefore, it is unnecessary to repeat what we have said on the subject. FirstPosition of the Knees.—The tibiae correspond with the left acetabulum, and the thighs with the right sacro-iliac symphysis— left anterior-tibialposition. Second Position of the Knees.—The tibiae at the right acetabu 850 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. lum, the thighs at the left sacro-iliac symphysis—right anterior- tibial position. Third Position of the Knees.—The tibia1 to the right sacro-iliac symphysis; the thighs to the left acetabulum; this is the reverse of the first position—the right posterior-tibial. Fourth Position of the Knees.—The tibiae to the left sacro-iliac symphysis ; the thighs to the right acetabulum, the reverse of the second position—the leftposterior-tibial. As soon as the knees are expelled, the various positions are reduced to the corresponding positions of the feet. Without care, it may be possible to confound the knee, especially when only one can be felt at the superior strait, Avith the elbow or shoulder. In the case of the elbow, the olecranon process and condyles will serve as guides, while the ribs and axilla will determine the fact of a shoulder presentation. It will be seen that I have not spoken of the management of pelvic presentations in cases in which the labor becomes complicated, and in which consequently it will be necessary for the accoucheur to interpose. This subject will be discussed in a future lecture, when treating of preternatural labor. LECTURE XXV. The young Accoucheur's Debut in the Lying-in Chamber—What he is to do, and what he is not to do; his Chat with the Nurse—The Examination per Vaginam; how it is conducted, and what it should reveal—Is the Patient Pregnant ?—Is she actually in Labor ?—Are the Pelvis and Soft Parts Normal or otherwise ? A "Woman may imagine herself in Labor, and yet not be Pregnant; Illustration— What is the Presentation of the Fcetus?—Is it Natural or Preternatural?—What will be the Duration of the Labor ?—How this question is to be answered— When Labor has commenced, the Bowels and Bladder to be attended to—Quietude of the Lying-in Woman important; Loquacity of the Nurse—The Stages of Labor; what are they?—Conduct of the Accoucheur during each of these Stapes —After the Escape of the Head, Rule to be followed—When the entire Expul- sion of the Foetus is completed, important rule to be observed—How many Liga- tures are to be applied to the Cord ?—The Author recommends but one—Reasons for—Trismus Nascentium, and Inflammation of the Umbilical Vessels ; Scholer's Opinion—When the Child is separated from the Mother, what is to be done?— Respiration of the Infant; Causes which Impede it—Asphyxia; Causes of— Treatment of Asphyxia—Marshall Hall's Method—Ability to resist Asphyxia greater in the New-Born Infant than in the Adult—The Opinion of Brachet, of Lyons, Josat, and others, as to the Restoration of Life some time after the Pulsa- tions of the Heart have ceased—Death of the Mother not necessarily Fatal to Foetus in Utero; Why ?—Brown-Sequard's Experiments. Gentlemen—We will noAV suppose that your services are demanded in a case of labor; and shall, therefore, proceed to speak of the duties devolving upon you at the bedside of your patient. The first entrance of the young accoucheur into the lying-in chamber is a matter of no little importance. In the first place, he has popular prejudice to contend Avith; he is not " an old gentleman, and con- sequently knows nothing of his business." The only means of putting an end to this prejudice, and of demonstrating that, although not a patriarch in years, yet he is nevertheless fully com- petent to the discharge of his duties, is his conduct after he crosses the threshold of the parturient room. One mistake in his debut in obstetric practice may exert a singularly unhappy influence over his future prospects; should he, on the contrary, make a favorable impression in his first case, the best consequences may ensue to him. Something more is required of the accoucheur, if he wish to suc- ceed, than a profound knowledge of his subject: conjoined to an intimate acquaintance with the varied details of the sick-room, he must understand human nature ; he must discriminate between a harmless concession to popular whim or caprice, and a concession 352 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. which may compromise his OAvn character and the dignity of his art. In a Avord, he is constantly to bear in mind the full measure of his responsibility. Punctuality and promptness, in responding to professional calls, are especially important in the practice of obstetric medicine. A messenger has arrived, requesting the immediate attendance of the accoucheur. The latter proceeds Avithout delay to the residence of the patient; he rings the bell; he is admitted ; and if this should be his first professional visit to the family, all eyes will naturally be turned toward him, surveying him with marked care; if he falter under the scrutinizing gaze, it will very likely be attributed to Avant of professional skill! His general bearing, as soon as he enters the house of his patient, should be that of a well-bred gentleman; he should manifest no excitement, but his conduct be such as to impress the conviction that he is accustomed to these calls, and understands how to comport himself. Soon after being introduced into the parlor, the nurse will probably leave the patient for the purpose of having a little preliminary chat Avith the doctor. In this interview Avith the nurse, if adroitly conducted, much can be learned as to the general condition of the patient—whether it is her first child—whether the labor has regularly commenced, Avhether she has suffered unusually from her pains, whether she is nervous and irritable, whether she is agitated at the doctor's arrival. These preliminaries over, the nurse then leaves Avith the promise that, in a few minutes she will return, and conduct you to the sick room. When you enter the room, your patient will be reclining on the bed or sofa, or sitting in a chair. In either case, you approach her gently and courteously, and, instead of saying, " Well, madam, you are about to have a baby—does it hurt much?" or some such kindred expression, bearing the impress of a vulgar mind—I say, in lieu of such rudeness, you enter into conversation with her, talking of any and everything except of the subject directly connected with the object of your visit. Talk of France, or Egypt, or Kamschatka, or the marine telegraph; in this way, a little professional diplomacy will enable you very successfully to accustom your patient to your presence. The first interview has passed; she finds that, after all, it is not such an embarrassing thing to hold converse with a doctor, and you will have impressed her quite favorably merely by your manner. She will rather like you, and will be apt, as soon as occa- sion presents itself, to say to the nurse—" What a clever man that is; he is so very agreeable." "Yes, madam," replies the nurse, u he knows what he is about." These mutual compliments between patient and nurse give you a substratum in that family; your authority will be hearkened to, and you will haye achieved an early and important victory. Well, thus much for the first scene—what next ? THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. 353 The object in sending for you was of course to have the benefit of your counsel and skill; as soon, therefore, as you have fairly introduced yourself to your patient, it will then be essential to become satisfied as to her true condition; to do this it will be necessary to institute a vaginal examination. For this purpose, you speak to the nurse, and tell her that you are anxious to ascertain how things are progressing. This is communicated by the nurse to the patient, and her assent is readily obtained; for, as a general rule, she will be found most solicitous to knoAV if " all is right.'' Allow me here to call attention to some few details in reference to this first examination. The patient should be in the recumbent position, either on her side or back; and whichever position may be assumed, it is important that she be near the edge of the bed, so that you may have every facility for conducting the examination. While the nurse is arranging the patient, you AA'ill generally be requested for the time being, to walk into an adjoining room ; but if not, be careful that you occupy yourself Avith something else than gazing at the movements of the parties; take a seat, and turn your back ; become thoughtful, as if lost in the solution of some great professional problem ; or, if a book be at hand, open it, and improve your mind. When everything has been arranged, you then proceed to make the examination, the mode of doing which has already been pointed out in Lecture XIII., to which I refer you. When you are summoned to at- tend a lady Avho supposes herself to be in labor, the examination which you institute will have the following objects: 1. Is she pregnant ? 2. Is she actually in labor, and has the os uteri begun to di- ' late ? (Fig. 54.) 3. Are the pelvis and soft parts in a normal condition, or are they deformed ? 4. Is the presentation of the foetus in accordance Avith the requirements of natural labor, or is it otherwise? These are the points to be ascertained in this exploration. I. Does Pregnancy Exist ?—You may think it strange, almost bordering on the ridiculous, that your services should be required by a lady Avho imagines her labor at hand, when in fact she is not 23 354 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. in gestation. But, alloAv me to tell you that such occurrences are noAV a part of history; and it would be a severe bloAv to your virgin aspirations to be found ministering, for several days, to the wants of a patient supposed to be in parturition, who in truth Avas not even pregnant. Women who have never borne children, and Avhose desire it has been to have offspring, are sometimes quite apt to imagine themselves in a state of gestation ; as I have remarked in a preceding lecture, the accoucheur should never rely upon any statements made by his patient in cases of this kind. It is his duty to judge for himself, irrespective of all adventitious or other influ- ences. His mind must be free from bias, and his decision of the case based upon the evidence which maybe presented to his senses. Such is the rule of conduct I would most earnestly enjoin on all, Avho may Avish to discharge their trust fearlessly, and at the same time justly. A most amusing case occurred in this city some years since, and will, perhaps, serve more effectually to illustrate an important truth in midAvifery than any argument I can advance. It is Avhat may be denominated a tangible fact, and is entitled to full appreciation : A lady, aged 47, married since her thirtieth year, had cherished an ardent desire to become a mother, but had not succeeded in her Avishes. She Avas about abandoning all hope, when, of a sudden, she noticed that her abdomen began to enlarge, and really imagined herself pregnant. In addition to other symptoms, she thought she distinctly felt the movements of the child. Her heart was full of joy; she received the congratulations of her numerous female friends, who complimented her on her prowess, and the final accom- plishment of her hopes after years of fruitless effort; she commenced making the necessary preparations for her approaching accouchement. Her physician was advised of the happy circumstance, and informed that his services in due time Avould be needed. In the course of a feAV months the labor commenced ; a messenger hastened to apprise the doctor that the lady's time had come, with an urgent request that he Avould be prompt in reaching the bedside of his delighted but suffering patient. The doctor arrived—all in the house Avas confusion, and in high expectation; the nurse Avas enchanted ; the husband, in a spirit of humility, could scarcely realize the advent of this long expected era in his life ; the patient was in actual labor; the pains frequent and distressing. The physician Avas entreated bv the good nurse to lose no time in assisting madam; he made an examination ; the silence of death noAV pervaded the lying-in cham- ber to receive from the lips of the oracle the exact facts of the case ; the friends Avere soon made joyful, by hearing from the doctor that all Avas right—that the labor Avas quite advanced, and in a very short time would be completed. The sufferings of the patient increased; she Avas urged to make the most of her pains : " To bear' THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 355 down and assist nature "—when lo ! in the midst of one of those 1 owerful efforts to "assist nature,'' there Avas heard an explosion, Avhich struck terror into all present, the doctor included. The patient, as soon as she recovered from the prodigious effort which had occasioned the explosion, exclaimed: " Oh ! dear Doctor, it's all over; do tell me if it's a boy !" The explosion was nothing more than an escape of air from the boAvels ; the patient having mistaken flatulence for pregnancy, and the rumbling of the gas in the intestines for the motions of the foetus! Let this case, there- fore, keep before you the recollection of the fact, that one of the first duties devolving on you in the examination is to be certain that your patient is pregnant. II. Has Labor Actually Commenced ?—You have only to refer to what we have said in Lecture XXIIL, regarding the signs of labor, and the mode of distinguishing between true and spurious pains, to be enabled at once to determine whether the parturient effort has really begun. If you find labor is in progress, your next care will be to acquaint yourselves with the character of the pains; are they merely commencing, and, therefore, slight, or have they already assumed a degree of intensity ? AVhat is the condition of the os uteri ? Has it begun to dilate, and to Avhat extent ? Does the membranous sac protrude, and Avhat is its A'olume ? These are important questions, for they will aid you in the prognosis as to the probable duration of the labor. Has your patient already borne a child, or is she a primipara ? In the latter, the labor is usually more protracted. III. Are the Pelris and Soft Parts in a Normal Condition ?— While conducting the vaginal examination, you should not fail to assure yourselves of the state of the pelvis and soft parts. Is the for- mer natural in its dimensions ? Is it deformed ? If so, whether by an increased or diminished capacity ? Is its diminished capacity such as to involve the safety of the mother or child, or Avill it only tend to make the labor tedious and more lengthened ? Hoav is the uterus—does it preserve its parallelism Avith the axis of the superior strait—or is it malposed, so as to exhibit either of the obliquities to which we alluded in the previous lecture ? Hoav arf the vagina and vulva? Are they contracted and rigid, or relaxed and dilata- ble? Is the bladder distended, or the rectum more or less filled with fecal matter ? These are so many points to be ascertained by the accoucheur in his first exploration ; they will involve no diffi- culty on his part, if he understand himself—nor will they, in any way, expose the patient to annoyance or suffering ; the index finger carefully introduced will be all that is necessary to arrive at just conclusions upon these various heads. IV. Is the Presentation of the Fcetus in Accordance with the Requirements of Xature ?—Does one of the extremities of the 356 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ovoid present at the superior strait ? If so, Avhich is it ? Is it the head, breech, feet, or knees ? If the head, is it the vertex, or face, and what position does it assume? If the presenting part have begun to descend into the pelvic cavity, is its descent consistent with the mechanism of labor, or otherwise ? Instead of one of the extremities, is some portion of the trunk of the foetus at the upper strait, constituting a cross birth ? In addition, the careful accou- cheur will inform himself as to other points; such as the tempera- ment, disposition, age, moral and physical condition, etc., of his patient. Is she plethoric, or feeble, and nervous ? Is she in good health, or is her labor complicated Avith some serious dis- ease, either of an acute or chronic form ? Is she young, or has she already approached the meridian of life, and yet a primi- para ? It can scarcely be necessary to impress upon you the importance of becoming thoroughly and promptly cognizant of these various conditions; in doing so, you place yourselves in a sti*6ng and safe position ; you know, at once, whether the labor is natural, or Avhether the interposition of science will be called for. In truth, with this knowledge, you will be not unlike the skilled general on the battle field, who, having fully informed himself of the various points of the field itself, and of the strength and arrangement of the adverse forces, knows, not only how, but when to make his attack. Under these circumstances, his charge upon the enemy will usually be one of victory, for the reason that it has been Avell con- sidered, and based upon a knowledge of circumstances more or less essential to success. So, gentlemen, will it be in the lying-in chamber in cases of trouble, if you will early inform yourselves of the true nature and extent of the difficulty to be overcome. Duration of the Labor.—Well, the examination has been made, and you are in possession of all the circumstances of the case, having ascertained that everything is auspicious to a natural deli- very. A pressing question, which will be urged not unfrequently by the patient and friends, as soon as you have completed the exa- mination, will be as to the probable duration of the labor. Much anxiety will be evinced for a prompt reply to this interrogatory, and the friends will be more or less importunate for your opinion. No measure of experience will enable you to give an unqualified an- swer to this inquiry, for there is a vast deal of caprice about nature, and although we may approximate, yet we cannot definitely fix the period which she will require for the completion of her Avork. In order, therefore, to relieve the very natural anxiety on this point, and, at the same time, avoid a positive committal, you should say— all is right, and everything will depend upon the character and efficiency of the pains. This is certainly an equivocal answer, but it will be accepted as quite satisfactory, and will serve to liberate THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 357 you from the consequences of naming any particular time in Avhich the delivery may be accomplished. Duties of the Accoucheur after Labor has Commenced.—As soon as you have ascertained that your patient is in labor, your next care should be to conduct her safely through it, and with this vieAV, Ave shall now speak of certain duties, which will necessarily de\'olve upon you. In the first place, if the boAvels have not been evacuated for one or two days, and more especially if the rectum be distended Avith faecal matter, it is quite essential that an enema should be administered, or, if preferred, some castor oil; and also if there bo an accumulation of urine in the bladder, the patient should be di- rected to attempt to relieve herself; if, hoAvever, she should be unable to do so, the catheter must be employed. You Avill not have forgotten what we said regarding the introduction of this instru- ment in the latter stages of pregnancy, or during labor; the posi- tion of the urethra at this time is nearly vertical, being more or less parallel to the internal surface of the symphysis pubis ; there- fore, the direction of the catheter, in order to reach the bladder, must be from below upward, describing nearly a perpendicular line. Quietude in the Chamber.—I would earnestly suggest that the room of the parturient AA^oman be kept quiet,, and that she be saved the perils of excitement from the presence of persons, Avho can ren- der no assistance, but Avho tend to contaminate the air, and often- times, by their frivolous conversation, disturb the patient. The nurse and one other assistant will suffice, under ordinary circum- stances, for all the purposes needed. You should early study the character and disposition of your patient—if she be nervous and timid, and full of despondency, open before her vistas of hope and cheerfulness; encouragement from her physician, in the hour of tribulation, is always a grateful boon to a confiding Avoman, and it should not be denied her at the time at which, of all others, she most needs support and comfort. The nurse, if loquacious, and fond of recording her doleful experience of " horrible cases," must be promptly checked. There seems to be a growing and morbid disposition on the part of certain unthinking females, to indulge in narrations of the frightful scenes they have witnessed in childbirth, and they usually aAail themselves of the most inopportune occasion for their recital. Nothing of this should be allowed, for it often- times has a most pernicious effect. It Avill be proper, as the labor is progressing, to ask the nurse if she have in readiness a piece of tape and a pair of scissors, which Avill be required as soon as the child is born for the purpose of tying and cutting the cord. I have knoAAm great confusion to ensue from the neglect of this apparently trivial direction. Stages of Labor.—In order to simplify as much as possible the 353 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. question of natural labor, we shall divide it into three stages, and shall speak of Avhat may be necessary for you to do in each one of them: First stage consists in the full dilatation of the os uteri, and rupture of the membranous sac; second stage, the descent and expulsion of the foetus; third stage, the delivery of the placenta. Authors differ much in their division of the various stages, but the one just given you Avill, I think, for practical purposes, be found sufficiently comprehensive. First Stage.—This I have just told you is occupied in the dilata- tion of the os uteri, and rupture of the membranous sac. During the commencement of this stage of labor, the pains are at first sight passing from the back to the thighs, and are denominated grinding ; it is not until the os uteri becomes so dilated and the membranous sac and presenting portions of the foetus begin to make a decided pres- sure upon it, that the pains assume a strongly marked bearing-down character. It is well to note the chancre in the female as soon as these latter pains are in full development; at this time, during a contraction, she grasps anything Avithin her reach, and endeavoring to fix her feet firmly against some resisting object, she holds her breath, and concentrates all her efforts on the uterus—the dia- phragm and abdominal muscles contributing their respective aid in this effort. This, I repeat, is Avhat you Avill ordinarily observe as a characteristic difference in the contractions of the uterus, during the commencement and completion of the first stage. You cannot but perceive that this very difference inculcates an important practical precept, viz., not to urge your patient to make any effort, or, in the ordinary phrase, " bear down " while the pains are simply grinding ; for, at this period, no effort of hers can avail; on the contrary, you should caution her to economize her strength until, when the os uteri has progressed in its dilatation, the contractions themselves become forcing, and, consequently, may be materially aided by the efforts of the female herself. The more, therefore, she endeavors to assist nature at this period, the greater, under ordinary circum- stances, will be the facility of the birth. Rupture of the Membranous Sac.—As a general principle, when the os uteri has become sufficiently dilated to enable the head of the foetus to pass (Fig. 54), there is a spontaneous rupture of the sac, followed by the escape of more or less of the amniotic fluid. You have, in a previous lecture, been admonished not to rupture the sac prematurely; for, in doing so, you deprive nature of an important adjunct in the dilatation of the os—the uniform and steady pressure of the sac itself. When the liquor amnii es- capes before the proper dilatation of the mouth of the uterus, instead of this gentle and effective pressure of the sac, there is simply the hard and unequal pressure of the head to accomplish the object, resulting ordinarily in a protracted delivery, and sometimes THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 359 in injury to both mother and child. There are, however, circum- stances in which it may become essen- tially necessary for you to rupture the " bag of waters'' early in the labor, and before the pro- per degree of dilata- tion has been accom- plished. .Suppose, for example, the labor from the very com- mencement should be extremely rapid, and that y'ou appre- hended a too sudden expulsion of the foe- tus and its annexae ; in a case of this kind, it will be your duty early to afford, by rupture of the sac, escape to the amniotic fluid. Should you fail to do so, the rapid and brusque evacuation of the uterine contents might endanger the life of the mother. The uterus, under these circumstances, would be apt to be thrown into a state of inertia, giving rise to hemorrhage, which, to say the least, Avould involve the safety of the parent in a greater or less degree of peril. If you will allow me to say so—you should, as a general ride, regard quick births as dangerous births. Position of the Parturient Woman.—Previous to the rupture of the sac of Avaters, the patient may be permitted to assume Avhat- ever position may be most agreeable to her. It is a great mistake to confine her to the bed from the very commencement of her labor. In the first place, it is uncalled for ; and secondly, while it enervates her strength, it is calculated also to break the Aving of her spirit, and occasion more or less depression. AHoav her, therefore, the largest liberty ; she may sit in a chair, recline on the sofa, Avalk about the chamber, or get on her knees. In one word, let her do just as she pleases* But after the rupture of the sac, it -will be prudent for her to remain in bed.f * If, in your examination per vaginam, you ascertain that the pelvis is unusually . capacious, then it will become important to depart from this rule, and enjoin upon your patient to continue in the recumbent position during the entire progress of the labor; otherwise, from the excessive size of the pelvis, there would be danger of a sud- den delivery while walking about the room. Such a contingency might result sadly. \ I am in the habit of ordering a cot to be placed by the side of the bed, for the Fig. 55. Os uteri fully dilated—membranous sac unruptured. 360 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. The position assumed by the female at the time of delivery varies in different countries. In England, the usual position is on the left side; in France, on the back—and, indeed, throughout Germany, Avith the exception of Vienna and Heidelberg, Avhere the English custom seems to prevail, the Avoman is ordinarily delivered on her back. In some portions of Jreland, it is said, the custom obtains of haA-ing the birth completed Avith the woman either in the stand- ing position or on her knees.* AY hen there is no special objection on the part of the patient, I am in the habit of recommending the position on the back, because I think she can give herself much more efficient support than when on the side ; and, in all cases of operative midwifery, whether manual or instrumental, the back is infinitely preferable. Let me here remark that, in some instances in Avhich the contractions of the uterus become defective, I have observed great advantage from allowing the female to place herself, for a short time, on her knees; this change of position will often- times stimulate the organ to reneAved effort. Imp>ropriety of Frequent Vaginal Examinations.—Let me cau- tion you against frequent vaginal examinations during this stage of labor. The practice of constantly introducing the finger into the vagina, is a vicious one ; nothing, under ordinary circumstances, can justify it; it is both annoying and injurious to the patient. After you have satisfied yourselves, as far as may be, of the true state of things in the examination you instituted at the commencement of labor, what necessity can there be for more than one or two repetitions until after the escape of the waters, when it becomes necessary again to explore, and inform yourselves as to the progress of delivery, and the precise position of the presenting part ? Diet of the Parturient Woman.—The patient should occasionally be permitted to take bland nourishment, such as tea, barley water, gruel, light broth, etc.; but do not fall into the pernicious habit of recommending wines, spirits, or other stimulants, unless specially indicated. They excite the system, and almost ahvays do harm. Ice Avater will be both grateful and efficient as a drink, particularly if there be a degree of lethargy in the contractions of the uterus. Rigidity of the Os Uteri.—In some cases, dilatation of the os uteri will be extremely slow and irksome, and this may be OAvin Hydrarg. muriat. gr. j. Sal ammoniac, gr. iv. Aquae destillatae, f. | vi. Ft. sol. It may also become necessary to touch the inflamed conjunctiva, by means of a camel's hair pencil, with the following solution, once a day: B; Nitrat. argenti, gr. ij. Aquae destillat. f. 3 j. Ft. sol. When the child falls asleep, with a view of preventing their agglu- tination, the outside borders of the lids should be smeared with fresh butter, fresh olive oil, or what perhaps is better, the red pre- cipitate ointment. The bowels are to be kept regular with castor oil, or flake manna in solution; and above all, the eyes to be pro- tected against the light. This treatment, if faithfully carried out, will effect a cure, and should not be surrendered for leeches, blisters, etc. They are not only rarely indicated, but frequently result in great danger to the infant. Remember that the young child bears the abstraction of blood badly, and the irritation of the cantharides is oftentimes most injurious. 426 THE PRINCIPLES AND PRACTICE OF OBSTETRL 'S. I should not omit to mention here the means employed by Chas- saignac; it consists in having a constant current of Avater running upon the eyes for several hours consecutively. It is said that it has been followed by much success. Sore Nipples.—These are a great annoyance to the puerperal woman, and unfortunately too often rebellious to treatment. The outer covering of the nipple, the mucous membrane, is made by the tractions of the child's mouth exquisitely tender, and in a day or two subsequently it cracks and becomes fissured. Sometimes, hoAvever, there is simple excoriation; the pain which the mother experiences is most intense; the nursing of her infant is a severe struggle betAveen duty and physical suffering. The true difficulty of relieving the sore nipples is this: no matter what remedy you may apply, every time the child is put to the breast it opens the fissures anew, and in this way what you may accomplish in one hour is undone in the next; and if, on the other hand, the child be not permitted to nurse, the breasts become engorged, inflammation ensues, and mammary abscess is the consequence. In these cases, numerous remedies have been suggested; but I have found nothing answer better Avhen the nipple is fissured than a solution of the nitrate of silver, say A'j. gr. to § j. of Avater. Let this be applied several times during the day, but be careful that the nipple is Avell washed before the child again takes it. It will be very desirable to use the nipple-shield, and allow the infant to nurse through it, thus protecting the nipple from the immediate irritation of the child's mouth. When there are no fissures, but simply tenderness, borax and Avater, equal parts of brandy and water, or gr. ii. of sulphate of zinc to 1\. of rose water, etc., may be employed with advantage.* In cases of mere excoriations, the tincture of cate- i chu Avill oftentimes be serviceable. Mammary Abscess.—This constitutes one of the banes of the lying-in room, inflicting upon the patient intense suffering, and oftentimes leading to tedious and protracted convalescence. My own opinion is that mammary abscess, in nineteen instances out of twenty, is the result of carelessness. It may be produced by cold, or a slight blow on the breast, etc.; but, according to my experi- ence, the most prolific cause is neglect in not having the breasts properly drawn. For example, the child may be delicate, and not able to extract the milk; or the nurse, in the gratification of some ancient prejudice derived from a remote ancestry, does not think it proper to allow the infant to be put to the breast for two or three * It is a good rule, especially in a primipara, to enjoin on the patient the neces- sity, during her pregnancy, of making daily gentle tractions on the nipples, with the finger and thumb. In this way the mucous covering becomes hardened, and can thus sustain with impunity the friction of the ohild's mouth. The tincture of myrrh may also be occasionally used with benefit. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 427 days after its birth. In this way the milk ducts become greatly distended, inflammation ensues, Avhich, if not promptly arrested, terminates in suppuration. If, therefore, the child be not able suf- ficiently to disgorge the breasts, have a young pup obtained; this latter is worth all the machines ever contrived for the purpose of draAving the mammae. Gentle friction with camphorated oil, and proper support given to the breasts by means of a handkerchief placed under them, and made to cross the shoulders, Avill be very proper aids. The moment inflammation of the breast is noticed, leeches should be freely applied, warm fomentations and poultices should follow, and a free use of saline cathartics, together Avith tolerant doses of tartarized antimony. The patient should not, while the breasts are engorged, be permitted to indulge in fluids. The pup should be applied whenever the breasts become distended; and remember, the moment pus is formed, make a free incision, and afford it an exit. When the abscess has been opened, and the purulent secretion finds issue, the use of pieces of broad adhesive plaster, for the purpose of making pressure, will materially facili- tate the process. Diet of the Puerperal Woman.—The diet of the puerperal woman for the first four or five days should be simple, consisting of gruels, arrow-root, tapioca, boiled rice, tea and toast, soft-boiled eggs, etc. If everything pass on favorably, she may then be in- dulged in meat and vegetables, and begin gradually to resume her ordinary fare. There will, however, sometimes be exceptions to this restricted diet; for instance, in cases of anaemia and marked dilapidation of the forces, a generous nutrition, together Avith tonics, Avill be indicated from the first. Recumbent Position after Delivery.—One point I wish strongly to impress upon your recollection—keep your patient in the recum- bent position for at least ten days after delivery, and she will subse- quently recognize the advantage of this rule by finding herself free from many of those troubles consequent upon too quickly " getting " up after child-birth; such as displacement of the uterus, bladder, or vagina. Consider, for a moment, the relative conditions of the uterus and vagina after the birth of the child. The uterus is large, possessing increased Aveight, while the vagina is relaxed, and inade- quate to furnish necessary support. Therefore, if, under these cir- cumstances, the patient rise from her bed, assume the erect posture, or walk about the room, what are you to expect but that the super- incumbent Aveight of the enlarged organ pressing upon a frail found- ation, the relaxed vagina, will necessarily lead to displacement ? I do not Avish you to understand that the patient is actually to"continue in bed for ten days, but she should maintain the horizontal posture; let her recline on the sofa, or a cot, but ah\-ays have her placed there by assistants, and not be permitted to reach it by her own efforts. 428 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Threatened Paralysis of the Lower Extremities.—It will occa- sionally happen that Avhen the patient commences to Avalk, she Avill experience more or less inability to move her limbs; there Avill be a feeling of numbness, with diminished sensibility. This condition of things will very naturally give rise to much anxiety. This inci- pient powerlessness of the lower extremities is usually accompanied by severe pain in the ischiatic nerve and its tributaries, and also by neuralgic sensations through the hips. I have generally observed the above phenomena after a tedious labor, and more especially after delivery by the forceps ; in the great majority of instances, they are the results of pressure on the sacral plexus of nerves during labor; and what is a very gratifying circumstance is—you may assure your patient, as a general rule, that they are transitory in their character. Sometimes, hoAvever, they are more permanent, requiring the application of leeches over the region of the sacrum, together Avith small blisters, for the purpose of removing the con- gested state of the parts. You will, however, meet with cases of paraplegia after delivery, in which there is not the slightest approach to pain. The paraple- gia, in these instances, is traceable to some morbid influence trans- mitted by the uterus to the spinal cord. It is, in fact, an example of simple reflex paralysis. The treatment should consist in the administration internally of strychnine, Avith Avhich may be advan- tageously conjoined the cold shoAver-bath applied to the spine. A very practical and interesting history of this form of paralysis as observed during gestation and after delivery, has been presented by R. Leroy D'Etiolles, Nonat, and Dr. BroAvn-Sequard.* The Umbilical Cord.—From the third to the sixth day, the cord will slough, and become detached from the umbilicus of the infant. Sometimes, before this takes place, and as the consequence of the sloughing process, there will be an extremely unpleasant smell emit- ted : the mother becomes alarmed, sends for you, and says she is afraid her child is mortifying! If you cannot at once readily and satisfactorily explain the cause of the foetid odor, and thus relieve the apprehensions of the parent, the mortification will be altogether on your side, should a practitioner be called in to aid you in your diagnosis! When the cord becomes detached, the umbilicus is dressed simply with a piece of burnt linen. This is an old practice among nurses, and it ansAvers usually every purpose. Sometimes, however, there will be a small granulation sprouting from the navel, known in the lying-in room as proud flesh ; the sprinkling of a few grains of calomel will generally suffice to remove it. Under'ordinary circumstances, the puerperal woman should be visited at least once every day for the first six days after delivery, • See Lectures on Paraplegia, by Brown-Sequard, London Lancet, 1860. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 429 and, if everything progress favorably, after this she may be seen every other day for a week or so. Umbilical Hemorrhage.—The neAv-born infant—fortunately it is of rare occurrence—is liable from the third to the eighteenth day to a serious hemorrhage, which is connected more or less directly with the detachment of the cord from the umbilicus* As soon as the cord becomes separated from the navel, it will sometimes happen that a slight oozing of blood ensues, but this is of little or no moment. It is in reference to the more formidable variety of hemor- rhage from the umbilicus that we propose to say a few words at this time. It is more important to direct attention to this subject for the reason that, although a rare complication, yet it is almost ahvays fatal. There is far from being an agreement as to the etiology of umbilical hemorrhage; in some instances it may be the result of imperfect closure of the vessels after the desiccation of the cord; it may arise from what is known as the hemorrhagic diathe- sis ; sometimes it is accompanied with jaundice; again, it may be connected Avith some hereditary influence; abscess of the umbilicus may occasion it; sometimes, too, it will result from carelessness in tying the cord. It is an interesting fact that this form of hemor- rhage most frequently attacks male in preference to female infants, and the mortality is greatly increased among the former. The treatment of umbilical hemorrhage Avill consist in the appli- cation of astringents and pressure, the ligature, caustics; and in some instances, the actual cautery has been advised.f Pain in the Uterus when the Child is Applied to the Breast.— Your attention will occasionally be directed by the mother to an excessive pain in the womb whenever the infant takes the breast. This might possibly give you some embarrassment if asked to explain the relation between the pain in the uterus and the trac- tions on the nipple ; but with a little reflection you will be enabled to give a most satisfactory exposition of the circumstance. It is another interesting illustration of reflex influence; the traction of the child's mouth on the nipple excites an action in the spinal nerves, Avhich is immediately transmitted to the medulla spinalis, and this latter, becoming the seat of irritation, imparts to the motor nerves of the uterus an influence which induces, for the time, contraction * Although, as a general rule, bleeding does not take place until the separation of Ae cord, yet it should be remembered that this is not universally the case. Pro- fuse hemorrhage may occur prior to this period, either as the result of injury, or as an idiopathic bleeding. \ The subject of umbilical hemorrhage has received some able contributions from our own countrymen: viz., Dr. John Homans (Boston Med. and Surg. Journal, 1849). Dr. Bowditch (Amer. Journal Med. Science, 1850). Dr. Bailey (Amer. Journal Med. Science, 1852). Dr. Minot(Ibid. 1852). Dr. Otis (Vir. Med. Journal. ISA!). Dr. Stephen Smith (New York Journal of Med., 1855). Dr. Conant Jenkens, (Transactions Amer. Med. Asso., 1858), and others 430 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of this organ, and consequently pain. But you may ask, do all nursing women complain of this pain ? By no means; some never experience the slightest inconvenience, while others, on the con- trary, of a sensitive nature, suffer for some days after delivery much annoyance. An efficient remedy Avill be the introduction of a sup- pository of belladonna into the vagina, which will prevent the contraction and consequently the pain in the uterus. Thrombus of the Vulva—A Thrombus or sanguineous tumor of the vulva, as it is sometimes called, may occur as a consequence of parturition. It results from an extravasation of blood in the surrounding cellular tissue, differing in this respect from the vari- cose tumor, the blood in this latter case being contained Avithin the vessels. Thrombus may appear in the unmarried, in the married Avho have not borne children, during pregnancy, at the time of labor, and subsequently to parturition. It is, although compara- tively a rare affection, most commonly connected with pregnancy and labor, and this arises from the predisposition of these tAvo con- ditions to the formation of the tumor—the obstructed venous circu- lation so engorging the vessels as to provoke, under some circum- stances, their rupture from slight causes. It may happen that this rupture, giving rise to extravasation, may take place during labor, but the fact may escape attention for some days after deliver)-, for the reason that the head or presenting part of the foetus may have temporarily acted as a sort of tampon, thus preventing the imme- diate formation of the tumor. Causes.—These are both predisposing and exciting—among the former may be classed the various modifications incident to gesta- tion and labor; a contracted pelvis, deformity of the soft parts, tAvin pregnancy, &c.; the exciting causes consist in falls, bloAVS, external violence of any kind, rude manipulations on the part of the accoucheur, forceps delivery, or undue pressure of the present- ing portion of the foetus; coughing or vomiting may also give rise to the extravasation. Symptoms.—One of the first and most prominent symptoms of thrombus is pain, which arises no doubt from rupture of the vessels, and also from pressure on the adjoining nerves. There is likewise more or less tumefaction, sometimes large at the very commence- ment, and again its development is not complete for several hours or days. When the thrombus has attained a large volume, it may impede the birth of the child, or the expulsion of the placenta • and cases are recorded in which retention of the urine and faeces ensued from pressure of the tumor on the bladder and rectum. Occasion- ally, the thrombus may suddenly burst, causing profuse and dan- gerous haemorrhage. The color of the outer covering, soon after the appearance of the tumor, will present a livid or bluish cast, and this is an important point in reference to the diagnosis of this form THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 427* of sanguineous engorgement. An interesting fact is this—the blood in these tumors, mixed more or less with purulent matter under inflammatory action, will sometimes emit a distinct stercoral odor, which might possibly lead to the erroneous opinion that the throm- bus is complicated with a recto-vaginal fistula. It has been Avell demonstrated by the surgeon—an interesting fact for the accou- cheur—that in abscesses situated in the vicinity of the rectum, it is quite usual, without any communication with the intestine, for the purulent secretion to possess the odor of faecal matter. Diagnosis.—While to the careful practitioner, the diagnosis of vaginal or vulvar thrombus presents no embarrassment, yet it may possibly be mistaken for other affections, such, for example, as incipient abscess, varicose tumor, oedema of the labia, hernia of the bladder (vaginal cystocele), omentum, or intestine, inversion of the vagina, or uterus, .-ed, and the internal surface may or may not reach the os uteri; Avhereas, in complete inversion, the inner surface protrudes through the mouth of the uterus—in a AA'ord, the organ is turned inside out. When this formidable accident presents itself—and it is in all truth formidable, oftentimes involving the life of the mother—it is of cardinal importance that it should be promptly recognised, for, as Ave shall remark, Avhen speaking of the treatment, the difficulty of restoring the organ to its original position Avill usually be pro- portionate to the time which has elapsed from the moment of its displacement. Diagnosis.—If you be in attendance upon a female in labor, and in\rersion occur, there can be no excuse for your ignorance of the circumstance; for you have been told until, I am sure, the repeti- tion must ring in your ears, that, as the child is passing through the maternal organs, your duty is to ascertain, by placing the hand on the hypogastric region, whether or not the uterus responds to the expulsion of the foetus—in other words, Avhether it is contracted. Suppose, then, in observing this rule—and to neglect it would be extremely culpable—you are unable to feel the uterus at the loAver portion of the abdomen ; but, in lieu of the organ, there should be distinctly recognised a cupped-like depression. Why, what Avould this state of things indicate ? If there be any truth in evidence, the irresistible deduction Avould be that the womb had become inverted either partially or completely. Whether the former or latter, would soon be revealed by the absence or presence of a large tumor protruding into, and sometimes even beyond the vagina. All doubt as to the true nature of the case would be promptly dis- sipated by a digital examination of the tumor itself. For example, if the inversion be incomplete, the finger, in being carried up to the os uteri, would distinctly feel the internal surface of the organ thrown downward, but still within the uterine cavity. On the con- trary, in complete inversion, the tumor will occupy the vagina, and occasionally extend beyond it, while the os uteri will be found above, and, as it were, forming a species of stricture around the upper portion of the inverted organ. In addition to these evi- dences, the tumor would be sensible to the touch, and the placenta attached to the inverted surface, or, if separated from it, the fact of its previous adhesion would be manifest from the peculiar aspect or feel of the part. When the uterus is in a state of complete inversion, the fallopian tubes, ovaries, and uterine ligaments, are necessarily drawn into tha cupped-like or funnel-shape cavity formed by the depression of the external surface of the fundus; and there are instances recorded in which the small intestines, the bladder, and a portion of the rectum, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 449 had also become prolapsed into the cavity. But the descent of these latter organs must rather be regarded as exceptions to the rule.* Is it possible to mistake Chronic Inversion for something else?— In a case of recent inversion, I repeat, it can scarcely be conceived that there could be an error of diagnosis; but where the displace- ment has become chronic, there might possibly be some embarrass- ment, and this leads me to dwell for a moment on certain morbid phenomena with Avhich inversion of the uterus might, without due thought, be confounded—such as prolapsus, procidentia, polypus, and other tumors connected with the Avomb. In simple prolapsus of the organ, the apex of the tumor is down- ward, the base upward, and, besides, the os tincae will come directly in contact with the finger. In procidentia, the apex is downward, the base upward, there is also the os tincae at the most pendent portion of the tumor. In polypus, the base is downAvard, the apex upward, consisting of a pedicle attached to the uterus; there is of course no os tincae, nor is there, as a general rule, any sensibility on pressure. In inversion, the apex is downward, the base upward, "and there> is no os tincae to be recognised at the lower portion of the tumor. y If, therefore, these distinctive differences be borne in memory, it seems to me that an erroneous diagnosis is barely possible; and yet there are, unhappily, authenticated instances in Avhich a ligature has been applied to an inverted uterus under the conviction that it «Avas a polypoid groAvth, and the life of the patient thus sacrificed through want of judgment. Death, howeAer, is not always the consequence of removal of the uterus by ligature, as will presently be shoAvn when speaking of extirpation of the organ. Inversion of the uterus, I have remarked, is a formidable compli- cation, and very frequently results in the destruction of the patient; death, under these circumstances, may ensue either from excessive hemorrhage, or from shock to the nervous system, and sometimes even from convulsions. Yet, on the other hand, the chronicles of obstetric medicine are not Avithout satisfactory evidence that women have survived for many years this displacement, after having proved rebellious to every effort to accomplish the restoration of the organ to its original position. 3Ir. Crosse states that, in seventy-two out of one hundred and nine fatal cases, death occurred Avithin a few hours; in eight Avithin a Aveek, and in six others in four weeks; of the remaining tAventy-three, one died at the fifth month, occasioned by an opera- * Levret reports a case of an inverted uterus, in a woman seventy years of age, oontaining a portion of the rectum, bladder, and small intestines, together with the fallopian tubes and ovaries. [Observations -sur la Cure Radicale de Plusieurs Polypes de la Matrice. Ob. 8, p. 132. Paris, 1762.] 29 450 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tion ; one at eight months; three at nine months, and the others at various periods from one to tAventy years.* Treatment.—Let us noAV suppose that you have a case of incom- plete inversion. How is it to be managed? No time should be lost in efforts to reduce the displacement. The patient should have all the advantage of position, being placed on her back, and the pelvis slightly raised above the plane of the thorax ; it is especially important to remember that, in this form of uterine displacement, there is very commonly retention of urine in consequence of the pressure of the tumor against the neck of the bladder. Therefore, do not omit, as a preliminary measure, to evacuate the urine by the introduction of the catheter. If the placenta be Still in adhesion with the uterus, do not on any account make an effort to detach it either by tractions on the cord—for these would only tend to increase the inversion—or by manipulations Avith the hand carried into the uterine cavity. On the contrary, AA'hat you should do is cautiously to introduce the hand Avithin the mouth of the uterus, and Avith the dorsal surface of the fingers exert gentle but uniform pressure up\A'ard against the inverted portion of the organ—and in this \A-ay, it will be made, generally speaking, to resume its position; this being accomplished, frictions on the abdomen, a small piece of ice introduced into the vagina, or the administration of ergot— should the uterus not contract Avith sufficient energy to separate the after-birth—may be resorted to Avith a view of evoking in- creased action. The placenta being separated, its extraction is to be accomplished according to the rules indicated in a previous* lecture. But hoAV are you to proceed Avith regard to the management of the uterus AA'hen in a state of complete inversion ? In this case, too, promptness is one of the great elements of success—indeed, if even a few hours lapse after the accident, it will be extremely diffi- cult to effect the reduction. Therefore, remember that, under these circumstances, action simultaneous, if possible, with the accident Avill prove the truest economy. In complete inversion, there will be one of two things—the placenta will either be sepa- rated from the organ, or it will be in connection with it. In the former instance, the tumor should be gently grasped by the hand, and a continued but cautious pressure made in the direction of the respective straits of the pelvis. This pressure, if faithfully per- sisted in, will oftentimes be productive of the happiest results— restoring the uterus, and protecting the patient against the annoy- ance and dangers of failure in the attempt at reduction. When, however, the placenta is still adherent to the inverted organ, there is some difference of opinion as to the proper course * Op. cit, p. 170. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 451 to be pursued. Authors are divided upon this subject, some follow- ing the counsel originally, I think, given by Puzos of previously detaching the after-birth, for the reason that in so doing the volume of the tumor Avill be diminished, and the possible danger of its subsequent extraction avoided. Others, again, maintain that the preliminary detachment of the after-birth is not necessary, and they proceed at once to replace the uterus without any reference what- ever to the deciduous mass.* I should advise you, gentlemen, to adopt neither of these sug- gestions peremptorily; it is not Avise—and science repudiates the notion—to have stereotyped rules of conduct for the sick room. You should have stereotyped principles, but the application of these principles must be governed by the circumstances, Avhich may sur- round each individual case. Therefore, the plan Avhich I suggest for your consideration is this—if the placenta be considerably detached at the time of the inversion, you may, before attempting to reduce the displacement, complete its separation, and then imme- diately, in the manner already indicated, proceed with your mani- pulations to accomplish the restoration of the organ. All things being equal, it is, in my judgment, far more desirable to attempt to replace the inverted uterus Avhile the placenta is still in connection Avith it, and for the very substantial reason that, under such circum- stances, the pressure is not made directly-against the Avomb itself— which must necessarily expose it to more or less injury—but the pressure, you perceive, is directed against the intervening object— ' the placenta. It may, hoAvever, be that the size of the after-birth Avill add so much to the volume of the tumor as to render the reduction physically impossible. In such case, of course, the proper alternative is the detachment of the placental mass. After the reduction has been accomplished, the hand is not to be suddenly withdraAA'n from'the uterus, but, on the contrary, it should be continued Avithin the cavity until the organ, through its contrac- tions, forcibly expels it; this will be the best safeguard against the recurrence of the inversion. Should every effort fail—and such in the most skilful hands will not mnfrequently be the case—care should be taken to return, if possible, the tumor Avithin the vagina and sustain it in situ by the india-rubber pessary, or a piece of soft sponge, and, if necessary, Avith the addition, also, of a bandage. It would seem that after the reduction of an inverted Avomb, the mortality is comparatively slight, for in fifty-tAvo cases in Avhich the organ was restored to its position, death occurred in seven only, or one in 7.3. Spontaneous Reduction of the Inverted Uterus.—There are * Great benefit will often be derived from the administration of ether, if there be nothing to contra-indicate its use; its relaxing effects will very much facilitate the reposition of the organ. 452 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. several cases reported of spontaneous restoration of the inverted uterus, after resisting every attempt at reduction. One of these occurred in the practice of the renowned Baudelocque, on AA'hose authority it has found a place in the historical archives of the pro- fession. I shall present it to you as recorded : Madame Bouchardat was delivered of her first child at Cape Francis, in 1782 ; at the time of the delivery of the placenta, effected by the hand introduced into the uterus, she complained of severe pain, and felt betAveen her thighs the protrusion of a large tumor, which Avas immediately returned Avithin the vagina. The lady became almost exsangui- nated, and so prostrate that the attending accoucheur Avas appre- hensive that, if he made any attempt to restore the organ, she would die in his hands. After seven or eight years of suffering, Madame B. visited Paris for the purpose of consulting Baudelocque. This distinguished accoucheur, after a thorough examination of the tumor, decided that it Avas an inverted uterus : he made several attempts to reduce it, but failed. He prescribed baths and rest. On the evening of the day preceding that appointed by Baudelocque for another attempt at reduction, 31adame B. was urged by some of her friends to walk about her room. When doing so, she fell suddenly in a sitting position on the floor; she complained of an unusual movement in the lower portion of the abdomen, and, for an instant, lost her consciousness. Baudelocque being sent for, avus soon at the house, and, on examination, could detect no tumor—it having spontaneously been restored. From this time, the patient improved in health. Having been a widoAV for several years, she married again, became pregnant, and Avas safely delivered at full term. This case, remember, I give you solely upon the testimony of Baudelocque. With less weight of authority, I should be disposed to rank it among what may be termed medical delusions. Extirpettion of the Inverted Uterus.—When it is impossible to return the uterus, the inversion becomes chronic ;* in this condi- tion, it may or may not cause much inconvenience, and even involve the life of the patient in danger. For example, Avhen it assumes the chronic form, the system may be gradually drained by the oozing, either of blood or mucus, Avhich is so apt to accompany this stage of the displacement. Again, indolent and rebellious ulcerations, induced by the friction of the dress, may ensue, and * There are some exceptional instances reported of chronic inversion of the uterus, in which the organ has been reduced after years of displacement. Among others, may be mentioned the remarkable case, which occurred in the practice of Prof J. P. White; the organ had been inverted for fifteen years; it was successfully reposited. The patient died sixteen days subsequently of peritonitis. Dr. Tyler Smith reduced an inverted uterus of twelve years' duration; patient recovered. [Foi details of Prof. White's case, see Am. Jour. Med. Sci., July, 1858. p. 13. For Dr Smith's, Am. Jour. Med. Sci., July, 1858 p. 270. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 453 these ulcerations so far compromise the safety of the woman as to suggest the very delicate and important alternative—extirpation of the inverted organ, as the only chance of safety. In the whole range of obstetric medicine, I knoAv of no more momentous ques- tion than this for the decision of the accoucheur; painful, indeed, is the responsibility of an operation, the very nature of which, to my mind, is horrid to contemplate; not so much because of the danger of the alternative, as that it absolutely unsexes the woman, and makes her existence one of irreparable sadness, more especially if she should not have passed the child-bearing period. I, there- fore, think that the fullest and most undoubted evidence that, all things fairly and deliberately weighed with the single motive of arriving at the truth, the operation affords the only hope of safety —will alone justify a resort to it. The following table, which I take from Dr. West,* gives the result in fifty cases of extirpation of the uterus for inversion con- nected with parturition. It will be seen that thirty-six of the cases were successful, twelve fatal, and in two instances, although the patients survived, it became necessary to abandon the opera- tion. The total also shows the results of the respective modes of performing the operation—ligature and excision. Who1 ~ber Eecovere!ed, it will oftentimes lead to erroneous decisions. In order that jou may have a clear understanding of its true import, and of the indications it involves, I shall divide it into two forms—relative and positive exhctustion. For practical purposes, this is, I think, a sound and important divi- sion, and if a just distinction be made between these two grades of exhaustion at the bed-side, all possibility of embarrassment xvill be at an end. Relative Exhaustion.—I have scarcely ever attended a case of labor, unless its duration was extremely brief, in which, during the throes of parturition, and more especially during the expulsive effort, the female did not exclaim, " Oh! I am so weak, I shall die if I have another pain." This, or something kindred to it, is, I may say, the stereotyped language of the parturient Avoman. Xow, gentlemen, if you give this phraseology a literal translation, if you take your patient at her Avord, you will at once conclude that a storm is gathering, and, in your anxiety to do something, you may be guilty of officiousness, Avhich will be quite likely to compromise the safety of the Avoman and her child, and do no great credit either to your judgment or skill. When you reflect, for a moment, on the severe sufferings occa- sioned by childbirth, and the commotion to Avhich the nervous svstem is subjected during a forcing labor-pain, you can readily conceive Avhy all this should beget a feeling of momentary prostra- tion, causing the female to believe that the recurrence of another pain will utterly annihilate her ! But how delusive this opinion of the patient, Avhose standard of danger is the amount of physical suffering she endures. Not so, however, Avith the enlightened accoucheur, Avhose duty it is to distinguish between fiction and reality, and to arrive at conclusions not from mere appearances, but from substantial fiicts as they may present themselves to him in the aggregate. The testimony of the patient, under the circumstances of which Ave speak, is the testimony simply of feeling, and not of judgment, and therefore it becomes useless as a guide for practice. As soon as the pain has passed over, the poor woman, Avho a moment before Avas admonishing every one about her that she Avas exhausted and would certainly die, not only becomes tranquil, but engages in conversation, and even Avill laugh Avith good heart at a merry jest, Avhich the accoucheur of tact will know so Avell Iioav to introduce for the purpose, as it Avere, of detaching her mind from herself, and oiving it temporary occupation in some other channel. Again : the pulse is good, the countenance is not haggard, there is no evi- dence Avhatever of a dilapidated condition of the vital forces—in a word, the prostration of Avhich the patient complained, and Avhich 460 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. she supposed to be the harbinger of inevitable death, is but the flitting of the April cloud OA'er the sun, causing for the instant a slight obscurity, in order that the glorious orb may become still more effulgent. This, gentlemen, is Avhat I term relative exhaus- tion, and is entitled to no consideration Avhatever, so far as being an indication for interference on the part of the practitioner. Positive Exhaustion.—Positive exhaustion, hoAvever, is alto- gether a different thing, and, except through opportune and skilful interference, will inevitably lead to death. Here there is no ima- gination, no fiction—all is a solemn, emphatic reality. The patient, after a pain, does not rally. The sunken countenance, flickering pulse, the cold and clammy perspiration, the pallor of the general surface, indicate Avith unerring certainty that the system is at a low ebb—that it is fast approaching utter dilapidation. There is no, or, if any, but a momentary response to stimulants. The forces will not react. In these cases, which fortunately may be regarded as rare, every successive pain has a direct tendency to increase the prostration, and if something be not promptly done to meet the emergency, the patient sinks. This something consists in delivering her without delay. Should the head of the child have passed through the mouth of the uterus, or be in the pelvic excavation, recourse should be had to the forceps. If, on the contrary, the head be still at the superior strait, and the mouth of the womb sufficiently dilated to permit the introduction of the hand, the alternative is version. The particular reasons for this choice Avill be fully stated when we speak of the indications and rules for turning. Hernia.—If a woman in labor be affected with hernia, whether it should have pre-existed, or be the result of extreme uterine effort, it will equally need the attention of the accoucheur. For example, suppose a case of femoral hernia: each successive pain may so increase the protrusion, as to give rise to the apprehension of its becoming strangulated. This latter contingency Avould necessarily subject the life of the patient to more or less hazard. In all cases, therefore, of hernial protrusion, one of the first duties of the prac- titioner should be, if possible, to reduce it, and then, by judicious support, to prevent its return. If, however, the hernia become irreducible, and increase during the pains of labor so as to place in jeopardy the safety of the patient, common sense at once tells you that the broad indication is to proceed without delay to artificial delivery, according to the rule to Avhich we have just referred under the head of positive exhaustion. Prolapsion of the Umbilical Cord.—This a very serious com- plication of labor, not that it subjects the life of the mother to any hazard, for it in no Avay compromises her safety; but it is of extreme danger to the child. Mortality and Frequency.—According to the statistical tables of THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 461 Dr. Churchill,* in 722 cases of prolapsion of the funis, 375 children were lost, or more than one half. 3Iany of the cases, however, it must be remembered, are taken from the records of Hospital prac- tice, and as a large number do not seek admission until some time after the occurrence, Avhen the chance of a safe delivery is dimi nished, and some not until the cord has ceased to pulsate—it follow that this mortality cannot be regarded as a true exponent of the results of private practice. In 152,574 cases, prolapsion of the cord , occurred 629 times, or about 1 in 218. You observe, therefore, '; from these tables tAvo facts: 1. That prolapsion of the cord is hap- pily not of very frequent occurrence. 2. That it is extremely fatal, / proving destructive to the child in more than one half of the cases. Causes.—There are certain causes, which strongly predispose to this accident, and may be enumerated as folloAvs: a pelvis, Avhich is preternaturally enlarged; the insertion of the placenta near the mouth of the uterus ; a cord, which is longer than ordinary ; the sudden escape of the liquor amnii, especially Avhen this latter is in unusual quantity; a shoulder, foot, or breech presentation, thus affording more space for the prolapse of the funis, and because, also, in these latter presentations the foetal extremity of the cord is nearer the inferior portion of the uterus; a contracted brim, preventing the descent of the head, and consequently predisposing the cord to pass into the vagina. To these may be added obliquities of the uterus, the tendency of which would be to incline the presenting portion of the foetus toAvard one or other of the borders rather than toAvard the centre of the superior strait, which Avould necessarily from the increased space predispose to a descent of the cord. Pro- lapsion of the funis is more frequent in Avomen who have borne several children than in the primipara, and this arises from the fact that, in the former, the uterine Avails have measurably lost their tenacity, and are more relaxed, and, therefore, facilitate the pro- lapsion. The above are some of the more prominent causes, which fiwor this complication. Diagnosis.—The diagnosis is not difficult, and may occasionally be determined before the rupture of the bag of Avaters, although, as a general rule, it is more readily arriAed at after the escape of the liquor amnii. In the former instance, the cord may be felt, during the interval of the uterine contraction, through the membranes, and the fact that what you feel is the cord may be ascertained by the important and characteristic circumstance that the pulsations are not synchronous or in accordance with those of the maternal heart, but are much more rapid.f Consequently, this * Churchill's Midwifery, 4th London Edition, p. 454. \ Scanzoni notes an interesting circumstance which, without an explanation, might lead to incorrect diagnosis, viz. that the umbilical arteries, before entering the cord, may pass for a greater or less distance along the membranes—insertio funiculi 462 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. will demonstrate very unequivocally that the beatings, if any be felt, are not connected with the arterial system of the mother. The same rule will enable you to distinguish betAveen the pulsa- tions of the umbilical arteries, and those ramifying on the lower portion of the uterus. After the rupture of the membranous sac, the loop or fold of the prolapsed funis can be distinctly recognized by the touch, and, therefore, all doubt as to the nature of the diffi- culty Avill be removed. 'Cause of Death in Prolapsion of the Cord.—What is it that causes the death of the child in prolapsion of the funis ? This is a question about Avhich there has existed a difference of opinion. Some have supposed that it was in consequence of the blood becom- ing coagulated in the descended portion of the cord ; but it is noAV very generally conceded that death ensues from the compression exercised upon the funis, thus interrupting the circulation betAveen the mother and child. One moment, if you please, upon this point of compression, and arrest of the circulation. You are not hastily to conclude, because the circulation is arrested, that, therefore, the child must necessarily be destroyed. It will sometimes happen that no pulsations can be detected in the cord for several minutes; the labor may advance, and by a change of position in the present- ing portion of the foetus, the compression Avill be removed, and the circulation re-established. It is well, therefore, to remember that compression of the cord, with an absence of pulsation, does not, as an inevitable consequence, imply that there are no longer any throes of the fcetal heart. Dr. Arneth, of Vienna, mentions four cases under his notice, in Avhich no pulsations had been detected in the cord for half an hour previous to delivery, and in each instance the child Avas born living. From what has been already stated touching the fatality of this complication to the child, it will become a paramount duty, in all cases of funis protrusion, at once to announce, not to the patient herself, but to her husband or some other relative, the apprehen- sions you experience as to the safety of the foetus. In doing this, you will have done nothing more than your duty; and Avhether the child be saATed or perish, you will have liberated yourselves from all responsibility, Avhich concealment of the fact Avould have im- posed. Frankness is an essential and A'ery necessary element in the character of a medical man ; and while the object of his pro- fession is to save human life, and palliate human suffering, yet it is equally incumbent upon him, Avhen he finds himself surrounded by dangers placing in imminent peril the safety of his patient, can- didly to disclose to those most interested in the issue of the case his doubts and fears. umbilicalis velamentosa—so that their pulsations may be felt, and jet the cord not be prolapsed. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 463 At what Period of Labor is Prolapsion most likely to Occur?— Prolapsion of the cord may occur at any period of labor—before the os uteri is much dilated, after it is fully dilated, or before and after the escape of the liquor amnii. The tendency of its descent, hoAvever, is greater after the rupture of the membranous sac, and this circumstance, therefore, is an additional motive why great caution should be exercised not prematurely to interfere Avith the integrity of the bag of waters. Treatment of a Prolapsed Funis.—What is to be done in cases in which the cord is prolapsed ? This is an interesting interroga- tory, and is Avorthy of consideration. If you imagine that the mere prolapsion of the umbilical cord is an indication for inter- ference on the part of the accoucheur, you Avill labor under serious error, and be quite likely, with this view of the subject, oftentimes to do mischief. There are three conditions in which this accident may present itself, each varying from the other, and requiring a different kind of management: 1. There may be no pulsations, and, at the same time, irresistible evidences of the death of the foetus from incipient decomposition of the cord. 2. The pulsations may continue strong and vigorous, showing that there is as yet no undue compression. 3. The pulsations, from being strong and vigorous, may become more and more weak, indicating that the pressure exercised upon the cord is endangering the circulation between the placenta and foetus. If you will bear in mind these three conditions, and give full appreciation to each one of them, your duties in this form of com- plication will not only be simplified, but what is very important they Avill be well defined. In the first place, therefore, if no pul- sations be detected, and there be palpable evidence that decompo- sition of the cord has commenced, then the proof is positive that the child is dead. Under these circumstances, it Avould be unne- cessary for the accoucheur to interfere ; on the contrary, the labor, all other things being equal, should be confined to the efforts of nature, for you have already been told that, in funis presentations, the only danger is to the child, the safety of the mother being in no Avay involved. Surely then, the important fact being ascer- tained—the death of the child—it would not only be uncalled for, but altogether unjustifiable to haAre recourse to artificial delivery, unless there be some circumstance, other than the prolapsion of the cord, rendering interposition necessary. Secondly, as long as the pulsations in the cord are strong and vigorous, there is no indi- cation of peril to the child, for the reason that the true element of danger consists in the interruption of the circulation through com- pression. While, then, the force of the pulsations is natural, it i# 464 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. manifest that there is no undue compression; therefore, it is unne- cessary to do more than merely place the cord—if it should have fallen beyond the vulva—high up in the vagina, for the purpose of protecting it from exposure to the atmosphere. The third condi- tion, hoAvever, presents different indications, and something must be attempted to prevent the effects of the compression, which are shoAA'n by the fact that the pulsations lose their ordinary force, and become more and more Aveak. Here, if the compression continue, there is very serious hazard to the child, and hoav the question arises—What, under the circumstances, is to be done ? 3Iuch has been said about the reposition of the prolapsed funis, and, with a vieAV to accomplish this object, numerous instruments have been constructed. I have very little confidence in any of these contrivances. They may sometimes succeed in dexterous hands, but very frequently they fail; and, more than this, the very attempt made to replace the fallen cord is oftentimes followed by injury, not only to the cord itself, but to the adjacent soft parts. It is amusing to hear some persons talk of the facility Avith which the reposition of the funis can be effected by the aid of these con- trivances. But, gentlemen, it is one thing to talk, and quite another thing to act. I have knoAvn many a plausible theory to give way and prove utterly negative, Avhen tested at the bedside of the patient. The very best instrument, in my opinion, for replacing the cord, is the fingers of the accoucheur. Let the middle and index fingers be gently introduced Avithin the vagina; they are thus brought in contact Avith the fold of the cord ; this latter should be directed toAvard one of the lateral and posterior points of the pelvis—most frequently toward the left sacro-iliac symphysis, for the reason that at this point there is usually more space, in conse- quence of the greater frequency of the first vertex position of the head. In this way it is sometimes possible to replace the cord within the uterus, and thus remove the compression to which it has been subjected. If this can be done, much good will have been accomplished, and the labor may then be committed to the resources of nature. It must be recollected that the attempt to replace the cord should be made only when the os uteri is Avell dilated, the head or presenting portion of the foetus at the superior strait, and not after it has passed into the pelvic excavation. In this latter case, we have a more efficient and prompt remedy in the immediate delivery of the child by the forceps.* * I should not omit to mention an ingenious plan, suggested by Dr. T. Gaillard Thomas, for the reposition of the cord. It consists essentially in what he terms postural treatment. The woman, in case of funis prolapsion, " is placed on hei knees, with the head down upon the bed " Dr. Thomas observes 'that-the causoj of this accident (prolapsion of the cord) reduce themselves to two, the slipperj nature of the displaced part, and the inclined plane offered it by the uterus, bj THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 465 According to Dr. Arneth, the funis is always replaced in the Vienna Lying-in Hospital Avhen the operation is practicable. The plan adopted, when the head presents, and is movable at the brim, the os uteri being fully dilated, is to push the funis upward, and lay it in the hollow of the neck of the child. There are forty- three cases recorded in the hospital register of this reposition, and in thirty-eight the children were born alive; in three of the remainder, the cord was almost pulseless when returned; in one instance, the forceps was resorted to in consequence of inertia of the uterus. But suppose the reposition of the funis cannot be brought about, are we then to do nothing ? To remain satisfied with the failure to replace the cord, and to consider the abortive attempt as the full measure of your duty, when the evidences of compression are beyond all peradventure, would be to consign the child to great peril, if not to certain death. Such conduct would not only be highly reprehensible, but would very properly subject you to merited rebuke, unless you had a good and justifiable reason for non-interference. There are two alternatives to which recourse may be had in a contingency of this kind—version and delivery by the forceps. It is extraordinary that there should exist among writers on mid- wifery such diverse opinions touching the propriety of these two alternatives; and it is equally unfortunate for the young accoucheur that these opinions should be recorded in the books, Avhich are supposed to contain correct rules of practice, and, therefore, regarded safe guides in the hour of doubt and embarrassment. One author, for example, inculcates the necessity of proceeding at once to the termination of the delivery by version " if the child be living, and the presenting part remain high up in the pelvis." The language just quoted is that of Denman, whose name deservedly carries Avith it great weight. No less an authority on the general question of obstetrics, Dr. Dewees, of whom our country has reason to be proud, holds that " Turning may be had recourse to, if the uterus be sufficiently dilated or dilatable for the operation, the head being still inclosed within the uterus, and there is no deformity of the pelvis." I might array before you the names of other dis- tinguished men in favor of the operation of turning, as a conserva- tive measure in prolapsion of the cord. But to do so, would, I apprehend, be of little moment. It is more important, I think, to examine, for the instant, the universal propriety of the rule incul cated. which to roll out of its cavity; and, second, that the only rational mode of treat- ment would be in inverting this plane, and thus turning to our advantage not onlj it, but the lubricity of the cord, which ordinarily constitutes the main barrier to oui success. [Transactions New York Academy of Medicine, Vol. II., Part II.] 30 466 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. The ostensible and only justifiable argument in favor of version in cases such as are now under consideration, is that it will afford the child the best means of safety. But while, on the other hand, we are prompted to do so much for the child, we are not to forget that the safety of the mother has claims equally urgent, which cannot be lightly regarded by the accoucheur. I low often is the life of the mother involved in peril in the operation of version, and how often, alas, does this peril terminate in her death ! You see, therefore, that in selecting the alternative you must be governed not by the abstract fact that the funis is prolapsed, but by a due consideration of all the surrounding circumstances. You are to consider Avhether, in full view of all the facts of the case, turning presents the greatest promise of safety to the child, Avithout com- promising the life of the parent. If my OAvn opinion be worth anything on this question, I should advise you, no matter how imminent may be the danger to the child, never to have recourse to version, except under the following conditions : 1. The head at the superior strait not having descended into the pelvic excavation; 2. The mouth of the uterus soft and dilatable, readily permitting the introduction of the hand ; 3. The pains must not be characterized by great vigor, for this Avould not only be a serious obstacle to the introduction of the hand, but would prove a substantial ground why version should not be attempted, for the reason that efficient and regular contractions Avould be likely to terminate the delivery more rapidly than it could be done by turning; 4. There should be no pelvic deformity, or, at all events, very slight. It must also be borne in memory, that, in version, the child is not unfrequently sacrificed, and often- times its death is traceable purely to compression of the cord during the manipulations, necessary to the accomplishment of the opera- tion. If the head should have passed into the pelvic ca\dty, and more especially if it should have reached the inferior strait, then the indication would obviously be to deliver without delay by the forceps, care being taken so to adjust the instrument as not to make pressure on the cord. Hemorrhage.—Hemorrhage or flooding before the birth of the child, will constitute, under certain circumstances, an important cause of artificial delivery. Your attention has already been directed to hemorrhage after the birth of the foetus; Ave shall noAV speak of this accident as it sometimes presents itself previously to the expulsion of the child. As associated, therefore, with the question of ante-partum flooding, we shall proceed to consider that form of it, which is more or less directly connected with placenta praevia. By the term placenta praevia, you are to understand the insertion of the after-birth either completely or partially over the neck of the womb. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 467 The almost necessary connexion between this attachment of the placental mass and hemorrhage will be pointed out immediately. The earlier writers promulgated some singular views in explanation of the reason why the placenta is occasionally found implanted over the cervix uteri. Some of them maintained that this was not the point of its original attachment, but that when found over the os uteri, it Avas the result simply of separation from its former place of insertion, and the consequent gravitation of the mass toward the neck of the organ. You are to remember, however, that this hypothesis, absurd as it is, was the offspring of those times in which physiology was scarcely in possession of a name, and when, consequently, our present advanced knowledge of embryonic development was one great blank. But even with our present knowledge, there is not a general concurrence of sentiment as to the true cause of placenta praevia. I am very much inclined to the opinion, however, recently suggested, that it is owing to the fact of the fecundation of the ovule after it has passed from the upper to the lower portion of the uterus to the immediate vicinity of the os uteri. This explanation at least possesses the merit of plausi- bility, and is due, I believe, to Dr. Tyler Smith. I have just told you that the placenta may be attached to the neck of the uterus either completely or partially. In the former instance, the after-birth may be said to rest, centre for centre, over the dependent part of the organ; Avhile, in the latter, only a portion of its border is found there. But what is essential for you to remember is, that, in either case, there Avill be, as a general rule, more or less hemorrhage. Indeed, were it not for the flooding attendant upon this form of presentation, placenta praevia would be altogether Avithout interest. It is, therefore, because of the serious danger in which both mother and child are involved from losses of blood in placental presentation, that it becomes a question entitled to your fullest consideration. I have endeavored, when discussing that subject, to portray to you the imminent peril of the lying-in Avoman in hemorrhage after the birth of the child; and noAV you Avill permit me to assure you that, kindred to that peril, is the hazard which life encounters from the hemorrhage consequent upon placenta praevia; nor must it be forgotten that the danger is more momentous in the latter case, from the circumstance that here, in addition to the safety of the mother, the life of the child becomes seriously involved. Is there a necessary connexion between placenta praevia and losses of blood, and if so, Avhat is that connexion? This is an exceedingly interesting question for the young accoucheur, and its solution -will at once point out to him, not only the true danger of this form of presentation, but it will also demonstrate beyond a peradventure the urgent necessity of unbroken vigilance in these 468 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. cases, so trying to the interests of both mother and child, and at the same time so harassing to the practitioner. Well, there is a connexion, and it is simply this : the direct cause of the hemorrhage is the rupture of one or more of the utero- placental vessels, in consequence of the Avidening or dilatation of the uterine extremity or internal orifice of the cervix. You will remember, when speaking of the gradual development of the uterus, under the influence of gestation, your attention Avas specially di- rected to the important fact, that, for the first five months, the accommodation of the groAving embryo is provided for exclusively by the increased capacity of the fundus and body of the gravid womb; and it is not until after the fifth month that the cervix of the organ begins, through a process of shortening, to contribute its proportion of space to the wants of the foetus. If this be really so, and I think there is no doubt of the fact, you will at once per- ceive how irresistibly, as a general rule, there is deduced from the recollection of this circumstance a most important practical principle in connexion with the question now under consideration. The principle to Avhich I allude is this: that in placenta prcevia, the hemorrhage may commence, not necessarily at the time of labor, but at the sixth month, and may continue at intervals, in more or less quantity, until the completion of the delivery at the full term. Contrary to the opinion of Stoltz, Cazeaux, Dr. MattheAvs Duncan, and others, I have endeavored to shoAv you that the shortening of the neck of the uterus in pregnancy commences at its uterine, and not at its vaginal extremity. As soon, therefore, as this shortening Commences, it will generally, to a greater or less extent, be at the expense of the integrity of some of the utero-placental vessels, which, in placenta prcevia, constitute an important connexion betAveen the upper portion of the cervix and maternal surface of the placental mass. I say generally, and it is, in a practical point of vieAv, and more particularly as regards a correct diagnosis, important that you should bear the word in memory, for you will sometimes meet with exceptional cases in which, in placenta prcevia, there is no sign of hemorrhage until the commencement of labor at the full term of utero-gestation. When, however, the bleeding commences at any period between the sixth and end of the ninth month, it is Avell to recollect that there is nothing fixed or regular in its recurrence. It will sometimes be shght, again copious, and may return at an interval of a feAV days; nor is it announced by any premonitory symptoms, its advent being more or less sudden. In some cases, too, strange to say, through a salutary clot, and the closing of the exposed utero-placental vessels, the woman will pass on to the completion of her pregnancy without the interposition of science. But these are extremely rare instances, and should in no way be relied upon as a reason for inaction on the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 469 part of the accoucheur. On the contrary, it will be his imperative duty, as we shall state under the head of treatment, promptly to interpose as soon as he becomes aware of the hemorrhage, no matter how slight it may be at its inception. The bleeding in cases of placenta prcevia has not been improperly termed unavoidable, in contradistinction to another form of hemorrhage during gestation, designated accidentcd. In the latter instance, the loss of blood is due to a sudden and partial separation of the placenta, when situ- ated in other portions of the uterus than over the cervix, and the separation is traceable mainly to falls, shocks, mental emotions, or sudden congestions. This accidental hemorrhage may arise, also, from rupture of one or more vessels of the umbilical cord. There is one point essential to note in connection with placenta prcevia, more particularly when the after-birth rests, centre for centre, oArer the cervix uteri, and the point to which I allude is this: the hemor- rhage is more profuse at the time of labor thctn if it should occur previously to the full term of gestation, for the reason that the effect of a labor-pain is to detach from the cervix a portion of the placental mass, and consequently expose a larger surface of the utero-placental vessels ; and these utero-placental vessels, it must be remembered, have, at the completion of gestation, attained their maximum of development; and, in this latter fact also, will be seen an additional reason for the greater profuseness of the flooding at the period of ordinary parturition. It Avill sometimes happen that the placenta, through the sponta- neous efforts of nature, will be expelled previously to the child; in this case, the head of the foetus, responsive to the contractions of the Avomb, may act as a Avedge against the bleeding surface of the cervix, and thus most opportunely arrest the hemorrhage. Again : if a Avoman have an extraordinarily capacious pelvis, and the con- tractions be marked by great vigor, the entire ovum—child, pla- centa, and membranes—may be suddenly thrown from the uterus, and in this case, too, if the vacated organ contract promptly there will be no flooding. These, hoAvever, it is to be recollected, are instan- ces contrary to the general rule. But as they have, and will again occur, it is incumbent to bear them in memory. When the expul- sion of the after-birth is preceded by that of the child, it is impor- tant to recollect that this is the result altogether of the strong con- tractions of the uterus, Avhich, in the first place, have been sufficient to detach the placental mass, and, secondly, to throw it into the world. In tliese instances, if one of the extremities of the ovoid should present, the delivery is usually accomplished without delay, and the case terminates auspiciously, for the simple reason that the separation of the placenta and the subsequent part of the labor has been effected in accordance with the natural effort. Malpositions of the foetus, however, are not at all infrequent in placenta praevia, 4:70 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and this should be remembered, in order that when they do occur their recognition may be prompt. This form of presentation neces- sarily enhances the danger to both mother and child. Symptoms.—If a pregnant female have hemorrhage from the uterus, at anytime betAveen the sixth and ninth month of gestation, and on investigation it be ascertained that there is no external cause for the bleeding, and if the blood Aoav in sudden gushes at inter- vals, even during the quietude of sleep, then the apprehension may arise that the hemorrhage is due to placenta pnvvia. If the hemor- rhage occur at the time of full parturition, and there be an absence. of any of the causes of accidental bleeding, and if the discharge of dblood become more profuse as the labor-throes advance, it is valua- ble presumptive evidence that the placenta is over the mouth of the uterus. Diagnosis.—In order that all uncertainty may be at an end, and the question of placenta prsevia placed beyond a doubt, it is Avell to recollect that there is one means by which the accoucheur can arrive with full truth at an accurate diagnosis ;* and this consists in the fact that, if the os uteri be dilated sufficiently to admit the introduction of the finger, he can feel quite distinctly the placenta resting over it. The contact of the finger Avith this mass will impart a soft, doughy sensation. It is possible, hoAvever, Avithout due caution, to mistake for the after-birth a clot or coagulum of blood. If it be the latter, it will be found movable, and may be readily brought aAvay by the finger. There will, occasionally, exist around the os uteri vegetations, either syphilitic or cancerous, and these, too, may through inattention be confounded Avith the placenta. This latter body may also sometimes be recognized by the finger through the parietes of the cervix, even when there is no dilatation ; but to accomplish this will require great nicety of touch, and a large experience in explorations of this kind. It is well, also, to recollect that, in placenta prsevia, the vessels of the vagina become greatly engorged, sympathizing in this respect with those of the lower segment of the uterus, and these arterial pulsations are marked by increased force. Treatment.—The most important and interesting circumstance connected with placenta prcevia is unquestionably its management; * According to statistical compilations from the journal of the Clinical Hospital, at Breslau, made by Dr. Von Glisczynski, (Med. Centr. Ztg.; Schmidt's Jahrb., 102, 5,) placenta prsevia occurs not quite as frequently as stated by others, only ninety cases having been there observed in 10,440 deliveries. The first indication is fur- nished by hemorrhage, during the latter third of pregnancy; sometimes as early as the fourth or fifth month. A certain diagnosis is not possible until the placenta itself can be felt. The fact that this abnormity occurs almost exclusively in multiparis leads to the hypothesis of defective reorganization of the womb, either from several pregnancies following each other in too short a time, or from inflammatory and othe! morbid conditions of the same. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 471 for although the fatality of these cases is comparatively great both to mother and child, yet, through prompt and judicious treatment, it may be much diminished.* You may be called to a case of this kind at any period before the completion of gestation, or at the time of labor, when the term of pregnancy has been accomplished, and parturition regularly commenced. We will suppose, in the first instance, the former case. The female may have reached the sixth, seventh, or eighth month; she discovers that she is losing blood from the vagina; it increases from day to day, and, in her anxiety, she sends for one of you. What, under the circumstances, are you to do? The first inquiry, which Avould naturally suggest itself to the mind of an intelligent physician, would be—What is the cause of the bleeding? Is it the result simply of a threatened premature delivery ? is it occasioned by some sudden shock or injury, thus presenting an example of acci- dental hemorrhage ? or is it traceable to the fact that the placenta is inserted over the neck of the uterus ? Tliese are the questions to be determined, and on their solution will depend the special treat- ment indicated. If you be of opinion—judging from the antecedent as well as the accompanying circumstances of the case—that the bleed- ing is due to placenta prcevia, then I Avould suggest to you to pur- sue the folloAving course: the patient should be placed on her back, with the hips slightly elevated; she should repose, not on a feather bed, but on a hard mattress ; the room, if in Avinter, not to be above a medium temperature; if in summer, the windoAvs and doors should be opened, in order that a pure and refreshing current of air may be promoted. It is most important to guard the patient against all excitement, whether of body or mind. If fear should have seized her, and the ner- vous system become in consequence much disturbed, one of the best medicines, under the circumstances, will be the comforting assurance of her medical man that he will carry her safely through her tribu- lation. Hoav often is it in the poAver of the accomplished physician by a dexterous use of the influence he possesses over his patient, to * Dr. Schwarz, having examined the official returns made by Hesse Cassel prac- titioners, states that during a period of 20 years, 519,328 births were reported by 150 accoucheurs, and among them 332 cases of placenta prsevia, or 1 in 15 64 labors; the numbers varying from 8 to 28 per annum. The mortality depends upon the degree of the presentations of the placenta, and also upon the mode of treatment; of the 332 cases reported by the Hesse practitioners, 86 died, or 1 in 3-86. These, it must be re- membered, embraced every variety of the accident, partial and complete. This cor- roborates in a remarkable manner the statistics of Prof Simpson, who shows from data furnished by lying-in hospitals and practitioners of large experience that the general mortality of the accident is 1 in 36, and also, with the mortality of cases enume- rated by Prof. Trask (Prize essay on placenta prsevia, Transactions American Medi- cal Association, 1855), which was, 237 deaths in 938 cases, or 1 in 3-95. The mor- tality after turning, according to Prof. Simpson, is 114 in 421 cases or 1 in 29 ; that afforded by Prof. Trask's record is 1 in 3 4. 472 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. fortify a perturbed spirit, and reanimate a drooping heart! It is highly necessary that constipation should be guarded against, for the very act of straining in the effort at defecation will have a ten- dency to increase the bleeding. Under the circumstances, should a movement be indicated, I should greatly prefer to enemata, the fol- loAving solution, a tablespoonful of Avhich may be taken once in two hours, until an aperient action is produced : Sulphat. magnesiae ^ i. Infus. fol. Rosar. f. 3j viij. Ft. sol. This is a combination, which I have employed with signal advan- tage in cases such as we are now considering. The patient should be restricted to cold drinks, nothing better, if it agree with the stomach, than iced lemonade. The diet bland and unstimulating. After the bowels have been gently acted on, I have recently experienced in two cases, in which the hemorrhage occurred at the sixth and seventh months respectively of gestation, decided benefit from the administration of the sulphate of the peroxyde of iron, the haemo- static properties of which are hoav well established; from five to fifteen drops, three times a day, in a wine-glass of cold water. To prevent injury to the teeth it should be taken through a glass-tube. One point you are not to neglect—Avhen the boAyels are to be moved, or the urine e\racuated, a bed-pan must be employed. On no account is the patient to be permitted to use the chair; the very effort may be folloAved by serious trouble in consequence of in- creased hemorrhage. Well, tliese are the preliminary measures to be adopted; but suppose the bleeding, notAvithstanding these measures, should continue, and so profusely as to affect the strength of the patient, and involve apprehensions as to the general issue. Then, in addition to what has already been suggested, it will be proper for you to institute a careful vaginal examination with a view of ascertaining the condition of the os uteri, which will either be sufficiently dilated to enable you to accomplish delivery, or it will not be so dilated. In the latter case, the bleeding continuing in exhausting profuseness, and the os uteri not at all or but slightly dilated, you have an important remedy in the tampon. I cannot understand why some clever and practical authors are opposed to the employment of the tampon in an emergency of this kind, for the arguments they urge are certainly, in my judgment, without the slightest basis. As a principal objection, they maintain that this instrument will be likely to produce internal hemorrhage, and thus destroy the patient. Those Avho raise this objection do so, I think, without sufficient thought, for it is quite evident that although internal flooding might possibly folloAV the employment of THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 475 the tampon in accidental hemorrhage, yet there is no ground for apprehension that it will ensue in placenta prsevia, for the reason that the bleeding surface is below, and the blood does not accumu- late within the cavity of the uterus, but collects between the tampon and I hat portion of the cervix from, which the placenta has, in part or totally, become detached. So far, therefore, from this agent provr- ing injurious, I regard it as one of the most efficient alternatives to Avhich, under the circumstances, the accoucheur can have recourse. The very principle, too, on which the tampon exercises a salutary influence is one, Avhich is directly opposed to the occurrence of internal hemorrhage ; for, by a uniform and gentle pressure, it causes a coagulum Avhich acts for the time as a check to further loss of blood. Thus, you see, you possess in this agent an admirable tem- porary remedy. If the os uteri be undilated, and the bleeding con- tinue profusely, the patient must of necessity sink unless there cau be something to hold it in check. For this purpose, I repeat, my groat faith is in the tampon, or plug, as it is sometimes called. NoAAr, an important question arises—How long is the plug to be employed ? My ansAver is until the os uteri is sufficiently dilated to enable you to introduce the hand, turn, and deliver. Version I hold to be the cardinal remedy in placenta prsevia, if the head of the fcetus be still at the superior strait, and the mouth of the Avomb will alloAv the introduction of the hand ; on the con- trary, if it should have descended into the pelvic excavation, the indication is at once to resort to the forceps. But how are you to know—if you employ the tampon—that the os uteri has undergone dilatation sufficient to justify artificial delivery? This fact can only be ascertained by occasionally removing the tampon, and making a digital examination; the time as well as the necessity for doing this should be regulated by the frequency and character of the pains. There is an additional advantage in the employment of the plug, and it is this—its very pressure against the lips of the uterus will excite action of the organ, and thus promote contractions which, of course, will tend to hasten the opening of the os, an object so desirable in cases such as Ave are now discussing. The tampon may consist of 'small pieces of old linen, or fine sponge, or Avhat is still better, if at hand, carded cotton-Avool—and they should be gently introduced into the vagina, piece after piece, until the entire passage is filled—the AA'hole to be retained in place by means of aj bandage. There are several modes of introduc- ing the plug. I adopt the folloAving: the index finger of one hand being introduced into the vagina, the palmar surface upward, I seize with an ordinary calculus forceps a small piece of the mate- rial to be employed, and direct it along the finger as far as the os uteri, against Avhich I exert slight pressure; and so suc- ceeding pieces are introduced until the canal is quite filled ujx 474 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. When necessary, they are to be removed, and replaced by other pieces. An efficient tampon will be the india-rubber bag, filled with ice- water (the colpeurynter). Let us noAV suppose that, on withdraAving the plug, it should be ascertained that the mouth of the womb is soft and dilatable, per mitting the introduction of the hand Avithout the fear of violence; how are you to proceed with the delivery ? I recommend, in case you should undertake the version of the fcetus, to proceed as follows : Carry your hand cautiously through the vagina to the mouth of the uterus—here, of course, you come in contact with the placenta, which is resting, more or less, over this portion of the organ. In a Avord, it occludes the opening through which your hand is to enter the uterine cavity. Make a slight circuit with your finger around the dilated os, and if you can find a portion of the placental surface which has become detached from the cervix, then, Avithout hesitation, select this as the point of entrance, and immediately introduce the hand for the purpose of bringing doAvn the feet. But, on the contrary, if you cannot detect the point at which the detachment has occurred, then my advice to you is at once to carry the hand immediately through the body of the placenta;* having thus gained admission into the cavity of the uterus, seek for the feet, bring them doAvn, and thus terminate the delivery. What is there objectionable in this practice ? You must remember, in the first place, that tAvo lives are in serious peril—time here is everything, and the sooner the deli- very is accomplished, the greater will be the chances of safety to both mother and child. If, therefore, by prompt and successful extraction of the foetus, you cause the uterus to contract—and this, under ordinary circumstances, will be the natural result—have you not, by thus efficiently closing the mouths of the utero-placental vessels, achieved the very object most essential to the safety of mother and child—the permanent arrest of the hemorrhage ? As I have already stated, the true and only danger of placenta praevia is in the losses of blood it occasions. Therefore, is it not the part of wisdom, the moment the opportunity occurs, to do that very thing which, under the contingency, is most likely to accom- plish the greatest amount of good—the prompt withdrawal of the foetus from the uterine cavity ? I think so, and it is for this sub- * I am aware that in this advice I differ with most of the standard authorities; but I am quite sure I am right. The objections urged by them to the practice inculcated are two-fold: 1st, The difficulty of penetrating the placenta ; 2d, The increased risk to the child from lacerations of this body. In reply to the ifrst objec- tion, I need only say that I have encountered very little difficulty in penetrating the mass; and to the second, I would simply remark' that the child is exposed to the most imminent peril by delay, and the best alternative in these cases is immediate delivery. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 475 stantial reason that I commend the practice just alluded to. With a due degree of caution, the Avell-instructed accoucheur, as soon as he has seized the feet of the child, and during the progress of his tractions, will be enabled to guard against inertia of the uterus, and having accomplished the delivery of the foetus, he will, through proper attention to his duties, have the gratification of finding the source of the hemorrhage arrested by the proper contraction of the organ. But suppose you deem it necessary to thrust your hand through the placenta, or you should be enabled to detect a portion of its border separated from the cervix, and select this as the point of entrance into the uterine cavity, in either case the interesting question arises—What are you to do Avith the placenta? My advice is—to pay no sort of attention to it; bring down the feet, deliver the child, and then, if the expidsion of the after-birth should not promptly follow, carry up the hand and bring it away. Artificial Detachment of the Placenta.—It is proper that I should here allude to the plan of artificial detachment of the pla- centa, suggested by Dr. Simpson. This eminent practitioner, in cases in Avhich turning cannot be had recourse to, inculcates the practice of separating the after-birth from its surrounding attach- ments ; and he seems to have been led to this mode of procedure from contrasting the diminished mortality in cases in which the placenta Avas spontaneously detached and expelled previously to the birth of the child—it being much less than under the operation of version. It does seem to me that Prof. Simpson, in his estimate of artificial separation, has not taken sufficiently into view the Avide difference between spontaneous and artificial detachment. The former is the Avork of nature—the act she accomplishes through the force of uterine contraction, and it is, also, through these very contractions that the mass, after being spontaneously detached, is in the same manner expelled. It is not strange, therefore, that, under these circumstances, this spontaneous effort of nature should prove an admirable haemostatic adjuvant in the profuse bleeding of pla- centa praevia. Does not the very same thing occur in ordinary labor, so far as the separation of the after-birth is concerned? Pray, Iioav is this mass detached, no matter where it may be situated within the uterine cavity, except through the successive contractions of the organ ?—And do not these very contractions, because they are in perfect consonance Avith the mechanism of nature, guard the parturient woman against an attack of hemor- rhage ? But suppose, Avith a vieAV of illustrating this point more fully, the accoucheur, after the birth of the child, should attempt, by premature and forced tractions on the umbilical cord, to hurry the operations of nature, and thereby cause an artificial detach- ment ; would there not, as a necessary consequence, in ninety-five cases out of one hundred, be more or less profuse bleeding ? Un- 476 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. doubtedly such would be the result, and there is, in my judgment, a striking analogy betAveen the tAvo instances. Prof. Simpson is also of opinion that the detached portion of the placenta constitutes almost exclusively the bleeding surface, and it is mainly on this hypothesis that is founded the practice he recommends; but if he be right in this conjecture, Iioav are Ave to explain the occurrence of profuse post-partum hemorrhage alter the placenta has been expelled? Will it be argued that, in pla- centa praevia, we have one kind of bleeding surface, and in hemorrhage after the expulsion of the after-birth, another ? The great bleeding-surface, as I have already told you, consists essentially of the utero-placental vessels, and is, therefore, strictly uterine, and not placental; at least it seems to me that this is the main source of the hemorrhage the quantity of blood passing from the separated portion of the after-birth being quite insignifi- cant. The view that the hemorrhage is derived almost entirely from the detached portion of the placenta, and not from the utero- placental vessels, Avas also maintained by the late Professor Hamil- ton, of Edinburgh.* It is proper, hoAvever, to remark, that the opinions Avith regard to the source of the hemorrhage in placenta praevia are conflicting, although the general belief is that it is derived from the uterus. Without mentioning other authorities, it may be well to state that Dr. Robert Lee, of London, is one of the sturdiest advocates of the doctrine that the blood proceeds from the uterine sinuses, while Dr. Radford, of Manchester, believes that it comes both from the placenta and uterus, although the larger quantity is furnished by the latter organ. One thing, however, is very certain, that the treatment of pla- centa praevia—more especially since the suggestion of Professor Simpson of detaching the placenta as a remedial resource—has pro- voked a Aery bitter controversy—indeed, in some instances, the contest has assumed unmistakable evidences of what, in plain lan- guage, may be called strong personalities, a feature always to be avoided in scientific discussions. In the fierce conflict of the political arena, such episodes are more or less in keeping with the subject-matter, but they should find no foothold in a profession like ours, intended, through the development of truth, to confer health and blessings on the human family. Dr. Barnes, so well known through his important contributions to obstetric science, is opposed to any attempt at forced effort for the purpose of detaching the placenta, and we are happy to find him so conservative on this interesting point. Nothing, in my opinion, will justify a forcible introduction of the hand into the uterine cavity—for violence, under these circumstances, will incur * Practical Observations, 2d Ed., p. 312. I THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 47V the serious peril of rupture of the organ—and well may it be asked cui bono? But Dr. Barnes, while opposed to artificial detachment of the entire placental mass, strenuously inculcates the advantage of partial artificial separation as a means of arresting the hemorrhage. It strikes me, however, that by thus increasing the area of the bleeding surface, Ave must necessarily increase the profuseness of the hemorrhage. His arguments are quite ingenious, and his essay well worthy of attention; * but it does really appear to me, after a careful perusal of his excellent monograph, that the lesson he teaches is not Avithout objection. At all events, I may be per- mitted to express the opinion that the views of Dr. Simpson with regard to the entire separation of the after-birth, and those of Dr. Barnes touching its partial detachment, are questions to be deter- mined, not by the reasoning of clever minds, but by the positive results in practice, which the future may disclose, either affirma- tively or negatively. The plan of artificial detachment of the placenta was suggested to Dr. Simpson from a consideration of the high mortality of the operation of turning compared with that folloAving cases of sponta- neous detachment or expulsion of the placenta previous to the birth of the child ; the mortality in the latter case being but one in fourteen. Cessation of hemorrhage took place in these cases imme- diately, for the most part, upon the detachment of the placenta; and believing that the same result Avould folloAV its artificial detach- ment, he suggested this as a resort in all cases of labor thus com- plicated, in which, from rigidity of the os uteri, or extreme exhaus- tion of the patient, turning could not be prudently resorted to. It has been objected to Dr. Simpson's statistics, that they embrace cases not adapted for comparison, including, as they do, cases occurring at every age, subjected to every variety of treat- ment, and some to no treatment at all; also cases complicated with rupture of the Avomb, convulsions, contracted pelvis, &c. To meet this objection, Prof. Trask, in his essay already alluded to, has collected all the published cases to Avhich he had access, together with others communicated to him. He has analysed them Avith a vieAv of presenting, as far as possible, the influence of various circumstances and conditions of the patient in determining a suc- cessful or fatal result. Anxious to give the reader the benefit of Dr. Trask's researches, and of affording Prof. Simpson the full benefit of his conclusions, I shall briefly allude to some of the most interesting and important, which are as follows: "The teachings of the best authorities are confirmed, that the period of greatest danger is betAveen the seventh month and the completion of pregnancy. Of the presentations in the 353 cases, 113 Avere of the head, or the head complicated Avith descent of the » The Physiology and Treatment of Placenta Prsevia. By Robert Barxes. 1857 478 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. funis or hand; 21 of the superior extremity; 22 of the pelvic extre- mity, and 2 of the umbilicus ; the remainder were probably, for the most part, of the head, but the proportion of unnatural presentations is very marked. " From Table I., embracing cases subjected to ordinary modes of. treatment, or dying undelivered, Ave learn that there Avere 141 recoveries and 59 deaths, or a mortality of 1 in 3.4." The influence of hemorrhage previous to delivery in affecting the result is thus shown: "If we noAV compare the 84 cases in which the hemorrhage was very severe, among the recoveries after artifi- cial delivery, Avith the 12 in Avhich it Avas moderate, Ave find the cases of ' moderate' bear to those of profuse hemorrhage the pro- portion of 1 in 8 of the whole. Among the fatal cases after artifi- cial delivery, the proportion of moderate to severe hemorrhage is 3 in 47, or about 1 moderate to 16 severe. Of cases requiring arti- ficial delivery as a whole, there was 1 case of moderate to 11 of severe hemorrhage, Avhile of those delivered spontaneously there was 1 moderate to 5^- severe. There is also a correspondence between the degree of presentation and the necessity for artificial delivery. Among cases of spontaneous expulsion of the child, there Avas a much larger proportion of partial presentations, and, as a consequence, less hemorrhage, and therefore a lower rate of mortality. " Adding the cases of Drs. Lever and Merriman to the cases in the table, Ave get a total of 96 saved, and 166 lost, or 1 in 2.7 of the whole saved. The mortality to the child in the cases of the practi- tioners of Hesse-Cassel is even greater, 85 having been born living, and 251 dead, or 1 3.9 of the Avhole saved. "Table II. embraces 36 cases of spontaneous expulsion of the pla- centa ; in these but 2 deaths are noted, both from diarrhoea subse- quent to labor." Dr. Trask adds to his cases others recorded by Dr. Simpson, and of the whole, 59 required manual assistance, while 78, or 57 per cent. were delivered by natural effort. Of cases embraced in the first table only 17 per cent. Avere delivered spontaneously; the inference is that "cases in Avhich the placenta is expelled before the birth of the child, as a class, are characterized by a tonicity of the womb and a vigor of uterine contraction which wre do not find in ordinary cases of the accident." There were 140 recoveries and 11 deaths, or a mortality of about 1 in 14. Dr. T. next proceeds to inquire Avhat success has attended artificial detachment of the placenta, as an expedient for putting an end to hemorrhage. " In Table III. are recorded the histories of 66 cases. The mortality of cases thus treated is stated to have been 1 in 4.6. The gross mortality, after its performance in the cases composing this table, is therefore somewhat less than the THE PR1NC1PLKS AND PRACTICE OF OBSTETRICS. 479 general mortality under ordinary modes of treatment, and espe- cially after tinning ; but it is very much greater than after sponta- neous expulsion of the placenta. In explanation of this, our author proceeds to show that the proportion of complete presentations Avas considerably larger among these than among cases constitut- ing (he first table; that the proportion of cases in which the hemorrhage Avas very alarming Avas much greater, and that alarm- ing exhaustion occurred in a much larger relative number than among cases in the first table. In other words, cases in which detachment was resorted to were, for the most part, at the time of the operation in a far less favorable condition for recovery than Avere the cases in which artificial delivery was resorted to. This circumstance is, of course, entitled to great weight in comparing the results of the tAvo modes of practice. " About one in three of these cases Avas delivered by spontaneous expulsion of the child, a much larger proportion than among cases of the first table. This fact, which is apparently at variance Avith the statement as.to the unusual severity of the cases we are consi- dering, receives a hap{)y explanation in the following facts. In the sj>ontaneous deliveries, after spontaneous separation of the placenta, the child followed the placenta, in more than half the cases, in ten minutes or less, Avhile in the spontaneous deliveries after artificial detachment, the child folloAved the placenta after a more or less prot racted interval. In the first case the contractions of the Avomb expelled placenta and child nearly together, but in the cases of artificial detachment, the hemorrhage having ceased in consequence of the detachment, the vital poAvers haA'e rallied, and, at various intervals from one-half hour up to eighteen hours, have expelled the child. " This table gives abundant evidences of the haemostatic powers of artificial detachment. Of 66 cases, in 35 hemorrhage ceased immediately and entirely, and in the remainder, AA'ith scarce an exception, it continued but a short time and in trifling degree. " Fifteen children were saved and thirty-two lost, or a trifle less than one in three saved. It is evident that unless delivery soou foUoAv this operation, the life of the child must almost necessarily be sacrificed. The result here given does not differ much from the results folloAving turning and spontaneous expulsion of placenta, in which a tritle less than one in three Avere saved. It is quite proba- ble that, as suggested by Dr. Barnes, the detachment, in at least some of the instances in Avhich the child Avas saved, had been only partially effected. " The plan of partial detachment, as recommended by Dr. Barnes, is designed to meet the objection to total detachment which arises from the peril in Avhich it places the child; sufficient connexion 480 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. with the mother still remaining to allow of changes in the blood required by the child." Ergot—the secale corn utum—is a remedy much employed by many practitioners in placenta prcevia. The Avell-known influence exercised by this agent in the production of uterine contraction has caused, I fear, a too indiscriminate resort to it. I have great" confidence in ergot, under its judicious administration, but I must protest against its empirical employment. I am opposed to its use in placenta prcevia in the folloAving conditions: 1. If the mouth of the uterus be sufficiently dilated to enable the accoucheur to have recourse to artificial delivery, the administration of ergot will, through the increased contraction it occasions, seriously interfere with the birth, Avhether it be accomplished by version or the for- ceps ; 2. If there be a cross-presentation of the foetus, then the remedy should not be given, from the very fact that the increased force of the uterus may, under the circumstances, cause rupture of the organ. On the other hand, should the presentation be right, and the hemorrhage continue, notwithstanding the tampon, Avhicb sometimes may be the case, then I should advocate ergot, even if the os uteri ivere not dilated. Under ordinary circumstances, one of the fundamental condi- tions justifying a resort to this drug is—that the mouth of the womb shall have undergone a measure of dilatation. But in the case under discussion I take exception to this rule, and for the very obvious reason that the os, although not dilated, will, from the, quantity of blood lost, be more or less relaxed and dilatable; and, therefore, the action of ergot, in lieu of mischief, will, through the increase of contractile effort, promptly accomplish the required dilatation, and oftentimes most happily promote the delivery. One word regarding the rupture of the membranous sac in pla- centa prcevia. If the hemorrhage be profuse, not controlled by the tampon, and the os uteri undilated, the rupture of the membranes will not be bad practice; for here, too, the os, though not dilated, is more or less relaxed in consequence of the depletion ; the escape of the amniotic fluid will impart activity to the contractions, and if it be found necessary, the moment it can be done, introduce the hand and terminate the delivery; or, if the head should have passed into the pelvic cavity, the forceps wdll be the resource. But hoAV, in placenta praevia, with an undilated os uteri, is the sac to be rup- tured? The best mode of doing this, is cautiously to penetrate, by means of a small catheter, the placenta, and alloAv the fluid to pass off through the instrument. Accidental Hemorrhage.—The character of flooding, which we have just been describing, is, as you have been informed, knoAvn as unavoidable, for the reason that it is in close relation with the implantation of the placenta over the cervix uteri. Accidental THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 481 hemorrhage, on the contrary, is in no way connected with placen- tal presentation, but occurs when this body is in union with other portions of the uterus. It may present itself at any period during gestation, or at the time of labor. We have already spoken of this form of hemorrhage in the earlier months of pregnancy, when dis- cussing the interesting subject of abortion. To-day, we shall con- fine our remarks to accidental flooding in the later months, or second half of pregnancy, also, after the parturient effort has com- menced. The true pathology of this form of bleeding is a partial or complete separation of the placental mass from the internal sur- face of the uterus ; and the causes capable of inducing the detach- ment maybe enumerated as follows: premature contractions of the uterus; external violence, such as falls, blows, carrying heavy bur- dens, etc.; mental emotion, sudden congestion of the womb, or undue pressure on the hypogastric region ; riding on horseback, or in a carriage, especially over rough roads or streets; among these causes, too, we are not to omit to mention the fascinating, but oftentimes dangerous polka and Avaltz. One of the severest, and, for the time being, most perilous exam- ples of accidental hemorrhage I have ever attended, Avas in the person of a lovely young married woman, who, although in most other matters, a sensible and refined lady, Avas so Avedded to the dance, that, at a brilliant reunion, she could not resist the tempta- tion to " take a turn," though nearly seven months pregnant! In half an hour afterward, she was attacked with flooding, and the scene Avas soon changed. She Avas transferred from the gay hall of fashion to the sick chamber, which Avas near proving to her the chamber of death! By constant and untiring effort, I succeeded in carrying her to the eighth month of her gestation, and then was fortunate enough to deliver her of a living child. I doubt, with the sad experience of her folly, Avhether she will again, under simi- lar circumstances, be induced to " take a turn." It AArill occasionally happen that, from some morbid condition of the after-birth, a portion of it will become detached from the ute- rus, thus giving rise to hemorrhage. I have met with a fair share of such cases. A good observer, and an eminent practitioner, Dr. Robert Lee, of London, maintains with much positiveness, that another cause of accidental hemorrhage is a shortening of the cord by being twisted around the neck of the child, thus inducing a par- tial detachment of the placenta. With all the respect I entertain for this distinguished writer, and with, I hope, a due appreciation of his courtesy oh my visit to London some five years since, I must say that my experience does not accord with his on this point. I have seen many cases in which the cord encircled the neck of the child—indeed, it is by no means a rare occurrence—but I have never known a single instance of hemorrhage arising from this cir- 31 482 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. cumstance. The thing, I admit, is possible, but not very probable, and for this reason, perhaps, it may be enumerated among the ^causes of the accident. Scanzoni also participates in the opinion of Dr. Lee on this point. There is one fact to Avhich I desire especially to direct attention, as an agent in the production of accidental flooding, and to which I do not think authors have attached sufficient importance. I allude to habitual and obstinate constipation. I could cite more than one instance in which I am quite satisfied the violent straining induced by this condition of the bowels has occasioned detachment of the placenta in some portion of its surface, and consequent hemorrhage. Therefore, remember it is essential, for this as well as for other reasons, that the bowels of the pregnant female be pro- perly regulated. Is it possible to confound accidental hemorrhage in the latter months of gestation with a discharge of blood altogether uncon- nected with a detachment of the after-birth ? This question is not without interest, and needs a moment's consideration ; it necessa- rily involves the inquiry, whether a pregnant woman at this period of gestation can lose blood from the uterus, and the ovum preserve its full integrity of union with the organ. There can be no doubt that this may occur; you have already been told that some Avomen menstruate, although pregnant; again, certain morbid conditions of the uterus may give rise to hemorrhage, and none of more importance, so far as a correct diagnosis is concerned, than polypus or a sub-mucous fibrous tumor of the organ. The diagnosis in such cases would not be difficult, and it is scarcely necessary for me to dwell longer upon the point than merely to remind you of the possibility of such contingencies. The placenta may become detached in two ways, even when its separation from the uterine surface is only partial; for example, the detachment may be more or less slight at some point of its cir- cumference ; this is the ordinary form of separation, as connected with accidental hemorrhage, and the bleeding is usually not pro- fuse ; it may occur several times during the pregnancy at an inter- val of some days, and it is generally of but little significance so far as the safety of the mother or child is in question. In these cases, rest in the recumbent posture, and a quiet mind, together with cold drinks at the time of the bleeding will generally suffice, and the patient be carried to the completion of her period. Yet a different state of things occasionally presents itself in this special form of placental detachment—the hemorrhage being most profuse, and menacing the lives of both child and parent. Here, the tampon should not be employed, for it cannot reach the source of the flood- ing, and its only tendency would be the conversion of an external into an internal hemorrhage. If the bleeding should not yield to THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 483 the means already cited—rest in the recumbent posture, elevation of the hips, cold drinks, etc., then there should be no scruple as to the course to be pursued—premature labor should be brought about Sometimes, the partial detachment of the after-birth, and the consequent hemorrhage, will be the result of premature contraction of the uterus, this being induced by some moral or physical cause. In such an event, the attention of the practitioner should be directed, if possible, to the lulling of these premature efforts, and for this purpose opium in some one of its preparations may be resorted to. I have great confidence in these cases in an opium suppository, one or two grains, introduced into the rectum, or thirty or forty drops of the tincture in a Avine-glass of tepid water thrown up as an injection. There is, however, another form of accidental flooding connected with partial detachment of the after-birth, most insidious in its inception, and at the same time fearful in its results—I allude to that condition of the placenta in which its entire peripheral border continues in union with the uterus, and the separation is limited to its central portion. Here there will be a species of pouch formed, into which the blood will be pouring from the utero-placental ves- sels ; in this case, hoAvever, there is no external evidence of hemor- rhage ; the blood does not, for it cannot pass from the uterus. It is veritably a concealed or internal hemorrhage, and the work of death may be accomplished before the practitioner even suspects the cause of the danger. Indeed, I am much disposed to refer some of those cases of sudden and supposed inexplicable dissolu- tion, Avhich occasionally occur in the latter part of pregnancy, to this peculiar, but happily not common form of hemorrhage. As I have just remarked, the blood does not escape externally, and therefore you are deprived of this physical proof; the only and oftentimes fatal evidence of the central separation of the placenta Avill be the exhaustion of your patient; the face grows pale, the heart becomes Aveak in its pulsations, the countenance presents the appear- ance of serious dilapidation, and, if some check be not speedily given to the bleeding, the patient sinks. In instances like these there is ne- cessarily much embarrassment; and it is difficult to know what to do. Usually there are no striking premonitory symptoms, and the counsel of the practitioner is not demanded until the mischief is far advanced. If, hoAvever, you should be called to a case of sudden prostration in the latter months of gestation, unexplained by any antecedent circumstances, it will be well to think of the possible connexion between this exhausted condition and central detachment of the placental body; and if you should be satisfied that the rela- tion of effect and cause really exists, then, in my judgment, the only hope will be in the prompt evacuation of the uterus, in order that, through efficient contraction, the bleeding vessels may be closed. Under these circumstances, I should not hesitate, at once to intro- duce a catheter into the uterus, and puncture the membranes with 484 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. a vieAv of allowing the liquor amnii to pass off, and thus evoke the needed effort. This would probably be the promptest and most certain method of accomplishing the object. Accidental Hemorrhage at the time of Labor.—If this character of hemorrhage should occur during the progress of labor—it cannot be regarded a frequent complication—it will need all the attention of the accoucheur. If it be profuse, and cannot be checked by the application of cold to the abdomen, or the introduction of a small piece of ice into the vagina, or injections of ice-water into the rectum; and it be ascertained that one of the extremities of the foetal ovoid presents, the element of hope will be in the rupture of the membranous sac, and, if this should not suffice to promote strong uterine contraction, recourse may be had to ergot. Should the hemorrhage, in defiance of these means, still continue—a rare circumstance—the labor must be terminated artificially either by the hand or the forceps. In the event of a cross-presentation, which, as I have just said, would contra-indicate both ergot and rupture of the membranes, the finger should be introduced into the os uteri, and gentle efforts made to dilate it. This species of titil- lation will oftentimes be followed by the happiest effects, and more- over, it must be recollected that, in these cases of loss of blood, the rigidity of the muscular fibre of the uterus is very much reduced, and, as a general rule, the dilatation of the mouth of the organ by means of the finger is more or less readily accomplished; the moment it is sufficiently open to permit the introduction of the hand, the indication is to proceed without delay to turn the child by bringing down the feet; for, the earlier version is attempted in cross-births—all things being equal—the greater the probability that the operation will be successful. Sometimes, when the hemorrhage continues without dilatation of the os uteri, and it is not characterized by such abundance as to compromise the safety of mother or child, great benefit will be derived from the judicious administration of anodynes, nothing better in these cases, if the stomach will tolerate it, than Dover's powder, in five grain doses as circumstances may indicate. Should nausea or vomiting preclude its administration, morphia or opium, should there be no contra-indication, may be substituted* It will be perceived that I have said nothing touching the use of stimulants in the exhaustion so apt to accompany these losses of blood, whether from placenta praevia or accidental hemorrhage. The great object of treatment is to arrest the bleeding by the vari- ous means indicated; at the same time, it will be necessary to sustain the strength by a judicious employment of laudanum, brandy, milk punch, etc.; and never omit, in these anaemic conditions, by means of hot flannels or hot water in bottles, to preserve, as far as may be, a proper temperature of the extremities. * Opium will, however, in some cases, have a tendency to increase the vomiting. LECTURE XXXII. Puerperal Convulsions, the different periods of their Occurrence—Muscular Action, on what is it dependent ?—Nervous Disturbance, Centric and Eccentric—Causes of Eccentric Disturbance—Modus Operandi of these Causes—Treatment of Eccen- tric Convulsions oftentimes empirical—Cases in Illustration—Irritation of Uterua as a Cause of Puerperal Convulsions during Pregnancy, at Time of Labor, and sub- sequent to Dehvery—Convulsions during Pregnancy more frequent in the Primi- para ; why ?—Period of Life at which Convulsions are most apt to occur—Blood- letting and Opium oftentimes routine in Treatment of Convulsions; just Distinc- tions essential—Opium, when a Stimulant, and when a Sedative—Fatality of Stereotyped Practice—Excessive Blood-letting; how it produces Convulsions— Treatment of Convulsions based upon their special Cause—Sulphuric Ether as a Therapeutic Agent—Convulsions and Head Presentations; relation of—Artificial Delivery, when indicated in Convulsions—Divisions of Convulsive Diseases; Epi- leptic, Hysteric, Cataleptic, Tetanic, etc.; how distinguished—Hysteria much more frequent in earlier months of Pregnancy—Symptoms, Diagnosis, and Prognosis of Puerperal Convulsions. Gentlemen—We now approach the consideration of one of the most formidable and perilous complications of the lying-in-chamber —puerperal convulsions. They may occur during pregnancy, at the time of labor, or subsequently to delivery. Under any circum- stances, their presence is fraught with more or less hazard to the mother and child, and, therefore, they claim the earnest thought of the accoucheur. As I am especially anxious to explain to you, as far as may be, the true pathology of convulsive movement, based ivpon a sound and rational physiology, you will permit me to recall to your recollection two great fundamental truths, for which we are indebted to the researches oi Flourens and Marshall Hall. The former has demonstrated that muscular action cannot be produced by irritation, either of the cerebrum,* cerebellum, or purely cere- * There is no doubt that strong mental emotion, accompanied by cephalalgia, obscure vision, etc., will sometimes be the starting point of convulsions both in the pregnant and parturient woman. All practitioners of observation have recognized this fact; but it must not, therefore, be concluded that the convulsion is the product, Bimply, of cerebral irritation, for this is adverse to a well-established physiological principle. The brain, in a variety of ways, may become the primary seat of some irritatiDg cause, whether from congestions, slight effusions, or some toxaemic influ- ence, such as uraemic intoxication, etc.; but this irritation cannot generate a con- vulsive movement, until it has affected the spinal cord, the great motor centre of the oconomy. It is an interesting fact, as pointed out by Andral and Brown-Sequard, ill at rigid spasms sometimes follow inflammation of the brain. 486 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. bral nerves, if the irritation be strictly confined to these portions of the nervous mass; and he has further shoAvn that muscular move- ment is the product of irritation—either direct or indirect—of the true spinal cord* and muscular nerves. It cannot be questioned that this is one of the most important developments of modern physiology. This great revelation, however, needed one more fact to impart to it its full interest, both in a physiological and pathological sense. The fact, as I have before remarked, has been supplied by Marshall Hall, who has demonstrated that irritation of the spinal cord may be induced through certain incident excitor nerves. Previously to the disclosure of this latter principle, it Avas supposed that all ner- vous aberrations, involving irritation of the spinal cord, were cen- tric, or, in other words, the result of an influence applied directly to this nervous centre. I may, perhaps, be Avrong in the remark that Marshall Hall was the first to call attention to this interesting fact, for the circumstance had been previously recorded by Whytt, Iiedi, Prochaska, Unzer, and H. Mayo; but I think it must be conceded that, without the practical application made by him of this great physiological truth, its benefit to science would have been extremely restricted. To him, therefore, belongs the honor of having faith- fully and perseveringly insisted, not only upon its importance, but its indispensable necessity for the proper diagnosis and treatment of disease. Now that the action of the incident excitor nerves ia understood, we have another division of nervous disturbance, viz., eccentric, in which an irritation is produced on the peripheral extre- mity of one or more nerves, and the impression thus made is con- veyed by the nervous trunks to the spinal cord; the impression, altogether independent of mind, becomes a sensation, which results in a motor impulse ; this latter is transmitted to certain muscles, and hence an abnormal movement of these muscles is the result. This is what is known as reflex action. All nervous aberrations, of whatever grade, may very properly be divided into two classes—centric or eccentric ; and you will find that this arrangement is not only founded upon a correct physi- ology, but will greatly contribute to the elucidation of that impor- tant chapter in your studies—nervous diseases. It is, therefore, under this classification that I propose to discuss the important question of puerperal convulsions, whether during pregnancy, as a complication of labor, or subsequently to the birth of the child. In either of these aspects, it is a question well entitled to the profound consideration of the medical man. * It must always be borne in mind that the spinal cord, physiologically consi- dered, is not the medulla spinalis of the anatomist; on the contrary, the true spinal cord consists of the medulla spinalis, medulla oblongata, pons varolii, crura cerebri, and the tubercula quadrigemina. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 487 Eccentric causes. These act on the true spinal system through excito-motory influence, by the transfer of an undue or pathological impression. These causes may be enumerated as follows: 1. Indi- gestible food in the stomach ; 2. Morbid matter of any description in the intestines, whether vitiated secretions, unassimilated food, or collections of faeces ; 3. Irritation of the bladder or rectum; 4. Irri tation of the uterine organs and vagina. It is important to bear in recollection that these various causes, under given circumstances, are capable of eA'oking an attack of con- vulsions ; so that, when called to a case of this serious nervous disturbance, your minds may be prepared, almost with the quick- ness of thought, to comprehend the relation of effect and cause, which may at the time exist between the convulsive movement and either of these specified agents. In this way, your diagnosis, sound at the very start, will enable you more successfully to meet the therapeutic indication. There is a vast deal both of routinism and empiricism in the treatment of puerperal convulsions, and this, lam quite confident, is mainly to be attributed to the fact that the practitioner in the hurry or, perhaps, alarm of the moment, suffers himself to regard the convulsion as a primary or idiopathic affection, instead of recollecting that in ninety-nine instances in a hundred it is but the product or result of some antecedent. 1. Indigestible Food in the Stomach.—Let us noAV inquire how it is that indigestible food in the stomach is capable of producing convulsions. It is not sufficient for you to knoAv the fact; on the contrary, you should be content—when demonstration is possible— with nothing short of demonstration itself. Therefore, I now tell you, as a principle well settled, that in these cases the irritation is first produced upon the terminal branches of the pneumogastric* nerve, and is thus conveyed through that nerve to the spinal cord, constituting, as I have already stated, an interesting and striking example of eccentric influence. You are Avell aware, gentlemen, of my fondness for practical, bedside truths; in contrast with mere hypothesis, they constitute so many gems for the medical man. With this conviction, you will pardon me, I am sure, for intro- ducing to your attention the following instructive case, the history and sequel of Avhich are, in my opinion, the best comments I can offer touching the treatment of convulsions dependent upon gastric repletion: Late in the evening of January 1,1857,1 Avas summoned in great haste to attend a young married lady, who was then in the eighth month of her pregnancy—a primipara; the messenger, her brother, told me she had just been attacked Avith a fit, and he desired very urgently that I Avould lose no time in hastening to the house. On • The physiologist has shown that the pneumogastric is an 6Xcitor, and, at tho game time a motor and ganglionic nerve, 488 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. my arrival, I learned she had been in excellent health up to that evening throughout the entire period of her gestation ; but about half an hour before I reached the house, she had, while in agreeable conversation with her husband, been attacked with convulsions. I had scarcely entered her room before another paroxysm occurred, developing all the ordinary phenomena of eclampsia. The first question naturally presenting itself to my mind was, what does this mean, or, in other words, Avas there any special and extraordinary cause for this alarming state of the patient? Immediately, I made running inquiries as to her previous health, etc., which, as I have just remarked, had been most excellent. On questioning the hus- band closely, he informed me that his Avife had partaken of a hearty tea, indulging freely in preserved quinces, and in addition, she had eaten a large quantity of plum-cake. Precisely two hours after this repast, the convulsions ensued. What, gentlemen, with these facts before you, would have been your judgment of the cause of the paroxysm, and Avhat your treatment ? Would you have applied a ligature to the arm and abstracted blood—the remedy of all others, in the opinion of some Avriters, which constitutes the sine qud non, the very sheet-anchor of hope in puerperal convul- sions—or would you, as I attempted to do, have taken a common sense vieAv of the case, and referred the perturbation of the nervous system to the presence in the stomach of the preserved quinces and p>lum-cake, acting as an irritant on the pneumogastric nerve, and thus, through eccentric agency, causing the convulsion ? This was my diagnosis, and, as you will presently learn, my therapeutics Avere in perfect accordance with it. Without loss of time, I administered twenty grains of the sulphate of zinc in half a tea-cup of tepid water, with a view of a prompt liberation of the stomach from its offending contents. In less than three minutes the emetic began to take effect, and the lurking enemy, under the guise of quinces and plum-cake, was very soon ejected. The quantity of these substances throAvn from the stomach nearly half filled an ordinary washbowl. The effect was all that could be desired; I remained with the patient four hours, there was no recurrence of the convulsion, and she lapsed into a sweet and undis- turbed sleep; respiration natural, pulse soft and equable, and the countenance indicative of tranquillity. The most positive directions were given as to the necessity of adhering scrupulously to a simple and bland diet.* This lady passed on to her full time, when I had * I took very good care—a practice I have been in the habit of pursuing—to test the urine for the purpose of ascertaining whether it contained albumen; there was not a trace of this element. This, therefore, was an example of convulsions purely due to nervous irritation induced by the presence of undigested food, and in no way connected with albuminuria or renal troubles. We shall, before completirces; the attack is folloAved by stertorous breathing, the patient present- ing the general condition of an apoplectic; after a certain time, the stertor ceases, and consciousness usually returns. There is no fixed rule as to the recurrence of the attacks; they may come on every ten, tAventy, forty minutes, and hours may sometimes inter- vene between the paroxysms. Such, gentlemen, is a brief sum- mary of the principal features which ordinarily accompany an attack of puerperal convulsions, and, as I have told you, once wit- nessed, they cannot readily be forgotten. Diagnosis.—It is proper to remember that the nervous system may be variously disturbed during pregnancy, at the time of labor, and subsequently to dehvery, and these disturbances may assume one of several phases; for instance, either hysteria,* catalepsy, epilepsy, tetanus, chorea, or the puerperal convulsion of which Ave have been speaking, may originate at either of these periods; it is needful, therefore, that a just distinction be made in reference to these different grades of nervous perturbation. In hysteria, consciousness is not lost, nor does either coma or stertorous respiration succeed the paroxysm ; there is great rest- lessness, amounting to violent jactitation, so that, unless the patient be well guarded, she will throAv herself from the bed ; oftentimes, there is laughing alternating with shrieking; and what is almost ahvays a prelude to the attack, is a sense of constriction of the oesophagus, occasioned by what is knoAvn as the globus hystericus. Catalepsy is characterized by one striking peculiarity, viz. the uniform persistence of position of the limbs during the paroxysm, corresponding with the position in which they were at the time of the invasion. I must confess I am unable to present any essential characteristic differences which will enable you to distinguish with positive cer- tainty epilepsy from puerperal convulsions; for I am disposed to regard eclampsia in the puerperal woman as bordering so closely on the true epileptic convulsion as to render a distinction, to say the least, extremely difficult. If there be a difference, it may be said to exist in the coma, which uniformly follows eclampsia, and * Hysteria, although, as a rare exception, it may occur at the time of labor much more usually develops itself in the first three months of pregnancy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 503 which, also, occasionally, but not universally, is a sequela of epi- lepsy. The continued rigidity of the limbs is the characteristic feature of tetanus, and leads readily to an accurate diagnosis. In chorea, the mind is undisturbed, and the affection consists principally in an inability to control muscular movement. Without some judgment, the practitioner might possibly, if he saw the patient during the stage of coma, confound this condition of things with apoplexy. But all error will be removed by a history of the case; for example, the coma of puerperal convulsions is pre- ceded by the spasmodic and convulsed action of the muscular system ; not so apoplexy ; and, besides, in this latter affection there would most probably be hemiplegia—the result of the cerebral extravasation. Again : it is well to bear in recollection that, even in convulsions, death will sometimes ensue from effusion of blood in the brain, constituting a veritable apoplexy, and, in such case, there will of course be hemiplegia more or less developed. ■ Prognosis.—So far as the mother is concerned, the prognosis can- not be said, according to the best observation, to be favorable; and yet I cannot agree with some Avritcrs, Avho maintain that more than one half die. It is, I think, more in keeping Avith facts to say that, under prompt and judicious treatment, at least 70 per cent, of the mothers are saved. Dr. Churchill states that, in 214,663 cases of labor, convulsions occurred 347 times, or 1 in about 618f. In 328 cases, 70 mothers were lost, or about 1 in 4^-. The mortality is much greater among the children ; some of these die in vtero during the paroxysm, and many of course are sacrificed by the operations, Avhich may be judged necessary for the safety of the mother, such as premature delivery, version, the forceps, and the crotchet. It should, however, not be forgotten that our prognosis, in reference to the safety of either mother or child, is to be graduated by the time at which the convulsion becomes developed, its duration, the frequency of its recurrence, the character of the convulsion itself, and the condition of the patient. Occasionally, although death does not ensue, there are some serious consequences resulting from convulsions, such as loss of memory, positive mania,* imbecility; and these may continue for a longer or shorter period. Cases are recorded in Avhich permanent amaurosis and deafness Avere the results. It is stated by some authors that the great majority of women who survive the invasion of convulsions are attacked with puerperal fever. This certainly does not accord with my experience, nor can I see any other than simply a coincident relation betAveen these two pathological phenomena. * Mania and other forms of insanity may occur after parturition, even when the labor has not been complicated with convulsions. Esquirol, perhaps the best authority on insanity, says: " The number of women who have become insane after LECTURE XXXIII. Puerperal Convulsions continued—Their Centric Causes; divided into Psychical and Physical; how distinguished. Toxaemia, or Blood-poisoning—Albuminuria, its Re- lations to Convulsions—Causes of Albuminuria—Ed. Robin's Theory not sustained —A Change in the Composition of the Blood a Cause—Illustrations and Proofs— Secretion, its Objects—A Change in the Kidney, Structural or Dynamic, a Cause of Albuminuria; Proofs—Pressure on the Renal Veins a Cause—Illustration—Albu- minuria more frequent in the Primipara; why?—Is Albuminuria a necessary Result of Diseased Kidney?—Does it always exist in Pregnancy ?—Uraemia, what is it?—Dr. CarlBraun and Urasmic Intoxication—Is Albuminuria always followed by Uraemia?—Is Urea a Poison?—Carbonate of Ammonia and Urea—Frerichs'a Theory—Orfila's Experiments with Carbonate of Ammonia on Animals; Result- Treatment of Uraemia, on what it should be based—Therapeutic Indications— Colchicum Autumnale and Guaiacum as Remedial Agents—Dr. Imbert Goubeyre and Bright's Disease in connexion with Albuminuria—Anaesthetics in Ura;mia. Gentlemen—In the preceding lecture Ave have been occupied Avith a consideration of the eccentric causes of convulsions; I propose to-day to speak of those influences which, through centric action, are capable so far of disturbing the nervous equilibrium as to occasion the convulsive spasm. The centric causes of convulsions are di- vided into psychical and physical. Under the former head are in- cluded all operations on the mind, known as emotions, so that the depressing passions, such as grief, or the more exciting emotions, such as joy, are to be regarded as among the psychical causes of this affection. The physical consist in various pathological condi- tions of one or other of the two great nervous centres, the brain and spinal cord ; for example, plethora, by inducing congestion of these centres, may provoke convulsions ; an anaemic state of the system, as has been already explained, may do the same thing; disease of the brain or spinal cord, whether of the substance or coverings, is also a centric cause. But, gentlemen, there is yet another centric agent capable of evoking convulsions, to which I desire especially, and somewhat in detail, to direct your attention. I allude to an impure or poisoned condition of the blood. Until within comparatively a short period, authors were silent on the subject of certain poisonous properties contained in the urinary secretion, or, at least, they did not attach their confinement is much greater than generally supposed. At the Hopital Sal- petriere nearly one twelfth of the insane women we received here became so aftei their dehvery." (Traite des Maladies llentales, vol. 1, p. 230.) THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 505 to it that specific interest, which late discussions have excited ; and hence the term toxcemia, or blood-poisoning, was not employed, as it noAV is, to denote a very peculiar and important state of the eco- nomy. While toxaemia is the generic term, there are various species or grades of blood-poisoning. This question is well deserving of attention, particularly at this time, for it has recently received prominent consideration.* In September, 1853, I published a paper entitled, " Thoughts on Urrv.mia," which was generally distributed among my medical friends in this city, and which is incorporated in my Avork on the diseases of women and children.f In that paper will be found the folloAving language in reference to one class of puerperal convul- sions, and I trust I may be pardoned for quoting it here : " Recently much has been Avritten, and questions proposed by learned acade- mies, respecting the connexion betAveen albuminuria and puerperal convulsions ; and the Avriters are almost unanimous in the opinion that albuminuria is the cause of these convulsions. Xoav, I con- tend that puerperal convulsions are frequently nothing more than uraeinic phenomena, as is proved by their causes, symptoms, dia- gnosis, and pathology. If, then, puerperal convulsions be the result of uraemic intoxication, they are not necessarily produced by albuminuria. There is often a coexistence of puerperal convul- sions, albuminuria, and oedema, general or local; but each one of these conditions may, and has existed irrespectively of the other." Causes of Albuminuria.—I propose now, as briefly as is consis- tent with the interest and importance of the subject, to examine the true relation of albuminuria to eclampsia, and also the points of relation betAveen this latter and Bright's disease of the kidney. AA'ith this view I shall commence Avith the consideration of the causes of albuminuria. Here Ave find various opinions : Edouard Robin maintains that the passage of albumen into the urine is the result of imperfect combustion ; that urea is produced by the oxy- genation of the albumen in the blood, and if the oxygenation do not take place the result will be albuminuria. This hypothesis possesses the attribute of ingenuity, but its demonstration seems to me difficult, for the obvious reason that Avhen albumen passes into the urinary secre- tion the quantity of urea, as a necessary consequence, should not be increased in the blood. It is, I believe, conceded that, although * The Uraemic Convulsions of Pregnancy, Parturition, and Childbed. By Dr. Carl R. Braun, etc., etc. Translated from the German by J. Matthews Duncan, F.R.C.P.S., etc., 1858. De 1'Albuminuric Puerperale et de ses Rapports avec l'Eclampsie. Par ii. LB DeciEUR A. Imbert Goubeyre. Memoire Couronne, dans la Seance Publique Annuelle. December, 1854. f See page 522. 506 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. albumen does occasionally exist in the urine without a diminu- tion in the fluid of urea, yet the converse of this is very often observed, viz. an increase of urea in the blood coexisting with albu- minuria. This, therefore, is in direct conflict with the explanation of Robin. It is stated by Dr. C. I. B. Williams that, per se, " albu- minuria indicates nothing more than congested kidney." I shall, on the contrary, attempt to show that other causes than simple congestion of the kidney will occasion albuminuria; and, in doing this, it will follow that Dr. Williams's opinion is far too exclusive. It is quite certain that the presence of albumen in the urine is not traceable to any one influence, for it is recognised under a great variety of circumstances, and I shall endeavor to prove that it is due to one of the following causes : 1. A change in the com- position of the blood; 2. A change in the kidney, either structural or dynamic; 3. Pressure on the renal veins. 1. Change in the Composition of the Blood.—It was a favorite doctrine of the old-school-men that the blood contained certain deleterious elements, which could not continue in the system with- out generating disease. This, too, was the opinion of Sydenham, Pitcairn, Cullen, and others ; andthe master-minds of the present day, with all their supposed progress, are compelled to admit that there is something more than mere conjecture in what was formerly termed the " peccant humors." The organs through which these humors or poisons pass from the economy are called glands; and each gland has its specific office assigned to it—that is, one of these glands furnishes an outlet for one character of material in the blood, and another gland for a different substance. Thus, while the liver is engaged in the secretion of bile, etc., and the kidney water, urea, etc., Ave find the intestines the media through which effete matters are throAvn off. These various offices are performed through what is called secretion, the true nature of which is still involved in mystery. It is true, we understand certain general principles respecting the secreting processes, but it cannot be denied that we are unable to explain many of the phenomena con- nected with this fundamental law of the physical mechanism. Al- though, therefore, we are ignorant of some of the processes con- nected with glandular elaboration in a state of health, yet it does not follow that we cannot explain many of the causes which, inter- fering Avith healthy secretion, result in morbid action. In order to apply this reasoning to the question before us, we will suppose—what will not be controverted—that in a variety of diseases occasionally accompanied by albuminuria, such as cholera, scarlatina, diabetes, etc., the constituents of the blood become changed by the introduction either of a poison or some other sub- stance. If this occur, it is quite manifest that the blood is no THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 507 longer normal, and because of its altered condition its elaboration in the kidney will also be modified; so that in lieu of the ordinary elements contained in the urine, we shall sometimes recognise albu- men, an absence of urea and other pathological phenomena. May this not be satisfactorily explained on the principle that the product of endosmosis will be modified in proportion to the changes in the fluid on which it acts ? Again: the blood is changed in pregnancy, various circumstances tending to this modification, viz. the forma- tion of kiesteine, the secretion of milk, the quantity of blood mate- rials passing through the circulation of the foetus, together with the diseases of the embryo itself, not to speak of its excretions, some of which we know enter the blood of the mother. These, then, being so many influences capable of altering the constituents of the blood, will they not explain, at least in some instances, the occasional presence of albuminuria in the pregnant female ? 2. A Change in the Kidney, either Structural or Dynamic.— Every structural change in the kidney may result in albuminuria, but we do not yet comprehend in what essentially these various changes consist. For example, though it may be true that the presence of albumen in Bright's disease, in scarlatina, etc., may be due to a desquamation of Bellini's tubes, yet this cannot be said of many other affections of the kidney in which albuminuria exists, but in which no desquamation takes place. Several interesting experiments have been made to prove that the urinary secretion is not absolutely dependent upon the nervous system by Segalas,* and some of a more decisive character by Dr. BroAvn-Sequard ;f Avhile, on the other hand, it has been satisfactorily shown that the nervous system may, under certain circumstances, exercise a marked influ- ence over this secretion, as is demonstrated by the researches of Brachet, J. Muller,J and Marchand. The latter has pointed out a very important fact connected with this subject. He produced in a dog not only all the symptoms of uraunia, after placing a ligature on the renal nerves, but also discovered urea in the blood, and in the matter vomited by the dog. Kramer is said to have detected albumen in the urine of animals, after dividing the sympathetic nerve in the neck. This, however, seems to need confirmation, as the same result has not followed the experiments of others. Dr. Sequard, after repeated trials, has failed in establishing the fact mentioned by Kramer. Budge found albuminuria after a puncture of the cerebellum; and CI. Bernard§ * Bulletin des Seances de l'Acad. de Med. de Paris. (Seances des 27 Aout et 23 Septembre, 1844.) f Experimental Researches applied to Physiology and Pathology, Philadelphia. 1852-3. P. 13. X Manuel de Physiol. Edite' par E. Littre. Paris, 1851. P. 391. § Comptes Rendus de l'Acad. des Seances de Paris, t. xxviiL, p. 393. 508 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. occasionally obtained the same result from a puncture of the medulla oblongata. In addition, hoAvever, to these demonstrations, Ave have numerous instances occurring in practice illustrating the influ- ence of the nervous centres—when laboring under disease or trau- matic injury—over the urinary secretion; and it is quite possible that the irritation of the uterine nerves during pregnancy, and in many of the diseases, both organic and functional, of the uterus itself, may, through reflex action of the medulla spinalis, produce various morbid changes in the urine. Again : it does appear to me that, if it can be proved that sudden emotions, shocks, otc, have an influence on the peculiar processes by Avhich the blood is continu- ally ridding itself of its deleterious materials, we shall, in this Avay, have opened to us a neAv field in our investigation of disease; Ave shall be enabled to elucidate many morbid phenomena which have heretofore been obscure, and, as a necessary consequence, deduce rational therapeutic principles. 3. Pressure on the Renal Veins.—Whatever may be the other causes Avhich operate in the production of albuminuria, there is a mass of irresistible testimony to demonstrate the positive influence of an obstructed renal circulation. G. Robinson,* Meyer,f and Frerichs, have abundantly proved that a ligature tied more or less completely around the renal veins Avill cause albumen to pass from the blood into the urinary secretion ; and again when the renal veins have become obliterated, in every instance in which the urine Avas examined, albuminuria was detected. Cases of this nature have been observed by Dance, Rayer, Duges, Velpeau, R. Lee, Cruveilhier, Stokes, Blot, Leudet, and others. In gestation, and especially in primiparae, albuminuria is often caused by pressure of the impregnated uterus on the renal vessels. Dr. Rose Cormack, I think, was the first to call attention to this subject. Dr. BroAvn- Sequard has positively ascertained the influence of pressure upon the renal vessels, in a lady who had albumen in her urine during the ninth month of pregnancy. He placed her in such a position that the pressure Avas much diminished, and after a certain time the urine ceased to contain albumen. When the ordinary attitude was resumed, there was soon a reappearance of albumen in the urine. In 106 multiparae, Blot detected albuminuria in eleven instances only, while in ninety-nine primiparae thirty exhibited it. The pro- portion, therefore, for the former is as one to ten, the latter as one to three. This is a remarkable difference, and must be due to some special cause.J It is quite evident that albuminuria is of fre- * Medico-Chirurg. Transac. of the Royal Med. Chirurg. Soc. of London. 1843. Vol. viiL, p. 51. \ Gaz. Med. de Paris. 1844. P. 419. X Women in their first pregnancy present a very different condition of the abao- minal walls from those who have already borne children. In the former, these walla THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 509 quent occurrence in pregnancy, and oftentimes results in death. Iinbert Goubeyre* states that of sixty-five pregnant Avomen attacked Avith albuminuria, twenty-seven died, five remained albu- minuric, and thirty-three Avere restored from tAvo to fourteen days after delivery. The frequency of puerperal convulsions in albu- minuric women is very great. According to the same author, of 159 Avomen laboring under albuminuria, ninety-four were attacked with convulsions. Cahenf and others have endeavored to show that albumen in the urine is caused by disease of the kidney. It cannot be denied that disease of this organ may coexist with gestation, and in such case the albuminuria may be traced to a morbid condition of the gland ; but to say that albuminuria cannot exist in pregnancy other than as a result of disease of the kidney is in direct opposition to well- established observation.J As a point of diagnosis, it may be incidentally mentioned that when albuminuria in pregnant women is caused by Bright's disease, there is frequently some degree of amblyopia§ and even amaurosis, while in simple albuminuria produced by pressure of the womb on blood-vessels, the retina preserves its functions. M. Lecorche, a are firm and resisting; in the latter, on the contrary, they are relaxed, and have lost much of their original tension. For this reason, in primiparse the impregnated uterus is more perfectly in the line of the axis of the superior strait of the pelvic canal; while in multipara;, the organ is disposed to fall forward, constituting ante-version, more or less, of the fundus. Precisely in proportion, therefore, to the inclination of the uterus forward from the direct line of ascent will be the probability of diminished pressure on the renal circulation. I believe, also, there is another reason why albuminuria is observed less frequently in multipara? than in primiparae. It is a well-known fact that women are much more disposed to miscarry in a first than in subsequent preg- nancies ; and, costeris paribus, this is no doubt owing in a measure to the greater irritation of the uterine nerves consequent upon a first gestation. May not, there. fore, this excess of irritation, by modifying the urinary secretion, be occasionally a cause of the more frequent presence of albuminuria ? I think so; and again, when, under these circumstances, the passage of albumen into the urine is followed by urea in the blood, as is often the case, even admitting that full uraemia does not take place, may not the nervous system become so much disturbed by the presence of urea as to induce premature action of the uterus, and consequently miscarriage? If there be any force in this reasoning, the preventive treatment of miscarriage in this con- dition of system may^prove far more successful than it has heretofore been. * Memoires de l'Academie Imperiale de Medecine. Tome xx. 1856. \ De la Nephrite Albumineuse chez les Femmes Enceintes. These, Paris, 1847. X Blot demonstrates the fact as follows: 1. The rapidity with which albuminuria disappears after delivery in almost every case, very often in two or three hours, some- times in one, after the expulsion of the child. 2. Absence of the symptoms of dis- eased kidney. 3. Certain characters of the urine entirely different from those of Bright's disease, as for instance, increase in its density, and the presence of more ?alts, and particularly urates. 4. In seven women who died, and in whom albumi- nuria had been detected, only three had slight pathological alterations in the kidney. [De l'Albuminurie chez les Femmes Enceintes. These, Paris, 1849.] § From a/i/?Ao$ dull, and u\p the eye. 510 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. pupil of Rayer, gives a table, shoAving that in 332 cases of Bright's disease, there was either amblyopia or amaurosis in 62 instances. The coexistence, therefore, of this symptom AA'ith albuminuria in the pregnant female should be regarded as grave. The opinion is now well settled, and concurred in by a great majority of writers, that albuminuria is, in many cases, simply the result of an active or passive congestion of the kidney. Anything, therefore, capable of obstructing the renal circulation, whether it be an enlarged uterus from pregnancy or disease, an ovarian tumor, or enlargement of the abdomen of any kind, may be enumerated among the causes of albuminuria. Christison, Rayer, and others maintain that the diminution of urea in the urine, and consequently its accumulation in the blood, is in proportion to the quantity of albumen, but this does not appear to be invariably the case ; for Bence Jones has recorded an instance of mollities ossium, in Avhich he presents an analysis of the urine, showing that albuminous matter may exist in great quantity, while the amount of urea remains per- fectly natural. Is Albuminuria always followed by Urcemia?*—That the pre- sence of albumen in the urine is not necessarily followed by uraemia is amply proved by observation ; and it is important that this fact should be well understood, for the reason that much error has arisen from the opinion entertained by certain writers, that there is a direct connexion betAveen uraemia and albuminuria. This error is not so much OAving to any inherent difficulty of the subject, as it is to that loose appreciation of facts, or, more properly speaking, to that Avant of healthy digestion of Avell-settled principles which, unfortu- nately, too often characterizes the writings of professional authors. I might cite a long list of observers to show that albumen, very frequently exists in the urine without any development of uraemic intoxication, but I apprehend this would be unnecessary. I shall, therefore, limit myself to two or three undoubted references. Franz Simon, for example, says he has frequently detected albuminuria in * It is important, in connexion with the subject under consideration, that tu« cerm uraemia should be clearly understood. Uraemia consists in disturbed action of the two nervous centres—the brain and spinal cord—producing either coma, partial, or complete convulsive paroxysms; the disturbances being directly traceable to the action of a peculiar poison on these nervous centres. They may be affected separately or together; and hence, according to Carpenter, there may be three forms of urajmic poisoning: 1. A state of stupor supervenes rather suddenly, from which the patient is with difficulty aroused, soon followed by complete coma, with stertorous breathing, etc., as in ordinary narcotic poisoning; 2. Convulsions of an epileptic character often affecting the entire muscular system, suddenly occur, but without loss of con sciousness; 3. Coma and convulsions may be combined. The existence of uraemia has been differently explained by authors; for example, some contend that it is due to albumen in the urine, others that it is caused by urea in the blood, while again both of these opinions have been rejected, and a new one advanced by Frerichs, viz. that uraemia results from the transformation of urea into the carbonate of ammonia, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 511 persons apparently in the enjoyment of good health; also others have observed it in articular rheumatism, in inflammation of the thoracic organs, intermittent and typhus fevers, in measles, cholera, and in chronic affections of the liver. In transitory renal catarrh, such, for instance, as occurs in erysipelas nearly as often as in scarla- tina, albumen, together with the well-known epithelial cylinders of Bellini's ducts, is found as constantly in the urine as in inflamma- tory affections of the kidneys, where it exists in connexion with the fibrinous plugs from the same ducts, as in true Bright's disease.* Edouard Robin says " the urine becomes albuminous in croup, in ascites, and in cases of capillary bronchitis, with emphysema, accom- panied by dyspnoea; in pulmonary phthisis, in gestation when suffi- ciently advanced to occasion a habitual congestion of the kidneys; in cyanosis, diabetes, etc., etc."f In order to prove that albumen may exist in the urine indepen- dently of any disease of the kidney, and Avithout any of those nervous disturbances characteristic of uraemic intoxication, Dr. M. T. Tegart mentions the folloAving interesting and conclusive expe- riment upon himself, and also confirmed in the person of one of his friends: He made for sometime aportion of hisordinary nourishment to consist of half a dozen eggs, and albumen, as a consequence, Avas soon detected in the urine.J Similar experiments have been made with similar results, by BaresAvil, CI. Bernard, BroAvn-Sequard,. and Dr. Hammond of Baltimore. There are few practitioners of careful observation, who will not endorse these statements. Indeed, I consider the principle to be so Avell established that the existence of albuminuria is not necessarily connected Avith uraemia, that further citations can scarcely be neces- sary to demonstrate the fact. Is Urea a Poison?—Urea was, I believe, first discovered in 1771, by Rouelle, Avho detected it in the urine. It owes its present name, however, to Fourcroy and Vauquelin. It Avas obtained pure for the first time by Dr. Prout in 1817. There is an interesting circumstance connected with this production—it is the first instance known of an organic compound being artificially produced, and this was accomplished by WOler from cyanic acid and ammonia. The true action of urea is variously described by authors, the general opinion being that it is a poison. Todd,§ Williams,|| Cor- mack,^[ Simon,*2 and others regard it in this light, and contend that * Physiological Chemistry. By Lehmann. T. L, p. 345. \ Ed. Robin, London Lancet, January 24, 1852, p. 96. X "These sur la Maladie de Bright" Paris, 1845. Gazette Medicale, Paria, 1846. p. 39. § Lumleian Lectures, in London Med. Gaz. 1849-50 | Principles of General Pathology. % London Journal of Medicine. 1849. Pp. 690-699. *» Lectures on General Pathology, Amer. Edit., p. 16L 512 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. its presence in the blood will occasion coma, convulsions, and other nervous phenomena. Indeed, it may be said that this has been the general opinion; it is proper, therefore, that this opinion be examined. If urea be a poison capable of producing convulsions, etc., the numerous experiments made on living animals in no Avay establish the fact. Among others, Prevost and Dumas,* Segalas, Tiedeman, Gmelin, Mitscherlich, CI. Bernard, Bareswil, Stannius/f and Frerichs, have extirpated the kidneys, and have never knoAvn conA'ulsions to ensue. This, it may be urged, is only negative proof. Negative, hoAvever, as it is, it must be admitted that it is testimony not Avithout value; and to it may be added the interesting experi- ments of Bichat, Courten, Gaspard, Vauquelin, Segalas, Stannius, Bernard, BroAvn-Sequard, Frerichs,J and others, Avho, after inject- ing into the veins urea and urine, never in a single instance observed a case of convulsions. Again: Bright, Christison, Rees, and Frerichs have cited cases in which a large quantity of urea existed in the blood of man unaccompanied by any of the symptoms of uraemia; and Frerichs says, in one instance, in Avhich he detected the greatest amount he had ever observed, there was no approach to unemic disturbance. Vauquelin and Segalas, so far from regard- ing urea as a poison, have proposed to administer it as a diuretic. Some recent experimenters, hoAvever, especially Dr. Hammond and Mr. Gallois, affirm that they have observed convulsions in rabbits after the injection of urea into the veins. But there is no proof that it Avas the urea itself Avhich caused the convulsions, and not 6ome other principle resulting from decomposition of the injected substance. The conclusions, therefore, from these facts appear irresistible that urea, to say the least, is not a virulent poison ; its excess in the blood will not per se produce uraemic intoxication, nor will it explain the numerous phenomena which are so frequently found to accompany its presence in the circulation. It Avas in vieAV of all these circumstances that Frerichs attempted to demonstrate that uraemia depended neither upon a diminished quantity of urea in the urine, nor upon an excess of the substance in the blood, nor upon albuminuria; but that it is traceable solely to carbonate of ammo- nia in the system, which, he says, is formed through the agency of a ferment from the urea itself. In other words, Frerichs''s doctrine is, that urcemia is exclusively due to the transformation of urea into the carbonate of ammonia. The modus in quo, however, of this transformation is not clear; there is no proof as to the manner in which it is accomplished; but the major point, viz. dependence * Annales de Chimie et de Physique. f Gaz. Med. de Paris. 1841. p. 168. X Die Bright'sche Nierenkrankeit, 1851. Analysed in Braithwaite's Retrospect^ 1852. Part xxv., p. 135. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 513 of urcemia on tl,e presence of the carbonate of ammonia, seems to rest on strong and cumulative testimony. Many years ago, Orfila produced convulsions in an animal by giving it, internally, the carbonate of ammonia; the animal, after becoming convulsed, died. Brown-Sequard has published the fol- lowing facts in Tessier's dissertation Sur V Uremie, Paris, 1856: Carbonate of ammonia injected into the stomach does not poison; it is absorbed slowly and passes off through the lungs AA'ith carbonic acid. If, on the contrary, it be injected in a certain amount into the blood, it has time to act on the nervous system, and to cause convulsions before it is expired.* CI. Bernard and Bareswil have detected carbonate of ammonia in the stomach and intestines of animals after the removal of the kidneys; and Lehmann has also observed it in the matter vomited by patients affected with cholera. Christison, Jakehs, and others, have recognised, under certain cir- cumstances, an ammoniacal odor in the blood. Until, hoAvever, the exposition of the peculiar vieAvs entertained by Frerichs as to the true cause of uraemic intoxication, no signifi- cant value Avas attached by authors to the presence of the carbonate of ammonia in the exhalations. Frerichs states that he has ascer- tained, through chemical analysis, the existence of this salt in the blood in all cases in which the symptoms of uraemia are developed ; but its true quantity is subjected to considerable variation. He further remarks that the tAvo following propositions he has proved beyond a doubt: 1. That in every case of urcvmic intoxication, a change of urea into carbonate of ammonia takes place ; 2. That the symptoms which characterize tirctmia can all be produced by the injection of carbonate of ammonia into the blood. After citing many experiments to fortify his opinion, he says he has frequently detected the alkaline salt hi the expired air of animals deprived of their kidneys, and into the veins of Avhich he had injected urea; these animals remained quiet and awake as long as the expired air was not impregnated Avith the ammonia; but the moment the lat- ter Avas observed, the various disorders of the nervous system characteristic of uraemic poisoning developed themselves. These Ariews of Frerichs will necessarily tend to the settlement of a vexed question, which has called forth the ingenuity of both the physiolo- gist and chemist. It may, hoAvever, be that the future Avill reveal the existence of other poisonous materials in the blood which, to the present time, have eluded observation; and, in their recogni- tion, Ave may find additional causes for the production of toxaemia. It has, indeed, been suggested that, in Bright's disease, the accu- * Manv facts have recently been developed in France, proving that the phe- nomena of uraemia must be due to some kind of poisoning. It has been shown by Piberet, Tessier, Picard, Rilliet, and Barthez, that in patients who have died from uraemia, there is no organic lesion of the nervous centres. 33 514 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mulation of oxalic acid in the blood will develop the symptoms of uraemic intoxication. ' I may here remark that Braun attributes the death of children to the same cause as that of the mothers in cases of puerperal con- vulsions from uraemia, viz. to poisoning by carbonate of ammonia which poison is found in the fcetal blood. Treatment of Ureemia*—This necessarily involves two objects: 1. The immediate restoration of the principal eliminators of the system, such as those of the kidney, skin, and bowels, with a vieAV of diminishing, through these outlets, the quantity of urea and noxious elements, Avhich may exist in the blood ; 2. The protection of the nervous centres, as far as may be, against the injurious effects of the carbonate of ammonia. In our therapeutic management of uraemia, it is important to remember that the skin contains an immense number of glands which, anatomically speaking, are similar to the corpuscles of Malpighi in the kidney, and which glands secrete water, urea, and salts. The various remedies, therefore, knoAvn to increase the cutaneous secretion should be employed in cases of uraemic poison- ing. With a view of neutralizing the carbonate of ammonia in the blood, Frerichs has strong faith in benzoic acid, in doses of five or ten grains, together with iced acidulated drinks. Anaesthetics in Ureemia.—Chloroform and sulphuric ether have been repeatedly employed in these cases with very favorable results • and I believe the credit is due to Prof. Simpson of an ingenious explanation of the mode of action of these agents in uraemic poison- ing. Availing himself of an important fact pointed out by the chemists, that chloroform produces a temporary diabetes mellitus, causing, of course, the appearance of sugar in the urine, and, per- haps, also in the blood; and that the addition of a little sugar to urine out of the body, prevents for a time the decomposition of its urea into carbonate of ammonia, the distinguished Professor sug- gests that the efficacy of anaesthesia in restraining and arresting the convulsions may be upon the ground of its preventing this decom- position.! * Dr. Maclagan, of Edinburgh, has drawn attention to the value of the colchicum autumnale in uraemic poisoning. The excellence of this remedy consists in its power of increasing the amount of urea in the urine. This fact, I believe, was first dis- covered by Chelius, of Heidelberg. Professor Krahmer, of Halle, has made some very interesting experiments on the subject of diuretic medicines. According to him, the average of urea secreted during the day in healthy urine is 19 64 grammes, while the tables of Becquerel give 16 grammes. Krahmer has shown that, under the influence of colchicum, the urea is increased to 22.34 grammes, and under the administration of guaiacum to 22.74 grammes. From the experiments of Krahmer, therefore, it appears that colchicum and guaiacum produce a greater secretion of urea than any known remedies. Dr. Hammond (American Journal of Med. Sciences, 1859, p. 275) has also tested the superiority of colchicum over several other diuretics \ Simpson's Obstetric Works, vol. vi. p. 827. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 515 Conclusions.—From what has been said, it appears to me the following conclusions may be fairly deduced: 1. Disease of the kidney will often produce albuminuria, but in a large number of cases albuminuria exists Avithout true disease of the gland, as a consequence of an active or a merely passive con- gestion, and it will also result from a variety of nervous disturb- ances.* 2. Albuminuria is often connected with uraemia, but is not the cause of it. 3. Uraemia is a nervous disturbance arising from a peculiar blood- poisoning. 4. If urea be a poison, the quantity of it which accumulates in the blood in cases of extirpation of the kidneys in animals, or in sup- pression of urine in man, is not sufficient to produce any manifest deleterious effect. 5. According to Frerichs, uraemia is merely a poisoning by the carbonate of ammonia, which is a product from the decomposition of urea. 6. The treatment of uraemia must consist in the free use of diuretics, sudoritics, and purgatives; the most suitable diuretics for this purpose being colchicum and guaiacum. * Dr. Imbert Goubeyre (Memoires de l'Acade"mie Impe"riale de Medecine. tome xx.) maintains that there is a 'puerperal albuminuria, and that it is symptomatic of, and nothing other than Bright's disease of the kidney; that there is a puerperal Bright's disease, as there is a puerperal peritonitis, etc. He also contends that puerperal eclampsia is actually puerperal Bright's disease, in which convulsions occur: in other words, that the eclampsia is but a sy mptom of albuminous nephritis, or Bright's disease Dr. Carl R. Braun (Urffimic Convulsions of Pregnancy, Parturi- tion, and Childbed) defines ursemic eclampsia as follows: " Eclampsia puerperalis is an acute affection of the motor functions of the nervous system (an acute neurosis of motility), characterized by insensibility, tonic and clonic spasms, and occurs only as an accessory phenomenon of another disease, generally of Bright's disease in an acute form (diabetes albuminosus, nephritis diffusa seu albuminosa), which, under certain circumstances, spreading its toxaemic effects on the nutrition of the brain and whole nervous system, produces those fearful accidents." If, then, we are to be guided by the statements of these two distinguished writers, and accept their opinions on this question, we must believe that when puerperal eclampsia occurs it does so as the effect of Brights disease of the kidney. From this hypothesis, too, it should follow that there will be a constant relation between Bright's disease and albuminuria, and also between that affection and eclampsia. But such is not the fact; for it has been shown that albuminuria may exist without structural alteration in the kidney, and also that the various forms of Bright's disease may be present without the detection of albumen in the urine. (See Begbie, Brit. For. Med. Chirurg, vol. xii., p. 46.) Again: acute Bright's disease is not always accompanied by uraemia and eclampsia; in 100 cases of Bright's malady, only from 60 to 70 were affected with uraemic eclampsia; and another extremely important fact is this—Bright's disease is not uniformly recognised in instances of fatal eclampsia. This latter circumstance is to my mind a very decided negative to the necessary relation between Bright's disease and uramic convulsions. LECTURE XXXIV. Manual Labor—Version, divided into Cephalic, Podalic, Pelvic, and Version by Ex- ternal Manipulation—Diagnosis of Manual Labor; important that it should be made early—Prognosis, how it varies—Indications of Manual Delivery; in what they consist—Time most suitable for Termination of Manual Delivery—Undilated Os Uteri, means of overcoming—Mode of Terminating Manual Delivery; the various Rules to be observed—Divisions of Manual Delivery—Rules for correcting Malpositions of the Head—What are these Malpositions, and how do they Ob- struct the Mechanism of Labor? Gentlemen—Your attention having been directed to the various causes of manual interference for the termination of delivery, you are now prepared for the discussion of the question—in what way is manual labor to be accomplished ? Before, however, entering upon the particulars of this interesting subject, it will be proper to make one or two preliminary observations touching version, or, as it is sometimes termed—turning. This operation consists in bring- ing doAvn to the superior strait one or other of the obstetric extremities of the foetus, and hence it is divided into cephalic, pelvic, and podalic version ; in addition, there is version by external mani- pulation. In the former case, the head is brought to the strait; in pelvic version, the nates or breech; in podalic, the feet; while in external cephalic version, of which we shall more particularly speak hereafter, an attempt is also made to bring the head down. Cephalic Version.—In the earliest periods of our science this was the only kind of version adopted; indeed, Hippocrates and his contemporaries speak of no other, turning by the feet being in no way alluded to by them, and consequently it must not only not have been practised, but altogether unknown. It was not until the sixteenth century that version by the feet was commended to the attention of the profession, as a substitute for version by the head; and although writers generally refer the credit of the suggestion to Pare and his pupil Guillemeau, yet it is but just to say that Franco preceded them both in the suggestion.* Guillemeau was the instrument in the seventeenth century of spreading the new view, and it was soon adopted by Mauriceau, the great obstetric authority of that age. From that period to the present, podalic version has been very generally adopted, while, at the same time, it must be * Franco was the first to describe and recommend version by the feet, which ha did in his Traite des Hernies, in 1561. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 517 admitted that version by the head has found its advocates even in our own times.* Let us now proceed to discuss the general question of manual labor under the following heads; and, in doing so, I shall endeavor to present the whole subject in'the most practical manner: 1. The Diagnosis; 2. The Prognosis; 3. The Indications; 4. The time most suitable for its termination; 5. The mode of termi- nating manual labor; 6. Its various divisions. 1. Diagnosis of Manual Delivery.—It has already been stated —and it is important to recollect the fact—that the introduction of the hand into the uterus, or, in other words, manual interference, can only be useful either in cases of malposition of the foetus, or in the event of the supervention during labor of certain accidents, such as hemorrhage, convulsions, etc., all of which accidents we have fully discussed. It, therefore, is manifest that the duty of the accoucheur, when at the bedside of his patient, is to ascertain whether the relation of the foetus to the pelvis be such as to enable nature, through her own resources, to accomplish delivery; or whether, in consequence of malposition, it will devolve upon him to render assistance. For example, if he should find the head at the superior strait, the question for him to determine is, does it present naturally ? If, on the contrary, one of the pelvic extremi- ties, either the breech, knees, or feet, should be there, is the posi- tion in accordance with the requirements of nature ? And again, should it be a cross-presentation of some portion of the trunk, necessarily involving the propriety of version, its exact position should be ascertained Avith a view of proceeding to delivery. It may, however, be that, so far as the presentation and position of the foetus are concerned, everything is perfectly natural, yet the occurrence of hemorrhage, convulsions, or some other complication, may render necessary manual delivery. As to the propriety and time of having recourse to this alternative, the peculiar nature of the case and its exigencies must determine. Is there any special period more favorable than another for the vaginal exploration necessary to ascertain the true position of the foetus ? There is undoubtedly—and that period is as soon as possible after the rup- ture of the membranous sac, for then the parts are more or less relaxed, and fitted to facilitate the object in view. It may be con- sidered, as a very general rule, that the difficulty of arriving at a correct diagnosis with regard to the presentation, position, etc., and more particularly the difficulty of either changing a malposition * A late writer, Dr. A. Mattei, is quite enthusiastic on the subject of cephalic version; he says he invariably adopts it in preference to podalie, unless there should be some insuperable obstacle; and he expresses his belief that cephalic will soon entirely supersede podalic version. [Essai sur Accouchement Physiologique. Par A. Mattei. Paris, 1855. P. 183.] 518 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. into a natural one, or of accomplishing version, will be enhanced in proportion to the period which has elapsed since the escape of the liquor amnii; for Avhen this takes place, the foetus is embraced more closely by the uterine Avails; the contractions as a consequence become more energetic, and the presenting part undergoes such intense pressure as oftentimes to render its recognition extremely difficult. Therefore, gentlemen, I cannot too emphatically impress upon you that there is a period of election for this kind of explo- ration, and if you will treasure the fact in memory, it will frequently aid you in rendering signal service to both mother and child. 2. Prognosis of Matiual Delivery.—When Ave consider the con- summate skill displayed by nature—if not contravened—in the expulsion of the child from the cavity of the uterus, and the safety with which it is accomplished, Ave cannot be surprised that this safety is necessarily greatly diminished Avhen manual delivery is had recourse to; for science, hoAvever matured and complete, cannot equal the triumphs of nature, when undisturbed by adventitious influences. And again, in a case of fearful hemorrhage, Avhere the poAvers of the system are near exhaustion, or in convulsions, when it becomes necessary, as the only alternative, to proceed to artificial delivery, the chances of life either to mother or child, from all these circumstances, are evidently diminished if compared Avith a natural parturition. Even the adjustment of a malposition, Avith a vieAv afterward of submitting the termination of the delivery to the resources of nature, will, to a certain extent, compromise more or less the safety of the mother and child, and the operation of version itself is by no means without its dangers, as I shall more particularly mention Avhen speaking of the manner of performing it. Therefore, in all cases of manual interference, it is a duty you OAve your patient, yourselves, and science, to exercise a frankness worthy of the noble profession you are pursuing, and to acquaint, not the patient herself, but the husband and friends more immedi- ately interested in her welfare, that what you propose doing, although it is an alternative fully justified by the circumstances, will involve in a certain degree of hazard both mother and child. In this honorable and high-toned course you lose nothing, but will gain much; for, besides the approbation of your own con- science, you will establish a reputation for candor and honesty—two essential attributes in the character of a physician, and which will always yield a handsome interest, so far as public patronage is concerned; and, after all, it is public patronage Avhich a medical man most needs ; but never let it be purchased at the cost of truth. 3. Indications of Manual Delivery.—The indications of manual delivery are not ahvays identical; for example, in one case there may be simply a malposition of the head, such as the presentation of the occipital or parietal regions; this malposition may oftentimes THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 519 be corrected by the timely and skilful manipulations of the accou- cheur, and the termination of the labor left to nature; again, it may be that flexion of the head has not taken place, rendering its descent into the pelvic cavity physically impossible; here, the accoucheur by opportune interference may cause the necessary flexion, and thus remove the obstacle; should the occiput remain at one of the sacro-iliac symphyses, it should be brought to either one or other of the acetabula, with a view of curtailing the dura- tion of the labor, thus shielding both parent and child from the dangers of a protracted parturition. In a presentation of the breech, knees, or feet, it may also become necessary to have recourse to manual interference under either of the following circumstances: 1. In case the labor should be com- plicated with any of the accidents to which we have alluded, placing in peril the life of the mother or child, and, therefore, rendering immediate delivery essential. 2. If either of these extremities of the foetus should present at the superior strait irregularly; for example, in the presentation of the feet, or knees, if one foot or knee should be so situated at the strait as to resist the contractile efforts of the uterus. Again : in a head presenta- tion it may become necessary to terminate the delivery by bringing down the feet, thus accomplishing the version of the fcetus ; and, also, when any portion of the trunk presents, the alternative, under ordinary circumstances, will be version. I am thus particular, gentlemen, in the details of the indications of manual delivery, in order that you may at once appreciate the necessity of sound judgment and just discrimination in the management of these various forms of preternatural labor. 4. Time most Suitable for the Termination of Manual Delivery. —One of the fundamental principles in midwifery, which should be constantly borne in recollection, is—that nothing will justify a forcible entrance into the cavity of the uterus; therefore, if the mouth of the organ be not so dilated or dilatable as to permit the introduction of the hand without violence, the operation should, under no circumstances, be attempted. So you perceive, the most suitable time for the accomplishment of manual delivery is as soon after the rupture of the membranous sac as possible ; or before the rupture, provided the os uteri be sufficiently dilated or dilatable, for at either of these periods the organ will be in a condition more or less favorable to the artificial termination of the labor. Suppose, hoAvever, that manual delivery be indicated, and, either from the length of time AA'hich has elapsed since the escape of the liquor amnii, or from other causes, the mouth of the organ should be so firmly contracted and rigid as to preclude the possibility of intro- ducing the hand, what, under these circumstances, is to be done? Are you to allow the patient to sink, or the child to be sacrificed, 520 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. without an effort to save them ? Here, you will have recourse to those agents best calculated to promote relaxation. If the patient be plethoric, your great remedy Avill be the lancet; should blood-letting be inadmissible, tolerant doses of tartar eme- tic or ipecacuanha—the former is preferable because more reliable —will be found essentially serviceable. Warm emollient injections into the vagina will also, in these cases, oftentimes have the hap- piest effect; and if it can be resorted to without too much incon- venience to the patient, the warm hip-bath, or merely sitting over the vapor of hot water, may result most beneficially. I have on several occasions found this latter very efficient. Here, too, you will have an important auxiliary in the belladonna ointment 3 j. of the extract to § j. of adeps. Let it be freely applied to the mouth of the uterus.* It is well to remember that, as exceptions to the general rule, cases will occasionally be met with in which the os uteri will be in a state of complete relaxation, although the rupture of the sac and escape of the waters have occurred several hours previously. 5. The Mode of terminating Manual Delivery.—The rules to be observed in all cases in which manual interference is called for are fe\v and simple, and should be faithfully carried out. It is, I am quite sure, to the neglect of these rules that Ave are to refer many of the unfortunate results too frequently succeeding manual labor. The rules are as follows: (a) As soon as the accoucheur has decided upon the necessity of interference, he should acquaint his patient with the fact; and, in doing so, care should be taken not to alarm her by the slightest intimation of any danger involved in the operation. The probabi- lities of the result should, on the contrary, as has already been remarked, be stated frankly to the husband and friends.f * It will sometimes happen that the os uteri resists all the means just indicated, and it will, therefore, in cases of urgent necessity, be proper to have recourse to what is known as artificial dilatation; this is to be effected in one of two ways, either through the agency of the fingers or an instrument. For the former purpose, one or two fingers may be cautiously introduced iDto the os, which will act both mechanically and physiologically in the accomplishment of the object. But when the safety of the mother or child depends upon a prompt dilatation, I should, in such an emergency, prefer incising the os uteri; the operation is without danger, and usually followed by rapid dilatation. In saying this, however, I would caution you against having recourse to it except in instances of full justification. The operation is performed as follows: the patient, on her back, is brought to the edge of the bed, one or two fingers are then introduced into the vagina, as far as the os, to serve as a guide for the probe-pointed bistoury, with which four or five small incisions are to be made iD the anterior and posterior lips. Should hemorrhage follow—a very rare circumstance—injections of cold water or small pledgets of lint will readily arrest it. f Some excellent authorities recommend, when it becomes necessary to have recourse to artificial delivery, whether manual or instrumental; to do so without communicating the fact to the patient. In my opinion this is bad advice, and should THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 521 (b) The patient should be placed crosswise, the bladder and rec- tum haA'ing been previously emptied, with her hips brought to the edge of the bed. I much prefer her to be on her back,* although many recommend that she should rest on her left side. If on the back, a fold of blanket to be placed under the hips, to prevent their sinking into the bed. The legs flexed at a right angle Avith the thighs, and held by two assistants as follows : let the left hand of the assistant on the right side be placed on the knee of the patient, and with the right hand in a state of supination placed on his lap, the assistant should take hold of the foot of the patient, holding it steadily during the operation. Precisely the same thing should be done by the assistant on the other side, with the excep- tion that he should place the right instead of the left hand on the knee, and grasp the foot Avith the left. The accoucheur is to be seated between the assistants. (c) The choice of the hand. This is important, for it will have much to do with the success of the operation. In all cases in which the feet present, the hand should be introduced correspond- ing Avith the heels of the foetus; Avhen the knees present, the hand corresponding with the tibiae; and in a breech presentation, the hand Avhich corresponds Avith the posterior surface of the thighs. In a head presentation, the hand corresponding Avith the face, for the purpose of giving the natural curve or flexion to the body dur- ing the operation of version. In all other presentations, the hand corresponding with the point of the uterus at which the feet are situated. (d) The hand not introduced into the uterus should be applied to the abdomen, with a view of steadying the organ during the manipulation. , {e) The hand to be well lubricated with oil, fresh lard, or some mucilaginous material; and, in case of version, the coat should be removed and the shirt sleeve rolled high up on the arm, care being taken also to anoint the latter. The accoucheur should be provided with an old sheet or apron for the purpose of protecting his dress. never be followed. The adroit practitioner, who possesses the confidence of his patient, can always obtain her consent to submit to whatever his judgment may deem proper. Besides, see in what a painful position he might possibly place him- self by attempting the operation without having previously admonished her of its necessity. In his attempt to act clandestinely, there would be more or less risk of rupturing the uterus, to say nothing of injury to the child, through the movements of the mother as soon as she became cognizant of what was going on. * I have on two occasions been obliged to deliver patients by version in a posi- tion not altogether convenient to them, but which greatly facilitated the operation— allowing them to rest on their elbows and knees. In both of these instances I had recourse to this position for the reason that the feet of the foetus corresponded with the anterior wall of the uterus. It will be at once seen how efficiently the position of the patients removed the embarrassment of the version. 522 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. (f) The hand to be introduced Avith fingers and thumb gathered in a conoidal form, and the time of a pain to be selected in carry- ing the hand into the vagina; it should at first be introduced from before backward, then the elbow should be gently depressed, and the fingers given an upAvard direction parallel to the axis of the superior strait; but the hand should not be made to enter the ute- rus except during an interval of pain. (g) When the hand is introduced, it should pursue that portion of the foetus corresponding with the posterior plane of the uterus, and in this way the difficulty will be avoided of confounding the shoulder with the hip, the elbow with the knee, or the fingers with the toes. (h) As soon as the hand has reached the feet, one or both should be gently seized, and, in the absence of contraction, brought down to the superior strait. (i) The version of the foetus should be made during freedom from uterine contraction, and the patient desired not to bear doAvn or employ any effort until the feet are beyond the vulva. The opera- tion to be performed Avith great caution, " Tarde et secure"—slowly and securely being the governing principle in these cases. 6. Divisions of Manual Delivery.—It seems to me that the mul- tiplied divisions made by most authors of manual delivery can have no other effect than that of confusing the mind of the stu- dent, and wearying the patience of the practitioner. The great object in teaching, I maintain, is to simplify as far as it may com- port Avith the nature of the subject discussed, so that the chief end of all instruction may be accomplished, viz. to be useful. With this vieAV, therefore, I shall present to you the folloAving classifica- tion or divisions of manual labor, which, while they will embrace every practical indication that may arise in the lying-in room, will, I trust, commend themselves to your appreciation because of their liberation from unnecessary and complicated details. I am quite sure that the numerous refinements, if I may so term them, into which Avriters enter in their varied divisions not only lead to con- fusion, but so perplex the reader as to cause him to despair of understanding them. To obviate, therefore, this difficulty, and with a view of exhibiting this important subject in a manner so simple and tangible that all may appreciate and comprehend it, I submit the following classification of the circumstances in Avhich it may become necessary to have recourse to manual interference :* First Division, embracing head presentations, and exhibiting two varieties; in the first variety, simple adjustment of the head from a malposition becomes necessary; or when this cannot be accomplished, version must be had recourse to; in the second vari- * The classification I propose is somewhat kindred to the one adopted by my old master, Capuron, but I think is more simplified. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 523 ety, version is indicated, in consequence of the occurrence of hemorrhage, convulsions, or other complications. Second Division, embracing pelvic presentations, viz., the breech, knees, and feet; this division also exhibits two varieties; in the first variety it may be necessary to interpose because of malposi- tion ; in the second, interference is called for because of the com- plication of some accident, rendering immediate delivery necessary. Third Division, embracing trunk presentations, including those of the shoulder and arm. We shall now proceed to indicate in what way adjustment is to be effected in the following positions of the head, embraced in the first division of our classification, viz., 1. Occipital region at the superior strait; 2. Either the left or right lateral region ; 3. When the head is not flexed ; 4. In occipitoanterior positions, where rotation is not effected; 5. In occipito-sacro-iliac or posterior posi- tions, where rotation is not effected. First Division.—1. Manual Delivery when the Occipital Region presents.—The occipital region may present at the superior strait as follows—and, in either case, it Avill be physically impossible for the head to descend into the pelvic cavity Avithout a change of posi- tion: 1. The neck of the foetus corresponds Avith the left acetabu- lum, Avhile the vertex is in apposition Avith the opposite sacro-iliac symphysis; 2. The neck regards the right acetabulum, and tho vertex the opposite sacro-iliac symphysis. 3. The neck is at the risrht sacro-iliac symphysis, the vertex at the left acetabulum; 4. The neck at the left sacro-iliac symphysis, the vertex at the right acetabulum. With a little reflexion, and bearing in memory what Ave have said respecting the fundamental conditions on Avhich is based the mechanism of natural delivery, it must be quite manifest that, in either of these positions of the occipital region, there is an urgent necessity for prompt interference on the part of the accoucheur. It is in cases like these, in Avhich the proper time for action being per- mitted to pass unimproved, that Ave find so much of disaster in the lying-in room. Here, for example, the contractions of the uterus— no matter Iioav vigorous—could prove of no possible avail in accom- plishing the delivery, for the reason of the physical disproportion, caused altogether by the malposition, between the head and mater- nal pelvis. Therefore, Avith a continuance of the uterine effort, and no adjustment of the abnormal presentation, the death of the child Avould be certain; and fortunate Avould it be for the mother, if she too Avere not sacrificed, from either exhaustion or rupture of the uterus! Let me then, in connexion with the case under considera- tion, again enjoin upon you the necessity of early acquainting your- selves with the true condition of things, so that your interposition may be opportune. Delay in arriving at an accurate diagnosis is 524 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. oftentimes, in these and kindred instances of disproportion between the organs of the mother and the presenting portion of the foetus, the cause of embryotomy or other operations, which would not have been called for if a proper degree of vigilance had been exer- cised. Supposing, then, that a careful vaginal examination should dis- close the fact that the occipital region of the child's head presented at the superior strait, the accoucheur will be compelled to do one of two things : either to adjust the head by placing it in a normal position, or, if this cannot be done, he must resort to version. The proper time for adjusting the head Avill be when the parts are soft and relaxed, and the head consequently more or less movable ; for this purpose the hand should be introduced, as already indi- cated, and the vertex brought in proper position with the strait; this being accomplished, should no accident intervene to render immediate delivery necessary, the termination of the labor may be committed to the efforts of nature. If, however, it become impos- sible to right the head, either by the hand or lever, the course to be pursued is to proceed at once to turn and deliver. 2. Manual Delivery, when either of the Lateral Regions of the, Head Presents.—If the head should present so that one of its lateral regions rests across the superior strait, there will be a physi- cal impossibility for it to pass without change of position; for, in such case, the largest diameter of the head—the occipito-mental— measuring h\ inches, is in apposition with one or other of the oblique diameters of the strait, which, you Avill recollect, is only 4j inches; rendering it, therefore, out of the question for a body of f>\ inches to make its exit through a space of 4~ inches. Here, too, there is a palpable necessity for early ascertaining this character of presentation, for, if it be permitted to remain unchanged under the influence of strong uterine contraction, serious consequences may ensue both to mother and child; the former incurring the hazard and consequences of exhaustion and rupture of the uterus; the latter the serious, if not fatal, effects of undue pressure. Re- member, also, that under these circumstances, if there be unneces- sary delay, the dreaded alternative of embryotomy may become the last resource! The lateral regions of the head may present as follows: First Position.—The vertex is in apposition with the left aceta- bulum, and the base of the cranium regards the opposite sacro- iliac symphysis. (Fig. 65.) Second Position.—The vertex is at the right acetabulum, and the base of the cranium at the opposite sacro-iliac symphysis. Third Position.—This is the reverse of the first, and conse. quently the vertex is at the right sacro-iliac symphysis, and the base of the cranium in correspondence with the left acetabulum. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 525 Fourth Position.—This is the reverse of the second, the vertex being in apposition with the left sacro-iliac symphysis, while the base of the cranium is at the right acetabulum. How can these four positions be distinguished in a vaginal examination, so that you may be able to recognise them individually? This is very readily accomplished by sim- ply ascertaining the exact po- sition of the ear of the child; for example, in the first posi- tion, if it be the right side of the head, the concave border of the ear regards the left iliac fossa; and the right iliac fossa (Fig. 65) if it be the left side of the head. In the second position, the relation of the ear with the points of the pelvis is the same as in the first position for each side of the head. In the third position of the right lateral region, the concave border of the ear is turned toward the right iliac fossa, whereas the convex border corres- ponds with the fossa, if it be the left lateral region. In the fourth position, the concave border of the ear corresponds with the right iliac fossa, if it be the right lateral region ; if, on the contrary, it be a presentation of the left lateral region, the convex portion of the ear regards this same fossa. Let us now suppose that you are in the lying-in chamber ; your patient is in labor, and you have ascertained that one of the lateral surfaces of the child's head presents at the superior strait. The very knowledge of this fact admonishes you that nature is at fault; she needs assistance, and the result of the labor will depend very much on the kind of assistance rendered—whether, for example, it be opportune and efficient, or tardy and unskilful. The indications in a case like this are two-fold, either to right the head by bringing the vertex to the strait, and then committing the achievement of the delivery to the natural efforts; or, if the adjustment of the malposition cannot be accomplished, then the necessity will be to terminate the labor by version. With a view of righting or adjust- ing the head, the hand should be cautiously introduced, and the attempt made, if in the first position, to raise the base of the cra- nium from the right sacro-ihac symphysis (Fig. 65), while with the Fig. 65. 526 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. other hand applied to the abdomen, gentle pressure should be directed on the left iliac region, for the purpose, if possible, of depressing the vertex in proper position. But if all attempts to right the head fail, then the indication is at once, if the parts be in proper condition, to proceed with the version of the foetus, the details of Avhich operation we shall discuss in a subsequent lecture. Manual Delivery, Nature being unable to accomplish Flexion.— In describing the mechanism of natural labor, it Avas stated that the head, AA'hen nature is not interrupted in her resources, under- goes three movements previous to its expulsion, viz. 1. Flexion; 2. Rotation; 3. Extension. The object and mode of production of these movements Avere fully explained at that time. Well, you are again in the lying-in room; the head presents in the most natural position, the posterior fontanelle regarding the left aceta- bulum, and the anterior the opposite sacro-iliac symphysis ; the contractions of the uterus have commenced, and increase in energy; the os uteri, under their influence, dilates, but there is no change in the head; time passes on, the contractions lose nothing of their vigor, but rather increase in power. On a vaginal examination, you ascertain that the head is still unchanged from its primitive relations with the superior strait; there is unusual heat in, the vagina, the seal}) is corrugated or in ridges, and the patienVs strength is giving way. Now, gentlemen, permit me to ask you, AA'hat do these symptoms disclose ? Do they not, in the most emphatic manner, portend trouble, and inculcate that nature is oppressed by some obstacle, which she is vainly struggling to overcome ; and do they not urgently call upon you for prompt and efficient succor? Do not misinterpret this silent but eloquent appeal of nature, in the hour of her tribulation! Decision and promptness here will enable you to save human life, and draw from grateful hearts the invocation of the blessings of heaven upon you. The well-educated accoucheur will perceive at a glance the true nature of the difficulty; he will recognise the important fact that, with all the efforts of the uterus, the flexion of the head has not been accomplished, and, as a consequence of the failure to bring about this movement, the first link in the mecha- nism of labor is Avanting; under these circumstances, the vigorous uterine contractions have been lost in the abortive attempt to accomplish the physical impossibility of causing a body of four inches and a half to pass through a space of only four inches and a half; for you will remember that the occipito-frontal diameter which measures in the clear four inches and a quarter, receives the addition of a quarter of an inch by the thickness of the scalp, hair, and sides of the uterus, thus making the aggregate of four inches and a half to make its exit through the oblique diameter of the superior strait, Avhich presents these same dimensions ! Here, then, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 527 is an opportunity for the exhibition of true science, which is ever in striking contrast with ignorance and empiricism. One of two contingencies will present itself in the case such as Ave have just described ; the suffering patient will have by her side a medical man, whose previous education entirely unfits him to appreciate the nature of the difficulty, and who consequently will be in the clouds as to what should be done to overcome the obsta- cle ; or it will be her good fortune to be attended by an accoucheur who has studied in the school of nature, is thoroughly imbued with the principles which ordinarily guide her in the parturient struggle, and Avho, therefore, is prepared promptly and efficiently to become her substitute in the hour of need. In the former case, ignorant of the true cause of the delay, the medical man will content him- self with assurances to the patient that " all is right;'' he will tell her to make the " most of her pains,'' and soon all will be over. These stereotyped expressions, the language of ignorance, may serve for a short time to cheer and infuse hope into the mind of the patient, and appease the anxiety of friends; a very feAV hours, however, will elapse before the predictions, so confidently made, will be proved to be false; the strength of the patient has entirely given way in consequence of the unavailing effort of nature to cause the flexion of the head—the severe pressure to which this latter has been subjected has resulted in the death of the foetus; and the head, from the long-continued contractions of the uterus, has become so firmly wedged at the superior strait as to render any effort to move it impossible. This is a sad picture; under the cir-' cumstances, the alternative may, perhaps, be craniotomy, Avhich will, in the existing condition of things, most probably compro- mise the life of the mother. Let us now reverse the scene. Science takes the place of igno- rance ; the well-instructed accoucheur, knowing that an important part of his duty, in the lying-in room, is opportunely to ascertain when nature is defeated in her plans, so that he may at once be prepared to interpose, will not remain a passive spectator of her unavailing struggles, but will proceed by a proper examination to inform himself of the true cause of the delay in the descent of the head. He soon becomes aware that the efforts to produce flexion have proved abortive; and in lieu of Avaiting until the work of death has been accomplished, so far as regards the foetus, and the life of the mother subjected to the most serious peril, he proceeds to do for nature Avhat she has vainly labored to accom- plish for herself—in one word, he produces the flexion of the head in the following manner: placing the patient on her back—or, if she prefer it, on the side—the accoucheur gently introduces his hand into the vagina, steadying the uterus Avith the other hand placed on the abdomen, and with the middle and index fingers 528 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. applied to one os parietale, and the thumb to the other, he cau- tiously, during the absence of a pain, elevates the face and depress- es the occiput, which necessarily results in the desired movement, viz. flexion. This timely interference—founded on a knoAvledge of the principles on Avhich rests the mechanism of labor—over- comes the obstacle, securing safety to both mother and child, and ensures to the medical man the enjoyment of a consciousness that he has performed his duty. 4. Manual Delivery in the Occipitoanterior Positions when Rotation is not effected.—The contractions of the uterus, we will suppose, have, as they ordinarily will, sufficed to cause the flexion of the head ; after this movement, you will recollect that the head rests diagonally in the pelvic cavity, and continues to do so until it has undergone rotation, the effect of Avhich is, in the occipito- anterior positions, to bring the occiput under the symphysis pubis, and the face into the hollow of the sacrum.* But it will sometimes happen that nature cannot effect this rotary movement—under these circumstances, the same phenomena will present themselves as in the case of non-flexion—undue pressure upon the head, corru- gated scalp, exhaustion of the mother, and serious hazard to the child. What is to be done ? Introduce your hand, and rotate the head ; if the hand be not sufficient, then recourse must be had to the forceps; the instrument to be applied in the manner I shall point out Avhen treating of operative michvifery. As soon as it has properly grasped the head, the movement of rotation can be accom- plished Avithout difficulty. This being effected, the instrument may be withdrawn, and the termination of the delivery confided to nature; should it, however, be found necessary, from the condition of the mother or other circumstances, promptly to achieve the labor, this may be done by the forceps. 5. Manual Delivery in the Occipito-sacro-iliac Positions when Rotation is not effected.—We have, in speaking of vertex presenta- tions and their relative frequency, directed particular attention to the discrepancy of opinion as to which is the second most frequent position of the vertex; and we have endeavored to account for this discrepancy by showing that authors have arrived at conflicting results for the reason that the basis of their calculations depended upon the circumstance—that their examination was made at different periods of labor. Before the time of Naegele the very general, indeed the universal opinion obtained that the second position of the vertex, in the order of frequency, was when the occiput corre- sponded with the right acetabulum. Naegele, however, established the fact that, although it is true the occiput is in correspondence with the right lateral portion of the pelvis, as the second most * Lecture IV., p. 48. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 529 common position of the head, it is only so after a certain progress has been made in the labor. He maintains that, primitively, the vertex is found to present second in frequency when the occiput is at the right sacro-iliac symphysis, and the forehead at the left acetabulum; but at the same time admits that the tendency of the head, in either of the occipito-posterior positions, is to disengage itself by turning the occiput toward one or other of the anterior lateral portions of the pelvis. Indeed, so generally does this spon- taneous conversion take place, that Naegele himself states, in 1244 occipito-posterior positions, in seventeen instances only did he observe the labor to terminate with the occiput traversing the posterior wall of the pelvis. So you perceive that, when in these positions the change into anterior ones does not take place, the circumstance is entitled to be regarded as an exception to an almost universal rule. If, however, you should meet with one of these exceptional cases, my advice would be to do Avhat nature has been unable to accom- plish, viz. bring the occiput toward one or other of the anterior and lateral points of the pelvis, depending upon the particular posterior occipital position, which the head may have originally assumed ; for instance, the right posterior occipital is to be brought to the right anterior point, and the left posterior occipital to the left anterior point. There are two motives for doing this: in the first place, it is following the course of nature Avhen she is not interrupted ; and secondly, it will render the duration of the labor much shorter, for the reason that, in the occipito-anterior positions, the occiput will have to traverse only the length of the symphysis pubis, while in the reverse positions it must pursue the entire length of the sacrum and coccyx. This increase in the ordinary duration of labor would necessarily expose the infant to the danger of protracted pressure, and the mother to the evils of exhaustion and other serious contingencies. This embraces the first variety of the First Division of our classification of head presentations in manual delivery; and it will be found, I hope, both simple and practical. The second variety of the First Division will be discussed in the succeeding lecture. 84 LECTURE XXXV. Manual Labor continued—Certain Complications of Labor rendering Manual Inter- ference necessary—What are these Complications?—Podalic Version, or Turning by the Feet—Rules for Podalic Version—Should one or both Feet be seized ?— Manner of Delivering the Child after the Feet have been brought to the Superior Strait—Rules for Extracting the Shoulders—Rules for Extracting the Head— Appalling Consequences of Ignorance—Case in Illustration—Pelvic Version— Cephalic Version by Internal Manipulation—Cephalic Version by External Manipulation—Prerequisites for its Performance—Mattei and his Views; Objec- tions to—Version in Cases of Pelvic Deformity, recommended by Denman—Prof. Simpson's advocacy of Version in Deformed Pelvis—Examination of his Opinion— Objections to Version in these Cases. Gentlemen—In the second variety of our classification of head presentations, in manual delivery, are to be included those cases in which the termination of the labor is effected by version; not because of any malposition of the head, but because of the occur- rence of some accident rendering prompt delivery absolutely necessary, either for the safety of the mother or child. We Avill imagine, for instance, everything is proceeding most auspiciously— the head presents in a natural position, the pains are normal, and there is a proper correspondence between the maternal organs and foetus. Under these favorable circumstances, however, the sky may become suddenly clouded, indicating a storm, and the severity of the storm, if you will permit me to carry out the figure, may be imagined by the character of the cloud. Let us illustrate. Sup- pose any of the accidents, in this favorable condition of things, capable of complicating natural labor should occur—such as hemor- rhage or convulsions. Here, the safety of the parent and child will necessarily be involved in more or less peril, and the degree of peril will depend very much on the gravity of the convulsions, hemor- rhage, or whatever else may represent the complication. It is to be borne in mind that artificial delivery will be indicated, not simply because the parturition is complicated with some accident, but because that accident—whatever it may be—has assumed a phase which, without an immediate termination of the labor, will compromise the lives of mother and child. We will now imagine that such a case presents itself, and you have determined, as the most rational alternative, to resort to version. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 531 Podalic Version.—How is this operation to be performed ? In the preceding lecture, some general rules were given, necessary to be observed in version; in addition to what was therfsaid, we shall now call your attention to a few details essential to be recollected when the operation of podalic turning is indicated. In the first place, I hold it to be a1 fundamental principle—one not to be for- gotten—that version should never be attempted after the head has escaped through the mouth of the uterus; and for tAvo important reasons: 1. After this es- cape, it will be impossible to return the head ; 2. The attempts to do so will incur the serious hazard of rup- turing the organ, or the vagina itself, or inflicting injury on the head of the fcetus. Again : should the head have descended into the pelvic cavity, although still within the uterus—and this will sometimes occur—the indication, as in the former case, will be to resort to forceps delivery, in prefer- ence to version. The hand, it has already been stated, should be in- troduced into the vagina in a conoidal shape during a pain, but not carried into the uterus except in the absence of pain ; the other hand to be applied to the abdomen for the purpose of steadying the womb. As soon as the hand has entered the cavity of the organ, before attempting to reach the feet, the first thing to do is cautiously to spread its palmar surface over the face of the child, and endeavor to place the occipital region in the opposite iliac fossa, by gently elevating and pressing with the hand thus expanded over the face. (Fig. 66.) This is a very material rule, and you cannot but appre- ciate the great advantage it affords in the successful performance of the operation. By placing the head in one or other of the iliac fossae, you at once provide sufficient space for the easy introduction of the hand and arm into the uterine cavity. 532 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. As a general rule, when the hand has entered the mouth of the B organ, this latter is thrown into more or. less violent contraction ; when this oc- curs, the hand must remain quiet until the contraction has expended itself. As soon as the uterus is freed from the contrac- tile effort, then the hand, with its palmar surface spread out on the surface of the child, is to be carried upAvard (Fig. 67), with a view of searching for the knees or feet. It is a mis- take to suppose that it is necessary ahvays to seize the feet in podalic version (Fig. 68); if you can grasp the knees, either one or both, then by gentle trac- tion on them you will rea- dily succeed in bringing the feet down to the su- perior strait. Is it essential to seize both knees, or both feet ? If both of either of these extremities can be conve- niently grasped, then it is well; but it is by no means essential, for whether one foot or one knee be seized, it should be brought doAAm, and the other will soon follow; should it not, the hand can readily be carried up again ; but this is rarely necessary. * When the extremities are grasped, traction is not to be made except dur- ing the absence of pain, while these extremities are within the uterine cavity Fie. 67. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 533 (Fig. 69.) One of the principal dangers to the child, in the operation of version, is from undue pressure of the umbilical cord; therefore, great caution is necessary in your manipulations to avoid compressing the cord, for fear of interrupt- ing the circulation be- tAveen the placenta and foetus; and be careful, too, not to detach the cord from the umbilicus, which might possibly happen, through Avant of proper caution, especially if it should be curtailed of its ordinary length, by being coiled around the neck or limbs of the child. Delivery of the Lower Extremities and Trunk.— Well, you have succeeded Fl»- *>. in bringing down the feet to the upper strait (Fig. 70), or within the vagina, what next ? If the indications for immediate delivery be not urgent, the termination of the labor may be submitted to the resour- ces of nature; on the con. trary, if the life of mother or child be in peril, admitting of no delay, then you are to proceed as follows: employ- ing the hand corresponding with the heels of the child, and gently seizing the loAver limbs above the ankle, trac- tion during a pain, is to be made downward and back- * ward in a line parallel to the axis of the superior strait; as soon as the limbs have passed beyond the vulva, they should be enveloped in soft linen in order to Fm. Tfli 534 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. protect them against injury from pressure of the hand ; then the two limbs should be seized, respectively, taking care to extend the thumbs length Avise on the posterior or anterior surface of each, as the case may be, in order that every precaution may be observed to avoid bruising them (Fig. 71); the tractions are to be continued, combining with them a movement of slight elevation and depression; when the hips reach the vulva, the hands are to be placed transversely across them, and the same movement of alternate elevation and depression continued (Fig. 72) ; as soon as the hips have escaped, the child should be supported by the pal- mar surface of one hand, while with the index and middle fingers of the other carefully introduced along the abdomen, the accouch- eur should bring down a loop of the cord, in order to prevent the possibility of lacerating it at the umbilicus during the progress of the delivery; in making this loop, traction should be used on the pla- cental extremity of the cord (Fig. 73). This being accomplished, the combined movement of traction THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 535 is to be continued until the entire body of the child is delivered except the shoulders. Delivery of the Arms.—When the shoulders reach the external organs it will be necessary to attend to the delivery of the arms; the one which is below is to be extracted first, and for this purpose the child being supported on the forearm of the accoucheur, he glides the index and middle fingers of the right hand (if it be the first position of the vertex) along the arm of the child as far as the humero-cubital articulation, and with the thumb in the hollow of the axilla, the arm is brought successively over the side of the head, the face and the neck; when delivered it will be on the right of the vulva. The child is then placed on the right arm of the accoucheur, and the tAvo fingers of the left hand are introduced for the purpose of extracting the other arm, which is above, the mechanism of which is precisely the same as in the other instance (Fii;-. 74). Extraction of the Had.— You may, perhaps, suppose that after the entire trunk has been liberated, the difficulty is at an end, and the successful termination of the delivery at hand. But such is not ahvays the case—indeed, the most im- portant, and oftentimes diffi- cult part of the operation is yet to be accomplished—I mean the extraction of the head; and here, permit me emphati- cally to admonish you that it is not to be delivered by brute force, but in accordance with the laAvs governing the mecha- nism of labor. Unfortunately, the recollection of this fact is too often unheeded, and the most disastrous results ensue. I have witnessed some appalling examples of mismanagement in these cases, well calculated to make the medical man pause, and reflect on the measure of his obligations in the sick-room. In order that you may fully appreciate the importance of this question, and Avith a vieAv of animating you to a just consideration 536 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of your duties when science is needed to take the place of natural effort, we will suppose that the operation of version has been per- * formed, and the entire child delivered with the exception of the head. After the shoulders and arms have been extracted, you find some obstruction to the descent of the head ; you make traction on the body of the child, hoping in this Avay to overcome the difficulty; there is, however, no response to these efforts; you desist for a time from all further action; the mother becomes impatient, the friends are anxious, and you are importuned to do something to achieve the delivery. Tractions are again resorted to, but Avithout any avail except to augment the impatience of the mother, and the anxiety of her friends. You are questioned as to the cause of the delay; you make some excuse, as unsatisfactory to yourselves as to those who seek the information; time still rolls on, and still no delivery. All confidence is lost in you; silent but Avithering evi- dences of rebuke take the place of smiles and pleasant Avords; a consultation is demanded ; some medical man, versed in his science and adequate to the emergencies of the lying-in chamber, is requested to meet you. He receives from you a history of the case; he examines the patient, discovers at once the real cause of the obstruction, and proceeds, with your concurrence, to remove it. In a very few moments, he accomplishes what you have vainly endeavored for hours to do, simply because, in the first place, he possesses the requisite knowledge, and, secondly, brings it to bear on the case in point. What is-it he does? He supports the child on the anterior surface of his arm, and with the index finger of the corresponding hand introduced into the vagina very soon ascertains the true nature of the obstacle to the descent of the head—this latter is resting obliquely at the superior strait with its great diameter—the occipito-mental, measuring five and a quarter inches—over the oblique diameter of the strait, which you will recollect gives but four ana a half inches. Your tractions, therefore, haAre been unavailing for the reason that they were exhausted in the futile attempt to overcome the physical impossibility of causing a body of five and a quarter inches to traverse a space* of only four and a half inches ! But, as I shall presently tell you, these tractions are occasionally more than futile ; they sometimes result in the de- struction of the child, a spectacle almost too shocking to dwell upon! The nature of the obstacle being clearly ascertained, the accou- rheur proceeds to overcome it as follows : he places the index and middle fingers of the hand already in the vagina just below the orbits, or it will suffice to introduce the index finger into the mouth ; and while he gently makes traction doAvnward, with the corres- ponding fingers of the other hand applied to the occiput, he elevates THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 537 this latter so that the combined movement results in approximatino the chin to the sternum, or, in other Avords, producing the movement of flexion (fig. 75); this being accom- plished, he then rotates the head bringing the occiput under the symphysis pubis, and the face into the hollow of the sacrum; as soon as the perineum is pressed upon, he has it supported by an assistant, and Avith a com- bined lateral and extractive force delivers the head. The entire operation can oftentimes be performed by the accomplished accou- cheur in the brief time I have taken to describe it. The simple question now arises—Avhy has he suc- ceeded, and why have you failed ? His success is the direct offspring of know- ledge ; Avhile your failure is the result of ignoranfte. He has stu- died and comprehends the mechanism of labor ; he knoAvs that the head, Avhether it be at the superior strait, first or last, must undergo three movements: flexion, rotation, and extension ; and he also understands it to be his duty, Avhen nature is contravened, to per- form these movements for her. Let us noAV, for a moment, look at the relative position of the two medical men so far as the judgment of the patient and her friends is concerned. You, Avho have been inadequate to the exigencies of the case, will be scorned as utterly unfit for the requirements of your profession; and scathing, indeed, will be the censure, should the patient exclaim—Doctor, you could have saved my child if you had understood your business, for I felt it move for several minutes after its little body was in the world ! Would not such language to a medical man, whose dereliction of duty has righteously called it forth, be the very cup of bitterness itself! Hoav different Avith him, who has so promptly exhibited the proof of both knoAvledge and skill. He has vindicated science, and imposed upon the patient and friends an obligation, which, if their hearts be in the right place, they never -will believe can be cancelled. Case in Illustration.—I could cite several melancholy examples 538 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of barbarous practice in these cases, to Avhich I have been called, merely, as it were, to bear testimony to the merciless destruction of human life; but I prefer, with the hope of impressing upon you the sacred responsibilities of duty, to bring before you a most heart- rending instance, mentioned to me by my friend and colleague, Prof. Valentine Mott, as having occurred in his practice some years since : An unfortunate woman, a prostitute, Avas taken in labor Avith her first child. A physician was summoned to attend her; finding it to be a case of shoulder presentation, he requested a con- sultation ; after much delay and great suffering, version was effected. The child Avas delivered Avith the exception of the head; to overcome the obstacle, simple brute force Avas resorted to ; the child's body constituted a lever upon which the most violent trac- tions were made, but all Avithout avail; a napkin was then attached to the body, and with this double lever the force was renewed—the two medical men straining every effort to bring, under this increased pressure, the head into the Avorld. Nature could not long resist this combination of power, and the result was—the body Avas torn from the head, the latter still remaining undelivered ! Under these circumstances, Prof. Mott was sent for ; he found the patient in almost a moribund state; in making an examination per vaginam, an extensive laceration of the neck of the uterus was discovered, through Avhich the detruncated head had escaped into the abdo- minal cavity! Here Avas a case in which science was paralysed, for the dying state of the unhappy sufferer rendered any effort to rescue her out of the question. This Avoman, prostitute as she Avas, and, as might be supposed, lost to every sense of refined feeling, exhibited a feAV moments before her death the strongest evidence of a philanthropic heart; evidence which, while it developed sym- pathy for the Avoes of others, was a telling rebuke to those avIio had participated in the act of her destruction. Her last words were these: " For God's sake, doctors, after I am dead examine my body, so that you may know how to relieve any one who may here- after suffer as I have done!" What a lesson do these words inculcate, and how graphically do they portray professional respon- sibility. Statistics of Podalic Version: Frequency.—Dr. Churchill has collected a total of 505,691 cases in which version was performed 4,133 times, or about one in 122£. These cases are tabulated as follows: English Practice.—71,483, version 247 times, or 1 in 247.* * Mr. E. Garland Figg has recently published some papers on the subject of ver- sion which, to say the least, are startling in the views they inculcate. It would really seem that this gentleman has discovered in the operation of Turning an ele- ment of safety for the parturient woman far more reliable than anything in the resources of nature. He tells us that since writing the papers alluded to he has THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 539 French Practice.—40,376, version 451 times, or about 1 in 89£. German Practice.—393,823, version 3,393 times, or 1 in 116. Mortality to the Mother.—In 2,939 cases, in Avhich the result to the mother is specially mentioned, 211 died, or nearly 1 in 14 ; it must be remembered, hoAvever, that this result is merely approx- imative so far as the operation itself is concerned, for the influence of the complications of labor, such as convulsions and hemorrhage, as also the duration of labor, are to be taken into the account of the mortality. Mortality of the Infant.—In 3,347 cases, in which the result to the child is detailed, 1,472 were lost, or rather more than 1 in 3.* It is unfortunate that in the results of the statistics just presented, no statement of the duration of the labors has been given ; for with a knowledge of this circumstance we could the more readily appre- ciate the true mortality of turning, both to mother and child. It cannot be denied that the mortality of child-birth, in natural as well as artificial parturition, is materially affected by the duration of the labor. This we shall prove under the head of instrumental delivery. Prof. Simpson has tabulated twenty-four cases in Avhich version was performed as reported by Dr. Collins of the Dublin Lying-in Hospital, with the following important results, shoAving the influ- ence exercised by the length of the labor on the death of the mothers. Although the cases are comparatively few, they are quite significant as to conclusions: Duration of Labor. Proportion of Deaths of Mothers. Below 24 hours. Above 24 hours. 1 in 21 died. 1 in 3 died. Pelvic Version.—Some authors recommend, in lieu of seeking for one or both feet, to introduce the hand and bring down the breech, attended sixty labors, fifty-five of which he terminated by turning! He has had but one maternal death, and that " occurred five days after the operation by inflamma- tion of the peritoneum of a patient who, with contracted pelvis, had submitted to the ordeal to produce her sixth full-timed dead child." Mr. Figg says in four instances he has broken the arms of the children; but this is of very little importance, for he advises not to be " too candid to the relatives, but at once by your own dictum transub- stantiate the injury into a slight sprain received by the infant striking its shoulder against the backbone of the mother while actively prosecuting its uterine gambols!" Really I cannot approve either of Mr. Figg's practice or his morality. [See London Med. Times and Gazette, Nov. 13 and 20, and Dec. 25. 1858.] * Ricker reports that, in the Duchy of Nassau, podalic version was resorted to 2,473 times in 304,150 cases of labor, or 1 in 123. The result to the mother was 176 deaths, or 1 in 14, corresponding very closely with the general mortality given by Dr. Churchill. Nearly 1 in 2 of the children was lost. According to the sta- tistical record of Prof. Schwerer, version was performed 182 times in 21,804 cases, or 1 in 119; 14 mothers were lost, or 1 in 13; 93 children lost, or 1 in 2. 510 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. when the child occupies a position in Avhich the breech is nearer the superior strait than the head. In my opinion, however, this prac- tice, AA'hen version is really indicated, will be found more difficult, and attended by more hazard than podalic version; therefore, I should advise you to give preference to the latter operation. Cephalic Version by Internal Manipulation.—As has already been remarked, version by the head Avas always practised by the ancients; noAvhere can I find podalic version oA'en alluded to by them. Their preference for cephalic turning was undoubtedly due to the doctrine the}r inculcated, viz. that the only natural and favorable position of the foetus, Avas when the head presented at the superior strait. Hence the counsel of Hippocrates, in all cases in which any other portion than the head presented, Avas to displace it, and substitute the cephalic extremity. He relied much on changing the position of the woman, for the purpose of bringing the head doAA'n, and gives particular directions as to this point. For instance, he recommends to place something under the hips during the labor, and also under the feet of the bed, so that the patient may be raised higher toAvard the feet. The hips are to be more elevated than the head, nor should the latter have any bolster. He further says that after the presentation of the fcetus has become changed, the patient is no longer to be elevated as just described, and a pillow should be placed under her head.* Cephalic version had for a long time fallen into neglect, so that it Avas rarely resorted to; I believe it is generally conceded that the credit of again introducing it to the attention of the profession is due to M. Flamant of Strasburgh, Avho, in 1795, became its earnest advocate. Since that period, many successful cases have been recorded. M. Busch, of Berlin, reports that, in 15 cases under his care, he delivered 14 living children ; Riecke lost 1 child in 16; Avhile Pucker, of the Duchy of Nassau, reports 10 cases, of which 9 terminated favorably for both mother and child. Other results might be cited, Avhich demonstrate the important fact that all things being equal, cephalic version is infinitely more favorable to the child than podalic, for in the 41 cases just quoted only 3 children Avere lost, or about 1 in 14. In podalic version, on the contrary, the loss is rather more than 1 in 3. The conditions justifying a resort to cephalic version may be enumerated as follows: 1st. The pelvis must possess its natural dimensions, for a con- tracted pelvis would present positive objections, unless it were ascertained that the head is unusually small. 4: * Supinse reclinatae molle quiddam coxis substernere oportet, atque etiam lecti pedibus aliquid supponere, quo altiores a pedibus decumbentes, esse queant. Sed et coxae capite sint altiores; nullum vero capiti cervical subsit. [De Mulier. Morb. lib 1 cap. p. 8.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 541 2d. The head must not be very remote from the superior strait* 3d. The foetus should enjoy a certain degree of mobility, other- wise the hazard to mother and child would be greatly enhanced. The operation, therefore, should be undertaken before the rupture of the membranous sac, or as soon after as possible. 4th. Cephalic version is indicated when the child is situated trans- versely, or, for example, in a shoulder presentation. Mode of Performing Cephalic Version.—Having previously ascertained the true position of the head, that hand is to be intro- duced Avhich corresponds Avith the portion of the uterus at which the head is situated; the other hand should steady the uterus through the abdominal parietes. If the membranes be still intact care should be exercised not to rupture them by cautiously gliding the hand between them and the internal surface of the uterus. As soon as the hand reaches the head, it should be grasped by the palmar surface, the accoucheur at the same time affording escape to the liquor amnii: an effort is then to be made to bring the head to the superior strait, while with the hand applied to the abdomen the pelvic extremity of the foetus should be elevated toward the central line. Dr. Wright,f of Cincinnati, in a paper on cephalic version to which was awarded a gold medal by the Ohio State Medical Society, suggests the folloAving operation: The fingers are to be applied to the top of the shoulders, and the thumb to the axilla, or to such part as will give command of the chest, and thus afford lateral force. With the other hand upon the abdomen, pressure is to be made so as to dislodge the breech, and cause it to ascend toward the centre of the cavity. Hence, without applying direct force to the head, it is thus brought to the superior strait; if, however, this fail, the head may then be grasped. Dr. Wright states that, in all the cases treated by him from the commencement, the children were born alive. Cephalic Version by External Manipulation.—It has been pro- posed, in certain malpositions of the foetus, to correct them by turning the child and bringing the head to the superior strait through manipulations made on the abdominal walls of the mother. That this species of version may, under some circumstances, be accom- plished, I have no doubt. But it involves certain prerequisites— such as an accurate knoA\dedge of the exact position of the foetus, * The following is the language of Yan Swieten on this point, and embodies, I think, very judicious counsel: "For while the foetus is disadvantageously situated in the womb, it cannot always be reduced to such a position as to come out by the head; this can be effected only when the head is not very distant from the orifice of the womb, so that it can be easily touched by the fingers of the midwife, and moved out of its position." [Van Swieten's Commentaries, vol. xiv., p. 14.] \ American Journal of Medical Sciences, July, 1855. 542 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sufficient laxity of the abdominal walls, and a ripe experience in this mode of manipulation. In order to ascertain the position of the foetus, recourse must be had to abdominal palpation, ausculta- tion, and the " toucher." One of the latest and most uncompro mising advocates of external version, Dr. A. Mattei,* in addition to transverse positions, recommends it in all cases of presentation of the breech, which he considers unnatural and dangerous, and contrary to the physiology of parturition. He advises that, as soon as it is ascertained the breech is at the superior strait, efforts should be made to carry it up to the fundus of the womb, and bring the head down, by means of external manipulation; and this he says is his general practice, in which he claims to have been remarkably successful. The time at which this conversion is to be made is from the sixth to the ninth month of pregnancy, for at this period the fcetus enjoys a greater degree of mobility in utero, and hence the greater facility of the operation. There are, I think, some cardinal objections to the practice recommended by Dr. Mattei in breech cases: 1. The difficulty of its execution. 2. The danger of provoking the uterus to premature action. 3. Nature, under ordinary circumstances, is quite capable of achieving the delivery Avhen the breech presents, although it must be recollected that the child incurs more hazard than in a head presentation. 4. The possibility that the foetus may right itself before the com- pletion of the term. For these reasons, therefore, I should advise you not to adopt the practice in the presentation of the nates. External manipulation, with a view of changing the position of the foetus, may be said to be a revival of an ancient practice. It, hoAvever, met with but little favor until within the present century. It is, I think, conceded that the credit is due to Dr. Wigand, of Hamburg, for the impulse which this operation has received in our own times, and more especially in Germany. His views, decidedly in full approbation of the measure, have the endorsement of some of the ablest German obstetricians, among whom may be mentioned Busch, Naegele, Kilian, Scanzoni, Arneth, Hohl, and others. In- deed, there is no doubt about the very general adoption of the practice by the leading men of the German school. In France too, Velpeau and Cazeaux recognise external manipulation as a proper resource; Avhile, as I have already stated, the Corsican physi- cian, Dr. Mattei, is more than enthusiastic on the subject. In Great Britain, on the contrary, it has failed of approbation. In our own country, it may, I think, be said that the question is still subjudice.\ * Essai sur l'Accouchement Physiologique. Par A. Mattei. P. 185. f An interesting case of cephalic version during labor, by external manipulation, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 543 Let us, for a moment, inquire what it is that the accoucheur pro- poses to accomplish by external manipulation ? The object is two- fold : 1. To change an abnormal position of the fcetus into one which is natural; 2. To avoid the necessity of introducing the hand within the cavity of the uterus for the purpose of bringing to the upper strait, through internal manipulation, either the head or the feet. This is undoubtedly the true analysis of the motive ; and if the object be carried out consistently AA'ith the safety of the mother and child, the operation is entitled to be hailed as one of the greatest benefactions to woman. It can scarcely be necessary to remark that a fundamental condition, before attempting external version, is an accurate knowledge of the position of the foetus in utero ; it is this knowledge which constitutes the entire justification of the procedure. The next question is, how is the position of the child to be ascertained ? I think the most reliable means is through ausculta- tion and abdominal palpation; but an important auxiliary will be found in the " toucher" or vaginal exploration. Auscultation, however, may sometimes lead to erroneous judgment, as in the case of a twin gestation. Well, we will suppose that the diagnosis of position has been satisfactorily determined, the next question is, at Avhat time should the operation be had recourse to ? Some writers, in agreement with Mattei, recommend its adoption during the latter months of pregnancy, say from the sixth to the ninth months. Without entering into any special argument on the subject, my advice to you is, not to attempt any interference until labor has commenced ; and, as a general rule, the manipulation should be made before the rupture of the " bag of waters," for, it is to be recollected, in pro- portion to the escape of the liquor amnii will be the diminished mobility of the foetus, and the consequent difficulty of the evo- lution. Mode of Performing the Operation.—The patient should rest on her back; the accoucheur then places one hand flatwise on that portion of the abdomen corresponding with the head of the fcetus, while the other hand is directed to the opposite point at which the breech will be found ; these two portions of the foetal surface being thus embraced, the one hand should gently depress the head toward the pelvis, and a movement of elevation imparted with the other to the breech. The tendency of this counter-movement will be to bring the head of the child to the superior strait, thus converting it from a transverse or oblique position to a cephalic presentation. As a comparative laxity of the abdominal and uterine walls is essential to the success of the operation, it is needless to remind with safety to mother and child by Prof B. Fordyce Barker, is recorded in the American Medical Times, June 2,1860. 544 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. you that these manipulations are to be restricted to the intervals of the labor pains. It is recommended while the pain continues, to place the patient on the side corresponding with the head, and at the same time to make uniform and guarded pressure on this latter by means of a small pilloAv or cushion. As soon as the pain ceases, the position on the back is to be again assumed, and the same character of manipulation continued. When the head has been made to descend, it will be disposed, should it enjoy much mobility, to resume more or less its former position; to obviate this, the membranous sac should be ruptured, so that, Avith the escape of the amniotic fluid, the head may become fixed. It has been suggested by Kilian and others, and Avith good reason I think, that the rectifi- cation of the child's position is not exclusively due to the external pressure of the hands; but that in connexion Avith this pressure must be taken into account the influence which it exercises in the correction of certain obliquities of the uterus, to which these mal- positions of the foetus are oftentimes due. If, as sometimes will occur, the operation should proA'e unsuc- cessful, the alternative Avill be version of the child by the introduc- tion of the hand into the uterus ; or the plan proposed by Dr. Wright may be attempted. If the head be brought down to the superior strait or not, and any complication present itself calling for immediate delivery, podalic version will be the resource. Version in Pelvic Deformity.—It now remains for me to call attention to the subject of version in certain cases of pelvic deformity, as recently revived by Prof. Simpson, who gives it the Aveight and authority of his name, and urges it as a substitute for craniotomy. I say revived, for it is Avell knoAvn that this practice Avas advocated by Denman and some of his contemporaries, but had fallen into almost utter oblivion until again introduced to the attention of the profession by the distinguished writer just named. The tAvo chief arguments in favor of version in pelvic deformity offered by Dr. Simpson, are: 1. That the transverse diameter at the base of the fcetal skull (the bi-mastoid) is less than the corresponding diameter at the arch of the cranium (the bi-parietal). 2. That the head may be extracted consistently with the life of the child, after the body has been delivered, through a smaller space than is needed for its passage in a vertex presentation, and impelled simply by the contractile efforts of the uterus. In addition to these two main propositions, he says that version, when deformity of the pelvis exists, contrasting it with craniotomy, gives the child a chance of life; it is more safe to the mother, because it can be performed earlier in labor, and more speedily; it enables us to adjust and extract the head through the imperfect pelvic brim in the most advantageous form and direction; lastly, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 545 it is a practice that can be followed when proper obstetric instru- ments are not at hand, and the avoidance of instruments is generally advisable when it is possible.* The importance of the question, and the high authority of the gentleman avIio commends its adoption to the profession, Avill justify an examination of the arguments adduced in its favor. It is undoubt- edly true, as Prof. Simpson alleges, that there is a difference in the respective transverse diameters of the foetal skull at its base and arch ; for the former measures three inches, while the latter gives three inches and a half. When describing to you the foetal head in connexion with child-birth,f you will remember I told you the characteristic difference between the base and arch of the cranium is, that the base at the completion of utero-gestation is ossified, and cannot be made to yield to pressure; and, moreover, I pointed out to you that this is a most essential provision, for the exercise of pressure on the lower portion of the brain and medulla oblongata Avould most likely result in the destruction of the child's life. The arch, on the contrary, from the peculiar construction of the sutures, overlapping each other, Avill yield occasionally half an inch in its transverse diameter, and the temporary pressure, consequent upon such diminution, could be sustained Avith impunity for the reason that the upper portion of the brain is not essential to life. It would, therefore, follow that if the contraction in the antero-posterior diameter at the superior strait were less than three and one-eighth inches, the delivery of the head by version would, I think, be physically impracticable; for admitting, for argument's sake, the opinion of Prof. Simpson, that the head can be made to traverse a smaller space, after the delivery of the body, than in an original vertex presentation, yet, as the transverse diameter of the base measures three inches,J and undergoes no diminution, it will need a space of at least three inches and an eighth to enable it to pass. But again: if there be a space of three inches and an eighth, it is possible that the head may descend in a vertex presentation, for the reason that the transverse diameter of the arch will occasionally, through the overlapping of the bones, yield to the extent of half an inch. Therefore, with such a pelvic deformity—such as we have described, it is far better to trust, all things being equal, to the resources of nature than attempt delivery by version. Although it is undoubtedly true, as a general principle in mechanics, that a body may be more easily drawn through a space when its apex pre- sents than impelled through the same space by a vis a tergo force * Provincial Medical and Surgical Journal, December, 1857. P. 647. f Lecture III. X It is proper to state that in the six cases of measurement of foetal heads given a% by Prof. Simpson, the bi-mastoid diameter (transverse of the base) varied from 2J inches to 3] inches. 35 546 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. directed against the base, yet I do not think this principle will always apply in the case of child-birth. I have much more confi- dence in the ability, of nature when not interfered with, than I have in the most consummate skill of man. What I mean is this—Sup- posing an instance of pelvic curtailment to the extent of three and an eighth inches, I should have more faith in the efforts of natur so to diminish the transverse diameter of the arch as to enable it to descend, than in the manipulations of the accoucheur, no matter what dexterity he might possess, after the body of the foetus had been delivered. But, gentlemen, there are, in my judgment, other serious objec- tions to version in these cases. You have been told—and the fact is perfectly patent—that turning, under the most favorable circum- stances, is an operation of peril both for mother and child ; and just in proportion as the natural dimensions of the pelvic canal are abridged, the peril will be enhanced. Again: another solid argu- ment, it seems to me, against version in pelvic deformity is, the v^ry probable contingency, after having subjected parent and child to the dangers of the alternative, that the delivery will be required to be terminated by craniotomy. My advice to you is this—if the antero-posterior diameter do not measure more than three and an eighth inches, trust, as long as circumstances will justify it, to the resources of nature;* if these be found inadequate, and there should be indications of peril either to mother or child, then, in lieu of version, have recourse to the forceps, for although, as a general rule, when the head is still at the superior strait, I prefer turning to forceps delivery, yet, in the event of a pelvic deformity, such as we have been considering, my choice would be the instrument. The safest practice, however, would unquestionably be the induc- tion of premature delivery, but this would, of course, involve the necessity of ascertaining the existence of the deformity at some time prior to the completion of utero-gestation .f * The resources of nature are occasionally most extraordinary in overcoming a disproportion between the head and pelvis. This fact is well known to accoucheurs, who have observed well; and it would be more frequently recognised in practice were it not for that too general sin—"meddlesome midwifery." \ When discussing the subject of premature artificial delivery, we shall mention the various grades of pelvic abridgment in which thifl alternative will be justifiable. LECTURE XXXVI. Manual Delivery continued—Presentation of the Breech, Knees, and Feet; Manual Delivery in—The Indications in these Pelvic Presentations—Malpositions of the Pelvic Extremities—Excessive Size of the Breech; how managed—Presentation of the Pelvic Extremities complicated with Hemorrhage, Exhaustion, Convul- sions— The Management of Pelvic Presentations in Inertia of the "Womb—Iner- tia, how divided—Inertia from Constitutional and Local Causes—Importance of the Distinction in a Therapeutical Sense—Blood-letting in Inertia, when to be employed—Ergot, when indicated. Gentlemen—We now proceed to the consideration of our second division of manual labor, embracing the pelvic presentations, viz. the breech, knees, and feet, and which also has two varieties. In the first variety, you will remember, it may become necessary to interpose because of malposition of these extremities; in the second, interference is called for because of the complication of some acci- dent, rendering immediate delivery essential. It is important that you should bear these two distinctions in recollection, as they will be the guides for the particular kind of interference indicated. Presentation of the Breech.—I have stated that, under ordinary circumstances, natural labor may be accomplished when either the breech,* feet, or knees present; but it may happen that nature is so far contravened AA'hen either of these extremities is at the supe- rior strait, either from malposition, excessive size, or from the occurrence of some accident placing in peril the life of mother or child, as to need the prompt interference of the accoucheur. Let us illustrate this interesting practical point. You are at the bed- side of your patient, labor has commenced, and a vaginal explora- tion has satisfied you that it is a case of breech presentation. You are content Avith the abstract fact that the breech is at the upper strait; you give yourselves no further concern, and rely upon the efforts of nature to terminate the delivery. Pain succeeds pain; time elapses, and yet, notwithstanding strong uterine contractions, the breech does not descend into the pelvic cavity; the reiterated efforts of the uterus have made a decided impression on the strength of the mother, while they have not failed to exercise a pressure more or less injurious on the foetus itself. * For the diagnosis and positions of these various presentations, see Lecture XXIV. 548 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In this state of things—animated to duty, perhaps, by the ardent appeals of the patient—you institute another examination for the purpose of ascertaining why the breech does not descend in response to the vigorous efforts of nature ; at this late hour, after the exhaustion of the mother from unavailing struggles to advance the labor, and the danger to the child from extreme pressure, you discover that the cause of the delay is due to one of two condi- tions—either the breech does not present properly, or its great size prevents its progress into the pelvic canal. Here, you perceive, the cardinal error consists in the fact that you were careless in not hav- ing ascertained the true nature of the obstruction at an early stage of labor; so that by opportune interference the difficulty might have been overcome, thus sparing the mother the possible fatal consequences to be apprehended from exhaustion and a protracted parturition, while the child would have been protected against the injurious effects of undue pressure. It is a great principle in midAA'ifery—one to be kept constantly before you—not to delay action until the mother and child are sacrificed, but to exhibit the aids which science will enable you to do opportunely, and in time to save human life. What would be your judgment of the navigator who, in disregard of the fearful storm, should remain perfectly passive, and awaken to a conscious- ness of peril only AA'hen his noble vessel had fallen a wreck to the howling tempest ? The parallel is perfect, so far as duty is con- cerned, between the captain to whom is intrusted the safety of his ship, and the medical man, who has in custody the life of his patient. If it should be found that the obstruction consists in malposition of the breech—in other words, if, instead of presenting centre for centre at the superior strait, one of the hips, the sacrum, or poste- rior surface of the thighs should rest upon some portion of the upper contour of the strait, the indication is obviously to bring the breech, without delay, in a position parallel to the long axis of the pelvis, so that it may be made to respond to the contractile efforts of the uterus. This rectifying of the position may be effected by the introduction of the hand, during the absence of pain, endea- voring gently to elevate the breech, and place it in proper relation with the strait; should the hand not be adequate, it may become necessary to resort to the lever, or one of the branches of the for- ceps. I have known instances in Avhich change of attitude in the patient has sufficed to accomplish the object. But we will suppose that these various expedients fail; what then is to be done? The next alternative, about which there should not be a moment's hesi- tation, is to introduce the hand and bring down the feet, the manner of doing which we shall explain before the close of this lecture. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 549 In the case of excessive size of the breech,* the accoucheur should endeavor to place his index finger in the bend of the thigh, situated posteriorly, and make gentle traction downward and backward in the direction of the axis of the superior strait; in the event of failure to accomplish this, the blunt hook or fillet may be substituted for the finger, of which we shall speak more particu- larly under the head of Instrumental Delivery. If, however, all these prove negative, then, as in the other instance, the feet must be brought down by the introduction of the hand. It may, however, happen that the pelvic extremities present in the most natural manner; but owing to the occurrence of some complica- tion, such as hemorrhage, convulsions, or exhaustion, by which the safety of the mo- ther and child may be com- promised, it will become expe- dient to terminate the labor. Under these circumstances, you will proceed as follows: Supposing the breech to pre- sent in the first position with the sacrum regarding the left acetabulum, and the posterior portion of the thighs in cor- respondence with the opposite sacrp-iliac symphysis, the left hand is to be carried up as far as the breech, which, by a gen- tle effort, you will attempt to elevate Avith a view of enabling you to bring down the limb which is behind, and afterward the one in front (Fig. 76); the delivery is then to be completed as if the feet originally presented^ If, * The breech will sometimes be found only relatively disproportionate in size, and there is a very important practical fact connected with this .circumstance. For example, it will occasionally happen that the feet present at the superior strait simultaneously with the breech. Under these circumstances, in consequence of the iucreased volume of the presenting parts, there will necessarily be more or less delay in the delivery, and very generally interference will be called for. Some authors recommend to replace the feet within the cavity of the uterus in order that more space may be allowed for the descent of the breoch. I cannot regard this aa judi- cious practice, and would advise you, instead of returning the feet, to seize one or both, and bring them down, thus converting the case into one of foot presenta- tion. f See Lecture XXN V Fig. 76. 550 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. however, it should be found impracticable to succeed in this Avay» recourse must be had to the blunt hook, by placing it in the groin of the limb, which is posterior, and making downward and backward tractions until the hips approach the vulva. The hand then can readily complete the extraction. The same rule of conduct is to govern you in either of the other three positions, remembering always to introduce the hand corresponding with the posterior surface of the thighs. Presentation of the Feet.—A presentation of the feet cannot be regarded so favorable to the safety of the child as Avhen the breech presents, and for the following reasons: The membranous sac is made to protrude, and becomes more or less elongated through the mouth of the uterus; it, therefore, is unable to reach its full development, and, in addition, it is liable to be early ruptured. Under the circumstances, the uterine orifice is but partially dilated, the consequence of which will be compression more or less serious of the foetus, to which may be added undue pressure of the umbilical cord, and not unfrequently premature detachment of the placenta, all of which are so many influences adverse to the safety of the child. On the contrary, in a breech presentation, the membranous sac does not rupture as a general rule, until the full dilatation of the orifice, and consequently both the foetus and cord are pro- tected, at least measurably, against the amount of compression to which they are exposed in a footling case. The life of the child, it should be recollected, is always more endangered when the pelvic extremities present in a primipara than in a multipara, for the reason that, as a general principle, the parturition in the former being more protracted, there is increased risk of pressure of the cord. In a footling, as in a breech presentation, it may become neces- sary for science to interpose, either because of malposition or of the occurrence of some accident calling for prompt delivery. In the case of malposition, before anything can be attempted, the first duty of the accoucheur will be to ascertain the special character of the obstacle; for example, the feet, in lieu of being so situated at the superior strait as to become responsive to the contractions of the uterus, may rest, one or both, on the anterior, posterior, or lateral borders of the strait, thus contravening every effort of the womb to cause their descent. Should not the source of the difficulty be early ascertained and removed, the consequence will be exhaustion of the female from fruitless efforts to overcome the physical obstruc- tion, and, perhaps, the sacrifice of the foetus from the effects of long continued pressure. The indication in such a contingency would be without delay to introduce the hand and right the feet, by bringing them in proper line with the strait. In the event of some complication, such as hemorrhage or convulsions, artificial THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 551 delivery must be accomplished remembering to introduce the hand, which corresponds with the heels (Fig. 11) of the child. Allow me here to make a suggestion not to be forgot- ten, and it is this: whenever the toes are found to corres- pond with one of the ante- rior and lateral portions of the pelvis, as soon as the hips are passing through the pel- vis, care should be exercised to rotate the foetus in its long axis, so as to bring the pos- terior plane of the child's body in apposition Avith one or other of the acetabula; if, for instance, the toes are toward the left cotyloid ca- vity, the back of the foetus should be brought to the right lateral point of the pelvis; if to the right coty- loid cavity, to the left lateral point. The object of this movement is to reduce the posterior to the anterior po- sition, and thus fiicilitate the delivery of the head. The same rule also applies in breech presentations, when the sacrum is at either of the sacro-iliac junctions. Presentation of the Knees. —This form of presentation is extremely rare, and Avhen it does occur, the general position of the foetus is the same as in presentation of the feet. The indications are also identical as in footling cases; if there be malposi- tion, it must be corrected ; and if the labor suffer from complication, delivery is to be accomplished. For this Fig. 77 Fig. 78. 552 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. purpose, the hand should be introduced which corresponds by its palmar surface with the anterior surfaces of the child (Fig. 78), and the knees being brought down, the same principles are to guide you as in a foot presentation. It may, hoAvever, be that there will be unusual difficulty in extricating the knees Avith the hand; in this case, the fillet may be advantageously employed, which, being placed in the ham of the leg which is posterior, doAvmvard and backward tractions are to be made until the knees are liberated. If these latter be situated so high up as to render the application of the fillet impracticable, then resort must be had to the blunt hook, which, being carefully inserted into the ham of the posterior limb, will enable you by proper extractive force to bring down the knees. Pelvic Presentations with Inertia of the Uterus.—I have called your attention to the management of pelvic presentations, under certain complications of labor ; and it noAv remains for me to speak of them in connection Avith inertia of the uterus. You Avill occa- sionally meet Avith cases in practice in Avhich, under breech pre- sentations—and the same thing may occur Avhen the vertex or any of the other extremities of the ovoid present—the uterus, after vigorous effort, ceases for sometime to contract. This cessation of effort on the part of the organ is very apt to be regarded as the uniform result of inertia, and hence, Avith this abstract vieAV, recourse is too frequently had to certain special remedies, which are knoAvn to excite uterine action. The term inertia is, I think, oftentimes misunderstood, and this very circumstance leads to bad, if not dangerous practice. The question is worthy of a moment's exami- nation, for it involves an important principle in the lying-in room. In order that you may comprehend what I mean, I shall regard inertia of the Avomb in child-birth as due to one of tAvo conditions: either to constitutional or local influence. Examples of the former you have in women who have suffered from antecedent disease, or from exhausting drains; inertia may also be traced to a naturally delicate organization; in certain susceptible constitutions, mental emotions will occasion it. Again : excessive plethora may be ranked among its causes. If this view of the subject be correct, it is very evident that one of the fundamental prerequisites for judicious treat- ment will be to distinguish the particular constitutional circumstance to Avhich the inaction of the organ is to be referred. In the case of inertia from previous disease, or any exhausting influences, the remedy will consist in the administration of stimulants together with generous and renovating diet; if, on the contrary, it be due to mental influence, resort must be had to those agents best calculated to calm the mind, and infuse it with the invigorating auxiliaries of hope and confidence. If the patient labor under plethora, then the abstraction of blood is broadly indicated—the quantity to depend upon the surrounding circumstances of the case. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 553 Among the local causes of inertia may be enumerated thefolIoAv- ing : increase in the volume of the uterus from an excessive quantity of liquor amnii, Avhich, by temporarily paralysing the muscular fibre of the organ, induces a state of more or less complete inacti- vity ; unavailing efforts of the uterus to rupture the membranous sac, occasioning exhaustion of its fibre ; unyielding condition of the cervix in consequence of an abnormal induration of the part; departure of the uterus from its long axis, so as to render abortive any effort to expel the contents, thus, as it were, tiring out the organ ; inherent debility of the uterine muscular fibre dependent upon want of proper nervous influence. You must perceive, gentlemen, how manifestly essential it is to examine critically into the existence of these various causes capable of producing inertia in order that the appropriate remedy may be employed. If, for example, you should be satisfied that the inactive condition of the organ is traceable to excessive distension from an unusual quantity of amniotic fluid, the indication will be at once to rupture the membranes, and, by the escape of the liquor amnii, liberate the uterus from the paralysis to aa hich it has been subjected by the excessive distending force. The same course, also, must be pursued when, in consequence of the prolonged resistance of the membranes, nature is unable to rupture them. If the source of the trouble be found to consist in an unyielding, indurated condition of the cervix, benefit may be derived from the application of the belladonna ointment; if this fail to afford the necessary relief? I should not, under the circumstances, hesitate to incise the cervix; and, in having recourse to this expedient, I would advise you to make several small incisions on the anterior and posterior lips. Suppose, however, that neither of the above conditions of the organ be present, and you should have ascertained that the inertia is due to malposition of the uterus, constituting a Avant of parallelism between its long axis and that of its superior strait, thus preventing the uterine effort from concentrating on the centre of the pelvic canal, and consequently wearying the organ in useless struggles to expel its contents. It can scarcely be necessary to say to you that, in such case, the indication would be two-fold: either to restore the uterus to its parallelism, or proceed at once to terminate the labor by artificial delivery. When the inertia can be traced to inherent debility of the uterus consequent upon a Avant of nervous power, then you will find an efficient remedy in ergot. If there be nothing to contra-indicate its administration, it may be given in infusion, powder, or tincture. For this special purpose, I prefer it in the form of infusion—say, 3 ij. of the poAvder in 5 iv. of boiling water; let it infuse for twenty minutes, a tablespoonful to be taken at an interval of ten 554 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. minutes, until action of the uterus is produced. If the ergot be of proper quality, it AAill rarely happen that it will not have the desired effect after a few doses are administered. In this latter character of inertia, I have found repeated drinks of ice water, taken in small quantity, to be of signal service in promoting uterine contraction; warm tea or gruel will occasionally have the same effect. LECTURE XXXVII. Manual Delivery continued—Trunk or Transverse Presentations, including the Abdomen, Chest, Back, and Sides of the Fcetus—Presentation of the Abdomen; its Diagnosis and Treatment—Presentation of the Chest, Back, and Sides; how Managed—Shoulder Presentation with or without Protrusion of the Arm—Treat- ment of—Management of these Cases by the Ancients, barbarous and destructive to the Child, because founded upon Ignorance of the Mechanism of Labor—Their Management, Philosophic and Conservative in our Times—Spontaneous Evolu- tion—Meaning of the Term—Divided into Cephalic and Pelvic—Comparative Rarity of Spontaneous Evolution—Statistics by Dr. Riecke—Statistics of Dublin Lying-in Hospital—Fearful Fatality to the Child in Spontaneous Evolution—Dr. Denman's Exposition of the Manner in which the Evolution is performed, shown to be Erroneous by Dr. Douglass, of Dublin—Spontaneous Evolution not to be relied upon when Artificial Delivery is indicated. Gentlemen—Our third division of manual labor embraces trunk or transverse presentations together Avith those of the arm and shoulder.* It is quite obvious that when the trunk, shoulder, or arm presents, it will be physically impossible for the child to pass, except through spontaneous evolution, for the reason of the dispro- portion which must necessarily exist between it and the maternal organs. Therefore, the alternative in this form of presentation will be to change the position of the child by version. I shall first speak of trunk presentations, and in doing so avoid the numerous subdivisions of authors, and present the subject to you under the folloAving heads: 1. Presentation of the abdomen; 2. Presentation of the chest; 3. Presentation of the back; 4. Presentation of the 6ides of the foetus, including the shoulder and hips. It is proper here to remark, that I shall recognise only two positions for each of the presentations of the trunk, and for the substantial reason that they practically embrace the various divi- sions of authors, inasmuch as the rules for their termination are identical.f Presentation of the Abdomen.—In this presentation, which is extremely rare, the child is in a state, as it were, of extension, and consequently the risk it incurs is much greater than in either of the * Indeed, some clever writers comprehend transverse presentations under those of one or other shoulder, believing that the abdomen, back, and sides of the fcetua are, when found at the superior strait, simply varieties of the shoulder presentation. | This is the classification suggested by Halmagrand, and others, and I adopt it because I think it not only rational, but eminently practical in its results. 556 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. other trunk presentations. When the abdomen is at the superior strait, the fact -will be ascertained by the presence of the umbilical cord, which sometimes Avill have descended into the vagina, and even protruded beyond the external parts ; the child lies so com- pletely across the pelvis that its anterior surface is in relation with the mouth of the uterus, Avhile the dorsal region looks toward the fundus of the organ. Whether the head be at the left or right side of the pelvis—or, in other words, in order to recognise the particu- lar position of the foetus, the accoucheur will readily discover in directing his finger from right to left, with Avhich side of the pelvis correspond the borders of the false ribs, the crests of the ilia, and the organs of generation. First Position.—Here the head is in relation Avith the left iliac fossa, while the feet regard the opposite point of the strait. In this position, the left hand, pro- perly prepared, should be introduced into the uterus (Fig. 79); it should then gently pass to the left side of the child, gliding along the entire posterior surface of the body until it reaches the feet, which, being seized, are to be brought down, and converted into the second position of the feet. The delivery to be terminated as if it were originally a footling case. Second Position.—This position is precisely the reverse of the preceding, the head corresponding with the right, and the feet with the left iliac fossa; in this case the right hand should be selected, and the delivery accomplished as in the former position ; the feet, however, in this instance will be converted into the first position. It may happen that, on introducing the hand, only one foot can be seized. Under these circumstances, let the foot which has been brought down be attached by a fillet, arid retained in position, while the hand is again introduced for the purpose of seeking for the other extremity which, when grasped, is to be placed by the side of the foot held by the fillet. Presentation of the Thorax.—When the thorax presents, it will be readily recognised by the ribs and sternum, as, in the presenta- tion of the abdomen, the anterior surface of the child's body is THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 557 downward, and the dorsal plane is upward. Here the head is much nearer the superior strait than the feet, rendering it more difficult to deliver by the feet than in an abdominal presentation; for this reason, it has been recommended to bring the head instead of the feet to the strait, and then confiding the termination of the labor to the natural resources, unless there be some urgent indica- tion for the immediate extraction of the child. The objection to the practice of cephalic version in this case is tAvo-fold: 1. It is very difficult to place the head of the child in proper position at the superior strait, without inflicting upon it more or less injury, and incurring at the same time the hazard of rupturing the uterus ; 2. If the head should be brought to the strait, and not placed in cor- respondence with the pelvis, the necessity will then arise of having recourse to podalic version. For these reasons, therefore, I should advise you to proceed at once, in case of thorax presentations, to seek for the feet. First Position.—The head is turned toward the left, and the feet toward the right iliac fossa. The left hand is to be introduced in the same manner as indicated in the first position of the abdo- men ; and when the feet are grasped, they are to be brought to the strait, and the labor is terminated as in the first position of the feet. Second Position.—The head to the right, and the feet regarding the left iliac fossa. The right hand is introduced, the feet grasped, • and the delivery accomplished as in the first position of the feet. Presentation of the Back.—When the back presents, the child is not subjected to the same degree of danger as in a presentation of the abdomen, for the reason that, instead of being extended, it is flexed on itself. There is no difficulty, with a due degree of attention, in recognising a back presentation ; the eATidences are : a broad, and more or less elastic tumor, the borders of the false ribs, together Avith the tAvo scapulas. These various points will also enable you to ascertain the particular position. First Position.—The head is in correspondence with the left, and the feet with the right iliac fossa. The left hand is to be introduced in a state of supination, and the foetus being gently grasped, its position is slightly changed, so that the back is brought toward the symphysis pubis; the hand then pursues the anterior plane of the body, and after successively passing over the abdomen and thighs, reaches the knees and feet, Avhich, being brought to the strait, are converted into the second position of the feet, and the labor is then terminated, as already indicated. Second Position.—Here, the situation of the child is reversed, the head being in relation Avith the right, and the feet with the left iliac fossa; the right hand being introduced, the same rules are to be observed as in the first position. Presentation of the Sides.—Under this head Avillbe embraced, aa 558 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. identical, the lateral surfaces and hips of the child, the recognition of the latter at the superior strait constituting the diagnosis of the presentation. The presence of one or other hip will be revealed by a small rounded tumor, the sacrum, crest of the ilium, and the organs of generation. First Position of the Right Hip.—In this position the head regards the left, while the feet are to the right of the pelvis ; the dorsal surface of the child is in relation with the symphysis pubis, and the anterior plane with the promontory of the sacrum. The left hand is introduced, and, after elevating the foetus, the feet are reached by pursuing the anterior surface of the child; they are then brought to the strait, and the delivery terminated. Second Position of the Right Hip.—The head to the right, the feet to the left of the pelvis; the anterior plane is in front, the posterior behind. The right hand is introduced, and manipulation the same as in the former case. First Position of the Left Hip.—The head toward the left iliac fossa, the feet to the right. With the left hand the foetus is to be elevated, and after pursuing the anterior surface of the body, which is in front, the feet are grasped and brought to the strait; the pre- sentation is reduced to the second position of the feet. Second Position of the Left Hip.—The head to the right, the feet to the left. The right hand is to be introduced; the same rules observed as in the previous instance, except that the feet are reduced to the first position. Presentation of the Shoulder.—In calling attention to shoulder presentations, it will be proper to divide them into two classes: 1. Where simply the shoulder presents; 2. Where, together with the shoulder, the arm and hand protrude. As we proceed, it will be seen that this is a very important division, and has involved con- flicting opinions in reference to the special practice to be adopted in these cases. It is a point of much moment to remember that always, in shoulder presentations, it is essential that an accurate diagnosis be made early; for, generally speaking, precisely in pro- portion to the time which has elapsed from the escape of the liquor amnii to the determination of the diagnosis, will be the difficulty of operating, and also the danger to the child. Some care will be needed in distinguishing the shoulder, for it may be confounded with the elboAv, the breech, hips, or knee. The true distinction, the one which makes it certain that it is a shoulder presentation, consists in recognising with the finger the scapula, clavicle, and the upper ribs, which may be done with a proper degree of caution. First Position of the Right Shoulder.—The head is to the left, and the feet to the right side of the pelvis; the back of the child is turned slightly upward toward the pubes, while its anterior plane has a posterior aspect. The left hand being introduced, the shoul- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 559 der is gently raised, and the feet are then sought for by carrying the hand along the anterior surface of the child's body ; they are then brought to the strait of the pelvis, being converted into the second position of the feet. Second Position of the Right Shoulder.—The head to the right, the feet to the left; the back of the child is posterior, and the ante- rior plane is directed forward and upward. With the right hand, the accoucheur elevates the shoulder; and seizing the feet, in tra- versing the anterior surface of the body, brings them to the strait converting them into the first position. First Position of the Left Shoulder.—The head to the left, the feet to the right; in other respects, the position of the child is the same as in the preceding example. The left hand is introduced, and the feet brought to the strait, converting them into the second position. Second Position of the Left Shoulder.—The head to the right, the feet to the left; the posterior plane of the child above and a little in front, the anterior plane below and slightly backward. The left hand is carried up to the shoulder and trunk, on Avhich a partial movement of rotation is effected in order to place the anterior plane below; the feet are then brought to the pelvis, being converted into the first position. Presentation of the Shoulder with Protrusipn of the Arm.—The treatment of this compound presentation by the accoucheurs of the present day forms not only a striking contrast, but exhibits in a most favorable manner the progress of obstetric science as compared Avith the practice inculcated by our predecessors. In this presen- tation, delivery was deemed impossible with safety to the child, and hence the most extraordinary rules were instituted for the manage- ment of these cases. Indeed, Avhenever the arm protruded, in shoulder presentations, the accoucheur in former times regarded it as one of the most formidable complications of the lying-in room; but one thought occupied his mind—the destruction of the child as the necessary and only means of saving the life of the mother. With this view, numerous expedients were resorted to ; one incul- cated the practice of twisting off the arm, and terminating the deli- very by bringing down the feet; another suggested amputation; a . third recommended to diminish the volume of the arm by means of scarifications and incisions. Deventer, with the hope of causing the foetus to withdraw the arm into the uterus, directed the hand to be pinched or pricked with a pin ; for the same purpose ice was employed. Need I tell you, also, that, ignorant of the principles on AA'hich rests the mechanism of labor, the absurd and reckless prac- tice was maintained by some of making tractions on the protruded arm, under the conviction that the body of the child could thus be delivered! 560 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. But all these were the suggestions of men who had not suffi- ciently studied in the school of nature; they neither comprehended her resources when undisturbed by contravening influences, nor did they appreciate the ability of science to aid her in the moment of want. Xow, hoAvever, through the advances which obstetric medi- cine has made, these murderous alternatives have been abandoned, and a more conservative and rational practice substituted. The protrusion of the arm, in a shoulder presentation, is no longer regarded as necessarily fatal to the child ; and, under ordinary cir- cumstances, these cases, Avith a proper degree of care, can be managed with safety to both mother and foetus. There are, Iioav- ever, it is Avell to remember, certain conditions connected Avith this form of presentation, AArhich will very much enhance the danger to the child, and not unfrequently involve the mother in more or less peril. If, for example, much time have elapsed since the escape of the liquor amnii, causing rigidity of the os uteri, or undue mani- pulations have been practised inducing an inflamed state of the maternal organs, the difficulty of terminating the delivery and the danger -will be greatly increased.* First Position of the Right Shoulder with Protrusion of the Arm.—The fact that the arm protrudes in a shoulder presentation, need occasion no undue alarm to the practitioner, for the circum- stance will neither necessarily involve the safety of the child, nor embarrass the operation essential to its delivery. Indeed, in these cases the termination of the labor by Aersion is, all things being equal, accomplished Avith more facility than in head presentations, for the reason that the feet, because of their not being situated so high up, are more readily seized, and there is also, as a general principle, more room for the introduction of the hand. In the first position of the right shoulder, the pelvis of the foetus will be toAvard the right and more or less toward the upper portion of the uterus, Avhile the head regards the left iliac fossa. The first thing to be done is to attach a fillet (which consists of a ribbon or piece of linen one inch in width, and twelve inches in length) around the wrist of the protruded arm. The fillet should at first be entrusted to an assistant, but after the feet are brought down to the strait, the accoucheur should take charge of it, the object of the fillet being not to prevent the ascent of the arm into the uterus (which Avill take place as the feet are brought down) but merely to keep the arm elongated on the body during the manipulation. As in the * The long-continued pressure of the contracting womb will very naturally occa- sion a livid hue of the arm, together with more or less tumefaction, giving rise ta the belief that the child is dead, thus inducing the practitioner to a resort to instru- ments to dissect the fcetus for the purpose of extracting it. This will oftentimes prove a fatal error, for these physical changes may occur without necessarily com- promising the life of the child. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 561 Fig. 80. first position of the right shoulder the feet regard more or less the right portion of the uterus, the left hand should be in- troduced, and carried as far as the axilla; it should then be directed along the ante- rior surfiice of the child's body, until the feet are reached; these are to be brought doAvn to the strait, and the labor terminated as in the second position of the feet. Second Position of the Right Shoulder with Protru- sion of the Arm.—In this case, the fillet is to be at- tached as in the first posi- tion ; the right hand is then to be introduced (Fig. 80), and directed along the ante- rior surface of* the child Avith a vieAV of reaching the feet; these are brought down to the strait (Fig. 81), and the delivery is terminated as in the first po- sition of the feet. First Position of the Left Shoulder with Protrusion of the Arm.—Here, the left hand is to be introduced, and the same rules followed as in the second position of the right shoulder, except that the feet are reduced to the second instead of the first position. Second Position of the Left Shoulder with Protru- sion of the Arm.—The right hand to be introduced, and the same principle pursued as in the first position of the right shoulder, the feet being re- duced to the first position. Sjio/ztaneous Evolution.—Having now spoken of the general principles which are to guide the practitioner in cases of shoulder 86 Fig. «L 562 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. presentations, either with or without protrusion of the arm, it ia proper that I should allude to two other questions in connexion with this subject, viz. evisceration in cases in which version is found impracticable, and spontaneous evolution. Evisceration of the foetus will engage attention in a future lecture, when treating of instrumental delivery; on the present occasion I propose to make a few observations in reference to the interesting point of spontaneous evolution. This term implies the ability possessed by nature of causing a voluntary change in the position of the foetus in utero, so that a part of the foetal body originally more or less remote from the superior strait may descend into the pelvic excavation, and be delivered without displacing that which first presented. Spon- taneous evolution is divided into cephalic and pelvic ; in the former, the head descends to the superior strait; in the latter, the pelvis. I must confess I have never, in the course of my observation, met with an instance of what may be properly termed spontaneous evo lution; although I have on more than one occasion heard medical gentlemen speak of it as having repeatedly fallen under their notice. I am inclined to think, however, that Avhile they intended no vio- lence to truth, their opinion was founded on a misapprehension of the real position of the foetus. There can be no doubt that this spontaneous change will sometimes take place ; for practitioners of conscience and high moral worth have testified to its having occurred in their practice. There is, however, a very general con- currence of opinion on one point, viz. its extreme rarity. It is mentioned by Dr. Riecke that it was observed only 10 times in 220,000 labors at Wurtemberg, while Drs. Johnston and Sinclair report its occurrence tAvice in 13,748 deliveries in the Dublin Lying- in Hospital. In the Vienna Hospital, under Dr. Spaeth, there was but one instance of spontaneous pelvic version in 12,523 cases of labor. Its fatality to the child is most fearful; in thirty cases men- tioned by Denman, but one child survived. Some of the older writers were unquestionably impressed with the idea of the great mobility of the foetus in utero, and it was upon this conviction, no doubt, that was based the direction of causing the pregnant female frequently to change her position, and, indeed, to be shaken for the purpose of overcoming a malpresentation, as directed by Hippocrates himself. But it is to Dr. Denman that we are indebted for the first full account, by the natural powers of the system, of what he denominated " spontaneous evolution.''* In the * Although it is conceded that Dr. Denman Avas the first author to direct special attention to the subject of "spontaneous evolution," yet the possibility of its occur- rence had been recognised previous to his time. Dr. Ramsbotham says Anthony Everard seems to have been thev first who described a case of " spontaneous evolu- tion." It happened in his own wife's third labor, and she had gone to her full term. The book in which the case is mentioned, a very scarce 12mo., is entitled Kovus et THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 563 course of his extended practical observation, he had noticed the spontaneous change in the position of the foetus under a shoulder presentation, but his explanation of the phenomenon has been shown by Dr. Douglass of Dublin to be erroneous. Denman maintained that, during the process of labor, in an interval of uterine repose, the shoulder and arm receded within the cavity of the organ, and were replaced by the breech of the child. Douglass,* on the con- trary, demonstrated the fallacy of Denman's opinion by proving that the foetus, without any recession of the superior extremity, descends into the pelvis doubled on itself, and is then expelled. He showed that the strong contractions of the uterus at first press the shoulder and chest into the pelvis, AA'hen the acromion process is. felt under the symphysis pubis; as the loins and nates descend into the pelvic excavation, the apex of the shoulder passes upward in the direction of the mons veneris, thus yielding more space for the passage of the breech into the cavity of the sacrum ; in this way, after sub- jecting the perineum to extraordinary distension, the nates together with the shoulder are expelled. With this explanation, Avhich is now generally admitted, it is evident that the shoulder becomes, as it Avere, fixed under the arch of the pubes, this latter being made a fulcrum on which the foetus revolves. In order that spontaneous evolution may be accomplished, it is essential that either the foetus be relatively small, or the pelvis more than ordinarily capacious; and it is an interesting fact to note that, in several instances in which this movement has been cited by authors, the foetus had not reached its full time. I cannot divest my mind of the conviction that a too full reliance on the ability of nature to effect spontaneous e\rolution has often- times been folloAved by bad results in the lying-in chamber. This reliance, in cases of shoulder presentation, causes the accoucheur to allow the proper time for terminating the delivery to pass, thus subjecting the mother to more or less hazard, and the life of the child to almost certain sacrifice. While, therefore, you are to con- cede the occasional occurrence of the phenomenon, yet my advice to you is—never to depend upon it as an alternative in any case in which it is possible to terminate the labor by the introduction of the hand, but to proceed without delay to bring down the feet as already indicated, the instant the fit opportunity will justify your interference. My reasons for this achice are as follows: 1. Spon- taneous evolution is among the extremely rare occurrences of the parturient room. 2. The child is almost always sacrificed. 3. The risk of rupture of the uterus from the necessarily protracted and Genuinus Eominis Brutique Animalis Exortus. It was printed at Middleburgh in 1661. * An Explanation of the Process of the Spontaneous Evolution of the Fxtus, etc By John C. Douglass, M.D., etc., Dublin, 1811. 564 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. increased contractions of the organ. 4. The great difficulty and consequent danger of terminating the delivery after the shoulder has been pressed low down into the pelvic cavity, in the event of nature being unable to accomplish the movement. It may, however, happen that you will not be called to the case until it is too late to attempt the version of the child, and that, under these circumstances, from the length of time wdiich has elapsed, the shoulder is so far forced into the pelvis as to render the effort to bring down the feet utterly impracticable. What, in such a contingency, is to be done f Here you will be compelled to have recourse to evisceration, or to the decapitation of the child; of the manner in which these operations are to be performed we shall speak under the head of embryotomy* * The following is an interesting example of podalic version, connected with mal- position of the uterus: it should more properly have been introduced when discuss- ing the displacements of the gravid womb: Some years since I was requested by Dr. Elwes, of the United States Army, to visit Mrs. B. at Fort Hamilton, Long Island, distant twelve miles from the city. I was informed by Drs. Carpenter and Elwes, the former of whom saw her at the commencement of her sickness, that she had been in labor, not, however, accompa- nied by very strong pain, for eight days, and that the liqdor amnii had been passing from her, in small quantities, for the four days previous to my visiting her. Dr. Carpenter, who was the family physician, and who had attended her in two former accouchements, stated that he had been unable to reach the mouth of the womb, and that, from the commencement of her labor up to the period at which I arrived, he had been completely foiled in every attempt to effect this object. Dr. Elwes had experienced the same difficulty. At the request of these gentlemen, I proceeded to make an examination. On introducing my finger into the vagina, I discovered a large resisting tumor, which I recognised to be the head of the foetus, the womb intervening between it and the finger. In examining very cautiously the surface of the tumor, I was unable to discover the os tincaj. It occurred to me that this was a case of retroversion of the neck of the womb, and in gently sliding my finger under the foetal head, and carrying it towards the posterior part of the pelvis, I felt the os tincae, which was turned so entirely backward as to regard the concavity of the sacrum. It was now quite apparent why the labor had been so protracted, and t was certain that while the uterus retained its present position, delivery would be out of the question. In consequence of the malposition of the womb, the whole force of the uterine contraction was directed in such way as to render it physically impos- sible (without laceration of this viscus) for the child to pass through the pelvis. The position of the uterus, under ordinary circumstances, is parallel, or nearly so, to the axis of the superior strait, so that the whole force of the contractile effort being directed from above downward, it is evident, should there be no impediment to a natural delivery, that the child must be propelled through the maternal pelvis. In this case, however, in consequence of the malposition of the womb, the force of the contractions was centred against the posterior wall of the cervix uteri, and the point of resistance was found to be the internal surface of the sacrum. This, then, accounts at once for the difficulty of the labor, and shows most conclusively that it could not have been otherwise than protracted. As soon as I had discovered the position of the uterus, and thus assured myself of the entire cause of the delay, I withdrew my hand, and suggested to Drs. Carpenter and Elwes, in which suggestion they both coincided, that, in my opinion, this case presented two indications, viz.: LECTURE XXXVIII. Instrumental Delivery—Instruments divided into Blunt and Cutting—Blunt Instru- ments—What are they ?—The Fillet and its Uses—The Blunt Hook and Yectis; their Uses— The Forceps—The Abuse of Instruments in Midwifery—Their too General and Indiscriminate Employment—The Object of the Forceps—The For- ceps an Instrument for both Mother and Child—Abuse of the Forceps—Case in Illustration—The Forceps a Precious Resource when employed with Judgment— Statistics of Forceps Delivery—What is the true Power of the Forceps ?—Is it a Tractor or Compressor?—The Forceps a Substitute for, or an Aid to, Uterine Effort—To what Part of the Child should the Instrument be applied?—The Advantages and Evils of the Forceps—How is the Head of the Child to be Grasped by the Instrument ?—Modification of the Forceps—Its Cranial and Pelvic Curves—The Author's Forceps—Indications for the Use of the Forceps—Time of Employing the Instrument—The Opinions of Denman, Merriman, and others— Objections to—The Justification of Forceps Delivery, a Question of Evidence to be Determined by the sound Judgment of the Accoucheur. Gentlemen—We shall now consider the second branch of preter- natural labor, viz. Instrumental Delivery—and here, permit melo say, we enter upon a most important discussion. The instruments recognised in midwifery are embraced under two classes—blunt and cutting instruments. The former are applied to the child, and do not necessarily involve its life; the latter are used either on the 1st. To rectify, as far as practicable, the malposition of the cervix uteri. 2d. To turn and deliver by the feet. I should have remarked that the mouth of the womb was quite soft and dilatable. It will, I apprehend, be unnecessary for me to enter into any argument to show the paramount necessity of the first indication; and if it be recollected that the patient was in a state of dangerous exhaustion, the propriety of the second will be evident But why, it may be •asked, not apply the forceps? My answer to this question shall be brief. The head of the foetus was still at the superior strait, and, without refer- ence to the opinions of others on this subject, I can aver for myself, that, where immediate delivery is indicated, I should always prefer (provided the parts were in a proper condition) turning by the feet, to the delay which must necessarily attend delivery by the forceps before the head has begun to descend into the excavation of the pelvis. The operation being agreed upon, Mrs. B. was placed on her back, with her breech on the edge of the bed, her legs flexed on her thighs, and her feet resting on the hands of Drs. C. and E., who were seated one on each side of me. I intro- duced my right hand, and, with the other applied to the abdomen, I reached the os tinea?; I then succeeded in fixing my index finger within the circle of the anterior lip, which was cautiously brought toward the centre of the pelvic excavation, at the same time gently pushing back the fundus with the hand applied to the abdo- men. In this way I succeeded in overcoming the malposition of the uterus; and in fulfilling the second indication I proceeded as Mows: Before determining on which 566 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mother or child. When employed on the mother, her safety will, as a consequence, be placed in more or less peril; and I need scarcely remark that the destruction of the child is the inevitable result of their use upon it. Blunt Instruments.—These consist of—1. The Fillet; 2. The Blunt Hook; 3. The Lever or Vectis; 4. The Forceps. 1. The Fillet.—This is simply a piece of ribbon or linen, one inch in width and twelve in length. It may be applied under the following circumstances: (a) In a breech presentation Avhere, in con- sequence either of the great size of the nates, or the undue slug- gishness of the labor, it becomes necessary to aid nature ; it should be passed up with the finger to the bend of one of the thighs, so as to encircle the groin, the two ends of the fillet are then seized by the accoucheur, and, with well-directed traction, it becomes a ready means of bringing down the breech, (b) In cases in which the trunk is expelled, and there is unusual delay in the descent of the shoulders, the fillet being placed under the axilla Avill be of essen- tial use. (c) The knees may have descended into the pelvic exca- vation, and, for want of proper uterine effort, remain there, thus protracting unnecessarily the delivery; here again the fillet carried to the bend of the knee becomes an important aid. (d) In version, Avhen only one foot has been brought doAvn, the fillet may be attached around the ankle, while the accoucheur seeks for the other foot, (e) In shoulder presentations with protrusion of the arm, the hand to employ in order to effect the version, I first acquainted myself with the pre- cise situation of the fcetal head, which I found to be placed in the second position of the vertex, the posterior fontanelle corresponding to the right acetabulum, and the anterior to the left sacro-iliac symphysis; consequently I introduced the right hand for the purpose of performing the version, in order that the natural curve might be given to the child's body. The hand was carried up in the usual manner until the feet were reached; these were gently grasped and brought into the vagina. The patient, at this time, became alarmingly exhausted; she rallied under the influ- ence of a little brandy and water, and I proceeded to complete the delivery without delay. The child was alive and vigorous, and both parent and offspring recovered from their perilous position, and are, I believe, at this time in tne enjoyment of good health. The above case is interesting on two accounts. In the first place, that the child Bhould not have been sacrificed by the great length of time Mrs. B. was in labor; and, secondly, the possibility of mistaking the retroversion for an imperforate condi- tion of the os tincae. Cases are recorded in which the orifice of the womb was com- pletely obliterated in women in labor. Lauverjat's case, in this particular, is inte- resting: it is cited by Sabatier in his Medecine Operatoire. Lauverjat not being able to detect the mouth of the womb, during labor, in a woman pregnant for the first time, made an incision into the portion of the uterus corresponding with the orifice. M. Gautier, a Parisian surgeon, had a similar case. Instances of the same kind are likewise quoted by Hammond and others. And in another part of this work I will give the particulars of two cases, in which, in consequence of injuries inflicted on the os tincae, it became necessary for me, at the time of labor, to incise the orifice, which resulted favorably to both mother and child. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 567 fillet should be placed around the wrist, for reasons already explained Avhen treating of this form of presentation. 2. The Blunt Hook.—This instrument is employed for most of the purposes for which the fillet is used, viz. to bring down the breech or shoulders, and also to facilitate the delivery of the knees, when their stay in the pelvic cavity is protracted. The mode of using the instrument is as follows: The fingers of one hand being carefully carried to the particular part of the foetus on which the blunt hook is to be applied, the instrument, previously warmed and oiled, is made gently to glide along the hand, which acts as a direc- Fio. 82. tor, and when the point is reached, either the bend of the thigh (Fig. 82), the knee, or axilla, as the case may be, the hooked extre- mity of the instrument is to be cautiously applied to either of these 568 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. parts, and then downward traction exercised. In this way, the foetus will be brought doAvn Avithout injury to it or the parent, and the delivery promptly terminated. As soon as the part reaches the vulva, the instrument should be withdrawn, and the delivery, if necessary, terminated by the hand. 3. The Lever or Vectis.—This instrument has been variously estimated by different writers on midwifery; some claiming for it merits of a high order, AA'hile others repudiate its use altogether. It has been urged that the lever can oftentimes become a substitute for the forceps, inasmuch as it may be made an instrument of trac- tion. It does seem to me, however, that under no circumstances should it be resorted to as a tractor; the only purpose to Avhich it can be legitimately applied is to correct peculiar malpositions of the head. For example, when the occiput is extended backward, the lever will prove, in dexterous hands,, an important auxiliary in changing the position to one of the vertex. Or, in case the head should fail to rotate in the pelvic cavity, and the hand be inade- quate to accomplish the movement, the vectis may be employed with good effect. Contrast between the Forceps and Lever.—I do not deem it necessary to institute any special contrast between the comparative advantages of the forceps and lever, as some authors have done; for, contrary to the opinion maintained by them, among whom may be mentioned Bland, Lowder, Dennison, and others, I hold that no comparison can be justly made, for the reason that, in their opera- tion, they are entirely different instruments—the one being a trac- tor, the other a corrector of malpositions. Whatever may be said in reference to the frequent necessity for the employment of the lever, I will merely state to you that, in the Dublin Lying-in Hos- pital, during the mastership of Dr. Collins, in sixteen thousand four hundred and fourteen deliveries, the lever was used but three times; and in the same institution, during the mastership of Dr. Shekleton, as reported by Drs. Sinclair and Johnston, in thirteen thousand seven hundred and forty-eight deliveries, the lever was resorted to but once! How strangely do these statistics compare with what we are so much in the habit of hearing, in these latter days, of what occurs in the private practice of certain medical gentlemen, who speak of their almost daily use of the vectis, forceps, or crotchet, precisely as if a man's skill in the lying-in room is to be measured by the fre- quency with which he resorts to instruments! I believe in the converse of this proposition; to my mind, the truly skilful accoucheur rarely (comparatively, at least) employs instruments, for the obvious reason, that, in the first place, he is thoroughly imbued with a know- ledge of the laws by which nature is regulated in the parturient effort; and, secondly, he is cognizant that, Avhen not interfered THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 569 with by officious meddling, this same nature is generally adequate to the proper accomplishment of her Avork. 4. The Forceps.—I shall not occupy your time with the early history of this instrument, nor with the various modifications it has undergone from its first introduction to the attention of the profes- sion. Suffice it to say that the obstetric arsenal, so far as the num- ber and kind of forceps are concerned, is not only a.vast armory, but has really become an institution in itself; and, indeed, it may be asked, Avith some degree of propriety, whether the interests of humanity would not have been more wisely served if some of the time employed in the construction and modification of this instru- ment had been given to the proper consideration of the more important question— Under what circumstances and in what man- ner is the Forceps to be Employed ? If this question, I repeat, had received more mature deliberation, we should have been spared the numerous appalling examples of injury and death consequent upon the unbounded love, which some practitioners have for instrumental delivery. It is time that plain language should be spoken on this Bubject; the spirit of conservative midwifery seems to have been lost in sleep; the ordinances of nature have been disregarded, and the accoucheur, with instrument in hand, rampant in his desire for opportunity, rushes with good heart and unmeasured confidence to what he deems the scene of conquest; but too often, alas! it proves a scene of harrowing agony to the unhappy pa- tient. One would almost think that nature had become emasculated of her power, and that what were once considered her OAvn admirable laws had been so changed, and she so utterly deprived of resources, as to render parturition no longer an act of hers—to be accom- plished in her own inimitable way, and by her OAvn consummate ordinances—but an act to be carried out according to the peculiar caprices of the accoucheur. Nature, gentlemen, is ahvays the same so far as her own fundamental laws give her an identity; she is hoav in this particular Avhat she was at the commencement of the world, whether as represented in the human family, in the animated tribes, or in the vegetable kingdom. I claim for her perfection of design and unequalled skill in the display of her own efforts, Avhen not contravened either by morbid influences, or the officiousness of man. It must, however, be conceded that she sometimes needs assistance, but that assistance, in order that it may be serviceable, should be both justifiable and opportune. Motives on which Forceps Delivery should be Based.—In the use of the forceps, I cannot too emphatically impress upon your recollection the necessity of keeping constantly iiiA'ieAV two cardinal principles: 1. A moral justification for its employment: 2. Such a use of it as shall secure, as far as may be, the maximum of good 570 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. viz. safety to both mother and child* With these maxims to guide him, the accoucheur, in the retrospect of his professional life, will find nothing for self-rebuke, but much for congratulation in the conviction that, in this particular, he has faithfully discharged .his duty to those Avho, in the hour of tribulation, looked to him for assistance. You, Avho have attended the obstetric clinic, where you enjoy such abundant opportunity of witnessing every variety of disease incident to Avomen and children, have on more than one occasion had arrayed before you instances of the fearful results arising from the unnecessary use of instruments; and with the hope of impressing you by example as well as by words, I shall take the liberty of refreshing your recollection with a brief abstract in reference to the melancholy case of a married woman, who was brought before you not a long time since, in whom there was com- plete occlusion of the meatus urinarius, with partial adhesion of the walls of the upper fourth of the vagina, together with a vesico- vaginal fistula,\ produced by forceps delivery. The following is the case, as reported in my work on the Diseases of Women and Children: \ Mrs. R., aged 22 years, married, complains of inability to pass her water in the natural Avay, and says it runs from her nearly all the time through the front passage. " How long, madam, have you been married ?" " Just tAventy-six months, sir." "'Were you a healthy woman before your marriage ?" " Yes, sir ; I never had a day's sickness, thank God!" " You have had a child, have you not?" "Yes, sir." "When was it born?" "Fifteen months ago, sir." " Hoav long were you in labor ?" " Three days, sir." " Was your labor severe ?" " No, sir, but it was lingering." " Had you any one to attend you ?" " Yes, sir, there Avere two doctors with me." " Was your child born alive ?" " Oh ! no, sir ; the * Prof Meigs says: " The forceps is the child's instrument." I think the eminent Professor is disposed, in this maxim, to curtail the advantages of the forceps in a manner not endorsed by the experience of the lying-in room. So far, therefore from circumscribing its benefits to the mere safety of the infant, I maintain that the forceps is an instrument for both mother and child, and its true benefits are fully realized only when, through opportune application, it enables the accoucheur to save the lives of both parent and 'offspring. \ The employment of the forceps may, without a due degree of care, give rise to vesico or urethro-vaginal fistulas, for the reason that sometimes great effort will be needed to cause the head to descend, being obstructed in its passage by the anterior wall of the pelvis; this effort necessarily falls more or less on the bladder and urethra, producing, if not fistulous openings, incontinence of urine from paralysis of the bladder, and other derangements. Still, it is well to recollect that these very difficulties may also arise from too long delay in a resort to the forceps, and may then be fairly chargeable to long-continued pressure on the parts, terminating in inflammation and ulceration. From these latter causes will sometimes arise a recto- vaginal fistula, more frequently, I think, than from the use of the instrument. X Page 346. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 571 poor little thing was all bruised, and its head was a good deal injured." "Why so, madam?" "The doctors did it, sir, with the instrument." " Then, you were delivered with instruments, were you ?" " Yes, sir, indeed I was, and a poor sufferer have I been ever since !" " No matter, my good woman, do not deplore the past; you have been cruelly wronged, but we will endeavor to do something for you ; at all events, we will make you more com- fortable." " Thank you, sir." " Before your delivery, had you any trouble with your water ?" " None in the world, sir." " How long after the birth of your child did you experience trouble in this way ?'' " Since the birth of my child, sir, my water has always troubled me. It runs from me, and 1 cannot help it!" "Did you call the attention of the doctors to thia circumstance ?" " No, sir, for they never came near me after I was delivered." " Then, madam, they did not do their duty." " Indeed, they did not, sir.'' " How long was it after the birth of your child that you left your bed ?" " I could not go about, sir, for nearly six months." " Have you had your courses since your confinement ?" " Only once, sir, about two months ago, and I thought I would have died from the forcing pain I had." " Did the usual quantity pass from you ?" " No, sir, very little, indeed." This case, gentlemen, exhibits another of the many instances of professional cruelty more or less frequently occurring in this popu- lous city; and it is, indeed, needful that something should be done to arrest the reckless temerity of men calling themselves physi- cians, Avho, if we are to judge them by their acts, place a very insignificant estimate on human life. But the melancholy feature of the whole business is, that these assaults on health and life are made under the protection of a diploma, and, therefore, are per- fectly Avithin the record ! No! a diploma, though it may serve the purposes of the holder, is insufficient to justify the moral wrong of the sufferings, the details of which have just been narrated. A diploma without knowledge is a curse to its possessor, and a fearful instrument of destruction to the community. With knowledge, too, must be conjoined a refined morality based upon that Christian principle—" Do unto others as you would wish others do unto you /" This poor woman, whose health was her only capital, whose daily bread was the product of her daily labor, has become involved, either through ignorance or unpardonable carelessness, in a compli- cation of maladies which, even if measurably relieved, -will cause her more or less distress during her entire existence. The first question, which naturally presents itself to the mind in viewing the serious afflictions of the patient, is this: What has produced this state of things, and could it by a proper exercise of judgment have been avoided ? She was delivered AA'ith instruments, and to their unskilful and unnecessary employment are to be referred all her 572 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. present difficulties. There is no evidence before us that the use of instruments Avas at all indicated. The patient observed that " her labor was not severe," it Avas " only lingering." She, then, has fallen a victim to that " hot haste," Avhich unfortunately too often prevails in the lying-in chamber, or to that undying fondness, which some men cherish for operative midAvifery. Let this case be a lesson to you; think of it in your hours of meditation, and may it prove a shield to those Avho confide their lives to your custody. In the eye of Heaven, murder loses nothing of its atrocity because concealed from the ken of human observation; so it is with the dark deeds of our profession. The diploma may afford a mantle, so far as earthly jurisdiction is concerned, but the time of reckoning will come with appalling retribution ! You are, however, gentlemen, not to misunderstand me; I con- demn only the abuse of the forceps, and desire to admonish you that Avhile in it you have, when properly employed, a means of accomplishing great good, yet, in reckless and unskilful hands, it is indeed an instrument of fearful destruction. On the one hand, it will enable you to save the lives of both mother and child, and rescue them from the dread consequences of embryotomy. On the other, it will oftentimes lead to the death of parent and offspring ; or if, peradventure, the former should survive, she will have entailed upon her troubles to which death itself is frequently preferable— such, for instance, as vesico-vaginal, urethro-vaginal, recto-vaginal fistulas, rupture of the uterus, and other lacerations of the soft parts, often the sad consequences in the practice of those gentle- men, who are in the habit of resorting to instrumental delivery without cause or justification. Prior to the introduction of the forceps in operative midwifery it was the usual practice, in all cases of difficult parturition in which the hand was unable to overcome the obstacle, to destroy the child and bring it aAvay piecemeal by means of hooks, etc. Therefore, while I most cordially admit that I regard the forceps, under proper employment, as one of the undoubted boons, which science has placed within the reach of the conscientious and skilful accoucheur, yet it would be an interesting inquiry—if the statistics could be fairly gathered—whether, in consequence of its reckless use, the good derived from the employment of this instrument has not been more than counterbalanced by the evil it has inflicted. It is a maxim of the assassin that " dead men tell no tales ;" is it not equally true that those practitioners, who destroy their patients by the rude and unjustifiable use of instruments, are very much dis- posed to alloAv their deeds of blood to accompany their victims to the grave, where, amid the silence of death, they may find shelter from the public gaze! Hence, the true difficulty of arriving at reliable statistics on this point. • THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 57? I trust I may be pardoned for the plain and emphatic manner in which I Avrite on this important question; but I feel that I have a sacred duty to discharge to you, and also to those, who, after you shall have left this University, will look to you for counsel and aid in the time of their anguish. But a short Avhile since, at the request of one of those truly good women, " a sister of mercy," I visited in a miserable hovel a poor creature, who had been attended in her confinement by a medical man, who found it necessary to call to his aid two of his professional friends. The woman had been in labor only six hours, when it was deemed necessary to resort to the forceps; she was delivered of a dead child with the right os parietale crushed, and the corresponding eye forced out of the socket! The unhappy mother had only been delivered four hours when I saw her; she was at that time vomiting, her face pale and haggard, with a pulse extremely rapid. I requested the physi- cians to be sent for, but they could not be found! On an examina- tion, I detected a rupture of the neck of the uterus,* and the poor creature was soon released from her sufferings, having expired just fourteen hours from the time her labor commenced !f What better * I may refer the reader to the prize essay on Rupture of the Womb, by Prof. James D. Trask, M.D., for some extremely interesting facts. His monograph is the most complete we have on the subject. His observations are based on over four hundred cases, which he has variously collected. The paper will be found in the American Journal of Medical Science for January and April, 1848. The following extract touching the results of treatment in this formidable complication will be read with interest: We formerly showed that the average duration of life, after rupture, with those delivered, was twenty-two hours; and that of the undelivered, but nine hours. By adding to these the new cases, we find that, of those delivered, fifty four per cent. survived beyond twenty-four hours; while of those dying undelivered, twenty seven per cent, survived beyond the same period. Relative success of different modes of Treatment when the Head and the whole or part of the Body has escaped into the Peritoneal Cavity. SUMMARY OF ALL THE CASES. Gastrotomy saved, 16, lost, 4, or 20 per cent. lost. Turning, Ac. " 23, " 50, or 68.5 Abandoned " 15, " 44, or 75 " " Relative success of different modes of Treatment when the Pelvis is Contracted. SUMMARY OF ALL THE CASES. Gastrotomy saved 6, lost 3, or 33 per cent. lost. Perforation, Ac. saved 15, " 30, or 65 " " Abandoned " 0, " 11, or 100 " " Adding together these two classes, we get, as the comparative results of the different modes of treatment;— Gastrotomy saved 22, lost 7, or 24 per cent. lost. Turning, perforation, &c. saved 38, " 80, or 68 " " Abandoned " 15, " 55, or 78 f This woman had previously borne two living children at full term; her parts were normal, and her mangled child presented the ordinary proportions; and yet, after a labor of six hours, the forceps was deemed the sheet-anchor of hope 1 574 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. comment, gentlemen, can I make on conduct like this, than simply cite it as an admonition when you shall have entered on the mission of practical duty, and become responsible not only for your oavh reputations, but for the lives of your patients, who may confide both in your honor and skill. I will not weary you with the narra- tion of kindred examples of cruelty, which I have Avitnessed—for the heart sickens, and the mind grows restive under the contempla- tion of such deeds of iniquity. A distinguished professional friend from the West, in speaking of the monomania, wrhich sometimes spreads among medical men in reference to certain peculiarities of practice, told me that some years since there prevailed in the valley of the Mississippi an almost uni- versal belief that cathartics constituted the great remedy for the cure of disease; in accordance with this general conviction, a doctor was in the habit of placing himself on the bank of the river, and as the people passed by, they were saluted with these words, " Hoav are your bowels to-day?" Indeed, I am not so confident that we have not a monomania of a different sort among us here; and it would not be strange if the gravid female passers-by should one of these days be greeted thus : " Safe delivery insured by instruments!" Statistics of Forceps Delivery—Frequency.—Dr. Churchill* gives the folioAving details: Among British practitioners, 594 forceps cases in 167,648 labors, or about 1 in 249. In France, 339 forceps cases in 47,475 labors, or about 1 in 140. In Germany, 7074 forceps cases in 755,593 labors, or about 1 in 106£. Taking the aggregate of these cases, the forceps was employed 8007 times in 850,713 cases, or about 1 in 106^. Mortality to the Mother.—As far as could be ascertained, in 812 forceps deliveries, among British practitioners, 38 mothers were lost, or 1 in 21 J. Among the French and Germans, in 4941 cases, 142 mothers were lost, or about 1 in 34. Mortality to the Child.—In Great Britain, in 694 cases, 142 children were lost, or about 1 in 5 ; and according to the statistics supplied by the Continent of Europe 858 children were lost in 5037 cases, or about 1 in 5%. The total result is that, in 5753 forceps cases, 180 mothers were lost, or about 1 in 32 ; and in 5731 cases, 98 children were born dead, or about 1 in 5; now, if we turn from the larger aggregates as furnished by Dr. Churchill, to other sources confined more to indi vidual practice, we shall have very different results. In the Edinburgh Maternity Hospital, there were 1475 women delivered under the superintendence of the Institution ; among these were 58 miscarriages or premature labors, being 1417 labors * Churchill's Midwifery, fourth London Edition, p. 344. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 575 at full term ; in these 1417 cases the forceps were applied 3 times or 1 in 472. Among the 1475 women delivered under the superin- tendence of the hospital (374 were delivered at the hospital, and 1101 at their own homes), there were 11 deaths, or 1 in 134.* In the Royal Maternity Charity of London, Eastern Division, under the supervision of Dr. Barnes,f in 2416 deliveries at the homes of the patients, the forceps was resorted to 6 times, or 1 in 401; deaths 7, or 1 in 345. In the same Institution, Western District, under the charge of Dr. J. Hall Davis, in 7371 deliveries at the houses of the patients, the forceps was applied 6 times, or 1 in 1220; deaths 16, or 1 in 456.3754; It is, I am sure, quite unnecessary to refer to additional statistics in proof of Avhat I am anxious to demonstrate, viz. that the records of private practice among medical men of judgment and skill exhibit very different results, both in the frequency and mortality of forceps delivery, from those presented by the mixed statistics of hospital and out-door deliveries. What is the True Power of the Forceps ?—Accoucheurs are divided in sentiment on this subject; some maintaining that it acts principally as a compressor, diminishing the volume of the head, and in this way facilitating its passage into the world. That the forceps, under certain conditions, is capable of diminishing the transverse diameter of the fcetal skull, is a question about Avhich there can be no doubt; but this diminution is only relative, and cannot, I think, exceed more than three or four lines without seri- ously compromising the life of the child ;§ so that, it must be remem- bered that the forceps as a mere compressor becomes deprived of much of its value as an instrument intended, under ordinary circumstances, and with judicious application, to save the lives of both parent and offspring. Again : the great majority of cases in which the use of the forceps is indicated will be those in Avhich no compression is needed, as we shall more particularly mention when speaking of the indications for forceps delivery. Therefore, I think it right that we should refer the true excellence of the instrument to its extractive properties. * Simpson's Obstetric Memoirs, vol. i., p. 854. f Dublin Quarterly Jour. Med., Aug. 1859, p. 99. X Difficult Parturition, by J. Hall Davis, 1858, p. 272. § When describing the foetal head, I told you that, in consequence of the overlap- ping of the two parietal bones, the head, during its progress through the pelvis, could be diminished, without harm to the child, to the extent of six lines or half an inch. This is really so; but you will bear in memory the marked difference between the two forces employed. In the one case, the force is derived from the energetic and continued contractions of the uterus, gradually accomplishing the desired diminu- tion in certain instances of relative disproportion; in the other, on the contrary, the force is artificial, and cannot, with whatever skill it may be exercised, equal in sahv tary effect the efforts of nature herself 576 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. It is, indeed, a tractor of precious value, and this, in my judgment, constitutes its chief attribute. The instrument should be regarded as simply an aid to nature, for it is only under one of two circum- stances, as I shall more particularly state to you, that its application becomes justifiable, A'iz. 1. When nature, exhausted in ineffectual effort, is unable to accomplish delivery; 2. When, in consequence of certain complications, the lives of mother and child would be compromised by delay. In one word, the forceps as a tractor becomes, as it were, a sub- stitute for the uterine contraction necessary to expel the child. Therefore, in all particulars, it should be made as rigidly as possi- ble to simulate, through extractive force, the uterus as an expidsor. I think I am right in this general proposition, and if you will, in the first place, accept it, and, secondly, suffer it to constitute the basis of conduct in cases in AA'hich delivery by the forceps maybe deemed advisable, I shall predict with great confidence that the instrument, in your hands, will cease to be one of destruction, and will prove of abiding service to your patients. There is one other advantage offered by the forceps Avhich I should not omit to mention : besides enabling us to extract the child, it will afford the facility of changing an unnatural into a natural position of the head. Dangers of Forceps Delivery.—It is right that we should here allude to some of the evil consequences occasionally resulting from the use of the instrument. Instances are recorded in which, espe- cially Avhere there was slight contraction, the bones of the pelvis have been fractured by the amount of force employed, or a separa- tion of the different symphyses, together with laceration of the ligaments. These accidents, however, should be regarded as among the comparatively rare consequences. Injuries to the soft parts are much more common. Rupture of the uterus or vagina, laceration of the perineum—by no means unfrequent results of forceps deli- very—thrombus of the vulva, pelvic abscesses, prolapsus of the womb, etc., may be counted among the sequelae of the use of the instrument, when sufficient care has not been developed in its appli- cation. The child, too, may suffer from contusion, fracture of the bones of the cranium, or congestion of the brain. To what Part of the Child should the Instrument be Applied? —It was formerly recommended, and the practice still obtains with some practitioners, to apply the forceps in certain cases of breech presentation—Smellie and Dr. Collins were two earnest supporters of this practice. I must confess that to attempt to extract the child by grasping its breech with the forceps appears to me, not only unwise, but most certainly calculated, if not positively to destroy its life, at least to entail upon it very serious injury. To become satisfied of this, it is only necessary to remember the anatomical conformation of the hips of the foetus, the more or less cartilaginous THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 577 condition of its pelvis, together with the want of correspondence betAveen the general physical volume of the breech, and the pecu- liar shape and curves of the forceps ; the recollection of these cir- cumstances will at once cause you, I think, to appreciate the im- portant practical truth that the forceps cannot, Avith due regard to the safety of the child, be employed in cases of breech presentation. Besides, even if, under the circumstances, the instrument were at all admissible, there is another objection to its use, viz. it cannot present the same advantages for the extraction of the child as either the fillet, the blunt hook, or the finger of the accoucheur applied to the bend of the thigh. Therefore, I would advise you, for the reasons just stated, never to have recourse to the forceps in this presentation. When the instrument is used, it should be applied exclusively to the head, and this may be done under two different conditions, viz., 1. When the head presents first; 2. After the delivery of the child, the head remaining in the pelvis. How is the Head to be Grasped by the Forceps.—Except in certain extremely rare cases, the instrument should be so applied as to seize the head thus: the internal surface of each blade of the forceps (the cranial curve) should be so adjusted as to be in cor- respondence Avith each os parietale, and extending on either side in the direction of the occipito-mental diameter of the head. Seized in this way, there will, as a general rule, be no danger of injury to the child; and, in the event of its being necessary, the proper degree of compression can be exercised so that the parietal bones may be made to overlap; and what is extremely essential, the head being grasped in this manner, the forceps, under the judicious mani- pulations of the accoucheur, will be better able to display its full power as a tractor, and bring the head into the world in accordance with the principles regulating the mechanism of labor ; for remem- ber, the forceps being a substitute for the natural forces, should, in every particular, be made to imitate as far as may be these very forces when not disturbed by some contravening influence. Modifications of the Forceps.—The instrument, as originally pre- sented, has undergone numerous changes depending upon the caprice or judgment of the innovator; I shall not weary you with a recital of these multiplied alterations, but shall content myself with simply remarking that the forceps, as now used, exhibits two curves : one of these is knoAvn as the cranial curve, intended to adapt itself to the shape of the child's head; the curves present two openings or fenestra, AA'hich accommodate themselves to the parietal regions of the foetal cranium. The instrument with the cranial curves is the one knoAvn as Denman's or the short-strait forceps; as this was intended to seize the head only when it had Avell descended to the inferior strait or outlet, the one curve for each blade (the cranial), ansAvered the purpose Avell enough ; but it was soon found that the 37 578 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. forceps so constructed was not adequate to the wants of the accou- cheur, when instrumental delivery was called for before the descent of 'the head had been accomplished ; and we are, therefore, indebted for another important modification of the instrument to those distin- guished accoucheurs, Smellie and Levret. The modification to which I allude consists in an additional curve, described as the pelvic curve the convexity of which regards the sacrum, while the concavity is turned towards the pubes. It is, as you perceive, in perfect corres- pondence with the two axes of the pelvic cavity, and, as is manifest, has special relations to the organs of the mother ; the cranial curve, on the contrary, has reference to the child only. The instrument with the curves just noticed is known as the long, the medium, and the short forceps. The latter, I have already remarked, is limited to delivery after the head is pressing on the perineum, while the two former may be employed for the extraction of the head, not only Avhen it is at the outlet, but in any portion of the pelvic cavity, or at the superior strait. The Author's Obstetric Case.—-I present my OAvn obstetric case of instruments, consisting of the forceps, the guard crotchet, the vectis, and pierce-crane or perforator. Fig. 83 represents my forceps, which, I believe, embodies some important improvements The curve of the blades, their lightness, and thinness (sufficiently strong, however, for all ordinary purposes), I regard as a very essential improvement. The blades of the forceps are usually too thick, unnecessarily so ; this circumstance frequently prevents their introduction, especially if the head be more than ordinarily large, or the pelvis somewhat contracted. In my judgment, therefore, the thinner the blades, consistently with the strength required, the more advantageous Avill the instrument be found. Instead of the pivot lock, I have substituted the button joint, and the advantage of this mode of articulation over the pivot will be at once conceded on testing the relative facility of locking the branches of the instru- ment. It appears to me that accoucheurs generally have paid too little attention to the handle of the forceps: I certainly do attach much value to this portion of the instrument, and I am satisfied that the indifference of practitioners to it has oftentimes led to failure in its just workings. In order to extract the head of the foetus safely, something more is needed than the mere adjustment of the blades; for if proper traction be not made, and proper direction given to the traction, the child will frequently be sacrificed, and more or less severe injury ensue to the soft parts of the mother. To obviate these difficulties, therefore, and to furnish every facility for the safe extraction of the child, I have provided a handle (Fig. 84) of sufficient length and curve. The curve at the extremity of the handle will afford greater facility to the operator, and give him THE PRINCIPLES AND PRACTICE OF OBSTETRICS. .579 more power than any forceps I have yet seen. To be satisfied of this fact, it is only necessary to test it by application of the instru- ment on the manikin. The length of the handle likewise affords a proper lever for the traction. The two rings (Fig. 83) will enable Fio. 85. Fio. 86. Fig. 87. Fio. 88. the operator to give proper direction to the force employed, and will, at the same time, facilitate very much the lateral movements so essential to impart to the child's head during the stages of its delivery.* Fig. 85 represents the ordinary pierce-crane or per- forator ; Fig. 86 the ordinary vectis or lever. The crotchet, AA'hich is usually employed in operative midwifery, is, in more senses than one, a murderous instrument, and has been folloAved by melancholy results. Under the most favorable circum- stances, and in the .most dexterous hands, it often does harm. It is Avell understood that it is never to be resorted to except in cases in which embryotomy is indicated. Its chief danger, therefore, re- gards the mother, for the reason that the purchase which this instrument takes on the child almost ahvays gives way, and if the accoucheur be not particularly circumspect, the soft parts of the parent—the uterus, the bladder, rectum, or vagina, will be more or less lacerated, often giving rise to disastrous consequences. With * After long trial, I can speak Arlth much confidence of the forceps described in the text; and I have the authority of our principal instrument makers for stating that they receive more orders for it than for any other forceps manufactured by them. Fio. 83. Fio. 84. 580 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. . a view of obviating this destructive tendency of the instrument, I have caused a guard-crotchet (Fig. 87) to be constructed, which I offer to the attention of the profession, allowing its merits to rest upon the judgment they may form of its utility. The adaptation of this instrument to the particular indications to be fulfilled in the use of the crotchet will, I think, be found to be all that can be desired. Fig. 88 presents a front view ; in the centre of the blade is a groove for the reception of the guard, Avhich is made to slide with facility to the point of the crotchet. The extremity of the guard (Fig. 87), on its external surface, is convex and smooth, and so completely conceals the sharp point of the crotchet as entirely to protect the soft parts from injury, even if the instrument should slip during the tractions made on it by the accoucheur; for, in this event, instead of the vagina, bladder, or rectum being lacerated by the point of the crotchet, they will suffer no injury, for the smooth surface only of the guard comes in contact with them. It will be seen that, at the other extremity of the guard, there is the ordinary blunt hook. This is important merely as a matter of economy. It is due to myself to state that these instruments are not pre- sented from any fondness I have for fame as an inventor; my ambition lies in a different direction. But they are the result of much reflection, and all I ask is that they may receive that degree of favor to which, on fair trial, they may be found legitimately entitled. Indications for the Use of the Forceps.—In considering the indications for the employment of the forceps, we approach one of the most important topics connected with the entire science of midwifery; and it is right that we should award to this question a due degree of appreciation. As one of the essential prerequisites for a resort to the instrument, it is absolutely necessary that nature should be at fault. It, therefore, remains for us to examine what the circumstances are which so far contravene her efforts as to need the interposition of science. These circumstances may be enume- rated as folloAvs: 1. A contracted pelvis; 2. A normal pelvis Avith the head larger than usual; 3. Defective parturient action, embraced under the general term of inertia; -. 4. The presence of some serious complication, such as hemor- rhage, convulsions, exhaustion, hernia, or prolapsion of the cord; 5. Rupture of the uterus, the head being in the pelvic cavity, or fixed at the superior strait; 6. The occurrence during labor of any circumstance which may place in jeopardy the life of the mother or child. With regard to the application of the forceps, in case of defective pelvic capacity, I am decidedly of opinion that if there be not a THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 581 space of three inches and an eighth in the antero-posterior diameter at the upper strait, and the same in the transverse diameter at the loAver or perineal strait, a living child at full term with its ordinary dimensions cannot be extracted ; and, moreover, any attempt to do so would more or less seriously compromise the integrity of the soft parts of the mother, if, indeed, it did not subject her life to peril. Some of the most melancholy results of forceps delivery are to be found among those instances of pelvic contraction, in which mere animal force has been employed with the delusive hope of overcoming the physical disproportion, and thus accomplish the labor. The Time of Resorting to the Forceps.—I cannot too emphati- cally admonish you against the danger of blind obedience to some of the lessons inculcated by certain distinguished writers as to the time of resorting to the forceps. You have just been told that the use of the instrument will sometimes be indicated Avhen there exists not the slightest disproportion between the foetus and maternal pelvis. The labor, for example, to a certain period, may have been perfectly natural, and all things have gone on Avell until the head reaches the inferior strait. At this stage of the labor, either con- ^ vulsions, hemorrhage, exhaustion, rupture of the uterus, etc., may J occur, and render immediate delivery absolutely necessary. It is important, therefore, that the rule for artificial delivery, under these circumstances, should be clearly understood, and the doctrine advanced by some of the older English authorities on the subject fairly examined. I cannot but regard the direction given by these authors, with regard to the particular time of applying the forceps, as fraught with evil, not only to the safety of both mother and child, but also to the reputation of the medical man. Dr. Merriman,* one of the ablest accoucheurs of modern times, observes—" No case is to be esteemed eligible for the application of the forceps, unless the ear of the child can be distinctly felt; so careful have the best professors of midAvifery been to guard against an improper use of the instrument, that it has been laid down as a rule of practice, that the forceps shoidd never be applied until the ear of the child has been within reach of the operator's finger for at least six hours." Dr. Denman, than Avhom no one has left a more merited reputation, says—"A practical rule has been formed, that the head of the child shall have rested for six hours as low as the perineum, that is, in a situation Avhich would alloAv of its appli- cation, before the instrument is applied, although the pains should have altogether ceased during the time." It is unnecessary to enumerate more authorities in support of this principle. Suffice it to sav that the dicta of Denman, Merriman, and others, have taken * Synopsis of the Various Kinds of Difficult Parturition. By Samuel Merriman, M.D., F.L.S. London, 1820, p. 156. 582 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. a strong hold of the English school, and their opinions have been too generally adopted. You will permit me to say that either of the precepts which I have just cited, if universally carried out, can- not but result oftentimes most seriously to mother and child, viz. that the "ear should first be felt, and that the head shall have rested for six hours as low as the perineum." In the first place, I Avould observe, my own experience teaches me that it is not always an easy thing to reach the ear, even when the head is at the inferior strait; and, secondly, not to interpose until the head shall have pressed upon the perineum for six hours will prove, in many instances, pernicious practice. To illustrate this point, let us suppose that the head is in the pelvic cavity; the mother suddenly becomes exhausted, either from hemorrhage or antecedent effort, or it may happen that the labor becomes complicated with convulsions. No matter what the special cause may be, we will hypothecate that, from the imminent danger, immediate delivery is absolutely indicated. The accoucheur introduces his finger, and endeavors to reach the ear; he does not succeed; the patient's situation becomes more and more alarming; he again makes the attempt to find the ear—he fails; his oavii judgment tells him, indeed everything clearly indicates that the forceps should be applied; but he cannot reach the ear! He delays in the hope that " the head may come down in the pelvis sufficiently low to enable him to feel one or both ears distinctly." Alas! this proves fallacious. The assistants supplicate him to do something to relieve the patient, for they see she is dying; and Avhat will it avail, under these sad circumstances, for him to exclaim : " I can do nothing, for the ear of the child cannot be felt !" Let it not be imagined that this is an overdraAvn picture ; such results must inevitably ensue from an adherence to the rule to Avhich I have just alluded. It is further alleged that "it is necessary to reach one or both ears, because they become the guides to the proper adaptation of the blades." This language, I must confess, surprises me not a little. If there be any meaning in it, it is simply this— that unless the ears be felt, it will be impossible to know how to arrange the blades of the instrument, because of the ignorance of the accoucheur as to the position of the head. Admitting the truth of this reasoning, when the head is at the inferior strait—which I most unequivocally deny—hoAV is the position to be ascertained wThen the head is still at the pelvic brim ? Certainly not by feeling the ears, for these cannot be recognised once in a thousand times previously to the descent of the head into the cavity of the pelvis. The position of the head can be told both at the inferior and supe- rior straits by the direction of the fontanelles, sagittal suture, etc.; and these will indicate the manner of applying the forceps, and seizing the head in its bi-parietal measurement. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 583 But again : " The head has not been pressing on the perineum for six hours;" Avhat is to be done in this case, when the life of either mother or child is menaced, and immediate delivery called for ? Are you, Avith watch in hand, to say to the earnest appeals of surrounding friends—" Oh ! I cannot interfere yet; I am Avait- ing for six hours to elapse !" You perceive, gentlemen, the absur- dity as well as the danger of the two rules to which I have referred; and you will allow me most emphatically to enjoin on you to pay no regard whatever either to the ear or the length of time the head may be in the excavation ; but, if all other things be equal, proceed to artificial delivery the moment the safety of mother or child becomes seriously endangered. The very essence of forceps delivery, that which commends itself so strongly to our consideration, is the ability with Avhich it oftentimes enables us to rescue both mother and infant. Therefore, if artificial delivery be indicated, have recourse to it before the life of the child has been sacrificed, or the vital forces of the mother so far expended as to render her recovery extremely doubtful. I do not advocate a med- dlesome midwifery; on the contrary, you will all bear Avitness that I am essentially conservative; but I do most strenuously recom- mend, when indicated, such an opportune application of the means put into our hands of affording relief as will achieve the highest measure of good to both parent and offspring. Perhaps, you may think it important that I should enter some- what in detail as to how you will be enabled to recognise that either the mother or child is in danger. All that I have to say in reply is, that the accoucheur, if he thoroughly comprehend the principles of his science, will through the proper exercise of his judgment readily arrive at a just diagnosis as to the propriety of action. For example, he must distinguish between positive and relative exhaus- tion; he must appreciate, in an attack of convulsions or hemorrhage, Avhether immediate delivery be indicated or not. Is the pressure on the head of the child from long-continued effort of the uterus such as to compromise its safety, thus calling for interference ? In cases of funis presentation, under what circumstances will the for- ceps be justified? If the uterus be ruptured during the partu- rient effort, and the head in the pelvic cavity, would not delivery by the forceps add to the feeble chances of the mother's reco- very ? All these are questions which must be determined, not in the lecture-hall, but at the bed-side of the patient; it will be a question of evidence, and that evidence will depend upon the surroundings of each case as they may present themselves to your observation. In one word, the problem to be solved is this—can nature accom- plish the delivery consistently Avith the safety of parent and child, or will the interposition of science be needed ? Nee temere, nee 584 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. timide—neither rashly nor timidly—is the maxim which should govern the accoucheur in cases of forceps application; and Avhile I would enjoin to its fullest extent the observance of caution, yet I cannot but impress upon you, as worthy of recollection, that so far as regards the general result it is far better, in dexterous hands, that the instrument should be employed five minutes too early than five minutes too late. LECTURE XXXIX. Forceps Delivery continued—Rules for the Application of the Forceps—The instru- ment may be employed when the Head is at the Inferior Strait, in the Pelvic Cavity, or at the Superior Strait.—The Head at the Outlet, with the Occiput toward the Pubes, and the Face in the Concavity of the Sacrum—The Head at the Outlet in a Reverse Po?ition—The Head in the Pelvic Cavity diagonally, the Occiput regarding the Left Lateral Portion of the Pelvis, the Face at the opposite Sacro-iliac Symphysis—The Head in the Pelvic Cavity diagonally, with the Occi- put at the Right Lateral Portion of the Pelvis, and the Face at the opposite Sacro- iliac Symphysis—The Head in the. Pelvic Cavity in Positions the reverse of the two preceding—Application of the Forceps, the Head being at the Superior Strait —Positions of the Head at this Strait—Difficulties of Forceps Delivery Avhen the Head is at the Upper Strait—Version, in such case, preferable—Case in Illustra- tion—Rules for Forceps Delivery, the Head being at the Superior Strait—Locked- Head—What does it mean ?—Waut of Concurrence among Authors as to what Locked-Head is—Is Locked-Head of Frequent Occurrence ?—Camper's Opinion— Dangers of Locked-Head to the Child and Mother—Under what Circumstan- ces may Locked-Head occur?—Application of the Forceps in Locked-Head— Rules for. Gentlemen—We shall now consider the rules to be observed in the application of the forceps, after you have decided that the use of the instrument is indicated. Permit me, however, to premise that forceps delivery may be resorted to under the folloAving cir- cumstances : 1. The head being at the inferior strait. 2. In the pelvic cavity at any point between the two straits. 3. At the superior strait. 4. After the trunk of the child has been delivered, and the head remains either at the brim, in the pelvic cavity, or at the outlet. We will suppose that you have fully determined, according to your best judgment, that the alternative for the safety of either mother or child is a resort to the forceps ; this opinion would neces- sarily, if it be a just one, presuppose that you had, through a proper vaginal examination, become informed of the exact relations of the head to the pelvis. Having, therefore, decided as to the propriety of artificial delivery, I will noAV mention Avhat I deem the elements essential to a successful accomplishment of the operation after the head has descended into the pelvic cavity : 1. The full consent of your patient must be had, and this can 586 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. readily be obtained if the accoucheur will only exercise a little adroitness. There is a cord in woman's heart, whicli if properly touched, will always prove responsive. Talk to her thus : Madam it is my duty to say to you that if your delivery be longer delayed your infant will incur very serious hazard of its life, and the time has now arrived when, if I act promptly, I shall be enabled to save your child, and spare you much protracted suffering. Oh ! dear doctor, but will not the instrument destroy my poor child ? So far, my good friend, from harming it, the forceps will enable me to bring it into the world Avithout inflicting the slightest injury upon it, and if it be alive when I commence the operation, of which there may be a possible doubt in consequence of the Arery severe pressure its head has undergone, I think I can very confidently promise you that the instrument will be the only means of enabling me to save your child. Oh ! doctor, then do not delay. I will submit to any- thing to have my child alive !* 2. The position of the patient is of much importance ; and I greatly prefer that she remain on her back rather than on her side, occupying the precise attitude which has already been described AA'hen speaking of version, A'iz. let her hips be brought to the edge of the bed, placing a double fold of linen or flannel under them in order to have them on a plane surface ; an assistant should be seated on either side, whose duty it shall be to flex the thigh and leg at a right angle allowing the foot to rest on his knee, one of the hands being placed on the knee of the patient, while the other gently seizes the foot, for the purpose of steadying it. The accou- cheur, Avith an apron to protect his dress, seats himself on a low chair betAveen his two assistants. The bladder and rectum, if dis- tended, should be relieved of their contents. 3. There is no necessity for any exposure of the patient's person, and this injunction should be scrupulously observed. 4. The os uteri should be sufficiently dilated and relaxed, as also the vagina and vulva to allow the head to pass ; otherwise, there would be the serious hazard of formidable and disastrous lacera- tions. To attempt to introduce the blades of the forceps into an undilated os would, in my opinion, be but the probable passport to the death of the patient; for, admitting the possibility of intro- ducing the instrument, would not the tractions necessary for the deli- * I am in the habit of having recourse to a very simple, and at the same time effect- ual mode of dispelling all apprehension from the mind of the mother in reference to any supposed injury or mutilation of the infant from forceps application, it is this: I ask her to double her two hands together, and I then place them within the blades or fenestra of the instrument; now, madam, I tell her, your hands represent the head of the child; do you feel any pain from the instrument ? Not the slightest. Neither will your child experience any pain or injury. Why, doctor, she will exclaim, you astonish me—I always thought that when instruments were employed the head of the child was dreadfully crushed 1 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 587 very of the head, be almost certainly followed by rupture of the cervix? 5. Previously to introduction, the blades should be separated, placed in a vase of warm water, and then properly lubricated with oil, fresh butter, or lard. G. In order to ensure the proper application of the forceps, with out injury to either mother or child, it is essential that the instru ment be introduced so that the cranial and pelvic curves of the blades correspond with the convexity of the head, and the concavity of the pelvis. 7. The introduction of either blade should always be preceded, if the head have not entirely escaped beyond the mouth of the uterus, by three fingers gently carried into the vagina, and cautiously insinuated between the head and uterine orifice ; this I hold to be one of the fundamental rules in forceps delivery, for tAvo important reasons: In the first place, you will be enabled by this rule pro- perly to adapt the blades to the portion of the cranium to which they should be applied; and, secondly, there will be no risk of injuring the cervix of the organ with the extremity of the instru- ment, which would almost certainly be the case Avithout the precau- tion just named. If, however, the head should have completely freed the cervix, and rest in the vagina, then it is not necessary to carry the fingers Avithin the cavity of the organ, but care should be taken that the extremity of either blade be so adjusted on the sides of the head that no injury be done to the mouth of the uterus ; and to accomplish this, let the fingers be carried up as far as the cervix, so that this may be guarded against violence. 8. Except when the occiput corresponds with the left lateral portion of the pelvis, the male branch should be intro- duced first. 9. At the time of intro- duction, the accoucheur should gently seize one branch of the instrument (the male branch with the left hand, the female branch Avith the right), so that the thumb shall be applied on the convex surface, midAvay betAveen the extremity of the han- dle and blade (Fig. 89), the branch on the grasp Fio. 89. while the middle and concave surface just beloAV ring fingers the ring, 588 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. wrth the index finger applied upon the outer portion of the ring itself* 10. The introduction must be made during the interval of uterine contraction; and before making any attempt to introduce the branch thus seized, I am in the habit of placing the instrument in such way that it shall be nearly parallel to the axis of the body (if the male branch, the parallel will be on the right side; if the female, on the left side); then the extremity of the blade is to be pressed on the palm of the hand already introduced into the vagina (Fig. 89), and in proportion as it penetrates the vagina, tie handle of the instrument is brought toward the operator. 11. Remember that, in the introduction of the forceps, nothing will justify brute force ; should there be some slight impediment to its passage, let the accoucheur employ his judgment, and not vio- lence, and with a little skilful manipulation the obstacle will, under ordinary circumstances, be readily removed. 12. The head should, as a general rule, be seized in the direction of its occipito- mental diameter, for in this way the greatest possible facility will be afforded for its safe extraction. It is a grave error to suppose that the blades should invariably be applied on the sides of the pelvis; it is the posi- tion of the head, as will hereafter be shown, which is to decide the position of the blades'. 13. When one branch has been properly intro- duced, it is to be intrusted to an aid, who takes it by the handle (Fig. 90), and holds it steadily, for the slightest movement will oftentimes embarrass the operator. The other branch is then introduced upon precisely the same general basis (Fig. 90); when it has embraced the head, the accoucheur then takes the handle of the branch which has been intrusted to the assistant, and by judicious manipulation will be * Let the student accustom himself, by frequent trials on the manikin, to seize the instrument in the manner described, and he will, I am sure, find great advantage in following the rule at the bedside.. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 589 enabled to bring the two handles in juxta-position, which constitutes Avhat is known as locking the forceps, a very essential, and, in my opinion, the most important part of the entire operation; for if the instrument lock, the proof is positive that it has been correctly applied. 14. After the instrument is locked (Fig. 91), many accoucheurs recommend that the handles should be kept closely in union, and, for this purpose, they re- sort to a napkin for the purpose of bind- ing them together. This, as a general rule, is bad practice, and should be had recourse to only in case of diminished pelvic capacity, when it becomes im- portant to lessen the volume of the head by more or less powerful pressure. 15. The force employed for the purpose of delivering the child should be compound, consisting of two thirds lateral and one thir extractive; and with this object, the right hand should, with its Fig. 92. dorsal surface upward, be made to seize the handle, while the index and middle fingers of the left hand (Fig. 92) are placed in the two rings of the instrument; occasionally, in the absence of pain, the fore-finger should be introduced into the vagina in order to ascer- ' tain the progress of the head. 16. The traction is to be made only during a pain, or while the uterus is contracting; after the contraction, the effort should cease until another recurrence of the pain ; and, during the interval of pain,* the handles should be slightly separated in order that the head may be liberated from any undue pressure. * If anaesthetics be had recourse to,-the pains will usually be more or less absent; and, in this case, the rule of making traction only during a pain does not obtain. There will also be an exception to the rule, when, in consequence of some serious and pressing complication, prompt extraction of the child is indicated. 590 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 17. As soon as the head begins to protrude at the vulva (if the occiput correspond with the symphysis pubis), the handle of the forceps should be successively but gradually elevated (Fig. 93), for Fio the purpose of producing the movement of extension, or bringing the chin from the sternum, so that when the head has completely escaped through the vulva, the handles of the instrument will describe a right angle Avith the abdomen of the mo- ther (Fig. 94). Should, Iioav- ever, the face correspond Avith the symphysis pubis, the di- rection to be given to the in- strument will be precisely the reverse, and, consequently, the head being delivered, the handles of the forceps will be at a right angle Avith the spi- nal column. 18. Care must be taken to make proper pressure on the perineum, as soon as the head begins to distend it. 19. When the head has been extracted, the instru- ment is to be removed, but this needs some caution ; for example, the forceps should be un- locked by directing the handle of the female branch toAvard the left thigh, and the handle of the male branch toAvard the right thigh ; this will readily enable you to detach the blades from the head in correspondence with their respective curved and convex surfaces. Fig. 94. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 591 You may, gentlemen, perhaps imagine that I have been unneces- sarily minute in the enumeration of the above rules of guidance; but, if my experience have not deceived me, there is not a direction inculcated Avhich will not be of value to you, when thrown upon your OAvn resources, in the use of the forceps. Study these rules faithfully, become familiar with them, and what is most essential— do not fail to appreciate why they are necessary to a successful forceps delivery. Brevity is ahvays commendable, but it should not be at the cost of an important fact. I shall now proceed to demonstrate the mode of applying the instrument in the various positions assumed by the head at the inferior strait; in doing so, I shall be enabled to reduce to their practical operation the different rules just cited. First Position—The Occiput regarding the Pubes, the Face in the Concavity of the Sacrum.—In this position of the head, the forceps is applied Avith more facility than in any other Avhich it may assume; and, indeed, it is the most frequent position at the inferior strait in Avhich artificial delivery is indicated. Let us noAV inquire under Avhat special circumstances the instrument becomes necessary in this first position of the head at the outlet. Here, the labor may have progressed most auspiciously; the uterus has contracted regularly and Avith due efficiency, Avhich has resulted in bringing the head completely doAvn into the pelvic cavity ; but at this period of the parturition a contre-temps may arise, such as convulsions, hemorrhage, exhaustion ; or it may be that there is a slight narrow- ing of the transverse or bis-ischiatic diameter ; or the coccyx, from rigidity of the sacro-coccygeal articulation, will not yield; or, again, there may supervene complete and rebellious inertia of the uterus; or, peradventure, rupture of the organ may take place. Any of these occurrences, therefore, Avould indicate the necessity of interference; and the proper time for the interference must rest Avith the urgency of the symptoms, and the sound judgment of the accoucheur. The consent of the patient, we assume, is had, her position on the bed arranged, the mouth of the uterus, as also the vagina and vulva are adequately relaxed and dilated, the bladder and rectum in the right condition, and the accoucheur with his two aids properly seated. The blades of the forceps have been immersed in warm Avater, and Avell lubricated Avith oil, or lard. In this position of the head, the fingers of the right hand are carefully passed into the vagina, and insinuated Avith caution between the sides of the child's head and the internal surface of the mouth of the uterus, should the head not have completely escaped from the organ; the male branch of the forceps is seized, as indicated (Fig. 89), and placed nearly parallel to the axis of the woman's body, on the right side; the extremity of the blade is then brought doAvn so as to 592 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. press against the palm of the hand already introducer, into the vagina, and the blade is then conducted, during the abf<»nce of con- traction, along the fingers to be adapted to the lateral surface of the child's head, the handle of the instrument being made gradually to approach the median line; when the introduction of the blade is com- pleted, the handle becomes parallel to the axis of the inferior strait. But how are you to be assured that the blade has properly grasped the head, and that the extremity of the fenestrum is near the inferior maxillary bone ? This may be ascertained from the fact that the blade has been introduced to the extent of four or five inches, that it is more or less firm, and in making gentle traction on the instrument in a straight line from within outward, there is a slight resistance. One branch, therefore, being adjusted, it is intrusted to an assistant, who holds it steadily in position (Fig. 90); the accoucheur then withdraws his right hand from the vagina, and proceeds to introduce the other, or female branch, as follows : the fingers of the left hand are carried into the vagina, to be insinuated betAveen the foetal head and os uteri; the female blade is next to be seized by the right hand, precisely as was the male blade (Fig. 90); and its introduction to be conducted upon the same principles, remembering that, in this case, the branch must strike nearly a parallel with the long axis of the patient's body on the left side, and is to be introduced over and not under the blade, which has been already adjusted. As soon as the introduction has been accomplished as far as the lock of the instrument, the hand is to be withdrawn, and the accoucheur then takes hold of both handles of the forceps for the purpose of locking it. Here, there will occasion- ally be experienced some difficulty, and this may arise from the fact that the first blade introduced has become deranged through inattention of the assistant, or it may be that the second has not been properly adjusted. In either case, the true difficulty, what- ever it may be, must be removed before the instrument can be made to lock. We will now suppose that all is correct: the accoucheur then places his right hand, the dorsal surface upward, on the handle of the forceps, the middle and ring fingers of the other hand (Fig. 92) being insinuated within the two rings; as soon as the pam com- mences, he begins his traction, which is to consist of a two tlurd lateral and one third extractive force ; this compound force it is most essential to remember, for it will add greatly to the facility of the delivery. As soon as the contraction ceases, so must the effort of the accoucheur be suspended, except in cases in which, from imminent danger either to the mother or child, immediate delivery is indicated. In these exceptional instances, therefore, it is well to recollect that the great object is the prompt termination of the labor THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 593 Those of you, who have never witnessed a case of forceps appli- cation, will be amazed to learn the amount of force sometimes required to achieve the delivery; the strongest arms will occasion- ally be found almost surrendering to the needed effort; and yet all this force, if it only be tempered with judgment, is not only justi- fiable, but will be quite consistent Avith the safety of mother and child. When the head begins to distend the perineum, this latter must be adequately supported, and this may be done by an assistant, or by the accoucheur himself, employing for this purpose the left hand, while he continues his tractions Avith the right. In proportion as the head advances, the handles of the instrument should be succes- sively elevated, Avith the view of bringing the chin of the child from the sternum, or, in other words, producing the movement of extension (Figs. 93, 94). When the head has escaped through the vulva, the instrument is to be removed; the accoucheur should place his finger around the neck of the child to ascertain whether or not it be encircled by the umbilical cord; if so, and the cord be draAvn tightly, so as to endanger the freedom of the placento-foetal circulation, one of tAvo things should be done: either to bring a loop of the co*d over the head, and thus liberate it from the pressure ; or, if this cannot be accomplished, lose no time in making a section of the encircled cord, and then, if the uterus do not immediately expel the child, the hand should be introduced for the purpos • of bringing down the arms, and thus expedite the delivery. Second Position—The Occiput regarding the Concavity of the Sacrum, the Face to the Pubes—-It will at once be seen that the head here is completely reversed; and, moreover, in this position the forceps will, in the majority of instances, be indicated for the reason of the protraction of the labor; for you are not to forget that the occiput, being posterior, must have traversed the entire length of the posterior wall of the pelvic cavity—consisting of the sacrum and coccyx—before it can make its exit; and, as a general rule, the increased duration of the labor will have so far perilled both mother and child as to render it necessary to resort to the forceps. But, in addition, any of the accidents already mentioned would constitute another motive for the use of the instrument. The rules for the introduction of the forceps are precisely the same as in the first position. It is well, however, to remember that there A\ill be more difficulty in the extraction of the head in this second position, and the force employed should be more guarded, for the face cannot be brought under the pubes with the same facility that the occiput was in the preceding case, because of the greater irregularity of its surface; again, the distension of the perineum wilf be much greater, because of the rounded and more prominent configuration of the occiput. It must also be recollected that, in 38 594 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. this position, the forceps, as soon as the head begins slightly to protrude, instead of being elevated, must be depressed, for the purpose of bringing the chin from the sternum, so that when the head is delivered the instrument will be at a right angle with the spinal column. Third Position—The Head presenting Diagonally, the Occiput regarding the Left Lateral Portion of the Pelvis, the Face at the Opposite Sacro-iliac Symphysis.—When describing the mechanism of natural labor, you Avere told that the head undergoes three move- ments—flexion, rotation, and extension—before its exit through the maternal organs can be effected; but it will sometimes happen that nature is so far contravened in the completion of this mechanism, that she will need the assistance of art for its accomplishment. Here then, we will suppose that flexion has taken place, and the head descended into the pelvic cavity in its diagonal position ; the uterus contracts Avith great effort, and continues to do so, but there is no change in the direction of the head ; it still occupies the dia- gonal position ; the strength of the mother, from the continued but ineffectual efforts of the uterus, begins to give way; the brain of the child, also, is in danger from severe pressure, as is evinced by the extreme heat and dryness of the vagina, and the corrugations of the scalp. What, under these circumstances, is to be done ? If the accou- cheur content himself with assuring the patient that the labor is progressing favorably, that it will soon be terminated, and all that is necessary is to " bear down" and " make the most of her pains," he will not only be delinquent in duty, but will find, when too late to remedy the evil, that he has, either through wanton carelessness or gross ignorance, allowed one, and perhaps two lives to be sacri- ficed. Instead, therefore, of such passive and unpardonable conduct, he should at once proceed to ascertain the true cause of the delay in the delivery. Let him inform himself why it is that the head is not responsive to the powerful contractions of the uterus; why, in a Avord, with such efforts on the part of the organ the labor is not ended. As soon as he discovers that nature has been struggling in vain to effect the movement of rotation, and recollecting that the head, so long as it occupies the diagonal position in the pelvic cavity, cannot make its exit, he will appreciate the certain danger of further delay, and will come promptly to the aid of the suffering patient by doing for hei? what nature has been unable to accomplish, viz. the rotation of the head. This, then, is a case for the interposition of the forceps ;* but hoAV is it to be introduced, the head occupying the diagonal position * Sometimes, the accoucheur will be able to rotate the head by the simple intro- duction of the hand; and, when this is done, if there be no urgent necessity, tho subsequent part of the labor may be left to the natural resources. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 595 in the pelvic cavity ? Assuredly not by placing the blades on the sides of the pelvis, for it is manifest that, in doing so, the lateral surfaces of the head could not be grasped; nor could the object for their introduction—rotation—be accomplished. Here, the female branch is to be introduced first, and for this purpose let it be held, as already described, by the right hand; and with the fingers of the other hand carried into the vagina as a guide, the extremity of the blade should be introduced toward the right foramen ovale, to the distance of about four inches, the handle of the instrument, in proportion as the blade passes along the parietal region of the head, being depressed and inclined toward the left thigh of the patient in order that it may become parallel to the oblique or diagonal position of the child's head. The female branch thus introduced is to be confided to an assistant; the male branch is then insinuated with the left hand along the fingers toward the left ischiatic notch, for the purpose of being adapted to the other parietal region of the head, care being taken to cause the handle to approximate that of the branch already introduced. The instrument is then locked; the hands grasping the forceps, as in the first and second position, the first thing to do is to make a movement of the instrument from left to right, the object being to rotate the head, which being accomplished, it is no longer in the diagonal position, but is so placed, that the occiput is in correspondence with the symphysis pubis, while the face is in the concavity of the sacrum. The ter- mination of the delivery is then to be conducted precisely as in the first position. Fourth Position—The Head presenting Diagonally, the Occi- put regarding the Right Lateral Portion of the Pelvis, the Face at the Opposite Sacro-iliac Symphysis.—In this position, the head is also oblique in the pelvis, and in order that it may have its transit insured, it must, as in the preceding case, undergo the movement of rotation. For this purpose the male branch of the forceps, seized Avith the left hand, is introduced first along the fingers of the other hand in the following manner: Carried into the vagina under the left foramen ovale, it is gradually depressed toAvard the right thigh of the patient until it becomes parallel to the diagonal direction of the head. The female branch is introduced toAvard the right ischi- atic notch, and the handle made to approximate that of the male branch. The instrument is then locked ; here, the movement must be from right to left, so that the occiput may be brought to the symphysis pubis, and the face in the concavity of the sacrum. The delivery is then terminated as usual. It is well to remember that when the head occupies at the inferior strait a diagonal position, it is not always situated as has just been described; for the occiput, in lieu of being at one of the anterior and lateral portions of the pelvis, may be turned toward one of the 596 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. posterior and lateral surfaces of the canal, while the face or forehead will present at one of the corresponding opposite anterior points. For example, in what are termed the posterior occipital positions, the occiput regards one of the sacro-iliac junctions, Avhile the fore- head will look toward the opposite anterior lateral surface of the pelvis. Now, the fact Avhich I AA'ish to impress upon you is thjs— no matter whether the occiput be anterior or posterior, the head still occupies a diagonal position, and consequently the obstacle to its passage is precisely the same ; therefore, in either case, the appli- cation of the forceps and the delivery are to be conducted in accord- ance with the same rules, Avith the simple exception that, in the occipito-posterior positions, the occiput, instead of being brought to the symphysis pubis, must be rotated into the concavity of the sacrum. Application of the Forceps, the Head being at the Superior Strait.—Precisely the same indications may present themselves for the use of the forceps, the head being at the brim or upper strait, as after its descent into the pelvic cavity; for example, hemorrhage, convulsions, inertia, exhaustion. But one of the principal causes, calling for the employment of the instrument in these cases, will be a slight disproportion between the head of the foetus and the brim, whether from contraction of the latter or an increased development of the former.* When this disproportion really exists, and the antero-posterior diameter is not less than three inches and a quarter, the forceps would probably present a safer mode of delivery than version. Yet, I am quite confident that to apply the forceps pro- perly at the upper strait is one of the most difficult operations in obstetric surgery, and the hazard of injury to the soft parts of the mother is very great; for here, you are to remember, besides the difficulty of accurately adjusting the instrument to the head of the child, there is the danger of lacerating the cervix uteri and peri- neum. Again : the safety of the child is much more likely to be compromised, in consequence of the more protracted tractions necessary to accomplish its delivery. But you may ask, what is the true difference in the danger of forceps application, when the head is at the inferior or superior strait ? A moment's thought will very satisfactorily explain this difference. In the former case, the instrument in order to grasp the head properly is required to pursue but one axis of the canal—the axis of the lower strait—while, on the contrary, the head being at the brim, one of the fundamental principles of success is, that the * It has already been stated that Prof Simpson, in revival of an old practice, has suggested the substitution of version for the forceps and craniotomy, when the head is at the superior strait, and there is a contraction of the brim; but of the propriety and oftentimes practicability of such substitution I have my doubts, as has been mentioned in a previous lecture. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 597 forceps shall be introduced in accordance with the two curves of the pelvic cavity, viz. the curve of the inferior and the curve of the superior straits. Therefore, I should advise you, whenever you have the election between the two alternatives, forceps or version- - if there be no contraction at the brim—to prefer version, unless the uterus be so firmly contracted around the body of the fcetus as to render the introduction of the hand impossible; in this event, it would be better to resort to the forceps. I have on several occasions been obliged to apply the instrument at the upper strait, and happily Avith safety to both mother and child, where the alternative of version did not exist. It will only be necessary, however, for you to attempt the operation once, to become persuaded of the difficulty and danger involved in it. The following case is in point: I requested two of my students, Messrs. Guernsey and Blodgett, to attend one of my clinic patients, who was in labor; she Avas twenty-four years of age, healthy and robust, and pregnant Avith her first child. She had been suffering more or less from slight pains for two days before these gentlemen visited her; and after the lapse of twenty-six hours from their first visit, Mr. Guernsey informed me that, notwithstanding strong uterine contractions for the last eight hours, there was no progress in the delivery, and the friends were becoming impatient. He also remarked (I had not yet seen the patient) that she Avas strong and muscular, with a bound- ing pulse. I suggested to him to bleed her to the. extent of § xij, and inform me in the course of two hours, whether any progress had been made. At this time I was sent for, and was accompanied by another pupil, Mr. De Courcey. When I arrived, the gentlemen in charge of the case remarked that the head was still at the upper strait, and that the pains, although severe, had occasioned no pro- gress in the delivery. On making a vaginal examination, I found their representations to be literally true ; the mouth of the uterus Avas dilated, but the head unusually large and resisting had not begun to disengage. The occiput Avas toAvard the left acetabulum, the anterior fontanelle at the opposite sacro-iliac symphysis, and the head in a demiflexed position. There Avas considerable heat about the vagina, and the scalp Avas evidently corrugated, shoAving that unusual pressure (all, hoAvever, unavailing) had been exerted on the head, and that the child from this cause Avas in more or less danger. The woman herself earnestly supplicated that Ave should deliver her, her only anxiety being tbe safety of her child. It Avas no easy matter to decide upon the course to be adopted in this case; it was evident, however, that artificial delivery was indicated; but Avhe- ther by version or the forceps Avas a question of some delicacy to determine. Under ordinary circumstances, there Avould have been no hesita- 508 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tion, for the head being at the superior strait, and interposition being necessary, version Avould be preferable. But, in this instance, the head Avas more than ordinarily large, and turning Avould, of course, have been attended not only with much difficulty to the operator, but Avith serious results most probably to both mother and child. Add to this, that the uterus Avas contracting with great energy, and it will be seen that the question naturally arose—which would afford the best chance to the mother and child, the forceps or turning ? I decided on the former, and in consequence of the peculiar circumstances of the case, departed, in this preference, from the rule Avhich I hold to be very generally proper—to turn rather than attempt delivery by the forceps when the head is at the upper strait. Proceeding cautiously, after some little difficulty I succeeded in adjusting the blades of the instrument, but found it utterly impossible to approximate the handles of the forceps, in consequence of the size of the head. I carefully held the handles, guarding against the possibility of the blades slipping, and com- menced my tractions cloAvmvard and backward, and succeeded in about twenty minutes in delivering the patient of a vigorous and unusually large living child. The application of the forceps, the head being at the superior strait, is a modern expedient; and the credit of having been the first to resort to this measure is generally, I believe, aAvarded to Palfyn, who, in 1723, actually applied the instrument and delivered the foetus. Before this time, the long forceps was not in use, and it Avas Avith the view of imitating the example of Palfyn that Smellie improved his forceps by adding to its length, and giving to it the curve on its border, thus causing it to correspond with the tAvo curves of the pelvis. Application of the Forceps at the Superior Strait, the O&ciput regarding the Pubes, the Forehead the Sacro-vertebral Prominence. —When describing the position of the foetal head, and the mechanism of its descent into the pelvic cavity, you were told that it is extremely rare for the occiput to remain, after the contractions of the uterus have fairly commenced, either at the pubes or sacrum, its tendency being to turn either to the right or left, thus convert- ing the direct into one of the oblique or diagonal positions. Yet as an exception, these direct positions may continue, and therefore, it is proper that the rules for the application of the forceps, under these circumstances, should be indicated. Here, the male branch is introduced first; the right hand, with the exception of the thumb, is carried along the vagina, and the ends of the fingers cautiously insinuated AA'ithin the cervix of the uterus; the branch of the instru- ment is held by the left hand, and introduced on the left side of the pelvis Avith a view of being adjusted on the lateral surface of the child's head. The branch is carried up to the distance of THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 599 seven or eight inches, so that the lock is brought quite near the vulva. In proportion as the blade glides along the side of the head, care should be taken to depress the handle, so that it may be brought parallel to the axis of the upper strait. This branch being arranged, it is to be entrusted to an assistant; and the female branch, held with the right hand, is to be carried up along the left hand previously inserted into the vagina; as soon as the blade begins to pass over the parietal protuberance of the head, the handle should be depressed as in the other instance, in order that the tAvo handles may be approximated and locked. This being accomplished, the forceps is seized, as previously indicated; and uoav there is a point of moment to be recollected, otherwise the difficulty of extraction will be very much enhanced, and so also will be the danger to the child. The point is this— before employing any extractive force, the first thing to do is, by a gentle rotary movement of the instrument, to bring the occiput in apposition Avith the left acetabulum, thus converting it into the first position of the vertex; in order to effect this, the outer extremity of the forceps must be Avell depressed, and directed toAvard the left thigh of the mother. We Avill noAv suppose the rotation to be effected ; then the compound force, already alluded to, is to be commenced, and the tractions made in a line parallel to the axis of the superior strait—caution being taken not to injure the perineum by the handles of the instrument—until the head is brought doAvn into the pelvic cavity. Noav, you are not to forget that the head, from the time its position Avas changed at the brim, occupies a diagonal direction. Therefore, as soon as you have caused it to descend into the excavation, all extractiA-e force must cease, until by another rotary movement you place it in the direct position by bringing the occiput to the symphysis pubis, and conse- quently the face into the concavity of the sacrum. Having done this, the delivery is to be terminated in accordance with the rules already mentioned Avhen speaking of the use of the forceps, the head being at the inferior strait. Application of the Forceps at the Superior Strait, the Occiput regarding the Sacro-vertebral Prominence, the Forehead the Sym- physis Pubis.—One moment's reflection on the relations of the head to the pelvis in this position, Avill serve to show you that the obstacle to delivery \A-ill be much greater than in the former case, for the reason that, here, the face is directed toward the pubes Avhich, as has already been explained, will cause the extraction to be both more difficult and protracted. There has prevailed a difference of opinion among writers as to the management of this position of the head. For example, Smellie advised that the face should be turned toward the concavity of the sacrum, either before or after the head had passed the superior strait. If you follow thia 600 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. direction—and it comes from veiy high authority—you will incur the almost certain hazard of destroying the child by the extreme torsion to AA'hich you subject its neck, amounting, as you perceive, to one-half of a circle. Again: it has been recommended, in this position, to place the border curve of the forceps in correspondence with the sacrum. The application of the instrument on the manikin will speedily convince you not only of the inconvenience, but the utter absurdity of this latter precept. Instead, therefore, of adopting either of the above rules, the forceps should be introduced precisely as in the former case, on the sides of the pelvis, and made to grasp the head on its lateral surfaces. After the instrument has been properly adjusted, a gentle rotary movement should be imparted to the forceps for the purpose of turning the forehead toward the left acetabulum ; then, Avith doAvnward and backAvard tractions, the head being brought into the pelvic cavity, it is again changed from the diagonal to the direct position by bringing the face to the sym- physis pubis. The delivery is subsequently terminated as has already been described, the head being at the inferior strait Avith the face to the pubes, and the occiput in the concavity of the sacrum. Application of the Forceps at the Superior Strait, the Occiput regarding the Left Acetabulum, the Forehead the opposite Sacro- iliac Symphysis.—It will be perceived that the head occupies in this position a diagonal direction at the upper strait; and the for- ceps is to be so introduced as to seize the head in its long or occipito-mental diameter. For this purpose, the female branch is introduced first; it is held by the right hand and glided along the fingers of the other, which are carried to the os uteri in the direction of the right sacro-iliac symphysis; the blade of the instru- ment is introduced toward this latter point until it embraces the forehead; it is then brought over* the temple, which Avill be found in correspondence either Avith the right foramen ovale or symphysis pubis, depending upon Avhether the head occupies the diagonal or transverse position. In proportion as the blade becomes adapted to the side of the head, the handle of the instrument must be gradually depressed toAvard the floor of the pelvis. This branch being thus adjusted, it is to be confided to an aid. The male branch is then held by the left hand, and directed along the fingers of the right, which are introduced into the vagina toAvard the sacrum; the blade is made to glide along the hand in the direction of the front of the sacrum; at first, the extremity of the handle is to be elevated Avith an inclination toAvard the left side of the pubes; in proportion, hoAvever, as the blade glides along the sacrum and under the head, the handle is gently depressed for the purpose of approximating it to that of the female branch. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 601 The two respective branches*being locked, the instrument is seized by both hands, as previously indicated. The direction of the extractive force must at the commencement be downward and backward, parallel to the axis of the superior strait, remembering to keep the handle of the forceps inclined toward the left thigh of the mother, in order to bring the head into the pelvic cavity; wheu the head has thus descended, do not forget that it still occupies the diagonal position. Therefore, all traction must cease until the occiput is rotated to the symphysis pubis; the delivery is then com- pleted as has been described. Application of the Forceps at the Superior Strait, the Occiput regarding the Right Acetabulum, the Forehead the opposite Sacro- iliac Symphysis.—Here, again, the relations of the head to the upper strait of the pelvis are the same as in the former position, and precisely the same principles are to be observed in the applica- tion of the instrument. The male branch is introduced first; it is held by the left hand, and passed along the fingers of the other hand, which are carried toward the left sacro-iliac symphysis; as soon as the blade embraces the forehead, it is then to be cautiously directed toward the temple, which will be found to correspond Avith the left foramen ovale, or symphysis pubis. The handle, in proportion as the instrument becomes adjusted, is to be depressed toward the floor of the pelvis. The female branch is now held by the right hand, and introduced along the fingers of the other hand. It should be directed under the head, following the ante- rior surface of the sacrum. The extremity of the handle, Avhich is at first elevated and turned toAvard the right groin of the mother, must, as the blade advances upon the head, be brought doAvnward or depressed for the purpose of uniting Avith the male branch. The instrument being locked, the handles are seized by the two hands, and an extractive force exercised dowmvard and backward parallel to the axis of the superior strait; Avhen the head is brought into the pelvic cavity, a rotary movement from right to left must be made, in order to turn the occiput to the symphysis pubis, and the face to the concavity of the sacrum. The delivery is afterward completed in the manner already indicated. Supposing the head to occupy reverse positions at the brim, viz. the forehead at the left or right acetabulum, and the occiput at the right or left sacro-iliac symphysis, the application of the forceps is to be conducted precisely on the same principles, remembering, however, that the male branch should always be under the symphysis pubis, and the female branch in front of the sacrum. Application of the Forceps in Locked-Head.—The term locked- head. is made to mean many different things, according to the defi- nitions gdven of it by the various writers, Avho have alluded to the subject. Without occupying time hi the enumeration of the con- 602 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. flicting opinions as to what lockecUhead really is, it will be sufficient, for all practical purposes, to state that the very term implies an immobility or fixedness of the head, which no poAver of the uterus can overcome; and which immobility is in part demonstrated by the fact that the head cannot be made either to ascend or descend by any manual effort of the accoucheur. And here, I may be per mitted to say, that I do not believe this condition of things to be possible in a well-conformed pelvis, the head possessing its ordinary dimensions. Locked-head, therefore, when it does occur, is, in my judgment, the result of a disproportion between the head of the fcetus and pelvic canal, whether from excessive size of the former, or dimi- nished capacity of the latter. This, too, is the opinion of Madame La Chapelle,* who, in her vast experience in the maternite" of Paris, never met with an example of locked-head Avhere there Avas a proper relation betAveen the foetus and maternal organs; moreover, this clever observer is inclined to believe that what has been supposed by most writers to be A'eritably locked-head, may be explained in another way, and referred to deformities of the pelvis, malpositions of the foetal head, or to strong and long-continued efforts of the uterus. It is quite evident to my mind, and amply proved by per- sonal experience, that there is oftentimes an erroneous diagnosis arrived at on this question in the lying-in room. I have more than once been summoned by my professional friends to meet them in counsel in cases of supposed immobility of the head; and, on a close examination of the state of things, I have found, not that the head was immovable, but simply that its progress through the pelvic canal was sluggish, requiring only that very essential, but too frequently neglected remedy—patience. There exists, also, a very remarkable discrepancy of opinion among writers as to the relative frequency of locked-head compared with other formidable obstacles calling for the interposition of science. For example, while it is conceded that it is of rare occur- rence in France, our own distinguished countryman, Dr. Dewees,f avoAvs that he has never recognised an example of it in his practice, which circumstance he refers to the fact of the generally prevailing healthy or normal pelvic conformation of our American women; yet Ave have a high authority, Camper,J assuring us that, in Hol- land, locked-head is by no means among the rare occurrences of the parturient chamber. This discrepancy, it seems to me, arises from the circumstance of the general Avant of concurrence as to the true meaning of the term locked-head; for I can see nothing in the Avomen of Holland so marvellously different from those either of France or America, Avhich could rationally account for the very * Pratique des Accouchements, p. 120. \ System of Midwifery. \ Acad, de Chirurg., tome v. p. 450. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 603 extraordinary alleged difference in the relative frequency of the complication under discussion. Therefore, I repeat, locked-head is one thing in Holland, another in France and our OAvn country This leads me to remark that statistics on any given subject, in order that they may possess their true value as reliable data, should have a common basis. Let us noAV examine in what the real dangers of this complica- tion consist, so far as regards the welfare of both child and parent, assuming the true practical definition of the term locked-head to be—an immobility in resistance to the most powerful contractions of the uterus, or the best directed manual efforts of the accoucheur. It is manifest that these dangers, if there be any, should be thoroughly and opportunely comprehended, for on the early recog- nition of this positive immobility of the head must depend the issue of weal or woe to mother and child. 1. Dangers to the Child.—When there is complete immobility of the head, notwithstanding the vigorous contractions of the uterus, it is too plain to need comment that the life of the child is exposed to the most imminent peril from one or other of the fol- * lowing circumstances: undue compression of the brain ; depression and fracture of the cranial bones; the formation of excessive epicranial sanguineous effusions, or even the detachment of the scalp itself, Avhich may ensue from powerful and protracted pressure of the contracting uterus. 2. Dangers to the Mother.—The continued resistance of the head to the impulsive efforts of the womb, may result disastrously to the mother in several Avays: for example, there may ensue con- vulsions or rupture of the organ in some portion of its area; undue pressure on the bladder, urethra, rectum, or vagina, giving rise to vesico-vaginal, urethro-vaginal, or recto-vaginal fistulae, abscesses or sloughs; and, also, the excessive compression of the sacral plexus of nerves may terminate in paraplegia, and other formidable derangements of the nervous system. If to these accidents be added the possibility of sudden congestions, not at all unlikely to occur under the circumstances, of the brain, lungs, etc., we shall have, I think, a picture of contingencies well calculated to aAvaken the attention and excite the vigilance of the conscientious accou- cheur. Under Avhat circumstances may locked-head occur? I have already stated that I do not think it possible, except in cases in Avhich there is a disproportion betAveen the foetus and pelvis; and conjoined Avith this must be the prerequisite facts : 1. That the disproportion is not such as to prevent the head from a partial descent, so that it may become absolutely locked; 2. There must be contractions of the uterus adequate to cause this partial descent. If'what I have just said be true, and I refer you for the demon- 601 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. stration to the bedside, it manifestly follows that, although dispro- portion may exist, yet, without sufficient contractile force, locked- head cannot ensue; for it is, as you will not fail to recollect, the continued impelling action of the uterus, Avhich wedges—I knoAv no better term—the head of the foetus into the contracted space Therefore, the real causes of this complication may be divided into the predisposing and exciting; the former refers to the dispropor- tion between the pelvic canal and foetus; Avhile the latter, the ex- citing cause, will be the effort of the uterus. Diagnosis of Locked-head.—The head may become locked either at the superior strait, or in the excavation. In either event, it will be in one of tAvo positions, A'iz. it will present directly or transversely. In the former case, the occiput will regard the pubes, and the face the sacrum, or vice versd; in the latter, the head being in the transverse direction, one of the ossa parietalia Avill be in front, the other behind. Before describing the means of reme- dying this difficulty, and thus protecting the mother and child against the dangers of the complication, it may not be unprofitable j to inquire, for the moment, in what the true diagnosis of locked- head consists, and Avhether it may not be likely to mistake some- thing else for it. The solution of this inquiry is essentially material, under the circumstances, to the proper duty of the accoucheur ; and here, alloAv me to impress upon you the necessity of a just dis- tinction betAveen what is and what is not. I am quite sure that want of proper judgment has oftentimes induced the inexperienced practitioner to imagine that he had a case of impacted or locked-head, when, in fact, this state of things had no sort of existence; the error has arisen in this way: he has recognised, by a digital examination, a more or less hard tumefac- tion of the scalp, a thick and swollen condition of the neck of the uterus, together Avith unusual engorgement of the vagina and vulva, and these phenomena, too, accompanied by strong uterine contrac- tions ; now, the question is, do these symptoms positively indicate locked-head? By no means; for the testimony, in order to be complete and of value, needs one more circumstance, which consti- tutes the essential and only positive proof of the head being locked, viz. its immobility notwithstanding the vigorous efforts of the uterus* Therefore, before determining that this complication exists, it must be first ascertained that the head is not apparently, but really fixed, or, in other words, immovable. A just diagnosis on this essential point, Avill be the means of preventing interference oftentimes not called for. There are few accoucheurs of extensive practice, who will not concur in the opinion that nature is frequently enabled to accomplish delivery by * It may be mentioned in this connexion that recession of the head between J,he pains is decisive evidence that impaction does not exist. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 605 her OAvn resources in cases in which all the symptoms above described, except the immobility of the head, are present; and hence you will occasionally see, in the course of your observation, examples of an extremely elongated head, the result of the extra- ordinary pressure it has undergone, and yet the child born alive. This goes to show the conservative care of nature, and how ade- quate she is, oftentimes under the most unfavorable circumstances, to perform her duty—if not officiously intruded upon—consist- ently with the safety of both mother and child.* But we will assume that all doubt as to the existence of locked- head is at an end, and the diagnosis complete; what, then, is to be done? The object to be accomplished is, unquestionably, to deliver the child as speedily as possible, for every moment which elapses from the time the head has become immovable is so much against both mother and child. The mode, however, to be adopted in the delivery will depend upon whether the child be alive or dead; and this, under the circumstances, I hold to be an important distinction. If the child be still living, recourse should be had to the forceps. On the contrary, if it be dead, I should recommend ' the perforator and cephalotribe as the most available means of terminating the birth. Afyplication of the Forceps in Locked-Head, in the Direct Posi- tion, the Occiput at the Pubes, the Face toward the Sacrum.— Before introducing the instrument, the true condition of the head must be fully comprehended; here, for example, resting as it does Avith the occipito-frontal diameter in accordance Avith the direct or antero-posterior of the pelvis, it is evident that the lateral surfaces of the head correspond with the sides of this canal; consequently, the rule is to introduce the blades of the forceps, one on the left and the other on the right side, in order that the head may be pro- perly grasped laterally in the direction of its occipito-mental dia- meter. The manner of introducing the instrument is the same as has previously been described in this position of the head when it is not locked or immovable. The blades, we will suppose, are pro- perly applied, and the handles in juxtaposition. What is next to be done ? A moment's thought will remind you that the forceps has grasped a head, which is completely immovable in the pelvic canal. Therefore, the brain of the accoucheur must be slightly exer- * In these cases, however, of more than ordinary difficulty, it becomes the accou- cheur to exercise a constant and judicious vigilance; otherwise, serious consequences may ensue. If, for example, he should recognise a giving way of the mother's strength, or any other circumstance likely to compromise her; or should he find that the pressure to which the head is subjected, is such as to place the life of the child in peril, then, of course, it will be his duty to interpose, and terminate the delivery. However, what I desire to inculcate is this : as long as the head is known to respond in its progress to the contractions of the uterus, all other things being equal, the labor should be committed to nature. 606 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. cised in order that he may determine upon the course to be pur- sued. What he is to do is this—the forceps being adjusted on the head, the accoucheur should seize the handles, and endeavor to change the position to a diagonal one by bringing the occiput toward the left acetabulum ; but much dexterity will be needed. If he attempt by mere force to push the head upward, he may inflict immeasu:1 able injury; or to endeavor by powerful tractions to cause the head to descend into the pelvis, before it has undergone the required change of position, would be equally dangerous and nugatory. He should, on the contrary, attempt in the first place, if I may so term it, to unlock or loosen the head by a cautious and continued lateral movement from right to left. This once accomplished, the occiput is to be placed in apposition with the left acetabulum, and the extraction terminated as already indicated. If the forehead be at the pubes, and the occiput toward the sacrum, the same rules obtain both for the introduction of the instrument, and the delivery of the child; except that, instead of the occiput, the forehead should, in converting the direct position into a diagonal one, be brought to the left acetabulum.* In the event of the head being locked when resting either in the diagonal or transverse position, the rules for the introduction of the instrument are the same as when the head occupies either of these positions, and is not locked. These rules have already been given; yet it is well to remember that, in both instances, the for- ceps should be so introduced as to seize the head on its lateral sur- faces, and not place one blade on the occiput, and the other on the face, as is recommended by some authors, when the head occupies a transverse position. * It may happen that, either in an occipito-pubic or occipito-sacral position, it will be easier to turn the occiput or forehead to the right instead of the left aceta- bulum. In such case it should be done without hesitation. LECTURE XL. Forceps Delivery continued—Use of the Instrument when the Head is retained after the Expulsion of the Body—Circumstances justifying the Forceps in these Cases—Application of the Instrument, the Head at the Inferior Strait, with the Occiput at the Symphysis Pubis, the Face in the Concavity of the Sacrum— Application in a reverse Position—When the Occiput is at the Left and Front of the Pelvis—The Occiput at the Right and Front of the Pelvis—Use of the Instru- ment, the Head resting at the Superior Strait—The Forceps in Face Presenta- tions—Under what Circumstances indicated—Practice of the Old Schoolmen in Face Presentations—Objections to—When Version is to be Preferred to Forceps Delivery in Face Presentations—The Manner in which the Face usually presents at the Superior Strait—Right Mento-iliac Position—Left Mento-iliac Position— Mode of Descent in these Positions—Manner and Difficulty of applying the For- ceps in Face Presentations at the Superior Strait—Use of the Instrument when the Face is at the Inferior Strait—Mento-anterior Position—Mento-posterior Posi- tion—Comparative Rarity of the latter Position—The Oblique Positions of the Face at the Inferior Strait—How managed—Face Presentation and Convulsions—Case in Illustration. Gentlemen—We have now to speak of the use of the forceps after the body of the child has made its exit through the maternal organs. Although, when discussing the natural presentations of the foetus in utero, I told you the presentation of either of the obstetric extremities of the ovoid is in perfect keeping with the resources of nature, yet, at the same time, you were admonished that the child encounters more hazard when either of the pelvic extremities is found at the superior strait, than in an ordinary vertex presenta- tion ; and for the double reason that, in the first place, the umbili- cal cord is much more liable, especially in footling cases, to undue and dangerous pressure; and, secondly, there is the possibility of more or less difficulty in delivering the head after the body has made its escape. The mode of overcoming this difficulty by sim- ple manipulation has been fully explained in a previous lecture. It may, hoAvever, sometimes be found impracticable to bring the head into the world by any manual effort, and, under these circum- stances, it Avill become necessary to resort to the forceps. I am inclined to believe that a dexterous accoucheur, one who not only knoAvs what to do, but hoAv the object is to be accom- plished, will almost always succeed in delivering the head by a manual operation, unless the obstacle be in consequence of more or less disproportion betAveen the head and pelvis, the^ latter being 608 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. slightly contracted, or the former slightly enlarged. In these latter instances, it is, I think, that the use of the forceps will be more fre- quently indicated after the trunk has been expelled. With, per- haps, more than my share of pelvic presentations, either in my OAA'n immediate practice or through consultation, I have met with but two cases in which I could not overcome difficulty in the delivery of the head by simple manipulation. In the tAvo cases alluded to, the arrest in the expulsion of the head Avas occasioned, in one instance, by a contraction of about one quarter of an inch in the antero-posterior diameter of the upper strait; in the other, the head Avas unusually large. In both cases I was obliged to have recourse to the forceps, and Avas fortunate in delivering the children alive. Some appalling results occasionally ensue from the rude and unskilful attempts to extract the head by manipulation. Such, for example, as the detruncation of the foetus, rupture of the uterus, breaking the neck of the child, or, Avhat is just as fearful, disloca- tion ; serious lacerations of the soft parts of the mother, involving the vagina, rectum, or bladder. Many a tale of woe could be told, if the truth Avere spoken, in reference to this point. There is no necessity for these sad consequences once in ten thousand times; and they accumulate merely because brute force is too often sub- stituted for judgment and skill. These melancholy occurrences in the lying-in chamber attract, unhappily, no special attention; sur- rounding friends are satisfied because they have had rung into their ears, and they have faith enough to believe it, that stereotyped phrase—" All was done that could be done !" Hoav fortunate for some men that they practise among a credulous public, and that their acts are subjected to no truth-revealing scrutiny! But is there a corresponding benefit to the public ?—is that public in any way requited for its measure of faith ? I think not. Indications for Forceps Delivery after the Expulsion of the Trunk.—It may become necessary to resort to the forceps for the purpose of delivering the head after the passage of the trunk through the maternal organs, under the folloAving circumstances: 1. In version, the entire operation being completed, except the extraction of the head, this latter being arrested in consequence of some disproportion, etc.; 2. In an original pelvic presentation, in which the natural effort has been adequate to expel the trunk but not the head; 3. The occurrence of convulsions, exhaustion, or any other serious complication, after the exit of the trunk has been completed. When, in any event, it becomes urgent to apply the instrument, the head may be arrested either at the superior or inferior strait, in the direct, diagonal, or transverse positions. We shall first describe the manner of using the forceps, the head having reached the inferior strait: THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 609 Application of the Forceps after the Escape of the Trunk, the Occiput regarding the Symphysis Pubis, the Face toward the Sa- crum.—If the head should have descended to the inferior strait, the first thing to do, as preliminary to the introduction of the instru- ment, is gently to elevate the trunk and arms of the fcetus toward ihe abdomen of the mother (Fig. 95). Thus elevated, they are to be maintained in this position by an assistant, while the application of the forceps is to be conducted as folloAvs : The male branch, held by the left hand, is glided along the fingers of the other hand on the side of the pelvis and head, precisely as has been indicated in the corresponding position of the vertex, with the occiput toward the pubes and the face in the concavity of the sacrum. This branch adjusted, it is entrusted to an aid, and the female branch is then seized by the right hand, and carried on the other side of the pel- vis. The instrument is locked, and the extractive and lateral forces conducted upon the same principles as previously described ; the extremity of the handle of the forceps should be gradually raised toward the pubes until the forehead has passed the vulva, and care should be taken to give proper support to the perineum, in order that laceration may be prevented. Application of the Forceps after the Escape of the Trunk, the Occiput at the Sacrum, the Face toward the Pubes.—Here the trunk and arms of the fcetus, instead of being elevated, should be directed backAvard in the direction of the perineum, and being held by an assistant, the accoucheur proceeds to introduce the forceps on the sides of the pelvis and head in the same manner as if it Avere a vertex presentation, with the occiput toward the sacrum, and the face at the pubes; the extractive and lateral forces, together with the delivery, are also to be governed by the same rules as in this latter position of the head. Application of the Forceps after the Escape of the Trunk, the Occiput toward the left and front of the Pelvis, the Face at the opposite Sacro-iliac Symphysis.—Here, you perceive, the head rests in a diagonal position, and the body of the child should be 39 610 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. placed in a corresponding direction. The trunk and arms, there- fore, should be turned toward the left thigh of the mother, and confided to an assistant. The instrument is then to be introduced as if the vertex presented with the occiput to the lateral portion of the pelvis, and the face regarding the opposite point of the pelvic canal. The occiput in this case being to the left and front of the pelvis, the female branch of the instrument- is introduced first; it is held by the right hand, and glided on the fingers of the left along the right side of the pelvis until it reaches the chin; it should be continued in the same direction as high as the forehead, from which point it should be made to pass, by the gentle pressure of the fingers, within the pelvis, under the middle of the face and upon the left temple, in order that it may be brought under the pubes; at the same time the extremity of the handle should be slightly depressed, and turned toward the left thigh, with the vieAV of adjusting the blade properly to the length of the head. This branch is now entrusted to the aid; the accoucheur then holds the male branch Avith his left hand, and introduces it along the fingers of the other hand in front of the sacrum, in order to grasp the other side of the head. The forceps is then locked, and before resorting to any extractive force, a rotary movement from left to right should be imparted to the instrument, for the purpose of placing the occiput at the pubes, and the face in the concavity of the sacrum. The combination of the lateral and extractive forces is next to be employed, and the delivery completed as if it were an original vertex presentation with the occiput toward the sym- physis pubis. Application of the Forceps after the Escape of the Trunk, the Occiput to the right and front of the Pelvis, the Face at the oppo- site Sacro-iliac Symphysis.—Here, again, the position of the head is diagonal in the pelvis, and the same rules are to be observed in the introduction of the forceps as in the preceding example, except that the male branch is to be introduced first, because the occiput, instead of being to the left, is to the right. It is to be brought under the pubes, while the female branch should be directed along the front of the sacrum, in order that the new curve of the instrument may correspond with the occiput, or anterior portion of the pelvis. The two branches being locked, rotation from right to left is first accomplished for the purpose of changing the direction of the head from the diagonal or oblique to the direct position, by placing the occiput in correspondence Avith the sym- physis pubis, and the face toward the sacrum. The delivery is then completed in accordance with the principles already indicated.* * If, after the escape of the trunk, it be found that the head occupies a diago- nal position, the reverse of those we have just described, viz. the occiput at either of the sacro-iliac symphyses, and the face to the lateral anterior surfaces of the pelvis THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 611 * Application of the Forceps, the Head at the Superior Strait.— Having pointed out the rules to be adopted in the use of the forceps, the head being at the inferior strait after the exit of the trunk, it remains for us to make one or two observations in refer- ence to the application of the instrument Avhen the head, from what- ever cause, becomes arrested at the brim. You have been reminded that, in a vertex presentation, and the body of the child yet within the uterus, the adjustment of the forceps, the head being at the upper strait, is one of the most difficult operations in obstetric sur- gery ; for this reason you will remember, when artificial delivery is indicated, and you have the alternative of choice, I recommend version in preference to instrumental delivery. But, however em- barrassing and perilous the application of the forceps in an ordinary vertex presentation at the superior strait, the difficulties and dangers are enhanced after the trunk has made its escape and the head remains at the brim; for here, you will perceive, is the increased difficulty of conducting the forceps to the strait, in consequence of the vagina being more or less obstructed by the upper portion of the child's body, and this, too, in proportion to the elevation of the head in the pelvis. If, however, you should have a case in which forceps delivery is indicated, the head remaining at the superior strait after the escape of the trunk, the same rules are to govern in the use of the instrument as if it were originally a vertex presenta- tion, and the head arrested at the brim, the only important difference being that proper provision is to be made for supporting the body of the child, as was pointed out Avhen speaking of the application of the instrument, the head being either in the excavation or at the inferior strait. Application of the Forceps in Face Presentation.—When treat- ing of face presentations,* you Avere told that, all things being equal, they are entitled to be regarded as natural, and, therefore, within the resources of nature. But here, as in the case of an ordi- nary vertex presentation, something untoward may occur render- ing it essential that artificial delivery should be resorted to. It is proper, therefore, that the rules for the use of the forceps in these cases should be indicated. It may, hoAvever, be premised that, in face presentations, if the face be at the superior strait, version should be preferred to instrumental delivery for the same reasons that this preference should obtain, under similar circumstances, Avhen the vertex presents and artificial aid becomes necessary. It the accoucheur should attempt, if possible, to turn the face toward the sacrum. In this, however, he would most likely be foiled; the alternative, under these cir- cumstances, would be to apply the forceps, remembering that the new curve of the instrument must correspond with the face. After the instrument is adjusted, the face is brought to the pubes, and the labor terminated as if it were an original vertex position, with the face in front and the occiput behind. *■ See Lecture xxiv. 612 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. t Avas the general practice among accoucheurs, before the mechanism of a face presentation was understood, to have recourse to various expedients for the purpose of overcoming what they supposed to be an insurmountable difficulty, when the visage came first. For example, one would recommend to push the face upAvard and reduce the pre- sentation to that of the vertex; another, to grasp the occiput Avith the fingers or lever, and draAV it toward the centre of the pelvis. Independently of the undeniable fact that these mutations of the head are not only extremely difficult to accomplish, and the attempt to effect them oftentimes accompanied by more or less danger to the child and mother, it is now Avell demonstrated that they are alto- gether unnecessary for the reason that nature, Avhen the proper proportion exists betAveen the head and maternal organs, is com- petent to cause by her own efforts the descent and expulsion of the child. Again: it was the custom of some practitioners, as soon as it Avas ascertained that the face presented, to resort at once either to version or the forceps. These abstract modes of procedure had no justification, and were all founded on the supposition that a face presentation was abnormal, and, therefore, beyond the ability of nature to remedy. But experience has proved the contrary of all this, and, in our day, when either version or the instrument is em ployed, it is not because the face presents, but because of some con- tingency or complication, which renders the interposition of science absolutely necessary. You have been told that, as a general rule, the face is found at the superior strait in one of two positions, although occasionally there will be variations; the positions to which I allude, are: 1. The forehead of the fcetus is toward the left iliac bone, while the chin regards the opposite side. This is recognised as the right mento-iliac position; and here the fronto-mental diameter of the face is in apposition or correspondence Avith the transverse or bis- iliac diameter of the brim, while, on the contrary, the transverse diameter of the face is parallel to the sacro-pubic diameter of the pelvis. 2. The forehead is toward the right iliac bone, and the chin to the opposite point. This, it will be perceived, is the reverse of the first position, and is known as the left mento-iliac. In either of these positions, the head, in its descent, undergoes tAvo move- ments—diagonal and direct. Thus, as the labor advances in the first position, it changes from the transverse to the oblique direc- tion, so that the fronto-mental diameter of the face accords with the right oblique diameter of the pelvis, the chin being opposite to the right foramen ovale ; then the chin, through the direct move- ment, is brought behind the pubes, and the forehead turned into the hollow of the sacrum. In the second position, the mechanism of descent is precisely the same, except that the rotary movement is from left to right instead of from right to left. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 613 My object in recalling to your recollection the peculiar direction of the face in these two most frequent presentations at the superior strait, is to show you the almost impossibility of applying the for- ceps, until the head has begun to assume, in the course of its descent, the oblique or diagonal position; for, until this is done, the face occupies the strait transversely, either exhibiting the right mento-iliac or left mento-iliac position. Therefore, if, before the change from the transverse to the oblique direction, there should be imminent urgency for artificial delivery, I advise you by all means to abandon any attempt with the forceps, and proceed to terminate the labor by version. It may, however, happen that the face will so present at the brim as that the chin shall correspond with the pubes, and this would be more likely, perhaps, to occur if there were a slight contraction or narrowing of the transverse dia- meter ; or, instead of the chin being at the pubes, it may corre- spond Avith one or other of the acetabula constituting au example of the diagonal or oblique presentation of the face. In such an event, although I should again as a general principle prefer version to the instrument, yet it is very evident, Avith a moment's reflection, that the forceps could be applied with about the same facility as if the vertex were at the superior strait. To illustrate, suppose the chin Avere toward the pubes. In this case, the face would exhibit a direct position, its mento-frontal diameter corresponding Avith the sacro-pubic diameter of the brim. The forceps, under these circumstances, should be introduced along the sides of the pelvis, and Avould consequently grasp the head in the proper or lateral direction. If, on the contrary, the chin regard one or other of the acetabula,* the mento-frontal diameter Avould be in apposition with one or other of the oblique diameters of the * It will sometimes occur, that the chin, in face presentations, will occupy a posterior position, corresponding with one or other of the sacro-iliac symphyses, and, under such circumstances, the natural powers may suffice, during the progress of the head, to bring the chin and anterior surface of the child's body in front, and thus the labor will be terminated without the assistance of the accoucheur. But we will suppose an example, in which this change in the position, from behind forwardi cannot be accomplished by the natural effort. In this contingency what is to be done? In the first place, it maybe remarked that the mere adjustment of tho forceps to the head would not of itself be so difficult: but it is to be remembered that, after the adjustment, the difiScult thing to accomplish is to bring the chin to the front of the pelvis, a fundamental requisite in all cases of face presentation in order that the head may make its exit; and this will be found, I may safely say, impossi- ble to do, unless the pelvis be unusually capacious or the head under size. There- fore, if nature prove incompetent to direct the chin toward the anterior half of the pelvis, and this should be ascertained opportunely, the resort should be version. If, however, from rigidity or other opposing conditions of the uterus, the hand cannot be introduced, and these antagonizing influences do not yield to the appropriate remedies already pointed out, then there is no alternative but craniotomy if the child bo dead; if alive, the question may arise, craniotomy or the Cesarean section— which topics will be fully discussed in a future lecture. 614 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. upper strait. In such an aspect of things, the forceps could also be applied, the same rules precisely being observed as if it Avere a vertex presentation with the occiput to the pubes, or to the left or right. So much for the management of face presentations, through the aid of instrumental delivery, the head being at the superior strait. Let us noAV examine the modus in quo of procedure after the head has passed into the pelvic excavation. Under these latter circum- stances, the chin will be either in front or posteriorly, constituting the mento-anterior or mento-posterior positions. The Mento-anterior Position.—In this position, the head may rest in the pelvic cavity either directly or obliquely, depending upon whether the chin has completely turned toward the pubes, or whether its aspect is to one or other of the lateral points of the excavation. In the former case, the head occupying the direct position, Avith the chin at the pubes and the forehead toward the sacrum, the forceps must be introduced hi the same manner as if the occiput Avere at the pubes and the face regarding the sacrum. The blades being adjusted to the head and properly locked, the first tractions should be directed dowmvard in order that the chin may be brought from under the pubic arcade; as soon as this is accomplished, not forgetting to protect the perineum by judicious support, the handle of the instrument is to be gradually elevated toward the abdomen for the purpose of completing the extraction of the face. In the oblique or diagonal position, Avith the chin at either the left or right of the anterior surface of the pelvis, the same rules are to be observed in the introduction of the instrument as if the occiput regarded one of these points; vvhen the head has been properly grasped, the first thing to be done is to produce a rotary movement from left to right, or from right to left, as the case may be, with a view of changing the position from the oblique to the direct. The delivery is then to be proceeded Avith as already described. The Mento-posterior Position.—It is most fortunate that this position of the face is comparatively of rare occurrence. You have been told that, in face presentations, the persistent tendency of the natural effort is, through a special mechanism, to bring the chin for- ward either to the pubes or to one or other of the lateral points of the anterior portion of the pelvis. Nature, however, is occasionally contravened in this effort, and then she relies entirely on the dis- creet interposition of the accoucheur. Suppose you had an example of mento-posterior position, what course would you pursue ? Li the first place, you are to recollect that in no case, unless as an exception, if I may be permitted to say so, to an almost universal rule, can the head be made to accomplish its exit through the maternal organs, the chin continuing to remain in a posterior posi- tion. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 615 When speaking of this position a few moments since, the face being at the superior strait, you were admonished of the difficulties attending it; these difficulties are in no way diminished after the face has descended into the pelvic cavity. When, therefore, you have become satisfied that nature is incompetent to bring the chin toward the anterior portion of the pelvis, and further delay would be perilous to the child, and not altogether without serious conse- quences to the mother, three indications will present themselves to the mind of the experienced accoucheur : 1. To endeavor by means of the forceps to bring doAvn the vertex, by making an extreme downward and backward traction, and thus substituting a vertex for a face presentation; 2. To endeavor, by an adroit rotary move- ment with the instrument, to detach the chin from one of the pos- terior to one of the anterior points of the pelvis ; 3. If the head should not have passed beyond the mouth of the uterus, and this latter be in a condition to justify the operation, version may be attempted. These, then, are the three alternatives, the tAvo first most difficult to accomplish, and, indeed, I may say the chances of failure greatly preponderating. Version, hoAvever, if the conditions premised be present, is much more feasible, and, in dexterous hands, may suc- ceed. Hypothecating that these three alternatives should fail, is there any other resort left, or is the mother to be permitted to die undelivered? This is a grave question—but yet it must be answered. The last resort, perfectly justifiable under the circum- stances, provided the child be dead, is craniotomy; should, on the contrary, there be satisfactory evidence that the child is alive, there may arise the momentous question—shall the child be sacrificed, or the chances of life betAveen it and its parent equalized by subjecting the latter to the hazards of the Cesarean section ? Before closing my remarks on the subject of face presentations, I may, I hope without the imputation of improper motives, be per- mitted briefly to narrate the two following instances in which I applied the forceps with safety to both mother and child; I am induced to refer to these cases, because they have, in my judgment, a useful practical bearing, and may, under similar circumstances, serve to remind you of your duty: Dr. Oatman requested me to visit in consultation with him a lady, aged tAventy-seven years, the mother of one child, three years old. She had been in active labor twenty-four hours before I saAV her; the pains from the commencement had been strong, and she suffered greatly from their more or less constant recurrence, the slight inter- mission between them constituting a remarkable feature in the labor. The membranous sac had become ruptured three hours after the commencement of the parturition-, but the mouth of the uterus was previouslv well dilated. Dr. Oatman, on making a vaginal exami- 616 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. nation, ascertained that the face presented; the head was slightly responsive to the vigorous contractions, but its descent into the pelvic cavity extremely sIoav ; after the face had fully reached the excavation, it became arrested, and notwithstanding the continued powerful efforts of the uterus, it made no farther progress. The mother's strength Avas yielding under the influence of these repeated but fruitless contractions, and the child's safety in great peril from the pressure to which it Avas exposed. It Avas at this period of the labor that a messenger reached me requesting that I Avould promptly meet Dr. Oatman. I immediately obeyed the summons, and on my arrival found the condition of things as described above. The face exhibited an example of mento-anterior presentation, the chin being at the left of the pubes, with the forehead regarding the opposite sacro-iliac symphysis ; in other Avords, the face rested in the left diagonal position. I soon became satisfied that nature had strug- gled long enough, but vainly, to produce on the head the rotary movement, which Avould have resulted in placing the chin in appo- sition Avith the pubes, and the forehead toward the sacrum. The basis for this opinion Avas the evident exhaustion of the mother, together Avith the unusual tumefaction of the child's face, and the increased heat in the \ragina ; these phenomena, remember, accompanied by poAverful but unavailing contractions of the uterus. There could be no doubt as to the course to be pursued under the circumstances; inaction on the part of the accoucheur, founded upon an abiding faith in the ability of nature to accomplish the delivery, would, without a doubt, have resulted most disastrously, for the evidence was abundant and unequivocal that, if this condi- tion of things had been permitted to continue, the forces of the mother would have given way, and the life of the child sacrificed. What, therefore, was the indication ? Why, evidently, to consume no time in idle expectation, but to proceed at once and render the needed assistance, so that, by opportune interference, the lives of both mother and child might be rescued from the dangers Avhich threatened them. Dr. Oatman concurred entirely in this view of the case, and at his request I applied the forceps in accordance Avith the rules already indicated. As soon as the instrument had been adjusted on the head, I brought, by a rotary inclination, the chin to the pubes, thus changing the position from the diagonal to the direct; this being accomplished through proper tractions as pre- viously described, I had no difficulty in bringing the head into the world. The child, a little daughter, Avas alive, and the mother had a favorable convalescence. Hesitation, or, perhaps, an hour's delay, would have rendered these agreeable results impossible. On another occasion, I received a note from Dr. Judson to meet him under the folloAving circumstances : He Avas in attendance on a lady in labor Avith her first child. She Avas twenty-one years of age, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 617 and, with the exception of a delicate nervous organization, enjoyed good health. Her parturition commenced at six o'clock a.m. Dr. J. suav her at eight; the pains were slight, but the labor had fairly begun. After remaining for an hour Avith her, he left with the request that he might be notified as soon as his services Avere needed. At four o'clock p.m., just ten hours from the first indi- cation of the parturient effort, he was again sent for. At this time, some progress had been made, the os uteri dilated to the size of a dollar piece, with increasing and recurrent pains. Things continued to progress; at seven o'clock the membranes ruptured, and there escaped an unusual quantity of liquor amnii. Soon after the rup- ture of the sac, the Dr. discovered the presentation to be that of the face. The pains increased in power, assuming an expulsive cha- racter ; the head began to descend into the pelvic cavity; at ten o'clock it had passed to the lower strait, Avith the chin to the pubes and the forehead to the sacrum. The pains noAV assumed a strong expulsive force, and during one of them, the patient Avas suddenly attacked Avith convulsions, Avithout any premonition Avhatever. In fifteen minutes there AA'as a second convulsion, the pains becoming more marked and vigorous. At this time, eleven o'clock p.m., I was requested to meet Dr. Judson. At half after eleven, Avhen I arrived, I found the uterus contracting Avith full force, and nature doing all she could to ter- minate the delivery. The features of the face Avere excessively tumefied, and, notwithstanding the vigor of the pains, the head did not advance in a corresponding ratio. Twenty minutes after my arrival, the third convulsion occurred. Tliese Avere all the facts of the case, and hoav the question to be determined Avas this— What, under the circumstances, was the most rational course to be pursued ? My own opinion, frankly expressed to my friend, the doctor, was—that the convulsions Avere of eccentric origin, due alto- gether to the irritation of the incident excitor nerves of the vagina; and this opinion was grounded upon the important fact that the convulsive movement did not occur until this extreme pressure had begun to exert itself on the walls of the vagina ; there had been no previous mdication of any such nervous derangement; there was an entire absence of any hydropic condition, etc., indicating the presence of albuminuria. Supposing this vieAV of the case to be sound, Avhat Avas the necessary practical deduction as to our line of conduct ? It Avas to remove, at the earliest possible moment, the cause of the irritation, and this could only be done by prompt artificial delivery. Therefore, as every instant of time Avas pre- cious, at the doctor's request I applied the forceps, having first placed the patient under the full influence of ether. I was fortu- nate in extracting a living child. The mother had no recurrence of the convulsion, and was soon in the enjoyment of her usual health. LECTURE XLI. Cutting Instruments—What they Involve—Importance of the Question—"What ia the Smallest Pelvic Capacity through which a Living Child can be made to pass, and what the Capacity through which a Child may be extracted piecemeal ?—Dis- crepancy of Opinion on these Questions—Symphyseotomy, in what it consists— Sigault its Originator—The true claims of the Operation—The Question exa- mined—Comparison instituted between Symphyseotomy and the Cesarean Section —Statistics of each—Deduction—The Caesarean Section—The Opinions in Great Britain and on the Continent of Europe as to the Merits of the Operation—Reasons for the marked Difference of Opinion—Analysis of the "Views of Authors touching the Caesarean Section—Statistics of the Operation—How its Fatality may be Modified—Opinion of the Author as to the Advantages of the Caesarean Section over Craniotomy—What are the Dangers of the Operation ?—The Benefits of Anaesthesia in controlling the Shock to the Nervous System—Post-mortem Caesar- ean Section, when resorted to—The Case of the Princess of Schwartzenberg—The Roman Law on the Subject of the Post-mortem Operation—Method of Performing the Caesarean Section; the Vertical Incision through the Linea Alba preferred— Why ?—Should the Operation be Performed before or after the Rupture of the Membranous Sac ?—How is the Child to be Extracted through the Opening in the Uterus ?—Rules for Removing the Placenta—Dressing the Wound, and sub- sequent Treatment—The Operation of Elytrotomy, as a Substitute for the Incision- into the Uterus, proposed by Jorg and others—Merits of the Operation—Dr. Christoforis and the Resectio-subperiostea of the Pubic Bones—Researches and Statistics of M. Philan-Dufeillay Gentlemen—Having described to you the blunt instruments used in midwifery, their object, and mode of employment, the next topic for our consideration xvill be the cutting instruments which, when resorted to, must of necessity either destroy the child, if alive, or subject the mother to the hazards of a perilous operation. You see, therefore, in the discussion of this question, we approach a point, the most important, perhaps, so far as a just decision is concerned, in the Avhole range of obstetric science—a point which not only involves human life, but imposes upon the medical man the highest and most sacred obligations. In the examination of this topic, I shall, I trust, have my mind emancipated from the thraldom of bias or preconceiA'ed opinion, and shall endeavor to reach the truth through a proper sifting of evidence; for, after all, the employment of cutting instruments, Avhether upon the child or mother, is simply a question of testimony to be developed by surrounding circum stances, and determined by the honest judgment of the accoucheur and his associates in counsel. Prerequisites for the Use of Cutting Instruments.—It should be THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 619 remembered that the fundamental prerequisite for a resort to these instruments is such a disproportion between the maternal organs and foetus as to render it physically impossible that the latter can be made to pass, either through the natural effort, version, or by the aid of the forceps, per vias naturales ; and this disproportion may arise from a contracted pelvis, the presence of osseous or sar- comatous tumors, a narrowing of the soft parts, an abnormally large child, or from malposition of the foetus itself. In either event, how- ever, the grave question presents itself, shall the cutting instrument be applied to the child, or to the mother? In the former case— assuming, of course, that the child is alive—it will inevitably be destroyed; in the latter, on the contrary, although the safety of the mother is in more or less peril, yet it is not necessarily compro- mised, and the chances of life are equalized between her and the child she carries within her. The decision of this question is, I repeat, of momentous import, and cannot be regarded lightly by the medical man who is governed by a high morality, and feels that there is nothing incompatible between the scientific physician and conscientious Christian. Amount of Pelvic Contraction consistent with the Birth of a Living Child.—As to what really constitutes a contracted pelvis, such as will not permit the transit of a living child at full term, there exists a remarkable discrepancy of opinion ; and this very circumstance, no doubt, will explain, in part at least, the conflicting vieAvs of authors regarding the justification for the employment of cutting instruments. For example, Busch, of Berlin, says, for a living child to pass, the antero-posterior diameter must measure from 2|- to 3 inches; Burns 3£; Dr. Joseph Clarke 3£. Dr. Os- born* places it a fraction beloAV 3 inches, AAdiile Dr. Ritgen is of opinion that a contraction of 2 inches is not inconsistent Avith the passage of a living foetus at maturity! My own opinion, arrived at not Avithout full consideration, and some share of experience, is that a diameter of 3£ inches antero-posteriorly is the smallest possible space, except under very rare exceptional circumstances, through which a living foetus at the end of gestation can make its exit,f and * " Whenever a woman falls into labor, the small diameter of whose pelvis mea- sures only 2| inches, one or other of the following circumstances must take place: 1. The child's head must be opened; 2. For the certain preservation of the child's life, the mother must be doomed to inevitable destruction by the Caesarean opera- tion ; 3. As a mean between the two extremes, the mother must submit to the division of the symphysis pubis (symphyseotomy), an operation less dangerous to the patient than the Cesarean section, but less safe for the chdd; or, if none of these means will be permitted, the wretched mother, abandoned by art to the excruciating and unavailing anguish of labor, will probably expire undelivered." [Essays on the Practice of Midwifery in Natural and Difficult Labor. By Wm. Osborn, M.D. 1792. p. 194] f See Lecture Fifth. 620 THE PRINCIPLES A.ND PRACTICE OF OBSTETRICS. even with such capacity, more or less hazard and a protracted delivery will be the almost necessary result.* Amount of Pelvic Deformity through which a Fcetus may be Extracted Piecemeal.—The same want of concurrence is noticed * An exception, perhaps, to this rule may be made in certain cases of hydroce- phalus, in which the bones of the head become so excessively yielding as to undergo an extraordinary pressure without destroying the life of the child. I saw a case of this kind some years since, which occurred in the practice of Dr. Hibbard of this city. He requested me to meet him in consultation under the following circum- stances : The lady, aged twenty-nine years, was taken in labor with her first child at 5 o'clock a.m. The doctor saw her at 8 o'clock; the pains, before he arrived, had commenced with an unusual degree of force; he found, on examination, the os uteri fully dilated, the membranous sac ruptured, and the head beginning to descend into the pelvic cavity. The pains lost nothing of their expulsive character, but con- tinued with regularity and vigor. There was, however, at 4 o'clock p.m., but a slight advance in the position of the head ; a' this time I saw the patient, being just eleven hours from the commencement of the labor. After giving a history of the case as above detailed, Dr. Hibbard requested me to examine the patient. The head rested diagonally in the pelvis, and had evidently continued to make progress under the strong contractions of the uterus, although the advance had been ex- tremely slow. During an interval of pain, I again introduced my finger into the vagina, when I very distinctly recognised a peculiar condition of the head ; it was flaccid to the' touch, and the bones were movable, the one upon the other. What could this be? Was it because of the death of the child, and its putrefaction? This hypothesis was soon removed, because auscultation revealed the beatings of the fcetal heart, and the mother, too, was conscious that her child was alive, for she very distinctly felt its movements. Here, then, was an interesting state of things, and there was much need of sound judgment. Some writers place great confidence in the flaccidity and overlapping of the bones of the head as an evidence of the death of the foetus ; and, therefore, in the case now under consideration, if this evidence had been accepted as worthy of guidance, it might possibly have happened that, under the conviction that the child had ceased to live, a resort may have been had to the perforator and crotchet for the purpose of bringing the dead foetus into the world, and thus terminating the deli- very. In these days of fondness for instruments, such an alternative is certainly not among the very improbable things of the lying-in room. From all the circumstances of the case, I had no doubt of the true cause of the flaccidity and overlapping of the bones, it was manifestly-an example of hydrocephalus; in this opinion, I was happy to find Dr. Hibbard fully concurred. With this diagnosis, the question arose—What, under the circumstances, was the course to be pursued ? It was agreed that the labor should be confided to nature, and for these obvious reasons: 1. The child was alive ; 2. The strength and general condition of the mother were good. The pains continued with their wonted force, and at half-past three o'clock a.m., twenty-two hours from the commencement of the parturition, we had the satisfaction of witness- ing the propriety of the course adopted in the birth of a living child; although alive its head exhibited a most uncomely appearance, in consequence of the extreme elongation it had undergone, the occipito-mental diameter measuring nine inches. It soon, however, recovered from this temporary malformation, and survived its birth four months and one week. The mother had an ordinary convalescence. I was anxious to ascertain the true condition of the pelvis in this case, and in carrying the finger to the upper strait, it was quite evident that there was an unusual contraction In the antero-posterior diameter, which could not have presented a fraction over three inches. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 621 among authors as to the extent of deformity through which it is possible to extract a child at full term, fragment by fragment, in the operation of embryotomy. Burns, for instance, justifies the operation, when there is a space of If inches; Hamilton 1*-; Osborn \\ ; Davis 1 inch ! Dr. Dewees, on the contrary, thinks if the contraction be less than 2 inches, embryotomy should not be resorted to. I have endeavored to shoAv (Lecture V.) that if the direct or antero-posterior diameter fail to measure from 2 to 2J inches, embryotomy cannot be accomplished without the almost certain hazard of laceration of the maternal organs, AA'hich may more or less involve life, or entail upon the parent sufferings to Avhich death itself Avould oftentimes be preferable ; and, therefore, I emphatically urge that the operation should not be attempted with a less space than 2J inches, with the single exception that the child be dead. Whether with this space, or even a greater one, it Avill ever be justifiable to resort to the perforator and crotchet, if the child be living, it will be our purpose to discuss as Ave proceed. Deductions.—Taking, therefore, the two extremes, which, in my judgment, will be found correct, viz. a space of 3\ inches for the passage of a living child,* and 1\ inches to justify embryotomy, the question naturally arises—what is the rule of conduct, when the pelcis shall present a contraction between these measurements, or beloAV 2\ inches, if it should be ascertained that the child is alive, and the woman at the full period of her gestation? In the exami- nation of this quest ion, it must be constantly borne in mind that the alternative of choice is to rest altogether upon the simple but important issue—shall the child, known to be alive, be sacrificed, in order that the mother may be saved ? or shall the mother be sub- jected to an operation, Avhich, while it Avill involve her in serious peril, Avill afford a reasonable, or, if I may be permitted to say so, more than a reasonable, hope for the life of the child, thus, as it were, equalizing the chances betAveen parent and offspring. If the latter course should be decided upon, the choice of operations to be performed on the mother, will be between what is known as sym- physeotomy and the Caesarean section ; if, on the contrary, it be determined to destroy the child, then resort is to be had to cranio- tomy, cephalotripsy, or embryotomy, as circumstances may indi- cate. I now propose to review in succession these various alternatives, yielding to each, as far as I can do so, its proper place in the scales * I am aware that authors of integrity have recorded examples of living children being born, through the natural effort, when the abridgement was less than 3-J inches; for example, Smellie aud Baudelocque both cite cases of this kind, in which [he head, natural and healtliy, had undergone extraordinary pressure, and was expelled without compromising the safety of the child. But these are to be regarded as exceptional instances, and, therefore, cannot form the basis of a principle. 622 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of right, and deducing from statistical data and other sources the basis of conduct by which the conscientious accoucheur is to be guided, when, from disproportion between the maternal organs and foetus, the latter cannot pass at full term, per vias naturales, except through the intervention of cutting instruments. 1. Symphyseotomy.—This consists in a section of the symphysis pubis, with the vieAV of giving such an increase of capacity, as to allow the exit of the child. The projector of this operation was a French medical student, named Sigault, A\rho made it the topic of a memoir, Avhich was presented to the Academy of Surgery in 1768 ; it was, however, not well received by the Academy. But Sigault, still firm in his conviction that he would be able to demonstrate the great fact that symphyseotomy was destined to become a sub- stitute for the Caesarean section, and entirely do away with the necessity of the latter operation, selected the same question as the subject of his thesis in the school of Angers in 1773.* It is due to this enthusiastic surgeon to state that, at first, he simply proposed to experiment on living animals, and then on condemned criminals; his essays on the dead subject having satisfied him of the correct- ness of his opinion as to the feasibility and advantage of the opera- tion on the living woman in certain cases of pelvic deformity. As on most questions of science, the persevering demands of Sigault for an opinion soon gave rise to two parties, the one in favor, and the other adverse to the suggestion. Among the former, may be mentioned the learned Holland physician, the well-known Dr. Camper, Avho, in 1774, wrote a letter on the subject to Van Gesscher, entitled, De Emolumentis Sectionis Synchondroseos Ossium Pubis in Partu difficili. Nothing, however, of a positively decided character developed itself in the minds of the profession, if we except the mere expres- sion of opinion as to the anticipated benefits or evils of the pro- posed operation, until 1777, when Sigault, assisted by his friend, A. Le Roy, tested the feasibility of his theory, by resorting to sym- physeotomy on a married woman, named Souchot, which resulted in safety to both mother and child. This woman, it appears, had previously borne four dead children. The success of the operation Avas like the electric current, for it Avinged its flight almost Avith the rapidity of lightning ; for the time being, all doubts were at an end, and Sigault Avas the idol of Continental Europe. His name became one of honor ; the poor student, who was ridiculed at first, was now the very centre of attraction ; he was the originator of a new epoch in obstetric science ; he had caused to be expunged from practice the " barbarous and deadly " Caesarean section, and substituted in its stead the " rational and conservative" operation of symphy- * The following is the title of the thesis: An in Partu contra Naturam Sectio Symphyseos Ossium Pubis Sectioue Csesarea promptior et tutior. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 623 seotomy. I am only quoting the words which were on every one's tongue at the period of Avhich I speak. His fame was not limited to the adulations of the body of the profession, but he became the recipient of the highest honors of learned academies—the very academies which had originally nearly crushed his spirit by the unfavorable manner in which his " rational and conservative " pro- position had been received ! The Academy of Medicine of Paris voted him a medal, bearing the following inscription : " Anno 1768, Sectionem Symphyseos Ossium Pubis invenit, Proposuit: Anno 1777, fecit feliciter 31. Sigault, D. M. Ipsiepie, centum calculos illos esse offerendos. Juvit M. Alph. Le Roy, D.M.P. Cui quinqua- ginta offerentur calculi illi argentei." In addition to this medal, making such honorable mention of Sigault, and his assistant, Alph. Le Roy, a royal pension was granted to the illustrious benefactor of the age. But this Avas not all; many an eloquent pen was busy with oblations of praise, and Sigault was lauded as the man, of all others, who had contributed a precious floAver to the garden of science, and had conferred on womankind a blessing which Avould not fail to be appreciated in all time. Indeed, there was a perfect furor in public opinion, and Sigault was its subject. Panegyric after panegyric Avas issued from the press, and he must have grown giddy Avith the eulogiums of his admiring friends, one of the most enthusiastic of Avhom, Roussel de Yausesme,* supposed that nothing short of inspiration could have led the mind of Sigault to such a magnificent conception: " At tandem Sigault, D.M.P. haec alta mente diu revolvens solus divino quasi afflatus numine quam monstrarat natura A'iam ingreditur.'' Again: under the influence of the same unbounded enthusiasm, this writer predicts that posterity will not fail to regard symphyseotomy as among the most useful of operations: " Non longam post elapsam annorum seriem, inter operationes maxime salutiferas annumeretur." I have thus presented this brief and running sketch of the origin of symphyseotomy, and of the acclamation by which its first success was received, in order that you may understand how oftentimes it happens that human judgment, even in grave matters of science, is premature in its decisions because of the crudeness with which investigation is carried out. Here we find upon simple assumption, founded in the first instance on the success of a solitary case, the professional mind, as it were, becomes startled at AA'hat it deems a great fact—learned bodies are impelled by the enthusiasm of the moment, and their imprimatur is affixed to Avhat the future proves to be the veriest phantom ! There is a moral in all this too palpable to need comment. Let us for a moment consider the objects of symphyseotomy, * De Sectione Symphyseos Ossium Pubis Admittanda. Paris, 1778. 624: THE PRINCIPLES AND PRACTICE OF OBSTETRICS. together Avith the results of the operation, and then determine AA'hether, in any event, it can become the substitute for the Cesa- rean section ; or Avhether, under any circumstances, it should con- tinue to receive the sanction of the profession as a humane or justi- fiable resort in the lying-in chamber. Its Objects.—The most ardent advocates of symphyseotomy based the motiA'e for its performance upon the exclusive facts—that it Avould so far increase the capacity of a deformed pelvis as to permit a living child to pass, and that it is a less dangerous operation than the Caesarean section. Ample experiment has very satisfactorily shoAvn that it is not possible, by the separation of the symphysis pubis, to obtain in the direction of the antero-posterior diameter, at the utmost, an increase beyond half an inch, and in accomplishing this there will be the serious hazard of lacerating the sacro-iliac syn- chondroses. If this be true—and the fact is, I think, universally conceded—it follows that no good result can be expected to the child if the contraction of the antero-posterior space should be a fraction under 1\ inches, for we hold that a living child cannot be made to pass if this diameter be less than 3 J inches; and even Avith that allotment the difficulty will be very great. As the chief motive for symphyseotomy is to save the child, that object would most certainly be defeated, if the space were much short of 2f inches. Another very important circumstance to be taken into account— and about AA'hich there is a general assent among authors—is that in consequence of the posterior relations to the pelvis of the sacro- iliac synchondroses, it ensues, as a necessary physical fact, that the greatest space obtained by this operation will be : 1. In the oblique diameter of the pelvis; 2. In the transverse; and, 3. In the antero- posterior. Noav, if it be remembered that it is the abridgment of the antero- posterior diameter, which in the first place constitutes the obstacle to the delivery, and, secondly, the motive for. a resort to the opera- tion, it would seem to follow, not only as an irresistible logical sequitur, but as an essential practical deduction, that unless sym- physeotomy will afford an additional space between the pubes and sacrum, such as beyond all peradventure Avill permit the passage of a living child, it fails to secure the object for which its advocates have contended; and, under the circumstances, in addition to the risks of the operation itself, it would become necessary to superadd the dangers to the mother of embryotomy, not to speak of the consequent sacrifice of the child. But let us suppose that the antero-posterior diameter shall measure 2| or even 3 inches—is symphyseotomy, with this space, indicated ? Its friends—If there be any now left—would perhaps be shocked at such an interrogatory. I have no hesitation, however, in saying, that in any case in which the division of the pelvic bones has been THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 625 recommended, I should myself, as an alternative, prefer the Caesa- rean section, for the obvious reason that I believe its dangers to both mother and child to be less than those involved in the opera tion of symphyseotomy. It has, I think, been shown that the first argument of the symphyseotomists—the acquisition of an increased space—when the contraction is less than 2f inches, is worthless in practice; and their second argument—that the operation is more conservative to parent and child—will be proved to be equally fallacious, as we shall see by a glance at the statistics of the two operations. Statistics.—It would appear that, in symphyseotomy, one mother is lost in every three, and one child in every two. These, it must be remembered, are simply the aggregate results of the operation ; there is no account taken of the serious and not unfrequently remote fatal issues to the mother in consequence of the injury inflicted on the soft parts, more particularly the bladder and uterus, to say nothing of the permanently crippled condition of the unhappy parent, which has occurred in more than one instance. If we now compare this table Avith that of the Caesarean section, we shall find that in the latter one mother is lost in 2^, while more than two thirds of the children are saved. Here, it is true, more mothers die, but the safety to the child is greatly increased. When, how- ever, a woman recovers from the Caesarean section, she has not entailed on her the accidents which so commonly result from sym- physeotomy, but she enjoys good health, and is not disqualified from attending to her ordinary dutieSj as is proved by the fact—Avhich has repeatedly occurred—of the same woman having been subjected to the operation several times, and with success to her and her child. Again: the results to the mother from the Caesarean operation just given, are not, in my opinion, to be regarded as fair exponents of its positive fatality, for they are taken from mixed cases, the great majority of which were no doubt operated on in extremis^ when the vital forces, from previous effort, had been so dilapidated as greatly to tend against recovery; and, as we proceed in the investigation of this question, I shall endeavor to demonstrate that the Caesarean section would be far more favorable to the safety of the mother if, as a general principle, it were resorted to earlier, and not left, as has been too often the case, until the last spark of life is near extinction. I can comprehend no difference, in this essential particular, between the Caesarean section and any other capital sur- gical operation. In the latter, is not the great element of success an opportune and timely resort to the knife, when the system is best prepared to resist the shock, and in condition to lead to reco- very ? The truth of this no one will doubt, and yet, so far as the Caesarean operation is concerned, this great conservative principle 40 626 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. has been sadly neglected. Therefore, for the reasons stated, my advice to you is to repudiate, as altogether unjustifiable, because without an equivalent for the hazard it involves, a recourse to sym- physeotomy. 2. The Ccesarean Section.—This operation consists in an incision through the abdominal walls and uterus of the mother, for the pur- pose of extracting the child; thig, at least, is the generally accepted definition. The definition, however, is too circumscribed, for, in strict construction, it is still the Caesarean section, whether the child be extracted by an opening through the abdominal parietes or vagina; hence it has been, I think, properly divided into abdo- minal hysterotomy and vaginal hysterotomy, depending upon whether the incision into the uterus be through the abdomen or A'agina. I do not deem it necessary to enter into any special dis- cussion touching the early history of this operation; I prefer rather to direct your attention to the important question— Under what cir- cumstances is the Ccesarean section justifiable, and what, as a con- servative resource, are its true relations to craniotomy ? Yew subjects, perhaps, in midwifery have given rise to more seri- ous discussion, and called forth more decided opinion, both for and against, than the very question which we are now to consider. Here, we find the controversy not limited to mere individuals, but it has, in the full sense of the term, become what may be truly called national. In Great Britain, for example, the almost univer- sal voice of the profession is in faATor of craniotomy in preference to the Caesarean section ; the writers and practitioners of that com- monwealth, as a very general principle, avow that there is no com- parison to be instituted between the value of the life of the mother and that of the child; and, therefore, in cases requiring cutting instruments, the perforator and crotchet are resorted to, whether the child be living or dead. On the Continent, on the contrary, the reverse of this obtains ; and craniotomy is, comparatively, much less frequently practised than the Caesarean section. It does really seem to me that, amid the conflict of sentiment, which has and still con- tinues to exist on this vexed topic, facts have had too frequently to yield to an inflexible determination not to surrender preconceived opinion ; in this way, and under the influence of a false principle, the human mind is oftentimes fettered in its judgment, and, as a consequence, much harm is entailed both upon science and huma- nity. Discrepancy of Opinion touching the Ccesarean Section.—I wish you distinctly to bear in memory that the controversy, with regard to the benefit or evil of the Caesarean operation, seems to rest on the contrast which authors have, in their own minds, insti- tuted between it and craniotomy, and also on the respective value which they affix to the life of the mother and child. It is worthy THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 627 of recollection, too, that the deductions of both parties are some- times from very false premises, as I hope to demonstrate before closing this lecture. It may not be without profit to array before you the opinions of some of the leading authors on this subject, and you will appreciate, in perusing their conflicting notions, the maxim—Quot homines tot sentential, which may be liberally trans- lated: As men's features differ so do their opinions. Dr. Osborn* says, " The valuable life of the mother should never be exposed to absolute destruction by the Caesarean operation for the certain safety of the child. The perforator should be had recourse to without reference to the life of the child." Mauriceauf writes, " The Caesarean section should never be per- formed on the living woman ; it is an inhuman, cruel, and barbar- ous operation." BaudelocqueJ holds, "To mutilate a living child, in order to avoid the Ccesarean section, is the offspring of ignorance and inhuma- nity ; nothing can excuse the practitioner who will have recourse to the perforator or crotchet without first being certain that the child is dead." Gardien§ says, " It is with good reason that prudent accoucheurs, in view of the fatal results of embryotomy, prefer the Cesarean operationf Dr. Weidemannfl " recommends the Caesarean section in every pelvic deformity in Avhich a living child cannot be delivered by other means /'' and he is most emphatic in his denunciation of the crotchet and perforator, for the following is his decided language, charac- terizino- the destruction of a living child by these means a monstrous crime: " In foetum vivum, uncas et perforatoria adigere, nefarv- dumfacinus est." Smellie,! England's great obstetric light, speaks thus : " When a woman cannot be delivered by any of the methods recommended in preternatural labors, on account of the narrowness or distortion of the pelvis, etc.; in such emergencies, if the woman is strong and of good habit of body, the Ccesarean operation is certainly advisa- ble, 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 hath sometimes succeeded, than leave them both to inevitable death." Sir F. Ould says, " The Caesarean operation is most certainly * Essays on the Practice of Midwifery, p. 225. \ Traite des Maladies des Femmes Grosses, vol. L, p. 352. j L'Art d'Accouchement, vol. ii., p. 220. § Traite complet d'Accouchement, p. 103. || Comparatio inter sect. Caesar, et dissectionem cartilag. et ligament pelv. in parta ob. pelv. august, impossib. T Midwifery, vol. i., p. 239. 628 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mortal, and I hope it will never be in the power of any one to prove it by experience." Merriman* speaks thus: " It cannot be matter of much surprise that, with so little success as has attended the Ccesarean operation in England, the British accoucheurs should be so reluctant to per- form or adopt it; and, therefore, recourse is never had to it, except in such deplorable cases only as preclude the possibility of delivery by any other means.'"' Blundellf says, " It is an axiom in British midwifery, that we are never to deliver by the Ccesarean operation, provided we can, in any way, deliver by the natural passages. I feel persuaded that women might sometimes be more safely and more easily delivered by the Ccesarean section, than by the passages of the pelvis; but if, acting on this persuasion, we were once to establish the princi- ple, that the Ccesarean delivery may be used as a substitute for delivery by the perforator, there would, I fear, be too many cases in which it would be needlessly adopted ; and men would now and then, not to say frequently, perform this operation in circumstances in toh ich it ought never to have been dreamed of. Where embryo- tomic delivery is practicable, let it be preferred." Dr. MaunsellJ observes, " The truth is, that in Great Britain the Cesarean operation never did, and never will, flourish.'' Dr. Murphy§ advises, "In order to decide upon the Caesarean section, you should weigh carefully the probable result to the mother, if the operation be not performed; and if it appear to you that perforation is impracticable, or so difficult to perform that the dan- ger seems to be nearly so great to the patient as opening the uterus, you are then authorized to undertake the operation, because, if there be a probability that perforation will not ensure safety to the mother, you are certainly bound to consider the child, and give it a reasonable chance for its life." Sufficient, I apprehend, has been done in the way of quoting authorities to demonstrate the extraordinary discrepancy of opinion on the question we are now considering; and it will be well to remind you that the writers I have cited are of no mediocre posi- tion ; on the contrary, they are men of eminent name. How is this difference of sentiment to be reconciled ? on what principle of reasoning can it be satisfactorily explained ? One would imagine that, according to every principle of logic, legitimate deductions are the necessary results of a legitimate construction of well-founded data. Is it, therefore, not true that many of these authors have given less consideration to this character of data than they have to * Synopsis of Difficult Parturition, p. 166. f Principles and Practice of Obstetric Medicine, p. 371. X Dublin Practice of Midwifery, p. 139. § Lectures on Principles and Praetice of Midwifery, p. 202. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 629 their own prejudices or preconceived notions ? I think so, and it is in this way only that I can account for the remarkable want of concurrence on a topic, involving so grave and sacred an interest as that of human life. When I speak of data, in connexion with this subject, I allude to certain statistical testimony, which, if properly discriminated, will oftentimes constitute, in questions such as we are now discussing, a very essential element for opinion; but do not forget that, for this testimony to become a recognised and safe substratum, it should be duly eliminated with the sole view of sus- taining a fundamental truth, and not for the purpose of affording apparent strength to individual sentiment. In one word, individual opinion should always yield to well-established facts, instead of attempting to accommodate facts to opinion. In order to illustrate what I desire most earnestly to urge, let us suppose that a certain number of you had decided in your own minds that, in consequence of the far greater value which you attach to the life of the mother than to that of the child, you would, under no circumstances, hesitate betAveen the Caesarean section and embryotomy, but that, in all cases calling for cutting instruments, your choice would be a resort to the latter expedient. Such a decision, I think you will agree with me, is legitimately entitled to be considered the offspring of preconceived opinion, and, as such, it Avould, of course, ignore the testimony of well-attested facts. Decisions like these, are, I maintain, unworthy of science ; they are one-sided, and, therefore, cannot be truthful. This brings me to the reiteration of what I have already stated in a pre- vious part of this lecture—that the choice between the Caesa- rean section and other modes of extracting the child, must be determined by a just balancing of evidence; and, with this con- viction, I shall now proceed to lay before you, as briefly as may be consistent with the import of the question, the particular kind of evidence by which, according to my judgment, we are to be guided. Contrast between the Ccesarean Section and Craniotomy Sta- tistics.—You have already seen that the Caesarean operation meets Avith but little favor in Great Britain, while, on the other hand, craniotomy has for a long* time been, and still continues to be, honored by the general endorsement of the profession of that enlightened nation. In order that you may at once appreciate the relative frequency of this alternative in Great Britain and on the continent of Europe, I will present you AA'ith the folloAving tables, which I derive from Dr. Churchill: Among British practitioners, 517 crotchet cases in 150,381 deliveries, or about 1 in 291 ; among the French and Italians, 69 crotchet cases in 38,908, or 1 in 563f; and among the Germans, 386 crotchet cases in 646,645 deliveries, or 1 in 1,675; altogether, 835,934 labors in Avhich the crotchet was 630 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. used, or 1 in 1,120*.* The mortality for the mothers is 1 in every 5; and, of course, the very nature of the operation demonstrates that all the children are sacrificed. But, gentlemen, it is essential you should note the important fact that these tables give us only the immediate deaths, in the proportion of 1 to 5 of the women who have been subjected to the hazards of craniotomy; not one word is said of the dreadful lacerations and destruction of the soft parts, sometimes terminating fatally, involving too frequently the unhappy sufferer in distress and anguish, which would cause her to invoke death as a blessing! Dr. Maunsellf says, "Dr. Joseph Clarke found it necessary in the Dublin Lying-in Hospital, to use the perforator in 1 in 208 cases. In the Wellesley Female Institution, it was employed during the year 1832, 1 in 21l£ cases; and during the year 1833, 1 in 137 cases.'' This record would seem to shoAV a striking average difference in the frequency of the operation, as exhibited by the statistics of Dr. Churchill; and AA'hat, it seems to me, must be apparent to every reflecting mind is, that these tables of Dr. Maunsell, presenting the number of craniotomy operations in well-conducted hospitals, super- vised by men of eminent skill, must fall greatly short of the true average frequency of this alternative among the profession in out- door or private practice, where oftentimes " hot-haste" and dispatch are substituted for patience and sober judgment! Again: Dr. Joseph Clarke mentions that in the 49 craniotomy operations performed by him in the Dublin Lying-in Hospital, 16 women out of the 49 died, or about 1 in 3; not 1 in 5, according to the statistics of Dr. Churchill. Thus, the sad result—16 of the mothers lost, and all the children destroyed in 49 cases; and yet it is but fair to presume that in the hands of Dr. Clarke, a gentleman of acknowledged skill and experience, assisted as he no doubt was, in counsel, by other eminent practitioners, this mortality is much less than when the operation is performed indiscriminately in private practice, and, alas! in instances in which there is too often a Avant, not only of proper deliberation as to the necessity of the alternative, but of ordinary dexterity in the execution of the deed. It is proper noAV, in the way of contrast, to turn to the results of the Caesarean section. It would seem that the mortality to the mothers in this operation is 1 in 2£, and to the children 1 in 3£. The deaths, therefore, among the mothers are much greater than in craniotomy, for, according to Dr. Churchill's tables, in this latter, the fatality is only 1 in 5. Yet, on the other hand, in 49 cases of craniotomy occurring in the Dublin Lying-in Hospital, under Dr. Joseph Clarke, 16 mothers were sacrificed, or 1 in 3 ! This cer- tainly reveals a melancholy picture, and it needs no argument to * Theory and Practice of Midwifery. London, 1860: p. 371. f Dublin Practice of Midwifery, p, 138. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 631 show, according to this latter table, how much more destructive to human life, if we embrace the fatality to both mothers and children, is craniotomy than the Caesarean section ; for, in the practice of Dr. Clarke, a practitioner of sound judgment and ripe experience, in 49 cases there was the dreadful sacrifice of 65 lives, supposing the children to have been alive at the time of the operation ! Nor does history record the condition of the 33 mothers who survived, whe- ther they were with or without lacerations. Thus, if Ave adopt Dr. Maunsell's record, as a proximate basis for opinion in reference to the relative mortality of the tAvo operations, the Caesarean section and craniotomy, the evidence will be greatly in favor of the former expedient; for while in craniotomy 1 in 3 of every mother is sacrificed, to say nothing of the contingent injuries, which, if they do not ultimately lead to death, will oftentimes impose upon the surviving mother a life of more or less suffering, every child is necessarily sacrificed. In the Caesarean operation, on the contrary, one child only is lost in every 3^, and one mother in every 2^. If, then, we suppose the Caesarean operation to be per- formed in 49 instances, we shall have, in contrast with 65 deaths, as in craniotomy, a very different result; 1 death in 2J of the mothers, and 1 in 3£ of the children. But, gentlemen, I wish to direct your attention very emphatically to another point in connexion with the statistics of the Caesarean section as furnished by Dr. Churchill; and in doing so, I shall endeavor to prove to you that they are not substantial data for a just comparison betAveen the relative fatality of the tAvo operations. In the first place, the number of Caesarean operations cited by him are Avhat may be termed mixed cases, including those of Great Bri- tain, the continent of Europe, and some in our own country. It is very Avell known that, more especially in Great Britain, in conse- quence of the very decided prejudice against the Caesarean operation, it has not been resorted to, in the great majority of instances, until the life of the mother was nearly extinct from previous effort, and her forces so prostrate as to deprive her of the elements essential to recuperation. Again: I think this objection is true, also, but not to the same extent, as regards the cases derived from the conti- nents of Europe and America, for it cannot be denied that, Avhat- ever may be the individual preference for' the Caesarean operation over craniotomy, there is more or less repugnance to commence it, and hence the general delay. If, in addition, Ave consider the effect on the mind of the patient when told that, in the best judgment of her medical advisers, the alternative for her life and that of her offspring is—to cut the child out of her womb through an incision of her abdomen, it is not difficult to appreciate Avhy, under the combination of protracted delay, and prostration, through fright, of the nervous force, one mother in every tAvo and one third should 632 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be sacrificed. I am free to confess I am not a little surprised that the mortality is not far greater in view of the circumstances just alluded to. It is a fact highly commendatory to their sagacity, and which, at the same time exhibits, I think, ample evidence of sound thought, that, as early as the sixteenth century, some of the Avriters on the question now before us gave very significant counsel, all other things being equal, as to the particular time during the labor of performing the Caesarean operation ; and I am strongly impressed with the conviction that, had their counsel been hearkened to, great w7ould have been the gain to the parturient woman. Rousset and Ruleau (the former wrote in 1581, the latter in 1704) recommended in the most decided manner that " the Ccesarean operation should be per- formed before the rude manipulations of the accoucheur had injured and more or less exhausted the woman." Levret,* the great obstetric authority of his times in France (1750), says, "As soon as the labor has fairly commenced it is proper to proceed Avith the operation, in order that the most favorable time may be selected for the operation itself, as well as for its consequences." With the sound advance which surgery has made in the present century, it is strange that more attention has not been given practically to these fundamental precepts, for no really experienced surgeon, I appre- hend, Avill attempt either to controvert their Avisdom, or the influ- ence they must necessarily exercise on the final issue of the Caesa- rean section. Therefore, I am quite confident, if the alternative were more opportunely resorted to ; if, in a word, the same principle of gui- dance should obtain in reference to it, Avhich we find to constitute the rule of action in all capital operations, the result would be A'astly different; and I have no hesitation in saying that, under these favorable circumstances, the Caesarean operation would not only prove to be infinitely less destructive to human life than craniotomy, but that it would soon take its rightful place as a just expedient in the lying-in chamber. The evidence in demonstration of the sound- ness of this opinion seems to me to be entirely satisfactory; for, in addition to other proofs, we have the strong corroborative testi- mony furnished by those examples in which the Caesarean operation has been performed several times on the same woman, with success to both mother and child; and in which cases, it is fairly to be pre- sumed that, at least, if not the first operation, the subsequent ones were undertaken opportunely before the strength of the mothers had become exhausted by antecedent and protracted effort. As a matter of statistical information, it is proper that I should refer to the folloAving data furnished by Keyser of Copenhagen, although * Levret, Suite des Observations sur les Causes des Accouchements Laborieux, p. 244. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 633 t they are someAvhat adverse to the position I have just assumed. I cannot but think there is some error in the details of the cases he cites. Keyser, taking the time of the operation from the com- mencement of labor, reports as folloAvs : first 24 hours, mortality to mothers 0.67, infants 0.28 ; between 25 and 72 hours, 0.55 to mothers, infants 0.33 ; more than 72 hours after labor commenced, mortality to mothers 0.72, to infants 0.60 ; so that between 25 and 72 hours it was most successful to mothers.* M. Simonf (1749) presented to the Academy of Surgery a col- lection of sixty-four cases of the Caesarean section, in more than one half of which the operation occurred in thirteen Avomen, some of these having been operated on two, three, five, six, and even seven times, and all were successful; singular enough, most of these ope- rations were without good cause, for, of the sixty-four Avomen, thirteen had borne children naturally either before or subsequent to the section. Stoltz, of Strasbourg, mentions fourteen undoubted eases in which the Caesarean section was resorted to Avith complete success twice on the same patient. Michaelis reports a case of a female, named Adawetz, born in 1795 ; she Avas four feet high, affected with rickets, and the antero-posterior diameter at the upper strait measured two and a fourth inches. In 1826, Dr. ZAvanck delivered her by the Caesarean section ; the child had been dead for some time previously to the operation, but the woman recovered. In 1830, this patient was again delivered through the same means by Prof. Weidemann, mother and child both saved. In 1832, the Caesarean section Avas resorted to for the third time, and the result was equally fortunate to parent and infant. Klein has gathered Avith much care 116 Caesarean sections, of which 90 were successful.! Dr. John Hull gives an analysis of 112 cases, of which 90 were successful.§ Halmagrand,| the able annotator of Maygrier, collected between the years 1835 and 1839 fifteen cases of Caesarean operation; of these, tAvelve of the mothers and thirteen of the children survived, Avhile three of the mothers and two of the children were lost; thus one mother in five died, and one child in about seven. These facts are well worthy of meditation, and in connexion with them it may be added that, in each of the fifteen cases recorded by Halmagrand, the only cause for resorting to the operation was a rachitic condi- tion of the woman. This author well asks, whether this extraor- dinary comparative success may not in part be due to the cir- cumstance that the operations Avere performed early, and before * London and Edinburgh Medical Journal, p. 542. f Premier volume des Memoires de l'Academie de Chirurgie. X Loder's Journal, vol. ii., p. 759 760. § Observations on Cresarean Operation. Manchester, 1798. P. 292. [ Nouvelles Demonstrations d' Aceouchements. Par Maygrier, p. 461. 634 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. * the system had become exhausted by fruitless effort. These statistics, it will be perceived, are beyond all contrast in favor of the Caesarean section over craniotomy. I desire it to be distinctly understood that my preference for the extraction of a living child through the abdomen of the parent, over its mutilation, is not an opinion of A'ery recent date, nor has it been arrived at, I trust, without due consideration. It is the opinion I have held and inculcated during my professorial life, as can be attested by the numerous pupils and others who have resorted to our University for instruction. In my translation of Chailly's Midwifery* (1844), I emphatically expressed my A'ieAvs upon the question of craniotomy in the folloAving unequivocal lar> guage: "In truth, it needs some nerve, and for a man of high moral feeling much evidence as to the necessity of the operation, before he can bring himself to the perpetration of an act, which # requires for his own peace of mind the fullest justification. He who would Avantonly thrust an instrument of death into the brain of a living fcetus, would not scruple, under the mantle of night, to use the stiletto of the assassin; and yet, hoAV frequently has the child been recklessly torn piecemeal from its mother's womb, and its fragments held up to the contemplation of the astonished and ignorant spectators as testimony undoubted of the operator's skill! Oh! could the grave speak, how eloquent, how damning to the character of those who speculate in human life, Avould be its revelations!" Such, gentlemen, was my language in 1844; and noAV, in 1861, with a more matured judgment and a riper experience, I am, if possible, the more strengthened in my con- viction. Therefore, in the fulness of my faith, I have no hesitation in saying that, if the child be alive, the woman at the completion of her pregnancy, and it be made manifest that the maternal passages are so contracted as to render it physically impossible that a living child can be extracted per vias naturales, I should between the two resources—craniotomy and the Ccesarean section—not hesitate to decide in favor of the latter.\ I am quite aware that this opinion, so emphatically stated, is at variance with the general vieAvs of the profession on this subject; but it has one merit, if no other, it is sincere, and founded upon Avhat I believe to be an honest analysis of all the evidence. In more than one instance on record it has been shoAvn that embryotomy has been had recourse to, and living children mutilated, when the women in subsequent labors Avere * A Practical Treatise on Midwifery. By M. Chailly. Translated from the French. Fifth edition, p. 385. \ It is proper here to remark that if it be ascertained the child is a monstei (although alive), or that it is affected with disease, which would result in its destruc- tion soon after delivery, this might constitute an exception to the rule. THE PRINCIPLES AND PRACTICE *0F OBSTETRICS. 635 delivered by means of the Caesarean section, with safety both to themselves and their offspring.* Dr. Charles S. Mills, of Richmond, Va., reports a case of Caesa- rean operation of more than ordinary interest, in which he saved both mother and child. The special interest of the case consists in the important fact that efforts were first made, because of the indis- position to resort to the Caesarean section, to deliver by embryo- tomy. His associates in counsel were Drs. Deane, Bolton, and Drew. The following is the language from the record: " It was now proposed that the patient should be anaesthetized, and an effort made to reach the abdomen of the child in order to eviscerate it, if, after a more thorough examination, it should appear that the child could then be brought away. This was accordingly done, and Dr. Bolton with great difficulty succeeded in passing two fingers through the superior strait so as to reach with their extremities the abdo- men of the child, but could make no use of them to conduct an * The following case I take from the North American Medical and Surgical Jour- nal, No. XXIV., October, 1831, p. 485, reported by George Fox, M.D.: Mrs. R., twenty-six years of age, was married 16th of May, 1830, and on the 14th of June, 1831, was in labor with her first child. Dr. George Fox was called to her assistance, and, finding that there was deformity of the pelvis, requested the counsel of Profs. James and Meigs, and Drs. Lukens, Hewson, and J. R. Barton. It was concluded, after repeated examinations, that the antero-posterior diameter did not exceed two inches. "The question arose as to what was to be done. The Caesa- rean operation was thought to be attended with so much risk to the mother as almost to be necessarily fatal, some of the most distinguished surgeons being entirely opposed to its performance; and Dr. Physic, who was called upon for his opinion on the propriety of tliis operation, was decided and positive in his opposition to it; under the weight of such authority, the idea of the Caesarean operation was aban- doned." It was then determined to perform cephalotomy, and Prof. Meigs agreed to undertake it. Before he commenced the operation, however, Prof M., conceiving, after further examination, that," cephalotomy would be attended with as much risk to the life of the mother as the Cesarean operation, thought it better to call another consultation to reconsider the propriety of performing the Caesarean operation." The consultation resulted in the opinion that the child was dead. Cephalotomy, there- fore, was performed. On the 22d of June, 1833, this same female was again in labor with her second child. Prof. Meigs was called in, and performed a second time the operation of cephalotomy. But we not told that in this case the child was dead; therefore, it is to be presumed it was alive. On March 25, 1835, this heroic woman was taken in labor with her third child. Dr. Joseph G. Nancrede was her physician, and, after mature deliberation, decided that the Caesarean section was the only appropriate operation in her case. Dr. Nancrede requested the counsel of Prof. Gibson, who concurred in opinion with him. Accordingly, in the presence of Dr. Nancrede, Prof. Dewees, Dr. Dove, of Richmond, Prof. Horner, Dr. Beattie, Dr. "William Coxe, Dr. Theodore Dewees, and Dr. Charles Bell Gibson, the distinguished professor performed the operation with entire success, saving both mother and child. November 5, 1837, Prof. Gibson was summoned to this patient, who was again in labor with her fourth child!! He again performed the Cesarean section, and with the same success, saviug both mother and child. These facts must carry with them their own comment. 636 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. instrument with certainty or safety to the mother, and was of opinion that it would be impossible to deliver the child through so narrow a passage even if he could succeed in eviscerating it. Being still loath to resort to the Caesarean section, until every effort to deliverer vias naturales had been tried and failed, the presenting leg was now enveloped in a bandage, and, the mother still being under the influence of chloroform, gradual but very powerful trac- tion was made, hoping still to force down the body into the pelvis. The greatest force which could be applied without risking the laceration and separation of the limb, produced no other effect than to bring doAvn the thigh a little loAver. Upon consultation, it was noAV unanimously thought that the Caesarean section should be made without further delay." Fortunate, indeed, was it that the attempt at embryotomy proved abortive, for it enabled Dr. Mills, through the exercise of his skill, to save tAvo lives, one of which would necessarily have been sacrificed, and the other subjected to more or less hazard.* Dangers to the Mother of the Ccesarean Section.—Let us now, for a moment, inquire in what consist the dangers to the mother in this operation. They are enumerated as follows: 1. Shock to the nervous sytem ; 2. Hemorrhage, or an escape from the uterus of the liquor amnii into the peritoneal cavity; 3. The possibility of* a portion of the intestines becoming compressed and strangu- lated, either in the opening of the abdominal parietes or uterus itself; 4. Inflammation involving the uterus, or peritoneum. In reference to these several dangers, the most serious is perito- neal inflammation together with its complications; and yet, from the statistics we have given, it would appear that the peril from this influence is not extravagant. Indeed, we have numerous and extra- ordinary instances of recovery after serious injury to the peritoneum and intestines from traumatic causes, such as the goring of an ox,f stabs in the abdomen, or the rude and unskilful cutting into the gravid uterus by unprofessional hands.;]; Cases, too, are recorded and accepted »as reliable, in which women have undergone the * Monthly Stethoscope and Reporter, July, 1856, p. 427. \ Fritz records a singular case, also witnessed by Naudot, of a pregnant woman having been gored in the abdomen by the horn of an ox; on the following day the wound was enlarged by means of a bistoury; the foetus was extracted, and the mother recovered! (See Velpeau's Mid., p. 548.) X The Caesarean operation was performed on a female in Ireland, named Alice O'Neal (1738), by an ignorant midwife, Mary Dunelly; the instrument employed was a razor; she held the lips of the wound together with her hand till some one went a mile and returned with silk and the common needles which tailors use; with these she joined the lips in the manner of the stitch employed ordinarily for harelip, and dressed the wound with white of eggs. The woman recovered in twenty-seven days. This ease, incredulous as we may be disposed, is regarded as perfectly truth- ful.—Edinburgh Medical Essays, vol. v. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 637 Caesarean operation after rupture of the womb, and have survived. These facts, I think, tend to demonstrate that, if all things be equal, the positive danger from inflammation per se is not as grave as is generally imagined; and this brings me to the repetition of one of the major propositions, that the serious peril of the Caesarean sec- tion is, in a great measure, due to—at all events, it is greatly en- hanced by—the unnecessary delay of the operation, when the woman's strength is exhausted, the womb and the adjacent organs fretted, and sometimes even inflamed through the jointly abortive efforts of nature and the injurious officiousness of the accoucheur; so that, oftentimes, a broad foundation for fatal results is already laid before the first stroke of the surgeon's knife. As to the other alleged dangers, such as the passage of blood or liquor amnii from the incised womb into the peritoneal cavity, or the strangulation of a fold of the intestines, why these, I contend, are not necessarily incident to the operation; they are chargeable to the carelessness of the assistants, whose duty it is, by efficient service, to see that these various contingencies do not occur. But the shock to the nervous system, you may urge, is a very important complication. Yes, gentlemen, this argument, I admit, was not without force, and great force, too, before the introduction into the lying-in room of that sterling boon to suffering woman— anaesthetics. It is in operations like the Caesarean section, in which the nervous system is thrown into tumult and disorder, and where psychical causes have an unbridled sway, that the magic of anaes- thesia discloses its full triumphs. Under its influence, the human system, emancipated for the time from the operation of external impressions, is lulled into more than the quietude of sweet and unbroken sleep. We have, therefore, in anaesthesia an important addition to our therapeutic agents which, when judiciously em- ployed, cannot but afford most happy results; the subjection in which it holds the nervous system, under capital operations, is dis- played not only in the unconsciousness of pain, but in the shield it affords against the consequences of the shock otherwise so apt to ensue. Indeed, if the importance of the uterus in its various connexions with other portions of the economy be recollected, it cannot appear strange that a lesion of this organ should be followed by marked pathological effects on the nervous system, and that these results on the nervous mass should, before the introduction of anaesthesia, have been prominent among the causes of the comparatively great fatality of the Caesarean section. As a general rule, it has been observed that AA'hen death ensues soon after the operation—say tAvo or three days—it is in consequence of the grave concussion sus- tained by the nervous system, as is evinced by the symptoms, which, under these circumstances, so speedily develop themselves, 638 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. such, for example, as a general sinking of the forces, vomiting and hiccough. In these cases, I repeat, in Avhich death so rapidly follows the operation, the true cause of destruction is not inflam- mation of the peritoneum, uterus, etc., but is to be traced to the profound impression to which the nervous system has been sub- jected. Post-mortem Ccesarean Section.—Before describing the manner in Avhich—when indicated—the Caesarean operation is to be per- formed, it is proper I should remind you that it sometimes becomes necessary to resort to this expedient even after the woman is dead ; and the practice is founded upon the wrell-known fact that the foetus does not necessarily die simultaneously with its mother. Indeed, there are numerous instances cited in which the post-mortem Caesa- rean section is alleged to have been had recourse to twelve, twenty, and even forty-eight hours after the demise of the parents, and the children extracted alive ; but a due degree of caution is to be exer- cised before accepting these cases as proved ; in most of them, it is quite probable that a state of syncope Avas mistaken for death. It is important, for the assured safety of the child, that no time be lost in its extraction after the death of the mother. There is, among others, one example recorded which, I believe, stands un- contradicted, and has received the A'ery general assent of the pro- fession. I allude to the extraordinary case of the Princess of Schwartzenberg, whose death occurred in Paris in 1810 under the most painful circumstances. She was one of the gay party partici- pating in the pleasures of a ball given by her brother-in-law, the Austrian ambassador. During that night of festivity there was an appalling conflagration which, together with other victims, caused the death of the princess, who was far advanced in gestation. On the day succeeding her death, a living child was removed by the Caesarean operation. This case, however, although well authenti- cated, Avhile it proves the possibility of the foetus in utero surviving its mother for several hours, should be regarded as a very rare ex- ception to the general rule ; for it is conceded that, as a principle, the child dies either before, shortly after, or simultaneously with its parent. Yet, notwithstanding this general fact, it is abundantly shoAATi that numerous children have been saved by the post-mortem Cesarean section. It is an interesting circumstance that one of the earliest legisla- tive acts among the Romans provided that no pregnant woman should be admitted to sepulture until her child had been removed by this operation: Negat lex regia mulierem qucepregnans mortua sit, humari antequam partus ei excidatur ; qui contra fecerit, spem animantis cum gravida peremisse videtur. In recognition of the propriety of this ancient law, and with the view of carrying it out practically in the sense in which it was no doubt originally intended, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 639 the Senate of Venice, in 1608, proclaimed the imposition of severe penalties upon every medical man, who should attempt this opera- tion on a woman supposed to be dead, without exercising as much caution as if she were alive.* History mentions more than one instance in which an incision had been made into the abdomen for the purpose of extracting a child from its supposed dead parent, when it was subsequently shown that she was still living! Hence, in all cases of post-mortem Caesarean operation, it is the first duty of the surgeon to be morally certain that the life of the mother is extinct; and, in order to avoid all error, to keep constantly in mind the sensible and conservative enactment of the Venetian Senate, to which allusion has just been made. Peu (1694) had the honesty to record a thrilling case, which occurred to him, and about which, therefore, there can exist no doubt. He says, in the early part of his practice he was requested to attend a young primipara in her accouchement; on his arrival at the house, the friends of the patient informed him that she had just expired, and so he thought himself; he proceeded at once to extract the child by the Caesarean section, but the instant he commenced his incision the woman gave a shudder?accompanied with grinding of the teeth, and a movement of the lips—un tressaillement accom- pagne de grincement des dents et de remllment des levres /f How the Operation should be Performed.\—I have already said, with unequivocal emphasis, that one of the essential elements of success in the Caesarean section is to commence the operation early, before the patient has become exhausted, and her system fretted by ill-advised interference on the part of her medical attendant; and I now state without qualification—that it is the duty of the accoucheur to ascertain at an early period of the labor Avhether the circumstances of the case are such, in his sound judgment aided by experienced counsel, as to justify a resort to this expedient. The moment the question is decided affirmatively, further delay is not only unnecessary, but fraught with danger. Supposing, therefore, that this material point has been duly determined, the next question arises—Should the patient be made acquainted with the nature of the operation ? Here, again, I may perchance differ with my pro- fessional brethren; but I am clearly of opinion that it is infinitely better, so far as the result is concerned, that the mother should be kept in partial ignorance; tell her, for example, that it has become necessary for the safety of her child and the termination of the * The King of Sicily (1749) passed the sentence of death on the physician, who failed to perform the Caesarean section on a female dying in the latter months of gestation. ■j- La Pratique des Accouchemens, p. 334. \ Prof. Fordyce Barker reports an interesting case of Caesarean section in the American Medical Times, Jan 26th, 1861. 640 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. labor, that you should interpose and assist nature, but sedulously keep from her the fact that you are about to lay open her abdomen and womb for the purpose of extracting the infant. Such a revela- tion, common sense tells us, Avould be received by the suffering woman with terror, acting injuriously on her nervous system, and thus, to an extent at least, presenting a barrier to recovery. But how, you may ask, can the operation be performed Avithout the knoAvledge of the patient? The ansAver to this question brings me to a most important point, and it is this—place her under the influence of ancesthesia, lull her into unconsciousness, and make her blissful in her igiiorance. These preludes having been decided upon, care should be taken to empty the bladder; the patient should be on her back, with the lower limbs slightly flexed; at least two assistants will be needed, Avell supplied Avith soft, delicate sponges. Things being thus pre- pared, the question presents itself—In what way is the incision to be made ? One author recommends the oblique, another the trans- verse, while a third urges a vertical opening thrqugh the linea alba. Each of these, it is contended, has its advantages and disadvantages. The vertical incision through the linea alba is most commonly resorted to, and this I shall describe. In selecting this point for the opening into the abdominal cavity, there is no fear of wounding the epigastric artery, nor is there any division of muscular fibre, and there is much less hazard of involving the intestines, than in either the oblique or transverse incision. Again: the uterus is opened in the central portion of its long axis, and in a direction parallel to its muscular tissue. On the other hand, the section through the linea alba is objected to by some, because, it is alleged there will be danger of injuring the bladder; and, also, as the tissues embraced in the opening are exclusively fibrous, the healing or cicatrization of the abdominal incision will necessarily be more or less tardy. These objections are not of much moment, for the bladder can be amply protected by evacuating its contents, and the comparative tardiness of the cicatrization is of very little consequence. The surgeon, placed on the right of the patient, with his two assistants on the opposite side, makes with a convex bistoury his incision from six to seven inches in length, commencing at the umbilicus and passing toward the pubes. This first incision will lay open the abdominal cavity, which, of course, will expose to view the peritoneal covering; this membrane should be cautiously incised below, so that the index finger may be introduced; a probe- pointed bistoury is then carried along the finger for the purpose of incising the peritoneum* to an extent corresponding with the * In order to avoid the incision of the peritoneum, Jorg in 1806, and Ritgen in 1820, proposed an operation which should lay open the vagina, instead of the ante- rior plane of the uterus. More recently this suggestion has been carried out in THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 641 external opening; great caution is to be exercised by the assistants as soon as the abdominal cavity is laid bare in steadying the uterus, and preventing the protrusion of the intestines; if this protrusion should occur, the intestines are to be gently compressed and re- placed by delicate warm sponges. The peritoneum being divided, the next stage is the incision of the uterus itself. This must be done discreetly, not by one abrupt stroke of the knife, but gradually, so that wdien the cavity of the organ is exposed, the membranous sac, if it should have preserved its integrity, may not be too suddenly opened, or the fcetus involved in the incision.* It is recommended to carry the incision into the uterus as high up as possible, so that the inferior point of the opening may not be as low down as the opening made into the abdomen. This precaution Avill, after the organ has contracted, prevent the escape of the lochial discharge into the abdominal cavity. It may possibly occur that the placenta will be so situated as to be included in the incision made into the uterine wall—it would be a rare cir- cumstance, however, for this mass is seldom found attached to the anterior plane of the organ—if so, do not become alarmed, but pro- ceed at once to extract the foetus, as if the accident had not Paris by A. Baudelocque, Jr.; the operation is called elytrotomy, and is performed as follows: The incision commencing near the spine of the pubes is extended, parallel with Poupart's ligament, to the anterior superior spinous process of the ilium. Carefully avoiding the epigastric artery, the abdominal parietes are divided; the peritoneum is then not incised, but pushed away from the iliac fossa into the excavation; the upper portion of the vagina is thus exposed, and a free incision being made into it, the index finger is introduced into the opening for the purpose of bringing the os uteri fully in the direction of the wound made in the abdomen; this transposition may be facilitated by pressing with the other hand the fundus of the organ Uickward. The os uteri being brought in correspondence with the open- ing made in the abdomen, the delivery is to be committed to nature, and the child expelled by the force of uterine contraction. Plausible as this operation may ap- pear—to me it is the very reverse—it failed completely in the hands of Baudelocque, and I am not aware that it has ever succeeded. * There exists a difference of opinion as to whether the Caesarean section should be performed before or after the escape of the liquor amniL If the amniotic fluid have not escaped, there will certainly be less danger of injuring the child with the knife, for the fluid will, to a certain extent, interpose between the surface of the foetus and the walls of the uterus; on the contrary, should the membranous sac be entire, there will De the danger, as soon as it is penetrated, of the fluid escaping into the peritoneal cavity. My own opinion is, that it is preferable to operate before the rupture of the sac; and as soon as the womb is laid open, I should advise, if possi- ble, the introduction of a catheter into the os uteri for the purpose of rupturing the membranes, and thus affording an escape to the fiuid through this orifice. If this cannot be accomplished, then it would be good practice to puncture the sac below the incision made into the uterus, and in this way the fluid would find its exit through the mouth of the organ, which would prevent the possibility of its passing into the peritoneal cavity. The assistants should, at all events, be on the alert, and, in the contingency of the sudden penetration of the sac by the bistoury, be prepared with sponges to prevent the flowing of the amniotic liquor into the abdomen. 41 642 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. occurred—in the following manner: Should the head be near the opening, seize it gently by placing the index-fingers below the [inferior maxillary bones, and employ proper extractive force; if, on the contrary, the breech be there, withdraw it first; if any other surface of the foetus present at the opening, introduce the hand very gently, and seize the feet, and thus deliver the child. As soon as the child is extracted, if it be alive, a ligature is to be applied to the cord, and then separated from its mother. What about the placenta? It is recommended by some authors to proceed at once, the moment the child is in the world, to remove the after-birth. In the event of complete detachment of the pla- centa or hemorrhage in consequence of partial detachment of this body and inertia of the uterus, there cannot be two opinions as to the propriety of the practice ; but in the absence of these contin- gencies, the rule I hold to be a bad one, and more or less perilous to the mother. Therefore, my advice to you is this—let nature do the work of separation, if she is not too long in performing it; and the moment the detachment has been accomplished, Avhich may be ascertained by slight tractions on the cord, then the mass is to be brought away, care being observed to remove with it the mem branes, for if they be permitted to remain in the uterus, their pre- sence will result in more or less irritation and distress to the patient. Be careful, also, after the withdrawal of the after-birth, to remove any coagula of blood from the uterine cavity. But suppose nature does not promptly detach the placenta, how long would it be judicious for the accoucheur to delay interference ? If in five or ten minutes after the extraction of the child the placenta Bhould not have become separated, it would, I think, be imprudent to wait longer; the accoucheur should then introduce his hand through the incision, and cause the artificial detachment in the manner described in a previous lecture. If the extraction of the after-birth be followed by inertia of the womb—a circumstance quite unlikely to occur—a small piece of ice momentarily applied to the lips of the opening will generally suffice to awaken tonic contrac- tions of the organ. Dressing the Wound.—One of the advantages of the operation by the vertical incision is, that there are no vessels exposed, and hence no hemorrhage; however, in cutting into the uterus itself some of the uterine arteries may be involved, but the bleeding can be readily stayed by the assistants making pressure on the orifices with the finger; soon after the extraction of the after-birth, the wound contracts, the incision made into its wall is reduced to one or two inches, and in this way all hemorrhage is arrested. For the purpose of closing the wound in the abdomen, the interrupted or twisted suture is usually employed; adhesive strips should be placed in the intervals of the suture, and care taken to leave the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 643 lower extremity of the wound open to afford escape to matter, etc. Nothing, of course, is done with the incision made into the uterus, for it unites speedily through the process of nature.* As soon as the external wound has been closed by means of suture, the whole should be covered with a piece of linen spread with simple cerate ; over this should be placed a compress supported by a circular bandage. It would be well, as a general rule, after the dressing has been com- pleted, to administer a composing draught for the purpose of quiet- ing the system, and inducing sleep. The rest of the treatment is to be conducted on general principles, in accordance with the develop- ment of circumstances.f Since the publication of the second edition of this volume, I have read with much pleasure an excellent essay on the " Statistics of the Caesarean Operation," by M. Philan-Dufeillay,J and it affords me no little satisfaction to find that his views are entirely coincident with my own.§ This author remarks, that " the method usually followed of simply comparing the deaths with the reco- veries after the operation, must lead to false deductions. In nume- rous cases, the deaths cannot be ascribed to the operation, but to antecedent conditions of the patient; which, in many instances, may be controlled." He presents a table of 88 cases, collected since 1845, in which the caesarean section has been performed; " of these, 50 recovered; of the remaining 38, the causes of death were, in six, some antecedent disease ; two died of puerperal fever, the operations having been performed in hospitals. In the 30 remaining cases, the deaths must be imputed, in part, at least, to the unsuccessful attempts made to deliver by the natural passages." M. Philan- Dufeillay then speaks of the influence of the duration of labor over the result: "In 29 successful cases, the natural powers were pre- served in 24 ; in 20, the duration of the labor was under 24 hours ; in 19 fatal cases, the forces were failing or exhausted in 18; and in 11 cases, the labor continued beyond 24 hours." He concludes that the caesarean operation, performed under favorable conditions, gives nearly 15 per cent, of recoveries. * Although, as a general rule, it is true that the lips of the wound into the uterus do become united through the contractions of the organ, yet this is not always the case. f It may not be out of place, as connected with the current literature of the question, to observe that it has recently been proposed by Dr. Cristoforis to substi- tute for the Caesarean section and symphyseotomy what he terms the resectio subpe- riosteal of the pubic bones, including the horizontal and descending rami He sug- gests first to enucleate the bones from their periosteal covering, in the hope that it will subsequently be filled by osseous deposits. He records four experiments on dogs, in which this deposit of bony matter followed the enucleation. [Ann. Univ. 1858. % Arch. Gen. de Med., 1861. § See page 632 of this volume. LECTURE XLII. Yaginal Caesarean Operation, or Vaginal-Hysterotomy—Indications for this Opera- tion—Two Cases in Illustration by the Author—Embryotomy—Meaning of the Term—Amount of Pelvic Contraction justifying Embryotomy—Dangers and Fatality of the Operation—Difference of Opinion among Authors as to the Circum- stances indicating Embryotomy—The Case of Elizabeth Sherwood, as reported by Dr. Osborn—The Dangerous Precedent growing out of that Case—Evidences of the Child's Death in Utero—"What are these Evidences?—Conflict of Sentiment among "Writers on this Question—Great Caution necessary in forming a Judgment —Analysis of the Evidence—Too General Use of the Perforator and Crotchet— Melancholy Results of this Fondness for Embryotomy—Case in Illustration—Mod' of Performing the Operation of Embryotomy—In Hydrocephalus, what is to be done?—Decollation—When to be resorted to—Evisceration—"When indicated— Cephalotripsy—Meaning of the Term—When to be employed. Gentlemen—Having disposed of the subject of the abdominal Ccesarean section, it is now proper that I should describe to you the vaginal Ccesarean operation, sometimes called vaginal-hystero- tomy. This operation may be necessary without any deformity of the pelvis, or any disproportion between it and the foetus, occasioned by an increased size of the latter. The usual causes indicating the necessity for the operation are traceable to some peculiar condition of the mouth of the uterus—for example, occlusion of the os uteri at the time of labor, or a hard, unyielding state of it, from scirrhous development, or a fibro-cartilaginous change. Again: it may some- times happen that the cervix of the organ is so completely malposed, either retro-verted or ante-verted, that it cannot be brought to its normal situation by the best directed manipulations of the accouch- eur. Under any of these circumstances, the whole force of the parturient effort is lost; there is no response to the contractions of the uterus, and the danger necessarily becomes complicated, involving the safety of the mother from rupture of the organ, the intervention of convulsions, or positive exhaustion of her vital forces; the destruction of the child will also be hazarded from long-continued and undue pressure. It is, therefore, when the labor is obstructed by one or other of these several conditions, manifestly a question for the sound judgment of the accoucheur as to the time of resorting to an ope- ration for the relief of parent and child—I repeat the terms parent and child, for it will be his duty, in cases like these, to proceed to artificial delivery the moment he is assured that nature is unable to overcome the obstacle, and not tarry until the mother is on the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 645 borders of death from exhaustion, or the child sacrificed by pro- tracted compression. I here reiterate what I have previously stated : interference should be opportune, so that in its exercise the maximum of good may be accomplished—the saving of the lives of both mother and child. I have had the good fortune to perform the vaginal Ccesarean operation twice, and with the most satisfactory results. These cases are of more than ordinary interest in several particulars; in the hope that they may prove instructive, and with a demand on your kind indulgence, I shall present them to you in detail as originally published :* December 19, 1843, Drs. Vermeule and Hold en requested me to meet them in consultation, in the case of Mrs. M., Avho had been in labor for tAventy-four hours. On arriving at the house, I learned the following particulars from the medical gentlemen: Mrs. M. was the mother of two children, and had been suffering severely, for the last fourteen hours, from strong expulsive pains, which, however, had not caused the slightest progress in the delivery. She Avas taken in labor Monday, December 18, at seven o'clock p.m., and on Tues- day, at seven p.m., I first saw her. Her pains were then almost constant; and such had been the severity of her suffering, that her cries for relief, as her medical attendants informed me, had attracted crowds of persons about the door. As soon as I entered her room, she exclaimed, " For God's sake, doctor, cut me open, or I shall die ; I never can be delivered without you cut me open." I was much struck with this language, especially as I had already been informed that she had previously borne two living children. At the request of the medical gentlemen, I proceeded to make an exami- nation per vaginam, and must confess that I Avas startled at what I discovered, expecting every instant, from the intensity of the con- tractions of the uterus, that this organ would be ruptured in some portion of its extent. I could distinctly feel a solid, resisting tumor at the superior strait, through the walls of the uterus; but I could detect no os tincce. In carrying my finger upAvard and backward toward the cul-de-sac of the vagina, I could trace two bridles, extending from this portion of the vagina to a point of the uterus, Avhich was quite rough and slightly elevated ; the roughness was transverse in shape, but with all the caution and nicety of manipula- tion I could bring to bear, I found it impossible to detect any open- ing in the womb. In passing my finger with great care from the bridles to the rough surface, and exploring the condition of the parts, with an anxious desire to afford the distressed patient prompt and effectual relief, I distinctly felt cicatrices, of which this rough surface was one. • New Tork Journal of Medicine. March, 1843. 646 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Here, then, Avas a condition of things produced by injury done to the soft parts at some previous period, resulting in the formation of cicatrices and bridles, and likewise in the closure of the mouth of the womb. At this stage of the examination, I knew nothing of the previous history of the patient more than I have already stated, and the first question I addressed to her was this: Have you ever had any difficulty in your previous confinements ? Have you ever been delivered with instruments ? She distinctly replied that her previous labors had been of short duration, and that she had never been delivered with instruments, nor had she sustained any injury in consequence of her confinements. Dr. Vermeule informed me that this was literally true, for he had attended her on those occasions. This information someAvhat puzzled me, for it was not in keeping with what any one might have conjectured, taking into view her actual condition, which was undoubtedly the result of direct injury done to the parts. I then suggested to Drs. Vermeule and Holden the propriety of questioning the patient still more closely, with the hope of eliciting something satisfactory as to the cause of her present difficulty; remarking, at the same time, that it would be absolutely necessary to have recourse to an operation for the purpose of delivering her. On assuring her that she was in a most perilous situation, and, at the same time, promising to do all in our power to relieve her, she voluntarily made the following confession: About six weeks after becoming pregnant, she called on the notorious Madame Restell, who, learning her situation, gave her some powders with directions for use; these powders, it appears, did not produce the desired effect. She returned again to this woman, and asked her if there were no other Avay to make her miscarry. " Yes," says Madame Restell, " I can probe you; but I must have my price for this operation." " What do you probe with ?" " A piece of whale- bone." "Well," observed the patient, "I cannot afford to pay your price, and I will probe myself She returned home, and used the whalebone several times; it produced considerable pain, , followed by discharge of blood. The whole secret was now dis- closed. Injuries inflicted on the mouth of the uterus by these violent attempts had resulted in the circumstances detailed above. It was evident, from the nature of this poor woman's sufferings and the expulsive character of her pains, that prompt artificial delivery was indicated. As the result of the case was doubtful, it was important to have the concurrent testimony of other medical gentlemen, and as it embodied great professional interest, I requested my friends, Dr. Detmold, and the late Drs. Washington and Doane, to see it. They reached the house without delay, and after examining minutely into all the facts, it was agreed that a bilateral section of THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 647 the mouth of the womb should be made. Accordingly, without loss of time, I performed the operation in the following manner: The patient was brought to the edge of the bed, and. placed on her back. The index finger of my left hand was introduced into the vagina as far as the roughness, which I supposed to be the original seat of the os tincce ; then a probe-pointed bistoury, the blade of which had been previously covered with a band of linen to within about four lines of its extremity, was carried along my finger until the point reached the rough surface. I succeeded in introducing the point of the instrument into the centre of this surface, and then made an incision of the left lateral portion of the os, and, before withdrawing the bistoury, I made the same kind of incision on the right side. I then withdrew the instrument, and in about five minutes it was evident that the head of the child made progress; the mouth of the womb dilated almost immediately, and the con- tractions were of the most expulsive character. There seemed, however, to be some ground for apprehension that the mouth of the uterus would not yield with sufficient readiness, and I made an incision of the posterior lip through its centre, extending the inci- sion to within a line of the peritoneal cavity. In ten minutes from this time, Mrs. M. was delivered of a strong, full-grown child, whose boisterous cries were heard with astonishment by the mother, and with sincere gratification by her medical friends. The expres- sion of that woman's gratitude, in thus being preserved from what she and her friends supposed to be inevitable death, was an ample compensation for the anxiety experienced by those, who were the humble instruments of affording her relief. This patient recovered rapidly, and did not, during the whole of her convalescence, present one unpleasant symptom. It is noAV ten Aveeks since the operation, and she and her infant are in the enjoyment of excellent health. I omitted to mention that the urethra was preternaturally dilated. I introduced my finger as far as the bladder without any conscious- ness on the part of the patient, such Avas the degree of its enlarge- ment. About ten days after the operation, the late Dr. Forry visited the patient with me, and heard from her own lips the narrative of her case, so far as her visit to Madame Restell is concerned, and which I have already stated. On Saturday, January 20, Dr. Forry again accompanied me on a visit, and a vaginal examination Avas made. The mouth of the womb was open, and permitted the intro- duction of the end of the forefinger; the two bridles were distinctly felt, extending from the upper and posterior portion of the vagina to the posterior lip of the os tincce, which they seemed firmly to grasp. In a professional point of view, this case is not Avithout interest. It is eA'ident that, without the operation, the patient must have 648 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sunk. She had been in labor precisely twenty-nine hours Avhen I made the section of her Avomb, and for tAventy hours previously the contractions were most energetic, possessing all the character- istics of true expulsive pains. But yet, Avith all this suffering, not the slightest change had been effected in the parts. If nature, therefore, had been competent to overcome the resistance, sufficient time was allowed for this purpose. Longer delay would undoubt- edly have placed the lives of both mother and child in extreme peril; for, from the reiterated but unavailing efforts of the Avomb, there was reason to anticipate rupture of this viscus, which would most probably have compromised the fife of the mother; while, at the same time, the child av&s exposed to congestion from constant pressure by the contractile force of the uterus. The second case is as follows:* On Saturday, November 6, 1847, at 6 a.m., Dr. Alexander Clinton was summoned to attend Mrs. L., aged thirty-six years, in labor Avith her first child. Dr. C. had been for some time the family physician of Mrs. L., and had attended her in repeated and severe attacks of nephritis. On arriving at the house he found Mrs. L. in labor, the pains being decided, and occurring Avith regularity at intervals of fifteen and twenty min- utes. In his examination per vaginam, the doctor was unable to detect the os tincae; he very cautiously explored the vagina and presenting portion of the womb with his finger, and, after several fruitless attempts to find the mouth of the uterus, he came to the conclusion that the difficulty of reaching the os was OAving to mal- position of the organ, probably retroversion of the cervix. Accord- ingly, he waited until evening, when the pains increasing in vio- lence, and assuming an expulsive character, he examined his patient, but without better success. He then proposed a consultation, the patient having been in labor fourteen hours. My colleague, Pro- fessor Mott, was sent for. On hearing the particulars of the case, he made a vaginal examination, and, after repeated attempts, failed in finding the mouth of the womb. Professor M. suggested that possibly some change might occur during the night in the position of the parts, Avhich would enable him to reach the os uteri, and left tlie house with the promise that he would return in the morning. Dr. Clinton continued with his patient during the night, and the pains recurred regularly with more or less force. He made several examinations in the night, but could feel nothing except a globular surface. In the morning, Nov. 7, at ten o'clock, Professor Mott returned. The pains were then much more violent, and the patient suffered severely. He again attempted by examination to reach the mouth of the womb, and again failed. To use his own language, " I have * American Journal of Medical Sciences. 1841. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 649 Been a great many obstetric cases, and have attended almost every variety of parturition, but it is the first time, after thirty-six hours' labor, that I could not feel the os tincae." The case was noAV assum- ing a dangerous phase ; the pains were frequent and expulsive, with an obliterated mouth of the uterus. The fear, therefore, Avas rupture of this organ, and death of the patient, with but little chance for the life of the child. The husband and friends were informed of the precarious situation of the patient. Drs. Mott and Clinton decided to have additional consultation, and at the request of these gentlemen I met them at one o'clock on Sunday, the patient having been in more or less active labor for forty hours. On examining her I could not feel the slightest trace of the os tincae, and I became satisfied, after a thorough exploration, that it was entirely obliterated. Under these circumstances, the death of the mother being inevitable without an operation, it was proposed to lay the womb open through the vagina, and at the request of the gentlemen, I proceeded to perform the operation as follows: With a probe-pointed bistoury covered to Avithin a feAV lines of its extremity with linen, and taking my finger as a guide, I made a bilateral section of the neck of the Avomb, extending the incision to within a line or two of the peritoneal cavity. The head of the child was immediately felt through the opening. The pains con- tinued with violence, but there was no progress in the delivery; the neck of the uterus was extremely hard and resisting, and pre- sented to the touch, after the incision, a cartilaginous feel. Dr. Mott and myself then left the patient in charge of Dr. Clinton, and returned again at six in the evening. At this time, although the pains had been severe, the head had not descended, nor had any impression been made on the opening. I then made an incision through the posterior lip; the patient was not in a condition to sustain bloodletting, and a Aveak solution of tartar-emetic was administered with a view, if possible, of producing relaxation. Dr. Clinton remained with his patient, and promised, if anything occurred during the night, to inform us of it. We were both sent for at two o'clock. Dr. Mott having arrived before me, and finding the patient suffering severely from violent and expulsive pains, all of which produced little or no change in the position of the child's head, enlarged the incision which I had pre- viously made in the posterior lip of the cervix. We remained until seven o'clock in the morning, when we left. The patient being much fatigued, a Dover's powder was ordered, Avhich procured a comfortable sleep, and temporary immunity from suffering. We called again at eleven o'clock. The opening had somewhat dilated, and the head could be more distinctly felt, but it had not begun to engage in the pelvis. There was much heat about the parts, and the scalp was corrugated. The pains continued Avith 650 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. regularity, losing nothing in violence, and at six o'clock in the even- ing of Monday the patient's strength, which had been cautiouslj guarded, was evidently giving Avay, and her pulse rose to one hun- dred and forty! In a word, the symptoms Avere most alarming. The question now presented itself—What was to be done? After mature deliberation, being essentially conservative in the whole management of the case, Ave determined to make an attempt to deliver Avith the forceps, certainly not an easy thing to do Avith the head of the foetus at the superior strait, not having begun to engage in the pelvis, and the mouth of the womb rigid and un- yielding. The forceps, however, after a full view of all the cir. cumstances, presented to us the most feasible means of effecting delivery. At the request of Drs. Mott and Clinton, I applied the instru- ment, and was fortunate enough, without much loss of time, in locking it. The head was situated diagonally at the upper strait, with flexion but partially made. At first, I directed my traction downward and backward, the handle of the forceps forming an acute angle with the axis of the inferior strait of the pelvis; and when I succeeded in flexing the chin of the child upon the sternum, I then rotated the handle of the instrument for the purpose of giving the demi-spiral movement to the head. In this way, after very great effort, I succeeded in bringing the head to the inferior strait, and with powerful, but well-guided tractions, drew it more than one half into the world. At this stage of the operation, my arms and hands were nearly paralysed, such was the force necessary to overcome the difficulty. I requested Dr. Mott, who was by my side, to relieve me, and after no inconsiderable effort he succeeded in bringing the head into the world; our gratification was in no way diminished by the fact that the child was alive, an event cer- tainly not to be expected. As strange as it may appear, the only inconvenience experienced by the mother after delivery was an inability to pass her water; this continued for about two weeks, rendering it necessary to intro- duce the catheter twice daily for the purpose of emptying the bladder. The mother and child are in the enjoyment of excellent health. It may, perhaps, be thought by some that the patient should have been delivered sooner, and that we subjected her to serious and unnecessary hazard in delaying delivery by forceps. This reasoning might possibly be sustained on general principles; but I think it will be conceded that, in this individual case, we were not only jus- tified in the delay, but the result proved the wisdom of the course we pursued. In my opinion, nothing, under the peculiar circum- stances of the case, could have warranted an attempt at artificial delivery, save an approach to exhaustion on the part of the mother^ THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 651 or the occurrence of some accident placing life in imminent peril The position of the fcetal head, and the condition of the mouth of the womb, were such as to render extremely probable the failure of any attempt at delivery. The obvious indication, therefore, wag to trust to nature as long as she was capable of acting, and for the accoucheur to proceed to artificial delivery the moment the general system exhibited unequivocal evidence of prostration. It may be asked whether this was primary or secondary closure of the os tincce. That it was secondary is manifest from two cir- cumstances : 1. The patient always menstruated regularly previous to her pregnancy; and secondly, to suppose that she could have become impregnated with an imperforate os tincm, is to suppose what, under the circumstances, may be called an absurdity. There are cases, however, recorded in which sexual intercourse was had through the female urethra, followed by impregnation, but in these examples there was a communication between the bladder and uterus. In the present instance, there existed no such communi- cation. The only rational explanation of the closure of the Avomb in this patient is, that it was the result of inflammation of the os uteri. Embryotomy.—The term embryotomy means literally the cutting up of the child for the purpose of diminishing its bulk, so that it may be brought aAvay in fragments. It may be of two kinds: 1. Where it becomes necessary simply to lessen the volume of the head, either by affording an outlet to the brain (cephalotomy), or removing the bones of the cranium piecemeal (craniotomy), or by means of the cephalotribe—an instrument of which we shall speak presently—crushing the head; 2. Where it is essential to extract the entire child in portions, thus involving more or less the section of the whole foetal mass. It can scarcely be necessary for me to remind you that the only justification which can be alleged for this operation, is such a dis- proportion between the maternal organs and foetus as to render it physically impossible that the latter can be made to pass, either through the natural effort, by the aid of the forceps, or version, sup- posing, of course, the woman to have arrived at the full period of her gestation. I have already remarked that it is not safe, so far as the mother is concerned, to attempt the extraction of a child by embryotomy if the antero-posterior diameter be less than from 2 to 2 J inches, unless, perhaps, in case of the child being dead, and more or less advanced in decomposition. Again: you have been told, that, as a general principle, although there are some exceptional instances, a living child cannot be delivered with a pelvic diameter under 3 J inches. If this be so—and I am quite confident that I am strictly within the record—the question arises, if the child be alive, and the diameter should fcyen measure 2£ inches, or if it should 652 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be more than 2j but less than 3£,* what is the course to be pur- sued? My own principle of action, under these circumstances, would be a preference for the Caesarean section over the mutilation of the child, and for the reasons detailed in the previous lecture; and, moreover, if I be correct in my argument in that lecture, an early resort to the Caesarean section with the aid of anaesthesia Avould so far diminish its dangers in contrast with embryotomy, as absolutely to render it, of the two expedients, but little, more fatal to the mother, while, instead of the necessary destruction of all the children, a very large portion of them would be saved; for you are not to forget that, under the most unfavorable circumstances, only 1 in every 3 J of the children is lost in the Caesarean operation. If, however, it be ascer- tained that the child is dead, then the circumstances of the case entirely change ; for the cardinal argument, I contend, in favor of the Caesarean operation is to prevent the horrid destruction of foetal existence, while at the same time the danger to the mother is but slightly enhanced. So that the child being dead, with a diameter even less than tAvo inches, I should unquestionably have recourse to embryotomy; for it would be only under the most desperate cir- cumstances, that, knowing the child to be sacrificed, the Caesarean operation could be selected as an alternative; and yet I must con- fess that if the antero-posterior diameter did not measure l£ inches, the Caesarean section would present, in my judgment, a better chance to the mother than embryotomy. You see, therefore, that if the antero-posterior diameter should not afford a space of one and one halff inches—even admitting the * It would be proper if the diameter were three and one-eighth inches, or even slightly under, to attempt delivery by the forceps, for it is barely possible that suc- cess might attend the effort. Should it, however, fail, as I am sure it would in the vast majority of cases, put the instrument aside, and have recourse (the child being alive) to the Caesarean section. \ The celebrated case of Elizabeth Sherwood, so repeatedly referred to by writers on midwifery, has, I am confident, been productive of bad practice, and I am dis- posed to think that, more especially in Great Britain, it has been regarded as ample authority for a resort to the perforator. So impressed am I with this conviction, and anxious as I am that the true facts of the case shall be properly appreciated, I do not consider an apology necessary for quoting it in extenso, as originally published by Dr. William Osborn, in whose practice the case occurred: " Elizabeth Sherwood was forty-two inches in height, and so deformed as never to be able to stand erect for one minute without a crutch under each arm. At the age of twenty-seven years she became with child. Early on Sunday morning, November 19, 1776, she complained of having been in pain the two preceding days and nights. I examined her per vaginam that evening with great attention. On the introduction of the finger, I perceived a tumor, equal in size, and not very unlike in the feel, to a child's head. It was, however, instantly discovered that this tumor was formed by the basis of the os sacrum, and last lumbar vertebra, which, projecting into the cavity of the pelvis at the brim, barely left room for one finger to pass between it and the symphysis pubis, so that the space from bone to bone at that part, could not THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 653 child to be dead—embryotomy is not to be resorted to, but the alternative is the Caesarean operation. If, on the contrary, this diameter should yield slightly over one and one half inches, then, Avith all the risk incurred by the mother from the operation, Avith a exceed three quarters of an inch. On the left side of the projection, quite to the ileum, which was about two inches and a half in length, the space was certainly not wider, and by some, who examined her afterward, it was thought to be narrower. On the right side, the aperture was rather more than two inches in length from the protu- berance to the ileum, and as it admitted the points of three fingers (lying over each other) in the widest part, it might at the utmost be about one inch and three quarters from the hind to the fore-part; but it became gradually narrower, both toward the ileum and toward the projection. " The membranes were not yet broken, but with some difficulty I felt the child's head through them, situated very high above the projection. The abdomen was hard and tender; as she seemed much fatigued for want of rest, fifteen drops of tinct. opii were given, by which some sleep was procured between the pains. The mem- branes broke some time after I left her, and there was the usual quantity of liquor amnii. The next morning, being hot and thirsty, and her pulse very quick, ten ounces of blood were taken from her arm; and the bandage accidentally slipping off soon after her arm was tied up, she might perhaps lose as much more before it was discovered. No alteration whatever had taken place either in the os uteri, which was still but little dilated, though soft and flabby, or in the position of the child's head. In so extraordinary and singular a case, I naturally wished for the advice and assistance of my professional friends. I met in consultation that evening Drs. Bromfield, Denman, Walker, and Mr. Watson. Every gentleman present imme- diately satisfied himself by examination per vaginam, of the dimensions of the pelvis, some thinking it rather narrower, but none wider than the dimensions stated above We weighed, with great deliberation, every circumstance by which our future conduct in this case ought to be regulated; particularly we used our best endeavors to determine the stale of the child in utero; and whether, if the Cesarean operation should be per- formed, which we had in contemplation to do for some time, there would be a certainty of preserving one life at least. We were rather disposed to believe that the child was dead. It was, therefore, agreed that an attempt at least, ought to be made to deliver the poor creature, by opening the child's head, and extracting it with the crotchet. " I commenced the operation about eleven o'clock that night. Even the first pari of the operation was attended with considerable difficulty and some danger. The os uteri was but little dilated, and awkwardly situated in the centre, and most contracted pari of the brim. The child's head lay loose above the brim and scarce within reach of the finger. I desired an assistant to compress the abdomen with sufficient force to keep the head in contact with the brim of the pelvis, so as to prevent it receding from the scissors. I introduced them with the utmost caution through the os uteri; and after repeated trials, at length succeeded in fixing the point into the sagittal suture; I very soon, with great facility, penetrated the cavity of the head, and with a common spoon extracted a quantity of the brain; breaking down the parietal bones, made an opening sufficient for the free discharge of what remained. In this state we left her; although fatigued with this part of the operation, no opiate was given, as I wished to have the full effect of the labor-pains. In this expectation I was disappointed, for, not- withstanding she was prevented from sleeping aU night by the frequency and violence of the pains, in the morning I was not sensible of the smallest alteration in the position of the child's head. During the whole day the pains were neither so strong nor so frequent as they had been; her pulse was extremely quick, but tokrably strong; the discharge from the vagina was very considerable in quantity, and most abominably fetid. Drs. Bromfield, Denman, and Hunter saw her in the course of the day; she 654 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. less space than two and one eighth inches, I should not hesitate to mutilate the child—being first satisfied of its death—for in this case, the compensating argument in favor of the Caesarean section—the safety of the child—does not obtain. was examined, besides, by more than thirty students in midwifery, which she willingly permitted at my request, from a representation of the singularity of her case and the utility which might result from its being more generally known. "Toward the evening, the pains considerably increased, and as I wished to benefit from the full effect of them, no opiate was given; she, therefore, had no sleep; and the pains continued through the whole night. When I first saw her the next morning, her strength was greatly reduced; her pulse beat one hundred and forty strokes in a minute, notwithstanding every precaution had been used to guard against fever, par- ticularly by forbidding all strong liquors, and by keeping the ward unusually cooL Eer spirits, however, were good, and her resolution unabated. Upon examination, a small portion of the head was found squeezed into the pelvis. " Our intention, by delaying the extraction of the child six and thirty hours after opening the head, was to allow the uterus opportunity to force the head as low and as much within reach of the crotchet as the nature of the case admitted; and after- ward to induce as great a degree of putrefaction as possible in the child's body, by which means it would become soft and compressible, and afford the least possible resistance in its extraction. These two purposes appeared to me most completely accomplished, and there was no advantage from further delay. On the contrary, I was fearful that so large a mass of putrid matter as a child at full term, with placenta, etc., remaining in the uterus longer than was absolutely necessary, might expose her to the future dan- ger of a putrid fever, if she should escape all material injury from the inevitable violence and consequent danger of the operation. " I determined to begin to make an attempt to extract the child; I call it an attempt, for I was far from being satisfied in my own mind of its practicability. Adverting to the very small space of only If inches at the utmost, and in the widest part, and that only on one side of the projecting sacrum, while the space, between it and the symphysis on the other side barely amounted to three quarters of an inch, I trust I am justified in my feelings and expression. "About 10 o'clock on Wednesday morning {the patient having been in labor since the previous Friday), I began the operation of extraction. The os uteri situated as before described, in the most contracted part of the brim, where the space was inca- pable of permitting the introduction of the curved point of the crotchet, without great difficulty and danger, I first endeavored to draw the os uteri with my finger into the widest part of the brim, and to dilate it as much as possible. Both these results were accomplished. I then introduced the crotchet through the perforation into the head, and by repealed efforts destroyed almost the whole of the parietal and frontal bones; as the bones became loose and detached, they were extracted with a small forceps, to prevent as much as possible the laceration of the vagina. " The great bulk of the head, formed by the basis of the skull, still, however, re- mained above the brim of the pelvis, and it was impossible to enter without either diminishing the volume, or changing the position; the former was the obvious method, for it was a continuation of the same process, and I trusted would be equally easy in the execution. I was, however, most egregiously mistaken and disappointed, being repeatedly foiled in every endeavor to break the solid bones of the base of the cranium, the instrument, at first, invariably slipping. At last, however, by changing the position of the instrument, I fixed the point, I believe, into the great foramen, and by that means became master of the most powerful purchase that the nature of the case admitted. Of this I availed myself to the utmost extent, steadily increasing my force, till it arrived to that degree of violence which nothing could justify but the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 655 The question of whether the child be alive or dead, is one of great significance, and is, in my judgment, with the reservations just stated, the turning point on Avhich must rest the final decision— Caesarean section or embryotomy. Therefore, it is right that we extreme necessity of the case, and the absolute inability, in repeated trials, of succeed- ing by gentler means. But even this force was to no purpose, for I made no impression on that solid bone, nor had it in the least advanced by all my exertions. " I became fearful of renewing the same force in the same way, and abandoned the first idea of breaking the bones of the cranium, and determined to try the second, of endeavoring to change the position. I once more examined, as accurately as»the ma,ngled state of the head would admit, how it presented. From the information thus procured, the second method appeared to me a forlorn hope; however, there was no other resource. I therefore again introduced the crotchet, fixed it in the great foramen, and got;possession of my former purchase, and succeeded, together with the two fingers of my left hand, in changing the position of the head, and thus diminishing its volume. Continuing my exertions with the crotchet, I soon perceived the head to advance into the pelvis. " Every difficulty was now removed, and, by a perseverance in the same means for a short time, the remaining part of the head was brought out of the os externum. After waiting a few minutes, a napkin was put round the neck of the child, and given to an assistant. I then introduced the crotchet, and, first opening the thorax, fixed it firmly in the sternum. By our united force, strongly exerted for about a quarter of an hour, the shoulders were brought down; and, lastly, after opening the abdomen, the whole body was extracted in the most putrid and dissolved state; but it appeared to be a moderately sized child at full term. The placenta came away without much trouble. The operation continued for about three hours; and the poor creature, although in strong labor three days, and her bodily strength much exhausted by violent and unavailing pains, yet she supported the whole business with surprising fortitude, and suffered much less than might reasonably have been expected either from the length of the labor or the extreme violence in the delivery. She went to Bleep soon after the operation, passed a good night, complained of very little pain, etc.; she recovered so fast, that she sal up the seventh day, acknowledging, with great gratitude, that she was then as well, in aU respects, as in any former period of her life. " As far as I know, this woman's pelvis was the smallest, through which a child at full time, and of the ordinary size, however lessened by art, has ever been extracted; and it was in contemplation in this very case, to perform the Ccesarean operation, if we could have been satisfied of the life of the child, upon the presumption of the impossi- bility of bringing it, under the circumstances of age and size, through the natural passages. I hope the event of the case may prove the means of frequently preventing that fatal operation (the Caesarean section) in future." [Essays on the Practice of Midwifery, By Wm. Osborn, p. 240-257.] I think I have rendered a substantial service by the insertion of this case here; it is no garbled statement; on the contrary, it is in ipsissimis verbis of Dr. Osborn him- self, just as it was distilled from his own pen. The underlinings are my own, and I iritend them as a sort of commentary upon the details. Dr. Osborn, in his day, occupied no mean position; his opinion was one of weight in all matters pertinent to obstetric science; and hence the case of Elizabeth Sherwood, from the circum- stance mainly of its having occurred in the practice of so distinguished a man, has not only become a part of history, but is regarded too frequently as an authority why embryotomy should be preferred to the Caesarean section. But how different the influence of this case on the professional mind, if the unhappy woman had died 656 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. should examine the evidence, which may enable us to determine if the child in utero be living or not. Authors differ as to the nature and value of this evidence ; some supposing that the question is one of easy decision, while others again, and certainly with good reason, regard it as a point, under certain circumstances, of much embar- rassment. Eridences of the Child's Death in Utero.—The folloAving are enumerated as among the ordinary proofs that the child has ceased to live: 1. The discharge of meconium per vaginam; 2. A flaccid condition of the cranial bones, overlapping each other; 3. A want of elasticity in the scalp under the force of uterine contraction; 4. Cessation of foetal movements; 5. Failure to detect the pulsa- tions of the foetal heart, or those of the umbilical cord ; 6. Fetid discharges from the vagina, together with the passage of small detached pieces of epidermis from the presenting portions of the foetus. Let us briefly consider the true import of these signs. Every practitioner of ordinary observation knows that the discharge of the meconium through the vagina of the mother is, per se, no evi- dence at all that the child is dead; for it may occur consistently AA'ith the life and full health of the foetus. In breech presentations, for example, it is one of the usual accompaniments of this form of birth; and I have known it to take place in an ordinary head pre- sentation, and the child born alive. The flaccidity of the cranial bones, together with their over- lapping, is one of the uniform circumstances attending hydrocepha- lus ; and hydrocephalus, although a deplorable complication, is no proof that the child does not live. A want of elasticity in the scalp, under the force of uterine effort, needs a word of comment. As a general rule, when the labor is developed, and the head pressed more or less against the walls of the pelvis, there will be recognised corresponding Avith the orifice of the uterus an elastic tumor formed by the scalp of the child's head. This tumor is the result of the contractions of the uterus under her accumulated sufferings I I now ask the reader to peruse every word of this statement with unbroken attention; and then I ask him whether, from the irresistible evidence furnished by the details of the statement, the fact of Elizabeth Sherwood having survived the operation is not a circumstance which would no!; be likely to occur once in ten thousand times ; and whether her recovery is not f ully entitled to be classed among the miraculous, hair-breadth escapes from death? Therefore, if this be so, it should be discarded from the books and the eulogiums of the lecture halls, as a guide for practice. It has exercised a singularly unhap py influence over the minds of some clever men; and has been, without due considera- tion, adopted as an evidence of the extreme deformity through which a child can I >e brought into the world by embryotomy, without compromising the safety of tm* mother. The only value of the evidence is, it proves simply what is universal!} ' admitted—that every rule has its exception. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 657 together Avith the resistance encountered by the head in its deseent. It is of no consequence, for it in no way involves the safety of the child. But in another aspect, it is of much interest. The tumor cannot form if the child be dead at the commencement of the labor, and if, after its formation, the foetus should die, the tumor becomes soft and flaccid. Again: even when the child continues to live, the tumor will occasionally lose its elastic tension, in consequence of an extravasation of blood under the scalp, constituting a species of cephalhmmatoma, or bloody tumor, and this is apt to occur AA'hen the head of the child encounters an exaggerated pressure, either as the result simply of strong uterine force, or conjointly with a con- traction of the pelvis. It may, also, happen that the child will be born alive and healthy without the slightest approach to the forma- tion of the tumor. As to the cessation of the foetal movements, it is well known that some women never feel the child move during the whole period or* pregnancy ; others again, after having experienced the sensation for a certain period, fail to do so afterward, and yet bring forth living children. The pulsations of the foetal heart may or may not be detected ; in the former instance, there can be no doubt that the child is alive; while in the latter, it does not necessarily follow that life is extinct. Foetid discharges from the vagina, together with the passage of small detached fragments of epidermis, indicating the decomposi- tion of the foetus, constitute very strong evidence that the child is dead; and yet there are cases recorded in which these phenomena have been recognised, and the child alive. Such instances, hoAV- ever, must be regarded as extremely rare exceptions to a very gene- ral rule. One of the most remarkable is that mentioned by Baudelocque* as having occurred in his own practice: He was called to a poor woman who had been in labor tAvo days ; there Avas emitted from the vagina an insupportable fcetor, commingled with fluids of the same character. The head of the child was at the upper strait, and the scalp soft and loose ; the epidermis and hair fell off Avith the mere pressure of the finger; there had been no movement of the foetus for the preceding twenty-four hours; the mother's pulse was feeble and quick; the tongue, gums, and lips were black, and she exhaled a cadaverous fcetor. These evidences —strong, indeed—of the child's death determined Baudelocque to resort to the crotchet; he held the instrument in his hand, but as he was about to introduce it, suddenly changed his mind, and decided to substitute for it the forceps, although convinced that the child was dead. It Avas a most happy substitution, as the * L'Art des Accouchemens, vol. ii., p. 229. 42 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sequel revealed, for he delivered the mother of a living child! The foetid discharges, etc., were the result of a gangrenous slough on the summit of the head, which, however, only involved the thickness of the integuments. So, you see, gentlemen, all these phenomena, denoting the de- composition of the foetus, may ensue, and yet the child be alive. But remember, as I have just remarked, such examples are to be regarded as altogether exceptional, and out of the ordinary record. The absence of pulsations in the cord does not, of necessity, imply the death of the foetus ; fori have already cited the authority of Dr. Arneth, of Vienna,* who mentions four cases under his im- mediate notice in which no pulsations had been detected for half an hour previous to delivery, and in each instance the child was born living. Procidentia of the cord, its coldness, and absence of pulsation, together with its incipient putrefaction, may be regarded as among the very decided proofs that the child is dead. The decision of this question is one of no ordinary import, and it, therefore, is the duty of the accoucheur to exercise a full mea- sure of discretion, in order that he may reach the truth ; and, above all, let him be cautious not to suffer himself to be led to a hasty conclusion from the mere love of bringing the child into the world piecemeal. Whether it be really a love for this kind of thing, or an indifference to the shedding of innocent blood, I will not undertake to determine; but of one fact I am quite confident—the perforator and crotchet are oftentimes employed in this metropolis with a recklessness altogether startling to those, who suffer conscience to have its share of influence in the doings of the lying-in chamber. ^ Culpable Indifference to Professional Obligation.—Not long since I was visited by a young medical gentleman, who had been in practice but a short period. In the course of conversation the subject of operative midwifery was introduced. He remarked that he had enjoyed the best opportunities of becoming familiar with the use of instruments, for his preceptor had performed the opera- tion of embryotomy on an average sixteen times a year!!! To you, gentlemen, such an announcement may appear like romance ; but I have myself Avitnessed in this city scenes of blood sufficient to satisfy my mind that it is not an exaggerated picture; and I will take the liberty of citing one case among several others now fresh in my memory, to show you that I do not speak Avithout cause, when I protest against the unholy acts of men, who were intended neither by Heaven nor education to assume the sacred duties of the parturient room. The particulars of the following case I have recorded in mv * See Lecture xxxi. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 659 Translation of Chailly's MidAvifery: " Two years since, I was re- quested to visit a poor Avoman who resided a feAv miles from this city; she had previously borne tAvo living children, and her con- finements had not been attended by any unusual circumstance. On arriving at the house, there was presented to my view a scene which I never can efface from memory. It was a spectacle at which the heart sickened; it Avas humiliating to my professional pride, and I could not but experience feelings of deep mortification. The un- fortunate sufferer had been in labor 26 hours, when two medical gentlemen, for reasons which I trust were satisfactory to them- selves and their consciences, decided to resort to the perforator. This instrument of death was accordingly thrust into the brain of a living child; the labor, however, did not advance, and they pro- ceeded to remove the foetus piecemeal. After four hours of des- perate toil—and I ask where could have been their feelings of humanity—they succeeded in bringing away the entire fcetus in a mangled condition, with the exception of the head which Avas still in the womb. The friends of the poor creature—for, destitute as she was, she was not without friends in this her hour of tribulation —her friends, I repeat, became alarmed—their confidence was lost, and the serious apprehensions entertained for her safety, induced them to call in additional aid. I was sent for, and on hearing the particulars of the case, so far as the messenger could communicate them, I hastened to the house, accompanied by my former pupils, Drs. Busteed and Burtzell. " The patient Avas pale and exhausted—her countenance was that of a dying woman—she was almost pulseless, with cold extremi- ties, and the perspiration of death on her! In her death agony she supplicated me to save her, and said, with a feeling which none but a mother can cherish, that she Avas willing to undergo any additional suffering, if she could only be spared to her children. Poor creature ! her measure of anguish Avas indeed full; and had she known that she was about being removed from her children by the atrocious butchery of men to Avhom she had entrusted her life, she would not have made the appeal she did. In approaching the bed of the dying woman, and on attempting to make a vaginal examination, to ascertain the condition of the womb, the head of the foetus being still in its cavity, having been separated from the trunk, you may well imagine my feelings on finding a mass of small intestines protruding from the vagina, and lying between the thighs! " The operators, not content with slaughtering the infant, had ruptured the uterus, through Avhich the intestines escaped, and thus abandoned the woman! She lay in this condition three hours be- fore I saw her, the doctors having left the house, stating nothing more could be done! Verily, death does terminate all human effort. The question may now be asked—Why was embryotomy had 660 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. recourse to in this case ? I never could ascertain. There must have been a secret reason for it—the burning love, perhaps, which tome men have for the eclat of bloody deeds. There Avas no deformity of the pelvis ; the head of the foetus was of the usual size ; and, a3 far as I could learn, it Avas an ordinary labor. The doctors judged it advisable to do something; they decided to turn and deliver by the feet. They accordingly proceeded, and, mistaking a hand for a foot, pulled it into the vagina. They were then foiled, and, in order to complete the delivery, commenced cutting up the fcetus, and extracting it piecemeal. Thus Avere tAvo lives Avantonly sacrificed. The patient died in about two hours after I arrived ; half an hour before she expired she observed—' My poor child was alive, for I felt it move when the doctors were tearing it from me /' Such language, uttered under such circumstances, was indeed graphic and eloquent in condemnation of those Avho had been participa- tors in this cruel tragedy.', The melancholy case which I have just cited, harroAving as it is, unfortunately is not alone; its counterparts have not only been Avitnessed in the lying-in room, but the archives of the profession record many such. Giraud* says, " I have on several occasions been present when embryotomy was performed by the most dis- tinguished practitioners, and the mothers have died immediately after the operation. In two instances, I myself assisted in extracting the foetus by fragments, and the mothers sank a feAv hours after- Avard ; in one, the intestines passed through a laceration of the uterus, and projected from the vagina; in the other, the vagina and posterior wall of the uterus were frightfully lacerated!" Mode of Performing the Operation of Embryotomy.—It must be kept in memory that this operation may be judged expedient by the accoucheur under se\'eral different circumstances ; for example, when there is such an abridgment in the diameters of the maternal organs as to render it physically impossible for the child, Avithout mutilation, to pass ; Avhere the maternal organs are normal in their dimensions, but the excessive size of the child constitutes the diffi- culty, as is illustrated in hydrocephalus; where there is no actual disproportion in the respective size of the child or organs, but where the obstacle consists in malposition of the foetus, Avhich cannot be rectified either by the hand or through the agency of an instru- ment, and which, therefore, may call for the dismemberment of the child. Trusting that you will not fail to keep in vieAv the line of argument which I have endeavored to lay before you, as to the justification of embryotomy, I shall now proceed to point out the mode of procedure usually adopted, after you have decided that the operation is a feasible and proper resource. Journal de Medicine. Par MM. Corvisart, Leroux, and Boyer. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 661 The patient isplaeed on her back, and brought to the edge of the bed, occupying precisely the same position, already described, when delivery is to be accomplished either by version or the for- ceps. The bladder and rectum being previously evacuated, two finders of one hand are to be introduced as far as the head of the child, to serve as a guide for the perforator or pierce-crane; if possible, the instrument should be made to enter the cranium through either the anterior or posterior fontanelle; or, if this can- not be done, any other portion may be selected, endeavoring, hoAV- ever, to avoid penetrating the sutures. As soon as the instrument ha3 entered, the handles should be separated, so as to facilitate as much as possible the complete breaking up of the brain. If it be necessary, a small spoon may be employed for the purpose of bringing away the cerebral mass ; and, if you are operating on a living child, allow me, in tnercy, to beseech you to be thorough in your work of death, and see that the medulla oblongata is de- stroyed, in order that you may be spared the sad scene of witnessing the sobs of the poor infant after it has been brought into the Avorld, mangled and mutilated! If, after the discharge of the brain, and the col- lapse of the cranial bones, the head should not ad- vance, then recourse may be had to the guard-crot- chet, Avhich may be in- serted into the foramen magnum occipitale, the socket of one of the eyes, or behind the mas- toid process. In addi- tion, should it be found necessary, the bone for- ceps may be employed for the purpose of remo- ving the bones of the head in fragments. As a general rule, when the head has passed, the trunk will folloAv Avithout much difficulty; if Iioaa-- ever there be an obsta- FaH 662 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. cle to its exit, the perforator may be introduced into the chest an<3 abdomen, for the purpose of evisceration, thus diminishing tho general bulk of the foetus. Instances will occasionally occur, in which, after the delivery of the trunk of the child (Avithout any pelvic deformity) the head becomes arrested at the superior stinit, and the accoucheur is unable from malposition, or some other cause, to bring it into the cavity of the pelvis. Under these circumstances the perforator and crotchet may again be indicated. In hydrocephalus,* provided there be evidence that the child is alive, I should caution you not hastily to decide on opening the cranium (Fig. 96) for the purpose of affording escape to the accu- mulated fluid, for, if the pelvis be natural, or even slightly con- tracted; it is possible that the efforts of the uterus may suffice to accomplish the expulsion of the foetus, and this, too, consistently with its safety. Therefore, my advice is—exercise a constant vigi- lance; sustain as far as may be,, the courage and hopes of your pcttient, and do not have recourse to the perfo- rator until you are satisfied of the inability of nature to terminate the labor, and that further delay would prove perilous to the mother. In a shoulder or arm presentation, it may happen that version cannot be performed; in such an event, it Avould be of little avail to attempt to amputate the arm, for this AA'ouId in no way facilitate the delivery. It Avould be far better practice to introduce the curved instrument, with an internal cutting border (Fig, 97), for the purpose of separating the head from the trunk, as was originally suggested by Celsus-; or, if this cannot be done, a pair of long scissors may be carried up, as Dubois recommends, in the folloAving manner: The finger to be cautiously introduced Avith a vieAv of ascertaining the position of the neck; as soon as this is done, the finger should be hooked round the neck to force it as near as possible to the upper strait, and then the scissors, carried up along the finger, Avill enable the accoucheur to complete the Avork of decollar tion. When this has been effected, traction should be j||| made on the shoulder or arm Avhich presents, and in this "fig. 97. way the trunk will be brought doAvn. The head, Avhich * It would seem that, in hydrocephalus, rupture of the uterus is not an unusual accompaniment. Dr. Thomas Keith has collected 74 cases of intra-uterine hydroce- phalus, and in 16 of these, the uterus became ruptured during labor. It has there- fore, been suggested in hydrocephalus, especially if the labor be prolonged, iMsiead of resorting to the perforator, and consequently destroying the child, to introduce &■ small trocar for the purpose of evacuating the fluid, which does not necessarily involve the safety of the foetus. [Simpson's Obstetric Works, vol. L, p. 654.} THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 663 of course remains within the uterus, is to be removed, as described in a previous lecture. There is still another alternative in these cases of arm or shoulder presentation, in which version is found impracticable; it is this—passing the finger along the arm or shoulder, as a guide to the axilla, the latter is penetrated by the perforator, and the chest eviscerated; this being accomplished, the delivery of the child, by making a lever of the arm, will not be difficult. Cephalotripsy.—It is proper, before concluding this lecture, that I should direct attention to an alternative which, in the judgment of some distinguished and experienced accoucheurs, may Avith great advantage to the mother, be substituted for the crotchet and other instruments, employed for the extraction of the foetus, after its cranium has been opened by the perforator. I allude to cepha- lotripsy, Avhich consists in crushing the child's head by what is called the cephalotribe or embryotomy forceps, and thus extracting it through the maternal organs. It has been Avell remarked that the true dangers to the mother in craniotomy are in no way to be referred to the mere act of perforation, but arise altogether from the subsequent use of the crotchet, bone forceps, etc., which are employed for the purpose of completing the delivery. There is much truth in this observation, and in order to overcome these undeniable objections to the crotchet, etc., A. Baudelocque, Jr., some years since constructed an instrument, knoAvn as the embry- otomy forceps or cephalotribe. It has, since its first introduction to the attention of the profession, undergone several modifications by different accoucheurs, among whom may be named Cazeaux (Fig. 98), and Scanzoni. The cephalotribe of the latter is a good instrument, and will be found to answer very efficiently all the pur- poses for which it is intended. It is an error, however, to suppose that the ce- phalotribe can do aAvay Avith the perfora- tor ; on the contrary, the true excellence of the instrument is developed only after the cranium has been previously emptied of the cerebral mass. It has been demonstrated by nume- rous experiments made on dead foetus- es by Hershent, that, if the instrument be applied to the head previous to the evacuation of its contents by the perfo- Fio. 98. rator, the diameter in accordance Avith which it is grasped will be diminished, while the other dimensions of the head become increased. If, on the other hand, the cranium 664 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be perforated and freed of the brain, and then crushed by means of the cephalotribe (Fig. 99), it is less voluminous, and the diame- ters much more contracted.* But the advantages of the instrument are not limited to the head of the child; it may be employed with benefit, if the fcetus be dead, in difficult breech presentations ; also, for the purpose of diminishing the volume of the thorax, should it be necessary after Fra. 99. the escape of the inferior extremities; and in some instances, in transverse positions of the trunk, when version cannot be effected in consequence of the impossibility of introducing the hand into the cavity of the uterus. One of the essential prerequisites for the use of the cephalotribe is a sufficient space in the pelvic canal to admit the passage of the foetus after it has been crushed. If, there- fore, there were not a space of at least two inches, the instrument could not be employed with any hope of success. ScanzonL N LECTURE XLIII. Hi* Induction of Premature Artificial Delivery—Premature Artificial Delivery- How divided—When is the Fcetus viable?—The Period of inducing Artificial Delivery with the hope of saving the Child—What was it that first suggested a Recourse to it ?—The History of the Operation—First performed in Great Britain —Statistical Tables showing the Diameters of the Foetal Head at Different Perioda of Development—The Opinion of Dr. Merriman and others, that Premature Deli- very should not be attempted in the Primipara—Objections to—The Causes of Artificial Delivery—What are they ?—Deformity of the Soft Parts sometimes a cause—Case in Illustration—Excessive vomiting in Pregnancy and Artificial Deli- very—Examination of the Question—Statistics of Premature Artificial Delivery contrasted with those of the Caesarean Section and Embryotomy—The various modes of inducing Artificial Delivery—Perforation of tke Membranes—Ergot, Dilatation of Os Uteri by prepared Sponge, according to the method of Kluge and Bruninghausen—Meissner's mode of Rupturing the Membranes—The Method of Kiwisch, or Water-douche—The Method of Cohen—Injection of Carbonic Acid into the Vagina as proposed by Dr. E. Brown-Sequard; its influence on contraction of non-striated muscular fibres—Induction of Abortion—Is it ever justifiable \ Gentlemen—In the two preceding lectures Ave have discussed the question of operative midwifery under two important aspects: 1. Whether the mother shall be subjected to a perilous alternative for the purpose of dividing the chances of life between herself and offspring; 2. Whether the child shall be mutilated, and brought into the Avorld piecemeal, thus sparing the mother the hazards of an operation performed on her own person. But I desire you distinctly to recollect that the discussion of this question had reference to the female, who should not only have arrived at the completion of her pregnancy, but who was actually in labor at the time at which your opinion Avas to be determined as to the choice of one or other of these expedients. In the examination of this subject, and in the pursuit of truth, we were necessarily compelled to narrate facts and circumstances well calculated to sicken the heart, and draAV largely on your sympathy. To-day Ave have a more agreeable duty to per- form ; for it is my purpose to present to your consideration an alter- native, which will oftentimes not only do away with the necessity of the Caesarean section and embryotomy, but will prove the means of greatly diminishing the destruction of human life. I allude to the induction of premature artificial delivery—one of the most precious boons which science has yet bequeathed to suffering woman. Premature artificial delivery may be properly divided into two 666 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. branches: 1. When the foetus is viable, or, in other words, has attained a degree of intra-uterine development, AA'hich Avill enable it to enjoy an independent or external existence ; 2. Previously to the viability of the fcetus. These tAA'O divisions of the subject I shall now proceed to examine, giving to each, as far as I may be enabled to do so, its respective value and indications. Premature Artificial Delivery when the Fcetus is Viable.—It is noAV very generally admitted that a foetus at the end of the sixth month of gestation is capable of living independently of its parent; and there are not a few examples of fcetal viability at an earlier period than the completion of the sixth month.* It is an interest- ing circumstance to note that the first suggestion of the alternative of premature artificial delivery originated in the fact observed by accoucheurs, that women, who had previously been subjected to the use of cutting instruments, in consequence of pelvic deformities obstructing the passage of a living child at full term, had been delivered Avithout a resort to these instruments, and with safety to themselves and offspring, when taken accidentally in labor at the seventh or eighth month of gestation. The earliest historical record touching this operation Ave find in the following language of Dr. Denman :f " A consultation of the most eminent men in London at that time (1756), Avas held to consider the moral rectitude and advantages Avhich might be expected from this practice, and it met with their general approbation." England, therefore, is not only entitled to the honor of having decided the morality and utility of the expedient, but to one of her medical men, Dr. Macauley, is due the credit of having been the first to have recourse to it, and with success to both mother and child. Soon after this, it became a recognised alternative in Great Britain. It Avas also adopted in Germany, Holland, and other countries, but, strange to say, it was repudiated in France as a "cruel and inhuman" operation, and it Avas not until 1831 that it was resorted to in that nation for the first time by Stoltz, of Stras- bourg, saving both mother and child. Since that period, it has met with general favor in France, and has been repeatedly performed. * When discussing the interesting subject of premature and protracted gestation, it was stated that France had enacted a law granting to a child born six months, or one hundred and eighty days after marriage, all its social and legal rights; and this law, wise in itself, though often subject to abuse, is predicated on the fact that children are sometimes sufficiently developed at this early period of pregnancy to enable them to live. The law originated in the desire to protect the honor of the parent and the privileges of the child, in these instances of premature delivery; but it cannot be regarded as a guide to the induction of premature artificial labor, for the reason that the viability of the foetus at the sixth month is to- be considered an exceptional circumstance, whereas, at the seventh month, it assumes more the cha- racter of the rule. ■j- Introduction to Practical Midwifery, p. 396. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 667 In bur own country, it is also in favor. In a Avord, under justifying circumstances premature artificial delivery now holds a high place among the alternatives of the lying-in room; for it must be remem- bered that the object of the operation is not merely to diminish the dangers to the mother, but also to save the life of the child. Let us examine Avhat it is that gives facility to the passage of a living child at the seventh and eighth months, which cannot possi- bly be brought into the world alive at the full period of utero-ges- tation. In order to determine this question, and decide what the pelvic capacity must be to alloAv the expulsion of a viable fcetus, it will be proper to ascertain the diameters of the head at the differ- ent periods of pregnancy. When the head begins to engage, it is its biparietal or transverse diameter Avhich traverses the antero- posterior of the pelvis, and consequently it is very important to have an accurate idea of the dimensions of the biparietal diameter. The following tables of M. Figueira and Ritgen, Avhich have been presented by Dr. Churchill,* are important, and elucidate fully this question: Age of Foetus. Biparietal Diameter. Occipito-Frontal Diameter. Occlpito-bregmatic Diameter. 7 months. 7* ,: 8 " 8} " 9 " 2 inches 9 lines. 3 inches. 3 inches 1 line. 3 inches 2 lines. 3 inches 4 lines. 3 inches 8 lines. 3 inches 9 lines. 3 inches 10 lines. 4 inches. 4 inches. 2 inches 10 lines. 3 inclies. 3 inches 1 line. 3 inches 2 lines. 3 inclies 4 lines. According to Ritgen, premature artificial delivery may be induced at the 29th week, when the antero-posterior diameter of pelvis is 2 inches 1 lines. 30th " " " " 2 " 8 " 31st " " " " 2 " 9 " 35th " " " " 2 " 10 " 36th " " " " 2 " 11 " 37th " «• «* " 3 " AlloAving for the overlapping of the parietal bones, and the con- sequent diminution of the biparietal measurement of the fcetal head, it Avould appear that the extremes indicating the operation, all other things being equal, Avill be 2j and a fraction less than 3J inches, and, indeed, it might become a question, if the antero-pos- terior diameter measured even 3£ inches, Avhether premature delivery would not present a better chance of life to both mother and child; for you are to remember that although Ave have stated that, as a general rule, a contraction of 3 J inches is the smallest space through * Theory and Practice of Midwifery, fourth London edition, 1860, p. 296. 668 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. which a living child can be made to pass at full term, yet its exit, if accomplished under this condition of things, would be attended by more or less peril. Some writers* have urged, as an objection to the operation in a primipara, the difficulty of arriving at an accurate idea of the true size of the pelvis; they allege the insufficiency of the pelvimeter to reach this fact, and maintain that the real dimensions can only be approximated. I must confess I am unable to appreciate the strength of this objection; for it matters not whether the accouch- eur can come Avithin one or more lines of the actual extent of the antero-posterior diameter; what he desires is simply to approxi- mate a knowledge of the physical condition of the pelvis, so that, with all the accessible facts before him, he may, assisted by other counsel, decide ichether or not the contraction is such as to render it morally certain that a living child cannot pass at the full term of pregnancy. This cardinal fact being ascertained, then the ques- tion legitimately presses—What is the general character of the deformity? Is it such as to preclude the birth of a viable child ? If not, there should exist no doubt as to the course to be pursued. If, however, the contraction be so marked, as to demonstrate the impossibility of the exit of a seven months' child, then the next alternative presents itself for consideration—the induction of abor- tion, which latter point will be fully examined before the close of this lecture. While, for argument's sake, I am willing to accord a due degree of force to the objection, that the pelvimeter is oftentimes insuffi- cient to allow us to judge of the real dimensions of the pelvis, yet I believe the experienced accoucheur will be enabled, under ordinary circumstances, by the introduction of the finger—the pelvimeter, in my opinion, par excellence in the exploration of the pelvis of a married woman—to ascertain whether the deformity is of a charac- ter to justify a resort to the operation noAV under discussion. Be it, however, as it may, the objections urged in reference to the primipara do not exist in the multipara; for, in the latter, we have a positive demonstration, not only of the existence, but the actual amount of the pelvic deformity. For example, suppose the case of a female, whose pelvis is so contracted that, having gone to the * Dr. Merriman has no doubt exercised more than ordinary influence in the emphatic language he employs against recourse to premature artificial delivery in a primipara. With all respect for his name and authority, I cannot think he is right. The following are his words: " The practice should never be adopted till experience has decidedly proved that the mother is incapable of bearing a full-grown fcetus alive." [Medico-Chirurgical Transactions of London, vol. iii., p. 144.] If this opinion be recognised to the letter, it must, of necessity, to a greater or less ^xtent, lead to dis- astrous results. It seems to me cruel, to say the least, that the tenure of an infant's Bafety should be the previous destruction of its little relative before its transit into the world. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 669 full period of gestation, she has been subjected one or more times either to the Caesarean section or to embryotomy, for the reason that a living child could not be made to pass per vias naturales. Here, then, is the certain evidence of past experience—a proved fact—not a question of mere speculative opinion. It is, in truth, what is termed in law, the strongest and most irrefragable species of testimony. In a case, therefore, like this, there is no basis for a conflict of thought; the sacred obligation is imposed on the accoucheur, if the space be adequate to the passage of a viable foe- tus, to induce premature action of the uterus, in order that both mother and child may be liberated from the perils of embryotomy or the Caesarean section, should the mother be permitted to go on to her full term. But, gentlemen, there are other conditions than a deformed pel- vis, in which the operation of premature artificial delivery may very legitimately be regarded as a justifiable alternative; although in reference to some of them there has,and still continues to exist a marked difference of sentiment. For example, there are some women who, from disease of the placenta or other influences, are in the habit of bringing into the world dead offspring, the physical appearances shoAving that death occurred a short time before the completion of pregnancy. In cases like these, it has been proposed to have recourse to premature artificial delivery, for the purpose of saving the children ; and again, the same alternative has been sug- gested in instances in A\diich the volume of the foetuses, in several successive labors, has been such as to render their passage through the maternal organs, although presenting their normal proportions, physically impossible. Certain serious diseases of the gravid woman are also enumerated among the causes justifying this expedient— such as dropsy of the cavities, placing in more or less peril the life of the mother; aneurism and strangulated hernia, procidentia, or retroversio uteri, complicating gestation ; the presence of abdomi- nal tumors exercising an undue pressure on the uterus and other organs; an intra-uterine, or intra-pelvic growth, curtailing the dimensions of the pelvis to such a degree as to prevent the passage of a living child at maturity; contractions of the soft parts ;* pro- * The following is an interesting case of contraction of the soft parts in which I performed, on two different occasions, the operation of premature artificial delivery with entire success tp both mother and children. The lady was a native of Canada. Her husband, some months after marriage, took her to South America, where she was delivered of a child. He stated to me that she had been suffered to continue in labor five days; and, after experiencing the most agonizing pains, she was spon- taneously, in the absence of her physicians, delivered of a putrid foetus of immense Bize. In two months after her delivery she began to walk about the room, and although weak, was otherwise in tolerable health. The first intimation she had of anything wrong, was excessive pain in any attempt at sexual intercourse; thia proved to be impossible. In the course of a few weeks they sailed for New York; as 670 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. fuse uterine hemorrhage, Avhether accidental or unavoidable, before the completion of pregnancy, seriously compromising the safety of the mother; convulsions and excessive vomiting. The various conditions I have just cited are to be weighed with due attention, and can only be considered as just motives for the operation after they have received the sanction of a calm and dis- soon as they arrived, my late lamented and distinguished friend, Dr. Bushe, was consulted in reference to the case. At this time his health was so infirm as to dis- qualify him for professional duty. He sent a note to me by her husband, requesting that I would take this lady under my charge. On visiting her, and making an exa- mination, I found the entire vulva in a state of adhesion, allowing only a small open- ing for the meatus urinarius. After hearing an account of her labor, this condition of things was easily explained. From the protracted and severe pressure of the head of the foetus against the walls of the vagina, inflammation ensued, resulting in Bloughing and consequent adhesion of the vaginal parietes. The indication in this case was obvious—the vagina nee ded restoration. Accord- ingly, I commenced an incision just below the meatus urinarius, and extended it about an inch downward ; the knife soon came in contact with cicatrices so resist- ing, that it appeared almost as if I was cutting on iron. The incision being com- pleted, I introduced a small sponge covered with oiled silk, and retained it in situ with the T bandage. Occasionally withdrawing the sponge, and renewing it, I found the vagina yielded slowly to this sort of pressure. With the aid of a small- sized rectum bougie, carefully introduced twice a week, and, after being withdrawn, replaced by the sponge, the vagina, in the course of a month, permitted the intro- duction of the finger. Then I had an opportunity of ascertaining its condition. It was filled with hard and unyielding cicatrices in the form of rings. Having suc- ceeded in dilating the vagina to this extent, I recommended my patient to continue the sponge, and occasionally to introduce a larger-sized bougie. In about three months afterward I was visited by her husband, who seemed somewhat chagrined; he stated that it pained him to say that his wife thought she was again pregnant. This I found really to be the case, though it is manifest from what has been said, that sexual intercourse must have been attended with great difficulty. With this, however, I had nothing to do; the mischief had been done, and it was my duty to provide in the best possible manner for the patient's safety. The sponge and bougie, gradually increasing the size of both, were continued, and the vagina seemed to yield slightly to this equable pressure. The patient having nearly reached the end of the seventh month of her gestation I deemed it prudent to hold a consultation as to the propriety of resorting to prema- ture delivery, feeling in my own mind that, although contractions of the soft parts do sometimes yield sufficiently to the combined influences of pregnancy and labor, yet, in her situation, it would, to say the least, be hazardous to the child to allow her to proceed to the full term. On proposing a consultation to the husband, he was anxious that a particular friend of his, Dr. Richardson, of Havana, then on a visit to this city, should be called in. This was accordingly done, and after a full sonsideration of all the circumstances, it was deemed prudent to bring on premature delivery. This I did, and delivered the lady of a healthy, living daughter. She again became pregnant, and went to the city of Baltimore, where she was delivered at full term, with the forceps, of a dead child, after a labor of six days' duration. In consequence of the contraction of the soft parts, the vagina was lacerated. About three years from her last labor, I was again consulted. She was pregnant, and, at the seventh month, I resorted to premature artificial delivery, the soft parts not being in a condition to justify delay until the completion of gestation. In this instance, too, the child was alive and healthy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 671 passionate judgment. In reference to convulsions, as a cause for the adoption of artificial delivery, it is to be remarked that the pregnant woman may be attacked with almost any grade of con- vulsive disorder ; and if this latter, either under the form of cata- lepsy, hysteria, chorea, epilepsy, or the true puerperal eclampsia, should prove rebellious to remedies, and, more especially, if the convulsion be traced to irritation of the uterus, and the life of the mother placed in peril, I should not hesitate to liberate the organ from the irritation by promoting its premature action. Excessive Vomiting as a Motive for Premature Delivery.—The Bubject of excessive vomiting in pregnancy, involving the life of the mother, has recently attracted much attention. In 1852 there Avas a remarkable discussion in the French Academy of Medicine, embracing more particularly the question—Is it ever justifiable to induce abortion in cases of excessive vomiting? The discussion greAV out of a report submitted to the Academy by M. Cazeaux, and there was much conflict of opinion on the subject, the ultimate decision being one of a mixed character. It is conceded that preg- nant Avomen have occasionally died from the effects of vomiting ; there are some striking instances recorded, and I am quite sure the unrecorded experience of practitioners could furnish many more examples. Without entering into a prolix discussion Avhether abor- tion is ever justifiable in these cases, it seems to me to be more a question of sound judgment than one of controversy; and, in this, as in all other instances, in which doubts may arise as to the proper course to be pursued in the treatment of disease, it is the para- mount duty of the medical man to fortify himself in every possible way by an appeal to judicious and experienced counsel, together with a searching review of all the surrounding circumstances of each individual case. In this Avay, with no preconceived opinion to sustain, with no prejudice to cloud his judgment, no false light to lead him into error, the sound physician will, I think, be enabled in these con- tingencies to arrive at a just decision ; and, at all events, whatever he may do under the influence of such antecedents, will have been done AAdth good and justifiable intent, and therefore will deserve, and must receive, the sanction of all right-thinking men. I can- not, for myself, recognise any difference betAveen the decision of (this question and multitudes of others more or less constantly pre- senting themselves to the practitioner while engaged in his daily rounds of duty. Where is the physician who has not, at times, been almost be- wildered in his desire to decide the nice question—;further depletion or stimulation, in a case, for example, of pneumonia, pleurisy, or typhus, knowing, at the same time, that on the correctness of his decision must depend the life of the patient! In a case like this, 672 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. after the proper exercise of his judgment, looking merely at the safety of the invalid, whatever that judgment may indicate, or whatever the issue may be, I hold that the medical man has dis. charged his duty. So, gentlemen, is it in symptomatic vomiting, endangering, if not checked, the safety of the mother. Look scrupulously at all the circumstances, and if, with the aid of ripe counsel, you should be impressed with the conviction that the best if not the only alternative is in premature delivery—then, in my opinion, you Avould deserve rebuke if you withheld this means of relief; for, after all, the question to be determined is the simple but grave one—life or death—and the decision has nothing to rest upon but human judgment. The tAvo chief arguments employed by those, who oppose the induction of premature delivery for the cause under consideration, are: 1. That, in some instances, pregnant women, who have been supposed to have been almost in a moribund state from the ex- haustion of vomiting, have recovered and brought forth living children; 2. That the physician is not justified in the performance of an operation, which necessarily leads to the death of the child. I do not perceive much force in this reasoning except in the abstract; and, when taken in connexion with all the circumstances presented by each case, it loses, in my view, all strength as a guide in prac- tice. To the first argument, therefore, I reply—that if a woman, apparently moribund from long-continued and excessive vomiting, should recover and reach' the full period of her gestation, it is a rare exception to a general rule, and, as an exception, utterly worthless as a precedent. Again: it is well known that women have died from the effects of this disturbance, who would in all probability have survived, if premature delivery had been resorted to. The second argument, it seems to me, is readily disposed of. The chances of saving the life of the mother, in these cases, are very much enhanced; and, without the operation, should the mother die, the life of the child is also sacrificed. But, I repeat, the whole question resolves itself into one of expediency, the word expediency in this case meaning—the interpretation which science, conscience, and a high morality may place on the necessity for action. In connexion with this subject, it may not be uninteresting to cite the following instance in which it became necessary to induce premature action of the uterus in a patient affected Avith hydatids of that organ: I was requested to visit a lady in consultation with Dr. Whiting, of this city. Several medical gentlemen had, previ- ously to my visit, seen and prescribed for the patient. When I saw her, in company with Dr. Whiting, she was apparently near dissolution. Her prostration Avas extreme; the countenance almost hippocratic; and, indeed, her friends had abandoned all hope of recovery. The particulars of the case are these: She was the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 673 mother of one child, seA'enteen months old; about four weeks previously to my visiting her, she had occasionally been troubled with nausea and vomiting, and for the last two Aveeks had vomited more or less constantly. ISTothing could be retained on her stomach, the vomiting having resisted every remedy which had been administered. It was under these circumstances that I Avas called to her. The medical gentlemen, who had previously visited her, had ordered cups, leeches, and blisters, over the region of the stomach, Avith various other remedies; but all without the slightest appreciable effect. The vomiting was still unchecked, and her death hourly expected. In examining critically the case, I came to the conclusion that the vomiting was merely a symptom of trouble elseAvhere, and that no remedy addressed to the stomach would be of the least avail in rescuing her from the imminent peril in which she Avas placed. On applying my hand'to the abdomen, I found the uterus enlarged, occupying the hypogastric region. The alarm- ing situation of the patient precluded delay; if her life were to be saved, everything admonished us that it was to be done by instan- taneous measures. My opinion was, that the vomiting Avas alto- gether sympathetic, occasioned by irritation of the uterus. I therefore suggested the propriety of endeavoring to bring about contraction of the organ, in order that its contents might be ex- pelled. This view was concurred in by Dr. Whiting. Accordingly, with the doctor's full approbation, and at his request, desperate and almost hopeless as the case was, I at once introduced a female catheter into the uterus; in a short time strong contractions ensued, and a large mass of hydatids was thrown off. Almost immediately, as if by enchantment, the vomiting ceased. The patient, after a tedious'convalescence from her extreme prostration, recovered, and is noAV in the enjoyment of robust health. Let this case impress on you the importance of tracing effects to causes ; and bear in recol- lection this cardinal truth—that the practitioner who prescribes for mere symptoms will oftentimes find himself surrounded by obscurity, which AA-ill necessarily frustrate the successful treatment of disease.* Statistics of the Operation.—It will be seen that no comparison can be instituted betAveen the results, to both mother and child, of premature artificial delivery, and those obtained from the Caesarean section and embryotomy. The mortality of the two latter alterna- tives has already been detailed; and we shall noAV, in contrast, present a brief schedule of the former. Prof. Hamiltonf had re- * Dr. Churchill records an interesting example in which he produced premature delivery at the sixth month, in a young woman pregnant with her third child, in consequence of excessive vomiting; he says, he "never saw such agony in any case" from the effects of vomiting. The mother "was delivered of a dead foetus, recovered rapidly, and has since borne a chfld at full term."—Churchill's System of Midwifery, p. 282. + Practical Observations 1840. P. 285. T 43 674 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. course to premature artificial delivery forty-six times, and forty-tAVO of the children Avere born alive; on one of his patients he per- formed the operation ten times. Dr. Ramsbotham,* under some very discouraging circumstances, induced labor prematurely sixty- tAvo times, and more than one half of the children were saved. Dr. Merriman,f in his OAvn immediate practice, and in consultation, has met Avith thirty-three cases in which the operation was performed, and nearly a third of the children saved. Dr. Robert Lee J had recourse to premature artificial delivery twelve times in one Avoman with complete success. In tAvo hundred and eighty cases collected by M. Figueira, one hundred and sixty-six children Avere saved, and only six mothers died. In the sixty-tAvo cases occurring in the practice of Dr. Ramsbotham, more than one half of the children were saved, and not one mother lost. Kilian, up to 1831, had gathered from various sources one hundred and sixty one opera- tions, the results of which Avere one hundred and fifteen living children, and eight mothers lost. It is, however, stated that five of these eight died from causes altogether unconnected with the delivery. It AA'ill be thus perceived that, in premature artificial labor, considerably more than one half of the children are rescued, Avith the insignificant mortality of one in fifty of the mothers ! Ad- mitting, therefore, that this operation should be had recourse to under circumstances fully justifying it, it cannot, I think, but be regarded as one of the brilliant substantial triumphs of science, opening to the contemplation of the conscientious accoucheur a gratifying and cheerful vista, and, at the same time, closing up an avenue, Avhich has proved so destructive to human life. The Various Modes of Operating for the Induction of Prema- ture Artificial Delivery.—These may be enumerated as follows : 1. The perforation of the membranes, for the purpose of affording escape to the liquor amnii; 2. The administration of ergot; 3. The dilatation of the os uteri by means of prepared sponge, knoAvn as the method of Kluge and Bruninghausen; 4. The method of Kiwisch, consisting of vaginal injections; 5. The vaginal tampon ; 6. Cohen's method, consisting of injections into the cavity of the uterus; 1. The injection of carbonic acid into the vagina; 8. Gal- * Dr. Ramsbotham observes, "It occurred to me between the years 1823 and 1S:U. to be compelled to induce labor prematurely forty times. This may seem perhaps, a very large number; and, in explanation, I may state that the extensive Charity, whicn has supplied the principal part of these cases, embraces the district of Spitalfields and Betnnal Green, whifih, I believe, contains more females with de- formed pelves than are to be met with over the same quantity of square acres in any other part of tne kingdom. In most of tne patients, also, the operation has been repeated, and some have undergone it five and six times."—Ramsbotham's System of Obstetrics, Keating's edition, p. 315. f Merriman on Difficult Parturition, p. 172. X Medical Gazette, Feb. 7, 1851, p. 245. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 675 vanism as suggested by Dr. Radford. I now propose briefly to examine each of these propositions. Perforation of tlie Membranes.—The first suggestion, that of perforating the membranes, is undoubtedly the most reliable so far as the mere production of uterine contraction is involved ; but it has certain counterbalancing inconveniences. It is known in Germany as the method of Scheele, although it is recorded that Macauley had recourse to this very expedient in the operation, Avhich he was the first to perform in England for the induction of premature delivery. The true objections to the perforation of the membranes are—that the escape of the liquor amnii* necessarily brings the Avails of the uterus more or less in contact with the surface of the fcetus, thus incurring the hazard, through undue pressure on the cord, of destroying the child by an interruption of the placento-foetal circu- lation ; again: the employment of a sharp instrument, with the object of perforation, will be likely to produce injury to the uterus; and it is also to be remembered that the presentation of the pelvic and other portions of the fcetus than the head, is far more frequently met with in premature than in full term births ;f and this latter fact Avould consequently enhance the dangers to the child,J in the event of its becoming necessary to perform version after the exit of the amniotic fluid. Paul Duboisg states that in the Maternite of Paris, during 1829 and the three succeeding years, of one hundred and * In order to obviate the objection that, in perforation of the membranes, the liquor amnii escapes in full quantity, Meissner, of Leipsic, has contrived a mode of opening them so that he can control the amount of fluid discharged. This he accom- plishes'by penetrating the membranes at a distance remote from the os uteri, by means of a long curved trocar embraced in its canula. He first introduces the canula alone between the posterior surface of the membranes and internal wall of the uterus, and being assured that the upper extremity is turned toward the sac of waters, the trocar is then introduced through the canula, and made to penetrate the membranes; as soon as this is done, the extremity of the canula is carried into the opening made by the trocar, and the latter is immediately withdrawn. In this way, Meissner says he can draw off sufficient fluid to cause the uterus to contract, without endangering the life of the child by the loss of the entire quantity. It does seem to me, that the idea has at least plausibility to recommend it; but the carrying it out practically—though no doubt feasible in the skilful hands of its author—would prove a most difficult operation, and apt, also, to endanger the lives of both mother and child, in consequence of injuries inflicted upon them Therefore, while men- tioning the operation of Meissner as a part of obstetric history, it is my duty to cau- tion the practitioner as to its too hasty adoption. At the same time, it is but just to remark that Meissner has recorded fourteen cases in which this plan' has been adopted with safety to both mother and child. f See Lecture iii. \ This only applies to those cases in which the child presents crosswise; for, I have very emphatically stated that, all things being equal, delivery can be accom- plished consistently with the safety of parent and offspring, in either a breech, knee, or foot presentation. § Mem. de l'Academie Roy. de Med, vol. ii., p. 271. 676 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. twenty-one foetuses born before the completion of seven months, fifty-one presented the pelvis, and five the shoulder. This expe- rience is amply confirmed by all good observers. In the thirty-three cases in the practice of Dr. Merriman, fifteen presented preterna- turally, and in the forty-one quoted by Dr. Ramsbotham, fourteen were preternatural. It may be mentioned here, that Stoltz recom- mends in cases of premature artificial delivery—if it be previously ascertained the fcetus occupies an irregular position—before bringing on labor, that an attempt should be made, through external abdo- minal version, to change the presentation to one of the head. To this there can be no objection in any cross-presentation of the foetus; but, as has been already stated, it should be limited to this latter presentation, and not had recourse to Avhen either of the pelvic extremities is at the superior strait. Administration of Ergot.—The second method—the adminis- tration of ergot—is to my mind extremely objectionable, although in the advocacy of its use under these circumstances by Dr. Rams- botham it certainly has the sanction of high authority. This author first administers ergot, say four or five doses, at intervals of four to six hours, and then ruptures the membranes. Paul Dubois, also, commends the employment of this drug in these cases. The pro- miscuous administration of ergot, for the induction of premature artificial delivery, must occasionally be attended with serious con- sequences to both mother and child. For, in the first place, the justification of the operation is founded partly on thefaet that there is such a contraction in the bony or soft structures of the mother— or such an excess of development in the foetus—as seriously to endanger her life and that of her child, if she be permitted to pass on to her full term. Noav, if one of the obstetric extremities of the fcetus should not present at the superior strait—and this cannot ahvays be ascertained before the dilatation of the uterine orifice—to administer ergot would be to ensure the death of the child, and incur the hazard of grave lacerations to the mother. In all cases, therefore, be it remembered, in which the child may present crosswise, or in any other position so as to cause a disproportion betAveen it and the parts through which it has to pass, ergot is certainly contra-indicated. Dilatation of Os Uteri by Prepared Sponge.—The dilatation of the os uteri by the prepared sponge, as suggested by Brunincr- hausen and Kluge, is, likeAvise, not without its objections. For instance, it may be found extremely difficult, in consequence either of resistance or malposition of the os, to introduce the sponge, and the abortive efforts made to accomplish the object may induce more or less irritation of the parts. It must, however, be conceded that it possesses a very marked advantage over the process of perforating the membranes, and allowing the liquor amnii to escape, for, in this case, as we have remarked, the safety of the child is more or less THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 677 compromised. The manner of performing the operation is as fol- io avs : Take a piece of prepared sponge, about three inches in length, conoidal in shape and properly pointed, with a string attached to the outer extremity so that it may, when needed, be AvithdraAvn. Instead of employing the speculum for the purpose of introducing it—an unnecessary annoyance and exposure of the patient—it will suffice to carry the index finger of one hand as far as the os uteri, and grasping the sponge with a narrow forceps it should be made to glide along the finger, which will act as a guide; in this Avay, it is introduced into the mouth of the organ, care being exercised not to penetrate too far, for fear of rupturing the membranes; and it is then to be secured by the tampon. The sponge thus arranged may be permitted to remain unchanged, should the uterus not be brought into action, for ten or twenty hours; at the end of this time it should be withdrawn, and for the purpose of removing irritation, the vagina thoroughly injected with tepid Avater. The first sponge is. then to be substituted by one slightly larger, if it be found neces- sary. If, however, after two or three days' trial, the contractions of the uterus be not provoked—an unusual circumstance—it must be laid aside, and some other expedient had recourse to. The modus operandi of this method is quite apparent, the sponge absorbs the moisture, always in more or less quantity about the os uteri; as a consequence, it enlarges, acting as an irritant on the incident excitor nerves of the vaginal-cervix, and thus, through reflex movement, brings on the needed contractions. Method of Kiwisch.—The method of Kiwisch, of Wurtzburg, knoAvn as the water-douche, was introduced to the attention of the profession in 1846, and is, perhaps, under ordinary circumstances, the safest and most reliable of all the plans yet proposed for the induction of premature delivery. It consists in throAving a stream of Avater against the os uteri continuously for ten or fifteen minutes ; and, to render the action of the stream more certain, the fluid should be alternately cold and warm. The suggestion of Kiwisch has met with very general favor; its modus operandi is, also, through reflex action. One of the advantages of the method is that it does not subject the patient to the necessity of keeping her bed, nor is it accompanied by the inconveniences of the other means already alluded to. The injection of the water may be repeated once in three or four hours until contractions of the organ are induced. Vaginal Tampon.—The vaginal tampon has been suggested by Scheller, as a means of inducing artificial delivery. It is well known* that the pressure of the tampon against the os uteri will, in many cases, provoke action of the organ ; and consequently it has been proposed as a suitable agent. It is, hoAvever, apt to occasion more or less suffering to the patient, and is now generally aban- * See Lecture xxxi. 678 THE HKINCIPLES AND PRACTICE OF OBSTETRICS. doned, for the more substantial reason that it is superseded by more efficacious means. Method of Cohen.—Xext, there is the method of Cohen, which consists, through the agency of a curved tube, in throwing fluid into the cavity of the uterus itself. This plan has its advocates, but it seems to me is not so efficient as the proposal of Kiwisch. Injection of Carbonic Acid.—I should not omit to mention the use of carbonic acid as a means of inducing premature action of the uterus. Dr. Brown-Sequard Avas the first to direct attention to its influence in causing contractions of non-striated muscular fibres. His observations on this subject will be found in the Memoirs of the Society of Biology, 1849 and '50, and also in his work entitled, " Experimented Researches applied to Physiology and Pathology," 1853, p. 117. Scanzoni, Simpson, C. and J. Braun, led by the experiments of Dr. Sequard, have employed this agent Avith complete success in several instances, not only as a means of provoking early contractions of the uterus, but also in inertia of the organ. The gas is injected into the vagina, and is quickly folloAved by marked results. Galvanism.—Galvanism Avas suggested by Dr. Radford, of Man- chester, in 1844, and he employed it with success in four cases of contracted pelvis; so also have Dr. Barnes and others been fortu- nate Avith this agent. Induction of Abortion*—Is it ever Justifiable ?—It noAV remains for us to examine the important question—is abortion, under any circumstances, a justifiable alternative? This question has been much controverted, and it is one on which the sentiment of the profession is not concurrent. In order that the special points in the discussion may be fully appreciated, they may be advanta- geously presented under the two folloAA'ing heads : 1st. When the maternal passages are so contracted—no matter from what cause— as to render it certain that a viable fcetus cannot be made to pass. 2. When the maternal passages are normal, but the mother's life is involved in alarming peril by the occurrence of some serious com- plication, such as convulsions, hemorrhage, or excessive vomiting. It is manifest that the moral part of the question turns upon the simple interrogatory—is the embryo in the earlier states of its existence a living being ? All correct physiology demonstrates that it becomes in truth, at the very moment of fecundation, imbued Avith vitality—the contact of the sperm cell and germ cell consti- tuting the act of the breathing of life. Jorg, of Leipsie, I believe, alone claims the doubtful merit of describing the human fcetus as * It is not of course intended here to discuss the general question of criminal abor- tion, which has become, both at home and abroad, a monstrous crime, owing in great measure to the laxity with which the laws on the subject are enforced. I may refer tlie reader to an instructive paper entitled " Criminal Abortion in America" by Hora- tio R. Storer, M.D., 1860. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 079 " only a higher species of intestinal worm, not endowed Avith a human soul, nor entitled to human attributes." With his infidel notions on this point he might have added—nor is the shedding of its blood of any more moment than the slaughtering of the calf! Besides the proofs of physiology, we have the testimony of the early fathers of the Catholic church ; that church has ahvays main- tained, with an unwavering consistency, so characteristic of its canons, that the destruction of the foetus in the Avomb of its parent, at any period from the first moment of conception, is a crime equal in turpitude to murder.* Assuming, therefore, as an incontrovertible fact that the humau embryo is in reality a living being, the suggestion naturally arises— are we justified, and, if so, under Avhat circumstances, in depriving it of its life ? It is quite certain that the only plea for such an alternative is the safety of the mother; and as to the force of this plea there has ahvays existed a difference of opinion. Here, then, Ave have the naked question—a woman is pregnant, carrying within her a living being—her pelvis is so abridged that it will be phy- sically impossible to afford exit to a viable foetus, and, consequently, if she proceed to her full term, the only chance of rescue Avill be the CVsarean section or embryotomy. Now, I repeat, what, under tliese circumstances, is the duty of the conscientious accoucheur, avIio is not actuated by a thirst for innocent blood, but avIio is most anx- ious to discharge Avith fidelity the sacred obligations which his pro- fession imposes upon him ? I cannot undertake to determine this question for others—it is one Avhich must be left to conscience and a sincere desire, as far as may be, to do Avhat is right. But, in no event, should a decision be arrived at Avithout first invoking the aid of Avise counsels, and duly considering all the surroundings of the case. On the other hand, suppose the instance of a pregnant Avoman, with a perfectly normal condition of the maternal organs, but who has not yet attained that period of gestation at which the child is viable—an(i she should suffer from some serious complication which would subject her, according to all human evidence, if not deli- vered, to the loss of her life—what, in this contingency, is the course to be pursued ? Here, in my judgment, the morale of the case is greatly changed ; for should the mother sink, in consequence of not being delivered, her child, also, must of necessity be sacri- ficed. Therefore, under these circumstances, if my coiwictions as to the danger to the mother were beyond a peradventure, I should not hesitate to induce abortion upon the broad ground that, with- out the operation two lires would certainly be sacrificed, while, with it, it is more than probable that one would be saved. * For an elaborate discussion of this whole question, see the Dublin Review for April and Oct. 1858. LECTURE XLIV. Puerperal Fever—Synonyms; its Fatality most Fearful—What is Puerperal Fever ? —Is it a Local Phlegmasia?—Objections to the Hypothesis—Is it in its Nature a Toxaemia, or Blood Poisoning ?—Proofs in Demonstration of this Opinion. Humo- ral Pathology—Puerperal Fever not confined to the Parturient Woman; it may attack Young Women, Pregnant and Non-Pregnant Women, New-born Children, and the Foetus in Utero. The true Meaning of the Term Puerperal State—Divi- sions of Puerperal Fever—Epidemic and Sporadic—Is it contagious : Discrepant Views; Proofs that it is a Zymotic Disease; Contagion accomplished only through an Animal Poison—Prof. Arneth's Account of Puerperal Fever in Vienna Hospi- tal—Its Propagation through Dissections. The Question of Transmissibihty through Decomposed Matter. Causes of Puerperal Fever. Symptoms—How Divided—Their Value—Anatomical Lesions—Not Uniform—Sometimes the only appreciable Change is in the Blood. Diagnosis—With what Affections Puerperal Fever may possibly be Confounded. Prognosis—in the Epidemic Form generally unfavorable; the usual Preludes to a Fatal Termination readily detected by the observant Physician. Treatment—Divided into Prophylactic and Remedial—Pro- phylactic—in what it Consists. Dr. Collins's Sanitary Measures in Dublin Lying- in Hospital—Results. Epidemic Puerperal Fever not always confined to Lying-in Hosp'itals; its occasional Ravages in large Cities and Villages. Remedial Treat- ment—Depletory Remedies—When employed—Stimulants ; when indicated. Opium Treatment; the Veratrum Viride. Gentlemen—I propose to-day to offer some general remarks on a disease, connected more or less directly with child-birth, than which there is, perhaps, no malady to which the female is liable that has called forth more discrepant opinions, or enlisted in its discus- sion abler and more accomplished minds. Writers in the profes- sion of the very highest order of intellect have been engaged in the study of this question—'and in defiance of the marked ability with Avhich it has been examined, the result still is that we are without a united verdict. I allude to what is generally known as puerperal fever. This affection has been described under a variety of names, such as—Febris puerperalis, febris puerperarum, perito- nitis, morbus puerperarum, metritis puerperalis, uterine phlebitis, child-bed fever, etc. ,W'ien it prevails in its epidemic form, it is full}' entitled to be denominated the scourge of the lying-in room. Its mortality even noAV, with all the advances of modern scientific investigation, is appalling, although it has undergone a comparative diminution from former periods of its history. Indeed, at one time, a recovery from this fearful malady Avas the exception, while the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 681 rule was death!* It, therefore, is a subject well Avorthy of inves- tigation ; to the accoucheur it is one of the deepest interest. I shall not attempt a history of this destructive affection, nor shall I venture to impose upon you an array of the conflicting tes- timony which has been presented touching its nature. I prefer rather, as briefly as may be consistent Avith the importance of the subject, to discuss it under the folloAving heads: 1st, What is puer- peral fever ? 2d, What its divisions? 3d, Is it contagious? 4th, Its causes. 5th, Its symptoms. 6th, Its lesions. 1th, Its diagnosis. 8th, Its prognosis. 9th, Its treatment. What is Puerperal Fever ?—The earlier writers regarded every form of fever occurriug at the time of child-birth as puerperal, and hence their views Avere extremely vague. No less precise and satis- factory are some of the modern teachings on this vexed question. We are told by one school that puerperal fever is an essential or specific disease—by another, that it is simply a local inflammation of a sthenic or active grade—again it is maintained that the phleg- masia is asthenic, assuming at its very inception a low typhoid type. In the opinion of some, it is in close alliance with hospital gangrene, while others hold that it partakes more or less of au ery- sipelatous inflammation. A prominent hypothesis, sustained Avith no little ability by Dr. Robert Lee, would seem to refer the true source of the malady to uterine phlebitis; and so I might proceed to enumerate other individual opinions as to the real nature of the disorder under discussion, but such an enumeration would beSvith- out profit, and, therefore, I omit it. It does really appear to me that, in the multiplied hypotheses Avhich have been presented in the attempted exposition of the essential nature of puerperal fever, there has been a sad confounding of terms. For example, simple peritonitis, metritis, etc., purely accidental, and, if you choose, spo- radic, totally unconnected Avith epidemic or typhoid influence, and liable to occur from cold, or the exercise of any other ordinary agency, have too often been regarded as the very types of puerpe- ral fever; and their inception, together Avith their progress and phenomena, looked upon as the reliable exponents of the epidemic puerperal disease, A\diich is, as Ave shall attempt to demonstrate, an entirely different pathological derangement. It is to be remem- bered that both the pregnant, parturient, and non-pregnant female may be attacked Avith peritonitis or metritis, precisely as the male may be invaded by pure inflammation of the peritoneum. Here, » * It is recorded by M. Malouin, in his account of the epidemic at Paris, in 1746, that scarcely one woman recovered. Prof. Young, describing the disease as it occurred in the Royal Infirmary, Edinburgh, 1773. says: li It began about the end of February, when almost every woman, as soon as she was delivered, or perhaps twenty-four hours after, was seized with it, and all of them died, though every method was used to cure the disorder." 682 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. then, there is nothing specific—nothing essential. It is, if I may so term it, an inflammation under ordinary circwpstanccs, and is to be treated on ordinary antiphlogistic principles. In this form of peritoneal inflammation, I repeat, Ave are not to seek for any speci- fic or mysterious something, Avhich has produced the affection. But it is a vastly different thing when true epidemic puerperal fever prevails—a fever usually characterized by depression of the vital forces, and exhibiting many of the phenomena of a typhoid affec- tion. With the distinction just made, the question noAV before us, naked and deprived of all collateral and adventitious issues, is— What is Puerperal Fever ? Is it in its origin a local disease—a phlegma- sia—and are the constitutional disturbances simply effects ? Or is its starting-point in the constitution, and the local lesions merely results? The Avhole matter is, it seems to me, narroAved doAvn to these two inquiries; and let us briefly examine them. Those who maintain that the origin of the disorder is traceable to a local phlegmasia have, with some slight show of reason, based their opinion on the circumstance that, in almost all the fatal cases of puerperal fever, autopsical examination has revealed the evi- dences of inflammation of the peritoneum, the uterus, its veins, or some of its appendages; and, therefore, they associate the relation of cause and effect. ]STo one will attempt to deny, with our pre- sent knowledge of pathology, that the lesions named are, more or less, accompaniments of the puerperal affection; and it will also be admitted, that the lesions are by no means confined to these struc- tures. Some of the ablest pathologists, aud among others Rokitan- sky, have demonstrated that the mucous lining of the alimentary canal and of the respiratory organs, the pleura, and the articula- tions themselves, will not unfrequently afford evidence of change of structure, under the form of exudations, congestion, or purulent secretions. But admitting the lesions to exist—and the fact can- not be controverted—do they prove that the source of puerperal fever is in the primary inflammation of some one or more of these structures ? I think not; and the hypothesis develops, in my judgment, the frequent fallacy of the post hoc propter hoc doctrine. To my mind, one of the most poAverful—indeed, it is irresistible— arguments against the local origin of puerperal fever, is, that occa- sionally, in certain marked and fatal cases of this disease, the patho- logist has been unable to recognise the slightest appreciable trace of inflammation in any of the viscera designated as the starting- point of the malady. This fact has been Avell pointed out in the researches of Dr. Ferguson, Tessier,* Tardieu,f Depaul,J and * Tessier, De la Diathese Purulente, p. 312. 1838. f Tardieu, Journal des Connaissances Medico-Chirurgicales, 1841, p. 233. X Depaul, Bulletin de l'Academie de Modecine, t, xxiii., p. 395. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 683 others. This being so, it is difficult to conceive with what degree of consistency the theory can be sustained, for certainly one affir- mative is worth a thousand negatives. Other arguments might be adduced, such as the occurrence of peritonitis, metritis, etc., in the parturient female, unaccompanied by any of the constitutional dis- turbances ordinarily characteristic of puerperal fever ; but the accu- mulation of further proof I do not deem necessary, and I have no hesitation in avowing that, as far as I can understand it, the entire weight of proof is adverse to the hypothesis. If, therefore, puerperal fever be not traceable to a local phleg- masia, what is its true source? A number of able observers have referred the origin of the affection to a peculiar altered condition of the blood—to a poison introduced into this fluid—in a Avord, they maintain that it is a veritable toxaemia, and in this a ieAv I fully concur. In my opinion, the whole chain of evidence on this point is in demonstration of the sentiment of Dr. Ferguson, that " the phenomena of puerperal fever originate in a vitiation of the fluids, and that the various forms of puerperal fever depend on this one cause of vitiated blood, and are readily deducible from it."* But you may very naturally ask, What is this poison, and how does it reach the blood ? The real essence of the contaminating element it may not be so easy to explain; it is one of those mysterious, subtile somethings which is more or less frequently met with, exhi- biting varied pathological phenomena, and oftentimes resulting, with remarkable promptitude, in the extinction of life. You may call it, after some of the older Avriters, a ferment or a morbific mat- ter, but this in no Avay facilitates the solution of the inquiry—Avhat is this poison ? Toxaemia, or blood-poisoning, is a generic term, and exhibits seve- ral varieties : in one instance it results in scarlet fever, in another in small-pox, in another in measles, in another in puerperal fever. Here, by some of the schools, I shall be charged with advocating humoral pathology, which has too generally been regarded as a doc- trine long since exploded. I have only to say in reply, that I ahvays endeavor to advocate truth, and do not believe in restrict- ing our science to any exclusive dogmas—" Je prends le Men oil je le trouve." Indeed, if time permitted, it would be an agreeable task to exa- mine somewhat in detail Avhether the doctrine of humoral pathology is altogether a phantom, Avithout a shade of scientific basis, as some of the schools maintain. The examination might, perhaps, result in the conviction that some of the finest displays of modern science, under the ministrations of organic chemistry, have not only ren- dered plausible, but have absolutely demonstrated, the truth of the doctrine of " peccant humors," as taught by the early fathers. * Ferguson on Puerperal Fever. 681: THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Hippocrates himself inculcated that fever was but the offspring of accumulated morbid matter in the blood, Avhich, aftev a certain number of days, through a process of fermentation, Avas throAvn off either by hemorrhage, alvine evacuations, the perspiratory surface, or through the development of some of the exanthemata. It does seem to me that the doctrine of fermentation finds a clever advo- cate in the distinguished cultivator of organic chemistry in our day —Liebig. His explanation of the morbid phenomena consequent on blood-poisoning is strongly kindred to the ancient theory. It is important to note that, Avhen blood-poisoning exists, its effects are not always identical; there are marked grades of seve- rity, and this is abundantly exemplified in scarlet fever. In some instances this latter affection assumes an extremely mild form—the scarlatina simplex—in other cases it proves the terror of the house- hold, seizing its victim in the full bloom of health, and terminating life in tAvo or three hours—the scarlatina maligna. In puerperal fever, also, there -will be observed a modification in the action of the poison, the disease being at times comparatively light, and again exhibiting a fearful virulence.* If we cannot explain the essence of the poison, yet observation proves that its influence on the economy may be very materially affected by certain conditions, such as the state of the atmosphere, the locality, etc. The testimony is ample showing a connexion between puerperal fever and erysipelas. The tAvo diseases may prevail simultaneously in the same neighborhood ; or if erysipelas alone prevail, a third party may communicate, from a patient affected Avith itr puerperal fever to a Avoman recently delivered.f On the other hand, Avell-authenticated instances are recorded of husbands and nurses, in attendance on women dead of puerperal fever, having been attacked Avith erysipelas ; and Dr. RigbyJ states that in an epidemic Avhich prevailed in the General Lying-in Hos- pital, London, the child of every female in Avhom the disease proved fatal died of erysipelas in a feAV hours.J * Diseases produced by blood poisoning have one especial characteristic—they are usually sudden in their invasion, and after running a fearful course for an inde- finite period, as suddenly disappear. This is within the experience of all vigilant practitioners. We recognise the fact constantly in yellow fever, cholera, typhus fever, measles, scarlet fever, puerperal fever, &c, all of which are due to the opera- tion of a morbid poison. In a pathological sense, the seat of lesion in the various affections resulting from a toxsemic influence is not without interest. In scarlatina and measles, for instance, the development is on the cutaneous surface ; in typhoid fever the glands of the small intestines are more or less involved, while in cholera it is the general gastro-intestinal mucous surface. In puerperal fever the serous sur- faces, and more especially the peritoneum, are usually affected. f In constitutional erysipelas, whether affecting the male or the non-pregnant female, a not unusual lesion will be inflammation of the peritoneum. X Rigby's Mid., p. 392. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 685 Although, as a general rule, puerperal fever attacks the parturient female,* yet it should be recollected that it is not exclusively confined to this class of patients. Young women, married and non- pregnant women, the new-born child,f and the fcetus in utero, even when the mother has no symptoms of the disease, are all liable to the affection; instances are recorded of its existence under these circumstances ; and what may surprise you still more, it has been shown that, in some cases, the male, if subjected to the peculiar poison known to generate the disease, will become sick, and exhibit lesions more or less in accordance with those found in women affected with puerperal fever. While it is proper to mention these exceptional cases, the important fact is, that in the great majority of instances, the disease attacks the parturient female—and I am inclined to adopt the explanation of the circumstance given by Trousseau, in the recent discussion of this question in the French Academy of Medicine—he says the lying-in female exhibits a pecu- liar morbid opportunity, and presents a remarkable pathological aptitude for the malady. Both in sporadic and epidemic puerperal fever, the special poison generating the disease may originate in the person of the parturient woman, and be conveyed into her blood through the absorption of putrid coagula, portions of placenta, &c.; but there are other modes by which the poison may be communicated, to which we shall refer under the head of contagion. What are the Divisions of Puerperal Fever ?—It has already been remarked that there are two distinct varieties of this djsease— one known as the sporadic, the other assuming the epidemic form. The characteristic of-the former is that it is an isolated affection, and does not extend ; Avhile the epidemic variety is not limited to one or tAAro cases, but involves districts and neighborhoods, oftentimes proving frightfully destructive. Some authors have made other distinctions, which do not appear to have much practical impor- tance—such as inflammatory puerperal fever; bilious or mucous puerperal fever ; typhoid puerperal fever, etc. * The folloAving is the language of Tarnier, and I quite agree with him in opinion : "In ordinary medical phraseology, the term puerperal state is understood to mean the particular condition presented by the recently delivered woman. This definition is entirely too limited. I adopt the division recently proposed by M. Monneret, viz. The first period of the puerperal state commences with conception; the second comprehends the puerperal state of all authors, that of the newly deli- vered female; the third period includes the entire term of lactation. To these three divisions I shall add a fourth—that of menstruation. In menstruation, in gestation, and in parturition, I can see but a series of inseparable facts, which tend to the same object—the reproduction of the species." [De la Fievre Puerperale, observe a l'Hos- pice do la Maternite par Stephane Tarnier. Paris. 1858 ] f Puerperal fever in the recently delivered female, the foetus, and the new-born child. By M. Lorain. Paris, 1856. 686 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Is Puerperal Fever Contagious ?—The views on this point are far from being concurrent; and one of the most emphatic advocates of the non-contagious character of the affection is our distinguished countryman, Prof. Meigs of Philadelphia; he is also sustained by Prof. Hodge, the able Prof, of Midwifery in the University of Pa. It is somewhat singular that these tAvo gentlemen, ripe obsen ers, and engaged as they have been in extensive practice, should so positively maintain an opinion in opposition, it seems, to me, to evidence Avhich, if thoroughly examined, is irresistible.* I do not deem it necessary to cite particular examples in which puerperal fever has been conveyed through the principle of contagion—they are so numerous, and so free from all doubt—in a Avord, they are so conclusive that I cannot conceive how they can be regarded othenvise than completely demonstrative of the point at issue. I have already remarked that puerperal fever may, under certain circumstances, originate with the patient herself. She may, so to speak, inoculate herself Avith the noxious element through absorp- tion of putrid coagula, or portions of the placenta remaining in the uterus; or she may derive the affection from the passage of some of the products of inflammation into her blood ; or the translation of the disease may be by contagion through the intervention of a third party ; and again, the inoculation may be traceable to the hand of the accoucheur carrying the poison into the system during his vaginal explorations. The question of the possibility of trans- mission of puerperal feA'er by the physician has received fresh support Avithin a few years from some German investigators.f * Dr. Holmes, of Boston, has discussed this question of contagion most elabo- rately, and I refer the reader to his admirable paper. \ In an interesting paper by Dr. Arneth, of Vienna, we have the following state- ment: Dr. Semmelweiss, assistant to the Prof, of Midwifery, was struck with the difference as to the prevalence of puerperal fever in the two clinics of the hospital; in one of these clinics, the pupils are midwives; in the other, medical students. The latter were, almost without exception, in the constant habit of assisting at autopsies, of which there were eight or ten nearly every day. The dissections were sometimes made by the students; or at least they handled the pathological preparations, and carefully examined them. Moreover, the assistant was accustomed to lecture on the obstetric operations which were performed on dead bodies. After such investiga- tions on the cadaver and such practice, it was not rare for the students to proceed immediately to the wards of the lying-in hospital, and examine the pregnant and parturient women. The pupils of the other clinic, being midwives, did not take any share in the occupations just alluded to ; and even the assistant of that clinic had comparatively but seldom to do with post-mortem examinations, as it was not a part of his duty to instruct midwives in pathology or in operative midwifery. Having convinced himself that the great prevalence of the disease in his wards was caused by the inoculation of the female genitals, Dr. Semmelweiss entertained the hope of being able to diminish the frightful mortality. He finally deduced from his researches these conclusions—Any fluid matter in a state of putrefaction, com- municated by linen, by a catheter, by a sponge, by small particles of the placenta, or even by the ambient atmosphere impregnated with the foul substances, may pro- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 6«7 It is now, I believe, very generally admitted that the laws of contagion can only operate when the disease thus communicated is the product of an animal poison ; and it is also, in my judgment, clearly established, that puerperal fever is rightfully classed among the zymotic diseases, or those whose existence depends on the presence of a noxious animal material. Since the publication of Dr. Arneth's paper, German physicians have made experiments on animals, which have given the following results: 1st, Any kind of putrefied animal matter introduced into the vagina of a parturient female may engender a malady bearing a strong resemblance to puerperal fever, and frequently followed by death ; 2d. A very small quantity of the fluid in the vagina of a Avoman or of an animal, attacked with puerperal fever, being introduced into the vagina of a parturient animal causes puerperal fever, or at least a disease very much like it. With the above results, it might very consistently be asked, Avhy every Avoman after parturition, is not affected Avith puerperal fever ; it Avould, at first view, seem that this should be so, for there is in more or less quantity, putrefied animal matter in the uterus or ra consisting in the extreme rapidity of the pulse, Avhich becomes weaker and fluttering, with cold extremities; the patient lapses into unconsciousness; there is a Ioav unintelligible muttering, toge- ther with subsultus tendinum; the tongue is parched and exhibits a brownish color, Avith vomiting of a dark offensive nature. These are the closing phenomena, and are soon folloAved by death. There is one striking peculiarity as to the position of the patient in this affection, and I regard it as quite characteristic—the patient remains on her back, AA'ith her knees drawn up, and she assumes this position for the reason that she seeks, as it were instinctively, to relieve the abdomen from pressure, the slightest adding greatly to her distress. This attitude not only relaxes the abdominal walls, but in a measure protects the patient from the weight of the bed- clothes. On the other hand, a spontaneous change of position on the side, for instance, should be hailed as a most favorable indi- cation. In the epidemic form of the disorder the symptoms are somewhat modified; as a general rule there is increased rapidity of the pulse ; and from the violence of the poison, a depressed condition of the forces is noticeable at the very invasion of the malady ; the disten- sion of the abdomen is much earlier developed, and the disease is more rapidly fatal, sometimes destroying the patient in twenty-four or thirty hours. In some instances, it is worthy of remark that there is an absence of pain on pressure, although the subsequent autopsy may disclose the existence of peritonitis. Lesions.—There is nothing uniform in the anatomical lesions accompanying this affection, although it may be stated that evi- dence of peritoneal inflammation is the most constantly met with THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 691 and it is no doubt for this reason that the disease has received the designation of puerperal peritonitis. When this lesion is observed it will be found almost always that the peritonitis is general, and not limited to one portion of the membrane; the sac vrill usually contain more or less sero-purulent effusion; and in this particular there is a marked difference between simple and puerperal peri- tonitis—in the former there are adhesions through pseudo-mem- branous formations, because in simple peritoneal inflammation, instead of a sero-purulent affection there is the presence of plastic lymph, the tendency of which is to produce these adhesions. In the uterus and its appendages there will also be exhibited various changes; uterine phlebitis is among the most uniform attendants upon the disease ; the abdominal viscera undergo morbid changes, exhibiting more or less abundantly purulent collections, and these collections will sometimes involve the various articulations. There is one peculiar feature usually characterizing the pathology of puer- peral fever—it is a softening of the tissues, and this will oftentimes be observed in the structures of the uterus, ovaries, peritoneal covering, liver, spleen, and other organs. In some instances there is no cognizable alteration of the peri- toneum, and strange to say M. Charrier* records the history of an epidemic puerperal fever in which lesions of the pleura were sub- stituted for those of the peritoneal sac. It is worthy of note that sometimes in its severest forms, and when most rapidly fatal, the only apparent changes are those exhi- bited by the blood ; but in what these changes actually consist it is not so easy to determine. It is darker, and loses much of its coagulable properties. According to Prof. Vogel,f it contains lactic acid, sometimes carbonate of ammonia, and again hydro-sulphate of ammonia, its globules do not redden on exposure to the atmosphere, and, therefore, the act of respiration is defective; the globules are in part decomposed, and dissolved in the serum. Diagnosis.—Where puerperal fever prevails as an epidemic, there can be no embarrassment in the diagnosis; the lines of the affection are so well defined that the observant physician will rea- dily appreciate its existence. Not so, however, in the sporadic form of the disorder; for here it may be mistaken for metritis, but this is of no material consequence, as the therapeutic management in either case would be the same. It may, however, be stated that in metritis the pain on pressure is more circumscribed, and the volume of the uterus itself much increased, the patient bearing pres- sure Avell until some portion of the organ is touched; whereas in peritonitis, the affected surface being more diffused, pressure on almost any point of the abdominal region would be followed by * De la fievre puerperale, epidemie en 1854. + Virchow. 692 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. more or less suffering. You are not to understand that pain in peritonitis is simply the offspring of pressure by the hand ; on tho contrary, the patient without either change of position or pressure will experience much agony, which at intervals will be increased by the passage of flatus from one portion to another of the intestine. There is some tact required in the manual exploration—too much force should not be used, for this, Avithout any compensating good, only aggravates the condition of the patient. Let the medical man keep his eyes, as he cautiously presses the abdomen, on the coun- tenance of the invalid, and he will quickly discover Avhether or not he inflicts suffering. When speaking of the attentions needed by the recently delivered woman, the general phenomena of after-pains Avere fully discussed, so that by reference to what was then said it would be an act of unpar- donable carelessness to mistake them for peritonitis. It is barely possible that some confusion might exist in discriminating between puerperal inflammation and tympanites intestinalis, which not unfre- quently folloAvs child-birth, and which has already been mentioned as one of the ordinary accompaniments of puerperal fever. In simple tympanites, howeArer, the pulse will be but slightly accele- rated ; no sunken, dejected condition of the countenance; and gentle pressure with frictions will diminish the pain. Tympanites, also, may be distinguished from effusion by percussion ; the former, tympanites, revealing a resonant sound, while the latter, effusion, would disclose the evidences of fluctuation. Prognosis.—It need scarcely be remarked, after what has been said touching the nature of the disease, that epidemic puerperal fever is one of the most fatal disorders of the lying-in room ; our prognosis, therefore, should ahvays be guarded, and no false hopes encouraged. Even in its sporadic type, the malady, although much less fatal, is full of danger. During the progress of the malady, the experienced observer will be enabled to foresee Avith prophetic truth its fatal termination by the presence of certain significant indications. I have, as has already been remarked, an abiding faith in the pulse; if it should not exceed 120 beats in the minute, this may be regarded as most favorable; but how different if it reach, and continue at that rate, from 140 to 160! A cessation of pain, without any diminution in the throes of the heart, accompanied with an anxious and drawn countenance—-fades hippocratica ; an oppressed respiration, showing imperfect decarbonization of the blood; involuntary intestinal discharges, the cadaveric odor, &c, may justly be regarded as the precursors of dissolution. Treatment.—The treatment of puerperal fever may very appro- priately be divided into prophylactic and remedial. Prophylactic Treatment.—In a disease so fearfully destructive, it can require no argument to show the vital importance of pre- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 693 ventive measures, if these can be proved to arrest the develop- ment of the malady. Without referring to other proofs, I shall content myself with alluding to the remarkable results obtained in the Dublin Lying-in Hospital, under the mastership of Dr. Collins. For the four years previous to the adoption of his sanitary mea- sures, the entire relative number of deaths in the hospital during the prevalence of puerperal fever, was 1 in 52; but from 1829 to 1833, under the system of purification, the disease almost entirely disappeared, and the mortality diminished to 1 in 190, 181, 187, 178, the average deaths in the aggregate being 1 in 184 cases. His preventive measures were as follows: The Avards of the hospital were closed, during the process of purification, against the admis- sion of patients; they were then filled, in rotation, with chlorine gas in a very condensed form, for the space of forty-eight hours, during which time the windows, doors, and fire-places were kept shut, so as to prevent, as much as possible, the escape of the gas. The floors and wood-Avork were covered with the chloride of lime, mixed with water to the consistence of cream, which was not removed for forty-eight hours or more. The wood-work was then painted, and the Avails and ceilings washed with fresh lime; the blankets, &c. scoured, and stoved in a temperature from 120° to 130°. In addition, the strictest attention Avas always paid to the proper ventilation of the wards. The beds were composed of straw, and never used a second time without washing the covers, and a renewal of the straw. Dr. Collins states that from the time of the adoption of this mode of purification until the termination of his mastership in 1833, not one patient died of puerperal fever.* The above results are not without interest, and they would seem very broadly to indicate the efficacy of chlorine as an element in destroying the poison of the disease. Dr. Collins further remarks that, in every instance of the death of a patient, if the most remote symptoms of fever had been pre- sent, besides scouring every article connected with the bedding, the wood-work and floor was washed with a solution of chloride of lime, and the entire ward whitewashed. This was readily effected, as the sick were invariably placed in a small ward, apart from the healthy. To this latter precaution, he observes, too much attention cannot be paid, as the instant separation is of vast importance to both. The suggestion of Dr. Collins in reference to the separation of the sick from the healthy is, in my opinion, a sine qua non to the arrest of epidemic puerperal fever as it prevails in hospital practice. In the crowded wards of the hospital, the poison becomes concen- trated, and this circumstance, I believe, is one of the chief reasons * Practical Treatise on Midwifery, p. 388. 694 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of the fearful spread of the affection in lying-in establishments. Here, then, is a subject worthy the attention of the philanthropist —let the laws of hygiene in reference to the health of the numerous poor, who seek shelter in our public institutions at the time of their accouchement, receive merited attention—let these laws be rigidly and humanely enforced, and the fearful outlet to life, through epi- demic puerperal fever, will be measurably closed. We are firm in our conviction, that if the poor were attended at their own homes —defective as they may be in ordinary comforts—instead of being exposed to the infection of croAvded wards, the bills of mortality would be greatly diminished. There is a Avonderful charm in pure air in all cases of disease, but more especially as regards convales- cence from the puerperal state. Although puerperal epidemic fever usually exhibits its most devastating effects in lying-in hospitals, yet it should be knoAvn that these disastrous results are not ahvays confined to this class of asylums. In 1819, the epidemic prevailed at the same time in Vienna, Prague, Dresden, Wurtzbourg, Bamberg, in several small cities of Italy, at Lyons, Paris, Dublin, GlasgOAv, Stockholm, and Petersburgh. It is also very remarkable that the epidemic has extended even to the females of some of the domestic animals— to sluts, for example, in the disease observed in London in 1787 and 1788; and to cows during the epidemic Avhich occurred in several parts of Scotland in 1821.* Remedial Treatment^—In regard to the remedial management of the disease, much difference of sentiment has existed, and the discrepancy is mainly due to the conflicting opinions Avhich have prevailed touching the pathology of the disorder. On the one hand, we are directed to depend on prompt and full depletory measures—Avhile, again, the stimulating method is considered as presenting the only hope. There is too much generalization in this kind of therapeutics, and neither the one nor the other plan can be resorted to Avithout a proper discrimination. Let it be care- fully treasured in memory, that there is no specific for this disease. In my judgment, the treatment of puerperal fever should not be restricted to the opinions of the respective schoolmen, but, as in other pathological conditions of the system, we should be governed by the special indications which may exist at the time. The lancet and other of the antiphlogistic agents, are oftentimes necessary in pneumonia, erysipelas, &c, but there are numerous cases in Avhich * Danyau, Bulletin de l'Academie de Medecine, t. xxiii. Paris 1858. + There is one point in the treatment, not only of puerperal fever, but as a rule of all puerperal diseases, which should claim in a special manner the attention of the accoucheur, and it is to forbid the patient suckling her child. This duty, so natu- ral and obligatory under ordinary circumstances, cannot be discharged with impu- nity while laboring under affections incident to the puerperal state. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 695 these measures would prove quickly fatal; the same remark applies to puerperal fever, and this imposes the importance of discussing the question of treatment in reference to the particular form of the disease which may present itself. We have, even in its epi- demic garb, Avhat may be termed inflammatory puerperal fever; and, again, the disorder will exhibit itself with all the phenomena of depression, simulating, at the very inception, the type of a low typhoid affection. If this be so—and its demonstration will be clearly recognised at the bedside—it folloAvs as a fundamental prin- ciple in therapeutics that the treatment of the two grades of the malady cannot be identical. In inflammatory puerperal fever— the nature of Avhich will be defined by the symptoms—prompt depletory measures are certainly indicated. But, in order that these measures may result in benefit, remember that they are to be resorted to opportunely—the bloAV is to be struck simultaneously Avith the advent of the enemy—no delay can be tolerated here, and the only hope of rescue is in the sudden arrest of the disease. Therefore, the prompt abstraction of blood is called for; take from the arm from twelve to thirty ounces of blood, depending of course on the urgency of the case, and in order that there may be nothing equivocal in the impression made on the system, bleed from a large orifice, let there be a bold and full stream; in one word, make your patient faint; syncope will more readily be accomplished by placing the patient in the sitting position during the abstraction of blood. Is the bleeding to be repeated ? Yes, if the indications justify it. But the repetition must not be delayed. Not more than three or four hours should elapse ; at this time, one, two, or more dozen leeches may be applied to the abdomen, resting with the judgment of the practitioner, and the bleeding promoted by warm fomentations. The next indication will be a free action on the bowels ; in order that there may be no unnecessary delay in the effect of the medi- cine, give immediately the good old searching compound: 1}.. Submur. Hydrarg. gr. x. Pulv. Jalapae gr. xv. " Antimonial. gr. ij. M. Let this be followed in two hours with the annexed draught: 1>. Sulphat. Magnesiae 3 ij. Infus. Sennae f. § iv. Mannae 3 i. Tinct. Jalapae f. 3 i. M. If free purgation be not accomplished, I should have recourse to Croton oil, which is a favorite remedy with me in these cases; it 696 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. acts promptly and thoroughly, producing full serous discharges; it stimulates the intestinal mucous surface, thus causing a powerful derivative influence, Avhich necessarily diminishes the engorged con- dition of the vessels of the inflamed peritoneum. #. OleiTiglii gtt. iv. Sacchar. Alb. 3 ii. Mucil. Acaciae f. 3 ij. M. A teaspoonful every half hour until free catharsis follows. When the bowels have been properly evacuated, it is essential to attend to that important emunctory—the skin; and with the combined vieAv of diaphoretic action, and calming nervous irrita- bility, one of the folloAving poAvders may be administered every two or three hours: 1>. Pulv. Doveri gr. xxiv. " Ipecac gr. vi. Divide in chartulas xij. The diet should consist, until the inflammatory stage has subsided, rigidly of diluents; a free use of the nitrate of potash, either in gruel or water, will be found of advantage—say gr. xij. of the potash to a tumbler of the fluid, three or four times a day. We have an important adjuvant in blisters, after the intensity of the disease is somewhat broken; instead, however, of placing them on the abdomen, I greatly prefer applying them on the inter- nal surface of the thighs, immediately over the femoral arteries. Order one or tAvo blisters, as the indication may be, each 4 inches by 6 ; keep up a free discharge by means of the epispastic oint- ment, and oftentimes the best results will ensue. I have said nothing of the specific influence of mercury in this disease. Except as a purgative at the commencement, I have but little faith in the remedy. I have seen repeated instances of the entire failure of any benefit from ptyalism, whether the mercury be administered internally or through inunction. Much has been said in commendation of the internal use of tur- pentine. It has been highly extolled by Dr. Brenan, of Dublin, and many able practitioners have endorsed his views. There can be no doubt of the efficacy of this medicine in relieving the tym- panites, which is so usual an accompaniment of the affection. Half an ounce of the turpentine, with the same quantity of castor oil every six or eight hours, will be found often effective in removing the intestinal flatus; and frequently it will mitigate the intensity of the pain as a counter-irritant to the abdomen. I may here remark that, in cases of severe tympanites intestinalis, I have found much benefit in large enemata of tepid water. It is needless to THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 697 observe that, as soon as the disease has yielded to the remedies, the recuperative poAvers of the system are to be aided by stimu- lants, tonics, and nutritious diet. In the adynamic form of the disease—that form characterized at the very commencement by a sinking of the forces, depletion is not to be attempted. Here, the vital forces, as far as may be, should be maintained. Stimulants, nutriment, and pure air are very une- quivocally indicated. But, alas! how often are our best-directed efforts made negative by the inexorable demands of the merciless foe. The sulphate of quinine, although by no means a new sug- gestion, has recently found favor in the hands of M. Beau, at the Hopital Cochin, Paris. He administers it in large doses, preceding its employment by an evacuation of the bowels. M. Beau states that the efficacy of the remedy consists in giving it to an extent to produce head-troubles, such as vertigo, deafness, &c, and these results should be continued for several days.* I should not here neglect to speak of the opium treatment, both in the sthenic and ataxic varieties of the disease, more especially when lesion of the peritoneal covering exists. As far as I know, the administration of large doses of opium in peritonitis, altogether unconnected with child-bearing, was first introduced to the atten- tion of the profession by that eminently practical clinical teacher, Dr. Graves, of Dublin. The first time he resorted to this remedy in peritoneal inflammation was in 1822 ; it Avas the case of a Avoman in Avhom the inflammation set in after the operation of tapping for dropsy. Dr. Graves says, "the case seemed so hopeless, and the agony the patient was suffering so intense, that I was induced to order opium for her in very large doses; she also got wine; to my great astonishment she recovered.''! Dr. Stokes, another of Dub- lin's eminent practitioners, subsequently employed opium in that most perilous form of peritoneal inflammation springing from per- foration—-in one case which recovered, he gave 105 grains in addition to what had been administered by injection.^ Prof. Alonzo Clark, of the College of Physicians and Surgeons of this city, has employed opium in heroic doses during the prevalence of puerperal fever at the Bellevue Hospital, and with good sue cess. * Bulletin de l'Academie de Medicine, t. xxi. p. 81. f For the conjoined experience of Drs. Graves and Stokes on this point, I refer the reader to the fifth volume of the Dublin Hospital Reports. X Clinical Lectures on the Practice of Medicine. Tol. ii., p. 244. 8 Some interesting details furnished by Prof. Keating, the able annotator of Dr. Ramsbotham, touching Dr. Clark's experience with opium in puerperal fever, will be found in Ramsbotham's System of Obstetrics, p. 534. I may here, however be permitted to quote the following as an evidence of the extraordinary extent to which opium may be administered without fatal results. Prof. Clark says : "Regarding the tolerance of opiates in some of these cases-at the risk of being charged with 698 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. It is an interesting fact that Avhen opium is administered in these cases so as to produce incipient narcotism, the respiration be- comes sensibly affected. Dr. Clark, with the respiratory move- ment reduced to 12, and, as a general rule, the pulse beloAV 100, with the concurrence of other favorable symptoms, such as a subsi- dence of the pain and tenderness, Avith diminution of the tympanites, gradually lessens the quantity of the drug, and finally discontinues it. Prof. Fordyce Barker speaks highly of the veratrum viride as a remedy in puerperal fever; it certainly exercises a marked control over the frequency of the pulse, and he observes, " in no disease have I seen its value more strikingly exhibited."* It requires extreme caution, and should not be employed except under circum- stances in which the most unceasing vigilance as to its administra- tion and effects can be exercised. rashness and trifling with human life—I will make some extracts from case seven. The treatment was commenced at 10 a.m., on 26th of Dec, two grains of opium hourly. A 2 p.m., no change in the symptoms, dose increased to gr. iv.; at 3, gr. iv.; at 4, gr. v.; at 5, gr. v.; at 6, gr. viii.; at 8, gr. x.; at 9, gr. xij.; at 11, sol. morph. sulph. (10 gr. to f 5 i) 3 iss.; at 12, 3i.; at 14 a.m. (respiration 6), 0; at 6 a.m., (respiration 12), opium gr. xij.; at 10, sol. 3 i.; at 12 M., opium gr. xij.; at 14 p.m., sol. 3 ij.; at 2i, 3 ij.; at 3£ opium, opium gr. xxiv.; at 5, gr. xij.; at 6 J, sol. 3 ijss.; at 7}, 3 ij.; at 9, opium gr. xiv.; at 10, gr. xvj.; at 11, gr. xviij.; 28th, at 1 a.m., sol. 3 ijss.; at 2, 3 iv-; at 34,, opium gr. xx.; at 4, sol. 3 ijss.; at 5, 3 iii.; at 6, 3 iijss.; at 64, opium gr. x.; at 7, sol. 3 iijss.; at 8, opium gr. xxij.; at 9 J, sol. 3 iv.; at 10, 3 iij.; at 114, 3 iij.; at 12, 0. Thus this woman took, in the first 26 hours of her treatment, opium Ixviij. and sulph. morph. gr. vij.; or counting one grain of sulph. morph. as four grains of opium, one hundred and six (106) grains of opium. In the second 24 hours, she took opium gr. cxlviii., and sulph. morph. Ixxxj., or opium four hundred and seventy-two (472) grains 1 On the third day, she took 236 grains; on the fourth, 120 grains; on the fifth, 54 grains; on the sixth, 22 grains; on the seventh, 8 grains; after which, the treatment was wholly sus- pended. This woman was not addicted to drinking, and, after her recovery, she assured me repeatedly that she did not know opium by sight, and had never taken it, or any of its preparations, unless it had been prescribed by a physician. This is, perhaps, ' horrible dosing,' and only justifiable as an experiment on a desperate disease; yet, this woman is alive to tell her own story, as are several others, who took surprising quantities of this drug. But later observations have shown that the tenth to the thirtieth part of this maximum is sufficient in controlling the disease." * Remarks on puerperal fever, New York Academy of Medicine, Oct. 1857. LECTURE XLV. Puerperal Mania; its Pathology—Is it a Phrenitis, or is it essentially a Disease of Exhaustion and Irritation ?—Opinions divided; Necroscopical Researches—At what Period of the Puerperal State is Mania most apt to Occur ?—Esquirol's Sta- tistics—Frequency of the Disease—Is Puerperal Mania liable to recur in a Subse- quent Birth ?—The Opinion of Dr. Gooch and others on this Point—Causes of Puerperal Mania—Predisposing and Exciting; Hereditary Influence—Symptoms —Rapid Pulse and Continued Restlessness—What do they Portend ?— Diagnosis— Puerperal Mania and Phrenitis, Distinction between—Prognosis—Records of Hospitals for the Insane; Records of Private Practice—Duration of Puerperal Mania—Is Permanent Aberration of Mind Probable in this Disease ?—Treatment —Marshall Hall and Blood-letting—Opiates—Their Importance—Moral Treat- ment. Gentlemen—Puerperal Mania will occupy our attention to-day; it is one of those affections incident to the puerperal Avoman, Avhich always to a greater or less extent has its melancholy surroundings. Imagine, for instance, a young mother, who has a few days since given birth to a child, to be suddenly deprived of her reason! Her mind has surrendered to the encroachments of morbid action, she is no longer cognizant of events as they pass, and is thus cut off from the inexpressible pleasure not only of intelligently gazing upon, but of ministering to, the wants of her new-born infant, Avhose very condition of dependence makes it an object of additional interest. Indeed, the affection very naturally throws a gloom over the house- hold, and is a subject Avell worthy the attention of the medical man. This malady may manifest itself during gestation, at the time of labor, or some days subsequently; again, it may become developed during the progress of lactation, or it may folloAv weaning. Instances have been recorded of its having occurred in very sensitive women immediately after conception. Pathology of the Disease.—There is no general agreement as to the pathology of this disease. By some it is supposed to be an inflammation of the brain and its membranes—a veritable phre- nitis; while others maintain that it is a disease more or less of exhaustion and intestinal irritation consequent upon the puerperal period. Without attempting to deny that puerperal insanity may, under circumstances, be the result of phrenitis, yet I think accurate clinical observation abundantly proves that, as a general rule, it is connected with a dilapidated condition of the forces. Some of the 700 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. most marked cases of melancholia—one of the forms of mania- -I have ever witnessed, sprang from the exhaustion of undue lactation. The nervous system of the menstruating, the pregnant, parturient, and nursing female is liable to various modifications—so many concussions, if you please, the tendency of Avhich is to impair to a greater or less extent its equilibrium, and thus dispose it to nume- rous derangements, one of the phases of which may be mania, or melancholia. I do not mean to be understood that mere exhaustion will necessarily occasion mania; but what I do believe is this, that there is a peculiar specific sensitiveness in the sexual organs of the female during the puerperal period, wrhich, under the influence of debilitating and other exciting causes, may so far affect the integrity of the nervous economy, as to generate certain morbid phenomena— in one case we may have hysteria, in another melancholy, in another convulsive movements, and in another partial or complete loss of reason. It is by no means a rare circumstance for some of these abnormal developments to present themselves during men- struation, in the course of gestation, or at the time of labor, or after the completion of this process. In brief, I believe that, as a general rule, puerperal mania is a sui generis insanity, and its pecu- liarity is traceable to certain agencies acting on the sexual system, and the subsequent re-action of this system on the nervous mass. It is quite probable that the discrepancy of opinion in regard to the pathology of the disease may have arisen from a want of proper discrimination in the results of necroscopical researches—for in- stance, it is well shown by these researches that, in what may be designated general insanity, evidences of inflammation of the brain and its membranes, may be regarded as the rule. But, according to the best observers, among whom may be mentioned Esquirol,* such is not the fact in the examination of those, who have died of puerperal mania. At what Period of the Puerperal State is Mania most apt to Occur ?—Although puerperal mania will occasionally exhibit itself during pregnancy, and after weaning, yet it is generally con- ceded that it is most liable to become developed a few days after delivery, and in the progress of advanced lactation. The folloAving tables by Esquirol are not without interest: In 1811, 1812, 1813, 1814, there were eleven hundred and nineteen insane women admit- ted into the Salpetriere, of whom ninety-two were affected Avith puerperal insanity; of these, 16 were attacked from the first to the fourth day after delivery; 21 from the fifth to the fifteenth day; 17 from the sixteenth to the sixtieth day ; 19 from the sixtieth day to the twelfth month of lactation; 19 after weaning. Frequency of the Disease.—This affection cannot be considered * Des Maladies Mentales, 1838. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 701 as of rare occurrence. Among seventeen hundred and nineteen cases of insane women in the Salpetriere, there were 52 cases of puerperal mania, and Dr. Haslam reports 84 cases among 1644 women admitted at Bethlem. Is Puerperal Mania Liable to Recur in a Subsequent Birth.— This is certainly an interesting inquiry—for when a female has once suffered from this affection, nothing can be more natural than that the husband and friends should be solicitous as to the proba- bility of its recurrence in a future parturition. One of the most practical writers on the disease under consideration, Dr. Gooch, is quite emphatic on this point. He says: " I have attended many patients, who came to London to be confined because they had been deranged after their former lying-in in the country; except in one instance, not one of the patients had a return of their disease !''* Such, too, is the tendency of the testimony presented by other eminent observers. I must confess it is adverse to my own personal experience. I once attended the wife of a clergyman from the South in her third labor; she had previously borne two living chil- dren, and in each of her confinements had been attacked with puer- peral mania. The labor in which I attended her was in all respects favorable, but in defiance of every caution, on the fifth day after delivery puerperal insanity set in.f I have a patient in this city, whom I have confined five times. In the tAvo first confinements nothing remarkable occurred. In the third, two days after the birth of her child, her husband was compelled to absent himself on urgent business; thirty-six hours after his departure, she lost her reason, and had a tedious convalescence of ten months. Twenty months from the period of her recovery she was again confined; and mania was again developed. In her fifth parturition she suf- fered no mental aberration. I could cite two other cases, which have occurred to me in consultation, one with Dr. White of this city, the otherj with Dr. Brown, of Little Falls, in which both patients became affected with puerperal mania in two consecutive deliveries. It may be that these cases will be regarded as coinci- dences, and do not bear the relation of cause and effect. However this may be, it seems to me that Avith the predisposition necessarily induced by a previous attack, together with the constant dread of a recurrence of the malady, the nervous system will be so agitated as to render it not at all improbable that mania having once become developed will be liable to exhibit itself at subsequent periods. Under the circumstances, it would at least be judicious to maintain * Most Important Diseases of Women, p. 120. f Hereditary influence no doubt had its sway in this instance, for both the father and the paternal uncle of the lady died maniacs. X In this case, too, there was hereditary predisposition, for the mother of the patient had suffered from puerperal mania soon after the birth of her only child. 702 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. a guarded opinion, and at the same time to exercise a safe measure of vigilance against the operation of all exciting influences. Causes.—These may be divided into the predisposing and excit- ing. Among the former, may be placed prominently hereditary in- fluence ;* a delicately organized nervous system keenly alive to moral and physical impressions ; unusual sensibility of the sexual organs ; and, in my opinion, a previous attack is entitled to be ranked among the predisposing causes of the affection. The exciting causes may be sudden mental emotions, Avhether of a depressing or elevating character ; disordered digestion ; disease of the uterus, or other of the genitalia; exhaustion from undue lactation, or from hemor- rhage, through the changes produced in the nervous system. Wean- ing is regarded by some Avriters as an excitant to puerperal mania, but I do not think it entitled to much prominence; if it were so, the disease would assuredly be apt to develop itself frequently in Avomen Avho, from want of proper feeling or other circumstances, do not suckle their children ; this, hoAvever, is shoAvn not to be the case. I am disposed to think that some of the instances of mania, Avhich have been referred to weaning, are due to the exhaustion consequent upon protracted lactation rendering the weaning a necessity. Symptoms.—The symptoms indicative of puerperal mania haA'e no special identity, and are subject to variations. Indeed, a very practical division of the disorder has been made into AA'hat is deno- minated mania and melancholia, each characterized more or less by symptoms differing from each other. Mania ordinarily occurs soon after delivery, while melancholia is more liable to manifest itself as the result of the exhaustion of undue lactation. In mania, there are usually all the indications of agitation and excitement—great irritability of temper—suspicion is a common symptom; sometimes there will be marked obstinacy and moroseness; the husband and infant become objects not only of indifference, but of actual dislike; there may or may not be febrile excitement; the pulse is some- times unchanged—and again, it is rapid with more or less fever. The patient will occasionally become extremely violent both in man- ner and language, and much vigilance required to prevent her inflicting injury upon herself or child. A very uniform and early symptom is restlessness soon after delivery—an inability to sleep— the patient is wakeful, throwing herself about the bed, and some- times sighing. This state of watchfulness, I cannot too emphati- cally remark, should ahvays be regarded with apprehension, and ag far as may be, means promptly employed to procure sleep. Usually the digestive functions are much disturbed, as indicated by the coated, slimy tongue, irregularity of the bowels, defective urinary * Dr. Burrows says that if the truth could always be ascertained, more than one half would probably be found to owe their origin to this cause. [Commentaries on Insanity.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 703 secretion; the patient, although hungry, will sometimes evince an indisposition to eat merely from obstinacy; this latter fact I have noticed on more than one occasion. In the other form of mania— melancholia—the symptoms are someAvhat different. Here, in lieu of excitement and violence, there is marked depression of spirits— there is, if I may so term it, a deep melancholy pervading every look and act of the invalid ; she is silent, listless, and indifferent to everything passing around her; the pulse is normal, with more or less deranged digestion. In one word, she is an object painful to contemplate, and it is one of those pictures in real life Avell calcu- lated deeply to impress the observer, and call forth his sympa- thies. s Diagnosis.—From what has been said of the symptoms and divisions of this disorder, the diagnosis cannot be difficult. The time and circumstances of its occurrence will also aid in facilitating a just opinion. Puerperal mania might possibly be misapprehended for phrenitis, but proper attention Avould soon reveal the error. In the latter affection, the hard and quickened pulse, the heated sur- face, the suffused eye, the intolerance of light and noise will very soon tell the story to the vigilant physician. Prognosis.—Many will be the anxious inquiries as to the proba- ble issue of the disease, and these inquiries will be directed to two points—in the first place, whether the disorder is likely to termi- nate fatally—and secondly, if not, Avhether the mind Avill be perma- nently affected ? I need not dwell on the constancy with which these appeals will be made, and the pressing urgency for a response. It, therefore, is the duty of the practitioner, by a proper apprecia- tion of the statistics of the affection, to be able at least to approxi- mate a truthful decision. It has been Avell remarked that the data furnished by the records of hospitals for the insane are not proper guides as to the results of this disease under other and more fiwora- ble circumstances.* The fact, I think, is well shown by the following reports: in ninety-two cases recorded by Esquirol, fifty-five re- covered, six died, and thirty-one incurable, or one in three; Dr. Haslam says, of eighty-five admitted into Bethlem, only fifty recovered, and thirty-five incurable ; Dr. Burrows reports fifty- seven cases, of which thirty-five recovered, and eleven incurable; among the thirty-five recoveries, twenty-eight occurred during the first six months. Private practice, I repeat, presents no such melancholy experi- * Dr. Gooch very truly observes, that the records of hospitals contain chiefly accounts of cases, which have been admitted because they have been unusually permanent, having already disappointed the hope, which is generally entertained and acted upon, of relief by private cure; the cases of short duration, which last only a few days or weeks, and which prove a large proportion, are totally overlooked or omitted in the inspection of hospital reports. 701 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ence. It is perfectly safe, under ordinary circumstances, to give a favorable opinion as to the termination of the disease, both as regards the restoration of body and mind. I say under ordinary circumstances, for there are occasionally certain conditions of the disorder which portend a fatal result, and it is proper that they should not elude the attention of the practitioner. These condi" tions are now admitted by the ablest physicians as of great moment in forming an accurate diagnosis—they are the rapid pulse, and continued restlessness at the very inception of the malady. When these two phenomena exist conjointly, they are to be regarded as tokens of no good. Happily the great majority of cases are not characterized by the quickened pulse, although watchfulness is a common attendant. I may here remark that the reason for the apprehension of danger from the rapid action of the heart, and the continued loss of rest, ia of easy solution—these tAvo symptoms will of necessity draw largely on the strength of the patient—there is no repair to the debilitated forces, and death, in these cases, may justly be attributed to ex- haustion of the system. Duration of Puerperal Mania.—In most instances, puerperal mania is of short duration, not unfrequently yielding to judicious treatment in a feAV days or weeks. Sometimes, however, the re- covery is protracted, and the loss of reason, more or less complete, Avill continue for many months. According to the most reliable data on the subject, Avell sustained by clinical observation, it may be affirmed that the average duration of the malady is from one to six months, while the permanent aberration of mind is the rare exception. Treatment.—A ripe and experienced judgment is essential to the proper treatment of this disease. The thoughtless practitioner, governed in his therapeutics by mere symptoms, will be extremely apt to commit a grave error in the management of the malady. The excitement and violence of the patient he will probably attribute to vascular fulness, a phlogistic state of system—it may be to phrenitis. With this view of the case, he will of course resort to depletory measures, the first of which will be the free use of the lancet. This is oftentimes a fatal mistake. Puerperal phrenitis, it would be well to remember, is among the very rare occurrences of the lying-in room; and it cannot be too emphatically borne in recollection that puerperal mania is, as a general rule, a disease of exhaustion and irritation. If the practitioner will but keep this cardinal fact before him, he will have the key to the treatment. I was forcibly struck some years since with the remark of that saga- cious observer, Dr. Marshall Hall—he says, " On being called to a case of puerperal mania, I have long been in the habit of asking whether the patient has or has not been bled; on this greatly de- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 705 pends the result of the case; if blood has been freely taken, the patient will probably die; if otherwise, most puerperal cases of mania issue well." If this language of the distinguished physiolo- gist were incorporated into a maxim, and inscribed upon the tablets of memory, well, indeed, would it be for the invalid attacked with puerperal insanity. If what has been said be true—that puerperal mania is most commonly a disease of exhaustion and irritation, then it Avould follow as a legitimate consequence that the two broad indications are to repair, as promptly as may be, the waste the system has under- gone, and, secondly, to allay the nervous irritability. Let me here ask—what is the most 'efficient, and, indeed, the only mode of re- pairing waste under these circumstances ? Is it not through proper nutrition ? But nutrition is not an exclusive process—it is but one link in a chain of processes. Food taken into the stomach will not necessarily nourish—its nutrient properties will depend upon its being properly digested; and if you wish ingesta to be converted into good blood, one material prerequisite is—that the chylopoietic functions shall be in good condition. I think I may say, without fear of contradiction, that a very uniform attendant upon puerperal mania is a disordered digestion, as is shoAvn by the coated tongue, foetid breath, loss of appetite, and irregularity of the bowels. Therefore, with such indications, the first thing to do is to admi- nister a cathartic, say gr. vi. submur. hydrag. with gr. xii. pulv. rhei; let this be followed in six hours by castor oil, or the follow- ing draught: Sulphat. Magnesise 3 i Infus. Senna? f. 1 iv Mannae 3 i Tinct. Jalapae f. 3 i M. One half this to be taken, and if not effectual, the remaining half in four hours. In these cases of coated tongue and foul breath, great benefit will sometimes be derived from an emetic of ipecacuanha—gr. x. to gr. xii. in half a tea-cup of warm water. When the bowels have been properly evacuated, it is most im- portant to quiet the nervous system; if the patient can be early put into a state of repose—if the exhausting and harassing watchful- ness be speedily arrested, the best results may be predicted. For this purpose, opiates, in some of their various forms, must be re- sorted to ; but it should be recollected that it is most desirable to make a prompt impression, and, therefore, a full dose should be administered at first, followed subsequently by a smaller quantity as circumstances may indicate. If there be nothing in the idiosyn- 45 706 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. crasy of the invalid to contra-indicate it, a grain or more of solid opium may be given, or thirty or forty drops of the tincture; one half grain or more of morphine will sometimes act admirably; 10 grains of Dover's poAvder; or the following may be prescribed: Syrup. Papav. f 3 vi Mucil. Acaciaa f 5 iii Sol. Sulph. Morphias (M.) gtt. xx. M. A table-spoonful every half-hour until sleep is obtained. Hyoscya- mus and camphor, five grains of each, was a favorite prescription with Dr. Gooch, especially where opiates could not be tolerated. It can scarcely be necessary to enjoin, that whichever of these reme- dies may be employed, they should be repeated according to the emergency of the case, and the sound discretion of the physician ; nor should they be resorted to if there be heat of system with much thirst. Cooling but gentle aperients, together with diaphoretics, will soon remove these latter symptoms. The spirits of mindererus, a tablespoonful every two or three hours, will be found a suitable diaphoretic for the purpose. If there be much heat about the head, evaporating lotions to the part will be of service, together with warm water fomentations to the feet; and if there be an approach—as sometimes will be the case —to stupor, blisters behind the ears may be applied with marked good results. The diet to be of easy digestion, and nutritious—and when not contra-indicated, animal food may be allowed freely. On the same principle, also, malt liquors, in proper quantity, will aid in accomplishing the object in view—the building up of the dilapi- dated forces. In one word, the judicious physician, seeing the indications, and fully appreciating the surroundings of each case as they may present themselves to his observation, must be the judge as to the special manner of adapting his therapeutics. I have said nothing of the moral treatment of puerperal mania; good nursing—by good nursing I mean discreet nursing—has much to do with the recovery. What the patient needs is the exercise of that oftentimes rare commodity in the sick-room—common sense. Above all things, let her be protected from the intrusion of inquisitive and talkative friends. Quietude is Avhat she most needs —great caution should be observed to avoid either in conversation or acts all causes of irritation; the nurse should be reminded that the patient is never to be left alone, for instances have occurred in which females, affected with this disease, have taken advantage of their solitude, and committed acts of personal violence. ^ One of the material points in the moral treatment of this affec- tion is to exercise a judicious restraint, without permitting the patient to become conscious that there is the slightest surveillance THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 707 over her actions. This is the perfection of good nursing. It is important, as she convalesces, to have her mind agreeably occupied in some way most congenial to her tastes—pleasant conversation, drives in the country, music, painting, etc., are all so many re- sources, which may be advantageously resorted to. In those examples in Avhich the mind of the patient continues unsettled, accompanied by violence,* rebellious to ordinary restraint, the question will of course arise as to the necessity of removing her to some Institution fitted for this special class of cases. The alternative, however, I should be indisposed to adopt except under the most urgent necessity. * The soothing influence of ether will oftentimes exhibit itself most beneficially in quieting the violent agitation, occasionally found to accompany thia disease. LECTURE XLVI. Phlegmasia Dolens, although generally incident to the puerperal state, is not alwaya so—It may develop itself in the non-puerperal woman, and also in the male sex; but little understood by the early Fathers—Mauriceau the first to direct special attention to it—His Views of its Pathology—The Views of Puzos and Levret— Historical Sketch of the Disease—Mr. White, of Manchester—Mr. Frye, of Glouces- ter—Dr. Ferrier—Mr. Hull—M. Albers—M. Bouillaud—Professor Davis, of Lon- don—Dr. Robert Lee—Is Phlegmasia Dolens a Crural Phlebitis ?—Dr. Macken- zie, of London—Is Phlegmasia Dolens a Toxasmia ?—Synonyms—Causes of the Dis- ease; Symptoms—Why is (Edema a Symptom of Phlegmasia Dolens?—Causes of Dropsical Effusion; the relation between the oedema of Phlegmasia Dolens, and Obstructed Venous Circulation—Proof—Are the Veins Absorbents ?—Lower's Ex- periments—Boerhaave; Van Swieten, Hoffman, Morgagni, Cullen—Majendie and Bouillaud— The (Edema of Pregnancy—How Explained—Which of the Inferior Ex- tremities is most liable to Phlegmasia Doleus?—The Causes of the Difference—At what Period after Labor does the Disease most usually occur?—Frequency of Phleg- masia Dolens—Statistics—Diagnosis—Prognosis—Progress, Duration, and Termina- tion of the Disease—Complications—What are they ?—Purulent Collections—Their Consequences—Peritonitis—Metro-Peritonitis—Treatment of Phlegmasia Dolens__ Its Indications—Local Applications with the view of diminishing Pain. Gentlemen—The disease known as Phlegmasia Dolens is usually classed among the affections incident to the puerperal state; but, at the same time, it should be recollected that it is not exclusively restricted to- this period, for it will occasionally develop itself in the non-puerperal woman; and examples of the disease have even been observed in the male sex. I have looked in vain for a descrip- tion of this interesting affection among the early Fathers of our science; there is the slightest possible allusion to it by Hippocrates • and if, perhaps, we except Rodericus a Castro,* we have nothing in addition touching it, until the time of Mauriceau, who appears to have been the first to have directed special attention to the dis- order. His views, as we shall presently see, of its pathology, are not the vieAvs recognised by science in our day; nor did his imme- diate successors, Puzos, Levret, and others, succeed in throwing any additional light on the true nature of the malady. It must however, be conceded, that these observers, although their pathology was crude and without a basis, exhibited remarkable cleverness in describing the more prominent symptoms of the disease, nor were their therapeutics of the affection, considering the times in which they lived, less worthy of note. * 1603. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 709 Historical Sketch of Phlegmasia Dolens.—Mauriceau attributed the origin of the affection to a collection of humors, which should have passed off with the lochial discharge; and he says the legs and thighs become cedematous and greatly swollen, sometimes extend- ing from the groin to the foot; the cedema and enlargement may in- volve one or both extremities.* Puzos supposed the disease to result from a deposit of milk in the part affected, this deposit commenc- ing in the groin and upper portion of the thigh; the pain experi- enced by the patient was usually in the direction of the large vessels coursing along the limb.f Levret, who also believed in the milky metastasis, tells us that the swelling caused by this deposit ordinarily terminates in infiltration of the cellular and adipose tissues of the parts affected, and that all these parts become very cedematous.J Mr. White,§ of Manchester, in 1784, maintained that the disease was due to an obstruction of the lymphatic vessels of the parts, and that these vessels became obstructed during the process of labor. Mr. Frye, of Gloucester, in an essay published in 1792, taught that the lymphatics at the brim of the pelvis, just under Poupart's liga- ment, became ruptured, and, as a consequence, there was an escape and diffusion of lymph into the cellular tissue of the limb. Dr. Fer- rier, on the contrary, believed that there was neither obstruction nor rupture of the lymphatic vessels, but that the pathology of the disease consisted essentially in inflammation of these vessels and glands. In 1800, Mr. Hull|| advocated the opinion that the proxi- mate cause of the disorder was an inflammation of all the organs * " J'ai vu plusieurs femmes apres £tre accouchees assez heureusement, avoir les jambes et les cuisses toutes cedemateuses et extraordinairement grosses, quelque- fois depuis I'aine jusques a I'extremite du pied, par fois d'un seul cote, et d'autres fois de tous les deux. Cet accident survient souvent ensuite d'une douleur sciatique causee par un reflux, qui se fait sur ces parties, des humeurs qui devroient etre eva- cuees par les vindanges, dont le gros nerf de la cuisse s'abreuve quelquefois tene- ment, qu'il en peut rester^a la femme une claudication dans la suite." [Traite des Maladies des femmes grosses, et de celles qui sont accouchees. Tome premier, p. 446. (1740).] f " Les dep6ts laiteux les plus communs, apres ceux des mamelles, sont ceux qui se font sur les extremites inferieurs. Ces depots ne se forment gueres avant le douzieme ou la quatorzieme jour de la couche. C'est dans I'aine et dans la partie superieur de la cuisse que le depot commence a donner des signes de sa presence par la douleur que l'accouchee y ressent; et la douleur suit ordinairement le trajet des gros vaisseaux qui descendent le long de la cuisse." [Traite des Accouchemens, p. 350. (1769).] X " H est cependant encore plus ordinaire de voir cet engorgement laiteux se ter- miner aux depens de l'infiltration du tissu cellulaire qui garnit les interstices des muscles de I'extremite du meme c6te, ensuite du tissu graisseux qui est sous la peau de la cuisse, de la jambe, et du pied. Toutes ces parties deviennent alors fort cedemateuses." [L'Art des Accouchemens, p. 177. (1766).] § An Inquiry into the Nature and Cause of that Swelling in one or both of the Lower Extremities, which sometimes happens to Lying-in Women. \ An Essay on Phlegmasia Dolens, by John Hull, M.D., Manchester, 1800. 710 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and tissues of the affected limb, resulting in a profuse pouring out of coagulable lymph; and in this way he explained the tension and SAvelling, tAvo of the prominent characteristics of the disease. Albers says the nerves are primarily affected—that the pain accompanying the disorder is essentially a neuralgia, and the oedema one of its effects.* It may here be remarked, that the opinion of Albers Avas, to a certain extent, sustained by Duges, Siebold, and others, but they did not altogether reject the pathological changes in the other tissues. So far, Ave have, I think, Avhat may be appropriately termed mixed opinions as to the true nature of phlegmasia dolens, Avithout much approach to a concurrence of sentiment among the authors cited. In January 1823, however, a new theory was advanced by M. Bouillaud,f who referred the disease to an inflammation and obstruction of the crural veins, and it is Avell to remark that this explanation is the one noAV very generally accepted by the profes- sion. It is claimed for M. Bouillaud, that he Avas the first to point out this pathological condition of the disease; but it seems very satisfactorily demonstrated that the credit really belongs to the late Professor Davis, of London. As early as 1817, he proved by dissection of a fatal case, which had occurred to him, that phleg- masia dolens involved an inflammation of the iliac and femoral veins; the dissection Avas Avitnessed by Mr. Lawrence. In May, 1823, Prof. Davis read before the Medical and Chirurgical Society,J an interesting paper on the disease. It will, therefore, be seen, that although Dr. Davis's essay did not appear until four months subsequently to the paper of M. Bouillaud, yet he had actually observed in dissection, six years previously, the pathological fact under consideration. Dr. Robert Lee, of London, concurs in the view that the patho- logy of the disease is really a crural phlebitis; but, at the same time, he maintains that the inflammation commences in the veins of the uterus.§ It is proper here to state that, in 1826, Mr. Guthrie had sug- gested the opinion that crural phlebitis was simply an extension of inflammation from the veins of the uterus ; and it was not until 1829 that Dr. Lee demonstrated the coincidence of uterine and crural phlebitis. In a more recent paper on this subject he writes thus :| " The results of the last twenty-four years' experience con- firm my previous observations, and I am satisfied that inflammation * Hufeland's Journal, p. 16, Feb. 1817. + De l'obliter. des veines et de son influence sur la format des hydrop. partieL Archives generales de med.. Janvier 1823, p. 188, T. 11. X Med. and Chirurg. Trans., vol. xii., 1823. § Pathological Researches on Inflammation of the Veins of the Uterus, Medico- Chirurg. Trans., vol. xv., 1829. | Cyclopaedia of Pract. Med., 1845, vol. iii.; Art. Phlegmas. Dolens, p. 529, et seq. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 711 of the iliac and femoral veins is the proximate cause of the disease, and that, in puerperal women, the inflammation commences in the uterine branches of the hypogastric veins." There is no doubt that Dr. Lee is correct in some cases, and that the crural phlebitis, A\hich results in phlegmasia dolens, does, in certain instances, com- mence in the veins of the uterus; but that this is not ahvays so is clearly shown by two facts: 1st. Phlegmasia Dolens has been recog- nised in the puerperal woman under circumstances in which the uterine veins were in no way involved. 2d. There are examples of the disease occurring in which the veins of the lower part of the extremity were alone the seat of inflammation, Avithout the slight- est manifestation of disturbance in the vessels of the uterus. That clever pathologist, Virchow, believes that the incipient morbid condition of the disease consists in the presence of a coagu- lum in the veins; and that the inflammation of the vessels, the effu- sion of lymph and purulent secretion, the breaking down of the coagulum and the presence of pus in it, are purely incidental to the occlusion of the veins. The last special writer on phlegmasia dolens, Dr. T. W. Macken- zie, of London, while admitting that the phlebitic theory of the affection is better sustained by facts than any other, which had preceded it, believes that he has demonstrated the following con- clusions at Avhich he has arrived : " 1st. Crural Phlebitis, in a pure and uncomplicated form, cannot give rise to all the local and general phenomena of the disease, and, therefore, cannot be its proximate cause. " 2d. Phlebitis itself is, for the most part, not a primary, but a secondary affection; and, in the great majority of cases, is a conse- quence of the circulation of impure or morbid blood in the veins. " 3d. The proximate cause of the disease is, therefore, presum- ably a morbific condition of the blood, which I have experimentally shown to be capable of producing not only the lesions of the veins met with in the disease, but all its other phenomena."* I have read with much interest the excellent monograph of Dr. Mackenzie, but really I do not see that he has proved anything Avhich all good observers are not willing freely to admit. In the first place, it seems to me that crural phlebitis,f like pneumonia, * The Pathology and Treatment of Phlegmasia Dolens, etc., 1862. j- It may be remarked, that phlebitis which precedes phlegmasia dolens, differs in no sensible particular from ordinary phlebitic inflammation. In men, as in women, this latter has been occasioned by carcinoma of the rectum, the introduction of a sound into the bladder, giving rise to inflammation of the veins of the prostate, and thus involving the adjacent venous trunks. An example of this is recorded by Cruveilhier. Valleix mentions two interesting cases of phlebitis caused by the pressure of an ovarian tumor. It is also well established that inflammation of tha iliac and femoral veins is not only not peculiar to women recently delivered, but may arise from suppression of the menses, malignant disease of the os and cervix uterij and from enlargement of the organ from any pathological cause. 712 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. pleurisy, or any other inflammation, is, if you please, a product or an effect of some antecedent; it will not, I think, be attempted to be shown that it has a spontaneous origin, and, therefore, it must be rightfully classed among the secondary affections. Again, in main- taining that a " morbific condition of the blood" is the proximate cause of the disease, he says what every experienced obstetrician will readily concede, is often, but not always, the case; or, in other words, that this state of the blood is frequently the starting point of the malady. If Ave look at the phases through Avhich the puer- peral woman passes, we cannot be surprised that she should, under certain circumstances, have her blood contaminated, exhibiting a veritable toxaemia. At the same time, I do not doubt that many other influences, such as cold, a protracted or instrumental deli- very, injury to the parts, &c, will cause crural phlebitis, which may result in the production of phlegmasia dolens. I cannot myself see much force in the position assumed by Dr. Mackenzie, that " crural phlebitis, in a pure and uncomplicated form, cannot give rise to all the local and general phenomena of the disease, and, therefore, cannot be its proximate cause." My OAvn opinion is—and this opinion is founded on clinical experience—that although crural phlebitis is undoubtedly an essential element of phlegmasia dolens, yet it by no means follows that this latter affec- tion Avill necessarily succeed every case of phlebitic inflammation; and, on the other hand, I am quite confident that I have observed examples of phlegmasia dolens developing itself as the consequence of a "pure and uncomplicated form'' of crural phlebitis. Synonyms.—Phlegmasia Dolens has been described under a variety of names, depending on the peculiar pathological view entertained by different authors. The following brief summary will fairly exhibit its varied nomenclature: Mauriceau called it swelling of the leg of the puerperal woman; Puzos and Levret, milky deposit, milky engorgement; Callisen, oedema puerperarum; White, phlegmasia alba dolens puerperarum; Good, spargosis puerperarum; Young, ecphyma cedematicum ; Robert Lee, phle- bitis cruralis; Rayer, hydrophlegmasia of the cellular tissue of the inferior extremities ; Duparcque, lymphatic,painful and leuco- phlegmasia. It has received, in addition, the following designa- tions : oedema lactium, phlegmasia lactea, anasarca serosa, swelled leg, white leg, milk leg. Causes.—Among the causes of phlegmasia dolens may be enu- merated—exposure to cold and dampness, errors of diet, too soon getting up after delivery, and there can be no doubt, that rude manipulations on the part of the accoucheur, instrumental delivery, a protracted labor during which the organs have undergone undue pressure, and the artificial extraction of the placenta, may be men- tioned as among the predisposing causes of the affection. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 713 Symptoms.—The symptoms which usually characterize this dis- ease cannot be said to be uniform, Avhile they are ordinarily coinci- dent Avith those of iliac and crural phlebitis. In the first place, the first indication of trouble may be a chill of more or less duration. Again, the first development of the disease will be a local pain on one or other side of the pelvis. It may be said that pain is one of the most constant symptoms of phlegmasia dolens, but it will vary in its type, severity, and seat; sometimes superficial, extremely acute and lancinating; at other times dull and deep-seated. It may be felt in the entire limb, or be confined to one portion only. It will usually commence in the groin, and extend dowmvards in the direction of the affected limb. Again, the first evidence of the malady will be an acute pain in the calf of the leg; when this occurs it will generally be observed that the swelling, a constant element of the disease, will commence at this point, or at the foot, and gradually travel up the leg and thigh. There is one circum- stance which may be regarded as pathognomonic of phlegmasia dolens when it attacks the thigh, and it is this—The finger can dis- tinctly trace the femoral vein from the groin as it courses down the thigh ; it imparts a sensation of hardness, and rolls, as it were, under the finger like a cord* Pressure upon this vein occasions very intense suffering, whilst pressure on other portions of the limb is ordinarily accompanied by little or no sensibility. The pain of phlegmasia dolens is occasioned by inflammation of the venous trunks, and it is worthy of remark that the pain folloAvs very exactly in the direction of the inflamed vessels. The exten- sion of the limb will increase the suffering, and hence the patient of her own accord usually places it in a state of semi-flexion, and requests that it may be retained in this position by means of a pil- low. The pain, under ordinary circumstances, is most acute dur- ing the first two or three days. It usually precedes the oedema; and yet there will sometimes be a simultaneous development of the two phenomena. The swelling or oedema of the limb, like the pain, is a uniform accompaniment of the disease. The general rule is that it appears first at that portion of the affected extremity at which the pain is originally experienced; this, hoAvever, is not always so, for it will occasionally be observed at some remote part of the limb distant from the seat of suffering, but always between this latter and the ultimate venous ramifications. It must, however, be remembered * The fact of feeling this cord is conclusive evidence of inflammation of the vein, and at the same time of the coagulation of the blood within the coats of the vessel. M. Lugol mentions, as an exceptional circumstance (Journal des Progres, t. xiv.) a remarkable fact, and cites an example in illustration—that nearly all the veins of the affected limb may become hard and knotty, presenting the peculiar feel of a 3ord. 714 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. that no matter where the oedema first appears, it soon involves the entire extremity. Its progress is almost always from the first seat of pain towards the lower portion of the limb. At times the swell- ing is enormous, giving to the affected extremity a volume twice the size of the other; at this period the integuments undergo extra- ordinary tension; they present a more or less glistening transpa- rence, and assume a marked white color. In consequence of the extreme tension of the parts, the finger -will not pit them on pres- sure ; and it is not until the lapse of some days, when the tissues become more relaxed, that the impression of the finger becomes visible. There is, as a general rule, a decided diminution in the size of the limb after twelve or fifteen days. The engorgement, Avhen excessive, may be much lessened by slight apertures made Avith the lancet, as in other examples of cedematous SAvellings. Occasionally there will be observed, on the Avhite and glistening surface of the extremity, reddish bands or spots running along the course of the inflamed vessels; sometimes, in lieu of these, there Avill be seen vesicles of a dark or blackish hue. Conjoined to the local symptoms, just described, may be men- tioned certain constitutional disturbances more or less incident to the affection. For example, the pulse will become accelerated, varying from 100 to 140 and upAvards; the tongue coated, Avith oftentimes marked thirst; countenance usually pale; the boAvels sometimes torpid, at other times diarrhoea will supervene; loss of appetite, and derangement of the urinary secretion, the latter being ordi- narily dark colored and turbid. The patient is irritable and restless. Sometimes the skin is dry and burning; again it will be covered Avith perspiration. Should the disease occur during preg- nancy, as will sometimes happen, there will be a diminished secre- tion of milk, and the breasts will become notably lessened, unless the malady should be of short duration. The lochial discharge is neither so constantly diminished or suppressed as would naturally be inferred would be the case. Why is (Edema a symptom of Phlegmasia Dolens ?—This is an interesting inquiry, and is readily explained. Anasarca, or oedema, is an infiltration of serum or the watery element of the blood into the cellular tissue, and represents, therefore, one of the numerous forms of dropsical effusion. There are various causes of anasarcous engorgements, such as disease of the liver, kidney, heart, etc., but of the pathology of these organs, and its conse- quences, it is not my purpose to speak at present. I shall limit myself to the solution of the simple inquiry— Why is anasarca the uniform accompaniment of phlegmasia dolens? The answer to this interrogatory is, in my opinion, conclusive evidence of what has already been stated, viz. that the pathology of phlegmasia dolens is an iliac or crural phlebitis. Anasarca, then, accompanies phleg THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 715 masia dolens because of venous obstruction, the obstruction in this special case depending upon the blocking up or occlusion of one or more of the veins of the affected limb, as the result of inflamma- tion. Let us examine this point a little, in detail. It has been shoAvn, I think, very conclusively, that one of the attributes of the venous system is its power of absorbing fluids; and it has been demonstrated that fluid substances may pass into and out of the veins, through the process of transudation or imbibition. But this physical act—imbibition or transudation—requires for its accom- plishment a certain condition of the veins; for example, if these latter be greatly distended with watery fluid, the further entrance of this material will be prevented; and when the vessels reach a maximum point of distension, the watery element of the blood will, through exosmosis, pass out through the coats of the engorged veins. Thus it will be seen that excessive plenitude of the veins will necessarily result in an effusion of fluid; and it must also be recollected that this fulness of the vessels is almost invariably in- duced by an obstacle to the free passage of the blood through the veins to the heart. In phlegmasia dolens, as has already been remarked, the femoral and iliac veins becoming the seat of inflam- mation are occluded, thus necessarily obstructing the circulation of the blood in these vessels; and this, therefore, is the true expla- nation of the relation which is found to subsist between phlegmasia dolens and anasarca. As early as the sixteenth century, Dr. Lower* satisfactorily established by experiments on living animals that an obstacle to the circulation of the blood through the veins would result in the effusion of serum. He placed a ligature around the ascending vena cava of a live dog, and then closed the wound; the animal soon became exhausted, and died in a few hours. The post-mortem examination revealed a large accumulation in the abdomen of a serous fluid similar to what would be observed in ascites. In another dog, he tied the jugular veins; after some hours, all the parts situated below the ligatures became very much tumefied ; in tAvo days the animal died as if from suffocation. In this case, also, a collection of serum was observed in the parts above the liga- tures. I might likeAvise cite Boerhaave and his illustrious commen- tator Van Swieten,f Hoffman,! Morgagni,§ Cullen,|| and others, in confirmation of the same view. Majendie, it may be here observed, was one of the strongest advocates of venous absorption. His experiments, quite conclusive * De corde, item de motu et calore sanguinis, eta Cap. ii, p. 123, et sequent •j- Van Swieten's Commentaries, t iv., p. 186 et seq., 1770. X Med. Prat., t. iv, cap. xiv., p. 431. § De sed. et caus. morb., epist. 38, § 19. || Elements of Practice, t. ii.. p. 556, 1787. 716 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. in themselves, was the starting-point, if I may so term it, of nume- rous learned researches on this and kindred questions. M. Bouillaud,* in 1823, wrote as follows: "I shall now speak of those dropsical effusions, reputed passive, and shall endeavor to prove, by fiicts and observations, that they all result from obstruction of some sort in the venous circulation; and, in a great number of instances, the obstruction consists in the occlusion of the veins of the part which is the seat of the dropsy." Andral,f too, has recorded his testi- mony in very positive terms of the relation between serous infiltra- tion and venous obstruction. Which of the Inferior Extremities is most frequently the Seat of Phlegmasia Dolens ?—It is well shoAvn by statistics that the left limb is more frequently attacked than the right; at the same time, it should be stated that sometimes both limbs become involved. This latter circumstance, hoAvever, is comparatively rare. Various theories have been suggested in explanation of the preference exhi- bited by the affection for the left extremity—such as the greater frequency of the position of the occiput of the fcetus to the left; the greater frequency of the attachment of the placenta to the left side of the uterus ;J the tendency of the female to rest on the left side rather than on the right side. One or other of these circumstances, or all of them conjoined, may or may not be the true cause, but further observation, I think, is needed to decide the question. Ad- mitting, hoAvever, that this is really the explanation, I do not see that science can be much benefited by it, for, with the exception of correcting the disposition to recline on the left rather than on the right side, nothing could be done to avert the more frequent occur- rence of the disease in the left extremity, and, indeed, if this could be accomplished, I can perceive no possible advantage derivable from it; for Avhether phlegmasia dolens attack the right or left limb, the progress of the affection, its phenomena, and therapeutics are identical. At what period after labor does the disease usually occur ?— From the most accurate information on this subject, it would seem that there is nothing positive; the affection may present itself from the first to the thirty-fifth day; but, as a general rule, it will be found to appear not later than three weeks from the time of partu- rition, although there are exceptional cases in which it has not manifested itself until the lapse of two months. * Arch, gen, de Med., t. ii., p. 188 et seq. f Precis d'Anat. Path., t. i, p 328. X M. Naegele, Jr., has proved, from his researches on the subject that the pla oenta is situated most commonly on the left surface of the uterus. For an account of these researches, as well as those of Dr. Von Ritgen, on the same subject, see page 373 of this volume. It may also be stated that Dr. Carriere, of Strasburg, records that in sixty-six cases in which the placental sound was detected, it was heard on the left side of the uterus in thirty-eight, and on the right in twenty-eight cases THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 717 Frequency of Phlegmasia Dolens.—This disease cannot be said to be of common occurrence. The best observers will, I think, concur in the following statistics gathered by M. Raige Delorme, as presenting a fair approximation to the facts touching this point.* In 1,897 females delivered in the Westminster Dispensary, White observed the disease five times; in 8,000 confinements in his OAvn practice, and at the Manchester Hospital, there were but four cases of the disease. Again, in 900 deliveries, Wyer records five cases; in 1897, Bland five cases; in 200, Sankey one case; in a practice of 26 years, Siebold has met with it five times ; Struve fifteen times in 18 years; Robert Lee 28 times in six years. With an extended field of observation, I find but three cases of phlegmasia dolens recorded in my note-book, and two of these occurred in consultation, one with Dr. Philips of Harlaem, the other with Dr. Forbes of Brooklyn. Diagnosis.—The diagnosis of phlegmasia dolens is not difficult. There are certain evidences of this disease, which cannot readily be mistaken—such as the pain along the vessels of the limb, the oede- ma, and especially the hard cord felt by the finger as it presses on the inflamed vein. Sometimes, however, it may be difficult to reach the inflamed vessel, and this may arise from one of two circum- stances—either because of the excessive engorgement of the part, or the profound position of the affected vein. But even in these events there can be no embarrassment; for the progress of the symptoms, and the particular nature of the oedema, will broadly indicate the affection. It may not be altogether unimportant to remark, that the anasarcous swelling of the limb may possibly be mistaken for the oedema symptomatic of disease of the liver, heart, or kidneys. But an error of this kind would disclose great carelessness on the part of the medical man. In these latter cases, for example, there would have been previous indications of disease of these organs; and, in addition, a proper local examination would disclose derange- ment in them, either functional or organic. Prognosis.—Phlegmasia Dolens is not, as a general rule, a grave affection, and it may, therefore, be said to terminate favor- ably ; when it destroys life, it does so through some of the more serious complications, which occasionally develop themselves in the progress of the disease. Progress, Duration, and Termination.—The febrile excitement, together with the pain and oedema, so characteristic of the disease, become gradually diminished. The pain subsides first; but the SAvelling continues more or less stationary from three to six weeks, and, under some circumstances, for a much longer period. Occa- sionally, however, when the disease is slight, the swelling will dis- * Compend. de Medecine Pratique, T. Sixieme, p. 471. 718 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. appear from twenty-four to forty-eight hours. As soon as the size of the limb begins sensibly to diminish, the tension is correspond- ingly less, and the impression of the finger on the surface much more evident. It will sometimes happen that the two extremities Avill become successively the seat of the disease, and precisely the same phenomena will present themselves as at the commencement of the attack. The usual termination of phlegmasia dolens is in reso- lution, which commences with the cessation of pain, and a dimi- nished size of the limb. But it should be recollected that this yielding of the symptoms will sometimes be promptly followed by a return of the pain and oedema, from error of diet, exposure to cold, or too early getting up. While resolution is progressing, an interesting change often takes place in the superficial veins of the limb; they become more or less distended with blood, showing that a new collateral circulation is going on. M. Duplay* was, I believe, the first to direct attention to this latter fact. The disease Avill sometimes lapse into a chronic state; the extre- mity then becomes enormously-enlarged, the surface is hard and irregular, and looks not unlike elephantiasis. Indeed, in some females the extremity doos not resume its natural size for months, and even years. It should also be mentioned that the affected limb will occa- sionally become the seat of abscesses, and these may be single or multiple; they may develop themselves in the subcutaneous or in the sub-aponeurotic cellular tissue; hence they will be superficial or deep-seated. In the latter case, the abscesses will frequently prove mischievous. Other complications may ensue, such as peritonitis, metro-peritonitis, ascites, etc. These latter, however, cannnot be regarded as the veritable accompaniments or sequelae of phlegma- sia dolens. Treatment.—This will be modified by two circumstances, which should be constantly borne in mind—the activity of the attack, and the constitution of the patient. If the pain and febrile excitement be severe, and the system plethoric, a dozen or more leeches may be applied, with signal advantage, to the groin, and over the inflamed femoral vein; these should be followed by warm poul- tices for the purpose of promoting the bleeding. The leeches may be repeated two or three times, in smaller number, depending on the indication which may present. Cathartics, unless there be diarrhoea, are especially proper: Commence with: R Hydrarg. c. creta gr. xij. followed by two wine glasses of the following saline mixture every four or six hours, until free purgation is accomplished : Diet, de Med., Art. Phleg. Dolens, 2d ed., p. 241. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 719 R Sulphat. magnesia, Sup. tart, potassse, aa § i. Aquae destillatse Oj. Ft. Sol. If there be evidences of sluggish liver with dry skin, it will be proper to administer occasional doses of calomel with antimony or Dover's powder—say gr. ii. of calomel with gr. £ of antimony, or gr. iv. of Dover's powder. It is very important to relieve the patient of pain, and procure her comfortable sleep. For this pur- pose a table-spoonful of the following may be given every half hour until the object is attained: R Syrup, papav. f. § j. Mucil. acaciae f. § ij. SoL sulph. morphiffi (Majend.) gtt. xii. M. When the limb is much engorged, great care should be observed in promoting aJree secretion of urine; for this purpose let cremor tartar water be freely taken as a drink; or the nitrate of potash given, gr. xv. in a tumbler of water or thin gruel, twice or thrice a day. The diet to be bland, and the most perfect rest enjoined, with the limb slightly raised from the plane of the body ; the nurse should be directed to protect the part from contact Avith the bed- clothes, which may be accomplished by means of a cradle. After the leeching and purging, marked benefit will oftentimes ensue from the application of small blisters, repeated according to circum- stances, not to the thigh, but to either the internal or external malleolus. I have great faith in the derivative action of blisters thus applied in the acute stage of phlegmasia dolens. If the vital forces become depressed, quinine, together Avith a nutritious diet, will be indicated. One word with regard to local applications, after the inflamma- tory state has passed, for the purpose of soothing pain. A warm bran poultice will sometimes give much relief— wrapping the limb in flannel, secured by oil silk; the extract of belladonna smeared over the painful portion of the extremity; gentle friction with lau- danum and sweet oil, camphorated oil, or soap liniment; and if the surface preserve its integrity, a good local application will be equal parts of chloroform and olive oil. It may here be mentioned that when the oedema is excessive, relief will be afforded by slight punctures, thus, through the escape of the serum, diminishing the tension, and consequently mitigating the pain. In the event of purulent collections, either superficial or pro- found, they are to be treated on general principles. LECTURE XLVII. Etherization-Its Importance; An*sthesia-meaning of the Term-Anaathetics in Midwifery of Recent Discovery-in Surgery, of Ancient Date; The Anaesthetic Agents now in use-Sulphuric Ether, Chloroform, and Amylene-Sulphuno Ether first employed as an Anaesthetic by Dr. Morton: in Parturition, by Prof. Simpson; its first trial in America, in Labor, by Dr. Keep, of Boston-Chloroform; its Introduction by Prof. Simpson; Amylene; Dr. Snow-Comparative Safety of Sulphuric Ether, Chloroform, and Amylene-Cardiac Syncope and Paralysis of the Heart from Chloroform—Indications for the use of Anaesthetics in Parturition- Should they be employed in Natural Labor?—Their value in Instrumental and Manual Delivery—Anaesthetics in Infancy—Influence of Etherization on Contrac- tions of the Uterus; on Mother and Child—Flourens on the Nervous System in Etherization—Time and Mode of resorting to Anaesthetics in Parturition—The Pulse; how affected by Etherization—Relaxing Effects of Etherization—Case in Illustration Gentlemen—It must be universally conceded that the contribution which science has made to suffering humanity—anaesthesia, or inser.sibility to pain—Avhether under the surgeon's knife, or during the throes of labor, should be regarded as among the most sterling offerings of the human mind. The term anaesthesia, in our day, is employed to designate a partial or positive unconsciousness through the administration of what are known as anaesthetics—more espe- cially ether and chloroform. But while employed in this sense, it is well to recollect that the true signification of the word is a loss or privation of feeling. Although the introduction of anaesthetic agents into the lying-in chamber for the purpose of diminishing the anguish of the parturient woman, is of recent origin, yet the idea and actual practice of having recourse to certain agents with the view of preventing suffering under surgical operations is of very ancient date. You will read, for example, in the older Greek and Roman authors, minute directions for the administration of their favorite mandragora as the great remedy for soothing pain ; while, ao-ain, among the Chinese, the Indian hemp seemed to possess superior anaesthetic charms. I do not propose, however, either to discuss in detail, or enter into the history of the interesting question of anaesthetics. I desire simply to present some general remarka touching their origin, employment, and results, during the progress of parturition ; with this view, I shall endeavor to indicate under what circumstances, in my judgment, etherization or anaesthesia will be a justifiable resort. It is needless to remind you that the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 721 first introduction of these agents into the lying-in room was very generally hailed by what, may be properly denominated a wild enthusiasm; and, as too often happens in the advent of new remedies, there was more zeal than judgment displayed in their administration. Hence, with some practitioners, anaesthetics were had recourse to in every case of labor; the one idea seemed to prevail—the accomplishment of child-birth without pain. With such an unrestricted and indiscriminate employment of these agents, two consequences were inevitable, viz. their abuse, and to a degree, loss of confidence in their virtues. The Ancesthetics now in Use.—The anaesthetic agents which have received more or less the sanction of the profession are : 1. Sulphuric Ether; 2. Chloroform; 3. Amylene. It may not be out of place very briefly to allude to each of these substan- ces. 1. Sulphuric Ether.—Without intending to take any part in the controversy as to whom is due the credit of suggesting the anaesthetic properties of sulphuric ether—whether it be Dr. Horace Wells, Dr. W. T. G. Morton, or Dr. Charles T. Jackson,* all countrymen of ours—it is, I think, universally admitted that the original administration of ether to prevent the pain of an operation was by Dr. Morton ; this occurred on the 30th of Sept. 1846, the ether being administered, by inhalation, to a man from Avhom Dr. Morton extracted a tooth without causing the slightest pain. Prof. Simpson was the first to resort to this agent in parturition, which he did on the 19th of Jan., 1847, and became satisfied of its anaesthetic properties without its interfering Avith the parturient effort. In our OAvn country, sulphuric ether was administered for the first time in labor, April 7th, 1847, by N. C. Keep, M.D., f of Boston, with most satisfactory results. It is an interesting fact that sulphuric ether was given, by inhalation, both in surgery and midwifery, for a period of several months in America and in Eu- rope, previously to the introduction of chloroform ; and, as far as I have been enabled to ascertain, not a single fatal case had occurred under its administration. It was, if I may so term it, not only in good repute, but had gained the very general confidence of the profession both here and abroad, until, as Ave shall presently see, the force of circumstances caused it measurably to give place to another anaesthetic—chloroform. 2. Chloroform.—When sulphuric ether had been tested, and its anaesthetic properties most satisfactorily demonstrated, anxious for something still better, which would be free from certain sup- * The reader may be interested, in a perusal of " A Defence of Dr. Charles T Jackson's claims to the Discovery of Etherization." Boston, 1848. f A report of the case will be found in the Boston Medical and Surgical Journal, April 14th, 1847. 722 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. posed objections, the untiring mind of Prof. Simpson, always in the pursuit of truth and improvement, developed the fact that chloro- form possessed in a marked degree anaesthetic virtues. The learned Professor subjected his own person to experiments, with a view of testing the value of the new agent; the reader will be more than amused with the graphic description by Prof. Miller, of the scene which ensued in Dr. Simpson's dining-room, when he and his two friends, Drs. Duncan and Keith, had placed themselves under the influence of chloroform.* The personal experiments with this sub- stance were most satisfactory to the gentlemen, who had submitted themselves to its influence; and the result was a paper from Prof. Simpson,f which although it provoked controversy, soon gave popularity to the new agent in the lying-in chamber, and, in a measure, caused its adoption as a substitute for sulphuric ether. One of the very first to have recourse to chloroform after the pub- lication of Prof. Simpson's paper, was Prof. Murphy,! of the London University—it was most successful in his hands, and he is since entitled to be ranked among its warmest advocates. 3. Amylene.—We are indebted for the discovery of this substance to M. Balard,§ Prof, of Chemistry in Paris, who brought it to the attention of the profession in 1844 ; and to Dr. John Snow,|| is due the credit of having been the first to employ amylene as an anaesthe- tic, Avhich he did in Kings College Hospital, in Nov. 185G. He made several experiments on animals, and inhaled small quanti- ties of it himself. Dr. Snow, after resorting to it in a number of operations, believes it to possess certain advantages over chloroform in many cases. Although it has not as yet been generally employed either in America or Great Britain, it has been extensively used, Avith favorable results, in Paris, Strasburg, and other places on the Continent. Comparative Safety of Sulphuric Ether, Chloroform, and Amy- lene.—On this question, more particularly in reference to the two former agents, the opinion of the profession is divided. The fact, however, is very certain, that the statistics derived from the admi- nistration of the two substances preponderate greatly in favor of sulphuric ether, as a safe and reliable anaesthetic. When chloroform destroys life, it would appear, from an analysis of the recorded fatal cases, that it does so through a peculiar influence exercised on the heart's action—a cardiac syncope, or what has been designated a paralysis of the organ. On the other hand, it has been satisfacto- * Surgical Experience of Chloroform, by Prof. Miller, pp. 10, 11. f An Account of a New Anaesthetic Agent as a Substitute' for' Sulphuric Ethel m Midwifery and Surgery, by J. Y. Simpson, M.D. Edin. 1847. X Chloroform in Child-birth, by Edward Wm, Murphy, M.D. 1855. § Annales de Chimie et de Physique, torn, xii., p. 320. | On Chloroform and other Anaesthetics, by John Snow, M.D. London, 1858. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 723 rily shown by experiments on animals, by Dr. Snow* and others, that sulphuric ether is incapable of producing sudden death by stoppage of the heart's action. As for myself, I have some time since abandoned the use of chlo- roform, and have recourse exclusively to sulphuric ether, which I have always found safe and reliable. I have had no experience with amylene, yet it has received very high commendation from those who have tested it. Dr. Snow has employed it in seven cases of labor with the most entire satisfaction ; aud he says " the great ease with which it can be breathed, OAving to its entire want of pungency, is a decided advantage it possesses over both ether and chloroform." With such testimony in its favor, it is not unreason- able to believe that it is destined to occupy an important place among the anaesthetic agents.f The Indications for Ancesthesia in Parturition.—In reference to the particular circumstances justifying the use of anaesthesia in the lying-in room, there is no concurrence of opinion among accou- cheurs ; on the contrary, there is much diversity of sentiment. With some it is the universal habit in every case of labor, no matter hoAV natural and auspicious it may promise to be, to resort at once either to sulphuric ether or chloroform. This, it seems to me, is really abusing a good thing. Labor is unquestionably a natural process—it is, indeed, entitled to be designated in strict physiolo- gical language a function. If this be so, is it right to interfere with a function, properly so called, as long as its exercise is normal, and within the true record of nature ? I think not. Again, there is another argument, which has al\Aays struck me with force, why anaesthesia should not be employed in a natural parturition, and it is this—the female, at the most interesting period of her fife—the time of labor, should, all other things being equal, have her mind unclouded, her intellect undisturbed, her judgment fully adequate to realize and appreciate the advent of a new and important era in her existence—the birth of her child. Therefore, I shall advise you not to resort to anaesthetics in natural and ordinary labors, except in * Dr. Snow, in his excellent work already alluded to, records in tabulated form fifty deaths from chloroform, and in all the cases (45) in which the symptoms which occurred at the time of death are reported, there is, he observed, every reason to conclude that death took place by cardiac syncope, or arrest of the action of the heart. In forty of the cases, the symptoms of danger appeared to arise entirely from cardiac syncope, and were not complicated by over-action of the chloroform in the brain. Again, he says, I am aware of only two deaths, which have been recorded as occurring during the administration of ether, and it is not probable that the death in either case was due to the ether. I hold it, therefore, he continues, to be almost impossible that a death from this agent can occur in the hands of a medi- cal man, who applies it with ordinary intelligence and attention. [Op. citat. p. 262.] f The pupil may consult with advantage, " A Treatise on Etherization in Child- Birth." By Prof. Walter Channing, M.D. Boston, 1848. 724 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the event of certain contingencies Avhich, in the judgment of the accoucheur, would justify their administration. The employment of these agents will be proper in cases of operative midAvifery, Avhe- ther instrumental or manual; in cases of unusual pain accompanying the labor; in instances of rigidity or an unyielding condition of the mouth of the womb, vagina, or perineum; in a Avoman of excessive nervous irritability ; in certain cases of irregular contraction of the uterus, in which the strength of the mother is severely tested Avith- out a corresponding progress in the delivery ; in many cases of puerperal convulsions, provided there is no tendency to cerebral congestion; in spasmodic contraction of the uterus before the birth of the child, and subsequently to the birth, the placenta being retained by the spasm of the organ. In some conditions of preg- nancy—for example, Avhere there is a degree of undue irritability of system, or the hysteric manifestation, or where it becomes neces- sary to extract a tooth ; and I may remind you that I have on seve- ral occasions derived marked benefit from the administration of sulphuric ether in cases of rebellious dysmenorrhcea. Let me here add that, in the irritability and convulsions of children,* etheriza- tion will oftentimes exhibit the happiest results. Tfie Influence of Ancesthetics on Uterine Contraction,—One of the original and chief objections to the employment of anaesthetics in midwifery Avas the apprehension, advanced by some authors, that they so completely controlled the action of the uterus as necessarily to expose the patient to all the hazards consequent upon inertia of the organ—such as hemorrhage, &c.; this, hoAvever, is an unfounded apprehension. It is a curious fact that, in some instan- ces, the activity of the uterus will occasionally become increased under the influence of these agents ; and in many cases, there will be no perceptible influence exercised either as to the force or regu- larity of the contractions. It is, however, true that when anaes- thesia is carried to its maximum—causing a state of complete unconsciousness, there will oftentimes be a suspension of the labor, the uterus resuming its wonted efforts as soon as the full effects begin to yield. Individual idosyncrasy has frequently a controlling influence on the result of the anaesthetic ; in some instances a very slight degree of etherization will suffice to afford relief, and again insensibility to suffering will not ensue except under full uncon- sciousness. * I have repeatedly had resort to etherization in children, and always with good effect. Dr. Snow's experience is amply confirmatory of its safety and efficiency in these cases. He says " he has given chloroform in a few instances as early as the age of eight and ten days, and in a considerable number before the age of two months; he has administered it to 186 infants under a year old; nor has he expe- rienced any ill effects from it either in these cases, or in those' of children mora advanced in life; it is, also, worthy of remark that none of the accidents from chic roform, which have been recorded, have occurred to young children." (p. 49.) THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 725 The secondary forces in parturition—the contraction of the dia- phragm and respiratory muscles—would necessarily be interfered with if, under the operation of anaesthesia, the sensitive nerves should become deprived of their special function—sensibility to impressions—for in this case reflex movement could not be accom- plished. The following are the conclusions of M. Flourens* touching the influence of anaesthetics, under gradual inhalation, on the nervous system, and they are not without interest: "Under their action, the nervous centres lose their powers in regular succession; first the cerebral lobes lose theirs, viz. the intellect; next the cerebellum is deprived of its, viz. the controlling of locomotion ; next the spinal cord loses its function of sensitiveness and motion; the medulla oblongata, however, still retains its functions, and, therefore, the animal lives ; with the loss of power in the medulla oblongata, life becomes extinct." The Influence of Ancestheties on the Safety of the Mother and Child.—Under judicious administration, it may be affirmed that, as a general rule, these agents may be employed during parturition, with safety to both mother and child. Time and Mode of Etherization.—As has already been remarked, some accoucheurs have recourse to etherization in nearly every case of natural labor, and, to be consistent, I suppose, they commence it simultaneously with the advent of the pains. We will, however, imagine that you will resort to it, under ordinary circumstances, only in cases of exaggerated suffering; and, therefore, as a general rule, this will manifest itself after the os uteri is so far dilated as to bring into play a positive tributary or nervous force, imparting to the uterine contractions a well-defined expulsive character. If, therefore, etherization be judged advisable, the necessity for a resort to it will usually exhibit itself at this stage of the labor. As a general principle, it will not be necessary to cause full etheriza- tion, the object being merely to lessen the amount of suffering; therefore, in such cases, unconsciousness is not called for; all that is needed is to produce diminished sensibility. It is proper, Avhether sulphuric ether or chloroform be used, to employ it at the time of a pain, and suspend it during the interval of contraction. Many contrivances have been suggested, under the term inhalers, for the purpose of accomplishing the object in view. But it seems to me, the plan originally proposed by Prof. Simpson will answer every purpose. Take a delicate hollow sponge, or a handkerchief, funnel shape, and, if chloroform be used, throw upon the sponge or handkerchief, a small quantity of the fluid (say fifteen to twenty- five minims). This should be applied to the nose and mouth of the • Gazette des Hopitaux, 20 Mars, 1847. 726 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. patient, Avith the request that she will inhale it. In a very short time its effects Avill become apparent in occasioning partial insensi- bility. This may be repeated, if necessary, on the recurrence of each pain. In cases, however, in which instrumental or manual delivery is to be accomplished, the patient should, previously to the introduction either of the instrument or hand, be put into a state of unconsciousness? When the instrument has been properly applied, the anaesthetic should, for a time, be suspended, in order that the delivery may be benefited by the contractions of the organ; but, if there be delay in bringing the child into the world, the chloroform may again be had recourse to Avith the vieAV of control- ling the sensibility to pain.* Although it is proper to commence with a small quantity of the chloroform, yet, in protracted labors, it may become necessary to consume several ounces. It is well to mention, in connexion Avith the administration of chloroform, that it is apt to produce nausea and vomiting, and, therefore, care should be taken to administer it before and not after a meal. If sulphuric ether be employed, it can be administered in much larger quantity—a fluid ounce may be poured into the sponge or handkerchief, and inhaled. The Influence of A/aesthetics on the Pulse.—If care be taken to watch the pulse, it will be found that usually it increases both in force and frequency at the commencement of the inhalation. On the contrary, Avhen insensibility is accomplished, it generally resumes its normal standard. If the patient have suffered from loss of blood, and also in cases of nausea or vomiting, the pulse will lose its force and frequency; but with these exceptions it is rare to observe the latter changes in the throes of the heart under the administration of anaesthetic agents. Relaxing Effects of Ancesthetics.—I have often observed in practice the influence of etherization in producing relaxation, and this attribute is manifest in other instances than in parturition. I had a short time since a striking illustration of the fact: Dr. Fran- cis Fleet, of this city, requested me to visit in consultation a young lady, aged nineteen years, who had never menstruated, and who, before placing herself under his care, had been subjected to a variety of emmenagogues, with a view of establishing the catame- nial function, but all without avail. The Doctor, on making an examination, discovered that, commencing about an inch from the vulva, there was an occlusion of the vagina. The passage wa? * Let it be distinctly understood that, in cases of version, the unconsciousness of the patient should be maintained until the accoucheur has succeeded in grasping the feet, and bringing them down to the superior strait. At this stage of the labor the anaesthetic should be suspended, for here it is important to have the advantage of the contractions of the uterus for the purpose of expediting the delivery THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 727 obstructed by a dense fibrous band. On introducing my finger, I recognised extraordinary sensibility of the parts together with unusual rigidity. The patient was placed under the influence of ether, which acted promptly in overcoming both the sensitiveness and rigidity. At the Doctor's request, I divided, with a bistoury, the membranous band, which immediately brought the os uteri within the feel of the finger. The menstrual blood, which had been accumulating for some time, but which had found no exit because of the obstruction, flowed freely; and the young lady was soon repaid for her fortitude by taking to her bosom her affianced lover. INDEX. A A.bdomen, changes in the, during pregnancy, 156; contraction of the muscles of the, simulating foetal movement, 181; how to conduct the examination of, to ascer- tain the existence of pregnancy, 193; application of the bandage to the, after childbirth, 404; presentations of the, 655. Abdominal parietes, pain in and relaxation of the, in pregnancy, 226 Abdominal pregnancy, 205. Abdominal tumors, 196. Abortion, statistics exhibiting the frequency of, 266, 267 ; various divisions of, 267, 268; period of pregnancy at which it is most frequent, 268, 269; causes of, 269-273; symptoms of, 274; prognosis and treatment of, 275-282; induction of; is it ever justifiable? 678, 679. Abscess, mammary, treatment of, 426, 427. Accoucheur, the, cardinal object of, 11, 548; his duties in the lying-in chamber, 351 et seq.; case evidencing the culpable indifference of an, to professional obli- gation, 658. After-birth. See Placenta. After-pains, 407, 411. Albuminose, 262. Albuminuria, often the cause of abortion, 272; causes of, 505; change in the com- position of the blood in, 506; change in the kidney, 507 ; pressure on the rerral veins, 508; less frequent in multiparas than in primiparae, 508, 509 ; not neces- sarily followed by uraemia, 510 ; summary of conclusions respecting, 515. Amnios, the, 244; source and uses of the liquor amnii, 245, 246. Amylene, use of, as an anaesthetic, 722. See Anaesthetics. Anaemia, connexion between abortion and, 271. Anaesthetics, advantages of, in the Caesarean section, 637; in midwifery, a recent discovery, 701; sulphuric ether, chloroform, and amylene, 721, 722; compara- tive safety of the three anaesthetics, 722, 723; indications for the use of, in par- turition, 723 ; influence of, on uterine contraction, 724; time and mode of using, 725 ; influence of, on the pulse, 726; relaxing .effects of, ib. Andral, M., on the increase of fibrin in the blood as a sign of inflammatory action, 133. Animalcula, question of their presence in the spermatic fluid, 115. Animalculists, doctrine of the, upon fecundation, 116. Animals, menstruation in, 104. Ante-version of the uterus, 234 Anterior sacral plexus, 4. Anus, circumstances necessitating internal examination of the female by the, 201; occlusion of the, in the infant, 423, 424. Aorta, abdominal, compression of the, as a means of checking uterine hemorrhage, 395. Apoplexy, placental, 273. Appetite, depraved, an evidence of pregnancy, 147. Areola, discoloration of the, as an evidence of pregnancy, 151; Dr. Montgomery's remarks on its essential characters, 151, 152. Arm, protrusion of the, in shoulder presentations, 559. Arneth, Dr., on the contagion of puerperal fever, 686. Articulations of the pelvis, the, 12 ; question as to their relaxation and separation during gestation and parturition, 15; of the foetal head, 32. 730 INDEX. ASC-CAR Ascites, or peritoneal dropsy, 197. Asphyxia, treatment of, in the new-born infant, 369. Assafcetida, advantages of, in cases of habitual abortion, 273. " Aunt Betty," case of, simulating pregnancy, 181. Aura seminalis, the, 116. Auscultation, mediate and immediate, 188 ; of the fcetal heart, 201. Axes of the pelvis, the, 19; their inclination, 20; necessity of an accurate know- ledge of their direction 21. B. Back, the, presentation of, 557. Ballottement, or passive motion of the fcetus, 185; rules for detecting, 186. Barker, Prof. Fordyce; on the Cfflsarean section, 639; on the use of veratrum viride in puerperal fever, 698. Barnes, Dr. Robt., on vesicular mole, 285; on fatty degeneration of the placenta, 320; on artificial detachment of the placenta, 476, 477; on application of the forceps, 575. Baudelocque, his six different positions of the vertex at the superior strait, 37 ; hia pelvimeter an accurate instrument, 69; case of spontaneous reduction of inverted uterus, reported by, 452; on the Caesarean section, 627 ; on elytro- tomy, 641; remarkable case recorded by, in which the child proved to be alive, in spite of the strongest evidence of death in utero, 657. Belladonna, its efficacy in arresting abortion, 277; in spasm of the os uteri, 380; in convulsions during labor, 498. Binder, the, application of, 404. Bischoff, on spermatozoa, 118. Blisters, an important auxiliary in the treatment of puerperal fever, 696. Blood, discharge of, from the vagina, 168; discharge of, in animals, at the period of heat, 313; constituents of, in a state of health, 133; buffy coat not always an index of inflammatory action, ib.; changes of, in the pregnant woman, 129— 134; circulation of, in the adult and the fcetus, 257-261; elaboration of, in the placenta, 261; change in the circulation in the infant after birth, 264; change in the composition of the, in uraemia, 505. Bloodletting, in pregnancy, remarks upon, 130, 217, 361; objections to, in the treat- ment of convulsions during gestation, 493, 494; when indicated in convulsions, 495 ; importance of, in inflammatory puerperal fever, 695 ; caution against, in ' puerperal mania, 704. Blood-poisoning, or toxaemia, 411, 504, 683; characteristic of diseases produced by, 684. Blood-vessels of the placenta, 247, 248. Blundell, Dr., on the operation of transfusion, 400,401; on the Cesarean section, 628. Boivin, Madame, on vertex presentations, 37; on the muscularity of the uterus, 126. Braun, Carl, on uraemia, 515. Breasts, the, changes in, after impregnation, 148. Breathing, oppressed, in pregnancy, treatment of, 230. Breech presentations, statistics of, 344; diagnosis, 345; prognosis, 346; first or left anterior sacral position, ib.; second or right anterior sacral position, 347 ; third or right posterior sacral position, 348; fourth or left posterior sacral position, ib.; manual delivery in, 547. Bright's disease, no necessary relation between, and uraemic convulsions, 515. Brown-Sequard, his conclusions on the subject of transfusion, 401, "402; on tho influence of carbonic acid on non-striated muscular fibres, 678. Bruit placentaire, the, 189. Buffy coat of the blood, not always the index of inflammatory action, 133. C. Caesarean section, the, 626; controversy with regard to the benefit or evil of the 626-629; contrast between the, and craniotomy statistics, with many illustra^ tive cases. 629-635; dangers to the mother from the, 636, 637; post-mortem Caasarean section, 638, 639 ; how the operation should be performed, 639-642 • dressing the wound, 642, 643; vaginal Caesarean section, or vaginal hysten> tomy, 644. Capuron, on the compressibility of the arch and base of the fcetal head, 32, Carbonic acid, injection of, as a means of inducing artificial delivery, 678. CAT-CUM INDEX. 731 Catalepsy, characteristic peculiarity of, 502. Catamenia, retention of the, mistaken for pregnancy, 79; period between puberty and their final cessation, 93; influence of climate on, 95—of education and mode of life, 96—of temperament, constitution, and race, 97; precocious and tardy, 98; causes of, ib. See Menses and Menstruation Cathartics, in pregnancy, 218. Catheter, the, directions for the introduction of, 233, 357, 412-414; obstacles to the ingress of the, 414. Caudle, caution against the use of, 405, 406. Cazeaux, on shortening of the neck of the womb, 168; embryotomy forceps, 663. Centric causes of abortion, 271. Cephalalgia, treatment of, in exhausting hemorrhage, 399. Cephalic version, 540 ; mode of performing, 541 et seq. Cephalotribe, the, 663 ; directions for its use, 663, 664. Cephalotripsy, meaning of the term, 663. Cervix, the, of the uterus, 87 ; progressive changes in its condition during the pro- gress of gestation, 164-169. Child. See Infant. Chloroform, first introduced by Prof. Simpson, 710. See Anaesthetics. Chorion, the, and its villi, uses of, 243, 244; in a case of twin labor, 441. Churchill, Dr., his statistics on breech presentations, 344; statistics on multiple preg- nancy, 431, 432; statistics upon the frequency and mortality of post-partum hemorrhage, 390; statistics of podalic version, 538 ; statistics of crotchet cases by, 629, 630—of Caesarean section, 630, 631; tables by, showing the diameters of the head at the different periods of pregnancy, 667 ; on a case of premature artificial delivery, 673. Circulation, difference between the adult and the foetal, 257-261; change in the, after birth, 264. Clark, Prof. Alonzo, interesting details on the use of opium in puerperal fever, 697, 698. Clarke, Dr. Joseph, on the comparative size and weight of the male and female foetus, 27. Clarke, Dr. Joseph, statistics of cases of craniotomy and Caesarean section by, 630, 631. Clay, Cliarles, on duration of pregnancy, 303. Clitoris, the, 75 ; Parent-Duchatelet on the. ib. Coagula, removal of after the delivery of the after-birth, 375. Coccyx, anatomy of the, 6; exercises an important influence during childbirth, 6, 7; dislocation and fracture of, 7. Cohen, his method of inducing artificial delivery, 678 Colchicum autumnale, value of, in uraemic poisoning, 514. Cold, application of, in cases of threatened abortion, 278; in post-partum hemor- rhage, 393-395. Collins, Dr., his statistics on breech presentations, 344; on the prophylactic treat- ment of puerperal fever, 693. Colostrum, the, 409. Colpeurynter, the, 474. Commissure, the superior and inferior, 73. Constipation, in pregnancy, 162; treatment of, 222; after delivery, 416, 422; in the infant, 423; sometimes a cause of accidental flooding, 482. Convulsions, connexion between, and the presence of coagula, 376; puerperal, 485; treatment of, during pregnancy, 492-497 ; during labor, 497-500; after deli- very, 500; centric causes of, 504. Cord, umbilical, composition of the, 250, 251; ordinary length of the, 251; knot- ted cords, 252; question of nervous tissue in the cord, 253. See Funia Coronal suture, the, 30. Corpus luteum, theory concerning the, 91; of pregnancy and menstruation, 112; interesting question concerning, 114. Cough, in pregnancy, 160, 230. Coxal bone, the, 7. Craniotomy, contrast between the statistics of, and those of the Ccesarean section, 629-635 ; condemnation of, 634; the Csasarean section to be preferred to, ib. Cristoforis, Dr., his substitute for the Cassarean section and symphyseotomy—secti* subperiostea, 643. Crotchet, the, as modified by the author, 679, 580; statistics of crotchet cases, 639. Cummiags, Dr., natural and artificial lactation, 419. 732 INDEX. DAL-FEM D. Dalton. Prof. J. C, on the corpus luteum of pregnancy, 113. Decidua reflexa, mode of origin of the, 243; uses of the, ib.; decidua membrana, 242. Deformity, pelvic, examination of the propriety of version in cases of, 544-546. Dehvery, manual, diagnosis and prognosis of, 517, 518; indications of, 518, 519; most suitable time for termination of, 519, 520; mode of terminating, 520-522; division of, 522 et seq.; in pelvic presentations, 547 ; in trunk or transverse, 555; in hip and shoulder, with protrusion of the arm, 558 et seq.; instrumental (see Forceps and Instruments), 565; premature artificial, 665—the objections to, considered, 668-674; statistics of, 673; the various modes of operating for the induction of premature artificial delivery, 674 et seq. Denman, Dr., on spontaneous evolution, 562; on the application of the forceps, 581. Desormeaux, interesting case recorded by, bearing on the duration of pregnancy, 300, 301. Deville, on muscularity of the uterus, 126. Diarrhoea, of pregnancy, treatment of, 223. Diet of the parturient woman, 360. Disease, transmission of, from parent to offspring, 263. Douglass, Dr., on spontaneous evolution, 563. Dropsy, cases of, simulating pregnancy, 179, 183; of the ovary, 197 ; of the uterus, 194; peritoneal, 197. Dubois, on vertex presentations, 38. Dubois and Pajot, table by, showing the influence of climate on menstruation, 96. Dyspnoea, in pregnancy, 160. E. Elytrotomy, description of the operation of, 641. Embryonic nutrition, 255. Embryotomy, the space through which a child may be extracted by, 66; the operation of, 651; amount of pelvic contraction justifying, 651, 652; case of Elizabeth Sherwood, as narrated by Dr. William Osborn, 652-656; evidences of the child's death in utero, 656-658; melancholy results of the fondness for, 660; mode of performing the operation, 660-663. Emetics, in pregnancy, 218. Encysted dropsy, 197. Ephemeral fever or weed, 430. Ergot, use of, to arrest uterine hemorrhage, 280; caution on the use of, 392 ; in pla- centa praevia, 480; in inertia of the uterus, 553 ; administration of, in premature artificial delivery, 676. Esquirol, statistics by, relating to the period of the development of puerperal fever, 700. Ether, sulphuric, use of, in convulsions during pregnafncy, 496; first employed by Dr. Morton, 721; first used in parturition by Prof Simpson, ib.; to be preferred to chloroform, 722, 723 ; mode of using, 725, 726. See Anaes- thetics. Etherization. See Anaesthetics. Evolution, spontaneous, observations on, 562, 563. Evrat, tampon suggested by, for reducing retro-version of the uterus, 238. Excito-motory action, phenomena of, 184. Extra-uterine pregnancy, its varieties, 203. F. Face presentations, statistics of, 339, 340; diagnosis of, 340; prognosis of, 341 • in the first or right mento-iliac position, 341, 342, 612; in the second or'left mento-iliac position, 342, 343, 612 ; use of the forceps in, 611-617 ; mento-ante- rior and mento-posterior positions, 614. Facies hippocratica, the, 692. Fallopian pregnancy, 204. Fallopian tubes, the, 89; how the fecundated ovule finds admission to, 119. Farr, Dr. William, summary of bis statistics on marriage in France, derived from the census of 1851, 123. Fecundation, meaning of the term, 110; theories of, 116; effect of, on the develop- ment of the uterus, 163 ; case of, effected at a menstrual period, 307, 308. Feet, presentation of the, 348, 550; four positions, 349. Female children, mortality of, compared with that of male, 38. FEV-GAS INDEX. 733 Fever, milk, 422 ; puerperal, 680 ; nature and origin of; 681-684; connexion between, and erysipelas, 684; the divisions of, 685; diversity of views on the question of contagion, 686-688 ; causes and symptoms of, 689; lesions, 690; diagnosis, 691,692; prognosis, 692; prophylactic treatment, 692-694; remedial treat- ment, 694-698 ; ephemeral or weed, 430. Fibrin, increase of, in the blood, in acute inflammation, 133; in pregnancy, 134. Fibrous growths of the uterus, 196. Fibrous tumor, case of, simulating pregnancy, 138. Figg, E. Garland, startling views of, on the subject of version, 538, 539. Figueira, M., tables from, showing the diameters of the head at the different periods of pregnancy, 667. Fillet, the, circumstances under which it may be applied, 566. Finnell, on extra-uterine pregnancy, 204. Fistula, urethro-vaginal or vesico-vaginal, diagnosis of, 78; sometimes a consequence of careless use of the forceps, 570. Flatus in the intestinal canal, after childbirth, treatment of, 415. Flooding, in pregnancy, 168 ; after the birth of the child, 388, 390. See Hemorrhage. Flourens, M., on the influence of anaesthetics on the nervous system, 725. Foetal movements in utero—how can they be excited ? 183; ballottement, or pas- sive motion of the foetus, 185 ; pulsations of the foetal heart, 187. Foetation, extra-uterine, causes, progress, and phenomena of, 206; diagnosis of, 208. Foetus, bones of the, 3; the festal head, its regions, diameters, sutures, fontanelles, &c, 27 ; difference between presentation and position of the, 35 (and see Head and Labor); quickening of the, in utero, the result of muscular contraction, 178; movements of, simulated, 181; nutrition of the, 255 ; does it breathe in utero? 264; viability of the—incapable of existence previous to the termination of the sixth month, 268, 666; the annexae, or appendages of the, 241; death of the, a cause of abortion, 272; is the determining cause of labor due to the action of the? 310 ; conditions for labor on the part of the, 338 ; presen- tations of, in natural labor, 339; face presentations; 339-343; pelvic presenta- tions, 343 ; breech presentations, 343-346 ; presentations of the feet and knees, 348-350; presentations in twin labors, 435; superfoetation, 442-445; malposi- tion of the, 458; spontaneous evolution of the, 562. Fontanelles, the anterior and posterior, 30, 31. Forceps, the, fundamental principle to be observed in delivery by, 56; in instru- mental delivery, 569 ; principles on which forceps delivery should be based, ib.; case illustrating abuse of the, 570 ; statistics of forceps delivery, 574; the true power of the, 575 ; dangers of forceps delivery, 576 ; the part of the child to which the instrument should be applied, 576; how the head should be grasped by the, 577 ; modifications of the, ib.; improvements in, devised by the author, 578; indications for the use of the, 580; time of resorting to the, 5$ 1-584 rules for the application of the, 585 et seq.; method of introductiou. 587, 588 locking, 589 ; force employed in delivery by the, and method of traction, 589, 590; unlocking, 590; mode of applying the, in the various positions assumed by the head at the inferior strait, 591-596; mode of applying with the head at the superior strait, 596-601 ; application of the, in locked-head, 601-606; use of the, when the head is retained after expulsion of the body, 607-611; in face presentation, 611-617 ; cases illustrating the application of the, 615-617; the embryotomy forceps, 663. Fossa, the triangular or recto-uterine, 82. . Fossa navicularis, the, 73. Fourchette, the, 73. Fox, Dr. George, interesting case reported by, illustrative of the advantage ot tne Caesarean section over cephalotomy, 635. Frerichs, his exposition of the true cause of uraemic intoxication, 513. Funis, the, pulsations of, 191; method of ligating, 367, 368; directions for traction on the, 375, 377; manner of dressing the, 406, 428 ; umbilical hemorrhage, 429 ; peculiarity of the, in a case of twin labor, 440 ; mortality, causes, diagno- sis, and treatment of prolapsion of the, 460-466. G. Galvanism, a means of artificial delivery, 678. Gardner peerage case, points in the, bearing on the duration of pregnancy, 299, 300. Gariel, treatment suggested by, for retroverted uterus. 239. Gastrotomy, danger of the operation of, in extra-uterine pregnancy, 214. 731 INDEX. GEN-HIP Generation, the organs of, 72: external, ib.; internal, 77; the ovaries, the essential organs of, 90; ancient theory of, 108. Gerdy, M., his explanation of external rotation of the head of the fcetus, 51. Germ-cell, 90, 111; seat of contact between the germ and sperm cells, 117. Gestation, evidences of, 143; suppression of the catamenia, 144; is ovutotion com- patible with ? 145; nausea and vomiting, with depraved appetite, 146; secre- tion of saliva, 148; changes in the breasts—the secretion of milk—the areola, 148-153 ; changes in the uterus and abdomen, 154; descent of the gravid ute- rus during the first two months, 155; positions of the gravid uterus, 156-161 ; change in the direction of the urethra, 161; oedema of lower extremities, ib.; effect of, on the development of the uterus, 163; phases through which the cer- vix of the uterus passes during, 164-169; enlargement of the uterus and dis- coloration of the vaginal walls, 170-174; quickening, 175; simulated quicken- ing, 179; how the movements of the foetus can be excited, 183; pulsation of the fcetal heart, 187; uterine murmur, 189; pulsations of the umbilical cord, 191 ; extra-uterine, causes, progress, and phenomena of, 206; premature and protracted, 268, 666. See Pregnancy. Glandular apparatus, the, of the external genitals, 77. Glans clitoridis, the, 75. Gooch, Dr., his testimony on the subject of the recurrence of puerperal mania, 701. Graaffian vesicles, the, 90, 111, 112. Graves, Dr., on the use of opium in puerperal fever, 697. Gubler, M., on milk in the breasts of the new-born infant, 421. H. Hall, Dr. Marshall, his "ready method," 370; on puerperal convulsions, 485, 486; on depletion in puerperal mania, 704. Halmagrand, statistics by, on the Caesarean section, 633. Halpiu, treatment suggested by, for retroverted uterus, 238. Haunch bone, the, 7. Head, the, of the foetus, 27; description of its regions, diameters, sutures, fonta- nelles, etc., 27; sutures of the foetal and adult head, 31; respective diameters of the fcetal head and adult female pelvis, 32; articulations and movements of the fcetal, ib.; frequency of head presentations, 33; cause of the frequency, 34 ; the author's classification of head presentations, 43; relations of, to the pelvis, 45; movements imposed upon the, 46; flexion, ib.; descent and rotation, 48; extension, 49; practical application, 54; presentation of the, calling for manual delivery, 524 et seq.; mode of applying the forceps with the head at the infe- rior strait, 591-596—at the superior strait, 596-601; application of the forceps in locked-head, 601-606; use of the forceps when the head is retained after expulsion of the body, 607-611; diameters of the, at the different periods of pregnancy, 667. Headache, treatment of, in exhausting hemorrhage, 399. Heart, the foetal, pulsations of, 187-189; palpitation of the, in pregnancy, 160, 224; hypertrophy of the, 225. Heat, the period of, in animals, 313. Hemorrhage, in pregnancy, 168; a symptom of abortion, 274, 275; difference between the, of menstruation and miscarriage, 275; treatment of, 280; true explanation of, in childbirth, 312; management of the placenta, in cases of, 38S; frequency and mortality of, 390; divisions of post-partum, 390, 391; external, and its treatment, 391 et seq.; treatment of exhaustion from, 396, 397 ; treatment of internal, ib ; secondary, 402, 403 ; umbilical, of the new- born infant, 429; in a case of inverted uterus mistaken for the placenta, 454 symptoms, diagnosis, and treatment of. as connected with placenta praevia' 466- 474; accidental, from partial separation of the placenta, 480-483; accidental, at the time of labor, 484 ; secondary, 402*. ' Hemorrhoids, in pregnancy, 162, 228. Hereditary transmission of disease, 263. Hermaphroditism, enlargement of the clitoris mistaken for, 75. Hernia of the gravid uterus, a rare affection, 240; in labor, 460. Hewitt, Graily, on hydatiform mole, 285. Hewson, Dr., measurements of the fcetal head by, 30. Hip, the, presentations of, 558. Hippocrates, doctrine of in head presentations, 338; his directions for version, 640 ■ fades hippocratica, 692. HOD-LAB INDEX. 735 Hodge, Prof., on the non-contagion of puerperal fever, 686. Hook, the blunt, mode of using in instrumental delivery, 567. Hour-glass contraction of the uterus, treatment of, 380-383. Humoral pathology, 683. Hunter, his theory of the membrana decidua, 242. Hunter, Dr. Septimus, case of malpractice in which the inverted uterus was mis- taken for the placenta, 454-456. Hydatiform moles, 284. Hydatids, can they form in, and be expelled from the uterus? 294, 295; premature delivery in a case of, 672. Hydrocephalus, rupture of the womb a not unusual accompaniment of, 662. Hydrometra, or dropsy of the uterus, 194. Hymen, the presence of the, no test of virginity, 78. Hysterotomy, vaginal and abdominal, 626; two interesting cases of vaginal, 645. See Caesarean section. I. Ilium, the, anatomy of, 8. Impregnation, aptitude for, 107 ; two orders of phenomena following, 124; effected at a menstrual period, 307, 308. India-rubber ball, advantages of the, as a support to the uterus, 58. Indigestion, convulsions induced by, 487, 488. Inertia of the uterus, causes of, 552 ; treatment of, 553. Infant, new-born, management of the, 367; treatment of asphyxia in, 369-371; wash ing and dressing the new-born, 406; caution against physicking and cramming the, 409; when it should be put to the breast, ib.; feeding the, 418 ; suppres- sion and retention of urine in the, 420; milk in the breasts of the new-born, 421; torpor of the bowels in the, 423; occlusion of the anus, 423, 424; puru- lent'ophthalmia, 424, 425 ; umbilical hemorrhage of the new-born, 429 ; morta- lity of the, in podalic version, 539 ; evidences of the death of the, in utero, 656- 658. instrumental delivery, 565. See Forceps and Instruments. Instruments, obstetric, the author's case of, 578; cutting, prerequisites for the use of, 618. See Symphyseotomy, Caesarean section, Cramotomy, Embryotomy. Interstitial pregnancy, 121, 205. Intra-uterine growths, 193. Inversio uteri, 446 et seq. Ischium, the tuberosity of the, 10; spinous process of, when malformed, may inter- fere with delivery, 11. J. Jacquemin, on discoloration of the walls of the vagina, 172. _ Jones, T. Wharton, his experiments showing the effects of belladonna on the circu- lation, 498. Jorg, on elytrotomy, 640. K. Keating, Prof., details furnished by, on the use of opium in puerperal fever, 697, Keep Dr. N. C, the first to use ether in parturition in this country, 121. Keiller, Dr., case of spurious pregnancy and spurious partunt.on reported by, 18^. Kevser, of Copenhagen, statistics by, on the Caesarean section, 633 Kiestein, explanation of its presence in the urine of the pregnant female 135. Kiwisch! his plan of the water-douche, for the induction of premature delivery, 67T. Knees, presentation of the, 349, 551; four positions, 349, 350 Krahmer, Prof., statistics by, on the duration of gestation in the cow, aw. Labia externa, or majora, 73; interna, or minora, 75. Trorfj0- Labor how affected by the sex of the child, 28; mechanism of, 44: first vertex position, ib.; flexion, 46; descent and rotation 48; extension, 49; expul ion of the shoulders and body, 52; second and third vertex positions, ib.; fourtb 7St> INDEX. LAC-MEI vertex position, 53; necessity of a practical knowledge of the principles of, 54; supposed case practically illustrating the mechanism of, ib.; obstruction to, from pelvic deformities, 57—from morbid growths, 63; case of, obstructed by polypus, ib.; the author's classification of, into natural and preternatural, 296 ; definition of natural, 297; order of sequence of the processes of, ib.; determin- ing cause of, 309; expulsive forces, 309, 310; the ovarian theory of, 312; Dr. John Power's theory of the determining cause of, 314-316; the author's expla- nation of the determining cause of, 318 ; seat and origin of the expulsive forces in, 321; primary and secondary forces of, 323, 324; preliminary signs of, 325- 328; essential or characteristic signs of, 328-331; the pains of, 329 ; true labor pains, 331; false labor pains, 332; cause of the dilatation of the os uteri in, ib.; rigors and vomiting during, 334; muco-sanguineous discharge in, ib.; formation and rupture of the membranous sac, or bag of waters, 334-336; con- ditions for, on the part of the mother and foetus, 337, 338; presentations in natural labor, 339-350; detailed directions for the guidance of the accoucheur in a case of, 351 et seq.; stages of, 357 et seq.; management of the puerperal woman after the birth of her child, 404-418, 427-430; after-pains, 407; management of a twin labor, 436 et seq.; superfoetation, 442-445 ; preternatu- ral 457 ; exhaustion during, 459 ; accidental hemorrhage at the time of, 484; treatment of convulsions during, 497-500; manual labor, 516; complications of, rendering manual interference necessary, 530; detailed directions for the application of the forceps, 591-601; use of anaesthetics in, 708. Lactation, in pregnancy, and other conditions of the system, 149, 150; sometimes a cause of abortion, 270; forbidden in puerperal fever, 694; Dr. Cummings on natural and artificial, 419. La Chapelle, Mad., on period of abortion, 268. Lambdoidal suture, the, 30. Laserre, M., on epidemics of puerperal fever, 689. Lee, Dr. Robert, his hypothesis with respect to puerperal fever, 681. Lever, the, in instrumental delivery, 568; contrast between the forceps and, ib. Levret, on the Cesarean operation, 632. Light, intolerance of,'arising from exhausting hemorrhage, 399. Linea ileo-pectinea, the, 17. Liquor amnii, source and uses of the, 245, 246; does it contain nutrient properties? 256. Lochial discharge, the, 417, 418. Locked-head, remarks on, 601, 602; definition of, 603; dangers of, to the child and mother, ib.; diagnosis of, 604 ; application of the forceps in, 605, 606. Lying-in chamber, detailed directions for the guidance of the young accoucheur in the duties of the, 351 et seq. M. Macauley, Dr., the first to practise premature artificial dehvery when the fcetus ia viable, 666. Malacosteon, a cause of pelvic deformity, 62. Male children, mortality of, compared with that of female, 28. Mammae, the, their relations to the uterus, 149; pains in the, during pregnancy, 226. See Lactation. Mania, occurrence of, after parturition, 503; puerperal its pathology, 699; the period at which it is most apt to occur, 700; not of rare occurrence, ib.; its • liability to recur, 701; causes and symptoms, 702; diagnosis and prognosis. 703 ; duration, 704; treatment, medicinal and moral, 704-707 Manual delivery. See Delivery. Manual labor, 457. Marriage, conducive to health and longevity, 123. Martin, Edward, his monograph on transfusion, 400. Mattei, A., on cephalic version by external manipulation, 542. Maunsell, Dr., statistics of craniotomy operations by, 631. Mauriceau, on moles, 283 ; on the Caesarean section, 627. Meatus urinarius, the, 76. Meconium, the, 409. Medulla spinalis, the reflex action of the, 178. Meigs, Prof, measurements of the fcetal head by, 30; on the non-contagioxw cha- racter of puerperal fever, 686. JIEI-OPI INDEX. 737 Meissner, his plan for perforating the membranes in premature artificial delivery, 675. Membrana decidua, Hunter's theory of the, 242 ; its true structure, ib. Membrana granulosa, the, 111. Membranes, perforation of the, in premature artificial delivery, 675. Menstruation. Menses, the; retention of, mistaken for pregnancy, 79; period be- tween puberty and their final cessation, 93; influence of climate on, 95—of education and mode of life, 96—of temperament, constitution, and race, 97; average age at which they first appear, 96; precocious and tardy, 98 ; causes of, ib.; dependent on organic development, 99; do not consist in the discharge of blood, but in the maturity of the ovules, 100; the ovular theory, 101; periodicity, ib.; source and nature of the menstrual fluid, 102, 292; duration and quantity lost at each menstrual period, 103; is menstruation peculiar to women ? 104; does the menstrual fluid contain poisonous elements? ib.; time of final cessation, 106; aptitude for impregnation just before the catamenial period, 107 ; suppression of, as a sign of pregnancy, 144; sometimes occur only during pregnancy, 146; retention of the, with interesting case, 194, 195; difference between the, and the hemorrhage of miscarriage, 275; case of fecundation effected at a menstrual period, 307, 308. Merriman, Dr., on the application of the forceps, 581; on the Caesarean section, 628; objection by, to premature artificial delivery in a primipara, 668. Meso-rectum, the, 4. Metrorrhagia, common occurrence of, at the critical period, 106. Metroscope, the, description of, 201. Midwifery, an exact science, 1. Milk, secretion of, an evidence of pregnancy, 149; instances of its secretion in other conditions, 150; in the breasts of the new-born infant, 421; milk fever, 422. Milk leg, 712. Mills, Dr. Charles S., interesting case of Caesarean section reported by, 635. Miscarriage. See Abortion. Moles, various opinions of authors respecting, 283, 284; the true moles—vesicular or hydatiform, 284-291; false moles —molae spuriae, 291-294 Mollities ossium, a cause of pelvic deformity, 62. Monkeys, menstruation in, 104. Monneret, on the puerperal state, 685. Mons veneris, the, 73. Montgomery, Dr., summary of his remarks on the areola of pregnancy, 152; on the temporary loss of mind during labor, 365. Morton, Dr., the first to administer ether to prevent the pain of a surgical opera- tion, 709. . ' Mucous follicles, increased secretion of the, as pregnancy advances, 166. Multipara, modifications of the cervix uteri in a, 169. Murphy, Dr., on the Caesarean section, 628. N. Naegele, on the inclinations of the planes of the pelvis, 19; his views on the mechanism of parturition, 38; on vertex presentations, 42 ; on oblique distor- tion of the pelvis, 65; on the period of pregnancy, 306. Nausea, in pregnancy, 128, 146; importance of, 128, 129; treatment, 220. Neboth, glands of, an erroneous appellation, 83. Nerves, sacral plexus of, 4. Nervous force as a determining cause of labor, Dr. John Power's theory of, 314-316. Nipple, how to remedy a sunken or flat, 410; treatment of sore, 426. Nutrition, a fundamental law of life, 254; objects of, ib.; embryonic, 255; pla- cental, 256. Nymphae, the, 75; enlargement of, simulating breech presentation, 76. 0. Obstetric case, the author's, 578. (Edema of the lower extremities, during pregnancy, 161. Ophthalmia neonatorum, causes, symptoms, and treatment of, 424, 425. Opium, comments on the use of, in the convulsions of pregnancy, 494; treatment by, in puerperal fever, 697. 738 INDEX. OS-PLA ' Os coccyx, anatomy of the, 6; important influence during childbirth, 6, 7; disloca* tion and fracture of, 7. Os innominatum, anatomy of the, 7. Os ischium, the, 10. Os pubis, the, 10. Os sacrum, the, description of, 3. Os sedentarium, the, 10. Os tincae, the, 81; cicatrices upon, not always reliable as evidences of childbirth, 88, condition of the, as pregnancy advances, 165 ; peculiar moisture of the lips of, an accompaniment of pregnancy, ib.; extraordinary thinness of the, at the timeoflabor, 172; cause ofits dilatation in labor, 332; rigidity of the, 360; spasm of the, treatment of, 378-380; mode of effecting artificial dilatation of the, 520 ; dilatation of, by prepared sponge, in cases of premature artificial delivery, 676. Osborn, Wm., on the amount of pelvic contraction consistent with the birth of a living child, 619; on the Caesarean section, 627 ; his report of the performance of embryotomy in the celebrated case of Elizabeth Sherwood, 652-656. Ovarian pregnancy, 203. Ovarian theory of parturition, 312. Ovaries, the, the essential organs of generation, 90. Ovary, the, the seat of contact between the germ and sperm cells, 119; enlargement of the, 196 ; diagnosis of prolapsed, 240. Ovisac, the, 112. Ovulation, is it incompatible with gestation? 145. Ovule, the fecundated, manner of admission to the Fallopian tube, 119; the deci- duous and the vitalized, 176. Ovum, blighted, interesting case of enlarged uterus caused by, 287-291. P. Pain, as a sign of labor, 329 ; true labor pains, 331; false labor pains, 332 Paralysis, treatment of, after delivery, 428. Paraplegia, after delivery, treatment of, #28. Parent, influence of the, upon progeny, 263. Parent- Duchatelet, on enlargement of the clitoris, 75. Parturition, primary forces of, 323; secondary forces, 324. See Labor. Pathology, humoral, 683. Pelvic axis, true meaning of the term, 19. Pelvic extremities, presentation of the, 343. Pelvic version, 539; spontaneous, 562. Pelvimeter, the, method of using, 69; the finger the best, 70, 668. Pelvis, the human, its position in the skeleton, and anatomy of the, 2; bones of, in the adult and fcetus, 3; its uses, 12; articulations or joints, ib.—question of their relaxation, 15; the greater and lesser, 16; the straits of the, 16, 17; planes of the two straits, 18; axes of the pelvis, 19; remarkable differences between that of the new-born child and that of the adult. 23; varieties of, depending upon the sex and age of the individual, 22, 23; its connexions with the soft parts, 23, -24; measurements, 24-26; respective diameters of the fcetal head find adult female pelvis, 32 ; deformities ofj two classes—increased capacity and diminished capacity, 57; illustrative case, 58, 59; varieties of pelvic deformity, 61, 619, 620; causes of, 62; oblique distortion of the, 65; determination of the smallest space through which a living child may be extracted, 66; exami- nation of the propriety of version in cases of pelvic deformity, 544-546 ■' amount of pelvic contraction consistent with the birth of a living child, 619' amount of pelvic deformity through which a child may be extracted piecemeal 620 Perineum, directions for supportiag the, in labor, 363-365; paralysis of the after delivery, 417. ' Peritoneal dropsy, diagnostic guides of, 197. Peritonitis, puerperal, 691. Peu, M., thrilling case of Caesarean section by, 639. Phlegmasia dolens, 708. Phlegmasia?, treatment of, during pregnancy, 13 Physometra of the uterus, a rare affection, 195. Piles, treatment of in pregnancy, 228, 229. Placeuta,, description of the, 246 ; foetal and maternal divisions of the, 247-249 • blood-vessels of the. 247. 248; fatty degeneration of the, 250; nutrition by the 256; manner in which the blood is conveyed from the, to the fcetus, 258 259- VAN-WRI INDEX. 743' Van Swieten, on the sensations connected with impregnation, 304. Vectis, the, in instrumental delivery, 568. Veins, varicose, treatment of, 229, 230. Veit, Dr., on the mortality of male infants, 28. Veratrum viride, a remedy in puerpera1 fever, 698. Vertebrae, the false sacral, 3. Version, conditions under which it is to oe resorted to, in prolapsion of the funis, 465. 466; directions for, in placenta prawia, 473,474; cephalic, 516, 540, 541; rules for, in manual delivery, 520-522; podalic, 531, 564; mode of performing 540, 541; mode of performing cephalic, by external manipulation, 543, 544; in pelvic deformity, 544-546; spontaneous pelvic, 5'62. Vertex, the, discrepancy among authors as to the number of positions of, 36 ; sta- tistics of vertex presentations, 37; the author's classification of vertex presen- tations, 43; mechanism in the first vertex position—left occipito-acetabular, 44; mechanism in the second and third vertex positions—right occipito-ace- tabular and right posterior occipito-iliac, 52 ; mechanism in the fourth vertex position—left posterior occipito-iliac, 53; presentations of, in cases calling for manual delivery, 526 et seq. Vesico-vaginal fistula, diagnosis of, 78. Vesicular moles, 284. Vestibulum, the, 76. Virchow, his theory of extra-uterine foetation, 206. Vomiting, in pregnancy, 128, 146; importance of, 128, 129; treatment of, 220; in labor, 334; excessive, as a motive for premature delivery, 671. Vulva, the, or external organs of generation, 72; treatment of pruritus of the, in pregnancy, 227, 228; thrombus of, 430. Vulvo-vaginal gland, the, 77 W. Water-douche, the, as proposed by Kiwisch for the induction of premature deli very, 677. Waters, the bag of, 245; formation and rupture of the, 334-336, 358. Weed or ephemeral fever, 430. Weidemann, on the Caesarean section, 627. West, Dr., statistics by, on extirpation of the uterus for inversion, 453. Whitehead, Dr., his statistics of abortion, 266, 267. " Whites," the, a vague and unmeaning disease, 166. Womb. See Uterus. Wright, Dr., on the mode of performing cephalic version. 641 Wood's Medical Catalogue. " As an American work, we are proud of it, and most cordially recommend it as the Text Book on Obstetrics."—Chicago Medical Examiner. "We have read no work on this subject for many years with so much unalloyed pleasure and profit. The style is plain, fresh—welling up from an exuberant foun- tain—compact. The whole Book exhibits the careful preparation of the success! tl Teacher. The plan and arrangement of the work are at once comprehensivo, sys- tematic, complete—and fully posted to the existing state of the science."—Philadel- phia Medical and Surgical Reporter. " The flattering success, which attended the work on the ' Diseases of Women and Children,' by Dr. Bedford, had prepared us to regard with unusual interest this systematic Treatise on the ' Principles and Practice of Obstetrics.' This new Book is no failure; our just expectations of the Author are fully met. He has presented us an originality, which is quite refreshing in these days of fluhkyism and imitation. We most cordially recommend the Book as a complete and most attractive Text Book on the science and art of Obstetrics."—Cincinnati Lancet and Observer. " Dr. Bedford's Book has had an unparalleled success, which speaks volumes for me intelligence of the Profession, as the Author, we think, has given us a work of more intrinsic value than any other on the same subject now in existence. Any interruption while reading it is an annoyance, and we return to the mental feast as the hungry child to its interrupted meal. The physician, who does not obtain a copy of this Book,'and read it, will not only be deprived of a treat, but should be considered behind the times; and the student who does not procure it is a careless fellow, or under poor instruction."—Cincinnati Medical and Surgical News. " We receive the volume as an addition to our library with thankfulness, and the hope that it may secure the patronage to which it is so justly entitled. The Book is unquestionably afaithful exponent of the Principles and Practice of Midwifery, brought up very fully to the existing state of our knowledge. It is systematic in its arrange- ment, clear and explicit in all its teachings."—American Journal of the Medical Sciences. " The skilful obstetrician wields a ready pen on every page. The Book is a com- plete Treatise on the subject which it discusses, and is very full in mattors which are but lightly dwelt upon in many of the works on Obstetrics."—North American Medico-Chirurgical Review. " This work must take the highest place among our Text Books on Obstetrics. It evidently embodies tho results of the Author's extensive' practice in thi3 branch of the Profession, expressed in a forcible and eloquent style, so as to impress the vast amount of information it contains on the mind of tho reader."—Pacific Medical and Surgical Journal. " A careful examination of Dr. Bedford's work justifies us in recommending it as the Text Book on Obstetrics—one in which the Practitioner will find detailed those rules which will guide him safely through the emergencies of obstetric practice."— San Francisco Medical Press. " The best Book on Obstetrics yet published in the English language; we most earnestly recommend it to our Physicians."—Philadelphia Eclectic Medical Journal. " Dr. Bedford's Book deals with accumulated facts and profound generalizations, in which none but the clearest intellect and the most critical observer can be per- fectly at home. Tn fulness of detail, lucidity of arrangement, and philosophical analysis, Prof. Bedford's ' Principles and Practice of Obstetrics' will long stand as a model work, and will become the favorite Text Book in the schools, as well as the moat valued guide of the Practitioner.—"North American Journal of Homoeopathy. " This Book comes from a high source. Prof. Bedford has long stood before the Medical Profession with authority in his department. His work displays, as would \>e expected from such a source, a thorough acquaintance with the literature of the subject, past and present, down to the very latest expedients, and the extensive iractical knowledge of a popular Obstetrician."—Berkshire Medical Journal THE DISEASES OF WOMEN AND CHILDREN. BY GUMLXG S. BEDFORD, A.M., M.D., Professor of Obstetrics, the Diseases of Women and Chi'dren, and Clinical Obstetrics, in the University of New York; Author of the Principles anil Practice of Obstetrics. [EIGHTH EDITION, CAREFULLY REVISED AND ENLARGED, 8vo, 670 pp. W. WOOD & CO., 61 WALKER ST., NEW YORK Price, $3.50, free of Postage. The rapid and widespread circulation of this eminently practical work is, we think, without precedent. It is a storehouse of knowledge for the student and practitioner of medicine—full of practical precepts and bed-side information. Rarely has any medical publication met with such universal commendation from the medical press, both at home and abroad. It has had awarded to it the high honor of a translation into the French and German. " Successful as the work has been at home and abroad, we were not prepared to see it achieve a success exceedingly rare in the history of American medical authorship, viz., a Translation into the French and German languages. We con- gratulate the author upon this high compliment paid to his labors in the still new field of uterine pathology, where so many struggle vainly for, reputation. While this translation is the highest possible acknowledgment of the value of Dr. Bed- ford's labors, it secondarily reflects creditably upon the rising importance of the American school of medicine."—American Medical Times. " We hail tho advent of such a work, abounding in practical matter of the deepest interest, and illustrated by principles and laws ordained by nature. Nor can we refrain from expressing our surprise and gratification at rinding the book so remarkably exempt from the superficial views that a'bound in the great thorough- fare of medicine. The rapid sale of this work we believe to be unprecedented in the history of medical literature in this country, which must be highly gratifying to the author, showing, as it does, the degree of estimation placed upon his labors by the medical public."—N. Y. Jour, of Med. and the Collateral Sciences. "Dr. Bedford's Book is worthy of its Author, a credit to his country, and; a valuable mine of instruction to the profession at large. We are quite sure that it ■ will be a welcome addition to professional libraries in Great Britain as well as America."—Brit, and For. Med.-Chir. Review. " We think this thy most valuable work on the subject ever presented to the profession. We have perused every page of the book with interost, and speak, therefore, from personal knowledge."—Cincinnati Med. Jour. " A careful perusal of Dr. Bedford's book has led us to believe that Us value wfl. continue to be acknowledged, and the author recognized as a most able and acute practitioner of medicine. The work is of the most practical character; every thing is made to tend toward the relief and treatment of disease, and remarkable skill is shown in quickly arriving at an accurate diagnosis. To get at once to the point ia the pervading characteristic of tho author's teachings. We cordially recommend k to all practitioners and students of medicine."—London Lancet. " It is to be regretted that we have not nore such books in Great Britain."— London Medical Times and Gazette. ■ " The Btyle of the author is very graphic. The dook not only proves Dr. Bedford to be a sound physician and an excellent clinical teacher, but it also affords evidence of an extensive acquaintance on his part with the literature of his subject on this Bide of the Atlantic."—London British Medical Journal. HAn examination of this work convinces us that the author possesses grea( talent for observation, and that his opinions are sound and practical. He shows an intimate knowledge of the doctrines of the ancients and the op'nions of the moderns. The variety of instruction contained in this volume, the ability with which it is pre- sented, and the truthful practical character of the doctrines advanced, give to it very great value."—Gazette Medicale, Paris. ____________W. Wood & Co. Medical Catalogue. " The working men in America are always on the look-out for the new lights rising over the old world, and they often too hastily adopt as the pure gold of science, the crude lucubrations which must find place with more valuable matter in the weekly medical press. But this observation does not apply to our author, who is J-editably known by other works, and in the one before us shows himself to be a judicious physician, anxious alike for the good of his patients and of his pupils; one who has acquired the happy art of teaching how to get at the characteristics of disease, and how to drag at the chain of effects, until the mind grasps the first link in the chain."—Rankin's Half- Yearly Abstract of the Med. Sciences. " The subjects have been developed with no ordinary powers of clinical instruo tion."—N. Y. Med. Times. ' We have been both pleased and instructed by a perusal of the book, and con fidently recommend it, therefore, to the profession, as an excellent repertorium of clinical medicine. The eminently practical ideas of the author, clothed in simpk and perspicuous language, are delivered in quite an attractive, affable, and off-hand manner."—Philadelphia Med. Examiner. "A work of great practical interest—one well calculated to interest and instruct the busy practitioner; it points out to him the most modern therapeutical agents, and their method of administration; and, above all, gives beautiful and satisfactory explanations, physiologically, of the symptoms of disease. This latter quality is a great merit of the book. As a faithful representation of the daily labors and duties of a physician of our day, and as an accurate delineation of the diseases of women and children, it is well deserving of our praise."—Virginia Med. and Surg. Jour. " We were actually fascinated into reading this entire volume, and have done ro most attentively; nor have we ever read a book with more pleasure and profit. There is not a disease connected with infancy or the female system which is not most ably discussed in this excellent work."—Dublin Quarterly Journal of Medical Science. " Professor Bedford's book is a good one. We like it, for we can digest a dinner uver it without going to sleep, and that is more than we can say of most medical books."—New Jersey Med. Reporter. u To read this work is to be struck with its truthfulness and "tility ; we find all that is useful in practice, ably communicated, and elegantly expressed. American works are not generally read on this side the Atlantic, but we recommend Dr. Bedford's book as worthy of the very best attention of the profession."—Midlanu Quarterly Journal of the Medical Sciences, London. " We have said, on former occasions, that the man who will bring forward clinical or practical instruction to boar upon the medical teachings of our country, will be immortalized. We want practical observations—fresh from the bed-side. Dr. Bed- ford's volume is drawn from an extensive clinic, founded by him in the University of New York, and is fortified by much reading and research. This is a good book, and the profession owes Dr. Bedford hearty thanks for the labor he has bestowed upon it."—Philadelphia Med. and Surgical Journal. " The work before us is eminently practical and therefore valuable as a contri- bution to medical knowledge. Prof. Bedford's extensive opportunities have enabled him thus to bring together a large number of the most interesting cases of female *nd infantile affections, and to indicate his views of their treatment. In the accom- plishment of the task, the author has evinced a degree of discernment which will, doubtless, add materially to his already extended reputation."—Southern Med. and Surg. Journal, Augusta, Georgia. " No one can read this book without becoming convinced that it contains much valuable instruction, and is the result of a large experience in this specialty."— New Hampshire Jour, of Med. " The work contains graphic descriptions of the diseases of women and children, with judicious advice as to treatment."—Boston Med. and Surg. Jour. Wood's Medical Catalogue. A XEW BOOK OX PRACTICE OF MEDICIXE. CLINICAL LECTURES PRINCIPLES AND PRACTICE OP MEDICINE. By JOHN HUGHES BENNETT, M.D., F.E.S.E. Professor of Institutes of Medicine, and Senior Professor of Clinical Medi- cine in the University of Edinburgh. One very Handsome Octavo Volume of over One Thousand Pages, with Five Hundred Illustrations on Wood. In Extra Cloth Binding, $5 50. Leather Binding, Price $5 00. This book has been pronounced the most superb as resards the fineness of the engravings and the clearness and beauty of printing, of any medical work yet issued in the Country. " "We recommend this volume with the most unqualified praise, to the attentive considera- tion of the practitioner and students. We have met with no work of late years on the principles of medicine more likely to advance the true and rightful scudy of our art."—Medi- cal Times and Gazette. " One of the most valuable books which have lately emanated from the medical press. No one devoted to the profession will fail to pe- ruse these lectures, and acquaint himself with the discoveries of so ardent an explorer in the field of medicine."—Ne-w York Journal of Medicine yet issued in the Country. " "We must heartily commend it to tho youn<» and old, the disciple and the master alike."— Charleston American Journal and Review. "A new work, in which the applications ot the microscope to clinical medicine are treated by a master hand. The great value of this work is, that it embodies, in a clear and concise man- ner, all the applications of the microscope to practical medicine. It is. in fact, a perfect manual on this subject, and as such to be wel- comed by all who consider diagnosis as the most important element in the study of dis- ease."— New Orleant Medical Nevts and Hos- pital Gazette. Wood's Medical Catalogue. In one handsome octavo volume, bound in muslin. Illustrated by beautifully colored litho- graphic plates. Price, $2.50. LECTURES ON THEllRUPTIVE FEVERS, AS NOW IN THE COURSE OF DELIVERY AT ST. THOMAS' HOSPITAL, LONDON. By GEORGE GREGORY, M.D., Fellow of the Royal College of Physicians of London, Physician to the Small Pox and Vaccina- tion Hospital at Highgate, Corresponding Member of the National Institute of "Wash- ington, etc. First American Edition, with numerous additions and amendments by the Author, comprising his latest views. With Notes and an Appen- dix, embodying the most recent opinions on Exanthematic Pathology, and also statistical tables and colored plates. By II. D. BULKLEY, M.D., Physician for the New York IIospitaT, Fellow of the" New York College of Physician* and Surgeons, etc., etc. " The very best which has yet bqpn published on Eruptive Fevers; and one which it should be the duty of every physician to provide him- self with."—Northern Lancet. " We cordially recommend it as the produc- tion of a man who has thoroughly investigated the subject of which it treats."—Western Jour. nal of Med. and Surgery. "This work abounds with valuable Informa- tion in regard to a class of diseases of very fre- quent occurrence and of fearful mortality."— Stethoscope. Lectures on Natural and Difficult Parturition. By EDWARD WILLIAM MURPHY, A.M., M.D., Professor of Midwifery, University College. London; Obstetric Physician, University College Hospital, and formerly Assistant-Physician to the Dublin Lying-in Hospital. One octavo volume, illustrated by sevcntv engravings, handsomely bound in leather. Price, $1.75. "The student will find it replete with iiccu- rnte and lucid instruction."—London Medical Gazette. " We know of no work which we can so heartily commend to the ^student, and to the accoucheur in active practice, as that which i THE LONDOX, EDINBURGH, AND DUBLIN COLLEGES OF PHYSICIANS. AND OF THE UNITED STATES PHARMACOPEIA, BEING A PRACTICAL COMPENDIUM OF MATERIA MEDICA AND PHARMACY. By ANTHONY TODD THOMPSON, M.D., F.L.S., Fellow of tho Royal College of Physicians, Professor of Materia Medica and Thera- peutics in University College, London, etc., etc. Seventh American Edition, much enlarged and improved. Edited by CHARLES A. LEE, M.D., Professor of General Pathology and Materia Medica in Geneva Medical College. Price $1 25, free of postage. affinities between them and their bases—of the quantity of opium in different preparations— a table for ascertaining the strength of wines— tables of weights and measures," especially of the fluids—on the measure of temperature of baths—of thp density of fluids—of the ingre- dients of the several mineral waters—changes of nomenclature, &c.; the whole forming a desideratum which nothing else can supply. It is the best work the doctors ever put forth." —Christian Intelligencer. " It is a most valuable epitome of all that relates to the Materia Medica."—Boston Medi- cal and Surgical Journal. „ "It ought to tie on the table of every practi- tioner."—Peninsular Journal of Medicine. "It contains an account of the different medi- cinal substances, with their properties, uses, modes of operation, doses, and incompatibles —the whole art and theory of prescribing, with tho means of adapting the remedy to the a^e, sex, temperament, habits, condition, and idio- syncrasies of the patients—an account of the several poisons, and the proper antidotes—the composition of all tho officinal preparations, and the method of preparing them—a complete set of prescriptions for fulfilling every indication in cases of various disease, with external appli- cations and collyria—separate formulae for the diseases of infants—a large number of dietetio preparations, adapted to the convalescent and the sick—a table of acids, with the chemical New Edition. THE PRACTITIONER'S PH ARM A COP (EI A, OR UNIVERSAL FORMULARY. CONTAINING TWO THOUSAND CLASSIFIED PRESCRIPTIONS, Selected from the Practice of the most eminent British and Foreign Medical Authorities, With an Abstract of tlie Three I3ritis!i Pharmacopoeias, And much other useful information for the Practitioner and Student, By JOHN FOOTE, M.R.C.S., With corrections and additions by an American Physician. One large 12mo. volume of 390 pages, bound in leather. Price $1.25. One of the very best Formularies published; it is very complete and compact, and has attained a widespread popularity. Report off Professor Valeiatiaie IVIott's Surgical CEitiiques in the University off I¥ew York, Sessiosa of 1§59-«J0. By SAMUEL W. FRANCIS, 12mo. cloth. Illustrated with a Steel Portrait of Dr. Mott. Price 90 cents. Wood's Medical Catalogue. OF NATURE AND ART IN THE CURE OF DISEASE. By SIR JOHN FORBES, M.D. (OXON.), F.R.S., rELLOW OF THE UOYAL £0LLBUE OK PHYSICIANS. PHYSICIAN' TO THE (JUEKN'S HOUSEHOLD, KTO-, ETC FROM THE SECOND LONDON EDITION. One very neat 12mo. volume, bound in muslin, Price $1.00. ....." We recommend this thoughtful and suggestive book to the careful perusal of all who value health, and especially to those who habitually resort to medicine. They will be less ready to fly to pills and powders when they know tho mischief these produce"—The Critic. M In this volume Sir John Forbes aims to Bhow that N.ituic has much more to do with the cure of dis nso than is generally supposed either by laymen or by the profession, and that Art accomplishes much less in that way than is commonly imagined. This book is d'-signed not merely for ;h.- profession, but for intellizont readers generally."—British Quarterly Review. DR. HOOPER'S PHYSICIANS' YADE-MECUM: OR, A MANUAL OF THE PRINCIPLES AND PRACTICE OF PHYSIC. Enlarged and Improved, WITH AN OUTLINE OF GENERAL PATHOLOGY AND THERAPEUTICS. By WM. A. GTJY, M.D., etc., WITH ADDITIONS BY JAMES STEWAET, M.D. In one 12mo. volume, strongly bound in leather, Price $1.00. SECOND EDITION. QU A CKERYllN MASKED; OR, A CONSIDERATION OF THE MOST PROMINENT EMPIRICAL SCHEMES OF THE PRESENT TIME. WITII AN ENUMEBATION OF SOME OF THE CAUSES WHICH CONTRIBUTE TO THEIR SUPPORT. By DAN KING, M.D. One 12mo. volume, bound in muslin, Price 75 cents. H0¥ TO NURSE SICK CHILDREN: Intended especially as a help to the Nurses at the Hospital for Sick Children; but CONTAINING DIRECTIONS THAT MAT BE FOUND OF SERVICE TO ALL WHO HATE THE CHARGE OF THE YOUNG. By CHAS. WEST, M.D. In one 18mo. volume, bound in muslin, Price 88 cents. u It Is beyond value."—Nelson's Am. Lancet. . " Should be in the hands of everv one who has charge of children."— Western Lancet. " Contains much judicious advice, which, If carefully followed, will contribute materially to the comfort of the little ones under their dhirge." —American Medical Time*. Wood's Medical Catalogue. A TEXT-BOOK OF PRACTICAL ANATOMY. Br EOBEET HARRISON, M.D., M.R.S.A., Professor of Anatomy and Surgery in the University of Dublin, etc. WITH ADDITIONS. By an AMERICAN PHYSICIAN. One very handsomo octavo volume of 720 pages. Illustrated by 160 Engraving! on Wood. Strongly bound in lfeather. Price, $2.50. •* W« recommend it in the itrongest terms."—New York Journal of Medicine. "It is one of the very best of the numerous treatises on Practical Anatomy. "The work is altogether such a one as every student should possess."—Ohio Me- dical and Surgical Jour- nal." u It might be well denomi- nated ' The Library of Prac- tical Anatomy,' for it indeed contains all that the student ean possibly require, in the prosecution of his studies."— Southern Medical and Sur- gical Journal. Woods Medical Catalogue. THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. By GEORGE BUDD, M.D., F.R.S., Professor of Medicine in King's College, London; late Fellow of Caius College, Cambridge. In one handsome Octavo volume, bound in Extra Muslin, Price $1 50. "There is no other work extant that gives so comprehensive a view of the various affections of the .stomach, and certainly none emanating from higher authority.''— Western Lancet. "This work is the fullest and most satisfac- tory one, exclusively devoted to the Stomach, that wc have ever perused."—Med. Counsellor. " To all thoso who have studied ' Budd on the Liver,' this companion work which we have now before us will be doubly welcome. " We are satisfied that the student can find nowhere a better treatise on the organic and functional disorders of the stomach."— Virgi- nia Med. Journal. " As a practical treatise it can hardly have a rival."—Boston Med. and Surg. Journal. " It is an eminently practical work, pointing out very clearly the indications for remedial measures, so far as our present clinical know- ledge enables us to go."—Dublin Quarterly Journal of Med. Science. "The profession, already indebted to Prof. Budd, for one of the best monographs on Dis- eases of the Liver, will not fail to appreciate the present excellent work on gastric affections."— Southern Med. and Surg. Jour. " We regard it as one of the best and most reliable works on the subject that has appeared for a long time."—Eclectic Med. Jour. " The whole subject is brought up quite to the times, treated in a full, clear, scientific, and highly practical way."—Iowa Med. Jour. " The work will be found an excellent mono- graph, which the dietetic habits of many Ame- ricans render of peculiar interest to the profes- sion in this country."—College Jour. Medical Science. HEADACHES: THEIR CAUSE AND THEIR CURE. By HENRY G. WRIGHT, M.R.C.S.L., L.S.A., Fellow Royal Medico-Chirurgical Society, Physician to the St. Pancras Royal Dispensary. In one neat little 12mo. volume of pages, bound in Muslin, Price 50 cents. 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THE PLACElfTA, THE ORGANIC NERVOUS SYSTEM, THE BLOOD, THE OXYGEN, AND THE ANIMAL NRPwVOUS SYSTEM, PHYSIOLO GICALLY EXAMINED. By JOHN O'REILLY, M.D., One Octavo volume, bound in muslin, Price $2 00. Fourth American from the Seventh London Edition. TEE FIRST LINES OF THE THEORY AND PRACTICE • or S TJ R a E R Y, INCLUDING THE PRINCIPAL OPERATIONS. By SAMUEL COOPER, M.D., Senior Surgeon to the University College Ilospital, and Professor of Surgery in the same College, etc., WITH NOTES AND ADDITIONS, By WILLARD PARKER, M.D., Professor of Surgery in the College of Physicians and Surgeons, etc. In two Octavo volumes. Illustrated, bound in leather. Price $5 00. WoocVs Medical Catalogue. A MAGNIFICENT WORK. Fourth Edition. A SERIES OF ANATOMICAL PL.ATES, With References and Physiological Comments, Illustrating the STRUCTURE OF THE DIFFERENT PARTS OF THE HUMAN BODY. By JOHN QUAIX, M.D., A Professor of Anatomy and Physiology in the University of London; and W. J. E. WILSON, M.D., Lecturer on Practical and Surgical Anatomy and Physiology, Revised with additional Notes, By JOSEPH PANCOAST, M.D., Professor of General, Descriptive, and Surgical Anatomy in Jefferson Medi- cal College of Philadelphia, Pa., Lecturer on Clinical Surgery at the Philadelphia Hospital. IN ONE SUPERB, QUARTO VOLUME, ILLUSTRATED BT TWO HUNDRED FINELY EXEClTliD LrTHOGRAPUIO PLATES, STRONGLY AND HANDSOMELY BOUND IN HALF MOROCCO, RAISED BANDS. Price $16 00, or with the Plates beautifully colored by hand, $31 00. The Publisher has no hesitation in saying that this is by far tho most complete set of Anato- mical Plates ever issued in America, while their beauty and fidelity to nature, and the very low prices at which they are offered, render them invaluable and within the reach of every profes- sional man. The fact that Pour Editions of so large a work have been sold is an evidence of the estimation in which it is held. "The text and plates both being excellent, "The plates are for the most part exceeding- rhe book is a treasure indeed."—Boston Medi- ly well executed. It is the cheapest work of eal and Surgical Journal. the kind ever published in this country."1— " Much superior as a system to any that have American Journal of Medical Science. heen hitherto published in this country."— Medico.- Chir. Review. A TREATISE ON FRACTURES IN THE VICINITY OF JOINTS, AND ON CERTAIN 0 FORMS OF ACCIDENTAL AND CONGENITAL DISLOCATIONS. By ROBERT WILLIAM SMITH, M.D., M.R.I.A., Fellow of the Royal College of Surgeons in Ireland, &c, &c. In one Svo. volume. Illustrated by one hundred and one very fine Wood Engra- vings, strongly bound in Muslin. Price $4 00. "One of our best models for conducting snreical observations."—American Journal of Medical Sciences. '• A volume full of interesting practical ob- servation?."'—Sir Benj. Brodie. 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MICROSCOPIC ANATOMY OF THE HUMAN BODY, 1ST HEALTH AND DISEASE. Br ARTHUR niLL HASSALL, M.B.; MEMBER OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, &c, &c ILLUSTRATED WITH NUMEROUS DRAWINGS IN COLOR, WITH ADDITIONS TO THE TEXT AND PLATE81 AND AM INTRODUCTION, CONTAINING INSTRUCTIONS IN MICROSCOPIC MANIPULATION, By HENRY VAN ARSDALE, M.D. Illustrated by seventy-nine accurately drawn and exquisitely colored lithographic plates, containing several hundred figures. Forming two large octavo volumes, handsomely and strongly bound iu leather, raised bands. Price $7. The Publishers take pride in offering to the Medical Profession a work which has heen pro- nounced the most complete in its department published. No pains nor expense havo been spared in its prodaction, and it is believed that it excels anything of the kind heretofore pub- lished. " Every page of it is a banquet, unfolding the marvels of creative wisdom and power. Such extraordinary displays of the minute organiza- tion of the internal mechanism of our bodies, in the two conditions of health and disease, create a strange feeling of wonder and amazement. While the work teaches how to understand appearances, it also points out the physiological functions and anatomical relations of parts. In short, the why and the wherefore in the sub- jects treated of are presented in a clear light." Boston Medical and Surgical Journal. "We express the conviction, forced upon us, after several years' consultation of similar works, while pursuing microscopical studies, that there is none better arranged nod illus- trated, and none which will give so general satisfaction, as that of Mr. IIassail, edited by Dr. Van Arsdale."—New York Journal of Me- dicine. ''It is marked by a simplicity of description, and by scientific accuracy in argument With these (the plates) we are delighted. 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ON DIABETES ANI ITS SUCCESSFUL TREATMENT, By J0E2J M. CAMPLIN, M.D., F.LS. (Second Edition.) One neat 12mo. volume. Prioe 50 cents. •*Krery physician should read it before undertaking to trsat a case of groaosuila."—Boston Med. and Burg. Journal. Wood's Medical Catalogue. A New Edition. MATERIA MEDICA AID THERAPEUTICS By MARTYN PAINE, A.M., M.D., LL.D., Profess* of the Institutes of Medicine and Materia Medica in the University of New York, etc., etc. In one handsome 12mo. volume, strongly bound in leather. Price, $1.25. " It abounds in facts, presented in the fewest words:" it "gives the essence of all the great treatises extant, on the Materia .Medica, and therefore mu.-t ahvars be a convenient book for reference as authority."—Boston Medical and tjurgicd Journal. " We have no doubt the objects of the pro- found author are fully carried out in the work, and it must prove of great assistance to a stu- dent attending his lectures."—Southern Medi- ral and Surgical Journal. ■• It will be found to be a useful and con- venient book for determining rapidly the pro- perties and doses of different medicines, and for ascertaining what are the proper doses and most approved formulae to be used in their administration, and as such we cheerfully recommend it."—North- Western Medical and Surgical Journal. '•Asa text-book for the student, and as a con- venient, reference-book for the practitioner, we regard it as a very valuable contribution to the profession."—Missouri Medical and Surgical Journal. '■ To the young gentlemen attending his lec- tures it will prove a convenient and useful work."—Western Journal of Medicine and Surgery. In one 12mo. volume, neatly bound in muslin. Price, $1.00. DISEASES OF MENSTRUATION AND OVARIAN INFLAMMATION, IN CONNECTION WITH STERILITY, PELVIC TUMORS, AND AFFECTIONS OF THE WOMB. By EDWARD JOHN TILT, M.D. " It is a comprehensive digest of all that has been added to medical science, within the last Itsw years, upon diseases of tho organs of con- ception in the female, with occasionally some original, and we are well pleased to say. very sound views of the writer."—Philadelphia Lancet. " After a dictionary and dispensatory there is no book, perhaps, belonging to the physician's library that is so well worth the amount neces- sary to procure it"—Nashville Journal of Medicine and Surgery. '•The best that has been published on the subject."—Boston Med. and Surg. Journal. "The objact of the work is to show how in- flammation, by reacting on the ovaries, pro- duces diseases of menstruation, sterility, and uterine disease. " We cordially recommend this little work to our readers."—Medical Examiner. "To every practitioner who is treating dis- eases of females, the book cannot fail to be one of the most, interesting that has recently ap- peared."— Western Lancet. " One of the most important [works] that has been issued from the press in a long time."— Western Journal of Medicine and Surgery. "The work is one which should be read by every practitioner, as most deserving of serious and careful consideration."—Brit. Am. Med. and Phys. Journal. A GOOD WORK ON CLIMATE IN DISEASE. CHANGE~OF AIR, OS, THE PHILOSOPHY OF TRAVELLING. Being Autumnal Excursions through France, Switzerland, Italy, Germany, and BeMnm- with Observations and Reflections on the Moral, Physical, and Medicinal Influence ' of Travelling Exercise, Change of Scene, Foreign Skies, and Voluntary Expatriation. To which is Prefixed ■WIZAJEl AJSTJD TEAR, OW nVEODEIWSr BABYLON, By JAMES JOHNSON, M.D., PHYSICIAN EXTRAORDINARY TO THE KINO. In one octavo volume, bound in leather. Price $1.60. Thia is a mast excellent work on the benefits of travelling for invalids and «>>«i,m v« v^-v. by aU who desire W Improve their health in this manner.* lnvaUd8> and **«M *• »«>«M ' T' X *. * OFFICE, 22 West Fourth Street, Merchants' Exchange. v a j T^o/■ Milk from to quarts, at , 1 per quart, "I sfz/ V Received Rat/nicut, I /'■fur/jut////, 4>v is: ^|x| ij : S ^ ^ >j ^ k / - <~**: t' -t NATIONAL LIBRARY OF MEDICINE 3% ''ty ■•Art" u.- **»^-?' '-4rfin 't' NLI1 01511507 M *M j* .-;,, ■•'. >^ll# V' ;V '^ At* \$H y* . . v ; ■ ■ ^ ■ ■'■■ ■■ :-''V--0&'-':''' ~ ■; *.'.'..v-*-.*" ■" -; ^ . • NLM015995074